2019 Commercial 5-Tier Formulary (List of Covered Drugs) What is the Drug List?
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1 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? 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 a 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 five cost-sharing tiers. Drug costs vary 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 (T1) - Includes low-cost preferred generic drugs. Tier 2 () - Includes higher-cost generic drugs. Tier 3 () - Includes preferred brand-name drugs and some higher-cost generic drugs. Tier 4 () - Includes higher-cost non-preferred brand-name drugs and generic drugs (some plans may be limited to a 30-daysupply). Tier 5 (T5 SP) - Includes higher-cost biologics or prescription drugs that require close monitoring for safety and efficacy. These medications must be obtained from Health First Family Pharmacy when possible and are limited to a 30-day supply. Preventive Care () - Includes some select preventive products, prescription medications and specific over-the-counter (OTC) medications available to you at no cost-sharing ($0) when applicable conditions are met. Generic drugs are prescription drugs that have the same active ingredients as brand drugs and are prescribed for the same reasons. When the patent expires on a brand name drug, the FDA permits new manufacturers to produce an equivalent of the brand name drug and make it available to the public. Generally, more than one manufacturer will produce 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 that is as safe and effective as the brand name drug Commercial/TPA 5 Tier Formulary Version 1 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-thecounter (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 4 or removed from the formulary. This formulary is current as of January 01, 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 Commercial/TPA 5 Tier Formulary Version 1 Page 2
3 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 TRADJENTA. 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 discounts for covered medications. To help you manage your drug costs, here are some money-saving tips to consider: Use 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. Talk to your doctor to see if switching to a generic equivalent of any brand-name drug you are taking is appropriate. Please see the list of drugs below to determine which generic drugs are included in lower cost-sharing tiers. 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 4 cost share unless the cost of the medication is greater than $500 per month, then it will be covered at the Tier 5 cost share. 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. The following are NOT covered by The Plan: Compounded drugs Cosmetics or any drugs used for cosmetic purposes 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) Some injectables (except insulin, Imitrex, and those requiring prior authorization) Most multivitamins and nutritional supplements (except prescription pre-natal vitamins and products covered under the Preventive Care benefit) Nonprescription supplies or substances Over-the-counter (OTC) medications (except products covered under the Preventive Care benefit), 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 2019 Commercial/TPA 5 Tier Formulary Version 1 Page 3
4 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 This list will be reviewed periodically and is subject to change. Medicine/Product Category and Who is Covered Examples of the Medicine/Product Covered Aspirin Individuals < 60 years Aspirin products < 325 MG Fluoride Children age 6 months through 5 years Folic Acid Women only through age 50 years Vitamin D Supplements Adults > 65 years of age Immunizations The age of coverage varies based on the vaccine product prescribed and recommendations by the U.S. Centers for Disease Control and Prevention Fluoride Chewable Tablet 0.25 MG and 0.5 MG; Fluoride Drops MG, 0.25 MG and 0.5 MG; Multivitamin W/ Fluoride Chewable 0.25 MG and 0.5 MG; Multivitamin W/ Fluoride Drops 0.25 MG and 0.5 MG; Multivitamin W/ Fluoride Suspension 0.25 MG and 0.5 MG Folic Acid Tablet 0.4 MG and 0.8 MG; Prenatal Multivitamins W/ Folic Acid (0.4 MG and 0.8 MG) Vitamin D 1,000 Units Or Less Per Dose Unit; Calcium With Vitamin D (1,000 Units Or Less Per Dose Unit) Covered immunizations include those that are routine vaccines recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention and that meet the 2019 Commercial/TPA 5 Tier Formulary Version 1 Page 4
