Health Alliance Plan. Commercial Formulary. July 1, 2015

Size: px
Start display at page:

Download "Health Alliance Plan. Commercial Formulary. July 1, 2015"

Transcription

1 Health Alliance Plan Commercial Formulary July 1, 2015 This document includes a list of the covered drugs (formulary) for our plan which is current as of July 1, When this drug list (formulary) refers to we, us, or our, it means Health Alliance Plan or Personal Alliance. When it refers to plan or our plan, it means Commercial HMO and AHL Plans For more information If you have questions about your plan please contact our Client Services Representative. You may contact us by phone or visit us at Our business hours are Monday through Friday from 8:00 a.m. to 8:00 p.m. and Saturday from 8:00 a.m. to 12 noon. For HMO Plans please call (800) For PPO Plans please call (888) Disclaimer: A drug's formulary status may change prior to being updated in this document. The listing of a drug does not imply coverage for all benefits. Some dosage forms or strengths of an existing formulary drug may not be covered. Please contact plan for details 1

2 What is the Prescription Drug Formulary (Drug List)? A formulary is a list of covered prescription drugs. Prescription drugs are self-administered drugs that you can obtain from pharmacies and that you use in the outpatient setting. The list of covered prescription drugs is selected 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. We will cover the drug listed in our formulary as long as the drug is medically necessary, the prescription is filled at a plan network pharmacy, and other plan rules are followed. Formulary list can change over time. We may add new drugs as they are approved by the FDA and likewise we may remove drugs as new information about safety and effectiveness is available. We may also change the tier which reflects your cost-share for the drug. We may update our rules for coverage meaning that we may add or remove the need for prior approval, quantity limits or criteria for coverage (see page XX for recent formulary changes). This list included medical drugs that are required to be obtained from HAP contracted Specialty Pharmacy. Medical drugs are drugs that are administered in the physician office or healthcare facility. These are generally supplied by your doctor or other healthcare provider. Drugs provided for home infusion therapy are also considered medical. Please refer to your Summary of Benefits and Coverage (SBC) for information about your cost-sharing for Medical drugs. We will post an updated Drug Formulary to our website at hap.org/formulary How do I use the Formulary? The formulary has a list of covered generic and brand name drugs and is organized by 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. Then look under the category name for your drug. If you are not sure what category to look under, you should look for your drug in the Index that is at the end of formulary list. The Index provides an alphabetical list of all of the drugs included in this document. You can also find your drug by searching the document, just type in the generic drug name in the search box. What is Generic Substitution? When an FDA approved generic drug is available, your prescription will be filled with the generic form of the medication. Generic drugs contain the same active ingredients and are equivalent in strength and dosage to the original brand name product. Generic drugs cost you and your plan less money than a brand name drug. What are Specialty drugs? Specialty drugs are biologics or prescription drugs that require close monitoring for safety and efficacy. For this reason HAP has contracted with Pharmacy Advantage, a specialty pharmacy from whom you can obtain specialty drugs. Specialty drugs require prior authorization and 2

3 Pharmacy Advantage can help you and your doctor submit a request for prior authorization for specialty drugs. You or your doctor can contact Pharmacy Advantage at (800) Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. The coverage requirements are listed on the Formulary. These requirements and limits may include: Prior Authorization: Some medications on our formulary have criteria you must meet before we cover them. This means that you will need to get approval from HAP before you fill your prescriptions for these drugs. Step Therapy: In some cases, HAP 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, HAP may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. Quantity : Certain drugs have quantity limits. Quantity limit is the maximum quantity that can be dispensed per each fill of medication or the maximum number of fills allowed for treatment of certain conditions. Specialty drugs injectable drugs (except insulin) and select oral drugs (e.g. opioid analgesics) are limited to a maximum 30-day supply per fill. Some specialty drugs require a15-day first fill. Benefit Limitations Our drug formulary applies to drugs used in an outpatient setting. It does not affect medication given in the doctor s office or while in the hospital. These are known as medical drugs. Note that some medical drugs are listed on this formulary because they are part of our Specialty Program. Please refer to what are specialty drug? section for information about these medications. The following are general drug coverage exclusions that apply to all members: Over-the-Counter (OTC) medications and their equivalents are not covered unless specified in the formulary or on the rider. Drug products used for cosmetic purposes are not covered. Experimental drugs and/or any drug products used in an experimental manner are not covered. Replacement of lost or stolen medication is not covered. Since the selected drug packages and coverage vary for each Plan, check your benefit package to verify your co-pays and exclusions What if my drug is not on the Formulary? When your drug is not listed on the Formulary it is considered non-formulary. You or your doctor can ask us to make an exception and cover your drug and one of HAP clinical specialists will evaluate if the medication will be covered by your plan. However it is best to first discuss with your doctor or pharmacist if one of the formulary alternatives will work for you. Exception approvals for standard non formulary medications will process at the highest non specialty ( three) copayment. Exception approvals for non-formulary Specialty medication will 3

4 process at the highest Specialty ( four) copayment. Non-formulary specialty medications when approved for use by the plan can be required to be dispensed by Pharmacy Advantage How do I request Prior Authorization or Formulary Exception? You or your doctor can ask us to make an exception to our requirements or limits. You may also ask us to cover a medication not included on our formulary or ask us to exempt you from a formulary requirement through the exception process. Your doctor must submit a request to us indicating why formulary requirements should not apply. Your doctor may use the forms available at hap.org/mrf to send us information when requesting either prior authorization or exception to the formulary. What is included in the Formulary List? The name of the covered drug is listed in the First column. Brand name drugs are capitalized (e.g., ADVAIR DISKUS) and generic drugs are listed in lower-case italics (e.g., gabapentin). When a generic drug is listed on the formulary only the generic is covered and the brand version of the generic is not covered. The second column represents the drug s cost-sharing level, or tier. Every drug on the Drug List is in one of 4 prescription cost-sharing tiers. The table below will translate how the 4 tiers shown in the Drug List are applicable to your plan s prescription drug benefit. Refer to your Summary of Benefits and Coverage for your cost-sharing information. Description of Copay * Preventive generic prescription preventive drugs that are mandated by the Affordable Care Act. These are covered at zero copay when Health Care Reform rules are met. Generic These are generic drugs and they have the lowest Copay Preferred Brand- These are formulary Brand drugs and have the lowest Brand Copay Non-Preferred Brand These are Brand name formulary drugs that are not in the Preferred Brand. Specialty Drugs These are drugs that are biologics or drugs that require close monitoring for safety and efficacy. Medical Drugs - These are drugs that are infused or administered in doctor s office or facility and are covered under the medical benefit of your plan. 0 copay 1 copay 2 copay 3 copay 4 copay Medical Coinsurance 4

5 The third column lists the Requirements/ that must be met for coverage of your drug. Please refer to the abbreviations used in this column and their explanation. The fourth column is the Comment section and may include specific information about strengths or dosage forms that are covered The fifth column is the list of covered lower cost alternatives that you may be able to use. Abbreviations for Requirements/ are as follows: You or your physician are required to get prior authorization from HAP before you fill your prescription for this drug. Without prior approval, we may not cover this drug. We limit the amount of this drug that is covered per prescription. For example, if it is normally considered safe to take only one pill per day for a certain drug, we may limit coverage for your prescription to no more than one pill per day. ST Before we will provide coverage for this drug, you must first try another drug(s) to treat your medical condition. This drug may only be covered if the other drug(s) does not work for you. This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) What are the changes to the formulary in the past 6 months? DATE (2015) DRUG NAME CHANGE FEBRUARY HARVONI Added as Specialty drug with, 4 SOVALDI Added as Specialty drug with, 4 VIEKRIA Added as Specialty drug with, 4 OLYSIO colchicine MARCH 2015 celecoxib FORTEO Removed from formulary generic now available and added to formulary Generic now available and added to formulary Changed requirement to step therapy Updated Step therapy to include trial with PROLIA OVIDREL Added with,, 3 FORMULARY ALTERNATIVE HARVONI, SOVALDI, VIKERIA meloxicam Alendronate Ibandronate 5

6 DATE DRUG NAME CHANGE APRIL 2015 PROAIR REICLICK Added with, 2 MAY 2015 IBRANCE Added as Specialty drug with, 4 MEFLOQUINE Atovaquone/Progu anil BUPRENORPHINE/ NALOXONE Added Added Added FORMULARY ALTERNATIVE 6

