Affinity Health Plan - UniCare Drug Formulary

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UniCare Drug Formulary

Note: Mandatory Generics

	Formulary	Non-Formulary
Allergy/ Cough & Cold
Antihistamines (Non-Sedating)	Loratidine, Loratidine-D, Loratidine syrup, Clarinex	Allegra, Allegra-D
Antihistamines (OTC & RX)	Consider OTC first, Generic RX, Astelin, Zyrtec, Zyrtec-D, Zyrtec Syrupⁱ	All Brand Products with Generic Equivalent
Cough & Cold	Consider OTC first, Generic	All Brand Products with Generic Equivalent
Nasal Steroids	Consider OTC Nasalcrom first, Flonase, Nasonex, Rhinocort, Rhinocort AQ	Beconase, Beconase AQ, Nasalide, Nasacort AQ, Nasarel, Nasacort, Vancenase, Vancenase AQ
Asthma / Respiratory
Leukotriene Modulators	Singulair	Zyflo, Accolateⁱⁱ
Steroid Inhalants	Flovent, Pulmicort (QL), QVAR, Aerobid, Aerobid-M, Azmacort, Beclovent, Vanceril, Vanceril-DS	All Brand Products with Generic Equivalent,
Sympathomimetics	Generic, Serevent, Foradil	All Brand Products with Generic Equivalent, Xopenexⁱⁱⁱ
Other Asthma Medications	Cromolyn, Advair, Combivent, Atrovent
Bladder
Genitourinary Medications	Oxybutynin, Detrol, Detrol LA	Ditropan, Ditropan XL
Blood Modifiers
Anticlaudication	Pentoxifylline	Trental
Anticoagulants	Warfarin, Coumadin	All Brand Products with Generic Equivalent
Antiplatelets	Generics, Aggrenox, Plavix	Agrylin, Ticlid, Ticlopidine, Pletal, Persantine
Diabetes
Insulin Sensitizing Agents	Avandia, Actos
Insulin	Humulin, Humalog, Lantus	Novolin, Novolog
Other Diabetic Medications	Generics Amaryl, Glucotrol XL, Glucophage, Glucophage XR, Glucovance, Glyset, Precose, Prandin, Starlix	All Brand Products with Generic Equivalent
Diabetic Supplies	Accucheck Advantage, Simplicity, & Complete Care Monitors & Supplies
Ear
AntiInfectives	Generics	All Brand Products with Generic Equivalent
Otic Miscellaneous	OTC Debrox generic, Cerumenex
Eye
Glaucoma Agents	Generics, Azopt, Alphagan, Betoptic-s, Cosopt, Trusopt, Xalatan,	All Brand Products with Generic Equivalent
Ophthalmic Allergy Agent	Cromolyn Sod, Zaditor, Livostin	Patanol, Optivar, Alomide, Alocril, Alamast, Crolom
Heart / Cardiovascular
Antihyperlipidemic-HMG CoA RI	Generics, Lipitor, Pravachol, Pravigard	Altocor, Lescol, Mevacor, Zocor
Antihyperlipidemic-Other	OTC Niacin, Gemfibrozil, Tricor, Welchol	All Brand Products with Generic Equivalent
ACE Inhibitors	Generics, Mavik, Altace, Monopril, Univasc, Lotensin	Aceon, Capoten, Prinivil/Zestril, Vasotec, Accupril, All Brand Products with Generic Equivalent
Angiotensin II Rec Antagonist (ARB)	Diovan, Cozaar	Atacand, Avapro, Micardis, Teveten
Antihypertensive Combinations	Generics, Diovan HCT, Hyzaar, Lopressor HCT, Lotrel, Monopril HCT, Tarka	Accuretic, Atacand HCT, Avalide, Corzide, Inderide, Inderide LA, Lexxel, Micardis HCT, Teczem CR, Capozide, Uniretic, Vaseretic, Tenoretic, Timolide, Prinzide, Zestoretic, Ziac, Lotensin HCT
Beta Blockers	Generics, Toprol XL	All Brand Products with Generic Equivalent
Calcium Channel Blockers	Generics, Covera HS, Verelan PM, Norvasc, Plendil, Sular, Cardizem LA	Vasocor, Cardene, Cardene SR, Dynacirc, Dynacirc CR, Adalat CC, Tiazac, All Brand Products with Generic Equivalent
Infection
Antifungals	Generic, Griseofulvin products, Diflucan, Lamisil	Nizoral, Sporanox, All Brand Products with Generic Equivalent
