08:00 Anti-Infective Agents 08:00. Anti-Infective Agents

Size: px
Start display at page:

Download "08:00 Anti-Infective Agents 08:00. Anti-Infective Agents"

Transcription

1 Anti-Infective Agents Anti-Infective Agents

2 08:08 ANTHELMINTICS MEBENDAZOLE 100 MG ORAL CHEWABLE TABLET VERMOX JAI :12.02 (AMINOGLYCOSIDES) GENTAMICIN SULFATE 40 MG / ML (BASE) INJECTION GENTAMICIN TOBRAMYCIN 28 MG INHALATION CAPSULE TOBI PODHALER NOV TOBRAMYCIN SULFATE 60 MG / ML (BASE) INHALATION SOLUTION A-TOBRAMYCIN TOBRAMYCIN TOBI 40 MG / ML (BASE) INJECTION JAMP-TOBRAMYCIN NOV : CEPHALOSPORINS (FIRST GENERATION CEPHALOSPORINS) CEFADROXIL Infectious Diseases or a designated prescriber. in Infectious Diseases or a designated prescriber.) 500 MG ORAL CAPSULE CEFAZOLIN SODIUM This Drug Product is a benefit for use by Home Parenteral Therapy (HPT) programs only. 500 MG / VIAL (BASE) INJECTION CEFAZOLIN STERILE CEFAZOLIN SODIUM 1 G / VIAL (BASE) INJECTION APO-CEFADROXIL A-CEFADROXIL CEFAZOLIN CEFAZOLIN STERILE CEFAZOLIN SODIUM UNIT OF ISSUE - REFER TO PRICE POLICY 5 EFFECTIVE APRIL 1, 2019

3 08: CEPHALOSPORINS (FIRST GENERATION CEPHALOSPORINS) CEFAZOLIN SODIUM 10 G / VIAL (BASE) INJECTION CEFAZOLIN CEFAZOLIN CEFAZOLIN CEFAZOLIN STERILE CEFAZOLIN SODIUM 100 G / G INJECTION CEFAZOLIN FKC FKC CEPHALEXIN 250 MG ORAL TABLET APO-CEPHALEX O-CEPHALEXIN A-CEPHALEXIN 500 MG ORAL TABLET APO-CEPHALEX O-CEPHALEXIN A-CEPHALEXIN 250 MG ORAL CAPSULE A-CEPHALEXIN 500 MG ORAL CAPSULE A-CEPHALEXIN 25 MG / ML ORAL SUSPENSION A-CEPHALEXIN MG / ML ORAL SUSPENSION A-CEPHALEXIN : CEPHALOSPORINS (SECOND GENERATION CEPHALOSPORINS) CEFPROZIL 250 MG ORAL TABLET APO-CEFPROZIL RAN-CEFPROZIL SANDOZ CEFPROZIL 500 MG ORAL TABLET RAN-CEFPROZIL SANDOZ CEFPROZIL RAN RAN PRODUCT IS NOT INTERCHANGEABLE 6 EFFECTIVE APRIL 1, 2019

4 08: CEPHALOSPORINS (SECOND GENERATION CEPHALOSPORINS) CEFUROXIME AXETIL 250 MG (BASE) ORAL TABLET APO-CEFUROXIME O-CEFUROXIME CEFTIN 500 MG (BASE) ORAL TABLET APO-CEFUROXIME O-CEFUROXIME CEFTIN : CEPHALOSPORINS (THIRD GENERATION CEPHALOSPORINS) CEFIXIME 400 MG ORAL TABLET O-CEFIXIME SUPRAX 20 MG / ML ORAL SUSPENSION SUPRAX ODN ODN CEFOTAXIME SODIUM 1 G / VIAL (BASE) INJECTION CEFOTAXIME SODIUM 2 G / VIAL (BASE) INJECTION CEFOTAXIME SODIUM CEFTAZIDIME 1 G / VIAL INJECTION FORTAZ 2 G / VIAL INJECTION FORTAZ 6 G / VIAL INJECTION FORTAZ CEFTRIAXONE SODIUM 0.25 G / VIAL (BASE) INJECTION CEFTRIAXONE FOR INJECTION USP CEFTRIAXONE SODIUM FOR INJECTION BP 1 G / VIAL (BASE) INJECTION CEFTRIAXONE FOR INJECTION USP CEFTRIAXONE FOR INJECTION USP CEFTRIAXONE SODIUM FOR INJECTION CEFTRIAXONE SODIUM FOR INJECTION BP 2 G / VIAL (BASE) INJECTION CEFTRIAXONE FOR INJECTION USP CEFTRIAXONE FOR INJECTION USP CEFTRIAXONE SODIUM FOR INJECTION BP UNIT OF ISSUE - REFER TO PRICE POLICY 7 EFFECTIVE APRIL 1, 2019

5 08: CEPHALOSPORINS (THIRD GENERATION CEPHALOSPORINS) CEFTRIAXONE SODIUM 10 G / VIAL (BASE) INJECTION CEFTRIAXONE SODIUM : MISCELLANEOUS B-LACTAMS (CARBAPENEMS) ERTAPENEM Infectious Diseases or a designated prescriber. in Infectious Diseases or a designated prescriber.) 1 G / VIAL INJECTION INVANZ MFC IMIPENEM/ CILASTATIN SODIUM Infectious Diseases or Hematology, or a designated prescriber in Infectious Diseases or Hematology, or a designated prescriber.) 500 MG / VIAL * 500 MG / VIAL (BASE) INJECTION PRIMAXIN MFC MEROPENEM Infectious Diseases or Hematology, or a designated prescriber. in Infectious Diseases or Hematology, or a designated prescriber.) 500 MG / VIAL INJECTION MEROPENEM 1 G / VIAL INJECTION MEROPENEM MEROPENEM FOR INJECTION USP PRODUCT IS NOT INTERCHANGEABLE 8 EFFECTIVE APRIL 1, 2019

