| Drug | Generic Name | Place of Service | Commercial/ASO/XEROX/HSA | GOLD w/PART D | GOLD NON-PART D | USACARE (KODAK PFFS) | KODAK CARESTREAM PPO/MAX/CDHP | CARESTREAM EPO | OPTION - current FHP starting 10/1/08 | USDIRECT | Policy |
| Abraxane | paciltaxel | office, outpatient | Prior authorization is required | Prior authorization is required | Prior authorization is required | No prior authorization is needed | Prior authorization required | Prior authorization not required | Prior authorization required | No prior authorization is needed | Abraxane |
| Accolate | zafirlukast | Pharmacy | SE:Must have a claim history showing 1 fill of an asthma medication in the past 12 months, otherwise prior authorization is needed. | SE:Must have a claim history showing 1 fill of an asthma medication in the past 12 months, otherwise prior authorization is needed. | Not a covered benefit. | SE:Must have a claim history showing 1 fill of an asthma medication in the past 12 months, otherwise prior authorization is needed. | Not a covered benefit. | Not a covered benefit, carved out to PharmaCare | Not covered, carved out to Medicaid | SE:Must have a claim history showing 1 fill of an asthma medication in the past 12 months, otherwise prior authorization is needed. | Leukotriene Modifiers |
| acetylcysteine for inhalation | acetylcysteine | Pharmacy | No prior authorization is needed | Requires Prior Authorization to determine coverage under Medicare Part B or D. | Requires Prior Authorization to determine coverage under Medicare Part B or D, if covered | Requires Prior Authorization to determine coverage under Medicare Part B or D. | Not a covered benefit. | Not a covered benefit, carved out to PharmaCare | Not covered, carved out to Medicaid | No prior authorization is needed | Medicare Part D vs Part B Determination |
| Aciphex | rabeprazole | Pharmacy | QL:Prior authorization is required and has a quantity limit of 30 pills per month (any strength) | QL: Prior authorization is not required unless requesting over 30 pills per month (any strength) | Not a covered benefit. | QL:Prior authorization is not required unless requesting over 30 pills per month (any strength) | Not a covered benefit. | Not a covered benefit, carved out to PharmaCare | Not covered, carved out to Medicaid | QL:Prior authorization is required and has a quantity limit of 30 pills per month (any strength) | PPI's |
| Actimmune | interferon gamma | Pharmacy | Prior authorization is required | Prior authorization is required. | Not a covered benefit. | Prior authorization required | Not a covered benefit. | Not a covered benefit, carved out to PharmaCare | Not covered, carved out to Medicaid | Prior authorization is required. | Actimmune |
| Actiq | fentanyl citrate lozenges | Pharmacy | QL:Prior authorization is required only if requesting over 60 per 30 days (most strengths). | QL:Prior authorization is required and has a quantity limit of 60 per 30 days (most strengths). | Not a covered benefit. | QL:Prior authorization is required and has a quantity limit of 60 per 30 days (most strengths). | Not a covered benefit. | Not a covered benefit, carved out to PharmaCare | Not covered, carved out to Medicaid | QL:Prior authorization is required only if requesting over 60 per 30 days (most strengths). | Pain Medication |
| Adipex | phentermine | Pharmacy | Prior authorization is required | Weight loss drugs are excluded from coverage except for Enhanced Plans for which prior authorization is not required | Not a covered benefit. | Weight loss drugs are excluded from coverage except for Enhanced Plans for which prior authorization is not required | Not a covered benefit. | Not a covered benefit, carved out to PharmaCare | Not covered, carved out to Medicaid | Prior authorization is required | Weight Loss Agents |
| Alimta | pemetrexed | office, outpatient | Prior authorization is required | Prior authorization is required | Prior authorization is required | No prior authorization is needed | Prior authorization required | Prior authorization not required | Prior authorization required | No prior authorization is needed | Select Biologic Chemotherapy Agents |
| Alkeran | melphalan | Pharmacy | No prior authorization is needed | Requires Prior Authorization to determine coverage under Medicare Part B or D. | Requires Prior Authorization to determine coverage under Medicare Part B or D, if covered | Requires Prior Authorization to determine coverage under Medicare Part B or D. | Not a covered benefit. | Not a covered benefit, carved out to PharmaCare | Not covered, carved out to Medicaid | No prior authorization is needed | New Drug Policy |
