Mercy Care Advantage (HMO SNP) · 2020-06-01 · Mercy Care Advantage (HMO SNP) 2020 Formulary...

Mercy Care Advantage (HMO SNP)2020 Formulary (List of Covered Drugs)PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER INTHIS PLAN

Formulary ID 00020345, Version 11

This formulary was updated on 06/01/2020. For more recent information or other questions, pleasecontact Mercy Care Advantage (HMO SNP) Member Services at 602‑586‑1730 or 1‑877‑436‑5288 or,for TTY users, 711, 8:00 a.m. – 8:00 p.m., 7 days a week, or visit www.MercyCareAZ.org.

Mercy Care Advantage (HMO SNP)Formulario para 2020 (Lista de Medicamentos Cubiertos)POR FAVOR LEA: ESTE DOCUMENTO CONTIENE INFORMACIÓN SOBRE LOS MEDICAMENTOS QUECUBRIMOS BAJO ESTE PLAN

Identificación del Formulario 00020345, Versión 11

Este formulario fue actualizado en 06/01/2020. Para la información más reciente o para otras preguntas,por favor llame a Servicios al Miembro de Mercy Care Advantage (HMO SNP) al 602‑586‑1730 ó al1‑877‑436‑5288, ó para los usuarios de TTY al 711, de 8:00 a.m. – 8:00 p.m., 7 días de la semana, ó visitewww.MercyCareAZ.org.

Visit/Viste www.MercyCareAZ.org

AZ-19-06-01

http://www.MercyCareAZ.org



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Mercy Care Advantage (HMO SNP)2020 Formulary(List of Covered Drugs)

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLANFormulary ID 00020345, Version 11

This formulary was updated on 06/01/2020. For more recent information or other questions, please contactMercy Care Advantage (HMO SNP) Member Services at 602-586-1730 or 1-877-436-5288 or, for TTY users, 711,8:00 a.m. – 8:00 p.m., 7 days a week, or visit www.MercyCareAZ.org.

Note to existing members: This formulary has changed since last year. Please review this document to makesure that it still contains the drugs you take.

When this drug list (formulary) refers to “we,” “us”, or “our,” it means Mercy Care. When it refers to “plan” or“our plan,” it means Mercy Care Advantage.

This document includes a list of the drugs (formulary) for our plan which is current as of 06/01/2020. Foran updated formulary, please contact us. Our contact information, along with the date we last updated theformulary, 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, 2021, and from time to timeduring the year.

The formulary, pharmacy network, and/or provider network may change at any time. You will receive noticewhen necessary.

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What is the Mercy Care Advantage (HMO SNP) Formulary?A formulary is a list of covered drugs selected by Mercy Care Advantage in consultation with a team of health careproviders, which represents the prescription therapies believed to be a necessary part of a quality treatmentprogram. Mercy Care Advantage will generally cover the drugs listed in our formulary as long as the drug ismedically necessary, the prescription is filled at a Mercy Care Advantage network pharmacy, and other plan rulesare 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 Mercy Care Advantage may add or remove drugson the Drug List during the year, move them to different cost-sharing tiers, or add new restrictions. We mustfollow Medicare rules in making these changes.

Changes that can affect you this year: In the below cases, you will be affected by coverage changes duringthe year:

• New generic drugs. We may immediately remove a brand name drug on our Drug List if we are replacingit with a new generic drug that will appear on the same or lower cost sharing tier and with the sameor fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand namedrug 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 thatchange, 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 howto request an exception, and you can also find information in the section below entitled “How do Irequest an exception to the Mercy Care Advantage (HMO SNP)’s Formulary?”

• Drugs removed from the market. If the Food and Drug Administration deems a drug on our formulary tobe unsafe or the drug’s manufacturer removes the drug from the market, we will immediately removethe 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 theformulary or add new restrictions to the brand name drug or move it to a different cost-sharing tier.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, we must notifyaffected members of the change at least 30 days before the change becomes effective, or at the time themember requests a refill of the drug, at which time the member will receive a 31-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 includeinformation on how to request an exception, and you can also find information in the section belowentitled “How do I request an exception to the Mercy Care Advantage (HMO SNP)’s Formulary?”

Changes that will not affect you if you are currently taking the drug. Generally, if you are taking a drug on our2020 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of thedrug during the 2020 coverage year except as described above. This means these drugs will remain available atthe same cost-sharing and with no new restrictions for those members taking them for the remainder of thecoverage year.

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The enclosed formulary is current as of 06/01/2020. To get updated information about the drugs covered byMercy Care Advantage, please contact us. Our contact information appears on the front and back cover pages.If we update the formulary during 2020 due to a non-maintenance formulary change, an updated version of theformulary and the notice issued to affected members will be posted on our website at www.MercyCareAZ.org.Printed formularies will be updated with the changes using an errata notice.

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

Medical ConditionThe formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the typeof medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listedunder the category, “Cardiovascular Agents”. If you know what your drug is used for, look for the category namein the list that begins on page 1. Then look under the category name for your drug.

Alphabetical ListingIf you are not sure what category to look under, you should look for your drug in the Index that begins on page 53.The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugsand generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will seethe page number where you can find coverage information. Turn to the page listed in the Index and find thename of your drug in the first column of the list.

What are generic drugs?Mercy Care Advantage covers both brand name drugs and generic drugs. A generic drug is approved by the FDAas having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brandname drugs.

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

• Prior Authorization: Mercy Care Advantage requires you or your physician to get prior authorization forcertain drugs. This means that you will need to get approval from Mercy Care Advantage before you fillyour prescriptions. If you don’t get approval, Mercy Care Advantage may not cover the drug.

• Quantity Limits: For certain drugs, Mercy Care Advantage limits the amount of the drug that Mercy CareAdvantage will cover. For example, Mercy Care Advantage provides 30 EA per 30 days per prescriptionfor simvastatin. This may be in addition to a standard one-month or three-month supply.

• Step Therapy: In some cases, Mercy Care Advantage requires you to first try certain drugs to treat yourmedical condition before we will cover another drug for that condition. For example, if Drug A and Drug Bboth treat your medical condition, Mercy Care Advantage may not cover Drug B unless you try Drug Afirst. If Drug A does not work for you, Mercy Care 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 beginson page 1. You can also get more information about the restrictions applied to specific covered drugs byvisiting our website. We have posted online documents that explain our prior authorization and step therapyrestrictions. You may also ask us to send you a copy. Our contact information, along with the date we lastupdated the formulary, appears on the front and back cover pages.


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You can ask Mercy Care 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 to theMercy Care Advantage’s formulary?” on page IV 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 Servicesand ask if your drug is covered.

If you learn that Mercy Care 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 Mercy Care Advantage. Whenyou receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is coveredby Mercy Care Advantage.

• You can ask Mercy Care Advantage to make an exception and cover your drug. See below for informationabout how to request an exception.

How do I request an exception to the Mercy Care Advantage (HMO SNP) Formulary?You can ask Mercy Care Advantage to make an exception to our coverage rules. There are several types ofexceptions 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 ata pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lowercost-sharing level.

• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs,Mercy Care 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, Mercy Care Advantage will only approve your request for an exception if the alternative drugsincluded on the plan’s formulary, or additional utilization restrictions would not be as effective in treating yourcondition 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 restrictionexception. When you request a formulary or utilization restriction exception you should submit a statementfrom your prescriber or physician supporting your request. Generally, we must make our decision within 72hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you oryour doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If yourrequest to expedite is granted, we must give you a decision no later than 24 hours after we get a supportingstatement 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, youmay be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need aprior authorization from us before you can fill your prescription. You should talk to your doctor to decide if youshould switch to an appropriate drug that we cover or request a formulary exception so that we will cover thedrug you take. While you talk to your doctor to determine the right course of action for you, we may cover yourdrug in certain cases during the first 90 days you are a member of our plan.

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For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will covera temporary 31-day supply. If your prescription is written for fewer days, we’ll allow refills to provide up to amaximum 31-day supply of medication. After your first 31-day supply, we will not pay for these drugs, even ifyou 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 yourability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will covera 31-day emergency supply of that drug while you pursue a formulary exception.

If you are admitted to or discharged from a long-term care facility, you will be allowed to refill a prescriptionupon admission or discharge.

For more informationFor more detailed information about your Mercy Care Advantage prescription drug coverage, please reviewyour Evidence of Coverage and other plan materials.

If you have questions about Mercy Care Advantage, please contact us. Our contact information, along with thedate 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, visithttp://www.medicare.gov.

Mercy Care Advantage’s FormularyThe formulary that begins on page 1 provides coverage information about the drugs covered by Mercy CareAdvantage. If you have trouble finding your drug in the list, turn to the Index that begins on page 53.

The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., SYNTHROID) andgeneric drugs are listed in lower-case italics (e.g., levothyroxine).

The “Drug Tier” column of the chart lists the category of each drug. Your cost sharing amounts depend onwhich category the drug is in:

Category Cost-sharing amount

Generic drugs(including brand drugs treated as generic) $0/$1.30/$3.60 copay

All other drugs $0/$3.90/$8.95 copay

Your copays may be less, depending on the level of “Extra Help” you are receiving. The Evidence of CoverageRider for People Who Get Extra Help Paying for Prescription Drugs (LIS Rider) lists the amount you will payfor your prescription drugs. You can also call Member Services to find out your cost sharing amount. Phonenumbers for Member Services are on the front and back cover pages.

http://www.medicare.gov

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The information in the Requirements/Limits column tells you if Mercy Care Advantage has any specialrequirements for coverage of your drug.

Abbreviation Requirements/Limits

B/D Covered under Medicare Part B or Part D. Most drugs are covered under PartD, but there are some drugs that can be covered under both Part B or Part Ddepending on what the drug is used for and how it is administered.

EA Each. Medications listed with EA indicates number of pills dispensed.

LA Limited access. This prescription may be available only at certain pharmacies.For more information consult the Pharmacy Directory.

NM Not available at mail-order.

PA Prior authorization. You or your provider need to get approval from our planbefore we will agree to cover the drug.

QL Quantity limits. The amount per fill or refill is shown.

ST Step therapy. This prescription drug requires that you’ve tried another drug first,which did not work for you.

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Mercy Care Advantage (HMO SNP)Formulario para 2020(Lista de Medicamentos Cubiertos)

POR FAVOR LEA: ESTE DOCUMENTO CONTIENE INFORMACIÓN SOBRE LOS MEDICAMENTOS QUECUBRIMOS BAJO ESTE PLANIdentificación del Formulario 00020345, Versión 11

Este formulario fue actualizado en el 1 de junio de 2020. Para la información más reciente o para otraspreguntas, por favor llame a Servicios al Miembro de Mercy Care Advantage (HMO SNP) al 602-586-1730 óal 1-877-436-5288, ó para los usuarios de TTY al 711, de 8:00 a.m. – 8:00 p.m., 7 días de la semana, ó visitewww.MercyCareAZ.org.

Nota para los miembros actuales: Este formulario cambió desde el año pasado. Por favor revisen estedocumento para asegurarse de que todavía contenga los medicamentos que usted toma.

Cuando esta lista de medicamentos (formulario) se refiere a “nosotros” o a “nuestros”, esto significa MercyCare. Cuando se refiere al “plan” o a “nuestro plan”, esto significa Mercy Care Advantage.

Este documento incluye una lista de los medicamentos (formulario) de nuestro plan, la cual está actualizada ala fecha de el 1 de junio de 2020. Para un formulario actualizado, por favor contáctenos. Nuestra informaciónde contacto, junto con la fecha en la que actualizamos por último el formulario, aparece en la portada y lacontraportada.

Generalmente usted debe usar farmacias de la red para usar su beneficio de medicamentos de prescripción.Los beneficios, el formulario, la red de farmacias, y/o los copagos/el coseguro pueden cambiar el 1º de enerode 2021, y de tiempo en tiempo durante el año.

El formulario, la red de farmacias, y/o la red de proveedores pueden cambiar en cualquier momento. Ustedrecibirá aviso cuando sea necesario.

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¿Qué es el Formulario de Mercy Care Advantage (HMO SNP)?Un formulario es una lista de medicamentos cubiertos seleccionados por Mercy Care Advantage en consultacon un equipo de proveedores del cuidado de la salud, el cual representa las terapias de prescripción/recetaque se considera son una parte necesaria de un programa de tratamiento de calidad. Generalmente, MercyCare Advantage cubrirá los medicamentos listados en nuestro formulario, siempre y cuando el medicamentosea médicamente necesario, la prescripción/receta sea surtida en una farmacia de la red de Mercy CareAdvantage, y se sigan otras reglas del plan. Para más información sobre cómo surtir sus prescripciones/recetas,por favor revise su Evidencia de Cobertura.

¿El Formulario (lista de medicamentos) puede cambiar?La mayoría de los cambios en la cobertura de medicamentos ocurren el 1º de enero, pero Mercy CareAdvantage puede agregar o eliminar medicamentos en la Lista de Medicamentos durante el año, cambiarlosa niveles de costo compartido distintos o agregar nuevas restricciones. Nosotros debemos seguir las reglas deMedicare para hacer estos cambios.

Cambios que pueden afectarle este año: En los casos a continuación, usted se verá afectado/a por los cambiosa la cobertura durante el año:

• Nuevos medicamentos genéricos. Nosotros podemos eliminar inmediatamente un medicamento demarca de nuestra Lista de Medicamentos si lo estamos reemplazando con un medicamento genériconuevo que aparecerá en el mismo nivel o en un nivel más bajo de costo compartido y con las mismaso menos restricciones. Además, al agregar el nuevo medicamento genérico, nosotros podemos decidirretener el medicamento de marca en nuestra Lista de Medicamentos, pero cambiarlo inmediatamente aun nivel de costo compartido distinto o agregar nuevas restricciones. Si actualmente usted está tomandodicho medicamento de marca, es posible que nosotros no le informemos por adelantado que haremosdicho cambio, pero más tarde le proveeremos información sobre el/los cambio/s específico/s quehayamos hecho.o Si nosotros hacemos dicho cambio, usted o la persona prescribiéndole pueden pedirnos que

hagamos una excepción y que continuemos cubriendo el medicamento de marca para usted.El aviso que nosotros le proveeremos también incluirá información sobre cómo solicitar unaexcepción, y usted también puede encontrar información en la sección a continuación titulada“¿Cómo solicito una excepción al Formulario de Mercy Care Advantage (HMO SNP)?”

• Medicamentos retirados del mercado. Si la Administración de Alimentos y Medicamentos consideraque un medicamento en nuestro formulario no es seguro, o si el fabricante del medicamento retirael medicamento del mercado, nosotros inmediatamente retiraremos el medicamento de nuestroformulario y les proveeremos un aviso a los miembros que estén tomando dicho medicamento.

• Otros cambios. Nosotros podemos hacer otros cambios que afecten a los miembros que actualmentetoman un medicamento. Por ejemplo, nosotros podemos agregar un medicamento genérico que nosea nuevo en el mercado para reemplazar un medicamento de marca actualmente en el formularioo agregar nuevas restricciones al medicamento de marca o cambiarlo a un nivel de costo compartidodistinto. O podemos hacer cambios basados en nuevas directrices clínicas. Si retiramos medicamentosde nuestro formulario, o agregamos autorización previa, límites de cantidad y/o restricciones de terapiaa pasos en un medicamento, nosotros debemos notificárselo a los miembros afectados por el cambiopor lo menos 360 días antes de que el cambio entre en vigor, ó cuando el miembro pida que se levuelva a surtir el medicamento, en cuyo momento, el miembro recibirá un suministro para 31 díasdel medicamento.

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o Si nosotros hacemos estos otros cambios, usted o la persona prescribiéndole pueden pedirnos quehagamos una excepción y que continuemos cubriendo el medicamento de marca para usted. Elaviso que le proveeremos también incluirá información sobre cómo solicitar una excepción, y ustedtambién puede encontrar información en la sección a continuación titulada “¿Cómo solicito unaexcepción al Formulario de Mercy Care Advantage (HMO SNP)?”

Cambios que no le afectarán si usted está tomando actualmente el medicamento. Generalmente, si ustedestá tomando un medicamento listado en nuestro Formulario de 2020 que fue cubierto a principios de año,nosotros no interrumpiremos ni reduciremos la cobertura del medicamento durante el año de cobertura 2020excepto como se describió anteriormente. Esto significa que estos medicamentos permanecerán disponiblesal mismo costo compartido y sin nuevas restricciones para aquellos miembros que los tomen durante el restodel año de la cobertura.

El formulario adjunto está vigente a partir de el 1 de junio de 2020. Para obtener información actualizada sobrelos medicamentos cubiertos por Mercy Care Advantage, por favor póngase en contacto con nosotros. Nuestrainformación de contacto aparece en la portada y la contraportada. Si nosotros actualizamos el formulario durante2020 debido a un cambio al formulario que no sea de mantenimiento, se publicará una versión actualizadadel formulario y se emitirá un aviso a los miembros afectados en nuestro sitio web www.MercyCareAZ.org.Los cambios a los formularios impresos se actualizarán por medio de un aviso de erratas.

¿Cómo uso el Formulario?Hay dos formas de encontrar su medicamento dentro del formulario:

Condición MédicaEl formulario empieza en la página 1. Los medicamentos en este formulario están agrupados en categorías,dependiendo del tipo de condiciones médicas para cuyo tratamiento de usan. Por ejemplo, los medicamentosusados para tratar una condición cardíaca están listados bajo la categoría de “Agentes Cardiovasculares”.Si usted sabe para qué se usa su medicamento, busque el nombre de la categoría en la lista que empieza enla página 1. Después busque en esa categoría el nombre de su medicamento.

Listado AlfabéticoSi usted no está seguro/a bajo qué categoría buscar, debería buscar su medicamento en el Índice que empiezaen la página 53. El Índice provee una lista en orden alfabético de todos los medicamentos incluidos en estedocumento. Tanto los medicamentos de marca como los medicamentos genéricos están listados en el Índice.Busque en el Índice y encuentre su medicamento. Junto a su medicamento, usted encontrará el númerode la página en la que podrá encontrar información sobre la cobertura. Pase a la página listada en el Índicey encuentre el nombre de su medicamento en la primera columna de la lista.

¿Qué son los medicamentos genéricos?Mercy Care Advantage cubre tanto a los medicamentos de marca como a los medicamentos genéricos.Un medicamento genérico es aprobado por la Administración de Alimentos y Medicamentos (FDA por sussiglas en inglés) por contar con el mismo ingrediente activo que el medicamento de marca. En general, losmedicamentos genéricos cuestan menos que los medicamentos de marca.


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¿Hay alguna restricción en mi cobertura?Algunos medicamentos cubiertos pueden contar con requerimientos adicionales o límites en la cobertura.Dichos requerimientos y límites pueden incluir:

• Autorización Previa: Mercy Care Advantage requiere que usted o su médico obtengan autorizaciónprevia para ciertos medicamentos. Esto significa que usted necesitará obtener la aprobación deMercy Care Advantage antes de surtir sus prescripciones/recetas. Si usted no obtiene la aprobación,Mercy Care Advantage puede no cubrir el costo del medicamento.

• Límites de Cantidades: Para ciertos medicamentos, Mercy Care Advantage limita la cantidad delmedicamento que Mercy Care Advantage cubrirá. Por ejemplo, Mercy Care Advantage provee30 píldoras cada una para 30 días por cada prescripción de Simvastatin. Esto puede ser en adiciónal suministro estándar para un mes o tres meses.

• Terapia a Pasos: En algunos casos, Mercy Care Advantage requiere que usted pruebe primero ciertosmedicamentos para tratar su condición médica antes de cubrir otro medicamento para dicha condición.Por ejemplo, si el Medicamento A y el Medicamento B tratan ambos su condición médica, Mercy CareAdvantage puede no cubrir el Medicamento B a menos que usted pruebe primero el Medicamento A.Si el Medicamento A no le funciona, entonces Mercy Care Advantage cubrirá el Medicamento B.

Usted puede informarse si hay cualquier requerimiento o límite adicional para sus medicamentos consultandoel formulario que empieza en la página 1. También puede obtener más información sobre las restriccionesaplicadas a medicamentos cubiertos específicos visitando nuestro sitio web. Nosotros hemos publicado undocumento en línea que explica nuestras restricciones sobre la autorización previa y la terapia a pasos. Ustedtambién puede pedirnos que le enviemos a usted una copia. Nuestra información de contacto, junto con lafecha de la última vez que actualizamos el formulario, aparece en la portada y la contraportada.

Usted puede pedirle a Mercy Care Advantage que haga una excepción a estas restricciones o límites, o parauna lista de otros medicamentos similares que puedan tratar su condición de salud. Vea la sección “¿Cómosolicito una excepción al formulario de Mercy Care Advantage?” en la página X para información sobre cómosolicitar una excepción.

¿Qué pasa si mi medicamento no está en el Formulario?Si su medicamento no está incluido en este formulario (lista de medicamentos cubiertos), primero usteddebería comunicarse con Servicios al Miembro y preguntar si su medicamento está cubierto. Si usted descubreque Mercy Care Advantage no cubre su medicamento, tiene dos opciones:

• Usted puede pedirle a Servicios al Miembro una lista de medicamentos similares que estén cubiertospor Mercy Care Advantage. Cuando usted reciba la lista, muéstresela a su doctor y pídale que leprescriba un medicamento similar que esté cubierto por Mercy Care Advantage.

• Usted puede solicitar que Mercy Care Advantage haga una excepción y cubra su medicamento. Veaabajo cómo solicitar una excepción.

¿Cómo solicito una excepción al Formulario de Mercy Care Advantage (HMO SNP)?Usted puede pedirle a Mercy Care Advantage que haga una excepción a nuestras normas de cobertura. Hayvarios tipos de excepciones que usted puede pedir que hagamos.

• Usted nos puede pedir que cubramos un medicamento, aún si no está en nuestro formulario. Si esaprobado, dicho medicamento será cubierto a un nivel de costo compartido predeterminado, y ustedno podrá pedirnos que le proveamos dicho medicamento a un nivel de costo compartido más bajo.

• Usted puede pedir que no apliquemos las restricciones o los límites a la cobertura en su medicamento.Por ejemplo, para ciertos medicamentos, Mercy Care Advantage limita la cantidad del medicamentoque nosotros cubriremos. Si su medicamento tiene un límite de cantidad, usted puede pedirnos que noapliquemos el límite y que cubramos una cantidad más grande.

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Generalmente, Mercy Care Advantage sólo aprobará su solicitud de excepción si los medicamentos alternosincluidos en el formulario del plan o las restricciones adicionales para su uso no serían tan efectivos tratandosu condición y/o podrían ocasionarle efectos médicos adversos.

Usted se debería comunicar con nosotros para pedirnos una decisión inicial de cobertura para una excepciónal formulario, o a la restricción de uso. Cuando usted solicite una excepción al formulario o a la restricción deuso, debería presentar una declaración de su médico o de la persona emitiendo la prescripción respaldandosu solicitud. Generalmente, nosotros debemos tomar nuestra decisión dentro de 72 horas después de recibirla declaración de respaldo de la persona emitiendo la prescripción. Usted puede solicitar una excepciónexpedita (rápida) si usted o su doctor creen que su salud podría verse seriamente dañada por esperar 72horas para una decisión. Si se le concede su solicitud de excepción expedita, nosotros debemos darle unadecisión no más tarde de 24 horas después de recibir la declaración de respaldo de su doctor o de la otrapersona emitiendo la prescripción.

¿Qué hago antes de que pueda hablar con mi doctor sobre cambiar mis medicamentos osolicitar una excepción?Como miembro nuevo o continuando de nuestro plan, usted puede estar tomando medicamentos que no esténen nuestro formulario. O usted puede estar tomando un medicamento que esté en nuestro formulario pero sucapacidad para obtenerlo puede ser limitada. Por ejemplo, usted puede necesitar nuestra autorización previaantes de poder surtir su prescripción/receta. Usted debería hablar con su doctor para decidir si debería cambiara un medicamento apropiado que nosotros cubramos, o solicitar una excepción al formulario para que nosotroscubramos el medicamento que usted toma. Mientras habla con su doctor para determinar el curso de acciónapropiado para usted, en ciertos casos, nosotros podemos cubrir su medicamento durante los primeros 90 díasen los que usted sea miembro de nuestro plan.

Para cada medicamento que no esté en nuestro formulario, o si su capacidad para obtener dicho medicamentoes limitada, nosotros cubriremos un suministro temporal para 31 días. Si su prescripción ha sido emitidapara menos días, nosotros permitiremos que la vuelva a surtir hasta que se le provea medicamento con unsuministro máximo de 31 días. Después de su primer suministro para 31 días, nosotros ya no pagaremos pordichos medicamentos, aún si usted ha sido miembro del plan durante menos de 90 días.

Si usted es residente de una instalación de cuidado a largo plazo y necesita un medicamento que no esté ennuestro formulario o si su capacidad para obtener sus medicamentos es limitada, pero ya pasaron los primeros 90días como miembro de nuestro plan, nosotros cubriremos un suministro de emergencia de dicho medicamentopara 31 días, mientras usted trata de obtener una excepción al formulario.

Si a usted se le admite o se le da de alta de una instalación de cuidado a largo plazo, se le permitirá que se lesurta una prescripción ante su admisión o dada de alta.

Para más informaciónPara información más detallada sobre su cobertura de medicamentos de prescripción/receta de Mercy CareAdvantage, por favor lea su Evidencia de Cobertura y otros materiales del plan.

Si tiene usted preguntas sobre Mercy Care Advantage, por favor contáctenos. Nuestra información de contacto,junto con la fecha en la que actualizamos por último el formulario, aparece en la portada y la contraportada.

Si tiene usted preguntas generales sobre la cobertura de medicamentos de prescripción/receta de Medicare,por favor llame a Medicare al 1-800-MEDICARE (1-800-633-4227) 24 horas al día, siete días de la semana. Losusuarios de TTY deberían llamar al 1-877-486-2048. Ó visite http://www.medicare.gov.

http://www.medicare.gov

XII

Formulario de Mercy Care AdvantageEl formulario que empieza en la página 1 provee información de cobertura sobre algunos de los medicamentoscubiertos por Mercy Care Advantage. Si usted tiene problemas para encontrar su medicamento en la lista,regrese al Índice que empieza en la página 53.

En la primera columna de la tabla aparece el nombre del medicamento. Los medicamentos de marca estánescritos en mayúsculas (ejem.: SYNTHROID) y los medicamentos genéricos están escritos en cursivas minúsculas(ejem.: levothyroxine).

La columna del “Nivel del Medicamento” de la tabla lista la categoría de cada medicamento. Sus cantidadesde costo compartido dependen de la categoría en la que se encuentre el medicamento:

Categoría Cantidad del costo compartido

Medicamentos genéricos(incluyendo medicamentos de marca tratados

como genéricos)Copago de $0/$1.30/$3.60

El resto de los otros medicamentos Copago de $0/$3.90/$8.95

Sus copagos pueden ser más bajos, dependiendo del nivel de “Ayuda Extra” que usted esté recibiendo.La Evidencia de Cobertura para Personas que Reciben Ayuda Extra para el Pago de Sus Medicamentos dePrescripción (Cláusula LIS) lista la cantidad que usted pagará por sus medicamentos de prescripción. Ustedtambién puede llamar a Servicios al Miembro para informarse sobre la cantidad de su costo compartido. Losnúmeros telefónicos de Servicios al Miembro están en la portada y la contraportada de este folleto.

