AETNA BETTER HEALTH OF NEW JERSEY Formulary

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "AETNA BETTER HEALTH OF NEW JERSEY Formulary"

Transcription

1 AETNA BETTER HEALTH OF NEW JERSEY Formulary NJ

2 FORMULARY What is the Aetna Better Health of New Jersey Formulary? This is a drug list created by Aetna Better Health of New Jersey ( plan ). Aetna Better Health of New Jersey will cover drugs on this list. Some drugs may have coverage rules. If the rules for that drug are met, Aetna Better Health of New Jersey will cover the drug. Drugs must also be filled at an Aetna Better Health of New Jersey network pharmacy. Can Aetna Better Health of New Jersey s Drug List change? The plan may add or remove drugs on the list. All drug removals from the formulary will be sent to the state for review before the change is made. Utilizing members and their providers will be notified at least 60 days before a drug is removed from the formulary. All changes to the formulary will be posted on the plan s website. How do I use Aetna Better Health of New Jersey s formulary? Column #1: lists the covered drug. Brand drugs are in upper case letters (e.g., DRUG). Generics are in lower case letters (e.g., drug). Column #2: lists the brand name of the drug when a generic is covered Column #3: shows coverage rules for the drug Drugs are also grouped by the type of condition they treat. Drugs used to treat an earache are listed under the section, Ear-Nose-Throat Medications. If you know what your drug is used for, please look for that section name on the drug list. Then look under that section for your drug. How much will I pay for covered drugs? Description 1-34 day supply GENERIC 1-34 day supply BRAND day supply GENERIC (mailorder only) day supply BRAND (mailorder only) FamilyCare Plan A No Copay No Copay No Copay No Copay FamilyCare Plan B No Copay No Copay No Copay No Copay FamilyCare Plan C $1 $5 $2 $10 FamilyCare Plan D $5 $5 $10 $10 FamilyCare Plan MLTSS No Copay No Copay No Copay No Copay American Indians and Alaska Native members will NOT have a copay. Page 1

3 FORMULARY What are some types of coverage rules? Prior Approval (): This means your doctor will need to get approval from the plan first before the drug can be filled at the pharmacy. If it is not approved, the plan will not cover the drug. Quantity Level Limits (QLL): This means there is a limit on the amount of drug the plan will cover. For example, the plan provides 60 pills in 30 days for some drugs. Step Therapy (ST): This means you may need to try certain drugs first to treat your condition. After the first drug is tried, the plan will then cover the other drug for that same condition. For example, Drug A and Drug B may treat your condition. The plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, then Drug B will be covered. What if my drug is not on Aetna Better Health of New Jersey s formulary? First, please call your doctor and ask if your drug is covered. If the plan does not cover the drug, then: Ask your doctor for a similar drug that is covered. Your doctor can ask the plan to cover your drug through the prior approval process. What are generic drugs? Aetna Better Health covers both brand and generic drugs. Generic drugs cost less and are approved by the Food and Drug Administration (FDA). Are Over-The-Counter () drugs covered? The plan will cover drugs on the formulary. Some drugs may have coverage rules. If the rules for that drug are met, the plan will cover the drug. Like other drugs, drugs need a prescription from a doctor if they are to be covered by the plan. Page 2

4 Qué es el formulario de Aetna Better Health of New Jersey? Es una lista de medicamentos creada por Aetna Better Health of New Jersey (el plan ). Aetna Better Health of New Jersey ofrece cobertura para los medicamentos de esta lista. Es posible que para algunos medicamentos se apliquen reglas de cobertura. Si se cumplen las reglas para esos medicamentos, Aetna Better Health of New Jersey los cubrirá. Además, los medicamentos deben adquirirse en una farmacia de la red de Aetna Better Health of New Jersey. Puede cambiar la lista de medicamentos de Aetna Better Health of New Jersey? El plan puede agregar o quitar medicamentos de la lista. Todas las eliminaciones de medicamentos del formulario se enviarán al estado, donde se revisarán antes de que se realice el cambio. Los miembros y proveedores que utilizan el formulario recibirán un aviso como mínimo 60 días antes de que se elimine un medicamento del formulario. Encontrará todos los cambios del formulario en el sitio en Internet del plan. Cómo utilizo el formulario de Aetna Better Health of New Jersey? Columna Nº 1: enumera los medicamentos cubiertos. Los medicamentos de marca aparecen en mayúscula (por ejemplo, MEDICAMENTO); los genéricos aparecen en minúscula (por ejemplo, medicamento). Columna Nº 2: enumera los medicamentos de marca cuando una opción genérica está cubierta. Columna Nº 3: muestra las reglas de cobertura de los medicamentos. Los medicamentos también están agrupados según el tipo de condición que tratan. Por ejemplo, los medicamentos que se usan para tratar un dolor de oído figuran en la sección, Ear Nose-Throat Medications. Si sabe para qué se usa el medicamento que usted toma, busque el nombre de esa sección en la lista de medicamentos y luego busque el medicamento en esa sección. Cuánto pagaré por los medicamentos cubiertos? Descripción Suministro para 1-34 días (GENÉRICOS) Suministro para 1-34 días (DE MARCA) Suministro para días (GENÉRICOS) Suministro para días (DE MARCA) FamilyCare Plan A Sin copago Sin copago Sin copago Sin copago FamilyCare Plan B Sin copago Sin copago Sin copago Sin copago FamilyCare Plan C $1 $5 $2 $10 FamilyCare Plan D $5 $5 $10 $10 FamilyCare Plan MLTSS Sin copago Sin copago Sin copago Sin copago Page 3

5 Los miembros que sean indígenas americanos o nativos de Alaska NO tienen copago. Cuáles son algunos de los tipos de reglas de cobertura? Aprobación previa (): significa que su médico primero deberá obtener la aprobación del plan antes de que se pueda adquirir el medicamento en la farmacia. Si no se aprueba, el plan no cubrirá el medicamento. Límites de cantidad (QLL): significa que el plan cubre hasta una cierta cantidad del medicamento. Por ejemplo, en el caso de algunos medicamentos, el plan cubre 60 píldoras en 30 días. Terapia escalonada (ST): significa que posiblemente primero deba probar ciertos medicamentos para tratar su condición. Después de probar el primer medicamento, el plan cubrirá el otro medicamento para la misma condición. Por ejemplo, el Medicamento A y el Medicamento B pueden tratar su condición. Es posible que el plan no cubra el Medicamento B a menos que usted primero pruebe el Medicamento A. Si el Medicamento A no funciona en su caso, entonces se cubrirá el Medicamento B. Qué sucede si el medicamento que tomo no está incluido en el formulario de Aetna Better Health of New Jersey? Primero, llame a su médico y pregúntele si su medicamento está cubierto. Si el plan no lo cubre, usted tiene dos opciones: Pida a su médico un medicamento similar que esté cubierto. Su médico puede solicitar que el plan cubra el medicamento a través del proceso de aprobación previa. Qué son los medicamentos genéricos? Aetna Better Health of New Jersey cubre tanto medicamentos de marca como genéricos. Los medicamentos genéricos cuestan menos y están aprobados por la Administración de Drogas y Alimentos (FDA). Los medicamentos de venta libre están cubiertos? El plan cubrirá los medicamentos de venta libre que figuren en el formulario. Es posible que para algunos medicamentos de venta libre se apliquen reglas de cobertura. Si se cumplen las reglas para esos medicamentos de venta libre, el plan los cubrirá. Al igual que con otros medicamentos, se requiere una receta del médico para que el plan brinde cobertura para los medicamentos de venta libre. Page 4

6 Aetna Better Health New Jersey Table of Contents *ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS*...3 *AMINOGLYCOSIDES*... 5 *ANALGESICS - ANTI-INFLAMMATORY*... 5 *ANALGESICS - NONNARCOTIC*...7 *ANALGESICS - OPIOID*... 8 *ANDROGENS-ANABOLIC* *ANORECTAL AGENTS*...11 *ANTACIDS*...12 *ANTHELMINTICS* *ANTIANGINAL AGENTS* *ANTIANXIETY AGENTS*...13 *ANTIARRHYTHMICS* *ANTIASTHMATIC AND BRONCHODILATOR AGENTS* *ANTICOAGULANTS* *ANTICONVULSANTS*...18 *ANTIDEPRESSANTS*...19 *ANTIDIABETICS* *ANTIDIARRHEALS*...25 *ANTIDOTES AND SPECIFIC ANTAGONISTS*...25 *ANTIDOTES* *ANTIEMETICS* *ANTIFUNGALS*...26 *ANTIHISTAMINES* *ANTIHYPERLIPIDEMICS*...28 *ANTIHYPERTENSIVES* *ANTI-INFECTIVE AGENTS - MISC.* *ANTIMALARIALS*...33 *ANTIMYASTHENIC AGENTS* *ANTIMYCOBACTERIAL AGENTS* *ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES*...33 *ANTIRKINSON AGENTS*...35 *ANTIPSYCHOTICS/ANTIMANIC AGENTS* *ANTISEPTICS & DISINFECTANTS*...38 *ANTIVIRALS*...38 *ASSORTED CLASSES* *BETA BLOCKERS* *CALCIUM CHANNEL BLOCKERS* *CARDIOTONICS* *CARDIOVASCULAR AGENTS - MISC.* *CEPHALOSPORINS*...46 *CHEMICALS*...47 *CONTRACEPTIVES*...47 *CORTICOSTEROIDS* *COUGH/COLD/ALLERGY*

7 *DERMATOLOGICALS* *DIAGNOSTIC PRODUCTS*...66 *DIGESTIVE AIDS*...66 *DIURETICS*...66 *ENDOCRINE AND METABOLIC AGENTS - MISC.*...67 *ESTROGENS*...68 *FLUOROQUINOLONES* *GASTROINTESTINAL AGENTS - MISC.*...69 *GENITOURINARY AGENTS - MISCELLANEOUS* *GOUT AGENTS*...71 *HEMATOLOGICAL AGENTS - MISC.* *HEMATOPOIETIC AGENTS*...72 *HEMOSTATICS*...74 *HETITIS C AGENT - COMBINATIONS*** *HYPNOTICS* *LAXATIVES* *MACROLIDES*...77 *MEDICAL DEVICES*...78 *MIGRAINE PRODUCTS*...85 *MINERALS & ELECTROLYTES*...85 *MOUTH/THROAT/DENTAL AGENTS*...88 *MULTIVITAMINS*...89 *MUSCULOSKELETAL THERAPY AGENTS*...94 *NASAL AGENTS - SYSTEMIC AND TOPICAL* *NEPRILYSIN INHIB (ARNI)-ANGIOTENSIN II RECEPT ANTAG COMB*** *NEUROMUSCULAR AGENTS* *NUTRIENTS*...96 *OPHTHALMIC AGENTS*...96 *OTIC AGENTS* *PENICILLINS* *PHARMACEUTICAL ADJUVANTS* *POTASSIUM REMOVING AGENTS*** *PROGESTINS* *PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.* *SODIUM-GLUCOSE CO-TRANSPORTER 2 INHIBITOR-BIGUANIDE COMB*** *SULFONAMIDES* *TETRACYCLINES* *THYROID AGENTS* *ULCER DRUGS* *URINARY ANTI-INFECTIVES* *URINARY ANTISSMODICS* *VAGINAL PRODUCTS* *VASOPRESSORS* *VITAMINS*

