AgeWell 1-Tier 2017 Formulary Addendum
|
|
|
- Caroline Davis
- 6 years ago
- Views:
Transcription
1 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 MG CAZIANT PAK CHOLESTYRAMINE LIGHT POW 4 GM/DOSE COMPRO SUP 25MG EMEND SUS 125MG NF 1 + BvD Formulary Enhancement N/A EPITOL TAB 200MG ERAXIS INJ 50MG GENGRAF CAP 50MG GRISEOFULVIN TAB MICR 500 GRISEOFULVIN TAB ULTR 125 GRISEOFULVIN TAB ULTR 250 HUMIRA PEN INJ PSORIASI KANUMA INJ 20/10ML NF 1 + PA1 Formulary Enhancement N/A LARISSIA TAB MEMANT TITRA PAK 5-10MG MEMANTINE TAB HCL 10MG MEMANTINE TAB HCL 5MG MESALAMINE TAB 800MG DR METHOCARBAM INJ 100MG/ML NF 1 + HR Formulary Enhancement N/A MUPIROCIN CRE 2% NILUTAMIDE TAB 150MG Page 1 of 7
2 FORMULARY CHANGES NORGESTIM-ETH ESTRAD TRIPHASIC TAB 0.18/0.215/0.25 MG- 35 MCG NUCALA INJ 100MG NF 1 + PA1 Formulary Enhancement N/A ORENCIA CLCK INJ 125MG/ML NF 1 + ST2 Formulary Enhancement N/A PANTOPRAZOLE INJ SOD 40MG PRAMIPEXOLE TAB 3.75MG PREDNISONE TAB 10 MG (21) PREDNISONE TAB 10 MG (48) PREDNISONE TAB 5 MG (21) PREDNISONE TAB 5 MG (48) RELISTOR TAB 150MG REPATHA PUSH INJ 420/3.5 NF 1 + PA1 Formulary Enhancement N/A RISEDRONATE SOD TAB 35 MG (12 PACK) RISEDRONATE TAB 150MG RISEDRONATE TAB 30MG RISEDRONATE TAB 5MG SPS SUS 15GM/60 SUMATRIPTAN SUC SOL AUTO-INJ NF 1 + QL 4.5 Formulary Enhancement N/A 4 MG/0.5ML SUBQ TOPOSAR INJ 1GM/50ML NF 1 + BvD Formulary Enhancement N/A VALSARTAN TAB 160MG VALSARTAN TAB 320MG VALSARTAN TAB 40MG VALSARTAN TAB 80MG VINCASAR PFS INJ 1MG/ML NF 1 + BvD Formulary Enhancement N/A Page 2 of 7
3 FORMULARY CHANGES YONDELIS INJ 1MG NF 1 + PA2 Formulary Enhancement N/A ZEBUTAL CAP EFFECTIVE 03/01/ 8-MOP CAP 10MG 1 NF CMS Required Deletion N/A ABACA/LAMIVU TAB ADRIAMYCIN INJ 20MG NF 1 + BvD Formulary Enhancement N/A ALYACEN TAB 1/35 AMLOD/OLMESA TAB 10-20MG AMLOD/OLMESA TAB 10-40MG AMLOD/OLMESA TAB 5-20MG AMLOD/OLMESA TAB 5-40MG APREPITANT CAP 125MG NF 1 + BvD Formulary Enhancement N/A APREPITANT CAP 40MG NF 1 + BvD Formulary Enhancement N/A APREPITANT CAP 80MG NF 1 + BvD Formulary Enhancement N/A APREPITANT PAK 80 & 125 NF 1 + BvD Formulary Enhancement N/A AZITHROMYCIN TAB 500 MG (3 PACK) BUPROBAN TAB 150MG 1 NF CMS Required Deletion N/A CERVARIX INJ 1 NF CMS Required Deletion N/A CREON CAP 12000UNT CREON CAP 24000UNT CREON CAP 3000UNIT CREON CAP 6000UNIT DAPTOMYCIN INJ 500MG DOCEFREZ INJ 20MG 1 + BvD NF CMS Required Deletion N/A EPCLUSA TAB NF 1 + PA1 Formulary Enhancement N/A Page 3 of 7
4 FORMULARY CHANGES EPINEPHRINE SOL AUTO-INJ 0.15 MG/0.3ML INJ EPIRUBICIN INJ 200MG NF 1 + BvD Formulary Enhancement N/A ERGOMAR SUB 2MG 1 NF CMS Required Deletion N/A ERGOT/CAFFEN TAB 1-100MG NF 1 + QL 40/28 Formulary Enhancement N/A ETHYNODIOL TAB 1-50 EZETIMIBE TAB 10MG FEMYNOR TAB GAMMAGARD SD INJ 10GM HU NF 1 + BvD Formulary Enhancement N/A GAMMAGARD SD INJ 5GM HU NF 1 + BvD Formulary Enhancement N/A INVOKAMET XR TAB INVOKAMET XR TAB INVOKAMET XR TAB INVOKAMET XR TAB MG KETEK TAB 300MG 1 NF CMS Required Deletion N/A KETEK TAB 400MG 1 NF CMS Required Deletion N/A KINRIX INJ KYPROLIS SOL 30MG NF 1 + BvD Formulary Enhancement N/A KYPROLIS SOL 60MG NF 1 + BvD Formulary Enhancement N/A LARTRUVO INJ 10MG/ML NF 1 + PA2 Formulary Enhancement N/A LEVALBUTEROL HCL NEB SOL 1.25 NF 1 + BvD Formulary Enhancement N/A MG/0.5ML INH (2.5MG/ML) LOW-OGESTREL TAB MELOXICAM SUS 7.5/5ML 1 NF CMS Required Deletion N/A MENEST TAB 2.5MG 1 + HR NF CMS Required Deletion N/A METFORMIN HCL ER (OSM) TAB ER 24H 1000 MG (OSMOTIC) Page 4 of 7
