List of Covered Drugs (Formulary) Empire BlueCross BlueShield HealthPlus Fully Integrated Duals Advantage (FIDA) Plan (Medicare-Medicaid Plan)

Size: px
Start display at page:

Download "List of Covered Drugs (Formulary) Empire BlueCross BlueShield HealthPlus Fully Integrated Duals Advantage (FIDA) Plan (Medicare-Medicaid Plan)"

Transcription

1 List of Covered s (Formulary) Empire BlueCross BlueShield HealthPlus Fully Integrated Duals Advantage (FIDA) Plan (Medicare-Medicaid Plan) 2015 Participant Services: (TTY 711) Monday through Friday from 8 a.m. to 8 p.m. local time ENYDMKT Formulary Formulary ID: Version: 14 Issued 11/01/2015

2 Empire FIDA Plan 2015 List of Covered s (Formulary) This is a list of drugs that Participants can get in the Empire BlueCross BlueShield HealthPlus Fully Integrated Duals Advantage (FIDA) Plan (Medicare-Medicaid Plan). Empire BlueCross BlueShield HealthPlus Fully Integrated Duals Advantage (FIDA) Plan (Medicare- Medicaid Plan) is a managed care plan that contracts with both Medicare and the New York State Department of Health (Medicaid) to provide benefits of both programs to Participants through the Fully Integrated Duals Advantage (FIDA) Demonstration. Empire BlueCross BlueShield HealthPlus is the trade name of HealthPlus HP, LLC, an independent licensee of the Blue Cross and Blue Shield Association. Benefits, List of Covered s, and pharmacy and provider networks may change from time to time throughout the year and on January 1 of each year. You can always check Empire FIDA Plan s up-to-date List of Covered s online at or by calling Empire FIDA Plan Participant Services at (TTY 711) Monday through Friday from 8 a.m. to 8 p.m. Limitations and restrictions may apply. For more information, call Empire FIDA Plan Participant Services or read the Empire FIDA Plan Participant Handbook. re are no copays for any covered drugs. You can get this information for free in other formats, such as Braille or large print. Call (TTY 711) Monday through Friday from 8 a.m. to 8 p.m. call is free. You can get this information for free in other languages. Call (TTY 711) Monday through Friday from 8 a.m. to 8 p.m. call is free. Usted puede obtener esta información gratuitamente en otros idiomas. Llame al (TTY 711) de lunes a viernes de 8 a.m. a 8 p.m. hora local. La llamada es gratuita. 您可以免費獲得此資訊的其他語言版本 請致電 (TTY 711) 當地時間週一至週五上午 8 點至晚上 8 點 此為免付費電話 Ou ka jwenn enfòmasyon sa gratis nan lòt lang. Rele (TTY 711) lendi rive vandredi depi 8 è a.m. pou 8 è p.m. nan lè lokal. Apèl sa gratis. È possibile ottenere queste informazioni gratuitamente in altre lingue. Chiamare (TTY 711) dal lunedì al venerdì, dalle 8:00 alle 20:00 ora locale. La chiamata è gratuita.? If you have questions, please call Empire FIDA Plan (TTY 711) Monday through Friday from 8 a.m. to 8 p.m. local time. call is free. For more information, visit H8417_15_20348_T_13 CMS Approved 12/24/2014 ENYDMKT

3 이정보는다른언어로무료로얻을수있습니다. 현지시간으로월요일부터금요일까지, 오전 8 시에서 오후 8 시사이에 (TTY 711) 번으로문의하십시오. 통화는무료입니다. Вы можете получить данную информацию бесплатно на любом языке. Звоните по номеру (TTY 711) с понедельника по пятницу с 8:00 до 20:00 по местному времени. Звонок бесплатный. State of New York has created a Participant Ombudsman Program called the Independent Consumer Advocacy Network (ICAN) to provide Participants free, confidential assistance on any services offered by Empire FIDA Plan. Participant Ombudsman may be reached toll-free at or online at If you have questions, please call Empire FIDA Plan (TTY 711) Monday through Friday from 8 a.m. to 8 p.m. local time. call is free. For more information, visit ENYDMKT

4 Frequently Asked Questions (FAQ) Find answers here to questions you have about this List of Covered s. You can read all of the FAQ to learn more, or look for a question and answer. 1. prescription drugs are on the List of Covered s? (We call the List of Covered s the List for short.) drugs on the List of Covered s that starts on page 11 are the drugs covered by Empire FIDA Plan. se drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as network pharmacies. Empire FIDA Plan will cover all drugs on the List if: your doctor or other network prescriber says you need them to get better or stay healthy, the drug is medically necessary for your condition, and you fill the prescription at an Empire FIDA Plan network pharmacy. Empire FIDA Plan may have additional steps to access certain drugs (see question #5 below). In some cases, you may have to do something before you can get a drug, like try other drugs first. You can also see an up-to-date list of drugs that we cover on our website at or call Participant Services at (TTY 711) Monday through Friday from 8 a.m. to 8 p.m. 2. Does the List ever change? Yes. Empire FIDA Plan may add or remove drugs on the List during the year. Generally, the List will only change if: a new drug comes along that works as well as a drug on the List now, or we learn that a drug is not safe. We may also change our rules about drugs. For example, we could: Decide to require or not require prior approval for a drug. (Prior approval is permission from Empire FIDA Plan or your Interdisciplinary Team (IDT) before you can get a drug.) Add or change the amount of a drug you can get (called quantity limits ). Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.)? If you have questions, please call Empire FIDA Plan (TTY 711) Monday through Friday from 8 a.m. to 8 p.m. local time. call is free. For more information, visit H8417_15_20348_T_13 CMS Approved 12/24/2014 ENYDMKT

5 (For more information on these drug rules, see page 11.) We will tell you when a drug you are taking is removed from the List. We will also tell you when we change our rules for covering a drug. Questions 3, 4, and 7 below have more information on what happens when the List changes. You can always check Empire FIDA Plan s up-to-date List online at You can also call Participant Services to check the current List at (TTY 711) Monday through Friday from 8 a.m. to 8 p.m. 3. happens when a cheaper drug comes along that works as well as a drug on the List now? If a cheaper drug becomes available that works as well as a drug on the List now: Your pharmacist may give you the cheaper drug the next time you fill your prescription. If you and your provider decide that the cheaper drug is not right for you, your provider can tell the pharmacist to continue to give you the drug you take now. Empire FIDA Plan may decide to take the more expensive drug off of the List. If you are taking a drug that we remove from the List because a cheaper drug that works just as well comes along, we will tell you at least 60 days before we remove it from the List or when you ask for a refill. n you can get a 60-day supply of the drug before the change to the List is made. If you get a notice like this, you should talk to your provider about starting a drug on the list or asking for an exception. 4. happens when we find out a drug is not safe? If the Food and Administration (FDA) says a drug you are taking is not safe, we will take it off the List right away. We will also send you a letter and call you to tell you that the unsafe drug was taken off the List. If you get a notice about an unsafe medicine, call your doctor right away. Your doctor can help you find another medicine that will work best for you. 5. Are there any restrictions or limits on drug coverage? Or are there any required actions to take in order to get certain drugs? Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases you must do something before you can get the drug. For example:? If you have questions, please call Empire FIDA Plan (TTY 711) Monday through Friday from 8 a.m. to 8 p.m. local time. call is free. For more information, visit ENYDMKT

6 Prior approval (or prior authorization): For some drugs, you or your doctor or other prescriber must get approval from Empire FIDA Plan or your Interdisciplinary Team (IDT) before you fill your prescription. If you don t get approval, Empire FIDA Plan may not cover the drug. Quantity limits: Sometimes Empire FIDA Plan limits the amount of a drug you can get. Step therapy: Sometimes Empire FIDA Plan requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn t work for you, then we will cover the second. You can find out if your drug has any additional requirements or limits by looking in the tables beginning on pages 11. You can also get more information by visiting our website at We have posted online documents that explain our prior authorization restriction and step therapy restrictions. You may also ask us to send you a copy. You can ask for an exception from these limits. Please see question 11 for more information on exceptions. If you are in a nursing facility or other long-term care facility and need a drug that is not on the List, or if you cannot easily get the drug you need, we can help. We will cover a 31-day emergency supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new Empire FIDA Plan Participant. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the List you can take instead or whether to request an exception. Please see question 11 for more information about exceptions. 6. How will you know if the drug you want has limitations or if there are required actions to take to get the drug? List of Covered s on page 11 has a column labeled Necessary actions, restrictions, or limits on use. 7. happens if we change our rules on how we cover some drugs? For example, if we add prior authorization (approval), quantity limits, and/or step therapy restrictions on a drug. We will tell you if we add prior approval, quantity limits, and/or step therapy restrictions on a drug. We will tell you at least 60 days before the restriction is added or when you next ask for a refill. n, you can? If you have questions, please call Empire FIDA Plan (TTY 711) Monday through Friday from 8 a.m. to 8 p.m. local time. call is free. For more information, visit H8417_15_20348_T_13 CMS Approved 12/24/2014 ENYDMKT