8 Aetna Better Health New Jersey lowercase italics = Generic drugs UPPERCASE BOLD = Brand name drugs Restrictions = QLL: 1 capsule per day for under age 12 and 2 capsules per day for age 12 and older = Maximum qty of 360 tablets per 365 days (6 months of therapy per year) = QLL AL = Age Limit Applies F = Female Only M = Male Only = Over the Counter = Prior Authorization Required QLL = Quantity Level Limit Applies ST = Step Therapy Required Drug Name Reference Restrictions *ADHD/ANTI NARCOLEPSY/ANTI OBESITY/ANOREXIANTS* *Adhd Agent - Selective Alpha Adrenergic Agonists*** guanfacine hcl er oral tablet extended release 24 hour 1, 2, 3 guanfacine hcl er oral tablet extended release 24 hour 4 *Adhd Agent - Selective Norepinephrine Reuptake Inhibitor*** STRATTERA ORAL CAPSULE 10 MG, 100 MG, 18 MG, 25 MG, 40 MG, 60 MG, 80 MG Intuniv Intuniv QLL (30 EA per 30 days); AL (Min 6 Years) QLL (30 Tablets per 30 days); AL (Min 6 Years) ST; QLL (30 Capsules per 30 days) 3

9 *Amphetamine Mixtures*** amphetamine-dextroamphet er oral capsule extended release 24 hour 10, 15, 20, 25, 5 amphetamine-dextroamphet er oral capsule extended release 24 hour 30 amphetamine-dextroamphetamine oral tablet 10, 12.5, 15, 20, 5, 7.5 amphetamine-dextroamphetamine oral tablet 30 *Amphetamines*** DEXEDRINE ORAL TABLET 10 MG, 5 MG dextroamphetamine sulfate er oral capsule extended release 24 hour 10, 15 dextroamphetamine sulfate er oral capsule extended release 24 hour 5 dextroamphetamine sulfate oral tablet 10 dextroamphetamine sulfate oral tablet 5 *Analeptics*** caffeine citrate oral solution 20 /ml, 60 /3ml *Stimulants - Misc.*** dexmethylphenidate hcl er oral capsule extended release 24 hour 10, 15, 20, 25, 30, 35, 40, 5 dexmethylphenidate hcl oral tablet 10, 2.5, 5 METADATE ER ORAL TABLET EXTENDED RELEASE 20 MG Adderall XR Adderall XR Adderall Adderall Dextroamphetamine Sulfate Dexedrine Dexedrine Zenzedi Dexedrine Focalin XR Focalin Methylphenidate HCl ER QLL (30 Capsules per 30 days); AL (Min 6 Years and Max 18 Years) QLL: 1 capsule per day for under age 12 and 2 capsules per day for age 12 and older; QLL (60 EA per 30 days); AL (Min 6 Years and Max 18 Years) QLL (90 Tablets per 30 days); AL (Min 6 Years and Max 18 Years) QLL (60 Tablets per 30 days); AL (Min 6 Years and Max 18 Years) QLL (180 EA per 30 days); AL (Min 6 Years and Max 18 Years) QLL (120 EA per 30 days); AL (Min 6 Years and Max 18 Years) QLL (90 EA per 30 days); AL (Min 6 Years and Max 18 Years) QLL (180 EA per 30 days); AL (Min 6 Years and Max 18 Years) QLL (180 EA per 30 days); AL (Min 6 Years and Max 18 Years) QLL (30 EA per 30 days); AL (Min 6 Years and Max 18 Years) QLL (60 Tablets per 30 days); AL (Min 6 Years and Max 18 Years) QLL (90 EA per 30 days); AL (Min 6 Years and Max 18 Years) 4

10 methylphenidate hcl er (cd) oral capsule extended release 10, 20, 30, 40, 50, 60 methylphenidate hcl er (la) oral capsule extended release 24 hour 20, 40 methylphenidate hcl er (la) oral capsule extended release 24 hour 30 methylphenidate hcl er oral tablet extended release 10 methylphenidate hcl er oral tablet extended release 18, 27, 54 methylphenidate hcl er oral tablet extended release 20 methylphenidate hcl er oral tablet extended release 36 methylphenidate hcl oral solution 10 /5ml, 5 /5ml methylphenidate hcl oral tablet 10, 20, 5 Metadate CD Ritalin LA Ritalin LA Concerta Metadate ER Concerta Methylin Ritalin QLL (30 Capsules per 30 days); AL (Min 6 Years and Max 18 Years) QLL (30 EA per 30 days); AL (Min 6 Years and Max 18 Years) QLL (60 EA per 30 days); AL (Min 6 Years and Max 18 Years) QLL (90 EA per 30 days); AL (Min 6 Years and Max 18 Years) QLL (30 Tablets per 30 days); AL (Min 6 Years and Max 18 Years) QLL (90 EA per 30 days); AL (Min 6 Years and Max 18 Years) QLL (60 Tablets per 30 days); AL (Min 6 Years and Max 18 Years) QLL (900 ML per 30 days); AL (Min 6 Years and Max 18 Years) QLL (90 Tablets per 30 days); AL (Min 6 Years and Max 18 Years) modafinil oral tablet 100, 200 Provigil ; QLL (30 EA per 30 days) *AMINOGLYCOSIDES* *Aminoglycosides*** neomycin sulfate oral tablet 500 paromomycin sulfate oral capsule 250 *ANALGESICS - ANTI INFLAMMATORY* *Anti-Tnf-Alpha - Monoclonoal Antibodies*** HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.2ML, 20 MG/0.4ML, 40 MG/0.8ML 5

11 *Cyclooxygenase 2 (Cox-2) Inhibitors*** celecoxib oral capsule 100, 200, 400, 50 CeleBREX ST *Gold Compounds*** RIDAURA ORAL CAPSULE 3 MG *Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** childrens ibuprofen 100 oral suspension 100 /5ml Childrens Motrin childrens ibuprofen oral suspension 40 /ml Medi-Profen cvs naproxen sodium oral tablet 220 Aleve diclofenac potassium oral tablet 50 diclofenac sodium er oral tablet extended release 24 hour 100 diclofenac sodium oral tablet delayed release 25, 50, 75 etodolac er oral tablet extended release 24 hour 400, 500, 600 etodolac oral capsule 200, 300 etodolac oral tablet 400 Lodine etodolac oral tablet 500 fenoprofen calcium oral tablet 600 flurbiprofen oral tablet 100, 50 ibuprofen junior strength oral tablet chewable Advil Junior Strength 100 ibuprofen oral capsule 200 Advil Migraine ibuprofen oral tablet 200 Wal-Profen ibuprofen oral tablet 400, 600, 800 indomethacin er oral capsule extended release 75 indomethacin oral capsule 25, 50 ketoprofen er oral capsule extended release 24 hour 200 ketoprofen oral capsule 50, 75 ketorolac tromethamine oral tablet 10 QLL (20 EA per 30 days) meclofenamate sodium oral capsule 100, 50 meloxicam oral tablet 15, 7.5 Mobic nabumetone oral tablet 500, 750 6

12 naproxen dr oral tablet delayed release 375, 500 EC-Naprosyn naproxen oral suspension 125 /5ml Naprosyn naproxen oral tablet 250, 500 Naprosyn naproxen oral tablet 375 naproxen sodium oral capsule 220 Aleve naproxen sodium oral tablet 275 oxaprozin oral tablet 600 Daypro piroxicam oral capsule 10, 20 Feldene sm ibuprofen jr oral tablet 100 Advil Junior Strength sulindac oral tablet 150, 200 tolmetin sodium oral capsule 400 tolmetin sodium oral tablet 200, 600 *Pyrimidine Synthesis Inhibitors*** leflunomide oral tablet 10, 20 Arava *Soluble Tumor Necrosis Factor Receptor Agents*** ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML, 50 MG/ML ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR 50 MG/ML *ANALGESICS - NONNARCOTIC* *Analgesics Other*** ACEPHEN RECTAL SUPPOSITORY 325 MG acetaminophen er oral tablet extended release Tylenol 8 Hour 650 acetaminophen extra strength oral liquid 500 /15ml Chloraseptic Sore Throat acetaminophen oral elixir 160 /5ml Medi-Tabs Childrens acetaminophen oral liquid 160 /5ml Little Remedies for Fever acetaminophen oral solution 160 /5ml acetaminophen oral suspension 160 /5ml Mapap Childrens acetaminophen oral tablet 325 Tylenol acetaminophen oral tablet 500 Medi-Tabs Extra Strength acetaminophen oral tablet chewable 80 Childrens Medi-Tabs acetaminophen rectal suppository 120, 650 Acephen 7

13 childrens acetaminophen oral tablet dispersible 80 Mapap Childrens non-aspirin jr strength oral tablet chewable 160 Medi-Tabs Junior Strength TRIAMINIC FEVER REDUCER ORAL SYRUP 160 MG/5ML *Analgesics-Sedatives*** butalbital-apap-caffeine oral capsule Zebutal QLL (180 Capsules per 30 days) butalbital-apap-caffeine oral tablet Esgic QLL (180 Tablets per 30 days) butalbital-aspirin-caffeine oral capsule Fiorinal QLL (180 Tablets per 30 days) ZEBUTAL ORAL CAPSULE MG Butalbital-AP-Caffeine QLL (180 Capsules per 30 days) *Salicylate Combinations*** choline & mag trisalicylate oral tablet 1000 choline-mag trisalicylate oral liquid 500 /5ml effervescent pain relief oral tablet effervescent Alka-Seltzer 325 *Salicylates*** aspirin ec oral tablet delayed release 325 Ecotrin aspirin oral tablet 325 Bayer Advanced Aspirin Reg St aspirin oral tablet chewable 81 Bayer Low Dose aspirin oral tablet delayed release 81 Aspir-Low aspirtab maximum strength oral tablet 500 Bayer Aspirin Extra Strength diflunisal oral tablet 500 salsalate oral tablet 500, 750 Disalcid *ANALGESICS - OPIOID* *Codeine Combinations*** acetaminophen-codeine #2 oral tablet acetaminophen-codeine #3 oral tablet Tylenol with Codeine #3 acetaminophen-codeine #4 oral tablet Tylenol with Codeine #4 acetaminophen-codeine oral solution /5ml 8

