AETNA BETTER HEALTH® Illinois formulary

Revised 5/2016

ILLINOIS FORMULARY REVISED May 2016

What is the Aetna Better Health Illinois Formulary? This is a drug list created by Aetna Better Health (“plan”). Aetna Better Health will cover drugs on this list. Some drugs may have coverage rules. If the rules for that drug are met, Aetna Better Health will cover the drug. Drugs must also be filled at an Aetna Better Health network pharmacy. Can Aetna Better Health’s Drug List change? Utilizing members and their providers will be notified at least 30 days before a drug is removed from the formulary. All changes to the formulary will be posted on the plan’s website. How do I use Aetna Better Health’s formulary? • • •

Column #1: lists the covered drug. Column #2: lists the brand name of the drug when a generic is covered Column #3: shows coverage rules for the drug

Drugs are also grouped by the type of condition they treat. Drugs used to treat an earache are listed under the section, Ear-Nose-Throat Medications. If you know what your drug is used for, please look for that section name on the drug list. Then look under that section for your drug. How much will I pay for covered drugs? You do not have to pay for covered drugs. What are some types of coverage rules? •

Prior Approval (PA): This means your doctor will need to get approval from the plan first before the drug can be filled at the pharmacy. If it is not approved, the plan will not cover the drug.

•

Quantity Level Limits (QLL): This means there is a limit on the amount of drug the plan will cover. For example, the plan provides 60 pills in 30 days for some drugs.

•

Step Therapy (ST): This means you may need to try certain drugs first to treat your condition. After the first drug is tried, the plan will then cover the other drug for that same condition. For

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ILLINOIS FORMULARY REVISED May 2016

example, Drug A and Drug B may treat your condition. The plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, then Drug B will be covered. What if my drug is not on Aetna Better Health’s formulary? First, please call your doctor and ask if your drug is covered. If the plan does not cover the drug, then: • •

Ask your doctor for a similar drug that is covered. Your doctor can ask the plan to cover your drug through the prior approval process.

What are generic drugs? Aetna Better Health covers both brand and generic drugs. Generic drugs cost less and are approved by the Food and Drug Administration (FDA). Are Over-The-Counter (OTC) drugs covered? The plan will cover OTC drugs on the formulary. Some OTC drugs may have coverage rules. If the rules for that OTC drug are met, the plan will cover the OTC drug. Most OTC drugs need a prescription from a doctor if they are to be covered by the plan.

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ILLINOIS FORMULARY REVISED May 2016

¿Qué es el formulario de Aetna Better Health para Illinois? Es una lista de medicamentos creada por Aetna Better Health (el “plan”). Aetna Better Health ofrece cobertura para los medicamentos de esta lista. Es posible que para algunos medicamentos se apliquen reglas de cobertura. Si se cumplen las reglas para esos medicamentos, Aetna Better Health los cubrirá. Además, los medicamentos deben adquirirse en una farmacia de la red de Aetna Better Health. ¿Puede cambiar la lista de medicamentos de Aetna Better Health? El plan puede agregar o quitar medicamentos de la lista. Todas las eliminaciones de medicamentos del formulario se enviarán al estado, donde se revisarán antes de que se realice el cambio. Los miembros y proveedores que utilizan el formulario recibirán un aviso como mínimo 30 días antes de que se elimine un medicamento del formulario. Encontrará todos los cambios del formulario en el sitio en Internet del plan. ¿Cómo utilizo el formulario de Aetna Better Health? • • •

Columna Nº 1: enumera los medicamentos cubiertos. Columna Nº 2: enumera los medicamentos de marca cuando una opción genérica está cubierta. Columna Nº 3: muestra las reglas de cobertura de los medicamentos.

Los medicamentos también están agrupados según el tipo de condición que tratan. Por ejemplo, los medicamentos que se usan para tratar un dolor de oído figuran en la sección, Ear-Nose-Throat Medications. Si sabe para qué se usa el medicamento que usted toma, busque el nombre de esa sección en la lista de medicamentos y luego busque el medicamento en esa sección. ¿Cuánto pagaré por los medicamentos cubiertos? Usted no tiene que pagar por los medicamentos cubiertos. ¿Cuáles son algunos de los tipos de reglas de cobertura? • •

Aprobación previa (PA): significa que su médico primero deberá obtener la aprobación del plan antes de que se pueda adquirir el medicamento en la farmacia. Si no se aprueba, el plan no cubrirá el medicamento. Límites de cantidad (QLL): significa que el plan cubre hasta una cierta cantidad del medicamento. Por ejemplo, en el caso de algunos medicamentos, el plan cubre 60 píldoras en 30 días.

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ILLINOIS FORMULARY REVISED May 2016

•

Terapia escalonada (ST): significa que posiblemente primero deba probar ciertos medicamentos para tratar su condición. Después de probar el primer medicamento, el plan cubrirá el otro medicamento para la misma condición. Por ejemplo, el Medicamento A y el Medicamento B pueden tratar su condición. Es posible que el plan no cubra el Medicamento B a menos que usted primero pruebe el Medicamento A. Si el Medicamento A no funciona en su caso, entonces se cubrirá el Medicamento B.

¿Qué sucede si el medicamento que tomo no está incluido en el formulario de Aetna Better Health? Primero, llame a su médico y pregúntele si su medicamento está cubierto. Si el plan no lo cubre, usted tiene dos opciones: • •

Pida a su médico un medicamento similar que esté cubierto. Su médico puede solicitar que el plan cubra el medicamento a través del proceso de aprobación previa.

¿Qué son los medicamentos genéricos? Aetna Better Health cubre tanto medicamentos de marca como genéricos. Los medicamentos genéricos cuestan menos y están aprobados por la Administración de Drogas y Alimentos (FDA). ¿Los medicamentos de venta libre están cubiertos? El plan cubrirá los medicamentos de venta libre que figuren en el formulario. Es posible que para algunos medicamentos de venta libre se apliquen reglas de cobertura. Si se cumplen las reglas para esos medicamentos de venta libre, el plan los cubrirá. Al igual que con otros medicamentos, se requiere una receta del médico para que el plan brinde cobertura para los medicamentos de venta libre.

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ILLINOIS FORMULARY REVISED May 2016 COVERED DRUG MEDICAMENTO CUBIERTO

REFERENCE DRUG NAME NOMBRE DE MEDICAMENTO DE REFERENCIA

REQUIREMENTS/LIMITS REQUERIMIENTOS/LÍMITES

ANESTHETICS

DRUGS USED TO RELIEVE PAIN IN SPECIFIC AREAS

ANESTÉSICOS

MEDICAMENTOS UTILIZADOS PARA ALIVIAR EL DOLOR EN ÁREAS ESPECÍFICAS TOPICAL ANESTHETICS / ANESTÉSICOS TÓPICOS lidocaine hcl Xylocaine lidocaine hcl viscous Xylocaine lidocaine-prilocaine Emla

ANTIINFECTIVES

DRUGS USED TO TREAT BACTERIAL, FUNGAL, OR VIRAL INFECTIONS

ANTIINFECCIOSOS

MEDICAMENTOS UTILIZADOS PARA TRATAR INFECCIONES CAUSADAS POR BACTERIAS, HONGOS O VIRUS CEPHALOSPORINS / CEFALOSPORINAS Cefaclor Ceclor cefaclor er Ceclor ER cefadroxil Duricef Cefdinir Omnicef Cefixime tabs, chewable, susp (not Suprax 500mg/5ml) cefpodoxime proxetil cefprozil cefuroxime Cephalexin 250mg, 500mg only ceftriaxone cefuroxime axetil CLINDAMYCINS / CLINDAMICINAS CLEOCIN GRANULES clindamycin ERYTHROMYCINS / ERITROMICINAS erythromycin erythromycin ethylsuccinate erythromycin w/sulfisoxazole OTHER MACROLIDES / OTROS MACRÓLIDOS azithromycin clarithromycin, er PENICILLINS / PENICILINAS amox tr-potassium clavulanate amoxicillin ampicillin dicloxacillin penicillin v potassium

Vantin Cefzil Ceftin Keflex Rocep Ceftin

QLL=2 grams/Rx

Cleocin Eryc E.E.S. Pediazole Zithromax Biaxin, Biaxin XL Augmentin Amoxil Principen Veetids

QLL for 250 mg=12 tabs/30 days QLL for 600 mg=8 tabs/30 days QLL=28 tabs/30 days QLL=28/30 days

ILLINOIS FORMULARY REVISED May 2016

COVERED DRUG MEDICAMENTO CUBIERTO

REFERENCE DRUG NAME NOMBRE DE MEDICAMENTO DE REFERENCIA

REQUIREMENTS/LIMITS REQUERIMIENTOS/LÍMITES

SULFONAMIDES / SULFONAMIDAS sulfamethoxazole/trimethoprim Septra sulfadiazine sulfatrim pediatric suspension TETRACYCLINES / TETRACICLINAS demeclocycline doxycycline Vibramycin minocycline hcl, ER Dynacin, ER tetracycline hcl Sumycin URINARY ANTIINFECTIVES / ANTIINFECCIOSOS URINARIOS FURADANTIN (25 MG/5 ML SUSPENSION) methenamine hippurate nitrofurantoin, Macrodantin nitrofurantoin macrocrystal Macrobid nitrofurantoin mono/macrocrystals trimethoprim

QUINOLONES / QUINOLONAS ciprofloxacin er ciprofloxacin hcl ofloxacin levofloxacin tablets, soln