La información en la columna de Requerimientos/Límites le indica si Mercy Care Advantage tiene cualquierrequerimiento especial para la cobertura de su medicamento.

Abreviación en Inglés Requerimientos/Límites

B/D Cubierto/a bajo la Parte B o la Parte D de Medicare. La mayoría de losmedicamentos están cubiertos bajo la Parte D, pero hay algunos medicamentosque pueden estar cubiertos tanto bajo la Parte B como la Parte D dependiendodel motivo por el que se esté usando el medicamento y cómo es administrado.

EA Each / cada uno/a. Los medicamentos listados con EA indican el número depíldoras despachadas.

LA Limited access / acceso limitado. Esta prescripción puede estar disponible sólo enciertas farmacias. Para más información consulte el Directorio de Farmacias.

NM No está disponible en pedidos por correo.

PA Prior authorization / autorización previa. Usted o su proveedor necesitanobtener la aprobación de nuestro plan antes de que nosotros accedamos a cubrirel medicamento.

QL Quantity limits / límites de cantidad. Se muestra la cantidad por suministro ocada vez que se surta el medicamento.

ST Step therapy / terapia a pasos. Este medicamento de prescripción requiere queusted haya probado otro medicamento antes, el cual no le haya funcionado.

XIII86.03.334.1-AZ

Nondiscrimination Notice

Mercy Care d/b/a Mercy Care Advantage (HMO SNP) complies with applicable federal civil rights laws anddoes not discriminate on the basis of race, color, national origin, age, disability or sex. Mercy Care d/b/aMercy Care Advantage (HMO SNP) does not exclude people or treat them differently because of race,color, national origin, age, disability or sex.

Mercy Care d/b/a Mercy Care Advantage (HMO SNP):

• Provides free aids and services to people with disabilities to communicate effectively with us,such as:

o Qualified sign language interpreterso Written information in other formats (large print, audio, accessible electronic formats,

other formats)• Provides free language services to people whose primary language is not English, such as:

o Qualified interpreterso Information written in other languages

If you need a qualified interpreter, written information in other formats, translation or other services,call the number on your ID card.

If you believe that Mercy Care d/b/a Mercy Care Advantage (HMO SNP) has failed to provide theseservices or discriminated in another way on the basis of race, color, national origin, age, disability or sex,you can file a grievance with our Civil Rights Coordinator at:

Address: Attn: Civil Rights Coordinator4500 East Cotton Center BoulevardPhoenix, AZ 85040

Telephone: 1-888-234-7358 (TTY 711)Email: [email protected]

You can file a grievance in person or by mail or email. If you need help filing a grievance, our Civil RightsCoordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office forCivil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services,200 Independence Avenue, SW Room 509F, HHH Building, Washington, D.C. 20201, 1-800-368-1019,1-800-537-7697 (TDD).

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

http://www.hhs.gov/ocr/office/file/index.html

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf


mailto:[email protected]

XIV86.03.335.2-AZ

Aviso de no discriminación

Mercy Care, que realiza operaciones comerciales como Mercy Care Advantage (HMO SNP), cumple conlas leyes federales de derechos civiles vigentes y no discrimina por cuestiones de raza, color, nacionalidad,edad, discapacidad o sexo. Mercy Care, que realiza operaciones comerciales como Mercy Care Advantage(HMO SNP), no excluye a las personas ni las trata de manera diferente debido a cuestiones de raza, color,nacionalidad, edad, discapacidad o sexo.

Mercy Care, que realiza operaciones comerciales como Mercy Care Advantage (HMO SNP):

• Brinda ayuda y servicios gratuitos a personas con discapacidades para que se comuniquen demanera eficaz con nosotros, como los siguientes:

o Intérpretes de lenguaje de señas calificadoso Información escrita en otros formatos (letra grande, audio, formatos electrónicos accesibles,

otros formatos)• Brinda servicios de idiomas gratuitos a las personas cuya lengua materna no sea inglés, como

los siguientes:o Intérpretes calificadoso Información escrita en otros idiomas

Si necesita un intérprete calificado, información escrita en otros formatos, servicios de traducción u otrosservicios, comuníquese con el número que aparece en su tarjeta de identificación.

Si considera que Mercy Care, que realiza operaciones comerciales como Mercy Care Advantage (HMOSNP), no le proporcionó estos servicios o lo discriminó de alguna otra manera por cuestiones de raza,color, nacionalidad, edad, discapacidad o sexo, puede presentar una queja ante nuestro Coordinador deDerechos Civiles:

Dirección: Attn: Civil Rights Coordinator4500 East Cotton Center BoulevardPhoenix, AZ 85040

Teléfono: 1-888-234-7358 (TTY 711)Correo electrónico: [email protected]

Puede presentar una queja en persona o por correo, fax o correo electrónico. Si necesita ayuda parapresentar una queja, nuestro Coordinador de Derechos Civiles está disponible para ayudarle.

También puede presentar un reclamo de derechos civiles ante el Departamento de Salud y ServiciosSociales de EE. UU., Oficina de Derechos Civiles, de manera electrónica a través del portal de reclamos dela Oficina de Derechos Civiles, disponible en https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, o por correoo teléfono a: U.S. Department of Health and Human Services, 200 Independence Avenue, SW Room 509F,HHH Building, Washington, D.C. 20201, 1-800-368-1019, 1-800-537-7697 (TDD).

Los formularios de reclamo están disponibles en http://www.hhs.gov/ocr/office/file/index.html.

http://www.hhs.gov/ocr/office/file/index.html


mailto:[email protected]

XV86.03.334.1-AZ

Multi-language Interpreter Services

English: ATTENTION: If you speak English, language assistance services, free of charge, are available to you.Call 1-877-436-5288 (TTY: 711).

Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llameal 1-877-436-5288 (TTY: 711).

Chinese: 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-877-436-5288 (TTY: 711)。

Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số1-877-436-5288 (TTY: 711).

Arabic:

Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wikanang walang bayad. Tumawag sa 1-877-436-5288 (TTY: 711).

Korean: 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-877-436-5288(TTY: 711) 번으로 전화해 주십시오.

French: ATTENTION: Si vous parlez français, des services d’aide linguistique vous sont proposés gratuitement.Appelez le 1-877-436-5288 (ATS: 711).

German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungenzur Verfügung. Rufnummer: 1-877-436-5288 (TTY: 711).

Russian: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услугиперевода. Звоните 1-877-436-5288 (телетайп: 711).

Japanese: 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-877-436-5288(TTY: 711) まで、お電話にてご連絡ください。

Persian:

Syriac:

Serbo-Croatian (Serbian): OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne suvam besplatno. Nazovite 1-877-436-5288 (TTY- Telefon za osobe sa oštećenim govorom ili sluhom: 711).

Thai:

2020 Formulary (List of Covered Drugs)

PA – Prior Authorization QL – Quantity Limits ST – Step Therapy B/D – Covered under Medicare B or D LA – Limited Access

NM – Not available at mail-order 1

Formulary ID 00020345 v11 06/01/2020

Drug Name Drug Tier Requirements/Limits ANALGESICS – DRUGS TO TREAT PAIN AND INFLAMMATION GOUT– DRUGS TO TREAT GOUT allopurinol tab GENERIC colchicine w/ probenecid GENERIC COLCRYS OTHER QL (120 tabs/30 days), NM MITIGARE OTHER QL (60 caps/30 days), NM probenecid GENERIC NSAIDS – DRUGS TO TREAT PAIN AND INFLAMMATION celecoxib CAPS 50mg GENERIC QL (240 caps/30 days) celecoxib CAPS 100mg GENERIC QL (120 caps/30 days) celecoxib CAPS 200mg GENERIC QL (60 caps/30 days) celecoxib CAPS 400mg GENERIC QL (30 caps/30 days) diclofenac potassium GENERIC QL (120 tabs/30 days) diclofenac sodium TB24; TBEC GENERIC diflunisal TABS GENERIC etodolac GENERIC flurbiprofen TABS 100mg GENERIC ibu tab 600mg GENERIC ibu tab 800mg GENERIC ibuprofen SUSP GENERIC NM ibuprofen TABS 400mg, 600mg, 800mg GENERIC meloxicam TABS GENERIC nabumetone TABS GENERIC naproxen TABS 250mg, 375mg, 500mg GENERIC naproxen dr GENERIC naproxen sodium TABS 275mg, 550mg GENERIC piroxicam CAPS GENERIC sulindac TABS GENERIC OPIOID ANALGESICS – DRUGS TO TREAT PAIN acetaminophen w/ codeine 300-15mg GENERIC QL (400 tabs/30 days), NM acetaminophen w/ codeine 300-30mg GENERIC QL (360 tabs/30 days), NM acetaminophen w/ codeine 300-60mg GENERIC QL (180 tabs/30 days), NM acetaminophen w/ codeine soln GENERIC QL (2700 mL/30 days), NM butorphanol tartrate SOLN 1mg/ml, 2mg/ml GENERIC NM nalbuphine hcl SOLN GENERIC NM tramadol hcl tab 50 mg GENERIC QL (240 tabs/30 days), NM tramadol-acetaminophen GENERIC QL (240 tabs/30 days), NM OPIOID ANALGESICS, CII – DRUGS TO TREAT PAIN endocet 2.5-325mg GENERIC QL (360 tabs/30 days), NM endocet 5-325mg GENERIC QL (360 tabs/30 days), NM

Drug Name Drug Tier Requirements/Limits endocet 7.5-325mg GENERIC QL (240 tabs/30 days), NM endocet 10-325mg GENERIC QL (180 tabs/30 days), NM fentanyl citrate LPOP GENERIC QL (120 lozenges/30 days), NM, PA fentanyl patch 12 mcg/hr GENERIC QL (10 patches/30 days), NM, PA fentanyl patch 25 mcg/hr GENERIC QL (10 patches/30 days), NM, PA fentanyl patch 50 mcg/hr GENERIC QL (10 patches/30 days), NM, PA fentanyl patch 75 mcg/hr GENERIC QL (10 patches/30 days), NM, PA fentanyl patch 100 mcg/hr GENERIC QL (10 patches/30 days), NM, PA hydroco/apap tab 5-325mg GENERIC QL (240 tabs/30 days), NM hydroco/apap tab 7.5-325 GENERIC QL (180 tabs/30 days), NM hydroco/apap tab 10-325mg GENERIC QL (180 tabs/30 days), NM hydrocodone-acetaminophen 7.5-325 mg/15ml GENERIC QL (2700 mL/30 days), NM hydrocodone-ibuprofen tab 7.5-200 mg GENERIC QL (150 tabs/30 days), NM hydromorphone hcl LIQD GENERIC QL (600 mL/30 days), NM hydromorphone hcl SOLN 10mg/ml, 50mg/5ml, 500mg/50ml GENERIC B/D, NM hydromorphone hcl TABS GENERIC QL (180 tabs/30 days), NM HYSINGLA ER OTHER QL (30 tabs/30 days), NM, PA lorcet hd tab 10-325mg GENERIC QL (180 tabs/30 days), NM lorcet plus tab 7.5-325 GENERIC QL (180 tabs/30 days), NM lorcet tab 5-325mg GENERIC QL (240 tabs/30 days), NM methadone hcl SOLN 5mg/5ml, 10mg/5ml GENERIC QL (450 mL/30 days), NM, PA methadone hcl 5mg GENERIC QL (90 tabs/30 days), NM, PA methadone hcl 10mg GENERIC QL (90 tabs/30 days), NM, PA methadone hcl intensol GENERIC QL (90 mL/30 days), NM, PA morphine ext-rel tab GENERIC QL (90 tabs/30 days), NM, PA morphine sul inj 1mg/ml GENERIC B/D, NM MORPHINE SULFATE SOLN 2mg/ml, 4mg/ml, 5mg/ml, 8mg/ml, 10mg/ml

OTHER B/D, NM

morphine sulfate SOLN 4mg/ml, 8mg/ml, 10mg/ml GENERIC B/D, NM morphine sulfate TABS GENERIC QL (180 tabs/30 days), NM morphine sulfate oral soln 10mg/5ml GENERIC QL (900 mL/30 days), NM morphine sulfate oral soln 20mg/5ml GENERIC QL (900 mL/30 days), NM morphine sulfate oral soln 100mg/5ml GENERIC QL (180 mL/30 days), NM NUCYNTA ER OTHER QL (60 tabs/30 days), NM, PA oxycodone hcl CAPS GENERIC QL (180 caps/30 days), NM oxycodone hcl CONC GENERIC QL (180 mL/30 days), NM oxycodone hcl SOLN GENERIC QL (900 mL/30 days), NM oxycodone hcl TABS GENERIC QL (180 tabs/30 days), NM oxycodone w/ acetaminophen 2.5-325mg GENERIC QL (360 tabs/30 days), NM oxycodone w/ acetaminophen 5-325mg GENERIC QL (360 tabs/30 days), NM oxycodone w/ acetaminophen 7.5-325mg GENERIC QL (240 tabs/30 days), NM oxycodone w/ acetaminophen 10-325mg GENERIC QL (180 tabs/30 days), NM

PA – Prior Authorization QL – Quantity Limits ST – Step Therapy NM – Not available at mail-order 2 B/D – Covered under Medicare B or D LA – Limited Access

Formulary ID 00020345 v11 06/01/2020

Drug Name Drug Tier Requirements/Limits ANESTHETICS – DRUGS FOR NUMBING LOCAL ANESTHETICS lidocaine hcl (local anesth.) GENERIC B/D, NM lidocaine inj 0.5% GENERIC B/D, NM lidocaine inj 1% GENERIC B/D, NM lidocaine inj 1.5% preservative free (pf) GENERIC B/D, NM ANTI-INFECTIVES – DRUGS TO TREAT INFECTIONS ANTI-BACTERIALS – MISCELLANEOUS amikacin sulfate SOLN GENERIC NM gentamicin in saline GENERIC NM gentamicin sulfate SOLN GENERIC NM neomycin sulfate TABS GENERIC NM paromomycin sulfate CAPS GENERIC NM streptomycin sulfate SOLR GENERIC NM sulfadiazine TABS GENERIC NM tobramycin NEBU GENERIC NM, PA tobramycin inj 1.2 gm/30ml GENERIC NM tobramycin inj 1.2gm GENERIC NM tobramycin inj 10mg/ml GENERIC NM tobramycin inj 80mg/2ml GENERIC NM tobramycin sulfate SOLN GENERIC NM ANTI-INFECTIVES – MISCELLANEOUS albendazole TABS GENERIC NM ALINIA OTHER NM atovaquone SUSP GENERIC NM aztreonam GENERIC NM CAYSTON OTHER NM, LA, PA clindamycin cap 75mg GENERIC NM clindamycin cap 300 mg GENERIC NM clindamycin hcl cap 150 mg GENERIC NM clindamycin phosphate in d5w GENERIC NM CLINDAMYCIN PHOSPHATE IN NACL OTHER NM clindamycin phosphate inj GENERIC NM clindamycin soln 75mg/5ml GENERIC NM colistimethate sodium SOLR GENERIC NM dapsone TABS GENERIC daptomycin GENERIC NM emverm GENERIC QL (12 tabs/365 days), NM ertapenem sodium GENERIC NM imipenem-cilastatin GENERIC NM ivermectin TABS GENERIC NM linezolid in sodium chloride GENERIC NM linezolid inj GENERIC NM linezolid susp GENERIC NM


Formulary ID 00020345 v11 06/01/2020

Drug Name Drug Tier Requirements/Limits linezolid tab 600mg GENERIC NM meropenem GENERIC NM methenamine hippurate GENERIC NM metronidazole TABS GENERIC NM metronidazole in nacl GENERIC NM nitrofurantoin macrocrystal 50mg, 100mg GENERIC NM nitrofurantoin monohyd macro GENERIC NM pentamidine isethionate inh GENERIC B/D, NM pentamidine isethionate inj GENERIC NM praziquantel TABS GENERIC NM SIVEXTRO OTHER NM sulfamethoxazole-trimethop ds GENERIC NM sulfamethoxazole-trimethoprim inj GENERIC NM sulfamethoxazole-trimethoprim susp GENERIC NM sulfamethoxazole-trimethoprim tab 400-80mg GENERIC NM SYNERCID OTHER NM tigecycline GENERIC NM trimethoprim TABS GENERIC NM vancomycin hcl CAPS 125mg GENERIC QL (120 caps/30 days), NM vancomycin hcl CAPS 250mg GENERIC QL (240 caps/30 days), NM vancomycin hcl SOLR 1gm, 5gm, 10gm, 500mg, 750mg GENERIC NM VANCOMYCIN IN NACL OTHER NM ANTIFUNGALS – DRUGS TO TREAT FUNGAL INFECTIONS ABELCET OTHER B/D, NM AMBISOME OTHER B/D, NM amphotericin b SOLR GENERIC B/D, NM caspofungin acetate GENERIC NM fluconazole SUSR; TABS GENERIC NM fluconazole inj nacl 200 GENERIC NM fluconazole inj nacl 400 GENERIC NM flucytosine CAPS GENERIC NM griseofulvin microsize GENERIC NM griseofulvin ultramicrosize GENERIC NM itraconazole CAPS GENERIC NM, PA ketoconazole TABS GENERIC NM, PA MYCAMINE OTHER NM NOXAFIL SUSP OTHER QL (630 mL/30 days) nystatin TABS GENERIC NM posaconazole GENERIC QL (93 tabs/30 days) terbinafine hcl TABS GENERIC QL (90 tabs/year), NM voriconazole SOLR; SUSR GENERIC NM, PA voriconazole TABS GENERIC NM ANTIMALARIALS – DRUGS TO TREAT MALARIA atovaquone-proguanil hcl GENERIC NM


Formulary ID 00020345 v11 06/01/2020

Drug Name Drug Tier Requirements/Limits chloroquine phosphate TABS GENERIC COARTEM OTHER NM mefloquine hcl GENERIC primaquine phosphate 26.3mg GENERIC NM PRIMAQUINE PHOSPHATE 26.3mg OTHER NM quinine sulfate CAPS GENERIC NM, PA ANTIRETROVIRAL AGENTS – DRUGS TO SUPPRESS HIV/AIDS INFECTION abacavir sulfate GENERIC NM APTIVUS OTHER NM atazanavir sulfate GENERIC NM CRIXIVAN OTHER NM didanosine GENERIC NM EDURANT OTHER NM efavirenz GENERIC NM EMTRIVA OTHER NM fosamprenavir tab 700 mg GENERIC NM FUZEON OTHER NM INTELENCE OTHER NM INVIRASE OTHER NM ISENTRESS OTHER NM ISENTRESS HD OTHER NM lamivudine GENERIC NM LEXIVA SUSP OTHER NM nevirapine susp 50 mg/5ml GENERIC NM nevirapine tab 100mg er GENERIC NM nevirapine tab 200mg GENERIC NM nevirapine tab 400mg er GENERIC NM NORVIR PACK OTHER NM NORVIR SOLN OTHER NM PIFELTRO OTHER NM PREZISTA SUSP OTHER QL (400 mL/30 days), NM PREZISTA TABS 75mg OTHER QL (480 tabs/30 days), NM PREZISTA TABS 150mg OTHER QL (240 tabs/30 days), NM PREZISTA TABS 600mg OTHER QL (60 tabs/30 days), NM PREZISTA TABS 800mg OTHER QL (30 tabs/30 days), NM REYATAZ PACK OTHER NM ritonavir GENERIC NM SELZENTRY OTHER NM stavudine GENERIC NM tenofovir disoproxil fumarate GENERIC NM TIVICAY OTHER NM TROGARZO OTHER NM, LA TYBOST OTHER NM VIDEX EC 125MG OTHER NM


Formulary ID 00020345 v11 06/01/2020

Drug Name Drug Tier Requirements/Limits VIDEX PEDIATRIC OTHER NM VIRACEPT OTHER NM VIREAD POWD OTHER NM VIREAD TABS 150mg, 200mg, 250mg OTHER NM zidovudine cap 100mg GENERIC NM zidovudine syp 50mg/5ml GENERIC NM zidovudine tab 300mg GENERIC NM ANTIRETROVIRAL COMBINATION AGENTS – DRUGS TO SUPPRESS HIV/AIDS INFECTION abacavir sulfate-lamivudine GENERIC NM abacavir sulfate-lamivudine-zidovudine GENERIC NM ATRIPLA OTHER NM BIKTARVY OTHER NM CIMDUO OTHER NM COMPLERA OTHER NM DELSTRIGO OTHER NM DESCOVY OTHER NM DOVATO OTHER NM EVOTAZ OTHER NM GENVOYA OTHER NM JULUCA OTHER NM KALETRA TAB 100-25MG OTHER NM KALETRA TAB 200-50MG OTHER NM lamivudine-zidovudine GENERIC NM lopinavir-ritonavir GENERIC NM ODEFSEY OTHER NM PREZCOBIX OTHER NM STRIBILD OTHER NM SYMFI OTHER NM SYMFI LO OTHER NM SYMTUZA OTHER NM TEMIXYS OTHER NM TRIUMEQ OTHER NM TRUVADA TAB 100-150 OTHER QL (30 tabs/30 days), NM TRUVADA TAB 133-200 OTHER QL (30 tabs/30 days), NM TRUVADA TAB 167-250 OTHER QL (30 tabs/30 days), NM TRUVADA TAB 200-300 OTHER QL (30 tabs/30 days), NM ANTITUBERCULAR AGENTS – DRUGS TO TREAT TUBERCULOSIS cycloserine CAPS GENERIC NM ethambutol hcl TABS GENERIC NM isoniazid TABS GENERIC isoniazid syp 50mg/5ml GENERIC paser d/r GENERIC NM PRIFTIN OTHER NM pyrazinamide TABS GENERIC NM



Formulary ID 00020345 v11 06/01/2020

Drug Name Drug Tier Requirements/Limits rifabutin GENERIC NM rifampin CAPS; SOLR GENERIC NM RIFATER OTHER NM SIRTURO OTHER NM, LA, PA TRECATOR OTHER NM ANTIVIRALS – DRUGS TO TREAT VIRAL INFECTIONS acyclovir CAPS; SUSP; TABS GENERIC NM acyclovir sodium GENERIC B/D, NM adefovir dipivoxil GENERIC NM BARACLUDE SOLN OTHER NM entecavir GENERIC NM EPCLUSA OTHER NM, PA EPIVIR HBV SOLN OTHER NM famciclovir TABS GENERIC NM ganciclovir sodium GENERIC B/D, NM HARVONI OTHER NM, PA lamivudine (hbv) GENERIC NM MAVYRET OTHER NM, PA oseltamivir phosphate CAPS 30mg GENERIC QL (168 caps/year), NM oseltamivir phosphate CAPS 45mg, 75mg GENERIC QL (84 caps/year), NM oseltamivir phosphate SUSR GENERIC QL (1080 mL/year), NM PEGASYS OTHER NM, PA PEGASYS PROCLICK OTHER NM, PA RELENZA DISKHALER OTHER QL (6 inhalers/year), NM ribavirin cap 200mg GENERIC NM ribavirin tab 200mg GENERIC NM rimantadine hydrochloride GENERIC NM valacyclovir hcl TABS GENERIC NM valganciclovir hcl GENERIC VEMLIDY OTHER NM VOSEVI OTHER NM, PA CEPHALOSPORINS – DRUGS TO TREAT INFECTIONS cefaclor GENERIC NM cefaclor er tab 500mg GENERIC NM cefadroxil GENERIC NM CEFAZOLIN IN DEXTROSE 2GM/100ML-4% OTHER NM cefazolin inj GENERIC NM cefazolin sodium SOLR 1gm GENERIC NM cefazolin sodium 1 gm/50ml GENERIC NM cefdinir GENERIC NM cefepime for inj GENERIC NM cefixime SUSR GENERIC NM cefoxitin for inj GENERIC NM cefpodoxime proxetil GENERIC NM


Formulary ID 00020345 v11 06/01/2020

Drug Name Drug Tier Requirements/Limits cefprozil GENERIC NM ceftazidime SOLR GENERIC NM CEFTAZIDIME/DEXTROSE OTHER NM ceftriaxone sodium SOLR 1gm, 2gm, 10gm, 250mg, 500mg GENERIC NM cefuroxime axetil GENERIC NM cefuroxime sodium GENERIC NM cephalexin CAPS 250mg, 500mg GENERIC NM cephalexin SUSR GENERIC NM tazicef SOLR GENERIC NM TEFLARO OTHER NM ERYTHROMYCINS/MACROLIDES – DRUGS TO TREAT INFECTIONS azithromycin PACK; SOLR; SUSR; TABS GENERIC NM clarithromycin TABS GENERIC NM clarithromycin er GENERIC NM clarithromycin for susp GENERIC NM DIFICID OTHER NM e.e.s. 400 GENERIC NM ery-tab GENERIC NM erythrocin lactobionate GENERIC NM erythrocin stearate GENERIC NM erythromycin base GENERIC NM erythromycin cap 250mg ec GENERIC NM erythromycin ethylsuccinate TABS GENERIC NM erythromycin tab ec GENERIC NM FLUOROQUINOLONES – DRUGS TO TREAT INFECTIONS CIPRO SUSR 500mg/5ml OTHER NM ciprofloxacin hcl tab GENERIC NM ciprofloxacin in d5w GENERIC NM levofloxacin TABS GENERIC NM levofloxacin in d5w GENERIC NM levofloxacin inj 25mg/ml GENERIC NM levofloxacin oral soln 25 mg/ml GENERIC NM moxifloxacin hcl TABS GENERIC NM PENICILLINS – DRUGS TO TREAT INFECTIONS amoxicillin GENERIC NM amoxicillin & pot clavulanate 200-28.5 chw tabs GENERIC NM amoxicillin & pot clavulanate 200/5ml susr GENERIC NM amoxicillin & pot clavulanate 250-125 tabs GENERIC NM amoxicillin & pot clavulanate 250/5ml susr GENERIC NM amoxicillin & pot clavulanate 400-57 chw tabs GENERIC NM amoxicillin & pot clavulanate 400/5ml susr GENERIC NM amoxicillin & pot clavulanate 500-125 tabs GENERIC NM amoxicillin & pot clavulanate 600/5ml susr GENERIC NM amoxicillin & pot clavulanate 875-125 tabs GENERIC NM


