healthpartners.com/pharmacy.

Size: px
Start display at page:

Download "healthpartners.com/pharmacy."

Transcription

1 4 Tier 2018 Formulary (List of covered drugs) For current information on the GenericsAdvantageRx Drug List, visit healthpartners.com/pharmacy. Effective: April 1, HealthPartners

2 What s the GenericsAdvantageRx drug list? This is the list of medicines (sometimes called a formulary) covered by your health plan. The drug list is reviewed by a team of experts every three months for new medicines, safety alerts and other updates. Who decides what s on the drug list? The HealthPartners Pharmacy and Therapeutics Committee manages the list. This team of experts is focused on safety, effectiveness and affordability. Visit healthpartners.com/pharmacy for more information. How do you use the drug list? The medicines on the drug list are listed in alphabetical order by type of medicine starting on page 3. Generic medicines are in lowercase italics (e.g., cephalexin) and are just as safe and effective as brand medicines but cost you less. Some generic medicines are very low-cost. Brand medicines are in ALL CAPS (e.g., KEFLEX) and are more costly than generic medicines. The Tier Status can be used to determine how much a medicine will cost you. For exact cost information, Find the tier status for your medicine. Review your Summary of Plan Benefits or contract for the copay or coinsurance for that Tier Status. Or, Log on to your myhealthpartners account to check your pharmacy benefits. Formulary Generics Formulary Brands Tier 3 Non-Formulary Generics &Brands (Non-Formulary medicines are not listed in this document) Generics & Brands What s a Medicine? medicines are usually prescribed by doctors whose focus is on the treatment of chronic and complex diseases. These medicines usually require more management, have a high price and aren t always stocked at retail pharmacies. Prescriptions for these medicines must be filled at a specialty pharmacy and are often covered at a different benefit than non-specialty medicines. Log on to your myhealthpartners account and click on My plan benefits on the Medical Plan tab to check your benefits for specialty medicines. What do the abbreviations in the More details column mean? This column gives special information about the medicine you re searching for. The abbreviations let you know there might be a special program or rule for the medicine. Use this key to help you navigate the drug list: Prior Authorization Required PA Step Therapy Required ST Age Edit AE Gender Edit Female GE Female Gender Edit Male GE Male Quantity Limit Smoking Cessation Benefit SC Trial Drug Program TD Weight Loss Benefit WL Oncology Benefit ONC

3 Why do you need prior authorization (PA) for some medicines? Even though some medicines are on the drug list, they need to meet the HealthPartners prior authorization criteria in order for the medicine to be covered by your pharmacy benefits. What s Step Therapy (ST)? Some medicines are on the drug list, but you need to try one or more other medicines first. HealthPartners covers a medicine with step therapy, if you've already tried the other medicine(s). If you haven't, you or your doctor will need to get approval from HealthPartners before the medicine will be covered by your lowest brand, generic or specialty copay or coinsurance. What s an Age Edit (AE)? An age edit means some medicines are only covered if you re within a specific age range. If you're not in the approved age range, you or your doctor will need to request approval from HealthPartners for your medicine to be covered. What s a Gender Edit (GE)? A gender edit means some medicines are covered for males or females only. If you're not in the approved gender group, you or your doctor will need to request approval from HealthPartners for your medicine to be covered. What s a Quantity Limit ()? This means HealthPartners limits the amount of the medicine you'll get each time you fill your prescription. The quantity limit may be less than the days supply listed in your contract or Summary Plan Description. What s the Trial Drug Program (TD)? The trial drug program is for new prescriptions for certain medicines that may not be well tolerated due to: Side effects High cost High potential for waste Your first 6 fills of a trial drug may be limited to less than a month supply. If the medicine works well, you ll get the rest of your month supply. If a copay applies to the medicine, you ll pay no more than one copay for each one month supply. What s the Weight Loss Benefit (WL)? This type of medicine may have limits on the amount you get or may not be covered under all plans. Log on to your myhealthpartners account and click on My plan benefits on the Medical Plan tab to check your benefits for weight loss. Weight Loss medicines are listed on the drug list under the Weight Loss medicine category. What s the Oncology Benefit (ONC)? These are oncology (cancer) medicines that must be filled at a specialty pharmacy, but you re only responsible for your regular generic or brand pharmacy copay or coinsurance. The HealthPartners family of health plans is underwritten and/or administered by HealthPartners, Inc., Group Health, Inc., HealthPartners Insurance Company or HealthPartners Administrators, Inc. Fully insured Wisconsin plans are underwritten by HealthPartners Insurance Company. (9/15) 2015 HealthPartners

4 List of Covered Drugs Table of Contents Alcohol Dependency...6 Allergy...6 Alpha-1 Antitrypsin Deficiency... 7 Anti-Addiction/Substance Abuse Treatment Agents... 7 Anti-Infective...7 Arthritis...15 Asthma & Copd...16 Behavioral Health...18 Birth Control Bleeding Disorders Blood Modifier...27 Blood Thinner Bone Health Cancer Corticosteroids Cough & Cold Cystic Fibrosis Dementia Diabetes...37 Ear Conditions Enzyme Replacement Eye Conditions Gout Heart Health Hereditary Angioedema Idiopathic Pulmonary Fibrosis Immune Deficiency...51 Immune Suppressant Kidney Failure...52 Men's Health Migraine...53 Mouth & Throat...54 Multiple Sclerosis Muscle Relaxant Other Conditions Pain Parkinson's...60 Pulmonary Hypertension Seizures / Epilepsy...61 Skin Conditions...64 Sleep Disorders...68 Smoking Cessation Stomach / Gastrointestinal Thyroid...71 Urinary & Bladder Health...72 Vaccines

5 Vitamins And Minerals...77 Weight Loss...79 Women's Health

6 List of Covered Drugs Drug Tier Status More Details Alcohol Dependency Alcohol Dependency acamprosate oral tablet,delayed release (dr/ec) 333 disulfiram oral tablet 250, 500 naltrexone oral tablet 50 Allergy Allergy, Eye azelastine ophthalmic (eye) drops 0.05 % cromolyn ophthalmic (eye) drops 4 % epinastine ophthalmic (eye) drops 0.05 % olopatadine ophthalmic (eye) drops 0.1 % Allergy, Injection epinephrine injection auto-injector 0.15 /0.15 ml, 0.15 /0.3 ml, 0.3 /0.3 ml Allergy, Other Nasal azelastine nasal aerosol,spray 137 mcg (0.1 %) ipratropium bromide nasal spray,non-aerosol 0.03 %, 42 mcg (0.06 %) Allergy, Other Oral GRASTEK SUBLINGUAL TABLET 2,800 BAU PA ODACTRA SUBLINGUAL TABLET 12 SQ-HDM PA RAGWITEK SUBLINGUAL TABLET 12 AMB A 1 UNIT Antihistamines, Oral PA cyproheptadine oral syrup 2 /5 ml cyproheptadine oral tablet 4 hydroxyzine hcl oral solution 10 /5 ml ; AE hydroxyzine hcl oral tablet 10, 25, 50 ; AE hydroxyzine pamoate oral capsule 100, 25, 50 ; AE promethazine oral syrup 6.25 /5 ml ; AE promethazine oral tablet 12.5, 25, 50 ; AE 6

7 Corticosteroids, Nasal flunisolide nasal spray,non-aerosol 25 mcg (0.025 %) fluticasone nasal spray,suspension 50 mcg/actuation Alpha-1 Antitrypsin Deficiency Alpha-1 Antitrypsin Deficiency ARALAST NP INTRAVENOUS RECON SOLN 1,000 MG, 500 MG GLASSIA INTRAVENOUS SOLUTION 1 GRAM/50 ML (2 %) PROLASTIN-C INTRAVENOUS RECON SOLN 1,000 MG PROLASTIN-C INTRAVENOUS SOLUTION 1,000 MG (+/-)/20 ML PA ZEMAIRA INTRAVENOUS RECON SOLN 1,000 MG Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents naloxone injection syringe 1 /ml NARCAN NASAL SPRAY,NON-AEROSOL 2 MG/ACTUATION, 4 MG/ACTUATION Anti-Infective Antibiotics, Cephalosporins cefadroxil oral capsule 500 cefadroxil oral suspension for reconstitution 250 /5 ml, 500 /5 ml cefadroxil oral tablet 1 gram cefdinir oral capsule 300 cefdinir oral suspension for reconstitution 125 /5 ml, 250 /5 ml cefprozil oral suspension for reconstitution 125 /5 ml, 250 /5 ml cefprozil oral tablet 250, 500 CEFTIN ORAL SUSPENSION FOR RECONSTITUTION 125 MG/5 ML, 250 MG/5 ML cefuroxime axetil oral tablet 250, 500 7

8 cephalexin oral capsule 250, 500 cephalexin oral suspension for reconstitution 125 /5 ml, 250 /5 ml SUPRAX ORAL CAPSULE 400 MG Antibiotics, Macrolides azithromycin oral suspension for reconstitution 100 /5 ml, 200 /5 ml azithromycin oral tablet 250, 500 azithromycin oral tablet 600 clarithromycin oral suspension for reconstitution 125 /5 ml, 250 /5 ml clarithromycin oral tablet 250, 500 DIFICID ORAL TABLET 200 MG PA Antibiotics, Other clindamycin hcl oral capsule 150, 300 clindamycin hcl oral capsule 75 clindamycin palmitate hcl oral recon soln 75 /5 ml linezolid oral suspension for reconstitution 100 /5 ml linezolid oral tablet 600 PA neomycin oral tablet 500 sulfamethoxazole-trimethoprim oral suspension /5 ml sulfamethoxazole-trimethoprim oral tablet , trimethoprim oral tablet 100 vancomycin intravenous recon soln 1,000, 10 gram, 5 gram, 500 vancomycin oral capsule 125, 250 XIFAXAN ORAL TABLET 200 MG, 550 MG PA Antibiotics, Penicillins amoxicillin oral capsule 250, 500 amoxicillin oral suspension for reconstitution 125 /5 ml, 200 /5 ml, 250 /5 ml, 400 /5 ml amoxicillin oral tablet 500, 875 amoxicillin oral tablet,chewable 125, PA