5 Medicine/Product Category and Who is Covered Contraceptive Methods Women only, through age 50 years Examples of the Medicine/Product Covered US Food and Drug Administration approved indications for age and/or gender limitations. Coverage also includes nonroutine immunizations used to prevent other illnesses such as typhoid, yellow fever, and Japanese encephalitis. Covered products include one or more Food and Drug Administration (FDA) approved 16 contraceptive methods available through the prescription drug benefit, including: Generic OTC spermicide and legend diaphragms; Today contraceptive sponge; Female condom; Femcap ; Generic oral, transdermal and intramuscular hormonal methods; Nuvaring ; Generic, OTC emergency contraceptives and Ella ; The intrauterine systems Mirena and Paragard ; The intradermal agent, Nexplanon If you have any questions regarding your eligibility for preventive care medications and preventive contraceptive coverage, please contact your employer or call Customer Service tollfree at (TTY/TDD relay: ) Monday through Friday from 8 a.m. to 6 p.m Commercial/TPA 5 Tier Formulary Version 1 Page 5
6 Step Therapy Reference Table Drug Name ALMOTRIPTAN, FROVATRIPTAN, NARATRIPTAN, RELPAX, ZOLMITRIPTAN, ZOLMITRIPTAN ODT, ZOMIG NASAL FOSRENAL, RENAGEL, RENVELA OXICONAXOLE ULORIC VIIBRYD WELCHOL SYMBICORT Drug that must be tried first Sumatriptan, rizatriptan in the last 180 days calcium acetate 667 mg in the last 180 days ketoconazole AND clotrimazole topical products in the last 180 days Allopurinol in the last 180 days Trial of any two (2) of the following drugs: bupropion, citalopram, duloxetine, escitalopram, fluoxetine, mirtazapine, paroxetine, sertraline, trazodone, venlafaxine in the last year cholestyramine or colestipol in the last 180 days Advair in the last 180 days 2019 Commercial/TPA 5 Tier Formulary Version 1 Page 6
7 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 98. 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 (SP): 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 (PA): 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 EA per 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 6. 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). No Cost-Share (): Select preventive products, prescription medications and specific over-the-counter (OTC) medications available to our members at no cost-sharing ($0) when applicable conditions are met Commercial/TPA 5 Tier Formulary Version 1 Page 7
8 2019 Commercial/TPA 5 Tier Formulary Version 1 Page 8
9 ANALGESICS acetaminophen-codeine oral solution 120 mg-12 mg /5 ml (5 ml), mg/5 ml, 240 mg-24 mg /10 ml (10 ml), 300 mg-30 mg /12.5 ml acetaminophen-codeine oral tablet mg, mg 2019 Commercial/TPA 5 Tier Formulary Version 1 Page 9 QL (2700 ML per 30 days) QL (240 EA per 30 days) acetaminophen-codeine oral tablet mg QL (180 EA per 30 days) almotriptan malate oral tablet 12.5 mg, 6.25 mg ST; QL (18 EA per 30 days) ASCOMP WITH CODEINE ORAL CAPSULE MG aspirin oral tablet 325 mg aspirin oral tablet,delayed release (dr/ec) 325 mg BAYER ASPIRIN ORAL TABLET 325 MG BUTALBITAL COMPOUND W/CODEINE ORAL CAPSULE MG butalbital-acetaminop-caf-cod oral capsule mg, mg QL (180 EA per 30 days) QL (180 EA per 30 days) butalbital-acetaminophen oral tablet mg QL (180 EA per 30 days) butalbital-acetaminophen-caff oral capsule mg butalbital-acetaminophen-caff oral tablet mg butalbital-aspirin-caffeine oral capsule mg butorphanol tartrate injection solution 1 mg/ml, 2 mg/ml BUTRANS TRANSDERMAL PATCH WEEKLY 10 MCG/HOUR, 15 MCG/HOUR, 20 MCG/HOUR, 5 MCG/HOUR, 7.5 MCG/HOUR QL (180 EA per 30 days) QL (180 EA per 30 days) QL (180 EA per 30 days) QL (4 EA per 28 days) codeine sulfate oral tablet 15 mg, 30 mg, 60 mg QL (180 EA per 30 days) codeine-butalbital-asa-caff oral capsule mg diclofenac potassium oral tablet 50 mg dihydroergotamine injection solution 1 mg/ml dihydroergotamine nasal spray,non-aerosol 0.5 mg/pump act. (4 mg/ml) ELMIRON ORAL CAPSULE 100 MG QL (180 EA per 30 days)
10 ENDOCET ORAL TABLET MG QL (180 EA per 30 days) ENDOCET ORAL TABLET MG, MG, MG ERGOMAR SUBLINGUAL TABLET 2 MG fentanyl citrate buccal lozenge on a handle 1,200 mcg, 1,600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcg fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr QL (240 EA per 30 days) PA; QL (120 EA per 30 days) QL (15 EA per 30 days) frovatriptan oral tablet 2.5 mg ST; QL (18 EA per 30 days) hydrocodone-acetaminophen oral solution mg/15 ml hydrocodone-acetaminophen oral tablet mg, mg hydrocodone-acetaminophen oral tablet mg, mg, mg, mg, mg hydrocodone-acetaminophen oral tablet mg hydrocodone-ibuprofen oral tablet mg, mg, mg QL (2700 ML per 30 days) QL (180 EA per 30 days) QL (240 EA per 30 days) QL (84 EA per 30 days) QL (50 EA per 30 days) hydromorphone oral tablet 2 mg, 4 mg, 8 mg QL (180 EA per 30 days) ibuprofen-oxycodone oral tablet mg QL (28 EA per 30 days) ketorolac oral tablet 10 mg levorphanol tartrate oral tablet 2 mg QL (180 EA per 30 days) LITE COAT ASPIRIN ORAL TABLET 325 MG mefenamic acid oral capsule 250 mg meperidine oral tablet 100 mg, 50 mg QL (180 EA per 30 days) methadone oral tablet 10 mg, 5 mg QL (240 EA per 30 days) MIGERGOT RECTAL SUPPOSITORY MG morphine concentrate oral solution 100 mg/5 ml (20 mg/ml) QL (20 EA per 28 days) QL (600 ML per 30 days) morphine concentrate oral syringe 20 mg/ml QL (600 EA per 30 days) morphine oral solution 10 mg/5 ml QL (2700 ML per 30 days) morphine oral solution 20 mg/5 ml (4 mg/ml) QL (1350 ML per 30 days) morphine oral tablet 15 mg, 30 mg QL (180 EA per 30 days) morphine oral tablet extended release 100 mg, 15 mg, 30 mg, 60 mg QL (90 EA per 30 days) morphine oral tablet extended release 200 mg QL (60 EA per 30 days) 2019 Commercial/TPA 5 Tier Formulary Version 1 Page 10
