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2012 Comprehensive Dual Preferred Drug List (List of Covered Drugs) WellCare of Florida 00 9 Please read: This document contains information about the drugs we cover in this plan. Last updated (10/01/2012) Florida Dual Eligible Cough & Cold Drug List PLEASE NOTE: The preferred formulary cough & cold drugs on this list are covered only for members age 20 or younger. 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 Florida Dual Eligible Cough & Cold Drug List PLEASE NOTE: The preferred formulary cough & cold drugs on this list are covered only for members age 20 or younger. 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 FLORIDA 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 simply allergy 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 Tablet Coverage Details: QL = Quantity Limit Page 1 of 15 Coverage Details FLORIDA DUAL ELIGIBLE PREFERRED DRUG LIST Drug Name total allergy medicine total allergy Second Generation Antihistamines cetirizine hcl children’s allergy cetirizine hcl children’s cetirizine hcl cetirizine hcl loratadine hives relief ferrousul iron Central Nervous System Agents Analgesics and Antipyretics acephen acetaminophen acetaminophen acetaminophen apap extra strength aspirin low dose Liquid Tablet Syrup Solution Chewable Tablet Solution Gum Patch (24 hour) Sympathomimetic (Adrenergic) Agents nasal decongestant pseudoephedrine hcl Blood Formation,Coagulation & Thrombosis Antianemia Drugs ferro-bob ferrous sulfate ferrous sulfate ferrous sulfate aspirin ec QL (300.00 per 31 days) QL (93.00 per 365 days) Syrup Tablet Tablet Elixir Tablet Enteric Coated Tablet Tablet Tablet Suppository Chewable Solution Tablet Tablet Tablet Chewable Enteric Coated Tablet Enteric Coated Tablet Tablet Coverage Details: QL = Quantity Limit Page 2 of 15 Coverage Details Tablet Tablet (24 hour) loratadine loratadine-d 24hr Autonomic Drugs Autonomic Drugs, Miscellaneous nicotine polacrilex nicotine apap aspirin children’s aspirin ec low dose Dosage Form QL (186.00 per 31 days) FLORIDA DUAL ELIGIBLE PREFERRED DRUG LIST Dosage Form Drug Name aspirin low dose bufpirin butalbital/acetaminophen/caffeine Enteric Coated Tablet Chewable Tablet Enteric Coated Tablet Tablet Capsule butalbital/acetaminophen/caffeine Tablet butalbital/acetaminophen/caffeine 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 mapap mapap Capsule Tablet Chewable Chewable Chewable Chewable Liquid Chewable Enteric Coated Tablet Liquid Enteric Coated Tablet Suppository Chewable Suspension Tablet Suspension Control Release Tablet Capsule Chewable Tablet maxapap maximum strength Tablet maxapap regular strength Tablet non-aspirin extra strength Tablet aspirin aspirin aspirin ed-apap enteric coated aspirin feverall ibuprofen junior strength ibuprofen ibuprofen infant’s mapap mapap arthritis pain Coverage Details: QL = Quantity Limit Page 3 of 15 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 (186.00 per 31 FLORIDA DUAL ELIGIBLE PREFERRED DRUG LIST Dosage Form Drug Name 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 Anticonvulsants clonazepam Anxiolytics, Sedatives, and Hypnotics acetaminophen pm alprazolam chlordiazepoxide hcl clorazepate dipotassium compoz compoz diazepam diazepam estazolam flurazepam hcl headache pm lorazepam lorazepam mapap pm nytol oxazepam pain relief pm extra strength pain reliever pm phenobarbital Tablet Tablet Tablet Capsule Tablet Capsule Tablet Solution Tablet Tablet Capsule Tablet Solution Tablet Tablet Tablet Capsule Tablet Tablet Elixir phenobarbital Tablet days 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 Coverage Details: QL = Quantity Limit Page 4 of 15 Coverage Details QL (2000.00 per 31 days) FLORIDA DUAL ELIGIBLE PREFERRED DRUG LIST Dosage Form Drug Name phenobarbital Tablet phenobarbital 16.2mg Tablet simply sleep sleep tabs sominex maximum strength sominex temazepam tetra-formula nighttime sleep aid triazolam Devices Tablet Tablet Tablet Tablet Capsule Tablet 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 AEROCHAMBER Z-STAT PLUS VALVED HOLDING CHAMBER W/FLOW VU AEROCHAMBER Z-STAT PLUS/FLOWSIGNAL 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 Device Coverage Details: QL = Quantity Limit Page 5 of 15 Coverage Details QL (310.00 per 31 days) QL (383.00 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) QL (2.00 per 31 days) QL (2.00 per 31 FLORIDA DUAL ELIGIBLE PREFERRED DRUG LIST Dosage Form Drug Name POCKET CHAMBER Device POCKET SPACER Device THRESHOLD IMT Device THRESHOLD PEP Device WATCHHALER Device WINDMILL TRAINER Device 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 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 chewable calcium liquid calcium/vitamin d mag64 Tablet Tablet Tablet Chewable Tablet Tablet Tablet Tablet Tablet Tablet Suspension Tablet Tablet Tablet Tablet Tablet Tablet Tablet Tablet Tablet Tablet Chewable Capsule Control Release Tablet Coverage Details: QL = Quantity Limit Page 6 of 15 Coverage Details 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 (1000.00 per 31 days) QL (1000.00 per 31 days) FLORIDA DUAL ELIGIBLE PREFERRED DRUG