9 amoxicillin-pot clavulanate oral suspension for reconstitution /5 ml, /5 ml, /5 ml, /5 ml amoxicillin-pot clavulanate oral tablet , , amoxicillin-pot clavulanate oral tablet,chewable , ampicillin oral capsule 250, 500 ampicillin oral suspension for reconstitution 125 /5 ml, 250 /5 ml dicloxacillin oral capsule 250, 500 penicillin v potassium oral recon soln 125 /5 ml, 250 /5 ml penicillin v potassium oral tablet 250, 500 Antibiotics, Quinolones CIPRO ORAL SUSPENSION,MICROCAPSULE RECON 250 MG/5 ML, 500 MG/5 ML ciprofloxacin hcl oral tablet 100, 250, 500, 750 ciprofloxacin oral suspension,microcapsule recon 250 /5 ml, 500 /5 ml levofloxacin oral solution 250 /10 ml levofloxacin oral tablet 250, 500, 750 moxifloxacin oral tablet 400 Antibiotics, Tetracyclines demeclocycline oral tablet 150, 300 doxycycline hyclate oral capsule 100 doxycycline hyclate oral capsule 50 PA doxycycline hyclate oral tablet 100 PA doxycycline hyclate oral tablet 20 doxycycline monohydrate oral capsule 100, 50 doxycycline monohydrate oral tablet 100, 50 minocycline oral capsule 100, 50, 75 tetracycline oral capsule 250, 500 Antifungals clotrimazole mucous membrane troche 10 9

10 CRESEMBA ORAL CAPSULE 186 MG PA fluconazole oral suspension for reconstitution 10 /ml, 40 /ml fluconazole oral tablet 100, 200 fluconazole oral tablet 150, 50 griseofulvin microsize oral suspension 125 /5 ml griseofulvin microsize oral tablet 500 griseofulvin ultramicrosize oral tablet 125, 250 itraconazole oral capsule 100 PA ketoconazole oral tablet 200 NOXAFIL ORAL SUSPENSION 200 MG/5 ML (40 MG/ML) NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC) 100 MG nystatin oral suspension 100,000 unit/ml nystatin oral tablet 500,000 unit terbinafine hcl oral tablet 250 voriconazole oral suspension for reconstitution 200 /5 ml (40 /ml) voriconazole oral tablet 200, 50 PA Anti-Infective, Other ALBENZA ORAL TABLET 200 MG PA atovaquone oral suspension 750 /5 ml BILTRICIDE ORAL TABLET 600 MG dapsone oral tablet 100, 25 ivermectin oral tablet 3 rifabutin oral capsule 150 SIVEXTRO ORAL TABLET 200 MG PA Antiprotozoals ALINIA ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML ALINIA ORAL TABLET 500 MG ST atovaquone-proguanil oral tablet , chloroquine phosphate oral tablet 250, PA PA PA ST

11 hydroxychloroquine oral tablet 200 mefloquine oral tablet 250 metronidazole oral tablet 250, 500 Antiviral, Hepatitis B adefovir oral tablet 10 BARACLUDE ORAL SOLUTION 0.05 MG/ML entecavir oral tablet 0.5, 1 EPIVIR HBV ORAL SOLUTION 25 MG/5 ML (5 MG/ML) lamivudine oral tablet 100 TYZEKA ORAL TABLET 600 MG VEMLIDY ORAL TABLET 25 MG Antiviral, Hepatitis C EPCLUSA ORAL TABLET MG HARVONI ORAL TABLET MG INTRON A INJECTION RECON SOLN 10 MILLION UNIT (1 ML), 18 MILLION UNIT (1 ML), 50 MILLION UNIT (1 ML) INTRON A INJECTION SOLUTION 10 MILLION UNIT/ML, 6 MILLION UNIT/ML MAVYRET ORAL TABLET MG OLYSIO ORAL CAPSULE 150 MG PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR 135 MCG/0.5 ML, 180 MCG/0.5 ML PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/ML PEGASYS SUBCUTANEOUS SYRINGE 180 MCG/0.5 ML PEGINTRON REDIPEN SUBCUTANEOUS PEN INJECTOR KIT 120 MCG/0.5 ML, 150 MCG/0.5 ML, 50 MCG/0.5 ML, 80 MCG/0.5 ML PEGINTRON SUBCUTANEOUS KIT 120 MCG/0.5 ML, 150 MCG/0.5 ML, 50 MCG/0.5 ML, 80 MCG/0.5 ML REBETOL ORAL SOLUTION 40 MG/ML ribavirin oral capsule 200 ribavirin oral tablet 200 SOVALDI ORAL TABLET 400 MG 11

12 VOSEVI ORAL TABLET MG ZEPATIER ORAL TABLET MG Antiviral, Hiv abacavir oral solution 20 /ml abacavir oral tablet 300 abacavir-lamivudine oral tablet abacavir-lamivudine-zidovudine oral tablet APTIVUS ORAL CAPSULE 250 MG APTIVUS ORAL SOLUTION 100 MG/ML atazanavir oral capsule 150, 200, 300 ATRIPLA ORAL TABLET MG COMPLERA ORAL TABLET MG CRIXIVAN ORAL CAPSULE 200 MG, 400 MG DESCOVY ORAL TABLET MG didanosine oral capsule,delayed release(dr/ec) 125, 200, 250, 400 EDURANT ORAL TABLET 25 MG efavirenz oral capsule 200, 50 efavirenz oral tablet 600 EMTRIVA ORAL CAPSULE 200 MG EMTRIVA ORAL SOLUTION 10 MG/ML EVOTAZ ORAL TABLET MG fosamprenavir oral tablet 700 FUZEON SUBCUTANEOUS RECON SOLN 90 MG GENVOYA ORAL TABLET MG INTELENCE ORAL TABLET 100 MG, 200 MG, 25 MG INVIRASE ORAL CAPSULE 200 MG INVIRASE ORAL TABLET 500 MG ISENTRESS HD ORAL TABLET 600 MG ISENTRESS ORAL POWDER IN PACKET 100 MG ISENTRESS ORAL TABLET 400 MG ISENTRESS ORAL TABLET,CHEWABLE 100 MG, 25 MG JULUCA ORAL TABLET MG 12

13 KALETRA ORAL TABLET MG, MG lamivudine oral solution 10 /ml lamivudine oral tablet 150, 300 lamivudine-zidovudine oral tablet LEXIVA ORAL SUSPENSION 50 MG/ML lopinavir-ritonavir oral solution /5 ml nevirapine oral suspension 50 /5 ml nevirapine oral tablet 200 nevirapine oral tablet extended release 24 hr 100, 400 NORVIR ORAL SOLUTION 80 MG/ML NORVIR ORAL TABLET 100 MG ODEFSEY ORAL TABLET MG PREZCOBIX ORAL TABLET MG-MG PREZISTA ORAL SUSPENSION 100 MG/ML PREZISTA ORAL TABLET 150 MG, 400 MG, 600 MG, 75 MG, 800 MG RESCRIPTOR ORAL TABLET 200 MG RESCRIPTOR ORAL TABLET, DISPERSIBLE 100 MG REYATAZ ORAL POWDER IN PACKET 50 MG SELZENTRY ORAL SOLUTION 20 MG/ML SELZENTRY ORAL TABLET 150 MG, 25 MG, 300 MG, 75 MG stavudine oral capsule 15, 20, 30, 40 stavudine oral recon soln 1 /ml STRIBILD ORAL TABLET MG tenofovir disoproxil fumarate oral tablet 300 TIVICAY ORAL TABLET 10 MG, 25 MG, 50 MG TRIUMEQ ORAL TABLET MG TRUVADA ORAL TABLET MG, MG, MG, MG TYBOST ORAL TABLET 150 MG VIDEX 2 GRAM PEDIATRIC ORAL RECON SOLN 10 MG/ML (FINAL) VIDEX 4 GRAM PEDIATRIC ORAL RECON SOLN 10 MG/ML (FINAL) 13

14 VIRACEPT ORAL TABLET 250 MG, 625 MG VIREAD ORAL POWDER 40 MG/SCOOP (40 MG/GRAM) VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG VITEKTA ORAL TABLET 150 MG, 85 MG ZERIT ORAL RECON SOLN 1 MG/ML zidovudine oral capsule 100 zidovudine oral syrup 10 /ml zidovudine oral tablet 300 Antiviral, Other acyclovir oral capsule 200 acyclovir oral suspension 200 /5 ml acyclovir oral tablet 400, 800 amantadine hcl oral capsule 100 amantadine hcl oral solution 50 /5 ml amantadine hcl oral tablet 100 famciclovir oral tablet 125, 250, 500 oseltamivir oral capsule 30, 45, 75 oseltamivir oral suspension for reconstitution 6 /ml PREVYMIS ORAL TABLET 240 MG, 480 MG PA RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MG/ACTUATION rimantadine oral tablet 100 TAMIFLU ORAL CAPSULE 30 MG, 45 MG, 75 MG TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION 6 MG/ML valacyclovir oral tablet 1 gram, 500 valganciclovir oral recon soln 50 /ml valganciclovir oral tablet 450 Tuberculosis cycloserine oral capsule 250 PA ethambutol oral tablet 100, 400 isoniazid oral solution 50 /5 ml isoniazid oral tablet 100, 300 PRIFTIN ORAL TABLET 150 MG 14

15 pyrazinamide oral tablet 500 rifampin oral capsule 150, 300 SIRTURO ORAL TABLET 100 MG PA TRECATOR ORAL TABLET 250 MG PA Urinary Anti-Infectives MONUROL ORAL PACKET 3 GRAM nitrofurantoin macrocrystal oral capsule 100, 25, 50 nitrofurantoin monohyd/m-cryst oral capsule 100 ; AE ; AE nitrofurantoin oral suspension 25 /5 ml ; AE Arthritis Arthritis, Other DEPEN TITRATABS ORAL TABLET 250 MG Disease Modifying Agents ACTEMRA SUBCUTANEOUS SYRINGE 162 MG/0.9 ML ENBREL SUBCUTANEOUS RECON SOLN 25 MG (1 ML) ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5ML (0.51), 50 MG/ML (0.98 ML) ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR 50 MG/ML (0.98 ML) KINERET SUBCUTANEOUS SYRINGE 100 MG/0.67 ML leflunomide oral tablet 10, 20 ORENCIA CLICKJECT SUBCUTANEOUS AUTO- INJECTOR 125 MG/ML ORENCIA SUBCUTANEOUS SYRINGE 125 MG/ML, 50 MG/0.4 ML, 87.5 MG/0.7 ML OTEZLA ORAL TABLET 30 MG OTEZLA STARTER ORAL TABLETS,DOSE PACK 10 MG (4)-20 MG (4)-30 MG (47), 10 MG (4)-20 MG (4)-30 MG(19) RASUVO (PF) SUBCUTANEOUS AUTO-INJECTOR 10 MG/0.2 ML, 12.5 MG/0.25 ML, 15 MG/0.3 ML, 17.5 MG/0.35 ML, 20 MG/0.4 ML, 22.5 MG/0.45 ML, 25 MG/0.5 ML, 27.5 MG/0.55 ML, 30 MG/0.6 ML, 7.5 MG/0.15 ML PA 15

