| Common Non-Covered Drugs |
Alternative Covered Medications |
| Accolate |
must try and fail Singulair (which requires PA for seasonal rhinitis - otherwise Singulair pays for asthmatics with a history of asthma meds) |
| Aceon |
one of following generics must be tried first - captopril, enalapril, or lisinopril. If failure with generic, one of the following must be tried - Mavik, Altace, Lotensin |
| Aerobid |
must try and fail on 2 of the following: Flovent, Beclovent, Pulmicort, QVAR |
| Aerobid-M |
must try and fail on 2 of the following: Flovent, Beclovent, Pulmicort, QVAR |
| Alamast |
must try and fail Cromolyn Sodium |
| Alocril |
must try and fail on Naphazoline OTC and Patanol |
| Alrex |
must try and fail 2 other generic ophthalmic anti-inflammatories and Vexol |
| Altoprev (previously Altocor) |
must try and fail generic lovastatin |
| Ambien CR |
must try and fail 2 of the following: Ambien, Restoril, Sonata, Prosom, Lunesta (#90 per 150 day limit applies if approved) |
| Amerge |
must try and fail Imitrex and Maxalt (1mg max #14/fill and one refill, 2.5mg max #9/fill and one refill) |
| Antara |
must try and fail 2 of the following: Triglide, Tricor, and/or Gemifibrozil |
| Asmanex |
must try and fail 2 of the following: Flovent, Qvar, and/or Pulmicort |
| Atacand |
must try and fail one generic ACE first (captopril, enalapril, lisinopril) - if failure on generic ACE must try and fail one of the following - Cozaar, Diovan, Avapro, Diovan HCT, Hyzaar, Avalide |
| Avinza |
must try and fail 2 other analgesics including MS Contin (Vicodin, Darvocet N100, etc) |
| Avonex |
must try and fail Betaseron and Copaxone |
| Axert |
must try and fail the following - Imitrex and Maxalt |
| Axid |
must try and fail famotidine, ranitidine and cimetidine |
| Azmacort |
must try and fail on 2 of the following: Flovent, Beclovent, Pulmicort, QVAR |
| Beconase AQ |
must try and fail on two: Nasacort AQ, Flonase, or Nasonex |
| Benicar |
must try and fail generic ACE first (captopril, enalapril, lisinopril) - if failure on generic ACE must try and fail one of the following - Cozaar, Diovan, Avapro, Diovan HCT, Hyzaar, Avalide |
| Biaxin XL |
must try and failed Zithromax (generic Biaxin covered, exception - acute sinusitis) |
| Boniva |
must try and fail Actonel and Fosamax |
| Brevicon |
must try and fail Modicon |
| Caduet |
must try and fail on Lipitor and Norvasc in past 13 months |
| Cardene SR |
Cardene |
| Cedax |
must try and fail 2 of the following - Omnicef, Ceftin, Cefzil, generic Velosef |
| Cipro XR |
must try and fail Cipro |
| Clarinex |
must try and fail loratadine and Allegra |
| Clenia |
must try and failed Plexion and Avar |
Clobex
|
Clobetasol
|
| Cordran cr/oint/lot/tape |
must try and fail 2 other medium potency topical steroids |
| Covera HS |
must try and fail generic Verapamil SR |
| Cyclessa |
ortho-tri-cyclen similar or alternate formulary bc's |
| Cymbalta |
STEP THERAPY REQUIRED, must have ONE of the following criteria: SSRI, Effexor/Effexor XR, Tricyclic Antidepressant, Quaternary Amine (ie: Trazodone), Bupropion (Wellbutrin product), Remeron, or hx of Diabetic medication or supply AND Gabapentin (Neurontin) w/in past 13 months |
| Demerol |
any narcotic analgesic |
| Demulen |
must try and fail Zovia (equal) |
| Detrol LA |
must try and fail on two: Oxybutinin, Ditropan XL, Enablex, or Vesicare |
| Dipentum |
must try and fail on two: Asacol, Pentasa, or Sulasalazine |
| Doryx |
must try and fail doxycycline |
| Dynabac |
must try and fail 2 of the following Zithromax, PCE, Erythromycin |
| Emend (reviewed case by case) |
must try and fail 2 of the following - Kytril, Compazine, Anzemet |
| Estrasorb |
must try formulary products: ie: Estrace, Ogen, Premarin/Prempro/Premphase etc. (GI distress from oral meds or dermatitis from patch could qualify for PA) |
| Estring |
must try formulary alternatives: Estrace, Ogen, Premarin/Prempro/Premphase etc. |
