Advantage Choice Pharmacy Benefit Guide

Size: px
Start display at page:

Download "Advantage Choice Pharmacy Benefit Guide"

Transcription

1 Advantage Choice Pharmacy Benefit Guide Effective November, 207

2

3 TABLE OF CONTENTS Advantage Choice Overview...i Advantage Choice Contact Numbers...i Understanding Coverage and Cost Sharing...ii About Generic Drugs...ii Formulary Overview...ii For Prospective Members...iii Understanding Our Symbols...iii Prior Authorization...iii Step Therapy...iii Quantity Limits...iii Affordable Care Act...iii Over-the-Counter...iii Limited Availability...iii Filling Your Prescriptions...iii Retail...iii Mail Order...iv Specialty Provider...iv Filling Your Prescriptions While Traveling...iv Drug Exceptions, Time Frames, and Enrollee Responsibilities...iv Medications Not Covered by Advantage Choice... vi Disclaimer... vii Nondiscrimination Notice...viii Translation Services... ix Advantage Choice Formulary...

4

5 ADVANTAGE CHOICE OVERVIEW The Advantage Choice pharmacy program offers a variety of high-quality, effective generic and brand-name prescription drugs. This guide provides information that is applicable to most members. For information specific to your plan, refer to your plan s prescription drug rider. When you need a prescription medication, you and your doctor can choose from six different levels, or tiers. Each tier has a different copayment. This gives you and your doctor the freedom to choose the medication that is right for you. At the same time, this will help you better budget your health care dollars. This guide provides an overview of your pharmacy benefit with UPMC Health Plan. It explains the copayment structure, the process for getting certain drugs covered, your options for filling prescriptions, important phone numbers, and more. ADVANTAGE CHOICE CONTACT NUMBERS Current Members: UPMC Health Plan Health Care Concierge team: UPMC Health Plan Pharmacy Services (for doctors and pharmacies): TTY Services: Prospective Members: Prospective members should direct their questions to their company s benefits administrator or to the UPMC Health Plan Health Care Concierge team at Online information is available at i

6 UNDERSTANDING COVERAGE AND COST SHARING Our formulary is the list of Food and Drug Administration (FDA)-approved drugs that we cover. UPMC Health Plan s Pharmacy and Therapeutics (P&T) Committee researches and evaluates medications it may cover. Committee members include local doctors and pharmacists who meet regularly during the year to review and update the formulary. Committee members base their decision on the drug s safety, effectiveness, and cost. Advantage Choice prescription drugs are organized into six copayment tiers on the formulary: Tier includes a majority of generic medications. Generic drugs offer the same level of safety and quality as their brand-name equivalents. They have the same amount of active ingredients as brand-name medications. Advantage Choice requires you to use a generic version of the drug if one is available. This means that if you receive a brand-name drug when a generic is available, you must pay the brand copayment in addition to the retail cost difference between the brand-name and generic forms of the drug. Tier 2 is for preferred-brand medications. UPMC Health Plan classifies these drugs as preferred because of their value and effectiveness. Tier is for non-preferred brand medications. Tier 4 is for specialty medications, for which you will have the highest level of cost sharing. Specialty medications usually treat complex and rare conditions. These drugs are created because of advancements in drug development. These drugs can be high-cost medications and biologicals regardless of how they are administered (injectable, oral, transdermal, or inhalant). Specialty drugs require close management by a physician. Physicians need to monitor these drugs due to potential side effects and the need for frequent dosage adjustments. Tier 5 is for select generic medications. Select generic medications are offered at no additional cost share to you. Many of these medications can help you to avoid getting sick and to improve your overall health. About Generic Drugs Generic drugs have the same active ingredients as their brandname equivalents, but cost significantly less. Not all drugs have a generic equivalent. Generally, new drugs receive patent protection. Once the patent expires, other pharmaceutical companies can produce the same drug in a generic formulation. Companies that make generic drugs do not have to invest large amounts of money in research, since the company making the brand-name equivalent has already done this. Also, generic companies do not need to advertise their drugs. As a result, generic drug makers can pass these savings on to you. Generic drugs have the same active ingredients as brand-name drugs, but their inactive ingredients can vary. This is why the generic drug might look different from the brand-name drug. Inactive ingredients can be dyes used to color the drug or powders used to shape the tablets. Inactive ingredients do not affect how the generic drug works. The FDA regulates generic drug manufacturers just as it regulates the makers of brand-name medications. The generic drug must pass strict FDA measurements to ensure that it delivers the same amount of the active ingredient in the same time frame as its brand-name counterpart. The manufacturer of the generic drug must prove that it produces its product under the same strict guidelines as the brand-name drug. FORMULARY OVERVIEW The most commonly prescribed Advantage Choice drugs are listed in the formulary section of this booklet. Please note that there are other drugs that Advantage Choice covers in addition to the ones listed in this booklet. For the latest information on the complete Advantage Choice formulary and other pharmacy benefits, visit our website at pharmacy. Select Advantage Choice to access the searchable drug list. You may also call our Health Care Concierge team at the number listed on the back of your member ID card or on page i of this booklet. If you are a current UPMC Health Plan member, refer to your Schedule of Benefits for your copayment amounts. If you did not receive a Schedule of Benefits in your Welcome Kit, contact our Health Care Concierge team at the number on the back of your member ID card. Your member ID card should also list your copayment amounts. Tier 6 is for zero cost share preventive drugs. In accordance with the Affordable Care Act of 200 (ACA), many select preventive medications are covered at no cost to you. ii

7 For Prospective Members If you are thinking about joining UPMC Health Plan and would like information about copayment amounts, review the Schedule of Benefits. You may have received one from your company s Benefits Administrator or Human Resources Department. If you did not receive a Schedule of Benefits, contact the UPMC Health Plan Health Care Concierge team at the number listed on page i of this booklet. UNDERSTANDING OUR SYMBOLS Prior Authorization You will see the symbol PA next to certain drugs on the formulary tables in this booklet. PA stands for prior authorization. If a drug requires prior authorization, the UPMC Health Plan Pharmacy Services Department must authorize the use of this drug before it will be covered. Drugs that require prior authorization are often: Newer drugs for which UPMC Health Plan wants to track usage. Drugs not used as a standard first-line option in treating a medical condition. Drugs with potential side effects that UPMC Health Plan wants to monitor for patient safety. Drugs categorized as specialty medications. Compounded medications that contain included ingredients require prior authorization. Step Therapy You will see the symbol ST next to certain drugs on the formulary tables in this booklet. ST stands for step therapy. Step therapy is the practice of using specific medications first when beginning drug therapy for a medical condition. The preferred first course of treatment may be generic medications or drugs that are considered as the standard first-line treatment. Step therapy is built into the electronic system that checks your medication history. A drug with step therapy will be automatically approved if there is a record that you have already tried the preferred drug(s). If there is no record that you tried the preferred drug(s) in your medication history, your physician must submit relevant clinical information to the UPMC Health Plan Pharmacy Services Department before it will be covered. Quantity Limits You will see the symbol QL next to certain drugs on the formulary tables in this booklet. QL stands for quantity limits. Quantity limits are drug-specific and limit the amount of certain drugs that can be dispensed during a specified period of time. These limits are based on FDA guidelines, clinical literature, and the manufacturer s instructions. Quantity limits promote appropriate use of the drug, prevent waste, and help control costs. For some drugs, the dosing guidelines may recommend that patients take the drug one time a day in a larger dose instead of several times a day in smaller doses. The quantity limits follow the guidelines and cover one larger dose per day. Your physician can request an exception to the quantity limit through the UPMC Health Plan Pharmacy Services Department. Prescriptions for controlled substances and specialty medications are limited to a 0-day supply. Affordable Care Act You will see the symbol ACA next to certain drugs on the formulary tables in this booklet. ACA stands for Affordable Care Act. In accordance with the Affordable Care Act of 200 (ACA), many select preventive medications are covered at no cost to you. Over-the-Counter You will see the symbol OTC next to certain drugs on the formulary tables in this booklet. OTC stands for over-thecounter. Even though over-the-counter drugs can typically be purchased without a prescription, a prescription is required for coverage of these medications on your pharmacy benefit. Limited Availability You will see the symbol LA next to certain drugs on the formulary tablets in this booklet. LA stands for limited availability. Limited availability drugs must be obtained through our designated specialty pharmacy provider. FILLING YOUR PRESCRIPTION Retail UPMC Health Plan s network of retail pharmacies includes hundreds of locations independent pharmacies as well as multistore chains throughout the region. You can take your prescription to any pharmacy in the network. You must use 75 percent of your medication before you can get a refill. iii

