Ventura County Medi-Cal Managed Care Commission (VCMMCC) dba
Gold Coast Health Plan Commission Meeting
DATE: Monday, June 27, 2011 TIME: 3:00-5:00 pm PLACE: 2240 E. Gonzales Road, Suite 200, Oxnard CA 93036
AGENDA
Call to Order, Welcome and Roll Call
Public Comment / Correspondence
1. Approve Minutes – May 23, 2011 Meeting Action Required
2.
Accept and File Management Update
For Information
3.
Accept and File Financial Report a. Cash Flow
For Information b. Reinsurance Action Required
4.
Management Recommendations
a. Auto Assignment Action Required
b. Pharmacy &Therapeutics Committee Appointment Action Required c. Credentials Committee Appointment Action Required d. Quality Committee Appointment Action Required e. Provider Advisory Committee Appointment Action Required f. Formulary Action Required g. Response from ScriptCare For Information
Comments from Commissioners
Meeting agenda available at http://www.goldcoasthealthplan.org
IN COMPLIANCE WITH THE AMERICANS WITH DISABILITIES ACT, IF YOU NEED SPECIAL ASSISTANCE TO PARTICIPATE IN THIS MEETING, PLEASE CONTACT TRACI AT 805/981-5320. REASONABLE ADVANCE NOTIFICATION OF THE NEED FOR ACCOMMODATION PRIOR TO THE MEETING (48 HOURS ADVANCE NOTICE IS PREFERABLE) WILL ENABLE US TO MAKE REASONABLE ARRANGEMENTS TO ENSURE ACCESSIBILITY TO THIS MEETING
Ventura County Medi-Cal Managed Care Commission (VCMMCC) dba Gold Coast Health Plan (GCHP)
Commission Meeting Minutes May 23, 2011
(Not official until approved)
CALL TO ORDER Chair Dial called the meeting to order at 3:05 p.m. in Suite 200 at the Ventura County Public Health Building located at 2240 E. Gonzales Road, Oxnard, CA 93036.
ROLL CALL COMMISSION MEMBERS IN ATTENDANCE David Araujo, MD, Ventura County Medical Center Family Medicine Residency Program Maylee Berry, Medi-Cal Beneficiary Advocate Lanyard Dial, MD, Ventura County Medical Association Robert Gonzalez, MD, Ventura County Health Care Agency Rick Jarvis, Private Hospitals / Healthcare System Roberto S. Juarez, Clinicas del Camino Real, Inc. Kathy Long, Ventura County Board of Supervisors Catherine Rodriguez, Ventura County Medical Health System
EXCUSED / ABSENT COMMISSIONERS Anil Chawla, MD, Clinicas del Camino Real, Inc. Laurie Eberst, RN, Private Hospitals / Healthcare System John Fankhauser, MD, Ventura County Medical Center Executive Committee
STAFF IN ATTENDANCE Earl Greenia, CEO Tin Kin Lee, Legal Counsel Traci R. McGinley, Clerk of the Board Charlie Cho, MD, Chief Medical Officer Andre Galvan, Project Management Specialist Guillermo Gonzalez, Government Affairs Director Darlane Johnsen, Chief Financial Officer Pamela Kapustay, RN, Health Services Director Steven Lalich, Communications Director Candice Limousin, Human Resources Director Audra Lucas, Administrative Assistant
Language Interpreting and Translating services provided by GCHP from Lourdes
González Campbell of Lourdes González Campbell and Associates. The Pledge of Allegiance was recited.
GCHP Commission Meeting Minutes May 23, 2011 - Page 1 of 4
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PUBLIC COMMENT / CORRESPONDENCE The following representatives were present regarding Agenda Item 4.b. Managed Care Medi-Cal Pharmacy Costs and Reimbursement (contract with ScriptCare), and expressed their concerns about the Contract with ScriptCare:
Robert Andonian, Pharmacy & Famrmacia Estrella. Ali Karandish, Stan’s Drugs Pharmacy. April Valusek, OMAC Pharmacy. Joe Hoffman, Oxnard Drug. John Skormand, Seeber’s Pharmacy. Pamela Miles, Home Care Pharmacy, Inc. James Lektwich, Rogers Pharmacy. Chris Platt, Medical Arts Pharmacy.
Kevin Brown, ScriptCare, Ltd, advised the Commission that the pharmacy contract originally had two network options, after discussing the contract with a number of pharmacists, they amended it and made it a single network contract. He announced that ScriptCare would be at the Hilton Garden Inn at 6:30 p.m. to discuss these issues and provide clarification to local pharmacies. Mr. Brown also announced that ScriptCare has opened a local office at 1701 Solar Street in Oxnard which will house approximately 20 employees.
The ScriptCare / Pharmacy contract was further discussed and that ScriptCare’s rates are within the range of other managed Medi-Cal Plans within the State.
David Cruz, Health Education League of America, expressed his belief and concern that the Plan was not ready to go “live” on July 1, 2011.
Christina Velasco, Clinicas del Camino Real, Inc., voiced her concerns regarding a recent Auto-Assignment Study Group meeting she attended and requested the Commission review the open meeting laws.
Pablo Ortiz, Gold Coast Broadcasting, introduced himself as his company is launching the Gold Coast Health Plan’s media campaign.
Richard Sochel, CSDS, Executive Director, thanked GCHP staff for attending a recent outreach hosted at his facility
1. APPROVAL OF MINUTES – APRIL 25, 2011 After a brief discussion, the following statement will be added to the Public Comment section of the minutes. “Tony Alatorre, Clinicas COO, Auto-Assignment Study Group Member, objected to Agenda Item 4b, Auto-Assignment Study Group Recommendations, being deferred.”
GCHP Commission Meeting Minutes May 23, 2011 - Page 2 of 4
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Item 3.a. 2) is hereby amended to read as follows: “Budget assumes a subordinated loan of $3.5 million beginning in December 2011. With the loan, GCHP will phase in all Total Net Equity requirements.”
Commissioner Araujo moved to approve the April 25, 2011, minutes as amended; Commissioner Gonzalez seconded. The motion carried. Approved 8-0.
4. MANAGEMENT RECOMMENDATIONS
b. Outpatient Pharmacy Reimbursement
CEO Greenia discussed the relationship between GCHP and ScriptCare as well as ScriptCare and local pharmacies, GCHP does not have contracts with individual pharmacies. Out of 126 contracts offered by ScriptCare, 96 had been accepted.
Counsel Tin Kin Lee advised the Commission that there is a list of items that ScriptCare must meet or there are possible financial consequences.
Clarification was made between the Fee-For-Service and Managed Care.
Chief Medical Officer Cho gave a brief explanation of the formulary to the Commission and those in attendance.
2. CEO UPDATE CEO Greenia announced that on May 12, 2011 management received confirmation from the State for the “Go-Live” date of July 1, 2011 from the State.
The Provider Directory was completed last Friday.
Dr. Cho has made strides in the formulary.
Our community outreach/education efforts continue. The Plan continues to execute contracts with Primary Care Physicians and other providers.
No Commission action was required.
3. FINANCIAL REPORT
CFO Johnsen presented the Balance Sheet, Statement of Revenue and Expenses, Monthly Cash Flow Projections, Tangible Net Equity and Administrative Expense Details.
Management received confirmation that the ACS moneys should be classified as a liability.
GCHP Commission Meeting Minutes
May 23, 2011 - Page 3 of 4
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The short term loan was reduced to $300,000.
No Commission action was required.
4. MANAGEMENT RECOMMENDATIONS
a. Auto-Assignment Study Group Recommendations The Study Group recommendations were discussed, including the definitions of Safety- Net, Traditional and Non-Traditional Providers. Additional comments from members of the Study Group that were present were received.
Commissioner Juarez moved to accept Items 1-4 of the Auto Assignment Study Group recommendation, and amend Item 5 to a three-to-one ratio, Commissioner Gonzalez seconded. The motion carried. Approved 5-3, with Commissioners Jarvis, Berry and Dial voting no.
c. Resolution to Execute Contract with State
Commissioner Long moved to approve the Resolution giving the Chief Executive Officer the authority to approve and execute the contracts with the State, Commissioner Eberst seconded. The motion carried. Approved 8-0, with all Commissioners present voting aye.
COMMENTS FROM COMMISSIONERS Commissioner Juarez commented on the complexity of the contracting process with Gold Coast Health Plan.
ADJOURNMENT
The meeting adjourned at 5:37 p.m.
GCHP Commission Meeting Minutes May 23, 2011 - Page 4 of 4
1-4
Chief Executive’s Monthly Report to Commission
June 27, 2011
PEOPLE (Organizational Structure)
We have added additional talent to our team:
o Accounts Payable Coordinator: Shannon Godina
o Clinical Operations Assistant: Dawn Lambert
o Claims Auditor Consultant: Chris Wilson
o Health Services: Judy Delp, RN; Dee Johnston, RN; Diana Lewis, RN; and
Kathy Price, RN
o Summer Intern: Jasmine Wilson
Offers have been extended to fill the QI Specialist and Systems Manager positions.
Recruitment and selection continues for: Sr. Claims Auditor, Pharmacist and a
Providers Relations Representative.
Introduced employee performance appraisal process.
SERVICE (Member & Provider Satisfaction, Government Relations)
Efforts continue for our inaugural ceremony on July 19. The GCHP team has reached
out to invite elected officials at the city, county, state and federal level and to obtain
proclamations.
In June, we held numerous outreach/education sessions, attended community
sponsored events, and placed print ads promoting our events in Vida and Ventura
County Star.
o June 1st and 7th, at 6:30 pm, Gold Coast Health Plan made presentations to
more than 50 people at the Rainbow Connection in both at their Oxnard and
Simi Valley locations.
o Wednesday, June 8th, at 10:00 am, we made a presentation at the Tri-Counties
Regional Center’s Oxnard location to approximately 60 staff members.
o Thursday, June 9th, at 5:30 pm, we made a presentation to twenty Medi-Cal
beneficiaries at the County’s West Ventura Medical Clinic.
o Tuesday, June 14th, at 10:30 am, we held an information session with the
Ventura County’s Area Agency on Aging Health Insurance Counseling and
Advocacy Program (HICAP) at their Ventura headquarters to 45 staff members.
o Tuesday, June 14th, at 6:00 pm, we attended the Ventura County Medical
Association’s dinner at the Spanish Hills Country Club and provided an update
to over 100 attendees.
2220 E. Gonzales Road, Suite 200, Oxnard, CA 93036 Phone (805) 981-5320
2-1
o Wednesday, June 15th, at 8:30 am, we held an information session with the
Department of Vocational Rehabilitation (DOR), at their Oxnard location.
o Thursday, June 16th, we conducted bilingual outreach to approximately 12
families at Harrington Elementary School in Oxnard.
o Friday, June 17th, at 12:00 pm, we met with the Mixteco Indigena Community
Organizing Project (MICOP) leadership to discuss partnership opportunities,
Our marketing and advertising efforts continue; some highlights:
o The pre-go-live advertising campaign began Monday, May 23rd and will
continue for 6 consecutive weeks on 8 radio stations (104.7 KCAQ-FM, 105.5
KFYV-FM, 103.7 KMLA-FM, 95.9 KOCP-FM, 910 KOXR-AM, 1590 KUNX-AM,
102.9 KXLM-FM, 96.7 KLJR-FM).
o Each station will run 45 60-second commercials per week for a total of 270
commercials per station and an 8 station 6 week grand total of 2,160
commercials.
o In the Metro Area or West County (Oxnard, Camarillo, Ventura, Port Hueneme,
Santa Paula, Fillmore, Ojai), 266,500 unique listeners (ages 12 and above) will
be reached. In the Total Survey Area (TSA) or East County, an additional
163,900 listeners (ages 12 and above) will be reached.
o Additionally, we will promote the Plan on “La Hora Mixteca” hosted by Fabian
Alfaro on KUNX 1590AM. This weekly independent radio show will run for 6
weeks in 1 hour segments. Coupled with his weekly show the program will
showcase Gold Coast Health Plan’s educational efforts to the Mixteco
Community by providing a unique platform to present Mixteco listeners with
information on the Plan.
o There will be 12, ¼ page color print ads placed in the Ventura County Star and
6, ¼ page color print ads placed in Vida, a weekly Spanish language
newspaper informing readers of the coming changes to Medi-Cal and
introducing them to Gold Coast Health Plan.
GCHP staff trained seven Mixteco Community Outreach Workers on the PCP
selection process. To date, the outreach workers have assisted over 3,500
beneficiaries complete their PCP selection forms.
The inaugural meeting of Consumer Advisory Committee was held on June 15.
The “Welcome” letters and packets were mailed to members on May 31. Distribution of
the Member handbook and identification cards begins today.
The Member Services Call Center (which employs 42 customer service
representatives, half of whom speak Spanish) continues to receive calls from
members and providers.
The U.S. House of Representatives budget bill calls for $800 billion in cuts to Medicaid
over a ten year period and transitions it to a “block grant” program. Representative
Lois Capps voted against the bill, while Representative Elton Gallegly voted in favor of
the bill, which was passed. Medicaid program advocates are encouraging supporters
2-2
to contact their Congressional representatives to urge them to oppose these drastic
cuts and changes. GCHP had a conference call with Nora Connors, Senator
Feinstein’s Senior Aide on Health and Medicaid to ensure that Senator Feinstein was
aware of the transition to Medi-Cal Managed Care in Ventura County. A meeting
request has been submitted to Senator Boxer’s senior aide on health.
GCHP staff participated in an “All-Plan” conference call to discuss California’s budget
situation and its impact on Medi-Cal Managed Care Plans. DHCS has not yet
submitted the required waiver request to CMS to implement the provisions of AB 97.
This legislation, approved by the Legislature and Governor, authorizes provider rate
reductions, visitation caps, and other cuts to the Medi-Cal Program. GCHP has
submitted a meeting request to DHCS Director Toby Douglas to discuss our unique
situation as a start-up and the State’s mandate to reduce Medi-Cal funding.
ACCESS (Robust Provider Network)
Provider contracting efforts continue; the network composition is summarized below:
Provider Type Number of
Contracts
Number of Providers
Primary Care Providers
23 163 Physicians; 190
mid-level practitioners
Specialist Physicians 63 1,809
Hospitals 9 11
Long-Term Care
Facilities
15
16
Laboratories 3 13
Pharmacies 1 (ScriptCare) 96
Home Health / Hospice 16 19
Optometrists 15 29
Other Providers 63 90
To date, 17 provider orientation sessions have been conducted throughout Ventura
County to educate providers about GCHP policies and procedures.
The first meeting of the Provider Advisory Committee was re-scheduled for July 7.
QUALITY (Comprehensive Medical Management)
The inaugural meeting of the Quality Committee was held June 2. The Committee
considered important issues relating to referral and prior authorization processes.
The Department of Health Care Services conducted full-scope validation Facility Site
Reviews on May 24, 25, and 26 at 17 contracted PCP offices/clinics. Some minor
issues were identified at a few of the sites and were immediately resolved to the
reviewers’ satisfaction. The sites were prepared even while juggling other critical
2-3
activities (i.e., VCMC had JCAHO on site at the same time). GCHP recognized the
sites with Certificates of Appreciation.
Health Services staff have scheduled meetings with the case management and
discharge planning departments at all hospitals in Ventura County to discuss
workflows and processes for continued stay review, discharge planning, coordination
of care and UM/CM needs.
Discussions have been held with long-term care facilities focused on their needs and
services and program coordination.
A small number of local independent pharmacies continue to voice concerns about
reimbursement rates. A follow-up letter from ScriptCare is included with this report.
On June 9, the Pharmacy and Therapeutics Committee reviewed the formulary and is
recommending approval by the Commission.
FINANCE (Optimize Rates, Ensure Long-Term Viability)
Our Claims Management department continues to implement the claims testing
program and remediate issues.
Procedures for Claims training and operational readiness continue to be developed.
A six week training program for ACS Claims Examiners dedicated to GCHP is in
process.
We have finalized language to accompany the Explanation of Benefits that
accompanies fee-for-service payments.
Secured a revolving line of credit in the amount of $500,000 from Rabobank.
Obtained renewal policies for Director’s and Officer’s insurance.
Secured Errors and Omissions policy.
Verified renewal of: Crime Insurance, Worker’s Compensation, and General
Commercial Liability coverage which is provided via Regional Government Services.
With the assistance of an insurance broker (Beecher Carlson), a vendor for “HMO
Specific Excess of Loss” Reinsurance has been identified. A presentation is included
in this month’s agenda for the Commission’s review and action.
GO-LIVE STATUS
As of June 24, 92% of our “deliverables” have been approved by the State.
Respectfully submitted,
Earl G. Greenia
Chief Executive Officer
2-4
3a-1
Gold Coast Health Plan
Cash Flow Projection- Pre-operational Period
January, 2011 through June 2011
January February March April May June
Cumulative Enrollment 0 0 0 0 0 0
Total Staff 14 19 24 27 32 33
Incremental Staff Increase 5 5 5 3 5 1
Beginning Cash Balance 443,102 327,432 339,823 56,936 308,705 229,556
Cash In-Flow
Revenue from State
Other Funding
277
12,584
Short Term Loan
Subordinated Debt
ACS - LOC*
265,000
-
595,000
300,000
780,000
Total Receipts - 265,000 277 595,000 12,584 1,080,000
Total Cash 443,102 592,432 340,100 651,936 321,289 1,309,556
Cash Out-Flows
Health Care Payments
Premium Tax
Total Health Care - - - - - -
Salaries & Benefits 33,192 114,520 149,272 200,481 - 520,867
Other Benefits 1,070 - -
Consultants & Temp Labor 6,450 2,525 12,507 16,587 10,098 10,000
RGS Fees*
3,234 4,676
13,000
Occupancy Office Lease
- 43,920
14,640
Furniture & Equipment 13,385 30,372 7,740 - - -
Computers & Equipment (Capitalized)
18,575 11,188 Computers, Monitors, Printers (Non- Capitalized) 595 50,638 4,084 1,493 32,813 6,000
Telecommunications Equipment
5,965 14,066 2,473
2,125
Info Systems - License Fees & Maintenance 38,700
-
Info Systems - Software
3,333 3,333 - 3,334
Travel & Entertainment
2,940 2,730 - -
Supplies 4,461 8,604 6,421 3,239 2,700 9,600
Dues & Publications
16,850 3,000 428 500
Phone/Internet
104 406 511 197 200
Outreach & Education
370 2,280 32,169 680,500
Insurance
-
20,000
Legal fees 2,996 11,200 6,814 2,801 2,187 2,500
Actuary fees 14,600 27,527 26,828 19,302 7,518 7,500
Other fees
19,368
-
Miscellaneous Operating Expenses 1,291 1,154 8,654 5,849 3,623 2,000
Sub Total Administrative Expense 115,670 252,609 283,164 343,231 91,733 1,292,766
ENDING CASH BALANCE
327,432
339,823
56,936
308,705
229,556
16,790
Notes:
- RGS payments are made two month in arrears from the invoiced due date. At June 30th accrued payroll and fees will be ~ $890K.
- Assumes $300K additional funding is obtained.
- Capitation is paid at the beginning of the month following the month of eligibility - estimated cash outflow for month of start up is ~$475K (excluding vendor payments)
3b-1
HMO Reinsurance
Gold Coast Health Plan
June 27, 2011
3b-2
Why should Gold Coast Health Plan
buy Reinsurance?
1. Financial Protection – Reinsurance can protect GCHP’s financial position from unpredicted catastrophic claim costs.
2. Predictability - Reinsurance can create predictable financial results year over year
3. Regulatory Requirement
Risk Based Capital offset
Smoothing effect of reinsurance on a start-up plan
4. Value added services - Reinsurers bring cost reduction strategies to high-cost claim situations:
Transplant Networks
Catastrophic Claims Management
Complex Claim Review and Bill Audits
3b-3
Gold Coast Health Plan
Market Summary
Managing General Underwriter / Carrier
Best's
Rating
Quoted
Did Not Quote
Comments
OneBeacon Insurance Company
A
HCC Life
A+
BEL / American Fidelity Assurance
A+
Quoted Indication Only
RGA
A+
Star Line / Lloyds of London
A+
Not interested in Start-up
Midwest Risk / U.S. Fire
A
Risk is too large
Presidio / ACE American
A+
Not interested in Start-up
IOA Re
A
Not Interested in Risk
Munich Re
A+
Not interested in Risk
3b-4
Original Rates Proposed
Gold Coast Health Plan Premium Comparison Summary
Deductible M edi-Cal Family/Adult M edi-Cal (All Other) Totals Composite*
Rate PM PM Estimated Annual
Premium
Rate PM PM Estimated Annual
Premium
Estimated Annual Premium
Rate PM PM
$250,000
American Fidelity Assurance $2.69 $2,248,560 $2.69 $894,963 $3,143,523 $2.69
RGA $2.29 $1,914,202 $6.87 $2,285,649 $4,199,851 $3.59
$300,000
American Fidelity Assurance $2.02 $1,688,510 $2.02 $672,054 $2,360,564 $2.02
RGA $1.82 $1,521,331 $5.47 $1,819,869 $3,341,200 $2.86
$350,000
OneBeacon $1.04 $869,332 $1.04 $346,008 $1,215,340 $1.04
American Fidelity Assurance $1.84 $1,538,049 $1.84 $612,168 $2,150,217 $1.84
$400,000
OneBeacon $0.84 $702,153 $0.84 $279,468 $981,621 $0.84
American Fidelity Assurance $1.61 $1,345,793 $1.61 $535,647 $1,881,440 $1.61
$450,000
OneBeacon $0.63 $526,614 $0.63 $209,601 $736,215 $0.63
American Fidelity Assurance $1.59 $1,329,075 $1.59 $528,993 $1,858,068 $1.59
HCC Life $2.17 $1,813,894 $2.17 $721,959 $2,535,853 $2.17
Estimated Membership
M edi-Cal (Family/Adult) 69,658
M edi-Cal (All Other) 27,725 *Composite Rate is for illustration only.
Total: 97,383
3b-5
Final Rates
Gold Coast Health Plan Premium Comparison Summary
Deductible M edi-Cal Family/Adult M edi-Cal (All Other) Totals
Rate PM PM Estimated Annual
Premium
Rate PM PM Estimated Annual
Premium
Estimated Annual Premium
$350,000
OneBeacon
$0.91
$760,665
$0.91
$302,757
$1,063,422
$400,000
OneBeacon
$0.73
$610,204
$0.73
$242,871
$853,075
$450,000
OneBeacon
$0.54
$451,384
$0.54
$179,658
$631,042
Estimated Membership
M edi-Cal (Family/Adult) 69,658
M edi-Cal (All Other) 27,725
Total: 97,383
3b-6
Coverage Summary
EFFECTIVE DATE: 12 months beginning July 1, 2011
DEDUCTIBLE: $350,000 per member per year
PREMIUM RATE: $0.91 per member per month
CLAIM REPORTING REQUIREMENTS: Incurred in 12 Months
Paid/Reported in 18 Months Filed in 21 Months
MAXIMUM LIMIT: $2,000,000 per member per year
COINSURANCE: 90%
CARRYOVER: 31 days (upon renewal with same carrier)
REIMBURSEMENT: Designed to mirror Gold Coast Health Plan contracted rates and exposures. Reimbursement based on GCHP contracted rates or if no contract, Medi-Cal Allowable.
3b-7
COVERED EXPENSES: EXCLUDED EXPENSES:
Hospital Inpatient Retail Rx (Over The Counter Prescription Drugs)
Hospital Outpatient Professional Services (except Transplant Case Rate)
Long Term Care Facility Insolvency
Rehabilitation Services Conversion
Home Health Care Services
Skilled Nursing Facility
Extended Care Facility
Pharmaceuticals
Durable Medical Equipment
Ambulance
For Summary Purposes Only. Refer to OneBeacon agreement for complete description of coverage.
To: Earl Greenia
Chief Executive Officer
Date: June 14, 2011
From: Tin Kin Lee
Re: Vote on Auto-Assignment Policy
TIN KIN LEE LAW OFFICES 55 South Lake Avenue | Suite 705 | Pasadena, CA 91101
626-229-9828 office | 626-229-9820 fax | [email protected]
M E M O R A N D U M
Gold Coast Health Plan
I.
QUESTIONS PRESENTED AND SHORT ANSWERS
Q: Can a Commissioner of Gold Coast Health Plan (“GCHP”) cast a vote to adopt or
amend an agenda item relating to procedures for “auto-assigning” GCHP members to
“safety net providers” or “traditional providers,” when such Commissioner has a
financial interest in the decision (e.g., as an investor, director, officer, employee of a
contracted safety net or traditional provider)?
A: No. If a Commissioner has a financial interest in the decision (e.g., as an investor,
director, officer, employee of a contracted safety net or traditional provider), then
that Commissioner may not cast a vote to adopt or amend the corresponding
agenda item.
Q: If one or more of the Commissioners who voted on the agenda item on auto-assignment
were disqualified due to the presence of a conflict of interest, then what procedures
should be followed?
A: Two alternatives may be considered: (1) Re-vote the item using the concept of
“legally required participation”; or (2) do not re-vote the item, but instead,
delegate the authority to accept or amend the recommendations of the study
group.
Memo re vote on auto-assignment 6-14-11 v2 -1-
4a-1
TIN KIN LEE
LAW OFFICES
Q: Can the Chair vote on the auto-assignment agenda item regardless of whether there is a
tie?
A: The Chair is not prohibited from voting at any time.
II.
FACTS
At GCHP‟s regular meeting of Commissioners held on May 23, 2011, Agenda
item 4.a was to approve the “Auto-Assignment Study Group Recommendations” which would
thereupon become GCHP‟s policy on auto-assignment. The study group that developed the
recommendations included health care providers from the community who are not
Commissioners.
The recommendations, as originally presented to the Commissioners, included the
following provisions:
Defined “Safety Net Provider,” “Traditional Provider” and “Non-Traditional
Provider.”
Limited assignment by GCHP of auto-assigned members to Safety Net Providers
and Traditional Providers only.
Weighted the assignment between Safety Net Providers and Traditional Providers
as follows: “Safety Net Providers will be assigned two members for every one
member assigned to Traditional Providers.”
Following discussion among the Commissioners, a motion to amend the study
group recommendations was made by Commissioner Juarez (and seconded by Commissioner
Gonzalez) to change the weighting such that “Safety Net Providers will be assigned three
[instead of two] members for every one member assigned to Traditional Providers.” Five
Commissioners (i.e., Commissioners Araujo, Gonzalez, Juarez, Long and Rodriguez) voted in
favor of the motion to amend the study group recommendations, while the remaining three
Memo re vote on auto-assignment 6-14-11 v2 -2-
4a-2
TIN KIN LEE
LAW OFFICES
Commissioners (i.e., Chairman Dial and Commissioners Berry and Jarvis) voted against the
motion to amend.1
Although counsel indicated at the meeting that the motion to amend had carried,
upon further consideration regarding the possible financial interests which certain
Commissioners may have in GCHP‟s Auto-Assignment Policy and the impact which such
financial interests would have on their ability to vote on the Auto-Assignment Policy, the
analysis set forth in this memorandum was prepared.
III.
ANALYSIS
A. The Political Reform Act prohibits a Commissioner’s participation in a decision in
which the Commissioner has a conflict of interest.
Pursuant to Article XII of the GCHP bylaws, Commissioners are subject to the
conflict of interest rules set forth in the Political Reform Act of 1974 (Calif. Gov. Code, §87100
et seq.) (the “Political Reform Act”).2
Under the Political Reform Act, a Commissioner will be deemed to have a
conflict of interest if a decision has a “reasonably foreseeable material financial effect” on a
Commissioner‟s economic interests.3
1 Commissioners Chawla, Eberst and Fankhauser were absent from this meeting.
2 See GCHP bylaws, Art. XII:
“VCMMCC members [i.e., Commissioners] are subject to conflict of interest laws, including
Government Code section 1090 and the 1974 Political Reform Act (Government Code section
8100 et seq.), as modified by Welfare and Institutions Code section 14087.57, and must identify
and disclose any conflicts and refrain from participating in any manner in such matters in
accordance with the applicable statutes. Members of the VCMMCC agree to adhere to all
relevant standards established by state or federal law regarding ethical behavior.” (Emphasis
added.)
3 See Title 2, Calif. Code of Regulations (“CCR”), §18700.
“No public official at any level of state or local government may make, participate in making or
in any way use or attempt to use his/her official position to influence a governmental decision in
Memo re vote on auto-assignment 6-14-11 v2 -3-
4a-3
TIN KIN LEE
LAW OFFICES
An “economic interest” includes (i) a direct or indirect investment worth $2,000
or more in a business entity; (ii) being a director, officer, partner, trustee, employee, or holding
any position of management in a business entity (or its parent or subsidiary); or (iii) any source
of income of $500 or more within 12 months prior to the time the decision is made.4
Exhibit A
sets forth some of the materiality standards that may be applicable regarding the agenda item‟s
financial effect on a Commissioner‟s economic interests.
For example, if the Auto-Assignment Policy would have a material financial
effect on a Commissioner‟s employer or source of income to the Commissioner (by increasing or
decreasing the applicable entity‟s revenues or expenses by an amount exceeding the stated
materiality threshold), then, that Commissioner may not “make, participate in making or in any
which he/she knows or has reason to know he/she has a disqualifying conflict of interest. A
public official has a conflict of interest if the decision will have a reasonably foreseeable material
financial effect on one or more of his/her economic interests, unless the public official can
establish either: (1) that the effect is indistinguishable from the effect on the public generally, or
(2) a public official's participation is legally required.” Also see Calif. Gov. Code, §87100
4 See, e.g., Calif. Gov. Code §87103:
“A public official has a financial interest in a decision within the meaning of Section 87100 if it is
reasonably foreseeable that the decision will have a material financial effect, distinguishable from
its effect on the public generally, on the official, a member of his or her immediate family, or on
any of the following:
“(a) Any business entity in which the public official has a direct or indirect investment worth two
thousand dollars ($2,000) or more.
“(b) Any real property in which the public official has a direct or indirect interest worth two
thousand dollars ($2,000) or more.
“(c) Any source of income, except gifts or loans by a commercial lending institution made in the
regular course of business on terms available to the public without regard to official status,
aggregating five hundred dollars ($500) or more in value provided or promised to, received by,
the public official within 12 months prior to the time when the decision is made.
“(d) Any business entity in which the public official is a director, officer, partner, trustee,
employee, or holds any position of management.
“(e) Any donor of, or any intermediary or agent for a donor of, a gift or gifts aggregating two
hundred fifty dollars ($250) or more in value provided to, received by, or promised to the public
official within 12 months prior to the time when the decision is made. The amount of the value of
gifts specified by this subdivision shall be adjusted biennially by the commission to equal the
same amount determined by the commission pursuant to subdivision (f) of Section 89503.”
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way use or attempt to use his/her official position to influence” a decision involving the Auto-
Assignment Policy.
Thus, to the extent (i) one or more Commissioners are employed by, or hold an
economic interest or management position in, a “Safety Net Provider” or a “Traditional
Provider” (as such terms are defined in the study group recommendations), and (ii) the Auto-
Assignment Policy has a material financial effect on that “Safety Net Provider” or “Traditional
Provider,” then, pursuant to the Political Reform Act, the applicable Commissioner would be
prohibited from voting to adopt or amend the Auto-Assignment Policy
B. Alternatives in the event of disqualification of one or more Commissioners.
Although on its face, it would seem a relatively simple fix to simply throw out the
disqualified votes and count only the disinterested votes from the May 23rd
meeting, this would
not be a viable option for various reasons, including the following:
If the Commissioner who made the motion to amend the auto-assignment agenda
item was disqualified, then, it would follow that the motion itself would be invalid
because a disqualified Commissioner would be prohibited from making,
participating in making or in any way using or attempting to use his official
position to influence a decision involving the Auto-Assignment Policy.
Introducing motions that might influence the direction of a decision on auto-
assignment would arguably constitute “participation in a decision” and would be
prohibited to a disqualified Commissioner. Thus, if the motion itself was invalid,
then a vote to approve or reject the invalid motion should likewise be of no effect.
If certain Commissioners were disqualified from casting their votes on May 23rd
,
then there may not have been a quorum present for purposes of voting on that
agenda item because disqualified Commissioners are not counted for purposes of
a quorum.5
For example, if seven Commissioners are required for a quorum, but
5
See 2 CCR §18702.1(b):
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there were only four disinterested Commissioners, a quorum would have been
lacking for valid action.
Even if certain disqualified Commissioners could be counted towards a quorum
using the concept of “legally required participation” discussed below, certain
procedures would need to be complied with in advance, including the prior
disclosure of any conflict applicable to each Commissioner as it relates to that
item.
consideration:
In view of these issues, the following possible alternatives are proposed for
1. Alternative 1: Re-vote the auto-assignment agenda item using the concept of
“legally required participation.”
If the May 23rd
motion to amend the Auto-Assignment Policy and its
corresponding vote were invalid for the reasons discussed above, then, the original auto-
assignment agenda item could be resubmitted for vote using the concept of “legally required
participation” as follows:
The vote may be resubmitted to the Commission at such time as all disinterested
Commissioners are present (which may include certain of those Commissioners
who were absent from the May 23rd
meeting).6
“When an official with a disqualifying conflict of interest abstains from making a governmental decision in an open session of the agency and the official remains on the dais or in his or her
designated seat during deliberations of the governmental decision in which he or she is
disqualified, his or her presence shall not be counted toward achieving a quorum.”
6 See 2 CCR §18708(c)(2):
“[a disqualified Commissioner shall not be allowed] to vote if a quorum can be convened of
other members of the agency who are not disqualified under Government Code section 87100,
whether or not such other members are actually present at the time of the disqualification.”
(Emphasis added.)
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If the disinterested Commissioners are insufficient in number to constitute a
quorum, then, the disqualified Commissioners may be permitted to participate,
but only to the extent needed to constitute a quorum, and shall not be permitted to
vote.7
For example, if there are four disinterested Commissioners, then three
disqualified Commissioners would be counted for purposes of establishing a
quorum for that item.
If the total number of disinterested Commissioners does not constitute a majority
of the quorum, then, one or more disqualified Commissioners may be permitted to
vote as needed such that the number of voting Commissioners would constitute a
majority of the quorum.8
For example, if there are only three disinterested
Commissioners (which is less than the four out of seven needed to take action),
then, one of the three disqualified Commissioners may be permitted to vote in
addition to being counted for purposes of establishing a quorum for that item.
The existence and nature of the conflict for each disqualified Commissioner
would need to be disclosed orally during open session prior to the re-vote.9
7 See 2 CCR §18708(c)(3):
“participation [shall be required] by the smallest number of officials with a conflict that are
“legally required” in order for the decision to be made. A random means of selection may be used
to select only the number of officials needed. When an official is selected, he or she is selected
for the duration of the proceedings in all related matters until his or her participation is no longer
legally required, or the need for invoking the exception no longer exists.” (Emphasis added.)
Also see 61 Ops. Cal. Atty. Gen. 243 (1978):
“Accordingly, the Fair Political Practices Commission (FPPC) ruled that where three of five
members of a city board of building review were disqualified pursuant to section 87100, only one
of the three disqualified members could participate in the hearing in order to create a quorum.
(4 FPPC Opinions 13 (No. 77-007, February 7, 1978).) [FN10] In reaching this conclusion, the
FPPC held that the concept of „legally required participation‟ is to be narrowly construed so that
the impact of the resulting bias can be minimized.” (Emphasis added.)
8 However, a disqualified Commissioner shall not be permitted to vote for the purpose of breaking a tie.
See 2 CCR §18708(c)(1).
9 See 2 CCR §18708(b).
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2. Alternative 2: Do not re-vote the auto-assignment agenda item, but instead,
delegate the authority to accept or amend the recommendations of the study
group.
A re-vote utilizing disqualified Commissioners under Alternative 1 described
above may be used only “if there exists no alternative source of decision consistent with the
purposes and terms of the statute authorizing the decision.”10
However, an “alternative source of decision” may be deemed to exist if the
decision on the Auto-Assignment Policy is delegated by the Commissioners to the CEO, for
example, which would then bypass the need to re-vote the item under the concept of “legally
required participation” of disqualified Commissioners as described above.
C. The Chair is not prohibited from voting at any time.
The GCHP bylaws are silent on the issue of when the Chair may or may not vote,
however, the bylaws permit the use of Roberts Rules of Order (current edition) to resolve
questions of procedure that are not otherwise addressed in the bylaws.11
Roberts Rules of Order (10th Ed.) generally gives the Chair the same right to vote
as other Commissioners, but states that “the chair protects his impartial position by exercising his
voting right only when his vote would affect the outcome, in which case he can either vote and
thereby change the result, or he can abstain.”12
There is an exception, however, for “small boards or committees.” A “small
board” is a board where “there are not more than about a dozen members present.”
10
See 2 CCR §18708(a):
“A public official who has a financial interest in a decision may establish that he or she is legally
required to make or to participate in the making of a governmental decision within the meaning of
Government Code section 87101 only if there exists no alternative source of decision consistent
with the purposes and terms of the statute authorizing the decision.”
11 See Bylaws, Art. X, sec. (j).
12 Roberts Rules of Order (10th Ed.), Sec. 4, pp. 50-51.
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“The rules governing such [small board] meetings are different
from the rules that hold in other assemblies, in the following
respects:…
“The chairman can speak in discussion without rising or leaving the chair; and, subject to rule or custom within the particular board (which should be uniformly followed regardless of how many members are present), he usually can make motions and usually
votes on all questions.”13
Based on the foregoing, Dr. Dial‟s vote on the auto assignment agenda item in his
capacity as Chair was appropriate and should have been counted (subject to the validity of the
motion).
13 Roberts Rules of Order (10th Ed.), Sec. 49, pp. 470-471 (emphasis added).
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Exhibit A
FINANCIAL MATERIALITY STANDARDS
2 CCR § 18705.1 (Materiality Standard: Economic Interests in Business Entities):
(c) Indirectly involved business entities. The following materiality standards
apply when a business entity in which a public official has an economic interest is indirectly
involved in a governmental decision. If more than one of the following subdivisions is applicable
to the business entity in question, apply the subdivision with the highest dollar thresholds…
(2) If the business entity is listed on the New York Stock Exchange, or if not
listed on the New York Stock Exchange, for its most recent fiscal year had net income of no less
than $2.5 million, the financial effect of a governmental decision on the business entity is
material if it is reasonably foreseeable that:
(A) The governmental decision will result in an increase or decrease to the
business entity's gross revenues for a fiscal year in the amount of $500,000 or more; or,
(B) The governmental decision will result in the business entity incurring or
avoiding additional expenses or reducing or eliminating existing expenses for a fiscal year in the
amount of $200,000 or more; or,
(C) The governmental decision will result in an increase or decrease in the value
of assets or liabilities of $500,000 or more.
(3) If the business entity is listed on either the NASDAQ or American Stock
Exchange, or if not so listed, for its most recent fiscal year had net income of no less than
$750,000, the financial effect of a governmental decision on the business entity is material if it is
reasonably foreseeable that:
(A) The governmental decision will result in an increase or decrease to the
business entity's gross revenues for a fiscal year in the amount of $300,000 or more; or,
(B) The governmental decision will result in the business entity incurring or
avoiding additional expenses or reducing or eliminating existing expenses for a fiscal year in the
amount of $100,000 or more; or,
(C) The governmental decision will result in an increase or decrease in the value
of assets or liabilities of $300,000 or more.
(4) If the business entity is not covered by subdivisions (c)(1)-(3), the financial
effect of a governmental decision on the business entity is material if it is reasonably foreseeable
that:
(A) The governmental decision will result in an increase or decrease in the
business entity's gross revenues for a fiscal year in the amount of $20,000 or more; or,
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(B) The governmental decision will result in the business entity incurring or
avoiding additional expenses or reducing or eliminating existing expenses for a fiscal year in the
amount of $5,000 or more; or,
(C) The governmental decision will result in an increase or decrease in the value
of the business entity's assets or liabilities of $20,000 or more.
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To: Ventura County Medi-Cal Managed Care Commission From: Earl Greenia, CEO
Date: May 23, 2011
RE: Auto-Assignment Policy BACKGROUND After establishing eligibility and upon enrollment into the plan, members are requested to select a Primary Care Provider (Physician or Clinic). In the event that a member does not timely select a PCP, the plan will assign the member to a provider. The Commission requested that a study group review issues related to the definition of “traditional provider” and the policy for auto assignment.
RECOMMENDATION The study group met on April 20, 2011 and again on May 18 to discuss the issue. It was recognized that a member has the right to change his/her Primary Care Physician whether self- selected or “auto-assigned” by notifying the plan, thus preserving the member’s freedom of choice. It was also recognized that the assignment process must give appropriate consideration to various member-specific factors, such as: zip code of Member’s residence, age, gender, and language.
The group developed the following recommendations:
1) That “Safety Net Provider” refers only to recognized disproportionate share hospitals (DSH), federally qualified health centers (FQHC), and rural health centers (RHC).
2) That “Traditional Provider” refers to those providers that have served Ventura County Medi-Cal beneficiaries for at least three years, and with a patient population / payor mix of at least 30% Medi-Cal and/or uninsured/charity care.
3) That “Non-Traditional Provider” refers to those providers that have served Ventura County Medi-Cal beneficiaries for at least one year.
4) That participation in the auto-assignment panel is limited to Safety Net Providers or Traditional Provider as defined above.
5) That assignment be weighted: Safety Net Providers will be assigned two members for every one member assigned to Traditional Providers.
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AGENDA ITEM 4-B
To: Ventura County Medi-Cal Managed Care Commission
From: Earl Greenia, CEO
Date: June 27, 2011
Re: Pharmacy & Therapeutics Committee Appointments Recommendation: Management requests that the Commission formally appoint additional members to the Pharmacy & Therapeutics Committee as recommended below.
Background: On April 26, 2010, the Commission established parameters for the Pharmacy & Therapeutics. No committee size was established. Each member serves a two-year term and may reapply for additional terms. Chaired by the Chief Medical Officer, the committee includes physicians from major disciplines, including primary care and specialty practices. Participants are bound by confidentiality and conflict of interest rules. In March, the Committee appointed eight members.
Discussion: As we started working on the formulary, the need for additional expertise arose and five additional members were recruited:
Ravi Bajwa, M.P.H., M.D., (Pulmonary Medicine), On staff at VCMC.
Daniel Clark, M.D. (Cardiology), Director of Medicine and Cardiology, VCMC since 1993. Clinical Professor of Family Medicine, UCLA.
Robert Fuladi, Pharm. D., Vice President, Clinical Pharmacist for Coastal Pharmaceutical Services Corporation since 2006. Vice President, Pharmacy Manager for Mission Health Care Pharmacy Corporation since 2000. Received a Bachelor of Science from Massachusetts College of Pharmacy in 1993 and a Doctor of Pharmacy from the University of Kansas in 2006.
Gary Nishida, M.D. (OB/Gyn), In private practice in Oxnard since 1984.
Pari Young, M.A., M.D. (Neurology), Las Posas Family Medicine Group.
AGENDA ITEM 4-C
To: Ventura County Medi-Cal Managed Care Commission
From: Earl Greenia, CEO
Date: June 27, 2011
Re: Credentialing Committee Appointments Recommendation: Management requests that the Commission appoint additional members to the Credentialing Committee as recommended below.
Background: On April 26, 2010, the Commission established parameters for the Credentialing Committee. The committee will consist of a minimum of 8 voting members, appointed by the Commission and representative of the composition of the contracted provider network. Each of the appointed members serves a two-year term and may reapply for additional terms, as there are no term limits. Chaired by the Chief Medical Officer, the committee includes physicians from major disciplines, including primary care and specialty practices. The committee has the option of inviting additional specialists, if necessary, to review case records, either in writing or in person. Participants are bound by confidentiality and conflict of interest rules. In February, the Committee appointed seven members.
Discussion: Dr. Cho has identified two additional candidates for our Credentialing Committee:
Gary J. Proffett, M.D. has been the Medical Director of Sea View IPA since 2000. He is a graduate of Universidad Autonoma de Guadalajara and completed his post-graduate training at State University of New York in Buffalo and St. Agnes Hospital in Baltimore, Maryland. He was in private practice (General/Family Medicine) from 1978 to 2000 in Granada Hills. During that time he held numerous Medical Directorships and Utilization Review Committee appointments at various hospitals and organizations including Granada Hills Community Hospital, Southern California IPA, Prudential Health Care, Astoria Convalescent hospital, and the Huntington Provider Group IPA. Dr. Proffett serves as Medical Director at several long-term care facilities in the county, such as Maywood Healthcare and Country Villa both of Oxnard and Vitas Hospice, Roze Room Hospice, Victoria Care Convalescent and Braewood Home Health Inc.
Lee Wan, M.D., is the Medical Director of the Coastal Eye Specialists Medical Group and has been in private practice in Oxnard since 1988. He is a graduate of Loma Linda University School of Medicine with his specialty training at USC. He was a Past President of the St. John’s Regional Medical Center Medical Staff where he served on numerous committees, including: Credentials, Quality Management and Quality Improvement. Currently, he serves on the Bylaws Committee and the Physician Support Committee. He is a delegate to the Organized Medical Staff Section of both CMA and AMA, while serving on the Board of Governors of Ventura County Medical Association. In addition, Dr. Wan has been serving as the Executive Vice
President of the Ventura County Ophthalmology Society since 2006.
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AGENDA ITEM 4-D
To: Ventura County Medi-Cal Managed Care Commission
From: Earl Greenia, CEO
Date: June 27, 2011
Re: Quality Assurance / Utilization Review / Peer Review Committee Appointments Recommendation: Management requests that the Commission appoint two additional members to the Committee as recommended below.
Background: On April 26, 2010, the Commission established broad parameters for this Committee. Each of the appointed members serves a two-year term and may reapply for additional terms, as there are no term limits. Chaired by the Chief Medical Officer, the committee includes physicians from major disciplines, including primary care and specialty practices. Participants are bound by confidentiality and conflict of interest rules. In March the Commission appointed 11 members.
Discussion: Dr. Cho identified two additional candidates who bring additional needed expertise:
Gary Proffett, M.D. (Family Medicine) - Sea View IPA Medical Director since 2000 and Medical Director for several Long Term Facilities
Victor Pulido, D.O. (Family Medicine) - Center for Family Health – CMH since 1998. Family Practice Residency, Riverside General Hospital, 1992.
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AGENDA ITEM 4-E
To: Ventura County Medi-Cal Managed Care Commission
From: Earl Greenia, CEO
Date: June 27, 2011
RE: Advisory Committee Appointment Recommendation: Management recommends that the Commission fill a vacancy on the Provider Advisory Committee created by a recent resignation.
Background: On January 24, 2011, the Commission appointed the initial Committee membership with Dr. Gary Jacobs (Optometrist) as the “Non-Physician Practitioner” representative. Unfortunately, Dr. Jacobs has resigned.