| Estrogel |
must have documented therapeutic and clincial failure on a formulary Estrogen patch |
| Estrostep |
must try and fail Ortho TriCyclen (Generic) |
| Estrostep FE |
must try and fail Ortho TriCyclen (Generic) |
| Factive |
must try and fail 2 of the following - Cipro, Floxin, Levaquin, Avelox |
| Flagyl 375 |
must try and fail Metronidazole 250 or 500 mg |
| Fluoxetine 40mg |
Fluoxetine 10mg or 20mg Capsules ONLY |
| Focalin and Focalin XR |
Ritalin, Adderall, Concerta, Strattera |
| Frova |
must try and fail the following - Imitrex, Maxalt (#9/fill w/one refill) |
| Genotropin |
Norditropin preferred agent (PA Required) |
| Geodon |
must try and fail 2 of the following: Risperdal, Abilify, and/or Zyprexa (Psychiatrist's EXEMPT for 38 and 48 CLOSED only) |
| Glyquin |
must try and fail Eldoquin Forte |
| Glyset |
must try and fail 2 other oral antidiabetic agents |
| Hepsera |
Epivir |
| Humira |
PA Required |
| Inspra |
spironolactone |
| Lamisil 1% solution |
must try and fail 2 of the following - Oxistat 1% lotion, Exelderm 1% lotion, Halotex 1% lotion |
| Lescol |
must try and fail 2 of the following - Pravachol, Zocor, Mevacor
|
| Lescol XL |
must try and fail 2 of the following - Pravachol, Zocor, Mevacor
|
Levemir
|
must try and fail formulary insulin
|
| Lexxel |
must try and fail Tarka |
| Lipitor |
must try and fail on 2 of the following: Mevacor, Zocor, or Pravachol (Lipitor 80mg to process to 2nd tier when approved) PFIZER GROUP EXEMPT |
| Locoid cream/oint/sol |
must try and fail 2 other medium potency topical steroids |
| Lofibra |
must try and fail 2 of the following: Triglide, Tricor, and/or Gemifibrozil |
| Lorabid |
must try and fail 2 of the following - Omnicef, Ceftin, Cefzil, generic Velosef |
| Lotemax |
must try and fail 2 generic ophthalmic anti-inflammatories, and Vexol |
| Luxiq |
betamethasone valerate (Dermatologist EXEMPT)
|
| Lyrica |
Neurontin, Tegretol, Depakote etc (PFIZER GROUP EXEMPT) |
| Mentax |
Same as OTC Lotrimin Ultra |
| Metaglip |
must try and fail metformin and glipizide together |
| Miacalcin |
must try and fail Fosamax and Actonel |
| Micardis |
must try and fail generic ACE first (captopril, enalapril, lisinopril) - if failure on generic ACE must try and fail one of the following - Cozaar, Diovan, Avapro, Diovan HCT, Hyzaar, Avalide |
| Micardis HCT |
must try and fail generic ACE first (captopril, enalapril, lisinopril) - if failure on generic ACE must try and fail one of the following - Cozaar, Diovan, Avapro, Diovan HCT, Hyzaar, Avalide |
| Mobic |
must try and fail 2 generic NSAIDs. Trial of Bextra and /or Celebrex NOT required |
| Naprelen |
must try and fail naproxen sodium |
| Nasarel |
must try and fail 2 of the following - Beconase, Beconase AQ, Flonase, Nasonex, Nasacort, Nasacort AQ |
Nevanac
|
must try and fail 2 formulary ophthal. drops (only use post op for 15 days)
|
| Nexium |
must try and fail Prilosec OTC AND Aciphex, and Prevacid Soltabs Category B for Pregnancy |
| Noroxin |
must try and fail 2 of the following - Cipro, Floxin, Levaquin, Avelox |
| Nor-Q-D |
must try and fail Micronor (equal) |
| NuLev |
must try and fail generic hyoscyamine |
| Olux |
must try and fail Luxiq (Dermatologist EXEMPT)
|
| Oruvail |
must try and fail generic ketoprofen or 2 generic NSAIDs |
| Ovace |
must try and fail generic sulfacetamide sodium |
| Ovcon |
must try and fail Modicon or Necon (options - not equal) |
| Oxytrol |
must try and fail Detrol and oxybutynin (oral tablets) |
| Pandel Cream |
must try and fail 2 other topical corticosteroids |
| Paxil CR (temporarily u/a via mftr.) |
must try and fail 2 of the following - generic paroxetine, fluoxetine, or Lexapro (mftr ceased on making and FDB obsoleted all NDCs) |
| Peg-Intron |
must try Pegasys (PA required) |
| Pergonal |
must try and fail Humegon |
| Pravigard PAC |
must try and fail Pravachol |
| Precision Test Strips |
other formulary test strips |
| Prevacid Capsules |