6 08: MISCELLANEOUS B-LACTAMS (CEPHAMYCINS) CEFOXITIN SODIUM Infectious Diseases or a designated prescriber. in Infectious Diseases or a designated prescriber.) 1 G / VIAL (BASE) INJECTION CEFOXITIN CEFOXITIN SODIUM 2 G / VIAL (BASE) INJECTION CEFOXITIN CEFOXITIN SODIUM :12.08 (CHLORAMPHENICOL) CHLORAMPHENICOL SODIUM SUCCINATE 1 G / VIAL (BASE) INJECTION CHLOROMYCETIN ERF : MACROLIDES (ERYTHROMYCINS) ERYTHROMYCIN 250 MG ORAL TABLET ERYTHRO-BASE 333 MG ORAL CAPSULE (ENTERIC-COATED PELLET) ERYC ERYTHROMYCIN STEARATE 250 MG ORAL TABLET ERYTHRO-S 500 MG ORAL TABLET ERYTHRO-S UNIT OF ISSUE - REFER TO PRICE POLICY 9 EFFECTIVE APRIL 1, 2019

7 08: MACROLIDES (OTHER MACROLIDES) AZITHROMYCIN 250 MG ORAL TABLET APO-AZITHROMYCIN Z AZITHROMYCIN AZITHROMYCIN JAMP-AZITHROMYCIN MAR-AZITHROMYCIN NOVO-AZITHROMYCIN AZITHROMYCIN SANDOZ AZITHROMYCIN ZITHROMAX 600 MG ORAL TABLET AZITHROMYCIN SIV MAR RESTRICTED BENEFIT - This product is a benefit when prescribed by a Specialist in Infectious Diseases or a designated prescriber (Refer to Section 3 - Criteria for Special Authorization of Select Drug Products of the Alberta Drug Benefit List for eligibility when the prescriber prescribing the medication is not a Specialist in Infectious Diseases or a designated prescriber.) 20 MG / ML ORAL SUSPENSION SANDOZ AZITHROMYCIN ZITHROMAX 40 MG / ML ORAL SUSPENSION GD-AZITHROMYCIN SANDOZ AZITHROMYCIN ZITHROMAX GMD CLARITHROMYCIN 250 MG ORAL TABLET CLARITHROMYCIN CLARITHROMYCIN CLARITHROMYCIN RAN-CLARITHROMYCIN SANDOZ CLARITHROMYCIN A-CLARITHROMYCIN BIAXIN BID 500 MG ORAL TABLET CLARITHROMYCIN SANDOZ CLARITHROMYCIN A-CLARITHROMYCIN BIAXIN BID 500 MG ORAL EXTENDED-RELEASE TABLET ACT CLARITHROMYCIN XL APO-CLARITHROMYCIN XL BIAXIN XL 25 MG / ML ORAL SUSPENSION CLARITHROMYCIN TARO-CLARITHROMYCIN BIAXIN SIV RAN BGP BGP APH BGP TAR BGP PRODUCT IS NOT INTERCHANGEABLE 10 EFFECTIVE APRIL 1, 2019

8 08: MACROLIDES (OTHER MACROLIDES) CLARITHROMYCIN 50 MG / ML ORAL SUSPENSION CLARITHROMYCIN TARO-CLARITHROMYCIN BIAXIN TAR BGP : PENICILLINS (NATURAL PENICILLINS) PENICILLIN G SODIUM 1,000,000 IU / VIAL INJECTION PENICILLIN G SODIUM PENICILLIN G SODIUM 5,000,000 IU / VIAL INJECTION PENICILLIN G SODIUM PENICILLIN G SODIUM 10,000,000 IU / VIAL INJECTION PENICILLIN G SODIUM PENICILLIN G SODIUM FKC FKC FKC PENICILLIN V POTASSIUM 300 MG ORAL TABLET PEN-VK : PENICILLINS (AMINOPENICILLINS) AMOXICILLIN TRIHYDRATE 250 MG (BASE) ORAL CHEWABLE TABLET NOVAMOXIN 250 MG (BASE) ORAL CAPSULE AMOXICILLIN AMOXICILLIN APO-AMOXI O-AMOXICILLIN NOVAMOXIN 500 MG (BASE) ORAL CAPSULE AMOXICILLIN AMOXICILLIN APO-AMOXI O-AMOXICILLIN MYLAN-AMOXICILLIN NOVAMOXIN -AMOXICILLIN SIV SIV UNIT OF ISSUE - REFER TO PRICE POLICY 11 EFFECTIVE APRIL 1, 2019

9 08: PENICILLINS (AMINOPENICILLINS) AMOXICILLIN TRIHYDRATE 25 MG / ML (BASE) ORAL SUSPENSION APO-AMOXI 50 MG / ML (BASE) ORAL SUSPENSION AMOXICILLIN TRIHYDRATE/ CLAVULANATE POTASSIUM 250 MG (BASE) * 125 MG (BASE) ORAL TABLET APO-AMOXI CLAV 500 MG (BASE) * 125 MG (BASE) ORAL TABLET APO-AMOXI CLAV CLAVULIN-500F 875 MG (BASE) * 125 MG (BASE) ORAL TABLET APO-AMOXI CLAV CLAVULIN MG / ML (BASE) * 6.25 MG / ML (BASE) ORAL SUSPENSION CLAVULIN-125F 40 MG / ML (BASE) * 5.7 MG / ML (BASE) ORAL SUSPENSION CLAVULIN MG / ML (BASE) * 12.5 MG / ML (BASE) ORAL SUSPENSION CLAVULIN-250F 80 MG / ML (BASE) * 11.4 MG / ML (BASE) ORAL SUSPENSION AMOXICILLIN AMOXICILLIN AMOXICILLIN SUGAR-REDUCED APO-AMOXI NOVAMOXIN NOVAMOXIN SUGAR-REDUCED CLAVULIN-400 AMPICILLIN Infectious Diseases or a designated prescriber. SIV in Infectious Diseases or a designated prescriber.) 250 MG ORAL CAPSULE NOVO-AMPICILLIN 500 MG ORAL CAPSULE NOVO-AMPICILLIN AMPICILLIN SODIUM 250 MG / VIAL (BASE) INJECTION AMPICILLIN SODIUM 500 MG / VIAL (BASE) INJECTION AMPICILLIN SODIUM 1 G / VIAL (BASE) INJECTION AMPICILLIN SODIUM 2 G / VIAL (BASE) INJECTION AMPICILLIN SODIUM PRODUCT IS NOT INTERCHANGEABLE 12 EFFECTIVE APRIL 1, 2019

