Download Quick Reference Preferred Drug List (PDL)

Quick Reference Preferred Drug List (PDL)
US Script Prior Authorization Phone: 1-866-399-0928 | Fax: 1-866-399-0929 | BHP Provider Inquiry Line: 1-866-296-8731
ADHD
■Adderall*
■Adderall-XR*
■Concerta*
■ Dextroamphetamine IR*,SR*
■ Metadate CD*
■ Methylin ER*
■ Methylphenidate SR*
■Methylphenidate*
ANALGESICS
■ Acetaminophen w/ cod.*
■ Fetanyl patches 72HR*
■Hydrocodone/APAP*
■Hydromorphone*
■Meperidine*
■Methadone*
■ Morphine sulfate IR*, SR*
■Oxycodone*
■Oxycodone/APAP*
■Oxycontin
■Roxicet
■Tramadol/APAP*
■Tramadol*
ANTI-ANXIETY
■Alprazolam*
■Diazepam*
■Lorazepam*
ANTIASTHMATIC AND
BRONCHODILATOR AGENTS
■ Advair Diskus
■ Aerospan
■Atrovent
■ Breo Ellipta
■Combivent
■ Cromolyn sodium*
■Dulera
■Flovent
■Foradil
■ ProAir HFA
■ Proventil HFA
■ Pulmicort Respules
■Serevent
■Spiriva
■Symbicort
ANTICONVULSANTS
■Carbamazepine*
■ Divalproex sodium ER*
■Ethosuximide*
■Gabapentin*
■Lamotrigine*
■Levetiracetam*
■Oxcarbazepine*
■Phenobarbital*
■Phenytoin*
■Topiramate*
■ Valproic acid*
■Zonisamide
ANTIDEPRESSANTS
■ Bupropion SR*, XL*
■Bupropion*
■ Brintellix (ST)
■Citalopram*
■Doxepin*
■Duloxetine*
■Escitalopram*
■Fluoxetine*
■Imipramine*
■Mirtazapine*
■Paroxetine*
■Sertraline*
■Trazadone*
■Paroxetine*
■Sertraline*
■Trazadone*
■Venlafaxine*
■Venlafaxine-XR*
■Viibryd
ANTIDIABETIC
■Acarbose*
■Avandamet
■Avandaryl
■Glimepiride*
■ Glipizide Tab SR 24HR*
■Glipizide*
■Glyburide*
■Humalog
■Humulin
■Jentadueto
■ Kombiglyze XR
■ Lantus Solostar
■Metformin*
■Novolog
■Pioglitazone*
■Onglyza
■Tradjenta
ANTIFUNGAL
■Fluconazole*
■Griseofulvin*
■Ketoconazole*
■ Nystatin susp*
■Terbinafine*
ANTIHISTAMINES
■Cetirizine*
■ Chlorpheniramine* (OTC)
■ Claritin Chew Tabs
■ Diphenhydramine* (OTC)
■ Fexofenadine hcl*
■ Loratadine* (OTC)
ANTIHYPERLIPIDEMICS
■ Atorvastatin calcium*
■Cholestyramine*
■Fenofibrate*
■Gemfibrozil*
■Lovastatin*
■Niacor
■Simvastatin*
ANTIHYPERTENSIVES
■Amlodipine besylatebenazepril hcl*
■Amlodipine*
■ Atenolol & Chlorthalidone*
■Atenolol*
■Benazepril*
■Bisoprolol/HCTZ*
■Bumetanide*
■Carvedilol*
■Chlorthalidone*
■Diltiazem*
■Felodipine*
■ Fosinopril sodium/HCTZ*
■Furosemide*
■HCTZ*
■Hydralazine*
■Indapamide*
■Irbesartan/HCTZ*
■Labetolol*
■Linsinopril*
■Linsinpril/HCTZ*
■Losartan*
■Losartan/HCTZ*
■Metolazone*
■ Metoprolol HCTZ*
■Metoprolol*
■ Nadolol*
■Propranolol*
■Quinapril*
■Ramipril*
■Spironolactone*
■Torsemide*
■ Triamterene & HCTZ*
■ Valsartan (ST)
■Verapamil*
ANTIPARASITICS
■Eurax
■ Permethrin Cream*
■ Permethrin Cream Rinse*(OTC)
ANTIVIRAL
■Acyclovir*
■Valacyclovir*
■ Valganciclovir hcl*
CEPHALOSPORINS
■Cefaclor*
■Cefadroxil*
■Cefdinir*
■Cefprozil*
■ Ceftin susp 250 MG/5ML
■Cefuroxime*
■Cephalexin*
CONTRACEPTIVES
■Alesse*
■Demulen*
■ Depo Provera*
■Desogen*
■Lo/Ovral*
■Mircette*
■ Modicon*
■Nordette*
■Norinyl*
■Nor-QD*
■Nuvaring
■ Ortho 777*
■ Ortho Cyclen*
■ Ortho Tri Cyclen*
■Ovral*
■Triphasil*
■Yasmin*
■ YAZ*
CORTICOSTEROIDS-ORAL
■Dexamethasone*
■Fludrocortisone*
