Comprehensive Preferred Drug List (List of Covered Drugs)

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "Comprehensive Preferred Drug List (List of Covered Drugs)"

Transcription

1 2015 Comprehensive referred Drug List (List of Covered Drugs) WellCare of Georgia Inter-pregnancy Care 00 9 lease read: This document contains information about the drugs we cover in this plan. ara solicitar este documento en español o para escuchar la traducción, llame al Servicio al Cliente al (TTY/TDD: ). lease note that the Georgia Inter-pregnancy Care referred Drug List is updated quarterly. roviders, please visit our website at to view updates to the preferred drug list. Members, please visit our website at to view updates to the preferred drug list. Last updated (4/01/2015)

2 Vaccines: Vaccines are covered under the Vaccines for Children program for members through 18 years of age. Coverage beyond the age of 18 is evaluated through the A process. This plan has a limit of 248 dosage units, unless otherwise specified through a quantity limit. Drug Name reference Details Coverage Details *Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexia nts* *Amphetamines**-*Amphetamine Mixtures*** amphetamine-dextroamphet er oral capsule extended release 24 hour 10, 15, 20, 25, 30, 5 amphetamine-dextroamphetamine oral tablet 10, 12.5, 15, 5, 7.5 amphetamine-dextroamphetamine oral tablet 20 amphetamine-dextroamphetamine oral tablet 30 *Amphetamines**-*Amphetamines*** dextroamphetamine sulfate er oral capsule extended release 24 hour 10, 15, 5 dextroamphetamine sulfate oral tablet 10, 5 VYVANSE ORAL CASULE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG *Stimulants - Misc.**-*Stimulants - Misc.*** dexmethylphenidate hcl oral tablet 10, 2.5, 5 METHYLIN ORAL TABLET CHEWABLE 10 MG, 2.5 MG, 5 MG methylphenidate hcl er oral tablet extendedrelease* 10 QL (62 EA per 31 days); AL (Min 6 Years and Max 20 Years) QL (93 EA per 31 days) QL (62 EA per 31 days) ST; Notes (Must fail preferred Vyvanse or Amphetamine-dextroamphetami ne ER capsules within the past 100 days.); QL (31 EA per 31 days); AL (Min 5 Years and Max 20 Years) QL (31 EA per 31 days); AL (Min 6 Years and Max 20 Years) QL (62 EA per 31 days); AL (Min 6 Years) AL (Min 6 Years) AL (Min 6 Years and Max 20 Years) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 1

3 Drug Name reference Details Coverage Details methylphenidate hcl er oral tablet extendedrelease* 18, 27, 36 methylphenidate hcl er oral tablet extendedrelease* 20 methylphenidate hcl er oral tablet extendedrelease* 54 QL (62 EA per 31 days); AL (Min 6 Years and Max 20 Years) QL (93 EA per 31 days); AL (Min 6 Years and Max 20 Years) QL (31 EA per 31 days); AL (Min 6 Years and Max 20 Years) methylphenidate hcl oral tablet 10, 5 AL (Min 6 Years) methylphenidate hcl oral tablet 20 *Alternative Medicines* *Alternative Medicine - M's**-*Alternative Medicine - Me's*** melatonin maximum strength oral tablet 5 OTC melatonin oral tablet 5 OTC *Aminoglycosides* *Aminoglycosides**-*Aminoglycosides*** BETHKIS INHALATION NEBULIZATION SOLUTION 300 MG/4ML *Analgesics - Anti-Inflammatory* *Anti-Tnf-Alpha - Monoclonal Antibodies**-*Anti-Tnf-Alpha - Monoclonal Antibodies*** HUMIRA EN SUBCUTANEOUS* KIT 40 MG/0.8ML HUMIRA EN-CROHNS STARTER SUBCUTANEOUS* KIT 40 MG/0.8ML HUMIRA SUBCUTANEOUS* 10 MG/0.2ML HUMIRA SUBCUTANEOUS* KIT 20 MG/0.4ML, 40 MG/0.8ML SIMONI SUBCUTANEOUS* 100 MG/ML, 50 MG/0.5ML *Gold Compounds**-*Gold Compounds*** RIDAURA ORAL CASULE 3 MG QL (93 EA per 31 days); AL (Min 6 Years) A A A A A A =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 2

4 Drug Name reference Details Coverage Details *Nonsteroidal Anti-Inflammatory Agents (Nsaids)**-*Cyclooxygenase 2 (Cox-2) Inhibitors*** CELEBREX ORAL CASULE 100 MG, 200 MG, 400 MG, 50 MG celecoxib oral capsule 100, 200, 400, 50 *Nonsteroidal Anti-Inflammatory Agents (Nsaids)**-*Nonsteroidal Anti-Inflammatory Agents (Nsaids)*** diclofenac potassium oral tablet 50 diclofenac sodium er oral tablet extended release 24 hr* 100 diclofenac sodium oral tablet delayed release 25, 50, 75 etodolac oral capsule 200, 300 etodolac oral tablet 400, 500 flurbiprofen oral tablet 100, 50 ibuprofen oral suspension 100 /5ml OTC ibuprofen oral tablet 400, 600, 800 indomethacin oral capsule 25, 50 ketorolac tromethamine oral tablet 10 meloxicam oral tablet 15, 7.5 nabumetone oral tablet 500, 750 ST; Notes (Must fail 2 preferred, generic DL NSAIDs within the past 100 days.); QL (31 EA per 31 days) ST; QL (31 EA per 31 days) Notes (Maximum of a 5 day supply per Rx per month); QL (20 EA per 31 days) naproxen oral suspension 125 /5ml QL (2000 ML per 31 days) naproxen oral tablet 250, 375, 500 naproxen sodium oral tablet 275, 550 oxaprozin oral tablet 600 piroxicam oral capsule 10, 20 sulindac oral tablet 150, 200 tolmetin sodium oral capsule 400 *yrimidine Synthesis Inhibitors**-*yrimidine Synthesis Inhibitors*** leflunomide oral tablet 10, 20 =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 3

5 Drug Name reference Details Coverage Details *Analgesics - Nonnarcotic* *Salicylates**-*Salicylates*** diflunisal oral tablet 500 salsalate oral tablet 500, 750 *Androgens-Anabolic* *Anabolic Steroids**-*Anabolic Steroids*** oxandrolone oral tablet 10, 2.5 A *Androgens**-*Androgens*** danazol oral capsule 100, 200, 50 *Anthelmintics* *Anthelmintics**-*Anthelmintics*** ALBENZA ORAL TABLET 200 MG A BILTRICIDE ORAL TABLET 600 MG A ivermectin oral tablet 3 QL (10 EA per 31 days) IN-X ORAL SUSENSION 50 MG/ML OTC reeses pinworm medicine oral suspension 144 /ml *Antianginal Agents* *Nitrates**-*Nitrates*** isosorbide dinitrate er oral tablet extendedrelease* 40 isosorbide dinitrate oral tablet 10, 20, 30, 5 isosorbide mononitrate er oral tablet extended release 24 hr* 120, 30, 60 isosorbide mononitrate oral tablet 10, 20 NITRO-BID TRANSDERMAL OINTMENT 2 % nitroglycerin transdermal patch 24 hr 0.1 /hr, 0.2 /hr, 0.4 /hr, 0.6 /hr NITROSTAT SUBLINGUAL TABLET SUBLINGUAL 0.3 MG, 0.4 MG, 0.6 MG *Antianxiety Agents* *Antianxiety Agents - Misc.**-*Antianxiety Agents - Misc.*** buspirone hcl oral tablet 10, 15, 30, 5, 7.5 =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 4 OTC

6 Drug Name reference Details Coverage Details meprobamate oral tablet 200, 400 *Benzodiazepines**-*Benzodiazepines*** diazepam oral solution 1 /ml QL (1240 ML per 31 days) *Antiarrhythmics* *Antiarrhythmics Type I-A**-*Antiarrhythmics Type I-A*** disopyramide phosphate oral capsule 100, 150 procainamide hcl injection solution 100 /ml, 500 /ml quinidine gluconate er oral tablet extendedrelease* 324 quinidine gluconate injection solution 80 /ml quinidine sulfate oral tablet 300 *Antiarrhythmics Type I-B**-*Antiarrhythmics Type I-B*** mexiletine hcl oral capsule 150, 200, 250 *Antiarrhythmics Type I-C**-*Antiarrhythmics Type I-C*** flecainide acetate oral tablet 100, 150, 50 propafenone hcl oral tablet 150, 225, 300 *Antiarrhythmics Type Iii**-*Antiarrhythmics Type Iii*** amiodarone hcl intravenous* solution 150 /3ml amiodarone hcl oral tablet 200, 400 ACERONE ORAL TABLET 200 MG, 400 MG *Antiasthmatic And Bronchodilator Agents* *Antiasthmatic - Monoclonal Antibodies**-*Anti-Ige Monoclonal Antibodies*** XOLAIR SUBCUTANEOUS* SOLUTION RECONSTITUTED 150 MG A =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 5

7 Drug Name reference Details Coverage Details *Anti-Inflammatory Agents**-*Anti-Inflammatory Agents*** cromolyn sodium inhalation nebulization solution 20 /2ml *Bronchodilators - Anticholinergics**-*Bronchodilators - Anticholinergics*** ATROVENT HFA INHALATION AEROSOL, SOLUTION 17 MCG/ACT QL (25.8 GM per 31 days) ipratropium bromide inhalation solution 0.02 % QL (480 ML per 31 days) TUDORZA RESSAIR INHALATION AEROSOL OWDER, BREATH ACTIVATED 400 MCG/ACT *Leukotriene Modulators**-*Leukotriene Receptor Antagonists*** montelukast sodium oral packet 4 montelukast sodium oral tablet 10 montelukast sodium oral tablet chewable 4, 5 zafirlukast oral tablet 10, 20 *Steroid Inhalants**-*Steroid Inhalants*** ASMANEX 120 METERED DOSES INHALATION AEROSOL OWDER, BREATH ACTIVATED 220 MCG/INH ASMANEX 30 METERED DOSES INHALATION AEROSOL OWDER, BREATH ACTIVATED 110 MCG/INH, 220 MCG/INH ASMANEX 60 METERED DOSES INHALATION AEROSOL OWDER, BREATH ACTIVATED 220 MCG/INH ASMANEX HFA INHALATION AEROSOL 100 MCG/ACT, 200 MCG/ACT budesonide inhalation suspension 0.25 /2ml, 0.5 /2ml FLOVENT DISKUS INHALATION AEROSOL OWDER, BREATH ACTIVATED 100 MCG/BLIST, 250 MCG/BLIST, 50 MCG/BLIST QL (1 EA per 30 days) AL (Min 1 Months and Max 2 Years) QL (1 EA per 30 days) QL (1 EA per 30 days) QL (1 EA per 30 days) QL (120 ML per 31 days); AL (Max 8 Years) QL (60 EA per 30 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 6