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Drug Name Drug Tier Requirements/Limits amoxicillin & pot clavulanate er 12hr 1000-62.5 tabs GENERIC NM ampicillin & sulbactam sodium GENERIC NM ampicillin cap 500mg GENERIC NM ampicillin inj GENERIC NM ampicillin sodium GENERIC NM BICILLIN L-A OTHER NM dicloxacillin sodium GENERIC NM nafcillin sodium for inj GENERIC NM nafcillin sodium for inj 10gm GENERIC NM oxacillin sodium SOLR GENERIC NM PENICILLIN G POT IN DEXTROSE 2MU OTHER NM PENICILLIN G POT IN DEXTROSE 3MU OTHER NM penicillin g procaine GENERIC NM penicillin g sodium GENERIC NM penicillin v potassium GENERIC NM penicilln gk inj 5mu GENERIC NM penicilln gk inj 20mu GENERIC NM pfizerpen-g inj 5mu GENERIC NM pfizerpen-g inj 20mu GENERIC NM piper/tazoba inj 2-0.25gm GENERIC NM piper/tazoba inj 3-0.375gm GENERIC NM piper/tazoba inj 4-0.5gm GENERIC NM piper/tazoba inj 12-1.5gm GENERIC NM piper/tazoba inj 36-4.5gm GENERIC NM TETRACYCLINES – DRUGS TO TREAT INFECTIONS doxy 100 GENERIC NM doxycycline (monohydrate) CAPS 50mg, 100mg GENERIC NM doxycycline (monohydrate) TABS 50mg, 75mg, 100mg GENERIC NM doxycycline hyclate CAPS; SOLR GENERIC NM doxycycline hyclate 20 mg GENERIC NM doxycycline hyclate 100 mg GENERIC NM minocycline hcl CAPS GENERIC NM mondoxyne nl cap 100mg GENERIC NM tetracycline hcl CAPS GENERIC NM ANTINEOPLASTIC AGENTS – DRUGS TO TREAT CANCER ALKYLATING AGENTS BENDEKA OTHER B/D, NM cyclophosphamide CAPS; SOLR GENERIC B/D, NM EMCYT OTHER NM GLEOSTINE OTHER NM LEUKERAN OTHER NM ANTHRACYCLINES adriamycin SOLN GENERIC B/D, NM doxorubicin hcl GENERIC B/D, NM


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Drug Name Drug Tier Requirements/Limits doxorubicin hcl liposomal GENERIC B/D, NM epirubicin hcl GENERIC B/D, NM ANTIMETABOLITES adrucil inj GENERIC B/D, NM ALIMTA OTHER B/D, NM azacitidine GENERIC B/D, NM cytarabine 20mg/ml GENERIC B/D, NM fluorouracil SOLN GENERIC B/D, NM gemcitabine inj soln GENERIC B/D, NM gemcitabine inj solr GENERIC B/D, NM mercaptopurine TABS GENERIC NM methotrexate sodium inj soln GENERIC B/D, NM methotrexate sodium inj solr GENERIC B/D, NM PURIXAN OTHER NM TABLOID OTHER NM ANTIMITOTIC, TAXOIDS ABRAXANE OTHER B/D, NM docetaxel CONC 20mg/ml, 80mg/4ml, 160mg/8ml, 200mg/10ml

GENERIC B/D, NM

DOCETAXEL CONC 80mg/4ml, 160mg/8ml OTHER B/D, NM docetaxel SOLN 20mg/2ml, 80mg/8ml, 160mg/16ml GENERIC B/D, NM DOCETAXEL SOLN 20mg/2ml, 80mg/8ml, 160mg/16ml OTHER B/D, NM paclitaxel GENERIC B/D, NM TAXOTERE OTHER B/D, NM ANTIMITOTIC, VINCA ALKALOIDS vincristine sulfate GENERIC B/D, NM vinorelbine tartrate GENERIC B/D, NM BIOLOGIC RESPONSE MODIFIERS AVASTIN OTHER NM, LA, PA BORTEZOMIB OTHER NM, PA DAURISMO OTHER NM, LA, PA ERIVEDGE OTHER NM, LA, PA FARYDAK OTHER NM, LA, PA HERCEPTIN OTHER NM, PA HERCEPTIN HYLECTA OTHER NM, PA IBRANCE CAPS OTHER QL (21 caps/28 days), NM, LA, PA IBRANCE TABS OTHER QL (21 tabs/28 days), NM, LA, PA IDHIFA OTHER QL (30 tabs/30 days), NM, LA, PA KADCYLA OTHER B/D, NM KANJINTI OTHER NM, PA KEYTRUDA OTHER NM, PA KISQALI OTHER NM, PA KISQALI FEMARA 200 DOSE OTHER NM, PA KISQALI FEMARA 400 DOSE OTHER NM, PA

Drug Name Drug Tier Requirements/Limits KISQALI FEMARA 600 DOSE OTHER NM, PA LYNPARZA OTHER NM, LA, PA MVASI OTHER NM, LA, PA NINLARO OTHER NM, PA ODOMZO OTHER NM, LA, PA OGIVRI OTHER NM, PA RITUXAN OTHER NM, LA, PA RITUXAN HYCELA OTHER NM, LA, PA RUBRACA OTHER NM, LA, PA RUXIENCE OTHER NM, PA TALZENNA OTHER NM, LA, PA TECENTRIQ OTHER NM, LA, PA TIBSOVO OTHER NM, LA, PA TRAZIMERA OTHER NM, PA TRUXIMA OTHER NM, PA VELCADE OTHER NM, PA VENCLEXTA OTHER NM, LA, PA VENCLEXTA STARTING PACK OTHER NM, LA, PA VERZENIO OTHER NM, LA, PA ZEJULA OTHER NM, LA, PA ZIRABEV OTHER NM, PA ZOLINZA OTHER NM, PA HORMONAL ANTINEOPLASTIC AGENTS abiraterone acetate GENERIC NM, PA anastrozole TABS GENERIC bicalutamide GENERIC NM DEPO-PROVERA INJ 400/ML OTHER B/D, NM ERLEADA OTHER NM, LA, PA exemestane GENERIC flutamide GENERIC NM fulvestrant GENERIC B/D, NM letrozole TABS GENERIC leuprolide inj 1mg/0.2 GENERIC NM, PA LUPRON DEPOT (1-MONTH) 3.75mg OTHER NM, PA LUPRON DEPOT INJ 11.25MG (3-MONTH) OTHER NM, PA LYSODREN OTHER NM megestrol ac sus 40mg/ml GENERIC NM megestrol ac tab 20mg GENERIC NM megestrol ac tab 40mg GENERIC NM megestrol sus 625mg/5ml GENERIC PA nilutamide GENERIC NM NUBEQA OTHER NM, LA, PA SOLTAMOX OTHER tamoxifen citrate TABS GENERIC


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Formulary ID 00020345 v11 06/01/2020

Drug Name Drug Tier Requirements/Limits toremifene citrate GENERIC TRELSTAR DEP INJ 3.75MG OTHER NM, PA TRELSTAR LA INJ 11.25MG OTHER NM, PA XTANDI OTHER NM, LA, PA ZYTIGA 500mg OTHER NM, LA, PA IMMUNOMODULATORS POMALYST 1mg, 2mg OTHER QL (21 caps/21 days), NM, LA, PA POMALYST 3mg, 4mg OTHER QL (21 caps/28 days), NM, LA, PA REVLIMID OTHER QL (28 caps/28 days), NM, LA, PA THALOMID 50mg, 100mg OTHER QL (28 caps/28 days), NM, PA THALOMID 150mg, 200mg OTHER QL (56 caps/28 days), NM, PA KINASE INHIBITORS AFINITOR 10mg OTHER QL (30 tabs/30 days), NM, PA AFINITOR DISPERZ 2mg OTHER QL (150 tabs/30 days), NM, PA AFINITOR DISPERZ 3mg OTHER QL (90 tabs/30 days), NM, PA AFINITOR DISPERZ 5mg OTHER QL (60 tabs/30 days), NM, PA ALECENSA OTHER NM, LA, PA ALUNBRIG OTHER NM, LA, PA AYVAKIT OTHER QL (30 tabs/30 days), NM, LA, PA BALVERSA OTHER NM, LA, PA BOSULIF OTHER NM, PA BRAFTOVI OTHER NM, LA, PA BRUKINSA OTHER NM, LA, PA CABOMETYX OTHER QL (30 tabs/30 days), NM, LA, PA CALQUENCE OTHER NM, LA, PA CAPRELSA OTHER NM, LA, PA COMETRIQ OTHER NM, LA, PA COPIKTRA OTHER NM, LA, PA COTELLIC OTHER NM, LA, PA erlotinib hcl 25mg GENERIC QL (90 tabs/30 days), NM, PA erlotinib hcl 100mg, 150mg GENERIC QL (30 tabs/30 days), NM, PA everolimus GENERIC QL (30 tabs/30 days), NM, PA GILOTRIF TAB 20MG OTHER NM, LA, PA GILOTRIF TAB 30MG OTHER NM, LA, PA GILOTRIF TAB 40MG OTHER NM, LA, PA ICLUSIG OTHER NM, LA, PA imatinib mesylate 100mg GENERIC QL (90 tabs/30 days), NM, PA imatinib mesylate 400mg GENERIC QL (60 tabs/30 days), NM, PA IMBRUVICA OTHER NM, LA, PA INLYTA 1mg OTHER QL (180 tabs/30 days), NM, LA, PA INLYTA 5mg OTHER QL (120 tabs/30 days), NM, LA, PA INREBIC OTHER NM, LA, PA IRESSA OTHER NM, LA, PA JAKAFI OTHER QL (60 tabs/30 days), NM, LA, PA

Drug Name Drug Tier Requirements/Limits LENVIMA 4 MG DAILY DOSE OTHER NM, LA, PA LENVIMA 8 MG DAILY DOSE OTHER NM, LA, PA LENVIMA 10 MG DAILY DOSE OTHER NM, LA, PA LENVIMA 12MG DAILY DOSE OTHER NM, LA, PA LENVIMA 14 MG DAILY DOSE OTHER NM, LA, PA LENVIMA 18 MG DAILY DOSE OTHER NM, LA, PA LENVIMA 20 MG DAILY DOSE OTHER NM, LA, PA LENVIMA 24 MG DAILY DOSE OTHER NM, LA, PA LORBRENA OTHER NM, LA, PA MEKINIST OTHER NM, LA, PA MEKTOVI OTHER NM, LA, PA NERLYNX OTHER NM, LA, PA NEXAVAR OTHER NM, LA, PA PIQRAY 200MG DAILY DOSE OTHER NM, PA PIQRAY 250MG DAILY DOSE OTHER NM, PA PIQRAY 300MG DAILY DOSE OTHER NM, PA ROZLYTREK OTHER NM, LA, PA RYDAPT OTHER NM, PA SPRYCEL OTHER NM, PA STIVARGA OTHER NM, LA, PA SUTENT OTHER QL (30 caps/30 days), NM, PA TAFINLAR OTHER NM, LA, PA TAGRISSO OTHER QL (30 tabs/30 days), NM, LA, PA TASIGNA OTHER NM, PA TURALIO OTHER NM, LA, PA TYKERB OTHER NM, LA, PA VITRAKVI OTHER NM, LA, PA VIZIMPRO OTHER NM, LA, PA VOTRIENT OTHER NM, LA, PA XALKORI OTHER NM, LA, PA XOSPATA OTHER NM, LA, PA ZELBORAF OTHER NM, LA, PA ZYDELIG OTHER NM, LA, PA ZYKADIA OTHER NM, LA, PA MISCELLANEOUS bexarotene GENERIC NM, PA hydroxyurea CAPS GENERIC NM LONSURF OTHER NM, PA MATULANE OTHER NM, LA SYLATRON 200mcg, 300mcg OTHER NM, PA SYNRIBO OTHER NM, PA TAZVERIK OTHER NM, LA, PA tretinoin (chemotherapy) GENERIC NM XPOVIO 60 MG ONCE WEEKLY OTHER NM, LA, PA XPOVIO 80 MG ONCE WEEKLY OTHER NM, LA, PA PA – Prior Authorization QL – Quantity Limits ST – Step Therapy NM – Not available at mail-order 13 B/D – Covered under Medicare B or D LA – Limited Access

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Drug Name Drug Tier Requirements/Limits XPOVIO 80 MG TWICE WEEKLY OTHER NM, LA, PA XPOVIO 100 MG ONCE WEEKLY OTHER NM, LA, PA PLATINUM-BASED AGENTS carboplatin GENERIC B/D, NM cisplatin SOLN GENERIC B/D, NM oxaliplatin inj 50mg GENERIC B/D, NM oxaliplatin inj 50mg/10ml GENERIC B/D, NM oxaliplatin inj 100mg GENERIC B/D, NM oxaliplatin inj 100mg/20ml GENERIC B/D, NM PROTECTIVE AGENTS leucovorin calcium SOLN 500mg/50ml GENERIC B/D, NM leucovorin calcium SOLR GENERIC B/D, NM leucovorin calcium TABS GENERIC NM MESNEX TABS OTHER NM TOPOISOMERASE INHIBITORS etoposide SOLN GENERIC B/D, NM

irinotecan hcl GENERIC B/D, NM toposar GENERIC B/D, NM CARDIOVASCULAR – DRUGS TO TREAT HEART AND CIRCULATION CONDITIONS ACE INHIBITOR COMBINATIONS – DRUGS TO TREAT HIGH BLOOD PRESSURE

amlodipine besylate-benazepril hcl cap 2.5-10 mg GENERIC amlodipine besylate-benazepril hcl cap 5-10 mg GENERIC amlodipine besylate-benazepril hcl cap 5-20 mg GENERIC amlodipine besylate-benazepril hcl cap 5-40 mg GENERIC amlodipine besylate-benazepril hcl cap 10-20 mg GENERIC amlodipine besylate-benazepril hcl cap 10-40 mg GENERIC

benazepril & hydrochlorothiazide GENERIC captopril & hydrochlorothiazide GENERIC enalapril maleate & hydrochlorothiazide GENERIC

fosinopril sodium & hydrochlorothiazide GENERIC lisinopril & hydrochlorothiazide GENERIC

quinapril-hydrochlorothiazide GENERICACE INHIBITORS – DRUGS TO TREAT HIGH BLOOD PRESSURE

benazepril hcl TABS GENERICcaptopril TABS GENERIC

enalapril maleate TABS GENERIC fosinopril sodium GENERIC

lisinopril TABS GENERICmoexipril hcl GENERIC

perindopril erbumine GENERIC quinapril hcl GENERIC

ramipril GENERICtrandolapril GENERIC

Drug Name Drug Tier Requirements/Limits ALDOSTERONE RECEPTOR ANTAGONISTS – DRUGS TO TREAT HIGH BLOOD PRESSURE eplerenone GENERICspironolactone TABS GENERICALPHA BLOCKERS – DRUGS TO TREAT HIGH BLOOD PRESSUREdoxazosin mesylate TABS GENERICprazosin hcl GENERICterazosin hcl GENERICANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS – DRUGS TO TREAT HIGH BLOOD PRESSUREamlodipine besylate-olmesartan medoxomil GENERICamlodipine besylate-valsartan tab GENERICamlodipine-valsartan-hydrochlorothiazide tab GENERICcandesartan cilexetil-hydrochlorothiazide GENERICENTRESTO OTHER irbesartan-hydrochlorothiazide GENERIClosartan-hydrochlorothiazide GENERIColmesartan medoxomil-amlodipine-hydrochlorothiazide GENERIColmesartan medoxomil-hydrochlorothiazide GENERICtelmisartan-amlodipine GENERICtelmisartan-hydrochlorothiazide GENERICvalsartan-hydrochlorothiazide GENERICANGIOTENSIN II RECEPTOR ANTAGONISTS – DRUGS TO TREAT HIGH BLOOD PRESSUREcandesartan cilexetil GENERICirbesartan GENERIClosartan potassium TABS GENERIColmesartan medoxomil TABS GENERIC telmisartan GENERIC valsartan GENERIC ANTIARRHYTHMICS – DRUGS TO CONTROL HEART RHYTHM amiodarone hcl soln GENERIC NM amiodarone tab 100mg GENERICamiodarone tab 200mg GENERICamiodarone tab 400mg GENERICdisopyramide phosphate GENERICdofetilide GENERIC NMflecainide acetate GENERIC MULTAQ OTHER NORPACE CR OTHER pacerone GENERICpropafenone hcl GENERICpropafenone hcl 12hr GENERICquinidine sulfate GENERICsorine GENERICsotalol hcl GENERICsotalol hcl (afib/afl) GENERIC


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Formulary ID 00020345 v11 06/01/2020

Drug Name Drug Tier Requirements/Limits ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS – DRUGS TO TREAT HIGH CHOLESTEROL atorvastatin calcium TABS GENERIC lovastatin GENERIC pravastatin sodium GENERIC rosuvastatin calcium GENERIC QL (30 tabs/30 days) simvastatin TABS 5mg, 10mg, 20mg, 40mg GENERIC simvastatin TABS 80mg GENERIC QL (30 tabs/30 days) ANTILIPEMICS, MISCELLANEOUS – DRUGS TO TREAT HIGH CHOLESTEROL cholestyramine GENERICcholestyramine light pack GENERICcholestyramine light powd GENERICcolesevelam hcl GENERICcolestipol hcl gran GENERICcolestipol hcl pack GENERICcolestipol hcl tabs GENERICezetimibe GENERICezetimibe-simvastatin GENERICfenofibrate TABS 48mg, 54mg, 145mg, 160mg GENERICfenofibrate micronized 67mg, 134mg, 200mg GENERICgemfibrozil TABS GENERICJUXTAPID OTHER NM, LA, PA niacin (antihyperlipidemic) GENERIC NM niacin er (antihyperlipidemic) 500mg GENERIC QL (60 tabs/30 days) niacin er (antihyperlipidemic) 750mg, 1000mg GENERICniacor GENERIC NM PRALUENT OTHER NM, PA prevalite GENERICVASCEPA OTHERBETA-BLOCKER/DIURETIC COMBINATIONS – DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS atenolol & chlorthalidone GENERIC bisoprolol & hydrochlorothiazide GENERICmetoprolol & hydrochlorothiazide GENERICpropranolol & hydrochlorothiazide GENERICBETA-BLOCKERS – DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONSacebutolol hcl CAPS GENERICatenolol TABS GENERICbetaxolol hcl GENERICbisoprolol fumarate GENERICBYSTOLIC 2.5mg, 5mg, 10mg OTHER QL (30 tabs/30 days) BYSTOLIC 20mg OTHER QL (60 tabs/30 days) carvedilol GENERIClabetalol hcl TABS GENERICmetoprolol succinate GENERICmetoprolol tartrate SOCT GENERIC NM

Drug Name Drug Tier Requirements/Limits metoprolol tartrate SOLN GENERIC NM metoprolol tartrate TABS 25mg, 50mg, 100mg GENERIC nadolol TABS GENERIC pindolol GENERICpropranolol cap er GENERICpropranolol hcl TABS GENERICpropranolol oral sol GENERICtimolol maleate TABS GENERICCALCIUM CHANNEL BLOCKERS – DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONSamlodipine besylate TABS GENERIC cartia xt GENERIC dilt-xr cap GENERIC diltiazem cap 240mg cd GENERIC diltiazem cap 360mg cd GENERIC diltiazem cap er/12hr GENERIC diltiazem hcl TABS GENERIC diltiazem hcl coated beads CP24 GENERIC diltiazem hcl coated beads cap sr 24hr GENERIC diltiazem hcl extended release beads cap sr GENERIC diltiazem inj GENERIC NMfelodipine GENERIC isradipine GENERIC nicardipine hcl CAPS GENERIC nifedipine TB24 GENERIC nifedipine er GENERIC nimodipine CAPS GENERIC NMNYMALIZE 60mg/20ml OTHER NMtaztia xt GENERIC tiadylt er GENERIC verapamil cap er GENERIC verapamil hcl SOLN GENERIC NMverapamil hcl TABS; TBCR GENERIC verapamil tab er GENERIC DIGITALIS GLYCOSIDES – DRUGS TO TREAT HEART CONDITIONS digitek .25mg GENERIC PA; PA if 70 years and older digitek .125mg GENERIC QL (30 tabs/30 days) digox 125mcg GENERIC QL (30 tabs/30 days) digox 250mcg GENERIC PA; PA if 70 years and older digoxin TABS 125mcg GENERIC QL (30 tabs/30 days) digoxin TABS 250mcg GENERIC PA; PA if 70 years and older digoxin inj GENERIC NM digoxin sol 50mcg/ml GENERIC PA; PA if 70 years and older DIURETICS – DRUGS TO TREAT HEART CONDITIONS acetazolamide CP12; TABS GENERIC



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PA – Prior Authorization QL – Quantity Limits ST – Step Therapy NM – Not available at mail-order B/D – Covered under Medicare B or D LA – Limited Access

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Drug Name Drug Tier Requirements/Limits amiloride & hydrochlorothiazide GENERIC amiloride hcl TABS GENERIC bumetanide inj 0.25/ml GENERIC NM bumetanide tab GENERIC chlorothiazide TABS GENERIC chlorthalidone GENERIC furosemide SOLN; TABS GENERIC furosemide inj GENERIC NM hydrochlorothiazide CAPS; TABS GENERIC indapamide GENERIC methazolamide TABS GENERIC metolazone GENERIC spironolactone & hydrochlorothiazide GENERIC torsemide tabs GENERIC triamterene & hydrochlorothiazide cap 37.5-25 mg GENERIC triamterene & hydrochlorothiazide tabs GENERIC MISCELLANEOUS aliskiren fumarate GENERIC clonidine hcl TABS GENERIC clonidine hcl ptwk GENERIC CORLANOR OTHER DEMSER OTHER NM, PA hydralazine hcl SOLN GENERIC NM hydralazine hcl TABS GENERIC midodrine hcl GENERIC NM minoxidil TABS GENERIC NORTHERA 100mg OTHER QL (90 caps/30 days), NM, LA, PA NORTHERA 200mg, 300mg OTHER QL (180 caps/30 days), NM, LA, PA ranolazine GENERIC NITRATES – DRUGS TO TREAT HEART CONDITIONS isosorb mononitrate tab GENERIC isosorbide dinitrate 5mg, 10mg, 20mg, 30mg GENERIC isosorbide mononitrate er GENERIC minitran GENERIC nitro-bid GENERIC NITRO-DUR DIS 0.3MG/HR OTHER NITRO-DUR DIS 0.8MG/HR OTHER nitroglycerin SOLN .4mg/spray GENERIC nitroglycerin SUBL GENERIC nitroglycerin td patch GENERIC PULMONARY ARTERIAL HYPERTENSION – DRUGS TO TREAT PULMONARY HYPERTENSIONADEMPAS OTHER QL (90 tabs/30 days), NM, LA, PA ambrisentan GENERIC QL (30 tabs/30 days), NM, LA, PA bosentan 62.5mg GENERIC QL (120 tabs/30 days), NM, LA, PA

Drug Name Drug Tier Requirements/Limits bosentan 125mg GENERIC QL (60 tabs/30 days), NM, LA, PA OPSUMIT OTHER QL (30 tabs/30 days), NM, LA, PA sildenafil citrate tab 20 mg (pulmonary hypertension) GENERIC QL (90 tabs/30 days), NM, PA treprostinil GENERIC NM, LA, PA VENTAVIS OTHER NM, PACENTRAL NERVOUS SYSTEM– DRUGS TO TREAT NERVOUS SYSTEM DISORDERS ANTIANXIETY – DRUGS TO TREAT ANXIETY alprazolam tab 0.5mg GENERIC QL (150 tabs/30 days), NM alprazolam tab 0.25mg GENERIC QL (150 tabs/30 days), NM alprazolam tab 1mg GENERIC QL (150 tabs/30 days), NM alprazolam tab 2 mg GENERIC QL (150 tabs/30 days), NM buspirone hcl TABS GENERIC NM fluvoxamine maleate TABS GENERIClorazepam SOLN GENERIC NMlorazepam TABS GENERIC QL (150 tabs/30 days), NM lorazepam intensol GENERIC QL (150 mL/30 days), NM ANTICONVULSANTS – DRUGS TO TREAT SEIZURES APTIOM OTHER QL (60 tabs/30 days) BANZEL SUS 40MG/ML OTHER PA BANZEL TAB 200MG OTHER PA BANZEL TAB 400MG OTHER PABRIVIACT INJ 50MG/5ML OTHER NM, PA BRIVIACT SOL 10MG/ML OTHER PA BRIVIACT TAB 10MG OTHER PA BRIVIACT TAB 25MG OTHER PA BRIVIACT TAB 50MG OTHER PA BRIVIACT TAB 75MG OTHER PA BRIVIACT TAB 100MG OTHER PA carbamazepine CHEW; CP12; SUSP; TABS; TB12 GENERIC CELONTIN OTHER clobazam GENERIC PA clonazepam TABS 2mg GENERIC QL (300 tabs/30 days), NM clonazepam TABS .5mg, 1mg GENERIC QL (90 tabs/30 days), NM clonazepam TBDP 2mg GENERIC QL (300 tabs/30 days), NM clonazepam TBDP .125mg, .25mg, .5mg, 1mg GENERIC QL (90 tabs/30 days), NM clorazepate dipotassium GENERIC QL (180 tabs/30 days), NM, PA;

PA if 65 years and older DIASTAT ACUDIAL OTHER NM DIASTAT PEDIATRIC OTHER NM diazepam TABS GENERIC QL (120 tabs/30 days), NM, PA;

PA if 65 years and older diazepam gel GENERIC NM diazepam inj GENERIC NM


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Drug Name Drug Tier Requirements/Limits diazepam intensol GENERIC QL (240 mL/30 days), NM, PA; PA

if 65 years and older diazepam oral soln 1 mg/ml GENERIC QL (1200 mL/30 days), NM, PA;

PA if 65 years and older dilantin cap 30mg GENERIC dilantin cap 100mg GENERIC dilantin chew tab 50mg GENERIC DILANTIN-125 SUSP OTHER divalproex sodium CSDR; TB24; TBEC GENERIC EPIDIOLEX OTHER QL (600 mL/30 days), NM, LA, PA epitol GENERIC ethosuximide CAPS; SOLN GENERIC felbamate GENERIC FYCOMPA SUSP OTHER QL (720 mL/30 days), PA FYCOMPA TABS 2mg, 4mg, 6mg OTHER QL (60 tabs/30 days), PA FYCOMPA TABS 8mg, 10mg, 12mg OTHER QL (30 tabs/30 days), PA gabapentin CAPS 100mg GENERIC QL (1080 caps/30 days) gabapentin CAPS 300mg GENERIC QL (360 caps/30 days) gabapentin CAPS 400mg GENERIC QL (270 caps/30 days) gabapentin SOLN GENERIC QL (2160 mL/30 days) gabapentin TABS 600mg GENERIC QL (180 tabs/30 days) gabapentin TABS 800mg GENERIC QL (120 tabs/30 days) lamotrigine CHEW; TABS; TB24 GENERIC levetiracetam SOLN GENERIC NM levetiracetam TABS; TB24 GENERIC levetiracetam in sodium chloride GENERIC NM levetiracetam oral soln 100 mg/ml GENERIC NAYZILAM OTHER NMoxcarbazepine GENERIC PEGANONE OTHER phenobarbital ELIX; TABS GENERIC PA; PA if 70 years and older phenobarbital sodium SOLN GENERIC NM, PA; PA if 70 years and older phenytek GENERIC phenytoin CHEW; SUSP GENERIC phenytoin sodium extended GENERIC phenytoin sodium inj 50mg/ml GENERIC NM pregabalin CAPS 25mg, 50mg, 75mg, 100mg, 150mg GENERIC QL (120 caps/30 days), PA pregabalin CAPS 200mg GENERIC QL (90 caps/30 days), PA pregabalin CAPS 225mg, 300mg GENERIC QL (60 caps/30 days), PA pregabalin SOLN GENERIC QL (900 mL/30 days), PA primidone TABS GENERIC roweepra GENERIC roweepra xr GENERIC SPRITAM OTHER subvenite tab GENERIC