7 get a 60-day supply of the drug before the change to the List is made. This gives you time to talk to your doctor or other prescriber about what to do next. 8. How can you find a drug on the List? re are two ways to find a drug: You can search alphabetically (if you know how to spell the drug), or You can search by medical condition. To search alphabetically, go to the Alphabetical Listing section on page 139. n look for the name of your drug in the list. To search by medical condition, find the section labeled List of drugs by medical condition on page 11. n find your medical condition. For example, if you have a heart condition, you should look in that category. That is where you will find drugs that treat heart conditions. 9. if the drug you want to take is not on the List? If you don t see your drug on the List, call Participant Services at (TTY 711) Monday through Friday from 8 a.m. to 8 p.m. and ask about it. If you learn that Empire FIDA Plan will not cover the drug, you can do one of these things: Ask Participant Services for a list of drugs like the one you want to take. n show the list to your doctor or other prescriber. He or she can prescribe a drug on the List that is like the one you want to take. Or You can ask the plan or your Interdisciplinary Team (IDT) to make an exception to cover your drug. Please see question 11 for more information about exceptions. 10. if you are a new Empire FIDA Plan Participant and can t find your drug on the List or have a problem getting your drug? We can help. We must cover up to 90 days of temporary supplies of your drug, as needed, during the first 90 days you are a Participant of Empire FIDA Plan. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the List you can take instead or whether to request an exception. We will cover up to 90 days of temporary supplies of your drug if: you are taking a drug that is not on our List, or health plan rules do not let you get the amount ordered by your prescriber, or? If you have questions, please call Empire FIDA Plan (TTY 711) Monday through Friday from 8 a.m. to 8 p.m. local time. call is free. For more information, visit ENYDMKT

8 the drug requires prior approval by Empire FIDA Plan or your Interdisciplinary Team (IDT), or you are taking a drug that is part of a step therapy restriction. If you live in a nursing facility or other long-term care facility, you may refill your prescription for as long as 98 days. You may refill the drug multiple times during the 98 days. This gives your prescriber time to change your drugs to ones on the List or ask for an exception. If you experience a change in the level of care you re getting that requires you to transition from one facility or treatment center to another, you may be eligible for a one-time temporary fill of the prescription you have now. For example, if you were discharged from the hospital and given a discharge list of medications based upon the hospital formulary, you may be able to get a one-time fill of the drug. You can get the temporary one-time fill exception regardless of whether or not you re in your first 90 days of program enrollment. Have your prescriber call us for details. 11. Can you ask for an exception to cover your drug? Yes. You can ask Empire FIDA Plan or your Interdisciplinary Team (IDT) to make an exception to cover a drug that is not on the List. You can also ask Empire FIDA Plan or your IDT to change the rules on your drug. For example, Empire FIDA Plan may limit the amount of a drug we will cover. If your drug has a limit, you can ask us or your IDT to change the limit and cover more. Other examples: You can ask us or your IDT to drop step therapy restrictions or prior approval requirements. 12. How long does it take to get an exception? First, Empire FIDA Plan or your Interdisciplinary Team (IDT) must receive a statement from your prescriber supporting your request for an exception. After we receive the statement, you will get a decision on your exception request within 72 hours. If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, you will get a decision within 24 hours of receiving your prescriber s supporting statement. 13. How can you ask for an exception? To ask for an exception, call your Care Manager. Your Care Manager will work with you and your provider to help you ask for an exception.? If you have questions, please call Empire FIDA Plan (TTY 711) Monday through Friday from 8 a.m. to 8 p.m. local time. call is free. For more information, visit H8417_15_20348_T_13 CMS Approved 12/24/2014 ENYDMKT

9 14. are generic drugs? Generic drugs are made up of the same ingredients as brand-name drugs. y usually cost less than the brand-name drug and usually don t have well-known names. Generic drugs are approved by the Food and Administration (FDA). Empire FIDA Plan covers both brand-name drugs and generic drugs. 15. are OTC drugs? OTC stands for over-the-counter. Empire FIDA Plan covers some OTC drugs when they are written as prescriptions by your provider. You can read the Empire FIDA Plan List to see what OTC drugs are covered. 16. Does Empire FIDA Plan cover OTC non-drug products? Empire FIDA Plan covers some OTC non-drug products when they are written as prescriptions by your provider. Empire FIDA Plan covers non-drug items such as vitamins and minerals. You can read the Empire FIDA Plan List to see what OTC non-drug products are covered. 17. is your copay? You will not be charged a copay for drugs on the List. 18. are drug tiers? s are groups of drugs of varying types with different rules and regulations. All Empire FIDA Plan tiers have no copay. 1 drugs are preferred Part D generic and brand-name drugs. 2 drugs are part D non-preferred brand-name and generic drugs which may require prior authorization. 3 includes non-part D drugs (both brand-name and generic drugs). Some drugs may require prior authorization. 4 includes over-the-counter drugs by prescription.? If you have questions, please call Empire FIDA Plan (TTY 711) Monday through Friday from 8 a.m. to 8 p.m. local time. call is free. For more information, visit ENYDMKT

10 List of Covered s list of covered drugs that begins on the next page gives you information about the drugs covered by Empire FIDA Plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 139. first column of the chart lists the name of the drug. Brand-name drugs are capitalized (e.g., ABELCET), and generic drugs are listed in lower-case italics (e.g., fluconazole). information in the necessary actions, restrictions, or limits on use column tells you if Empire FIDA Plan has any rules for covering your drug. Here are the meanings of the codes used in the Necessary actions, restrictions, or limits on use column: B/D: HI: LA: MO: This prescription drug may be covered under Medicare Part B (for example, meaning you get the drug in your provider s office) or Part D (meaning you get it from your pharmacy). It depends on the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. Either way, you will still pay nothing for the drug. Home Infusion. This prescription drug may be covered under our medical benefit. For more information, call Member Services. Limited Availability. This prescription may be available only at certain pharmacies. For more information, please call Member Services. Mail-Order. This prescription drug is available through our mail-order service, as well as through our retail network pharmacies. Consider using mail order for your long-term (maintenance) medications (such as high blood pressure medications). Retail network pharmacies may be more appropriate for short-term prescriptions (such as antibiotics). PAR: Prior Authorization required. plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you don t get approval, we may not cover the drug. QLL: Quantity Limit. For certain drugs, the plan limits the amount of the drug that we will cover. ST: Step rapy. In some cases, the plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if A and B both treat your medical condition, we may not cover B unless you try A first. If A does not work for you, we will then cover B. Note: asterisk (*) next to a drug means the drug is not a Part D drug. se drugs also have different rules for appeals. An appeal is a formal way of asking us to review a coverage decision and to change it if you think we made a mistake. For example, Empire FIDA Plan or your Interdisciplinary Team (IDT) might decide that a drug that you want is not covered or is no longer covered by Medicare or Medicaid. If you or your doctor or other prescriber disagrees with the decision, you can appeal. To ask for instructions on how to appeal, call Participant Services at (TTY 711) or the FIDA? If you have questions, please call Empire FIDA Plan (TTY 711) Monday through Friday from 8 a.m. to 8 p.m. local time. call is free. For more information, visit H8417_15_20348_T_13 CMS Approved 12/24/2014 ENYDMKT

11 Participant Ombudsman at You can also read the Participant Handbook to learn how to appeal a decision.? If you have questions, please call Empire FIDA Plan (TTY 711) Monday through Friday from 8 a.m. to 8 p.m. local time. call is free. For more information, visit ENYDMKT

12 Name of ANTI - INFECTIVES ANTIFUNGAL AGENTS ABELCET 2 $0 B/D PAR; MO AMBISOME 2 $0 B/D PAR; MO amphotericin b 2 $0 B/D PAR; MO CANCIDAS 2 $0 B/D PAR; MO clotrimazole mucous membrane 2 $0 MO ERAXIS(WATER DILUENT) 2 $0 PAR; MO fluconazole 2 $0 MO fluconazole in dextrose(iso-o) 2 $0 fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/100 ml fluconazole in nacl (iso-osm) intravenous piggyback 400 mg/200 ml 2 $0 MO 2 $0 flucytosine 2 $0 MO griseofulvin microsize oral suspension 2 $0 MO griseofulvin ultramicrosize 2 $0 MO itraconazole 2 $0 PAR; MO ketoconazole oral 2 $0 MO NOXAFIL ORAL SUSPENSION 2 $0 PAR; MO; QLL (630 per 30 days) nystatin oral suspension 2 $0 MO nystatin oral tablet 2 $0 MO terbinafine hcl oral 2 $0 MO; QLL (30 per 30 days) voriconazole intravenous 2 $0 MO voriconazole oral suspension for reconstitution 2 $0 PAR; MO; QLL (300 per 30 days) voriconazole oral tablet 200 mg 2 $0 PAR; MO; QLL (60 per 30 days) voriconazole oral tablet 50 mg 2 $0 PAR; MO; QLL (120 per 30 days) ANTIVIRALS abacavir 2 $0 MO H8417_15_20348_T_13 CMS Approved 12/24/2014 ENYDMKT