8 Drug Name reference Details Coverage Details FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 220 MCG/ACT FLOVENT HFA INHALATION AEROSOL 44 MCG/ACT ULMICORT INHALATION SUSENSION 1 MG/2ML *Sympathomimetics**-*Adrenergic Combinations*** ADVAIR DISKUS INHALATION AEROSOL OWDER, BREATH ACTIVATED MCG/DOSE, MCG/DOSE, MCG/DOSE ADVAIR HFA INHALATION AEROSOL MCG/ACT, MCG/ACT, MCG/ACT COMBIVENT RESIMAT INHALATION AEROSOL, SOLUTION MCG/ACT DULERA INHALATION AEROSOL MCG/ACT, MCG/ACT ipratropium-albuterol inhalation solution (3) /3ml SYMBICORT INHALATION AEROSOL MCG/ACT, MCG/ACT *Sympathomimetics**-*Beta Adrenergics*** albuterol sulfate inhalation nebulization solution (2.5 /3ml) 0.083% albuterol sulfate inhalation nebulization solution (5 /ml) 0.5% albuterol sulfate inhalation nebulization solution 0.63 /3ml, 1.25 /3ml QL (12 GM per 30 days) QL (10.6 GM per 30 days) QL (120 ML per 31 days); AL (Max 8 Years) QL (60 EA per 30 days) QL (12 GM per 30 days) QL (4 GM per 20 days) QL (13 GM per 30 days) QL (720 ML per 31 days) QL (10.2 GM per 30 days) QL (720 ML per 31 days) QL (300 ML per 31 days) albuterol sulfate oral syrup 2 /5ml QL (2480 ML per 31 days) albuterol sulfate oral tablet 2, 4 FORADIL AEROLIZER INHALATION CASULE 12 MCG metaproterenol sulfate oral syrup 10 /5ml SEREVENT DISKUS INHALATION AEROSOL OWDER, BREATH ACTIVATED 50 MCG/DOSE terbutaline sulfate injection solution 1 /ml QL (60 EA per 30 days) QL (60 EA per 30 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 7

9 Drug Name reference Details Coverage Details terbutaline sulfate oral tablet 2.5, 5 VENTOLIN HFA INHALATION AEROSOL, SOLUTION 108 (90 BASE) MCG/ACT *Xanthines**-*Xanthines*** ELIXOHYLLIN ORAL ELIXIR 80 MG/15ML theophylline er oral tablet extended release 12 hr* 100, 200, 300, 450 theophylline er oral tablet extended release 24 hr* 400, 600 theophylline oral solution 80 /15ml *Anticoagulants* *Coumarin Anticoagulants**-*Coumarin Anticoagulants*** JANTOVEN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG warfarin sodium oral tablet 1, 10, 2, 2.5, 3, 4, 5, 6, 7.5 *Anticonvulsants* *Anticonvulsants - Benzodiazepines**-*Anticonvulsants - Benzodiazepines*** clonazepam oral tablet 0.5, 1, 2 *Anticonvulsants - Misc.**-*Anticonvulsants - Misc.*** QL (36 GM per 31 days) carbamazepine oral suspension 100 /5ml QL (2480 ML per 31 days) carbamazepine oral tablet 200 QL (248 EA per 31 days) carbamazepine oral tablet chewable 100 QL (310 EA per 31 days) EITOL ORAL TABLET 200 MG QL (248 EA per 31 days) gabapentin oral capsule 100 QL (310 EA per 31 days) gabapentin oral capsule 300 QL (372 EA per 31 days) gabapentin oral capsule 400 QL (279 EA per 31 days) gabapentin oral solution 250 /5ml QL (2230 ML per 31 days) gabapentin oral tablet 600, 800 lamotrigine oral tablet 100, 150, 200 =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 8

10 Drug Name reference Details Coverage Details lamotrigine oral tablet 25 QL (310 EA per 31 days) lamotrigine oral tablet chewable 25, 5 QL (310 EA per 31 days) levetiracetam intravenous* solution 500 /5ml levetiracetam oral solution 100 /ml QL (1000 ML per 31 days) levetiracetam oral tablet 1000, 500, 750 levetiracetam oral tablet 250 QL (372 EA per 31 days) oxcarbazepine oral suspension 300 /5ml QL (1240 ML per 31 days) oxcarbazepine oral tablet 150 QL (310 EA per 31 days) oxcarbazepine oral tablet 300 QL (248 EA per 31 days) oxcarbazepine oral tablet 600 primidone oral tablet 250 QL (248 EA per 31 days) primidone oral tablet 50 QL (310 EA per 31 days) topiramate oral capsule sprinkle 15, 25 QL (310 EA per 31 days) topiramate oral tablet 100, 25, 50 QL (310 EA per 31 days) topiramate oral tablet 200 QL (248 EA per 31 days) zonisamide oral capsule 100 QL (186 EA per 31 days) zonisamide oral capsule 25 QL (310 EA per 31 days) zonisamide oral capsule 50 QL (372 EA per 31 days) *Gaba Modulators**-*Gaba Modulators*** GABITRIL ORAL TABLET 12 MG, 16 MG tiagabine hcl oral tablet 2, 4 *Hydantoins**-*Hydantoins*** DILANTIN ORAL CASULE 30 MG QL (310 EA per 31 days) fosphenytoin sodium injection solution 100 pe/2ml EGANONE ORAL TABLET 250 MG QL (372 EA per 31 days) phenytoin oral suspension 125 /5ml QL (930 ML per 31 days) phenytoin oral tablet chewable 50 QL (372 EA per 31 days) phenytoin sodium extended oral capsule 100, 200, 300 phenytoin sodium injection solution 50 /ml *Succinimides**-*Succinimides*** ethosuximide oral capsule 250 ethosuximide oral solution 250 /5ml QL (930 ML per 31 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 9

11 Drug Name reference Details Coverage Details *Valproic Acid**-*Valproic Acid*** divalproex sodium er oral tablet extended release 24 hr* 250 divalproex sodium er oral tablet extended release 24 hr* 500 QL (310 EA per 31 days) QL (279 EA per 31 days) divalproex sodium oral capsule sprinkle 125 QL (310 EA per 31 days) divalproex sodium oral tablet delayed release 125, 250 divalproex sodium oral tablet delayed release 500 QL (310 EA per 31 days) QL (279 EA per 31 days) valproic acid oral capsule 250 QL (310 EA per 31 days) valproic acid oral solution 250 /5ml QL (2790 ML per 31 days) valproic acid oral syrup 250 /5ml QL (2790 ML per 31 days) *Antidepressants* *Alpha-2 Receptor Antagonists (Tetracyclics)**-*Alpha-2 Receptor Antagonists (Tetracyclics)*** mirtazapine oral tablet 15, 30, 45, 7.5 mirtazapine oral tablet dispersible 15, 30, 45 *Antidepressants - Misc.**-*Antidepressants - Misc.*** bupropion hcl er (sr) oral tablet extended release 12 hr* 100, 150, 200 bupropion hcl er (xl) oral tablet extended release 24 hr* 150, 300 bupropion hcl oral tablet 100, 75 maprotiline hcl oral tablet 25, 50, 75 *Monoamine Oxidase Inhibitors (Maois)**-*Monoamine Oxidase Inhibitors (Maois)*** phenelzine sulfate oral tablet 15 tranylcypromine sulfate oral tablet 10 =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 10

12 Drug Name reference Details Coverage Details *Selective Serotonin Reuptake Inhibitors (Ssris)**-*Selective Serotonin Reuptake Inhibitors (Ssris)*** citalopram hydrobromide oral tablet 10, 20, 40 escitalopram oxalate oral tablet 10, 20, 5 fluoxetine hcl oral capsule 10, 20, 40 fluoxetine hcl oral solution 20 /5ml fluoxetine hcl oral tablet 10, 20 fluvoxamine maleate oral tablet 100, 25, 50 paroxetine hcl oral tablet 10, 20, 30, 40 sertraline hcl oral tablet 100, 25, 50 *Serotonin Modulators**-*Serotonin Modulators*** nefazodone hcl oral tablet 100, 150, 200, 250, 50 trazodone hcl oral tablet 100, 150, 50 *Serotonin-Norepinephrine Reuptake Inhibitors (Snris)**-*Serotonin-Norepinephrine Reuptake Inhibitors (Snris)*** venlafaxine hcl er oral capsule extended release 24 hour 150, 37.5, 75 venlafaxine hcl oral tablet 100, 25, 37.5, 50, 75 *Tricyclic Agents**-*Tricyclic Agents*** amitriptyline hcl oral tablet 10, 100, 150, 25, 50, 75 amoxapine oral tablet 100, 150, 25, 50 clomipramine hcl oral capsule 25, 50, 75 desipramine hcl oral tablet 10, 100, 150, 25, 50, 75 doxepin hcl oral capsule 10, 100, 25, 50, 75 doxepin hcl oral concentrate 10 /ml QL (31 EA per 31 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 11

13 Drug Name reference Details Coverage Details imipramine hcl oral tablet 10, 25, 50 nortriptyline hcl oral capsule 10, 25, 50, 75 nortriptyline hcl oral solution 10 /5ml QL (2325 ML per 31 days) protriptyline hcl oral tablet 10, 5 *Antidiabetics* *Alpha-Glucosidase Inhibitors**-*Alpha-Glucosidase Inhibitors*** acarbose oral tablet 100, 25, 50 *Antidiabetic Combinations**-*Dipeptidyl eptidase-4 Inhibitor-Biguanide Combinations*** JANUMET ORAL TABLET MG, MG JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HR* MG, MG, MG JENTADUETO ORAL TABLET MG, MG, MG *Antidiabetic Combinations**-*Sodium-Glucose Co-Transporter 2 Inhibitor-Biguanide Comb*** INVOKAMET ORAL TABLET MG, MG, MG, MG *Antidiabetic Combinations**-*Sulfonylurea-Biguanide Combinations*** glipizide-metformin hcl oral tablet , , glyburide-metformin oral tablet , , *Antidiabetic Combinations**-*Sulfonylurea-Thiazolidinedion e Combinations*** AVANDARYL ORAL TABLET 4-1 MG, 4-2 MG, 8-4 MG ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days.) ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days.) ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days.); QL (31 EA per 31 days) ST ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days.) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 12

