providence medicare advantage plans .../media/files...2017/08/16 · updated the formulary, appears...

PROVIDENCE MEDICARE ADVANTAGE PLANS PRESCRIPTION DRUG FORMULARY

2018 LIST OF COVERED DRUGS

PLEASEREAD: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN

Formulary ID: 00018080, Version: 15

This formulary was updated on 8/16/2017. For more recent information or other questions, please contact Providence Health Assurance Customer Service, at 503-574-8000 or 1-800-603-2340 or, for TTY users, 711, seven days a week, between 8 a.m. and 8 p.m. (Pacific Time), or visit www.providencehealthassurance.com.

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http://www.providencehealthassurance.com/

Providence Medicare Advantage Plans

2018 Formulary

(List of Covered Drugs)

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

When this drug list (formulary) refers to "we," "us", or "our," it means Providence Health Assurance. When it refers to "plan" or "our plan," it means Providence Medicare Advantage Plans.

This document includes a list of the drugs (formulary) for our plan which is current as of 1/1/2018. For an VQEBUFE formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2019, and from time to time during the year.

The Formulary may change at any time. You will receive notice when necessary.

Providence Medicare Advantage Plans is an HMO, HMO-POS, and HMO SNP plan with a Medicare and Oregon Health Plan contract. Enrollment in Providence Medicare Advantage Plans depends on contract renewal.

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

Can the Formulary (drug list) change? Generally, if you are taking a drug on our 2018 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2018 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety.

If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug, or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug's manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of January 1, 2018. To get updated information about the drugs covered by Providence Medicare Advantage Plans, please contact us. Our contact information appears on the front and back cover pages. If we make any mid-year non-maintenance changes to the Providence Medicare Advantage Plans formulary, we will mail you a copy of the formulary changes via errata sheets to ensure that you have a complete and updated formulary.

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

Medical Condition

The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins on page 119.Then look under the category name for your drug.

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AlphabeticalListing

If you are not sure what category to look under, you should look for your drug in the Index that begins on page 98.The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

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

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

• Prior Authorization: Providence Medicare Advantage Plans requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Providence Medicare Advantage Plans before you fill your prescriptions. If you don't get approval, Providence Medicare Advantage Plans may not cover the drug.

• Quantity Limits: For certain drugs, Providence Medicare Advantage Plans limits the amount of the drug that Providence Medicare Advantage Plans will cover. For example, Providence Medicare Advantage Plans provides 1 tablet per day per prescription for simvastatin 40mg tablets. This may be in addition to a standard one-month or three-month supply.

• Step Therapy: In some cases, Providence Medicare Advantage Plans requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Providence Medicare Advantage Plans may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Providence Medicare Advantage Plans will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You can ask Providence Medicare Advantage Plans 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 the Providence Medicare Advantage Plans' formulary?" on page iv for information about how to request an exception.

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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 Customer Service and ask if your drug is covered.

If you learn that Providence Medicare Advantage Plans does not cover your drug, you have two options:

• You can ask Customer Service for a list of similar drugs that are covered by Providence MedicareAdvantage Plans. When you receive the list, show it to your doctor and ask him or her to prescribe asimilar drug that is covered by Providence Medicare Advantage Plans.

• You can ask Providence Medicare Advantage Plans to make an exception and cover your drug. Seebelow for information about how to request an exception.

How do I request an exception to the Providence Medicare Advantage Plans’ Formulary? You can ask Providence Medicare Advantage Plans to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

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

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

• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs,Providence Medicare Advantage Plans limits the amount of the drug that we will cover. If your drughas a quantity limit, you can ask us to waive the limit and cover a greater amount.

Generally, Providence Medicare Advantage Plans will only approve your request for an exception if the alternative drugs included on the plan's formulary, the lower cost-sharing drug, or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

You should contact us to ask us for an initial coverage decision for a formulary, tiering, or utilization restriction exception. When you request a formulary, tiering, or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber's supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

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What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with 93-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.

Level of care change: Day Supply For members transitioning from a SNF to LTC: 31 day supply SNF to Home (Retail): 30 day supply LTC-LTC: 31 day supply Hospital to Home (Retail): 30 day supply

For more information For more detailed information about your Providence Medicare Advantage Plans prescription drug coverage, please review your Evidence of Coverage and other plan materials.

If you have questions about Providence Medicare Advantage Plans, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov.

Providence Medicare Advantage Plans’ Formulary The formulary that begins on page 1 provides coverage information about the drugs covered by Providence Medicare Advantage Plans. If you have trouble finding your drug in the list, turn to the Index that begins on page 98.

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The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., JANUVIA®)) and generic drugs are listed in lower-case italics (e.g., captopril).

The second column of the chart lists the Drug Tier. The Drug Tier name lets you know the amount you will pay at the pharmacy.

• Tier 1 is the lowest cost share tier, and you will pay your preferred generic copay.• Tier 2 you will pay your generic drug copay• Tier 3 you will pay your preferred brand name drug copay• Tier 4 you will pay your non-preferred drug coinsurance• Tier 5 is the highest cost share tier, and you will pay your specialty coinsurance

Please note that the brand and generic status of a drug may be different during the Coverage Gap and Catastrophic Coverage Phases as determined by the Food and Drug Administration (FDA) regulatory status.

The information in the Requirements/Limits column tells you if Providence Medicare Advantage Plans has any special requirements for coverage of your drug.

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The following abbreviations may be found within the body of this document

COVERAGENOTES ABBREVIATIONS

ABBREVIATION DESCRIPTION EXPLANATION

UtilizationManagementRestrictions

PA Prior Authorization Restriction

You (or your physician) are required to get prior authorization from Providence Medicare Advantage Plans before you fill your prescription for this drug. Without prior approval, Providence Medicare Advantage Plans may not cover this drug.

QL QuantityLimit Restriction

Providence Medicare Advantage Plans limits the amount of this drug that is covered per prescription, or within a specific time frame.

ST Step Therapy Restriction

Before Providence Medicare Advantage Plans will provide coverage for this drug, you must first try another drug to treat your medical condition. This drug may only be covered if the other drug does not work for you.

Other Special Requirements for Coverage

LA Limited Access Drug

This prescription may be available only at certain pharmacies. For more information consult your Provider and Pharmacy Directory or call Customer Service at 503-574-8000 or 1-800-603-2340, seven days a week, between 8 a.m. and 8 p.m. (Pacific Time). TTY users should call 711.

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Non-discrimination Statement Providence Health Plan and Providence Health Assurance comply with applicable Federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability, or sex. Providence Health Plan and Providence Health Assurance do not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Providence Health Plan and Providence Health Assurance: x Provide free aids and services to people with disabilities to communicate effectively with us, such as:

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

formats) x Provide free language services to people whose primary language is not English, such as:

o Qualified interpreters o Information written in other languages

If you are a Medicare member who needs these services, call 503-574-8000 or 1-800-603-2340. All other members can call 503-574-7500 or 1-800-878-4445. Hearing impaired members may call our TTY line at 711.

If you believe that Providence Health Plan or Providence Health Assurance has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with our Non-discrimination Coordinator by mail:

Providence Health Plan and Providence Health Assurance Attn: Non-discrimination Coordinator

PO Box 4158

Portland, OR 97208-4158

If you need help filing a grievance, and you are a Medicare member call 503-574-8000 or 1-800- 603-2340. All other members can call 503-574-7500 or 1-800-878-4445 (TTY line at 711) for assistance. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil 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 DC 20201 1-800-368-1019, 1-800-537-7697 (TTY)

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

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Language Access Information

ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-800-603-2340 (TTY: 711).

Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-603-2340 (TTY: 711).

Chinese: 㲐シ烉⤪㝄ぐἧ䓐䷩橼ᷕ㔯ĭġぐ⎗ẍ屣䌚⼿婆妨㎜≑㚵⊁įġ婳农暣ġ1-800-603- 2340 ĩTTY: 711炸ġ

Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-603-2340 (TTY: 711).

Korean: 㨰㢌aG䚐ạ㛨⪰G㇠㟝䚌㐐⏈Gᷱ㟤SG㛬㛨G㫴㠄G㉐⽸㏘⪰Gⱨ⨀⦐G㢨㟝䚌㐘G㍌G㢼㏩⏼␘UG1-800-603-2340 �77

Punjabi: ਿਧਆਨ ਿਦਓ: ਜੇ ਤੁ ੰ ਜਾਬੀ ਬੋ ੇ ੋ ੱ ਚ ਸਹਾਇਤਾ ਸੇ ੁ ੇ ਲਈ ਮੁਸ ਪ ਲਦ ਹ, ਤ ਭਾਸ਼ਾ ਿਵ ਵਾ ਤਹਾਡ ਫਤ ਉਪਲਬਧ ਹੈ। 1-800603-2340 (TTY: 711) 'ਤੇ ਕਾਲ ਕਰੋ।

German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-800-603-2340 (TTY: 711).

Laotian: ໂປດຊາບ��ຖ້◌ າວ່◌ າ ທ່◌ ້ ◌ າພາສາ ລາວ��ການບິ◌ລການຊ່◌ ວຍເຫຼ◌ ້ ◌ານເວ ອດານພາສາ��ໂດຍ່◌ບເສັ ຽຄ າ��ແມ ນມພ ອມໃຫ ທ ານ��ໂທຣ 1-800-603-2340 (TTY: 711). ◌ ່◌ ່ ◌ ້ ◌ ້ ◌ ່◌

Romanian: ATENȚIE: Dacă vorbiți limba română, vă stau la dispoziție servicii de asistență lingvistică, gratuit. Sunați la 1-800-603-2340 (TTY: 711).

French: ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-800-603-2340 (ATS: 711).

Thai: เรียน: ถ้าคุณพดูภาษาไทยคุณสามารถใช้บริการช่วยเหลอืทางภาษาได้ฟร ี โทร 1-800-603-2340 (TTY: 711)

Persian:

��جهوتέ̱ϩΏ��ϥΏ�ϑ̱ϩα̵ Ε الΕ�̵ϥΏ�ϡε�̵έΏ �ϥ ϱ̱έ�ΕέϭιΏ ί �ˬΩ̵̭ϥ �̵ϡ�ϭ Ε̱ �̵αέϑ ί ��Ωϱέ̵ ̱Ώ �αϡΕ 1-800-603-2340 (TTY: 711) Ώ��ΩεΏ �̵ϡ�ϡϩ έϑ

Providence Medicare Advantage Plans is an HMO, HMO-POS, and HMO SNP plan with a Medicare and Oregon Health Plan contract. Enrollment in Providence Medicare Advantage Plans depends on contract renewal.

