Supplemental Preferred Drug List (List Of Covered Drugs)
2021Supplemental Preferred Drug List (List of Covered Drugs)Lista de medicamentos preferidos ysuplementarios (Lista de medicamentos cubiertos)WellCare of New Jersey00Please read: This document contains information about the drugs we cover in this plan.Lea: este documento contiene información sobre los medicamentos que cubrimos bajo este plan.Last updated (10/01/2021)Última actualización (10/01/2021)CAD 68012M State Approved 04232021 WellCare 2021092-21-6NJ1JMDCVR72576M 0121
Drug NamePreference Details Coverage Details*Alternative Medicines**Alternative Medicine - Me's***melatonin maximum strength oral tablet 5 mgPmelatonin oral tablet 12 mg*Analgesics - Anti-Inflammatory*P*Nonsteroidal Anti-Inflammatory Agents(Nsaids)***childrens ibuprofen oral suspension 40 mg/mlPibuprofen oral suspension 100 mg/5mlPibuprofen oral tablet 200 mgPnaproxen sodium oral tablet 220 mg*Analgesics - Nonnarcotic*P*Analgesics Other***ACEPHEN RECTAL SUPPOSITORY 325MG, 650 MGPacetaminophen oral solution 160 mg/5mlPacetaminophen oral tablet 325 mgPQL (279 EA per 31 days)acetaminophen oral tablet 500 mgPQL (186 EA per 31 days)acetaminophen oral tablet chewable 325 mgPapap extra strength oral tablet 500 mgPQL (186 EA per 31 days)apap oral tablet 325 mgPQL (279 EA per 31 days)childrens non-asa pain relief oral tabletchewable 80 mgPchildrens non-aspirin oral tablet chewable 80mgPchildrens pain reliever oral tablet chewable80 mgPchildrens silapap oral liquid 160 mg/5mlPchildrens tactinal oral tablet chewable 80 mgPed-apap oral liquid 160 mg/5mlPinfants silapap oral solution 100 mg/mlPmapap arthritis pain oral tablet extendedrelease 650 mgPMAPAP CHILDRENS ORAL SUSPENSION160 MG/5MLPmapap oral capsule 500 mgPmapap oral liquid 160 mg/5mlPQL (93 EA per 31 days)QL (186 EA per 31 days)P Preferred, Asterisk(*) N/A, PA Prior Authorization, ST Step Therapy, QL Quantity Limit, AL AgeLimit, OTC Products Require Rx, UPPERCASE Brand name drugs/ lowercase italics Generic drugs1
Drug NamePreference Details Coverage Detailsmapap oral tablet 325 mgPQL (279 EA per 31 days)mapap oral tablet 500 mgPQL (186 EA per 31 days)mapap oral tablet chewable 80 mgPmaxapap maximum strength oral tablet 500mgPQL (186 EA per 31 days)maxapap regular strength oral tablet 325 mgPQL (279 EA per 31 days)non-aspirin extra strength oral tablet 500 mgPQL (186 EA per 31 days)non-aspirin oral tablet 325 mgPQL (279 EA per 31 days)non-aspirin pain relief oral tablet 325 mgPQL (279 EA per 31 days)nortemp infants oral suspension 80 mg/0.8mlPpain & fever childrens oral solution 160mg/5mlPpain relief extra strength oral tablet 500 mgPQL (186 EA per 31 days)pain relief oral tablet 500 mgPQL (186 EA per 31 days)PHARBETOL EXTRA STRENGTH ORALTABLET 500 MGPQL (186 EA per 31 days)PHARBETOL ORAL TABLET 325 MGPQL (279 EA per 31 days)q-pap oral tablet 325 mgPQL (279 EA per 31 days)tactinal extra strength oral tablet 500 mgPQL (186 EA per 31 days)tactinal oral tablet 325 mg*Salicylate Combinations***PQL (279 EA per 31 days)tri-buffered aspirin oral tablet 325 mg*Salicylates***Paspirin childrens oral tablet chewable 81 mgPaspirin ec low dose oral tablet delayedrelease 81 mgPaspirin ec oral tablet delayed release 325 mgPaspirin oral tablet 325 mg, 81 mgPaspirin oral tablet chewable 81 mgPaspirin rectal suppository 300 mg, 600 mgPECPIRIN ORAL TABLET DELAYEDRELEASE 325 MG*Anorectal And Related Products*P*Rectal Combinations - Misc.***eq hemorrhoidal rectal suppository 0.2585.39 %PP Preferred, Asterisk(*) N/A, PA Prior Authorization, ST Step Therapy, QL Quantity Limit, AL AgeLimit, OTC Products Require Rx, UPPERCASE Brand name drugs/ lowercase italics Generic drugs2