■Hydrocortisone*
■Methylprednisolone*
■Prednisolone*
■Prednisone*
■Veripred
COUGH/COLD
■Benzonatate*
■Brompheniramine &
pseudoephedrine tab SR
■Cetirizine-pseudoephedrine tab SR
■Chlorpheniramine &
pseudoephedrine cap CR
■ Decon-A Liquid
■Delsym
■Dextromethorphanguaifenesin Liquid*
■ Guaifenesin DM* (OTC)
■Guaifenesin/PSE*
■ Guaifenesin-Codeine Soln*
■Hydrocodone w/homatropine*
■Hydrocodone-Guaifenesin*
■ Mucinex D TAB ER 12H
■Phenyleph-Chlorphen w/
DM- GG*
■Phenylephrine-Chlorphen-DM*
■ Promethazine w/ codeine*
■Robitussin Cough/Cold/Flu liquid
NASAL AGENTS
■ Azelastine hcl*
■Bactroban
■Flunisolide*
■ Fluticasone propionate*
■ Nasacort AQ*
■Nasonex
■ Ipratropium bromide*
LRA’S
■ Montelukast sodium*
■Zafirlukast*
MACROLIDES
■Azithromycin*
■Clarithromycin*
■Erythromycin*
MIGRAINE
■Butalbital-APAP-Caffeine*
■Butalbital-Aspirin-Caffeine*
■IsomethepteneDichloralphenazone-APAP*
■ Naratriptan hcl*
■ Rizatriptan benzoate*
■Sumatriptan*
MISC. ANTI-INFECTIVES
■Doxycycline*
■Metronidazole*
■Minocycline*
■ Sulfamethoxazole-TMP DS*
MUSCLE RELAXANTS
■Baclofen*
■Chlorzoxazone*
■Cyclobenzaprine*
■Methocarbamol*
■Orphenadrine*
■Tizanidine*
NSAIDS AND COX II’S-ORAL
■Celebrex
■Diclofenac*
■Etodolac*
■Ibuprofen*
■Indomethacin*
■Meloxicam*
■Nabumetone*
■ Naproxen sodium*
■ Oxaprozin*
■Piroxicam*
■Salsalate*
■Sulindac*
PENICILLINS
■ Amoxicillin & K clavulanate*
■Amoxicillin*
■Ampicillin*
■ Penicillin VK
■ Betamethasone valerate*
■Calcipotriene*
■Ciclopirox*
■Clindamycin*
■Clobetasol*
■Clotrimazole*
■Diflorasone
■Econazole*
■Erythromycin*
■Fluocinonide*
■Gentamicin*
■Halobetasol*
■Hydrocortisone Acetate
w/Pramoxine*
■Hydrocortisone*
■Ketoconzole*
■Lactic Acid (Ammonium
Lactate)*
■Metronidazole*
■Mometasone*
■Mupirocin*
■Neomycin-Bacitracin-Polymyxin
* (OTC)
■Nystatin*
■ Selenium sulfide*
■Tretinoin*
■Triamcinolone*
■Zovirax
ULCER DRUGS
■Cimetidine*
■Famotidine*
■ First-omeprazole susp 2 MG/ML
■lansoprazole*
■Omeprazole*
■Pantoprazole*
■Ranitidine*
■ Ranitidine Syrup*
■Zegerid
VAGINAL PREPARATIONS
■ Clindamycin vaginal cream
■Clindesse
■Estrace
■Gynazole-1
■ Metronidazole vaginal*
■ Miconazole vaginal* (OTC)
■ Nystatin vaginal
■ Premarin cream
■ Terconazole vaginal*
QUINOLONES
■Ciprofloxacin*
■Levofloxacin*
■Ofloxacin*
TOPICALS-DERMATOLOGICALS
■Acyclovir*
■ Benzoyl Peroxide*
■ Betamethasone diprop.*
Symbol Key: OTC = Over-The-Counter * = Generic Substitution Required
Color Key: ■ Prescribe without Restrictions ■ Medication may have quantity limit, age limit, etc. ■ Medication requires Prior Authorization
Disclaimer: This chart is intended to be used as a quick reference, and does not contain all items available on the BHS Preferred Drug List. For a complete
listing of all items available, please consult the text version of the BHP Preferred Drug List which is included as part of the BHS Provider Manual. The PDL is
also available online at www.buckeyehealthplan.com. Effective Date: 4/28/2015
©Buckeye Health Plan. All rights reserved.
