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AETNA BETTER HEALTH® Illinois formulary
AETNA BETTER HEALTH® Illinois formulary Revised 1/2016 ILLINOIS FORMULARY REVISED January 2016 What is the Aetna Better Health Illinois Formulary? This is a drug list created by Aetna Better Health (“plan”). Aetna Better Health will cover drugs on this list. Some drugs may have coverage rules. If the rules for that drug are met, Aetna Better Health will cover the drug. Drugs must also be filled at an Aetna Better Health network pharmacy. Can Aetna Better Health’s Drug List change? The plan may add or remove drugs on the list. All drug removals from the formulary will be sent to the state for review before the change is made. Utilizing members and their providers will be notified at least 30 days before a drug is removed from the formulary. All changes to the formulary will be posted on the plan’s website. How do I use Aetna Better Health’s formulary? Column #1: lists the covered drug. Brand drugs are in upper case letters (e.g., DRUG). Generics are in lower case letters (e.g., drug). Column #2: lists the brand name of the drug when a generic is covered Column #3: shows coverage rules for the drug Drugs are also grouped by the type of condition they treat. Drugs used to treat an earache are listed under the section, Ear-Nose-Throat Medications. If you know what your drug is used for, please look for that section name on the drug list. Then look under that section for your drug. How much will I pay for covered drugs? You do not have to pay for covered drugs. What are some types of coverage rules? Prior Approval (PA): This means your doctor will need to get approval from the plan first before the drug can be filled at the pharmacy. If it is not approved, the plan will not cover the drug. Quantity Level Limits (QLL): This means there is a limit on the amount of drug the plan will cover. For example, the plan provides 60 pills in 30 days for some drugs. Step Therapy (ST): This means you may need to try certain drugs first to treat your condition. After the first drug is tried, the plan will then cover the other drug for that same condition. For Page 1 ILLINOIS FORMULARY REVISED January 2016 example, Drug A and Drug B may treat your condition. The plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, then Drug B will be covered. What if my drug is not on Aetna Better Health’s formulary? First, please call your doctor and ask if your drug is covered. If the plan does not cover the drug, then: Ask your doctor for a similar drug that is covered. Your doctor can ask the plan to cover your drug through the prior approval process. What are generic drugs? Aetna Better Health covers both brand and generic drugs. Generic drugs cost less and are approved by the Food and Drug Administration (FDA). Are Over-The-Counter (OTC) drugs covered? The plan will cover OTC drugs on the formulary. Some OTC drugs may have coverage rules. If the rules for that OTC drug are met, the plan will cover the OTC drug. Like other drugs, OTC drugs need a prescription from a doctor if they are to be covered by the plan. Page 2 ILLINOIS FORMULARY REVISED January 2016 ¿Qué es el formulario de Aetna Better Health para Illinois? Es una lista de medicamentos creada por Aetna Better Health (el “plan”). Aetna Better Health ofrece cobertura para los medicamentos de esta lista. Es posible que para algunos medicamentos se apliquen reglas de cobertura. Si se cumplen las reglas para esos medicamentos, Aetna Better Health los cubrirá. Además, los medicamentos deben adquirirse en una farmacia de la red de Aetna Better Health. ¿Puede cambiar la lista de medicamentos de Aetna Better Health? El plan puede agregar o quitar medicamentos de la lista. Todas las eliminaciones de medicamentos del formulario se enviarán al estado, donde se revisarán antes de que se realice el cambio. Los miembros y proveedores que utilizan el formulario recibirán un aviso como mínimo 30 días antes de que se elimine un medicamento del formulario. Encontrará todos los cambios del formulario en el sitio en Internet del plan. ¿Cómo utilizo el formulario de Aetna Better Health? Columna Nº 1: enumera los medicamentos cubiertos. Los medicamentos de marca aparecen en mayúscula (por ejemplo, MEDICAMENTO); los genéricos aparecen en minúscula (por ejemplo, medicamento). Columna Nº 2: enumera los medicamentos de marca cuando una opción genérica está cubierta. Columna Nº 3: muestra las reglas de cobertura de los medicamentos. Los medicamentos también están agrupados según el tipo de condición que tratan. Por ejemplo, los medicamentos que se usan para tratar un dolor de oído figuran en la sección, Ear-Nose-Throat Medications. Si sabe para qué se usa el medicamento que usted toma, busque el nombre de esa sección en la lista de medicamentos y luego busque el medicamento en esa sección. ¿Cuánto pagaré por los medicamentos cubiertos? Usted no tiene que pagar por los medicamentos cubiertos. ¿Cuáles son algunos de los tipos de reglas de cobertura? Aprobación previa (PA): significa que su médico primero deberá obtener la aprobación del plan antes de que se pueda adquirir el medicamento en la farmacia. Si no se aprueba, el plan no cubrirá el medicamento. Límites de cantidad (QLL): significa que el plan cubre hasta una cierta cantidad del medicamento. Por ejemplo, en el caso de algunos medicamentos, el plan cubre 60 píldoras en 30 días. Page 3 ILLINOIS FORMULARY REVISED January 2016 Terapia escalonada (ST): significa que posiblemente primero deba probar ciertos medicamentos para tratar su condición. Después de probar el primer medicamento, el plan cubrirá el otro medicamento para la misma condición. Por ejemplo, el Medicamento A y el Medicamento B pueden tratar su condición. Es posible que el plan no cubra el Medicamento B a menos que usted primero pruebe el Medicamento A. Si el Medicamento A no funciona en su caso, entonces se cubrirá el Medicamento B. ¿Qué sucede si el medicamento que tomo no está incluido en el formulario de Aetna Better Health? Primero, llame a su médico y pregúntele si su medicamento está cubierto. Si el plan no lo cubre, usted tiene dos opciones: Pida a su médico un medicamento similar que esté cubierto. Su médico puede solicitar que el plan cubra el medicamento a través del proceso de aprobación previa. ¿Qué son los medicamentos genéricos? Aetna Better Health cubre tanto medicamentos de marca como genéricos. Los medicamentos genéricos cuestan menos y están aprobados por la Administración de Drogas y Alimentos (FDA). ¿Los medicamentos de venta libre están cubiertos? El plan cubrirá los medicamentos de venta libre que figuren en el formulario. Es posible que para algunos medicamentos de venta libre se apliquen reglas de cobertura. Si se cumplen las