Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download ohana dual eligible preferred drug list
Document related concepts
no text concepts found
Transcript
2012 Comprehensive Dual Eligible Preferred Drug List (List of Covered Drugs) ‘Ohana Health Plan 00 9 Please read: This document contains information about the drugs we cover in this plan. Last updated (10/01/2012) Ohana Dual Eligible Cough & Cold Drug List Non-Formulary Drugs Preferred Formulary Drugs ANTITUSSIVES,NON-NARCOTIC Benzonatate TESSALON 200 MG CAPSULE BENZONATATE 100 MG CAPSULE BENZONATATE 200 MG CAPSULE Dextromethorphan Polistirex DELSYM 30 MG/5 ML EXTENDED-RELEASE SUSPENSION Dextromethorphan HBr ROBITUSSIN PEDIATRIC COUGH SYP NON-NARC ANTITUSS-1ST GEN. ANTIHISTAMINE-DECONGEST Brompheniramine/Dextromethorphan HBr/Pseudoephedrine HCl ALLANHIST PDX DROPS BROMFED DM SYRUP BROMHIST PDX DROPS ENDACOF-PD DROPS BROTAPP DM LIQUID Q-TAPP DM ELIXIR Brophenaramine/Dextromethorphan HBr/Phenylephrine HCl COLD/COUGH CHILDRENS ELIXIR RYNEX DM DIMAPHEN DM ELIXIR Chlorpheniramine/Dextromethorphan HBr/Phenylephrine HCl C-PHEN DM PD-COF SYRUP RONDEX-DM SYRUP SILDEC PE-DM SYRUP DE-CHLOR DM LIQUID CORFEN DM NOHIST-DM TRI-DEX PE Chlorpheniramine/Dextromethorphan HBr/Pseudoephedrine HCl PEDIATRIC COUGH-COLD LIQUID KIDKARE COUGH/COLD MESEHIST DM Dexchlorpheniramine/Pseudoephedrine HCl/Chlophedianol HCl VANACOF LIQUID Chlorpheniramine/Dextromethorphan HBr DIMETAPP LONG-ACTING COUGH LIQ ROBITUSSIN LONG ACTING LIQUID Promethazine HCl/Dextromethorphan HBr PROMETHAZINE-DM SYRUP EXPECTORANTS DECONGESTANT-EXPECTORANT COMBINATIONS Guaifenesin/Phenylephrine HCl DONATUSSIN DROPS PE-GUAI DROPS DESPEC LIQUID RESCON-GG LIQUID NON-NARCOTIC DECONGESTANT-EXPECTORANT-ANTITUSSIVE Guaifenesin/Dextromethorphan HBr/Phenylephreine ROBAFEN CF SYRUP Last updated 09/25/2012 Page 1 of 2 Ohana Dual Eligible Cough & Cold Drug List Non-Formulary Drugs Preferred Formulary Drugs NON-NARCOTIC ANTITUSSIVE AND EXPECTORANT COMB. Dextromethorphan HBr/Guaifenesin DURATUSS DM ELIXIR SIMUC-DM ELIXIR SU-TUSS DM ELIXIR MUCUS RELIEF COUGH LIQUID GUAIFENESIN DM SYRUP IOPHEN DM-NR LIQUID EXTRA ACTION COUGH REFENESEN DM ROBAFEN DM CLEAR ROBITUSSIN COUGH CHEST CONGESTION DM LIQUID DIABETIC TUSSIN DM LIQUID Q-TUSSIN-DM SYRUP SILTUSSIN DM COUGH SYRUP SILTUSSIN DM DAS COUGH SYRUP MUCOSA DM MUCINEX FAST MAX DM MAX LIQUID NARCOTIC ANTITUSSIVE-1ST GENERATION ANTIHISTAMINE Chlorpheniramine/Hydrocodone Polistirex TUSSIONEX PENNKINETIC SUSP TUSSICAPS HYDROCODONE-CHLORPHENIRAMINE SUSPENSION Codeine Phosphate/Promethazine HCl PROMETHAZINE-CODEINE SYRUP NARCOTIC ANTITUSSIVE-1ST GEN. ANTIHISTAMINE-DECONGESTANT Codeine/Phenylephrine HCl/Promethazine Dexbrompheniramine/Hydrocodone Bit/Phenylephrine HCl CYTUSS-HC NR SYRUP HC 2.5-PE 5-DBROM 1 MG SYRUP HC/PE/DBROM SYRUP PROMETH VC W/COD SYRUP PROMETHAZINE VC/COD SYRUP Pseudoephedrine HCl/Codeine/Chlorpheniramine PHENYLHISTINE DH NARCOTIC ANTITUSSIVE-ANTICHOLINERGIC COMBINATION Hydrocodone Bit/Homatropine HYDROMET SYRUP HYDROCODONE-HOMATROPINE NARCOTIC ANTITUSSIVE-EXPECTORANT COMBINATION Guaifenesin/Hydrocodone Bit HYDROCODONE-GUAIFENESIN SYRUP NARCOF SYRUP TUSSICLEAR DH SYRUP Codeine Phosphate/Guaifenesin CHERATUSSIN AC SYRUP GUAIFENESIN-CODEINE SYRUP IOPHEN C-NR NARCOTIC