10 08: PENICILLINS (PENICILLINASE-RESISTANT PENICILLINS) CLOXACILLIN SODIUM 250 MG (BASE) ORAL CAPSULE NOVO-CLOXIN 500 MG (BASE) ORAL CAPSULE NOVO-CLOXIN 25 MG / ML (BASE) ORAL LIQUID NOVO-CLOXIN 500 MG / VIAL (BASE) INJECTION CLOXACILLIN 1 G / VIAL (BASE) INJECTION CLOXACILLIN 2 G / VIAL (BASE) INJECTION CLOXACILLIN : PENICILLINS (EXTENDED-SPECTRUM PENICILLINS) PIPERACILLIN SODIUM/ TAZOBACTAM SODIUM Infectious Diseases or Hematology, or a designated prescriber. in Infectious Diseases or Hematology, or a designated prescriber.) 2 G / VIAL (BASE) * 250 MG / VIAL (BASE) INJECTION PIPERACILLIN AND TAZOBACTAM PIPERACILLIN AND TAZOBACTAM PIPERACILLIN AND TAZOBACTAM PIPERACILLIN SODIUM/TAZOBACTAM SODIUM 3 G / VIAL (BASE) * 375 MG / VIAL (BASE) INJECTION PIPERACILLIN/TAZOBACTAM 4 G / VIAL (BASE) * 500 MG / VIAL (BASE) INJECTION PIPERACILLIN AND TAZOBACTAM PIPERACILLIN AND TAZOBACTAM PIPERACILLIN AND TAZOBACTAM PIPERACILLIN SODIUM/TAZOBACTAM SODIUM PIPERACILLIN AND TAZOBACTAM PIPERACILLIN AND TAZOBACTAM PIPERACILLIN AND TAZOBACTAM PIPERACILLIN SODIUM/TAZOBACTAM SODIUM PIPERACILLIN/TAZOBACTAM TGT TGT TGT UNIT OF ISSUE - REFER TO PRICE POLICY 13 EFFECTIVE APRIL 1, 2019

11 08:12.20 (SULFONAMIDES) SULFAMETHOXAZOLE/ TRIMETHOPRIM 100 MG * 20 MG ORAL TABLET SULFATRIM 400 MG * 80 MG ORAL TABLET SULFATRIM 800 MG * 160 MG ORAL TABLET SULFATRIM DS 40 MG / ML * 8 MG / ML ORAL SUSPENSION A-TRIMEL 80 MG / ML * 16 MG / ML INJECTION SEPTRA APC SULFASALAZINE 500 MG ORAL TABLET SULFASALAZINE 500 MG ORAL ENTERIC-COATED TABLET SULFASALAZINE :12.24 (TETRACYCLINES) DOXYCYCLINE HYCLATE 100 MG (BASE) ORAL TABLET APO-DOXY DOXYCYCLINE A-DOXYCYCLINE 100 MG (BASE) ORAL CAPSULE APO-DOXY DOXYCYCLINE A-DOXYCYCLINE MINOCYCLINE HCL 50 MG (BASE) ORAL CAPSULE APO-MINOCYCLINE MYLAN-MINOCYCLINE NOVO-MINOCYCLINE 100 MG (BASE) ORAL CAPSULE APO-MINOCYCLINE MYLAN-MINOCYCLINE NOVO-MINOCYCLINE TETRACYCLINE HCL 250 MG ORAL CAPSULE TETRACYCLINE PRODUCT IS NOT INTERCHANGEABLE 14 EFFECTIVE APRIL 1, 2019

12 08:12.28 (MISCELLANEOUS ) SPIRAMYCIN 750,000 IU ORAL CAPSULE ROVAMYCINE-250 1,500,000 IU ORAL CAPSULE ROVAMYCINE-500 ODN ODN : MISCELLANEOUS (GLYCOPEPTIDES) VANCOMYCIN HCL 125 MG (BASE) ORAL CAPSULE JAMP-VANCOMYCIN VANCOCIN 250 MG (BASE) ORAL CAPSULE JAMP-VANCOMYCIN VANCOCIN 500 MG / VIAL (BASE) INJECTION VANCOMYCIN HCL 1 G / VIAL (BASE) INJECTION VANCOMYCIN HCL 10 G / VIAL INJECTION STERILE VANCOMYCIN HCL VANCOMYCIN HCL SLP SLP FKC RESTRICTED BENEFIT This Drug Product is a benefit for use by Home Parenteral Therapy (HPT) programs only. 08: MISCELLANEOUS (LINCOMYCINS) CLINDAMYCIN HCL 150 MG (BASE) ORAL CAPSULE APO-CLINDAMYCIN O-CLINDAMYCIN A-CLINDAMYCIN 300 MG (BASE) ORAL CAPSULE APO-CLINDAMYCIN O-CLINDAMYCIN A-CLINDAMYCIN UNIT OF ISSUE - REFER TO PRICE POLICY 15 EFFECTIVE APRIL 1, 2019

13 08: MISCELLANEOUS (LINCOMYCINS) CLINDAMYCIN PALMITATE HCL 15 MG / ML (BASE) ORAL SOLUTION DALACIN C PALMITATE CLINDAMYCIN PHOSPHATE 150 MG / ML (BASE) INJECTION CLINDAMYCIN CLINDAMYCIN (60 & 120 ML) DALACIN C PHOSPHATE : MISCELLANEOUS (OXAZOLIDINONES) LINEZOLID Infectious Diseases or a designated prescriber. in Infectious Diseases or a designated prescriber.) 600 MG ORAL TABLET APO-LINEZOLID SANDOZ LINEZOLID ZYVOXAM : MISCELLANEOUS (POLYMYXINS) COLISTIMETHATE SODIUM 150 MG / VIAL INJECTION COLISTIMETHATE FOR INJECTION PRODUCT IS NOT INTERCHANGEABLE 16 EFFECTIVE APRIL 1, 2019