Drug Name Drug Tier Requirements/Limits SYMPAZAN OTHER PA tiagabine hcl GENERICtopiramate CPSP; TABS GENERICvalproate sodium SOLN GENERIC NMvalproate sodium oral soln GENERICvalproic acid CAPS GENERICVALTOCO OTHER NM vigabatrin powd pack 500mg GENERIC QL (180 packets/30 days), NM, LA, PA vigabatrin tab 500mg GENERIC QL (180 tabs/30 days), NM, LA, PA vigadrone GENERIC QL (180 packets/30 days), NM, LA, PA VIMPAT 50mg OTHER QL (120 tabs/30 days) VIMPAT 100mg, 150mg, 200mg OTHER QL (60 tabs/30 days) VIMPAT INJ 200MG/20ML OTHER NM VIMPAT SOL 10MG/ML OTHER QL (1200 mL/30 days) zonisamide CAPS GENERICANTIDEMENTIA – DRUGS TO TREAT DEMENTIA AND MEMORY LOSS donepezil hydrochloride TABS 5mg GENERIC QL (30 tabs/30 days) donepezil hydrochloride TABS 10mg GENERICdonepezil hydrochloride TBDP 5mg GENERIC QL (30 tabs/30 days) donepezil hydrochloride TBDP 10mg GENERICgalantamine hydrobromide SOLN GENERICgalantamine hydrobromide TABS GENERIC QL (60 tabs/30 days) galantamine hydrobromide er GENERIC QL (30 caps/30 days) memantine hcl cp24 GENERIC PA; PA if < 30 yrs memantine soln GENERIC PA; PA if < 30 yrs memantine tabs GENERIC PA; PA if < 30 yrs memantine titration pak GENERIC NM, PA; PA if < 30 yrs NAMZARIC C4PK OTHER NM NAMZARIC CP24 OTHER rivastigmine tartrate 1.5mg, 3mg GENERIC QL (90 caps/30 days) rivastigmine tartrate 4.5mg, 6mg GENERIC QL (60 caps/30 days) rivastigmine td patch 24hr 4.6 mg/24hr GENERIC QL (30 patches/30 days) rivastigmine td patch 24hr 9.5 mg/24hr GENERIC QL (30 patches/30 days) rivastigmine td patch 24hr 13.3 mg/24hr GENERIC QL (30 patches/30 days) ANTIDEPRESSANTS – DRUGS TO TREAT DEPRESSION amitriptyline hcl TABS GENERICamoxapine GENERICbupropion hcl TABS GENERICbupropion hcl TB12 GENERICbupropion hcl TB24 150mg, 300mg GENERICcitalopram hydrobromide GENERICclomipramine hcl CAPS GENERIC PAdesipramine hcl TABS GENERICdesvenlafaxine succinate GENERIC QL (30 tabs/30 days), PA



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Formulary ID 00020345 v11 06/01/2020

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Drug Name Drug Tier Requirements/Limits doxepin hcl CAPS; CONC GENERIC

DRIZALMA SPRINKLE 20mg, 30mg, 60mg OTHER QL (60 caps/30 days), PA DRIZALMA SPRINKLE 40mg OTHER QL (90 caps/30 days), PA duloxetine hcl CPEP 20mg, 30mg, 60mg GENERIC QL (60 caps/30 days)

EMSAM OTHER QL (30 patches/30 days), PA escitalopram oxalate GENERIC

FETZIMA 20mg, 40mg OTHER QL (60 caps/30 days), PA FETZIMA 80mg, 120mg OTHER QL (30 caps/30 days), PA

FETZIMA TITRATION PACK OTHER NM, PA fluoxetine cap 10mg GENERIC fluoxetine cap 20mg GENERIC fluoxetine cap 40mg GENERIC fluoxetine hcl SOLN GENERIC

imipramine hcl TABS GENERIC maprotiline hcl GENERIC

MARPLAN TAB 10MG OTHER QL (180 tabs/30 days) mirtazapine TABS; TBDP GENERIC

nefazodone hcl GENERIC nortriptyline hcl CAPS; SOLN GENERIC

paroxetine hcl tabs GENERIC PAXIL SUSP OTHER QL (900 mL/30 days)

phenelzine sulfate TABS GENERIC protriptyline hcl GENERIC

sertraline hcl CONC; TABS GENERIC tranylcypromine sulfate GENERIC trazodone hcl TABS 50mg, 100mg, 150mg GENERIC

trimipramine maleate CAPS 25mg GENERIC QL (240 caps/30 days) trimipramine maleate CAPS 50mg GENERIC QL (120 caps/30 days) trimipramine maleate CAPS 100mg GENERIC QL (60 caps/30 days)

TRINTELLIX 5mg OTHER QL (120 tabs/30 days) TRINTELLIX 10mg OTHER QL (60 tabs/30 days) TRINTELLIX 20mg OTHER QL (30 tabs/30 days)

venlafaxine hcl CP24; TABS GENERIC VIIBRYD STARTER PACK OTHER NM VIIBRYD TAB OTHER QL (30 tabs/30 days)

ANTIPARKINSONIAN AGENTS – DRUGS TO TREAT PARKINSONS DISEASE amantadine hcl CAPS GENERIC QL (120 caps/30 days)

amantadine hcl SYRP; TABS GENERIC APOKYN OTHER QL (20 cartridges/30 days), NM,

LA, PA benztropine mesylate inj GENERIC NM benztropine mesylate tab 0.5mg GENERIC PA; PA if 70 years and older benztropine mesylate tab 1mg GENERIC PA; PA if 70 years and older benztropine mesylate tab 2mg GENERIC PA; PA if 70 years and older

Drug Name Drug Tier Requirements/Limits bromocriptine mesylate CAPS; TABS GENERIC carbidopa-levodopa GENERIC carbidopa/levodopa/entacapone GENERIC entacapone GENERIC NEUPRO OTHER pramipexole tab 0.5mg GENERIC pramipexole tab 0.25mg GENERIC pramipexole tab 0.75mg GENERIC pramipexole tab 0.125mg GENERIC pramipexole tab 1.5mg GENERIC pramipexole tab 1mg GENERIC rasagiline mesylate TABS GENERIC ropinirole tab 0.5mg GENERIC ropinirole tab 0.25mg GENERIC ropinirole tab 1mg GENERIC ropinirole tab 2mg GENERIC ropinirole tab 3mg GENERIC ropinirole tab 4mg GENERIC ropinirole tab 5mg GENERIC selegiline hcl CAPS; TABS GENERIC trihexyphenidyl hcl GENERIC PA; PA if 70 years and older ANTIPSYCHOTICS – DRUGS TO TREAT PSYCHOSES ABILIFY MAINTENA OTHER QL (1 injection/28 days) aripiprazole odt GENERIC QL (60 tabs/30 days) aripiprazole oral solution 1 mg/ml GENERIC QL (900 mL/30 days) aripiprazole tab GENERIC QL (30 tabs/30 days) ARISTADA 441mg/1.6ml, 662mg/2.4ml, 882mg/3.2ml OTHER QL (1 injection/28 days) ARISTADA 1064mg/3.9ml OTHER QL (1 injection/56 days) ARISTADA INITIO OTHER NM CAPLYTA OTHER QL (30 caps/30 days) chlorpromazine hcl TABS GENERIC chlorpromazine inj GENERIC NM clozapine odt 12.5mg, 25mg GENERIC NM, PA clozapine odt 100mg GENERIC QL (270 tabs/30 days), NM, PA clozapine odt 150mg GENERIC QL (180 tabs/30 days), NM, PA clozapine odt 200mg GENERIC QL (135 tabs/30 days), NM, PA clozapine tab 25mg GENERIC NM clozapine tab 50mg GENERIC NM clozapine tab 100mg GENERIC QL (270 tabs/30 days), NM clozapine tab 200mg GENERIC QL (135 tabs/30 days), NM FANAPT OTHER QL (60 tabs/30 days), NM, PA FANAPT TITRATION PACK OTHER NM, PA fluphenazine decanoate SOLN GENERIC NM fluphenazine hcl CONC; ELIX; TABS GENERIC


Formulary ID 00020345 v11 06/01/2020


Formulary ID 00020345 v11 06/01/2020

Drug Name Drug Tier Requirements/Limits fluphenazine hcl SOLN GENERIC NM GEODON SOLR OTHER QL (6 mL/3 days), NM haloperidol TABS GENERIChaloperidol conc 2mg/ml GENERIChaloperidol decanoate SOLN GENERIC NM haloperidol lactate inj 5mg/ml GENERIC NM INVEGA SUST INJ 39 MG/0.25 ML OTHER QL (1 injection/28 days), NM INVEGA SUST INJ 78 MG/0.5 ML OTHER QL (1 injection/28 days), NM INVEGA SUST INJ 117 MG/0.75 ML OTHER QL (1 injection/28 days), NM INVEGA SUST INJ 156MG/ML OTHER QL (1 injection/28 days), NM INVEGA SUST INJ 234 MG/1.5 ML OTHER QL (1 injection/28 days), NM INVEGA TRINZA OTHER QL (1 injection/90 days), NM LATUDA 20mg, 40mg, 60mg, 120mg OTHER QL (30 tabs/30 days) LATUDA 80mg OTHER QL (60 tabs/30 days) loxapine succinate GENERIC molindone hcl GENERIC NUPLAZID CAPS OTHER QL (30 caps/30 days), NM, LA, PA NUPLAZID TABS 10MG OTHER QL (30 tabs/30 days), NM, LA, PA olanzapine SOLR GENERIC QL (3 vials/1 day), NM olanzapine TABS 2.5mg, 5mg, 10mg GENERIC QL (60 tabs/30 days) olanzapine TABS 7.5mg, 15mg, 20mg GENERIC QL (30 tabs/30 days) olanzapine TBDP 5mg, 15mg, 20mg GENERIC QL (30 tabs/30 days) olanzapine TBDP 10mg GENERIC QL (60 tabs/30 days) paliperidone 1.5mg, 3mg, 9mg GENERIC QL (30 tabs/30 days) paliperidone 6mg GENERIC QL (60 tabs/30 days) perphenazine TABS GENERIC PERSERIS OTHER QL (1 injection/30 days) pimozide GENERIC quetiapine fumarate TABS GENERIC quetiapine fumarate TB24 50mg, 300mg, 400mg GENERIC QL (60 tabs/30 days), PA quetiapine fumarate TB24 150mg, 200mg GENERIC QL (30 tabs/30 days), PA REXULTI 3mg, 4mg OTHER QL (30 tabs/30 days) REXULTI .25mg, .5mg, 1mg, 2mg OTHER QL (60 tabs/30 days) RISPERDAL INJ 12.5MG OTHER QL (2 injections/28 days), NM RISPERDAL INJ 25MG OTHER QL (2 injections/28 days), NM RISPERDAL INJ 37.5MG OTHER QL (2 injections/28 days), NM RISPERDAL INJ 50MG OTHER QL (2 injections/28 days), NM risperidone SOLN GENERIC QL (240 mL/30 days) risperidone TABS GENERIC risperidone TBDP 1mg, 2mg, 3mg, 4mg GENERIC QL (60 tabs/30 days) risperidone TBDP .25mg, .5mg GENERIC QL (90 tabs/30 days) SAPHRIS OTHER QL (60 tabs/30 days) SECUADO OTHER QL (30 patches/30 days) thioridazine hcl TABS GENERIC

Drug Name Drug Tier Requirements/Limits thiothixene GENERIC trifluoperazine hcl GENERIC VERSACLOZ OTHER QL (600 mL/30 days), NM, PA VRAYLAR 1.5mg OTHER QL (60 caps/30 days), PA VRAYLAR 3mg, 4.5mg, 6mg OTHER QL (30 caps/30 days), PA VRAYLAR THERAPY PACK OTHER NM, PA ziprasidone hcl GENERIC QL (60 caps/30 days) ziprasidone mesylate GENERIC QL (6 injections/3 days), NM ZYPREXA RELPREVV 300mg OTHER QL (2 vials/28 days), NM, PA ZYPREXA RELPREVV 405mg OTHER QL (1 vial/28 days), NM, PA ZYPREXA RELPREVV INJ 210MG OTHER QL (2 vials/28 days), NM, PA ATTENTION DEFICIT HYPERACTIVITY DISORDER – DRUGS TO TREAT ADHD amphetamine-dextroamphetamine cap sr 24hr 5 mg GENERIC QL (90 caps/30 days) amphetamine-dextroamphetamine cap sr 24hr 10 mg GENERIC QL (90 caps/30 days) amphetamine-dextroamphetamine cap sr 24hr 15 mg GENERIC QL (30 caps/30 days) amphetamine-dextroamphetamine cap sr 24hr 20 mg GENERIC QL (30 caps/30 days) amphetamine-dextroamphetamine cap sr 24hr 25 mg GENERIC QL (30 caps/30 days) amphetamine-dextroamphetamine cap sr 24hr 30 mg GENERIC QL (30 caps/30 days) amphetamine-dextroamphetamine tab 5 mg GENERIC QL (120 tabs/30 days) amphetamine-dextroamphetamine tab 7.5 mg GENERIC QL (120 tabs/30 days) amphetamine-dextroamphetamine tab 10 mg GENERIC QL (120 tabs/30 days) amphetamine-dextroamphetamine tab 12.5 mg GENERIC QL (120 tabs/30 days) amphetamine-dextroamphetamine tab 15 mg GENERIC QL (90 tabs/30 days) amphetamine-dextroamphetamine tab 20 mg GENERIC QL (90 tabs/30 days) amphetamine-dextroamphetamine tab 30 mg GENERIC QL (60 tabs/30 days) atomoxetine hcl 10mg, 18mg, 25mg GENERIC QL (120 caps/30 days) atomoxetine hcl 40mg GENERIC QL (60 caps/30 days) atomoxetine hcl 60mg, 80mg, 100mg GENERIC QL (30 caps/30 days) dexmethylphenidate hcl TABS 2.5mg, 5mg GENERIC QL (120 tabs/30 days) dexmethylphenidate hcl TABS 10mg GENERIC QL (60 tabs/30 days) guanfacine er (adhd) GENERIC PA; PA if 70 years and older metadate er tab 20mg GENERIC QL (90 tabs/30 days) methylphenidate hcl TABS 5mg, 10mg GENERIC QL (180 tabs/30 days) methylphenidate hcl TABS 20mg GENERIC QL (90 tabs/30 days) methylphenidate hcl oral soln 5mg/5ml GENERIC QL (1800 mL/30 days) methylphenidate hcl oral soln 10mg/5ml GENERIC QL (900 mL/30 days) methylphenidate hcl tbcr 10 mg GENERIC QL (90 tabs/30 days) methylphenidate hcl tbcr 20mg GENERIC QL (90 tabs/30 days) HYPNOTICS – DRUGS TO TREAT INSOMNIA BELSOMRA OTHER QL (30 tabs/30 days), NM doxepin hcl (sleep) GENERIC QL (30 tabs/30 days), NM eszopiclone GENERIC QL (30 tabs/30 days), NM, PA; PA

applies if 70 years and older after a 90-day supply in a calendar year


Formulary ID 00020345 v11 06/01/2020

Drug Name Drug Tier Requirements/Limits HETLIOZ OTHER NM, LA, PA temazepam 7.5mg GENERIC QL (30 caps/30 days), NM, PA; PA

applies if 65 years and older after a 90-day supply in a calendar year

temazepam 15mg GENERIC QL (60 caps/30 days), NM, PA; PA applies if 65 years and older after a 90-day supply in a calendar year

zaleplon GENERIC QL (60 caps/30 days), NM, PA; PA applies if 70 years and older after a 90-day supply in a calendar year

zolpidem tartrate TABS GENERIC QL (30 tabs/30 days), NM, PA; PA applies if 70 years and older after a 90-day supply in a calendar year

MIGRAINE – DRUGS TO TREAT SEVERE HEADACHES AIMOVIG OTHER QL (1 pen/30 days), NM, PA dihydroergotamine mesylate inj 1 mg/ml GENERIC NM dihydroergotamine mesylate nasal spr 4 mg/ml GENERIC QL (8 mL/30 days), NM, PA eletriptan hydrobromide GENERIC QL (12 tabs/30 days), NM EMGALITY SOAJ OTHER QL (2 pens/30 days), NM, PA EMGALITY SOSY 120mg/ml OTHER QL (2 syringes/30 days), NM, PA ergotamine w/ caffeine TABS GENERIC NM naratriptan hcl GENERIC QL (12 tabs/30 days), NM rizatriptan benzoate GENERIC QL (18 tabs/30 days), NM rizatriptan benzoate odt GENERIC QL (18 tabs/30 days), NM sumatriptan SOLN 5mg/act GENERIC QL (24 inhalers/30 days), NM sumatriptan SOLN 20mg/act GENERIC QL (12 inhalers/30 days), NM sumatriptan inj 4mg/0.5ml GENERIC QL (18 injections/30 days), NM sumatriptan inj 6mg/0.5ml GENERIC QL (12 injections/30 days), NM sumatriptan succinate TABS GENERIC QL (12 tabs/30 days), NM zolmitriptan TABS GENERIC QL (12 tabs/30 days), NM zolmitriptan odt GENERIC QL (12 tabs/30 days), NM MISCELLANEOUS AUSTEDO 6mg OTHER QL (60 tabs/30 days), NM, PA AUSTEDO 9mg, 12mg OTHER QL (120 tabs/30 days), NM, PA lithium carbonate CAPS; TABS GENERIC lithium carbonate er GENERIC LITHIUM SOLN 8MEQ/5ML OTHER LYRICA CR OTHER QL (60 tabs/30 days), PA NUEDEXTA OTHER QL (60 caps/30 days), PA pyridostigmine tab 60mg GENERIC NM riluzole GENERIC tetrabenazine 12.5mg GENERIC QL (240 tabs/30 days), NM, PA tetrabenazine 25mg GENERIC QL (120 tabs/30 days), NM, PA


Formulary ID 00020345 v11 06/01/2020

Drug Name Drug Tier Requirements/Limits MULTIPLE SCLEROSIS AGENTS – DRUGS TO TREAT MULTIPLE SCLEROSIS BETASERON OTHER QL (14 syringes/28 days), NM, PA dalfampridine TB12 GENERIC NM, PA GILENYA OTHER QL (28 caps/28 days), NM, PA

glatiramer acetate 20mg/ml GENERIC QL (30 syringes/30 days), NM, PA glatiramer acetate 40mg/ml GENERIC QL (12 syringes/28 days), NM, PA

glatopa 20mg/ml GENERIC QL (30 syringes/30 days), NM, PA glatopa 40mg/ml GENERIC QL (12 syringes/28 days), NM, PA MUSCULOSKELETAL THERAPY AGENTS – DRUGS TO TREAT MUSCLE SPASMS baclofen TABS 10mg, 20mg GENERIC NM carisoprodol TABS 350mg GENERIC QL (120 tabs/30 days), NM, PA;

PA if 70 years and older cyclobenzaprine hcl TABS 5mg, 10mg GENERIC NM, PA; PA if 70 years and older dantrolene sodium CAPS GENERIC NM methocarbamol TABS GENERIC NM, PA; PA if 70 years and older tizanidine hcl TABS GENERIC NM NARCOLEPSY/CATAPLEXY – DRUGS FOR SLEEP DISORDERS armodafinil 50mg GENERIC QL (90 tabs/30 days), PA armodafinil 150mg, 200mg, 250mg GENERIC QL (30 tabs/30 days), PA XYREM OTHER QL (540 mL/30 days), NM, LA, PA PSYCHOTHERAPEUTIC-MISC acamprosate calcium GENERICbuprenorphine hcl SUBL GENERIC QL (90 tabs/30 days), NM, PA buprenorphine hcl-naloxone hcl dihydrate 2-0.5mg GENERIC QL (90 films/30 days), NM buprenorphine hcl-naloxone hcl dihydrate 4-1mg GENERIC QL (90 films/30 days), NM buprenorphine hcl-naloxone hcl dihydrate 8-2mg GENERIC QL (90 films/30 days), NM buprenorphine hcl-naloxone hcl dihydrate 12-3mg GENERIC QL (60 films/30 days), NM buprenorphine hcl-naloxone hcl sl GENERIC QL (90 tabs/30 days), NM bupropion hcl (smoking deterrent) GENERIC NM CHANTIX OTHER NM, PACHANTIX CONTINUING MONTH OTHER NM, PACHANTIX STARTER PACK OTHER NM, PAdisulfiram TABS GENERICEVZIO OTHER NMnaloxone inj 0.4mg/ml GENERIC NMnaloxone inj 1mg/ml GENERIC NMnaltrexone hcl TABS GENERIC NMNARCAN OTHER NMNICOTROL INHALER OTHER NMNICOTROL NS OTHER NMVIVITROL OTHER NMENDOCRINE AND METABOLIC– DRUGS TO TREAT DIABETES AND REGULATE HORMONES ANDROGENS – DRUGS TO REGULATE MALE HORMONES ANADROL-50 OTHER NM, PA


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Formulary ID 00020345 v11 06/01/2020

Drug Name Drug Tier Requirements/Limits ANDRODERM OTHER QL (30 patches/30 days), PA oxandrolone tab 2.5mg GENERIC NM, PA oxandrolone tab 10mg GENERIC NM, PA testosterone GEL 1%, 25mg/2.5gm, 50mg/5gm GENERIC QL (300 grams/30 days), PA testosterone cypionate SOLN GENERIC NM, PA testosterone enanthate SOLN GENERIC NM, PA ANTIDIABETICS, INJECTABLE – DRUGS TO TREAT DIABETES BASAGLAR KWIKPEN OTHER BD ALCOHOL SWABS OTHER NM BD ULTRAFINE INSULIN SYRINGE OTHER NM BD ULTRAFINE/NANO PEN NEEDLES OTHER NM BYDUREON BCISE OTHER QL (4 pens/28 days) BYDUREON PEN OTHER QL (4 pens/28 days) BYETTA OTHER QL (1 pen/30 days) FIASP OTHER FIASP FLEXTOUCH OTHER FIASP PENFILL OTHER GAUZE PADS 2" X 2" OTHER NM HUMULIN R INJ U-500 OTHER B/D HUMULIN R U-500 KWIKPEN OTHER INSULIN PEN NEEDLE OTHER NM INSULIN SAFETY NEEDLES OTHER NM INSULIN SYRINGE OTHER NM LEVEMIR OTHER LEVEMIR FLEXTOUCH OTHER NOVOLIN 70/30 OTHER (brand RELION not covered) NOVOLIN 70/30 FLEXPEN OTHER (brand RELION not covered) NOVOLIN N OTHER (brand RELION not covered) NOVOLIN N FLEXPEN OTHER (brand RELION not covered) NOVOLIN R OTHER (brand RELION not covered) NOVOLIN R FLEXPEN OTHER (brand RELION not covered) NOVOLOG OTHER NOVOLOG 70/30 FLEXPEN OTHER NOVOLOG FLEXPEN OTHER NOVOLOG MIX 70/30 OTHER NOVOLOG PENFILL OTHER OZEMPIC INJ 0.25 OR 0.5MG/DOSE OTHER QL (1 pen/28 days) OZEMPIC INJ 1MG/DOSE OTHER QL (2 pens/28 days) SOLIQUA 100/33 OTHER QL (10 pens/30 days) TRESIBA FLEXTOUCH OTHER TRESIBA INJ OTHER TRULICITY OTHER QL (4 pens/28 days) VICTOZA OTHER QL (3 pens/30 days) XULTOPHY 100/3.6 OTHER QL (5 pens/30 days)


Formulary ID 00020345 v11 06/01/2020

Drug Name Drug Tier Requirements/Limits ANTIDIABETICS, ORAL – DRUGS TO TREAT DIABETES acarbose TABS GENERIC FARXIGA OTHER QL (30 tabs/30 days) glimepiride 1mg, 2mg GENERIC QL (90 tabs/30 days) glimepiride 4mg GENERIC QL (60 tabs/30 days) glip/metform tab 2.5-250mg GENERIC QL (240 tabs/30 days) glip/metform tab 2.5-500mg GENERIC QL (120 tabs/30 days) glip/metform tab 5-500mg GENERIC QL (120 tabs/30 days) glipizide TABS 5mg GENERIC QL (240 tabs/30 days) glipizide TABS 10mg GENERIC QL (120 tabs/30 days) glipizide TB24 2.5mg, 5mg GENERIC QL (90 tabs/30 days) glipizide TB24 10mg GENERIC QL (60 tabs/30 days) glipizide xl 2.5mg, 5mg GENERIC QL (90 tabs/30 days) glipizide xl 10mg GENERIC QL (60 tabs/30 days) glyburide TABS 1.25mg GENERIC QL (480 tabs/30 days), PA;

PA if 70 years and older glyburide TABS 2.5mg GENERIC QL (240 tabs/30 days), PA;

PA if 70 years and older glyburide TABS 5mg GENERIC QL (120 tabs/30 days), PA;

PA if 70 years and older glyburide micronized 1.5mg GENERIC QL (240 tabs/30 days), PA;

PA if 70 years and older glyburide micronized 3mg GENERIC QL (120 tabs/30 days), PA;

PA if 70 years and older glyburide micronized 6mg GENERIC QL (60 tabs/30 days), PA;

PA if 70 years and older glyburide-metformin tab 1.25-250 mg GENERIC QL (240 tabs/30 days), PA;

PA if 70 years and older glyburide-metformin tab 2.5-500 mg GENERIC QL (120 tabs/30 days), PA;

PA if 70 years and older glyburide-metformin tab 5-500mg GENERIC QL (120 tabs/30 days), PA;

PA if 70 years and older GLYXAMBI OTHER QL (30 tabs/30 days) JANUMET OTHER QL (60 tabs/30 days) JANUMET XR TAB 50-500MG OTHER QL (60 tabs/30 days) JANUMET XR TAB 50-1000 OTHER QL (60 tabs/30 days) JANUMET XR TAB 100-1000 OTHER QL (30 tabs/30 days) JANUVIA OTHER QL (30 tabs/30 days) JARDIANCE 10mg OTHER QL (60 tabs/30 days) JARDIANCE 25mg OTHER QL (30 tabs/30 days) JENTADUETO OTHER QL (60 tabs/30 days) JENTADUETO TAB XR 2.5-1000 MG OTHER QL (60 tabs/30 days) JENTADUETO TAB XR 5-1000 MG OTHER QL (30 tabs/30 days) metformin er 500mg GENERIC QL (120 tabs/30 days);