ANTITUSSIVE-DECONGESTANT-EXPECTORANT COMBINATIONS Codeine Phosphate/Guaifenesin/Pseudoephedrine HCl CHERATUSSIN DAC SYRUP Last updated 09/25/2012 Page 2 of 2 ‘OHANA DUAL ELIGIBLE PREFERRED DRUG LIST Drug Name Antihistamine Drugs First Generation Antihistamines aler-cap aler-dryl alertab aller-chlor aller-chlor allergy relief children’s allergy relief allergy tablets allergy altaryl altaryl anti-hist allergy anti-hist banophen banophen banophen diphenhydramine hcl brotapp chlorhist chlorphen chlorpheniramine maleate complete allergy medication complete allergy relief diabetic tussin allergy diphenhist diphenhist diphenhist diphenhydramine hcl diphenhydramine hcl dormin genahist pharbedryl q-dryl q-dryl q-tapp quenalin scot-tussin allergy relief formula siladryl allergy silphen cough Dosage Form Capsule Tablet Tablet Syrup Tablet Liquid Tablet Tablet Tablet Elixir Syrup Tablet Capsule Capsule Liquid Tablet Liquid Liquid Tablet Tablet Tablet Tablet Tablet Syrup Capsule Liquid Tablet Capsule Tablet Capsule Capsule Capsule Capsule Liquid Elixir Syrup Liquid Liquid Syrup Coverage Details: PA= Prior Authorization, QL= Quantity Limit Page 1 of 17 Coverage Details ‘OHANA DUAL ELIGIBLE PREFERRED DRUG LIST Drug Name simply allergy total allergy medicine total allergy Second Generation Antihistamines cetirizine hcl children’s allergy cetirizine hcl children’s cetirizine hcl cetirizine hcl loratadine hives relief loratadine loratadine-d 24hr Autonomic Drugs Autonomic Drugs, Miscellaneous nicotine polacrilex nicotine Sympathomimetic (Adrenergic) Agents nasal decongestant pseudoephedrine hcl sudafed 12 hour Blood Formation,Coagulation & Thrombosis Antianemia Drugs ferro-bob ferrous sulfate ferrous sulfate ferrous sulfate ferrous sulfate ferrousul iron Central Nervous System Agents Analgesics and Antipyretics acephen acetaminophen acetaminophen acetaminophen apap extra strength apap aspirin childrens aspirin ec low dose aspirin ec Dosage Form Tablet Liquid Tablet Syrup Solution Chewable Tablet Solution Tablet Tablet (24 hour) Gum Patch (24 hour) QL (300.00 per 31 days) QL (960.00 per 365 days) QL (93.00 per 365 days) Syrup Tablet Tablet (12 hour) Tablet Elixir Solution Tablet Enteric Coated Tablet Tablet Tablet Suppository Chewable Solution Tablet Tablet Tablet Chewable Enteric Coated Tablet Enteric Coated Coverage Details: PA= Prior Authorization, QL= Quantity Limit Page 2 of 17 Coverage Details QL (186.00 per 31 days) ‘OHANA DUAL ELIGIBLE PREFERRED DRUG LIST Drug Name aspirin low dose aspirin low dose aspirin aspirin aspirin bufpirin butalbital/acetaminophen/caffeine butalbital/acetaminophen/caffeine butalbital/acetaminophen/caffeine butalbital/acetaminophen butalbital/asa/caffeine butalbital/aspirin/caffeine children,s non-aspirin pain relief children,s non-aspirin pain reliever children,s non-aspirin children,s pain reliever children,s silapap children,s tactinal ecpirin ed-apap enteric coated aspirin ibuprofen junior strength ibuprofen ibuprofen infants mapap mapap arthritis pain mapap mapap mapap maxapap maximum strength maxapap regular strength non-aspirin extra strength non-aspirin pain relief non-aspirin pain & fever childrens Dosage Form Tablet Tablet Enteric Coated Tablet Chewable Tablet Enteric Coated Tablet