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You can find information on what the symbols and abbreviationson this table mean by going to page vii of the Introduction.

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Medicare Advantage Plans 2018 Formulary (List of Covered Drugs)

Drug Name Drug Tier Requirements/Limits

ANALGESICS

NONSTEROIDAL ANTI-INFLAMMATORY DRUGS celecoxib (50 mg capsule, 100 mg capsule, 200 mg capsule)

2-Generic QL (2 PER 1 DAYS)

celecoxib 400 mg capsule 2-Generic QL (1 PER 1 DAYS)

diclofenac potassium 2-Generic

diclofenac sodium (25 mg tablet dr, 50 mg tablet dr, 75 mg tablet dr, 100 mg tab er 24h)

2-Generic

diflunisal 2-Generic

etodolac 2-Generic

flurbiprofen 2-Generic

ibuprofen (100 mg/5ml oral susp, 400 mg tablet, 600 mg tablet, 800 mg tablet)

2-Generic

KETOPROFEN 200 MG CAP24H PEL 4-Non-Preferred Drug

QL (1 PER 1 DAYS)

KETOPROFEN 50 MG CAPSULE 4-Non-Preferred Drug

QL (6 PER 1 DAYS)

KETOPROFEN 75 MG CAPSULE 4-Non-Preferred Drug

QL (4 PER 1 DAYS)

meclofenamate sodium 2-Generic

meloxicam (7.5 mg tablet, 7.5 mg/5ml oral susp, 15 mg tablet)

2-Generic

nabumetone 2-Generic

naproxen (125 mg/5ml oral susp, 250 mg tablet, 375 mg tablet, 375 mg tablet dr, 500 mg tablet dr, 500 mg tablet)

2-Generic

naproxen sodium (275 mg tablet, 550 mg tablet)

2-Generic

piroxicam 2-Generic

sulindac 2-Generic



2

tolmetin sodium 2-Generic

OPIOID ANALGESICS, LONG-ACTING FENTANYL (12 MCG/HR PATCH TD72, 25 MCG/HR PATCH TD72, 50MCG/HR PATCH TD72, 75MCG/HR PATCH TD72, 100 MCG/HR PATCH TD72)

4-Non-Preferred Drug

QL (15 PER 30 OVER TIME)

LEVORPHANOL TARTRATE 5-Specialty

methadone hcl (5 mg/5 ml solution, 10 mg/5 ml solution)

2-Generic

methadone hcl 10 mg tablet 2-Generic QL (4 PER 1 DAYS)

METHADONE HCL 10 MG/ML VIAL 4-Non-Preferred Drug

methadone hcl 5 mg tablet 2-Generic QL (8 PER 1 DAYS)

morphine sulfate (15 mg tablet er, 30 mg tablet er)


morphine sulfate 100 mg tablet er 2-Generic QL (1 PER 1 DAYS)

morphine sulfate 60 mg tablet er 2-Generic QL (2 PER 1 DAYS)

OXYCODONE HCL (10 MG TAB ER 12H, 15 MG TAB ER 12H, 20 MG TAB ER 12H, 30 MG TAB ER 12H, 40 MG TAB ER 12H, 60 MG TAB ER 12H)

3-Preferred Brand QL (2 PER 1 DAYS)

OXYCODONE HCL 80 MG TAB ER 12H 3-Preferred Brand QL (4 PER 1 DAYS)

OXYCONTIN (10 MG TABLET, 15 MG TABLET, 20 MG TABLET, 30 MG TABLET, 40 MG TABLET, 60 MG TABLET)

3-Preferred Brand QL (2 PER 1 DAYS)

OXYCONTIN 80 MG TABLET 3-Preferred Brand QL (4 PER 1 DAYS)

TRAMADOL HCL (100 MG TBMP 24HR, 100 MG TAB ER 24H, 200 MG TBMP 24HR, 200 MG TAB ER 24H, 300 MG TAB ER 24H, 300 MG TBMP 24HR)


QL (1 PER 1 DAYS)

OPIOID ANALGESICS, SHORT-ACTING acetaminophen with codeine phosphate (120-12mg/5 solution, 300mg/12.5 solution, 300mg-30mg tablet, 300mg-60mg tablet, 300mg-15mg tablet)

2-Generic




3

ascomp with codeine 2-Generic PA FOR 65 YEARS AND OLDER

ASTRAMORPH-PF (1 MG/ML AMPUL, 1 MG/2 ML AMPULE)


butalbit/acetamin/caff/codeine 50-325-30 capsule

2-Generic PA FOR 65 YEARS AND OLDER

butalbital/aspirin/caffeine 50-325-40 capsule


BUTORPHANOL TARTRATE (1 MG/ML VIAL, 2 MG/ML VIAL)


butorphanol tartrate 10 mg/ml spray 2-Generic

codeine phosphate/butalbital/aspirin/caffeine


endocet (2.5-325 mg tablet, 5-325 tablet, 7.5-325 mg tablet)

2-Generic

endocet 10-325 mg tablet 2-Generic QL (8 PER 1 DAYS)

FENTANYL CITRATE 4-Non-Preferred Drug

PA, QL (4 PER 1 DAYS)

hydrocodone bitartrate/acetaminophen (2.5-108/5 solution, 5 mg-325mg tablet, 5-217mg/10 solution, 7.5-325/15 solution, 7.5-325 mg tablet, 10mg-325mg tablet)

2-Generic

hydromorphone hcl (1 mg/ml liquid, 2 mg tablet)

2-Generic

hydromorphone hcl 4 mg tablet 2-Generic QL (8 PER 1 DAYS)

hydromorphone hcl 8 mg tablet 2-Generic QL (4 PER 1 DAYS)

HYDROMORPHONE HCL/PF 4-Non-Preferred Drug

LAZANDA 4-Non-Preferred Drug

PA

lorcet 2-Generic

lorcet hd 2-Generic

lorcet plus 7.5-325 mg tablet 2-Generic

lortab (5-325 mg tablet, 7.5-325 mg tablet, 10-325 mg tablet)

2-Generic




4

morphine sulfate (10 mg/5 ml solution, 20 mg/5 ml solution)

2-Generic

MORPHINE SULFATE (2 MG/ML CARTRIDGE, 2 MG/ML SYRINGE, 4 MG/ML SYRINGE, 4 MG/ML CARTRIDGE)


morphine sulfate 100 mg/5ml solution 2-Generic QL (6 ML PER 1 DAYS)

morphine sulfate 15 mg tablet 2-Generic QL (8 PER 1 DAYS)

morphine sulfate 30 mg tablet 2-Generic QL (4 PER 1 DAYS)

MORPHINE SULFATE/PF (0.5 MG/ML VIAL, 1 MG/ML VIAL)


oxycodone hcl (5 mg/5 ml solution, 5 mg capsule, 5 mg tablet)

2-Generic

oxycodone hcl 10 mg tablet 2-Generic QL (8 PER 1 DAYS)




oxycodone hcl/acetaminophen (2.5-325 mg tablet, 5-325/5 ml solution, 5 mg-325mg tablet, 7.5-325 mg tablet)

2-Generic

oxycodone hcl/acetaminophen 10mg-325mg tablet


oxycodone hcl/aspirin 2-Generic

oxymorphone hcl 10 mg tablet 2-Generic QL (4 PER 1 DAYS)

oxymorphone hcl 5 mg tablet 2-Generic QL (8 PER 1 DAYS)

roxicet 2-Generic

tramadol hcl 50 mg tablet 2-Generic QL (8 PER 1 DAYS)

tramadol hcl/acetaminophen 2-Generic QL (10 PER 1 DAYS)


ANESTHETICS

LOCAL ANESTHETICS glydo 2-Generic



5

LIDOCAINE 5 % ADH. PATCH 4-Non-Preferred Drug


LIDOCAINE 5 % OINT. (G) 4-Non-Preferred Drug

PA TO CONFIRM PART D COVERAGE

lidocaine hcl (2 % jelly(ml), 2 % solution, 2 % jel/pf app, 40 mg/ml solution)

2-Generic

LIDOCAINE HCL (5 MG/ML VIAL, 20 MG/ML VIAL)


LIDOCAINE HCL/PF (5 MG/ML VIAL, 20 MG/ML AMPUL, 20 MG/ML VIAL)



ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS

ALCOHOL DETERRENTS/ANTI-CRAVING acamprosate calcium 2-Generic

disulfiram 2-Generic

naltrexone hcl 2-Generic

revia 2-Generic

OPIOID DEPENDENCE TREATMENTS BUPRENORPHINE HCL (0.3 MG/ML VIAL, 0.3 MG/ML SYRINGE)


buprenorphine hcl (2 mg tab subl, 8 mg tab subl)


buprenorphine hcl/naloxone hcl 2-Generic QL (3 PER 1 DAYS)

OPIOID REVERSAL AGENTS naloxone hcl 2-Generic

NARCAN 4-Non-Preferred Drug


SMOKING CESSATION AGENTS buproban 2-Generic

bupropion hcl 150 mg tab er 12h 2-Generic

CHANTIX 3-Preferred Brand



6

NICOTROL 4-Non-Preferred Drug

NICOTROL NS 4-Non-Preferred Drug


ANTIBACTERIALS

AMINOGLYCOSIDES garamycin 2-Generic

gentak 2-Generic

gentamicin sulfate (0.1 % oint. (g), 0.1 % cream (g), 0.3 % oint. (g), 0.3 % drops)

2-Generic

GENTAMICIN SULFATE (20 MG/2 ML VIAL, 40 MG/ML VIAL)


GENTAMICIN SULFATE/PF 4-Non-Preferred Drug

neomycin sulfate 2-Generic

paromomycin sulfate 2-Generic

STREPTOMYCIN SULFATE 4-Non-Preferred Drug

tobramycin 2-Generic

TOBRAMYCIN SULFATE (1.2 G VIAL, 10 MG/ML VIAL, 40 MG/ML VIAL)


