Care Wisconsin 2017 Formulary Addendum
|
|
- Raymond Benson
- 6 years ago
- Views:
Transcription
1 - Non-Formulary, PA - Prior Authorization, HR High Risk Medication, QL Quantity Limit per 30 days, EFFECTIVE 01/01/ ABILIFY MAINT INJ 400 1/26 + ST2 Formulary Enhancement N/A ABILIFY MAINT SUSP 300 1/26 + ST2 Formulary Enhancement N/A IM* (1.5ML SYR) ADRUCIL INJ 500/10ML 1 + BvD Formulary Enhancement N/A AMP-SULBACTA INJ 1.5GM 1 + BvD Formulary Enhancement N/A ARIPIPRAZOLE TAB 15 1 Formulary Enhancement N/A ODT BUPROPION TAB /31 Formulary Enhancement N/A CAZIANT PAK 1 Formulary Enhancement N/A CHOLESTYRAMINE LIGHT 1 Formulary Enhancement N/A POW 4 GM/DOSE COMPRO SUP 25 1 Formulary Enhancement N/A EMEND SUS BvD Formulary Enhancement N/A EPITOL TAB Formulary Enhancement N/A ERAXIS INJ PA1 Formulary Enhancement N/A GENGRAF CAP BvD Formulary Enhancement N/A HUMIRA PEN INJ PSORIASI 1 Formulary Enhancement N/A LAMOTRIGINE TAB 25 ODT 1 Formulary Enhancement N/A LAMOTRIGINE TAB 50 ER 1 Formulary Enhancement N/A LAMOTRIGINE TAB 50 ODT 1 Formulary Enhancement N/A LAMOTRIGINE TAB DISP Formulary Enhancement N/A LAMOTRIGINE TAB DISP Formulary Enhancement N/A LARISSIA TAB 1 Formulary Enhancement N/A MESALAMINE TAB 800 DR 1 Formulary Enhancement N/A Page 1 of 12
2 Care Wisconsin - Non-Formulary, PA - Prior Authorization, HR High Risk Medication, QL Quantity Limit per 30 days, METHOCARBAM INJ 100/ML 1 + HR Formulary Enhancement N/A NILUTAMIDE TAB /31 Formulary Enhancement N/A NORGESTIM-ETH ESTRAD TRIPHASIC TAB 0.18/0.215/ MCG 1 Formulary Enhancement N/A ORENCIA CLCK INJ 125/ML 1 + ST2 Formulary Enhancement N/A PRAMIPEXOLE TAB /31 Formulary Enhancement N/A PREDNISONE TAB 10 (21) 1 Formulary Enhancement N/A PREDNISONE TAB 10 (48) 1 Formulary Enhancement N/A PREDNISONE TAB 5 (21) 1 Formulary Enhancement N/A PREDNISONE TAB 5 (48) 1 Formulary Enhancement N/A RELISTOR TAB ST2 Formulary Enhancement N/A REPATHA PUSH INJ 420/ PA1 Formulary Enhancement N/A SPS SUS 15GM/60 1 Formulary Enhancement N/A SUMATRIPTAN SUC SOL 5/31 Formulary Enhancement N/A AUTO-INJ 4 /0.5ML SUBQ VIIBRYD KIT STARTER 1/26 Formulary Enhancement N/A VINCASAR PFS INJ 1/ML 1 + BvD Formulary Enhancement N/A YONDELIS INJ PA2 Formulary Enhancement N/A EFFECTIVE 03/01/ 8-MOP CAP 10 1 CMS Required Deletion N/A ABACA/LAMIVU TAB Formulary Enhancement N/A ADRIAMYCIN INJ BvD Formulary Enhancement N/A ALYACEN TAB 1/35 1 Formulary Enhancement N/A AMLOD/OLMESA TAB AMLOD/OLMESA TAB Formulary Enhancement N/A Formulary Enhancement N/A Page 2 of 12
3 - Non-Formulary, PA - Prior Authorization, HR High Risk Medication, QL Quantity Limit per 30 days, AMLOD/OLMESA TAB 5-20 Formulary Enhancement N/A AMLOD/OLMESA TAB 5-40 Formulary Enhancement N/A APREPITANT CAP BvD Formulary Enhancement N/A APREPITANT CAP 40 + BvD Formulary Enhancement N/A APREPITANT CAP 80 + BvD Formulary Enhancement N/A APREPITANT PAK 80 & /31 + BvD Formulary Enhancement N/A AZITHROMYCIN TAB 500 (3 PACK) 1 Formulary Enhancement N/A BUPROBAN TAB /31 CMS Required Deletion N/A CERVARIX INJ 1 CMS Required Deletion N/A DAPTOMYCIN INJ BvD Formulary Enhancement N/A EPCLUSA TAB PA1 Formulary Enhancement N/A EPINEPHRINE SOL AUTO-INJ 1 Formulary Enhancement N/A 0.15 /0.3ML INJ EPIRUBICIN INJ BvD Formulary Enhancement N/A ERGOMAR SUB 2 1 CMS Required Deletion N/A ERYTHROM ETH SUS 200/5ML 1 Formulary Enhancement N/A ETHYNODIOL TAB Formulary Enhancement N/A FEMYNOR TAB Formulary Enhancement N/A GILDESS TAB 1.5/30 1 CMS Required Deletion N/A INVOKAMET XR TAB /31 Formulary Enhancement N/A 1000 INVOKAMET XR TAB /31 Formulary Enhancement N/A INVOKAMET XR TAB /31 Formulary Enhancement N/A Page 3 of 12