13 Name of abacavir-lamivudine-zidovudine 2 $0 MO acyclovir oral capsule 2 $0 MO acyclovir oral suspension 200 mg/5 ml 2 $0 MO acyclovir oral tablet 2 $0 MO acyclovir sodium intravenous recon soln 500 mg 2 $0 B/D PAR acyclovir sodium intravenous solution 2 $0 B/D PAR; MO adefovir 2 $0 MO amantadine hcl oral capsule 2 $0 MO amantadine hcl oral tablet 2 $0 MO APTIVUS ORAL CAPSULE 2 $0 MO APTIVUS ORAL SOLUTION 2 $0 ATRIPLA 2 $0 MO BARACLUDE 2 $0 PAR; MO cidofovir 2 $0 B/D PAR; MO COMPLERA 2 $0 MO CRIXIVAN ORAL CAPSULE 200 MG, 400 MG 2 $0 MO DAKLINZA 2 $0 PAR; MO; QLL (30 per 30 days) didanosine 2 $0 MO EDURANT 2 $0 MO EMTRIVA 2 $0 MO entecavir 2 $0 PAR; MO EPIVIR HBV ORAL SOLUTION 2 $0 MO EPIVIR ORAL SOLUTION 2 $0 MO EPZICOM 2 $0 MO EVOTAZ 2 $0 MO famciclovir oral tablet 125 mg, 250 mg 2 $0 MO; QLL (60 per 30 days) famciclovir oral tablet 500 mg 2 $0 MO; QLL (21 per 7 days) foscarnet 2 $0 B/D PAR; MO FUZEON SUBCUTANEOUS RECON SOLN 2 $0 MO; QLL (60 per 30 days) ENYDMKT

14 Name of ganciclovir sodium 2 $0 MO HARVONI 2 $0 PAR; MO; QLL (28 per 28 days) INTELENCE ORAL TABLET 100 MG, 200 MG 2 $0 MO INTELENCE ORAL TABLET 25 MG 2 $0 INVIRASE 2 $0 MO ISENTRESS 2 $0 MO KALETRA 2 $0 MO lamivudine 2 $0 MO lamivudine-zidovudine 2 $0 MO LEXIVA 2 $0 MO nevirapine 2 $0 MO NORVIR 2 $0 MO OLYSIO 2 $0 PAR; MO PREZCOBIX 2 $0 MO PREZISTA ORAL SUSPENSION 2 $0 MO PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG 2 $0 MO RELENZA DISKHALER 2 $0 MO; QLL (60 per 180 days) RESCRIPTOR 2 $0 MO RETROVIR INTRAVENOUS 2 $0 MO REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG 2 $0 MO REYATAZ ORAL POWDER IN PACKET 2 $0 MO ribasphere oral capsule 2 $0 PAR; MO ribasphere oral tablet 200 mg 2 $0 PAR; MO ribavirin oral capsule 2 $0 PAR; MO ribavirin oral tablet 200 mg 2 $0 PAR; MO rimantadine 2 $0 MO SELZENTRY 2 $0 MO SOVALDI 2 $0 PAR; MO H8417_15_20348_T_13 CMS Approved 12/24/2014 ENYDMKT

15 Name of stavudine 2 $0 MO STRIBILD 2 $0 MO SUSTIVA 2 $0 MO SYNAGIS 2 $0 PAR; MO; LA TAMIFLU ORAL CAPSULE 30 MG 2 $0 MO; QLL (84 per 1 day) TAMIFLU ORAL CAPSULE 45 MG 2 $0 MO; QLL (42 per 1 day) TAMIFLU ORAL CAPSULE 75 MG 2 $0 MO; QLL (56 per 365 days) TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION TIVICAY 2 $0 MO TRIUMEQ 2 $0 MO TRIZIVIR 2 $0 MO TRUVADA 2 $0 MO TYBOST 2 $0 MO 2 $0 MO; QLL (360 per 180 days) TYZEKA 2 $0 PAR; MO valacyclovir 2 $0 MO; QLL (30 per 1 day) VALCYTE ORAL TABLET 2 $0 MO valganciclovir 2 $0 MO VIDEX 2 GRAM PEDIATRIC 2 $0 MO VIDEX 4 GRAM PEDIATRIC 2 $0 MO VIEKIRA PAK 2 $0 PAR; MO VIRACEPT ORAL TABLET 2 $0 MO VIRAMUNE XR 2 $0 MO VIRAZOLE 2 $0 PAR; MO VIREAD ORAL POWDER 2 $0 MO; QLL (240 per 30 days) VIREAD ORAL TABLET 2 $0 MO VITEKTA 2 $0 MO ZIAGEN ORAL SOLUTION 2 $0 MO zidovudine 2 $0 MO ENYDMKT

16 Name of CEPHALOSPORINS cefaclor oral capsule 2 $0 MO cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml 2 $0 MO cefaclor oral tablet extended release 12 hr 2 $0 MO cefadroxil oral capsule 2 $0 MO cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml 2 $0 MO cefadroxil oral tablet 2 $0 MO cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml 2 $0 MO cefazolin injection recon soln 1 gram, 500 mg 2 $0 MO cefazolin injection recon soln 10 gram, 100 gram, 20 gram, 300 g 2 $0 cefazolin intravenous 2 $0 cefdinir 2 $0 MO cefepime 2 $0 MO cefoxitin in dextrose, iso-osm 2 $0 cefoxitin intravenous recon soln 1 gram 2 $0 MO cefoxitin intravenous recon soln 10 gram, 2 gram 2 $0 cefpodoxime 2 $0 MO cefprozil 2 $0 MO ceftazidime injection recon soln 1 gram, 2 gram 2 $0 MO ceftazidime injection recon soln 6 gram 2 $0 ceftriaxone in dextrose,iso-os 2 $0 MO ceftriaxone injection recon soln 1 gram, 2 gram, 250 mg, 500 mg 2 $0 MO ceftriaxone injection recon soln 10 gram 2 $0 ceftriaxone intravenous recon soln 2 $0 MO cefuroxime axetil oral tablet 2 $0 MO H8417_15_20348_T_13 CMS Approved 12/24/2014 ENYDMKT

17 Name of cefuroxime sodium injection recon soln 1.5 gram, 750 mg 2 $0 MO cefuroxime sodium intravenous 2 $0 cephalexin oral capsule 250 mg, 500 mg 1 $0 MO cephalexin oral suspension for reconstitution 1 $0 MO cephalexin oral tablet 1 $0 MO TEFLARO 2 $0 MO ERYTHROMYCINS / OTHER MACROLIDES azithromycin intravenous 2 $0 MO azithromycin oral suspension for reconstitution 2 $0 MO azithromycin oral tablet 250 mg (6 pack) 2 $0 azithromycin oral tablet 250 mg, 500 mg, 600 mg 2 $0 MO clarithromycin oral suspension for reconstitution 2 $0 MO clarithromycin oral tablet 2 $0 MO clarithromycin oral tablet extended release 24 hr 2 $0 MO; QLL (28 per 1 day) ery-tab 2 $0 MO erythrocin (as stearate) oral tablet 250 mg 2 $0 MO ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG 2 $0 erythromycin ethylsuccinate oral tablet 2 $0 MO erythromycin oral tablet 2 $0 MO MISCELLANEOUS ANTIINFECTIVES ALBENZA 2 $0 MO ALINIA ORAL SUSPENSION FOR RECONSTITUTION ALINIA ORAL TABLET 2 $0 MO amikacin injection solution 1,000 mg/4 ml, 500 mg/2 ml 2 $0 MO; QLL (180 per 3 days) 2 $0 MO atovaquone 2 $0 PAR; MO atovaquone-proguanil 2 $0 MO ENYDMKT

18 Name of AZACTAM IN DEXTROSE (ISO-OSM) 2 $0 aztreonam 2 $0 MO baciim 2 $0 BILTRICIDE 2 $0 MO CAPASTAT 2 $0 CAYSTON 2 $0 PAR; MO; LA chloramphenicol sod succinate 2 $0 chloroquine phosphate oral 2 $0 MO clindamycin hcl 2 $0 MO clindamycin phosphate injection 2 $0 MO clindamycin phosphate intravenous solution 300 mg/2 ml, 900 mg/6 ml clindamycin phosphate intravenous solution 600 mg/4 ml 2 $0 2 $0 MO colistin (colistimethate na) 2 $0 MO DAPSONE 2 $0 MO DARAPRIM 2 $0 MO ethambutol 2 $0 MO gentamicin injection 2 $0 MO gentamicin sulfate (ped) (pf) 2 $0 MO gentamicin sulfate (pf) intravenous solution 100 mg/10 ml GENTAMICIN SULFATE (PF) INTRAVENOUS SOLUTION 60 MG/6 ML gentamicin sulfate (pf) intravenous solution 80 mg/8 ml 2 $0 MO 2 $0 2 $0 hydroxychloroquine oral 1 $0 MO imipenem-cilastatin 2 $0 MO INVANZ INJECTION 2 $0 MO isoniazid oral 1 $0 MO ivermectin oral 2 $0 MO H8417_15_20348_T_13 CMS Approved 12/24/2014 ENYDMKT

19 Name of linezolid intravenous 2 $0 linezolid oral 2 $0 PAR; MO; QLL (28 per 1 day) linezolid-0.9% sodium chloride 2 $0 mefloquine 2 $0 MO MEPRON 2 $0 PAR; MO meropenem 2 $0 MO metro i.v. 2 $0 MO metronidazole in nacl (iso-os) 2 $0 MO metronidazole oral 2 $0 MO MYCOBUTIN 2 $0 MO NEBUPENT 2 $0 B/D PAR; MO neomycin 2 $0 MO paromomycin 2 $0 MO PASER 2 $0 MO PENTAM 2 $0 MO pin-x oral suspension 4 $0 [*] PIN-X ORAL TABLET,CHEWABLE 4 $0 MO; [*] PRIFTIN 2 $0 MO PRIMAQUINE 2 $0 MO pyrazinamide 2 $0 MO reese's pinworm medicine 4 $0 [*] rifabutin 2 $0 MO rifampin intravenous 2 $0 MO rifampin oral 2 $0 MO RIFATER 2 $0 MO STREPTOMYCIN INTRAMUSCULAR 2 $0 MO STROMECTOL 2 $0 MO SYNERCID 2 $0 ENYDMKT