Cipro XR Cipro Floxin Levaquin

QLL=3 tabs/Rx QLL=28 tabs/30 days QLL=14 tabs/90 days

TOPICAL ANTIBACTERIAL DRUGS / MEDICAMENTOS ANTIBACTERIALES TÓPICOS Bactroban Nasal OTC bacitracin topical ointment bacitracin/polymyxin B chlorhexidine gluconate erythromycin gentamicin sulfate mupirocin ointment, cream silver sulfadiazine sulfacetamide sodium OTC triple antibiotic cream

PA Polysporin Peridex Eryderm Genoptic Bactroban Silvadene Ovace Neosporin

ORAL ANTIFUNGAL DRUGS / MEDICAMENTOS ANTIFÚNGICOS ORALES clotrimazole fluconazole GRISEOFULVIN TAB MICR 500mg griseofulvin 125 mg/5 ml suspension GRISEOFULVIN TAB ULTR

Mycelex Diflucan GRIFULVIN V GRIS-PEG

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ILLINOIS FORMULARY REVISED May 2016

COVERED DRUG MEDICAMENTO CUBIERTO itraconazole capsule ketoconazole nystatin SPORANOX (ORAL SOLUTION) terbinafine Terbinafine topical

REFERENCE DRUG NAME NOMBRE DE MEDICAMENTO DE REFERENCIA

REQUIREMENTS/LIMITS REQUERIMIENTOS/LÍMITES

Sporanox Nizoral Mycostatin Lamisil

STEP

QLL=84 tabs/year

VAGINAL ANTIFUNGALS / MEDICAMENTOS ANTIFÚNGICOS VAGINALES OTC clotrimazole miconazole 200 mg suppositories nystatin terconazole

Mycelex Monistat 3 Mycostatin Terazol

OTHER TOPICAL ANTIFUNGALS / OTROS MEDICAMENTOS ANTIINFECCIOSOS ciclopirox OTC clotrimazole econazole nitrate ketoconazole OTC miconazole 2% nystatin

Loprox/Penlac Lotrimin Spectazole Nizoral

TOPICAL ANTIFUNGAL-CORTICOSTEROID COMB / CORTICOSTEROIDES Y ANTIFÚNGICOS TÓPICOS COMBINADOS clotrimazole/betamethasone nystatin w/triamcinolone

Lotrisone Mycolog II

ANTIRETROVIRALS & PROTEASE INHIBITORS /ANTIRRETROVIRALES E INHIBIDORES DE LA PROTEASA Abacavir; Lamivudine, 3TC; Zidovudine, ZDV APTIVUS ATRIPLA LAMIVUDINE/ZIDOVUDINE COMPLERA CRIXIVAN didanosine EDURANT EMTRIVA EPIVIR HBV 5mg/ml suspension ONLY Lamivudine, 3TC, HBV EPZICOM

TRIZIVIR

COMBIVIR

EPIVIR, EPIVIR HBV

FUZEON INTELENCE Page 7

ILLINOIS FORMULARY REVISED May 2016 INVIRASE KALETRA LEXIVA Nevirapine, Nevirapine ER tabs, oral solution

COVERED DRUG MEDICAMENTO CUBIERTO NORVIR PREZISTA RESCRIPTOR REYATAZ Stavudine STRIBILD SUSTIVA Tivicay

Viramune, Viramune XR

REFERENCE DRUG NAME NOMBRE DE MEDICAMENTO DE REFERENCIA

REQUIREMENTS/LIMITS REQUERIMIENTOS/LÍMITES

Zerit

Triumeq TRUVADA VIDEX SOLUTION, CHEWABLE TABS VIRACEPT VIREAD Vitekta ABACAVIR Zidovudine

ZIAGEN

OTHER ANTIINFECTIVE DRUGS / OTROS MEDICAMENTOS ANTIINFECCIOSOS CLEOCIN (100 MG VAGINAL OVULE) Dapsone atovaquone suspension

MEPRON

STEP

OTHER ANTIVIRAL DRUGS / OTROS MEDICAMENTOS ANTIVIRALES OTC Abreva Acyclovir Acyclovir 5% ointment amantadine hcl Entecavir Famciclovir Ganciclovir ISENTRESS PEGINTRON PEGINTRON REDIPEN PEGASYS Rimantadine

Zovirax Zovirax Symmetrel

QLL=90 caps or tabs/30 days

BARACLUDE Famvir

Flumadine

PA PA PA COVERED DURING FLU SEASON (OCT 1, 2014 TO April 30, 2015); QLL=7 tabs/30 days Page 8

ILLINOIS FORMULARY REVISED May 2016 REBETOL (ORAL SOLUTION) RELENZA

MUST BE ON INTERFERON COVERED DURING FLU SEASON (OCT 1, 2014 TO April 30, 2015); QLL/Rx=20 inhalation diskus/Rx MUST BE ON INTERFERON

Ribavirin COVERED DRUG MEDICAMENTO CUBIERTO Sovaldi

REFERENCE DRUG NAME NOMBRE DE MEDICAMENTO DE REFERENCIA

REQUIREMENTS/LIMITS REQUERIMIENTOS/LÍMITES PA QLL=14 tabs/14 days

SELZENTRY TAMIFLU

COVERED DURING FLU SEASON (OCT 1, 2014 TO april 30, 2015); QLL=75mg 10 capsules/Rx; 45mg=10 capsules /Rx; 30mg=20 capsules/Rx; 12mg/ml oral suspension=3 bottles/Rx PA

TYZEKA Valacyclovir

Valtrex

ZOVIRAX 5% CREAM

500 mg tablet QLL=60 tabs/30 days 1 gram tablet QLL=30 tabs/30 days

ANTITUBERCULOSIS DRUGS / MEDICAMENTOS ANTITUBERCULOSOS Ethambutol Isoniazid Rifabutin PRIFTIN Pyrazinamide Rifampin

Myambutol Nydrazid MYCOBUTIN

Rifadin

AMEBICIDES / AMIBICIDAS YODOXIN

ANTHELMINTICS / ANTIHELMÍNTICOS ALBENZA Mebendazole Ivermectin

STROMECTOL

PLASMODICIDES / PLASMODICIDAS chloroquine phosphate DARAPRIM hydroxychloroquine sulfate Mefloquine

Plaquenil Lariam

TRICHOMONOCIDES / TRICOMONICIDAS Metronidazole

Flagyl Page 9

ILLINOIS FORMULARY REVISED May 2016 AMINOGLYCOSIDES / AMINOGLUCÓSIDOS Neomycin Paromomycin

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ILLINOIS FORMULARY REVISED May 2016

ANTINEOPLASTIC/IMMUNOSUPPRESSANT DRUGS

DRUGS USED FOR CANCER TREATMENT, TRANSPLANTS OR OTHER RARE CONDITIONS Medications within this class are covered for FDA-approved indications and may require prior authorization. All injectable medications within this class require prior authorization.

MEDICAMENTOS INMUNOSUPRESORES/ANTINEOPLÁSICOS

MEDICAMENTOS UTILIZADOS PARA EL TRATAMIENTO DEL CÁNCER, ENFERMEDADES RARAS O TRASPLANTES

Los medicamentos de esta clase están cubiertos para el uso según las indicaciones aprobadas por la FDA y pueden requerir autorización previa. Todos los medicamentos inyectables dentro de esta clase requieren autorización previa.

anagrelide capsules anastrozole tablets AZASAN azathioprine tablets Bicalutamide Capecitabine CEENU CAPSULE cyclophosphamide caps cyclosporine capsule, oral soln DROXIA CAPSULE EMCYT CAPSULE ENBREL etoposide capsule Exemestane FARESTON TABLET fluorouracil cream, solution flutamide capsule

Imatinib

HEXALEN CAPSULE HUMIRA HYCAMTIN CAPSULE hydroxyurea capsule, tablet IRESSA TABLET leflunomide tablet leucovorin tablet LEUKERAN TABLET Letrozole LYSODREN TABLET MATULANE CAPSULE megestrol acetate suspension (40mg/ml), mercaptopurine tablet MESNEX TABLET methotrexate tablet

Agrylin Arimidex Imuran Casodex

PA; QLL for 500mg = #154/21 days; QLL for 150mg = #140/21 days Cytoxan Sandimmune

PA Vepesid Aromasin Efudex GLEEVEC

PA PA

Hydrea Arava

Femara

Megace Purinethol Trexall Page 11

ILLINOIS FORMULARY REVISED May 2016

mycophenolate 250 mg capsules, 500 mg tablets Mycophenolate 200mg suspensions mycophenolate 180mg, 360mg tablet Neupogen NEXAVAR TABLET NILANDRON TABLET RAPAMUNE ORAL SOLN Revlimid Rituxan Sirolimus tablets Sutent TABLOID TABLET tacrolimus capsule tamoxifen citrate tablet TARCEVA TABLET TARGRETIN TOPICAL GEL, Bexarotene TABLET Thalidomide tretinoin capsule, cream, gel, solution TYKERB TABLET Votrient

CellCept Cellcept Susp MYFORTIC TABLET

PA PA

Rapamune

PA; QLL=30/30 days PA PA; QLL=30/30days, except 50mg QLL= #28/42 days

Prograf Nolvadex

PA

TARGRETIN Tablet

Vesinoid

PA; 50mg& 100mg QLL=#30/30 days, 150mg & 200mg QLL= #60/30 days PA PA; QLL=120/30 days

AUTONOMIC AND CNS MEDICATIONS

DRUGS USED FOR PAIN MANAGEMENT AND OTHER BEHAVIORAL CONDITIONS (E.G, ANXIETY, DEPRESSION, DIFFICULTY SLEEPING, SEIZURES, ETC.)