(generic of GLUCOPHAGE XR)

Drug Name Drug Tier Requirements/Limits metformin er 750mg GENERIC QL (60 tabs/30 days);

(generic of GLUCOPHAGE XR) metformin hcl TABS 500mg GENERIC QL (150 tabs/30 days) metformin hcl TABS 850mg GENERIC QL (90 tabs/30 days) metformin hcl TABS 1000mg GENERIC QL (75 tabs/30 days) nateglinide GENERIC QL (90 tabs/30 days) pioglitazone hcl GENERIC QL (30 tabs/30 days) repaglinide 2mg GENERIC QL (240 tabs/30 days) repaglinide .5mg, 1mg GENERIC QL (120 tabs/30 days) SYNJARDY TAB 5-500MG OTHER QL (120 tabs/30 days) SYNJARDY TAB 5-1000MG OTHER QL (60 tabs/30 days) SYNJARDY TAB 12.5-500MG OTHER QL (60 tabs/30 days) SYNJARDY TAB 12.5-1000MG OTHER QL (60 tabs/30 days) SYNJARDY XR TAB 5-1000MG OTHER QL (60 tabs/30 days) SYNJARDY XR TAB 10-1000MG OTHER QL (60 tabs/30 days) SYNJARDY XR TAB 12.5-1000MG OTHER QL (60 tabs/30 days) SYNJARDY XR TAB 25-1000MG OTHER QL (30 tabs/30 days) TRADJENTA OTHER QL (30 tabs/30 days) XIGDUO XR TAB 2.5-1000MG OTHER QL (60 tabs/30 days) XIGDUO XR TAB 5-500MG OTHER QL (60 tabs/30 days) XIGDUO XR TAB 5-1000MG OTHER QL (60 tabs/30 days) XIGDUO XR TAB 10-500MG OTHER QL (30 tabs/30 days) XIGDUO XR TAB 10-1000MG OTHER QL (30 tabs/30 days) BISPHOSPHONATES – DRUGS TO TREAT BONE LOSS alendronate sodium soln 70mg/75ml GENERICalendronate sodium tab 5 mg GENERICalendronate sodium tab 10 mg GENERICalendronate sodium tab 35 mg GENERICalendronate sodium tab 40 mg GENERIC NM alendronate sodium tab 70 mg GENERICibandronate sodium tabs GENERIC B/D pamidronate disodium GENERIC B/D, NM pamidronate inj 30mg GENERIC B/D, NM pamidronate inj 90mg GENERIC B/D, NM risedronate sodium TABS 5mg, 35mg, 150mg GENERIC risedronate sodium TBEC GENERIC zoledronic acid inj 4mg/100ml GENERIC B/D, NM zoledronic acid inj 5mg/100ml GENERIC B/D, NM zoledronic inj 4mg/5ml GENERIC B/D, NM CHELATING AGENTS CHEMET OTHER NM clovique GENERIC NM, PA deferasirox TABS 90mg, 360mg GENERIC NM, PA JADENU 180mg OTHER NM, LA, PA


Formulary ID 00020345 v11 06/01/2020



Formulary ID 00020345 v11 06/01/2020

Drug Name Drug Tier Requirements/Limits JADENU SPRINKLE OTHER NM, LA, PA kionex sus 15gm/60ml GENERIC NM LOKELMA OTHER penicillamine TABS GENERIC NM sodium polystyrene sulfonate powder GENERIC NM sodium polystyrene sulfonate susp GENERIC NM sps susp 15gm/60ml GENERIC NM trientine hcl GENERIC NM, PA VELTASSA OTHER LA, PA CONTRACEPTIVES – DRUGS FOR BIRTH CONTROL altavera tab GENERIC alyacen 1/35 GENERIC amethia GENERIC amethia lo GENERIC apri GENERIC aranelle GENERIC ashlyna GENERIC aubra GENERIC aviane GENERIC balziva GENERIC bekyree GENERIC blisovi 24 fe GENERIC blisovi fe 1.5/30 GENERIC briellyn GENERIC camila GENERIC camrese lo GENERIC caziant pak GENERIC cryselle-28 GENERIC cyclafem 1/35 GENERIC cyclafem 7/7/7 GENERIC cyred tab GENERIC dasetta 1/35 GENERIC dasetta 7/7/7 GENERIC deblitane GENERIC desogestrel & ethinyl estradiol GENERIC desogestrel-ethinyl estradiol (biphasic) GENERIC drospirenone-ethinyl estradiol GENERIC drospirenone-ethinyl estradiol-levomefolate calcium GENERIC ELLA OTHER NMeluryng GENERIC emoquette GENERIC enpresse-28 GENERIC enskyce GENERIC errin GENERIC


Formulary ID 00020345 v11 06/01/2020

Drug Name Drug Tier Requirements/Limits estarylla tab 0.25-35 GENERIC ethynodiol diacet & eth estrad GENERICethynodiol tab 1-50 GENERICetonogestrel-ethinyl estradiol GENERICfalmina GENERICfayosim GENERICfemynor GENERICgianvi tab 3-0.02mg GENERIChailey 24 fe GENERICheather GENERICincassia GENERICintrovale GENERICisibloom GENERICjasmiel GENERICjolessa tab 0.15-0.03 mg GENERICjolivette GENERICjuleber GENERICjunel 1.5/30 GENERICjunel 1/20 GENERICjunel fe 1.5/30 GENERICjunel fe 1/20 GENERICjunel fe 24 GENERICkaitlib fe GENERICkariva GENERICkelnor 1/35 GENERICkelnor 1/50 GENERICkurvelo GENERIClarin 1.5/30 GENERIClarin 1/20 GENERIClarin fe 1.5/30 GENERIClarin fe 1/20 GENERIClarissia tab GENERIClayolis fe GENERICleena tab GENERIClessina GENERIClevonest GENERIClevonor-eth est tab 0.15-0.02/0.025/0.03mg & eth est 0.01mg

GENERIC

levonor/ethi tab GENERIClevonorg-eth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7)

GENERIC

levonorg-eth est tab 0.15-0.03mg (84) & eth est tab 0.01mg(7)

GENERIC

levonorgestrel & eth estradiol GENERIClevonorgestrel-ethinyl estradiol 0.15-0.03mg (91-day) GENERIC


Formulary ID 00020345 v11 06/01/2020

Drug Name Drug Tier Requirements/Limits levora 0.15/30-28 GENERIC loryna GENERIC low-ogestrel GENERIC lutera GENERIC lyza GENERIC marlissa GENERIC medroxyprogesterone acetate (contraceptive) GENERIC NM melodetta 24 fe GENERIC mibelas 24 fe GENERIC microgestin 1.5/30 GENERIC microgestin 1/20 GENERIC microgestin fe 1.5/30 GENERIC microgestin fe 1/20 GENERIC mili GENERIC mono-linyah tab 0.25-35 GENERIC necon 0.5/35-28 GENERIC nikki GENERIC nora-be tab 0.35mg GENERIC nore/eth/fer chw 0.4mg-35 GENERIC noreth/ethin chw fe GENERIC norethin acet & estrad-fe GENERIC norethindrone (contraceptive) GENERIC norethindrone acet & eth estra GENERIC norgest/ethi tab 0.25/35 GENERIC norgestimate-ethinyl estradiol (triphasic) 0.18-25/0.215-25/0.25-25 mg-mcg

GENERIC

norgestimate-ethinyl estradiol (triphasic) 0.18-35/0.215-35/0.25-35 mg-mcg

GENERIC

nortrel 0.5/35 (28) GENERIC nortrel 1/35 GENERIC nortrel 7/7/7 GENERIC ocella tab 3-0.03mg GENERIC orsythia GENERIC philith GENERIC pimtrea GENERIC pirmella 1/35 GENERIC portia-28 GENERIC previfem GENERIC reclipsen GENERIC rivelsa GENERIC setlakin tab GENERIC sharobel GENERIC sprintec 28 GENERIC sronyx GENERIC syeda GENERIC



Formulary ID 00020345 v11 06/01/2020

Drug Name Drug Tier Requirements/Limits tarina 24 fe GENERIC tarina fe 1/20 GENERICtilia fe GENERICtri-estarylla GENERICtri-legest fe GENERICtri-linyah GENERICtri-lo marzia GENERICtri-lo-estarylla GENERICtri-lo-sprintec GENERICtri-mili GENERICtri-previfem GENERICtri-sprintec GENERICtri-vylibra GENERICtri-vylibra lo GENERICtrivora-28 GENERICtulana GENERICtydemy GENERICvelivet GENERICvienva GENERICviorele GENERICvyfemla GENERICvylibra GENERICwymzya fe GENERICxulane dis 150-35 GENERICzarah GENERICzovia 1/35e GENERICENDOMETRIOSIS danazol CAPS GENERIC NM SYNAREL OTHER NM ENZYME REPLACEMENTS – DRUGS TO TREAT ENZYME DEFICIENCIES ALDURAZYME OTHER NM, LA, PA CARBAGLU OTHER NM, LA, PA CERDELGA OTHER NM, PA CEREZYME OTHER NM, LA, PA CYSTADANE OTHER NM, LA CYSTAGON OTHER NM, LA, PA FABRAZYME OTHER NM, LA, PA KUVAN OTHER NM, LA, PA levocarnitine (metabolic modifiers) GENERIC B/D LUMIZYME OTHER NM, LA, PA miglustat GENERIC NM, PA NAGLAZYME OTHER NM, LA, PA nitisinone GENERIC NM, PA NITYR OTHER NM, LA, PA


Formulary ID 00020345 v11 06/01/2020

Drug Name Drug Tier Requirements/Limits ORFADIN OTHER NM, LA, PA sodium phenylbutyrate GENERIC NM, PA ESTROGENS – DRUGS TO REGULATE FEMALE HORMONES DELESTROGEN 10mg/ml OTHER NM estradiol PTWK; TABS GENERICestradiol vaginal cream GENERICestradiol vaginal tab GENERICestradiol valerate inj GENERIC NMfyavolv GENERICjinteli GENERICnorethindrone acetate-ethinyl estradiol GENERICyuvafem vaginal tablet 10 mcg GENERICGLUCOCORTICOIDS – DRUGS TO TREAT INFLAMMATORY RESPONSE cortisone acetate TABS GENERIC NM dexamethasone CONC; ELIX; SOLN; TABS GENERIC NM dexamethasone sodium phosphate GENERIC NM fludrocortisone acetate TABS GENERIChydrocortisone TABS GENERIC NM methylpr ss inj GENERIC B/D, NM methylpred pak 4mg GENERIC NM methylpred tab 4mg GENERIC B/D, NM methylpred tab 8mg GENERIC B/D, NM methylpred tab 16mg GENERIC B/D, NM methylpred tab 32mg GENERIC B/D, NM methylprednisolone acetate GENERIC B/D, NM pred sod pho sol 5mg/5ml GENERIC B/D, NM prednisolone sodium phosphate SOLN 15mg/5ml GENERIC B/D, NM prednisolone sol 15mg/5ml GENERIC B/D, NM prednisolone sol 25mg/5ml GENERIC B/D, NM prednisone con 5mg/ml GENERIC B/D, NM prednisone pak 5mg GENERIC NM prednisone pak 10mg GENERIC NM prednisone sol 5mg/5ml GENERIC B/D, NM prednisone tab 1mg GENERIC B/D, NM prednisone tab 2.5mg GENERIC B/D, NM prednisone tab 5mg GENERIC B/D, NM prednisone tab 10mg GENERIC B/D, NM prednisone tab 20mg GENERIC B/D, NM prednisone tab 50mg GENERIC B/D, NM SOLU-CORTEF OTHER NM GLUCOSE ELEVATING AGENTS – DRUGS TO TREAT LOW BLOOD SUGAR diazoxide SUSP GENERIC GLUCAGEN HYPOKIT OTHER NM GLUCAGON EMERGENCY KIT OTHER NM


Formulary ID 00020345 v11 06/01/2020

Drug Name Drug Tier Requirements/Limits GVOKE PFS OTHER NM PROGLYCEM SUS 50MG/ML OTHER MISCELLANEOUS cabergoline GENERIC NMcalcitonin (salmon) GENERIC B/D cinacalcet hcl 30mg, 90mg GENERIC B/D, QL (120 tabs/30 days), NM cinacalcet hcl 60mg GENERIC B/D, QL (60 tabs/30 days), NM FORTEO OTHER NM, PA GENOTROPIN OTHER NM, PAGENOTROPIN MINIQUICK OTHER NM, PAINCRELEX OTHER NM, LA, PAKORLYM OTHER NM, LA, PALUPRON DEP-PED INJ 7.5MG OTHER NM, PALUPRON DEP-PED INJ 11.25MG (3-MONTH) OTHER NM, PALUPRON DEPOT-PED (1-MONTH OTHER NM, PALUPRON DEPOT-PED (3-MONTH OTHER NM, PANATPARA OTHER NM, PAoctreotide acetate GENERIC NM, PAOSPHENA OTHER PAPROLIA OTHER QL (1 injection/180 days), NM raloxifene tab 60mg GENERIC SIGNIFOR OTHER NM, LA, PASOMATULINE DEPOT OTHER NM, PA SOMAVERT OTHER NM, LA, PATYMLOS OTHER NM, PAXGEVA OTHER NM, PAPHOSPHATE BINDER AGENTS – DRUGS TO REGULATE CALCIUM AND PHOSPHORUS LEVELSAURYXIA OTHER QL (360 tabs/30 days), PA calcium acetate (phosphate binder) CAPS GENERIC QL (360 caps/30 days) calcium acetate (phosphate binder) TABS GENERIC QL (360 tabs/30 days) sevelamer carbonate PACK 2.4gm GENERIC QL (180 packets/30 days) sevelamer carbonate PACK .8gm GENERIC QL (540 packets/30 days) sevelamer carbonate TABS GENERIC QL (540 tabs/30 days) PROGESTINS – DRUGS TO REGULATE FEMALE HORMONES medroxyprogesterone acetate tab GENERIC norethindrone acetate TABS GENERIC THYROID AGENTS – DRUGS TO REGULATE THYROID LEVELSeuthyrox GENERIC levo-t GENERIC levothyroxine sodium TABS GENERIC levoxyl GENERIC liothyronine sodium TABS GENERIC methimazole TABS GENERIC propylthiouracil TABS GENERIC


Formulary ID 00020345 v11 06/01/2020

Drug Name Drug Tier Requirements/Limits SYNTHROID OTHER unithroid GENERICVASOPRESSINS – DRUGS TO REGULATE PITUITARY HORMONESdesmopressin acetate spray GENERICdesmopressin acetate spray refrigerated GENERICdesmopressin acetate tabs GENERICdesmopressin inj 4mcg/ml GENERIC NMSTIMATE OTHER NMGASTROINTESTINAL– DRUGS TO TREAT STOMACH AND INTESTINAL DISORDERS ANTIEMETICS – DRUGS FOR NAUSEA AND VOMITING aprepitant GENERIC B/D, NM aprepitant pak 80mg & 125mg GENERIC B/D, NM compro supp GENERIC NM dronabinol GENERIC B/D, QL (60 caps/30 days), NM EMEND SUSR OTHER B/D, NM granisetron hcl SOLN GENERIC NM granisetron hcl TABS GENERIC B/D, NM meclizine hcl TABS GENERIC NM metoclopramide hcl SOLN; TABS GENERIC NM metoclopramide hcl inj GENERIC NM ondansetron hcl TABS GENERIC B/D, NM ondansetron hcl inj GENERIC NM ondansetron hcl oral soln GENERIC B/D, NM ondansetron odt GENERIC B/D, NM prochlorperazine inj GENERIC NM prochlorperazine maleate TABS GENERICprochlorperazine supp GENERIC NMpromethazine hcl SYRP; TABS GENERIC NM, PA; PA if 70 years and older promethazine hcl inj GENERIC NM, PA; PA if 70 years and older scopolamine GENERIC QL (10 patches/30 days), NM, PA;

PA if 70 years and older ANTISPASMODICS – DRUGS FOR STOMACH SPASMS dicyclomine hcl cap 10mg GENERIC NMdicyclomine hcl soln 10mg/5ml GENERIC NMdicyclomine hcl tab 20mg GENERIC NMglycopyrrolate tab 1mg GENERIC NMglycopyrrolate tab 2mg GENERIC NMH2-RECEPTOR ANTAGONISTS – DRUGS FOR ULCERS AND STOMACH ACIDfamotidine SUSR GENERICfamotidine TABS 20mg, 40mg GENERICfamotidine in n acl GENERIC NM famotidine inj GENERIC NM nizatidine CAPS GENERIC

37



Formulary ID 00020345 v11 06/01/2020

Drug Name Drug Tier Requirements/Limits INFLAMMATORY BOWEL DISEASE balsalazide disodium GENERIC NM budesonide ec GENERIC NM colocort GENERIC NM hydrocortisone (enema) GENERIC NM mesalamine CPDR GENERIC mesalamine ENEM GENERIC NM mesalamine SUPP GENERIC NM mesalamine TBEC 1.2gm GENERIC mesalamine w/ cleanser GENERIC NM sulfasalazine TABS GENERIC sulfasalazine ec GENERIC LAXATIVES constulose GENERIC enulose GENERIC gavilyte-c GENERIC NM gavilyte-g GENERIC NM gavilyte-n/flavor pack GENERIC NM generlac GENERICGOLYTELY OTHER NM lactulose SOLN GENERIClactulose (encephalopathy) GENERICNULYTELY/FLAVOR PACKS OTHER NM peg 3350-kcl-sod bicarb-sod chloride-sod sulfate GENERIC NM peg 3350-potassium chloride-sod bicarbonate-sod chloride GENERIC NM PLENVU OTHER NM SUPREP BOWEL PREP KIT OTHER NM trilyte GENERIC NM MISCELLANEOUS alosetron hcl GENERIC PA AMITIZA CAP 8MCG OTHER QL (180 caps/30 days) AMITIZA CAP 24MCG OTHER QL (60 caps/30 days) cromolyn sodium (mastocytosis) GENERIC diphenoxylate w/ atropine GENERIC NM GATTEX OTHER NM, LA, PA LINZESS OTHER QL (30 caps/30 days) loperamide hcl CAPS GENERIC NM misoprostol TABS GENERICMOVANTIK 12.5mg OTHER QL (60 tabs/30 days), NM MOVANTIK 25mg OTHER QL (30 tabs/30 days), NM RELISTOR SOLN OTHER NM, PA sucralfate TABS GENERIC ursodiol CAPS; TABS GENERIC XIFAXAN 550mg OTHER PA



Formulary ID 00020345 v11 06/01/2020

Drug Name Drug Tier Requirements/Limits PANCREATIC ENZYMES CREON OTHER ZENPEP OTHER PROTON PUMP INHIBITORS – DRUGS FOR ULCERS AND STOMACH ACID DEXILANT OTHER QL (30 caps/30 days) esomeprazole magnesium CPDR GENERIC QL (30 caps/30 days), ST lansoprazole CPDR GENERIC QL (30 caps/30 days) omeprazole cap 10mg GENERIComeprazole cap 20mg GENERIComeprazole cap 40mg GENERICpantoprazole sodium SOLR GENERIC NMpantoprazole sodium tbec GENERICrabeprazole sodium GENERIC QL (30 tabs/30 days) GENITOURINARY– DRUGS TO TREAT GENITAL AND URINARY TRACT CONDITIONS BENIGN PROSTATIC HYPERPLASIA– DRUGS TO TREAT ENLARGED PROSTATE alfuzosin hcl GENERIC QL (30 tabs/30 days) dutasteride CAPS GENERIC QL (30 caps/30 days) dutasteride-tamsulosin hcl GENERIC QL (30 caps/30 days) finasteride TABS 5mg GENERIC tamsulosin hcl GENERIC MISCELLANEOUS bethanechol chloride TABS GENERIC NM potassium citrate (alkalinizer) er tabs GENERIC NMURINARY ANTISPASMODICS – DRUGS TO TREAT URINARY INCONTINENCEMYRBETRIQ OTHER QL (30 tabs/30 days) oxybutynin chloride SYRP GENERICoxybutynin chloride TABS GENERICoxybutynin chloride TB24 5mg GENERIC QL (30 tabs/30 days) oxybutynin chloride TB24 10mg, 15mg GENERIC QL (60 tabs/30 days) tolterodine tartrate CP24 GENERIC QL (30 caps/30 days), ST tolterodine tartrate TABS GENERIC ST TOVIAZ OTHER QL (30 tabs/30 days) trospium chloride TABS GENERIC QL (60 tabs/30 days) VAGINAL ANTI-INFECTIVES clindamycin phosphate vaginal GENERIC NM metronidazole vaginal GENERIC NM terconazole vaginal GENERIC NM vandazole GENERIC NM HEMATOLOGIC – DRUGS TO TREAT BLOOD DISORDERS ANTICOAGULANTS – BLOOD THINNERS COUMADIN OTHER ELIQUIS 2.5mg OTHER QL (60 tabs/30 days) ELIQUIS 5mg OTHER QL (74 tabs/30 days)


Formulary ID 00020345 v11 06/01/2020

Drug Name Drug Tier Requirements/Limits ELIQUIS STARTER PACK OTHER QL (74 tabs/30 days) enoxaparin sodium GENERIC NM fondaparinux sodium GENERIC NM heparin sod (porcine) in d5w GENERIC NM heparin sod inj 1000/ml GENERIC B/D, NM heparin sod inj 5000/ml GENERIC B/D, NM heparin sod inj 10000/ml GENERIC B/D, NM heparin sod inj 20000/ml GENERIC B/D, NM HEPARIN SODIUM/NACL 0.45% OTHER NM jantoven GENERIC PRADAXA OTHER QL (60 caps/30 days) warfarin sodium GENERIC XARELTO 2.5mg OTHER QL (60 tabs/30 days) XARELTO 10mg, 15mg, 20mg OTHER QL (30 tabs/30 days) XARELTO STARTER PACK OTHER QL (51 tabs/30 days), NM HEMATOPOIETIC GROWTH FACTORS PROCRIT OTHER NM, PA ZARXIO OTHER NM, PA MISCELLANEOUS anagrelide hcl GENERIC BERINERT OTHER QL (24 boxes/30 days), NM, LA,

PA cilostazol GENERIC DROXIA OTHER ENDARI OTHER NM, LA, PA HAEGARDA 2000unit OTHER QL (30 vials/30 days), NM, LA, PA HAEGARDA 3000unit OTHER QL (20 vials/30 days), NM, LA, PA icatibant acetate GENERIC QL (9 syringes/30 days), NM, PA pentoxifylline TBCR GENERIC PROMACTA PACK 12.5mg OTHER QL (360 packets/30 days), NM,

LA, PA PROMACTA TABS 12.5mg, 25mg OTHER QL (30 tabs/30 days), NM, LA, PA PROMACTA TABS 50mg, 75mg OTHER QL (60 tabs/30 days), NM, LA, PA tranexamic acid SOLN; TABS GENERIC NM PLATELET AGGREGATION INHIBITORS aspirin-dipyridamole GENERICBRILINTA OTHER clopidogrel tab 75mg GENERICprasugrel hcl GENERICIMMUNOLOGIC AGENTS – DRUGS TO TREAT DISORDERS OF THE IMMUNE SYSTEM DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) – DRUGS TO TREAT RHEUMATOID ARTHRITIS ENBREL SOLR OTHER QL (16 vials/28 days), NM, PA ENBREL SOSY 25mg/0.5ml OTHER QL (16 syringes/28 days), NM, PA ENBREL SOSY 50mg/ml OTHER QL (8 syringes/28 days), NM, PA


Formulary ID 00020345 v11 06/01/2020

Drug Name Drug Tier Requirements/Limits ENBREL MINI OTHER QL (8 injections/28 days), NM, PA ENBREL SURECLICK OTHER QL (8 injections/28 days), NM, PA HUMIRA 10mg/0.1ml, 20mg/0.2ml OTHER QL (2 injections/28 days), NM, PA HUMIRA 40mg/0.4ml OTHER QL (6 injections/28 days), NM, PA HUMIRA INJ 10MG/0.2ML OTHER QL (2 syringes/28 days), NM, PA HUMIRA KIT 20MG/0.4ML OTHER QL (2 syringes/28 days), NM, PA HUMIRA KIT 40MG/0.8ML OTHER QL (6 syringes/28 days), NM, PA HUMIRA PEDIATRIC CROHNS DISEASE OTHER NM, PA HUMIRA PEN OTHER QL (6 pens/28 days), NM, PA HUMIRA PEN CD/UC/HS STARTER OTHER NM, PA HUMIRA PEN INJ CD/UC/HS STARTER OTHER NM, PA HUMIRA PEN INJ PS/UV STARTER OTHER NM, PA HUMIRA PEN-PS/UV STARTER OTHER NM, PA hydroxychloroquine sulfate GENERIC leflunomide TABS GENERIC QL (30 tabs/30 days) methotrexate sodium tabs GENERIC NM REMICADE OTHER NM, PA RENFLEXIS OTHER NM, LA, PA RINVOQ OTHER QL (30 tabs/30 days), NM, PA SKYRIZI OTHER QL (7 injections/year), NM, PA STELARA SOLN 45mg/0.5ml OTHER QL (1 vial/28 days), NM, LA, PA STELARA SOSY OTHER QL (1 syringe/28 days), NM, PA XATMEP OTHER B/D, NM XELJANZ OTHER QL (60 tabs/30 days), N M, P A XELJANZ XR OTHER QL (30 tabs/30 days), NM, PA IMMUNOGLOBULINS BIVIGAM OTHER NM, PA GAMASTAN S/D OTHER B/D, NM GAMMAGARD LIQUID OTHER NM, PA GAMMAGARD S/D OTHER NM, PA GAMMAKED OTHER NM, PA GAMMAPLEX OTHER NM, PA GAMMAPLEX 10GM/100ML OTHER NM, PA GAMUNEX-C OTHER NM, PA OCTAGAM OTHER NM, PA PANZYGA OTHER NM, PA PRIVIGEN OTHER NM, PA IMMUNOMODULATORS ACTIMMUNE OTHER NM, LA, PA ARCALYST OTHER NM, PA INTRON-A INJ 10MU OTHER B/D, NM INTRON-A INJ 18MU OTHER B/D, NM INTRON-A INJ 25MU OTHER B/D, NM INTRON-A INJ 50MU OTHER B/D, NM