20 Name of tobramycin in % nacl 2 $0 B/D PAR; MO; QLL (280 per 28 days) tobramycin sulfate injection recon soln 2 $0 tobramycin sulfate injection solution 2 $0 MO TRECATOR 2 $0 MO TYGACIL 2 $0 MO XIFAXAN ORAL TABLET 550 MG 2 $0 MO ZYVOX INTRAVENOUS PARENTERAL SOLUTION 200 MG/100 ML ZYVOX INTRAVENOUS PARENTERAL SOLUTION 600 MG/300 ML ZYVOX ORAL SUSPENSION FOR RECONSTITUTION 2 $0 2 $0 MO 2 $0 PAR; MO; QLL (1800 per 1 day) ZYVOX ORAL TABLET 2 $0 PAR; MO; QLL (28 per 1 day) PENICILLINS amoxicillin oral capsule 1 $0 MO amoxicillin oral suspension for reconstitution 1 $0 MO amoxicillin oral tablet 1 $0 MO amoxicillin oral tablet,chewable 125 mg, 250 mg 1 $0 MO amoxicillin-pot clavulanate 2 $0 MO ampicillin 2 $0 MO ampicillin sodium injection 2 $0 MO ampicillin sodium intravenous 2 $0 ampicillin-sulbactam injection recon soln 1.5 gram, 3 gram 2 $0 MO ampicillin-sulbactam injection recon soln 15 gram 2 $0 ampicillin-sulbactam intravenous recon soln 1.5 gram ampicillin-sulbactam intravenous recon soln 3 gram 2 $0 2 $0 MO BICILLIN C-R 2 $0 MO H8417_15_20348_T_13 CMS Approved 12/24/2014 ENYDMKT

21 Name of BICILLIN L-A 2 $0 MO dicloxacillin 2 $0 MO nafcillin injection 2 $0 MO nafcillin intravenous recon soln 2 gram 2 $0 MO oxacillin injection 2 $0 MO oxacillin intravenous 2 $0 PENICILLIN G POT IN DEXTROSE 2 $0 penicillin g potassium 2 $0 MO penicillin g procaine intramuscular syringe 1.2 million unit/2 ml penicillin g procaine intramuscular syringe 600,000 unit/ml 2 $0 MO 2 $0 penicillin g sodium 2 $0 MO penicillin v potassium 2 $0 MO piperacillin-tazobactam 2 $0 MO QUINOLONES ciprofloxacin (mixture) oral tablet, er multiphase 24 hr 1,000 mg 1 $0 MO; QLL (14 per 1 day) ciprofloxacin (mixture) oral tablet, er multiphase 24 hr 500 mg 1 $0 MO; QLL (3 per 1 day) ciprofloxacin hcl oral tablet 1 $0 MO ciprofloxacin lactate intravenous solution 200 mg/20 ml ciprofloxacin lactate intravenous solution 400 mg/40 ml 1 $0 MO 1 $0 levofloxacin intravenous 2 $0 MO levofloxacin oral tablet 2 $0 MO; QLL (14 per 1 day) moxifloxacin 2 $0 MO; QLL (21 per 1 day) ofloxacin oral tablet 400 mg 2 $0 SULFA'S / RELATED AGENTS sulfadiazine oral 2 $0 MO ENYDMKT

22 Name of sulfamethoxazole-trimethoprim 1 $0 MO TETRACYCLINES demeclocycline oral 2 $0 MO DOXY $0 MO doxycycline hyclate intravenous 2 $0 doxycycline hyclate oral capsule 2 $0 MO doxycycline hyclate oral tablet 100 mg, 20 mg 2 $0 MO doxycycline hyclate oral tablet 50 mg 2 $0 doxycycline hyclate oral tablet,delayed release (dr/ec) doxycycline monohydrate oral capsule 100 mg, 150 mg, 50 mg 2 $0 MO 2 $0 MO doxycycline monohydrate oral capsule 75 mg 2 $0 MO; QLL (60 per 1 day) doxycycline monohydrate oral tablet 2 $0 MO minocycline oral capsule 2 $0 MO minocycline oral tablet 2 $0 MO tetracycline 2 $0 MO URINARY TRACT AGENTS MACRODANTIN ORAL CAPSULE 50 MG 2 $0 PAR; MO methenamine hippurate 2 $0 MO nitrofurantoin macrocrystal oral capsule 50 mg 2 $0 PAR; MO trimethoprim 2 $0 MO VANCOMYCIN VANCOMYCIN IN D5W INTRAVENOUS PIGGYBACK 1 GRAM/200 ML VANCOMYCIN IN D5W INTRAVENOUS PIGGYBACK 500 MG/100 ML 2 $0 B/D PAR; MO 2 $0 B/D PAR VANCOMYCIN IN DEXTROSE ISO-OSM 2 $0 B/D PAR vancomycin intravenous 2 $0 B/D PAR; MO vancomycin oral capsule 125 mg 2 $0 PAR; MO; QLL (40 per 1 day) H8417_15_20348_T_13 CMS Approved 12/24/2014 ENYDMKT

23 Name of vancomycin oral capsule 250 mg 2 $0 PAR; MO; QLL (80 per 1 day) ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS amifostine crystalline 2 $0 PAR; MO dexrazoxane hcl intravenous recon soln 250 mg 2 $0 B/D PAR dexrazoxane hcl intravenous recon soln 500 mg 2 $0 B/D PAR; MO ELITEK 2 $0 PAR; MO FUSILEV 2 $0 B/D PAR; MO KEPIVANCE 2 $0 leucovorin calcium injection recon soln 100 mg, 200 mg, 350 mg, 50 mg 2 $0 B/D PAR; MO leucovorin calcium injection recon soln 500 mg 2 $0 B/D PAR leucovorin calcium oral 2 $0 MO mesna 2 $0 B/D PAR; MO MESNEX ORAL 2 $0 MO XGEVA 2 $0 PAR; MO; QLL (1.7 per 28 days) ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ABRAXANE 2 $0 B/D PAR; MO AFINITOR 2 $0 PAR; MO AFINITOR DISPERZ 2 $0 PAR; MO ALIMTA 2 $0 PAR; MO anastrozole 2 $0 MO ARRANON 2 $0 B/D PAR ARZERRA 2 $0 B/D PAR; MO ASTAGRAF XL 2 $0 B/D PAR; MO AVASTIN INTRAVENOUS SOLUTION 25 MG/ML AVASTIN INTRAVENOUS SOLUTION 25 MG/ML (16 ML) 2 $0 PAR; MO 2 $0 PAR azacitidine 2 $0 PAR; MO ENYDMKT

24 Name of azathioprine 2 $0 B/D PAR; MO BELEODAQ 2 $0 PAR; MO bexarotene 2 $0 PAR; MO bicalutamide 2 $0 MO BICNU 2 $0 B/D PAR; MO bleomycin 2 $0 B/D PAR; MO BLINCYTO 2 $0 PAR; MO BOSULIF 2 $0 PAR; MO BUSULFEX 2 $0 B/D PAR CAPRELSA 2 $0 PAR; MO; LA carboplatin intravenous solution 2 $0 B/D PAR; MO CELLCEPT INTRAVENOUS 2 $0 B/D PAR; MO CELLCEPT ORAL SUSPENSION FOR RECONSTITUTION 2 $0 B/D PAR; MO cisplatin 2 $0 B/D PAR; MO cladribine 2 $0 B/D PAR; MO CLOLAR 2 $0 B/D PAR; MO COMETRIQ 2 $0 PAR; MO COSMEGEN 2 $0 B/D PAR; MO cyclophosphamide oral capsule 2 $0 B/D PAR; MO cyclosporine intravenous 2 $0 B/D PAR cyclosporine modified 2 $0 B/D PAR; MO cyclosporine oral capsule 2 $0 B/D PAR; MO CYRAMZA INTRAVENOUS SOLUTION 10 MG/ML CYRAMZA INTRAVENOUS SOLUTION 10 MG/ML (50 ML) 2 $0 PAR; MO 2 $0 PAR cytarabine 2 $0 B/D PAR; MO cytarabine (pf) injection solution 100 mg/5 ml (20 mg/ml), 2 gram/20 ml (100 mg/ml) 2 $0 B/D PAR; MO H8417_15_20348_T_13 CMS Approved 12/24/2014 ENYDMKT