Drug Namehemorrhoidal rectal suppository 0.25-3-85.5%, 0.25-85.39 %*Antacids*Preference Details Coverage DetailsP*Antacid & Simethicone***antacid anti-gas max strength oralsuspension 400-400-40 mg/5mlPantacid anti-gas oral suspension 200-200-20mg/5mlPantacid extra strength oral suspension 400400-40 mg/5mlPantacid iii oral suspension 400-400-40mg/5mlPMAALOX ADVANCED MAX ST ORALSUSPENSION 400-400-40 MG/5MLPMAALOX MAX ORAL SUSPENSION 400400-40 MG/5MLPMAALOX MULTI SYMPTOM MAX ST ORALSUSPENSION 400-400-40 MG/5MLPmilantex extra strength oral suspension 400400-40 mg/5mlPMINTOX PLUS ORAL TABLET CHEWABLE200-200-25 MG*Antacid Combinations***PACID GONE ORAL TABLET CHEWABLE160-105 MGPgnp foaming antacid oral tablet chewable 8020 mgPMI-ACID ORAL TABLET CHEWABLE 700300 MG*Antacids - Aluminum Salts***aluminum hydroxide gel oral suspension 320mg/5ml*Antacids - Bicarbonate***sodium bicarbonate oral tablet 325 mg, 650mg*Antacids - Calcium Salts***PPPantacid oral tablet chewable 500 mgPcalcium antacid extra strength oral tabletchewable 750 mgPP Preferred, Asterisk(*) N/A, PA Prior Authorization, ST Step Therapy, QL Quantity Limit, AL AgeLimit, OTC Products Require Rx, UPPERCASE Brand name drugs/ lowercase italics Generic drugs3
Drug NamePreference Details Coverage Detailscalcium antacid oral tablet chewable 500 mgPcalcium carbonate antacid oral suspension1250 mg/5mlPcalcium carbonate antacid oral tablet 648 mgPcalcium carbonate antacid oral tabletchewable 500 mgPCAL-GEST ANTACID ORAL TABLETCHEWABLE 500 MGPMAALOX ORAL TABLET CHEWABLE 600MGPTITRALAC ORAL TABLET CHEWABLE 420MG*Antacids - Magnesium Salts***magnesium oxide oral tablet 250 mg, 400mg, 420 mg*Anthelmintics*PP*Anthelmintics***reeses pinworm medicine oral suspension144 (50 base) mg/ml*Antidiabetics*P*Diabetic Other***BD GLUCOSE ORAL TABLET CHEWABLE5 GMglucose oral tablet chewable 4 gm*Antidiarrheal/Probiotic Agents*PP*Antidiarrheal/Probiotic Agents - Misc.***bismatrol oral suspension 262 mg/15mlPbismatrol oral tablet chewable 262 mgPbismuth oral tablet chewable 262 mgPdiotame oral tablet chewable 262 mgPKAOPECTATE EXTRA STRENGTH ORALSUSPENSION 525 MG/15MLPKAOPECTATE ORAL SUSPENSION 262MG/15MLPKAO-TIN ORAL SUSPENSION 262MG/15MLPpink bismuth oral suspension 262 mg/15mlPpink bismuth oral tablet chewable 262 mgPP Preferred, Asterisk(*) N/A, PA Prior Authorization, ST Step Therapy, QL Quantity Limit, AL AgeLimit, OTC Products Require Rx, UPPERCASE Brand name drugs/ lowercase italics Generic drugs4
Drug NamePreference Details Coverage Detailsstomach relief oral suspension 262 mg/15ml,527 mg/30mlPstomach relief oral tablet chewable 262 mgPstomach relief plus oral suspension 525mg/15ml*Antiperistaltic Agents***Panti-diarrheal oral liquid 1 mg/5mlPLOPERAMIDE A-D ORAL TABLET 2 MGPloperamide hcl oral liquid 1 mg/5ml*Antidotes And Specific Antagonists*P*Antidotes And Specific Antagonists***ipecac oral syrupPsm ipecac syrup oral syrup*Antiemetics*P*Antiemetics - Anticholinergic***meclizine hcl oral tablet 12.5 mg, 25 mgPtravel sickness oral tablet chewable 25 mg*Antihistamines*P*Antihistamines - Alkylamines***aller-chlor oral syrup 2 mg/5mlPaller-chlor oral tablet 4 mgPallergy oral tablet 4 mgPallergy relief oral tablet 4 mgPchlorhist oral tablet 4 mgPDIABETIC TUSSIN ALLERGY ORALSYRUP 2 MG/5ML*Antihistamines - Ethanolamines***Paler-cap oral capsule 25 mgPaler-dryl oral tablet 50 mgPalertab oral tablet 25 mgPallergy relief childrens oral liquid 12.5 mg/5mlPaltaryl oral elixir 12.5 mg/5mlPaltaryl oral syrup 12.5 mg/5mlPanti-hist allergy oral tablet 25 mgPBANOPHEN ORAL CAPSULE 25 MGPBANOPHEN ORAL LIQUID 12.5 MG/5MLPP Preferred, Asterisk(*) N/A, PA Prior Authorization, ST Step Therapy, QL Quantity Limit, AL AgeLimit, OTC Products Require Rx, UPPERCASE Brand name drugs/ lowercase italics Generic drugs5