7 ANTIHISTAMINE DRUGS FIRST GENERATION ANTIHISTAMINES ETHANOLAMINE DERIVATIVES carbinoxamine clemastine fumarate diphenhydramine phenyltoloxamine-acetaminophen FIRST GEN. ANTIHIST. DERIVATIVES, MISC. cyproheptadine hcl PHENOTHIAZINE DERIVATIVES promethazine & phenylephrine promethazine hcl brompheniramine PROPYLAMINE DERIVATIVES brompheniramine & phenyleph brompheniramine & pseudoeph chlorpheniramine & phenylephrine chlorpheniramine & pseudoeph chlorpheniramine tannate-phenylephrine tannate chlorpheniramine tan-pyrilamine tanphenylephrine tan chlorpheniramine-methscopolamine chlorpheniramine-phenylephrine-methscopolamine chlorpheniramine-pseudoephedrine & methscopolamine chlorpheniramine-pyrilamine & phenylephrine chlorphen-phenyltolox-pe dexchlorpheniramine maleate ED-CHLOR-TAN (chlorpheniramine) For 2- plans: drugs listed as 3 and 4 default to 2 copayment F or 3- plans: drugs listed as 4 default to 3 copayment () Prior authorization, (ST) Step Therapy, () Quantity limit () This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800)

8 ANTIHISTAMINE DRUGS SECOND GENERATION ANTIHISTAMINES loratadine ( 30 tabs/ 30 days) loratadine Syrup loratadine & pseudoephedrine SEMPREX-D (acrivastine & pseudoephedrine) ANTI-INFECTIVE AGENTS ANTHELMINTICS ALBENZA (albendazole) BILTRICIDE (praziquantel) mebendazole STROMECTOL (ivermectin) ANTIBACTERIALS AMINOGLYCOSIDES neomycin sulfate (60 tabs/ 30 days) tobramycin bacitracin clindamycin clindamycin ANTIBACTERIALS, MISCELLANEOUS Nebs for inhalation Capsule Solution vancomycin hcl XIFAXAN (rifaximin) ZYVOX (linezolid) ZYVOX (linezolid) CEPHALOORINS CEDAX (ceftibuten) cefaclor cefadroxil cefdinir (60 ml/day) suspension (28/14 days) tabs For 2- plans: drugs listed as 3 and 4 default to 2 copayment F or 3- plans: drugs listed as 4 default to 3 copayment () Prior authorization, (ST) Step Therapy, () Quantity limit () This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800)

9 ANTI-INFECTIVE AGENTS ANTIBACTERIALS CEPHALOORINS cefditoren pivoxil cefpodoxime proxetil cefprozil CEFTIN (cefuroxime) cefuroxime cephalexin SUPRAX (cefixime) MACROLIDES azithromycin azithromycin azithromycin clarithromycin (8 Pack/ fill) Pack (120 ml/fill) Suspension (8 tab /fill) Tablets clarithromycin E.E.S. GRANULES (erythromycin ethylsuccinate) ERYPED 200 (erythromycin ethylsuccinate) ERYPED 400 (erythromycin ethylsuccinate) erythromycin ethylsuccinate erythromycin-sulfisoxazole Extended-release Tablets Granules for suspension Granules for Suspension Granules for Suspension KETEK (telithromycin) PCE (erythromycin base (coated)) ZMAX (azithromycin) PENICILLINS amoxicillin amoxicillin & pot clavulanate For 2- plans: drugs listed as 3 and 4 default to 2 copayment F or 3- plans: drugs listed as 4 default to 3 copayment () Prior authorization, (ST) Step Therapy, () Quantity limit () This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800)

10 ANTI-INFECTIVE AGENTS ANTIBACTERIALS PENICILLINS ampicillin dicloxacillin sodium penicillin v QUINOLONES AVELOX (moxifloxacin hcl) ciprofloxacin Extended-release Tablets ciprofloxacin FACTIVE (gemifloxacin mesylate) Tablets levofloxacin Solution levofloxacin NOROXIN (norfloxacin) Tablets ofloxacin sulfadiazine SULFONAMIDES (SYSTEMIC) sulfamethoxazole-trimethoprim sulfasalazine demeclocycline hcl doxycycline minocycline hcl tetracycline hcl TETRACYCLINES ANTIFUNGAL (SYSTEMIC) ALLYLAMINES LAMISIL (terbinafine hcl) terbinafine hcl (90 caps/ 30 days) 50 MG AND 100 MG (14 Pack/ fill) Granules For 2- plans: drugs listed as 3 and 4 default to 2 copayment F or 3- plans: drugs listed as 4 default to 3 copayment () Prior authorization, (ST) Step Therapy, () Quantity limit () This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800)

11 ANTI-INFECTIVE AGENTS ANTIFUNGAL (SYSTEMIC) ANTIFUNGALS, MISCELLANEOUS griseofulvin fluconazole AZOLES itraconazole ketoconazole NOXAFIL (posaconazole) ORANOX (itraconazole) voriconazole POLYENES FIRST-BXN MOUTHWASH (diphenhydraminelidocaine-nystatin) nystatin ( 240ML/ FILL) nystatin (mouth-throat) flucytosine dapsone PYRIMIDINES ANTIMYCOBACTERIALS ANTIMYCOBACTERIALS, MISCELLANEOUS cycloserine ANTITUBERCULOSIS AGENTS ethambutol hcl isoniazid isoniazid & rifampin MYCOBUTIN (rifabutin) SER (aminosalicylic acid) PRIFTIN (rifapentine) pyrazinamide For 2- plans: drugs listed as 3 and 4 default to 2 copayment F or 3- plans: drugs listed as 4 default to 3 copayment () Prior authorization, (ST) Step Therapy, () Quantity limit () This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800)

12 ANTI-INFECTIVE AGENTS ANTIMYCOBACTERIALS ANTITUBERCULOSIS AGENTS rifampin RIFATER (isoniazid-rifampin w/ pyrazinamide) SIRTURO (bedaquiline fumarate) TRECATOR (ethionamide) ANTIPROTOZOALS AMEBICIDES paromomycin sulfate ANTIMALARIALS atovaquone-proguanil hcl chloroquine COARTEM (artemether-lumefantrine) hydroxychloroquine sulfate mefloquine hcl primaquine phosphate Only covered for treatment Only Covered for treatment Tablet (5 tabs / 30 days) Only covered for treatment QUALAQUIN (quinine sulfate) ANTIPROTOZOALS, MISCELLANEOUS ALINIA (nitazoxanide) (60 ml/ fill) Suspension ALINIA (nitazoxanide) FLAGYL ER (metronidazole) MEPRON (atovaquone) metronidazole tinidazole ANTIVIRALS (SYSTEMIC) ADAMANTANES rimantadine hydrochloride (6 tab/ fill) Tablet For 2- plans: drugs listed as 3 and 4 default to 2 copayment F or 3- plans: drugs listed as 4 default to 3 copayment () Prior authorization, (ST) Step Therapy, () Quantity limit () This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800)

13 ANTI-INFECTIVE AGENTS ANTIVIRALS (SYSTEMIC) ANTIRETROVIRALS abacavir sulfate (60 tabs/ 30 day) APTIVUS (tipranavir) ATRIPLA (efavirenz-emtricitabine-tenofovir disoproxil fumarate) COMPLERA (emtricitabine-rilpivirine-tenofovir disoproxil fumarate) (30 tab / 30 days) (30 tab/ 30 days) CRIXIVAN (indinavir sulfate) CRIXIVAN (indinavir sulfate) (180 tabs/ 30 day) 100 MG (180 tabs/ 30 day) 200 and 400 MG didanosine EDURANT (rilpivirine hcl) (60 caps/ 30 day) ( 30 tab / 30 day) EMTRIVA (emtricitabine) EMTRIVA (emtricitabine) (60 caps/ 30 day) Capsule (680ml / 30 day) Solution EPIVIR (lamivudine) EPIVIR HBV (lamivudine) EPZICOM (abacavir sulfate-lamivudine) FUZEON (enfuvirtide) INTELENCE (etravirine) (60 caps/ 30 day) (60 tab / 30 day) (1 kit /30 day) (60 tab / 30 day) INVIRASE (saquinavir) INVIRASE (saquinavir) (120 caps/ 30 day) Capsules (120 tabs/ 30 day) Tablets ISENTRESS (raltegravir potassium) (60 tabs/ 30 day) KALETRA (lopinavir-ritonavir) KALETRA (lopinavir-ritonavir) (640ml / 30 day) Solution (60 tab / 30 day) Tablet lamivudine lamivudine-zidovudine (60 tabs/ 30 day) (60 tab / 30 day) LEXIVA (fosamprenavir calcium) (1500ml / 30 day) Suspension For 2- plans: drugs listed as 3 and 4 default to 2 copayment F or 3- plans: drugs listed as 4 default to 3 copayment () Prior authorization, (ST) Step Therapy, () Quantity limit () This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800)