14 acetaminophen-codeine oral tablet acetaminophen-codeine oral tablet Tylenol with Codeine #4 ASCOMP-CODEINE ORAL CAPSULE MG Butalbital-ASA-Caff-Codeine QLL (180 Capsules per 30 days) butalbital-apap-caff-cod oral capsule QLL (180 Capsules per 30 days) butalbital-asa-caff-codeine oral capsule Fiorinal/Codeine #3 QLL (180 Capsules per 30 days) *Hydrocodone Combinations*** hydrocodone-acetaminophen oral solution /5ml, /10ml, Hycet /15ml hydrocodone-acetaminophen oral tablet , 5-325, Lortab hydrocodone-ibuprofen oral tablet , Ibudone QLL (240 Tablets per 30 days) hydrocodone-ibuprofen oral tablet QLL (240 Tablets per 30 days) *Opioid Agonists*** codeine sulfate oral tablet 15, 30, 60 QLL (30 Tablets per 30 days) fentanyl citrate buccal lozenge on a handle 1200 mcg, 1600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg Actiq QLL (90 Lozenges per 30 days) fentanyl transdermal patch 72 hour 100 mcg/hr Duragesic-100 fentanyl transdermal patch 72 hour 12 mcg/hr Duragesic-12 fentanyl transdermal patch 72 hour 25 mcg/hr Duragesic-25 ; QLL (10 Patches per 30 days) ; QLL (10 Patches per 30 days) ; QLL (10 Patches per 30 days) fentanyl transdermal patch 72 hour 37.5 mcg/hr, 87.5 mcg/hr fentanyl transdermal patch 72 hour 50 mcg/hr Duragesic-50 ; QLL (10 Patches per 30 days) fentanyl transdermal patch 72 hour 75 mcg/hr Duragesic-75 ; QLL (10 Patches per 30 days) hydromorphone hcl oral tablet 2, 4 Dilaudid QLL (180 Tablets per 30 days) hydromorphone hcl oral tablet 8 Dilaudid QLL (120 Tablets per 30 days) hydromorphone hcl rectal suppository 3 methadone hcl oral concentrate 10 /ml Methadose ; QLL (1240 ml per 30 days) methadone hcl oral solution 10 /5ml ; QLL (30 ml per 30 days) methadone hcl oral solution 5 /5ml ; QLL (1200 ml per 30 days) 9

15 methadone hcl oral tablet 10, 5 Dolophine ; QLL (240 Tablets per 30 days) methadone hcl oral tablet soluble 40 Methadose morphine sulfate (concentrate) oral solution 100 /5ml, 20 /ml morphine sulfate er beads oral capsule extended release 24 hour 30, 60 morphine sulfate er oral capsule extended release 24 hour 10, 100, 20, 30, 50, 60, 80 Kadian ; QLL (60 Capsules per 30 days) morphine sulfate er oral tablet extended release 100, 15, 200, 30, 60 MS Contin ; QLL (60 Tablets per 30 days) morphine sulfate oral solution 10 /5ml, 20 /5ml morphine sulfate oral tablet 15, 30 QLL (60 Tablets per 30 days) morphine sulfate rectal suppository 10, 20, 30, 5 oxycodone hcl oral capsule 5 QLL (240 Tablets per 30 days) oxycodone hcl oral concentrate 100 /5ml QLL (3600 per 30 days) oxycodone hcl oral solution 5 /5ml QLL (1200 per 30 days) oxycodone hcl oral tablet 10, 20 QLL (180 Tablets per 30 days) oxycodone hcl oral tablet 15, 30 Roxicodone QLL (180 Tablets per 30 days) oxycodone hcl oral tablet 5 Roxicodone QLL (240 Tablets per 30 days) OXYCONTIN ORAL TABLET ER 12 HOUR ABUSE-DETERRENT 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG oxymorphone hcl er oral tablet extended release 12 hour 10, 15, 20, 30, 40, 5, 7.5 OxyCODONE HCl ER ; ST; QLL (90 EA per 30 days) ; QLL (2 EA per 1 day) oxymorphone hcl oral tablet 10, 5 Opana ST; QLL (2 EA per 1 day) tramadol hcl oral tablet 50 Ultram ; QLL (240 Tablets per 30 days) *Opioid Combinations*** oxycodone-acetaminophen oral tablet , , 5-325, Endocet QLL (240 Tablets per 30 days) oxycodone-aspirin oral tablet QLL (240 Tablets per 30 days) *Opioid Partial Agonists*** buprenorphine hcl sublingual tablet sublingual 2, 8 ; QLL (480 per 30 days) buprenorphine hcl-naloxone hcl sublingual tablet sublingual 2-0.5, 8-2 ; QLL (480 per 30 days) 10

16 butorphanol tartrate nasal solution 10 /ml QLL (1 Bottle per 30 days) SUBOXONE SUBLINGUAL FILM 12-3 MG, MG, 4-1 MG, 8-2 MG *Tramadol Combinations*** tramadol-acetaminophen oral tablet *ANDROGENS-ANABOLIC* *Androgens*** danazol oral capsule 100, 200, 50 testosterone cypionate intramuscular solution 100 /ml, 200 /ml testosterone enanthate intramuscular solution 200 /ml testosterone transdermal gel 10 /act (2%) Ultracet Depo-Testosterone Fortesta testosterone transdermal gel 12.5 /act (1%) Vogelxo Pump testosterone transdermal gel 25 /2.5gm (1%), 50 /5gm (1%) *ANORECTAL AGENTS* *Intrarectal Steroids*** CORTIFOAM RECTAL FOAM 10 % hydrocortisone rectal enema 100 /60ml *Nitrate Vasodilating Agents*** RECTIV RECTAL OINTMENT 0.4 % *Rectal Anesthetic/Steroids*** LIDAZONE HC RECTAL CREAM % lidocaine-hydrocortisone ace rectal cream % lidocaine-hydrocortisone ace rectal kit %, 3-1 % PROCTOFOAM HC RECTAL FOAM 1-1 % *Rectal Steroids*** PROCTOSOL HC RECTAL CREAM 2.5 % PROCTOZONE-HC RECTAL CREAM 2.5 % AndroGel Cortenema Lidocaine-Hydrocortisone Ace LidaZone HC Hydrocortisone Hydrocortisone ; QLL (240 Tablets per 30 days) ; QLL (10 ML per 90 days) ; QLL (2 canisters per 30 days) ; QLL (4 canisters per 30 days) ; QLL (30 GM per 30 days) 11

17 *ANTACIDS* *Antacid & Simethicone*** aluminum-magnesium-simethicone oral suspension /5ml Flanax Heartburn Relief antacid/simethicone ds oral suspension /5ml Maalox Max cvs antacid & anti-gas oral tablet chewable Maalox Advanced Max St DI-GEL ORAL SUSPENSION MG/5ML *Antacid Combinations*** ACID GONE ORAL SUSPENSION GNP Foaming Antacid MG/15ML heartburn antacid ex st oral tablet chewable Acid Gone *Antacids - Bicarbonate*** sodium bicarbonate oral tablet 325, 650 *Antacids - Calcium Salts*** calcium antacid ultra strength oral tablet chewable 1000 Tums Ultra 1000 calcium carbonate antacid oral tablet chewable 500 Cal-Gest Antacid calcium carbonate antacid oral tablet chewable 750 Tums Kids childrens pepto oral tablet chewable 400 Childrens Soothe *Antacids - Magnesium Salts*** magnesium oxide oral tablet 250, 400 magnesium oxide oral tablet 420 Maox *ANTHELMINTICS* *Anthelmintics*** ALBENZA ORAL TABLET 200 MG reeses pinworm medicine oral suspension 144 /ml reeses pinworm medicine oral tablet 180 *ANTIANGINAL AGENTS* *Nitrates*** isosorbide dinitrate er oral tablet extended release 40 12

18 isosorbide dinitrate oral tablet 10, 20, 30 isosorbide dinitrate oral tablet 5 Isordil Titradose isosorbide mononitrate er oral tablet extended release 24 hour 120, 30, 60 isosorbide mononitrate oral tablet 10, 20 MINITRAN TRANSDERMAL TCH 24 HOUR 0.1 MG/HR, 0.2 MG/HR, 0.4 Nitroglycerin MG/HR, 0.6 MG/HR NITRO-BID TRANSDERMAL OINTMENT 2 % nitroglycerin er oral capsule extended release Nitro-Time 2.5, 6.5, 9 nitroglycerin sublingual tablet sublingual 0.3, 0.4, 0.6 Nitrostat nitroglycerin transdermal patch 24 hour 0.1 /hr, 0.4 /hr Nitro-Dur nitroglycerin transdermal patch 24 hour 0.2 /hr, 0.6 /hr Minitran NITRO-TIME ORAL CAPSULE EXTENDED RELEASE 2.5 MG, 6.5 MG, 9 Nitroglycerin ER MG *ANTIANXIETY AGENTS* *Antianxiety Agents - Misc.*** buspirone hcl oral tablet 10, 15, 5, 7.5 QLL (90 Tablets per 30 days) hydroxyzine hcl oral syrup 10 /5ml hydroxyzine hcl oral tablet 10, 25, 50 hydroxyzine pamoate oral capsule 100 hydroxyzine pamoate oral capsule 25, 50 Vistaril meprobamate oral tablet 200, 400 *Benzodiazepines*** alprazolam er oral tablet extended release 24 hour 0.5, 1, 2, 3 Xanax XR ALPRAZOLAM INTENSOL ORAL CONCENTRATE 1 MG/ML alprazolam oral tablet 0.25, 0.5, 1, 2 Xanax 13

19 alprazolam oral tablet dispersible 0.25, 0.5, 1, 2 alprazolam xr oral tablet extended release 24 hour 0.5, 1, 2, 3 Xanax XR chlordiazepoxide hcl oral capsule 10, 25, 5 clorazepate dipotassium oral tablet 15, 3.75 clorazepate dipotassium oral tablet 7.5 Tranxene-T DIAZEM INTENSOL ORAL CONCENTRATE 5 MG/ML Diazepam diazepam oral solution 1 /ml diazepam oral tablet 10, 2, 5 Valium lorazepam injection solution 2 /ml Ativan LORAZEM INTENSOL ORAL CONCENTRATE 2 MG/ML LORazepam lorazepam oral concentrate 2 /ml LORazepam Intensol lorazepam oral tablet 0.5, 1, 2 Ativan oxazepam oral capsule 10, 15, 30 *ANTIARRHYTHMICS* *Antiarrhythmics Type I-A*** disopyramide phosphate oral capsule 100, Norpace 150 quinidine gluconate er oral tablet extended release 324 quinidine sulfate oral tablet 200, 300 *Antiarrhythmics Type I-B*** mexiletine hcl oral capsule 150, 200, 250 *Antiarrhythmics Type I-C*** flecainide acetate oral tablet 100, 150, 50 propafenone hcl er oral capsule extended release 12 hour 225, 325, 425 Rythmol SR propafenone hcl oral tablet 150, 225, 300 *Antiarrhythmics Type Iii*** amiodarone hcl oral tablet 200, 400 Pacerone MULTAQ ORAL TABLET 400 MG 14

20 *ANTIASTHMATIC AND BRONCHODILATOR AGENTS* *Adrenergic Combinations*** ANORO ELLIPTA INHALATION AEROSOL POWDER BREATH QLL (1 EA per 30 days) ACTIVATED MCG/INH BREO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED MCG/INH, QLL (1 EA per 30 days) MCG/INH COMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION MCG/ACT DULERA INHALATION AEROSOL MCG/ACT, MCG/ACT ipratropium-albuterol inhalation solution (3) /3ml STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION MCG/ACT ST; QLL (1 ea per 30 days) *Anti-Inflammatory Agents*** cromolyn sodium inhalation nebulization solution 20 /2ml *Beta Adrenergics*** albuterol sulfate inhalation nebulization solution (2.5 /3ml) 0.083%, (5 /ml) 0.5% QLL (375 ml per 30 days) albuterol sulfate inhalation nebulization solution 0.63 /3ml, 1.25 /3ml albuterol sulfate oral syrup 2 /5ml albuterol sulfate oral tablet 2, 4 ARCAPTA NEOHALER INHALATION CAPSULE 75 MCG levalbuterol tartrate inhalation aerosol 45 mcg/act metaproterenol sulfate oral syrup 10 /5ml metaproterenol sulfate oral tablet 10, 20 STRIVERDI RESPIMAT INHALATION AEROSOL SOLUTION 2.5 MCG/ACT terbutaline sulfate oral tablet 2.5, 5 VENTOLIN HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACT Xopenex HFA ST; QLL (375 ML per 30 days); AL (Max 18 Years) ST; QLL (2 INH per 30 days) QLL (2 Inhalers per 30 days) 15