16 RIDAURA ORAL CAPSULE 3 MG Asthma & Copd Asthma & Copd, Other ATROVENT HFA INHALATION HFA AEROSOL INHALER 17 MCG/ACTUATION cromolyn inhalation solution for nebulization 20 /2 ml DALIRESP ORAL TABLET 500 MCG PA ipratropium bromide inhalation solution 0.02 % montelukast oral granules in packet 4 montelukast oral tablet 10 montelukast oral tablet,chewable 4, 5 Bronchodilators, Inhaled albuterol sulfate inhalation solution for nebulization 0.63 /3 ml, 1.25 /3 ml, 2.5 /3 ml (0.083 %), 5 /ml INCRUSE ELLIPTA INHALATION BLISTER WITH DEVICE 62.5 MCG/ACTUATION SEREVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCG/DOSE STRIVERDI RESPIMAT INHALATION MIST 2.5 MCG/ACTUATION VENTOLIN HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION Bronchodilators, Oral albuterol sulfate oral syrup 2 /5 ml albuterol sulfate oral tablet 2, 4 albuterol sulfate oral tablet extended release 12 hr 4, 8 theophylline oral tablet extended release 12 hr 100, 200, 300, 450 theophylline oral tablet extended release 600 Combination Agents, Inhaled ADVAIR DISKUS INHALATION BLISTER WITH DEVICE MCG/DOSE, MCG/DOSE, MCG/DOSE 16

17 ADVAIR HFA INHALATION HFA AEROSOL INHALER MCG/ACTUATION, MCG/ACTUATION, MCG/ACTUATION ANORO ELLIPTA INHALATION BLISTER WITH DEVICE MCG/ACTUATION BREO ELLIPTA INHALATION BLISTER WITH DEVICE MCG/DOSE, MCG/DOSE COMBIVENT RESPIMAT INHALATION MIST MCG/ACTUATION DULERA INHALATION HFA AEROSOL INHALER MCG/ACTUATION, MCG/ACTUATION fluticasone-salmeterol inhalation aerosol powdr breath activated mcg/actuation, mcg/actuation, mcg/actuation ipratropium-albuterol inhalation solution for nebulization (2.5 base)/3 ml TRELEGY ELLIPTA INHALATION BLISTER WITH DEVICE MCG Corticosteroids, Inhaled ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 200 MCG/ACTUATION ASMANEX HFA INHALATION HFA AEROSOL INHALER 100 MCG/ACTUATION, 200 MCG/ACTUATION ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (30 DOSES), 220 MCG (120 DOSES), 220 MCG (30 DOSES), 220 MCG (60 DOSES) budesonide inhalation suspension for nebulization 0.25 /2 ml, 0.5 /2 ml, 1 /2 ml FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 250 MCG/ACTUATION, 50 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION, 220 MCG/ACTUATION, 44 MCG/ACTUATION PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 180 MCG/ACTUATION, 90 MCG/ACTUATION PA 17

18 QVAR INHALATION AEROSOL 40 MCG/ACTUATION, 80 MCG/ACTUATION QVAR REDIHALER INHALATION HFA AEROSOL BREATH ACTIVATED 40 MCG/ACTUATION, 80 MCG/ACTUATION Behavioral Health Antipsychotic aripiprazole oral solution 1 /ml AE aripiprazole oral tablet 10, 15, 2, 20, 30, 5 aripiprazole oral tablet,disintegrating 10, 15 chlorpromazine oral tablet 10, 100, 200, 25, 50 clozapine oral tablet 100, 200, 25, 50 clozapine oral tablet,disintegrating 100, 12.5, 150, 200, 25 FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG FANAPT ORAL TABLETS,DOSE PACK 1MG(2)- 2MG(2)- 4MG(2)-6MG(2) AE PA; AE PA AE PA; AE PA PA fluphenazine hcl oral concentrate 5 /ml AE fluphenazine hcl oral elixir 2.5 /5 ml AE fluphenazine hcl oral tablet 1, 10, 2.5, 5 AE haloperidol lactate oral concentrate 2 /ml AE haloperidol oral tablet 0.5, 1, 10, 2, 20, 5 LATUDA ORAL TABLET 120 MG, 40 MG, 60 MG, 80 MG AE PA; LATUDA ORAL TABLET 20 MG PA loxapine succinate oral capsule 10, 25, 5, 50 AE NUPLAZID ORAL TABLET 17 MG olanzapine oral tablet 10, 15, 2.5, 20, 5, 7.5 olanzapine oral tablet,disintegrating 10, 15, 20, 5 AE PA; AE 18

19 paliperidone oral tablet extended release 24hr 1.5, 3, 6, 9 perphenazine oral tablet 16, 2, 4, 8 quetiapine oral tablet 100, 200, 25, 300, 400, 50 quetiapine oral tablet extended release 24 hr 150, 200, 300, 400, 50 REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG PA AE AE PA; AE PA risperidone oral solution 1 /ml AE risperidone oral tablet 0.25, 0.5, 1, 2, 3, 4 risperidone oral tablet,disintegrating 0.25, 0.5, 1, 2, 3, 4 SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 10 MG, 2.5 MG, 5 MG thioridazine oral tablet 10, 100, 25, 50 AE PA; AE PA AE thiothixene oral capsule 1, 10, 2, 5 AE trifluoperazine oral tablet 1, 10, 2, 5 AE VERSACLOZ ORAL SUSPENSION 50 MG/ML PA; AE VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG, 4.5 MG, 6 MG VRAYLAR ORAL CAPSULE,DOSE PACK 1.5 MG (1)- 3 MG (6) ziprasidone hcl oral capsule 20, 40, 60, 80 Anxiety alprazolam oral tablet 0.25, 0.5, 1, 2 alprazolam oral tablet extended release 24 hr 0.5, 1, 2, 3 buspirone oral tablet 10, 15, 30, 5, 7.5 PA PA AE chlordiazepoxide hcl oral capsule 10, 25 chlordiazepoxide hcl oral capsule 5 lorazepam oral concentrate 2 /ml 19

20 lorazepam oral tablet 0.5, 1, 2 Attention Deficit/Hyperactivity Disorder (Adhd) adderall xr oral capsule,extended release 24hr 10, 15, 20, 25, 30, 5 atomoxetine oral capsule 10, 100, 18, 25, 40, 60, 80 dexmethylphenidate oral capsule,er biphasic , 15, 20, 25, 30, 35, 40, 5 dexmethylphenidate oral tablet 10, 2.5, 5 dextroamphetamine oral capsule, extended release 10, 15, 5 dextroamphetamine oral tablet 10, 5 dextroamphetamine-amphetamine oral tablet 10, 12.5, 15, 20, 30, 5, 7.5 guanfacine oral tablet extended release 24 hr 1, 2, 3, 4 metadate er oral tablet extended release 20 methylphenidate hcl oral capsule, er biphasic , 20, 30, 40, 50, 60 methylphenidate hcl oral capsule,er biphasic , 20, 30, 40, 60 methylphenidate hcl oral tablet 10, 20, 5 methylphenidate hcl oral tablet extended release 10, 20 methylphenidate hcl oral tablet extended release 24hr 18, 27, 36, 54 QUILLICHEW ER ORAL TABLET,CHEW,IR- ER.BIPHASIC24HR 20 MG, 30 MG QUILLIVANT XR 25 MG/5 ML SUSP 300 MG 5 MG/ML (25 MG/5 ML) QUILLIVANT XR 25 MG/5 ML SUSP 600 MG 5 MG/ML (25 MG/5 ML) QUILLIVANT XR 25 MG/5 ML SUSP 750 MG 5 MG/ML (25 MG/5 ML) QUILLIVANT XR 25 MG/5 ML SUSP 900 MG 5 MG/ML (25 MG/5 ML) 20

21 QUILLIVANT XR ORAL SUSPENSION,EXT REL 24HR,RECON 5 MG/ML (25 MG/5 ML) VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG VYVANSE ORAL TABLET,CHEWABLE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG Bipolar Disorder lithium carbonate oral capsule 150, 300, 600 lithium carbonate oral tablet 300 lithium carbonate oral tablet extended release 300, 450 lithium citrate oral solution 8 meq/5 ml Depression, Atypical Antidepressants bupropion hcl oral tablet 100, 75 bupropion hcl oral tablet extended release 12 hr 100, 150, 200 bupropion hcl oral tablet extended release 24 hr 150, 300 mirtazapine oral tablet 15, 30, 45, 7.5 Depression, Maois phenelzine oral tablet 15 tranylcypromine oral tablet 10 Depression, Serotonin Modulators nefazodone oral tablet 100, 150, 200, 250, 50 trazodone oral tablet 100, 150, 300, 50 Depression, Snris desvenlafaxine succinate oral tablet extended release 24 hr 100, 25, 50 duloxetine oral capsule,delayed release(dr/ec) 20, 30, 60 venlafaxine oral capsule,extended release 24hr 150, 37.5, 75 venlafaxine oral tablet 100, 25, 37.5, 50, 75 21

22 Depression, Ssris citalopram oral solution 10 /5 ml citalopram oral tablet 10, 20, 40 escitalopram oxalate oral solution 5 /5 ml escitalopram oxalate oral tablet 10, 20, 5 fluoxetine oral capsule 10, 20, 40 fluoxetine oral solution 20 /5 ml (4 /ml) fluvoxamine oral tablet 100, 25, 50 paroxetine hcl oral tablet 10, 20, 30, 40 PAXIL ORAL SUSPENSION 10 MG/5 ML sertraline oral concentrate 20 /ml sertraline oral tablet 100, 25, 50 Depression, Tricyclic & Tetracyclic Antidepressants amitriptyline oral tablet 10, 100, 150, 25, 50, 75 AE clomipramine oral capsule 25, 50, 75 AE desipramine oral tablet 10, 100, 150, 25, 50, 75 doxepin oral capsule 10, 100, 150, 25, 50, 75 AE doxepin oral concentrate 10 /ml AE imipramine hcl oral tablet 10, 25, 50 AE nortriptyline oral capsule 10, 25, 50, 75 nortriptyline oral solution 10 /5 ml Birth Control Contraceptives, Other NUVARING VAGINAL RING MG/24 HR xulane transdermal patch weekly mcg/24 hr Emergency Contraception ELLA ORAL TABLET 30 MG levonorgestrel oral tablet

