Brand New Day Formulary. (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN

Size: px
Start display at page:

Download "Brand New Day Formulary. (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN"

Transcription

1 Brand New Day Harmony Choice for Medi-Medi (HMO SNP) Dual Coverage (HMO SNP) Classic Care Drug Savings (HMO) Bridges Drug Savings (HMO SNP) Bridges Choice for Medi-Medi (HMO SNP) Classic Choice for Medi-Medi (HMO SNP) 018 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission ID, 180 Version Number 1 This formulary was updated on January 1, 018. For more recent information or other questions, please contact Brand New Day Member Services, at or, for TTY users, , Hours are: October 1 - February 1: 7 days a week, 8:00 a.m. 8:00 p.m. February 15 September 0: Monday- Friday, 8:00 a.m. 8:00 p.m., or visit ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call (TTY: ). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: ). H088_018 AbridgedComprehensive_Formulary_Accepted

2 Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means Brand New Day. When it refers to plan or our plan, it means Harmony Choice for Medi Medi (HMO SNP), Dual Coverage (HMO SNP), Classic Care Drug Savings (HMO), In Control Drug Savings (HMO SNP), In Control Choice for Medi-Medi (HMO SNP), Bridges Drug Savings (HMO SNP), Bridges Choice for Medi-Medi (HMO SNP), Harmony Drug Savings (HMO SNP), Classic Choice for Medi-Medi (HMO), Embrace Care Drug Savings (HMO SNP), Embrace Choice for Medi Medi (HMO SNP), Classic Care Drug Savings (HMO). This document includes list of the drugs (formulary) for our plan which is current as of (effective January 1, 018). For updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, premiums, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 019, and from time to time during the year. You must continue to pay your Medicare Part B premium. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. What is the Brand New Day Formulary? A formulary is a list of covered drugs selected by Brand New Day in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Brand New Day will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Brand New Day network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 018 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 018 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of January 1, 018. To get updated information about the drugs covered by Brand New Day, please contact us. Our contact information appears on the front H088_018 AbridgedComprehensive ii

3 and back cover pages. In the event of midyear non-maintenance formulary changes we will send you a letter notifying you have the changes. We will post an updated version of the Brand New Day formulary on our website at If you would like a printed version of the corrections, we will mail it to you upon request. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 1 (after this introduction). The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular agents. If you know what your drug is used for, look for the category name in the list that begins 1 (after this introduction). Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page I-1. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? Brand New Day covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: Brand New Day requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Brand New Day before you fill your prescriptions. If you don t get approval, Brand New Day may not cover the drug. Quantity Limits: For certain drugs, Brand New Day limits the amount of the drug that Brand New Day will cover. For example, Brand New Day provides18 tablets per prescription for sumatriptan succinate oral. This may be in addition to a standard one-month or three-month supply. H088_018 AbridgedComprehensive iii

4 Step Therapy: In some cases, Brand New Day 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, Brand New Day may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Brand New Day will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1 (after this introduction). You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask Brand New Day to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the Brand New Day formulary? on page v for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered. This document includes only a partial list of covered drugs, so Brand New Day may cover your drug. For more information, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you learn that Brand New Day does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by Brand New Day. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Brand New Day. You can ask Brand New Day to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the Brand New Day Formulary? You can ask Brand New Day to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. H088_018 AbridgedComprehensive iv

5 You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Brand New Day limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, Brand New Day will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, or utilization restriction exception. When you request a formulary or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 7 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 7 hours for a decision. If your request to expedite is granted, we must give you a decision no later than hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or reque sting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 0-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 0-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with 98 day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 1-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. Members who change treatment settings due to changes in level of care are also considered in Transition. These members will be provided with an appropriate transition refill. For more information For more detailed information about your Brand New Day prescription drug coverage, please review your Evidence of Coverage and other plan materials. H088_018 AbridgedComprehensive v

6 If you have questions about Brand New Day, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) hours a day/7 days a week. TTY users should call Or, visit Brand New Day s Formulary The formulary that begins on page 1 provides coverage information about some of the drugs covered by Brand New Day. If you have trouble finding your drug in the list, turn to the Index that begins on page I-1. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g. MORPHINE ORAL TABLET 15 MG) and generic drugs are listed in lower-case italics (e.g. acetaminophen-codeine 10-1/5 ml solution ml). The information in the Requirements/Limits column tells you if Brand New Day has any special requirements for coverage of your drug. The Formulary may change at any time. You will receive notice when necessary. H088_018 AbridgedComprehensive vi

7 The following Utilization Management abbreviations may be found within the body of this document COVERAGE NOTES ABBREVIATIONS ABBREVIATION DESCRIPTION EXPLANATION Utilization Management Restrictions PA PA BvD PA-HRM PA NSO QL ST Prior Authorization Restriction Prior Authorization Restriction for Part B vs Part D Determination Prior Authorization Restriction for High Risk Medications Prior Authorization Restriction for New Starts Only Quantity Limit Restriction Step Therapy Restriction You (or your physician) are required to get prior authorization from Brand New Day before you fill your prescription for this drug. Without prior approval, Brand New Day may not cover this drug. This drug may be eligible for payment under Medicare Part B or Part D. You (or your physician) are required to get prior authorization from Brand New Day to determine that this drug is covered under Medicare Part D before you fill your prescription for this drug. Without prior approval, Brand New Day may not cover this drug. This drug has been deemed by CMS to be potentially harmful and therefore, a High Risk Medication for Medicare beneficiaries 65 years or older. Members age 65 yrs or older are required to get prior authorization from Brand New Day before you fill your prescription for this drug. Without prior approval, Brand New Day may not cover this drug If you are a new member or if you have not taken this drug before, you (or your physician) are required to get prior authorization from Brand New Day before you fill your prescription for this drug. Without prior approval, Brand New Day may not cover this drug. Brand New Day limits the amount of this drug that is covered per prescription, or within a specific time frame. Before Brand New Day will provide coverage for this drug, you must first try another drug(s) to treat your medical condition. This drug may only H088_018 AbridgedComprehensive vii

8 ABBREVIATION DESCRIPTION EXPLANATION be covered if the other drug(s) does not work for you. The following additional coverage note abbreviations may be found within the body of this document OTHER SPECIAL REQUIREMENTS FOR COVERAGE ABBREVIATION DESCRIPTION EXPLANATION EX LA GC NM Excluded Part D Drug Limited Access Drug Gap Coverage Non-Mail Order Drug This prescription drug is not normally covered in a Medicare Prescription Drug Plan. The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at ,. TTY/TDD users should call We provide coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. You may be able to receive greater than a 1- month supply of most of the drugs on your formulary via mail order at a reduced cost share. Drugs not available via your mail order benefit are noted with NM in the Requirements/Limits column of your formulary. HI Home Infusion Drug This prescription drug may be covered under our medical benefit. For more information, call H088_018 AbridgedComprehensive viii

9 ABBREVIATION DESCRIPTION EXPLANATION Member Services at ,. TTY/TDD users should call ABBREVIATION adh. patch aer br act aer pow aer pow ba aer refill aer w/adap ampul blkbaginj cap dr mp cap ds pk cap er 1h cap er h cap er deg cap er pel cap mphase cap.sa h cap.sr 1h cap.sr h caph pct caph pel STRENGTH AND DOSAGE FORM ABBREVIATIONS DESCRIPTION adhesive patch aerosol, breath activated aerosol, powder aerosol powder, breath activated aerosol refill aerosol with adapter ampule bulk bag injection capsule, delayed release multiphasic capsule, dose pack capsule, 1 hour extended release capsule, hour extended release capsule, extended release degradable capsule, extended release pellets capsule, multiphasic capsule, hour sustained action capsule, 1 hour sustained release capsule, hour sustained release capsule, hour controlled-onset pellets capsule, hour sustained release pellets H088_018 AbridgedComprehensive ix

10 ABBREVIATION DESCRIPTION cap sprink capsule, sprinkle cap sr pel capsule sustained release pellets cap w/dev capsule with device capsule dr capsule, delayed release capsule er capsule, extended release capsule sa capsule, sustained action cmb cappad combination: capsule, pad cmb ont fm combination: ointment, foam cmb ont lt combination: ointment, lotion cmb tabpad combination: tablet, pad combo. pkg combination package cpmp 1hr capsule, 1 hour multiphasic cpmp hr capsule, hour multiphasic cpmp 0-70 capsule, multiphasic, 0%-70% cpmp capsule, multiphasic, 50%-50% cream(g), cream(gm) cream (grams) cream(ml) cream (milliliters) cream/appl cream with applicator cream, er (g) cream, extended release (grams) cream pack cream, package dehp fr bg di(-ethylhexyl)phthalate free bag dis needle disposable needle disk w/dev disk with inhalation device disp syrin disposable syringe drops susp drops, suspension drps hpvis drops, hyperviscous emul adhes emulsion adhesive emul packt emulsion packet emulsn(g) emulsion (grams) foam/appl. foam with applicator froz.piggy frozen piggyback g gram gel/pf app gel with prefilled applicator gel (gm) gel (grams) gel (ml) gel (milliliters) gel md pmp gel in metered dose pump gel w/appl gel with applicator gel w/pump gel with pump gran pack granule pack hfa aer ad hfa aerosol adapter infus. btl infusion bottle insuln pen insulin pen ip soln intraperitoneal solution irrig soln irrigating solution H088_018 AbridgedComprehensive x