Drug NamePreference Details Coverage DetailsBANOPHEN ORAL TABLET 25 MGPBENADRYL ALLERGY CHILDRENS ORALLIQUID 12.5 MG/5MLPcomplete allergy medication oral tablet 25 mgPcomplete allergy relief oral tablet 25 mgPdiphenhist oral capsule 25 mgPdiphenhist oral liquid 12.5 mg/5mlPdiphenhist oral tablet 25 mgPdiphenhydramine hcl oral capsule 25 mg, 50mgPdiphenhydramine hcl oral tablet 25 mgPgenahist oral capsule 25 mgPpharbedryl oral capsule 25 mg, 50 mgPq-dryl oral capsule 25 mgPq-dryl oral liquid 12.5 mg/5mlPSCOT-TUSSIN ALLERGY RELIEF ORALLIQUID 12.5 MG/5MLPsiladryl allergy oral liquid 12.5 mg/5mlPsilphen cough oral syrup 12.5 mg/5mlPTOTAL ALLERGY MEDICINE ORAL LIQUID12.5 MG/5MLPtotal allergy oral tablet 25 mg*Antihistamines - Non-Sedating***PALLEGRA ALLERGY CHILDRENS ORALTABLET 30 MGPallergy oral tablet dispersible 10 mgPcetirizine hcl childrens alrgy oral syrup 1mg/mlPQL (300 ML per 31 days)cetirizine hcl childrens oral solution 1 mg/mlPQL (300 ML per 31 days)cetirizine hcl oral syrup 5 mg/5mlPQL (300 ML per 31 days)cetirizine hcl oral tablet 10 mg, 5 mgPchildrens loratadine oral syrup 5 mg/5mlPfexofenadine hcl oral tablet 180 mg, 60 mgPloratadine childrens oral solution 5 mg/5mlPQL (310 ML per 31 days)loratadine hives relief oral solution 5 mg/5mlPQL (310 ML per 31 days)loratadine oral tablet 10 mgPQL (310 ML per 31 days)P Preferred, Asterisk(*) N/A, PA Prior Authorization, ST Step Therapy, QL Quantity Limit, AL AgeLimit, OTC Products Require Rx, UPPERCASE Brand name drugs/ lowercase italics Generic drugs6
Drug NamePreference Details Coverage Details*Antiseptics & Disinfectants**Chlorine Antiseptic Combinations***dakins external solution 0.4-0.5 %*Chlorine Antiseptics***Pchlorhexidine gluconate external liquid 4 %Pdakins (1/2 strength) external solution 0.25 %Pdakins (1/4 strength) external solution 0.125%*Iodine Antiseptics***OPERAND POVIDONE-IODINE EXTERNALSOLUTION 10 %povidone-iodine external solution 10 %*Cough/Cold/Allergy*QL (480 ML per 31 days)PPP*Antitussive - Nonnarcotic***benzonatate oral capsule 100 mg, 200 mgPDELSYM ORAL SUSPENSION EXTENDEDRELEASE 30 MG/5MLPROBITUSSIN CHILDRENS COUGH LAORAL SYRUP 7.5 MG/5ML*Antitussive - Opioid***hydrocodone-homatropine oral syrup 5-1.5mg/5mlhydrocodone-homatropine oral tablet YM NIGHT TIME MULTI-SYMPTORAL LIQUID 15-6.25-325 MG/15ML*Antitussive-Expectorant***PPPPcheratussin ac oral syrup 100-10 mg/5mlPdiabetic siltussin-dm oral liquid 100-10mg/5mlPDIABETIC TUSSIN MAX ST ORAL LIQUID10-200 MG/5MLPextra action cough oral syrup 100-10 mg/5mlPMUCINEX FAST-MAX DM MAX ORALLIQUID 20-400 MG/20MLPmucus relief dm cough oral tablet 20-400 mgPP Preferred, Asterisk(*) N/A, PA Prior Authorization, ST Step Therapy, QL Quantity Limit, AL AgeLimit, OTC Products Require Rx, UPPERCASE Brand name drugs/ lowercase italics Generic drugs7
Drug NamePreference Details Coverage ratussin dac oral solution 30-10-100mg/5mlrobafen cf cough/cold oral syrup 5-10-100mg/5ml*Decongestant & Antihistamine***PPALAVERT ALLERGY/SINUS ORAL TABLETEXTENDED RELEASE 12 HOUR 5-120 MGPALLEGRA-D ALLERGY & CONGESTIONORAL TABLET EXTENDED RELEASE 12HOUR 60-120 MGPallergy relief/nasal decongest oral tabletextended release 24 hour 10-240 mgPBROTAPP ORAL LIQUID 1-15 MG/5MLPcetirizine-pseudoephedrine er oral tabletextended release 12 hour 5-120 mgPfexofenadine-pseudoephed er oral tabletextended release 24 hour 180-240 mgPmaxifed tr oral tablet 1.25-30 mgPQ-TAPP ORAL ELIXIR 1-15 MG/5MLPtriprolidine-pse oral tablet 2.5-60 mg*Decongestant W/ Expectorant***Ptussin pe oral liquid 5-100 mg/5ml*Expectorants***Pchest congestion relief oral tablet 400 mgPdiabetic siltussin das-na oral liquid 100mg/5mlPmucus relief oral tablet 400 mgPrefenesen 400 oral tablet 400 mgPrefenesen oral tablet 200 mgProbafen oral syrup 100 mg/5ml*Misc. Respiratory Inhalants***PBRONCHO SALINE INHALATIONAEROSOL SOLUTION 0.9 %Psodium chloride inhalation nebulizationsolution 0.9 %PP Preferred, Asterisk(*) N/A, PA Prior Authorization, ST Step Therapy, QL Quantity Limit, AL AgeLimit, OTC Products Require Rx, UPPERCASE Brand name drugs/ lowercase italics Generic drugs8