Discussion: Management recommends the appointment of Dr. Clive Salmon (podiatrist) to fill the vacancy. His brief biography follows:
Dr. Salmon earned a Bachelor’s degree in Biology from Long Beach State University and graduated from the California College of Podiatric Medicine in 1979. He has been in private practice in Oxnard since 1980 and served as the staff podiatrist for Camarillo State Hospital from 1984 to its closure in 1996.
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List of Covered Drugs
Effective
July 1, 2011
4f-1
INTRODUCTION We are pleased to provide the 2011 Gold Coast Health Plan List of Covered Drugs as a useful reference and informational tool. The GCHP List of Covered Drugs can assist practitioners in selecting clinically appropriate and cost effective products for their patients.
The information contained in the GCHP List of Covered Drugs is provided solely for the convenience of medical providers. We do not warrant or assure accuracy of such information nor is it intended to be comprehensive in nature. This List of Covered Drugs is not intended to be a substitute for the knowledge, expertise, skill and judgment of the medical provider in his or her choice of prescription drugs. All the information in this List of Covered Drugs is provided as a reference for drug therapy selection. Specific drug selection for an individual patient rests solely with the prescriber.
We assume no responsibility for the actions or omissions of any medical provider based upon reliance, in whole or in part, on the information contained herein. The medical provider should consult the drug manufacturer's product literature or standard references for more detailed information.
National guidelines can be found on the National Guideline Clearinghouse site at http://www.guideline.gov
PREFACE The GCHP List of Covered Drugs is organized by sections. Each section is divided by therapeutic drug class primarily defined by mechanism of action. Unless exceptions are noted, generally all applicable dosage forms and strengths of the drug cited are included in the GCHP List of Covered Drugs. Generics should be considered the first line of prescribing.
Drugs represented in the GCHP List of Covered Drugs may have varying cost to the plan member based on the plans benefit structure. Generic medications typically are available at the lowest cost, brand-name medications on the GCHP List of Covered Drugs will generally cost more than generics, and brand-name medications not on the list will generally cost the most.
PHARMACY AND THERAPEUTICS (P&T) COMMITTEE The services of the GCHP Pharmacy and Therapeutics Committee ("P&T Committee") are utilized to approve safe and clinically effective drug therapies. The P&T Committee is an external advisory body of experts. The P&T Committee's voting members include physicians and pharmacists, all of whom have a broad background of clinical and academic expertise regarding prescription drugs. Employees with significant clinical expertise are invited to meet with the P&T Committee. Voting members of the P&T Committee must disclose any financial relationship or conflicts of interest with any pharmaceutical manufacturers.
GENERIC SUBSTITUTION Generic substitution is a pharmacy action whereby a generic version is dispensed rather than a prescribed brand-name product. However, not all strengths or dosage forms of the generic name in may be generically available. The GCHP List of Covered Drugs is a mandatory generic drug list. So whenever a generic to a covered agent becomes available, it is added. And if the branded agent was part of the cover drug list, the branded agent will be removed from the covered drug list.
Generic drugs are usually priced lower than their brand-name equivalents. Generic drugs are:
• Approved by the U.S. Food and Drug Administration for safety and effectiveness, and are manufactured under the
same strict standards that apply to brand-name drugs.
• Tested in humans to assure the generic is absorbed into the bloodstream in a similar rate and extent compared to the brand-name drug (bioequivalence). Generics may be different from the brand in size, color, and inactive ingredients, but this does not alter their effectiveness or ability to be absorbed just like the brand-name drug.
• Manufactured in the same strength and dosage form as the brand-name drugs.
• When a generic drug is substituted for a brand-name drug, you can expect the generic to produce the same clinical effect and safety profile as the brand-name drug (therapeutic equivalence).
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SPECIALTY PLAN DESIGN Specialty Guideline Management (SGM)
SGM is our utilization management program that helps ensure appropriate utilization for specialty medication based on currently accepted evidence-based medicine guidelines. The utilization management program is available for all therapeutic areas dispensed by our specialty pharmacies. SGM is designed to ensure safety and efficacy while preventing off-guideline utilization. Medications which may be included in the SGM program are identified in the GCHP List of Covered Drugs under the heading of “Specialty Medications” for your reference. SGM may also be combined with Inventory Management/ Dose Optimization and Optimal Drug Mix through High Performance Specialty Design to appropriately manage specialty medications.
PLAN DESIGN The GCHP List of Covered Drugs is a closed drug list plan design. The medications listed on the drug list are covered by the plan as represented. Certain medications on the list are covered if utilization management criteria are met (i.e. Step Therapy, LMN, CPA, Quantity Limits, etc); requests for use of such medications outside of their listed criteria will be reviewed for medical necessity.
Should it become necessary to write a prescription for a drug, which is not on the GCHP List of Covered Drugs, one must obtain clinical prior authorization.
LEGEND CPA Clinical Prior Authorization LMN Letter of Medical Necessity QL Quantity Limit STEP Step Therapy
OTC Over the Counter
The GCHP List of Covered Drugs allows members to receive up to 10 prescriptions per month. The items below are exempt from the monthly limitation:
1. Nursing home patients
2. Newborns using their mother's ID
3. Antibiotics
4. Contraceptives
5. Meds for cancer treatment
6. Meds for diabetes
7. Meds for transplant patients
8. Individual medications or medication classes as determined by GCHP 9. Individual members with multiple chronic illnesses as determined by GCHP on a case-by-case basis
DRUG COST KEY
$ $1 to $10 $$ $11 to $50 $$$ $51 to $100 $$$$ $101 to $500 $$$$$ $501 to $1,000 $$$$$$ $1,001 to $5,000
$$$$$$$ $5,001 to $10,000
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EXCLUDED THERAPEUTIC CLASSES AND DRUGS FROM GCHP LIST OF COVERED DRUGS These therapeutic classes of drugs are carved out from the GCHP List of Covered Drugs. This means that when one of these medications is prescribed, it will be filled by the pharmacist, who in turn will bill the State of California for reimbursement.
DEPENDENCTY TREATMENT Buprenorphine HCl
Acamprosate Calcium Naltrexone HCl
Buprenorphine HCl-Naloxone HCl Naltrexone
HIV Amprenavir Tipranavir Efavirenz-Emtricitabine-Tenofovir DF Lamivudine-Zidovudine Indinavir Sulfate Emtricitabine Lamivudine Abacavir Sulfate-Lamivudine Saquinavir
Enfuvirtide
Etravirine Saquinavir Mesylate Raltegravir Potassium Lopinavir-Ritonavir Fosamprenavir Calcium Ritonavir Darunavir Ethanolate Delavirdine Mesylate Zidovudine Atazanavir Sulfate Maraviroc
Efavirenz Abacavir Sulfate-Lamivudine- Zidovudine Emtricitabine-Tenofovir Disoproxil Fumarate Nevirapine Tenofovir Disoproxil Fumarate Stavudine Abacavir Sulfate
ERECTILE DYSFUNCTION
PSYCHIATRIC Amantadine HCl Aripiprazole Asenapine Maleate Benztropine Mesylate Biperiden HCl Chlorpromazine HCl Chlorprothixene Clozapine Fluphenazine Decanoate
Fluphenazine Enanthate Fluphenazine HCl Haloperidol Haloperidol Decanoate
Haloperidol Lactate
Iloperidone Isocarboxazid Lithium Carbonate Lithium Citrate Loxapine HCl Loxapine Succinate
Mesoridazine Besylate Molindone HCl Olanzapine Olanzapine-Fluoxetine HCl Olanzapine Pamoate Paliperidone Paliperidone Palmitate
Perphenazine
Phenelzine Sulfate Pimozide Procyclidine HCl Promazine HCl Quetiapine Risperidone Selegiline TD Patch Thioridazine HCl Thiothixene Thiothixene HCl
Tranylcypromine Sulfate Trifluoperazine HCl Ziprasidone HCl
Ziprasidone Mesylate
NOTICE The information contained in this document is proprietary. The information may not be copied in whole or in part without written permission. All rights reserved.
This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers that are not affiliated with Gold Coast Health Plan.
When viewing the GCHP List of Covered Drugs via the Internet, please be advised that the GCHP List of Covered Drugs
is updated periodically and changes may appear prior to their effective date to allow for client notification.
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GCHP List of Covered Drugs
Therapeutic Category
Therapeutic Category Therapeutic Class Brand Names Generic Name Strength(s) Coverage Rx Cost LMN, QL, Step, CPA
ANESTHETICS TOPICAL ANESTHETICS LIDODERM Lidocaine Patch 5% Generic $$$$$ XYLOCAINE Lidocaine HCl 2% gel, 5% onit Generic $$ XYLOCAINE Lidocaine HCl Viscous 2% Generic $$ ANTIINFECTIVES ALLYLAMINE CLOTRIMAZOLE
Clotrimazole Vaginal, Topical, Troches Generic $ to $$$$
LAMISIL Terbinafine Oral 250mg Generic $$$$ NIZORAL Ketoconazole Topical Generic $$ NYSTATIN Nystatin Swish and Swallow Generic $$ TERCONAZOLE Terconazole Vaginal Generic $$ AMINOGLYCOSIDES AMIKIN Amikacin IV Generic $$$$ QL= 14 days
GARAMYCIN Gentamicin IM or IV Generic $$ QL= 14 days
NEOMYCIN Neomycin Sulfate ‐Oral 500mg Generic $$$$ QL= 2 tabs/30 days
TOBREX Tobramycin IV Generic $$$ QL= 14 days
VANCOCIN Vancomycin Oral, IV Generic $$$ AMINOPENICILLINS AMOXIL Amoxacillin‐Oral Generic $$ AMPICILLIN Ampicillin IV
125mg, 250mg, 500mg, 1g, 2g 10g
, Generic $$$ LMN
AUGMENTIN Amoxacillin/Clavulanate‐Tabs,
Susp Generic $$$
UNASYN Ampicillin/Sulbactam IV Generic $$$ LMN
ANTIBIOTICS BACTROBAN Mupirocin Generic $$ NEOSPORIN Neomycin/Polymyxin Gramicidin Generic $$ ANTIFUNGALS GRIS‐PEG Griseofulvin Oral 125mg, 250mg Generic $$ NYSTOP Nystatin Topical Powder Generic $$ ANCOBON Flucytosine Oral 250mg, 500mg Brand $ LMN
ANTI‐MYCOBACTERIAL ISONIAZID Isoniazid Oral Generic $$ MYAMBUTOL Ethambutol Oral 100mg, 400mg Generic $$$ PYRAZINAMIDE Pyrazinamide Oral 500mg Generic $$$ RIFADIN Rifampin Oral 150mg, 300mg Generic $$$ ANTIPARASITICS ACTICIN Permethrin Lotion 1% Generic $$ ARALEN Chloroquin Phosphate Oral 250mg Generic $$$ DAPSONE Dapsone Oral 25mg, 100mg Generic $$ MEBENDAZOLE Mebendazole Oral 100mg Generic $$$ OVIDE Malathion Lotion 0.50% Generic $$$$ PLAQUENIL Hydroxychloroquine Sulfate 200mg Generic $$$ PRIMAQUINE Primaquine Oral 26.3mg Generic $$$$ ALBENZA Albendazole Oral 200mg Brand $$$$ ALINIA Nitazoxanide Oral 500mg Brand $$$$$ BILTRICIDE Praziquantal Oral 600mg Brand $$$ STROMECTOL Ivermectin Oral 3mg Brand $$$$ YODOXIN Iodoquinol Oral 210mg, 650mg Brand $$$$ ANTI‐PSEUDOMONAL PCN ZOSYN Pipercillin/Tazobactam IV Generic $$$$ LMN
ANTI‐VIRAL CYTOVENE Gancyclovir IV 500mg Generic $ LMN
FAMVIR Famcyclovir Oral 125mg, 250mg, 500mg Generic $$$$ RIBAPAK Ribavirin Oral 400mg, 600mg Generic $$$$ Specialty
SYMMETREL Amantadine Oral Generic $$$ VALTREX Valacyclovir HCl 500mg, 1g Generic $$$$ CPA
ZOVIRAX Acyclovir Oral, IV Generic $$$$ LMN; IV only
RELENZA Zanamivir Oral 5mg Brand $$$ QL= 20 tabs/30 days
TAMIFLU Oseltamir Oral 30mg, 45mg, 70mg Brand $$$$ QL= 10 caps (45mg, 75mg) 20 caps
(30mg) 100ml/30 days (oral susp)
BURN PRODUCTS SILVADENE Silver Sulfadiazine Generic $$$ CARBAPENAM INVANZ Ertapenem IV Generic $$$$$ LMN
MERREM Meropenem IV Generic $$$$ LMN
PRIMAXIN Imipenem/Cilastin IV Generic $$$$$ LMN
CEPHALOSPORINS 1ST GENERATION
ANCEF Cefazolin Generic $$$ KEFLIN Cephalothin‐Oral Generic $$$
CEPHALOSPORINS 2ND GENERATION
CEFOTAN Cefotetan‐IV Generic $$$ LMN
CEFTIN Cefuroxime IV, Oral Generic $$$ LMN
MEFOXIN Cefoxitin‐IV Generic $$ LMN
CEPHALOSPORINS 3RD GENERATION
CLAFORAN Cefotaxime IV Generic $$$ LMN
FORTAZ Ceftazidime IV Generic $$$ LMN; Specialty
ROCEPHIN Ceftriaxone IV Generic $$$ VANTIN Cefpodoxime proxetil‐Oral Generic $$$ LMN
CEPHALOSPORINS 4TH GENERATION
MAXIPIME Cefapime IV Generic $$ LMN
CLINDAMYIN CLEOCIN Clindamycin Oral, IV Generic $$$ LMN
ECHINOCANDINS CANCIDAS Caspofungin Acetate 50mg, 70mg Brand $$ LMN; Specialty
MYCAMINE Micafungin IV 50mg, 100mg Brand $$$ LMN
ERYTHROMYCIN EES Erythromycin Esthylsuccinate 400mg Generic $$$
ERYTHROCIN Erythromycin Stearate 25mg, 500mg Generic $$
$ ‐‐‐‐‐‐‐‐‐ $1 to $10
$$ ‐‐‐‐‐‐‐‐‐ $11 to $50
$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100
$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500
$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000
$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000
4f-5
6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 1 of 17
GCHP List of Covered Drugs
Therapeutic Category
Therapeutic Category Therapeutic Class Brand Names Generic Name Strength(s) Coverage Rx Cost LMN, QL, Step, CPA
FLUORDQUINOLONE BACTRIM DS Sulfamethoxazole/Trimethoprim Generic $$
CIPRO Ciprofloxacin Oral Generic $$$
FLAGYL Metronidazole Oral, IV Generic $$ to $$$$
LEVAQUIN Levofloxacin Oral Generic $$
MACRODANTIN Nitrofurantoin Macorcrystal Oral Generic $$
AVELOX Moxifloxacin Oral Brand $$$ LMN
CUBICIN Daptomycin IV 500mg Brand $$$$ LMN
VIBATIV Televancin IV 250mg, 750mg Brand $$$ LMN
ZYVOX Linezolid Oral, IV Brand $$$$$$ LMN; Specialty
HEP B & HEP C RIBAVIRIN Ribavirin Oral 200mg, 400mg, 600mg Generic $$$$ Specialty
EMTRIVA Emtricitabine Oral 200mg Brand $$$$$
EPIVIR Lamivudine Oral 150mg, 300mg Brand $$$$
INFERGEN Interferon Brand $$$$$$ Specialty
TYZEKA Telbivudine Oral 600mg Brand $$$$$
IMIDAZOLE ANTIFUNGALS NIZORAL Ketoconazole Oral 200mg Generic $$$
MACROLIDES BIAXIN Clarithromycin Oral Generic $$$
ZITHROMAX Azithromycin Oral Generic $$
QL= 28 tabs/14 days, Max 2
fills/30 days (250mg & 500mg);
280ml/14 days, Max 2 fills of
280ml/30 days (125mg/5ml &
250mg/5ml) CPA (600mg); QL= 8
tabs/10 days, Max 2 fills/30 days
(250mg); 4 tabs/10 days,Max 2
fills/30 days (500mg)
MONOBACTAM AZACTAM Aztreonam IV Generic $$$$$ LMN
PENICILLIN BICILLIN L‐A Benzathine IM Generic $$$$ LMN
PENICILLN GK Penicillin G IV Generic $$$ LMN
PENICILLN VK Penicillin VK‐oral Generic $$$
PENICILLINASE RESISTANT PCN DYCILL Dicloxacillin‐Oral Generic $$
NAFCILLIN Nafcillin IV Generic $$$$ LMN POLYENE
ANITFUNGALS AMBISOME Amphotericin B Liposome 510mg Brand $$$$ LMN; Specialty
TETRACYCLINE DOXYCYCLINE Doxycycline Oral Generic $$
TETRACYCLINE Tetracycline Oral Generic $$
TYGACIL Tigecycline IV 50mg Brand $$$$$ LMN
TRIAZOLE ANTIFUNGALS DIFLUCAN Fluconazole Oral 50mg, 100mg, 150mg, 200mg Generic $$$$ LMN
ANTINEOPLASTIC/
IMMUNOSUPRESSANT
ANTINEOPLASTIC/
IMMUNOSUPRESSANT
NOXAFIL Posaconazole Oral 40mg/ml Brand $$$$$ LMN
SPORANOX Itraconazole Oral 100mg Brand $$$$ LMN
ADRIAMYCIN Doxorubicin HCl 2mg/ml Generic $$$$
2.5g/50ml, 5g/100ml, ADRUCIL Fluorouracil
500mg/10ml Generic $$
ARIMIDEX Anastrozole 1mg Generic $$$$
AROMASIN Exemestane 25mg Generic $$$$ Step: anastrozole
CASODEX Bicalutamide 50mg Generic $$$$
CELLCEPT Mycophenolate Mofetil 250mg, 500mg Generic $$$$
50mg/50ml, 100mg/100ml, CISPLATIN Cisplatin
200mg/200ml Generic $$$
FASLODEX Fulvestrant 250mg/5ml Generic $$$$$$
FEMARA Letrozole 2.5mg Generic $$$$$
HALAVEN Eribulin Mesylate 1mg/2ml Generic $$$$$$
HYCAMTIN Topotecan HCl 4mg Generic $$$$$
HYDREA Hydroxyurea 500mg Generic $$$$
IFEX Ifosfamide 1 gm, 3 gm Generic $$$$$$
IMURAN Azathioprine 50mg Generic $$$$$
IXEMPRA Ixabepilone 15mg, 45mg Generic $$$$$$
JEVTANA Cabazitaxel 60mg/1.5ml Generic $$$$$$$
MATULANE Procarbazine HCl 50mg Generic $$$$$$$
MEGACE Megestrol Acetate 20mg, 40mg Generic $$$$$
1g, 1g/40ml, 25mg/ml, 50mg/2ml, MEXATE Methotrexate Sodium
250mg/10ml Generic $$$$$$
MITOMYCIN Mitomycin 5mg, 20mg, 40mg Generic $$$$$$
NEORAL Cyclosporine 25mg, 100mg Generic $$$$$$
NOLVADEX Tamoxifen Citrate 10mg, 20mg Generic $$$$
NPLATE Romiplostim 250mcg, 500mcg Generic $$$$$$
30mg/5ml, 100mg/16.7ml, ONXOL Paclitaxel
150mg/25ml, 300mg/50ml Generic $$$$$
PURINETHOL Mercaptopurine 50mg Generic $$$$
RHEUMATREX Methotrexate Sodium 2.5mg Generic $$$$
SANDIMMUNE Cyclosporine 50mg/ml Generic $$$$$$
TOPOSAR Etoposide 20mg/ml Generic $$$$$
TRISENOX Arsenic Trioxide 10mg/10ml Generic $$$$$
VELCADE Bortezomib 3.5mg Generic $$$$$$
VINBLASTINE Vinblastine Sulfate 1mg/ml Generic $$$$
VINCRISTINE Vincristine Sulfate 1mg/ml Generic $$$$
$ ‐‐‐‐‐‐‐‐‐ $1 to $10
$$ ‐‐‐‐‐‐‐‐‐ $11 to $50
$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100
$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500
$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000
$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000
4f-6
6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 2 of 17
GCHP List of Covered Drugs
Therapeutic Category
Therapeutic Category Therapeutic Class Brand Names Generic Name Strength(s) Coverage Rx Cost LMN, QL, Step, CPA
TREANDA Bendamustine HCl 25mg, 100mg Brand $$$$ AUTONOMIC & CNS ANALGESICS BUTALBITAL Butalbital Generic $$
10mg/ml, 25mg/ml, 50mg/ml, DEMEROL Meperidine HCl
Generic $$$ CPA; QL= 120ml/30 days
DILAUDID Hydromorphone HCl 1mg, 2mg, 4mg, 8mg Generic $$$ QL= 120 tabs/30 days
12mcg, 25mcg, 50mcg, 75mcg,
DURAGESIC Fentanyl TD Patch
100mcg Generic $$$$ CPA; QL= 15/30days
FIORICET Butalbital‐Acetaminophen‐
Caffeine 50‐325‐40mg Generic $$
METHADONE Methadone HCl 5mg, 10mg, 40mg Generic $$$ CPA; QL= 120 tabs/30 days
MS CONTIN Morphine Sulfate 15mg, 30mg, 60mg, 10mg, 200mg Generic $$$ QL= 120 tabs/30 days
REPREXAIN Hydrocodone‐Ibuprofen 2.5‐200mg, 5‐200mg, 7.5‐200mg,
10‐200mg Generic $$$$ QL= 120 tabs/30 days
ROXICODONE Oxycodone HCl 5mg, 10mg, 15mg, 20mg, 30mg,
40mg, 80mg Generic $$$ QL= 120 tabs/30 days
TYLENOL/COD Acetaminophen w/ Codeine 300‐15mg, 300‐30mg, 300‐60mg Generic $$$ QL= 120 tabs/30 days
ULTRAM Tramadol HCl 50mg, 100mg, 200mg, 300mg Generic $$$$ QL= 120 tabs/30 days
2.5‐500mg, 5‐325mg, 5‐500mg, 7.5‐325mg, 7.5‐650mg, 7.5‐ VICODIN Hydrocodone‐Acetaminophen 650mg, 7.5‐750mg, 10‐300mg, 10‐ Generic $$$ QL= 120 tabs/30 days
325mg, 10‐500mg, 10‐650mg, 10‐ 660mg FENTORA Fentanyl Citrate
100mcg, 200mcg, 300mcg,
400mcg, 600mcg, 800mcg Brand $$$$$ CPA
OPANA ER Oxymorphone HCl 5mg, 7.5mg, 10mg, 15mg, 20mg,
30mg, 40mg Brand $$$$ QL= 120 tabs/30 days
OXYCONTIN Oxycodone HCl 10mg, 15mg, 20mg, 30mg, 40mg,
60mg, 80mg, 160mg Brand $$$$ CPA; QL= 120 tabs/30 days
ANTIANXIETY ATIVAN Lorazepam 0.5mg, 1mg, 2mg, Generic $$$ QL= 120tabs/30days
BUSPAR Buspirone HCl 5mg, 7.5mg, 10mg, 15mg, 30mg Generic $$$ QL= 120tabs/30days
LIBRIUM Chlordiazepoxide HCl 5mg, 10mg, 25mg Generic $$ QL= 120tabs/30days
TRANXENE‐T Clorazepate Dipotassium 3.75mg, 7.5mg, 15mg Generic $$ QL= 120tabs/30days
VALIUM Diazepam 2mg, 5mg, 10mg Generic $$ QL= 120tabs/30days
XANAX Alprazolam 0.25mg, 0.5mg, 1mg, 2mg Generic $$ QL= 120tabs/30days
ANTICONVULSANTS DEPAKOTE SPR Divalproex Sodium Sprinkle 125mg, 250mg, 500mg Generic $$$ DEPAKOTE, DEPAKOTE ER Divalproex Sodium 125mg, 250mg, 500mg Generic $$$ DILANTIN Phenytoin Sodium 100mg Generic $$ KEPPRA Levetiracetam
100mg/ml, 250mg, 500mg, 750mg, 1000mg
Generic $$$
KLONOPIN Clonazepam 0.125mg, 0.25mg, 0.5mg, 1mg,
2mg Generic $$
LAMICTAL Lamotrigine 25mg, 50mg, 100mg, 150mg,
200mg, 250mg Generic $$
MYSOLINE Primidone 50mg, 250mg Generic $$$ NEURONTIN Gabapentin
100mg, 300mg, 400mg, 600mg, 800mg
Generic $$$$
PHENOBARB Phenobarbital 15mg, 30mg, 32.4mg, 60mg,
100mg Generic $$
PHENYTEK Phenytoin Sodium 200mg, 300mg Generic $$ TEGRETOL Carbamazepine 200mg, 400mg Generic $$$ TOPAMAX Topiramate 25mg, 50mg, 100mg, 200mg Generic $$ TOPAMAX SPRINKLE Topiramate Sprinkle 15mg, 25mg Generic $$ TRILEPTAL Oxcarbazepine Suspension 300mg/5ml Generic $$$ ZONEGRAN Zonisamide 25MG,50mg, 100mg Generic $$ CARBATROL Carbamazepine 100mg, 200mg, 300mg Brand $$$$ KEPPRA XR Levetiracetam SR 500mg, 750mg Brand $$$ LAMICTAL XR Lamotrigine SR
25mg, 100mg, 150mg, 200mg, 300mg
Brand $$$$
LYRICA
Pregabalin
25mg, 50mg, 75mg, 100mg,
150mg, 200mg, 225mg, 300mg
Brand
$$$$
Step: gabapentin
VIMPAT
Lacosamide 50mg, 100mg, 150mg, 200mg,
10mg/ml
Brand
$$$$
ANTIDEMENTIA ARICEPT, ARICEPT ODT Donepezil Hydrochloride 5mg, 10mg, 23mg Generic $$$$ EXELON Rivastigmine Tartrate 1.5mg, 3mg, 4.5mg, 6mg Generic $$$$ EXELON PATCH Rivastigmine TD Patch 4.6mg/24HR, 9.5mg/24HR Brand $$$$ NAMENDA Memantine HCl 5mg, 5‐10mg, 10mg Brand $$$$ ANTIDEPRESSANTS ANAFRANIL Clomipramine HCl 25mg, 50mg, 75mg Generic $ CELEXA Citalopram Hydrobromide 10mg, 20mg, 40mg Generic $$ DESYREL Trazodone HCl 50mg, 100mg, 150mg, 300mg Generic $$
75mg/ml, 100mg/ml
$ ‐‐‐‐‐‐‐‐‐ $1 to $10
$$ ‐‐‐‐‐‐‐‐‐ $11 to $50
$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100
$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500
$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000
$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000
4f-7
6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 3 of 17
GCHP List of Covered Drugs
Therapeutic Category
Therapeutic Category Therapeutic Class Brand Names Generic Name Strength(s) Coverage Rx Cost LMN, QL, Step, CPA
EFFEXOR Venlafaxine HCl 25mg, 37.5mg, 50mg, 75mg,
100mg Generic $$
EFFEXOR ER Venlafaxine HCl SR 37.5mg, 75mg, 150mg, 225mg Generic $$$
ELAVIL Amitriptyline HCl
10mg, 25mg, 50mg, 75mg, 100mg,
150mg
Generic $$
LEXAPRO Escitalopram Oxalate 5mg, 10mg, 20mg Generic $$$$
Step: Failure of two: citalopram,
fluoxetine, fluvoxamine,
paroxetine, sertraline
LUVOX Fluvoxamine Maleate 25mg, 50mg, 100mg Generic $$$
MIRTAZAPINE Mirtazapine 7.5mg, 15mg, 30mg, 45mg Generic $$$
10mg, 25mg, 50mg, 75mg, 100mg, NORPRAMIN Desipramine HCl
150mg Generic $$
PAMELOR Nortriptyline HCl 10mg, 25mg, 50mg, 75mg Generic $$$
PAXIL Paroxetine HCl 10mg, 12.5mg, 20mg, 30mg, 40mg Generic $$
PROZAC Fluoxetine HCl 10mg, 20mg, 40mg, 90mg Generic $$
PROZAC WEEKLY Fluoxetine HCl 90mg Generic $$
Step: Failure of two: citalopram,
fluoxetine, fluvoxamine,
paroxetine, sertraline
SERZONE Nefazodone HCl
SINEQUAN Doxepin HCl
50mg, 100mg, 150mg, 200mg,
250mg
10mg, 25mg, 50mg, 75mg, 100mg,
150mg
Generic $$$
Generic $$
TOFRANIL Imipramine HCl 10mg, 25mg, 50mg Generic $$
75mg, 100mg, 150mg, 200mg, WELLBUTRIN, WELLBUTRIN XL Bupropion HCl, Bupropion HCl SR
300mg Generic $$$
ZOLOFT Sertraline HCl 25mg, 50mg, 100mg Generic $$
APLENZIN Bupropion HBr 174mg, 348mg, 522mg Brand $$
CYMBALTA Duloxetine HCl 20mg, 30mg, 60mg Brand $$$$ Step: venlafaxine ER HCL
PRISTIQ Desvenlafaxine Succinate 50mg, 100mg Brand $$$ Step: venlafaxine ER HCL
SAVELLA Milnacipran HCl 12.5mg, 25mg, 50mg, 100mg Brand $$$$ LMN
ANTIEMETIC COMPAZINE Prochlorperazine Maleate 5mg, 10mg Generic $$
PHEREGAN Promethazine HCl 12.5mg, 25mg, 50mg Generic $$
TIGAN Trimethobenzamide HCl 300mg/5ml Generic $$$
ZOFRAN Ondansetron HCl 4mg, 8mg, 24mg Generic $$$ QL= 30 tabs (4mg & 8mg); 1 tab
(24mg); per 30 days
EMEND Aprepitant 80mg, 115mg, 125mg, 150mg Brand $$$$ LMN: Specialty
KYTRIL Granisetron HCl 1mg, 0.1mg/ml, 1mg/ml Brand $$$$ LMN: Specialty
CPA; QL= 3 bottles (sol); per 30 ZOFRAN Ondansetron HCl and Dextrose 32mg/50ml Brand $$$
ANTIPARKINSON COGENTIN Benztropine Mesylate 0.5mg, 1mg, 2mg Generic $$
0.125mg, 0.25mg, 0.5mg, 0.75mg,
days
MIRAPEX Pramipexole Dihydrochloride
REQUIP Ropinirole Hydrochloride
SINEMET Carbidopa & Levodopa
1mg
0.25mg, 0.5mg, 1mg, 2mg, 3mg,
4mg, 5mg
10‐100mg, 25‐100mg, 25‐250mg,
50‐200mg
Generic $$$
Generic $$
Generic $$$
AZILECT Rasagiline Mesylate 0.5mg, 1mg Brand $$$
COMTAN Entacapone 200mg Brand $$$$
LODOSYN Carbidopa 25mg Brand $$$
0.375mg, 0.75mg, 1.5mg, 3mg,
Step: Pramipexole
MIRAPEX ER Pramipexole Dihydrochloride SR 4.5mg
Brand $$$$ Dihydrochloride
REQUIP XL Ropinirole Hydrochloride SR 2mg, 4mg, 6mg, 8mg, 12mg Brand $$$$ Step: Ropinirole Hydrochloride
DRUGS TO TREAT HEADACHES AMERGE Naratriptan HCl 1mg, 2.5mg Generic $$$$ Step: Sumatriptan Succinate; QL=
9 tabs/30 days (1mg & 2.5mg)
IMITREX Sumatriptan Succinate 25mg, 50mg, 100mg Generic $$$
IMITREX Sumatriptan Succinate Injection 4mg/0.5ml, 6mg/0.5ml Generic $$$
AXERT Almotriptan Malate 6.25mg, 12.5mg Brand $$$
FROVA Frovatriptan Succinate 2.5mg Brand $$$$
MAXALT, MAXALT‐MLT Rizatriptan Benzoate 5mg, 10mg Brand $$$$
RELPAX Eletriptan Hydrobromide 20mg, 40mg Brand $$$$
SUMATRIPTAN Sumatriptan Nasal Spray 5mg/ACT, 20mg/ACT Brand $$$
ZOMIG NASAL SPRAY Zolmitriptan Nasal Spray 5mg Brand $$$$
QL= 9 tabs/30 days (25mg, 50mg,
& 100mg) QL= 1 kit/30 days (2
syringes); 2 vials/30 days Step:
Sumatriptan Succinate; QL=
9 tabs/30 days (6.25mg); 9
tabs/30 days (12.5 mg) Step:
Sumatriptan Succinate; QL=
9 tabs/30 days
Step: Sumatriptan Succinate; QL=
9 tabs/30 days
Step: Sumatriptan Succinate; QL=
9 tabs/30 days
QL= 6 devices/30 days (5mg &
20mg spray) Step: Sumatriptan
Succinate; QL=
9 devices/30 days
$ ‐‐‐‐‐‐‐‐‐ $1 to $10
$$ ‐‐‐‐‐‐‐‐‐ $11 to $50
$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100
$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500
$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000
$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000
4f-8
6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 4 of 17
GCHP List of Covered Drugs
Therapeutic Category
Therapeutic Category Therapeutic Class Brand Names Generic Name Strength(s) Coverage Rx Cost LMN, QL, Step, CPA
ZOMIG, ZOMIG ZMT Zolmitriptan 2.5mg, 5mg Brand $$$$
NEUROMUSCULAR MESTINON Pyridostigmine Bromide 60mg, 60mg/5ml Brand $$$$
Step: Sumatriptan Succinate; QL=
9 tabs/30 days
SEDATIVE/ HYPNOTIC AMBIEN Zolpidem Tartrate 5mg, 10mg, 6.25mg, 12.5mg Generic $$ QL= 30 tabs/30 days
RESTORIL Temazepam 7.5mg, 15mg, 30mg Generic $$ QL= 30 caps/30 days
SONATA Zaleplon 5mg, 10mg Generic $$ QL= 30 caps/30 days
STIMULANTS ADDERALL Amphetamine‐
Dextroamphetamine
5mg, 7.5mg, 10mg, 15mg, 20mg,
30mg Generic $$$ CPA; Age > 23
DESOXYN Methamphetamine HCl 5mg Generic $$$$ CPA; Age > 23
5mg, 10mg, 18mg, 20mg, 27mg, RITALIN Methylphenidate HCl
Amphetamine‐ 36mg, 54mg
Generic $$$$ CPA; Age > 23
ADDERALL XR Dextroamphetamine SR
5mg, 10mg, 15mg, 20mg, 30mg Brand $$$$$ CPA; Age > 23
CONCERTA Methylphenidate HCl 18mg, 27mg, 36mg, 54mg Brand $$$$$ CPA; Age > 23
2.5mg, 5mg, 10mg, 15mg, 20mg, FOCALIN, FOCALIN XR Dexmethylphenidate HCl
METADATE CD Methylphenidate HCl
30mg, 40mg
10mg, 20mg, 30mg, 40mg, 50mg,
60mg
Brand $$$$ CPA; Age > 23
Brand $$$$$ CPA; Age > 23
NUVIGIL Armodafinil 50mg, 150mg, 250mg Brand $$$$$ CPA; Age > 23
PROVIGIL Modafinil 100mg, 200mg, 300mg Brand $$$$$ CPA; Age > 23
RITALIN LA Methylphenidate HCl 10mg, 20mg, 30mg, 40mg Brand $$$$ CPA; Age > 23
10mg, 18mg, 25mg, 40mg, 60mg,
ANGIOTENSIN CONVERTING
STRATTERA Atomoxetine HCl
VYVANSE Lisdexamfetamine Dimesylate
80mg, 100mg
20mg, 30mg, 40mg, 50mg, 60mg,
70mg
Brand $$$$ CPA; Age > 23
Brand $$$$$ CPA; Age > 23
CARDIOVASCULAR ENZYME INHIBITORS
ACCUPRIL Quinapril HCl 5mg, 10mg, 20mg, 40mg Generic $$$
ALTACE Ramipril 1.25mg, 2.5mg, 5mg, 10mg Generic $$$
CAPOTEN Captopril 12.5mg, 25mg, 50mg, 100mg Generic $$$
LOTENSIN Benazepril HCl 5mg, 10mg, 20mg, 40mg Generic $$$
MONOPRIL Fosinopril Sodium 10mg, 20mg, 40mg Generic $$
VASOTEC Enalapril Maleate 2.5mg, 5mg, 10mg, 20mg Generic $$
ZESTRIL lisinopril 2.5mg, 5mg, 10mg, 20mg, 30mg Generic $$
ANGIOTENSIN II RECEPTOR
ANTAGONISTS
COZAAR Losartan Potassium 25mg, 50mg, 100mg Generic $$$$
AVAPRO Irbesartan 75mg, 150mg, 300mg Brand $$$$ Step: losartan potassium
BENICAR Olmesartan Medoxomil 5mg, 20mg, 40mg Brand $$$ Step: losartan potassium
DIOVAN Valsartan 40mg, 80mg, 160mg, 320mg Brand $$$ Step: losartan potassium
MICARDIS Telmisartan 20mg, 40mg, 80mg Brand $$$$ Step: losartan potassium
ANTIARRHYTHMICS BETAPACE Sotalol HCl 80mg, 120mg, 160mg, 240mg Generic $$$$
PACERONE Amiodarone HCl 200mg Generic $$$
RYTHMOL Propafenone HCl 150mg, 225mg, 325mg, 425mg Generic $$$$
TAMBOCOR Flecainide Acetate 50mg, 100mg, 150mg, 200mg Generic $$$$$
BETA‐ADRENERGIC ANTAGONISTS COREG Carvedilol 3.125mg, 6.25mg, 12.5mg, 25mg Generic $$$$
CORGARD Nadolol 20mg, 40mg, 80mg Generic $$
20mg, 60mg, 80mg, 120mg, INDERAL Propranolol HCl
160mg Generic $$$
LOPRESSOR Metoprolol Tartrate 25mg, 50mg, 100mg Generic $$$
NORMODYNE Labetalol HCl 100mg, 200mg, 300mg Generic $$$
TENORMIN Atenolol 25mg, 50mg, 100mg Generic $$$
TOPROL XL Metoprolol Succinate 25mg, 50mg, 100mg, 200mg Generic $$$$
ZEBETA Bisoprolol Fumarate 5mg, 10mg Generic $$$$
CALCIUM ANTAGONISTS CARDENE Nicardipine HCl 20mg, 30mg Generic $$
CARDIZEM Diltiazem HCl
30mg, 60mg, 90mg, 180mg,
240mg, 120mg/24, 180mg/24,
240mg/24, 300mg/24, 360mg/24
Generic $$$$
ISOPTIN Verapamil HCl 40mg, 80mg, 180mg, 240mg Generic $$$
NORVASC Amlodipine Besylate 2.5mg, 5mg, 10mg Generic $$$
PROCARDIA Nifedipine 10mg, 20mg Generic $$
PROCARDIA XL Nifedipine SR 30mg, 60mg, 90mg Generic $$$$
SULAR Nisoldipine 8.5mg, 17mg, 25.5mg, 34mg, Generic $$$$
CARDIAC GLYCOSIDES LANOXIN Digoxin 0.125mg, 0.25mg Generic $$$
CENTRALLY ACTING
ANTIHYPERTENSIVES
COMBINATION
ALDOMET Methyldopa 250mg, 500mg Generic $$$$
CATAPRES Clonidine HCl 0.1mg, 0.2mg, 0.3mg Generic $$$
TENEX Guanfacine HCl 1mg, 2mg Generic $$$$
25‐15mg, 25‐25mg, 50‐15mg, 50‐
ANTIHYPERTENSIVES CAPOZIDE Captopril & Hydrochlorothiazide
Losartan Potassium & HYZAAR
Hydrochlorothiazide
LOTENSIN HCT Benazepril & Hydrochlorothiazide
25mg
50‐12.5mg, 100‐12.5mg, 100‐
25mg
5‐6.5mg, 10‐12.5mg, 20‐12.5mg,
20‐25mg
Generic $$$
Generic $$$
Generic $$$
$ ‐‐‐‐‐‐‐‐‐ $1 to $10
$$ ‐‐‐‐‐‐‐‐‐ $11 to $50
$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100
$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500
$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000
$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000
4f-9
6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 5 of 17
GCHP List of Covered Drugs
Therapeutic Category
Therapeutic Category Therapeutic Class Brand Names Generic Name Strength(s) Coverage Rx Cost LMN, QL, Step, CPA
LOTREL Amlodipine Besylate‐Benazepril
HCl
Fosinopril Sodium &
2.5‐10mg, 5‐10mg, 5‐20mg, 10‐
20mg Generic $$$
MONOPRIL HCT Hydrochlorothiazide
10‐12.5mg, 20‐12.5mg Generic $$$$
UNIRETIC Moexipril‐Hydrochlorothiazide 7.5‐12.5mg, 15‐12.5mg, 15‐25mg Generic $$$
VASERETIC
Enalapril Maleate &
Hydrochlorothiazide
5‐12.5mg, 10‐25mg Generic $$$$
ZESTORETIC Lisinopril & Hydrochlorothiazide 10‐12.5mg, 20‐12.5mg, 20‐25mg Generic $$$
AVALIDE Irbesartan‐Hydrochlorothiazide
Amlodipine Besylate‐Olmesartan AZOR
Medoxomil
Olmesartan Medoxomil‐
150‐12.5mg, 300‐12.5mg, 300‐
25mg
5‐20mg, 5‐40mg, 10‐20mg, 10‐
40mg
Brand $$$$ Step: losartan potassium HCT
Brand $$$$ Step: amlodipine
BENICAR HCT Hydrochlorothiazide
20‐12.5mg, 40‐12.5mg, 40‐25mg Brand $$$$ Step: losartan potassium HCT
DIOVAN HCT Valsartan‐Hydrochlorothiazide
80‐12.5mg, 160‐12.5mg, 160‐
25mg, 320‐12.5mg, 320‐25mg
Brand $$$$ Step: losartan potassium HCT
TRIBENZOR
Olmesartan‐Amlodipine‐
Hydrochlorothiazide
Brand $$$$ LMN
DIURETICS, LOOP BUMEX Bumetanide 0.5mg, 1mg, 2mg, Generic $$$
LASIX Furosemide 20mg, 40mg, 80mg Generic $$
EDECRIN Ethacrynic Acid 25mg Brand $$$ CPA
Spironolactone & DIURETICS, POTASSIUM SPARING ALDACTAZIDE
Hydrochlorothiazide 25/25mg Generic $$$
ALDACTONE Spironolactone 25mg, 50mg, 100mg Generic $$$
INSPRA Eplerenone 25mg, 50mg Generic $$$$
Triamterene & MAXZIDE
Hydrochlorothiazide 37.5‐25mg, 50‐25mg, 75‐50mg Generic $$$
DIURETICS, THIAZIDE & RELATED
DRUGS
HEPARIN & HEPARIN
MIDAMOR Amiloride HCl 5mg Generic $$$$ Step: spironolactone
HYDRODIURIL Hydrochlorothiazide 12.5mg, 25mg, 50mg Generic $$$
HYGROTON Chlorthalidone 25mg, 50mg, 100mg Generic $$$$
LOZOL Indapamide 1.25mg, 2.5mg Generic $$$
ZAROXOLYN Metolazone 2.5mg, 5mg, 10mg Generic $$$$
30mg/0.3ml, 40mg/0.4ml,
60mg/0.6ml, 80mg/0.8ml,
ANTAGONISTS
HMG‐COA REDUCTASE
LOVENOX Enoxaparin Sodium 100mg/ml, 150mg/ml,
120mg/0.8ml
Brand $$$$$$ LMN: Available at Retail
INHIBITORS MEVACOR Lovastatin 20mg, 40mg Generic $$$$
PRAVACHOL Pravastatin Sodium 10mg, 20mg, 40mg, 80mg Generic $$$$
ZOCOR Simvastatin 5mg, 10mg, 20mg, 40mg, 80mg Generic $$$
LIPITOR Atorvastatin Calcium 10mg, 20mg, 40mg, 80mg Brand $$$$ Step: simvastatin 80mg
HYPOLIPOPROTEINEMICS COLESTID Colestipol HCl 1g, 5g Generic $$$$
54mg, 67mg, 134mg, 160mg, LOFIBRA Fenofibrate
200mg Generic $$$
LOPID Gemfibrozil 600mg Generic $$$
