S5596_001, 006, 014, 018, 057, 063

Size: px
Start display at page:

Download "S5596_001, 006, 014, 018, 057, 063"

Transcription

1 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 recent information or other questions, please contact Anthem Blue MedicareRx Plus (PDP) Customer Service, at or, for TTY users, 7, 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October through February, and Monday to Friday (except holi from February through September 0., or visit S96_00, 006, 0, 08, 07, 06 Y0_8_9_U_0 CMS Accepted 08//07 Plus_PDP_86_v_806_

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 Anthem Blue Cross and Blue Shield. When it refers to plan or our plan, it means Anthem Blue MedicareRx Plus (PDP). This document includes a list of the drugs (formulary) for our plan which is current as of June, 08. For an 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, formulary, pharmacy network, and/or copayments/coinsurance may change on January, 09, and from time to time during the year. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. Effective Date June, 08 Plus_PDP_86_v_806_

3 What is the Anthem Blue MedicareRx Plus (PDP) formulary? A formulary is a list of covered drugs selected by our plan 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. Our plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a plan 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 08 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 08 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 Administration (FDA) 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 June, 08. To get updated information about the drugs covered by our plan, please contact us. Our contact information appears on the front and back cover pages. If any other type of approved formulary change (nonmaintenance change) is made during the year, we will notify you by sending you a list of these changes, or by sending you an updated formulary. How do I use the formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 8. 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, Hypertension/ Lipids. If you know what your drug is used for, look for the category name in the list that begins on page 8. 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 9. 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? Our plan 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: Our plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from our plan before you fill your prescriptions. If you don't get approval, our plan may not cover the drug. Effective Date June, 08 Plus_PDP_86_v_806_

4 Quantity Limits: For certain drugs, our plan limits the amount of the drug that our plan will cover. For example, our plan provides 0 tablets per prescription for donepezil. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, our plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if A and B both treat your medical condition, our plan may not cover B unless you try A first. If A does not work for you, our plan will then cover B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 8. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online 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 our plan 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 Anthem Blue MedicareRx Plus (PDP)'s formulary? on page 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 Customer Service and ask if your drug is covered. If you learn that our plan does not cover your drug, you have two options: You can ask Customer Service for a list of similar drugs that are covered by our plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by our plan. You can ask our plan 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 Anthem Blue MedicareRx Plus (PDP)'s formulary? You can ask our plan 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 predetermined 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 approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, our plan 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, our plan 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, tiering or utilization restriction exception. When you request a formulary, tiering 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 requesting 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 Effective Date June, 08 Plus_PDP_86_v_806_

5 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 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 a 98-day transition supply, consistent with dispensing increment (unless you have a prescription written for fewer. 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 -day emergency supply of that drug (unless you have a prescription for fewer while you pursue a formulary exception. During the time when you are getting a temporary supply of a drug, you should talk to your prescriber or prescribing physician to decide what to do when your supply runs out. You can call Customer Service to ask for a list of covered drugs that treat the same medical condition. This list can help your doctor find a covered drug that might work for you while you pursue a formulary exception. Please refer to the Evidence of Coverage for more information about exceptions. For more information For more detailed information about our plan prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about our plan, 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 -800-MEDICARE ( ), hours a day/7 days a week. TTY users should call Or, visit Our plan s formulary The formulary on page 8 provides coverage information about the drugs covered by our plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 9. The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., SPIRIVA) and generic drugs are listed in lowercase italics (e.g., atenolol). The information in the column tells you if our plan has any special requirements for coverage of your drug. QLL Quantity Limits: Restricts the frequency, amount or dosage of medication for which you can obtain benefits each time you get a prescription filled (most often set on a monthly basis). PAR Prior Authorization: The process of obtaining approval for certain prescriptions before benefits will be approved. You, your doctor or other network provider will need to request prior authorization before you fill the prescription. ST Step Therapy: The process of first trying a certain drug or drugs to determine if that drug or those drugs will treat your medical condition before your plan will cover another drug for that condition. B/D Part B vs. Part D: This drug may be covered under either your Part D prescription drug benefits or as a Part B drug under your medical benefits, as determined by Medicare. LA Limited Access: This prescription may be available only at certain pharmacies. For more information, consult your Pharmacy Directory or call Customer Service at , 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October through February, and Monday to Friday Effective Date June, 08 Plus_PDP_86_v_806_

6 (except holi from February through September 0. TTY/TDD users should call 7. INJ Injectable: The drug is available in injectable form. Mail Orders: Prescription drugs available through mail order. CG Coverage Gap: We provide additional coverage of this prescription drug in the coverage gap. Please refer to your Evidence of Coverage for more information about this coverage. Effective Date June, 08 6 Plus_PDP_86_v_806_

7 Cost-sharing for a one-month supply of a covered Part D prescription drug during the Initial Coverage Stage: Cost-Sharing : Preferred Generic Network Pharmacy with preferred cost-sharing (0-day supply) or Mail-Order Pharmacy** (0-day supply) Network Pharmacy with standard cost-sharing (0-day supply) or Long-Term-Care Pharmacy (-day supply) Cost-Sharing : Generic Network Pharmacy with preferred cost-sharing (0-day supply) or Mail-Order Pharmacy** (0-day supply) Network Pharmacy with standard cost-sharing (0-day supply) or Long-Term-Care Pharmacy (-day supply) Cost-Sharing : Preferred Brand Network Pharmacy with preferred cost-sharing (0-day supply) or Mail-Order Pharmacy** (0-day supply) Network Pharmacy with standard cost-sharing (0-day supply) or Long-Term-Care Pharmacy (-day supply) Cost-Sharing : Nonpreferred s Network Pharmacy with preferred cost-sharing (0-day supply) or Mail-Order Pharmacy** (0-day supply) Network Pharmacy with standard cost-sharing (0-day supply) or Long-Term-Care Pharmacy (-day supply) Cost-Sharing : Specialty * Network Pharmacy with preferred cost-sharing (0-day supply) or Mail-Order Pharmacy** (0-day supply) Network Pharmacy with standard cost-sharing (0-day supply) or Long-Term-Care Pharmacy (-day supply) Cost-Sharing 6: Select Care s Network Pharmacy with preferred cost-sharing (0-day supply) or Mail-Order Pharmacy** (0-day supply) Network Pharmacy with standard cost-sharing (0-day supply) or Long-Term-Care Pharmacy (-day supply) Please refer to our Evidence of Coverage for more information on cost sharing. $.00 $9.00 $.00 $7.00 $0.00 $.00 Network Pharmacy with preferred cost-sharing A network pharmacy that offers covered drugs to members of our plan that may have lower cost-sharing levels than other network pharmacies with standard cost-sharing. * A long-term supply is not available for drugs in the : Specialty ** Mail-Order Pharmacy Mail-order service allows you to order a 0 90-day supply of drugs. The drugs available through our plan s mail-order service are marked as mail-order drugs in our drug list. 9% 7% % % $0.00 $.00 Effective Date June, 08 7 Plus_PDP_86_v_806_

8 Covered Medications by Therapeutic Category Legend Generic drugs are shown in lowercase italic (e.g., atenolol). Brand-name drugs are shown in capital letters (e.g., SPIRIVA). QLL Quantity Limits: Restricts the frequency, amount or dosage of medication for which you can obtain benefits each time you get a prescription filled (most often set on a monthly basis). PAR Prior Authorization: The process of obtaining approval for certain prescriptions before benefits will be approved. You, your doctor or other network provider will need to request prior authorization before you fill the prescription. ST Step Therapy: The process of first trying a certain drug or drugs to determine if that drug or those drugs will treat your medical condition before your plan will cover another drug for that condition. B/D Part B vs. Part D: This drug may be covered under either your Part D prescription drug benefits or as a Part B drug under your medical benefits, as determined by Medicare. LA Limited Access: This prescription may be available only at certain pharmacies. For more information, consult your Pharmacy Directory or call Customer Service at , 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October through February, and Monday to Friday (except holi from February through September 0. TTY/TDD users should call 7. INJ Injectable: The drug is available in injectable form. Mail Orders: Prescription drugs available through mail order. CG Coverage Gap: We provide additional coverage of this prescription drug in the coverage gap. Please refer to your Evidence of Coverage for more information about this coverage. Name Anti - Infectives abacavir oral solution abacavir oral tablet abacavir-lamivudine abacavir-lamivudinezidovudine ABELCET acyclovir oral capsule acyclovir oral suspension 00 / ml acyclovir oral tablet acyclovir sodium intravenous solution 0 /ml ; QLL (960 per 0 ; QLL (60 per 0 ; QLL (0 per 0 ; QLL (60 per 0 B/D PAR; B/D PAR; Name adefovir ALBENZA ALINIA ORAL SUSPENSION FOR RECONSTITUTION ALINIA ORAL TABLET amantadine hcl AMBISOME amikacin injection solution,000 / ml, 00 / ml amoxicillin oral capsule amoxicillin oral suspension for reconstitution amoxicillin oral tablet PAR; ; QLL (80 per 0 ; QLL (6 per 0 B/D PAR; Plus_PDP_86_v_806_ 8 Effective Date June, 08

