Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold...

155
2021 Part D Model Formulary (Abridged and Comprehensive) 10/05/2020 1 Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 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 00021519, Version Number 6 This formulary was updated on 10/05/2020. For more recent information or other questions, please contact us, Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services, at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily excluding major holidays or visit GreatPlainsMedicareAdvantage.com.

Transcript of Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold...

Page 1: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

2021 Part D Model Formulary (Abridged and Comprehensive)

10/05/2020 1

Great Plains Medicare Advantage Gold (HMO I-SNP)

2021 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 00021519, Version Number 6 This formulary was updated on 10/05/2020. For more recent information or other questions, please contact us, Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services, at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily excluding major holidays or visit GreatPlainsMedicareAdvantage.com.

Page 2: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

2021 Part D Model Formulary (Abridged and Comprehensive)

10/05/2020 2

Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to “we,” “us”, or “our,” it means Great Plains Medicare Advantage Gold (HMO I-SNP). When it refers to “plan” or “our plan,” it means Great Plains Medicare Advantage Gold (HMO I-SNP). This document includes list of the drugs (formulary) for our plan which is current as of 10/05/2020. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2022, and from time to time during the year.

What is the Great Plains Medicare Advantage Gold (HMO I-SNP) Formulary? A formulary is a list of covered drugs selected by Great Plains Medicare Advantage in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Great Plains Medicare Advantage will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Great Plains Medicare Advantage network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

Can the Formulary (drug list) change? Most changes in drug coverage happen on January 1, but we may add or remove drugs on the Drug List during the year, move them to different cost-sharing tiers, or add new restrictions. We must follow the Medicare rules in making these changes. Changes that can affect you this year: In the below cases, you will be affected by coverage changes during the year:

• New generic drugs. We may immediately remove a brand name drug on our Drug List if we are replacing it with a new generic drug that will appear on the same or lower cost sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our Drug List, but immediately move it to a different cost-sharing tier or add new restrictions. If you are currently taking that brand name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made.

o If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on how to request an exception, and you can also find information in the section below entitled “How do I request an exception to the Great Plains Medicare Advantage Gold (HMO I-SNP)’s Formulary?”

Page 3: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

2021 Part D Model Formulary (Abridged and Comprehensive)

10/05/2020 3

• Drugs removed from the market. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug.

• Other changes. We may make other changes that affect members currently taking a drug. For instance, we may add a generic drug that is not new to market to replace a brand name drug currently on the formulary; or add new restrictions to the brand name drug or move it to a different cost sharing tier or both. Or we may make changes based on new clinical guidelines. If we remove drugs from our formulary, [or] add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 30 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 30-day supply of the drug.

o If we make these other changes, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on how to request an exception, and you can also find information in the section below entitled “How do I request an exception to the Great Plains Medicare Advantage Gold (HMO I-SNP)’s Formulary?

Changes that will not affect you if you are currently taking the drug. Generally, if you are taking a drug on our 2021 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2021 coverage year except as described above. This means these drugs will remain available at the same cost sharing and with no new restrictions for those members taking them for the remainder of the coverage year. You will not get direct notice this year about changes that do not affect you. However, on January 1 of the next year, such changes would affect you, and it is important to check the Drug List for the new benefit year for any changes to drugs. The enclosed formulary is current as of 10/05/2020. To get updated information about the drugs covered by Great Plains Medicare Advantage, please contact us. Our contact information appears on the front and back cover pages. The formulary will be updated and posted at the beginning of each month with the most current information.

How do I use the Formulary? There are two ways to find your drug within the formulary:

Medical Condition The formulary begins on page 8. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular agents. If you know what your drug is used for, look for the category name in the list that begins on page 8. Then look under the category name for your drug.

Page 4: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

2021 Part D Model Formulary (Abridged and Comprehensive)

10/05/2020 4

Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 66. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

What are generic drugs? Great Plains Medicare Advantage covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.

Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

• Prior Authorization: Great Plains Medicare Advantage requires you [or your physician] to get prior

authorization for certain drugs. This means that you will need to get approval from Great Plains Medicare Advantage before you fill your prescriptions. If you don’t get approval, Great Plains Medicare Advantage may not cover the drug.

• Quantity Limits: For certain drugs, Great Plains Medicare Advantage limits the amount of the drug

that Great Plains Medicare Advantage will cover. For example, Great Plains Medicare Advantage provides 120 units per prescription for morphine sulfate 15mg er tables. This may be in addition to a standard one-month or three-month supply.

• Step Therapy: In some cases, Great Plains Medicare Advantage 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, Great Plains Medicare Advantage may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Great Plains Medicare Advantage will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 7. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted online a document that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask Great Plains Medicare Advantage to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception

Page 5: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

2021 Part D Model Formulary (Abridged and Comprehensive)

10/05/2020 5

to the Great Plains Medicare Advantage’s formulary?” on page 5 for information about how to request an exception.

What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered. If you learn that Great Plains Medicare Advantage does not cover your drug, you have two options:

• You can ask Member Services for a list of similar drugs that are covered by Great Plains Medicare Advantage. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Great Plains Medicare Advantage.

• You can ask Great Plains Medicare Advantage to make an exception and cover your drug. See below

for information about how to request an exception.

How do I request an exception to the Great Plains Medicare Advantage Gold (HMO I-SNP)’s Formulary? You can ask Great Plains Medicare Advantage to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

• You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.

• You can ask us to cover a formulary drug at a lower cost-sharing level [if this drug is not on the specialty tier]. If approved this would lower the amount you must pay for your drug.

• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs,

Great Plains Medicare Advantage limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

Generally, Great Plains Medicare Advantage will only approve your request for an exception if the alternative drugs included on the plan’s formulary, [the lower cost-sharing drug] or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, or utilization restriction exception. When you request a formulary or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited

Page 6: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

2021 Part D Model Formulary (Abridged and Comprehensive)

10/05/2020 6

(fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 31-day supply. If your prescription is written for fewer days, we’ll allow refills to provide up to a maximum 31-day supply of medication. After your first 31-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility and you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug while you pursue a formulary exception. We will provide a one-time 31-day transition supply per drug, which will cover a temporary supply if you have a change in your medications due to a level-of-care change. A level of care change may include: • Entering or leaving a LTC facility • Discharged from a hospital or home • End a Medicare Part A skilled nursing facility stay • Give up Hospice status and revert back to standard Medicare benefits • End an LTC Facility stay and return to their home

For more information For more detailed information about your Great Plains Medicare Advantage prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Great Plains Medicare Advantage, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov.

Page 7: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

2021 Part D Model Formulary (Abridged and Comprehensive)

10/05/2020 7

Great Plains Medicare Advantage Formulary The formulary below provides coverage information about the drugs covered by Great Plains Medicare Advantage. If you have trouble finding your drug in the list, turn to the Index that begins on page 102. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., TIVICAY 10MG TAB) and generic drugs are listed in lower-case italics (e.g., zidovudine 100mg cap), The information in the Requirements/Limits column tells you if Great Plains Medicare Advantage has any special requirements for coverage of your drug.

• First Fill Limited to one-month supply (FF): You may be able to receive greater than a 1-monthsupply of

most of the drugs on your Formulary. Drugs noted with “FF” are limited to a 1-monthsupply for both Retail and Mail Order on your first fill only. After the first fill, an extended day supply would be available.

• Limited Distribution (LD): The symbol [LD] next to a drug name indicates that the drug has been noted

as being restricted to certain pharmacies by the Food and Drug Administration. These drug scan only be obtained at specialty designated pharmacies able to appropriately handle the drugs.

• Non-Extended Day Supply (NDS): You may be able to receive greater than a 1-month supply of most of

the drugs on your Formulary via mail order at a reduced cost share. Drugs noted with “NDS” are limited to a 1-month supply for both Retail and Mail Order.

• 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 Plan may not cover the drug.

• Prior Authorization Restriction for Part B vs Part D Determination (PA_BvD): This drug may be eligible

for payment under Medicare Part B or Part D. You (or your physician) are required to get prior authorization from The Plan to determine that this drug is covered under Medicare Part D before you fill your prescription for this drug. Without prior approval, The Plan may not cover this drug.

• Prior Authorization Restriction for New Starts Only (PA_NSO): If this drug is new to the member, you

(or your physician) are required to get prior authorization from The Plan before you fill your prescription for this drug. Without prior approval, The Plan may not cover this drug.

• Quantity Limits (QL): For certain drugs, The Plan limits the amount of the drug that The Plan will cover.

This could include a: per fill, daily, monthly, or yearly limitation.

• 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, The Plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, The Plan will then cover Drug B.

• Step Therapy for New Starts Only (ST_NSO): If this drug is new to the member, you are required to first

try certain drugs to treat your medical condition before we will cover another drug for that condition.

Page 8: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

2021 Part D Model Formulary (Abridged and Comprehensive)

10/05/2020 8

• SI - CMS defined Select Insulins. Please refer to your Evidence of Coverage (EOC) for additional information regarding coverage of these products.

Page 9: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

2021 Part D Model Formulary (Abridged and Comprehensive)

10/05/2020 9

Great Plains Medicare Advantage Gold is an HMO I-SNP with a Medicare contract. Enrollment in Great Plains Medicare Advantage Gold depends on contract renewal. Great Plains Medicare Advantage Gold complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. This formulary was updated on 10/05/2020. For more recent information or other questions, please contact us, Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services, at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily excluding major holidays or visit GreatPlainsMedicareAdvantage.com.

Page 10: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS AMPHETAMINES

amphetamine 10mg er cap 2 amphetamine 10mg tab 2 amphetamine 12.5mg tab 2 amphetamine 15mg er cap 2 amphetamine 15mg tab 2 amphetamine 20mg er cap 2 amphetamine 20mg tab 2 amphetamine 25mg er cap 2 amphetamine 30mg er cap 2 amphetamine 30mg tab 2 amphetamine 5mg er cap 2 amphetamine 5mg tab 2 amphetamine 7.5mg tab 2 dextroamphetamine sulfate 10mg er cap 2 dextroamphetamine sulfate 10mg tab 2 dextroamphetamine sulfate 15mg er cap 2 dextroamphetamine sulfate 1mg/ml oral soln 2 dextroamphetamine sulfate 5mg er cap 2 dextroamphetamine sulfate 5mg tab 2 procentra 5mg/5ml oral soln 2

ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD) AGENTS atomoxetine 100mg cap 2 QL=60 EA/30 Days atomoxetine 10mg cap 2 QL=60 EA/30 Days atomoxetine 18mg cap 2 QL=60 EA/30 Days atomoxetine 25mg cap 2 QL=60 EA/30 Days atomoxetine 40mg cap 2 QL=60 EA/30 Days atomoxetine 60mg cap 2 QL=60 EA/30 Days atomoxetine 80mg cap 2 QL=60 EA/30 Days guanfacine 1mg er tab 1 guanfacine 2mg er tab 1 guanfacine 3mg er tab 1 guanfacine 4mg er tab 1

DOPAMINE AND NOREPINEPHRINE REUPTAKE INHIBITORS (DNRIS) SUNOSI 150MG TAB 3 PA QL=30 EA/30 Days SUNOSI 75MG TAB 3 PA QL=30 EA/30 Days

HISTAMINE H3-RECEPTOR ANTAGONIST/INVERSE AGONISTS WAKIX 17.8MG TAB 5 NDS PA QL=60 EA/30 Days WAKIX 4.45MG TAB 5 NDS PA QL=60 EA/30 Days

STIMULANTS - MISC. armodafinil 150mg tab 2 PA QL=30 EA/30 Days armodafinil 200mg tab 2 PA QL=30 EA/30 Days armodafinil 250mg tab 2 PA QL=30 EA/30 Days armodafinil 50mg tab 2 PA QL=30 EA/30 Days dexmethylphenidate 10mg er cap 2

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

8

Page 11: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

dexmethylphenidate 10mg tab 2 dexmethylphenidate 15mg er cap 2 dexmethylphenidate 2.5mg tab 2 dexmethylphenidate 20mg er cap 2 dexmethylphenidate 25mg er cap 2 dexmethylphenidate 30mg er cap 2 dexmethylphenidate 35mg er cap 2 dexmethylphenidate 40mg er cap 2 dexmethylphenidate 5mg er cap 2 dexmethylphenidate 5mg tab 2 methylphenidate 10mg chew tab 2 methylphenidate 10mg cr cap 2 methylphenidate 10mg er tab 2 methylphenidate 10mg la cap 2 methylphenidate 10mg tab 2 METHYLPHENIDATE 18MG ER TAB 3 methylphenidate 18mg er tab 2 methylphenidate 1mg/ml oral soln 2 methylphenidate 2.5mg chew tab 2 methylphenidate 20mg cr cap 2 methylphenidate 20mg er tab 2 methylphenidate 20mg la cap 2 methylphenidate 20mg tab 2 methylphenidate 27mg sr tab 2 methylphenidate 2mg/ml oral soln 2 methylphenidate 30mg cr cap 2 methylphenidate 30mg la cap 2 methylphenidate 36mg sr tab 2 methylphenidate 40mg cr cap 2 methylphenidate 40mg la cap 2 methylphenidate 50mg cr cap 2 methylphenidate 54mg sr tab 2 methylphenidate 5mg chew tab 2 methylphenidate 5mg tab 2 methylphenidate 60mg cr cap 2 methylphenidate 60mg la cap 2 modafinil 100mg tab 2 PA QL=60 EA/30 Days modafinil 200mg tab 2 PA QL=60 EA/30 Days

AMEBICIDES AMEBICIDES

SOLOSEC 2GM GRANULES 4 PA

AMINOGLYCOSIDES AMINOGLYCOSIDES

amikacin 250mg/ml inj 2 ARIKAYCE 590MG/8.4ML INH SUSP 5 NDS PA QL=252 ML/30 Days GENTAMICIN 0.8MG/ML INJ 2

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

9

Page 12: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

gentamicin 1.2mg/ml inj 2 GENTAMICIN 1.6MG/ML INJ 2 GENTAMICIN 1MG/ML INJ 2 gentamicin 40mg/ml inj 2 neomycin sulfate 500mg tab 1 PAROMOMYCIN 250MG CAP 4 STREPTOMYCIN 1000MG INJ 4 TOBRAMYCIN 10MG/ML INJ 2 tobramycin 40mg/ml inj 2 tobramycin 60mg/ml inh soln 5 NDS PA QL=300 ML/30 Days

ANALGESICS - ANTI-INFLAMMATORY ANTIRHEUMATIC - ENZYME INHIBITORS

OLUMIANT 1MG TAB 5 NDS PA OLUMIANT 2MG TAB 5 NDS PA RINVOQ 15MG ER TAB 5 NDS PA XELJANZ 10MG TAB 5 NDS PA XELJANZ 5MG TAB 5 NDS PA XELJANZ XR 11MG TAB 5 NDS PA XELJANZ XR 22MG TAB 5 NDS PA

ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIES HUMIRA 10MG/0.1ML SYRINGE 5 NDS PA HUMIRA 10MG/0.2ML SYRINGE 5 NDS PA HUMIRA 20MG/0.2ML SYRINGE 5 NDS PA HUMIRA 20MG/0.4ML SYRINGE 5 NDS PA HUMIRA 40MG/0.4ML AUTO-INJECTOR 5 NDS PA HUMIRA 40MG/0.4ML SYRINGE 5 NDS PA HUMIRA 40MG/0.8ML AUTO-INJECTOR 5 NDS PA HUMIRA 40MG/0.8ML SYRINGE 5 NDS PA HUMIRA PEDIATRIC CROHN'S STARTER PACK (3) 5 80MG/0.8ML INJ

NDS PA

HUMIRA PEDIATRIC CROHN'S STARTER PACK 5 SYRINGE (2) 40MG/0.4ML

NDS PA

HUMIRA PEN - CROHN'S STARTER PACK 5 40MG/0.8ML INJ

NDS PA

HUMIRA PEN - CROHN'S STARTER PACK 5 80MG/0.8ML INJ

NDS PA

HUMIRA PEN - PSORIASIS STARTER PACK 5 40MG/0.8ML INJ

NDS PA

HUMIRA PEN - PSORIASIS STARTER PACK 5 80MG/0.8ML INJ

NDS PA

SIMPONI 100MG/ML AUTO-INJECTOR 5 NDS PA SIMPONI 100MG/ML SYRINGE 5 NDS PA SIMPONI 50MG/0.5ML AUTO-INJECTOR 5 NDS PA SIMPONI 50MG/0.5ML SYRINGE 5 NDS PA

GOLD COMPOUNDS RIDAURA 3MG CAP 3

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

10

Page 13: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

INTERLEUKIN-1 BLOCKERS ARCALYST 220MG INJ 5 NDS PA

INTERLEUKIN-6 RECEPTOR INHIBITORS ACTEMRA 162MG/0.9ML AUTO-INJECTOR 5 NDS PA ACTEMRA 162MG/0.9ML SYRINGE 5 NDS PA KEVZARA 150MG/1.14ML AUTO-INJECTOR 5 NDS PA KEVZARA 150MG/1.14ML SYRINGE 5 NDS PA KEVZARA 200MG/1.14ML AUTO-INJECTOR 5 NDS PA KEVZARA 200MG/1.14ML SYRINGE 5 NDS PA

NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS) celecoxib 100mg cap 1 QL=60 EA/30 Days celecoxib 200mg cap 1 QL=60 EA/30 Days celecoxib 400mg cap 1 QL=60 EA/30 Days celecoxib 50mg cap 1 QL=60 EA/30 Days diclofenac potassium 50mg tab 2 diclofenac sodium 100mg er tab 2 diclofenac sodium 25mg dr tab 2 diclofenac sodium 50mg dr tab 2 diclofenac sodium 50mg/misoprostol 0.2mg dr tab 2 diclofenac sodium 75mg dr tab 2 diclofenac sodium 75mg/misoprostol 0.2mg dr tab 2 etodolac 200mg cap 2 etodolac 300mg cap 2 etodolac 400mg er tab 2 etodolac 400mg tab 2 etodolac 500mg er tab 2 etodolac 500mg tab 2 etodolac 600mg er tab 2 flurbiprofen 100mg tab 1 ibu 600mg tab 1 ibu 800mg tab 1 ibuprofen 20mg/ml susp 2 ibuprofen 400mg tab 1 ibuprofen 600mg tab 1 ibuprofen 800mg tab 1 INDOCIN 50MG RECTAL SUPP 3 indomethacin 25mg cap 2 indomethacin 50mg cap 2 indomethacin 75mg er cap 2 KETOPROFEN 200MG ER CAP 4 ketorolac tromethamine 10mg tab 1 QL=20 EA/5 Days meloxicam 15mg tab 1 meloxicam 7.5mg tab 1 nabumetone 500mg tab 2 nabumetone 750mg tab 2 naproxen 250mg tab 1

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

11

Page 14: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

naproxen 375mg dr tab 1 naproxen 375mg tab 1 naproxen 500mg dr tab 1 naproxen 500mg tab 1 naproxen sodium 275mg tab 2 naproxen sodium 550mg tab 2 oxaprozin 600mg tab 2 piroxicam 10mg cap 2 piroxicam 20mg cap 2 sulindac 150mg tab 1 sulindac 200mg tab 1 TOLMETIN 400MG CAP 4 TOLMETIN 600MG TAB 4

PHOSPHODIESTERASE 4 (PDE4) INHIBITORS OTEZLA 28-DAY STARTER PACK 5 NDS PA OTEZLA 30MG TAB 5 NDS PA

PYRIMIDINE SYNTHESIS INHIBITORS leflunomide 10mg tab 2 leflunomide 20mg tab 2

SELECTIVE COSTIMULATION MODULATORS ORENCIA 125MG/ML AUTO-INJECTOR 5 NDS PA ORENCIA 125MG/ML SYRINGE 5 NDS PA ORENCIA 50MG/0.4ML SYRINGE 5 NDS PA ORENCIA 87.5MG/0.7ML SYRINGE 5 NDS PA

SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS ENBREL 25MG INJ 5 NDS PA ENBREL 25MG/0.5ML INJ 5 NDS PA ENBREL 25MG/0.5ML SYRINGE 5 NDS PA ENBREL 50MG/ML AUTO-INJECTOR 5 NDS PA ENBREL 50MG/ML CARTRIDGE 5 NDS PA ENBREL 50MG/ML SYRINGE 5 NDS PA

ANALGESICS - NONNARCOTIC SALICYLATES

diflunisal 500mg tab 2 ANALGESICS - OPIOID

OPIOID AGONISTS CODEINE SULFATE 15MG TAB 3 QL=240 EA/30 Days codeine sulfate 30mg tab 2 QL=240 EA/30 Days codeine sulfate 60mg tab 2 QL=180 EA/30 Days fentanyl 0.012mg/hr patch 2 QL=10 EA/30 Days fentanyl 0.025mg/hr patch 2 QL=10 EA/30 Days fentanyl 0.05mg/hr patch 2 QL=10 EA/30 Days fentanyl 0.075mg/hr patch 2 QL=10 EA/30 Days FENTANYL 0.1MG BUCCAL TAB 4 PA QL=120 EA/30 Days fentanyl 0.1mg/hr patch 2 QL=10 EA/30 Days FENTANYL 0.2MG BUCCAL TAB 4 PA QL=120 EA/30 Days

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

12

Page 15: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

fentanyl 0.2mg lozenge 2 PA QL=120 EA/30 Days FENTANYL 0.4MG BUCCAL TAB 4 PA QL=120 EA/30 Days fentanyl 0.4mg lozenge 2 PA QL=120 EA/30 Days FENTANYL 0.6MG BUCCAL TAB 4 PA QL=120 EA/30 Days fentanyl 0.6mg lozenge 2 PA QL=120 EA/30 Days FENTANYL 0.8MG BUCCAL TAB 4 PA QL=120 EA/30 Days fentanyl 0.8mg lozenge 2 PA QL=120 EA/30 Days fentanyl 1.2mg lozenge 2 PA QL=120 EA/30 Days fentanyl 1.6mg lozenge 2 PA QL=120 EA/30 Days FENTORA 100MCG BUCCAL TAB 4 PA QL=120 EA/30 Days FENTORA 200MCG BUCCAL TAB 4 PA QL=120 EA/30 Days FENTORA 400MCG BUCCAL TAB 4 PA QL=120 EA/30 Days FENTORA 600MCG BUCCAL TAB 4 PA QL=120 EA/30 Days FENTORA 800MCG BUCCAL TAB 4 PA QL=120 EA/30 Days hydrocodone bitartrate 10mg er cap 2 QL=60 EA/30 Days hydrocodone bitartrate 15mg er cap 2 QL=60 EA/30 Days hydrocodone bitartrate 20mg er cap 2 QL=60 EA/30 Days hydrocodone bitartrate 30mg er cap 2 QL=60 EA/30 Days hydrocodone bitartrate 40mg er cap 2 QL=60 EA/30 Days hydrocodone bitartrate 50mg er cap 2 QL=60 EA/30 Days hydromorphone 10mg/ml (1ml) inj 2 hydromorphone 10mg/ml (5ml) inj 2 hydromorphone 1mg/ml oral soln 2 QL=2400 ML/30 Days hydromorphone 2mg tab 2 QL=450 EA/30 Days hydromorphone 4mg tab 2 QL=240 EA/30 Days hydromorphone 8mg tab 2 QL=120 EA/30 Days methadone 10mg tab 2 QL=360 EA/30 Days METHADONE 1MG/ML ORAL SOLN 2 QL=3600 ML/30 Days METHADONE 2MG/ML ORAL SOLN 2 QL=1800 ML/30 Days methadone 5mg tab 2 QL=360 EA/30 Days morphine sulfate 100mg er tab 2 QL=120 EA/30 Days morphine sulfate 15mg er tab 2 QL=120 EA/30 Days morphine sulfate 15mg tab 2 QL=180 EA/30 Days morphine sulfate 200mg er tab 2 QL=120 EA/30 Days morphine sulfate 20mg/ml oral soln 2 QL=180 ML/30 Days morphine sulfate 2mg/ml oral soln 2 QL=1800 ML/30 Days morphine sulfate 30mg er tab 2 QL=120 EA/30 Days morphine sulfate 30mg tab 2 QL=180 EA/30 Days morphine sulfate 4mg/ml oral soln 2 QL=900 ML/30 Days morphine sulfate 60mg er tab 2 QL=120 EA/30 Days NUCYNTA 100MG ER TAB 4 QL=60 EA/30 Days NUCYNTA 150MG ER TAB 4 QL=60 EA/30 Days NUCYNTA 200MG ER TAB 4 QL=60 EA/30 Days NUCYNTA 250MG ER TAB 4 QL=60 EA/30 Days NUCYNTA 50MG ER TAB 4 QL=60 EA/30 Days oxycodone 10mg tab 2 QL=180 EA/30 Days

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

13

Page 16: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

oxycodone 15mg tab 2 QL=180 EA/30 Days oxycodone 1mg/ml oral soln 2 QL=5400 ML/30 Days oxycodone 20mg tab 2 QL=180 EA/30 Days oxycodone 20mg/ml oral soln 2 QL=270 ML/30 Days oxycodone 30mg tab 2 QL=180 EA/30 Days oxycodone 5mg cap 2 QL=360 EA/30 Days oxycodone 5mg tab 2 QL=360 EA/30 Days oxymorphone 10mg tab 2 QL=360 EA/30 Days oxymorphone 5mg tab 2 QL=360 EA/30 Days tramadol 100mg er tab 2 QL=60 EA/30 Days tramadol 100mg er tab (matrix delivery) 2 QL=60 EA/30 Days tramadol 200mg er tab 2 QL=60 EA/30 Days tramadol 200mg er tab (matrix delivery) 2 QL=60 EA/30 Days tramadol 300mg er tab 2 QL=60 EA/30 Days tramadol 300mg er tab (matrix delivery) 2 QL=60 EA/30 Days tramadol 50mg tab 2 QL=240 EA/30 Days XTAMPZA 13.5MG ER CAP 3 QL=120 EA/30 Days XTAMPZA 18MG ER CAP 3 QL=120 EA/30 Days XTAMPZA 27MG ER CAP 3 QL=120 EA/30 Days XTAMPZA 36MG ER CAP 3 QL=120 EA/30 Days XTAMPZA 9MG ER CAP 3 QL=120 EA/30 Days

OPIOID COMBINATIONS acetaminophen 21.7mg/ml/hydrocodone bitartrate 0.5mg/ml oral soln

2 QL=5400 ML/30 Days

acetaminophen 24mg/ml/codeine phosphate 2.4mg/ml oral soln

2 QL=4980 ML/30 Days

acetaminophen 300mg/codeine phosphate 15mg tab 2 QL=390 EA/30 Days acetaminophen 300mg/codeine phosphate 30mg tab 2 QL=390 EA/30 Days acetaminophen 300mg/codeine phosphate 60mg tab 2 QL=390 EA/30 Days acetaminophen 300mg/hydrocodone bitartrate 10mg tab

2 QL=390 EA/30 Days

acetaminophen 300mg/hydrocodone bitartrate 5mg tab

2 QL=390 EA/30 Days

acetaminophen 300mg/hydrocodone bitartrate 7.5mg tab

2 QL=390 EA/30 Days

acetaminophen 325mg/hydrocodone bitartrate 10mg tab

2 QL=360 EA/30 Days

acetaminophen 325mg/hydrocodone bitartrate 5mg tab

2 QL=360 EA/30 Days

acetaminophen 325mg/hydrocodone bitartrate 7.5mg tab

2 QL=360 EA/30 Days

acetaminophen 325mg/oxycodone 10mg tab 2 QL=360 EA/30 Days acetaminophen 325mg/oxycodone 2.5mg tab 2 QL=360 EA/30 Days acetaminophen 325mg/oxycodone 5mg tab 2 QL=360 EA/30 Days acetaminophen 325mg/oxycodone 7.5mg tab 2 QL=360 EA/30 Days acetaminophen 325mg/tramadol 37.5mg tab 2 QL=360 EA/30 Days

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

14

Page 17: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

ASPIRIN 325MG/OXYCODONE 4.84MG TAB 2 QL=360 EA/30 Days endocet 325-10mg tab 2 QL=360 EA/30 Days endocet 325-5mg tab 2 QL=360 EA/30 Days endocet 325-7.5mg tab 2 QL=360 EA/30 Days hydrocodone bitartrate 10mg/ibuprofen 200mg tab 2 QL=480 EA/30 Days hydrocodone bitartrate 5mg/ibuprofen 200mg tab 2 QL=480 EA/30 Days hydrocodone bitartrate 7.5mg/ibuprofen 200mg tab 2 QL=480 EA/30 Days lorcet 325-10mg tab 2 QL=360 EA/30 Days lorcet 325-5mg tab 2 QL=360 EA/30 Days

OPIOID PARTIAL AGONISTS buprenorphine 0.005mg/hr weekly patch 2 QL=4 EA/28 Days buprenorphine 0.0075mg/hr weekly patch 2 QL=4 EA/28 Days buprenorphine 0.015mg/hr weekly patch 2 QL=4 EA/28 Days buprenorphine 0.01mg/hr weekly patch 2 QL=4 EA/28 Days buprenorphine 0.02mg/hr weekly patch 2 QL=4 EA/28 Days buprenorphine 12mg/naloxone 3mg sublingual film 1 buprenorphine 2mg sl tab 1 buprenorphine 2mg/naloxone 0.5mg sl tab 1 buprenorphine 2mg/naloxone 0.5mg sublingual film 1 buprenorphine 4mg/naloxone 1mg sublingual film 1 buprenorphine 8mg sl tab 1 buprenorphine 8mg/naloxone 2mg sl tab 1 buprenorphine 8mg/naloxone 2mg sublingual film 1 butorphanol tartrate 1mg/act nasal inhaler 2 QL=10 ML/30 Days ZUBSOLV 1.4-0.36MG SL TAB 3 QL=90 EA/30 Days ZUBSOLV 11.4-2.9MG SL TAB 3 QL=60 EA/30 Days ZUBSOLV 2.9-0.71MG SL TAB 3 QL=90 EA/30 Days ZUBSOLV 5.7-1.4MG SL TAB 3 QL=90 EA/30 Days ZUBSOLV 8.6-2.1MG SL TAB 3 QL=60 EA/30 Days

ANDROGENS-ANABOLIC ANABOLIC STEROIDS

ANADROL-50 50MG TAB 4 oxandrolone 10mg tab 2 oxandrolone 2.5mg tab 2

ANDROGENS ANDRODERM 2MG/24HR PATCH 3 PA QL=60 EA/30 Days ANDRODERM 4MG/24HR PATCH 3 PA QL=30 EA/30 Days danazol 100mg cap 2 danazol 200mg cap 2 danazol 50mg cap 2 METHITEST 10MG TAB 4 PA METHYLTESTOSTERONE 10MG CAP 4 PA testosterone 1% (25mg) gel 2 PA QL=300 GM/30 Days testosterone 1% (50mg) gel 2 PA QL=300 GM/30 Days testosterone 1.62% (1.25gm) gel 2 PA QL=75 GM/30 Days testosterone 1.62% (2.5gm) gel 2 PA QL=150 GM/30 Days

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

15

Page 18: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

TESTOSTERONE 12.5MG/ACT GEL 4 PA QL=300 GM/30 Days testosterone 20.25mg/act gel 2 PA QL=150 GM/30 Days testosterone cypionate 100mg/ml inj 2 testosterone cypionate 200mg/ml (1ml) inj 2 testosterone cypionate 200mg/ml inj 2 TESTOSTERONE ENANTHATE 200MG/ML INJ 2

ANORECTAL AGENTS INTRARECTAL STEROIDS

hydrocortisone 1.67mg/ml enema 2 UCERIS 2MG/ACT RECTAL FOAM 4 PA

VASODILATING AGENTS RECTIV 0.4% RECTAL OINTMENT 4 QL=30 GM/30 Days

ANORECTAL AND RELATED PRODUCTS RECTAL COMBINATIONS

hydrocortisone/pramoxine 1-1% rectal cream 2 RECTAL STEROIDS

procto-med 2.5% cream 2 procto-pak 1% rectal cream 2 proctosol 2.5% cream 2 proctozone hc 2.5% cream 2

ANTHELMINTICS ANTHELMINTICS

albendazole 200mg tab 2 BENZNIDAZOLE 100MG TAB 3 PA BENZNIDAZOLE 12.5MG TAB 3 PA ivermectin 3mg tab 2 praziquantel 600mg tab 2

ANTIANGINAL AGENTS ANTIANGINALS-OTHER

ranolazine 1000mg er tab 2 ranolazine 500mg er tab 2

NITRATES isosorbide dinitrate 10mg tab 1 isosorbide dinitrate 20mg tab 1 isosorbide dinitrate 30mg tab 1 isosorbide dinitrate 40mg tab 2 isosorbide dinitrate 5mg tab 1 isosorbide mononitrate 10mg tab 1 isosorbide mononitrate 120mg er tab 1 isosorbide mononitrate 20mg tab 1 isosorbide mononitrate 30mg er tab 2 isosorbide mononitrate 60mg er tab 1 minitran 0.1mg/hr patch 1 minitran 0.2mg/hr patch 1 minitran 0.4mg/hr patch 1

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

16

Page 19: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

minitran 0.6mg/hr patch 1 NITRO-BID 2% OINTMENT 3 NITRO-DUR 0.3MG/HR PATCH 4 NITRO-DUR 0.8MG/HR PATCH 4 nitroglycerin 0.1mg/hr patch 1 nitroglycerin 0.2mg/hr patch 1 nitroglycerin 0.3mg sl tab 1 nitroglycerin 0.4mg sl tab 1 nitroglycerin 0.4mg/act spray 2 nitroglycerin 0.4mg/hr patch 1 nitroglycerin 0.6mg sl tab 1 nitroglycerin 0.6mg/hr patch 1

ANTIANXIETY AGENTS ANTIANXIETY AGENTS - MISC.

buspirone 10mg tab 1 buspirone 15mg tab 1 buspirone 30mg tab 1 buspirone 5mg tab 1 buspirone 7.5mg tab 1 hydroxyzine 10mg tab 1 hydroxyzine 25mg tab 1 hydroxyzine 2mg/ml oral soln 2 hydroxyzine 50mg tab 1 HYDROXYZINE PAMOATE 100MG CAP 2 hydroxyzine pamoate 25mg cap 1 hydroxyzine pamoate 50mg cap 1

BENZODIAZEPINES alprazolam 0.25mg odt 2 alprazolam 0.25mg tab 1 alprazolam 0.5mg er tab 2 alprazolam 0.5mg odt 2 alprazolam 0.5mg tab 1 alprazolam 1mg er tab 2 alprazolam 1mg odt 2 alprazolam 1mg tab 1 ALPRAZOLAM 1MG/ML ORAL SOLN 4 alprazolam 2mg er tab 2 alprazolam 2mg odt 2 alprazolam 2mg tab 1 alprazolam 3mg er tab 2 chlordiazepoxide 10mg cap 1 chlordiazepoxide 25mg cap 1 chlordiazepoxide 5mg cap 1 clorazepate dipotassium 15mg tab 2 clorazepate dipotassium 3.75mg tab 2 clorazepate dipotassium 7.5mg tab 2

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

17

Page 20: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

diazepam 10mg tab 1 DIAZEPAM 1MG/ML ORAL SOLN 2 diazepam 2mg tab 1 diazepam 5mg tab 1 diazepam 5mg/ml oral soln 2 lorazepam 0.5mg tab 1 lorazepam 1mg tab 1 lorazepam 2mg tab 1 lorazepam 2mg/ml oral soln 2 OXAZEPAM 10MG CAP 3 OXAZEPAM 15MG CAP 3 OXAZEPAM 30MG CAP 3

ANTIARRHYTHMICS ANTIARRHYTHMICS TYPE I-A

disopyramide 100mg cap 2 disopyramide 150mg cap 2 NORPACE 100MG ER CAP 3 NORPACE 150MG ER CAP 2 quinidine gluconate 324mg er tab 2 QUINIDINE SULFATE 200MG TAB 2 QUINIDINE SULFATE 300MG TAB 2

ANTIARRHYTHMICS TYPE I-B mexiletine 150mg cap 3 mexiletine 200mg cap 3 mexiletine 250mg cap 3

ANTIARRHYTHMICS TYPE I-C flecainide acetate 100mg tab 2 flecainide acetate 150mg tab 2 flecainide acetate 50mg tab 2 propafenone 150mg tab 2 propafenone 225mg er cap 2 propafenone 225mg tab 2 propafenone 300mg tab 2 propafenone 325mg er cap 2 propafenone 425mg er cap 2

ANTIARRHYTHMICS TYPE III amiodarone 100mg tab 2 amiodarone 200mg tab 1 amiodarone 400mg tab 2 dofetilide 0.125mg cap 2 dofetilide 0.25mg cap 3 dofetilide 0.5mg cap 3 MULTAQ 400MG TAB 3 pacerone 100mg tab 2 pacerone 200mg tab 1 pacerone 400mg tab 2

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

18

Page 21: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

ANTIASTHMATIC AND BRONCHODILATOR AGENTS ANTIASTHMATIC - MONOCLONAL ANTIBODIES

FASENRA 30MG/ML AUTO-INJECTOR 5 PA FASENRA 30MG/ML SYRINGE 5 PA NUCALA 100MG INJ 5 NDS PA NUCALA 100MG/ML AUTO-INJECTOR 5 NDS PA NUCALA 100MG/ML SYRINGE 5 NDS PA XOLAIR 150MG INJ 5 NDS PA QL=6 EA/30 Days XOLAIR 150MG/ML SYRINGE 5 NDS PA QL=6 ML/30 Days XOLAIR 75MG/0.5ML SYRINGE 5 NDS PA QL=6 ML/30 Days

BRONCHODILATORS - ANTICHOLINERGICS ATROVENT 17MCG INH 4 INCRUSE 62.5MCG/INH INH 3 ipratropium bromide 0.2mg/ml inh soln 2 PA BvD LONHALA 25MCG/ML INH SOLN 3 ST

LEUKOTRIENE MODULATORS montelukast 10mg tab 1 montelukast 4mg chew tab 1 montelukast 4mg granules 2 montelukast 5mg chew tab 1 zafirlukast 10mg tab 2 zafirlukast 20mg tab 2

SELECTIVE PHOSPHODIESTERASE 4 (PDE4) INHIBITORS DALIRESP 250MCG TAB 4 PA DALIRESP 500MCG TAB 4 PA

STEROID INHALANTS ARNUITY 100MCG INH 3 QL=30 EA/30 Days ARNUITY 200MCG INH 3 QL=30 EA/30 Days ARNUITY 50MCG INH 3 QL=30 EA/30 Days ASMANEX 100MCG HFA INH 3 QL=13 GM/30 Days ASMANEX 110MCG (30ACT) INH 3 QL=1 EA/30 Days ASMANEX 200MCG HFA INH 3 QL=13 GM/30 Days ASMANEX 220MCG (120ACT) INH 3 QL=1 EA/30 Days ASMANEX 220MCG (30ACT) INH 3 QL=1 EA/30 Days ASMANEX 220MCG (60ACT) INH 3 QL=1 EA/30 Days ASMANEX 50MCG HFA INH 3 QL=13 GM/30 Days budesonide 0.125mg/ml inh susp 2 PA BvD QL=120 ML/30 Days budesonide 0.25mg/ml inh susp 2 PA BvD QL=120 ML/30 Days budesonide 0.5mg/ml inh susp 2 PA BvD QL=120 ML/30 Days FLOVENT 100MCG/BLIST INH 3 QL=60 EA/30 Days FLOVENT 110MCG INH 3 QL=24 GM/30 Days FLOVENT 220MCG INH 3 QL=24 GM/30 Days FLOVENT 250MCG/BLIST INH 3 QL=60 EA/30 Days FLOVENT 44MCG INH 3 QL=21.20 GM/30 Days FLOVENT 50MCG/BLIST INH 3 QL=60 EA/30 Days

SYMPATHOMIMETICS

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

19

Page 22: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

ADVAIR 0.045-0.021MG INH 4 QL=12 GM/30 Days ADVAIR 0.115-0.021MG INH 4 QL=12 GM/30 Days ADVAIR 0.23-0.021MG INH 4 QL=12 GM/30 Days albuterol 0.21mg/ml inh soln 1 PA BvD albuterol 0.417mg/ml inh soln 1 PA BvD albuterol 0.4mg/ml oral soln 2 albuterol 0.83mg/ml inh soln 2 PA BvD albuterol 2mg tab 2 ALBUTEROL 4MG ER TAB 3 albuterol 4mg tab 2 albuterol 5mg/ml inh soln 2 PA BvD ALBUTEROL 8MG ER TAB 3 ANORO 0.0625-0.025MG INH 3 QL=60 EA/30 Days BREO 0.1-0.025MG INH 3 QL=60 EA/30 Days BREO 0.2-0.025MG INH 3 QL=60 EA/30 Days BROVANA 15MCG/2ML INH SOLN 4 PA BvD COMBIVENT 0.1-0.02MG INH 3 DULERA 0.005-0.1MG INH 3 QL=13 GM/30 Days DULERA 0.005-0.2MG INH 3 QL=13 GM/30 Days DULERA 50-5MCG INH 3 QL=13 GM/30 Days fluticasone propionate 0.1mg/salmeterol 0.05mg inh 3 QL=60 EA/30 Days fluticasone propionate 0.25mg/salmeterol 0.05mg inh 3 QL=60 EA/30 Days fluticasone propionate 0.5mg/salmeterol 0.05mg inh 3 QL=60 EA/30 Days FLUTICASONE PROPIONATE/SALMETEROL XINAFOATE 113-14MCG/ACT POWDER INH

3 QL=1 EA/30 Days

FLUTICASONE PROPIONATE/SALMETEROL XINAFOATE 232-14MCG/ACT POWDER INH

3 QL=1 EA/30 Days

FLUTICASONE PROPIONATE/SALMETEROL XINAFOATE 55-14MCG/ACT POWDER INH

3 QL=1 EA/30 Days

ipratropium/albuterol 0.5-2.5mg/3ml inh soln 2 PA BvD LEVALBUTEROL 0.045MG INH 4 ST QL=30 GM/30 Days levalbuterol 0.103mg/ml inh soln 2 PA BvD levalbuterol 0.21mg/ml inh soln 2 PA BvD levalbuterol 0.417mg/ml inh soln 2 PA BvD levalbuterol 2.5mg/ml inh soln 2 PA BvD METAPROTERENOL SULFATE 2MG/ML ORAL SOLN

3

PERFOROMIST 20MCG/2ML INH SOLN 4 PA BvD SEREVENT 50MCG/DOSE INH 3 STIOLTO 0.0025-0.0025MG INH 3 QL=4 GM/30 Days terbutaline sulfate 2.5mg tab 2 terbutaline sulfate 5mg tab 2 TRELEGY 0.1-0.0625-0.025MG INH 3 QL=60 EA/30 Days VENTOLIN 108MCG INH 3 QL=36 GM/30 Days wixela 0.1-0.05mg inh 3 QL=60 EA/30 Days wixela 0.25-0.05mg inh 3 QL=60 EA/30 Days

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

20

Page 23: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

wixela 0.5-0.05mg inh 3 QL=60 EA/30 Days XOPENEX 45MCG INH 4 ST QL=30 GM/30 Days

XANTHINES THEO-24 100MG ER CAP 4 THEO-24 200MG ER CAP 4 THEO-24 300MG ER CAP 4 THEO-24 400MG ER CAP 4 THEOPHYLLINE 300MG ER TAB 3 theophylline 400mg er tab 1 theophylline 5.33mg/ml oral soln 2 theophylline 600mg er tab 1

ANTICOAGULANTS COUMARIN ANTICOAGULANTS

jantoven 10mg tab 1 jantoven 1mg tab 1 jantoven 2.5mg tab 1 jantoven 2mg tab 1 jantoven 3mg tab 1 jantoven 4mg tab 1 jantoven 5mg tab 1 jantoven 6mg tab 1 jantoven 7.5mg tab 1 warfarin sodium 10mg tab 1 warfarin sodium 1mg tab 1 warfarin sodium 2.5mg tab 1 warfarin sodium 2mg tab 1 warfarin sodium 3mg tab 1 warfarin sodium 4mg tab 1 warfarin sodium 5mg tab 1 warfarin sodium 6mg tab 1 warfarin sodium 7.5mg tab 1

DIRECT FACTOR XA INHIBITORS ELIQUIS 2.5MG TAB 3 ELIQUIS 30-DAY STARTER PACK 5MG 3 ELIQUIS 5MG TAB 3 XARELTO 10MG TAB 3 XARELTO 15MG TAB 3 XARELTO 2.5MG TAB 3 XARELTO 20MG TAB 3 XARELTO KIT PACK 3

HEPARINS AND HEPARINOID-LIKE AGENTS enoxaparin sodium 100mg/ml (0.3ml) syringe 2 QL=18 ML/30 Days enoxaparin sodium 100mg/ml (0.4ml) syringe 2 QL=24 ML/30 Days enoxaparin sodium 100mg/ml (0.6ml) syringe 2 QL=36 ML/30 Days enoxaparin sodium 100mg/ml (0.8ml) syringe 2 QL=48 ML/30 Days enoxaparin sodium 100mg/ml (1ml) syringe 2 QL=60 ML/30 Days

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

21

Page 24: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

enoxaparin sodium 150mg/ml (0.8ml) syringe 2 QL=48 ML/30 Days enoxaparin sodium 150mg/ml (1ml) syringe 2 QL=60 ML/30 Days fondaparinux sodium 12.5mg/ml (0.4ml) syringe 2 fondaparinux sodium 12.5mg/ml (0.6ml) syringe 2 fondaparinux sodium 12.5mg/ml (0.8ml) syringe 2 fondaparinux sodium 5mg/ml syringe 2 FRAGMIN 10000UNIT/ML SYRINGE 4 FRAGMIN 12500UNIT/0.5ML SYRINGE 4 FRAGMIN 15000UNIT/0.6ML SYRINGE 4 FRAGMIN 18000UNT/0.72ML SYRINGE 4 FRAGMIN 2500UNIT/0.2ML SYRINGE 4 FRAGMIN 5000UNIT/0.2ML SYRINGE 4 FRAGMIN 7500UNIT/0.3ML SYRINGE 4 FRAGMIN 95000UNIT/3.8ML INJ 4 heparin sodium porcine 10000unit/ml inj 2 heparin sodium porcine 1000unit/ml inj 2 heparin sodium porcine 20000unit/ml inj 2 heparin sodium porcine 5000unit/ml inj 2

THROMBIN INHIBITORS PRADAXA 110MG CAP 3 PRADAXA 150MG CAP 3 PRADAXA 75MG CAP 3

ANTICONVULSANTS AMPA GLUTAMATE RECEPTOR ANTAGONISTS

FYCOMPA 0.5MG/ML SUSP 4 PA NSO FYCOMPA 10MG TAB 4 PA NSO FYCOMPA 12MG TAB 4 PA NSO FYCOMPA 2MG TAB 4 PA NSO FYCOMPA 4MG TAB 4 PA NSO FYCOMPA 6MG TAB 4 PA NSO FYCOMPA 8MG TAB 4 PA NSO

ANTICONVULSANTS - BENZODIAZEPINES clobazam 10mg tab 2 clobazam 2.5mg/ml susp 2 clobazam 20mg tab 2 clonazepam 0.125mg odt 2 clonazepam 0.25mg odt 2 clonazepam 0.5mg odt 2 clonazepam 0.5mg tab 1 clonazepam 1mg odt 2 clonazepam 1mg tab 1 clonazepam 2mg odt 2 clonazepam 2mg tab 1 DIASTAT 10MG RECTAL GEL 4 DIASTAT 2.5MG RECTAL GEL 4 DIASTAT 20MG RECTAL GEL 4

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

22

Page 25: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

DIAZEPAM 10MG/2ML RECTAL GEL 4 DIAZEPAM 2.5MG/0.5ML RECTAL GEL 4 DIAZEPAM 20MG/4ML RECTAL GEL 4 NAYZILAM 5MG/0.1ML NASAL SPRAY 4 SYMPAZAN 10MG ORAL FILM 4 ST_NSO SYMPAZAN 20MG ORAL FILM 4 ST_NSO SYMPAZAN 5MG ORAL FILM 4 ST_NSO VALTOCO 10MG DOSE KIT 10MG/0.1ML PACK 4 VALTOCO 15MG DOSE KIT 7.5MG/0.1ML PACK 4 VALTOCO 20MG DOSE KIT 10MG/0.1ML PACK 4 VALTOCO 5MG DOSE KIT 5MG/0.1ML PACK 4

ANTICONVULSANTS - MISC. APTIOM 200MG TAB 4 PA NSO APTIOM 400MG TAB 4 PA NSO APTIOM 600MG TAB 4 PA NSO APTIOM 800MG TAB 4 PA NSO BANZEL 200MG TAB 3 PA NSO BANZEL 400MG TAB 3 PA NSO BANZEL 40MG/ML SUSP 3 PA NSO BRIVIACT 100MG TAB 4 PA NSO QL=60 EA/30 Days BRIVIACT 10MG TAB 4 PA NSO QL=60 EA/30 Days BRIVIACT 10MG/ML ORAL SOLN 4 PA NSO BRIVIACT 25MG TAB 4 PA NSO QL=60 EA/30 Days BRIVIACT 50MG TAB 4 PA NSO QL=60 EA/30 Days BRIVIACT 75MG TAB 4 PA NSO QL=60 EA/30 Days carbamazepine 100mg chew tab 2 carbamazepine 100mg er cap 3 carbamazepine 100mg er tab 3 carbamazepine 200mg er cap 3 carbamazepine 200mg er tab 3 carbamazepine 200mg tab 2 carbamazepine 20mg/ml susp 2 carbamazepine 300mg er cap 2 carbamazepine 400mg er tab 2 EPIDIOLEX 100MG/ML ORAL SOLN 3 PA NSO epitol 200mg tab 2 FINTEPLA 2.2MG/ML ORAL SOLN 5 NDS PA NSO QL=360 ML/30 Days gabapentin 100mg cap 2 gabapentin 300mg cap 2 gabapentin 400mg cap 2 gabapentin 50mg/ml oral soln 2 gabapentin 600mg tab 2 gabapentin 800mg tab 2 LAMICTAL XR BLUE KIT 4 LAMICTAL XR GREEN KIT 4 LAMICTAL XR ORANGE KIT 4

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

23

Page 26: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

lamotrigine 100mg er tab 2 lamotrigine 100mg odt 2 lamotrigine 100mg tab 1 lamotrigine 150mg tab 1 lamotrigine 200mg er tab 2 lamotrigine 200mg odt 2 lamotrigine 200mg tab 1 lamotrigine 250mg er tab 2 lamotrigine 25mg chew tab 2 lamotrigine 25mg er tab 2 lamotrigine 25mg odt 2 lamotrigine 25mg pack 2 lamotrigine 25mg tab 1 lamotrigine 300mg er tab 2 lamotrigine 50mg er tab 2 lamotrigine 50mg odt 2 lamotrigine 5mg chew tab 2 lamotrigine ODT kit 2 lamotrigine tab 25mg (42)/100mg (7) starter pack 2 lamotrigine tab 25mg (84)/100mg (14) starter pack 2 levetiracetam 1000mg tab 2 levetiracetam 100mg/ml oral soln 2 levetiracetam 250mg tab 2 levetiracetam 500mg er tab 2 levetiracetam 500mg tab 2 levetiracetam 750mg er tab 2 levetiracetam 750mg tab 2 oxcarbazepine 150mg tab 1 oxcarbazepine 300mg tab 1 oxcarbazepine 600mg tab 1 oxcarbazepine 60mg/ml susp 2 OXTELLAR 150MG ER TAB 4 OXTELLAR 300MG ER TAB 4 OXTELLAR 600MG ER TAB 4 pregabalin 100mg cap 1 pregabalin 150mg cap 1 pregabalin 200mg cap 1 pregabalin 20mg/ml oral soln 2 pregabalin 225mg cap 1 pregabalin 25mg cap 1 pregabalin 300mg cap 1 pregabalin 50mg cap 1 pregabalin 75mg cap 1 primidone 250mg tab 1 primidone 50mg tab 1 QUDEXY 100MG ER CAP 4 PA NSO

