Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Ohana Health Plan
Document related concepts
no text concepts found
Transcript
2011 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 (01/01/2011) ‘OHANA DUAL ELIGIBLE PREFERRED DRUG LIST Drug Name Analgesics acetamin acetaminophen pm acetaminophen acetaminophen acetaminophen acetaminophen acetaminophen acetaminophen apap extra strength apap butalbital /acetaminophen /caffeine butalbital /apap /caffeine butalbital/apap/caffeine childrens non-aspirin pain relief childrens non-aspirin pain reliever childrens non-aspirin childrens pain reliever childrens pain/fever childrens silapap childrens tactinal ed-apap headache pm infants mapap mapap arthritis pain mapap pm mapap mapap masophen maxapap maximum strength maxapap regular strength non-aspirin extra strength non-aspirin pain relief non-aspirin pain relief extra strength pain relief pm extra strength pain relief pain reliever pm pharbetol extra strength pharbetol Dosage Form Coverage Details Tablet Tablet Capsule Chewable Elixir Solution Suppository Tablet Tablet Tablet Tablet Tablet Capsule Chewable Chewable Chewable Chewable Suspension Liquid Chewable Liquid Tablet Suspension Control Release Tablet Tablet Chewable Tablet Tablet Tablet Tablet Tablet Tablet Tablet Tablet Tablet Tablet Tablet Tablet Tablet Page 1 of 23 Coverage Details: PA- Prior Authorization; QL= Quantity Limit ‘OHANA DUAL ELIGIBLE PREFERRED DRUG LIST Drug Name q-pap extra strength q-pap tactinal extra strength tactinal tylophen un-aspirin Nonsteroidal Anti-inflammatory Drugs aspirin childrens aspirin ec low dose aspirin ec low strength aspirin ec aspirin low dose aspirin low dose aspirin aspirin aspirin aspir-trin bufpirin butalbital /aspirin /caffeine butalbital/asa/caffeine ecpirin enteric coated aspirin ibuprofen junior strength ibuprofen ibuprofen tri-buffered aspirin triple buffered aspirin Anesthetics Local Anesthetics fleet relief w/applicator fleet relief phenazopyridine hcl Antibacterials Dosage Form Coverage Details Tablet Tablet Tablet Tablet Tablet Tablet Chewable Enteric Coated Tablet Enteric Coated Tablet Enteric Coated Tablet Tablet Enteric Coated Tablet Chewable Tablet Enteric Coated Tablet Enteric Coated Tablet Tablet Tablet Capsule Enteric Coated Tablet Enteric Coated Tablet Chewable Suspension Tablet Tablet Tablet Ointment Ointment Tablet Page 2 of 23 Coverage Details: PA- Prior Authorization; QL= Quantity Limit ‘OHANA DUAL ELIGIBLE PREFERRED DRUG LIST Drug Name Antibacterials, Other bacitracin /neomycin /polymyxin bacitracin zinc bacitracin denorex daily double antibiotic neoporacin operand povidone/iodine povidone-iodine prep swab povidone-iodine povidone-iodine povidone-iodine triple antibiotic Anticonvulsants Anticonvulsants, Other clonazepam orally disintegrating clonazepam Antidotes, Deterrents, and Toxicologic Agents Antidotes actidose /sorbitol actidose-aqua activated charcoal CHARCOAL ACTIVATED charcoal activated charcoal charcocaps IPECAC kerr insta-char little remedies poison treatment Dosage Form Coverage Details Ointment Ointment Ointment Shampoo Ointment Ointment Solution Swab Ointment Solution Swab Ointment Chewable Dispersible Tablet Tablet Liquid Liquid Capsule Capsule Tablet Capsule Capsule Syrup Liquid Suspension for Reconstitution Deterrents nicotine polacrilex Gum nicotine Patch (24 hour) Antiemetics aler-cap aler-dryl alertab altaryl altaryl Capsule Tablet Tablet Elixir Syrup Page 3 of 23 Coverage Details: PA- Prior Authorization; QL= Quantity Limit QL (960.00 per 365 days) QL (93.00 per 365 days) ‘OHANA DUAL ELIGIBLE