9 Name amoxicillin oral tablet, chewable, 0 amoxicillin-pot clavulanate oral suspension for reconstitution / ml, 00-7 / ml, / ml amoxicillin-pot clavulanate oral suspension for reconstitution 0-6. / ml amoxicillin-pot clavulanate oral tablet 0- amoxicillin-pot clavulanate oral tablet 00-, 87- amoxicillin-pot clavulanate oral tablet extended release hr amoxicillin-pot clavulanate oral tablet,chewable amphotericin b ampicillin oral capsule 00 ampicillin sodium injection ampicillin sodium intravenous ampicillin-sulbactam injection recon soln. gram, gram ampicillin-sulbactam injection recon soln gram ampicillin-sulbactam intravenous recon soln. gram ampicillin-sulbactam intravenous recon soln gram APTIVUS ORAL CAPSULE APTIVUS ORAL SOLUTION atazanavir oral capsule 0, 00 atazanavir oral capsule 00 atovaquone B/D PAR; ; QLL (0 per 0 QLL (80 per 0 ; QLL (60 per 0 ; QLL (0 per 0 PAR; Name atovaquone-proguanil oral tablet 0-00 atovaquone-proguanil oral tablet 6.- ATRIPLA AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION -. MG/ ML AVELOX IN NACL (ISO- OSTIC) AZACTAM AZACTAM IN DEXTROSE (ISO-OSM) azithromycin intravenous azithromycin oral packet azithromycin oral suspension for reconstitution 00 / ml azithromycin oral suspension for reconstitution 00 / ml azithromycin oral tablet 0 (6 pack) azithromycin oral tablet 0, 00, 600 aztreonam baciim bacitracin intramuscular BARACLUDE ORAL SOLUTION BICILLIN C-R BICILLIN L-A BIKTARVY CANCIDAS CAPASTAT CAYSTON cefaclor oral capsule cefaclor oral suspension for reconstitution / ml cefaclor oral suspension for reconstitution 0 / ml cefaclor oral suspension for reconstitution 7 / ml ; QLL (0 per 0 ; CG PAR; ; QLL (0 per 0 B/D PAR; PAR; ; LA Plus_PDP_86_v_806_ 9 Effective Date June, 08

10 Name cefaclor oral tablet extended release hr cefadroxil oral capsule cefadroxil oral suspension for reconstitution 0 / ml, 00 / ml cefadroxil oral tablet cefazolin in dextrose (iso-os) intravenous piggyback gram/0 ml, gram/0 ml cefazolin injection recon soln gram, 00 cefazolin injection recon soln 0 gram, 00 gram, 0 gram, 00 g cefazolin intravenous cefdinir cefepime cefepime in dextrose,iso-osm intravenous piggyback gram/0 ml cefepime in dextrose,iso-osm intravenous piggyback gram/00 ml cefixime cefotaxime injection recon soln gram, gram, 00 cefotaxime injection recon soln 0 gram cefotetan cefoxitin in dextrose, iso-osm cefoxitin intravenous recon soln gram, gram cefoxitin intravenous recon soln 0 gram cefpodoxime cefprozil oral suspension for reconstitution / ml cefprozil oral suspension for reconstitution 0 / ml cefprozil oral tablet CEFTAZIDIME IN DW ceftazidime injection recon soln gram, gram ceftazidime injection recon soln 6 gram Name ceftriaxone in dextrose,iso-os ceftriaxone injection recon soln gram, gram, 0, 00 ceftriaxone injection recon soln 0 gram CEFTRIAXONE INJECTION RECON SOLN 00 GRAM ceftriaxone intravenous recon soln gram, gram cefuroxime axetil oral tablet cefuroxime sodium injection recon soln 70 cefuroxime sodium intravenous recon soln. gram cefuroxime sodium intravenous recon soln 7. gram cephalexin oral capsule 0, 00 cephalexin oral suspension for reconstitution cephalexin oral tablet chloramphenicol sod succinate chloroquine phosphate ciprofloxacin hcl oral tablet 00 ciprofloxacin hcl oral tablet 0, 00, 70 ciprofloxacin in % dextrose ciprofloxacin lactate intravenous solution 00 / 0 ml clarithromycin clindamycin hcl clindamycin in % dextrose clindamycin phosphate injection clindamycin phosphate intravenous clotrimazole mucous membrane COARTEM colistin (colistimethate na) Plus_PDP_86_v_806_ 0 Effective Date June, 08

11 Name COMPLERA CRIXIVAN ORAL CAPSULE 00 MG CRIXIVAN ORAL CAPSULE 00 MG dapsone oral daptomycin DARAPRIM demeclocycline DESCOVY dicloxacillin didanosine oral capsule, delayed release(dr/ec) 00 didanosine oral capsule, delayed release(dr/ec) 0, 00 DORIPENEM INTRAVENOUS RECON SOLN 0 MG doxy-00 doxycycline hyclate oral capsule doxycycline hyclate oral tablet 00, 0, 0, 7 doxycycline monohydrate oral capsule 00, 0 doxycycline monohydrate oral tablet 00, 0, 7 doxycycline monohydrate oral tablet 0 EDURANT efavirenz oral capsule 00 efavirenz oral capsule 0 efavirenz oral tablet EMTRIVA ORAL CAPSULE EMTRIVA ORAL SOLUTION entecavir ; QLL (0 per 0 ; QLL (60 per 0 ; QLL (80 per 0 ; QLL (0 per 0 ; QLL (60 per 0 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (60 per 0 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (80 per 0 PAR; Name EPCLUSA EPIVIR HBV ORAL SOLUTION erythrocin (as stearate) oral tablet 0 ERYTHROCIN INTRAVENOUS RECON SOLN 00 MG erythromycin ethylsuccinate oral tablet erythromycin oral capsule, delayed release(dr/ec) erythromycin oral tablet ethambutol EVOTAZ famciclovir oral tablet, 0 famciclovir oral tablet 00 fluconazole in dextrose(iso-o) FLUCONAZOLE IN NACL (ISO-OSM) INTRAVENOUS PIGGYBACK 00 MG/0 ML fluconazole in nacl (iso-osm) intravenous piggyback 00 /00 ml fluconazole in nacl (iso-osm) intravenous piggyback 00 /00 ml fluconazole oral suspension for reconstitution fluconazole oral tablet 00, 0, 00 fluconazole oral tablet 0 flucytosine oral capsule 0 flucytosine oral capsule 00 fosamprenavir foscarnet PAR; ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (60 per 0 ; QLL ( per 7 ; CG ; QLL (0 per 0 B/D PAR Plus_PDP_86_v_806_ Effective Date June, 08

12 Name FUZEON SUBCUTANEOUS RECON SOLN ganciclovir sodium intravenous recon soln gentamicin in nacl (iso-osm) intravenous piggyback 00 /00 ml, 60 /0 ml, 80 /0 ml GENTAMICIN IN NACL (ISO-OSM) INTRAVENOUS PIGGYBACK 00 MG/0 ML, 0 MG/00 ML gentamicin in nacl (iso-osm) intravenous piggyback 70 / 0 ml, 80 /00 ml, 90 /00 ml gentamicin injection gentamicin sulfate (ped) (pf) gentamicin sulfate (pf) intravenous solution 00 / 0 ml GENTAMICIN SULFATE (PF) INTRAVENOUS SOLUTION 60 MG/6 ML GENVOYA griseofulvin microsize oral suspension griseofulvin ultramicrosize HARVONI hydroxychloroquine imipenem-cilastatin intravenous recon soln 0 imipenem-cilastatin intravenous recon soln 00 INTELENCE ORAL TABLET 00 MG INTELENCE ORAL TABLET 00 MG INTELENCE ORAL TABLET MG ; QLL (60 per 0 B/D PAR; ; QLL (0 per 0 PAR; ; QLL (8 per 8 ; QLL (0 per 0 ; QLL (60 per 0 ; QLL (80 per 0 Name INVANZ INTRAVENOUS INVIRASE ORAL CAPSULE INVIRASE ORAL TABLET ISENTRESS HD ISENTRESS ORAL POWDER IN PACKET ISENTRESS ORAL TABLET ISENTRESS ORAL TABLET,CHEWABLE 00 MG ISENTRESS ORAL TABLET,CHEWABLE MG isoniazid injection isoniazid oral solution isoniazid oral tablet itraconazole ivermectin JULUCA KALETRA ORAL TABLET 00- MG KALETRA ORAL TABLET 00-0 MG ketoconazole oral lamivudine oral solution lamivudine oral tablet 00 lamivudine oral tablet 0 lamivudine oral tablet 00 lamivudine-zidovudine levofloxacin in dw intravenous piggyback 0 /0 ml levofloxacin in dw intravenous piggyback 00 /00 ml, 70 /0 ml ; QLL (00 per 0 ; QLL (0 per 0 ; QLL (60 per 0 ; QLL (0 per 0 ; QLL (80 per 0 ; QLL (70 per 0 ; CG PAR; ; QLL (0 per 0 ; QLL (00 per 0 ; QLL (0 per 0 ; QLL (960 per 0 ; QLL (60 per 0 ; QLL (0 per 0 ; QLL (60 per 0 Plus_PDP_86_v_806_ Effective Date June, 08