Tablet Capsule Tablet Tablet Tablet Capsule Tablet Chewable Chewable Chewable Chewable Liquid Chewable Enteric Coated Tablet Liquid Enteric Coated Tablet Chewable Suspension Tablet Suspension Control Release Tablet Capsule Chewable Tablet Tablet Tablet Tablet Tablet Tablet Solution Coverage Details: PA= Prior Authorization, QL= Quantity Limit Page 3 of 17 Coverage Details QL (186.00 per 31 days) QL (186.00 per 31 days) QL (124.00 per 31 days) QL (186.00 per 31 days) QL (279.00 per 31 days) QL (186.00 per 31 days) QL (279.00 per 31 days QL (279.00 per 31 days) QL (279.00 per 31 days) QL (279.00 per 31 days) ‘OHANA DUAL ELIGIBLE PREFERRED DRUG LIST Drug Name pain relief extra strength pain relief pharbetol extra strength pharbetol q-pap tactinal extra strength tactinal tri-buffered aspirin Anticonvulsants clonazepam odt clonazepam Anxiolytics, Sedatives, and Hypnotics acetaminophen pm alprazolam er alprazolam odt alprazolam xr alprazolam chlordiazepoxide hcl clorazepate dipotassium compoz compoz diazepam diazepam estazolam flurazepam hcl headache pm lorazepam lorazepam lorazepam mapap pm nytol oxazepam pain relief pm extra strength pain reliever pm phenobarbital sodium phenobarbital phenobarbital phenobarbital 15mg phenobarbital 16.2mg simply sleep sleep tabs Dosage Form Tablet Tablet Tablet Tablet Tablet Tablet Tablet Tablet Dispersible Tablet Tablet Tablet Tablet (24 hour) Dispersible Tablet Tablet (24 hour) Tablet Capsule Tablet Capsule Tablet Solution Tablet Tablet Capsule Tablet Concentration Solution Tablet Tablet Tablet Capsule Tablet Tablet Solution Elixir Tablet Tablet Tablet Tablet Tablet Coverage Details: PA= Prior Authorization, QL= Quantity Limit Page 4 of 17 Coverage Details QL (186.00 per 31 days) QL (186.00 per 31 days) QL (186.00 per 31 days) QL (279.00 per 31 days) QL (279.00 per 31 days) QL (186.00 per 31 days) QL (279.00 per 31 days) QL (2000.00 per 31 days) QL (310.00 per 31 days) QL (383.00 per 31 days) ‘OHANA DUAL ELIGIBLE PREFERRED DRUG LIST Drug Name sleep-tabs sominex maximum strength sominex temazepam tetra-formula nighttime sleep aid triazolam Contraceptives Dosage Form Tablet Tablet Tablet Capsule Tablet Tablet ENCARE ENCARE VCF VAGINAL CONTRACEPTIVE FOAM Devices ACE AEROSOL CLOUD ENHANCER AEROCHAMBER MV AEROCHAMBER PLUS/LARGE MASK AEROCHAMBER PLUS/MASK AEROCHAMBER PLUS/SMALL MASK AEROCHAMBER PLUS AEROCHAMBER Z-STAT PLUS VALVED HOLDING CHAMBER W/FLOW VU AEROCHAMBER Z-STAT PLUS/FLOWSIGNAL AEROCHAMBER/FLOWSIGNAL EASIVENT IN-CHECK DIAL INSPIRATORYFLOW TRAINER INHALER COMPANIONS MICROCHAMBER MICROSPACER OPTICHAMBER ADVANTAGE OPTIHALER MDI DRUG DELIVERY SYSTEM OPTIHALER PFLEX POCKET CHAMBER POCKET SPACER THRESHOLD IMT THRESHOLD PEP WATCHHALER WINDMILL TRAINER Diagnostic Agents Diabetes Mellitus ACCU-CHEK COMFORT CURVE TEST STRIPS ACCU-CHEK COMPACT TEST DRUM Gel Suppository Foam Device Device Device Device Device Device Device QL (2.00 per 31 days) QL (2.00 per 31 days QL (2.00 per 31 days QL (2.00 per 31 days QL (2.00 per 31 days QL (2.00 per 31 days QL (2.00 per 31 days Device Device Device Device Device Device Device Device Device Device Device Device Device Device Device Device Device QL (2.00 per 31 days QL (2.00 per 31 days QL (2.00 per 31 days QL (2.00 per 31 days QL (2.00 per 31 days