| Alvesco | ciclesonide | Pharmacy | Prior authorization is required | Prior authorization is required | Not a covered benefit. | Prior authorization is required | Not a covered benefit. | Not a covered benefit, carved out to PharmaCare | Not covered, carved out to Medicaid | Prior authorization is required | New Drug Policy |
| Ambien/CR | zolpidem tartrate | Pharmacy | QL: Prior authorization is not required unless requesting over 15 tablets (any strength) per 30 days | QL:Prior authorization is not required unless requesting over 30 tablets (any strength) per 60 days | Not a covered benefit. | QL:Prior authorization is not required unless requesting over 30 tablets (any strength) per 60 days | Not a covered benefit. | Not a covered benefit, carved out to PharmaCare | Not covered, carved out to Medicaid | QL:Prior authorization is not required unless requesting over 15 tablets (any strength) per 30 days | Select Hypnotics |
| Amerge | naratriptan | Pharmacy | QL: Prior authorization is not required unless requesting over (18) 1mg or (9) 2.5 mg tablets | QL:Prior authorization is not required unless requesting over (18) 1mg or (9) 2.5 mg tablets | Not a covered benefit. | QL:Prior authorization is not required unless requesting over (18) 1mg or (9) 2.5 mg tablets | Not a covered benefit. | Not a covered benefit, carved out to PharmaCare | Not covered, carved out to Medicaid | QL:Prior authorization is not required unless requesting over (18) 1mg or (9) 2.5 mg tablets | Prescription Drug Quantity Limits |
| Amevive* | alefacept | office, outpatient | Prior authorization is required | Prior authorization is required | Prior authorization is required | No prior authorization is needed | Prior authorization required | Prior authorization not required | Prior authorization required | No prior authorization is needed | Psoriasis Drug Therapy |
| Pharmacy | Prior authorization is required | Prior authorization is required | Not a covered benefit. | Prior authorization required | Not a covered benefit. | Not a covered benefit, carved out to PharmaCare | Not covered, carved out to Medicaid | Prior authorization is required | |||
| Amitiza | lubiprostone | Pharmacy | Prior authorization is required | Prior authorization is required | Not a covered benefit. | Prior authorization required | Not a covered benefit. | Not a covered benefit, carved out to PharmaCare | Not covered, carved out to Medicaid | Prior authorization is required | Constipation/IBS Medications |
| Anzemet | dolasetron | Pharmacy | QL:Prior authorization required if requesting over (14) 50mg or (7) 100 mg tablets | QL:Prior authorization is required to determine coverage under Medicare B or D and if requesting over (14) 50mg or (7) 100 mg tablets | QL:Prior authorization is required to determine coverage under Medicare B or D and if requesting over (14) 50mg or (7) 100 mg tablets | Prior authorization is required to determine coverage under Medicare B or D and if requesting over (14) 50mg or (7) 100 mg tablets | Not a covered benefit. | Not a covered benefit, carved out to PharmaCare | Not covered, carved out to Medicaid | QL:Prior authorization required if requesting over (14) 50mg or (7) 100 mg tablets | Prescription Drug Quantity Limits and Medicare Part D vs Part B Determination |
| Aracalyst | rilonacept | Pharmacy | Prior authorization is required | Prior authorization is required | Not a covered benefit. | Prior authorization is required | Not a covered benefit. | Not a covered benefit, carved out to PharmaCare | Not covered, carved out to Medicaid | Prior authorization is required | New Drug Policy |
| Aralast | alpha1 proteinase inhibitor | office, outpatient | Prior authorization is required | Prior authorization is required | Prior authorization required | NO PRIOR AUTHORIZATION REQUIRED | Prior authorization required | Prior authorization not required | Prior authorization is required | No prior authorization is needed | Alpha-1 Antitrypsin Inhibitor Therapy |
| Pharmacy | N/A | Prior authorization is required | Not a covered benefit. | Prior authorization is required. | Not a covered benefit. | Not a covered benefit, carved out to PharmaCare | Not covered, carved out to Medicaid | Prior authorization is required. | |||