Formulary ID 00020345 v11 06/01/2020

Drug Name Drug Tier Requirements/Limits IMMUNOSUPPRESSANTS azathioprine TABS GENERIC B/D BENLYSTA OTHER NM, PA cyclosporine CAPS; SOLN GENERIC B/D, NM cyclosporine modified (for microemulsion) GENERIC B/D, NM everolimus (immunosuppressant) GENERIC B/D, NM gengraf GENERIC B/D, NM mycophenolate mofetil CAPS; SUSR; TABS GENERIC B/D, NM mycophenolate sodium tbec GENERIC B/D, NM NULOJIX OTHER B/D, NM PROGRAF PACK OTHER B/D, NM SANDIMMUNE SOLN 100mg/ml OTHER B/D, NM sirolimus SOLN; TABS GENERIC B/D, NM tacrolimus CAPS GENERIC B/D, NM ZORTRESS TAB 0.5MG OTHER B/D, NM ZORTRESS TAB 0.25MG OTHER B/D, NM ZORTRESS TAB 0.75MG OTHER B/D, NM ZORTRESS TAB 1MG OTHER B/D, NM VACCINES ACTHIB OTHER NM ADACEL OTHER NM BCG VACCINE OTHER NM BEXSERO OTHER NM BOOSTRIX OTHER NM DAPTACEL OTHER NM DIPHTHERIA/TETANUS TOXOID OTHER B/D, NM ENGERIX-B SUSP OTHER B/D, NM GARDASIL 9 OTHER NM HAVRIX OTHER NM HIBERIX OTHER NM IMOVAX RABIES (H.D.C.V.) OTHER B/D, NM INFANRIX OTHER NM IPOL INACTIVATED IPV OTHER NM IXIARO OTHER NM KINRIX OTHER NM M-M-R II OTHER NM MENACTRA OTHER NM MENVEO OTHER NM PEDIARIX OTHER NM PEDVAX HIB OTHER NM PENTACEL OTHER NM PROQUAD OTHER NM QUADRACEL OTHER NM RABAVERT OTHER B/D, NM



Formulary ID 00020345 v11 06/01/2020

Drug Name Drug Tier Requirements/Limits RECOMBIVAX HB OTHER B/D, NM ROTARIX OTHER NM ROTATEQ OTHER NM SHINGRIX OTHER QL (2 vials per lifetime), NM TDVAX OTHER B/D, NM TENIVAC OTHER B/D, NM TRUMENBA OTHER NM TWINRIX INJ OTHER NM TYPHIM VI OTHER NM VAQTA OTHER NM VARIVAX OTHER NM YF-VAX OTHER NM ZOSTAVAX OTHER QL (1 vial per lifetime), NM NUTRITIONAL/SUPPLEMENTS – VITAMINS AND SUPPLEMENTS ELECTROLYTES klor-con 8 GENERIC klor-con 10 GENERIC klor-con m10 GENERIC klor-con m15 GENERIC klor-con m20 GENERIC klor-con pak 20meq GENERIC klor-con spr cap 8meq GENERIC klor-con spr cap 10meq GENERIC MAGNESIUM SULFATE SOLN 2gm/50ml, 4gm/100ml, 4gm/50ml, 20gm/500ml, 40gm/1000ml

OTHER NM

magnesium sulfate SOLN 2gm/50ml, 4gm/100ml, 4gm/50ml, 20gm/500ml, 40gm/1000ml, 50%

GENERIC NM

MAGNESIUM SULFATE IN D5W OTHER NM magnesium sulfate in dextrose GENERIC NM magnesium sulfate inj 50% GENERIC NM potassium chloride CPCR GENERIC potassium chloride PACK GENERIC potassium chloride SOLN 10%, 20% GENERIC potassium chloride TBCR GENERIC potassium chloride microencapsulated crystals er GENERIC sodium chloride SOLN 2.5meq/ml GENERIC NM sodium fluoride chew; tab; 1.1 (0.5 f) mg/ml soln GENERIC NM TPN ELECTROLYTES OTHER B/D, NM IV NUTRITION AMINOSYN II INJ 10% OTHER B/D, NM AMINOSYN-PF 7% OTHER B/D, NM AMINOSYN-PF INJ 10% OTHER B/D, NM CLINIMIX 4.25%/DEXTROSE 5% OTHER B/D, NM CLINIMIX 5%/DEXTROSE 15% OTHER B/D, NM


Formulary ID 00020345 v11 06/01/2020

Drug Name Drug Tier Requirements/Limits CLINIMIX 5%/DEXTROSE 20% OTHER B/D, NM CLINIMIX INJ 4.25/D10 OTHER B/D, NM clinisol sf 15% GENERIC B/D, NM CLINOLIPID OTHER B/D, NM FREAMINE HBC 6.9% OTHER B/D, NM FREAMINE III OTHER B/D, NM hepatamine GENERIC B/D, NM INTRALIPID 30% OTHER B/D, NM intralipid inj 20% GENERIC B/D, NM NEPHRAMINE OTHER B/D, NM nutrilipid inj 20% GENERIC B/D, NM plenamine GENERIC B/D, NM premasol 10% GENERIC B/D, NM PROCALAMINE OTHER B/D, NM PROSOL OTHER B/D, NM TRAVASOL OTHER B/D, NM TROPHAMINE INJ 10% OTHER B/D, NM IV REPLACEMENT SOLUTIONS dextrose 2.5%/nacl 0.45% GENERIC NM dextrose 5% GENERIC NM DEXTROSE 5% /ELECTROLYTE OTHER NM dextrose 5%/nacl 0.2% GENERIC NM DEXTROSE 5%/NACL 0.3% OTHER NM dextrose 5%/nacl 0.9% GENERIC NM dextrose 5%/nacl 0.45% GENERIC NM dextrose 5%/nacl 0.225% GENERIC NM dextrose 5%/potassium chl GENERIC NM dextrose 10% flex contain GENERIC NM DEXTROSE 10% W/ SODIUM CHLORIDE 0.2% OTHER NM dextrose 10%/nacl 0.45% GENERIC NM dextrose 50% GENERIC NM dextrose in lactated ringers GENERIC NM dextrose inj 70% GENERIC NM ISOLYTE P OTHER NM ISOLYTE S OTHER NM kcl0.15%/d5w/nacl0.2% GENERIC NM KCL 0.3%/D5W/NACL 0.9% OTHER NM kcl 0.3%/d5w/nacl 0.45% GENERIC NM kcl 0.15%/d5w/nacl 0.9% GENERIC NM KCL 0.15%/D5W/NACL 0.225% OTHER NM kcl 0.075%/d5w/nacl 0.45% GENERIC NM kcl/d5w inj 0.3% GENERIC NM kcl/d5w/nacl inj 0.22%/0.45% GENERIC NM kcl/d5w/nacl inj .15/.45% GENERIC NM



Formulary ID 00020345 v11 06/01/2020

Drug Name Drug Tier Requirements/Limits kcl/nacl inj 0.3-0.9 GENERIC NM kcl/nacl inj 0.15%-0.9% GENERIC NM lactated ringer's GENERIC NM NORMOSOL-M IN D5W OTHER NM NORMOSOL-R OTHER NM NORMOSOL-R IN D5W OTHER NM PLASMA-LYTE A OTHER NM PLASMA-LYTE-148 OTHER NM pot chloride inj 2meq/ml GENERIC NM potassium chloride SOLN .4meq/ml, 2meq/ml, 10meq/100ml, 10meq/50ml, 20meq/100ml, 40meq/100ml

GENERIC NM

potassium chloride in nacl GENERIC NM sodium chloride SOLN 3%, 5% GENERIC NM sodium chloride 0.45% GENERIC NM sodium chloride inj 0.9% GENERIC NM VITAMINS calcitriol CAPS GENERIC B/D

calcitriol inj GENERIC B/D, NM calcitriol oral soln 1 mcg/ml GENERIC B/D

M-NATAL PLUS OTHER NM paricalcitol CAPS GENERIC B/D PNV FOLIC ACID + IRON MUL OTHER NM PRENATAL OTHER NM

PRENATAL PLUS OTHER NM PRENATAL PLUS LOW IRON OTHER NM RAYALDEE OTHER TRICARE OTHER NM OPHTHALMIC – DRUGS TO TREAT EYE CONDITIONS ANTI-INFECTIVE/ANTI-INFLAMMATORY – DRUGS TO TREAT INFECTIONS AND INFLAMMATION bacitracin-poly-neomycin-hc GENERIC NM blephamide OINT GENERIC NM neomycin-polymy-dexameth GENERIC NM neomycin-polymyxin-hc (ophth) GENERIC NM sulfacetamide sod-prednisolone GENERIC NM TOBRADEX OINT OTHER NM TOBRADEX ST OTHER NM tobramycin-dexamethasone GENERIC NM ZYLET OTHER NM ANTI-INFECTIVES – DRUGS TO TREAT INFECTIONS AZASITE OTHER NM bacitracin (ophthalmic) GENERIC NM bacitracin-polymyxin b (ophth) GENERIC NM BESIVANCE OTHER NM CILOXAN OINT OTHER NM



Formulary ID 00020345 v11 06/01/2020

Drug Name Drug Tier Requirements/Limits ciprofloxacin hcl (ophth) GENERIC NM erythromycin (ophth) GENERIC NM gatifloxacin (ophth) GENERIC NM gentak GENERIC NM gentamicin sulfate soln (ophth) GENERIC NM MOXEZA OTHER NM moxifloxacin hcl (ophth) GENERIC NM NATACYN OTHER NM neomycin-bacitracin zn-polymyxin GENERIC NM neomycin-polymyxin-gramicidin GENERIC NM ofloxacin (ophth) GENERIC NM polymyxin b-trimethoprim GENERIC NM sulfacetamide sodium (ophth) GENERIC NM tobramycin (ophth) GENERIC NM trifluridine GENERIC NM ZIRGAN OTHER NM ANTI-INFLAMMATORIES – DRUGS TO TREAT INFLAMMATION ALREX OTHER NM bromfenac sodium (ophth) GENERIC NM BROMSITE OTHER NM dexamethasone sodium phosphate (ophth) GENERIC NM diclofenac sodium (ophth) GENERIC NM DUREZOL OTHER NM fluorometholone GENERIC NM flurbiprofen sodium GENERIC NM ILEVRO OTHER NM ketorolac tromethamine (ophth) GENERIC NM LOTEMAX GEL; OINT OTHER NM loteprednol etabonate GENERIC NM prednisolone acetate (ophth) GENERIC NM prednisolone sodium phosphate (ophth) GENERIC NM PROLENSA OTHER NM ANTIALLERGICS – DRUGS TO TREAT ALLERGIES azelastine drop 0.05% GENERIC NM BEPREVE OTHER NM cromolyn sodium (ophth) GENERIC NM LASTACAFT OTHER NM olopatadine hcl 0.2% GENERIC NM PAZEO OTHER NM ANTIGLAUCOMA – DRUGS TO TREAT GLAUCOMA ALPHAGAN P SOL 0.1% OTHER AZOPT OTHER betaxolol hcl (ophth) GENERICBETOPTIC-S OTHER


Formulary ID 00020345 v11 06/01/2020

Drug Name Drug Tier Requirements/Limits brimonidine sol 0.2% GENERIC brimonidine sol 0.15% GENERIC carteolol hcl (ophth) GENERIC COMBIGAN OTHER dorzolamide hcl GENERIC dorzolamide hcl-timolol maleate GENERIC latanoprost SOLN GENERIC levobunolol hcl GENERIC LUMIGAN OTHER PHOSPHOLINE IODIDE OTHER pilocarpine hcl SOLN GENERICRHOPRESSA OTHERSIMBRINZA OTHERtimolol maleate (ophth) soln GENERICtimolol maleate gel GENERICtimolol maleate ophth soln 0.5% (once-daily) GENERICtravoprost GENERIC MISCELLANEOUS ATROPINE SULFATE SOLN 1% OTHER CYSTARAN OTHER NM, LA, PA proparacaine hcl SOLN GENERIC NM RESTASIS OTHER QL (60 single use vials/30 days) RESTASIS MULTIDOSE OTHER QL (1 bottle/30 days) RESPIRATORY – DRUGS TO TREAT BREATHING DISORDERS ANTICHOLINERGIC/BETA AGONIST COMBINATIONS – DRUGS TO TREAT COPD

ANORO ELLIPTA OTHER QL (60 blisters/30 days)BEVESPI AEROSPHERE OTHER QL (1 inhaler/30 days)COMBIVENT RESPIMAT OTHER QL (2 inhalers/30 days)ipratropium-albuterol nebu GENERIC B/DTRELEGY ELLIPTA OTHER QL (60 blisters/30 days)ANTICHOLINERGICS – DRUGS TO TREAT COPD ATROVENT HFA OTHER QL (2 inhalers/30 days) INCRUSE ELLIPTA OTHER QL (30 blisters/30 days) ipratropium bromide SOLN GENERIC B/D ipratropium bromide (nasal) GENERIC ANTIHISTAMINES – DRUGS TO TREAT ALLERGIES azelastine spr 0.1% GENERIC NM azelastine spr 0.15% GENERIC NM cetirizine syrup GENERIC NM cyproheptadine hcl SYRP; TABS GENERIC NM, PA; PA if 70 years and older diphenhydramine hcl inj 50mg/ml GENERIC NM hydroxyzine hcl SYRP; TABS GENERIC NM, PA; PA if 70 years and older hydroxyzine hcl inj GENERIC NM, PA; PA if 70 years and older hydroxyzine pamoate CAPS 25mg, 50mg GENERIC NM, PA; PA if 70 years and older



Formulary ID 00020345 v11 06/01/2020

Drug Name Drug Tier Requirements/Limits levocetirizine dihydrochloride GENERIC NM BETA AGONISTS – DRUGS TO TREAT ASTHMA AND COPD albuterol sulfate AERS 108mcg/act GENERIC QL (2 inhalers/30 days);

(generic of Proair HFA) albuterol sulfate AERS 108mcg/act GENERIC QL (2 inhalers/30 days);

(generic of Ventolin HFA) albuterol sulfate NEBU GENERIC B/D albuterol sulfate SYRP GENERIC albuterol sulfate TABS GENERIC albuterol sulfate TB12 GENERIC levalbuterol hcl NEBU GENERIC B/D levalbuterol hcl soln nebu conc 1.25 mg/0.5ml GENERIC B/D levalbuterol tartrate hfa GENERIC QL (2 inhalers/30 days) SEREVENT DISKUS OTHER QL (60 inhalations/30 days) terbutaline sulfate TABS GENERIC VENTOLIN HFA OTHER QL (2 inhalers/30 days) LEUKOTRIENE MODULATORS montelukast sodium CHEW; PACK; TABS GENERIC zafirlukast GENERIC MAST CELL STABILIZERS – DRUGS TO TREAT ALLERGIES cromolyn sod neb 20mg/2ml GENERIC B/D MISCELLANEOUS acetylcysteine SOLN 10%, 20% GENERIC B/D, NM ARALAST NP OTHER NM, LA, PA DALIRESP OTHER epinephrine (anaphylaxis) .15mg/0.3ml, .3mg/0.3ml GENERIC NM; (generic of EpiPen) epinephrine (anaphylaxis) .15mg/0.15ml, .3mg/0.3ml GENERIC NM; (generic of Adrenaclick) ESBRIET OTHER NM, PA FASENRA OTHER NM, LA, PA FASENRA PEN OTHER NM, LA, PA KALYDECO OTHER NM, PA NUCALA OTHER NM, LA, PA OFEV OTHER NM, PA ORKAMBI OTHER NM, PA PROLASTIN-C OTHER NM, LA, PA PULMOZYME OTHER NM, PA SYMDEKO OTHER NM, LA, PA SYMJEPI OTHER NM theo-24 GENERIC theophylline GENERICtheophylline tab er 12hr 300 mg GENERICtheophylline tab er 12hr 450 mg GENERICtheophylline tab sr 24hr GENERICTRIKAFTA OTHER NM, LA, PA



Formulary ID 00020345 v11 06/01/2020

Drug Name Drug Tier Requirements/Limits XOLAIR OTHER NM, LA, PA ZEMAIRA OTHER NM, LA, PA NASAL STEROIDS – DRUGS TO TREAT ALLERGIES flunisolide (nasal) GENERIC QL (3 bottles/30 days), NM fluticasone propionate (nasal) GENERIC QL (1 bottle/30 days), NM STEROID INHALANTS – DRUGS TO TREAT ASTHMA ARNUITY ELLIPTA OTHER QL (30 inhalations/30 days)budesonide (inhalation) .25mg/2ml, .5mg/2ml GENERIC B/DFLOVENT DISKUS 50mcg/blist, 100mcg/blist OTHER QL (120 inhalations/30 days)FLOVENT DISKUS 250mcg/blist OTHER QL (240 inhalations/30 days)FLOVENT HFA OTHER QL (2 inhalers/30 days)PULMICORT FLEXHALER OTHER QL (2 inhalers/30 days)STEROID/BETA-AGONIST COMBINATIONS – DRUGS TO TREAT ASTHMA AND COPD

ADVAIR DISKUS OTHER QL (60 inhalations/30 days) ADVAIR HFA OTHER QL (1 inhaler/30 days)

BREO ELLIPTA OTHER QL (60 blisters/30 days) SYMBICORT OTHER QL (1 inhaler/30 days) TOPICAL – DRUGS TO TREAT EAR AND SKIN CONDITIONS DERMATOLOGY, ACNE amnesteem GENERIC NM, PA avita GENERIC QL (45 grams/30 days), NM, PA

benzoyl peroxide-erythromycin GENERIC NM claravis GENERIC NM, PA clindamycin phosphate (topical) GEL GENERIC QL (75 grams/30 days), NM clindamycin phosphate (topical) LOTN GENERIC NM clindamycin phosphate (topical) SOLN GENERIC QL (60 mL/30 days), NM

ery pad 2% GENERIC NM erythromycin (acne aid) GENERIC NM isotretinoin CAPS GENERIC NM, PA myorisan GENERIC NM, PA sulfacetamide sodium (acne) GENERIC NM tretinoin CREA GENERIC QL (45 grams/30 days), NM, PA tretinoin GEL .01%, .025% GENERIC QL (45 grams/30 days), NM, PA zenatane GENERIC NM, PA DERMATOLOGY, ANTIBIOTICS gentamicin sulfate (topical) GENERIC NM mupirocin OINT GENERIC QL (220 grams/30 days), NM silver sulfadiazine CREA GENERIC NM ssd GENERIC NM SULFAMYLON CREA OTHER NM DERMATOLOGY, ANTIFUNGALS ciclopirox CREA GENERIC QL (90 grams/30 days), NM ciclopirox SUSP GENERIC QL (60 mL/30 days), NM


Formulary ID 00020345 v11 06/01/2020

Drug Name Drug Tier Requirements/Limits clotrimazole (topical) CREA GENERIC NM clotrimazole (topical) SOLN GENERIC QL (30 mL/30 days), NM clotrimazole w/ betamethasone CREA GENERIC NM ketoconazole cream GENERIC QL (60 grams/30 days), NM nyamyc GENERIC QL (60 grams/30 days), NM nystatin (topical) CREA; OINT GENERIC NM nystatin (topical) POWD GENERIC QL (60 grams/30 days), NM nystop GENERIC QL (60 grams/30 days), NM DERMATOLOGY, ANTIPSORIATICS acitretin GENERIC NM, PA calcipotriene CREA; OINT GENERIC QL (120 grams/30 days), NM, PA calcipotriene SOLN GENERIC QL (120 mL/30 days), NM, PA calcitrene GENERIC QL (120 grams/30 days), NM, PA tazarotene CREA GENERIC QL (60 grams/30 days), NM, PA TAZORAC CREA .05% OTHER QL (60 grams/30 days), NM, PA DERMATOLOGY, ANTISEBORRHEICS ketoconazole shampoo GENERIC NM selenium sulfide LOTN GENERIC NM DERMATOLOGY, CORTICOSTEROIDS ala-cort GENERIC NM

alclometasone dipropionate GENERIC NM betamethasone dipropionate (topical) GENERIC NM betamethasone dipropionate augmented GENERIC NM betamethasone valerate CREA; LOTN; OINT GENERIC NM ENSTILAR OTHER QL (120 grams/30 days), NM, PA fluocinolone acetonide CREA; OIL; OINT GENERIC NM fluocinolone acetonide SOLN GENERIC QL (90 mL/30 days), NM fluocinolone acetonide oil body GENERIC NM fluocinonide CREA .05% GENERIC QL (120 grams/30 days), NM fluocinonide GEL GENERIC QL (60 grams/30 days), NM fluocinonide OINT GENERIC QL (60 grams/30 days), NM fluocinonide SOLN GENERIC QL (60 mL/30 days), NM fluocinonide emulsified base GENERIC QL (120 grams/30 days), NM fluticasone propionate CREA; OINT GENERIC NM halobetasol propionate CREA; OINT GENERIC QL (50 grams/30 days), NM hydrocortisone (topical) cream 1% GENERIC NM hydrocortisone (topical) cream 2.5% GENERIC NM hydrocortisone (topical) lotion 2.5% GENERIC NM hydrocortisone (topical) oint 2.5% GENERIC NM hydrocortisone butyrate cream 0.1% GENERIC QL (45 grams/30 days), NM hydrocortisone butyrate oint 0.1% GENERIC QL (45 grams/30 days), NM mometasone furoate CREA; OINT; SOLN GENERIC NM texacort soln 2.5% GENERIC NM triamcinolone acetonide (topical) CREA .1% GENERIC QL (454 grams/30 days), NM


Formulary ID 00020345 v11 06/01/2020

Drug Name Drug Tier Requirements/Limits triamcinolone acetonide (topical) CREA .025%, .5% GENERIC NM triamcinolone acetonide (topical) LOTN GENERIC NM triamcinolone acetonide (topical) OINT .025%, .1%, .5% GENERIC NM DERMATOLOGY, LOCAL ANESTHETICS glydo GENERIC QL (30 mL/30 days), NM, PA

lidocaine PTCH 5% GENERIC QL (3 patches/1 day), NM, PA lidocaine hcl GEL GENERIC QL (30 mL/30 days), NM, PA

lidocaine hcl SOLN 4% GENERIC QL (50 mL/30 days), NM, PA lidocaine oint 5% GENERIC QL (50 grams/30 days), NM, PA

lidocaine-prilocaine GENERIC QL (30 grams/30 days), NM, PA DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE ammonium lactate CREA; LOTN GENERIC NM diclofenac sodium (topical) 1% gel GENERIC QL (1000 grams/30 days), NM,

PA fluorouracil (topical) CREA 5% GENERIC QL (40 grams/30 days), NM

fluorouracil (topical) SOLN GENERIC QL (10 mL/30 days), NM imiquimod CREA 5% GENERIC QL (24 packets/30 days), NM

metronidazole (topical) CREA; LOTN GENERIC NM metronidazole gel 0.75% GENERIC NM PANRETIN OTHER QL (60 grams/30 days), NM PICATO .05% OTHER QL (2 tubes/30 days), NM PICATO .015% OTHER QL (3 tubes/30 days), NM podofilox SOLN GENERIC NM procto-med hc GENERIC NM procto-pak GENERIC NM proctosol hc cre 2.5% GENERIC NM proctozone-hc GENERIC NM RECTIV OTHER QL (30 grams/30 days), NM rosadan cre 0.75% GENERIC NM tacrolimus (topical) GENERIC QL (100 grams/30 days), NM TARGRETIN GEL OTHER QL (60 grams/30 days), NM, PA VALCHLOR OTHER QL (60 grams/30 days), NM, LA, PA DERMATOLOGY, SCABICIDES AND PEDICULIDES malathion GENERIC NM

permethrin cre 5% GENERIC NM DERMATOLOGY, WOUND CARE AGENTS

acetic acid .25% GENERIC NM REGRANEX OTHER QL (30 grams/30 days), NM, PA SANTYL OTHER NM sodium chlor sol 0.9% irr GENERIC NM water for irrigation, sterile GENERIC NM MOUTH/THROAT/DENTAL AGENTS

cevimeline hcl GENERIC chlorhexidine gluconate (mouth-throat) GENERIC NM

Drug Name Drug Tier Requirements/Limits clotrimazole LOZG GENERIC NM lidocaine hcl (mouth-throat) GENERIC NM nystatin (mouth-throat) GENERIC NM paroex sol 0.12% GENERIC NM periogard GENERIC NM pilocarpine hcl (oral) GENERICtriamcinolone acetonide (mouth) GENERIC NM OTIC – DRUGS TO TREAT CONDITIONS OF THE EAR acetic acid (otic) GENERIC NM CIPRODEX OTHER NM flac GENERIC NM fluocinolone acetonide (otic) GENERIC NM neomycin-polymyxin-hc (otic) GENERIC NM ofloxacin (otic) GENERIC NM


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Formulary I D 00020345 v11 06/01/2020

Index abacavir sulfate 5abacavir sulfate-lamivudine 6abacavir sulfate-lamivudine-zidovudine 6ABELCET 4ABILIFY MAINTENA 23abiraterone acetate 11ABRAXANE 10acamprosate calcium 27acarbose 29acebutolol hcl 16acetaminophen w/ codeine 300-15mg 1acetaminophen w/ codeine 300-30mg 1acetaminophen w/ codeine 300-60mg 1acetaminophen w/ codeine soln 1acetazolamide 17acetic acid 51acetic acid (otic) 52acetylcysteine 48acitretin 50ACTHIB 42ACTIMMUNE 41acyclovir 7acyclovir sodium 7ADACEL 42adefovir dipivoxil 7ADEMPAS 18adriamycin 9adrucil inj 10ADVAIR DISKUS 49ADVAIR HFA 49AFINITOR 12AFINITOR DISPERZ 12AIMOVIG 26ala-cort 50albendazole 3albuterol sulfate 48alclometasone dipropionate 50ALDURAZYME 34ALECENSA 12alendronate sodium soln 70mg/75ml 30alendronate sodium tab 10 mg 30alendronate sodium tab 35 mg 30alendronate sodium tab 40 mg 30alendronate sodium tab 5 mg 30alendronate sodium tab 70 mg 30alfuzosin hcl 39ALIMTA 10ALINIA 3aliskiren fumarate 18allopurinol tab . 1

alosetron hcl 38ALPHAGAN P SOL 0.1% 46alprazolam tab 0.25mg 19alprazolam tab 0.5mg 19alprazolam tab 1mg 19alprazolam tab 2 mg 19ALREX 46altavera tab 31ALUNBRIG 12alyacen 1/35 31amantadine hcl 22AMBISOME 4ambrisentan 18amethia 31amethia lo 31amikacin sulfate 3amiloride & hydrochlorothiazide 18amiloride hcl 18AMINOSYN II INJ 10% 43AMINOSYN-PF 7% 43AMINOSYN-PF INJ 10% 43amiodarone hcl soln 15amiodarone tab 100mg 15amiodarone tab 200mg 15amiodarone tab 400mg 15AMITIZA CAP 24MCG 38AMITIZA CAP 8MCG 38amitriptyline hcl 21amlodipine besylate 17amlodipine besylate-benazepril hcl cap 10-20 mg 14amlodipine besylate-benazepril hcl cap 10-40 mg 14amlodipine besylate-benazepril hcl cap 2.5-10 mg 14amlodipine besylate-benazepril hcl cap 5-10 mg 14amlodipine besylate-benazepril hcl cap 5-20 mg 14amlodipine besylate-benazepril hcl cap 5-40 mg 14amlodipine besylate-olmesartan medoxomil 15amlodipine besylate-valsartan tab 15amlodipine-valsartan-hydrochlorothiazide tab 15ammonium lactate 51amnesteem 49amoxapine 21amoxicillin 8amoxicillin & pot clavulanate 200/5ml susr 8amoxicillin & pot clavulanate 200-28.5 chw tabs 8amoxicillin & pot clavulanate 250/5ml susr 8amoxicillin & pot clavulanate 250-125 tabs 8amoxicillin & pot clavulanate 400/5ml susr 8amoxicillin & pot clavulanate 400-57 chw tabs 8amoxicillin & pot clavulanate 500-125 tabs 8amoxicillin & pot clavulanate 600/5ml susr 8