14 Drug Name reference Details Coverage Details *Antidiabetic Combinations**-*Thiazolidinedione-Biguanide Combinations*** AVANDAMET ORAL TABLET MG, MG pioglitazone hcl-metformin hcl oral tablet , *Biguanides**-*Biguanides*** metformin hcl er (osm) oral tablet extended release 24 hr* 500 metformin hcl er oral tablet extended release 24 hr* 500, 750 metformin hcl oral tablet 1000, 500, 850 ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days.) ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days.) RIOMET ORAL SOLUTION 500 MG/5ML QL (900 ML per 31 days) *Diabetic Other**-*Diabetic Other*** GLUCAGEN HYOKIT INJECTION SOLUTION RECONSTITUTED 1 MG GLUCAGEN INJECTION SOLUTION RECONSTITUTED 1 MG GLUCAGON EMERGENCY INJECTION KIT 1 MG *Dipeptidyl eptidase-4 (Dpp-4) Inhibitors**-*Dipeptidyl eptidase-4 (Dpp-4) Inhibitors*** JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG TRADJENTA ORAL TABLET 5 MG *Incretin Mimetic Agents (Glp-1 Receptor Agonists)**-*Incretin Mimetic Agents (Glp-1 Receptor Agonists)*** BYDUREON SUBCUTANEOUS* 2 MG QL (2 EA per 31 days) QL (2 EA per 31 days) QL (2 EA per 31 days) ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days.) ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days.); QL (31 EA per 31 Days) ST; Notes (Must fail preferred Metformin, Metformin ER, Riomet); QL (4 EA per 28 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 13

15 Drug Name reference Details Coverage Details BYDUREON SUBCUTANEOUS* SUSENSION RECONSTITUTED 2 MG *Insulin Sensitizing Agents**-*Thiazolidinediones*** AVANDIA ORAL TABLET 2 MG, 4 MG, 8 MG pioglitazone hcl oral tablet 15, 30, 45 *Insulin**-*Human Insulin*** AIDRA INJECTION SOLUTION 100 UNIT/ML AIDRA SOLOSTAR SUBCUTANEOUS* 100 UNIT/ML HUMALOG KWIKEN SUBCUTANEOUS* 100 UNIT/ML HUMALOG MIX 50/50 SUBCUTANEOUS* SUSENSION (50-50) 100 UNIT/ML HUMALOG MIX 75/25 KWIKEN SUBCUTANEOUS* (75-25) 100 UNIT/ML HUMALOG MIX 75/25 SUBCUTANEOUS* SUSENSION (75-25) 100 UNIT/ML HUMALOG SUBCUTANEOUS* SOLUTION 100 UNIT/ML HUMULIN 70/30 SUBCUTANEOUS* SUSENSION (70-30) 100 UNIT/ML HUMULIN N KWIKEN SUBCUTANEOUS* 100 UNIT/ML HUMULIN N SUBCUTANEOUS* SUSENSION 100 UNIT/ML HUMULIN R INJECTION SOLUTION 100 UNIT/ML HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS* SOLUTION 500 UNIT/ML LANTUS SOLOSTAR SUBCUTANEOUS* 100 UNIT/ML ST; Notes (Must fail preferred Metformin, Metformin ER, Riomet); QL (4 EA per 28 days) ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days.) ST; Notes (Must fail preferred metformin, metformin er, or riomet within the past 100 days.) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) OTC; QL (60 ML per 31 days) QL (60 ML per 31 days) OTC; QL (60 ML per 31 days) OTC; QL (60 ML per 31 days) QL (60 ML per 31 days) QL (60 ML per 31 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 14

16 Drug Name reference Details Coverage Details LANTUS SUBCUTANEOUS* SOLUTION 100 UNIT/ML *Sodium-Glucose Co-Transporter 2 (Sglt2) Inhibitors**-*Sodium-Glucose Co-Transporter 2 (Sglt2) Inhibitors*** INVOKANA ORAL TABLET 100 MG, 300 MG JARDIANCE ORAL TABLET 10 MG, 25 MG *Sulfonylureas**-*Sulfonylureas*** chlorpropamide oral tablet 100, 250 glimepiride oral tablet 1, 2, 4 glipizide er oral tablet extended release 24 hr* 10, 2.5, 5 glipizide oral tablet 10, 5 GLIIZIDE XL ORAL TABLET EXTENDED RELEASE 24 HR* 10 MG, 2.5 MG, 5 MG glyburide micronized oral tablet 1.5, 3, 6 glyburide oral tablet 1.25, 2.5, 5 *Antifungals* *Antifungals**-*Antifungals*** griseofulvin microsize oral suspension 125 /5ml griseofulvin microsize oral tablet 500 griseofulvin ultramicrosize oral tablet 125, 250 nystatin oral tablet unit terbinafine hcl oral tablet 250 *Imidazole-Related Antifungals**-*Imidazoles*** ketoconazole oral tablet 200 *Imidazole-Related Antifungals**-*Triazoles*** fluconazole oral suspension reconstituted 10 /ml, 40 /ml QL (60 ML per 31 days) ST ST QL (450 ML per 31 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 15

17 Drug Name reference Details Coverage Details fluconazole oral tablet 100, 150, 200, 50 *Antihyperlipidemics* *Bile Acid Sequestrants**-*Bile Acid Sequestrants*** cholestyramine light oral packet 4 gm cholestyramine light oral powder 4 gm/dose cholestyramine oral packet 4 gm cholestyramine oral powder 4 gm/dose *Fibric Acid Derivatives**-*Fibric Acid Derivatives*** fenofibrate micronized oral capsule 134, 200, 67 fenofibrate oral tablet 160, 54 gemfibrozil oral tablet 600 *H Coa Reductase Inhibitors**-*H Coa Reductase Inhibitors*** atorvastatin calcium oral tablet 10, 20, 40, 80 lovastatin oral tablet 10, 20, 40 pravastatin sodium oral tablet 10, 20, 40, 80 simvastatin oral tablet 10, 20, 40, 5, 80 *Intestinal Cholesterol Absorption Inhibitors**-*Intestinal Cholesterol Absorption Inhibitors*** ZETIA ORAL TABLET 10 MG A *Nicotinic Acid Derivatives**-*Nicotinic Acid Derivatives*** NIACOR ORAL TABLET 500 MG *Antihypertensives* *Ace Inhibitors**-*Ace Inhibitors*** benazepril hcl oral tablet 10, 20, 40, 5 captopril oral tablet 100, 12.5, 25, 50 =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 16

18 Drug Name reference Details Coverage Details enalapril maleate oral tablet 10, 2.5, 20, 5 fosinopril sodium oral tablet 10, 20, 40 lisinopril oral tablet 10, 2.5, 20, 30, 40, 5 quinapril hcl oral tablet 10, 20, 40, 5 ramipril oral capsule 1.25, 10, 2.5, 5 *Angiotensin Ii Receptor Antagonists**-*Angiotensin Ii Receptor Antagonists*** losartan potassium oral tablet 100, 25, 50 *Antiadrenergic Antihypertensives**-*Antiadrenergics - Centrally Acting*** clonidine hcl oral tablet 0.1, 0.2, 0.3 guanfacine hcl oral tablet 1, 2 methyldopa oral tablet 250, 500 *Antihypertensive Combinations**-*Ace Inhibitors & Thiazide/Thiazide-Like*** benazepril-hydrochlorothiazide oral tablet , , 20-25, captopril-hydrochlorothiazide oral tablet 25-15, 25-25, 50-15, enalapril-hydrochlorothiazide oral tablet 10-25, lisinopril-hydrochlorothiazide oral tablet , , *Antihypertensive Combinations**-*Angiotensin Ii Receptor Antag & Thiazide/Thiazide-Like*** losartan potassium-hctz oral tablet , , QL (31 EA per 31 days) QL (31 EA per 31 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 17

19 Drug Name reference Details Coverage Details *Antihypertensive Combinations**-*Beta Blocker & Diuretic Combinations*** atenolol-chlorthalidone oral tablet , bisoprolol-hydrochlorothiazide oral tablet , , propranolol-hctz oral tablet 40-25, *Vasodilators**-*Vasodilators*** hydralazine hcl injection solution 20 /ml hydralazine hcl oral tablet 10, 100, 25, 50 minoxidil oral tablet 10, 2.5 *Anti-Infective Agents - Misc.* *Anti-Infective Agents - Misc.**-*Anti-Infective Agents - Misc.*** metronidazole oral tablet 250, 500 trimethoprim oral tablet 100 *Anti-Infective Misc. - Combinations**-*Anti-Infective Misc. - Combinations*** sulfamethoxazole-tmp ds oral tablet sulfamethoxazole-trimethoprim oral suspension /5ml sulfamethoxazole-trimethoprim oral tablet *Antiprotozoal Agents**-*Antiprotozoal Agents*** atovaquone oral suspension 750 /5ml *Leprostatics**-*Leprostatics*** dapsone oral tablet 100, 25 *Lincosamides**-*Lincosamides*** clindamycin hcl oral capsule 150, 300, 75 clindamycin palmitate hcl oral solution reconstituted 75 /5ml clindamycin phosphate injection solution 300 /2ml, 600 /4ml, 9 gm/60ml, 900 /6ml QL (1200 ML per 31 days) QL (2400 ML per 31 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 18

20 Drug Name reference Details Coverage Details clindamycin phosphate intravenous* solution 300 /2ml *Antimalarials* *Antimalarial Combinations**-*Antimalarial Combinations*** atovaquone-proguanil hcl oral tablet *Antimalarials**-*Antimalarials*** DARARIM ORAL TABLET 25 MG hydroxychloroquine sulfate oral tablet 200 mefloquine hcl oral tablet 250 primaquine phosphate oral tablet 26.3 *Antimyasthenic/Cholinergic Agents* *Antimyasthenic/Cholinergic Agents**-*Antimyasthenic/Cholinergic Agents*** MESTINON ORAL SYRU 60 MG/5ML MESTINON ORAL TABLET EXTENDEDRELEASE* 180 MG pyridostigmine bromide oral tablet 60 *Antimycobacterial Agents* *Antimycobacterial Agents**-*Antimycobacterial Agents*** ethambutol hcl oral tablet 100, 400 isoniazid injection solution 100 /ml isoniazid oral tablet 100, 300 pyrazinamide oral tablet 500 rifabutin oral capsule 150 rifampin intravenous* solution reconstituted 600 rifampin oral capsule 150, 300 *Antiparkinson Agents* *Antiparkinson Anticholinergics**-*Antiparkinson Anticholinergics*** benztropine mesylate oral tablet 0.5, 1, 2 trihexyphenidyl hcl oral elixir 0.4 /ml =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 19

