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2013 Comprehensive Dual Preferred Drug List (List of Covered Drugs) WellCare of Kentucky 00 9 Please read: This document contains information about the drugs we cover in this plan. Last updated (1/01/2013) Kentucky 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 Kentucky 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 DIABETIC TUSSIN DM LIQUID GUAIFENESIN DM SYRUP Q-TUSSIN-DM SYRUP IOPHEN DM-NR LIQUID SILTUSSIN DM COUGH SYRUP EXTRA ACTION COUGH SILTUSSIN DM DAS COUGH SYRUP REFENESEN DM MUCOSA DM ROBAFEN DM CLEAR MUCINEX FAST MAX DM MAX LIQUID ROBITUSSIN COUGH CHEST CONGESTION DM 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 Dexbrompheniramine/Hydrocodone Bit/Phenylephrine HCl CYTUSS-HC NR SYRUP HC 2.5-PE 5-DBROM 1 MG SYRUP HC/PE/DBROM SYRUP Codeine/Phenylephrine HCl/Promethazine 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 Drug Name Dosage Form 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 brotapp chlorhist chlorphen chlorpheniramine maleate complete allergy medication complete allergy relief diabetic tussin allergy diphenhist diphenhist diphenhist diphenhydramine hcl diphenhydramine hcl diphenhydramine hcl dormin genahist pharbedryl q-dryl q-dryl q-tapp quenalin scot-tussin allergy relief formula siladryl allergy silphen cough Capsule Tablet Tablet Syrup Tablet Liquid Tablet Tablet Tablet Elixir Syrup Tablet Capsule Capsule Liquid Tablet Liquid Tablet Tablet Tablet Tablet Tablet Syrup Capsule Liquid Tablet Liquid Capsule Tablet Capsule Capsule Capsule Capsule Liquid Elixir Syrup Liquid Liquid Syrup Coverage Details: QL= Quantity Limit Page 1 of 14 Coverage Details KENTUCKY DUAL ELIGIBLE PREFERRED DRUG LIST Drug Name Dosage Form simply allergy total allergy medicine total allergy Second Generation Antihistamines cetirizine hcl children’s allergy cetirizine hcl children’s cetirizine hcl loratadine hives relief Tablet Liquid Tablet loratadine Autonomic Drugs Autonomic Drugs, Miscellaneous nicotine Tablet Syrup Solution Tablet Solution Patch (24 hour) Sympathomimetic (Adrenergic) Agents pseudoephedrine hcl Blood Formation,Coagulation & Thrombosis Antianemia Drugs ferro-bob ferrous sulfate ferrous sulfate ferrous sulfate ferrousul iron Central Nervous System Agents Analgesics and Antipyretics acetaminophen acetaminophen acetaminophen 325mg Chewable Solution Tablet apap extra strength Tablet apap Tablet aspirin children’s aspirin ec low dose Chewable Enteric Coated Tablet Enteric Coated Tablet Tablet Enteric Coated Coverage Details: QL= Quantity Limit Page 2 of 14 QL (70.00 per 365 days) Tablet Elixir Tablet Enteric Coated Tablet Tablet Tablet Tablet aspirin low dose aspirin low dose QL (300.00 per 31 days) Tablet acetaminophen 500mg aspirin ec Coverage Details QL (279.00 per 31 days) QL (186.00 per 31 days) QL (186.00 per 31 days) QL (279.00 per 31 days) KENTUCKY DUAL ELIGIBLE PREFERRED DRUG LIST Drug Name Dosage Form bufpirin Tablet Chewable Tablet Enteric Coated Tablet Tablet butalbital/acetaminophen/caffeine 50MG;325MG;40MG Capsule butalbital/acetaminophen/caffeine 50MG;325MG;40MG Tablet butalbital/acetaminophen/caffeine 50MG;500MG;40MG Tablet butalbital/acetaminophen Tablet 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 mapap 500mg Capsule Tablet Chewable Chewable Chewable Chewable Liquid Chewable Enteric Coated Tablet Liquid Enteric Coated Tablet Suspension Tablet Suspension Control Release Tablet Capsule mapap mapap 325mg Chewable Tablet mapap 500mg Tablet maxapap maximum strength Tablet maxapap regular strength Tablet non-aspirin extra strength Tablet aspirin aspirin aspirin ed-apap enteric coated aspirin ibuprofen ibuprofen infant’s mapap mapap arthritis pain Coverage Details: QL= Quantity Limit Page 3 of 14 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 (93.00 per 31 days) QL (186.00 per 31 days) QL (279.00 per 31 days) QL (186.00 per 31 days) QL (186.00 per 31 days) QL (279.00 per 31 days) QL (186.00 per 31 days) KENTUCKY DUAL ELIGIBLE PREFERRED DRUG LIST Drug Name Dosage Form non-aspirin pain relief Tablet non-aspirin Tablet pain & fever children’s pain relief extra strength Solution