21 *Bronchodilators - Anticholinergics*** ATROVENT HFA INHALATION AEROSOL SOLUTION 17 MCG/ACT INCRUSE ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 62.5 MCG/INH ipratropium bromide inhalation solution 0.02 % *Leukotriene Receptor Antagonists*** montelukast sodium oral packet 4 Singulair ; QLL (30 Packets per 30 days); AL (Max 2 Years) montelukast sodium oral tablet 10 Singulair QLL (30 Tablets per 30 days) montelukast sodium oral tablet chewable 4, 5 Singulair QLL (30 Tablets per 30 days) zafirlukast oral tablet 10, 20 Accolate ST; QLL (60 Tablets per 30 days) *Steroid Inhalants*** budesonide inhalation suspension 0.25 /2ml, 0.5 /2ml Pulmicort ; QLL (120 ml per 30 days) FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/BLIST, 250 MCG/BLIST, 50 MCG/BLIST PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED 180 MCG/ACT, 90 QLL (1 Inhaler per 30 days) MCG/ACT QVAR INHALATION AEROSOL SOLUTION 40 MCG/ACT, 80 MCG/ACT *Xanthines*** theophylline er oral tablet extended release 12 Theochron hour 100, 200, 300 theophylline er oral tablet extended release 12 hour 450 theophylline er oral tablet extended release 24 hour 400, 600 theophylline oral solution 80 /15ml 16

22 *ANTICOAGULANTS* *Coumarin Anticoagulants*** JANTOVEN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 Warfarin Sodium MG, 7.5 MG warfarin sodium oral tablet 1, 2, 2.5, 3, 4, 5, 6 Jantoven warfarin sodium oral tablet 10, 7.5 Coumadin *Direct Factor Xa Inhibitors*** ELIQUIS ORAL TABLET 2.5 MG, 5 MG XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG XARELTO STARTER CK ORAL TABLET THERAPY CK 15 & 20 MG *Heparins And Heparinoid-Like Agents*** heparin sodium (porcine) injection solution 1000 unit/ml, unit/ml, unit/ml, 5000 unit/ml heparin sodium (porcine) pf injection solution 5000 unit/0.5ml sash kit intravenous kit unit/ml-% *Low Molecular Weight Heparins*** enoxaparin sodium subcutaneous solution 100 /ml, 120 /0.8ml, 150 /ml, 30 /0.3ml, 40 /0.4ml, 60 /0.6ml, 80 Lovenox QLL (42 syringes per 180 days) /0.8ml FRAGMIN SUBCUTANEOUS SOLUTION UNIT/ML, UNIT/0.5ML, UNIT/0.6ML, QLL (21 syringes per 180 days) UNT/0.72ML, 2500 UNIT/0.2ML, 5000 UNIT/0.2ML FRAGMIN SUBCUTANEOUS SOLUTION 7500 UNIT/0.3ML QLL (21 syringes per 180 Days) *Synthetic Heparinoid-Like Agents*** fondaparinux sodium subcutaneous solution ; QLL (21 SYRINGES per 10 /0.8ml, 2.5 /0.5ml, 5 /0.4ml, 7.5 Arixtra 180 days) /0.6ml 17

23 *Thrombin Inhibitors - Selective Direct & Reversible*** PRADAXA ORAL CAPSULE 150 MG, 75 MG *ANTICONVULSANTS* *Anticonvulsants - Benzodiazepines*** clonazepam oral tablet 0.5, 1, 2 KlonoPIN clonazepam oral tablet dispersible 0.125, 0.25, 0.5, 1, 2 diazepam rectal gel 10, 20 Diastat AcuDial QLL (2 EA per 30 days) diazepam rectal gel 2.5 Diastat Pediatric QLL (2 EA per 30 days) *Anticonvulsants - Misc.*** carbamazepine er oral capsule extended release 12 hour 100, 200, 300 Carbatrol QLL (120 Tablets per 30 days) carbamazepine er oral tablet extended release 12 hour 100 TEGretol-XR ; QLL: 300ea per 30 days for ages 6-15, 360ea per 30 days for age 16 and older carbamazepine er oral tablet extended release TEGretol-XR 12 hour 200, 400 QLL (120 Tablets per 30 days) carbamazepine oral suspension 100 /5ml TEGretol carbamazepine oral tablet 200 Epitol carbamazepine oral tablet chewable 100 gabapentin oral capsule 100, 300, 400 Neurontin QLL (6 EA per 1 day) gabapentin oral solution 250 /5ml Neurontin QLL (180 ML per 30 days) gabapentin oral tablet 600 Neurontin QLL (6 EA per 1 day) gabapentin oral tablet 800 Neurontin QLL (4.5 tablet per 1 day) lamotrigine oral tablet 100, 150, 200, 25 LaMICtal lamotrigine oral tablet chewable 25, 5 LaMICtal levetiracetam oral solution 100 /ml Keppra levetiracetam oral tablet 1000, 250, 500, 750 Keppra oxcarbazepine oral suspension 300 /5ml Trileptal oxcarbazepine oral tablet 150, 300, 600 Trileptal primidone oral tablet 250, 50 Mysoline topiramate oral capsule sprinkle 15, 25 Topamax Sprinkle QLL (120 Capsules per 30 days) topiramate oral tablet 100, 200, 25, Topamax 50 QLL (120 Tablets per 30 days) 18

24 zonisamide oral capsule 100, 25 Zonegran QLL (180 Capsules per 30 days) zonisamide oral capsule 50 QLL (180 Capsules per 30 days) *Carbamates*** felbamate oral suspension 600 /5ml Felbatol felbamate oral tablet 400, 600 Felbatol *Gaba Modulators*** GABITRIL ORAL TABLET 12 MG, 16 MG QLL (60 Tablets per 30 days) tiagabine hcl oral tablet 2, 4 Gabitril QLL (60 Tablets per 30 days) *Hydantoins*** PHENYTOIN INFATABS ORAL TABLET Phenytoin CHEWABLE 50 MG phenytoin oral suspension 125 /5ml Dilantin phenytoin oral tablet chewable 50 Dilantin Infatabs phenytoin sodium extended oral capsule 100 Dilantin *Succinimides*** CELONTIN ORAL CAPSULE 300 MG ethosuximide oral capsule 250 Zarontin ethosuximide oral solution 250 /5ml Zarontin *Valproic Acid*** divalproex sodium er oral tablet extended release 24 hour 250, 500 Depakote ER divalproex sodium oral tablet delayed release 125, 250, 500 Depakote valproic acid oral capsule 250 Depakene valproic acid oral solution 250 /5ml Depakene *ANTIDEPRESSANTS* *Alpha-2 Receptor Antagonists (Tetracyclics)*** mirtazapine oral tablet 15 Remeron QLL (30 Tablets per 30 days) mirtazapine oral tablet 30 Remeron QLL (60 Tablets per 30 days) mirtazapine oral tablet 45 Remeron QLL (45 Tablets per 30 days) mirtazapine oral tablet 7.5 QLL (30 Tablets per 30 days) mirtazapine oral tablet dispersible 15, 45 Remeron SolTab QLL (30 Tablets per 30 days) mirtazapine oral tablet dispersible 30 Remeron SolTab QLL (60 Tablets per 30 days) 19

25 *Antidepressants - Misc.*** bupropion hcl er (sr) oral tablet extended release 12 hour 100 Wellbutrin SR QLL (120 Tablets per 30 days) bupropion hcl er (sr) oral tablet extended release 12 hour 150, 200 Wellbutrin SR QLL (60 Tablets per 30 days) bupropion hcl er (xl) oral tablet extended release 24 hour 150 Wellbutrin XL QLL (90 Tablets per 30 days) bupropion hcl er (xl) oral tablet extended release 24 hour 300 Wellbutrin XL QLL (30 Tablets per 30 days) bupropion hcl oral tablet 100 QLL (135 Tablets per 30 days) bupropion hcl oral tablet 75 QLL (180 Tablets per 30 days) maprotiline hcl oral tablet 25, 50, 75 *Modified Cyclics*** trazodone hcl oral tablet 100, 150, 50 *Monoamine Oxidase Inhibitors (Maois)*** MARPLAN ORAL TABLET 10 MG phenelzine sulfate oral tablet 15 Nardil tranylcypromine sulfate oral tablet 10 Parnate *Selective Serotonin Reuptake Inhibitors (Ssris)*** citalopram hydrobromide oral solution 10 /5ml QLL (600 ML per 30 days) citalopram hydrobromide oral tablet 10, 20, 40 CeleXA QLL (30 Tablets per 30 days) escitalopram oxalate oral solution 5 /5ml Lexapro QLL (30 Tablets per 30 days) escitalopram oxalate oral tablet 10, 20, Lexapro 5 QLL (30 Tablets per 30 days) fluoxetine hcl oral capsule 10 PROzac QLL (30 Capsules per 30 days) fluoxetine hcl oral capsule 20 PROzac QLL (120 Capsules per 30 days) fluoxetine hcl oral capsule 40 PROzac QLL (60 Capsules per 30 days) fluoxetine hcl oral solution 20 /5ml QLL (600 ML per 30 days) fluoxetine hcl oral tablet 10 QLL (30 Tablets per 30 days) fluvoxamine maleate oral tablet 100 QLL (90 Tablets per 30 days) fluvoxamine maleate oral tablet 25 QLL (30 Tablets per 30 days) fluvoxamine maleate oral tablet 50 QLL (60 Tablets per 30 days) paroxetine hcl oral tablet 10, 20 Paxil QLL (30 Tablets per 30 days) paroxetine hcl oral tablet 30 Paxil QLL (60 Tablets per 30 days) 20

26 paroxetine hcl oral tablet 40 Paxil QLL (45 Tablets per 30 days) sertraline hcl oral concentrate 20 /ml Zoloft QLL (300 ML per 30 days) sertraline hcl oral tablet 100 Zoloft QLL (75 Tablets per 30 days) sertraline hcl oral tablet 25 Zoloft QLL (30 Tablets per 30 days) sertraline hcl oral tablet 50 Zoloft QLL (60 Tablets per 30 days) *Serotonin-Norepinephrine Reuptake Inhibitors (Snris)*** duloxetine hcl oral capsule delayed release particles 20, 30, 60 Cymbalta QLL (30 Capsules per 30 days) venlafaxine hcl er oral capsule extended release 24 hour 150 Effexor XR QLL (60 Capsules per 30 days) venlafaxine hcl er oral capsule extended release 24 hour 37.5, 75 Effexor XR QLL (30 Capsules per 30 days) venlafaxine hcl oral tablet 100, 25, 37.5, 50, 75 *Tricyclic Agents*** amitriptyline hcl oral tablet 10, 100, 150, 50, 75 amitriptyline hcl oral tablet 25 Elavil desipramine hcl oral tablet 10, 25 Norpramin desipramine hcl oral tablet 100, 150, 50, 75 doxepin hcl oral capsule 10, 100, 150, 25, 50, 75 doxepin hcl oral concentrate 10 /ml imipramine hcl oral tablet 10, 25, 50 Tofranil nortriptyline hcl oral capsule 10, 25, 50, 75 Pamelor nortriptyline hcl oral solution 10 /5ml protriptyline hcl oral tablet 10, 5 *ANTIDIABETICS* *Alpha-Glucosidase Inhibitors*** acarbose oral tablet 100, 25, 50 Precose *Biguanides*** metformin hcl er oral tablet extended release 24 hour 500, 750 Glucophage XR metformin hcl oral tablet 1000, 500, 850 Glucophage 21