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

24

Page 27: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

QUDEXY 150MG ER CAP 4 PA NSO QUDEXY 200MG ER CAP 4 PA NSO QUDEXY 25MG ER CAP 4 PA NSO QUDEXY 50MG ER CAP 4 PA NSO roweepra 1000mg tab 2 roweepra 500mg er tab 1 roweepra 500mg tab 1 roweepra 750mg er tab 1 roweepra 750mg tab 2 SPRITAM 1000MG TAB FOR ORAL SUSP 4 PA NSO SPRITAM 250MG TAB FOR ORAL SUSP 4 PA NSO SPRITAM 500MG TAB FOR ORAL SUSP 4 PA NSO SPRITAM 750MG TAB FOR ORAL SUSP 4 PA NSO TOPIRAMATE 100MG ER CAP 4 PA NSO topiramate 100mg tab 1 TOPIRAMATE 150MG ER CAP 4 PA NSO topiramate 15mg cap 2 TOPIRAMATE 200MG ER CAP 4 PA NSO topiramate 200mg tab 1 topiramate 25mg cap 2 TOPIRAMATE 25MG ER CAP 4 PA NSO topiramate 25mg tab 1 TOPIRAMATE 50MG ER CAP 4 PA NSO topiramate 50mg tab 1 TROKENDI 100MG ER CAP 4 PA NSO TROKENDI 200MG ER CAP 4 PA NSO TROKENDI 25MG ER CAP 4 PA NSO TROKENDI 50MG ER CAP 4 PA NSO VIMPAT 100MG TAB 3 QL=60 EA/30 Days VIMPAT 10MG/ML ORAL SOLN 3 VIMPAT 150MG TAB 3 QL=60 EA/30 Days VIMPAT 200MG TAB 3 QL=60 EA/30 Days VIMPAT 50MG TAB 3 QL=60 EA/30 Days zonisamide 100mg cap 1 zonisamide 25mg cap 1 zonisamide 50mg cap 1

CARBAMATES felbamate 120mg/ml susp 2 felbamate 400mg tab 2 felbamate 600mg tab 2 XCOPRI 100MG TAB 3 XCOPRI 12.5/25MG TITRATION PACK 3 XCOPRI 150/200MG TITRATION PACK 3 XCOPRI 150MG TAB 3 XCOPRI 200MG TAB 3 XCOPRI 50/100MG TITRATION PACK 3

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

25

Page 28: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

XCOPRI 50MG TAB 3 XCOPRI TAB 150/200MG PACK 3 XCOPRI TAB 50/200MG PACK 3

GABA MODULATORS tiagabine 12mg tab 2 tiagabine 16mg tab 2 tiagabine 2mg tab 2 tiagabine 4mg tab 2 vigabatrin 500mg powder for oral soln 5 NDS PA NSO vigabatrin 500mg tab 5 NDS PA NSO vigadrone 500mg powder for oral soln 5 NDS PA NSO

HYDANTOINS DILANTIN 30MG ER CAP 3 PEGANONE 250MG TAB 3 phenytoin 25mg/ml susp 2 phenytoin 50mg chew tab 2 phenytoin sodium 100mg er cap 1 phenytoin sodium 200mg er cap 2 phenytoin sodium 300mg er cap 2

SUCCINIMIDES CELONTIN 300MG CAP 3 ethosuximide 250mg cap 2 ethosuximide 50mg/ml oral soln 2

VALPROIC ACID divalproex sodium 125mg dr cap 2 divalproex sodium 125mg dr tab 1 divalproex sodium 250mg dr tab 1 divalproex sodium 250mg er tab 2 divalproex sodium 500mg dr tab 1 divalproex sodium 500mg er tab 2 valproic acid 250mg cap 2 valproic acid 50mg/ml oral soln 2

ANTIDEPRESSANTS ALPHA-2 RECEPTOR ANTAGONISTS (TETRACYCLICS)

mirtazapine 15mg odt 2 mirtazapine 15mg tab 1 mirtazapine 30mg odt 2 mirtazapine 30mg tab 1 mirtazapine 45mg odt 2 mirtazapine 45mg tab 1 mirtazapine 7.5mg tab 2

ANTIDEPRESSANTS - MISC. APLENZIN 174MG ER TAB 4 ST_NSO APLENZIN 348MG ER TAB 4 ST_NSO APLENZIN 522MG ER TAB 4 ST_NSO bupropion 100mg er tab 2

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

26

Page 29: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

bupropion 100mg tab 2 bupropion 150mg sr (12 hr) tab 2 bupropion 150mg xl (24 hr) tab 2 bupropion 200mg er tab 2 bupropion 300mg er tab 2 bupropion 75mg tab 2 MAPROTILINE 25MG TAB 2 MAPROTILINE 50MG TAB 2 MAPROTILINE 75MG TAB 2

MONOAMINE OXIDASE INHIBITORS (MAOIS) EMSAM 12MG/24HR PATCH 4 EMSAM 6MG/24HR PATCH 4 EMSAM 9MG/24HR PATCH 4 MARPLAN 10MG TAB 3 phenelzine 15mg tab 2 tranylcypromine 10mg tab 2

SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS) citalopram 10mg tab 1 citalopram 20mg tab 1 citalopram 2mg/ml oral soln 2 citalopram 40mg tab 1 escitalopram 10mg tab 1 escitalopram 1mg/ml oral soln 2 escitalopram 20mg tab 1 escitalopram 5mg tab 1 fluoxetine 10mg cap 1 fluoxetine 10mg tab 2 fluoxetine 20mg cap 1 fluoxetine 20mg tab 2 fluoxetine 40mg cap 1 fluoxetine 4mg/ml oral soln 1 fluvoxamine maleate 100mg er cap 2 ST_NSO fluvoxamine maleate 100mg tab 1 fluvoxamine maleate 150mg er cap 2 ST_NSO fluvoxamine maleate 25mg tab 1 fluvoxamine maleate 50mg tab 1 paroxetine 10mg tab 2 paroxetine 12.5mg er tab 2 paroxetine 20mg tab 2 paroxetine 25mg er tab 2 paroxetine 30mg tab 2 paroxetine 37.5mg er tab 2 paroxetine 40mg tab 2 PAXIL 10MG/5ML SUSP 4 PEXEVA 10MG TAB 4 PEXEVA 20MG TAB 4

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

27

Page 30: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

PEXEVA 30MG TAB 4 PEXEVA 40MG TAB 4 sertraline 100mg tab 1 sertraline 20mg/ml oral soln 2 sertraline 25mg tab 1 sertraline 50mg tab 1

SEROTONIN MODULATORS NEFAZODONE 100MG TAB 4 NEFAZODONE 150MG TAB 4 NEFAZODONE 200MG TAB 4 NEFAZODONE 250MG TAB 2 NEFAZODONE 50MG TAB 2 trazodone 100mg tab 1 trazodone 150mg tab 1 trazodone 300mg tab 2 trazodone 50mg tab 1 TRINTELLIX 10MG TAB 3 ST_NSO QL=30 EA/30 Days TRINTELLIX 20MG TAB 3 ST_NSO QL=30 EA/30 Days TRINTELLIX 5MG TAB 3 ST_NSO QL=30 EA/30 Days VIIBRYD 10/20MG STARTER PACK 4 ST_NSO QL=30 EA/30 Days VIIBRYD 10MG TAB 4 ST_NSO QL=30 EA/30 Days VIIBRYD 20MG TAB 4 ST_NSO QL=30 EA/30 Days VIIBRYD 40MG TAB 4 ST_NSO QL=30 EA/30 Days

SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIS) desvenlafaxine succinate 100mg er tab 2 desvenlafaxine succinate 25mg er tab 2 desvenlafaxine succinate 50mg er tab 2 DRIZALMA 20MG DR CAP 4 ST_NSO DRIZALMA 30MG DR CAP 4 ST_NSO DRIZALMA 40MG DR CAP 4 ST_NSO DRIZALMA 60MG DR CAP 4 ST_NSO duloxetine 20mg dr cap 2 duloxetine 30mg dr cap 2 duloxetine 40mg dr cap 2 ST_NSO QL=30 EA/30 Days duloxetine 60mg dr cap 2 FETZIMA 120MG ER CAP 4 ST_NSO QL=30 EA/30 Days FETZIMA 20MG ER CAP 4 ST_NSO QL=30 EA/30 Days FETZIMA 40MG ER CAP 4 ST_NSO QL=30 EA/30 Days FETZIMA 80MG ER CAP 4 ST_NSO QL=30 EA/30 Days FETZIMA PACK 4 ST_NSO QL=30 EA/30 Days venlafaxine 100mg tab 1 venlafaxine 150mg er cap 1 venlafaxine 25mg tab 1 venlafaxine 37.5mg er cap 1 venlafaxine 37.5mg tab 1 venlafaxine 50mg tab 1

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

28

Page 31: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

venlafaxine 75mg er cap 1 venlafaxine 75mg tab 1

TRICYCLIC AGENTS amitriptyline 100mg tab amitriptyline 10mg tab amitriptyline 150mg tab amitriptyline 25mg tab amitriptyline 50mg tab amitriptyline 75mg tab AMOXAPINE 100MG TAB AMOXAPINE 150MG TAB AMOXAPINE 25MG TAB AMOXAPINE 50MG TAB clomipramine 25mg cap clomipramine 50mg cap clomipramine 75mg cap desipramine 100mg tab desipramine 10mg tab desipramine 150mg tab desipramine 25mg tab desipramine 50mg tab desipramine 75mg tab doxepin 100mg cap doxepin 10mg cap doxepin 10mg/ml oral soln doxepin 150mg cap doxepin 25mg cap doxepin 50mg cap doxepin 75mg cap imipramine 10mg tab imipramine 25mg tab imipramine 50mg tab imipramine pamoate 100mg cap imipramine pamoate 125mg cap imipramine pamoate 150mg cap imipramine pamoate 75mg cap nortriptyline 10mg cap nortriptyline 25mg cap NORTRIPTYLINE 2MG/ML ORAL SOLN nortriptyline 50mg cap nortriptyline 75mg cap protriptyline 10mg tab protriptyline 5mg tab trimipramine 100mg cap trimipramine 25mg cap trimipramine 50mg cap

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

29

2 2 2 2 2 2 3 3 3 3 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 3 2 2 2 2 2 2 2

Page 32: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

ANTIDIABETICS ALPHA-GLUCOSIDASE INHIBITORS

acarbose 100mg tab 2 acarbose 25mg tab 2 acarbose 50mg tab 2 miglitol 100mg tab 2 miglitol 25mg tab 2 miglitol 50mg tab 2

ANTIDIABETIC COMBINATIONS glipizide 2.5mg/metformin 250mg tab 1 glipizide 2.5mg/metformin 500mg tab 1 glipizide 5mg/metformin 500mg tab 1 glyburide 1.25mg/metformin 250mg tab 1 glyburide 2.5mg/metformin 500mg tab 1 glyburide 5mg/metformin 500mg tab 1 GLYXAMBI 10-5MG TAB 3 QL=30 EA/30 Days GLYXAMBI 25-5MG TAB 3 QL=30 EA/30 Days JANUMET 1000-100MG ER TAB 3 QL=30 EA/30 Days JANUMET 1000-50MG ER TAB 3 QL=60 EA/30 Days JANUMET 1000-50MG TAB 3 QL=60 EA/30 Days JANUMET 500-50MG ER TAB 3 QL=60 EA/30 Days JANUMET 500-50MG TAB 3 QL=60 EA/30 Days JENTADUETO 2.5-1000MG ER TAB 3 QL=30 EA/30 Days JENTADUETO 2.5-1000MG TAB 3 QL=60 EA/30 Days JENTADUETO 2.5-500MG TAB 3 QL=60 EA/30 Days JENTADUETO 2.5-850MG TAB 3 QL=60 EA/30 Days JENTADUETO 5-1000MG ER TAB 3 QL=30 EA/30 Days SOLIQUA 100UNIT-0.033MG/ML PEN INJ 3 PA QL=15 ML/25 Days SYNJARDY 10-1000MG ER TAB 3 QL=30 EA/30 Days SYNJARDY 12.5-1000MG ER TAB 3 QL=60 EA/30 Days SYNJARDY 12.5-1000MG TAB 3 QL=60 EA/30 Days SYNJARDY 12.5-500MG TAB 3 QL=60 EA/30 Days SYNJARDY 25-1000MG ER TAB 3 QL=30 EA/30 Days SYNJARDY 5-1000MG ER TAB 3 QL=60 EA/30 Days SYNJARDY 5-1000MG TAB 3 QL=60 EA/30 Days SYNJARDY 5-500MG TAB 3 QL=60 EA/30 Days TRIJARDY 10-5-1000MG ER TAB 3 QL=30 EA/30 Days TRIJARDY 12.5-2.5-1000MG ER TAB 3 QL=60 EA/30 Days TRIJARDY 25-5-1000MG ER TAB 3 QL=30 EA/30 Days TRIJARDY 5-2.5-1000MG ER TAB 3 QL=60 EA/30 Days XIGDUO 10-1000MG ER TAB 3 QL=30 EA/30 Days XIGDUO 10-500MG ER TAB 3 QL=30 EA/30 Days XIGDUO 2.5-1000MG ER TAB 3 QL=60 EA/30 Days XIGDUO 5-1000MG ER TAB 3 QL=60 EA/30 Days XIGDUO 5-500MG ER TAB 3 QL=30 EA/30 Days XULTOPHY 100UNIT-3.6MG/ML PEN INJ 3 PA SI QL=15 ML/30 Days

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

30

Page 33: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

BIGUANIDES metformin 1000mg tab 1 metformin 100mg/ml soln 2 metformin 500mg er tab 1 metformin 500mg tab 1 metformin 750mg er tab 1 metformin 850mg tab 1 RIOMET 500MG/5ML ER SUSP 4

DIABETIC OTHER BAQSIMI 3MG/DOSE NASAL POWDER 3 QL=2 EA/7 Days diazoxide 50mg/ml susp 2 GLUCAGEN 1MG INJ 3 QL=2 EA/7 Days GLUCAGON (RDNA) 1MG INJ 3 QL=2 EA/7 Days GVOKE 0.5MG/0.1ML AUTO-INJECTOR 3 QL=.20 ML/7 Days GVOKE 0.5MG/0.1ML SYRINGE 3 QL=.20 ML/7 Days GVOKE 1MG/0.2ML AUTO-INJECTOR 3 QL=.40 ML/7 Days GVOKE 1MG/0.2ML SYRINGE 3 QL=.40 ML/7 Days KORLYM 300MG TAB 5 NDS PA

DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS JANUVIA 100MG TAB 3 QL=30 EA/30 Days JANUVIA 25MG TAB 3 QL=30 EA/30 Days JANUVIA 50MG TAB 3 QL=30 EA/30 Days TRADJENTA 5MG TAB 3 QL=30 EA/30 Days

DOPAMINE RECEPTOR AGONISTS - ANTIDIABETIC CYCLOSET 0.8MG TAB 4

INCRETIN MIMETIC AGENTS (GLP-1 RECEPTOR AGONISTS) BYDUREON 2MG PEN INJ 3 QL=4 EA/28 Days BYDUREON 2MG/0.85ML AUTO-INJECTOR 3 QL=3.40 ML/28 Days OZEMPIC 2MG/1.5ML PEN INJ 3 QL=1.50 ML/28 Days OZEMPIC 2MG/1.5ML PEN INJ (1MG DOSE) 3 QL=3 ML/28 Days RYBELSUS 14MG TAB 3 QL=30 EA/30 Days RYBELSUS 3MG TAB 3 QL=30 EA/30 Days RYBELSUS 7MG TAB 3 QL=30 EA/30 Days VICTOZA 18MG/3ML PEN INJ 3 QL=9 ML/30 Days

INSULIN FIASP 100UNIT/ML CARTRIDGE 3 SI FIASP 100UNIT/ML INJ 3 SI FIASP 100UNIT/ML PEN INJ 3 SI HUMULIN R 500UNIT/ML INJ 3 PA BvD SI HUMULIN R 500UNIT/ML PEN INJ 3 SI LANTUS 100UNIT/ML INJ 3 SI LANTUS 100UNIT/ML PEN INJ 3 SI LEVEMIR 100UNIT/ML INJ 3 SI LEVEMIR 100UNIT/ML PEN INJ 3 SI NOVOLIN 70-30UNIT/ML INJ 3 SI NOVOLIN N 100UNIT/ML INJ 3 SI

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

31

Page 34: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

NOVOLIN N 100UNIT/ML PEN INJ 3 SI NOVOLIN R 100UNIT/ML INJ 3 SI NOVOLIN R 100UNIT/ML PEN INJ 3 SI NOVOLOG 100UNIT/ML CARTRIDGE 3 SI NOVOLOG 100UNIT/ML INJ 3 SI NOVOLOG 100UNIT/ML PEN INJ 3 SI NOVOLOG MIX 70-30UNIT/ML INJ 3 SI NOVOLOG MIX 70-30UNIT/ML PEN INJ 3 SI TOUJEO 300UNIT/ML PEN INJ 3 SI TOUJEO MAX 300UNIT/ML PEN INJ (3ML) 3 SI TRESIBA 100UNIT/ML INJ 3 SI TRESIBA 100UNIT/ML PEN INJ 3 SI TRESIBA 200UNIT/ML PEN INJ 3 SI

INSULIN SENSITIZING AGENTS AVANDIA 2MG TAB 3 AVANDIA 4MG TAB 3 pioglitazone 15mg tab 1 pioglitazone 30mg tab 1 pioglitazone 45mg tab 1

MEGLITINIDE ANALOGUES nateglinide 120mg tab 2 nateglinide 60mg tab 2 repaglinide 0.5mg tab 2 repaglinide 1mg tab 2 repaglinide 2mg tab 2

SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS FARXIGA 10MG TAB 3 QL=30 EA/30 Days FARXIGA 5MG TAB 3 QL=30 EA/30 Days JARDIANCE 10MG TAB 3 QL=30 EA/30 Days JARDIANCE 25MG TAB 3 QL=30 EA/30 Days

SULFONYLUREAS glimepiride 1mg tab 1 glimepiride 2mg tab 1 glimepiride 4mg tab 1 glipizide 10mg er tab 1 glipizide 10mg tab 1 glipizide 2.5mg er tab 1 glipizide 5mg er tab 1 glipizide 5mg tab 1 glyburide 1.25mg tab 2 glyburide 1.5mg tab 2 glyburide 2.5mg tab 2 glyburide 3mg tab 2 glyburide 5mg tab 2 glyburide 6mg tab 2

ANTIDIARRHEAL/PROBIOTIC AGENTS

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

32

Page 35: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

ANTIPERISTALTIC AGENTS atropine sulfate 0.005mg/ml/diphenoxylate 0.5mg/ml 2 oral soln atropine sulfate 0.025mg/diphenoxylate 2.5mg tab 2 loperamide 2mg cap 1

ANTIDOTES AND SPECIFIC ANTAGONISTS ANTIDOTES - CHELATING AGENTS

CHEMET 100MG CAP 3 deferasirox 125mg tab for oral susp 2 deferasirox 180mg granules 5 NDS deferasirox 180mg tab 2 deferasirox 250mg tab for oral susp 2 deferasirox 360mg granules 5 NDS deferasirox 360mg tab 2 deferasirox 500mg tab for oral susp 2 deferasirox 90mg granules 5 NDS deferasirox 90mg tab 2 FERRIPROX 1000MG TAB 5 NDS PA FERRIPROX 100MG/ML ORAL SOLN 5 NDS PA FERRIPROX 500MG TAB 5 NDS PA

OPIOID ANTAGONISTS NALOXONE 0.4MG/ML CARTRIDGE 2 QL=2 ML/2 Days naloxone 0.4mg/ml inj 2 QL=2 ML/2 Days naloxone 1mg/ml syringe 1 naltrexone 50mg tab 1 NARCAN 4MG/0.1ML NASAL SPRAY 2 VIVITROL 380MG INJ 5 NDS

ANTIEMETICS 5-HT3 RECEPTOR ANTAGONISTS

granisetron 1mg tab 2 PA BvD QL=60 EA/30 Days ondansetron 0.8mg/ml oral soln 2 PA BvD ONDANSETRON 24MG TAB 2 PA BvD ondansetron 4mg odt 2 PA BvD ondansetron 4mg tab 2 PA BvD ondansetron 8mg odt 2 PA BvD ondansetron 8mg tab 2 PA BvD SANCUSO 3.1MG/24HR PATCH 4 QL=2 EA/14 Days

ANTIEMETICS - ANTICHOLINERGIC meclizine 12.5mg tab 1 meclizine 25mg tab 1 scopolamine 0.0139mg/hr patch 2 trimethobenzamide 300mg cap 2

ANTIEMETICS - MISCELLANEOUS doxylamine succinate 10mg/pyridoxine 10mg dr tab 2 QL=120 EA/30 Days dronabinol 10mg cap 2 PA dronabinol 2.5mg cap 2 PA

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

33

Page 36: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

dronabinol 5mg cap 2 PA SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS

aprepitant 125mg cap 2 PA BvD QL=3 EA/2 Days aprepitant 125mg/aprepitant 80mg pack 2 PA BvD QL=6 EA/4 Days aprepitant 40mg cap 2 PA BvD QL=3 EA/2 Days aprepitant 80mg cap 2 PA BvD QL=6 EA/4 Days VARUBI 90MG TAB 4 PA BvD QL=4 EA/28 Days

ANTIFUNGALS ANTIFUNGAL - GLUCAN SYNTHESIS INHIBITORS (ECHINOCANDINS)

caspofungin acetate 50mg inj 5 NDS caspofungin acetate 70mg inj 5 NDS ERAXIS 100MG INJ 3 ERAXIS 50MG INJ 3 micafungin sodium 100mg inj 2 micafungin sodium 50mg inj 2

ANTIFUNGALS ABELCET 5MG/ML INJ 4 PA BvD AMBISOME 50MG INJ 4 PA BvD AMPHOTERICIN B 50MG INJ 4 PA BvD flucytosine 250mg cap 2 flucytosine 500mg cap 2 griseofulvin 125mg tab 2 griseofulvin 250mg tab 2 griseofulvin 25mg/ml susp 2 griseofulvin 500mg tab 2 nystatin 500000unit tab 2 terbinafine 250mg tab 1

IMIDAZOLE-RELATED ANTIFUNGALS fluconazole 100mg tab 2 fluconazole 10mg/ml susp 2 fluconazole 150mg tab 1 fluconazole 200mg tab 2 fluconazole 2mg/ml (100ml) inj 2 fluconazole 2mg/ml (200ml) inj 2 fluconazole 40mg/ml susp 2 fluconazole 50mg tab 2 itraconazole 100mg cap 2 PA itraconazole 10mg/ml oral soln 2 PA ketoconazole 200mg tab 1 NOXAFIL 40MG/ML SUSP 3 PA posaconazole 100mg dr tab 2 PA voriconazole 200mg inj 2 PA voriconazole 200mg tab 2 PA voriconazole 40mg/ml susp 2 PA voriconazole 50mg tab 2 PA

ANTIHISTAMINES

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

34

Page 37: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

ANTIHISTAMINES - NON-SEDATING cetirizine 1mg/ml oral soln 2 desloratadine 5mg tab 2 levocetirizine 0.5mg/ml oral soln 2 levocetirizine 5mg tab 1

ANTIHISTAMINES - PHENOTHIAZINES promethazine 1.25mg/ml oral soln 2 promethazine 12.5mg rectal supp 2 promethazine 12.5mg tab 1 promethazine 25mg rectal supp 2 promethazine 25mg tab 1 promethazine 50mg tab 1 promethegan 25mg rectal supp 2 PROMETHEGAN 50MG RECTAL SUPP 3

ANTIHISTAMINES - PIPERIDINES cyproheptadine 0.4mg/ml oral soln 2 cyproheptadine 4mg tab 2

ANTIHYPERLIPIDEMICS ANTIHYPERLIPIDEMICS - COMBINATIONS

ezetimibe 10mg/simvastatin 10mg tab 2 QL=30 EA/30 Days ezetimibe 10mg/simvastatin 20mg tab 2 QL=30 EA/30 Days ezetimibe 10mg/simvastatin 40mg tab 2 QL=30 EA/30 Days ezetimibe 10mg/simvastatin 80mg tab 2 QL=30 EA/30 Days

ANTIHYPERLIPIDEMICS - MISC. omega-3 acid ethyl esters (usp) 1000mg cap 2 VASCEPA 0.5GM CAP 3 QL=120 EA/30 Days VASCEPA 1GM CAP 3 QL=120 EA/30 Days

BILE ACID SEQUESTRANTS cholestyramine resin 4gm sf powder for oral susp 3 cholestyramine resin 4gm sf powder for oral susp (sugar free)

2

colesevelam 3750mg powder for oral susp 2 colesevelam 625mg tab 2 colestipol 1000mg tab 2 colestipol 5000mg granules for oral susp 2 prevalite 4gm powder for oral susp 2

FIBRIC ACID DERIVATIVES ANTARA 30MG CAP 4 ANTARA 90MG CAP 4 fenofibrate 134mg cap 2 fenofibrate 145mg tab 2 FENOFIBRATE 150MG CAP 4 fenofibrate 160mg tab 2 fenofibrate 200mg cap 2 fenofibrate 48mg tab 2 FENOFIBRATE 50MG CAP 4

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

35

Page 38: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

fenofibrate 54mg tab 2 fenofibrate 67mg cap 2 fenofibric acid 135mg dr cap 2 fenofibric acid 45mg dr cap 2 gemfibrozil 600mg tab 1 LIPOFEN 150MG CAP 4 LIPOFEN 50MG CAP 4 TRIGLIDE 160MG TAB 4

HMG COA REDUCTASE INHIBITORS atorvastatin 10mg tab 1 atorvastatin 20mg tab 1 atorvastatin 40mg tab 1 atorvastatin 80mg tab 1 fluvastatin 20mg cap 2 fluvastatin 40mg cap 2 fluvastatin 80mg er tab 2 lovastatin 10mg tab 1 lovastatin 20mg tab 1 lovastatin 40mg tab 1 pravastatin sodium 10mg tab 1 pravastatin sodium 20mg tab 1 pravastatin sodium 40mg tab 1 pravastatin sodium 80mg tab 1 rosuvastatin calcium 10mg tab 1 rosuvastatin calcium 20mg tab 1 rosuvastatin calcium 40mg tab 1 rosuvastatin calcium 5mg tab 1 simvastatin 10mg tab 1 simvastatin 20mg tab 1 simvastatin 40mg tab 1 simvastatin 5mg tab 1 simvastatin 80mg tab 1

INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS ezetimibe 10mg tab 2 QL=30 EA/30 Days

MICROSOMAL TRIGLYCERIDE TRANSFER PROTEIN (MTP) INHIBITORS JUXTAPID 10MG CAP 5 NDS PA JUXTAPID 20MG CAP 5 NDS PA JUXTAPID 30MG CAP 5 NDS PA JUXTAPID 40MG CAP 5 NDS PA JUXTAPID 5MG CAP 5 NDS PA JUXTAPID 60MG CAP 5 NDS PA

NICOTINIC ACID DERIVATIVES niacin 1000mg er tab 2 niacin 500mg er tab 2 niacin 750mg er tab 2

PROPROTEIN CONVERTASE SUBTILISIN/KEXIN TYPE 9 INHIBITORS

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

36

Page 39: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

PRALUENT 150MG/ML AUTO-INJECTOR 4 PA QL=2 ML/28 Days PRALUENT 75MG/ML AUTO-INJECTOR 4 PA QL=2 ML/28 Days REPATHA 140MG/ML AUTO-INJECTOR 4 PA QL=2 ML/28 Days REPATHA 140MG/ML SYRINGE 4 PA QL=2 ML/28 Days REPATHA 420MG/3.5ML CARTRIDGE 4 PA QL=3.50 ML/28 Days

ANTIHYPERTENSIVES ACE INHIBITORS

benazepril 10mg tab 1 benazepril 20mg tab 1 benazepril 40mg tab 1 benazepril 5mg tab 1 captopril 100mg tab 2 captopril 12.5mg tab 2 captopril 25mg tab 2 captopril 50mg tab 2 enalapril maleate 10mg tab 1 enalapril maleate 2.5mg tab 1 enalapril maleate 20mg tab 1 enalapril maleate 5mg tab 1 fosinopril sodium 10mg tab 1 fosinopril sodium 20mg tab 1 fosinopril sodium 40mg tab 1 lisinopril 10mg tab 1 lisinopril 2.5mg tab 1 lisinopril 20mg tab 1 lisinopril 30mg tab 1 lisinopril 40mg tab 1 lisinopril 5mg tab 1 moexipril 15mg tab 2 moexipril 7.5mg tab 2 perindopril erbumine 2mg tab 2 perindopril erbumine 4mg tab 2 perindopril erbumine 8mg tab 2 QBRELIS 1MG/ML ORAL SOLN 4 PA quinapril 10mg tab 1 quinapril 20mg tab 1 quinapril 40mg tab 1 quinapril 5mg tab 1 ramipril 1.25mg cap 1 ramipril 10mg cap 1 ramipril 2.5mg cap 1 ramipril 5mg cap 1 trandolapril 1mg tab 1 trandolapril 2mg tab 1 trandolapril 4mg tab 1

AGENTS FOR PHEOCHROMOCYTOMA

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

37

Page 40: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

DEMSER 250MG CAP 5 NDS phenoxybenzamine 10mg cap 2

ANGIOTENSIN II RECEPTOR ANTAGONISTS irbesartan 150mg tab 1 irbesartan 300mg tab 1 irbesartan 75mg tab 1 losartan potassium 100mg tab 1 losartan potassium 25mg tab 1 losartan potassium 50mg tab 1 olmesartan medoxomil 20mg tab 1 olmesartan medoxomil 40mg tab 1 olmesartan medoxomil 5mg tab 1 telmisartan 20mg tab 2 telmisartan 40mg tab 2 telmisartan 80mg tab 2 valsartan 160mg tab 1 valsartan 320mg tab 1 valsartan 40mg tab 1 valsartan 80mg tab 1

ANTIADRENERGIC ANTIHYPERTENSIVES clonidine 0.00417mg/hr weekly patch 2 clonidine 0.00833mg/hr weekly patch 2 clonidine 0.0125mg/hr weekly patch 2 clonidine 0.1mg tab 1 clonidine 0.2mg tab 1 clonidine 0.3mg tab 1 doxazosin 1mg tab 1 doxazosin 2mg tab 1 doxazosin 4mg tab 1 doxazosin 8mg tab 1 guanfacine 1mg tab 2 guanfacine 2mg tab 2 methyldopa 250mg tab 2 methyldopa 500mg tab 2 prazosin 1mg cap 1 prazosin 2mg cap 1 prazosin 5mg cap 1 terazosin 10mg cap 1 terazosin 1mg cap 1 terazosin 2mg cap 1 terazosin 5mg cap 1

ANTIHYPERTENSIVE COMBINATIONS amlodipine 10mg/benazepril 20mg cap 2 amlodipine 10mg/benazepril 40mg cap 2 amlodipine 10mg/hydrochlorothiazide 12.5mg/valsartan 160mg tab

2

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

38

Page 41: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

amlodipine 10mg/hydrochlorothiazide 25mg/valsartan 160mg tab

2

amlodipine 10mg/hydrochlorothiazide 25mg/valsartan 320mg tab

2

amlodipine 10mg/olmesartan medoxomil 20mg tab 2 amlodipine 10mg/olmesartan medoxomil 40mg tab 2 amlodipine 10mg/valsartan 160mg tab 2 amlodipine 10mg/valsartan 320mg tab 2 amlodipine 2.5mg/benazepril 10mg cap 2 amlodipine 5mg/benazepril 10mg cap 2 amlodipine 5mg/benazepril 20mg cap 2 amlodipine 5mg/benazepril 40mg cap 2 amlodipine 5mg/hydrochlorothiazide 12.5mg/valsartan 160mg tab

2

amlodipine 5mg/hydrochlorothiazide 25mg/valsartan 160mg tab

2

amlodipine 5mg/olmesartan medoxomil 20mg tab 2 amlodipine 5mg/olmesartan medoxomil 40mg tab 2 amlodipine 5mg/valsartan 160mg tab 2 amlodipine 5mg/valsartan 320mg tab 2 atenolol 100mg/chlorthalidone 25mg tab 2 atenolol 50mg/chlorthalidone 25mg tab 2 benazepril 10mg/hydrochlorothiazide 12.5mg tab 2 benazepril 20mg/hydrochlorothiazide 12.5mg tab 2 benazepril 20mg/hydrochlorothiazide 25mg tab 2 benazepril 5mg/hydrochlorothiazide 6.25mg tab 2 bisoprolol fumarate 10mg/hydrochlorothiazide 6.25mg tab

1

bisoprolol fumarate 2.5mg/hydrochlorothiazide 6.25mg tab

1

bisoprolol fumarate 5mg/hydrochlorothiazide 6.25mg tab

1

captopril 25mg/hydrochlorothiazide 15mg tab 2 CAPTOPRIL 25MG/HYDROCHLOROTHIAZIDE 25MG TAB

2

captopril 50mg/hydrochlorothiazide 15mg tab 2 CAPTOPRIL 50MG/HYDROCHLOROTHIAZIDE 25MG TAB

2

enalapril maleate 10mg/hydrochlorothiazide 25mg tab

1

enalapril maleate 5mg/hydrochlorothiazide 12.5mg tab

1

fosinopril sodium 10mg/hydrochlorothiazide 12.5mg tab

2

fosinopril sodium 20mg/hydrochlorothiazide 12.5mg tab

2

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

39

Page 42: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

hydrochlorothiazide 12.5mg/irbesartan 150mg tab 2 hydrochlorothiazide 12.5mg/irbesartan 300mg tab 2 hydrochlorothiazide 12.5mg/lisinopril 10mg tab 1 hydrochlorothiazide 12.5mg/lisinopril 20mg tab 1 hydrochlorothiazide 12.5mg/losartan potassium 2 100mg tab hydrochlorothiazide 12.5mg/losartan potassium 50mg 2 tab hydrochlorothiazide 12.5mg/olmesartan medoxomil 1 20mg tab hydrochlorothiazide 12.5mg/olmesartan medoxomil 1 40mg tab hydrochlorothiazide 12.5mg/quinapril 10mg tab 2 hydrochlorothiazide 12.5mg/quinapril 20mg tab 2 hydrochlorothiazide 12.5mg/valsartan 160mg tab 2 hydrochlorothiazide 12.5mg/valsartan 320mg tab 2 hydrochlorothiazide 12.5mg/valsartan 80mg tab 2 hydrochlorothiazide 15mg/methyldopa 250mg tab 2 hydrochlorothiazide 25mg/lisinopril 20mg tab 1 hydrochlorothiazide 25mg/losartan potassium 100mg tab

2

hydrochlorothiazide 25mg/methyldopa 250mg tab 2 hydrochlorothiazide 25mg/metoprolol tartrate 100mg 2 tab hydrochlorothiazide 25mg/metoprolol tartrate 50mg 2 tab hydrochlorothiazide 25mg/olmesartan medoxomil 1 40mg tab hydrochlorothiazide 25mg/propranolol 40mg tab 2 hydrochlorothiazide 25mg/propranolol 80mg tab 2 hydrochlorothiazide 25mg/quinapril 20mg tab 2 hydrochlorothiazide 25mg/valsartan 160mg tab 2 hydrochlorothiazide 25mg/valsartan 320mg tab 2 hydrochlorothiazide 50mg/metoprolol tartrate 100mg tab

2

TEKTURNA HCT 150-12.5MG TAB 4 TEKTURNA HCT 150-25MG TAB 4 TEKTURNA HCT 300-12.5MG TAB 4 TEKTURNA HCT 300-25MG TAB 4 TRANDOLAPRIL 1MG/VERAPAMIL 240MG ER TAB 4 trandolapril 2mg/verapamil 180mg er tab 2 trandolapril 2mg/verapamil 240mg er tab 2 trandolapril 4mg/verapamil 240mg er tab 2

DIRECT RENIN INHIBITORS aliskiren 150mg tab 2 aliskiren 300mg tab 2

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

40

Page 43: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS (SARAS) eplerenone 25mg tab 2 eplerenone 50mg tab 2

VASODILATORS hydralazine 100mg tab 2 hydralazine 10mg tab 2 hydralazine 25mg tab 2 hydralazine 50mg tab 2 minoxidil 10mg tab 1 minoxidil 2.5mg tab 1

ANTI-INFECTIVE AGENTS - MISC. ANTI-INFECTIVE AGENTS - MISC.

metronidazole 250mg tab 1 metronidazole 375mg cap 2 metronidazole 500mg tab 1 metronidazole 5mg/ml inj 2 pentamidine isethionate 300mg inj 2 pentamidine isethionate 50mg/ml inh soln 2 PA BvD tinidazole 250mg tab 2 tinidazole 500mg tab 2 trimethoprim 100mg tab 1 XIFAXAN 200MG TAB 4 PA QL=9 EA/3 Days XIFAXAN 550MG TAB 4 PA QL=60 EA/30 Days

ANTI-INFECTIVE MISC. - COMBINATIONS sulfamethoxazole 400mg/trimethoprim 80mg tab 1 sulfamethoxazole 40mg/ml/trimethoprim 8mg/ml susp 2 sulfamethoxazole 800mg/trimethoprim 160mg tab 1

ANTIPROTOZOAL AGENTS ALINIA 100MG/5ML SUSP 3 PA QL=150 ML/3 Days ALINIA 500MG TAB 3 PA QL=6 EA/3 Days atovaquone 150mg/ml susp 2

CARBAPENEMS CILASTATIN 250MG/IMIPENEM 250MG INJ 2 cilastatin 500mg/imipenem 500mg inj 2 ertapenem 1000mg inj 2 meropenem 1000mg inj 2 meropenem 500mg inj 2

CYCLIC LIPOPEPTIDES daptomycin 500mg inj 5 NDS

GLYCOPEPTIDES DALVANCE 500MG INJ 5 NDS FIRVANQ 25MG/ML ORAL SOLN 2 FIRVANQ 50MG/ML ORAL SOLN 2 vancomycin 1000mg inj 2 vancomycin 100mg/ml inj 2 vancomycin 125mg cap 2 QL=120 EA/30 Days

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

41

Page 44: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

vancomycin 250mg cap 2 QL=120 EA/30 Days VANCOMYCIN 250MG INJ 2 vancomycin 500mg inj 2 vancomycin 750mg inj 2

LEPROSTATICS dapsone 100mg tab 2 dapsone 25mg tab 2

LINCOSAMIDES clindamycin 12mg/ml inj 2 clindamycin 150mg cap 1 clindamycin 150mg/ml (2ml) inj 2 clindamycin 150mg/ml (4ml) inj 2 clindamycin 150mg/ml (6ml) inj 2 clindamycin 15mg/ml oral soln 2 clindamycin 18mg/ml inj 2 clindamycin 300mg cap 1 clindamycin 6mg/ml inj 2 clindamycin 75mg cap 1

MONOBACTAMS aztreonam 1000mg inj 2 CAYSTON 75MG INH SOLN 5 NDS PA

OXAZOLIDINONES linezolid 20mg/ml susp 2 linezolid 2mg/ml inj 2 linezolid 600mg tab 2 SIVEXTRO 200MG INJ 5 NDS PA QL=6 EA/6 Days SIVEXTRO 200MG TAB 5 NDS PA QL=6 EA/6 Days

PLEUROMUTILINS XENLETA 600MG TAB 5 NDS PA QL=14 EA/7 Days

POLYMYXINS colistin 75mg/ml inj 2 polymyxin b 250000unit/ml inj 2

ANTIMALARIALS ANTIMALARIAL COMBINATIONS

atovaquone 250mg/proguanil 100mg tab 2 atovaquone 62.5mg/proguanil 25mg tab 2 COARTEM 20-120MG TAB 3

ANTIMALARIALS CHLOROQUINE PHOSPHATE 250MG TAB 3 chloroquine phosphate 500mg tab 2 hydroxychloroquine sulfate 200mg tab 2 KRINTAFEL 150MG TAB 3 MEFLOQUINE 250MG TAB 3 PRIMAQUINE PHOSPHATE 26.3MG TAB 1 quinine sulfate 324mg cap 2 PA

ANTIMYASTHENIC/CHOLINERGIC AGENTS

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

42

Page 45: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

ANTIMYASTHENIC/CHOLINERGIC AGENTS GUANIDINE 125MG TAB 3 pyridostigmine bromide 12mg/ml oral soln 2 pyridostigmine bromide 180mg er tab 2 pyridostigmine bromide 60mg tab 2 RUZURGI 10MG TAB 5 NDS PA

ANTIMYCOBACTERIAL AGENTS ANTIMYCOBACTERIAL AGENTS

ethambutol 100mg tab 2 ethambutol 400mg tab 2 isoniazid 100mg tab 1 ISONIAZID 10MG/ML ORAL SOLN 3 isoniazid 300mg tab 1 PASER D/R 4GM GRANULES 3 PRIFTIN 150MG TAB 4 pyrazinamide 500mg tab 2 rifabutin 150mg cap 2 rifampin 150mg cap 2 rifampin 300mg cap 2 rifampin 600mg inj 2 SIRTURO 100MG TAB 5 NDS PA SIRTURO 20MG TAB 5 NDS PA TRECATOR 250MG TAB 4

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES ALKYLATING AGENTS

CYCLOPHOSPHAMIDE 25MG CAP 2 PA BvD CYCLOPHOSPHAMIDE 50MG CAP 2 PA BvD LEUKERAN 2MG TAB 3

ANTIMETABOLITES mercaptopurine 50mg tab 2 methotrexate 2.5mg tab 2 methotrexate 25mg/ml (2ml) inj 1 methotrexate 25mg/ml inj 1 PURIXAN 2000MG/100ML SUSP 4 TABLOID 40MG TAB 3 XATMEP 2.5MG/ML ORAL SOLN 4 PA

ANTINEOPLASTIC - BCL-2 INHIBITORS VENCLEXTA 100MG TAB 5 NDS PA NSO VENCLEXTA 10MG TAB 3 PA NSO VENCLEXTA 50MG TAB 3 PA NSO VENCLEXTA STARTING PACK 5 NDS PA NSO

ANTINEOPLASTIC - HEDGEHOG PATHWAY INHIBITORS DAURISMO 100MG TAB 5 NDS PA NSO DAURISMO 25MG TAB 5 NDS PA NSO ERIVEDGE 150MG CAP 5 NDS PA NSO ODOMZO 200MG CAP 5 NDS PA NSO

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

43

Page 46: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

ANTINEOPLASTIC - HORMONAL AND RELATED AGENTS abiraterone acetate 250mg tab 2 QL=120 EA/30 Days anastrozole 1mg tab 1 bicalutamide 50mg tab 1 DEPO-PROVERA 400MG/ML INJ 4 ELIGARD 22.5MG SYRINGE 4 ELIGARD 30MG SYRINGE 4 ELIGARD 45MG SYRINGE 4 ELIGARD 7.5MG SYRINGE 4 EMCYT 140MG CAP 3 ERLEADA 60MG TAB 5 NDS PA NSO QL=120 EA/30 Days exemestane 25mg tab 4 FIRMAGON 120MG INJ 3 PA NSO FIRMAGON 80MG INJ 3 PA NSO flutamide 125mg cap 2 letrozole 2.5mg tab 1 leuprolide acetate 5mg/ml inj 2 LUPRON 11.25MG SYRINGE 5 LUPRON 22.5MG SYRINGE 5 LUPRON 3.75MG SYRINGE 5 LUPRON 30MG SYRINGE 5 LUPRON 45MG SYRINGE 5 LUPRON 7.5MG SYRINGE 5 LYSODREN 500MG TAB 3 megestrol acetate 20mg tab 2 PA NSO megestrol acetate 40mg tab 2 PA NSO megestrol acetate 40mg/ml susp 2 PA nilutamide 150mg tab 5 NDS NUBEQA 300MG TAB 5 NDS PA NSO QL=120 EA/30 Days SOLTAMOX 10MG/5ML ORAL SOLN 4 PA NSO tamoxifen 10mg tab 1 tamoxifen 20mg tab 1 toremifene 60mg tab 2 TRELSTAR 11.25MG INJ 5 TRELSTAR 22.5MG INJ 5 TRELSTAR 3.75MG INJ 5 XTANDI 40MG CAP 5 NDS PA NSO QL=120 EA/30 Days

ANTINEOPLASTIC - IMMUNOMODULATORS POMALYST 1MG CAP 5 NDS PA NSO POMALYST 2MG CAP 5 NDS PA NSO POMALYST 3MG CAP 5 NDS PA NSO POMALYST 4MG CAP 5 NDS PA NSO

ANTINEOPLASTIC - XPO1 INHIBITORS XPOVIO 100 MG ONCE WEEKLY 5 NDS PA NSO QL=32 EA/28 Days XPOVIO 40MG ONCE WEEKLY PACK 5 NDS PA NSO XPOVIO 40MG TWICE WEEKLY PACK 5 NDS PA NSO

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

44

Page 47: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

XPOVIO 60 MG ONCE WEEKLY 5 NDS PA NSO QL=32 EA/28 Days XPOVIO 60MG TWICE WEEKLY PACK 5 NDS PA NSO XPOVIO 80 MG ONCE WEEKLY 5 NDS PA NSO QL=32 EA/28 Days XPOVIO 80 MG TWICE WEEKLY 5 NDS PA NSO QL=32 EA/28 Days

ANTINEOPLASTIC COMBINATIONS INQOVI 5 TABLET PACK 5 NDS PA NSO QL=5 EA/28 Days KISQALI FEMARA CO-PACK 200 PACK 5 NDS PA NSO QL=49 EA/28 Days KISQALI FEMARA CO-PACK 400 PACK 5 NDS PA NSO QL=70 EA/28 Days KISQALI FEMARA CO-PACK 600 PACK 5 NDS PA NSO QL=91 EA/28 Days LONSURF 6.14-15MG TAB 5 NDS PA NSO LONSURF 8.19-20MG TAB 5 NDS PA NSO

ANTINEOPLASTIC ENZYME INHIBITORS AFINITOR 10MG TAB 5 NDS PA NSO QL=30 EA/30 Days AFINITOR 2MG TAB FOR ORAL SUSP 5 NDS PA NSO AFINITOR 3MG TAB FOR ORAL SUSP 5 NDS PA NSO AFINITOR 5MG TAB FOR ORAL SUSP 5 NDS PA NSO ALECENSA 150MG CAP 5 NDS PA NSO QL=240 EA/30 Days ALUNBRIG 180MG TAB 5 NDS PA NSO QL=30 EA/30 Days ALUNBRIG 30MG TAB 5 NDS PA NSO QL=120 EA/30 Days ALUNBRIG 90MG TAB 5 NDS PA NSO QL=30 EA/30 Days ALUNBRIG INITIATION PACK 5 NDS PA NSO QL=30 EA/30 Days AYVAKIT 100MG TAB 5 NDS PA NSO QL=30 EA/30 Days AYVAKIT 200MG TAB 5 NDS PA NSO QL=30 EA/30 Days AYVAKIT 300MG TAB 5 NDS PA NSO QL=30 EA/30 Days BALVERSA 3MG TAB 5 NDS PA NSO QL=60 EA/30 Days BALVERSA 4MG TAB 5 NDS PA NSO QL=60 EA/30 Days BALVERSA 5MG TAB 5 NDS PA NSO QL=30 EA/30 Days BOSULIF 100MG TAB 5 NDS PA NSO BOSULIF 400MG TAB 5 NDS PA NSO BOSULIF 500MG TAB 5 NDS PA NSO BRAFTOVI 75MG CAP 5 NDS PA NSO QL=180 EA/30 Days BRUKINSA 80MG CAP 5 NDS PA NSO QL=120 EA/30 Days CABOMETYX 20MG TAB 5 NDS PA NSO CABOMETYX 40MG TAB 5 NDS PA NSO CABOMETYX 60MG TAB 5 NDS PA NSO CALQUENCE 100MG CAP 5 NDS PA NSO QL=60 EA/30 Days CAPRELSA 100MG TAB 5 NDS PA NSO QL=60 EA/30 Days CAPRELSA 300MG TAB 5 NDS PA NSO QL=30 EA/30 Days COMETRIQ 100MG DAILY DOSE CARTON PACK 5 NDS PA NSO COMETRIQ 140MG DAILY DOSE CARTON PACK 5 NDS PA NSO COMETRIQ 60MG DAILY DOSE CARTON PACK 5 NDS PA NSO COPIKTRA 15MG CAP 5 NDS PA NSO QL=60 EA/30 Days COPIKTRA 25MG CAP 5 NDS PA NSO QL=60 EA/30 Days COTELLIC 20MG TAB 5 NDS PA NSO QL=63 EA/28 Days erlotinib 100mg tab 2 PA NSO erlotinib 150mg tab 2 PA NSO

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

45

Page 48: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

erlotinib 25mg tab 2 PA NSO everolimus 2.5mg tab 2 PA NSO QL=30 EA/30 Days everolimus 5mg tab 2 PA NSO QL=30 EA/30 Days everolimus 7.5mg tab 2 PA NSO QL=30 EA/30 Days FARYDAK 10MG CAP 5 NDS PA NSO FARYDAK 20MG CAP 5 NDS PA NSO GILOTRIF 20MG TAB 5 NDS PA NSO QL=30 EA/30 Days GILOTRIF 30MG TAB 5 NDS PA NSO QL=30 EA/30 Days GILOTRIF 40MG TAB 5 NDS PA NSO QL=30 EA/30 Days IBRANCE 100MG CAP 5 NDS PA NSO QL=21 EA/28 Days IBRANCE 100MG TAB 5 NDS PA NSO QL=21 EA/28 Days IBRANCE 125MG CAP 5 NDS PA NSO QL=21 EA/28 Days IBRANCE 125MG TAB 5 NDS PA NSO QL=21 EA/28 Days IBRANCE 75MG CAP 5 NDS PA NSO QL=21 EA/28 Days IBRANCE 75MG TAB 5 NDS PA NSO QL=21 EA/28 Days ICLUSIG 15MG TAB 5 NDS PA NSO QL=60 EA/30 Days ICLUSIG 45MG TAB 5 NDS PA NSO QL=30 EA/30 Days IDHIFA 100MG TAB 5 NDS PA NSO QL=30 EA/30 Days IDHIFA 50MG TAB 5 NDS PA NSO QL=30 EA/30 Days imatinib 100mg tab 3 imatinib 400mg tab 3 IMBRUVICA 140MG CAP 5 NDS PA NSO QL=90 EA/30 Days IMBRUVICA 140MG TAB 5 NDS PA NSO QL=30 EA/30 Days IMBRUVICA 280MG TAB 5 NDS PA NSO QL=30 EA/30 Days IMBRUVICA 420MG TAB 5 NDS PA NSO QL=30 EA/30 Days IMBRUVICA 560MG TAB 5 NDS PA NSO QL=30 EA/30 Days IMBRUVICA 70MG CAP 5 NDS PA NSO QL=30 EA/30 Days INLYTA 1MG TAB 5 NDS PA NSO INLYTA 5MG TAB 5 NDS PA NSO INREBIC 100MG CAP 5 NDS PA NSO QL=120 EA/30 Days IRESSA 250MG TAB 5 NDS PA NSO JAKAFI 10MG TAB 5 NDS PA NSO QL=60 EA/30 Days JAKAFI 15MG TAB 5 NDS PA NSO QL=60 EA/30 Days JAKAFI 20MG TAB 5 NDS PA NSO QL=60 EA/30 Days JAKAFI 25MG TAB 5 NDS PA NSO QL=60 EA/30 Days JAKAFI 5MG TAB 5 NDS PA NSO QL=60 EA/30 Days KISQALI 200MG DAILY DOSE PACK 5 NDS PA NSO QL=21 EA/28 Days KISQALI 400MG DAILY DOSE PACK 5 NDS PA NSO QL=42 EA/28 Days KISQALI 600MG DAILY DOSE PACK 5 NDS PA NSO QL=63 EA/28 Days KOSELUGO 10MG CAP 5 NDS PA NSO KOSELUGO 25MG CAP 5 NDS PA NSO LENVIMA 10 10MG PACK 5 NDS PA NSO QL=30 EA/30 Days LENVIMA 12 4MG PACK 5 NDS PA NSO QL=90 EA/30 Days LENVIMA 14 PACK 5 NDS PA NSO QL=60 EA/30 Days LENVIMA 18 PACK 5 NDS PA NSO QL=90 EA/30 Days LENVIMA 20 10MG PACK 5 NDS PA NSO QL=60 EA/30 Days