reglas para esos medicamentos de venta libre, el plan los cubrirá. Al igual que con otros medicamentos, se requiere una receta del médico para que el plan brinde cobertura para los medicamentos de venta libre. Page 4 ILLINOIS FORMULARY REVISED January 2016 COVERED DRUG MEDICAMENTO CUBIERTO REFERENCE DRUG NAME NOMBRE DE MEDICAMENTO DE REFERENCIA REQUIREMENTS/LIMITS REQUERIMIENTOS/LÍMITES ANESTHETICS DRUGS USED TO RELIEVE PAIN IN SPECIFIC AREAS ANESTÉSICOS MEDICAMENTOS UTILIZADOS PARA ALIVIAR EL DOLOR EN ÁREAS ESPECÍFICAS TOPICAL ANESTHETICS / ANESTÉSICOS TÓPICOS lidocaine hcl Xylocaine lidocaine hcl viscous Xylocaine lidocaine-prilocaine Emla ANTIINFECTIVES DRUGS USED TO TREAT BACTERIAL, FUNGAL, OR VIRAL INFECTIONS ANTIINFECCIOSOS MEDICAMENTOS UTILIZADOS PARA TRATAR INFECCIONES CAUSADAS POR BACTERIAS, HONGOS O VIRUS CEPHALOSPORINS / CEFALOSPORINAS Cefaclor Ceclor cefaclor er Ceclor ER cefadroxil Duricef Cefdinir Omnicef cefpodoxime proxetil Vantin cefprozil Cefzil cefuroxime Ceftin Cephalexin 250mg, 500mg only Keflex ceftriaxone Rocephin QLL=2 grams/Rx cefuroxime axetil Ceftin SUPRAX QLL= 1 tab/Rx CLINDAMYCINS / CLINDAMICINAS CLEOCIN GRANULES clindamycin Cleocin ERYTHROMYCINS / ERITROMICINAS erythromycin Eryc erythromycin ethylsuccinate E.E.S. erythromycin w/sulfisoxazole Pediazole OTHER MACROLIDES / OTROS MACRÓLIDOS azithromycin Zithromax QLL for 250 mg=12 tabs/30 days QLL for 600 mg=8 tabs/30 days clarithromycin, er Biaxin, Biaxin XL QLL=28 tabs/30 days PENICILLINS / PENICILINAS amox tr-potassium clavulanate Augmentin QLL=28/30 days amoxicillin Amoxil ampicillin Principen dicloxacillin penicillin v potassium Veetids ILLINOIS FORMULARY REVISED January 2016 COVERED DRUG MEDICAMENTO CUBIERTO REFERENCE DRUG NAME NOMBRE DE MEDICAMENTO DE REFERENCIA REQUIREMENTS/LIMITS REQUERIMIENTOS/LÍMITES SULFONAMIDES / SULFONAMIDAS sulfamethoxazole/trimethoprim Septra sulfadiazine sulfatrim pediatric suspension TETRACYCLINES / TETRACICLINAS demeclocycline doxycycline Vibramycin minocycline hcl Dynacin tetracycline hcl Sumycin URINARY ANTIINFECTIVES / ANTIINFECCIOSOS URINARIOS FURADANTIN (25 MG/5 ML SUSPENSION) methenamine hippurate nitrofurantoin, Macrodantin nitrofurantoin macrocrystal Macrobid nitrofurantoin mono/macrocrystals trimethoprim QUINOLONES / QUINOLONAS ciprofloxacin er ciprofloxacin hcl ofloxacin levofloxacin tablets, soln Cipro XR Cipro Floxin Levaquin QLL=3 tabs/Rx QLL=28 tabs/30 days QLL=14 tabs/90 days TOPICAL ANTIBACTERIAL DRUGS / MEDICAMENTOS ANTIBACTERIALES TÓPICOS OTC bacitracin topical ointment bacitracin/polymyxin B chlorhexidine gluconate erythromycin gentamicin sulfate mupirocin ointment, cream silver sulfadiazine sulfacetamide sodium OTC triple antibiotic cream Polysporin Peridex Eryderm Genoptic Bactroban Silvadene Ovace Neosporin ORAL ANTIFUNGAL DRUGS / MEDICAMENTOS ANTIFÚNGICOS ORALES clotrimazole fluconazole GRISEOFULVIN TAB MICR 500mg griseofulvin 125 mg/5 ml suspension GRISEOFULVIN TAB ULTR Mycelex Diflucan GRIFULVIN V GRIS-PEG Page 6 ILLINOIS FORMULARY REVISED January 2016 COVERED DRUG MEDICAMENTO CUBIERTO itraconazole capsule ketoconazole nystatin SPORANOX (ORAL SOLUTION) terbinafine Terbinafine topical REFERENCE DRUG NAME NOMBRE DE MEDICAMENTO DE REFERENCIA REQUIREMENTS/LIMITS REQUERIMIENTOS/LÍMITES Sporanox Nizoral Mycostatin STEP Lamisil QLL=84 tabs/year VAGINAL ANTIFUNGALS / MEDICAMENTOS ANTIFÚNGICOS VAGINALES OTC clotrimazole miconazole 200 mg suppositories nystatin terconazole Mycelex Monistat 3 Mycostatin Terazol OTHER TOPICAL ANTIFUNGALS / OTROS MEDICAMENTOS ANTIINFECCIOSOS ciclopirox OTC clotrimazole econazole nitrate ketoconazole OTC miconazole 2% nystatin Loprox/Penlac Lotrimin Spectazole Nizoral TOPICAL ANTIFUNGAL-CORTICOSTEROID COMB / CORTICOSTEROIDES Y ANTIFÚNGICOS TÓPICOS COMBINADOS clotrimazole/betamethasone nystatin w/triamcinolone Lotrisone Mycolog II ANTIRETROVIRALS & PROTEASE INHIBITORS /ANTIRRETROVIRALES E INHIBIDORES DE LA PROTEASA Abacavir; Lamivudine, 3TC; Zidovudine, ZDV APTIVUS ATRIPLA LAMIVUDINE/ZIDOVUDINE COMPLERA CRIXIVAN didanosine EDURANT EMTRIVA EPIVIR Lamivudine, 3TC EPZICOM TRIZIVIR COMBIVIR EPIVIR HBV FUZEON INTELENCE Page 7 ILLINOIS FORMULARY REVISED January 2016 INVIRASE KALETRA LEXIVA Nevirapine, Nevirapine ER tabs, oral solution COVERED DRUG MEDICAMENTO CUBIERTO Viramune, Viramune XR REFERENCE DRUG NAME NOMBRE DE MEDICAMENTO DE REFERENCIA REQUIREMENTS/LIMITS REQUERIMIENTOS/LÍMITES NORVIR PREZISTA RESCRIPTOR REYATAZ Stavudine STRIBILD SUSTIVA Tivicay Zerit Triumeq TRUVADA VIDEX SOLUTION, CHEWABLE TABS VIRACEPT VIRAMUNE XR 100mg only VIREAD Vitekta ABACAVIR Zidovudine ZIAGEN OTHER ANTIINFECTIVE DRUGS / OTROS MEDICAMENTOS ANTIINFECCIOSOS CLEOCIN (100 MG VAGINAL OVULE) Dapsone atovaquone suspension MEPRON STEP OTHER ANTIVIRAL DRUGS / OTROS MEDICAMENTOS ANTIVIRALES Acyclovir amantadine hcl Entecavir Famciclovir Ganciclovir ISENTRESS PEGINTRON PEGINTRON REDIPEN PEGASYS Zovirax Symmetrel QLL=90 caps or tabs/30 days BARACLUDE Famvir PA PA PA Page 8 ILLINOIS FORMULARY REVISED January 2016 Rimantadine Flumadine COVERED DURING FLU SEASON (OCT 1, 2014 TO April 30, 2015); QLL=7 tabs/30 days MUST BE ON INTERFERON COVERED DURING FLU SEASON (OCT 1, 2014 TO April 30, 2015); QLL/Rx=20 inhalation diskus/Rx MUST BE ON INTERFERON REFERENCE DRUG NAME REQUIREMENTS/LIMITS REQUERIMIENTOS/LÍMITES REBETOL (ORAL SOLUTION) RELENZA Ribavirin COVERED DRUG MEDICAMENTO CUBIERTO NOMBRE DE MEDICAMENTO DE REFERENCIA Sovaldi PA QLL=14 tabs/14 days SELZENTRY TAMIFLU COVERED DURING FLU SEASON (OCT 1, 2014 TO april 30, 2015); QLL=75mg 10 capsules/Rx; 45mg=10 capsules /Rx; 30mg=20 capsules/Rx; 12mg/ml oral suspension=3 bottles/Rx PA TYZEKA Valacyclovir Valtrex 500 mg tablet QLL=60 tabs/30 days 1 gram tablet QLL=30 tabs/30 days ZOVIRAX (5% CREAM, OINTMENT) ANTITUBERCULOSIS DRUGS / MEDICAMENTOS ANTITUBERCULOSOS Ethambutol Isoniazid Rifabutin PRIFTIN Pyrazinamide Rifampin Myambutol Nydrazid MYCOBUTIN Rifadin AMEBICIDES / AMIBICIDAS YODOXIN ANTHELMINTICS / ANTIHELMÍNTICOS ALBENZA Mebendazole Ivermectin STROMECTOL PLASMODICIDES / PLASMODICIDAS chloroquine phosphate DARAPRIM hydroxychloroquine sulfate Mefloquine Plaquenil Lariam Page 9 ILLINOIS FORMULARY REVISED January 2016 TRICHOMONOCIDES / TRICOMONICIDAS Metronidazole Flagyl AMINOGLYCOSIDES / AMINOGLUCÓSIDOS Neomycin Paromomycin Page 10 ILLINOIS FORMULARY REVISED January 2016 ANTINEOPLASTIC/IMMUNOSUPPRESSANT DRUGS DRUGS USED FOR CANCER TREATMENT, TRANSPLANTS OR OTHER RARE CONDITIONS Medications within this class are covered for FDA-approved indications and may require prior authorization. All injectable medications within this class require prior authorization. MEDICAMENTOS INMUNOSUPRESORES/ANTINEOPLÁSICOS MEDICAMENTOS UTILIZADOS PARA EL TRATAMIENTO DEL CÁNCER, ENFERMEDADES RARAS O TRASPLANTES Los medicamentos