Drug NamePreference Details Coverage Details*Non-Narc Antitussive-Antihistamine***DIMETAPP LONG ACT COUGH/COLDORAL SYRUP 1-7.5 MG/5MLPpromethazine-dm oral syrup 6.25-15 mg/5mlPROBITUSSIN CHILD COUGH/COLD LAORAL LIQUID 1-7.5 MG/5ML*Non-Narc Antitussive-DecongestantAntihistamine***Pbrotapp dm oral liquid 15-1-5 mg/5mlPcold/cough childrens oral elixir 2.5-1-5mg/5mlPcorfen-dm oral liquid 10-4-15 mg/5mlPkidkare cough/cold oral liquid 15-1-5 mg/5mlPnohist-dm oral liquid 10-4-15 mg/5mlPrynex dm oral liquid 2.5-1-5 mg/5mlPVANACOF ORAL LIQUID 30-1-12.5 MG/5ML*Opioid Antitussive-Antihistamine***Phydrocod polst-cpm polst er oral suspensionextended release 10-8 mg/5mlPpromethazine-codeine oral syrup 6.25-10mg/5mlPTUSSICAPS ORAL CAPSULE EXTENDEDRELEASE 12 HOUR 10-8 MG, 5-4 MG*Opioid ine dh oral liquid 30-2-10 mg/5mlpromethazine vc/codeine oral syrup 6.25-510 mg/5ml*Dermatologicals*PPP*Acne Products***acne medication 5 external lotion 5 %Pbenzoyl peroxide cleanser external liquid 6 %Pbenzoyl peroxide external gel 10 %, 5 %PPANOXYL WASH EXTERNAL LIQUID 10 %*Antibiotic Mixtures Topical***Pbacitracin-neomycin-polymyxin externalointment 400-5-5000PP Preferred, Asterisk(*) N/A, PA Prior Authorization, ST Step Therapy, QL Quantity Limit, AL AgeLimit, OTC Products Require Rx, UPPERCASE Brand name drugs/ lowercase italics Generic drugs9
Drug Namedouble antibiotic external ointment 50010000 unit/gmtriple antibiotic external ointment 3.5-4005000 , 5-400-5000*Antibiotics - Topical***Preference Details Coverage DetailsPPbacitracin external ointment 500 unit/gmPbacitracin zinc external ointment 500 unit/gm*Antifungals - Topical***Panti-fungal external powder 1 %Pterbinafine hcl external cream 1 %*Antihistamines - Topical***Panti-itch maximum strength external cream 2%PBENADRYL ITCH STOPPING EXTERNALGEL 2 %Pitch relief external cream 2 %*Corticosteroids - Topical***PAVEENO ANTI-ITCH MAX ST EXTERNALCREAM 1 %Phydrocortisone external cream 0.5 %, 1 %Phydrocortisone external lotion 1 %Phydrocortisone external ointment 0.5 %, 1 %Phydrocortisone max st external cream 1 %Phydrocortisone max st/12 moist externalcream 1 %PHYDROSKIN EXTERNAL CREAM 1 %Pkp hydrocortisone external cream 1 %PPREPARATION H EXTERNAL CREAM 1 %Ptgt anti-itch/aloe/vit e external cream 1 %*Emollients***PAMLACTIN EXTERNAL LOTION 12 %PQL (400 GM per 31 days)ammonium lactate external cream 12 %PQL (400 GM per 31 days)ammonium lactate external lotion 12 %*Imidazole-Related Antifungals Topical***PQL (400 GM per 31 days)clotrimazole external cream 1 %Pclotrimazole external solution 1 %PP Preferred, Asterisk(*) N/A, PA Prior Authorization, ST Step Therapy, QL Quantity Limit, AL AgeLimit, OTC Products Require Rx, UPPERCASE Brand name drugs/ lowercase italics Generic drugs10
Drug NamePreference Details Coverage Details*Keratolytic/Antimitotic Agents***CLEAR AWAY 1-STEP WART REMOVEREXTERNAL PAD 40 %PCOMPOUND W EXTERNAL LIQUID 17 %PCOMPOUND W MAXIMUM STRENGTHEXTERNAL GEL 17 %PFREEZONE EXTERNAL LIQUID 17.6 %PSALACTIC FILM EXTERNAL SOLUTION 17%*Local Anesthetics - Topical***Pcapsaicin external cream 0.025 %*Scabicides & Pediculicides***Ppermethrin external lotion 1 %*Tar Products***PTERA-GEL TAR EXTERNAL SHAMPOO 0.5%*Topical Steroid Combinations***QL (60 GM per 30 days)Phydrocortisone-aloe external cream 1 %Psm hydrocortisone plus external cream 1 %*Gastrointestinal Agents - Misc.*P*Antiflatulents***mi-acid gas relief oral tablet chewable 80 mgPmytab gas oral tablet chewable 80 mgPsimethicone oral suspension 40 mg/0.6mlPsimethicone oral tablet chewable 80 mg*Genitourinary Agents - Miscellaneous*P*Urinary Analgesics***AZO URINARY PAIN RELIEF ORALTABLET 99.5 MGPphenazopyridine hcl oral tablet 95 mgPurinary pain relief max st oral tablet 97.5 mg*Hematopoietic Agents*P*Cobalamins***cyanocobalamin injection solution 1000mcg/mlPvitamin b-12 er oral tablet extended release1000 mcgPP Preferred, Asterisk(*) N/A, PA Prior Authorization, ST Step Therapy, QL Quantity Limit, AL AgeLimit, OTC Products Require Rx, UPPERCASE Brand name drugs/ lowercase italics Generic drugs11