MEDICAMENTOS PARA TRATAR AFECCIONES DEL SISTEMA NERVIOSO CENTRAL Y AUTÓNOMO

MEDICAMENTOS UTILIZADOS PARA CONTROLAR EL DOLOR Y OTRAS CONDICIONES DEL COMPORTAMIENTO (POR EJEMPLO, ANSIEDAD, DEPRESIÓN, DIFICULTADES PARA DORMIR, CONVULSIONES, ETC.)

ALCOHOL ANTAGONIST / ANTAGONISTAS DEL ALCOHOL DISULFIRAM Evzio Naltrexone Narcan Nasal Spray Vivitrol ANALGESICS / ANALGÉSICOS OTC acetaminophen tablets, capsules, suppositories, liquids, drops tramadol hcl tramadol hcl-acetaminophen Tramadol ER

ANTABUSE

QLL=380mg/intramuscular dose Tylenol Ultram Ultracet

QLL= up to 4 grams APAP/day QLL=240 tabs/30 days QLL= 4 grams APAP/day QLL=30 tabs/30 days Page 12

ILLINOIS FORMULARY REVISED May 2016 CLASS II NARCOTICS / DROGAS CLASE II codeine sulfate fentanyl patches fentanyl lozenges hydromorphone hcl methadone hcl morphine sulfate ER Morphine sulfate IR oxycodone-acetaminophen oxycodone-aspirin oxycodone hcl

Duragesic Actiq Dilaudid Dolophine MS Contin Percocet

Oxyir

OXYCONTIN Oxymorphone ER

QLL=30 tabs/30 days PA; QLL=10 patches/30 days QLL=90 lozenges /30 days QLL for 8 mg=120 tabs/30 days PA; QLL=540 tabs/30 days

PA; QLL=90/30 days QLL=240 tabs/30 days or up to 4 grams APAP/day QLL=240 tabs/30 days QLL for 5 mg=240 tabs/30 days, 10 mg, 15 mg, 20 mg, or 30 mg=150 tabs/30 days PA/QLL=90 tabs/30 days

Opana ER

PA; QLL= 60/30 DAYS

acetaminophen-codeine Bunavail Buprenorphine hydrocodone-acetaminophen (excludes combinations with 300mg acetaminophen strengths)

Tylenol #3

QLL= 4 grams APAP/day QLL=12.6 mg/2.1 mg per day QLL=24mg/day QLL= 4 grams APAP/day

hydrocodone bit-ibuprofen SUBOXONE FILM, buprenorphine/naloxone SL tabs

Vicoprofen

CLASS III NARCOTICS / DROGAS CLASE III

Subutex

QLL=240 tabs/30 days 2mg/0.5mg QLL=90 /30 days 4mg/1mg QLL=180/30 days 8mg/2mg QLL=90/30 days 12mg/3mg QLL=60/days

Miscellaneous Psychotherapeutic/ Varios psicoterapéutico CAMPRAL

Campral

Modafanil

Provigil

PA QLL=#30/30 days DRUGS TO PREVENT AND TREAT HEADACHES / MEDICAMENTOS PARA PREVENIR Y TRATAR DOLORES DE CABEZA butalbital/acetaminophen/caffeine (50/325/40) butalbital/acetaminophen/caffeine/ codeine (50/325/40/30) butalbital/aspirin/caffeine (50/325/40)

Esgic/Fioricet/Triad Fioricet w/codeine Fiorinal, Fortabs

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ILLINOIS FORMULARY REVISED May 2016 butalbital compound capsule (50/325/40/30) butorphanol nasal spray ERGOMAR ergotamine/caffeine Sumatriptan sumatriptan (inj) MIGRANAL RELPAX Naratriptan Rizatriptan, Rizatriptan ODT

ANXIOLYTICS / ANSIOLÍTICOS alprazolam, -XR, intensol solution buspirone hcl chlordiazepoxide hcl clorazepate dipotassium Clonazepam diazepam 2.5 mg, 10 mg, 20 mg rectal gel Diazepam Lorazepam, 2mg/ml injection Meprobamate Oxazepam

Fiorinal w/codeine Stadol Cafergot Imitrex Imitrex

Amerge Maxalt, Maxalt MLT Xanax, XR Buspar Librium Tranxene T-Tab Klonopin

QLL=1 bottle/30 days

QLL=6 nasal sprays/30 days; 9 tabs/30 days QLL=4 vials/30 days; 2 kits/30 days QLL=8 units/30 days QLL=6 tabs/30 days QLL=9 tabs/30 days QLL=12 tabs/30 days

QLL=90 tabs/30 days

QLL=2 pkgs/30 days Valium Ativan

QLL=3/34 DAYS (INJECTION: QLL and no PA for LTC members)

Serax

SEDATIVE & HYPNOTIC DRUGS / MEDICAMENTOS HIPNÓTICOSY SEDANTES Estazolam flurazepam hcl temazepam 7.5 mg, 15 mg, & 30 mg ROZEREM

Dalmane Restoril

QLL=30 tabs/30 days QLL=30 caps/30 days QLL=30 caps/30 days QLL=30 tabs/30 days

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ILLINOIS FORMULARY REVISED May 2016

Zaleplon Zolpidem 5mg, 10mg

Sonata Ambien

QLL=30 caps/30 days QLL=30 tabs/30 days

ANTIMANIA DRUGS / ANTIMANÍACOS lithium carbonate

Eskalith/CR

lithium citrate

CARBAMAZEPINES / CARBAMAZEPINAS Carbamazepine carbamazepine ER CARBATROL oxcarbazepine tablets, suspension

Tegretol Tegretol XR

QLL=120/30 days

Trileptal

ANTICONVULSAN AND BENZODIAZEPINES / ANTICONVULSIVOS Y BENZODIACEPINAS Clonazepam

Klonopin

HYDANTOINS / HIDANTOÍNAS

phenytoin sodium, extended DILANTIN INFATABS, DILANTIN 30 MG EXTENDED RELEASE PHENYTEK

Dilantin, ER

VALPROIC ACID AND DERIVATIVES / ÁCIDO VALPÓRICO Y DERIVADOS DEPAKOTE ER, DELAYED RELEASE,SPRINKLE divalproex sodium ER, delayed-release valproic acid

Depakote ER, Delayed-Release Depakene

ANTICONVULSANT BARBITURATES / BARBITÚRICOS UTILIZADOS PARA EVITAR CONVULSIONES Mephobarbital Phenobarbital Primidone

Mebaral Mysoline

OTHER ANTICONVULSANTS / OTROS MEDICAMENTOS UTILIZADOS PARA EVITAR CONVULSIONES CELONTIN Ethosuximide Felbamate Gabapentin GABITRIL Lamotrigine Levetiracetam NEURONTIN SOLUTION Topiramate Zonisamide

FELBATOL Neurontin

QLL=180 units/30 days QLL=60 tabs/30 days

Lamictal Keppra Topamax Zonegran

QLL=180 units/30 days

MAO INHIBITORS / INHIBIDORES DE MAO MARPLAN NARDIL Tranylcypromine

Parnate

TERTIARY AMINES / AMINAS TERCIARIAS amitriptyline hcl

Elavil Page 15

ILLINOIS FORMULARY REVISED May 2016

Clomipramine doxepin hcl imipramine hcl, IMIPRAMINE PAMOATE

Anafranil Sinequan Tofranil,PM

Trimipramine

PA

Surmontil

SECONDARY AMINES / AMINAS SECUNDARIAS Amoxapine desipramine hcl nortriptyline hcl Protriptyline

Norpramin Pamelor

SELECTIVE SEROTONIN REUPTAKE INHIBITOR / INHIBIDORES SELECTIVOS DE LA RECAPTACIÓN DE LA SEROTONINA Citalopram

Celexa

Escitalopram

Lexapr o Prozac

fluoxetine hcl

QLL=30 tabs/30 days or 300 ml/30 days QLL=30 tab/30 days

Pexeva

QLL for 10 mg=30 caps/30 days; 20 mg, 40 mg= 60 tabs/caps/ 30 days; soln=150 ml/30 days QLL for 100 mg=90 tabs/30 days; 50 mg=60 tabs/30 days; 25 mg= 30 tabs/30 days QLL=60 tabs/30 days; soln=300 ml/30 days PA

Pristiq

PA

fluvoxamine maleate

Luvox

paroxetine hcl

Paxil

sertraline hcl

Zoloft

OTHER ANTIDEPRESSANTS / OTROS ANTIDEPRESIVOS amitriptyline/ chlordiazepoxide budeprion sr bupropion, xl, sr

Maprotiline mirtazapine, ODT trazodone hcl 50 mg, 100 mg, & 150 mg venlafaxine, ER (ER capsules only) Duloxetine

Wellbutrin SR Wellbutrin

Remeron Desyrel Effexor, Effexor XR Cymbalta

QLL for 25 mg=30 tabs/30 days; 50 mg or 100 mg=60 tabs/30 days; soln=75 ml/30 days

QLL=60 tabs/30 days QLL=90 tabs/30 days (IR); 60 tabs/30 days (SR 12 hr); 30 tabs/30 days (XL 24 hr) QLL=30 tabs/30 days

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ILLINOIS FORMULARY REVISED May 2016

ANTIVERTIGO AND ANTIEMETIC DRUGS / MEDICAMENTOS ANTIEMÉTICOS Y PARA TRATAR EL VÉRTIGO Granisetron

Meclizine ondansetron hcl, ODT prochlorperazine maleate promethazine hcl EMEND

Kytril

PA

Zofran, Zofran ODT Compazine Phenergan

ANTIPARKINSON ANTICHOLINERGIC DRUGS / MEDICAMENTOS ANTICOLINÉRGICOS PARA TRATAR EL MAL DE PARKINSON benztropine mesylate, injection