13 Name levofloxacin intravenous levofloxacin oral solution levofloxacin oral tablet LEXIVA ORAL SUSPENSION LEXIVA ORAL TABLET linezolid intravenous linezolid oral suspension for reconstitution linezolid oral tablet linezolid-0.9% sodium chloride lopinavir-ritonavir mefloquine meropenem methenamine hippurate methenamine mandelate metro i.v. metronidazole in nacl (iso-os) metronidazole oral tablet 0 metronidazole oral tablet 00 minocycline oral capsule minocycline oral tablet morgidox oral capsule 0 moxifloxacin in nacl (iso-osm) nafcillin in dextrose iso-osm intravenous piggyback gram/0 ml nafcillin in dextrose iso-osm intravenous piggyback gram/00 ml nafcillin injection recon soln gram, gram nafcillin intravenous NEBUPENT neomycin nevirapine oral suspension nevirapine oral tablet ; QLL (800 per 0 ; QLL (0 per 0 PAR; ; QLL (800 per 0 PAR; ; QLL (60 per 0 ; QLL (80 per 0 ; CG B/D PAR; ; QLL (00 per 0 ; QLL (60 per 0 Name nevirapine oral tablet extended release hr 00 nevirapine oral tablet extended release hr 00 nitrofurantoin macrocrystal oral capsule 00, 0 nitrofurantoin monohyd/mcryst NORVIR ORAL CAPSULE NORVIR ORAL SOLUTION NORVIR ORAL TABLET NOXAFIL ORAL SUSPENSION nystatin oral suspension nystatin oral tablet ODEFSEY oseltamivir oxacillin in dextrose(iso-osm) intravenous piggyback gram/0 ml oxacillin injection recon soln gram oxacillin injection recon soln gram paromomycin PASER penicillin g potassium penicillin g procaine intramuscular syringe. million unit/ ml penicillin g procaine intramuscular syringe 600, 000 unit/ml penicillin v potassium PENTAM pfizerpen-g piperacillin-tazobactam intravenous recon soln. gram,.7 gram,. gram, 0. gram ; QLL (0 per 0 PAR; PAR; QLL (60 per 0 ; QLL (80 per 0 ; QLL (60 per 0 PAR; ; QLL (0 per 0 Plus_PDP_86_v_806_ Effective Date June, 08

14 Name PREZCOBIX PREZISTA ORAL SUSPENSION PREZISTA ORAL TABLET 0 MG PREZISTA ORAL TABLET 600 MG, 800 MG PREZISTA ORAL TABLET 7 MG PRIFTIN PRIMAQUINE pyrazinamide RELENZA DISKHALER RESCRIPTOR ORAL TABLET RESCRIPTOR ORAL TABLET, DISPERSIBLE RETROVIR INTRAVENOUS REYATAZ ORAL CAPSULE 0 MG, 00 MG REYATAZ ORAL CAPSULE 00 MG REYATAZ ORAL POWDER IN PACKET ribasphere oral tablet 00 ribavirin oral capsule ribavirin oral tablet 00 rifabutin rifampin intravenous rifampin oral RIFATER rimantadine ritonavir SELZENTRY ORAL SOLUTION SELZENTRY ORAL TABLET 0 MG, 00 MG SELZENTRY ORAL TABLET MG ; QLL (0 per 0 ; QLL (00 per 0 ; QLL (80 per 0 ; QLL (60 per 0 ; QLL (00 per 0 ; QLL (60 per 80 ; QLL (80 per 0 ; QLL (60 per 0 ; QLL (60 per 0 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (60 per 0 ; QLL (80 per 0 ; QLL (0 per 0 ; QLL (0 per 0 Name SELZENTRY ORAL TABLET 7 MG SIRTURO stavudine oral capsule, 0 stavudine oral capsule 0, 0 STREPTOMYCIN STRIBILD STROMECTOL sulfadiazine sulfamethoxazoletrimethoprim intravenous sulfamethoxazoletrimethoprim oral suspension sulfamethoxazoletrimethoprim oral tablet SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 00 MG/ ML, 00 MG/ ML SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 00 MG/ ML SUSTIVA ORAL CAPSULE 00 MG SUSTIVA ORAL CAPSULE 0 MG SUSTIVA ORAL TABLET SYMFI LO SYNAGIS SYNERCID TAMIFLU TECHNIVIE TEFLARO tenofovir disoproxil fumarate terbinafine hcl oral tetracycline oral capsule 00 TIGECYCLINE ; QLL (60 per 0 PAR; ; LA ; QLL (0 per 0 ; QLL (60 per 0 ; QLL (0 per 0 ST; ; QLL (0 per 0 ; QLL (60 per 0 ; QLL (0 per 0 ; QLL (0 per 0 PAR; ; LA PAR; ; QLL (6 per 8 ; QLL (0 per 0 ; CG Plus_PDP_86_v_806_ Effective Date June, 08

15 Name tinidazole oral tablet 0 tinidazole oral tablet 00 TIVICAY ORAL TABLET 0 MG TIVICAY ORAL TABLET MG, 0 MG tobramycin in 0.% nacl for nebulization tobramycin sulfate injection recon soln tobramycin sulfate injection solution TRECATOR trimethoprim TRIUMEQ TRUVADA TYBOST valacyclovir oral tablet gram valacyclovir oral tablet 00 valganciclovir oral tablet VANCOMYCIN IN 0.9 % SODIUM CHL INTRAVENOUS PIGGYBACK VANCOMYCIN IN DEXTROSE % INTRAVENOUS PIGGYBACK GRAM/ 00 ML VANCOMYCIN IN DEXTROSE % INTRAVENOUS PIGGYBACK 00 MG/00 ML, 70 MG/0 ML vancomycin intravenous recon soln,000, 0 gram, gram, 00 VANCOMYCIN INTRAVENOUS RECON SOLN 70 MG ; QLL (60 per 0 ; QLL (60 per 0 B/D PAR; ; QLL (80 per 8 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (60 per 0 B/D PAR B/D PAR; B/D PAR B/D PAR; Name vancomycin oral capsule 0 VIBATIV INTRAVENOUS RECON SOLN 70 MG VIDEX GRAM PEDIATRIC VIDEX GRAM PEDIATRIC VIDEX EC ORAL CAPSULE,DELAYED RELEASE(DR/EC) MG VIRACEPT ORAL TABLET 0 MG VIRACEPT ORAL TABLET 6 MG VIRAMUNE ORAL SUSPENSION VIREAD ORAL POWDER VIREAD ORAL TABLET voriconazole intravenous voriconazole oral suspension for reconstitution voriconazole oral tablet 00 voriconazole oral tablet 0 VOSEVI ZERIT ORAL RECON SOLN ZIAGEN ORAL SOLUTION zidovudine oral capsule zidovudine oral syrup zidovudine oral tablet ZMAX PAR; ; QLL (80 per 0 PAR ; QLL (00 per 0 ; QLL (00 per 0 ; QLL (90 per 0 ; QLL (00 per 0 ; QLL (0 per 0 ; QLL (00 per 0 ; QLL (0 per 0 ; QLL (0 per 0 PAR; PAR; PAR; PAR; ; QLL (0 per 0 ; QLL (00 per 0 ; QLL (960 per 0 ; QLL (80 per 0 ; QLL (90 per 0 ; QLL (60 per 0 Plus_PDP_86_v_806_ Effective Date June, 08