14 ANTI-INFECTIVE AGENTS ANTIVIRALS (SYSTEMIC) ANTIRETROVIRALS LEXIVA (fosamprenavir calcium) (120 tabs/ 30 day) Tablet nevirapine NORVIR (ritonavir) NORVIR (ritonavir) (60 tab / 30 day) (60 tabs/ 30 day) Capsule (240 ml/ 30 day) Solution PREZISTA (darunavir) RESCRIPTOR (delavirdine mesylate) REYATAZ (atazanavir sulfate) SELZENTRY (maraviroc) stavudine STRIBILD (elvitegravir-cobicistat-emtricitabinetenofovir) (60 tabs/ 30 day) (180 tab/ 30 day) (60 caps/ 30 day) ( 60 tabs/ 30 day) (60 caps/ 30 day) (30 tab/ 30 day) SUSTIVA (efavirenz) SUSTIVA (efavirenz) (30 caps/ 30 day) Capsule (30 tab/ 30 day) Tablet TRUVADA (emtricitabine-tenofovir disoproxil fumarate) (30 tab / 30 day) required for HIV prophylaxis VIDEX PEDIATRIC (didanosine) (800 ml/ 30 day) VIRACEPT (nelfinavir mesylate) VIRAMUNE (nevirapine) VIREAD (tenofovir disoproxil fumarate) ZIAGEN (abacavir sulfate) zidovudine (120 tabs/ 30 day) (480 ml / 30 day) (30 tab/ 30 day) (480ml / 30 day) (60 tab/ 30 day) zidovudine zidovudine HCV ANTIVIRALS HARVONI (ledipasvir-sofosbuvir) (60 caps/ 30 day) Capsule (480ml / 30 day) Syrup INCIVEK (telaprevir) For 2- plans: drugs listed as 3 and 4 default to 2 copayment F or 3- plans: drugs listed as 4 default to 3 copayment () Prior authorization, (ST) Step Therapy, () Quantity limit () This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800)

15 ANTI-INFECTIVE AGENTS ANTIVIRALS (SYSTEMIC) HCV ANTIVIRALS SOVALDI (sofosbuvir) VICTRELIS (boceprevir) VIEKIRA K (ombitasvir-paritaprevir-ritonavir & dasabuvir) INTERFERONS PEGASYS (peginterferon alfa-2a) Kit PEGASYS (peginterferon alfa-2a) Solution PEG-INTRON (peginterferon alfa-2a) PEG-INTRON REDIPEN (peginterferon alfa-2a) MONOCLONAL ANTIBODIES SYNAGIS (palivizumab) MED Medical Coinsurance NEURAMINIDASE INHIBITORS RELENZA DISKHALER (zanamivir) (20 Blister /365 days) TAMIFLU (oseltamivir phosphate) (10 caps /fill, 2 fill /365 days) TAMIFLU (oseltamivir phosphate) (10 caps /fill, 2 fill /365 days) Gel Caps TAMIFLU (oseltamivir phosphate) acyclovir NUCLEOSIDES AND NUCLEOTIDES (75 ml / fill, 2 fill /365 days) Suspension BARACLUDE (entecavir) entecavir famciclovir For 2- plans: drugs listed as 3 and 4 default to 2 copayment F or 3- plans: drugs listed as 4 default to 3 copayment () Prior authorization, (ST) Step Therapy, () Quantity limit () This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800)

16 ANTI-INFECTIVE AGENTS ANTIVIRALS (SYSTEMIC) NUCLEOSIDES AND NUCLEOTIDES ganciclovir HEPSERA (adefovir dipivoxil) ribavirin (hepatitis c) TYZEKA (telbivudine) valacyclovir hcl VALCYTE (valganciclovir hcl) URINARY ANTI-INFECTIVES methenamine-hyosc-methylene blue-benzoic acidphenyl sal methenamine-hyosc-methylene blue-sod phosphenyl sal methenamine-hyosc-methylene blue-sod phosphenyl sal (120 CAPS /30 DAYS) MONUROL (fosfomycin tromethamine) nitrofurantoin PRIMSOL (trimethoprim) trimethoprim ANTINEOPLASTIC AGENTS AFINITOR (everolimus) AFINITOR (everolimus) Dispersable tab is non formulary anastrozole bicalutamide capecitabine For 2- plans: drugs listed as 3 and 4 default to 2 copayment F or 3- plans: drugs listed as 4 default to 3 copayment () Prior authorization, (ST) Step Therapy, () Quantity limit () This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800)

17 ANTINEOPLASTIC AGENTS CEENU (lomustine) COMETRIQ (cabozantinib s-malate) cyclophosphamide DROXIA (hydroxyurea (sickle cell anemia)) EMCYT (estramustine phosphate sodium) ERIVEDGE (vismodegib) etoposide exemestane FARESTON (toremifene citrate) floxuridine flutamide GILOTRIF (afatinib dimaleate) GLEEVEC (imatinib mesylate) HEXALEN (altretamine) HYCAMTIN (topotecan hcl) hydroxyurea IBRANCE (palbociclib) IMBRUVICA (ibrutinib) INLYTA (axitinib) INTRON-A (interferon) INTRON-A W/DILUENT (interferon) IRESSA (gefitinib) For 2- plans: drugs listed as 3 and 4 default to 2 copayment F or 3- plans: drugs listed as 4 default to 3 copayment () Prior authorization, (ST) Step Therapy, () Quantity limit () This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800)

18 ANTINEOPLASTIC AGENTS JAKAFI (ruxolitinib phosphate) letrozole LEUKERAN (chlorambucil) LYSODREN (mitotane) MATULANE (procarbazine hcl) megestrol acetate MEKINIST (trametinib dimethyl sulfoxide) mercaptopurine methotrexate MYLERAN (busulfan) NEXAVAR (sorafenib tosylate) NILANDRON (nilutamide) POMALYST (pomalidomide) REVLIMID (lenalidomide) RHEUMATREX (methotrexate sodium (antirheumatic)) RITUXAN (rituximab) MED Medical Coinsurance RYCEL (dasatinib) STIVARGA (regorafenib) SUTENT (sunitinib malate) SYLATRON (peginterferon alfa-2b (antineoplastic)) TABLOID (thioguanine) For 2- plans: drugs listed as 3 and 4 default to 2 copayment F or 3- plans: drugs listed as 4 default to 3 copayment () Prior authorization, (ST) Step Therapy, () Quantity limit () This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800)

19 ANTINEOPLASTIC AGENTS TAFINLAR (dabrafenib mesylate) tamoxifen citrate TARCEVA (erlotinib) TARGRETIN (bexarotene) Capsule TASIGNA (nilotinib) temozolomide tretinoin (chemotherapy) TREXALL (methotrexate) Capsule TYKERB (lapatinib ditosylate) vandetanib VOTRIENT (pazopanib hcl) XALKORI (crizotinib) XTANDI (enzalutamide) ZELBORAF (vemurafenib) ZOLINZA (vorinostat) ZYTIGA (abiraterone acetate) AUTONOMIC DRUGS ANTICHOLINERGIC AGENTS ANTIMUSCARINICS/ANTISSMODICS atropine sulfate ATROVENT HFA (ipratropium bromide) (15 inhalers /364 days) For 2- plans: drugs listed as 3 and 4 default to 2 copayment F or 3- plans: drugs listed as 4 default to 3 copayment () Prior authorization, (ST) Step Therapy, () Quantity limit () This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800)

20 AUTONOMIC DRUGS ANTICHOLINERGIC AGENTS ANTIMUSCARINICS/ANTISSMODICS CANTIL (mepenzolate bromide) clidinium & chlordiazepoxide dicyclomine hcl glycopyrrolate hyoscyamine sulfate ipratropium bromide ipratropium bromide (nasal) methscopolamine bromide propantheline bromide IRIVA HANDIHALER (tiotropium bromide monohydrate) TUDORZA PRESSAIR (aclidinium bromide) AUTONOMIC DRUGS, MISCELLANEOUS CHANTIX (varenicline tartrate) CHANTIX (varenicline tartrate) T0 (56 tabs/28 days, 6 fills/365 days) T0 (56 tabs/28 days, 1 fills/365 days) HCR Rules apply HCR Rules apply nicotine T0 (14 Patches /14 days, 12 fills/365 days) Patch; HCR Rules apply nicotine polacrilex NICOTROL INHALER (nicotine) T0 (360 units /30 days, 6 fills/365 days) T0 (340 units/30 days, 6 fill /365 day) Gum, lozenge; HCR Rules apply NICOTROL NS (nicotine) T0 (340 units/30 days, 6 fill /365 day) RASYMTHOMIMETIC (CHOLINERGIC AGENTS) bethanechol chloride cevimeline hcl donepezil hydrochloride For 2- plans: drugs listed as 3 and 4 default to 2 copayment F or 3- plans: drugs listed as 4 default to 3 copayment () Prior authorization, (ST) Step Therapy, () Quantity limit () This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800)