11 naratriptan oral tablet 1 mg, 2.5 mg ST; QL (18 EA per 30 days) NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR 100 MG, 150 MG, 200 MG, 250 MG, 50 MG NUCYNTA ORAL TABLET 100 MG, 50 MG, 75 MG PA; QL (60 EA per 30 days) PA; QL (180 EA per 30 days) oxycodone oral solution 5 mg/5 ml QL (5400 ML per 30 days) oxycodone oral tablet 10 mg, 15 mg, 20 mg QL (180 EA per 30 days) oxycodone oral tablet 30 mg QL (120 EA per 30 days) oxycodone oral tablet 5 mg QL (240 EA per 30 days) oxycodone-acetaminophen oral tablet mg QL (180 EA per 30 days) oxycodone-acetaminophen oral tablet mg, mg, mg QL (240 EA per 30 days) oxycodone-aspirin oral tablet mg QL (360 EA per 30 days) oxymorphone oral tablet 10 mg, 5 mg QL (120 EA per 30 days) oxymorphone oral tablet extended release 12 hr 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg, 7.5 mg pentazocine-naloxone oral tablet mg QL (60 EA per 30 days) RELPAX ORAL TABLET 20 MG, 40 MG ST; QL (18 EA per 30 days) rizatriptan oral tablet 10 mg, 5 mg QL (18 EA per 30 days) rizatriptan oral tablet,disintegrating 10 mg, 5 mg QL (18 EA per 30 days) sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg sumatriptan succinate subcutaneous pen injector 6 mg/0.5 ml sumatriptan succinate subcutaneous solution 6 mg/0.5 ml QL (18 EA per 30 days) QL (8 ML per 30 days) QL (8 ML per 30 days) tramadol oral tablet 50 mg QL (240 EA per 30 days) tramadol oral tablet extended release 24 hr 100 mg, 200 mg, 300 mg tramadol oral tablet, er multiphase 24 hr 100 mg, 200 mg, 300 mg QL (30 EA per 30 days) QL (30 EA per 30 days) tramadol-acetaminophen oral tablet mg QL (240 EA per 30 days) XTAMPZA ER ORAL CAPSULE,SPRINKLE,ER 12HR TMPRR 13.5 MG, 18 MG, 27 MG, 36 MG, 9 MG QL (60 EA per 30 days) zolmitriptan oral tablet 2.5 mg, 5 mg ST; QL (18 EA per 30 days) 2019 Commercial/TPA 5 Tier Formulary Version 1 Page 11
12 zolmitriptan oral tablet,disintegrating 2.5 mg, 5 mg ZOMIG NASAL SPRAY,NON-AEROSOL 2.5 MG, 5 MG ANESTHETICS lidocaine hcl laryngotracheal solution 4 % lidocaine hcl mucous membrane jelly 2 % lidocaine hcl mucous membrane solution 4 % (40 mg/ml) lidocaine hcl topical cream 3 % lidocaine hcl topical lotion 3 % ST; QL (18 EA per 30 days) ST; QL (12 EA per 30 days) lidocaine topical adhesive patch,medicated 5 % PA; QL (90 EA per 30 days) lidocaine topical ointment 5 % PA; QL (150 GM per 30 days) LIDOCAINE VISCOUS MUCOUS MEMBRANE SOLUTION 2 % lidocaine-prilocaine topical cream % lidocaine-prilocaine topical kit % phenazopyridine oral tablet 100 mg, 200 mg SYNERA TOPICAL PATCH, MEDICATED SELF-HEATING MG ANTIALLERGY cromolyn oral concentrate 100 mg/5 ml ANTIARTHRITICS allopurinol oral tablet 100 mg, 300 mg celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg colchicine oral capsule 0.6 mg colchicine oral tablet 0.6 mg DEPEN TITRATABS ORAL TABLET 250 MG diclofenac sodium oral tablet extended release 24 hr 100 mg diclofenac sodium oral tablet,delayed release (dr/ec) 25 mg, 50 mg, 75 mg etodolac oral capsule 200 mg, 300 mg etodolac oral tablet 400 mg, 500 mg etodolac oral tablet extended release 24 hr 400 mg, 500 mg, 600 mg fenoprofen oral tablet 600 mg PA ; QL (60 EA per 30 days) 2019 Commercial/TPA 5 Tier Formulary Version 1 Page 12
13 flurbiprofen oral tablet 100 mg flurbiprofen oral tablet 50 mg ibuprofen oral tablet 400 mg, 600 mg, 800 mg T1 indomethacin oral capsule 25 mg, 50 mg ketoprofen oral capsule 50 mg, 75 mg leflunomide oral tablet 10 mg, 20 mg ; QL (30 EA per 30 days) meclofenamate oral capsule 100 mg meclofenamate oral capsule 50 mg meloxicam oral suspension 7.5 mg/5 ml meloxicam oral tablet 15 mg, 7.5 mg nabumetone oral tablet 500 mg, 750 mg naproxen oral tablet 250 mg, 375 mg, 500 mg T1 naproxen oral tablet,delayed release (dr/ec) 375 mg, 500 mg OTEZLA ORAL TABLET 30 MG PA; OTEZLA STARTER ORAL TABLETS,DOSE PACK 10 MG (4)-20 MG (4)-30 MG (47), 10 MG (4)-20 MG (4)-30 MG(19) oxaprozin oral tablet 600 mg piroxicam oral capsule 10 mg, 20 mg probenecid oral tablet 500 mg probenecid-colchicine oral tablet mg RIDAURA ORAL CAPSULE 3 MG sulindac oral tablet 150 mg, 200 mg tolmetin oral capsule 400 mg tolmetin oral tablet 200 mg, 600 mg ULORIC ORAL TABLET 40 MG, 80 MG ST; XELJANZ ORAL TABLET 10 MG PA; ; QL (60 EA per 30 days) XELJANZ ORAL TABLET 5 MG PA; XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR 11 MG ANTIASTHMATICS acetylcysteine solution 100 mg/ml (10 %), 200 mg/ml (20 %) PA PA; 2019 Commercial/TPA 5 Tier Formulary Version 1 Page 13