14 08:14.04 ANTIFUNGALS (ALLYLAMINES) TERBINAFINE HCL 250 MG (BASE) ORAL TABLET ACT TERBINAFINE APO-TERBINAFINE O-TERBINAFINE -TERBINAFINE TERBINAFINE TERBINAFINE A-TERBINAFINE LAMISIL APH SIV NOV :14.08 ANTIFUNGALS (AZOLES) FLUCONAZOLE 50 MG ORAL TABLET ACT FLUCONAZOLE APO-FLUCONAZOLE MYLAN-FLUCONAZOLE NOVO-FLUCONAZOLE FLUCONAZOLE 100 MG ORAL TABLET ACT FLUCONAZOLE APO-FLUCONAZOLE MYLAN-FLUCONAZOLE NOVO-FLUCONAZOLE FLUCONAZOLE 10 MG / ML ORAL SUSPENSION DIFLUCAN APH APH RESTRICTED BENEFIT - This product is a benefit when prescribed by a Specialist in Infectious Diseases or a designated prescriber (Refer to Section 3 - Criteria for Special Authorization of Select Drug Products of the Alberta Drug Benefit List for eligibility when the prescriber prescribing the medication is not a Specialist in Infectious Diseases or a designated prescriber.) 2 MG / ML INJECTION DIFLUCAN UNIT OF ISSUE - REFER TO PRICE POLICY 17 EFFECTIVE APRIL 1, 2019

15 08:14.08 ANTIFUNGALS (AZOLES) ITRACONAZOLE 100 MG ORAL CAPSULE MINT-ITRACONAZOLE SPORANOX 10 MG / ML ORAL SOLUTION SPORANOX MPI JAI RESTRICTED BENEFIT - This product is a benefit when prescribed by a Specialist in Infectious Diseases or a designated prescriber. JAI (Refer to Section 3 - Criteria for Special Authorization of Select Drug Products of the Alberta Drug Benefit List for eligibility when the prescriber prescribing the medication is not a Specialist in Infectious Diseases or a designated prescriber.) KETOCONAZOLE 200 MG ORAL TABLET APO-KETOCONAZOLE A-KETOCONAZOLE VORICONAZOLE Infectious Diseases or a designated prescriber in Infectious Diseases or a designated prescriber.) 50 MG ORAL TABLET SANDOZ VORICONAZOLE A-VORICONAZOLE VFEND 200 MG ORAL TABLET SANDOZ VORICONAZOLE A-VORICONAZOLE VFEND 40 MG / ML ORAL SUSPENSION VFEND 200 MG / VIAL INJECTION VFEND PRODUCT IS NOT INTERCHANGEABLE 18 EFFECTIVE APRIL 1, 2019

16 08:14.16 ANTIFUNGALS (ECHINOCANDINS) CASPOFUNGIN Infectious Diseases or a designated prescriber. in Infectious Diseases or a designated prescriber.) 50 MG / VIAL INJECTION CASPOFUNGIN CANCIDAS 70 MG / VIAL INJECTION CASPOFUNGIN CANCIDAS MDA MFC MDA MFC :14.28 ANTIFUNGALS (POLYENES) AMPHOTERICIN B 50 MG / VIAL INJECTION FUNGIZONE IV BMS NYSTATIN 100,000 UNIT / ML ORAL SUSPENSION JAMP-NYSTATIN -NYSTATIN A-NYSTATIN :16.92 ANTIMYCOBACTERIALS (MISCELLANEOUS ANTIMYCOBACTERIALS) DAPSONE 100 MG ORAL TABLET MAR-DAPSONE DAPSONE MAR NTI RIFABUTIN Infectious Diseases or a designated prescriber in Infectious Diseases or a designated prescriber.) 150 MG ORAL CAPSULE MYCOBUTIN UNIT OF ISSUE - REFER TO PRICE POLICY 19 EFFECTIVE APRIL 1, 2019

17 08: LAMIVUDINE RESTRICTED BENEFIT - This product is a benefit when initiated by a Specialist in Internal Medicine or a designated prescriber. 100 MG ORAL TABLET ANTIVIRALS ANTIRETROVIRALS (NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS) APO-LAMIVUDINE HBV HEPTOVIR TENOFOVIR DISOPROXIL FUMARATE RESTRICTED BENEFIT - This product is a benefit for the treatment of chronic hepatitis B when prescribed by a Specialist in Internal Medicine or a designated prescriber MG (BASE) ORAL TABLET APO-TENOFOVIR O-TENOFOVIR JAMP-TENOFOVIR MYLAN-TENOFOVIR DISOPROXIL NAT-TENOFOVIR -TENOFOVIR A-TENOFOVIR VIREAD NTP GIL :18.20 ANTIVIRALS (INTERFERONS) PEGINTERFERON ALFA-2A RESTRICTED BENEFIT This product is a benefit for the treatment of chronic hepatitis B when prescribed by a Specialist in Internal Medicine or a designated prescriber. (For eligibility for the treatment of chronic hepatitis C refer to Criteria for Special Authorization of Select Drug Products of the List and Criteria for Special Authorization of Select Drug Products of the Alberta Human Services Drug Benefit Supplement for Alberta Human Services clients.) 180 MCG / SYR INJECTION SYRINGE PEGASYS (0.5 ML SYRINGE) HLR PRODUCT IS NOT INTERCHANGEABLE 20 EFFECTIVE APRIL 1, 2019

18 08:18.32 ANTIVIRALS (NUCLEOSIDES AND NUCLEOTIDES) ACYCLOVIR 200 MG ORAL TABLET APO-ACYCLOVIR MYLAN-ACYCLOVIR A-ACYCLOVIR 400 MG ORAL TABLET APO-ACYCLOVIR MYLAN-ACYCLOVIR A-ACYCLOVIR 800 MG ORAL TABLET APO-ACYCLOVIR MYLAN-ACYCLOVIR A-ACYCLOVIR 40 MG / ML ORAL SUSPENSION ZOVIRAX ENTECAVIR RESTRICTED BENEFIT - This product is a benefit for the treatment of chronic hepatitis B when prescribed by a Specialist in Internal Medicine or a designated prescriber ADEFOVIR DIPIVOXIL RESTRICTED BENEFIT - This product is a benefit for the treatment of chronic hepatitis B when prescribed by a Specialist in Internal Medicine or a designated prescriber. 10 MG ORAL TABLET APO-ADEFOVIR HEPSERA GIL MG ORAL TABLET APO-ENTECAVIR O-ENTECAVIR JAMP-ENTECAVIR -ENTECAVIR BARACLUDE BMS GANCICLOVIR SODIUM 500 MG / VIAL (BASE) INJECTION CYTOVENE CAG UNIT OF ISSUE - REFER TO PRICE POLICY 21 EFFECTIVE APRIL 1, 2019