Drug Namevitamin b-12 oral tablet 1000 mcg, 250 mcg,500 mcgvitamin b-12 sublingual tablet sublingual1000 mcg*Folic Acid/Folates***Preference Details Coverage DetailsPPfolic acid oral tablet 1 mg, 400 mcg, 800 mcg*Iron***Pferro-bob oral tablet 325 (65 fe) mgPferrous sulfate oral elixir 220 (44 fe) mg/5mlPferrous sulfate oral tablet 325 (65 fe) mgPferrous sulfate oral tablet delayed release324 (65 fe) mg, 325 (65 fe) mgPferrousul oral tablet 325 (65 fe) mgPiron oral tablet 325 (65 fe) mg, 90 (18 fe) mgPPOLY-IRON 150 ORAL CAPSULE 150 MGPslow release iron oral tablet extended release160 (50 fe) mg*Hypnotics/Sedatives/Sleep DisorderAgents*P*Antihistamine Hypnotic Combinations***headache pm oral tablet 25-500 mgPQL (62 EA per 31 days)mapap pm oral tablet 500-25 mgPQL (62 EA per 31 days)pain relief pm extra strength oral tablet 50025 mgPQL (62 EA per 31 days)pain reliever pm oral tablet 500-25 mg*Antihistamine Hypnotics***PQL (62 EA per 31 days)compoz oral capsule 50 mgPcompoz oral tablet 50 mgPdiphenhydramine hcl (sleep) oral tablet 50mgPNYTOL ORAL TABLET 25 MGPSIMPLY SLEEP ORAL TABLET 25 MGPsleep tabs oral tablet 25 mgPsleep-tabs oral tablet 25 mgPSOMINEX ORAL TABLET 25 MGPtetra-formula nighttime sleep oral tablet 50mgPP Preferred, Asterisk(*) N/A, PA Prior Authorization, ST Step Therapy, QL Quantity Limit, AL AgeLimit, OTC Products Require Rx, UPPERCASE Brand name drugs/ lowercase italics Generic drugs12
Drug NamePreference Details Coverage Details*Laxatives**Bulk Laxatives***fiber laxative oral tablet 625 mgPfiber oral tablet 625 mgPFIBERGEN ORAL TABLET 625 MGPfiber-lax oral tablet 625 mgPkonsyl daily fiber oral packet 100 %PKONSYL FIBER ORAL TABLET 625 MGPMETAMUCIL ORAL CAPSULE 0.36 GM,0.52 GMPMETAMUCIL ORAL WAFERPMETAMUCIL SMOOTH TEXTURE ORALPACKET 28 %PMETAMUCIL SMOOTH TEXTURE ORALPOWDER 28.3 %, 58.6 %Pnatural fiber therapy oral powder 30.9 %,48.57 %Pnatural vegetable fiber oral powder 48.57 %PREGULOID ORAL CAPSULE 0.52 GM*Laxatives - Miscellaneous***Pcvs glycerin adult rectal suppository 2 gmPsorbitol oral solution 70 %*Laxatives & Dss***PDOC-Q-LAX ORAL TABLET 8.6-50 MGPPERI-COLACE ORAL TABLET 8.6-50 MGPsenna plus oral tablet 8.6-50 mgPsenna s oral tablet 8.6-50 mgPsenna-docusate sodium oral tablet 8.6-50 mgPSENNALAX-S ORAL TABLET 8.6-50 MGPsenna-s oral tablet 8.6-50 mgPsenna-time s oral tablet 8.6-50 mgPsennosides-docusate sodium oral tablet 8.650 mg*Saline Laxative Mixtures***Penema rectal enema 7-19 gm/118mlPphosphate laxative oral solution 0.9-2.4gm/5mlPP Preferred, Asterisk(*) N/A, PA Prior Authorization, ST Step Therapy, QL Quantity Limit, AL AgeLimit, OTC Products Require Rx, UPPERCASE Brand name drugs/ lowercase italics Generic drugs13
Drug NamePreference Details Coverage Details*Saline Laxatives***citrate of magnesia oral solution 1.745gm/30mlPCITROMA ORAL SOLUTION 1.745GM/30MLPDULCOLAX MILK OF MAGNESIA ORALSUSPENSION 400 MG/5MLPmagnesium citrate oral solution 1.745gm/30mlPmilk of magnesia oral suspension 400mg/5ml, 7.75 %*Stimulant Laxatives***PBISAC-EVAC RECTAL SUPPOSITORY 10MGPbiscolax rectal suppository 10 mgPCARTERS LITTLE PILLS ORAL TABLETDELAYED RELEASE 5 MGPcorrect oral tablet delayed release 5 mgPCORRECTOL ORAL TABLET DELAYEDRELEASE 5 MGPducodyl oral tablet delayed release 5 mgPEX-LAX ORAL TABLET CHEWABLE 15 MGPEX-LAX ULTRA ORAL TABLET DELAYEDRELEASE 5 MGPFEENAMINT ORAL TABLET DELAYEDRELEASE 5 MGPFLEET LAXATIVE ORAL TABLETDELAYED RELEASE 5 MGPgentle laxative oral tablet delayed release 5mgPlaxative rectal suppository 10 mgPnatural senna laxative oral tablet 64.8-324mgPsenexon oral liquid 8.8 mg/5mlPsenexon oral tablet 8.6 mgPsenna lax oral tablet 8.6 mgPsenna laxative oral tablet 25 mg, 8.6 mgPsenna oral syrup 8.8 mg/5mlPsenna oral tablet 8.6 mgPP Preferred, Asterisk(*) N/A, PA Prior Authorization, ST Step Therapy, QL Quantity Limit, AL AgeLimit, OTC Products Require Rx, UPPERCASE Brand name drugs/ lowercase italics Generic drugs14