PREFERRED DRUG LIST Drug Name anti-hist allergy anti-hist banophen banophen banophen complete allergy medication complete allergy medicine complete allergy relief diphenhist diphenhist diphenhist diphenhydramine hcl diphenhydramine hcl dormin genahist meclizine hcl nervine pharbedryl q-dryl q-dryl quenalin scot-tussin allergy relief formula siladryl allergy silphen cough simply allergy total allergy medicine total allergy Antifungals clotrimazole anti-fungal clotrimazole clotrimazole miconazole 3 combo pack miconazole 7 miconazole 7 miconazole nitrate miconazole nitrate miconazole terbinafine hcl tolnaftate 1% antifungal tolnaftate tolnaftate Dosage Form Coverage Details Tablet Capsule Capsule Liquid Tablet Tablet Capsule Tablet Capsule Liquid Tablet Capsule Tablet Capsule Capsule Tablet Tablet Capsule Capsule Liquid Syrup Liquid Liquid Syrup Tablet Liquid Tablet Cream Cream Solution Kit Cream Suppository Cream Suppository Cream Cream Cream Cream Powder Page 4 of 23 Coverage Details: PA- Prior Authorization; QL= Quantity Limit ‘OHANA DUAL ELIGIBLE PREFERRED DRUG LIST Drug Name tolnaftate Antiparasitics Pediculicides/ Scabicides a-200 permethrin Anxiolytics Anxiolytics, Other alprazolam er alprazolam xr alprazolam chlordiazepoxide hcl clonazepam clorazepate dipotassium diazepam diazepam lorazepam lorazepam oxazepam Blood Glucose Regulators Glycemic Agents BD GLUCOSE GLUCOSE HY-VEE GLUCOSE ULTILET GLUCOSE Cardiovascular Agents Dyslipidemics endur-acin niacin cr niacin sr niacin sr niacin td Dosage Form Coverage Details Solution Aerosol Lotion Tablet (24 hour) Tablet (24 hour) Tablet Capsule Tablet Tablet Solution Tablet Solution Tablet Capsule Chewable Chewable Chewable Chewable Control Release Tablet Control Release Capsule Control Release Capsule Control Release Tablet Control Release Capsule Page 5 of 23 Coverage Details: PA- Prior Authorization; QL= Quantity Limit QL (60.00 per 31 days) ‘OHANA DUAL ELIGIBLE PREFERRED DRUG LIST Drug Name niacin td Dosage Form Coverage Details Control Release Tablet Control Release Capsule Control Release Tablet Tablet Tablet Control Release Capsule Control Release Tablet niacin tr niacin tr niacin niacin-50 nicotinic acid sr slo-niacin Central Nervous System Agents butalbital /aspirin /caffeine butalbital/asa/caffeine Dermatological Agents acne medication 10 acne-clear allergy cream anti-itch maximum strength benadryl itch stopping benzoyl peroxide benzoyl peroxide beta care betatar gel clean & clear persa-gel extra strength clean & clear persa-gel maximum strength clearplex v clearskin COPPERTONE SUNBLOCK SPF15 del-aqua denorex daily doak tar ELTA TAN ELTA TAR ionil-t itch relief mg217 medicated tar shampoo NEUTROGENA MOISTURE SPF15UNTINTED neutrogena on-the-spot acne treatment Tablet Capsule Gel Gel Cream Cream Gel Gel Lotion Shampoo Gel Gel Gel Cream Lotion Cream Shampoo Shampoo Cream Cream Shampoo Cream Shampoo Lotion Gel Page 6 of 23 Coverage Details: PA- Prior Authorization; QL= Quantity Limit ‘OHANA DUAL ELIGIBLE PREFERRED DRUG LIST Drug Name neutrogena t/gel extra strength panoxyl wash pc-tar preparation h tera-gel tar Gastrointestinal Agents Gastrointestinal Agents, Other acid gone alamag-plus alcalak almacone almacone-ii double strength alternagel aluminum hydroxide antacid anti-gas maximum strength antacid anti-gas regular strength antacid anti-gas antacid extra strength anti-gas antacid i antacid iii antacid ultra strength antacid antacid anti-diarrheal bisac-evac bisac-evac bisacodyl ec bisacodyl biscolax bismatrol bismatrol bismuth bufpirin calcium antacid extra strength calcium