3 Tier Formulary (List of Covered Drugs)

Size: px
Start display at page:

Download "3 Tier Formulary (List of Covered Drugs)"

Transcription

1 Effective: August 1, 2016 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 and pharmacists, the Drug List is an extensive list of safe and effective, FDA-approved, brand name and generic prescription drugs used to treat the most common medical conditions. The Health First Pharmacy and Therapeutics Committee (P&T), a panel of physicians and pharmacists, developed our Drug List and updates it regularly. The list includes quality drugs available to you at reasonable cost. Only those medications that have successfully passed federally required clinical testing and evaluation and have been proven effective are included. The P&T Committee reviews and evaluates all available literature about a drug when updating the list. About Tiers Most covered prescription drugs will be categorized into one of three tiers. The cost of drugs varies widely, even though several different medications may be used to treat the same condition. What you pay for the prescription depends upon what tier the drug is listed in. Health First Health Plans and Insurance (The Plan) offers many benefit plans that can vary in coverage for each tier. Details about your specific benefit for each tier are included in The Plan s Summary of Benefits. Prescriptions that exceed a 30 day supply will default to a 90 day supply copay (this does not apply to coinsurances). For coinsurances, you will always pay a percentage of the total cost after the applicable deductible is met. Tier 1 Generic Drugs Tier 2 Preferred Brand Name Drugs and some generics Tier 3 Non-Preferred Brand Name Drugs and some generics Tier 3 Specialty Drugs (Must obtain from Health First Family Pharmacy and limited to a 30-day supply.) For members who reside outside the state of Florida, an exception will be considered to allow the medication to be filled at another pharmacy. Please contact Customer Service Department to initiate this process. No Cost Share Generic drugs are prescription drugs that are identified by their chemical name. When the patent has expired on a brand name drug, the FDA permits new manufacturers to create an equivalent of the brand name drug and make it available to the public. Generally, more than one manufacturer will create generic versions, although often the same pharmaceutical firm that produces the brand name drug also makes the generic version. This prompts competitive pricing of the generic version and usually results in a less expensive drug Commercial 3 Tier Formulary Version 4 Page 1

2 What will my expenses be? Every plan is different, and your financial obligation will vary based on your specific plan. You are responsible for any cost sharing your plan requires. What is a deductible? A deductible is a set dollar amount that you must pay each calendar year before your health plan starts paying. If your plan includes an integrated pharmacy deductible, it will accumulate with your in-network medical deductible. Refer to your plan documents to see when your deductible starts over for your plan. What is the difference between a copayment and coinsurance? Copayments and coinsurance are types of member cost sharing, and they represent the portion of covered prescription expenses members must pay. A copayment is a flat dollar amount while coinsurance is a percentage of the total allowable charges. What does out-of-pocket maximum mean? The out-of-pocket maximum protects you from catastrophic medical and prescription drug expenses by limiting how much you have to pay during the benefit year. Your cost sharing for covered prescription drugs (deductible, coinsurance and copayment) all accumulate with your in-network medical out-of-pocket maximum. Refer to your plan documents to see when your out-of-pocket maximum starts over for your plan and to verify the specific cost sharing you have for specific tiers. The Drug List is subject to change In order to continue to offer a safe and cost effective selection of prescription drugs, The Plan periodically makes changes to the Drug List. These changes may include removing medications, adding restrictions, and/or covering a drug at a higher tier. Updated formularies are posted to the website as changes are made. The following list represents some of the most common scenarios in which changes to drug coverage will occur: Throughout the year, new medications are approved by the FDA. It is the policy of The Plan that new drugs will be excluded for 6 months from the date of FDA approval, during which time the Health First P&T Committee can review the drug for safety and efficacy. When a medication is withdrawn from the market due to safety reasons or if it becomes available over-the-counter (OTC). At the time that a medication on the HFP Drug List becomes available OTC, it may be excluded from coverage from that point forward. When a brand-name prescription drug loses its patent and the equivalent generic form is added to the Drug List, the brand-name drug may be moved to Tier 3 or removed from the formulary. This formulary is current as of August 1, To get updated information about covered drugs, please visit our Web site at myhfhp.org or call Customer Service toll-free at (TTY/TDD relay: ) Monday through Friday from 8 a.m. to 6 p.m. 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: The Plan requires you and/or your physician to get prior authorization for certain drugs. This means that you will need to get approval from us before you fill your prescriptions. In order for The Plan to pay for these drugs, the physician ordering the prescription is required to submit all medical information to The Plan documenting the medical necessity. These drugs are identified in the Drug List. Step Therapy: In some cases, The Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. A complete list of drugs which require step therapy is listed in the reference table on page 8. Quantity Limits: For some covered drugs, there is a maximum amount that will be covered by The Plan over a certain period of time. For example, The Plan covers 30 tablets every 30 days or 90 tablets every 90 days for Jalyn. How can I make the most of my prescription drug benefit? Prescription drug costs continue to rise every year and can represent a significant part of your healthcare expenses. The Plan helps you pay for your medications by sharing the cost with you and providing substantial 2016 Commercial 3 Tier Formulary Version 4 Page 2

3 discounts for covered medications. To help you manage your drug costs, here are some money-saving tips to consider: Use Tier 1 generic medications whenever possible. Generic drugs are the chemical equivalent of brand-name drugs, and are just as effective in most cases. If you take generic drugs you will generally pay less, so talk to your doctor to see if switching to a generic equivalent of any brand-name you are taking is appropriate. Please see the list of drugs below to determine which drugs are included in Tier 1. See if your prescription pills can be split in half. For some medications, pills may be available in different strengths but still have the same price. If you need one of these select medications, your doctor may be able to write your prescription for double the strength and half of the number of pills you d normally need. Then you d split them in half, so you d get the proper dose saving up to 50 percent of the cost! The drugs that may be eligible for the Pill-Splitting program are marked with the symbol (1/2) on the drug list. Review this information with your doctor if your drug qualifies. What if my drug is not on the Formulary? If your drug is not included in this formulary, you should first contact Customer Service and confirm that your drug is not covered. If you learn that The 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 The Plan. When you receive the list, show it to your doctor and ask if switching to a covered medication is appropriate. You can ask your physician to send The Plan information requesting we make an exception and cover your drug. If The Plan approves the request for an exception to the formulary, the approved drug will be covered at the Tier 3 cost share. The following are NOT covered by The Plan: Compounded drugs Cosmetics or any drugs used for cosmetic purposes (such as Retin-A, Rogaine, Topical Minoxidil, and Vaniqa) Diabetic supplies, blood glucose monitors and test strips other than those manufactured by Abbott under the product name Freestyle, Precision, and test strips Erectile dysfunction drugs (such as Viagra) Infertility drugs (such as Clomid) Injectables (except insulin, Imitrex, and those requiring prior authorization) Multivitamins and nutritional supplements (except prescription pre-natal vitamins) Nicotine products Nonprescriptive supplies or substances Oral and topical antifungals for onychomycosis (such as Lamisil, Sporanox, and Penlac) Over-the-counter (OTC) medications (such as Lotrimin, Zantac 75, Pepcid AC or their generic formulations), or any drug for which a similar over-the-counter version is available All new drugs approved by the FDA will be excluded from the preferred drug list/formulary unless the Health First P&T Committee, in its sole discretion, decides to waive this exclusion for a particular drug. Support garments Syringes, needles, or other disposable supplies (except those used with insulin) Excluded drugs The Plan does not provide coverage for all drugs. In addition to the drugs marked excluded in this drug list, newly FDA approved drugs are not covered unless the Health First P&T Committee in its sole discretion approves these drugs for coverage. The Plan will automatically exclude a particular drug if a generic version becomes available and an entire class of drugs if a particular drug within that class becomes available over the counter Commercial 3 Tier Formulary Version 4 Page 3

4 Health First Health Plans and Insurance Formulary The formulary provides coverage information about some of the drugs covered by The Plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 86. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., PRADAXA) and generic drugs are listed in lower-case italics (e.g., lisinopril). The information in the Notes column tells you if The Plan has any special requirements for coverage of your drug. Specialty Pharmacy : Must be obtained from Health First Family Pharmacy and are limited to a 30-day supply. For members who reside outside the state of Florida, an exception will be considered to allow the medication to be filled at another pharmacy. Please contact Customer Service Department to initiate this process. Prior Authorization (): The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from The Plan before you fill your prescriptions. If you don't get approval, the drug will not be covered. Quantity Limit (QL): Quantity Limits may also be listed. For example, 30/30 days would mean your coverage of this drug is limited to 30 pills every 30 days. Prescriptions written for more than the suggested Quantity Limits will only be honored up to the listed amount unless an exception is requested by your physician and approved by The Plan. Step Therapy (ST): In some cases, The Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. A complete list of drugs which require step therapy is listed in the reference table on page 8. Pill Splitting (1/2): You may be able to split these pills in half. Begin by asking your doctor if pill-splitting is right for you. If it is, your doctor will write your prescription for half the number of pills and double the strength you normally need. For example, instead of 30 pills of 20 mg, you d get a prescription for 15 pills of 40 mg. Then you or the pharmacy can split them in half for the correct dose. This way, you save 50 percent of the cost. Maintenance Drug (): You may be taking these drugs on a long-term basis. Maintenance medications are generally those used to treat chronic conditions and long-term conditions. **Some exceptions may apply (i.e. certain medications used for ADHD, asthma/copd rescue, acute pain, and acute infections) Commercial 3 Tier Formulary Version 4 Page 4

