Ny pdl 8-7-06.xls

WELLCARE NEW YORK HEALTHPLANS PROVIDER
PREFERRED DRUG LIST HANDBOOK - 2006
CHILD HEALTH PLUS AND FAMILY HEALTH PLUS
Cost Index
Quality Indicator
QTY / Therapeutic Limit
Specific Limitations
Generic Name
Brand Name
(Optional Info)
ANALGESICS
Opioid Analgesics
LORCET, LORTAB- 2.5/500, 5/500, 7.5/500, 7.5/650, 10/650, 10/500, ELIXIR, VICODIN 10/660, 7.5/750 METHADONEMSIR TABS, MSIR ORAL CONC, MS CONTIN, OXYCODONEPERCOCET, TYLOX, ROXILOX, ROXICET, ENDOCET #240 / 30DS
#3ml / 30DS
Non-Opioid Analgesics
Suspension covered
Age-OTC susp
for<21 y.o. only
#20 / 30DS
History of 2 generic
Quality Indicator Key= DER= Prior Authorization ; ST= Step Edit; Age= Age Limit/Requirement; QL= Quanity Limit ANESTHETICS
AURALGAN, OTIC, A/B OTIC, AUROTO & RX-OTIC ANTIBACTERIALS - ORAL
Beta-Lactam, Cephalosporins
Beta-Lactam, Penicillins
E-MYCIN, ERY-TAB, ILOSONE, E.E.S., ERYTHROCIN, Macrolides
Quinolones
Sulfonamides
Tetracyclines
Antibacterials, Other
Granules=200ml/3ODS
ANTI-CONVULSANTS
Benzodiazepines
Calcium Channel Modifying Agents $$$$
GABA Augmenting Agents
Quality Indicator Key= DER= Prior Authorization ; ST= Step Edit; Age= Age Limit/Requirement; QL= Quanity Limit Glutamate Reducing Agents
Sodium Channel Inhibitors
ANTIDEMENTIA
Cholinesterase Inhibitors
Antidementia Agents, Other
ANTIDEPRESSANTS
MAO Inhibitors
Reuptake Inhibitors
10mg=#30/30 DS
20mg=#60/30DS
#30 / 30DS
50mg=#15/30DS
100mg=#60/30DS
#30 / 30DS
Antidepressants, Other
#90 / 30DS
#240 / 30DS
Buproprion (immediate and sustained release) #60 / 30DS
ANTIEMETICS
4mg or 8mg=#12/30DS;
Sol=100ml/30DS
24mg=#1/30DS
Quality Indicator Key= DER= Prior Authorization ; ST= Step Edit; Age= Age Limit/Requirement; QL= Quanity Limit ANTIFUNGALS
ANTIGOUT
ANTIHISTAMINE DRUGS,
ANTITUSSIVES, EXPECTORANTS,
AND MUCOLYTIC AGENTS
All cough/cold medication, other than single entity guaifenesin, including antitussives, decongestants, and expectorants or any combination are limited to recipients under the age of 21. Antihistamine
CLARITIN, REDITABS, SYRUP OTC; LORATADINE- Decongestant/ Expectorant
Antihistamine/Decongestant
PHENERGAN VCSUDAL -12, PEDIOX CHEWABLE, DE-CONGESTINE, Antitussives (Non-Narcotic)
Antitussives (Non Narcotic) /
Expectorant
Antitussives(Non-
Narcotic)/Antihistamine
Carbetapentane tannate/Clorpheniramine tannate Antitussives (Non-Narcotic) /
Antihistamine / Decongestant /
Expectorant
Brompheniramine/Pseudoephedrine/Dextromethorphan ANDEHIST DM, BROMATANE DX, BROMAXEFED DMCARDEC DM, CARBAXEFED DM, CARBOFED DM, Carbinoxamine/Pseudoephedrine/Dextromethorphan Chlorpheniramine/Phenylephrine/Dextromethorphan Dextromethorphan /Guaifenesin /Phenylephrine HCl/ Antitussives - Narcotic
Antitussives (Narcotic) /
Antihistamine
Quality Indicator Key= DER= Prior Authorization ; ST= Step Edit; Age= Age Limit/Requirement; QL= Quanity Limit Antitussives (Narcotic) /
Decongestant
Antitussives (Narcotic) /
Antihistamine / Decongestant
Hydrocodone/ Chlorpheniramine/ Phenylephrine Hydrocodone/ Chlorpheniramine/ Pseudophedrine Antitussives (Narcotic) / Expectorant G