de esta clase están cubiertos para el uso según las indicaciones aprobadas por la FDA y pueden requerir autorización previa. Todos los medicamentos inyectables dentro de esta clase requieren autorización previa. anagrelide capsules anastrozole tablets AZASAN azathioprine tablets Bicalutamide CEENU CAPSULE cyclophosphamide caps cyclosporine capsule, oral soln DROXIA CAPSULE EMCYT CAPSULE ENBREL etoposide capsule Exemestane FARESTON TABLET fluorouracil cream, solution flutamide capsule GLEEVEC HEXALEN CAPSULE HUMIRA HYCAMTIN CAPSULE hydroxyurea capsule, tablet IRESSA TABLET leflunomide tablet leucovorin tablet LEUKERAN TABLET Letrozole LYSODREN TABLET MATULANE CAPSULE megestrol acetate suspension (40mg/ml), tablet mercaptopurine tablet MESNEX TABLET methotrexate tablet Agrylin Arimidex Imuran Casodex Cytoxan Sandimmune PA Vepesid Aromasin Efudex PA PA Hydrea Arava Femara Megace Purinethol Trexall Page 11 ILLINOIS FORMULARY REVISED January 2016 mycophenolate 250 mg capsules, 500 mg tablets Mycophenolate 200mg suspensions mycophenolate 180mg, 360mg tablet NEXAVAR TABLET NILANDRON TABLET RAPAMUNE ORAL SOLN Sirolimus tablets TABLOID TABLET tacrolimus capsule tamoxifen citrate tablet TARCEVA TABLET TARGRETIN TOPICAL GEL, Bexarotene TABLET tretinoin capsule, cream, gel, solution TYKERB TABLET CellCept Cellcept Susp MYFORTIC TABLET PA Rapamune Prograf Nolvadex PA TARGRETIN Tablet Vesinoid PA AUTONOMIC AND CNS MEDICATIONS DRUGS USED FOR PAIN MANAGEMENT AND OTHER BEHAVIORAL CONDITIONS (E.G, ANXIETY, DEPRESSION, DIFFICULTY SLEEPING, SEIZURES, ETC.) MEDICAMENTOS PARA TRATAR AFECCIONES DEL SISTEMA NERVIOSO CENTRAL Y AUTÓNOMO MEDICAMENTOS UTILIZADOS PARA CONTROLAR EL DOLOR Y OTRAS CONDICIONES DEL COMPORTAMIENTO (POR EJEMPLO, ANSIEDAD, DEPRESIÓN, DIFICULTADES PARA DORMIR, CONVULSIONES, ETC.) ALCOHOL ANTAGONIST / ANTAGONISTAS DEL ALCOHOL DISULFIRAM Evzio Naltrexone Vivitrol ANTABUSE QLL=380mg/intramuscular dose ANALGESICS / ANALGÉSICOS OTC acetaminophen tablets, capsules, suppositories, liquids, drops tramadol hcl tramadol hcl-acetaminophen Tramadol ER Tylenol QLL= up to 4 grams APAP/day Ultram Ultracet QLL=240 tabs/30 days QLL= 4 grams APAP/day QLL=30 tabs/30 days CLASS II NARCOTICS / DROGAS CLASE II codeine sulfate fentanyl patches fentanyl lozenges hydromorphone hcl methadone hcl morphine sulfate ER Morphine sulfate IR Duragesic Actiq Dilaudid Dolophine MS Contin QLL=30 tabs/30 days PA; QLL=10 patches/30 days QLL=90 lozenges /30 days QLL for 8 mg=120 tabs/30 days PA; QLL=540 tabs/30 days PA; QLL=90/30 days Page 12 ILLINOIS FORMULARY REVISED January 2016 oxycodone-acetaminophen oxycodone-aspirin oxycodone hcl Percocet Oxyir OXYCONTIN Oxymorphone ER Opana ER QLL=240 tabs/30 days or up to 4 grams APAP/day QLL=240 tabs/30 days QLL for 5 mg=240 tabs/30 days, 10 mg, 15 mg, 20 mg, or 30 mg=150 tabs/30 days PA/QLL=90 tabs/30 days PA; QLL= 60/30 DAYS CLASS III NARCOTICS / DROGAS CLASE III acetaminophen-codeine Bunavail Buprenorphine hydrocodone-acetaminophen (excludes combinations with 300mg acetaminophen strengths) Tylenol #3 hydrocodone bit-ibuprofen SUBOXONE FILM, buprenorphine/naloxone SL tabs Vicoprofen Subutex QLL= 4 grams APAP/day QLL=12.6 mg/2.1 mg per day buccally Bunavail buccal film. QLL=24mg/day QLL= 4 grams APAP/day QLL=240 tabs/30 days 2mg/0.5mg QLL=90 /30 days 4mg/1mg QLL=180/30 days 8mg/2mg QLL=90/30 days 12mg/3mg QLL=60/days Miscellaneous Psychotherapeutic/ Varios psicoterapéutico acamprosate Campral Modafanil Provigil PA QLL=#30/30 days DRUGS TO PREVENT AND TREAT HEADACHES / MEDICAMENTOS PARA PREVENIR Y TRATAR DOLORES DE CABEZA butalbital/acetaminophen/caffeine (50/325/40) butalbital/acetaminophen/caffeine/ codeine (50/325/40/30) butalbital/aspirin/caffeine (50/325/40) butalbital compound capsule (50/325/40/30) butorphanol nasal spray ERGOMAR ergotamine/caffeine Sumatriptan sumatriptan (inj) MIGRANAL Esgic/Fioricet/Triad Fioricet w/codeine Fiorinal, Fortabs Fiorinal w/codeine Stadol Cafergot Imitrex Imitrex QLL=1 bottle/30 days QLL=6 nasal sprays/30 days; 9 tabs/30 days QLL=4 vials/30 days; 2 kits/30 days QLL=8 units/30 days Page 13 ILLINOIS FORMULARY REVISED January 2016 RELPAX QLL=6 tabs/30 days ANXIOLYTICS / ANSIOLÍTICOS alprazolam, -XR, intensol solution buspirone hcl chlordiazepoxide hcl clorazepate dipotassium Clonazepam diazepam 2.5 mg, 10 mg, 20 mg rectal gel Diazepam Lorazepam, 2mg/ml injection Meprobamate Oxazepam Xanax, XR Buspar Librium Tranxene T-Tab Klonopin QLL=90 tabs/30 days QLL=2 pkgs/30 days Valium Ativan QLL=3/34 DAYS (INJECTION: QLL and no PA for LTC members) Serax SEDATIVE & HYPNOTIC DRUGS / MEDICAMENTOS HIPNÓTICOSY SEDANTES Estazolam flurazepam hcl temazepam 7.5 mg, 15 mg, & 30 mg ROZEREM Dalmane Restoril QLL=30 tabs/30 days QLL=30 caps/30 days QLL=30 caps/30 days QLL=30 tabs/30 days Page 14 ILLINOIS FORMULARY REVISED January 2016 Zaleplon Zolpidem 5mg, 10mg Sonata Ambien QLL=30 caps/30 days QLL=30 tabs/30 days ANTIMANIA DRUGS / ANTIMANÍACOS lithium carbonate Eskalith/CR lithium citrate CARBAMAZEPINES / CARBAMAZEPINAS Carbamazepine carbamazepine ER CARBATROL oxcarbazepine tablets, suspension Tegretol Tegretol XR QLL=120/30 days Trileptal ANTICONVULSAN AND BENZODIAZEPINES / ANTICONVULSIVOS Y BENZODIACEPINAS Clonazepam Klonopin HYDANTOINS / HIDANTOÍNAS phenytoin sodium, extended DILANTIN INFATABS, DILANTIN 30 MG EXTENDED RELEASE PHENYTEK Dilantin, ER VALPROIC ACID AND DERIVATIVES / ÁCIDO VALPÓRICO Y DERIVADOS DEPAKOTE ER, DELAYED RELEASE,SPRINKLE divalproex sodium ER, delayed-release valproic acid Depakote ER, Delayed-Release Depakene ANTICONVULSANT BARBITURATES / BARBITÚRICOS UTILIZADOS PARA EVITAR CONVULSIONES Mephobarbital Phenobarbital Primidone Mebaral Mysoline OTHER ANTICONVULSANTS / OTROS MEDICAMENTOS UTILIZADOS PARA EVITAR CONVULSIONES CELONTIN Ethosuximide Felbamate Gabapentin GABITRIL Lamotrigine Levetiracetam NEURONTIN SOLUTION Topiramate Zonisamide FELBATOL Neurontin QLL=180 units/30 days QLL=60 tabs/30 days Lamictal Keppra Topamax Zonegran QLL=180 units/30 days MAO INHIBITORS / INHIBIDORES DE MAO MARPLAN NARDIL Tranylcypromine Parnate TERTIARY AMINES / AMINAS TERCIARIAS amitriptyline hcl Elavil Page 15 ILLINOIS FORMULARY REVISED January 2016 Clomipramine doxepin hcl imipramine hcl, IMIPRAMINE PAMOATE Anafranil Sinequan Tofranil,PM Trimipramine PA Surmontil SECONDARY AMINES / AMINAS SECUNDARIAS Amoxapine desipramine hcl nortriptyline hcl Protriptyline Norpramin Pamelor SELECTIVE SEROTONIN REUPTAKE INHIBITOR / INHIBIDORES SELECTIVOS DE LA RECAPTACIÓN DE LA SEROTONINA Citalopram Celexa Escitalopram Lexapr o Prozac fluoxetine hcl QLL=30 tabs/30 days or 300 ml/30 days QLL=30 tab/30 days Pexeva QLL for 10 mg=30 caps/30 days; 20 mg, 40 mg= 60 tabs/caps/ 30 days; soln=150 ml/30 days QLL for 100 mg=90 tabs/30 days; 50 mg=60 tabs/30 days; 25 