8 For specific pharmacy names, locations, and telephone numbers, visit or call our Health Care Concierge team. The phone number is listed on the back of your member ID card and on page i of this booklet. Mail Order If you take maintenance medications for a chronic condition, you can get them through a mail-order pharmacy. Maintenance medications are drugs that are taken on a regular, long-term basis. This may include drugs to treat high blood pressure, diabetes, asthma, high cholesterol, and more. With convenient mail-order service: You receive a 90-day supply of most drugs, plus refills, as prescribed by your doctor. You usually pay a lower out-of-pocket cost for a 90-day supply at a mail-order pharmacy than you would pay at a retail pharmacy. You get these drugs delivered right to your door. Most mail-order prescriptions are written for a 90-day supply. If your doctor writes for a 0-day supply with two refills, the mail order facility may combine the prescription to make a 90-day supply. If you do not want a 90-day supply, you should indicate this on the mail-order form. For a new medication, UPMC Health Plan recommends that you try a 0-day supply of the drug from a retail pharmacy. That way your doctor has a chance to make sure that it is the right dose for you and that it does not cause any side effects. Once you re confident that the medication is appropriate, ask your doctor to write a prescription for a 90-day supply of each maintenance drug that you need (plus refills if appropriate). Then order the supply through the mail-order pharmacy. To avoid running out of your mail-order prescription, reorder your medication while you still have an adequate supply remaining, allowing a few weeks for processing and delivery. To request refills, you may order online or over the telephone. You can request a mail-order form by calling our Health Care Concierge team or requesting the form on the UPMC Health Plan website at Specialty Provider Specialty medications that require special handling, provider coordination, or patient education that cannot be provided by a retail pharmacy must be obtained through our designated specialty provider. When you are prescribed a specialty medication and use a specialty provider, you get mail-order delivery and improved access to drugs, as many retail pharmacies do not carry these types of medications. Specialty providers also improve care by providing education for our members and expanded access to health care professionals trained in the proper use of these specialty medications. A specialty provider offers cost-effective health care and medication management and compliance programs. Filling Your Prescription When Traveling When you travel outside the western Pennsylvania area, thousands of pharmacies across the country will honor your UPMC Health Plan member ID card. To locate a participating pharmacy, contact our Health Care Concierge team at the phone number listed on the back of your member ID card or on page i of this booklet. To fill a prescription at a participating out-of-area pharmacy, present your UPMC Health Plan member ID card. Some pharmacies may ask you to pay the full price of the medication. If that happens and your claim is approved, you will be reimbursed the amount you paid for the medication, less the appropriate copayment. You can request a Pharmacy Program Direct Reimbursement Claim Form by calling our Health Care Concierge team or requesting the form on the UPMC Health Plan website at If you will be away from home for an extended period of time, or if you will be traveling outside of the country, you may want to use our mail-order service so that you receive a 90-day supply before you leave home. Medication Supplies Not Covered by UPMC Health Plan No authorizations will be provided for medications that are reported by the member, provider, or pharmacy to be lost, misplaced, stolen, destroyed, or damaged. Medications received at no charge to the member (workers compensation, medications purchased with a manufacturer s coupon, etc.) will not be covered. Prescriptions that were written more than a year ago will not be covered. Your doctor will need to write a new prescription. Drug Exceptions, Time Frames, and Enrollee Responsibilities If the medication you take is not on the list of covered drugs for your benefit plan (also called a formulary ), you can ask us to cover it. A request for a non-formulary medication will only be approved if there is documented evidence that the formulary alternatives are not effective in treating your condition; the formulary alternatives would cause adverse side effects; or a contraindication exists such that you cannot safely try the formulary alternatives. iv

9 As a first step, you can contact Member Services for a list of similar drugs that are covered by your plan or you can go to for this information. When you have the list, show it to your doctor and see whether he or she is able to prescribe one of the drugs on this list. If you need to request a non-formulary medication, contact Member Services or access the non-formulary request form on the MyHealth OnLine website. When you make this request, we may contact your prescriber or physician for information to support your request. After UPMC Health Plan receives your request, we will make our decision within 72 hours. You can request a faster (expedited) decision if you or your doctor believe that waiting up to 72 hours for a decision could seriously harm your health. If your request to expedite is granted, we must give you a decision no later than 24 hours from when we received your request. If we deny your request for a non-formulary medication, you may request an internal review of that decision by contacting Member Services. If the denial of the non-formulary medication request is upheld through an internal review, you may then request an external review by an Independent Review Organization (IRO). Requests for an external review can also be made by contacting Member Services at v

10 MEDICATIONS NOT COVERED BY ADVANTAGE CHOICE The following medications are benefit exclusions and will not be covered under the pharmacy benefit: Antimalarial agents when used for prevention Antiobesity medications, including but not limited to appetite suppressants and lipase inhibitors Blood or blood plasma products* Compounded products containing excluded ingredients (examples are compounded hormone replacement therapies and compounded narcotic analgesics) Drugs labeled for investigational use Drugs used for cosmetic purposes or hair growth Drugs used to treat sexual dysfunction (examples are Viagra, Levitra, Muse, Caverject, Stendra) Fertility agents Legend vitamins (other than prenatal, fluoride, and certain therapeutic vitamins) Most over-the-counter medications** Needles/syringes (other than insulin)* Nutrition and dietary supplements* Ostomy supplies* Therapeutic devices/appliances* Urine strips (Because our doctors feel blood glucose strips are more accurate than urine test strips in measuring blood glucose, urine strips are not a covered benefit.) *Please note that, under certain circumstances, your medical benefits may cover the items marked with an asterisk (*). For information on these items, you can contact our Health Care Concierge team at the number listed on the back of your member ID card. If you have not yet received an ID card, call the Health Care Concierge team number listed on page i of this booklet. **Additional over-the-counter medications may be covered in accordance with the ACA. The Preventive Services Guide available on the UPMC Health Plan website contains information regarding this coverage. vi