5 FORMULARY CHANGES METFORMIN HCL ER (OSM) TAB ER 24H 500 MG METHOTREXATE INJ 25MG/ML NF 1 + BvD Formulary Enhancement N/A MYCOPHENOLAT INJ 500MG NF 1 + BvD Formulary Enhancement N/A MYTESI TAB 125MG NAMZARIC CAP NAMZARIC CAP 21-10MG NAMZARIC CAP 7-10MG NAPHAZOLINE SOL 0.1% OP 1 NF CMS Required Deletion N/A NIFEDICAL XL TAB 30MG 1 NF CMS Required Deletion N/A NIFEDICAL XL TAB 60MG 1 NF CMS Required Deletion N/A NIFEDIPINE ER OSMOTIC RELEASE TAB ER 24H 30 MG NIFEDIPINE ER OSMOTIC RELEASE TAB ER 24H 60 MG NIFEDIPINE ER OSMOTIC RELEASE TAB ER 24H 90 MG NITROGLYCERI SUB 0.6MG NITROGLYCERN SUB 0.3MG NITROGLYCERN SUB 0.4MG NORETH/ETHIN TAB 1/20 OFLOXACIN TAB 300MG OLM MED/HCTZ TAB OLM MED/HCTZ TAB OLM MED/HCTZ TAB 40-25MG OLMESA MEDOX TAB 20MG OLMESA MEDOX TAB 40MG Page 5 of 7
6 FORMULARY CHANGES OLMESA MEDOX TAB 5MG TAB MG TAB MG TAB MG TAB MG TAB MG ORKAMBI TAB NF 1 + PA1 Formulary Enhancement N/A OSELTAMIVIR CAP 30MG OSELTAMIVIR CAP 45MG OSELTAMIVIR CAP 75MG PEDIARIX INJ 0.5ML PLASMA-LYTE INJ 56/D5W 1 NF CMS Required Deletion N/A PRIMSOL SOL 50MG/5ML QUETIAPINE TAB 150MG ER QUETIAPINE TAB 200MG ER QUETIAPINE TAB 300MG ER QUETIAPINE TAB 400MG ER QUETIAPINE TAB 50MG ER RANITIDINE INJ 50MG/2ML 1 NF CMS Required Deletion N/A RASAGILINE TAB 0.5MG RASAGILINE TAB 1MG RESERPINE TAB 0.1MG 1 + HR NF CMS Required Deletion N/A RHEUMATREX TAB 2.5MG 4X6 1 + BvD NF CMS Required Deletion N/A Page 6 of 7
7 FORMULARY CHANGES RUBRACA TAB 200MG NF 1 + PA2 Formulary Enhancement N/A RUBRACA TAB 300MG NF 1 + PA2 Formulary Enhancement N/A STAVUDINE SOL 1MG/ML 1 NF CMS Required Deletion N/A TRAVOPROST DRO 0.004% 1 NF CMS Required Deletion N/A TYZEKA TAB 600MG 1 NF CMS Required Deletion N/A VALGANCICLOV SOL 50MG/ML VARIZIG INJ 125UNIT 1 NF CMS Required Deletion N/A VEMLIDY TAB 25MG NF 1 + PA2 Formulary Enhancement N/A VITEKTA TAB 150MG 1 NF CMS Required Deletion N/A VITEKTA TAB 85MG 1 NF CMS Required Deletion N/A YUVAFEM TAB 10MCG ZERIT SOL 1MG/ML Page 7 of 7
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
Care Wisconsin 2017 Formulary Addendum
- 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
Current 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
Memorial 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
Care 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
Upcoming 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
Memorial 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
Provider 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
QL (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)
The 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
Quarterly 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
ATRIO 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)
Acyclovir Ointment. Aetna Better Health Louisiana. Products Affected. acyclovir ointment 5 % external Details. Criteria
Acyclovir Ointment acyclovir ointment 5 % external Aetna Better Health Louisiana Use of oral acyclovir in the previous 130 days 1 Adcirca ADCIRCA TABLET 20 MG ORAL Use of sildenafil in previous 30 days
2018 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
ATRIO 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
Acyclovir Ointment. Aetna Better Health Kentucky. Products Affected. acyclovir ointment 5 % external Details. Criteria