27 *Diabetic Other*** BD GLUCOSE ORAL TABLET CHEWABLE 5 GM cvs glucose bits oral tablet chewable 1 gm GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED 1 MG GLUCAGON EMERGENCY INJECTION KIT 1 MG glucose oral tablet chewable 4 gm *Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors*** alogliptin benzoate oral tablet 12.5, 25, 6.25 TRADJENTA ORAL TABLET 5 MG *Dipeptidyl Peptidase-4 Inhibitor- Biguanide Combinations*** alogliptin-metformin hcl oral tablet , JENTADUETO ORAL TABLET MG, MG, MG JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR MG *Dpp-4 Inhibitor-Thiazolidinedione Combinations*** alogliptin-pioglitazone oral tablet , , , 25-15, 25-30, *Human Insulin*** APIDRA INJECTION SOLUTION 100 UNIT/ML BASAGLAR KWIKPEN SUBCUTANEOUS SOLUTION PEN INJECTOR 100 UNIT/ML HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN INJECTOR 100 UNIT/ML, 200 UNIT/ML HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN INJECTOR (50-50) 100 UNIT/ML 22 Dex4 Quick Dissolve Glucose Nesina Kazano Oseni ST; QLL (30 EA per 30 days) ST; QLL (60 EA per 30 days) ST; QLL (60 EA per 30 days) ST; QLL (30 EA per 30 days) AL (Max 18 Years) AL (Max 18 Years)

28 HUMALOG MIX 50/50 SUBCUTANEOUS SUSPENSION (50-50) 100 UNIT/ML HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN AL (Max 18 Years) INJECTOR (75-25) 100 UNIT/ML HUMALOG MIX 75/25 SUBCUTANEOUS SUSPENSION (75-25) 100 UNIT/ML HUMALOG SUBCUTANEOUS SOLUTION 100 UNIT/ML HUMALOG SUBCUTANEOUS SOLUTION CARTRIDGE 100 UNIT/ML HUMULIN 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML HUMULIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML HUMULIN R INJECTION SOLUTION 100 UNIT/ML HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML LANTUS SUBCUTANEOUS SOLUTION 100 UNIT/ML LEVEMIR FLEXTOUCH SUBCUTANEOUS SOLUTION PEN INJECTOR 100 UNIT/ML LEVEMIR SUBCUTANEOUS SOLUTION 100 UNIT/ML NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML NOVOLIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML NOVOLIN R INJECTION SOLUTION 100 UNIT/ML NOVOLIN R RELION INJECTION SOLUTION 100 UNIT/ML NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 AL (Max 18 Years) UNIT/ML NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS SUSPENSION PEN INJECTOR (70-30) 100 UNIT/ML AL (Max 18 Years) 23

29 NOVOLOG MIX 70/30 SUBCUTANEOUS SUSPENSION (70-30) 100 UNIT/ML NOVOLOG SUBCUTANEOUS SOLUTION 100 UNIT/ML *Incretin Mimetic Agents (Glp-1 Receptor Agonists)*** TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR 0.75 ST MG/0.5ML, 1.5 MG/0.5ML *Meglitinide Analogues*** nateglinide oral tablet 120, 60 Starlix repaglinide oral tablet 0.5 repaglinide oral tablet 1, 2 Prandin *Sodium-Glucose Co-Transporter 2 (Sglt2) Inhibitors*** INVOKANA ORAL TABLET 100 MG, 300 MG ST; QLL (30 EA per 30 days) *Sulfonylurea-Biguanide Combinations*** glipizide-metformin hcl oral tablet , , glyburide-metformin oral tablet glyburide-metformin oral tablet , Glucovance *Sulfonylureas*** chlorpropamide oral tablet 100, 250 glimepiride oral tablet 1, 2, 4 Amaryl glipizide er oral tablet extended release 24 hour 10, 2.5, 5 Glucotrol XL glipizide oral tablet 10, 5 Glucotrol glipizide xl oral tablet extended release 24 hour 10, 2.5, 5 Glucotrol XL glyburide oral tablet 1.25, 2.5, 5 tolazamide oral tablet 250, 500 tolbutamide oral tablet 500 *Sulfonylurea-Thiazolidinedione Combinations*** pioglitazone hcl-glimepiride oral tablet 30-2, 30-4 Duetact QLL (30 Tablets per 30 days) 24

30 *Thiazolidinedione-Biguanide Combinations*** pioglitazone hcl-metformin hcl oral tablet , Actoplus Met QLL (90 Tablets per 30 days) *Thiazolidinediones*** AVANDIA ORAL TABLET 2 MG, 4 MG ST; QLL (30 Tablets per 30 days) pioglitazone hcl oral tablet 15, 30, 45 Actos QLL (30 Tablets per 30 days) *ANTIDIARRHEALS* *Antidiarrheal Agents - Misc.*** acidophilus probiotic oral tablet 10 Probiata bismuth subsalicylate oral tablet chewable 262 Pepto-Bismol InstaCool cvs bismuth oral tablet 262 Pepto-Bismol cvs probiotic (lactobacillus) oral capsule Culturelle Immunity Support lactobacillus extra strength oral capsule Dofus PEDIA-LAX PROBIOTIC YUMS ORAL TABLET CHEWABLE pink bismuth maximum strength oral suspension 525 /15ml Pepto-Bismol Max Strength pink bismuth oral suspension 262 /15ml Kaopectate *Antiperistaltic Agents*** anti-diarrheal oral capsule 2 Imodium A-D diphenoxylate-atropine oral liquid /5ml diphenoxylate-atropine oral tablet Lomotil lofene oral tablet Lomotil loperamide hcl oral capsule 2 Imodium A-D loperamide hcl oral liquid 1 /5ml loperamide hcl oral suspension 1 /7.5ml Imodium A-D loperamide hcl oral tablet 2 Loperamide A-D *ANTIDOTES AND SPECIFIC ANTAGONISTS* *Antidotes And Specific Antagonists*** sm ipecac syrup oral syrup 25

31 *ANTIDOTES* *Antidotes - Chelating Agents*** CHEMET ORAL CAPSULE 100 MG *Antidotes*** sm ipecac syrup oral syrup *Opioid Antagonists*** naloxone hcl injection solution 0.4 /ml naltrexone hcl oral tablet 50 NARCAN NASAL LIQUID 4 MG/0.1ML *ANTIEMETICS* *5-Ht3 Receptor Antagonists*** granisetron hcl oral tablet 1 ondansetron hcl oral solution 4 /5ml Zofran QLL (50 ml per 30 Dayss) ondansetron hcl oral tablet 24 QLL (8 Tablets per 30 days) ondansetron hcl oral tablet 4, 8 Zofran QLL (21 EA per 30 Dayss) ondansetron oral tablet dispersible 4, 8 Zofran ODT QLL (21 EA per 30 Dayss) *Antiemetic Combinations*** anti-nausea oral solution Little Tummys Nausea Relief *Antiemetics - Anticholinergic*** DRAMAMINE LESS DROWSY ORAL TABLET 25 MG RA Motion Sickness Relief meclizine hcl oral tablet 12.5 meclizine hcl oral tablet 25 Dramamine Less Drowsy travel sickness oral tablet chewable 25 *Substance P/Neurokinin 1 (Nk1) Receptor Antagonists*** EMEND ORAL CAPSULE 125 MG, 40 MG, 80 & 125 MG, 80 MG Aprepitant QLL (6 EA per 30 days) *ANTIFUNGALS* *Antifungals*** griseofulvin microsize oral suspension 125 /5ml griseofulvin microsize oral tablet 500 griseofulvin ultramicrosize oral tablet 125, Gris-PEG 250 nystatin oral tablet unit terbinafine hcl oral tablet 250 LamISIL QLL (84 Tablets per 1 Year) 26

32 *Imidazoles*** ketoconazole oral tablet 200 *Triazoles*** fluconazole oral suspension reconstituted 10 /ml, 40 /ml Diflucan fluconazole oral tablet 100, 150, 200, 50 Diflucan itraconazole oral capsule 100 Sporanox Pulsepak SPORANOX ORAL SOLUTION 10 MG/ML *ANTIHISTAMINES* *Antihistamines - Alkylamines*** ALA-HIST IR ORAL TABLET 2 MG aller-chlor oral syrup 2 /5ml Diabetic Tussin Allergy brompheniramine tannate oral tablet chewable 12 chlorpheniramine maleate er oral tablet extended release 12 Chlor-Trimeton Allergy chlorpheniramine maleate oral tablet 4 Wal-finate *Antihistamines - Ethanolamines*** allergy medication childrens oral liquid 12.5 /5ml Total Allergy Medicine allergy medication oral tablet 25 Benadryl Allergy allergy relief childrens oral tablet dispersible 12.5 Wal-Dryl Allergy Rel Childrens allergy relief oral capsule 25 Benadryl Dye-Free Allergy ARBINOXA ORAL TABLET 4 MG Carbinoxamine Maleate carbinoxamine maleate oral solution 4 /5ml carbinoxamine maleate oral tablet 4 Arbinoxa clemastine fumarate oral tablet 1.34 PX Dayhist Allergy clemastine fumarate oral tablet 2.68 cvs allergy childrens oral tablet chewable 12.5 Benadryl Allergy Childrens diphenhydramine hcl oral capsule 25 Benadryl Dye-Free Allergy diphenhydramine hcl oral capsule 50 Banophen diphenhydramine hcl oral elixir 12.5 /5ml silphen cough oral syrup 12.5 /5ml *Antihistamines - Non-Sedating*** allergy relief for kids oral syrup 5 /5ml Claritin 27

33 cetirizine hcl oral solution 1 /ml ZyrTEC Childrens Allergy QLL (150 ML per 30 days); AL (Min 6 Years) cetirizine hcl oral syrup 1 /ml, 5 /5ml ZyrTEC Childrens Allergy QLL (150 ML per 30 days); AL (Min 6 Years) cetirizine hcl oral tablet 10 ZyrTEC Allergy cetirizine hcl oral tablet 5 cetirizine hcl oral tablet chewable 10, 5 Wal-Zyr Childrens fexofenadine hcl oral tablet 180 Mucinex Allergy fexofenadine hcl oral tablet 60 Allegra Allergy loratadine allergy relief oral tablet dispersible Wal-vert 10 loratadine oral tablet 10 KLS AllerClear *Antihistamines - Phenothiazines*** PHENADOZ RECTAL SUPPOSITORY 12.5 MG, 25 MG Promethazine HCl PHENERGAN RECTAL SUPPOSITORY 12.5 MG, 25 MG, 50 MG Promethazine HCl promethazine hcl oral solution 6.25 /5ml promethazine hcl oral syrup 6.25 /5ml promethazine hcl oral tablet 12.5, 25, 50 promethazine hcl rectal suppository 12.5, 50 Phenergan promethazine hcl rectal suppository 25 Promethegan PROMETHEGAN RECTAL SUPPOSITORY 12.5 MG, 25 MG, 50 MG Promethazine HCl *Antihistamines - Piperidines*** cyproheptadine hcl oral syrup 2 /5ml cyproheptadine hcl oral tablet 4 *ANTIHYPERLIPIDEMICS* *Bile Acid Sequestrants*** cholestyramine light oral packet 4 gm Prevalite cholestyramine oral packet 4 gm Questran colestipol hcl oral granules 5 gm Colestid Flavored colestipol hcl oral packet 5 gm Colestid colestipol hcl oral tablet 1 gm Colestid PREVALITE ORAL CKET 4 GM Cholestyramine Light 28