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amoxicillin & pot clavulanate 875-125 tabs 8amoxicillin & pot clavulanate er 12hr 1000-62.5 tabs 9amphetamine-dextroamphetamine cap sr

24hr 10 mg 25amphetamine-dextroamphetamine cap sr





24hr 5 mg 25amphetamine-dextroamphetamine tab 10 mg 25amphetamine-dextroamphetamine tab 12.5 mg 25amphetamine-dextroamphetamine tab 15 mg 25amphetamine-dextroamphetamine tab 20 mg 25amphetamine-dextroamphetamine tab 30 mg 25amphetamine-dextroamphetamine tab 5 mg 25amphetamine-dextroamphetamine tab 7.5 mg 25amphotericin b 4ampicillin & sulbactam sodium 9ampicillin cap 500mg 9ampicillin inj 9ampicillin sodium 9ANADROL-50 . 27anagrelide hcl 40anastrozole 11ANDRODERM 28ANORO ELLIPTA 47APOKYN 22aprepitant 37aprepitant pak 80mg & 125mg 37apri 31APTIOM 19APTIVUS 5ARALAST NP 48aranelle 31ARCALYST 41aripiprazole odt 23aripiprazole oral solution 1 mg/ml 23aripiprazole tab 23ARISTADA 23ARISTADA INITIO 23armodafinil 27ARNUITY ELLIPTA 49ashlyna 31aspirin-dipyridamole 40atazanavir sulfate 5atenolol 16atenolol & chlorthalidone 16

atomoxetine hcl 25atorvastatin calcium 16atovaquone 3atovaquone-proguanil hcl 4ATRIPLA 6ATROPINE SULFATE 47ATROVENT HFA 47aubra 31AURYXIA 36AUSTEDO 26AVASTIN 10aviane 31avita 49AYVAKIT 12azacitidine 10AZASITE 45azathioprine 42azelastine drop 0.05% 46azelastine spr 0.1% 47azelastine spr 0.15% 47azithromycin 8AZOPT 46aztreonam 3bacitracin (ophthalmic) 45bacitracin-polymyxin b (ophth) 45bacitracin-poly-neomycin-hc 45baclofen 27balsalazide disodium 38BALVERSA 12balziva 31BANZEL SUS 40MG/ML 19BANZEL TAB 200MG 19BANZEL TAB 400MG 19BARACLUDE 7BASAGLAR KWIKPEN 28BCG VACCINE 42BD ALCOHOL SWABS 28BD ULTRAFINE INSULIN S YRINGE 28BD ULTRAFINE/NANO PEN N EEDLES 28bekyree 31BELSOMRA 25benazepril & hydrochlorothiazide 14benazepril hcl 14BENDEKA 9BENLYSTA 42benzoyl peroxide-erythromycin 49benztropine mesylate inj 22benztropine mesylate tab 0.5mg 22benztropine mesylate tab 1mg 22benztropine mesylate tab 2mg 22BEPREVE 46BERINERT 40

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BESIVANCE 45betamethasone dipropionate (topical) 50betamethasone dipropionate augmented 50betamethasone valerate 50BETASERON 27betaxolol hcl 16betaxolol hcl (ophth) 46bethanechol chloride 39BETOPTIC-S 46BEVESPI AEROSPHERE 47bexarotene 13BEXSERO 42bicalutamide 11BICILLIN L -A 9BIKTARVY 6bisoprolol & hydrochlorothiazide 16bisoprolol fumarate 16BIVIGAM 41blephamide 45blisovi 24 fe 31blisovi fe 1.5/30 31BOOSTRIX 42BORTEZOMIB 10bosentan 18, 19BOSULIF 12BRAFTOVI 12BREO ELLIPTA 49briellyn 31BRILINTA 40brimonidine sol 0.15% 47brimonidine sol 0.2% 47BRIVIACT INJ 5 0MG/5ML 19BRIVIACT SOL 10MG/ML 19BRIVIACT TAB 100MG 19BRIVIACT TAB 10MG 19BRIVIACT TAB 25MG 19BRIVIACT TAB 50MG 19BRIVIACT TAB 75MG 19bromfenac sodium (ophth) 46bromocriptine mesylate 23BROMSITE 46BRUKINSA 12budesonide (inhalation) 49budesonide ec 38bumetanide inj 0.25/ml 18bumetanide tab 18buprenorphine hcl 27buprenorphine hcl-naloxone hcl dihydrate 12-3mg 27buprenorphine hcl-naloxone hcl dihydrate 2-0.5mg 27buprenorphine hcl-naloxone hcl dihydrate 4-1mg 27buprenorphine hcl-naloxone hcl dihydrate 8-2mg 27buprenorphine hcl-naloxone hcl sl 27

bupropion hcl 21bupropion hcl (smoking deterrent) 27buspirone hcl 19butorphanol tartrate 1BYDUREON BCISE 28BYDUREON PEN 28BYETTA 28BYSTOLIC 16cabergoline 36CABOMETYX 12calcipotriene 50calcitonin (salmon) 36calcitrene 50calcitriol 45calcitriol inj 45calcitriol oral soln 1 mcg/ml 45calcium acetate (phosphate binder) 36CALQUENCE 12camila 31camrese lo 31candesartan cilexetil 15candesartan cilexetil-hydrochlorothiazide 15CAPLYTA 23CAPRELSA 12captopril 14captopril & hydrochlorothiazide 14CARBAGLU 34carbamazepine 19carbidopa/levodopa/entacapone 23carbidopa-levodopa 23carboplatin 14carisoprodol 27carteolol hcl (ophth) 47cartia xt 17carvedilol 16caspofungin acetate 4CAYSTON 3caziant pak 31cefaclor 7cefaclor er tab 500mg 7cefadroxil 7CEFAZOLIN IN DEXTROSE 2GM/100ML-4% 7cefazolin inj 7cefazolin sodium 7cefazolin sodium 1 gm/50ml 7cefdinir 7cefepime for inj 7cefixime 7cefoxitin for inj 7cefpodoxime proxetil 7cefprozil 8ceftazidime 8

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CEFTAZIDIME/DEXTROSE 8ceftriaxone sodium 8cefuroxime axetil 8cefuroxime sodium 8celecoxib 1CELONTIN 19cephalexin 8CERDELGA 34CEREZYME 34cetirizine syrup 47cevimeline hcl 51CHANTIX 27CHANTIX CONTINUING MONTH 27CHANTIX STARTER PACK 27CHEMET 30chlorhexidine gluconate (mouth-throat) 51chloroquine phosphate 5chlorothiazide 18chlorpromazine hcl 23chlorpromazine inj 23chlorthalidone 18cholestyramine 16cholestyramine light pack 16cholestyramine light powd 16ciclopirox 49cilostazol 40CILOXAN 45CIMDUO 6cinacalcet hcl 36CIPRO 8CIPRODEX 52ciprofloxacin hcl (ophth) 46ciprofloxacin hcl tab 8ciprofloxacin in d5w 8cisplatin 14citalopram hydrobromide 21claravis 49clarithromycin . 8clarithromycin er 8clarithromycin for susp 8clindamycin cap 300 mg 3clindamycin cap 75mg 3clindamycin hcl cap 150 mg 3clindamycin phosphate (topical) 49clindamycin phosphate in d5w 3CLINDAMYCIN PHOSPHATE IN NACL 3clindamycin phosphate inj 3clindamycin phosphate vaginal 39clindamycin soln 75mg/5ml 3CLINIMIX 4.25%/DEXTROSE 5% 43CLINIMIX 5%/DEXTROSE 15% 43CLINIMIX 5%/DEXTROSE 20% 44

CLINIMIX INJ 4.25/D10 44clinisol sf 15% 44CLINOLIPID 44clobazam 19clomipramine hcl 21clonazepam 19clonidine hcl 18clonidine hcl ptwk 18clopidogrel tab 75mg 40clorazepate dipotassium 19clotrimazole 52clotrimazole (topical) 50clotrimazole w/ betamethasone 50clovique 30clozapine odt 23clozapine tab 100mg 23clozapine tab 200mg 23clozapine tab 25mg 23clozapine tab 50mg 23COARTEM 5colchicine w/ probenecid 1COLCRYS 1colesevelam hcl 16colestipol hcl gran 16colestipol hcl pack 16colestipol hcl tabs 16colistimethate sodium 3colocort 38COMBIGAN 47COMBIVENT RESPIMAT 47COMETRIQ 12COMPLERA 6compro supp 37constulose 38COPIKTRA 12CORLANOR 18cortisone acetate 35COTELLIC 12COUMADIN 39CREON 39CRIXIVAN 5cromolyn sod neb 20mg/2ml 48cromolyn sodium (mastocytosis) 38cromolyn sodium (ophth) 46cryselle-28 31cyclafem 1/35 31cyclafem 7/7/7 31cyclobenzaprine hcl 27cyclophosphamide 9cycloserine 6cyclosporine 42cyclosporine modified (for microemulsion) 42

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cyproheptadine hcl 47cyred tab 31CYSTADANE 34CYSTAGON 34CYSTARAN 47cytarabine 10dalfampridine 27DALIRESP 48danazol 34dantrolene sodium 27dapsone 3DAPTACEL 42daptomycin 3dasetta 1/35 31dasetta 7/7/7 31DAURISMO 10deblitane 31deferasirox 30DELESTROGEN 35DELSTRIGO 6DEMSER 18DEPO-PROVERA INJ 400/ML 11DESCOVY 6desipramine hcl 21desmopressin acetate spray 37desmopressin acetate spray refrigerated 37desmopressin acetate tabs 37desmopressin inj 4mcg/ml 37desogestrel & ethinyl estradiol 31desogestrel-ethinyl estradiol (biphasic) 31desvenlafaxine succinate 21dexamethasone 35dexamethasone sodium phosphate 35dexamethasone sodium phosphate (ophth) 46DEXILANT 39dexmethylphenidate hcl 25dextrose 10% flex contain 44DEXTROSE 10% W/ SODIUM CHLORIDE 0.2% 44dextrose 10%/nacl 0.45% 44dextrose 2.5%/nacl 0.45% 44dextrose 5% 44DEXTROSE 5% /ELECTROLYTE 44dextrose 5%/nacl 0.2% 44dextrose 5%/nacl 0.225% 44DEXTROSE 5%/NACL 0.3% 44dextrose 5%/nacl 0.45% 44dextrose 5%/nacl 0.9% 44dextrose 5%/potassium chl 44dextrose 50% 44dextrose in lactated ringers 44dextrose inj 70% 44DIASTAT ACUDIAL 19

DIASTAT PEDIATRIC 19diazepam 19diazepam gel 19diazepam inj 19diazepam intensol 20diazepam oral soln 1 mg/ml 20diazoxide 35diclofenac potassium 1diclofenac sodium 1diclofenac sodium (ophth) 46diclofenac sodium (topical) 1% gel 51dicloxacillin sodium 9dicyclomine hcl cap 10mg 37dicyclomine hcl soln 10mg/5ml 37dicyclomine hcl tab 20mg 37didanosine 5DIFICID 8diflunisal 1digitek 17digox 17digoxin 17digoxin inj 17digoxin sol 50mcg/ml 17dihydroergotamine mesylate inj 1 mg/ml 26dihydroergotamine mesylate nasal spr 4 mg/ml 26dilantin cap 100mg 20dilantin cap 30mg 20dilantin chew tab 50mg 20DILANTIN-125 SUSP 20diltiazem cap 240mg cd 17diltiazem cap 360mg cd 17diltiazem cap er/12hr 17diltiazem hcl 17diltiazem hcl coated beads 17diltiazem hcl coated beads cap sr 24hr 17diltiazem hcl extended release beads cap sr 17diltiazem inj 17dilt-xr cap 17diphenhydramine hcl inj 50mg/ml 47diphenoxylate w/ atropine 38DIPHTHERIA/TETANUS TOXOID 42disopyramide phosphate 15disulfiram 27divalproex sodium 20docetaxel 10DOCETAXEL 10dofetilide 15donepezil hydrochloride 21dorzolamide hcl 47dorzolamide hcl-timolol maleate 47DOVATO 6doxazosin mesylate 15

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doxepin hcl 22doxepin hcl (sleep) 25doxorubicin hcl 9doxorubicin hcl liposomal 10doxy 100 9doxycycline (monohydrate) 9doxycycline hyclate 9doxycycline hyclate 100 mg 9doxycycline hyclate 20 mg 9DRIZALMA SPRINKLE 22dronabinol 37drospirenone-ethinyl estradiol 31drospirenone-ethinyl estradiol-levomefolate calcium 31DROXIA 40duloxetine hcl 22DUREZOL 46dutasteride 39dutasteride-tamsulosin hcl 39e.e.s. 4 00 8EDURANT 5efavirenz 5eletriptan hydrobromide 26ELIQUIS 39ELIQUIS STARTER PACK 40ELLA 31eluryng 31EMCYT 9EMEND 37EMGALITY 26emoquette 31EMSAM 22EMTRIVA 5emverm 3enalapril maleate 14enalapril maleate & hydrochlorothiazide 14ENBREL 40ENBREL MINI 41ENBREL SURECLICK 41ENDARI 40endocet 10-325mg 2endocet 2.5-325mg 1endocet 5-325mg 1endocet 7.5-325mg 2ENGERIX-B 42enoxaparin sodium 40enpresse-28 31enskyce 31ENSTILAR 50entacapone 23entecavir 7ENTRESTO 15enulose 38

EPCLUSA 7EPIDIOLEX 20epinephrine (anaphylaxis) 48epirubicin hcl 10epitol 20EPIVIR HBV 7eplerenone 15ergotamine w/ caffeine 26ERIVEDGE 10ERLEADA 11erlotinib hcl 12errin 31ertapenem sodium 3ery p ad 2% 49ery-tab 8erythrocin lactobionate 8erythrocin stearate 8erythromycin (acne aid) 49erythromycin (ophth) 46erythromycin base 8erythromycin cap 250mg ec 8erythromycin ethylsuccinate 8erythromycin tab ec 8ESBRIET 48escitalopram oxalate 22esomeprazole magnesium 39estarylla tab 0.25-35 32estradiol 35estradiol vaginal cream 35estradiol vaginal tab 35estradiol valerate inj 35eszopiclone 25ethambutol hcl 6ethosuximide 20ethynodiol diacet & eth estrad 32ethynodiol tab 1-50 32etodolac 1etonogestrel-ethinyl estradiol 32etoposide 14euthyrox 36everolimus 12everolimus (immunosuppressant) 42EVOTAZ 6EVZIO 27exemestane 11ezetimibe 16ezetimibe-simvastatin 16FABRAZYME 34falmina 32famciclovir 7famotidine 37famotidine in nacl 37

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famotidine inj 37FANAPT 23FANAPT TITRATION PACK 23FARXIGA 29FARYDAK 10FASENRA 48FASENRA PEN 48fayosim 32felbamate 20felodipine 17femynor 32fenofibrate 16fenofibrate micronized 16fentanyl citrate 2fentanyl patch 1 00 mcg/hr 2fentanyl patch 1 2 mcg/hr 2fentanyl patch 2 5 mcg/hr 2fentanyl patch 5 0 mcg/hr 2fentanyl patch 7 5 mcg/hr 2FETZIMA 22FETZIMA TITRATION PACK 22FIASP 28FIASP FLEXTOUCH 28FIASP PENFILL 28finasteride 39flac 52flecainide acetate 15FLOVENT DISKUS 49FLOVENT HFA 49fluconazole 4fluconazole inj nacl 200 4fluconazole inj nacl 400 4flucytosine 4fludrocortisone acetate 35flunisolide (nasal) 49fluocinolone acetonide 50fluocinolone acetonide (otic) 52fluocinolone acetonide oil body 50fluocinonide 50fluocinonide emulsified base 50fluorometholone 46fluorouracil 10fluorouracil (topical) 51fluoxetine cap 1 0mg 22fluoxetine cap 2 0mg 22fluoxetine cap 4 0mg 22fluoxetine hcl 22fluphenazine decanoate 23fluphenazine hcl 23, 24flurbiprofen 1flurbiprofen s odium 46flutamide 11

fluticasone propionate 50fluticasone propionate (nasal) 49fluvoxamine maleate 19fondaparinux sodium 40FORTEO 36fosamprenavir tab 7 00 mg 5fosinopril sodium 14fosinopril sodium & hydrochlorothiazide 14FREAMINE HBC 6.9% 44FREAMINE III 44fulvestrant 11furosemide 18furosemide inj 18FUZEON 5fyavolv 35FYCOMPA 20gabapentin 20galantamine hydrobromide 21galantamine hydrobromide er 21GAMASTAN S /D 41GAMMAGARD LIQUID 41GAMMAGARD S/D 41GAMMAKED 41GAMMAPLEX 41GAMMAPLEX 10GM/100ML 41GAMUNEX-C 41ganciclovir sodium 7GARDASIL 9 42gatifloxacin (ophth) 46GATTEX 38GAUZE PADS 2 28gavilyte-c 38gavilyte-g 38gavilyte-n/flavor pack 38gemcitabine inj soln 10gemcitabine inj solr 10gemfibrozil 16generlac 38gengraf 42GENOTROPIN 36GENOTROPIN M INIQUICK 36gentak 46gentamicin in saline 3gentamicin sulfate 3gentamicin sulfate (topical) 49gentamicin sulfate soln (ophth) 46GENVOYA 6GEODON 24gianvi tab 3-0.02mg 32GILENYA 27GILOTRIF TAB 20MG 12GILOTRIF TAB 30MG 12

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GILOTRIF TAB 40MG 12glatiramer acetate 20mg/ml 27glatiramer acetate 40mg/ml 27glatopa 27GLEOSTINE 9glimepiride 29glip/metform tab 2.5-250mg 29glip/metform tab 2.5-500mg 29glip/metform tab 5-500mg 29glipizide 29glipizide xl 29GLUCAGEN HYPOKIT 35GLUCAGON E MERGENCY KIT 35glyburide 29glyburide micronized 29glyburide-metformin tab 1.25-250 mg 29glyburide-metformin tab 2.5-500 mg 29glyburide-metformin tab 5-500mg 29glycopyrrolate tab 1mg 37glycopyrrolate tab 2mg 37glydo 51GLYXAMBI 29GOLYTELY 38granisetron hcl 37griseofulvin microsize 4griseofulvin ultramicrosize 4guanfacine er (adhd) 25GVOKE PFS 36HAEGARDA 40hailey 24 fe 32halobetasol propionate 50haloperidol 24haloperidol conc 2mg/ml 24haloperidol decanoate 24haloperidol lactate inj 5mg/ml 24HARVONI 7HAVRIX 42heather 32heparin sod (porcine) in d5w 40heparin sod inj 1000/ml 40heparin sod inj 10000/ml 40heparin sod inj 20000/ml 40heparin sod inj 5000/ml 40HEPARIN SODIUM/NACL 0.45% 40hepatamine 44HERCEPTIN 10HERCEPTIN HYLECTA 10HETLIOZ 26HIBERIX 42HUMIRA 41HUMIRA INJ 10MG/0.2ML 41HUMIRA KIT 20MG/0.4ML 41

HUMIRA KIT 40MG/0.8ML 41HUMIRA PEDIATRIC CROHNS DISEASE 41HUMIRA PEN 41HUMIRA PEN CD/UC/HS STARTER 41HUMIRA PEN INJ CD/UC/HS STARTER 41HUMIRA PEN INJ PS/UV STARTER 41HUMIRA PEN-PS/UV STARTER 41HUMULIN R INJ U-500 28HUMULIN R U-500 KWIKPEN 28hydralazine hcl 18hydrochlorothiazide 18hydroco/apap tab 10-325mg 2hydroco/apap tab 5-325mg 2hydroco/apap tab 7.5-325 2hydrocodone-acetaminophen 7.5-325 mg/15ml 2hydrocodone-ibuprofen tab 7.5-200 mg 2hydrocortisone 35hydrocortisone (enema) 38hydrocortisone (topical) cream 1% 50hydrocortisone (topical) cream 2.5% 50hydrocortisone (topical) lotion 2.5% 50hydrocortisone (topical) oint 2.5% 50hydrocortisone butyrate cream 0.1% 50hydrocortisone butyrate oint 0.1% 50hydromorphone hcl 2hydroxychloroquine sulfate 41hydroxyurea 13hydroxyzine hcl 47hydroxyzine hcl inj 47hydroxyzine pamoate 47HYSINGLA ER 2ibandronate sodium tabs 30IBRANCE 10ibu tab 600mg . 1ibu tab 800mg . 1ibuprofen 1icatibant acetate 40ICLUSIG 12IDHIFA 10ILEVRO 46imatinib mesylate 12IMBRUVICA 12imipenem-cilastatin 3imipramine hcl 22imiquimod 51IMOVAX RABIES (H.D.C.V.) 42incassia 32INCRELEX 36INCRUSE ELLIPTA 47indapamide 18INFANRIX 42INLYTA 12

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INREBIC 12INSULIN PEN NEEDLE 28INSULIN SAFETY NEEDLES 28INSULIN SYRINGE 28INTELENCE 5INTRALIPID 30% 44intralipid inj 20% 44INTRON-A INJ 10MU 41INTRON-A INJ 18MU 41INTRON-A INJ 25MU 41INTRON-A INJ 50MU 41introvale 32INVEGA SUST INJ 117 MG/0.75 ML 24INVEGA SUST INJ 156MG/ML 24INVEGA SUST INJ 234 MG/1.5 ML 24INVEGA SUST INJ 39 MG/0.25 ML 24INVEGA SUST INJ 78 MG/0.5 ML 24INVEGA TRINZA 24INVIRASE 5IPOL INACTIVATED IPV 42ipratropium bromide 47ipratropium bromide (nasal) 47ipratropium-albuterol nebu 47irbesartan 15irbesartan-hydrochlorothiazide 15IRESSA 12irinotecan hcl 14ISENTRESS 5ISENTRESS HD 5isibloom 32ISOLYTE P 44ISOLYTE S 44isoniazid 6isoniazid syp 50mg/5ml 6isosorb mononitrate tab 18isosorbide dinitrate 18isosorbide mononitrate er 18isotretinoin 49isradipine 17itraconazole 4ivermectin 3IXIARO 42JADENU 30JADENU SPRINKLE 31JAKAFI 12jantoven 40JANUMET 29JANUMET XR TAB 100-1000 29JANUMET XR TAB 50-1000 29JANUMET XR TAB 50-500MG 29JANUVIA 29JARDIANCE 29

jasmiel 32JENTADUETO 29JENTADUETO TAB XR 2.5-1000 MG 29JENTADUETO TAB XR 5-1000 MG 29jinteli 35jolessa tab 0.15-0.03 mg 32jolivette 32juleber 32JULUCA 6junel 1.5/30 32junel 1/20 32junel fe 1.5/30 32junel fe 1/20 32junel fe 24 32JUXTAPID 16KADCYLA 10kaitlib fe 32KALETRA TAB 100-25MG 6KALETRA TAB 200-50MG 6KALYDECO 48KANJINTI 10kariva 32kcl 0.075%/d5w/nacl 0.45% 44KCL 0.15%/D5W/NACL 0.225% 44kcl 0.15%/d5w/nacl 0.9% 44kcl 0.3%/d5w/nacl 0.45% 44KCL 0.3%/D5W/NACL 0.9% 44kcl/d5w inj 0.3% 44kcl/d5w/nacl inj .15/.45% 44kcl/d5w/nacl inj 0.22%/0.45% 44kcl/nacl inj 0.15%-0.9% 45kcl/nacl inj 0.3-0.9 45kcl0.15%/d5w/nacl0.2% 44kelnor 1/35 32kelnor 1/50 32ketoconazole 4ketoconazole cream 50ketoconazole shampoo 50ketorolac tromethamine (ophth) 46KEYTRUDA 10KINRIX 42kionex sus 15gm/60ml 31KISQALI 10KISQALI FEMARA 200 DOSE 10KISQALI FEMARA 400 DOSE 10KISQALI FEMARA 600 DOSE 11klor-con 10 43klor-con 8 43klor-con m10 43klor-con m15 43klor-con m20 43klor-con pak 20meq 43

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klor-con spr cap 10meq 43klor-con spr cap 8meq 43KORLYM 36kurvelo 32KUVAN 34labetalol hcl 16lactated ringer's 45lactulose 38lactulose (encephalopathy) 38lamivudine 5lamivudine (hbv) 7lamivudine-zidovudine 6lamotrigine 20lansoprazole 39larin 1.5/30 32larin 1/20 32larin fe 1.5/30 32larin fe 1/20 32larissia tab 32LASTACAFT 46latanoprost 47LATUDA 24layolis fe 32leena tab 32leflunomide 41LENVIMA 10 MG DAILY DOSE 13LENVIMA 12MG DAILY DOSE 13LENVIMA 14 MG DAILY DOSE 13LENVIMA 18 MG DAILY DOSE 13LENVIMA 20 MG DAILY DOSE 13LENVIMA 24 MG DAILY DOSE 13LENVIMA 4 MG DAILY DOSE 13LENVIMA 8 MG DAILY DOSE 13lessina 32letrozole 11leucovorin calcium 14LEUKERAN 9leuprolide inj 1mg/0.2 11levalbuterol hcl 48levalbuterol hcl soln nebu conc 1.25 mg/0.5ml 48levalbuterol tartrate hfa 48LEVEMIR 28LEVEMIR FLEXTOUCH 28levetiracetam 20levetiracetam in sodium chloride 20levetiracetam oral soln 100 mg/ml 20levobunolol hcl 47levocarnitine (metabolic modifiers) 34levocetirizine dihydrochloride 48levofloxacin 8levofloxacin in d5w 8levofloxacin inj 25mg/ml 8

levofloxacin oral soln 25 mg/ml 8levonest 32levonor/ethi tab 32levonor-eth est tab 0.15-0.02/0.025/0.03mg &

eth est 0.01mg 32levonorgestrel & eth estradiol 32levonorgestrel-ethinyl estradiol 0.15-0.03mg (91-day) 32levonorg-eth est tab 0.1-0.02mg(84) &

eth est tab 0.01mg(7) 32levonorg-eth est tab 0.15-0.03mg (84) &

eth est tab 0.01mg(7) 32levora 0.15/30-28 33levo-t 36levothyroxine sodium 36levoxyl 36LEXIVA 5lidocaine 51lidocaine hcl 51lidocaine hcl (local anesth.) 3lidocaine hcl (mouth-throat) 52lidocaine inj 0.5% 3lidocaine inj 1.5% preservative free (pf) 3lidocaine inj 1% 3lidocaine oint 5% 51lidocaine-prilocaine 51linezolid in sodium chloride 3linezolid inj 3linezolid susp 3linezolid tab 600mg 4LINZESS 38liothyronine sodium 36lisinopril 14lisinopril & hydrochlorothiazide 14lithium carbonate 26lithium carbonate er 26LITHIUM SOLN 8MEQ/5ML 26LOKELMA 31LONSURF 13loperamide hcl 38lopinavir-ritonavir 6lorazepam 19lorazepam intensol 19LORBRENA 13lorcet hd tab 10-325mg 2lorcet plus tab 7.5-325 2lorcet tab 5-325mg 2loryna 33losartan potassium 15losartan-hydrochlorothiazide 15LOTEMAX 46loteprednol etabonate 46lovastatin 16