14 ADVAIR DISKUS INHALATION BLISTER WITH DEVICE MCG/DOSE, MCG/DOSE, MCG/DOSE ADVAIR HFA INHALATION HFA AEROSOL INHALER MCG/ACTUATION, MCG/ACTUATION, MCG/ACTUATION albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %), 2.5 mg/0.5 ml, 5 mg/ml albuterol sulfate oral syrup 2 mg/5 ml albuterol sulfate oral tablet 2 mg, 4 mg aminophylline intravenous solution 250 mg/10 ml ANORO ELLIPTA INHALATION BLISTER WITH DEVICE MCG/ACTUATION ARCAPTA NEOHALER INHALATION CAPSULE, W/INHALATION DEVICE 75 MCG ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 200 MCG/ACTUATION ASMANEX HFA INHALATION HFA AEROSOL INHALER 100 MCG/ACTUATION, 200 MCG/ACTUATION ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (30 DOSES), 220 MCG (120 DOSES), 220 MCG (30 DOSES), 220 MCG (60 DOSES) ATROVENT HFA INHALATION HFA AEROSOL INHALER 17 MCG/ACTUATION BREO ELLIPTA INHALATION BLISTER WITH DEVICE MCG/DOSE, MCG/DOSE BROVANA INHALATION SOLUTION FOR NEBULIZATION 15 MCG/2 ML budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml, 1 mg/2 ml COMBIVENT RESPIMAT INHALATION MIST MCG/ACTUATION cromolyn inhalation solution for nebulization 20 mg/2 ml DULERA INHALATION HFA AEROSOL INHALER MCG/ACTUATION, MCG/ACTUATION ; QL (60 EA per 30 days) ; QL (12 GM per 30 days) ; QL (13 GM per 30 days) ; QL (1 EA per 30 days) ; QL (26 GM per 30 days) PA; ; QL (8 GM per 30 days) ; QL (13 GM per 30 days) 2019 Commercial/TPA 5 Tier Formulary Version 1 Page 14
15 FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 50 MCG/ACTUATION FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 220 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ACTUATION ipratropium bromide inhalation solution 0.02 % ipratropium-albuterol inhalation solution for nebulization 0.5 mg-3 mg(2.5 mg base)/3 ml levalbuterol hcl inhalation solution for nebulization 0.31 mg/3 ml, 0.63 mg/3 ml, 1.25 mg/0.5 ml, 1.25 mg/3 ml metaproterenol oral syrup 10 mg/5 ml metaproterenol oral tablet 10 mg, 20 mg montelukast oral granules in packet 4 mg ; QL (60 EA per 30 days) ; QL (240 EA per 30 days) ; QL (12 GM per 30 days) ; QL (24 GM per 30 days) ; QL (10.6 GM per 30 days) montelukast oral tablet 10 mg ; QL (30 EA per 30 days) montelukast oral tablet,chewable 4 mg, 5 mg ; QL (30 EA per 30 days) SEREVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCG/DOSE SPIRIVA RESPIMAT INHALATION MIST 1.25 MCG/ACTUATION, 2.5 MCG/ACTUATION SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE 18 MCG STIOLTO RESPIMAT INHALATION MIST MCG/ACTUATION STRIVERDI RESPIMAT INHALATION MIST 2.5 MCG/ACTUATION SYMBICORT INHALATION HFA AEROSOL INHALER MCG/ACTUATION, MCG/ACTUATION terbutaline oral tablet 2.5 mg, 5 mg theophylline oral tablet extended release 12 hr 100 mg, 200 mg, 300 mg, 450 mg ; QL (60 EA per 30 days) ; QL (4 GM per 30 days) ; QL (30 EA per 30 days) ; QL (4 GM per 30 days) ST; ; QL (10.2 GM per 30 days) 2019 Commercial/TPA 5 Tier Formulary Version 1 Page 15
16 TRELEGY ELLIPTA INHALATION BLISTER WITH DEVICE MCG VENTOLIN HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION XOLAIR SUBCUTANEOUS RECON SOLN 150 MG PA; ; QL (36 GM per 30 days) PA; zafirlukast oral tablet 10 mg, 20 mg ; QL (60 EA per 30 days) ZYFLO CR ORAL TABLET, ER MULTIPHASE 12 HR 600 MG PA; ; QL (120 EA per 30 days) ZYFLO ORAL TABLET 600 MG PA; ; QL (120 EA per 30 days) ANTIBIOTICS AK-POLY-BAC OPHTHALMIC (EYE) OINTMENT ,000 UNIT/GRAM amoxicillin oral capsule 250 mg, 500 mg amoxicillin oral suspension for reconstitution 125 mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml amoxicillin oral tablet 500 mg, 875 mg amoxicillin oral tablet,chewable 125 mg amoxicillin oral tablet,chewable 250 mg amoxicillin-pot clavulanate oral suspension for reconstitution mg/5 ml, mg/5 ml, mg/5 ml amoxicillin-pot clavulanate oral suspension for reconstitution mg/5 ml amoxicillin-pot clavulanate oral tablet mg amoxicillin-pot clavulanate oral tablet mg, mg amoxicillin-pot clavulanate oral tablet extended release 12 hr 1, mg amoxicillin-pot clavulanate oral tablet,chewable mg, mg ampicillin oral capsule 250 mg, 500 mg AVAR TOPICAL CLEANSER 10-5 % (W/W) AVAR-E GREEN TOPICAL CREAM 10-5 % (W/W) AVAR-E TOPICAL CREAM 10-5 % (W/W) AZASITE OPHTHALMIC (EYE) DROPS 1 % azithromycin oral packet 1 gram T1 T1 T1 T Commercial/TPA 5 Tier Formulary Version 1 Page 16
17 azithromycin oral suspension for reconstitution 100 mg/5 ml, 200 mg/5 ml azithromycin oral tablet 250 mg, 500 mg, 600 mg bacitracin ophthalmic (eye) ointment 500 unit/gram bacitracin-polymyxin b ophthalmic (eye) ointment ,000 unit/gram BACTROBAN NASAL NASAL OINTMENT 2 % BESIVANCE OPHTHALMIC (EYE) DROPS,SUSPENSION 0.6 % BLEPHAMIDE S.O.P. OPHTHALMIC (EYE) OINTMENT % CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML cefaclor oral capsule 250 mg, 500 mg cefadroxil oral capsule 500 mg cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet 1 gram cefazolin injection recon soln 1 gram, 300 g, 500 mg cefdinir oral capsule 300 mg cefdinir oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml cefixime oral suspension for reconstitution 100 mg/5 ml, 200 mg/5 ml cefpodoxime oral suspension for reconstitution 100 mg/5 ml, 50 mg/5 ml cefpodoxime oral tablet 100 mg, 200 mg cefprozil oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml cefprozil oral tablet 250 mg, 500 mg ceftriaxone injection recon soln 1 gram, 10 gram, 2 gram, 250 mg, 500 mg cefuroxime axetil oral tablet 250 mg, 500 mg cefuroxime sodium injection recon soln 750 mg cephalexin oral capsule 250 mg, 500 mg T1 T1 PA 2019 Commercial/TPA 5 Tier Formulary Version 1 Page 17