QUESTRAN Cholestyramine 4g Generic $$$
LOVAZA Omega‐3‐acid Ethyl Esters 1g Brand $$$$
NIASPAN Niacin 500mg, 750mg, 1000mg Brand $$$$
WELCHOL Colesevelam HCl 625mg, 3.75g Brand $$$$
ZETIA Ezetimibe 10mg Brand $$$$ Step: simvastatin 40mg
NITRATES IMDUR Isosorbide Mononitrate 10mg, 20mg, 30mg, 60mg, 120mg Generic $$$$
ISORDIL Isosorbide Dinitrate 5mg, 10mg, 20mg, 30mg, 40mg Generic $$$$
NITRO‐DUR Nitroglycerin 2.5mg, 6.5mg, 0.1mg/HR,
0.2mg/HR, 0.4mg/HR, 0.6mg/HR
Generic $$$$
ORAL ANTICOAGULANTS,
NITROSTAT Nitroglycerin 0.4mg, 0.6mg Generic $$$$
1mg, 2mg, 2.5mg, 3mg, 4mg, 5mg,
VITAMIN K COUMADIN Warfarin Sodium
6mg, 7.5mg, 10mg Generic $$$
PERIPHERAL VASCULAR DISEASE PLETAL Cilostazol 50mg, 100mg Generic $$$
TRENTAL Pentoxifylline 400mg Generic $$$$
AGGRENOX Aspirin‐Dipyridamole 25‐200mg Brand $$$
EFFIENT Prasugrel HCl 5mg, 10mg Brand $$$$ Step: Plavix
PLAVIX Clopidogrel Bisulfate 75mg, 300mg Brand $$$$ CPA
POTASSIUM SUPPLEMENTS MICRO‐K Potassium Chloride 8mEq, 10mEq, 20mEq Generic $$
PULMONARY HYPERTENSION ADCIRCA Tadalafil 20mg Brand $$$$$$
LETAIRISLD Ambrisentan 5mg, 10mg Brand $$$$$$ LMN; Specialty
REMODULINLD Treprostinil Sodium 1mg/ml, 2.5mg/ml, 5mg/ml, 10mg/ml
Brand $$$$$$ LMN; Specialty
REVATIO Sildenafil Citrate 20mg, 10mg/12.5ml Brand $$$$$$ LMN; Specialty
TRACLEERLD Bosentan 62.5mg, 125mg Brand $$$$$$ LMN; Specialty
$ ‐‐‐‐‐‐‐‐‐ $1 to $10
$$ ‐‐‐‐‐‐‐‐‐ $11 to $50
$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100
$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500
$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000
$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000
4f-10
6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 6 of 17
GCHP List of Covered Drugs
Therapeutic Category
Therapeutic Category Therapeutic Class Brand Names Generic Name Strength(s) Coverage Rx Cost LMN, QL, Step, CPA
VENTAVISLD Iloprost 10mcg/ml, 20mcg/ml Brand $$$$$$ LMN; Specialty
REFRACTORY ANGINA RANEXA Ranolazine 500mg, 1000mg Brand $$$$ LMN
THERAPEUTIC VITAMINS &
MINERALS FOLTX Folic Acid 400mcg, 800mcg, 1000mcg, 1g Generic $$
ROCALTROL Calcitriol 0.25mcg, 0.5mcg Generic $$$$ HECTOROL Doxercalciferol
0.5mcg, 1mcg, 2.5mcg, 2mcg/ml,
4mcg/2ml Brand $$$$$
VASODILATOR APRESOLINE
ANTIHYPERTENSIVES Hydralazine HCl 10mg, 25mg, 50mg, 100mg Generic $$$$
CARDURA Doxazosin Mesylate 1mg, 2mg, 4mg, 8mg Generic $$$$ HYTRIN Terazosin HCl 1mg, 2mg, 5mg, 10mg Generic $$$ MINIPRESS Prazosin HCl 1mg, 2mg, 5mg Generic $$$
VASOPRESSORS PROAMATINE Midodrine HCl 2.5mg, 5mg, 10mg Generic $$$ VITAMINS & MINERALS &
CEREFOLIN L‐Methylfolate w/ Vit B12‐V it B6‐
Brand $$$$
DIPROSONE
ELOCON
FLORONE
KENALOG
LIDEX
TEMOVATE
TOPICORT
RELATED PRODUCTS Vit B2
METANX L‐Methylfolate w/ Vit B6‐Vit B12 Brand $$$$
DERMATOLOGICAL ANTIACNE BENZACLIN
Clindamycin Phosphate‐Benzoyl
Peroxide
1‐5% Generic $$$$
BENZAMYCIN Benzoyl Peroxide‐Erythromycin 5‐3% Generic $$$$
CLEOCIN‐T Clindamycin Phosphate 1%, 2% Generic $$$$
DIFFERIN Adapalene 0.1%, 0.3% Generic $$$$ CPA
ERYTHROMYCIN BASE Erythromycin Generic $$$
METROGEL Metronidazole Gel 0.75% Generic $$$
METROLOTION Metronidazole 0.75% Generic $$$
RETIN‐A Tretinoin 0.25%, 0.375%, 0.05%, 0.1% Generic $$$$ Age >34
SUMAXIN Sulfacetamide Sodium w/ Sulfur 10‐1%, 10‐4%, 10‐5% Generic $$$$
FINACEA, FINACEA PLUS KIT Azelaic Acid 15%, Kit Brand $$$$
RETIN‐A MICRO Tretinoin Microsphere 0.04%, 0.1% Brand $$$$ Age >34
ANTIPRURITIC ATARAX Hydroxyzine HCl 10mg, 25mg, 50mg Generic $$
VISTARIL Hydroxyzine Pamoate 25mg, 50mg, 100mg Generic $$
ANTIPSORIASIS & ANTIECZEMA DOVONEX Calcipotriene 0.005% Generic $$$$$
KLARON Sulfacetamide Sodium 10% Generic $$$$
SELSUN BLUE Selenium Sulfide 1%, 2.25%, 2.5% Generic $
TAZORAC Tazarotene 0.05%, 0.1% Brand $$$$
VECTICAL Calcitriol 3mcg/gm Brand $$$$$ Step: calcipotriene
SCABICIDES ELIMITE Permethrin 5% Generic $$$$
LINDANE Lindane 1% Generic $$$
EURAX Crotamiton 10% Brand $$$$
TOPICAL CORTICOSTEROID DESOWEN Desonide 5% Generic $$$$
Betamethasone Dipropionate DIPROLENE
Augmented 5% Generic $$$
Betamethasone Dipropionate
Mometasone Furoate
Diflorasone Diacetate
Triamcinolone Acetonide
Fluocinonide Clobetasol
Propionate
5% Generic $$$ 0.1% Generic $$$
0.05% Generic $$$
0.025%, 0.1%, 0.5% Generic $$
0.05% Generic $$
5% Generic $$
TOPICAL DERMATOLOGICAL
ALDARA
Desoximetasone
Imiquimod
0.05%, 0.25%
5%
Generic
Generic
$$
$$$
CPA
CARAC
ELIDEL
PROTOPIC
Fluorouracil
Pimecrolimus
Tacrolimus
0.5%
1%
0.03%, 0.1%
Brand
Brand
Brand
$$$$
$$$$
$$$$
CPA
CPA
EAR, NOSE, THROAT DRUGS AFFECTING THE EAR AURALGAN Benzocaine‐Antipyrine Generic $$$ CORTISPORIN
Neomycin‐Colistin‐HC‐ Thonzonium Generic $$
OCUFLOX Ofloxacin 0.3% Generic $$$ CERUMENEX Triethanolamine Oleate Brand $$$ CIPRODEX Ciprofloxacin‐Dexamethasone 0.3‐0.1% Brand $$$$ DRUGS AFFECTING THE NOSE ASTELIN Azelastine HCl 0.1% Generic $$$$ QL= 2 bottles/30 days
FLONASE Fluticasone Propionate 50mcg Generic $$$ QL= 2 inhrs/30 days
NASALIDE Flunisolide 0.025% Generic $$$ QL= 3 inhrs/bottles/30 days
ASTEPRO Azelastine HCl 137mcg, 0.15% Brand $$$$ QL= 2 bottles/30 days
BECONASE AQ Beclomethasone Dipropionate Monohyd
0.042% Brand $$$$ Step: Fail one: flunisolide, fluticasone, OMNARIS
NASACORT AQ Triamcinolone Acetonide 55mcg/ACT Brand $$$$ Step: Fail one: flunisolide,
fluticasone, OMNARIS
NASONEX Mometasone Furoate 50mcg/ACT Brand $$$$ Step: Fail one: flunisolide,
fluticasone, OMNARIS
OMNARIS Ciclesonide 50mcg/ACT Brand $$$$ Step: Fail one: flunisolide,
fluticasone
PATANASE Olopatadine HCl 0.6% Brand $$$$ RHINOCORT AQUA Budesonide 32mcg/ACT Brand $$$$ Step: Fail one
$ ‐‐‐‐‐‐‐‐‐ $1 to $10
$$ ‐‐‐‐‐‐‐‐‐ $11 to $50
$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100
$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500
$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000
$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000
4f-11
6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 7 of 17
GCHP List of Covered Drugs
Therapeutic Category
Therapeutic Category Therapeutic Class Brand Names Generic Name Strength(s) Coverage Rx Cost LMN, QL, Step, CPA
DRUGS AFFECTING THE THROAT
AND MOUTH
VERAMYST Fluticasone Furoate 27.5mcg Brand $$$$
PERIDEX Chlorhexidine Gluconate 0.12% Generic $$$
Step: Fail one: flunisolide,
fluticasone, OMNARIS
ENDOCRINE AMYLIN ANALOGUES SYMLIN/SYMLINPEN Pramlintide Acetate 600mcg, 1000mcg Brand $$$$ CPA; QL= 7 vials; 8 pens/30 days
ANTITHYROID DRUGS PROPYLTHIOURACIL Propylthiouracil 50mg, 100mg, 200mg, 400mg Generic $$
TAPAZOLE Methimazole 5mg, 10mg Generic $$
DIPEPTIDYL PEPTIDASE ‐ IV INHIB JANUMET Sitagliptin‐Metformin HCl 50‐500mg, 50‐1000mg Brand $$$$$
JANUVIA Sitagliptin Phosphate 25mg, 50mg, 100mg Brand $$$$
ONGLYZA Saxagliptin HCl 2.5mg, 5mg Brand $$$$
ENDOCRINE CORTROSYN Cosyntropin 0.25mg Generic $$$$
MEDROL Methylprednisolone 2mg, 4mg, 8mg, 16mg, 32mg Generic $$$
GLUCOCORTICOID AMARYL Glimepiride 1mg, 2mg, 4mg Generic $$$
DECADRON Dexamethasone 0.5mg, 0.75mg, 1.5mg, 4mg, 6mg Generic $$$
DEPO‐MEDROL Methylprednisolone Acetate 40mg/ml, 80mg/ml Generic $$$$
HYTONE Hydrocortisone 0.5%, 1%, 2.5% Generic $$$
STERAPRED Prednisone 5mg, 10mg, 20mg Generic $$$$
VERIPRED 20 Prednisolone Sod Phosphate 20mg/5ml Brand $$$$
GLUCOSE ELEVATING GLUCAGEN Glucagon HCl 1mg Brand $$$$$
Antihemophilic Factor HEMOSTATICS XYNTHA
Recombinant PAF 250u, 500u, 1000u, 2000u, 3000u Brand $$$$ LMN
INCRETIN MIMETICS BYETTA Exenatide 5mcg, 10mcg Brand $$$$ CPA; QL= 2 syringes/30 days
VICTOZA Liraglutide 18mg/3ml Brand $$$$ CPA; QL= 3 syringes/30 days
INSULIN APIDRA Insulin Glulisine 100u/ml Brand $$$$ Step: Humalog
HUMALOG Insulin Lispro 50/50, 75/25, 100u/ml Brand $$$$
HUMULIN Insulin Isophane & Regular 50/50, 70/30 Brand $$$
HUMULIN N Insulin Isophane 100u/ml Brand $$$
HUMULIN R Insulin Isophane 100u/ml, 500u/ml Brand $$$
LANTUS Insulin Glargine 100u/ml, 500u/ml Brand $$$$
LEVEMIR, FLEXPEN Insulin Detemir 100u/ml Brand $$$$
NOVOLIN Insulin Isophane & Regular 70/30 Brand $$$
NOVOLIN N Insulin Isophane 100u/ml Brand $$$
NOVOLIN R Insulin Isophane 100u/ml Brand $$$
NOVOLOG Insulin Aspart 70/30, 100u/ml Brand $$$$
INSULIN SENSITIZERS ACTOPLUS MET Pioglitazone HCl‐Metformin HCl 15/850mg, 30/1000mg Brand $$$$
ACTOS Pioglitazone HCl 15mg, 30mg, 45mg Brand $$$$
Rosiglitazone Maleate‐Metformin 2‐500mg, 2‐1000mg, 4‐500mg, 4‐ AVANDAMET
HCl 1000mg
4‐1mg, 4‐2mg, 4‐4mg, 8‐2mg, 8‐
Brand $$$$ LMN
AVANDARYL Rosiglitazone Maleate‐Glimepiride 4mg
Brand $$$$ LMN
DUETACT Pioglitazone HCl‐Glimepiride 30‐2mg, 30‐4mg Brand $$$$
MINERALOCORTICOID FLORINEF Fludrocortisone Acetate 0.1mg Generic $$$
ORAL HYPOGLYCEMIC GLUCOPHAGE Metformin HCl 500mg, 750mg, 850mg, 1000mg Generic $$$
GLUCOPHAGE XR Metformin HCl SR 500mg, 750mg Generic $$$
GLUCOTROL Glipizide 5mg, 10mg Generic $$$
GLUCOTROL XL Glipizide SR 2.5mg, 5mg, 10mg Generic $$$
GLUCOVANCE Glyburide‐Metformin 1.25‐250mg, 2.5‐500mg, 5‐500mg Generic $$$$
MICRONASE Glyburide 1.25mg,. 2.5mg, 5mg Generic $$$
PRECOSE Acarbose 25mg, 50mg, 100mg Generic $$$
STARLIX Nateglinide 60mg, 120mg Generic $$$$
PRANDIMET Repaglinide‐Metformin HCl 1‐500mg, 2‐500mg Brand $$$$
RIOMET Metformin HCl 500mg/5ml Brand $$$$
OSTEOPOROSIS FOSAMAX Alendronate Sodium 5mg, 10mg, 35mg, 70mg Generic $$$
MIACALCIN Calcitonin 200u/ACT Generic $$$$
MIACALCIN Injection Calcitonin 200u/ml Generic $$$$ LMN
ACTONEL, ACTONEL WITH
CALCIUM
Risedronate Sodium, Risedronate
Sod with Calcium Carbonate
5mg, 30mg, 35mg, 75mg, 150mg Brand $$$$ Step: alendronate
BONIVA Ibandronate Sodium 3mg/3ml Brand $$$$ LMN
BONIVA Ibandronate Sodium 2.5mg, 150mg Brand $$$$
FORTEO Teriparatide 600mcg/2.4ml Brand $$$$$ LMN; Specialty
PROLIA Denosumab 60mg/ml Brand $$$$$$ Step: Failure on Bisphosphonate
ZOMETA Zoledronic Acid 4mg/5ml Brand $$$$$$ LMN; Specialty
THYROID SUPPLEMENTS ARMOUR THYRO Thyroid 32.5mg, 65mg, 130mg, 195mg Generic $$
LEVOTHROID Levothyroxine Sodium
25mcg, 50mcg, 75mcg, 88mcg,
100mcg, 112mcg, 125mcg,
137mcg, 150mcg, 175mcg,
200mcg, 300mcg, 500mcg
Generic $$
$ ‐‐‐‐‐‐‐‐‐ $1 to $10
$$ ‐‐‐‐‐‐‐‐‐ $11 to $50
$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100
$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500
$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000
$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000
4f-12
6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 8 of 17
GCHP List of Covered Drugs
Therapeutic Category
Therapeutic Category Therapeutic Class Brand Names Generic Name Strength(s) Coverage Rx Cost LMN, QL, Step, CPA
SYNTHROID Levothyroxine Sodium
137mcg, 150mcg, 175mcg,
200mcg, 300mcg
Brand $$$
GASTROINTESTINAL ANTIDIARRHEAL IMODIUM Loperamide HCl 2mg Generic $$
LOMOTIL Diphenoxylate w/ Atropine 2.5mg Generic $$
ANTISPASMODICS/ DRUGS AFFEC GI MOTILITY
T BENTYL Dicyclomine HCl 10mg, 20mg Generic $$$
LEVBID Hyoscyamine Sulfate 0.0125mg, 0375mg Generic $$
REGLAN Metoclopramide HCl 5mg, 10mg Generic $$
ANTIULCER CARAFATE Sucralfate 1g Generic $$$$
CYTOTEC Misoprostol 100mcg, 200mcg Generic $$$$
PEPCID Famotidine 40mg Generic $$$
ZANTAC Ranitidine HCl 300mg Generic $$$
APPETITE STIMULANT MEGACE Megestrol Acetate 40mg/ml Generic $$$$
GI DRUGS ANALPRAM‐HC Hydrocortisone Acetate w/ Pramoxine
1‐1%, 1‐2.5%, 2.5%, 2.5‐1% Generic $$$$
AZULFIDINE Sulfasalazine 500mg Generic $$$
COLAZAL Balsalazide Disodium 750mg Generic $$$$
GOLYTELY PEG 3350‐KCl‐Na Bicarb‐NaCl‐Na Sulfate Generic $$$$
NULYTELY PEG 3350‐KCl‐Sod Bicarb‐NaCl Generic $$$$
URSO, URSO FORTE Ursodiol 250mg, 500mg Generic $$$$
ASACOL, ASACOL HD Mesalamine 400mg, 800mg Brand $$$ LMN
CANASA Mesalamine 1000mg Brand $$$$ LMN
CREON Amy‐Lip‐Prot 5, 10, 20, 6000u, 12000u, 24000u Brand $$$$ DIPENTUM Olsalazine Sodium 250mg Brand $$$$ LIALDA Mesalamine 1.2g Brand $$$$ LMN
PENTASA Mesalamine 250mg, 500mg Brand $$$$ LMN
HELICOBACTER PYLORI HELIDAC Metronidaz‐Tetracyc‐Bis Brand $$$$ PREVPAC Amoxicillin‐Clarithro‐Lansopraz Brand $$$$ IRRITABLE BOWEL AMITIZA Lubiprostone 8mcg, 24mcg Brand $$$$ MISCELLANEOUS GI DRUGS CEPHULAC Lactulose 10g/15ml, 20g/30ml Generic $$$$ FOSRENOL Lanthanum Carbonate 250mg, 500mg, 750mg, 1000mg Brand $$$$$
RENAGEL Sevelamer 400mg, 800mg Brand $$$$$ RENVELA Sevelamer Carbonate 800mg, 0.8g, 2.4g Brand $$$$$ PROTON PUMP INHIBITORS PREVACID Lansoprazole 15mg, 30mg Generic $$$$ PRILOSEC Omeprazole 10mg, 40mg Generic $$ PROTONIX Pantoprazole 20mg, 40mg Generic $$$ Step: Failure of two: omeprazole,
ACIPHEX Rabeprazole Sodium EC 20mg Brand $$$$ pantoprazole, lansoprazole; QL=
34 caps/packets/30 days
Step: Failure of two: omeprazole,
DEXILANT (formerly KAPIDEX) Dexlansoprazole 30mg, 60mg Brand $$$$ pantoprazole, lansoprazole; QL=
34 caps/packets/30 days
Step: Failure of two: omeprazole,
NEXIUM Esomeprazole Magnesium 20mg, 40mg Brand $$$$ pantoprazole, lansoprazole; QL=
34 caps/packets/30 days
IMMUNOLOGICALS &
VACCINES IMMUNOLOGICALS & VACCINES MICRHOGAM PL Rho D Immune Globulin 50mcg Brand $$$$$$
PRIVIGEN Immune Globulin 5g, 10g, 20g Brand $$$$$$ LMN
RHOGAM PLUS Rho D Immune Globulin 300mcg Brand $$$$$$ MEDICAL (MISCELLANEOU SUPPLIES
S) DIABETIC SUPPLIES
ACCU‐CHEK ‐ kits, strips and supplies Brand $$$$ QL= 100 strips/30 days
ONE TOUCH ‐ kits, strips and Brand $$$$ QL= 100 strips/30 days supplies
TRUE ‐ kits, strips and supplies Brand $$$ QL= 100 strips/30 days
MUSCULOSKELETAL CNS MUSCLE RELAXANTS FLEXERIL Cyclobenzaprine HCl 5mg, 10mg Generic $$$ QL= 90 tabs/30 days
DIRECT MUSCLE RELAXANTS LIORESAL Baclofen 10mg, 20mg Generic $$$$
DRUGS TO PREVENT & TREAT GOUT
BENEMID Probenecid 500mg Generic $$$$
ZYLOPRIM Allopurinol 100mg, 300mg Generic $$$
LEVOXYL Levothyroxine Sodium
UNITHROID Levothyroxine Sodium
25mcg, 50mcg, 75mcg, 88mcg,
100mcg, 112mcg, 125mcg,
137mcg, 150mcg, 175mcg,
200mcg, 300mcg
25mcg, 50mcg, 75mcg, 88mcg,
100mcg, 112mcg, 125mcg,
137mcg, 150mcg, 175mcg,
200mcg, 300mcg
25mcg, 50mcg, 75mcg, 88mcg,
100mcg, 112mcg, 125mcg,
Generic $$
Generic $$
$ ‐‐‐‐‐‐‐‐‐ $1 to $10
$$ ‐‐‐‐‐‐‐‐‐ $11 to $50
$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100
$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500
$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000
$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000
4f-13
6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 9 of 17
GCHP List of Covered Drugs
Therapeutic Category
Therapeutic Category Therapeutic Class Brand Names Generic Name Strength(s) Coverage Rx Cost LMN, QL, Step, CPA
LESSINA‐28 Generic $$
Levonorgestrel & Ethinyl Estradiol
LEVORA‐28 Tab 0.15 MG‐30 MCG
Generic $$
Norgestrel & Ethinyl Estr LO/OVRAL
0.3 MG‐30 MCG
adiol Tab Generic
$$
Norethindrone Ace & Eth LOESTRIN FE Estradiol‐FE Tab 1 MG‐20
inyl MCG, Generic
$$
1.5 MG‐30 MCG
COLCRYS Colchicine 0.6mg Brand $$$$ Step: NSAIDS
ULORIC Febuxostat 40mg, 80mg Brand $$$$ Step: allopurinol
GOUT PROBEN/COLCH Colchicine w/ Probenecid 500‐0.5 Generic $$$
NON‐STEROIDAL
ANTIINFLAMMATORY AGENTS CLINORIL Sulindac 150mg, 200mg Generic $$$
DAYPRO Oxaprozin 600mg Generic $$$$
FELDENE Piroxicam 10mg, 20mg Generic $$$$
INDOCIN Indomethacin 25mg, 50mg, 75mg Generic $$
MOBIC Meloxicam 7.5mg, 15mg Generic $$$$
MOTRIN Ibuprofen 800mg Generic $$
220mg, 250mg, 275mg, 375m g, NAPROSYN Naproxen
500mg, 550mg Generic $$$
ORUDIS Ketoprofen 50mg, 75mg, 200mg Generic $$$
RELAFEN Nabumetone 500mg, 750mg Generic $$$
VOLTAREN Diclofenac Sodium 50mg, 75mg, 100mg Generic $$$
CELEBREX Celecoxib 50mg, 100mg, 200mg, 400mg Brand $$$$ Step: Fail Any 2 NSAIDs
SALICYLATES & RELATED DRUGS DISALCID Salsalate 500mg, 750mg Generic $$
OBSTETRICAL &
GYNECOLOGICAL ANDROGEN ANDRODERM Testosterone 2.5mg/24HR, 5mg/24HR Brand $
ANDROGEL Testosterone 1% Brand $
TESTIM Testosterone 1% Brand $
Medroxyprogesterone Acetate IM CONTRACEPTIVES, NON ORAL DEPO‐PROVERA
DEPO‐PROVERA
Susp 150 MG/ML
Medroxyprogesterone Acetate IM
Susp 400 MG/ML
Generic $$$
Brand $$$$
NUVARING
Etonogestrel‐Ethinyl Estradiol VA
Ring 0.120‐0.015 MG/24HR
Brand $$$
ORTHO EVRA
Norelgestromin‐Ethinyl Estradiol
TD PTWK 150‐20 MCG/24HR
Brand $$$
CONTRACEPTIVES, ORAL APRI Desogestrel & Ethinyl Estradiol
Tab 0.15 MG‐30 MCG
Generic $$$
ARANELLE Norethindrone‐Eth Estradiol Tab
0.5‐35/1‐35/0.5‐35 MG‐MCG
Generic $$
AVIANE
CESIA
CRYSELLE‐28
CYCLESSA
Levonorgestrel & Ethinyl Estradiol
Tab 0.1 MG‐20 MCG
Desogest‐Ethin Est Tab 0.1‐
0.025/0.125‐0.025/0.15‐0.025MG‐
MG Norgestrel & Ethinyl Estradiol
Tab
0.3 MG‐30 MCG
Desogest‐Ethin Est Tab 0.1‐
0.025/0.125‐0.025/0.15‐0.025MG‐
MG
Generic $$
Generic $$
Generic $$
Generic $$
DESOGEN‐28
Desogestrel & Ethinyl Estradiol
Tab 0.15 MG‐30 MCG
Generic $$$
ENPRESSE‐28 Levonorgestrel‐Eth Estra Tab 0.05‐
30/0.075‐40/0.125‐30MG‐MCG
Generic $$
ESTROSTEP FE Norethindrone Ac‐Ethinyl Estrad‐
Fe Tab 1‐20/1‐30/1‐35 MG‐MCG
Generic $$$
JUNEL FE
Norethindrone Ace & Ethinyl
Estradiol‐FE Tab 1 MG‐20MCG, 1.5
MG‐30 MCG
Generic $$
KARIVA
Desogest‐Eth Estrad & Eth Estrad
Tab 0.15‐0.02/0.01 MG(21/5)
Generic $$$
KELNOR Ethynodiol Diacetate & Ethinyl
Estradiol Tab 1 MG‐35 MCG
Generic $$
Levonorgestrel & Ethinyl Estradiol
Tab 0.1 MG‐20 MCG
$ ‐‐‐‐‐‐‐‐‐ $1 to $10
$$ ‐‐‐‐‐‐‐‐‐ $11 to $50
$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100
$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500
$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000
$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000
4f-14
6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 10 of 17
GCHP List of Covered Drugs
Therapeutic Category
Therapeutic Category Therapeutic Class Brand Names Generic Name Strength(s) Coverage Rx Cost LMN, QL, Step, CPA
LOW‐OGESTREL
LUTERA
MICROGESTIN
MICROGESTIN FE
Norgestrel & Ethinyl Estradiol Tab
0.3 MG‐30 MCG Levonorgestrel &
Ethinyl Estradiol Tab 0.1 MG‐20
MCG Norethindrone Ace & Ethinyl
Estradiol Tab 1 MG‐20 MCG, 1.5
MG‐30 MCG
Norethindrone Ace & Ethinyl
Estradiol‐FE Tab 1 MG‐20 MCG,
1.5 MG‐30 MCG
Generic $$
Generic $$
Generic $$
Generic $$
MIRCETTE
Desogest‐Eth Estrad & Eth Estrad
Tab 0.15‐0.02/0.01 MG(21/5)
Generic $$$
MODICON
Norethindrone & Ethinyl Estradiol
Tab 0.5 MG‐35MCG
Generic $$$
MONONESSA
Norgestimate & Ethinyl Estradiol
Tab 0.25 MG‐35 MCG
Generic $$
NECON
Norethindrone & Ethinyl Estradiol
Tab 0.5 MG‐35 MCG, 1 MG‐35
MCG, 0.5‐35/0.75‐35/1‐35 MG‐
MCG
Generic $$
NORDETTE
Levonorgestrel & Ethinyl Estradiol
Tab 0.15 MG‐30 MCG
Generic $$$
NORINYL Norethindrone & Mestranol Tab 1
MG‐35MCG, 1 MG‐50 MCG
Generic $$
NORTREL
OCELLA
Norethindrone & Ethinyl Estradiol
Tab 0.5 MG‐35 MCG, 1 MG‐35
MCG, 0.5‐35/0.75‐35/1‐35 MG‐
MCG Drospirenone‐Ethinyl
Estradiol Tab 3‐0.03 MG
Generic $$
Generic $$$
ORTHO TRI‐CYCLEN
Norgestimate‐Eth Estrad Tab 0.18‐
35/0.215‐35/0.25‐35 MG‐MCG
Generic $$
ORTHO‐CEPT Desogestrel & Ethinyl Estradiol
Tab 0.15 MG‐30 MCG
Generic $$
ORTHO‐CYCLEN Norgestimate & Ethinyl Estradiol
Tab 0.25 MG‐35 MCG
Generic $$$
ORTHO‐NOVUM
Norethindrone & Ethinyl Estradiol
Tab 1 MG‐35 MCG, 1 MG‐50MCG,
0.5‐35/0.75‐35/1‐35 MG‐M
Generic $$$
OVCON 35
Norethindrone & Ethinyl Estradiol
Tab 0.4 MG
Generic $$$
PREVIFEM
Norgestimate & Ethinyl Estradiol
Tab 0.25 MG‐35 MCG
Generic $$
SEASONALE Levonorgestrel & Ethinyl Estradiol
(91‐Day) Tab 0.15‐0.03 MG
Generic $$$$
SOLIA Desogestrel & Ethinyl Estradiol
Tab 0.15 MG‐30 MCG
Generic $$
SPRINTEC 28 Norgestimate & Ethinyl Estradiol
Tab 0.25 MG‐35 MCG
Generic $$
TRINESSA Norgestimate‐Eth Estrad Tab 0.18‐
35/0.215‐35/0.25‐35 MG‐MCG
Generic $$
TRI‐NORINYL Norethindrone‐Eth Estradiol Tab
0.5‐35/1‐35/0.5‐35 MG‐MCG
Generic $$$
TRI‐PREVIFEM Norgestimate‐Eth Estrad Tab 0.18‐
35/0.215‐35/0.25‐35 MG‐MCG
Generic $$
TRI‐SPRINTEC Norgestimate‐Eth Estrad Tab 0.18‐
35/0.215‐35/0.25‐35 MG‐MCG
Generic $$
TRIVORA‐28 Levonorgestrel‐Eth Estra Tab 0.05‐
30/0.075‐40/0.125‐30MG‐MCG
Generic $$
$ ‐‐‐‐‐‐‐‐‐ $1 to $10
$$ ‐‐‐‐‐‐‐‐‐ $11 to $50
$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100
$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500
$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000
$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000
4f-15
6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 11 of 17
GCHP List of Covered Drugs
Therapeutic Category
Therapeutic Category Therapeutic Class Brand Names Generic Name Strength(s) Coverage Rx Cost LMN, QL, Step, CPA
VELIVET
Desogest‐Ethin Est Tab 0.1‐
0.025/0.125‐0.025/0.15‐0.025MG‐
Generic
$$
MG YASMIN
Drospirenone‐Ethinyl Estradiol Tab 3‐0.03 MG Generic $$$
YAZ Drospirenone‐Ethinyl Estradiol
Tab 3‐0.02 MG Generic $$$$
ZOVIA
Ethynodiol Diacetate & Ethinyl Estradiol Tab 1 MG‐35 MCG, 1 MG‐
50 MCG
Generic
$$
ORTHO TRI‐CYCLEN LO
Norgestimate‐Eth Estrad Tab 0.18‐
25/0.215‐25/0.25‐25 MG‐MCG
Brand
$$
CPA
ESTROGEN CLIMARA Estradiol TD 0.025mg, 0.0375mg, 0.05mg,
0.06mg, 0.075mg, 0.1mg Generic $$$$ QL= 5 patches/30 days
ESTRACE Estradiol 0.5mg, 1mg, 2mg Generic $$ OGEN Estropipate 0.75mg, 1.5mg, 3mg Generic $$ ALORA Estradiol 0.025mg, 0.05mg, 0.075mg, 0.1 mg Brand $$$ QL= 68 packets/30 days
ESTRACE VAG Estradiol Vaginal Cream Brand $$$ ESTRASORB Estradiol Brand $$$ QL= 68 packets/30 days
ESTROGEL Estradiol Brand $$$$ QL= 2 pump bottles/30 days
PREMARIN Estrogens, Conjugated 0.3mg, 0.45mg, 0.625mg, 0.9mg 1.25mg
, Brand $$$
PREMARIN VAG Estrogens, Conjugated Vaginal
Cream 0.625mg Brand $$
VIVELLE‐DOT Estradiol 0.0375, 0.025mg, 0.05mg,
0.075mg, 0.1mg Brand $$$$ QL= 10 patches/30 days
ESTROGEN/ PROGESTIN
COMBINATIONS ACTIVELLA
Estradiol & Norethindrone
Acetate 1‐0.5mg Generic $$$$
FEMHRT Norethindrone Acetate‐Ethinyl
Estradiol 0.5mg‐2.5mcg, 1mg‐5mcg Generic $$$$
ANGELIQ Drospirenone‐Estradiol 0.5‐1mg Brand $$$$ CLIMARA PRO Estradiol‐Levonorgestrel Brand $$$ QL= 5 patches/30 days
COMBIPATCH Estradiol‐Norethindrone Ace 0.05/0.14mg, 0.05/0.25mg Brand $$$ PREFEST Estradiol/Estrad‐Norgestimate Brand $$$$
PREMPHASE Conj Est/Conj Est‐Medroxypro Ac Brand $$$
PREMPRO Conjugated Estrogen‐
Medroxyprogest Acetate
0.3‐1.5mg, 0.45‐1.5mg, 0.625‐
2.5mg, 0.625‐5mg Brand $$$
PRENATAL VITAMINS NATALCARE PLUS Prenatal Vit w/ Fe Fumarate‐FA Generic $$ Step: Prenatal OTC
PRENATAL Prenatal Rx Generic $$ Step: Prenatal OTC
PRENATE ELITE Prenatal Vit w/ Fe Fum‐
Methylfolate‐FA Brand $$$$ Step: Prenatal OTC
PROGESTIN AYGESTIN Norethindrone Acetate 5mg Generic $$$$ NOR‐QD Norethindrone 0.35mg Generic $$$ PROVERA Medroxyprogesterone Acetate 2.5mg, 5mg, 10mg Generic $$$ SELECTIVE ESTROGEN RECEPTOR
MODULATOR EVISTA Raloxifene HCl 60mg Brand $$$$
OPHTHALMIC ANTIGLAUCOMA ALPHAGAN P Brimonidine Tartrate 0.1%, 0.15% Generic $$$ BETAGAN Levobunolol HCl 0.25%, 0.5% Generic $$ LUMIGAN Bimatoprost 0.01%, 0.03% Generic $$$ PILOCARPINE Pilocarpine HCl 1%, 2%, 3%, 4%, 6% Generic $$ TIMOPTIC Timolol Maleate 0.25%, 0.5% Generic $$$ TIMOPTIC‐XE Timolol Maleate 0.25%, 0.5% Generic $$$ XALATAN Latanoprost 0.005% Generic $$$ OPHTHALMIC ACULAR, LS Ketorolac Tromethamine 0.5%, 0.4% Generic $$$$ BROMDAY Bromfenac Sodium 0.09% Generic $$$$ CROLOM Cromolyn Sodium 4% Generic $$ OMNIPRED Prednisolone Acetate 1% Generic $$$$ OPTIVAR Azelastine HCl 0.05% Generic $$$$ VOLTAREN Diclofenac Sodium 0.1% Generic $$ ACUVAIL Ketorolac Tromethamine 0.45% Brand $$$ LMN
PATANOL Olopatadine HCl 0.1% Brand $$$$ RESTASIS Cyclosporine 0.05% Brand $$$$ QL= 60 vials/30 days
OPHTHALMIC ANTIINFECTIVE/
CORTICOSTEROIDS MAXITROL
Neomycin‐Polymyxin‐
Dexamethasone 0.1% Generic $$
TOBRADEX Neomycin‐Polymyxin‐
Dexamethasone Generic $$$
OPHTHALMIC CORTICOSTEROID PRED FORTE Prednisolone Acetate 1% Generic $$
ALREX Loteprednol Etabonate 0.2% Brand $$$$ FML FORTE Fluorometholone 0.25% Brand $$ LOTEMAX Loteprednol Etabonate 0.5% Brand $$$
$ ‐‐‐‐‐‐‐‐‐ $1 to $10
$$ ‐‐‐‐‐‐‐‐‐ $11 to $50
$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100
$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500
$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000
$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000
4f-16
6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 12 of 17
GCHP List of Covered Drugs
Therapeutic Category
Therapeutic Category Therapeutic Class Brand Names Generic Name Strength(s) Coverage Rx Cost LMN, QL, Step, CPA
OPHTHALMIC TOPICAL
ANTIBACTERIAL BLEPH‐10 Sulfacetamide Sodium 10% Generic $$
CILOXAN Ciprofloxacin HCl 3% Generic $$$
ILOTYCIN Erythromycin Generic $$
POLYTRIM Polymyxin B‐Trimethoprim Generic $
AZASITE Azithromycin 1% Brand $$
ZYMAR Gatifloxacin 0.3% Brand $$$
OVER THE COUNTER ANALGESICS ADVIL Ibuprofen 200mg OTC $ QL= 100 tabs/30 days
ALEVE Naproxen Sodium 220mg OTC $ QL= 100 tabs/30 days
ASA Aspirin 81mg, 325mg OTC $ QL= 120 tabs/30 days
ANTIACNE BENZOYL Benzoyl Peroxide 5% OTC $$ QL= 85g/ 30days
ANTIHISTAMINE ALLEGRA Fexofenadine 30mg, 60mg, 180mg OTC $$ Step: Claritin; QL= 30 tabs/30 days
ALLEGRA‐D Fexofenadine‐Pseudoephedrine 12 hour, 24 hour OTC $$ QL= 30 tabs/30 days
BENADRYL Diphenhydramine HCl 25mg, 50mg OTC $ QL= 100 caps/30 days
CLARITIN Loratadine 5mg, 10mg OTC $$ QL= 30caps/30 days
ZYRTEC Cetirizine HCl 5mg, 10mg OTC $$ QL= 30 tabs/30 days
ZYRTEC‐D Cetirizine ‐Pseudoephedrine 5mg/120mg OTC $$ QL= 30 tabs/30 days
BIRTH CONTROL CONDOMS Condoms OTC $$ QL= 12/30 days
SPERMACIDAL PRODUCTS Spermacidal Products Sponge, Foam, Cream, Gel OTC $$
COUGH SUPPRESSANT DELSYM Dextromethorphan Polistirex 30mg/5ml OTC $$ QL= 148 ml/30 days
DIETARY PRENATAL VITAMINS Prenatal Vitamins OTC $$ QL= 100 tabs/30 days
25mg, 50mg, 100mg, 200MG, PYRIDOXINE Pyridoxine HCl
250MG, 500MG OTC $$ QL= 60 tabs/30 days
VITAMIN K Phytonadione 100mcg OTC $$ QL= 60 tabs/30 days
H2 ANTAGONIST PEPCID Famotidine 10mg, 20mg OTC $$ QL= 90 tabs/30 days
ZANTAC Ranitidine HCl 75mg, 150mg OTC $$ QL= 90 tabs/30 days
LAXATIVES & CATHARTICS COLACE Docusate Sodium 100mg OTC $ QL= 60 caps/30 days
Fructose‐Dextrose‐Phosphoric EMETROL
Acid OTC $ QL= 240ml/ 30 days
GLYCOLAX Polyethylene Glycol OTC $$ PROTON PUMP
INHIBITORS PRILOSEC Omeprazole 20mg OTC $$ QL= 42 tabs/30 days
ZEGERID Omeprazole‐Sodium Bicarbonate 20‐1100 OTC $$ QL= 42 tabs/30 days
RESPIRATORY ANTIHISTAMINE/ DECONGESTANT
COMBINATIONS
ALLEGRA‐D Fexofenadine‐Pseudoephedrine 60mg/120mg, 180mg/240mg Generic $$
PHENERGAN/CODEINE Promethazine w/ Codeine 6.25‐10mg Generic $$
ZYRTEC‐D Cetirizine‐Pseudoephedrine 5mg/120mg Generic $$$
ANTIHISTAMINES PERIACTIN Cyproheptadine HCl 4mg Generic $$
PHENERGAN Promethazine HCl 12.5mg, 25mg, 50mg Generic $$
ANTITUSSIVE & EXPECTORANT CONGESTAC Pseudoephedrine‐Guaifenesin Generic $$$
PHENERGAN DM Promethazine‐DM Generic $$
PHENERGAN/CODEINE Promethazine w/ Codeine Generic $$
PRO‐CLEAR Guaifenesin‐Codeine 300‐10mg Generic $$
Dextromethorphan‐Pot PROLEX DM
Guaiacolsulfon Generic $$
TESSALON Benzonatate 100mg, 200mg Generic $$
TUSSIONEX Hydrocod Polst‐Chlorphen Polst Generic $$$
BETA‐2 ADRENERGIC PROVENTIL Albuterol Sulfate 2mg, 4mg Generic $$
VENTOLIN Albuterol 90mcg Generic $$$$ QL= 3 inhrs/30 days
BROVANA Arformoterol Tartrate 15mcg Brand $$$$ Step: Foradil
CPA; QL= 12 caps/12pk; 120 FORADIL Formoterol Fumarate Brand $$$$
caps/60pk; per 30 days
PERFOROMIST Formoterol Fumarate 20mcg Brand $$$$ CPA; QL= 120 vials/30 days
PROAIR HFA Albuterol Sulfate Brand $$$$ QL= 3 inhrs/30 days
SEREVENT DISKUS Salmeterol Xinafoate 50mcg Brand $$$$ Step: Foradil
XOPENEX Levalbuterol HCl 0.31mg, 0.63mg, 1.25mg/3ml Brand $$$$ Step: albuterol
XOPENEX HFA Levalbuterol Tartrate Brand $$$$
DRUGS FOR ASTHMA ATROVENT Ipratropium Bromide 0.02% Generic $$$$
ADVAIR DISKUS Fluticasone‐Salmeterol 100/50, 250/50, 500/50 Brand $$$$
Step: albuterol; QL= 3 inhrs/30
days
QL= 120 inhs/60pk; 28 inhs/28pk;
14 inhs/14pk; per 30 days
ADVAIR HFA Fluticasone‐Salmeterol 45/21, 115/21, 230/21 Brand $$$$ QL= 2 inhrs/30 days
ASMANEX Mometasone Furoate 110mcg, 220mcg Brand $$$$
QL= 1 inh (#14 inhalation units); 2
inhs (#30, #60, #120 inhalation
units); per 30 days
ATROVENT HFA Ipratropium Bromide HFA 17mcg Brand $$$$ QL= 2 inhrs HFA/30 days
COMBIVENT Ipratropium‐Albuterol 18‐103mcg/ACT Brand $$$$ QL= 3 inhrs/30 days
CPA; QL= 3 units/pkg size 1; 4 EPIPEN, EPIPEN‐JR Epinephrine 0.15mg, 0.3mg Brand $$$$
units/pkg size 2; per 30 days
$ ‐‐‐‐‐‐‐‐‐ $1 to $10
$$ ‐‐‐‐‐‐‐‐‐ $11 to $50
$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100
$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500
$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000
$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000
4f-17
6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 13 of 17
GCHP List of Covered Drugs
Therapeutic Category
Therapeutic Category Therapeutic Class Brand Names Generic Name Strength(s) Coverage Rx Cost LMN, QL, Step, CPA
FLOVENT HFA
Fluticasone Propionate HFA
44mcg, 110mcg, 220mcg
Brand
$$$$
QL= 44mcg ‐ 2 inhrs; 110mcg ‐ 1
inhr; 220mcg ‐ 3 inhrs; per 30
days
PULMICORT
Budesonide
0.25mg/2ml, 0.5mg/2ml, 1mg/ml
Brand
$$$$
QL= 70 amps (0.25mg/2ml or
0.5mg/2ml); 35 amps (1mg/2ml);
2 inhrs; per 30 days
PULMICORT FLEXHALER Budesonide 90mcg, 180mcg Brand $$$$ QL= 2 inhs (90 mcg); 3 inhs (180
mcg); per 30 days
SPIRIVA Tiotropium Bromide Monohydr ate 18mcg Brand $$$$ QL= 1 pkg (6 caps or 90 caps); 2
pkgs (30 caps); per 30 days
SYMBICORT Budesonide‐Formoterol Fumarate 80‐4.5mcg/ACT, 160‐4.5mcg/ACT Brand $$$$ QL= 2 inhrs/30 days
TWINJECT Epinephrine 0.15mg, 0.3mg Brand $$$$
CPA; QL= 3 units/pkg size 1; 4
units/pkg size 2; per 30 days
LEUKOTRIENE MODIFIERS ACCOLATE Zafirlukast 10mg, 20mg Brand $$$$ Step: Singulair
SINGULAIR Montelukast Sodium 10mg Brand $$$$
METHYL XANTHINE THEO‐DUR Theophylline 100mg, 200mg, 300mg Generic $$$
THEOPHYLLINE ANHYDROUS Theophylline Brand $$
UROLOGICAL ANTICHOLINERGIC
ANTISPASMODICS DITROPAN XL Oxybutynin Chloride 5mg, 10mg Generic $$
SANCTURA, SANCTURA XR Trospium Chloride 20mg, 60mg Generic $$$
ENABLEX Darifenacin Hydrobromide 7.5mg, 15mg Brand $$$
GELNIQUE Oxybutynin Chloride 10% Brand $$$
OXYTROL Oxybutynin 3.9mg/24HR Brand $$$
TOVIAZ Fesoterodine Fumarate 4mg, 8mg Brand $$$$
VESICARE Solifenacin Succinate 5mg, 10mg Brand $$$
GENITOURINARY PRODUCTS FLOMAX Tamsulosin HCl 0.4mg Generic $$$$
PROSCAR Finasteride 5mg Generic $$$$
AVODART Dutasteride 0.5mg Brand $$$$
RAPAFLO Silodosin 4mg, 8mg Brand $$$$
UROXATRAL Alfuzosin HCl 10mg Brand $$$
URINARY ANESTHETICS PYRIDIUM Phenazopyridine HCl 100mg, 200mg Generic $$
SPECIALTY SPECIALTY MEDICATIONS AMINOCAPROIC ACID Aminocaproic Acid 250mg/ml, 500mg Generic $$$$$$ LMN
BLEOMYCIN Bleomycin Sulfate 15u, 30u Generic $$$$$$
CABERGOLINE Cabergoline 0.5mg Generic $$$$$$ LMN
50mg/5ml, 150mg/15ml,
CARBOPLATIN Carboplatin 450mg/45ml, 600mg/60ml, 50mg,
150mg, 450mg
Generic $$$$$$
CLADRIBINE Cladribine 1mg/ml Generic $$$$$$
DACARBAZINE Dacarbazine 100mg, 200mg Generic $$$$$$
DAUNORUBINCIN Daunorubicin HCl 20mg, 5mg/ml Generic $$$$$$
DEFEROXAMINE Deferoxamine Mesylate 500mg, 2g Generic $$$$$$
DESMOPRESSIN Desmopressin Acetate 0.1mg, 0.2mg, 4mcg/ml, 0.1% Generic $$$$$ LMN
EPOPROSTENOLLD Epoprostenol Sodium 0.5mg, 1.5mg Generic $$$$$$ LMN
FLUDARABINE Fludarabine Phosphate 50mg, 50mg/2ml Generic $$$$$$
1mg, 0.1mg/ml, 1mg/ml, GRANISETRON Granisetron HCl
4mg/4ml, Generic $$$$$$ LMN
LEUPROLIDE Leuprolide Acetate 1mg/0.2ml, 5mg/ml Generic $$$$$$
MYCOPHENOLATE Mycophenolate Mofetil 250mg, 500mg Generic $$$$$$ LMN
NOVAREL Chorionic Gonadotropin 10000u Generic $$$$$$ LMN
100mcg, 200mcg, 500mcg, OCTREOTIDE Octreotide Acetate
PACLITAXEL Paclitaxel
PAMIDRONATE Pamidronate Disodium
1000mcg, 1mg/ml, 50mcg/ml
100mg, 6mg/ml, 30mg/5ml,
150mg/25ml, 300mg/50ml
30mg, 90mg, 30mg/10ml,
90mg/10ml
Generic $$$$$$ LMN
Generic $$$$$$
Generic $$$$$$
PREGNYLM
TACROLIMUS
VITAMIN K1
ABELCET
Chorionic Gonadotropin 10000u
Tacrolimus 0.5mg, 1mg, 5mg
Phytonadione 1mg/0.5ml, 2mg/
Amphotericin B Lipid 5mg/ml
Generic $$$$$$ LMN
Generic $$$$$$ LMN
ml Generic $$$$$$ LMN
Brand $$$$$$ LMN
Brand $$$$$$ LMN
Brand $$$$$$ LMN
Brand $$$$$$ LMN
ACTHARLD Corticotropin 80u
ACTHREL
ACTIMMUNELD
Corticorelin Ovine Triflutate 100mcg
Interferon Gamma‐1B 2000000u/0.5ml
ADVATE 250u, 500u, 1000
Antihemophilic Factor rAHF‐PFM 3000u
u, 1500u, 2000u, Brand $$$$$$ LMN
AFINITOR Everolimus 2.5mg, 5mg, 10m g Brand $$$$$$ ALDURAZYMELD
Laronidase 2.9mg/5ml Brand $$$$$$ LMN
ALFERON NM Interferon Alfa‐n3 5000000u/ml Brand $$$$$$ LMN
ALIMTA Pemetrexed Disodium 100mg, 500mg Brand $$$$$$ ALKERAN Melphalan 2mg, 50mg Brand $$$$$$ ALOXI Palonosetron HCl 0.25mg Brand $$$$$$ ALPHANATE Antihemophilic Factor/VWF 250‐500u, 1000‐1 500u, 1500u Brand $$$$$$$ LMN
ALPHANINE Coagulation Factor IX 500u, 1000u, 150 0u Brand $$$$$$$ LMN
AMEVIVE Alefacept 15mg Brand $$$$$$ LMN
$ ‐‐‐‐‐‐‐‐‐ $1 to $10
$$ ‐‐‐‐‐‐‐‐‐ $11 to $50
$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100
$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500
$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000