5 Preventive Care Medications: $0 Cost-share Medications and Products The Affordable Care Act (ACA), commonly known as health care reform, was signed into federal law in The ACA requires private insurers to cover certain preventive services without any patient cost-sharing (i.e., copayments, coinsurance and deductible) when they are delivered by a network provider. The Department of Health and Human Services (HHS) has recognized several recommending bodies (e.g., United States Preventive Services Task Force [USPSTF], Advisory Committee on Immunization Practices [ACIP], and Health Resources and Services Administration [HRSA]) who have identified several medication categories that fall within the preventive health mandate. The following products, prescription medications and specific over-the-counter (OTC) medications (notated in Tier throughout this formulary) are available to our members at no ($0) cost-sharing when: Prescribed by a health care professional (all prescription and OTC medications will require a prescription) Age and/or gender appropriate U.S. Preventive Services Task Force A & B Recommendation Medications and Supplements Aspirin for Cardiovascular Disease (Generic only mg, 81 mg tablets) males age and females age Aspirin for Preeclampsia (Generic only 81 mg tablets) females less than 55 years of age Vitamin D (50000 unit capsules) Iron (Ferrous Sulfate, 325 mg tablets) Folic Acid (1 mg tablets) Pediatric Multiple Vitamins w/ Fluoride (1 mg chewable tablets, 0.5 mg/ml solution) Pediatric Multiple Vitamins w/ Iron (15 mg chewable tablets, 10 mg/ml drops) Sodium Fluoride (1 mg tablets, 1 mg chewable tablets) Bowel Preparation for Colon Rectal Cancer Screening For adults 50 years of age and older with a limit of 3 prescriptions per year Coverages include the following generic products: Bisacodyl Magnesium citrate, Milk of magnesia PEG-3350-Electrolyte products Tobacco Cessation Medications If you need help to quit smoking or using tobacco products, these preventive medications will be available at $0 cost-share. To qualify, you must be: 18 years of age or older and Receiving counseling and have a prescription from a health care provider Up to two, 3-month treatment courses are covered at no cost each year. Any additional treatment may be subject to a cost-share. Covered treatment regimens include: Nicotine replacement therapy (nicotine patches, nicotine gum, nicotine lozenges, nicotine inhaler, nicotine nasal spray) Chantix Generic Zyban (bupropion) 2016 Commercial 3 Tier Formulary Version 4 Page 5

6 Breast Cancer Preventive Medications For women who are at increased risk for breast cancer but who have not had breast cancer, medications such as tamoxifen or raloxifene are available at $0 cost-share. If you are 35 years of age or older and have not had breast cancer, talk to your doctor about your risk. If appropriate, your doctor may offer to prescribe one of these risk-reducing medications. Your doctor can then submit a Prior Authorization request to get the medication approved at $0 cost-share if coverage criteria are met. Contraceptive Methods Oral contraceptives combined: AZURETTE, BEKYREE, DESOGESTREL-EE, KARIVA, KIMIDESS, NECON, PIMTREA, VIORELE ALTAVERA, ALYACEN, APRI, AUBRA, AVIANE, BALZIVA, BLISOVI, BRIELLYN, CHATEAL, CRYSELLE, CYCLAFEM, CYRED DASETTA, DELYLA, DESOGESTREL-EE, DROSPIRENONE-EE, ELINEST, EMOQUETTE, ENSKYCE, ESTARYLLA, FALMINA GIANVI, GILDAGIA, GILDESS, JULEBRER, JUNEL, KELNOR, KURVELO, LARIN, LAYOLIS, LESSINA, LEVONORGESTREL-EE LEVORA, LOMEDIA, LORYNA, LOW-OGESTREL, LUTERA, MARLISSA, MICROGESTIN, MONO-LINYAH, MONONESSA, NECON NIKKI, NORETHIN-EE, NORGESTIMATE-EE, NORINYL, NORTREL, OCELLA, OGESTREL, ORSYTHIA, PHILITH, PIRMELLA, PORTIA PREVIFEM, RECLIPSEN, SOLIA, SPRINTEC, SRONYX, SYEDA, TARINA, VESTURA, VYFEMLA, WERA, WYMZYA, ZARAH ZENCHENT, ZOVIA Oral contraceptives extended/continuous use: AMETHYST, LEVONORGESTREL-ETHINYL ESTRAD ORAL TABLET 90-20MCG; AMETHIA, ASHLYNA, CAMRESE, DAYSEE, INTROVALE, JOLESSA, LEVONORGEST-ETH ESTRAD 91-DAY ORAL TABLET; QUASENSE, SETLAKIN Oral Contraceptives progestin only CAMILA, DEBLITANE, ERRIN, HEATHER, JENCYCLA, JOLIVETTE, LYZA, NORA-BE, NORETHINDRONE, NORLYROC, SHAROBEL 0.35 MG Injection: MEDROXYPROGESTERONE 150 MG INJ Patch: XULANE TCH (generic OrthoEvra) Vaginal Ring: NUVARING (Vaginal Ring) Emergency Contraception-Progestin: ECONTRA EZ, FALLBACK SOLO, LEVONORGESTREL 0.75 MG, MY WAY, NEXT CHOICE ONE DOSE, OPCICON ONE-STEP Emergency Contraception- Ulipristal Acetate: ELLA Implantable Rod: NEXPLANON IUD Copper: RAGUARD 2016 Commercial 3 Tier Formulary Version 4 Page 6

7 IUD Progestin: MIRENA Diaphragm with Spermicide: OMNIFLEX DIAPHRAM Contraceptive Methods Continued Sponge with Spermicide: TODAY SPONGE Cervical Cap with Spermicide: FEMCAP, PRENTIF Female Condom: FC FEMALE CONDOM Spermicide alone: NONOXYNOL-9 GEL *** The FDA Birth Control Guide additionally lists sterilization surgery for men and male condoms, but the HRSA Guidelines exclude services relating to a man s reproductive capacity. If you have any questions regarding your eligibility for preventive care medications and preventive contraceptive coverage, please contact your employer or call Customer Service toll-free at (TTY/TDD relay: ) Monday through Friday from 8 a.m. to 6 p.m Commercial 3 Tier Formulary Version 4 Page 7

8 Step Therapy Reference Table Step Therapy Reference Table Drug that must be tried first Drug that must be tried first ACTONEL alendronate TANASE Veramyst or fluticasone nasal AVANDIA Any pioglitazone containing product RELX sumatriptan AXERT sumatriptan RENAGEL calcium acetate 667 mg CELEBREX/CELECOXIB meloxicam RENVELA calcium acetate 667 mg CYCLOSET ESZOPICLONE Any metformin containing product Zolpidem IR RIZATRIPTAN; RIZATRIPTAN ODT sumatriptan EURAX CREAM EXELDERM FOSRENAL FROVA permethrin AND lindane topical products ketoconazole AND clotrimazole topical products calcium acetate 667 mg sumatriptan TOLAZAMIDE TOLBUTAMIDE TREXIMET Any glipizide containing product AND any glimepiride containing product Any glipizide containing product AND any glimepiride containing product sumatriptan GLYSET Any metformin containing product ULORIC allopurinol LEVATOL LYRICA Any Tier 1 or Tier 2 formulary beta blocker gabapentin VIIBRYD Trial of any two (2) of the following drugs: bupropion, citalopram, duloxetine, escitalopram, fluoxetine, mirtazapine, paroxetine, sertraline, trazodone, venlafaxine METFORMIN SR24 HR OSMOSTIC Trial of metformin ER (generic Glucophage XL) WELCHOL cholestyramine or colestipol NARATRIPTAN NASONEX OMNARIS sumatriptan Veramyst or fluticasone nasal Veramyst or fluticasone nasal ZOLMITRIPTAN; ZOLMITRIPTAN ODT ZOMIG NASAL sumatriptan sumatriptan OXISTAT ketoconazole AND clotrimazole topical products 2016 Commercial 3 Tier Formulary Version 4 Page 8