| Aralen | chloroquine | Pharmacy | Prior authorization is required | No prior authorization is needed. | Not a covered benefit. | No prior authorization is needed. | Not a covered benefit. | Not a covered benefit, carved out to PharmaCare | Not covered, carved out to Medicaid | Prior authorization is required | Antimalarial Drugs Policy |
| Aranesp | darbepoetin | office, outpatient | Prior authorization is required | Prior authorization is required. | Prior authorization is required. | No prior authorization is needed. | Prior authorization required | Prior authorization not required | Prior authorization is required. | No prior authorization is needed | Erythropoietic Agents |
| Pharmacy | Prior authorization is required | Prior authorization is required. | Not a covered benefit. | Prior authorization is required. | Not a covered benefit. | Not a covered benefit, carved out to PharmaCare | Not covered, carved out to Medicaid | Prior authorization is required. | |||
| Atacand | candesartan cilexetil | Pharmacy | Prior authorization is required. | SE:Prior authorization is required unless claims history shows fill of ACE inhibitor in the past 18 months, then step edits will allow payment | Not a covered benefit. | SE: Prior authorization is required unless claims history shows fill of ACE inhibitor in the past 18 months, then step edits will allow payment | Not a covered benefit. | Not a covered benefit, carved out to PharmaCare | Not covered, carved out to Medicaid | Prior authorization is required. | ACE/ARB Policy |
| Avalide | hydrochlorothiazide; irbesartan | Pharmacy | SE: Prior authorization is required unless claims history shows fill of ACE inhibitor in the past 18 months, then step edits will allow payment | SE: Prior authorization is required unless claims history shows fill of ACE inhibitor in the past 18 months, then step edits will allow payment | Not a covered benefit. | SE:Prior authorization is required unless claims history shows fill of ACE inhibitor in the past 18 months, then step edits will allow payment | Not a covered benefit. | Not a covered benefit, carved out to PharmaCare | Not covered, carved out to Medicaid | SE: Prior authorization is required unless claims history shows fill of ACE inhibitor in the past 18 months, then step edits will allow payment | ACE/ARB Policy |
| Avapro | irbesartan | Pharmacy | SE: Prior authorization is required unless claims history shows fill of ACE inhibitor in the past 18 months, then step edits will allow payment | SE:Prior authorization is required unless claims history shows fill of ACE inhibitor in the past 18 months, then step edits will allow payment | Not a covered benefit. | SE:Prior authorization is required unless claims history shows fill of ACE inhibitor in the past 18 months, then step edits will allow payment | Not a covered benefit. | Not a covered benefit, carved out to PharmaCare | Not covered, carved out to Medicaid | SE: Prior authorization is required unless claims history shows fill of ACE inhibitor in the past 18 months, then step edits will allow payment | ACE/ARB Policy |
| Avastin | bevacizumab | office, outpatient | Prior authorization is required | Prior authorization is required | Prior authorization is required | NO PRIOR AUTHORIZATION REQUIRED, unless for use in the eye | Prior authorization required | Prior authorization not required | Prior authorization is required | NO PRIOR AUTHORIZATION REQUIRED, unless for use in the eye | Select Biologic Chemotherapy Agents |
| Avinza | morphine sulfate | Pharmacy | SE, QL: Prior authorization is not required unless requesting over 30 pills per month or claims history does not show fill of immediate release pain reliever in past 90 days. | SE, QL: Prior authorization is not required unless requesting over 30 pills per month or claims history does not show fill of immediate release pain reliever in past 90 days. | Not a covered benefit. | SE,QL:Prior authorization is not required unless requesting over 30 pills per month or claims history does not show fill of immediate release pain reliever in past 90 days. | Not a covered benefit. | Not a covered benefit, carved out to PharmaCare | Not covered, carved out to Medicaid | SE, QL: Prior authorization is not required unless requesting over 30 pills per month or claims history does not show fill of immediate release pain reliever in past 90 days. | Pain Medication |