$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000
4f-18
6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 14 of 17
GCHP List of Covered Drugs
Therapeutic Category
Therapeutic Category Therapeutic Class Brand Names Generic Name Strength(s) Coverage Rx Cost LMN, QL, Step, CPA
AMPYRALD Dalfampridine 10mg Brand $$$$$$ LMN
APOKYNLD Apomorphine Hydrochloride 50mg, 100mg, 20mg/ml Brand $$$$$$ LMN
ARALASTLD Proteinase Inhibitor 400mg, 500mg, 800mg, 1000mg Brand $$$$$$ LMN
25mcg, 40mcg, 60mcg, 100mcg,
ARANESP Darbepoetin Alfa‐Polysorbate 150mcg, 200mcg, 300mcg,
500mcg
Brand $$$$$$ CPA; QL= 2 inj/30 days; Available
at Retail
ARCALYST Rilonacept 220mg Brand $$$$$$ LMN
AREDIA Pamidronate Disodium 30mg, 90mg Brand $$$$$$ LMN
ARIXTRA Fondaparinux Sodium 2.5mg/0.5ml, 5mg/0.4ml,
7.5mg/0.6ml, 10mg/0.8ml Brand $$$$$$
CPA; QL= 28 inj/14 days; Available
at Retail
AVASTIN Bevacizumab Brand $$$$$$
AVONEX Interferon Beta‐1a 30mcg Brand $$$$$$ LMN
BARACLUDE Entecavir 0.5mg, 1mg, 0.05mg/ml Brand $$$$$$ LMN
BEBULIN VH Factor IX Complex 200‐1200u Brand $$$$$$$ LMN
BENEFIX Coagulation Factor IX 250u, 500u, 1000u, 2000u Brand $$$$$$$ LMN
BETASERON Interferon Beta‐1b 0.3mg Brand $$$$$$ LMN
BICNU Carmustine 100mg Brand $$$$$$
BOTOX OnabotulinumtoxinA 50u, 100u, 200u Brand $$$$$$ LMN
BRAVELLE Urofollitropin 75u, 150u, 300u, 600u, 900u Brand $$$$$$ LMN
CAMPATH Alemtuzumab 30mg/ml Brand $$$$$$ LMN
CAMPTOSAR Irinotecan HCl 20mg/ml Brand $$$$$$
CARIMUNE Immune Globulin 3g, 6g, 12g Brand $$$$$$ LMN
CELLCEPT Mycophenolate Mofetil 250mg, 500mg, 250mg/ml Brand $$$$$$ LMN
CEREDASE Alglucerase 80u/ml Brand $$$$$$ LMN
CEREZYMELD Imiglucerase 200u, 400u Brand $$$$$$ LMN
CETROTIDE Cetrorelix Acetate 0.25mg, 3mg Brand $$$$$$ LMN
CIMZIA Certolizumab Pegol 200mg/ml Brand $$$$$$ Step: Fail 2 DMARD
CINRYZELD C1 Inhibitor 500u Brand $$$$$$ LMN COLY‐MYCIN
M Colistimethate Sodium 150mg Brand $$$$$$ LMN
COPAXONE Glatiramer Acetate 20mg/ml Brand $$$$$$ LMN
COPEGUS Ribavirin 200mg Brand $$$$$$ LMN
CYCLOPHOSPHAMIDE Cyclophosphamide 25mg, 50mg, 500mg, 1g, 2g Brand $$$$$$
CYTOGAM Cytomegalovirus Immune Globulin Brand $$$$$$ LMN
CYTOXAN Cyclophosphamide 2g Brand $$$$$$ LMN
0.1mg, 0.2mg, 4mcg/ml, DDAVP Desmopressin Acetate
15mcg/ml, 0.1% Brand $$$$$$ LMN
DESFERAL Deferoxamine Mesylate 500mg, 2g Brand $$$$$$ LMN
DOXIL Doxorubicin HCl Liposomal 2mg/ml Brand $$$$$$
ELAPRASELD Idursulfase 6mg/3ml Brand $$$$$$ LMN
ELIGARD Leuprolide Acetate 7.5mg, 22.5mg, 30mg, 45mg Brand $$$$$$
ELLENCE Epirubicin HCl 2mg/ml Brand $$$$$$ LMN
ELOXATIN Oxaliplatin 50mg, 100mg, 200mg Brand $$$$$$
ELSPAR Asparaginase 10000u Brand $$$$$$
ENBREL Etanercept 25mg, 25mg/0.5ml, 50mg/ml Brand $$$$$$ Step: Fail 2 DMARD
ENGERIX Hepatitis B Vaccine 10mcg/0.5ml, 20mcg/ml Brand $$$$$$ LMN
2000u/ml, 3000u/ml, 4000u/ml,
EPOGEN Epoetin Alfa 10000u/ml, 20000u/ml,
40000u/ml
Brand $$$$$$ CPA; QL= 2 inj/30 days; Available
at Retail
ERBITUX Cetuximab 100mg, 200mg Brand $$$$$$
ETHYOLM Amifostine Crystalline 500mg Brand $$$$$$ LMN
EUFLEXXA Sodium Hyaluronate 10mg/ml Brand $$$$$$ LMN
EVOXAC Cevimeline HCl 30mg Brand $$$$$$ LMN
EXJADELD Deferasirox 125mg, 250mg, 500mg Brand $$$$$$
EXTAVIA Interferon Beta‐1b 0.3mg Brand $$$$$$ LMN
FABRAZYMELD Agalsidase beta 5mg, 35mg Brand $$$$$$ LMN
FEIBA VH Antiinhibitor Coagulant Complex Brand $$$$$$ LMN
FERRLECIT Sod Ferric Gluc Cmplx 12.5mg Brand $$$$$$ LMN
FLEBOGAMMALD Immune Globulin 5%, 10% Brand $$$$$$ LMN
FLOLANLD Epoprostenol Sodium 0.5mg, 1.5mg Brand $$$$$$ LMN
FLUDARA Fludarabine Phosphate 50mg Brand $$$$$$
FOLLISTIM Follitropin Beta 75u, 150u, 300u, 600u, 900u Brand $$$$$$ LMN
2500u/0.2ml, 5000u/0.2ml,
FRAGMIN Dalteparin Sodium 7500u/0.3ml, 10000u/ml,
25000u/ml, 9500u, 12500u,
15000u, 18000u
Brand $$$$$$ CPA; QL=2 inj/30 days; Available
at Retail
GAMASTANLD Immune Globulin Brand $$$$$$ LMN
GAMMAGARD SD Immune Globulin
1g/10ml, 2.5g/25ml, 5g/50ml,
10g/100ml, 20g/200ml,
30g/300ml, 0.5g, 2.5g, 5g, 10g
Brand $$$$$$ LMN
GAMUNEX Immune Globulin 10%, 1g/10ml, 2.5g/25ml, 5g/5ml,
10g/100ml, 20g/200ml
Brand $$$$$$ LMN
GANIRELIX Ganirelix Acetate Brand $$$$$$ LMN
$ ‐‐‐‐‐‐‐‐‐ $1 to $10
$$ ‐‐‐‐‐‐‐‐‐ $11 to $50
$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100
$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500
$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000
$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000
4f-19
6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 15 of 17
GCHP List of Covered Drugs
Therapeutic Category
Therapeutic Category Therapeutic Class Brand Names Generic Name Strength(s) Coverage Rx Cost LMN, QL, Step, CPA
NOVOSEVEN Coagulation Factor VIIa
Brand $$$$$$$ LMN
NUTROPINLD
Somatropin 5mg, 10mg, 5mg/2ml, 20mg/2ml Brand $$$$$$ CPA
OCTAGAMLD Immune Globulin 2.5g, 5g, 10g, 25g Brand $$$$$$ LMN
OMNITROPELD Somatropin 5.8mg, 5mg/1.5ml, 10mg/1.5ml Brand $$$$$$ CPA
ONTAK Denileukin Diftitox 150mcg/ml Brand $$$$$$ ORENCIA Abatacept 250mg Brand $$$$$$ CPA
ORTHOVISC Hyaluronan 15mg/ml Brand $$$$$$ LMN
PEGASYS Peginterferon alfa‐2a 180mcg/0.5ml, 180mcg/ml Brand $$$$$$ LMN
PEG‐INTRON Peginterferon alfa‐2b 50mcg, 80mcg, 120mcg, 150mcg Brand $$$$$$ LMN
PHENTOLAMINE Phentolamine Mesylate Brand $$$$$$ LMN
POLYGAM S/DM Immune Globulin 0.5g, 2.5g, 5g, 10g Brand $$$$$$ LMN
2000u/ml, 3000u/ml, 4000u/ml, PROCRIT Epoetin Alfa 10000u/ml, 20000u/ml, Brand $$$$$$ LMN; Available at Retail
30000u/ml, 40000u/ml PROFILNINELD
Factor IX Complex 500u, 1500u, 1500u Brand $$$$$$$ LMN
PROGRAF Tacrolimus 0.5mg, 1mg, 5mg, 5mg/ml Brand $$$$$$ LMN
PULMOZYME Dornase Alfa 1mg/ml Brand $$$$$$ LMN
RAPAMUNE Sirolimus 0.5mg, 1mg, 2mg, 1mg/ml Brand $$$$$$ LMN
REBETOL Ribavirin 200mg, 4mg/ml Brand $$$$$$ LMN
GEMZAR Gemcitabine HCl 200mg, 1g Brand $$$$$$
0.2mg, 0.4mg, 0.6mg, 0.8mg, 1mg,
GENOTROPIN Somatropin 1.2mg, 1.4mg, 1.6mg, 1.8mg, 2mg,
5mg, 12mg
Brand $$$$$$ CPA
GILENYA Fingolimod HCl 0.5mg Brand $$$$$$ LMN
GLEEVEC Imatinib Mesylate 100mg, 400mg Brand $$$$$$
GONAL‐F Follitropin Alfa 300, 450, 900, 75u, 450u, 1050u Brand $$$$$$ LMN
HAVRIX Hepatitis A Vaccine 720u, 1440u Brand $$$$$$ LMN
HEALON Sodium Hyaluronate 10mg/ml, 14mg/ml, 23mg/ml Brand $$$$$$ LMN
HELIXATE FS Antihemophilic Factor 250u, 500u, 1000u, 2000u, 3000u Brand $$$$$$ LMN
HEMOFIL M Antihemophilic Factor
220‐400u, 401‐800u, 801‐1700u,
1701u+
Brand $$$$$$ LMN
HEPSERA Adefovir Dipivoxil 10mg Brand $$$$$$ LMN
HERCEPTIN Trastuzumab 440mg Brand $$$$$$
500u, 600u, 1000u, 1200u, 2000u, HUMATE‐P Antihemophilic Factor/VWF
2400u Brand $$$$$$
HUMATROPE Somatropin 5mg, 6mg, 12mg, 24mg Brand $$$$$$ CPA
HUMIRA Adalimumab 20mg/0.4ml, 40mg/0.8ml, Brand $$$$$$ Step: Fail 2 DMARD
HYALGAN Sodium Hyaluronate 20mg/2ml Brand $$$$$$ LMN
HYPERHEP Hepatitis B Immune Globulin Brand $$$$$$ LMN
HYPERRHO Rho D Immune Globulin 50mcg, 300mcg Brand $$$$$$ LMN
INCRELEX Mecasermin 40mg/4ml Brand $$$$$$ CPA
INNOHEP Tinzaparin Sodium 20000u/ml Brand $$$$$$ LMN; Available at Retail
INTRON‐A Interferon Alfa‐2B 3u, 5u, 10u, 18u, 25u, 50u Brand $$$$$$ QL= 2 inj/30 days
KINERET Anakinra Brand $$$$$$ LMN
KOATE‐DVI Antihemophilic Factor 250u, 500u, 1000u Brand $$$$$$
250u, 500u, 1000u, 2000u, 3000u,
KOGENATE FS Antihemophilic Factor 250/BS, 500/BS, 1000/BS,
2000/BS, 3000/BS
Brand $$$$$$ LMN
KUVANLD Sapropterin Dihydrochloride 100mg Brand $$$$$$ LMN
LEUKERAN Chlorambucil 2mg Brand $$$$$$
LEUSTATIN Cladribine 1mg/ml Brand $$$$$$ LMN
LUCENTISLD Ranibizumab Brand $$$$$$ LMN
3.75mg, 7.5mg, 11.25mg, 22.5mg, LUPRON Leuprolide Acetate
30mg Brand $$$$$$
MACUGENLD Pegaptanib Sodium Brand $$$$$$ LMN
220‐400u, 401‐800u, 801‐1700u, MONARC‐M Antihemophilic Factor
1701u+ Brand $$$$$$ LMN
MONOCLATE‐P Antihemophilic Factor 250u, 500u, 1000u, 1500u Brand $$$$$$ LMN
MONONINE Coagulation Factor IX 250u, 500u, 1000u Brand $$$$$$$ LMN
MYOZYMELD Alglucosidase Alfa 50mg Brand $$$$$$ LMN
NAGLAZYMELD Galsulfase 1mg/ml Brand $$$$$$ LMN
NAVELBINE Vinorelbine Tartrate 10mg/ml, 50mg/5ml Brand $$$$$$
NEULASTA Pegfilgrastim 6mg/0.6ml Brand $$$$$$ CPA; QL= 2 inj/30 days
NEUPOGEN Filgrastim
300mcg, 480mcg, 300mcg/0.5ml,
480mcg/0.8ml
Brand $$$$$$ LMN; Available at Retail
NEXAVARLD Sorafenib Tosylate 200mg Brand $$$$$$
5mg/1.5ml, 10mg/1.5ml, NORDITROPIN Somatropin
15mg/1.5ml, 30mg/3ml Brand $$$$$$ CPA
1200mcg, 2400mcg, 4800mcg,
1mg, 2mg, 5mg, 8mg
$ ‐‐‐‐‐‐‐‐‐ $1 to $10
$$ ‐‐‐‐‐‐‐‐‐ $11 to $50
$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100
$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500
$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000
$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000
4f-20
6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 16 of 17
GCHP List of Covered Drugs
Therapeutic Category
Therapeutic Category Therapeutic Class Brand Names Generic Name Strength(s) Coverage Rx Cost LMN, QL, Step, CPA
SUPPRELINLD
SUTENT
Histrelin Acetate
Sunitinib Malate
50mg Brand $$$$$$
12.5mg, 25mg, 50mg Brand $$$$$$
50mg, 100mg/ml Brand $$$$$$ LMN
2mg/ml Brand $$$$$$ LMN
8mg/ml Brand $$$$$$ LMN
25mg, 100mg, 150mg Brand $$$$$$
75mg, 1% Brand $$$$$$
150mg, 200mg Brand $$$$$$
20mg/0.5ml, 20mg/ml, 80mg/2ml, Brand $$$$$$
80mg/4ml 5mg, 20mg, 100mg, 140mg,
Brand $$$$$$$ 180mg, 250mg
5mg Brand $$$$$$ CPA
50mg, 150mg, 200mg100mg, Brand $$$$$$
500u, 1000u Brand $$$$$$ LMN
25mg Brand $$$$$$ LMN
1.1mg Brand $$$$$$ LMN
50mg Brand $$$$$$ LMN
300mg/5ml Brand $$$$$$ LMN
25mg/ml Brand $$$$$$
3.75mg, 11.25mg, 22.5mg Brand $$$$$$
SYNAGISLD
SYNARELM
Palivizumab IM
Nafarelin Acetate
SYNVISC Hylan Intra‐articular
TARCEVA Erlotinib
TARGRETIN Bexarotene
TASIGNA Nilotinib
TAXOTERE Docetaxel
TEMODAR Temozolomide
TEV‐TROPINLD Somatropin
THALOMID Thalidomide
THROMBAT III Antithrombin III
THYMOGLOBULIN
THYROGENLD
Anti‐Thymocyte Globulin
Thyrotropin Alfa
TICE BCG Live Intravesical
TOBI Tobramycin
TORISEL
TRELSTARLD
Temsirolimus
Triptorelin Pamoate
TWINRIX Hepatitis A (Inact)‐Hep B (Recomb) Vac Brand $$$$$$ LMN
TYKERBLD Lapatinib Ditosylate 250mg Brand $$$$$$
TYSABRILD Natalizumab 300mg/15ml Brand $$$$$$ LMN
VALCYTE Valganciclovir HCl 450mg, 50mg/ml Brand $$$$$$ LMN
VANTASLD Histrelin Acetate 50mg Brand $$$$$$
VFEND Voriconazole 50mg, 200mg, 40mg/ l Brand $$$$$$ LMN
VIDAZALD Azacitidine 100mg Brand $$$$$$
VINORELBINE Vinorelbine Tartrate 10mg/ml, 50mg/5ml Brand $$$$$$ VIREAD Tenofovir Disoproxil Fumarate 300mg Brand $$$$$$ CPA
VISUDYNELD Verteporfin 15mg Brand $$$$$$ LMN
VIVAGLOBINLD Immune Globulin 160mg/ml Brand $$$$$$ LMN
VOTRIENTLD Pazopanib HCl 200mg Brand $$$$$$
WINRHO SDF Rho D Immune Globulin 600u, 1500u, 2500u, 5 15000u
000u, Brand $$$$$$ LMN
XELODA Capecitabine 150mg, 500mg Brand $$$$$$ XENAZINELD
Tetrabenazine 12.5mg, 25mg Brand $$$$$$ LMN
XIAFLEXLD
Collagenase Clostridium Histolyticum
0.9mg Brand $$$$$$ LMN
REBIF Interferon Beta‐1a 22mcg/0.5ml, 44mcg/0.5ml Brand $$$$$$ LMN
RECLAST Zoledronic Acid 5mg/100ml Brand $$$$$$ LMN
RECOMBINATE Antihemophilic Factor 220‐400u, 401‐800u, 801‐1240u, 1241‐1800u
Brand $$$$$$ LMN
REFACTOLD Antihemophilic Factor 250u, 500u, 1000u, 2000u
REFLUDAN Lepirudin 50mg
REMICADE Infliximab 100mg
REPRONEX Menotropins 75u
REVLIMIDLD Lenalidomide 5mg, 10mg, 15mg, 25mg
RHOPHYLACLD Rho D Immune Globulin 1500u/2ml
RIBASPHERE Ribavirin 200mg, 400mg, 600mg
RIMSO‐50 Dimethyl Sulfoxide 50%
RITUXAN Rituximab 100mg, 500mg
SAIZEN Somatropin 5mg, 8.8mg
10mg, 20mg, 30mg, 50mcg/ml,
SANDOSTATIN Octreotide Acetate 100mcg, 200mcg, 500mcg,
1000mcg
SENSIPAR Cinacalcet HCl 30mg, 60mg, 90mg
SEROSTIMLD Somatropin 4mg, 5mg, 6mg, 8.8mg
SIMPONI Golimumab 50mg
Brand $$$$$$ LMN
Brand $$$$$$ LMN
Brand $$$$$$ Step: Fail 2 DMARD
Brand $$$$$$ LMN
Brand $$$$$$ LMN
Brand $$$$$$ LMN
Brand $$$$$$ LMN
Brand $$$$$$ LMN
Brand $$$$$$ Brand $$$$$$ CPA
Brand $$$$$$
Brand $$$$$$ LMN
Brand $$$$$$ LMN
Brand $$$$$$ Step: Fail 2 DMARD
SOLU‐CORTEF Hydrocortisone Sodium Succinate 100mg, 250mg, 500mg, 1000mg Brand $$$$$$ LMN
SOMAVERTLD Pegvisomant 10mg, 15mg, 20mg Brand $$$$$$ LMN
20mg, 50mg, 70mg, 80mg, 100mg, SPRYCEL Dasatinib
140mg Brand $$$$$$
STIMATE Desmopressin Acetate 1.5mg/ml Brand $$$$$$ LMN
Sodium Hyaluronate Intra‐ SUPARTZ
articular 25mg/2.5ml Brand $$$$$$ LMN
m
XOLAIRLD Omalizumab 150mg Brand $$$$$$ LMN
1mcg, 2mcg, 4mcg, 2mcg/ml, ZEMPLAR Paricalcitol
5mcg/ml Brand $$$$$$ LMN
ZINECARD Dexrazoxane 250mg, 500mg Brand $$$$$$ LMN
ZOLADEX Goserelin Acetate 3.6mg, 10.8mg Brand $$$$$$
ZORBTIVE Somatropin 8.8mg Brand $$$$$$ CPA
$ ‐‐‐‐‐‐‐‐‐ $1 to $10
$$ ‐‐‐‐‐‐‐‐‐ $11 to $50
$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100
$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500
$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000
$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000
4f-21
6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 17 of 17
GCHP List of Covered Drugs
Brand Name
Brand Names Generic Name Strength(s) Coverage Rx Cost LMN, QL, Step, CPA ABELCET Amphotericin B Lipid 5mg/ml Brand $$$$$$ LMN ACCOLATE Zafirlukast 10mg, 20mg Brand $$$$ Step: Singulair ACCU‐CHEK ‐ kits, strips and
supplies Brand $$$$ QL= 100 strips/30 days ACCUPRIL Quinapril HCl 5mg, 10mg, 20mg, 40mg Generic $$$
Step: Failure of two: omeprazole, ACIPHEX Rabeprazole Sodium EC 20mg Brand $$$$ pantoprazole, lansoprazole; QL= 34
caps/packets/30 days ACTHARLD
Corticotropin 80u Brand $$$$$$ LMN ACTHREL Corticorelin Ovine Triflutate 100mcg Brand $$$$$$ LMN ACTICIN Permethrin Lotion 1% Generic $$ ACTIMMUNELD
Interferon Gamma‐1B 2000000u/0.5ml Brand $$$$$$ LMN ACTIVELLA Estradiol & Norethindrone Acetate 1‐0.5mg Generic $$$$ ACTONEL, ACTONEL WITH
CALCIUM
Risedronate Sodium, Risedronate Sod wit
Calcium Carbonate h
5mg, 30mg, 35mg, 75mg, 150mg
Brand
$$$$
Step: alendronate
ACTOPLUS MET Pioglitazone HCl‐Metformin HCl 15/850mg, 30/1000mg Brand $$$$ ACTOS Pioglitazone HCl 15mg, 30mg, 45mg Brand $$$$ ACULAR, LS Ketorolac Tromethamine 0.5%, 0.4% Generic $$$$ ACUVAIL Ketorolac Tromethamine 0.45% Brand $$$ LMN ADCIRCA Tadalafil 20mg Brand $$$$$$
ADDERALL
Amphetamine‐Dextroamphetamine
5mg, 7.5mg, 10mg, 15mg, 20mg, 30mg
Generic
$$$
CPA; Age > 23
ADDERALL XR
Amphetamine‐Dextroamphetamine SR
5mg, 10mg, 15mg, 20mg, 30mg
Brand
$$$$$
CPA; Age > 23
ADRIAMYCIN Doxorubicin HCl 2mg/ml Generic $$$$ ADRUCIL Fluorouracil 2.5g/50ml, 5g/100ml, 500mg/10ml Generic $$
ADVAIR DISKUS
Fluticasone‐Salmeterol
100/50, 250/50, 500/50
Brand
$$$$ QL= 120 inhs/60pk; 28 inhs/28pk; 14
inhs/14pk; per 30 days
ADVAIR HFA Fluticasone‐Salmeterol 45/21, 115/21, 230/21 Brand $$$$ QL= 2 inhrs/30 days
ADVATE
Antihemophilic Factor rAHF‐PFM
250u, 500u, 1000u, 1500u, 2000u, 3000u
Brand
$$$$$$
LMN
ADVIL Ibuprofen 200mg OTC $ QL= 100 tabs/30 days AFINITOR Everolimus 2.5mg, 5mg, 10mg Brand $$$$$$ AGGRENOX Aspirin‐Dipyridamole 25‐200mg Brand $$$ ALBENZA Albendazole Oral 200mg Brand $$$$
ALDACTAZIDE
Spironolactone & Hydrochlorothiazide
25/25mg
Generic
$$$
ALDACTONE Spironolactone 25mg, 50mg, 100mg Generic $$$ ALDARA Imiquimod 5% Generic $$$ CPA ALDOMET Methyldopa 250mg, 500mg Generic $$$$ ALDURAZYMELD
Laronidase 2.9mg/5ml Brand $$$$$$ LMN ALEVE Naproxen Sodium 220mg OTC $ QL= 100 tabs/30 days ALFERON NM
Interferon Alfa‐n3 5000000u/ml Brand $$$$$$ LMN ALIMTA Pemetrexed Disodium 100mg, 500mg Brand $$$$$$ ALINIA Nitazoxanide Oral 500mg Brand $$$$$ ALKERAN Melphalan 2mg, 50mg Brand $$$$$$ ALLEGRA Fexofenadine 30mg, 60mg, 180mg OTC $$ Step: Claritin; QL= 30 tabs/30 days ALLEGRA‐D Fexofenadine‐Pseudoephedrine 12 hour, 24 hour OTC $$ QL= 30 tabs/30 days ALLEGRA‐D Fexofenadine‐Pseudoephedrine 60mg/120mg, 180mg/240mg Generic $$ ALORA Estradiol 0.025mg, 0.05mg, 0.075mg, 0.1mg Brand $$$ QL= 68 packets/30 days ALOXI Palonosetron HCl 0.25mg Brand $$$$$$ ALPHAGAN P Brimonidine Tartrate 0.1%, 0.15% Generic $$$ ALPHANATE Antihemophilic Factor/VWF 250‐500u, 1000‐1500u, 1500u Brand $$$$$$$ LMN ALPHANINE Coagulation Factor IX 500u, 1000u, 1500u Brand $$$$$$$ LMN ALREX Loteprednol Etabonate 0.2% Brand $$$$ ALTACE Ramipril 1.25mg, 2.5mg, 5mg, 10mg Generic $$$ AMARYL Glimepiride 1mg, 2mg, 4mg Generic $$$ AMBIEN Zolpidem Tartrate 5mg, 10mg, 6.25mg, 12.5mg Generic $$ QL= 30 tabs/30 days AMBISOME Amphotericin B Liposome 510mg Brand $$$$ LMN; Specialty
AMERGE
Naratriptan HCl
1mg, 2.5mg
Generic
$$$$ Step: Sumatriptan Succinate; QL= 9 tabs/
days (1mg & 2.5mg)
30
AMEVIVE Alefacept 15mg Brand $$$$$$ LMN AMIKIN Amikacin IV Generic $$$$ QL= 14 days AMINOCAPROIC ACID Aminocaproic Acid 250mg/ml, 500mg Generic $$$$$$ LMN AMITIZA Lubiprostone 8mcg, 24mcg Brand $$$$
$ ‐‐‐‐‐‐‐‐‐ $1 to $10 $$ ‐‐‐‐‐‐‐‐‐ $11 to $50 $$$ ‐‐‐‐‐‐‐‐‐ $51 to $100 $$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500 $$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000 $$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000 4f-22 6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 1 of 18
GCHP List of Covered Drugs
Brand Name Brand Names Generic Name Strength(s) Coverage Rx Cost LMN, QL, Step, CPA
AMOXIL Amoxacillin‐Oral Generic $$ AMPICILLIN Ampicillin IV 125mg, 250mg, 500mg, 1g, 2g, 10g Generic $$$ LMN
AMPYRALD
Dalfampridine 10mg Brand $$$$$$ LMN
ANAFRANIL Clomipramine HCl 25mg, 50mg, 75mg Generic $ ANALPRAM‐HC Hydrocortisone Acetate w/ Pramoxine 1‐1%, 1‐2.5%, 2.5%, 2.5‐1% Generic $$$$ ANCEF Cefazolin Generic $$$ ANCOBON
ANDRODERM
ANDROGEL
ANGELIQ
Flucytosine Oral
Testosterone
Testosterone
Drospirenone‐Estradiol
250mg, 500mg
2.5mg/24HR, 5mg/24HR
1%
0.5‐1mg
Brand
Brand
Brand
Brand
$
$
$
$$$$
LMN
APIDRA Insulin Glulisine 100u/ml Brand $$$$ Step: Humalog
APLENZIN Bupropion HBr 174mg, 348mg, 522mg Brand $$ APOKYNLD
Apomorphine Hydrochloride 50mg, 100mg, 20mg/ml Brand $$$$$$ LMN
APRESOLINE Hydralazine HCl 10mg, 25mg, 50mg, 100mg Generic $$$$ APRI
Desogestrel & Ethinyl Estradiol Tab 0.15
MG‐30 MCG Generic $$$
ARALASTLD Proteinase Inhibitor 400mg, 500mg, 800mg, 1000mg Brand $$$$$$ LMN
ARALEN Chloroquin Phosphate Oral 250mg Generic $$$
Norethindrone‐Eth Estradiol Tab 0.5‐35/1‐ ARANELLE
35/0.5‐35 MG‐MCG 25mcg, 40mcg, 60mcg, 100mcg, 150mcg,
Generic $$
ARANESP Darbepoetin Alfa‐Polysorbate 200mcg, 300mcg, 500mcg
Brand $$$$$$ CPA; QL= 2 inj/30 days; Available at Retail
ARCALYST Rilonacept 220mg Brand $$$$$$ LMN
AREDIA Pamidronate Disodium 30mg, 90mg Brand $$$$$$ LMN
ARICEPT, ARICEPT ODT Donepezil Hydrochloride 5mg, 10mg, 23mg Generic $$$$
ARIMIDEX Anastrozole 1mg Generic $$$$
2.5mg/0.5ml, 5mg/0.4ml, 7.5mg/0.6ml, ARIXTRA Fondaparinux Sodium
10mg/0.8ml Brand $$$$$$ CPA; QL= 28 inj/14 days; Available at Retail
ARMOUR THYRO Thyroid 32.5mg, 65mg, 130mg, 195mg Generic $$
AROMASIN Exemestane 25mg Generic $$$$ Step: anastrozole
ASA Aspirin 81mg, 325mg OTC $ QL= 120 tabs/30 days
ASACOL, ASACOL HD Mesalamine 400mg, 800mg Brand $$$ LMN QL= 1 inh (#14 inhalation units); 2
inhs
ASMANEX Mometasone Furoate 110mcg, 220mcg Brand $$$$ (#30, #60, #120 inhalation units); per 30
days
ASTELIN Azelastine HCl 0.1% Generic $$$$ QL= 2 bottles/30 days
ASTEPRO Azelastine HCl 137mcg, 0.15% Brand $$$$ QL= 2 bottles/30 days
ATARAX Hydroxyzine HCl 10mg, 25mg, 50mg Generic $$
ATIVAN Lorazepam 0.5mg, 1mg, 2mg, Generic $$$ QL= 120tabs/30days
ATROVENT Ipratropium Bromide 0.02% Generic $$$$
ATROVENT HFA Ipratropium Bromide HFA 17mcg Brand $$$$ QL= 2 inhrs HFA/30 days
AUGMENTIN Amoxacillin/Clavulanate‐Tabs, Susp Generic $$$
AURALGAN Benzocaine‐Antipyrine Generic $$$
AVALIDE Irbesartan‐Hydrochlorothiazide 150‐12.5mg, 300‐12.5mg, 300‐25mg Brand $$$$ Step: losartan potassium HCT
AVANDAMET Rosiglitazone Maleate‐Metformin HCl 2‐500mg, 2‐1000mg, 4‐500mg, 4‐1000mg Brand $$$$ LMN
AVANDARYL Rosiglitazone Maleate‐Glimepiride 4‐1mg, 4‐2mg, 4‐4mg, 8‐2mg, 8‐4mg Brand $$$$ LMN
AVAPRO Irbesartan 75mg, 150mg, 300mg Brand $$$$ Step: losartan potassium
AVASTIN Bevacizumab Brand $$$$$$
AVELOX Moxifloxacin Oral Brand $$$ LMN
Levonorgestrel & Ethinyl Estradiol Tab 0.1 AVIANE
MG‐20 MCG Generic $$
AVODART Dutasteride 0.5mg Brand $$$$
AVONEX Interferon Beta‐1a 30mcg Brand $$$$$$ LMN
AXERT Almotriptan Malate 6.25mg, 12.5mg Brand $$$
Step: Sumatriptan Succinate; QL= 9 tabs/30
days (6.25mg); 9 tabs/30 days (12.5 mg)
AYGESTIN Norethindrone Acetate 5mg Generic $$$$
AZACTAM Aztreonam IV Generic $$$$$ LMN
AZASITE Azithromycin 1% Brand $$
AZILECT Rasagiline Mesylate 0.5mg, 1mg Brand $$$
Amlodipine Besylate‐Olmesartan AZOR
Medoxomil 5‐20mg, 5‐40mg, 10‐20mg, 10‐40mg Brand $$$$ Step: amlodipine
AZULFIDINE Sulfasalazine 500mg Generic $$$
$ ‐‐‐‐‐‐‐‐‐ $1 to $10
$$ ‐‐‐‐‐‐‐‐‐ $11 to $50
$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100
$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500
$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000
$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000
4f-23
6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 2 of 18
GCHP List of Covered Drugs
Brand Name Brand Names Generic Name Strength(s) Coverage Rx Cost LMN, QL, Step, CPA
BACTRIM DS Sulfamethoxazole/Trimethoprim Generic $$ BACTROBAN Mupirocin Generic $$ BARACLUDE Entecavir 0.5mg, 1mg, 0.05mg/ml Brand $$$$$$ LMN
BEBULIN VH Factor IX Complex 200‐1200u Brand $$$$$$$ LMN
BECONASE AQ
Beclomethasone Dipropionate Monohyd
0.042%
Brand
$$$$ Step: Fail one: flunisolide, fluticasone,
OMNARIS
BENADRYL Diphenhydramine HCl 25mg, 50mg OTC $ QL= 100 caps/30 days BENEFIX Coagulation Factor IX 250u, 500u, 1000u, 2000u Brand $$$$$$$ LMN BENEMID Probenecid 500mg Generic $$$$ BENICAR Olmesartan Medoxomil 5mg, 20mg, 40mg Brand $$$ Step: losartan potassium BENICAR HCT
Olmesartan Medoxomil‐
Hydrochlorothiazide 20‐12.5mg, 40‐12.5mg, 40‐25mg Brand $$$$ Step: losartan potassium HCT
BENTYL Dicyclomine HCl 10mg, 20mg Generic $$$ BENZACLIN Clindamycin Phosphate‐Benzoyl Peroxide 1‐5% Generic $$$$ BENZAMYCIN Benzoyl Peroxide‐Erythromycin 5‐3% Generic $$$$ BENZOYL Benzoyl Peroxide 5% OTC $$ QL= 85g/ 30days BETAGAN Levobunolol HCl 0.25%, 0.5% Generic $$ BETAPACE Sotalol HCl 80mg, 120mg, 160mg, 240mg Generic $$$$ BETASERON Interferon Beta‐1b 0.3mg Brand $$$$$$ LMN
QL= 28 tabs/14 days, Max 2 fills/30 days BIAXIN Clarithromycin Oral Generic $$$
(250mg & 500mg); 280ml/14 days, Max 2
fills of 280ml/30 days (125mg/5ml &
BICILLIN L‐A
Benzathine IM
Generic
$$$$
250mg/5ml)
LMN BICNU Carmustine 100mg Brand $$$$$$ BILTRICIDE Praziquantal Oral 600mg Brand $$$ BLEOMYCIN Bleomycin Sulfate 15u, 30u Generic $$$$$$ BLEPH‐10 Sulfacetamide Sodium 10% Generic $$ BONIVA Ibandronate Sodium 3mg/3ml Brand $$$$ LMN BONIVA Ibandronate Sodium 2.5mg, 150mg Brand $$$$ BOTOX OnabotulinumtoxinA 50u, 100u, 200u Brand $$$$$$ LMN BRAVELLE Urofollitropin 75u, 150u, 300u, 600u, 900u Brand $$$$$$ LMN BROMDAY Bromfenac Sodium 0.09% Generic $$$$ BROVANA Arformoterol Tartrate 15mcg Brand $$$$ Step: Foradil BUMEX Bumetanide 0.5mg, 1mg, 2mg, Generic $$$ BUSPAR Buspirone HCl 5mg, 7.5mg, 10mg, 15mg, 30mg Generic $$$ QL= 120tabs/30days BUTALBITAL Butalbital Generic $$ BYETTA Exenatide 5mcg, 10mcg Brand $$$$ CPA; QL= 2 syringes/30 days CABERGOLINE Cabergoline 0.5mg Generic $$$$$$ LMN CAMPATH Alemtuzumab 30mg/ml Brand $$$$$$ LMN CAMPTOSAR Irinotecan HCl 20mg/ml Brand $$$$$$ CANASA Mesalamine 1000mg Brand $$$$ LMN CANCIDAS Caspofungin Acetate 50mg, 70mg Brand $$ LMN; Specialty CAPOTEN Captopril 12.5mg, 25mg, 50mg, 100mg Generic $$$ CAPOZIDE Captopril & Hydrochlorothiazide 25‐15mg, 25‐25mg, 50‐15mg, 50‐25mg Generic $$$ CARAC Fluorouracil 0.5% Brand $$$$ CARAFATE Sucralfate 1g Generic $$$$ CARBATROL Carbamazepine 100mg, 200mg, 300mg Brand $$$$
CARBOPLATIN
Carboplatin
50mg/5ml, 150mg/15ml, 450mg/45ml,
600mg/60ml, 50mg, 150mg, 450mg
Generic
$$$$$$
CARDENE Nicardipine HCl 20mg, 30mg Generic $$
CARDIZEM Diltiazem HCl 120mg/24, 180mg/24, 240mg/24, Generic $$$$
CARDURA Doxazosin Mesylate 1mg, 2mg, 4mg, 8mg Generic $$$$ CARIMUNE Immune Globulin 3g, 6g, 12g Brand $$$$$$ LMN CASODEX Bicalutamide 50mg Generic $$$$ CATAPRES Clonidine HCl 0.1mg, 0.2mg, 0.3mg Generic $$$ CEFOTAN Cefotetan‐IV Generic $$$ LMN CEFTIN Cefuroxime IV, Oral Generic $$$ LMN CELEBREX Celecoxib 50mg, 100mg, 200mg, 400mg Brand $$$$ Step: Fail Any 2 NSAIDs CELEXA Citalopram Hydrobromide 10mg, 20mg, 40mg Generic $$
$ ‐‐‐‐‐‐‐‐‐ $1 to $10
$$ ‐‐‐‐‐‐‐‐‐ $11 to $50 $$$ ‐‐‐‐‐‐‐‐‐ $51 to $100 $$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500 $$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000 $$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000 4f-24 6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 3 of 18
30mg, 60mg, 90mg, 180mg, 240mg,
300mg/24, 360mg/24
GCHP List of Covered Drugs
Brand Name Brand Names Generic Name Strength(s) Coverage Rx Cost LMN, QL, Step, CPA
CELLCEPT Mycophenolate Mofetil 250mg, 500mg Generic $$$$ CELLCEPT Mycophenolate Mofetil 250mg, 500mg, 250mg/ml Brand $$$$$$ LMN CEPHULAC Lactulose 10g/15ml, 20g/30ml Generic $$$$ CEREDASE Alglucerase 80u/ml Brand $$$$$$ LMN
CEREFOLIN
L‐Methylfolate w/ Vit B12‐Vit B6‐Vit B2
Brand
$$$$
CEREZYMELD Imiglucerase 200u, 400u Brand $$$$$$ LMN
CERUMENEX Triethanolamine Oleate Brand $$$
CESIA
Desogest‐Ethin Est Tab 0.1‐0.025/0.125‐
0.025/0.15‐0.025MG‐MG
Generic
$$
CETROTIDE Cetrorelix Acetate 0.25mg, 3mg Brand $$$$$$ LMN CILOXAN Ciprofloxacin HCl 3% Generic $$$ CIMZIA Certolizumab Pegol 200mg/ml Brand $$$$$$ Step: Fail 2 DMARD CINRYZE
LD
CIPRO
C1 Inhibitor 500u Brand $$$$$$ LMN
CIPRODEX Ciprofloxacin Oral
Ciprofloxacin‐Dexamethasone
0.3‐0.1%
Generic
Brand
$$$
$$$$
CISPLATIN
Cisplatin
50mg/50ml, 100mg/100ml, 200mg/200ml
Generic
$$$
CLADRIBINE Cladribine 1mg/ml Generic $$$$$$ CLAFORAN Cefotaxime IV Generic $$$ LMN CLARITIN Loratadine 5mg, 10mg OTC $$ QL= 30caps/30 days CLEOCIN Clindamycin Oral, IV Generic $$$ LMN CLEOCIN‐T Clindamycin Phosphate 1%, 2% Generic $$$$ CLIMARA Estradiol TD
0.025mg, 0.0375mg, 0.05mg, 0.06mg,
0.075mg, 0.1mg Generic $$$$ QL= 5 patches/30 days
CLIMARA PRO Estradiol‐Levonorgestrel Brand $$$ QL= 5 patches/30 days CLINORIL Sulindac 150mg, 200mg Generic $$$ CLOTRIMAZOLE Clotrimazole Vaginal, Topical, Troches Generic $ to $$$$ COGENTIN Benztropine Mesylate 0.5mg, 1mg, 2mg Generic $$ COLACE Docusate Sodium 100mg OTC $ QL= 60 caps/30 days COLAZAL Balsalazide Disodium 750mg Generic $$$$ COLCRYS Colchicine 0.6mg Brand $$$$ Step: NSAIDS COLESTID Colestipol HCl 1g, 5g Generic $$$$ COLY‐MYCIN M Colistimethate Sodium 150mg Brand $$$$$$ LMN COMBIPATCH Estradiol‐Norethindrone Ace 0.05/0.14mg, 0.05/0.25mg Brand $$$ COMBIVENT Ipratropium‐Albuterol 18‐103mcg/ACT Brand $$$$ QL= 3 inhrs/30 days COMPAZINE Prochlorperazine Maleate 5mg, 10mg Generic $$ COMTAN Entacapone 200mg Brand $$$$ CONCERTA Methylphenidate HCl 18mg, 27mg, 36mg, 54mg Brand $$$$$ CPA; Age > 23 CONDOMS Condoms OTC $$ QL= 12/30 days CONGESTAC Pseudoephedrine‐Guaifenesin Generic $$$ COPAXONE Glatiramer Acetate 20mg/ml Brand $$$$$$ LMN COPEGUS Ribavirin 200mg Brand $$$$$$ LMN COREG Carvedilol 3.125mg, 6.25mg, 12.5mg, 25mg Generic $$$$ CORGARD Nadolol 20mg, 40mg, 80mg Generic $$ CORTISPORIN Neomycin‐Colistin‐HC‐Thonzonium Generic $$ CORTROSYN Cosyntropin 0.25mg Generic $$$$ COUMADIN Warfarin Sodium
1mg, 2mg, 2.5mg, 3mg, 4mg, 5mg, 6mg,
7.5mg, 10mg Generic $$$
COZAAR Losartan Potassium 25mg, 50mg, 100mg Generic $$$$ CREON Amy‐Lip‐Prot 5, 10, 20, 6000u, 12000u, 24000u Brand $$$$ CROLOM Cromolyn Sodium 4% Generic $$ CRYSELLE‐28
Norgestrel & Ethinyl Estradiol Tab 0.3 MG
30 MCG
‐ Generic $$
CUBICIN Daptomycin IV 500mg Brand $$$$ LMN
CYCLESSA
Desogest‐Ethin Est Tab 0.1‐0.025/0.125‐
0.025/0.15‐0.025MG‐MG
Generic
$$
CYCLOPHOSPHAMIDE Cyclophosphamide 25mg, 50mg, 500mg, 1g, 2g Brand $$$$$$ CYMBALTA Duloxetine HCl 20mg, 30mg, 60mg Brand $$$$ Step: venlafaxine ER HCL CYTOGAM Cytomegalovirus Immune Globulin Brand $$$$$$ LMN CYTOTEC Misoprostol 100mcg, 200mcg Generic $$$$ CYTOVENE Gancyclovir IV 500mg Generic $ LMN
$ ‐‐‐‐‐‐‐‐‐ $1 to $10
$$ ‐‐‐‐‐‐‐‐‐ $11 to $50 $$$ ‐‐‐‐‐‐‐‐‐ $51 to $100 $$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500 $$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000 $$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000 4f-25 6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 4 of 18
GCHP List of Covered Drugs
Brand Name Brand Names Generic Name Strength(s) Coverage Rx Cost LMN, QL, Step, CPA
CYTOXAN Cyclophosphamide 2g Brand $$$$$$ LMN DACARBAZINE Dacarbazine 100mg, 200mg Generic $$$$$$ DAPSONE Dapsone Oral 25mg, 100mg Generic $$ DAUNORUBINCIN Daunorubicin HCl 20mg, 5mg/ml Generic $$$$$$ DAYPRO Oxaprozin 600mg Generic $$$$
DDAVP
Desmopressin Acetate
0.1mg, 0.2mg, 4mcg/ml, 15mcg/ml, 0.1%
Brand
$$$$$$
LMN
DECADRON Dexamethasone 0.5mg, 0.75mg, 1.5mg, 4mg, 6mg Generic $$$ DEFEROXAMINE Deferoxamine Mesylate 500mg, 2g Generic $$$$$$ DELSYM Dextromethorphan Polistirex 30mg/5ml OTC $$ QL= 148 ml/30 days
DEMEROL
Meperidine HCl 10mg/ml, 25mg/ml, 50mg/ml, 75mg/ml,
100mg/ml
Generic
$$$
CPA; QL= 120ml/30 days
DEPAKOTE SPR Divalproex Sodium Sprinkle 125mg, 250mg, 500mg Generic $$$ DEPAKOTE, DEPAKOTE ER Divalproex Sodium 125mg, 250mg, 500mg Generic $$$ DEPO‐MEDROL Methylprednisolone Acetate 40mg/ml, 80mg/ml Generic $$$$ DEPO‐PROVERA
Medroxyprogesterone Acetate IM Susp
150 MG/ML Generic $$$
DEPO‐PROVERA Medroxyprogesterone Acetate IM Susp
400 MG/ML
Brand
$$$$
DESFERAL Deferoxamine Mesylate 500mg, 2g Brand $$$$$$ LMN DESMOPRESSIN Desmopressin Acetate 0.1mg, 0.2mg, 4mcg/ml, 0.1% Generic $$$$$ LMN
DESOGEN‐28 Desogestrel & Ethinyl Estradiol Tab 0.15
MG‐30 MCG
Generic
$$$
DESOWEN Desonide 5% Generic $$$$ DESOXYN Methamphetamine HCl 5mg Generic $$$$ CPA; Age > 23 DESYREL Trazodone HCl 50mg, 100mg, 150mg, 300mg Generic $$
Step: Failure of two: omeprazole, DEXILANT (formerly KAPIDEX) Dexlansoprazole 30mg, 60mg Brand $$$$ pantoprazole, lansoprazole; QL= 34
caps/packets/30 days DIFFERIN Adapalene 0.1%, 0.3% Generic $$$$ CPA DIFLUCAN Fluconazole Oral 50mg, 100mg, 150mg, 200mg Generic $$$$ LMN DILANTIN Phenytoin Sodium 100mg Generic $$ DILAUDID Hydromorphone HCl 1mg, 2mg, 4mg, 8mg Generic $$$ QL= 120 tabs/30 days DIOVAN Valsartan 40mg, 80mg, 160mg, 320mg Brand $$$ Step: losartan potassium DIOVAN HCT Valsartan‐Hydrochlorothiazide
80‐12.5mg, 160‐12.5mg, 160‐25mg, 320‐
12.5mg, 320‐25mg Brand $$$$ Step: losartan potassium HCT
DIPENTUM Olsalazine Sodium 250mg Brand $$$$
DIPROLENE
Betamethasone Dipropionate Augmented
5%
Generic
$$$
DIPROSONE Betamethasone Dipropionate 5% Generic $$$ DISALCID Salsalate 500mg, 750mg Generic $$ DITROPAN XL Oxybutynin Chloride 5mg, 10mg Generic $$ DOVONEX Calcipotriene 0.005% Generic $$$$$ DOXIL Doxorubicin HCl Liposomal 2mg/ml Brand $$$$$$ DOXYCYCLINE Doxycycline Oral Generic $$ DUETACT Pioglitazone HCl‐Glimepiride 30‐2mg, 30‐4mg Brand $$$$
DURAGESIC
Fentanyl TD Patch
12mcg, 25mcg, 50mcg, 75mcg, 100mcg
Generic
$$$$
CPA; QL= 15/30days
DYCILL Dicloxacillin‐Oral Generic $$ EDECRIN Ethacrynic Acid 25mg Brand $$$ CPA EES Erythromycin Esthylsuccinate 400mg Generic $$$ EFFEXOR Venlafaxine HCl 25mg, 37.5mg, 50mg, 75mg, 100mg Generic $$ EFFEXOR ER Venlafaxine HCl SR 37.5mg, 75mg, 150mg, 225mg Generic $$$ EFFIENT Prasugrel HCl 5mg, 10mg Brand $$$$ Step: Plavix ELAPRASELD
Idursulfase 6mg/3ml Brand $$$$$$ LMN
ELAVIL
Amitriptyline HCl
10mg, 25mg, 50mg, 75mg, 100mg, 150mg
Generic
$$
ELIDEL Pimecrolimus 1% Brand $$$$ CPA ELIGARD Leuprolide Acetate 7.5mg, 22.5mg, 30mg, 45mg Brand $$$$$$ ELIMITE Permethrin 5% Generic $$$$ ELLENCE Epirubicin HCl 2mg/ml Brand $$$$$$ LMN ELOCON Mometasone Furoate 0.1% Generic $$$ ELOXATIN Oxaliplatin 50mg, 100mg, 200mg Brand $$$$$$ ELSPAR Asparaginase 10000u Brand $$$$$$ EMEND Aprepitant 80mg, 115mg, 125mg, 150mg Brand $$$$ LMN: Specialty
$ ‐‐‐‐‐‐‐‐‐ $1 to $10
$$ ‐‐‐‐‐‐‐‐‐ $11 to $50 $$$ ‐‐‐‐‐‐‐‐‐ $51 to $100 $$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500 $$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000 $$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000 4f-26 6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 5 of 18
GCHP List of Covered Drugs
Brand Name Brand Names Generic Name Strength(s) Coverage Rx Cost LMN, QL, Step, CPA
ESTROSTEP FE Norethindrone Ac‐Ethinyl Estrad‐Fe Tab
20/1‐30/1‐35 MG‐MCG
1‐
Generic
$$$
ETHYOLM Amifostine Crystalline 500mg Brand $$$$$$ LMN
EUFLEXXA Sodium Hyaluronate 10mg/ml Brand $$$$$$ LMN EURAX Crotamiton 10% Brand $$$$ EVISTA Raloxifene HCl 60mg Brand $$$$ EVOXAC Cevimeline HCl 30mg Brand $$$$$$ LMN EXELON Rivastigmine Tartrate 1.5mg, 3mg, 4.5mg, 6mg Generic $$$$ EXELON PATCH Rivastigmine TD Patch 4.6mg/24HR, 9.5mg/24HR Brand $$$$ EXJADELD
Deferasirox 125mg, 250mg, 500mg Brand $$$$$$ EXTAVIA Interferon Beta‐1b 0.3mg Brand $$$$$$ LMN FABRAZYMELD
Agalsidase beta 5mg, 35mg Brand $$$$$$ LMN FAMVIR Famcyclovir Oral 125mg, 250mg, 500mg Generic $$$$ FASLODEX Fulvestrant 250mg/5ml Generic $$$$$$ FEIBA VH Antiinhibitor Coagulant Complex Brand $$$$$$ LMN FELDENE Piroxicam 10mg, 20mg Generic $$$$ FEMARA Letrozole 2.5mg Generic $$$$$ FEMHRT Norethindrone Acetate‐Ethinyl Estradiol 0.5mg‐2.5mcg, 1mg‐5mcg Generic $$$$