19 08:18.32 ANTIVIRALS (NUCLEOSIDES AND NUCLEOTIDES) VALACYCLOVIR 500 MG ORAL TABLET APO-VALACYCLOVIR (CAPLET) O-VALACYCLOVIR JAMP-VALACYCLOVIR MAR-VALACYCLOVIR MYLAN-VALACYCLOVIR (CAPLET) VALACYCLOVIR (CAPLET) SANDOZ VALACYCLOVIR A-VALACYCLOVIR VALACYCLOVIR VALACYCLOVIR VALTREX (CAPLET) 1,000 MG ORAL TABLET APO-VALACYCLOVIR (CAPLET) MYLAN-VALACYCLOVIR (CAPLET) -VALACYCLOVIR (CAPLET) MAR SIV VALGANCICLOVIR HCL 450 MG (BASE) ORAL TABLET APO-VALGANCICLOVIR O-VALGANCICLOVIR A-VALGANCICLOVIR VALCYTE 50 MG / ML ORAL SUSPENSION VALCYTE HLR HLR :30.08 ANTIPROTOZOALS (ANTIMALARIALS) CHLOROQUINE PHOSPHATE 250 MG ORAL TABLET A-CHLOROQUINE HYDROXYCHLOROQUINE SULFATE 200 MG ORAL TABLET APO-HYDROXYQUINE MINT-HYDROXYCHLOROQUINE PLAQUENIL SULFATE MPI SAV PRIMAQUINE PHOSPHATE 15 MG (BASE) ORAL TABLET PRIMAQUINE PHOSPHATE SAV PRODUCT IS NOT INTERCHANGEABLE 22 EFFECTIVE APRIL 1, 2019

20 08:30.08 ANTIPROTOZOALS (ANTIMALARIALS) QUININE SULFATE 200 MG ORAL CAPSULE APO-QUININE JAMP-QUININE A-QUININE 300 MG ORAL CAPSULE APO-QUININE JAMP-QUININE A-QUININE :30.92 ANTIPROTOZOALS (MISCELLANEOUS ANTIPROTOZOALS) ATOVAQUONE 150 MG / ML ORAL SUSPENSION MEPRON METRONIDAZOLE 250 MG ORAL TABLET METRONIDAZOLE 5 MG / ML INJECTION FLAGYL METRONIDAZOLE BAX :36 URINARY ANTI-INFECTIVES FOSFOMYCIN TROMETHAMINE 3 G (BASE) ORAL POWDER PACKET JAMP-FOSFOMYCIN MONUROL PAL NITROFURANTOIN 50 MG ORAL TABLET NITROFURANTOIN 100 MG ORAL TABLET NITROFURANTOIN 50 MG ORAL CAPSULE (MACROCRYSTALS) A-NITROFURANTOIN 100 MG ORAL CAPSULE (MACROCRYSTALS) A-NITROFURANTOIN 100 MG ORAL CAPSULE (MACROCRYSTALS/MONOHYDRATE) NITROFURANTOIN MACROBID ASC TRIMETHOPRIM 100 MG ORAL TABLET TRIMETHOPRIM 200 MG ORAL TABLET TRIMETHOPRIM UNIT OF ISSUE - REFER TO PRICE POLICY 23 EFFECTIVE APRIL 1, 2019

00:00 Antihistamine Drugs 00:00. Non-Classified Drugs

00:00 Antihistamine Drugs 00:00. Non-Classified Drugs 00:00 Antihistamine Drugs 00:00 Non-Classified Drugs 00:00 NON-CLASSIFIED DRUGS 00:00.02 (DIABETES SUPPLIES) DIABETES SUPPLIES 00000999955 00000999941 00000999985 00000999952 00000999957 BLOOD GLUCOSE

More information

92:00. Miscellaneous Therapeutic Agents. 92:00 Miscellaneous Therapeutic Agents

92:00. Miscellaneous Therapeutic Agents. 92:00 Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents ALENDRONATE SODIUM 70 MG ORAL TABLET 00002299712 00002352966 00002381494 00002248730 00002388553 00002385031 00002394871 00002286335 00002284006

More information

2018 Comprehensive Formulary (List of Covered Drugs) Medicare Advantage Plans

2018 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 information

HAP Empowered MI Health Link Medicare-Medicaid Plan 2019 List of Covered Drugs (Formulary)

HAP Empowered MI Health Link Medicare-Medicaid Plan 2019 List of Covered Drugs (Formulary) H9712_2019 LOCD; Approved HAP Empowered MI Health Link Medicare-Medicaid Plan 2019 List of Covered Drugs (Formulary) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT S WE COVER IN THIS PLAN. CMS Approved

More information

2016 COMPREHENSIVE FORMULARY

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.

More information

2018 Comprehensive Formulary (List of Covered Drugs) Medicare Advantage Plans

2018 Comprehensive Formulary (List of Covered Drugs) Medicare Advantage Plans 018 Comprehensive Formulary (List of Covered s) Medicare Advantage Plans WellCare/ Ohana Plans in the following state: IL WellCare Choice (HMO-POS), WellCare Plus (HMO) WellCare Rx (HMO) Plans in the following

More information

Product List Brand name Generic name Strength CEPHALOSPORINS Kezolin Injection Cefazolin For Injection USP 1g K-zidime Injection Ceftazidime For

Product List Brand name Generic name Strength CEPHALOSPORINS Kezolin Injection Cefazolin For Injection USP 1g K-zidime Injection Ceftazidime For Product List Brand name Generic name Strength CEPHALOSPORINS Kezolin Injection Cefazolin For Injection USP 1g K-zidime Injection Ceftazidime For Injection USP 250mg, 500mg, 1g Ceftazidime + Sulbactam injection

More information

2017 Comprehensive Formulary (List of Covered Drugs) Medicare Advantage Plans

2017 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 Easy Choice Health Plan Plans in the following state: CA Easy Choice Best Plan(HMO)