QLL=3/34 DAYS (INJECTION ONLY COVERED FOR LTC RESIDENTS)

Trihexyphenidyl

OTHER ANTIPARKINSON DRUGS / OTROS MEDICAMENTOS PARA TRATAR EL MAL DE PARKINSON bromocriptine mesylate 2.5 mg carbidopa/levodopa

Parlodel Sinemet

Entacapone

COMTAN

Pramipexole

Mirapex

Ropinirole

Requip

QLL=90 tabs/30 days

STALEVO

PA; QLL=270 tabs/30 days

PA; QLL=120 tabs/30 days

Selegiline carbidopa/levodopa/entacapone

ANTIPSYCHOTIC DRUGS / ANTIPSICÓTICOS chlorpromazine tablets, 25mg/ml ampules clozapine 12.5 mg, 25 mg, & 100 mg fluphenazine tablets, decanoate injection, hydrochloride injection

25mg/ml ampules COVERED for LTC RESIDENTS ONLY; all others require PA; QLL=3 AMP/34 Prolixin

(HCL INJ ONLY-QLL=1/34 DAYS COVERED for LTC RESIDENTS); all others require PA for hcl inj only

Page 17

ILLINOIS FORMULARY REVISED May 2016 haloperidol tablets, decanoate injection, lactate injection

(LACTATE INJ ONLY-covered for LTC RESIDENTS; all others require PA; QLL=3/34 DAYS) COVERED FOR LTC RESIDENTS; ALL OTHERS REQUIRE PA

INVEGA SUSTENNA INVEGA TRINZA

PA

Latuda

PA

Loxapine olanzapine, olanzapine ODT

Zyprexa Zyprexa Zydis

Orally Disintegrating Tablet (ODT) ONLY- REQUIRES PA

Risperdal, Risperdal M-Tab

QLL=60 tabs/30 days; STEP (ODT only) COVERED FOR LTC RESIDENTS, ALL OTHERS REQUIRE PA QLL=1/14 DAYS

Seroquel

QLL=90 tabs/30 days; 300 mg=60 tabs/30 days PA

Perphenazine risperidone, odt Risperdal Consta

Quetiapine Saphris Thioridazine Thiothixene Trifluoperazine Ziprasidone

Geodon STEP CNS STIMULANT DRUGS / MEDICAMENTOS PARA ESTIMULAR EL SISTEMA NERVIOSO CENTRAL amphetamine/dextroamphetamine

Dextroamphetamine dexmethylphenidate IR methylin, er tabs, methylin suspension methylphenidate er, sr 10 mg , 20 mg (methylphenidate ER 18 mg, 27 mg, 35 mg, 54 mg are non-formulary and requires PA) methylphenidate hcl methylphenidate ER capsule

Adderall, Adderall XR

Focalin

Ritalin, Ritalin-SR Ritalin-SR Ritalin METADATE CD, Ritalin LA

PA less than 6yrs and over 18 years; Immediate release QLL=90 tabs/30 days; Extended release QLL=30 PA less than 6yrs and over 18 years; PA less than 6yrs and over 18 years; PA less than 6yrs and over 18 years; QLL=120 tabs/30 days PA less than 6yrs and over 18 years PA less than 6yrs and over 18 years; QLL=120 tabs/30 days PA less than 6yrs and over 18 years; QLL=60 caps/30 days

Page 18

ILLINOIS FORMULARY REVISED May 2016 STRATTERA

PA; QLL=60 caps/30 days

ANTIDEMENTIA DRUGS / MEDICAMENTOS PARA TRATAR LA DEMENCIA donepezil 5 MG, 10 MG (23 MG IS NON-FORMULARY) donepezil ODT galantamine, -ER

Aricept

QLL=30 tabs/30 days

Aricept ODT

QLL=30 tabs/30 days

Razadyne, Razadyne ER

Memantine rivastigmine capsules

NAMENDA Exelon capsules

galantamine QLL=60 tabs/30 days galantamine ER QLL=30 caps/30 days QLL=60 caps/30 days

SMOKING CESSATION DRUGS / MEDICAMENTOS PARA DEJAR DE FUMAR Buproban

Zyban

CHANTIX OTC nicotine patch

Nicoderm

Duration for all formulary smoking cessation meds=84 days/year Duration for all formulary smoking cessation meds=84 days/year Duration for all formulary smoking cessation meds=84 days/year

OTHER CNS DRUGS / OTROS MEDICAMENTOS QUE ACTÚAN SOBRE EL SISTEMA NERVIOSO CENTRAL caffeine citrate oral solution Pyridostigmine

CARDIOVASCULAR MEDICATIONS

DRUGS USEDFOR HEART CONDITIONS (HIGHBLOODPRESSURE,CHOLESTEROL,CHEST PAIN,ETC.)

MEDICAMENTOS PARA TRATAR ENFERMEDADES CARDIOVASCULARES

MEDICAMENTOS UTILIZADOS PARA TRATAR CONDICIONES DEL CORAZÓN (POR EJEMPLO, PRESIÓN SANGUÍNEA ALTA, COLESTEROL, DOLOR EN EL PECHO, ETC.)

CARDIAC GLYCOSIDES / GLUCÓSIDOS CARDÍACOS Digoxin LANOXIN

Lanoxin

CALCIUM ANTAGONISTS / SOBREDOSIS DE ANTAGONISTAS DEL CALCIO Amlodipine

cartia xt diltiazem er diltiazem hcl diltia xt dilt-CD felodipine er Isradipine nicardipine hcl nifediac cc nifedipine, er

Norvasc Cardizem CD Tiazac/Taztia XT, Cardizem SR Cardizem Cardizem CD Cardizem CD Plendil DynaCirc Cardene ProcardiaProcardia XL

QLL= 30 tabs/30 days 10mg; 60tabs /30 days 5mg; 120 tabs/30 days 2.5mg QLL=60 caps or tabs/30 days QLL=120 tabs/30 days

Extended Release QLL=90 tabs/30 days Page 19

ILLINOIS FORMULARY REVISED May 2016 Nimodipine Nisoldipine verapamil, er

Nimotop Sular Verelan/Calan/Calan SR

QLL=60 tabs/30 days QLL for Immediate Release=120 units/30days; QLL for Extended Release=60 units/30 days

CARBONIC ANHYDRASE INHIBITORS / INHIBIDORES DE LA ANHIDRASA CARBÓNICA acetazolamide, ER

Diamox

LOOP DIURETICS / DIURÉTICOS DE ASA Bumetanide Furosemide Torsemide

Bumex Lasix Demadex

THIAZIDE AND RELATED DRUGS / TIAZIDA Y MEDICAMENTOS RELACIONADOS Chlorthalidone Chlorothiazide Hydrochlorothiazide Indapamide Methyclothiazide Metolazone

Microzide Lozol Zaroxolyn

POTASSIUM SPARING DIURETICS / DIURÉTICOS QUE NO AFECTAN EL POTASIO Amiloride amiloride hcl w/hctz Spironolactone spironolactone w/hctz triamterene w/hctz

Midamor Moduretic Aldactone Aldactazide Maxzide/Diazide

BETA-ADRENERGIC ANTAGONIST DRUGS / ANTAGONISTAS BETA ADRENÉRGICOS Acebutolol Atenolol Betaxolol bisoprolol fumarate Carvedilol labetalol hcl metoprolol succinate metoprolol tartrate Nadolol Pindolol propranolol, er timolol maleate

Tenormin Kerlone Zebeta Coreg Normodyne/Trandate Toprol XL Lopressor Corgard Inderal/LA

VASODILATOR ANTIHYPERTENSIVES / ANTIHIPERTENSORES VASODILATORES doxazosin mesylate hydralazine hcl Minoxidil prazosin hcl terazosin hcl

Cardura Appresdine Minipress Hytrin

QLL=30 tabs/30 days

QLL 1mg, 2mg, 5mg=30/30 days; QLL 10 mg=60/30 days

Page 20

ILLINOIS FORMULARY REVISED May 2016 CENTRALLY ACTING ANTIHYPERTENSIVES / ANTIHIPERTENSORES DE ACCIÓN CENTRAL clonidine patches clonidine tablets guanfacine hcl

Catapres TTS Catapres Tenex

methyldopa

ANGIOTENSIN CONVERTING ENZYME INHIBITORS / ANTAGONISTAS DE LA ENZIMA CONVERTIDORA DE ANGIOTENSINA Benazepril Captopril Enalapril Fosinopril Lisinopril

Lotensin Capoten Vasotec Monopril Prinivil/Zestril

Moexipril perindopril Ramipril Quinapril trandolapril

Univasc Aceon Altace Accupril Mavik

QLL=30 tabs/30 days; 40 mg=60 tabs/30 days

ANGIOTENSIN II RECEPTOR ANTAGONISTS / ANTAGONISTAS DE LOS RECEPTORES DE ANGIOTENSINA II Candesartan, Candesartan HCTZ Atacand, Atacand HCT Valsartan, Valsartan HCTZ

DIOVAN, Diovan HCT

Losartan, Losartan HCTZ

Cozaar,Hyzaar

Irbesartan, Irbesartan HCTZ

Avapro, Avilide

QLL=60 tabs/30 days;

OTHER ANTIHYPERTENSIVES / OTROS ANTIHIPERTENSIVOS amlodipine/benazepril 2.5/10 mg, 5/10 mg, 5/20 mg, 10/20 mg, 10/40 mg atenolol w/chlorthalidone benazepril hcl w/hctz bisoprolol fumarate w/hctz captopril w/hctz enalapril maleate w/hctz fosinopril w/hctz lisinopril w/hctz methyldopa w/hctz metoprolol w/hctz moexipril w/hctz propranolol hcl w/hctz quinapril w/hctz