23 my way oral tablet 1.5 next choice one dose oral tablet 1.5 Oral Contraceptives altavera (28) oral tablet alyacen 1/35 (28) oral tablet mcg alyacen 7/7/7 (28) oral tablet 0.5/0.75/1-35 mcg apri oral tablet aranelle (28) oral tablet 0.5/1/ mcg aubra oral tablet mcg aviane oral tablet mcg azurette (28) oral tablet x21 /0.01 x 5 balziva (28) oral tablet mcg blisovi fe 1.5/30 (28) oral tablet mcg (21)/75 (7) blisovi fe 1/20 (28) oral tablet 1-20 mcg (21)/75 (7) brevicon (28) oral tablet mcg briellyn oral tablet mcg camila oral tablet 0.35 caziant (28) oral tablet 0.1/.125/ mcg chateal oral tablet cryselle (28) oral tablet mcg cyclafem 1/35 (28) oral tablet mcg cyclafem 7/7/7 (28) oral tablet 0.5/0.75/1-35 mcg dasetta 1/35 (28) oral tablet mcg dasetta 7/7/7 (28) oral tablet 0.5/0.75/1-35 mcg desogestrel-ethinyl estradiol oral tablet drospirenone-ethinyl estradiol oral tablet elinest oral tablet mcg emoquette oral tablet enpresse oral tablet (6)/75-40 (5)/125-30(10) 23

24 enskyce oral tablet errin oral tablet 0.35 estarylla oral tablet mcg falmina (28) oral tablet mcg gianvi (28) oral tablet gildagia oral tablet mcg gildess 1.5/30 (21) oral tablet mcg gildess 1/20 (21) oral tablet mcg gildess fe 1.5/30 (28) oral tablet mcg (21)/75 (7) gildess fe 1/20 (28) oral tablet 1-20 mcg (21)/75 (7) heather oral tablet 0.35 introvale oral tablets,dose pack,3 month mcg jencycla oral tablet 0.35 jolessa oral tablets,dose pack,3 month mcg jolivette oral tablet 0.35 junel 1.5/30 (21) oral tablet mcg junel 1/20 (21) oral tablet mcg junel fe 1.5/30 (28) oral tablet mcg (21)/75 (7) junel fe 1/20 (28) oral tablet 1-20 mcg (21)/75 (7) kariva (28) oral tablet x21 /0.01 x 5 kelnor 1/35 (28) oral tablet mcg kurvelo oral tablet larin 1/20 (21) oral tablet mcg larin fe 1.5/30 (28) oral tablet mcg (21)/75 (7) larin fe 1/20 (28) oral tablet 1-20 mcg (21)/75 (7) leena 28 oral tablet 0.5/1/ mcg lessina oral tablet mcg levonest (28) oral tablet (6)/75-40 (5)/125-30(10) 24

25 levonorgestrel-ethinyl estrad oral tablet mcg, levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month mcg levora-28 oral tablet loryna (28) oral tablet low-ogestrel (28) oral tablet mcg lutera (28) oral tablet mcg lyza oral tablet 0.35 marlissa oral tablet microgestin 1.5/30 (21) oral tablet mcg microgestin 1/20 (21) oral tablet mcg microgestin fe 1.5/30 (28) oral tablet mcg (21)/75 (7) microgestin fe 1/20 (28) oral tablet 1-20 mcg (21)/75 (7) mono-linyah oral tablet mcg mononessa (28) oral tablet mcg myzilra oral tablet (6)/75-40 (5)/125-30(10) necon 0.5/35 (28) oral tablet mcg necon 1/35 (28) oral tablet mcg necon 1/50 (28) oral tablet mcg necon 10/11 (28) oral tablet /1-35 mcg/-mcg necon 7/7/7 (28) oral tablet 0.5/0.75/1-35 mcg nora-be oral tablet 0.35 norethindrone (contraceptive) oral tablet 0.35 norethindrone ac-eth estradiol oral tablet mcg norgestimate-ethinyl estradiol oral tablet 0.18/0.215/ mcg, 0.18/0.215/ mcg (28), mcg norinyl 1/35 (28) oral tablet mcg nortrel 0.5/35 (28) oral tablet mcg nortrel 1/35 (21) oral tablet mcg 25

26 nortrel 1/35 (28) oral tablet mcg nortrel 7/7/7 (28) oral tablet 0.5/0.75/1-35 mcg ocella oral tablet ogestrel (28) oral tablet mcg orsythia oral tablet mcg philith oral tablet mcg pimtrea (28) oral tablet x21 /0.01 x 5 pirmella oral tablet 0.5/0.75/1-35 mcg, mcg portia oral tablet previfem oral tablet mcg quasense oral tablets,dose pack,3 month mcg reclipsen (28) oral tablet sprintec (28) oral tablet mcg sronyx oral tablet mcg syeda oral tablet tilia fe oral tablet 1-20(5)/1-30(7) /1-35mcg (9) tri-estarylla oral tablet 0.18/0.215/ mcg (28) tri-legest fe oral tablet 1-20(5)/1-30(7) /1-35mcg (9) tri-linyah oral tablet 0.18/0.215/ mcg (28) tri-lo-estarylla oral tablet 0.18/0.215/ mcg tri-lo-sprintec oral tablet 0.18/0.215/ mcg trinessa (28) oral tablet 0.18/0.215/ mcg (28) trinessa lo oral tablet 0.18/0.215/ mcg tri-previfem (28) oral tablet 0.18/0.215/ mcg (28) tri-sprintec (28) oral tablet 0.18/0.215/ mcg (28) 26

27 trivora (28) oral tablet (6)/75-40 (5)/125-30(10) velivet triphasic regimen (28) oral tablet 0.1/.125/ mcg vestura (28) oral tablet viorele (28) oral tablet x21 /0.01 x 5 vyfemla (28) oral tablet mcg wera (28) oral tablet mcg zarah oral tablet zenchent (28) oral tablet mcg zovia 1/35e (28) oral tablet mcg zovia 1/50e (28) oral tablet mcg Bleeding Disorders Bleeding Disorders, Hemophilia STIMATE NASAL SPRAY,NON-AEROSOL 150 MCG/SPRAY (0.1 ML) Bleeding Disorders, Other PA AMICAR ORAL SOLUTION 250 MG/ML (25 %) AMICAR ORAL TABLET 500 MG Blood Modifier Blood Modifiers ARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCG/ML, 150 MCG/0.75 ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE 10 MCG/0.4 ML, 100 MCG/0.5 ML, 150 MCG/0.3 ML, 200 MCG/0.4 ML, 25 MCG/0.42 ML, 300 MCG/0.6 ML, 40 MCG/0.4 ML, 500 MCG/ML, 60 MCG/0.3 ML GRANIX SUBCUTANEOUS SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML ; ONC LEUKINE INJECTION RECON SOLN 250 MCG NEULASTA SUBCUTANEOUS SYRINGE 6 MG/0.6ML NEULASTA SUBCUTANEOUS SYRINGE, W/ WEARABLE INJECTOR 6 MG/0.6 ML 27

28 NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6 ML NEUPOGEN INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML PROCRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML PROMACTA ORAL TABLET 12.5 MG, 25 MG, 50 MG, 75 MG REBINYN INTRAVENOUS RECON SOLN 1,000 (+/- ) UNIT, 2,000 (+/-) UNIT, 500 (+/-) UNIT ZARXIO INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML Clotting Disorders ADVATE INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/- ) UNIT, 3,000 (+/-) UNIT, 4,000 (+/-) UNIT, 500 (+/-) UNIT ADYNOVATE INTRAVENOUS SOLUTION 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT, 750 (+/-) UNIT AFSTYLA INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT RANGE, 1,500 (+/-) UNIT RANGE, 2,000 (+/- ) UNIT RANGE, 2,500 (+/-) UNIT RANGE, 250 (+/- ) UNIT RANGE, 3,000 (+/-) UNIT RANGE, 500 (+/- ) UNIT RANGE ALPHANATE INTRAVENOUS RECON SOLN 1,000 (400 VWF) UNIT/10 ML, 1,500 (600 VWF) UNIT/10 ML, 2,000 (800 VWF) UNIT/10 ML, 250 (100 VWF) UNIT/5 ML, 500 (200 VWF) UNIT/5 ML ALPHANINE SD INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 500 (+/-) UNIT ALPROLIX INTRAVENOUS RECON SOLN 1,000 UNIT, 2,000 UNIT, 250 UNIT, 3,000 UNIT, 4,000 UNIT, 500 UNIT BEBULIN INTRAVENOUS RECON SOLN 700 (+/-) UNIT 28

29 BENEFIX INTRAVENOUS RECON SOLN 1,000 UNIT, 2,000 UNIT, 250 UNIT, 3,000 UNIT, 500 UNIT COAGADEX INTRAVENOUS RECON SOLN 250 (+/-) UNIT RANGE, 500 (+/-) UNIT RANGE CORIFACT INTRAVENOUS RECON SOLN 1,000-1,600 UNIT ELOCTATE INTRAVENOUS RECON SOLN 1,000 UNIT, 1,500 UNIT, 2,000 UNIT, 250 UNIT, 3,000 UNIT, 4,000 UNIT, 5,000 UNIT, 500 UNIT, 6,000 UNIT, 750 UNIT FEIBA NF INTRAVENOUS RECON SOLN 1,750-3,250 UNIT, UNIT, 651-1,200 UNIT HELIXATE FS INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT HEMOFIL M HIGH INTRAVENOUS RECON SOLN 801-1,500 UNIT HEMOFIL M LOW INTRAVENOUS RECON SOLN UNIT HEMOFIL M MID INTRAVENOUS RECON SOLN UNIT HEMOFIL M SUPER HIGH INTRAVENOUS RECON SOLN 1,501-2,000 UNIT HUMATE-P INTRAVENOUS RECON SOLN 1,000-2,400 UNIT, UNIT, 500-1,200 UNIT IDELVION INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 500 (+/-) UNIT IXINITY INTRAVENOUS RECON SOLN 1,000 UNIT, 1,500 UNIT, 2,000 UNIT, 250 UNIT, 3,000 UNIT, 500 UNIT KOATE-DVI INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 250 (+/-) UNIT, 500 (+/-) UNIT KOGENATE FS INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT KOVALTRY INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT MONOCLATE-P INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 1,500 (+/-) UNIT 29

30 NOVOEIGHT INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT NOVOSEVEN RT INTRAVENOUS RECON SOLN 1 MG (1,000 MCG), 2 MG (2,000 MCG), 5 MG (5,000 MCG), 8 MG (8,000 MCG) NUWIQ INTRAVENOUS RECON SOLN 1000 (+/-) UNIT, 2,000 (+/-) UNIT, 2,500 UNIT, 250 (+/-) UNIT, 3,000 UNIT, 4,000 UNIT, 500 (+/-) UNIT OBIZUR INTRAVENOUS RECON SOLN 500 (+/-) UNIT RANGE PLASMANATE INTRAVENOUS PARENTERAL SOLUTION 5 % PROFILNINE INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 500 (+/-) UNIT RECOMBINATE INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 500 (+/-) UNIT RIXUBIS INTRAVENOUS RECON SOLN 1,000 UNIT, 2,000 UNIT, 250 UNIT, 3,000 UNIT, 500 UNIT THROMBATE III INTRAVENOUS RECON SOLN 500 (+/-) UNIT TRETTEN INTRAVENOUS RECON SOLN 2,500 UNIT VONVENDI INTRAVENOUS RECON SOLN 1,300 (+/-) UNIT RANGE, 650 (+/-) UNIT RANGE WILATE INTRAVENOUS RECON SOLN 1,000-1,000 UNIT, UNIT, UNIT, UNIT XYNTHA INTRAVENOUS SOLUTION 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 500 (+/-) UNIT XYNTHA SOLOFUSE INTRAVENOUS SYRINGE 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT Blood Thinner Anticoagulants ELIQUIS ORAL TABLET 2.5 MG, 5 MG ELIQUIS ORAL TABLETS,DOSE PACK 5 MG (74 TABS) 30