18 cephalexin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml CILOXAN OPHTHALMIC (EYE) OINTMENT 0.3 % CIPRO HC OTIC (EAR) DROPS,SUSPENSION % CIPRODEX OTIC (EAR) DROPS,SUSPENSION % ciprofloxacin (mixture) oral tablet, er multiphase 24 hr 1,000 mg, 500 mg ciprofloxacin hcl ophthalmic (eye) drops 0.3 % ciprofloxacin hcl oral tablet 100 mg ciprofloxacin hcl oral tablet 250 mg, 500 mg, 750 mg ciprofloxacin hcl otic (ear) dropperette 0.2 % QL (60 EA per 30 days) ciprofloxacin oral suspension,microcapsule recon 250 mg/5 ml, 500 mg/5 ml clarithromycin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml clarithromycin oral tablet 250 mg, 500 mg clarithromycin oral tablet extended release 24 hr 500 mg CLEOCIN VAGINAL SUPPOSITORY 100 MG CLINDACIN ETZ TOPICAL SWAB 1 % CLINDACIN P TOPICAL SWAB 1 % clindamycin hcl oral capsule 150 mg, 300 mg clindamycin palmitate hcl oral recon soln 75 mg/5 ml clindamycin phosphate topical gel 1 % clindamycin phosphate topical lotion 1 % clindamycin phosphate topical solution 1 % clindamycin phosphate topical swab 1 % clindamycin phosphate vaginal cream 2 % COLY-MYCIN S OTIC (EAR) DROPS,SUSPENSION MG/ML CORTISPORIN TOPICAL CREAM , MG/G-UNIT/G-% CORTISPORIN TOPICAL OINTMENT 1 % cycloserine oral capsule 250 mg T1 T1 T Commercial/TPA 5 Tier Formulary Version 1 Page 18
19 dapsone oral tablet 100 mg, 25 mg demeclocycline oral tablet 150 mg, 300 mg dicloxacillin oral capsule 250 mg, 500 mg DIFICID ORAL TABLET 200 MG PA doxycycline hyclate oral capsule 100 mg, 50 mg doxycycline hyclate oral tablet 100 mg doxycycline monohydrate oral capsule 100 mg, 50 mg doxycycline monohydrate oral tablet 100 mg, 50 mg, 75 mg E.E.S. 400 ORAL TABLET 400 MG E.E.S. GRANULES ORAL SUSPENSION FOR RECONSTITUTION 200 MG/5 ML ERY PADS TOPICAL SWAB 2 % ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 250 MG, 333 MG, 500 MG ERYTHROCIN (AS STEARATE) ORAL TABLET 250 MG erythromycin ethylsuccinate oral tablet 400 mg erythromycin ophthalmic (eye) ointment 5 mg/gram (0.5 %) erythromycin oral capsule,delayed release(dr/ec) 250 mg erythromycin oral tablet 250 mg, 500 mg erythromycin with ethanol topical gel 2 % erythromycin with ethanol topical solution 2 % erythromycin with ethanol topical swab 2 % erythromycin-benzoyl peroxide topical gel 3-5 % ethambutol oral tablet 100 mg, 400 mg FIRVANQ ORAL RECON SOLN 25 MG/ML, 50 MG/ML gatifloxacin ophthalmic (eye) drops 0.5 % GENTAK OPHTHALMIC (EYE) OINTMENT 0.3 % (3 MG/GRAM) gentamicin ophthalmic (eye) drops 0.3 % gentamicin ophthalmic (eye) ointment 0.3 % (3 mg/gram) 2019 Commercial/TPA 5 Tier Formulary Version 1 Page 19
20 gentamicin topical cream 0.1 % gentamicin topical ointment 0.1 % isoniazid oral solution 50 mg/5 ml isoniazid oral tablet 100 mg, 300 mg levofloxacin ophthalmic (eye) drops 0.5 % levofloxacin oral solution 250 mg/10 ml levofloxacin oral tablet 250 mg, 500 mg, 750 mg linezolid oral suspension for reconstitution 100 mg/5 ml linezolid oral tablet 600 mg PA methenamine hippurate oral tablet 1 gram metronidazole oral tablet 250 mg, 500 mg metronidazole vaginal gel 0.75 % minocycline oral capsule 100 mg, 50 mg, 75 mg MONUROL ORAL PACKET 3 GRAM MOXEZA OPHTHALMIC (EYE) DROPS, VISCOUS 0.5 % mupirocin topical ointment 2 % neomycin oral tablet 500 mg neomycin-bacitracin-poly-hc ophthalmic (eye) ointment ,000 mg-unit/g-1% neomycin-bacitracin-polymyxin ophthalmic (eye) ointment ,000 mg-unit-unit/g neomycin-polymyxin b-dexameth ophthalmic (eye) drops,suspension 3.5mg/ml-10,000 unit/ml- 0.1 % neomycin-polymyxin b-dexameth ophthalmic (eye) ointment 3.5 mg/g-10,000 unit/g-0.1 % neomycin-polymyxin-gramicidin ophthalmic (eye) drops 1.75 mg-10,000 unit-0.025mg/ml neomycin-polymyxin-hc otic (ear) drops,suspension ,000-1 mg/ml-unit/ml-% neomycin-polymyxin-hc otic (ear) solution ,000-1 mg/ml-unit/ml-% nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg nitrofurantoin monohyd/m-cryst oral capsule 100 mg nitrofurantoin oral suspension 25 mg/5 ml PA 2019 Commercial/TPA 5 Tier Formulary Version 1 Page 20
21 ofloxacin ophthalmic (eye) drops 0.3 % ofloxacin oral tablet 400 mg ofloxacin otic (ear) drops 0.3 % penicillin v potassium oral recon soln 125 mg/5 ml, 250 mg/5 ml penicillin v potassium oral tablet 250 mg, 500 mg polymyxin b sulfate injection recon soln 500,000 unit polymyxin b sulf-trimethoprim ophthalmic (eye) drops 10,000 unit- 1 mg/ml PRIFTIN ORAL TABLET 150 MG pyrazinamide oral tablet 500 mg rifabutin oral capsule 150 mg rifampin oral capsule 150 mg, 300 mg ROSANIL TOPICAL CLEANSER 10-5 % (W/W) ROSULA CLEANSING CLOTHS TOPICAL PADS, MEDICATED 10-5 % silver sulfadiazine topical cream 1 % SSD TOPICAL CREAM 1 % SSS 10-5 TOPICAL CREAM 10-5 % (W/W) SSS 10-5 TOPICAL FOAM 10-5 % streptomycin intramuscular recon soln 1 gram sulfacetamide sodium ophthalmic (eye) drops 10 % sulfacetamide sodium ophthalmic (eye) ointment 10 % sulfacetamide sodium-sulfur topical cleanser 10-2 %, 10-5 % (w/w), %, % sulfacetamide sodium-sulfur topical cream 10-2 %, 10-5 % (w/w), % sulfacetamide sodium-sulfur topical lotion 10-5 % (w/v) sulfacetamide sodium-sulfur topical pads, medicated 10-4 % sulfacetamide sodium-sulfur topical suspension 10-5 % 2019 Commercial/TPA 5 Tier Formulary Version 1 Page 21
