Endocrine Drugs

KP Wellness

 10:51 AM  -  Public

7. Endocrine

7.1  Antithyroid Agents
TIER 1
Methimazole (Tapazole)
Propylthiouracil (Propylthiouracil)

7.2  Thyroid Hormones
TIER 1
Levothyroxine Sodium (Levoxyl)
TIER 2
Liothyronine Sodium (Cytomel)
Synthroid (Levothyroxine Sodium)
Tirosint (Levothyroxine Sodium)
TIER 3
Thyroid tablets (Armour Thyroid)
T3 liothyronine sodium and T4 levothyroxine sodium (Thyrolar) 

KP Wellness

 10:50 AM  -  Public

7.3  Adrenal Hormones
TIER 1
Dexamethasone (Decadron)
Fludrocortisone Acetate (Florinef Acetate)
Hydrocortisone Tablet (Cortef)
Methylprednisolone Tablet, Dose Pack (Medrol 4, 16 mg)
Orapred (Prednisolone Sodium Phosphate  Solution, Oral)
Prednisolone Sodium Phosphate Solution, Oral (Pediapred)
Prednisolone Syrup (Prelone)
Prednisone (Meticorten)
TIER 2
Medrol 2, 8, 24, 32 mg (Methylprednisolone Tablet)
Pediapred (Prednisolone Sodium Phosphate  Solution, Oral)
TIER 3
Betamethasone Oral Solution (Celestone Oral Solution)
Prednisolone Sodium Phosphate (Orapred ODT)

7.4  Miscellaneous Hormones
7.4.1 ANDROGENS
TIER 1
Danazol (Danocrine)
TIER 2
Androderm (Testosterone)
Android (Methyltestosterone)
Oxandrolone (Oxandrin)**
Testim (Testosterone)
TIER 3
Testosterone Gel for Topical Use (Androgel)
Testosterone buccal system (Striant) 

KP Wellness

 10:49 AM  -  Public

7.4.2  OVULATORY STIMULANTS
Coverage is determined by the consumer’s prescription drug
benefit plan .
TIER 1
Clomiphene Citrate (Clomid)
Clomiphene Citrate (Serophene)
TIER 2
Gonal-F (Follitropin Alpha, Recombinant)
Gonal-F RFF  (Follitropin Alpha, Recombinant)
Luveris (Lutropin Alpha)
TIER 3
Urofollitropin (Bravelle)
Follitropin Beta (Follistim AQ)
Menotropins for injection, USP (Menopur)
Choriogonadotropin Alfa Injection (Ovidrel)
Menotropins for Injection (Repronex)

7.4.3  MISCELLANEOUS AGENTS
TIER 1
Calcitriol (Rocaltrol)
Desmopressin Acetate (DDAVP)
Octreotide Acetate (Octreotide Acetate)
TIER 2
Cabergoline (Dostinex)
Calcitonin Salmon Nasal Spray (Miacalcin)
Calcitonin, Salmon, Synthetic Nasal
Spray (Fortical)
Hectorol (Doxercalciferol)
Kuvan (Sapropterin Tablet, Soluble)
Samsca (Tolvaptan)
Sandostatin (Octreotide Acetate)
Synarel (Nafarelin Acetate)
Zemplar (Paricalcitol)
TIER 3
Cinacalcet (Sensipar)
Desmopressin Acetate Nasal Spray (Stimate)

7.4.4  GONADOTROPIN & RELATED AGENTS
Coverage is determined by the consumer’s prescription drug benefit plan .
TIER 2
Cetrotide (Cetrorelix Acetate)
TIER 3
Ganirelix Acetate