11 ABBREVIATION iv soln. jel jelly/app jel/pf app kit cl&crm kt crm le kt lotn ce kt oint le lotion, er lozenge hd m.ht patch ma buc tab mcg med. pad med. swab med. tape ml muc er 1h ndl fr inj nl fm susp oint. (g), oint.(gm) oral conc oral susp paste (g) patch td patch td7 patch tdsw patch tdwk pca syring pca vial pellet(ea) pen ij kit pen injctr pggybk btl plast. bag powd pack sol md pmp sol w/appl sol/pf app sol-gel soln recon soln(gram) spray susp DESCRIPTION intravenous solution jelly jelly with applicator jelly with pre-filled applicator kit: cleanser and cream kit: cream, lotion emollient kit: lotion, cream emollient kit: ointment, lotion emollient lotion, extended release lozenge handle medicated heated patch mucoadhesive buccal tablet microgram medicated pad medicated swab medicated tape milligram milliliter mucoadhesive system, 1 hour extended release needle for injection nail film suspension ointment (grams) oral concentrate oral suspension paste (grams) patch, hour transdermal patch, 7 hour transdermal patch, biweekly transdermal patch, weekly transdermal patient-controlled analgesic syringe patient-controlled analgesic vial pellet (each) pen injector kit pen injector piggyback bottle plastic bag powder pack solution with multi-dose pump solution with applicator solution with pre-filled applicator solution, gel-forming solution, reconstituted solution (grams) spray, suspension H088_018 AbridgedComprehensive xi

12 ABBREVIATION spray/pump stick(ea) supp.rect supp.vag suppos. sus er h sus er rec sus mc rec suspdr pkt susp recon syringekit tab chew tab er 1h tab er h tab er prt tab er seq tab disper tab ds pk tab er tab mphase tab part tab rap dr tab rapdis tab subl tab.sr 1h tab.sr h tabergrhr tablet dr tablet, er tablet eff tablet sa tablet sol tb er dspk tb mp dspk tb rd dspk tbdspk mo tbmp 1hr tbmp hr u vag ring DESCRIPTION spray with pump stick (each) suppository, rectal suppository, vaginal suppository suspension, hour extended release suspension, extended release reconstituted suspension, microcapsule reconstituted suspension, delayed release packet suspension, reconstituted syringe kit tablet, chewable tablet, 1 hour extended release tablet, hour extended release tablet, extended release particles tablet, extended release sequels tablet, dispersible tablet, dose pack tablet, hour extended release tablet, multiphasic tablet, particles tablet, rapid disintegrating delayed release tablet, rapid disintegrating tablet, sublingual tablet, 1 hour sustained release tablet, hour sustained release tablet, hour gradual extended release tablet, delayed release tablet, extended release tablet, effervescent tablet, sustained action tablet, soluble tablet, extended release dose pack tablet, multiphasic dose pack tablet, rapid disintegrating dose pack tablet, -month dose pack tablet, 1 hour multiphasic tablet, hour multiphasic unit vaginal ring H088_018 AbridgedComprehensive xii

13 The following is a brief summary of Brand New Day Plans Co-payments/Co-insurance during Initial Coverage Period. Amounts shown are for In-Network Retail and Mail Order Pharmacy. Harmony Choice for Medi-Medi (HMO SNP), Plan 00: $05 deductible (Deductible does not apply to tier 1 and tier 6) Drug Tier Drug Tier Name Retail (0-day supply) Retail (90-day supply) Mail-Order (90-day supply except tier 5) 1 Preferred Generic $0 co-pay $0 co-pay $0 co-pay Generic 5% co-insurance 5% co-insurance 5% co-insurance Preferred Brand 5% co-insurance 5% co-insurance 5% co-insurance Non-Preferred Drug 5% co-insurance 5% co-insurance 5% co-insurance 5 Specialty Tier 5% co-insurance Not available 5% co-insurance (0-day supply only) 6 Select Care Drugs $0 co-pay $0 co-pay $0 co-pay H088_018 AbridgedComprehensive xiii

14 Brand New Day Dual Coverage, Plan 0; Deductible $05; (Doesn t apply to Tier 1, and 6) Drug Tier Drug Tier Name Retail (0-day supply) Retail (90-day supply) Mail-Order (90-day supply except tier 5) 1 Preferred Generic $0 co-pay $0 co-pay $0 co-pay Generic $0 co-pay $0 co-pay $0 co-pay Preferred Brand 5% co-insurance 5% co-insurance 5% co-insurance Non-Preferred Drug 5% co-insurance 5% co-insurance 5% co-insurance 5 Specialty Tier 5% co-insurance Not available 5% co-insurance (0-day supply only) 6 Select Care Drugs $0 co-pay $0 co-pay $0 co-pay H088_018 AbridgedComprehensive xiv

15 Classic Care Drug Savings (HMO), Plan 05: No Deductible Drug Tier Drug Tier Name Retail (0-day supply) Retail (90-day supply) Mail-Order (90-day supply except tier 5) 1 Preferred Generic $0 co-pay $0 copay $0 co-pay Generic $8 co-pay $ co-pay $16 co-pay Preferred Brand $5 co-pay $15 co-pay $90 co-pay Non-Preferred Drug $75 co-pay $5 co-pay $5 co-pay 5 Specialty Tier % co-insurance Not available % coinsurance (0-day supply only) 6 Select Care Drugs $0 co-pay $0 co-pay $0 co-pay H088_018 AbridgedComprehensive xv

16 Bridges Drug Savings (HMO SNP), Plan 08: No Deductible Drug Tier Drug Tier Name Retail (0-day supply) Retail (90-day supply) Mail-Order (90-day supply except tier 5) 1 Preferred Generic $0 co-pay $0 co-pay $0 co-pay Generic $8 co-pay $ co-pay $16 co-pay Preferred Brand $5 co-pay $15 co-pay $90 co-pay Non-Preferred Drug $75 co-pay $5 co-pay $5 co-pay 5 Specialty Tier % co-insurance Not available % co-insurance (0-day supply only) 6 Select Care Drugs $0 co-pay $0 co-pay $0 co-pay H088_018 AbridgedComprehensive xvi

17 Brand New Day Bridges Choice for Medi-Medi (HMO SNP), Plan 09: $05 Deductible (Deductible doesn t apply to tier 1 and tier 6) Drug Tier Drug Tier Name Retail (0-day supply) Retail (90-day supply) Mail-Order (90-day supply except tier 5) 1 Preferred Generic $0 co-pay $0 co-pay $0 co-pay Generic 5% co-insurance 5% co-insurance 5% co-insurance Preferred Brand 5% co-insurance 5% co-insurance 5% co-insurance Non-Preferred Drug 5% co-insurance 5% co-insurance 5% co-insurance 5 Specialty Tier 5% co-insurance Not available 5% co-insurance (0-day supply only) 6 Select Care Drugs $0 co-pay $0 co-pay $0 co-pay H088_018 AbridgedComprehensive xvii

18 Brand New Day Classic Choice for Medi-Medi (HMO), Plan 0: $05 Deductible (Deductible doesn t apply to tier 1 and tier 6) Drug Tier Drug Tier Name Retail (0-day supply) Retail (90-day supply) Mail-Order (90-day supply except tier 5) 1 Preferred Generic $0 co-pay $0 co-pay $0 co-pay Generic 5% co-insurance 5% co-insurance 5% co-insurance Preferred Brand 5% co-insurance 5% co-insurance 5% co-insurance Non-Preferred Drug 5% co-insurance 5% co-insurance 5% co-insurance 5 Specialty Tier 5% co-insurance Not available 5% co-insurance (0-day supply only) 6 Select Care Drugs $0 co-pay $0 co-pay $0 co-pay H088_018 AbridgedComprehensive xviii