ANTIBACTERIALS, OTHER BACIIM 4-Non-Preferred

Drug

bacitracin 500 unit/g oint. (g) 2-Generic

BACITRACIN 50000 UNIT VIAL 4-Non-Preferred Drug

CHLORAMPHENICOL SOD SUCCINATE 4-Non-Preferred Drug

CLEOCIN PHOS 300 MG/2ML ADDVAN 4-Non-Preferred Drug



7

clindacin etz 1% pledget 2-Generic

clindacin p 2-Generic

clindacin pac 2-Generic

clindamycin hcl 2-Generic

clindamycin palmitate hcl 2-Generic

CLINDAMYCIN PHOSPHATE (1 % FOAM, 150 MG/ML VIAL, 300 MG/2ML VIAL PORT, 600 MG/4ML VIAL PORT, 900MG/6ML VIAL PORT)


clindamycin phosphate (1 % lotion, 1 % gel (gram), 1 % med. swab, 1 % solution, 2 % cream/appl)

2-Generic

CLINDAMYCIN PHOSPHATE IN 0.9 % SODIUM CHLORIDE


CLINDAMYCIN PHOSPHATE/DEXTROSE 5 % IN WATER


COLISTIN (AS COLISTIMETHATE SODIUM)


DALVANCE 5-Specialty PA

DAPTOMYCIN 5-Specialty

erythromycin base/benzoyl peroxide 2-Generic

LINEZOLID (100 MG/5ML SUSP RECON, 600MG/300 IV SOLN, 600 MG TABLET)

5-Specialty

LINEZOLID IN 0.9 % SODIUM CHLORIDE 5-Specialty

methenamine hippurate 2-Generic

metronidazole (0.75 % gel w/appl, 250 mg tablet, 375 mg capsule, 500 mg tablet)

2-Generic

METRONIDAZOLE IN SODIUM CHLORIDE


MONUROL 4-Non-Preferred Drug

mupirocin 2% ointment 2-Generic

NITROFURANTOIN 4-Non-Preferred Drug




8

nitrofurantoin macrocrystal (50 mg capsule, 100 mg capsule)

2-Generic

nitrofurantoin monohydrate/macrocrystals

2-Generic

ORBACTIV 5-Specialty PA

SIVEXTRO 5-Specialty PA

SYNERCID 5-Specialty

TIGECYCLINE 4-Non-Preferred Drug

tinidazole 2-Generic

trimethoprim 2-Generic

VANCOMYCIN HCL 4-Non-Preferred Drug

VANCOMYCIN HCL/DEXTROSE 5 % IN WATER


VANCOMYCIN IN 0.9 % SODIUM CHLORIDE (VANCOMYCIN/0.9 % 750MG/.15L FROZ.PIGGY, VANCOMYCIN/0.9 % 500MG/100 ML FROZ.PIGGY)


vandazole 2-Generic

XIFAXAN 200 MG TABLET 3-Preferred Brand PA, QL (3 PER 1 DAYS)

XIFAXAN 550 MG TABLET 5-Specialty PA, QL (2 PER 1 DAYS)

BETA-LACTAM, CEPHALOSPORINS AVYCAZ 5-Specialty

CEDAX (180 MG/5 ML SUSPENSION, 400 MG CAPSULE)


cefaclor (125 mg/5ml susp recon, 250 mg/5ml susp recon, 250 mg capsule, 375 mg/5ml susp recon, 500 mg capsule)

2-Generic

cefadroxil (1 g tablet, 250 mg/5ml susp recon, 500 mg capsule, 500 mg/5ml susp recon)

2-Generic




9

CEFAZOLIN SODIUM 4-Non-Preferred Drug

cefdinir (125 mg/5ml susp recon, 250 mg/5ml susp recon, 300 mg capsule)

2-Generic

CEFEPIME HCL 4-Non-Preferred Drug

CEFEPIME HCL IN DEXTROSE 5 % IN WATER


CEFOTAXIME SODIUM 4-Non-Preferred Drug

CEFOTETAN DISODIUM 4-Non-Preferred Drug

CEFOXITIN SODIUM 4-Non-Preferred Drug

cefpodoxime proxetil (50 mg/5 ml susp recon, 100 mg tablet, 100 mg/5ml susp recon, 200 mg tablet)

2-Generic

cefprozil (125 mg/5ml susp recon, 250 mg tablet, 250 mg/5ml susp recon, 500 mg tablet)

2-Generic

CEFTAZIDIME 4-Non-Preferred Drug

CEFTIBUTEN (180 MG/5ML SUSP RECON, 400 MG CAPSULE)


CEFTRIAXONE SODIUM 4-Non-Preferred Drug

CEFTRIAXONE SODIUM IN ISO-OSMOTIC DEXTROSE (1 G/50 ML PIGGYBACK, 1 G/50 ML FROZ.PIGGY, 2 G/50 ML PIGGYBACK, 2 G/50 ML FROZ.PIGGY)


cefuroxime axetil 2-Generic

CEFUROXIME SODIUM 4-Non-Preferred Drug

cephalexin (125 mg/5ml susp recon, 250 mg tablet, 250 mg capsule, 250 mg/5ml susp recon, 500 mg tablet, 500 mg capsule)

2-Generic




10

TAZICEF 4-Non-Preferred Drug

ZERBAXA 5-Specialty

BETA-LACTAM, OTHER AZTREONAM 4-Non-Preferred

Drug

DORIBAX 500 MG VIAL 4-Non-Preferred Drug

DORIPENEM 4-Non-Preferred Drug

imipenem/cilastatin sodium 2-Generic

INVANZ 1 GM VIAL 4-Non-Preferred Drug

MEROPENEM 4-Non-Preferred Drug

MEROPENEM IN 0.9 % SODIUM CHLORIDE


BETA-LACTAM, PENICILLINS amoxicillin (125 mg tab chew, 125 mg/5ml susp recon, 200 mg/5ml susp recon, 250 mg capsule, 250 mg tab chew, 250 mg/5ml susp recon, 400 mg/5ml susp recon, 500 mg tablet, 500 mg capsule, 875 mg tablet)

2-Generic

amoxicillin/potassium clavulanate (200-28.5mg tab chew, 200-28.5/5 susp recon, 250-125 mg tablet, 250-62.5/5 susp recon, 400-57mg tab chew, 400-57mg/5 susp recon, 500-125 mg tablet, 600-42.9/5 susp recon, 875-125 mg tablet, 1000-62.5 tab er 12h)

2-Generic

AMPICILLIN SODIUM 4-Non-Preferred Drug

AMPICILLIN SODIUM/SULBACTAM SODIUM


ampicillin trihydrate (125 mg/5ml susp recon, 250 mg capsule, 250 mg/5ml susp recon, 500 mg capsule)

2-Generic




11

BICILLIN C-R 4-Non-Preferred Drug

BICILLIN L-A 4-Non-Preferred Drug

dicloxacillin sodium 2-Generic

NAFCILLIN SODIUM (1 G VIAL, 1 G VIAL PORT, 2 G VIAL, 10 G VIAL)


OXACILLIN SODIUM 4-Non-Preferred Drug

OXACILLIN SODIUM IN ISO-OSMOTIC DEXTROSE


PENICILLIN G POTASSIUM 4-Non-Preferred Drug

PENICILLIN G PROCAINE 1.2MM/2 ML SYRINGE


PENICILLIN G SODIUM 4-Non-Preferred Drug

penicillin v potassium (125 mg/5ml soln recon, 250 mg tablet, 250 mg/5ml soln recon, 500 mg tablet)

2-Generic

PFIZERPEN 4-Non-Preferred Drug

PIPERACILLIN SODIUM/TAZOBACTAM SODIUM


MACROLIDES AZASITE 4-Non-Preferred

Drug

azithromycin (100 mg/5ml susp recon, 200 mg/5ml susp recon, 250 mg tablet, 500 mg tablet, 600 mg tablet)

2-Generic

AZITHROMYCIN (500 MG VIAL PORT, 500 MG VIAL)


clarithromycin (125 mg/5ml susp recon, 250 mg/5ml susp recon, 250 mg tablet, 500 mg tab er 24h, 500 mg tablet)

2-Generic

E.E.S. 400 4-Non-Preferred Drug




12

ery 2-Generic

ERY-TAB 4-Non-Preferred Drug

erygel 2-Generic

ERYTHROCIN LACTOBIONATE (500 MG VIAL, 500 MG ADDVNT VL)


ERYTHROCIN STEARATE 4-Non-Preferred Drug

ERYTHROMYCIN BASE (250 MG TABLET, 500 MG TABLET)


erythromycin base 5 mg/gram oint. (g) 2-Generic

erythromycin base/ethyl alcohol (2 % med. swab, 2 % solution, 2 % gel (gram))

2-Generic

ERYTHROMYCIN ETHYLSUCCINATE (200 MG/5ML SUSP RECON, 400 MG TABLET)


QUINOLONES AVELOX IV 4-Non-Preferred

Drug

ciprofloxacin hcl (0.2 % droperette, 0.3 % drops, 100 mg tablet, 250 mg tablet, 500 mg tablet, 750 mg tablet)

2-Generic

CIPROFLOXACIN LACTATE 4-Non-Preferred Drug

CIPROFLOXACIN LACTATE/DEXTROSE 5 % IN WATER


ciprofloxacin/ciprofloxacin hcl 2-Generic

GATIFLOXACIN 4-Non-Preferred Drug

levofloxacin (0.5 % drops, 250mg/10ml solution, 250 mg tablet, 500 mg tablet, 500mg/20ml solution, 750 mg tablet)

2-Generic

LEVOFLOXACIN 25 MG/ML VIAL 4-Non-Preferred Drug

LEVOFLOXACIN/DEXTROSE 5 % IN WATER





13

moxifloxacin hcl 400 mg tablet 2-Generic

MOXIFLOXACIN HCL IN SODIUM ACETATE AND SULFATE,WATER,ISO-OSM


ofloxacin (0.3 % drops, 300 mg tablet, 400 mg tablet)

2-Generic

VIGAMOX 3-Preferred Brand

SULFONAMIDES bleph-10 2-Generic

silver sulfadiazine 2-Generic

sulfacetamide sodium (10 % drops, 10 % suspension, 10 % oint. (g))

2-Generic

sulfadiazine 2-Generic

sulfamethoxazole/trimethoprim (200-40mg/5 oral susp, 400mg-80mg tablet, 800-160/20 oral susp, 800-160 mg tablet)

2-Generic

SULFAMETHOXAZOLE/TRIMETHOPRIM 80-16MG/ML VIAL


sulfamide 2-Generic

TETRACYCLINES avidoxy 2-Generic

DEMECLOCYCLINE HCL 4-Non-Preferred Drug

DOXY 100 4-Non-Preferred Drug

doxycycline hyclate (20 mg tablet, 50 mg capsule, 100 mg capsule, 100 mg tablet)