22 sulfacetamide sod-sulfur-urea topical cleanser % sulfadiazine oral tablet 500 mg sulfamethoxazole-trimethoprim intravenous solution mg/5 ml sulfamethoxazole-trimethoprim oral suspension mg/5 ml sulfamethoxazole-trimethoprim oral tablet mg, mg SULFAMYLON TOPICAL CREAM 85 MG/G tetracycline oral capsule 250 mg, 500 mg THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG TOBRADEX OPHTHALMIC (EYE) OINTMENT % TOBRADEX ST OPHTHALMIC (EYE) DROPS,SUSPENSION % tobramycin in % nacl inhalation solution for nebulization 300 mg/5 ml tobramycin ophthalmic (eye) drops 0.3 % tobramycin-dexamethasone ophthalmic (eye) drops,suspension % TRECATOR ORAL TABLET 250 MG trimethoprim oral tablet 100 mg vancomycin intravenous recon soln 1,000 mg, 500 mg 2019 Commercial/TPA 5 Tier Formulary Version 1 Page 22 T1 vancomycin oral capsule 125 mg, 250 mg PA VIGAMOX OPHTHALMIC (EYE) DROPS 0.5 % PA; PA; XIFAXAN ORAL TABLET 200 MG PA; QL (9 EA per 30 days) XIFAXAN ORAL TABLET 550 MG PA; ; QL (90 EA per 30 days) ZYLET OPHTHALMIC (EYE) DROPS,SUSPENSION % ANTICOAGULANTS ELIQUIS ORAL TABLET 2.5 MG, 5 MG ELIQUIS ORAL TABLETS,DOSE PACK 5 MG (74 TABS) enoxaparin subcutaneous solution 300 mg/3 ml QL (24 ML per 30 days) enoxaparin subcutaneous syringe 100 mg/ml, 150 mg/ml QL (28 ML per 30 days)
23 enoxaparin subcutaneous syringe 120 mg/0.8 ml, 80 mg/0.8 ml 2019 Commercial/TPA 5 Tier Formulary Version 1 Page 23 QL (22.4 ML per 30 days) enoxaparin subcutaneous syringe 30 mg/0.3 ml QL (8.4 ML per 30 days) enoxaparin subcutaneous syringe 40 mg/0.4 ml QL (11.2 ML per 30 days) enoxaparin subcutaneous syringe 60 mg/0.6 ml QL (16.8 ML per 30 days) fondaparinux subcutaneous syringe 10 mg/0.8 ml PA; QL (24 ML per 30 days) fondaparinux subcutaneous syringe 2.5 mg/0.5 ml PA; QL (15 ML per 30 days) fondaparinux subcutaneous syringe 5 mg/0.4 ml PA; QL (12 ML per 30 days) fondaparinux subcutaneous syringe 7.5 mg/0.6 ml PA; QL (18 ML per 30 days) heparin (porcine) injection solution 10,000 unit/ml, 20,000 unit/ml, 5,000 unit/ml heparin, porcine (pf) injection solution 1,000 unit/ml heparin, porcine (pf) injection syringe 5,000 unit/0.5 ml JANTOVEN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG warfarin oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg XARELTO ORAL TABLET 10 MG XARELTO ORAL TABLET 15 MG, 20 MG XARELTO ORAL TABLETS,DOSE PACK 15 MG (42)- 20 MG (9) ANTIDOTES MOVANTIK ORAL TABLET 12.5 MG, 25 MG PA naloxone injection syringe 1 mg/ml naltrexone oral tablet 50 mg ANTIFUNGALS caspofungin intravenous recon soln 50 mg, 70 mg PA CICLODAN TOPICAL SOLUTION 8 % ciclopirox topical cream 0.77 % ciclopirox topical gel 0.77 % ciclopirox topical shampoo 1 % ciclopirox topical solution 8 % T1 T1
24 ciclopirox topical suspension 0.77 % clotrimazole mucous membrane troche 10 mg clotrimazole topical cream 1 % clotrimazole topical solution 1 % clotrimazole-betamethasone topical cream % clotrimazole-betamethasone topical lotion % econazole topical cream 1 % ERTACZO TOPICAL CREAM 2 % PA fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg flucytosine oral capsule 250 mg, 500 mg griseofulvin microsize oral suspension 125 mg/5 ml GYNAZOLE-1 VAGINAL CREAM 2 % itraconazole oral capsule 100 mg PA; QL (120 EA per 30 days) ketoconazole oral tablet 200 mg ketoconazole topical cream 2 % ketoconazole topical shampoo 2 % MENTAX TOPICAL CREAM 1 % naftifine topical cream 1 %, 2 % NAFTIN TOPICAL GEL 1 % NATACYN OPHTHALMIC (EYE) DROPS,SUSPENSION 5 % NOXAFIL INTRAVENOUS SOLUTION 300 MG/16.7 ML NOXAFIL ORAL SUSPENSION 200 MG/5 ML (40 MG/ML) NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC) 100 MG nystatin oral suspension 100,000 unit/ml nystatin oral tablet 500,000 unit nystatin topical cream 100,000 unit/gram nystatin topical ointment 100,000 unit/gram nystatin topical powder 100,000 unit/gram nystatin-triamcinolone topical cream 100, unit/g-% PA PA PA 2019 Commercial/TPA 5 Tier Formulary Version 1 Page 24
