Download Preferred Drug List and more Lecture notes Acting in PDF only on Docsity!
SH- Select Health PerformRx Pharmacy Services Phone 1-866-610-2773 | Fax 1-866-610- Member Services Phone 1-888-276- Providers may request the addition or deletion of a medication to this list. Requests must include the drug name, rationale for inclusion on the list, role in therapy, and medications that may be replaced by the addition. Please direct such requests to: Pharmacy and Therapeutics Committee at Select Health P.O. Box 40849 Charleston, SC 29423 Members may request changes to the list by calling Member Services. For the most current Preferred Drug List (PDL), please use the searchable PDL on our website, www.selecthealthofsc.com.
First Choice by Select Health of South Carolina
Preferred Drug List
Antihistamine Drugs
Ethanolamine Derivatives
dimenhydrinate oral diphenhydramine hcl injection solution 50 mg/ml diphenhydramine hcl injection syringe diphenhydramine hcl oral capsule diphenhydramine hcl oral liquid diphenhydramine hcl oral syrup diphenhydramine hcl oral tablet SLEEP AID (DOXYLAMINE)
First Gen. Antihist. Derivatives, Misc.
cyproheptadine
First Generation Antihistamines
chlorpheniramine maleate oral tablet cyproheptadine dimenhydrinate oral diphenhydramine hcl injection solution 50 mg/ml diphenhydramine hcl injection syringe diphenhydramine hcl oral capsule diphenhydramine hcl oral liquid diphenhydramine hcl oral syrup diphenhydramine hcl oral tablet SLEEP AID (DOXYLAMINE)
Phenothiazine Derivatives
promethazine oral syrup QL (240 ML per 30 days) promethazine oral tablet promethazine rectal PROMETHAZINE VC QL (240 ML per 30 days) promethazine-dm QL (240 ML per 30 days)
Piperazine Derivatives
hydroxyzine hcl oral hydroxyzine pamoate meclizine oral tablet 12.5 mg, 25 mg meclizine oral tablet,chewable
loratadine oral tablet loratadine oral tablet,disintegrating ST LORATADINE-D ST WAL-FEX D 24 HOUR ST
Anti-Infective Agents
1St Generation Cephalosporin Antibiotics
cefadroxil oral capsule cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet cephalexin oral capsule 250 mg, 500 mg cephalexin oral suspension for reconstitution
2Nd Generation Cephalosporin Antibiotics
cefprozil cefuroxime axetil oral tablet
3Rd Generation Cephalosporin Antibiotics
cefdinir oral capsule QL (1 FL per 30 DYs) cefdinir oral suspension for reconstitution 125 mg/5 ml QL (240 ML per 30 DYs) cefdinir oral suspension for reconstitution 250 mg/5 ml QL (1 FL per 30 DYs) cefixime oral capsule QL (10 EA per 30 days) cefpodoxime oral tablet SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML, 200 MG/ ML
4Th Generation Cephalosporin Antibiotics
cefepime injection recon soln 1 gram SPECIALTY PA
Adamantane Antivirals
amantadine hcl oral capsule amantadine hcl oral solution
Allylamine Antifungals