Acyclovir Ointment acyclovir ointment 5 % external Aetna Better Health Kentucky Use of oral acyclovir or Abreva in the previous 130 days 1 Adcirca ADCIRCA TABLET 20 MG ORAL Use of sildenafil in previous
Acyclovir Ointment. Aetna Better Health New Jersey. Products Affected. acyclovir ointment 5 % external Details. Criteria
Acyclovir Ointment acyclovir ointment 5 % external Aetna Better Health New Jersey Use of oral acyclovir or Abreva in the previous 130 days 1 Adcirca tadalafil (pah) tablet 20 mg oral Use of sildenafil
New 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
Acyclovir Ointment. Aetna Better Health Virginia Medallion/FAMIS 3.0. Products Affected. acyclovir ointment 5 % external Details.
Aetna Better Health Virginia Medallion/FAMIS 3.0 Acyclovir Ointment acyclovir ointment 5 % external Use of oral acyclovir in the previous 130 days 1 Adcirca tadalafil (pah) tablet 20 mg oral Use of sildenafil
2018 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
COMPREHENSIVE 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
2018 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
WELLCARE 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
Memorial 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,
2018 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
Provider 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
Antibiotic 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
Information 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
2018 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
2018 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
2018 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
Allergies 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
2018 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
Partnership 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.
Memorial 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
(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
BCN 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
New 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
2018 Comprehensive Preferred Drug List (List of Covered Drugs)
2018 Comprehensive referred Drug List (List of Covered Drugs) Care1st Health lan Arizona Family lanning lease read: This document contains information about the drugs we cover in this plan. lease note
Step Therapy Criteria Last Updated 6/1/2018
Step Therapy Last Updated 6/1/2018 For information on obtaining an updated coverage determination or an exception to a coverage determination please call Freedom Health Member Services at 1-800-401-2740
Provider Partners Health Plan of Ohio (HMO SNP) 2019 Formulary (List of Covered Drugs)
Provider Partners Health Plan of Ohio (H SNP) 2019 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Formulary ID 19582, Version 5
Partnership 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
2016 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
LEGEND. 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
HealthPartners 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
2018 Comprehensive Preferred Drug List (List of Covered Drugs)
2018 Comprehensive referred Drug List (List of Covered Drugs) WellCare of Georgia lanning for Healthy Babies: Interpregnancy Care lease read: This document tells about the drugs we cover in this plan.