Antivirals - Flu	Amantadine, Flumadine, Relenza, Tamiflu
Antivirals - Herpes	Generics, Famvir, Valtrex	All Brand Products with Generic Equivalent
Antibiotics
Cephalosporins - 1st Generation	Generic Prefered 1st Line, Duricef Oral Susp	All Brand Products with Generic Equivalent
Cephalosporins - 2nd Generation	Generic Prefered 1st Line, Cefzil	All Brand Products with Generic Equivalent, Ceftin, Ceclor CD, Lorabid
Cephalosporins - 3rd Generation	Generic Prefered 1st Line, Cedax, Omnicef	All Brand Products with Generic Equivalent, Suprax, Vantin, Spectrocef
Macrolides	Generic, Zithromax	Biaxin, Dynabac, All Brand Products with Generic Equivalent
Fluoroquinolones	Cipro, Tequin, Floxin	Avelox, Levaquin, Noroxin, Maxaquin, Penetrex
Penicillins	Generic, Augmentin	All Brand Products with Generic Equivalent
Tetracyclines	Generic	All Brand Products with Generic Equivalent
Other Antibiotics		Zyvox
Mental Health
Antianxiety Agents	Generics	Buspar, All Brand Products with Generic Equivalent
Antidepressants - SSRI	Fluoxetine, Lexapro, Paxil CR, Prozac Weekly, Zoloft	All Brand Products with Generic Equivalent
Antidepressants - Other	Generics, Fluvoxamine, Effexor, Effexor XR, Remeron, Remeron soltab, Serzone, Wellbutrin SR	All Brand Products with Generic Equivalent
Antipsychotics	Clozapine, Clozaril, Geodon, Risperdal, Zyprexa
Alzheimers	Aricept, Exelon, Reminyl
Hypnotics - Quantity Limits	Generics, Ambien (QL), Sonata (QL)	All Brand Products with Generic Equivalent
Migraine Products - Quantity Limits	Amerge, Axert, Imitrex, Maxalt, Zomig, Frova, Relpax
Men's Health
Impotence Agents		Edex, Muse, Viagra, Levitra, Cialis
Prostatic Hypertrophy Agents	Generics, Flomax, Proscar	Cardura, Hytrin
Osteoporosis
Calcium Regulators	Actonel, Fosamax	Didronel, Miacalcin
Hormone Receptor Modulators	Evista
Other
Birth Control general	OTC Condoms, Foam
Smoking Deterrents	OTC Patches, Lozenge, Zyban, Nicotrol Inhaler
Pain / Arthritis / Muscles
Analgesics - Narcotic	Generics, MS Contin, MSIA, OxyContin, Oxyfast, Oxy-IR	All Brand Products with Generic Equivalent
Analgesics - NSAIDs & Cox II	Generics, Arthrotec, Mobic	All Brand Products with Generic Equivalent, Bextra, Cataflam, Celebrex, Daypro, Lodine XL, Oruvail, Relafen, Vioxx, Voltaren XR
Skin
Dermatological - all	Generics, Brands with no Generics Available	All Brand Products with Generic Equivalent, Benzamycin, Benzaclin
Stomach / Ulcer
H-2 Antagonists	Cimetidine, Famotidine, Ranitidine	Axid (brand & generic) & All Brand Products with OTC or Generic Equivalent
Proton Pump Inhibitors	Generic, Omeprazole 10mg, Prilosec OTC 20mg, Protonix, Nexium^iv	Aciphex, Prilosec 10mg & 40mg, Aciphex, Prevacid^v, Prevacid Nap
Misc Stomach/Ulcer Products	Metoclopramide	Reglan
Thyroid
Thyroid medications	Levoxyl, Synthroid
Woman's Health
Contraceptives	Generics, Cyclessa, Desogen, Estrostep, Estrostep FE, Loestrin, Loestrin FE, Mircette, Nor-QD, Nordette, Ortho-Cept, Ortho-Cyclen, Othro-Tricyclen, Ovral, Micronor, Modicon, Yasmin, Ortho-Evra, Seasonale	Alesse, Brevicon, Demulen, Levlite, Lo-Ovral, Ovcon, Norinyl, Tri-Levlen, Tri-Phasil, Tri-Norinyl
Estrogens / HRT	Activella, Cenestin, Combipatch, Fem HRT, Ortho-Prefest, Premarin, Prempro, Premphase	All Brand Products with Generic Equivalent