terbinafine hcl oral
Amebicides
metronidazole oral tablet
AL = Age Limit PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
Aminoglycoside Antibiotics
ARIKAYCE SPECIALTY PA
TOBI PODHALER SPECIALTY PA
Aminopenicillin Antibiotics
amoxicillin oral capsule amoxicillin oral suspension for reconstitution amoxicillin oral tablet amoxicillin oral tablet,chewable 125 mg, 250 mg amoxicillin-pot clavulanate oral suspension for reconstitution amoxicillin-pot clavulanate oral tablet amoxicillin-pot clavulanate oral tablet,chewable ampicillin oral capsule AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION 125-31.25 MG/5 ML
Anthelmintics
BILTRICIDE
Antifungals, Miscellaneous
griseofulvin microsize griseofulvin ultramicrosize SSKI
Antimalarials
atovaquone-proguanil oral tablet 250 - 100 mg atovaquone-proguanil oral tablet 62.5-25 mg QL (90 EA per 30 days) chloroquine phosphate QL (90 EA per 30 days) hydroxychloroquine oral tablet 200 mg QL (90 EA per 30 days) mefloquine primaquine pyrimethamine SPECIALTY PA quinidine gluconate oral quinidine sulfate oral tablet
Antimycobacterials, Miscellaneous
dapsone oral
AL = Age Limit PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
Erythromycin Antibiotics
ERYTHROCIN (AS STEARATE) ORAL
TABLET 250 MG
erythromycin ethylsuccinate oral suspension for reconstitution 200 mg/5 ml erythromycin ethylsuccinate oral tablet erythromycin oral
Glycopeptide Antibiotics
FIRVANQ ORAL RECON SOLN 25 MG/ML
vancomycin oral VIBATIV INTRAVENOUS RECON SOLN 750 MG
SPECIALTY PA
Glycylcycline Antibiotics
tigecycline SPECIALTY PA
Hcv Polymerase Inhibitor Antivirals
EPCLUSA ORAL PELLETS IN PACKET SPECIALTY PA
EPCLUSA ORAL TABLET 200-50 MG SPECIALTY PA
HARVONI ORAL PELLETS IN PACKET SPECIALTY PA
ledipasvir-sofosbuvir 90-400 mg SPECIALTY PA sofosbuvir-velpatasvir 400- 100 SPECIALTY PA SOVALDI ORAL PELLETS IN PACKET SPECIALTY PA
Hcv Protease Inhibitor Antivirals
MAVYRET SPECIALTY PA
Hcv Replication Complex Inhibitors
EPCLUSA ORAL PELLETS IN PACKET SPECIALTY PA
EPCLUSA ORAL TABLET 200-50 MG SPECIALTY PA
HARVONI ORAL PELLETS IN PACKET SPECIALTY PA
ledipasvir-sofosbuvir 90-400 mg SPECIALTY PA MAVYRET SPECIALTY PA sofosbuvir-velpatasvir 400- 100 SPECIALTY PA
Hiv Entry And Fusion Inhibitors
FUZEON SUBCUTANEOUS RECON SOLN SPECIALTY PA
maraviroc
RUKOBIA ER 600 MG TABLET SPECIALTY PA
SELZENTRY ORAL TABLET 25 MG, 75 MG
Hiv Integrase Inhibitor Antiretrovirals
BIKTARVY
DOVATO
GENVOYA
ISENTRESS HD
ISENTRESS ORAL TABLET
ISENTRESS ORAL TABLET,CHEWABLE
TIVICAY
TIVICAY PD
TRIUMEQ
Hiv Nonnucleoside Rev.Transcrip. Inhib.
DELSTRIGO
EDURANT
efavirenz efavirenz-lamivu-tenofov disop etravirine nevirapine oral suspension nevirapine oral tablet ODEFSEY PIFELTRO RESCRIPTOR VIRAMUNE XR
Hiv Nucleoside, Nucleotide Rt Inhibitors
abacavir abacavir-lamivudine abacavir-lamivudine-zidovudine BIKTARVY CIMDUO DELSTRIGO DESCOVY ORAL TABLET 200-25 MG didanosine DOVATO