| Axert | almotriptan | Pharmacy | QL: Prior authorization is required only if requesting over the following quantity limits: (12) 6.25 mg; (8) 12.5 mg tablets | QL: Prior authorization is required only if requesting over the following quantity limits: (12) 6.25 mg; (8) 12.5 mg tablets | Not a covered benefit. | QL:Prior authorization is required only if requesting over the following quantity limits: (12) 6.25 mg; (8) 12.5 mg tablets | Not a covered benefit. | Not a covered benefit, carved out to PharmaCare | Not covered, carved out to Medicaid | QL: Prior authorization is required only if requesting over the following quantity limits: (12) 6.25 mg; (8) 12.5 mg tablets | Prescription Drug Quantity Limits |
| Azasan | azathioprine | Pharmacy | No prior authorization is needed | Requires Prior Authorization to determine coverage under Medicare Part B or D. | Requires Prior Authorization to determine coverage under Medicare Part B or D, if covered | Requires Prior Authorization to determine coverage under Medicare Part B or D. | Not a covered benefit. | Not a covered benefit, carved out to PharmaCare | Not covered, carved out to Medicaid | No prior authorization is needed | Medicare BvsD Policy |
| Azor | amlodipine+ olmesartan | Pharmacy | SE: Prior authorization is required unless claims history shows fill of ACE inhibitor in the past 18 months, then step edits will allow payment | Prior authorization is required | Not a covered benefit. | Prior authorization is required | Not a covered benefit. | Not a covered benefit, carved out to PharmaCare | Not covered, carved out to Medicaid | SE: Prior authorization is required unless claims history shows fill of ACE inhibitor in the past 18 months, then step edits will allow payment | ACE/ARB Policy |
| Baraclude* | entecavir | Pharmacy | Prior authorization is required | Prior authorization is required | Not a covered benefit. | Prior authorization is required | Not a covered benefit. | Not a covered benefit, carved out to PharmaCare | Not covered, carved out to Medicaid | Prior authorization is required. | Hepatitis B Oral Agents |
| Benicar/HCT | hydrochlorothiazide; olmesartan medoxomil | Pharmacy | SE: Prior authorization is required unless claims history shows fill of ACE inhibitor in the past 18 months, then step edits will allow payment | SE: Prior authorization is required unless claims history shows fill of ACE inhibitor in the past 18 months, then step edits will allow payment | Not a covered benefit. | SE:Prior authorization is required unless claims history shows fill of ACE inhibitor in the past 18 months, then step edits will allow payment | Not a covered benefit. | Not a covered benefit, carved out to PharmaCare | Not covered, carved out to Medicaid | SE:Prior authorization is required unless claims history shows fill of ACE inhibitor in the past 18 months, then step edits will allow payment | ACE/ARB Policy |
| Boniva IV | ibandronate sodium | office, outpatient | Prior authorization is required | Prior authorization is required | Prior authorization is required | No prior authorization is needed | Prior authorization required | Prior authorization not required | Prior authorization is required | No prior authorization is needed | Osteoporosis Medications |
| Bontril | phendimetrazine | Pharmacy | Prior authorization is required | Weight loss drugs are excluded from coverage except for Enhanced Plans for which prior authorization is not required | Not a covered benefit. | Weight loss drugs are excluded from coverage except for Enhanced Plans for which prior authorization is not required | Not a covered benefit. | Not a covered benefit, carved out to PharmaCare | Not covered, carved out to Medicaid | Prior authorization is required | Weight Loss Agents |
| Botox | botulinum toxin type a | office, outpatient | Prior authorization is required | Prior authorization is required | Prior authorization is required | NO PRIOR AUTHORIZATION REQUIRED | Prior authorization is required | Prior authorization not required | Prior authorization is required | NO PRIOR AUTHORIZATION REQUIRED | botulinum toxin policy |
| CaloMist | cyanocobalamin | Pharmacy | Prior authoriztion is required | Not a covered benefit | Not a covered benefit. | Not Covered | Not a covered benefit. | Not a covered benefit, carved out to PharmaCare | Not covered, carved out to Medicaid | Prior authorization is required | New Drug Policy |