antacid calcium carbonate calcium carbonate cal-gest antacid carters little pills Dosage Form Coverage Details Shampoo Liquid Shampoo Pads Shampoo Chewable Chewable Chewable Suspension Suspension Suspension Suspension Suspension Suspension Suspension Suspension Suspension Suspension Suspension Chewable Suspension Liquid Suppository Enteric Coated Tablet Enteric Coated Tablet Suppository Suppository Chewable Suspension Chewable Tablet Chewable Chewable Chewable Tablet Chewable Enteric Coated Page 7 of 23 Coverage Details: PA- Prior Authorization; QL= Quantity Limit ‘OHANA DUAL ELIGIBLE PREFERRED DRUG LIST Drug Name chewable antacid chooz citrate of magnesia citroma correct corrective laxative correctol extra gentle correctol d.o.s. diocto diocto dioctyl s.s. diotame disposable enema doc-q-lace doc-q-lace doc-q-lace doc-q-lax docu soft docu docusate calcium docusate sodium w/sennosides docusate sodium docusate sodium docusil docusoft-s dok plus dok dok dss ducodyl dulcolax milk of magnesia dulcolax stool softener enema disposable ENEMEEZ MINI ex-lax ultra Dosage Form Coverage Details Tablet Chewable Chewable Solution Solution Enteric Coated Tablet Enteric Coated Tablet Capsule Enteric Coated Tablet Capsule Liquid Syrup Capsule Chewable Enema Capsule Liquid Syrup Tablet Capsule Liquid Capsule Tablet Capsule Tablet Capsule Capsule Tablet Capsule Tablet Capsule Enteric Coated Tablet Suspension Capsule Enema Enema Enteric Coated Page 8 of 23 Coverage Details: PA- Prior Authorization; QL= Quantity Limit ‘OHANA DUAL ELIGIBLE PREFERRED DRUG LIST Drug Name EX-LAX fast dissolve antacid feenamint fiber laxative fiber Tablet fiber therapy fiber therapy fibergen fiber-lax fibertab fleet laxative fleet laxative foaming antacid formulation r gentle laxative geri-lanta glycerin adult hem-prep imogen IPECAC kaopectate extra strength kaopectate stool softener kaopectate kao-tin kao-tin konsyl fiber KONSYL laxa basic 250 laxa basic laxmar liquid antacid extra strength loperamide a-d loperamide hcl maalox advanced maximum strength maalox advanced maalox max maalox multi symptom maximum strength Dosage Form Coverage Details Tablet Chewable Chewable Enteric Coated Tablet Tablet Tablet Capsule Powder Tablet Tablet Tablet Suppository Enteric Coated Tablet Chewable Ointment Enteric Coated Tablet Suspension Suppository Suppository Liquid Syrup Suspension Capsule Suspension Capsule Suspension Tablet Pack Capsule Capsule Powder Suspension Tablet Liquid Suspension Suspension Suspension Suspension Page 9 of 23 Coverage Details: PA- Prior Authorization; QL= Quantity Limit ‘OHANA DUAL ELIGIBLE PREFERRED DRUG LIST Drug Name maalox regular strength magic bullets magnesium oxide mag-oxide metafiber metamucil multihealth fiber metamucil original texture metamucil smooth texture fiber singles metamucil smooth texture sugar free metamucil smooth texture mi-acid gas relief mi-acid milantex extra strength milantex milk of magnesia mintox extra strength mintox plus mytab gas natural fiber therapy natural psyllium fiber natural senna laxative natural vegetable fiber natural vegetable laxative peptic relief peri-colace phillips liqui-gels phillips milk of magnesia phillips milk of magnesia regular phosphate laxative pink bismuth regular strength pink bismuth pink bismuth reguloid reguloid senexon senexon senna lax senna laxative senna maximum strength senna plus senna s Dosage Form Coverage Details Suspension Suppository Tablet Tablet Powder Powder Powder Pack Powder Powder Chewable Chewable Suspension Suspension Suspension Suspension Chewable Chewable Powder Powder