4 Care Wisconsin - Non-Formulary, PA - Prior Authorization, HR High Risk Medication, QL Quantity Limit per 30 days, INVOKAMET XR TAB /31 Formulary Enhancement N/A KINRIX INJ 1 Formulary Enhancement N/A KYPROLIS SOL BvD Formulary Enhancement N/A KYPROLIS SOL BvD Formulary Enhancement N/A LARTRUVO INJ 10/ML 1 + PA2 Formulary Enhancement N/A LORCET HD TAB /31 Formulary Enhancement N/A LOW-OGESTREL TAB 1 Formulary Enhancement N/A MELOXICAM SUS 7.5/5ML 310/31 CMS Required Deletion N/A MENEST TAB PA2 CMS Required Deletion N/A METHOTREXATE INJ 25/ML 1 + BvD Formulary Enhancement N/A METHYLERGON TAB CMS Required Deletion N/A MYCOPHENOLAT INJ BvD Formulary Enhancement N/A MYTESI TAB Formulary Enhancement N/A NAPHAZOLINE SOL 0.1% OP 1 CMS Required Deletion N/A NIFEDICAL XL TAB 30 NIFEDICAL XL TAB 60 62/31 62/31 CMS Required Deletion N/A CMS Required Deletion N/A NIFEDIPINE ER OSMOTIC RELEASE TAB ER 24H 30 62/31 Formulary Enhancement N/A NIFEDIPINE ER OSMOTIC RELEASE TAB ER 24H 60 62/31 Formulary Enhancement N/A NIFEDIPINE ER OSMOTIC RELEASE TAB ER 24H 90 62/31 Formulary Enhancement N/A NITROGLYCERI SUB Formulary Enhancement N/A NITROGLYCERN SUB Formulary Enhancement N/A NITROGLYCERN SUB Formulary Enhancement N/A Page 4 of 12
5 Care Wisconsin - Non-Formulary, PA - Prior Authorization, HR High Risk Medication, QL Quantity Limit per 30 days, Formulary Enhancement N/A Formulary Enhancement N/A NORETH/ETHIN TAB 1/20 1 Formulary Enhancement N/A OFLOXACIN TAB Formulary Enhancement N/A OLM MED/HCTZ TAB Formulary Enhancement N/A OLM MED/HCTZ TAB Formulary Enhancement N/A OLM MED/HCTZ TAB OLMESA MEDOX TAB 20 Formulary Enhancement N/A OLMESA MEDOX TAB 40 Formulary Enhancement N/A OLMESA MEDOX TAB 5 Formulary Enhancement N/A OLMESARTAN-AMLODIPINE- HCTZ TAB OLMESARTAN-AMLODIPINE- HCTZ TAB Formulary Enhancement N/A OLMESARTAN-AMLODIPINE- HCTZ TAB Formulary Enhancement N/A OLMESARTAN-AMLODIPINE- HCTZ TAB Formulary Enhancement N/A OLMESARTAN-AMLODIPINE- HCTZ TAB Formulary Enhancement N/A ORKAMBI TAB PA1 Formulary Enhancement N/A OSELTAMIVIR CAP /365 Formulary Enhancement N/A OSELTAMIVIR CAP 45 56/365 Formulary Enhancement N/A OSELTAMIVIR CAP 75 56/365 Formulary Enhancement N/A PANCREAZE CAP 1 Formulary Enhancement N/A PEDIARIX INJ 0.5ML 1 Formulary Enhancement N/A PERTZYE CAP DR 4000 U 1 Formulary Enhancement N/A QUETIAPINE TAB 150 ER 93/31 Formulary Enhancement N/A QUETIAPINE TAB 200 ER Formulary Enhancement N/A QUETIAPINE TAB 300 ER 62/31 Formulary Enhancement N/A QUETIAPINE TAB 400 ER 62/31 Formulary Enhancement N/A Page 5 of 12
6 Care Wisconsin - Non-Formulary, PA - Prior Authorization, HR High Risk Medication, QL Quantity Limit per 30 days, QUETIAPINE TAB 50 ER 124/31 Formulary Enhancement N/A RANITIDINE INJ 50/2ML 1 CMS Required Deletion N/A RASAGILINE TAB 0.5 Formulary Enhancement N/A RASAGILINE TAB 1 Formulary Enhancement N/A RESERPINE TAB PA1 CMS Required Deletion N/A RESERPINE TAB CMS Required Deletion N/A STAVUDINE SOL 1/ML 2480/31 CMS Required Deletion N/A TRAVOPROST DRO 0.004% 1 CMS Required Deletion N/A TYZEKA TAB PA1 CMS Required Deletion N/A VALGANCICLOV SOL 50/ML 1 Formulary Enhancement N/A VARIZIG INJ 125UNIT 1 CMS Required Deletion N/A VITEKTA TAB CMS Required Deletion N/A VITEKTA TAB 85 1 CMS Required Deletion N/A YUVAFEM TAB 10MCG 1 Formulary Enhancement N/A ZERIT SOL 1/ML 2480/31 Formulary Enhancement N/A EFFECTIVE 04/01/ AMIFOSTINE SOL 500 IV 1 CMS Required Deletion N/A AMIODARONE HCL TAB 100 DOXYCYCLINE HYC SOL 100 IV LOPINAVIR-RITONAVIR SOL /5ML MENOMUNE INJECTABLE SUBQ NECON 1/35 (28) TAB MCG 1 Formulary Enhancement N/A 1 CMS Required Deletion N/A 1 Formulary Enhancement N/A 1 CMS Required Deletion N/A 1 CMS Required Deletion N/A Page 6 of 12
7 - Non-Formulary, PA - Prior Authorization, HR High Risk Medication, QL Quantity Limit per 30 days, 1 Formulary Enhancement N/A 93/90 + HR 93/31 + HR Formulary Enhancement N/A 1 + PA1 CMS Required Deletion N/A 1 Formulary Enhancement N/A /2ML INJ RUBRACA TAB PA2 Formulary Enhancement N/A RUBRACA TAB PA2 Formulary Enhancement N/A EFFECTIVE 06/01/ AMETHYST TAB MCG 1 CMS required Deletion N/A AZILECT TAB 0.5 AZILECT TAB 1 AZOR TAB AZOR TAB rasagiline mes tab 0.5 mg, 1 + ql rasagiline mes tab 1 mg, 1 + ql NORGESTIMATE-ETH ESTRADIOL TAB MCG PHENOBARBITAL TAB 32.4 PRALUENT SOL PFS 150 /ML SUBQ RANITIDINE HCL SOL 50 amlodipineolmesartan tab mg, 1 + ql amlodipineolmesartan tab mg, 1 + ql Page 7 of 12
8 - Non-Formulary, PA - Prior Authorization, HR High Risk Medication, QL Quantity Limit per 30 days, AZOR TAB 5-20 AZOR TAB 5-40 CALCIUM ACETATE TAB 667 amlodipineolmesartan tab 5-20 mg, 1 + ql amlodipineolmesartan tab 5-40 mg, 1 + ql 1 Formulary Enhancement N/A CELLCEPT IV SOL 500 IV 1 + BvD CUBICIN SOL 500 IV 1 + BvD DESVENLAFAXINE SUCC ER TAB 24HR 100 DESVENLAFAXINE SUCC ER TAB 24HR 25 DESVENLAFAXINE SUCC ER TAB 24HR 50 E.E.S. GRANULES SUSP 200 /5ML EMEND CAP 125 mycophenolate mofetil hcl sol 500 mg iv, 1 + bvd daptomycin sol 500 mg iv, 1 + bvd 1 Formulary Enhancement N/A 1 Formulary Enhancement N/A 1 Formulary Enhancement N/A 1 + BvD erythromycin ethylsuc susp 200 mg/5ml, 1 aprepitant cap 125 mg, 1 + ql + bvd Page 8 of 12