| Caverject | alprostadil | Pharmacy | QL: Prior authorization is required only if requesting over 6 injections per month | QL:Drugs to treat erectile dysfunction are excluded from coverage except for Enhanced Plans, then prior authorization is required if requesting more than 6 injections per month. | Not a covered benefit. | QL:Prior authorization is required only if requesting over 6 injections per month | Not a covered benefit. | Not a covered benefit, carved out to PharmaCare | Not covered, carved out to Medicaid | Prior authorization is required only if requesting over 6 injections per month | Prescription Drug Quantity Limits |
| Celebrex | celecoxib | Pharmacy | SE: Prior authorization is required if under 65 or if no claims history showing Celebrex, 2 NSAID, or anticoagulant fill in the past 12 months | SE: Prior authorization is required if under 65 or if no claims history showing Celebrex, 2 NSAID, or anticoagulant fill in the past 12 months | Not a covered benefit. | SE:Prior authorization is required if under 65 or if no claims history showing Celebrex, 2 NSAID, or anticoagulant fill in the past 12 months | Not a covered benefit. | Not a covered benefit, carved out to PharmaCare | Not covered, carved out to Medicaid | SE: Prior authorization is required if under 65 or if no claims history showing Celebrex, 2 NSAID, or anticoagulant fill in the past 12 months | COX-2 Inhibitors |
| Cellcept | mycophenolate mofetil | Pharmacy | No prior authorization is needed. | Requires Prior Authorization to determine coverage under Medicare Part B or D. | Requires Prior Authorization to determine coverage under Medicare Part B or D, if covered | Requires Prior Authorization to determine coverage under Medicare Part B or D. | Not a covered benefit. | Not a covered benefit, carved out to PharmaCare | Not covered, carved out to Medicaid | No prior authorization is needed | Medicare BvsD Policy |
| Ceprotin* | human protein C | office, outpatient | Prior authorization is required | Prior authorization is required | Prior authorization is required | No prior authorization is needed | Prior authorization is required | Prior authorization not required | Prior authorization is required | No prior authorization is needed | Orphan Drug(s) and Biologicals |
| Ceredase | algucerase | office, outpatient | Prior authorization is required | Prior authorization is required. | Prior authorization is required. | No prior authorization is needed | Prior authorization is required. | Prior authorization not required | Prior authorization is required | No prior authorization is needed | Gauchers Disease Type I |
| Cerezyme | imiglucerase | office, outpatient | Prior authorization is required | Prior authorization is required. | Prior authorization is required. | No prior authorization is needed | Prior authorization is required. | Prior authorization not required | Prior authorization is required | No prior authorization is needed | Gauchers Disease Type I |
| Cialis | tadalafil | Pharmacy | QL: Prior authorization is required only if requesting over 4 pills per month | QL:Drugs to treat erectile dysfunction are excluded from coverage except for Enhanced Plans, then prior authorization is required if requesting more than 4 pills per 30 days. | Not a covered benefit. | QL:Prior authorization is required only if requesting over 4 pills per month | Not a covered benefit. | Not a covered benefit, carved out to PharmaCare | Not covered, carved out to Medicaid | QL:Prior authorization is required only if requesting over 4 pills per month | Prescription Drug Quantity Limits |
| Cimzia* | certolizumab | office, outpatient | Prior authorization is required | Prior authorization is required | Prior authorization is required | No prior authorization is needed | Prior authorization is required | Prior authorization not required | Prior authorization is required | No prior authorization is needed | New Drug Policy |
| Clolar | clofarabine | office, outpatient | Prior authorization is required | Prior authorization is required | Prior authorization is required | No prior authorization is needed | Prior authorization is required | Prior authorization not required | Prior authorization is required | No prior authorization is needed | Orphan Drug(s) and Biologicals |
| Corticosteriods | ie:prednisone | Pharmacy | No prior authorization required | No prior authorization required | Requires Prior Authorization to determine coverage under Medicare Part B or D. | No prior authorization required | Not a covered benefit. | Not a covered benefit, carved out to PharmaCare | Not covered, carved out to Medicaid | No prior authorization is needed | Medicare Part D vs Part B Determination |