25 nystatin-triamcinolone topical ointment 100, unit/gram-% NYSTOP TOPICAL POWDER 100,000 UNIT/GRAM oxiconazole topical cream 1 % ST terbinafine hcl oral tablet 250 mg QL (30 EA per 30 days) terconazole vaginal cream 0.4 %, 0.8 % terconazole vaginal suppository 80 mg voriconazole oral suspension for reconstitution 200 mg/5 ml (40 mg/ml) voriconazole oral tablet 200 mg, 50 mg PA VUSION TOPICAL OINTMENT % ANTIHISTAMINE AND DECONGESTANT COMBINATION PROMETHAZINE VC ORAL SYRUP MG/5 ML promethazine-phenylephrine oral syrup mg/5 ml ANTIHISTAMINES azelastine ophthalmic (eye) drops 0.05 % BEPREVE OPHTHALMIC (EYE) DROPS 1.5 % carbinoxamine maleate oral tablet 4 mg clemastine oral tablet 2.68 mg cyproheptadine oral tablet 4 mg desloratadine oral tablet 5 mg ; QL (30 EA per 30 days) diphenhydramine hcl injection solution 50 mg/ml diphenhydramine hcl injection syringe 50 mg/ml EMADINE OPHTHALMIC (EYE) DROPS 0.05 % epinastine ophthalmic (eye) drops 0.05 % hydroxyzine hcl intramuscular solution 25 mg/ml, 50 mg/ml hydroxyzine hcl oral solution 10 mg/5 ml hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg PA 2019 Commercial/TPA 5 Tier Formulary Version 1 Page 25
26 hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg LASTACAFT OPHTHALMIC (EYE) DROPS 0.25 % levocetirizine oral solution 2.5 mg/5 ml 2019 Commercial/TPA 5 Tier Formulary Version 1 Page 26 QL (6 ML per 30 days) levocetirizine oral tablet 5 mg ; QL (30 EA per 30 days) olopatadine ophthalmic (eye) drops 0.1 % QL (10 ML per 30 days) PATADAY OPHTHALMIC (EYE) DROPS 0.2 % PAZEO OPHTHALMIC (EYE) DROPS 0.7 % promethazine injection solution 25 mg/ml, 50 mg/ml promethazine oral syrup 6.25 mg/5 ml promethazine oral tablet 12.5 mg, 25 mg, 50 mg ANTIHYPERGLYCEMICS QL (10 ML per 30 days) acarbose oral tablet 100 mg, 25 mg, 50 mg ; QL (90 EA per 30 days) BYDUREON BCISE SUBCUTANEOUS AUTO-INJECTOR 2 MG/0.85 ML BYDUREON SUBCUTANEOUS PEN INJECTOR 2 MG/0.65 ML BYDUREON SUBCUTANEOUS SUSPENSION,EXTENDED REL RECON 2 MG BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/DOSE (250 MCG/ML) 1.2 ML chlorpropamide oral tablet 100 mg, 250 mg ; QL (3.4 ML per 28 days) ; QL (4 EA per 28 days) ; QL (4 EA per 28 days) ; QL (2.4 ML per 28 days) ; QL (1.2 ML per 30 days) CYCLOSET ORAL TABLET 0.8 MG PA; ; QL (180 EA per 30 days) FIASP FLEXTOUCH U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) FIASP U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML ; QL (60 ML per 30 days) ; QL (60 ML per 30 days) glimepiride oral tablet 1 mg T1 ; QL (240 EA per 30 days) glimepiride oral tablet 2 mg T1 ; QL (120 EA per 30 days) glimepiride oral tablet 4 mg T1 ; QL (60 EA per 30 days) glipizide oral tablet 10 mg T1 ; QL (120 EA per 30 days) glipizide oral tablet 5 mg T1 ; QL (240 EA per 30 days) glipizide oral tablet extended release 24hr 10 mg, 2.5 mg, 5 mg T1 ; QL (60 EA per 30 days)
27 glipizide-metformin oral tablet mg ; QL (240 EA per 30 days) glipizide-metformin oral tablet mg, mg ; QL (120 EA per 30 days) glyburide micronized oral tablet 1.5 mg, 3 mg ; QL (120 EA per 30 days) glyburide micronized oral tablet 6 mg ; QL (60 EA per 30 days) glyburide oral tablet 1.25 mg ; QL (480 EA per 30 days) glyburide oral tablet 2.5 mg ; QL (240 EA per 30 days) glyburide oral tablet 5 mg ; QL (60 EA per 30 days) glyburide-metformin oral tablet mg ; QL (240 EA per 30 days) glyburide-metformin oral tablet mg, mg GLYXAMBI ORAL TABLET 10-5 MG, 25-5 MG HUMULIN R U-500 (CONC) INSULIN SUBCUTANEOUS SOLUTION 500 UNIT/ML ; QL (120 EA per 30 days) ; QL (20 ML per 30 days) JARDIANCE ORAL TABLET 10 MG, 25 MG ; QL (30 EA per 30 days) JENTADUETO ORAL TABLET 2.5-1,000 MG, MG, MG LANTUS SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) LANTUS U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML LEVEMIR FLEXTOUCH U-100 INSULN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) LEVEMIR U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML ; QL (60 EA per 30 days) ; QL (60 ML per 30 days) ; QL (60 ML per 30 days) ; QL (60 ML per 30 days) ; QL (60 ML per 30 days) metformin oral tablet 1,000 mg T1 ; QL (60 EA per 30 days) metformin oral tablet 500 mg T1 ; QL (150 EA per 30 days) metformin oral tablet 850 mg T1 ; QL (90 EA per 30 days) metformin oral tablet extended release 24 hr 500 mg metformin oral tablet extended release 24 hr 750 mg T1 T1 ; QL (120 EA per 30 days) ; QL (60 EA per 30 days) miglitol oral tablet 100 mg, 25 mg, 50 mg ; QL (90 EA per 30 days) nateglinide oral tablet 120 mg, 60 mg ; QL (90 EA per 30 days) 2019 Commercial/TPA 5 Tier Formulary Version 1 Page 27
28 NOVOLIN 70/30 U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-30) NOVOLIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML NOVOLIN R REGULAR U-100 INSULN INJECTION SOLUTION 100 UNIT/ML NOVOLOG FLEXPEN U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML NOVOLOG MIX U-100 INSULN SUBCUTANEOUS SOLUTION 100 UNIT/ML (70-30) NOVOLOG MIX 70-30FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30) NOVOLOG PENFILL U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNIT/ML NOVOLOG U-100 INSULIN ASPART SUBCUTANEOUS SOLUTION 100 UNIT/ML OZEMPIC SUBCUTANEOUS PEN INJECTOR 0.25 MG OR 0.5 MG(2 MG/1.5 ML) OZEMPIC SUBCUTANEOUS PEN INJECTOR 1 MG/0.75 ML (2 MG/1.5 ML) ; QL (60 ML per 30 days) ; QL (60 ML per 30 days) ; QL (60 ML per 30 days) ; QL (60 ML per 30 days) ; QL (60 ML per 30 days) ; QL (60 ML per 30 days) ; QL (60 ML per 30 days) ; QL (60 ML per 30 days) ; QL (1.5 ML per 28 days) ; QL (3 ML per 28 days) pioglitazone oral tablet 15 mg, 30 mg, 45 mg ; QL (30 EA per 30 days) pioglitazone-glimepiride oral tablet 30-2 mg, 30-4 mg pioglitazone-metformin oral tablet mg, mg ; QL (30 EA per 30 days) ; QL (90 EA per 30 days) repaglinide oral tablet 0.5 mg, 1 mg, 2 mg ; QL (90 EA per 30 days) SEGLUROMET ORAL TABLET 2.5-1,000 MG, MG, 7.5-1,000 MG, MG ; QL (60 EA per 30 days) STEGLATRO ORAL TABLET 15 MG, 5 MG ; QL (30 EA per 30 days) SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR 2,700 MCG/2.7 ML SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR 1,500 MCG/1.5 ML SYNJARDY ORAL TABLET ,000 MG, MG, 5-1,000 MG, MG 2019 Commercial/TPA 5 Tier Formulary Version 1 Page 28