Drug NamePreference Details Coverage DetailsSENNA SMOOTH ORAL TABLET 15 MGPSENNACON ORAL TABLET 8.6 MGPsenna-lax oral tablet 8.6 mgPsenna-tabs oral tablet 8.6 mgPsenna-time oral tablet 8.6 mgPSENNO ORAL TABLET 8.6 MGPstimulant laxative oral tablet delayed release5 mgPwomens laxative oral tablet delayed release5 mg*Surfactant Laxatives***PCORRECTOL EXTRA GENTLE ORALCAPSULE 100 MGPdiocto oral liquid 50 mg/5mlPdiocto oral syrup 60 mg/15mlPdocqlace oral capsule 100 mgPdocu soft oral capsule 100 mgPdocusate calcium oral capsule 240 mgPdocusate sodium oral capsule 250 mgPdocusate sodium oral tablet 100 mgPDOCUSIL ORAL CAPSULE 100 MGPDOK ORAL CAPSULE 100 MG, 250 MGPDOK ORAL TABLET 100 MGPdss oral capsule 100 mg, 250 mgPDULCOLAX STOOL SOFTENER ORALCAPSULE 100 MGPKAO-TIN ORAL CAPSULE 240 MGPlaxa basic oral capsule 100 mgPsilace oral liquid 150 mg/15mlPsilace oral syrup 60 mg/15mlPSOF-LAX ORAL CAPSULE 100 MGPstool softener oral capsule 100 mg, 250 mgPSURFAK ORAL CAPSULE 240 MG*Medical Devices And Supplies*P*Respiratory Therapy Supplies***ACE AEROSOL CLOUD ENHANCERPQL (2 EA per 365 days)P Preferred, Asterisk(*) N/A, PA Prior Authorization, ST Step Therapy, QL Quantity Limit, AL AgeLimit, OTC Products Require Rx, UPPERCASE Brand name drugs/ lowercase italics Generic drugs15
Drug NamePreference Details Coverage DetailsIN-CHECK DIAL FLOW TRAINER DEVICEPQL (2 EA per 365 days)PFLEXPQL (2 EA per 365 days)THRESHOLD IMTPQL (2 EA per 365 days)THRESHOLD PEP DEVICEPQL (2 EA per 365 days)WINDMILL TRAINER*Spacer/Aerosol-Holding Chambers &Supplies***PQL (2 EA per 365 days)AEROCHAMBER MVPQL (2 EA per 365 days)AEROCHAMBER PLUS FLO-VUPQL (2 EA per 365 days)AEROCHAMBER PLUS FLO-VU LARGEPQL (2 EA per 365 days)AEROCHAMBER PLUS FLO-VU SMALLPQL (2 EA per 365 days)AEROCHAMBER PLUS FLO-VU W/MASKPQL (2 EA per 365 days)AEROCHAMBER W/FLOWSIGNALPQL (2 EA per 365 days)AEROCHAMBER Z-STAT PLUSPQL (2 EA per 365 days)AEROCHAMBER Z-STAT PLUS CHAMBRPQL (2 EA per 365 days)EASIVENTPQL (2 EA per 365 days)MICROCHAMBERPQL (2 EA per 365 days)MICROSPACERPQL (2 EA per 365 days)OPTICHAMBER ADVANTAGEPQL (2 EA per 365 days)OPTICHAMBER FACE MASK-LARGEPQL (2 EA per 365 days)OPTICHAMBER FACE MASK-MEDIUMPQL (2 EA per 365 days)OPTICHAMBER FACE MASK-SMALLPQL (2 EA per 365 days)OPTIHALERPQL (2 EA per 365 days)OPTIHALER DEVICEPQL (2 EA per 365 days)POCKET CHAMBER DEVICEPQL (2 EA per 365 days)POCKET SPACER DEVICEPQL (2 EA per 365 days)WATCHHALER DEVICE*Minerals & Electrolytes*PQL (2 EA per 365 days)*Calcium Combinations***calcium d3 oral tablet 600-200 mg-unitPcalcium 600-d oral tablet 600-400 mg-unitPcalcium carb-cholecalciferol oral tablet 500125 mg-unit, 500-400 mg-unitPcalcium carbonate w/vitamin d oral tablet600-400 mg-unitPP Preferred, Asterisk(*) N/A, PA Prior Authorization, ST Step Therapy, QL Quantity Limit, AL AgeLimit, OTC Products Require Rx, UPPERCASE Brand name drugs/ lowercase italics Generic drugs16
Drug NamePreference Details Coverage Detailscalcium carbonate-vitamin d oral tablet 500400 mg-unit, 600-400 mg-unitPcalcium high potency/vitamin d oral tablet600-200 mg-unitPcalcium oral tablet 500-125 mg-unitPcalcium-carb 600 d oral tablet 600-125 mgunitPcalcium-vitamin d oral tablet 500-125 mgunit, 600-125 mg-unit, 600-200 mg-unitPCALTRATE 600 D ORAL TABLET 600-800MG-UNITPCELEBRATE CALCIUM PLUS 500 ORALTABLET CHEWABLE 500-333 MG-UNITPliquid calcium/vitamin d oral capsule 600-200mg-unitPOYSCO 500 D ORAL TABLET 500-200 MGUNITPoyst-cal d oral tablet 250-125 mg-unitPoyster calcium d oral tablet 250-125 mgunitPoyster shell calcium d oral tablet 500-400mg-unitPoyster shell calcium 500 d oral tablet 500125 mg-unitPoyster shell calcium w/d oral tablet 500-200mg-unitPoyster shell calcium/d oral tablet 250-125mg-unit, 500-200 mg-unitPoyster shell calcium/vitamin d oral packet500-200 mg-unitPoyster shell calcium/vitamin d oral tablet 250125 mg-unit, 500-200 mg-unitPoyster shell/vitamin d oral tablet 600-125 mgunitPra calcium hi-cal/vitamin d oral tablet 500-125mg-unit*Calcium***CAL-CARB FORTE ORAL TABLET 1250(500 CA) MGPPP Preferred, Asterisk(*) N/A, PA Prior Authorization, ST Step Therapy, QL Quantity Limit, AL AgeLimit, OTC Products Require Rx, UPPERCASE Brand name drugs/ lowercase italics Generic drugs17