mg= 30 tabs/30 days QLL=60 tabs/30 days; soln=300 ml/30 days PA Pristiq PA fluvoxamine maleate Luvox paroxetine hcl Paxil sertraline hcl Zoloft QLL for 25 mg=30 tabs/30 days; 50 mg or 100 mg=60 tabs/30 days; soln=75 ml/30 days OTHER ANTIDEPRESSANTS / OTROS ANTIDEPRESIVOS amitriptyline/ chlordiazepoxide budeprion sr bupropion, xl, sr Maprotiline mirtazapine, ODT trazodone hcl 50 mg, 100 mg, & 150 mg venlafaxine, ER (ER capsules only) Duloxetine Wellbutrin SR Wellbutrin Remeron Desyrel Effexor, Effexor XR Cymbalta QLL=60 tabs/30 days QLL=90 tabs/30 days (IR); 60 tabs/30 days (SR 12 hr); 30 tabs/30 days (XL 24 hr) QLL=30 tabs/30 days Page 16 ILLINOIS FORMULARY REVISED January 2016 ANTIVERTIGO AND ANTIEMETIC DRUGS / MEDICAMENTOS ANTIEMÉTICOS Y PARA TRATAR EL VÉRTIGO Granisetron Meclizine ondansetron hcl, ODT prochlorperazine maleate promethazine hcl EMEND Kytril PA Zofran, Zofran ODT Compazine Phenergan PA ANTIPARKINSON ANTICHOLINERGIC DRUGS / MEDICAMENTOS ANTICOLINÉRGICOS PARA TRATAR EL MAL DE PARKINSON benztropine mesylate, injection QLL=3/34 DAYS (INJECTION ONLY COVERED FOR LTC RESIDENTS) Trihexyphenidyl OTHER ANTIPARKINSON DRUGS / OTROS MEDICAMENTOS PARA TRATAR EL MAL DE PARKINSON bromocriptine mesylate 2.5 mg carbidopa/levodopa Parlodel Sinemet Entacapone COMTAN Pramipexole Mirapex Ropinirole Requip QLL=90 tabs/30 days STALEVO PA; QLL=270 tabs/30 days PA; QLL=120 tabs/30 days Selegiline carbidopa/levodopa/entacapone ANTIPSYCHOTIC DRUGS / ANTIPSICÓTICOS chlorpromazine tablets, 25mg/ml ampules clozapine 12.5 mg, 25 mg, & 100 mg fluphenazine tablets, decanoate injection, hydrochloride injection Prolixin 25mg/ml ampules COVERED for LTC RESIDENTS ONLY; all others require PA; QLL=3 AMP/34 Days (HCL INJ ONLY-QLL=1/34 DAYS COVERED for LTC RESIDENTS); all others require PA for hcl inj only Page 17 ILLINOIS FORMULARY REVISED January 2016 haloperidol tablets, decanoate injection, lactate injection (LACTATE INJ ONLY-covered for LTC RESIDENTS; all others require PA; QLL=3/34 DAYS) COVERED FOR LTC RESIDENTS; ALL OTHERS REQUIRE PA INVEGA SUSTENNA INVEGA TRINZA PA Latuda PA Loxapine olanzapine, olanzapine ODT Zyprexa Zyprexa Zydis Orally Disintegrating Tablet (ODT) ONLY- REQUIRES PA Risperdal, Risperdal M-Tab QLL=60 tabs/30 days; STEP (ODT only) COVERED FOR LTC RESIDENTS, ALL OTHERS REQUIRE PA QLL=1/14 DAYS Seroquel QLL=90 tabs/30 days; 300 mg=60 tabs/30 days PA Perphenazine risperidone, odt Risperdal Consta Quetiapine Saphris Thioridazine Thiothixene Trifluoperazine Ziprasidone Geodon STEP CNS STIMULANT DRUGS / MEDICAMENTOS PARA ESTIMULAR EL SISTEMA NERVIOSO CENTRAL amphetamine/dextroamphetamine Dextroamphetamine dexmethylphenidate IR methylin, er tabs, methylin suspension methylphenidate er, sr 10 mg , 20 mg (methylphenidate ER 18 mg, 27 mg, 35 mg, 54 mg are non-formulary and requires PA) methylphenidate hcl methylphenidate ER capsule Adderall, Adderall XR Focalin Ritalin, Ritalin-SR Ritalin-SR Ritalin METADATE CD, Ritalin LA PA less than 6yrs and over 18 years; Immediate release QLL=90 tabs/30 days; Extended release QLL=30 caps/30 days18 years; PA less than 6yrs and over PA less than 6yrs and over 18 years; PA less than 6yrs and over 18 years; QLL=120 tabs/30 days PA less than 6yrs and over 18 years PA less than 6yrs and over 18 years; QLL=120 tabs/30 days PA less than 6yrs and over 18 years; QLL=60 caps/30 days Page 18 ILLINOIS FORMULARY REVISED January 2016 STRATTERA PA; QLL=60 caps/30 days ANTIDEMENTIA DRUGS / MEDICAMENTOS PARA TRATAR LA DEMENCIA donepezil 5 MG, 10 MG (23 MG IS NON-FORMULARY) donepezil ODT galantamine, -ER Aricept QLL=30 tabs/30 days Aricept ODT QLL=30 tabs/30 days Razadyne, Razadyne ER Memantine rivastigmine capsules NAMENDA Exelon capsules galantamine QLL=60 tabs/30 days galantamine ER QLL=30 caps/30 days QLL=60 caps/30 days SMOKING CESSATION DRUGS / MEDICAMENTOS PARA DEJAR DE FUMAR Buproban Zyban CHANTIX OTC nicotine patch Nicoderm Duration for all formulary smoking cessation meds=84 days/year Duration for all formulary smoking cessation meds=84 days/year Duration for all formulary smoking cessation meds=84 days/year OTHER CNS DRUGS / OTROS MEDICAMENTOS QUE ACTÚAN SOBRE EL SISTEMA NERVIOSO CENTRAL caffeine citrate oral solution Pyridostigmine CARDIOVASCULAR MEDICATIONS DRUGS USEDFOR HEART CONDITIONS (HIGHBLOODPRESSURE,CHOLESTEROL,CHEST PAIN,ETC.) MEDICAMENTOS PARA TRATAR ENFERMEDADES CARDIOVASCULARES MEDICAMENTOS UTILIZADOS PARA TRATAR CONDICIONES DEL CORAZÓN (POR EJEMPLO, PRESIÓN SANGUÍNEA ALTA, COLESTEROL, DOLOR EN EL PECHO, ETC.) CARDIAC GLYCOSIDES / GLUCÓSIDOS CARDÍACOS Digoxin LANOXIN Lanoxin CALCIUM ANTAGONISTS / SOBREDOSIS DE ANTAGONISTAS DEL CALCIO Amlodipine cartia xt diltiazem er diltiazem hcl diltia xt dilt-CD felodipine er Isradipine nicardipine hcl nifediac cc nifedipine, er Norvasc Cardizem CD Tiazac/Taztia XT, Cardizem SR Cardizem Cardizem CD Cardizem CD Plendil DynaCirc Cardene ProcardiaProcardia XL QLL= 30 tabs/30 days 10mg; 60tabs /30 days 5mg; 120 tabs/30 days 2.5mg QLL=60 caps or tabs/30 days QLL=120 tabs/30 days Extended Release QLL=90 tabs/30 days Page 19 ILLINOIS FORMULARY REVISED January 2016 Nimodipine Nisoldipine verapamil, er Nimotop Sular Verelan/Calan/Calan SR QLL=60 tabs/30 days QLL for Immediate Release=120 units/30days; QLL for Extended Release=60 units/30 days CARBONIC ANHYDRASE INHIBITORS / INHIBIDORES DE LA ANHIDRASA CARBÓNICA acetazolamide, ER Diamox LOOP DIURETICS / DIURÉTICOS DE ASA Bumetanide Furosemide Torsemide Bumex Lasix Demadex THIAZIDE AND RELATED DRUGS / TIAZIDA Y MEDICAMENTOS RELACIONADOS Chlorthalidone Chlorothiazide Hydrochlorothiazide Indapamide Methyclothiazide Metolazone Microzide Lozol Zaroxolyn POTASSIUM SPARING DIURETICS / DIURÉTICOS QUE NO AFECTAN EL POTASIO Amiloride amiloride hcl w/hctz Spironolactone spironolactone w/hctz triamterene w/hctz Midamor Moduretic Aldactone Aldactazide Maxzide/Diazide BETA-ADRENERGIC ANTAGONIST DRUGS / ANTAGONISTAS BETA ADRENÉRGICOS Acebutolol Atenolol Betaxolol bisoprolol fumarate Carvedilol labetalol hcl metoprolol succinate metoprolol tartrate Nadolol Pindolol propranolol, er timolol maleate Tenormin Kerlone Zebeta Coreg Normodyne/Trandate Toprol XL Lopressor Corgard Inderal/LA VASODILATOR ANTIHYPERTENSIVES / ANTIHIPERTENSORES VASODILATORES doxazosin mesylate hydralazine hcl Minoxidil prazosin hcl terazosin hcl Cardura Appresdine Minipress Hytrin QLL=30 tabs/30 days QLL 1mg, 2mg, 5mg=30/30 days; QLL 10 mg=60/30 days CENTRALLY ACTING ANTIHYPERTENSIVES / ANTIHIPERTENSORES DE ACCIÓN CENTRAL clonidine patches Catapres TTS Page 20 ILLINOIS FORMULARY REVISED January 2016 clonidine tablets guanfacine hcl Catapres Tenex Page 21 ILLINOIS FORMULARY REVISED January 2016 methyldopa ANGIOTENSIN CONVERTING ENZYME INHIBITORS / ANTAGONISTAS DE LA ENZIMA CONVERTIDORA DE ANGIOTENSINA