31 enoxaparin subcutaneous solution 300 /3 ml enoxaparin subcutaneous syringe 100 /ml, 120 /0.8 ml, 150 /ml, 30 /0.3 ml, 40 /0.4 ml, 60 /0.6 ml, 80 /0.8 ml fondaparinux subcutaneous syringe 10 /0.8 ml, 2.5 /0.5 ml, 5 /0.4 ml, 7.5 /0.6 ml heparin (porcine) injection cartridge 5,000 unit/ml (1 ml) heparin (porcine) injection solution 1,000 unit/ml, 10,000 unit/ml, 20,000 unit/ml, 5,000 unit/ml PA heparin (porcine) injection syringe 5,000 unit/ml heparin, porcine (pf) injection syringe 5,000 unit/0.5 ml jantoven oral tablet 1, 10, 2, 2.5, 3, 4, 5, 6, 7.5 PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG warfarin oral tablet 1, 10, 2, 2.5, 3, 4, 5, 6, 7.5 PA XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG XARELTO ORAL TABLETS,DOSE PACK 15 MG (42)- 20 MG (9) Platelet Inhibitors anagrelide oral capsule 0.5, 1 aspirin-dipyridamole oral capsule, er multiphase 12 hr BRILINTA ORAL TABLET 60 MG, 90 MG cilostazol oral tablet 100, 50 clopidogrel oral tablet 75 dipyridamole oral tablet 25, 50, 75 pentoxifylline oral tablet extended release 400 prasugrel oral tablet 10, 5 ZONTIVITY ORAL TABLET 2.08 MG PA Bone Health Bone Health, Other etidronate disodium oral tablet 200,

32 Osteoporosis alendronate oral solution 70 /75 ml alendronate oral tablet 10, 35, 5, 70 alendronate oral tablet 40 calcitonin (salmon) nasal spray,non-aerosol 200 unit/actuation FORTEO SUBCUTANEOUS PEN INJECTOR 20 MCG/DOSE MCG/2.4 ML FORTICAL NASAL SPRAY,NON-AEROSOL 200 UNIT/ACTUATION ibandronate oral tablet 150 TYMLOS SUBCUTANEOUS PEN INJECTOR 80 MCG (3,120 MCG/1.56 ML) Cancer Cancer, Alkylating Agents EMCYT ORAL CAPSULE 140 MG GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG, 5 MG HEXALEN ORAL CAPSULE 50 MG ; ONC LEUKERAN ORAL TABLET 2 MG MATULANE ORAL CAPSULE 50 MG ; ONC melphalan oral tablet 2 MYLERAN ORAL TABLET 2 MG temozolomide oral capsule 100, 140, 180, 20, 250, 5 ; ONC VALCHLOR TOPICAL GEL % ; ONC; Cancer, Antiandrogens bicalutamide oral tablet 50 flutamide oral capsule 125 XTANDI ORAL CAPSULE 40 MG ; ONC; TD ZYTIGA ORAL TABLET 250 MG, 500 MG ; ONC; TD Cancer, Antimetabolites capecitabine oral tablet 150, 500 ; ONC hydroxyurea oral capsule 500 LONSURF ORAL TABLET MG, MG ; ONC mercaptopurine oral tablet 50 32

33 TABLOID ORAL TABLET 40 MG Cancer, Aromatase Inhibitors anastrozole oral tablet 1 exemestane oral tablet 25 letrozole oral tablet 2.5 Cancer, Hdac Inhibitors ZOLINZA ORAL CAPSULE 100 MG ; ONC; TD Cancer, Immunosuppressives AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG, 3 MG, 5 MG AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG CYCLOPHOSPHAMIDE ORAL CAPSULE 25 MG, 50 MG methotrexate sodium (pf) injection solution 25 /ml ; ONC; TD ; ONC; TD methotrexate sodium injection solution 25 /ml methotrexate sodium oral tablet 2.5 POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG Cancer, Interferons SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG Cancer, Natural And Semi-Synthetic ; ONC ; ONC ; ONC ; ONC etoposide oral capsule 50 HYCAMTIN INTRAVENOUS RECON SOLN 4 MG ; ONC HYCAMTIN ORAL CAPSULE 0.25 MG, 1 MG ; ONC Cancer, Other Agents LYSODREN ORAL TABLET 500 MG ; ONC megestrol oral tablet 20, 40 ODOMZO ORAL CAPSULE 200 MG ; ONC ZEJULA ORAL CAPSULE 100 MG ; ONC 33

34 Cancer, Retinoids tretinoin (chemotherapy) oral capsule 10 ; ONC Cancer, Serms SOLTAMOX ORAL SOLUTION 10 MG/5 ML tamoxifen oral tablet 10, 20 Cancer, Signal Transduction Inhibitors ALECENSA ORAL CAPSULE 150 MG ; ONC BOSULIF ORAL TABLET 100 MG, 500 MG ; ONC; TD BOSULIF ORAL TABLET 400 MG PA CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG ; ONC; TD CAPRELSA ORAL TABLET 100 MG, 300 MG ; ONC COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1), 140 MG/DAY(80 MG X1-20 MG X3), 60 MG/DAY (20 MG X 3/DAY) ; ONC COTELLIC ORAL TABLET 20 MG ; ONC ERIVEDGE ORAL CAPSULE 150 MG ; ONC; TD GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG ; ONC IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG ; ONC ICLUSIG ORAL TABLET 15 MG, 45 MG ; ONC IDHIFA ORAL TABLET 100 MG, 50 MG ; ONC imatinib oral tablet 100, 400 ; ONC; TD IMBRUVICA ORAL CAPSULE 140 MG, 70 MG ; ONC IMBRUVICA ORAL TABLET 140 MG, 280 MG, 420 MG, 560 MG ; ONC INLYTA ORAL TABLET 1 MG, 5 MG ; ONC; TD IRESSA ORAL TABLET 250 MG ; ONC; TD JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG KISQALI FEMARA CO-PACK ORAL TABLET 200 MG/DAY(200 MG X 1)-2.5 MG, 400 MG/DAY(200 MG X 2)-2.5 MG, 600 MG/DAY(200 MG X 3)-2.5 MG KISQALI ORAL TABLET 200 MG/DAY (200 MG X 1), 400 MG/DAY (200 MG X 2), 600 MG/DAY (200 MG X 3) ; ONC; TD ; ONC ; ONC MEKINIST ORAL TABLET 0.5 MG, 2 MG ; ONC 34

35 NERLYNX ORAL TABLET 40 MG ; ONC NEXAVAR ORAL TABLET 200 MG ; ONC; TD NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG ; ONC RYDAPT ORAL CAPSULE 25 MG ; ONC SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG ; ONC; TD STIVARGA ORAL TABLET 40 MG ; ONC SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG ; ONC; TD TAFINLAR ORAL CAPSULE 50 MG, 75 MG ; ONC TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG ; ONC; TD TASIGNA ORAL CAPSULE 150 MG, 200 MG ; ONC; TD TYKERB ORAL TABLET 250 MG ; ONC VERZENIO ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG ; ONC VOTRIENT ORAL TABLET 200 MG ; ONC; TD XALKORI ORAL CAPSULE 200 MG, 250 MG ; ONC; TD ZELBORAF ORAL TABLET 240 MG ; ONC ZYKADIA ORAL CAPSULE 150 MG ; ONC; TD Corticosteroids Corticosteroids, Injectable dexamethasone sodium phosphate injection solution 4 /ml Corticosteroids, Oral DEXAMETHASONE INTENSOL ORAL DROPS 1 MG/ML dexamethasone oral elixir 0.5 /5 ml dexamethasone oral solution 0.5 /5 ml dexamethasone oral tablet 0.5, 0.75, 1, 1.5, 4, 6 dexamethasone oral tablet 2 fludrocortisone oral tablet 0.1 hydrocortisone oral tablet 10, 20, 5 MEDROL ORAL TABLET 2 MG methylprednisolone oral tablet 16, 32, 4, 8 methylprednisolone oral tablets,dose pack 4 35

36 MILLIPRED ORAL TABLET 5 MG prednisolone oral solution 15 /5 ml prednisolone sodium phosphate oral solution 15 /5 ml (3 /ml), 25 /5 ml (5 /ml), 5 base/5 ml (6.7 /5 ml) PREDNISONE INTENSOL ORAL CONCENTRATE 5 MG/ML prednisone oral solution 5 /5 ml prednisone oral tablet 1, 10, 2.5, 20, 5, 50 prednisone oral tablets,dose pack 10, 5 Cough & Cold Cough & Cold benzonatate oral capsule 100, 200 codeine-guaifenesin oral liquid /5 ml ; AE promethazine vc oral syrup /5 ml promethazine-dm oral syrup /5 ml Cystic Fibrosis Cystic Fibrosis acetylcysteine solution 100 /ml (10 %), 200 /ml (20 %) CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML KALYDECO ORAL GRANULES IN PACKET 50 MG, 75 MG KALYDECO ORAL TABLET 150 MG ORKAMBI ORAL TABLET MG, MG PULMOZYME INHALATION SOLUTION 1 MG/ML ; tobramycin in % nacl inhalation solution for nebulization 300 /5 ml Dementia Dementia donepezil oral tablet 10, 5 donepezil oral tablet,disintegrating 10, 5 galantamine oral capsule,ext rel. pellets 24 hr 16, 24, 8 36