21 AUTONOMIC DRUGS RASYMTHOMIMETIC (CHOLINERGIC AGENTS) EXELON (rivastigmine) (30 Patches/ 30 day) EXELON (rivastigmine) galantamine hydrobromide guanidine hcl MESTINON (pyridostigmine bromide) MESTINON TIMESN (pyridostigmine bromide) MYTELASE (ambenonium chloride) neostigmine physostigmine salicylate pilocarpine hcl (oral) pyridostigmine bromide (30 Patches/ 30 day) Patches rivastigmine SKELETAL MUSCLE RELAXANTS CENTRALLY ACTING SKELETAL MUSCLE RELAXNT carisoprodol carisoprodol w/ aspirin cyclobenzaprine hcl metaxalone methocarbamol tizanidine hcl DIRECT-ACTING SKELETAL MUSCLE RELAXANTS dantrolene sodium GABA-DERIVATIVE SKELETAL MUSCLE RELAXANT baclofen NEUROMUSCULAR BLOCKING AGENTS pancuronium bromide Tabs vecuronium bromide For 2- plans: drugs listed as 3 and 4 default to 2 copayment F or 3- plans: drugs listed as 4 default to 3 copayment () Prior authorization, (ST) Step Therapy, () Quantity limit () This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800)

22 AUTONOMIC DRUGS SKELETAL MUSCLE RELAXANTS SKELETAL MUSCLE RELAXANTS, MISCELLANEOUS orphenadrine citrate SYMTHOLYTIC ADRENERGIC BLOCKING AGENTS ALPHA-ADRENERGIC BLOCKING AGENT(SYMTH) alfuzosin hcl dihydroergotamine mesylate ergoloid mesylates (8 units /30 days) tamsulosin hcl SYMTHOMIMETIC (ADRENERGIC) AGENTS ALPHA- AND BETA-ADRENERGIC AGONISTS AUVI-Q (epinephrine) (30 caps /30 days) ephedrine sulfate (pressors) epinephrine Auto Injector epinephrine Solution EPIPEN (epinephrine) EPIPEN 2-K (epinephrine) EPIPEN-JR 2-K (epinephrine) norepinephrine bitartrate ALPHA-ADRENERGIC AGONISTS LUSONAL (phenylephrine) midodrine hcl phenylephrine hcl (pressors) BETA-ADRENERGIC AGONISTS ADVAIR DISKUS (fluticasone-salmeterol) ADVAIR HFA (fluticasone-salmeterol) (1 inhaler/30 days) (1 inhaler/30 days) albuterol Tablets, syrup, solution for inhalation ARCAPTA NEOHALER (indacaterol maleate) (30 caps/30 days) For 2- plans: drugs listed as 3 and 4 default to 2 copayment F or 3- plans: drugs listed as 4 default to 3 copayment () Prior authorization, (ST) Step Therapy, () Quantity limit () This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800)

23 AUTONOMIC DRUGS SYMTHOMIMETIC (ADRENERGIC) AGENTS BETA-ADRENERGIC AGONISTS BROVANA (arformoterol tartrate) COMBIVENT (ipratropium-albuterol) COMBIVENT REIMAT (ipratropium-albuterol) FORADIL AEROLIZER (formoterol fumarate) ipratropium-albuterol levalbuterol Nebs MAXAIR AUTOHALER (pirbuterol acetate) metaproterenol sulfate PROAIR HFA, VENTOLIN HFA PERFOROMIST (formoterol fumarate) PROAIR HFA (albuterol) PROAIR REICLICK (albuterol) (120 / 3o days) (15 canister/365 days) (15 canister/365 days) PROVENTIL HFA (albuterol) SEREVENT DISKUS (salmeterol xinafoate) terbutaline sulfate PROAIR HFA, VENTOLIN HFA VENTOLIN HFA (albuterol) (15 canister/365 days) XOPENEX HFA (levalbuterol) BLOOD DERIVATIVES PROAIR HFA, VENTOLIN HFA albumin, human BLOOD FORMATION,COAGULATION & THROMBOSIS ANTIANEMIA DRUGS IRON PRERATIONS b-complex w/ c-min-fe & folic acid fe asparto gly-fe fum-b12-folic acid-vit c-succinic acid fe fumarate-vitamin c-vitamin b12-folic acid For 2- plans: drugs listed as 3 and 4 default to 2 copayment F or 3- plans: drugs listed as 4 default to 3 copayment () Prior authorization, (ST) Step Therapy, () Quantity limit () This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800)

24 BLOOD FORMATION,COAGULATION & THROMBOSIS ANTIANEMIA DRUGS IRON PRERATIONS FERREX 150 FORTE (iron polysaccharide complexvit b12-folic acid) FERRO-PLEX HEMATINIC (ferrous fumaratedocusate na-c-e-b12-if-folic acid) ferrous fumarate w/ b12-vit c-fa-ifc ferrous fumarate-folic acid ferrous fumarate-folic acid Tablets ferrous sulfate-vitamin c-folic acid iron combinations iron polysaccharide complex-vit b12-folic acid iron-folic acid-vitamin b12-vitamin c-docusate sodium iron-vitamin c-vitamin b12-folic acid NEPHRON FA (ferrous fumarate w/ fa-dss-b complex-vit c) polysaccharide iron complex ANTIHEMORRHAGIC AGENTS HEMOSTATICS ADVATE (antihemophilic factor) MED Medical Coinsurance ALPHANATE/VON WILLEBRAND FACTOR COMPLEX/HUMAN (antihemophilic factor/von willebrand factor complex (human)) MED Medical Coinsurance ALPHANINE SD (coagulation factor ix) MED Medical Coinsurance aminocaproic acid Syrup aminocaproic acid (300 tab / fill) Tablets antihemophilic factor MED Medical Coinsurance BEBULIN (factor ix complex) MED Medical Coinsurance For 2- plans: drugs listed as 3 and 4 default to 2 copayment F or 3- plans: drugs listed as 4 default to 3 copayment () Prior authorization, (ST) Step Therapy, () Quantity limit () This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800)

The 365-day period begins with the first dispensing transaction for each Ontario Drug Benefit (ODB) recipient on or after October 1, 2015.

The 365-day period begins with the first dispensing transaction for each Ontario Drug Benefit (ODB) recipient on or after October 1, 2015. Ontario Public Drug Programs, Ministry of Health and Long-Term Care Chronic-use Medications List by In accordance with subsection 18 (11.1) of Ontario Regulation 201/96 made under the Ontario Drug Benefit

More information

Measuring Generic Efficiency in Part D

Measuring Generic Efficiency in Part D Measuring in Part D Rates among Medicare Part D Generic efficiency rate is a measurement of the total number of prescrip=ons filled as a generic for products with a direct generic subs=tute within a therapeu=c

More information

PROJECT LIST GENERIC PRODUCTS

PROJECT LIST GENERIC PRODUCTS PROJECT LIST GENERIC PRODUCTS Acetylcysteine, Effervescent tablets 200 mg, 600 mg Alendronate sodium, Tablets 10, 70 mg Alfuzosin,Tablets 2.5mg Alfuzosin, ER Tablets 10 mg Ambroxol, Effervescent tablets

More information

Club Members save even more with the $4 Plus Plan!

Club Members save even more with the $4 Plus Plan! Club Members save even more with the $4 Plus Plan! ITEM DESCRIPTION Acephen Supp 650MG 12 Acetam Tab 325MG 30 90 Acyclovir Cap 200MG 30 90 Albuterol Syr 2MG/5ML 120 360 Albuterol Sulfate Nebulizer Ud Sol

More information

Drug Cost Estimates Generics

Drug Cost Estimates Generics Cost Estimates Generics Note: The retail pharmacy prices displayed below are estimates only. The actual price of your prescription W/ CODEINE TAB 300-30 MG ACYCLOVIR TAB 400 MG ALBUTEROL INHAL AEROSOL

More information

PREFERRED GENERIC DRUG LIST

PREFERRED GENERIC DRUG LIST These discount programs are NOT health insurance policies and are not intended as a substitute for insurance. The programs do not qualify as a minimum creditable coverage under Massachusetts law or where

More information

$4, 30-day $10, 90-day

$4, 30-day $10, 90-day $4 Prescriptions - Choose from hundreds of generic drugs and over the counter medications. Free Home Delivery Mailed right to your home Free shipping Prescription Program includes up to a 30-day supply