21 Drug Name reference Details Coverage Details trihexyphenidyl hcl oral tablet 2, 5 *Antiparkinson Dopaminergics**-*Antiparkinson Dopaminergics*** amantadine hcl oral capsule 100 amantadine hcl oral syrup 50 /5ml amantadine hcl oral tablet 100 bromocriptine mesylate oral capsule 5 bromocriptine mesylate oral tablet 2.5 *Antiparkinson Dopaminergics**-*Levodopa Combinations*** carbidopa-levodopa er oral tablet extendedrelease* , carbidopa-levodopa oral tablet , , *Antiparkinson Dopaminergics**-*Nonergoline Dopamine Receptor Agonists*** pramipexole dihydrochloride oral tablet 0.125, 0.25, 0.5, 0.75, 1, 1.5 ropinirole hcl oral tablet 0.25, 0.5, 1, 2, 3, 4, 5 *Antiparkinson Monoamine Oxidase Inhibitors**-*Antiparkinson Monoamine Oxidase Inhibitors*** selegiline hcl oral capsule 5 selegiline hcl oral tablet 5 *Antipsychotics/Antimanic Agents* *Antimanic Agents**-*Antimanic Agents*** lithium carbonate er oral tablet extendedrelease* 300, 450 lithium carbonate oral capsule 150, 300, 600 lithium carbonate oral tablet 300 lithium oral solution 8 meq/5ml ST; Notes (Must fail preferred ropinirole within the past 100 days.) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 20

22 Drug Name reference Details Coverage Details *Benzisoxazoles**-*Benzisoxazoles*** INVEGA SUSTENNA INTRAMUSCULAR* SUSENSION 117 MG/0.75ML INVEGA SUSTENNA INTRAMUSCULAR* SUSENSION 156 MG/ML INVEGA SUSTENNA INTRAMUSCULAR* SUSENSION 234 MG/1.5ML INVEGA SUSTENNA INTRAMUSCULAR* SUSENSION 39 MG/0.25ML INVEGA SUSTENNA INTRAMUSCULAR* SUSENSION 78 MG/0.5ML RISERIDONE M-TAB ORAL TABLET DISERSIBLE 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG risperidone oral solution 1 /ml risperidone oral tablet 0.25, 0.5, 1, 2, 3, 4 risperidone oral tablet dispersible 0.25, 0.5, 1, 2, 3, 4 *Butyrophenones**-*Butyrophenones*** haloperidol decanoate intramuscular* solution 100 /ml, 50 /ml A; QL (0.75 ML per 28 days); AL (Min 18 Years) A; QL (1 ML per 28 days); AL (Min 18 Years) A; QL (1.5 ML per 28 days); AL (Min 18 Years) A; QL (0.25 ML per 28 days); AL (Min 18 Years) A; QL (0.5 ML per 28 days); AL (Min 18 Years) QL (62 EA per 31 days); AL (Min 5 Years) QL (496 ML per 31 days); AL (Min 5 Years) QL (62 EA per 31 days); AL (Min 5 Years) QL (62 EA per 31 days); AL (Min 5 Years) AL (Min 18 Years) haloperidol lactate injection solution 5 /ml AL (Min 3 Years) haloperidol lactate oral concentrate 2 /ml AL (Min 3 Years) haloperidol oral tablet 0.5, 1, 10, 2, 5 *Dibenzapines**-*Dibenzodiazepines*** clozapine oral tablet 100, 200, 25, 50 clozapine oral tablet dispersible 12.5 AL (Min 3 Years) AL (Min 18 Years) QL (31 EA per 31 days); AL (Min 18 Years) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 21

23 Drug Name reference Details Coverage Details *Dibenzapines**-*Dibenzo-Oxepino yrroles*** SAHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG, 5 MG *Dibenzapines**-*Dibenzothiazepines*** quetiapine fumarate oral tablet 100, 200, 25, 300, 400, 50 *Dibenzapines**-*Dibenzoxazepines*** loxapine succinate oral capsule 10, 25, 5, 50 *Dibenzapines**-*Thienbenzodiazepines*** olanzapine oral tablet 10, 15, 2.5, 20, 5, 7.5 *henothiazines**-*henothiazines*** chlorpromazine hcl oral tablet 10, 100, 200, 25, 50 fluphenazine decanoate injection solution 25 /ml fluphenazine hcl oral concentrate 5 /ml fluphenazine hcl oral elixir 2.5 /5ml fluphenazine hcl oral tablet 1, 10, 2.5, 5 perphenazine oral tablet 16, 2, 4, 8 prochlorperazine maleate oral tablet 10, 5 ST; Notes (Must fail preferred quetiapine, olanzapine, or risperidone within the past 100 days.); AL (Min 18 Years) AL (Min 10 Years) AL (Min 18 Years) QL (31 EA per 31 days); AL (Min 13 Years) AL (Min 6 Months) AL (Min 12 Years) QL (248 ML per 31 days); AL (Min 18 Years) QL (2480 ML per 31 days); AL (Min 18 Years) AL (Min 18 Years and Max 999 Years) AL (Min 12 Years) AL (Min 2 Years) prochlorperazine suppository 25 AL (Min 2 Years) thioridazine hcl oral tablet 10, 100, 25, 50 trifluoperazine hcl oral tablet 1, 10, 2, 5 AL (Min 2 Years) AL (Min 6 Years) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 22

24 Drug Name reference Details Coverage Details *Quinolinone Derivatives**-*Quinolinone Derivatives*** ABILIFY MAINTENA INTRAMUSCULAR* SUSENSION RECONSTITUTED 300 MG, 400 MG ABILIFY ORAL SOLUTION 1 MG/ML ABILIFY ORAL TABLET 10 MG, 15 MG, 2 MG, 20 MG, 30 MG, 5 MG *Thioxanthenes**-*Thioxanthenes*** thiothixene oral capsule 1, 10, 2, 5 *Antivirals* *Hepatitis Agents**-*Hepatitis B Agents*** entecavir oral tablet 0.5, 1 A *Herpes Agents**-*Herpes Agents - urine Analogues*** acyclovir oral capsule 200 A ST; Notes (Must fail 2 preferreds of the following: quetiapine, olanzapine, risperidone within the past 100 days.) ST; Notes (Must fail 2 preferreds of the following: quetiapine, olanzapine, risperidone within the past 100 days.) AL (Min 12 Years) acyclovir oral suspension 200 /5ml QL (3500 ML per 31 days) acyclovir oral tablet 400, 800 valacyclovir hcl oral tablet 1 gm, 500 QL (62 EA per 31 days) *Influenza Agents**-*Influenza Agents*** rimantadine hcl oral tablet 100 *Influenza Agents**-*Neuraminidase Inhibitors*** RELENZA DISKHALER INHALATION AEROSOL OWDER, BREATH ACTIVATED 5 MG/BLISTER QL (40 EA per 365 days); AL (Min 7 Years) TAMIFLU ORAL CASULE 30 MG QL (40 EA per 365 days) TAMIFLU ORAL CASULE 45 MG, 75 MG QL (20 EA per 365 days) TAMIFLU ORAL SUSENSION RECONSTITUTED 6 MG/ML QL (360 ML per 365 days); AL (Max 18 Years) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 23

25 Drug Name reference Details Coverage Details *Assorted Classes* *Immunosuppressive Agents**-*Cyclosporine Analogs*** cyclosporine modified oral capsule 100, 25, 50 cyclosporine modified oral solution 100 /ml cyclosporine oral capsule 100, 25 GENGRAF ORAL CASULE 100 MG, 25 MG GENGRAF ORAL SOLUTION 100 MG/ML SANDIMMUNE ORAL SOLUTION 100 MG/ML *Immunosuppressive Agents**-*Inosine Monophosphate Dehydrogenase Inhibitors*** mycophenolate mofetil oral capsule 250 mycophenolate mofetil oral suspension reconstituted 200 /ml mycophenolate mofetil oral tablet 500 *Immunosuppressive Agents**-*Macrolide Immunosuppressants*** HECORIA ORAL CASULE 0.5 MG, 1 MG, 5 MG tacrolimus oral capsule 0.5, 1, 5 *Immunosuppressive Agents**-*urine Analogs*** azathioprine oral tablet 50 *Beta Blockers* *Alpha-Beta Blockers**-*Alpha-Beta Blockers*** carvedilol oral tablet 12.5, 25, 3.125, 6.25 labetalol hcl intravenous* solution 5 /ml labetalol hcl oral tablet 100, 200, 300 *Beta Blockers Cardio-Selective**-*Beta Blockers Cardio-Selective*** atenolol oral tablet 100, 25, 50 bisoprolol fumarate oral tablet 10, 5 =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 24

26 Drug Name reference Details Coverage Details metoprolol succinate er oral tablet extended release 24 hr* 100, 200, 25, 50 metoprolol tartrate intravenous* solution 1 /ml metoprolol tartrate oral tablet 100, 25, 50 *Beta Blockers Non-Selective**-*Beta Blockers Non-Selective*** nadolol oral tablet 20, 40, 80 pindolol oral tablet 10, 5 propranolol hcl er oral capsule extended release 24 hour 120, 160, 60, 80 propranolol hcl intravenous* solution 1 /ml propranolol hcl oral tablet 10, 20, 40, 60, 80 SORINE ORAL TABLET 120 MG, 160 MG, 240 MG, 80 MG sotalol hcl (af) oral tablet 120, 160, 80 sotalol hcl oral tablet 120, 160, 240, 80 timolol maleate oral tablet 10, 20, 5 *Calcium Channel Blockers* *Calcium Channel Blockers**-*Calcium Channel Blockers*** amlodipine besylate oral tablet 10, 2.5, 5 CARTIA XT ORAL CASULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG diltiazem hcl er beads oral capsule extended release 24 hour 120, 180, 240, 300, 360, 420 diltiazem hcl er coated beads oral capsule extended release 24 hour 120, 180, 240, 300, 360 diltiazem hcl er oral capsule extended release 12 hour 120, 60, 90 =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 25