Benazepril Captopril Enalapril Fosinopril Lisinopril Lotensin Capoten Vasotec Monopril Prinivil/Zestril Moexipril perindopril Ramipril Quinapril trandolapril Univasc Aceon Altace Accupril Mavik QLL=30 tabs/30 days; 40 mg=60 tabs/30 days ANGIOTENSIN II RECEPTOR ANTAGONISTS / ANTAGONISTAS DE LOS RECEPTORES DE ANGIOTENSINA II Candesartan, Candesartan HCTZ Atacand, Atacand HCT Valsartan, Valsartan HCTZ DIOVAN, Diovan HCT Losartan, Losartan HCTZ Cozaar,Hyzaar Irbesartan, Irbesartan HCTZ Avapro, Avilide QLL=60 tabs/30 days; OTHER ANTIHYPERTENSIVES / OTROS ANTIHIPERTENSIVOS amlodipine/benazepril 2.5/10 mg, 5/10 mg, 5/20 mg, 10/20 mg, 10/40 mg atenolol w/chlorthalidone benazepril hcl w/hctz bisoprolol fumarate w/hctz captopril w/hctz enalapril maleate w/hctz fosinopril w/hctz lisinopril w/hctz methyldopa w/hctz metoprolol w/hctz moexipril w/hctz propranolol hcl w/hctz quinapril w/hctz Resperine Lotrel 2.5/10 mg, 5/10 mg, 5/20 mg, 10/20, 10/40 mg Tenoretic Lotensin HCT Ziac Capozide Vaseretic Monopril HCT Prinzide/Zestoretic Lopressor HCT Uniretic Inderide Quinaretic NITRATES / NITRATOS isosorbide dinitrate, ER isosorbide mononitrate, ER nitro-bid ointment Isochron/Isordil Imdur/Ismo/Monoket Page 22 ILLINOIS FORMULARY REVISED January 2016 nitroglycerin (patch, sublingual tablet, extended-release capsule) NITROSTAT Nitro-Dur/Nitrostat OTHER VASODILATING DRUGS / OTROS MEDICAMENTOS VASODILATADORES ADCIRCA PA/QLL=60 tabs/30 days SILDENAFIL REVATIO PA/QLL=90 tabs/30 days CLASS 1A ANTIARRHYTHMICS / ANTIARRÍTMICOS DE CLASE 1A disopyramide, er Procainamide quinidine gluconate quinidine sulfate Norpace CLASS 1B Antiarrhythmic / ANTIARRÍTMICOS DE CLASE 1B Mexiletine Mexitil PA CLASS 1C Antiarrhythmics / ANTIARRÍTMICOS DE CLASE 1C flecainide acetate propafenone hcl Tambocor Rythmol PA OTHER ANTIARRHYTHMICS / OTROS ANTIARRÍTMICOS Amiodarone Pacerone MULTAQ PA sotalol, af Betapace HYPOLIPOPROTEINEMICS / HIPOLIPOPROTEINÉMICOS Cholestyramine colestipol hcl Fenofibrate Gemfibrozil OTC niacin OTC SLO NIACIN Colestid Lofibra, Tricor Lopid QLL=60 tabs/30 days Page 23 ILLINOIS FORMULARY REVISED January 2016 fenofibric acid ZETIA TRILIPIX STEP HMG-COA REDUCTASE INHIBITORS / INHIBIDORES DE LA REDUCTASA DE LA HMG-COA Atorvastatin Lovastatin Pravastatin Simvastatin Fluvastatin, ER Lipitor Mevacor Pravachol Zocor LESCOL, Lescol XL QLL= 30 tabs/ 30 days QLL=30 tabs/30 days; 40 mg=60 tabs/30 days QLL=30 tabs/30 days QLL=30 tabs/30 days QLL=30 caps/30 days OTHER CARDIOVASCULAR DRUGS / OTROS MEDICAMENTOS PARA TRATAR AFECCIONES CARDIOVASCULARES Midodrine Pentoxifylline ProAmatine Trental DERMATOLOGICAL MEDICATIONS DRUGS USED TO TREAT SWELLING, REDNESS, ITCHING OR ALLERGIC SKIN REACTIONS, ACNE, HAIR LICE, ETC. MEDICAMENTOS DERMATOLÓGICOS MEDICAMENTOS UTILIZADOS PARA REDUCIR INFLAMACIONES, ENROJECIMIENTO DE LA PIEL, PICAZÓN O REACCIONES ALÉRGICAS DE LA PIEL, ACNÉ, PEDICULOSIS, ETC. TOPICAL CORTICOSTEROID DRUGS / CORTICOSTEROIDES TÓPICOS alclometasone dipropionate Amcinonide betamethasone dipropionate betamethasone valerate clobetasol propionate Desonide Desoximetasone diflorasone diacetate Fluocinolone Fluocinonide fluticasone propionate Halobetasol hydrocortisone (prescription and OTC forms covered) hydrocortisone butyrate hydrocortisone valerate lidocaine-hydrocortisone mometasone furoate Prednicarbate triamcinolone acetonide Aclovate Diprolene Beta-Val Clobevate/Temovate Desowen/Lokara Topicort Apexicon/Maxiflor/Psorcon Cutivate Ultravate Ala-Cort/Cetacort/Hytone Locoid Westcort Elocon Dermatop Kenalog ANTIPRURITIC DRUGS / MEDICAMENTOS ANTIPRURÍTICOS hydroxyzine hcl Page 24 ILLINOIS FORMULARY REVISED January 2016 hydroxyzine pamoate ANTIACNE DRUGS / MEDICAMENTOS PARA TRATAR EL ACNÉ adapalene cream, gel (0.1% only) Amnesteem Benzoyl Peroxide cream lotion, wash, cream Claravis clindamycin phosphate Clindamycin/benzoyl peroxide Erythromycin Erythromycin/Benzoyl Peroxide METROGEL 1% TOPICAL GEL Metronidazole sod.sulfacetamide/sulfur10-5% only Sotret Tretinoin Differin Accutane Accutane Cleocin T/Clindamax Benzaclin A/T/S / Emgel/Erycette Metrocream/Metrolotion Avar/Plexion Accutane Avita/Retin-A QLL=20 gram tube/30days KERATOLYTIC DRUGS / MEDICAMENTOS QUERATOLÍTICOS CONDYLOX GEL podofilox solution Condylox ANTIPSORIASIS AND ANTIECZEMA DRUGS / MEDICAMENTOS PARA TRATAR PSORIASIS Y ECCEMAS calcipotriene ointment, scalp solution OTC DOAK TAR DISTILLATE, OIL DRITHO-SCALP POLYTAR selenium sulfide sulfacetamide sodium calcitriol ointment Dovonex Selseb Carmol Scalp VECTICAL OINTMENT ORAL DERMATOLOGICAL DRUGS / MEDICAMENTOS DERMATOLÓGICOS ORALES OXSORALEN ULTRA TOPICAL DERMATOLOGICAL DRUGS / MEDICAMENTOS DERMATOLÓGICOS ORALES ammonium lactate CARAC ELIDEL FLUOROPLEX Fluorouracil imiquimod 5% cream HYPERCARE SANTYL OTC zinc oxide ointment Tacrolimus Lac-Hydrin STEP/QLL=30 gm/30 days Efudex Aldara Desitin Protopic SCABICIDES / ESCABICIDAS Acticin Malathion Elimite 5% Topical Cream Ovide Page 25 ILLINOIS FORMULARY REVISED January 2016 OTC permethrin 1% lotion Nix Page 26 ILLINOIS FORMULARY REVISED January 2016 permethrin 5% cream (prescription strength) OTC Pyrethrin 0.33% ULESFIA LOTION Elimite EAR-NOSE-THROAT MEDICATIONS DRUGS USED FOR EAR INFECTIONS, NASAL ALLERGIES OR DRY MOUTH MEDICAMENTOS PARA TRATAR AFECCIONES DE NARIZ, OÍDO Y GARGANTA MEDICAMENTOS UTILIZADOS PARA TRATAR INFECCIONES NASALES, DEL OÍDO O BOCA SECA DRUGS AFFECTING THE EAR / MEDICAMENTOS PARA AFECCIONES DE OÍDO antipyrine/benzocaine otic acetic acid otic CIPRO HC CIPRODEX OTIC neomycin/polymixin/hydrocortisone Ofloxacin Benzotic/Otogesic DRUGS AFFECTING THE NOSE / MEDICAMENTOS PARA AFECCIONES DE NARIZ Azelastine Flunisolide fluticasone propionate ipratropium bromide OTC Nasacort AQ Oxymetazoline Astelin Nasarel Flonase Atrovent QLL= 2 bottles/30 days STEP STEP Afrin DRUGS AFFECTING THE THROAT AND MOUTH / MEDICAMENTOS PARA AFECCIONES DE BOCA Y GARGANTA chlorhexidine gluconate doxycycline hyclate pilocarpine hcl triamcinolone acetonide 0.1% paste Peridex Periostat Salagen Kenalog ENDOCRINE MEDICATIONS USED FOR DIABETES, LOW/HIGH THYROID LEVELS, OSTEOPOROSIS, ETC. MEDICAMENTOS PARA TRATAR AFECCIONES ENDÓCRINAS UTILIZADOS PARA TRATAR DIABETES, NIVELES BAJOS/ALTOS DE HORMONA TIROIDEA, OSTEOPOROSIS, ETC. ORAL HYPOGLYCEMIC DRUGS / MEDICAMENTOS HIPOGLUCÉMICOS ORALES Acarbose Chlorpropamide Glimepiride glipizide, er glipizide-metformin Glyburide glyburide-metformin Precose Diabinese Amaryl Glucotrol, XL Metaglip Diabeta/Micronase Glucovance Page 27 ILLINOIS FORMULARY REVISED January 2016 metformin, ─er Nateglinide Repeglinide PRANDIMET JANUMET, JANUMET XR JANUVIA STEP Januvia JANUVIA STEP Jentadueto Tolazamide Tolazamide Tolbutamide Tradjenta Glucophage, XR Starlix Prandin STEP STEP STEP STEP INSULIN SENSITIZERS / SENSIBILIZADORES DE INSULINA AVANDAMET