11 UPMC Health Plan Inc. administers group and individual products for UPMC Health Coverage Inc., UPMC Health Network Inc., UPMC Health Options Inc., and UPMC Health Plan Inc. Please note that throughout this document, we use the terms UPMC Health Plan and the Health Plan to refer to UPMC Health Coverage Inc., UPMC Health Network Inc., UPMC Health Options Inc., and UPMC Health Plan Inc., as well as plans administered by UPMC Benefit Management Services Inc. This managed care plan may not cover all of your health care expenses. Read your contract carefully to determine which health care services are covered. This Pharmacy Benefit Guide is current as of November, 207. For the latest information on the Advantage Choice drug formulary and other pharmacy benefits, visit Select Advantage Choice to access the searchable drug list. You may also call our Health Care Concierge team at the number listed on the back of your member ID card and on page i of this booklet. vii

12 NONDISCRIMINATION NOTICE UPMC Health Plan complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. UPMC Health Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. UPMC Health Plan : Provides free aids and services to people with disabilities so that they can communicate effectively with us, such as: Qualified sign language interpreters. Written information in other formats (large print, audio, accessible electronic formats, other formats). Provides free language services to people whose primary language is not English, such as: Qualified interpreters. Information written in other languages. If you need these services, contact the Civil Rights Administrator. If you believe that UPMC Health Plan has failed to provide these services or has discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Administrator UPMC Health Plan 600 Grant Street - 55th Floor Pittsburgh, PA 529 Phone: (TTY: ) Fax: HealthPlanCompliance@upmc.edu You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, the Civil Rights Administrator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at lobby.jsf, or by mail or phone at U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 2020, TTY/TDD users should call Complaint forms are available at UPMC Health Plan is the marketing name used to refer to the following companies, which are licensed to issue individual and group health insurance products or which provide third party administration services for group health plans: UPMC Health Network Inc., UPMC Health Options Inc., UPMC Health Coverage Inc., UPMC Health Plan Inc., UPMC Health Benefits Inc., UPMC for You Inc., and/or UPMC Benefit Management Services Inc. viii

13 Translation Services ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: ). 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY: ) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: ). ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: ). Wann du [Deitsch (Pennsylvania German / Dutch)] schwetzscht, kannscht du mitaus Koschte ebber gricke, ass dihr helft mit die englisch Schprooch. Ruf selli Nummer uff: Call (TTY: ). 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: ) 번으로전화해주십시오. ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero (TTY: ). ملحوظة: إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. الصم والبكم: (. اتصل برقم )رقم هاتف ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS : ). ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: ). સ ચન : જ તમ ગ જર ત બ લત હ, ત નન:શ લ ક ભ ષ સહ ય સ વ ઓ તમ ર મ ટ ઉપલબ ધ છ. ફ ન કર (TTY: ). UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer (TTY: ). ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele (TTY: ). ប រយ ត ន បរ ស នជ អ នកន យ យ ភ ស ខ ម រ, បសវ ជ ន យខ នកភ ស ប យម នគ ត ឈ ន ល គ អ ចម នស រ រ រ បរ អ នក ច រ ទ រស ព ទ (TTY: ) ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para (TTY: ). ix

14 Table of Contents ANTI - INFECTIVES... ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS... 6 AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH CARDIOVASCULAR, HYPERTENSION & LIPIDS... 4 DERMATOLOGICALS/TOPICAL THERAPY DIAGNOSTICS & MISCELLANEOUS AGENTS EAR, NOSE & THROAT MEDICATIONS... 6 ENDOCRINE/DIABETES GASTROENTEROLOGY... 7 IMMUNOLOGY, VACCINES & BIOTECHNOLOGY MUSCULOSKELETAL & RHEUMATOLOGY... 8 OBSTETRICS & GYNECOLOGY... 8 OPHTHALMOLOGY... 9 RESPIRATORY, ALLERGY, COUGH & COLD UROLOGICALS... 0 VITAMINS, HEMATINICS & ELECTROLYTES Index... 6

15 List of Abbreviations ACA: Affordable Care Act. LA: Limited Availability. This prescription may be available only at certain pharmacies. For more information, please call Customer Service. OTC: Over the Counter. An OTC drug is a non-prescription drug. PA: Prior Authorization. The 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. QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover. ST: Step Therapy. 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 Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. 2

16 ANTI - INFECTIVES ANTIFUNGAL AGENTS ABELCET INTRAVENOUS SUSPENSION AMBISOME INTRAVENOUS SUSPENSION FOR RECONSTITUTION amphotericin b injection recon soln CANCIDAS INTRAVENOUS RECON SOLN CASPOFUNGIN INTRAVENOUS RECON SOLN clotrimazole mucous membrane troche CRESEMBA INTRAVENOUS RECON SOLN 4 QL CRESEMBA ORAL CAPSULE 4 QL ERAXIS(WATER DILUENT) INTRAVENOUS RECON SOLN fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/00 ml, 400 mg/200 ml fluconazole oral suspension for reconstitution fluconazole oral tablet QL flucytosine oral capsule 4 griseofulvin microsize oral suspension griseofulvin microsize oral tablet griseofulvin ultramicrosize oral tablet itraconazole oral capsule PA; QL ketoconazole oral tablet MYCAMINE INTRAVENOUS RECON SOLN NOXAFIL ORAL SUSPENSION 4 PA NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC) nystatin oral powder 50 million unit, 500 million unit nystatin oral suspension nystatin oral tablet 4 PA; QL ONMEL ORAL TABLET PA; QL

17 ORAVIG BUCCAL MUCO-ADHESIVE BUCCAL TABLET PA; QL SPORANOX ORAL SOLUTION PA terbinafine hcl oral tablet QL voriconazole intravenous solution voriconazole oral suspension for reconstitution 4 QL voriconazole oral tablet 4 QL ANTIVIRALS abacavir oral tablet QL abacavir-lamivudine oral tablet QL abacavir-lamivudine-zidovudine oral tablet QL acyclovir oral capsule acyclovir oral suspension 200 mg/5 ml acyclovir oral tablet acyclovir sodium intravenous solution adefovir oral tablet 4 PA amantadine hcl oral capsule amantadine hcl oral solution amantadine hcl oral tablet APTIVUS ORAL CAPSULE 4 QL APTIVUS ORAL SOLUTION 4 QL ATRIPLA ORAL TABLET 4 QL BARACLUDE ORAL SOLUTION 4 PA cidofovir intravenous solution COMPLERA ORAL TABLET 4 QL CRIXIVAN ORAL CAPSULE 200 MG, 400 MG 2 QL DAKLINZA ORAL TABLET 4 PA; LA; QL DESCOVY ORAL TABLET 4 QL didanosine oral capsule,delayed release(dr/ec) QL EDURANT ORAL TABLET 4 QL EMTRIVA ORAL CAPSULE 2 QL 4