QL (2.00 per 31 days QL (2.00 per 31 days QL (2.00 per 31 days QL (2.00 per 31 days QL (2.00 per 31 days QL (2.00 per 31 days QL (2.00 per 31 days QL (2.00 per 31 days QL (2.00 per 31 days QL (2.00 per 31 days QL (2.00 per 31 days QL (2.00 per 31 days Strip Strip QL (100.00 per 31 days) QL (102.00 per 31 days) Coverage Details: PA= Prior Authorization, QL= Quantity Limit Page 5 of 17 Coverage Details ‘OHANA DUAL ELIGIBLE PREFERRED DRUG LIST Drug Name Electrolytic, Caloric, and Water Balance Irrigating Solutions curity sterile saline sodium chloride Replacement Preparations calcarb 600/vitamin d calcarb 600 cal-carb forte calci-chew calcio del mar calcium + d calcium 600/vitamin d calcium 600 calcium 600-d calcium carbonate/vitamin d calcium carbonate calcium carbonate calcium high potency + vitamin d calcium high potency calcium oyster shell calcium/vitamin d calcium calcium-carb 600 + d calcium-carb 600 caltrate 600+D caltrate 600 chelated zinc chewable calcium liquid calcium/vitamin d mag64 mag-delay magnacaps magnesium mag-sr plus calcium mag-sr MAG-TAB SR Dosage Form Solution Solution Tablet Tablet Tablet Chewable Tablet Tablet Tablet Tablet Tablet Tablet Suspension Tablet Tablet Tablet Tablet Tablet Tablet Tablet Tablet Tablet Tablet Tablet Chewable Capsule Control Release Tablet Control Release Tablet Capsule Tablet Control Release Tablet Control Release Tablet Control Release Tablet Coverage Details: PA= Prior Authorization, QL= Quantity Limit Page 6 of 17 Coverage Details QL (1000.00 per 31 days) QL (1000.00 per 31 days) ‘OHANA DUAL ELIGIBLE PREFERRED DRUG LIST Drug Name oralyte freezer pops orazinc os-cal 500 + d os-cal 500 oysco 500+d oysco 500 oysco d oyst-cal d oyst-cal-d 500 oyster calcium/vitamin d oyster shell calcium + d oyster shell calcium + vitamin d oyster shell calcium 500 + d oyster shell calcium/d oyster shell calcium/vitamin d oyster shell/vitamin d oystercal oyster-d PHOS-NAK POWDER CONCENTRATE rehydralyte revital freezer pops revital liquid squeezers zinc gluconate zinc methionate zinc picolinate zinc sulfate zinc sulfate zinc-220 zinc Eye, Ear, Nose & Throat Preparations Antiallergic Agents alaway cromolyn sodium ketotifen fumarate Anti-infectives auraphene-b auro eardrops ear drops earwax removal aid ear wax drops e-r-o ear drops e-r-o ear wax removal system Dosage Form Solution Capsule Tablet Chewable Tablet Tablet Tablet Tablet Tablet Tablet Tablet Tablet Tablet Tablet Tablet Tablet Tablet Tablet Pack Solution Solution Solution Tablet Capsule Tablet Capsule Tablet Capsule Tablet Solution Aerosol Solution Solution Solution Solution Solution Solution Solution Coverage Details: PA= Prior Authorization, QL= Quantity Limit Page 7 of 17 Coverage Details ‘OHANA DUAL ELIGIBLE PREFERRED DRUG LIST Drug Name h.e.a.r. murine ear murine for ear wax removal system otix thera-ear EENT Drugs, Miscellaneous altamist artificial tears artificial tears ayr deep sea nasal spray humist hypotears liquitears little noses saline nasal moist na-zone ocean for kids polyvinyl alcohol saline mist saline nasal spray sea soft nasal mist tears again tears again ultra fresh pm Gastrointestinal Drugs Antacids and Adsorbents acid gone actidose/sorbitol actidose-aqua alamag-plus alcalak almacone almacone-ii double