Drug NamePreference Details Coverage DetailsCALCI-CHEW ORAL TABLET CHEWABLE1250 (500 CA) MGPcalcium 600 oral tablet 600 mgPcalcium carbonate oral suspension 1250(500 ca) mg/5mlPcalcium carbonate oral tablet 1250 (500 ca)mg, 1500 (600 ca) mg, 600 mgPcalcium high potency oral tablet 600 mgPcalcium lactate oral tablet 648 mgPcalcium oral tablet 600 mgPcalcium oyster shell oral tablet 1250 (500 ca)mgPcalcium-carb 600 oral tablet 600 mgPcal-lac oral capsule 500 mgPCALTRATE 600 ORAL TABLET 1500 (600CA) MGPOYSCO 500 ORAL TABLET 500 MGPOYSTERCAL ORAL TABLET 500 MG*Electrolytes Oral***PORALYTE FREEZER POPS ORALSOLUTIONORALYTE ORAL SOLUTION*Magnesium***PQL (4000 ML per 31 days)PQL (4000 ML per 31 days)MAG64 ORAL TABLET EXTENDEDRELEASE 535 (64 MG) MGPmag-delay oral tablet extended release 535(64 mg) mgPmagnacaps oral capsule 100 mgPmagnesium oral tablet 250 mgPmagnesium oxide 400 oral packet 240 mgPmagnesium oxide oral tablet 400 (240 mg)mg, 400 (241.3 mg) mg, 420 (252 mg) mgPMAGNESIUM-OXIDE ORAL TABLET 400(241.3 MG) MGPMAG-TAB SR ORAL TABLET EXTENDEDRELEASE 84 MG (7MEQ)*Sodium***sodium chloride oral tablet 1 gmPPP Preferred, Asterisk(*) N/A, PA Prior Authorization, ST Step Therapy, QL Quantity Limit, AL AgeLimit, OTC Products Require Rx, UPPERCASE Brand name drugs/ lowercase italics Generic drugs18
Drug NamePreference Details Coverage Details*Zinc***ORAZINC ORAL CAPSULE 220 (50 ZN) MGPzinc gluconate oral tablet 50 mgPzinc oral tablet 50 mgPzinc sulfate oral capsule 220 (50 zn) mgPzinc sulfate oral tablet 220 (50 zn) mgPzinc-220 oral capsule 220 (50 zn) mg*Mouth/Throat/Dental Agents*P*Lozenge - Combinations***DELSYM COUGH RELIEFMOUTH/THROAT LOZENGE 5-5 MG*Multivitamins*P*B-Complex W/ C & Folic Acid***NEPHRONEX ORAL TABLETPRENAL ORAL CAPSULE 1 MGPrena-vite rx oral tablet 1 mgPreno caps oral capsule 1 mg*B-Complex W/ C***Pvitamin b complex-c oral capsule*Multiple Vitamins W/ Minerals***Pcentamin oral liquidPcentavite a-z complete-mineral oral tabletPcentavite oral liquidPCEROVITE ADVANCED FORMULA ORALTABLETPCERTAVITE/ANTIOXIDANTS ORAL LIQUIDPgerivite complete oral tabletPmultivitamin & mineral oral liquidPSUPER NU-THERA ORAL TABLETPthera vital m oral tabletPtherabasic-m oral tabletPthera-m oral tabletPtherapeutic liquid oral solutionPtherapeutic-m oral tabletPTOTAL FORMULA 3 ORAL TABLETPvitamins a-d-e/selenium oral tabletPP Preferred, Asterisk(*) N/A, PA Prior Authorization, ST Step Therapy, QL Quantity Limit, AL AgeLimit, OTC Products Require Rx, UPPERCASE Brand name drugs/ lowercase italics Generic drugs19
Drug NamePreference Details Coverage Details*Multivitamins***daily multiple vitamins oral tabletPdaily vite oral tabletPdaily vites oral tabletPmulti-day oral tabletPmulti-vitamin oral tabletPmulti-vitamins oral tabletPonce daily oral tabletPone-daily multi vitamins oral tabletPTHERA ORAL TABLETPTHERA/BETA-CAROTENE ORAL TABLETPtherapeutic oral tabletPthera-tabs oral tablet*Ped Mv W/ Iron***Ppolyvitamin/iron oral solution 10 mg/ml*Pediatric Multiple Vitamins W/ C & Fa***Pchildrens chewable multi vits oral tabletchewable*Pediatric Multiple Vitamins W/ C***Ppolyvitamin oral solution 35 mg/ml*Pediatric Vitamins A & D W/ C***Ptri-vitamin oral solution 1500-400-35*Prenatal Mv & Min W/Fe-Fa***Ppnv prenatal plus multivit dha oral 27-1 &312 mgPprenatal low iron oral tablet 27-0.8 mg*Specialty Vitamins Products***Pvitamins for hair oral capsulePvitamins for hair oral tablet*Nasal Agents - Systemic And Topical*P*Nasal Agents - Misc.***altamist spray nasal solution 0.65 %PAYR NASAL SOLUTION 0.65 %Pdeep sea nasal spray nasal solution 0.65 %PHUMIST NASAL SOLUTION 0.65 %PP Preferred, Asterisk(*) N/A, PA Prior Authorization, ST Step Therapy, QL Quantity Limit, AL AgeLimit, OTC Products Require Rx, UPPERCASE Brand name drugs/ lowercase italics Generic drugs20