More information

QUANTITY LIMITS TABLE

QUANTITY LIMITS TABLE S TABLE / TABLA DE ABILIFY ARIPIPRAZOLE ORAL SOLUTION 900 ML IN 30 DAYS ABILIFY DISCMELT 10 MG ARIPIPRAZOLE TAB RAPDIS 30 TABS IN 30 DAYS ABILIFY DISCMELT 15 MG ARIPIPRAZOLE TAB RAPDIS 60 TABS IN 30 DAYS

More information

Directory of Generic Medications Eligible for Rx Savings Program Flat Fees

Directory of Generic Medications Eligible for Rx Savings Program Flat Fees Directory of Generic Medications Eligible for Rx Savings Program Flat Fees CONNECTICUT VERSION If you re already enrolled in the FREE* Rx Savings Program, use this guide to find your best choices. And,

More information

Scott & White Health Plan Formulary

Scott & White Health Plan Formulary Scott & White Health Plan Formulary 3 rd Qtr 2015 P a g e 2 Table of Contents What is my prescription drug coverage?... 3 What is the Scott & White Health Plan formulary?... 3 How was the formulary created

More information

Retail Prescription Program Drug List

Retail Prescription Program Drug List Retail Prescription Program Drug List Price Matters New Men s Health Category Convenience Free Home Delivery Our 4 prescriptions have saved our customers over 3 billion The program is available to everyone,

More information

612 Program Midtown Express Pharmacy

612 Program Midtown Express Pharmacy ALENDRONATE SOD TAB 35MG (max 1 per week) $37.00 $70.00 ALENDRONATE SOD TAB 70MG (max 1 per week) $37.00 $70.00 ALLOPURINOL TAB 100MG $20.00 $38.00 ALLOPURINOL TAB 300MG $20.00 $38.00 AMITRIPTYLINE TAB

More information

Members enjoy more Pharmacy savings *

Members enjoy more Pharmacy savings * Sam s Plus Members enjoy more Pharmacy savings 5 prescription drugs available for FREE Generic medications: Donepezil, Pioglitazone, Escitalopram, Finasteride and Vitamin D2 50,000IU are $ 0 for a 30-day

More information

MVP s Medicare Stars Ratings: High Risk Medications

MVP s Medicare Stars Ratings: High Risk Medications MVP s Medicare Stars Ratings: High Risk Medications The Center for Medicare and Medicaid Services (CMS) uses the Star Rating System to evaluate Medicare Advantage health plans as well as their networks

More information

Palliative Care Drug Plan (Plan P) Formulary List of drugs PharmaCare covers

Palliative Care Drug Plan (Plan P) Formulary List of drugs PharmaCare covers Palliative Care Drug Plan (Plan P) Formulary List of drugs PharmaCare covers Important Notes: Last Updated: May 11, 2015 Pharmacists must submit a claim on PharmaNet at the time of purchase to enable coverage.

More information

$10.00 PRESCRIPTION PROGRAM DETAILS

$10.00 PRESCRIPTION PROGRAM DETAILS $10.00 PRESCRIPTION PROGRAM DETAILS 1. The $10.00 program applies only to certain generic drugs at commonly prescribed 90 day usage dosages. (See list). 2. The Program may change without notification and

More information

Home Delivery Prescription Program Drug List

Home Delivery Prescription Program Drug List Home Delivery Prescription Program Drug List Low-cost prescriptions, right in your mailbox. Now you can have your generic prescriptions mailed right to your home, no matter where you live. Because we think

More information

UnitedHealthcare Group Medicare Advantage (PPO)

UnitedHealthcare Group Medicare Advantage (PPO) Your Plan Explained UnitedHealthcare Group Medicare Advantage (PPO) UHEX11MP3230855_001 Y0066_100616_09113 Your Medicare. This brochure explains your Medicare Advantage plan, a type of health plan also

More information

Covered California s 2016 Formularies

Covered California s 2016 Formularies Covered California s 2016 Formularies An analysis of the drugs per tier in all 12 health plans that are available for treating and preventing HIV (pp 1 24) and for treating hepatitis B (pp 26 37) and hepatitis

More information

Generic Pharmacy Discount

Generic Pharmacy Discount Generic Pharmacy Discount 83 Park Place Blvd Suite 101 Clearwater, FL 33759 Fourth Quarter 2014 727.461.6044 800.314.0088 Pharmacies Generic Discount Program Information Enclosed information provided

More information

BlueSaver Generic Preventive Care Drug Program List

BlueSaver Generic Preventive Care Drug Program List An independent licensee of the Blue Cross and Blue Shield Association. BlueSaver Generic Preventive Care Drug Program List Preventive care drugs are drugs that can help keep you from developing a health

More information

2015 Formulary (List of Covered Drugs)

2015 Formulary (List of Covered Drugs) Blue Cross Medicare Advantage Basic (HMO) SM Blue Cross Medicare Advantage Premier Plus (HMO-POS) SM 015 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS

More information

Pharmacy Savings Program

Pharmacy Savings Program Pharmacy Savings Program SELECT GENERICS DRUG LIST The Pharmacy Savings Program provides you with savings on select generic medications included on this list. The prices for these select generic medications

More information

HIV 1. A reference guide for prescription HIV-1 medications

HIV 1. A reference guide for prescription HIV-1 medications HIV 1 A reference guide for prescription HIV-1 medications Several different kinds of antiretroviral drugs are currently used to treat HIV-1 infection. These medicines are the ones most commonly used in

More information

2015 List of Covered Drugs

2015 List of Covered Drugs +B/LVW2I'UXJV5B$SSURYHG 2015 List of Covered s (Formulary) FOR MORE INFORMATION, contact Member Services at 1-855-735-4398 from 8 a.m. to 8 p.m., seven days a week. TTY users call 711. On weekends and

More information

Avoid paying too much for your prescriptions

Avoid paying too much for your prescriptions Quality health plans & benefits Healthier living Financial well-being Intelligent solutions 2016 Aetna Rx Step Program Medicine List Avoid paying too much for your prescriptions It s important to try to

More information

MICHILD CHILDREN S SPECIAL HEALTH CARE SERVICES (CSHCS) FORMULARY Effective October 2015

MICHILD CHILDREN S SPECIAL HEALTH CARE SERVICES (CSHCS) FORMULARY Effective October 2015 MICHILD CHILDREN S SPECIAL HEALTH CARE SERVICES (CSHCS) FORMULARY Effective October 2015 Provided by EnvisionRxOptions Introduction The Total Health Care (THC) MIChild Children s Special Health Care Services

More information

(Comprehensive list of covered drugs)

(Comprehensive list of covered drugs) Standard Plan 015 Prescription Drug Formulary (Comprehensive list of covered drugs) +306$SSURYHG)RUPXODU\)LOH6XEPLVVLRQ,'9HUVLRQ1XPEHU16 This document contains information about the drugs we cover in this

More information

FORMULARY. (List of Covered Drugs) Molina Dual Options Medicare-Medicaid Plan

FORMULARY. (List of Covered Drugs) Molina Dual Options Medicare-Medicaid Plan FORMULARY (List of Covered Drugs) 2015 Molina Dual Options Medicare-Medicaid Plan Version 14 UPDATED: 11/2015 Member Services (877) 901-8181, TTY/TDD 711 Monday - Friday, 8 a.m. - 8 p.m. local time H8046_15_16003_0002_MMPILRx

More information

Members enjoy more Pharmacy savings *

Members enjoy more Pharmacy savings * Sam s Plus Members enjoy more Pharmacy savings 5 prescription drugs available for FREE Generic medications: Donepezil, Pioglitazone, Escitalopram, Finasteride and Vitamin D2 50,000IU are $ 0 for a 30-day

More information

Drugs with Anticholinergic Activity

Drugs with Anticholinergic Activity PL Detail-Document #271206 This PL Detail-Document gives subscribers additional insight related to the Recommendations published in PHARMACIST S LETTER / PRESCRIBER S LETTER December 2011 Drugs with Anticholinergic

More information

Drug Classifications. Cholinergic (parasympathetic) drugs Ex. Acetylcholine, bethanecol, neostigmine, guanidine

Drug Classifications. Cholinergic (parasympathetic) drugs Ex. Acetylcholine, bethanecol, neostigmine, guanidine Drug Classifications I. Autonomic nervous system drugs Cholinergic (parasympathetic) drugs Ex. Acetylcholine, bethanecol, neostigmine, guanidine Cholinergic blocking drugs Ex. Atropine, scopolamine Adrenergic

More information

Product Catalog. 65862-0073-60 Abacavir Tablets 300 mg 60 80 80 AB Ziagen Yellow

Product Catalog. 65862-0073-60 Abacavir Tablets 300 mg 60 80 80 AB Ziagen Yellow 65862-0073-60 Abacavir Tablets 300 mg 60 80 80 AB Ziagen Yellow 13107-0058-01 Acetaminophen & Codeine Tablets, C-III 300 mg / 15 mg 100 216 216 AA Tylenol-Codeine White/Off-White 13107-0059-01 Acetaminophen