More information

Gastrointestinal Drugs

Gastrointestinal Drugs Gastrointestinal Drugs Gastrointestinal Drugs 56:08 ANTIDIARRHEA AGENTS DIPHENOXYLATE HCL/ ATROPINE SULFATE 2.5 MG * 0.025 MG ORAL TABLET 00000036323 LOMOTIL PFI 0.4994 56:14 CHOLELITHOLYTIC AGENTS URSODIOL

More information

2018 Comprehensive Formulary (List of Covered Drugs) Medicare Advantage Plans

2018 Comprehensive Formulary (List of Covered Drugs) Medicare Advantage Plans 018 Comprehensive Formulary (List of Covered s) Medicare Advantage Plans WellCare Health Plans Plans in the following states: GA, NC, SC, TN WellCare Choice (HMO), WellCare Choice (HMO-POS) WellCare Essential

More information

3. This solution retains potency for 2 8 hours at room temperature after reconstitution.

3. 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 information

2018 Comprehensive Formulary (List of Covered Drugs) Prescription Drug Plans

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

More information

2018 Comprehensive Formulary (List of Covered Drugs) Medicare Advantage Plans

2018 Comprehensive Formulary (List of Covered Drugs) Medicare Advantage Plans 018 Comprehensive Formulary (List of Covered s) Medicare Advantage Plans WellCare/ Ohana Plans in the following state: IL WellCare Choice (HMO-POS), WellCare Plus (HMO) WellCare Rx (HMO) Plans in the following

More information

Surveillance of ICU - Acquired Infections National Feedback Report Risk Factor Indicators Year 2015

Surveillance of ICU - Acquired Infections National Feedback Report Risk Factor Indicators Year 2015 Surveillance of ICU - Acquired Infections National Feedback Report Risk Factor Indicators Year 2015 Scientific Institute of Public Health Direction of Public Health and Surveillance National Surveillance

More information

PRESCRIPTION DRUGS FORMULARY 1. I ~~ [ tl-i I Classicare (HMO)

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

More information

2017 Comprehensive Formulary (List of Covered Drugs) Medicare Advantage Plans

2017 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 Health Plans Plans in the following states: GA, SC WellCare Choice (HMO), WellCare

More information

Health First Health Plans 2016 Formulary (List of Covered Drugs)

Health First Health Plans 2016 Formulary (List of Covered Drugs) Updated: November 1, 2016 Florida Hospital SunSaver Plan (HMO-POS) Florida Hospital Explorer Plan (HMO-POS) Health First Health Plans 2016 Formulary (List of Covered s) PLEASE READ: THIS DOCUMENT CONTAINS

More information

Partnership 2017 Formulary. List of Covered Drugs

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.

More information

2017 Formulary (List of Covered Drugs)

2017 Formulary (List of Covered Drugs) MedStar Medicare Choice (HMO) 2017 Formulary (List of Covered s) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. HPMS Approved Formulary File Submission ID: 00017201,

More information

2017 Comprehensive Formulary (List of Covered Drugs) Medicare Advantage Plans

2017 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 information

COMPREHENSIVE FORMULARY

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

More information

Y0070_NA026578_WCM_FOR_ENG_FINAL_02 CMS Approved NA5V02FOR59890E 0915 WellCare 2015 NA_09_15

Y0070_NA026578_WCM_FOR_ENG_FINAL_02 CMS Approved NA5V02FOR59890E 0915 WellCare 2015 NA_09_15 2015 Comprehensive e Formulary (List of Covered ed Drugs) Medicare e Advantage Plans Please Read: This document contains information about some of the drugs we cover in this plan. This formulary was updated

More information

2017 COMPREHENSIVE FORMULARY

2017 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 information

Memorial Hermann Advantage HMO Formulary. (List of Covered Drugs)

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,

More information

2017 Comprehensive Formulary (List of Covered Drugs) Prescription Drug Plans

2017 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 information

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 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 information

2015 Comprehensive Formulary (List of Covered Drugs)

2015 Comprehensive Formulary (List of Covered Drugs) 2015 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 information

2019 Formulary (List of Covered Drugs)

2019 Formulary (List of Covered Drugs) MEDICARE ADVANTAGE PLANS 2019 Formulary (List of Covered Drugs) Presbyterian Senior Care (HMO) Presbyterian Senior Care (HMO-POS) Presbyterian MediCare PPO Please Read: This document contains information

More information

Partnership 2017 Formulary. List of Covered Drugs

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

More information

Comprehensive Formulary

Comprehensive Formulary 2015 Comprehensive Formulary (List of Covered Drugs) Medicare Advantage Plans Please Read: This document contains information about some of the drugs we cover in this plan. This formulary was updated on

More information

Baptist Health Plan Advantage (HMO) 2017 Formulary (List of Covered Drugs)

Baptist Health Plan Advantage (HMO) 2017 Formulary (List of Covered Drugs) Baptist Health Plan Advantage (HMO) 2017 Formulary (List of Covered s) Formulary ID: 17202, Version 19 PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary

More information

Health First Health Plans 2019 Formulary (List of Covered Drugs)

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)

More information

Comprehensive Formulary (List of Covered Drugs)

Comprehensive Formulary (List of Covered Drugs) 2015 Comprehensive Formulary (List of Covered Drugs) Medicare Advantage Plans Please Read: This document contains information about some of the drugs we cover in this plan. This formulary was updated on

More information

2015 Comprehensive Formulary (List of Covered Drugs)

2015 Comprehensive Formulary (List of Covered Drugs) 2015 Comprehensive Formulary (List of Covered Drugs) Medicare Advantage Plans Please Read: This document contains information about some of the drugs we cover in this plan. This formulary was updated on

More information

Comprehensive Preferred Drug List (List of Covered Drugs)

Comprehensive Preferred Drug List (List of Covered Drugs) 2014 Comprehensive referred Drug List (List of Covered Drugs) WellCare Georgia Family lanning 00 9 lease read: This document contains information about the drugs we cover in this plan. ara solicitar este

More information

2018 Formulary. (List of Covered Drugs)

2018 Formulary. (List of Covered Drugs) 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 ID: 18390 Version #: 18 This formulary

More information

Prescription Drug Formulary

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

More information

COMPREHENSIVE FORMULARY

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

More information

Health First Health Plans 2019 Formulary (List of Covered Drugs)

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

More information

Prescription Drug Formulary

Prescription Drug Formulary Prescription Drug Formulary 016 This formulary was updated on 05/4/016. For more recent information or other questions, please contact Essence Healthcare, Inc. Customer Service at (866) 597-9560 or, for

More information

EmblemHealth Medicare HMO

EmblemHealth Medicare HMO EmblemHealth Medicare HMO 2019 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN 19197v10 This formulary was updated on 03/01/2019.