Tablet Powder Tablet Suspension Tablet Capsule Suspension Suspension Solution Suspension Chewable Suspension Capsule Powder Liquid Tablet Tablet Tablet Tablet Tablet Tablet Page 10 of 23 Coverage Details: PA- Prior Authorization; QL= Quantity Limit ‘OHANA DUAL ELIGIBLE PREFERRED DRUG LIST Drug Name senna smooth senna senna sennacon senna-docusate sodium senna-ex senna-gen senna-lax sennalax-s senna-max senna-s senna-Tablet senna-time s senna-time senno SENOKOT S sen-o-Tablet silace silace simethicone sodium bicarbonate sof-lax stimulant laxative stomach relief plus stomach relief stomach relief stool softener sur-q-lax titralac trial ag trial antacid womens laxative XENICAL Histamine2 (H2) Blocking Agents acid reducer cimetidine acid reducer cimetidine famotidine heartburn relief maximum strength Dosage Form Coverage Details Tablet Syrup Tablet Tablet Tablet Tablet Tablet Tablet Tablet Tablet Tablet Tablet Tablet Tablet Tablet Tablet Tablet Liquid Syrup Chewable Tablet Capsule Enteric Coated Tablet Suspension Chewable Suspension Capsule Capsule Chewable Chewable Chewable Enteric Coated Tablet Capsule Tablet Tablet Tablet Tablet Tablet Page 11 of 23 Coverage Details: PA- Prior Authorization; QL= Quantity Limit PA ‘OHANA DUAL ELIGIBLE PREFERRED DRUG LIST Drug Name heartburn relief pepcid ac maximum strength ranitidine 75 ranitidine acid reducer Proton Pump Inhibitors OMEPRAZOLE Genitourinary Agents Genitourinary Agents, Other encare ENCARE phenazopyridine hcl VCF VAGINAL CONTRACEPTIVE FOAM Dosage Form Coverage Details Tablet Tablet Tablet Tablet Enteric Coated Tablet Gel Suppository Tablet Foam Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal) Glucocorticoids/ Mineralocorticoids hydrocortisone /aloe hydrocortisone maximum strength plus 12 moisturizers hydrocortisone maximum strength hydrocortisone plus 12 hydrocortisone hydrocortisone preparation h hydrocortisone Miscellaneous Therapeutic Agents curity sterile saline gelatin sodium chloride 0.9% vial sodium chloride 0.9% irrigation SORBITOL Ophthalmic Agents Ophthalmic Agents, Other artificial tears artificial tears hypotears liquitears polyvinyl alcohol tears again tears again ultra fresh pm Ophthalmic Anti-allergy Agents alaway ketotifen fumarate Cream Cream Cream Cream Cream Ointment Cream Solution Capsule Solution Solution Solution Ointment Solution Solution Solution Solution Ointment Solution Ointment Solution Solution Page 12 of 23 Coverage Details: PA- Prior Authorization; QL= Quantity Limit ‘OHANA DUAL ELIGIBLE PREFERRED DRUG LIST Drug Name Otic Agents auraphene-b auro eardrops ear drops earwax removal aid ear wax drops e-r-o ear drops e-r-o ear wax removal system h.e.a.r. murine ear murine for ear wax removal system otix thera-ear Respiratory Tract Agents Antihistamines acetaminophen pm aler-cap aler-dryl alertab aller-chlor aller-chlor allergy relief childrens allergy relief allergy tablets allergy altaryl altaryl anti-hist allergy anti-hist banophen banophen banophen bromaline dm bromaline bromhist-dm bromphenex dm bromplex-dm brotapp dm brotapp ceron-dm ceron-dm cetirizine hcl childrens allergy Dosage Form Coverage Details Solution Solution Solution Solution Solution Solution Solution Solution Solution Solution Solution Tablet Capsule Tablet Tablet Syrup Tablet Liquid Tablet Tablet Tablet Elixir Syrup Tablet Capsule Capsule Liquid Tablet Elixir Solution Liquid Syrup Syrup Liquid Liquid Syrup Liquid Syrup Page 13 of 23 Coverage Details: PA- Prior Authorization; QL= Quantity Limit ‘OHANA DUAL ELIGIBLE PREFERRED DRUG LIST Drug Name cetirizine hcl childrens cetirizine