37 galantamine oral solution 4 /ml galantamine oral tablet 12, 4, 8 memantine oral solution 2 /ml memantine oral tablet 10, 5 memantine oral tablets,dose pack 5-10 rivastigmine tartrate oral capsule 1.5, 3, 4.5, 6 Diabetes Diabetes, Alpha-Glucosidase Inhibitors acarbose oral tablet 100, 25, 50 miglitol oral tablet 100, 25, 50 Diabetes, Biguanides metformin oral tablet 1,000, 500, 850 metformin oral tablet extended release 24 hr 500, 750 Diabetes, Dpp-4 Inhibitor / Biguanide Combinations JENTADUETO ORAL TABLET 2.5-1,000 MG, MG, MG JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-1,000 MG, 5-1,000 MG Diabetes, Dpp-4 Inhibitors TRADJENTA ORAL TABLET 5 MG Diabetes, Glp-1 Agonists BYDUREON BCISE SUBCUTANEOUS AUTO- INJECTOR 2 MG/0.85 ML BYDUREON SUBCUTANEOUS PEN INJECTOR 2 MG/0.65 ML BYDUREON SUBCUTANEOUS SUSPENSION,EXTENDED REL RECON 2 MG BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML, 5 MCG/DOSE (250 MCG/ML) 1.2 ML TRULICITY SUBCUTANEOUS PEN INJECTOR 0.75 MG/0.5 ML, 1.5 MG/0.5 ML VICTOZA 2-PAK SUBCUTANEOUS PEN INJECTOR 0.6 MG/0.1 ML (18 MG/3 ML) 37

38 VICTOZA 3-PAK SUBCUTANEOUS PEN INJECTOR 0.6 MG/0.1 ML (18 MG/3 ML) Diabetes, Intermediate-Acting Insulins HUMULIN N NPH INSULIN KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) HUMULIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML Diabetes, Long-Acting Insulins BASAGLAR KWIKPEN U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) LEVEMIR FLEXTOUCH U-100 INSULN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) LEVEMIR U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML Diabetes, Meglitinides ST ST nateglinide oral tablet 120, 60 repaglinide oral tablet 0.5, 1, 2 Diabetes, Other Oral Agents CYCLOSET ORAL TABLET 0.8 MG PA Diabetes, Pre-Mixed Insulins HUMALOG MIX INSULN U-100 SUBCUTANEOUS SUSPENSION 100 UNIT/ML (50-50) HUMALOG MIX KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (50-50) HUMALOG MIX KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (75-25) HUMALOG MIX 75-25(U-100)INSULN SUBCUTANEOUS SUSPENSION 100 UNIT/ML (75-25) HUMULIN 70/30 U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-30) 38

39 HUMULIN 70/30 U-100 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30) Diabetes, Rapid-Acting Insulins HUMALOG JUNIOR KWIKPEN U-100 SUBCUTANEOUS INSULIN PEN, HALF-UNIT 100 UNIT/ML HUMALOG KWIKPEN INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML, 200 UNIT/ML (3 ML) HUMALOG U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNIT/ML HUMALOG U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML Diabetes, Rescue Agents GLUCAGEN HYPOKIT INJECTION RECON SOLN 1 MG GLUCAGEN INJECTION RECON SOLN 1 MG GLUCAGON EMERGENCY KIT (HUMAN) INJECTION KIT 1 MG Diabetes, Sglt2 Inhibitor / Biguanide Combinations INVOKAMET ORAL TABLET 150-1,000 MG, MG, 50-1,000 MG, MG INVOKAMET XR ORAL TABLET, IR - ER, BIPHASIC 24HR 150-1,000 MG, MG, 50-1,000 MG, MG SYNJARDY ORAL TABLET ,000 MG, MG, 5-1,000 MG, MG SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, ,000 MG, 25-1,000 MG, 5-1,000 MG Diabetes, Sglt2 Inhibitors ST ST ST ST INVOKANA ORAL TABLET 100 MG, 300 MG ST JARDIANCE ORAL TABLET 10 MG, 25 MG ST Diabetes, Short-Acting Insulins HUMULIN R REGULAR U-100 INSULN INJECTION SOLUTION 100 UNIT/ML HUMULIN R U-500 (CONC) INSULIN SUBCUTANEOUS SOLUTION 500 UNIT/ML 39

40 HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN 500 UNIT/ML (3 ML) Diabetes, Sulfonylurea / Biguanide Combination glipizide-metformin oral tablet , , Diabetes, Sulfonylureas glimepiride oral tablet 1, 2, 4 glipizide oral tablet 10, 5 glipizide oral tablet extended release 24hr 10, 2.5, 5 glyburide micronized oral tablet 1.5, 3, 6 GE Female; AE glyburide oral tablet 1.25, 2.5, 5 GE Female; AE Diabetes, Thiazolidinedione / Biguanide Combinations pioglitazone-metformin oral tablet , Diabetes, Thiazolidinedione / Sulfonylurea Combinations pioglitazone-glimepiride oral tablet 30-2, 30-4 Diabetes, Thiazolidinediones pioglitazone oral tablet 15, 30, 45 Ear Conditions Anti-Infectives, Ear acetic acid otic (ear) solution 2 % acetic acid-aluminum acetate otic (ear) drops 2 % CIPRO HC OTIC (EAR) DROPS,SUSPENSION % CIPRODEX OTIC (EAR) DROPS,SUSPENSION % neomycin-polymyxin-hc otic (ear) drops,suspension ,000-1 /ml-unit/ml-% neomycin-polymyxin-hc otic (ear) solution ,000-1 /ml-unit/ml-% ofloxacin otic (ear) drops 0.3 % 40

41 Ear Conditions, Other fluocinolone acetonide oil otic (ear) drops 0.01 % Enzyme Replacement Enzyme Replacement CERDELGA ORAL CAPSULE 84 MG CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC) 12,000-38,000-60,000 UNIT, 24,000-76, ,000 UNIT, 3,000-9,500-15,000 UNIT, 36, , ,000 UNIT, 6,000-19,000-30,000 UNIT STRENSIQ SUBCUTANEOUS SOLUTION 100 MG/ML, 40 MG/ML SUCRAID ORAL SOLUTION 8,500 UNIT/ML ZAVESCA ORAL CAPSULE 100 MG Eye Conditions Anti-Infectives, Eye bacitracin ophthalmic (eye) ointment 500 unit/gram bacitracin-polymyxin b ophthalmic (eye) ointment ,000 unit/gram BESIVANCE OPHTHALMIC (EYE) DROPS,SUSPENSION 0.6 % BLEPHAMIDE S.O.P. OPHTHALMIC (EYE) OINTMENT % CILOXAN OPHTHALMIC (EYE) OINTMENT 0.3 % ciprofloxacin hcl ophthalmic (eye) drops 0.3 % erythromycin ophthalmic (eye) ointment 5 /gram (0.5 %) gentamicin ophthalmic (eye) ointment 0.3 % (3 /gram) moxifloxacin ophthalmic (eye) drops 0.5 % neomycin-bacitracin-polymyxin ophthalmic (eye) ointment ,000 -unit-unit/g neomycin-polymyxin b-dexameth ophthalmic (eye) ointment 3.5 /g-10,000 unit/g-0.1 % neomycin-polymyxin-gramicidin ophthalmic (eye) drops ,000 unit-0.025/ml ofloxacin ophthalmic (eye) drops 0.3 % PA WL 41

42 polymyxin b sulf-trimethoprim ophthalmic (eye) drops 10,000 unit- 1 /ml sulfacetamide sodium ophthalmic (eye) drops 10 % sulfacetamide sodium ophthalmic (eye) ointment 10 % sulfacetamide-prednisolone ophthalmic (eye) drops 10 %-0.23 % (0.25 %) TOBRADEX OPHTHALMIC (EYE) OINTMENT % tobramycin ophthalmic (eye) drops 0.3 % tobramycin-dexamethasone ophthalmic (eye) drops,suspension % TOBREX OPHTHALMIC (EYE) OINTMENT 0.3 % trifluridine ophthalmic (eye) drops 1 % ZIRGAN OPHTHALMIC (EYE) GEL 0.15 % Anti-Inflammatories, Eye bromfenac ophthalmic (eye) drops 0.09 % dexamethasone sodium phosphate ophthalmic (eye) drops 0.1 % diclofenac sodium ophthalmic (eye) drops 0.1 % fluorometholone ophthalmic (eye) drops,suspension 0.1 % flurbiprofen sodium ophthalmic (eye) drops 0.03 % FML S.O.P. OPHTHALMIC (EYE) OINTMENT 0.1 % ketorolac ophthalmic (eye) drops 0.4 %, 0.5 % PRED FORTE OPHTHALMIC (EYE) DROPS,SUSPENSION 1 % PRED MILD OPHTHALMIC (EYE) DROPS,SUSPENSION 0.12 % prednisolone acetate ophthalmic (eye) drops,suspension 1 % prednisolone sodium phosphate ophthalmic (eye) drops 1 % Eye Conditions, Other atropine ophthalmic (eye) drops 1 % atropine ophthalmic (eye) ointment 1 % 42

43 cyclopentolate ophthalmic (eye) drops 1 % CYSTARAN OPHTHALMIC (EYE) DROPS 0.44 % homatropaire ophthalmic (eye) drops 5 % phenylephrine hcl ophthalmic (eye) drops 10 %, 2.5 % RESTASIS MULTIDOSE OPHTHALMIC (EYE) DROPS 0.05 % RESTASIS OPHTHALMIC (EYE) DROPPERETTE 0.05 % Glaucoma betaxolol ophthalmic (eye) drops 0.5 % bimatoprost ophthalmic (eye) drops 0.03 % brimonidine ophthalmic (eye) drops 0.15 %, 0.2 % carteolol ophthalmic (eye) drops 1 % COSOPT (PF) OPHTHALMIC (EYE) DROPPERETTE % PA dorzolamide ophthalmic (eye) drops 2 % dorzolamide-timolol ophthalmic (eye) drops /ml latanoprost ophthalmic (eye) drops % levobunolol ophthalmic (eye) drops 0.5 % LUMIGAN OPHTHALMIC (EYE) DROPS 0.01 % methazolamide oral tablet 25, 50 pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %, 4 % timolol maleate ophthalmic (eye) drops 0.25 %, 0.5 % timolol maleate ophthalmic (eye) gel forming solution 0.25 %, 0.5 % TRAVATAN Z OPHTHALMIC (EYE) DROPS % travoprost (benzalkonium) ophthalmic (eye) drops % ZIOPTAN (PF) OPHTHALMIC (EYE) DROPPERETTE % Gout Gout PA allopurinol oral tablet 100, 300 colchicine oral capsule

HealthPartners GenericsPlusRx

HealthPartners GenericsPlusRx HealthPartners GenericsPlusRx 2018 Formulary (List of covered drugs) For current information on the GenericsPlusRx Drug List, visit healthpartners.com/pharmacy. Effective: October 1, 2018 2018 HealthPartners

More information

HealthPartners PreferredRx

HealthPartners PreferredRx HealthPartners PreferredRx 2018 Formulary (List of covered drugs) For current information on the PreferredRx Drug List, visit healthpartners.com/pharmacy. Effective: October 1, 2018 2018 HealthPartners