9 - Non-Formulary, PA - Prior Authorization, HR High Risk Medication, QL Quantity Limit per 30 days, EMEND CAP 40 EMEND CAP 80 & 125 EMEND CAP 80 EPINEPHRINE SOL AUTO-INJ 0.3 /0.3ML INJ EPZICOM TAB ERYPED 200 SUSP 200 /5ML GALANTAMINE HBR TAB 12 GALANTAMINE HBR TAB 4 GALANTAMINE HBR TAB 8 KALETRA SOL /5ML KISQALI 200 DOSE TAB BvD 12/31 + BvD + BvD aprepitant cap 40 mg, 1 + ql + bvd aprepitant cap 80 & 125 mg, 1 + ql 12/31 + bvd aprepitant cap 80 mg, 1 + ql + bvd 2/60 Formulary Enhancement N/A 1 abacavir sullamivudine tab mg, 1 + ql erythromycin ethylsuc susp 200 mg/5ml, 1 1 Formulary Enhancement N/A 1 Formulary Enhancement N/A 1 Formulary Enhancement N/A 1 lopinavirritonavir sol mg/5ml, PA2 Formulary Enhancement N/A Page 9 of 12
10 Care Wisconsin - Non-Formulary, PA - Prior Authorization, HR High Risk Medication, QL Quantity Limit per 30 days, KISQALI 400 DOSE TAB PA2 Formulary Enhancement N/A KISQALI 600 DOSE TAB PA2 Formulary Enhancement N/A KLOR-CON M10 TAB ER 10 MEQ 1 Formulary Enhancement N/A KLOR-CON M20 TAB ER 20 MEQ 1 Formulary Enhancement N/A LINZESS CAP 72 MCG 1 Formulary Enhancement N/A MENOMUNE INJ SUBQ 1 Formulary Enhancement N/A METFORMIN HCL ER (OSM) TAB ER 24H /31 CMS required Deletion N/A NILANDRON TAB 150 NITROFURANTOIN MONOHYD MACRO CAP 100 NITROSTAT TAB SL 0.3 SL NITROSTAT TAB SL 0.4 SL NITROSTAT TAB SL 0.6 SL OXACILLIN SOD SOL 2 GM INJ POTASSIUM CHLORIDE CRYS ER TAB 10 MEQ POTASSIUM CHLORIDE CRYS ER TAB 20 MEQ 62/31 nilutamide tab 150 mg, 1 + ql 62/ HR Formulary Enhancement N/A nitroglycerin tab sl 0.3 mg sl, 1 nitroglycerin tab sl 0.4 mg sl, 1 nitroglycerin tab sl 0.6 mg sl, 1 1 CMS required Deletion N/A 1 Formulary Enhancement N/A 1 Formulary Enhancement N/A Page 10 of 12
11 - Non-Formulary, PA - Prior Authorization, HR High Risk Medication, QL Quantity Limit per 30 days, PRADAXA CAP Formulary Enhancement N/A PRALUENT SOL PFS 75 /ML SUBQ 1 + PA1 CMS required Deletion N/A RIVASTIGMINE PAT 24H 13.3 /24HR TD Formulary Enhancement N/A RIVASTIGMINE PAT 24H 4.6 /24HR TD Formulary Enhancement N/A RIVASTIGMINE PAT 24H 9.5 /24HR TD Formulary Enhancement N/A SELZENTRY TAB /31 Formulary Enhancement N/A SELZENTRY TAB 75 62/31 Formulary Enhancement N/A SEROQUEL XR TAB ER 24H 150 SEROQUEL XR TAB ER 24H 200 SEROQUEL XR TAB ER 24H 300 SEROQUEL XR TAB ER 24H 400 SEROQUEL XR TAB ER 24H 50 TAMIFLU CAP 30 93/31 62/31 62/31 124/31 + ST2 112/365 quetiapine fum er tab er 24h 150 mg, 1 + ql 93/31 quetiapine fum er tab er 24h 200 mg, 1 + ql quetiapine fum er tab er 24h 300 mg, 1 + ql 62/31 quetiapine fum er tab er 24h 400 mg, 1 + ql 62/31 quetiapine fum er tab er 24h 50 mg, 1 + ql 124/31 oseltamivir phos cap 30 mg, 1 + ql 112/365 Page 11 of 12
12 - Non-Formulary, PA - Prior Authorization, HR High Risk Medication, QL Quantity Limit per 30 days, TAMIFLU CAP 45 TAMIFLU CAP 75 TRIBENZOR TAB TRIBENZOR TAB TRIBENZOR TAB TRIBENZOR TAB TRIBENZOR TAB /365 56/365 VALCYTE SOL 50 /ML 1 oseltamivir phos cap 45 mg, 1 + ql 56/365 oseltamivir phos cap 75 mg, 1 + ql 56/365 olmesartanamlodipine-hctz tab mg, 1 + ql olmesartanamlodipine-hctz tab mg, 1 + ql olmesartanamlodipine-hctz tab mg, 1 + ql olmesartanamlodipine-hctz tab mg, 1 + ql olmesartanamlodipine-hctz tab mg, 1 + ql valganciclovir hcl sol 50 mg/ml, 1 Page 12 of 12
AgeWell 5-Tier 2017 Formulary Addendum
EFFECTIVE 01/01/ ABILIFY MAINT INJ 400MG ADRUCIL INJ 500/10ML NF 2 + BvD Formulary Enhancement N/A AMMONIUM LAC CRE 12% NF 1 Formulary Enhancement N/A AMMONIUM LAC LOT 12% 2 1 Formulary Enhancement N/A
More informationAgeWell 1-Tier 2017 Formulary Addendum
FORMULARY CHANGES EFFECTIVE 01/01/ ABILIFY MAINT INJ 400MG ADRUCIL INJ 500/10ML NF 1 + BvD Formulary Enhancement N/A AMMONIUM LAC CRE 12% BUPROPION TAB 150MG BUTAL/APAP TAB 50-325MG CAZIANT PAK CHOLESTYRAMINE
More informationCurrent as of November 1, 2017