SYLATRON SPECIALTY PA
Lincomycin Antibiotics
CLEOCIN INTRAVENOUS SOLUTION 900
MG/6 ML
SPECIALTY PA
clindamycin hcl oral capsule 150 mg, 300 mg clindamycin palmitate hcl
Monobactam Antibiotics
CAYSTON SPECIALTY PA
Monoclonal Antibody Antivirals
EVUSHELD (EUA) QL (6 ML per 180 days); AL SYNAGIS SPECIALTY AL
Natural Penicillin Antibiotics
BICILLIN L-A
penicillin g potassium injection recon soln 20 million unit
SPECIALTY PA
penicillin v potassium
Neuraminidase Inhibitor Antivirals
oseltamivir QL (2 FL per 365 days) RELENZA DISKHALER QL (2 FL per 365 DYs)
Nucleoside And Nucleotide Antivirals
acyclovir oral capsule acyclovir oral suspension 200 mg/5 ml acyclovir oral tablet adefovir SPECIALTY PA cidofovir SPECIALTY PA CYTOVENE SPECIALTY PA entecavir molnupiravir QL (40 EA per 30 days); AL REBETOL ORAL SOLUTION SPECIALTY PA remdesivir SYMTUZA valacyclovir oral tablet 1 gram QL (30 EA per 30 days) valacyclovir oral tablet 500 mg QL (60 EA per 30 days) VEKLURY
AL = Age Limit PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
Other Macrolide Antibiotics
azithromycin oral packet QL (1 FL per 30 DYs) azithromycin oral suspension for reconstitution QL (1 FL per 30 DYs) azithromycin oral tablet 250 mg QL (6 QY per 30 DYs) azithromycin oral tablet 500 mg QL (1 FL per 30 DYs) azithromycin oral tablet 600 mg QL (8 QY per 30 DYs) clarithromycin QL (1 FL per 30 DYs) DIFICID ORAL TABLET PA
Oxazolidinone Antibiotics
ZYVOX INTRAVENOUS PIGGYBACK 600
MG/300 ML
SPECIALTY PA
Penicillinase-Resistant Penicillins
dicloxacillin
Polyene Antifungals
nystatin oral
Polymyxin Antibiotics
colistin (colistimethate na) SPECIALTY PA
Quinolone Antibiotics
ciprofloxacin QL (300 ML per 30 days) ciprofloxacin hcl oral tablet 250 mg, 500 mg QL (60 QY per 30 DYs) ciprofloxacin hcl oral tablet 750 mg QL (28 EA per 14 days) levofloxacin oral solution QL (1 FL per 30 DYs) levofloxacin oral tablet QL (14 QY per 30 DYs)
Rifamycin Antibiotics
MYCOBUTIN
rifampin oral
Siderophore Cephalosporins
FETROJA SPECIALTY PA
Streptogramin Antibiotics
SYNERCID SPECIALTY PA
Sulfonamide Antibiotics (Systemic)
sulfadiazine
AL = Age Limit PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
BESREMI SPECIALTY PA
bexarotene SPECIALTY PA bicalutamide BICNU SPECIALTY PA BLENREP 100 MG VIAL SPECIALTY PA bleomycin SPECIALTY PA BLINCYTO SPECIALTY PA BOSULIF SPECIALTY PA BREYANZI SPECIALTY PA BREYANZI CD4 COMPONENT (2OF 2) SPECIALTY PA BREYANZI CD8 COMPONENT (1OF 2) SPECIALTY PA BRUKINSA SPECIALTY PA busulfan SPECIALTY PA CAPRELSA SPECIALTY PA carboplatin SPECIALTY PA cisplatin intravenous solution SPECIALTY PA cladribine SPECIALTY PA clofarabine SPECIALTY PA COMETRIQ SPECIALTY PA cyclophosphamide intravenous SPECIALTY PA cytarabine SPECIALTY PA cytarabine (pf) SPECIALTY PA dacarbazine SPECIALTY PA DACOGEN SPECIALTY PA dactinomycin SPECIALTY PA DANYELZA SPECIALTY PA DARZALEX FASPRO SPECIALTY PA daunorubicin intravenous solution SPECIALTY PA DOCEFREZ SPECIALTY PA docetaxel intravenous solution 160 mg/16 ml ( mg/ml), 160 mg/8 ml (20 mg/ml), 20 mg/2 ml ( mg/ml), 20 mg/ml (1 ml), 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (10 mg/ml)