| Copegus* | ribavirin | Pharmacy | Prior authorization is required | Prior authorization is required | Not a covered benefit. | Prior authorization is required. | Not a covered benefit. | Not a covered benefit, carved out to PharmaCare | Not covered, carved out to Medicaid | Prior authorization is required. | Chronic Hepatitis C Treatment |
| Cozaar | losartan potassium | Pharmacy | Prior authorization is required. | SE:Prior authorization is required unless claims history shows fill of ACE inhibitor in the past 18 months, then step edits will allow payment | Not a covered benefit. | SE:Prior authorization is required unless claims history shows fill of ACE inhibitor in the past 18 months, then step edits will allow payment | Not a covered benefit. | Not a covered benefit, carved out to PharmaCare | Not covered, carved out to Medicaid | Prior authorization is required. | ACE/ARB Policy |
| Cytoxan | cyclophosphamide | Pharmacy | No prior authorization is needed. | Requires Prior Authorization to determine coverage under Medicare Part B or D. | Requires Prior Authorization to determine coverage under Medicare Part B or D. | Requires Prior Authorization to determine coverage under Medicare Part B or D. | Not a covered benefit. | Not a covered benefit, carved out to PharmaCare | Not covered, carved out to Medicaid | NO PRIOR AUTHORIZATION REQUIRED | Medicare Part D vs Part B Determination |
| Dacogen | decitabine | office, outpatient | Prior authorization is required | Prior authorization is required | Prior authorization is required | No prior authorization is needed | Prior authorization is required | Prior authorization not required | Prior authorization is required | NO PRIOR AUTHORIZATION REQUIRED | Myelodysplastic Syndrome Selected Agents |
| Dalmane | flurazepam | Pharmacy | QL: Prior authorization is required if requesting over 15 tablets per 30 days. | Benzodiazapines are excluded from coverage except for Enhanced Plans, then prior authorization is required if requesting more than 30 pills per 60 days. | Not a covered benefit. | QL:Prior authorization is required if requesting more than 30 tablets/capsules per 60 days. | Not a covered benefit. | Not a covered benefit, carved out to PharmaCare | Not covered, carved out to Medicaid | QL: Prior authorization is required if requesting over 15 tablets per 30 days. | Select Hypnotics |
| Daraprim | pyrimethamine | Pharmacy | Prior authorization is required | No prior authorization is needed. | Not a covered benefit. | No prior authorization is needed. | Not a covered benefit. | Not a covered benefit, carved out to PharmaCare | Not covered, carved out to Medicaid | Prior authorization is required | Antimalarial Drugs Policy |
| Didrex | benzphetamine | Pharmacy | Prior authorization is required | Weight loss drugs are excluded from coverage except for Enhanced Plans for which prior authorization is not required | Not a covered benefit. | Weight loss drugs are excluded from coverage except for Enhanced Plans for which prior authorization is not required | Not a covered benefit. | Not a covered benefit, carved out to PharmaCare | Not covered, carved out to Medicaid | Prior authorization is required | Weight Loss Agents |
| Diovan/HCT | hydrochlorothiazide; valsartan | Pharmacy | SE:Prior authorization is required unless claims history shows fill of ACE inhibitor in the past 18 months, then step edits will allow payment | SE:Prior authorization is required unless claims history shows fill of ACE inhibitor in the past 18 months, then step edits will allow payment | Not a covered benefit. | SE:Prior authorization is required unless claims history shows fill of ACE inhibitor in the past 18 months, then step edits will allow payment | Not a covered benefit. | Not a covered benefit, carved out to PharmaCare | Not covered, carved out to Medicaid | SE:Prior authorization is required unless claims history shows fill of ACE inhibitor in the past 18 months, then step edits will allow payment | ACE/ARB Policy |
| Doral | quazepam | Pharmacy | QL: Prior authorization is required if requesting over 15 tablets per 30 days. | Benzodiazapines are excluded from coverage except for Enhanced Plans, then prior authorization is required if requesting more than 30 pills per 60 days. | Not a covered benefit. | QL:Prior authorization is not required unless requesting more than 15 tablets/capsules per 30 days. | Not a covered benefit. | Not a covered benefit, carved out to PharmaCare | Not covered, carved out to Medicaid | QL: Prior authorization is required if requesting over 15 tablets per 30 days. | Select Hypnotics |