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low-ogestrel 33loxapine succinate 24LUMIGAN 47LUMIZYME 34LUPRON DEPOT (1-MONTH) 11LUPRON DEPOT INJ 11.25MG (3-MONTH) 11LUPRON DEPOT-PED (1-MONTH 36LUPRON DEPOT-PED (3-MONTH 36LUPRON DEP-PED INJ 11.25MG (3-MONTH) 36LUPRON DEP-PED INJ 7.5MG 36lutera 33LYNPARZA 11LYRICA CR 26LYSODREN 11lyza 33magnesium sulfate 43MAGNESIUM SULFATE 43MAGNESIUM SULFATE IN D5W 43magnesium sulfate in dextrose 43magnesium sulfate inj 50% 43malathion 51maprotiline hcl 22marlissa 33MARPLAN TAB 10MG 22MATULANE 13MAVYRET 7meclizine hcl 37medroxyprogesterone acetate (contraceptive) 33medroxyprogesterone acetate tab 36mefloquine hcl . 5megestrol ac sus 40mg/ml 11megestrol ac tab 20mg 11megestrol ac tab 40mg 11megestrol sus 625mg/5ml 11MEKINIST 13MEKTOVI 13melodetta 24 fe 33meloxicam 1memantine hcl cp24 21memantine soln 21memantine tabs 21memantine titration pak 21MENACTRA 42MENVEO 42mercaptopurine 10meropenem 4mesalamine 38mesalamine w/ cleanser 38MESNEX 14metadate er tab 20mg 25metformin er 29

30

metformin hcl 30methadone hcl 2methadone hcl 10mg 2methadone hcl 5mg 2methadone hcl intensol 2methazolamide 18methenamine hippurate 4methimazole 36methocarbamol 27methotrexate sodium inj soln 10methotrexate sodium inj solr 10methotrexate sodium tabs 41methylphenidate hcl 25methylphenidate hcl oral soln 25methylphenidate hcl tbcr 10 mg 25methylphenidate hcl tbcr 20mg 25methylpr ss inj 35methylpred pak 4mg 35methylpred tab 16mg 35methylpred tab 32mg 35methylpred tab 4mg 35methylpred tab 8mg 35methylprednisolone acetate 35metoclopramide hcl 37metoclopramide hcl inj 37metolazone 18metoprolol & hydrochlorothiazide 16metoprolol succinate 16metoprolol tartrate 16, 17metronidazole . 4metronidazole (topical) 51metronidazole gel 0.75% 51metronidazole in nacl 4metronidazole vaginal 39mibelas 24 fe 33microgestin 1.5/30 33microgestin 1/20 33microgestin fe 1.5/30 33microgestin fe 1/20 33midodrine hcl 18miglustat 34mili 33minitran 18minocycline hcl 9minoxidil 18mirtazapine 22misoprostol 38MITIGARE 1M-M-R II 42M-NATAL PLUS 45moexipril hcl 14molindone hcl 24

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mometasone furoate 50mondoxyne nl cap 100mg 9mono-linyah tab 0.25-35 33montelukast sodium 48morphine ext-rel tab 2morphine sul inj 1mg/ml 2morphine sulfate 2MORPHINE SULFATE 2morphine sulfate oral soln 100mg/5ml 2morphine sulfate oral soln 10mg/5ml 2morphine sulfate oral soln 20mg/5ml 2MOVANTIK 38MOXEZA 46moxifloxacin hcl 8moxifloxacin hcl (ophth) 46MULTAQ 15mupirocin 49MVASI 11MYCAMINE 4mycophenolate mofetil 42mycophenolate sodium tbec 42myorisan 49MYRBETRIQ 39nabumetone 1nadolol 17nafcillin sodium for inj 9nafcillin sodium for inj 10gm 9NAGLAZYME 34nalbuphine hcl . 1naloxone inj 0.4mg/ml 27naloxone inj 1mg/ml 27naltrexone hcl 27NAMZARIC 21naproxen 1naproxen dr 1naproxen sodium 1naratriptan hcl 26NARCAN 27NATACYN 46nateglinide 30NATPARA 36NAYZILAM 20necon 0.5/35-28 33nefazodone hcl 22neomycin sulfate 3neomycin-bacitracin zn-polymyxin 46neomycin-polymy-dexameth 45neomycin-polymyxin-gramicidin 46neomycin-polymyxin-hc (ophth) 45neomycin-polymyxin-hc (otic) 52NEPHRAMINE 44NERLYNX 13

NEUPRO 23nevirapine susp 50 mg/5ml 5nevirapine tab 100mg er 5nevirapine tab 200mg 5nevirapine tab 400mg er 5NEXAVAR 13niacin (antihyperlipidemic) 16niacin er (antihyperlipidemic) 16niacor 16nicardipine hcl 17NICOTROL INHALER 27NICOTROL NS 27nifedipine 17nifedipine er 17nikki 33nilutamide 11nimodipine 17NINLARO 11nitisinone 34nitro-bid 18NITRO-DUR DIS 0.3MG/HR 18NITRO-DUR DIS 0.8MG/HR 18nitrofurantoin macrocrystal 4nitrofurantoin monohyd macro 4nitroglycerin 18nitroglycerin td patch 18NITYR 34nizatidine 37nora-be tab 0.35mg 33nore/eth/fer chw 0.4mg-35 33noreth/ethin chw fe 33norethin acet & estrad-fe 33norethindrone (contraceptive) 33norethindrone acet & eth estra 33norethindrone acetate 36norethindrone acetate-ethinyl estradiol 35norgest/ethi tab 0.25/35 33norgestimate-ethinyl estradiol (triphasic)

0.18-25/0.215-25/0.25-25 mg-mcg 33norgestimate-ethinyl estradiol (triphasic)

0.18-35/0.215-35/0.25-35 mg-mcg 33NORMOSOL-M IN D5W 45NORMOSOL-R 45NORMOSOL-R IN D5W 45NORPACE CR 15NORTHERA 18nortrel 0.5/35 (28) 33nortrel 1/35 33nortrel 7/7/7 33nortriptyline hcl 22NORVIR PACK 5NORVIR SOLN 5

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NOVOLIN 70/30 28NOVOLIN 70/30 FLEXPEN 28NOVOLIN N 28NOVOLIN N FLEXPEN 28NOVOLIN R 28NOVOLIN R FLEXPEN 28NOVOLOG 28NOVOLOG 70/30 FLEXPEN 28NOVOLOG FLEXPEN 28NOVOLOG MIX 70/30 28NOVOLOG PENFILL 28NOXAFIL 4NUBEQA 11NUCALA 48NUCYNTA ER 2NUEDEXTA 26NULOJIX 42NULYTELY/FLAVOR PACKS 38NUPLAZID CAPS 24NUPLAZID TABS 10MG 24nutrilipid inj 20% 44nyamyc 50NYMALIZE 17nystatin 4nystatin (mouth-throat) 52nystatin (topical) 50nystop 50ocella tab 3-0.03mg 33OCTAGAM 41octreotide acetate 36ODEFSEY 6ODOMZO 11OFEV 48ofloxacin (ophth) 46ofloxacin (otic) 52OGIVRI 11olanzapine 24olmesartan medoxomil 15olmesartan medoxomil-amlodipine-

hydrochlorothiazide 15olmesartan medoxomil-hydrochlorothiazide 15olopatadine hcl 0.2% 46omeprazole cap 10mg 39omeprazole cap 20mg 39omeprazole cap 40mg 39ondansetron hcl 37ondansetron hcl inj 37ondansetron hcl oral soln 37ondansetron odt 37OPSUMIT 19ORFADIN 35ORKAMBI 48

orsythia 33oseltamivir phosphate 7OSPHENA 36oxacillin sodium 9oxaliplatin inj 100mg 14oxaliplatin inj 100mg/20ml 14oxaliplatin inj 50mg 14oxaliplatin inj 50mg/10ml 14oxandrolone tab 10mg 28oxandrolone tab 2.5mg 28oxcarbazepine 20oxybutynin chloride 39oxycodone hcl 2oxycodone w/ acetaminophen 10-325mg 2oxycodone w/ acetaminophen 2.5-325mg 2oxycodone w/ acetaminophen 5-325mg 2oxycodone w/ acetaminophen 7.5-325mg 2OZEMPIC INJ 0.25 OR 0.5MG/DOSE 28OZEMPIC INJ 1MG/DOSE 28pacerone 15paclitaxel 10paliperidone 24pamidronate disodium 30pamidronate inj 30mg 30pamidronate inj 90mg 30PANRETIN 51pantoprazole sodium 39pantoprazole sodium tbec 39PANZYGA 41paricalcitol 45paroex sol 0.12% 52paromomycin sulfate 3paroxetine hcl tabs 22paser d/r 6PAXIL 22PAZEO 46PEDIARIX 42PEDVAX HIB 42peg 3350-kcl-sod bicarb-sod chloride-sod sulfate 38peg 3350-potassium chloride-sod bicarbonate-sod

chloride 38PEGANONE 20PEGASYS 7PEGASYS PROCLICK 7penicillamine . 31PENICILLIN G POT IN DEXTROSE 2MU 9PENICILLIN G POT IN DEXTROSE 3MU 9penicillin g procaine 9penicillin g sodium 9penicillin v potassium 9penicilln gk inj 20mu 9penicilln gk inj 5mu 9

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PENTACEL 42pentamidine isethionate inh 4pentamidine isethionate inj 4pentoxifylline 40perindopril erbumine 14periogard 52permethrin cre 5% 51perphenazine 24PERSERIS 24pfizerpen-g inj 20mu 9pfizerpen-g inj 5mu 9phenelzine sulfate 22phenobarbital 20phenobarbital sodium 20phenytek 20phenytoin 20phenytoin sodium extended 20phenytoin sodium inj 50mg/ml 20philith 33PHOSPHOLINE IODIDE 47PICATO 51PIFELTRO 5pilocarpine hcl 47pilocarpine hcl (oral) 52pimozide 24pimtrea 33pindolol 17pioglitazone hcl 30piper/tazoba inj 12-1.5gm 9piper/tazoba inj 2-0.25gm 9piper/tazoba inj 3-0.375gm 9piper/tazoba inj 36-4.5gm 9piper/tazoba inj 4-0.5gm 9PIQRAY 200MG DAILY DOSE 13PIQRAY 250MG DAILY DOSE 13PIQRAY 300MG DAILY DOSE 13pirmella 1/35 33piroxicam 1PLASMA-LYTE A 45PLASMA-LYTE-148 45plenamine 44PLENVU 38PNV FOLIC ACID + IRON MUL 45podofilox 51polymyxin b-trimethoprim 46POMALYST 12portia-28 33posaconazole 4pot chloride inj 2meq/ml 45potassium chloride 43, 45potassium chloride in nacl 45potassium chloride microencapsulated crystals er 43

potassium citrate (alkalinizer) er tabs 39PRADAXA 40PRALUENT 16pramipexole tab 0.125mg 23pramipexole tab 0.25mg 23pramipexole tab 0.5mg 23pramipexole tab 0.75mg 23pramipexole tab 1.5mg 23pramipexole tab 1mg 23prasugrel hcl .. 40pravastatin sodium 16praziquantel .... 4prazosin hcl 15pred sod pho sol 5mg/5ml 35prednisolone acetate (ophth) 46prednisolone sodium phosphate 35prednisolone sodium phosphate (ophth) 46prednisolone sol 15mg/5ml 35prednisolone sol 25mg/5ml 35prednisone con 5mg/ml 35prednisone pak 10mg 35prednisone pak 5mg 35prednisone sol 5mg/5ml 35prednisone tab 10mg 35prednisone tab 1mg 35prednisone tab 2.5mg 35prednisone tab 20mg 35prednisone tab 50mg 35prednisone tab 5mg 35pregabalin 20premasol 10% 44PRENATAL 45PRENATAL PLUS 45PRENATAL PLUS LOW IRON 45prevalite 16previfem 33PREZCOBIX 6PREZISTA 5PRIFTIN................................ 6primaquine phosphate 5PRIMAQUINE PHOSPHATE 5primidone 20PRIVIGEN 41probenecid 1PROCALAMINE 44prochlorperazine inj 37prochlorperazine maleate 37prochlorperazine supp 37PROCRIT 40procto-med hc 51procto-pak 51proctosol hc cre 2.5% 51

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proctozone-hc 51PROGLYCEM SUS 50MG/ML 36PROGRAF 42PROLASTIN-C 48PROLENSA 46PROLIA 36PROMACTA 40promethazine hcl 37promethazine hcl inj 37propafenone hcl 15propafenone hcl 12hr 15proparacaine hcl 47propranolol & hydrochlorothiazide 16propranolol cap er 17propranolol hcl 17propranolol oral sol 17propylthiouracil 36PROQUAD 42PROSOL 44protriptyline hcl 22PULMICORT FLEXHALER 49PULMOZYME 48PURIXAN 10pyrazinamide 6pyridostigmine tab 60mg 26QUADRACEL 42quetiapine fumarate 24quinapril hcl 14quinapril-hydrochlorothiazide 14quinidine sulfate 15quinine sulfate . 5RABAVERT 42rabeprazole sodium 39raloxifene tab 60mg 36ramipril 14ranolazine 18rasagiline mesylate 23RAYALDEE 45reclipsen 33RECOMBIVAX HB 43RECTIV 51REGRANEX 51RELENZA DISKHALER 7RELISTOR 38REMICADE 41RENFLEXIS 41repaglinide 30RESTASIS 47RESTASIS MULTIDOSE 47REVLIMID 12REXULTI 24REYATAZ 5

RHOPRESSA 47ribavirin cap 200mg 7ribavirin tab 200mg 7rifabutin 7rifampin 7RIFATER 7riluzole 26rimantadine hydrochloride 7RINVOQ 41risedronate sodium 30RISPERDAL INJ 12.5MG 24RISPERDAL INJ 25MG 24RISPERDAL INJ 37.5MG 24RISPERDAL INJ 50MG 24risperidone 24ritonavir 5RITUXAN 11RITUXAN HYCELA 11rivastigmine tartrate 21rivastigmine td patch 24hr 13.3 mg/24hr 21rivastigmine td patch 24hr 4.6 mg/24hr 21rivastigmine td patch 24hr 9.5 mg/24hr 21rivelsa 33rizatriptan benzoate 26rizatriptan benzoate odt 26ropinirole tab 0.25mg 23ropinirole tab 0.5mg 23ropinirole tab 1mg 23ropinirole tab 2mg 23ropinirole tab 3mg 23ropinirole tab 4mg 23ropinirole tab 5mg 23rosadan cre 0.75% 51rosuvastatin calcium 16ROTARIX 43ROTATEQ 43roweepra 20roweepra xr 20ROZLYTREK 13RUBRACA 11RUXIENCE 11RYDAPT 13SANDIMMUNE 42SANTYL 51SAPHRIS 24scopolamine 37SECUADO 24selegiline hcl 23selenium sulfide 50SELZENTRY 5SEREVENT DISKUS 48sertraline hcl 22

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setlakin tab 33sevelamer carbonate 36sharobel 33SHINGRIX 43SIGNIFOR 36sildenafil citrate tab 20 mg (pulmonary hypertension) 19silver sulfadiazine 49SIMBRINZA 47simvastatin 16sirolimus 42SIRTURO 7SIVEXTRO 4SKYRIZI 41sodium chlor sol 0.9% irr 51sodium chloride 43, 45sodium chloride 0.45% 45sodium chloride inj 0.9% 45sodium fluoride chew; tab; 1.1 (0.5 f) mg/ml soln 43sodium phenylbutyrate 35sodium polystyrene sulfonate powder 31sodium polystyrene sulfonate susp 31SOLIQUA 100/33 28SOLTAMOX 11SOLU-CORTEF 35SOMATULINE DEPOT 36SOMAVERT 36sorine 15sotalol hcl 15sotalol hcl (afib/afl) 15spironolactone 15spironolactone & hydrochlorothiazide 18sprintec 28 33SPRITAM 20SPRYCEL 13sps susp 15gm/60ml 31sronyx 33ssd 49stavudine 5STELARA 41STIMATE 37STIVARGA 13streptomycin sulfate 3STRIBILD 6subvenite tab 20sucralfate 38sulfacetamide sodium (acne) 49sulfacetamide sodium (ophth) 46sulfacetamide sod-prednisolone 45sulfadiazine 3sulfamethoxazole-trimethop ds 4sulfamethoxazole-trimethoprim inj 4sulfamethoxazole-trimethoprim susp 4

sulfamethoxazole-trimethoprim tab 400-80mg 4SULFAMYLON 49sulfasalazine 38sulfasalazine ec 38sulindac 1sumatriptan 26sumatriptan inj 4mg/0.5ml 26sumatriptan inj 6mg/0.5ml 26sumatriptan succinate 26SUPREP BOWEL PREP KIT 38SUTENT 13syeda 33SYLATRON 13SYMBICORT 49SYMDEKO 48SYMFI 6SYMFI LO 6SYMJEPI 48SYMPAZAN 21SYMTUZA 6SYNAREL 34SYNERCID 4SYNJARDY TAB 12.5-1000MG 30SYNJARDY TAB 12.5-500MG 30SYNJARDY TAB 5-1000MG 30SYNJARDY TAB 5-500MG 30SYNJARDY XR TAB 10-1000MG 30SYNJARDY XR TAB 12.5-1000MG 30SYNJARDY XR TAB 25-1000MG 30SYNJARDY XR TAB 5-1000MG 30SYNRIBO 13SYNTHROID 37TABLOID 10tacrolimus 42tacrolimus (topical) 51TAFINLAR 13TAGRISSO 13TALZENNA 11tamoxifen citrate 11tamsulosin hcl 39TARGRETIN 51tarina 24 fe 34tarina fe 1/20 34TASIGNA 13TAXOTERE 10tazarotene 50tazicef 8TAZORAC 50taztia xt 17TAZVERIK 13TDVAX 43TECENTRIQ 11

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TEFLARO 8telmisartan 15telmisartan-amlodipine 15telmisartan-hydrochlorothiazide 15temazepam 26TEMIXYS 6TENIVAC 43tenofovir disoproxil fumarate 5terazosin hcl 15terbinafine hcl . 4terbutaline sulfate 48terconazole vaginal 39testosterone 28testosterone cypionate 28testosterone enanthate 28tetrabenazine 26tetracycline hcl 9texacort soln 2.5% 50THALOMID 12theo-24 48theophylline 48theophylline tab er 12hr 300 mg 48theophylline tab er 12hr 450 mg 48theophylline tab sr 24hr 48thioridazine hcl 24thiothixene 25tiadylt er 17tiagabine hcl 21TIBSOVO 11tigecycline 4tilia fe 34timolol maleate 17timolol maleate (ophth) soln 47timolol maleate gel 47timolol maleate ophth soln 0.5% (once-daily) 47TIVICAY 5tizanidine hcl 27TOBRADEX 45TOBRADEX ST 45tobramycin 3tobramycin (ophth) 46tobramycin inj 1.2 gm/30ml 3tobramycin inj 1.2gm 3tobramycin inj 10mg/ml 3tobramycin inj 80mg/2ml 3tobramycin sulfate 3tobramycin-dexamethasone 45tolterodine tartrate 39topiramate 21toposar 14toremifene citrate 12torsemide tabs 18

TOVIAZ 39TPN ELECTROLYTES 43TRADJENTA 30tramadol hcl tab 50 mg 1tramadol-acetaminophen 1trandolapril 14tranexamic acid 40tranylcypromine sulfate 22TRAVASOL 44travoprost 47TRAZIMERA 11trazodone hcl 22TRECATOR 7TRELEGY ELLIPTA 47TRELSTAR DEP INJ 3.75MG 12TRELSTAR LA INJ 11.25MG 12treprostinil 19TRESIBA FLEXTOUCH 28TRESIBA INJ 28tretinoin 49tretinoin (chemotherapy) 13triamcinolone acetonide (mouth) 52triamcinolone acetonide (topical) 50-51triamterene & hydrochlorothiazide cap 37.5-25 mg 18triamterene & hydrochlorothiazide tabs 18TRICARE 45trientine hcl 31tri-estarylla 34trifluoperazine hcl 25trifluridine 46trihexyphenidyl hcl 23TRIKAFTA 48tri-legest fe 34tri-linyah 34tri-lo marzia 34tri-lo-estarylla 34tri-lo-sprintec 34trilyte 38trimethoprim . 4tri-mili 34trimipramine maleate 22TRINTELLIX 22tri-previfem 34tri-sprintec 34TRIUMEQ 6trivora-28 34tri-vylibra 34tri-vylibra lo 34TROGARZO 5TROPHAMINE INJ 10% 44trospium chloride 39TRULICITY 28

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TRUMENBA 43TRUVADA TAB 100-150 6TRUVADA TAB 133-200 6TRUVADA TAB 167-250 6TRUVADA TAB 200-300 6TRUXIMA 11tulana 34TURALIO 13TWINRIX INJ 43TYBOST 5tydemy 34TYKERB 13TYMLOS 36TYPHIM VI 43unithroid 37ursodiol 38valacyclovir hcl 7VALCHLOR 51valganciclovir hcl 7valproate sodium 21valproate sodium oral soln 21valproic acid 21valsartan 15valsartan-hydrochlorothiazide 15VALTOCO 21vancomycin h cl 4VANCOMYCIN IN NACL 4vandazole 39VAQTA 43VARIVAX 43VASCEPA 16VELCADE 11velivet 34VELTASSA 31VEMLIDY 7VENCLEXTA 11VENCLEXTA STARTING PACK 11venlafaxine hcl 22VENTAVIS 19VENTOLIN HFA 48verapamil cap er 17verapamil hcl 17verapamil tab er 17VERSACLOZ 25VERZENIO 11VICTOZA 28VIDEX EC 125MG 5VIDEX PEDIATRIC 6vienva 34vigabatrin powd pack 500mg 21vigabatrin tab 500mg 21vigadrone 21

VIIBRYD STARTER PACK 22VIIBRYD TAB 22VIMPAT 21VIMPAT INJ 200MG/20ML 21VIMPAT SOL 10MG/ML 21vincristine sulfate 10vinorelbine tartrate 10viorele 34VIRACEPT 6VIREAD 6VITRAKVI 13VIVITROL 27VIZIMPRO 13voriconazole 4VOSEVI 7VOTRIENT 13VRAYLAR 25VRAYLAR THERAPY PACK 25vyfemla 34vylibra 34warfarin sodium 40water for irrigation, sterile 51wymzya fe 34XALKORI 13XARELTO 40XARELTO STARTER PACK 40XATMEP 41XELJANZ 41XELJANZ XR 41XGEVA 36XIFAXAN 38XIGDUO XR TAB 10-1000MG 30XIGDUO XR TAB 10-500MG 30XIGDUO XR TAB 2.5-1000MG 30XIGDUO XR TAB 5-1000MG 30XIGDUO XR TAB 5-500MG 30XOLAIR 49XOSPATA 13XPOVIO 100 MG ONCE WEEKLY 14XPOVIO 60 MG ONCE WEEKLY 13XPOVIO 80 MG ONCE WEEKLY 13XPOVIO 80 MG TWICE WEEKLY 14XTANDI 12xulane dis 150-35 34XULTOPHY 100/3.6 28XYREM 27YF-VAX 43yuvafem vaginal tablet 10 mcg 35zafirlukast 48zaleplon 26zarah 34ZARXIO 40

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ZEJULA 11ZELBORAF 13ZEMAIRA 49zenatane 49ZENPEP 39zidovudine cap 100mg 6zidovudine syp 50mg/5ml 6zidovudine tab 300mg 6ziprasidone hcl 25ziprasidone mesylate 25ZIRABEV 11ZIRGAN 46zoledronic acid inj 4mg/100ml 30zoledronic acid inj 5mg/100ml 30zoledronic inj 4mg/5ml 30ZOLINZA 11

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................................zolmitriptan 26zolmitriptan odt 26zolpidem tartrate 26zonisamide 21ZORTRESS TAB 0.25MG 42ZORTRESS TAB 0.5MG 42ZORTRESS TAB 0.75MG 42ZORTRESS TAB 1MG 42ZOSTAVAX 43zovia 1/35e 34ZYDELIG 13ZYKADIA 13ZYLET 45ZYPREXA RELPREVV 25ZYPREXA RELPREVV INJ 210MG 25ZYTIGA, 12

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Mercy Care Advantage (HMO SNP) Member Services Call 602‑586‑1730 or 1‑877‑436‑5288

Calls to these numbers are free. 8:00 a.m. – 8:00 p.m., 7 days a week.

Member Services also has free language interpreter services available for non-English speakers.

TTY 711 Calls to this number are free. 8:00 a.m. – 8:00 p.m., 7 days a week.

Write Mercy Care Advantage (HMO SNP) 4755 S. 44th Place Phoenix, AZ 85040

Website www.MercyCareAZ.org

This formulary was updated on 06/01/2020. For more recent information or other questions, please contact Mercy Care Advantage (HMO SNP) Member Services at 602‑586‑1730 or 1‑877‑436‑5288 or, for TTY users, 711, 8:00 a.m. – 8:00 p.m., 7 days a week, or visit www.MercyCareAZ.org.

Servicios al Miembro de Mercy Care Advantage (HMO SNP) Llame 602‑586‑1730 o 1‑877‑436‑5288

Las llamadas a estos números son gratis. 8:00 a.m. a 8:00 p.m., 7 días de la semana.

Servicios al Miembro también tiene servicios gratuitos de interpretación de idiomas disponibles para personas que no hablan inglés.

TTY 711 Las llamadas a este número son gratis. 8:00 a.m. a 8:00 p.m., 7 días de la semana.

Escriba Mercy Care Advantage (HMO SNP) 4755 S. 44th Place Phoenix, AZ 85040

Sitio Web www.MercyCareAZ.org

Este formulario fue actualizado en 06/01/2020. Para la información más reciente o para otras preguntas, por favor llame a Servicios al Miembro de Mercy Care Advantage (HMO SNP) al 602‑586‑1730 ó al 1‑877‑436‑5288, ó para los usuarios de TTY al 711, de 8:00 a.m. – 8:00 p.m., 7 días de la semana, ó visite www.MercyCareAZ.org.





Mercy Care Advantage (HMO SNP) · 2020-06-01 · Mercy Care Advantage (HMO SNP) 2020 Formulary...

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Transcript of Mercy Care Advantage (HMO SNP) · 2020-06-01 · Mercy Care Advantage (HMO SNP) 2020 Formulary...