SPECIALTY PA
DOXIL SPECIALTY PA
doxorubicin intravenous solution SPECIALTY PA DROXIA ELIGARD SPECIALTY PA ELIGARD (3 MONTH) SPECIALTY PA ELIGARD (4 MONTH) SPECIALTY PA ELIGARD (6 MONTH) SPECIALTY PA ELZONRIS SPECIALTY PA EMCYT ENHERTU SPECIALTY PA epirubicin intravenous recon soln 50 mg SPECIALTY PA epirubicin intravenous solution SPECIALTY PA ERBITUX SPECIALTY PA ERIVEDGE SPECIALTY PA ERWINAZE SPECIALTY PA ETOPOPHOS SPECIALTY PA etoposide SPECIALTY PA everolimus (antineoplastic) oral tablet 10 mg PA exemestane FARESTON SPECIALTY PA FASLODEX SPECIALTY PA FENSOLVI SPECIALTY PA FIRMAGON KIT W DILUENT SYRINGE SPECIALTY PA FIRMAGON SUBCUTANEOUS RECON SOLN 120 MG
SPECIALTY PA
floxuridine SPECIALTY PA fludarabine SPECIALTY PA flutamide FOLOTYN SPECIALTY PA FOTIVDA SPECIALTY PA FYARRO SPECIALTY PA GAVRETO 100 MG CAPSULE SPECIALTY PA gemcitabine intravenous recon soln SPECIALTY PA gemcitabine intravenous solution 1 gram/26.3 ml (38 mg/ml), 2 gram/52.6 ml (38 mg/ml), 200 mg/5.26 ml (38 mg/ml)
SPECIALTY PA
GLIADEL WAFER SPECIALTY PA
leuprolide subcutaneous kit SPECIALTY PA LUMAKRAS SPECIALTY PA LUPANETA PACK (1 MONTH) SPECIALTY PA LUPANETA PACK (3 MONTH) SPECIALTY PA LUPRON DEPOT SPECIALTY PA LUPRON DEPOT (3 MONTH) SPECIALTY PA LUPRON DEPOT (4 MONTH) SPECIALTY PA LUPRON DEPOT (6 MONTH) SPECIALTY PA LUPRON DEPOT-PED SPECIALTY PA LUPRON DEPOT-PED (3 MONTH) SPECIALTY PA LYSODREN MARGENZA SPECIALTY PA MATULANE megestrol oral suspension 400 mg/10 ml ( mg/ml) megestrol oral suspension 625 mg/5 ml ( mg/ml) QL (150 ML per 30 DYs) megestrol oral tablet melphalan melphalan hcl SPECIALTY PA mercaptopurine methotrexate sodium methotrexate sodium (pf) mitomycin intravenous SPECIALTY PA mitoxantrone SPECIALTY PA MONJUVI 200 MG VIAL SPECIALTY PA MVASI SPECIALTY PA MYLERAN nelarabine SPECIALTY PA NEXAVAR SPECIALTY PA nilutamide SPECIALTY PA NUBEQA SPECIALTY PA OGIVRI SPECIALTY PA ONCASPAR SPECIALTY PA ONTRUZANT SPECIALTY PA
AL = Age Limit PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
ONUREG 200 MG TABLET SPECIALTY PA
ONUREG 300 MG TABLET SPECIALTY PA
ORGOVYX SPECIALTY PA
oxaliplatin intravenous recon soln SPECIALTY PA oxaliplatin intravenous solution 100 mg/20 ml, 50 mg/10 ml (5 mg/ml)
SPECIALTY PA
paclitaxel SPECIALTY PA PADCEV SPECIALTY PA PEMAZYRE SPECIALTY PA PEPAXTO SPECIALTY PA PERJETA SPECIALTY PA PHESGO 1,200 MG-600 MG-30,000 UNIT/ ML
SPECIALTY PA
PHESGO 600 MG-600 MG-20,000 UNIT/10 ML SPECIALTY PA
PHOTOFRIN SPECIALTY PA