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

46

Page 49: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

LENVIMA 24 PACK 5 NDS PA NSO QL=90 EA/30 Days LENVIMA 4 4MG PACK 5 NDS PA NSO QL=30 EA/30 Days LENVIMA 8 4MG PACK 5 NDS PA NSO QL=60 EA/30 Days LORBRENA 100MG TAB 5 NDS PA NSO QL=30 EA/30 Days LORBRENA 25MG TAB 5 NDS PA NSO QL=90 EA/30 Days LYNPARZA 100MG TAB 5 NDS PA NSO QL=120 EA/30 Days LYNPARZA 150MG TAB 5 NDS PA NSO QL=120 EA/30 Days MEKINIST 0.5MG TAB 5 NDS PA NSO QL=90 EA/30 Days MEKINIST 2MG TAB 5 NDS PA NSO QL=30 EA/30 Days MEKTOVI 15MG TAB 5 NDS PA NSO QL=180 EA/30 Days NERLYNX 40MG TAB 5 NDS PA NSO NEXAVAR 200MG TAB 5 NDS PA NSO QL=120 EA/30 Days NINLARO 2.3MG CAP 5 NDS PA NSO NINLARO 3MG CAP 5 NDS PA NSO NINLARO 4MG CAP 5 NDS PA NSO PEMAZYRE 13.5MG TAB 5 NDS PA NSO QL=14 EA/21 Days PEMAZYRE 4.5MG TAB 5 NDS PA NSO QL=14 EA/21 Days PEMAZYRE 9MG TAB 5 NDS PA NSO QL=14 EA/21 Days PIQRAY 200MG DAILY DOSE PACK 5 NDS PA NSO QL=30 EA/30 Days PIQRAY 250MG DAILY DOSE PACK 5 NDS PA NSO QL=60 EA/30 Days PIQRAY 300MG DAILY DOSE 150MG PACK 5 NDS PA NSO QL=60 EA/30 Days QINLOCK 50MG TAB 5 NDS PA NSO QL=90 EA/30 Days RETEVMO 40MG CAP 5 NDS PA NSO QL=180 EA/30 Days RETEVMO 80MG CAP 5 NDS PA NSO QL=120 EA/30 Days ROZLYTREK 100MG CAP 5 NDS PA NSO QL=30 EA/30 Days ROZLYTREK 200MG CAP 5 NDS PA NSO QL=90 EA/30 Days RUBRACA 200MG TAB 5 NDS PA NSO QL=120 EA/30 Days RUBRACA 250MG TAB 5 NDS PA NSO QL=120 EA/30 Days RUBRACA 300MG TAB 5 NDS PA NSO QL=120 EA/30 Days RYDAPT 25MG CAP 5 NDS PA NSO SPRYCEL 100MG TAB 5 NDS PA NSO SPRYCEL 140MG TAB 5 NDS PA NSO SPRYCEL 20MG TAB 5 NDS PA NSO SPRYCEL 50MG TAB 5 NDS PA NSO SPRYCEL 70MG TAB 5 NDS PA NSO SPRYCEL 80MG TAB 5 NDS PA NSO STIVARGA 40MG TAB 5 NDS PA NSO QL=84 EA/28 Days SUTENT 12.5MG CAP 5 NDS PA NSO SUTENT 25MG CAP 5 NDS PA NSO SUTENT 37.5MG CAP 5 NDS PA NSO SUTENT 50MG CAP 5 NDS PA NSO TABRECTA 150MG TAB 5 NDS PA NSO QL=120 EA/30 Days TABRECTA 200MG TAB 5 NDS PA NSO QL=120 EA/30 Days TAFINLAR 50MG CAP 5 NDS PA NSO QL=120 EA/30 Days TAFINLAR 75MG CAP 5 NDS PA NSO QL=120 EA/30 Days TAGRISSO 40MG TAB 5 NDS PA NSO

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

47

Page 50: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

TAGRISSO 80MG TAB 5 NDS PA NSO TALZENNA 0.25MG CAP 5 NDS PA NSO QL=90 EA/30 Days TALZENNA 1MG CAP 5 NDS PA NSO QL=30 EA/30 Days TASIGNA 150MG CAP 5 NDS PA NSO TASIGNA 200MG CAP 5 NDS PA NSO TASIGNA 50MG CAP 5 NDS PA NSO TAZVERIK 200MG TAB 5 NDS PA NSO QL=240 EA/30 Days TIBSOVO 250MG TAB 5 NDS PA NSO QL=60 EA/30 Days TUKYSA 150MG TAB 5 NDS PA NSO QL=120 EA/30 Days TUKYSA 50MG TAB 5 NDS PA NSO QL=120 EA/30 Days TURALIO 200MG CAP 5 NDS PA NSO QL=120 EA/30 Days TYKERB 250MG TAB 5 NDS PA NSO VERZENIO 100MG TAB 5 NDS PA NSO QL=56 EA/28 Days VERZENIO 150MG TAB 5 NDS PA NSO QL=56 EA/28 Days VERZENIO 200MG TAB 5 NDS PA NSO QL=56 EA/28 Days VERZENIO 50MG TAB 5 NDS PA NSO QL=56 EA/28 Days VITRAKVI 100MG CAP 5 NDS PA NSO VITRAKVI 20MG/ML ORAL SOLN 5 NDS PA NSO VITRAKVI 25MG CAP 5 NDS PA NSO VIZIMPRO 15MG TAB 5 NDS PA NSO QL=30 EA/30 Days VIZIMPRO 30MG TAB 5 NDS PA NSO QL=30 EA/30 Days VIZIMPRO 45MG TAB 5 NDS PA NSO QL=30 EA/30 Days VOTRIENT 200MG TAB 5 NDS PA NSO XALKORI 200MG CAP 5 NDS PA NSO QL=60 EA/30 Days XALKORI 250MG CAP 5 NDS PA NSO QL=60 EA/30 Days XOSPATA 40MG TAB 5 NDS PA NSO ZEJULA 100MG CAP 5 NDS PA NSO QL=90 EA/30 Days ZELBORAF 240MG TAB 5 NDS PA NSO QL=240 EA/30 Days ZOLINZA 100MG CAP 5 NDS PA NSO ZYDELIG 100MG TAB 5 NDS PA NSO QL=60 EA/30 Days ZYDELIG 150MG TAB 5 NDS PA NSO QL=60 EA/30 Days ZYKADIA 150MG TAB 5 NDS PA NSO QL=90 EA/30 Days

ANTINEOPLASTICS MISC. ACTIMMUNE 2000000UNIT/0.5ML INJ 5 NDS PA NSO bexarotene 75mg cap 2 PA NSO hydroxyurea 500mg cap 2 INTRON A 10MU INJ 3 INTRON A 10MU/ML INJ 3 INTRON A 18MU INJ 5 NDS INTRON A 50MU INJ 5 NDS INTRON A 6000000UNIT/ML INJ 3 MATULANE 50MG CAP 5 NDS SYNRIBO 3.5MG INJ 5 NDS tretinoin 10mg cap 1

CHEMOTHERAPY RESCUE/ANTIDOTE AGENTS LEUCOVORIN 10MG TAB 2

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

48

Page 51: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

LEUCOVORIN 15MG TAB 2 leucovorin 25mg tab 2 leucovorin 5mg tab 2 MESNEX 400MG TAB 3

ANTIPARKINSON AGENTS ANTIPARKINSON ANTICHOLINERGICS

benztropine mesylate 2mg tab 1 trihexyphenidyl 2mg tab 1 trihexyphenidyl 5mg tab 1

ANTIPARKINSON DOPAMINERGICS amantadine 10mg/ml oral soln 2 bromocriptine 2.5mg tab 2 bromocriptine 5mg cap 2 carbidopa 10mg/levodopa 100mg odt 2 carbidopa 10mg/levodopa 100mg tab 1 carbidopa 25mg/levodopa 100mg er tab 1 carbidopa 25mg/levodopa 100mg odt 2 carbidopa 25mg/levodopa 100mg tab 1 carbidopa 25mg/levodopa 250mg odt 2 carbidopa 50mg/levodopa 200mg er tab 1 NEUPRO 1MG/24HR PATCH 4 NEUPRO 2MG/24HR PATCH 4 NEUPRO 3MG/24HR PATCH 4 NEUPRO 4MG/24HR PATCH 4 NEUPRO 6MG/24HR PATCH 4 NEUPRO 8MG/24HR PATCH 4 pramipexole 0.125mg tab 1 pramipexole 0.25mg tab 1 pramipexole 0.375mg er tab 2 pramipexole 0.5mg tab 1 pramipexole 0.75mg er tab 2 pramipexole 0.75mg tab 1 pramipexole 1.5mg er tab 2 pramipexole 1.5mg tab 1 pramipexole 1mg tab 1 pramipexole 2.25mg er tab 2 pramipexole 3.75mg er tab 2 pramipexole 3mg er tab 2 pramipexole 4.5mg er tab 2 ropinirole 0.25mg tab 1 ropinirole 0.5mg tab 1 ropinirole 12mg er tab 2 ropinirole 2mg er tab 2 ropinirole 3mg tab 1 ropinirole 4mg er tab 2 ropinirole 4mg tab 1

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

49

Page 52: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

ropinirole 5mg tab 1 ropinirole 6mg er tab 2 ropinirole 8mg er tab 2

ANTIPARKINSON AND RELATED THERAPY AGENTS ANTIPARKINSON ADJUNCTIVE THERAPY

carbidopa 25mg tab 2 NOURIANZ 20MG TAB 4 PA QL=30 EA/30 Days NOURIANZ 40MG TAB 4 PA QL=30 EA/30 Days

ANTIPARKINSON ANTICHOLINERGICS benztropine mesylate 0.5mg tab 1 benztropine mesylate 1mg tab 1 trihexyphenidyl 0.4mg/ml oral soln 2

ANTIPARKINSON COMT INHIBITORS entacapone 200mg tab 2 tolcapone 100mg tab 2

ANTIPARKINSON DOPAMINERGICS amantadine 100mg cap 2 amantadine 100mg tab 2 APOKYN 30MG/3ML CARTRIDGE 5 NDS PA QL=86 ML/30 Days CARBIDOPA 12.5MG/ENTACAPONE 3 200MG/LEVODOPA 50MG TAB CARBIDOPA 18.75MG/ENTACAPONE 3 200MG/LEVODOPA 75MG TAB CARBIDOPA 25MG/ENTACAPONE 3 200MG/LEVODOPA 100MG TAB carbidopa 25mg/levodopa 250mg tab 1 CARBIDOPA 31.25MG/ENTACAPONE 3 200MG/LEVODOPA 125MG TAB CARBIDOPA 37.5MG/ENTACAPONE 3 200MG/LEVODOPA 150MG TAB CARBIDOPA 50MG/ENTACAPONE 3 200MG/LEVODOPA 200MG TAB ropinirole 1mg tab 1 ropinirole 2mg tab 1 STALEVO 12.5-200-50MG TAB 4 STALEVO 18.75-200-75MG TAB 4 STALEVO 25-200-100MG TAB 4 STALEVO 31.25-200-125MG TAB 4 STALEVO 37.5-200-150MG TAB 4 STALEVO 50-200-200MG TAB 4

ANTIPARKINSON MONOAMINE OXIDASE INHIBITORS rasagiline 0.5mg tab 2 rasagiline 1mg tab 2 selegiline 5mg cap 2 selegiline 5mg tab 2

ANTIPSYCHOTICS/ANTIMANIC AGENTS

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

50

Page 53: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

ANTIMANIC AGENTS lithium carbonate 150mg cap 2 lithium carbonate 300mg cap 2 lithium carbonate 300mg er tab 2 lithium carbonate 300mg tab 2 lithium carbonate 450mg er tab 2 lithium carbonate 600mg cap 2 lithium citrate 60mg/ml oral soln 2

ANTIPSYCHOTICS - MISC. CAPLYTA 42MG CAP 4 PA NSO QL=30 EA/30 Days EQUETRO 100MG ER CAP 4 EQUETRO 200MG ER CAP 4 EQUETRO 300MG ER CAP 4 LATUDA 120MG TAB 4 ST_NSO QL=30 EA/30 Days LATUDA 20MG TAB 4 ST_NSO QL=30 EA/30 Days LATUDA 40MG TAB 4 ST_NSO QL=30 EA/30 Days LATUDA 60MG TAB 4 ST_NSO QL=30 EA/30 Days LATUDA 80MG TAB 4 ST_NSO QL=30 EA/30 Days NUPLAZID 10MG TAB 4 PA NSO QL=30 EA/30 Days NUPLAZID 34MG CAP 4 PA NSO QL=30 EA/30 Days VRAYLAR 1.5/3MG MIXED PACK 4 PA NSO QL=30 EA/30 Days VRAYLAR 1.5MG CAP 4 PA NSO QL=30 EA/30 Days VRAYLAR 3MG CAP 4 PA NSO QL=30 EA/30 Days VRAYLAR 4.5MG CAP 4 PA NSO QL=30 EA/30 Days VRAYLAR 6MG CAP 4 PA NSO QL=30 EA/30 Days ziprasidone 20mg cap 2 ziprasidone 20mg inj 2 ziprasidone 40mg cap 2 ziprasidone 60mg cap 2 ziprasidone 80mg cap 2

BENZISOXAZOLES FANAPT 10MG TAB 4 PA NSO QL=60 EA/30 Days FANAPT 12MG TAB 4 PA NSO QL=60 EA/30 Days FANAPT 1MG TAB 4 PA NSO QL=60 EA/30 Days FANAPT 2MG TAB 4 PA NSO QL=60 EA/30 Days FANAPT 4MG TAB 4 PA NSO QL=60 EA/30 Days FANAPT 6MG TAB 4 PA NSO QL=60 EA/30 Days FANAPT 8MG TAB 4 PA NSO QL=60 EA/30 Days FANAPT TITRATION PACK 4 PA NSO QL=60 EA/30 Days INVEGA 117MG/0.75ML SYRINGE 4 PA NSO INVEGA 156MG/ML SYRINGE 4 PA NSO INVEGA 234MG/1.5ML SYRINGE 4 PA NSO INVEGA 273MG/0.875ML SYRINGE 4 PA NSO INVEGA 39MG/0.25ML SYRINGE 4 PA NSO INVEGA 410MG/1.315ML SYRINGE 4 PA NSO INVEGA 546MG/1.75ML SYRINGE 4 PA NSO

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

51

Page 54: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

INVEGA 78MG/0.5ML SYRINGE 4 PA NSO INVEGA 819MG/2.625ML SYRINGE 4 PA NSO paliperidone 1.5mg er tab 3 PA NSO QL=30 EA/30 Days paliperidone 3mg er tab 3 PA NSO QL=30 EA/30 Days paliperidone 6mg er tab 3 PA NSO QL=60 EA/30 Days paliperidone 9mg er tab 3 PA NSO QL=30 EA/30 Days PERSERIS 120MG SYRINGE 5 NDS PERSERIS 90MG SYRINGE 5 NDS RISPERDAL 12.5MG INJ 4 PA NSO RISPERDAL 25MG INJ 4 PA NSO RISPERDAL 37.5MG INJ 4 PA NSO RISPERDAL 50MG INJ 4 PA NSO risperidone 0.25mg odt 2 risperidone 0.25mg tab 2 risperidone 0.5mg odt 2 risperidone 0.5mg tab 2 risperidone 1mg odt 2 risperidone 1mg tab 2 risperidone 1mg/ml oral soln 2 risperidone 2mg odt 2 risperidone 2mg tab 2 risperidone 3mg odt 2 risperidone 3mg tab 2 risperidone 4mg odt 2 risperidone 4mg tab 2

BUTYROPHENONES haloperidol 0.5mg tab 2 haloperidol 10mg tab 2 haloperidol 1mg tab 2 haloperidol 20mg tab 2 haloperidol 2mg tab 2 haloperidol 2mg/ml oral soln 2 haloperidol 5mg tab 2 haloperidol 5mg/ml inj 2 haloperidol decanoate 100mg/ml (1ml) inj 2 haloperidol decanoate 100mg/ml inj 2 haloperidol decanoate 50mg/ml inj 2 haloperidol decanoate 50mg/ml inj 2

DIBENZAPINES clozapine 100mg odt 2 clozapine 100mg tab 2 CLOZAPINE 12.5MG ODT 2 CLOZAPINE 150MG ODT 4 CLOZAPINE 200MG ODT 4 clozapine 200mg tab 2 clozapine 25mg odt 2

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

52

Page 55: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

clozapine 25mg tab 2 clozapine 50mg tab 2 loxapine 10mg cap 2 loxapine 25mg cap 2 loxapine 50mg cap 2 loxapine 5mg cap 2 olanzapine 10mg inj 2 olanzapine 10mg odt 2 olanzapine 10mg tab 2 olanzapine 15mg odt 2 olanzapine 15mg tab 2 olanzapine 2.5mg tab 2 olanzapine 20mg odt 2 olanzapine 20mg tab 2 olanzapine 5mg odt 2 olanzapine 5mg tab 2 olanzapine 7.5mg tab 2 quetiapine 100mg tab 2 quetiapine 150mg er tab 2 quetiapine 200mg er tab 2 quetiapine 200mg tab 2 quetiapine 25mg tab 2 quetiapine 300mg er tab 2 quetiapine 300mg tab 2 quetiapine 400mg er tab 2 quetiapine 400mg tab 2 quetiapine 50mg er tab 2 quetiapine 50mg tab 2 SAPHRIS 10MG SL TAB 4 PA NSO QL=60 EA/30 Days SAPHRIS 2.5MG SL TAB 4 PA NSO QL=60 EA/30 Days SAPHRIS 5MG SL TAB 4 PA NSO QL=60 EA/30 Days SECUADO 3.8MG/24HR PATCH 4 PA NSO QL=30 EA/30 Days SECUADO 5.7MG/24HR PATCH 4 PA NSO QL=30 EA/30 Days SECUADO 7.6MG/24HR PATCH 4 PA NSO QL=30 EA/30 Days VERSACLOZ 50MG/ML SUSP 4 ZYPREXA 210MG INJ 4

DIHYDROINDOLONES MOLINDONE 10MG TAB 4 MOLINDONE 25MG TAB 4 MOLINDONE 5MG TAB 4

PHENOTHIAZINES chlorpromazine 100mg tab 2 chlorpromazine 10mg tab 2 chlorpromazine 200mg tab 2 chlorpromazine 25mg tab 2 chlorpromazine 50mg tab 2

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

53

Page 56: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

compro 25mg rectal supp 2 FLUPHENAZINE 0.5MG/ML ORAL SOLN 3 fluphenazine 10mg tab 3 fluphenazine 1mg tab 3 fluphenazine 2.5mg tab 3 FLUPHENAZINE 2.5MG/ML INJ 3 fluphenazine 5mg tab 3 FLUPHENAZINE 5MG/ML ORAL SOLN 3 fluphenazine decanoate 25mg/ml inj 2 perphenazine 16mg tab 2 perphenazine 2mg tab 2 perphenazine 4mg tab 2 perphenazine 8mg tab 2 prochlorperazine 10mg tab 2 prochlorperazine 25mg rectal supp 2 prochlorperazine 5mg tab 2 thioridazine 100mg tab 2 thioridazine 10mg tab 2 thioridazine 25mg tab 2 thioridazine 50mg tab 2 trifluoperazine 10mg tab 2 trifluoperazine 1mg tab 2 trifluoperazine 2mg tab 2 trifluoperazine 5mg tab 2

QUINOLINONE DERIVATIVES ABILIFY 300MG INJ 5 NDS PA NSO ABILIFY 300MG SYRINGE 5 NDS PA NSO ABILIFY 400MG INJ 5 NDS PA NSO ABILIFY 400MG SYRINGE 5 NDS PA NSO aripiprazole 10mg odt 2 PA NSO QL=60 EA/30 Days aripiprazole 10mg tab 2 aripiprazole 15mg odt 2 PA NSO QL=60 EA/30 Days aripiprazole 15mg tab 2 aripiprazole 1mg/ml oral soln 2 PA NSO aripiprazole 20mg tab 2 aripiprazole 2mg tab 2 aripiprazole 30mg tab 2 aripiprazole 5mg tab 2 ARISTADA 1064MG/3.9ML SYRINGE 5 PA NSO ARISTADA 441MG/1.6ML SYRINGE 5 NDS PA NSO ARISTADA 662MG/2.4ML SYRINGE 5 NDS PA NSO ARISTADA 675MG/2.4ML SYRINGE 5 NDS PA NSO ARISTADA 882MG/3.2ML SYRINGE 5 PA NSO REXULTI 0.25MG TAB 5 NDS PA NSO QL=30 EA/30 Days REXULTI 0.5MG TAB 5 NDS PA NSO QL=30 EA/30 Days REXULTI 1MG TAB 5 NDS PA NSO QL=30 EA/30 Days

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

54

Page 57: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

REXULTI 2MG TAB 5 NDS PA NSO QL=30 EA/30 Days REXULTI 3MG TAB 5 NDS PA NSO QL=30 EA/30 Days REXULTI 4MG TAB 5 NDS PA NSO QL=30 EA/30 Days

THIOXANTHENES thiothixene 10mg cap 2 thiothixene 1mg cap 2 thiothixene 2mg cap 2 thiothixene 5mg cap 2

ANTIVIRALS ANTIRETROVIRALS

abacavir 20mg/ml oral soln 2 abacavir 300mg tab 2 abacavir 300mg/lamivudine 150mg/zidovudine 300mg tab

2

abacavir 600mg/lamivudine 300mg tab 2 APTIVUS 100MG/ML ORAL SOLN 5 NDS APTIVUS 250MG CAP 5 NDS atazanavir 150mg cap 2 atazanavir 200mg cap 2 atazanavir 300mg cap 2 ATRIPLA 600-200-300MG TAB 5 NDS BIKTARVY 50-200-25MG TAB 5 NDS CIMDUO 300-300MG TAB 5 NDS COMPLERA 200-25-300MG TAB 5 NDS CRIXIVAN 200MG CAP 3 CRIXIVAN 400MG CAP 3 DELSTRIGO 100-300-300MG TAB 5 NDS DESCOVY 200-25MG TAB 5 NDS DIDANOSINE 250MG DR CAP 3 DIDANOSINE 400MG DR CAP 3 DOVATO 50-300MG TAB 5 NDS EDURANT 25MG TAB 5 NDS efavirenz 200mg cap 2 efavirenz 50mg cap 2 efavirenz 600mg tab 2 EMTRIVA 10MG/ML ORAL SOLN 3 EMTRIVA 200MG CAP 3 EVOTAZ 300-150MG TAB 5 NDS fosamprenavir 700mg tab 5 NDS FUZEON 90MG INJ 5 NDS GENVOYA 150-150-200-10MG TAB 5 NDS INTELENCE 100MG TAB 5 NDS INTELENCE 200MG TAB 5 NDS INTELENCE 25MG TAB 5 NDS INVIRASE 500MG TAB 5 NDS ISENTRESS 100MG CHEW TAB 3

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

55

Page 58: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

ISENTRESS 100MG GRANULES FOR ORAL SUSP 3 ISENTRESS 25MG CHEW TAB 3 ISENTRESS 400MG TAB 3 ISENTRESS 600MG TAB 3 JULUCA 50-25MG TAB 5 NDS QL=30 EA/30 Days KALETRA 100-25MG TAB 3 KALETRA 200-50MG TAB 5 NDS lamivudine 10mg/ml oral soln 2 lamivudine 150mg tab 2 lamivudine 150mg/zidovudine 300mg tab 2 lamivudine 300mg tab 2 LEXIVA 50MG/ML SUSP 3 lopinavir 80mg/ml/ritonavir 20mg/ml oral solution 5 NDS NEVIRAPINE 100MG ER TAB 3 nevirapine 10mg/ml susp 2 nevirapine 200mg tab 1 nevirapine 400mg er tab 2 NORVIR 100MG ORAL POWDER 3 NORVIR 80MG/ML ORAL SOLN 3 ODEFSEY 200-25-25MG TAB 5 NDS PIFELTRO 100MG TAB 5 NDS PREZCOBIX 150-800MG TAB 5 NDS PREZISTA 100MG/ML SUSP 3 QL=375 ML/30 Days PREZISTA 150MG TAB 3 QL=240 EA/30 Days PREZISTA 600MG TAB 5 NDS QL=60 EA/30 Days PREZISTA 75MG TAB 3 QL=480 EA/30 Days PREZISTA 800MG TAB 5 NDS QL=30 EA/30 Days REYATAZ 50MG ORAL POWDER 5 NDS ritonavir 100mg tab 2 RUKOBIA 600MG ER TAB 5 NDS SELZENTRY 150MG TAB 5 NDS SELZENTRY 20MG/ML ORAL SOLN 5 NDS SELZENTRY 25MG TAB 3 SELZENTRY 300MG TAB 5 NDS SELZENTRY 75MG TAB 5 NDS stavudine 15mg cap 2 stavudine 20mg cap 2 stavudine 30mg cap 2 stavudine 40mg cap 2 STRIBILD 150-150-200-300MG TAB 5 NDS QL=30 EA/30 Days SYMFI 400-300-300MG TAB 3 SYMFI 600-300-300MG TAB 3 SYMTUZA 800-150-200-10MG TAB 5 NDS tenofovir disoproxil fumarate 300mg tab 2 TIVICAY 10MG TAB 4 TIVICAY 25MG TAB 4

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

56

Page 59: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

TIVICAY 50MG TAB 5 NDS TIVICAY 5MG TAB FOR ORAL SUSP 3 TRIUMEQ 600-50-300MG TAB 5 NDS TRUVADA 100-150MG TAB 5 NDS TRUVADA 133-200MG TAB 5 NDS TRUVADA 167-250MG TAB 5 NDS TRUVADA 200-300MG TAB 5 NDS TYBOST 150MG TAB 3 VIRACEPT 250MG TAB 5 NDS VIRACEPT 625MG TAB 5 NDS VIREAD 150MG TAB 5 NDS VIREAD 200MG TAB 5 NDS VIREAD 250MG TAB 5 NDS VIREAD 40MG/GM ORAL POWDER 3 zidovudine 100mg cap 2 zidovudine 10mg/ml oral soln 2 zidovudine 300mg tab 2

CMV AGENTS PREVYMIS 240MG TAB 5 NDS PA QL=30 EA/30 Days PREVYMIS 480MG TAB 5 NDS PA QL=30 EA/30 Days valganciclovir 450mg tab 5 NDS valganciclovir 50mg/ml oral soln 5 NDS

HEPATITIS AGENTS adefovir dipivoxil 10mg tab 2 entecavir 0.5mg tab 2 entecavir 1mg tab 2 EPIVIR HBV 5MG/ML ORAL SOLN 3 lamivudine 100mg tab 2 MAVYRET 100-40MG TAB 5 NDS PA QL=90 EA/30 Days PEGASYS 180MCG/0.5ML AUTO-INJECTOR 5 NDS PEGASYS 180MCG/0.5ML SYRINGE 5 NDS PEGASYS 180MCG/ML INJ 5 NDS ribavirin 200mg cap 1 ribavirin 200mg tab 1 SOFOSBUVIR 400MG/VELPATASVIR 100MG TAB 5 NDS PA QL=30 EA/30 Days VEMLIDY 25MG TAB 5 NDS VOSEVI 400-100-100MG TAB 5 NDS PA QL=30 EA/30 Days

HERPES AGENTS acyclovir 200mg cap 1 acyclovir 400mg tab 1 acyclovir 40mg/ml susp 2 acyclovir 50mg/ml inj 2 PA BvD acyclovir 800mg tab 1 famciclovir 125mg tab 2 famciclovir 250mg tab 2 famciclovir 500mg tab 2

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

57

Page 60: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

valacyclovir 1000mg tab 1 valacyclovir 500mg tab 1

INFLUENZA AGENTS oseltamivir 30mg cap 2 QL=84 EA/180 Days oseltamivir 45mg cap 2 QL=42 EA/180 Days oseltamivir 6mg/ml susp 2 QL=540 ML/180 Days oseltamivir 75mg cap 2 QL=42 EA/180 Days RELENZA 5MG/BLISTER INH 3 QL=120 EA/30 Days RIMANTADINE 100MG TAB 3 XOFLUZA 20MG THERAPY PACK 4 QL=2 EA/30 Days XOFLUZA 40MG THERAPY PACK 4 QL=2 EA/30 Days

ASSORTED CLASSES IMMUNOSUPPRESSIVE AGENTS

AZASAN 100MG TAB 4 PA BvD AZASAN 75MG TAB 4 PA BvD cyclosporine 100mg cap 2 PA BvD cyclosporine 25mg cap 2 PA BvD cyclosporine modified 100mg cap 2 PA BvD cyclosporine modified 25mg cap 2 PA BvD gengraf 100mg cap 2 PA BvD gengraf 100mg/ml oral soln 2 PA BvD gengraf 25mg cap 2 PA BvD mycophenolate mofetil 200mg/ml susp 2 PA BvD mycophenolate mofetil 250mg cap 2 PA BvD mycophenolate mofetil 500mg tab 2 PA BvD SANDIMMUNE 100MG/ML ORAL SOLN 4 PA BvD sirolimus 0.5mg tab 2 PA BvD sirolimus 1mg tab 2 PA BvD sirolimus 2mg tab 2 PA BvD tacrolimus 0.5mg cap 1 PA BvD tacrolimus 1mg cap 1 PA BvD tacrolimus 5mg cap 1 PA BvD

BETA BLOCKERS ALPHA-BETA BLOCKERS

carvedilol 12.5mg tab 1 carvedilol 25mg tab 1 carvedilol 3.125mg tab 1 carvedilol 6.25mg tab 1 labetalol 100mg tab 2 labetalol 200mg tab 2 labetalol 300mg tab 2

BETA BLOCKERS CARDIO-SELECTIVE acebutolol 200mg cap 1 acebutolol 400mg cap 1 atenolol 100mg tab 1 atenolol 25mg tab 1

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

58

Page 61: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

atenolol 50mg tab 1 betaxolol 10mg tab 1 betaxolol 20mg tab 1 bisoprolol fumarate 10mg tab 1 bisoprolol fumarate 5mg tab 1 BYSTOLIC 10MG TAB 3 BYSTOLIC 2.5MG TAB 3 BYSTOLIC 20MG TAB 3 BYSTOLIC 5MG TAB 3 metoprolol succinate 100mg er tab 1 metoprolol succinate 200mg er tab 1 metoprolol succinate 25mg er tab 1 metoprolol succinate 50mg er tab 1 metoprolol tartrate 100mg tab 1 metoprolol tartrate 25mg tab 1 metoprolol tartrate 50mg tab 1

BETA BLOCKERS NON-SELECTIVE INNOPRAN 120MG ER CAP 4 INNOPRAN 80MG ER CAP 4 nadolol 20mg tab 2 nadolol 40mg tab 2 nadolol 80mg tab 2 pindolol 10mg tab 2 pindolol 5mg tab 2 propranolol 10mg tab 1 propranolol 120mg er cap 2 propranolol 160mg er cap 2 propranolol 20mg tab 1 propranolol 40mg tab 1 PROPRANOLOL 4MG/ML ORAL SOLN 2 propranolol 60mg er cap 2 propranolol 60mg tab 1 propranolol 80mg er cap 2 propranolol 80mg tab 1 PROPRANOLOL 8MG/ML ORAL SOLN 2 sorine 120mg tab 1 sorine 160mg tab 1 sorine 240mg tab 1 sorine 80mg tab 1 sotalol 120mg tab 1 sotalol 160mg tab 1 sotalol 240mg tab 1 sotalol 80mg tab 1 sotalol af 120mg tab 1 sotalol AF 160mg tab 1 sotalol AF 80mg tab 1

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

59

Page 62: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

timolol 10mg tab 2 timolol 20mg tab 2 timolol 5mg tab 2

CALCIUM CHANNEL BLOCKERS CALCIUM CHANNEL BLOCKERS

amlodipine 10mg tab 1 amlodipine 2.5mg tab 1 amlodipine 5mg tab 1 CARDIZEM 120MG ER TAB 4 cartia 120mg er cap 2 cartia 180mg er cap 2 cartia 240mg er cap 2 cartia 300mg er cap 2 DILT 120MG ER CAP 2 DILT 180MG ER CAP 2 DILT 240MG ER CAP 2 diltiazem 120mg er (12 hr) cap 2 diltiazem 120mg er (24 hr) cap 2 diltiazem 120mg tab 1 diltiazem 180mg er cap 2 diltiazem 240mg er cap 2 diltiazem 300mg er cap 2 diltiazem 30mg tab 1 diltiazem 360mg er cap 2 diltiazem 420mg er cap 2 diltiazem 60mg er cap 2 diltiazem 60mg tab 1 diltiazem 90mg er cap 2 diltiazem 90mg tab 1 felodipine 10mg er tab 1 felodipine 2.5mg er tab 1 felodipine 5mg er tab 1 isradipine 2.5mg cap 2 isradipine 5mg cap 2 matzim 180mg er tab 2 matzim 240mg er tab 2 matzim 300mg er tab 2 matzim 360mg er tab 2 matzim 420mg er tab 2 nicardipine 20mg cap 2 nicardipine 30mg cap 2 nifedipine 10mg cap 2 nifedipine 20mg cap 2 nifedipine 30mg er tab 2 nifedipine 30mg osmotic er tab 2 nifedipine 60mg er tab 2

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

60

Page 63: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

nifedipine 60mg osmotic er tab 2 nifedipine 90mg er tab 2 nifedipine 90mg osmotic er tab 2 nimodipine 30mg cap 2 nisoldipine 17mg er tab 2 nisoldipine 20mg er tab 2 NISOLDIPINE 25.5MG ER TAB 2 nisoldipine 30mg er tab 2 nisoldipine 34mg er tab 2 nisoldipine 40mg er tab 2 nisoldipine 8.5mg er tab 2 taztia 120mg er cap 2 taztia 180mg er cap 2 taztia 240mg er cap 2 taztia 300mg er cap 2 taztia 360mg er cap 2 tiadylt 120mg er cap 2 tiadylt 180mg er cap 2 tiadylt 240mg er cap 2 tiadylt 300mg er cap 2 tiadylt 360mg er cap 2 tiadylt 420mg er cap 2 VERAPAMIL 100MG ER CAP 2 verapamil 120mg er cap 2 verapamil 120mg er tab 2 verapamil 120mg tab 1 verapamil 180mg er cap 2 verapamil 180mg er tab 2 VERAPAMIL 200MG ER CAP 2 verapamil 240mg er cap 2 verapamil 240mg er tab 2 VERAPAMIL 300MG ER CAP 2 VERAPAMIL 360MG ER CAP 2 verapamil 40mg tab 1 verapamil 80mg tab 1

CARDIOTONICS CARDIAC GLYCOSIDES

digitek 0.125mg tab 2 digitek 0.25mg tab 2 digox 125mcg tab 2 digox 250mcg tab 2 digoxin 0.05mg/ml oral soln 2 digoxin 0.125mg tab 2 digoxin 0.25mg tab 2

CARDIOVASCULAR AGENTS - MISC. CARDIOVASCULAR AGENTS MISC. - COMBINATIONS

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

61

Page 64: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

amlodipine 10mg/atorvastatin 10mg tab 2 amlodipine 10mg/atorvastatin 20mg tab 2 amlodipine 10mg/atorvastatin 40mg tab 2 amlodipine 10mg/atorvastatin 80mg tab 2 amlodipine 2.5mg/atorvastatin 10mg tab 2 amlodipine 2.5mg/atorvastatin 20mg tab 2 amlodipine 2.5mg/atorvastatin 40mg tab 2 amlodipine 5mg/atorvastatin 10mg tab 2 amlodipine 5mg/atorvastatin 20mg tab 2 amlodipine 5mg/atorvastatin 40mg tab 2 amlodipine 5mg/atorvastatin 80mg tab 2 BIDIL 37.5-20MG TAB 3 ENTRESTO 24-26MG TAB 3 QL=60 EA/30 Days ENTRESTO 49-51MG TAB 3 QL=60 EA/30 Days ENTRESTO 97-103MG TAB 3 QL=60 EA/30 Days

PROSTAGLANDIN VASODILATORS ORENITRAM 0.125MG ER TAB 4 PA ORENITRAM 0.25MG ER TAB 5 NDS PA ORENITRAM 1MG ER TAB 5 NDS PA ORENITRAM 2.5MG ER TAB 5 NDS PA ORENITRAM 5MG ER TAB 5 NDS PA VENTAVIS 10MCG/ML INH SOLN 5 NDS PA VENTAVIS 20MCG/ML INH SOLN 5 NDS PA

PULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR ANTAGONISTS ambrisentan 10mg tab 2 PA QL=30 EA/30 Days ambrisentan 5mg tab 2 PA QL=30 EA/30 Days bosentan 125mg tab 2 PA QL=60 EA/30 Days bosentan 62.5mg tab 2 PA QL=60 EA/30 Days OPSUMIT 10MG TAB 5 NDS PA QL=30 EA/30 Days TRACLEER 32MG TAB FOR ORAL SUSP 5 NDS PA QL=120 EA/30 Days

PULMONARY HYPERTENSION - PHOSPHODIESTERASE INHIBITORS alyq 20mg tab 1 PA sildenafil 20mg tab 1 PA tadalafil 20mg tab 1 PA

PULMONARY HYPERTENSION - PROSTACYCLIN RECEPTOR AGONIST UPTRAVI 1000MCG TAB 5 NDS PA UPTRAVI 1200MCG TAB 5 NDS PA UPTRAVI 1400MCG TAB 5 NDS PA UPTRAVI 1600MCG TAB 5 NDS PA UPTRAVI 200MCG TAB 5 NDS PA UPTRAVI 400MCG TAB 5 NDS PA UPTRAVI 600MCG TAB 5 NDS PA UPTRAVI 800MCG TAB 5 NDS PA UPTRAVI TITRATION PACK 5 NDS PA QL=200 EA/28 Days

PULMONARY HYPERTENSION - SOL GUANYLATE CYCLASE STIMULATOR ADEMPAS 0.5MG TAB 5 NDS PA

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

62

Page 65: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

ADEMPAS 1.5MG TAB 5 NDS PA ADEMPAS 1MG TAB 5 NDS PA ADEMPAS 2.5MG TAB 5 NDS PA ADEMPAS 2MG TAB 5 NDS PA

SINUS NODE INHIBITORS CORLANOR 5MG TAB 4 PA CORLANOR 5MG/5ML ORAL SOLN 4 PA CORLANOR 7.5MG TAB 4 PA

TRANSTHYRETIN STABILIZERS VYNDAMAX 61MG CAP 5 NDS PA QL=30 EA/30 Days VYNDAQEL 20MG CAP 5 NDS PA QL=120 EA/30 Days

CEPHALOSPORINS CEPHALOSPORIN COMBINATIONS

AVYCAZ 500-2000MG INJ 5 NDS ZERBAXA 1000-500MG INJ 5 NDS

CEPHALOSPORINS - 1ST GENERATION cefadroxil 1000mg tab 2 cefadroxil 100mg/ml susp 2 cefadroxil 500mg cap 1 cefadroxil 50mg/ml susp 2 cefazolin 1000mg inj 2 cefazolin 200mg/ml inj 2 cefazolin 500mg inj 2 cephalexin 250mg cap 1 cephalexin 25mg/ml susp 1 cephalexin 500mg cap 1 cephalexin 50mg/ml susp 1

CEPHALOSPORINS - 2ND GENERATION cefaclor 250mg cap 2 CEFACLOR 25MG/ML SUSP 4 cefaclor 500mg cap 2 CEFACLOR 500MG ER TAB 4 CEFACLOR 50MG/ML SUSP 4 CEFACLOR 75MG/ML SUSP 4 cefotetan 1000mg inj 2 cefotetan 2000mg inj 2 cefoxitin 1000mg inj 2 cefoxitin 2000mg inj 2 cefoxitin 200mg/ml inj 2 cefprozil 250mg tab 1 cefprozil 25mg/ml susp 1 cefprozil 500mg tab 1 cefprozil 50mg/ml susp 1 cefuroxime 1500mg inj 2 cefuroxime 250mg tab 2 cefuroxime 500mg tab 2

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

63

Page 66: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

cefuroxime 750mg inj 2 cefuroxime 95mg/ml inj 2

CEPHALOSPORINS - 3RD GENERATION cefdinir 25mg/ml susp 1 cefdinir 300mg cap 1 cefdinir 50mg/ml susp 1 cefixime 20mg/ml susp 2 cefixime 400mg cap 2 cefixime 40mg/ml susp 2 cefpodoxime 100mg tab 2 cefpodoxime 10mg/ml susp 2 cefpodoxime 200mg tab 2 cefpodoxime 20mg/ml susp 2 ceftazidime 1000mg inj 2 ceftazidime 2000mg inj 2 ceftazidime 200mg/ml inj 2 ceftriaxone 1000mg inj 2 ceftriaxone 100mg/ml inj 2 ceftriaxone 2000mg inj 2 ceftriaxone 250mg inj 2 ceftriaxone 500mg inj 2 SUPRAX 100MG CHEW TAB 4 SUPRAX 200MG CHEW TAB 4 SUPRAX 500MG/5ML SUSP 4 tazicef 1gm inj 2 tazicef 2gm inj 2 tazicef 6gm inj 2

CEPHALOSPORINS - 4TH GENERATION cefepime 1000mg inj 2 cefepime 2000mg inj 2

CEPHALOSPORINS - 5TH GENERATION TEFLARO 400MG INJ 5 NDS TEFLARO 600MG INJ 5 NDS

CONTRACEPTIVES COMBINATION CONTRACEPTIVES - ORAL

altavera 28 day pack 2 alyacen 1/35 28 day pack 2 amethia 91 day pack 2 apri 28 day pack 2 aranelle 28 pack 2 ashlyna 91 day pack 2 aubra 28 day pack 2 aviane 28 pack 2 balziva 28 day pack 2 blisovi 21 fe 1.5/30 28 day 2 blisovi 24 fe 1/20 28 day pack 2

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

64

Page 67: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

briellyn 28 day pack 2 camreselo 91 day pack 2 caziant 28 day pack 2 cryselle 28 pack 2 cyclafem 1/35 28 day pack 2 cyclafem 7/7/7 28 day pack 2 cyred 28 day pack 2 desogestrel/ethinyl estradiol pack 2 drospirenone 3mg/ethinyl estradiol 0.02mg/inert 1 mg pack

2

drospirenone 3mg/ethinyl estradiol 0.03mg/inert ingredients 1mg pack

2

emoquette pack 2 enpresse 28 day pack 2 enskyce 28 day pack 2 estarylla 28 day pack 2 ethinyl estradiol 0.01mg/ethinyl estradiol 0.02mg/levonorgestrel 0.1mg 91 day pack

2

ethinyl estradiol 0.01mg/ethinyl estradiol 0.03mg/levonorgestrel 0.15mg pack

2

ethinyl estradiol 0.025mg/ferrous fumarate 75mg/norethindrone 0.8mg pack

2

ethinyl estradiol 0.025mg/inert/norgestimate 0.18mg/0.215mg/0.25mg pack

2

ethinyl estradiol 0.02mg/inert ingredients 1mg/levonorgestrel 0.1mg pack

2

ethinyl estradiol 0.02mg/levonorgestrel 0.09mg pack 2 ethinyl estradiol 0.02mg/norethindrone acetate 1mg pack

2

ethinyl estradiol 0.02mg/norethindrone acetate 1mg/ferrous fumarate 75mg chewable 28 day pack

2

ethinyl estradiol 0.035mg/ethynodiol 1mg 28 day pack 2 ethinyl estradiol 0.035mg/ferrous fumarate 75mg/norethindrone 0.4mg pack

2

ethinyl estradiol 0.035mg/inert/norgestimate 0.18mg/0.215mg/0.25mg pack

2

ethinyl estradiol 0.035mg/norgestimate 0.25mg pack 2 ethinyl estradiol 0.03mg/0.04mg /inert/levonorgestrel 0.05mg/ 0.075mg pack

2

ethinyl estradiol 0.03mg/inert ingredients 1mg/levonorgestrel 0.15mg pack

2

ethinyl estradiol 0.03mg/levonorgestrel 0.15mg tab 28 day pack

2

ethinyl estradiol 0.05mg/ethynodiol 1mg/inert ingredients 1mg 28 day pack

2

ethinyl estradiol/levonorgestrel 91 day pack 2

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

65

Page 68: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

falmina 28 day pack 2 fayosim 91 day pack 2 femynor 28 day pack 2 gianvi 28-day pack 2 hailey 24 fe 28 day pack 2 introvale 91 day pack 2 isibloom 28 day pack 2 jasmiel 28 day pack 2 juleber 28 day pack 2 junel 1.5/30 21 day pack 2 junel 1/20 21 day pack 2 junel fe 1.5/30 28 day pack 2 junel fe 1/20 28 day pack 2 junel fe 24 1/20 28 day pack 2 kaitlib fe 28 day pack 2 kariva 28 day pack 2 kelnor 1/35 28 day pack 2 kelnor 1/50 28 day pack 2 kurvelo pack 2 larin 1.5/30 pack 2 larin 1/20 pack 2 larin fe 1.5/30 pack 2 larin fe 1/20 pack 2 larissia 28 day pack 2 layolis fe 28 pack 2 leena 28 day pack 2 lessina 28 day pack 2 levonest 28 day pack 2 levora 0.15/30 28 day pack 2 LO LOESTRIN FE 28 DAY PACK 4 loryna 28 day pack 2 low-ogestrel 28 day pack 2 lutera 28 day pack 2 marlissa 28 day pack 2 melodetta 24 fe chewable 28 day pack 2 mibelas 24 fe chewable 28 day pack 2 microgestin 1.5/30 21 day pack 2 microgestin 1/20 21 day pack 2 microgestin fe 1.5/30 28 day pack 2 microgestin fe 1/20 28 day pack 2 mili 28 day pack 2 NATAZIA 28 DAY PACK 4 necon 0.5/35 28 day pack 2 nikki 28 day pack 2 nortrel 0.5/35 28 day pack 2 nortrel 1/35 21 day pack 2

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

66

Page 69: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

nortrel 1/35 28 day pack 2 nortrel 7/7/7 28 day pack 2 ocella 28 day pack 2 orsythia 28 day pack 2 pimtrea pack 2 pirmella 1/35 28 day pack 2 portia 28 day pack 2 previfem 28 day pack 2 reclipsen 28 day pack 2 rivelsa 91 day pack 2 setlakin 91 day pack 2 sprintec 28 day pack 2 sronyx 28 day pack 2 syeda 28 day pack 2 tarina 24 fe 1/20 28 day pack 2 tarina fe 1/20 28 day pack 2 tri-estarylla 28 day pack 2 tri-legest 28 day pack 2 tri-lo-estarylla 28 day pack 2 tri-lo-sprintec 28 day pack 2 tri-mili 28 day pack 2 tri-previfem 28 day pack 2 tri-sprintec 28 day pack 2 tri-vylibra 28 day pack 2 tri-vylibra lo 28 day pack 2 trivora 28 day pack 2 tydemy 28 day pack 2 velivet 28 day pack 2 vienva 28 day pack 2 vyfemla 28 day pack 2 vylibra 28 day pack 2 wymzya fe 28 day pack 2 YASMIN 28 DAY PACK 4 zarah pack 2 zovia 1/35e 28 day pack 2

COMBINATION CONTRACEPTIVES - TRANSDERMAL XULANE 0.00146-0.00625MG/HR PATCH 3

COMBINATION CONTRACEPTIVES - VAGINAL eluryng 0.000625-0.005mg/hr vaginal system 2 etonogestrel-ethinyl estradiol 0.120-0.015mg/24hr vaginal ring

2

PROGESTIN CONTRACEPTIVES - INJECTABLE medroxyprogesterone acetate 150mg/ml inj 2 medroxyprogesterone acetate 150mg/ml syringe 2

PROGESTIN CONTRACEPTIVES - ORAL camila 28 day 0.35mg pack 2

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

67

Page 70: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

deblitane 28 day 0.35mg pack 2 errin 28 day 0.35mg pack 2 incassia 28 day 0.35mg pack 2 lyza 0.35mg pack 2 nora-be 28 day 0.35mg pack 2 norethindrone 0.35mg pack 2 sharobel 28 day 0.35mg pack 2 SLYND 4MG PACK 4

CORTICOSTEROIDS GLUCOCORTICOSTEROIDS

budesonide 3mg dr cap 3 budesonide 9mg er tab 2 PA QL=30 EA/30 Days CORTISONE ACETATE 25MG TAB 4 dexamethasone 0.1mg/ml oral soln 2 dexamethasone 0.5mg tab 1 dexamethasone 0.75mg tab 1 dexamethasone 1.5mg tab 1 DEXAMETHASONE 1MG TAB 2 DEXAMETHASONE 2MG TAB 2 dexamethasone 4mg tab 1 dexamethasone 6mg tab 1 hydrocortisone 10mg tab 1 hydrocortisone 20mg tab 1 hydrocortisone 5mg tab 1 MEDROL 2MG TAB 3 methylprednisolone 16mg tab 2 methylprednisolone 32mg tab 2 methylprednisolone 4mg pack 2 methylprednisolone 4mg tab 2 methylprednisolone 8mg tab 2 MILLIPRED 5MG TAB 4 PA BvD prednisolone 10mg odt 2 prednisolone 15mg odt 2 prednisolone 1mg/ml oral soln 2 prednisolone 2mg/ml oral soln 2 prednisolone 30mg odt 2 PREDNISOLONE 3MG/ML ORAL SOLN 2 prednisolone 4mg/ml oral soln 2 PREDNISOLONE 5MG/ML ORAL SOLN 4 PA BvD prednisone 10mg tab 1 prednisone 1mg tab 1 PREDNISONE 1MG/ML ORAL SOLN 2 prednisone 2.5mg tab 1 prednisone 20mg tab 1 prednisone 50mg tab 1 prednisone 5mg tab 1

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

68

Page 71: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

PREDNISONE 5MG/ML ORAL SOLN 3 MINERALOCORTICOIDS

fludrocortisone 0.1mg tab 2 COUGH/COLD/ALLERGY

COUGH/COLD/ALLERGY COMBINATIONS CLARINEX-D 2.5-120MG ER TAB 4 PHENYLEPHRINE 1MG/ML/PROMETHAZINE 1.25MG/ML ORAL SOLN

2

MUCOLYTICS acetylcysteine 100mg/ml inh soln 2 PA BvD acetylcysteine 200mg/ml inh soln 2 PA BvD

DERMATOLOGICALS ACNE PRODUCTS

adapalene 0.1% cream 2 PA adapalene 0.1% gel 2 PA adapalene 0.3% gel 2 PA adapalene/benzoyl peroxide 0.1-2.5% gel 2 PA amnesteem 10mg cap 2 amnesteem 20mg cap 2 amnesteem 40mg cap 2 avita 0.025% cream 2 PA avita 0.025% gel 2 PA benzoyl peroxide 5%/clindamycin phosphate 1.2% topical gel

2 QL=90 GM/30 Days

claravis 10mg cap 2 claravis 20mg cap 2 claravis 30mg cap 2 claravis 40mg cap 2 clindacin 1% pad 2 QL=120 EA/30 Days clindamycin 1% gel 2 QL=180 GM/30 Days clindamycin 1% lotion 2 QL=180 ML/30 Days clindamycin 1% pad 2 QL=120 EA/30 Days clindamycin 1% topical soln 2 QL=300 ML/30 Days clindamycin/benzoyl peroxide 1-5% gel 2 QL=100 GM/30 Days clindamycin/benzoyl peroxide 1.2-2.5% gel 2 QL=100 GM/30 Days EPIDUO 0.3-2.5% GEL 4 PA ERY 2% PAD 2 erythromycin 2% gel 2 erythromycin 2% topical soln 2 erythromycin/benzoyl peroxide 5-3% gel 2 isotretinoin 10mg cap 2 isotretinoin 20mg cap 2 isotretinoin 30mg cap 2 isotretinoin 40mg cap 2 myorisan 10mg cap 2 myorisan 20mg cap 2

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

69

Page 72: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

myorisan 30mg cap 2 myorisan 40mg cap 2 neuac 5-1.2% gel 2 QL=90 GM/30 Days sulfacetamide sodium 10% lotion 2 tretinoin 0.01% gel 2 PA tretinoin 0.025% cream 2 PA tretinoin 0.025% gel 2 PA tretinoin 0.04% gel 2 PA tretinoin 0.05% cream 2 PA tretinoin 0.05% gel 2 PA tretinoin 0.1% cream 2 PA tretinoin 0.1% gel 2 PA VELTIN 1.2-0.025% GEL 4 zenatane 10mg cap 2 zenatane 20mg cap 2 zenatane 30mg cap 2 zenatane 40mg cap 2

ANTIBIOTICS - TOPICAL CORTISPORIN 0.5% CREAM 4 CORTISPORIN 1% OINTMENT 4 gentamicin 0.1% cream 2 QL=120 GM/30 Days gentamicin 0.1% ointment 2 QL=120 GM/30 Days mupirocin 2% ointment 2 QL=220 GM/30 Days

ANTIFUNGALS - TOPICAL betamethasone/clotrimazole 1-0.05% cream 2 QL=270 GM/30 Days betamethasone/clotrimazole 1-0.05% lotion 2 QL=180 ML/30 Days ciclopirox 0.77% cream 2 QL=270 GM/30 Days ciclopirox 0.77% gel 2 QL=300 GM/30 Days ciclopirox 0.77% lotion 2 QL=240 ML/30 Days ciclopirox 1% shampoo 2 QL=240 ML/30 Days ciclopirox 8% topical soln 2 QL=13.20 ML/30 Days clotrimazole 1% cream 2 QL=180 GM/30 Days clotrimazole 1% topical soln 2 QL=240 ML/30 Days econazole nitrate 1% cream 1 QL=255 GM/30 Days ketoconazole 2% cream 2 QL=240 GM/30 Days ketoconazole 2% foam 2 QL=300 GM/30 Days ketoconazole 2% shampoo 1 QL=360 ML/30 Days ketodan 2% foam 2 QL=300 GM/30 Days MENTAX 1% CREAM 4 QL=120 GM/30 Days naftifine 1% cream 2 QL=270 GM/30 Days naftifine 2% cream 2 QL=240 GM/30 Days NAFTIN 2% GEL 4 QL=270 GM/30 Days nyamyc 100000unit/gm topical powder 2 QL=480 GM/30 Days nystatin 100000unit/ml cream 2 QL=240 GM/30 Days nystatin 100unit/mg ointment 2 QL=240 GM/30 Days nystatin 100unit/mg topical powder 2 QL=480 GM/30 Days