Current as of November 1, 2017 ZYTIGA 500 MG ORAL TABLETS Formulary Addition TIER 5 QL = 2 PER DAY BENLYSTA 200 MG/ML AUTO- INJECTOR Formulary Addition TIER 5 BENLYSTA 200 MG/ML PREFILLED SYRINGE Formulary
More informationCare Wisconsin 2018 Formulary Addendum
pharmacies, - Non-Formulary, PA - Prior Authorization, QL Quantity Limit per 30 days, ST - Step Therapy EFFECTIVE 01/01/ 0.5 ML SUMATRIPTAN 4 MG CARTRIDGE 0.5 ML SUMATRIPTAN 6 MG Last Updated: 03/24/ Effective
More informationProvider Partners Pennsylvania Advantage Plan Offered by Provider Partners Health Plan April 2019 Formulary Addendum
Provider Partners Pennsylvania Advantage Plan Offered by Provider Partners Health Plan April 2019 Formulary Addendum Below is a list formulary changes for the benefit year 2019. This is not a complete
More informationUpcoming Changes to Retiree RxCare s 5 Tier Formulary
Upcoming Changes to Retiree RxCare s 5 Tier Formulary Retiree RxCare may add or remove drugs from our formulary during the year. If we remove drugs from our formulary, [or] add prior authorization, quantity
More informationMemorial Hermann Advantage HMO & PPO April 2018 Formulary Addendum
Memorial Hermann Advantage HMO & PPO April 2018 Formulary Addendum Changes may have occurred since the printing of your current Memorial Hermann Advantage HMO & PPO Formulary. Medications that may have
More informationMemorial Hermann Advantage HMO November 2015 Formulary Addendum
Memorial Hermann Advantage HMO November 2015 Formulary Addendum Changes may have occurred since the printing of your current Medicare Advantage HMO Formulary. Medications may have been added or removed
More informationATRIO Health Plans 2018 SNP Plans Formulary Change Notice
Formulary ID: 18007 ATRIO Special Needs Plan ATRIO Special Needs Plan (Rogue) ATRIO Special Needs Plan (Willamette) ATRIO Health Plans 2018 SNP Plans Formulary Change Notice ATRIO Health Plans may remove
More informationATRIO Health Plans 2018 PPO Plans Formulary Change Notice
Formulary ID: 18032 ATRIO Bronze Rx (Basin) ATRIO Silver Rx ATRIO Gold Rx ATRIO Bronze Rx (Umpqua) ATRIO Bronze Rx (Rogue) ATRIO Silver Rx (Rogue) ATRIO Gold Rx (Willamette) ATRIO Silver Rx (Willamette)
More informationQL (0.5 per 365 days); AGE (Min 7 Years) ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE 2 LF-( MCG)-5LF/0.5 ML
Tier 1 Zero Cost Share Preventive Drugs 2018 Marketplace Plans Drug Name Requirements/Limits ADACEL(TDAP ADOLESDULT)(PF) INTRAMUSCULAR SUSPENSION 2 LF-(2.5-5-3-5 MCG)-5LF/0.5 ML ADACEL(TDAP ADOLESDULT)(PF)
More informationThe following summary describes changes to Part D formularies from January to September 2016
FORMULARY ADDITIONS & DELETIONS UPDATE 2016: The following summary describes changes to Part D formularies from January to September 2016 Affected Drug Reference Name of Reason for Alternative Drugs (alternative
More informationQuarterly pharmacy formulary change notice
Provider Bulletin December 2017 Quarterly pharmacy formulary notice The formulary s listed in the table below apply to all Anthem HealthKeepers Plus members. These s were reviewed and approved at the third
More information2018 Year-to-date Formulary Additions and Deletions
Health Choice Generations may add or remove drugs from our formulary during the year. If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on
More information2018 Comprehensive Formulary (List of Covered Drugs) Prescription Drug Plans
018 Comprehensive Formulary (List of Covered s) Prescription Plans WellCare Prescription Insurance, Inc. Plans in all states: WellCare Classic (PDP) Please Read: This document contains information about
More informationBCN Advantage Formulary Updates: April, 2018
Attention BCN Advantage members: This is a list of changes made to the BCN Advantage formulary since its initial release in October, 2017 BCN Advantage may add or remove drugs from our formulary during
More information2016 MEDICARE PART D DRUG FORMULARY
2016 MEDICARE PART D DRUG FORMULARY 1199SEIU EmblemHealth VIP Medicare Plan Abridged Medication List This abridged formulary was updated on 11/01/2016. This is not a complete list of drugs covered by our
More informationNew Jersey Department of Human Services State Upper Limit (SUL) List - PROPOSED Effective