More information

2018 MEDICARE PART D DRUG FORMULARY

2018 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 information

Prescription Drug Formulary

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,

More information

Prescription Drug Formulary

Prescription Drug Formulary Prescription Drug Formulary 018 This formulary was updated on 08/16/017. For more recent information or other questions, please contact Essence Healthcare, Inc. Customer Service, at 1-866-597-9560 or,

More information

2019 HAP Formulary. List of covered drugs, cost tiers and how it all works

2019 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 information

2016 COMPREHENSIVE FORMULARY

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

More information

2018 List of Covered Drugs (Formulary)

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

More information

2015 Formulary (List of Covered Drugs)

2015 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 information

Geisinger Gold $0 Deductible Rx Comprehensive Formulary. (List of Covered Drugs)

Geisinger Gold $0 Deductible Rx Comprehensive Formulary. (List of Covered Drugs) Geisinger Gold $0 Deductible Rx 016 Comprehensive Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on 11/9/16.

More information

2018 Formulary. (List of Covered Drugs)

2018 Formulary. (List of Covered Drugs) 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 ID: 18390 Version #: 11 This formulary

More information

Health First Health Plans 2018 Formulary (List of Covered Drugs)

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

More information

2018 MEDICARE PART D DRUG FORMULARY

2018 MEDICARE PART D DRUG FORMULARY 2018 MEDICARE PART D DRUG FORMULARY EmblemHealth HMO 5-Tier Comprehensive Medication List This formulary was updated on 06/01/2018. For more recent information or other questions, please contact EmblemHealth

More information

2017 Formulary. (List of Covered Drugs) Medicare GenerationRx (Employer PDP)

2017 Formulary. (List of Covered Drugs) Medicare GenerationRx (Employer PDP) Medicare GenerationRx (Employer PDP) 017 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on 11/01/017.

More information

Memorial Hermann Advantage HMO & PPO Formulary. (List of Covered Drugs)

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

More information

Empire MediBlue Select (HMO) 2019 Formulary (List of Covered Drugs) Please read: ,

Empire 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 information

2017 COMPREHENSIVE FORMULARY

2017 COMPREHENSIVE FORMULARY 017 COMPREHENSIVE FORMULARY (LIST OF COVERED DRUGS) PRESCRIPTION DRUG PLANS Please Read: This document contains information about the drugs we cover in this plan. This formulary was updated on 09/01/016.

More information

Comprehensive Preferred Drug List (List of Covered Drugs)

Comprehensive Preferred Drug List (List of Covered Drugs) 2018 Comprehensive referred Drug List (List of Covered Drugs) WellCare Georgia lanning for Healthy Babies - Family lanning lease read: This document tells about the drugs we cover in this plan. If you

More information

OPTIMA MEDICARE. OPTIMA COMMUNITY COMPLETE (HMO SNP) 2019 Formulary List of Covered Drugs

OPTIMA MEDICARE. OPTIMA COMMUNITY COMPLETE (HMO SNP) 2019 Formulary List of Covered Drugs OPTIMA MEDICARE OPTIMA COMMUNITY COMPLETE (HMO SNP) 2019 Formulary List of Covered Drugs PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File

More information

Prescription Drug Formulary

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

More information

GuildNet Gold. Formulary Medicare Advantage Prescription Drug Plan

GuildNet Gold. Formulary Medicare Advantage Prescription Drug Plan GuildNet Gold Medicare Advantage Prescription Drug Plan Formulary 2018 This formulary was updated on 11/01/2018. For more recent information or other questions, please contact the Plan at 1-800-815-0000

More information

EnvisionRxPlus Formulary. (List of Covered Drugs)

EnvisionRxPlus 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 information

Provider Partners Illinois Advantage Plan (HMO SNP) 2019 Formulary (List of Covered Drugs)

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

More information

Florida Hospital Care Advantage 2017 Formulary (List of Covered Drugs)

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

More information

2018 List of Covered Drugs (Formulary)

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

More information

2018 Formulary. (List of Covered Drugs) Medicare GenerationRx (Employer PDP)

2018 Formulary. (List of Covered Drugs) Medicare GenerationRx (Employer PDP) Medicare GenerationRx (Employer PDP) 018 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on 07/01/018.

More information

2016 Formulary (List of Covered Drugs)

2016 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 information

Health First Health Plans 2015 Formulary (List of Covered Drugs)

Health First Health Plans 2015 Formulary (List of Covered Drugs) Updated: October 27, 2015 Florida Hospital SunSaver Plan (HMO-POS) Florida Hospital Explorer Plan (HMO-POS) Health First Health Plans 2015 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS

More information

2018 Formulary. (List of Covered Drugs) Medicare GenerationRx (Employer PDP)

2018 Formulary. (List of Covered Drugs) Medicare GenerationRx (Employer PDP) Medicare GenerationRx (Employer PDP) 018 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on 10/01/017.

More information

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) 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 information

2019 Comprehensive Preferred Drug List (List of Covered Drugs)

2019 Comprehensive Preferred Drug List (List of Covered Drugs) 2019 Comprehensive referred Drug List (List of Covered Drugs) WellCare Georgia lanning for Healthy Babies - Family lanning lease read: This document tells about the we cover in this plan. If you speak

More information

(List of Covered Drugs)

(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 information

Amerivantage Dual Coordination (HMO SNP) 2019 Formulary (List of Covered Drugs) Please read: Amerivantage Dual Coordination (HMO SNP)

Amerivantage Dual Coordination (HMO SNP) 2019 Formulary (List of Covered Drugs) Please read: Amerivantage Dual Coordination (HMO SNP) Amerivantage Dual Coordination (H SNP) 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 October, 08.