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

70

Page 73: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

nystop 100000unit/gm topical powder 2 QL=480 GM/30 Days oxiconazole 1% cream 2 QL=270 GM/30 Days OXISTAT 1% LOTION 4 QL=240 ML/30 Days

ANTI-INFLAMMATORY AGENTS - TOPICAL DICLOFENAC EPOLAMINE 1.3% PATCH 4 PA QL=60 EA/30 Days diclofenac sodium 1% gel 3 QL=1000 GM/30 Days diclofenac sodium 1.5% topical soln 2 QL=450 ML/30 Days FLECTOR 1.3% PATCH 4 PA QL=60 EA/30 Days

ANTINEOPLASTIC OR PREMALIGNANT LESION AGENTS - TOPICAL CARAC 0.5% CREAM 4 diclofenac sodium 3% gel 2 PA QL=300 GM/30 Days FLUOROPLEX 1% CREAM 4 FLUOROURACIL 2% TOPICAL SOLN 3 fluorouracil 5% cream 2 FLUOROURACIL 5% TOPICAL SOLN 3 PICATO 0.015% GEL 4 QL=3 EA/10 Days PICATO 0.05% GEL 4 QL=2 EA/10 Days TARGRETIN 1% GEL 5 NDS PA NSO VALCHLOR 0.016% GEL 5 NDS PA NSO QL=240 GM/30 Days

ANTIPSORIATICS acitretin 10mg cap 2 acitretin 17.5mg cap 2 acitretin 25mg cap 2 calcipotriene 0.005% cream 3 PA QL=240 GM/30 Days calcipotriene 0.005% ointment 2 PA QL=240 GM/30 Days calcipotriene 0.005% topical soln 2 PA CALCITRIOL 0.0003% OINTMENT 4 methoxsalen 10mg cap 2 SKYRIZI 150MG DOSE PACK 75MG/0.83ML 5 PA SORILUX 0.005% FOAM 4 PA STELARA 45MG/0.5ML INJ 5 PA STELARA 45MG/0.5ML SYRINGE 5 PA STELARA 90MG/ML SYRINGE 5 PA TALTZ 80MG/ML AUTO-INJECTOR 5 NDS PA TALTZ 80MG/ML SYRINGE 5 NDS PA tazarotene 0.1% cream 2 TAZORAC 0.05% CREAM 4 TAZORAC 0.05% GEL 4 TAZORAC 0.1% GEL 4

ANTISEBORRHEIC PRODUCTS selenium sulfide 2.5% shampoo 1

ANTIVIRALS - TOPICAL acyclovir 5% cream 2 QL=5 GM/7 Days acyclovir 5% ointment 2 QL=60 GM/30 Days DENAVIR 1% CREAM 4 QL=5 GM/7 Days

BURN PRODUCTS

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

71

Page 74: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

silver sulfadiazine 1% cream 2 ssd 1% cream 2 SULFAMYLON 85MG/GM CREAM 3

CORTICOSTEROIDS - TOPICAL ala-cort 1% cream 2 alclometasone dipropionate 0.05% cream 2 alclometasone dipropionate 0.05% ointment 2 betamethasone 0.05% aug cream 2 betamethasone 0.05% aug lotion 2 betamethasone 0.05% aug ointment 2 betamethasone 0.05% cream 2 BETAMETHASONE 0.05% GEL 2 betamethasone 0.05% lotion 2 betamethasone 0.05% ointment 2 betamethasone 0.1% cream 2 betamethasone 0.1% lotion 2 betamethasone 0.1% ointment 2 BETAMETHASONE/CALCIPOTRIENE 0.005-0.064% LOTION

4 QL=420 GM/30 Days

calcipotriene/betamethasone 0.005-0.064% ointment 2 PA QL=420 GM/30 Days CAPEX 0.01% SHAMPOO 4 clobetasol propionate 0.05% cream 3 clobetasol propionate 0.05% e cream 3 clobetasol propionate 0.05% e foam 3 clobetasol propionate 0.05% foam 3 clobetasol propionate 0.05% gel 3 clobetasol propionate 0.05% lotion 3 clobetasol propionate 0.05% ointment 3 clobetasol propionate 0.05% shampoo 3 clobetasol propionate 0.05% spray 3 clobetasol propionate 0.05% topical soln 3 QL=450 ML/30 Days clodan 0.05% shampoo 2 CORDRAN 4MCG/SQCM TAPE 4 desonide 0.05% ointment 2 desoximetasone 0.05% cream 2 QL=300 GM/30 Days desoximetasone 0.05% gel 2 QL=240 GM/30 Days desoximetasone 0.05% ointment 2 QL=300 GM/30 Days desoximetasone 0.25% cream 2 QL=300 GM/30 Days desoximetasone 0.25% ointment 2 QL=300 GM/30 Days fluocinolone acetonide 0.01% cream 2 fluocinolone acetonide 0.01% topical soln 2 fluocinolone acetonide 0.025% cream 2 fluocinolone acetonide 0.025% ointment 2 fluocinolone acetonide 0.1mg/ml oil 2 fluocinonide 0.05% e cream 2 fluocinonide 0.05% gel 2

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

72

Page 75: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

fluocinonide 0.05% ointment 2 fluocinonide 0.05% topical soln 2 fluticasone propionate 0.005% ointment 2 fluticasone propionate 0.05% cream 2 halobetasol propionate 0.05% cream 2 halobetasol propionate 0.05% ointment 2 hydrocortisone 1% cream 2 hydrocortisone 2.5% cream 2 hydrocortisone 2.5% lotion 2 hydrocortisone 2.5% ointment 2 mometasone furoate 0.1% cream 2 mometasone furoate 0.1% lotion 2 mometasone furoate 0.1% ointment 2 PREDNICARBATE 0.1% CREAM 3 PREDNICARBATE 0.1% OINTMENT 3 TACLONEX 0.05-0.005% LOTION 4 PA QL=420 GM/30 Days triamcinolone acetonide 0.0147% spray 2 triamcinolone acetonide 0.025% cream 2 triamcinolone acetonide 0.025% lotion 2 triamcinolone acetonide 0.025% ointment 2 triamcinolone acetonide 0.1% cream 2 triamcinolone acetonide 0.1% lotion 2 triamcinolone acetonide 0.1% ointment 2 triamcinolone acetonide 0.5% cream 2 triamcinolone acetonide 0.5% ointment 2 triderm 0.1% cream 2

ECZEMA AGENTS DUPIXENT 200MG/1.14ML SYRINGE 5 NDS PA DUPIXENT 300MG/2ML AUTO-INJECTOR 5 NDS PA DUPIXENT 300MG/2ML SYRINGE 5 NDS PA

EMOLLIENTS ammonium lactate 12% cream 2 ammonium lactate 12% lotion 2

ENZYMES - TOPICAL SANTYL 250UNIT/GM OINTMENT 3 QL=90 GM/30 Days

IMMUNOMODULATING AGENTS - TOPICAL IMIQUIMOD 3.75% CREAM 4 imiquimod 5% cream 2 ZYCLARA 2.5% CREAM 4 ZYCLARA 3.75% CREAM 4

IMMUNOSUPPRESSIVE AGENTS - TOPICAL pimecrolimus 1% cream 2 tacrolimus 0.03% ointment 2 QL=100 GM/30 Days tacrolimus 0.1% ointment 2 QL=100 GM/30 Days

KERATOLYTIC/ANTIMITOTIC AGENTS CONDYLOX 0.5% GEL 4

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

73

Page 76: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

podofilox 0.5% topical soln 2 LOCAL ANESTHETICS - TOPICAL

LIDOCAINE 2% GEL 2 lidocaine 4% topical soln 2 lidocaine 5% ointment 2 PA QL=107 GM/30 Days lidocaine 5% patch 2 PA QL=90 EA/30 Days lidocaine/prilocaine 2.5-2.5% cream 2 QL=60 GM/30 Days

ROSACEA AGENTS azelaic acid 15% gel 2 FINACEA 15% FOAM 3 metronidazole 0.75% cream 2 metronidazole 0.75% gel 2 metronidazole 0.75% lotion 2 metronidazole 1% gel 2

SCABICIDES & PEDICULICIDES lindane 1% shampoo 2 malathion 0.5% lotion 2 permethrin 5% cream 2 SKLICE 0.5% LOTION 4 QL=117 GM/15 Days

WOUND CARE PRODUCTS REGRANEX 0.01% GEL 3 QL=30 GM/15 Days

DIGESTIVE AIDS DIGESTIVE ENZYMES

CREON 120000-76000-24000UNIT DR CAP 3 CREON 15000-9500-3000UNIT DR CAP 3 CREON 30000-19000-6000UNIT DR CAP 3 CREON 36000-114000-180000UNIT DR CAP 3 CREON 60000-38000-12000UNIT DR CAP 3 SUCRAID 8500UNIT/ML ORAL SOLN 5 NDS PA ZENPEP 105000-79000-25000UNIT DR CAP 4 ST ZENPEP 14000-10000-3000UNIT DR CAP 4 ST ZENPEP 24000-17000-5000UNIT DR CAP 4 ST ZENPEP 40000-126000-168000UNIT DR CAP 4 ST ZENPEP 42000-32000-10000UNIT DR CAP 4 ST ZENPEP 63000-47000-15000UNIT DR CAP 4 ST ZENPEP 84000-63000-20000UNIT DR CAP 4 ST

DIURETICS CARBONIC ANHYDRASE INHIBITORS

acetazolamide 125mg tab 2 acetazolamide 250mg tab 2 acetazolamide 500mg er cap 2 methazolamide 25mg tab 2 methazolamide 50mg tab 2

DIURETIC COMBINATIONS ALDACTAZIDE 50-50MG TAB 4 amiloride 5mg/hydrochlorothiazide 50mg tab 1

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

74

Page 77: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

hydrochlorothiazide 25mg/spironolactone 25mg tab 2 hydrochlorothiazide 25mg/triamterene 37.5mg cap 1 hydrochlorothiazide 25mg/triamterene 37.5mg tab 1 hydrochlorothiazide 50mg/triamterene 75mg tab 1

LOOP DIURETICS bumetanide 0.25mg/ml inj 2 bumetanide 0.5mg tab 2 bumetanide 1mg tab 2 bumetanide 2mg tab 2 ethacrynic acid 25mg tab 2 furosemide 10mg/ml inj 2 furosemide 10mg/ml oral soln 2 furosemide 10mg/ml syringe 2 furosemide 20mg tab 1 furosemide 40mg tab 1 furosemide 80mg tab 1 FUROSEMIDE 8MG/ML ORAL SOLN 2 torsemide 100mg tab 1 torsemide 10mg tab 1 torsemide 20mg tab 1 torsemide 5mg tab 1

POTASSIUM SPARING DIURETICS amiloride 5mg tab 1 spironolactone 100mg tab 1 spironolactone 25mg tab 1 spironolactone 50mg tab 1 triamterene 100mg cap 2 triamterene 50mg cap 2

THIAZIDES AND THIAZIDE-LIKE DIURETICS chlorthalidone 25mg tab 2 chlorthalidone 50mg tab 2 DIURIL 250MG/5ML SUSP 3 hydrochlorothiazide 12.5mg cap 1 hydrochlorothiazide 12.5mg tab 1 hydrochlorothiazide 25mg tab 1 hydrochlorothiazide 50mg tab 1 indapamide 1.25mg tab 1 indapamide 2.5mg tab 1 metolazone 10mg tab 2 metolazone 2.5mg tab 2 metolazone 5mg tab 2

ENDOCRINE AND METABOLIC AGENTS - MISC. BONE DENSITY REGULATORS

ALENDRONIC ACID 0.933MG/ML ORAL SOLN 4 alendronic acid 10mg tab 1 alendronic acid 35mg tab 1

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

75

Page 78: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

alendronic acid 70mg tab 1 FORTEO 600MCG/2.4ML PEN INJ 5 NDS ibandronic acid 150mg tab 1 QL=1 EA/30 Days NATPARA 100MCG CARTRIDGE 5 NDS PA NATPARA 25MCG CARTRIDGE 5 NDS PA NATPARA 50MCG CARTRIDGE 5 NDS PA NATPARA 75MCG CARTRIDGE 5 NDS PA PROLIA 60MG/ML SYRINGE 4 PA risedronate sodium 150mg tab 2 risedronate sodium 30mg tab 2 risedronate sodium 35mg (12) pack 2 risedronate sodium 35mg (4) pack 2 risedronate sodium 35mg tab 2 risedronate sodium 5mg tab 2 salmon calcitonin 200unit/act nasal spray 2 TYMLOS 3120MCG/1.56ML PEN INJ 5 NDS XGEVA 120MG/1.7ML INJ 5 NDS PA

GNRH/LHRH ANTAGONISTS ORILISSA 150MG TAB 3 PA QL=30 EA/30 Days ORILISSA 200MG TAB 3 PA QL=60 EA/30 Days

GROWTH HORMONE RECEPTOR ANTAGONISTS SOMAVERT 10MG INJ 5 NDS PA SOMAVERT 15MG INJ 5 NDS PA SOMAVERT 20MG INJ 5 NDS PA SOMAVERT 25MG INJ 5 NDS PA SOMAVERT 30MG INJ 5 NDS PA

GROWTH HORMONES GENOTROPIN 0.2MG SYRINGE 5 NDS PA GENOTROPIN 0.4MG SYRINGE 5 NDS PA GENOTROPIN 0.6MG SYRINGE 5 NDS PA GENOTROPIN 0.8MG SYRINGE 5 NDS PA GENOTROPIN 1.2MG SYRINGE 5 NDS PA GENOTROPIN 1.4MG SYRINGE 5 NDS PA GENOTROPIN 1.6MG SYRINGE 5 NDS PA GENOTROPIN 1.8MG SYRINGE 5 NDS PA GENOTROPIN 12MG CARTRIDGE 5 NDS PA GENOTROPIN 1MG SYRINGE 5 NDS PA GENOTROPIN 2MG SYRINGE 5 NDS PA GENOTROPIN 5MG CARTRIDGE 5 NDS PA

HORMONE RECEPTOR MODULATORS OSPHENA 60MG TAB 4 PA raloxifene 60mg tab 3

INSULIN-LIKE GROWTH FACTORS (SOMATOMEDINS) INCRELEX 40MG/4ML INJ 5 NDS PA

LHRH/GNRH AGONIST ANALOG PITUITARY SUPPRESSANTS LUPANETA PACK 1-MONTH PACK 5 NDS

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

76

Page 79: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

LUPANETA PACK 3-MONTH PACK 5 SYNAREL 2MG/ML NASAL INHALER 5 NDS

METABOLIC MODIFIERS calcitriol 0.00025mg cap 2 calcitriol 0.0005mg cap 2 calcitriol 0.001mg/ml oral soln 2 CARBAGLU 200MG TAB FOR ORAL SUSP 4 PA cinacalcet 30mg tab 2 cinacalcet 60mg tab 2 cinacalcet 90mg tab 2 doxercalciferol 0.0005mg cap 2 doxercalciferol 0.001mg cap 2 doxercalciferol 0.0025mg cap 2 GALAFOLD 28 DAY WALLET 123MG PACK 5 NDS PA QL=15 EA/30 Days KUVAN 100MG POWDER FOR ORAL SOLN 5 NDS PA KUVAN 100MG TAB 5 NDS PA KUVAN 500MG POWDER FOR ORAL SOLN 5 NDS PA levocarnitine 100mg/ml oral soln 2 levocarnitine 330mg tab 2 nitisinone 10mg cap 5 NDS PA nitisinone 2mg cap 5 NDS PA nitisinone 5mg cap 5 NDS PA ORFADIN 20MG CAP 5 NDS PA ORFADIN 4MG/ML SUSP 5 NDS PA PALYNZIQ 10MG/0.5ML SYRINGE 5 NDS PA PALYNZIQ 2.5MG/0.5ML SYRINGE 5 NDS PA PALYNZIQ 20MG/ML SYRINGE 5 NDS PA paricalcitol 0.001mg cap 2 paricalcitol 0.002mg cap 2 paricalcitol 0.004mg cap 2 RAVICTI 1.1GM/ML ORAL SOLN 5 NDS PA sodium phenylbutyrate 0.94mg/mg oral powder 2

POSTERIOR PITUITARY HORMONES DDAVP 0.01% NASAL SOLN 4 desmopressin acetate 0.01mg/act nasal spray 2 desmopressin acetate 0.1mg tab 2 desmopressin acetate 0.2mg tab 2 STIMATE 1.5MG/ML NASAL INHALER 4

PROLACTIN INHIBITORS cabergoline 0.5mg tab 2

SOMATOSTATIC AGENTS octreotide 0.05mg/ml inj 1 octreotide 0.1mg/ml inj 1 octreotide 0.2mg/ml inj 1 octreotide 0.5mg/ml inj 1 octreotide 1mg/ml inj 1

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

77

Page 80: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

SIGNIFOR 0.3MG/ML INJ 5 NDS PA QL=60 ML/30 Days SIGNIFOR 0.6MG/ML INJ 5 NDS PA QL=60 ML/30 Days SIGNIFOR 0.9MG/ML INJ 5 NDS PA QL=60 ML/30 Days SOMATULINE 120MG/0.5ML SYRINGE 5 NDS SOMATULINE 60MG/0.2ML SYRINGE 5 NDS SOMATULINE 90MG/0.3ML SYRINGE 5 NDS

VASOPRESSIN RECEPTOR ANTAGONISTS JYNARQUE 15MG TAB 5 NDS PA QL=120 EA/30 Days JYNARQUE 30MG TAB 5 NDS PA QL=120 EA/30 Days JYNARQUE 45/15 THERAPY PACK 5 NDS PA QL=60 EA/30 Days JYNARQUE 60/30 THERAPY PACK 5 NDS PA QL=60 EA/30 Days JYNARQUE 90/30 THERAPY PACK 5 NDS PA QL=60 EA/30 Days JYNARQUE TAB 15/15MG THERAPY PACK 5 NDS PA QL=60 EA/30 Days JYNARQUE TAB 30/15MG THERAPY PACK 5 NDS PA QL=60 EA/30 Days

ESTROGENS ESTROGEN COMBINATIONS

amabelz 0.5/0.1mg 28 day pack 2 amabelz 1/0.5mg 28 day pack 2 ANGELIQ 0.25/0.5MG 28 DAY PACK 4 ANGELIQ 0.5/1MG 28 DAY PACK 4 CLIMARA PRO 0.00188-0.000625MG/HR PATCH 4 COMBIPATCH 0.00208-0.00583MG/HR PATCH 4 COMBIPATCH 0.00208-0.0104MG/HR PATCH 4 estradiol 0.5mg/norethindrone acetate 0.1mg pack 2 estradiol 1mg/norethindrone acetate 0.5mg pack 2 ethinyl estradiol 0.0025mg/norethindrone acetate 2 0.5mg pack ethinyl estradiol 0.005mg/norethindrone acetate 1mg 2 pack fyavolv 0.0025-0.5mg tab 2 fyavolv 0.005-1mg tab 2 jinteli 0.005-1mg tab 2 lopreeza 1/0.5mg 28 day pack 2 mimvey pack 2 PREFEST 30 DAY PACK 4 PREMPHASE 28 DAY PACK 3 PREMPRO 0.3/1.5MG 28 DAY PACK 3 PREMPRO 0.45/1.5 28 DAY PACK 3 PREMPRO 0.625/2.5MG 28 DAY PACK 3 PREMPRO 0.625/5MG 28 DAY PACK 3

ESTROGENS ALORA 0.025MG/24HR PATCH 4 ALORA 0.05MG/24HR PATCH 4 ALORA 0.075MG/24HR PATCH 4 ALORA 0.1MG/24HR PATCH 4 DELESTROGEN 10MG/ML INJ 4

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

78

Page 81: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

DEPO-ESTRADIOL 5MG/ML INJ 4 dotti 0.025mg/24hr patch 2 dotti 0.0375mg/24hr patch 2 dotti 0.05mg/24hr patch 2 dotti 0.075mg/24hr patch 2 dotti 0.1mg/24hr patch 2 estradiol 0.00104mg/hr twice weekly patch 2 estradiol 0.00104mg/hr weekly patch 2 estradiol 0.00156mg/hr twice weekly patch 2 estradiol 0.00156mg/hr weekly patch 2 estradiol 0.00208mg/hr twice weekly patch 2 estradiol 0.00208mg/hr weekly patch 2 estradiol 0.0025mg/hr weekly patch 2 estradiol 0.00312mg/hr weekly patch 2 estradiol 0.00313mg/hr twice weekly patch 2 estradiol 0.00417mg/hr twice weekly patch 2 estradiol 0.00417mg/hr weekly patch 2 estradiol 0.5mg tab 1 estradiol 1mg tab 1 estradiol 2mg tab 1 estradiol valerate 20mg/ml inj 2 estradiol valerate 40mg/ml inj 2 EVAMIST 1.53MG/SPRAY SPRAY 4 MENEST 0.3MG TAB 4 MENEST 0.625MG TAB 4 MENEST 1.25MG TAB 4 MENOSTAR 14MCG/24HR PATCH 4 PREMARIN 0.3MG TAB 3 PREMARIN 0.45MG TAB 3 PREMARIN 0.625MG TAB 4 PREMARIN 0.9MG TAB 3 PREMARIN 1.25MG TAB 3

FLUOROQUINOLONES FLUOROQUINOLONES

BAXDELA 450MG TAB 3 PA QL=60 EA/30 Days CIPRO 5GM/100ML SUSP 4 ciprofloxacin 250mg tab 1 ciprofloxacin 2mg/ml inj 2 ciprofloxacin 500mg tab 1 ciprofloxacin 750mg tab 1 levofloxacin 250mg tab 1 levofloxacin 25mg/ml inj 2 levofloxacin 25mg/ml oral soln 2 levofloxacin 500mg tab 1 levofloxacin 5mg/ml (100ml) inj 2 levofloxacin 5mg/ml (150ml) inj 2

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

79

Page 82: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

levofloxacin 750mg tab 1 moxifloxacin 1.6mg/ml inj 2 moxifloxacin 400mg tab 2 ofloxacin 400mg tab 2

GASTROINTESTINAL AGENTS - MISC. 5-HT4 RECEPTOR AGONISTS

MOTEGRITY 1MG TAB 4 PA MOTEGRITY 2MG TAB 4 PA

AGENTS FOR CHRONIC IDIOPATHIC CONSTIPATION (CIC) TRULANCE 3MG TAB 3

BILE ACID SYNTHESIS DISORDER AGENTS CHOLBAM 250MG CAP 5 NDS PA CHOLBAM 50MG CAP 5 NDS PA

FARNESOID X RECEPTOR (FXR) AGONISTS OCALIVA 10MG TAB 5 NDS PA QL=30 EA/30 Days OCALIVA 5MG TAB 5 NDS PA QL=30 EA/30 Days

GALLSTONE SOLUBILIZING AGENTS CHENODAL 250MG TAB 5 NDS ursodiol 250mg tab 1 ursodiol 300mg cap 2 ursodiol 500mg tab 1

GASTROINTESTINAL ANTIALLERGY AGENTS cromolyn sodium 20mg/ml oral soln 2

GASTROINTESTINAL CHLORIDE CHANNEL ACTIVATORS AMITIZA 24MCG CAP 4 AMITIZA 8MCG CAP 4

GASTROINTESTINAL STIMULANTS metoclopramide 10mg tab 1 metoclopramide 1mg/ml oral soln 2 metoclopramide 5mg tab 1

INFLAMMATORY BOWEL AGENTS balsalazide disodium 750mg cap 2 CIMZIA 200MG INJ 5 NDS PA CIMZIA 200MG/ML SYRINGE 5 NDS PA DIPENTUM 250MG CAP 4 mesalamine 1000mg rectal supp 2 mesalamine 1200mg dr tab 2 mesalamine 375mg er cap 2 mesalamine 400mg dr cap 2 mesalamine 66.7mg/ml enema 2 mesalamine 800mg dr tab 2 sulfasalazine 500mg dr tab 1 sulfasalazine 500mg tab 1

INTESTINAL ACIDIFIERS enulose 10gm/15ml oral soln 1 generlac 10gm/15ml oral soln 1

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

80

Page 83: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

IRRITABLE BOWEL SYNDROME (IBS) AGENTS alosetron 0.5mg tab 2 alosetron 1mg tab 2 LINZESS 145MCG CAP 3 PA LINZESS 290MCG CAP 3 PA LINZESS 72MCG CAP 3 PA

PERIPHERAL OPIOID RECEPTOR ANTAGONISTS MOVANTIK 12.5MG TAB 3 PA MOVANTIK 25MG TAB 3 PA SYMPROIC 0.2MG TAB 3 PA

PHOSPHATE BINDER AGENTS AURYXIA 210MG TAB 4 PA calcium acetate 667mg cap 2 calcium acetate 667mg tab 2 FOSRENOL 1000MG ORAL POWDER 3 FOSRENOL 750MG ORAL POWDER 3 lanthanum carbonate 1000mg chew tab 2 lanthanum carbonate 500mg chew tab 2 lanthanum carbonate 750mg chew tab 2 PHOSLYRA 667MG/5ML ORAL SOLN 3 SEVELAMER 400MG TAB 3 sevelamer 800mg tab 2 sevelamer carbonate 2400mg powder for oral susp 2 sevelamer carbonate 800mg powder for oral susp 2 sevelamer carbonate 800mg tab 2 VELPHORO 500MG CHEW TAB 4

SHORT BOWEL SYNDROME (SBS) AGENTS GATTEX 5MG INJ 5 NDS PA

GENITOURINARY AGENTS - MISCELLANEOUS ALKALINIZERS

potassium citrate 10meq er tab 2 potassium citrate 15meq er tab 2 potassium citrate 5meq er tab 2

CYSTINOSIS AGENTS CYSTAGON 150MG CAP 3 CYSTAGON 50MG CAP 3

GENITOURINARY IRRIGANTS sodium chloride 0.154meq/ml soln 2

INTERSTITIAL CYSTITIS AGENTS ELMIRON 100MG CAP 3

PROSTATIC HYPERTROPHY AGENTS alfuzosin 10mg er tab 1 CARDURA 4MG ER TAB 4 CARDURA 8MG ER TAB 4 dutasteride 0.5mg cap 2 dutasteride 0.5mg/tamsulosin 0.4mg cap 2

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

81

Page 84: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

finasteride 5mg tab 1 silodosin 4mg cap 2 silodosin 8mg cap 2 tamsulosin 0.4mg cap 1

URINARY STONE AGENTS LITHOSTAT 250MG TAB 4 THIOLA 100MG DR TAB 4 THIOLA 100MG TAB 4 THIOLA 300MG DR TAB 4

GOUT AGENTS GOUT AGENT COMBINATIONS

colchicine 0.5mg/probenecid 500mg tab 2 GOUT AGENTS

allopurinol 100mg tab 1 allopurinol 300mg tab 1 COLCHICINE 0.6MG CAP 3 febuxostat 40mg tab 2 ST febuxostat 80mg tab 2 ST MITIGARE 0.6MG CAP 3

URICOSURICS probenecid 500mg tab 2

HEMATOLOGICAL AGENTS - MISC. BRADYKININ B2 RECEPTOR ANTAGONISTS

icatibant 10mg/ml syringe 5 NDS PA COMPLEMENT INHIBITORS

BERINERT 500UNIT INJ 5 NDS PA CINRYZE 500UNIT INJ 5 NDS PA HAEGARDA 2000UNIT INJ 5 NDS PA HAEGARDA 3000UNIT INJ 5 NDS PA RUCONEST 2100UNIT INJ 5 NDS PA

HEMATAOLOGIC - TYROSINE KINASE INHIBITORS TAVALISSE 100MG TAB 5 NDS PA QL=60 EA/30 Days TAVALISSE 150MG TAB 5 NDS PA QL=60 EA/30 Days

HEMATORHEOLOGIC AGENTS pentoxifylline 400mg er tab 1

PLASMA KALLIKREIN INHIBITORS TAKHZYRO 300MG/2ML INJ 5 NDS PA QL=4 ML/28 Days

PLATELET AGGREGATION INHIBITORS anagrelide 0.5mg cap 2 anagrelide 1mg cap 2 aspirin 25mg/dipyridamole 200mg er cap 2 BRILINTA 60MG TAB 4 BRILINTA 90MG TAB 4 CABLIVI 11MG INJ 5 NDS PA QL=30 EA/30 Days cilostazol 100mg tab 1 cilostazol 50mg tab 1

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

82

Page 85: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

clopidogrel 75mg tab 1 dipyridamole 25mg tab 2 dipyridamole 50mg tab 2 dipyridamole 75mg tab 2 prasugrel 10mg tab 2 prasugrel 5mg tab 2 ZONTIVITY 2.08MG TAB 4 PA

HEMATOPOIETIC AGENTS AGENTS FOR GAUCHER DISEASE

CERDELGA 84MG CAP 5 NDS PA QL=60 EA/30 Days miglustat 100mg cap 5 NDS PA

AGENTS FOR SICKLE CELL ANEMIA DROXIA 200MG CAP 3 DROXIA 300MG CAP 3 DROXIA 400MG CAP 3 ENDARI 5GM POWDER FOR ORAL SOLN 5 NDS PA QL=180 EA/30 Days OXBRYTA 500MG TAB 5 NDS PA QL=90 EA/30 Days

HEMATOPOIETIC GROWTH FACTORS ARANESP 100MCG/0.5ML SYRINGE 4 PA BvD ST ARANESP 100MCG/ML INJ 4 PA BvD ST ARANESP 10MCG/0.4ML SYRINGE 4 PA BvD ST ARANESP 150MCG/0.3ML SYRINGE 4 PA BvD ST ARANESP 200MCG/0.4ML SYRINGE 4 PA BvD ST ARANESP 200MCG/ML INJ 4 PA BvD ST ARANESP 25MCG/0.42ML SYRINGE 4 PA BvD ST ARANESP 25MCG/ML INJ 4 PA BvD ST ARANESP 300MCG/0.6ML SYRINGE 4 PA BvD ST ARANESP 300MCG/ML INJ 4 PA BvD ST ARANESP 40MCG/0.4ML SYRINGE 4 PA BvD ST ARANESP 40MCG/ML INJ 4 PA BvD ST ARANESP 500MCG/ML SYRINGE 4 PA BvD ST ARANESP 60MCG/0.3ML SYRINGE 4 PA BvD ST ARANESP 60MCG/ML INJ 4 PA BvD ST DOPTELET 20MG TAB 5 NDS PA QL=60 EA/30 Days DOPTELET 40MG DAILY DOSE PACK 5 NDS PA QL=10 EA/5 Days DOPTELET 60MG DAILY DOSE PACK 5 NDS PA QL=15 EA/5 Days FULPHILA 6MG/0.6ML SYRINGE 5 NDS NIVESTYM 300MCG/0.5ML SYRINGE 5 NDS NIVESTYM 300MCG/ML INJ 5 NDS NIVESTYM 480MCG/0.8ML SYRINGE 5 NDS NIVESTYM 480MCG/1.6ML INJ 5 NDS PROMACTA 12.5MG POWDER FOR ORAL SUSP 5 NDS PA PROMACTA 12.5MG TAB 5 NDS PA PROMACTA 25MG POWDER FOR ORAL SUSP 5 NDS PA PROMACTA 25MG TAB 5 NDS PA PROMACTA 50MG TAB 5 NDS PA

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

83

Page 86: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

PROMACTA 75MG TAB 5 NDS PA RETACRIT 10000UNIT/ML INJ 3 PA BvD RETACRIT 2000UNIT/ML INJ 3 PA BvD RETACRIT 3000UNIT/ML INJ 3 PA BvD RETACRIT 40000UNIT/ML INJ 3 PA BvD RETACRIT 4000UNIT/ML INJ 3 PA BvD ZARXIO 300MCG/0.5ML SYRINGE 5 NDS ZARXIO 480MCG/0.8ML SYRINGE 5 NDS ZIEXTENZO 6MG/0.6ML SYRINGE 5 NDS

HEMOSTATICS HEMOSTATICS - SYSTEMIC

tranexamic acid 650mg tab 2 HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS

BARBITURATE HYPNOTICS phenobarbital 100mg tab 2 phenobarbital 15mg tab 2 phenobarbital 16.2mg tab 2 phenobarbital 30mg tab 2 phenobarbital 32.4mg tab 2 phenobarbital 4mg/ml oral soln 2 phenobarbital 60mg tab 2 phenobarbital 64.8mg tab 2 phenobarbital 97.2mg tab 2

NON-BARBITURATE HYPNOTICS estazolam 1mg tab 2 estazolam 2mg tab 2 eszopiclone 1mg tab 2 QL=30 EA/30 Days eszopiclone 2mg tab 2 QL=30 EA/30 Days eszopiclone 3mg tab 2 QL=30 EA/30 Days FLURAZEPAM 15MG CAP 3 FLURAZEPAM 30MG CAP 3 temazepam 15mg cap 1 temazepam 22.5mg cap 2 temazepam 30mg cap 1 temazepam 7.5mg cap 2 triazolam 0.125mg tab 2 triazolam 0.25mg tab 2 zaleplon 10mg cap 2 QL=30 EA/30 Days zaleplon 5mg cap 2 QL=30 EA/30 Days zolpidem tartrate 10mg tab 2 QL=30 EA/30 Days zolpidem tartrate 5mg tab 2 QL=60 EA/30 Days

SELECTIVE MELATONIN RECEPTOR AGONISTS HETLIOZ 20MG CAP 5 NDS PA QL=30 EA/30 Days ramelteon 8mg tab 2 QL=30 EA/30 Days

LAXATIVES LAXATIVE COMBINATIONS

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

84

Page 87: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

CLENPIQ 75-21.9-0.0625MG/ML ORAL SOLN 3 GAVILYTE-C ORAL SOLN 1 gavilyte-g powder for oral soln 1 gavilyte-n powder for oral soln 1 peg 3350/electrolyte oral soln 1 peg 3350/kcl/sodium bicarbonate/sodium chloride powder for oral soln

1

trilyte powder for oral soln 1 LAXATIVES - MISCELLANEOUS

constulose 10gm/15ml oral soln 1 KRISTALOSE 20GM POWDER FOR ORAL SOLN 4 lactulose 667mg/ml oral soln 1

MACROLIDES AZITHROMYCIN

AZITHROMYCIN 1000MG POWDER FOR ORAL SUSP

4

azithromycin 20mg/ml susp 1 azithromycin 250mg pack 1 azithromycin 250mg tab 1 azithromycin 40mg/ml susp 1 azithromycin 500mg inj 2 azithromycin 500mg pack 1 azithromycin 500mg tab 1 azithromycin 600mg tab 2 ZITHROMAX 1GM POWDER FOR ORAL SUSP 4

CLARITHROMYCIN clarithromycin 250mg tab 1 CLARITHROMYCIN 25MG/ML SUSP 3 clarithromycin 500mg er tab 2 clarithromycin 500mg tab 1 CLARITHROMYCIN 50MG/ML SUSP 3

ERYTHROMYCINS ery-tab 250mg dr tab 2 ery-tab 333mg dr tab 2 ery-tab 500mg dr tab 2 ERYTHROCIN 500MG INJ 4 erythromycin 250mg dr cap 2 erythromycin 250mg dr tab 2 erythromycin 250mg tab 2 erythromycin 333mg dr tab 2 erythromycin 500mg dr tab 2 erythromycin 500mg tab 2 erythromycin ethylsuccinate 40mg/ml susp 2 erythromycin ethylsuccinate 80mg/ml susp 2

FIDAXOMICIN DIFICID 200MG TAB 3 PA QL=20 EA/10 Days

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

85

Page 88: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

MEDICAL DEVICES PARENTERAL THERAPY SUPPLIES

INSULIN SYRINGE (DISP) U-100 1/2ML 2 MEDICAL DEVICES AND SUPPLIES

BANDAGES-DRESSINGS-TAPE GAUZE PADS & DRESSINGS - PADS 2 X 2 2

MISC. DEVICES ISOPROPYL ALCOHOL 0.7ML/ML PAD 2

PARENTERAL THERAPY SUPPLIES INSULIN PEN NEEDLE 2 INSULIN SYRINGE (DISP) U-100 0.3ML 2 INSULIN SYRINGE (DISP) U-100 1ML 2 NEEDLES INSULIN DISP. SAFETY 2

MIGRAINE PRODUCTS CALCITONIN GENE-RELATED PEPTIDE (CGRP) RECEPTOR ANTAG

AIMOVIG 140MG/ML AUTO-INJECTOR 3 PA AIMOVIG 70MG/ML AUTO-INJECTOR 3 PA EMGALITY 100MG/ML SYRINGE 3 PA EMGALITY 120MG/ML AUTO-INJECTOR 3 PA EMGALITY 120MG/ML SYRINGE 3 PA

MIGRAINE PRODUCTS dihydroergotamine mesylate 0.5mg/act nasal inhaler 3 QL=16 ML/30 Days

SEROTONIN AGONISTS eletriptan 20mg tab 2 QL=18 EA/30 Days eletriptan 40mg tab 2 QL=18 EA/30 Days naratriptan 1mg tab 2 QL=18 EA/30 Days naratriptan 2.5mg tab 2 QL=18 EA/30 Days rizatriptan 10mg odt 2 QL=36 EA/60 Days rizatriptan 10mg tab 2 QL=36 EA/60 Days rizatriptan 5mg odt 2 QL=36 EA/60 Days rizatriptan 5mg tab 2 QL=36 EA/60 Days sumatriptan 100mg tab 1 QL=18 EA/30 Days sumatriptan 12mg/ml inj 2 QL=5 ML/30 Days SUMATRIPTAN 12MG/ML SYRINGE 4 QL=5 ML/30 Days sumatriptan 20mg/act nasal spray 2 QL=12 EA/30 Days sumatriptan 25mg tab 1 QL=18 EA/30 Days sumatriptan 50mg tab 1 QL=18 EA/30 Days sumatriptan 5mg/act nasal spray 2 QL=12 EA/30 Days zolmitriptan 2.5mg odt 2 QL=18 EA/30 Days zolmitriptan 2.5mg tab 2 QL=18 EA/30 Days zolmitriptan 5mg odt 2 QL=18 EA/30 Days zolmitriptan 5mg tab 2 QL=18 EA/30 Days ZOMIG 2.5MG NASAL SPRAY 4 QL=16 EA/30 Days ZOMIG 5MG NASAL SPRAY 4 QL=12 EA/30 Days

MINERALS & ELECTROLYTES ELECTROLYTE MIXTURES

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

86

Page 89: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

GLUCOSE 100MG/ML/SODIUM CHLORIDE 0.0342 3 MEQ/ML INJ

PA BvD

GLUCOSE 100MG/ML/SODIUM CHLORIDE 0.0769 3 MEQ/ML INJ

PA BvD

GLUCOSE 25MG/ML/SODIUM CHLORIDE 0.0769 2 MEQ/ML INJ glucose 50 mg/ml/potassium chloride 2 0.04meq/ml/sodium chloride 4.5mg/ml inj glucose 50mg/ml/potassium chloride 0.01 2 meq/ml/sodium chloride 0.0769 meq/ml inj glucose 50mg/ml/potassium chloride 0.02 meq/ml inj 2 glucose 50mg/ml/potassium chloride 0.02 2 meq/ml/sodium chloride 0.0342 meq/ml inj glucose 50mg/ml/potassium chloride 0.02 2 meq/ml/sodium chloride 0.154 meq/ml inj glucose 50mg/ml/potassium chloride 2 0.02meq/ml/sodium chloride 4.5mg/ml inj glucose 50mg/ml/potassium chloride 0.03 2 meq/ml/sodium chloride 0.0769 meq/ml inj GLUCOSE 50MG/ML/POTASSIUM CHLORIDE 0.04 3 MEQ/ML/SODIUM CHLORIDE 0.154 MEQ/ML INJ glucose 50mg/ml/sodium chloride 0.0342 meq/ml inj 2 glucose 50mg/ml/sodium chloride 4.5mg/ml inj 2 glucose 50mg/ml/sodium chloride 9mg/ml inj 2 ISOLYTE P INJ 3 ISOLYTE S INJ 3 KCL/D5W/LR INJ 0.15% 3 NORMOSOL-M INJ 2 PLASMA-LYTE 148 INJ 3 PLASMALYTE A INJ 3 potassium chloride 0.02 meq/ml/sodium chloride 2 0.0769 meq/ml inj potassium chloride 0.02 meq/ml/sodium chloride 2 0.154 meq/ml inj POTASSIUM CHLORIDE 0.04 MEQ/ML/SODIUM 2 CHLORIDE 0.154 MEQ/ML INJ TPN ELECTROLYTES INJ 2 PA BvD

MAGNESIUM magnesium sulfate 500mg/ml inj 2 magnesium sulfate 500mg/ml syringe 2

POTASSIUM K-TAB 8MEQ ER TAB 2 klor-con 10meq er tab 1 klor-con 10meq micro er tab 1 KLOR-CON 15MEQ MICRO ER TAB 2 klor-con 20meq micro er tab 1

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

87

Page 90: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

klor-con 20meq powder for oral soln 2 klor-con 8meq er tab 1 POTASSIUM CHLORIDE 0.1MEQ/ML INJ 2 POTASSIUM CHLORIDE 0.2MEQ/ML INJ 2 POTASSIUM CHLORIDE 0.4MEQ/ML INJ 2 potassium chloride 1.33meq/ml oral soln 2 potassium chloride 10meq er cap 1 potassium chloride 10meq er tab 1 potassium chloride 10meq micro er tab 1 potassium chloride 2.67meq/ml oral soln 2 potassium chloride 20meq er tab 2 potassium chloride 20meq micro er tab 1 potassium chloride 20meq powder for oral soln 2 potassium chloride 2meq/ml (20ml) inj 2 potassium chloride 2meq/ml inj 2 potassium chloride 8meq er cap 1 potassium chloride 8meq er tab 1

SODIUM sodium chloride 30mg/ml inj 2 sodium chloride 4.5mg/ml inj 2 sodium chloride 50mg/ml inj 2 sodium chloride 9mg/ml inj 2

MISCELLANEOUS THERAPEUTIC CLASSES CHELATING AGENTS

clovique 250mg cap 2 PA penicillamine 250mg tab 2 trientine 250mg cap 2 PA

IMMUNOMODULATORS REVLIMID 10MG CAP 5 NDS PA NSO QL=30 EA/30 Days REVLIMID 15MG CAP 5 NDS PA NSO QL=30 EA/30 Days REVLIMID 2.5MG CAP 5 NDS PA NSO QL=30 EA/30 Days REVLIMID 20MG CAP 5 NDS PA NSO QL=30 EA/30 Days REVLIMID 25MG CAP 5 NDS PA NSO QL=30 EA/30 Days REVLIMID 5MG CAP 5 NDS PA NSO QL=30 EA/30 Days THALOMID 100MG CAP 5 NDS PA NSO THALOMID 150MG CAP 5 NDS PA NSO THALOMID 200MG CAP 5 NDS PA NSO THALOMID 50MG CAP 5 NDS PA NSO

IMMUNOSUPPRESSIVE AGENTS ASTAGRAF 0.5MG ER CAP 4 PA BvD ASTAGRAF 1MG ER CAP 4 PA BvD ASTAGRAF 5MG ER CAP 4 PA BvD azathioprine 50mg tab 2 PA BvD cyclosporine modified 100mg/ml oral soln 2 PA BvD cyclosporine modified 50mg cap 2 PA BvD ENVARSUS 0.75MG ER TAB 4 PA BvD

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

88

Page 91: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

ENVARSUS 1MG ER TAB 4 PA BvD ENVARSUS 4MG ER TAB 4 PA BvD everolimus 0.25mg tab 2 PA BvD everolimus 0.5mg tab 2 PA BvD everolimus 0.75mg tab 2 PA BvD mycophenolic acid 180mg dr tab 2 PA BvD mycophenolic acid 360mg dr tab 2 PA BvD PROGRAF 0.2MG GRANULES FOR ORAL SUSP 4 PA BvD PROGRAF 1MG GRANULES FOR ORAL SUSP 4 PA BvD sirolimus 1mg/ml oral soln 2 PA BvD ZORTRESS 1MG TAB 4 PA BvD

POTASSIUM REMOVING AGENTS kionex 15gm/60ml susp 2 LOKELMA 10GM POWDER FOR ORAL SUSP 3 PA LOKELMA 5GM POWDER FOR ORAL SUSP 3 PA sodium polystyrene sulfonate 15000mg powder for oral susp

2

sodium polystyrene sulfonate 250mg/ml susp 2 sps 15gm/60ml susp 2 VELTASSA 16.8GM POWDER FOR ORAL SUSP 4 PA VELTASSA 25.2GM POWDER FOR ORAL SUSP 4 PA VELTASSA 8.4GM POWDER FOR ORAL SUSP 4 PA

SYSTEMIC LUPUS ERYTHEMATOSUS AGENTS BENLYSTA 200MG/ML AUTO-INJECTOR 5 NDS PA QL=4 ML/28 Days BENLYSTA 200MG/ML SYRINGE 5 NDS PA QL=4 ML/28 Days

MOUTH/THROAT/DENTAL AGENTS ANESTHETICS TOPICAL ORAL

lidocaine 2% topical soln 2 ANTI-INFECTIVES - THROAT

clotrimazole 10mg lozenge 2 nystatin 100000unit/ml susp 2 ORAVIG 50MG BUCCAL TAB 4

ANTISEPTICS - MOUTH/THROAT chlorhexidine gluconate 0.12% mouthwash 1

STEROIDS - MOUTH/THROAT/DENTAL triamcinolone acetonide 0.1% oral paste 2

THROAT PRODUCTS - MISC. cevimeline 30mg cap 2 pilocarpine 5mg tab 2 pilocarpine 7.5mg tab 2

MUSCULOSKELETAL THERAPY AGENTS CENTRAL MUSCLE RELAXANTS

baclofen 10mg tab 2 baclofen 20mg tab 2 carisoprodol 350mg tab 2 chlorzoxazone 500mg tab 1

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

89

Page 92: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

1cyclobenzaprine 10mg tab

1cyclobenzaprine 5mg tab

4METAXALONE 400MG TAB

2metaxalone 800mg tab

1methocarbamol 500mg tab

1methocarbamol 750mg tab

2orphenadrine citrate 100mg er tab

2tizanidine 2mg cap

2tizanidine 2mg tab

2tizanidine 4mg cap

2tizanidine 4mg tab

2tizanidine 6mg cap DIRECT MUSCLE RELAXANTS

2dantrolene sodium 100mg cap

2dantrolene sodium 25mg cap

2dantrolene sodium 50mg cap

NASAL AGENTS - SYSTEMIC AND TOPICAL NASAL ANTIALLERGY

1azelastine 0.137mg/act nasal inhaler

2azelastine 0.206mg/act nasal inhaler

2olopatadine 0.665mg/act nasal inhaler NASAL ANTICHOLINERGICS

2ipratropium bromide 0.021mg/act nasal inhaler

2ipratropium bromide 0.042mg/act nasal inhaler NASAL STEROIDS

4FLUNISOLIDE 0.025MG/ACT NASAL INHALER QL=50 ML/30 Days

2fluticasone propionate 0.05mg/act nasal inhaler QL=32 GM/30 Days

NEUROMUSCULAR AGENTS ALS AGENTS

2riluzole 50mg tab

NUTRIENTS CARBOHYDRATES

2glucose 100mg/ml inj PA BvD

2glucose 50mg/ml inj LIPIDS

2INTRALIPID 20GM/100ML INJ PA BvD

4INTRALIPID 30GM/100ML INJ PA BvD

2NUTRILIPID 20GM/100ML INJ PA BvD PROTEINS

4AMINOSYN-PF 7% INJ PA BvD

3CLINIMIX 4.25/10 INJ PA BvD

3CLINIMIX 4.25/5 INJ PA BvD

3CLINIMIX 5/15 INJ PA BvD

3CLINIMIX 5/20 INJ PA BvD

3CLINIMIX E 2.75/5 INJ PA BvD

3CLINIMIX E 4.25/10 INJ PA BvD

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

90

Page 93: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

CLINIMIX E 4.25/5 INJ 3 PA BvD CLINIMIX E 5/15 INJ 3 PA BvD CLINIMIX E 5/20 INJ 3 PA BvD clinisol 15% inj 2 PA BvD FREAMINE 6.9% INJ 4 PA BvD HEPATAMINE 8% INJ 2 PA BvD NEPHRAMINE 5.4% INJ 4 PA BvD plenamine 15% inj 2 PA BvD PREMASOL 10% INJ 4 PA BvD PROCALAMINE 3% INJ 4 PA BvD PROSOL 20% INJ 4 PA BvD TRAVASOL 10% INJ 4 PA BvD TROPHAMINE 10% INJ 4 PA BvD

OPHTHALMIC AGENTS BETA-BLOCKERS - OPHTHALMIC

betaxolol 0.5% ophth soln 2 BETIMOL 0.25% OPHTH SOLN 4 BETIMOL 0.5% OPHTH SOLN 3 BETOPTIC S 0.25% OPHTH SUSP 4 CARTEOLOL 1% OPHTH SOLN 2 COMBIGAN 2-5MG/ML OPHTH SOLN 3 dorzolamide 20mg/ml/timolol 5mg/ml ophth soln 2 dorzolamide/timolol 22.3-6.8mg/ml ophth soln (preservative-free)

2

LEVOBUNOLOL 0.5% OPHTH SOLN 2 TIMOLOL 0.25% OPHTH GEL 3 timolol 0.25% ophth soln 1 TIMOLOL 0.5% OPHTH GEL 3 timolol 0.5% ophth soln 1 TIMOPTIC 0.25% OPHTH GEL 3 TIMOPTIC 0.25% OPHTH SOLN (PRESERVATIVE-FREE)

4

TIMOPTIC 0.5% OPHTH GEL 3 TIMOPTIC 0.5% OPHTH SOLN (PRESERVATIVE-FREE)

4

CYCLOPLEGIC MYDRIATICS ATROPINE SULFATE 1% OPHTH SOLN 2

MIOTICS PHOSPHOLINE IODIDE 0.125% OPHTH SOLN 3 pilocarpine 1% ophth soln 2 pilocarpine 2% ophth soln 2 pilocarpine 4% ophth soln 2

OPHTHALMIC ADRENERGIC AGENTS ALPHAGAN 0.1% OPHTH SOLN 4 apraclonidine 0.5% ophth soln 2 brimonidine tartrate 0.15% ophth soln 3

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

91

Page 94: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

brimonidine tartrate 0.2% ophth soln 2 IOPIDINE 1% OPHTH SOLN 4 SIMBRINZA 0.2-1% OPHTH SUSP 3

OPHTHALMIC ANTI-INFECTIVES AZASITE 1% OPHTH SOLN 3 BACITRACIN 0.5UNIT/MG OPHTH OINTMENT 2 bacitracin 0.5unit/mg/polymyxin b 10unit/mg ophth ointment

2 QL=7 GM/7 Days

CILOXAN 0.3% OPHTH OINTMENT 4 QL=7 GM/7 Days ciprofloxacin 0.3% ophth soln 2 QL=60 ML/30 Days erythromycin 0.5% ophth ointment 2 QL=7 GM/7 Days gatifloxacin 0.5% ophth soln 2 QL=5 ML/7 Days GENTAK 0.3% OPHTH OINTMENT 2 QL=7 GM/7 Days gentamicin 0.3% ophth soln 2 QL=10 ML/7 Days GRAMICIDIN 0.025MG/ML/NEOMYCIN 1.75MG/ML/POLYMYXIN B 10000UNIT/ML OPHTH SOLN

2 QL=10 ML/7 Days

levofloxacin 0.5% ophth soln 1 QL=60 ML/30 Days moxifloxacin 0.5% ophth soln 1 QL=6 ML/7 Days NATACYN 5% OPHTH SUSP 3 QL=15 ML/7 Days neomycin/bacitracin/polymyxin ophth ointment 5(3.5)mg-400unit-10000unit

2 QL=7 GM/7 Days

ofloxacin 0.3% ophth soln 2 QL=60 ML/30 Days polymyxin b 10000unit/ml/trimethoprim 1mg/ml ophth soln