9 Covered Generic Drugs The following brand name drugs have generic alternatives that may be a cost savings to you Brand Name Drug Brand Tier Generic Alternative CRESTOR atorvastatin, simvastatin DEXILANT omeprazole, pantoprazole BENICAR losartan Formulary Changes Change Previous Tier New Tier Effective Date New Requirements/ Limits EPIPEN & EPIPEN JR ADD -- 2/15/2016 VENTOLIN HFA INHALATION AEROSOL, ADD -- 4/25/2016 QL (36 GM per 31 RETHA SUBCUTANEOUS ADD -- 4/25/2016 PRALUENT SUBCUTANEOUS ADD -- 4/25/2016 ENTRESTO ORAL TABLET ADD -- 4/25/2016 valsartan oral tablet TIER CHANGE 4/25/2016 sumatriptan succinate oral tablet QL CHANGE 4/25/2016 QL increased to 18 EA per 31 days celecoxib oral capsule TIER CHANGE; ST REMOVED 4/25/2016 XARELTO ORAL TABLET REMOVED 8/1/2016 REMOVED ELIQUIS ORAL TABLET ADD -- 8/1/ Commercial 3 Tier Formulary Version 4 Page 9

10 Formulary Changes Change Previous Tier New Tier Effective Date New Requirements/ Limits TIKOSYN ORAL CAPSULE ADD -- 8/1/2016 rosuvastatin calcium oral tablet ADD -- 8/1/2016 QL (31 EA per 31 diclofenac sod. 1% transdermal gel ADD -- 8/1/ Commercial 3 Tier Formulary Version 4 Page 10

11 ADHD/ANTI-NARCOLEPSY/ANTI- OBESITY/ANOREXIANTS ADHD AGENT - SELECTIVE ALPHA ADRENERGIC AGONISTS STIMULANTS - MISC. DAYTRANA TRANSDERMAL TCH guanfacine hcl er oral tablet extended release 24 hr QL (31 EA per 31 dexmethylphenidate hcl er oral capsule extended release 24 hour ADHD AGENT - SELECTIVE NOREPINEPHRINE REUPTAKE INHIBITOR STRATTERA ORAL CAPSULE AMPHETAMINE MIXTURES ADDERALL XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR amphetamine-dextroamphetamine oral tablet AMPHETAMINES dextroamphetamine sulfate er oral capsule extended release 24 hour dextroamphetamine sulfate oral tablet methamphetamine hcl oral tablet VYVANSE ORAL CAPSULE ANOREXIANTS NON-AMPHETAMINE dexmethylphenidate hcl oral tablet FOCALIN XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 25 MG, 35 MG methylphenidate hcl er (la) oral capsule extended release 24 hour methylphenidate hcl er oral tablet extended release 24 hr methylphenidate hcl er oral tablet extendedrelease methylphenidate hcl oral solution methylphenidate hcl oral tablet methylphenidate hcl oral tablet chewable modafinil oral tablet ; ; QL (31 EA per 31 phentermine hcl oral capsule 15 mg QL (180 EA Max Qty Per Fill Retail) NUVIGIL ORAL TABLET ; ; QL (31 EA per 31 phentermine hcl oral capsule 30 mg, 37.5 mg QL (90 EA Max Qty Per Fill Retail) phentermine hcl oral tablet QL (90 EA Max Qty Per Fill Retail) AMINOGLYCOSIDES AMINOGLYCOSIDES neomycin sulfate oral tablet QL Quantity Limit applies SP Specialty Pharmacy Maintenance Drug No Cost Share ($0) 2016 Commercial 3 Tier Formulary Version 4 Page 11

12 paromomycin sulfate oral capsule streptomycin sulfate intramuscular solution reconstituted ANALGESICS - ANTI-INFLAMMATORY ANTI-TNF-ALPHA - MONOCLONOAL ANTIBODIES HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS HUMIRA PEN SUBCUTANEOUS HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS HUMIRA PEN-PSORIASIS STARTER SUBCUTANEOUS HUMIRA SUBCUTANEOUS CYCLOOXYGENASE 2 (COX-2) INHIBITORS celecoxib oral capsule GOLD COMPOUNDS RIDAURA ORAL CAPSULE INTERLEUKIN-1 BLOCKERS ARCALYST SUBCUTANEOUS RECONSTITUTED ; ; ; ; ; ; NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS) diclofenac potassium oral tablet diclofenac sodium er oral tablet extended release 24 hr diclofenac sodium oral tablet delayed release etodolac er oral tablet extended release 24 hr etodolac oral capsule etodolac oral tablet fenoprofen calcium oral tablet flurbiprofen oral tablet ibuprofen oral tablet 400 mg, 600 mg, 800 mg indomethacin oral capsule ketoprofen oral capsule ketorolac tromethamine oral tablet meclofenamate sodium oral capsule mefenamic acid oral capsule meloxicam oral suspension meloxicam oral tablet nabumetone oral tablet naproxen dr oral tablet delayed release 375 mg naproxen dr oral tablet delayed release 500 mg naproxen oral tablet QL Quantity Limit applies SP Specialty Pharmacy Maintenance Drug No Cost Share ($0) 2016 Commercial 3 Tier Formulary Version 4 Page 12

13 naproxen sodium oral tablet 275 mg, 550 mg butalbital-aspirin-caffeine oral capsule oxaprozin oral tablet piroxicam oral capsule sulindac oral tablet tolmetin sodium oral capsule tolmetin sodium oral tablet PYRIMIDINE SYNTHESIS INHIBITORS leflunomide oral tablet ; QL (31 EA per 31 SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS ENBREL SUBCUTANEOUS ENBREL SUBCUTANEOUS KIT ; ; ; QL (8 EA per 31 SALICYLATES aspirin ec low dose oral tablet delayed release aspirin ec oral tablet delayed release aspirin low dose oral tablet chewable aspirin low dose oral tablet delayed release aspirin low strength oral tablet chewable aspirin oral tablet 325 mg aspirin oral tablet chewable ANALGESICS - OPIOID CODEINE COMBINATIONS ENBREL SURECLICK SUBCUTANEOUS ; acetaminophen-codeine #2 oral tablet QL (248 EA per 31 ANALGESICS - NONNARCOTIC ANALGESICS-SEDATIVES butalbital-acetaminophen oral tablet butalbital-apap-caffeine oral capsule butalbital-apap-caffeine oral tablet mg butalbital-asa-caffeine oral capsule acetaminophen-codeine #3 oral tablet QL (248 EA per 31 acetaminophen-codeine #4 oral tablet QL (248 EA per 31 acetaminophen-codeine oral solution acetaminophen-codeine oral tablet QL (248 EA per 31 ASCOMP-CODEINE ORAL CAPSULE QL Quantity Limit applies SP Specialty Pharmacy Maintenance Drug No Cost Share ($0) 2016 Commercial 3 Tier Formulary Version 4 Page 13

14 butalbital-apap-caff-cod oral capsule meperidine hcl oral tablet butalbital-asa-caff-codeine oral capsule HYDROCODONE COMBINATIONS meperitab oral tablet 50 mg methadone hcl oral tablet QL (248 EA per 31 hydrocodone-acetaminophen oral solution mg/15ml morphine sulfate (concentrate) oral solution 100 mg/5ml hydrocodone-acetaminophen oral tablet mg, mg, mg hydrocodone-acetaminophen oral tablet mg, mg, mg hydrocodone-ibuprofen oral tablet mg, mg IBUDONE ORAL TABLET MG OPIOID AGONISTS QL (403 EA per 31 QL (248 EA per 31 QL (155 EA per 31 QL (155 EA per 31 codeine sulfate oral tablet QL (248 EA per 31 fentanyl citrate buccal lollipop fentanyl transdermal patch 72 hr 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr QL (15 EA per 31 hydromorphone hcl oral tablet QL (248 EA per 31 morphine sulfate er oral tablet extendedrelease morphine sulfate oral solution morphine sulfate oral tablet QL (248 EA per 31 NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR NUCYNTA ORAL TABLET ONA ER ORAL oxycodone hcl oral solution oxycodone hcl oral tablet 10 mg, 20 mg, 5 mg oxycodone hcl oral tablet 15 mg, 30 mg oxymorphone hcl er oral tablet extended release 12 hr oxymorphone hcl oral tablet QL (61 EA per 31 Days) QL (248 EA per 31 QL (62 EA per 31 Days) levorphanol tartrate oral tablet QL Quantity Limit applies SP Specialty Pharmacy Maintenance Drug No Cost Share ($0) 2016 Commercial 3 Tier Formulary Version 4 Page 14