27 Drug Name reference Details Coverage Details diltiazem hcl intravenous* solution 125 /25ml, 25 /5ml, 50 /10ml diltiazem hcl oral tablet 120, 30, 60, 90 dilt-xr oral capsule extended release 24 hour 120, 180, 240 MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HR* 180 MG, 240 MG, 300 MG, 360 MG, 420 MG NIFEDIAC CC ORAL TABLET EXTENDED RELEASE 24 HR* 30 MG, 60 MG NIFEDICAL XL ORAL TABLET EXTENDED RELEASE 24 HR* 30 MG, 60 MG nifedipine er oral tablet extended release 24 hr* 90 nifedipine er osmotic oral tablet extended release 24 hr* 30, 60, 90 nifedipine oral capsule 10 verapamil hcl er oral capsule extended release 24 hour 100, 120, 180, 200, 240, 300, 360 verapamil hcl er oral tablet extendedrelease* 120, 180, 240 verapamil hcl oral tablet 120, 40, 80 *Cardiotonics* *Cardiac Glycosides**-*Cardiac Glycosides*** digoxin injection solution 0.25 /ml digoxin oral solution 0.05 /ml digoxin oral tablet 0.125, 250 mcg *Cardiovascular Agents - Misc.* *eripheral Vasodilators**-*eripheral Vasodilators*** no flush niacin oral tablet 500 OTC =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 26

28 Drug Name reference Details Coverage Details *ulmonary Hypertension - Endothelin Receptor Antagonists**-*ulmonary Hypertension - Endothelin Receptor Antagonists*** LETAIRIS ORAL TABLET 10 MG, 5 MG A *ulmonary Hypertension - hosphodiesterase Inhibitors**-*ulmonary Hypertension - hosphodiesterase Inhibitors*** sildenafil citrate oral tablet 20 A *Cephalosporins* *Cephalosporins - 1St Generation**-*Cephalosporins - 1St Generation*** cefadroxil oral capsule 500 cefadroxil oral suspension reconstituted 250 /5ml, 500 /5ml cefadroxil oral tablet 1 gm cephalexin oral capsule 250, 500, 750 cephalexin oral suspension reconstituted 125 /5ml cephalexin oral suspension reconstituted 250 /5ml *Cephalosporins - 2Nd Generation**-*Cephalosporins - 2Nd Generation*** cefaclor oral capsule 250, 500 cefprozil oral suspension reconstituted 125 /5ml, 250 /5ml cefprozil oral tablet 250, 500 cefuroxime axetil oral suspension reconstituted 125 /5ml cefuroxime axetil oral tablet 250, 500 *Cephalosporins - 3Rd Generation**-*Cephalosporins - 3Rd Generation*** cefdinir oral capsule 300 cefdinir oral suspension reconstituted 125 /5ml, 250 /5ml QL (300 ML per 31 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 27

29 Drug Name reference Details Coverage Details cefpodoxime proxetil oral suspension reconstituted 100 /5ml, 50 /5ml cefpodoxime proxetil oral tablet 100, 200 *Contraceptives* *Combination Contraceptives - Oral**-*Biphasic Contraceptives - Oral*** KARIVA ORAL TABLET /0.01 MG (21/5) *Combination Contraceptives - Oral**-*Combination Contraceptives - Oral*** ALTAVERA ORAL TABLET MG-MCG ARI ORAL TABLET MG-MCG AVIANE ORAL TABLET MG-MCG BALZIVA ORAL TABLET MG-MCG briellyn oral tablet mcg CRYSELLE-28 ORAL TABLET MG-MCG EMOQUETTE ORAL TABLET MG-MCG ESTARYLLA ORAL TABLET MG-MCG GIANVI ORAL TABLET MG JUNEL 1.5/30 ORAL TABLET MG-MCG JUNEL 1/20 ORAL TABLET 1-20 MG-MCG JUNEL FE 1.5/30 ORAL TABLET MG-MCG JUNEL FE 1/20 ORAL TABLET 1-20 MG-MCG KELNOR 1/35 ORAL TABLET 1-35 MG-MCG LESSINA ORAL TABLET MG-MCG LEVORA 0.15/30 (28) ORAL TABLET MG-MCG LORYNA ORAL TABLET MG LOW-OGESTREL ORAL TABLET MG-MCG =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 28

30 Drug Name reference Details Coverage Details LUTERA ORAL TABLET MG-MCG MICROGESTIN 1.5/30 ORAL TABLET MG-MCG MICROGESTIN 1/20 ORAL TABLET 1-20 MG-MCG MICROGESTIN FE 1.5/30 ORAL TABLET MG-MCG MICROGESTIN FE 1/20 ORAL TABLET 1-20 MG-MCG MONONESSA ORAL TABLET MG-MCG NECON 0.5/35 (28) ORAL TABLET MG-MCG NECON 1/35 (28) ORAL TABLET 1-35 MG-MCG NORTREL 0.5/35 (28) ORAL TABLET MG-MCG NORTREL 1/35 (21) ORAL TABLET 1-35 MG-MCG NORTREL 1/35 (28) ORAL TABLET 1-35 MG-MCG OCELLA ORAL TABLET MG ORTIA-28 ORAL TABLET MG-MCG REVIFEM ORAL TABLET MG-MCG RECLISEN ORAL TABLET MG-MCG SOLIA ORAL TABLET MG-MCG SRINTEC 28 ORAL TABLET MG-MCG SRONYX ORAL TABLET MG-MCG SYEDA ORAL TABLET MG VESTURA ORAL TABLET MG ZARAH ORAL TABLET MG ZENCHENT FE ORAL TABLET CHEWABLE MG-MCG =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 29

31 Drug Name reference Details Coverage Details ZOVIA 1/35E (28) ORAL TABLET 1-35 MG-MCG *Combination Contraceptives - Oral**-*Extended-Cycle Contraceptives - Oral*** QUASENSE ORAL TABLET MG QL (91 EA per 91 days) *Combination Contraceptives - Oral**-*Triphasic Contraceptives - Oral*** CAZIANT ORAL TABLET 0.1/0.125/ MG ENRESSE-28 ORAL TABLET NECON 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG NORTREL 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG TRI-ESTARYLLA ORAL TABLET 0.18/0.215/0.25 MG-35 MCG TRINESSA (28) ORAL TABLET 0.18/0.215/0.25 MG-35 MCG TRI-REVIFEM ORAL TABLET 0.18/0.215/0.25 MG-35 MCG TRI-SRINTEC ORAL TABLET 0.18/0.215/0.25 MG-35 MCG TRIVORA (28) ORAL TABLET VELIVET ORAL TABLET 0.1/0.125/ MG *Combination Contraceptives - Vaginal**-*Combination Contraceptives - Vaginal*** NUVARING VAGINAL RING MG/24HR *Emergency Contraceptives**-*Emergency Contraceptives*** levonorgestrel oral tablet 0.75 QL (4 EA per 31 days) NEXT CHOICE ONE DOSE ORAL TABLET 1.5 MG LAN B ONE-STE ORAL TABLET 1.5 MG OTC OTC =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 30

32 Drug Name reference Details Coverage Details *rogestin Contraceptives - Injectable**-*rogestin Contraceptives - Injectable*** medroxyprogesterone acetate intramuscular* suspension 150 /ml *rogestin Contraceptives - Oral**-*rogestin Contraceptives - Oral*** CAMILA ORAL TABLET 0.35 MG ERRIN ORAL TABLET 0.35 MG JOLIVETTE ORAL TABLET 0.35 MG NORA-BE ORAL TABLET 0.35 MG *Corticosteroids* *Glucocorticosteroids**-*Glucocorticosteroids* ** hydrocortisone oral tablet 10, 20, 5 prednisone oral solution 5 /5ml prednisone oral tablet 1, 10, 2.5, 20, 5 *Mineralocorticoids**-*Mineralocorticoids*** fludrocortisone acetate oral tablet 0.1 *Dermatologicals* *Acne roducts**-*acne Combinations*** benzoyl peroxide-erythromycin external 5-3 % *Acne roducts**-*acne roducts*** LAVOCLEN-4 CREAMY WASH EXTERNAL LIQUID 4 % LAVOCLEN-8 CREAMY WASH EXTERNAL LIQUID 8 % *Antibiotics - Topical**-*Antibiotics - Topical*** bacitracin zinc external ointment 500 unit/gm OTC *Antifungals - Topical**-*Antifungals - Topical*** ciclopirox external solution 8 % ciclopirox olamine external cream 0.77 % nystatin external cream unit/gm nystatin external ointment unit/gm QL (1 ML per 93 days) =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 31

33 Drug Name reference Details Coverage Details nystatin external powder unit/gm terbinafine hcl external cream 1 % OTC *Antifungals - Topical**-*Imidazole-Related Antifungals - Topical*** baza antifungal external cream 2 % OTC clotrimazole external cream 1 % OTC clotrimazole external solution 1 % OTC econazole nitrate external cream 1 % ketoconazole external cream 2 % ketoconazole external shampoo 2 % *Anti-Inflammatory Agents - Topical**-*Anti-Inflammatory Agents - Topical*** VOLTAREN TRANSDERMAL 1 % QL (300 GM per 31 days) *Antivirals - Topical**-*Antivirals - Topical*** DENAVIR EXTERNAL CREAM 1 % ZOVIRAX EXTERNAL CREAM 5 % *Emollient/Keratolytic Agents**-*Emollient/Keratolytic Agents*** REMEVEN EXTERNAL CREAM 50 % X-VIATE EXTERNAL CREAM 40 % *Rosacea Agents**-*Rosacea Agents*** metronidazole external 1 % metronidazole external cream 0.75 % *Scabicides & ediculicides**-*scabicides & ediculicides*** malathion external lotion 0.5 % ST; Notes (Must fail preferred oral acyclovir or valacyclovir within the past 100 days.) ST; Notes (Must fail preferred oral acyclovir or valacyclovir within the past 100 days.) QL (118 ML per 31 days); AL (Min 6 Years) spinosad external suspension 0.9 % AL (Min 4 Years) *Diagnostic roducts* *Diagnostic Drugs**-*Diagnostic Drugs*** dipyridamole intravenous* solution 5 /ml =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 32