FENTORA
Fentanyl Citrate 100mcg, 200mcg, 300mcg, 400mcg,
600mcg, 800mcg
Brand
$$$$$
CPA
FERRLECIT Sod Ferric Gluc Cmplx 12.5mg Brand $$$$$$ LMN FINACEA, FINACEA PLUS KIT Azelaic Acid 15%, Kit Brand $$$$ FIORICET Butalbital‐Acetaminophen‐Caffeine 50‐325‐40mg Generic $$ FLAGYL Metronidazole Oral, IV Generic $$ to $$$$ FLEBOGAMMALD
Immune Globulin 5%, 10% Brand $$$$$$ LMN FLEXERIL Cyclobenzaprine HCl 5mg, 10mg Generic $$$ QL= 90 tabs/30 days FLOLANLD
Epoprostenol Sodium 0.5mg, 1.5mg Brand $$$$$$ LMN FLOMAX Tamsulosin HCl 0.4mg Generic $$$$ FLONASE Fluticasone Propionate 50mcg Generic $$$ QL= 2 inhrs/30 days FLORINEF Fludrocortisone Acetate 0.1mg Generic $$$ FLORONE Diflorasone Diacetate 0.05% Generic $$$
FLOVENT HFA
Fluticasone Propionate HFA
44mcg, 110mcg, 220mcg
Brand
$$$$ QL= 44mcg ‐ 2 inhrs; 110m
220mcg ‐ 3 inhrs; per 30 d
cg ‐ 1 inhr;
ays
FLUDARA Fludarabine Phosphate 50mg Brand $$$$$$ FLUDARABINE Fludarabine Phosphate 50mg, 50mg/2ml Generic $$$$$$ FML FORTE Fluorometholone 0.25% Brand $$ FOCALIN, FOCALIN XR Dexmethylphenidate HCl
2.5mg, 5mg, 10mg, 15mg, 20mg, 30mg,
40mg Brand $$$$ CPA; Age > 23
FOLLISTIM Follitropin Beta 75u, 150u, 300u, 600u, 900u Brand $$$$$$ LMN FOLTX Folic Acid 400mcg, 800mcg, 1000mcg, 1g Generic $$
FORADIL
Formoterol Fumarate
Brand
$$$$ CPA; QL= 12 caps/12pk; 12
per 30 days
0 caps/60pk;
FORTAZ Ceftazidime IV Generic $$$ LMN; Specialty
$ ‐‐‐‐‐‐‐‐‐ $1 to $10
$$ ‐‐‐‐‐‐‐‐‐ $11 to $50 $$$ ‐‐‐‐‐‐‐‐‐ $51 to $100 $$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500 $$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000 $$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000 4f-27 6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 6 of 18
EMETROL Fructose‐Dextrose‐Phosphoric Acid OTC $ QL= 240ml/ 30 days
EMTRIVA Emtricitabine Oral 200mg Brand $$$$$ ENABLEX Darifenacin Hydrobromide 7.5mg, 15mg Brand $$$ ENBREL Etanercept 25mg, 25mg/0.5ml, 50mg/ml Brand $$$$$$ Step: Fail 2 DMARD
ENGERIX Hepatitis B Vaccine 10mcg/0.5ml, 20mcg/ml Brand $$$$$$ LMN
ENPRESSE‐28 Levonorgestrel‐Eth Estra Tab 0.05‐
30/0.075‐40/0.125‐30MG‐MCG
Generic
$$
EPIPEN, EPIPEN‐JR
Epinephrine
0.15mg, 0.3mg
Brand
$$$$ CPA; QL= 3 units/pkg size 1; 4 units/pkg
size 2; per 30 days
EPIVIR Lamivudine Oral 150mg, 300mg Brand $$$$
EPOGEN
Epoetin Alfa 2000u/ml, 3000u/ml, 4000u/ml,
10000u/ml, 20000u/ml, 40000u/ml
Brand
$$$$$$
CPA; QL= 2 inj/30 days; Available at Retail
EPOPROSTENOLLD Epoprostenol Sodium 0.5mg, 1.5mg Generic $$$$$$ LMN
ERBITUX Cetuximab 100mg, 200mg Brand $$$$$$
ERYTHROCIN Erythromycin Stearate 25mg, 500mg Generic $$
ERYTHROMYCIN BASE Erythromycin Generic $$$
ESTRACE Estradiol 0.5mg, 1mg, 2mg Generic $$
ESTRACE VAG Estradiol Vaginal Cream Brand $$$
ESTRASORB Estradiol Brand $$$ QL= 68 packets/30 days
ESTROGEL Estradiol Brand $$$$ QL= 2 pump bottles/30 days
GCHP List of Covered Drugs
Brand Name Brand Names Generic Name Strength(s) Coverage Rx Cost LMN, QL, Step, CPA
FORTEO Teriparatide 600mcg/2.4ml Brand $$$$$ LMN; Specialty
FOSAMAX Alendronate Sodium 5mg, 10mg, 35mg, 70mg Generic $$$ FOSRENOL Lanthanum Carbonate 250mg, 500mg, 750mg, 1000mg Brand $$$$$
FRAGMIN
Dalteparin Sodium
2500u/0.2ml, 5000u/0.2ml, 7500u/0.3ml,
10000u/ml, 25000u/ml, 9500u, 12500u,
Brand
$$$$$$
CPA; QL=2 inj/30 days; Available at Retail
15000u, 18000u
FROVA
Frovatriptan Succinate
2.5mg
Brand
$$$$ Step: Sumatriptan Succinate; QL= 9 tabs/30
days
GAMASTANLD Immune Globulin Brand $$$$$$ LMN
GAMMAGARD SD Immune Globulin
1g/10ml, 2.5g/25ml, 5g/50ml, 10g/100ml,
20g/200ml, 30g/300ml, 0.5g, 2.5g, 5g, 10g
Brand $$$$$$ LMN
GAMUNEX Immune Globulin
10%, 1g/10ml, 2.5g/25ml, 5g/5ml,
10g/100ml, 20g/200ml
Brand $$$$$$ LMN
GANIRELIX Ganirelix Acetate Brand $$$$$$ LMN
GARAMYCIN Gentamicin IM or IV Generic $$ QL= 14 days
GELNIQUE Oxybutynin Chloride 10% Brand $$$
GEMZAR Gemcitabine HCl 200mg, 1g Brand $$$$$$
GENOTROPIN Somatropin
0.2mg, 0.4mg, 0.6mg, 0.8mg, 1mg, 1.2mg,
1.4mg, 1.6mg, 1.8mg, 2mg, 5mg, 12mg
Brand $$$$$$ CPA
GILENYA Fingolimod HCl 0.5mg Brand $$$$$$ LMN
GLEEVEC Imatinib Mesylate 100mg, 400mg Brand $$$$$$
GLUCAGEN Glucagon HCl 1mg Brand $$$$$
GLUCOPHAGE Metformin HCl 500mg, 750mg, 850mg, 1000mg Generic $$$
GLUCOPHAGE XR Metformin HCl SR 500mg, 750mg Generic $$$
GLUCOTROL Glipizide 5mg, 10mg Generic $$$
GLUCOTROL XL Glipizide SR 2.5mg, 5mg, 10mg Generic $$$
GLUCOVANCE Glyburide‐Metformin 1.25‐250mg, 2.5‐500mg, 5‐500mg Generic $$$$
GLYCOLAX Polyethylene Glycol OTC $$
GOLYTELY PEG 3350‐KCl‐Na Bicarb‐NaCl‐Na Sulfate Generic $$$$
GONAL‐F Follitropin Alfa 300, 450, 900, 75u, 450u, 1050u Brand $$$$$$ LMN
GRANISETRON Granisetron HCl 1mg, 0.1mg/ml, 1mg/ml, 4mg/4ml, Generic $$$$$$ LMN
GRIS‐PEG Griseofulvin Oral 125mg, 250mg Generic $$
HALAVEN Eribulin Mesylate 1mg/2ml Generic $$$$$$
HAVRIX Hepatitis A Vaccine 720u, 1440u Brand $$$$$$ LMN
HEALON Sodium Hyaluronate 10mg/ml, 14mg/ml, 23mg/ml Brand $$$$$$ LMN
0.5mcg, 1mcg, 2.5mcg, 2mcg/ml, HECTOROL Doxercalciferol
4mcg/2ml Brand $$$$$
HELIDAC Metronidaz‐Tetracyc‐Bis Brand $$$$ HELIXATE
FS Antihemophilic Factor 250u, 500u, 1000u, 2000u, 3000u Brand $$$$$$ LMN
HEMOFIL M Antihemophilic Factor 220‐400u, 401‐800u, 801‐1700u, 1701u+ Brand $$$$$$ LMN
HEPSERA Adefovir Dipivoxil 10mg Brand $$$$$$ LMN
HERCEPTIN Trastuzumab 440mg Brand $$$$$$
HUMALOG Insulin Lispro 50/50, 75/25, 100u/ml Brand $$$$
HUMATE‐P Antihemophilic Factor/VWF 500u, 600u, 1000u, 1200u, 2000u, 2400u Brand $$$$$$
HUMATROPE Somatropin 5mg, 6mg, 12mg, 24mg Brand $$$$$$ CPA
HUMIRA Adalimumab 20mg/0.4ml, 40mg/0.8ml, Brand $$$$$$ Step: Fail 2 DMARD
HUMULIN Insulin Isophane & Regular 50/50, 70/30 Brand $$$
HUMULIN N Insulin Isophane 100u/ml Brand $$$
HUMULIN R Insulin Isophane 100u/ml, 500u/ml Brand $$$
HYALGAN Sodium Hyaluronate 20mg/2ml Brand $$$$$$ LMN
HYCAMTIN Topotecan HCl 4mg Generic $$$$$
HYDREA Hydroxyurea 500mg Generic $$$$
HYDRODIURIL Hydrochlorothiazide 12.5mg, 25mg, 50mg Generic $$$
HYGROTON Chlorthalidone 25mg, 50mg, 100mg Generic $$$$
HYPERHEP Hepatitis B Immune Globulin Brand $$$$$$ LMN
HYPERRHO Rho D Immune Globulin 50mcg, 300mcg Brand $$$$$$ LMN
HYTONE Hydrocortisone 0.5%, 1%, 2.5% Generic $$$
HYTRIN Terazosin HCl 1mg, 2mg, 5mg, 10mg Generic $$$
$ ‐‐‐‐‐‐‐‐‐ $1 to $10
$$ ‐‐‐‐‐‐‐‐‐ $11 to $50
$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100
$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500
$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000
$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000
4f-28
6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 7 of 18
GCHP List of Covered Drugs
Brand Name Brand Names Generic Name Strength(s) Coverage Rx Cost LMN, QL, Step, CPA
HYZAAR Losartan Potassium & Hydrochlorothiazide 50‐12.5mg, 100‐12.5mg, 100‐25mg
Generic
$$$
IFEX Ifosfamide 1 gm, 3 gm Generic $$$$$$
ILOTYCIN Erythromycin Generic $$
IMDUR Isosorbide Mononitrate 10mg, 20mg, 30mg, 60mg, 120mg Generic $$$$
IMITREX Sumatriptan Succinate 25mg, 50mg, 100mg Generic $$$ QL= 9 tabs/30 days (25
100mg)
g, 50mg, &
IMITREX Sumatriptan Succinate Injection 4mg/0.5ml, 6mg/0.5ml Generic $$$ QL= 1 kit/30 days (2 syri
days
nges); 2 vials/30
IMODIUM Loperamide HCl 2mg Generic $$ IMURAN Azathioprine 50mg Generic $$$$$ INCRELEX Mecasermin 40mg/4ml Brand $$$$$$ CPA INDERAL Propranolol HCl 20mg, 60mg, 80mg, 120mg, 160mg Generic $$$ INDOCIN Indomethacin 25mg, 50mg, 75mg Generic $$ INFERGEN Interferon Brand $$$$$$ Specialty INNOHEP Tinzaparin Sodium 20000u/ml Brand $$$$$$ LMN; Available at Retail INSPRA Eplerenone 25mg, 50mg Generic $$$$ INTRON‐A Interferon Alfa‐2B 3u, 5u, 10u, 18u, 25u, 50u Brand $$$$$$ QL= 2 inj/30 days INVANZ Ertapenem IV Generic $$$$$ LMN ISONIAZID Isoniazid Oral Generic $$ ISOPTIN Verapamil HCl 40mg, 80mg, 180mg, 240mg Generic $$$ ISORDIL Isosorbide Dinitrate 5mg, 10mg, 20mg, 30mg, 40mg Generic $$$$ IXEMPRA Ixabepilone 15mg, 45mg Generic $$$$$$ JANUMET Sitagliptin‐Metformin HCl 50‐500mg, 50‐1000mg Brand $$$$$ JANUVIA Sitagliptin Phosphate 25mg, 50mg, 100mg Brand $$$$ JEVTANA Cabazitaxel 60mg/1.5ml Generic $$$$$$$
JUNEL FE Norethindrone Ace & Ethinyl Estradiol
Tab 1 MG‐20MCG, 1.5 MG‐30 MCG
‐FE Generic $$
KARIVA
Desogest‐Eth Estrad & Eth Estrad Tab 0
0.02/0.01 MG(21/5)
.15‐ Generic
$$$
KEFLIN Cephalothin‐Oral Generic $$$ KELNOR
Ethynodiol Diacetate & Ethinyl Estradi
Tab 1 MG‐35 MCG ol
Generic $$ KENALOG Triamcinolone Acetonide 0.025%, 0.1%, 0.5% Generic $$ KEPPRA Levetiracetam
100mg/ml, 250mg, 500mg, 750mg,
1000mg Generic $$$
KEPPRA XR Levetiracetam SR 500mg, 750mg Brand $$$ KINERET Anakinra Brand $$$$$$ LMN KLARON Sulfacetamide Sodium 10% Generic $$$$ KLONOPIN Clonazepam 0.125mg, 0.25mg, 0.5mg, 1mg, 2mg Generic $$ KOATE‐DVI Antihemophilic Factor 250u, 500u, 1000u Brand $$$$$$
KOGENATE FS Antihemophilic Factor 250u, 500u, 1000u, 2000u, 3000u, 250/BS,
500/BS, 1000/BS, 2000/BS, 3000/BS Brand $$$$$$ LMN
KUVANLD
Sapropterin Dihydrochloride
100mg
Brand
$$$$$$
LMN KYTRIL Granisetron HCl 1mg, 0.1mg/ml, 1mg/ml Brand $$$$ LMN: Specialty
LAMICTAL
Lamotrigine 25mg, 50mg, 100mg, 150mg, 200mg,
250mg
Generic
$$
LAMICTAL XR
Lamotrigine SR
25mg, 100mg, 150mg, 200mg, 300mg
Brand
$$$$
LAMISIL Terbinafine Oral 250mg Generic $$$$ LANOXIN Digoxin 0.125mg, 0.25mg Generic $$$ LANTUS Insulin Glargine 100u/ml, 500u/ml Brand $$$$ LASIX Furosemide 20mg, 40mg, 80mg Generic $$ LESSINA‐28
Levonorgestrel & Ethinyl Estradiol Tab
MG‐20 MCG
0.1 Generic $$
LETAIRISLD
Ambrisentan 5mg, 10mg Brand $$$$$$ LMN; Specialty LEUKERAN Chlorambucil 2mg Brand $$$$$$ LEUPROLIDE Leuprolide Acetate 1mg/0.2ml, 5mg/ml Generic $$$$$$ LEUSTATIN Cladribine 1mg/ml Brand $$$$$$ LMN LEVAQUIN
LEVBID
Levofloxacin Oral
Hyoscyamine Sulfate
0.0125mg, 0375mg
Generic
Generic
$$
$$
LEVEMIR, FLEXPEN Insulin Detemir 100u/ml Brand $$$$
$ ‐‐‐‐‐‐‐‐‐ $1 to $10
$$ ‐‐‐‐‐‐‐‐‐ $11 to $50 $$$ ‐‐‐‐‐‐‐‐‐ $51 to $100 $$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500 $$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000 $$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000 4f-29 6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 8 of 18
m
GCHP List of Covered Drugs
Brand Name Brand Names Generic Name Strength(s) Coverage Rx Cost LMN, QL, Step, CPA
LEVORA‐28 Levonorgestrel & Ethinyl Estradiol Tab 0.
MG‐30 MCG
5
25mcg, 50mcg, 75mcg, 88mcg, 100mcg,
Generic
$$
LEVOTHROID Levothyroxine Sodium 112mcg, 125mcg, 137mcg, 150mcg, Generic $$ 175mcg, 200mcg, 300mcg, 500mcg 25mcg, 50mcg, 75mcg, 88mcg, 100mcg,
LEVOXYL Levothyroxine Sodium 112mcg, 125mcg, 137mcg, 150mcg, Generic $$ 175mcg, 200mcg, 300mcg Step: Failure of two: citalopram,
LEXAPRO Escitalopram Oxalate 5mg, 10mg, 20mg Generic $$$$ fluoxetine, fluvoxamine, paroxetine, sertraline
LIALDA Mesalamine 1.2g Brand $$$$ LMN LIBRIUM Chlordiazepoxide HCl 5mg, 10mg, 25mg Generic $$ QL= 120tabs/30days LIDEX Fluocinonide 0.05% Generic $$ LIDODERM Lidocaine Patch 5% Generic $$$$$ LINDANE Lindane 1% Generic $$$ LIORESAL Baclofen 10mg, 20mg Generic $$$$ LIPITOR Atorvastatin Calcium 10mg, 20mg, 40mg, 80mg Brand $$$$ Step: simvastatin 80mg
LO/OVRAL Norgestrel & Ethinyl Estradiol Tab 0.3 MG
30 MCG
‐
Generic
$$
LODOSYN Carbidopa 25mg Brand $$$
LOESTRIN FE
Norethindrone Ace & Ethinyl Estradiol‐FE
Tab 1 MG‐20 MCG, 1.5 MG‐30 MCG
Generic
$$
LOFIBRA Fenofibrate 54mg, 67mg, 134mg, 160mg, 200mg Generic $$$ LOMOTIL Diphenoxylate w/ Atropine 2.5mg Generic $$ LOPID Gemfibrozil 600mg Generic $$$ LOPRESSOR Metoprolol Tartrate 25mg, 50mg, 100mg Generic $$$ LOTEMAX Loteprednol Etabonate 0.5% Brand $$$ LOTENSIN Benazepril HCl 5mg, 10mg, 20mg, 40mg Generic $$$ LOTENSIN HCT Benazepril & Hydrochlorothiazide 5‐6.5mg, 10‐12.5mg, 20‐12.5mg, 20‐25mg Generic $$$
LOTREL Amlodipine Besylate‐Benazepril HCl 2.5‐10mg, 5‐10mg, 5‐20mg, 10‐20mg Generic $$$
LOVAZA Omega‐3‐acid Ethyl Esters 1g Brand $$$$ 30mg/0.3ml, 40mg/0.4ml, 60mg/0.6ml,
LOVENOX Enoxaparin Sodium 80mg/0.8ml, 100mg/ml, 150mg/ml, Brand $$$$$$ LMN: Available at Retail 120mg/0.8ml
LOW‐OGESTREL Norgestrel & Ethinyl Estradiol Tab 0.3 MG
30 MCG
‐
Generic
$$
LOZOL Indapamide 1.25mg, 2.5mg Generic $$$ LUCENTISLD
Ranibizumab Brand $$$$$$ LMN LUMIGAN Bimatoprost 0.01%, 0.03% Generic $$$
LUPRON
Leuprolide Acetate
3.75mg, 7.5mg, 11.25mg, 22.5mg, 30mg
Brand
$$$$$$
LUTERA Levonorgestrel & Ethinyl Estradiol Tab 0.
MG‐20 MCG
1
Generic
$$
LUVOX Fluvoxamine Maleate 25mg, 50mg, 100mg Generic $$$
LYRICA
Pregabalin 25mg, 50mg, 75mg, 100mg, 150mg,
200mg, 225mg, 300mg
Brand
$$$$
Step: gabapentin
MACRODANTIN Nitrofurantoin Macorcrystal Oral Generic $$ MACUGENLD
Pegaptanib Sodium Brand $$$$$$ LMN MATULANE Procarbazine HCl 50mg Generic $$$$$$$
MAXALT, MAXALT‐MLT
Rizatriptan Benzoate
5mg, 10mg
Brand
$$$$ Step: Sumatriptan Succinate; QL= 9 tabs/
days
30
MAXIPIME Cefapime IV Generic $$ LMN MAXITROL Neomycin‐Polymyxin‐Dexamethasone 0.1% Generic $$ MAXZIDE Triamterene & Hydrochlorothiazide 37.5‐25mg, 50‐25mg, 75‐50mg Generic $$$ MEBENDAZOLE Mebendazole Oral 100mg Generic $$$ MEDROL Methylprednisolone 2mg, 4mg, 8mg, 16mg, 32mg Generic $$$ MEFOXIN Cefoxitin‐IV Generic $$ LMN MEGACE Megestrol Acetate 20mg, 40mg Generic $$$$$ MEGACE Megestrol Acetate 40mg/ml Generic $$$$
$ ‐‐‐‐‐‐‐‐‐ $1 to $10
$$ ‐‐‐‐‐‐‐‐‐ $11 to $50 $$$ ‐‐‐‐‐‐‐‐‐ $51 to $100 $$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500 $$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000 $$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000 4f-30 6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 9 of 18
1
GCHP List of Covered Drugs
Brand Name Brand Names Generic Name Strength(s) Coverage Rx Cost LMN, QL, Step, CPA
MONONESSA Norgestimate & Ethinyl Estradiol Tab 0
MG‐35 MCG
.25
Generic
$$
MONONINE Coagulation Factor IX 250u, 500u, 1000u Brand $$$$$$$ LMN MONOPRIL Fosinopril Sodium 10mg, 20mg, 40mg Generic $$ MONOPRIL HCT Fosinopril Sodium & Hydrochlorothiaz ide 10‐12.5mg, 20‐12.5mg Generic $$$$ MOTRIN Ibuprofen 800mg Generic $$ MS CONTIN Morphine Sulfate 15mg, 30mg, 60mg, 10mg, 200mg Generic $$$ QL= 120 tabs/30 days MYAMBUTOL Ethambutol Oral 100mg, 400mg Generic $$$ MYCAMINE Micafungin IV 50mg, 100mg Brand $$$ LMN MYCOPHENOLATE Mycophenolate Mofetil 250mg, 500mg Generic $$$$$$ LMN MYOZYME
LD Alglucosidase Alfa 50mg Brand $$$$$$ LMN
MYSOLINE Primidone 50mg, 250mg Generic $$$ NAFCILLIN Nafcillin IV Generic $$$$ LMN NAGLAZYMELD
Galsulfase 1mg/ml Brand $$$$$$ LMN NAMENDA Memantine HCl 5mg, 5‐10mg, 10mg Brand $$$$
NAPROSYN
Naproxen 220mg, 250mg, 275mg, 375m g, 500mg,
550mg
Generic
$$$
NASACORT AQ
Triamcinolone Acetonide
55mcg/ACT
Brand
$$$$ Step: Fail one: flunisolide, f
OMNARIS
luticasone,
NASALIDE Flunisolide 0.025% Generic $$$ QL= 3 inhrs/bottles/30 day s
NASONEX
Mometasone Furoate
50mcg/ACT
Brand
$$$$ Step: Fail one: flunisolide, f
OMNARIS
luticasone,
NATALCARE PLUS Prenatal Vit w/ Fe Fumarate‐FA Generic $$ Step: Prenatal OTC NAVELBINE Vinorelbine Tartrate 10mg/ml, 50mg/5ml Brand $$$$$$
$ ‐‐‐‐‐‐‐‐‐ $1 to $10
$$ ‐‐‐‐‐‐‐‐‐ $11 to $50 $$$ ‐‐‐‐‐‐‐‐‐ $51 to $100 $$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500 $$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000 $$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000 4f-31 6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 10 of 18
MERREM Meropenem IV Generic $$$$ LMN
MESTINON Pyridostigmine Bromide 60mg, 60mg/5ml Brand $$$$ METADATE CD Methylphenidate HCl 10mg, 20mg, 30mg, 40mg, 50mg, 60mg Brand $$$$$ CPA; Age > 23
METANX L‐Methylfolate w/ Vit B6‐Vit B12 Brand $$$$ METHADONE Methadone HCl 5mg, 10mg, 40mg Generic $$$ CPA; QL= 120 tabs/30 days
METROGEL Metronidazole Gel 0.75% Generic $$$ METROLOTION Metronidazole 0.75% Generic $$$ MEVACOR Lovastatin 20mg, 40mg Generic $$$$ MEXATE Methotrexate Sodium
1g, 1g/40ml, 25mg/ml, 50mg/2ml,
250mg/10ml Generic $$$$$$
MIACALCIN Calcitonin 200u/ACT Generic $$$$ MIACALCIN Injection Calcitonin 200u/ml Generic $$$$ LMN
MICARDIS Telmisartan 20mg, 40mg, 80mg Brand $$$$ Step: losartan potassium
MICRHOGAM PL Rho D Immune Globulin 50mcg Brand $$$$$$
MICROGESTIN
Norethindrone Ace & Ethinyl Estradiol Tab
1 MG‐20 MCG, 1.5 MG‐30 MCG
Generic $$
MICROGESTIN FE Norethindrone Ace & Ethinyl Estradiol‐FE
Tab 1 MG‐20 MCG, 1.5 MG‐30 MCG
Generic $$
MICRO‐K Potassium Chloride 8mEq, 10mEq, 20mEq Generic $$ MICRONASE Glyburide 1.25mg,. 2.5mg, 5mg Generic $$$
MIDAMOR Amiloride HCl 5mg Generic $$$$ Step: spironolactone
MINIPRESS Prazosin HCl 1mg, 2mg, 5mg Generic $$$ MIRAPEX Pramipexole Dihydrochloride 0.125mg, 0.25mg, 0.5mg, 0.75mg, 1mg Generic $$$
MIRAPEX ER
Pramipexole Dihydrochloride SR
0.375mg, 0.75mg, 1.5mg, 3mg, 4.5mg
Brand
$$$$
Step: Pramipexole Dihydrochloride
MIRCETTE Desogest‐Eth Estrad & Eth Estrad Tab 0
0.02/0.01 MG(21/5)
.15‐
Generic
$$$
MIRTAZAPINE Mirtazapine 7.5mg, 15mg, 30mg, 45mg Generic $$$ MITOMYCIN Mitomycin 5mg, 20mg, 40mg Generic $$$$$$ MOBIC Meloxicam 7.5mg, 15mg Generic $$$$ MODICON
Norethindrone & Ethinyl Estradiol Tab
MG‐35MCG
0.5 Generic $$$
MONARC‐M Antihemophilic Factor 220‐400u, 401‐800u, 801‐1700u, 1701u+ Brand $$$$$$ LMN
MONOCLATE‐P Antihemophilic Factor 250u, 500u, 1000u, 1500u Brand $$$$$$ LMN
GCHP List of Covered Drugs
Brand Name Brand Names Generic Name Strength(s) Coverage Rx Cost LMN, QL, Step, CPA
Norethindrone & Ethinyl Estradiol Tab 0.5 Generic $$
500mg Generic $$$$ QL= 2 tabs/30 days
25mg, 100mg Generic $$$$$$
Generic $$
6mg/0.6ml Brand $$$$$$ CPA; QL= 2 inj/30 days
NECON MG‐35 MCG, 1 MG‐35 MCG, 0.5‐35/0.75‐
35/1‐35 MG‐MCG
NEOMYCIN Neomycin Sulfate ‐Oral
NEORAL Cyclosporine
NEOSPORIN Neomycin/Polymyxin Gramicidin
NEULASTA Pegfilgrastim
NEUPOGEN Filgrastim 300mcg, 480mcg, 300mcg/0.5ml,
480mcg/0.8ml Brand $$$$$$ LMN; Available at Retail
NEURONTIN
Gabapentin
100mg, 300mg, 400mg, 600mg, 800mg
Generic
$$$$
NEXAVARLD Sorafenib Tosylate 200mg Brand $$$$$$
Step: Failure of two: omeprazole, NEXIUM Esomeprazole Magnesium 20mg, 40mg Brand $$$$ pantoprazole, lansoprazole; QL= 34
caps/packets/30 days NIASPAN Niacin 500mg, 750mg, 1000mg Brand $$$$
NITRO‐DUR
Nitroglycerin 2.5mg, 6.5mg, 0.1mg/HR, 0.2mg/HR,
0.4mg/HR, 0.6mg/HR
Generic
$$$$
NITROSTAT Nitroglycerin 0.4mg, 0.6mg Generic $$$$ NIZORAL Ketoconazole Topical Generic $$ NIZORAL Ketoconazole Oral 200mg Generic $$$ NOLVADEX Tamoxifen Citrate 10mg, 20mg Generic $$$$ NORDETTE
Levonorgestrel & Ethinyl Estradiol Tab 0.15
MG‐30 MCG Generic $$$
NORDITROPIN
Somatropin 5mg/1.5ml, 10mg/1.5ml, 15mg/1.5ml,
30mg/3ml
Brand
$$$$$$
CPA
NORINYL Norethindrone & Mestranol Tab 1 MG‐
35MCG, 1 MG‐50 MCG
Generic
$$
NORMODYNE Labetalol HCl 100mg, 200mg, 300mg Generic $$$ NORPRAMIN Desipramine HCl 10mg, 25mg, 50mg, 75mg, 100mg, 150mg Generic $$ NOR‐QD Norethindrone 0.35mg Generic $$$
NORTREL MG‐35 MCG, 1 MG‐35 MCG, 0.5‐35/0.75‐ Generic $$
NORVASC Amlodipine Besylate 2.5mg, 5mg, 10mg Generic $$$ NOVAREL Chorionic Gonadotropin 10000u Generic $$$$$$ LMN NOVOLIN Insulin Isophane & Regular 70/30 Brand $$$ NOVOLIN N Insulin Isophane 100u/ml Brand $$$ NOVOLIN R Insulin Isophane 100u/ml Brand $$$ NOVOLOG Insulin Aspart 70/30, 100u/ml Brand $$$$
NOVOSEVEN
Coagulation Factor VIIa 1200mcg, 2400mcg, 4800mcg, 1mg, 2mg,
5mg, 8mg
Brand
$$$$$$$
LMN
NOXAFIL Posaconazole Oral 40mg/ml Brand $$$$$ LMN NPLATE Romiplostim 250mcg, 500mcg Generic $$$$$$ NULYTELY PEG 3350‐KCl‐Sod Bicarb‐NaCl Generic $$$$ NUTROPINLD
Somatropin 5mg, 10mg, 5mg/2ml, 20mg/2ml Brand $$$$$$ CPA
NUVARING Etonogestrel‐Ethinyl Estradiol VA Ring
0.120‐0.015 MG/24HR
Brand
$$$
NUVIGIL Armodafinil 50mg, 150mg, 250mg Brand $$$$$ CPA; Age > 23 NYSTATIN Nystatin Swish and Swallow Generic $$ NYSTOP Nystatin Topical Powder Generic $$ OCELLA
Drospirenone‐Ethinyl Estradiol Tab 3‐0.03
MG Generic $$$
OCTAGAMLD
Immune Globulin 2.5g, 5g, 10g, 25g Brand $$$$$$ LMN OCTREOTIDE Octreotide Acetate
100mcg, 200mcg, 500mcg, 1000mcg,
1mg/ml, 50mcg/ml Generic $$$$$$ LMN
OCUFLOX Ofloxacin 0.3% Generic $$$ OGEN Estropipate 0.75mg, 1.5mg, 3mg Generic $$
OMNARIS
Ciclesonide
50mcg/ACT
Brand
$$$$
Step: Fail one: flunisolide, fluticasone
OMNIPRED Prednisolone Acetate 1% Generic $$$$ OMNITROPELD
Somatropin 5.8mg, 5mg/1.5ml, 10mg/1.5ml Brand $$$$$$ CPA ONE TOUCH ‐ kits, strips a
supplies
nd
Brand
$$$$
QL= 100 strips/30 days
$ ‐‐‐‐‐‐‐‐‐ $1 to $10
$$ ‐‐‐‐‐‐‐‐‐ $11 to $50 $$$ ‐‐‐‐‐‐‐‐‐ $51 to $100 $$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500 $$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000 $$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000 4f-32 6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 11 of 18
Norethindrone & Ethinyl Estradiol Tab 0.5
35/1‐35 MG‐MCG
GCHP List of Covered Drugs
Brand Name Brand Names Generic Name Strength(s) Coverage Rx Cost LMN, QL, Step, CPA
ONGLYZA Saxagliptin HCl 2.5mg, 5mg Brand $$$$
ONTAK Denileukin Diftitox 150mcg/ml Brand $$$$$$
30mg/5ml, 100mg/16.7ml, 150mg/25ml, ONXOL Paclitaxel
OPANA ER Oxymorphone HCl
300mg/50ml
5mg, 7.5mg, 10mg, 15mg, 20mg, 30mg,
40mg
Generic $$$$$
Brand $$$$ QL= 120 tabs/30 days
OPTIVAR Azelastine HCl 0.05% Generic $$$$
ORENCIA Abatacept 250mg Brand $$$$$$ CPA
Norelgestromin‐Ethinyl Estradiol TD PTWK ORTHO EVRA
ORTHO TRI‐CYCLEN
ORTHO TRI‐CYCLEN LO
ORTHO‐CEPT
ORTHO‐CYCLEN
ORTHO‐NOVUM
150‐20 MCG/24HR
Norgestimate‐Eth Estrad Tab 0.18‐
35/0.215‐35/0.25‐35 MG‐MCG
Norgestimate‐Eth Estrad Tab 0.18‐
25/0.215‐25/0.25‐25 MG‐MCG
Desogestrel & Ethinyl Estradiol Tab 0.15
MG‐30 MCG
Norgestimate & Ethinyl Estradiol Tab 0.25
MG‐35 MCG Norethindrone & Ethinyl
Estradiol Tab 1
MG‐35 MCG, 1 MG‐50MCG, 0.5‐35/0.75‐
35/1‐35 MG‐M
Brand $$$
Generic $$
Brand $$ CPA
Generic $$
Generic $$$
Generic $$$
ORTHOVISC Hyaluronan 15mg/ml Brand $$$$$$ LMN
ORUDIS Ketoprofen 50mg, 75mg, 200mg Generic $$$
Norethindrone & Ethinyl Estradiol Tab 0.4 OVCON 35
MG Generic $$$
OVIDE Malathion Lotion 0.50% Generic $$$$
10mg, 15mg, 20mg, 30mg, 40mg, 60mg, OXYCONTIN Oxycodone HCl
80mg, 160mg Brand $$$$ CPA; QL= 120 tabs/30 days
OXYTROL Oxybutynin 3.9mg/24HR Brand $$$
PACERONE Amiodarone HCl 200mg Generic $$$
100mg, 6mg/ml, 30mg/5ml, 150mg/25ml, PACLITAXEL Paclitaxel
300mg/50ml Generic $$$$$$
PAMELOR Nortriptyline HCl 10mg, 25mg, 50mg, 75mg Generic $$$
PAMIDRONATE Pamidronate Disodium 30mg, 90mg, 30mg/10ml, 90mg/10ml Generic $$$$$$
PATANASE Olopatadine HCl 0.6% Brand $$$$
PATANOL Olopatadine HCl 0.1% Brand $$$$
PAXIL Paroxetine HCl 10mg, 12.5mg, 20mg, 30mg, 40mg Generic $$
PEGASYS Peginterferon alfa‐2a 180mcg/0.5ml, 180mcg/ml Brand $$$$$$ LMN
PEG‐INTRON Peginterferon alfa‐2b 50mcg, 80mcg, 120mcg, 150mcg Brand $$$$$$ LMN
PENICILLN GK Penicillin G IV Generic $$$ LMN
PENICILLN VK Penicillin VK‐oral Generic $$$
PENTASA Mesalamine 250mg, 500mg Brand $$$$ LMN
PEPCID Famotidine 40mg Generic $$$
PEPCID Famotidine 10mg, 20mg OTC $$ QL= 90 tabs/30 days
PERFOROMIST Formoterol Fumarate 20mcg Brand $$$$ CPA; QL= 120 vials/30 days
PERIACTIN Cyproheptadine HCl 4mg Generic $$
PERIDEX Chlorhexidine Gluconate 0.12% Generic $$$
PHENERGAN Promethazine HCl 12.5mg, 25mg, 50mg Generic $$
PHENERGAN DM Promethazine‐DM Generic $$
PHENERGAN/CODEINE Promethazine w/ Codeine 6.25‐10mg Generic $$
PHENERGAN/CODEINE Promethazine w/ Codeine Generic $$
PHENOBARB Phenobarbital 15mg, 30mg, 32.4mg, 60mg, 100mg Generic $$
PHENTOLAMINE Phentolamine Mesylate Brand $$$$$$ LMN
PHENYTEK Phenytoin Sodium 200mg, 300mg Generic $$
PHEREGAN Promethazine HCl 12.5mg, 25mg, 50mg Generic $$
PILOCARPINE Pilocarpine HCl 1%, 2%, 3%, 4%, 6% Generic $$
PLAQUENIL Hydroxychloroquine Sulfate 200mg Generic $$$
PLAVIX Clopidogrel Bisulfate 75mg, 300mg Brand $$$$ CPA
PLETAL Cilostazol 50mg, 100mg Generic $$$ POLYGAM
S/DM Immune Globulin 0.5g, 2.5g, 5g, 10g Brand $$$$$$ LMN
POLYTRIM Polymyxin B‐Trimethoprim Generic $
PRANDIMET Repaglinide‐Metformin HCl 1‐500mg, 2‐500mg Brand $$$$
PRAVACHOL Pravastatin Sodium 10mg, 20mg, 40mg, 80mg Generic $$$$
PRECOSE Acarbose 25mg, 50mg, 100mg Generic $$$
$ ‐‐‐‐‐‐‐‐‐ $1 to $10
$$ ‐‐‐‐‐‐‐‐‐ $11 to $50
$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100
$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500
$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000
$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000
4f-33
6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 12 of 18
GCHP List of Covered Drugs
Brand Name Brand Names Generic Name Strength(s) Coverage Rx Cost LMN, QL, Step, CPA
PRED FORTE Prednisolone Acetate 1% Generic $$ PREFEST Estradiol/Estrad‐Norgestimate Brand $$$$ PREGNYLM
Chorionic Gonadotropin 10000u Generic $$$$$$ LMN
PREMARIN
Estrogens, Conjugated
0.3mg, 0.45mg, 0.625mg, 0.9mg, 1.25mg
Brand
$$$
PREMARIN VAG Estrogens, Conjugated Vaginal Cream 0.625mg Brand $$
PREMPHASE Conj Est/Conj Est‐Medroxypro Ac Brand $$$ PREMPRO
Conjugated Estrogen‐Medroxyprogest
Acetate
0.3‐1.5mg, 0.45‐1.5mg, 0.625‐2.5mg, 0.625
5mg
‐ Brand $$$
PRENATAL Prenatal Rx Generic $$ Step: Prenatal OTC PRENATAL VITAMINS Prenatal Vitamins OTC $$ QL= 100 tabs/30 days
PRENATE ELITE
Prenatal Vit w/ Fe Fum‐Methylfolate‐FA
Brand
$$$$
Step: Prenatal OTC
PREVACID Lansoprazole 15mg, 30mg Generic $$$$ PREVIFEM
Norgestimate & Ethinyl Estradiol Tab 0.2
MG‐35 MCG
5 Generic $$
PREVPAC Amoxicillin‐Clarithro‐Lansopraz Brand $$$$ PRILOSEC Omeprazole 10mg, 40mg Generic $$ PRILOSEC Omeprazole 20mg OTC $$ QL= 42 tabs/30 days PRIMAQUINE Primaquine Oral 26.3mg Generic $$$$ PRIMAXIN Imipenem/Cilastin IV Generic $$$$$ LMN PRISTIQ Desvenlafaxine Succinate 50mg, 100mg Brand $$$ Step: venlafaxine ER HCL PRIVIGEN Immune Globulin 5g, 10g, 20g Brand $$$$$$ LMN PROAIR HFA Albuterol Sulfate Brand $$$$ QL= 3 inhrs/30 days PROAMATINE Midodrine HCl 2.5mg, 5mg, 10mg Generic $$$ PROBEN/COLCH Colchicine w/ Probenecid 500‐0.5 Generic $$$ PROCARDIA Nifedipine 10mg, 20mg Generic $$ PROCARDIA XL Nifedipine SR 30mg, 60mg, 90mg Generic $$$$ PRO‐CLEAR Guaifenesin‐Codeine 300‐10mg Generic $$
2000u/ml, 3000u/ml, 4000u/ml, PROCRIT Epoetin Alfa 10000u/ml, 20000u/ml, 30000u/ml, Brand $$$$$$ LMN; Available at Retail
40000u/ml PROFILNINELD
Factor IX Complex 500u, 1500u, 1500u Brand $$$$$$$ LMN PROGRAF Tacrolimus 0.5mg, 1mg, 5mg, 5mg/ml Brand $$$$$$ LMN
PROLEX DM
Dextromethorphan‐Pot Guaiacolsulfon
Generic
$$
PROLIA Denosumab 60mg/ml Brand $$$$$$ Step: Failure on Bisphosphonate PROPYLTHIOURACIL Propylthiouracil 50mg, 100mg, 200mg, 400mg Generic $$ PROSCAR Finasteride 5mg Generic $$$$ PROTONIX Pantoprazole 20mg, 40mg Generic $$$ PROTOPIC Tacrolimus 0.03%, 0.1% Brand $$$$ CPA PROVENTIL Albuterol Sulfate 2mg, 4mg Generic $$ PROVERA Medroxyprogesterone Acetate 2.5mg, 5mg, 10mg Generic $$$ PROVIGIL Modafinil 100mg, 200mg, 300mg Brand $$$$$ CPA; Age > 23 PROZAC Fluoxetine HCl 10mg, 20mg, 40mg, 90mg Generic $$
Step: Failure of two: citalopram, PROZAC WEEKLY Fluoxetine HCl 90mg Generic $$ fluoxetine, fluvoxamine, paroxetine,
sertraline
PULMICORT
Budesonide
0.25mg/2ml, 0.5mg/2ml, 1mg/ml
Brand
$$$$
QL= 70 amps (0.25mg/2ml or 0.5mg/2ml
35 amps (1mg/2ml); 2 inhrs; per 30 days
);
PULMICORT FLEXHALER
Budesonide
90mcg, 180mcg
Brand
$$$$
QL= 2 inhs (90 mcg); 3 inhs (180 mcg); pe
30 days
r
PULMOZYME Dornase Alfa 1mg/ml Brand $$$$$$ LMN PURINETHOL Mercaptopurine 50mg Generic $$$$ PYRAZINAMIDE Pyrazinamide Oral 500mg Generic $$$ PYRIDIUM Phenazopyridine HCl 100mg, 200mg Generic $$
PYRIDOXINE
Pyridoxine HCl 25mg, 50mg, 100mg, 200MG, 250MG,
500MG
OTC
$$
QL= 60 tabs/30 days
QUESTRAN Cholestyramine 4g Generic $$$ RANEXA Ranolazine 500mg, 1000mg Brand $$$$ LMN RAPAFLO Silodosin 4mg, 8mg Brand $$$$ RAPAMUNE Sirolimus 0.5mg, 1mg, 2mg, 1mg/ml Brand $$$$$$ LMN REBETOL Ribavirin 200mg, 4mg/ml Brand $$$$$$ LMN
$ ‐‐‐‐‐‐‐‐‐ $1 to $10
$$ ‐‐‐‐‐‐‐‐‐ $11 to $50 $$$ ‐‐‐‐‐‐‐‐‐ $51 to $100 $$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500 $$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000 $$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000 4f-34 6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 13 of 18
GCHP List of Covered Drugs
Brand Name Brand Names Generic Name Strength(s) Coverage Rx Cost LMN, QL, Step, CPA
REBIF Interferon Beta‐1a 22mcg/0.5ml, 44mcg/0.5ml Brand $$$$$$ LMN
RECLAST Zoledronic Acid 5mg/100ml Brand $$$$$$ LMN
220‐400u, 401‐800u, 801‐1240u, 1241‐ RECOMBINATE Antihemophilic Factor Brand $$$$$$ LMN
1800u
REFACTOLD
Antihemophilic Factor 250u, 500u, 1000u, 2000u Brand $$$$$$ LMN
REFLUDAN Lepirudin 50mg Brand $$$$$$ LMN
REGLAN Metoclopramide HCl 5mg, 10mg Generic $$ RELAFEN Nabumetone 500mg, 750mg Generic $$$ RELENZA Zanamivir Oral 5mg Brand $$$ QL= 20 tabs/30 days
RELPAX Eletriptan Hydrobromide 20mg, 40mg Brand $$$$ Step: Sumatriptan Succinate; QL= 9 tabs/30
days
REMICADE Infliximab 100mg Brand $$$$$$ Step: Fail 2 DMARD
REMODULINLD Treprostinil Sodium 1mg/ml, 2.5mg/ml, 5mg/ml, 10mg/ml Brand $$$$$$ LMN; Specialty
RENAGEL Sevelamer 400mg, 800mg Brand $$$$$ RENVELA Sevelamer Carbonate 800mg, 0.8g, 2.4g Brand $$$$$
REPREXAIN
Hydrocodone‐Ibuprofen 2.5‐200mg, 5‐200mg, 7.5‐200mg, 10‐
200mg
Generic
$$$$
QL= 120 tabs/30 days
REPRONEX Menotropins 75u Brand $$$$$$ LMN
REQUIP
Ropinirole Hydrochloride
0.25mg, 0.5mg, 1mg, 2mg, 3mg, 4mg, 5mg
Generic
$$
REQUIP XL Ropinirole Hydrochloride SR 2mg, 4mg, 6mg, 8mg, 12mg Brand $$$$ Step: Ropinirole Hydrochloride
RESTASIS Cyclosporine 0.05% Brand $$$$ QL= 60 vials/30 days
RESTORIL Temazepam 7.5mg, 15mg, 30mg Generic $$ QL= 30 caps/30 days
RETIN‐A Tretinoin 0.25%, 0.375%, 0.05%, 0.1% Generic $$$$ Age >34
RETIN‐A MICRO Tretinoin Microsphere 0.04%, 0.1% Brand $$$$ Age >34
REVATIO Sildenafil Citrate 20mg, 10mg/12.5ml Brand $$$$$$ LMN; Specialty
REVLIMIDLD Lenalidomide 5mg, 10mg, 15mg, 25mg Brand $$$$$$ LMN
RHEUMATREX Methotrexate Sodium 2.5mg Generic $$$$ RHINOCORT AQUA Budesonide 32mcg/ACT Brand $$$$ Step: Fail one
RHOGAM PLUS Rho D Immune Globulin 300mcg Brand $$$$$$ RHOPHYLACLD
Rho D Immune Globulin 1500u/2ml Brand $$$$$$ LMN
RIBAPAK Ribavirin Oral 400mg, 600mg Generic $$$$ Specialty
RIBASPHERE Ribavirin 200mg, 400mg, 600mg Brand $$$$$$ LMN
RIBAVIRIN Ribavirin Oral 200mg, 400mg, 600mg Generic $$$$ Specialty
RIFADIN Rifampin Oral 150mg, 300mg Generic $$$ RIMSO‐50 Dimethyl Sulfoxide 50% Brand $$$$$$ LMN
RIOMET Metformin HCl 500mg/5ml Brand $$$$
RITALIN
Methylphenidate HCl 5mg, 10mg, 18mg, 20mg, 27mg, 36mg,
54mg
Generic
$$$$
CPA; Age > 23
RITALIN LA Methylphenidate HCl 10mg, 20mg, 30mg, 40mg Brand $$$$ CPA; Age > 23
RITUXAN Rituximab 100mg, 500mg Brand $$$$$$ ROCALTROL Calcitriol 0.25mcg, 0.5mcg Generic $$$$ ROCEPHIN Ceftriaxone IV Generic $$$ ROXICODONE Oxycodone HCl
5mg, 10mg, 15mg, 20mg, 30mg, 40mg,
80mg Generic $$$ QL= 120 tabs/30 days
RYTHMOL Propafenone HCl 150mg, 225mg, 325mg, 425mg Generic $$$$ SAIZEN Somatropin 5mg, 8.8mg Brand $$$$$$ CPA
SANCTURA, SANCTURA XR Trospium Chloride 20mg, 60mg Generic $$$ SANDIMMUNE Cyclosporine 50mg/ml Generic $$$$$$
SANDOSTATIN
Octreotide Acetate 10mg, 20mg, 30mg, 50mcg/ml, 100mcg,
200mcg, 500mcg, 1000mcg
Brand
$$$$$$
SAVELLA Milnacipran HCl 12.5mg, 25mg, 50mg, 100mg Brand $$$$ LMN
SEASONALE Levonorgestrel & Ethinyl Estradiol (9
Tab 0.15‐0.03 MG
1‐Day)
Generic
$$$$
SELSUN BLUE Selenium Sulfide 1%, 2.25%, 2.5% Generic $ SENSIPAR Cinacalcet HCl 30mg, 60mg, 90mg Brand $$$$$$ LMN
SEREVENT DISKUS Salmeterol Xinafoate 50mcg Brand $$$$ Step: Foradil
SEROSTIMLD
Somatropin 4mg, 5mg, 6mg, 8.8mg Brand $$$$$$ LMN
SERZONE
Nefazodone HCl
50mg, 100mg, 150mg, 200mg, 250mg
Generic
$$$
SILVADENE Silver Sulfadiazine Generic $$$ SIMPONI Golimumab 50mg Brand $$$$$$ Step: Fail 2 DMARD
SINEMET
Carbidopa & Levodopa 10‐100mg, 25‐100mg, 25‐250mg, 50‐
200mg
Generic
$$$
$ ‐‐‐‐‐‐‐‐‐ $1 to $10
$$ ‐‐‐‐‐‐‐‐‐ $11 to $50
$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100
$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500
$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000
$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000
4f-35
6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 14 of 18
GCHP List of Covered Drugs
Brand Name Brand Names Generic Name Strength(s) Coverage Rx Cost LMN, QL, Step, CPA
SINEQUAN
Doxepin HCl
10mg, 25mg, 50mg, 75mg, 100mg, 150mg
Generic
$$
SINGULAIR Montelukast Sodium 10mg Brand $$$$
SOLIA Desogestrel & Ethinyl Estradiol Tab 0.15
MG‐30 MCG
Generic
$$
SOLU‐CORTEF Hydrocortisone Sodium Succinate 100mg, 250mg, 500mg, 1000mg Brand $$$$$$ LMN
SOMAVERTLD
Pegvisomant 10mg, 15mg, 20mg Brand $$$$$$ LMN
SONATA Zaleplon 5mg, 10mg Generic $$ QL= 30 caps/30 days
SPERMACIDAL PRODUCTS Spermacidal Products Sponge, Foam, Cream, Gel OTC $$
SPIRIVA
Tiotropium Bromide Monohydrate
18mcg
Brand
$$$$ QL= 1 pkg (6 caps or 90 caps); 2 pkgs (30
caps); per 30 days
SPORANOX Itraconazole Oral 100mg Brand $$$$ LMN
SPRINTEC 28 Norgestimate & Ethinyl Estradiol Tab 0.