18 EMTRIVA ORAL SOLUTION 2 QL entecavir oral tablet 4 PA EPCLUSA ORAL TABLET 4 PA; LA; QL EPIVIR HBV ORAL SOLUTION 2 PA EVOTAZ ORAL TABLET 4 QL famciclovir oral tablet QL fosamprenavir oral tablet QL foscarnet intravenous solution FUZEON SUBCUTANEOUS RECON SOLN 4 QL ganciclovir sodium intravenous recon soln GENVOYA ORAL TABLET 4 QL HARVONI ORAL TABLET 4 PA; LA; QL INTELENCE ORAL TABLET 4 QL INVIRASE ORAL CAPSULE 4 QL INVIRASE ORAL TABLET 4 QL ISENTRESS HD ORAL TABLET 4 QL ISENTRESS ORAL POWDER IN PACKET 4 QL ISENTRESS ORAL TABLET 4 QL ISENTRESS ORAL TABLET,CHEWABLE 4 QL KALETRA ORAL TABLET 4 QL lamivudine oral solution QL lamivudine oral tablet 00 mg lamivudine oral tablet 50 mg, 00 mg QL lamivudine-zidovudine oral tablet QL LEXIVA ORAL SUSPENSION 4 QL LEXIVA ORAL TABLET 4 QL lopinavir-ritonavir oral solution QL MAVYRET ORAL TABLET 4 PA; LA; QL nevirapine oral suspension QL nevirapine oral tablet QL nevirapine oral tablet extended release 24 hr QL 5

19 NORVIR ORAL CAPSULE 2 QL NORVIR ORAL SOLUTION 2 QL NORVIR ORAL TABLET 2 QL ODEFSEY ORAL TABLET 4 QL OLYSIO ORAL CAPSULE 4 PA; LA; QL oseltamivir oral capsule QL PREZCOBIX ORAL TABLET 4 QL PREZISTA ORAL SUSPENSION 4 QL PREZISTA ORAL TABLET 50 MG, 600 MG, 75 MG, 800 MG RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 4 QL QL RESCRIPTOR ORAL TABLET 2 QL RESCRIPTOR ORAL TABLET, DISPERSIBLE 2 QL RETROVIR INTRAVENOUS SOLUTION 4 QL REYATAZ ORAL CAPSULE 50 MG, 200 MG, 00 MG 4 QL REYATAZ ORAL POWDER IN PACKET 4 QL rimantadine oral tablet SELZENTRY ORAL SOLUTION 4 PA; QL SELZENTRY ORAL TABLET 4 PA; QL SOVALDI ORAL TABLET 4 PA; LA; QL stavudine oral capsule QL stavudine oral recon soln QL STRIBILD ORAL TABLET 4 QL SUSTIVA ORAL CAPSULE 4 QL SUSTIVA ORAL TABLET 4 QL SYNAGIS INTRAMUSCULAR SOLUTION 4 PA; LA; QL TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION QL TECHNIVIE ORAL TABLET 4 PA; LA; QL TIVICAY ORAL TABLET 4 QL TRIUMEQ ORAL TABLET 4 QL 6

20 TRUVADA ORAL TABLET 4 QL TYBOST ORAL TABLET 2 valacyclovir oral tablet QL valganciclovir oral recon soln 4 valganciclovir oral tablet VEMLIDY ORAL TABLET 4 PA; QL VIDEX 2 GRAM PEDIATRIC ORAL RECON SOLN 2 QL VIEKIRA PAK ORAL TABLETS,DOSE PACK 4 PA; LA; QL VIEKIRA XR ORAL TABLET, IR - ER, BIPHASIC 24HR 4 PA; LA; QL VIRACEPT ORAL TABLET 4 QL VIREAD ORAL POWDER 4 QL VIREAD ORAL TABLET 4 QL VOSEVI ORAL TABLET 4 PA; LA; QL ZEPATIER ORAL TABLET 4 PA; LA; QL ZIAGEN ORAL SOLUTION 2 QL zidovudine oral capsule QL zidovudine oral syrup QL zidovudine oral tablet QL CEPHALOSPORINS cefaclor oral capsule cefaclor oral suspension for reconstitution 25 mg/5 ml, 250 mg/5 ml, 75 mg/5 ml cefaclor oral tablet extended release 2 hr cefadroxil oral capsule cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet CEFAZOLIN IN 0.9% SOD CHLORIDE INTRAVENOUS PIGGYBACK cefazolin in dextrose (iso-os) intravenous piggyback gram/50 ml, 2 gram/50 ml 7

21 CEFAZOLIN IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK 2 GRAM/50 ML cefazolin injection recon soln cefazolin intravenous recon soln cefdinir oral capsule cefdinir oral suspension for reconstitution cefditoren pivoxil oral tablet CEFEPIME IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK cefepime in dextrose,iso-osm intravenous piggyback cefepime injection recon soln cefixime oral suspension for reconstitution cefotaxime injection recon soln cefotetan injection recon soln cefotetan intravenous recon soln cefoxitin in dextrose, iso-osm intravenous piggyback cefoxitin intravenous recon soln cefpodoxime oral suspension for reconstitution cefpodoxime oral tablet cefprozil oral suspension for reconstitution cefprozil oral tablet CEFTAZIDIME IN D5W INTRAVENOUS PIGGYBACK ceftazidime injection recon soln CEFTIN ORAL SUSPENSION FOR RECONSTITUTION ceftriaxone in dextrose,iso-os intravenous piggyback ceftriaxone injection recon soln gram, 0 gram, 2 gram, 250 mg, 500 mg ceftriaxone intravenous recon soln cefuroxime axetil oral tablet 8

22 cefuroxime sodium injection recon soln 750 mg cefuroxime sodium intravenous recon soln cephalexin oral capsule 250 mg, 500 mg 5 cephalexin oral capsule 750 mg cephalexin oral suspension for reconstitution 25 mg/5 ml cephalexin oral suspension for reconstitution 250 mg/5 ml cephalexin oral tablet MAXIPIME INTRAVENOUS RECON SOLN SUPRAX ORAL CAPSULE SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 00 MG/5 ML, 500 MG/5 ML SUPRAX ORAL TABLET,CHEWABLE TEFLARO INTRAVENOUS RECON SOLN ZINACEF IN STERILE WATER INTRAVENOUS PIGGYBACK ERYTHROMYCINS & OTHER MACROLIDES azithromycin intravenous recon soln azithromycin oral packet azithromycin oral suspension for reconstitution azithromycin oral tablet clarithromycin oral suspension for reconstitution clarithromycin oral tablet clarithromycin oral tablet extended release 24 hr QL DIFICID ORAL TABLET 4 ST; QL e.e.s. 400 oral tablet ERYPED 200 ORAL SUSPENSION FOR RECONSTITUTION ERYPED 400 ORAL SUSPENSION FOR RECONSTITUTION ery-tab oral tablet,delayed release (dr/ec) 250 mg, mg 9

