OPTIMA HEALTH Preferred Drugs List October-December 2012
Dear Doctor: Please refer to this list when prescribing for your patient. Your patient will have lower drug costs if you prescribe generic drugs and allow brand substitution for dual-branded products.
PA= prior authorization required Qty= quantity limit SE= step edit required Small Case Letters= tier 1 Uppercase First Letter=tier 2 P=Brand obtained at tier 2
ANESTHETICS Class III Progestins ANTIBIOTICS ANTIHYPERTENSIVES Antiandrogens Vasodilators Antiestrogen Miscellaneous Antineoplastics Centrally-Acting TOPICAL ANTIBACTERIALS ANTIFUNGALS-ORAL ACE Inhibitors TOPICAL ANTIVIRALS ANTIFUNGALS-OTHER SUPPRESSANTS Suspensions/Liquids Only ANTIVIRALS-ORAL Angiotensin II Receptor Antagonists Capsules/Tablets Only ANTIARRHYTHMICS Drugs for Pheochromocytoma ONCOLOGYDRUGS Alkylating Agents Combination Antihypertensives SPECIALIZED INDICATIONS Antimetabolites Androgen OTHER CARDIAC NARCOTICS CHOLESTEROL LOWERING DRUGS VASODILATING DRUGS Nitrates Drugs for Mania Drugs for Vertigo/Emesis BETA BLOCKERS Class III Cardioselective Antidepressants Miscellaneous Pain Medications Non-Cardioselective ANTIPLATELET DRUGS CNS Stimulants DERMATOLOGY Acne Drugs Alpha/Beta Antagonists ANTICOAGULANTS CALCIUM CHANNEL BLOCKERS Miscellaneous CNS Drugs HEMOSTATICS Drugs for Psoriasis and Eczema CNS DRUGSDRUGS Anxiolytics Alzheimer’s Drugs Antipsychotics Keratolytics DIURETICS Potassium-Sparing Diuretics Miscellaneous Headache Drugs Sedative/Hypnotics Thiazide Diuretics Scabicides Anticonvulsants Corticosteroids Loop Diuretics Drugs for Parkinsonism CARDIAC GLYCOSIDES Hypoglycemics OB/GYN MEDICATIONS
Infertility medications are not covered.
Estrogens Miscellaneous GI Drugs Estrogen/Androgen Combinations Estrogen/Progestin Combinations Arthritis Drugs Contraceptives Other Corticosteroid Products Skeletal Muscle Relaxants Topical Immunosuppressives Miscellaneous ENT DRUGS BIOTECH DRUGS Drugs for the Ear VITAMINS AND MINERALS Vitamins Affecting Coagulation Potassium Supplements Nasal Corticosteroids Thyroid Medications Throat/Mouth Medications Potassium-Removing Resins Phosphorous Reducer ENDOCRINE DRUGS MUSCULO-SKELETAL Diarrhea Medications Corticosteroids MEDICATIONS Miscellaneous Gout Drugs GI Motility Drugs Oxytocics
Uloric (Tier 3) Prenatal Vitamins Mineralocorticoids Salicylates Androgens Ulcer/GERD Medications
Dexilant (Tier 3) SE PLEASE NOTE QUANTITY LIMITS PER Progestins DISPENSING. Members of FAMIS do not have this OTC benefit. PSYLLIUM Methylxanthines FORMULATION ANALGESICS & ANTIFLAMMATORIESSIMETHICONE Antivirals ACETAMINOPHEN OB/GYN Topical Anti-infective Miscellaneous Corticosteroids CIMETIDINE RANITIDINE Miscellaneous Miscellaneous PRILOSEC OPHTHALMIC MEDICATIONS CHLORPHENIRAMINE Topical Corticosteroids ANTIGLAUCOMA DRUGS LORATADINE Cardioselective Beta-Blockers RESPIRATORY Non-Selective Beta-Blockers IBUPROFEN MEDICATIONS Antihistamines DIPHENHYDRAMINE UROLOGICALS Anticholinergic/Antispasmodics Miscellaneous Topical PSEUDOEPHEDRINE Antihistamine/ Cholinergic Stimulants Decongestant Combinations GASTROINTESTINALS AL & MG HYDROXIDE BROMP/PSEUDOEPHEDRINE Anesthetics AL & MG HYDROXIDE SIMETHICONE LORATADINE/PSEUDOEPHEDRINE LOPERAMIDE Miscellaneous ZYRTEC – D Antitussives, Expectorants BISACODYL Narcotic-Containing TRIPROL/PSEUDOEPHEDRINE DOCUSATE CALCIUM GUAIFENESIN GUAIFENESIN DM Anti-infectives/Corticosteroids DOCUSATE SODIUM CP/PSEUDOEPHEDRINE/DM GUAIFENESIN/PSEUDOEPHEDRINE NonNarcotic Containing ANTIDOTES SALINE NASAL SPRAY Anti-infectives FORMULARY FOR OTC PRODUCTS- OPTIMA FAMILY CARE ONLY AQUAPHOR GENERIC PRODUCTS MUST BE USED WHERE AVAILABLE. A prescription is Beta-2 Agonists required for OTC products to be covered MILK OF MAGNESIA by the plan. Prescriptions may be BACITRACIN written or phoned to the pharmacy. NONOXYNOL 9 BACITRACIN/NEOMYCIN/POLYMIXIN CLOTRIMAZOLE Quantity Limits MICONAZOLE
Sentara Health Care Pharmacy Services,
October 2012. No portion of this PYRETHRIN TERBENAFINE PYRETHRIN HYROCORTISONE PERMETHRIN DIAPER RASH MEDICATION NICOTINE VITAMIN A & D OINTMENT NICOTINE NICOTINE NICOTINE NICOTINE CENTRUM SILVER NICOTINE POLY-VI-SOL NICOTINE POLY-VI-SOL W/ IRON CARBAMIDE
please utilize the ‘Drug Search Tool’
SODIUM CHLORIDE FERROUS SULFATE For Prior Authorization Requests: Generic Drug Policy ERGOCALCIFEROL MULTIVITAMINS NIFEREX-150 PRENATAL VITAMINS For Step-Edits: CALCIUM CARBONATE OS-CAL+D OS-CAL+D OS-CAL+D Prior Authorization Requests CALTRATE CALTRATE PLUS CALTRATE 600 CALTRATE 600+D PLUS MAGNESIUM
SALIX PHARMACEUTICALS, INC. PRESS RELEASE Salix Pharmaceuticals Announces License Agreement for a New Extended Intestinal Release Formulation of Rifaximin EIR (Extended Intestinal Release) Formulation of Rifaximin to be Studied for Crohn's Disease RALEIGH, N.C.--[1])--Salix Pharmaceuticals, Ltd. (NASDAQ:SLXP) and Alfa Wassermann S.p.A. today announced that they have entered into
OPTIMA HEALTH Preferred Drugs List October-December 2012