LIST Dosage Form Drug Name 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 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 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 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 Tablet Tablet Tablet Tablet Pack Capsule Tablet Capsule Solution Aerosol Solution Solution Solution Solution Solution Solution Coverage Details: QL = Quantity Limit Page 7 of 15 Coverage Details FLORIDA DUAL ELIGIBLE PREFERRED DRUG LIST Drug Name 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 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 SIMPLY SALINE 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 Dosage Form Solution Solution Solution Solution Solution Solution Solution Solution Ointment Solution Solution Solution Solution Solution Solution Solution Solution Solution Solution Solution Solution Solution Aerosol Ointment Solution Ointment Chewable Chewable Chewable Suspension Suspension Suspension Suspension Suspension Suspension Suspension Suspension Suspension Coverage Details: QL = Quantity Limit Page 8 of 15 Coverage Details QL (15.00 per 31 days) FLORIDA 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 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 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 Dosage Form Suspension Chewable Suspension Chewable Chewable Chewable Tablet Chewable Chewable 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 Liquid Suspension Chewable Suspension Suspension Chewable Suspension Coverage Details: QL = Quantity Limit Page 9 of 15 Coverage Details FLORIDA DUAL ELIGIBLE PREFERRED DRUG LIST Drug Name Antiemetics meclizine hcl Antiflatulents mi-acid gas relief mytab gas simethicone Antiulcer Agents and Acid Suppressants omeprazole Cathartics and Laxatives bisac-evac bisac-evac bisacodyl ec bisacodyl biscolax carters little pills citrate of magnesia citroma correct correctol extra gentle correctol 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 Dosage Form Tablet Chewable Chewable Chewable Enteric Coated Tablet Suppository Enteric Coated Tablet Enteric Coated Tablet Suppository Suppository Enteric Coated Tablet Solution Solution Enteric Coated Tablet Capsule Enteric Coated Tablet Capsule Liquid Syrup Enema Capsule Tablet Capsule Liquid Capsule Tablet Capsule Tablet Capsule Tablet Capsule Tablet Coverage Details: QL = Quantity Limit Page 10 of 15 Coverage Details FLORIDA DUAL ELIGIBLE PREFERRED DRUG LIST Dosage Form Drug Name 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 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 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 Pack Capsule Capsule Powder Suppository Solution Powder Powder Powder Pack Powder Powder Suspension Powder Tablet Powder Tablet Solution Capsule Powder Coverage Details: QL = Quantity Limit Page 11 of 15 Coverage Details FLORIDA DUAL ELIGIBLE PREFERRED DRUG LIST Dosage Form Drug Name 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 silace sof-lax sorbitol stimulant laxative Liquid Tablet Tablet Tablet Tablet Tablet Tablet Tablet Tablet Syrup Tablet Tablet Tablet Tablet Tablet Tablet Tablet Tablet Tablet Tablet Tablet Liquid Syrup Capsule Solution Enteric Coated Tablet Capsule Capsule Capsule Enteric Coated Tablet stool softener surfak sur-q-lax women’s laxative Emetics IPECAC Hormones and Synthetic Substitutes Antihypoglycemic Agents BD GLUCOSE GLUCOSE ULTILET GLUCOSE Respiratory Tract Agents Expectorants chest congestion relief Syrup Chewable Chewable Chewable Tablet Coverage Details: QL = Quantity Limit Page 12 of 15 Coverage Details FLORIDA DUAL ELIGIBLE PREFERRED DRUG LIST Drug Name guaifenesin 200mg refenesin 400mg 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 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 Dosage Form Tablet Tablet Syrup Nebulizer Ointment Ointment Ointment Solution Ointment Cream Cream Ointment Solution Lotion Solution Cream Ointment Cream Cream Cream Cream Ointment Cream Cream Cream Cream Gel Cream Liquid Tablet Liquid Tablet Liquid Tablet Coverage Details: QL = Quantity Limit Page 13 of 15 Coverage Details QL (60.00 per 31 days) FLORIDA DUAL ELIGIBLE PREFERRED DRUG LIST Drug Name 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 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 folic acid vitamin b-12 cr vitamin b-12 tr vitamin b-12 vitamin b-12 Vitamin C ascorbic acid ascorbic acid vitamin c vitamin c vitamin c Dosage Form Tablet Tablet Tablet Liquid Tablet Solution Liquid Chewable Tablet Tablet Tablet Tablet Capsule Tablet Capsule Tablet Tablet Tablet Tablet Solution Tablet Tablet Tablet Tablet Tablet Tablet Tablet Solution Tablet Control Release Tablet Control Release Tablet Sublingual Tablet Chewable Tablet Chewable Syrup Tablet Coverage Details: QL = Quantity Limit Page 14 of 15 Coverage Details FLORIDA DUAL ELIGIBLE PREFERRED DRUG LIST Drug Name Vitamin D calciferol vitamin d3 vitamin d3 vitamin d vitamin d vitamin d-400 Dosage Form Solution Capsule Tablet Capsule Tablet Tablet Coverage Details: QL = Quantity Limit Page 15 of 15 Coverage Details QL (4.00 per 31 days)
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