34 *Fibric Acid Derivatives*** fenofibrate micronized oral capsule 134, 200, 67 Lofibra fenofibrate oral tablet 145, 48 Tricor fenofibrate oral tablet 160, 54 Lofibra fenofibric acid oral capsule delayed release 135, 45 Trilipix gemfibrozil oral tablet 600 Lopid QLL (60 Tablets per 30 days) *H Coa Reductase Inhibitors*** atorvastatin calcium oral tablet 10, 20, Lipitor 40, 80 QLL (30 Tablets per 30 days) fluvastatin sodium oral capsule 20 Lescol QLL (30 Capsules per 30 days) fluvastatin sodium oral capsule 40 QLL (30 Capsules per 30 days) lovastatin oral tablet 10, 20 QLL (30 Tablets per 30 days) lovastatin oral tablet 40 Mevacor QLL (60 Tablets per 30 days) pravastatin sodium oral tablet 10 QLL (30 Tablets per 30 days) pravastatin sodium oral tablet 20, 40, 80 Pravachol QLL (30 Tablets per 30 days) rosuvastatin calcium oral tablet 10, 20, Crestor 40, 5 ; QLL (30 EA per 30 days) simvastatin oral tablet 10, 20, 40, 5 Zocor, 80 QLL (30 Tablets per 30 days) *Intestinal Cholesterol Absorption Inhibitors*** ezetimibe oral tablet 10 Zetia ST *ANTIHYPERTENSIVES* *Ace Inhibitor & Calcium Channel Blocker Combinations*** amlodipine besy-benazepril hcl oral capsule 10-20, 10-40, 5-10, 5-20 Lotrel amlodipine besy-benazepril hcl oral capsule , 5-40 *Ace Inhibitors & Thiazide/Thiazide- Like*** benazepril-hydrochlorothiazide oral tablet 10 Lotensin HCT 12.5, , benazepril-hydrochlorothiazide oral tablet captopril-hydrochlorothiazide oral tablet 25 15, 25-25, 50-15,

35 enalapril-hydrochlorothiazide oral tablet Vaseretic enalapril-hydrochlorothiazide oral tablet fosinopril sodium-hctz oral tablet , lisinopril-hydrochlorothiazide oral tablet , , Zestoretic moexipril-hydrochlorothiazide oral tablet , 15-25, quinapril-hydrochlorothiazide oral tablet , , Accuretic *Ace Inhibitors*** benazepril hcl oral tablet 10, 20, 40 Lotensin benazepril hcl oral tablet 5 captopril oral tablet 100, 12.5, 25, 50 enalapril maleate oral tablet 10, 2.5, 20, 5 Vasotec fosinopril sodium oral tablet 10, 20, 40 lisinopril oral tablet 10, 20 Prinivil QLL (30 Tablets per 30 days) lisinopril oral tablet 2.5, 30, 5 Zestril QLL (30 Tablets per 30 days) lisinopril oral tablet 40 Zestril QLL (60 Tablets per 30 days) moexipril hcl oral tablet 15, 7.5 perindopril erbumine oral tablet 2 perindopril erbumine oral tablet 4, 8 Aceon quinapril hcl oral tablet 10, 20, 40, Accupril 5 ramipril oral capsule 1.25, 10, 2.5, Altace 5 trandolapril oral tablet 1, 2, 4 Mavik *Adrenolytics-Central & Thiazide/Thiazide-Like Comb*** methyldopa-hydrochlorothiazide oral tablet , *Angiotensin Ii Receptor Antag & Ca Channel Blocker Comb*** amlodipine besylate-valsartan oral tablet , , 5-160, Exforge QLL (1 EA per 1 day) 30

36 *Angiotensin Ii Receptor Antag & Thiazide/Thiazide-Like*** candesartan cilexetil-hctz oral tablet , , Atacand HCT irbesartan-hydrochlorothiazide oral tablet , Avalide losartan potassium-hctz oral tablet , , Hyzaar valsartan-hydrochlorothiazide oral tablet , , , , Diovan HCT QLL (30 Tablets per 30 days) *Angiotensin Ii Receptor Antagonists*** candesartan cilexetil oral tablet 16, 32, Atacand 4, 8 irbesartan oral tablet 150, 300, 75 Avapro losartan potassium oral tablet 100, 25, Cozaar 50 valsartan oral tablet 160, 320, 40, 80 Diovan QLL (60 Tablets per 30 days) *Angiotensin Ii Receptor Ant-Ca Channel Blocker-Thiazides*** amlodipine-valsartan-hctz oral tablet , , , Exforge HCT QLL (1 EA per 1 day) 12.5, *Antiadrenergics - Centrally Acting*** clonidine hcl oral tablet 0.1, 0.2, 0.3 Catapres clonidine hcl transdermal patch weekly 0.1 /24hr Catapres-TTS-1 clonidine hcl transdermal patch weekly 0.2 /24hr Catapres-TTS-2 clonidine hcl transdermal patch weekly 0.3 /24hr Catapres-TTS-3 guanfacine hcl oral tablet 1 QLL (240 EA per 30 days) guanfacine hcl oral tablet 2 QLL (120 EA per 30 days) methyldopa oral tablet 250, 500 *Antiadrenergics - Peripherally Acting*** doxazosin mesylate oral tablet 1, 2, 4, 8 Cardura QLL (30 Tablets per 30 days) 31

AETNA BETTER HEALTH Formulary Guide Aetna Better Health Of Virginia Formulary Guide March 2018

AETNA BETTER HEALTH Formulary Guide Aetna Better Health Of Virginia Formulary Guide March 2018 AETNA BETTER HEALTH Formulary Guide Aetna Better Health Of Virginia Formulary Guide March 2018 http://www.aetnabetterhealth.com/virginia AETNA BETTER HEALTH Formulary Guide What is the Aetna Better Health

More information

Aetna Better Health Virginia. Table of Contents

Aetna Better Health Virginia. Table of Contents Aetna Better Health Virginia Table of Contents *ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS*...4 *ALTERNATIVE MEDICINES*...6 *AMINOGLYCOSIDES*... 6 *ANALGESICS - ANTI-INFLAMMATORY*...7 *ANALGESICS -

More information

AETNA BETTER HEALTH Formulary Guide Aetna Better Health Pennsylvania Formulary Guide April 2018

AETNA BETTER HEALTH Formulary Guide Aetna Better Health Pennsylvania Formulary Guide April 2018 AETNA BETTER HEALTH Formulary Guide 2018 Aetna Better Health Pennsylvania Formulary Guide April 2018 AETNA BETTER HEALTH Formulary Guide 2018 What is the Aetna Better Health in Pennsylvania Formulary?

More information

AETNA BETTER HEALTH OF NEW JERSEY Formulary

AETNA BETTER HEALTH OF NEW JERSEY Formulary AETNA BETTER HEALTH OF NEW JERSEY Formulary 2-01-2018 NJ-14-05-38 FORMULARY What is the Aetna Better Health of New Jersey Formulary? This is a drug list created by Aetna Better Health of New Jersey ( plan

More information

Aetna Better Health of Louisiana

Aetna Better Health of Louisiana AETNA BETTER HEALTH Formulary Guide Aetna Better Health of Louisiana Formulary Guide January 2018 www.aetnabetterhealth.com/louisiana 1 AETNA BETTER HEALTH Formulary Guide What is the Aetna Better Health

More information

Qualified Health Plans 2018 Drug Formulary for HMOs and PPOs

Qualified Health Plans 2018 Drug Formulary for HMOs and PPOs Qualified Health Plans 2018 Drug Formulary for HMOs and PPOs THIS DOCUMENT HAS INFORMATION ABOUT THE PRESCRIPTION DRUGS WE COVER FOR QUALIFIED HEALTH PLANS. Qualified Health Plans (QHP) are Affordable

More information

2017 Drug List for Commercial Health Plans

2017 Drug List for Commercial Health Plans 2017 Drug List for Commercial Health Plans Use this drug list also known as a formulary to learn about the prescription drugs we cover in all commercial health plans. Commercial health plans are a type

More information

4-TIER HIGH DEDUCTIBLE HEALTH PLAN FORMULARY Effective May 2018

4-TIER HIGH DEDUCTIBLE HEALTH PLAN FORMULARY Effective May 2018 4-TIER HIGH DEDUCTIBLE HEALTH PLAN FORMULARY Effective May 2018 Provided by EnvisionRx Introduction The Total Health Care (THC) 4-Tier High Deductible Health Plan Formulary was developed to serve as a

More information

AETNA BETTER HEALTH Formulary Guide Aetna Better Health of Kentucky Formulary Guide March 2018

AETNA BETTER HEALTH Formulary Guide Aetna Better Health of Kentucky Formulary Guide March 2018 AETNA BETTER HEALTH Formulary Guide Aetna Better Health of Kentucky Formulary Guide March 2018 http://www.aetnabetterhealth.com/kentucky AETNA BETTER HEALTH Formulary Guide What is the Aetna Better Health

More information

PHP Centennial Care Formulary/Preferred Drug Listing

PHP Centennial Care Formulary/Preferred Drug Listing PHP Centennial Care Formulary/Preferred Drug Listing The Centennial Care Preferred Drug List is subject to change. Presbyterian Centennial Care This list is in order by therapeutic class. To find a specific

More information

Signature Advantage (HMO SNP) 2018 Comprehensive Formulary. List of Covered Drugs

Signature Advantage (HMO SNP) 2018 Comprehensive Formulary. List of Covered Drugs Signature Advantage (HMO SNP) 208 Comprehensive Formulary List of Covered Drugs PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission

More information

New Jersey Department of Human Services State Upper Limit (SUL) List - PROPOSED Effective

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

More information

2018 Ohana Medicaid Comprehensive Preferred Drug List (QUEST Integration) (List of Covered Drugs)

2018 Ohana Medicaid Comprehensive Preferred Drug List (QUEST Integration) (List of Covered Drugs) 2018 Ohana Medicaid Comprehensive referred Drug List (QUEST Integration) (List of Covered Drugs) Ohana Health lan 00 lease read this document. It has details about the drugs we cover for the Ohana QUEST

More information

3-TIER FORMULARY Effective November 2017

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

More information

Blue Cross of Idaho s Multi-Tier Prescription Drug Formulary for Qualified Health Plans

Blue Cross of Idaho s Multi-Tier Prescription Drug Formulary for Qualified Health Plans Blue Cross of Idaho s Multi-Tier Prescription Drug Formulary for Qualified Health Plans This document is a searchable PDF. On your keyboard press Ctrl+F (Command+F for Mac) and a search field will open.