hcl cetirizine hcl chlorhist chlorphen chlorpheniramine maleate chlor-tripolon complete allergy medication complete allergy medicine complete allergy relief compoz compoz c-phen dm c-phen dm de-chlor dm de-chlor dr dex pc diabetic tussin allergy DIHYDRO-CP ENDACOF-DM diphenhist diphenhist diphenhist diphenhydramine hcl diphenhydramine hcl dormin genahist headache pm histadec dm hydrocodone polistirex and chlorpheniramine polistirex loratadine hives relief loratadine loratadine-d 24hr mapap pm nervine nytol pain relief pm extra strength pain reliever pm pd-cof pediahist dm Dosage Form Coverage Details Solution Chewable Tablet Tablet Tablet Tablet Syrup Tablet Capsule Tablet Capsule Tablet Liquid Syrup Syrup Syrup Syrup Syrup Syrup Syrup Capsule Liquid Tablet Capsule Tablet Capsule Capsule Tablet Syrup Liquid Solution Tablet Tablet (24 hour) Tablet Tablet Tablet Tablet Tablet Syrup Liquid Page 14 of 23 Coverage Details: PA- Prior Authorization; QL= Quantity Limit ‘OHANA DUAL ELIGIBLE PREFERRED DRUG LIST Drug Name pharbedryl promethazine /codeine promethazine vc/codeine pse brom dm q-dryl q-dryl q-tapp dm q-tapp quenalin rondex-dm reme tussin dm scot-tussin allergy relief formula siladryl allergy sildec pe-dm sildec-dm silphen cough simply allergy simply sleep sleep Tablet sleep-ettes d sleep-Tablet sominex maximum strength sominex su-tuss dm total allergy medicine total allergy Mast Cell Stabilizers cromolyn sodium Respiratory Tract Agents, Other altamist ayr benzonatate bromaline dm bromaline bromphenex dm brotapp dm brotapp ceron-dm cheratussin ac cheratussin dac chest congestion relief Dosage Form Coverage Details Capsule Syrup Syrup Syrup Capsule Liquid Elixir Elixir Syrup Syrup Syrup Liquid Liquid Syrup Syrup Syrup Tablet Tablet Tablet Tablet Tablet Tablet Tablet Elixir Liquid Tablet Aerosol Solution Solution Capsule Elixir Solution Syrup Liquid Liquid Syrup Syrup Solution Tablet Page 15 of 23 Coverage Details: PA- Prior Authorization; QL= Quantity Limit ‘OHANA DUAL ELIGIBLE PREFERRED DRUG LIST Drug Name CONGESTAC coughtab c-phen dm c-phen dm de-chlor dm de-chlor dr deep sea nasal spray despec dex pc DIHYDRO-CP fenesin ir gani-tuss dm nr guaifenesin guaifenesin-dm humist little noses saline loratadine-d 24hr mucus relief mytussin ac nasal moist nasal moisturizer na-zone ocean for kids organ-i nr pediahist dm promethazine /codeine promethazine vc/codeine pse brom dm PSEUDOEPHEDRINE /GUAIFENESIN pseudoephedrine hcl pseudoephedrine hcl pv chest congestion relief pv tussin pe q-tapp dm q-tapp q-tussin dm ra mucus relief expectorant refenesen 400 reme tussin dm RESCON-GG Dosage Form Coverage Details Tablet Tablet Liquid Syrup Syrup Syrup Solution Liquid Syrup Syrup Tablet Liquid Tablet Syrup Solution Solution Tablet (24 hour) Tablet Syrup Solution Solution Solution Solution Tablet Liquid Syrup Syrup Syrup Syrup Syrup Tablet Tablet Liquid Elixir Elixir Syrup Tablet Tablet Syrup Liquid Page 16 of 23 Coverage Details: PA- Prior Authorization; QL= Quantity Limit ‘OHANA DUAL ELIGIBLE PREFERRED DRUG LIST Drug Name Dosage Form Coverage Details robafen ac saline mist saline nasal spray sea soft nasal mist sildec pe-dm sodium chloride yl zinc gluconate natural zinc gluconate zinc Sedatives/Hypnotics acetaminophen pm butalbital /acetaminophen /caffeine butalbital /aspirin /caffeine butalbital/apap/caffeine compoz compoz diphenhydramine hcl estazolam flurazepam hcl headache pm mapap pm nytol pain relief pm extra strength pain reliever pm phenobarbital sodium phenobarbital Tablet Tablet Tablet Capsule Capsule Tablet Tablet Tablet Capsule Tablet