19 Brand New Day Classic Care Drug Savings (HMO), Plan 07: No deductible Drug Tier Drug Tier Name Retail (0-day supply) Retail (90-day supply) Mail-Order (90-day supply except tier 5) 1 Preferred Generic $0 co-pay $0 co-pay $0 co-pay Generic $10 co-pay $0 co-pay $0 co-pay Preferred Brand $5 co-pay $15 co-pay $90 co-pay Non-Preferred Drug $90 co-pay $70 co-pay $70 co-pay 5 Specialty Tier % co-insurance Not available % co-insurance (0 day supply only) 6 Select Care Drugs $0 co-pay $0 co-pay $0 co-pay H088_018 AbridgedComprehensive xix

20 Table of Contents Analgesics... Anesthetics... 8 Anti-Addiction/Substance Abuse Treatment Agents...9 Antianxiety Agents...10 Antibacterials Anticancer Agents... 0 Anticholinergic Agents... 9 Anticonvulsants...9 Antidementia Agents... Antidepressants... Antidiabetic Agents... 6 Antifungals...0 Antigout Agents... Antihistamines... Anti-Infectives (Skin And Mucous Membrane)... Antimigraine Agents... Antimycobacterials... Antinausea Agents... Antiparasite Agents...6 Antiparkinsonian Agents...7 Antipsychotic Agents...8 Antivirals (Systemic)...5 Blood Products/Modifiers/Volume Expanders Caloric Agents...60 Cardiovascular Agents... 6 Central Nervous System Agents Contraceptives...79 Dental And Oral Agents...85 Dermatological Agents...85 Devices Enzyme Replacement/Modifiers...90 Eye, Ear, Nose, Throat Agents...91 Gastrointestinal Agents Genitourinary Agents...98 Heavy Metal Antagonists Hormonal Agents, Stimulant/Replacement/Modifying

21 Immunological Agents Inflammatory Bowel Disease Agents Irrigating Solutions Metabolic Bone Disease Agents Miscellaneous Therapeutic Agents Ophthalmic Agents Replacement Preparations Respiratory Tract Agents... 1 Skeletal Muscle Relaxants Sleep Disorder Agents Vasodilating Agents...18 Vitamins And Minerals...19

22 Analgesics Analgesics, Miscellaneous acetaminophen-codeine oral solution 10-1 /5 ml acetaminophen-codeine oral tablet acetaminophen-codeine oral tablet 00-0 acetaminophen-codeine oral tablet ascomp with codeine oral capsule BELBUCA BUCCAL FILM 150 MCG, 00 MCG, 50 MCG, 600 MCG, 75 MCG, 750 MCG, 900 MCG buprenorphine hcl injection solution 0. /ml buprenorphine hcl injection syringe 0. /ml buprenorphine transdermal patch weekly 10 mcg/hour, 15 mcg/hour, 0 mcg/hour, 5 mcg/hour, 7.5 mcg/hour butalbital compound w/codeine oral capsule butalbital-acetaminop-caf-cod oral capsule , butalbital-acetaminophen oral tablet 50-5 butalbital-acetaminophen-caff oral capsule butalbital-acetaminophen-caff oral tablet butalbital-aspirin-caffeine oral capsule QL (700 per 0 days) QL (60 per 0 days) (Tylenol-Codeine #) QL (60 per 0 days) (Tylenol-Codeine #) QL (180 per 0 days) (Buprenex) PA-HRM; QL (180 per 0 days); AGE (Max 6 Years) QL (60 per 0 days) (Butrans) QL ( per 8 days) PA-HRM; QL (180 per 0 days); AGE (Max 6 Years) PA-HRM; QL (180 per 0 days); AGE (Max 6 Years) (Tencon) PA-HRM; QL (180 per 0 days); AGE (Max 6 Years) (Esgic) PA-HRM; QL (180 per 0 days); AGE (Max 6 Years) (Esgic) PA-HRM; QL (180 per 0 days); AGE (Max 6 Years) (Fiorinal) PA-HRM; QL (180 per 0 days); AGE (Max 6 Years)

23 BUTRANS TRANSDERMAL QL ( per 8 days) PATCH WEEKLY 7.5 MCG/HOUR capacet oral capsule PA-HRM; QL (180 per 0 days); AGE (Max 6 Years) codeine sulfate oral tablet 15, 0, QL (180 per 0 days) 60 endocet oral tablet 10-5 QL (0 per 0 days) endocet oral tablet.5-5, 5-5 QL (60 per 0 days) endocet oral tablet QL (00 per 0 days) fentanyl citrate buccal lozenge on a handle 1,00 mcg, 1,600 mcg, 00 mcg, (Actiq) 5 PA; NM; NDS; QL (10 per 0 days) 00 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 7 hour 100 (Duragesic) QL (10 per 0 days) mcg/hr, 1 mcg/hr, 5 mcg/hr, 50 mcg/hr, 75 mcg/hr hydrocodone-acetaminophen oral solution QL (700 per 0 days) /5 ml hydrocodone-acetaminophen oral solution QL (700 per 0 days) 5-16 /7.5ml(7.5ml) hydrocodone-acetaminophen oral solution (Hycet) QL (700 per 0 days) /15 ml hydrocodone-acetaminophen oral tablet (Norco) QL (60 per 0 days) 10-5, hydrocodone-acetaminophen oral tablet (Verdrocet) QL (60 per 0 days).5-5 hydrocodone-acetaminophen oral tablet (Lorcet (hydrocodone)) QL (60 per 0 days) 5-5 hydrocodone-ibuprofen oral tablet 7.5- QL (150 per 0 days) 00 hydromorphone (pf) injection solution 10 (/ml) (5 ml), 10 /ml hydromorphone injection solution /ml, /ml hydromorphone injection syringe (Dilaudid) /ml, /ml hydromorphone oral liquid 1 /ml (Dilaudid) QL (100 per 0 days) hydromorphone oral tablet,, 8 (Dilaudid) QL (180 per 0 days)

24 HYSINGLA ER ORAL TABLET,ORAL ONLY,EXT.REL. HR 100 MG, 10 MG, 0 MG, 0 MG, 0 MG, 60 MG, 80 MG LAZANDA NASAL SPRAY,NON- AEROSOL 100 MCG/SPRAY, 00 MCG/SPRAY, 00 MCG/SPRAY lorcet (hydrocodone) oral tablet 5-5 QL (0 per 0 days) 5 PA; NM; NDS; QL (0 per 0 days) QL (60 per 0 days) lorcet hd oral tablet 10-5 QL (60 per 0 days) lorcet plus oral tablet QL (60 per 0 days) methadone injection solution 10 /ml methadone oral solution 10 /5 ml, 5 QL (1800 per 0 days) /5 ml methadone oral tablet 10 (Dolophine) QL (60 per 0 days) methadone oral tablet 5 (Dolophine) QL (180 per 0 days) methadose oral tablet,soluble 0 QL (90 per 0 days) morphine /ml carpuject outer, l/f, p/f, sdv /ml morphine /ml carpuject outer,l/f,p/f, sdv /ml morphine 8 /ml syringe 8 /ml morphine concentrate oral solution 100 QL (180 per 0 days) /5 ml (0 /ml) morphine intravenous syringe 10 /ml, /ml, /ml, 8 /ml morphine oral solution 10 /5 ml QL (700 per 0 days) morphine oral solution 0 /5 ml ( QL (00 per 0 days) /ml) MORPHINE ORAL TABLET 15 MG QL (180 per 0 days) MORPHINE ORAL TABLET 0 MG QL (10 per 0 days) morphine oral tablet extended release 100 (MS Contin) QL (60 per 0 days), 00, 60 morphine oral tablet extended release 15 (MS Contin) QL (90 per 0 days), 0 morphine sulfate 10 /ml vial 10 /ml NUCYNTA ER ORAL TABLET EXTENDED RELEASE 1 HR 100 MG, 150 MG, 00 MG, 50 MG, 50 MG QL (60 per 0 days) 5