PIQRAY SPECIALTY PA
POLIVY INTRAVENOUS RECON SOLN 140
MG
SPECIALTY PA
POMALYST SPECIALTY PA
PROLEUKIN SPECIALTY PA
QINLOCK SPECIALTY PA
RETEVMO SPECIALTY PA
REVLIMID ORAL CAPSULE 10 MG, 15 MG,
2.5 MG, 25 MG, 5 MG
SPECIALTY PA
RIABNI SPECIALTY PA
RITUXAN SPECIALTY PA
RITUXAN HYCELA SPECIALTY PA
romidepsin intravenous recon soln SPECIALTY PA ROZLYTREK SPECIALTY PA RUXIENCE SPECIALTY PA RYBREVANT SPECIALTY PA SARCLISA SPECIALTY PA SCEMBLIX SPECIALTY PA SPRYCEL SPECIALTY PA STIVARGA SPECIALTY PA
AL = Age Limit PA = Prior Authorization QL = Quantity Limit ST = Step Therapy
UKONIQ SPECIALTY PA
valrubicin SPECIALTY PA VECTIBIX SPECIALTY PA VELCADE SPECIALTY PA VIDAZA SPECIALTY PA vinblastine SPECIALTY PA vincristine SPECIALTY PA vinorelbine SPECIALTY PA VOTRIENT SPECIALTY PA XALKORI SPECIALTY PA XPOVIO SPECIALTY PA XTANDI SPECIALTY PA YERVOY SPECIALTY PA YESCARTA SPECIALTY PA ZALTRAP SPECIALTY PA ZANOSAR SPECIALTY PA ZELBORAF SPECIALTY PA ZEPZELCA SPECIALTY PA ZEVALIN (Y-90) SPECIALTY PA ZIRABEV SPECIALTY PA ZOLADEX SPECIALTY PA ZOLINZA SPECIALTY PA ZYKADIA ORAL TABLET SPECIALTY PA ZYNLONTA SPECIALTY PA
Antitoxins,Immune Glob,Toxoids,Vaccines
Antitoxins And Immune Globulins
ASCENIV SPECIALTY PA
CUTAQUIG SPECIALTY PA
CUVITRU SUBCUTANEOUS SOLUTION 10
GRAM/50 ML (20 %)
SPECIALTY PA
CYTOGAM INTRAVENOUS SOLUTION 50
MG/ML
SPECIALTY PA
FLEBOGAMMA DIF INTRAVENOUS
SOLUTION 5 %
SPECIALTY PA
GAMASTAN S/D SPECIALTY PA
GAMUNEX-C INJECTION SOLUTION 1
GRAM/10 ML (10 %), 10 GRAM/100 ML (
%), 2.5 GRAM/25 ML (10 %), 20 GRAM/200 ML
(10 %), 5 GRAM/50 ML (10 %)
SPECIALTY PA
HIZENTRA SUBCUTANEOUS SOLUTION 1
GRAM/5 ML (20 %), 2 GRAM/10 ML (20 %), 4
GRAM/20 ML (20 %)
SPECIALTY PA
HIZENTRA SUBCUTANEOUS SYRINGE SPECIALTY PA
HYPERRHO S/D INTRAMUSCULAR
SYRINGE 1,500 UNIT (300 MCG)
SPECIALTY PA
PRIVIGEN SPECIALTY PA
RHOGAM ULTRA-FILTERED PLUS SPECIALTY PA
RHOPHYLAC SPECIALTY PA
WINRHO SDF SPECIALTY PA
XEMBIFY SPECIALTY PA
Toxoids
ADACEL(TDAP ADOLESN/ADULT)(PF)
BOOSTRIX TDAP
Vaccines
AFLURIA QD 2021-22(3YR UP)(PF) QL (0.5 ML per 241 days); AL AFLURIA QD 2021-22(6-35MO)(PF) QL (0.25 ML per 241 days); AL AFLURIA QUAD 2021-2022(6MO UP) QL (0.5 ML per 241 days); AL COMIRNATY (PF) FLUAD QUAD 2021-22(65Y UP)(PF) QL (0.5 ML per 241 days); AL FLUARIX QUAD 2021-2022 (PF) QL (0.5 ML per 241 days); AL FLUBLOK QUAD 2021-2022 (PF) QL (0.5 ML per 241 days); AL FLUCELVAX QUAD 2021- 2022 QL (0.5 ML per 241 days); AL FLUCELVAX QUAD 2021-2022 (PF) QL (0.5 ML per 241 days); AL FLULAVAL QUAD 2021-2022 (PF) QL (0.5 ML per 241 days); AL FLUMIST QUAD 2021- 2022 QL (1 EA per 241 days); AL FLUZONE HIGHDOSE QUAD 21-22 PF QL (0.7 ML per 241 days); AL FLUZONE QUAD 2021 - 2022 QL (0.5 ML per 241 days); AL FLUZONE QUAD 2021-2022 (PF) QL (0.5 ML per 241 days); AL JANSSEN COVID-19 VACCINE (EUA) MODERNA COVID- 19 VACCINE (EUA)