25 Name of cytarabine (pf) injection solution 20 mg/ml 2 $0 B/D PAR dacarbazine 2 $0 B/D PAR; MO daunorubicin intravenous solution 2 $0 B/D PAR DAUNOXOME 2 $0 B/D PAR; MO decitabine 2 $0 B/D PAR; MO DOCEFREZ INTRAVENOUS RECON SOLN 20 MG docetaxel intravenous solution 10 mg/ml, 140 mg/7 ml (20 mg/ml), 160 mg/16 ml (10 mg/ml), 20 mg/2 ml (10 mg/ml) docetaxel intravenous solution 20 mg/ml (1 ml), 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (10 mg/ml) 2 $0 B/D PAR 2 $0 B/D PAR 2 $0 B/D PAR; MO DOXIL 2 $0 B/D PAR; MO doxorubicin intravenous recon soln 2 $0 B/D PAR doxorubicin intravenous solution 2 $0 B/D PAR; MO DROXIA 2 $0 MO EMCYT 2 $0 MO epirubicin intravenous solution 200 mg/100 ml 2 $0 B/D PAR epirubicin intravenous solution 50 mg/25 ml 2 $0 B/D PAR; MO ERBITUX 2 $0 PAR; MO ERIVEDGE 2 $0 PAR; MO ERWINAZE 2 $0 B/D PAR; MO ETOPOPHOS 2 $0 B/D PAR; MO etoposide intravenous 2 $0 B/D PAR; MO exemestane 2 $0 MO FARESTON 2 $0 MO FARYDAK ORAL CAPSULE 10 MG 2 $0 PAR; MO; QLL (60 per 30 days) FARYDAK ORAL CAPSULE 15 MG, 20 MG 2 $0 PAR; MO; QLL (30 per 30 days) FASLODEX 2 $0 PAR; MO FIRMAGON KIT W DILUENT SYRINGE 2 $0 B/D PAR; MO ENYDMKT

26 Name of fludarabine intravenous recon soln 2 $0 B/D PAR; MO fludarabine intravenous solution 2 $0 B/D PAR fluorouracil intravenous 2 $0 B/D PAR; MO flutamide 2 $0 MO FOLOTYN 2 $0 B/D PAR; MO GAZYVA 2 $0 PAR; MO gemcitabine intravenous recon soln 1 gram, 200 mg 2 $0 B/D PAR; MO gemcitabine intravenous recon soln 2 gram 2 $0 B/D PAR gemcitabine intravenous solution 2 $0 B/D PAR gengraf 2 $0 B/D PAR; MO GILOTRIF 2 $0 PAR; MO GLEEVEC 2 $0 PAR; MO GLEOSTINE 2 $0 MO HALAVEN 2 $0 PAR; MO HERCEPTIN 2 $0 PAR; MO HEXALEN 2 $0 MO hydroxyurea 2 $0 MO IBRANCE 2 $0 PAR; MO; QLL (30 per 30 days) ICLUSIG 2 $0 PAR; MO idarubicin 2 $0 B/D PAR IFEX 2 $0 B/D PAR; MO ifosfamide intravenous recon soln 1 gram 2 $0 B/D PAR; MO ifosfamide intravenous recon soln 3 gram 2 $0 B/D PAR ifosfamide intravenous solution 2 $0 B/D PAR IMBRUVICA 2 $0 PAR; MO INLYTA 2 $0 PAR; MO irinotecan intravenous solution 100 mg/5 ml, 40 mg/2 ml 2 $0 B/D PAR; MO irinotecan intravenous solution 500 mg/25 ml 2 $0 B/D PAR H8417_15_20348_T_13 CMS Approved 12/24/2014 ENYDMKT

27 Name of ISTODAX 2 $0 PAR; MO IXEMPRA 2 $0 B/D PAR; MO JAKAFI 2 $0 PAR; MO JEVTANA 2 $0 B/D PAR; MO KADCYLA 2 $0 PAR; MO KEYTRUDA 2 $0 PAR; MO LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG [1]/DAY) LENVIMA ORAL CAPSULE 14 MG (10 MG[1] -4 MG[1])/DAY, 20 MG/DAY (10 MG [2]/DAY) LENVIMA ORAL CAPSULE 24 MG (10 MG[2] -4 MG[1])/DAY letrozole 2 $0 MO LEUKERAN 2 $0 MO 2 $0 PAR; MO; QLL (30 per 30 days) 2 $0 PAR; MO; QLL (60 per 30 days) 2 $0 PAR; MO; QLL (90 per 30 days) leuprolide 2 $0 PAR; MO LOMUSTINE 2 $0 MO LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG, 7.5 MG LUPRON DEPOT-PED INTRAMUSCULAR KIT 7.5 MG (PED) 2 $0 PAR; MO 2 $0 PAR; MO LYNPARZA 2 $0 PAR; MO; QLL (480 per 30 days) LYSODREN 2 $0 MO MATULANE 2 $0 MO megestrol oral suspension 400 mg/10 ml (10 ml) 2 $0 PAR megestrol oral suspension 400 mg/10 ml (40 mg/ml) 2 $0 PAR; MO megestrol oral tablet 2 $0 PAR; MO MEKINIST 2 $0 PAR; MO melphalan hcl 2 $0 B/D PAR mercaptopurine 2 $0 MO methotrexate sodium 2 $0 MO ENYDMKT

28 Name of methotrexate sodium (pf) injection recon soln 2 $0 methotrexate sodium (pf) injection solution 2 $0 MO mitomycin 2 $0 B/D PAR; MO mitoxantrone 2 $0 MO MUSTARGEN 2 $0 B/D PAR; MO mycophenolate mofetil 2 $0 B/D PAR; MO mycophenolate sodium 2 $0 B/D PAR; MO NEXAVAR 2 $0 PAR; MO; LA; QLL (120 per 30 days) NILANDRON 2 $0 MO NIPENT 2 $0 B/D PAR; MO NULOJIX 2 $0 B/D PAR; MO octreotide acetate 2 $0 PAR; MO ONCASPAR 2 $0 B/D PAR; MO OPDIVO 2 $0 PAR; MO oxaliplatin intravenous recon soln 100 mg 2 $0 B/D PAR; MO oxaliplatin intravenous recon soln 50 mg 2 $0 B/D PAR oxaliplatin intravenous solution 2 $0 B/D PAR; MO paclitaxel 2 $0 B/D PAR; MO PERJETA 2 $0 PAR; MO POMALYST 2 $0 PAR; MO PROGRAF INTRAVENOUS 2 $0 B/D PAR; MO PURIXAN 2 $0 PAR; MO RAPAMUNE 2 $0 B/D PAR; MO REVLIMID ORAL CAPSULE 10 MG 2 $0 PAR; MO; LA; QLL (60 per 30 days) REVLIMID ORAL CAPSULE 15 MG, 2.5 MG, 20 MG, 25 MG 2 $0 PAR; MO; LA; QLL (30 per 30 days) REVLIMID ORAL CAPSULE 5 MG 2 $0 PAR; MO; LA; QLL (150 per 30 days) RITUXAN 2 $0 PAR; MO H8417_15_20348_T_13 CMS Approved 12/24/2014 ENYDMKT

29 Name of SIMULECT INTRAVENOUS RECON SOLN 10 MG SIMULECT INTRAVENOUS RECON SOLN 20 MG 2 $0 B/D PAR 2 $0 B/D PAR; MO sirolimus 2 $0 B/D PAR; MO SOLTAMOX 2 $0 MO SOMATULINE DEPOT 2 $0 MO SPRYCEL 2 $0 PAR; MO STIVARGA 2 $0 PAR; MO; QLL (120 per 30 days) SUTENT 2 $0 PAR; MO SYNRIBO 2 $0 PAR; MO TABLOID 2 $0 MO tacrolimus oral 2 $0 B/D PAR; MO TAFINLAR 2 $0 PAR; MO tamoxifen 2 $0 MO TARCEVA 2 $0 PAR; MO TARGRETIN 2 $0 PAR; MO TASIGNA 2 $0 PAR; MO THALOMID ORAL CAPSULE 100 MG, 50 MG 2 $0 PAR; MO; QLL (30 per 30 days) THALOMID ORAL CAPSULE 150 MG, 200 MG 2 $0 PAR; MO; QLL (60 per 30 days) thiotepa 2 $0 B/D PAR; MO toposar 2 $0 B/D PAR; MO topotecan 2 $0 B/D PAR; MO TORISEL 2 $0 B/D PAR; MO TREANDA 2 $0 B/D PAR; MO TRELSTAR 2 $0 MO TRELSTAR DEPOT 2 $0 TRELSTAR LA 2 $0 tretinoin (chemotherapy) 2 $0 MO TREXALL 2 $0 MO ENYDMKT

30 Name of TRISENOX 2 $0 B/D PAR; MO TYKERB 2 $0 PAR; MO; LA UNITUXIN 2 $0 MO VECTIBIX 2 $0 PAR; MO VELCADE 2 $0 PAR; MO vinblastine intravenous solution 2 $0 B/D PAR; MO vincasar pfs intravenous solution 1 mg/ml 2 $0 B/D PAR vincasar pfs intravenous solution 2 mg/2 ml 2 $0 B/D PAR; MO vincristine 2 $0 B/D PAR; MO vinorelbine 2 $0 B/D PAR; MO VOTRIENT 2 $0 PAR; MO XALKORI 2 $0 PAR; MO XTANDI 2 $0 PAR; MO YERVOY 2 $0 PAR; MO ZALTRAP 2 $0 PAR; MO ZANOSAR 2 $0 B/D PAR; MO ZELBORAF 2 $0 PAR; MO ZOLINZA 2 $0 PAR; MO ZORTRESS 2 $0 B/D PAR; MO ZYDELIG 2 $0 PAR; MO; QLL (60 per 30 days) ZYKADIA 2 $0 PAR; MO ZYTIGA 2 $0 PAR; MO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ANTICONVULSANTS APTIOM 2 $0 ST; MO BANZEL ORAL SUSPENSION 2 $0 PAR; MO; QLL (2400 per 30 days) BANZEL ORAL TABLET 200 MG 2 $0 PAR; MO; QLL (480 per 30 days) BANZEL ORAL TABLET 400 MG 2 $0 PAR; MO; QLL (240 per 30 days) carbamazepine oral capsule, er multiphase 12 hr 2 $0 MO H8417_15_20348_T_13 CMS Approved 12/24/2014 ENYDMKT