HYCOSIN, HYCOTUSS & VI-Q-TUSS, CODICLEAR DHROBITUSSIN A-C, CHERATUSSIN AC, GANI- TUSS Antitussives (Narcotic) /
Decongestant/ Expectorant
Hydrocodone / Pseudoephedrine/ Guaifenesin DRITUSS HD, MYTUSSIN DACROBITUSSIN DAC, CHERATUSSIN DAC, HALOTUSSIN ANTI-INFLAMMATORIES
Glucocorticoids
#20 / 30DS
ANTIMIGRAINES
Abortive
#12 / 30DS
Quality Indicator Key= DER= Prior Authorization ; ST= Step Edit; Age= Age Limit/Requirement; QL= Quanity Limit Prophylactic
ANTIMYCOBACTERIALS
Antituberculars
Antimycobacterials, Other
ANTINEOPLASTICS
Aromatase Inhibitors
Antimetabolites
Miscellaneous Antineoplastics
Alkylating Agents
Antibiotics
Antimetabolities
Antimitotic Agents
Biological Response Modifiers
Epipodophyllotoxins
Platinum Coordination Complex
ANTIPARASITICS
Antihelmetics
Antiprotozoals
Quality Indicator Key= DER= Prior Authorization ; ST= Step Edit; Age= Age Limit/Requirement; QL= Quanity Limit Pediculicides/Scabicides
#60mls / 30DS
ANTIPARKINSON AGENTS

COMT Inhibitors
Dopamine Agonists
#60 / 30DS
Antiparkinson Agents, Other
ANTIPSYCHOTICS
Non-Phenothiazines
Non-Phenothiazines, Atypical
#60 / 30DS 2syringes/30
Not FDA indicated for <
DS for Consta
12 years old
Not FDA indicated for <
#60 / 30DS
12 years old
Phenothiazines
ANTIVIRALS
CMV Agents
Antiherpetic Agents
Anti-HIV Agents, Fusion Inhibitors
Anti-HIV Agents, Non-nucleoside
Reverse Transcriptase Inhibitors
Quality Indicator Key= DER= Prior Authorization ; ST= Step Edit; Age= Age Limit/Requirement; QL= Quanity Limit Non-nucleoside Reverse
Transcriptase Inhibitors
#30 / 30DS
#60 / 30DS
#30 / 30DS
#30 / 30DS
Anti-HIV Agents, Protease Inhibitors $$$$$
#310 / 30DS
#120 / 30DS
#60 / 30DS
Anti-Influenza Agents
Antivirals, Other
ANXIOLYTICS
Benzodiazepines
Anxiolytics, Other
AUTONOMIC AGENTS
Parasympatholytics
Parasympathomimetics
Sympathomimetics
#2 inj./ 30DS
BIPOLAR AGENTS
Quality Indicator Key= DER= Prior Authorization ; ST= Step Edit; Age= Age Limit/Requirement; QL= Quanity Limit BLOOD GLUCOSE REGULATORS
Antihypoglycemics
#240 / 30DS
Insulins
Glucose Meters and Strips
#100/30DS
ACCU- CHECK , ASENCIAACCUSURE, AIMSCO, B-L, CARE ONE ULTIGUARD, EXEL, FIRST CHOICE, RELION, SURE-JECT, STORE #100 / 30 DS
#100 / 30DS
Available only through
mailorder:
Accuchek 1-888-744-3671
Diabetic Miscellaneous
#100/30DS
BLOOD PRODUCTS, MODIFIERS,
EXPANDERS
Anticoagulants
#20 / 30DS
Blood Formation Products
Platelet Aggregation Inhibitors
Hematological Agent, Other
CARDIOVASCULAR AGENTS
ACE Inhibitors
Angiotensin II Receptor Blocker
#30 / 30DS
#30 / 30DS
Alpha-Adrenergic Agonists
Quality Indicator Key= DER= Prior Authorization ; ST= Step Edit; Age= Age Limit/Requirement; QL= Quanity Limit Alpha-Adrenergic Blocking Agents
Antiarrhythmics
#240 / 30DS
Beta-adrenergic Blocking Agents
Calcium Channel Blocking Agents
Direct Cardiac Inotropics
Diuretics
#240 / 30DS
Dyslipidemics
20mg=#30/30DS
40mg=#60/30DS
#30 / 30DS
#30 / 30DS
Vasodilators