16 Name ZYVOX INTRAVENOUS PARENTERAL SOLUTION 00 MG/00 ML Antineoplastic / Immunosuppressant s ABRAXANE PAR; adriamycin intravenous solution B/D PAR adrucil intravenous solution. gram/0 ml B/D PAR adrucil intravenous solution gram/00 ml, 00 /0 ml B/D PAR; AFINITOR PAR; AFINITOR DISPERZ PAR; ALECENSA PAR; ; QLL (0 per 0 ALIMTA PAR; ALIQOPA PAR; ; LA ALKERAN ORAL B/D PAR; ALUNBRIG ORAL TABLET 80 MG PAR; ; QLL (0 per 0 ALUNBRIG ORAL TABLET 0 MG PAR; ; QLL (80 per 0 ALUNBRIG ORAL TABLET 90 MG PAR; ; QLL (60 per 0 ALUNBRIG ORAL TABLETS,DOSE PACK PAR; ; QLL (0 per 80 anastrozole ; QLL (0 per 0 ARRANON B/D PAR ARZERRA PAR; ASTAGRAF XL B/D PAR; AVASTIN PAR; azacitidine PAR; azathioprine B/D PAR; azathioprine sodium B/D PAR BAVENCIO PAR; ; LA BELEODAQ PAR; BENDEKA B/D PAR; BESPONSA B/D PAR; bexarotene PAR; bicalutamide ; QLL (0 per 0 BICNU B/D PAR; Name bleomycin BLINCYTO INTRAVENOUS KIT BORTEZOMIB BOSULIF ORAL TABLET 00 MG BOSULIF ORAL TABLET 00 MG, 00 MG busulfan BUSULFEX CABOMETYX ORAL TABLET 0 MG CABOMETYX ORAL TABLET 0 MG, 60 MG CALQUENCE CAPRELSA ORAL TABLET 00 MG CAPRELSA ORAL TABLET 00 MG carboplatin intravenous solution CELLCEPT INTRAVENOUS cisplatin cladribine clofarabine CLOLAR COMETRIQ ORAL CAPSULE 00 MG/ DAY(80 MG X-0 MG X) COMETRIQ ORAL CAPSULE 0 MG/ DAY(80 MG X-0 MG X) COMETRIQ ORAL CAPSULE 60 MG/DAY (0 MG X /DAY) COSMEGEN COTELLIC B/D PAR; PAR; PAR; PAR; ; QLL (0 per 0 PAR; ; QLL (0 per 0 B/D PAR B/D PAR PAR; ; LA; QLL (90 per 0 PAR; ; LA; QLL (0 per 0 PAR; ; LA PAR; ; LA; QLL (90 per 0 PAR; ; LA; QLL (0 per 0 B/D PAR; B/D PAR; B/D PAR; B/D PAR; B/D PAR PAR; ; QLL (6 per 8 PAR; ; QLL ( per 8 PAR; ; QLL (8 per 8 B/D PAR; PAR; ; LA; QLL (90 per 0 Plus_PDP_86_v_806_ 6 Effective Date June, 08

17 Name CYCLOPHOSPHAMIDE ORAL CAPSULE cyclosporine intravenous cyclosporine modified oral capsule 00 cyclosporine modified oral capsule, 0 cyclosporine modified oral solution cyclosporine oral capsule CYRAMZA cytarabine (pf) injection solution 00 / ml (0 / ml), gram/0 ml (00 / ml) cytarabine (pf) injection solution 0 /ml cytarabine injection solution 0 /ml dacarbazine dactinomycin DARZALEX daunorubicin intravenous solution decitabine dexrazoxane hcl intravenous recon soln 0 dexrazoxane hcl intravenous recon soln 00 docetaxel intravenous solution 60 /6 ml (0 /ml), 0 / ml (0 /ml) docetaxel intravenous solution 60 /8 ml (0 /ml), 0 /ml ( ml), 80 / ml (0 /ml), 80 /8 ml (0 /ml) DOCETAXEL INTRAVENOUS SOLUTION 0 MG/ML doxorubicin intravenous recon soln 0 doxorubicin intravenous recon soln 0 doxorubicin intravenous solution B/D PAR; B/D PAR B/D PAR; B/D PAR; B/D PAR; B/D PAR; PAR; B/D PAR; B/D PAR B/D PAR; B/D PAR; B/D PAR PAR; ; LA B/D PAR B/D PAR; B/D PAR B/D PAR; B/D PAR B/D PAR B/D PAR; B/D PAR; Name doxorubicin, peg-liposomal DROXIA ELITEK EMCYT EMPLICITI ENVARSUS XR epirubicin intravenous solution ERBITUX ERIVEDGE ERLEADA ERWINAZE ETOPOPHOS etoposide intravenous EVOMELA exemestane FARESTON FARYDAK ORAL CAPSULE 0 MG FARYDAK ORAL CAPSULE MG, 0 MG FASLODEX FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 0 MG FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 80 MG fludarabine intravenous recon soln fludarabine intravenous solution fluorouracil intravenous flutamide FOLOTYN GAZYVA gemcitabine intravenous recon soln gram, 00 gemcitabine intravenous recon soln gram PAR; PAR; PAR; B/D PAR; B/D PAR; PAR; PAR; ; QLL (0 per 0 PAR; PAR; B/D PAR; B/D PAR; B/D PAR; ; QLL (60 per 0 ; QLL (0 per 0 PAR; ; QLL (60 per 0 PAR; ; QLL (0 per 0 PAR; PAR; ; QLL ( per 6 PAR; ; QLL ( per 8 B/D PAR; B/D PAR B/D PAR; B/D PAR; PAR; B/D PAR; B/D PAR Plus_PDP_86_v_806_ 7 Effective Date June, 08

18 Name gemcitabine intravenous solution gram/6. ml (8 /ml), 00 /.6 ml (8 /ml) gemcitabine intravenous solution gram/.6 ml (8 /ml) gengraf oral capsule 00 gengraf oral capsule gengraf oral solution GILOTRIF GLEOSTINE HALAVEN HERCEPTIN HEXALEN hydroxyurea IBRANCE ICLUSIG ORAL TABLET MG ICLUSIG ORAL TABLET MG idarubicin IDHIFA ORAL TABLET 00 MG IDHIFA ORAL TABLET 0 MG ifosfamide intravenous recon soln ifosfamide intravenous solution imatinib oral tablet 00 imatinib oral tablet 00 IMBRUVICA ORAL CAPSULE 0 MG IMBRUVICA ORAL CAPSULE 70 MG IMBRUVICA ORAL TABLET IMFINZI B/D PAR; B/D PAR B/D PAR; B/D PAR; B/D PAR; PAR; ; QLL (0 per 0 PAR; PAR; B/D PAR; PAR; ; QLL (0 per 0 PAR; QLL (60 per 0 PAR; ; QLL (0 per 0 B/D PAR PAR; ; LA; QLL (0 per 0 PAR; ; LA; QLL (60 per 0 B/D PAR; B/D PAR PAR; ; QLL (0 per 0 PAR; ; QLL (60 per 0 PAR; ; QLL (0 per 0 PAR; ; QLL (0 per 0 PAR; ; QLL (0 per 0 PAR; ; LA Name INLYTA ORAL TABLET MG INLYTA ORAL TABLET MG IRESSA irinotecan intravenous solution 00 / ml, 0 / ml irinotecan intravenous solution 00 / ml ISTODAX IXEMPRA JAKAFI ORAL TABLET 0 MG JAKAFI ORAL TABLET MG JAKAFI ORAL TABLET 0 MG JAKAFI ORAL TABLET MG JAKAFI ORAL TABLET MG JEVTANA KADCYLA KEYTRUDA INTRAVENOUS SOLUTION KISQALI FEMARA CO- PACK ORAL TABLET 00 MG/DAY(00 MG X )-. MG KISQALI FEMARA CO- PACK ORAL TABLET 00 MG/DAY(00 MG X )-. MG KISQALI FEMARA CO- PACK ORAL TABLET 600 MG/DAY(00 MG X )-. MG KISQALI ORAL TABLET 00 MG/DAY (00 MG X ) KISQALI ORAL TABLET 00 MG/DAY (00 MG X ) PAR; ; QLL (0 per 0 PAR; ; QLL (0 per 0 B/D PAR; B/D PAR PAR; PAR; PAR; ; QLL (0 per 0 PAR; ; QLL (00 per 0 PAR; ; QLL (7 per 0 PAR; ; QLL (60 per 0 PAR; ; QLL (00 per 0 PAR; PAR; PAR; PAR; ; QLL (9 per 8 PAR; ; QLL (70 per 8 PAR; ; QLL (9 per 8 PAR; ; QLL ( per PAR; ; QLL ( per Plus_PDP_86_v_806_ 8 Effective Date June, 08