1 QL=10 ML/7 Days

SULFACETAMIDE SODIUM 10% OPHTH OINTMENT 2 QL=7 GM/7 Days sulfacetamide sodium 10% ophth soln 2 QL=15 ML/7 Days tobramycin 0.3% ophth soln 2 QL=60 ML/30 Days TOBREX 0.3% OPHTH OINTMENT 4 QL=7 GM/7 Days TRIFLURIDINE 1% OPHTH SOLN 2 QL=15 ML/7 Days ZIRGAN 0.15% OPHTH GEL 3 QL=10 GM/7 Days

OPHTHALMIC IMMUNOMODULATORS RESTASIS 0.05% OPHTH SUSP 3

OPHTHALMIC KINASE INHIBITORS RHOPRESSA 0.02% OPHTH SOLN 3 QL=5 ML/30 Days ROCKLATAN 0.05-0.2MG/ML OPHTH SOLN 3 QL=5 ML/30 Days

OPHTHALMIC LOCAL ANESTHETICS proparacaine 0.5% ophth soln 2

OPHTHALMIC NERVE GROWTH FACTORS OXERVATE 0.002% OPHTH SOLN 5 NDS PA QL=112 ML/365 Days

OPHTHALMIC STEROIDS ALREX 0.2% OPHTH SUSP 3 BLEPHAMIDE 0.2-10% OPHTH OINTMENT 4 BLEPHAMIDE 0.2-10% OPHTH SUSP 4 DEXAMETHASONE PHOSPHATE 0.1% OPHTH SOLN

2

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

92

Page 95: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

dexamethasone/neomycin/polymyxin b 0.1% ophth 2 ointment dexamethasone/neomycin/polymyxin b 0.1% ophth 2 susp dexamethasone/tobramycin 0.3-0.1% ophth susp 2 DUREZOL 0.05% OPHTH SUSP 3 FLAREX 0.1% OPHTH SUSP 4 fluorometholone 0.1% ophth susp 2 FML 0.1% OPHTH OINTMENT 4 FML FORTE LIQUIFILM 0.25% OPHTH SUSP 4 hydrocortisone 10mg/ml/neomycin 3.5mg/ml/polymyxin b 10000unit/ml ophth susp

2

LOTEMAX 0.5% OPHTH GEL 3 LOTEMAX 0.5% OPHTH OINTMENT 3 loteprednol etabonate 0.5% ophth susp 1 MAXIDEX 0.1% OPHTH SUSP 3 neomycin/polymyxin/bacitracin/hydrocortisone ophth ointmentment 1%

2

PRED MILD 0.12% OPHTH SUSP 3 PRED-G 0.3-0.6% OPHTH OINTMENT 4 PRED-G 0.3-1% OPHTH SUSP 3 PREDNISOLONE 1% OPHTH SOLN 2 PREDNISOLONE ACETATE 1% OPHTH SUSP 2 PREDNISOLONE SODIUM PHOSPHATE 2.5MG/ML/SULFACETAMIDE SODIUM 100MG/ML OPHTH SOLN

2

TOBRADEX 0.05-0.3% OPHTH SUSP 4 TOBRADEX 0.1-0.3% OPHTH OINTMENT 3 ZYLET 0.5-0.3% OPHTH SUSP 3

OPHTHALMICS - MISC. ALOCRIL 2% OPHTH SOLN 3 ALOMIDE 0.1% OPHTH SOLN 3 azelastine 0.05% ophth soln 2 AZOPT 1% OPHTH SUSP 3 BEPREVE 1.5% OPHTH SOLN 4 bromfenac 0.09% ophth soln 2 cromolyn sodium 4% ophth soln 2 CYSTARAN 0.44% OPHTH SOLN 5 NDS PA QL=60 ML/30 Days diclofenac sodium 0.1% ophth soln 1 dorzolamide 2% ophth soln 1 epinastine 0.05% ophth soln 2 FLURBIPROFEN SODIUM 0.03% OPHTH SOLN 1 ILEVRO 0.3% OPHTH SUSP 3 ketorolac tromethamine 0.4% ophth soln 2 ketorolac tromethamine 0.5% ophth soln 1 LASTACAFT 0.25% OPHTH SOLN 4

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

93

Page 96: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

NEVANAC 0.1% OPHTH SUSP 3 olopatadine 0.1% ophth soln 1 olopatadine 0.2% ophth soln 1 PROLENSA 0.07% OPHTH SOLN 4

PROSTAGLANDINS - OPHTHALMIC bimatoprost 0.03% ophth soln 2 QL=5 ML/30 Days latanoprost 0.005% ophth soln 1 QL=5 ML/30 Days LUMIGAN 0.01% OPHTH SOLN 3 QL=5 ML/30 Days travoprost 0.004% ophth soln 2 QL=5 ML/30 Days ZIOPTAN 0.015MG/ML OPHTH SOLN 4 ST QL=30 EA/30 Days

OTIC AGENTS OTIC AGENTS - MISCELLANEOUS

acetic acid 2% otic soln 2 OTIC ANTI-INFECTIVES

CETRAXAL 0.2% OTIC SOLN 3 CIPROFLOXACIN 0.2% OTIC SOLN 3 ofloxacin 0.3% otic soln 2

OTIC COMBINATIONS CIPRO HC 0.2-1% OTIC SUSP 4 ciprofloxacin/dexamethasone 0.3-0.1% otic susp 2 hydrocortisone 10mg/ml/neomycin 2 3.5mg/ml/polymyxin b 10000unit/ml otic soln hydrocortisone 10mg/ml/neomycin 2 3.5mg/ml/polymyxin b 10000unit/ml otic susp

OTIC STEROIDS acetic acid/hydrocortisone 1-2% otic soln 2 flac 0.01% otic soln 2 fluocinolone acetonide 0.01% otic soln 2

PASSIVE IMMUNIZING AND TREATMENT AGENTS IMMUNE SERUMS

BIVIGAM 5GM/50ML INJ 5 NDS PA FLEBOGAMMA 5GM/50ML INJ 5 NDS PA GAMMAGARD 10GM INJ 5 NDS PA GAMMAGARD 2.5GM/25ML INJ 5 NDS PA GAMMAGARD 5GM INJ 5 NDS PA GAMMAKED 1GM/10ML INJ 5 NDS PA GAMMAPLEX 10GM/100ML INJ 5 NDS PA GAMMAPLEX 10GM/200ML INJ 5 NDS PA GAMMAPLEX 20GM/200ML INJ 5 NDS PA GAMMAPLEX 5GM/50ML INJ 5 NDS PA GAMUNEX 1GM/10ML INJ 5 NDS PA OCTAGAM 1GM/20ML INJ 5 NDS PA OCTAGAM 2GM/20ML INJ 5 NDS PA PANZYGA 10GM/100ML INJ 5 NDS PA PANZYGA 1GM/10ML INJ 5 NDS PA PANZYGA 2.5GM/25ML INJ 5 NDS PA

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

94

Page 97: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

PANZYGA 20GM/200ML INJ 5 NDS PA PANZYGA 30GM/300ML INJ 5 NDS PA PANZYGA 5GM/50ML INJ 5 NDS PA PRIVIGEN 20GM/200ML INJ 5 NDS PA VARIZIG 125UNIT/1.2ML INJ 5 NDS

PENICILLINS AMINOPENICILLINS

amoxicillin 125mg chew tab 1 amoxicillin 250mg cap 1 AMOXICILLIN 250MG CHEW TAB 2 amoxicillin 25mg/ml susp 1 amoxicillin 40mg/ml susp 1 amoxicillin 500mg cap 1 amoxicillin 500mg tab 1 amoxicillin 50mg/ml susp 1 amoxicillin 80mg/ml susp 1 amoxicillin 875mg tab 1 ampicillin 1000mg inj 2 ampicillin 100mg/ml inj 2 AMPICILLIN 125MG INJ 3 AMPICILLIN 500MG CAP 1

NATURAL PENICILLINS BICILLIN L-A 1200000UNIT/2ML SYRINGE 3 BICILLIN L-A 2400000UNIT/4ML SYRINGE 3 BICILLIN L-A 600000UNIT/ML SYRINGE 3 penicillin g potassium 1000000unit/ml inj 2 PENICILLIN G POTASSIUM 40000UNIT/ML INJ 2 PENICILLIN G POTASSIUM 60000UNIT/ML INJ 2 PENICILLIN G PROCAINE 600000UNIT/ML SYRINGE

3

PENICILLIN G SODIUM 100000UNIT/ML INJ 3 penicillin v potassium 250mg tab 1 PENICILLIN V POTASSIUM 25MG/ML ORAL SOLN 1 penicillin v potassium 500mg tab 1 PENICILLIN V POTASSIUM 50MG/ML ORAL SOLN 1

PENICILLIN COMBINATIONS AMOXICILLIN 1000MG/CLAVULANATE 62.5MG ER TAB

4

amoxicillin 120mg/ml/clavulanate 8.58mg/ml susp 2 AMOXICILLIN 200MG/CLAVULANATE 28.5MG CHEW TAB

3

amoxicillin 250mg/clavulanate 125mg tab 2 AMOXICILLIN 400MG/CLAVULANATE 57MG CHEW TAB

3

amoxicillin 40mg/ml/clavulanate 5.7mg/ml susp 2 amoxicillin 500mg/clavulanate 125mg tab 1

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

95

Page 98: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

amoxicillin 50mg/ml/clavulanate 12.5mg/ml susp 2 amoxicillin 80mg/ml/clavulanate 11.4mg/ml susp 2 amoxicillin 875mg/clavulanate 125mg tab 1 ampicillin 1000mg/sulbactam 500mg inj 2 ampicillin 100mg/ml/sulbactam 50mg/ml inj 2 ampicillin 2000mg/sulbactam 1000mg inj 2 BICILLIN 300000-300000UNIT/ML SYRINGE 3 BICILLIN 450000-150000UNIT/ML SYRINGE 3 piperacillin 2000mg/tazobactam 250mg inj 2 piperacillin 200mg/ml/tazobactam 25mg/ml inj 2 piperacillin 3000mg/tazobactam 375mg inj 2 piperacillin 4000mg/tazobactam 500mg inj 2 ZOSYN 2000-250MG INJ 4 ZOSYN 3000-375MG INJ 4

PENICILLINASE-RESISTANT PENICILLINS dicloxacillin 250mg cap 2 dicloxacillin 500mg cap 2 nafcillin 1000mg inj 2 nafcillin 100mg/ml inj 2 nafcillin 2000mg inj 2 oxacillin 1000mg inj 2 oxacillin 100mg/ml inj 2 oxacillin 2000mg inj 2 OXACILLIN 20MG/ML INJ 3 OXACILLIN 40MG/ML INJ 3

PROGESTINS PROGESTINS

medroxyprogesterone acetate 10mg tab 1 medroxyprogesterone acetate 2.5mg tab 1 medroxyprogesterone acetate 5mg tab 1 megestrol acetate 125mg/ml susp 2 PA norethindrone acetate 5mg tab 2 progesterone 100mg cap 2 progesterone 200mg cap 2

PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. AGENTS FOR CHEMICAL DEPENDENCY

acamprosate calcium 333mg dr tab 2 disulfiram 250mg tab 2 disulfiram 500mg tab 2 LUCEMYRA 0.18MG TAB 4 PA QL=168 EA/14 Days

ANTI-CATAPLECTIC AGENTS XYREM 500MG/ML ORAL SOLN 5 NDS PA QL=540 ML/30 Days

ANTIDEMENTIA AGENTS donepezil 10mg odt 2 QL=30 EA/30 Days donepezil 10mg tab 1 donepezil 23mg tab 2 QL=30 EA/30 Days

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

96

Page 99: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

donepezil 5mg odt 2 QL=30 EA/30 Days donepezil 5mg tab 1 galantamine 12mg tab 2 galantamine 4mg tab 2 galantamine 8mg tab 2 galantamine hydrobromide 16mg er cap 2 galantamine hydrobromide 24mg er cap 2 GALANTAMINE HYDROBROMIDE 4MG/ML ORAL SOLN

4

galantamine hydrobromide 8mg er cap 2 memantine 10mg tab 1 memantine 10mg/memantine 5mg pack 1 memantine 14mg er cap 2 memantine 21mg er cap 2 memantine 28mg er cap 2 memantine 2mg/ml oral soln 2 memantine 5mg tab 1 memantine 7mg er cap 2 NAMENDA 28 TITRATION PACK 4 rivastigmine 0.192mg/hr patch 2 rivastigmine 0.396mg/hr patch 2 rivastigmine 0.554mg/hr patch 2 rivastigmine 1.5mg cap 2 rivastigmine 3mg cap 2 rivastigmine 4.5mg cap 2 rivastigmine 6mg cap 2

COMBINATION PSYCHOTHERAPEUTICS AMITRIPTYLINE 10MG/PERPHENAZINE 2MG TAB 2 AMITRIPTYLINE 10MG/PERPHENAZINE 4MG TAB 2 amitriptyline 12.5mg/chlordiazepoxide 5mg tab 2 amitriptyline 25mg/chlordiazepoxide 10mg tab 2 AMITRIPTYLINE 25MG/PERPHENAZINE 2MG TAB 2 AMITRIPTYLINE 25MG/PERPHENAZINE 4MG TAB 2 AMITRIPTYLINE 50MG/PERPHENAZINE 4MG TAB 2 fluoxetine 25mg/olanzapine 12mg cap 2 fluoxetine 25mg/olanzapine 3mg cap 2 fluoxetine 25mg/olanzapine 6mg cap 2 fluoxetine 50mg/olanzapine 12mg cap 2 fluoxetine 50mg/olanzapine 6mg cap 2

FIBROMYALGIA AGENTS SAVELLA 100MG TAB 3 QL=60 EA/30 Days SAVELLA 12.5MG TAB 3 QL=60 EA/30 Days SAVELLA 25MG TAB 3 QL=60 EA/30 Days SAVELLA 4-WEEK TITRATION PACK 3 SAVELLA 50MG TAB 3 QL=60 EA/30 Days

MOVEMENT DISORDER DRUG THERAPY

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

97

Page 100: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

AUSTEDO 12MG TAB 5 NDS PA AUSTEDO 6MG TAB 5 NDS PA AUSTEDO 9MG TAB 5 NDS PA INGREZZA 40MG CAP 5 NDS PA INGREZZA 80MG CAP 5 NDS PA tetrabenazine 12.5mg tab 2 PA tetrabenazine 25mg tab 2 PA

MULTIPLE SCLEROSIS AGENTS AUBAGIO 14MG TAB 5 NDS AUBAGIO 7MG TAB 5 NDS AVONEX 30MCG/0.5ML AUTO-INJECTOR 5 NDS AVONEX 30MCG/0.5ML SYRINGE 5 NDS dalfampridine 10mg er tab 3 QL=60 EA/30 Days EXTAVIA 0.3MG INJ 5 NDS GILENYA 0.5MG CAP 5 NDS glatiramer acetate 20mg/ml syringe 2 PA glatiramer acetate 40mg/ml syringe 2 PA glatopa 20mg/ml syringe 2 PA glatopa 40mg/ml syringe 2 PA MAYZENT 0.25MG TAB 5 NDS MAYZENT 2MG TAB 5 NDS PLEGRIDY 125MCG/0.5ML AUTO-INJECTOR 5 NDS PLEGRIDY 125MCG/0.5ML SYRINGE 5 NDS PLEGRIDY PEN STARTER PACK 5 NDS PLEGRIDY STARTER PACK 5 NDS REBIF 22MCG/0.5ML AUTO-INJECTOR 5 NDS QL=6 ML/30 Days REBIF 22MCG/0.5ML SYRINGE 5 NDS QL=6 ML/30 Days REBIF 44MCG/0.5ML AUTO-INJECTOR 5 NDS QL=6 ML/30 Days REBIF 44MCG/0.5ML SYRINGE 5 NDS QL=6 ML/30 Days REBIF REBIDOSE PACK 5 NDS QL=6 ML/30 Days REBIF TITRATION PACK 5 NDS QL=6 ML/30 Days TECFIDERA 120MG DR CAP 5 NDS TECFIDERA 240MG DR CAP 5 NDS TECFIDERA 30-DAY STARTER PACK 5 NDS

PSEUDOBULBAR AFFECT (PBA) AGENTS NUEDEXTA 20-10MG CAP 3 PA QL=60 EA/30 Days

PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. ERGOLOID MESYLATES USP 1MG TAB 4 PIMOZIDE 1MG TAB 3 PIMOZIDE 2MG TAB 3

SMOKING DETERRENTS bupropion 150mg sr tab 2 CHANTIX 0.5MG TAB 3 CHANTIX 1MG TAB 3 CHANTIX CONTINUING MONTHS OF THERAPY 1MG PACK

3

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

98

Page 101: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

3CHANTIX FIRST MONTH OF THERAPY PACK

3NICOTROL 10MG INH SOLN

3NICOTROL 10MG/ML NASAL INHALER TRANSTHYRETIN AMYLOIDOSIS AGENTS

5TEGSEDI 284MG/1.5ML SYRINGE NDS PA QL=6 ML/28 Days

RESPIRATORY AGENTS - MISC. ALPHA-PROTEINASE INHIBITOR (HUMAN)

5ARALAST 1000MG INJ NDS

5GLASSIA 1000MG/50ML INJ NDS PA

5PROLASTIN 1000MG INJ NDS PA

5ZEMAIRA 1000MG INJ NDS CYSTIC FIBROSIS AGENTS

5KALYDECO 150MG TAB NDS PA QL=60 EA/30 Days

5KALYDECO 25MG GRANULES NDS PA QL=60 EA/30 Days

5KALYDECO 50MG GRANULES NDS PA QL=60 EA/30 Days

5KALYDECO 75MG GRANULES NDS PA QL=60 EA/30 Days

5ORKAMBI 125-100MG GRANULES NDS PA QL=60 EA/30 Days

5ORKAMBI 125-100MG TAB NDS PA QL=120 EA/30 Days

5ORKAMBI 125-200MG TAB NDS PA QL=120 EA/30 Days

5ORKAMBI 188-150MG GRANULES NDS PA QL=60 EA/30 Days

5PULMOZYME 1MG/ML INH SOLN NDS PA BvD

5SYMDEKO 50-75MG/75MG PACK NDS PA QL=60 EA/30 Days

5SYMDEKO TAB 4-WEEK PACK NDS PA QL=60 EA/30 Days

5TRIKAFTA 100-50-75MG/150MG PACK NDS PA QL=90 EA/30 Days PULMONARY FIBROSIS AGENTS

5ESBRIET 267MG CAP NDS PA

5ESBRIET 267MG TAB NDS PA

5ESBRIET 801MG TAB NDS PA

5OFEV 100MG CAP NDS PA

5OFEV 150MG CAP NDS PA

SULFONAMIDES SULFONAMIDES

3SULFADIAZINE 500MG TAB

TETRACYCLINES AMINOMETHYLCYCLINES

5NUZYRA 150MG TAB NDS PA QL=30 EA/14 Days GLYCYLCYCLINES

5TIGECYCLINE 50MG INJ NDS TETRACYCLINES

2demeclocycline 150mg tab

2demeclocycline 300mg tab

2doxy 100mg inj

2doxycycline hyclate 100mg cap

1doxycycline hyclate 100mg tab

1doxycycline hyclate 20mg tab

1doxycycline hyclate 50mg cap

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

99

Page 102: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

doxycycline monohydrate 100mg cap 1 doxycycline monohydrate 100mg tab 1 doxycycline monohydrate 50mg cap 1 doxycycline monohydrate 50mg tab 1 doxycycline monohydrate 5mg/ml susp 2 minocycline 100mg cap 1 minocycline 100mg tab 2 minocycline 50mg cap 1 minocycline 50mg tab 2 minocycline 75mg cap 1 minocycline 75mg tab 2 mondoxyne 100mg cap 1 tetracycline 250mg cap 2 tetracycline 500mg cap 2 VIBRAMYCIN 50MG/5ML SUSP 4

THYROID AGENTS ANTITHYROID AGENTS

methimazole 10mg tab 1 methimazole 5mg tab 1 propylthiouracil 50mg tab 2

THYROID HORMONES euthyrox 100mcg tab 1 euthyrox 112mcg tab 1 euthyrox 125mcg tab 1 euthyrox 137mcg tab 1 euthyrox 150mcg tab 1 euthyrox 175mcg tab 1 euthyrox 200mcg tab 1 euthyrox 25mcg tab 1 euthyrox 50mcg tab 1 euthyrox 75mcg tab 1 euthyrox 88mcg tab 1 levo-t 100mcg tab 1 levo-t 112mcg tab 1 levo-t 125mcg tab 1 levo-t 137mcg tab 1 levo-t 150mcg tab 1 levo-t 175mcg tab 1 levo-t 200mcg tab 1 levo-t 25mcg tab 1 levo-t 300mcg tab 1 levo-t 50mcg tab 1 levo-t 75mcg tab 1 levo-t 88mcg tab 1 levothyroxine sodium 0.025mg tab 1 levothyroxine sodium 0.05mg tab 1

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

100

Page 103: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

levothyroxine sodium 0.075mg tab 1 levothyroxine sodium 0.088mg tab 1 levothyroxine sodium 0.112mg tab 1 levothyroxine sodium 0.125mg tab 1 levothyroxine sodium 0.137mg tab 1 levothyroxine sodium 0.15mg tab 1 levothyroxine sodium 0.175mg tab 1 levothyroxine sodium 0.1mg tab 1 levothyroxine sodium 0.2mg tab 1 levothyroxine sodium 0.3mg tab 1 levoxyl 100mcg tab 1 levoxyl 112mcg tab 1 levoxyl 125mcg tab 1 levoxyl 137mcg tab 1 levoxyl 150mcg tab 1 levoxyl 175mcg tab 1 levoxyl 200mcg tab 1 levoxyl 25mcg tab 1 levoxyl 50mcg tab 1 levoxyl 75mcg tab 1 levoxyl 88mcg tab 1 liothyronine sodium 0.005mg tab 2 liothyronine sodium 0.025mg tab 2 liothyronine sodium 0.05mg tab 2 SYNTHROID 100MCG TAB 4 SYNTHROID 112MCG TAB 4 SYNTHROID 125MCG TAB 4 SYNTHROID 137MCG TAB 4 SYNTHROID 150MCG TAB 4 SYNTHROID 175MCG TAB 4 SYNTHROID 200MCG TAB 4 SYNTHROID 25MCG TAB 4 SYNTHROID 300MCG TAB 4 SYNTHROID 50MCG TAB 4 SYNTHROID 75MCG TAB 4 SYNTHROID 88MCG TAB 4 unithroid 100mcg tab 1 unithroid 112mcg tab 1 unithroid 125mcg tab 1 unithroid 150mcg tab 1 unithroid 175mcg tab 1 unithroid 200mcg tab 1 unithroid 25mcg tab 1 unithroid 300mcg tab 1 unithroid 50mcg tab 1 unithroid 75mcg tab 1

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

101

Page 104: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

unithroid 88mcg tab 1 TOXOIDS

TOXOID COMBINATIONS ADACEL INJ 3 ADACEL SYRINGE 3 BOOSTRIX INJ 3 BOOSTRIX SYRINGE 3 DAPTACEL INJ 3 DIPHTHERIA/TETANUS TOXOID INJ 3 PA BvD INFANRIX INJ 3 KINRIX INJ 3 KINRIX PF INJ 3 PEDIARIX INJ 3 QUADRACEL INJ 3 TDVAX 4-4UNIT/ML INJ 3 PA BvD TENIVAC 4-10UNIT/ML SYRINGE 3 PA BvD

ULCER DRUGS ANTISPASMODICS

CUVPOSA 1MG/5ML ORAL SOLN 4 dicyclomine 10mg cap 1 dicyclomine 20mg tab 1 glycopyrrolate 1mg tab 2 glycopyrrolate 2mg tab 2

H-2 ANTAGONISTS cimetidine 200mg tab 2 cimetidine 300mg tab 2 cimetidine 400mg tab 2 cimetidine 800mg tab 2 famotidine 20mg tab 2 famotidine 8mg/ml susp 2

MISC. ANTI-ULCER sucralfate 1000mg tab 1

PROTON PUMP INHIBITORS esomeprazole 20mg dr cap 3 lansoprazole 15mg dr cap 2 lansoprazole 30mg dr cap 2 NEXIUM 2.5MG GRANULES FOR ORAL SUSP 4 NEXIUM 5MG GRANULES FOR ORAL SUSP 4 omeprazole 20mg dr cap 2 pantoprazole 20mg dr tab 1 rabeprazole sodium 20mg dr tab 2

ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS ANTISPASMODICS

dicyclomine 2mg/ml oral soln 2 METHSCOPOLAMINE BROMIDE 2.5MG TAB 2 METHSCOPOLAMINE BROMIDE 5MG TAB 2

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

102

Page 105: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

H-2 ANTAGONISTS CIMETIDINE 60MG/ML ORAL SOLN 2 famotidine 40mg tab 2 nizatidine 150mg cap 2 nizatidine 300mg cap 2

MISC. ANTI-ULCER sucralfate 100mg/ml susp 2

PROTON PUMP INHIBITORS esomeprazole 10mg granules for oral susp 4 esomeprazole 20mg granules for oral susp 4 esomeprazole 40mg dr cap 3 esomeprazole 40mg granules for oral susp 4 NEXIUM 10MG GRANULES FOR ORAL SUSP 4 NEXIUM 20MG GRANULES FOR ORAL SUSP 4 NEXIUM 40MG GRANULES FOR ORAL SUSP 4 omeprazole 10mg dr cap 1 omeprazole 40mg dr cap 2 pantoprazole 40mg dr tab 1

ULCER DRUGS - PROSTAGLANDINS misoprostol 0.1mg tab 2 misoprostol 0.2mg tab 2

ULCER THERAPY COMBINATIONS amoxicillin 500mg/clarithromycin 500mg/lansoprazole 30mg pack

2

PYLERA 140-125-125MG CAP 4 URINARY ANTI-INFECTIVES URINARY ANTI-INFECTIVES

methenamine hippurate 1000mg tab 2 MONUROL 5.631GM POWDER FOR ORAL SOLN 4 nitrofurantoin macro 25mg/nitrofurantoin mono 75mg cap

2

nitrofurantoin macrocrystals 100mg cap 2 nitrofurantoin macrocrystals 50mg cap 2

URINARY ANTISPASMODICS URINARY ANTISPASMODIC - ANTIMUSCARINICS (ANTICHOLINERGIC)

darifenacin 15mg er tab 2 darifenacin 7.5mg er tab 2 oxybutynin chloride 10mg er tab 2 oxybutynin chloride 15mg er tab 2 oxybutynin chloride 1mg/ml oral soln 2 oxybutynin chloride 5mg er tab 2 oxybutynin chloride 5mg tab 2 solifenacin succinate 10mg tab 1 solifenacin succinate 5mg tab 1 tolterodine tartrate 1mg tab 2 tolterodine tartrate 2mg er cap 2

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

103

Page 106: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

tolterodine tartrate 2mg tab 2 tolterodine tartrate 4mg er cap 2 trospium chloride 20mg tab 2 trospium chloride 60mg er cap 2

URINARY ANTISPASMODICS - BETA-3 ADRENERGIC AGONISTS MYRBETRIQ 25MG ER TAB 3 MYRBETRIQ 50MG ER TAB 3

URINARY ANTISPASMODICS - CHOLINERGIC AGONISTS bethanechol chloride 10mg tab 1 bethanechol chloride 25mg tab 1 bethanechol chloride 50mg tab 1 bethanechol chloride 5mg tab 1

URINARY ANTISPASMODICS - DIRECT MUSCLE RELAXANTS flavoxate 100mg tab 2

VACCINES BACTERIAL VACCINES

ACTHIB INJ 3 BCG LIVE TICE STRAIN 50MG INJ 3 BEXSERO SYRINGE 3 HIBERIX 10MCG INJ 3 MENACTRA INJ 3 MENVEO INJ 3 PEDVAXHIB 7.5MCG/0.5ML INJ 3 TRUMENBA SYRINGE 3 TYPHIM VI 25MCG/0.5ML INJ 3 TYPHIM VI 25MCG/0.5ML SYRINGE 3

VIRAL VACCINES ENGERIX-B 10MCG/0.5ML SYRINGE 3 PA BvD ENGERIX-B 20MCG/ML SYRINGE 3 PA BvD GARDASIL 9 INJ 3 PA GARDASIL 9 SYRINGE 3 PA HAVRIX 1440ELU/ML INJ 3 HAVRIX 1440ELU/ML SYRINGE 3 HAVRIX 720ELU/0.5ML SYRINGE 3 IMOVAX 2.5UNIT/ML INJ 3 PA BvD IPOL INJ 3 IXIARO 0.012MG/ML SYRINGE 3 M-M-R II INJ 3 PROQUAD INJ 3 RABAVERT 2.5UNIT/ML INJ 3 PA BvD RECOMBIVAX 10MCG/ML INJ 3 PA BvD RECOMBIVAX 10MCG/ML SYRINGE 3 PA BvD RECOMBIVAX 40MCG/ML INJ 3 PA BvD RECOMBIVAX 5MCG/0.5ML SYRINGE 3 PA BvD ROTARIX SUSP 3 ROTATEQ SUSP 3

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

104

Page 107: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

DRUG NAME DRUG TIER REQUIREMENTS/LIMITS

SHINGRIX 50MCG/0.5ML INJ 3 TWINRIX 720UNIT SYRINGE 3 VAQTA 25UNIT/0.5ML INJ 3 VAQTA 25UNIT/0.5ML SYRINGE 3 VAQTA 50UNIT/ML INJ 3 VAQTA 50UNIT/ML SYRINGE 3 VARIVAX 1350PFU/0.5ML INJ 3 YF-VAX 4000UNIT/ML INJ 3

VAGINAL AND RELATED PRODUCTS VAGINAL ANTI-INFECTIVES

CLEOCIN 100MG VAGINAL INSERT 4 clindamycin 2% vaginal cream 2 CLINDESSE 2% VAGINAL CREAM 4 metronidazole 0.75% vaginal gel 2 MICONAZOLE NITRATE 200MG VAGINAL INSERT 4 terconazole 0.4% vaginal cream 2 TERCONAZOLE 0.8% VAGINAL CREAM 2 terconazole 80mg vaginal insert 2 vandazole 0.75% vaginal gel 2

VAGINAL ESTROGENS estradiol 0.01% vaginal cream 2 estradiol 0.01mg vaginal insert 2 PREMARIN 0.625MG/GM VAGINAL CREAM 3 yuvafem 10mcg vaginal insert 2

VAGINAL PROGESTINS CRINONE 4% VAGINAL GEL 3 PA CRINONE 8% VAGINAL GEL 3 PA

VASOPRESSORS ANAPHYLAXIS THERAPY AGENTS

epinephrine 0.5mg/ml auto-injector 2 QL=2 EA/15 Days epinephrine 1mg/ml auto-injector 2 QL=2 EA/15 Days SYMJEPI 0.15MG/0.3ML SYRINGE 3 QL=2 EA/15 Days SYMJEPI 0.3MG/0.3ML SYRINGE 3 QL=2 EA/15 Days

NEUROGENIC ORTHOSTATIC HYPOTENSION (NOH) - AGENTS NORTHERA 100MG CAP 5 NDS PA NORTHERA 200MG CAP 5 NDS PA NORTHERA 300MG CAP 5 NDS PA

VASOPRESSORS midodrine 10mg tab 2 midodrine 2.5mg tab 2 midodrine 5mg tab 2

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

105

Page 108: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

ALPHABETICAL LISTING OF DRUGS

A

abacavir 20mg/ml oral solnabacavir 300mg tababacavir 300mg/lamivudine 150mg/zidovudine 300mg tababacavir 600mg/lamivudine 300mg tabABELCET 5MG/ML INJABILIFY 300MG INJABILIFY 300MG SYRINGEABILIFY 400MG INJABILIFY 400MG SYRINGEabiraterone acetate 250mg tabacamprosate calcium 333mg dr tabacarbose 100mg tabacarbose 25mg tabacarbose 50mg tabacebutolol 200mg capacebutolol 400mg capacetaminophen 21.7mg/ml/hydrocodone bitartrate 0.5mg/ml oral solnacetaminophen 24mg/ml/codeine phosphate 2.4mg/ml oral solnacetaminophen 300mg/codeine phosphate 15mg tabacetaminophen 300mg/codeine phosphate 30mg tabacetaminophen 300mg/codeine

55

55 55

55

34 54 54

54 54

44

96

30 30 30 58 58 14

14

14

14

14

acetaminophen 300mg/hydrocodone bitartrate 10mg tabacetaminophen 300mg/hydrocodone bitartrate 5mg tabacetaminophen 300mg/hydrocodone bitartrate 7.5mg tabacetaminophen 325mg/hydrocodone bitartrate 10mg tabacetaminophen 325mg/hydrocodone bitartrate 5mg tabacetaminophen 325mg/hydrocodone bitartrate 7.5mg tabacetaminophen 325mg/oxycodone 10mg tabacetaminophen 325mg/oxycodone 2.5mg tabacetaminophen 325mg/oxycodone 5mg tabacetaminophen 325mg/oxycodone 7.5mg tabacetaminophen 325mg/tramadol 37.5mg tabacetazolamide 125mg tabacetazolamide 250mg tabacetazolamide 500mg er capacetic acid 2% otic solnacetic acid/hydrocortisone 1-2% otic solnacetylcysteine 100mg/ml inh soln

14

14

14

14

14

14

14

14

14

14

14

74 74 74

94 94

69

acetylcysteine 200mg/ml 69 inh solnacitretin 10mg cap 71 acitretin 17.5mg cap 71 acitretin 25mg cap 71 ACTEMRA 11 162MG/0.9ML AUTO-INJECTORACTEMRA 11 162MG/0.9ML SYRINGEACTHIB INJ 104 ACTIMMUNE 48 2000000UNIT/0.5ML INJacyclovir 200mg cap 57 acyclovir 400mg tab 57 acyclovir 40mg/ml susp 57 acyclovir 5% cream 71 acyclovir 5% ointment 71 acyclovir 50mg/ml inj 57 acyclovir 800mg tab 57 ADACEL INJ 102 ADACEL SYRINGE 102 adapalene 0.1% cream 69 adapalene 0.1% gel 69 adapalene 0.3% gel 69 adapalene/benzoyl 69 peroxide 0.1-2.5% geladefovir dipivoxil 10mg 57 tabADEMPAS 0.5MG TAB 62 ADEMPAS 1.5MG TAB 63 ADEMPAS 1MG TAB 63 ADEMPAS 2.5MG TAB 63 ADEMPAS 2MG TAB 63 ADVAIR 0.045-0.021MG 20 INHADVAIR 0.115-0.021MG 20 INHADVAIR 0.23-0.021MG 20 INHAFINITOR 10MG TAB 45 AFINITOR 2MG TAB FOR 45 ORAL SUSP

phosphate 60mg tab

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

106

Page 109: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

ALPHABETICAL LISTING OF DRUGS

AFINITOR 3MG TAB FOR 45 aliskiren 300mg tab 40 amabelz 1/0.5mg 28 day 78 ORAL SUSP allopurinol 100mg tab 82 packAFINITOR 5MG TAB FOR 45 allopurinol 300mg tab 82 amantadine 100mg cap 50 ORAL SUSP ALOCRIL 2% OPHTH 93 amantadine 100mg tab 50 AIMOVIG 140MG/ML 86 SOLN amantadine 10mg/ml oral 49 AUTO-INJECTOR ALOMIDE 0.1% OPHTH 93 solnAIMOVIG 70MG/ML 86 SOLN AMBISOME 50MG INJ 34 AUTO-INJECTOR ALORA 0.025MG/24HR 78 ambrisentan 10mg tab 62 ala-cort 1% cream 72 PATCH ambrisentan 5mg tab 62 albendazole 200mg tab 16 ALORA 0.05MG/24HR 78 amethia 91 day pack 64 albuterol 0.21mg/ml inh 20 PATCH amikacin 250mg/ml inj 9 soln ALORA 0.075MG/24HR 78 amiloride 5mg tab 75 albuterol 0.417mg/ml inh 20 PATCH amiloride 74 soln ALORA 0.1MG/24HR 78 5mg/hydrochlorothiazide albuterol 0.4mg/ml oral 20 PATCH 50mg tabsoln alosetron 0.5mg tab 81 AMINOSYN-PF 7% INJ 90 albuterol 0.83mg/ml inh 20 alosetron 1mg tab 81 amiodarone 100mg tab 18 soln ALPHAGAN 0.1% 91 amiodarone 200mg tab 18 albuterol 2mg tab 20 OPHTH SOLN amiodarone 400mg tab 18 ALBUTEROL 4MG ER 20 alprazolam 0.25mg odt 17 AMITIZA 24MCG CAP 80 TAB alprazolam 0.25mg tab 17 AMITIZA 8MCG CAP 80 albuterol 4mg tab 20 alprazolam 0.5mg er tab 17 amitriptyline 100mg tab 29 albuterol 5mg/ml inh soln 20 alprazolam 0.5mg odt 17 amitriptyline 10mg tab 29 ALBUTEROL 8MG ER 20 alprazolam 0.5mg tab 17 AMITRIPTYLINE 97 TAB alprazolam 1mg er tab 17 10MG/PERPHENAZINE alclometasone 72 alprazolam 1mg odt 17 2MG TABdipropionate 0.05% alprazolam 1mg tab 17 AMITRIPTYLINE 97 cream ALPRAZOLAM 1MG/ML 17 10MG/PERPHENAZINE alclometasone 72 ORAL SOLN 4MG TABdipropionate 0.05% alprazolam 2mg er tab 17 amitriptyline 97 ointment alprazolam 2mg odt 17 12.5mg/chlordiazepoxide ALDACTAZIDE 50-50MG 74 alprazolam 2mg tab 17 5mg tabTAB alprazolam 3mg er tab 17 amitriptyline 150mg tab 29 ALECENSA 150MG CAP 45 ALREX 0.2% OPHTH 92 amitriptyline 25mg tab 29 ALENDRONIC ACID 75 SUSP amitriptyline 97 0.933MG/ML ORAL altavera 28 day pack 64 25mg/chlordiazepoxide SOLN ALUNBRIG 180MG TAB 45 10mg tabalendronic acid 10mg tab 75 ALUNBRIG 30MG TAB 45 AMITRIPTYLINE 97 alendronic acid 35mg tab 75 ALUNBRIG 90MG TAB 45 25MG/PERPHENAZINE alendronic acid 70mg tab 76 ALUNBRIG INITIATION 45 2MG TABalfuzosin 10mg er tab 81 PACK AMITRIPTYLINE 97 ALINIA 100MG/5ML 41 alyacen 1/35 28 day pack 64 25MG/PERPHENAZINE SUSP alyq 20mg tab 62 4MG TABALINIA 500MG TAB 41 amabelz 0.5/0.1mg 28 day 78 amitriptyline 50mg tab 29 aliskiren 150mg tab 40 pack

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

107

Page 110: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

ALPHABETICAL LISTING OF DRUGS

AMITRIPTYLINE 97 amlodipine 39 amlodipine 39 50MG/PERPHENAZINE 10mg/valsartan 320mg 5mg/olmesartan 4MG TAB tab medoxomil 20mg tabamitriptyline 75mg tab 29 amlodipine 2.5mg tab 60 amlodipine 39 amlodipine 10mg tab 60 amlodipine 62 5mg/olmesartan amlodipine 62 2.5mg/atorvastatin 10mg medoxomil 40mg tab10mg/atorvastatin 10mg tab amlodipine 39 tab amlodipine 62 5mg/valsartan 160mg tabamlodipine 62 2.5mg/atorvastatin 20mg amlodipine 39 10mg/atorvastatin 20mg tab 5mg/valsartan 320mg tabtab amlodipine 62 ammonium lactate 12% 73 amlodipine 62 2.5mg/atorvastatin 40mg cream10mg/atorvastatin 40mg tab ammonium lactate 12% 73 tab amlodipine 39 lotionamlodipine 62 2.5mg/benazepril 10mg amnesteem 10mg cap 69 10mg/atorvastatin 80mg cap amnesteem 20mg cap 69 tab amlodipine 5mg tab 60 amnesteem 40mg cap 69 amlodipine 38 amlodipine 62 AMOXAPINE 100MG 29 10mg/benazepril 20mg 5mg/atorvastatin 10mg TABcap tab AMOXAPINE 150MG 29 amlodipine 38 amlodipine 62 TAB10mg/benazepril 40mg 5mg/atorvastatin 20mg AMOXAPINE 25MG TAB 29 cap tab AMOXAPINE 50MG TAB 29 amlodipine 38 amlodipine 62 AMOXICILLIN 95 10mg/hydrochlorothiazid 5mg/atorvastatin 40mg 1000MG/CLAVULANAT e 12.5mg/valsartan tab E 62.5MG ER TAB160mg tab amlodipine 62 amoxicillin 95 amlodipine 39 5mg/atorvastatin 80mg 120mg/ml/clavulanate 10mg/hydrochlorothiazid tab 8.58mg/ml suspe 25mg/valsartan 160mg amlodipine 39 amoxicillin 125mg chew 95 tab 5mg/benazepril 10mg cap tabamlodipine 39 amlodipine 39 AMOXICILLIN 95 10mg/hydrochlorothiazid 5mg/benazepril 20mg cap 200MG/CLAVULANATE e 25mg/valsartan 320mg amlodipine 39 28.5MG CHEW TABtab 5mg/benazepril 40mg cap amoxicillin 250mg cap 95 amlodipine 39 amlodipine 39 AMOXICILLIN 250MG 95 10mg/olmesartan 5mg/hydrochlorothiazide CHEW TABmedoxomil 20mg tab 12.5mg/valsartan 160mg amoxicillin 95 amlodipine 39 tab 250mg/clavulanate 10mg/olmesartan amlodipine 39 125mg tabmedoxomil 40mg tab 5mg/hydrochlorothiazide amoxicillin 25mg/ml susp 95 amlodipine 39 25mg/valsartan 160mg AMOXICILLIN 95 10mg/valsartan 160mg tab 400MG/CLAVULANATE tab 57MG CHEW TAB

amoxicillin 40mg/ml susp 95

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

108

Page 111: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

ALPHABETICAL LISTING OF DRUGS

amoxicillin 95 ampicillin 96 aprepitant 80mg cap 34 40mg/ml/clavulanate 1000mg/sulbactam apri 28 day pack 64 5.7mg/ml susp 500mg inj APTIOM 200MG TAB 23 amoxicillin 500mg cap 95 ampicillin 100mg/ml inj 95 APTIOM 400MG TAB 23 amoxicillin 500mg tab 95 ampicillin 96 APTIOM 600MG TAB 23 amoxicillin 103 100mg/ml/sulbactam APTIOM 800MG TAB 23 500mg/clarithromycin 50mg/ml inj APTIVUS 100MG/ML 55 500mg/lansoprazole AMPICILLIN 125MG INJ 95 ORAL SOLN30mg pack ampicillin 96 APTIVUS 250MG CAP 55 amoxicillin 95 2000mg/sulbactam ARALAST 1000MG INJ 99 500mg/clavulanate 1000mg inj aranelle 28 pack 64 125mg tab AMPICILLIN 500MG 95 ARANESP 83 amoxicillin 50mg/ml susp 95 CAP 100MCG/0.5ML amoxicillin 96 ANADROL-50 50MG 15 SYRINGE50mg/ml/clavulanate TAB ARANESP 100MCG/ML 83 12.5mg/ml susp anagrelide 0.5mg cap 82 INJamoxicillin 80mg/ml susp 95 anagrelide 1mg cap 82 ARANESP 83 amoxicillin 96 anastrozole 1mg tab 44 10MCG/0.4ML SYRINGE80mg/ml/clavulanate ANDRODERM 15 ARANESP 83 11.4mg/ml susp 2MG/24HR PATCH 150MCG/0.3ML amoxicillin 875mg tab 95 ANDRODERM 15 SYRINGEamoxicillin 96 4MG/24HR PATCH ARANESP 83 875mg/clavulanate ANGELIQ 0.25/0.5MG 28 78 200MCG/0.4ML 125mg tab DAY PACK SYRINGEamphetamine 10mg er 8 ANGELIQ 0.5/1MG 28 78 ARANESP 200MCG/ML 83 cap DAY PACK INJamphetamine 10mg tab 8 ANORO 0.0625-0.025MG 20 ARANESP 83 amphetamine 12.5mg tab 8 INH 25MCG/0.42ML amphetamine 15mg er 8 ANTARA 30MG CAP 35 SYRINGEcap ANTARA 90MG CAP 35 ARANESP 25MCG/ML 83 amphetamine 15mg tab 8 APLENZIN 174MG ER 26 INJamphetamine 20mg er 8 TAB ARANESP 83 cap APLENZIN 348MG ER 26 300MCG/0.6ML amphetamine 20mg tab 8 TAB SYRINGEamphetamine 25mg er 8 APLENZIN 522MG ER 26 ARANESP 300MCG/ML 83 cap TAB INJamphetamine 30mg er 8 APOKYN 30MG/3ML 50 ARANESP 83 cap CARTRIDGE 40MCG/0.4ML SYRINGEamphetamine 30mg tab 8 apraclonidine 0.5% ophth 91 ARANESP 40MCG/ML 83 amphetamine 5mg er cap 8 soln INJamphetamine 5mg tab 8 aprepitant 125mg cap 34 ARANESP 500MCG/ML 83 amphetamine 7.5mg tab 8 aprepitant 34 SYRINGEAMPHOTERICIN B 34 125mg/aprepitant 80mg ARANESP 83 50MG INJ pack 60MCG/0.3ML SYRINGEampicillin 1000mg inj 95 aprepitant 40mg cap 34

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

109

Page 112: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

ALPHABETICAL LISTING OF DRUGS

ARANESP 60MCG/ML 83 ASMANEX 220MCG 19 ATRIPLA 55 INJ (60ACT) INH 600-200-300MG TABARCALYST 220MG INJ 11 ASMANEX 50MCG HFA 19 atropine sulfate 33 ARIKAYCE 9 INH 0.005mg/ml/diphenoxylat 590MG/8.4ML INH SUSP aspirin 82 e 0.5mg/ml oral solnaripiprazole 10mg odt 54 25mg/dipyridamole atropine sulfate 33 aripiprazole 10mg tab 54 200mg er cap 0.025mg/diphenoxylate aripiprazole 15mg odt 54 ASPIRIN 15 2.5mg tabaripiprazole 15mg tab 54 325MG/OXYCODONE ATROPINE SULFATE 1% 91 aripiprazole 1mg/ml oral 54 4.84MG TAB OPHTH SOLNsoln ASTAGRAF 0.5MG ER 88 ATROVENT 17MCG INH 19 aripiprazole 20mg tab 54 CAP AUBAGIO 14MG TAB 98 aripiprazole 2mg tab 54 ASTAGRAF 1MG ER CAP 88 AUBAGIO 7MG TAB 98 aripiprazole 30mg tab 54 ASTAGRAF 5MG ER CAP 88 aubra 28 day pack 64 aripiprazole 5mg tab 54 atazanavir 150mg cap 55 AURYXIA 210MG TAB 81 ARISTADA 54 atazanavir 200mg cap 55 AUSTEDO 12MG TAB 98 1064MG/3.9ML atazanavir 300mg cap 55 AUSTEDO 6MG TAB 98 SYRINGE atenolol 100mg tab 58 AUSTEDO 9MG TAB 98 ARISTADA 54 atenolol 39 AVANDIA 2MG TAB 32 441MG/1.6ML SYRINGE 100mg/chlorthalidone AVANDIA 4MG TAB 32 ARISTADA 54 25mg tab aviane 28 pack 64 662MG/2.4ML SYRINGE atenolol 25mg tab 58 avita 0.025% cream 69 ARISTADA 54 atenolol 50mg tab 59 avita 0.025% gel 69 675MG/2.4ML SYRINGE atenolol 39 AVONEX 30MCG/0.5ML 98 ARISTADA 54 50mg/chlorthalidone AUTO-INJECTOR882MG/3.2ML SYRINGE 25mg tab AVONEX 30MCG/0.5ML 98 armodafinil 150mg tab 8 atomoxetine 100mg cap 8 SYRINGEarmodafinil 200mg tab 8 atomoxetine 10mg cap 8 AVYCAZ 500-2000MG 63 armodafinil 250mg tab 8 atomoxetine 18mg cap 8 INJarmodafinil 50mg tab 8 atomoxetine 25mg cap 8 AYVAKIT 100MG TAB 45 ARNUITY 100MCG INH 19 atomoxetine 40mg cap 8 AYVAKIT 200MG TAB 45 ARNUITY 200MCG INH 19 atomoxetine 60mg cap 8 AYVAKIT 300MG TAB 45 ARNUITY 50MCG INH 19 atomoxetine 80mg cap 8 AZASAN 100MG TAB 58 ashlyna 91 day pack 64 atorvastatin 10mg tab 36 AZASAN 75MG TAB 58 ASMANEX 100MCG HFA 19 atorvastatin 20mg tab 36 AZASITE 1% OPHTH 92 INH atorvastatin 40mg tab 36 SOLNASMANEX 110MCG 19 atorvastatin 80mg tab 36 azathioprine 50mg tab 88 (30ACT) INH atovaquone 150mg/ml 41 azelaic acid 15% gel 74 ASMANEX 200MCG HFA 19 susp azelastine 0.05% ophth 93 INH atovaquone 42 solnASMANEX 220MCG 19 250mg/proguanil 100mg azelastine 0.137mg/act 90 (120ACT) INH tab nasal inhalerASMANEX 220MCG 19 atovaquone 42 azelastine 0.206mg/act 90 (30ACT) INH 62.5mg/proguanil 25mg nasal inhaler

tab

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

110

Page 113: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

ALPHABETICAL LISTING OF DRUGS

AZITHROMYCIN 85 benazepril 39 betamethasone 0.05% 72 1000MG POWDER FOR 20mg/hydrochlorothiazid ointmentORAL SUSP e 12.5mg tab betamethasone 0.1% 72 azithromycin 20mg/ml 85 benazepril 39 creamsusp 20mg/hydrochlorothiazid betamethasone 0.1% 72 azithromycin 250mg pack 85 e 25mg tab lotionazithromycin 250mg tab 85 benazepril 40mg tab 37 betamethasone 0.1% 72 azithromycin 40mg/ml 85 benazepril 5mg tab 37 ointmentsusp benazepril 39 BETAMETHASONE/CAL 72 azithromycin 500mg inj 85 5mg/hydrochlorothiazide CIPOTRIENE azithromycin 500mg pack 85 6.25mg tab 0.005-0.064% LOTIONazithromycin 500mg tab 85 BENLYSTA 200MG/ML 89 betamethasone/clotrimaz 70 azithromycin 600mg tab 85 AUTO-INJECTOR ole 1-0.05% creamAZOPT 1% OPHTH SUSP 93 BENLYSTA 200MG/ML 89 betamethasone/clotrimaz 70 aztreonam 1000mg inj 42 SYRINGE ole 1-0.05% lotion

B

BACITRACIN 0.5UNIT/MG OPHTH OINTMENTbacitracin 0.5unit/mg/polymyxin b 10unit/mg ophth ointmentbaclofen 10mg tabbaclofen 20mg tabbalsalazide disodium 750mg capBALVERSA 3MG TABBALVERSA 4MG TABBALVERSA 5MG TABbalziva 28 day packBANZEL 200MG TABBANZEL 400MG TABBANZEL 40MG/ML SUSPBAQSIMI 3MG/DOSE NASAL POWDERBAXDELA 450MG TABBCG LIVE TICE STRAIN 50MG INJbenazepril 10mg tabbenazepril 10mg/hydrochlorothiazid e 12.5mg tabbenazepril 20mg tab

92

92

89 89 80

45 45 45 64 23 23 23

31

79 104

37 39

37

BENZNIDAZOLE 100MG TABBENZNIDAZOLE 12.5MG TABbenzoyl peroxide 5%/clindamycin phosphate 1.2% topical gelbenztropine mesylate 0.5mg tabbenztropine mesylate 1mg tabbenztropine mesylate 2mg tabBEPREVE 1.5% OPHTH SOLNBERINERT 500UNIT INJbetamethasone 0.05% aug creambetamethasone 0.05% aug lotionbetamethasone 0.05% aug ointmentbetamethasone 0.05% creamBETAMETHASONE 0.05% GELbetamethasone 0.05% lotion

16

16

69

50

50

49

93

82 72

72

72

72

72

72

betaxolol 0.5% ophth solnbetaxolol 10mg tabbetaxolol 20mg tabbethanechol chloride 10mg tabbethanechol chloride 25mg tabbethanechol chloride 50mg tabbethanechol chloride 5mg tabBETIMOL 0.25% OPHTH SOLNBETIMOL 0.5% OPHTH SOLNBETOPTIC S 0.25% OPHTH SUSPbexarotene 75mg capBEXSERO SYRINGEbicalutamide 50mg tabBICILLIN 300000-300000UNIT/ML SYRINGEBICILLIN 450000-150000UNIT/ML SYRINGEBICILLIN L-A 1200000UNIT/2ML SYRINGE

