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Optima preferred and standard drugs july 2000

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
ONCOLOGY DRUGS
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 & ANTIFLAMMATORIES SIMETHICONE
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

Source: http://www.tfabenefits.com/pdf/1357930015.343.pdf

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