must try and fail Priolosec OTC and Aciphex then Prevacid Solutabs |
| Prevacid Naprapac |
must try and fail Naproxen, Priolosec OTC, and Aciphex |
| Prevacid Solutabs |
must try and fail Prilosec OTC and Aciphex (PA required for over age 18) |
| Prilosec Rx |
must try and fail Prilosec OTC and Aciphex, and Prevacid Soltabs (PA required) |
| Protonix |
must try and fail Prilosec OTC, Aciphex, and Previcid Soltabs |
| Prozac 40mg |
Fluoxetine 10mg or 20mg, Paroxetine, Lexapro |
| Prozac Weekly |
Fluoxetine 10mg or 20mg, Paroxetine, Lexapro |
| Quixin Eye Drops |
must try and fail Ocuflox or Ciloxan |
| Raptiva |
Amevive |
| Rebetol |
must try and fail Copegus or generic Rebetol |
| Relpax |
must try and fail Imitrex and Maxalt |
| Restasis |
none - use OTC artificial tears (Opthalmologist EXEMPT)
|
| Rhinocort |
must try and fail 2 of the following - Beconase, Beconase AQ, Flonase, Nasonex, Nasacort, Nasacort AQ |
| Rhinocort Aqua |
must try and fail 2 of the following - Beconase, Beconase AQ, Flonase, Nasonex, Nasacort, Nasacort AQ |
| Rozerem |
must try and fail 2 of the following: Ambien, Sonata, Restoril, Prosom, Lunesta (#90 per 150day limit applies if approved) |
| Sanctura |
must try and fail 2 of the following: Vesicare, Enablex, Ditropan/XL, Oxytrol patches. |
| Sarafem |
Fluoxetine 10 mg or 20mg CAPSULES ONLY, Paroxetine, Lexapro |
| Seasonale |
use generic oral contraceptives |
| Semprex - D |
must try and fail loraradine-D or Allegra-D |
| Serzone (psych exempt) |
must try and fail 2 of the following - Remeron, Wellbutrin, Wellbutrin SR, Effexor, Effexor XR |
| Skelid |
must try and fail Fosamax and Actonel |
| Spectracef |
must try and fail 2 of the following - Omnicef, Ceftin, Cefzil, generic Velosef |
| Suprax |
must try and fail 2 of the following - Omnicef, Ceftin, Cefzil, generic Velosef |
| Symbyax |
must try and fail generic Fluoxetine and Zyprexa |
| Tequin |
must try and fail 2 of the following - Cipro, Floxin, Levaquin, Avelox |
| Testim |
must try and fail Androderm and Androgel |
| Testoderm |
must try and fail Androderm and Androgel |
| Teveten |
must try and fail generic ACE first (captopril, enalapril, lisinopril) - if failure on generic ACE must try and fail one of the following - Cozaar, Diovan, Avapro, Diovan HCT, Hyzaar, Avalide |
| Travatan |
must try and fail 2 of the following - Alphagan, Alphagan P, Cosopt, Lumigan, Timolol, Xalatan |
| Topical Steroids - Brand |
must use generic topical steroids |
| Triaz Pads |
must try and fail Benzoyl Peroxide OTC and Triaz Gel/Lotion |
| TriLuma |
use Flucinolone/hydroquinone/tretinoin |
| Tri-Norinyl |
Ortho-Novum 7/7/7 (option - not equal) |
| Uniretic |
must try and fail 2 of the following - Captopril HCTZ, Enalapril/HCTZ, Lisinopril/HCTZ |
| Vantin-Suspension |
must try and fail 2 of the following - Omnicef, Ceftin, Cefzil, generic Velosef TABLETS COVERED GENERICALLY |
Vanos
|
generic formulary topical steroids (Dermatologist EXEMPT)
|
| Verelan PM |
must try and fail generic Verapamil SR |
| Vicoprofen |
generic hydrocodone/APAP, ibuprofen |
| Vigamox |
Ciloxin (Opthalmologists and members under 1 year old exempt) |
| Wellbutrin XL |
Wellbutrin SR |
| Xibrom |
must try and fail 2 formulary ophthal. drops (only use post op for 15 days)
|
| Zagam |
must try and fail 2 of the following - Cipro, Floxin, Levaquin, Avelox |
| Zegerid |
Priolosec OTC, Aciphex, and Prevacid Soltabs
|
Zmax
|
Azithromycin (Zithromax) Phizer Exempt
|
| Zomig |
must try and fail 2 of the following - Imitrex, Maxalt |
| Zyflo |
must try and fail Singulair |
| Zymar |
Ciloxin, Ocuflox
|
| Zyrtec |
must try and fail Claritin OTC and Allegra (COVERED for members under age 12) over age 12 PA required |
| Zyrtec D |
must try and fail Claritin OTC and Allegra (COVERED for members under age 12)
|
| Zyrtec Syrup |
Zyrtec Syrup (Covered for members under age 12) over age 12 PA required, must try and fail Claritin OTC and Allegra. |