Lotrel 2.5/10 mg, 5/10 mg, 5/20 mg, 10/20, 10/40 mg Tenoretic Lotensin HCT Ziac Capozide Vaseretic Monopril HCT Prinzide/Zestoretic Lopressor HCT Uniretic Inderide Quinaretic

Resperine

Page 21

ILLINOIS FORMULARY REVISED May 2016 NITRATES / NITRATOS

isosorbide dinitrate, ER isosorbide mononitrate, ER nitro-bid ointment nitroglycerin (patch, sublingual tablet, extended-release capsule) NITROSTAT

Isochron/Isordil Imdur/Ismo/Monoket Nitro-Dur/Nitrostat

OTHER VASODILATING DRUGS / OTROS MEDICAMENTOS VASODILATADORES ADCIRCA

PA/QLL=60 tabs/30 days

SILDENAFIL

REVATIO

PA/QLL=90 tabs/30 days

CLASS 1A ANTIARRHYTHMICS / ANTIARRÍTMICOS DE CLASE 1A disopyramide, er Procainamide quinidine gluconate quinidine sulfate

Norpace

CLASS 1B Antiarrhythmic / ANTIARRÍTMICOS DE CLASE 1B Mexiletine

Mexitil

PA

CLASS 1C Antiarrhythmics / ANTIARRÍTMICOS DE CLASE 1C flecainide acetate propafenone hcl

Tambocor Rythmol

PA

OTHER ANTIARRHYTHMICS / OTROS ANTIARRÍTMICOS Amiodarone

Pacerone

MULTAQ

PA

sotalol, af

Betapace

HYPOLIPOPROTEINEMICS / HIPOLIPOPROTEINÉMICOS Cholestyramine colestipol hcl Fenofibrate Gemfibrozil OTC niacin OTC SLO NIACIN fenofibric acid ZETIA

Colestid Lofibra, Tricor Lopid

QLL=60 tabs/30 days

TRILIPIX STEP

HMG-COA REDUCTASE INHIBITORS / INHIBIDORES DE LA REDUCTASA DE LA HMG-COA Atorvastatin Lovastatin

Pravastatin Simvastatin Fluvastatin, ER

Lipitor Mevacor Pravachol Zocor LESCOL, Lescol XL

QLL= 30 tabs/ 30 days QLL=30 tabs/30 days; 40 mg=60 tabs/30 days QLL=30 tabs/30 days QLL=30 tabs/30 days QLL=30 caps/30 days Page 22

ILLINOIS FORMULARY REVISED May 2016 OTHER CARDIOVASCULAR DRUGS / OTROS MEDICAMENTOS PARA TRATAR AFECCIONES CARDIOVASCULARES Midodrine Pentoxifylline

ProAmatine Trental

DERMATOLOGICAL MEDICATIONS

DRUGS USED TO TREAT SWELLING, REDNESS, ITCHING OR ALLERGIC SKIN REACTIONS, ACNE, HAIR LICE, ETC.

MEDICAMENTOS DERMATOLÓGICOS

MEDICAMENTOS UTILIZADOS PARA REDUCIR INFLAMACIONES, ENROJECIMIENTO DE LA PIEL, PICAZÓN O REACCIONES ALÉRGICAS DE LA PIEL, ACNÉ, PEDICULOSIS, ETC.

TOPICAL CORTICOSTEROID DRUGS / CORTICOSTEROIDES TÓPICOS alclometasone dipropionate Amcinonide betamethasone dipropionate betamethasone valerate clobetasol propionate Desonide Desoximetasone diflorasone diacetate Fluocinolone Fluocinonide fluticasone propionate Halobetasol hydrocortisone (prescription and OTC forms covered) hydrocortisone butyrate hydrocortisone valerate lidocaine-hydrocortisone mometasone furoate Prednicarbate triamcinolone acetonide

Aclovate Diprolene Beta-Val Clobevate/Temovate Desowen/Lokara Topicort Apexicon/Maxiflor/Psorcon

Cutivate Ultravate Ala-Cort/Cetacort/Hytone Locoid Westcort Elocon Dermatop Kenalog

ANTIPRURITIC DRUGS / MEDICAMENTOS ANTIPRURÍTICOS hydroxyzine hcl

Page 23

ILLINOIS FORMULARY REVISED May 2016

hydroxyzine pamoate

ANTIACNE DRUGS / MEDICAMENTOS PARA TRATAR EL ACNÉ adapalene cream, gel (0.1% only) Amnesteem Benzoyl Peroxide cream lotion, wash, cream Claravis clindamycin phosphate Clindamycin/benzoyl peroxide Erythromycin Erythromycin/Benzoyl Peroxide METROGEL 1% TOPICAL GEL Metronidazole sod.sulfacetamide/sulfur10-5% only Sotret Tretinoin

Differin Accutane Accutane Cleocin T/Clindamax Benzaclin A/T/S / Emgel/Erycette

Metrocream/Metrolotion Avar/Plexion Accutane Avita/Retin-A

QLL=20 gram tube/30days

KERATOLYTIC DRUGS / MEDICAMENTOS QUERATOLÍTICOS CONDYLOX GEL podofilox solution

Condylox

ANTIPSORIASIS AND ANTIECZEMA DRUGS / MEDICAMENTOS PARA TRATAR PSORIASIS Y ECCEMAS calcipotriene ointment, scalp solution OTC DOAK TAR DISTILLATE, OIL DRITHO-SCALP POLYTAR selenium sulfide sulfacetamide sodium calcitriol ointment

Dovonex

Selseb Carmol Scalp VECTICAL OINTMENT

ORAL DERMATOLOGICAL DRUGS / MEDICAMENTOS DERMATOLÓGICOS ORALES OXSORALEN ULTRA

TOPICAL DERMATOLOGICAL DRUGS / MEDICAMENTOS DERMATOLÓGICOS ORALES

ammonium lactate CARAC ELIDEL FLUOROPLEX Fluorouracil imiquimod 5% cream HYPERCARE SANTYL OTC zinc oxide ointment Tacrolimus

Lac-Hydrin STEP/QLL=30 gm/30 days Efudex Aldara

Desitin Protopic

STEP

SCABICIDES / ESCABICIDAS Acticin Malathion

Elimite 5% Topical Cream Ovide Page 24

ILLINOIS FORMULARY REVISED May 2016 OTC permethrin 1% lotion

Nix

Page 25

ILLINOIS FORMULARY REVISED May 2016

permethrin 5% cream (prescription strength) OTC Pyrethrin 0.33% ULESFIA LOTION

Elimite

EAR-NOSE-THROAT MEDICATIONS

DRUGS USED FOR EAR INFECTIONS, NASAL ALLERGIES OR DRY MOUTH

MEDICAMENTOS PARA TRATAR AFECCIONES DE NARIZ, OÍDO Y GARGANTA

MEDICAMENTOS UTILIZADOS PARA TRATAR INFECCIONES NASALES, DEL OÍDO O BOCA SECA

DRUGS AFFECTING THE EAR / MEDICAMENTOS PARA AFECCIONES DE OÍDO antipyrine/benzocaine otic acetic acid otic CIPRO HC CIPRODEX OTIC neomycin/polymixin/hydrocortisone Ofloxacin

Benzotic/Otogesic

DRUGS AFFECTING THE NOSE / MEDICAMENTOS PARA AFECCIONES DE NARIZ Azelastine Flunisolide fluticasone propionate ipratropium bromide OTC Nasacort AQ Oxymetazoline

Astelin Nasarel Flonase Atrovent

QLL= 2 bottles/30 days

STEP STEP

Afrin

DRUGS AFFECTING THE THROAT AND MOUTH / MEDICAMENTOS PARA AFECCIONES DE BOCA Y GARGANTA chlorhexidine gluconate doxycycline hyclate pilocarpine hcl triamcinolone acetonide 0.1% paste

Peridex Periostat Salagen Kenalog

ENDOCRINE MEDICATIONS

USED FOR DIABETES, LOW/HIGH THYROID LEVELS, OSTEOPOROSIS, ETC.

MEDICAMENTOS PARA TRATAR AFECCIONES ENDÓCRINAS

UTILIZADOS PARA TRATAR DIABETES, NIVELES BAJOS/ALTOS DE HORMONA TIROIDEA, OSTEOPOROSIS, ETC.