New Jersey Department of Human Services State Upper Limit () List - PROPOSED Effective 07-01-2018 New ABACAVIR FATE ORAL TABLET 300 MG ABACAVIR FATE/LAMIVUDINE ORAL TABLET 600-300MG ABACAVIR FATE/LAMIVUDINE/ZIDOVUDINE
More information2018 MEDICARE PART D DRUG FORMULARY EmblemHealth HMO 5-Tier Comprehensive Medication List
2018 MEDICARE PART D DRUG FORMULARY EmblemHealth HMO 5-Tier Comprehensive Medication List This comprehensive formulary was updated on 09/13/2017. For more recent information or other questions, please
More information2018 Formulary. (List of Covered Drugs) Group UCare for Seniors (HMO-POS)
08 Formulary (List of Covered Drugs) Group UCare for Seniors (HMO-POS) This formulary was updated on 0/0/08. For more recent information or other questions, please contact UCare for Seniors Customer Services
More information2015 MEDICARE PART D DRUG FORMULARY
2015 MEDICARE PART D DRUG FORMULARY 1199SEIU Medicare Advantage Formulary This formulary was updated on 08/08/2014. For more recent information or other questions, please contact EmblemHealth at 1-877-447-1199
More informationPartnership 2017 Formulary. List of Covered Drugs
Partnership 207 Formulary List of Covered Drugs PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN ID 7379, Version Number 26 This formulary was updated on 0/24/207.
More informationH0544_058, 059, 066, 067
Anthem MediBlue Select (H) 09 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on February, 09. For more recent
More informationAnthem MediBlue Plus (HMO) 2019 Formulary (List of Covered Drugs) Please read: ,
Anthem MediBlue Plus (H) 09 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on March, 09. For more recent
More information2018 Formulary (List of Covered Drugs) UCare for Seniors Prime (HMO-POS) UCare for Seniors Standard (HMO-POS)
208 Formulary (List of Covered Drugs) UCare for Seniors Prime (HMO-POS) UCare for Seniors Standard (HMO-POS) This formulary was updated on 05/0/208. For more recent information or other questions, please
More information2017 Comprehensive Formulary (List of Covered Drugs) Prescription Drug Plans
We re in this together: Quality Health Care 017 Comprehensive Formulary (List of Covered s) Prescription Plans WellCare Prescription Insurance, Inc. Plans in all states: WellCare Extra (PDP) Plans in the
More informationMemorial Hermann Advantage HMO & PPO Formulary. (List of Covered Drugs)
Memorial Hermann Advantage H & PPO 2017 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File 00017383, Version
More information2018 Formulary (List of Covered Drugs)
018 Formulary (List of Covered Drugs) UCare for Seniors Essentials Rx (HMO-POS) UCare for Seniors Value Plus (HMO-POS) UCare for Seniors Classic (HMO-POS) This formulary was updated on 11/01/018. For more
More information2018 Formulary (List of Covered Drugs) UCare for Seniors Prime (HMO-POS) UCare for Seniors Standard (HMO-POS)
208 Formulary (List of Covered Drugs) UCare for Seniors Prime (HMO-POS) UCare for Seniors Standard (HMO-POS) This formulary was updated on 09/08/207. For more recent information or other questions, please
More information2018 Formulary (List of Covered Drugs)
08 Formulary (List of Covered Drugs) UCare for Seniors Essentials Rx (HMO-POS) UCare for Seniors Value Plus (HMO-POS) UCare for Seniors Classic (HMO-POS) This formulary was updated on 04/0/08. For more
More information2018 Formulary. (List of Covered Drugs) Group UCare for Seniors (HMO-POS)
08 Formulary (List of Covered Drugs) Group UCare for Seniors (HMO-POS) This formulary was updated on 0/0/08. For more recent information or other questions, please contact UCare for Seniors Customer Services
More informationAntibiotic Treatments. Arthritis & Pain. Asthma. Cholesterol
MAX Saver Plan Drug List 08/06/14 GENERIC NAME Allergies and Cold & Flu BENZONATATE CAP 100 MG 14 42 cap CETIRIZINE HCL TAB 10MG 30 90 tab CETIRIZINE HCL TAB 5MG 30 90 tab DIPHENHYDRAMINE HCL CAP 50 MG
More information2017 Comprehensive Formulary (List of Covered Drugs) Medicare Advantage Plans
We re in this together: Quality Health Care 017 Comprehensive Formulary (List of Covered s) Medicare Advantage Plans WellCare/ Ohana Plans in the following states: AR, CT, FL, IL, KY, LA, NJ, NY, TX, TN