29 SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, ,000 MG, 25-1,000 MG, 5-1,000 MG TANZEUM SUBCUTANEOUS PEN INJECTOR 30 MG/0.5 ML, 50 MG/0.5 ML TOUJEO SOLOSTAR U-300 INSULIN SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (1.5 ML) ; QL (4 EA per 28 days) ; QL (21 ML per 30 days) TRADJENTA ORAL TABLET 5 MG ; QL (30 EA per 30 days) TRESIBA FLEXTOUCH U-100 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) TRESIBA FLEXTOUCH U-200 SUBCUTANEOUS INSULIN PEN 200 UNIT/ML (3 ML) VICTOZA 2-PAK SUBCUTANEOUS PEN INJECTOR 0.6 MG/0.1 ML (18 MG/3 ML) VICTOZA 3-PAK SUBCUTANEOUS PEN INJECTOR 0.6 MG/0.1 ML (18 MG/3 ML) ANTIINFECTIVES/MISCELLANEOU S ALBENZA ORAL TABLET 200 MG ALINIA ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML ALINIA ORAL TABLET 500 MG PA atovaquone oral suspension 750 mg/5 ml atovaquone-proguanil oral tablet mg, mg benznidazole oral tablet 100 mg, 12.5 mg PA BILTRICIDE ORAL TABLET 600 MG chloroquine phosphate oral tablet 250 mg, 500 mg DARAPRIM ORAL TABLET 25 MG hydroxychloroquine oral tablet 200 mg ivermectin oral tablet 3 mg mefloquine oral tablet 250 mg paromomycin oral capsule 250 mg PENTAM INJECTION RECON SOLN 300 MG PA ; QL (60 ML per 30 days) ; QL (36 ML per 30 days) ; QL (9 ML per 30 days) ; QL (9 ML per 30 days) PA 2019 Commercial/TPA 5 Tier Formulary Version 1 Page 29
30 primaquine oral tablet 26.3 mg QL (30 EA per 30 days) quinine sulfate oral capsule 324 mg ANTIINFLAM.TUMOR NECROSIS FACTOR INHIBITING AGENTS ENBREL SUBCUTANEOUS RECON SOLN 25 MG (1 ML) ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5ML (0.51) ENBREL SUBCUTANEOUS SYRINGE 50 MG/ML (0.98 ML) ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR 50 MG/ML (0.98 ML) HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML HUMIRA PEN CROHN'S-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA PEN PSORIASIS-UVEITIS SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2 ML, 20 MG/0.4 ML HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML ANTINEOPLASTICS ACTIMMUNE SUBCUTANEOUS SOLUTION 100 MCG/0.5 ML ADRUCIL INTRAVENOUS SOLUTION 500 MG/10 ML 2019 Commercial/TPA 5 Tier Formulary Version 1 Page 30 PA; ; QL (8 EA per 28 days) PA; ; QL (4 ML per 28 days) PA; ; QL (8 ML per 28 days) PA; ; QL (8 ML per 28 days) PA; ; QL (3 EA per 180 days) PA; ; QL (6 EA per 180 days) PA; ; QL (4 EA per 180 days) PA; ; QL (4 EA per 28 days) PA; ; QL (2 EA per 28 days) PA; ; QL (4 EA per 28 days) AFINITOR ORAL TABLET 10 MG PA; ; QL (60 EA per 30 days) AFINITOR ORAL TABLET 2.5 MG, 5 MG, 7.5 MG ALIQOPA INTRAVENOUS RECON SOLN 60 MG PA PA; PA; anastrozole oral tablet 1 mg ; QL (30 EA per 30 days) BAVENCIO INTRAVENOUS SOLUTION 20 MG/ML PA; bexarotene oral capsule 75 mg PA;
31 bicalutamide oral tablet 50 mg BUSULFEX INTRAVENOUS SOLUTION 60 MG/10 ML CALQUENCE ORAL CAPSULE 100 MG PA; capecitabine oral tablet 150 mg, 500 mg PA CAPRELSA ORAL TABLET 100 MG PA; ; QL (60 EA per 30 days) CAPRELSA ORAL TABLET 300 MG PA; ; QL (30 EA per 30 days) cyclophosphamide oral capsule 25 mg, 50 mg diclofenac sodium topical gel 3 % PA EMCYT ORAL CAPSULE 140 MG PA ERLEADA ORAL TABLET 60 MG PA; exemestane oral tablet 25 mg FARESTON ORAL TABLET 60 MG ; QL (30 EA per 30 days) fluorouracil intravenous solution 1 gram/20 ml, 2.5 gram/50 ml, 5 gram/100 ml, 500 mg/10 ml fluorouracil topical cream 5 % fluorouracil topical solution 2 %, 5 % flutamide oral capsule 125 mg GLEEVEC ORAL TABLET 100 MG, 400 MG PA; hydroxyurea oral capsule 500 mg IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG 2019 Commercial/TPA 5 Tier Formulary Version 1 Page 31 IDHIFA ORAL TABLET 100 MG, 50 MG PA; PA PA; ; QL (21 EA per 28 days) imatinib oral tablet 100 mg PA; ; QL (180 EA per 30 days) imatinib oral tablet 400 mg PA; ; QL (60 EA per 30 days) IMBRUVICA ORAL CAPSULE 140 MG PA; QL (120 EA per 30 days) IMBRUVICA ORAL CAPSULE 70 MG PA; ; QL (30 EA per 30 days) IMBRUVICA ORAL TABLET 140 MG, 280 MG, 420 MG, 560 MG INTRON A INJECTION RECON SOLN 10 MILLION UNIT (1 ML), 18 MILLION UNIT (1 ML), 50 MILLION UNIT (1 ML) INTRON A INJECTION SOLUTION 10 MILLION UNIT/ML, 6 MILLION UNIT/ML JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 5 MG PA; ; QL (30 EA per 30 days) PA PA PA; JAKAFI ORAL TABLET 25 MG PA; ; QL (60 EA per 30 days)
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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
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