23 erythrocin (as stearate) oral tablet 250 mg ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG erythromycin ethylsuccinate oral suspension for reconstitution erythromycin ethylsuccinate oral tablet erythromycin oral capsule,delayed release(dr/ec) erythromycin oral tablet MISCELLANEOUS ANTIINFECTIVES ALBENZA ORAL TABLET 2 ALINIA ORAL SUSPENSION FOR RECONSTITUTION ALINIA ORAL TABLET 2 amikacin injection solution,000 mg/4 ml, 500 mg/2 ml atovaquone oral suspension atovaquone-proguanil oral tablet PA AZACTAM IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK aztreonam injection recon soln baciim intramuscular recon soln bacitracin intramuscular recon soln BETHKIS INHALATION SOLUTION FOR NEBULIZATION BILTRICIDE ORAL TABLET 2 CAPASTAT INJECTION RECON SOLN CAYSTON INHALATION SOLUTION FOR NEBULIZATION chloramphenicol sod succinate intravenous recon soln QL 4 QL chloroquine phosphate oral tablet PA clindamycin hcl oral capsule CLINDAMYCIN IN 0.9 % SOD CHLOR INTRAVENOUS PIGGYBACK

24 clindamycin in 5 % dextrose intravenous piggyback clindamycin palmitate hcl oral recon soln clindamycin pediatric oral recon soln clindamycin phosphate injection solution clindamycin phosphate intravenous solution COARTEM ORAL TABLET 2 colistin (colistimethate na) injection recon soln CUBICIN INTRAVENOUS RECON SOLN CYCLOSERINE ORAL CAPSULE dapsone oral tablet daptomycin intravenous recon soln DARAPRIM ORAL TABLET PA DORIBAX INTRAVENOUS RECON SOLN DORIPENEM INTRAVENOUS RECON SOLN ethambutol oral tablet gentamicin in nacl (iso-osm) intravenous piggyback 00 mg/00 ml, 60 mg/50 ml, 70 mg/50 ml, 80 mg/00 ml, 80 mg/50 ml, 90 mg/00 ml GENTAMICIN IN NACL (ISO-OSM) INTRAVENOUS PIGGYBACK 00 MG/50 ML, 20 MG/00 ML gentamicin injection solution gentamicin sulfate (ped) (pf) injection solution gentamicin sulfate (pf) intravenous solution 00 mg/0 ml GENTAMICIN SULFATE (PF) INTRAVENOUS SOLUTION 60 MG/6 ML hydroxychloroquine oral tablet imipenem-cilastatin intravenous recon soln INVANZ INJECTION RECON SOLN INVANZ INTRAVENOUS RECON SOLN isoniazid injection solution

25 isoniazid oral solution isoniazid oral tablet ivermectin oral tablet LINCOCIN INJECTION SOLUTION lincomycin injection solution linezolid intravenous parenteral solution linezolid oral suspension for reconstitution 4 QL linezolid oral tablet 4 QL linezolid-0.9% sodium chloride intravenous parenteral solution mefloquine oral tablet PA meropenem intravenous recon soln metro i.v. intravenous piggyback metronidazole in nacl (iso-os) intravenous piggyback metronidazole oral capsule metronidazole oral tablet NEBUPENT INHALATION RECON SOLN 2 neomycin oral tablet paromomycin oral capsule PASER ORAL GRANULES DR FOR SUSP IN PACKET PENTAM INJECTION RECON SOLN polymyxin b sulfate injection recon soln PRIFTIN ORAL TABLET PRIMAQUINE ORAL TABLET PA pyrazinamide oral tablet quinine sulfate oral capsule PA rifabutin oral capsule RIFAMATE ORAL CAPSULE rifampin intravenous recon soln rifampin oral capsule 2 2

26 RIFATER ORAL TABLET SIRTURO ORAL TABLET 4 PA SIVEXTRO INTRAVENOUS RECON SOLN 4 QL SIVEXTRO ORAL TABLET 4 QL STREPTOMYCIN INTRAMUSCULAR RECON SOLN SYNERCID INTRAVENOUS RECON SOLN TIGECYCLINE INTRAVENOUS RECON SOLN tinidazole oral tablet TOBI PODHALER INHALATION CAPSULE 4 QL TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE tobramycin in % nacl inhalation solution for nebulization tobramycin in 0.9 % nacl intravenous piggyback 60 mg/50 ml tobramycin sulfate injection recon soln tobramycin sulfate injection solution TRECATOR ORAL TABLET TYGACIL INTRAVENOUS RECON SOLN 4 QL 4 QL XIFAXAN ORAL TABLET 200 MG QL XIFAXAN ORAL TABLET 550 MG 4 PA; QL ZYVOX INTRAVENOUS PARENTERAL SOLUTION 200 MG/00 ML PENICILLINS amoxicillin oral capsule 5 amoxicillin oral suspension for reconstitution amoxicillin oral tablet amoxicillin oral tablet,chewable 25 mg, 250 mg amoxicillin-pot clavulanate oral suspension for reconstitution amoxicillin-pot clavulanate oral tablet

27 amoxicillin-pot clavulanate oral tablet extended release 2 hr amoxicillin-pot clavulanate oral tablet,chewable ampicillin oral capsule 5 ampicillin sodium injection recon soln ampicillin sodium intravenous recon soln ampicillin-sulbactam injection recon soln ampicillin-sulbactam intravenous recon soln.5 gram AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION MG/5 ML BICILLIN C-R INTRAMUSCULAR SYRINGE BICILLIN L-A INTRAMUSCULAR SYRINGE dicloxacillin oral capsule nafcillin in dextrose iso-osm intravenous piggyback nafcillin injection recon soln gram, 0 gram nafcillin injection recon soln 2 gram QL nafcillin intravenous recon soln oxacillin in dextrose(iso-osm) intravenous piggyback oxacillin injection recon soln oxacillin intravenous recon soln 2 gram PENICILLIN G POT IN DEXTROSE INTRAVENOUS PIGGYBACK penicillin g potassium injection recon soln penicillin g procaine intramuscular syringe penicillin g sodium injection recon soln penicillin v potassium oral recon soln penicillin v potassium oral tablet 250 mg 5 penicillin v potassium oral tablet 500 mg pfizerpen-g injection recon soln 4

28 piperacillin-tazobactam intravenous recon soln 2.25 gram,.75 gram, 4.5 gram, 40.5 gram QUINOLONES AVELOX IN NACL (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK ciprofloxacin (mixture) oral tablet, er multiphase 24 hr ciprofloxacin hcl oral tablet 00 mg, 750 mg ciprofloxacin hcl oral tablet 250 mg, 500 mg 5 ciprofloxacin in 5 % dextrose intravenous piggyback ciprofloxacin lactate intravenous solution ciprofloxacin oral suspension,microcapsule recon 5 QL FACTIVE ORAL TABLET QL levofloxacin in d5w intravenous piggyback levofloxacin intravenous solution levofloxacin oral solution levofloxacin oral tablet moxifloxacin oral tablet MOXIFLOXACIN-SOD.ACE,SUL-WATER INTRAVENOUS PIGGYBACK ofloxacin oral tablet 00 mg, 400 mg SULFA'S & RELATED AGENTS sulfadiazine oral tablet sulfamethoxazole-trimethoprim intravenous solution sulfamethoxazole-trimethoprim oral suspension sulfamethoxazole-trimethoprim oral tablet sulfatrim oral suspension TETRACYCLINES demeclocycline oral tablet doxy-00 intravenous recon soln doxycycline hyclate oral capsule