Tablet pain relief Tablet pharbetol extra strength Tablet pharbetol Tablet q-pap Tablet tactinal extra strength Tablet tactinal Tablet tri-buffered aspirin Anxiolytics, Sedatives, and Hypnotics acetaminophen pm compoz compoz headache pm mapap pm nytol pain relief pm extra strength pain reliever pm simply sleep sleep tabs sominex maximum strength sominex tetra-formula nighttime sleep aid Devices Tablet ACE AEROSOL CLOUD ENHANCER Device AEROCHAMBER MV Device AEROCHAMBER PLUS/LARGE MASK Device AEROCHAMBER PLUS/MASK Device AEROCHAMBER PLUS/SMALL MASK Device AEROCHAMBER PLUS Device QL (279.00 per 31 days) QL (279.00 per 31 days) 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) Tablet Capsule Tablet Tablet Tablet Tablet Tablet Tablet Tablet Tablet Tablet Tablet Tablet Coverage Details: QL= Quantity Limit Page 4 of 14 Coverage Details 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) KENTUCKY DUAL ELIGIBLE PREFERRED DRUG LIST Coverage Details Drug Name Dosage Form AEROCHAMBER Z-STAT PLUS VALVED HOLDING CHAMBER W/FLOW VU AEROCHAMBER Z-STAT PLUS/FLOWSIGNAL Device QL (2.00 per 365 days) Device AEROCHAMBER/FLOWSIGNAL Device EASIVENT Device IN-CHECK DIAL INSPIRATORYFLOW 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 WATCHHALER Device WINDMILL TRAINER Device 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) Electrolytic, Caloric, and Water Balance Irrigating Solutions curity sterile saline Solution sodium chloride Solution Replacement Preparations calcarb 600/vitamin d calcarb 600 cal-carb forte calci-chew calcio del mar calcium + d calcium 600/vitamin d Tablet Tablet Tablet Chewable Tablet Tablet Tablet Coverage Details: QL= Quantity Limit Page 5 of 14 QL (1000.00 per 31 days) QL (1000.00 per 31 days) KENTUCKY DUAL ELIGIBLE PREFERRED DRUG LIST Drug Name Dosage Form 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 calctrate 600+D caltrate 600 chewable calcium liquid calcium/vitamin d mag64 Tablet Tablet Tablet Suspension 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 Capsule Tablet Chewable Tablet Tablet Tablet Tablet Tablet Tablet Tablet Tablet Tablet Tablet mag-delay magnacaps magnesium mag-sr plus calcium mag-sr mag-tab sr orazinc os-cal 500 + d os-cal 500 oysco 500+d oysco 500 oysco d oyst-cal d 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 Coverage Details: QL= Quantity Limit Page 6 of 14 Coverage Details KENTUCKY DUAL ELIGIBLE PREFERRED DRUG LIST Drug Name Dosage Form oyster shell/vitamin d oystercal oyster-d PHOS-NAK POWDER CONCENTRATE zinc sulfate zinc sulfate zinc-220 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 h.e.a.r. murine ear murine for ear wax removal system otix thera-ear EENT Drugs, Miscellaneous altamist artificial tears artificial tears Tablet Tablet Tablet Pack Capsule Tablet Capsule 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 Solution Solution Solution Solution Solution Solution Solution Solution Solution Solution Solution Solution Solution Aerosol Solution Solution Solution Solution Solution Solution Solution Solution Solution Solution Solution Solution Solution Ointment Solution Coverage Details: QL= Quantity Limit Page 7 of 14 Coverage Details QL (15.00 per 31 days) KENTUCKY DUAL ELIGIBLE PREFERRED DRUG LIST Drug Name Dosage Form sea soft nasal mist tears again tears again ultra fresh pm Gastrointestinal Drugs Antacids and Adsorbents acid gone 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 antacid ultra strength antacid antacid calcium antacid extra strength calcium antacid calcium carbonate calcium carbonate cal-gest antacid chewable antacid geri-lanta liquid antacid extra strength 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 Solution Ointment Solution Ointment Chewable Chewable Chewable Suspension Suspension Suspension Suspension Suspension Suspension Suspension Suspension Suspension Suspension Chewable Suspension Chewable Chewable Chewable Tablet Chewable Chewable Suspension Suspension Suspension Suspension Suspension Suspension Suspension Chewable Tablet Tablet Chewable Suspension Suspension Chewable Coverage Details: QL= Quantity Limit Page 8 of 14 Coverage Details KENTUCKY DUAL ELIGIBLE PREFERRED