91

59 59

104

104

104

104

91

91

91

48 104 44 96

96

95

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

111

Page 114: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

ALPHABETICAL LISTING OF DRUGS

BICILLIN L-A 95 BRILINTA 60MG TAB 82 buprenorphine 15 2400000UNIT/4ML BRILINTA 90MG TAB 82 12mg/naloxone 3mg SYRINGE brimonidine tartrate 91 sublingual filmBICILLIN L-A 95 0.15% ophth soln buprenorphine 2mg sl tab 15 600000UNIT/ML brimonidine tartrate 92 buprenorphine 15 SYRINGE 0.2% ophth soln 2mg/naloxone 0.5mg sl BIDIL 37.5-20MG TAB 62 BRIVIACT 100MG TAB 23 tabBIKTARVY 55 BRIVIACT 10MG TAB 23 buprenorphine 15 50-200-25MG TAB BRIVIACT 10MG/ML 23 2mg/naloxone 0.5mg bimatoprost 0.03% ophth 94 ORAL SOLN sublingual filmsoln BRIVIACT 25MG TAB 23 buprenorphine 15 bisoprolol fumarate 10mg 59 BRIVIACT 50MG TAB 23 4mg/naloxone 1mg tab BRIVIACT 75MG TAB 23 sublingual filmbisoprolol fumarate 39 bromfenac 0.09% ophth 93 buprenorphine 8mg sl tab 15 10mg/hydrochlorothiazid soln buprenorphine 15 e 6.25mg tab bromocriptine 2.5mg tab 49 8mg/naloxone 2mg sl tabbisoprolol fumarate 39 bromocriptine 5mg cap 49 buprenorphine 15 2.5mg/hydrochlorothiazid BROVANA 15MCG/2ML 20 8mg/naloxone 2mg e 6.25mg tab INH SOLN sublingual filmbisoprolol fumarate 5mg 59 BRUKINSA 80MG CAP 45 bupropion 100mg er tab 26 tab budesonide 0.125mg/ml 19 bupropion 100mg tab 27 bisoprolol fumarate 39 inh susp bupropion 150mg sr (12 27 5mg/hydrochlorothiazide budesonide 0.25mg/ml 19 hr) tab6.25mg tab inh susp bupropion 150mg sr tab 98 BIVIGAM 5GM/50ML 94 budesonide 0.5mg/ml inh 19 bupropion 150mg xl (24 27 INJ susp hr) tabBLEPHAMIDE 0.2-10% 92 budesonide 3mg dr cap 68 bupropion 200mg er tab 27 OPHTH OINTMENT budesonide 9mg er tab 68 bupropion 300mg er tab 27 BLEPHAMIDE 0.2-10% 92 bumetanide 0.25mg/ml inj 75 bupropion 75mg tab 27 OPHTH SUSP bumetanide 0.5mg tab 75 buspirone 10mg tab 17 blisovi 21 fe 1.5/30 28 64 bumetanide 1mg tab 75 buspirone 15mg tab 17 day bumetanide 2mg tab 75 buspirone 30mg tab 17 blisovi 24 fe 1/20 28 day 64 buprenorphine 15 buspirone 5mg tab 17 pack 0.005mg/hr weekly patch buspirone 7.5mg tab 17 BOOSTRIX INJ 102 buprenorphine 15 butorphanol tartrate 15 BOOSTRIX SYRINGE 102 0.0075mg/hr weekly 1mg/act nasal inhalerbosentan 125mg tab 62 patch BYDUREON 2MG PEN 31 bosentan 62.5mg tab 62 buprenorphine 15 INJBOSULIF 100MG TAB 45 0.015mg/hr weekly patch BYDUREON 31 BOSULIF 400MG TAB 45 buprenorphine 0.01mg/hr 15 2MG/0.85ML BOSULIF 500MG TAB 45 weekly patch AUTO-INJECTORBRAFTOVI 75MG CAP 45 buprenorphine 0.02mg/hr 15 BYSTOLIC 10MG TAB 59 BREO 0.1-0.025MG INH 20 weekly patch BYSTOLIC 2.5MG TAB 59 BREO 0.2-0.025MG INH 20 BYSTOLIC 20MG TAB 59 briellyn 28 day pack 65 BYSTOLIC 5MG TAB 59

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

112

Page 115: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

ALPHABETICAL LISTING OF DRUGS

C CAPTOPRIL 39 carbidopa 25mg tab 50

cabergoline 0.5mg tab 77 25MG/HYDROCHLOROT CARBIDOPA 50

CABLIVI 11MG INJ 82 HIAZIDE 25MG TAB 25MG/ENTACAPONE

CABOMETYX 20MG 45 captopril 50mg tab 37 200MG/LEVODOPA

TAB captopril 39 100MG TAB

CABOMETYX 40MG 45 50mg/hydrochlorothiazid carbidopa 49

TAB e 15mg tab 25mg/levodopa 100mg er

CABOMETYX 60MG 45 CAPTOPRIL 39 tab

TAB 50MG/HYDROCHLOROT carbidopa 49

calcipotriene 0.005% 71 HIAZIDE 25MG TAB 25mg/levodopa 100mg

cream CARAC 0.5% CREAM 71 odt

calcipotriene 0.005% 71 CARBAGLU 200MG TAB 77 carbidopa 49

ointment FOR ORAL SUSP 25mg/levodopa 100mg

calcipotriene 0.005% 71 carbamazepine 100mg 23 tab

topical soln chew tab carbidopa 49

calcipotriene/betamethas 72 carbamazepine 100mg er 23 25mg/levodopa 250mg

one 0.005-0.064% cap odt

ointment carbamazepine 100mg er 23 carbidopa 50

calcitriol 0.00025mg cap 77 tab 25mg/levodopa 250mg

CALCITRIOL 0.0003% 71 carbamazepine 200mg er 23 tab

OINTMENT cap CARBIDOPA 50

calcitriol 0.0005mg cap 77 carbamazepine 200mg er 23 31.25MG/ENTACAPONE

calcitriol 0.001mg/ml oral 77 tab 200MG/LEVODOPA

soln carbamazepine 200mg 23 125MG TAB

calcium acetate 667mg 81 tab CARBIDOPA 50

cap carbamazepine 20mg/ml 23 37.5MG/ENTACAPONE

calcium acetate 667mg 81 susp 200MG/LEVODOPA

tab carbamazepine 300mg er 23 150MG TAB

CALQUENCE 100MG 45 cap CARBIDOPA 50

CAP carbamazepine 400mg er 23 50MG/ENTACAPONE

camila 28 day 0.35mg 67 tab 200MG/LEVODOPA

pack carbidopa 49 200MG TAB

camreselo 91 day pack 65 10mg/levodopa 100mg carbidopa 49

CAPEX 0.01% 72 odt 50mg/levodopa 200mg er

SHAMPOO carbidopa 49 tab

CAPLYTA 42MG CAP 51 10mg/levodopa 100mg CARDIZEM 120MG ER 60

CAPRELSA 100MG TAB 45 tab TAB

CAPRELSA 300MG TAB 45 CARBIDOPA 50 CARDURA 4MG ER TAB 81

captopril 100mg tab 37 12.5MG/ENTACAPONE CARDURA 8MG ER TAB 81

captopril 12.5mg tab 37 200MG/LEVODOPA carisoprodol 350mg tab 89

captopril 25mg tab 37 50MG TAB CARTEOLOL 1% OPHTH 91

captopril 39 CARBIDOPA 50 SOLN

25mg/hydrochlorothiazid 18.75MG/ENTACAPONE cartia 120mg er cap 60

e 15mg tab 200MG/LEVODOPA cartia 180mg er cap 60 75MG TAB cartia 240mg er cap 60

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

113

Page 116: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

ALPHABETICAL LISTING OF DRUGS

cartia 300mg er cap 60 cefpodoxime 200mg tab 64 chlordiazepoxide 10mg 17 carvedilol 12.5mg tab 58 cefpodoxime 20mg/ml 64 capcarvedilol 25mg tab 58 susp chlordiazepoxide 25mg 17 carvedilol 3.125mg tab 58 cefprozil 250mg tab 63 capcarvedilol 6.25mg tab 58 cefprozil 25mg/ml susp 63 chlordiazepoxide 5mg 17 caspofungin acetate 50mg 34 cefprozil 500mg tab 63 capinj cefprozil 50mg/ml susp 63 chlorhexidine gluconate 89 caspofungin acetate 70mg 34 ceftazidime 1000mg inj 64 0.12% mouthwashinj ceftazidime 2000mg inj 64 CHLOROQUINE 42 CAYSTON 75MG INH 42 ceftazidime 200mg/ml inj 64 PHOSPHATE 250MG SOLN ceftriaxone 1000mg inj 64 TABcaziant 28 day pack 65 ceftriaxone 100mg/ml inj 64 chloroquine phosphate 42 cefaclor 250mg cap 63 ceftriaxone 2000mg inj 64 500mg tabCEFACLOR 25MG/ML 63 ceftriaxone 250mg inj 64 chlorpromazine 100mg 53 SUSP ceftriaxone 500mg inj 64 tabcefaclor 500mg cap 63 cefuroxime 1500mg inj 63 chlorpromazine 10mg tab 53 CEFACLOR 500MG ER 63 cefuroxime 250mg tab 63 chlorpromazine 200mg 53 TAB cefuroxime 500mg tab 63 tabCEFACLOR 50MG/ML 63 cefuroxime 750mg inj 64 chlorpromazine 25mg tab 53 SUSP cefuroxime 95mg/ml inj 64 chlorpromazine 50mg tab 53 CEFACLOR 75MG/ML 63 celecoxib 100mg cap 11 chlorthalidone 25mg tab 75 SUSP celecoxib 200mg cap 11 chlorthalidone 50mg tab 75 cefadroxil 1000mg tab 63 celecoxib 400mg cap 11 chlorzoxazone 500mg tab 89 cefadroxil 100mg/ml susp 63 celecoxib 50mg cap 11 CHOLBAM 250MG CAP 80 cefadroxil 500mg cap 63 CELONTIN 300MG CAP 26 CHOLBAM 50MG CAP 80 cefadroxil 50mg/ml susp 63 cephalexin 250mg cap 63 cholestyramine resin 4gm 35 cefazolin 1000mg inj 63 cephalexin 25mg/ml susp 63 sf powder for oral suspcefazolin 200mg/ml inj 63 cephalexin 500mg cap 63 cholestyramine resin 4gm 35 cefazolin 500mg inj 63 cephalexin 50mg/ml susp 63 sf powder for oral susp cefdinir 25mg/ml susp 64 CERDELGA 84MG CAP 83 (sugar free)cefdinir 300mg cap 64 cetirizine 1mg/ml oral 35 ciclopirox 0.77% cream 70 cefdinir 50mg/ml susp 64 soln ciclopirox 0.77% gel 70 cefepime 1000mg inj 64 CETRAXAL 0.2% OTIC 94 ciclopirox 0.77% lotion 70 cefepime 2000mg inj 64 SOLN ciclopirox 1% shampoo 70 cefixime 20mg/ml susp 64 cevimeline 30mg cap 89 ciclopirox 8% topical soln 70 cefixime 400mg cap 64 CHANTIX 0.5MG TAB 98 CILASTATIN 41 cefixime 40mg/ml susp 64 CHANTIX 1MG TAB 98 250MG/IMIPENEM cefotetan 1000mg inj 63 CHANTIX CONTINUING 98 250MG INJcefotetan 2000mg inj 63 MONTHS OF THERAPY cilastatin 41 cefoxitin 1000mg inj 63 1MG PACK 500mg/imipenem 500mg cefoxitin 2000mg inj 63 CHANTIX FIRST MONTH 99 injcefoxitin 200mg/ml inj 63 OF THERAPY PACK cilostazol 100mg tab 82 cefpodoxime 100mg tab 64 CHEMET 100MG CAP 33 cilostazol 50mg tab 82 cefpodoxime 10mg/ml 64 CHENODAL 250MG TAB 80 CILOXAN 0.3% OPHTH 92 susp OINTMENT

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

114

Page 117: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

ALPHABETICAL LISTING OF DRUGS

CIMDUO 300-300MG 55 clarithromycin 500mg tab 85 CLINIMIX E 4.25/5 INJ 91 TAB CLARITHROMYCIN 85 CLINIMIX E 5/15 INJ 91 cimetidine 200mg tab 102 50MG/ML SUSP CLINIMIX E 5/20 INJ 91 cimetidine 300mg tab 102 CLENPIQ 85 clinisol 15% inj 91 cimetidine 400mg tab 102 75-21.9-0.0625MG/ML clobazam 10mg tab 22 CIMETIDINE 60MG/ML 103 ORAL SOLN clobazam 2.5mg/ml susp 22 ORAL SOLN CLEOCIN 100MG 105 clobazam 20mg tab 22 cimetidine 800mg tab 102 VAGINAL INSERT clobetasol propionate 72 CIMZIA 200MG INJ 80 CLIMARA PRO 78 0.05% creamCIMZIA 200MG/ML 80 0.00188-0.000625MG/H clobetasol propionate 72 SYRINGE R PATCH 0.05% e creamcinacalcet 30mg tab 77 clindacin 1% pad 69 clobetasol propionate 72 cinacalcet 60mg tab 77 clindamycin 1% gel 69 0.05% e foamcinacalcet 90mg tab 77 clindamycin 1% lotion 69 clobetasol propionate 72 CINRYZE 500UNIT INJ 82 clindamycin 1% pad 69 0.05% foamCIPRO 5GM/100ML 79 clindamycin 1% topical 69 clobetasol propionate 72 SUSP soln 0.05% gelCIPRO HC 0.2-1% OTIC 94 clindamycin 12mg/ml inj 42 clobetasol propionate 72 SUSP clindamycin 150mg cap 42 0.05% lotionCIPROFLOXACIN 0.2% 94 clindamycin 150mg/ml 42 clobetasol propionate 72 OTIC SOLN (2ml) inj 0.05% ointmentciprofloxacin 0.3% ophth 92 clindamycin 150mg/ml 42 clobetasol propionate 72 soln (4ml) inj 0.05% shampoociprofloxacin 250mg tab 79 clindamycin 150mg/ml 42 clobetasol propionate 72 ciprofloxacin 2mg/ml inj 79 (6ml) inj 0.05% sprayciprofloxacin 500mg tab 79 clindamycin 15mg/ml oral 42 clobetasol propionate 72 ciprofloxacin 750mg tab 79 soln 0.05% topical solnciprofloxacin/dexamethas 94 clindamycin 18mg/ml inj 42 clodan 0.05% shampoo 72 one 0.3-0.1% otic susp clindamycin 2% vaginal 105 clomipramine 25mg cap 29 citalopram 10mg tab 27 cream clomipramine 50mg cap 29 citalopram 20mg tab 27 clindamycin 300mg cap 42 clomipramine 75mg cap 29 citalopram 2mg/ml oral 27 clindamycin 6mg/ml inj 42 clonazepam 0.125mg odt 22 soln clindamycin 75mg cap 42 clonazepam 0.25mg odt 22 citalopram 40mg tab 27 clindamycin/benzoyl 69 clonazepam 0.5mg odt 22 claravis 10mg cap 69 peroxide 1.2-2.5% gel clonazepam 0.5mg tab 22 claravis 20mg cap 69 clindamycin/benzoyl 69 clonazepam 1mg odt 22 claravis 30mg cap 69 peroxide 1-5% gel clonazepam 1mg tab 22 claravis 40mg cap 69 CLINDESSE 2% 105 clonazepam 2mg odt 22 CLARINEX-D 69 VAGINAL CREAM clonazepam 2mg tab 22 2.5-120MG ER TAB CLINIMIX 4.25/10 INJ 90 clonidine 0.00417mg/hr 38 clarithromycin 250mg tab 85 CLINIMIX 4.25/5 INJ 90 weekly patchCLARITHROMYCIN 85 CLINIMIX 5/15 INJ 90 clonidine 0.00833mg/hr 38 25MG/ML SUSP CLINIMIX 5/20 INJ 90 weekly patchclarithromycin 500mg er 85 CLINIMIX E 2.75/5 INJ 90 clonidine 0.0125mg/hr 38 tab CLINIMIX E 4.25/10 INJ 90 weekly patch

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

115

Page 118: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

ALPHABETICAL LISTING OF DRUGS

clonidine 0.1mg tab 38 colistin 75mg/ml inj 42 CREON 74 clonidine 0.2mg tab 38 COMBIGAN 2-5MG/ML 91 15000-9500-3000UNIT clonidine 0.3mg tab 38 OPHTH SOLN DR CAPclopidogrel 75mg tab 83 COMBIPATCH 78 CREON 74 clorazepate dipotassium 17 0.00208-0.00583MG/HR 30000-19000-6000UNIT 15mg tab PATCH DR CAPclorazepate dipotassium 17 COMBIPATCH 78 CREON 74 3.75mg tab 0.00208-0.0104MG/HR 36000-114000-180000U clorazepate dipotassium 17 PATCH NIT DR CAP7.5mg tab COMBIVENT 20 CREON 74 clotrimazole 1% cream 70 0.1-0.02MG INH 60000-38000-12000UNIT clotrimazole 1% topical 70 COMETRIQ 100MG 45 DR CAPsoln DAILY DOSE CARTON CRINONE 4% VAGINAL 105 clotrimazole 10mg 89 PACK GELlozenge COMETRIQ 140MG 45 CRINONE 8% VAGINAL 105 clovique 250mg cap 88 DAILY DOSE CARTON GELclozapine 100mg odt 52 PACK CRIXIVAN 200MG CAP 55 clozapine 100mg tab 52 COMETRIQ 60MG 45 CRIXIVAN 400MG CAP 55 CLOZAPINE 12.5MG 52 DAILY DOSE CARTON cromolyn sodium 80 ODT PACK 20mg/ml oral solnCLOZAPINE 150MG 52 COMPLERA 55 cromolyn sodium 4% 93 ODT 200-25-300MG TAB ophth solnCLOZAPINE 200MG 52 compro 25mg rectal supp 54 cryselle 28 pack 65 ODT CONDYLOX 0.5% GEL 73 CUVPOSA 1MG/5ML 102 clozapine 200mg tab 52 constulose 10gm/15ml 85 ORAL SOLNclozapine 25mg odt 52 oral soln cyclafem 1/35 28 day 65 clozapine 25mg tab 53 COPIKTRA 15MG CAP 45 packclozapine 50mg tab 53 COPIKTRA 25MG CAP 45 cyclafem 7/7/7 28 day 65 COARTEM 20-120MG 42 CORDRAN 4MCG/SQCM 72 packTAB TAPE cyclobenzaprine 10mg 90 CODEINE SULFATE 12 CORLANOR 5MG TAB 63 tab15MG TAB CORLANOR 5MG/5ML 63 cyclobenzaprine 5mg tab 90 codeine sulfate 30mg tab 12 ORAL SOLN CYCLOPHOSPHAMIDE 43 codeine sulfate 60mg tab 12 CORLANOR 7.5MG TAB 63 25MG CAPcolchicine 82 CORTISONE ACETATE 68 CYCLOPHOSPHAMIDE 43 0.5mg/probenecid 500mg 25MG TAB 50MG CAPtab CORTISPORIN 0.5% 70 CYCLOSET 0.8MG TAB 31 COLCHICINE 0.6MG 82 CREAM cyclosporine 100mg cap 58 CAP CORTISPORIN 1% 70 cyclosporine 25mg cap 58 colesevelam 3750mg 35 OINTMENT cyclosporine modified 58 powder for oral susp COTELLIC 20MG TAB 45 100mg capcolesevelam 625mg tab 35 CREON 74 cyclosporine modified 88 colestipol 1000mg tab 35 120000-76000-24000UNI 100mg/ml oral solncolestipol 5000mg 35 T DR CAP cyclosporine modified 58 granules for oral susp 25mg cap

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

116

Page 119: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

ALPHABETICAL LISTING OF DRUGS

cyclosporine modified 88 deferasirox 360mg 33 desoximetasone 0.05% 72 50mg cap granules ointmentcyproheptadine 0.4mg/ml 35 deferasirox 360mg tab 33 desoximetasone 0.25% 72 oral soln deferasirox 500mg tab 33 creamcyproheptadine 4mg tab 35 for oral susp desoximetasone 0.25% 72 cyred 28 day pack 65 deferasirox 90mg 33 ointmentCYSTAGON 150MG CAP 81 granules desvenlafaxine succinate 28 CYSTAGON 50MG CAP 81 deferasirox 90mg tab 33 100mg er tabCYSTARAN 0.44% 93 DELESTROGEN 78 desvenlafaxine succinate 28 OPHTH SOLN 10MG/ML INJ 25mg er tab

D

dalfampridine 10mg er tabDALIRESP 250MCG TABDALIRESP 500MCG TABDALVANCE 500MG INJdanazol 100mg capdanazol 200mg capdanazol 50mg capdantrolene sodium 100mg

98

19 19 41 15 15 15 90

DELSTRIGO 100-300-300MG TABdemeclocycline 150mg tabdemeclocycline 300mg tabDEMSER 250MG CAPDENAVIR 1% CREAMDEPO-ESTRADIOL 5MG/ML INJDEPO-PROVERA

55

99

99

38 71 79

44

desvenlafaxine succinate 50mg er tabdexamethasone 0.1mg/ml oral solndexamethasone 0.5mg tabdexamethasone 0.75mg tabdexamethasone 1.5mg tabDEXAMETHASONE 1MG TABDEXAMETHASONE 2MG

28

68

68 68

68 68

68 capdantrolene sodium 25mg capdantrolene sodium 50mg capdapsone 100mg tabdapsone 25mg tabDAPTACEL INJdaptomycin 500mg injdarifenacin 15mg er tabdarifenacin 7.5mg er tabDAURISMO 100MG TABDAURISMO 25MG TABDDAVP 0.01% NASAL SOLNdeblitane 28 day 0.35mg packdeferasirox 125mg tab for oral suspdeferasirox 180mg granulesdeferasirox 180mg tabdeferasirox 250mg tab for oral susp

90

90

42 42

102 41

103 103 43 43 77

68

33

33

33 33

400MG/ML INJDESCOVY 200-25MG TABdesipramine 100mg tabdesipramine 10mg tabdesipramine 150mg tabdesipramine 25mg tabdesipramine 50mg tabdesipramine 75mg tabdesloratadine 5mg tabdesmopressin acetate 0.01mg/act nasal spraydesmopressin acetate 0.1mg tabdesmopressin acetate 0.2mg tabdesogestrel/ethinyl estradiol packdesonide 0.05% ointmentdesoximetasone 0.05% creamdesoximetasone 0.05% gel

55

29 29 29 29 29 29 35 77

77

77

65

72 72

72

TABdexamethasone 4mg tabdexamethasone 6mg tabDEXAMETHASONE PHOSPHATE 0.1% OPHTH SOLNdexamethasone/neomycin /polymyxin b 0.1% ophth ointmentdexamethasone/neomycin /polymyxin b 0.1% ophth suspdexamethasone/tobramyc in 0.3-0.1% ophth suspdexmethylphenidate 10mg er capdexmethylphenidate 10mg tabdexmethylphenidate 15mg er capdexmethylphenidate 2.5mg tabdexmethylphenidate 20mg er cap

68 68 92

93

93

93

8

9

9

9

9

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

117

Page 120: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

ALPHABETICAL LISTING OF DRUGS

dexmethylphenidate 9 DICLOFENAC 71 dihydroergotamine 86 25mg er cap EPOLAMINE 1.3% mesylate 0.5mg/act nasal dexmethylphenidate 9 PATCH inhaler30mg er cap diclofenac potassium 11 DILANTIN 30MG ER 26 dexmethylphenidate 9 50mg tab CAP35mg er cap diclofenac sodium 0.1% 93 DILT 120MG ER CAP 60 dexmethylphenidate 9 ophth soln DILT 180MG ER CAP 60 40mg er cap diclofenac sodium 1% gel 71 DILT 240MG ER CAP 60 dexmethylphenidate 5mg 9 diclofenac sodium 1.5% 71 diltiazem 120mg er (12 60 er cap topical soln hr) capdexmethylphenidate 5mg 9 diclofenac sodium 100mg 11 diltiazem 120mg er (24 60 tab er tab hr) capdextroamphetamine 8 diclofenac sodium 25mg 11 diltiazem 120mg tab 60 sulfate 10mg er cap dr tab diltiazem 180mg er cap 60 dextroamphetamine 8 diclofenac sodium 3% gel 71 diltiazem 240mg er cap 60 sulfate 10mg tab diclofenac sodium 50mg 11 diltiazem 300mg er cap 60 dextroamphetamine 8 dr tab diltiazem 30mg tab 60 sulfate 15mg er cap diclofenac sodium 11 diltiazem 360mg er cap 60 dextroamphetamine 8 50mg/misoprostol 0.2mg diltiazem 420mg er cap 60 sulfate 1mg/ml oral soln dr tab diltiazem 60mg er cap 60 dextroamphetamine 8 diclofenac sodium 75mg 11 diltiazem 60mg tab 60 sulfate 5mg er cap dr tab diltiazem 90mg er cap 60 dextroamphetamine 8 diclofenac sodium 11 diltiazem 90mg tab 60 sulfate 5mg tab 75mg/misoprostol 0.2mg DIPENTUM 250MG CAP 80 DIASTAT 10MG RECTAL 22 dr tab DIPHTHERIA/TETANUS 102 GEL dicloxacillin 250mg cap 96 TOXOID INJDIASTAT 2.5MG RECTAL 22 dicloxacillin 500mg cap 96 dipyridamole 25mg tab 83 GEL dicyclomine 10mg cap 102 dipyridamole 50mg tab 83 DIASTAT 20MG RECTAL 22 dicyclomine 20mg tab 102 dipyridamole 75mg tab 83 GEL dicyclomine 2mg/ml oral 102 disopyramide 100mg cap 18 diazepam 10mg tab 18 soln disopyramide 150mg cap 18 DIAZEPAM 10MG/2ML 23 DIDANOSINE 250MG DR 55 disulfiram 250mg tab 96 RECTAL GEL CAP disulfiram 500mg tab 96 DIAZEPAM 1MG/ML 18 DIDANOSINE 400MG DR 55 DIURIL 250MG/5ML 75 ORAL SOLN CAP SUSPDIAZEPAM 23 DIFICID 200MG TAB 85 divalproex sodium 125mg 26 2.5MG/0.5ML RECTAL diflunisal 500mg tab 12 dr capGEL digitek 0.125mg tab 61 divalproex sodium 125mg 26 DIAZEPAM 20MG/4ML 23 digitek 0.25mg tab 61 dr tabRECTAL GEL digox 125mcg tab 61 divalproex sodium 250mg 26 diazepam 2mg tab 18 digox 250mcg tab 61 dr tabdiazepam 5mg tab 18 digoxin 0.05mg/ml oral 61 divalproex sodium 250mg 26 diazepam 5mg/ml oral 18 soln er tabsoln digoxin 0.125mg tab 61 divalproex sodium 500mg 26 diazoxide 50mg/ml susp 31 digoxin 0.25mg tab 61 dr tab

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

118

Page 121: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

ALPHABETICAL LISTING OF DRUGS

divalproex sodium 500mg 26 doxercalciferol 0.001mg 77 DROXIA 400MG CAP 83 er tab cap DULERA 0.005-0.1MG 20 dofetilide 0.125mg cap 18 doxercalciferol 0.0025mg 77 INHdofetilide 0.25mg cap 18 cap DULERA 0.005-0.2MG 20 dofetilide 0.5mg cap 18 doxy 100mg inj 99 INHdonepezil 10mg odt 96 doxycycline hyclate 99 DULERA 50-5MCG INH 20 donepezil 10mg tab 96 100mg cap duloxetine 20mg dr cap 28 donepezil 23mg tab 96 doxycycline hyclate 99 duloxetine 30mg dr cap 28 donepezil 5mg odt 97 100mg tab duloxetine 40mg dr cap 28 donepezil 5mg tab 97 doxycycline hyclate 20mg 99 duloxetine 60mg dr cap 28 DOPTELET 20MG TAB 83 tab DUPIXENT 73 DOPTELET 40MG DAILY 83 doxycycline hyclate 50mg 99 200MG/1.14ML DOSE PACK cap SYRINGEDOPTELET 60MG DAILY 83 doxycycline monohydrate 100 DUPIXENT 300MG/2ML 73 DOSE PACK 100mg cap AUTO-INJECTORdorzolamide 2% ophth 93 doxycycline monohydrate 100 DUPIXENT 300MG/2ML 73 soln 100mg tab SYRINGEdorzolamide 91 doxycycline monohydrate 100 DUREZOL 0.05% OPHTH 93 20mg/ml/timolol 5mg/ml 50mg cap SUSPophth soln doxycycline monohydrate 100 dutasteride 0.5mg cap 81 dorzolamide/timolol 91 50mg tab dutasteride 81 22.3-6.8mg/ml ophth soln doxycycline monohydrate 100 0.5mg/tamsulosin 0.4mg (preservative-free) 5mg/ml susp capdotti 0.025mg/24hr patchdotti 0.0375mg/24hr patchdotti 0.05mg/24hr patchdotti 0.075mg/24hr patchdotti 0.1mg/24hr patchDOVATO 50-300MG TABdoxazosin 1mg tabdoxazosin 2mg tabdoxazosin 4mg tabdoxazosin 8mg tabdoxepin 100mg capdoxepin 10mg capdoxepin 10mg/ml oral solndoxepin 150mg capdoxepin 25mg capdoxepin 50mg capdoxepin 75mg capdoxercalciferol 0.0005mg cap

79 79

79 79 79 55 38 38 38 38 29 29 29

29 29 29 29 77

doxylamine succinate 10mg/pyridoxine 10mg dr tabDRIZALMA 20MG DR CAPDRIZALMA 30MG DR CAPDRIZALMA 40MG DR CAPDRIZALMA 60MG DR CAPdronabinol 10mg capdronabinol 2.5mg capdronabinol 5mg capdrospirenone 3mg/ethinyl estradiol 0.02mg/inert 1 mg packdrospirenone 3mg/ethinyl estradiol 0.03mg/inert ingredients 1mg packDROXIA 200MG CAPDROXIA 300MG CAP

33

28

28

28

28

33 33 34 65

65

83 83

E

econazole nitrate 1% creamEDURANT 25MG TABefavirenz 200mg capefavirenz 50mg capefavirenz 600mg tabeletriptan 20mg tabeletriptan 40mg tabELIGARD 22.5MG SYRINGEELIGARD 30MG SYRINGEELIGARD 45MG SYRINGEELIGARD 7.5MG SYRINGEELIQUIS 2.5MG TABELIQUIS 30-DAY STARTER PACK 5MGELIQUIS 5MG TAB

70

55 55 55 55 86 86 44

44

44

44

21 21

21

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

119

Page 122: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

ALPHABETICAL LISTING OF DRUGS

ELMIRON 100MG CAP 81 ENBREL 50MG/ML 12 epinastine 0.05% ophth 93 eluryng 67 SYRINGE soln0.000625-0.005mg/hr ENDARI 5GM POWDER 83 epinephrine 0.5mg/ml 105 vaginal system FOR ORAL SOLN auto-injectorEMCYT 140MG CAP 44 endocet 325-10mg tab 15 epinephrine 1mg/ml 105 EMGALITY 100MG/ML 86 endocet 325-5mg tab 15 auto-injectorSYRINGE endocet 325-7.5mg tab 15 epitol 200mg tab 23 EMGALITY 120MG/ML 86 ENGERIX-B 104 EPIVIR HBV 5MG/ML 57 AUTO-INJECTOR 10MCG/0.5ML SYRINGE ORAL SOLNEMGALITY 120MG/ML 86 ENGERIX-B 20MCG/ML 104 eplerenone 25mg tab 41 SYRINGE SYRINGE eplerenone 50mg tab 41 emoquette pack 65 enoxaparin sodium 21 EQUETRO 100MG ER 51 EMSAM 12MG/24HR 27 100mg/ml (0.3ml) syringe CAPPATCH enoxaparin sodium 21 EQUETRO 200MG ER 51 EMSAM 6MG/24HR 27 100mg/ml (0.4ml) syringe CAPPATCH enoxaparin sodium 21 EQUETRO 300MG ER 51 EMSAM 9MG/24HR 27 100mg/ml (0.6ml) syringe CAPPATCH enoxaparin sodium 21 ERAXIS 100MG INJ 34 EMTRIVA 10MG/ML 55 100mg/ml (0.8ml) syringe ERAXIS 50MG INJ 34 ORAL SOLN enoxaparin sodium 21 ERGOLOID MESYLATES 98 EMTRIVA 200MG CAP 55 100mg/ml (1ml) syringe USP 1MG TABenalapril maleate 10mg 37 enoxaparin sodium 22 ERIVEDGE 150MG CAP 43 tab 150mg/ml (0.8ml) syringe ERLEADA 60MG TAB 44 enalapril maleate 39 enoxaparin sodium 22 erlotinib 100mg tab 45 10mg/hydrochlorothiazid 150mg/ml (1ml) syringe erlotinib 150mg tab 45 e 25mg tab enpresse 28 day pack 65 erlotinib 25mg tab 46 enalapril maleate 2.5mg 37 enskyce 28 day pack 65 errin 28 day 0.35mg pack 68 tab entacapone 200mg tab 50 ertapenem 1000mg inj 41 enalapril maleate 20mg 37 entecavir 0.5mg tab 57 ERY 2% PAD 69 tab entecavir 1mg tab 57 ery-tab 250mg dr tab 85 enalapril maleate 5mg 37 ENTRESTO 24-26MG 62 ery-tab 333mg dr tab 85 tab TAB ery-tab 500mg dr tab 85 enalapril maleate 39 ENTRESTO 49-51MG 62 ERYTHROCIN 500MG 85 5mg/hydrochlorothiazide TAB INJ12.5mg tab ENTRESTO 97-103MG 62 erythromycin 0.5% ophth 92 ENBREL 25MG INJ 12 TAB ointmentENBREL 25MG/0.5ML 12 enulose 10gm/15ml oral 80 erythromycin 2% gel 69 INJ soln erythromycin 2% topical 69 ENBREL 25MG/0.5ML 12 ENVARSUS 0.75MG ER 88 solnSYRINGE TAB erythromycin 250mg dr 85 ENBREL 50MG/ML 12 ENVARSUS 1MG ER TAB 89 capAUTO-INJECTOR ENVARSUS 4MG ER TAB 89 erythromycin 250mg dr 85 ENBREL 50MG/ML 12 EPIDIOLEX 100MG/ML 23 tabCARTRIDGE ORAL SOLN erythromycin 250mg tab 85

EPIDUO 0.3-2.5% GEL 69

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

120

Page 123: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

ALPHABETICAL LISTING OF DRUGS

erythromycin 333mg dr 85 estradiol 0.00208mg/hr 79 ethinyl estradiol 65 tab weekly patch 0.01mg/ethinyl estradiol erythromycin 500mg dr 85 estradiol 0.0025mg/hr 79 0.03mg/levonorgestrel tab weekly patch 0.15mg packerythromycin 500mg tab 85 estradiol 0.00312mg/hr 79 ethinyl estradiol 65 erythromycin 85 weekly patch 0.025mg/ferrous ethylsuccinate 40mg/ml estradiol 0.00313mg/hr 79 fumarate susp twice weekly patch 75mg/norethindrone erythromycin 85 estradiol 0.00417mg/hr 79 0.8mg packethylsuccinate 80mg/ml twice weekly patch ethinyl estradiol 65 susp estradiol 0.00417mg/hr 79 0.025mg/inert/norgestima erythromycin/benzoyl 69 weekly patch te peroxide 5-3% gel estradiol 0.01% vaginal 105 0.18mg/0.215mg/0.25mg ESBRIET 267MG CAP 99 cream packESBRIET 267MG TAB 99 estradiol 0.01mg vaginal 105 ethinyl estradiol 65 ESBRIET 801MG TAB 99 insert 0.02mg/inert ingredients escitalopram 10mg tab 27 estradiol 0.5mg tab 79 1mg/levonorgestrel escitalopram 1mg/ml oral 27 estradiol 78 0.1mg packsoln 0.5mg/norethindrone ethinyl estradiol 65 escitalopram 20mg tab 27 acetate 0.1mg pack 0.02mg/levonorgestrel escitalopram 5mg tab 27 estradiol 1mg tab 79 0.09mg packesomeprazole 10mg 103 estradiol 78 ethinyl estradiol 65 granules for oral susp 1mg/norethindrone 0.02mg/norethindrone esomeprazole 20mg dr 102 acetate 0.5mg pack acetate 1mg packcap estradiol 2mg tab 79 ethinyl estradiol 65 esomeprazole 20mg 103 estradiol valerate 79 0.02mg/norethindrone granules for oral susp 20mg/ml inj acetate 1mg/ferrous esomeprazole 40mg dr 103 estradiol valerate 79 fumarate 75mg chewable cap 40mg/ml inj 28 day packesomeprazole 40mg 103 eszopiclone 1mg tab 84 ethinyl estradiol 65 granules for oral susp eszopiclone 2mg tab 84 0.035mg/ethynodiol 1mg estarylla 28 day pack 65 eszopiclone 3mg tab 84 28 day packestazolam 1mg tab 84 ethacrynic acid 25mg tab 75 ethinyl estradiol 65 estazolam 2mg tab 84 ethambutol 100mg tab 43 0.035mg/ferrous estradiol 0.00104mg/hr 79 ethambutol 400mg tab 43 fumarate twice weekly patch ethinyl estradiol 78 75mg/norethindrone estradiol 0.00104mg/hr 79 0.0025mg/norethindrone 0.4mg packweekly patch acetate 0.5mg pack ethinyl estradiol 65 estradiol 0.00156mg/hr 79 ethinyl estradiol 78 0.035mg/inert/norgestima twice weekly patch 0.005mg/norethindrone te estradiol 0.00156mg/hr 79 acetate 1mg pack 0.18mg/0.215mg/0.25mg weekly patch ethinyl estradiol 65 packestradiol 0.00208mg/hr 79 0.01mg/ethinyl estradiol ethinyl estradiol 65 twice weekly patch 0.02mg/levonorgestrel 0.035mg/norgestimate

0.1mg 91 day pack 0.25mg pack

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

121

Page 124: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

ALPHABETICAL LISTING OF DRUGS

ethinyl estradiol 65 everolimus 0.25mg tab 89 FASENRA 30MG/ML 19 0.03mg/0.04mg everolimus 0.5mg tab 89 AUTO-INJECTOR/inert/levonorgestrel everolimus 0.75mg tab 89 FASENRA 30MG/ML 19 0.05mg/ 0.075mg pack everolimus 2.5mg tab 46 SYRINGEethinyl estradiol 65 everolimus 5mg tab 46 fayosim 91 day pack 66 0.03mg/inert ingredients everolimus 7.5mg tab 46 febuxostat 40mg tab 82 1mg/levonorgestrel EVOTAZ 300-150MG 55 febuxostat 80mg tab 82 0.15mg pack TAB felbamate 120mg/ml susp 25 ethinyl estradiol 65 exemestane 25mg tab 44 felbamate 400mg tab 25 0.03mg/levonorgestrel EXTAVIA 0.3MG INJ 98 felbamate 600mg tab 25 0.15mg tab 28 day pack ezetimibe 10mg tab 36 felodipine 10mg er tab 60 ethinyl estradiol 65 ezetimibe 35 felodipine 2.5mg er tab 60 0.05mg/ethynodiol 10mg/simvastatin 10mg felodipine 5mg er tab 60 1mg/inert ingredients tab femynor 28 day pack 66 1mg 28 day pack ezetimibe 35 fenofibrate 134mg cap 35 ethinyl 65 10mg/simvastatin 20mg fenofibrate 145mg tab 35 estradiol/levonorgestrel tab FENOFIBRATE 150MG 35 91 day pack ezetimibe 35 CAPethosuximide 250mg cap 26 10mg/simvastatin 40mg fenofibrate 160mg tab 35 ethosuximide 50mg/ml 26 tab fenofibrate 200mg cap 35 oral soln ezetimibe 35 fenofibrate 48mg tab 35 etodolac 200mg cap 11 10mg/simvastatin 80mg FENOFIBRATE 50MG 35 etodolac 300mg cap 11 tab CAPetodolac 400mg er tabetodolac 400mg tabetodolac 500mg er tabetodolac 500mg tabetodolac 600mg er tabetonogestrel-ethinyl estradiol 0.120-0.015mg/24hr vaginal ringeuthyrox 100mcg tabeuthyrox 112mcg tabeuthyrox 125mcg tabeuthyrox 137mcg tabeuthyrox 150mcg tabeuthyrox 175mcg tabeuthyrox 200mcg tabeuthyrox 25mcg tabeuthyrox 50mcg tabeuthyrox 75mcg tabeuthyrox 88mcg tabEVAMIST 1.53MG/SPRAY SPRAY

11 11 11 11 11 67

100 100 100 100 100 100 100 100 100 100 100 79

F

falmina 28 day packfamciclovir 125mg tabfamciclovir 250mg tabfamciclovir 500mg tabfamotidine 20mg tabfamotidine 40mg tabfamotidine 8mg/ml suspFANAPT 10MG TABFANAPT 12MG TABFANAPT 1MG TABFANAPT 2MG TABFANAPT 4MG TABFANAPT 6MG TABFANAPT 8MG TABFANAPT TITRATION PACKFARXIGA 10MG TABFARXIGA 5MG TABFARYDAK 10MG CAPFARYDAK 20MG CAP

66 57 57 57

102 103 102 51 51 51 51 51 51 51 51

32 32 46 46

fenofibrate 54mg tabfenofibrate 67mg capfenofibric acid 135mg dr capfenofibric acid 45mg dr capfentanyl 0.012mg/hr patchfentanyl 0.025mg/hr patchfentanyl 0.05mg/hr patchfentanyl 0.075mg/hr patchFENTANYL 0.1MG BUCCAL TABfentanyl 0.1mg/hr patchFENTANYL 0.2MG BUCCAL TABfentanyl 0.2mg lozengeFENTANYL 0.4MG BUCCAL TABfentanyl 0.4mg lozenge

36 36 36

36

12

12

12 12

12

12 12

13 13

13

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

122

Page 125: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

ALPHABETICAL LISTING OF DRUGS

FENTANYL 0.6MG 13 FLAREX 0.1% OPHTH 93 fluocinolone acetonide 72 BUCCAL TAB SUSP 0.025% ointmentfentanyl 0.6mg lozengeFENTANYL 0.8MG BUCCAL TABfentanyl 0.8mg lozengefentanyl 1.2mg lozengefentanyl 1.6mg lozengeFENTORA 100MCG

13 13

13 13 13 13

flavoxate 100mg tabFLEBOGAMMA 5GM/50ML INJflecainide acetate 100mg tabflecainide acetate 150mg tab

104 94

18

18

fluocinolone acetonide 0.1mg/ml oilfluocinonide 0.05% e creamfluocinonide 0.05% gelfluocinonide 0.05% ointment

72

72

72 73

BUCCAL TABFENTORA 200MCG BUCCAL TAB

13 flecainide acetate 50mg tabFLECTOR 1.3% PATCH

18

71

fluocinonide 0.05% topical solnfluorometholone 0.1%

73

93 FENTORA 400MCG BUCCAL TABFENTORA 600MCG

13

13

FLOVENT 100MCG/BLIST INHFLOVENT 110MCG INH

19

19

ophth suspFLUOROPLEX 1% CREAM

71

BUCCAL TAB FLOVENT 220MCG INH 19 FLUOROURACIL 2% 71 FENTORA 800MCG 13 FLOVENT 19 TOPICAL SOLNBUCCAL TABFERRIPROX 1000MG 33

250MCG/BLIST INHFLOVENT 44MCG INH 19

fluorouracil 5% creamFLUOROURACIL 5%

71 71

TABFERRIPROX 100MG/ML ORAL SOLNFERRIPROX 500MG TABFETZIMA 120MG ER CAPFETZIMA 20MG ER CAPFETZIMA 40MG ER CAPFETZIMA 80MG ER CAPFETZIMA PACKFIASP 100UNIT/ML CARTRIDGEFIASP 100UNIT/ML INJFIASP 100UNIT/ML PEN INJFINACEA 15% FOAMfinasteride 5mg tabFINTEPLA 2.2MG/ML ORAL SOLNFIRMAGON 120MG INJFIRMAGON 80MG INJ

33

33 28

28 28 28 28 31

31 31

74 82 23

44 44

FLOVENT 50MCG/BLIST INHfluconazole 100mg tabfluconazole 10mg/ml suspfluconazole 150mg tabfluconazole 200mg tabfluconazole 2mg/ml (100ml) injfluconazole 2mg/ml (200ml) injfluconazole 40mg/ml suspfluconazole 50mg tabflucytosine 250mg capflucytosine 500mg capfludrocortisone 0.1mg tabFLUNISOLIDE 0.025MG/ACT NASAL INHALERfluocinolone acetonide 0.01% creamfluocinolone acetonide

19

34 34 34 34 34

34

34 34 34 34 69 90

72

94

TOPICAL SOLNfluoxetine 10mg capfluoxetine 10mg tabfluoxetine 20mg capfluoxetine 20mg tabfluoxetine 25mg/olanzapine 12mg capfluoxetine 25mg/olanzapine 3mg capfluoxetine 25mg/olanzapine 6mg capfluoxetine 40mg capfluoxetine 4mg/ml oral solnfluoxetine 50mg/olanzapine 12mg capfluoxetine

27 27 27 27 97

97

97

27 27

97

97 FIRVANQ 25MG/ML ORAL SOLNFIRVANQ 50MG/ML ORAL SOLNflac 0.01% otic soln

41

41

94

0.01% otic solnfluocinolone acetonide 0.01% topical solnfluocinolone acetonide 0.025% cream

72

72

50mg/olanzapine 6mg capFLUPHENAZINE 0.5MG/ML ORAL SOLNfluphenazine 10mg tab

54

54

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

123

Page 126: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

ALPHABETICAL LISTING OF DRUGS

fluphenazine 1mg tab 54 FLUTICASONE 20 FOSRENOL 1000MG 81 fluphenazine 2.5mg tab 54 PROPIONATE/SALMETE ORAL POWDERFLUPHENAZINE 54 ROL XINAFOATE FOSRENOL 750MG 81 2.5MG/ML INJ 55-14MCG/ACT ORAL POWDERfluphenazine 5mg tab 54 POWDER INH FRAGMIN 22 FLUPHENAZINE 54 fluvastatin 20mg cap 36 10000UNIT/ML 5MG/ML ORAL SOLN fluvastatin 40mg cap 36 SYRINGEfluphenazine decanoate 54 fluvastatin 80mg er tab 36 FRAGMIN 22 25mg/ml inj fluvoxamine maleate 27 12500UNIT/0.5ML FLURAZEPAM 15MG 84 100mg er cap SYRINGECAP fluvoxamine maleate 27 FRAGMIN 22 FLURAZEPAM 30MG 84 100mg tab 15000UNIT/0.6ML CAP fluvoxamine maleate 27 SYRINGEflurbiprofen 100mg tab 11 150mg er cap FRAGMIN 22 FLURBIPROFEN 93 fluvoxamine maleate 27 18000UNT/0.72ML SODIUM 0.03% OPHTH 25mg tab SYRINGESOLN fluvoxamine maleate 27 FRAGMIN 22 flutamide 125mg cap 44 50mg tab 2500UNIT/0.2ML fluticasone propionate 73 FML 0.1% OPHTH 93 SYRINGE0.005% ointment OINTMENT FRAGMIN 22 fluticasone propionate 73 FML FORTE LIQUIFILM 93 5000UNIT/0.2ML 0.05% cream 0.25% OPHTH SUSP SYRINGEfluticasone propionate 90 fondaparinux sodium 22 FRAGMIN 22 0.05mg/act nasal inhaler 12.5mg/ml (0.4ml) syringe 7500UNIT/0.3ML fluticasone propionate 20 fondaparinux sodium 22 SYRINGE0.1mg/salmeterol 0.05mg 12.5mg/ml (0.6ml) syringe FRAGMIN 22 inh fondaparinux sodium 22 95000UNIT/3.8ML INJfluticasone propionate 20 12.5mg/ml (0.8ml) syringe FREAMINE 6.9% INJ 91 0.25mg/salmeterol fondaparinux sodium 22 FULPHILA 6MG/0.6ML 83 0.05mg inh 5mg/ml syringe SYRINGEfluticasone propionate 20 FORTEO 600MCG/2.4ML 76 furosemide 10mg/ml inj 75 0.5mg/salmeterol 0.05mg PEN INJ furosemide 10mg/ml oral 75 inh fosamprenavir 700mg tab 55 solnFLUTICASONE 20 fosinopril sodium 10mg 37 furosemide 10mg/ml 75 PROPIONATE/SALMETE tab syringeROL XINAFOATE fosinopril sodium 39 furosemide 20mg tab 75 113-14MCG/ACT 10mg/hydrochlorothiazid furosemide 40mg tab 75 POWDER INH e 12.5mg tab furosemide 80mg tab 75 FLUTICASONE 20 fosinopril sodium 20mg 37 FUROSEMIDE 8MG/ML 75 PROPIONATE/SALMETE tab ORAL SOLNROL XINAFOATE fosinopril sodium 39 FUZEON 90MG INJ 55 232-14MCG/ACT 20mg/hydrochlorothiazid fyavolv 0.0025-0.5mg tab 78 POWDER INH e 12.5mg tab fyavolv 0.005-1mg tab 78

fosinopril sodium 40mg 37 FYCOMPA 0.5MG/ML 22 tab SUSP

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

124

Page 127: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

ALPHABETICAL LISTING OF DRUGS

FYCOMPA 10MG TAB 22 GAMMAPLEX 94 GENOTROPIN 2MG 76 FYCOMPA 12MG TAB 22 5GM/50ML INJ SYRINGEFYCOMPA 2MG TAB 22 GAMUNEX 1GM/10ML 94 GENOTROPIN 5MG 76 FYCOMPA 4MG TAB 22 INJ CARTRIDGEFYCOMPA 6MG TAB 22 GARDASIL 9 INJ 104 GENTAK 0.3% OPHTH 92 FYCOMPA 8MG TAB 22 GARDASIL 9 SYRINGE 104 OINTMENT

G

gabapentin 100mg capgabapentin 300mg capgabapentin 400mg capgabapentin 50mg/ml oral solngabapentin 600mg tabgabapentin 800mg tabGALAFOLD 28 DAY WALLET 123MG PACKgalantamine 12mg tabgalantamine 4mg tabgalantamine 8mg tabgalantamine hydrobromide 16mg er capgalantamine hydrobromide 24mg er capGALANTAMINE HYDROBROMIDE 4MG/ML ORAL SOLNgalantamine hydrobromide 8mg er capGAMMAGARD 10GM INJGAMMAGARD 2.5GM/25ML INJGAMMAGARD 5GM INJGAMMAKED 1GM/10ML INJGAMMAPLEX 10GM/100ML INJGAMMAPLEX 10GM/200ML INJGAMMAPLEX 20GM/200ML INJ

23 23 23 23

23 23 77

97 97 97 97

97

97

97

94

94

94 94

94

94

94

gatifloxacin 0.5% ophth solnGATTEX 5MG INJGAUZE PADS & DRESSINGS - PADS 2 X 2GAVILYTE-C ORAL SOLNgavilyte-g powder for oral solngavilyte-n powder for oral solngemfibrozil 600mg tabgenerlac 10gm/15ml oral solngengraf 100mg capgengraf 100mg/ml oral solngengraf 25mg capGENOTROPIN 0.2MG SYRINGEGENOTROPIN 0.4MG SYRINGEGENOTROPIN 0.6MG SYRINGEGENOTROPIN 0.8MG SYRINGEGENOTROPIN 1.2MG SYRINGEGENOTROPIN 1.4MG SYRINGEGENOTROPIN 1.6MG SYRINGEGENOTROPIN 1.8MG SYRINGEGENOTROPIN 12MG CARTRIDGEGENOTROPIN 1MG

92

81 86

85

85

85

36 80

58 58

58 76

76

76

76

76

76

76

76

76

76

gentamicin 0.1% creamgentamicin 0.1% ointmentgentamicin 0.3% ophth solnGENTAMICIN 0.8MG/ML INJgentamicin 1.2mg/ml injGENTAMICIN 1.6MG/ML INJGENTAMICIN 1MG/ML INJgentamicin 40mg/ml injGENVOYA 150-150-200-10MG TABgianvi 28-day packGILENYA 0.5MG CAPGILOTRIF 20MG TABGILOTRIF 30MG TABGILOTRIF 40MG TABGLASSIA 1000MG/50ML INJglatiramer acetate 20mg/ml syringeglatiramer acetate 40mg/ml syringeglatopa 20mg/ml syringeglatopa 40mg/ml syringeglimepiride 1mg tabglimepiride 2mg tabglimepiride 4mg tabglipizide 10mg er tabglipizide 10mg tabglipizide 2.5mg er tabglipizide 2.5mg/metformin 250mg tabglipizide 2.5mg/metformin 500mg