| Duragesic | fentanyl | Pharmacy | SE, QL: Prior authorization is not required unless requesting over 20 patches per month or claims history does not show fill of immediate release pain reliever in past 90 days. | SE, QL: Prior authorization is not required unless requesting over 20 patches per month or claims history does not show fill of immediate release pain reliever in past 90 days. | Not a covered benefit. | SE,QL:Prior authorization is not required unless requesting over 20 patches per month or claims history does not show fill of immediate release pain reliever in past 90 days. | Not a covered benefit. | Not a covered benefit, carved out to PharmaCare | Not covered, carved out to Medicaid | SE, QL: Prior authorization is not required unless requesting over 20 patches per month or claims history does not show fill of immediate release pain reliever in past 90 days. | Pain Medication |
| Edex | alprostadil | Pharmacy | QL: Prior authorization is required only if requesting over 6 injections per month | QL:Drugs to treat erectile dysfunction are excluded from coverage except for Enhanced Plans, then prior authorization is required if requesting more than 6 injections per month. | Not a covered benefit. | QL:Prior authorization is required only if requesting over 6 injections per month | Not a covered benefit. | Not a covered benefit, carved out to PharmaCare | Not covered, carved out to Medicaid | QL:Prior authorization is required only if requesting over 6 pellets per month | Prescription Drug Quantity Limits |
| Elaprase | idursuifase | office, outpatient | Prior authorization is required | Prior authorization is required | Prior authorization is required | No prior authorization is needed | Prior authorization is required | Prior authorization not required | Prior authorization is required | NO PRIOR AUTHORIZATION REQUIRED | Orphan Drug(s) and Biologicals |
| Elidel | pimecrolimus | Pharmacy | SE: Prior authorization is required unless claims history shows fill within the past 12 months of Elidel or corticosteriod, then step edits will allow payment. | SE: Prior authorization is required unless claims history shows fill within the past 12 months of Elidel or corticosteriod, then step edits will allow payment. | Not a covered benefit. | SE:Prior authorization is required unless claims history shows fill within the past 12 months of Elidel or corticosteriod, then step edits will allow payment. | Not a covered benefit. | Not a covered benefit, carved out to PharmaCare | Not covered, carved out to Medicaid | SE: Prior authorization is required unless claims history shows fill within the past 12 months of Elidel or corticosteriod, then step edits will allow payment. | Dermatologicals for Imflammation |
| Eloxatin | oxaliplatin | office, outpatient | Prior authorization is required | Prior authorization is required | Prior authorization is required | No prior authorization is needed | Prior authorization is required | Prior authorization not required | Prior authorization is required | NO PRIOR AUTHORIZATION REQUIRED | Select Biologic Chemotherapy Agents |
| Emend | aprepitant | Pharmacy | QL: Prior authorization is required if requesting over the quantity limit of 2 Tri-pack or (8) 80mg or (2) 125 mg every 30 days | QL: Prior authorization is required to determine coverage under Medicare B or D and if requesting over the quantity limit of 1 Tri-pack or (4) 80mg or (1) 125 mg every 10 days | Requires Prior Authorization to determine coverage under Medicare Part B or D. | QL: Prior authorization is required to determine coverage under Medicare B or D and if requesting over the quantity limit of 1 Tri-pack or (4) 80mg or (1) 125 mg every 10 days | Not a covered benefit. | Not a covered benefit, carved out to PharmaCare | Not covered, carved out to Medicaid | QL: Prior authorization is required if requesting over the quantity limit of 2 Tri-pack or (8) 80mg or (2) 125 mg every 30 days | Prescription Drug Quantity Limits and Medicare Part D vs Part B Determination |
| Emend | fosaprepitant | office, outpatient | Prior authorization is required | Prior authorization is required | Prior authorization is required | No prior authorization is needed | Prior authorization is required | Prior authorization not required | Prior authorization is required | Prior authorization not required | New Drug Policy |