strength aluminum hydroxide antacid anti-gas maximum strength antacid anti-gas regular strength antacid anti-gas antacid extra strength anti-gas antacid i antacid iii Dosage Form Solution Solution Solution Solution Solution Solution Ointment Solution Solution Solution Solution Solution Solution Solution Solution Solution Solution Solution Solution Solution Solution Ointment Solution Ointment Chewable Liquid Liquid Chewable Chewable Suspension Suspension Suspension Suspension Suspension Suspension Suspension Suspension Suspension Coverage Details: PA= Prior Authorization, QL= Quantity Limit Page 8 of 17 Coverage Details QL (15.00 per 31 days) ‘OHANA DUAL ELIGIBLE PREFERRED DRUG LIST Drug Name antacid ultra strength antacid antacid calcium antacid extra strength calcium antacid calcium carbonate calcium carbonate cal-gest antacid charcoal activate charcoal activated charcoal charcocaps chewable antacid geri-lanta kerr insta-char liquid antacid extra strength little remedies poison treatment maalox advanced maximum strength maalox advanced maalox max maalox multi symptom maximum strength maalox regular strength MAALOX magnesium-oxide mag-oxide mi-acid milantex extra strength milantex mintox plus sodium bicarbonate titralac Antidiarrhea Agents anti-diarrheal bismatrol bismatrol bismuth diotame kaopectate extra strength kaopectate kao-tin loperamide a-d Dosage Form Suspension Chewable Suspension Chewable Chewable Chewable Tablet Chewable Capsule Tablet Capsule Capsule Chewable Suspension Liquid Suspension Suspension Suspension Suspension Suspension Suspension Suspension Chewable Tablet Tablet Chewable Suspension Suspension Chewable Tablet Chewable Liquid Chewable Suspension Chewable Chewable Suspension Suspension Suspension Tablet Coverage Details: PA= Prior Authorization, QL= Quantity Limit Page 9 of 17 Coverage Details ‘OHANA DUAL ELIGIBLE PREFERRED DRUG LIST Drug Name loperamide hcl pink bismuth regular strength pink bismuth pink bismuth stomach relief plus stomach relief stomach relief Antiemetics meclizine hcl Antiflatulents mi-acid gas relief mytab gas simethicone Antiulcer Agents and Acid Suppressants acid reducer cimetidine acid reducer cimetidine famotidine heartburn relief maximum strength heartburn relief omeprazole PEPCID AC MAXIMUM STRENGTH ranitidine 75 ranitidine acid reducer Cathartics and Laxatives bisac-evac bisac-evac bisacodyl ec bisacodyl biscolax carters little pills citrate of magnesia citroma correct correctol extra gentle correctol Dosage Form Liquid Suspension Chewable Suspension Suspension Chewable Suspension Tablet Chewable Chewable Chewable Tablet Tablet Tablet Tablet Tablet Tablet Enteric Coated Tablet Tablet Tablet Tablet Suppository Enteric Coated Tablet Enteric Coated Tablet Suppository Suppository Enteric Coated Tablet Solution Solution Enteric Coated Tablet Capsule Enteric Coated Coverage Details: PA= Prior Authorization, QL= Quantity Limit Page 10 of 17 Coverage Details ‘OHANA DUAL ELIGIBLE PREFERRED DRUG LIST Drug Name d.o.s. diocto diocto disposable enema docqlace doc-q-lax docu soft docu docusate calcium docusate sodium/senna docusate sodium docusate sodium docusil dok plus dok dok dss ducodyl dulcolax milk of magnesia dulcolax stool softener enema ready-to-use enemeez