34 Drug Name reference Details Coverage Details *Diagnostic Tests**-*Diagnostic Tests*** ACCU-CHEK ACTIVE IN VITRO STRI ACCU-CHEK AVIVA LUS IN VITRO STRI ACCU-CHEK COMFORT CURVE IN VITRO STRI ACCU-CHEK COMACT TEST DRUM IN VITRO STRI ACCU-CHEK SMARTVIEW IN VITRO STRI Notes (QL: 200/31 DS for Members 21 years old and younger; QL: 100/31 DS for Members over 21 years old); OTC Notes (QL: 200/31 DS for Members 21 years old and younger; QL: 100/31 DS for Members over 21 years old); OTC Notes (QL: 200/31 DS for Members 21 years old and younger; QL: 100/31 DS for Members over 21 years old); OTC Notes (QL: 204/31 DS for Members 21 years old and younger; QL: 102/31 DS for Members over 21 years old); OTC Notes (QL: 200/31 DS for Members 21 years old and younger; QL: 100/31 DS for Members over 21 years old); OTC CLINISTIX IN VITRO STRI OTC; QL (100 EA per 31 days) DIASTIX IN VITRO STRI OTC; QL (100 EA per 31 days) FREESTYLE INSULINX TEST IN VITRO STRI FREESTYLE LITE TEST IN VITRO STRI Notes (QL: 200/31 DS for Members 21 years old and younger; QL: 100/31 DS for Members over 21 years old); OTC Notes (QL: 200/31 DS for Members 21 years old and younger; QL: 100/31 DS for Members over 21 years old); OTC =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 33

35 Drug Name reference Details Coverage Details FREESTYLE TEST IN VITRO STRI Notes (QL: 200/31 DS for Members 21 years old and younger; QL: 100/31 DS for Members over 21 years old); OTC KETOSTIX IN VITRO STRI OTC; QL (100 EA per 31 days) RECISION XTRA BLOOD GLUCOSE IN VITRO STRI RECISION XTRA KETONE IN VITRO STRI *Digestive Aids* *Digestive Enzymes**-*Digestive Enzymes*** CREON ORAL CASULE DELAYED RELEASE ARTICLES UNIT, UNIT, UNIT, UNIT, 6000 UNIT ERTZYE ORAL CASULE DELAYED RELEASE ARTICLES UNIT, 8000 UNIT *Diuretics* *Carbonic Anhydrase Inhibitors**-*Carbonic Anhydrase Inhibitors*** acetazolamide oral tablet 125, 250 methazolamide oral tablet 25, 50 *Diuretic Combinations**-*Diuretic Combinations*** amiloride-hydrochlorothiazide oral tablet 5-50 spironolactone-hctz oral tablet triamterene-hctz oral capsule triamterene-hctz oral tablet , *Loop Diuretics**-*Loop Diuretics*** bumetanide injection solution 0.25 /ml bumetanide oral tablet 0.5, 1, 2 furosemide oral solution 10 /ml, 8 /ml Notes (QL: 200/31 DS for Members 21 years old and younger; QL: 100/31 DS for Members over 21 years old); OTC =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ 34 OTC

36 Drug Name reference Details Coverage Details furosemide oral tablet 20, 40, 80 torsemide oral tablet 10, 100, 20, 5 *otassium Sparing Diuretics**-*otassium Sparing Diuretics*** spironolactone oral tablet 100, 25, 50 *Thiazides And Thiazide-Like Diuretics**-*Thiazides And Thiazide-Like Diuretics*** chlorothiazide oral tablet 250, 500 chlorthalidone oral tablet 25, 50 hydrochlorothiazide oral capsule 12.5 hydrochlorothiazide oral tablet 12.5, 25, 50 indapamide oral tablet 1.25, 2.5 metolazone oral tablet 10, 2.5, 5 *Endocrine And Metabolic Agents - Misc.* *Bone Density Regulators**-*Bisphosphonates*** alendronate sodium oral tablet 10, 35, 40, 5, 70 *Bone Density Regulators**-*Calcitonins*** calcitonin (salmon) nasal solution 200 unit/act FORTICAL NASAL SOLUTION 200 UNIT/ACT *Metabolic Modifiers**-*Gaa Deficiency Treatment - Agents*** LUMIZYME INTRAVENOUS* SOLUTION RECONSTITUTED 50 MG *Metabolic Modifiers**-*Hyperparathyroid Treatment - Vitamin D Analogs*** calcitriol oral capsule 0.25 mcg, 0.5 mcg calcitriol oral solution 1 mcg/ml *osterior ituitary Hormones**-*Vasopressin*** desmopressin ace spray refrig nasal solution 0.01 % desmopressin acetate oral tablet 0.1, 0.2 =referred, Dagger=N/A, Asterisk(*)=N/A, A=rior Authorization, ST=Step Therapy, QL=Quantity Limit, AL=Age Limit, Notes=Notes, OTC=OTC-Covered w/rx, UERCASE= Brand name drugs/ A 35

New Jersey Medicaid Comprehensive Preferred Drug List (List of Covered Drugs)

New Jersey Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 2015 New Jersey Medicaid Comprehensive referred Drug List (List of Covered Drugs) WellCare of New Jersey 00 lease read: This document contains information about the drugs we cover in this plan. lease note

More information

Georgia Medicaid Comprehensive Preferred Drug List (List of Covered Drugs)

Georgia Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 2015 Georgia Medicaid Comprehensive referred Drug List (List of Covered Drugs) WellCare of Georgia, Inc. 00 9 lease read: This document contains information about the drugs we cover in this plan. ara solicitar

More information

Harmony Medicaid Comprehensive Preferred Drug List (List of Covered Drugs)

Harmony Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 00 9 2015 Harmony Medicaid Comprehensive referred Drug List (List of Covered Drugs) Harmony Health lan lease read: This document contains information about the drugs we cover in this plan. lease note that

More information

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

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

Harmony Medicaid Comprehensive Preferred Drug List (List of Covered Drugs)

Harmony Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 2015 Harmony Medicaid Comprehensive referred Drug List (List of Covered Drugs) Harmony Health lan 00 9 lease read: This document contains information about the drugs we cover in this plan. lease note that

More information

Georgia Medicaid Comprehensive Preferred Drug List (List of Covered Drugs)

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

More information

South Carolina Medicaid Comprehensive Preferred Drug List (List of Covered Drugs)

South Carolina Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 2018 South Carolina Medicaid Comprehensive referred Drug List (List of Covered Drugs) WellCare of South Carolina 00 lease read: This document contains information about the drugs we cover in this plan.

More information

Harmony Medicaid Comprehensive Preferred Drug List (List of Covered Drugs)

Harmony Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 2017 Harmony Medicaid Comprehensive referred Drug List (List of Covered Drugs) Harmony Health lan lease read: This document contains information about the drugs we cover in this plan. lease note that the

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

New York Medicaid Comprehensive Preferred Drug List (List of Covered Drugs)

New York Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 2018 New York Medicaid Comprehensive referred Drug List (List of Covered Drugs) WellCare Health lans, Inc. 00 lease read: This document has information about drugs we cover in this plan. lease note that

More information

2018 Harmony Medicaid Comprehensive Preferred Drug List (List of Covered Drugs)

2018 Harmony Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 2018 Harmony Medicaid Comprehensive referred Drug List (List of Covered Drugs) Harmony Health lan lease read: This document contains information about the drugs we cover in this plan. lease note that the

More information

Harmony Medicaid Comprehensive Preferred Drug List (List of Covered Drugs)

Harmony Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 2018 Harmony Medicaid Comprehensive referred Drug List (List of Covered Drugs) Harmony Health lan lease read: This document contains information about the drugs we cover in this plan. lease note that the

More information

Georgia Families Comprehensive Preferred Drug List (List of Covered Drugs)

Georgia Families Comprehensive Preferred Drug List (List of Covered Drugs) 2018 Georgia Families Comprehensive referred Drug List (List of Covered Drugs) WellCare of Georgia, Inc. 00 9 lease read: This document tells about the drugs we cover in this plan. If you speak a different

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

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

2018 Georgia Families Comprehensive Preferred Drug List (List of Covered Drugs)

2018 Georgia Families Comprehensive Preferred Drug List (List of Covered Drugs) 2018 Georgia Families Comprehensive referred Drug List (List of Covered Drugs) WellCare of Georgia, Inc. lease read: This document tells about the drugs we cover in this plan. If you speak a different

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

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

2018 Ohana Medicaid Comprehensive Preferred Drug List (QUEST Integration) (List of Covered Drugs)

2018 Ohana Medicaid Comprehensive Preferred Drug List (QUEST Integration) (List of Covered Drugs) 2018 Ohana Medicaid Comprehensive referred Drug List (QUEST Integration) (List of Covered Drugs) Ohana Health lan 00 lease read this document. It has details about the drugs we cover for the Ohana QUEST

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

Signature Advantage (HMO SNP) 2018 Comprehensive Formulary. List of Covered Drugs

Signature Advantage (HMO SNP) 2018 Comprehensive Formulary. List of Covered Drugs Signature Advantage (HMO SNP) 208 Comprehensive Formulary List of Covered Drugs PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission

More information

2018 FORMULARY (List of Covered Drugs)

2018 FORMULARY (List of Covered Drugs) InterCommunity Health Network CCO 2018 FORMULARY (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on 11/01/2017.