| Enbrel* | etanercept | Pharmacy | Prior authorization is required | Prior authorization is required | Not a covered benefit. | Prior authorization is required. | Not a covered benefit. | Not a covered benefit, carved out to PharmaCare | Not covered, carved out to Medicaid | Prior authorization is required | Psoriasis Drug Therapy/ Arthropathy Drug Therapy |
| Epivir-HBV | Pharmacy | lamivudine | Prior authorization is required | No prior authorization is required | Not a covered benefit. | No prior authorization is needed. | Not a covered benefit. | Not a covered benefit, carved out to PharmaCare | Not covered, carved out to Medicaid | Prior authorization is required. | Hepatitis B Oral Agents |
| Epogen | erythropoietin | Pharmacy | Prior authorization is required | Prior authorization is required | Not a covered benefit. | Prior authorization is required. | Not a covered benefit. | Not a covered benefit, carved out to PharmaCare | Not covered, carved out to Medicaid | Prior authorization is required. | Erythropoietic Agents |
| office, outpatient | Prior authorization is required | Prior authorization is required | Prior authorization is required | No prior authorization is needed | Prior authorization is required | Prior authorization not required | Prior authorization is required. | NO PRIOR AUTHORIZATION REQUIRED | |||
| Erbitux | cetuximab | office, outpatient | Prior authorization is required | Prior authorization is required | Prior authorization is required | No prior authorization is needed | Prior authorization is required | Prior authorization not required | Prior authorization is required | NO PRIOR AUTHORIZATION REQUIRED | Select Biologic Chemotherapy Agents |
| Exforge | amlodipine + valspartan | Pharmacy | SE: Prior authorization is required unless claims history shows fill of ACE inhibitor in the past 18 months, then step edits will allow payment | Prior authorization is required | Not a covered benefit. | Prior authorization is required. | Not a covered benefit. | Not a covered benefit, carved out to PharmaCare | Not covered, carved out to Medicaid | SE: Prior authorization is required unless claims history shows fill of ACE inhibitor in the past 18 months, then step edits will allow payment | ACE/ARB Policy |
| Exjade | deferasirox | Pharmacy | Prior authorization is required | Prior authorization is required | Not a covered benefit. | Prior authorization is required. | Not a covered benefit. | Not a covered benefit, carved out to PharmaCare | Not covered, carved out to Medicaid | Prior authorization is required | Orphan Drug(s) and Biologicals |
| Fabrazyme | agalsidase beta | office, outpatient | Prior authorization is required | Prior authorization is required | Prior authorization is required | No prior authorization is needed | Prior authorization is required. | Prior authorization not required | Prior authorization is required. | NO PRIOR AUTHORIZATION REQUIRED | Fabry Disease (treatment of) |
| Pharmacy | Prior authorization is required | Prior authorization is required | Not a covered benefit. | Prior authorization is required. | Not a covered benefit. | Not a covered benefit, carved out to PharmaCare | Not covered, carved out to Medicaid | Prior authorization is required. | |||
| Fansidar | sulfadoxine/pyrimethamine | Pharmacy | Prior authorization is required | No prior authorization is needed. | Not a covered benefit. | No prior authorization is needed. | Not a covered benefit. | Not a covered benefit, carved out to PharmaCare | Not covered, carved out to Medicaid | Prior authorization is required | Antimalarial Drugs Policy |
| Fentanyl | fentanyl | Pharmacy | SE, QL: Prior authorization is not required unless requesting over 20 patches per month or claims history does not show fill of immediate release pain reliever in past 90 days. | SE, QL: Prior authorization is not required unless requesting over 20 patches per month or claims history does not show fill of immediate release pain reliever in past 90 days. | Not a covered benefit. | QL,SE:Prior authorization is not required unless requesting over 20 patches per month or claims history does not show fill of immediate release pain reliever in past 90 days. | Not a covered benefit. | Not a covered benefit, carved out to PharmaCare | Not covered, carved out to Medicaid | SE, QL: Prior authorization is not required unless requesting over 20 patches per month or claims history does not show fill of immediate release pain reliever in past 90 days. | Pain Medication |
| Fentora | fentanyl citrate tablets | Pharmacy | QL:Prior authorization is requ |