DRUG LIST Drug Name Dosage Form sodium bicarbonate titralac Antidiarrhea Agents anti-diarrheal bismatrol bismatrol bismuth diotame kaopectate extra strength kaopectate kao-tin loperamide a-d 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 omeprazole Tablet Chewable Cathartics and Laxatives bisac-evac bisacodyl ec bisacodyl biscolax carters little pills citrate of magnesia citroma correct Liquid Chewable Suspension Chewable Chewable Suspension Suspension Suspension Tablet Liquid Suspension Chewable Suspension Suspension Chewable Suspension Tablet Chewable Chewable Chewable Enteric Coated Tablet Enteric Coated Tablet Enteric Coated Tablet Suppository Suppository Enteric Coated Tablet Solution Solution Enteric Coated Tablet Coverage Details: QL= Quantity Limit Page 9 of 14 Coverage Details KENTUCKY DUAL ELIGIBLE PREFERRED DRUG LIST Drug Name Dosage Form correctol extra gentle correctol Capsule Enteric Coated Tablet Capsule Liquid Syrup Enema Capsule Tablet Capsule Liquid Capsule Tablet Capsule Tablet Capsule Tablet Capsule Tablet Capsule Enteric Coated Tablet Suspension Capsule Enema Enteric Coated Tablet Chewable Enteric Coated Tablet Tablet Tablet Powder Tablet Tablet Enteric Coated Tablet Enteric Coated Tablet Capsule Tablet 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 ex-lax ultra EX-LAX feenamint fiber laxative fiber tabs fiber therapy fibergen fiber-lax fleet laxative gentle laxative kao-tin konsyl fiber Coverage Details: QL= Quantity Limit Page 10 of 14 Coverage Details KENTUCKY DUAL ELIGIBLE PREFERRED DRUG LIST Drug Name Dosage Form KONSYL 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 silace Pack 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 Liquid Coverage Details: QL= Quantity Limit Page 11 of 14 Coverage Details KENTUCKY DUAL ELIGIBLE PREFERRED DRUG LIST Drug Name Dosage Form silace sof-lax sorbitol stimulant laxative Syrup Capsule Solution Enteric Coated Tablet Capsule Capsule Capsule Enteric Coated Tablet stool softener surfak sur-q-lax womens laxative Emetics IPECAC Hormones and Synthetic Substitutes Antihypoglycemic Agents BD GLUCOSE GLUCOSE ULTILET GLUCOSE Respiratory Tract Agents Expectorants chest congestion relief refenesen 400 refenesen robafen Mucolytic Agents sodium chloride Skin and Mucous Membrane Preparations Anti-infectives bacitracin zinc bacitracin/neomycin/polymyxin bacitracin clotrimazole double antibiotic miconazole nitrate miconazole neoporacin operand povidone/iodine permethrin povidone-iodine terbinafine hcl triple antibiotic Syrup Chewable Chewable Chewable Tablet Tablet Tablet Syrup Nebulizer Ointment Ointment Ointment Solution Ointment Cream Cream Ointment Solution Lotion Solution Cream Ointment Coverage Details: QL= Quantity Limit Page 12 of 14 Coverage Details QL (60.00 per 31 days) KENTUCKY DUAL ELIGIBLE PREFERRED DRUG LIST Drug Name Dosage Form 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 itch relief 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 multivitamin/fluoride multivitamins nephronex once daily one-daily multi vitamins renal rena-vite rx reno caps super nu-thera thera vital m thera therabasic-m therapeutic liquid Cream Cream Cream Cream Ointment Cream Cream Cream Cream Gel Cream Liquid Tablet Liquid Tablet Liquid Tablet Tablet Tablet Tablet Liquid Tablet Solution Liquid Chewable Tablet Tablet Tablet Tablet Capsule Tablet Capsule Tablet Tablet Tablet Tablet solution Coverage Details: QL= Quantity Limit Page 13 of 14 Coverage Details KENTUCKY DUAL ELIGIBLE PREFERRED DRUG LIST Drug Name Dosage Form therapeutic therapeutic-m thera-tabs therems m therems total formula 3 vitamins for hair Vitamin B Complex cyanocobalamin folic acid vitamin b-12 cr Tablet Tablet Tablet Tablet Tablet Tablet Tablet vitamin b-12 tr vitamin b-12 vitamin b-12 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 vitamin k Solution Tablet Control Release Tablet Control Release Tablet Sublingual Tablet Chewable Tablet Chewable Syrup Tablet Solution Capsule Tablet Capsule Tablet Tablet Tablet Coverage Details: QL= Quantity Limit Page 14 of 14 Coverage Details QL (4.00 per 31 days)
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