Membership Clinic 2015
Membership Clinic 2015 ISD 15 has asked NeoPath to evaluate different options for how we can improve clinic accessibility, enhance the patient experience, boost utilization of the ISD 15 clinic and maintain
Health 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)
PA Prior authorization ST Step therapy QL Quantity limit AE Age Edit. Last Updated: January 1,
Preventive Drug List Preventive drugs are used to help avoid disease and maintain health. Some insurance plans have a benefit that allows you to buy preventive drugs at a copay. Check your plan details
2018 Comprehensive Preferred Drug List (List of Covered Drugs)
2018 Comprehensive referred Drug List (List of Covered Drugs) WellCare of Georgia lanning for Healthy Babies: Interpregnancy Care lease read: This document tells about the we cover in this plan. If you
2018 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
Florida 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
PA Prior authorization ST Step therapy QL Quantity limit AE Age Edit. More Details. Last Update: July 1,
Preventive Drug List Preventive drugs are used to help avoid disease and maintain health. Some insurance plans have a benefit that allows you to buy preventive drugs at a copay. Check your plan details
Updated: 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
PLEASE 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:
AETNA BETTER HEALTH Formulary Guide. Aetna Better Health of Michigan Formulary Guide September 2018
AETNA BETTER HEALTH Formulary Guide Aetna Better Health of Michigan Formulary Guide September 2018 AETNA BETTER HEALTH Formulary Guide http://www.aetnabetterhealth.com/michigan What is the Aetna Better
Superior 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
2017 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
AETNA BETTER HEALTH Formulary Guide. Aetna Better Health of Michigan Formulary Guide January 2019
AETNA BETTER HEALTH Formulary Guide Aetna Better Health of Michigan Formulary Guide January 2019 AETNA BETTER HEALTH Formulary Guide http://www.aetnabetterhealth.com/michigan What is the Aetna Better Health
Health 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
SIGNATURE ADVANTAGE Formulary. (List of Covered Drugs)
SIGNATURE ADVANTAGE 2019 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Formulary ID 19552, Version Number 5 This formulary was
AETNA BETTER HEALTH Formulary Guide. Aetna Better Health of Michigan Formulary Guide July 2016
AETNA BETTER HEALTH Formulary Guide Aetna Better Health of Michigan Formulary Guide July 2016 AETNA BETTER HEALTH Formulary Guide http://www.aetnabetterhealth.com/michigan What is the Aetna Better Health
Health 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
AETNA BETTER HEALTH Formulary Guide. Aetna Better Health of Michigan Formulary Guide December 2017
AETNA BETTER HEALTH Formulary Guide Aetna Better Health of Michigan Formulary Guide December 2017 AETNA BETTER HEALTH Formulary Guide http://www.aetnabetterhealth.com/michigan What is the Aetna Better
2018 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
FRESENIUS TOTAL HEALTH (PPO SNP)
FRESENIUS TOTAL HEALTH (PPO SNP) 07 Formulary List of Covered Drugs PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN H9 7444, V This formulary was updated on 07/0/07.
HealthPartners GenericsPlusRx
HealthPartners GenericsPlusRx 2018 Formulary (List of covered drugs) For current information on the GenericsPlusRx Drug List, visit healthpartners.com/pharmacy. Effective: October 1, 2018 2018 HealthPartners
PHP Commercial Large Group Plans (Non-Metal Plans) Formulary Therapeutic Class Listing
Presbyterian Health Plan Presbyterian Insurance Company, Inc. PHP Commercial Large Group Plans (Non-Metal Plans) Formulary Therapeutic Class Listing This list is in order by therapeutic class. To find
Prescription 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
2015 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
PLEASE 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
3-TIER FORMULARY Effective November 2017
3-TIER FORMULARY Effective November 2017 Provided by EnvisionRx Introduction The Total Health Care (THC) 3-Tier Formulary was developed to serve as a guide for physicians, pharmacists, health care professionals
COMPREHENSIVE FORMULARY
COMPREHENSIVE FORMULARY HEALTHTEAM ADVANTAGE PLAN I (PPO) HEALTHTEAM ADVANTAGE PLAN II (PPO) (LIST OF COVERED DRUGS) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN
Superior 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 6 This formulary
2019 Comprehensive Formulary
Centers Plan for Medicare Advantage Care (HMO) 09 Comprehensive Formulary This formulary was updated on /08. For more recent information or other questions, please contact Centers Plan for Healthy Living
PREFERRED DRUG LIST 2018
PREFERRED DRUG LIST 2018 PDL National Formulary Preferred Drug List - May 2018 - The Preferred Drug List is a guide identifying preferred brandname medicines within select therapeutic categories. The Preferred
PA Prior authorization ST Step therapy QL Quantity limit AE Age Edit. More Details. Last Updated: April 1,
Preventive Drug List Preventive drugs are used to help avoid disease and maintain health. Some insurance plans have a benefit that allows you to buy preventive drugs at a copay. Check your plan details
2018 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
2016 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
2018 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
COVERAGE NOTES ABBREVIATIONS. Prior Authorization Applies. ST for New Starts Only
COVERAGE NOTES ABBREVIATIONS ABBREVIATION PA PA NSO PA BvD PA-HRM QL ST ST NSO CB GM GF AGE AGE AGE DESCRIPTION Prior Authorization Applies PA for New Starts Only Part D vs. Part B Only PA for High Risk
2016 COMPREHENSIVE FORMULARY
016 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 11/01/016.