mini ex-lax ultra EX-LAX feenamint fiber laxative fiber tabs fiber therapy fibergen fiber-lax fleet laxative gentle laxative kao-tin konsyl fiber KONSYL Dosage Form Tablet Capsule Liquid Syrup Enema Capsule Tablet Capsule Liquid Capsule Tablet Capsule Tablet Capsule Tablet Capsule Tablet Capsule Enteric Coated Tablet Suspension Capsule Enema Enema Enteric Coated Tablet Chewable Enteric Coated Tablet Tablet Tablet Powder Tablet Tablet Enteric Coated Tablet Enteric Coated Tablet Capsule Tablet Pack Coverage Details: PA= Prior Authorization, QL= Quantity Limit Page 11 of 17 Coverage Details ‘OHANA DUAL ELIGIBLE PREFERRED DRUG LIST Drug Name laxa basic 250 laxa basic laxmar magic bullets magnesium citrate metafiber metamucil multihealth fiber metamucil original texture metamucil smooth texture fiber singles metamucil smooth texture sugar free metamucil smooth texture milk of magnesia natural fiber therapy natural senna laxative natural vegetable fiber peri-colace phosphate laxative reguloid reguloid senexon senexon senna lax senna laxative senna maximum strength senna plus senna s senna smooth senna/docusate sodium senna senna sennacon senna-gen senna-lax sennalax-s senna-s senna-tabs senna-time s senna-time senno SENOKOT S silace Dosage Form Capsule Capsule Powder Suppository Solution Powder Powder Powder Pack Powder Powder Suspension Powder Tablet Powder Tablet Solution Capsule Powder Liquid Tablet Tablet Tablet Tablet Tablet Tablet Tablet Tablet Syrup Tablet Tablet Tablet Tablet Tablet Tablet Tablet Tablet Tablet Tablet Tablet Liquid Coverage Details: PA= Prior Authorization, QL= Quantity Limit Page 12 of 17 Coverage Details ‘OHANA DUAL ELIGIBLE PREFERRED DRUG LIST Drug Name silace sof-lax sorbitol stimulant laxative Dosage Form Syrup Capsule Solution Enteric Coated Tablet Capsule Capsule Capsule Enteric Coated Tablet stool softener surfak sur-q-lax womens laxative Emetics IPECAC GI Drugs, Miscellaneous XENICAL Hormones and Synthetic Substitutes Antihypoglycemic Agents BD GLUCOSE GLUCOSE ULTILET GLUCOSE Miscellaneous Therapeutic Agents Other Miscellaneous Therapeutic Agents Gelatin Respiratory Tract Agents Expectorants chest congestion relief guaifenesin 200mg refenesen 400 robafen Mucolytic Agents sodium chloride Skin and Mucous Membrane Preparations Anti-infectives a-200 acne medication 10 acne-clear bacitracin zinc bacitracin/neomycin/polymyxin bacitracin benzoyl peroxide benzoyl peroxide clean & clear persa-Gel extra strength Syrup Capsule Chewable Chewable Chewable Capsule Tablet Tablet Tablet Syrup Nebulizer Aerosol Gel Gel Ointment Ointment Ointment Gel Lotion Gel Coverage Details: PA= Prior Authorization, QL= Quantity Limit Page 13 of 17 Coverage Details PA ‘OHANA DUAL ELIGIBLE PREFERRED DRUG LIST Drug Name clean & clear persa-Gel maximum strength clearplex v clearskin clotrimazole anti-fungal clotrimazole clotrimazole denorex daily double antibiotic miconazole 3 combo pack miconazole 7 miconazole 7 miconazole nitrate miconazole nitrate miconazole neoporacin NEUTROGENA ON-THE-SPOT ACNE TREATMENT operand povidone/iodine panoxyl wash permethrin povidone-iodine prep swab povidone-iodine povidone-iodine povidone-iodine terbinafine hcl tolnaftate 1% antifungal tolnaftate tolnaftate tolnaftate triple antibiotic