31 Name of carbamazepine oral suspension 100 mg/5 ml 2 $0 MO carbamazepine oral tablet 2 $0 MO carbamazepine oral tablet extended release 12 hr 2 $0 MO carbamazepine oral tablet,chewable 2 $0 MO CELONTIN ORAL CAPSULE 300 MG 2 $0 MO clonazepam oral tablet 0.5 mg 2 $0 PAR; MO; QLL (1200 per 30 days) clonazepam oral tablet 1 mg 2 $0 PAR; MO; QLL (600 per 30 days) clonazepam oral tablet 2 mg 2 $0 PAR; MO; QLL (300 per 30 days) clonazepam oral tablet,disintegrating mg 2 $0 PAR; MO; QLL (4800 per 30 days) clonazepam oral tablet,disintegrating 0.25 mg 2 $0 PAR; MO; QLL (2400 per 30 days) clonazepam oral tablet,disintegrating 0.5 mg 2 $0 PAR; MO; QLL (1200 per 30 days) clonazepam oral tablet,disintegrating 1 mg 2 $0 PAR; MO; QLL (600 per 30 days) clonazepam oral tablet,disintegrating 2 mg 2 $0 PAR; MO; QLL (300 per 30 days) diazepam rectal 2 $0 MO; QLL (2 per 1 day) DILANTIN CAPSULES 2 $0 MO DILANTIN EXTENDED CAPSULES 2 $0 MO DILANTIN INFATABS 2 $0 MO divalproex 2 $0 MO epitol 2 $0 MO EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 100 MG EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 200 MG EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 300 MG ethosuximide 2 $0 MO felbamate 2 $0 MO 2 $0 MO; QLL (480 per 30 days) 2 $0 MO; QLL (240 per 30 days) 2 $0 MO; QLL (180 per 30 days) fosphenytoin 2 $0 B/D PAR; MO FYCOMPA ORAL TABLET 10 MG, 12 MG 2 $0 MO; QLL (30 per 30 days) FYCOMPA ORAL TABLET 2 MG 2 $0 MO; QLL (180 per 30 days) ENYDMKT

32 Name of FYCOMPA ORAL TABLET 4 MG 2 $0 MO; QLL (90 per 30 days) FYCOMPA ORAL TABLET 6 MG 2 $0 MO; QLL (60 per 30 days) FYCOMPA ORAL TABLET 8 MG 2 $0 MO; QLL (45 per 30 days) gabapentin oral capsule 100 mg 2 $0 MO; QLL (1080 per 30 days) gabapentin oral capsule 300 mg 2 $0 MO; QLL (360 per 30 days) gabapentin oral capsule 400 mg 2 $0 MO; QLL (270 per 30 days) gabapentin oral solution 250 mg/5 ml 2 $0 MO; QLL (2160 per 30 days) gabapentin oral solution 250 mg/5 ml (5 ml), 300 mg/6 ml (6 ml) 2 $0 QLL (2160 per 30 days) gabapentin oral tablet 600 mg 2 $0 MO; QLL (180 per 30 days) gabapentin oral tablet 800 mg 2 $0 MO; QLL (135 per 30 days) GABITRIL 2 $0 MO lamotrigine oral tablet 2 $0 MO lamotrigine oral tablet, chewable dispersible 2 $0 MO levetiracetam in nacl (iso-os) intravenous piggyback 1,000 mg/100 ml, 1,500 mg/100 ml levetiracetam in nacl (iso-os) intravenous piggyback 500 mg/100 ml 2 $0 B/D PAR 2 $0 B/D PAR; MO levetiracetam intravenous 2 $0 B/D PAR; MO levetiracetam oral solution 100 mg/ml 2 $0 MO levetiracetam oral solution 500 mg/5 ml (5 ml) 2 $0 levetiracetam oral tablet 2 $0 MO levetiracetam oral tablet extended release 24 hr 500 mg levetiracetam oral tablet extended release 24 hr 750 mg 2 $0 MO; QLL (180 per 30 days) 2 $0 MO; QLL (120 per 30 days) LYRICA ORAL CAPSULE 100 MG 2 $0 PAR; MO; QLL (180 per 30 days) LYRICA ORAL CAPSULE 150 MG 2 $0 PAR; MO; QLL (120 per 30 days) LYRICA ORAL CAPSULE 200 MG 2 $0 PAR; MO; QLL (90 per 30 days) LYRICA ORAL CAPSULE 225 MG, 300 MG 2 $0 PAR; MO; QLL (60 per 30 days) LYRICA ORAL CAPSULE 25 MG 2 $0 PAR; MO; QLL (720 per 30 days) H8417_15_20348_T_13 CMS Approved 12/24/2014 ENYDMKT

33 Name of LYRICA ORAL CAPSULE 50 MG 2 $0 PAR; MO; QLL (360 per 30 days) LYRICA ORAL CAPSULE 75 MG 2 $0 PAR; MO; QLL (240 per 30 days) LYRICA ORAL SOLUTION 2 $0 PAR; MO; QLL (900 per 30 days) ONFI ORAL SUSPENSION 2 $0 PAR; MO; QLL (480 per 30 days) ONFI ORAL TABLET 10 MG 2 $0 PAR; MO; QLL (120 per 30 days) ONFI ORAL TABLET 20 MG 2 $0 PAR; MO; QLL (60 per 30 days) oxcarbazepine 2 $0 MO OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 300 MG OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 600 MG PEGANONE 2 $0 MO 2 $0 MO; QLL (480 per 30 days) 2 $0 MO; QLL (240 per 30 days) 2 $0 MO; QLL (120 per 30 days) phenobarbital oral elixir 2 $0 PAR; MO; QLL (3000 per 30 days) phenobarbital oral tablet 100 mg 2 $0 PAR; QLL (120 per 30 days) phenobarbital oral tablet 15 mg 2 $0 PAR; MO; QLL (800 per 30 days) phenobarbital oral tablet 16.2 mg 2 $0 PAR; MO; QLL (741 per 30 days) phenobarbital oral tablet 30 mg 2 $0 PAR; MO; QLL (400 per 30 days) phenobarbital oral tablet 32.4 mg 2 $0 PAR; MO; QLL (370 per 30 days) phenobarbital oral tablet 60 mg 2 $0 PAR; MO; QLL (200 per 30 days) phenobarbital oral tablet 64.8 mg 2 $0 PAR; MO; QLL (185 per 30 days) phenobarbital oral tablet 97.2 mg 2 $0 PAR; MO; QLL (123 per 30 days) phenytoin oral suspension 100 mg/4 ml 2 $0 phenytoin oral suspension 125 mg/5 ml 2 $0 MO phenytoin oral tablet,chewable 2 $0 MO phenytoin sodium extended 2 $0 MO phenytoin sodium intravenous solution 2 $0 B/D PAR; MO phenytoin sodium intravenous syringe 2 $0 B/D PAR ENYDMKT

34 Name of POTIGA ORAL TABLET 200 MG, 300 MG, 400 MG 2 $0 MO; QLL (90 per 30 days) POTIGA ORAL TABLET 50 MG 2 $0 MO; QLL (270 per 30 days) primidone 2 $0 MO SABRIL 2 $0 PAR; MO; LA; QLL (180 per 30 days) tiagabine 2 $0 MO topiramate oral capsule, sprinkle 2 $0 PAR; MO topiramate oral tablet 2 $0 PAR; MO valproate sodium 2 $0 B/D PAR; MO valproic acid 2 $0 MO valproic acid (as sodium salt) oral solution 250 mg/5 ml valproic acid (as sodium salt) oral solution 250 mg/5 ml (5 ml), 500 mg/10 ml (10 ml) 2 $0 MO 2 $0 VIMPAT INTRAVENOUS 2 $0 B/D PAR; QLL (1200 per 30 days) VIMPAT ORAL SOLUTION 2 $0 MO; QLL (1200 per 30 days) VIMPAT ORAL TABLET 100 MG 2 $0 MO; QLL (120 per 30 days) VIMPAT ORAL TABLET 150 MG 2 $0 MO; QLL (80 per 30 days) VIMPAT ORAL TABLET 200 MG 2 $0 MO; QLL (60 per 30 days) VIMPAT ORAL TABLET 50 MG 2 $0 MO; QLL (240 per 30 days) zonisamide 2 $0 MO ANTIPARKINSONISM AGENTS APOKYN 2 $0 PAR; MO; LA AZILECT 2 $0 MO benztropine oral 2 $0 PAR; MO bromocriptine 2 $0 MO carbidopa-levodopa 2 $0 MO entacapone 2 $0 MO NEUPRO 2 $0 PAR; MO; QLL (30 per 30 days) H8417_15_20348_T_13 CMS Approved 12/24/2014 ENYDMKT