More information

HIV MEDICATIONS AT A GLANCE. Atripla 600/200/300 mg tablet 02300699 1 tablet daily. Complera 200/25/300 mg tablet 02374129 1 tablet daily

HIV MEDICATIONS AT A GLANCE. Atripla 600/200/300 mg tablet 02300699 1 tablet daily. Complera 200/25/300 mg tablet 02374129 1 tablet daily HIV MEDICATIONS AT A GLANCE Generic Name Trade Name Strength DIN Usual Dosage Single Tablet Regimen (STR) Products Efavirenz/ emtricitabine/ Emtricitabine/ rilpivirine/ elvitegravir/ cobicistat/ emtricitabine/

More information

Pharmaceutical Manufacturing Formulations

Pharmaceutical Manufacturing Formulations HANDBOOK OF Pharmaceutical Manufacturing Formulations Uncompressed Solid Products VOLUME 2 Sarfaraz K. Niazi CRC PRESS Boca Raton London New York Washington, D.C. Table of Contents Parti Regulatory and

More information

Network Health Insurance Corporation Upcoming Negative Changes to the Medicare Part D Formulary

Network Health Insurance Corporation Upcoming Negative Changes to the Medicare Part D Formulary Requesting an Exception to the Formulary You can ask Network Health Insurance Corporation to make an exception to our coverage rules. Generally, we will only approve your request for an exception if alternative

More information

Guidance for Industry Hypertension Indication: Drug Labeling for Cardiovascular Outcome Claims

Guidance for Industry Hypertension Indication: Drug Labeling for Cardiovascular Outcome Claims Guidance for Industry Hypertension Indication: Drug Labeling for Cardiovascular Outcome Claims U.S. Department of Health and Human Services Food and Drug Administration Center for Drug Evaluation and Research

More information

SAVE ON MEDICAL SERVICES and PRESCRIPTION DRUGS for ongoing conditions

SAVE ON MEDICAL SERVICES and PRESCRIPTION DRUGS for ongoing conditions SAVE ON MEDICAL SERVICES and PRESCRIPTION DRUGS for ongoing conditions With Dickinson College s Value Based Insurance Design (VBID) If you have an ongoing condition, you can live well. You will need to

More information

Patient Information Leaflet Drug interaction with ED drug treatments

Patient Information Leaflet Drug interaction with ED drug treatments Patient Information Leaflet Drug interaction with ED drug treatments This document is intended for information purposes only and should be used in conjunction with the advice and further details to be

More information

Members enjoy more Pharmacy savings *

Members enjoy more Pharmacy savings * Sam s Plus Members enjoy more Pharmacy savings 5 prescription drugs available for FREE Generic medications: Donepezil, Pioglitazone, Escitalopram, Finasteride and Vitamin D2 50,000IU are $ 0 for a 30-day

More information

Magellan Rx Medicare Basic (PDP) 2016 Formulary. (List of Covered Drugs)

Magellan Rx Medicare Basic (PDP) 2016 Formulary. (List of Covered Drugs) Magellan Rx Medicare Basic (PDP) 2016 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE S WE COVER IN THIS PLAN Formulary File 16144, Version 22 This formulary

More information

EXCHANGES_CVSC_NY3 eff 10/01/2015

EXCHANGES_CVSC_NY3 eff 10/01/2015 EXCHANGES_CVSC_NY3 eff 10/01/2015 Drug Name ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS Amphetamines amphetamine-dextroamphetamine cap sr 1 QL (90 caps / 25 days) 24hr 5 amphetamine-dextroamphetamine

More information

Each un coated tablet contains: Nimesulide. Each un coated tablet contains: Nimesulide Paracetamol

Each un coated tablet contains: Nimesulide. Each un coated tablet contains: Nimesulide Paracetamol Sr No. Generic Name Composition Claim 1 Tabs. 100/ 2 + Para Tabs. 3 + Tizanidine Tabs. 4 + Tabs. 5 +Serratio Tabs. 6 +Serratio Tabs. 7 Aceclo Tabs. IP 8 Aceclo + Para Tabs. 9 Aceclo + Para + Chlorzoxazone

More information

Marketplace Health Plans Template Assessment Tool October 2014

Marketplace Health Plans Template Assessment Tool October 2014 Marketplace Health Plans Template Assessment Tool October 2014 Beginning in January 2015, state and federal Marketplaces (aka exchanges) will again offer a range of insurance plans called qualified health

More information

Avoid paying too much for your prescriptions 2015 Aetna Rx Step Program Medicine List

Avoid paying too much for your prescriptions 2015 Aetna Rx Step Program Medicine List Quality health plans & benefits Healthier living Financial well-being Intelligent solutions Avoid paying too much for your prescriptions 2015 Aetna Rx Step Program Medicine List 05.03.392.1 C (10/14) It

More information

PSYCHOSOMATIC INSTITUTE OF SAN ANTONIO New Patient Information

PSYCHOSOMATIC INSTITUTE OF SAN ANTONIO New Patient Information PSYCHOSOMATIC INSTITUTE OF SAN ANTONIO New Patient Information Name: Last: First: MI: Birth Date: Sex: M F Marital Status: Single Married Divorced Separated Widowed Partnered Other Preferred name: Emergency

More information

Formulary for mental health medications

Formulary for mental health medications Formulary for mental health medications The Medicines Management Committee has approved this list of formulary medicines with links to national and local prescribing guidelines. If a medicine for a mental

More information

May 2015 P&T Updates. Prior Authorization. Traditional. Formulary. Yes No. Formulary. Non Formulary. Non Formulary. Non Formulary

May 2015 P&T Updates. Prior Authorization. Traditional. Formulary. Yes No. Formulary. Non Formulary. Non Formulary. Non Formulary Commercial Triple Tier 4th Tier Applicable Traditional s EVOTAZ 2 2 Alternatives Flovent Diskus/HFA, Pulmicort Flexhaler, Qvar, Asmanex HFA eszopiclone, zaleplon, zolpidem, amitriptyline, mirtazapine,

More information

An Overview of Mayo Clinic Tests Designed for Detecting Drug Abuse

An Overview of Mayo Clinic Tests Designed for Detecting Drug Abuse Drug Testing An Overview of Mayo Clinic Tests Designed for Detecting Drug Abuse Printed on August 18, 2016 1:59 pm CST 2016 Mayo Foundation for Medical Education and Research (MFMER). All rights reserved.

More information

PREFERRED GENERIC DRUG LIST

PREFERRED GENERIC DRUG LIST ALLERGIES & COLD AND FLU Preferred generic drugs MARCH 2013 supply* for $5 supply* for $10 and $15 * The day supply is based upon the average dispensing patterns for the specific drug and strength. 90-

More information

AETNA BETTER HEALTH OF OHIO a MyCare Ohio plan

AETNA BETTER HEALTH OF OHIO a MyCare Ohio plan AETNA BETTER HEALTH OF OHIO a MyCare Ohio plan 2015 List of Covered Drugs/Formulary Aetna Better Health of Ohio, a MyCare Ohio plan (Medicare-Medicaid Plan) is a health plan that contracts with Medicare

More information

Pharmacological Management of Dementia

Pharmacological Management of Dementia Pharmacological Management of Dementia Christopher Sullivan Lead Clinical Pharmacist South and West Devon Devon Partnership Trust Overview Management of cognitive symptoms Management of non-cognitive symptoms

More information

MEDICATIONS COMMONLY USED IN CHRONIC KIDNEY DISEASE. HealthPartners Kidney Health Clinic 2011

MEDICATIONS COMMONLY USED IN CHRONIC KIDNEY DISEASE. HealthPartners Kidney Health Clinic 2011 MEDICATIONS COMMONLY USED IN CHRONIC KIDNEY DISEASE HealthPartners Kidney Health Clinic 2011 People with chronic kidney disease (CKD) require multiple medications. This handout will help explain the reason

More information

Psychiatric Medications: Pearls and Pitfalls. The majority of medications used in patients with psychiatric diagnoses have more than one use.