Anti-inflammatory Agents hydrocortisone maximum strength plus 12 moisturizers hydrocortisone maximum strength hydrocortisone/aloe hydrocortisone hydrocortisone hydroskin preparation h hydrocortisone Antipruritics and Local Anesthetics allergy cream anti-itch maximum strength benadryl itch stopping Dosage Form Gel Gel Cream Cream Cream Solution Shampoo Ointment Kit Cream Suppository Cream Suppository Cream Ointment Cream Solution Liquid Lotion Swab Ointment Solution Swab Cream Cream Cream Powder Solution Ointment Cream Cream Cream Cream Ointment Cream Cream Cream Cream Gel Coverage Details: PA= Prior Authorization, QL= Quantity Limit Page 14 of 17 Coverage Details QL (60.00 per 31 days) ‘OHANA DUAL ELIGIBLE PREFERRED DRUG LIST Drug Name itch relief phenazopyridine hcl Cell Stimulants and Proliferants formulation r hem-prep Emollients, Demulcents, and Protectants preparation h Keratoplastic Agents beta care betatar Gel ELTA TAR ionil-t mg217 medicated tar shampoo neutrogena t/Gel extra strength pc-tar tera-Gel tar Sunscreen Agents COPPERTONE SUNBLOCK SPF15 NEUTROGENA MOISTURE SPF15UNTINTED Vitamins Multivitamin Preparations centamin centavite a-z complete multivitamin/minerals centavite cerovite advanced formula certavite/antioxidants daily multiple vitamins daily vite formula twenty-one gerivite complete golden age vitamin/minerals multi-day multi-vit/fluoride multivitamin & mineral multi-vitamin/fluoride multi-vitamin nephronex once daily one-daily multi vitamins renal rena-vite rx reno caps Dosage Form Cream Tablet Ointment Suppository Pads Shampoo Cream Shampoo Shampoo Shampoo Shampoo Shampoo Lotion Lotion Liquid Tablet Liquid Tablet Liquid Tablet Tablet Tablet Tablet Liquid Tablet Solution Liquid Chewable Tablet Tablet Tablet Tablet Capsule Tablet Capsule Coverage Details: PA= Prior Authorization, QL= Quantity Limit Page 15 of 17 Coverage Details ‘OHANA DUAL ELIGIBLE PREFERRED DRUG LIST Drug Name super nu-thera thera vital m thera therabasic-m THERAPEUTIC LIQUID therapeutic therapeutic-m thera-tabs therems m therems total formula 3 vitamins for hair Vitamin B Complex cyanocobalamin endur-acin folic acid niacin sr niacin sr niacin td niacin td niacin tr niacin tr niacin niacin-50 nicotinic acid sr slo-niacin vitamin b-12 cr vitamin b-12 tr vitamin b-12 vitamin b-12 Dosage Form Tablet Tablet Tablet Tablet Solution Tablet Tablet Tablet Tablet Tablet Tablet Tablet Solution Control Release Tablet Tablet Control Release Capsule Control Release Tablet Control Release Capsule Control Release Tablet Control Release Capsule Control Release Tablet Tablet Tablet Control Release Capsule Control Release Tablet Control Release Tablet Control Release Tablet Sublingual Tablet Coverage Details: PA= Prior Authorization, QL= Quantity Limit Page 16 of 17 Coverage Details ‘OHANA DUAL ELIGIBLE PREFERRED DRUG LIST Drug Name Vitamin C ascorbic acid ascorbic acid vitamin c vitamin c vitamin c Vitamin D calciferol vitamin d3 vitamin d3 vitamin d vitamin d vitamin d-400 Vitamin K Activity MEPHYTON Dosage Form Chewable Tablet Chewable Syrup Tablet Solution Capsule Tablet Capsule Tablet Tablet Tablet Coverage Details: PA= Prior Authorization, QL= Quantity Limit Page 17 of 17 Coverage Details QL (4.00 per 31 days)
Related documents