15 tramadol hcl er (biphasic) oral tablet extended release 24 hr 100 mg, 200 mg tramadol hcl er (biphasic) oral tablet extended release 24 hr 300 mg tramadol hcl er oral tablet extended release 24 hr 100 mg, 200 mg tramadol hcl er oral tablet extended release 24 hr 300 mg QL (31 EA per 31 Days) QL (31 EA per 31 Days) QL (31 EA per 31 Days) QL (31 EA per 31 Days) tramadol hcl oral tablet QL (372 EA per 31 OPIOID COMBINATIONS ENDOCET ORAL TABLET MG, MG, MG, MG oxycodone-acetaminophen oral tablet mg, mg, mg, mg oxycodone-aspirin oral tablet QL (248 EA per 31 QL (248 EA per 31 oxycodone-ibuprofen oral tablet QL (155 EA per 31 ROXICET ORAL TABLET QL (248 EA per 31 OPIOID RTIAL AGONISTS buprenorphine hcl sublingual tablet sublingual butorphanol tartrate injection solution BUTRANS TRANSDERMAL TCH WEEKLY pentazocine-naloxone hcl oral tablet SUBOXONE SUBLINGUAL FILM TRAMADOL COMBINATIONS tramadol-acetaminophen oral tablet ANDROGENS-ANABOLIC ANABOLIC STEROIDS oxandrolone oral tablet ANDROGENS ANDROGEL PUMP TRANSDERMAL ANDROGEL TRANSDERMAL MG/1.25GM (1.62%), 25 MG/2.5GM (1%) ANDROGEL TRANSDERMAL 40.5 MG/2.5GM (1.62%), 50 MG/5GM (1%) danazol oral capsule testosterone cypionate intramuscular solution 100 mg/ml, 200 mg/ml testosterone enanthate intramuscular solution testosterone transdermal 12.5 mg/act (1%), 25 mg/2.5gm, 25 mg/2.5gm (1%), 50 mg/5gm, 50 mg/5gm (1%) ; ; QL (300 GM per 31 ; ; ; QL (300 GM per 31 ; ; ; QL (300 GM per 31 QL Quantity Limit applies SP Specialty Pharmacy Maintenance Drug No Cost Share ($0) 2016 Commercial 3 Tier Formulary Version 4 Page 15

16 ANORECTAL AGENTS BILTRICIDE ORAL TABLET INTRARECTAL STEROIDS ivermectin oral tablet hydrocortisone enema ANTIANGINAL AGENTS NITRATE VASODILATING AGENTS ANTIANGINALS-OTHER RECTIV OINTMENT RECTAL ANESTHETIC/STEROIDS ANALPRAM ADVANCED COMBINATION KIT hydrocortisone ace-pramoxine cream lidocaine-hydrocortisone ace lidocaine-hydrocortisone ace cream lidocaine-hydrocortisone ace kit PROCORT CREAM PROCTOFOAM HC FOAM RECTAL STEROIDS anucort-hc suppository hydrocortisone acetate suppository PROCTO-K CREAM PROCTOSOL HC CREAM PROCTOZONE-HC CREAM ANTHELMINTICS ANTHELMINTICS ALBENZA ORAL TABLET RANEXA ORAL TABLET EXTENDED RELEASE 12 HR NITRATES isosorbide dinitrate er oral tablet extendedrelease isosorbide dinitrate oral tablet isosorbide mononitrate er oral tablet extended release 24 hr isosorbide mononitrate oral tablet MINITRAN TRANSDERMAL TCH 24 HR NITRO-BID TRANSDERMAL OINTMENT nitroglycerin transdermal patch 24 hr NITROSTAT SUBLINGUAL TABLET SUBLINGUAL 0.3 MG, 0.6 MG NITROSTAT SUBLINGUAL TABLET SUBLINGUAL 0.4 MG ANTIANXIETY AGENTS ANTIANXIETY AGENTS - MISC. QL Quantity Limit applies SP Specialty Pharmacy Maintenance Drug No Cost Share ($0) 2016 Commercial 3 Tier Formulary Version 4 Page 16

17 buspirone hcl oral tablet ANTIARRHYTHMICS TYPE I-A hydroxyzine hcl intramuscular solution hydroxyzine hcl oral solution disopyramide phosphate oral capsule NORCE CR ORAL CAPSULE EXTENDED RELEASE 12 HOUR ; hydroxyzine hcl oral syrup procainamide hcl injection solution hydroxyzine hcl oral tablet hydroxyzine pamoate oral capsule meprobamate oral tablet BENZODIAZEPINES alprazolam er oral tablet extended release 24 hr alprazolam oral tablet alprazolam xr oral tablet extended release 24 hr chlordiazepoxide hcl oral capsule clorazepate dipotassium oral tablet DIAZEM INTENSOL ORAL CONCENTRATE diazepam oral concentrate diazepam oral solution 1 mg/ml diazepam oral tablet lorazepam oral concentrate lorazepam oral tablet ANTIARRHYTHMICS quinidine gluconate er oral tablet extendedrelease quinidine sulfate er oral tablet extendedrelease quinidine sulfate oral tablet ANTIARRHYTHMICS TYPE I-C flecainide acetate oral tablet propafenone hcl er oral capsule extended release 12 hour propafenone hcl oral tablet ANTIARRHYTHMICS TYPE III amiodarone hcl oral tablet 200 mg, 400 mg MULTAQ ORAL TABLET TIKOSYN ORAL CAPSULE ANTIASTHMATIC AND BRONCHODILATOR AGENTS 5-LIPOXYGENASE INHIBITORS ZYFLO CR ORAL TABLET EXTENDED RELEASE 12 HR ; ; QL (124 EA per 31 QL Quantity Limit applies SP Specialty Pharmacy Maintenance Drug No Cost Share ($0) 2016 Commercial 3 Tier Formulary Version 4 Page 17

18 ADRENERGIC COMBINATIONS ADVAIR DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED ADVAIR HFA INHALATION AEROSOL ANORO ELLIPTA INHALATION AEROSOL POWDER, BREATH ACTIVATED BREO ELLIPTA INHALATION AEROSOL POWDER, BREATH ACTIVATED COMBIVENT RESPIMAT INHALATION AEROSOL, DULERA INHALATION AEROSOL ipratropium-albuterol inhalation solution SYMBICORT INHALATION AEROSOL MCG/ACT SYMBICORT INHALATION AEROSOL MCG/ACT ; QL (62 EA per 31 ; QL (12 GM per 31 ; QL (13 GM per 31 ANTI-IGE MONOCLONAL ANTIBODIES XOLAIR SUBCUTANEOUS RECONSTITUTED ANTI-INFLAMMATORY AGENTS ST; ; QL (10.2 GM per 31 ST; ; QL (13.8 GM per 31 ; cromolyn sodium inhalation nebulization solution BETA ADRENERGICS albuterol sulfate inhalation nebulization solution albuterol sulfate oral syrup albuterol sulfate oral tablet ARCAPTA NEOHALER INHALATION CAPSULE BROVANA INHALATION NEBULIZATION levalbuterol hcl inhalation nebulization solution ; metaproterenol sulfate oral syrup metaproterenol sulfate oral tablet PROVENTIL HFA INHALATION AEROSOL, SEREVENT DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED STRIVERDI RESPIMAT INHALATION AEROSOL, QL (13.4 GM per 31 Days) ; QL (62 EA per 31 terbutaline sulfate oral tablet VENTOLIN HFA INHALATION AEROSOL, QL (36 GM per 31 QL Quantity Limit applies SP Specialty Pharmacy Maintenance Drug No Cost Share ($0) 2016 Commercial 3 Tier Formulary Version 4 Page 18