2-Generic

DOXYCYCLINE HYCLATE 100 MG VIAL 4-Non-Preferred Drug

doxycycline monohydrate (25 mg/5 ml susp recon, 50 mg capsule, 50 mg tablet, 75 mg tablet, 100 mg tablet, 100 mg capsule, 150 mg tablet)

2-Generic




14

dynacin (50 mg tablet, 100 mg tablet) 2-Generic

minocycline hcl (50 mg tablet, 50 mg capsule, 75 mg capsule, 75 mg tablet, 100 mg capsule, 100 mg tablet)

2-Generic

mondoxyne nl (nl 50 mg capsule, nl 100 mg capsule)

2-Generic

morgidox (50 mg capsule, 100 mg capsule)

2-Generic

TETRACYCLINE HCL 4-Non-Preferred Drug


ANTICONVULSANTS

ANTICONVULSANTS, OTHER BRIVIACT (10 MG TABLET, 25 MG TABLET, 50 MG TABLET, 75 MG TABLET, 100 MG TABLET)

5-Specialty QL (2 PER 1 DAYS)

BRIVIACT (10 MG/ML ORAL SOLN, 50 MG/5 ML VIAL)


levetiracetam (100 mg/ml solution, 250 mg tablet, 500 mg tab er 24h, 500 mg/5ml solution, 500 mg tablet, 750 mg tab er 24h, 750 mg tablet, 1000 mg tablet)

2-Generic

LEVETIRACETAM 500 MG/5ML VIAL 4-Non-Preferred Drug

LEVETIRACETAM IN SODIUM CHLORIDE, ISO-OSMOTIC


POTIGA 4-Non-Preferred Drug

roweepra 2-Generic

SPRITAM 4-Non-Preferred Drug

PA FOR NEW STARTS ONLY

CALCIUM CHANNEL MODIFYING AGENTS CELONTIN 4-Non-Preferred

Drug



15

ethosuximide (250 mg/5ml solution, 250 mg capsule)

2-Generic

zonisamide 2-Generic

GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS DIASTAT 3-Preferred Brand

DIAZEPAM (2.5 MG KIT, 5-7.5-10MG KIT, 12.5-15-20 KIT)

3-Preferred Brand

divalproex sodium 2-Generic

gabapentin (100 mg capsule, 250 mg/5ml solution, 300 mg capsule, 300 mg/6ml solution, 400 mg capsule, 600 mg tablet, 800 mg tablet)

2-Generic

GABITRIL (12 MG TABLET, 16 MG TABLET)


ONFI (10 MG TABLET, 20 MG TABLET) 5-Specialty PA FOR NEW STARTS ONLY, QL (2 PER 1 DAYS)

ONFI 2.5 MG/ML SUSPENSION 4-Non-Preferred Drug


phenobarbital (15 mg tablet, 16.2 mg tablet, 20 mg/5 ml elixir, 30 mg tablet, 32.4 mg tablet, 60 mg tablet, 64.8 mg tablet, 97.2mg tablet, 100 mg tablet)

2-Generic PA FOR NEW STARTS ONLY AND FOR 65 YEARS AND OLDER

primidone 2-Generic

SABRIL 5-Specialty LA

tiagabine hcl 2-Generic

valproic acid 2-Generic

valproic acid (as sodium salt) (valproate sodium) (salt) 250 mg/5ml solution, salt) 500mg/10ml solution)

2-Generic

VALPROIC ACID (AS SODIUM SALT) 500 MG/5ML VIAL


GLUTAMATE REDUCING AGENTS felbamate (400 mg tablet, 600 mg tablet, 600 mg/5ml oral susp)

2-Generic




16

FYCOMPA (0.5 MG/ML ORAL SUSP, 2 MG TABLET, 4 MG TABLET, 6 MG TABLET, 8 MG TABLET, 10 MG TABLET, 12 MG TABLET)



LAMICTAL (BLUE) 4-Non-Preferred Drug

LAMICTAL (GREEN) 4-Non-Preferred Drug

LAMICTAL (ORANGE) 4-Non-Preferred Drug

LAMICTAL XR (BLUE) 4-Non-Preferred Drug

LAMICTAL XR (GREEN) 4-Non-Preferred Drug

LAMICTAL XR (ORANGE) 4-Non-Preferred Drug

lamotrigine (5 mg tb chw dsp, 25 mg tablet, 25 mg tab er 24, 25mg (35) tab ds pk, 25 mg tb chw dsp, 50 mg tab er 24, 100 mg tab er 24, 100 mg tablet, 150 mg tablet, 200 mg tablet, 200 mg tab er 24, 250 mg tab er 24, 300 mg tab er 24)

2-Generic

topiramate (15 mg cap sprink, 25 mg cap sprink, 25 mg tablet, 50 mg tablet, 100 mg tablet, 200 mg tablet)

2-Generic

topiramate (25 mg cap spr 24, 50 mg cap spr 24, 100 mg cap spr 24, 150 mg cap spr 24, 200 mg cap spr 24)

2-Generic PA FOR NEW STARTS ONLY

SODIUM CHANNEL AGENTS APTIOM 4-Non-Preferred

Drug

BANZEL (40 MG/ML SUSPENSION, 200 MG TABLET, 400 MG TABLET)





17

carbamazepine (100 mg tab er 12h, 100 mg cpmp 12hr, 100 mg tab chew, 100 mg/5ml oral susp, 200 mg tablet, 200 mg tab er 12h, 200 mg cpmp 12hr, 300 mg cpmp 12hr, 400 mg tab er 12h)

2-Generic

DILANTIN 30 MG CAPSULE 4-Non-Preferred Drug

epitol 2-Generic

FOSPHENYTOIN SODIUM 4-Non-Preferred Drug

oxcarbazepine (150 mg tablet, 300 mg tablet, 300 mg/5ml oral susp, 600 mg tablet)

2-Generic

PEGANONE 4-Non-Preferred Drug

phenytoin (50 mg tab chew, 100 mg/4ml oral susp, 125 mg/5ml oral susp)

2-Generic

PHENYTOIN SODIUM (50 MG/ML VIAL, 50 MG/ML AMPUL)


phenytoin sodium extended 2-Generic

VIMPAT (10 MG/ML SOLUTION, 50 MG TABLET, 100 MG TABLET, 150 MG TABLET, 200 MG/20 ML VIAL, 200 MG TABLET)



ANTIDEMENTIA AGENTS

CHOLINESTERASE INHIBITORS donepezil hcl (5 mg tab rapdis, 5 mg tablet, 10 mg tablet, 10 mg tab rapdis)

2-Generic

DONEPEZIL HCL 23 MG TABLET 4-Non-Preferred Drug

galantamine hbr (4 mg tablet, 4 mg/ml solution, 8 mg cap24h pel, 8 mg tablet, 12 mg tablet, 16 mg cap24h pel, 24 mg cap24h pel)

2-Generic

RIVASTIGMINE 4-Non-Preferred Drug

QL (1 PER 1 DAYS)



18

rivastigmine tartrate 2-Generic QL (2 PER 1 DAYS)

N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST memantine hcl (5 mg tablet, 10 mg tablet)


memantine hcl 2 mg/ml solution 2-Generic QL (12 ML PER 1 DAYS)

memantine hcl 5 mg-10 mg tab ds pk 2-Generic

NAMENDA XR (7 MG CAPSULE, 14 MG CAPSULE, 21 MG CAPSULE, 28 MG CAPSULE)



NAMENDA XR TITRATION PACK 4-Non-Preferred Drug

PA


ANTIDEPRESSANTS

ANTIDEPRESSANTS, OTHER budeprion sr 2-Generic

bupropion hcl (75 mg tablet, 100 mg tablet, 100 mg tab er 12h, 150 mg tab er 24h, 200 mg tab er 12h, 300 mg tab er 24h)

2-Generic

mirtazapine odt (15 mg, 45 mg, 30 mg) 2-Generic

mirtazapine tablet (15 mg, 45 mg, 7.5 mg, 30mg)

2-Generic

olanzapine/fluoxetine hcl 2-Generic

perphenazine/amitriptyline hcl 2-Generic

MONOAMINE OXIDASE INHIBITORS EMSAM 5-Specialty

MARPLAN 4-Non-Preferred Drug

phenelzine sulfate 2-Generic

TRANYLCYPROMINE SULFATE 4-Non-Preferred Drug



19

SSRIS/SNRIS (SELECTIVE SEROTONIN REUPTAKE INHIBITOR/SEROTONIN AND NOREPINEPHRINE REUPTAKE INHIBITOR)

citalopram hydrobromide (10 mg tablet, 10 mg/5 ml solution, 20 mg tablet, 40 mg tablet)

2-Generic

DESVENLAFAXINE 4-Non-Preferred Drug

PA FOR NEW STARTS ONLY, QL (1 PER 1 DAYS)

DESVENLAFAXINE FUMARATE 4-Non-Preferred Drug


DESVENLAFAXINE SUCCINATE 4-Non-Preferred Drug


escitalopram oxalate (5 mg tablet, 5 mg/5 ml solution, 10 mg tablet, 20 mg tablet)

2-Generic

FETZIMA 4-Non-Preferred Drug


fluoxetine hcl (10 mg tablet, 10 mg capsule, 20 mg tablet, 20 mg/5 ml solution, 20 mg capsule, 40 mg capsule, 60 mg tablet, 90 mg capsule dr)

2-Generic

fluvoxamine maleate (25 mg tablet, 50 mg tablet, 100 mg tablet)

2-Generic

maprotiline hcl 2-Generic

nefazodone hcl 2-Generic

paroxetine hcl (10 mg tablet, 20 mg tablet, 30 mg tablet, 40 mg tablet)

2-Generic

PAXIL 10 MG/5 ML SUSPENSION 4-Non-Preferred Drug

sertraline hcl (20 mg/ml oral conc, 25 mg tablet, 50 mg tablet, 100 mg tablet)

2-Generic

trazodone hcl 2-Generic

TRINTELLIX 4-Non-Preferred Drug





20

venlafaxine hcl (25 mg tablet, 37.5 mg cap er 24h, 37.5 mg tablet, 50 mg tablet, 75 mg cap er 24h, 75 mg tablet, 100 mg tablet, 150 mg cap er 24h)

