EFFECTIVE JULY Drug Formulary

Size: px
Start display at page:

Download "EFFECTIVE JULY 2015. 2015 Drug Formulary"

Transcription

1 EFFECTIVE JULY Drug Formulary For members covered through large employer groups with a 3-tier in-network pharmacy benefit or members with an out-of-network pharmacy benefit Access PPO Alliance Connect / Alliant Plus Core / Group Health Options PPO

2 Drug Formulary INTRODUCTION Development of the Drug Formulary At Group Health the Drug Formulary is the cornerstone of medication therapy, quality assurance, and cost containment. It is a list of medications that are usually covered under a member s medical coverage agreement. The Formulary is developed by the Group Health Pharmacy and Therapeutics committee (P&T), which is composed of physicians representing various medical specialties from across the Group Health system and network providers, pharmacists, and a consumer member. The P&T committee reviews the medications in all therapeutic categories and selects the most appropriate in each class based on safety, effectiveness, and cost. The Formulary helps health care providers to offer the most effective drug therapy possible with the limited resources available. Having a formulary allows Group Health to offer the safest, most effective, and most cost-effective health care possible. The P&T committee meets quarterly to review new and existing medications to ensure that the Formulary remains responsive to the needs of members and providers. The Formulary is updated periodically and is subject to change. If a medication will be removed from the formulary, members who had filled the medication in the prior 3 months will be notified of the upcoming change. A formulary change notice will be posted on the member website at least 30 days prior to the effective date. Formulary Listing and Drug Coverage Drug coverage is based on an individual s contracted benefit and formulary status. Coverage for a specific medication is subject to each member s medical coverage agreement. Please consult your Benefit Booklet or call Customer Service if you have questions about your drug coverage. Group Health will only cover FDA-approved medications used for non-experimental therapies. Most plans exclude experimental and investigational drugs, over-the-counter drugs, drugs used in the treatment of sexual dysfunction disorders, medicines for anticipated illness while traveling, or drugs used for cosmetic purposes. Please consult your Benefit Booklet for limitations and exclusions. Medications are listed by generic name if a generic is available. Brand names may be listed only to serve as a guide. Listing of a brand name does not imply coverage of a specific brand. Generic drugs are substituted when available and allowed by the prescriber. When a generic is available, the brand-name medication is generally considered non-formulary and subject to higher cost shares. Injection medications that are typically administered by a professional in a clinical setting may not be listed on the formulary. For coverage of these drugs, refer to your Benefit Booklet. How to Search the Formulary Medications on the formulary are listed by therapeutic class. An alphabetical index is included to assist in locating specific medications. Generic Drugs When a drug company identifies a drug in the laboratory, that company is granted a patent on the drug for a period up to 20 years. During the life of the patent, no other manufacturer is allowed to produce or sell the same drug product without the patent-holder's approval, thus eliminating direct price competition. Patent protection allows the original drug company to recoup the cost of research and development and to make a profit. After the patent expires, other pharmaceutical manufacturers may develop, test, and market medications with the same active ingredients. These chemically identical products, generic drugs, contain exact quantities of the same active ingredient

3 in the same dosage form as the brand-name product and they are more affordable than the brand-name product. Prior Authorization (PA) Drugs The P&T Committee determines a number of drugs require prior authorization to confirm coverage. These medications most often have alternatives drugs on the formulary, safety concerns or a high potential for inappropriate use. Prescribers do not need authorization to prescribe the drug, only to determine coverage for a patient. To request coverage for prior authorization medications, your prescriber must contact Group Health. Medications requiring Prior Authorization are listed with PA in the right hand column. New drugs to the market may require prior authorization until reviewed by the Pharmacy and Therapeutics Committee. Step Therapy (ST) Drugs Step Therapy is a process where you must try a certain drug, such as a generic alternative, before receiving coverage for a similar but non-preferred medication. Instead of your prescriber contacting Group Health, we look at your prescription history and if you have tried the preferred agent, you will be automatically covered for the non-preferred agent. This makes coverage for you easier and reduces the amount of work for your prescriber. Medications requiring Step Therapy are listed with ST in the right hand column. Quantity Limit (QL) Drugs Medications with quantity limits are indicated with QL in the right-hand column. Quantity limits align with FDA-approved indications and dosing for safe and effective use of the drug. To request exceptions to quantity limits, your prescriber must contact Group Health. Day Supply Limit (DS) for Select Drugs Medications with day supply limit are indicated with DS in the right-hand column. These Medications are limited to a one month supply at a time. The 1-month limit minimizes waste of unused medications when there is a change in the prescribed drug or quantity. Medications Limited to Select Pharmacies Some medications are limited to Group Health mail order pharmacy and/or a designated specialty pharmacy. These pharmacies work closely with patients to manage certain specialty medications to ensure you get the most from your treatment. The pharmacy works with you and your doctor to confirm your medication is working for you, reaches out to you to set up refills, and reminds you of needed labs and review the results with you. For a list of these medications, see Appendix A. To order these medications or for questions related to these medications, you can contact the Group Health Specialty Medication Pharmacy at Members with an out-of-network benefit may use a network pharmacy; however, they may pay a higher cost share. Preventative Medications and Preferred Contraceptives Most plans cover Affordable Care Act (ACA) requirements for preventative care medications and contraceptives in full. Please consult your Benefit Booklet under Preventive Services or call Customer Service if you have questions about your coverage for these drugs. Below is the list of the preventative medications covered in full. Aspirin 81 mg and 325 mg. Limited to 30 units per 30 days Calcitriol (Vitamin D) 400 Units and 1000 Units Ferrous sulfate 15 mg/ml oral drops Folic acid 400 mg and 800 mg

