Transcription of Presbyterian Centennial Care
1 MPC051617 1 9/1/2018 Presbyterian Centennial care PHP Centennial care Formulary/Preferred Drug Listing The Centennial care Preferred Drug List is subject to change. This list is in order by therapeutic class. To find a specific drug, use the search feature available in Adobe Acrobat Reader (keyboard shortcut: Ctrl+F). MPC051617 2 9/1/2018 Presbyterian Health Plan Centennial care CURRENT AS OF 9/1/2018 lowercase italics = Generic drugs UPPERCASE BOLD = Brand name drugs Tier Notes SP = Specialty Pharmacy Drug Name Tier Notes *ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANORE XIANTS* *ADHD AGENT - SELECTIVE ALPHA ADRENERGIC AGONISTS** guanfacine hcl er oral tablet extended release 24 hour 1 mg, 2 mg, 3 mg, 4 mg Covered QL (30 EA per 30 days) *ADHD AGENT - SELECTIVE NOREPINEPHRINE REUPTAKE INHIBITOR** atomoxetine hcl oral capsule 10 mg, 100 mg, 18 mg, 25 mg, 40 mg, 60 mg, 80 mg Covered ST.
2 QL (30 EA per 30 days) *AMPHETAMINE MIXTURES** amphetamine-dextroamphet er oral capsule extended release 24 hour 10 mg, 15 mg, 5 mg Covered PA required for 19 years of age and older.; Schedule II medications are limited to a 34 day maximum.; QL (30 EA per 30 days); AG (Min 6 Years and Max 18 Years) amphetamine-dextroamphet er oral capsule extended release 24 hour 20 mg, 25 mg, 30 mg Covered PA required for 19 years of age and older.; Schedule II medications are limited to a 34 day maximum.; QL (60 EA per 30 days); AG (Min 6 Years and Max 18 Years) amphetamine-dextroamphetamine oral tablet 10 mg, mg, 15 mg, 20 mg, 5 mg, mg Covered PA required for 19 years of age and older.; Schedule II medications are limited to a 34 day maximum.; QL (90 EA per 30 days); AG (Min 3 Years and Max 18 Years) amphetamine-dextroamphetamine oral tablet 30 mg Covered PA required for 19 years of age and older.
3 ; Schedule II medications are limited to a 34 day maximum.; QL (60 EA per 30 days); AG (Min 3 Years and Max 18 Years) *AMPHETAMINES** dextroamphetamine sulfate er oral capsule extended release 24 hour 10 mg, 15 mg, 5 mg Covered PA required for 19 years of age and older.; Schedule II medications are limited to a 34 day maximum.; QL (60 EA per 30 days); AG (Min 6 Years and Max 18 Years) dextroamphetamine sulfate oral tablet 10 mg, 5 mg Covered PA required for 19 years of age and older.; Schedule II medications are limited to a 34 day maximum.; QL (90 EA per 30 days); AG (Min 3 Years and Max 18 Years) MPC051617 3 9/1/2018 Drug Name Tier Notes VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG Covered PA; Schedule II medications are limited to a 34 day maximum.
4 ; QL (30 EA per 30 days); AG (Min 6 Years) *ANALEPTICS** caffeine citrate intravenous solution 60 mg/3ml Covered caffeine citrate oral solution 20 mg/ml Covered *STIMULANTS - MISC.** armodafinil oral tablet 200 mg, 250 mg Covered PA; QL (30 EA per 30 days) armodafinil oral tablet 50 mg Covered PA; QL (90 EA per 30 days) dexmethylphenidate hcl er oral capsule extended release 24 hour 10 mg, 15 mg, 20 mg, 30 mg, 35 mg, 40 mg, 5 mg Covered ST; PA required for patients 19 years of age and older.; Schedule II medications are limited to a 34 day maximum.; QL (30 EA per 30 days); AG (Min 6 Years and Max 18 Years) dexmethylphenidate hcl er oral capsule extended release 24 hour 25 mg Covered ST; PA required for patients 19 years of age and older.
5 ; Schedule II medications are limited to a 34 day maximum.; QL (30 EA per 30 days); AG (Min 6 Years and Max 18 Years) dexmethylphenidate hcl oral tablet 10 mg, mg Covered ST; PA required for patients 19 years of age and older.; Schedule II medications are limited to a 34 day maximum.; QL (60 EA per 30 days); AG (Min 6 Years and Max 18 Years) dexmethylphenidate hcl oral tablet 5 mg Covered ST; PA required for patients 19 years of age and older.; Schedule II medications are limited to a 34 day maximum.; QL (60 EA per 60 days); AG (Min 6 Years and Max 18 Years) methylphenidate hcl er (cd) oral capsule extended release 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg Covered PA required for 19 years of age and older.; Schedule II medications are limited to a 34 day maximum.
6 ; QL (30 EA per 30 days); AG (Min 6 Years and Max 18 Years) methylphenidate hcl er oral tablet extended release 10 mg, 36 mg Covered PA required for 19 years of age and older.; Schedule II medications are limited to a 34 day maximum.; QL (60 EA per 30 days); AG (Min 6 Years and Max 18 Years) methylphenidate hcl er oral tablet extended release 18 mg, 27 mg, 54 mg Covered PA required for 19 years of age and older.; Schedule II medications are limited to a 34 day maximum.; QL (30 EA per 30 days); AG (Min 6 Years and Max 18 Years) methylphenidate hcl er oral tablet extended release 20 mg Covered PA required for 19 years of age and older.; Schedule II medications are limited to a 34 day maximum.; QL (90 EA per 30 days); AG (Min 6 Years and Max 18 Years) MPC051617 4 9/1/2018 Drug Name Tier Notes methylphenidate hcl er oral tablet extended release 24 hour 18 mg, 27 mg, 54 mg Covered PA required for 19 years of age and older.