29 doxycycline hyclate oral tablet 00 mg, 20 mg doxycycline monohydrate oral capsule 00 mg, 50 mg doxycycline monohydrate oral suspension for reconstitution doxycycline monohydrate oral tablet MINOCIN INTRAVENOUS RECON SOLN minocycline oral capsule morgidox oral capsule 00 mg tetracycline oral capsule URINARY TRACT AGENTS methenamine hippurate oral tablet methenamine mandelate oral tablet nitrofurantoin macrocrystal oral capsule nitrofurantoin monohyd/m-cryst oral capsule trimethoprim oral tablet VANCOMYCIN VANCOMYCIN IN 0.9% SODIUM CL INTRAVENOUS PIGGYBACK VANCOMYCIN IN 0.9% SODIUM CL INTRAVENOUS SOLUTION GRAM/250 ML,.25 GRAM/250 ML,.5 GRAM/250 ML,.5 GRAM/500 ML,.75 GRAM/250 ML,.75 GRAM/500 ML, 2 GRAM/500 ML, 750 MG/50 ML, 750 MG/250 ML VANCOMYCIN IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK 500 MG/00 ML VANCOMYCIN IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK 750 MG/50 ML vancomycin intravenous recon soln vancomycin oral capsule 4 VIBATIV INTRAVENOUS RECON SOLN 750 MG ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS 2 6

30 ADJUNCTIVE AGENTS amifostine crystalline intravenous recon soln 4 dexrazoxane hcl intravenous recon soln 4 LA ELITEK INTRAVENOUS RECON SOLN 4 LA KEPIVANCE INTRAVENOUS RECON SOLN 4 leucovorin calcium oral tablet mesna intravenous solution 4 LA MESNEX ORAL TABLET 4 XGEVA SUBCUTANEOUS SOLUTION 4 PA; QL ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS ABRAXANE INTRAVENOUS SUSPENSION FOR RECONSTITUTION 4 LA adriamycin intravenous solution 4 LA adrucil intravenous solution 4 LA AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 4 PA; QL AFINITOR ORAL TABLET 4 PA; QL ALECENSA ORAL CAPSULE 4 PA; LA; QL ALIMTA INTRAVENOUS RECON SOLN 4 LA ALUNBRIG ORAL TABLET 4 PA; LA; QL anastrozole oral tablet ARRANON INTRAVENOUS SOLUTION 4 LA AVASTIN INTRAVENOUS SOLUTION 4 LA azathioprine oral tablet azathioprine sodium injection recon soln bexarotene oral capsule 4 PA bicalutamide oral tablet BICNU INTRAVENOUS RECON SOLN 4 LA bleo 5k injection recon soln 4 bleomycin injection recon soln 4 LA BOSULIF ORAL TABLET 4 PA; QL busulfan intravenous solution 4 LA 7

31 BUSULFEX INTRAVENOUS SOLUTION 4 LA CABOMETYX ORAL TABLET 4 PA; LA; QL capecitabine oral tablet 4 PA CAPRELSA ORAL TABLET 4 PA; QL carboplatin intravenous solution 4 LA CELLCEPT INTRAVENOUS INTRAVENOUS RECON SOLN cisplatin intravenous solution 4 LA cladribine intravenous solution 4 LA COMETRIQ ORAL CAPSULE 4 PA; QL COTELLIC ORAL TABLET 4 PA; LA; QL cyclophosphamide intravenous recon soln 4 LA CYCLOPHOSPHAMIDE ORAL CAPSULE 4 cyclosporine intravenous solution 4 cyclosporine modified oral capsule cyclosporine modified oral solution cyclosporine oral capsule cytarabine (pf) injection solution 4 LA cytarabine injection solution 4 LA dacarbazine intravenous recon soln 4 LA daunorubicin intravenous recon soln 4 LA daunorubicin intravenous solution 4 LA docetaxel intravenous solution 80 mg/4 ml (20 mg/ml) 4 4 LA; QL doxorubicin intravenous recon soln 4 LA doxorubicin intravenous solution 4 LA doxorubicin, peg-liposomal intravenous suspension ELIGARD ( MONTH) SUBCUTANEOUS SYRINGE ELIGARD (4 MONTH) SUBCUTANEOUS SYRINGE LA 4 PA; QL 4 PA; QL 8

32 ELIGARD (6 MONTH) SUBCUTANEOUS SYRINGE 4 PA; QL ELIGARD SUBCUTANEOUS SYRINGE 4 PA; QL EMCYT ORAL CAPSULE 4 PA epirubicin intravenous recon soln 200 mg 4 LA epirubicin intravenous solution 4 LA ERBITUX INTRAVENOUS SOLUTION 4 LA ERIVEDGE ORAL CAPSULE 4 PA; LA; QL ETOPOPHOS INTRAVENOUS RECON SOLN 4 LA etoposide intravenous solution 4 PA; LA etoposide oral capsule 4 PA exemestane oral tablet FARESTON ORAL TABLET 4 FARYDAK ORAL CAPSULE 4 PA; LA; QL FASLODEX INTRAMUSCULAR SYRINGE 4 LA FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 4 PA; LA; QL floxuridine injection recon soln 4 LA fludarabine intravenous recon soln 4 LA fludarabine intravenous solution 4 LA fluorouracil intravenous solution 4 LA flutamide oral capsule gemcitabine intravenous recon soln 4 LA gemcitabine intravenous solution 4 LA gengraf oral capsule gengraf oral solution GILOTRIF ORAL TABLET 4 PA; LA; QL GLEEVEC ORAL TABLET 4 PA; QL GLEOSTINE ORAL CAPSULE 4 PA HEXALEN ORAL CAPSULE HYCAMTIN ORAL CAPSULE 4 PA hydroxyurea oral capsule 9

33 IBRANCE ORAL CAPSULE 4 PA; LA; QL ICLUSIG ORAL TABLET 4 PA; QL idarubicin intravenous solution 4 LA; QL IDHIFA ORAL TABLET 4 PA; LA ifosfamide intravenous recon soln 4 LA ifosfamide intravenous solution 4 LA ifosfamide-mesna intravenous kit 4 LA IMBRUVICA ORAL CAPSULE 4 PA; QL INLYTA ORAL TABLET 4 PA; LA; QL IODOPEN INTRAVENOUS SOLUTION IRESSA ORAL TABLET 4 PA; LA; QL irinotecan intravenous solution 4 LA IXEMPRA INTRAVENOUS RECON SOLN 4 LA JAKAFI ORAL TABLET 4 PA; LA; QL KISQALI FEMARA CO-PACK ORAL TABLET 4 PA; LA; QL KISQALI ORAL TABLET 4 PA; LA; QL LENVIMA ORAL CAPSULE 4 PA; LA; QL letrozole oral tablet QL LEUKERAN ORAL TABLET 2 leuprolide subcutaneous kit 4 PA; LA lipodox intravenous suspension 4 LA LONSURF ORAL TABLET 4 PA; LA LUPRON DEPOT ( MONTH) INTRAMUSCULAR SYRINGE KIT LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT LUPRON DEPOT (6 MONTH) INTRAMUSCULAR SYRINGE KIT LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT LUPRON DEPOT-PED ( MONTH) INTRAMUSCULAR SYRINGE KIT 4 PA; LA; QL 4 PA; LA; QL 4 PA; LA; QL 4 PA; LA; QL 4 PA; LA; QL LUPRON DEPOT-PED INTRAMUSCULAR KIT 4 PA; LA; QL 20