Isosorbide mononitrate (extended release) MINIPRESSNITROGLYCERIN, NITREK, NITRO-DUR, NITROQUICK, NITRO-BID, NITROL OINTMENT, DEPONIT, MINITRAN, NITREK, MINITRAN, TRANSDERM-NITRO, NITRODISC, Nitroglycerin ointment, patches, SR, tablets, sublingual Quality Indicator Key= DER= Prior Authorization ; ST= Step Edit; Age= Age Limit/Requirement; QL= Quanity Limit CENTRAL NERVOUS SYSTEM
AGENTS
Amphetamines
#30 / 30DS
Concerta #30
Smoking Cessation Agents
* There is a maxium 3 month per year benefit DENTAL AND ORAL AGENTS
DERMATOLOGICAL AGENTS
Dermatological Anesthetics
Dermatological Antibacterials
#240gm / 30DS
Dermatological Antifungals
Group 1 Anti-Inflammatory Agents
Clobetasol emollient, cream, oint, gel 0.05% Group 2 Anti-Inflammatory Agents
Betamethasone dipropionate cream, oint 0.05% Quality Indicator Key= DER= Prior Authorization ; ST= Step Edit; Age= Age Limit/Requirement; QL= Quanity Limit Group 3 Anti-Inflammatory Agents
Group 4 Anti-Inflammatory Agents
Group 5 Anti-Inflammatory Agents
Dermatological Antipruritic
Dermatological Keratolytics
Dermatological Miotic Inhibitors
Duration of Therapy
#60/30DS SE-Must use 1st
20weeks.Not FDA
line topical acne products:i.e. indicated children
Dermatological Retinoids
Cleocin-T,Emgel, T-Stat
under 12yrs of age.
< 26 years of age
Dermatological Tar Derivatives
Dermatological Vitamin D Analogs
Dermatological Agents, Other
First try a steroid for 4
#30gm/30DS
DETERRENTS / REPLACEMENTS
Quality Indicator Key= DER= Prior Authorization ; ST= Step Edit; Age= Age Limit/Requirement; QL= Quanity Limit Alcohol Deterrents
ENZYME REPLACEMENTS /
MODIFIERS
LIPRAM, PANCREASE MT, CREON, KU-ZYME, ULTRASE, PANCREASE, PANOKASE, VIOKASE, PANCRELIPASE & PANCREATIC ENZYME, CREON EYE, EAR, NOSE, AND THORAT
(EENT) PREPARATIONS
Nasal Corticosteroids
Other Nasal Products
GASTROINTESTINAL AGENTS
Antispasmodics, Gastrointestinal
H2 Blocking Agents
Protectants

Proton Pump Inhibitors
Gastrointestinal Agents, Others
ACTIGALLCHRONULAC, ENULOSE, CEPHULAC & #527gm / 30DS
GENITOURINARY AGENTS
Antispasmodics, Urinary
Benign Prostatic Hypertrophy
Agents
Impotence Agents
HORMONAL AGENTS, STIMULANT /
REPLACEMENT / MODIFYING
Adrenal Topical
Quality Indicator Key= DER= Prior Authorization ; ST= Step Edit; Age= Age Limit/Requirement; QL= Quanity Limit Group 1 Anti-Inflammatory Agents
Clobetasol emollient, cream, oint, gel 0.05% Group 2 Anti-Inflammatory Agents
Betamethasone dipropionate cream, oint 0.05% Group 3 Anti-Inflammatory Agents
Group 4 Anti-Inflammatory Agents
Group 5 Anti-Inflammatory Agents
Adrenal Oral
Parathyroid / Metabolic Bone
Disease Agents/Osteoarthritis
Pituitary
Prostaglandins
Androgens
Estrogens
Quality Indicator Key= DER= Prior Authorization ; ST= Step Edit; Age= Age Limit/Requirement; QL= Quanity Limit Estrogen/Progestin combination
Estrogen/Androgen combination
Oral Contraceptives
Ethinyl estradial/ Norethindrone acetate Ethinyl estradial/ Norethindrone acetate MICROGESTIN Fe 1.5/30; 1/20, JUNEL Fe 1.5/30; 1/20 Oral Contraceptives,Other