35 Name of pramipexole oral tablet 2 $0 MO ropinirole oral tablet 2 $0 MO selegiline hcl 2 $0 MO TASMAR ORAL TABLET 100 MG 2 $0 MO tolcapone 2 $0 MO MIGRAINE / CLUSTER HEADACHE THERAPY ERGOMAR 2 $0 MO MIGRANAL 2 $0 MO; QLL (8 per 28 days) rizatriptan 2 $0 MO; QLL (12 per 30 days) sumatriptan succinate oral 2 $0 MO; QLL (9 per 30 days) sumatriptan succinate subcutaneous cartridge 2 $0 MO; QLL (4 per 30 days) sumatriptan succinate subcutaneous pen injector 4 mg/0.5 ml, 6 mg/0.5 ml sumatriptan succinate subcutaneous pen injector 6 mg/0.5 ml (auto-injector) 2 $0 MO; QLL (4 per 30 days) 2 $0 QLL (4 per 30 days) sumatriptan succinate subcutaneous solution 2 $0 MO; QLL (4 per 30 days) sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml 2 $0 QLL (4 per 30 days) zolmitriptan 2 $0 MO; QLL (9 per 30 days) ZOMIG NASAL 2 $0 MO; QLL (6 per 30 days) MISCELLANEOUS NEUROLOGICAL THERAPY AMPYRA 2 $0 PAR; MO; LA; QLL (60 per 30 days) COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML 2 $0 PAR; MO; QLL (30 per 30 days) 2 $0 PAR; MO; QLL (12 per 28 days) donepezil oral tablet 10 mg, 5 mg 2 $0 MO; QLL (30 per 30 days) donepezil oral tablet,disintegrating 2 $0 MO; QLL (30 per 30 days) EXELON TRANSDERMAL 2 $0 MO; QLL (30 per 30 days) galantamine oral capsule,ext rel. pellets 24 hr 2 $0 MO; QLL (30 per 30 days) ENYDMKT

36 Name of galantamine oral solution 2 $0 MO; QLL (180 per 30 days) galantamine oral tablet 2 $0 MO; QLL (60 per 30 days) GILENYA 2 $0 PAR; MO; QLL (30 per 30 days) GLATOPA 2 $0 PAR; MO; QLL (30 per 30 days) NAMENDA ORAL SOLUTION 2 $0 PAR; MO; QLL (300 per 30 days) NAMENDA ORAL TABLET 10 MG 2 $0 MO; QLL (60 per 30 days) NAMENDA ORAL TABLET 5 MG 2 $0 MO; QLL (90 per 30 days) NAMENDA TITRATION PAK 2 $0 MO; QLL (60 per 30 days) NAMENDA XR ORAL CAP,SPRINKLE,ER 24HR DOSE PACK NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 24HR NAMZARIC 2 $0 MO 2 $0 PAR; MO; QLL (28 per 365 days) 2 $0 PAR; MO; QLL (30 per 30 days) NUEDEXTA 2 $0 MO; QLL (60 per 30 days) rivastigmine tartrate oral capsule 2 $0 MO; QLL (60 per 30 days) rivastigmine transdermal patch 2 $0 MO; QLL (30 per 30 days) TECFIDERA 2 $0 PAR; MO tetrabenazine oral tablet 12.5 mg 2 $0 PAR; MO; QLL (240 per 30 days) tetrabenazine oral tablet 25 mg 2 $0 PAR; MO; QLL (120 per 30 days) TYSABRI 2 $0 MO; LA XENAZINE ORAL TABLET 12.5 MG 2 $0 PAR; MO; LA; QLL (240 per 30 days) XENAZINE ORAL TABLET 25 MG 2 $0 PAR; MO; LA; QLL (120 per 30 days) MUSCLE RELAXANTS / ANTISPASMODIC THERAPY baclofen 2 $0 MO cyclobenzaprine oral tablet 2 $0 PAR; MO dantrolene 2 $0 MO MESTINON ORAL SYRUP 2 $0 MO MESTINON TIMESPAN 2 $0 MO H8417_15_20348_T_13 CMS Approved 12/24/2014 ENYDMKT

37 Name of pyridostigmine bromide 2 $0 MO tizanidine oral tablet 2 $0 MO NARCOTIC ANALGESICS ABSTRAL 2 $0 PAR; MO; QLL (120 per 30 days) acetaminophen-codeine oral solution 120 mg-12 mg /5 ml (5 ml), 240 mg-24 mg /10 ml (10 ml), 300 mg-30 mg /12.5 ml acetaminophen-codeine oral solution mg/5 ml 2 $0 QLL (4500 per 30 days) 2 $0 MO; QLL (4500 per 30 days) acetaminophen-codeine oral tablet mg 2 $0 MO; QLL (390 per 30 days) acetaminophen-codeine oral tablet mg 2 $0 MO; QLL (360 per 30 days) acetaminophen-codeine oral tablet mg 2 $0 MO; QLL (180 per 30 days) ACTIQ 2 $0 PAR; MO; QLL (120 per 30 days) buprenorphine hcl injection solution 2 $0 MO buprenorphine hcl injection syringe 2 $0 buprenorphine hcl sublingual tablet 2 mg 2 $0 PAR; MO; QLL (240 per 30 days) buprenorphine hcl sublingual tablet 8 mg 2 $0 PAR; MO; QLL (60 per 30 days) butalbital compound w/codeine 2 $0 PAR; MO duramorph (pf) injection solution 0.5 mg/ml 2 $0 B/D PAR; MO duramorph (pf) injection solution 1 mg/ml 2 $0 B/D PAR endocet oral tablet mg, mg, mg 2 $0 MO; QLL (360 per 30 days) fentanyl citrate 2 $0 PAR; MO; QLL (120 per 30 days) fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr 2 $0 ST; MO; QLL (15 per 30 days) FENTORA 2 $0 PAR; MO; QLL (120 per 30 days) hydrocodone-acetaminophen oral solution mg/5 ml hydrocodone-acetaminophen oral solution mg/15 ml hydrocodone-acetaminophen oral tablet mg, mg, mg 2 $0 QLL (2700 per 30 days) 2 $0 MO; QLL (2700 per 30 days) 2 $0 MO; QLL (390 per 30 days) ENYDMKT

Formulary (Drug List) Anthem HealthKeepers Medicare-Medicaid Plan (MMP), a Commonwealth Coordinated Care Plan

Formulary (Drug List) Anthem HealthKeepers Medicare-Medicaid Plan (MMP), a Commonwealth Coordinated Care Plan Formulary (Drug List) Anthem HealthKeepers Medicare-Medicaid Plan (MMP), a Commonwealth Coordinated Care Plan Member Services: 1-855-817-5787 (TTY 711) Monday through Friday 8 a.m. to 8 p.m. local time

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

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

Formulary (Drug List) Anthem Blue Cross Cal MediConnect Plan (Medicare-Medicaid Plan)

Formulary (Drug List) Anthem Blue Cross Cal MediConnect Plan (Medicare-Medicaid Plan) Santa Clara County, CA 2016 Formulary (Drug List) Anthem Blue Cross Cal MediConnect Plan (Medicare-Medicaid Plan) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN.

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

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

2018 Formulary. (List of Covered Drugs) CareMore Cal MediConnect Plan (Medicare-Medicaid Plan) Los Angeles County, CA

2018 Formulary. (List of Covered Drugs) CareMore Cal MediConnect Plan (Medicare-Medicaid Plan) Los Angeles County, CA 2018 Formulary (List of Covered Drugs) CareMore Cal MediConnect Plan (Medicare-Medicaid Plan) Los Angeles County, CA 2018 PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS

More information

Formulary (Drug List) Anthem Blue Cross Cal MediConnect Plan (Medicare-Medicaid Plan)

Formulary (Drug List) Anthem Blue Cross Cal MediConnect Plan (Medicare-Medicaid Plan) Santa Clara County, CA 2017 Formulary (Drug List) Anthem Blue Cross Cal MediConnect Plan (Medicare-Medicaid Plan) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN.

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

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

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

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

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

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

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 (Drug List) Anthem Blue Cross Cal MediConnect Plan (Medicare-Medicaid Plan)

Formulary (Drug List) Anthem Blue Cross Cal MediConnect Plan (Medicare-Medicaid Plan) Santa Clara County, CA 2018 Formulary (Drug List) Anthem Blue Cross Cal MediConnect Plan (Medicare-Medicaid Plan) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN.

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

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 June, 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

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

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

Anthem MediBlue Coordination Plus (HMO) 2018 Formulary (List of Covered Drugs) Please read: , Anthem MediBlue Coordination Plus (H) 08 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on October, 08.

More 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

(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

<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 Dual Advantage (H SNP) Formulary (List (List of of Covered s) Please read: This document contains information

More information

Formulary (Drug List) Anthem Blue Cross Cal MediConnect Plan (Medicare-Medicaid Plan)

Formulary (Drug List) Anthem Blue Cross Cal MediConnect Plan (Medicare-Medicaid Plan) Santa Clara County, CA 2018 Formulary (Drug List) Anthem Blue Cross Cal MediConnect Plan (Medicare-Medicaid Plan) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN.