More information

2017 Drug List for Commercial Health Plans

2017 Drug List for Commercial Health Plans 2017 Drug List for Commercial Health Plans Use this drug list also known as a formulary to learn about the prescription drugs we cover in all commercial health plans. Commercial health plans are a type

More information

PREFERRED DRUG LIST 2018

PREFERRED DRUG LIST 2018 PREFERRED DRUG LIST 2018 PDL National Formulary Preferred Drug List - May 2018 - The Preferred Drug List is a guide identifying preferred brandname medicines within select therapeutic categories. The Preferred

More information

Qualified Health Plans 2018 Drug Formulary for HMOs and PPOs

Qualified Health Plans 2018 Drug Formulary for HMOs and PPOs Qualified Health Plans 2018 Drug Formulary for HMOs and PPOs THIS DOCUMENT HAS INFORMATION ABOUT THE PRESCRIPTION DRUGS WE COVER FOR QUALIFIED HEALTH PLANS. Qualified Health Plans (QHP) are Affordable

More information

PHP Centennial Care Formulary/Preferred Drug Listing

PHP Centennial Care Formulary/Preferred Drug Listing PHP Centennial Care Formulary/Preferred Drug Listing The Centennial Care Preferred Drug List is subject to change. Presbyterian Centennial Care This list is in order by therapeutic class. To find a specific

More information

2018 Presbyterian Individual and Family Metal Plans/Employer Group Metal Plans Formulary Therapeutic Class Listing

2018 Presbyterian Individual and Family Metal Plans/Employer Group Metal Plans Formulary Therapeutic Class Listing Presbyterian Health Plan, Inc. Presbyterian Insurance Company, Inc. 018 Presbyterian Individual and Family Metal Plans/Employer Group Metal Plans Formulary Therapeutic Class Listing This list in order

More information

COMMERCIAL FORMULARY Effective April 2018

COMMERCIAL FORMULARY Effective April 2018 COMMERCIAL FORMULARY Effective April 2018 Provided by EnvisionRx Introduction The Total Health Care (THC) Commercial Formulary was developed to serve as a guide for physicians, pharmacists, health care

More information

COMMERCIAL FORMULARY Effective November 2017

COMMERCIAL FORMULARY Effective November 2017 COMMERCIAL FORMULARY Effective November 2017 Provided by EnvisionRx Introduction The Total Health Care (THC) Commercial Formulary was developed to serve as a guide for physicians, pharmacists, health care

More information

3-TIER FORMULARY Effective November 2017

3-TIER FORMULARY Effective November 2017 3-TIER FORMULARY Effective November 2017 Provided by EnvisionRx Introduction The Total Health Care (THC) 3-Tier Formulary was developed to serve as a guide for physicians, pharmacists, health care professionals

More information

MEDICAID FORMULARY Effective November 2017

MEDICAID FORMULARY Effective November 2017 MEDICAID FORMULARY Effective November 2017 Provided by EnvisionRx Introduction The Total Health Care (THC) Medicaid Formulary was developed to serve as a guide for physicians, pharmacists, health care

More information

Effective: August 1, 2015 Non-QHP Commercial and TPA Plans 5 Tier Formulary (List of Covered Drugs)

Effective: August 1, 2015 Non-QHP Commercial and TPA Plans 5 Tier Formulary (List of Covered Drugs) Effective: August 1, 2015 Non-QHP Commercial and TPA Plans 5 Tier Formulary (List of Covered Drugs) What is the Drug List? Also called a formulary by doctors and pharmacists, the Drug List is an extensive

More information

2015 Comprehensive Formulary (List of Covered Drugs)

2015 Comprehensive Formulary (List of Covered Drugs) 2015 Comprehensive Formulary (List of Covered Drugs) Medicare Advantage Plans Please Read: This document contains information about some of the drugs we cover in this plan. This formulary was updated on

More information

PHP Centennial Care Formulary/Preferred Drug Listing

PHP Centennial Care Formulary/Preferred Drug Listing PHP Centennial Care Formulary/Preferred Drug Listing The Centennial Care Preferred Drug List is subject to change. Presbyterian Centennial Care This list is in alphabetical order. To find a specific drug,

More information

AETNA BETTER HEALTH Formulary Guide Aetna Better Health Pennsylvania Formulary Guide April 2018

AETNA BETTER HEALTH Formulary Guide Aetna Better Health Pennsylvania Formulary Guide April 2018 AETNA BETTER HEALTH Formulary Guide 2018 Aetna Better Health Pennsylvania Formulary Guide April 2018 AETNA BETTER HEALTH Formulary Guide 2018 What is the Aetna Better Health in Pennsylvania Formulary?

More information

4-TIER HIGH DEDUCTIBLE HEALTH PLAN FORMULARY Effective May 2018

4-TIER HIGH DEDUCTIBLE HEALTH PLAN FORMULARY Effective May 2018 4-TIER HIGH DEDUCTIBLE HEALTH PLAN FORMULARY Effective May 2018 Provided by EnvisionRx Introduction The Total Health Care (THC) 4-Tier High Deductible Health Plan Formulary was developed to serve as a

More information

COMPREHENSIVE FORMULARY

COMPREHENSIVE FORMULARY 08 COMPREHENSIVE FORMULARY CARE N CARE CHOICE PREMIUM (PPO) CARE N CARE CHOICE PLUS (PPO) CARE N CARE CHOICE (PPO) CARE N CARE CLASSIC (HMO) (LIST OF COVERED DRUGS) PLEASE READ: THIS DOCUMENT CONTAINS

More information

Aetna Better Health Virginia. Table of Contents

Aetna Better Health Virginia. Table of Contents Aetna Better Health Virginia Table of Contents *ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS*...4 *ALTERNATIVE MEDICINES*...6 *AMINOGLYCOSIDES*... 6 *ANALGESICS - ANTI-INFLAMMATORY*...7 *ANALGESICS -

More information

AETNA BETTER HEALTH Formulary Guide Aetna Better Health Of Virginia Formulary Guide March 2018

AETNA BETTER HEALTH Formulary Guide Aetna Better Health Of Virginia Formulary Guide March 2018 AETNA BETTER HEALTH Formulary Guide Aetna Better Health Of Virginia Formulary Guide March 2018 http://www.aetnabetterhealth.com/virginia AETNA BETTER HEALTH Formulary Guide What is the Aetna Better Health

More information

AETNA BETTER HEALTH Formulary Guide Aetna Better Health of Kentucky Formulary Guide March 2018

AETNA BETTER HEALTH Formulary Guide Aetna Better Health of Kentucky Formulary Guide March 2018 AETNA BETTER HEALTH Formulary Guide Aetna Better Health of Kentucky Formulary Guide March 2018 http://www.aetnabetterhealth.com/kentucky AETNA BETTER HEALTH Formulary Guide What is the Aetna Better Health

More information

2017 Presbyterian Individual and Family Metal Plans/Employer Group Metal Plans Formulary Therapeutic Class Listing

2017 Presbyterian Individual and Family Metal Plans/Employer Group Metal Plans Formulary Therapeutic Class Listing Presbyterian Health Plan, Inc. Presbyterian Insurance Company, Inc. 207 Presbyterian Individual and Family Metal Plans/Employer Group Metal Plans Formulary Therapeutic Class Listing This list in order

More information

Aetna Better Health of Louisiana

Aetna Better Health of Louisiana AETNA BETTER HEALTH Formulary Guide Aetna Better Health of Louisiana Formulary Guide January 2018 www.aetnabetterhealth.com/louisiana 1 AETNA BETTER HEALTH Formulary Guide What is the Aetna Better Health

More information

AETNA BETTER HEALTH Formulary Guide. Aetna Better Health of Michigan Formulary Guide December 2017

AETNA BETTER HEALTH Formulary Guide. Aetna Better Health of Michigan Formulary Guide December 2017 AETNA BETTER HEALTH Formulary Guide Aetna Better Health of Michigan Formulary Guide December 2017 AETNA BETTER HEALTH Formulary Guide http://www.aetnabetterhealth.com/michigan What is the Aetna Better

More information

QUALIFIED HEALTH PLAN FORMULARY Effective January 2018

QUALIFIED HEALTH PLAN FORMULARY Effective January 2018 QUALIFIED HEALTH PLAN FORMULARY Effective January 2018 Provided by EnvisionRx Introduction The Total Health Care (THC) Qualified Health Plan Formulary was developed to serve as a guide for physicians,

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

AETNA BETTER HEALTH Formulary Guide. Aetna Better Health of Michigan Formulary Guide February 2017

AETNA BETTER HEALTH Formulary Guide. Aetna Better Health of Michigan Formulary Guide February 2017 AETNA BETTER HEALTH Formulary Guide Aetna Better Health of Michigan Formulary Guide February 2017 AETNA BETTER HEALTH Formulary Guide http://www.aetnabetterhealth.com/michigan What is the Aetna Better

More information

EnvisionRxPlus Formulary. (List of Covered Drugs)

EnvisionRxPlus Formulary. (List of Covered Drugs) EnvisionRxPlus 018 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission 18365, Version Number

More information

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

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

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/ Ohana Plans in the following states: AR, CT, FL, IL, KY, LA, NJ, NY, TX, TN

More information

2016 Aetna Pharmacy Drug Guide Four Tier Open Aetna Premier Plus Plan

2016 Aetna Pharmacy Drug Guide Four Tier Open Aetna Premier Plus Plan Quality health plans & benefits Healthier living Financial well-being Intelligent solutions 2016 Aetna Pharmacy Drug Guide Four Tier Open Aetna Premier Plus Plan www.aetna.com 2016 Aetna Inc. 05.05.341.1

More information

Comprehensive Formulary

Comprehensive Formulary Comprehensive Formulary 2016 List of covered drugs Updated December 1, 2016 Live Healthy! Choose HEALTH CHOICE HealthChoiceEssential.com 2016 Comprehensive Formulary Introduction Health Choice Insurance

More information

Medi-Cal Formulary. Foreword. How do I use the Care1st Medi-Cal Formulary? What if my drug is not on the Care1st Medi-Cal Formulary?

Medi-Cal Formulary. Foreword. How do I use the Care1st Medi-Cal Formulary? What if my drug is not on the Care1st Medi-Cal Formulary? Medi-Cal Formulary Foreword The Care1st Medi-Cal Formulary is a list of covered and preferred drug agents for Care1st Medi-Cal members. The drug list includes drugs used to treat common diseases or health

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

Medi-Cal Formulary. Foreword. How do I use the Care1st Medi-Cal Formulary? What if my drug is not on the Care1st Medi-Cal Formulary?

Medi-Cal Formulary. Foreword. How do I use the Care1st Medi-Cal Formulary? What if my drug is not on the Care1st Medi-Cal Formulary? Medi-Cal Formulary Foreword The Care1st Medi-Cal Formulary is a list of covered and preferred drug agents for Care1st Medi-Cal members. The drug list includes drugs used to treat common diseases or health

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

2016 Provider Directory. Drug Formulary

2016 Provider Directory. Drug Formulary 2016 Provider Directory Drug Formulary lowercase italics= Generic drugs UPPERCASE BOLD= Brand name drugs Drug Tier Notes Antihistamine Drugs Ethanolamine Derivatives clemastine oral tablet diphenhydramine

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

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

Quarterly pharmacy formulary change notice

Quarterly pharmacy formulary change notice Provider Bulletin December 2017 Quarterly pharmacy formulary notice The formulary s listed in the table below apply to all Anthem HealthKeepers Plus members. These s were reviewed and approved at the third

More information

Care Wisconsin 2017 Formulary Addendum

Care Wisconsin 2017 Formulary Addendum - Non-Formulary, PA - Prior Authorization, HR High Risk Medication, QL Quantity Limit per 30 days, EFFECTIVE 01/01/ ABILIFY MAINT INJ 400 1/26 + ST2 Formulary Enhancement N/A ABILIFY MAINT SUSP 300 1/26

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

Formulary. Medi-Cal. Healthy Kids. and

Formulary. Medi-Cal. Healthy Kids. and ormulary Medi-Cal and Healthy Kids 2015 IEHP Medi-Cal 2015 ormulary Table of Contents ADHD/Anti-Narcolepsy/Anti-Obesity/Anorexiants... 3 Aminoglycosides... 4 Analgesics - Anti-Inflammatory... 4 Analgesics

More information

healthpartners.com/pharmacy.