More information

Comprehensive Preferred Drug List (List of Covered Drugs)

Comprehensive Preferred Drug List (List of Covered Drugs) Comprehensive referred Drug List (List of Covered Drugs) WellCare Georgia lanning for Healthy Babies - Family lanning lease read: This document tells about the drugs we cover in this plan. If you speak

More information

2018 Formulary (List of Covered Drugs)

2018 Formulary (List of Covered Drugs) MEDICARE ADVANTAGE PLANS 2018 Formulary (List of Covered Drugs) Presbyterian Dual Plus (HMO SNP) Please Read: This document contains information about the drugs we cover in this plan. HPMS Approved Formulary

More information

Provider Partners Health Plan of Ohio (HMO SNP) 2019 Formulary (List of Covered Drugs)

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

More information

Superior Select Health Plans Formulary. (List of Covered Drugs)

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

More information

2015 MEDICARE PART D DRUG FORMULARY

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

More information

Harvard Pilgrim Health Care Stride SM Basic Rx (HMO), Stride SM Gain Rx (HMO), Stride SM Value Rx (HMO) and Stride SM Value Rx Plus (HMO)

Harvard Pilgrim Health Care Stride SM Basic Rx (HMO), Stride SM Gain Rx (HMO), Stride SM Value Rx (HMO) and Stride SM Value Rx Plus (HMO) HP19FORM05 Harvard Pilgrim Health Care Stride SM Basic Rx (HMO), Stride SM Gain Rx (HMO), Stride SM Value Rx (HMO) and Stride SM Value Rx Plus (HMO) 019 Formulary (List of Covered Drugs) PLEASE READ: THIS

More information

Anthem MediBlue Plus (HMO) 2019 Formulary (List of Covered Drugs) Please read: ,

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 February, 09. For more recent

More information

Anthem MediBlue Access (PPO) 2018 Formulary (List of Covered Drugs) Please read: , https://shop.anthem.

Anthem 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 information

Anthem MediBlue Dual Advantage (HMO SNP) 2018 Formulary (List of Covered Drugs) Please read: , https://shop.anthem.

Anthem 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 information

FORMULARY (List of Covered Drugs)

FORMULARY (List of Covered Drugs) brand new day HE A L T HC A R E YO U C A N F E E L G O O D A B O UT 019 FORMULARY (List of Covered Drugs) Brand New Day Harmony Choice Plan (HMO CSNP) 0 Brand New Day Dual Access Plan (HMO DSNP) Brand

More information

2018 Formulary (List of Covered Drugs) UCare for Seniors Prime (HMO-POS) UCare for Seniors Standard (HMO-POS)

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

More information

List of Covered Drugs (Formulary)

List of Covered Drugs (Formulary) List of Covered Drugs (Formulary) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. This formulary was updated on 7/1/2018. Member Services: 1-855-878-1784 (TTY 711)

More information

Amerivantage Select (HMO) 2019 Formulary (List of Covered Drugs) Please read: Amerivantage Select (HMO)

Amerivantage 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 information

2016 LIST OF COVERED DRUGS (FORMULARY) VNSNY CHOICE FIDA Complete (Medicare-Medicaid Plan) TTY: 711

2016 LIST OF COVERED DRUGS (FORMULARY) VNSNY CHOICE FIDA Complete (Medicare-Medicaid Plan) TTY: 711 2016 LIST OF COVERED DRUGS (FORMULARY) VNSNY CHOICE FIDA Complete (Medicare-Medicaid Plan) Formulary ID: 16512.000, Version: 15 Effective: July 01, 2016 Call CHOICE toll-free: 1-866-783-1444 TTY: 711 8

More information

Centers Plan for Medicare Advantage Care (HMO) 2018 Comprehensive Formulary

Centers Plan for Medicare Advantage Care (HMO) 2018 Comprehensive Formulary Centers Plan for Medicare Advantage Care (HMO) 08 Comprehensive Formulary This formulary was updated on 0/08 For more recent information or other questions, please contact Centers Plan for Healthy Living

More information

<2017> Formulary (List (List of of Covered Drugs)

<2017> Formulary (List (List of of Covered Drugs) < Logo (flush upper left corner /8 x /8 margins)> Anthem Access (Regional PPO) Formulary (List (List of of Covered s) Please read: This document contains information

More information

Empire MediBlue Plus (HMO) 2018 Formulary (List of Covered Drugs) Please read: ,

Empire 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 information

H0544_058, 059, 066, 067, 069

H0544_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 information

(List of Covered Drugs)

(List of Covered Drugs) Amerivantage (H) Formulary Formulary (List of Covered s) (List of Covered s) Please read: read: This This document document

More information

S5596_003, 007, 015, 019, 058

S5596_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 information

Amerivantage Classic (HMO) 2018 Formulary (List of Covered Drugs) Please read: Amerivantage Classic (HMO)

Amerivantage Classic (HMO) 2018 Formulary (List of Covered Drugs) Please read: Amerivantage Classic (HMO) Amerivantage Classic (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 September, 08. For more recent

More information

FORMULARY List of Covered Drugs

FORMULARY List of Covered Drugs Blue Cross Blue Shield of Arizona Advantage (HMO) (BCBSAZ Advantage) 017 FORMULARY List of Covered Drugs PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved

More information

CHAPTER 10 Reconstitution of Powdered Drugs

CHAPTER 10 Reconstitution of Powdered Drugs CHAPTER 10 RECONSTITUTION OF POWDERED DRUGS 89 CHAPTER 10 Reconstitution of Powdered Drugs Objectives The learner will: 1. prepare solutions from powdered drugs using directions printed on vial labels.

More information

BlueShield of Northeastern New York Formulary. List of Covered Drugs

BlueShield of Northeastern New York Formulary. List of Covered Drugs BlueShield of Northeastern New York 018 Formulary List of Covered s PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission ID 00018103,

More information

Anthem 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 (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 information

Amerivantage Classic (HMO) 2019 Formulary (List of Covered Drugs) Please read: Amerivantage Classic (HMO)

Amerivantage 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 information

2016 MEDICARE PART D DRUG FORMULARY

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

More information