2-Generic

VENLAFAXINE HCL (37.5 MG TAB ER 24, 75 MG TAB ER 24, 150 MG TAB ER 24, 225 MG TAB ER 24)


QL (1 PER 1 DAYS)

VIIBRYD 4-Non-Preferred Drug


TRICYCLICS amitriptyline hcl 2-Generic

amoxapine 2-Generic

clomipramine hcl 2-Generic

desipramine hcl 2-Generic

imipramine hcl 2-Generic

imipramine pamoate 2-Generic

nortriptyline hcl (10 mg/5 ml solution, 10 mg capsule, 25 mg capsule, 50 mg capsule, 75 mg capsule)

2-Generic

protriptyline hcl 2-Generic

TRIMIPRAMINE MALEATE 4-Non-Preferred Drug


ANTIEMETICS

ANTIEMETICS, OTHER COMPRO 4-Non-Preferred

Drug

meclizine hcl (12.5 mg tablet, 25 mg tablet)

2-Generic

metoclopramide hcl (5 mg tablet, 5 mg/5 ml solution, 10 mg tablet)

2-Generic

METOCLOPRAMIDE HCL 5 MG/ML VIAL 4-Non-Preferred Drug

perphenazine 2-Generic



21

PROCHLORPERAZINE 4-Non-Preferred Drug

PROCHLORPERAZINE EDISYLATE 4-Non-Preferred Drug

prochlorperazine maleate 2-Generic

EMETOGENIC THERAPY ADJUNCTS AKYNZEO 4-Non-Preferred

Drug QL (4 PER 28 OVER TIME)

APREPITANT 125 MG CAPSULE 4-Non-Preferred Drug


APREPITANT 125MG-80MG CAP DS PK 4-Non-Preferred Drug






DRONABINOL 4-Non-Preferred Drug

PA

EMEND 125 MG POWDER PACKET 4-Non-Preferred Drug


GRANISETRON HCL 1 MG TABLET 4-Non-Preferred Drug

QL (2 PER 1 DAYS)

ondansetron 2-Generic

ondansetron hcl (4 mg/5 ml solution, 4 mg tablet, 8 mg tablet, 24 mg tablet)

2-Generic

ONDANSETRON HCL 2 MG/ML VIAL 4-Non-Preferred Drug

ONDANSETRON HCL/PF 4-Non-Preferred Drug

VARUBI 4-Non-Preferred Drug





22


ANTIFUNGALS

ANTIFUNGALS ABELCET 4-Non-Preferred

Drug PA TO CONFIRM PART D COVERAGE

AMBISOME 4-Non-Preferred Drug


AMPHOTERICIN B 4-Non-Preferred Drug


CANCIDAS 5-Specialty

CASPOFUNGIN ACETATE 5-Specialty

ciclodan (0.77% cream, 8% solution) 2-Generic

ciclopirox (0.77 % gel (gram), 1 % shampoo, 8 % solution)

2-Generic

ciclopirox olamine (0.77 % cream (g), 0.77 % suspension)

2-Generic

clotrimazole (1 % cream (g), 1 % solution)

2-Generic

CLOTRIMAZOLE 10 MG TROCHE 4-Non-Preferred Drug

ECONAZOLE NITRATE 4-Non-Preferred Drug

fluconazole (10 mg/ml susp recon, 40 mg/ml susp recon, 50 mg tablet, 100 mg tablet, 150 mg tablet, 200 mg tablet)

2-Generic

FLUCONAZOLE IN DEXTROSE, ISO-OSMOTIC


FLUCONAZOLE IN SODIUM CHLORIDE, ISO-OSMOTIC


FLUCYTOSINE 5-Specialty

GRISEOFULVIN ULTRAMICROSIZE 4-Non-Preferred Drug

GRISEOFULVIN, MICROSIZE (125 MG/5ML ORAL SUSP, 500 MG TABLET)




23

ITRACONAZOLE 4-Non-Preferred Drug

ketoconazole (2 % cream (g), 2 % foam, 2 % shampoo)

2-Generic

ketodan 2-Generic

miconazole nitrate 200 mg supp.vag 2-Generic

NATACYN 4-Non-Preferred Drug

NOXAFIL (40 MG/ML SUSPENSION, DR 100 MG TABLET)


PA

nyamyc 2-Generic

nyata 2-Generic

nystatin (50mm unit powder(ea), 150mm unit powder(ea), 500mm unit powder(ea), 500k unit tablet, 100000/ml oral susp, 100000/g powder, 100000/g cream (g), 100000/g oint. (g))

2-Generic

NYSTATIN/TRIAMCINOLONE ACETONIDE


nystop 2-Generic

terbinafine hcl 250 mg tablet 2-Generic

terconazole (0.4 % cream/appl, 0.8 % cream/appl, 80 mg supp.vag)

2-Generic

VORICONAZOLE (50 MG TABLET, 200 MG TABLET, 200 MG VIAL, 200 MG/5ML SUSP RECON)


PA


ANTIGOUT AGENTS

ANTIGOUT AGENTS allopurinol 2-Generic

COLCHICINE 0.6 MG TABLET 3-Preferred Brand

COLCRYS 3-Preferred Brand

probenecid 2-Generic



24

probenecid/colchicine 2-Generic

ULORIC 4-Non-Preferred Drug

PA

ZURAMPIC 4-Non-Preferred Drug

PA


ANTIMIGRAINE AGENTS

ERGOT ALKALOIDS cafergot 2-Generic QL (40 PER 28 OVER TIME)

DIHYDROERGOTAMINE MESYLATE (1 MG/ML AMPUL, 1 MG/ML VIAL)


QL (24 ML PER 28 OVER TIME)

DIHYDROERGOTAMINE MESYLATE 0.5MG/SPRY SPRAY/PUMP

5-Specialty QL (8 ML PER 30 OVER TIME)

ergotamine tartrate/caffeine 2-Generic QL (40 PER 28 OVER TIME)

MIGERGOT 4-Non-Preferred Drug


MIGRANAL 5-Specialty QL (8 ML PER 30 OVER TIME)

SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS NARATRIPTAN HCL 4-Non-Preferred

Drug QL (9 PER 30 OVER TIME)

rizatriptan benzoate 2-Generic QL (12 PER 30 OVER TIME)

sumatriptan succinate (25 mg tablet, 50 mg tablet, 100 mg tablet)

2-Generic QL (9 PER 30 OVER TIME)

SUMATRIPTAN SUCCINATE (4 MG/0.5ML PEN INJCTR, 4 MG/0.5ML CARTRIDGE, 6 MG/0.5ML PEN INJCTR, 6 MG/0.5ML SYRINGE, 6 MG/0.5ML CARTRIDGE, 6 MG/0.5ML VIAL)



ZOLMITRIPTAN 4-Non-Preferred Drug

ST, QL (9 PER 30 OVER TIME)



25


ANTIMYASTHENIC AGENTS

PARASYMPATHOMIMETICS guanidine hcl 2-Generic

MESTINON 60 MG/5 ML SYRUP 3-Preferred Brand

pyridostigmine bromide 2-Generic

ANTIMYCOBACTERIALS

ANTIMYCOBACTERIALS, OTHER dapsone 2-Generic

RIFABUTIN 4-Non-Preferred Drug

ANTITUBERCULARS CAPASTAT SULFATE 4-Non-Preferred

Drug

cycloserine 2-Generic

ethambutol hcl 2-Generic

isoniazid (50 mg/5 ml solution, 100 mg tablet, 300 mg tablet)

2-Generic

ISONIAZID 100 MG/ML VIAL 4-Non-Preferred Drug

PASER 4-Non-Preferred Drug

PRIFTIN 4-Non-Preferred Drug

pyrazinamide 2-Generic

rifampin (150 mg capsule, 300 mg capsule)

2-Generic

RIFAMPIN 600 MG VIAL 4-Non-Preferred Drug

RIFATER 4-Non-Preferred Drug



26

SIRTURO 5-Specialty LA

TRECATOR 4-Non-Preferred Drug


ANTINEOPLASTICS

ALKYLATING AGENTS CEENU 4-Non-Preferred

Drug

CYCLOPHOSPHAMIDE CAPSULES (25 MG, 50 MG)

3-Preferred Brand PA TO CONFIRM PART D COVERAGE

GLEOSTINE 4-Non-Preferred Drug

HEXALEN 5-Specialty

LEUKERAN 3-Preferred Brand

LOMUSTINE 4-Non-Preferred Drug

MATULANE 5-Specialty LA

VALCHLOR 5-Specialty LA

ANTIANDROGENS bicalutamide 2-Generic

flutamide 2-Generic

NILUTAMIDE 5-Specialty

XTANDI 5-Specialty PA FOR NEW STARTS ONLY, LA

ZYTIGA 5-Specialty PA FOR NEW STARTS ONLY

ANTIANGIOGENIC AGENTS POMALYST 5-Specialty PA FOR NEW STARTS ONLY, LA

REVLIMID 5-Specialty PA FOR NEW STARTS ONLY, LA

THALOMID 5-Specialty

ANTIESTROGENS/MODIFIERS EMCYT 4-Non-Preferred

Drug



27

FARESTON 5-Specialty

FASLODEX 5-Specialty PA FOR NEW STARTS ONLY

SOLTAMOX 4-Non-Preferred Drug

tamoxifen citrate 2-Generic

ANTIMETABOLITES ALIMTA 5-Specialty

DROXIA 4-Non-Preferred Drug

fluorouracil (2 % solution, 5 % solution, 5 % cream (g))

2-Generic

hydroxyurea 2-Generic

mercaptopurine 2-Generic

PURIXAN 4-Non-Preferred Drug

TABLOID 4-Non-Preferred Drug

ANTINEOPLASTICS, OTHER ALUNBRIG 5-Specialty PA FOR NEW STARTS ONLY

AMIFOSTINE CRYSTALLINE 4-Non-Preferred Drug

BCG LIVE 3-Preferred Brand

leucovorin calcium (5 mg tablet, 10 mg tablet, 15 mg tablet, 25 mg tablet)

2-Generic

LEUCOVORIN CALCIUM (50 MG VIAL, 100 MG VIAL, 200 MG VIAL, 350 MG VIAL, 500 MG VIAL)


LONSURF 15 MG-6.14 MG TABLET 5-Specialty PA FOR NEW STARTS ONLY, LA, QL (100 PER 28 OVER TIME)