70 70 92

9

10 10

10

10 55

66 98 46 46 46 99

98

98

98 98 32 32 32 32 32 32 30

30

SYRINGE tab

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

125

Page 128: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

ALPHABETICAL LISTING OF DRUGS

glipizide 5mg er tab 32 glucose 87 GRAMICIDIN 92 glipizide 5mg tab 32 50mg/ml/potassium 0.025MG/ML/NEOMYCI glipizide 5mg/metformin 30 chloride N 500mg tab 0.02meq/ml/sodium 1.75MG/ML/POLYMYXI GLUCAGEN 1MG INJ 31 chloride 4.5mg/ml inj N B 10000UNIT/ML GLUCAGON (RDNA) 31 glucose 87 OPHTH SOLN1MG INJ 50mg/ml/potassium granisetron 1mg tab 33 glucose 100mg/ml inj 90 chloride 0.03 griseofulvin 125mg tab 34 GLUCOSE 87 meq/ml/sodium chloride griseofulvin 250mg tab 34 100MG/ML/SODIUM 0.0769 meq/ml inj griseofulvin 25mg/ml 34 CHLORIDE 0.0342 GLUCOSE 87 suspMEQ/ML INJ 50MG/ML/POTASSIUM griseofulvin 500mg tab 34 GLUCOSE 87 CHLORIDE 0.04 guanfacine 1mg er tab 8 100MG/ML/SODIUM MEQ/ML/SODIUM guanfacine 1mg tab 38 CHLORIDE 0.0769 CHLORIDE 0.154 guanfacine 2mg er tab 8 MEQ/ML INJ MEQ/ML INJ guanfacine 2mg tab 38 GLUCOSE 87 glucose 50mg/ml/sodium 87 guanfacine 3mg er tab 8 25MG/ML/SODIUM chloride 0.0342 meq/ml guanfacine 4mg er tab 8 CHLORIDE 0.0769 inj GUANIDINE 125MG TAB 43 MEQ/ML INJ glucose 50mg/ml/sodium 87 GVOKE 0.5MG/0.1ML 31 glucose 50 87 chloride 4.5mg/ml inj AUTO-INJECTORmg/ml/potassium chloride glucose 50mg/ml/sodium 87 GVOKE 0.5MG/0.1ML 31 0.04meq/ml/sodium chloride 9mg/ml inj SYRINGEchloride 4.5mg/ml inj glyburide 1.25mg tab 32 GVOKE 1MG/0.2ML 31 glucose 50mg/ml inj 90 glyburide 30 AUTO-INJECTORglucose 87 1.25mg/metformin 250mg GVOKE 1MG/0.2ML 31 50mg/ml/potassium tab SYRINGEchloride 0.01 meq/ml/sodium chloride 0.0769 meq/ml injglucose 50mg/ml/potassium chloride 0.02 meq/ml injglucose 50mg/ml/potassium chloride 0.02 meq/ml/sodium chloride 0.0342 meq/ml injglucose 50mg/ml/potassium chloride 0.02 meq/ml/sodium chloride 0.154 meq/ml inj

87

87

87

glyburide 1.5mg tabglyburide 2.5mg tabglyburide 2.5mg/metformin 500mg tabglyburide 3mg tabglyburide 5mg tabglyburide 5mg/metformin 500mg tabglyburide 6mg tabglycopyrrolate 1mg tabglycopyrrolate 2mg tabGLYXAMBI 10-5MG TABGLYXAMBI 25-5MG TAB

32 32 30

32 32 30

32 102 102 30

30

H

HAEGARDA 2000UNIT INJHAEGARDA 3000UNIT INJhailey 24 fe 28 day packhalobetasol propionate 0.05% creamhalobetasol propionate 0.05% ointmenthaloperidol 0.5mg tabhaloperidol 10mg tabhaloperidol 1mg tabhaloperidol 20mg tabhaloperidol 2mg tabhaloperidol 2mg/ml oral

82

82

66 73

73

52 52 52 52 52 52

soln

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

126

Page 129: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

ALPHABETICAL LISTING OF DRUGS

haloperidol 5mg tab 52 HUMIRA PEDIATRIC 10 hydrochlorothiazide 40 haloperidol 5mg/ml inj 52 CROHN'S STARTER 12.5mg/losartan haloperidol decanoate 52 PACK (3) 80MG/0.8ML potassium 100mg tab100mg/ml (1ml) inj INJ hydrochlorothiazide 40 haloperidol decanoate 52 HUMIRA PEDIATRIC 10 12.5mg/losartan 100mg/ml inj CROHN'S STARTER potassium 50mg tabhaloperidol decanoate 52 PACK SYRINGE (2) hydrochlorothiazide 40 50mg/ml inj 40MG/0.4ML 12.5mg/olmesartan haloperidol decanoate 52 HUMIRA PEN - 10 medoxomil 20mg tab50mg/ml inj CROHN'S STARTER hydrochlorothiazide 40 HAVRIX 1440ELU/ML 104 PACK 40MG/0.8ML INJ 12.5mg/olmesartan INJ HUMIRA PEN - 10 medoxomil 40mg tabHAVRIX 1440ELU/ML 104 CROHN'S STARTER hydrochlorothiazide 40 SYRINGE PACK 80MG/0.8ML INJ 12.5mg/quinapril 10mg HAVRIX 720ELU/0.5ML 104 HUMIRA PEN - 10 tabSYRINGE PSORIASIS STARTER hydrochlorothiazide 40 heparin sodium porcine 22 PACK 40MG/0.8ML INJ 12.5mg/quinapril 20mg 10000unit/ml inj HUMIRA PEN - 10 tabheparin sodium porcine 22 PSORIASIS STARTER hydrochlorothiazide 40 1000unit/ml inj PACK 80MG/0.8ML INJ 12.5mg/valsartan 160mg heparin sodium porcine 22 HUMULIN R 31 tab20000unit/ml inj 500UNIT/ML INJ hydrochlorothiazide 40 heparin sodium porcine 22 HUMULIN R 31 12.5mg/valsartan 320mg 5000unit/ml inj 500UNIT/ML PEN INJ tabHEPATAMINE 8% INJ 91 hydralazine 100mg tab 41 hydrochlorothiazide 40 HETLIOZ 20MG CAP 84 hydralazine 10mg tab 41 12.5mg/valsartan 80mg HIBERIX 10MCG INJ 104 hydralazine 25mg tab 41 tabHUMIRA 10MG/0.1ML 10 hydralazine 50mg tab 41 hydrochlorothiazide 40 SYRINGE hydrochlorothiazide 75 15mg/methyldopa 250mg HUMIRA 10MG/0.2ML 10 12.5mg cap tabSYRINGE hydrochlorothiazide 75 hydrochlorothiazide 75 HUMIRA 20MG/0.2ML 10 12.5mg tab 25mg tabSYRINGE hydrochlorothiazide 40 hydrochlorothiazide 40 HUMIRA 20MG/0.4ML 10 12.5mg/irbesartan 150mg 25mg/lisinopril 20mg tabSYRINGE tab hydrochlorothiazide 40 HUMIRA 40MG/0.4ML 10 hydrochlorothiazide 40 25mg/losartan potassium AUTO-INJECTOR 12.5mg/irbesartan 300mg 100mg tabHUMIRA 40MG/0.4ML 10 tab hydrochlorothiazide 40 SYRINGE hydrochlorothiazide 40 25mg/methyldopa 250mg HUMIRA 40MG/0.8ML 10 12.5mg/lisinopril 10mg tabAUTO-INJECTOR tab hydrochlorothiazide 40 HUMIRA 40MG/0.8ML 10 hydrochlorothiazide 40 25mg/metoprolol tartrate SYRINGE 12.5mg/lisinopril 20mg 100mg tab

tab

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

127

Page 130: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

ALPHABETICAL LISTING OF DRUGS

hydrochlorothiazide 40 hydrocodone bitartrate 13 hydromorphone 2mg tab 13 25mg/metoprolol tartrate 20mg er cap hydromorphone 4mg tab 13 50mg tab hydrocodone bitartrate 13 hydromorphone 8mg tab 13 hydrochlorothiazide 40 30mg er cap hydroxychloroquine 42 25mg/olmesartan hydrocodone bitartrate 13 sulfate 200mg tabmedoxomil 40mg tab 40mg er cap hydroxyurea 500mg cap 48 hydrochlorothiazide 40 hydrocodone bitartrate 13 hydroxyzine 10mg tab 17 25mg/propranolol 40mg 50mg er cap hydroxyzine 25mg tab 17 tab hydrocodone bitartrate 15 hydroxyzine 2mg/ml oral 17 hydrochlorothiazide 40 5mg/ibuprofen 200mg tab soln25mg/propranolol 80mg hydrocodone bitartrate 15 hydroxyzine 50mg tab 17 tab 7.5mg/ibuprofen 200mg HYDROXYZINE 17 hydrochlorothiazide 40 tab PAMOATE 100MG CAP25mg/quinapril 20mg tab hydrocortisone 1% cream 73 hydroxyzine pamoate 17 hydrochlorothiazide 75 hydrocortisone 16 25mg cap25mg/spironolactone 1.67mg/ml enema hydroxyzine pamoate 17 25mg tab hydrocortisone 10mg tab 68 50mg caphydrochlorothiazide 25mg/triamterene 37.5mg caphydrochlorothiazide 25mg/triamterene 37.5mg tabhydrochlorothiazide 25mg/valsartan 160mg tabhydrochlorothiazide 25mg/valsartan 320mg tabhydrochlorothiazide 50mg tabhydrochlorothiazide 50mg/metoprolol tartrate 100mg tabhydrochlorothiazide 50mg/triamterene 75mg tabhydrocodone bitartrate 10mg er caphydrocodone bitartrate 10mg/ibuprofen 200mg tabhydrocodone bitartrate 15mg er cap

75

75

40

40

75

40

75

13

15

13

hydrocortisone 10mg/ml/neomycin 3.5mg/ml/polymyxin b 10000unit/ml ophth susphydrocortisone 10mg/ml/neomycin 3.5mg/ml/polymyxin b 10000unit/ml otic solnhydrocortisone 10mg/ml/neomycin 3.5mg/ml/polymyxin b 10000unit/ml otic susphydrocortisone 2.5% creamhydrocortisone 2.5% lotionhydrocortisone 2.5% ointmenthydrocortisone 20mg tabhydrocortisone 5mg tabhydrocortisone/pramoxin e 1-1% rectal creamhydromorphone 10mg/ml (1ml) injhydromorphone 10mg/ml (5ml) injhydromorphone 1mg/ml oral soln

93

94

94

73

73

73

68 68 16

13

13

13

I

ibandronic acid 150mg tabIBRANCE 100MG CAPIBRANCE 100MG TABIBRANCE 125MG CAPIBRANCE 125MG TABIBRANCE 75MG CAPIBRANCE 75MG TABibu 600mg tabibu 800mg tabibuprofen 20mg/ml suspibuprofen 400mg tabibuprofen 600mg tabibuprofen 800mg tabicatibant 10mg/ml syringeICLUSIG 15MG TABICLUSIG 45MG TABIDHIFA 100MG TABIDHIFA 50MG TABILEVRO 0.3% OPHTH SUSPimatinib 100mg tabimatinib 400mg tabIMBRUVICA 140MG CAPIMBRUVICA 140MG TAB

76

46 46 46 46 46 46 11 11 11 11 11 11 82 46 46 46 46 93

46 46 46

46

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

128

Page 131: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

ALPHABETICAL LISTING OF DRUGS

IMBRUVICA 280MG TAB 46 INSULIN PEN NEEDLE 86 IPOL INJ 104 IMBRUVICA 420MG TAB 46 INSULIN SYRINGE 86 ipratropium bromide 90 IMBRUVICA 560MG TAB 46 (DISP) U-100 0.3ML 0.021mg/act nasal IMBRUVICA 70MG CAP 46 INSULIN SYRINGE 86 inhalerimipramine 10mg tab 29 (DISP) U-100 1/2ML ipratropium bromide 90 imipramine 25mg tab 29 INSULIN SYRINGE 86 0.042mg/act nasal imipramine 50mg tab 29 (DISP) U-100 1ML inhalerimipramine pamoate 29 INTELENCE 100MG TAB 55 ipratropium bromide 19 100mg cap INTELENCE 200MG TAB 55 0.2mg/ml inh solnimipramine pamoate 29 INTELENCE 25MG TAB 55 ipratropium/albuterol 20 125mg cap INTRALIPID 90 0.5-2.5mg/3ml inh solnimipramine pamoate 29 20GM/100ML INJ irbesartan 150mg tab 38 150mg cap INTRALIPID 90 irbesartan 300mg tab 38 imipramine pamoate 29 30GM/100ML INJ irbesartan 75mg tab 38 75mg cap INTRON A 10MU INJ 48 IRESSA 250MG TAB 46 IMIQUIMOD 3.75% 73 INTRON A 10MU/ML INJ 48 ISENTRESS 100MG 55 CREAM INTRON A 18MU INJ 48 CHEW TABimiquimod 5% cream 73 INTRON A 50MU INJ 48 ISENTRESS 100MG 56 IMOVAX 2.5UNIT/ML 104 INTRON A 48 GRANULES FOR ORAL INJ 6000000UNIT/ML INJ SUSPincassia 28 day 0.35mg 68 introvale 91 day pack 66 ISENTRESS 25MG 56 pack INVEGA 117MG/0.75ML 51 CHEW TABINCRELEX 40MG/4ML 76 SYRINGE ISENTRESS 400MG TAB 56 INJ INVEGA 156MG/ML 51 ISENTRESS 600MG TAB 56 INCRUSE 62.5MCG/INH 19 SYRINGE isibloom 28 day pack 66 INH INVEGA 234MG/1.5ML 51 ISOLYTE P INJ 87 indapamide 1.25mg tab 75 SYRINGE ISOLYTE S INJ 87 indapamide 2.5mg tab 75 INVEGA 51 isoniazid 100mg tab 43 INDOCIN 50MG RECTAL 11 273MG/0.875ML ISONIAZID 10MG/ML 43 SUPP SYRINGE ORAL SOLNindomethacin 25mg cap 11 INVEGA 39MG/0.25ML 51 isoniazid 300mg tab 43 indomethacin 50mg cap 11 SYRINGE ISOPROPYL ALCOHOL 86 indomethacin 75mg er 11 INVEGA 51 0.7ML/ML PADcap 410MG/1.315ML isosorbide dinitrate 10mg 16 INFANRIX INJ 102 SYRINGE tabINGREZZA 40MG CAP 98 INVEGA 546MG/1.75ML 51 isosorbide dinitrate 20mg 16 INGREZZA 80MG CAP 98 SYRINGE tabINLYTA 1MG TAB 46 INVEGA 78MG/0.5ML 52 isosorbide dinitrate 30mg 16 INLYTA 5MG TAB 46 SYRINGE tabINNOPRAN 120MG ER 59 INVEGA 52 isosorbide dinitrate 40mg 16 CAP 819MG/2.625ML tabINNOPRAN 80MG ER 59 SYRINGE isosorbide dinitrate 5mg 16 CAP INVIRASE 500MG TAB 55 tabINQOVI 5 TABLET PACK 45 IOPIDINE 1% OPHTH 92 isosorbide mononitrate 16 INREBIC 100MG CAP 46 SOLN 10mg tab

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

129

Page 132: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

ALPHABETICAL LISTING OF DRUGS

isosorbide mononitrate 16 JANUMET 500-50MG 30 JYNARQUE TAB 78 120mg er tabisosorbide mononitrate 16

TABJANUVIA 100MG TAB 31

30/15MG THERAPY PACK

20mg tabisosorbide mononitrate 30mg er tabisosorbide mononitrate 60mg er tabisotretinoin 10mg capisotretinoin 20mg capisotretinoin 30mg capisotretinoin 40mg capisradipine 2.5mg capisradipine 5mg capitraconazole 100mg capitraconazole 10mg/ml oral solnivermectin 3mg tabIXIARO 0.012MG/ML SYRINGE

J

JAKAFI 10MG TABJAKAFI 15MG TABJAKAFI 20MG TABJAKAFI 25MG TABJAKAFI 5MG TABjantoven 10mg tabjantoven 1mg tabjantoven 2.5mg tabjantoven 2mg tabjantoven 3mg tabjantoven 4mg tabjantoven 5mg tabjantoven 6mg tabjantoven 7.5mg tabJANUMET 1000-100MG ER TABJANUMET 1000-50MG ER TABJANUMET 1000-50MG TABJANUMET 500-50MG ER TAB

16

16

69 69 69 69 60 60 34 34

16 104

46 46 46 46 46 21 21 21 21 21 21 21 21 21 30

30

30

30

JANUVIA 25MG TABJANUVIA 50MG TABJARDIANCE 10MG TABJARDIANCE 25MG TABjasmiel 28 day packJENTADUETO 2.5-1000MG ER TABJENTADUETO 2.5-1000MG TABJENTADUETO 2.5-500MG TABJENTADUETO 2.5-850MG TABJENTADUETO 5-1000MG ER TABjinteli 0.005-1mg tabjuleber 28 day packJULUCA 50-25MG TABjunel 1.5/30 21 day packjunel 1/20 21 day packjunel fe 1.5/30 28 day packjunel fe 1/20 28 day packjunel fe 24 1/20 28 day packJUXTAPID 10MG CAPJUXTAPID 20MG CAPJUXTAPID 30MG CAPJUXTAPID 40MG CAPJUXTAPID 5MG CAPJUXTAPID 60MG CAPJYNARQUE 15MG TABJYNARQUE 30MG TABJYNARQUE 45/15 THERAPY PACKJYNARQUE 60/30 THERAPY PACKJYNARQUE 90/30 THERAPY PACKJYNARQUE TAB 15/15MG THERAPY PACK

31 31 32 32 66 30

30

30

30

30

78 66 56 66 66 66

66 66

36 36 36 36 36 36 78 78 78

78

78

78

K

kaitlib fe 28 day packKALETRA 100-25MG TABKALETRA 200-50MG TABKALYDECO 150MG TABKALYDECO 25MG GRANULESKALYDECO 50MG GRANULESKALYDECO 75MG GRANULESkariva 28 day packKCL/D5W/LR INJ 0.15%kelnor 1/35 28 day packkelnor 1/50 28 day packketoconazole 2% creamketoconazole 2% foamketoconazole 2% shampooketoconazole 200mg tabketodan 2% foamKETOPROFEN 200MG ER CAPketorolac tromethamine 0.4% ophth solnketorolac tromethamine 0.5% ophth solnketorolac tromethamine 10mg tabKEVZARA 150MG/1.14ML AUTO-INJECTORKEVZARA 150MG/1.14ML SYRINGEKEVZARA 200MG/1.14ML AUTO-INJECTOR

66 56

56

99 99

99

99

66 87 66 66 70 70 70

34 70 11

93

93

11

11

11

11

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

130

Page 133: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

ALPHABETICAL LISTING OF DRUGS

KEVZARA 11 labetalol 100mg tab 58 lansoprazole 30mg dr cap 102 200MG/1.14ML labetalol 200mg tab 58 lanthanum carbonate 81 SYRINGE labetalol 300mg tab 58 1000mg chew tabKINRIX INJ 102 lactulose 667mg/ml oral 85 lanthanum carbonate 81 KINRIX PF INJ 102 soln 500mg chew tabkionex 15gm/60ml susp 89 LAMICTAL XR BLUE 23 lanthanum carbonate 81 KISQALI 200MG DAILY 46 KIT 750mg chew tabDOSE PACK LAMICTAL XR GREEN 23 LANTUS 100UNIT/ML 31 KISQALI 400MG DAILY 46 KIT INJDOSE PACK LAMICTAL XR ORANGE 23 LANTUS 100UNIT/ML 31 KISQALI 600MG DAILY 46 KIT PEN INJDOSE PACK lamivudine 100mg tab 57 larin 1.5/30 pack 66 KISQALI FEMARA 45 lamivudine 10mg/ml oral 56 larin 1/20 pack 66 CO-PACK 200 PACK soln larin fe 1.5/30 pack 66 KISQALI FEMARA 45 lamivudine 150mg tab 56 larin fe 1/20 pack 66 CO-PACK 400 PACK lamivudine 56 larissia 28 day pack 66 KISQALI FEMARA 45 150mg/zidovudine 300mg LASTACAFT 0.25% 93 CO-PACK 600 PACK tab OPHTH SOLNklor-con 10meq er tab 87 lamivudine 300mg tab 56 latanoprost 0.005% 94 klor-con 10meq micro er 87 lamotrigine 100mg er tab 24 ophth solntab lamotrigine 100mg odt 24 LATUDA 120MG TAB 51 KLOR-CON 15MEQ 87 lamotrigine 100mg tab 24 LATUDA 20MG TAB 51 MICRO ER TAB lamotrigine 150mg tab 24 LATUDA 40MG TAB 51 klor-con 20meq micro er 87 lamotrigine 200mg er tab 24 LATUDA 60MG TAB 51 tab lamotrigine 200mg odt 24 LATUDA 80MG TAB 51 klor-con 20meq powder 88 lamotrigine 200mg tab 24 layolis fe 28 pack 66 for oral soln lamotrigine 250mg er tab 24 leena 28 day pack 66 klor-con 8meq er tab 88 lamotrigine 25mg chew 24 leflunomide 10mg tab 12 KORLYM 300MG TAB 31 tab leflunomide 20mg tab 12 KOSELUGO 10MG CAP 46 lamotrigine 25mg er tab 24 LENVIMA 10 10MG 46 KOSELUGO 25MG CAP 46 lamotrigine 25mg odt 24 PACKKRINTAFEL 150MG TAB 42 lamotrigine 25mg pack 24 LENVIMA 12 4MG PACK 46 KRISTALOSE 20GM 85 lamotrigine 25mg tab 24 LENVIMA 14 PACK 46 POWDER FOR ORAL lamotrigine 300mg er tab 24 LENVIMA 18 PACK 46 SOLN lamotrigine 50mg er tab 24 LENVIMA 20 10MG 46 K-TAB 8MEQ ER TAB 87 lamotrigine 50mg odt 24 PACKkurvelo pack 66 lamotrigine 5mg chew tab 24 LENVIMA 24 PACK 47 KUVAN 100MG 77 lamotrigine ODT kit 24 LENVIMA 4 4MG PACK 47 POWDER FOR ORAL lamotrigine tab 25mg 24 LENVIMA 8 4MG PACK 47 SOLN (42)/100mg (7) starter lessina 28 day pack 66 KUVAN 100MG TAB 77 pack letrozole 2.5mg tab 44 KUVAN 500MG 77 lamotrigine tab 25mg 24 LEUCOVORIN 10MG 48 POWDER FOR ORAL (84)/100mg (14) starter TABSOLN pack LEUCOVORIN 15MG 49

L lansoprazole 15mg dr cap 102 TAB

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

131

Page 134: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

ALPHABETICAL LISTING OF DRUGS

leucovorin 25mg tab 49 levofloxacin 5mg/ml 79 levoxyl 112mcg tab 101 leucovorin 5mg tab 49 (100ml) inj levoxyl 125mcg tab 101 LEUKERAN 2MG TAB 43 levofloxacin 5mg/ml 79 levoxyl 137mcg tab 101 leuprolide acetate 5mg/ml 44 (150ml) inj levoxyl 150mcg tab 101 inj levofloxacin 750mg tab 80 levoxyl 175mcg tab 101 LEVALBUTEROL 20 levonest 28 day pack 66 levoxyl 200mcg tab 101 0.045MG INH levora 0.15/30 28 day 66 levoxyl 25mcg tab 101 levalbuterol 0.103mg/ml 20 pack levoxyl 50mcg tab 101 inh soln levo-t 100mcg tab 100 levoxyl 75mcg tab 101 levalbuterol 0.21mg/ml 20 levo-t 112mcg tab 100 levoxyl 88mcg tab 101 inh soln levo-t 125mcg tab 100 LEXIVA 50MG/ML SUSP 56 levalbuterol 0.417mg/ml 20 levo-t 137mcg tab 100 LIDOCAINE 2% GEL 74 inh soln levo-t 150mcg tab 100 lidocaine 2% topical soln 89 levalbuterol 2.5mg/ml inh 20 levo-t 175mcg tab 100 lidocaine 4% topical soln 74 soln levo-t 200mcg tab 100 lidocaine 5% ointment 74 LEVEMIR 100UNIT/ML 31 levo-t 25mcg tab 100 lidocaine 5% patch 74 INJ levo-t 300mcg tab 100 lidocaine/prilocaine 74 LEVEMIR 100UNIT/ML 31 levo-t 50mcg tab 100 2.5-2.5% creamPEN INJ levo-t 75mcg tab 100 lindane 1% shampoo 74 levetiracetam 1000mg tab 24 levo-t 88mcg tab 100 linezolid 20mg/ml susp 42 levetiracetam 100mg/ml 24 levothyroxine sodium 100 linezolid 2mg/ml inj 42 oral soln 0.025mg tab linezolid 600mg tab 42 levetiracetam 250mg tab 24 levothyroxine sodium 100 LINZESS 145MCG CAP 81 levetiracetam 500mg er 24 0.05mg tab LINZESS 290MCG CAP 81 tab levothyroxine sodium 101 LINZESS 72MCG CAP 81 levetiracetam 500mg tab 24 0.075mg tab liothyronine sodium 101 levetiracetam 750mg er 24 levothyroxine sodium 101 0.005mg tabtab 0.088mg tab liothyronine sodium 101 levetiracetam 750mg tab 24 levothyroxine sodium 101 0.025mg tabLEVOBUNOLOL 0.5% 91 0.112mg tab liothyronine sodium 101 OPHTH SOLN levothyroxine sodium 101 0.05mg tablevocarnitine 100mg/ml 77 0.125mg tab LIPOFEN 150MG CAP 36 oral soln levothyroxine sodium 101 LIPOFEN 50MG CAP 36 levocarnitine 330mg tab 77 0.137mg tab lisinopril 10mg tab 37 levocetirizine 0.5mg/ml 35 levothyroxine sodium 101 lisinopril 2.5mg tab 37 oral soln 0.15mg tab lisinopril 20mg tab 37 levocetirizine 5mg tab 35 levothyroxine sodium 101 lisinopril 30mg tab 37 levofloxacin 0.5% ophth 92 0.175mg tab lisinopril 40mg tab 37 soln levothyroxine sodium 101 lisinopril 5mg tab 37 levofloxacin 250mg tab 79 0.1mg tab lithium carbonate 150mg 51 levofloxacin 25mg/ml inj 79 levothyroxine sodium 101 caplevofloxacin 25mg/ml 79 0.2mg tab lithium carbonate 300mg 51 oral soln levothyroxine sodium 101 caplevofloxacin 500mg tab 79 0.3mg tab lithium carbonate 300mg 51

levoxyl 100mcg tab 101 er tab

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

132

Page 135: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

ALPHABETICAL LISTING OF DRUGS

lithium carbonate 300mg tab

51 LOTEMAX 0.5% OPHTH GEL

93 malathion 0.5% lotionMAPROTILINE 25MG

74 27

lithium carbonate 450mg er tab

51 LOTEMAX 0.5% OPHTH OINTMENT

93 TABMAPROTILINE 50MG 27

lithium carbonate 600mg caplithium citrate 60mg/ml oral solnLITHOSTAT 250MG TABLO LOESTRIN FE 28 DAY PACKLOKELMA 10GM POWDER FOR ORAL SUSPLOKELMA 5GM POWDER FOR ORAL

51

51

82 66

89

89

loteprednol etabonate 0.5% ophth susplovastatin 10mg tablovastatin 20mg tablovastatin 40mg tablow-ogestrel 28 day packloxapine 10mg caploxapine 25mg caploxapine 50mg caploxapine 5mg capLUCEMYRA 0.18MG TAB

93

36 36 36 66 53 53 53 53 96

TABMAPROTILINE 75MG TABmarlissa 28 day packMARPLAN 10MG TABMATULANE 50MG CAPmatzim 180mg er tabmatzim 240mg er tabmatzim 300mg er tabmatzim 360mg er tabmatzim 420mg er tabMAVYRET 100-40MG

27

66 27 48 60 60 60 60 60 57

SUSP LUMIGAN 0.01% OPHTH 94 TABLONHALA 25MCG/ML INH SOLN

19 SOLNLUPANETA PACK 76

MAXIDEX 0.1% OPHTH SUSP

93

LONSURF 6.14-15MG 45 1-MONTH PACK MAYZENT 0.25MG TAB 98 TAB LUPANETA PACK 77 MAYZENT 2MG TAB 98 LONSURF 8.19-20MG TABloperamide 2mg caplopinavir 80mg/ml/ritonavir 20mg/ml oral solutionlopreeza 1/0.5mg 28 day packlorazepam 0.5mg tablorazepam 1mg tablorazepam 2mg tablorazepam 2mg/ml oral solnLORBRENA 100MG TABLORBRENA 25MG TAB

45

33 56

78

18 18 18 18

47 47

3-MONTH PACKLUPRON 11.25MG SYRINGELUPRON 22.5MG SYRINGELUPRON 3.75MG SYRINGELUPRON 30MG SYRINGELUPRON 45MG SYRINGELUPRON 7.5MG SYRINGElutera 28 day packLYNPARZA 100MG TAB

44

44

44

44

44

44

66 47

meclizine 12.5mg tabmeclizine 25mg tabMEDROL 2MG TABmedroxyprogesterone acetate 10mg tabmedroxyprogesterone acetate 150mg/ml injmedroxyprogesterone acetate 150mg/ml syringemedroxyprogesterone acetate 2.5mg tabmedroxyprogesterone acetate 5mg tabMEFLOQUINE 250MG TAB

33 33 68 96

67

67

96

96

42

lorcet 325-10mg tablorcet 325-5mg tabloryna 28 day packlosartan potassium 100mg tablosartan potassium 25mg tablosartan potassium 50mg tab

15 15 66 38

38

38

LYNPARZA 150MG TABLYSODREN 500MG TABlyza 0.35mg pack

M

magnesium sulfate 500mg/ml injmagnesium sulfate 500mg/ml syringe

47 44 68

87

87

megestrol acetate 125mg/ml suspmegestrol acetate 20mg tabmegestrol acetate 40mg tabmegestrol acetate 40mg/ml suspMEKINIST 0.5MG TAB

96

44

44

44

47

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

133

Page 136: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

ALPHABETICAL LISTING OF DRUGS

MEKINIST 2MG TAB 47 metformin 100mg/ml soln 31 methylphenidate 18mg er 9 MEKTOVI 15MG TAB 47 metformin 500mg er tab 31 tabmelodetta 24 fe chewable 66 metformin 500mg tab 31 methylphenidate 1mg/ml 9 28 day pack metformin 750mg er tab 31 oral solnmeloxicam 15mg tab 11 metformin 850mg tab 31 methylphenidate 2.5mg 9 meloxicam 7.5mg tab 11 methadone 10mg tab 13 chew tabmemantine 10mg tab 97 METHADONE 1MG/ML 13 methylphenidate 20mg cr 9 memantine 97 ORAL SOLN cap10mg/memantine 5mg METHADONE 2MG/ML 13 methylphenidate 20mg er 9 pack ORAL SOLN tabmemantine 14mg er cap 97 methadone 5mg tab 13 methylphenidate 20mg la 9 memantine 21mg er cap 97 methazolamide 25mg tab 74 capmemantine 28mg er cap 97 methazolamide 50mg tab 74 methylphenidate 20mg 9 memantine 2mg/ml oral 97 methenamine hippurate 103 tabsoln 1000mg tab methylphenidate 27mg sr 9 memantine 5mg tab 97 methimazole 10mg tab 100 tabmemantine 7mg er cap 97 methimazole 5mg tab 100 methylphenidate 2mg/ml 9 MENACTRA INJ 104 METHITEST 10MG TAB 15 oral solnMENEST 0.3MG TAB 79 methocarbamol 500mg 90 methylphenidate 30mg cr 9 MENEST 0.625MG TAB 79 tab capMENEST 1.25MG TAB 79 methocarbamol 750mg 90 methylphenidate 30mg la 9 MENOSTAR 79 tab cap14MCG/24HR PATCH methotrexate 2.5mg tab 43 methylphenidate 36mg sr 9 MENTAX 1% CREAM 70 methotrexate 25mg/ml 43 tabMENVEO INJ 104 (2ml) inj methylphenidate 40mg cr 9 mercaptopurine 50mg tab 43 methotrexate 25mg/ml inj 43 capmeropenem 1000mg inj 41 methoxsalen 10mg cap 71 methylphenidate 40mg la 9 meropenem 500mg inj 41 METHSCOPOLAMINE 102 capmesalamine 1000mg 80 BROMIDE 2.5MG TAB methylphenidate 50mg cr 9 rectal supp METHSCOPOLAMINE 102 capmesalamine 1200mg dr 80 BROMIDE 5MG TAB methylphenidate 54mg sr 9 tab methyldopa 250mg tab 38 tabmesalamine 375mg er cap 80 methyldopa 500mg tab 38 methylphenidate 5mg 9 mesalamine 400mg dr cap 80 methylphenidate 10mg 9 chew tabmesalamine 66.7mg/ml 80 chew tab methylphenidate 5mg tab 9 enema methylphenidate 10mg cr 9 methylphenidate 60mg cr 9 mesalamine 800mg dr tab 80 cap capMESNEX 400MG TAB 49 methylphenidate 10mg er 9 methylphenidate 60mg la 9 METAPROTERENOL 20 tab capSULFATE 2MG/ML methylphenidate 10mg la 9 methylprednisolone 16mg 68 ORAL SOLN cap tabMETAXALONE 400MG 90 methylphenidate 10mg 9 methylprednisolone 32mg 68 TAB tab tabmetaxalone 800mg tab 90 METHYLPHENIDATE 9 methylprednisolone 4mg 68 metformin 1000mg tab 31 18MG ER TAB pack

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

134

Page 137: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

ALPHABETICAL LISTING OF DRUGS

methylprednisolone 4mg 68 micafungin sodium 34 misoprostol 0.2mg tab 103 tab 100mg inj MITIGARE 0.6MG CAP 82 methylprednisolone 8mg 68 micafungin sodium 50mg 34 M-M-R II INJ 104 tab inj modafinil 100mg tab 9 METHYLTESTOSTERON 15 MICONAZOLE NITRATE 105 modafinil 200mg tab 9 E 10MG CAP 200MG VAGINAL moexipril 15mg tab 37 metoclopramide 10mg tab 80 INSERT moexipril 7.5mg tab 37 metoclopramide 1mg/ml 80 microgestin 1.5/30 21 day 66 MOLINDONE 10MG TAB 53 oral soln pack MOLINDONE 25MG TAB 53 metoclopramide 5mg tab 80 microgestin 1/20 21 day 66 MOLINDONE 5MG TAB 53 metolazone 10mg tab 75 pack mometasone furoate 0.1% 73 metolazone 2.5mg tab 75 microgestin fe 1.5/30 28 66 creammetolazone 5mg tab 75 day pack mometasone furoate 0.1% 73 metoprolol succinate 59 microgestin fe 1/20 28 66 lotion100mg er tab day pack mometasone furoate 0.1% 73 metoprolol succinate 59 midodrine 10mg tab 105 ointment200mg er tab midodrine 2.5mg tab 105 mondoxyne 100mg cap 100 metoprolol succinate 59 midodrine 5mg tab 105 montelukast 10mg tab 19 25mg er tab miglitol 100mg tab 30 montelukast 4mg chew 19 metoprolol succinate 59 miglitol 25mg tab 30 tab50mg er tab miglitol 50mg tab 30 montelukast 4mg 19 metoprolol tartrate 59 miglustat 100mg cap 83 granules100mg tab mili 28 day pack 66 montelukast 5mg chew 19 metoprolol tartrate 25mg 59 MILLIPRED 5MG TAB 68 tabtab mimvey pack 78 MONUROL 5.631GM 103 metoprolol tartrate 50mg 59 minitran 0.1mg/hr patch 16 POWDER FOR ORAL tab minitran 0.2mg/hr patch 16 SOLNmetronidazole 0.75% 74 minitran 0.4mg/hr patch 16 morphine sulfate 100mg 13 cream minitran 0.6mg/hr patch 17 er tabmetronidazole 0.75% gel 74 minocycline 100mg cap 100 morphine sulfate 15mg er 13 metronidazole 0.75% 74 minocycline 100mg tab 100 tablotion minocycline 50mg cap 100 morphine sulfate 15mg 13 metronidazole 0.75% 105 minocycline 50mg tab 100 tabvaginal gel minocycline 75mg cap 100 morphine sulfate 200mg 13 metronidazole 1% gel 74 minocycline 75mg tab 100 er tabmetronidazole 250mg tab 41 minoxidil 10mg tab 41 morphine sulfate 20mg/ml 13 metronidazole 375mg cap 41 minoxidil 2.5mg tab 41 oral solnmetronidazole 500mg tab 41 mirtazapine 15mg odt 26 morphine sulfate 2mg/ml 13 metronidazole 5mg/ml inj 41 mirtazapine 15mg tab 26 oral solnmexiletine 150mg cap 18 mirtazapine 30mg odt 26 morphine sulfate 30mg er 13 mexiletine 200mg cap 18 mirtazapine 30mg tab 26 tabmexiletine 250mg cap 18 mirtazapine 45mg odt 26 morphine sulfate 30mg 13 mibelas 24 fe chewable 66 mirtazapine 45mg tab 26 tab28 day pack mirtazapine 7.5mg tab 26 morphine sulfate 4mg/ml 13

misoprostol 0.1mg tab 103 oral soln

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

135

Page 138: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

ALPHABETICAL LISTING OF DRUGS

morphine sulfate 60mg er 13 naloxone 0.4mg/ml inj 33 NEFAZODONE 50MG 28 tab naloxone 1mg/ml syringe 33 TABMOTEGRITY 1MG TAB 80 naltrexone 50mg tab 33 neomycin sulfate 500mg 10 MOTEGRITY 2MG TAB 80 NAMENDA 28 97 tabMOVANTIK 12.5MG TAB 81 TITRATION PACK neomycin/bacitracin/poly 92 MOVANTIK 25MG TAB 81 naproxen 250mg tab 11 myxin ophth ointment moxifloxacin 0.5% ophth 92 naproxen 375mg dr tab 12 5(3.5)mg-400unit-10000u soln naproxen 375mg tab 12 nitmoxifloxacin 1.6mg/ml inj 80 naproxen 500mg dr tab 12 neomycin/polymyxin/bacit 93 moxifloxacin 400mg tab 80 naproxen 500mg tab 12 racin/hydrocortisone MULTAQ 400MG TAB 18 naproxen sodium 275mg 12 ophth ointmentment 1%mupirocin 2% ointment 70 tab NEPHRAMINE 5.4% INJ 91 mycophenolate mofetil 58 naproxen sodium 550mg 12 NERLYNX 40MG TAB 47 200mg/ml susp tab neuac 5-1.2% gel 70 mycophenolate mofetil 58 naratriptan 1mg tab 86 NEUPRO 1MG/24HR 49 250mg cap naratriptan 2.5mg tab 86 PATCHmycophenolate mofetil 58 NARCAN 4MG/0.1ML 33 NEUPRO 2MG/24HR 49 500mg tab NASAL SPRAY PATCHmycophenolic acid 180mg 89 NATACYN 5% OPHTH 92 NEUPRO 3MG/24HR 49 dr tab SUSP PATCHmycophenolic acid 360mg 89 NATAZIA 28 DAY PACK 66 NEUPRO 4MG/24HR 49 dr tab nateglinide 120mg tab 32 PATCHmyorisan 10mg cap 69 nateglinide 60mg tab 32 NEUPRO 6MG/24HR 49 myorisan 20mg cap 69 NATPARA 100MCG 76 PATCHmyorisan 30mg cap 70 CARTRIDGE NEUPRO 8MG/24HR 49 myorisan 40mg cap 70 NATPARA 25MCG 76 PATCHMYRBETRIQ 25MG ER 104 CARTRIDGE NEVANAC 0.1% OPHTH 94 TAB NATPARA 50MCG 76 SUSPMYRBETRIQ 50MG ER 104 CARTRIDGE NEVIRAPINE 100MG ER 56 TAB NATPARA 75MCG 76 TAB

N

nabumetone 500mg tabnabumetone 750mg tabnadolol 20mg tabnadolol 40mg tabnadolol 80mg tabnafcillin 1000mg injnafcillin 100mg/ml injnafcillin 2000mg injnaftifine 1% creamnaftifine 2% creamNAFTIN 2% GELNALOXONE 0.4MG/ML CARTRIDGE

11 11 59 59 59 96 96 96 70 70 70 33

CARTRIDGENAYZILAM 5MG/0.1ML NASAL SPRAYnecon 0.5/35 28 day packNEEDLES INSULIN DISP. SAFETYNEFAZODONE 100MG TABNEFAZODONE 150MG TABNEFAZODONE 200MG TABNEFAZODONE 250MG TAB

23

66 86

28

28

28

28

nevirapine 10mg/ml suspnevirapine 200mg tabnevirapine 400mg er tabNEXAVAR 200MG TABNEXIUM 10MG GRANULES FOR ORAL SUSPNEXIUM 2.5MG GRANULES FOR ORAL SUSPNEXIUM 20MG GRANULES FOR ORAL SUSP

56 56 56 47

103

102

103

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

136

Page 139: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

ALPHABETICAL LISTING OF DRUGS

NEXIUM 40MG 103 NITRO-DUR 0.3MG/HR 17 NORPACE 150MG ER 18 GRANULES FOR ORAL PATCH CAPSUSP NITRO-DUR 0.8MG/HR 17 NORTHERA 100MG CAP 105 NEXIUM 5MG 102 PATCH NORTHERA 200MG CAP 105 GRANULES FOR ORAL nitrofurantoin macro 103 NORTHERA 300MG CAP 105 SUSP 25mg/nitrofurantoin nortrel 0.5/35 28 day 66 niacin 1000mg er tab 36 mono 75mg cap packniacin 500mg er tab 36 nitrofurantoin 103 nortrel 1/35 21 day pack 66 niacin 750mg er tab 36 macrocrystals 100mg cap nortrel 1/35 28 day pack 67 nicardipine 20mg cap 60 nitrofurantoin 103 nortrel 7/7/7 28 day pack 67 nicardipine 30mg cap 60 macrocrystals 50mg cap nortriptyline 10mg cap 29 NICOTROL 10MG INH 99 nitroglycerin 0.1mg/hr 17 nortriptyline 25mg cap 29 SOLN patch NORTRIPTYLINE 29 NICOTROL 10MG/ML 99 nitroglycerin 0.2mg/hr 17 2MG/ML ORAL SOLNNASAL INHALER patch nortriptyline 50mg cap 29 nifedipine 10mg cap 60 nitroglycerin 0.3mg sl tab 17 nortriptyline 75mg cap 29 nifedipine 20mg cap 60 nitroglycerin 0.4mg sl tab 17 NORVIR 100MG ORAL 56 nifedipine 30mg er tab 60 nitroglycerin 0.4mg/act 17 POWDERnifedipine 30mg osmotic 60 spray NORVIR 80MG/ML 56 er tab nitroglycerin 0.4mg/hr 17 ORAL SOLNnifedipine 60mg er tab 60 patch NOURIANZ 20MG TAB 50 nifedipine 60mg osmotic 61 nitroglycerin 0.6mg sl tab 17 NOURIANZ 40MG TAB 50 er tab nitroglycerin 0.6mg/hr 17 NOVOLIN 31 nifedipine 90mg er tab 61 patch 70-30UNIT/ML INJnifedipine 90mg osmotic 61 NIVESTYM 83 NOVOLIN N 31 er tab 300MCG/0.5ML 100UNIT/ML INJnikki 28 day pack 66 SYRINGE NOVOLIN N 32 nilutamide 150mg tab 44 NIVESTYM 300MCG/ML 83 100UNIT/ML PEN INJnimodipine 30mg cap 61 INJ NOVOLIN R 32 NINLARO 2.3MG CAP 47 NIVESTYM 83 100UNIT/ML INJNINLARO 3MG CAP 47 480MCG/0.8ML NOVOLIN R 32 NINLARO 4MG CAP 47 SYRINGE 100UNIT/ML PEN INJnisoldipine 17mg er tab 61 NIVESTYM 83 NOVOLOG 100UNIT/ML 32 nisoldipine 20mg er tab 61 480MCG/1.6ML INJ CARTRIDGENISOLDIPINE 25.5MG 61 nizatidine 150mg cap 103 NOVOLOG 100UNIT/ML 32 ER TAB nizatidine 300mg cap 103 INJnisoldipine 30mg er tab 61 nora-be 28 day 0.35mg 68 NOVOLOG 100UNIT/ML 32 nisoldipine 34mg er tab 61 pack PEN INJnisoldipine 40mg er tab 61 norethindrone 0.35mg 68 NOVOLOG MIX 32 nisoldipine 8.5mg er tab 61 pack 70-30UNIT/ML INJnitisinone 10mg cap 77 norethindrone acetate 96 NOVOLOG MIX 32 nitisinone 2mg cap 77 5mg tab 70-30UNIT/ML PEN INJnitisinone 5mg cap 77 NORMOSOL-M INJ 87 NOXAFIL 40MG/ML 34 NITRO-BID 2% 17 NORPACE 100MG ER 18 SUSPOINTMENT CAP NUBEQA 300MG TAB 44

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

137

Page 140: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

ALPHABETICAL LISTING OF DRUGS

NUCALA 100MG INJ 19 octreotide 0.1mg/ml inj 77 ONDANSETRON 24MG 33 NUCALA 100MG/ML 19 octreotide 0.2mg/ml inj 77 TABAUTO-INJECTOR octreotide 0.5mg/ml inj 77 ondansetron 4mg odt 33 NUCALA 100MG/ML 19 octreotide 1mg/ml inj 77 ondansetron 4mg tab 33 SYRINGE ODEFSEY 200-25-25MG 56 ondansetron 8mg odt 33 NUCYNTA 100MG ER 13 TAB ondansetron 8mg tab 33 TAB ODOMZO 200MG CAP 43 OPSUMIT 10MG TAB 62 NUCYNTA 150MG ER 13 OFEV 100MG CAP 99 ORAVIG 50MG BUCCAL 89 TAB OFEV 150MG CAP 99 TABNUCYNTA 200MG ER 13 ofloxacin 0.3% ophth soln 92 ORENCIA 125MG/ML 12 TAB ofloxacin 0.3% otic soln 94 AUTO-INJECTORNUCYNTA 250MG ER 13 ofloxacin 400mg tab 80 ORENCIA 125MG/ML 12 TAB olanzapine 10mg inj 53 SYRINGENUCYNTA 50MG ER 13 olanzapine 10mg odt 53 ORENCIA 50MG/0.4ML 12 TAB olanzapine 10mg tab 53 SYRINGENUEDEXTA 20-10MG 98 olanzapine 15mg odt 53 ORENCIA 12 CAP olanzapine 15mg tab 53 87.5MG/0.7ML SYRINGENUPLAZID 10MG TAB 51 olanzapine 2.5mg tab 53 ORENITRAM 0.125MG 62 NUPLAZID 34MG CAP 51 olanzapine 20mg odt 53 ER TABNUTRILIPID 90 olanzapine 20mg tab 53 ORENITRAM 0.25MG ER 62 20GM/100ML INJ olanzapine 5mg odt 53 TABNUZYRA 150MG TAB 99 olanzapine 5mg tab 53 ORENITRAM 1MG ER 62 nyamyc 100000unit/gm 70 olanzapine 7.5mg tab 53 TABtopical powder olmesartan medoxomil 38 ORENITRAM 2.5MG ER 62 nystatin 100000unit/ml 70 20mg tab TABcream olmesartan medoxomil 38 ORENITRAM 5MG ER 62 nystatin 100000unit/ml 89 40mg tab TABsusp olmesartan medoxomil 38 ORFADIN 20MG CAP 77 nystatin 100unit/mg 70 5mg tab ORFADIN 4MG/ML 77 ointment olopatadine 0.1% ophth 94 SUSPnystatin 100unit/mg 70 soln ORILISSA 150MG TAB 76 topical powder olopatadine 0.2% ophth 94 ORILISSA 200MG TAB 76 nystatin 500000unit tab 34 soln ORKAMBI 125-100MG 99 nystop 100000unit/gm 71 olopatadine 0.665mg/act 90 GRANULEStopical powder nasal inhaler ORKAMBI 125-100MG 99

O

OCALIVA 10MG TABOCALIVA 5MG TABocella 28 day packOCTAGAM 1GM/20ML INJOCTAGAM 2GM/20ML INJoctreotide 0.05mg/ml inj

80 80 67 94

94

77

OLUMIANT 1MG TABOLUMIANT 2MG TABomega-3 acid ethyl esters (usp) 1000mg capomeprazole 10mg dr capomeprazole 20mg dr capomeprazole 40mg dr capondansetron 0.8mg/ml oral soln

10 10 35

103 102 103 33

TABORKAMBI 125-200MG TABORKAMBI 188-150MG GRANULESorphenadrine citrate 100mg er taborsythia 28 day packoseltamivir 30mg caposeltamivir 45mg cap

99

99

90

67 58 58

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

138

Page 141: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

ALPHABETICAL LISTING OF DRUGS

oseltamivir 6mg/ml susp 58 oxycodone 10mg tab 13 paricalcitol 0.001mg cap 77 oseltamivir 75mg cap 58 oxycodone 15mg tab 14 paricalcitol 0.002mg cap 77 OSPHENA 60MG TAB 76 oxycodone 1mg/ml oral 14 paricalcitol 0.004mg cap 77 OTEZLA 28-DAY 12 soln PAROMOMYCIN 250MG 10 STARTER PACK oxycodone 20mg tab 14 CAPOTEZLA 30MG TAB 12 oxycodone 20mg/ml oral 14 paroxetine 10mg tab 27 oxacillin 1000mg inj 96 soln paroxetine 12.5mg er tab 27 oxacillin 100mg/ml inj 96 oxycodone 30mg tab 14 paroxetine 20mg tab 27 oxacillin 2000mg inj 96 oxycodone 5mg cap 14 paroxetine 25mg er tab 27 OXACILLIN 20MG/ML 96 oxycodone 5mg tab 14 paroxetine 30mg tab 27 INJ oxymorphone 10mg tab 14 paroxetine 37.5mg er tab 27 OXACILLIN 40MG/ML 96 oxymorphone 5mg tab 14 paroxetine 40mg tab 27 INJ OZEMPIC 2MG/1.5ML 31 PASER D/R 4GM 43 oxandrolone 10mg tab 15 PEN INJ GRANULESoxandrolone 2.5mg tab 15 OZEMPIC 2MG/1.5ML 31 PAXIL 10MG/5ML SUSP 27 oxaprozin 600mg tab 12 PEN INJ (1MG DOSE) PEDIARIX INJ 102 OXAZEPAM 10MG CAPOXAZEPAM 15MG CAPOXAZEPAM 30MG CAPOXBRYTA 500MG TABoxcarbazepine 150mg taboxcarbazepine 300mg taboxcarbazepine 600mg taboxcarbazepine 60mg/ml suspOXERVATE 0.002% OPHTH SOLNoxiconazole 1% creamOXISTAT 1% LOTIONOXTELLAR 150MG ER TABOXTELLAR 300MG ER TABOXTELLAR 600MG ER TABoxybutynin chloride 10mg er taboxybutynin chloride 15mg er taboxybutynin chloride 1mg/ml oral solnoxybutynin chloride 5mg er taboxybutynin chloride 5mg tab

18 18 18 83 24 24 24 24

92

71 71 24

24

24

103

103

103

103

103

P

pacerone 100mg tabpacerone 200mg tabpacerone 400mg tabpaliperidone 1.5mg er tabpaliperidone 3mg er tabpaliperidone 6mg er tabpaliperidone 9mg er tabPALYNZIQ 10MG/0.5ML SYRINGEPALYNZIQ 2.5MG/0.5ML SYRINGEPALYNZIQ 20MG/ML SYRINGEpantoprazole 20mg dr tabpantoprazole 40mg dr tabPANZYGA 10GM/100ML INJPANZYGA 1GM/10ML INJPANZYGA 2.5GM/25ML INJPANZYGA 20GM/200ML INJPANZYGA 30GM/300ML INJPANZYGA 5GM/50ML INJ

18 18 18 52 52 52 52 77

77

77

102 103 94

94

94

95

95

95

PEDVAXHIB 7.5MCG/0.5ML INJpeg 3350/electrolyte oral solnpeg 3350/kcl/sodium bicarbonate/sodium chloride powder for oral solnPEGANONE 250MG TABPEGASYS 180MCG/0.5ML AUTO-INJECTORPEGASYS 180MCG/0.5ML SYRINGEPEGASYS 180MCG/ML INJPEMAZYRE 13.5MG TABPEMAZYRE 4.5MG TABPEMAZYRE 9MG TABpenicillamine 250mg tabpenicillin g potassium 1000000unit/ml injPENICILLIN G POTASSIUM 40000UNIT/ML INJPENICILLIN G POTASSIUM 60000UNIT/ML INJ