19 Name KISQALI ORAL TABLET 600 MG/DAY (00 MG X ) KYPROLIS LARTRUVO LENVIMA ORAL CAPSULE 0 MG/DAY (0 MG X /DAY) LENVIMA ORAL CAPSULE MG/DAY(0 MG X - MG X ), 0 MG/DAY (0 MG X ), 8 MG/DAY ( MG X ) LENVIMA ORAL CAPSULE 8 MG/DAY (0 MG X - MG X), MG/DAY(0 MG X - MG X ) letrozole leucovorin calcium injection recon soln 00, 00, 0, 0 leucovorin calcium injection recon soln 00 leucovorin calcium oral tablet 0,, leucovorin calcium oral tablet LEUKERAN leuprolide subcutaneous kit levoleucovorin intravenous recon soln 0 LONSURF LUPRON DEPOT LUPRON DEPOT-PED INTRAMUSCULAR KIT 7. MG (PED) LYNPARZA ORAL CAPSULE LYNPARZA ORAL TABLET LYSODREN MARQIBO MATULANE PAR; ; QLL (6 per PAR; PAR; ; LA PAR; ; QLL (0 per 0 PAR; ; QLL (60 per 0 PAR; ; QLL (90 per 0 ; QLL (0 per 0 PAR; PAR PAR; PAR; ; QLL ( per 8 PAR; ; QLL ( per 8 PAR; ; QLL (80 per 0 PAR; ; QLL (0 per 0 Name megestrol oral suspension 00 /0 ml (0 ml), 800 / 0 ml (0 ml) megestrol oral suspension 00 /0 ml (0 /ml) megestrol oral tablet MEKINIST ORAL TABLET 0. MG MEKINIST ORAL TABLET MG melphalan melphalan hcl mercaptopurine mesna MESNEX ORAL methotrexate sodium (pf) injection recon soln methotrexate sodium (pf) injection solution methotrexate sodium injection methotrexate sodium oral mitomycin intravenous recon soln 0 mitomycin intravenous recon soln 0 mitoxantrone mycophenolate mofetil hcl mycophenolate mofetil oral capsule mycophenolate mofetil oral suspension for reconstitution mycophenolate mofetil oral tablet MYLOTARG NERLYNX NEXAVAR nilutamide NINLARO NIPENT NULOJIX PAR PAR; PAR; PAR; ; QLL (90 per 0 PAR; ; QLL (0 per 0 B/D PAR; B/D PAR B/D PAR; B/D PAR; B/D PAR; B/D PAR B/D PAR; B/D PAR; B/D PAR; PAR; ; LA PAR; ; LA; QLL (80 per 0 PAR; ; LA; QLL (0 per 0 ; QLL (0 per 0 PAR; ; QLL ( per 8 B/D PAR; PAR; Plus_PDP_86_v_806_ 9 Effective Date June, 08

20 Name octreotide acetate injection solution,000 mcg/ml octreotide acetate injection solution 00 mcg/ml, 00 mcg/ml, 0 mcg/ml octreotide acetate injection syringe 00 mcg/ml ( ml), 0 mcg/ml ( ml) octreotide acetate injection syringe 00 mcg/ml ( ml) ODOMZO ONCASPAR OPDIVO oxaliplatin intravenous recon soln 00 oxaliplatin intravenous recon soln 0 oxaliplatin intravenous solution 00 /0 ml oxaliplatin intravenous solution 0 /0 ml ( / ml) paclitaxel PERJETA POMALYST ORAL CAPSULE MG POMALYST ORAL CAPSULE MG POMALYST ORAL CAPSULE MG, MG PORTRAZZA PROGRAF INTRAVENOUS PURIXAN RAPAMUNE ORAL SOLUTION REVLIMID ORAL CAPSULE 0 MG REVLIMID ORAL CAPSULE MG,. MG, 0 MG, MG PAR; PAR; PAR; PAR; PAR; ; LA; QLL (0 per 0 PAR; PAR; B/D PAR; B/D PAR B/D PAR; B/D PAR; B/D PAR; PAR; PAR; ; QLL (0 per 0 PAR; ; QLL (60 per 0 PAR; ; QLL (0 per 0 B/D PAR; PAR; B/D PAR; PAR; ; LA; QLL (60 per 0 PAR; ; LA; QLL (0 per 0 Name REVLIMID ORAL CAPSULE MG RITUXAN RITUXAN HYCELA ROMIDEPSIN RUBRACA ORAL TABLET 00 MG RUBRACA ORAL TABLET 0 MG, 00 MG RYDAPT SIGNIFOR SIMULECT INTRAVENOUS RECON SOLN 0 MG SIMULECT INTRAVENOUS RECON SOLN 0 MG sirolimus oral tablet 0., SOLTAX SOMATULINE DEPOT SPRYCEL STIVARGA SUTENT ORAL CAPSULE. MG SUTENT ORAL CAPSULE MG, 7. MG, 0 MG SYNRIBO TABLOID tacrolimus oral capsule 0. tacrolimus oral capsule, TAFINLAR TAGRISSO ORAL TABLET 0 MG PAR; ; LA; QLL (0 per 0 B/D PAR; B/D PAR; PAR PAR; ; LA; QLL (80 per 0 PAR; ; LA; QLL (0 per 0 PAR; ; QLL (0 per 0 PAR; B/D PAR B/D PAR; B/D PAR; PAR; PAR; ; QLL (0 per 0 PAR; ; QLL (0 per 0 PAR; ; QLL (90 per 0 PAR; ; QLL (0 per 0 PAR; B/D PAR; B/D PAR; PAR; ; QLL (0 per 0 PAR; ; LA; QLL (60 per 0 Plus_PDP_86_v_806_ 0 Effective Date June, 08

21 Name TAGRISSO ORAL TABLET 80 MG tamoxifen TARCEVA ORAL TABLET 00 MG, 0 MG TARCEVA ORAL TABLET MG TARGRETIN TOPICAL TASIGNA ORAL CAPSULE 0 MG, 00 MG TASIGNA ORAL CAPSULE 0 MG TECENTRIQ THALOMID ORAL CAPSULE 00 MG, 0 MG THALOMID ORAL CAPSULE 0 MG, 00 MG thiotepa toposar topotecan intravenous recon soln topotecan intravenous solution TORISEL TREANDA INTRAVENOUS RECON SOLN TRELSTAR INTRAMUSCULAR SYRINGE. MG/ ML TRELSTAR INTRAMUSCULAR SYRINGE. MG/ ML TRELSTAR INTRAMUSCULAR SYRINGE.7 MG/ ML tretinoin (chemotherapy) PAR; ; LA; QLL (0 per 0 PAR; ; QLL (0 per 0 PAR; ; QLL (90 per 0 PAR; ; QLL (60 per 0 PAR; ; QLL ( per 8 PAR; ; QLL (60 per 8 PAR; ; LA; QLL (0 per PAR; ; QLL (0 per 0 PAR; ; QLL (60 per 0 B/D PAR; B/D PAR; B/D PAR B/D PAR; PAR; B/D PAR; PAR; ; QLL ( per 8 PAR; ; QLL ( per 68 PAR; ; QLL ( per 8 Name TRISENOX INTRAVENOUS SOLUTION MG/ML TYKERB UNITUXIN VECTIBIX VELCADE VENCLEXTA ORAL TABLET 0 MG VENCLEXTA ORAL TABLET 00 MG VENCLEXTA ORAL TABLET 0 MG VENCLEXTA STARTING PACK VERZENIO vinblastine intravenous solution /ml vincasar pfs intravenous solution /ml vincasar pfs intravenous solution / ml vincristine vinorelbine VOTRIENT VYXEOS XALKORI XATMEP XGEVA XTANDI YERVOY YONDELIS ZALTRAP ZANOSAR B/D PAR; PAR; ; LA; QLL (80 per 0 B/D PAR; PAR; PAR; PAR; ; LA; QLL (60 per 0 PAR; ; LA; QLL (0 per 0 PAR; ; LA; QLL (0 per 0 PAR; ; LA; QLL (8 per 6 PAR; ; LA; QLL (60 per 0 B/D PAR; B/D PAR B/D PAR; B/D PAR; B/D PAR; PAR; ; QLL (0 per 0 B/D PAR; PAR; ; QLL (60 per 0 PAR; ; QLL (.7 per 8 PAR; ; QLL (0 per 0 PAR; B/D PAR; PAR; B/D PAR; Plus_PDP_86_v_806_ Effective Date June, 08