6 mg Norelgestromin/0.75 mg ethinyl estradiol HORMONAL AGENTS,
SUPPRESSANT
Pituitary

Sex Hormones / Modifiers

IMMUNOLOGICAL AGENTS
Immune Suppressants
Immunomodulators
INFLAMMATORY BOWEL DISEASE
AGENTS
Quality Indicator Key= DER= Prior Authorization ; ST= Step Edit; Age= Age Limit/Requirement; QL= Quanity Limit Glucocorticoids
Salicylates
Sulfasalazine is the 1st
line of therapy for
ulcerative colitis
Sulfonamides
JOINT/CONNECTIVE TISSUE/
MUSCULARSKELETAL AGENTS
Antirheumatics
MISCELLANEOUS THERAPEUTIC
OPTHALMIC AGENTS
Opthalmic Anti-allergy Agents
Opthalmic Antibacterials
Opthalmic Antiglaucoma Agents
#3ml / 30DS
Opthalmic Ani-inflammatories
Quality Indicator Key= DER= Prior Authorization ; ST= Step Edit; Age= Age Limit/Requirement; QL= Quanity Limit Opthalmic Antivirals
Ophthalmic
Antihistamine/Decongestant Combo G
OBSTETRICAL & GYNECOLOGICAL
AGENTS
Monophasic Oral Contraceptives
Ethinyl estradial/ Norethindrone acetate Ethinyl estradial/ Norethindrone acetate MICROGESTIN Fe 1.5/30; 1/20, JUNEL Fe 1.5/30; 1/20 6 mg Norelgestromin/0.75 mg ethinyl estradiol #90 / 90DS
Ethinyl estradial 30 / Levonorgestrel .15 Biphasic Oral Contraceptives
Triphasic Oral Contraceptives
Progestin Only Oral Contraceptives
Progestin Agents
OB/GYN Anti-infectives
Miscellaneous - OB/GYN
Quality Indicator Key= DER= Prior Authorization ; ST= Step Edit; Age= Age Limit/Requirement; QL= Quanity Limit 2 pack/30 DS
OTIC AGENTS
Otic Antibacterials
Otic Anti-inflammatories
Hydrocortisone Acetate & HC/Pramoxine Otic, Other
AURALGAN, OTIC, A/B OTIC, AUROTO & RX-OTIC RESPIRATORY TRACT AGENTS
Antileukotrienes
Bronchodilators, Anticholinergic
Bronchodilators, Anti-
inflammatories
Approved for children 8
#120ml / 30DS
years old or younger
Approved for 6 years
old and older
Bronchodilators, Xanthines
Bronchodilators, Sympathomimetic
Mast Cell Stabilizers
Mucolytics
Respiratory Tract Agents, Other
Quality Indicator Key= DER= Prior Authorization ; ST= Step Edit; Age= Age Limit/Requirement; QL= Quanity Limit E-Z SPACER, OPTI CHAMBER, AEROCHAMBER, ECLIPSE COMPACT, MICROCHAMBER, #2 / 365 DS
SEDATIVES / HYPNOTICS
History use of 2:
Generic Halcion,
#14 / 30DS
Prosom, or Restoril
SKELETAL MUSCLE RELAXANTS
THERAPEUTIC NUTRIENTS /
MINERALS / ELECTROLYTES
Electrolytes / Minerals
Potassium Chloride Effervescent tablets, powder, 8 mEq K-LOR, KLOR-CON, K-LYTE, MICRO-K, SLOW-K Miscellaneous
Vitamins
ULTRA NATALCARE, ULTRA NATAL, MYNATE 90 PLUS, PRENATAL MR 90 Fe, PRENATAL PLUS, PRENATAL Z, PREMESIS RX, PRIMACARE ONE, PRIMACARE COMBO, PRENATAL RX 1, PRENATAL -U, CAL-NATE,PRENATAL -H ,NATALCARE, NUTRINATE,PRENATAL RX, VINATE GT, VINATE II,ADVANCED NATALCARE,VITAFOL-OB, PRENATAL FORMULA 3,ADVANCED-RF NATALCARE,NUTRISPIRE, PRENATAVITE,PRENATAL 1 PLUS 1, PRENATAL LOW IRON, PRENATABS OBN,VINATE-M,UNI-KAR PLUS C, NATALCARE PIC, Quality Indicator Key= DER= Prior Authorization ; ST= Step Edit; Age= Age Limit/Requirement; QL= Quanity Limit

Source: https://www.wellcare.com/WCAssets/corporate/assets/NY_Forms_Pharmacy_PreferredDrugList.pdf