More information2018 List of Covered Drugs (Formulary)
208 List of Covered Drugs (Formulary) UCare s MSHO and UCare Connect + Medicare This is a list of drugs that members can get in UCare s MSHO and UCare Connect + Medicare. UCare s MSHO and UCare Connect
More informationHealth First Health Plans 2019 Formulary (List of Covered Drugs)
Updated: 10/2018 Health First Health Plans 2019 Formulary (List of Covered Drugs) Classic Plan (HMO-POS) Value Plan (HMO) Rewards Plan (HMO) Employer Group Plus A Plan (HMO) Employer Group Plus B Plan
More information2018 Year-to-date Formulary Additions
Health Choice Generations may add or remove drugs from our formulary during the year. If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on
More informationHealth First Health Plans 2019 Formulary (List of Covered Drugs)
Updated: March 1, 2019 Health First Health Plans 2019 Formulary (List of Covered Drugs) SunSaver (HMO) Employer Group Plus C Plan (HMO) Employer Group Plus D Plan (HMO) Employer Group POS B Plan (HMO-POS)
More informationAnthem MediBlue Plus (HMO) 2019 Formulary (List of Covered Drugs) Please read: ,
Anthem MediBlue Plus (H) 09 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on February, 09. For more recent
More information2018 Formulary Addendum 2018 FORMULARY CHANGES
Below is a list formulary changes for the benefit year 2018. This is not a complete list of drugs covered by the Part D plan. The formulary changes are reflected in the 2018 downloadable formulary on the
More informationExpress Scripts Medicare (PDP) 2019 Formulary (List of Covered Drugs)
Value Plan Express Scripts Medicare (PDP) 2019 Formulary (List of Covered s) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Formulary ID Number: 19157, Version 8
More information2018 Formulary (List of Covered Drugs)
BlueCare Plus (HMO SNP) SM 018 Formulary (List of Covered Drugs) We have made no changes to this formulary since /1/018. For more recent information or other questions, please contact BlueCare Plus SM
More information2018 Formulary. BlueAdvantage (PPO) SM. (List of Covered Drugs) bcbstmedicare.com
BlueAdvantage (PPO) SM 018 Formulary (List of Covered Drugs) BlueAdvantage Diamond (PPO) SM BlueAdvantage Ruby (PPO) SM BlueAdvantage Sapphire (PPO) SM BlueAdvantage Garnet (PPO) SM We have made no changes
More informationAnthem MediBlue Coordination Plus (HMO) 2018 Formulary (List of Covered Drugs) Please read: ,
Anthem MediBlue Coordination Plus (H) 08 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on October, 08.
More informationEmpire MediBlue Plus (HMO) 2018 Formulary (List of Covered Drugs) Please read: ,
Empire MediBlue Plus (H) 08 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on October, 08. For more recent
More informationNew Jersey Department of Human Services State Upper Limit (SUL) List - PROPOSED Effective
Generic_Name Current NJ SUL New NJ SUL Proposed ACETAMINOPHEN WITH CODEINE PHOSPHATE ORAL TABLET 300MG-30MG 0.12455 ACETAMINOPHEN WITH CODEINE PHOSPHATE ORAL TABLET 300MG-60MG 0.25688 ALBUTEROL SULFATE
More informationPLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN.
HealthPartners UnityPoint Health Align (PPO) HealthPartners UnityPoint Health Symmetry (PPO) (Collectively known as HealthPartners UnityPoint Health) 017 Formulary (List of Covered Drugs) PLEASE READ:
More informationAnthem Blue Cross MedicareRx Standard (PDP) 2019 Formulary (List of Covered Drugs) Please read: ,
Anthem Blue Cross MedicareRx Standard (PDP) 09 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on February,
More informationHealth First Health Plans 2018 Formulary (List of Covered Drugs)
Updated: July 1, 2018 Classic Plan (HMO-POS) Value Plan (HMO) Rewards Plan (HMO) Employer Group Plus A Plan (HMO) Employer Group Plus B Plan (HMO) Employer Group POS Plan (HMO-POS) Health First Health
More informationWELLCARE HEALTH PLAN 2015 STEP THERAPY CRITERIA (No Changes Made Since: 10/2014)
WELLCARE HEALTH PLAN 2015 STEP THERAPY CRITERIA (No Changes Made Since: 10/2014) **To get updated information about the drugs covered by WellCare, please visit our website (https://www.wellcare.com) or
More informationPLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT SOME OF THE DRUGS WE COVER IN THIS PLAN.