AVANDARYL AVANDIA DUETACT Pioglitazone pioglitazone/metformin ACTOS ACTOPLUS MET QLL=60 tabs/30 days QLL=60 tabs/30 days QLL=30 tabs/30 days QLL=30 tabs/30 days QLL=30 tabs/30 days QLL=90 tabs/30 days OTHER GLUCOSE-LOWERING DRUGS Drugs Byetta Trulicity Invokana Invokamet Farxiga STEP STEP STEP STEP STEP INSULIN (VIALS ONLY) / INSULINA (SOLO EN FRASCOS) Each insulin type has QLL=6 vials/30 day supply HUMALOG 50/50 VIAL HUMALOG 75/25 VIAL HUMALOG 100U VIAL HUMULIN 50/50 VIAL HUMULIN R (100 U/ML VIAL) HUMULIN R (500 U/ML VIAL) HUMULIN 70/30 VIAL NOVOLIN 70/30 VIAL NOVOLIN R VIAL NOVOLIN N VIAL NOVOLOG VIAL NOVOLOG MIX 70/30 VIAL LANTUS VIAL LEVEMIR VIAL GLUCOSE ELEVATING DRUGS / MEDICAMENTOS QUE ELEVAN EL NIVEL DE GLUCOSA GLUCAGEN VIALS GLUCAGON OTC glucose chewable tablets GLUCOCORTICOID DRUGS / GLUCOCORTICOIDES Cortisone Page 28 ILLINOIS FORMULARY REVISED January 2016 Dexamethasone Hydrocortisone Methylprednisolone Prednisolone Prednisone Prednisolone phosphate orally disintegrating tablet Cortef Medrol Prelone Sterapred ORAPRED ODT GROWTH HORMONES / HORMONAS DE CRECIMIENTO Omnitrope vials NORDITROPIN PA PA NORDITROPIN NORDIFLEX NUTROPIN NUTROPIN AQ PA PA PA MINERALOCORTICOID DRUGS / MINERALOCORTICOIDES fludrocortisone acetate Florinef THYROID SUPPLEMENTS / SUPLEMENTOS TIROIDEOS NP Thyroid Levothroid levothyroxine sodium Levoxyl Liothyronine thyroid, dessicated Unithroid ARMOUR THYROID Synthroid Synthroid Cytomel Armour Thyroid Synthroid ANTITHYROID DRUGS / MEDICAMENTOS ANTITIROIDEOS Methimazole Propylthiouracil Tapazole ANDROGEN DRUGS / ANDRÓGENOS Danazol testosterone cypionate (200 mg/ml only) OTHER ENDOCRINE DRUGS / OTROS MEDICAMENTOS ENDÓCRINOS alendronate sodium Fosamax Cabergoline Dostinex calcitonin nasal spray CHEMET Miacalcin desmopressin acetate DDAVP/Minirin Etidronate QLL 35 mg or 70 mg=4 tabs/30 days; QLL 5 mg,10 mg, 40 mg=30 tabs/30 days COVERED FOR ENDO; ALL OTHERS REQUIRE PA; QLL=1 bottle/30 days; QLL=90 tabs/30 days Didronel Page 29 ILLINOIS FORMULARY REVISED January 2016 fortical nasal spray SENSIPAR PA GASTROINTESTINAL MEDICATIONS DRUGS USED FOR HEART BURN, REDUCE ACID PRODUCTION IN THE STOMACH, DIARRHEA, CONSTIPATION, ETC. MEDICAMENTOS PARA TRATAR AFECCIONES GASTROINTESTINALES MEDICAMENTOS UTILIZADOS PARA TRATAR LA ACIDEZ, REDUCIR LA PRODUCCIÓN DE ÁCIDO DEL ESTÓMAGO, DIARREA, CONSTIPACIÓN, ETC. ANTIDIARRHEAL DRUGS / ANTIDIARRÉICOS Page 30 ILLINOIS FORMULARY REVISED January 2016 bismuth subsalicylate diphenoxylate w/atropine OTC loperamide Pepto Bismol Lomotil Imodium ANTISPASMODICS – DRUGS AFFECT GI MOTILITY / ANTIESPASMÓDICOS – MEDICAMENTOS QUE AFECTAN LA MOTILIDAD GASTROINTESTINAL dicyclomine hcl glycopyrrolate tablets Hyoscyamine metoclopramide hcl Bentyl Robinul Nulev/Levbrel Reglan ANTIULCER DRUGS (OTC AND PRESCRIPTION FORMS COVERED) / MEDICAMENTOS PARA PREVENIR ÚLCERAS (COBERTURA PARA MEDICAMENTOS CON RECETA Y DE VENTA LIBRE) Cimetidine Famotidine Nizatidine Ranitidine Tagamet Pepcid Axid Zantac OTHER ANTIULCER DRUGS / OTROS MEDICAMENTOS PARA PREVENIR ÚLCERAS Misoprostol Sucralfate Cytotec Carafate PROTON PUMP INHIBITORS / INHIBIDORES DE LA BOMBA DE PROTONES OTC omeprazole, First Omeprazole Pantoprazole OTC Prilosec Protonix QLL=120 tabs /30 days STEP QLL=30 tabs/30 days OTC esomeprazole OTC Nexium QLL=2 caps/DAY OTC lansoprazole OTC Prevacid QLL=2 caps/day LAXATIVES AND CATHARTICS / LAXANTES Y PURGANTES OTC bisacodyl OTC docusate OTC docusate-senna Generlac OTC glycerin OTC MIRALAX polyethylene glycol 3350 powder for solution OTC psyllium OTC SENOKOT (brand and generic dosage forms covered) OTC SORBITOL 70% ORAL SOLN Dulcolax Colace Peri-Colace Fleet Miralax Metamucil QLL=527 g/30 days QLL=527 g/30 days OTHER GI DRUGS / OTROS MEDICAMENTOS PARA TRATAR AFECCIONES GASTROINTESTINALES OTC aluminum hydroxide gel OTC antacid liquid, suspension AMITIZA ASACOL Alternagel QLL=60 caps/30 days Page 31 ILLINOIS FORMULARY REVISED January 2016 Dezicol OTC calcium antacid tablet CANASA CORTIFOAM CREON 5, 10, 15, CREON LIPASE 6,000; 12,000; 24,000 UNITS DIPENTUM OTC effervescent pain relief OTC hemorrhoidal cream OTC hydrocortisone enema suspension Hydrocortisone 2.5% rectal cream Tums Alka Seltzer PreparationH Proctosol-hydrocortisone 2.5% rectal cream IPECAC SYRUP mesalamine enema NULYTELY WITH FLAVOR PACKS Octreotide acetate (inj) PANCREAZE PANCRELIPASE 5,000 UNITS PEG 3350 ELECTROLYTE SOLUTION PENTASA PROCTOFOAM-HC Propantheline OTC simethicone drops Sandostatin LAR sulfasalazine, sulfasalazine delayed-release sulfazine, sulfazine delayed -release Ursodiol VIOKASE 8, 16 ZENPEP 5,000U; 10,000U, 15,000U, 20,000U PA PA Azulfidine Azulfidine Actigall Formatted Table IMMUNOLOGICALS AND VACCINES VACCINES AND DRUGS USED FOR MULTIPLE SCLEROSIS ESTIMULADORES INMUNOLÓGICOS Y VACUNAS VACUNAS Y MEDICAMENTOS UTILIZADOS PARA TRATAR ESCLEROSIS MÚLTIPLE FLUMIST COVERED DURING FLU SEASON (OCT 1, 2012 TO April 30, 2013); PA >49 YEARS; QLL=#1/YEAR RHOGAM MicRhoGAM INTERFERONS USED FOR MULTIPLE Page 32 ILLINOIS FORMULARY REVISED January 2016 SCLEROSIS / INTERFERONES UTILIZADOS PARA TRATAR ESCLEROSIS MÚLTIPLE AUBAGIO COPAXONE EXTAVIA GLATOPA REBIF PA PA PA PA PA MUSCULOSKELETAL MEDICATIONS DRUGS USED TO RELEIVE PAIN, MUSCLE SPASMS, JOINT PAIN/SWELLING DUE TO GOUT MEDICAMENTOS PARA TRATAR AFECCIONES MUSCULOESQUELÉTICAS MEDICAMENTOS UTILIZADOS PARA ALIVIAR DOLOR, ESPASMOS DE LOS MÚSCULOS, DOLOR ARTICULAR/HINCHAZÓN PROVOCADOS POR LA GOTA SALICYLATES AND RELATED DRUGS / SALICILATOS Y MEDICAMENTOS RELACIONADOS OTC aspirin 81 mg, 325 mg, Ecotrin choline magnesium trisalicylate Diflunisal Salsalate Dolobid Disalcid NON-STEROIDAL ANTIINFLAMMATORY AGENTS / AGENTES ANTIINFLAMATORIOS NO ESTEROIDES diclofenac sodium Etodolac Fenoprofen Flurbiprofen ibuprofen (prescription and OTC forms covered) Indomethacin Ketoprofen Ketorolac Meclofenamate Meloxicam Nabumetone Naproxen OTC naproxen Lodine/Lodine XL Anasaid Motrin Indocin SR Orudis/Oruvail Toradol QLL=20 tabs/30 days and 2 Rxs per 90 days Mobic Relafen Naprosyn Aleve Page 33 ILLINOIS FORMULARY REVISED January 2016 Oxaprozin Piroxicam Sulindac Tolmetin Daypro Feldene Clinoril COX-2 Inhibitors Celecoxib Celebrex STEP OTHER DRUGS FOR ARTHRITIS / OTROS MEDICAMENTOS PARA TRATAR ARTRITIS RIDAURA Hyalgan COVERED FOR RHEUMATOLOGISTS; ALL OTHERS REQUIRE PA PA Gel-One PA DRUGS TO PREVENT AND TREAT GOUT / MEDICAMENTOS PARA PREVENIR Y TRATAR LA GOTA Allopurinol colchicine colchicine / probenecid Probenecid ULORIC Zyloprim Colcrys STEP DIRECT MUSCLE RELAXANTS / RELAJANTES MUSCULARES DIRECTOS Baclofen dantrolene capsule tizanidine hcl Dantrium Zanaflex CNS MUSCLE RELAXANTS / RELAJANTES MUSCULARES QUE ACTÚAN SOBRE EL SISTEMA NERVIOSO CENTRAL Carisoprodol cyclobenzaprine hcl Methocarbamol Metaxalone Soma Flexeril Robaxin Skelaxin PA (refer to HFS