More information

South Carolina Medicaid Comprehensive Preferred Drug List (List of Covered Drugs)

South Carolina Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 2018 South Carolina Medicaid Comprehensive referred Drug List (List of Covered Drugs) WellCare of South Carolina 00 lease read: This document contains information about the drugs we cover in this plan.

More information

2018 Harmony Medicaid Comprehensive Preferred Drug List (List of Covered Drugs)

2018 Harmony Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 2018 Harmony Medicaid Comprehensive referred Drug List (List of Covered Drugs) Harmony Health lan lease read: This document contains information about the drugs we cover in this plan. lease note that the

More information

Harmony Medicaid Comprehensive Preferred Drug List (List of Covered Drugs)

Harmony Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 2017 Harmony Medicaid Comprehensive referred Drug List (List of Covered Drugs) Harmony Health lan lease read: This document contains information about the drugs we cover in this plan. lease note that the

More information

New York Medicaid Comprehensive Preferred Drug List (List of Covered Drugs)

New York Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 2018 New York Medicaid Comprehensive referred Drug List (List of Covered Drugs) WellCare Health lans, Inc. 00 lease read: This document has information about drugs we cover in this plan. lease note that

More information

Harmony Medicaid Comprehensive Preferred Drug List (List of Covered Drugs)

Harmony Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 2018 Harmony Medicaid Comprehensive referred Drug List (List of Covered Drugs) Harmony Health lan lease read: This document contains information about the drugs we cover in this plan. lease note that the

More information

Blue Cross of Idaho s Standard Six-Tier Prescription Drug Formulary

Blue Cross of Idaho s Standard Six-Tier Prescription Drug Formulary Blue Cross of Idaho s Standard Six-Tier Prescription Drug Formulary This document is a searchable PDF. On your keyboard press Ctrl+F (Command+F for Mac) and a search field will open. Type in the name of

More information

PA Prior authorization ST Step therapy QL Quantity limit AE Age Edit. More Details. Last Update: October 1,

PA Prior authorization ST Step therapy QL Quantity limit AE Age Edit. More Details. Last Update: October 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

More information

Georgia Families Comprehensive Preferred Drug List (List of Covered Drugs)

Georgia Families Comprehensive Preferred Drug List (List of Covered Drugs) 2018 Georgia Families Comprehensive referred Drug List (List of Covered Drugs) WellCare of Georgia, Inc. 00 9 lease read: This document tells about the drugs we cover in this plan. If you speak a different

More information

QUALIFIED HEALTH PLAN FORMULARY Effective January 2018

QUALIFIED HEALTH PLAN FORMULARY Effective January 2018 QUALIFIED HEALTH PLAN FORMULARY Effective January 2018 Provided by EnvisionRx Introduction The Total Health Care (THC) Qualified Health Plan Formulary was developed to serve as a guide for physicians,

More information

2016 Aetna Pharmacy Drug Guide Four Tier Open Aetna Premier Plus Plan

2016 Aetna Pharmacy Drug Guide Four Tier Open Aetna Premier Plus Plan Quality health plans & benefits Healthier living Financial well-being Intelligent solutions 2016 Aetna Pharmacy Drug Guide Four Tier Open Aetna Premier Plus Plan www.aetna.com 2016 Aetna Inc. 05.05.341.1

More information

Effective: August 1, 2015 Non-QHP Commercial and TPA Plans 5 Tier Formulary (List of Covered Drugs)

Effective: August 1, 2015 Non-QHP Commercial and TPA Plans 5 Tier Formulary (List of Covered Drugs) Effective: August 1, 2015 Non-QHP Commercial and TPA Plans 5 Tier Formulary (List of Covered Drugs) What is the Drug List? Also called a formulary by doctors and pharmacists, the Drug List is an extensive

More information

PA Prior authorization ST Step therapy QL Quantity limit AE Age Edit. More Details. Last Update: July 1,

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

More information

Harmony Medicaid Comprehensive Preferred Drug List (List of Covered Drugs)

Harmony Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 2015 Harmony Medicaid Comprehensive referred Drug List (List of Covered Drugs) Harmony Health lan 00 9 lease read: This document contains information about the drugs we cover in this plan. lease note that

More information

2017 Aetna Pharmacy Drug Guide Four Tier Open Aetna Premier Plus Plan

2017 Aetna Pharmacy Drug Guide Four Tier Open Aetna Premier Plus Plan Quality health plans & benefits Healthier living Financial well-being Intelligent solutions 2017 Aetna Pharmacy Drug Guide Four Tier Open Aetna Premier Plus Plan www.aetna.com 2017 Aetna Inc. 05.05.341.1

More information

COMMERCIAL FORMULARY Effective April 2018

COMMERCIAL FORMULARY Effective April 2018 COMMERCIAL FORMULARY Effective April 2018 Provided by EnvisionRx Introduction The Total Health Care (THC) Commercial Formulary was developed to serve as a guide for physicians, pharmacists, health care

More information

2018 FORMULARY (List of Covered Drugs)

2018 FORMULARY (List of Covered Drugs) InterCommunity Health Network CCO 2018 FORMULARY (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on 11/01/2017.

More information

Harmony Medicaid Comprehensive Preferred Drug List (List of Covered Drugs)

Harmony Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 00 9 2015 Harmony Medicaid Comprehensive referred Drug List (List of Covered Drugs) Harmony Health lan lease read: This document contains information about the drugs we cover in this plan. lease note that

More information

Georgia Medicaid Comprehensive Preferred Drug List (List of Covered Drugs)

Georgia Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 2015 Georgia Medicaid Comprehensive referred Drug List (List of Covered Drugs) WellCare of Georgia, Inc. 00 9 lease read: This document contains information about the drugs we cover in this plan. ara solicitar

More information

Antibiotic Treatments. Arthritis & Pain. Asthma. Cholesterol

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

More information

2017 Aetna Pharmacy Drug Guide Five Tier Open Aetna Value Plus Plan

2017 Aetna Pharmacy Drug Guide Five Tier Open Aetna Value Plus Plan Quality health plans & benefits Healthier living Financial well-being Intelligent solutions 2017 Aetna Pharmacy Drug Guide Five Tier Open Aetna Value Plus Plan www.aetna.com 2017 Aetna Inc. 05.05.354.1

More information

New Jersey Medicaid Comprehensive Preferred Drug List (List of Covered Drugs)

New Jersey Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 2015 New Jersey Medicaid Comprehensive referred Drug List (List of Covered Drugs) WellCare of New Jersey 00 lease read: This document contains information about the drugs we cover in this plan. lease note

More information

Georgia Medicaid Comprehensive Preferred Drug List (List of Covered Drugs)

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

More information

COMMERCIAL FORMULARY Effective November 2017

COMMERCIAL FORMULARY Effective November 2017 COMMERCIAL FORMULARY Effective November 2017 Provided by EnvisionRx Introduction The Total Health Care (THC) Commercial Formulary was developed to serve as a guide for physicians, pharmacists, health care

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

2017 Presbyterian Individual and Family Metal Plans/Employer Group Metal Plans Formulary Therapeutic Class Listing

2017 Presbyterian Individual and Family Metal Plans/Employer Group Metal Plans Formulary Therapeutic Class Listing Presbyterian Health Plan, Inc. Presbyterian Insurance Company, Inc. 207 Presbyterian Individual and Family Metal Plans/Employer Group Metal Plans Formulary Therapeutic Class Listing This list in order

More information

MEDICAID FORMULARY Effective November 2017

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

More information

2018 Presbyterian Individual and Family Metal Plans/Employer Group Metal Plans Formulary Therapeutic Class Listing

2018 Presbyterian Individual and Family Metal Plans/Employer Group Metal Plans Formulary Therapeutic Class Listing Presbyterian Health Plan, Inc. Presbyterian Insurance Company, Inc. 018 Presbyterian Individual and Family Metal Plans/Employer Group Metal Plans Formulary Therapeutic Class Listing This list in order

More information

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 Aetna Better Health of Michigan Formulary Guide December 2017 AETNA BETTER HEALTH Formulary Guide http://www.aetnabetterhealth.com/michigan What is the Aetna Better

More information

List of preferred medications Member formulary

List of preferred medications Member formulary List of preferred medications 08 Member formulary What is the GHP Family Formulary? A formulary is a list of drugs selected by GHP Family, which represents medications believed to be a necessary part of

More information

AETNA BETTER HEALTH Formulary Guide. Aetna Better Health of Michigan Formulary Guide February 2017

AETNA BETTER HEALTH Formulary Guide. Aetna Better Health of Michigan Formulary Guide February 2017 AETNA BETTER HEALTH Formulary Guide Aetna Better Health of Michigan Formulary Guide February 2017 AETNA BETTER HEALTH Formulary Guide http://www.aetnabetterhealth.com/michigan What is the Aetna Better

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

Commercial Metal 5-Tier Formulary (List of Covered Drugs)

Commercial Metal 5-Tier Formulary (List of Covered Drugs) Updated: September 15, 2017 Small Group Metal Plans Individual Metal Plans Commercial Metal 5-Tier Formulary (List of Covered Drugs) What is the Drug List? Also called a formulary by doctors and pharmacists,

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

PREFERRED DRUG LIST 2018

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

More information

PHP Centennial Care Formulary/Preferred Drug Listing

PHP Centennial Care Formulary/Preferred Drug Listing PHP Centennial Care Formulary/Preferred Drug Listing The Centennial Care Preferred Drug List is subject to change. Presbyterian Centennial Care This list is in alphabetical order. To find a specific drug,

More information

Health Choice Utah Formulary

Health Choice Utah Formulary 2017 Health Choice Utah Formulary Welcome to Our Family! ienvenidos a Nuestra Familia! Updated November 2017 What is the Health Choice Utah Formulary/Preferred Drug List (PDL)? A Formulary / Preferred

More information

ULTRAM LIVING ROOM FURNITURE

ULTRAM LIVING ROOM FURNITURE ULTRAM LIVING ROOM FURNITURE Ultram Living Room Furniture Snort ultram 50 mg How long does ultram take to work Tramadol 50mg generic for ultram Is ultram good for nerve pain How long until ultram wears

More information

Geisinger Health Plan Pharmacy Department Internal Mail Code North Academy Avenue Danville, PA CHIP Pharmacy Benefit

Geisinger Health Plan Pharmacy Department Internal Mail Code North Academy Avenue Danville, PA CHIP Pharmacy Benefit List of covered drugs for Geisinger Kids Plans 8 Member formulary Geisinger Health Plan Pharmacy Department Internal Mail Code 3-46 North Academy Avenue Danville, PA 78 CHIP Pharmacy Benefit The CHIP Pharmacy

More information

IS ULTRAM A CONTROLLED SUBSTANCE IN NORTH CAROLINA

IS ULTRAM A CONTROLLED SUBSTANCE IN NORTH CAROLINA IS ULTRAM A CONTROLLED SUBSTANCE IN NORTH CAROLINA Is Ultram A Controlled Substance In North Carolina How many ultram to get high Highest dose of ultram Ultram now a controlled substance Is ultram used

More information

Care Wisconsin 2018 Formulary Addendum

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

More information

2018 HEALTH CHOICE ARIZONA FORMULARY

2018 HEALTH CHOICE ARIZONA FORMULARY 2018 HEALTH CHOICE ARIZONA FORMULARY ARIZONA Questions? Contact the Health Choice Arizona Pharmacy Department at 800-322-8670. Welcome to Our Family! ienvenidos a Nuestra Familia! Update: April 1, 2018

More information

Memorial Hermann Advantage HMO & PPO April 2018 Formulary Addendum

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

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

Quarterly pharmacy formulary change notice

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

More information

Stanford Health Care Advantage 2018 Formulary List of Covered Drugs

Stanford Health Care Advantage 2018 Formulary List of Covered Drugs Stanford Health Care Advantage 018 Formulary List of Covered Drugs PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN 0001801, 1 This formulary was updated on 01/01/018.