Psychiatric Medications: Pearls and Pitfalls. The majority of medications used in patients with psychiatric diagnoses have more than one use. Psychiatric Medications: Pearls and Pitfalls Rule #1 The majority of medications used in patients with psychiatric diagnoses have more than one use. Without access to the patient s medical record, to review

More information

BC Cancer Agency & Canadian Cancer Society Financial Support Drug Program (FSDP) for Cancer Patients. Drug Benefit List. Updated February 15, 2016

BC Cancer Agency & Canadian Cancer Society Financial Support Drug Program (FSDP) for Cancer Patients. Drug Benefit List. Updated February 15, 2016 BC Cancer Agency & Canadian Cancer Society Financial Support Drug Program (FSDP) for Cancer Patients Drug Benefit List Updated February 15, 2016 The FSDP will operate following rules established by the

More information

First Health Part D Value Plus (PDP) 2014 Formulary. (List of Covered Drugs)

First Health Part D Value Plus (PDP) 2014 Formulary. (List of Covered Drugs) 2014 Formulary (List of Covered s) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on 10/28/2014. For more recent information or other questions,

More information

Arizona Department of Health Services/ Division of Behavioral Health Services Behavioral Health Drug List Effective 1/1/2014

Arizona Department of Health Services/ Division of Behavioral Health Services Behavioral Health Drug List Effective 1/1/2014 Arizona Department of Health Services/ Division of Behavioral Health Services Behavioral Health Drug List Effective 1/1/2014 The Arizona Department of Health Services, Division of Behavioral Health Services,

More information

HealthyBlue Select Generics

HealthyBlue Select Generics Certain drugs are considered generic preventive by CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. s Pharmacy Management Team. As a HealthyBlue CDH member, the drugs listed below are not

More information

HELPFUL TIPS WHEN FACING CHRONIC HEPATITIS C

HELPFUL TIPS WHEN FACING CHRONIC HEPATITIS C HELPFUL TIPS WHEN FACING CHRONIC HEPATITIS C STAYING PROACTIVE DURING TREATMENT No matter how chronic hepatitis C (genotype 1) entered your life, there are things you can do to stay proactive while you

More information

AvMed Medicare Choice

AvMed Medicare Choice AvMed Medicare Choice 2016 Comprehensive Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Note to existing members: This formulary

More information

Drug/Drug and Drug/Food Interactions with Target-Specific Oral Anticoagulants

Drug/Drug and Drug/Food Interactions with Target-Specific Oral Anticoagulants Drug/Drug and Drug/Food Interactions with Target-Specific Oral Anticoagulants Sara R. Vazquez, PharmD, BCPS, CACP Clinical Pharmacist University of Utah Health Care Thrombosis Service Nothing to disclose

More information

North Carolina Marketplace Plans with More Affordable Drug Cost Sharing for People with HIV

North Carolina Marketplace Plans with More Affordable Drug Cost Sharing for People with HIV North Carolina Marketplace Plans with More Affordable Drug Cost Sharing for People with HIV Of North Carolina s marketplace insurance offerings, only Blue Cross Blue Shield s plans are potentially affordable

More information

Emit Drugs of Abuse Urine Assays Cross-Reactivity List. Answers for life.

Emit Drugs of Abuse Urine Assays Cross-Reactivity List. Answers for life. Emit Drugs of Abuse Urine Assays Cross-Reactivity List Answers for life. Contents Emit II Plus Amphetamines...4 Emit II Plus Barbiturate...8 Emit II Plus Benzodiazepine... 12 Emit II Plus Cannabinoid...

More information

for Extended Stability Parenteral Drugs Third Edition Caryn M. Bing, R.Ph., M.S., FASHP Editor

for Extended Stability Parenteral Drugs Third Edition Caryn M. Bing, R.Ph., M.S., FASHP Editor Extended Stability for Parenteral Drugs Third Edition Editor Caryn M. Bing, R.Ph., M.S., FASHP 1 American Society of Health-System Pharmacists Bethesda, Maryland Contents Preface Acknowledgments x/ Dedication

More information

Updated MAR 26, 2013 Myelography Seizures:

Updated MAR 26, 2013 Myelography Seizures: Updated MAR 26, 2013 Myelography Medications to be evaluated prior to myelography. This list is to assist the radiologist, pharmacist, and radiology technologist in evaluating medication risk associated

More information

Extra Value Drug List. *

Extra Value Drug List. * List. * Brand Diabetes Levemir 100 units/ml Vial 10mL $122.29 Levemir FlexPen 100 units/ml 15mL $203.03 NovoLog 100 units/ml Vial 10mL $116.84 NovoLog FlexPen Syringe 15mL $222.41 NovoLog 100 units/ml

More information

2016 Cigna-HealthSpring Rx COMPREHENSIVE DRUG LIST (Formulary)

2016 Cigna-HealthSpring Rx COMPREHENSIVE DRUG LIST (Formulary) 2016 Cigna-HealthSpring Rx COMPREHENSIVE LIST (Formulary) Please read: This document contains information about all of the drugs we cover in this plan. Plan covered Cigna-HealthSpring Rx Secure (PDP) This

More information

Effective Date: 6/3/14

Effective Date: 6/3/14 North Shore-Long Island Jewish Health System, Inc. Long Island Jewish Medical Center PATIENT CARE SERVICES POLICY TITLE: ORDERING, ADMINISTRATION AND DISPOSAL OF ORAL CHEMOTHERAPEUTIC AGENTS Prepared by:

More information

2016 Comprehensive List of Covered Drugs

2016 Comprehensive List of Covered Drugs Healthcare Marketplace Comprehensive Exchange Drug List: CY2016 2016 Comprehensive List of Covered Drugs PLEASE READ: THIS DOCUMENT HAS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. Covered persons

More information

USP Medicare Model Guidelines v6.0 (Categories and Classes)

USP Medicare Model Guidelines v6.0 (Categories and Classes) USP Medicare Model Guidelines v6.0 (Categories and Classes) USP Category Analgesics Nonsteroidal Anti-inflammatory Drugs Opioid Analgesics, Long-acting Opioid Analgesics, Short-acting Anesthetics Local

More information

Clinically Significant Cardiovascular. Drug Interactions. April 30, 2014 Michael A Militello, PharmD, BCPS Cardiovascular Clinical Pharmacist

Clinically Significant Cardiovascular. Drug Interactions. April 30, 2014 Michael A Militello, PharmD, BCPS Cardiovascular Clinical Pharmacist Clinically Significant Cardiovascular Drug Interactions April 30, 2014 Michael A Militello, PharmD, BCPS Cardiovascular Clinical Pharmacist Introduction Drug interactions represent 3-5% of preventable

More information

Attachment E Annual ESTIMATED Usage based on 2007 volumes

Attachment E Annual ESTIMATED Usage based on 2007 volumes Description Quantity # Orders Dept ABILIFY 10MG TABLET 660 22 Children's Vil. ABILIFY 15MG TABLET 150 4 Children's Vil. ABILIFY 20MG TABLET 300 10 Children's Vil. ABILIFY 5MG TABLET 840 20 Children's Vil.

More information

FORMULARY. List of Covered Drugs. Good health is where you live. Ultimate Premier Ultimate Premier Plus Ultimate Elite Ultimate Elite Plus

FORMULARY. List of Covered Drugs. Good health is where you live. Ultimate Premier Ultimate Premier Plus Ultimate Elite Ultimate Elite Plus 2015 FORMULARY List of Covered Drugs Ultimate Premier Ultimate Premier Plus Ultimate Elite Ultimate Elite Plus PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This

More information

Drug Treatment Program Update

Drug Treatment Program Update Drug Treatment Program Update As of May 211 Drug Treatment Program Update A key component of the Centre s mandate is to monitor the impact of HIV/AIDS on British Columbia. The Centre provides essential

More information

. ก ก 1. Actifed tab/syr. Triprolidine : should be stored in tight, light-resistant Pseudoepedrine : Triprolidine (p.25) Pseudoepedrine (p.

. ก ก 1. Actifed tab/syr. Triprolidine : should be stored in tight, light-resistant Pseudoepedrine : Triprolidine (p.25) Pseudoepedrine (p. ก ก. 2553 (p.807) 3. Adrenaline inj. 1mg/ml (Epinephrine inj.) ( Druginfor. p.629) 4. Aminophylline/ Theophylline inj. (Drug infor. Ed. 11 th p.1339) 5. Amlodipine + HCTZ (Moduretic). ก ก 1. Actifed tab/syr.

More information

Preferred Drug List. (List of Covered Drugs) This document includes Passport Health Plan s complete 2015 formulary.