ORAL HYPOGLYCEMIC DRUGS / MEDICAMENTOS HIPOGLUCÉMICOS ORALES Acarbose Chlorpropamide Glimepiride glipizide, er glipizide-metformin Glyburide glyburide-metformin

Precose Diabinese Amaryl Glucotrol, XL Metaglip Diabeta/Micronase Glucovance Page 26

ILLINOIS FORMULARY REVISED May 2016

metformin, ─er Nateglinide Repeglinide Repeglinide/Metformin JANUMET, JANUMET XR Januvia Jentadueto Tolazamide Tolbutamide Tradjenta

Glucophage, XR Starlix

Prandin PRANDIMET

STEP STEP STEP STEP

INSULIN SENSITIZERS / SENSIBILIZADORES DE INSULINA AVANDAMET AVANDARYL AVANDIA DUETACT Pioglitazone pioglitazone/metformin

OTHER GLUCOSE-LOWERING DRUGS Drugs

ACTOS ACTOPLUS MET

QLL=60 tabs/30 days QLL=60 tabs/30 days QLL=30 tabs/30 days QLL=30 tabs/30 days QLL=30 tabs/30 days QLL=90 tabs/30 days

Byetta Trulicity Invokana Invokamet Farxiga

STEP STEP STEP STEP STEP

INSULIN (VIALS ONLY) / INSULINA (SOLO EN FRASCOS) Each insulin type has QLL=6 vials/30 day supply HUMALOG 50/50 VIAL HUMALOG 75/25 VIAL HUMALOG 100U VIAL HUMULIN 50/50 VIAL HUMULIN R (100 U/ML VIAL) HUMULIN R (500 U/ML VIAL) HUMULIN 70/30 VIAL NOVOLIN 70/30 VIAL NOVOLIN R VIAL NOVOLIN N VIAL NOVOLOG VIAL NOVOLOG MIX 70/30 VIAL LANTUS VIAL LEVEMIR VIAL

GLUCOSE ELEVATING DRUGS / MEDICAMENTOS QUE ELEVAN EL NIVEL DE GLUCOSA GLUCAGEN VIALS GLUCAGON OTC glucose chewable tablets

GLUCOCORTICOID DRUGS / GLUCOCORTICOIDES Cortisone

Page 27

ILLINOIS FORMULARY REVISED May 2016 Dexamethasone Hydrocortisone Methylprednisolone Prednisolone Prednisone Prednisolone phosphate orally disintegrating tablet

Cortef Medrol Prelone Sterapred ORAPRED ODT

GROWTH HORMONES / HORMONAS DE CRECIMIENTO Omnitrope vials

PA

MINERALOCORTICOID DRUGS / fludrocortisone acetate

Florinef

THYROID SUPPLEMENTS / SUPLEMENTOS NP Thyroid Levothroid levothyroxine sodium Levoxyl Liothyronine thyroid, dessicated Unithroid

ARMOUR TH Synthroid Synthroid Cytomel Armour Synthroid

ANTITHYROID DRUGS / MEDICAMENTOS Methimazole Propylthiouracil

Tapazole

ANDROGEN DRUGS / ANDRÓGENOS Danazol testosterone cypionate (200 mg/ml only)

OTHER ENDOCRINE DRUGS / OTROS MEDICAMENTOS ENDÓCRINOS alendronate sodium Cabergoline calcitonin nasal spray CHEMET

desmopressin acetate

QLL 35 mg or 70 mg=4 tabs/30 days; COVERED FOR ENDO; ALL OTHERS

Fosamax Dostinex

Miacalcin

DDAVP/Minirin

Etidronate fortical nasal spray

Didronel

Ibandronate Inj

Boniva

Pamidronate Inj

Aredia

SENSIPAR

QLL=1 bottle/30 days; QLL=90 tabs/30 days

PA

Page 28

ILLINOIS FORMULARY REVISED May 2016 GASTROINTESTINAL MEDICATIONS

DRUGS USED FOR HEART BURN, REDUCE ACID PRODUCTION IN THE STOMACH, DIARRHEA, CONSTIPATION, ETC.

MEDICAMENTOS PARA TRATAR AFECCIONES GASTROINTESTINALES

MEDICAMENTOS UTILIZADOS PARA TRATAR LA ACIDEZ, REDUCIR LA PRODUCCIÓN DE ÁCIDO DEL ESTÓMAGO, DIARREA, CONSTIPACIÓN, ETC.

ANTIDIARRHEAL DRUGS / ANTIDIARRÉICOS bismuth subsalicylate diphenoxylate w/atropine OTC loperamide

Pepto Bismol Lomotil Imodium

ANTISPASMODICS – DRUGS AFFECT GI MOTILITY / ANTIESPASMÓDICOS – MEDICAMENTOS QUE AFECTAN LA MOTILIDAD GASTROINTESTINAL dicyclomine hcl glycopyrrolate tablets Hyoscyamine metoclopramide hcl

Bentyl Robinul Nulev/Levbrel Reglan

ANTIULCER DRUGS (OTC AND PRESCRIPTION FORMS COVERED) / MEDICAMENTOS PARA PREVENIR ÚLCERAS (COBERTURA PARA MEDICAMENTOS CON RECETA Y DE VENTA LIBRE) Cimetidine Famotidine Nizatidine Ranitidine

Tagamet Pepcid Axid Zantac

OTHER ANTIULCER DRUGS / OTROS MEDICAMENTOS PARA PREVENIR ÚLCERAS Misoprostol Sucralfate

Cytotec Carafate

PROTON PUMP INHIBITORS / INHIBIDORES DE LA BOMBA DE PROTONES OTC omeprazole, First Omeprazole Pantoprazole

OTC Prilosec Protonix

OTC esomeprazole

OTC Nexium

QLL=2 caps/DAY

OTC lansoprazole

OTC Prevacid

QLL=2 caps/day

QLL=120 tabs /30 days STEP QLL=30 tabs/30 days

LAXATIVES AND CATHARTICS / LAXANTES Y PURGANTES OTC bisacodyl OTC docusate OTC docusate-senna Generlac OTC glycerin OTC MIRALAX polyethylene glycol 3350 powder for solution OTC psyllium OTC SENOKOT (brand and generic dosage forms covered)

Dulcolax Colace Peri-Colace Fleet Miralax Metamucil

QLL=527 g/30 days QLL=527 g/30 days

Page 29

ILLINOIS FORMULARY REVISED May 2016 OTC SORBITOL 70% ORAL SOLN

OTHER GI DRUGS / OTROS MEDICAMENTOS PARA TRATAR AFECCIONES GASTROINTESTINALES OTC aluminum hydroxide gel OTC antacid liquid, suspension AMITIZA ASACOL Dezicol OTC calcium antacid tablet CANASA

CORTIFOAM CREON 5, 10, 15, CREON LIPASE 6,000; 12,000; 24,000 UNITS DIPENTUM OTC effervescent pain relief OTC hemorrhoidal cream OTC hydrocortisone enema suspension Hydrocortisone 2.5% rectal cream IPECAC SYRUP mesalamine enema NULYTELY WITH FLAVOR PACKS Octreotide acetate (inj) PANCREAZE PANCRELIPASE 5,000 UNITS PEG 3350 ELECTROLYTE SOLUTION PENTASA PROCTOFOAM-HC Propantheline OTC simethicone drops Sandostatin LAR sulfasalazine, sulfasalazine delayed-release sulfazine, sulfazine delayed -release Ursodiol VIOKASE 8, 16 ZENPEP 5,000U; 10,000U, 15,000U, 20,000U

Alternagel

QLL=60 caps/30 days

Tums

Alka Seltzer PreparationH Proctosol-hydrocortisone 2.5% rectal cream

PA

PA Azulfidine Azulfidine Actigall

IMMUNOLOGICALS AND VACCINES VACCINES AND DRUGS USED FOR MULTIPLE SCLEROSIS ESTIMULADORES INMUNOLÓGICOS Y VACUNASVACUNAS Y MEDICAMENTOS UTILIZADOS

PARA TRATAR ESCLEROSIS MÚLTIPLE

Page 30

ILLINOIS FORMULARY REVISED May 2016 FLUMIST

COVERED DURING FLU SEASON (OCT 1, 2012 TO April 30, 2013); PA >49 YEARS; QLL=#1/YEAR

RHOGAM MicRhoGAM

INTERFERONS USED FOR MULTIPLE SCLEROSIS / INTERFERONES UTILIZADOS PARA TRATAR ESCLEROSIS MÚLTIPLE AUBAGIO COPAXONE EXTAVIA GLATOPA REBIF

PA PA PA PA PA

MUSCULOSKELETAL MEDICATIONS

DRUGS USED TO RELEIVE PAIN, MUSCLE SPASMS, JOINT PAIN/SWELLING DUE TO GOUT

MEDICAMENTOS PARA TRATAR AFECCIONES MUSCULOESQUELÉTICAS MEDICAMENTOS UTILIZADOS PARA

ALIVIAR DOLOR, ESPASMOS DE LOS MÚSCULOS, DOLOR ARTICULAR/HINCHAZÓN PROVOCADOS POR LA GOTA

SALICYLATES AND RELATED DRUGS / SALICILATOS Y MEDICAMENTOS RELACIONADOS OTC aspirin 81 mg, 325 mg, choline magnesium trisalicylate Diflunisal Salsalate

Ecotrin Dolobid Disalcid

NON-STEROIDAL ANTIINFLAMMATORY AGENTS / AGENTES ANTIINFLAMATORIOS NO ESTEROIDES diclofenac sodium Etodolac Fenoprofen Flurbiprofen Ibuprofen (prescription and OTC forms covered) Indomethacin Ketoprofen Ketorolac Meclofenamate Meloxicam Nabumetone Naproxen OTC naproxen

Lodine/Lodine XL Anasaid Motrin Indocin SR Orudis/Oruvail Toradol

QLL=20 tabs/30 days and 2 Rxs per 90 days

Mobic Relafen Naprosyn Aleve Page 31

ILLINOIS FORMULARY REVISED May 2016

Oxaprozin Piroxicam Sulindac Tolmetin

Daypro Feldene Clinoril

COX-2 Inhibitors Celecoxib

Celebrex

OTHER DRUGS FOR ARTHRITIS / OTROS MEDICAMENTOS PARA TRATAR ARTRITIS RIDAURA

STEP

Hyalgan

COVERED FOR RHEUMATOLOGISTS; ALL OTHERS REQUIRE PA PA

Gel-One

PA

DRUGS TO PREVENT AND TREAT GOUT / MEDICAMENTOS PARA PREVENIR Y TRATAR LA GOTA Allopurinol colchicine colchicine / probenecid Probenecid ULORIC

Zyloprim

Colcrys STEP

DIRECT MUSCLE RELAXANTS / RELAJANTES MUSCULARES DIRECTOS Baclofen dantrolene capsule tizanidine hcl