34 LYNPARZA ORAL CAPSULE 4 PA; QL LYNPARZA ORAL TABLET 4 PA; QL LYSODREN ORAL TABLET 4 PA; LA MATULANE ORAL CAPSULE megestrol oral suspension 400 mg/0 ml (40 mg/ml) megestrol oral tablet MEKINIST ORAL TABLET 4 PA; LA; QL melphalan oral tablet mercaptopurine oral tablet methotrexate sodium (pf) injection recon soln 4 methotrexate sodium (pf) injection solution 4 methotrexate sodium injection solution 4 methotrexate sodium oral tablet mitomycin intravenous recon soln 4 LA mitoxantrone intravenous concentrate 4 LA MUSTARGEN INJECTION RECON SOLN 4 LA mycophenolate mofetil hcl intravenous recon soln 4 mycophenolate mofetil oral capsule mycophenolate mofetil oral suspension for reconstitution mycophenolate mofetil oral tablet mycophenolate sodium oral tablet,delayed release (dr/ec) MYLERAN ORAL TABLET 2 LA NEXAVAR ORAL TABLET 4 PA; LA; QL nilutamide oral tablet 4 PA; LA NINLARO ORAL CAPSULE 4 PA; LA; QL NULOJIX INTRAVENOUS RECON SOLN 4 PA; LA octreotide acetate injection solution 4 LA octreotide acetate injection syringe 4 LA ODOMZO ORAL CAPSULE 4 PA; LA; QL 2 4

35 ONCASPAR INJECTION SOLUTION 4 LA oxaliplatin intravenous recon soln 4 LA oxaliplatin intravenous solution 4 LA paclitaxel intravenous concentrate 4 LA PHOTOFRIN INTRAVENOUS RECON SOLN 4 LA PROGRAF INTRAVENOUS SOLUTION 4 RAPAMUNE ORAL SOLUTION 4 PA RITUXAN INTRAVENOUS CONCENTRATE 4 PA; LA RUBRACA ORAL TABLET 4 PA; QL RYDAPT ORAL CAPSULE 4 PA; LA; QL SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON SIGNIFOR LAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 4 PA; LA; QL 4 PA; LA; QL SIGNIFOR SUBCUTANEOUS SOLUTION 4 PA; LA; QL SIMULECT INTRAVENOUS RECON SOLN 4 LA sirolimus oral tablet SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 4 PA; LA; QL SPRYCEL ORAL TABLET 4 PA; QL STIVARGA ORAL TABLET 4 PA; LA; QL SUPPRELIN LA IMPLANT KIT 4 PA; LA; QL SUTENT ORAL CAPSULE 4 PA; LA; QL SYLVANT INTRAVENOUS RECON SOLN 4 PA; LA TABLOID ORAL TABLET 2 PA tacrolimus oral capsule TAFINLAR ORAL CAPSULE 4 PA; LA; QL TAGRISSO ORAL TABLET 4 PA; LA; QL tamoxifen oral tablet TARCEVA ORAL TABLET 00 MG, 50 MG 4 PA; LA; QL TARCEVA ORAL TABLET 25 MG 4 PA; LA TARGRETIN TOPICAL GEL 4 PA 22

36 TASIGNA ORAL CAPSULE 4 PA; QL TEMODAR INTRAVENOUS RECON SOLN 4 temozolomide oral capsule 4 PA; LA THALOMID ORAL CAPSULE 4 PA; LA; QL toposar intravenous solution 4 LA topotecan intravenous recon soln 4 LA topotecan intravenous solution 4 LA TORISEL INTRAVENOUS RECON SOLN 4 LA TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION.25 MG,.75 MG TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 22.5 MG 4 PA; QL 4 PA; LA; QL TRELSTAR INTRAMUSCULAR SYRINGE 4 PA; LA; QL tretinoin (chemotherapy) oral capsule 4 TRISENOX INTRAVENOUS SOLUTION 4 LA TYKERB ORAL TABLET 4 PA; LA; QL VANTAS IMPLANT KIT 4 PA; LA; QL VENCLEXTA ORAL TABLET 00 MG 4 PA; QL vinblastine intravenous solution 4 LA vincasar pfs intravenous solution 4 LA vincristine intravenous solution 4 LA vinorelbine intravenous solution 4 LA VOTRIENT ORAL TABLET 4 PA; LA; QL XALKORI ORAL CAPSULE 4 PA; LA; QL XERMELO ORAL TABLET 4 PA; QL XTANDI ORAL CAPSULE 4 PA; LA; QL ZANOSAR INTRAVENOUS RECON SOLN 4 LA ZEJULA ORAL CAPSULE 4 PA; QL ZELBORAF ORAL TABLET 4 PA; LA; QL ZOLADEX SUBCUTANEOUS IMPLANT 4 PA; LA; QL ZOLINZA ORAL CAPSULE 4 PA; LA; QL ZORTRESS ORAL TABLET 4 2

37 ZYDELIG ORAL TABLET 4 PA; QL ZYKADIA ORAL CAPSULE 4 PA; LA; QL ZYTIGA ORAL TABLET 4 PA; LA; QL AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH ANTICONVULSANTS APTIOM ORAL TABLET PA; QL BANZEL ORAL SUSPENSION PA BANZEL ORAL TABLET PA BRIVIACT INTRAVENOUS SOLUTION PA; QL BRIVIACT ORAL SOLUTION PA; QL BRIVIACT ORAL TABLET PA; QL carbamazepine oral capsule, er multiphase 2 hr carbamazepine oral suspension 00 mg/5 ml carbamazepine oral tablet carbamazepine oral tablet extended release 2 hr carbamazepine oral tablet,chewable CELONTIN ORAL CAPSULE 00 MG 2 clonazepam oral tablet clonazepam oral tablet,disintegrating ST diazepam rectal kit DILANTIN ORAL CAPSULE 0 MG 2 divalproex oral capsule, delayed rel sprinkle divalproex oral tablet extended release 24 hr divalproex oral tablet,delayed release (dr/ec) epitol oral tablet ethosuximide oral capsule ethosuximide oral solution felbamate oral suspension felbamate oral tablet fosphenytoin injection solution FYCOMPA ORAL SUSPENSION PA; QL 24

38 FYCOMPA ORAL TABLET PA; QL gabapentin oral capsule gabapentin oral solution 250 mg/5 ml gabapentin oral tablet 600 mg, 800 mg GRALISE 0-DAY STARTER PACK ORAL TABLET EXTENDED RELEASE 24 HR GRALISE ORAL TABLET EXTENDED RELEASE 24 HR lamotrigine oral tablet PA; QL PA; QL lamotrigine oral tablet, chewable dispersible QL levetiracetam in nacl (iso-os) intravenous piggyback levetiracetam intravenous solution levetiracetam oral solution levetiracetam oral tablet levetiracetam oral tablet extended release 24 hr QL LYRICA ORAL CAPSULE PA; QL LYRICA ORAL SOLUTION PA; QL ONFI ORAL SUSPENSION PA; QL ONFI ORAL TABLET 0 MG, 20 MG PA; QL oxcarbazepine oral suspension oxcarbazepine oral tablet PEGANONE ORAL TABLET phenobarbital oral elixir phenobarbital oral tablet phenytoin oral suspension 25 mg/5 ml phenytoin oral tablet,chewable phenytoin sodium extended oral capsule phenytoin sodium intravenous solution phenytoin sodium intravenous syringe primidone oral tablet QL roweepra oral tablet 25