25 NUCYNTA ORAL TABLET 100 MG, QL (181 per 0 days) 50 MG, 75 MG oxycodone oral concentrate 0 /ml QL (10 per 0 days) oxycodone oral solution 5 /5 ml QL (100 per 0 days) oxycodone oral tablet 10 QL (180 per 0 days) oxycodone oral tablet 15, 0 (Roxicodone) QL (10 per 0 days) oxycodone oral tablet 0 QL (10 per 0 days) oxycodone oral tablet 5 (Roxicodone) QL (180 per 0 days) oxycodone oral tablet,oral only,ext.rel.1 (OxyContin) QL (60 per 0 days) hr 10, 15, 0, 0, 0, 60 oxycodone oral tablet,oral only,ext.rel.1 hr 80 (OxyContin) 5 NM; NDS; QL (10 per 0 days) oxycodone-acetaminophen oral solution QL (1800 per 0 days) 5-5 /5 ml oxycodone-acetaminophen oral tablet 10- (Percocet) QL (0 per 0 days) 5 oxycodone-acetaminophen oral tablet (Percocet) QL (60 per 0 days).5-5, 5-5 oxycodone-acetaminophen oral tablet (Percocet) QL (00 per 0 days) oxycodone-aspirin oral tablet QL (60 per 0 days) OXYCONTIN ORAL QL (60 per 0 days) TABLET,ORAL ONLY,EXT.REL.1 HR 10 MG, 15 MG, 0 MG, 0 MG, 0 MG, 60 MG OXYCONTIN ORAL QL (10 per 0 days) TABLET,ORAL ONLY,EXT.REL.1 HR 80 MG oxymorphone oral tablet 10 (Opana) QL (10 per 0 days) oxymorphone oral tablet 5 (Opana) QL (180 per 0 days) oxymorphone oral tablet extended release QL (60 per 0 days) 1 hr 10, 15, 0, 0, 0, 5, 7.5 reprexain oral tablet.5-00 QL (150 per 0 days) tencon oral tablet 50-5 PA-HRM; QL (180 per 0 days); AGE (Max 6 Years) tramadol oral tablet 50 (Ultram) 1 GC; QL (0 per 0 days) 6

26 tramadol-acetaminophen oral tablet 7.5- (Ultracet) QL (0 per 0 days) 5 XTAMPZA ER ORAL QL (60 per 0 days) CAPSULE,SPRINKLE,ER 1HR TMPRR 1.5 MG, 18 MG, 9 MG XTAMPZA ER ORAL QL (10 per 0 days) CAPSULE,SPRINKLE,ER 1HR TMPRR 7 MG XTAMPZA ER ORAL QL (0 per 0 days) CAPSULE,SPRINKLE,ER 1HR TMPRR 6 MG zebutal oral capsule PA-HRM; QL (180 per 0 days); AGE (Max 6 Years) Nonsteroidal Anti-Inflammatory Agents CALDOLOR INTRAVENOUS RECON SOLN 00 MG/ ML (100 MG/ML) celecoxib oral capsule 100, 00, (Celebrex) QL (60 per 0 days) 50 celecoxib oral capsule 00 (Celebrex) QL (60 per 0 days) diclofenac potassium oral tablet 50 diclofenac sodium oral tablet extended (Voltaren-XR) release hr 100 diclofenac sodium oral tablet,delayed release (dr/ec) 5, 50, 75 diclofenac-misoprostol oral (Arthrotec 50) tablet,ir,delayed rel,biphasic mcg diclofenac-misoprostol oral (Arthrotec 75) tablet,ir,delayed rel,biphasic mcg diflunisal oral tablet 500 etodolac oral capsule 00, 00 etodolac oral tablet 00 (Lodine) etodolac oral tablet 500 etodolac oral tablet extended release hr 00, 500, 600 fenoprofen oral tablet 600 flurbiprofen oral tablet 100, 50 ibuprofen oral suspension 100 /5 ml (Children's Profen IB) 7

27 ibuprofen oral tablet 00, 600, 1 GC 800 indomethacin oral capsule 5 1 PA-HRM; GC; QL (0 per 0 days); AGE (Max 6 Years) indomethacin oral capsule 50 1 PA-HRM; GC; QL (10 per 0 days); AGE (Max 6 Years) indomethacin oral capsule, extended release 75 PA-HRM; QL (60 per 0 days); AGE (Max 6 Years) indomethacin sodium intravenous recon soln 1 ketoprofen oral capsule 50, 75 ketoprofen oral capsule,ext rel. pellets hr 00 ketorolac oral tablet 10 PA-HRM; QL (0 per 0 days); AGE (Max 6 Years) mefenamic acid oral capsule 50 (Ponstel) meloxicam oral suspension 7.5 /5 ml meloxicam oral tablet 15, 7.5 (Mobic) 1 GC nabumetone oral tablet 500, 750 naproxen oral suspension 15 /5 ml (Naprosyn) naproxen oral tablet 50, 75 1 GC naproxen oral tablet 500 (Naprosyn) 1 GC naproxen oral tablet,delayed release (EC-Naprosyn) (dr/ec) 75, 500 piroxicam oral capsule 10, 0 (Feldene) sulindac oral tablet 150, 00 Anesthetics Local Anesthetics glydo mucous membrane jelly in applicator % lidocaine (pf) injection solution 10 /ml (Xylocaine-MPF) (1 %), 15 /ml (1.5 %), 0 /ml ( %) lidocaine (pf) injection solution 0 /ml ( %) lidocaine (pf) injection solution 5 /ml (0.5 %) (Xylocaine-MPF) 8

28 lidocaine hcl % vial inner,ltx-fr,p/f,sdv (Xylocaine-MPF) 0 /ml ( %) lidocaine hcl injection solution 10 /ml (Xylocaine) (1 %), 0 /ml ( %), 5 /ml (0.5 %) lidocaine hcl mucous membrane jelly % lidocaine hcl mucous membrane solution % (0 /ml) lidocaine topical adhesive patch,medicated 5 % (Lidoderm) PA; QL (90 per 0 days) lidocaine topical ointment 5 % PA; QL (90 per 0 days) lidocaine viscous mucous membrane solution % lidocaine-prilocaine topical cream.5-.5 % Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate oral tablet,delayed release (dr/ec) BUNAVAIL BUCCAL FILM.1-0. QL (0 per 0 days) MG BUNAVAIL BUCCAL FILM.-0.7 QL (60 per 0 days) MG, 6.-1 MG buprenorphine hcl sublingual tablet, 8 PA; QL (90 per 0 days) buprenorphine-naloxone sublingual tablet -0.5, 8- QL (90 per 0 days) bupropion hcl (smoking deter) oral tablet (Zyban) extended release 1 hr 150 CHANTIX CONTINUING MONTH QL (168 per 8 days) BOX ORAL TABLET 1 MG CHANTIX ORAL TABLET 0.5 MG, 1 QL (168 per 8 days) MG CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG (11)- 1 MG () QL (5 per 8 days) disulfiram oral tablet 50, 500 (Antabuse) naloxone injection solution 0. /ml 9

29 naloxone injection syringe 0. /ml, 1 /ml naltrexone oral tablet 50 (Revia) NARCAN NASAL SPRAY,NON- QL ( per 0 days) AEROSOL MG/ACTUATION, MG/ACTUATION NICOTROL INHALATION QL (1008 per 90 days) CARTRIDGE 10 MG SUBOXONE SUBLINGUAL FILM QL (60 per 0 days) 1- MG, 8- MG SUBOXONE SUBLINGUAL FILM - QL (0 per 0 days) 0.5 MG, -1 MG ZUBSOLV SUBLINGUAL TABLET QL (0 per 0 days) MG, MG, MG, MG, MG ZUBSOLV SUBLINGUAL TABLET MG QL (60 per 0 days) Antianxiety Agents Benzodiazepines alprazolam oral tablet 0.5, 0.5, 1 (Xanax) 1 GC; QL (10 per 0 days) alprazolam oral tablet (Xanax) 1 GC; QL (150 per 0 days) buspirone oral tablet 10, 15, 0, 5, 7.5 chlordiazepoxide hcl oral capsule 10, 5, 5 1 GC; QL (10 per 0 days) clonazepam oral tablet 0.5, 1 (Klonopin) 1 GC; QL (90 per 0 days) clonazepam oral tablet (Klonopin) 1 GC; QL (00 per 0 days) clonazepam oral tablet,disintegrating QL (90 per 0 days) 0.15, 0.5, 0.5, 1 clonazepam oral tablet,disintegrating QL (00 per 0 days) clorazepate dipotassium oral tablet 15 QL (180 per 0 days),.75 clorazepate dipotassium oral tablet 7.5 (Tranxene T-Tab) QL (180 per 0 days) DIASTAT ACUDIAL RECTAL KIT MG, MG 10