website: http://www.hfs.illinois.gov/pharmacy /carisoprodol.html); Cummulative QLL=240 tabs/365 days QLL=120 tabs/30 days QLL=120 tabs/30 days QLL=120 tabs/30 days OTHER MUSCULOSKELETAL MEDICATIONS /OTROS MEDICAMENTOS PARA TRATAR AFECCIONES MUSCULOESQUELÉTICAS OTC capsaicin Page 34 ILLINOIS FORMULARY REVISED January 2016 RILUTEK PA NUTRITION, BLOOD MODIFIERS, ELECTROLYTES VITAMINS AND DRUGS USED TO REDUCE BLEEDING NUTRICIÓN, AGENTES QUE MODIFICAN LA SANGRE, ELECTROLITOS VITAMINAS Y MEDICAMENTOS UTILIZADOS PARA REDUCIR EL SANGRADO THERAPEUTIC VITAMINS & MINERALS / MINERALES Y VITAMINAS TERAPÉUTICAS OTC calciferol, OTC ergocalciferol drops Calcitriol calcium acetate OTC calcium carbonate, OTC calcium carbonate 600 mg + D OTC calcium citrate CYANOCOBALAMIN INJ (VITAMIN B12) ergocalciferol 1.25 mg capsule, (prescription) OTC ferrous fumerate OTC ferrous gluconate OTC ferrous sulfate OTC Fish Oil folic acid (prescription-strength covered only) Levocarnitine OTC magnesium oxide OTC multivitamins (generic, adult multivitamins) NEPHROCAPS, NEPHROCAPS QT OTC pyridoxine (vitamin B6) OTC sodium bicarbonate sodium fluoride stannous fluoride rinse OTC vitamin C 500, 1000 mg OTC vitamin D OTC thiamine (vitamin B1) Paricalcitol Drisdol Calcijex/Rocaltrol Phoslo Caltrate Citracal Vitamin D2 Iron PA ZEMPLAR PA POTASSIUM SUPPLEMENTS / SUPLEMENTOS DE POTASIO citric acid monohydrate, sodium citrate dihydrate oral solution klor con, klor con m, klor con effervescent potassium chloride tablets, oral solution SHOHL'S MODIFIED Bicitra K-Dur/Klotrix POTASSIUM REMOVING RESINS / RESINAS PARA ELIMINAR POTASIO sodium polystyrene sulfonate, powder Kayexalate ORAL ANTICOAGULANTS / ANTICOAGULANTES ORALES Page 35 ILLINOIS FORMULARY REVISED January 2016 warfarin sodium Xarelto Eliquis Coumadin PA PA HEPARINS / HEPARINAS heparin sodium vials [inj] (heparin lock flush solution requires PA) LOW-MOLECULAR WEIGHT HEPARINS (LMWH) / HEPARINAS DE BAJO PESO MOLECULAR enoxaparin [inj] FRAGMIN [inj] Lovenox Fondaparinux (inj) Arixtra 10 DAYS W/O PA 10 DAYS W/O PA (10 DAYS=10 SYRINGES) (10 DAYS=10 SYRINGES) 21 days without PA ANTIPLATELET DRUGS / MEDICAMENTOS ANTIPLAQUETARIOS Cilostazol Clopidogrel Dipyridamole ticlopidine hcl Pletal Plavix Persantine Ticlid QLL=30 tabs/30 days HEMOSTATICS / HEMOSTÁTICOS Amicar MEPHYTON BLOOD DETOXICANTS / Enulose Generlac Lactulose RENVELA OTHER BLOOD MODIFIERS / DESINTOXICANTES DE LA SANGRE Anagrelide SOLIRIS Agrylin PA OBSTETRICAL & GYNECOLOGICAL MEDICATIONS BIRTH CONTROL PILLS, VITAMINS FOR PREGANCY, HORMONE REPLACEMENT THERAPY FOR MENOPAUSAL WOMEN, ETC. MEDICAMENTOS PARA TRATAR AFECCIONES OBSTÉTRICAS Y GINECOLÓGICAS PÍLDORAS ANTICONCEPTIVAS, VITAMINAS PARA EL EMBARAZO, TERAPIA DE REEMPLAZO HORMONAL PARA MUJERES MENOPÁUSICAS, ETC. CONTRACEPTIVES / ANTICONCEPTIVOS Apri Aranelle Aviane Azurette Balziva Brevicon Camila Desogen Tri-Norinyl Alesse-28 Mircette Ovcon-35 Modicon Nor-Q-D Page 36 ILLINOIS FORMULARY REVISED January 2016 Caziant Cesia Condoms Cryselle ELLA Enpresse Errin Cyclessa Cyclessa Lo/Ovral-28 Tri-levlen 28 Nor-Q-D Page 37 ILLINOIS FORMULARY REVISED January 2016 Gianvi gildess FE Jolessa Jolivette junel, junel FE Kariva kelnor 1/35 Leena Lessina OTC levonorgestrel levora-28 low-ogestrel Lutera Mirena mirogestin, microgestin FE Mononessa Necon Yaz Loestrin FE Seasonale Nor-Q-D Loestrin, Loestrin FE Mircette Demulen 1/35-28 Tri-Norinyl Alesse-28 Plan B Nordette-28 Lo/Ovral-28 Alesse-28 Loestrin, Loestrin FE Ortho-Cyclen Modicon, Necon, Norinyl 1+35, Norinyl 1+50, Ortho Novum Nexplanon nora-be Nortrel NUVARING Ocella Ogestrel Ethinyl Estradiol; Norelgestromin patch OTC NEXT CHOICE QLL=2 tabs (1 pkg)/1 month; QLL=6 tabs (3 pkg)/year QLL= 1 implant/3 years Nor-Q-D Modicon, Norinyl 1+35, Ortho Novum QLL=1 ring/month Yasmin 28, Yaz Ovral-28 ORTHO EVRA OTC PLAN B ONE STEP QLL=3 patches/28 days QLL=2 tabs (1 pkg)/1 month; QLL=6 tabs (3 pkg)/year QLL=1 tab (1 pkg)/1 month; QLL=3 tabs (3 pkg)/year Paragard Portia Previfem Quasense Reclipsen Solia Sprintec Sronyx tilia fe tri-legest Trinessa tri-previfem Nordette-28 Ortho-Cyclen Seasonale Desogen Desogen Ortho-Cyclen Alesse-28 Estrostep Fe Estrostep Fe Ortho Tri-Cyclen Ortho Tri-Cyclen Page 38 ILLINOIS FORMULARY REVISED January 2016 tri-sprintec trivora-28 Velivet Zenchent zovia 1/35E zovia 1/50E Ortho Tri-Cyclen Tri-Levlen 28 Cyclessa Ortho Novum Demulen 1/35-28 Demulen 1/50-21 PRENATAL VITAMINS; covered for females only; QLL=100 tabs/90 days for all legend prenatal vitamins VITAMINAS PRENATALES; se brinda cobertura solo para mujeres; QLL = 100 tabletas cada 90 días para todas las vitaminas prenatales con receta advanced care plus bp multinatal plus cal-nate concept dha Folbecal natalcare glosstabs natatab Rx Prenafirst prenatal advantage (prenatal AD) prenatabs FA prenatal H prenatabs rx prenatal U SELECT-OB, SELECT-OB+ DHA trimesis rx Trinate ultra-natal vinate II vinate az vinate calcium vinatal forte vinate gt vinate m vinate one vinate ultra vitafol-ob vitafol-pn Vitaspire OB/GYN TOPICAL ANTIINFECTIVES / ANTIINFECCIOSOS TÓPICOS GINECOLÓGICOS acidic vaginal jelly clindamycin 2% vaginal cream CLEOCIN OVULE metronidazole 0.75% vaginal gel, 1% gel OTC miconazole vaginal suppositories, cream Clindamax MetroGel ESTROGEN DRUGS / ESTRÓGENOS Page 39 ILLINOIS FORMULARY REVISED January 2016 estradiol tablets estradiol transdermal patch estropipate ESTRACE VAGINAL CREAM ESTRING FEMRING MENEST PREMARIN VAGINAL CREAM W/APPLICATOR VAGIFEM Estrace Climara Ogen/Ortho-Est QLL=4 patches/30 days ESTROGEN-PROGESTIN COMBINATIONS / COMBINACIONES DE ESTRÓGENO/PROGESTINA ACTIVELLA CLIMARA PRO COMBIPATCH estradiol/norethindrone acetate 1 mg-0.5 mg FEMHRT PREFEST PREMPHASE PREMPRO Activella1 mg-0.5mg SELECTIVE ESTROGEN RECEPTOR MODULATOR / MODULADOR SELECTIVO DE RECEPTORES ESTROGÉNICOS Raloxifene EVISTA QLL=30 tabs/30 days PROGESTIN DRUGS / PROGESTINAS Camila Errin Jolivette medroxyprogesterone acetate (inj) medroxyprogesterone acetate tablets nora-be norethindrone acetate PROGESTERONE CAPSULE Micronor/Nor-Q-D Micronor/Nor-Q-D Micronor/Nor-Q-D Depo Provera Provera Micronor/Nor-Q-D Aygestin PROMETRIUM QLL for injection=1/90 days OTHER OB/GYN DRUGS / OTROS MEDICAMENTOS GINECOLÓGICOS METHERGINE TABLETS OPHTHALMIC MEDICATIONS DRUGS USED FOR EYE INFECTIONS, DRY EYES, GLAUCOMA, ETC. MEDICAMENTOS OFTÁLMICOS MEDICAMENTOS UTILIZADOS PARA TRATAR INFECCIONES EN LOS OJOS, OJOS SECOS, GLAUCOMA, ETC. OPHTHALMIC TOPICAL ANTIBACTERIAL DRUGS / MEDICAMENTOS ANTIBACTERIALES OFTÁLMICOS TÓPICOS bacitracin ophth ointment bacitracin/polymixin ophth ointment AK-Poly Bac Page 40 ILLINOIS FORMULARY REVISED January 2016 ciprofloxacin hcl (ophth drops) CILOXAN OPTHALMIC OINTMENT erythromycin gentamicin sulfate levofloxacin neomycin/polymyxin/bacitracin neomycin/polymyxin/gramicidin