104

85

85

26 57

57

57

47 47 47 88 95

95

95

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

139

Page 142: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

ALPHABETICAL LISTING OF DRUGS

PENICILLIN G 95 phenobarbital 15mg tab 84 pioglitazone 30mg tab 32 PROCAINE phenobarbital 16.2mg tab 84 pioglitazone 45mg tab 32 600000UNIT/ML phenobarbital 30mg tab 84 piperacillin 96 SYRINGE phenobarbital 32.4mg tab 84 2000mg/tazobactam PENICILLIN G SODIUM 95 phenobarbital 4mg/ml 84 250mg inj100000UNIT/ML INJ oral soln piperacillin 96 penicillin v potassium 95 phenobarbital 60mg tab 84 200mg/ml/tazobactam 250mg tab phenobarbital 64.8mg tab 84 25mg/ml injPENICILLIN V 95 phenobarbital 97.2mg tab 84 piperacillin 96 POTASSIUM 25MG/ML phenoxybenzamine 10mg 38 3000mg/tazobactam ORAL SOLN cap 375mg injpenicillin v potassium 95 PHENYLEPHRINE 69 piperacillin 96 500mg tab 1MG/ML/PROMETHAZI 4000mg/tazobactam PENICILLIN V 95 NE 1.25MG/ML ORAL 500mg injPOTASSIUM 50MG/ML SOLN PIQRAY 200MG DAILY 47 ORAL SOLN phenytoin 25mg/ml susp 26 DOSE PACKpentamidine isethionate 41 phenytoin 50mg chew tab 26 PIQRAY 250MG DAILY 47 300mg inj phenytoin sodium 100mg 26 DOSE PACKpentamidine isethionate 41 er cap PIQRAY 300MG DAILY 47 50mg/ml inh soln phenytoin sodium 200mg 26 DOSE 150MG PACKpentoxifylline 400mg er 82 er cap pirmella 1/35 28 day pack 67 tab phenytoin sodium 300mg 26 piroxicam 10mg cap 12 PERFOROMIST 20 er cap piroxicam 20mg cap 12 20MCG/2ML INH SOLN PHOSLYRA 667MG/5ML 81 PLASMA-LYTE 148 INJ 87 perindopril erbumine 37 ORAL SOLN PLASMALYTE A INJ 87 2mg tab PHOSPHOLINE IODIDE 91 PLEGRIDY 98 perindopril erbumine 37 0.125% OPHTH SOLN 125MCG/0.5ML 4mg tab PICATO 0.015% GEL 71 AUTO-INJECTORperindopril erbumine 37 PICATO 0.05% GEL 71 PLEGRIDY 98 8mg tab PIFELTRO 100MG TAB 56 125MCG/0.5ML permethrin 5% cream 74 pilocarpine 1% ophth 91 SYRINGEperphenazine 16mg tab 54 soln PLEGRIDY PEN 98 perphenazine 2mg tab 54 pilocarpine 2% ophth 91 STARTER PACKperphenazine 4mg tab 54 soln PLEGRIDY STARTER 98 perphenazine 8mg tab 54 pilocarpine 4% ophth 91 PACKPERSERIS 120MG 52 soln plenamine 15% inj 91 SYRINGE pilocarpine 5mg tab 89 podofilox 0.5% topical 74 PERSERIS 90MG 52 pilocarpine 7.5mg tab 89 solnSYRINGE pimecrolimus 1% cream 73 polymyxin b 92 PEXEVA 10MG TAB 27 PIMOZIDE 1MG TAB 98 10000unit/ml/trimethopri PEXEVA 20MG TAB 27 PIMOZIDE 2MG TAB 98 m 1mg/ml ophth solnPEXEVA 30MG TAB 28 pimtrea pack 67 polymyxin b 42 PEXEVA 40MG TAB 28 pindolol 10mg tab 59 250000unit/ml injphenelzine 15mg tab 27 pindolol 5mg tab 59 POMALYST 1MG CAP 44 phenobarbital 100mg tab 84 pioglitazone 15mg tab 32 POMALYST 2MG CAP 44

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

140

Page 143: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

ALPHABETICAL LISTING OF DRUGS

POMALYST 3MG CAP 44 potassium chloride 8meq 88 prazosin 5mg cap 38 POMALYST 4MG CAP 44 er tab PRED MILD 0.12% 93 portia 28 day pack 67 potassium citrate 10meq 81 OPHTH SUSPposaconazole 100mg dr 34 er tab PRED-G 0.3-0.6% 93 tab potassium citrate 15meq 81 OPHTH OINTMENTpotassium chloride 0.02 87 er tab PRED-G 0.3-1% OPHTH 93 meq/ml/sodium chloride potassium citrate 5meq er 81 SUSP0.0769 meq/ml inj tab PREDNICARBATE 0.1% 73 potassium chloride 0.02 87 PRADAXA 110MG CAP 22 CREAMmeq/ml/sodium chloride PRADAXA 150MG CAP 22 PREDNICARBATE 0.1% 73 0.154 meq/ml inj PRADAXA 75MG CAP 22 OINTMENTPOTASSIUM CHLORIDE 87 PRALUENT 150MG/ML 37 PREDNISOLONE 1% 93 0.04 MEQ/ML/SODIUM AUTO-INJECTOR OPHTH SOLNCHLORIDE 0.154 PRALUENT 75MG/ML 37 prednisolone 10mg odt 68 MEQ/ML INJ AUTO-INJECTOR prednisolone 15mg odt 68 POTASSIUM CHLORIDE 88 pramipexole 0.125mg tab 49 prednisolone 1mg/ml oral 68 0.1MEQ/ML INJ pramipexole 0.25mg tab 49 solnPOTASSIUM CHLORIDE 88 pramipexole 0.375mg er 49 prednisolone 2mg/ml oral 68 0.2MEQ/ML INJ tab solnPOTASSIUM CHLORIDE 88 pramipexole 0.5mg tab 49 prednisolone 30mg odt 68 0.4MEQ/ML INJ pramipexole 0.75mg er 49 PREDNISOLONE 68 potassium chloride 88 tab 3MG/ML ORAL SOLN1.33meq/ml oral soln pramipexole 0.75mg tab 49 prednisolone 4mg/ml oral 68 potassium chloride 88 pramipexole 1.5mg er tab 49 soln10meq er cap pramipexole 1.5mg tab 49 PREDNISOLONE 68 potassium chloride 88 pramipexole 1mg tab 49 5MG/ML ORAL SOLN10meq er tab pramipexole 2.25mg er 49 PREDNISOLONE 93 potassium chloride 88 tab ACETATE 1% OPHTH 10meq micro er tab pramipexole 3.75mg er 49 SUSPpotassium chloride 88 tab PREDNISOLONE 93 2.67meq/ml oral soln pramipexole 3mg er tab 49 SODIUM PHOSPHATE potassium chloride 88 pramipexole 4.5mg er tab 49 2.5MG/ML/SULFACETA 20meq er tab prasugrel 10mg tab 83 MIDE SODIUM potassium chloride 88 prasugrel 5mg tab 83 100MG/ML OPHTH 20meq micro er tab pravastatin sodium 10mg 36 SOLNpotassium chloride 88 tab prednisone 10mg tab 68 20meq powder for oral pravastatin sodium 20mg 36 prednisone 1mg tab 68 soln tab PREDNISONE 1MG/ML 68 potassium chloride 88 pravastatin sodium 40mg 36 ORAL SOLN2meq/ml (20ml) inj tab prednisone 2.5mg tab 68 potassium chloride 88 pravastatin sodium 80mg 36 prednisone 20mg tab 68 2meq/ml inj tab prednisone 50mg tab 68 potassium chloride 8meq 88 praziquantel 600mg tab 16 prednisone 5mg tab 68 er cap prazosin 1mg cap 38 PREDNISONE 5MG/ML 69

prazosin 2mg cap 38 ORAL SOLN

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

141

Page 144: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

ALPHABETICAL LISTING OF DRUGS

PREFEST 30 DAY PACK 78 PRIMAQUINE 42 PROMACTA 75MG TAB 84 pregabalin 100mg cap 24 PHOSPHATE 26.3MG promethazine 1.25mg/ml 35 pregabalin 150mg cap 24 TAB oral solnpregabalin 200mg cap 24 primidone 250mg tab 24 promethazine 12.5mg 35 pregabalin 20mg/ml oral 24 primidone 50mg tab 24 rectal suppsoln PRIVIGEN 20GM/200ML 95 promethazine 12.5mg tab 35 pregabalin 225mg cap 24 INJ promethazine 25mg rectal 35 pregabalin 25mg cap 24 probenecid 500mg tab 82 supppregabalin 300mg cap 24 PROCALAMINE 3% INJ 91 promethazine 25mg tab 35 pregabalin 50mg cap 24 procentra 5mg/5ml oral 8 promethazine 50mg tab 35 pregabalin 75mg cap 24 soln promethegan 25mg rectal 35 PREMARIN 0.3MG TAB 79 prochlorperazine 10mg 54 suppPREMARIN 0.45MG TAB 79 tab PROMETHEGAN 50MG 35 PREMARIN 0.625MG 79 prochlorperazine 25mg 54 RECTAL SUPPTAB rectal supp propafenone 150mg tab 18 PREMARIN 105 prochlorperazine 5mg tab 54 propafenone 225mg er 18 0.625MG/GM VAGINAL procto-med 2.5% cream 16 capCREAM procto-pak 1% rectal 16 propafenone 225mg tab 18 PREMARIN 0.9MG TAB 79 cream propafenone 300mg tab 18 PREMARIN 1.25MG TAB 79 proctosol 2.5% cream 16 propafenone 325mg er 18 PREMASOL 10% INJ 91 proctozone hc 2.5% 16 capPREMPHASE 28 DAY 78 cream propafenone 425mg er 18 PACK progesterone 100mg cap 96 capPREMPRO 0.3/1.5MG 28 78 progesterone 200mg cap 96 proparacaine 0.5% ophth 92 DAY PACK PROGRAF 0.2MG 89 solnPREMPRO 0.45/1.5 28 78 GRANULES FOR ORAL propranolol 10mg tab 59 DAY PACK SUSP propranolol 120mg er 59 PREMPRO 0.625/2.5MG 78 PROGRAF 1MG 89 cap28 DAY PACK GRANULES FOR ORAL propranolol 160mg er 59 PREMPRO 0.625/5MG 78 SUSP cap28 DAY PACK PROLASTIN 1000MG INJ 99 propranolol 20mg tab 59 prevalite 4gm powder for 35 PROLENSA 0.07% 94 propranolol 40mg tab 59 oral susp OPHTH SOLN PROPRANOLOL 59 previfem 28 day pack 67 PROLIA 60MG/ML 76 4MG/ML ORAL SOLNPREVYMIS 240MG TAB 57 SYRINGE propranolol 60mg er cap 59 PREVYMIS 480MG TAB 57 PROMACTA 12.5MG 83 propranolol 60mg tab 59 PREZCOBIX 150-800MG 56 POWDER FOR ORAL propranolol 80mg er cap 59 TAB SUSP propranolol 80mg tab 59 PREZISTA 100MG/ML 56 PROMACTA 12.5MG 83 PROPRANOLOL 59 SUSP TAB 8MG/ML ORAL SOLNPREZISTA 150MG TAB 56 PROMACTA 25MG 83 propylthiouracil 50mg 100 PREZISTA 600MG TAB 56 POWDER FOR ORAL tabPREZISTA 75MG TAB 56 SUSP PROQUAD INJ 104 PREZISTA 800MG TAB 56 PROMACTA 25MG TAB 83 PROSOL 20% INJ 91 PRIFTIN 150MG TAB 43 PROMACTA 50MG TAB 83 protriptyline 10mg tab 29

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

142

Page 145: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

ALPHABETICAL LISTING OF DRUGS

protriptyline 5mg tab 29 QUINIDINE SULFATE 18 REGRANEX 0.01% GEL 74 PULMOZYME 1MG/ML 99 200MG TAB RELENZA 5MG/BLISTER 58 INH SOLN QUINIDINE SULFATE 18 INHPURIXAN 43 300MG TAB repaglinide 0.5mg tab 32 2000MG/100ML SUSP quinine sulfate 324mg 42 repaglinide 1mg tab 32 PYLERA 103 cap repaglinide 2mg tab 32 140-125-125MG CAPpyrazinamide 500mg tabpyridostigmine bromide 12mg/ml oral solnpyridostigmine bromide 180mg er tabpyridostigmine bromide 60mg tab

Q

QBRELIS 1MG/ML ORAL SOLNQINLOCK 50MG TABQUADRACEL INJQUDEXY 100MG ER CAPQUDEXY 150MG ER CAPQUDEXY 200MG ER CAPQUDEXY 25MG ER CAPQUDEXY 50MG ER CAPquetiapine 100mg tabquetiapine 150mg er tabquetiapine 200mg er tabquetiapine 200mg tabquetiapine 25mg tabquetiapine 300mg er tabquetiapine 300mg tabquetiapine 400mg er tabquetiapine 400mg tabquetiapine 50mg er tabquetiapine 50mg tabquinapril 10mg tabquinapril 20mg tabquinapril 40mg tabquinapril 5mg tabquinidine gluconate 324mg er tab

43 43

43

43

37

47 102 24

25

25

25 25 53 53 53 53 53 53 53 53 53 53 53 37 37 37 37 18

R

RABAVERT 2.5UNIT/ML INJrabeprazole sodium 20mg dr tabraloxifene 60mg tabramelteon 8mg tabramipril 1.25mg capramipril 10mg capramipril 2.5mg capramipril 5mg capranolazine 1000mg er tabranolazine 500mg er tabrasagiline 0.5mg tabrasagiline 1mg tabRAVICTI 1.1GM/ML ORAL SOLNREBIF 22MCG/0.5ML AUTO-INJECTORREBIF 22MCG/0.5ML SYRINGEREBIF 44MCG/0.5ML AUTO-INJECTORREBIF 44MCG/0.5ML SYRINGEREBIF REBIDOSE PACKREBIF TITRATION PACKreclipsen 28 day packRECOMBIVAX 10MCG/ML INJRECOMBIVAX 10MCG/ML SYRINGERECOMBIVAX 40MCG/ML INJRECOMBIVAX 5MCG/0.5ML SYRINGERECTIV 0.4% RECTAL OINTMENT

104

102

76 84 37 37 37 37 16 16 50 50 77

98

98

98

98

98 98 67

104

104

104

104

16

REPATHA 140MG/ML AUTO-INJECTORREPATHA 140MG/ML SYRINGEREPATHA 420MG/3.5ML CARTRIDGERESTASIS 0.05% OPHTH SUSPRETACRIT 10000UNIT/ML INJRETACRIT 2000UNIT/ML INJRETACRIT 3000UNIT/ML INJRETACRIT 40000UNIT/ML INJRETACRIT 4000UNIT/ML INJRETEVMO 40MG CAPRETEVMO 80MG CAPREVLIMID 10MG CAPREVLIMID 15MG CAPREVLIMID 2.5MG CAPREVLIMID 20MG CAPREVLIMID 25MG CAPREVLIMID 5MG CAPREXULTI 0.25MG TABREXULTI 0.5MG TABREXULTI 1MG TABREXULTI 2MG TABREXULTI 3MG TABREXULTI 4MG TABREYATAZ 50MG ORAL POWDERRHOPRESSA 0.02% OPHTH SOLNribavirin 200mg capribavirin 200mg tabRIDAURA 3MG CAP

37

37

37

92

84

84

84

84

84

47 47 88 88 88 88 88 88 54 54 54 55 55 55 56

92

57 57 10

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

143

Page 146: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

ALPHABETICAL LISTING OF DRUGS

rifabutin 150mg cap 43 rivastigmine 0.554mg/hr 97 RUBRACA 200MG TAB 47 rifampin 150mg cap 43 patch RUBRACA 250MG TAB 47 rifampin 300mg cap 43 rivastigmine 1.5mg cap 97 RUBRACA 300MG TAB 47 rifampin 600mg inj 43 rivastigmine 3mg cap 97 RUCONEST 2100UNIT 82 riluzole 50mg tab 90 rivastigmine 4.5mg cap 97 INJRIMANTADINE 100MG 58 rivastigmine 6mg cap 97 RUKOBIA 600MG ER 56 TAB rivelsa 91 day pack 67 TABRINVOQ 15MG ER TAB 10 rizatriptan 10mg odt 86 RUZURGI 10MG TAB 43 RIOMET 500MG/5ML ER 31 rizatriptan 10mg tab 86 RYBELSUS 14MG TAB 31 SUSP rizatriptan 5mg odt 86 RYBELSUS 3MG TAB 31 risedronate sodium 76 rizatriptan 5mg tab 86 RYBELSUS 7MG TAB 31 150mg tab ROCKLATAN 92 RYDAPT 25MG CAP 47 risedronate sodium 30mg tabrisedronate sodium 35mg (12) packrisedronate sodium 35mg (4) packrisedronate sodium 35mg tabrisedronate sodium 5mg tabRISPERDAL 12.5MG INJRISPERDAL 25MG INJRISPERDAL 37.5MG INJRISPERDAL 50MG INJrisperidone 0.25mg odtrisperidone 0.25mg tabrisperidone 0.5mg odtrisperidone 0.5mg tabrisperidone 1mg odtrisperidone 1mg tabrisperidone 1mg/ml oral solnrisperidone 2mg odtrisperidone 2mg tabrisperidone 3mg odtrisperidone 3mg tabrisperidone 4mg odtrisperidone 4mg tabritonavir 100mg tabrivastigmine 0.192mg/hr patchrivastigmine 0.396mg/hr

76

76

76

76

76

52 52 52 52 52 52 52 52 52 52 52

52 52 52 52 52 52 56 97

97

0.05-0.2MG/ML OPHTH SOLNropinirole 0.25mg tabropinirole 0.5mg tabropinirole 12mg er tabropinirole 1mg tabropinirole 2mg er tabropinirole 2mg tabropinirole 3mg tabropinirole 4mg er tabropinirole 4mg tabropinirole 5mg tabropinirole 6mg er tabropinirole 8mg er tabrosuvastatin calcium 10mg tabrosuvastatin calcium 20mg tabrosuvastatin calcium 40mg tabrosuvastatin calcium 5mg tabROTARIX SUSPROTATEQ SUSProweepra 1000mg tabroweepra 500mg er tabroweepra 500mg tabroweepra 750mg er tabroweepra 750mg tabROZLYTREK 100MG CAPROZLYTREK 200MG

49 49 49 50 49 50 49 49 49 50 50 50 36

36

36

36

104 104 25 25 25 25 25 47

47

S

salmon calcitonin 200unit/act nasal spraySANCUSO 3.1MG/24HR PATCHSANDIMMUNE 100MG/ML ORAL SOLNSANTYL 250UNIT/GM OINTMENTSAPHRIS 10MG SL TABSAPHRIS 2.5MG SL TABSAPHRIS 5MG SL TABSAVELLA 100MG TABSAVELLA 12.5MG TABSAVELLA 25MG TABSAVELLA 4-WEEK TITRATION PACKSAVELLA 50MG TABscopolamine 0.0139mg/hr patchSECUADO 3.8MG/24HR PATCHSECUADO 5.7MG/24HR PATCHSECUADO 7.6MG/24HR PATCHselegiline 5mg capselegiline 5mg tabselenium sulfide 2.5% shampooSELZENTRY 150MG TAB

76

33

58

73

53 53 53 97 97 97 97

97 33

53

53

53

50 50 71

56

patch CAP

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

144

Page 147: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

ALPHABETICAL LISTING OF DRUGS

SELZENTRY 20MG/ML 56 SIMPONI 50MG/0.5ML 10 solifenacin succinate 5mg 103 ORAL SOLN AUTO-INJECTOR tabSELZENTRY 25MG TAB 56 SIMPONI 50MG/0.5ML 10 SOLIQUA 30 SELZENTRY 300MG TAB 56 SYRINGE 100UNIT-0.033MG/ML SELZENTRY 75MG TAB 56 simvastatin 10mg tab 36 PEN INJSEREVENT 20 simvastatin 20mg tab 36 SOLOSEC 2GM 9 50MCG/DOSE INH simvastatin 40mg tab 36 GRANULESsertraline 100mg tab 28 simvastatin 5mg tab 36 SOLTAMOX 10MG/5ML 44 sertraline 20mg/ml oral 28 simvastatin 80mg tab 36 ORAL SOLNsoln sirolimus 0.5mg tab 58 SOMATULINE 78 sertraline 25mg tab 28 sirolimus 1mg tab 58 120MG/0.5ML SYRINGEsertraline 50mg tab 28 sirolimus 1mg/ml oral 89 SOMATULINE 78 setlakin 91 day pack 67 soln 60MG/0.2ML SYRINGESEVELAMER 400MG 81 sirolimus 2mg tab 58 SOMATULINE 78 TAB SIRTURO 100MG TAB 43 90MG/0.3ML SYRINGEsevelamer 800mg tab 81 SIRTURO 20MG TAB 43 SOMAVERT 10MG INJ 76 sevelamer carbonate 81 SIVEXTRO 200MG INJ 42 SOMAVERT 15MG INJ 76 2400mg powder for oral SIVEXTRO 200MG TAB 42 SOMAVERT 20MG INJ 76 susp SKLICE 0.5% LOTION 74 SOMAVERT 25MG INJ 76 sevelamer carbonate 81 SKYRIZI 150MG DOSE 71 SOMAVERT 30MG INJ 76 800mg powder for oral PACK 75MG/0.83ML SORILUX 0.005% FOAM 71 susp SLYND 4MG PACK 68 sorine 120mg tab 59 sevelamer carbonate 81 sodium chloride 81 sorine 160mg tab 59 800mg tab 0.154meq/ml soln sorine 240mg tab 59 sharobel 28 day 0.35mg 68 sodium chloride 30mg/ml 88 sorine 80mg tab 59 pack inj sotalol 120mg tab 59 SHINGRIX 105 sodium chloride 4.5mg/ml 88 sotalol 160mg tab 59 50MCG/0.5ML INJ inj sotalol 240mg tab 59 SIGNIFOR 0.3MG/ML 78 sodium chloride 50mg/ml 88 sotalol 80mg tab 59 INJ inj sotalol af 120mg tab 59 SIGNIFOR 0.6MG/ML 78 sodium chloride 9mg/ml 88 sotalol AF 160mg tab 59 INJ inj sotalol AF 80mg tab 59 SIGNIFOR 0.9MG/ML 78 sodium phenylbutyrate 77 spironolactone 100mg 75 INJ 0.94mg/mg oral powder tabsildenafil 20mg tab 62 sodium polystyrene 89 spironolactone 25mg tab 75 silodosin 4mg cap 82 sulfonate 15000mg spironolactone 50mg tab 75 silodosin 8mg cap 82 powder for oral susp sprintec 28 day pack 67 silver sulfadiazine 1% 72 sodium polystyrene 89 SPRITAM 1000MG TAB 25 cream sulfonate 250mg/ml susp FOR ORAL SUSPSIMBRINZA 0.2-1% 92 SOFOSBUVIR 57 SPRITAM 250MG TAB 25 OPHTH SUSP 400MG/VELPATASVIR FOR ORAL SUSPSIMPONI 100MG/ML 10 100MG TAB SPRITAM 500MG TAB 25 AUTO-INJECTOR solifenacin succinate 103 FOR ORAL SUSPSIMPONI 100MG/ML 10 10mg tab SPRITAM 750MG TAB 25 SYRINGE FOR ORAL SUSP

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

145

Page 148: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

ALPHABETICAL LISTING OF DRUGS

SPRYCEL 100MG TAB 47 sulfacetamide sodium 70 SUTENT 37.5MG CAP 47 SPRYCEL 140MG TAB 47 10% lotion SUTENT 50MG CAP 47 SPRYCEL 20MG TAB 47 SULFACETAMIDE 92 syeda 28 day pack 67 SPRYCEL 50MG TAB 47 SODIUM 10% OPHTH SYMDEKO 99 SPRYCEL 70MG TAB 47 OINTMENT 50-75MG/75MG PACKSPRYCEL 80MG TAB 47 sulfacetamide sodium 92 SYMDEKO TAB 4-WEEK 99 sps 15gm/60ml susp 89 10% ophth soln PACKsronyx 28 day pack 67 SULFADIAZINE 500MG 99 SYMFI 400-300-300MG 56 ssd 1% cream 72 TAB TABSTALEVO 50 sulfamethoxazole 41 SYMFI 600-300-300MG 56 12.5-200-50MG TAB 400mg/trimethoprim TABSTALEVO 50 80mg tab SYMJEPI 0.15MG/0.3ML 105 18.75-200-75MG TAB sulfamethoxazole 41 SYRINGESTALEVO 50 40mg/ml/trimethoprim SYMJEPI 0.3MG/0.3ML 105 25-200-100MG TAB 8mg/ml susp SYRINGESTALEVO 50 sulfamethoxazole 41 SYMPAZAN 10MG 23 31.25-200-125MG TAB 800mg/trimethoprim ORAL FILMSTALEVO 50 160mg tab SYMPAZAN 20MG 23 37.5-200-150MG TAB SULFAMYLON 72 ORAL FILMSTALEVO 50 85MG/GM CREAM SYMPAZAN 5MG ORAL 23 50-200-200MG TAB sulfasalazine 500mg dr 80 FILMstavudine 15mg cap 56 tab SYMPROIC 0.2MG TAB 81 stavudine 20mg cap 56 sulfasalazine 500mg tab 80 SYMTUZA 56 stavudine 30mg cap 56 sulindac 150mg tab 12 800-150-200-10MG TABstavudine 40mg cap 56 sulindac 200mg tab 12 SYNAREL 2MG/ML 77 STELARA 45MG/0.5ML 71 sumatriptan 100mg tab 86 NASAL INHALERINJ sumatriptan 12mg/ml inj 86 SYNJARDY 10-1000MG 30 STELARA 45MG/0.5ML 71 SUMATRIPTAN 86 ER TABSYRINGE 12MG/ML SYRINGE SYNJARDY 30 STELARA 90MG/ML 71 sumatriptan 20mg/act 86 12.5-1000MG ER TABSYRINGE nasal spray SYNJARDY 30 STIMATE 1.5MG/ML 77 sumatriptan 25mg tab 86 12.5-1000MG TABNASAL INHALER sumatriptan 50mg tab 86 SYNJARDY 12.5-500MG 30 STIOLTO 20 sumatriptan 5mg/act 86 TAB0.0025-0.0025MG INH nasal spray SYNJARDY 25-1000MG 30 STIVARGA 40MG TAB 47 SUNOSI 150MG TAB 8 ER TABSTREPTOMYCIN 10 SUNOSI 75MG TAB 8 SYNJARDY 5-1000MG 30 1000MG INJ SUPRAX 100MG CHEW 64 ER TABSTRIBILD 56 TAB SYNJARDY 5-1000MG 30 150-150-200-300MG SUPRAX 200MG CHEW 64 TABTAB TAB SYNJARDY 5-500MG 30 SUCRAID 8500UNIT/ML 74 SUPRAX 500MG/5ML 64 TABORAL SOLN SUSP SYNRIBO 3.5MG INJ 48 sucralfate 1000mg tab 102 SUTENT 12.5MG CAP 47 SYNTHROID 100MCG 101 sucralfate 100mg/ml susp 103 SUTENT 25MG CAP 47 TAB

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

146

Page 149: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

ALPHABETICAL LISTING OF DRUGS

SYNTHROID 112MCG 101 TALTZ 80MG/ML 71 TEKTURNA HCT 40 TAB SYRINGE 150-25MG TABSYNTHROID 125MCG 101 TALZENNA 0.25MG CAP 48 TEKTURNA HCT 40 TAB TALZENNA 1MG CAP 48 300-12.5MG TABSYNTHROID 137MCG 101 tamoxifen 10mg tab 44 TEKTURNA HCT 40 TAB tamoxifen 20mg tab 44 300-25MG TABSYNTHROID 150MCG 101 tamsulosin 0.4mg cap 82 telmisartan 20mg tab 38 TAB TARGRETIN 1% GEL 71 telmisartan 40mg tab 38 SYNTHROID 175MCG 101 tarina 24 fe 1/20 28 day 67 telmisartan 80mg tab 38 TAB pack temazepam 15mg cap 84 SYNTHROID 200MCG 101 tarina fe 1/20 28 day 67 temazepam 22.5mg cap 84 TAB pack temazepam 30mg cap 84 SYNTHROID 25MCG 101 TASIGNA 150MG CAP 48 temazepam 7.5mg cap 84 TAB TASIGNA 200MG CAP 48 TENIVAC 4-10UNIT/ML 102 SYNTHROID 300MCG 101 TASIGNA 50MG CAP 48 SYRINGETAB TAVALISSE 100MG TAB 82 tenofovir disoproxil 56 SYNTHROID 50MCG 101 TAVALISSE 150MG TAB 82 fumarate 300mg tabTAB tazarotene 0.1% cream 71 terazosin 10mg cap 38 SYNTHROID 75MCG 101 tazicef 1gm inj 64 terazosin 1mg cap 38 TAB tazicef 2gm inj 64 terazosin 2mg cap 38 SYNTHROID 88MCG 101 tazicef 6gm inj 64 terazosin 5mg cap 38 TAB TAZORAC 0.05% 71 terbinafine 250mg tab 34

T

TABLOID 40MG TABTABRECTA 150MG TABTABRECTA 200MG TABTACLONEX 0.05-0.005% LOTIONtacrolimus 0.03% ointmenttacrolimus 0.1% ointmenttacrolimus 0.5mg captacrolimus 1mg captacrolimus 5mg captadalafil 20mg tabTAFINLAR 50MG CAPTAFINLAR 75MG CAPTAGRISSO 40MG TABTAGRISSO 80MG TABTAKHZYRO 300MG/2ML INJTALTZ 80MG/ML AUTO-INJECTOR

43 47 47 73

73

73 58 58 58 62 47 47 47 48 82

71

CREAMTAZORAC 0.05% GELTAZORAC 0.1% GELtaztia 120mg er captaztia 180mg er captaztia 240mg er captaztia 300mg er captaztia 360mg er capTAZVERIK 200MG TABTDVAX 4-4UNIT/ML INJTECFIDERA 120MG DR CAPTECFIDERA 240MG DR CAPTECFIDERA 30-DAY STARTER PACKTEFLARO 400MG INJTEFLARO 600MG INJTEGSEDI 284MG/1.5ML SYRINGETEKTURNA HCT 150-12.5MG TAB

71 71 61 61 61 61 61 48

102 98

98

98

64 64 99

40

terbutaline sulfate 2.5mg tabterbutaline sulfate 5mg tabterconazole 0.4% vaginal creamTERCONAZOLE 0.8% VAGINAL CREAMterconazole 80mg vaginal inserttestosterone 1% (25mg) geltestosterone 1% (50mg) geltestosterone 1.62% (1.25gm) geltestosterone 1.62% (2.5gm) gelTESTOSTERONE 12.5MG/ACT GELtestosterone 20.25mg/act gel

20

20

105

105

105

15

15

15

15

16

16

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

147

Page 150: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

ALPHABETICAL LISTING OF DRUGS

testosterone cypionate 100mg/ml injtestosterone cypionate 200mg/ml (1ml) injtestosterone cypionate 200mg/ml injTESTOSTERONE ENANTHATE 200MG/ML INJtetrabenazine 12.5mg tabtetrabenazine 25mg tabtetracycline 250mg captetracycline 500mg capTHALOMID 100MG CAPTHALOMID 150MG CAPTHALOMID 200MG CAP

16

16

16

16

98 98

100 100 88 88 88

tiadylt 180mg er captiadylt 240mg er captiadylt 300mg er captiadylt 360mg er captiadylt 420mg er captiagabine 12mg tabtiagabine 16mg tabtiagabine 2mg tabtiagabine 4mg tabTIBSOVO 250MG TABTIGECYCLINE 50MG INJTIMOLOL 0.25% OPHTH GELtimolol 0.25% ophth solnTIMOLOL 0.5% OPHTH GEL

61 61 61 61 61 26 26 26 26 48 99 91

91 91

TOBRADEX 0.1-0.3% OPHTH OINTMENTtobramycin 0.3% ophth solnTOBRAMYCIN 10MG/ML INJtobramycin 40mg/ml injtobramycin 60mg/ml inh solnTOBREX 0.3% OPHTH OINTMENTtolcapone 100mg tabTOLMETIN 400MG CAPTOLMETIN 600MG TABtolterodine tartrate 1mg tab

93

92

10

10 10

92

50 12 12

103

THALOMID 50MG CAPTHEO-24 100MG ER CAPTHEO-24 200MG ER CAPTHEO-24 300MG ER CAP

88 21

21

21

timolol 0.5% ophth solntimolol 10mg tabtimolol 20mg tabtimolol 5mg tabTIMOPTIC 0.25% OPHTH GELTIMOPTIC 0.25% OPHTH

91 60 60 60 91

91

tolterodine tartrate 2mg er captolterodine tartrate 2mg tabtolterodine tartrate 4mg er capTOPIRAMATE 100MG

103

104

104

25 THEO-24 400MG ER 21 SOLN ER CAPCAPTHEOPHYLLINE 300MG 21

(PRESERVATIVE-FREE)TIMOPTIC 0.5% OPHTH 91

topiramate 100mg tabTOPIRAMATE 150MG

25 25

ER TAB GEL ER CAPtheophylline 400mg er tab

21 TIMOPTIC 0.5% OPHTH SOLN

91 topiramate 15mg capTOPIRAMATE 200MG

25 25

theophylline 5.33mg/ml oral solntheophylline 600mg er tab

21

21

(PRESERVATIVE-FREE)tinidazole 250mg tabtinidazole 500mg tabTIVICAY 10MG TAB

41 41 56

ER CAPtopiramate 200mg tabtopiramate 25mg capTOPIRAMATE 25MG ER

25 25 25

THIOLA 100MG DR TAB 82 TIVICAY 25MG TAB 56 CAPTHIOLA 100MG TABTHIOLA 300MG DR TAB

82 82

TIVICAY 50MG TABTIVICAY 5MG TAB FOR

57 57

topiramate 25mg tabTOPIRAMATE 50MG ER

25 25

thioridazine 100mg tabthioridazine 10mg tabthioridazine 25mg tabthioridazine 50mg tabthiothixene 10mg capthiothixene 1mg capthiothixene 2mg capthiothixene 5mg captiadylt 120mg er cap

54 54 54 54 55 55 55 55 61

ORAL SUSPtizanidine 2mg captizanidine 2mg tabtizanidine 4mg captizanidine 4mg tabtizanidine 6mg capTOBRADEX 0.05-0.3% OPHTH SUSP

90 90 90 90 90 93

CAPtopiramate 50mg tabtoremifene 60mg tabtorsemide 100mg tabtorsemide 10mg tabtorsemide 20mg tabtorsemide 5mg tabTOUJEO 300UNIT/ML PEN INJ

25 44 75 75 75 75 32

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

148

Page 151: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

ALPHABETICAL LISTING OF DRUGS

TOUJEO MAX 32 TRELEGY 20 trientine 250mg cap 88 300UNIT/ML PEN INJ 0.1-0.0625-0.025MG INH tri-estarylla 28 day pack 67 (3ML) TRELSTAR 11.25MG INJ 44 trifluoperazine 10mg tab 54 TPN ELECTROLYTES INJ 87 TRELSTAR 22.5MG INJ 44 trifluoperazine 1mg tab 54 TRACLEER 32MG TAB 62 TRELSTAR 3.75MG INJ 44 trifluoperazine 2mg tab 54 FOR ORAL SUSP TRESIBA 100UNIT/ML 32 trifluoperazine 5mg tab 54 TRADJENTA 5MG TAB 31 INJ TRIFLURIDINE 1% 92 tramadol 100mg er tab 14 TRESIBA 100UNIT/ML 32 OPHTH SOLNtramadol 100mg er tab 14 PEN INJ TRIGLIDE 160MG TAB 36 (matrix delivery) TRESIBA 200UNIT/ML 32 trihexyphenidyl 0.4mg/ml 50 tramadol 200mg er tab 14 PEN INJ oral solntramadol 200mg er tab 14 tretinoin 0.01% gel 70 trihexyphenidyl 2mg tab 49 (matrix delivery) tretinoin 0.025% cream 70 trihexyphenidyl 5mg tab 49 tramadol 300mg er tab 14 tretinoin 0.025% gel 70 TRIJARDY 10-5-1000MG 30 tramadol 300mg er tab 14 tretinoin 0.04% gel 70 ER TAB(matrix delivery) tretinoin 0.05% cream 70 TRIJARDY 30 tramadol 50mg tab 14 tretinoin 0.05% gel 70 12.5-2.5-1000MG ER trandolapril 1mg tab 37 tretinoin 0.1% cream 70 TABTRANDOLAPRIL 40 tretinoin 0.1% gel 70 TRIJARDY 25-5-1000MG 30 1MG/VERAPAMIL tretinoin 10mg cap 48 ER TAB240MG ER TAB triamcinolone acetonide 73 TRIJARDY 30 trandolapril 2mg tab 37 0.0147% spray 5-2.5-1000MG ER TABtrandolapril 40 triamcinolone acetonide 73 TRIKAFTA 99 2mg/verapamil 180mg er 0.025% cream 100-50-75MG/150MG tab triamcinolone acetonide 73 PACKtrandolapril 40 0.025% lotion tri-legest 28 day pack 67 2mg/verapamil 240mg er triamcinolone acetonide 73 tri-lo-estarylla 28 day 67 tab 0.025% ointment packtrandolapril 4mg tab 37 triamcinolone acetonide 73 tri-lo-sprintec 28 day 67 trandolapril 40 0.1% cream pack4mg/verapamil 240mg er triamcinolone acetonide 73 trilyte powder for oral 85 tab 0.1% lotion solntranexamic acid 650mg 84 triamcinolone acetonide 73 trimethobenzamide 33 tab 0.1% ointment 300mg captranylcypromine 10mg 27 triamcinolone acetonide 89 trimethoprim 100mg tab 41 tab 0.1% oral paste tri-mili 28 day pack 67 TRAVASOL 10% INJ 91 triamcinolone acetonide 73 trimipramine 100mg cap 29 travoprost 0.004% ophth 94 0.5% cream trimipramine 25mg cap 29 soln triamcinolone acetonide 73 trimipramine 50mg cap 29 trazodone 100mg tab 28 0.5% ointment TRINTELLIX 10MG TAB 28 trazodone 150mg tab 28 triamterene 100mg cap 75 TRINTELLIX 20MG TAB 28 trazodone 300mg tab 28 triamterene 50mg cap 75 TRINTELLIX 5MG TAB 28 trazodone 50mg tab 28 triazolam 0.125mg tab 84 tri-previfem 28 day pack 67 TRECATOR 250MG TAB 43 triazolam 0.25mg tab 84 tri-sprintec 28 day pack 67

triderm 0.1% cream 73

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

149

Page 152: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

ALPHABETICAL LISTING OF DRUGS

TRIUMEQ 57 UCERIS 2MG/ACT 16 VALTOCO 20MG DOSE 23 600-50-300MG TAB RECTAL FOAM KIT 10MG/0.1ML PACKtrivora 28 day pack 67 unithroid 100mcg tab 101 VALTOCO 5MG DOSE 23 tri-vylibra 28 day pack 67 unithroid 112mcg tab 101 KIT 5MG/0.1ML PACKtri-vylibra lo 28 day pack 67 unithroid 125mcg tab 101 vancomycin 1000mg inj 41 TROKENDI 100MG ER 25 unithroid 150mcg tab 101 vancomycin 100mg/ml inj 41 CAP unithroid 175mcg tab 101 vancomycin 125mg cap 41 TROKENDI 200MG ER 25 unithroid 200mcg tab 101 vancomycin 250mg cap 42 CAP unithroid 25mcg tab 101 VANCOMYCIN 250MG 42 TROKENDI 25MG ER 25 unithroid 300mcg tab 101 INJCAP unithroid 50mcg tab 101 vancomycin 500mg inj 42 TROKENDI 50MG ER 25 unithroid 75mcg tab 101 vancomycin 750mg inj 42 CAP unithroid 88mcg tab 102 vandazole 0.75% vaginal 105 TROPHAMINE 10% INJ 91 UPTRAVI 1000MCG TAB 62 geltrospium chloride 20mg 104 UPTRAVI 1200MCG TAB 62 VAQTA 25UNIT/0.5ML 105 tab UPTRAVI 1400MCG TAB 62 INJtrospium chloride 60mg 104 UPTRAVI 1600MCG TAB 62 VAQTA 25UNIT/0.5ML 105 er cap UPTRAVI 200MCG TAB 62 SYRINGETRULANCE 3MG TAB 80 UPTRAVI 400MCG TAB 62 VAQTA 50UNIT/ML INJ 105 TRUMENBA SYRINGE 104 UPTRAVI 600MCG TAB 62 VAQTA 50UNIT/ML 105 TRUVADA 100-150MG 57 UPTRAVI 800MCG TAB 62 SYRINGETAB UPTRAVI TITRATION 62 VARIVAX 105 TRUVADA 133-200MG 57 PACK 1350PFU/0.5ML INJTAB ursodiol 250mg tab 80 VARIZIG 95 TRUVADA 167-250MG 57 ursodiol 300mg cap 80 125UNIT/1.2ML INJTAB ursodiol 500mg tab 80 VARUBI 90MG TAB 34 TRUVADA 200-300MG TABTUKYSA 150MG TABTUKYSA 50MG TABTURALIO 200MG CAPTWINRIX 720UNIT SYRINGETYBOST 150MG TABtydemy 28 day packTYKERB 250MG TABTYMLOS 3120MCG/1.56ML PEN INJTYPHIM VI 25MCG/0.5ML INJTYPHIM VI 25MCG/0.5ML SYRINGE

U

57

48 48 48

105

57 67 48 76

104

104

V

valacyclovir 1000mg tabvalacyclovir 500mg tabVALCHLOR 0.016% GELvalganciclovir 450mg tabvalganciclovir 50mg/ml oral solnvalproic acid 250mg capvalproic acid 50mg/ml oral solnvalsartan 160mg tabvalsartan 320mg tabvalsartan 40mg tabvalsartan 80mg tabVALTOCO 10MG DOSE KIT 10MG/0.1ML PACKVALTOCO 15MG DOSE KIT 7.5MG/0.1ML PACK

58 58 71 57 57

26 26

38 38 38 38 23

23

VASCEPA 0.5GM CAPVASCEPA 1GM CAPvelivet 28 day packVELPHORO 500MG CHEW TABVELTASSA 16.8GM POWDER FOR ORAL SUSPVELTASSA 25.2GM POWDER FOR ORAL SUSPVELTASSA 8.4GM POWDER FOR ORAL SUSPVELTIN 1.2-0.025% GELVEMLIDY 25MG TABVENCLEXTA 100MG TABVENCLEXTA 10MG TAB

35 35 67 81

89

89

89

70 57 43

43

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

150

Page 153: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

ALPHABETICAL LISTING OF DRUGS

VENCLEXTA 50MG TAB 43 vigabatrin 500mg powder 26 vyfemla 28 day pack 67 VENCLEXTA STARTING 43 for oral soln vylibra 28 day pack 67 PACK vigabatrin 500mg tab 26 VYNDAMAX 61MG CAP 63 venlafaxine 100mg tab 28 vigadrone 500mg powder 26 VYNDAQEL 20MG CAP 63 venlafaxine 150mg er capvenlafaxine 25mg tabvenlafaxine 37.5mg er capvenlafaxine 37.5mg tabvenlafaxine 50mg tabvenlafaxine 75mg er capvenlafaxine 75mg tabVENTAVIS 10MCG/ML INH SOLNVENTAVIS 20MCG/ML INH SOLNVENTOLIN 108MCG INHVERAPAMIL 100MG ER CAPverapamil 120mg er capverapamil 120mg er tabverapamil 120mg tabverapamil 180mg er capverapamil 180mg er tabVERAPAMIL 200MG ER

28 28 28

28 28 29 29 62

62

20 61

61 61 61 61 61 61

for oral solnVIIBRYD 10/20MG STARTER PACKVIIBRYD 10MG TABVIIBRYD 20MG TABVIIBRYD 40MG TABVIMPAT 100MG TABVIMPAT 10MG/ML ORAL SOLNVIMPAT 150MG TABVIMPAT 200MG TABVIMPAT 50MG TABVIRACEPT 250MG TABVIRACEPT 625MG TABVIREAD 150MG TABVIREAD 200MG TABVIREAD 250MG TABVIREAD 40MG/GM ORAL POWDERVITRAKVI 100MG CAPVITRAKVI 20MG/ML

28

28 28 28 25 25

25 25 25 57 57 57 57 57 57

48 48

W

WAKIX 17.8MG TABWAKIX 4.45MG TABwarfarin sodium 10mg tabwarfarin sodium 1mg tabwarfarin sodium 2.5mg tabwarfarin sodium 2mg tabwarfarin sodium 3mg tabwarfarin sodium 4mg tabwarfarin sodium 5mg tabwarfarin sodium 6mg tabwarfarin sodium 7.5mg tabwixela 0.1-0.05mg inhwixela 0.25-0.05mg inhwixela 0.5-0.05mg inhwymzya fe 28 day pack

X

8 8

21

21 21

21 21 21 21 21 21

20 20 21 67

CAP ORAL SOLN XALKORI 200MG CAP 48

verapamil 240mg er cap 61 VITRAKVI 25MG CAP 48 XALKORI 250MG CAP 48

verapamil 240mg er tab 61 VIVITROL 380MG INJ 33 XARELTO 10MG TAB 21

VERAPAMIL 300MG ER 61 VIZIMPRO 15MG TAB 48 XARELTO 15MG TAB 21

CAP VIZIMPRO 30MG TAB 48 XARELTO 2.5MG TAB 21

VERAPAMIL 360MG ER 61 VIZIMPRO 45MG TAB 48 XARELTO 20MG TAB 21

CAP voriconazole 200mg inj 34 XARELTO KIT PACK 21

verapamil 40mg tab 61 voriconazole 200mg tab 34 XATMEP 2.5MG/ML 43

verapamil 80mg tab 61 voriconazole 40mg/ml 34 ORAL SOLN

VERSACLOZ 50MG/ML 53 susp XCOPRI 100MG TAB 25

SUSP voriconazole 50mg tab 34 XCOPRI 12.5/25MG 25

VERZENIO 100MG TAB 48 VOSEVI 400-100-100MG 57 TITRATION PACK

VERZENIO 150MG TAB 48 TAB XCOPRI 150/200MG 25

VERZENIO 200MG TAB 48 VOTRIENT 200MG TAB 48 TITRATION PACK

VERZENIO 50MG TAB 48 VRAYLAR 1.5/3MG 51 XCOPRI 150MG TAB 25

VIBRAMYCIN 100 MIXED PACK XCOPRI 200MG TAB 25

50MG/5ML SUSP VRAYLAR 1.5MG CAP 51 XCOPRI 50/100MG 25

VICTOZA 18MG/3ML 31 VRAYLAR 3MG CAP 51 TITRATION PACK

PEN INJ VRAYLAR 4.5MG CAP 51 XCOPRI 50MG TAB 26

vienva 28 day pack 67 VRAYLAR 6MG CAP 51

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

151

Page 154: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

ALPHABETICAL LISTING OF DRUGS

XCOPRI TAB 26 XPOVIO 80 MG ONCE 45 zenatane 40mg cap 70 150/200MG PACK WEEKLY ZENPEP 74 XCOPRI TAB 50/200MG 26 XPOVIO 80 MG TWICE 45 105000-79000-25000UNI PACK WEEKLY T DR CAPXELJANZ 10MG TAB 10 XTAMPZA 13.5MG ER 14 ZENPEP 74 XELJANZ 5MG TAB 10 CAP 14000-10000-3000UNIT XELJANZ XR 11MG TAB 10 XTAMPZA 18MG ER 14 DR CAPXELJANZ XR 22MG TAB 10 CAP ZENPEP 74 XENLETA 600MG TAB 42 XTAMPZA 27MG ER 14 24000-17000-5000UNIT XGEVA 120MG/1.7ML 76 CAP DR CAPINJ XTAMPZA 36MG ER 14 ZENPEP 74 XIFAXAN 200MG TAB 41 CAP 40000-126000-168000U XIFAXAN 550MG TAB 41 XTAMPZA 9MG ER CAP 14 NIT DR CAPXIGDUO 10-1000MG ER 30 XTANDI 40MG CAP 44 ZENPEP 74 TAB XULANE 67 42000-32000-10000UNIT XIGDUO 10-500MG ER 30 0.00146-0.00625MG/HR DR CAPTAB PATCH ZENPEP 74 XIGDUO 2.5-1000MG ER 30 XULTOPHY 30 63000-47000-15000UNIT TAB 100UNIT-3.6MG/ML DR CAPXIGDUO 5-1000MG ER 30 PEN INJ ZENPEP 74 TAB XYREM 500MG/ML 96 84000-63000-20000UNIT XIGDUO 5-500MG ER 30 ORAL SOLN DR CAPTABXOFLUZA 20MG THERAPY PACKXOFLUZA 40MG THERAPY PACKXOLAIR 150MG INJXOLAIR 150MG/ML SYRINGE

58

58

19 19

Y

YASMIN 28 DAY PACKYF-VAX 4000UNIT/ML INJyuvafem 10mcg vaginal insert

Z

67 105

105

ZERBAXA 1000-500MG INJzidovudine 100mg capzidovudine 10mg/ml oral solnzidovudine 300mg tabZIEXTENZO 6MG/0.6ML SYRINGE

63

57 57

57 84

XOLAIR 75MG/0.5ML 19 zafirlukast 10mg tab 19 ZIOPTAN 0.015MG/ML 94 SYRINGE zafirlukast 20mg tab 19 OPHTH SOLNXOPENEX 45MCG INH 21 zaleplon 10mg cap 84 ziprasidone 20mg cap 51 XOSPATA 40MG TAB 48 zaleplon 5mg cap 84 ziprasidone 20mg inj 51 XPOVIO 100 MG ONCE 44 zarah pack 67 ziprasidone 40mg cap 51 WEEKLY ZARXIO 300MCG/0.5ML 84 ziprasidone 60mg cap 51 XPOVIO 40MG ONCE 44 SYRINGE ziprasidone 80mg cap 51 WEEKLY PACK ZARXIO 480MCG/0.8ML 84 ZIRGAN 0.15% OPHTH 92 XPOVIO 40MG TWICE 44 SYRINGE GELWEEKLY PACK ZEJULA 100MG CAP 48 ZITHROMAX 1GM 85 XPOVIO 60 MG ONCE 45 ZELBORAF 240MG TAB 48 POWDER FOR ORAL WEEKLY ZEMAIRA 1000MG INJ 99 SUSPXPOVIO 60MG TWICE 45 zenatane 10mg cap 70 ZOLINZA 100MG CAP 48 WEEKLY PACK zenatane 20mg cap 70 zolmitriptan 2.5mg odt 86

zenatane 30mg cap 70 zolmitriptan 2.5mg tab 86

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

152

Page 155: Great Plains Medicare Advantage Gold (HMO I-SNP) 2021 ......Great Plains Medicare Advantage Gold (HMO I-SNP) Member Services at 1-844-637-4760 or, for TTY users, 711, 8am to 8pm daily

ALPHABETICAL LISTING OF DRUGS

zolmitriptan 5mg odt 86

tab

SPRAY

SPRAY

SL TAB

SL TAB

SL TAB

TAB

TAB

CREAM

SUSP

zolmitriptan 5mg tab 86 zolpidem tartrate 10mg 84

zolpidem tartrate 5mg tab 84 ZOMIG 2.5MG NASAL 86

ZOMIG 5MG NASAL 86

zonisamide 100mg cap 25 zonisamide 25mg cap 25 zonisamide 50mg cap 25 ZONTIVITY 2.08MG TAB 83 ZORTRESS 1MG TAB 89 ZOSYN 2000-250MG INJ 96 ZOSYN 3000-375MG INJ 96 zovia 1/35e 28 day pack 67 ZUBSOLV 1.4-0.36MG 15

ZUBSOLV 11.4-2.9MG 15

ZUBSOLV 2.9-0.71MG 15

ZUBSOLV 5.7-1.4MG SL 15

ZUBSOLV 8.6-2.1MG SL 15

ZYCLARA 2.5% CREAM 73 ZYCLARA 3.75% 73

ZYDELIG 100MG TAB 48 ZYDELIG 150MG TAB 48 ZYKADIA 150MG TAB 48 ZYLET 0.5-0.3% OPHTH 93

ZYPREXA 210MG INJ 53

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table.

153