22 Name ZEJULA PAR; ; LA; QLL (90 per 0 ZELBORAF PAR; ; QLL (0 per 0 ZOLINZA PAR; ; QLL (0 per 0 ZORTRESS ORAL TABLET 0. MG B/D PAR; ZORTRESS ORAL TABLET 0. MG, 0.7 MG B/D PAR; ZYDELIG PAR; ; QLL (60 per 0 ZYKADIA PAR; ; QLL (0 per 0 ZYTIGA ORAL TABLET 0 MG PAR; ; QLL (0 per 0 ZYTIGA ORAL TABLET 00 MG PAR; ; QLL (60 per 0 Autonomic / Cns s, Neurology / Psych ABILIFY MAINTENA ; QLL ( per 8 acetaminophen-codeine oral solution 0 - / ml ( ml), 0 - /0 ml (0 ml), 00-0 /. ml QLL (00 per 0 acetaminophen-codeine oral solution 0- / ml ; QLL (00 per 0 acetaminophen-codeine oral tablet 00- ; QLL (90 per 0 acetaminophen-codeine oral tablet 00-0 ; QLL (60 per 0 acetaminophen-codeine oral tablet ; QLL (80 per 0 ADASUVE QLL (0 per 0 alprazolam oral tablet ; QLL (0 per 0 amitriptyline PAR; amoxapine AMPYRA APOKYN PAR; ; LA; QLL (60 per 0 PAR; ; LA Name APTIOM aripiprazole oral solution aripiprazole oral tablet 0 aripiprazole oral tablet aripiprazole oral tablet aripiprazole oral tablet 0, 0 aripiprazole oral tablet aripiprazole oral tablet, disintegrating 0 aripiprazole oral tablet, disintegrating atomoxetine oral capsule 0, 8,, 0 atomoxetine oral capsule 00, 60, 80 baclofen BANZEL ORAL SUSPENSION BANZEL ORAL TABLET 00 MG BANZEL ORAL TABLET 00 MG benztropine injection benztropine oral BRIVIACT INTRAVENOUS BRIVIACT ORAL SOLUTION BRIVIACT ORAL TABLET 0 MG BRIVIACT ORAL TABLET 00 MG, 7 MG BRIVIACT ORAL TABLET MG BRIVIACT ORAL TABLET 0 MG bromocriptine buprenorphine hcl injection solution ST; ; QLL (900 per 0 ; QLL (90 per 0 ; QLL (60 per 0 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (80 per 0 ; QLL (90 per 0 ; QLL (60 per 0 PAR; ; QLL (60 per 0 PAR; ; QLL (0 per 0 PAR; ; QLL (00 per 0 PAR; ; QLL (80 per 0 PAR; ; QLL (0 per 0 PAR; PAR; PAR PAR; ; QLL (600 per 0 PAR; ; QLL (600 per 0 PAR; ; QLL (60 per 0 PAR; ; QLL (0 per 0 PAR; ; QLL (0 per 0 ; QLL (90 per 0 Plus_PDP_86_v_806_ Effective Date June, 08

23 Name buprenorphine hcl injection syringe buprenorphine hcl sublingual tablet buprenorphine hcl sublingual tablet 8 buprenorphine-naloxone sublingual tablet -0. buprenorphine-naloxone sublingual tablet 8- bupropion hcl oral tablet 00 bupropion hcl oral tablet 7 bupropion hcl oral tablet extended release hr 00 bupropion hcl oral tablet extended release hr 0, 00 bupropion hcl oral tablet extended release hr 0 bupropion hcl oral tablet extended release hr 00 buspirone oral tablet 0 buspirone oral tablet,, 7. buspirone oral tablet 0 butorphanol tartrate injection butorphanol tartrate nasal carbamazepine oral capsule, er multiphase hr carbamazepine oral suspension 00 / ml carbamazepine oral suspension 00 /0 ml carbamazepine oral tablet carbamazepine oral tablet extended release hr carbamazepine oral tablet, chewable carbidopa-levodopa oral tablet QLL (0 per 0 ; QLL (0 per 0 ; QLL (60 per 0 ; QLL (60 per 0 ; QLL (90 per 0 ; QLL ( per 0 ; QLL (80 per 0 ; QLL (0 per 0 ; QLL (60 per 0 ; QLL (90 per 0 ; QLL (0 per 0 ; CG ; QLL ( per 8 Name carbidopa-levodopa oral tablet extended release carbidopa-levodopa oral tablet,disintegrating celecoxib CELONTIN ORAL CAPSULE 00 MG chlorpromazine injection chlorpromazine oral tablet 0 chlorpromazine oral tablet 00, 00,, 0 citalopram oral solution citalopram oral tablet 0 citalopram oral tablet 0 citalopram oral tablet 0 clomipramine clonazepam oral tablet 0. clonazepam oral tablet clonazepam oral tablet clonazepam oral tablet, disintegrating 0. clonazepam oral tablet, disintegrating 0. clonazepam oral tablet, disintegrating 0. clonazepam oral tablet, disintegrating clonazepam oral tablet, disintegrating clonidine hcl oral tablet extended release hr clorazepate dipotassium clozapine oral tablet 00 clozapine oral tablet 00 PAR; PAR; PAR; PAR; ; QLL (600 per 0 ; CG; QLL (0 per 0 ; CG; QLL (60 per 0 ; CG; QLL (0 per 0 PAR; ; QLL (00 per 0 ; QLL (600 per 0 ; QLL (00 per 0 ; QLL (800 per 0 ; QLL (00 per 0 ; QLL (00 per 0 ; QLL (600 per 0 ; QLL (00 per 0 ; QLL (70 per 0 ; QLL (0 per 0 Plus_PDP_86_v_806_ Effective Date June, 08

24 Name clozapine oral tablet clozapine oral tablet 0 clozapine oral tablet, disintegrating 00 clozapine oral tablet, disintegrating. CLOZAPINE ORAL TABLET, DISINTEGRATING 0 MG CLOZAPINE ORAL TABLET, DISINTEGRATING 00 MG clozapine oral tablet, disintegrating codeine sulfate oral tablet, 0 codeine sulfate oral tablet 60 COPAXONE SUBCUTANEOUS SYRINGE 0 MG/ML COPAXONE SUBCUTANEOUS SYRINGE 0 MG/ML cyclobenzaprine oral tablet 0, cyclobenzaprine oral tablet 7. dantrolene oral capsule 00 dantrolene oral capsule, 0 desipramine DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE HR 00 MG DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE HR 0 MG ; QLL (080 per 0 ; QLL (0 per 0 QLL (70 per 0 QLL (60 per 0 QLL (80 per 0 QLL (0 per 0 QLL (080 per 0 ; QLL (60 per 0 ; QLL (80 per 0 PAR; ; QLL (0 per 0 PAR; ; QLL ( per 8 PAR; PAR; PAR; ; QLL (0 per 0 ; QLL (0 per 0 Name DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE HR 00 MG DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE HR 0 MG desvenlafaxine succinate oral tablet extended release hr 00 desvenlafaxine succinate oral tablet extended release hr desvenlafaxine succinate oral tablet extended release hr 0 dextroamphetamine oral tablet 0 dextroamphetamine oral tablet dextroamphetamineamphetamine oral capsule, extended release hr dextroamphetamineamphetamine oral tablet 0,.,, 0,, 7. dextroamphetamineamphetamine oral tablet 0 DIASTAT DIASTAT ACUDIAL diazepam intensol diazepam oral concentrate diazepam oral solution / ml ( /ml) diazepam oral tablet 0 diazepam oral tablet diazepam oral tablet diazepam rectal ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (80 per 0 ; QLL (0 per 0 ; QLL (80 per 0 ; QLL (90 per 0 PAR; ; QLL (0 per 0 PAR; ; QLL (90 per 0 PAR; ; QLL (60 per 0 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (00 per 0 ; QLL (0 per 0 ; QLL (600 per 0 ; QLL (0 per 0 Plus_PDP_86_v_806_ Effective Date June, 08