Quick Reference Preferred Drug List (PDL)
Alphabetical
US Script Prior Authorization Phone: 1-866-399-0928 | Fax: 1-866-399-0929 | BHP Provider Inquiry Line: 1-866-296-8731
■Acarbose*
■ Acetaminophen w/ cod.*
■Acyclovir*
■Adderall*
■Adderall-XR*
■ Advair Diskus
■ Aerospan
■Alesse*
■Alprazolam*
■Amlodipine besylatebenazepril hcl*
■Amlodipine*
■ Amoxicillin & K clavulanate*
■Amoxicillin*
■Ampicillin*
■ Atenolol & Chlorthalidone*
■Atenolol*
■ Atorvastatin calcium*
■Atrovent
■Avandamet
■Avandaryl
■ Azelastine hcl nasal*
■Azithromycin*
■Baclofen*
■ Bactroban nasal
■Benazepril*
■Benzonatate*
■ Benzoyl Peroxide*
■ Betamethasone diprop.*
■ Betamethasone valerate*
■Bisoprolol/HCTZ*
■ Breo Ellipta
■Brintellix
■Brompheniramine &
pseudoephedrine tab sr
■Bumetanide*
■ Bupropion SR*
■Bupropion*
■Butalbital-APAP-Caffeine*
■Butalbital-Aspirin-Caffeine*
■Calcipotriene*
■Carbamazepine*
■Carvedilol*
■Cefaclor*
■Cefadroxil*
■Cefdinir*
■Cefprozil*
■ Ceftin susp 250 MG/5ML
■Cefuroxime*
■Celebrex
■Cephalexin*
■Cetirizine*
■Cetirizine-pseudoe-phedrine
tab sr
■Chlorpheniramine &
pseudoephedrine cap cr
■Chlorpheniramine*
■Chlorthalidone*
■Chlorzoxazone*
■Cholestyramine*
■ Ciclopirox *
■Cimetidine*
■Ciprofloxacin*
■Citalopram*
■Clarithromycin*
■ Claritin Chew Tabs
■ Clindamycin Vaginal cream
■Clindamycin*
■Clindesse
■Clobetasol*
■Clotrimazole*
■Combivent
■Concerta*
■ Cromolyn sodium*
■Cyclobenzaprine*
■ Decon-A Liquid
■Delsym
■Demulen*
■ Depo Provera*
■Desogen*
■Dexamethasone*
■ Dextroamphetamine IR*
■Dextromethorphan■Diazepam*
■Diclofenac*
■Diflorasone
■Diltiazem*
■Diphenhydramine*
■ Divalproex sod ER*
■Doxepin*
■Doxycycline*
■Dulera
■Duloxetine*
■Econazole*
■Erythromycin*
■Escitalopram*
■Estrace
■Ethosuximide*
■Etodolac*
■Eurax
■Famotidine*
■Felodipine*
■Fenofibrate*
■ Fetanyl patches 72HR*
■ Fexofenadine hcl*
■First-omeprazole susp
2 MG/ML
■Flovent
■Fluconazole*
■Fludrocortisone*
■Flunisolide*
■Fluocinonide*
■Fluoxetine*
■ Fluticasone propionate*
■Foradil
■ Fosinopril sodium/HCTZ*
■Furosemide*
■Gabapentin*
■Gemfibrozil*
■Gentamicin*
■Glimepiride*
■ Glipizide Tab SR 24HR*
■Glipizide*
■Glyburide*
■Griseofulvin*
■ Guaifenesin DM*
■Guaifenesin/PSE*
■ Guaifenesin-Codeine Soln*
■Gynazole-1
■Halobetasol*
■HCTZ*
■Humulin
■Humalog
■Hydralazine*
■ Hydrocodone w/
■Hydrocodone/APAP*
■Hydrocodone-Guaifenesin*
■ Hydrocortisone Acetate w/
■Hydrocortisone*
■Hydrocortisone*
■Hydromorphone*
■Ibuprofen*
■Imipramine*
■Indapamide*
■Indomethacin*
■ Ipratropium bromide *
■Irbesartan/HCTZ*
■IsomethepteneDichloralphenazone-APAP*
■Jentadueto
■Ketoconazole*
■Ketoconzole*
■ Kombiglyze XR
■Labetolol*
■ Lactic Acid
■Lamotrigine*
■ lansoprazole *