Ofloxacin polymyxin/trimethoprim sulfacetamide sodium tobramycin sulfate TOBREX OINTMENT VIGAMOX ZYMAXID Ciloxan Garamycin/Gentak Quixin Neosporin Ocuflox Polytrim Bleph-10 Tobrex OPHTHALMIC CORTICOSTEROID DRUGS / MEDICAMENTOS CORTICOSTEROIDES OFTÁLMICOS dexamethasone fluorometholone FML FORTE PRED MILD prednisolone Omnipred/Pred Forte OPHTHALMIC ANTIINFECTIVE/CORTICOSTEROIDS / ANTIINFECCIOSOS/CORTICOSTEROIDES OFTÁLMICOS neomycin/polymixin/hydrocortisone neomycin/polymyxin/dexamethasone prednisolone/sulfacetamide TOBRADEX OINTMENT tobramycin/dexamethasone susp Cortisporin Methadex/Maxitrol Tobradex ANTIGLAUCOMA DRUGS / MEDICAMENTOS ANTIGLAUCOMA acetazolamide, ER Alphagan P 0.1% AZOPT BETOPTIC S betaxolol hcl brimonidine tartrate 0.15%, 0.2% carteolol hcl COMBIGAN dorzolamide dorzolamide/timolol ISOPTO CARBACHOL Latanoprost Alphagan P Trusopt Cosopt Xalatan Page 41 ILLINOIS FORMULARY REVISED January 2016 levobunolol hcl LUMIGAN methazolamide metipranolol PHOSPHOLINE IODIDE pilocarpine hcl timolol maleate TRAVATAN Z Travoprost Betagan STEP Optipranolol Isopto Carpine Timoptic/Timoptic-XE PA PA OTHER OPHTHALMIC DRUGS / OTROS MEDICAMENTOS OFTÁLMICOS ak-con Azelastine OTC artificial tears atropine sulfate drops, ointment cromolyn sodium Cyclopentolate 1% diclofenac sodium Epinastine flurbiprofen sodium ketorolac tromethamine ISOPTO HOMATROPINE ISOPTO HYOSCINE MUROCOLL-2 NEVANAC PATANOL phenylephrine OTC REFRESH TEARS, LIQUIGEL (15 ML AND 30 ML BOTTLE ONLY) OTC sodium chloride 5% drops, ointment OTC SYSTANE (15 ML AND 30 ML BOTTLE ONLY) Trifluridine Tropicamide ketotifen OTC Optivar Tears Again Isopto Atropine Crolom Cyclogyl Voltaren Elestat Ocufen Acular, Acular LS STEP Tropicacyl OTC Zaditor RESPIRATORY MEDICATIONS DRUGS USED FOR ASTHMA, ALLERGIES, COUGH/COLD, ETC. MEDICAMENTOS PARA AFECCIONES RESPIRATORIAS MEDICAMENTOS UTILIZADOS PARA TRATAR ASMA, ALERGIAS, TOS/RESFRÍO, ETC. BETA-2 ADRENERGIC DRUGS / MEDICAMENTOS ADRENÉRGICOS BETA-2 albuterol sulfate (inhalation soln, syrup, tablet) metaproterenol QLL=390 ml/30 days for inhalation soln Page 42 ILLINOIS FORMULARY REVISED January 2016 Foradil Terbutaline VENTOLIN HFA Arcapta Neohaler Striverdi Respimat STEP QLL= 2 inhalers/30 days INHALED CORTICOSTEROIDS / CORTICOSTEROIDES INHALADOS ADVAIR DISKUS Covered for ages 4-11 years; all others require PA ADVAIR HFA budesonide respules 0.25 mg/2 ml, 0.50 mg/2 ml, 1mg/2ml PA Pulmicort Respules FLOVENT DISKUS QVAR PULMICORT FLEXHALER/INHALER SYMBICORT QLL=120 ml/30 days (60 respules/30 days) PA for all members over age 5 QLL=1 inhaler or flexhaler/30 days LEUKOTRIENE MODIFIERS / MODIFICADORES DE LEUCOTRIENOS Montelukast Zafirlukast SINGULAIR Accolate QLL=30 tabs/30 days STEP THERAPY FOR MEMBERS WITH DIAGNOSIS OF ASTHMA; QLL=60 tabs/30 days METHYL XANTHINE DRUGS / METILXANTINAS aminophylline theophylline, er OTHER RESPIRATORY DRUGS / OTROS MEDICAMENTOS PARA AFECCIONES RESPIRATORIAS ATROVENT (INHALER) cromolyn sodium inhalation soln EPIPEN, EPIPEN JR epinephrine pen 0.15mg , 0.3mg ipratropium bromide ipratropium bromide/albuterol inhalation soln COMBIVENT RESPIMAT SPIRIVA, Spiriva Respimat Intal Adrenaclick STEP; QLL=30 caps/30 days Tudorza Incruse Ellipta sodium chloride 0.9% nebulizer solution OTC ANTIHISTAMINES / ANTIHISTAMÍNICOS Bromax carbinoxamine Page 43 ILLINOIS FORMULARY REVISED January 2016 cetirizine OTC tablets, cetirizine-D OTC tablets, cetirizine OTC solution cetirizine syrup (prescription and OTC) chlorpheniramine maleate clemastine fumarate cyproheptadine hcl Dexchlorpheniramine solution only diphenhydramine (prescription and OTC forms covered) hydroxyzine hcl OTC loratadine, OTC loratadine-D Vazol solution OTC Zyrtec, Zyrtec Syrup cetirizine-D QLL=60 tabs/30 days cetirizine soln QLL=150 ml/30 days Tavist Periactin Benadryl OTC Claritin, Claritin-D OTC loratadine-D=30 tabs/30 days ANTIHISTAMINE-DECONGESTANT COMBINATIONS COMBINACIONES DE ANTIHISTAMÍNICOS-DESCONGESTIVOS brompheniramine/phenyephrine oral soln OTC brompheniramine-pseudoephedrine elixir ceron drops, syrup lohist-lq liquid r-tanna pediatric suspension Virdec 1mg-3.5mg/ml Drops Rondec drops, syrup ANTITUSSIVE AND EXPECTORANT DRUGS / ANTITUSÍGENOS Y EXPECTORANTES Benzonatate OTC CHERATUSSIN AC Tessalon guaifenesin-dm nr liquid guaifenesin tablets guaifenesin w/codeine Humibid Romilar AC/Tussi-Organidin DM NR MUCINEX, Mucinex D, DM OTC promethazine vc w/codeine syrup Phenergan VC w/Codeine promethazine vc syrup Phenergan VC promethazine w/dm syrup OTC tussin DM Virdec DM 3.5mg-1mg-3mg/ml Drops Phenergan DM Robitussin DM OTHER DRUGS FOR COUGH, COLD, ALLERGY / OTROS TRATAMIENTOS PARA TRATAR ALERGIAS, TOS Y RESFRÍO OTC nasal spray Afrin OTC pseudoephedrine (all generic dosage Sudafed forms covered) TOXICOLOGY MEDICATIONS DRUGS USED TO TREAT OVERDOSE OR REDUCE HIGH LEVELS OF COPPER IN THE BODY MEDICAMENTOS TOXICOLÓGICOS MEDICAMENTOS PARA TRATAR LA SOBREDOSIS O REDUCIR LOS NIVELES DE COBRE EN EL CUERPO Page 44 ILLINOIS FORMULARY REVISED January 2016 acetylcysteine CUPRIMINE UROLOGICAL MEDICATIONS DRUGS USED TO TREAT OVERACTIVE BLADDER, CONDITIONS FOR THE PROSTATE, ETC. MEDICAMENTOS UROLÓGICOS MEDICAMENTOS UTILIZADOS PARA TRATAR LA HIPERACTIVIDAD DE LA VEJIGA, CONDICIONES DE LA PRÓSTATA, ETC. ANTICHOLINERGIC ANTISPASMODICS DRUGS / ANTIESPASMÓDICOS ANTICOLINÉRGICOS Flavoxate oxybutynin chloride oxybutynin chloride er Tolteridone IR Trospium ER Trospium Urispas Ditropan Ditropan XL Detrol SANCTURA XR Sanctura STEP STEP STEP; QLL=60 tabs/30 days CHOLINERGIC STIMULANTS / ESTIMULANTES COLINÉRGICOS Bethanecol URINARY ANESTHETICS / ANESTÉSICOS URINARIOS phenazopyridine hcl Pyridium/Urodol OTHER GENITOURINARY PRODUCTS / OTROS PRODUCTOS GENITOURINARIOS Alfuzosin ELMIRON Finasteride K-PHOS CYTRA, -K Potassium citrate Tamsulosin Uroxatral Proscar Flomax QLL=60 caps/30 days MEDICAL (MISCELLANEOUS) SUPPLIES BLOOD GLUCOSE METERS, TEST STRIPS, OTHER SUPPLIES; SPACERS AND PEAK FLOW METERS FOR ASTHMA SUMINISTROS MÉDICOS (VARIOS) MEDIDORES DE LA GLUCOSA EN SANGRE, TIRAS REACTIVAS, OTROS SUMINISTROS; ESPACIADORES Y MEDIDORES DEL FLUJO MÁXIMO PARA EL ASMA DIABETIC SUPPLIES: Combined QLL for test strips=150/month / SUMINISTROS DIABÉTICOS: QLL combinado para tiras reactivas = 150 por mes Page 45 ILLINOIS FORMULARY REVISED January 2016 MICROLET LANCING DEVICE/LANCETS AUTOJECT 2 INJECTION DEVICE insulin syringes ONE TOUCH ULTRA2, UKTRALINK, ULTRAMINI, ULTRASMART, VERIO, VERIO IQ ONE TOUCH SELECT ONE TOUCH TEST STRIPS, CONTROL SOLUTION SOFT TOUCH SOFTCLIX CHEMSTRIP KETOSTIX OTHER SUPPLIES / OTROS SUMINISTROS AEROCHAMBER, MICROCHAMBER ALCOHOL PREP PADS ASSESS PEAK FLOW METER MICROCHAMBER PEAK FLOW METER PERSONAL BEST PEAK FLOW METER QLL=#1/YEAR QLL=#1/YEAR QLL=#1/YEAR QLL=#1/YEAR Page 46
Loprox/Penlac
Lotrimin
Spectazole
Nizoral