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 Comprehensive Formulary 2016 List of covered drugs Updated December 1, 2016 Live Healthy! Choose HEALTH CHOICE HealthChoiceEssential.com 2016 Comprehensive Formulary Introduction Health Choice Insurance

More information

Stanford Health Care Advantage 2018 Formulary List of Covered Drugs

Stanford Health Care Advantage 2018 Formulary List of Covered Drugs Stanford Health Care Advantage 018 Formulary List of Covered Drugs PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN 0001801, 1 This formulary was updated on 04/01/018.

More information

2018 Commercial Drug Formulary

2018 Commercial Drug Formulary 08 Commercial Drug Formulary 8 D PRESCRIPTION DRUG BENEFITS The following is a comprehensive listing by drug class of formulary medications approved under the Apex Prescription Drug Benefit. Brand name

More information

2018 Formulary. (List of Covered Drugs)

2018 Formulary. (List of Covered Drugs) 2018 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 #: 7 This formulary

More information

Medi-Cal Formulary 2016

Medi-Cal Formulary 2016 Medi-Cal ormulary 2016 IEHP Medi-Cal 2016 ormulary Table of Contents Analgesics... 2 Anesthetics... 3 Antiarthritics... 3 Antiasthmatics... 4 Antibiotics... 6 Anticoagulants... 10 Antifungals... 10 Antihistamine

More information

General Formulary Information

General Formulary Information List of covered drugs for Triple Choice and Traditional Plans 8 Member formulary General Formulary Information This formulary is applicable to the Triple Choice and Traditional Prescription Medication

More information

Stanford Health Care Advantage 2018 Formulary List of Covered Drugs

Stanford Health Care Advantage 2018 Formulary List of Covered Drugs Stanford Health Care Advantage 018 Formulary List of Covered Drugs PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN 0001801, 1 This formulary was updated on 0/01/018.

More information

Medi-Cal Formulary. Foreword. How do I use the Care1st Medi-Cal Formulary? What if my drug is not on the Care1st Medi-Cal Formulary?

Medi-Cal Formulary. Foreword. How do I use the Care1st Medi-Cal Formulary? What if my drug is not on the Care1st Medi-Cal Formulary? Medi-Cal Formulary Foreword The Care1st Medi-Cal Formulary is a list of covered and preferred drug agents for Care1st Medi-Cal members. The drug list includes drugs used to treat common diseases or health

More information

CARE1ST HEALTH PLAN 2017 FORMULARY

CARE1ST HEALTH PLAN 2017 FORMULARY CARE1ST HEALTH PLAN 2017 FORMULARY FORMULARIO DE MEDICAMENTOS LIST OF COVERED DRUGS LISTA DE MEDICAMENTOS CUBIERTOS Counties / Condados: El Paso, Fresno, Los Angeles, Merced Orange, Riverside, San Bernardino,

More information

Medi-Cal Formulary. Foreword. How do I use the Care1st Medi-Cal Formulary? What if my drug is not on the Care1st Medi-Cal Formulary?

Medi-Cal Formulary. Foreword. How do I use the Care1st Medi-Cal Formulary? What if my drug is not on the Care1st Medi-Cal Formulary? Medi-Cal Formulary Foreword The Care1st Medi-Cal Formulary is a list of covered and preferred drug agents for Care1st Medi-Cal members. The drug list includes drugs used to treat common diseases or health

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

Prescription Drug Formulary

Prescription Drug Formulary Prescription Drug 016 This formulary was updated on 03//016. For more recent information or other questions, please contact Essence Healthcare, Inc. Customer Service at (866) 597-9560 or, for TTY users,

More information

Immunological Agents Inflammatory Bowel Disease Agents Irrigating Solutions Metabolic Bone Disease Agents...

Immunological Agents Inflammatory Bowel Disease Agents Irrigating Solutions Metabolic Bone Disease Agents... Table of Contents Analgesics... Anesthetics... 9 Anti-Addiction/Substance Abuse Treatment Agents...9 Antianxiety Agents...10 Antibacterials... 11 Anticancer Agents... 0 Anticholinergic Agents... 9 Anticonvulsants...9

More information

2017 HEALTH CHOICE ARIZONA FORMULARIO

2017 HEALTH CHOICE ARIZONA FORMULARIO 2017 HEALTH CHOICE ARIZONA FORMULARIO ARIZONA Preguntas? Póngase en contacto con los Servicios a Farmacias de Health Choice Arizona al 800-322-8670. Welcome to Our Family! ienvenidos a Nuestra Familia!

More information

Formulary Medi-Cal 2018

Formulary Medi-Cal 2018 ormulary Medi-Cal 2018 IEHP Medi-Cal 2018 ormulary Table of Contents Analgesics... 2 Anesthetics... 3 Antiarthritics... 3 Antiasthmatics... 4 Antibiotics... 5 Anticoagulants... 9 Antifungals... 10 Antihistamine

More information

2017 Comprehensive Formulary. (List of Covered Drugs) SMALL GROUP AND INDIVIDUAL

2017 Comprehensive Formulary. (List of Covered Drugs) SMALL GROUP AND INDIVIDUAL 07 Comprehensive Formulary (List of Covered Drugs) SMALL GROUP AND INDIVIDUAL SummaCare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national

More information

LIST OF COVERED DRUGS

LIST OF COVERED DRUGS LIST OF COVERED DRUGS Community Care Plus FIDA-MMP 2017 1.877.ICS.2525 www.icsny.org H4465_ListofCoveredDrugs_2017_82216 H4465_ListofCoveredDrugs_2017_82216 ICS Community Care Plus FIDA-MMP 2017 List of

More information

IEHP Medi-Cal LISTA DE MEDICAMENTOS CUBIERTOS DE Tabla de Contenido

IEHP Medi-Cal LISTA DE MEDICAMENTOS CUBIERTOS DE Tabla de Contenido 2016 IEHP Medi-Cal LISTA DE MEDICAMENTOS CUBIERTOS DE 2016 Tabla de Contenido Analgésicos... 3 Anestésicos... 4 Antiartríticos... 5 Antiasmáticos... 5 Antibióticos... 7 Anticoagulantes... 11 Antifúngicos...

More information

General Formulary Information

General Formulary Information List of covered drugs 8 Member formulary General Formulary Information This formulary is applicable to the Triple Choice and Traditional Prescription Medication Benefit plans offered by Geisinger Health

More information

2018 HEALTH CHOICE ARIZONA FORMULARIO

2018 HEALTH CHOICE ARIZONA FORMULARIO 2018 HEALTH CHOICE ARIZONA FORMULARIO ARIZONA Preguntas? Póngase en contacto con los Servicios a Farmacias de Health Choice Arizona al 800-322-8670. Welcome to Our Family! ienvenidos a Nuestra Familia!

More information

Formulary Medi-Cal 2017

Formulary Medi-Cal 2017 ormulary Medi-Cal 2017 IEHP Medi-Cal 2017 ormulary Table of Contents Analgesics... 3 Anesthetics... 4 Antiarthritics... 4 Antiasthmatics... 5 Antibiotics... 6 Anticoagulants... 11 Antifungals... 11 Antihistamine

More information

2017 Comprehensive Formulary

2017 Comprehensive Formulary MoDOT/MSHP Medical and Life Insurance Plan 07 Comprehensive Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated

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

VillageCareMAX Full Advantage FIDA Plan (Medicare-Medicaid Plan)

VillageCareMAX Full Advantage FIDA Plan (Medicare-Medicaid Plan) H9345_MBR16_03 CMS Approved VillageCareMAX Full Advantage FIDA Plan (Medicare-Medicaid Plan) 2016 List of Covered Drugs (Formulary) This formulary was updated on 10/01/2016. For more recent information

More information

Formulario 2018 Lista de Medicamentos Cubiertos

Formulario 2018 Lista de Medicamentos Cubiertos Génesis Constellation Health (HMO SNP) Génesis Prime Constellation Health (HMO SNP) Genesis @ Home Constellation Health (HMO SNP) Orión Constellation Health (HMO) Formulario 208 Lista de Medicamentos Cubiertos

More information

LiveWe Formulary/Formulario (List of Covered Drugs)/ (Lista de medicamentos cubiertos) (HMO)

LiveWe Formulary/Formulario (List of Covered Drugs)/ (Lista de medicamentos cubiertos) (HMO) 018 Formulary/Formulario (List of Covered Drugs)/ (Lista de medicamentos cubiertos) Bronx, Kings (Brooklyn), Queens, Nassau, New York (Manhattan), Suffolk and Westchester Counties PLEASE READ: THIS DOCUMENT

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

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

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

ANALGESICS - TREATMENT OF PAIN ANALGESICS

ANALGESICS - TREATMENT OF PAIN ANALGESICS 2018 First Choice VIP Care Plus Formulary Document: 2018 Formulary Formulary ID: 18395 Last Updated: 03/2018 Effective Date: 04-01-2018 Name of Drug ANALGESICS - TREATMENT OF PAIN ANALGESICS 8 HOUR ER

More information

LIST OF COVERED DRUGS

LIST OF COVERED DRUGS LIST OF COVERED DRUGS Community Care Plus FIDA-MMP 2017 1.877.ICS.2525 www.icsny.org H4465_ListofCoveredDrugs_2017_82216 Table of Contents Analgesics... 3 Anesthetics... 14 Anti-Addiction/Substance Abuse

More information

UNIVERSITY HEALTH CARE ADVANTAGE (HMO) 2015 FORMULARY (LIST OF COVERED DRUGS)

UNIVERSITY HEALTH CARE ADVANTAGE (HMO) 2015 FORMULARY (LIST OF COVERED DRUGS) UNIVERSITY HEALTH CARE ADVANTAGE (HMO) 2015 FORMULARY (LIST OF COVERED DRUGS) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN 15492.000, 16 This formulary was updated

More information

FORMULARY JANUARY 2018

FORMULARY JANUARY 2018 FORMULARY JANUARY 2018 EpiphanyRx Formulary (Drug List) EpiphanyRx regularly updates this list with medications approved by the U.S. Food and Drug Administration. Your prescription drug benefit plan may

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

Current as of November 1, 2017

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

More information

Formulary. Medi-Cal. Healthy Kids. and

Formulary. Medi-Cal. Healthy Kids. and ormulary Medi-Cal and Healthy Kids 2015 IEHP Medi-Cal 2015 ormulary Table of Contents ADHD/Anti-Narcolepsy/Anti-Obesity/Anorexiants... 3 Aminoglycosides... 4 Analgesics - Anti-Inflammatory... 4 Analgesics

More information

Your Guide to Prescription Drug Benefits

Your Guide to Prescription Drug Benefits Your Guide to Prescription Drug Benefits 2018 ESSENTIAL FORMULARY GUIDE FOR INDIVIDUAL AND SMALL GROUP* PLANS *Does not apply to the following Small Group plans. For these plans, please refer to the 2018

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