LONSURF 20 MG-8.19 MG TABLET 5-Specialty PA FOR NEW STARTS ONLY, LA, QL (80 PER 28 OVER TIME)

LYSODREN 3-Preferred Brand

mitoxantrone hcl 2-Generic




28

NINLARO 5-Specialty PA FOR NEW STARTS ONLY

PROLEUKIN 5-Specialty

RUBRACA 5-Specialty PA FOR NEW STARTS ONLY, LA

RYDAPT 5-Specialty PA FOR NEW STARTS ONLY

SYLATRON 5-Specialty PA FOR NEW STARTS ONLY

SYLATRON 4-PACK 5-Specialty PA FOR NEW STARTS ONLY

SYNRIBO 5-Specialty PA FOR NEW STARTS ONLY

TRISENOX 4-Non-Preferred Drug

ZOLINZA 5-Specialty PA FOR NEW STARTS ONLY

AROMATASE INHIBITORS, 3RD GENERATION anastrozole 2-Generic

EXEMESTANE 4-Non-Preferred Drug

letrozole 2-Generic

ENZYME INHIBITORS etoposide 20 mg/ml vial 2-Generic

toposar 2-Generic

topotecan hcl 4 mg vial 2-Generic

MOLECULAR TARGET INHIBITORS AFINITOR 5-Specialty PA FOR NEW STARTS ONLY

AFINITOR DISPERZ 5-Specialty PA FOR NEW STARTS ONLY

ALECENSA 5-Specialty PA FOR NEW STARTS ONLY

BOSULIF 5-Specialty PA FOR NEW STARTS ONLY

CABOMETYX 5-Specialty PA FOR NEW STARTS ONLY

CAPRELSA 5-Specialty PA FOR NEW STARTS ONLY, LA

COMETRIQ 5-Specialty PA FOR NEW STARTS ONLY, LA

COTELLIC 5-Specialty PA FOR NEW STARTS ONLY, QL (63 PER 28 OVER TIME)




29

ERIVEDGE 5-Specialty PA FOR NEW STARTS ONLY, LA

FARYDAK 5-Specialty PA FOR NEW STARTS ONLY, QL (6 PER 21 OVER TIME)

GILOTRIF 5-Specialty PA FOR NEW STARTS ONLY, LA

IBRANCE 5-Specialty PA FOR NEW STARTS ONLY, LA, QL (21 PER 28 OVER TIME)

ICLUSIG 5-Specialty PA FOR NEW STARTS ONLY, LA

IMATINIB MESYLATE 5-Specialty PA FOR NEW STARTS ONLY

IMBRUVICA 5-Specialty PA FOR NEW STARTS ONLY, LA

INLYTA 5-Specialty PA FOR NEW STARTS ONLY, LA

IRESSA 5-Specialty PA FOR NEW STARTS ONLY, QL (1 PER 1 DAYS)

JAKAFI 5-Specialty PA FOR NEW STARTS ONLY, LA

KISQALI 5-Specialty PA FOR NEW STARTS ONLY

KISQALI FEMARA CO-PACK 5-Specialty PA FOR NEW STARTS ONLY

LENVIMA 5-Specialty PA FOR NEW STARTS ONLY, LA

LYNPARZA 50 MG CAPSULE 5-Specialty PA FOR NEW STARTS ONLY, LA

MEKINIST 5-Specialty PA FOR NEW STARTS ONLY

NEXAVAR 5-Specialty PA FOR NEW STARTS ONLY

ODOMZO 5-Specialty PA FOR NEW STARTS ONLY

SPRYCEL 5-Specialty PA FOR NEW STARTS ONLY

STIVARGA 5-Specialty PA FOR NEW STARTS ONLY

SUTENT 5-Specialty PA FOR NEW STARTS ONLY

TAFINLAR 5-Specialty PA FOR NEW STARTS ONLY

TAGRISSO 5-Specialty PA FOR NEW STARTS ONLY

TARCEVA 5-Specialty PA FOR NEW STARTS ONLY

TASIGNA 5-Specialty PA FOR NEW STARTS ONLY

TYKERB 5-Specialty PA FOR NEW STARTS ONLY

VENCLEXTA (10 MG TABLET, 50 MG TABLET)

3-Preferred Brand PA FOR NEW STARTS ONLY




30

VENCLEXTA 100 MG TABLET 5-Specialty PA FOR NEW STARTS ONLY

VENCLEXTA STARTING PACK 5-Specialty PA FOR NEW STARTS ONLY

VOTRIENT 5-Specialty PA FOR NEW STARTS ONLY

XALKORI 5-Specialty PA FOR NEW STARTS ONLY, LA

ZEJULA 5-Specialty PA FOR NEW STARTS ONLY

ZELBORAF 5-Specialty PA FOR NEW STARTS ONLY

ZYDELIG 5-Specialty PA FOR NEW STARTS ONLY, QL (2 PER 1 DAYS)

ZYKADIA 5-Specialty PA FOR NEW STARTS ONLY

MONOCLONAL ANTIBODY/ANTIBODY-DRUG CONJUGATE RITUXAN 5-Specialty PA FOR NEW STARTS ONLY

RITUXAN HYCELA 5-Specialty PA FOR NEW STARTS ONLY

SYLVANT 5-Specialty PA FOR NEW STARTS ONLY

RETINOIDS BEXAROTENE 5-Specialty PA FOR NEW STARTS ONLY

PANRETIN 5-Specialty

TARGRETIN 1% GEL 5-Specialty PA FOR NEW STARTS ONLY

TRETINOIN 10 MG CAPSULE 5-Specialty PA FOR NEW STARTS ONLY

TREATMENT ADJUNCTS ELITEK 5-Specialty

MESNEX 400 MG TABLET 3-Preferred Brand


ANTIPARASITICS

ANTIHELMINTHICS ALBENZA 4-Non-Preferred

Drug PA

EMVERM 4-Non-Preferred Drug

PA

ivermectin 2-Generic



31

ANTIPROTOZOALS ALINIA 100 MG/5 ML SUSPENSION 4-Non-Preferred

Drug QL (150 ML PER 30 OVER TIME)

ALINIA 500 MG TABLET 3-Preferred Brand QL (6 PER 30 OVER TIME)

ATOVAQUONE 5-Specialty

ATOVAQUONE/PROGUANIL HCL 4-Non-Preferred Drug

chloroquine phosphate 2-Generic

COARTEM 4-Non-Preferred Drug

DARAPRIM 5-Specialty

hydroxychloroquine sulfate 2-Generic

mefloquine hcl 2-Generic

NEBUPENT 4-Non-Preferred Drug


PENTAM 300 4-Non-Preferred Drug

primaquine phosphate 2-Generic

PEDICULICIDES/SCABICIDES lindane 2-Generic

permethrin 5 % cream (g) 2-Generic


ANTIPARKINSON AGENTS

ANTICHOLINERGICS benztropine mesylate (0.5 mg tablet, 1 mg tablet, 2 mg tablet)

2-Generic

trihexyphenidyl hcl (2 mg/5 ml elixir, 2 mg tablet, 5 mg tablet)

2-Generic

ANTIPARKINSON AGENTS, OTHER amantadine hcl (50 mg/5 ml solution, 100 mg tablet, 100 mg capsule)

2-Generic



32

CARBIDOPA/LEVODOPA/ENTACAPONE 4-Non-Preferred Drug

ENTACAPONE 4-Non-Preferred Drug

DOPAMINE AGONISTS APOKYN 5-Specialty PA, LA

bromocriptine mesylate 2-Generic

pramipexole di-hcl (0.125 mg tablet, 0.25 mg tablet, 0.5 mg tablet, 0.75 mg tablet, 1 mg tablet, 1.5 mg tablet)

2-Generic

ropinirole hcl (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet, 2 mg tablet, 3 mg tablet, 4 mg tablet, 5 mg tablet)

2-Generic

DOPAMINE PRECURSORS/L-AMINO ACID DECARBOXYLASE INHIBITORS CARBIDOPA 4-Non-Preferred

Drug

carbidopa/levodopa 2-Generic

MONOAMINE OXIDASE B (MAO-B) INHIBITORS RASAGILINE MESYLATE 4-Non-Preferred

Drug

selegiline hcl 2-Generic


ANTIPSYCHOTICS

1ST GENERATION/TYPICAL CHLORPROMAZINE HCL (10 MG TABLET, 25 MG TABLET, 25 MG/ML AMPUL, 50 MG TABLET, 100 MG TABLET, 200 MG TABLET)


FLUPHENAZINE DECANOATE 4-Non-Preferred Drug

fluphenazine hcl (1 mg tablet, 2.5 mg/5ml elixir, 2.5 mg tablet, 5 mg tablet, 5 mg/ml oral conc, 10 mg tablet)

2-Generic

FLUPHENAZINE HCL 2.5 MG/ML VIAL 4-Non-Preferred Drug



33

haloperidol 2-Generic

HALOPERIDOL DECANOATE 4-Non-Preferred Drug

HALOPERIDOL LACTATE (5 MG/ML VIAL, 5 MG/ML AMPUL)


haloperidol lactate 2 mg/ml oral conc 2-Generic

loxapine succinate 2-Generic

molindone hcl 2-Generic

pimozide 2-Generic

thioridazine hcl 2-Generic PA FOR NEW STARTS ONLY AND FOR 65 YEARS AND OLDER

thiothixene 2-Generic

trifluoperazine hcl 2-Generic

2ND GENERATION/ATYPICAL ABILIFY MAINTENA 5-Specialty

aripiprazole (1 mg/ml solution, 2 mg tablet, 5 mg tablet, 10 mg tablet, 15 mg tablet, 20 mg tablet, 30 mg tablet)

2-Generic

ARIPIPRAZOLE (10 MG TAB RAPDIS, 15 MG TAB RAPDIS)


ARISTADA 5-Specialty

FANAPT 4-Non-Preferred Drug

GEODON 20 MG/ML VIAL 4-Non-Preferred Drug


INVEGA SUSTENNA 117 MG/0.75 ML 5-Specialty QL (0.75 ML PER 30 OVER TIME)

INVEGA SUSTENNA 156 MG/ML SYRG 5-Specialty QL (1 ML PER 30 OVER TIME)

INVEGA SUSTENNA 234 MG/1.5 ML 5-Specialty QL (1.5 ML PER 30 OVER TIME)

INVEGA SUSTENNA 39 MG/0.25 ML 4-Non-Preferred Drug

QL (0.25 ML PER 30 OVER TIME)