HealthPartners Freedom Vital with Rx (Cost) HealthPartners Freedom Balance with Rx (Cost) HealthPartners Freedom Ultimate with Rx (Cost) HealthPartners Freedom Ultimate with Enhanced Rx (Cost) HealthPartners
More information2015 Formulary (List of Covered Drugs)
MedStar Medicare Choice (HMO) 2015 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. HPMS Approved Formulary File Submission ID: 00015465,
More informationPartnership 2017 Formulary. List of Covered Drugs
Partnership 207 Formulary List of Covered Drugs PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN ID 7379, Version Number 9 This formulary was updated on 5/23/207. For
More information2018 List of Covered Drugs (Formulary)
208 List of Covered Drugs (Formulary) UCare s MSHO and UCare Connect + Medicare This is a list of drugs that members can get in UCare s MSHO and UCare Connect + Medicare. UCare s MSHO and UCare Connect
More informationFlorida Hospital Care Advantage 2017 Formulary (List of Covered Drugs)
Updated: November 1, 2017 Explorer Plan (HMO-POS) SunSaver Plan (HMO-POS) Florida Hospital Care Advantage 2017 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE
More informationUpdated: November 1, 2017 Classic Plan (HMO-POS) Value Plan (HMO) Rewards Plan (HMO) Health First Health Plans 2017 Formulary (List of Covered Drugs)
Updated: November 1, 2017 Classic Plan (HMO-POS) Value Plan (HMO) Rewards Plan (HMO) Health First Health Plans 2017 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT
More informationNotice of Negative Formulary Changes (List of Covered Drugs)
Care1st Health Plan 601 Potrero Grande Drive Monterey Park, CA 91755 www.care1stmedicare.com Notice of Negative Formulary Changes (List of Covered Drugs) Care1st Health Plan may add/remove drugs from the
More informationAllergies and Cold & Flu
MAX Saver Plan Drug List 01/23/17 GENERIC NAME Allergies and Cold & Flu BENZONATATE CAP 100 MG 14 42 cap CETIRIZINE HCL TAB 10MG 30 90 tab CETIRIZINE HCL TAB 5MG 30 90 tab DIPHENHYDRAMINE HCL CAP 50 MG
More informationAnthem MediBlue Dual Advantage (HMO SNP) 2018 Formulary (List of Covered Drugs) Please read: , https://shop.anthem.
Anthem MediBlue Dual Advantage (H SNP) 08 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on June, 08. For
More informationEmpire MediBlue Select (HMO) 2019 Formulary (List of Covered Drugs) Please read: ,
Empire MediBlue Select (H) 09 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on February, 09. For more recent
More information2017 COMPREHENSIVE FORMULARY
017 COMPREHENSIVE FORMULARY (LIST OF COVERED DRUGS) MEDICARE ADVANTAGE PLANS Please Read: This document contains information about the drugs we cover in this plan. This formulary was updated on 09/01/016.
More informationMemorial Hermann Advantage HMO Formulary. (List of Covered Drugs)
Memorial Hermann Advantage H 2019 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission ID 19563,
More informationAnthem Connect Plus (HMO) 2019 Formulary (List of Covered Drugs) Please read: ,
Anthem Connect Plus (H) 019 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on March 1, 019. For more recent
More informationAnthem MediBlue Access (PPO) 2018 Formulary (List of Covered Drugs) Please read: , https://shop.anthem.
Anthem MediBlue Access (PPO) 08 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on June, 08. For more recent
More informationOPTIMA HEALTH OPTIMA FAMILY CARE (JANUARY MARCH 2019) PRESCRIPTION DRUG FORMULARY WITH MEDICAID EXPANSION (XP) Effective: January 1, 2019
OPTIMA HEALTH PRESCRIPTION DRUG FORMULARY OPTIMA FAMILY CARE WITH MEDICAID EXPANSION (XP) (JANUARY MARCH 2019) Revised: 1/2/2019 Table of Contents Analgesics - Drugs for Pain... 3 Analgesics - Drugs for
More informationH0544_058, 059, 066, 067, 069
Anthem MediBlue Select (H) 08 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on July, 08. For more recent
More informationCOMPREHENSIVE FORMULARY
08 COMPREHENSIVE FORMULARY CARE N CARE CHOICE PREMIUM (PPO) CARE N CARE CHOICE PLUS (PPO) CARE N CARE CHOICE (PPO) CARE N CARE CLASSIC (HMO) (LIST OF COVERED DRUGS) PLEASE READ: THIS DOCUMENT CONTAINS
More information2016 COMPREHENSIVE FORMULARY
016 COMPREHENSIVE FORMULARY (LIST OF COVERED DRUGS) PRESCRIPTION DRUG PLANS Please Read: This document contains information about some of the drugs we cover in this plan. This formulary was updated on
More informationInformation for Vermont Prescribers of Prescription Drugs (Long Form)
Information for Vermont Prescribers of Prescription Drugs (Long Form) Beyaz (Drospirenone-Ethinyl Estradiol-Levomefolate Calcium) This list does not imply that the products on this chart are interchangeable
More informationS5596_003, 007, 015, 019, 058
Anthem Blue MedicareRx Premier (PDP) 08 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on May, 08. For more
More informationWhat is the CHRISTUS Health Plan Generations (HMO) / CHRISTUS Health Plan Generations Plus (HMO) Formulary?
CHRISTUS Health Plan Generations (HMO) CHRISTUS Health Plan Generations Plus (HMO) 019 Comprehensive Formulary PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT SOME OF THE DRUGS WE COVER IN THIS PLAN
More informationS5596_001, 006, 014, 018, 057, 063
Anthem Blue MedicareRx Plus (PDP) 09 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on February, 09. For
More information2019 HAP Formulary. List of covered drugs, cost tiers and how it all works
HAP Empowered Duals (HMO SNP) 209 HAP Formulary List of covered drugs, cost tiers and how it all works PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THESE PLANS. This formulary
More informationLEGEND. Tier 1: Covered Medications
LEGEND : Covered Medications BvD: Part B vs. Part D-This prescription drug may be covered under Medicare Part B or D depending upon the circumstances. HRM: High Risk Medication (PA required for ages 65
More information2018 MEDICARE PART D DRUG FORMULARY
2018 MEDICARE PART D DRUG FORMULARY National Drug Plan (PDP) Standard/Enhanced This abridged formulary was updated on 11/1/2018. This is not a complete list of drugs covered by our plan. For a complete
More informationAnthem Heart (HMO SNP) 2019 Formulary (List of Covered Drugs) Please read: This document contains information about the drugs we cover in this plan.