MG‐35 MCG
25
Generic
$$
SPRYCEL
Dasatinib
20mg, 50mg, 70mg, 80mg, 100mg, 140mg
Brand
$$$$$$
STARLIX Nateglinide 60mg, 120mg Generic $$$$ STERAPRED Prednisone 5mg, 10mg, 20mg Generic $$$$ STIMATE Desmopressin Acetate 1.5mg/ml Brand $$$$$$ LMN
STRATTERA
Atomoxetine HCl 10mg, 18mg, 25mg, 40mg, 60mg, 80mg,
100mg
Brand
$$$$
CPA; Age > 23
STROMECTOL Ivermectin Oral 3mg Brand $$$$ SULAR Nisoldipine 8.5mg, 17mg, 25.5mg, 34mg, Generic $$$$
SUMATRIPTAN
Sumatriptan Nasal Spray
5mg/ACT, 20mg/ACT
Brand
$$$
QL= 6 devices/30 days (5mg & 20mg spray)
SUMAXIN Sulfacetamide Sodium w/ Sulfur 10‐1%, 10‐4%, 10‐5% Generic $$$$ SUPARTZ Sodium Hyaluronate Intra‐articular 25mg/2.5ml Brand $$$$$$ LMN
SUPPRELINLD Histrelin Acetate 50mg Brand $$$$$$
SUTENT Sunitinib Malate 12.5mg, 25mg, 50mg Brand $$$$$$ SYMBICORT Budesonide‐Formoterol Fumarate 80‐4.5mcg/ACT, 160‐4.5mcg/ACT Brand $$$$ QL= 2 inhrs/30 days
SYMLIN/SYMLINPEN Pramlintide Acetate 600mcg, 1000mcg Brand $$$$ CPA; QL= 7 vials; 8 pens/30 days
SYMMETREL Amantadine Oral Generic $$$ SYNAGISLD
Palivizumab IM 50mg, 100mg/ml Brand $$$$$$ LMN
SYNARELM Nafarelin Acetate 2mg/ml Brand $$$$$$ LMN
SYNTHROID
Levothyroxine Sodium
25mcg, 50mcg, 75mcg, 88mcg, 100mcg,
112mcg, 125mcg, 137mcg, 150mcg,
175mcg, 200mcg, 300mcg
Brand
$$$
SYNVISC Hylan Intra‐articular 8mg/ml Brand $$$$$$ LMN
TACROLIMUS Tacrolimus 0.5mg, 1mg, 5mg Generic $$$$$$ LMN
TAMBOCOR Flecainide Acetate 50mg, 100mg, 150mg, 200mg Generic $$$$$
TAMIFLU
Oseltamir Oral
30mg, 45mg, 70mg
Brand
$$$$ QL= 10 caps (45mg, 75mg) 20 caps (30mg)
100ml/30 days (oral susp)
TAPAZOLE Methimazole 5mg, 10mg Generic $$ TARCEVA Erlotinib 25mg, 100mg, 150mg Brand $$$$$$ TARGRETIN Bexarotene 75mg, 1% Brand $$$$$$ TASIGNA Nilotinib 150mg, 200mg Brand $$$$$$ TAXOTERE Docetaxel
20mg/0.5ml, 20mg/ml, 80mg/2ml,
80mg/4ml Brand $$$$$$
TAZORAC Tazarotene 0.05%, 0.1% Brand $$$$ TEGRETOL Carbamazepine 200mg, 400mg Generic $$$
TEMODAR
Temozolomide
5mg, 20mg, 100mg, 140mg, 180mg, 250mg
Brand
$$$$$$$
TEMOVATE Clobetasol Propionate 5% Generic $$ TENEX Guanfacine HCl 1mg, 2mg Generic $$$$ TENORMIN Atenolol 25mg, 50mg, 100mg Generic $$$ TERCONAZOLE Terconazole Vaginal Generic $$ TESSALON Benzonatate 100mg, 200mg Generic $$ TESTIM Testosterone 1% Brand $ TETRACYCLINE Tetracycline Oral Generic $$ TEV‐TROPINLD
Somatropin 5mg Brand $$$$$$ CPA
THALOMID Thalidomide 50mg, 150mg, 200mg100mg, Brand $$$$$$ THEO‐DUR Theophylline 100mg, 200mg, 300mg Generic $$$ THEOPHYLLINE ANHYDROUS Theophylline Brand $$ THROMBAT III Antithrombin III 500u, 1000u Brand $$$$$$ LMN
$ ‐‐‐‐‐‐‐‐‐ $1 to $10
$$ ‐‐‐‐‐‐‐‐‐ $11 to $50
$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100
$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500
$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000
$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000
4f-36
6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 15 of 18
GCHP List of Covered Drugs
Brand Name Brand Names Generic Name Strength(s) Coverage Rx Cost LMN, QL, Step, CPA
THYMOGLOBULIN Anti‐Thymocyte Globulin 25mg Brand $$$$$$ LMN THYROGENLD
Thyrotropin Alfa 1.1mg Brand $$$$$$ LMN TICE BCG Live Intravesical 50mg Brand $$$$$$ LMN TIGAN Trimethobenzamide HCl 300mg/5ml Generic $$$ TIMOPTIC Timolol Maleate 0.25%, 0.5% Generic $$$ TIMOPTIC‐XE Timolol Maleate 0.25%, 0.5% Generic $$$ TOBI Tobramycin 300mg/5ml Brand $$$$$$ LMN
TOBRADEX
Neomycin‐Polymyxin‐Dexamethasone
Generic
$$$
TOBREX Tobramycin IV Generic $$$ QL= 14 days TOFRANIL Imipramine HCl 10mg, 25mg, 50mg Generic $$ TOPAMAX Topiramate 25mg, 50mg, 100mg, 200mg Generic $$ TOPAMAX SPRINKLE Topiramate Sprinkle 15mg, 25mg Generic $$ TOPICORT Desoximetasone 0.05%, 0.25% Generic $$ TOPOSAR Etoposide 20mg/ml Generic $$$$$ TOPROL XL Metoprolol Succinate 25mg, 50mg, 100mg, 200mg Generic $$$$ TORISEL Temsirolimus 25mg/ml Brand $$$$$$ TOVIAZ Fesoterodine Fumarate 4mg, 8mg Brand $$$$ TRACLEERLD
Bosentan 62.5mg, 125mg Brand $$$$$$ LMN; Specialty TRANXENE‐T Clorazepate Dipotassium 3.75mg, 7.5mg, 15mg Generic $$ QL= 120tabs/30days TREANDA Bendamustine HCl 25mg, 100mg Brand $$$$ TRELSTAR
LD Triptorelin Pamoate 3.75mg, 11.25mg, 22.5mg Brand $$$$$$
TRENTAL Pentoxifylline 400mg Generic $$$$
TRIBENZOR Olmesartan‐Amlodipine‐
Hydrochlorothiazide
Brand
$$$$
LMN
TRILEPTAL Oxcarbazepine Suspension 300mg/5ml Generic $$$ TRINESSA
Norgestimate‐Eth Estrad Tab 0.18‐ Generic $$ 35/0.215‐35/0.25‐35 MG‐MCG
Norethindrone‐Eth Estradiol Tab 0.5‐35/1‐ TRI‐NORINYL
35/0.5‐35 MG‐MCG Generic $$$
TRI‐PREVIFEM
Norgestimate‐Eth Estrad Tab 0.18‐
35/0.215‐35/0.25‐35 MG‐MCG Generic $$
TRISENOX Arsenic Trioxide 10mg/10ml Generic $$$$$ TRI‐SPRINTEC
Norgestimate‐Eth Estrad Tab 0.18‐
35/0.215‐35/0.25‐35 MG‐MCG Generic $$
TRIVORA‐28 Levonorgestrel‐Eth Estra Tab 0.05‐
30/0.075‐40/0.125‐30MG‐MCG Generic $$
TRUE ‐ kits, strips and supplies
Brand
$$$
QL= 100 strips/30 days
TUSSIONEX Hydrocod Polst‐Chlorphen Polst Generic $$$
TWINJECT
Epinephrine
0.15mg, 0.3mg
Brand
$$$$ CPA; QL= 3 units/pkg size 1
size 2; per 30 days
; 4 units/pkg
TWINRIX
Hepatitis A (Inact)‐Hep B (Recomb) Vac
Brand
$$$$$$
LMN
TYGACIL Tigecycline IV 50mg Brand $$$$$ LMN TYKERB
LD Lapatinib Ditosylate 250mg Brand $$$$$$
TYLENOL/COD Acetaminophen w/ Codeine 300‐15mg, 300‐30mg, 300‐60mg Generic $$$ QL= 120 tabs/30 days TYSABRILD
Natalizumab 300mg/15ml Brand $$$$$$ LMN TYZEKA Telbivudine Oral 600mg Brand $$$$$ ULORIC Febuxostat 40mg, 80mg Brand $$$$ Step: allopurinol ULTRAM Tramadol HCl 50mg, 100mg, 200mg, 300mg Generic $$$$ QL= 120 tabs/30 days UNASYN Ampicillin/Sulbactam IV Generic $$$ LMN UNIRETIC Moexipril‐Hydrochlorothiazide 7.5‐12.5mg, 15‐12.5mg, 15‐25mg Generic $$$
25mcg, 50mcg, 75mcg, 88mcg, 100mcg, UNITHROID Levothyroxine Sodium 112mcg, 125mcg, 137mcg, 150mcg, Generic $$
175mcg, 200mcg, 300mcg UROXATRAL Alfuzosin HCl 10mg Brand $$$ URSO, URSO FORTE Ursodiol 250mg, 500mg Generic $$$$ VALCYTE Valganciclovir HCl 450mg, 50mg/ml Brand $$$$$$ LMN VALIUM Diazepam 2mg, 5mg, 10mg Generic $$ QL= 120tabs/30days VALTREX Valacyclovir HCl 500mg, 1g Generic $$$$ CPA VANCOCIN Vancomycin Oral, IV Generic $$$ VANTAS
LD Histrelin Acetate 50mg Brand $$$$$$
VANTIN Cefpodoxime proxetil‐Oral Generic $$$ LMN
$ ‐‐‐‐‐‐‐‐‐ $1 to $10
$$ ‐‐‐‐‐‐‐‐‐ $11 to $50 $$$ ‐‐‐‐‐‐‐‐‐ $51 to $100 $$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500 $$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000 $$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000 4f-37 6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 16 of 18
GCHP List of Covered Drugs
Brand Name Brand Names Generic Name Strength(s) Coverage Rx Cost LMN, QL, Step, CPA
VASERETIC
Enalapril Maleate & Hydrochlorothiazide
5‐12.5mg, 10‐25mg
Generic
$$$$
VASOTEC Enalapril Maleate 2.5mg, 5mg, 10mg, 20mg Generic $$
VECTICAL Calcitriol 3mcg/gm Brand $$$$$ Step: calcipotriene
VELCADE Bortezomib 3.5mg Generic $$$$$$
VELIVET Desogest‐Ethin Est Tab 0.1‐0.025/0.125‐
0.025/0.15‐0.025MG‐MG
Generic $$
VENTAVISLD Iloprost 10mcg/ml, 20mcg/ml Brand $$$$$$ LMN; Specialty
VENTOLIN Albuterol 90mcg Generic $$$$ QL= 3 inhrs/30 days
Step: Fail one: flunisolide, fluticasone, VERAMYST Fluticasone Furoate 27.5mcg Brand $$$$
VERIPRED 20 Prednisolone Sod Phosphate 20mg/5ml Brand $$$$
VESICARE Solifenacin Succinate 5mg, 10mg Brand $$$
OMNARIS
VFEND Voriconazole 50mg, 200mg, 40mg/ml Brand $$$$$$ LMN
VIBATIV Televancin IV 250mg, 750mg Brand $$$ LMN
2.5‐500mg, 5‐325mg, 5‐500mg, 7.5‐325mg,
VICODIN Hydrocodone‐Acetaminophen 7.5‐650mg, 7.5‐650mg, 7.5‐750mg, 10‐
300mg, 10‐325mg, 10‐500mg, 10‐650mg,
10‐660mg
Generic $$$ QL= 120 tabs/30 days
VICTOZA Liraglutide 18mg/3ml Brand $$$$ CPA; QL= 3 syringes/30 days
VIDAZALD Azacitidine 100mg Brand $$$$$$
VIMPAT Lacosamide 50mg, 100mg, 150mg, 200mg, 10mg/ml Brand $$$$
VINBLASTINE Vinblastine Sulfate 1mg/ml Generic $$$$
VINCRISTINE Vincristine Sulfate 1mg/ml Generic $$$$
VINORELBINE Vinorelbine Tartrate 10mg/ml, 50mg/5ml Brand $$$$$$
VIREAD Tenofovir Disoproxil Fumarate 300mg Brand $$$$$$ CPA
VISTARIL Hydroxyzine Pamoate 25mg, 50mg, 100mg Generic $$
VISUDYNELD Verteporfin 15mg Brand $$$$$$ LMN
VITAMIN K Phytonadione 100mcg OTC $$ QL= 60 tabs/30 days
VITAMIN K1 Phytonadione 1mg/0.5ml, 2mg/ml Generic $$$$$$ LMN
VIVAGLOBINLD Immune Globulin 160mg/ml Brand $$$$$$ LMN
VIVELLE‐DOT Estradiol 0.0375, 0.025mg, 0.05mg, 0.075mg, 0.1mg Brand $$$$ QL= 10 patches/30 days
VOLTAREN Diclofenac Sodium 50mg, 75mg, 100mg Generic $$$
VOLTAREN Diclofenac Sodium 0.1% Generic $$
VOTRIENTLD Pazopanib HCl 200mg Brand $$$$$$
VYVANSE Lisdexamfetamine Dimesylate 20mg, 30mg, 40mg, 50mg, 60mg, 70mg Brand $$$$$ CPA; Age > 23
WELCHOL Colesevelam HCl 625mg, 3.75g Brand $$$$
WELLBUTRIN, WELLBUTRIN XL Bupropion HCl, Bupropion HCl SR 75mg, 100mg, 150mg, 200mg, 300mg Generic $$$
WINRHO SDF Rho D Immune Globulin 600u, 1500u, 2500u, 5000u, 15000u Brand $$$$$$ LMN
XALATAN Latanoprost 0.005% Generic $$$
XANAX Alprazolam 0.25mg, 0.5mg, 1mg, 2mg Generic $$ QL= 120tabs/30days
XELODA Capecitabine 150mg, 500mg Brand $$$$$$
XENAZINELD Tetrabenazine 12.5mg, 25mg Brand $$$$$$ LMN
XIAFLEXLD Collagenase Clostridium Histolyticum 0.9mg Brand $$$$$$ LMN
XOLAIRLD Omalizumab 150mg Brand $$$$$$ LMN
XOPENEX Levalbuterol HCl 0.31mg, 0.63mg, 1.25mg/3ml Brand $$$$ Step: albuterol
XOPENEX HFA Levalbuterol Tartrate Brand $$$$ Step: albuterol; QL= 3 inhrs/30 days
XYLOCAINE Lidocaine HCl 2% gel, 5% onit Generic $$
XYLOCAINE Lidocaine HCl Viscous 2% Generic $$
XYNTHA Antihemophilic Factor Recombinant PAF 250u, 500u, 1000u, 2000u, 3000u Brand $$$$ LMN
YASMIN
YAZ
Drospirenone‐Ethinyl Estradiol Tab 3‐0.03
MG Drospirenone‐Ethinyl Estradiol Tab
3‐0.02
MG
Generic $$$
Generic $$$$
YODOXIN Iodoquinol Oral 210mg, 650mg Brand $$$$
ZANTAC Ranitidine HCl 300mg Generic $$$
$ ‐‐‐‐‐‐‐‐‐ $1 to $10
$$ ‐‐‐‐‐‐‐‐‐ $11 to $50
$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100
$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500
$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000
$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000
4f-38
6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 17 of 18
GCHP List of Covered Drugs
Brand Name Brand Names Generic Name Strength(s) Coverage Rx Cost LMN, QL, Step, CPA
ZANTAC Ranitidine HCl 75mg, 150mg OTC $$ QL= 90 tabs/30 days
ZAROXOLYN Metolazone 2.5mg, 5mg, 10mg Generic $$$$ ZEBETA Bisoprolol Fumarate 5mg, 10mg Generic $$$$ ZEGERID Omeprazole‐Sodium Bicarbonate 20‐1100 OTC $$ QL= 42 tabs/30 days
ZEMPLAR
Paricalcitol
1mcg, 2mcg, 4mcg, 2mcg/ml, 5mcg/ml
Brand
$$$$$$
LMN
ZESTORETIC Lisinopril & Hydrochlorothiazide 10‐12.5mg, 20‐12.5mg, 20‐25mg Generic $$$ ZESTRIL lisinopril 2.5mg, 5mg, 10mg, 20mg, 30mg Generic $$ ZETIA Ezetimibe 10mg Brand $$$$ Step: simvastatin 40mg
ZINECARD Dexrazoxane 250mg, 500mg Brand $$$$$$ LMN
CPA (600mg); QL= 8 tabs/10 days, Max 2
ZITHROMAX Azithromycin Oral Generic $$ fills/30 days (250mg); 4 tabs/10 days,Max
2 fills/30 days (500mg)
ZOCOR Simvastatin 5mg, 10mg, 20mg, 40mg, 80mg Generic $$$ ZOFRAN Ondansetron HCl 4mg, 8mg, 24mg Generic $$$
QL= 30 tabs (4mg & 8mg); 1 tab (24mg);
per 30 days
ZOFRAN Ondansetron HCl and Dextrose 32mg/50ml Brand $$$ CPA; QL= 3 bottles (sol); per 30 days
ZOLADEX Goserelin Acetate 3.6mg, 10.8mg Brand $$$$$$ ZOLOFT Sertraline HCl 25mg, 50mg, 100mg Generic $$ ZOMETA Zoledronic Acid 4mg/5ml Brand $$$$$$ LMN; Specialty
ZOMIG NASAL SPRAY
Zolmitriptan Nasal Spray
5mg
Brand
$$$$ Step: Sumatriptan Succinate; QL= 9
devices/30 days
ZOMIG, ZOMIG ZMT Zolmitriptan 2.5mg, 5mg Brand $$$$ Step: Sumatriptan Succinate; QL= 9 tabs/30
days
ZONEGRAN Zonisamide 25MG,50mg, 100mg Generic $$ ZORBTIVE Somatropin 8.8mg Brand $$$$$$ CPA
ZOSYN Pipercillin/Tazobactam IV Generic $$$$ LMN
Ethynodiol Diacetate & Ethinyl Estradiol ZOVIA
Generic $$
Tab 1 MG‐35 MCG, 1 MG‐50 MCG
ZOVIRAX Acyclovir Oral, IV Generic $$$$ LMN; IV only
ZYLOPRIM Allopurinol 100mg, 300mg Generic $$$ ZYMAR Gatifloxacin 0.3% Brand $$$ ZYRTEC Cetirizine HCl 5mg, 10mg OTC $$ QL= 30 tabs/30 days
ZYRTEC‐D Cetirizine ‐Pseudoephedrine 5mg/120mg OTC $$ QL= 30 tabs/30 days
ZYRTEC‐D Cetirizine‐Pseudoephedrine 5mg/120mg Generic $$$ ZYVOX Linezolid Oral, IV Brand $$$$$$ LMN; Specialty
$ ‐‐‐‐‐‐‐‐‐ $1 to $10
$$ ‐‐‐‐‐‐‐‐‐ $11 to $50
$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100
$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500
$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000
$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000
4f-39
6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 18 of 18
GCHP List of Covered Drugs
Generic Name
Brand Names Generic Name Strength(s) Coverage Rx Cost LMN, QL, Step, CPA
ORENCIA Abatacept 250mg Brand $$$$$$ CPA
PRECOSE Acarbose 25mg, 50mg, 100mg Generic $$$
TYLENOL/COD Acetaminophen w/ Codeine 300‐15mg, 300‐30mg, 300‐60mg Generic $$$ QL= 120 tabs/30 days
ZOVIRAX Acyclovir Oral, IV Generic $$$$ LMN; IV only
HUMIRA Adalimumab 20mg/0.4ml, 40mg/0.8ml, Brand $$$$$$ Step: Fail 2 DMARD
DIFFERIN Adapalene 0.1%, 0.3% Generic $$$$ CPA
HEPSERA Adefovir Dipivoxil 10mg Brand $$$$$$ LMN
FABRAZYMELD Agalsidase beta 5mg, 35mg Brand $$$$$$ LMN
ALBENZA Albendazole Oral 200mg Brand $$$$
VENTOLIN Albuterol 90mcg Generic $$$$ QL= 3 inhrs/30 days
PROAIR HFA Albuterol Sulfate Brand $$$$ QL= 3 inhrs/30 days
PROVENTIL Albuterol Sulfate 2mg, 4mg Generic $$
AMEVIVE Alefacept 15mg Brand $$$$$$ LMN
CAMPATH Alemtuzumab 30mg/ml Brand $$$$$$ LMN
FOSAMAX Alendronate Sodium 5mg, 10mg, 35mg, 70mg Generic $$$
UROXATRAL Alfuzosin HCl 10mg Brand $$$
CEREDASE Alglucerase 80u/ml Brand $$$$$$ LMN
MYOZYMELD Alglucosidase Alfa 50mg Brand $$$$$$ LMN
ZYLOPRIM Allopurinol 100mg, 300mg Generic $$$
AXERT Almotriptan Malate 6.25mg, 12.5mg Brand $$$
Step: Sumatriptan Succinate; QL= 9 tabs/30
days (6.25mg); 9 tabs/30 days (12.5 mg)
XANAX Alprazolam 0.25mg, 0.5mg, 1mg, 2mg Generic $$ QL= 120tabs/30days
SYMMETREL Amantadine Oral Generic $$$
LETAIRISLD Ambrisentan 5mg, 10mg Brand $$$$$$ LMN; Specialty
ETHYOLM Amifostine Crystalline 500mg Brand $$$$$$ LMN
AMIKIN Amikacin IV Generic $$$$ QL= 14 days
MIDAMOR Amiloride HCl 5mg Generic $$$$ Step: spironolactone
AMINOCAPROIC ACID Aminocaproic Acid 250mg/ml, 500mg Generic $$$$$$ LMN
PACERONE Amiodarone HCl 200mg Generic $$$
ELAVIL Amitriptyline HCl 10mg, 25mg, 50mg, 75mg, 100mg, 150mg Generic $$
NORVASC Amlodipine Besylate 2.5mg, 5mg, 10mg Generic $$$
LOTREL Amlodipine Besylate‐Benazepril HCl 2.5‐10mg, 5‐10mg, 5‐20mg, 10‐20mg Generic $$$
AZOR
Amlodipine Besylate‐Olmesartan
Medoxomil
5‐20mg, 5‐40mg, 10‐20mg, 10‐40mg Brand $$$$ Step: amlodipine
AUGMENTIN Amoxacillin/Clavulanate‐Tabs, Susp Generic $$$
AMOXIL Amoxacillin‐Oral Generic $$
PREVPAC Amoxicillin‐Clarithro‐Lansopraz Brand $$$$
ADDERALL Amphetamine‐Dextroamphetamine 5mg, 7.5mg, 10mg, 15mg, 20mg, 30mg Generic $$$ CPA; Age > 23
ADDERALL XR Amphetamine‐Dextroamphetamine SR 5mg, 10mg, 15mg, 20mg, 30mg Brand $$$$$ CPA; Age > 23
ABELCET Amphotericin B Lipid 5mg/ml Brand $$$$$$ LMN
AMBISOME Amphotericin B Liposome 510mg Brand $$$$ LMN; Specialty
AMPICILLIN Ampicillin IV 125mg, 250mg, 500mg, 1g, 2g, 10g Generic $$$ LMN
UNASYN Ampicillin/Sulbactam IV Generic $$$ LMN
CREON Amy‐Lip‐Prot 5, 10, 20, 6000u, 12000u, 24000u Brand $$$$
KINERET Anakinra Brand $$$$$$ LMN
ARIMIDEX Anastrozole 1mg Generic $$$$ HELIXATE
FS Antihemophilic Factor 250u, 500u, 1000u, 2000u, 3000u Brand $$$$$$ LMN
HEMOFIL M Antihemophilic Factor 220‐400u, 401‐800u, 801‐1700u, 1701u+ Brand $$$$$$ LMN
KOATE‐DVI Antihemophilic Factor 250u, 500u, 1000u Brand $$$$$$
KOGENATE FS Antihemophilic Factor
250u, 500u, 1000u, 2000u, 3000u, 250/BS,
500/BS, 1000/BS, 2000/BS, 3000/BS
Brand $$$$$$ LMN
MONARC‐M Antihemophilic Factor 220‐400u, 401‐800u, 801‐1700u, 1701u+ Brand $$$$$$ LMN
MONOCLATE‐P Antihemophilic Factor 250u, 500u, 1000u, 1500u Brand $$$$$$ LMN
220‐400u, 401‐800u, 801‐1240u, 1241‐ RECOMBINATE Antihemophilic Factor
1800u Brand $$$$$$ LMN
REFACTOLD Antihemophilic Factor 250u, 500u, 1000u, 2000u Brand $$$$$$ LMN
$ ‐‐‐‐‐‐‐‐‐ $1 to $10
$$ ‐‐‐‐‐‐‐‐‐ $11 to $50
$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100
$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500
$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000
$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000
4f-40
6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 1 of 18
GCHP List of Covered Drugs
Generic Name Brand Names Generic Name Strength(s) Coverage Rx Cost LMN, QL, Step, CPA
ADVATE
Antihemophilic Factor rAHF‐PFM
250u, 500u, 1000u, 1500u, 2000u, 3000u
Brand
$$$$$$
LMN
XYNTHA
Antihemophilic Factor Recombinant PAF
250u, 500u, 1000u, 2000u, 3000u
Brand
$$$$
LMN
ALPHANATE Antihemophilic Factor/VWF 250‐500u, 1000‐1500u, 1500u Brand $$$$$$$ LMN HUMATE‐P Antihemophilic Factor/VWF 500u, 600u, 1000u, 1200u, 2000u, 2400u Brand $$$$$$ FEIBA VH Antiinhibitor Coagulant Complex Brand $$$$$$ LMN THROMBAT III Antithrombin III 500u, 1000u Brand $$$$$$ LMN THYMOGLOBULIN Anti‐Thymocyte Globulin 25mg Brand $$$$$$ LMN APOKYNLD
Apomorphine Hydrochloride 50mg, 100mg, 20mg/ml Brand $$$$$$ LMN EMEND Aprepitant 80mg, 115mg, 125mg, 150mg Brand $$$$ LMN: Specialty BROVANA Arformoterol Tartrate 15mcg Brand $$$$ Step: Foradil NUVIGIL Armodafinil 50mg, 150mg, 250mg Brand $$$$$ CPA; Age > 23 TRISENOX Arsenic Trioxide 10mg/10ml Generic $$$$$ ELSPAR Asparaginase 10000u Brand $$$$$$ ASA Aspirin 81mg, 325mg OTC $ QL= 120 tabs/30 days AGGRENOX Aspirin‐Dipyridamole 25‐200mg Brand $$$ TENORMIN Atenolol 25mg, 50mg, 100mg Generic $$$
STRATTERA
Atomoxetine HCl 10mg, 18mg, 25mg, 40mg, 60mg, 80mg,
100mg
Brand
$$$$
CPA; Age > 23
LIPITOR Atorvastatin Calcium 10mg, 20mg, 40mg, 80mg Brand $$$$ Step: simvastatin 80mg VIDAZALD
Azacitidine 100mg Brand $$$$$$ IMURAN Azathioprine 50mg Generic $$$$$ FINACEA, FINACEA PLUS KIT Azelaic Acid 15%, Kit Brand $$$$ ASTELIN Azelastine HCl 0.1% Generic $$$$ QL= 2 bottles/30 days ASTEPRO Azelastine HCl 137mcg, 0.15% Brand $$$$ QL= 2 bottles/30 days OPTIVAR Azelastine HCl 0.05% Generic $$$$ AZASITE Azithromycin 1% Brand $$
ZITHROMAX
Azithromycin Oral
Generic
$$
CPA (600mg); QL= 8 tabs/1
fills/30 days (250mg); 4 tab
2 fills/30 days (500mg)
0 days, Max 2
s/10 days,Max
AZACTAM
Aztreonam IV
Generic
$$$$$
LMN LIORESAL Baclofen 10mg, 20mg Generic $$$$ COLAZAL Balsalazide Disodium 750mg Generic $$$$ TICE BCG Live Intravesical 50mg Brand $$$$$$ LMN
BECONASE AQ
Beclomethasone Dipropionate Monohyd
0.042%
Brand
$$$$ Step: Fail one: flunisolide, fl
OMNARIS
uticasone,
LOTENSIN HCT
Benazepril & Hydrochlorothiazide
5‐6.5mg, 10‐12.5mg, 20‐12.5mg, 20‐25mg
Generic
$$$
LOTENSIN Benazepril HCl 5mg, 10mg, 20mg, 40mg Generic $$$ TREANDA Bendamustine HCl 25mg, 100mg Brand $$$$ BICILLIN L‐A Benzathine IM Generic $$$$ LMN AURALGAN Benzocaine‐Antipyrine Generic $$$ TESSALON Benzonatate 100mg, 200mg Generic $$ BENZOYL Benzoyl Peroxide 5% OTC $$ QL= 85g/ 30days BENZAMYCIN Benzoyl Peroxide‐Erythromycin 5‐3% Generic $$$$ COGENTIN Benztropine Mesylate 0.5mg, 1mg, 2mg Generic $$ DIPROSONE Betamethasone Dipropionate 5% Generic $$$ DIPROLENE Betamethasone Dipropionate Augmented 5% Generic $$$ AVASTIN Bevacizumab Brand $$$$$$ TARGRETIN Bexarotene 75mg, 1% Brand $$$$$$ CASODEX Bicalutamide 50mg Generic $$$$ LUMIGAN Bimatoprost 0.01%, 0.03% Generic $$$ ZEBETA Bisoprolol Fumarate 5mg, 10mg Generic $$$$ BLEOMYCIN Bleomycin Sulfate 15u, 30u Generic $$$$$$ VELCADE Bortezomib 3.5mg Generic $$$$$$ TRACLEER
LD Bosentan 62.5mg, 125mg Brand $$$$$$ LMN; Specialty
ALPHAGAN P Brimonidine Tartrate 0.1%, 0.15% Generic $$$ BROMDAY Bromfenac Sodium 0.09% Generic $$$$
PULMICORT
Budesonide
0.25mg/2ml, 0.5mg/2ml, 1mg/ml
Brand
$$$$
QL= 70 amps (0.25mg/2ml o
35 amps (1mg/2ml); 2 inhrs
r 0.5mg/2ml);
; per 30 days
$ ‐‐‐‐‐‐‐‐‐ $1 to $10
$$ ‐‐‐‐‐‐‐‐‐ $11 to $50 $$$ ‐‐‐‐‐‐‐‐‐ $51 to $100 $$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500 $$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000 $$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000 4f-41 6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 2 of 18
GCHP List of Covered Drugs
Generic Name Brand Names Generic Name Strength(s) Coverage Rx Cost LMN, QL, Step, CPA
PULMICORT FLEXHALER Budesonide 90mcg, 180mcg Brand $$$$ QL= 2 inhs (90 mcg); 3 inhs (180 mcg); per
30 days
RHINOCORT AQUA Budesonide 32mcg/ACT Brand $$$$ Step: Fail one
SYMBICORT Budesonide‐Formoterol Fumarate 80‐4.5mcg/ACT, 160‐4.5mcg/ACT Brand $$$$ QL= 2 inhrs/30 days
BUMEX Bumetanide 0.5mg, 1mg, 2mg, Generic $$$
APLENZIN Bupropion HBr 174mg, 348mg, 522mg Brand $$
WELLBUTRIN, WELLBUTRIN XL Bupropion HCl, Bupropion HCl SR 75mg, 100mg, 150mg, 200mg, 300mg Generic $$$
BUSPAR Buspirone HCl 5mg, 7.5mg, 10mg, 15mg, 30mg Generic $$$ QL= 120tabs/30days
BUTALBITAL Butalbital Generic $$
FIORICET Butalbital‐Acetaminophen‐Caffeine 50‐325‐40mg Generic $$
CINRYZELD C1 Inhibitor 500u Brand $$$$$$ LMN
JEVTANA Cabazitaxel 60mg/1.5ml Generic $$$$$$$
CABERGOLINE Cabergoline 0.5mg Generic $$$$$$ LMN
DOVONEX Calcipotriene 0.005% Generic $$$$$
MIACALCIN Calcitonin 200u/ACT Generic $$$$
MIACALCIN Injection Calcitonin 200u/ml Generic $$$$ LMN
ROCALTROL Calcitriol 0.25mcg, 0.5mcg Generic $$$$
VECTICAL Calcitriol 3mcg/gm Brand $$$$$ Step: calcipotriene
XELODA Capecitabine 150mg, 500mg Brand $$$$$$
CAPOTEN Captopril 12.5mg, 25mg, 50mg, 100mg Generic $$$
CAPOZIDE Captopril & Hydrochlorothiazide 25‐15mg, 25‐25mg, 50‐15mg, 50‐25mg Generic $$$
CARBATROL
TEGRETOL
LODOSYN
Carbamazepine 100mg, 200mg, 300mg Brand $$$$
Carbamazepine 200mg, 400mg Generic $$$
Carbidopa 25mg Brand $$$
10‐100mg, 25‐100mg, 25‐250mg, 50‐ SINEMET Carbidopa & Levodopa
200mg Generic $$$
CARBOPLATIN
Carboplatin
50mg/5ml, 150mg/15ml, 450mg/45ml,
600mg/60ml, 50mg, 150mg, 450mg
Generic $$$$$$
BICNU
COREG
CANCIDAS
MAXIPIME
ANCEF
CLAFORAN
CEFOTAN
MEFOXIN
VANTIN
FORTAZ
ROCEPHIN
CEFTIN
CELEBREX
KEFLIN
CIMZIA
ZYRTEC
ZYRTEC‐D
ZYRTEC‐D
CETROTIDE
ERBITUX
EVOXAC
LEUKERAN
LIBRIUM
PERIDEX
ARALEN
HYGROTON
QUESTRAN
NOVAREL
PREGNYLM
Carmustine 100mg Brand $$$$$$ Carvedilol
3.125mg, 6.25mg, 12.5mg, 25mg Generic $$$$ Caspofungin
Acetate 50mg, 70mg Brand $$ LMN; Specialty
Cefapime IV Generic $$ LMN
Cefazolin Generic $$$ Cefotaxime IV
Generic $$$ LMN
Cefotetan‐IV Generic $$$ LMN
Cefoxitin‐IV Generic $$ LMN
Cefpodoxime proxetil‐Oral Generic $$$ LMN
Ceftazidime IV Generic $$$ LMN; Specialty
Ceftriaxone IV Generic $$$
Cefuroxime IV, Oral Generic $$$ LMN
Celecoxib 50mg, 100mg, 200mg, 400mg Brand $$$$ Step: Fail Any 2 NSAIDs
Cephalothin‐Oral Generic $$$
Certolizumab Pegol 200mg/ml Brand $$$$$$ Step: Fail 2 DMARD
Cetirizine HCl 5mg, 10mg OTC $$ QL= 30 tabs/30 days
Cetirizine ‐Pseudoephedrine 5mg/120mg OTC $$ QL= 30 tabs/30 days
Cetirizine‐Pseudoephedrine 5mg/120mg Generic $$$
Cetrorelix Acetate 0.25mg, 3mg Brand $$$$$$ LMN
Cetuximab 100mg, 200mg Brand $$$$$$
Cevimeline HCl 30mg Brand $$$$$$ LMN
Chlorambucil 2mg Brand $$$$$$
Chlordiazepoxide HCl 5mg, 10mg, 25mg Generic $$ QL= 120tabs/30days
Chlorhexidine Gluconate 0.12% Generic $$$ Chloroquin Phosphate
Oral 250mg Generic $$$
Chlorthalidone 25mg, 50mg, 100mg Generic $$$$
Cholestyramine 4g Generic $$$ Chorionic
Gonadotropin 10000u Generic $$$$$$ LMN
Chorionic Gonadotropin 10000u Generic $$$$$$ LMN
OMNARIS Ciclesonide 50mcg/ACT Brand $$$$ Step: Fail one: flunisolide, fluticasone
PLETAL
SENSIPAR
CILOXAN
Cilostazol 50mg, 100mg Generic $$$ Cinacalcet
HCl 30mg, 60mg, 90mg Brand $$$$$$ LMN
Ciprofloxacin HCl 3% Generic $$$
$ ‐‐‐‐‐‐‐‐‐ $1 to $10
$$ ‐‐‐‐‐‐‐‐‐ $11 to $50
$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100
$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500
$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000
$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000
4f-42
6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 3 of 18
GCHP List of Covered Drugs
Generic Name Brand Names Generic Name Strength(s) Coverage Rx Cost LMN, QL, Step, CPA
CIPRO Ciprofloxacin Oral Generic $$$
CIPRODEX Ciprofloxacin‐Dexamethasone 0.3‐0.1% Brand $$$$
CISPLATIN Cisplatin 50mg/50ml, 100mg/100ml, 200mg/200ml Generic $$$
CELEXA Citalopram Hydrobromide 10mg, 20mg, 40mg Generic $$
CLADRIBINE Cladribine 1mg/ml Generic $$$$$$
LEUSTATIN Cladribine 1mg/ml Brand $$$$$$ LMN
QL= 28 tabs/14 days, Max 2 fills/30 days
BIAXIN Clarithromycin Oral Generic $$$ (250mg & 500mg); 280ml/14 days, Max 2
fills of 280ml/30 days (125mg/5ml &
250mg/5ml)
CLEOCIN Clindamycin Oral, IV Generic $$$ LMN
CLEOCIN‐T Clindamycin Phosphate 1%, 2% Generic $$$$
BENZACLIN Clindamycin Phosphate‐Benzoyl Peroxide 1‐5% Generic $$$$
TEMOVATE Clobetasol Propionate 5% Generic $$
ANAFRANIL Clomipramine HCl 25mg, 50mg, 75mg Generic $
KLONOPIN Clonazepam 0.125mg, 0.25mg, 0.5mg, 1mg, 2mg Generic $$
CATAPRES Clonidine HCl 0.1mg, 0.2mg, 0.3mg Generic $$$
PLAVIX Clopidogrel Bisulfate 75mg, 300mg Brand $$$$ CPA
TRANXENE‐T Clorazepate Dipotassium 3.75mg, 7.5mg, 15mg Generic $$ QL= 120tabs/30days
CLOTRIMAZOLE Clotrimazole Vaginal, Topical, Troches Generic $ to $$$$
ALPHANINE Coagulation Factor IX 500u, 1000u, 1500u Brand $$$$$$$ LMN
BENEFIX Coagulation Factor IX 250u, 500u, 1000u, 2000u Brand $$$$$$$ LMN
MONONINE Coagulation Factor IX 250u, 500u, 1000u Brand $$$$$$$ LMN
1200mcg, 2400mcg, 4800mcg, 1mg, 2mg, NOVOSEVEN Coagulation Factor VIIa
5mg, 8mg Brand $$$$$$$ LMN
COLCRYS Colchicine 0.6mg Brand $$$$ Step: NSAIDS
PROBEN/COLCH Colchicine w/ Probenecid 500‐0.5 Generic $$$
WELCHOL Colesevelam HCl 625mg, 3.75g Brand $$$$
COLESTID Colestipol HCl 1g, 5g Generic $$$$
COLY‐MYCIN M Colistimethate Sodium 150mg Brand $$$$$$ LMN
XIAFLEXLD Collagenase Clostridium Histolyticum 0.9mg Brand $$$$$$ LMN
CONDOMS Condoms OTC $$ QL= 12/30 days
PREMPHASE Conj Est/Conj Est‐Medroxypro Ac Brand $$$
PREMPRO Conjugated Estrogen‐Medroxyprogest
Acetate
0.3‐1.5mg, 0.45‐1.5mg, 0.625‐2.5mg, 0.625‐
5mg
Brand $$$
ACTHREL Corticorelin Ovine Triflutate 100mcg Brand $$$$$$ LMN
ACTHARLD Corticotropin 80u Brand $$$$$$ LMN
CORTROSYN Cosyntropin 0.25mg Generic $$$$
CROLOM Cromolyn Sodium 4% Generic $$
EURAX Crotamiton 10% Brand $$$$
FLEXERIL Cyclobenzaprine HCl 5mg, 10mg Generic $$$ QL= 90 tabs/30 days
CYCLOPHOSPHAMIDE Cyclophosphamide 25mg, 50mg, 500mg, 1g, 2g Brand $$$$$$
CYTOXAN Cyclophosphamide 2g Brand $$$$$$ LMN
NEORAL Cyclosporine 25mg, 100mg Generic $$$$$$
RESTASIS Cyclosporine 0.05% Brand $$$$ QL= 60 vials/30 days
SANDIMMUNE Cyclosporine 50mg/ml Generic $$$$$$
PERIACTIN Cyproheptadine HCl 4mg Generic $$
CYTOGAM Cytomegalovirus Immune Globulin Brand $$$$$$ LMN
DACARBAZINE Dacarbazine 100mg, 200mg Generic $$$$$$
AMPYRALD Dalfampridine 10mg Brand $$$$$$ LMN
FRAGMIN Dalteparin Sodium
2500u/0.2ml, 5000u/0.2ml, 7500u/0.3ml,
10000u/ml, 25000u/ml, 9500u, 12500u,
15000u, 18000u
Brand $$$$$$ CPA; QL=2 inj/30 days; Available at Retail
DAPSONE Dapsone Oral 25mg, 100mg Generic $$
CUBICIN Daptomycin IV 500mg Brand $$$$ LMN
25mcg, 40mcg, 60mcg, 100mcg, 150mcg, ARANESP Darbepoetin Alfa‐Polysorbate
200mcg, 300mcg, 500mcg Brand $$$$$$ CPA; QL= 2 inj/30 days; Available at Retail
ENABLEX Darifenacin Hydrobromide 7.5mg, 15mg Brand $$$
SPRYCEL Dasatinib 20mg, 50mg, 70mg, 80mg, 100mg, 140mg Brand $$$$$$
$ ‐‐‐‐‐‐‐‐‐ $1 to $10
$$ ‐‐‐‐‐‐‐‐‐ $11 to $50
$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100
$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500
$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000
$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000
4f-43
6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 4 of 18
GCHP List of Covered Drugs
Generic Name Brand Names Generic Name Strength(s) Coverage Rx Cost LMN, QL, Step, CPA
DAUNORUBINCIN Daunorubicin HCl 20mg, 5mg/ml Generic $$$$$$ EXJADE
LD Deferasirox 125mg, 250mg, 500mg Brand $$$$$$
DEFEROXAMINE Deferoxamine Mesylate 500mg, 2g Generic $$$$$$
DESFERAL Deferoxamine Mesylate 500mg, 2g Brand $$$$$$ LMN
ONTAK Denileukin Diftitox 150mcg/ml Brand $$$$$$ PROLIA Denosumab 60mg/ml Brand $$$$$$ Step: Failure on Bisphosphonate
NORPRAMIN
Desipramine HCl
10mg, 25mg, 50mg, 75mg, 100mg, 150mg
Generic
$$
DDAVP
Desmopressin Acetate
0.1mg, 0.2mg, 4mcg/ml, 15mcg/ml, 0.1%
Brand
$$$$$$
LMN
DESMOPRESSIN Desmopressin Acetate 0.1mg, 0.2mg, 4mcg/ml, 0.1% Generic $$$$$ LMN
STIMATE Desmopressin Acetate 1.5mg/ml Brand $$$$$$ LMN
KARIVA Desogest‐Eth Estrad & Eth Estrad T
0.02/0.01 MG(21/5)
ab 0.15‐
Generic
$$$
MIRCETTE Desogest‐Eth Estrad & Eth Estrad Tab 0.15‐
0.02/0.01 MG(21/5)
Generic $$$
CESIA
Desogest‐Ethin Est Tab 0.1‐0.025/0.125‐