INVEGA SUSTENNA 78 MG/0.5 ML 4-Non-Preferred Drug

QL (0.5 ML PER 30 OVER TIME)




34

INVEGA TRINZA 5-Specialty

LATUDA 5-Specialty PA FOR NEW STARTS ONLY, QL (1 PER 1 DAYS)

NUPLAZID 5-Specialty PA FOR NEW STARTS ONLY, LA, QL (2 PER 1 DAYS)

olanzapine (2.5 mg tablet, 5 mg tablet, 5 mg tab rapdis, 7.5 mg tablet, 10 mg tab rapdis, 10 mg tablet, 15 mg tab rapdis, 15 mg tablet, 20 mg tablet, 20 mg tab rapdis)

2-Generic

OLANZAPINE 10 MG VIAL 4-Non-Preferred Drug

paliperidone 2-Generic

quetiapine fumarate (25 mg tablet, 50 mg tablet, 100 mg tablet, 200 mg tablet, 300 mg tablet, 400 mg tablet)

2-Generic

QUETIAPINE FUMARATE (50 MG TAB ER 24H, 150 MG TAB ER 24H, 200 MG TAB ER 24H, 300 MG TAB ER 24H, 400 MG TAB ER 24H)

3-Preferred Brand

REXULTI 5-Specialty PA FOR NEW STARTS ONLY

RISPERDAL CONSTA (12.5 MG SYR, 25 MG SYR)



RISPERDAL CONSTA (37.5 MG SYR, 50 MG SYR)

5-Specialty QL (2 PER 28 OVER TIME)

risperidone (0.25 mg tablet, 0.25 mg tab rapdis, 0.5 mg tab rapdis, 0.5 mg tablet, 1 mg tab rapdis, 1 mg/ml solution, 1 mg tablet, 2 mg tablet, 2 mg tab rapdis, 3 mg tab rapdis, 3 mg tablet, 4 mg tab rapdis, 4 mg tablet)

2-Generic

SAPHRIS 4-Non-Preferred Drug


VRAYLAR 4-Non-Preferred Drug


ziprasidone hcl 2-Generic

ZYPREXA RELPREVV 4-Non-Preferred Drug




35

TREATMENT-RESISTANT CLOZAPINE (12.5 MG TAB RAPDIS, 25 MG TAB RAPDIS, 100 MG TAB RAPDIS, 150 MG TAB RAPDIS, 200 MG TAB RAPDIS)


clozapine (25 mg tablet, 50 mg tablet, 100 mg tablet, 200 mg tablet)

2-Generic

VERSACLOZ 4-Non-Preferred Drug


ANTISPASTICITY AGENTS

ANTISPASTICITY AGENTS baclofen 2-Generic

DANTROLENE SODIUM 4-Non-Preferred Drug

tizanidine hcl (2 mg tablet, 4 mg tablet) 2-Generic

ANTIVIRALS

ANTI-CYTOMEGALOVIRUS (CMV) AGENTS FOSCARNET SODIUM 4-Non-Preferred

Drug

GANCICLOVIR SODIUM 4-Non-Preferred Drug


VALGANCICLOVIR HCL (50 MG/ML SOLN RECON, 450 MG TABLET)

5-Specialty

ZIRGAN 3-Preferred Brand

ANTI-HEPATITIS B (HBV) AGENTS ADEFOVIR DIPIVOXIL 4-Non-Preferred

Drug

BARACLUDE 0.05 MG/ML SOLUTION 4-Non-Preferred Drug

ENTECAVIR 4-Non-Preferred Drug



36

EPIVIR HBV 25 MG/5 ML SOLN 3-Preferred Brand

lamivudine 100 mg tablet 2-Generic

VEMLIDY 5-Specialty

ANTI-HEPATITIS C (HCV) AGENTS, DIRECT ACTING AGENTS DAKLINZA 5-Specialty PA, QL (1 PER 1 DAYS)

EPCLUSA 5-Specialty PA, QL (1 PER 1 DAYS)

HARVONI 5-Specialty PA, QL (1 PER 1 DAYS)

OLYSIO 5-Specialty PA

SOVALDI 5-Specialty PA

TECHNIVIE 5-Specialty PA, QL (2 PER 1 DAYS)

VIEKIRA PAK 5-Specialty PA, QL (4 PER 1 DAYS)

VIEKIRA XR 5-Specialty PA, QL (3 PER 1 DAYS)

ZEPATIER 5-Specialty PA, QL (1 PER 1 DAYS)

ANTI-HEPATITIS C (HCV) AGENTS, OTHER INTRON A (10 MILLION UNITS VIL, 18 MILLION UNIT/3 ML, 18 MILLION UNITS VIL, 25 MILLION UNIT/2.5ML, 50 MILLION UNITS VIL)

5-Specialty

moderiba (200 mg tablet, 400-400 mg dosepack, 600-600 mg dosepack, 600-400 mg dosepack)

2-Generic

PEGASYS (180 MCG/ML VIAL, 180 MCG/0.5 ML SYRINGE)

5-Specialty

PEGASYS PROCLICK 5-Specialty

PEGINTRON 5-Specialty

PEGINTRON REDIPEN 5-Specialty

REBETOL 40 MG/ML SOLUTION 5-Specialty

ribasphere (200 mg tablet, 200 mg capsule)

2-Generic

ribavirin (200 mg capsule, 200 mg tablet)

2-Generic




37

ANTI-HIV AGENTS, INTEGRASE INHIBITORS (INSTI) GENVOYA 5-Specialty

ISENTRESS (100 MG TABLET CHEW, 400 MG TABLET)

5-Specialty

ISENTRESS (25 MG TABLET CHEW, 100 MG POWDER PACKET)

3-Preferred Brand

ISENTRESS HD 5-Specialty

STRIBILD 5-Specialty

TIVICAY (25 MG TABLET, 50 MG TABLET)

5-Specialty

TIVICAY 10 MG TABLET 3-Preferred Brand

ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI) ATRIPLA 5-Specialty

COMPLERA 5-Specialty

EDURANT 5-Specialty

INTELENCE (100 MG TABLET, 200 MG TABLET)

5-Specialty

INTELENCE 25 MG TABLET 3-Preferred Brand

nevirapine (50 mg/5 ml oral susp, 100 mg tab er 24h, 200 mg tablet, 400 mg tab er 24h)

2-Generic

ODEFSEY 5-Specialty

RESCRIPTOR 3-Preferred Brand

SUSTIVA 3-Preferred Brand

ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTI)

abacavir sulfate 2-Generic

abacavir sulfate/lamivudine 2-Generic

abacavir sulfate/lamivudine/zidovudine 2-Generic

DESCOVY 5-Specialty

didanosine 2-Generic




38

EMTRIVA (10 MG/ML SOLUTION, 200 MG CAPSULE)

3-Preferred Brand

lamivudine (10 mg/ml solution, 150 mg tablet, 300 mg tablet)

2-Generic

lamivudine/zidovudine 2-Generic

RETROVIR 200 MG/20 ML VIAL 4-Non-Preferred Drug

stavudine (1 mg/ml soln recon, 15 mg capsule, 20 mg capsule, 30 mg capsule, 40 mg capsule)

2-Generic

TRUVADA 5-Specialty

VIDEX 3-Preferred Brand

VIREAD (150 MG TABLET, 200 MG TABLET, 250 MG TABLET, 300 MG TABLET, POWDER)

5-Specialty

ZERIT 1 MG/ML SOLUTION 3-Preferred Brand

ZIAGEN 20 MG/ML SOLUTION 3-Preferred Brand

zidovudine (10 mg/ml syrup, 100 mg capsule, 300 mg tablet)

2-Generic

ANTI-HIV AGENTS, OTHER FUZEON 5-Specialty

SELZENTRY (20 MG/ML ORAL SOLN, 75 MG TABLET, 150 MG TABLET, 300 MG TABLET)

5-Specialty

SELZENTRY 25 MG TABLET 3-Preferred Brand

TRIUMEQ 5-Specialty

TYBOST 3-Preferred Brand

ANTI-HIV AGENTS, PROTEASE INHIBITORS APTIVUS (100 MG/ML SOLUTION, 250 MG CAPSULE)

5-Specialty

CRIXIVAN 3-Preferred Brand

EVOTAZ 5-Specialty

INVIRASE 5-Specialty




39

KALETRA 100-25 MG TABLET 3-Preferred Brand

KALETRA 200-50 MG TABLET 5-Specialty

LEXIVA 50 MG/ML SUSPENSION 3-Preferred Brand

LEXIVA 700 MG TABLET 5-Specialty

lopinavir/ritonavir 2-Generic

NORVIR (80 MG/ML SOLUTION, 100 MG TABLET, 100 MG SOFTGEL CAP)

3-Preferred Brand

PREZCOBIX 5-Specialty

PREZISTA (100 MG/ML SUSPENSION, 600 MG TABLET, 800 MG TABLET)

5-Specialty

PREZISTA (75 MG TABLET, 150 MG TABLET)

3-Preferred Brand

REYATAZ (50 MG POWDER PACKET, 150 MG CAPSULE, 200 MG CAPSULE, 300 MG CAPSULE)

5-Specialty

VIRACEPT 3-Preferred Brand

ANTI-INFLUENZA AGENTS oseltamivir phosphate 2-Generic

RELENZA 3-Preferred Brand

rimantadine hcl 2-Generic

ANTIHERPETIC AGENTS acyclovir (200 mg capsule, 200 mg/5ml oral susp, 400 mg tablet, 800 mg tablet)

2-Generic

ACYCLOVIR SODIUM (50 MG/ML VIAL, 500 MG VIAL, 1000 MG VIAL)



famciclovir 2-Generic

TRIFLURIDINE 4-Non-Preferred Drug

valacyclovir hcl 2-Generic




40


ANXIOLYTICS

ANXIOLYTICS, OTHER buspirone hcl 2-Generic

doxepin hcl (10 mg/ml oral conc, 10 mg capsule, 25 mg capsule, 50 mg capsule, 75 mg capsule, 100 mg capsule, 150 mg capsule)

2-Generic

BENZODIAZEPINES clonazepam 2-Generic PA FOR NEW STARTS ONLY

clorazepate dipotassium 2-Generic PA FOR NEW STARTS ONLY

diazepam (2 mg tablet, 5 mg/5 ml solution, 5 mg tablet, 5 mg/ml oral conc, 10 mg tablet)