Tablet Tablet Tablet Tablet Solution Elixir phenobarbital phenobarbital 15mg Tablet Tablet phenobarbital 16.2mg Tablet simply sleep sleep Tablet sleep-ettes d sleep-Tablet sominex maximum strength sominex temazepam triazolam Therapeutic Nutrients/Minerals/ Electrolytes Electrolytes/Minerals alcalak Tablet Tablet Tablet Tablet Tablet Tablet Capsule Tablet Syrup Solution Solution Solution Syrup Nebulizer Tablet Tablet Tablet Chewable Page 17 of 23 Coverage Details: PA- Prior Authorization; QL= Quantity Limit 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 antacid calcarb 600/vitamin d calcarb 600 cal-carb forte calci-chew calcio del mar calcium + d calcium 250+d calcium 500/vitamin d calcium 600/vitamin d calcium 600+d calcium 600 calcium 600-d calcium antacid extra strength calcium antacid calcium carbonate/vitamin d calcium carbonate 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 cal-gest antacid caltrate 600+d caltrate 600 centamin centavite a-z complete multivitamin/minerals centavite cerovite advanced formula cerovite certa vite chelated zinc chewable antacid chewable calcium chooz fast dissolve antacid ferro-bob Dosage Form Coverage Details Chewable Tablet Tablet Tablet Chewable Tablet Tablet Tablet Tablet Tablet Tablet Tablet Tablet Chewable Chewable Tablet Chewable Suspension Tablet Tablet Tablet Tablet Tablet Tablet Tablet Tablet Chewable Tablet Tablet Liquid Tablet Liquid Tablet Liquid Liquid Tablet Chewable Chewable Chewable Chewable Tablet Page 18 of 23 Coverage Details: PA- Prior Authorization; QL= Quantity Limit ‘OHANA DUAL ELIGIBLE PREFERRED DRUG LIST Drug Name ferrous sulfate ferrous sulfate ferrous sulfate ferrousul formula twenty-one gerivite complete golden age vitamin/minerals hi-cal iron liquid calcium/vitamin d mag64 mag-delay magnacaps magnesium oxide magnesium mag-oxide mag-sr plus calcium mag-sr MAG-TAB SR multi-vitamin /fluoride multi-vitamin/fluoride 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 Dosage Form Coverage Details Elixir Tablet Enteric Coated Tablet Tablet Tablet Tablet Liquid Tablet Tablet Capsule Control Release Tablet Control Release Tablet Capsule Tablet Tablet Tablet Control Release Tablet Control Release Tablet Control Release Tablet Chewable Solution Solution Capsule Tablet Chewable Tablet Tablet Tablet Tablet Tablet Tablet Tablet Tablet Tablet Tablet Page 19 of 23 Coverage Details: PA- Prior Authorization; QL= Quantity Limit ‘OHANA DUAL ELIGIBLE PREFERRED DRUG LIST Drug Name oyster shell calcium/vitamin d oyster shell/vitamin d oystercal oyster-d PHOS-NAK POWDER CONCENTRATE poly-vitamin/fluoride re multivit with fluoride rehydralyte revital freezer pops revital liquid squeezers super calcium/d super calcium super multiple super nu-thera thera vital m therabasic-m THERAPEUTIC LIQUID therapeutic-m therems m titralac total formula 3 trial antacid vitamins for hair yl zinc gluconate natural zinc gluconate ZINC METHIONATE zinc picolinate zinc sulfate zinc sulfate zinc-220 zinc zincate Vitamins ascorbic acid ascorbic acid calcarb 600/vitamin d calciferol calcium + d calcium 250+d calcium 500/vitamin d calcium 600/vitamin d Dosage Form Coverage Details Tablet Tablet Tablet Tablet Pack Solution Chewable Solution Solution Solution Tablet Tablet Tablet Tablet Tablet Tablet Solution Tablet Tablet Chewable Tablet Chewable Tablet Tablet Tablet Capsule Tablet Capsule Tablet Capsule Tablet Capsule Chewable Tablet Tablet Solution Tablet Tablet Tablet Tablet Page 20 of 23 Coverage Details: PA- Prior Authorization; QL= Quantity Limit ‘OHANA DUAL ELIGIBLE PREFERRED DRUG LIST Drug