19 BRONCHODILATORS - ANTICHOLINERGICS ATROVENT HFA INHALATION AEROSOL, ipratropium bromide inhalation solution SPIRIVA HANDIHALER INHALATION CAPSULE SPIRIVA RESPIMAT INHALATION AEROSOL, ; QL (26 GM per 31 ; QL (31 EA per 31 LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium oral packet montelukast sodium oral tablet ; QL (31 EA per 31 montelukast sodium oral tablet chewable ; QL (31 EA per 31 zafirlukast oral tablet ; QL (62 EA per 31 MIXED ADRENERGICS epinephrine hcl injection solution 1 mg/ml STEROID INHALANTS ASMANEX 120 METERED DOSES INHALATION AEROSOL POWDER, BREATH ACTIVATED ASMANEX 14 METERED DOSES INHALATION AEROSOL POWDER, BREATH ACTIVATED ; QL (1 EA per 31 Days) ; QL (1 EA per 31 Days) ASMANEX 30 METERED DOSES INHALATION AEROSOL POWDER, BREATH ACTIVATED ASMANEX 60 METERED DOSES INHALATION AEROSOL POWDER, BREATH ACTIVATED ASMANEX 7 METERED DOSES INHALATION AEROSOL POWDER, BREATH ACTIVATED ASMANEX HFA INHALATION AEROSOL budesonide inhalation suspension FLOVENT DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED FLOVENT HFA INHALATION AEROSOL XANTHINES aminophylline intravenous solution theophylline er oral tablet extended release 12 hr theophylline er oral tablet extended release 24 hr ANTICOAGULANTS COUMARIN ANTICOAGULANTS ; QL (1 EA per 31 Days) ; QL (1 EA per 31 Days) ; QL (1 EA per 31 Days) ; QL (13 GM per 30 ; QL (124 EA per 31 ; QL (24 GM per 31 JANTOVEN ORAL TABLET warfarin sodium oral tablet QL Quantity Limit applies SP Specialty Pharmacy Maintenance Drug No Cost Share ($0) 2016 Commercial 3 Tier Formulary Version 4 Page 19

20 DIRECT FACTOR XA INHIBITORS ELIQUIS ORAL TABLET XARELTO ORAL TABLET 10 MG ; QL (31 EA per 31 XARELTO ORAL TABLET 15 MG, 20 MG HERINS AND HERINOID-LIKE AGENTS heparin sodium (porcine) injection solution 1000 unit/ml, unit/ml, unit/ml, 5000 unit/ml heparin sodium (porcine) pf injection solution LOW MOLECULAR WEIGHT HERINS enoxaparin sodium injection solution enoxaparin sodium subcutaneous solution 100 mg/ml, 150 mg/ml enoxaparin sodium subcutaneous solution 120 mg/0.8ml, 80 mg/0.8ml enoxaparin sodium subcutaneous solution 30 mg/0.3ml enoxaparin sodium subcutaneous solution 40 mg/0.4ml enoxaparin sodium subcutaneous solution 60 mg/0.6ml SYNTHETIC HERINOID-LIKE AGENTS QL (24 ML per 30 Days) QL (28 ML per 30 Days) QL (22.4 ML per 30 Days) QL (8.4 ML per 30 Days) QL (11.2 ML per 30 Days) QL (16.8 ML per 30 Days) fondaparinux sodium subcutaneous solution THROMBIN INHIBITORS - SELECTIVE DIRECT & REVERSIBLE PRADAXA ORAL CAPSULE 150 MG, 75 MG ANTICONVULSANTS ANTICONVULSANTS - BENZODIAZEPINES clonazepam oral tablet diazepam ANTICONVULSANTS - MISC. BANZEL ORAL SUSPENSION BANZEL ORAL TABLET carbamazepine er oral capsule extended release 12 hour carbamazepine er oral tablet extended release 12 hr ; ; carbamazepine oral suspension carbamazepine oral tablet carbamazepine oral tablet chewable gabapentin oral capsule 100 mg, 300 mg ; QL (372 EA per 31 gabapentin oral capsule 400 mg ; QL (279 EA per 31 QL Quantity Limit applies SP Specialty Pharmacy Maintenance Drug No Cost Share ($0) 2016 Commercial 3 Tier Formulary Version 4 Page 20

21 gabapentin oral solution ; QL (2232 ML per 31 gabapentin oral tablet 600 mg ; QL (186 EA per 31 gabapentin oral tablet 800 mg ; QL (140 EA per 31 LAMICTAL ODT ORAL KIT LAMICTAL ODT ORAL TABLET DISPERSIBLE lamotrigine oral tablet lamotrigine oral tablet chewable levetiracetam er oral tablet extended release 24 hr 500 mg levetiracetam er oral tablet extended release 24 hr 750 mg ; QL (93 EA per 31 Days) levetiracetam oral solution levetiracetam oral tablet 750 mg, 1000 mg ; QL (186 EA per 31 ; QL (124 EA per 31 ; QL (93 EA per 31 levetiracetam oral tablet 250 mg ; QL (62 EA per 31 levetiracetam oral tablet 500 mg ; QL (186 EA per 31 LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 25 MG, 50 MG, 75 MG LYRICA ORAL CAPSULE 225 MG, 300 MG ST; ; QL (93 EA per 31 ST; ; QL (62 EA per 31 oxcarbazepine oral suspension oxcarbazepine oral tablet POTIGA ORAL TABLET primidone oral tablet topiramate oral capsule sprinkle topiramate oral tablet VIMT ORAL VIMT ORAL TABLET zonisamide oral capsule CARBAMATES felbamate oral suspension felbamate oral tablet GABA MODULATORS GABITRIL ORAL TABLET 12 MG, 16 MG SABRIL ORAL TABLET tiagabine hcl oral tablet 2 mg tiagabine hcl oral tablet 4 mg ; ; ; QL (1240 ML per 31 ; ; QL (62 EA per 31 ; QL (124 EA per 31 QL Quantity Limit applies SP Specialty Pharmacy Maintenance Drug No Cost Share ($0) 2016 Commercial 3 Tier Formulary Version 4 Page 21

22 HYDANTOINS PEGANONE ORAL TABLET phenytoin oral suspension 125 mg/5ml phenytoin sodium extended oral capsule SUCCINIMIDES CELONTIN ORAL CAPSULE ethosuximide oral capsule ethosuximide oral solution VALPROIC ACID divalproex sodium er oral tablet extended release 24 hr divalproex sodium oral capsule sprinkle divalproex sodium oral tablet delayed release valproic acid oral capsule valproic acid oral solution valproic acid oral syrup ANTIDEPRESSANTS ALPHA-2 RECEPTOR ANTAGONISTS (TETRACYCLICS) mirtazapine oral tablet 15 mg, 7.5 mg ; QL (93 EA per 31 mirtazapine oral tablet 30 mg, 45 mg ; QL (31 EA per 31 mirtazapine oral tablet dispersible ; QL (31 EA per 31 ANTIDEPRESSANTS - MISC. bupropion hcl er (sr) oral tablet extended release 12 hr bupropion hcl er (xl) oral tablet extended release 24 hr bupropion hcl oral tablet maprotiline hcl oral tablet MODIFIED CYCLICS BRINTELLIX ORAL TABLET nefazodone hcl oral tablet 100 mg, 150 mg, 250 mg, 50 mg ; QL (62 EA per 31 ; QL (31 EA per 31 ; QL (62 EA per 31 nefazodone hcl oral tablet 200 mg ; QL (93 EA per 31 trazodone hcl oral tablet VIIBRYD ORAL KIT VIIBRYD ORAL TABLET MONOAMINE OXIDASE INHIBITORS (MAOIS) EMSAM TRANSDERMAL TCH 24 HR MARPLAN ORAL TABLET ST; QL (31 EA per 31 ST; ; QL (31 EA per 31 ; phenelzine sulfate oral tablet QL Quantity Limit applies SP Specialty Pharmacy Maintenance Drug No Cost Share ($0) 2016 Commercial 3 Tier Formulary Version 4 Page 22

23 tranylcypromine sulfate oral tablet SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS) citalopram hydrobromide oral solution citalopram hydrobromide oral tablet escitalopram oxalate oral solution escitalopram oxalate oral tablet 10 mg, 20 mg ; 1/2 escitalopram oxalate oral tablet 5 mg fluoxetine hcl oral capsule 10 mg, 20 mg ; QL (93 EA per 31 fluoxetine hcl oral capsule 40 mg ; QL (62 EA per 31 fluoxetine hcl oral solution fluvoxamine maleate oral tablet paroxetine hcl er oral tablet extended release 24 hr paroxetine hcl oral tablet XIL ORAL SUSPENSION PEXEVA ORAL TABLET sertraline hcl oral concentrate sertraline hcl oral tablet ; QL (62 EA per 31 SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIS) duloxetine hcl oral capsule delayed release particles 20 mg, 60 mg duloxetine hcl oral capsule delayed release particles 30 mg duloxetine hcl oral capsule delayed release particles 40 mg PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR venlafaxine hcl er oral capsule extended release 24 hour 150 mg venlafaxine hcl er oral capsule extended release 24 hour 37.5 mg, 75 mg ; QL (62 EA per 31 Days) ; QL (93 EA per 31 Days) ; QL (62 EA per 31 ; QL (31 EA per 31 ; QL (31 EA per 31 ; QL (93 EA per 31 venlafaxine hcl oral tablet ; QL (93 EA per 31 TRICYCLIC AGENTS amitriptyline hcl oral tablet amoxapine oral tablet clomipramine hcl oral capsule desipramine hcl oral tablet doxepin hcl oral capsule doxepin hcl oral concentrate imipramine hcl oral tablet imipramine pamoate oral capsule nortriptyline hcl oral capsule QL Quantity Limit applies SP Specialty Pharmacy Maintenance Drug No Cost Share ($0) 2016 Commercial 3 Tier Formulary Version 4 Page 23