More information

2018 Formulary. BlueAdvantage (PPO) SM. (List of Covered Drugs) bcbstmedicare.com

2018 Formulary. BlueAdvantage (PPO) SM. (List of Covered Drugs) bcbstmedicare.com BlueAdvantage (PPO) SM 018 Formulary (List of Covered Drugs) BlueAdvantage Diamond (PPO) SM BlueAdvantage Ruby (PPO) SM BlueAdvantage Sapphire (PPO) SM BlueAdvantage Garnet (PPO) SM We have made no changes

More information

2018 Formulary (List of Covered Drugs)

2018 Formulary (List of Covered Drugs) BlueCare Plus (HMO SNP) SM 018 Formulary (List of Covered Drugs) We have made no changes to this formulary since /1/018. For more recent information or other questions, please contact BlueCare Plus SM

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

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

H0544_058, 059, 066, 067

H0544_058, 059, 066, 067 Anthem MediBlue Select (H) 09 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on February, 09. For more recent

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

Anthem MediBlue Select (HMO) 2016 Formulary (List of Covered Drugs)

Anthem MediBlue Select (HMO) 2016 Formulary (List of Covered Drugs) Anthem MediBlue Select (H) 06 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, 06. For more recent

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 March, 09. For more recent

More information

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

Anthem Connect Plus (HMO) 2019 Formulary (List of Covered Drugs) Please read: , Anthem Connect Plus (H) 019 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on March 1, 019. For more recent

More information

S5596_001, 006, 014, 018, 057, 063

S5596_001, 006, 014, 018, 057, 063 Anthem Blue MedicareRx Plus (PDP) 08 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on May, 08. For more

More 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

Amerivantage Dual Coordination (HMO SNP) 2018 Formulary (List of Covered Drugs) Please read: Amerivantage Dual Coordination (HMO SNP)

Amerivantage Dual Coordination (HMO SNP) 2018 Formulary (List of Covered Drugs) Please read: Amerivantage Dual Coordination (HMO SNP) Amerivantage Dual Coordination (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

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

Blue MedicareRx Value (PDP) 2018 Formulary (List of Covered Drugs) Please read: , https://shop.anthem.

Blue MedicareRx Value (PDP) 2018 Formulary (List of Covered Drugs) Please read: , https://shop.anthem. Blue MedicareRx Value (PDP) 08 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on May, 08. For more recent

More information

This formulary was updated on May 1, For more recent information

This formulary was updated on May 1, For more recent information Amerivantage ESRD (H-POS 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 May, 08. 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 January, 09. For more recent

More information

2019 Formulary. BlueAdvantage (PPO) SM. (List of Covered Drugs) bcbstmedicare.com

2019 Formulary. BlueAdvantage (PPO) SM. (List of Covered Drugs) bcbstmedicare.com BlueAdvantage (PPO) SM 019 Formulary (List of Covered Drugs) BlueAdvantage Diamond (PPO) SM BlueAdvantage Ruby (PPO) SM BlueAdvantage Sapphire (PPO) SM BlueAdvantage Garnet (PPO) SM We have made no changes

More 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 07/31/2017. For more recent information or other questions, please contact the Plan at 1-800-815-0000

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

<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)> BCBSHP Prime Select (H) Formulary (List (List of of Covered s) Please read: This document contains information about

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

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 November, 07. For more recent

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

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

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

S5596_001, 006, 014, 018, 057, 063

S5596_001, 006, 014, 018, 057, 063 Anthem Blue MedicareRx Plus (PDP) 09 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on February, 09. For

More information

Anthem Blue Cross MedicareRx Standard (PDP) 2019 Formulary (List of Covered Drugs) Please read: ,

Anthem Blue Cross MedicareRx Standard (PDP) 2019 Formulary (List of Covered Drugs) Please read: , Anthem Blue Cross MedicareRx Standard (PDP) 09 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on February,

More 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

Anthem Diabetes (HMO SNP) 2019 Formulary (List of Covered Drugs) Please read: ,

Anthem Diabetes (HMO SNP) 2019 Formulary (List of Covered Drugs) Please read: , Anthem Diabetes (H SNP) 019 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on March 1, 019. For more recent

More information

BCBSGa Blue MedicareRx Standard (PDP) 2018 Formulary (List of Covered Drugs) Please read: ,

BCBSGa Blue MedicareRx Standard (PDP) 2018 Formulary (List of Covered Drugs) Please read: , BCBSGa Blue MedicareRx Standard (PDP) 08 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on October, 08.

More information

Express Scripts Medicare (PDP) 2019 Formulary (List of Covered Drugs)

Express Scripts Medicare (PDP) 2019 Formulary (List of Covered Drugs) Value Plan Express Scripts Medicare (PDP) 2019 Formulary (List of Covered s) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Formulary ID Number: 19157, Version 8

More information

2017 MEDICARE PART D DRUG FORMULARY

2017 MEDICARE PART D DRUG FORMULARY 2017 MEDICARE PART D DRUG FORMULARY National Drug Plan (PDP) Standard/Enhanced This abridged formulary was updated on 11. This is not a complete list of drugs covered by our plan. For a complete listing

More information

2017 Formulary (List of Covered Drugs)

2017 Formulary (List of Covered Drugs) 017 Formulary (List of Covered s) PLEASE READ: This document contains information about the drugs we cover in this plan. Y011_17_0810A_CHP_MT_FINAL_ Populated Template (08901) 0001709_, v0 This formulary

More information

PLEASE READ: This document contains information about the drugs we cover in this plan.

PLEASE READ: This document contains information about the drugs we cover in this plan. 01 Formulary (List of Covered s) CareMore Value Plus (H), CareMore Breathe (H SNP), CareMore Diabetes (H SNP), CareMore ESRD (H SNP), CareMore Heart (H SNP) CareMore Reliance (H SNP) PLEASE READ: This

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

FORMULARY (LIST OF COVERED DRUGS)

FORMULARY (LIST OF COVERED DRUGS) 2017 FORMULARY (LIST OF COVERED DRUGS) Michigan Complete Health Medicare-Medicaid Plan (MMP) Note to existing members: This formulary has changed since last year. Please review this document to make sure

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

Formulary (Drug List)

Formulary (Drug List) Formulary (Drug List) CareMore Cal MediConnect Plan (Medicare-Medicaid Plan) Los Angeles County, CA 2015 PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. This formulary

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

Pharmacy Benefit Guide

Pharmacy Benefit Guide Pharmacy Benefit Guide Together with CCHP PO Box 997 - MS 6280 Milwaukee, WI 520-997 Toll-free: -844-20-4677 togethercchp.org Pharmacy Program Overview The pharmacy program of Together with Children s

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

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

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

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 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

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

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

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

CareMore Classic (HMO) 2018 Formulary (List of Covered Drugs)

CareMore Classic (HMO) 2018 Formulary (List of Covered Drugs) CareMore Classic (H) 018 Formulary (List of Covered s) PLEASE READ: This document contains information about the drugs we cover in this plan. Y011_18 U_00 CMS Accepted 10//017 00018_P, v1 This formulary

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 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

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

(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

Formulary. (List of Covered Drugs) PLEASE READ: ConnectiCare Medicare Advantage Plans

Formulary. (List of Covered Drugs) PLEASE READ: ConnectiCare Medicare Advantage Plans ConnectiCare Medicare Advantage Plans 2017 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. 00017204, V8 This formulary was updated

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

Mutual of Omaha Rx (PDP) 2019 Formulary (List of Covered Drugs)

Mutual of Omaha Rx (PDP) 2019 Formulary (List of Covered Drugs) Plus Plan Mutual of Omaha Rx (PDP) 019 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Formulary ID Number: 1916, Version This 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

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

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

Senior Preferred (HMO) 2019 Formulary (List of Covered Drugs)

Senior Preferred (HMO) 2019 Formulary (List of Covered Drugs) Senior Preferred (HMO) 2019 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary ID: 19116, Version 5 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

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN.

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. HealthPartners UnityPoint Health Align (PPO) HealthPartners UnityPoint Health Symmetry (PPO) HealthPartners UnityPoint Health Group (PPO) (Collectively known as HealthPartners UnityPoint Health) 018 Formulary

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

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

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

What is the CHRISTUS Health Plan Generations (HMO) / CHRISTUS Health Plan Generations Plus (HMO) Formulary?

What is the CHRISTUS Health Plan Generations (HMO) / CHRISTUS Health Plan Generations Plus (HMO) Formulary? CHRISTUS Health Plan Generations (HMO) CHRISTUS Health Plan Generations Plus (HMO) 019 Comprehensive Formulary PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT SOME OF THE DRUGS WE COVER IN THIS PLAN

More information

(List of of Covered Drugs) Drugs)

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

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

HealthPartners Minnesota Senior Health Options (MSHO) (HMO SNP) 2018 List of Covered Drugs (Formulary)

HealthPartners Minnesota Senior Health Options (MSHO) (HMO SNP) 2018 List of Covered Drugs (Formulary) HealthPartners Minnesota Senior Health Options (MSHO) (HMO SNP) 2018 List of Covered Drugs (Formulary) This is a list of drugs that members can get in HealthPartners MSHO. HealthPartners is a health plan

More information

Amerivantage Dual Coordination (HMO SNP) 2018 Formulary (List of Covered Drugs) Please read: Amerivantage Dual Coordination (HMO SNP)

Amerivantage Dual Coordination (HMO SNP) 2018 Formulary (List of Covered Drugs) Please read: Amerivantage Dual Coordination (HMO SNP) Amerivantage Dual Coordination (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 March, 08. 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

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

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

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

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

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