Dantrium Zanaflex

CNS MUSCLE RELAXANTS / RELAJANTES MUSCULARES QUE ACTÚAN SOBRE EL SISTEMA NERVIOSO CENTRAL Carisoprodol

cyclobenzaprine hcl Methocarbamol Metaxalone

Soma

Flexeril Robaxin Skelaxin

PA (refer to HFS website: http://www.hfs.illinois.gov/pharmacy /carisoprodol.html); Cummulative QLL=240 tabs/365 days QLL=120 tabs/30 days QLL=120 tabs/30 days QLL=120 tabs/30 days

OTHER MUSCULOSKELETAL MEDICATIONS /OTROS MEDICAMENTOS PARA TRATAR AFECCIONES MUSCULOESQUELÉTICAS OTC capsaicin Page 32

ILLINOIS FORMULARY REVISED May 2016 RILUTEK

PA

NUTRITION, BLOOD MODIFIERS, ELECTROLYTES VITAMINS AND DRUGS USED TO REDUCE BLEEDING NUTRICIÓN, AGENTES QUE MODIFICAN LA SANGRE, ELECTROLITOS VITAMINAS Y MEDICAMENTOS UTILIZADOS PARA REDUCIR EL SANGRADO THERAPEUTIC VITAMINS & MINERALS / MINERALES Y VITAMINAS TERAPÉUTICAS OTC calciferol, OTC ergocalciferol drops Calcitriol calcium acetate OTC calcium carbonate, OTC calcium carbonate 600 mg + D OTC calcium citrate CYANOCOBALAMIN INJ (VITAMIN B12) ergocalciferol 1.25 mg capsule, (prescription) OTC ferrous fumerate OTC ferrous gluconate OTC ferrous sulfate OTC Fish Oil folic acid (prescription-strength covered only) Levocarnitine

Drisdol Calcijex/Rocaltrol Phoslo Caltrate Citracal Vitamin D2

Iron

PA

OTC magnesium oxide OTC multivitamins (generic, adult multivitamins) NEPHROCAPS, NEPHROCAPS QT OTC pyridoxine (vitamin B6) OTC sodium bicarbonate sodium fluoride stannous fluoride rinse OTC vitamin C 500, 1000 mg OTC vitamin D OTC thiamine (vitamin B1) Paricalcitol

ZEMPLAR

ST

POTASSIUM SUPPLEMENTS / SUPLEMENTOS DE POTASIO citric acid monohydrate, sodium citrate dihydrate oral solution klor con, klor con m, klor con effervescent potassium chloride tablets, oral solution SHOHL'S MODIFIED

Bicitra

K-Dur/Klotrix

POTASSIUM REMOVING RESINS / RESINAS PARA ELIMINAR POTASIO sodium polystyrene sulfonate, powder

Kayexalate

ORAL ANTICOAGULANTS / ANTICOAGULANTES ORALES warfarin sodium Xarelto Eliquis

Coumadin

PA PA

Page 33

ILLINOIS FORMULARY REVISED May 2016 HEPARINS / HEPARINAS

heparin sodium vials [inj] (heparin lock flush solution requires PA)

LOW-MOLECULAR WEIGHT HEPARINS (LMWH) / HEPARINAS DE BAJO PESO MOLECULAR enoxaparin [inj] FRAGMIN [inj]

Lovenox

Fondaparinux (inj)

Arixtra ANTIPLATELET DRUGS / MEDICAMENTOS ANTIPLAQUETARIOS Cilostazol Clopidogrel Dipyridamole ticlopidine hcl

Pletal Plavix Persantine Ticlid

First 10 DAYS W/O PA First 10 DAYS W/O PA (10 DAYS=10 SYRINGES) First 21 days without PA

QLL=30 tabs/30 days

HEMOSTATICS / HEMOSTÁTICOS Amicar MEPHYTON

BLOOD DETOXICANTS / Enulose Generlac Lactulose RENVELA

OTHER BLOOD MODIFIERS / DESINTOXICANTES DE LA SANGRE Anagrelide SOLIRIS

Agrylin PA

OBSTETRICAL & GYNECOLOGICAL MEDICATIONS BIRTH CONTROL PILLS, VITAMINS FOR PREGANCY, HORMONE REPLACEMENT THERAPY FOR MENOPAUSAL WOMEN, ETC. MEDICAMENTOS PARA TRATAR AFECCIONES OBSTÉTRICAS Y GINECOLÓGICAS PÍLDORAS ANTICONCEPTIVAS, VITAMINAS PARA EL EMBARAZO, TERAPIA DE REEMPLAZO HORMONAL PARA MUJERES MENOPÁUSICAS, ETC. CONTRACEPTIVES / ANTICONCEPTIVOS Apri Aranelle Aviane Azurette Balziva Brevicon Camila Caziant Cesia Condoms Cryselle ELLA Enpresse

Desogen Tri-Norinyl Alesse-28 Mircette Ovcon-35 Modicon Nor-Q-D Cyclessa Cyclessa Lo/Ovral-28 Tri-levlen 28 Page 34

ILLINOIS FORMULARY REVISED May 2016 Errin Gianvi gildess FE Jolessa Jolivette junel, junel FE Kariva kelnor 1/35 Leena Lessina OTC levonorgestrel levora-28 low-ogestrel Lutera Mirena mirogestin, microgestin FE Mononessa Necon

Nor-Q-D Yaz Loestrin FE Seasonale Nor-Q-D Loestrin, Loestrin FE Mircette Demulen 1/35-28 Tri-Norinyl Alesse-28 Plan B Nordette-28 Lo/Ovral-28 Alesse-28 Loestrin, Loestrin FE Ortho-Cyclen Modicon, Necon, Norinyl 1+35, Norinyl 1+50, Ortho Novum

Nexplanon nora-be Nortrel NUVARING Ocella Ogestrel Ethinyl Estradiol; Norelgestromin patch OTC NEXT CHOICE

QLL= 1 implant/3 years Nor-Q-D Modicon, Norinyl 1+35, Ortho Novum QLL=1 ring/month Yasmin 28, Yaz Ovral-28 ORTHO EVRA

OTC PLAN B ONE STEP Paragard Portia Previfem Quasense Reclipsen Solia Sprintec Sronyx tilia fe tri-legest Trinessa tri-previfem

QLL=2 tabs (1 pkg)/1 month; QLL=6 tabs (3 pkg)/year

QLL=3 patches/28 days QLL=2 tabs (1 pkg)/1 month; QLL=6 tabs (3 pkg)/year QLL=1 tab (1 pkg)/1 month; QLL=3 tabs (3 pkg)/year

Nordette-28 Ortho-Cyclen Seasonale Desogen Desogen Ortho-Cyclen Alesse-28 Estrostep Fe Estrostep Fe Ortho Tri-Cyclen Ortho Tri-Cyclen Page 35

ILLINOIS FORMULARY REVISED May 2016 tri-sprintec trivora-28 Velivet Zenchent zovia 1/35E zovia 1/50E

Ortho Tri-Cyclen Tri-Levlen 28 Cyclessa Ortho Novum Demulen 1/35-28 Demulen 1/50-21

PRENATAL VITAMINS; covered for females only; QLL=100 tabs/90 days for all legend prenatal vitamins VITAMINAS PRENATALES; se brinda cobertura solo para mujeres; QLL = 100 tabletas cada 90 días para todas las vitaminas prenatales con receta advanced care plus bp multinatal plus

OB/GYN TOPICAL ANTIINFECTIVES / ANTIINF

concept dha Folbecal natalcare glosstabs natatab Rx Prenafirst prenatal advantage (prenatal AD) prenatabs FA prenatal H prenatabs rx prenatal U SELECT-OB, SELECT-OB+ DHA trimesis rx Trinate ultra-natal vinate II vinate az vinate calcium vinatal forte vinate gt vinate m vinate one vinate ultra vitafol-ob vitafol-pn Vitaspire

OTHER OB/GYN DRUGS / OTROS MEDICAMENTOS GINECOLÓGICOS METHERGINE TABLETS Lupron Depot

PA

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ILLINOIS FORMULARY REVISED May 2016 OPHTHALMIC MEDICATIONS

DRUGS USED FOR EYE INFECTIONS, DRY EYES, GLAUCOMA, ETC.

MEDICAMENTOS OFTÁLMICOS

MEDICAMENTOS UTILIZADOS PARA TRATAR INFECCIONES EN LOS OJOS, OJOS SECOS, GLAUCOMA, ETC.