Name calcium 600+d calcium 600-d calcium carbonate/vitamin d calcium high potency + vitamin d calcium/vitamin d calcium calcium-carb 600 + d caltrate 600+d centamin centavite a-z complete multivitamin/minerals centavite cerovite advanced formula cerovite certa vite cyanocobalamin daily multiple vitamins daily vitamin formula daily vite folic acid formula twenty-one gerivite complete golden age vitamin/minerals liquid calcium/vitamin d MEPHYTON multi-day multi-vitamin /fluoride multi-vitamin/fluoride multi-vitamin nephronex once daily one-daily multi vitamins os-cal 500 + d oysco 500+d 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 Dosage Form Coverage Details Tablet Tablet Tablet Tablet Tablet Tablet Tablet Tablet Liquid Tablet Liquid Tablet Liquid Liquid Solution Tablet Tablet Tablet Tablet Tablet Tablet Liquid Capsule Tablet Tablet Chewable Solution Tablet Tablet Tablet Tablet Tablet Tablet Tablet Tablet Tablet Tablet Tablet Tablet Tablet Tablet Page 21 of 23 Coverage Details: PA- Prior Authorization; QL= Quantity Limit ‘OHANA DUAL ELIGIBLE PREFERRED DRUG LIST Drug Name oyster shell calcium/vitamin d oyster shell/vitamin d oyster-d poly-vitamin/fluoride re multivit with fluoride renal renaphro rena-vite rx reno caps super calcium/d super multiple super nu-thera tab-a-vite thera vital m thera therabasic-m THERAPEUTIC LIQUID therapeutic therapeutic-m thera-Tablet therems m therems total formula 3 vitamin b-12 cr vitamin b-12 tr Dosage Form Coverage Details Tablet Tablet Tablet Solution Chewable Capsule Capsule Tablet Capsule Tablet Tablet Tablet Tablet Tablet Tablet Tablet Solution Tablet Tablet Tablet Tablet Tablet Tablet Control Release Tablet Control Release Tablet Sublingual Tablet Chewable Syrup Tablet Capsule Tablet Capsule Tablet Tablet Tablet vitamin b-12 vitamin b-12 vitamin c vitamin c vitamin c vitamin d3 vitamin d3 vitamin d vitamin d vitamin d-400 vitamins for hair Devices AEROCHAMBER MV Device AEROCHAMBER Z-STAT PLUS/FLOWSIGNAL Device Page 22 of 23 Coverage Details: PA- Prior Authorization; QL= Quantity Limit QL (2.00 per 365 days) QL (2.00 per 365 days) ‘OHANA DUAL ELIGIBLE PREFERRED DRUG LIST Drug Name Dosage Form Coverage Details AEROCHAMBER/FLOWSIGNAL Device AEROCHAMBER PLUS/LARGE MASK Device AEROCHAMBER PLUS/MASK Device AEROCHAMBER PLUS/SMALL MASK Device AEROCHAMBER PLUS Device AEROCHAMBER Z-STAT PLUS VALVED HOLDING CHAMBER Device W/FLOW VU EASIVENT Device IN-CHECK DIAL INSPIRATORY FLOW TRAINER Device INHALER COMPANIONS Device MICROCHAMBER Device MICROSPACER Device OPTICHAMBER ADVANTAGE Device OPTIHALER MDI DRUG DELIVERY SYSTEM Device OPTIHALER Device PFLEX Device POCKET CHAMBER Device POCKET SPACER Device THRESHOLD IMT Device THRESHOLD PEP Device VORTEX HOLDING CHAMBER/MASK/ADULT Device VORTEX HOLDING CHAMBER/MASK/CHILDS Device VORTEX HOLDING CHAMBER/MASK/TODDLER Device VORTEX VALVED HOLDING CHAMBER Device WATCHHALER Device WINDMILL TRAINER Device Page 23 of 23 Coverage Details: PA- Prior Authorization; QL= Quantity Limit QL (2.00 per 365 days) QL (2.00 per 365 days) QL (2.00 per 365 days) QL (2.00 per 365 days) QL (2.00 per 365 days) QL (2.00 per 365 days) QL (2.00 per 365 days) QL (2.00 per 365 days) QL (2.00 per 365 days) QL (2.00 per 365 days) QL (2.00 per 365 days) QL (2.00 per 365 days) QL (2.00 per 365 days) QL (2.00 per 365 days) QL (2.00 per 365 days) QL (2.00 per 365 days) QL (2.00 per 365 days) QL (2.00 per 365 days) QL (2.00 per 365 days) QL (2.00 per 365 days) QL (2.00 per 365 days) QL (2.00 per 365 days) QL (2.00 per 365 days) QL (2.00 per 365 days) QL (2.00 per 365 days)
Related documents