30 DIASTAT RECTAL KIT.5 MG diazepam injection solution 5 /ml QL (10 per 8 days) diazepam intensol oral concentrate 5 QL (100 per 0 days) /ml diazepam oral solution 5 /5 ml (1 QL (100 per 0 days) /ml) diazepam oral tablet 10,, 5 (Valium) 1 GC; QL (10 per 0 days) diazepam rectal kit , (Diastat AcuDial) diazepam rectal kit.5 (Diastat) lorazepam injection solution /ml, (Ativan) QL ( per 0 days) /ml lorazepam injection syringe /ml QL ( per 0 days) lorazepam oral tablet 0.5, 1 (Ativan) 1 GC; QL (90 per 0 days) lorazepam oral tablet (Ativan) 1 GC; QL (150 per 0 days) ONFI ORAL SUSPENSION.5 MG/ML 5 PA NSO; NM; NDS; QL (80 per 0 days) ONFI ORAL TABLET 10 MG, 0 MG 5 PA NSO; NM; NDS; QL (60 per 0 days) temazepam oral capsule 15, 0 (Restoril) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any benzodiazepine hypnotic drug); QL (0 per 0 days); AGE (Max 6 Years) Antibacterials Aminoglycosides BETHKIS INHALATION 5 PA BvD; NM; NDS SOLUTION FOR NEBULIZATION 00 MG/ ML gentamicin 10 /ml vial sdv 60 /6 ml 11

31 gentamicin in nacl (iso-osm) intravenous piggyback 100 /100 ml, 100 /50 ml, 10 /100 ml, 60 /50 ml, 70 /50 ml, 80 /100 ml, 80 /50 ml, 90 /100 ml gentamicin injection solution 0 /ml gentamicin sulfate (ped) (pf) injection solution 0 / ml gentamicin sulfate (pf) intravenous solution 100 /10 ml neomycin oral tablet GC streptomycin intramuscular recon soln 1 gram TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE 8 MG tobramycin in 0.5 % nacl inhalation solution for nebulization 00 /5 ml tobramycin in 0.9 % nacl intravenous piggyback 60 /50 ml tobramycin sulfate injection solution 10 /ml, 0 /ml Antibacterials, Miscellaneous bacitracin intramuscular recon soln 50,000 unit chloramphenicol sod succinate intravenous recon soln 1 gram 5 NM; NDS; QL ( per 8 days) (Tobi) 5 PA BvD; NM; NDS (BACiiM) clindamycin 75 /5 ml soln 75 /5 ml (Cleocin Pediatric) clindamycin hcl oral capsule 150, 00 (Cleocin HCl), 75 clindamycin in 5 % dextrose intravenous (Cleocin in 5 % piggyback 00 /50 ml, 600 /50 ml, 900 /50 ml dextrose) clindamycin pediatric oral recon soln 75 /5 ml clindamycin phosphate injection solution 150 (/ml) (6 ml) clindamycin phosphate injection solution (Cleocin) 150 /ml clindamycin phosphate intravenous solution 600 / ml (Cleocin) 1

32 colistin (colistimethate na) injection (Coly-Mycin M recon soln 150 Parenteral) daptomycin intravenous recon soln 500 (Cubicin) 5 NM; NDS linezolid intravenous parenteral solution (Zyvox) 5 NM; NDS 600 /00 ml linezolid oral suspension for (Zyvox) 5 NM; NDS reconstitution 100 /5 ml linezolid oral tablet 600 (Zyvox) 5 NM; NDS methenamine hippurate oral tablet 1 (Hiprex) gram metronidazole in nacl (iso-os) intravenous piggyback 500 /100 ml (Metro I.V.) metronidazole oral tablet 50, 500 (Flagyl) nitrofurantoin macrocrystal oral capsule 100, 50 (Macrodantin) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (10 per 0 days); AGE (Max 6 Years) nitrofurantoin macrocrystal oral capsule 5 nitrofurantoin monohyd/m-cryst oral capsule 100 (Macrodantin) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (10 per 0 days); AGE (Max 6 Years) (Macrobid) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (60 per 0 days); AGE (Max 6 Years) 1

33 polymyxin b sulfate injection recon soln 500,000 unit SYNERCID INTRAVENOUS 5 NM; NDS RECON SOLN 500 MG trimethoprim oral tablet GC vancomycin in dextrose 5 % intravenous piggyback 1 gram/00 ml, 500 /100 ml, 750 /150 ml vancomycin intravenous recon soln 1,000, 10 gram, 5 gram, 500, 750 vancomycin oral capsule 15, 50 (Vancocin) 5 NM; NDS XIFAXAN ORAL TABLET 00 MG 5 PA; NM; NDS; QL (9 per 0 days) XIFAXAN ORAL TABLET 550 MG 5 PA; NM; NDS Cephalosporins cefaclor oral capsule 50, 500 cefaclor oral suspension for reconstitution 15 /5 ml, 50 /5 ml, 75 /5 ml cefadroxil oral capsule 500 cefadroxil oral suspension for reconstitution 50 /5 ml, 500 /5 ml cefadroxil oral tablet 1 gram cefazolin in dextrose (iso-os) intravenous piggyback gram/100 ml cefazolin injection recon soln 1 gram, 10 gram, 500 cefazolin intravenous recon soln 1 gram cefdinir oral capsule 00 cefdinir oral suspension for reconstitution 15 /5 ml, 50 /5 ml cefditoren pivoxil oral tablet 00 cefditoren pivoxil oral tablet 00 (Spectracef) CEFEPIME 1 GM INJECTION 1 GRAM/50 ML CEFEPIME INJECTION RECON (Maxipime) SOLN 1 GRAM, GRAM CEFEPIME-DEXTROSE GM/50 ML GRAM/50 ML cefotaxime injection recon soln 1 gram, 10 gram, gram (Claforan) 1

34 cefotaxime injection recon soln 500 cefoxitin gm piggyback bag gram/50 ml cefoxitin intravenous recon soln 1 gram, 10 gram cefoxitin intravenous recon soln gram cefpodoxime oral suspension for reconstitution 100 /5 ml, 50 /5 ml cefpodoxime oral tablet 100, 00 cefprozil oral suspension for reconstitution 15 /5 ml, 50 /5 ml cefprozil oral tablet 50, 500 ceftazidime injection recon soln gram (Fortaz) ceftazidime injection recon soln 6 gram (TAZICEF) ceftibuten oral capsule 00 (Cedax) ceftibuten oral suspension for (Cedax) reconstitution 180 /5 ml ceftriaxone 1 gm piggyback l/g, single use 1 gram/50 ml ceftriaxone gm piggyback l/f, single use gram/50 ml ceftriaxone injection recon soln 1 gram, 10 gram, 50, 500 ceftriaxone intravenous recon soln 1 gram, gram cefuroxime axetil oral tablet 50, 500 cefuroxime sodium injection recon soln (Zinacef) 750 cefuroxime sodium intravenous recon soln (Zinacef) 1.5 gram, 7.5 gram cephalexin oral capsule 50, 500 (Keflex) 1 GC cephalexin oral suspension for reconstitution 15 /5 ml, 50 /5 ml cephalexin oral tablet 50, 500 MEFOXIN IN DEXTROSE (ISO- OSM) INTRAVENOUS PIGGYBACK 1 GRAM/50 ML, GRAM/50 ML SUPRAX ORAL CAPSULE 00 MG 15

35 SUPRAX ORAL TABLET,CHEWABLE 100 MG, 00 MG tazicef injection recon soln 1 gram, gram, 6 gram TEFLARO INTRAVENOUS RECON SOLN 00 MG, 600 MG Macrolides azithromycin intravenous recon soln 500 (Zithromax) azithromycin oral packet 1 gram (Zithromax) azithromycin oral suspension for (Zithromax) reconstitution 100 /5 ml, 00 /5 ml azithromycin oral tablet 50 (Zithromax Z-Pak) azithromycin oral tablet 50 (6 pack), 500 ( pack) azithromycin oral tablet 500, 600 (Zithromax) clarithromycin oral suspension for reconstitution 15 /5 ml, 50 /5 ml clarithromycin oral tablet 50, 500 clarithromycin oral tablet extended release hr 500 DIFICID ORAL TABLET 00 MG 5 ST; NM; NDS; QL (0 per 10 days) e.e.s. 00 oral tablet 00 e.e.s. granules oral suspension for reconstitution 00 /5 ml ERYPED 00 ORAL SUSPENSION FOR RECONSTITUTION 00 MG/5 ML ERYPED 00 ORAL SUSPENSION FOR RECONSTITUTION 00 MG/5 ML ery-tab oral tablet,delayed release (dr/ec) 50, 500 ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) MG erythrocin (as stearate) oral tablet 50 16