24 protriptyline hcl oral tablet SURMONTIL ORAL CAPSULE trimipramine maleate oral capsule ANTIDIABETICS ALPHA-GLUCOSIDASE INHIBITORS acarbose oral tablet ; QL (93 EA per 31 GLYSET ORAL TABLET ST; ANTIDIABETIC - AMYLIN ANALOGS SYMLINPEN 120 SUBCUTANEOUS SYMLINPEN 60 SUBCUTANEOUS BIGUANIDES metformin hcl er (osm) oral tablet extended release 24 hr 1000 mg metformin hcl er (osm) oral tablet extended release 24 hr 500 mg metformin hcl er oral tablet extended release 24 hr 500 mg metformin hcl er oral tablet extended release 24 hr 750 mg ST; ; QL (62 EA per 31 ST; ; QL (155 EA per 31 ; QL (124 EA per 31 ; QL (62 EA per 31 metformin hcl oral tablet 1000 mg ; QL (62 EA per 31 metformin hcl oral tablet 500 mg ; QL (155 EA per 31 metformin hcl oral tablet 850 mg ; QL (93 EA per 31 DIABETIC OTHER GLUCAGEN HYPOKIT INJECTION RECONSTITUTED GLUCAGON EMERGENCY INJECTION KIT PROGLYCEM ORAL SUSPENSION DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS TRADJENTA ORAL TABLET DIPEPTIDYL PEPTIDASE-4 INHIBITOR-BIGUANIDE COMBINATIONS JENTADUETO ORAL TABLET DOMINE RECEPTOR AGONISTS - ERGOT DERIVATIVES CYCLOSET ORAL TABLET ST; HUMAN INSULIN HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS LEVEMIR FLEXTOUCH SUBCUTANEOUS LEVEMIR SUBCUTANEOUS NOVOLIN 70/30 RELION SUBCUTANEOUS SUSPENSION ; QL (20 ML per 28 ; QL (60 ML per 31 ; QL (60 ML per 31 ; QL (60 ML per 31 QL Quantity Limit applies SP Specialty Pharmacy Maintenance Drug No Cost Share ($0) 2016 Commercial 3 Tier Formulary Version 4 Page 24

25 NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION ; QL (60 ML per 31 BYETTA 10 MCG PEN SUBCUTANEOUS ; QL (4.8 ML per 31 NOVOLIN N RELION SUBCUTANEOUS SUSPENSION ; QL (60 ML per 31 BYETTA 5 MCG PEN SUBCUTANEOUS ; QL (4.8 ML per 31 NOVOLIN N SUBCUTANEOUS SUSPENSION NOVOLIN R INJECTION NOVOLIN R RELION INJECTION NOVOLOG FLEXPEN SUBCUTANEOUS NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS NOVOLOG MIX 70/30 SUBCUTANEOUS SUSPENSION NOVOLOG PENFILL SUBCUTANEOUS NOVOLOG SUBCUTANEOUS TRESIBA FLEXTOUCH SUBCUTANEOUS ; QL (60 ML per 31 ; QL (60 ML per 31 ; QL (60 ML per 31 ; QL (60 ML per 31 ; QL (60 ML per 31 ; QL (60 ML per 31 ; QL (60 ML per 31 ; QL (60 ML per 31 ; QL (60 ML per 31 INCRETIN MIMETIC AGENTS (GLP-1 RECEPTOR AGONISTS) BYDUREON SUBCUTANEOUS BYDUREON SUBCUTANEOUS SUSPENSION RECONSTITUTED TANZEUM SUBCUTANEOUS MEGLITINIDE ANALOGUES nateglinide oral tablet ; QL (93 EA per 31 repaglinide oral tablet ; QL (93 EA per 31 Days) SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGL) INHIBITORS JARDIANCE ORAL TABLET SULFONYLUREA-BIGUANIDE COMBINATIONS glipizide-metformin hcl oral tablet mg glipizide-metformin hcl oral tablet mg, mg glyburide-metformin oral tablet mg glyburide-metformin oral tablet mg, mg SULFONYLUREAS chlorpropamide oral tablet ; QL (248 EA per 31 ; QL (124 EA per 31 ; QL (248 EA per 31 ; QL (124 EA per 31 glimepiride oral tablet 1 mg ; QL (248 EA per 31 QL Quantity Limit applies SP Specialty Pharmacy Maintenance Drug No Cost Share ($0) 2016 Commercial 3 Tier Formulary Version 4 Page 25

26 glimepiride oral tablet 2 mg ; QL (124 EA per 31 glimepiride oral tablet 4 mg ; QL (62 EA per 31 glipizide er oral tablet extended release 24 hr 10 mg glipizide er oral tablet extended release 24 hr 2.5 mg glipizide er oral tablet extended release 24 hr 5 mg ; QL (62 EA per 31 ; QL (248 EA per 31 ; QL (124 EA per 31 glipizide oral tablet 10 mg ; QL (124 EA per 31 glipizide oral tablet 5 mg ; QL (248 EA per 31 glipizide xl oral tablet extended release 24 hr glyburide micronized oral tablet 1.5 mg, 3 mg ; QL (124 EA per 31 glyburide micronized oral tablet 6 mg ; QL (62 EA per 31 glyburide oral tablet 1.25 mg ; QL (496 EA per 31 glyburide oral tablet 2.5 mg ; QL (248 EA per 31 glyburide oral tablet 5 mg ; QL (124 EA per 31 tolazamide oral tablet ST; tolbutamide oral tablet ST; SULFONYLUREA-THIAZOLIDINEDIONE COMBINATIONS pioglitazone hcl-glimepiride oral tablet THIAZOLIDINEDIONES AVANDIA ORAL TABLET ST; pioglitazone hcl oral tablet ANTIDIARRHEALS ANTIPERISTALTIC AGENTS diphenatol oral tablet diphenoxylate-atropine oral liquid diphenoxylate-atropine oral tablet ; QL (31 EA per 31 loperamide hcl oral capsule MOTOFEN ORAL TABLET ANTIDOTES ANTIDOTES - CHELATING AGENTS CHEMET ORAL CAPSULE EXJADE ORAL TABLET SOLUBLE FERRIPROX ORAL TABLET OPIOID ANTAGONISTS naltrexone hcl oral tablet ANTIEMETICS ; QL Quantity Limit applies SP Specialty Pharmacy Maintenance Drug No Cost Share ($0) 2016 Commercial 3 Tier Formulary Version 4 Page 26

27 5-H RECEPTOR ANTAGONISTS ANZEMET ORAL TABLET flucytosine oral capsule griseofulvin microsize oral suspension granisetron hcl oral tablet nystatin oral tablet ondansetron hcl oral solution terbinafine hcl oral tablet QL (31 EA per 31 ondansetron hcl oral tablet 24 mg QL (31 EA per 31 IMIDAZOLES ondansetron hcl oral tablet 4 mg, 8 mg ondansetron oral tablet dispersible ANTIEMETICS - ANTICHOLINERGIC meclizine hcl oral tablet TIGAN INTRAMUSCULAR trimethobenzamide hcl oral capsule ANTIEMETICS - MISCELLANEOUS QL (62 EA per 31 ketoconazole oral tablet TRIAZOLES fluconazole oral tablet itraconazole oral capsule NOXAFIL ORAL SUSPENSION voriconazole oral tablet ANTIHISTAMINES CESAMET ORAL CAPSULE dronabinol oral capsule SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS ; QL (62 EA per 31 EMEND ORAL CAPSULE ; QL (62 EA per 31 ANTIFUNGALS ANTIFUNGALS ANTIHISTAMINES - ETHANOLAMINES carbinoxamine maleate oral tablet clemastine fumarate oral syrup clemastine fumarate oral tablet 2.68 mg diphenhydramine hcl injection solution ANTIHISTAMINES - NON-SEDATING levocetirizine dihydrochloride oral solution QL Quantity Limit applies SP Specialty Pharmacy Maintenance Drug No Cost Share ($0) 2016 Commercial 3 Tier Formulary Version 4 Page 27