More information

HealthPartners Minnesota Health Care Programs

HealthPartners Minnesota Health Care Programs HealthPartners Minnesota Health Care Programs 2018 Formulary (List of covered drugs) For current information on the Minnesota Health Care Programs Drug List, visit healthpartners.com/pharmacy. Effective:

More information

healthpartners.com/pharmacy.

healthpartners.com/pharmacy. HealthPartners Empower HSA NationalONE Embedded Silver 4000-100 Rx Plus HealthPartners Empower HSA NationalONE Embedded Silver 3000-80 Rx Plus 2017 Formulary (List of covered drugs) For current information

More information

Information for Vermont Prescribers of Prescription Drugs (Long Form)

Information for Vermont Prescribers of Prescription Drugs (Long Form) Information for Vermont Prescribers of Prescription Drugs (Long Form) Natazia (Estradiol Valerate-Dienogest) This list does not imply that the products on this chart are interchangeable or have the same

More information

HealthPartners PreferredRx

HealthPartners PreferredRx HealthPartners PreferredRx Drug List (formulary) For current information on the PreferredRx Drug List, visit healthpartners.com/pharmacy. Effective: April 1, 2014 2013 HealthPartners What s the PreferredRx

More information

PA Prior authorization ST Step therapy QL Quantity limit AE Age Edit. Last Updated: January 1,

PA Prior authorization ST Step therapy QL Quantity limit AE Age Edit. Last Updated: January 1, Preventive Drug List Preventive drugs are used to help avoid disease and maintain health. Some insurance plans have a benefit that allows you to buy preventive drugs at a copay. Check your plan details

More information

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

PA Prior authorization ST Step therapy QL Quantity limit AE Age Edit. More Details. Last Updated: April 1, Preventive Drug List Preventive drugs are used to help avoid disease and maintain health. Some insurance plans have a benefit that allows you to buy preventive drugs at a copay. Check your plan details

More information

HealthPartners Compass $2850 HSA (Silver) 2016 Formulary. (List of covered drugs)

HealthPartners Compass $2850 HSA (Silver) 2016 Formulary. (List of covered drugs) HealthPartners Compass $2850 HSA (Silver) 2016 Formulary (List of covered drugs) For current information on the GenericsAdvantageRx Drug List, visit healthpartners.com/pharmacy. Effective: October 1, 2016

More information

BAYER HEALTHCARE PHARMA $ $4.42

BAYER HEALTHCARE PHARMA $ $4.42 Information for Vermont Prescribers of Prescription Drugs (Long Form) Yasmin (Drospirenone and Ethinyl Estradiol) This list does not imply that the products on this chart are interchangeable or have the

More information

BAYER HEALTHCARE PHARMA. Per Pill Aftera Oral Tablet 1.5 MG TEVA/WOMENS HEALTH $16.20 $16.20 SANDOZ $92.76 $1.

BAYER HEALTHCARE PHARMA. Per Pill Aftera Oral Tablet 1.5 MG TEVA/WOMENS HEALTH $16.20 $16.20 SANDOZ $92.76 $1. Information for Vermont Prescribers of Prescription Drugs (Long Form) Yasmin (Drospirenone and Ethinyl Estradiol) This list does not imply that the products on this chart are interchangeable or have the

More information

Information for Vermont Prescribers of Prescription Drugs (Long Form)

Information for Vermont Prescribers of Prescription Drugs (Long Form) Information for Vermont Prescribers of Prescription Drugs (Long Form) Beyaz (Drospirenone-Ethinyl Estradiol-Levomefolate Calcium) This list does not imply that the products on this chart are interchangeable

More information

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

PA Prior authorization ST Step therapy QL Quantity limit AE Age Edit. More Details. Last Update: July 1, Preventive Drug List Preventive drugs are used to help avoid disease and maintain health. Some insurance plans have a benefit that allows you to buy preventive drugs at a copay. Check your plan details

More information

Information for Vermont Prescribers of Prescription Drugs (Long Form)

Information for Vermont Prescribers of Prescription Drugs (Long Form) Information for Vermont Prescribers of Prescription Drugs (Long Form) Beyaz (Drospirenone-Ethinyl Estradiol-Levomefolate Calcium) This list does not imply that the products on this chart are interchangeable

More information

Preventive Drug List. More Details. Alcohol Dependency Alcohol Dependency acamprosate oral tablet,delayed release (dr/ec) disulfiram oral tablet

Preventive Drug List. More Details. Alcohol Dependency Alcohol Dependency acamprosate oral tablet,delayed release (dr/ec) disulfiram oral tablet Preventive Drug List Preventive drugs are used to help avoid disease and maintain health. Some insurance plans have a benefit that allows you to buy preventive drugs at a copay. Check your plan details

More information

QL (0.5 per 365 days); AGE (Min 7 Years) ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE 2 LF-( MCG)-5LF/0.5 ML

QL (0.5 per 365 days); AGE (Min 7 Years) ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE 2 LF-( MCG)-5LF/0.5 ML Tier 1 Zero Cost Share Preventive Drugs 2018 Marketplace Plans Drug Name Requirements/Limits ADACEL(TDAP ADOLESDULT)(PF) INTRAMUSCULAR SUSPENSION 2 LF-(2.5-5-3-5 MCG)-5LF/0.5 ML ADACEL(TDAP ADOLESDULT)(PF)

More information

Acyclovir Ointment. Aetna Better Health New Jersey. Products Affected. acyclovir ointment 5 % external Details. Criteria

Acyclovir Ointment. Aetna Better Health New Jersey. Products Affected. acyclovir ointment 5 % external Details. Criteria Acyclovir Ointment acyclovir ointment 5 % external Aetna Better Health New Jersey Use of oral acyclovir or Abreva in the previous 130 days 1 Adcirca tadalafil (pah) tablet 20 mg oral Use of sildenafil

More information

Care Wisconsin 2018 Formulary Addendum

Care Wisconsin 2018 Formulary Addendum pharmacies, - Non-Formulary, PA - Prior Authorization, QL Quantity Limit per 30 days, ST - Step Therapy EFFECTIVE 01/01/ 0.5 ML SUMATRIPTAN 4 MG CARTRIDGE 0.5 ML SUMATRIPTAN 6 MG Last Updated: 03/24/ Effective

More information

Acyclovir Ointment. Aetna Better Health Kentucky. Products Affected. acyclovir ointment 5 % external Details. Criteria

Acyclovir Ointment. Aetna Better Health Kentucky. Products Affected. acyclovir ointment 5 % external Details. Criteria Acyclovir Ointment acyclovir ointment 5 % external Aetna Better Health Kentucky Use of oral acyclovir or Abreva in the previous 130 days 1 Adcirca ADCIRCA TABLET 20 MG ORAL Use of sildenafil in previous

More information

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

Commercial Metal 5-Tier Formulary (List of Covered Drugs) Updated: September 1, 2018 Small Group Metal Plans Individual Metal Plans Commercial Metal 5-Tier Formulary (List of Covered Drugs) What is the Drug List? Also called a formulary by doctors and pharmacists,

More information

Acyclovir Ointment. Aetna Better Health Louisiana. Products Affected. acyclovir ointment 5 % external Details. Criteria

Acyclovir Ointment. Aetna Better Health Louisiana. Products Affected. acyclovir ointment 5 % external Details. Criteria Acyclovir Ointment acyclovir ointment 5 % external Aetna Better Health Louisiana Use of oral acyclovir in the previous 130 days 1 Adcirca ADCIRCA TABLET 20 MG ORAL Use of sildenafil in previous 30 days

More information

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

Commercial Metal 5-Tier Formulary (List of Covered Drugs) Updated: January 1, 2019 Small Group Metal Plans Individual Metal Plans Commercial Metal 5-Tier Formulary (List of Covered Drugs) What is the Drug List? Also called a formulary by doctors and pharmacists,

More information

Antibiotic Treatments. Arthritis & Pain. Asthma. Cholesterol

Antibiotic Treatments. Arthritis & Pain. Asthma. Cholesterol MAX Saver Plan Drug List 08/06/14 GENERIC NAME Allergies and Cold & Flu BENZONATATE CAP 100 MG 14 42 cap CETIRIZINE HCL TAB 10MG 30 90 tab CETIRIZINE HCL TAB 5MG 30 90 tab DIPHENHYDRAMINE HCL CAP 50 MG

More information

2019 Commercial 5-Tier Formulary (List of Covered Drugs) What is the Drug List?

2019 Commercial 5-Tier Formulary (List of Covered Drugs) What is the Drug List? Effective: January 1, 2019 Large and Small Group Health Plans Individual Health Plans Third Party Administered Health Plans 2019 Commercial 5-Tier Formulary (List of Covered Drugs) What is the Drug List?

More information

2018 Commercial 3-Tier Formulary (List of Covered Drugs)

2018 Commercial 3-Tier Formulary (List of Covered Drugs) Effective: July 1, 2018 Large Group Health Plans Small Group Health Plans 2018 Commercial 3-Tier Formulary (List of Covered Drugs) What is the Drug List? Also called a formulary by doctors and pharmacists,

More information

Acyclovir Ointment. Aetna Better Health Virginia Medallion/FAMIS 3.0. Products Affected. acyclovir ointment 5 % external Details.

