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)
2 *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; 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.
3 ; 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.; 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.
4 ; 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.; 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.
5 ** 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.; 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) 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.
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 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.
8 ; 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.; 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.
9 ; 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.
10 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.; 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.