AETNA BETTER HEALTH Formulary Guide. Aetna Better Health of Michigan
AETNA BETTER HEALTH Formulary Guide Aetna Better Health of Michigan Formulary Guide April 2016 AETNA BETTER HEALTH Formulary Guide http://www.aetnabetterhealth.com/michigan What is the Aetna Better Health
PRESCRIPTION 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
Prescription Drug Formulary
Prescription Drug Formulary 016 This formulary was updated on 07/6/016. For more recent information or other questions, please contact Essence Healthcare, Inc. Customer Service at (866) 597-9560 or, for
Memorial Hermann Advantage HMO & PPO Abridged Formulary. (Partial List of Covered Drugs)
Memorial Hermann Advantage H & PPO 2017 Abridged Formulary (Partial List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT SOME OF THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary
healthpartners.com/pharmacy.
HealthPartners Empower HSA NationalONE Embedded Silver 4000-100 Rx Plus HealthPartners Empower HSA NationalONE Embedded Silver 3000-80 Rx Plus 2017 Formulary (List of covered drugs) For current information
2018 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
2019 Formulary Annual Notice of Change
Updated: October 1, 2018 2019 Formulary Annual Notice of Change Medicare Advantage Plans (MAPD) This is a listing of the changes that have occurred to the 2019 MAPD formulary. For a complete list, please
HealthPartners Minnesota Health Care Programs
HealthPartners Minnesota Health Care Programs 2018 Formulary (List of covered drugs) For current information on the Minnesota Health Care Programs Drug List, visit healthpartners.com/pharmacy. Effective:
H0544_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
HHSC TX MEDICAID PREFERRED DRUG LIST (PDL) OCTOBER 26, 2018
ANDROGENIC AGENTS ANDRODERM (TRANSDERM) NPD NPD For this, the Board believed that the drug ANDROGEL GEL PACKET (TRANSDERM.) NPD NPD X being recommended as preferred meets the fiscal requirements of ANDROGEL
Anthem 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
Prescription Drug Formulary
Prescription Drug Formulary 2017 Advantage Plus (HMO) This formulary was updated on 08/2/2016. For more recent information or other questions, please contact Essence Healthcare, Inc. Customer Service,
Formulary (Drug List) Anthem HealthKeepers Medicare-Medicaid Plan (MMP), a Commonwealth Coordinated Care Plan
Formulary (Drug List) Anthem HealthKeepers Medicare-Medicaid Plan (MMP), a Commonwealth Coordinated Care Plan Member Services: 1-855-817-5787 (TTY 711) Monday through Friday 8 a.m. to 8 p.m. local time
healthpartners.com/pharmacy.
4 Tier 2018 Formulary (List of covered drugs) For current information on the GenericsAdvantageRx Drug List, visit healthpartners.com/pharmacy. Effective: April 1, 2018 2018 HealthPartners What s the GenericsAdvantageRx
MEDICAID FORMULARY Effective November 2017
MEDICAID FORMULARY Effective November 2017 Provided by EnvisionRx Introduction The Total Health Care (THC) Medicaid Formulary was developed to serve as a guide for physicians, pharmacists, health care
2018 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
2018 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
Express 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