■ Lantus Solostar
■ Levetiracetam *
■Levofloxacin*
■Linsinopril*
■Linsinpril/HCTZ*
■Lo/Ovral*
■Loratadine*
■Lorazepam*
■Losartan*
■Losartan/HCTZ*
■Lovastatin*
■Meloxicam*
■Meperidine*
■ Metadate CD*
■Metformin*
■Methadone*
■Methocarbamol*
■ Methylin ER*
■ Methylphenidate SR*
■Methylphenidate*
■Methylprednisolone*
■Metolazone*
■ Metoprolol HCTZ*
■Metoprolol*
■Metronidazole*
■ Metronidazole vaginal*
■Metronidazole*
■ Miconazole vaginal*
■Minocycline*
■Mircette*
■Mirtazapine*
■Modicon*
■Mometasone*
■ Montelukast sodium*
■ Morphine sulfate IR*
■ Mucinex D ER 12H
■Mupirocin*
■Nabumetone*
■Nadolol*
■ Naproxen sodium*
■Naproxen*
■ Naratriptan hcl*
■ Nasacort AQ*
■Nasonex
■Neomycin-Bacitracin■Niacor
■Nordette*
■Norinyl*
■Nor-QD*
■Novolog
■Nuvaring
■ Nystatin vaginal
■ Nystatin susp*
■Ofloxacin*
■Omeprazole*
■Onglyza
■Orphenadrine*
■ Ortho 777*
■ Ortho Cyclen*
■ Ortho Tri Cyclen*
■Ovral*
■ Oxaprozin*
■Oxcarbazepine*
■Oxycodone*
■Oxycodone/APAP*
■Oxycontin*
■Pantoprazole*
■Paroxetine*
■Paroxetine*
■ Penicillin VK
■ Permethrin Cream*
■ Permethrin Cream Rinse*
■Phenobarbital*
■Phenyleph-Chlorphen w/
DM-GG*
■PhenylephrineChlorphen-DM*
■Phenytoin*
■Pioglitazone*
■Piroxicam*
■Prednisolone*
■Prednisone*
■ Premarin cream
■ ProAir HFA
■ Promethazine w/ codeine*
■Propranolol*
■ Proventil HFA
■ Pulmicort Respules
■Quinapril*
■Ramipril*
■ Ranitidine Syrup*
■Ranitidine*
■ Rizatriptan benzoate*
■Robitussin NT Cough/cold/flu
liquid
■Roxicet
■Salsalate*
■ Selenium sulfide*
■Serevent
■Sertraline*
■Sertraline*
■Simvastatin*
■Spiriva
■Spironolactone*
■ Sulfamethoxazole-TMP DS*
■Sulindac*
■Sumatriptan*
■Symbicort
■Terbinafine*
■ Terconazole vaginal*
■Tizanidine*
■Topiramate*
■Torsemide*
■Tradjenta
■Tramadol*
■Tramadol/APAP*
■Trazadone*
■Trazadone*
■Tretinoin*
■Triamcinolone*
■ Triamterene & HCTZ*
■Triphasil*
■Valacyclovir*
■ Valganciclovir hcl*
■ Valproic acid*
■Valsartan
■Venlafaxine*
■Venlafaxine-XR*
■Verapamil*
■Veripred
■Viibryd
■Yasmin*
■YAZ*
■Zafirlukast*
■Zegerid
■Zonisamide*
■Zovirax
Symbol Key: OTC = Over-The-Counter * = Generic Substitution Required
Color Key: ■ Prescribe without Restrictions ■ Medication may have quantity limit, age limit, etc. ■ Medication requires Prior Authorization
Disclaimer: This chart is intended to be used as a quick reference, and does not contain all items available on the BHS Preferred Drug List. For a complete
listing of all items available, please consult the text version of the BHP Preferred Drug List which is included as part of the BHS Provider Manual. The PDL is
also available online at www.buckeyehealthplan.com. Effective Date: 4/28/2015
©Buckeye Health Plan. All rights reserved.