2-Generic PA FOR NEW STARTS ONLY

lorazepam (0.5 mg tablet, 1 mg tablet, 2 mg tablet, 2 mg/ml oral conc)

2-Generic

lorazepam intensol 2-Generic

oxazepam 2-Generic

BIPOLAR AGENTS

MOOD STABILIZERS lithium carbonate 2-Generic

lithium citrate 2-Generic

BLOOD GLUCOSE REGULATORS

ANTIDIABETIC AGENTS acarbose 2-Generic

ALOGLIPTIN BENZOATE 4-Non-Preferred Drug


ALOGLIPTIN BENZOATE/METFORMIN HCL


PA

ALOGLIPTIN BENZOATE/PIOGLITAZONE HCL





41

BYDUREON 3-Preferred Brand

BYDUREON PEN 3-Preferred Brand

BYETTA 3-Preferred Brand

CYCLOSET 4-Non-Preferred Drug

FARXIGA 4-Non-Preferred Drug

PA

glimepiride 1-Preferred Generic

glipizide 1-Preferred Generic

glipizide/metformin hcl 2-Generic

GLYXAMBI 4-Non-Preferred Drug

PA

INVOKAMET 4-Non-Preferred Drug

PA

INVOKAMET XR 4-Non-Preferred Drug

PA

INVOKANA 4-Non-Preferred Drug

PA

JANUMET 4-Non-Preferred Drug

PA

JANUMET XR (50-1,000 MG TABLET, 100-1,000 MG TABLET)



JANUMET XR 50-500 MG TABLET 4-Non-Preferred Drug


JANUVIA 4-Non-Preferred Drug


JARDIANCE 4-Non-Preferred Drug

PA

JENTADUETO 4-Non-Preferred Drug

PA

JENTADUETO XR 4-Non-Preferred Drug

PA

KAZANO 4-Non-Preferred Drug

PA




42

KOMBIGLYZE XR (5-1,000 MG TAB, 5-500 MG TABLET)



KOMBIGLYZE XR 2.5-1,000 MG TAB 4-Non-Preferred Drug


metformin hcl (500 mg tablet, 750 mg tab er 24h, 850 mg tablet, 1000 mg tablet)

1-Preferred Generic

metformin hcl 500 mg tab er 24h (generic for glucophage xr)

1-Preferred Generic

nateglinide 2-Generic

NESINA 4-Non-Preferred Drug


ONGLYZA 4-Non-Preferred Drug


OSENI 4-Non-Preferred Drug


pioglitazone hcl 1-Preferred Generic

pioglitazone hcl/glimepiride 2-Generic

pioglitazone hcl/metformin hcl 2-Generic

repaglinide 2-Generic

RIOMET 4-Non-Preferred Drug

SYMLINPEN 120 5-Specialty PA, QL (10.8 ML PER 30 OVER TIME)

SYMLINPEN 60 5-Specialty PA, QL (6 ML PER 30 OVER TIME)

SYNJARDY 4-Non-Preferred Drug

PA

SYNJARDY XR 4-Non-Preferred Drug

PA

tolbutamide 2-Generic

TRADJENTA 4-Non-Preferred Drug


VICTOZA 2-PAK 3-Preferred Brand QL (9 ML PER 30 OVER TIME)

VICTOZA 3-PAK 3-Preferred Brand QL (9 ML PER 30 OVER TIME)




43

XIGDUO XR 4-Non-Preferred Drug

PA

GLYCEMIC AGENTS GLUCAGON EMERGENCY KIT 3-Preferred Brand QL (2 PER 30 OVER TIME)

PROGLYCEM 4-Non-Preferred Drug

INSULINS HUMALOG 3-Preferred Brand

HUMALOG JUNIOR KWIKPEN 3-Preferred Brand

HUMALOG KWIKPEN U-100 3-Preferred Brand

HUMALOG KWIKPEN U-200 3-Preferred Brand

HUMALOG MIX 50-50 3-Preferred Brand

HUMALOG MIX 50-50 KWIKPEN 3-Preferred Brand

HUMALOG MIX 75-25 3-Preferred Brand

HUMALOG MIX 75-25 KWIKPEN 3-Preferred Brand

humulin 70-30 2-Generic

humulin 70/30 kwikpen 2-Generic

humulin n 2-Generic

humulin n kwikpen 2-Generic

humulin r 2-Generic

humulin r u-500 2-Generic

humulin r u-500 kwikpen 2-Generic

LANTUS 3-Preferred Brand

LANTUS SOLOSTAR 3-Preferred Brand

LEVEMIR 3-Preferred Brand

LEVEMIR FLEXTOUCH 3-Preferred Brand

TOUJEO SOLOSTAR 3-Preferred Brand

TRESIBA FLEXTOUCH U-100 3-Preferred Brand

TRESIBA FLEXTOUCH U-200 3-Preferred Brand




44


BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS

ANTICOAGULANTS ELIQUIS 3-Preferred Brand

ENOXAPARIN SODIUM (100 MG/ML SYRINGE, 150 MG/ML SYRINGE)


QL (2 ML PER 1 DAYS)

ENOXAPARIN SODIUM (80MG/0.8ML SYRINGE, 120MG/.8ML SYRINGE)


QL (1.6 ML PER 1 DAYS)

ENOXAPARIN SODIUM 30MG/0.3ML SYRINGE









FONDAPARINUX SODIUM 10MG/0.8ML SYRINGE

5-Specialty QL (0.8 ML PER 1 DAYS)

FONDAPARINUX SODIUM 2.5 MG/0.5 SYRINGE



FONDAPARINUX SODIUM 5MG/0.4ML SYRINGE


FONDAPARINUX SODIUM 7.5MG/0.6 SYRINGE


FRAGMIN (2,500 UNITS/0.2 ML SYR, 5,000 UNITS/0.2 ML SYR)



FRAGMIN (25,000 UNITS/ML VIAL, 95,000 UNITS/3.8 ML VL)

5-Specialty QL (30.4 ML PER 30 OVER TIME)

FRAGMIN 10,000 UNITS/ML SYRING 5-Specialty QL (30 ML PER 30 OVER TIME)

FRAGMIN 12,500 UNITS/0.5 ML 5-Specialty QL (15 ML PER 30 OVER TIME)

FRAGMIN 15,000 UNITS/0.6 ML 5-Specialty QL (18 ML PER 30 OVER TIME)

FRAGMIN 18,000 UNITS/0.72 ML 5-Specialty QL (21.6 ML PER 30 OVER TIME)

FRAGMIN 7,500 UNITS/0.3 ML SYR 5-Specialty QL (9 ML PER 30 OVER TIME)

HEPARIN SODIUM,PORCINE (5000/ML VIAL, 5000/ML(1) CARTRIDGE, 10000/ML VIAL, 20000/ML VIAL)




45

HEPARIN SODIUM,PORCINE 1000/ML VIAL



HEPARIN SODIUM,PORCINE IN 0.45 % SODIUM CHLORIDE


HEPARIN SODIUM,PORCINE/DEXTROSE 5 % IN WATER


HEPARIN SODIUM,PORCINE/PF 1000/ML VIAL



HEPARIN SODIUM,PORCINE/PF 5000/0.5ML VIAL


jantoven 2-Generic

PRADAXA 4-Non-Preferred Drug

SAVAYSA 4-Non-Preferred Drug

warfarin sodium 2-Generic

XARELTO 3-Preferred Brand

BLOOD FORMATION MODIFIERS anagrelide hcl 2-Generic

ARANESP (10 MCG/0.4 ML SYRINGE, 25 MCG/0.42 ML SYRING, 25 MCG/ML VIAL, 40 MCG/ML VIAL, 40 MCG/0.4 ML SYRINGE, 60 MCG/0.3 ML SYRINGE, 60 MCG/ML VIAL, 100 MCG/0.5 ML SYRINGE)


PA

ARANESP (100 MCG/ML VIAL, 150 MCG/0.3 ML SYRINGE, 150 MCG/0.75 ML VIAL, 200 MCG/0.4 ML SYRINGE, 200 MCG/ML VIAL, 300 MCG/0.6 ML SYRINGE, 300 MCG/ML VIAL, 500 MCG/1 ML SYRINGE)

5-Specialty PA

EPOGEN (2,000 UNITS/ML VIAL, 3,000 UNITS/ML VIAL, 4,000 UNITS/ML VIAL, 10,000 UNITS/ML VIAL, 20,000 UNITS/2 ML VIAL)


PA

EPOGEN (20,000 VIAL, 40,000 VIAL) 5-Specialty PA




46

GRANIX 5-Specialty

LEUKINE 250 MCG VIAL 5-Specialty

MOZOBIL 5-Specialty QL (2.4 ML PER 1 DAYS)

NEULASTA 5-Specialty QL (1.2 ML PER 28 OVER TIME)

NEUPOGEN 5-Specialty

PROCRIT (2,000 VIAL, 3,000 VIAL, 4,000 VIAL, 10,000 VIAL)


PA

PROCRIT (20,000 VIAL, 40,000 VIAL) 5-Specialty PA

PROMACTA 5-Specialty PA

ZARXIO 5-Specialty

HEMOSTASIS AGENTS TRANEXAMIC ACID (1000 MG/10 VIAL, 1000 MG/10 AMPUL)


tranexamic acid 650 mg tablet 2-Generic

PLATELET MODIFYING AGENTS aspirin/dipyridamole 2-Generic

BRILINTA 3-Preferred Brand

cilostazol 2-Generic

clopidogrel bisulfate 75 mg tablet 2-Generic

EFFIENT 3-Preferred Brand


CARDIOVASCULAR AGENTS

ALPHA-ADRENERGIC AGONISTS CLONIDINE 4-Non-Preferred

Drug

clonidine hcl (0.1 mg tablet, 0.2 mg tablet, 0.3 mg tablet)

1-Preferred Generic

midodrine hcl 2-Generic

NORTHERA 5-Specialty PA, LA



47

ALPHA-ADRENERGIC BLOCKING AGENTS doxazosin mesylate 2-Generic

PHENOXYBENZAMINE HCL 5-Specialty

prazosin hcl 2-Generic

terazosin hcl 1-Preferred Generic

ANGIOTENSIN II RECEPTOR ANTAGONISTS candesartan cilexetil 2-Generic

eprosartan mesylate 2-Generic

irbesartan 1-Preferred Generic

providence medicare advantage plans .../media/files...2017/08/16 · updated the formulary, appears...

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