28 levocetirizine dihydrochloride oral tablet ANTIHISTAMINES - PHENOTHIAZINES PHENADOZ SUPPOSITORY promethazine hcl injection solution promethazine hcl oral solution promethazine hcl oral syrup micronized colestipol hcl oral tablet PREVALITE ORAL CKET PREVALITE ORAL POWDER WELCHOL ORAL TABLET ST; FIBRIC ACID DERIVATIVES fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg promethazine hcl oral tablet promethazine hcl suppository fenofibrate oral tablet 145 mg, 48 mg fenofibrate oral tablet 160 mg, 54 mg PROMETHEGAN SUPPOSITORY ANTIHISTAMINES - PIPERIDINES cyproheptadine hcl oral tablet ANTIHYPERLIPIDEMICS ANTIHYPERLIPIDEMICS - MISC. omega-3-acid ethyl esters oral capsule VASCE ORAL CAPSULE BILE ACID SEQUESTRANTS cholestyramine light oral packet cholestyramine light oral powder cholestyramine oral packet cholestyramine oral powder colestipol hcl oral granules colestipol hcl oral tablet fenofibric acid oral capsule delayed release gemfibrozil oral tablet HMG COA REDUCTASE INHIBITORS atorvastatin calcium oral tablet 10 mg ; QL (31 EA per 31 atorvastatin calcium oral tablet 20 mg, 40 mg, 80 mg ; 1/2; QL (31 EA per 31 CRESTOR ORAL TABLET ; 1/2; QL (31 EA per 31 fluvastatin sodium oral capsule lovastatin oral tablet pravastatin sodium oral tablet ; QL (31 EA per 31 rosuvastatin calcium oral tablet ; QL (31 EA per 31 QL Quantity Limit applies SP Specialty Pharmacy Maintenance Drug No Cost Share ($0) 2016 Commercial 3 Tier Formulary Version 4 Page 28

29 simvastatin oral tablet ; QL (31 EA per 31 lisinopril-hydrochlorothiazide oral tablet INTEST CHOLEST ABSORP INHIB-HMG COA REDUCTASE INHIB COMB moexipril-hydrochlorothiazide oral tablet LIPTRUZET ORAL TABLET ; QL (93 EA per 31 Days) quinapril-hydrochlorothiazide oral tablet VYTORIN ORAL TABLET ACE INHIBITORS INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS ZETIA ORAL TABLET NICOTINIC ACID DERIVATIVES niacin er (antihyperlipidemic) oral tablet extendedrelease NIACOR ORAL TABLET ANTIHYPERTENSIVES ACE INHIBITOR & CALCIUM CHANNEL BLOCKER COMBINATIONS amlodipine besy-benazepril hcl oral capsule ACE INHIBITORS & THIAZIDE/THIAZIDE-LIKE benazepril-hydrochlorothiazide oral tablet captopril-hydrochlorothiazide oral tablet enalapril-hydrochlorothiazide oral tablet ; QL (31 EA per 31 fosinopril sodium-hctz oral tablet benazepril hcl oral tablet captopril oral tablet enalapril maleate oral tablet fosinopril sodium oral tablet lisinopril oral tablet moexipril hcl oral tablet perindopril erbumine oral tablet quinapril hcl oral tablet ramipril oral capsule trandolapril oral tablet ADRENOLYTICS-CENTRAL & THIAZIDE/THIAZIDE-LIKE COMB methyldopa-hydrochlorothiazide oral tablet AGENTS FOR PHEOCHROMOCYTOMA DIBENZYLINE ORAL CAPSULE ANGIOTENSIN II RECEPTOR ANTAG & CA CHANNEL BLOCKER COMB QL Quantity Limit applies SP Specialty Pharmacy Maintenance Drug No Cost Share ($0) 2016 Commercial 3 Tier Formulary Version 4 Page 29

30 amlodipine besylate-valsartan oral tablet ANGIOTENSIN II RECEPTOR ANT-CA CHANNEL BLOCKER- THIAZIDES AZOR ORAL TABLET ANGIOTENSIN II RECEPTOR ANTAG & THIAZIDE/THIAZIDE- LIKE BENICAR HCT ORAL TABLET candesartan cilexetil-hctz oral tablet ; QL (31 EA per 31 Days) irbesartan-hydrochlorothiazide oral tablet losartan potassium-hctz oral tablet valsartan-hydrochlorothiazide oral tablet ANGIOTENSIN II RECEPTOR ANTAGONISTS BENICAR ORAL TABLET ; 1/2 candesartan cilexetil oral tablet ; QL (31 EA per 31 Days) eprosartan mesylate oral tablet irbesartan oral tablet 150 mg, 75 mg irbesartan oral tablet 300 mg ; 1/2 losartan potassium oral tablet 100 mg, 50 mg ; 1/2 losartan potassium oral tablet 25 mg telmisartan oral tablet valsartan oral tablet ; 1/2 amlodipine-valsartan-hctz oral tablet TRIBENZOR ORAL TABLET ANTIADRENERGICS - CENTRALLY ACTING clonidine hcl oral tablet clonidine hcl transdermal patch weekly guanfacine hcl oral tablet methyldopa oral tablet ANTIADRENERGICS - PERIPHERALLY ACTING doxazosin mesylate oral tablet prazosin hcl oral capsule terazosin hcl oral capsule BETA BLOCKER & DIURETIC COMBINATIONS atenolol-chlorthalidone oral tablet bisoprolol-hydrochlorothiazide oral tablet metoprolol-hydrochlorothiazide oral tablet propranolol-hctz oral tablet DIRECT RENIN INHIBITORS & CALCIUM CHANNEL BLOCKER COMB TEKAMLO ORAL TABLET QL Quantity Limit applies SP Specialty Pharmacy Maintenance Drug No Cost Share ($0) 2016 Commercial 3 Tier Formulary Version 4 Page 30

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

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

More information

Information for Vermont Prescribers of Prescription Drugs (Long Form)

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

More information

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

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

5 Tier Commercial Formulary (List of Covered Drugs)

5 Tier Commercial Formulary (List of Covered Drugs) Effective: August 1, 2015 Small Group Qualified Health Plans Individual Qualified Health Plans What is the Drug List? Also called a formulary by doctors and pharmacists, the Drug List is an extensive list

More information

Information for Vermont Prescribers of Prescription Drugs (Long Form)

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

More information

PHP Commercial Large Group Plans (Non-Metal Plans) Formulary Therapeutic Class Listing

PHP Commercial Large Group Plans (Non-Metal Plans) Formulary Therapeutic Class Listing Presbyterian Health Plan Presbyterian Insurance Company, Inc. PHP Commercial Large Group Plans (Non-Metal Plans) Formulary Therapeutic Class Listing This list is in order by therapeutic class. To find

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

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

2017 Drug List for Qualified Health Plans

2017 Drug List for Qualified Health Plans 207 Drug List for Qualified Health Plans HAP Personal Alliance and small group Use this drug list also known as a formulary to learn about the prescription drugs we cover in all qualified health plans.

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

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

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

Information for Vermont Prescribers of Prescription Drugs (Long Form)

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

More information

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

AETNA BETTER HEALTH Formulary Guide Aetna Better Health Of Virginia Formulary Guide October 2017

AETNA BETTER HEALTH Formulary Guide Aetna Better Health Of Virginia Formulary Guide October 2017 AETNA BETTER HEALTH Formulary Guide Aetna Better Health Of Virginia Formulary Guide October 2017 http://www.aetnabetterhealth.com/virginia AETNA BETTER HEALTH Formulary Guide What is the Aetna Better Health

More information

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

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

More information

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

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

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

More information

AETNA BETTER HEALTH Formulary Guide Aetna Better Health Of Virginia Formulary Guide June 2017

AETNA BETTER HEALTH Formulary Guide Aetna Better Health Of Virginia Formulary Guide June 2017 AETNA BETTER HEALTH Formulary Guide Aetna Better Health Of Virginia Formulary Guide June 2017 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 Virginia Formulary Guide April 2017

AETNA BETTER HEALTH Formulary Guide Aetna Better Health Of Virginia Formulary Guide April 2017 AETNA BETTER HEALTH Formulary Guide Aetna Better Health Of Virginia Formulary Guide April 2017 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 Virginia Formulary Guide December 2017

AETNA BETTER HEALTH Formulary Guide Aetna Better Health Of Virginia Formulary Guide December 2017 AETNA BETTER HEALTH Formulary Guide Aetna Better Health Of Virginia Formulary Guide December 2017 http://www.aetnabetterhealth.com/virginia AETNA BETTER HEALTH Formulary Guide What is the Aetna Better

More information

AETNA BETTER HEALTH Formulary Guide Aetna Better Health Of Virginia Formulary Guide August 2017

AETNA BETTER HEALTH Formulary Guide Aetna Better Health Of Virginia Formulary Guide August 2017 AETNA BETTER HEALTH Formulary Guide Aetna Better Health Of Virginia Formulary Guide August 2017 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 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

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

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

More information

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

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

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

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

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

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

More information

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

Step Therapy Criteria Last Updated 6/1/2018

Step Therapy Criteria Last Updated 6/1/2018 Step Therapy Last Updated 6/1/2018 For information on obtaining an updated coverage determination or an exception to a coverage determination please call Freedom Health Member Services at 1-800-401-2740

More information

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

South Carolina Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 2015 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

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

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

More information

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

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

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

More information

2017 Ohana Medicaid Comprehensive Preferred Drug List (QUEST Integration) (List of Covered Drugs)

2017 Ohana Medicaid Comprehensive Preferred Drug List (QUEST Integration) (List of Covered Drugs) 2017 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

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

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

More information

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

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

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

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

More information

2018 Care1st Health Plan Arizona Medicaid Comprehensive Preferred Drug List (List of Covered Drugs)

2018 Care1st Health Plan Arizona Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 2018 Care1st Health lan Arizona Medicaid Comprehensive referred Drug List (List of Covered Drugs) Care1st Health lan Arizona lease read: This document contains information about the we cover in this plan.