Anthem Heart (H SNP) 019 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on October 1, 018. For more recent
More informationProvider Partners Illinois Advantage Plan (HMO SNP) 2019 Formulary (List of Covered Drugs)
Provider Partners Illinois Advantage Plan (H SNP) 2019 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Formulary ID 19547, Version
More informationHealthPartners PreferredRx
HealthPartners PreferredRx 2018 Formulary (List of covered drugs) For current information on the PreferredRx Drug List, visit healthpartners.com/pharmacy. Effective: October 1, 2018 2018 HealthPartners
More informationAnthem Diabetes (HMO SNP) 2019 Formulary (List of Covered Drugs) Please read: ,
Anthem Diabetes (H SNP) 019 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on March 1, 019. For more recent
More informationExpress Scripts Medicare (PDP) 2017 Formulary (List of Covered Drugs)
Choice Plan Express Scripts Medicare (PDP) 017 Formulary (List of Covered s) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Formulary File Submission ID: 17070, V18
More information3. This solution retains potency for 2 8 hours at room temperature after reconstitution.
1 CHAPTER 10 Reconstitution of Powdered Drugs Problems 10.1 (page 124) 1. The drug should be stored at or below 86 F (30 C). 2. This drug is administered IM or IV. 3. This solution retains potency for
More informationAmerivantage Select (HMO) 2019 Formulary (List of Covered Drugs) Please read: Amerivantage Select (HMO)
Amerivantage Select (H) 09 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on February, 09. For more recent
More informationBlue MedicareRx Value (PDP) 2018 Formulary (List of Covered Drugs) Please read: , https://shop.anthem.
Blue MedicareRx Value (PDP) 08 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on May, 08. For more recent
More information2018 Comprehensive Formulary (List of Covered Drugs) Medicare Advantage Plans
018 Comprehensive Formulary (List of Covered s) Medicare Advantage Plans WellCare Health Plans Please Read: Plans in the following states: AR, FL, GA, KY, MS, NC, NY, SC, TN WellCare Access (HMO SNP),
More informationAmerivantage Classic (HMO) 2019 Formulary (List of Covered Drugs) Please read: Amerivantage Classic (HMO)
Amerivantage Classic (H) 09 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on February, 09. For more recent
More information2016 Formulary (List of Covered Drugs)
MedStar Medicare Choice (HMO) 2016 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. HPMS Approved Formulary File Submission ID: 00016319,
More information2017 Formulary (List of Covered Drugs)
Tribute Health Plan of Arkansas (H POS SNP) H1587 001 2017 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Formulary ID 17384, Version
More information2019 Formulary. BlueAdvantage (PPO) SM. (List of Covered Drugs) bcbstmedicare.com
BlueAdvantage (PPO) SM 019 Formulary (List of Covered Drugs) BlueAdvantage Diamond (PPO) SM BlueAdvantage Ruby (PPO) SM BlueAdvantage Sapphire (PPO) SM BlueAdvantage Garnet (PPO) SM We have made no changes
More informationPRESCRIPTION DRUGS FORMULARY 1. I ~~ [ tl-i I Classicare (HMO)
PRESCRIPTION DRUGS FORMULARY 1 2018 I ~~ [ tl-i I Classicare (HMO) MCS Classicare 2018 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS
More informationGuildNet Gold. Formulary Medicare Advantage Prescription Drug Plan
GuildNet Gold Medicare Advantage Prescription Drug Plan Formulary 2018 This formulary was updated on 07/31/2017. For more recent information or other questions, please contact the Plan at 1-800-815-0000
More informationExpress Scripts Medicare (PDP) 2018 Formulary (List of Covered Drugs)
Saver Plan Express Scripts Medicare (PDP) 2018 Formulary (List of Covered s) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Formulary ID Number: 18152, Version 9
More informationS5596_001, 006, 014, 018, 057, 063
Anthem Blue MedicareRx Plus (PDP) 08 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on May, 08. For more
More informationPLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN.
HealthPartners Freedom Group (Cost) HealthPartners Journey Group (PPO) HealthPartners Retiree National Choice (PDP) (Collectively known as HealthPartners) 019 Formulary II (List of Covered Drugs) PLEASE
More informationBCBSGa Blue MedicareRx Standard (PDP) 2018 Formulary (List of Covered Drugs) Please read: ,
BCBSGa Blue MedicareRx Standard (PDP) 08 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on October, 08.
More informationAnthem MediBlue Access (PPO) 2018 Formulary (List of Covered Drugs) Please read: , https://shop.anthem.
Anthem MediBlue Access (PPO) 08 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on November, 07. For more
More informationExpress Scripts Medicare (PDP) 2018 Formulary (List of Covered Drugs)
Choice Plan Express Scripts Medicare (PDP) 2018 Formulary (List of Covered s) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Formulary ID Number: 18155, Version 9
More information(List of Covered Drugs)
Superior Select Health Plans H-POS SNP 2019 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Formulary ID 19550, Version Number 5
More informationSuperior Select Health Plans Formulary. (List of Covered Drugs)
Superior Select Health Plans 2018 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Formulary ID 18379, Version Number 14 This formulary
More informationPrescription Drug Formulary
Prescription Drug Formulary 018 This formulary was updated on 09/5/018. For more recent information or other questions, please contact Essence Healthcare, Inc. Customer Service, at 1-866-597-9560 or, for
More informationEnvisionRxPlus Formulary. (List of Covered Drugs)
EnvisionRxPlus 018 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission 18365, Version Number
More informationExpress Scripts Medicare (PDP) 2018 Formulary (List of Covered Drugs)
Choice Plan Express Scripts Medicare (PDP) 2018 Formulary (List of Covered s) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Formulary ID Number: 18155, Version 11
More information