Acyclovir Ointment. Aetna Better Health Virginia Medallion/FAMIS 3.0. Products Affected. acyclovir ointment 5 % external Details. Aetna Better Health Virginia Medallion/FAMIS 3.0 Acyclovir Ointment acyclovir ointment 5 % external Use of oral acyclovir in the previous 130 days 1 Adcirca tadalafil (pah) tablet 20 mg oral Use of sildenafil

More information

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

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

More information

Allergies and Cold & Flu

Allergies and Cold & Flu MAX Saver Plan Drug List 01/23/17 GENERIC NAME Allergies and Cold & Flu BENZONATATE CAP 100 MG 14 42 cap CETIRIZINE HCL TAB 10MG 30 90 tab CETIRIZINE HCL TAB 5MG 30 90 tab DIPHENHYDRAMINE HCL CAP 50 MG

More information

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

2018 Formulary (List of Covered Drugs) UCare for Seniors Prime (HMO-POS) UCare for Seniors Standard (HMO-POS) 208 Formulary (List of Covered Drugs) UCare for Seniors Prime (HMO-POS) UCare for Seniors Standard (HMO-POS) This formulary was updated on 05/0/208. For more recent information or other questions, please

More information

WELLCARE HEALTH PLAN 2015 STEP THERAPY CRITERIA (No Changes Made Since: 10/2014)

WELLCARE HEALTH PLAN 2015 STEP THERAPY CRITERIA (No Changes Made Since: 10/2014) WELLCARE HEALTH PLAN 2015 STEP THERAPY CRITERIA (No Changes Made Since: 10/2014) **To get updated information about the drugs covered by WellCare, please visit our website (https://www.wellcare.com) or

More information

Comprehensive Preferred Drug List (List of Covered Drugs)

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

More information

2019 Comprehensive Preferred Drug List (List of Covered Drugs)

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

More information

Comprehensive Preferred Drug List (List of Covered Drugs)

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

More information

2018 Formulary (List of Covered Drugs)

2018 Formulary (List of Covered Drugs) 018 Formulary (List of Covered Drugs) UCare for Seniors Essentials Rx (HMO-POS) UCare for Seniors Value Plus (HMO-POS) UCare for Seniors Classic (HMO-POS) This formulary was updated on 11/01/018. For more

More information

Third Party Administered Health Plans 5 Tier Formulary (List of Covered Drugs)

Third Party Administered Health Plans 5 Tier Formulary (List of Covered Drugs) Effective: September 11, 2017 Large Group Non Qualified Health Plans Third Party Administered Health Plans 5 Tier Formulary (List of Covered Drugs) What is the Drug List? Also called a formulary by doctors

More information

3 Tier Formulary (List of Covered Drugs)

3 Tier Formulary (List of Covered Drugs) Effective: September 11, 2017 Large Group Non-Qualified Health Plans Small Group Non-Qualified Health Plans 3 Tier Formulary (List of Covered Drugs) What is the Drug List? Also called a formulary by doctors

More information

Current as of November 1, 2017

Current as of November 1, 2017 Current as of November 1, 2017 ZYTIGA 500 MG ORAL TABLETS Formulary Addition TIER 5 QL = 2 PER DAY BENLYSTA 200 MG/ML AUTO- INJECTOR Formulary Addition TIER 5 BENLYSTA 200 MG/ML PREFILLED SYRINGE Formulary

More information

Comprehensive Preferred Drug List (List of Covered Drugs)

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

More information

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

2018 Formulary (List of Covered Drugs) UCare for Seniors Prime (HMO-POS) UCare for Seniors Standard (HMO-POS) 208 Formulary (List of Covered Drugs) UCare for Seniors Prime (HMO-POS) UCare for Seniors Standard (HMO-POS) This formulary was updated on 09/08/207. For more recent information or other questions, please

More information

2018 Formulary (List of Covered Drugs)

2018 Formulary (List of Covered Drugs) 08 Formulary (List of Covered Drugs) UCare for Seniors Essentials Rx (HMO-POS) UCare for Seniors Value Plus (HMO-POS) UCare for Seniors Classic (HMO-POS) This formulary was updated on 04/0/08. For more

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

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

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) Group UCare for Seniors (HMO-POS)

2018 Formulary. (List of Covered Drugs) Group UCare for Seniors (HMO-POS) 08 Formulary (List of Covered Drugs) Group UCare for Seniors (HMO-POS) This formulary was updated on 0/0/08. For more recent information or other questions, please contact UCare for Seniors Customer Services

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

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

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

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

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

Memorial Hermann Advantage HMO & PPO April 2018 Formulary Addendum

Memorial Hermann Advantage HMO & PPO April 2018 Formulary Addendum Memorial Hermann Advantage HMO & PPO April 2018 Formulary Addendum Changes may have occurred since the printing of your current Memorial Hermann Advantage HMO & PPO Formulary. Medications that may have

More information

ANALGESICS TREATMENT OF PAIN ANALGESICS, OTHER

ANALGESICS TREATMENT OF PAIN ANALGESICS, OTHER ANALGESICS TREATMENT OF PAIN ANALGESICS, OTHER acetaminophen-codeine oral solution 20-2 /5 ml acetaminophen-codeine oral tablet 300-5, 300-30, 300-60 ASCOMP WITH CODEINE ORAL CAPSULE 30-50-325-40 MG BUTALBITAL

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

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

2018 Formulary. (List of Covered Drugs) Group UCare for Seniors (HMO-POS)

2018 Formulary. (List of Covered Drugs) Group UCare for Seniors (HMO-POS) 08 Formulary (List of Covered Drugs) Group UCare for Seniors (HMO-POS) This formulary was updated on 0/0/08. For more recent information or other questions, please contact UCare for Seniors Customer Services

More information

Individual Qualified Health Plans 5 Tier Commercial Formulary (List of Covered Drugs)

Individual Qualified Health Plans 5 Tier Commercial Formulary (List of Covered Drugs) Effective: September 11, 2017 What is the Drug List? Also called a formulary by doctors and pharmacists, the Drug List is an extensive list of safe and effective, FDA-approved, brand name and generic prescription

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

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

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

2019 Ohana Community Care Services (CCS) Comprehensive Preferred Drug List (List of Covered Drugs)

2019 Ohana Community Care Services (CCS) Comprehensive Preferred Drug List (List of Covered Drugs) 2019 Ohana Community Care Services (CCS) Comprehensive referred Drug List (List of Covered Drugs) Ohana Health lan 00 lease read: This document contains information about the drugs we cover in this plan.

More information

Provider Partners Pennsylvania Advantage Plan Offered by Provider Partners Health Plan April 2019 Formulary Addendum

Provider Partners Pennsylvania Advantage Plan Offered by Provider Partners Health Plan April 2019 Formulary Addendum Provider Partners Pennsylvania Advantage Plan Offered by Provider Partners Health Plan April 2019 Formulary Addendum Below is a list formulary changes for the benefit year 2019. This is not a complete

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

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

2018 Ohana Community Care Services (CCS) Comprehensive Preferred Drug List (List of Covered Drugs)

2018 Ohana Community Care Services (CCS) Comprehensive Preferred Drug List (List of Covered Drugs) 2018 Ohana Community Care Services (CCS) Comprehensive referred Drug List (List of Covered Drugs) Ohana Health lan 00 lease read: This document contains information about the drugs we cover in this plan.

More information

HealthPartners PreferredRx

HealthPartners PreferredRx HealthPartners PreferredRx 2018 Formulary (List of covered drugs) For current information on the PreferredRx Drug List, visit healthpartners.com/pharmacy. Effective: April 1, 2018 2017 HealthPartners What

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

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

BCN Advantage Formulary Updates: April, 2018

BCN Advantage Formulary Updates: April, 2018 Attention BCN Advantage members: This is a list of changes made to the BCN Advantage formulary since its initial release in October, 2017 BCN Advantage may add or remove drugs from our formulary during

More information

ANALGESICS - TREATMENT OF PAIN ANALGESICS, OTHER

ANALGESICS - TREATMENT OF PAIN ANALGESICS, OTHER ANALGESICS - TREATMENT OF PAIN ANALGESICS, OTHER acetaminophen-codeine oral solution 20-2 /5 ml (5 ml), 300-30 /2.5 ml acetaminophen-codeine oral solution 20-2 /5 ml acetaminophen-codeine oral tablet 300-5,

More information

ANALGESICS - TREATMENT OF PAIN ANALGESICS, OTHER

ANALGESICS - TREATMENT OF PAIN ANALGESICS, OTHER 09 Tier Standard Member Formulary Formulary ID: 9393 Effective Date: 3//09 Updated: 0/09 ANALGESICS - TREATMENT OF PAIN ANALGESICS, OTHER acetaminophen-codeine oral solution 0 - /5 ml (5 ml), 300-30 /.5

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

ATRIO Health Plans 2018 SNP Plans Formulary Change Notice

ATRIO Health Plans 2018 SNP Plans Formulary Change Notice Formulary ID: 18007 ATRIO Special Needs Plan ATRIO Special Needs Plan (Rogue) ATRIO Special Needs Plan (Willamette) ATRIO Health Plans 2018 SNP Plans Formulary Change Notice ATRIO Health Plans may remove

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

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

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

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

PRESCRIPTION DRUG FORMULARY

PRESCRIPTION DRUG FORMULARY OPTIMA HEALTH PRESCRIPTION DRUG FORMULARY OPTIMA FAMILY CARE (FAMIS) (April June 2019) Revised: 3/27/2019 Table of Contents Analgesics - Drugs for Pain... 3 Analgesics - Drugs for Pain and Inflammation...

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

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

New Jersey Department of Human Services State Upper Limit (SUL) List - PROPOSED Effective Generic_Name Current NJ SUL New NJ SUL Proposed ACETAMINOPHEN WITH CODEINE PHOSPHATE ORAL TABLET 300MG-30MG 0.12455 ACETAMINOPHEN WITH CODEINE PHOSPHATE ORAL TABLET 300MG-60MG 0.25688 ALBUTEROL SULFATE

More information

Analgesics Analgesics

Analgesics Analgesics 07 5 Tier Standard Member Formulary Formulary ID: 79 Effective Date: 7//07 Last Updated: 6/0/07 Drug Name Drug Tier Requirements/Limits Analgesics Analgesics acetaminophen-codeine oral solution 0 - /5

More information

ANALGESICS - TREATMENT OF PAIN ANALGESICS, OTHER

ANALGESICS - TREATMENT OF PAIN ANALGESICS, OTHER 09 Tier Standard Member Formulary Formulary ID: 8390 Effective Date: //09 Updated: 0/09 ANALGESICS - TREATMENT OF PAIN ANALGESICS, OTHER acetaminophen-codeine oral solution 0 - /5 ml (5 ml), 300-30 /.5

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

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

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

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

ANALGESICS - TREATMENT OF PAIN ANALGESICS, OTHER

ANALGESICS - TREATMENT OF PAIN ANALGESICS, OTHER 209 2 Tier Standard- Keystone First VIP Choice Document: 209 Formulary Formulary ID: 9393 Updated: 03/209 Effective Date: 04-0-209 ANALGESICS - TREATMENT OF PAIN ANALGESICS, OTHER acetaminophen-codeine

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

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

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

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

More information

H0544_058, 059, 066, 067, 069

H0544_058, 059, 066, 067, 069 Anthem MediBlue Select (H) 08 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on July, 08. For more recent

More information

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

FRESENIUS TOTAL HEALTH (PPO SNP)

FRESENIUS TOTAL HEALTH (PPO SNP) FRESENIUS TOTAL HEALTH (PPO SNP) 07 Formulary List of Covered Drugs PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN H9 7444, V This formulary was updated on 07/0/07.

More information

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

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

More information

2017 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

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

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

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

More information

Formulary (Drug List) Anthem 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

ATRIO Health Plans 2018 PPO Plans Formulary Change Notice

ATRIO Health Plans 2018 PPO Plans Formulary Change Notice Formulary ID: 18032 ATRIO Bronze Rx (Basin) ATRIO Silver Rx ATRIO Gold Rx ATRIO Bronze Rx (Umpqua) ATRIO Bronze Rx (Rogue) ATRIO Silver Rx (Rogue) ATRIO Gold Rx (Willamette) ATRIO Silver Rx (Willamette)

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

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

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