OPHTHALMIC TOPICAL ANTIBACTERIAL DRUGS / MEDICAMENTOS ANTIBACTERIALES OFTÁLMICOS TÓPICOS bacitracin ophth ointment bacitracin/polymixin ophth ointment ciprofloxacin hcl (ophth drops) CILOXAN OPTHALMIC OINTMENT erythromycin gentamicin sulfate levofloxacin neomycin/polymyxin/bacitracin neomycin/polymyxin/gramicidin Ofloxacin polymyxin/trimethoprim sulfacetamide sodium tobramycin sulfate TOBREX OINTMENT VIGAMOX ZYMAXID

AK-Poly Bac Ciloxan

Garamycin/Gentak Quixin Neosporin Ocuflox Polytrim Bleph-10 Tobrex

OPHTHALMIC CORTICOSTEROID DRUGS / MEDICAMENTOS CORTICOSTEROIDES OFTÁLMICOS dexamethasone fluorometholone FML FORTE PRED MILD prednisolone

Omnipred/Pred Forte

OPHTHALMIC ANTIINFECTIVE/CORTICOSTEROIDS / ANTIINFECCIOSOS/CORTICOSTEROIDES OFTÁLMICOS neomycin/polymixin/hydrocortisone neomycin/polymyxin/dexamethasone prednisolone/sulfacetamide TOBRADEX OINTMENT tobramycin/dexamethasone susp

Cortisporin Methadex/Maxitrol

Tobradex

ANTIGLAUCOMA DRUGS / MEDICAMENTOS ANTIGLAUCOMA acetazolamide, ER Alphagan P 0.1% AZOPT BETOPTIC S betaxolol hcl brimonidine tartrate 0.15%, 0.2%

Alphagan P

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ILLINOIS FORMULARY REVISED May 2016 carteolol hcl COMBIGAN dorzolamide dorzolamide/timolol ISOPTO CARBACHOL Latanoprost levobunolol hcl LUMIGAN methazolamide metipranolol PHOSPHOLINE IODIDE pilocarpine hcl timolol maleate TRAVATAN Z Travoprost

Trusopt Cosopt Xalatan Betagan STEP Optipranolol Isopto Carpine Timoptic/Timoptic-XE PA PA

OTHER OPHTHALMIC DRUGS / OTROS MEDICAMENTOS OFTÁLMICOS ak-con Azelastine OTC artificial tears atropine sulfate drops, ointment cromolyn sodium Cyclopentolate 1% diclofenac sodium Epinastine flurbiprofen sodium ketorolac tromethamine ISOPTO HOMATROPINE ISOPTO HYOSCINE MUROCOLL-2 NEVANAC

Olopatadine

phenylephrine OTC REFRESH TEARS, LIQUIGEL (15 ML AND 30 ML BOTTLE ONLY) OTC sodium chloride 5% drops, ointment OTC SYSTANE (15 ML AND 30 ML BOTTLE ONLY) Trifluridine Tropicamide ketotifen OTC

Optivar Tears Again Isopto Atropine Crolom Cyclogyl Voltaren Elestat Ocufen Acular, Acular LS

STEP

PATANOL

Tropicacyl

OTC Zaditor

RESPIRATORY MEDICATIONS DRUGS USED FOR ASTHMA, ALLERGIES, COUGH/COLD, ETC. MEDICAMENTOS PARA AFECCIONES RESPIRATORIAS MEDICAMENTOS UTILIZADOS PARA TRATAR ASMA, ALERGIAS, TOS/RESFRÍO, ETC. Page 38

ILLINOIS FORMULARY REVISED May 2016 BETA-2 ADRENERGIC DRUGS / MEDICAMENTOS ADRENÉRGICOS BETA-2 albuterol sulfate (inhalation soln, syrup, tablet) metaproterenol Foradil Terbutaline VENTOLIN HFA Arcapta Neohaler Striverdi Respimat

QLL=390 ml/30 days for inhalation STEP QLL= 2 inhalers/30 days

INHALED CORTICOSTEROIDS / CORTICOSTEROIDES INHALADOS ADVAIR DISKUS

Covered for ages 4-11 years; all others require PA

ADVAIR HFA budesonide respules 0.25 mg/2 ml, 0.50 mg/2 ml, 1mg/2ml

PA Pulmicort Respules

FLOVENT DISKUS QVAR PULMICORT FLEXHALER/INHALER SYMBICORT

QLL=120 ml/30 days (60 respules/30 days) PA for all members over age 5

QLL=1 inhaler or flexhaler/30 days

LEUKOTRIENE MODIFIERS / MODIFICADORES DE LEUCOTRIENOS Montelukast Zafirlukast

SINGULAIR Accolate

METHYL XANTHINE DRUGS / METILXANTINAS

QLL=30 tabs/30 days STEP THERAPY FOR MEMBERS WITH DIAGNOSIS OF ASTHMA; QLL=60 tabs/30 days

aminophylline theophylline, er

OTHER RESPIRATORY DRUGS / OTROS MEDICAMENTOS PARA AFECCIONES RESPIRATORIAS ATROVENT (INHALER) cromolyn sodium inhalation soln EPIPEN, EPIPEN JR epinephrine pen 0.15mg , 0.3mg ipratropium bromide ipratropium bromide/albuterol inhalation soln COMBIVENT RESPIMAT SPIRIVA, Spiriva Respimat

Intal Adrenaclick

STEP; QLL=30 caps/30 days

Tudorza Incruse Ellipta sodium chloride 0.9% nebulizer solution OTC Page 39

ILLINOIS FORMULARY REVISED May 2016 ANTIHISTAMINES / ANTIHISTAMÍNICOS

Bromax carbinoxamine cetirizine OTC tablets, cetirizine-D OTC tablets, cetirizine OTC solution cetirizine syrup (prescription and OTC) chlorpheniramine maleate clemastine fumarate cyproheptadine hcl Dexchlorpheniramine solution only diphenhydramine (prescription and OTC forms covered) hydroxyzine hcl OTC loratadine, OTC loratadine-D Vazol solution

OTC Zyrtec, Zyrtec Syrup

cetirizine-D QLL=60 tabs/30 days cetirizine soln QLL=150 ml/30 days

Tavist Periactin Benadryl

OTC Claritin, Claritin-D

OTC loratadine-D=30 tabs/30 days

ANTIHISTAMINE-DECONGESTANT COMBINATIONS COMBINACIONES DE ANTIHISTAMÍNICOS-DESCONGESTIVOS brompheniramine/phenyephrine oral soln OTC brompheniramine-pseudoephedrine elixir ceron drops, syrup lohist-lq liquid r-tanna pediatric suspension Virdec 1mg-3.5mg/ml Drops

Rondec drops, syrup

ANTITUSSIVE AND EXPECTORANT DRUGS / ANTITUSÍGENOS Y EXPECTORANTES Benzonatate OTC CHERATUSSIN AC

Tessalon

guaifenesin-dm nr liquid guaifenesin tablets guaifenesin w/codeine MUCINEX, Mucinex D, DM OTC promethazine vc w/codeine syrup

Humibid Romilar AC/Tussi-Organidin DM NR Phenergan VC w/Codeine

promethazine vc syrup

Phenergan VC

promethazine w/dm syrup OTC tussin DM Virdec DM 3.5mg-1mg-3mg/ml Drops

Phenergan DM Robitussin DM

OTHER DRUGS FOR COUGH, COLD, ALLERGY / OTROS TRATAMIENTOS PARA TRATAR ALERGIAS, TOS Y RESFRÍO OTC nasal spray OTC pseudoephedrine (all generic dosage forms covered)

Afrin Sudafed

Page 40

ILLINOIS FORMULARY REVISED May 2016 TOXICOLOGY MEDICATIONS

DRUGS USED TO TREAT OVERDOSE OR REDUCE HIGH LEVELS OF COPPER IN THE BODY

MEDICAMENTOS TOXICOLÓGICOS

MEDICAMENTOS PARA TRATAR LA SOBREDOSIS O REDUCIR LOS NIVELES DE COBRE EN EL CUERPO acetylcysteine CUPRIMINE

UROLOGICAL MEDICATIONS

DRUGS USED TO TREAT OVERACTIVE BLADDER, CONDITIONS FOR THE PROSTATE, ETC.

MEDICAMENTOS UROLÓGICOS

MEDICAMENTOS UTILIZADOS PARA TRATAR LA HIPERACTIVIDAD DE LA VEJIGA, CONDICIONES DE LA PRÓSTATA, ETC.

ANTICHOLINERGIC ANTISPASMODICS DRUGS / ANTIESPASMÓDICOS ANTICOLINÉRGICOS Flavoxate oxybutynin chloride oxybutynin chloride er Tolteridone IR Trospium ER Trospium

Urispas Ditropan Ditropan XL Detrol SANCTURA XR Sanctura

STEP STEP STEP; QLL=60 tabs/30 days

CHOLINERGIC STIMULANTS / ESTIMULANTES COLINÉRGICOS Bethanecol

URINARY ANESTHETICS / ANESTÉSICOS URINARIOS phenazopyridine hcl

Pyridium/Urodol

OTHER GENITOURINARY PRODUCTS / OTROS PRODUCTOS GENITOURINARIOS Alfuzosin ELMIRON Finasteride K-PHOS CYTRA, -K Potassium citrate Tamsulosin

Uroxatral Proscar

Flomax

QLL=60 caps/30 days

MEDICAL (MISCELLANEOUS) SUPPLIES BLOOD GLUCOSE METERS, TEST STRIPS, OTHER SUPPLIES; SPACERS AND PEAK FLOW METERS FOR ASTHMA SUMINISTROS MÉDICOS (VARIOS) MEDIDORES DE LA GLUCOSA EN SANGRE, TIRAS REACTIVAS, OTROS SUMINISTROS; ESPACIADORES Y MEDIDORES DEL FLUJO MÁXIMO PARA EL ASMA

DIABETIC SUPPLIES: Combined QLL for test strips=150/month / SUMINISTROS DIABÉTICOS: QLL combinado para tiras reactivas = 150 por mes

Page 41

ILLINOIS FORMULARY REVISED May 2016

MICROLET LANCING DEVICE/LANCETS AUTOJECT 2 INJECTION DEVICE insulin syringes ONE TOUCH ULTRA2, UKTRALINK, ULTRAMINI, ULTRASMART, VERIO, VERIO IQ ONE TOUCH SELECT ONE TOUCH TEST STRIPS, CONTROL SOLUTION SOFT TOUCH SOFTCLIX CHEMSTRIP KETOSTIX

OTHER SUPPLIES / OTROS SUMINISTROS AEROCHAMBER, MICROCHAMBER ALCOHOL PREP PADS ASSESS PEAK FLOW METER MICROCHAMBER PEAK FLOW METER PERSONAL BEST PEAK FLOW METER

QLL=#1/YEAR QLL=#1/YEAR QLL=#1/YEAR QLL=#1/YEAR

Page 42