25 Name diclofenac potassium diclofenac sodium oral diclofenac sodium topical gel % diflunisal dihydroergotamine nasal DILANTIN INFATABS DILANTIN ORAL CAPSULE 0 MG divalproex oral capsule, delayed rel sprinkle divalproex oral tablet extended release hr divalproex oral tablet,delayed release (dr/ec) donepezil oral tablet 0, donepezil oral tablet donepezil oral tablet, disintegrating doxepin oral capsule doxepin oral concentrate duloxetine oral capsule, delayed release(dr/ec) 0 duloxetine oral capsule, delayed release(dr/ec) 0 duloxetine oral capsule, delayed release(dr/ec) 0 duloxetine oral capsule, delayed release(dr/ec) 60 duramorph (pf) injection solution 0. /ml duramorph (pf) injection solution /ml EMSAM endocet oral tablet 0- endocet oral tablet -, 7.- entacapone epitol ; QLL (000 per 0 ; QLL (8 per 8 ; CG; QLL (0 per 0 ST; ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (80 per 0 ; QLL (0 per 0 ; QLL (90 per 0 ; QLL (60 per 0 ; QLL (80 per 0 QLL (80 per 0 PAR; ; QLL (0 per 0 ; QLL (60 per 0 ; QLL (60 per 0 Name EQUETRO ORAL CAPSULE, ER MULTIPHASE HR 00 MG EQUETRO ORAL CAPSULE, ER MULTIPHASE HR 00 MG EQUETRO ORAL CAPSULE, ER MULTIPHASE HR 00 MG ergoloid ERGOMAR escitalopram oxalate oral solution escitalopram oxalate oral tablet 0 escitalopram oxalate oral tablet 0 escitalopram oxalate oral tablet ethosuximide oral capsule ethosuximide oral solution etodolac oral capsule etodolac oral tablet etodolac oral tablet extended release hr FANAPT ORAL TABLET MG FANAPT ORAL TABLET 0 MG, MG FANAPT ORAL TABLET MG FANAPT ORAL TABLET MG FANAPT ORAL TABLET 6 MG FANAPT ORAL TABLET 8 MG FANAPT ORAL TABLETS,DOSE PACK felbamate fenoprofen oral tablet fentanyl citrate ; QLL (80 per 0 ; QLL (0 per 0 ; QLL (80 per 0 PAR; ; QLL (600 per 0 ; QLL (60 per 0 ; QLL (0 per 0 ; QLL (0 per 0 ST; ; QLL (70 per 0 ST; ; QLL (60 per 0 ST; ; QLL (60 per 0 ST; ; QLL (80 per 0 ST; ; QLL (0 per 0 ST; ; QLL (90 per 0 ST; ; QLL (6 per 6 PAR; ; QLL (0 per 0 Plus_PDP_86_v_806_ Effective Date June, 08

26 Name fentanyl transdermal patch 7 hour 00 mcg/hr, mcg/hr, 0 mcg/hr, 7 mcg/hr fentanyl transdermal patch 7 hour mcg/hr FETZIMA ORAL CAPSULE,EXT REL HR DOSE PACK FETZIMA ORAL CAPSULE,EXTENDED RELEASE HR 0 MG, 80 MG FETZIMA ORAL CAPSULE,EXTENDED RELEASE HR 0 MG FETZIMA ORAL CAPSULE,EXTENDED RELEASE HR 0 MG fluoxetine oral capsule 0 fluoxetine oral capsule 0 fluoxetine oral capsule 0 fluoxetine oral solution fluphenazine decanoate fluphenazine hcl injection fluphenazine hcl oral flurbiprofen fluvoxamine oral tablet 00 fluvoxamine oral tablet fluvoxamine oral tablet 0 fosphenytoin FYCOMPA ORAL SUSPENSION FYCOMPA ORAL TABLET 0 MG, MG FYCOMPA ORAL TABLET MG FYCOMPA ORAL TABLET MG PAR; ; QLL ( per 0 PAR; ; QLL ( per 0 PAR; ; QLL (6 per 6 PAR; ; QLL (0 per 0 PAR; ; QLL (80 per 0 PAR; ; QLL (90 per 0 ; CG; QLL (0 per 0 ; CG; QLL (0 per 0 ; CG; QLL (60 per 0 ; QLL (600 per 0 ; QLL (90 per 0 ; QLL (60 per 0 ; QLL (80 per 0 ; QLL (70 per 0 ; QLL (0 per 0 ; QLL (80 per 0 ; QLL (90 per 0 Name FYCOMPA ORAL TABLET 6 MG FYCOMPA ORAL TABLET 8 MG gabapentin oral capsule 00 gabapentin oral capsule 00 gabapentin oral capsule 00 gabapentin oral solution 0 / ml gabapentin oral solution 0 / ml ( ml), 00 /6 ml (6 ml) gabapentin oral tablet 600 gabapentin oral tablet 800 GABITRIL ORAL TABLET MG GABITRIL ORAL TABLET 6 MG galantamine oral capsule,ext rel. pellets hr galantamine oral solution galantamine oral tablet GEODON INTRAMUSCULAR glatiramer subcutaneous syringe 0 /ml glatiramer subcutaneous syringe 0 /ml glatopa subcutaneous syringe 0 /ml guanfacine oral tablet extended release hr guanidine haloperidol decanoate haloperidol lactate injection haloperidol lactate intramuscular haloperidol lactate oral haloperidol oral tablet 0. ; QLL (60 per 0 ; QLL ( per 0 ; QLL (080 per 0 ; QLL (60 per 0 ; QLL (70 per 0 ; QLL (60 per 0 QLL (60 per 0 ; QLL (80 per 0 ; QLL (0 per 0 ; QLL (0 per 0 ; QLL (80 per 0 ; QLL (60 per 0 ; QLL (6 per 8 PAR; ; QLL (0 per 0 PAR; ; QLL ( per 0 PAR; ; QLL (0 per 0 PAR; ; QLL (0 per 0 ; CG Plus_PDP_86_v_806_ 6 Effective Date June, 08

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

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

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

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

More information

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

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

More information

Anthem 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

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

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

More information

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

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

More information

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

Empire MediBlue Select (HMO) 2019 Formulary (List of Covered Drugs) Please read: ,

Empire MediBlue Select (HMO) 2019 Formulary (List of Covered Drugs) Please read: , Empire MediBlue Select (H) 09 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on February, 09. For more recent

More information

Anthem MediBlue 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

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

H0544_058, 059, 066, 067, 069

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

More information

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

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

More information

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

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

More information

H0544_058, 059, 066, 067

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

More information

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

Anthem MediBlue Plus (HMO) 2019 Formulary (List of Covered Drugs) Please read: , Anthem MediBlue Plus (H) 09 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on February, 09. For more recent

More information

<2017> Formulary (List (List of of Covered Drugs)

<2017> Formulary (List (List of of Covered Drugs) < Logo (flush upper left corner /8 x /8 margins)> Anthem Dual Advantage (H SNP) Formulary (List (List of of Covered s) Please read: This document contains information

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

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

More information

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

Anthem MediBlue Plus (HMO) 2019 Formulary (List of Covered Drugs) Please read: , Anthem MediBlue Plus (H) 09 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on March, 09. For more recent

More information

(List of Covered Drugs)

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

More information

<2017> Formulary (List (List of of Covered Drugs)

<2017> Formulary (List (List of of Covered Drugs) < Logo (flush upper left corner /8 x /8 margins)> Anthem Access (Regional PPO) Formulary (List (List of of Covered s) Please read: This document contains information

More information

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

Anthem MediBlue Select (HMO) 2016 Formulary (List of Covered Drugs) Anthem MediBlue Select (H) 06 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on October, 06. For more recent

More information

Amerivantage Dual Coordination (HMO SNP) 2019 Formulary (List of Covered Drugs) Please read: Amerivantage Dual Coordination (HMO SNP)

Amerivantage Dual Coordination (HMO SNP) 2019 Formulary (List of Covered Drugs) Please read: Amerivantage Dual Coordination (HMO SNP) Amerivantage Dual Coordination (H SNP) 09 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on October, 08.

