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Kent health plan

KENT HEALTH PLAN (revised 6/28/11 )
ANALGESICS
Quinolones
Anti Arthritic
Sulfas and Related Products
Tetracyclines
Narcotic-Long Acting
Fentanyl (cancer diagnosis only—PAP)
MS Contin (cancer diagnosis only—PAP)
Antifungal Agents
Oxycontin (cancer diagnosis only—PAP)
Narcotic-Short Acting (QL 180/mo)
Antiviral
ASTHMA –ALLERGY
Non-Narcotic
Inhaled Anticholinergics
Atrovent PAP-E
Combivent PAP-E
Antihistamines
Salicylates
ANTIBIOTICS/ANTI-INFECTIVES
Cephlasporins
Bronchodilators-Short Acting
Alupent--PAP
Erythromycins & other Macrolides
Bronchodilators – Long Acting
Serevent (COPD)--PAP
Penicillins
Bronchodilator oral
ASTHMA --ALLERGY cont
Peripheral Vasodilators
LABA/Corticosteroid
Advair Discus PA & PAP
Inhaled Corticosteroids
Iotropics
Flovent HFA--PAP-E (If failed QVAR)
QVAR--PAP-E
Hypotensive Combination
Corticosteroid nasal
Lekotriene Inhibitors
Singulair PA and PAP
CARDIAC MEDICATIONS
Ace Inhibitors
Hypotensive/Other
Lipotropic--Lopids
Angiotensin Receptor Antagonists
Diovan-PA and PAP
DIABETES
Ace Inhibitors
Insulins-Basal
Lantus-PAP-E
Beta Blockers
Levemir-PAP-E
Coreg CR-PAP
Insulin Mixes
Novolin 70/30-PAP-E
Humulin 70/30-PAP-E
Humalog 75/25-PAP-E
Insulins-Rapid Acting
Toprol XL-PAP
Humalog-PAP-E
Novolog-PAP-E
Calcium Channel Blockers
Insulins Traditional
Novolin u100-PAP-E
Humulin u100-PAP-E
ORAL AGENTS
Plendil--PAP (QL 1/day)
Alpha-Glucosidase Inhibitors
Cardiovascular Alpha 1-Adrenergic Blockers
Coronary Vasodilators
Actos-PAP 2
ORAL AGENTS cont
MISCELLANEOUS
Glucometers
Gout Therapy
Hematolic Agents/ Anti-platelet
Supplies
Lancets and syringes up to 100 per month Muscle Relaxants
GASTROINTESTINAL
Anti-diarrheals
Premarin-PAP
Anti-nausea Agents
Antispasmotic
Anti-ulcer
Anorectal Preparations
Blood Thinners
GI Stimulants
Laxatives
Calcium Metabolism
Evista-PAP
Boniva-PAP
Corticosteroids
Proton Pump Inhibitors
Cough & Cold Preparations
(w/ Codeine Syr-g QL 7 days) Phenergan Syrup-g (QL 7 days) DIURETICS
Tessolon Perles-g (max 21 days per month) Nutritional Supplements
Immunosupression
MISCELLANEOUS
Estrogens
Cenestin-PAP
Steroid Antibiotic Combination
Menest-PAP
Premarin-PAP
Corticosteroids
Estrogen & Androgen Combination
Estratest-PAP
Estrogen & Progesterone Combination
Premphase-PAP
Decongestants
Prempro-PAP
Progesterone
TOPICAL AGENTS
Epi-Pen-1 with 1 refill per year
(additional requires a PA)
Anti-infectives
Scabicides/Pediculcides
Potassium Replacement
Steroids
OPTHALMIC
Antibiotics
VAGINAL PREPARATIONS
Glaucoma
Travatan-PAP
Xalatan-PAP
All doses may not be covered
Psychotropics and anticonvulsants covered by First
Health and MI health card
Generic medications if available—no brand names if
generic available without PA
PAP-special fund for immediate needs until PAP
available
PAP-E—no PA needed until after 3 months
PA—needs prior auth (no PAP available)
Call Kent Health Plan if any questions

Source: http://dev.kenthealthplan.org/wp-content/uploads/2013/07/FormularyAJune20111.pdf

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