36 ERYTHROCIN INTRAVENOUS RECON SOLN 1,000 MG, 500 MG erythromycin ethylsuccinate oral tablet (E.E.S. 00) 00 erythromycin oral capsule,delayed release(dr/ec) 50 erythromycin oral tablet 50, 500 Miscellaneous B-Lactam Antibiotics aztreonam injection recon soln 1 gram, gram (Azactam) CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML 5 NM; LA; NDS imipenem-cilastatin intravenous recon (Primaxin IV) soln 50, 500 INVANZ INJECTION RECON SOLN 1 GRAM meropenem intravenous recon soln 1 (Merrem) gram, 500 Penicillins amoxicillin oral capsule 50, GC amoxicillin oral suspension for 1 GC reconstitution 15 /5 ml, 00 /5 ml, 50 /5 ml, 00 /5 ml amoxicillin oral tablet 500, GC amoxicillin oral tablet,chewable 15, 1 GC 50 amoxicillin-pot clavulanate oral suspension for reconstitution /5 ml, /5 ml amoxicillin-pot clavulanate oral (Augmentin) suspension for reconstitution /5 ml amoxicillin-pot clavulanate oral (Augmentin ES-600) suspension for reconstitution /5 ml amoxicillin-pot clavulanate oral tablet amoxicillin-pot clavulanate oral tablet , (Augmentin) 17

37 amoxicillin-pot clavulanate oral tablet,chewable , ampicillin oral capsule 50, GC ampicillin oral suspension for 1 GC reconstitution 15 /5 ml, 50 /5 ml ampicillin sodium injection recon soln 1 gram, 10 gram, 15, gram, 50, 500 ampicillin sodium intravenous recon soln gram ampicillin-sulbactam injection recon soln (Unasyn) 1.5 gram, 15 gram, gram BICILLIN C-R INTRAMUSCULAR SYRINGE 1,00,000 UNIT/ ML(600K/600K), 1,00,000 UNIT/ ML(900K/00K) BICILLIN L-A INTRAMUSCULAR SYRINGE 1,00,000 UNIT/ ML,,00,000 UNIT/ ML, 600,000 UNIT/ML dicloxacillin oral capsule 50, 500 nafcillin gm vial sterile, latex-free gram nafcillin injection recon soln 1 gram nafcillin injection recon soln 10 gram 5 NM; NDS nafcillin intravenous recon soln gram 5 NM; NDS oxacillin in dextrose(iso-osm) intravenous piggyback 1 gram/50 ml, gram/50 ml oxacillin injection recon soln 10 gram, gram oxacillin intravenous recon soln 1 gram penicillin g pot in dextrose intravenous piggyback 1 million unit/50 ml, million unit/50 ml, million unit/50 ml penicillin g potassium injection recon soln (Pfizerpen-G) 5 million unit penicillin g procaine intramuscular syringe 1. million unit/ ml, 600,000 unit/ml 18

38 penicillin gk 0 million unit 0 million (Pfizerpen-G) unit penicillin v potassium oral recon soln 15 /5 ml, 50 /5 ml penicillin v potassium oral tablet 50, 500 pfizerpen-g injection recon soln 0 million unit piperacillin-tazobactam intravenous (Zosyn) recon soln.5 gram,.75 gram,.5 gram, 0.5 gram Quinolones ciprofloxacin hcl oral tablet 100, GC ciprofloxacin hcl oral tablet 50, 500 (Cipro) 1 GC ciprofloxacin in 5 % dextrose intravenous piggyback 00 /100 ml ciprofloxacin in 5 % dextrose intravenous (Cipro in D5W) piggyback 00 /00 ml ciprofloxacin lactate intravenous solution 00 /0 ml, 00 /0 ml ciprofloxacin oral (Cipro) suspension,microcapsule recon 50 /5 ml, 500 /5 ml levofloxacin in d5w intravenous piggyback 50 /50 ml, 500 /100 ml, 750 /150 ml levofloxacin intravenous solution 5 /ml levofloxacin oral solution 50 /10 ml levofloxacin oral tablet 50, 500, (Levaquin) 750 moxifloxacin oral tablet 00 (Avelox) ofloxacin oral tablet 00, 00 Sulfonamides sulfadiazine oral tablet 500 sulfamethoxazole-trimethoprim intravenous solution /5 ml sulfamethoxazole-trimethoprim oral suspension 00-0 /5 ml (Sulfatrim) 19

39 sulfamethoxazole-trimethoprim oral (Bactrim) 1 GC tablet sulfamethoxazole-trimethoprim oral (Bactrim DS) 1 GC tablet sulfatrim oral suspension 00-0 /5 ml Tetracyclines doxy-100 intravenous recon soln 100 doxycycline hyclate oral capsule 100 (Vibramycin) doxycycline hyclate oral capsule 50 (Morgidox) doxycycline hyclate oral tablet 100, 0 doxycycline monohydrate oral capsule (Monodox) 100 doxycycline monohydrate oral capsule 150 doxycycline monohydrate oral capsule 50 (Mondoxyne NL) doxycycline monohydrate oral capsule 75 (Monodox) doxycycline monohydrate oral suspension (Vibramycin) for reconstitution 5 /5 ml doxycycline monohydrate oral tablet 100 (Avidoxy) doxycycline monohydrate oral tablet 150, 50, 75 minocycline oral capsule 100, 50, (Minocin) 75 minocycline oral tablet 100, 50, 75 tigecycline intravenous recon soln 50 (Tygacil) 5 NM; NDS Anticancer Agents Anticancer Agents ABRAXANE INTRAVENOUS 5 NM; NDS SUSPENSION FOR RECONSTITUTION 100 MG adriamycin intravenous solution 10 /5 PA BvD ml, 0 /10 ml adrucil intravenous solution.5 gram/50 ml, 500 /10 ml PA BvD 0

FORMULARY (List of Covered Drugs)

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

More information

Brand New Day Formulary. (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN

Brand New Day Formulary. (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Brand New Day In Control Drug Savings (HMO SNP) In Control Choice for Medi-Medi (HMO SNP) Embrace Care Drug Savings (HMO SNP) Embrace Choice for Medi-Medi (HMO SNP) 018 Formulary (List of Covered Drugs)

More information

In Control Drug Savings (HMO SNP) In Control Choice for Medi-Medi (HMO SNP) Embrace Care Drug Savings (HMO SNP) Embrace Choice for Medi-Medi (HMO

In Control Drug Savings (HMO SNP) In Control Choice for Medi-Medi (HMO SNP) Embrace Care Drug Savings (HMO SNP) Embrace Choice for Medi-Medi (HMO 018 In Control Drug Savings (HMO SNP) In Control Choice for Medi-Medi (HMO SNP) Embrace Care Drug Savings (HMO SNP) Embrace Choice for Medi-Medi (HMO SNP) 1801 19 December 01 8 Note to existing members:

More information

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

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

More information

2018 Sharp Direct Advantage TM Comprehensive Drug List

2018 Sharp Direct Advantage TM Comprehensive Drug List 018 Sharp Direct Advantage TM Comprehensive Drug List Sharp Health Plan: Off Exchange Drug List List of covered drugs for Employer sponsored plans July 017 Sharp Health Plan 018 Formulary (List of Covered

More information

2018 Sharp Direct Advantage TM Comprehensive Drug List

2018 Sharp Direct Advantage TM Comprehensive Drug List 018 Sharp Direct Advantage TM Comprehensive Drug List List of covered drugs for Sharp Direct Advantage Gold Card (HMO) & Sharp Direct Advantage Platinum Card (HMO) Sharp Direct Advantage Gold Card (HMO)

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

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

Aurora Special Needs Plan (HMO SNP) 2018 Formulary. (List of Covered Drugs)

Aurora Special Needs Plan (HMO SNP) 2018 Formulary. (List of Covered Drugs) Aurora Special Needs Plan (HMO SNP) 08 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission 80,

More information

Brand New Day. Harmony Care Plan (HMO SNP) 2019 Formulary. (List of Covered Drugs)

Brand New Day. Harmony Care Plan (HMO SNP) 2019 Formulary. (List of Covered Drugs) Brand New Day Harmony Care Plan (HMO SNP) 019 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission

More information

2017 Formulary (List of Covered Drugs)

2017 Formulary (List of Covered Drugs) DRAFT ATRIO Bronze Rx (Basin) (PPO) ATRIO Bronze Rx (Rogue) (PPO) ATRIO Bronze Rx (Umpqua) (PPO) ATRIO Gold Rx (PPO) ATRIO Gold Rx (Rogue) (PPO) ATRIO Gold Rx (Willamette) (PPO) ATRIO Silver Rx (PPO) ATRIO

More information

2018 Formulary (List of Covered Drugs)

2018 Formulary (List of Covered Drugs) DRAFT ATRIO Bronze Rx (Basin) (PPO) ATRIO Bronze Rx (Rogue) (PPO) ATRIO Bronze Rx (Umpqua) (PPO) ATRIO Gold Rx (PPO) ATRIO Gold Rx (Willamette) (PPO) ATRIO Silver Rx (PPO) ATRIO Silver Rx (Rogue) (PPO)

More information

Brand New Day. Embrace Care Plan (HMO SNP) Embrace Choice Medi-Medi Plan (HMO SNP) 2019 Formulary. (List of Covered Drugs)