More information

2019 Ohana Medicaid Comprehensive Preferred Drug List (QUEST Integration) (List of Covered Drugs)

2019 Ohana Medicaid Comprehensive Preferred Drug List (QUEST Integration) (List of Covered Drugs) 2019 Ohana Medicaid Comprehensive referred Drug List (QUEST Integration) (List of Covered Drugs) Ohana Health lan lease read this document. It has details about the drugs we cover for the Ohana QUEST Integration

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 lease read this document. It has details about the drugs we cover for the Ohana QUEST Integration

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 Formulary Guide. Aetna Better Health of Florida Florida Healthy Kids Formulary Guide January 2019

AETNA BETTER HEALTH Formulary Guide. Aetna Better Health of Florida Florida Healthy Kids Formulary Guide January 2019 AETNA BETTER HEALTH Formulary Guide Aetna Better Health of Florida Florida Healthy Kids Formulary Guide January 2019 AETNA BETTER HEALTH Formulary Guide www.aetnabetterhealth.com/florida What is a Formulary?

More information

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

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

More information

AETNA BETTER HEALTH Formulary Guide Aetna Better Health Pennsylvania Formulary Guide May 2017

AETNA BETTER HEALTH Formulary Guide Aetna Better Health Pennsylvania Formulary Guide May 2017 AETNA BETTER HEALTH Formulary Guide 2017 Aetna Better Health Pennsylvania Formulary Guide May 2017 AETNA BETTER HEALTH Formulary Guide 2017 What is the Aetna Better Health in Pennsylvania Formulary? This

More information

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

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

More information

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

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

More information

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

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

More information

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

AETNA BETTER HEALTH Formulary Guide Aetna Better Health Pennsylvania Formulary Guide April 2019

AETNA BETTER HEALTH Formulary Guide Aetna Better Health Pennsylvania Formulary Guide April 2019 AETNA BETTER HEALTH Formulary Guide 2019 Aetna Better Health Pennsylvania Formulary Guide April 2019 AETNA BETTER HEALTH Formulary Guide 2019 What is the Aetna Better Health in Pennsylvania Formulary?

More information

Allergies and Cold & Flu

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

More information

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

AETNA BETTER HEALTH Formulary Guide. Aetna Better Health of Florida Florida Healthy Kids Formulary Guide October 2017

AETNA BETTER HEALTH Formulary Guide. Aetna Better Health of Florida Florida Healthy Kids Formulary Guide October 2017 AETNA BETTER HEALTH Formulary Guide Aetna Better Health of Florida Florida Healthy Kids Formulary Guide October 2017 AETNA BETTER HEALTH Formulary Guide https://www.aetnabetterhealth.com/florida What is

More information

2018 New Jersey Medicaid Comprehensive Preferred Drug List (List of Covered Drugs)

2018 New Jersey Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 2018 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

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

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

More information

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

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

More information

AETNA BETTER HEALTH Formulary Guide Aetna Better Health Pennsylvania Formulary Guide March 2019

AETNA BETTER HEALTH Formulary Guide Aetna Better Health Pennsylvania Formulary Guide March 2019 AETNA BETTER HEALTH Formulary Guide 2019 Aetna Better Health Pennsylvania Formulary Guide March 2019 AETNA BETTER HEALTH Formulary Guide 2019 What is the Aetna Better Health in Pennsylvania Formulary?

More information

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

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

More information

2018 South Carolina Medicaid Comprehensive Preferred Drug List (List of Covered Drugs)

2018 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 lease read: This document contains information about the drugs we cover in this plan. lease

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) 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

2018 South Carolina Medicaid Comprehensive Preferred Drug List (List of Covered Drugs)

2018 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 lease read: This document contains information about the drugs we cover in this plan. lease

More information

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

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

More information

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

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

More information

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

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

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

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

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

New York Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 2017 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

2019 Kentucky Medicaid Comprehensive Preferred Drug List (List of Covered Drugs)

2019 Kentucky Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 2019 Kentucky Medicaid Comprehensive referred Drug List (List of Covered Drugs) WellCare of Kentucky lease read: This document contains information about the drugs we cover in this plan. lease note that

More information

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

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

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

Partnership 2017 Formulary. List of Covered Drugs

Partnership 2017 Formulary. List of Covered Drugs Partnership 207 Formulary List of Covered Drugs PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN ID 7379, Version Number 26 This formulary was updated on 0/24/207.

More information

Memorial Hermann Advantage HMO Formulary. (List of Covered Drugs)

Memorial Hermann Advantage HMO Formulary. (List of Covered Drugs) Memorial Hermann Advantage H 2019 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission ID 19563,

More information

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

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

More information

Health First Health Plans 2015 Formulary (List of Covered Drugs)

Health First Health Plans 2015 Formulary (List of Covered Drugs) Updated: October 27, 2015 Florida Hospital SunSaver Plan (HMO-POS) Florida Hospital Explorer Plan (HMO-POS) Health First Health Plans 2015 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS

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 of Louisiana. February 2018

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

More information

COMPREHENSIVE FORMULARY

COMPREHENSIVE FORMULARY COMPREHENSIVE FORMULARY HEALTHTEAM ADVANTAGE PLAN I (PPO) HEALTHTEAM ADVANTAGE PLAN II (PPO) (LIST OF COVERED DRUGS) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN

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

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

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

New York Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 2017 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

Aetna Better Health of Louisiana

Aetna Better Health of Louisiana AETNA BETTER HEALTH Formulary Guide Aetna Better Health of Louisiana Formulary Guide January 2019 www.aetnabetterhealth.com/louisiana 1 AETNA BETTER HEALTH Formulary Guide What is the Aetna Better Health

More information

Memorial Hermann Advantage HMO & PPO Formulary. (List of Covered Drugs)

Memorial Hermann Advantage HMO & PPO Formulary. (List of Covered Drugs) Memorial Hermann Advantage H & PPO 2017 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File 00017383, Version

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

Aetna Better Health of Louisiana. December 2018

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

More information

Mercy Care Table of Contents

Mercy Care Table of Contents List Mercy Care Table of Contents *ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS*...5 *ALTERNATIVE MEDICINES*... 8 *AMINOGLYCOSIDES*... 8 *ANALGESICS - ANTI-INFLAMMATORY*... 8 *ANALGESICS - NONNARCOTIC*...11

More information

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

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

More information

Mercy Care Table of Contents

Mercy Care Table of Contents List April 2019 Mercy Care Table of Contents *ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS*...3 *ALTERNATIVE MEDICINES*... 6 *AMINOGLYCOSIDES*... 6 *ANALGESICS - ANTI-INFLAMMATORY*... 6 *ANALGESICS -

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

Mercy Care Table of Contents

Mercy Care Table of Contents List January 2019 Mercy Care Table of Contents *ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS*...3 *ALTERNATIVE MEDICINES*... 6 *AMINOGLYCOSIDES*... 6 *ANALGESICS - ANTI-INFLAMMATORY*... 6 *ANALGESICS

More information

Mercy Care Table of Contents

Mercy Care Table of Contents List February 2019 Mercy Care Table of Contents *ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS*...3 *ALTERNATIVE MEDICINES*... 6 *AMINOGLYCOSIDES*... 6 *ANALGESICS - ANTI-INFLAMMATORY*... 6 *ANALGESICS

More information

Mercy Care Table of Contents

Mercy Care Table of Contents List January 2019 Mercy Care Table of Contents *ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS*...5 *ALTERNATIVE MEDICINES*... 8 *AMINOGLYCOSIDES*... 8 *ANALGESICS - ANTI-INFLAMMATORY*... 8 *ANALGESICS

More information

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

South Carolina Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 2016 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

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

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

More information

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

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

South Carolina Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) 2017 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