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

More information

2018 Formulary. (List of Covered Drugs)

2018 Formulary. (List of Covered Drugs) 2018 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. HPMS Approved Formulary File Submission ID: 18390 Version #: 7 This formulary

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

2017 Formulary for North Dakota Medicaid Expansion Members

2017 Formulary for North Dakota Medicaid Expansion Members 07 Formulary for North Dakota Medicaid Expansion Members Please refer to the following list (formulary) of commonly prescribed medications that are covered by insurance. This is not a complete list; to

More information

AETNA BETTER HEALTH OF NEW JERSEY Formulary

AETNA BETTER HEALTH OF NEW JERSEY Formulary AETNA BETTER HEALTH OF NEW JERSEY Formulary 4-01-2017 NJ-14-05-38 FORMULARY What is the Aetna Better Health of New Jersey Formulary? This is a drug list created by Aetna Better Health of New Jersey ( plan

More information

Preferred Drug List. Select Health PerformRx Pharmacy Services Phone Fax

Preferred Drug List. Select Health PerformRx Pharmacy Services Phone Fax Preferred Drug List Select Health PerformRx Pharmacy Services Phone 1.866.610.2773 Fax 1.866.610.2775 Member Services Phone 1.888.276.2020 Providers may request the addition or deletion of a medication

More information

Blue Cross of Idaho s Multi-Tier Prescription Drug Formulary for Qualified Health Plans

Blue Cross of Idaho s Multi-Tier Prescription Drug Formulary for Qualified Health Plans Blue Cross of Idaho s Multi-Tier Prescription Drug Formulary for Qualified Health Plans This document is a searchable PDF. On your keyboard press Ctrl+F (Command+F for Mac) and a search field will open.

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

Medi-Cal Formulary 2016

Medi-Cal Formulary 2016 Medi-Cal ormulary 2016 IEHP Medi-Cal 2016 ormulary Table of Contents Analgesics... 2 Anesthetics... 3 Antiarthritics... 3 Antiasthmatics... 4 Antibiotics... 6 Anticoagulants... 10 Antifungals... 10 Antihistamine

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

ANALGESICS ANALGESICS

ANALGESICS ANALGESICS 2018 2 Tier Standard Member Formulary Formulary ID: 18396 Effective Date: 1/1/2018 Last Updated: 12/20/2017 Name of Drug ANALGESICS ANALGESICS acetaminophen-codeine oral solution 120-12 /5 ml (5 ml), 120-12

More information

Blue Cross of Idaho s Standard Six-Tier Prescription Drug Formulary

Blue Cross of Idaho s Standard Six-Tier Prescription Drug Formulary Blue Cross of Idaho s Standard Six-Tier Prescription Drug Formulary This document is a searchable PDF. On your keyboard press Ctrl+F (Command+F for Mac) and a search field will open. Type in the name of

More information

2017 Aetna Pharmacy Drug Guide Four Tier Open Aetna Premier Plus Plan

2017 Aetna Pharmacy Drug Guide Four Tier Open Aetna Premier Plus Plan Quality health plans & benefits Healthier living Financial well-being Intelligent solutions 2017 Aetna Pharmacy Drug Guide Four Tier Open Aetna Premier Plus Plan www.aetna.com 2017 Aetna Inc. 05.05.341.1

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

ANALGESICS ANALGESICS

ANALGESICS ANALGESICS 08 5 Tier Standard Member Formulary Formulary ID: 890 Effective Date: //08 Updated: 0/08 Drug Name Drug Tier Requirements/Limits ANALGESICS ANALGESICS acetaminophen-codeine oral solution 0 - /5 ml (5 ml),

More information

List of preferred medications Member formulary

List of preferred medications Member formulary List of preferred medications 08 Member formulary What is the GHP Family Formulary? A formulary is a list of drugs selected by GHP Family, which represents medications believed to be a necessary part of

More information

Alphabetical Listing. PA = Prior Authorization QL = Quantity Limits Per Prescription Days Supply ST = Step Therapy

Alphabetical Listing. PA = Prior Authorization QL = Quantity Limits Per Prescription Days Supply ST = Step Therapy 899/17 A abacavir oral tablet 300 mg abacavir-lamivudine oral tablet 600-300 mg abacavir-lamivudine-zidovudine oral tablet 300-150-300 mg ABREVA TOPICAL CREAM 10 % acarbose oral tablet 100 mg, 25 mg,

More information

AETNA BETTER HEALTH OF NEW JERSEY Formulary

AETNA BETTER HEALTH OF NEW JERSEY Formulary AETNA BETTER HEALTH OF NEW JERSEY Formulary 2-01-2018 NJ-14-05-38 FORMULARY What is the Aetna Better Health of New Jersey Formulary? This is a drug list created by Aetna Better Health of New Jersey ( plan

More information

Formulary Medi-Cal 2018

Formulary Medi-Cal 2018 ormulary Medi-Cal 2018 IEHP Medi-Cal 2018 ormulary Table of Contents Analgesics... 2 Anesthetics... 3 Antiarthritics... 3 Antiasthmatics... 4 Antibiotics... 5 Anticoagulants... 9 Antifungals... 10 Antihistamine

More information

UUHP Exchange Formulary

UUHP Exchange Formulary UUHP Exchange Formulary Table of Contents Analgesic, Anti-Inflammatory Or Antipyretic... Anesthetics...7 Anorectal Preparations...7 Antidotes And Other Reversal Agents... 7 Anti-Infective Agents... 8 Antineoplastics...

More information

ANALGESICS - TREATMENT OF PAIN ANALGESICS

ANALGESICS - TREATMENT OF PAIN ANALGESICS 08 5 Tier Standard- Member Formulary Formulary ID: 890 Updated: 0/08 Effective Date: 0-0-08 ANALGESICS - TREATMENT OF PAIN ANALGESICS acetaminophen-codeine oral solution 0 - /5 ml (5 ml), 0- /5 ml, 00-0

More information

ANALGESICS - TREATMENT OF PAIN ANALGESICS

ANALGESICS - TREATMENT OF PAIN ANALGESICS 018 5 Tier Standard- Keystone First VIP Choice Document: 018 Formulary Formulary ID: 18390 Updated: 03/018 Effective Date: 04-01-018 Drug Name Drug Tier Requirements/Limits ANALGESICS - TREATMENT OF PAIN

More information

ANALGESICS - TREATMENT OF PAIN ANALGESICS

ANALGESICS - TREATMENT OF PAIN ANALGESICS 2018 First Choice VIP Care Plus Formulary Document: 2018 Formulary Formulary ID: 18395 Last Updated: 03/2018 Effective Date: 04-01-2018 Name of Drug ANALGESICS - TREATMENT OF PAIN ANALGESICS 8 HOUR ER

More information

Your Guide to Prescription Drug Benefits

Your Guide to Prescription Drug Benefits Your Guide to Prescription Drug Benefits 2018 ESSENTIAL FORMULARY GUIDE FOR INDIVIDUAL AND SMALL GROUP* PLANS *Does not apply to the following Small Group plans. For these plans, please refer to the 2018

More information

Prescription Drug Formulary and Network Pharmacies

Prescription Drug Formulary and Network Pharmacies 205 Prescription Formulary and Network Pharmacies H5826_MA_254_205_v_02_FormularyPharmacytier Accepted Offered by Community HealthFirst MA Special Needs Plan (HMO SNP) 205 Prescription Formulary (List

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

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 9

More information

Formulary Medi-Cal 2017

Formulary Medi-Cal 2017 ormulary Medi-Cal 2017 IEHP Medi-Cal 2017 ormulary Table of Contents Analgesics... 3 Anesthetics... 4 Antiarthritics... 4 Antiasthmatics... 5 Antibiotics... 6 Anticoagulants... 11 Antifungals... 11 Antihistamine

More information

2017 Aetna Pharmacy Drug Guide Five Tier Open Aetna Value Plus Plan

2017 Aetna Pharmacy Drug Guide Five Tier Open Aetna Value Plus Plan Quality health plans & benefits Healthier living Financial well-being Intelligent solutions 2017 Aetna Pharmacy Drug Guide Five Tier Open Aetna Value Plus Plan www.aetna.com 2017 Aetna Inc. 05.05.354.1

More information

IEHP Medi-Cal LISTA DE MEDICAMENTOS CUBIERTOS DE Tabla de Contenido

IEHP Medi-Cal LISTA DE MEDICAMENTOS CUBIERTOS DE Tabla de Contenido 2016 IEHP Medi-Cal LISTA DE MEDICAMENTOS CUBIERTOS DE 2016 Tabla de Contenido Analgésicos... 3 Anestésicos... 4 Antiartríticos... 5 Antiasmáticos... 5 Antibióticos... 7 Anticoagulantes... 11 Antifúngicos...

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

List of preferred medications Member formulary

List of preferred medications Member formulary List of preferred medications 08 Member formulary What is the GHP Family Formulary? A formulary is a list of drugs selected by GHP Family, which represents medications believed to be a necessary part of

More information

Express Scripts Medicare (PDP) 2016 Formulary (List of Covered Drugs)

Express Scripts Medicare (PDP) 2016 Formulary (List of Covered Drugs) Express Scripts Medicare (PDP) 206 Formulary (List of Covered s) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT SOME OF THE DRUGS COVERED BY THIS PLAN Formulary ID Number: 6034, v6 This formulary

More information

Prescription Drug Formulary

Prescription Drug Formulary Prescription Drug 016 This formulary was updated on 03//016. For more recent information or other questions, please contact Essence Healthcare, Inc. Customer Service at (866) 597-9560 or, for TTY users,

More information

AgeWell 1-Tier 2017 Formulary Addendum

AgeWell 1-Tier 2017 Formulary Addendum FORMULARY CHANGES EFFECTIVE 01/01/ ABILIFY MAINT INJ 400MG ADRUCIL INJ 500/10ML NF 1 + BvD Formulary Enhancement N/A AMMONIUM LAC CRE 12% BUPROPION TAB 150MG BUTAL/APAP TAB 50-325MG CAZIANT PAK CHOLESTYRAMINE

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