This formulary does not list all products covered. Please consider a generic drug in any class as a first line medication. All generic and brand medications without a generic equivalent are covered unless specifically listed as a non-formulary agent or are restricted by the plans benefit guidelines.

Proton Pump Inhibitors are limited to 30 units for 30 days, except Prilosec OTC which is limited to # 60 capsules per 30 days.
Viagra limited to 6 tabs per 30 days Males 18 & Older.
Ambien and Sonata are limited to # 15 tablets/capsules per 30 days supply.
Pulmicort - Maximum monthly dosage equals #60 ampules of 0.5mg/2ml or #60 ampules of 0.25mg/2ml
Smoking Deterrents are allowed only up to a 90 day per year total limit.
Relenza, Tamiflu are allowed only once per flu season.
Migraine Agents: Dosage limitations see table below:

AGENT	Dose	Suggested limits/ month based on max # headaches that can be safely treated/month
Axert	6.25mg 12.5mg	#12 tablets (2 boxes) #12 tablets (2 boxes)
Imitrex Injection	6 mg	# 8 syringes ( 4 boxes)
Imitrex Nasal Spray	5mg 20 mg	#12 unit dose sprays ( 2 boxes) #12 unit dose sprays ( 2 boxes)
Imitrex Oral (Sumatriptan )	25 mg 50 mg 100mg	# 9 tablets ( 1 box) # 9 tablets ( 1 box) # 9 tablets ( 1 box)
Frova	2.5mg	# 9 tablets (1 box)
Amerge (Naratriptan )	1mg 2.5 mg	# 9 tablets ( 1 box) # 9 tablets ( 1 box)
Zomig ( Zolmitriptan) Zomig ZMT	2.5 mg 5 mg 2.5mg	# 6 tablets ( 1 box) # 6 tablets ( 2 boxes) # 6 tablets ( 1 box)
Maxalt and Maxalt MLT (Rizatriptan )	5mg 10mg	# 12 tablets ( 2 boxes) # 12 tablets ( 2 boxes)
Migranal Nasal Spray (Dihydroergotamine)	2 mg	# 1 box ( 4 ampules or 4 doses)
Relpax	20mg 40mg	#1 box (6 tablets) #1 box (6 tablets)

Zyrtec, Zyrtec-D, Zyrtec Syrup, Clarinex, Claritin-D, are covered after the failure of an OTC product.
Accolate coverage requires failure of 30 day trial of Singulair.
Xopenex will be allowed after a 30 day failure of albuterol nebulizer solution.
Nexium & Protonix require failure of 30 days of generic omeprazole 10mg or Prilosec OTC 20mg.
Prevacid & Aciphex require failure of 30 days of Nexium or Protonix.

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