7 ; Schedule II medications are limited to a 34 day maximum.; QL (30 EA per 30 days); AG (Min 6 Years and Max 18 Years) methylphenidate hcl er oral tablet extended release 24 hour 36 mg Covered PA required for 19 years of age and older.; Schedule II medications are limited to a 34 day maximum.; QL (60 EA per 30 days); AG (Min 6 Years and Max 18 Years) methylphenidate hcl oral tablet 10 mg, 20 mg, 5 mg Covered PA required for 19 years of age and older.; Schedule II medications are limited to a 34 day maximum.; QL (90 EA per 30 days); AG (Min 6 Years and Max 18 Years) *AMINOGLYCOSIDES* *AMINOGLYCOSIDES** neomycin sulfate oral tablet 500 mg Covered tobramycin inhalation nebulization solution 300 mg/5ml Covered SP *ANALGESICS - ANTI-INFLAMMATORY* *ANTIRHEUMATIC - JANUS KINASE (JAK) INHIBITORS** XELJANZ ORAL TABLET 10 MG Covered PA; SP; QL (60 EA per 30 Days) XELJANZ ORAL TABLET 5 MG Covered PA; SP; QL (60 EA per 30 days) XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR 11 MG Covered PA; SP; QL (30 EA per 30 days) *ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES** HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 Covered PA; SP; Approve 1 box quantity of 6 to start initial therapy.
8 ; QL (6 EA per 30 days) HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 Covered PA; Approve 1 box quantity of 4 to start initial therapy.; QL (4 EA per 30 days) HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 , 10 , 20 , 20 , 40 , 40 Covered PA; SP; QL (2 EA per 28 days) *ANTI-TNF-ALPHA - MONOCLONOAL ANTIBODIES** HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 Covered PA; SP; QL (2 EA per 28 days) HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 Covered PA; SP; Approve 1 box quantity of 6 to start initial therapy.; QL (6 EA per 30 days) HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 Covered PA; SP; Approve 1 box quantity of 4 to start initial therapy.; QL (4 EA per 30 days) MPC051617 5 9/1/2018 Drug Name Tier Notes HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 , 10 , 20 , 20 , 40 , 40 Covered PA; SP.
9 QL (2 EA per 28 days) *CYCLOOXYGENASE 2 (COX-2) INHIBITORS** celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg Covered QL (60 EA per 30 days) *GOLD COMPOUNDS** RIDAURA ORAL CAPSULE 3 MG Covered *NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)** childrens ibuprofen oral suspension 40 mg/ml Covered diclofenac sodium er oral tablet extended release 24 hour 100 mg Covered diclofenac sodium oral tablet delayed release 25 mg, 50 mg, 75 mg Covered etodolac er oral tablet extended release 24 hour 400 mg, 500 mg, 600 mg Covered etodolac oral capsule 200 mg, 300 mg Covered etodolac oral tablet 400 mg, 500 mg Covered flurbiprofen oral tablet 100 mg, 50 mg Covered ibuprofen junior strength oral tablet chewable 100 mg Covered ibuprofen lysine intravenous solution 10 mg/ml MED ibuprofen oral suspension 100 mg/5ml Covered ibuprofen oral tablet 200 mg, 400 mg, 600 mg.
10 800 mg Covered INDOCIN ORAL SUSPENSION 25 MG/5ML Covered INDOCIN RECTAL SUPPOSITORY 50 MG Covered indomethacin er oral capsule extended release 75 mg Covered indomethacin oral capsule 25 mg, 50 mg Covered ketoprofen er oral capsule extended release 24 hour 200 mg Covered meloxicam oral tablet 15 mg, mg Covered MOTRIN IB ORAL TABLET 200 MG Covered nabumetone oral tablet 500 mg, 750 mg Covered naproxen dr oral tablet delayed release 375 mg, 500 mg Covered naproxen oral suspension 125 mg/5ml Covered naproxen oral tablet 250 mg, 375 mg, 500 mg Covered naproxen sodium oral tablet 275 mg, 550 mg Covered oxaprozin oral tablet 600 mg Covered piroxicam oral capsule 10 mg, 20 mg Covered sulindac oral tablet 150 mg, 200 mg Covered MPC051617 6 9/1/2018 Drug Name Tier Notes *PYRIMIDINE SYNTHESIS INHIBITORS** leflunomide oral tablet 10 mg, 20 mg Covered *SELECTIVE COSTIMULATION MODULATORS** ORENCIA CLICKJECT SUBCUTANEOUS SOLUTION AUTO-INJECTOR 125 MG/ML Covered PA; SP; QL (4 ML per 30 days) ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 125 MG/ML Covered PA; SP; QL (4 ML per 28 days) ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 50 Covered PA; SP; QL ( ML per 28 days) ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE Covered PA; SP; QL ( ML per 28 days) *SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS** ENBREL MINI SUBCUTANEOUS SOLUTION CARTRIDGE 50 MG/ML Covered PA; SP.