Brand New Day. Embrace Care Plan (HMO SNP) Embrace Choice Medi-Medi Plan (HMO SNP) 2019 Formulary. (List of Covered Drugs) Brand New Day Embrace Care Plan (HMO SNP) Embrace Choice Medi-Medi Plan (HMO SNP) 019 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS

More information

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

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

More information

Prescription Drug Formulary

Prescription Drug Formulary Prescription Drug Formulary 2017 Advantage Plus (HMO) This formulary was updated on 08/2/2016. For more recent information or other questions, please contact Essence Healthcare, Inc. Customer Service,

More information

Prescription Drug Formulary

Prescription Drug Formulary Prescription Drug Formulary 016 This formulary was updated on 07/6/016. For more recent information or other questions, please contact Essence Healthcare, Inc. Customer Service at (866) 597-9560 or, for

More information

2019 Sharp Direct Advantage SM Comprehensive Drug List

2019 Sharp Direct Advantage SM Comprehensive Drug List 019 Sharp Direct Advantage SM Comprehensive Drug List List of covered drugs for Sharp Direct Advantage (HMO) Medicare Plans Sharp Direct Advantage (HMO) 019 Formulary (List of Covered Drugs) PLEASE READ:

More information

Aurora Special Needs Plan HMO SNP Formulary. (List of Covered Drugs)

Aurora Special Needs Plan HMO SNP Formulary. (List of Covered Drugs) Aurora Special Needs Plan HMO SNP 07 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 7044,

More information

2018 FORMULARY. (List of Covered Drugs) Prominence Health Plan (HMO)

2018 FORMULARY. (List of Covered Drugs) Prominence Health Plan (HMO) Prominence Health Plan (HMO) 2018 FORMULARY (List of Covered Drugs) Please read: This document contains information about the drugs we cover in this plan. HPMS Approved Formulary File Submission ID: 1802,

More information

(List of Covered Drugs)

(List of Covered Drugs) (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on April 1, 018. For more recent information or other questions,

More information

Senior Care Plus Formulary. (List of Covered Drugs)

Senior Care Plus Formulary. (List of Covered Drugs) Senior Care Plus 2018 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission ID: 180 Version Number:

More information

Senior Care Plus Formulary. (List of Covered Drugs)

Senior Care Plus Formulary. (List of Covered Drugs) Senior Care Plus 2018 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission ID: 180 Version Number:

More information

Senior Care Plus Formulary - MAPD. (List of Covered Drugs)

Senior Care Plus Formulary - MAPD. (List of Covered Drugs) Senior Care Plus 2018 Formulary - MAPD (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission ID: 180 Version

More information

Senior Care Plus Formulary. (List of Covered Drugs)

Senior Care Plus Formulary. (List of Covered Drugs) Senior Care Plus 2018 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission ID: 180 Version Number:

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

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

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

More information

Prescription Drug Formulary

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

More information

2017 Comprehensive Formulary

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

More information

Senior Care Plus PDP Formulary. (List of Covered Drugs)

Senior Care Plus PDP Formulary. (List of Covered Drugs) Senior Care Plus 018 PDP 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: 1800 Version

More information

Senior Care Plus Formulary. (List of Covered Drugs)

Senior Care Plus Formulary. (List of Covered Drugs) Senior Care Plus 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: 1915 Version Number:

More information

2017 Formulary (List of Covered Drugs)

2017 Formulary (List of Covered Drugs) DRAFT ATRIO Special Needs Plan (HMO SNP) ATRIO Special Needs Plan (Rogue) (HMO SNP) ATRIO Special Needs Plan (Willamette) (HMO SNP) 207 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS

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

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

PHP (HMO SNP) 2018 Formulary (List of Covered Drugs)

PHP (HMO SNP) 2018 Formulary (List of Covered Drugs) FLORIDA PHP (HMO SNP) 08 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on August 4, 08. For more recent

More information

2019 Comprehensive Formulary

2019 Comprehensive Formulary Centers Plan for Dual Coverage Care (HMO SNP) Centers Plan for Nursing Home Care (HMO SNP) Centers Plan for Medicaid Advantage Plus (HMO SNP) 209 Comprehensive Formulary This formulary was updated on /209.

More information

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

Geisinger Gold $0 Deductible Rx Comprehensive Formulary. (List of Covered Drugs) Geisinger Gold $0 Deductible Rx 018 Comprehensive Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on January,

More information

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

Geisinger Gold $0 Deductible Rx Comprehensive Formulary. (List of Covered Drugs) Geisinger Gold $0 Deductible Rx 018 Comprehensive Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on August

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

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

PHP (HMO SNP) 2018 Formulary (List of Covered Drugs)

PHP (HMO SNP) 2018 Formulary (List of Covered Drugs) FLORIDA PHP (HMO SNP) 08 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on November 0, 08. For more recent

More information

Senior Care Plus PDP Formulary. (List of Covered Drugs)

Senior Care Plus PDP Formulary. (List of Covered Drugs) Senior Care Plus 018 PDP 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: 1800 Version

More information

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

Geisinger Gold $0 Deductible Rx Formulary. (List of Covered Drugs) Geisinger Gold $0 Deductible Rx 019 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on January 1, 019.

More information

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

Geisinger Gold $0 Deductible Rx Comprehensive Formulary. (List of Covered Drugs) Geisinger Gold $0 Deductible Rx 017 Comprehensive Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on August

More information

PHP (HMO SNP) 2018 Formulary (List of Covered Drugs)

PHP (HMO SNP) 2018 Formulary (List of Covered Drugs) FLORIDA PHP (HMO SNP) 08 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on August 6, 07. For more recent

More information

PHP (HMO SNP) 2018 Formulary (List of Covered Drugs)

PHP (HMO SNP) 2018 Formulary (List of Covered Drugs) FLORIDA PHP (HMO SNP) 08 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on February, 08. For more recent

More information

Geisinger Gold Standard Rx Comprehensive Formulary. (List of Covered Drugs)

Geisinger Gold Standard Rx Comprehensive Formulary. (List of Covered Drugs) Geisinger Gold Standard Rx 208 Comprehensive Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on July,

More information

Geisinger Gold Standard Rx Comprehensive Formulary. (List of Covered Drugs)

Geisinger Gold Standard Rx Comprehensive Formulary. (List of Covered Drugs) Geisinger Gold Standard Rx 208 Comprehensive Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on December

More information

Geisinger Gold Triple Tier Employer Group Rx Comprehensive Formulary. (List of Covered Drugs)

Geisinger Gold Triple Tier Employer Group Rx Comprehensive Formulary. (List of Covered Drugs) Geisinger Gold Triple Tier Employer Group Rx 018 Comprehensive Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was

More information

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

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

More information

FORMULARY List of Covered Drugs

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

More information

2019 Comprehensive Formulary

2019 Comprehensive Formulary 2019 Comprehensive Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on 02/28/2019. For more recent information

More information

Geisinger Gold Standard Rx Formulary. (List of Covered Drugs)

Geisinger Gold Standard Rx Formulary. (List of Covered Drugs) Geisinger Gold Standard Rx 209 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on August 30, 208. For

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

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

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

More information

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

201 F L L A A HI N N AIN INF A I N A H IN HI LAN H A F F I N 8 10/09/2018 F H H H

201 F L L A A HI N N AIN INF A I N A H IN HI LAN H A F F I N 8 10/09/2018 F H H H P H 東華 01 F L H L A A HI N N AIN INF A I N A H IN HI LAN H A F F I 0001958 N 8 10/09/018 F H 1 888 775 7888 1 877 81 88 8 8 00 8 00 H H H0571_01 _11_FINAL_ Note to existing members: This formulary has

More information

2019 Formulary (List of Covered Drugs)

2019 Formulary (List of Covered Drugs) DRAFT ATRIO Special Needs Plan (HMO SNP) ATRIO Special Needs Plan (Willamette) (HMO SNP) 209 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN

More information

CCH Senior Select ro r H S

CCH Senior Select ro r H S P 9 CCH Senior Select ro r H S 東華 H S 9 or l r i t o Co ere r S H S C C S H S C H S H S ro e or l r ile S i ion 009536 er ion er 7 i or l r te on 08/23/208 or ore recent in or tion or ot er e tion le e

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 PHP (HMO SNP) 08 Formul lary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on July 5, 08. For more recent information

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

2017 Comprehensive Formulary

2017 Comprehensive Formulary Centers Plan for Medicare Advantage Care (HMO) 07 Comprehensive Formulary This formulary was updated on /07. For more recent information or other questions, please contact Centers Plan for Healthy Living

More information

LIST OF COVERED DRUGS

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

More information

PERS Moda Health PPORX (PPO) PERS Moda Health Rx (PDP)

PERS Moda Health PPORX (PPO) PERS Moda Health Rx (PDP) PERS Moda Health PPORX (PPO) PERS Moda Health Rx (PDP) 018 Comprehensive Formulary (complete list of covered drugs) Please read: this document contains information about 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

Moda Health Plan, Inc.