0.025/0.15‐0.025MG‐MG
Generic $$
CYCLESSA Desogest‐Ethin Est Tab 0.1‐0.025/0.125‐
0.025/0.15‐0.025MG‐MG
Generic $$
VELIVET Desogest‐Ethin Est Tab 0.1‐0.025/0.125‐
0.025/0.15‐0.025MG‐MG
Generic $$
APRI
DESOGEN‐28
ORTHO‐CEPT
SOLIA
Desogestrel & Ethinyl Estradiol Tab 0.15
MG‐30 MCG Desogestrel & Ethinyl
Estradiol Tab 0.15
MG‐30 MCG
Desogestrel & Ethinyl Estradiol Tab 0.15
MG‐30 MCG Desogestrel & Ethinyl
Estradiol Tab 0.15
MG‐30 MCG
Generic $$$
Generic $$$
Generic $$
Generic $$
DESOWEN Desonide 5% Generic $$$$
TOPICORT Desoximetasone 0.05%, 0.25% Generic $$
PRISTIQ Desvenlafaxine Succinate 50mg, 100mg Brand $$$ Step: venlafaxine ER HCL
DECADRON Dexamethasone 0.5mg, 0.75mg, 1.5mg, 4mg, 6mg Generic $$$
DEXILANT (formerly KAPIDEX) Dexlansoprazole 30mg, 60mg Brand $$$$
2.5mg, 5mg, 10mg, 15mg, 20mg, 30mg,
Step: Failure of two: omeprazole,
pantoprazole, lansoprazole; QL= 34
caps/packets/30 days
FOCALIN, FOCALIN XR Dexmethylphenidate HCl 40mg
Brand $$$$ CPA; Age > 23
ZINECARD Dexrazoxane 250mg, 500mg Brand $$$$$$ LMN
DELSYM Dextromethorphan Polistirex 30mg/5ml OTC $$ QL= 148 ml/30 days
PROLEX DM Dextromethorphan‐Pot Guaiacolsulfon Generic $$
VALIUM Diazepam 2mg, 5mg, 10mg Generic $$ QL= 120tabs/30days
VOLTAREN Diclofenac Sodium 50mg, 75mg, 100mg Generic $$$
VOLTAREN Diclofenac Sodium 0.1% Generic $$
DYCILL Dicloxacillin‐Oral Generic $$
BENTYL Dicyclomine HCl 10mg, 20mg Generic $$$
FLORONE Diflorasone Diacetate 0.05% Generic $$$
LANOXIN Digoxin 0.125mg, 0.25mg Generic $$$
30mg, 60mg, 90mg, 180mg, 240mg,
CARDIZEM Diltiazem HCl 120mg/24, 180mg/24, 240mg/24,
300mg/24, 360mg/24
Generic $$$$
RIMSO‐50 Dimethyl Sulfoxide 50% Brand $$$$$$ LMN
BENADRYL Diphenhydramine HCl 25mg, 50mg OTC $ QL= 100 caps/30 days
LOMOTIL Diphenoxylate w/ Atropine 2.5mg Generic $$
DEPAKOTE, DEPAKOTE ER Divalproex Sodium 125mg, 250mg, 500mg Generic $$$
DEPAKOTE SPR Divalproex Sodium Sprinkle 125mg, 250mg, 500mg Generic $$$
20mg/0.5ml, 20mg/ml, 80mg/2ml, TAXOTERE Docetaxel
80mg/4ml Brand $$$$$$
COLACE Docusate Sodium 100mg OTC $ QL= 60 caps/30 days
ARICEPT, ARICEPT ODT Donepezil Hydrochloride 5mg, 10mg, 23mg Generic $$$$
$ ‐‐‐‐‐‐‐‐‐ $1 to $10
$$ ‐‐‐‐‐‐‐‐‐ $11 to $50
$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100
$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500
$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000
$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000
4f-44
6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 5 of 18
GCHP List of Covered Drugs
Generic Name Brand Names Generic Name Strength(s) Coverage Rx Cost LMN, QL, Step, CPA
PULMOZYME Dornase Alfa 1mg/ml Brand $$$$$$ LMN
CARDURA Doxazosin Mesylate 1mg, 2mg, 4mg, 8mg Generic $$$$ SINEQUAN Doxepin HCl 10mg, 25mg, 50mg, 75mg, 100mg, 150mg Generic $$
HECTOROL
Doxercalciferol 0.5mcg, 1mcg, 2.5mcg, 2mcg/ml,
4mcg/2ml
Brand
$$$$$
ADRIAMYCIN Doxorubicin HCl 2mg/ml Generic $$$$ DOXIL Doxorubicin HCl Liposomal 2mg/ml Brand $$$$$$ DOXYCYCLINE Doxycycline Oral Generic $$ ANGELIQ Drospirenone‐Estradiol 0.5‐1mg Brand $$$$
YAZ Drospirenone‐Ethinyl Estradiol Tab
MG
3‐0.02
Generic
$$$$
OCELLA
YASMIN
Drospirenone‐Ethinyl Estradiol Tab 3‐0.03
MG Drospirenone‐Ethinyl Estradiol Tab
3‐0.03
MG
Generic $$$
Generic $$$
CYMBALTA Duloxetine HCl 20mg, 30mg, 60mg Brand $$$$ Step: venlafaxine ER HCL
AVODART Dutasteride 0.5mg Brand $$$$
RELPAX Eletriptan Hydrobromide 20mg, 40mg Brand $$$$
EMTRIVA Emtricitabine Oral 200mg Brand $$$$$
VASOTEC Enalapril Maleate 2.5mg, 5mg, 10mg, 20mg Generic $$
VASERETIC Enalapril Maleate & Hydrochlorothiazide 5‐12.5mg, 10‐25mg Generic $$$$
Step: Sumatriptan Succinate; QL= 9 tabs/30
days
LOVENOX Enoxaparin Sodium
30mg/0.3ml, 40mg/0.4ml, 60mg/0.6ml,
80mg/0.8ml, 100mg/ml, 150mg/ml,
120mg/0.8ml
Brand $$$$$$ LMN: Available at Retail
COMTAN Entacapone 200mg Brand $$$$
BARACLUDE Entecavir 0.5mg, 1mg, 0.05mg/ml Brand $$$$$$ LMN
CPA; QL= 3 units/pkg size 1; 4 units/pkg EPIPEN, EPIPEN‐JR Epinephrine 0.15mg, 0.3mg Brand $$$$
TWINJECT Epinephrine 0.15mg, 0.3mg Brand $$$$
size 2; per 30 days CPA; QL= 3 units/pkg
size 1; 4 units/pkg size 2; per 30 days
ELLENCE Epirubicin HCl 2mg/ml Brand $$$$$$ LMN
INSPRA Eplerenone 25mg, 50mg Generic $$$$
2000u/ml, 3000u/ml, 4000u/ml, EPOGEN Epoetin Alfa
PROCRIT Epoetin Alfa
10000u/ml, 20000u/ml, 40000u/ml
2000u/ml, 3000u/ml, 4000u/ml,
10000u/ml, 20000u/ml, 30000u/ml,
40000u/ml
Brand $$$$$$ CPA; QL= 2 inj/30 days; Available at Retail
Brand $$$$$$ LMN; Available at Retail
EPOPROSTENOLLD Epoprostenol Sodium 0.5mg, 1.5mg Generic $$$$$$ LMN
FLOLANLD Epoprostenol Sodium 0.5mg, 1.5mg Brand $$$$$$ LMN
HALAVEN Eribulin Mesylate 1mg/2ml Generic $$$$$$
TARCEVA Erlotinib 25mg, 100mg, 150mg Brand $$$$$$
INVANZ Ertapenem IV Generic $$$$$ LMN
ERYTHROMYCIN BASE Erythromycin Generic $$$
ILOTYCIN Erythromycin Generic $$
EES Erythromycin Esthylsuccinate 400mg Generic $$$
ERYTHROCIN Erythromycin Stearate 25mg, 500mg Generic $$
LEXAPRO Escitalopram Oxalate 5mg, 10mg, 20mg Generic $$$$
NEXIUM Esomeprazole Magnesium 20mg, 40mg Brand $$$$
ESTRACE Estradiol 0.5mg, 1mg, 2mg Generic $$
Step: Failure of two: citalopram,
fluoxetine, fluvoxamine, paroxetine,
sertraline Step: Failure of two:
omeprazole, pantoprazole,
lansoprazole; QL= 34
caps/packets/30 days
ESTRASORB Estradiol Brand $$$ QL= 68 packets/30 days
ESTROGEL Estradiol Brand $$$$ QL= 2 pump bottles/30 days
VIVELLE‐DOT Estradiol 0.0375, 0.025mg, 0.05mg, 0.075mg, 0.1mg Brand $$$$ QL= 10 patches/30 days
ALORA Estradiol 0.025mg, 0.05mg, 0.075mg, 0.1mg Brand $$$ QL= 68 packets/30 days
ACTIVELLA Estradiol & Norethindrone Acetate 1‐0.5mg Generic $$$$
0.025mg, 0.0375mg, 0.05mg, 0.06mg, CLIMARA Estradiol TD
0.075mg, 0.1mg Generic $$$$ QL= 5 patches/30 days
ESTRACE VAG Estradiol Vaginal Cream Brand $$$
$ ‐‐‐‐‐‐‐‐‐ $1 to $10
$$ ‐‐‐‐‐‐‐‐‐ $11 to $50
$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100
$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500
$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000
$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000
4f-45
6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 6 of 18
GCHP List of Covered Drugs
Generic Name Brand Names Generic Name Strength(s) Coverage Rx Cost LMN, QL, Step, CPA
NUVARING Etonogestrel‐Ethinyl Estradiol VA Ri
0.120‐0.015 MG/24HR
ng
Brand
$$$
TOPOSAR Etoposide 20mg/ml Generic $$$$$ AFINITOR Everolimus 2.5mg, 5mg, 10mg Brand $$$$$$ AROMASIN Exemestane 25mg Generic $$$$ Step: anastrozole BYETTA Exenatide 5mcg, 10mcg Brand $$$$ CPA; QL= 2 syringes/30 days ZETIA Ezetimibe 10mg Brand $$$$ Step: simvastatin 40mg BEBULIN VH Factor IX Complex 200‐1200u Brand $$$$$$$ LMN PROFILNINELD
Factor IX Complex 500u, 1500u, 1500u Brand $$$$$$$ LMN FAMVIR Famcyclovir Oral 125mg, 250mg, 500mg Generic $$$$ PEPCID Famotidine 40mg Generic $$$ PEPCID Famotidine 10mg, 20mg OTC $$ QL= 90 tabs/30 days ULORIC Febuxostat 40mg, 80mg Brand $$$$ Step: allopurinol LOFIBRA Fenofibrate 54mg, 67mg, 134mg, 160mg, 200mg Generic $$$
FENTORA
Fentanyl Citrate 100mcg, 200mcg, 300mcg, 400mcg,
600mcg, 800mcg
Brand
$$$$$
CPA
DURAGESIC Fentanyl TD Patch 12mcg, 25mcg, 50mcg, 75mcg, 100mcg Generic
$$$$ CPA; QL= 15/30days
TOVIAZ Fesoterodine Fumarate 4mg, 8mg Brand $$$$ ALLEGRA Fexofenadine 30mg, 60mg, 180mg OTC $$ Step: Claritin; QL= 30 tabs/30 days ALLEGRA‐D Fexofenadine‐Pseudoephedrine 12 hour, 24 hour OTC $$ QL= 30 tabs/30 days ALLEGRA‐D Fexofenadine‐Pseudoephedrine 60mg/120mg, 180mg/240mg Generic $$
NEUPOGEN
Filgrastim 300mcg, 480mcg, 300mcg/0.5ml,
480mcg/0.8ml
Brand
$$$$$$
LMN; Available at Retail
PROSCAR Finasteride 5mg Generic $$$$ GILENYA Fingolimod HCl 0.5mg Brand $$$$$$ LMN TAMBOCOR Flecainide Acetate 50mg, 100mg, 150mg, 200mg Generic $$$$$ DIFLUCAN Fluconazole Oral 50mg, 100mg, 150mg, 200mg Generic $$$$ LMN ANCOBON Flucytosine Oral 250mg, 500mg Brand $ LMN FLUDARA Fludarabine Phosphate 50mg Brand $$$$$$ FLUDARABINE Fludarabine Phosphate 50mg, 50mg/2ml Generic $$$$$$ FLORINEF Fludrocortisone Acetate 0.1mg Generic $$$ NASALIDE Flunisolide 0.025% Generic $$$ QL= 3 inhrs/bottles/30 days LIDEX Fluocinonide 0.05% Generic $$ FML FORTE Fluorometholone 0.25% Brand $$ ADRUCIL Fluorouracil 2.5g/50ml, 5g/100ml, 500mg/10ml Generic $$ CARAC Fluorouracil 0.5% Brand $$$$
Step: Failure of two: citalopram, PROZAC WEEKLY Fluoxetine HCl 90mg Generic $$ fluoxetine, fluvoxamine, paroxetine,
sertraline PROZAC Fluoxetine HCl 10mg, 20mg, 40mg, 90mg Generic $$
VERAMYST
Fluticasone Furoate
27.5mcg
Brand
$$$$ Step: Fail one: flunisolide, fluticasone,
OMNARIS
FLONASE Fluticasone Propionate 50mcg Generic $$$ QL= 2 inhrs/30 days
FLOVENT HFA
Fluticasone Propionate HFA
44mcg, 110mcg, 220mcg
Brand
$$$$ QL= 44mcg ‐ 2 inhrs; 110mcg ‐ 1 inhr;
220mcg ‐ 3 inhrs; per 30 days
ADVAIR DISKUS Fluticasone‐Salmeterol 100/50, 250/50, 500/50 Brand $$$$ QL= 120 inhs/60pk; 28 inhs/28pk; 14
inhs/14pk; per 30 days
ADVAIR HFA Fluticasone‐Salmeterol 45/21, 115/21, 230/21 Brand $$$$ QL= 2 inhrs/30 days
$ ‐‐‐‐‐‐‐‐‐ $1 to $10
$$ ‐‐‐‐‐‐‐‐‐ $11 to $50 $$$ ‐‐‐‐‐‐‐‐‐ $51 to $100 $$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500 $$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000 $$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000 4f-46 6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 7 of 18
PREFEST Estradiol/Estrad‐Norgestimate Brand $$$$ CLIMARA PRO Estradiol‐Levonorgestrel Brand $$$ QL= 5 patches/30 days
COMBIPATCH Estradiol‐Norethindrone Ace 0.05/0.14mg, 0.05/0.25mg Brand $$$ PREMARIN Estrogens, Conjugated 0.3mg, 0.45mg, 0.625mg, 0.9mg, 1.25mg Brand $$$
PREMARIN VAG Estrogens, Conjugated Vaginal Cream 0.625mg Brand $$
OGEN Estropipate 0.75mg, 1.5mg, 3mg Generic $$ ENBREL Etanercept 25mg, 25mg/0.5ml, 50mg/ml Brand $$$$$$ Step: Fail 2 DMARD
EDECRIN Ethacrynic Acid 25mg Brand $$$ CPA
MYAMBUTOL Ethambutol Oral 100mg, 400mg Generic $$$ KELNOR
Ethynodiol Diacetate & Ethinyl Estradiol
Tab 1 MG‐35 MCG Generic $$
ZOVIA
Ethynodiol Diacetate & Ethinyl Estradiol
Tab 1 MG‐35 MCG, 1 MG‐50 MCG
Generic $$
GCHP List of Covered Drugs
Generic Name Brand Names Generic Name Strength(s) Coverage Rx Cost LMN, QL, Step, CPA
LUVOX Fluvoxamine Maleate 25mg, 50mg, 100mg Generic $$$ FOLTX Folic Acid 400mcg, 800mcg, 1000mcg, 1g Generic $$
GONAL‐F Follitropin Alfa 300, 450, 900, 75u, 450u, 1050u Brand $$$$$$ LMN
FOLLISTIM Follitropin Beta 75u, 150u, 300u, 600u, 900u Brand $$$$$$ LMN
ARIXTRA Fondaparinux Sodium 2.5mg/0.5ml, 5mg/0.4ml, 7.5mg/0.6ml,
10mg/0.8ml Brand $$$$$$ CPA; QL= 28 inj/14 days; Available at Retail
CPA; QL= 12 caps/12pk; 120 caps/60pk; FORADIL Formoterol Fumarate Brand $$$$
per 30 days
PERFOROMIST Formoterol Fumarate 20mcg Brand $$$$ CPA; QL= 120 vials/30 days
MONOPRIL Fosinopril Sodium 10mg, 20mg, 40mg Generic $$
MONOPRIL HCT Fosinopril Sodium & Hydrochlorothiazide 10‐12.5mg, 20‐12.5mg Generic $$$$
FROVA Frovatriptan Succinate 2.5mg Brand $$$$
Step: Sumatriptan Succinate; QL= 9 tabs/30
days
EMETROL Fructose‐Dextrose‐Phosphoric Acid OTC $ QL= 240ml/ 30 days
FASLODEX Fulvestrant 250mg/5ml Generic $$$$$$
LASIX Furosemide 20mg, 40mg, 80mg Generic $$
NEURONTIN Gabapentin 100mg, 300mg, 400mg, 600mg, 800mg Generic $$$$
NAGLAZYMELD Galsulfase 1mg/ml Brand $$$$$$ LMN
CYTOVENE Gancyclovir IV 500mg Generic $ LMN
GANIRELIX Ganirelix Acetate Brand $$$$$$ LMN
ZYMAR Gatifloxacin 0.3% Brand $$$
GEMZAR Gemcitabine HCl 200mg, 1g Brand $$$$$$
LOPID Gemfibrozil 600mg Generic $$$
GARAMYCIN Gentamicin IM or IV Generic $$ QL= 14 days
COPAXONE Glatiramer Acetate 20mg/ml Brand $$$$$$ LMN
AMARYL Glimepiride 1mg, 2mg, 4mg Generic $$$
GLUCOTROL Glipizide 5mg, 10mg Generic $$$
GLUCOTROL XL Glipizide SR 2.5mg, 5mg, 10mg Generic $$$
GLUCAGEN Glucagon HCl 1mg Brand $$$$$
MICRONASE Glyburide 1.25mg,. 2.5mg, 5mg Generic $$$
GLUCOVANCE Glyburide‐Metformin 1.25‐250mg, 2.5‐500mg, 5‐500mg Generic $$$$
SIMPONI Golimumab 50mg Brand $$$$$$ Step: Fail 2 DMARD
ZOLADEX Goserelin Acetate 3.6mg, 10.8mg Brand $$$$$$
GRANISETRON Granisetron HCl 1mg, 0.1mg/ml, 1mg/ml, 4mg/4ml, Generic $$$$$$ LMN
KYTRIL Granisetron HCl 1mg, 0.1mg/ml, 1mg/ml Brand $$$$ LMN: Specialty
GRIS‐PEG Griseofulvin Oral 125mg, 250mg Generic $$
PRO‐CLEAR Guaifenesin‐Codeine 300‐10mg Generic $$
TENEX Guanfacine HCl 1mg, 2mg Generic $$$$
TWINRIX Hepatitis A (Inact)‐Hep B (Recomb) Vac Brand $$$$$$ LMN
HAVRIX Hepatitis A Vaccine 720u, 1440u Brand $$$$$$ LMN
HYPERHEP Hepatitis B Immune Globulin Brand $$$$$$ LMN
ENGERIX Hepatitis B Vaccine 10mcg/0.5ml, 20mcg/ml Brand $$$$$$ LMN
SUPPRELINLD Histrelin Acetate 50mg Brand $$$$$$
VANTASLD Histrelin Acetate 50mg Brand $$$$$$
ORTHOVISC Hyaluronan 15mg/ml Brand $$$$$$ LMN
APRESOLINE Hydralazine HCl 10mg, 25mg, 50mg, 100mg Generic $$$$
HYDRODIURIL Hydrochlorothiazide 12.5mg, 25mg, 50mg Generic $$$
TUSSIONEX Hydrocod Polst‐Chlorphen Polst Generic $$$
2.5‐500mg, 5‐325mg, 5‐500mg, 7.5‐325mg,
VICODIN Hydrocodone‐Acetaminophen
REPREXAIN Hydrocodone‐Ibuprofen
7.5‐650mg, 7.5‐650mg, 7.5‐750mg, 10‐
300mg, 10‐325mg, 10‐500mg, 10‐650mg,
10‐660mg
2.5‐200mg, 5‐200mg, 7.5‐200mg, 10‐
200mg
Generic $$$ QL= 120 tabs/30 days
Generic $$$$ QL= 120 tabs/30 days
HYTONE Hydrocortisone 0.5%, 1%, 2.5% Generic $$$
ANALPRAM‐HC Hydrocortisone Acetate w/ Pramoxine 1‐1%, 1‐2.5%, 2.5%, 2.5‐1% Generic $$$$
SOLU‐CORTEF Hydrocortisone Sodium Succinate 100mg, 250mg, 500mg, 1000mg Brand $$$$$$ LMN
DILAUDID Hydromorphone HCl 1mg, 2mg, 4mg, 8mg Generic $$$ QL= 120 tabs/30 days
PLAQUENIL Hydroxychloroquine Sulfate 200mg Generic $$$
HYDREA Hydroxyurea 500mg Generic $$$$
ATARAX Hydroxyzine HCl 10mg, 25mg, 50mg Generic $$
$ ‐‐‐‐‐‐‐‐‐ $1 to $10
$$ ‐‐‐‐‐‐‐‐‐ $11 to $50
$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100
$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500
$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000
$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000
4f-47
6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 8 of 18
GCHP List of Covered Drugs
Generic Name Brand Names Generic Name Strength(s) Coverage Rx Cost LMN, QL, Step, CPA
Ketoconazole Topical Generic $$
$ ‐‐‐‐‐‐‐‐‐ $1 to $10
$$ ‐‐‐‐‐‐‐‐‐ $11 to $50 $$$ ‐‐‐‐‐‐‐‐‐ $51 to $100 $$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500 $$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000 $$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000
$$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 4f-48
9 of 18
VISTARIL Hydroxyzine Pamoate 25mg, 50mg, 100mg Generic $$
SYNVISC Hylan Intra‐articular 8mg/ml Brand $$$$$$ LMN
LEVBID Hyoscyamine Sulfate 0.0125mg, 0375mg Generic $$
BONIVA Ibandronate Sodium 3mg/3ml Brand $$$$ LMN
BONIVA Ibandronate Sodium 2.5mg, 150mg Brand $$$$
ADVIL Ibuprofen 200mg OTC $ QL= 100 tabs/30 days
MOTRIN Ibuprofen 800mg Generic $$
ELAPRASELD Idursulfase 6mg/3ml Brand $$$$$$ LMN
IFEX Ifosfamide 1 gm, 3 gm Generic $$$$$$
VENTAVISLD Iloprost 10mcg/ml, 20mcg/ml Brand $$$$$$ LMN; Specialty
GLEEVEC Imatinib Mesylate 100mg, 400mg Brand $$$$$$
CEREZYMELD Imiglucerase 200u, 400u Brand $$$$$$ LMN
PRIMAXIN Imipenem/Cilastin IV Generic $$$$$ LMN
TOFRANIL Imipramine HCl 10mg, 25mg, 50mg Generic $$
ALDARA Imiquimod 5% Generic $$$ CPA
CARIMUNE Immune Globulin 3g, 6g, 12g Brand $$$$$$ LMN
FLEBOGAMMALD Immune Globulin 5%, 10% Brand $$$$$$ LMN
GAMASTANLD Immune Globulin Brand $$$$$$ LMN
GAMMAGARD SD Immune Globulin
1g/10ml, 2.5g/25ml, 5g/50ml, 10g/100ml,
20g/200ml, 30g/300ml, 0.5g, 2.5g, 5g, 10g
Brand $$$$$$ LMN
GAMUNEX Immune Globulin
10%, 1g/10ml, 2.5g/25ml, 5g/5ml,
10g/100ml, 20g/200ml
Brand $$$$$$ LMN
OCTAGAMLD Immune Globulin 2.5g, 5g, 10g, 25g Brand $$$$$$ LMN
POLYGAM S/DM Immune Globulin 0.5g, 2.5g, 5g, 10g Brand $$$$$$ LMN
PRIVIGEN Immune Globulin 5g, 10g, 20g Brand $$$$$$ LMN
VIVAGLOBINLD Immune Globulin 160mg/ml Brand $$$$$$ LMN
LOZOL Indapamide 1.25mg, 2.5mg Generic $$$
INDOCIN Indomethacin 25mg, 50mg, 75mg Generic $$
REMICADE Infliximab 100mg Brand $$$$$$ Step: Fail 2 DMARD
NOVOLOG Insulin Aspart 70/30, 100u/ml Brand $$$$
LEVEMIR, FLEXPEN Insulin Detemir 100u/ml Brand $$$$
LANTUS Insulin Glargine 100u/ml, 500u/ml Brand $$$$
APIDRA Insulin Glulisine 100u/ml Brand $$$$ Step: Humalog
HUMULIN N Insulin Isophane 100u/ml Brand $$$
HUMULIN R Insulin Isophane 100u/ml, 500u/ml Brand $$$
NOVOLIN N Insulin Isophane 100u/ml Brand $$$
NOVOLIN R Insulin Isophane 100u/ml Brand $$$
HUMULIN Insulin Isophane & Regular 50/50, 70/30 Brand $$$
NOVOLIN Insulin Isophane & Regular 70/30 Brand $$$
HUMALOG Insulin Lispro 50/50, 75/25, 100u/ml Brand $$$$
INFERGEN Interferon Brand $$$$$$ Specialty
INTRON‐A Interferon Alfa‐2B 3u, 5u, 10u, 18u, 25u, 50u Brand $$$$$$ QL= 2 inj/30 days
ALFERON NM Interferon Alfa‐n3 5000000u/ml Brand $$$$$$ LMN
AVONEX Interferon Beta‐1a 30mcg Brand $$$$$$ LMN
REBIF Interferon Beta‐1a 22mcg/0.5ml, 44mcg/0.5ml Brand $$$$$$ LMN
BETASERON Interferon Beta‐1b 0.3mg Brand $$$$$$ LMN
EXTAVIA Interferon Beta‐1b 0.3mg Brand $$$$$$ LMN
ACTIMMUNELD Interferon Gamma‐1B 2000000u/0.5ml Brand $$$$$$ LMN
YODOXIN Iodoquinol Oral 210mg, 650mg Brand $$$$
ATROVENT Ipratropium Bromide 0.02% Generic $$$$
ATROVENT HFA Ipratropium Bromide HFA 17mcg Brand $$$$ QL= 2 inhrs HFA/30 days
COMBIVENT Ipratropium‐Albuterol 18‐103mcg/ACT Brand $$$$ QL= 3 inhrs/30 days
AVAPRO Irbesartan 75mg, 150mg, 300mg Brand $$$$ Step: losartan potassium
AVALIDE Irbesartan‐Hydrochlorothiazide 150‐12.5mg, 300‐12.5mg, 300‐25mg Brand $$$$ Step: losartan potassium HCT
CAMPTOSAR Irinotecan HCl 20mg/ml Brand $$$$$$
ISONIAZID Isoniazid Oral Generic $$
ISORDIL Isosorbide Dinitrate 5mg, 10mg, 20mg, 30mg, 40mg Generic $$$$
IMDUR Isosorbide Mononitrate 10mg, 20mg, 30mg, 60mg, 120mg Generic $$$$
SPORANOX Itraconazole Oral 100mg Brand $$$$ LMN
STROMECTOL Ivermectin Oral 3mg Brand $$$$
IXEMPRA Ixabepilone 15mg, 45mg Generic $$$$$$
NIZORAL Ketoconazole Oral 200mg Generic $$$
NIZORAL
6/23/2011
GCHP List of Covered Drugs
Generic Name Brand Names Generic Name Strength(s) Coverage Rx Cost LMN, QL, Step, CPA
ORUDIS Ketoprofen 50mg, 75mg, 200mg Generic $$$ ACULAR, LS Ketorolac Tromethamine 0.5%, 0.4% Generic $$$$
ACUVAIL Ketorolac Tromethamine 0.45% Brand $$$ LMN
NORMODYNE Labetalol HCl 100mg, 200mg, 300mg Generic $$$
VIMPAT
Lacosamide
50mg, 100mg, 150mg, 200mg, 10mg/ml
Brand
$$$$
CEPHULAC Lactulose 10g/15ml, 20g/30ml Generic $$$$ EPIVIR Lamivudine Oral 150mg, 300mg Brand $$$$
LAMICTAL
Lamotrigine 25mg, 50mg, 100mg, 150mg, 200mg,
250mg
Generic
$$
LAMICTAL XR Lamotrigine SR 25mg, 100mg, 150mg, 200mg, 300mg Brand
$$$$
PREVACID Lansoprazole 15mg, 30mg Generic $$$$ FOSRENOL Lanthanum Carbonate 250mg, 500mg, 750mg, 1000mg Brand $$$$$ TYKERBLD Lapatinib Ditosylate 250mg Brand $$$$$$ ALDURAZYMELD Laronidase 2.9mg/5ml Brand $$$$$$ LMN
XALATAN Latanoprost 0.005% Generic $$$ REVLIMIDLD Lenalidomide 5mg, 10mg, 15mg, 25mg Brand $$$$$$ LMN
REFLUDAN Lepirudin 50mg Brand $$$$$$ LMN
FEMARA Letrozole 2.5mg Generic $$$$$ ELIGARD Leuprolide Acetate 7.5mg, 22.5mg, 30mg, 45mg Brand $$$$$$ LEUPROLIDE Leuprolide Acetate 1mg/0.2ml, 5mg/ml Generic $$$$$$ LUPRON Leuprolide Acetate 3.75mg, 7.5mg, 11.25mg, 22.5mg, 30mg Brand $$$$$$ XOPENEX Levalbuterol HCl 0.31mg, 0.63mg, 1.25mg/3ml Brand $$$$ Step: albuterol
XOPENEX HFA Levalbuterol Tartrate Brand $$$$ Step: albuterol; QL= 3 inhrs/30 days
KEPPRA
Levetiracetam 100mg/ml, 250mg, 500mg, 750mg,
1000mg
Generic
$$$
KEPPRA XR Levetiracetam SR 500mg, 750mg Brand $$$ BETAGAN Levobunolol HCl 0.25%, 0.5% Generic $$ LEVAQUIN Levofloxacin Oral Generic $$ SEASONALE
Levonorgestrel & Ethinyl Estradiol
Tab 0.15‐0.03 MG
(91‐Day) Generic $$$$
AVIANE Levonorgestrel & Ethinyl Estradiol
MG‐20 MCG
Tab 0.1 Generic $$
LESSINA‐28 Levonorgestrel & Ethinyl Estradiol
MG‐20 MCG
Tab 0.1 Generic $$
LUTERA Levonorgestrel & Ethinyl Estradiol
MG‐20 MCG
Tab 0.1 Generic $$
LEVORA‐28 Levonorgestrel & Ethinyl Estradiol
MG‐30 MCG
Tab 0.15 Generic $$
NORDETTE Levonorgestrel & Ethinyl Estradiol
MG‐30 MCG
Tab 0.15 Generic $$$
ENPRESSE‐28 Levonorgestrel‐Eth Estra Tab 0.05‐
30/0.075‐40/0.125‐30MG‐MCG Generic $$
TRIVORA‐28 Levonorgestrel‐Eth Estra Tab 0.05‐
30/0.075‐40/0.125‐30MG‐MCG Generic $$
25mcg, 50mcg, 75mcg, 88mcg, 100mcg, LEVOTHROID Levothyroxine Sodium 112mcg, 125mcg, 137mcg, 150mcg, Generic $$
175mcg, 200mcg, 300mcg, 500mcg 25mcg, 50mcg, 75mcg, 88mcg, 100mcg,
LEVOXYL Levothyroxine Sodium 112mcg, 125mcg, 137mcg, 150mcg, Generic $$ 175mcg, 200mcg, 300mcg 25mcg, 50mcg, 75mcg, 88mcg, 100mcg,
SYNTHROID Levothyroxine Sodium 112mcg, 125mcg, 137mcg, 150mcg, Brand $$$ 175mcg, 200mcg, 300mcg 25mcg, 50mcg, 75mcg, 88mcg, 100mcg,
UNITHROID Levothyroxine Sodium 112mcg, 125mcg, 137mcg, 150mcg, Generic $$ 175mcg, 200mcg, 300mcg
XYLOCAINE Lidocaine HCl 2% gel, 5% onit Generic $$ XYLOCAINE Lidocaine HCl Viscous 2% Generic $$ LIDODERM Lidocaine Patch 5% Generic $$$$$ LINDANE Lindane 1% Generic $$$ ZYVOX Linezolid Oral, IV Brand $$$$$$ LMN; Specialty
$ ‐‐‐‐‐‐‐‐‐ $1 to $10
$$ ‐‐‐‐‐‐‐‐‐ $11 to $50 $$$ ‐‐‐‐‐‐‐‐‐ $51 to $100 $$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500 $$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000 $$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000 4f-49 6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 10 of 18
GCHP List of Covered Drugs
Generic Name Brand Names Generic Name Strength(s) Coverage Rx Cost LMN, QL, Step, CPA
VICTOZA Liraglutide 18mg/3ml Brand $$$$ CPA; QL= 3 syringes/30 days
VYVANSE Lisdexamfetamine Dimesylate 20mg, 30mg, 40mg, 50mg, 60mg, 70mg Brand $$$$$ CPA; Age > 23
ZESTRIL lisinopril 2.5mg, 5mg, 10mg, 20mg, 30mg Generic $$ ZESTORETIC Lisinopril & Hydrochlorothiazide 10‐12.5mg, 20‐12.5mg, 20‐25mg Generic $$$
CEREFOLIN
L‐Methylfolate w/ Vit B12‐Vit B6‐Vit B2
Brand
$$$$
METANX L‐Methylfolate w/ Vit B6‐Vit B12 Brand $$$$ IMODIUM Loperamide HCl 2mg Generic $$ CLARITIN Loratadine 5mg, 10mg OTC $$ QL= 30caps/30 days
ATIVAN Lorazepam 0.5mg, 1mg, 2mg, Generic $$$ QL= 120tabs/30days
COZAAR Losartan Potassium 25mg, 50mg, 100mg Generic $$$$ HYZAAR Losartan Potassium & Hydrochlorothiazid e 50‐12.5mg, 100‐12.5mg, 100‐25mg Generic $$$ ALREX Loteprednol Etabonate 0.2% Brand $$$$ LOTEMAX Loteprednol Etabonate 0.5% Brand $$$ MEVACOR Lovastatin 20mg, 40mg Generic $$$$ AMITIZA Lubiprostone 8mcg, 24mcg Brand $$$$ OVIDE Malathion Lotion 0.50% Generic $$$$ MEBENDAZOLE Mebendazole Oral 100mg Generic $$$ INCRELEX Mecasermin 40mg/4ml Brand $$$$$$ CPA
PROVERA Medroxyprogesterone Acetate 2.5mg, 5mg, 10mg Generic $$$ DEPO‐PROVERA
Medroxyprogesterone Acetate IM Susp
150 MG/ML Generic $$$
DEPO‐PROVERA Medroxyprogesterone Acetate IM Susp
400 MG/ML
Brand
$$$$
MEGACE Megestrol Acetate 20mg, 40mg Generic $$$$$ MEGACE Megestrol Acetate 40mg/ml Generic $$$$ MOBIC Meloxicam 7.5mg, 15mg Generic $$$$ ALKERAN Melphalan 2mg, 50mg Brand $$$$$$ NAMENDA Memantine HCl 5mg, 5‐10mg, 10mg Brand $$$$ REPRONEX Menotropins 75u Brand $$$$$$ LMN
DEMEROL
Meperidine HCl 10mg/ml, 25mg/ml, 50mg/ml, 75mg/ml,
100mg/ml
Generic
$$$
CPA; QL= 120ml/30 days
PURINETHOL Mercaptopurine 50mg Generic $$$$ MERREM Meropenem IV Generic $$$$ LMN
ASACOL, ASACOL HD Mesalamine 400mg, 800mg Brand $$$ LMN
CANASA Mesalamine 1000mg Brand $$$$ LMN
LIALDA Mesalamine 1.2g Brand $$$$ LMN
PENTASA Mesalamine 250mg, 500mg Brand $$$$ LMN
GLUCOPHAGE Metformin HCl 500mg, 750mg, 850mg, 1000mg Generic $$$ RIOMET Metformin HCl 500mg/5ml Brand $$$$ GLUCOPHAGE XR Metformin HCl SR 500mg, 750mg Generic $$$ METHADONE Methadone HCl 5mg, 10mg, 40mg Generic $$$ CPA; QL= 120 tabs/30 days
DESOXYN Methamphetamine HCl 5mg Generic $$$$ CPA; Age > 23
TAPAZOLE Methimazole 5mg, 10mg Generic $$ MEXATE Methotrexate Sodium
1g, 1g/40ml, 25mg/ml, 50mg/2ml,
250mg/10ml Generic $$$$$$
RHEUMATREX Methotrexate Sodium 2.5mg Generic $$$$ ALDOMET Methyldopa 250mg, 500mg Generic $$$$ CONCERTA Methylphenidate HCl 18mg, 27mg, 36mg, 54mg Brand $$$$$ CPA; Age > 23
RITALIN
Methylphenidate HCl 5mg, 10mg, 18mg, 20mg, 27mg, 36mg,
54mg
Generic
$$$$
CPA; Age > 23
RITALIN LA Methylphenidate HCl 10mg, 20mg, 30mg, 40mg Brand $$$$ CPA; Age > 23
METADATE CD Methylphenidate HCl 10mg, 20mg, 30mg, 40mg, 50mg, 60mg Brand $$$$$ CPA; Age > 23
MEDROL Methylprednisolone 2mg, 4mg, 8mg, 16mg, 32mg Generic $$$ DEPO‐MEDROL Methylprednisolone Acetate 40mg/ml, 80mg/ml Generic $$$$ REGLAN Metoclopramide HCl 5mg, 10mg Generic $$ ZAROXOLYN Metolazone 2.5mg, 5mg, 10mg Generic $$$$ TOPROL XL Metoprolol Succinate 25mg, 50mg, 100mg, 200mg Generic $$$$ LOPRESSOR Metoprolol Tartrate 25mg, 50mg, 100mg Generic $$$ METROLOTION Metronidazole 0.75% Generic $$$ METROGEL Metronidazole Gel 0.75% Generic $$$
$ ‐‐‐‐‐‐‐‐‐ $1 to $10
$$ ‐‐‐‐‐‐‐‐‐ $11 to $50
$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100
$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500
$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000
$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000
4f-50
6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 11 of 18
GCHP List of Covered Drugs
Generic Name Brand Names Generic Name Strength(s) Coverage Rx Cost LMN, QL, Step, CPA
FLAGYL Metronidazole Oral, IV Generic $$ to $$$$
HELIDAC Metronidaz‐Tetracyc‐Bis Brand $$$$
MYCAMINE Micafungin IV 50mg, 100mg Brand $$$ LMN
PROAMATINE Midodrine HCl 2.5mg, 5mg, 10mg Generic $$$
SAVELLA Milnacipran HCl 12.5mg, 25mg, 50mg, 100mg Brand $$$$ LMN
MIRTAZAPINE Mirtazapine 7.5mg, 15mg, 30mg, 45mg Generic $$$
CYTOTEC Misoprostol 100mcg, 200mcg Generic $$$$
MITOMYCIN Mitomycin 5mg, 20mg, 40mg Generic $$$$$$
PROVIGIL Modafinil 100mg, 200mg, 300mg Brand $$$$$ CPA; Age > 23
UNIRETIC Moexipril‐Hydrochlorothiazide 7.5‐12.5mg, 15‐12.5mg, 15‐25mg Generic $$$
ASMANEX Mometasone Furoate 110mcg, 220mcg Brand $$$$
ELOCON Mometasone Furoate 0.1% Generic $$$
NASONEX Mometasone Furoate 50mcg/ACT Brand $$$$
SINGULAIR Montelukast Sodium 10mg Brand $$$$
QL= 1 inh (#14 inhalation units); 2 inhs
(#30, #60, #120 inhalation units); per 30
days
Step: Fail one: flunisolide, fluticasone,
OMNARIS
MS CONTIN Morphine Sulfate 15mg, 30mg, 60mg, 10mg, 200mg Generic $$$ QL= 120 tabs/30 days
AVELOX Moxifloxacin Oral Brand $$$ LMN
BACTROBAN Mupirocin Generic $$
CELLCEPT Mycophenolate Mofetil 250mg, 500mg Generic $$$$ CELLCEPT
Mycophenolate Mofetil 250mg, 500mg, 250mg/ml Brand $$$$$$ LMN
MYCOPHENOLATE Mycophenolate Mofetil 250mg, 500mg Generic $$$$$$ LMN
RELAFEN Nabumetone 500mg, 750mg Generic $$$ CORGARD
Nadolol 20mg, 40mg, 80mg Generic $$
SYNARELM Nafarelin Acetate 2mg/ml Brand $$$$$$ LMN
NAFCILLIN Nafcillin IV Generic $$$$ LMN
220mg, 250mg, 275mg, 375m g, 500mg, NAPROSYN Naproxen
550mg Generic $$$
ALEVE Naproxen Sodium 220mg OTC $ QL= 100 tabs/30 days
Step: Sumatriptan Succinate; QL= 9 tabs/30 AMERGE Naratriptan HCl 1mg, 2.5mg Generic $$$$
days (1mg & 2.5mg)
TYSABRILD Natalizumab 300mg/15ml Brand $$$$$$ LMN
STARLIX Nateglinide 60mg, 120mg Generic $$$$
SERZONE Nefazodone HCl 50mg, 100mg, 150mg, 200mg, 250mg Generic $$$
NEOMYCIN Neomycin Sulfate ‐Oral 500mg Generic $$$$ QL= 2 tabs/30 days
NEOSPORIN Neomycin/Polymyxin Gramicidin Generic $$
CORTISPORIN Neomycin‐Colistin‐HC‐Thonzonium Generic $$
MAXITROL Neomycin‐Polymyxin‐Dexamethasone 0.1% Generic $$
TOBRADEX Neomycin‐Polymyxin‐Dexamethasone Generic $$$
NIASPAN Niacin 500mg, 750mg, 1000mg Brand $$$$
CARDENE Nicardipine HCl 20mg, 30mg Generic $$
PROCARDIA Nifedipine 10mg, 20mg Generic $$
PROCARDIA XL Nifedipine SR 30mg, 60mg, 90mg Generic $$$$
TASIGNA Nilotinib 150mg, 200mg Brand $$$$$$
SULAR Nisoldipine 8.5mg, 17mg, 25.5mg, 34mg, Generic $$$$
ALINIA Nitazoxanide Oral 500mg Brand $$$$$
MACRODANTIN Nitrofurantoin Macorcrystal Oral Generic $$
2.5mg, 6.5mg, 0.1mg/HR, 0.2mg/HR, NITRO‐DUR Nitroglycerin
0.4mg/HR, 0.6mg/HR Generic $$$$
NITROSTAT Nitroglycerin 0.4mg, 0.6mg Generic $$$$
Norelgestromin‐Ethinyl Estradiol TD PTWK ORTHO EVRA
150‐20 MCG/24HR Brand $$$
NOR‐QD Norethindrone 0.35mg Generic $$$
Norethindrone & Ethinyl Estradiol Tab 0.4 OVCON 35
NECON
MG Norethindrone & Ethinyl Estradiol Tab
0.5
MG‐35 MCG, 1 MG‐35 MCG, 0.5‐35/0.75‐
35/1‐35 MG‐MCG
Generic $$$
Generic $$
$ ‐‐‐‐‐‐‐‐‐ $1 to $10
$$ ‐‐‐‐‐‐‐‐‐ $11 to $50
$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100
$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500
$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000
$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000
4f-51
6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 12 of 18
GCHP List of Covered Drugs
Generic Name Brand Names Generic Name Strength(s) Coverage Rx Cost LMN, QL, Step, CPA
NORTREL
Norethindrone & Ethinyl Estradiol Tab 0.5