Drug NamePreference Details Coverage DetailsLITTLE NOSES SALINE NASAL SOLUTION0.65 %PNASAL MOIST NASAL SOLUTION 0.65 %Pna-zone nasal solution 0.65 %POCEAN FOR KIDS NASAL SOLUTION 0.65%Psaline mist spray nasal solution 0.65 %Psaline nasal spray nasal solution 0.65 %Psea soft nasal mist nasal solution 0.65 %*Nasal Mast Cell Stabilizers***Pcromolyn sodium nasal aerosol solution 5.2mg/act*Systemic Decongestants***pseudoephedrine hcl oral tablet 30 mg, 60mgSUDAFED 12 HOUR ORAL TABLETEXTENDED RELEASE 12 HOUR 120 MG*Ophthalmic Agents*PPP*Artificial Tear And LubricantCombinations***artificial tears ophthalmic ointment 83-15 %PHYPOTEARS OPHTHALMIC SOLUTION 1-1%PTEARS AGAIN OPHTHALMIC OINTMENTPULTRA FRESH PM OPHTHALMICOINTMENT*Artificial Tear Solutions***Ptears again ophthalmic solution*Artificial Tears And Lubricants***Partificial tears ophthalmic solution 1.4 %PQL (15 ML per 31 days)liquitears ophthalmic solution 1.4 %PQL (15 ML per 31 Days)polyvinyl alcohol ophthalmic solution 1.4 %*Ophthalmic Antiallergic***PQL (15 ML per 31 Days)ALAWAY OPHTHALMIC SOLUTION 0.025%Pketotifen fumarate ophthalmic solution 0.025%PP Preferred, Asterisk(*) N/A, PA Prior Authorization, ST Step Therapy, QL Quantity Limit, AL AgeLimit, OTC Products Require Rx, UPPERCASE Brand name drugs/ lowercase italics Generic drugs21
Drug NamePreference Details Coverage Details*Otic Agents**Otic Agents - Miscellaneous***auraphene-b otic solution 6.5 %Pear drops earwax aid otic solution 6.5 %Pearwax treatment drops otic solution 6.5 %PE-R-O EAR DROPS OTIC SOLUTION 6.5 %PE-R-O EAR WAX REMOVAL SYSTEM OTICSOLUTION 6.5 %PMURINE EAR OTIC SOLUTION 6.5 %PMURINE EAR WAX REMOVAL SYSTEMOTIC SOLUTION 6.5 %POTIX OTIC SOLUTION 6.5 %*Psychotherapeutic And NeurologicalAgents - Misc.*P*Smoking Deterrents***nicotine polacrilex mouth/throat gum 2 mg, 4mgnicotine transdermal patch 24 hour 14mg/24hr, 21 mg/24hr, 7 *PQL (4032 EA per 365 days)PQL (70 EA per 365 days)*H-2 Antagonists***cimetidine oral tablet 200 mgPfamotidine oral tablet 10 mg*Proton Pump Inhibitors***Pomeprazole oral tablet delayed release 20mg*Vaginal And Related Products*
ORAL LIQUID 15-6.25-325 MG/15ML: P *Antitussive-Expectorant*** cheratussin ac oral syrup 100-10 mg/5ml. P: diabetic siltussin-dm oral liquid 100-10 mg/5ml. P: DIABETIC TUSSIN MAX ST ORAL LIQUID 10-200 MG/5ML. P: extra action cough oral syrup 100-10 mg/5ml. P: MUCINEX FAST-MAX DM MAX ORAL LIQUID 20-400 MG/20ML. P: mucus relief dm cough oral .
Jul 01, 2021 · History of unacceptable/toxic side effects to preferred drug . Member’s condition is clinically stable; changing to a preferred drug might cause deterioration of the member’s condition. 2. The requested drug may be approved if both of the following are true: There has been a therapeutic failure of at least . two . preferred drugs
Cigna-HealthSpring Rx Secure-Xtra Preferred Pharmacies Other network pharmacies Tier 1: Preferred Generic 1 4 Tier 2: Non-Preferred Generic 4 10 Tier 3: Preferred Brand 20% 22% Tier 4: Non-Preferred Brand 35% 40% Tier 5: Specialty 33% 33% . Rev.
members What is the UMP Preferred Drug List? The Uniform Medical Plan (UMP) Preferred Drug List (PDL) offers a choice of prescription drugs that are safe, effective, and evidence-based. The list also provides value. By choosing
member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug.
Select 4 Tier Drug List. Drug list — Four Tier Drug Plan . Your prescription benefit comes with a drug list, which is also called a formulary. This list is made up of brand-name and generic prescription drugs approved by the U.S. Food & Drug Administration (FDA). The following is a list
Lyrica Onfi Oxtellar XR Potiga Sabril Spritam Stavzor Trokendi XR Vimpat 2 preferred medications are required before a non-preferred will be . pediatric patient under six (6) years of age. Prior authorization forms available on the web at: . DELAWARE MEDICAL ASSISTANCE PROGRAM (DMAP) PREFERRED DRUG LIST .
Dental Preferred Provider Organization . The Preferred Provider Network (PPO) provides a benefit for covered services based on the CareFirst Preferred Allowed Benefit. This level of reimbursement applies to members covered under our Preferred Dental Plans. Preferred Dental members may seek treatment from any Preferred Dental provider in the .
2 - DRUG LIST Updated 10/2018 Welcome to Humana-The Humana Drug List (also known as a formulary) is effective on January 1st unless otherwise specified. This is an all-inclusive list and may change throughout the year. What is the Drug List? The Drug List is a list of covered medicines s