Moda Health Plan, Inc. Moda Health Plan, Inc. 017 Comprehensive Formulary (complete list of covered drugs) Please read: this document contains information about the drugs we cover in this plan Note to existing members: This

More information

CCH Senior Select ro r H S

CCH Senior Select ro r H S P CCH Senior Select ro r H S 東華 H S or l r i t o Co ere r S H S C C S H S C H S H S ro e or l r ile S i ion 009536 er ion er 9 i or l r te on 0/09/208 or ore recent in or tion or ot er e tion le e cont

More information

PERS Moda Health PPORX (PPO) PERS Moda Health Rx (PDP)

PERS Moda Health PPORX (PPO) PERS Moda Health Rx (PDP) PERS Moda Health PPORX (PPO) PERS Moda Health Rx (PDP) 2017 Comprehensive Formulary (complete list of covered drugs) Please read: this document contains information about the drugs we cover in this plan

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

2019 FORMULARY. (List of Covered Drugs) Prominence Health Plan (HMO)

2019 FORMULARY. (List of Covered Drugs) Prominence Health Plan (HMO) Prominence Health Plan (HMO) 019 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: 1915,

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

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

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

Senior Preferred (HMO) 2019 Formulary (List of Covered Drugs) Senior Preferred (HMO) 09 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary ID: 96, Version 3 This formulary

More information

Premier Formulary Medicare Plans. RMHP is a Medicare-approved Cost plan. Enrollment in RMHP depends on contract renewal.

Premier Formulary Medicare Plans. RMHP is a Medicare-approved Cost plan. Enrollment in RMHP depends on contract renewal. Premier Formulary 017 Medicare Plans RMHP is a Medicare-approved Cost plan. Enrollment in RMHP depends on contract renewal. H060_PH_PH9_0711016 Approved PH9R07/11/16þ Notice of Nondiscrimination Rocky

More information

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

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

More information

PHP (HMO SNP) 2018 Formulary (List of Covered Drugs)

PHP (HMO SNP) 2018 Formulary (List of Covered Drugs) CALIFORNIA PHP (HMO SNP) 08 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on November 0, 08. For more

More information

HealthPartners Minnesota Senior Health Options (MSHO) (HMO SNP) 2016 List of Covered Drugs (Formulary)

HealthPartners Minnesota Senior Health Options (MSHO) (HMO SNP) 2016 List of Covered Drugs (Formulary) HealthPartners Minnesota Senior Health Options (MSHO) (HMO SNP) 2016 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

PHP (HMO SNP) 2018 Formulary (List of Covered Drugs)

PHP (HMO SNP) 2018 Formulary (List of Covered Drugs) PHP (HMO SNP) 08 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN CALIFORNIA This formulary was updated on May 4, 08. For more recent

More information

Moda Health Plan, Inc.

Moda Health Plan, Inc. Moda Health Plan, Inc. 018 Comprehensive Formulary (complete list of covered drugs) Please read: this document contains information about the drugs we cover in this plan Note to existing members: This

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

2018 Formulary. (List of Covered Drugs)

2018 Formulary. (List of Covered Drugs) 018 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. HPMS Approved Formulary File Submission ID: 18390 Version #: 18 This formulary

More information

2019 Comprehensive Formulary

2019 Comprehensive Formulary Centers Plan for Medicare Advantage Care (HMO) 09 Comprehensive Formulary This formulary was updated on /08. For more recent information or other questions, please contact Centers Plan for Healthy Living

More information

HealthPartners Minnesota Senior Health Options (MSHO) (HMO SNP) 2019 MSHO List of Covered Drugs (Formulary)

HealthPartners Minnesota Senior Health Options (MSHO) (HMO SNP) 2019 MSHO List of Covered Drugs (Formulary) HealthPartners Minnesota Senior Health Options (MSHO) (HMO SNP) 2019 MSHO List of Covered Drugs (Formulary) This document is called the List of Covered Drugs (also known as the Drug List). It tells you

More information

Moda Health HMO Moda Health HMO Enhanced + RX (HMO) Moda Health PPORX Enhanced (PPO) Moda Health PPORX (PPO)

Moda Health HMO Moda Health HMO Enhanced + RX (HMO) Moda Health PPORX Enhanced (PPO) Moda Health PPORX (PPO) Moda Health HMO Moda Health HMO Enhanced + RX (HMO) Moda Health PPORX Enhanced (PPO) Moda Health PPORX (PPO) Moda Health Plan, Inc. 019 Comprehensive Formulary (complete list of covered drugs) Please read:

More information

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

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT SOME OF THE DRUGS WE COVER IN THIS PLAN. HealthPartners Freedom Vital with Rx (Cost) HealthPartners Freedom Balance with Rx (Cost) HealthPartners Freedom Ultimate with Rx (Cost) HealthPartners Freedom Ultimate with Enhanced Rx (Cost) HealthPartners

More information

CCHP Senior Program (HMO) 東華耆英 (HMO) 計劃

CCHP Senior Program (HMO) 東華耆英 (HMO) 計劃 Plan Year 018 CCHP Senior Program (HMO) 東華耆英 (HMO) 計劃 018 Formulary (List of Covered Drugs) 藥物表 ( 保障藥物一覽表 ) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved

More information

PERS Moda Health Rx (PDP)

PERS Moda Health Rx (PDP) PERS Moda Health Rx (PDP) 019 Comprehensive Formulary (complete list of covered drugs) Please read: this document contains information about the drugs we cover in this plan Note to existing members: This

More information

2018 Formulary. (List of Covered Drugs)

2018 Formulary. (List of Covered Drugs) 018 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. HPMS Approved Formulary File Submission ID: 18390 Version #: 11 This formulary

More information

VillageCareMAX Medicare Health Advantage (HMO SNP) 2019 Formulary. (List of Covered Drugs)

VillageCareMAX Medicare Health Advantage (HMO SNP) 2019 Formulary. (List of Covered Drugs) VillageCareMAX Medicare Health Advantage (HMO SNP) 209 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Approved Formulary File Submission

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) (Collectively known as HealthPartners UnityPoint Health) 017 Formulary (List of Covered Drugs) PLEASE READ:

More information

icare Family Care Partnership (HMO SNP) (H ) 2019 Formulary (List of Covered Drugs)

icare Family Care Partnership (HMO SNP) (H ) 2019 Formulary (List of Covered Drugs) icare Family Care Partnership (HMO SNP) (H37-007) 09 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File

More information

CCHP Senior Program (HMO) 東華耆英 (HMO) 計劃

CCHP Senior Program (HMO) 東華耆英 (HMO) 計劃 Plan Year 018 CCHP Senior Program (HMO) 東華耆英 (HMO) 計劃 018 Formulary (List of Covered Drugs) 藥物表 ( 保障藥物一覽表 ) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved

More information

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

PRESCRIPTION DRUGS FORMULARY 1. I ~~ [ tl-i I Classicare (HMO) PRESCRIPTION DRUGS FORMULARY 1 2018 I ~~ [ tl-i I Classicare (HMO) MCS Classicare 2018 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS

More information

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 Freedom Group (Cost) HealthPartners Journey Group (PPO) HealthPartners Retiree National Choice (PDP) (Collectively known as HealthPartners) 019 Formulary II (List of Covered Drugs) PLEASE

More information

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

Florida Hospital Care Advantage 2017 Formulary (List of Covered Drugs) Updated: November 1, 2017 Explorer Plan (HMO-POS) SunSaver Plan (HMO-POS) Florida Hospital Care Advantage 2017 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE

More information

Updated: November 1, 2017 Classic Plan (HMO-POS) Value Plan (HMO) Rewards Plan (HMO) Health First Health Plans 2017 Formulary (List of Covered Drugs)

Updated: November 1, 2017 Classic Plan (HMO-POS) Value Plan (HMO) Rewards Plan (HMO) Health First Health Plans 2017 Formulary (List of Covered Drugs) Updated: November 1, 2017 Classic Plan (HMO-POS) Value Plan (HMO) Rewards Plan (HMO) Health First Health Plans 2017 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT

More information

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

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

More information

VillageCareMAX Full Advantage FIDA Plan (Medicare-Medicaid Plan)

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

More information

Stanford Health Care Advantage 2018 Formulary List of Covered Drugs

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

More information