39 SABRIL ORAL POWDER IN PACKET 4 PA; LA; QL SABRIL ORAL TABLET 4 PA; LA; QL tiagabine oral tablet topiramate oral capsule, sprinkle QL topiramate oral tablet valproate sodium intravenous solution valproic acid (as sodium salt) oral solution 250 mg/5 ml valproic acid oral capsule vigabatrin oral powder in packet 4 PA; LA; QL VIMPAT INTRAVENOUS SOLUTION PA VIMPAT ORAL SOLUTION PA VIMPAT ORAL TABLET PA zonisamide oral capsule ANTIPARKINSONISM AGENTS APOKYN SUBCUTANEOUS CARTRIDGE 4 PA; QL benztropine injection solution benztropine oral tablet bromocriptine oral capsule bromocriptine oral tablet carbidopa oral tablet ST carbidopa-levodopa oral tablet carbidopa-levodopa oral tablet extended release carbidopa-levodopa oral tablet,disintegrating carbidopa-levodopa-entacapone oral tablet DUOPA J-TUBE INTESTINAL PUMP SUSPENSION entacapone oral tablet pramipexole oral tablet rasagiline oral tablet ropinirole oral tablet 26 4 PA; LA ropinirole oral tablet extended release 24 hr ST

40 selegiline hcl oral capsule selegiline hcl oral tablet tolcapone oral tablet ST trihexyphenidyl oral elixir trihexyphenidyl oral tablet MIGRAINE & CLUSTER HEADACHE THERAPY almotriptan malate oral tablet ST; QL dihydroergotamine injection solution dihydroergotamine nasal spray,non-aerosol QL eletriptan hbr oral tablet ST; QL ERGOMAR SUBLINGUAL TABLET PA; QL frovatriptan oral tablet ST; QL isometh-dichloral-acetaminophn oral capsule naratriptan oral tablet QL nodolor oral capsule rizatriptan oral tablet 0 mg QL rizatriptan oral tablet 5 mg QL rizatriptan oral tablet,disintegrating 0 mg QL rizatriptan oral tablet,disintegrating 5 mg QL sumatriptan nasal spray,non-aerosol QL sumatriptan succinate oral tablet QL sumatriptan succinate subcutaneous cartridge 2 QL sumatriptan succinate subcutaneous pen injector 2 QL sumatriptan succinate subcutaneous solution 2 QL sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml 2 QL zolmitriptan oral tablet QL zolmitriptan oral tablet,disintegrating QL ZOMIG NASAL SPRAY,NON-AEROSOL QL MISCELLANEOUS NEUROLOGICAL THERAPY AMPYRA ORAL TABLET EXTENDED RELEASE 2 HR 4 PA; LA; QL 27

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

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

More information

2016 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

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

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

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

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

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

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

<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

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

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

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

(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

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

Anthem MediBlue Access (PPO) 2018 Formulary (List of Covered Drugs) Please read: , https://shop.anthem. Anthem MediBlue Access (PPO) 08 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on November, 07. For more

More information

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

Anthem MediBlue Dual Advantage (HMO SNP) 2018 Formulary (List of Covered Drugs) Please read: , https://shop.anthem. Anthem MediBlue Dual Advantage (H SNP) 08 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on June, 08. For

More information

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

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

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

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

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 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

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

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

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

Anthem Heart (HMO SNP) 2019 Formulary (List of Covered Drugs) Please read: This document contains information about the drugs we cover in this plan.

Anthem Heart (HMO SNP) 2019 Formulary (List of Covered Drugs) Please read: This document contains information about the drugs we cover in this plan. Anthem Heart (H SNP) 019 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on October 1, 018. For more recent

More information

Amerivantage Classic (HMO) 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

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

<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

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

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

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

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

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 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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

<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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

08:00 Anti-Infective Agents 08:00. Anti-Infective Agents Anti-Infective Agents Anti-Infective Agents 08:08 ANTHELMINTICS MEBENDAZOLE 100 MG ORAL CHEWABLE TABLET 00000556734 VERMOX JAI 5.0300 08:12.02 (AMINOGLYCOSIDES) GENTAMICIN SULFATE 40 MG / ML (BASE) INJECTION

More information

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

2017 Comprehensive Formulary (List of Covered Drugs) Medicare Advantage Plans We re in this together: Quality Health Care 017 Comprehensive Formulary (List of Covered s) Medicare Advantage Plans Easy Choice Health Plan Plans in the following state: CA Easy Choice Best Plan(HMO)

More information

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

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

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

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

List of Covered Drugs (Formulary) Empire BlueCross BlueShield HealthPlus Fully Integrated Duals Advantage (FIDA) Plan (Medicare-Medicaid Plan) List of Covered s (Formulary) Empire BlueCross BlueShield HealthPlus Fully Integrated Duals Advantage (FIDA) Plan (Medicare-Medicaid Plan) 2015 Participant Services: 1-855-817-5789 (TTY 711) Monday through

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

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 (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

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

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

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

(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

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

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

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

2015 MEDICARE PART D DRUG FORMULARY

2015 MEDICARE PART D DRUG FORMULARY 2015 MEDICARE PART D DRUG FORMULARY National Drug Plan (PDP) Standard/Enhanced This formulary was updated on 11/01/2015. For more recent information or other questions, please contact Customer Service

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

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 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

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

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

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

2018 Comprehensive Formulary (List of Covered Drugs) Prescription Drug Plans 018 Comprehensive Formulary (List of Covered s) Prescription Plans WellCare Prescription Insurance, Inc. Plans in all states: WellCare Classic (PDP) Please Read: This document contains information about

More information

(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

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

Prescription Drug Formulary

Prescription Drug Formulary 019 Prescription Drug Formulary Essence Advantage (HMO) Essence Advantage Select (HMO) Serving the St. Louis area and Boone County, Missouri This formulary was updated on 08/3/018. For more recent information

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

Prescription Drug Formulary

Prescription Drug Formulary 019 Prescription Drug Formulary This formulary was updated on 11/07/018. For more recent information or other questions, please contact CoxHealth MedicarePlus Customer Service at 1-866-597-9560 or, for

More information

SIGNATURE ADVANTAGE Formulary. (List of Covered Drugs)

SIGNATURE ADVANTAGE Formulary. (List of Covered Drugs) SIGNATURE ADVANTAGE 2019 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Formulary ID 19552, Version Number 5 This formulary was

More information

BlueCross BlueShield of Western New York Formulary. List of Covered Drugs

BlueCross BlueShield of Western New York Formulary. List of Covered Drugs BlueCross BlueShield of Western 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

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