More information

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

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

More information

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

Amerivantage Classic (HMO) 2018 Formulary (List of Covered Drugs) Please read: Amerivantage Classic (HMO) Amerivantage Classic (H) 08 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on November, 07. For more recent

More information

Amerivantage Select (HMO) 2019 Formulary (List of Covered Drugs) Please read: Amerivantage Select (HMO)

Amerivantage Select (HMO) 2019 Formulary (List of Covered Drugs) Please read: Amerivantage Select (HMO) Amerivantage Select (H) 09 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on February, 09. For more recent

More information

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

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

More information

Amerivantage Classic (HMO) 2019 Formulary (List of Covered Drugs) Please read: Amerivantage Classic (HMO)

Amerivantage Classic (HMO) 2019 Formulary (List of Covered Drugs) Please read: Amerivantage Classic (HMO) Amerivantage Classic (H) 09 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on January, 09. For more recent

More information

Amerivantage Classic (HMO) 2019 Formulary (List of Covered Drugs) Please read: Amerivantage Classic (HMO)

Amerivantage Classic (HMO) 2019 Formulary (List of Covered Drugs) Please read: Amerivantage Classic (HMO) Amerivantage Classic (H) 09 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on February, 09. For more recent

More information

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

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

More information

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

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

This formulary was updated on May 1, For more recent information Amerivantage ESRD (H-POS SNP) 08 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on May, 08. For more recent

More information

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

<2017> Formulary (List (List of of Covered Drugs)

<2017> Formulary (List (List of of Covered Drugs) < Logo (flush upper left corner /8 x /8 margins)> BCBSHP Prime Select (H) Formulary (List (List of of Covered s) Please read: This document contains information about

More information

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

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

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

More information

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

2015 Formulary (List of Covered Drugs)

2015 Formulary (List of Covered Drugs) MedStar Medicare Choice (HMO) 2015 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. HPMS Approved Formulary File Submission ID: 00015465,

More information

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

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

More information

Formulary (Drug List) Anthem 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

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

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

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

More information

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

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

More information

2017 Formulary (List of Covered Drugs)

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

More information

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

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

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

More information

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

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

More information

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

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

More information

2018 Formulary (List of Covered Drugs)

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

More information

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

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

More information

BlueShield of Northeastern New York Formulary. List of Covered Drugs

BlueShield of Northeastern New York Formulary. List of Covered Drugs BlueShield of Northeastern New York 018 Formulary List of Covered s PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission ID 00018103,

More information

2016 MEDICARE PART D DRUG FORMULARY

2016 MEDICARE PART D DRUG FORMULARY 2016 MEDICARE PART D DRUG FORMULARY 1199SEIU EmblemHealth VIP Medicare Plan Abridged Medication List This abridged formulary was updated on 11/01/2016. This is not a complete list of drugs covered by our

More information

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

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

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

More information

2018 MEDICARE PART D DRUG FORMULARY

2018 MEDICARE PART D DRUG FORMULARY 2018 MEDICARE PART D DRUG FORMULARY National Drug Plan (PDP) Standard/Enhanced This abridged formulary was updated on 11/1/2018. This is not a complete list of drugs covered by our plan. For a complete

More information

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

Amerivantage Dual Coordination (HMO SNP) 2018 Formulary (List of Covered Drugs) Please read: Amerivantage Dual Coordination (HMO SNP) Amerivantage Dual Coordination (H SNP) 08 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on March, 08. For

More information

2019 HAP Formulary. List of covered drugs, cost tiers and how it all works

2019 HAP Formulary. List of covered drugs, cost tiers and how it all works HAP Empowered Duals (HMO SNP) 209 HAP Formulary List of covered drugs, cost tiers and how it all works PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THESE PLANS. This formulary

More information

2018 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

2015 MEDICARE PART D DRUG FORMULARY

2015 MEDICARE PART D DRUG FORMULARY 2015 MEDICARE PART D DRUG FORMULARY 1199SEIU Medicare Advantage Formulary This formulary was updated on 08/08/2014. For more recent information or other questions, please contact EmblemHealth at 1-877-447-1199

More information

GuildNet Gold. Formulary Medicare Advantage Prescription Drug Plan

GuildNet Gold. Formulary Medicare Advantage Prescription Drug Plan GuildNet Gold Medicare Advantage Prescription Drug Plan Formulary 2018 This formulary was updated on 11/01/2018. For more recent information or other questions, please contact the Plan at 1-800-815-0000

More information

GuildNet Gold. Formulary Medicare Advantage Prescription Drug Plan

GuildNet Gold. Formulary Medicare Advantage Prescription Drug Plan GuildNet Gold Medicare Advantage Prescription Drug Plan Formulary 2018 This formulary was updated on 07/31/2017. For more recent information or other questions, please contact the Plan at 1-800-815-0000

More information

2017 MEDICARE PART D DRUG FORMULARY

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

More information

2018 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

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

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

(List of of Covered Drugs) Drugs)

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

More information

2018 Comprehensive Formulary (List of Covered Drugs) Medicare Advantage Plans

2018 Comprehensive Formulary (List of Covered Drugs) Medicare Advantage Plans 018 Comprehensive Formulary (List of Covered s) Medicare Advantage Plans WellCare/ Ohana Plans in the following state: IL WellCare Choice (HMO-POS), WellCare Plus (HMO) WellCare Rx (HMO) Plans in the following

More information

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

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

More information

FORMULARY (LIST OF COVERED DRUGS)

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

More information

2017 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

2016 COMPREHENSIVE FORMULARY

2016 COMPREHENSIVE FORMULARY 016 COMPREHENSIVE FORMULARY (LIST OF COVERED DRUGS) MEDICARE ADVANTAGE PLANS Please Read: This document contains information about the drugs we cover in this plan. This formulary was updated on 11/01/016.

More information

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

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

More information

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

2017 Comprehensive Formulary (List of Covered Drugs) Medicare Advantage Plans We re in this together: Quality Health Care 017 Comprehensive Formulary (List of Covered s) Medicare Advantage Plans WellCare Health Plans Plans in the following states: GA, SC WellCare Choice (HMO), WellCare

More information

2017 Formulary. (List of Covered Drugs) Medicare GenerationRx (Employer PDP)

2017 Formulary. (List of Covered Drugs) Medicare GenerationRx (Employer PDP) Medicare GenerationRx (Employer PDP) 017 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on 11/01/017.

More information

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

Care Wisconsin 2018 Formulary Addendum

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

More information

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

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

More information

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 WPS MedicareRx Plan (PDP) 019 Formulary List of Covered s 0001953 Version 8 PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on 11/15/018.

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

2018 Comprehensive Formulary (List of Covered Drugs) Medicare Advantage Plans

2018 Comprehensive Formulary (List of Covered Drugs) Medicare Advantage Plans 018 Comprehensive Formulary (List of Covered s) Medicare Advantage Plans WellCare/ Ohana Plans in the following state: IL WellCare Choice (HMO-POS), WellCare Plus (HMO) WellCare Rx (HMO) Plans in the following

More information

2018 MEDICARE PART D DRUG FORMULARY

2018 MEDICARE PART D DRUG FORMULARY 2018 MEDICARE PART D DRUG FORMULARY EmblemHealth HMO 5-Tier Comprehensive Medication List This formulary was updated on 06/01/2018. For more recent information or other questions, please contact EmblemHealth

More information

EmblemHealth Medicare HMO

EmblemHealth Medicare HMO EmblemHealth Medicare HMO 2019 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN 19197v10 This formulary was updated on 03/01/2019.

More information

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

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

More information

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

Pharmacy Benefit Guide

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

More information

2019 Prescription Drug Formulary. Mutual of Omaha CareAdvantage Complete (HMO)

2019 Prescription Drug Formulary. Mutual of Omaha CareAdvantage Complete (HMO) Mutual of Omaha CareAdvantage Complete (HMO) 019 Prescription Formulary This formulary was updated on 0/0/019. For more recent information or other questions, please contact Mutual of Omaha Medicare Advantage

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

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

(List of Covered Drugs)

(List of Covered Drugs) Superior Select Health Plans H-POS SNP 2019 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Formulary ID 19550, Version Number 5

More information

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

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

More information

BlueShield of Northeastern New York Formulary. List of Covered Drugs

BlueShield of Northeastern New York Formulary. List of Covered Drugs BlueShield of Northeastern New York 018 Formulary List of Covered s PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission ID 00018103,

More information

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

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

Express Scripts Medicare (PDP) 2018 Formulary (List of Covered Drugs)

Express Scripts Medicare (PDP) 2018 Formulary (List of Covered Drugs) Choice Plan Express Scripts Medicare (PDP) 2018 Formulary (List of Covered s) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Formulary ID Number: 18155, Version 11

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

2019 FORMULARY PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN

2019 FORMULARY PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN ALOHACARE ADVANTAGE PLUS (HMO SNP) 209 FORMULARY list of covered drugs FORMULARY ID 0009069, VERSION 4 PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary

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

Provider Partners Illinois Advantage Plan (HMO SNP) 2019 Formulary (List of Covered Drugs)

Provider Partners Illinois Advantage Plan (HMO SNP) 2019 Formulary (List of Covered Drugs) Provider Partners Illinois Advantage Plan (H SNP) 2019 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Formulary ID 19547, Version

More information

Provider Partners Health Plan of Ohio (HMO SNP) 2019 Formulary (List of Covered Drugs)

Provider Partners Health Plan of Ohio (HMO SNP) 2019 Formulary (List of Covered Drugs) Provider Partners Health Plan of Ohio (H SNP) 2019 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Formulary ID 19582, Version 5

More information