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Medicaid-Covered Diabetic Supplies Now Processed Through Pharmacy - page 8 / 8

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Latuda® (Lurasidone HCl)

Treatment of members with schizophrenia. (Note: efficacy was established in four 6-week controlled studies of adult patients with schizophrenia.)

$446.24 (30 tablets)

Lo LoestrinTM Fe (Norethindrone Acetate and Ethinyl Estradiol, and Ferrous Fumarate)

For women to prevent pregnancy.

$71.99 (28-day pack)

NuedextaTM (Dextromethorphan HBr/ Quinidine)

Treatment of pseudobulbar affect (PBA).

$519.55 (60 tablets)

Pradaxa® (Dabigatran Etexilate Mesylate)

To reduce the risk of stroke and systemic embolism in members with non-valvular atrial fibrillation.

$215.15 (60 tablets)

Restasis® (Cyclosporine)

Treatment of dry eye syndrome.

$125.20-$250.41 (30-60 vials)

$25.31 - $58.47 Generic Monophasic OCPs

none

Warfarin Sodium $4.93 - $6.06

Liquitears, Hypotears (Artificial Tears) $2.34 - $7.37 (15-32mL)

Medication Reviews

Atypical Antipsychotics $10.20 - $750.60

Brand Name (Generic Name)

BeyazTM (Drospirenone/ Ethinyl Estradiol/ Levomefolate)

KapvayTM (Clonidine HCl ER)

Indication

Cost per 30 day supply (or Preferred Drug List

with endometriosis, dysmenorrheal, dysfunctional uterine bleeding.

per Unit) Treatment of hypermenorrhea $75.44

Alternatives

$25.31 - $58.47 Generic Monophasic OCPs

Clonidine tablets $3.81 (30 tablets)

Clonidine patch $228.49 (4 patches)

(menorrhagia) and

pain associated

(28-day pack)

Treatment of attention deficit hyperactivity disorder (ADHD) as monotherapy or as adjunctive therapy to stimulant medications.

$133.87 (60 tablets)

© 2011 Passport Health Plan/Passport Advantage (PHA-11101)

8

Passport Health Plan Drug Status

Remain non-preferred.

Remain non-preferred.

Remain non-preferred.

Remain non-preferred.

Remain non-preferred.

Remain non-preferred.

Remove from Preferred Drug List.

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