Preferred Drug List. (List of Covered Drugs) This document includes Passport Health Plan s complete 2015 formulary. Drug List (List of Covered Drugs) This document includes Passport Health Plan s complete 2015 formulary. What is the Passport Health Plan formulary? The formulary is a list of preferred drugs covered by

More information

ALZHEIMER'S DRUGS. Details. Step 2: Exelon Patch 13.3 mg/24 hour transdermal Exelon Patch 4.6 mg/24 hr transdermal

ALZHEIMER'S DRUGS. Details. Step 2: Exelon Patch 13.3 mg/24 hour transdermal Exelon Patch 4.6 mg/24 hr transdermal ALZHEIMER'S DRUGS Products Affected Step 1: donepezil 10 mg disintegrating tablet donepezil 10 mg tablet donepezil 23 mg tablet donepezil 5 mg disintegrating tablet donepezil 5 mg tablet galantamine 12

More information

Medicines To Help You High Blood Pressure

Medicines To Help You High Blood Pressure Medicines To Help You High Blood Pressure Use this guide to help you talk to your doctor, pharmacist, or nurse about your blood pressure medicines. The guide lists all of the FDA-approved products now

More information

PSYCHOPHARMACOLOGY AND WORKING WITH PSYCHIATRY PROVIDERS. Juanaelena Garcia, MD Psychiatry Director Institute for Family Health

PSYCHOPHARMACOLOGY AND WORKING WITH PSYCHIATRY PROVIDERS. Juanaelena Garcia, MD Psychiatry Director Institute for Family Health PSYCHOPHARMACOLOGY AND WORKING WITH PSYCHIATRY PROVIDERS Juanaelena Garcia, MD Psychiatry Director Institute for Family Health Learning Objectives Learn basics about the various types of medications that

More information

2016 List of Covered Drugs

2016 List of Covered Drugs 1 UnitedHealthcare Connected for MyCare Ohio (Medicare-Medicaid Plan) 2016 List of Covered Drugs (Formulary) This is a list of drugs that members can get in UnitedHealthcare Connected for MyCare Ohio.

More information

AETNA BETTER HEALTH Prior Authorization guidelines for Step Therapy

AETNA BETTER HEALTH Prior Authorization guidelines for Step Therapy AETNA BETTER HEALTH Prior Authorization guidelines for Step Therapy Definition A form of automated Prior Authorization whereby one or more prerequisite medications, which may or may not be in the same

More information

First Health Part D Premier Plus (PDP) 2014 Formulary. (List of Covered Drugs)

First Health Part D Premier Plus (PDP) 2014 Formulary. (List of Covered Drugs) 2014 Formulary (List of Covered s) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on 10/28/2014. For more recent information or other questions,

More information

To Learn More: Medicines To Help You High Blood Pressure

To Learn More: Medicines To Help You High Blood Pressure Medicines To Help You High Blood Pressure Use this guide to help you talk to your doctor, pharmacist, or nurse about your blood pressure medicines. The guide lists all of the FDA-approved products now

More information

Daclatasvir (Daklinza)

Daclatasvir (Daklinza) FACTSHEET Daclatasvir (Daklinza) Summary Daclatasvir (Daklinza) is a medication used to treat hepatitis C. It is taken with sofosbuvir (Sovaldi) and sometimes ribavirin. This combination is approved in

More information

July 2015 P & T Updates

July 2015 P & T Updates Commercial Triple Tier 4th Tier Applicable Traditional CORLANOR 3 2 2 tablets per day GLYXAMBI 3 2 1 tablet per day Alternatives carvedilol, bisoprolol, metoprolol succinate, digoxin, hydralazine, isosorbide

More information

Medications Used in the Management of Disruptive Behavior Disorders

Medications Used in the Management of Disruptive Behavior Disorders The following medication chart is provided as a brief guide to some of the medications used in the management of various behavior disorders, along with their potential benefits and possible side effects.

More information

Anthem MediBlue Dual Advantage (HMO SNP) 2016 Formulary (List of Covered Drugs)

Anthem MediBlue Dual Advantage (HMO SNP) 2016 Formulary (List of Covered Drugs) Anthem MediBlue Dual Advantage (H SNP) 06 Formulary (List of Covered s) Please read: This document contains information about the drugs we cover in this plan. This formulary was updated on May, 06. For

More information

Look-Alike Drug Names with Recommended Tall Man Letters

Look-Alike Drug Names with Recommended Tall Man Letters FDA and ISMP Lists of Look-Alike Drug Names with Recommended Tall Man Letters Since 2008, ISMP has maintained a list of drug name pairs and trios with recommended, bolded tall man (uppercase) letters to

More information

NOTICES. Approved and Required Medications Lists for Emergency Medical Services Agencies and Emergency Medical Services Providers

NOTICES. Approved and Required Medications Lists for Emergency Medical Services Agencies and Emergency Medical Services Providers NOTICES Approved and Required Medications Lists for Emergency Medical Services Agencies and Emergency Medical Services Providers [45 Pa.B. 5451] [Saturday, August 29, 2015] Under 28 Pa. Code 1027.3(c)

More information

Treatments for stroke prevention in Atrial Fibrillation as recommended by the Canadian Cardiovascular Society

Treatments for stroke prevention in Atrial Fibrillation as recommended by the Canadian Cardiovascular Society Treatments for stroke prevention in Atrial Fibrillation as recommended by the Canadian Cardiovascular Society Coumadin (Warfarin) Does this medication need ongoing monitoring of blood clotting times? Yes.

More information

PDL Excerpts Illustrating Proposed Changes

PDL Excerpts Illustrating Proposed Changes PDL Excerpts Illustrating Proposed Changes Antidepressants, Other (SNRIs) o Duloxetine added as a preferred agent PREFERRED venlafaxine ER capsules duloxetine capsules SNRIS AP desvenlafaxine ER desvenlafaxine

More information

Abridged Formulary 2016 (Partial List of Covered Drugs)

Abridged Formulary 2016 (Partial List of Covered Drugs) Abridged Formulary 2016 (Partial List of Covered Drugs) THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Indiana University Health Plans Medicare Choice HMO-POS Indiana University

More information

AETNA BETTER HEALTH SM PREMIER PLAN

AETNA BETTER HEALTH SM PREMIER PLAN AETNA BETTER HEALTH SM PREMIER PLAN 2015 List of Covered Drugs/Formulary Aetna Better Health SM Premier Plan (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Illinois Medicaid

More information

HMO and PPO Updates May 2013- Commercial Results

HMO and PPO Updates May 2013- Commercial Results HMO and PPO Updates May 2013- Commercial Results ELIQUIS Non Triple Tier Formular y 4th Tier Applicable Traditional Alternatives warfarin, Xarelto, Pradaxa TAMIFLU - EXPANDED INDICATION 2 No 2 No No None

More information

Bulletin #29. Manitoba Drug Benefits and Interchangeability Formulary Amendments

Bulletin #29. Manitoba Drug Benefits and Interchangeability Formulary Amendments Manitoba Drug Benefits and Interchangeability Formulary Amendments The following changes will be made to the Pharmacare benefit list effective March 1, 2001 Inside This Issue Part 1 Additions pg. 2 Part

More information

DRUG DRIVING OFFENCES

DRUG DRIVING OFFENCES DRUG DRIVING OFFENCES Taking drug can affect body and mind coordination that can significantly impair the ability to drive a motor vehicle. Road Traffic Ordinance (Cap 374) was amended in 2011 in order

More information

Price Increases for Brand Name Prescription Drugs Since October 2012

Price Increases for Brand Name Prescription Drugs Since October 2012 Price Increases for Brand Name Prescription Drugs Since October 2012 Medication and Dose * * ABILIFY 1 MG/ML SOLUTION $4.15 $6.32 52.32% ABILIFY 10 MG TABLET $18.76 $29.12 55.25% ABILIFY 15 MG TABLET $18.70

More information

Perioperative Medication Management

Perioperative Medication Management CARDIOVASCULAR Beta blockers (metoprolol, atenolol, others) Should be continued until and including the day of Ace inhibitors (ACEI) & Angiotensin receptor blockers (ARB) (captopril, lisinopril, losartan,

More information

motrin ib tab 200mg 3 $0 NM; * NAPROXEN SODIUM CAP 220 MG 3 $0 NM; * non-asa jr tab 160mg 3 $0 NM; * non-aspirin chw 80mg 3 $0 NM; * pain relief dro 8

motrin ib tab 200mg 3 $0 NM; * NAPROXEN SODIUM CAP 220 MG 3 $0 NM; * non-asa jr tab 160mg 3 $0 NM; * non-aspirin chw 80mg 3 $0 NM; * pain relief dro 8 NY_MMP_CY16_2T_STND eff 03/01/2016 ANALGESICI - FARMACI TRATTAMENTO DEL DOLORE E DELLE INFIAMM GOTTA - FARMACI TRATTAMENTO DELLA GOTTA allopurinol tab 100 mg 1 $0 allopurinol tab 300 mg 1 $0 colchicine

More information

Lamictal, lamotrigine Lithium, lithobid, eskalith Depakote, valproate Trileptal, oxcarbazepine Tegretol, equetro, carbamazepine Atypicals (aripiprazole, abilify, olanzapine, zyprexa, invega, risperdal,

More information