MG‐35 MCG, 1 MG‐35 MCG, 0.5‐35/0.75‐
Generic
$$
35/1‐35 MG‐MCG MODICON
Norethindrone & Ethinyl Estradiol Tab 0.5
MG‐35MCG Generic $$$
ORTHO‐NOVUM
Norethindrone & Ethinyl Estradiol Tab 1
MG‐35 MCG, 1 MG‐50MCG, 0.5‐35/0.75‐
35/1‐35 MG‐M
Generic
$$$
NORINYL
Norethindrone & Mestranol Tab 1 MG‐
35MCG, 1 MG‐50 MCG
Generic
$$
MICROGESTIN
Norethindrone Ace & Ethinyl Estradiol Tab
1 MG‐20 MCG, 1.5 MG‐30 MCG
Generic
$$
LOESTRIN FE
Norethindrone Ace & Ethinyl Estradiol‐FE
Tab 1 MG‐20 MCG, 1.5 MG‐30 MCG
Generic
$$
MICROGESTIN FE
Norethindrone Ace & Ethinyl Estradiol‐FE
Tab 1 MG‐20 MCG, 1.5 MG‐30 MCG
Generic
$$
JUNEL FE
Norethindrone Ace & Ethinyl Estradiol‐FE
Tab 1 MG‐20MCG, 1.5 MG‐30 MCG
Generic
$$
AYGESTIN Norethindrone Acetate 5mg Generic $$$$
FEMHRT Norethindrone Acetate‐Ethinyl Estradiol 0.5mg‐2.5mcg, 1mg‐5mcg Generic $$$$
ESTROSTEP FE Norethindrone Ac‐Ethinyl Estrad‐Fe Tab 1‐
20/1‐30/1‐35 MG‐MCG Generic $$$
ARANELLE Norethindrone‐Eth Estradiol Tab 0.5‐35/1‐
35/0.5‐35 MG‐MCG Generic $$
TRI‐NORINYL Norethindrone‐Eth Estradiol Tab 0.5‐35/1‐
35/0.5‐35 MG‐MCG Generic $$$
MONONESSA Norgestimate & Ethinyl Estradiol Tab 0.25
MG‐35 MCG Generic $$
ORTHO‐CYCLEN Norgestimate & Ethinyl Estradiol Tab 0.25
MG‐35 MCG Generic $$$
PREVIFEM Norgestimate & Ethinyl Estradiol Tab 0.25
MG‐35 MCG Generic $$
SPRINTEC 28 Norgestimate & Ethinyl Estradiol Tab 0.25
MG‐35 MCG Generic $$
ORTHO TRI‐CYCLEN LO Norgestimate‐Eth Estrad Tab 0.18‐
25/0.215‐25/0.25‐25 MG‐MCG
Brand
$$
CPA
ORTHO TRI‐CYCLEN Norgestimate‐Eth Estrad Tab 0.18‐
35/0.215‐35/0.25‐35 MG‐MCG
Generic
$$
TRINESSA Norgestimate‐Eth Estrad Tab 0.18‐
35/0.215‐35/0.25‐35 MG‐MCG Generic $$
TRI‐PREVIFEM Norgestimate‐Eth Estrad Tab 0.18‐
35/0.215‐35/0.25‐35 MG‐MCG Generic $$
TRI‐SPRINTEC Norgestimate‐Eth Estrad Tab 0.18‐
35/0.215‐35/0.25‐35 MG‐MCG Generic $$
CRYSELLE‐28 Norgestrel & Ethinyl Estradiol Tab 0.3 MG‐
30 MCG Generic $$
LO/OVRAL Norgestrel & Ethinyl Estradiol Tab 0.3 MG‐
30 MCG Generic $$
LOW‐OGESTREL Norgestrel & Ethinyl Estradiol Tab 0.3 MG‐
30 MCG Generic $$
PAMELOR Nortriptyline HCl 10mg, 25mg, 50mg, 75mg Generic $$$ NYSTATIN Nystatin Swish and Swallow Generic $$ NYSTOP Nystatin Topical Powder Generic $$
OCTREOTIDE
Octreotide Acetate 100mcg, 200mcg, 500mcg, 1000mcg,
1mg/ml, 50mcg/ml
Generic
$$$$$$
LMN
SANDOSTATIN Octreotide Acetate 10mg, 20mg, 30mg, 50mcg/ml, 100mcg
200mcg, 500mcg, 1000mcg
, Brand $$$$$$
OCUFLOX Ofloxacin 0.3% Generic $$$ BENICAR Olmesartan Medoxomil 5mg, 20mg, 40mg Brand $$$ Step: losartan potassium
$ ‐‐‐‐‐‐‐‐‐ $1 to $10
$$ ‐‐‐‐‐‐‐‐‐ $11 to $50 $$$ ‐‐‐‐‐‐‐‐‐ $51 to $100 $$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500 $$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000 $$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000 4f-52 6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 13 of 18
GCHP List of Covered Drugs
Generic Name Brand Names Generic Name Strength(s) Coverage Rx Cost LMN, QL, Step, CPA
BENICAR HCT Olmesartan Medoxomil‐
Hydrochlorothiazide 20‐12.5mg, 40‐12.5mg, 40‐25mg Brand $$$$ Step: losartan potassium HCT
g)
TRIBENZOR Olmesartan‐Amlodipine‐
Hydrochlorothiazide Brand $$$$ LMN
PATANASE Olopatadine HCl 0.6% Brand $$$$ PATANOL Olopatadine HCl 0.1% Brand $$$$ DIPENTUM Olsalazine Sodium 250mg Brand $$$$ XOLAIRLD
Omalizumab 150mg Brand $$$$$$ LMN LOVAZA Omega‐3‐acid Ethyl Esters 1g Brand $$$$ PRILOSEC Omeprazole 10mg, 40mg Generic $$ PRILOSEC Omeprazole 20mg OTC $$ QL= 42 tabs/30 days ZEGERID Omeprazole‐Sodium Bicarbonate 20‐1100 OTC $$ QL= 42 tabs/30 days BOTOX OnabotulinumtoxinA 50u, 100u, 200u Brand $$$$$$ LMN
ZOFRAN
Ondansetron HCl
4mg, 8mg, 24mg
Generic
$$$ QL= 30 tabs (4mg & 8mg); 1 tab
per 30 days
(24mg);
ZOFRAN Ondansetron HCl and Dextrose 32mg/50ml Brand $$$ CPA; QL= 3 bottles (sol); per 30 days
TAMIFLU Oseltamir Oral 30mg, 45mg, 70mg Brand $$$$ QL= 10 caps (45mg, 75mg) 20 c
100ml/30 days (oral susp)
aps (30m
ELOXATIN Oxaliplatin 50mg, 100mg, 200mg Brand $$$$$$ DAYPRO Oxaprozin 600mg Generic $$$$ TRILEPTAL Oxcarbazepine Suspension 300mg/5ml Generic $$$ OXYTROL Oxybutynin 3.9mg/24HR Brand $$$ DITROPAN XL Oxybutynin Chloride 5mg, 10mg Generic $$ GELNIQUE Oxybutynin Chloride 10% Brand $$$ OXYCONTIN Oxycodone HCl
10mg, 15mg, 20mg, 30mg, 40mg, 60mg
80mg, 160mg
, Brand $$$$ CPA; QL= 120 tabs/30 days
ROXICODONE
Oxycodone HCl 5mg, 10mg, 15mg, 20mg, 30mg, 40mg,
80mg
Generic
$$$
QL= 120 tabs/30 days
OPANA ER
Oxymorphone HCl 5mg, 7.5mg, 10mg, 15mg, 20mg, 30mg,
40mg
Brand
$$$$
QL= 120 tabs/30 days
ONXOL
Paclitaxel 30mg/5ml, 100mg/16.7ml, 150mg/25m
300mg/50ml
l, Generic
$$$$$
PACLITAXEL
Paclitaxel 100mg, 6mg/ml, 30mg/5ml, 150mg/25
300mg/50ml
l, Generic
$$$$$$
SYNAGISLD Palivizumab IM 50mg, 100mg/ml Brand $$$$$$ LMN
ALOXI Palonosetron HCl 0.25mg Brand $$$$$$ AREDIA Pamidronate Disodium 30mg, 90mg Brand $$$$$$ LMN PAMIDRONATE Pamidronate Disodium 30mg, 90mg, 30mg/10ml, 90mg/10ml Generic $$$$$$ PROTONIX Pantoprazole 20mg, 40mg Generic $$$
ZEMPLAR
Paricalcitol
1mcg, 2mcg, 4mcg, 2mcg/ml, 5mcg/ml
Brand
$$$$$$
LMN
PAXIL Paroxetine HCl 10mg, 12.5mg, 20mg, 30mg, 40mg Generic $$ VOTRIENTLD
Pazopanib HCl 200mg Brand $$$$$$
GOLYTELY
PEG 3350‐KCl‐Na Bicarb‐NaCl‐Na Sulf
ate
Generic
$$$$
NULYTELY PEG 3350‐KCl‐Sod Bicarb‐NaCl Generic $$$$ MACUGENLD
Pegaptanib Sodium Brand $$$$$$ LMN NEULASTA Pegfilgrastim 6mg/0.6ml Brand $$$$$$ CPA; QL= 2 inj/30 days PEGASYS Peginterferon alfa‐2a 180mcg/0.5ml, 180mcg/ml Brand $$$$$$ LMN PEG‐INTRON Peginterferon alfa‐2b 50mcg, 80mcg, 120mcg, 150mcg Brand $$$$$$ LMN SOMAVERTLD
Pegvisomant 10mg, 15mg, 20mg Brand $$$$$$ LMN ALIMTA Pemetrexed Disodium 100mg, 500mg Brand $$$$$$ PENICILLN GK Penicillin G IV Generic $$$ LMN PENICILLN VK Penicillin VK‐oral Generic $$$ TRENTAL Pentoxifylline 400mg Generic $$$$ ELIMITE Permethrin 5% Generic $$$$ ACTICIN Permethrin Lotion 1% Generic $$ PYRIDIUM Phenazopyridine HCl 100mg, 200mg Generic $$ PHENOBARB Phenobarbital 15mg, 30mg, 32.4mg, 60mg, 100mg Generic $$ PHENTOLAMINE Phentolamine Mesylate Brand $$$$$$ LMN DILANTIN Phenytoin Sodium 100mg Generic $$ PHENYTEK Phenytoin Sodium 200mg, 300mg Generic $$ VITAMIN K Phytonadione 100mcg OTC $$ QL= 60 tabs/30 days
$ ‐‐‐‐‐‐‐‐‐ $1 to $10
$$ ‐‐‐‐‐‐‐‐‐ $11 to $50 $$$ ‐‐‐‐‐‐‐‐‐ $51 to $100 $$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500 $$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000 $$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000 4f-53 6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 14 of 18
m
GCHP List of Covered Drugs
Generic Name Brand Names Generic Name Strength(s) Coverage Rx Cost LMN, QL, Step, CPA
VITAMIN K1 Phytonadione 1mg/0.5ml, 2mg/ml Generic $$$$$$ LMN PILOCARPINE Pilocarpine HCl 1%, 2%, 3%, 4%, 6% Generic $$ ELIDEL Pimecrolimus 1% Brand $$$$ CPA ACTOS Pioglitazone HCl 15mg, 30mg, 45mg Brand $$$$ DUETACT Pioglitazone HCl‐Glimepiride 30‐2mg, 30‐4mg Brand $$$$ ACTOPLUS MET Pioglitazone HCl‐Metformin HCl 15/850mg, 30/1000mg Brand $$$$ ZOSYN Pipercillin/Tazobactam IV Generic $$$$ LMN FELDENE Piroxicam 10mg, 20mg Generic $$$$ GLYCOLAX Polyethylene Glycol OTC $$ POLYTRIM Polymyxin B‐Trimethoprim Generic $ NOXAFIL Posaconazole Oral 40mg/ml Brand $$$$$ LMN MICRO‐K Potassium Chloride 8mEq, 10mEq, 20mEq Generic $$ MIRAPEX Pramipexole Dihydrochloride 0.125mg, 0.25mg, 0.5mg, 0.75mg, 1mg Generic $$$
MIRAPEX ER
Pramipexole Dihydrochloride SR
0.375mg, 0.75mg, 1.5mg, 3mg, 4.5mg
Brand
$$$$
Step: Pramipexole Dihydrochloride
SYMLIN/SYMLINPEN Pramlintide Acetate 600mcg, 1000mcg Brand $$$$ CPA; QL= 7 vials; 8 pens/30 days EFFIENT Prasugrel HCl 5mg, 10mg Brand $$$$ Step: Plavix PRAVACHOL Pravastatin Sodium 10mg, 20mg, 40mg, 80mg Generic $$$$ BILTRICIDE Praziquantal Oral 600mg Brand $$$ MINIPRESS Prazosin HCl 1mg, 2mg, 5mg Generic $$$ OMNIPRED Prednisolone Acetate 1% Generic $$$$ PRED FORTE Prednisolone Acetate 1% Generic $$ VERIPRED 20 Prednisolone Sod Phosphate 20mg/5ml Brand $$$$ STERAPRED Prednisone 5mg, 10mg, 20mg Generic $$$$
LYRICA
Pregabalin 25mg, 50mg, 75mg, 100mg, 150mg,
200mg, 225mg, 300mg
Brand
$$$$
Step: gabapentin
PRENATAL Prenatal Rx Generic $$ Step: Prenatal OTC NATALCARE PLUS Prenatal Vit w/ Fe Fumarate‐FA Generic $$ Step: Prenatal OTC
PRENATE ELITE
Prenatal Vit w/ Fe Fum‐Methylfolate‐FA
Brand
$$$$
Step: Prenatal OTC
PRENATAL VITAMINS Prenatal Vitamins OTC $$ QL= 100 tabs/30 days PRIMAQUINE Primaquine Oral 26.3mg Generic $$$$ MYSOLINE Primidone 50mg, 250mg Generic $$$ BENEMID Probenecid 500mg Generic $$$$ MATULANE Procarbazine HCl 50mg Generic $$$$$$$ COMPAZINE Prochlorperazine Maleate 5mg, 10mg Generic $$ PHENERGAN Promethazine HCl 12.5mg, 25mg, 50mg Generic $$ PHEREGAN Promethazine HCl 12.5mg, 25mg, 50mg Generic $$ PHENERGAN/CODEINE Promethazine w/ Codeine 6.25‐10mg Generic $$ PHENERGAN/CODEINE Promethazine w/ Codeine Generic $$ PHENERGAN DM Promethazine‐DM Generic $$ RYTHMOL Propafenone HCl 150mg, 225mg, 325mg, 425mg Generic $$$$ INDERAL Propranolol HCl 20mg, 60mg, 80mg, 120mg, 160mg Generic $$$ PROPYLTHIOURACIL Propylthiouracil 50mg, 100mg, 200mg, 400mg Generic $$ ARALASTLD
Proteinase Inhibitor 400mg, 500mg, 800mg, 1000mg Brand $$$$$$ LMN CONGESTAC Pseudoephedrine‐Guaifenesin Generic $$$ PYRAZINAMIDE Pyrazinamide Oral 500mg Generic $$$ MESTINON Pyridostigmine Bromide 60mg, 60mg/5ml Brand $$$$
PYRIDOXINE
Pyridoxine HCl 25mg, 50mg, 100mg, 200MG, 250MG,
500MG
OTC
$$
QL= 60 tabs/30 days
ACCUPRIL Quinapril HCl 5mg, 10mg, 20mg, 40mg Generic $$$ Step: Failure of two: omeprazole,
ACIPHEX Rabeprazole Sodium EC 20mg Brand $$$$ pantoprazole, lansoprazole; QL= 34 caps/packets/30 days
EVISTA Raloxifene HCl 60mg Brand $$$$ ALTACE Ramipril 1.25mg, 2.5mg, 5mg, 10mg Generic $$$ LUCENTIS
LD Ranibizumab Brand $$$$$$ LMN
ZANTAC Ranitidine HCl 300mg Generic $$$ ZANTAC Ranitidine HCl 75mg, 150mg OTC $$ QL= 90 tabs/30 days RANEXA Ranolazine 500mg, 1000mg Brand $$$$ LMN AZILECT Rasagiline Mesylate 0.5mg, 1mg Brand $$$ PRANDIMET Repaglinide‐Metformin HCl 1‐500mg, 2‐500mg Brand $$$$ HYPERRHO Rho D Immune Globulin 50mcg, 300mcg Brand $$$$$$ LMN MICRHOGAM PL Rho D Immune Globulin 50mcg Brand $$$$$$
$ ‐‐‐‐‐‐‐‐‐ $1 to $10 $$ ‐‐‐‐‐‐‐‐‐ $11 to $50 $$$ ‐‐‐‐‐‐‐‐‐ $51 to $100 $$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500 $$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000 $$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000 4f-54 6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 15 of 18
GCHP List of Covered Drugs
Generic Name Brand Names Generic Name Strength(s) Coverage Rx Cost LMN, QL, Step, CPA
RHOGAM PLUS Rho D Immune Globulin 300mcg Brand $$$$$$
RHOPHYLACLD Rho D Immune Globulin 1500u/2ml Brand $$$$$$ LMN
WINRHO SDF Rho D Immune Globulin 600u, 1500u, 2500u, 5000u, 15000u Brand $$$$$$ LMN
COPEGUS Ribavirin 200mg Brand $$$$$$ LMN
REBETOL Ribavirin 200mg, 4mg/ml Brand $$$$$$ LMN
RIBASPHERE Ribavirin 200mg, 400mg, 600mg Brand $$$$$$ LMN
RIBAPAK Ribavirin Oral 400mg, 600mg Generic $$$$ Specialty
RIBAVIRIN Ribavirin Oral 200mg, 400mg, 600mg Generic $$$$ Specialty
RIFADIN Rifampin Oral 150mg, 300mg Generic $$$
ARCALYST Rilonacept 220mg Brand $$$$$$ LMN
ACTONEL, ACTONEL WITH
CALCIUM
Risedronate Sodium, Risedronate Sod with
Calcium Carbonate
5mg, 30mg, 35mg, 75mg, 150mg Brand $$$$ Step: alendronate
RITUXAN Rituximab 100mg, 500mg Brand $$$$$$
EXELON Rivastigmine Tartrate 1.5mg, 3mg, 4.5mg, 6mg Generic $$$$
EXELON PATCH Rivastigmine TD Patch 4.6mg/24HR, 9.5mg/24HR Brand $$$$
MAXALT, MAXALT‐MLT Rizatriptan Benzoate 5mg, 10mg Brand $$$$
NPLATE Romiplostim 250mcg, 500mcg Generic $$$$$$
REQUIP Ropinirole Hydrochloride 0.25mg, 0.5mg, 1mg, 2mg, 3mg, 4mg, 5mg Generic $$
Step: Sumatriptan Succinate; QL= 9 tabs/30
days
REQUIP XL Ropinirole Hydrochloride SR 2mg, 4mg, 6mg, 8mg, 12mg Brand $$$$ Step: Ropinirole Hydrochloride
AVANDARYL Rosiglitazone Maleate‐Glimepiride 4‐1mg, 4‐2mg, 4‐4mg, 8‐2mg, 8‐4mg Brand $$$$ LMN
AVANDAMET Rosiglitazone Maleate‐Metformin HCl 2‐500mg, 2‐1000mg, 4‐500mg, 4‐1000mg Brand $$$$ LMN
SEREVENT DISKUS Salmeterol Xinafoate 50mcg Brand $$$$ Step: Foradil
DISALCID Salsalate 500mg, 750mg Generic $$
KUVANLD Sapropterin Dihydrochloride 100mg Brand $$$$$$ LMN
ONGLYZA Saxagliptin HCl 2.5mg, 5mg Brand $$$$ SELSUN
BLUE Selenium Sulfide 1%, 2.25%, 2.5% Generic $
ZOLOFT Sertraline HCl 25mg, 50mg, 100mg Generic $$
RENAGEL Sevelamer 400mg, 800mg Brand $$$$$
RENVELA Sevelamer Carbonate 800mg, 0.8g, 2.4g Brand $$$$$
REVATIO Sildenafil Citrate 20mg, 10mg/12.5ml Brand $$$$$$ LMN; Specialty
RAPAFLO Silodosin 4mg, 8mg Brand $$$$
SILVADENE Silver Sulfadiazine Generic $$$
ZOCOR Simvastatin 5mg, 10mg, 20mg, 40mg, 80mg Generic $$$
RAPAMUNE Sirolimus 0.5mg, 1mg, 2mg, 1mg/ml Brand $$$$$$ LMN
JANUVIA Sitagliptin Phosphate 25mg, 50mg, 100mg Brand $$$$
JANUMET Sitagliptin‐Metformin HCl 50‐500mg, 50‐1000mg Brand $$$$$
FERRLECIT Sod Ferric Gluc Cmplx 12.5mg Brand $$$$$$ LMN
EUFLEXXA Sodium Hyaluronate 10mg/ml Brand $$$$$$ LMN
HEALON Sodium Hyaluronate 10mg/ml, 14mg/ml, 23mg/ml Brand $$$$$$ LMN
HYALGAN Sodium Hyaluronate 20mg/2ml Brand $$$$$$ LMN
SUPARTZ Sodium Hyaluronate Intra‐articular 25mg/2.5ml Brand $$$$$$ LMN
VESICARE Solifenacin Succinate 5mg, 10mg Brand $$$
GENOTROPIN Somatropin
0.2mg, 0.4mg, 0.6mg, 0.8mg, 1mg, 1.2mg,
1.4mg, 1.6mg, 1.8mg, 2mg, 5mg, 12mg
Brand $$$$$$ CPA
HUMATROPE Somatropin 5mg, 6mg, 12mg, 24mg Brand $$$$$$ CPA
5mg/1.5ml, 10mg/1.5ml, 15mg/1.5ml, NORDITROPIN Somatropin
30mg/3ml Brand $$$$$$ CPA
NUTROPINLD Somatropin 5mg, 10mg, 5mg/2ml, 20mg/2ml Brand $$$$$$ CPA
OMNITROPELD Somatropin 5.8mg, 5mg/1.5ml, 10mg/1.5ml Brand $$$$$$ CPA
SAIZEN Somatropin 5mg, 8.8mg Brand $$$$$$ CPA
SEROSTIMLD Somatropin 4mg, 5mg, 6mg, 8.8mg Brand $$$$$$ LMN
TEV‐TROPINLD Somatropin 5mg Brand $$$$$$ CPA
ZORBTIVE Somatropin 8.8mg Brand $$$$$$ CPA
NEXAVARLD Sorafenib Tosylate 200mg Brand $$$$$$
BETAPACE Sotalol HCl 80mg, 120mg, 160mg, 240mg Generic $$$$
SPERMACIDAL PRODUCTS Spermacidal Products Sponge, Foam, Cream, Gel OTC $$
ALDACTONE Spironolactone 25mg, 50mg, 100mg Generic $$$
ALDACTAZIDE Spironolactone & Hydrochlorothiazide 25/25mg Generic $$$
$ ‐‐‐‐‐‐‐‐‐ $1 to $10
$$ ‐‐‐‐‐‐‐‐‐ $11 to $50
$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100
$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500
$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000
$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000
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6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 16 of 18
GCHP List of Covered Drugs
Generic Name Brand Names Generic Name Strength(s) Coverage Rx Cost LMN, QL, Step, CPA
CARAFATE Sucralfate 1g Generic $$$$
BLEPH‐10 Sulfacetamide Sodium 10% Generic $$
KLARON Sulfacetamide Sodium 10% Generic $$$$
SUMAXIN Sulfacetamide Sodium w/ Sulfur 10‐1%, 10‐4%, 10‐5% Generic $$$$
BACTRIM DS Sulfamethoxazole/Trimethoprim Generic $$
AZULFIDINE Sulfasalazine 500mg Generic $$$
CLINORIL Sulindac 150mg, 200mg Generic $$$
SUMATRIPTAN Sumatriptan Nasal Spray 5mg/ACT, 20mg/ACT Brand $$$ QL= 6 devices/30 days (5mg & 20mg spray)
IMITREX Sumatriptan Succinate 25mg, 50mg, 100mg Generic $$$
IMITREX Sumatriptan Succinate Injection 4mg/0.5ml, 6mg/0.5ml Generic $$$
SUTENT Sunitinib Malate 12.5mg, 25mg, 50mg Brand $$$$$$
QL= 9 tabs/30 days (25mg, 50mg, &
100mg) QL= 1 kit/30 days (2 syringes); 2
vials/30 days
PROGRAF Tacrolimus 0.5mg, 1mg, 5mg, 5mg/ml Brand $$$$$$ LMN
PROTOPIC Tacrolimus 0.03%, 0.1% Brand $$$$ CPA
TACROLIMUS Tacrolimus 0.5mg, 1mg, 5mg Generic $$$$$$ LMN
ADCIRCA Tadalafil 20mg Brand $$$$$$
NOLVADEX Tamoxifen Citrate 10mg, 20mg Generic $$$$
FLOMAX Tamsulosin HCl 0.4mg Generic $$$$
TAZORAC Tazarotene 0.05%, 0.1% Brand $$$$
TYZEKA Telbivudine Oral 600mg Brand $$$$$
VIBATIV Televancin IV 250mg, 750mg Brand $$$ LMN
MICARDIS Telmisartan 20mg, 40mg, 80mg Brand $$$$ Step: losartan potassium
RESTORIL Temazepam 7.5mg, 15mg, 30mg Generic $$ QL= 30 caps/30 days
TEMODAR Temozolomide 5mg, 20mg, 100mg, 140mg, 180mg, 250mg Brand $$$$$$$
TORISEL Temsirolimus 25mg/ml Brand $$$$$$
VIREAD Tenofovir Disoproxil Fumarate 300mg Brand $$$$$$ CPA
HYTRIN Terazosin HCl 1mg, 2mg, 5mg, 10mg Generic $$$
LAMISIL Terbinafine Oral 250mg Generic $$$$
TERCONAZOLE Terconazole Vaginal Generic $$
FORTEO Teriparatide 600mcg/2.4ml Brand $$$$$ LMN; Specialty
ANDRODERM Testosterone 2.5mg/24HR, 5mg/24HR Brand $
ANDROGEL Testosterone 1% Brand $
TESTIM Testosterone 1% Brand $
XENAZINELD Tetrabenazine 12.5mg, 25mg Brand $$$$$$ LMN
TETRACYCLINE Tetracycline Oral Generic $$
THALOMID Thalidomide 50mg, 150mg, 200mg100mg, Brand $$$$$$
THEO‐DUR Theophylline 100mg, 200mg, 300mg Generic $$$
THEOPHYLLINE ANHYDROUS Theophylline Brand $$ ARMOUR
THYRO Thyroid 32.5mg, 65mg, 130mg, 195mg Generic $$
THYROGENLD Thyrotropin Alfa 1.1mg Brand $$$$$$ LMN
TYGACIL Tigecycline IV 50mg Brand $$$$$ LMN
TIMOPTIC Timolol Maleate 0.25%, 0.5% Generic $$$
TIMOPTIC‐XE Timolol Maleate 0.25%, 0.5% Generic $$$
INNOHEP Tinzaparin Sodium 20000u/ml Brand $$$$$$ LMN; Available at Retail
QL= 1 pkg (6 caps or 90 caps); 2 pkgs (30 SPIRIVA Tiotropium Bromide Monohydrate 18mcg Brand $$$$
caps); per 30 days
TOBI Tobramycin 300mg/5ml Brand $$$$$$ LMN
TOBREX Tobramycin IV Generic $$$ QL= 14 days
TOPAMAX Topiramate 25mg, 50mg, 100mg, 200mg Generic $$ TOPAMAX
SPRINKLE Topiramate Sprinkle 15mg, 25mg Generic $$
HYCAMTIN Topotecan HCl 4mg Generic $$$$$
ULTRAM Tramadol HCl 50mg, 100mg, 200mg, 300mg Generic $$$$ QL= 120 tabs/30 days
HERCEPTIN Trastuzumab 440mg Brand $$$$$$
DESYREL Trazodone HCl 50mg, 100mg, 150mg, 300mg Generic $$
REMODULINLD Treprostinil Sodium 1mg/ml, 2.5mg/ml, 5mg/ml, 10mg/ml Brand $$$$$$ LMN; Specialty
RETIN‐A Tretinoin 0.25%, 0.375%, 0.05%, 0.1% Generic $$$$ Age >34
RETIN‐A MICRO Tretinoin Microsphere 0.04%, 0.1% Brand $$$$ Age >34
KENALOG Triamcinolone Acetonide 0.025%, 0.1%, 0.5% Generic $$
NASACORT AQ Triamcinolone Acetonide 55mcg/ACT Brand $$$$
MAXZIDE Triamterene & Hydrochlorothiazide 37.5‐25mg, 50‐25mg, 75‐50mg Generic $$$
Step: Fail one: flunisolide, fluticasone,
OMNARIS
$ ‐‐‐‐‐‐‐‐‐ $1 to $10
$$ ‐‐‐‐‐‐‐‐‐ $11 to $50
$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100
$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500
$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000
$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000
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6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 17 of 18
GCHP List of Covered Drugs
Generic Name Brand Names Generic Name Strength(s) Coverage Rx Cost LMN, QL, Step, CPA
CERUMENEX Triethanolamine Oleate Brand $$$
TIGAN Trimethobenzamide HCl 300mg/5ml Generic $$$
TRELSTARLD Triptorelin Pamoate 3.75mg, 11.25mg, 22.5mg Brand $$$$$$
SANCTURA, SANCTURA XR Trospium Chloride 20mg, 60mg Generic $$$
BRAVELLE Urofollitropin 75u, 150u, 300u, 600u, 900u Brand $$$$$$ LMN
URSO, URSO FORTE Ursodiol 250mg, 500mg Generic $$$$
VALTREX Valacyclovir HCl 500mg, 1g Generic $$$$ CPA
VALCYTE Valganciclovir HCl 450mg, 50mg/ml Brand $$$$$$ LMN
DIOVAN Valsartan 40mg, 80mg, 160mg, 320mg Brand $$$ Step: losartan potassium
80‐12.5mg, 160‐12.5mg, 160‐25mg, 320‐ DIOVAN HCT Valsartan‐Hydrochlorothiazide
12.5mg, 320‐25mg Brand $$$$ Step: losartan potassium HCT
VANCOCIN Vancomycin Oral, IV Generic $$$
EFFEXOR Venlafaxine HCl 25mg, 37.5mg, 50mg, 75mg, 100mg Generic $$
EFFEXOR ER Venlafaxine HCl SR 37.5mg, 75mg, 150mg, 225mg Generic $$$
ISOPTIN Verapamil HCl 40mg, 80mg, 180mg, 240mg Generic $$$
VISUDYNELD Verteporfin 15mg Brand $$$$$$ LMN
VINBLASTINE Vinblastine Sulfate 1mg/ml Generic $$$$
VINCRISTINE Vincristine Sulfate 1mg/ml Generic $$$$
NAVELBINE Vinorelbine Tartrate 10mg/ml, 50mg/5ml Brand $$$$$$
VINORELBINE Vinorelbine Tartrate 10mg/ml, 50mg/5ml Brand $$$$$$
VFEND Voriconazole 50mg, 200mg, 40mg/ml Brand $$$$$$ LMN
1mg, 2mg, 2.5mg, 3mg, 4mg, 5mg, 6mg, COUMADIN Warfarin Sodium
7.5mg, 10mg Generic $$$
ACCOLATE Zafirlukast 10mg, 20mg Brand $$$$ Step: Singulair
SONATA Zaleplon 5mg, 10mg Generic $$ QL= 30 caps/30 days
RELENZA Zanamivir Oral 5mg Brand $$$ QL= 20 tabs/30 days
RECLAST Zoledronic Acid 5mg/100ml Brand $$$$$$ LMN
ZOMETA Zoledronic Acid 4mg/5ml Brand $$$$$$ LMN; Specialty
Step: Sumatriptan Succinate; QL= 9 tabs/30 ZOMIG, ZOMIG ZMT Zolmitriptan 2.5mg, 5mg Brand $$$$
ZOMIG NASAL SPRAY Zolmitriptan Nasal Spray 5mg Brand $$$$
days Step: Sumatriptan Succinate;
QL= 9 devices/30 days
AMBIEN Zolpidem Tartrate 5mg, 10mg, 6.25mg, 12.5mg Generic $$ QL= 30 tabs/30 days
ZONEGRAN Zonisamide 25MG,50mg, 100mg Generic $$
ACCU‐CHEK ‐ kits, strips and
supplies
ONE TOUCH ‐ kits, strips and
supplies
Brand $$$$ QL= 100 strips/30 days
Brand $$$$ QL= 100 strips/30 days
TRUE ‐ kits, strips and supplies Brand $$$ QL= 100 strips/30 days
$ ‐‐‐‐‐‐‐‐‐ $1 to $10
$$ ‐‐‐‐‐‐‐‐‐ $11 to $50
$$$ ‐‐‐‐‐‐‐‐‐ $51 to $100
$$$$ ‐‐‐‐‐‐‐‐‐ $101 to $500
$$$$$ ‐‐‐‐‐‐‐‐ $501 to $1,000
$$$$$$ ‐‐‐‐‐‐‐ $1,001 to $5,000
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6/23/2011 $$$$$$$ ‐‐‐‐‐‐‐ $5,001 to $10,000 18 of 18
June 23, 2011
Earl Greenia
Chief Executive Officer
Gold Coast Health Plan
2220 E. Gonzales Road, Suite 200
Oxnard, CA 93036
Dear Earl,
Thank you for the opportunity to provide this written update to you and the Commission. Script
Care and GCHP have been working diligently to ensure a successful go-live on July 1. Some
recent successes include:
- Script Care and your Pharmacy and Therapeutics Committee recently completed the
final draft of the List of Covered Drugs (formulary).
- We officially opened our local office at 1701 Solar, Oxnard, CA on June 20, 2011. The
office has begun fielding calls and inquiries regarding the Pharmacy Services program.
Our customer service department will begin providing 24 hour access on July 1, 2011.
- We are making the final adjustments on the plan design in the adjudication system to be
completed on June 27.
- Script Care has completed the Pharmacy Network development, and the network has
been loaded and activated in the system.
I understand that there has been concern voiced by a few of the local independent pharmacy
owners. Any transition from a fee-for-service to a managed care reimbursement system will
create some anxiety. Since the last commission meeting, we have continued outreach to
independent and chain providers in the community. We held two open forum meetings with 27
attendees, 4 direct provider meetings, 6 pharmacy location meetings and multiple conference
calls with chain providers. We have addressed concerns such as timing of activation, member
awareness, changes in program design, the list of covered drugs, and reimbursement rates.
We have conducted multiple meetings with these pharmacies over the past two months to hear
their concerns. We have provided information including cost analysis and the detailed MAC list.
4g-1
We also made some favorable adjustments to the original contract offer based on the concerns
expressed by these providers. These included combining the limited and restricted network to
offer more favorable reimbursement, limiting the network to provide contract pharmacies with
increased volume opportunity, and increasing the dispensing fee in the Long Term Care
population to $2.25, an increase of $1.00 per prescription.
We have provided a comparative analysis (please see attached Exhibit A) including some of the
other COHS pharmacy reimbursement rates and other local PBM reimbursement rates to
address the fairness on the contracted rates that continues to be expressed directly to Script
Care by these few providers. The comparison illustrates that the adjustments SCL made to the
original contract offering make the GCHP reimbursement rates more favorable to pharmacies
than what is found in similar programs.
Original concerns regarding the brand reimbursements rates have decreased among providers
after a cost analysis was conducted to demonstrate the manner in which brand claims were
adjudicated. Providers were able to see that little to no change is found in the reimbursement of
brand drugs. The focus moved to generic products and concerns were voiced that pharmacies
would only see gross profit margin averages of $1.25 to $2.00 per script. We understand
pharmacy reimbursements will be reduced in comparison to the Medi-Cal FFS rates although not
to the level expressed by these few providers. Exhibit B utilizes a generic reimbursement
comparison provided by the referenced local independent providers on May 24, 2011. In this
analysis we added the acquisition cost provided by a local independent pharmacy to give
reference to the average margins expected on these items.
Script Care/GCHP will be conducting a Pharmacy Benefit Outreach Program on June 29 at
7:30pm held at the Adagio Building, Hilton Garden Inn, 2000 Solar Drive. The program has
been announced (please see Exhibit C) to all providers in the network. With the expectation of
an average 3,500+ transactions a day, the focus of the meeting will be to educate pharmacies
on changes, procedures and requirements to enable a smoother transition.
Again, thank you for the opportunity to provide this response.
Sincerely,
Kevin J. Brown Executive Vice President Script Care, Ltd.
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4g-3
EXHIBIT A: PROGRAM RATE COMPARISON
CenCal
PHA
GCHP
Restat (PBM) Commercial
Contract Limited
Restat (PBM) Commercial
Contract Restricted
Retail Brand - 30
AWP - 17.65% or U&C
AWP - 17.65% or U&C
AWP - 17.65% or U&C
AWP - 18% or U&C
AWP - 20% or U&C
-Dispensing Fee
$1.25
$1.25
$1.25
$1.25
$0.95
Retail Generic-30
MAC or AWP - 27%
or U&C
MAC or AWP - 27%
or U&C
SCL MAC or AWP -
22% or U&C
MAC or AWP -25%
or U&C
MAC or AWP -25% or
U&C -Dispensing Fee
$1.25
$1.25
$1.25
$1.25
$0.95
Retail Brand -90
AWP - 22% or U&C
AWP - 22% or U&C
AWP - 21% or U&C
AWP - 23% or U&C
AWP - 25% or U&C
-Dispensing Fee
$0.00
$0.00
$0.00
$0.25
$0.00
Retail Generic - 90
MAC or AWP - 22%
or U&C
MAC or AWP -
22% or U&C
SCL MAC or AWP -
22% or U&C
MAC or AWP - 25%
or U&C
MAC or AWP -25% or
U&C -Dispensing Fee
$0.00
$0.00
$0.00
$0.25
$0.00
Retail Brand - LTC
AWP - 17.65% or U&C
AWP - 17.65% or U&C
AWP - 17.65% or U&C
N/A
N/A
-Dispensing Fee
$1.25
$1.25
$2.25
N/A
N/A
Retail Generic - LTC
MAC or AWP - 27% or U&C
MAC or AWP - 27% or U&C
SCL MAC or AWP - 22% or U&C
N/A
N/A
-Dispensing Fee
$1.25
$1.25
$2.25
N/A
N/A
4g-4
EXHIBIT B
DATE
DRUG
NDC
QTY
MEDI-CAL
REIMBURSEMENT
SCL MAC
SCRIPT CARE
REIMBURSEMENT
(SAMPLE) LOCAL INDEPENDENT
ACQUISTION COST
5/24/2011 GLIPIZIDE 5MG 00591046010 30 $9.35 0.0699 $3.35 $0.68
5/24/2011 BENAZEPRL 40MG 00185004805 30 $21.97 0.1753 $6.51 $1.88
5/24/2011 LISINOPRIL 20MG 00185010210 30 $9.64 0.114 $4.67 $2.10
5/24/2011 GLYBURIDE 5MG 64720012511 30 $15.74 0.0926 $4.03 $2.94
5/24/2011 METFORMIN 1000 68382003010 60 $17.20 0.1135 $8.06 $3.00
5/24/2011 AZITHRO 200/5 59762312001 15 $34.58 1.32 $21.05 $13.06
5/24/2011 CEPHALEXIN 500MG 61442016205 30 $15.44 0.1911 $6.98 $5.86
5/24/2011 OXYCODONE 30MG 00406853001 90 $114.49 1.309 $119.06 $29.29
5/24/2011 NAPROXEN 500 68462019001 60 $12.19 0.0858 $6.40 $3.61
5/24/2011 IBU 100/5ML 45802095226 120 $15.95 0.0373 $5.73 $2.67
5/24/2011 AMOX 250/5 00143988915 150 $11.55 0.0254 $5.06 $4.69
5/24/2011 CEPHALEXIN 250/5 68180012402 200 $33.39 0.0917 $19.59 $12.56
5/24/2011 AMOX TR-K CLD 66685101202 100 $60.72 0.3755 $38.80 $16.58
5/24/2011 HCTZ 00603385632 30 $6.90 0.018 $1.79 $0.33
5/24/2011 VICODIN GENERIC 00591034905 30 $18.48 0.4763 $15.54 $0.75
5/24/2011 RANITIDINE 150 64679090603 60 $10.85 0.0658 $5.20 $2.40
5/24/2011 IBU 800 55111068405 30 $9.16 0.0638 $3.16 $1.30
5/24/2011 ATENOLOL 50 00781150610 30 $8.75 0.0535 $2.86 $0.60
Based on local Indpendents sample claims provided 5/24/11:
Current Medi-Cal Est. Margin - $17.89/Generic Rx
GCHP Contract Est Margin -$9.64/Generic Rx
Exhibit C
Pharmacy Benefit Outreach Program
Wednesday June 29, 2011
7:30 PM
Adagio Building, Hilton Garden Inn
2000 Solar Drive
Oxnard
This program will outline the upcoming transition from the
Medi-Cal FFS Program to the GCHP Pharmacy Services
Program for the County of Ventura beginning July 1, 2011.
All GCHP contracted pharmacies should plan to attend or
send at least one representative. Pertinent procedures and
guidelines will be discussed and highlighted at this time.
GCHP Pharmacy Services Procedure Manuals and the GCHP
List of Covered Drugs will be available.
For More Information Contact:
Jade Thibodeaux
1-800-880-9902 ext. 1153
4g-5