4 Over-the-counter nicotine replacement patches, gum, and lozenge. Prior authorization required. Sodium fluoride chewable tabs and drops Tamoxifen generic Raloxifene generic In accordance with the Affordable Care Act (ACA) requirements for preventive services, most Group Health plans provide full coverage for contraceptives. If your plan offers ACA benefits, all prescribed FDA approved contraceptive methods from on the Group Health formulary list will be covered in full when obtained in-network. For plans with out-of-network (OON) benefits, contraceptives will be subject to the OON cost-share. Preferred contraceptives are listed on the formulary under Contraception as Tier 1 and Tier 2. If you request coverage for a non-preferred contraceptive, we will contact your provider to recommend a preferred generic or therapeutically equivalent product. If you and your provider determine that the preferred contraceptive(s) would be medically inappropriate, your provider must request a contraceptive waiver. Please consult your Benefit Booklet under Preventive Services or call Customer Service if you have questions about your coverage for contraceptives. Non-Formulary Drugs Medications not listed in this document are not on the formulary at the time of publication. The most current information is online at Non-formulary drugs are not covered unless approved by the health plan as medically necessary. The prescriber must contact Group Health to determine the medical necessity of the non-formulary medication. An alternative formulary medication will be recommended when clinically appropriate. If a medical exception is not approved, the patient is responsible for the full price of the drug. Covered Diabetic Supplies Some diabetic supplies may be covered at Tier 1 cost share if they are filled as a prescription. These items are: Preferred blood glucose test strips: o One Touch Verio o One Touch Ultra o Prodigy prior authorization required o Breeze 2 prior authorization required o Contour Next prior authorization required o Freestyle prior authorization required Disposable insulin syringes and needles Lancing device and lancets Preferred blood glucose meters are covered only when filled through the mail order pharmacy. Over-the-Counter (OTC) Drugs A few plans offer coverage for OTC drugs. For these plans, a list of covered OTC drugs can be found in Appendix B. You may contact Customer Service at to find if you have OTC drug coverage.

5 Mail Order Pharmacy Service Mail order is convenient for patients and efficiently utilizes Group Health s resources. This service works best for drugs that must be taken on regular basis, such as birth control pills and drugs for high blood pressure, high cholesterol, or other chronic conditions. To begin using Mail Order, ask your prescriber to send the prescription directly to the Mail Order Pharmacy. To transfer an existing prescription from a retail pharmacy, contact the Mail Order Pharmacy. Address: Group Health Mail Order Pharmacy PO Box Seattle, WA Phone: RXRX ( ) Fax: , or toll-free Additional Information Please contact Customer Service at with any questions or concerns regarding information contained in this document. The most current drug formulary is available to search at Table of Contents ALLERGY... 1 ANTIEMESIS/ANTIVERTIGO... 2 ASTHMA... 3 AUTONOMIC NERVOUS SYSTEM DISORDERS... 5 BEHAVIORAL HEALTH - ANTIDEPRESSANTS... 6 BEHAVIORAL HEALTH - OTHER... 9 CARDIOVASCULAR DISEASE - ARRHYTHMIA CARDIOVASCULAR DISEASE - CARDIAC STIMULANT CARDIOVASCULAR DISEASE - HYPERTENSION CARDIOVASCULAR DISEASE - LIPID IRREGULARITY CARDIOVASCULAR DISEASE - MISCELLANEOUS AGENTS CARDIOVASCULAR DISEASE - VASODILATION CONTRACEPTION/OXYTOCICS COUGH AND COLD DERMATOLOGY - ACNE DERMATOLOGY - ANTIINFECTIVE DERMATOLOGY - ANTIINFLAMMATORY DERMATOLOGY - ANTIPRURITIC DRUGS DERMATOLOGY - MISCELLANEOUS DERMATOLOGY - PSORIASIS/ECZEMA DIABETES EAR - GENERAL DISORDERS ELECTROLYTE REGULATION ENDOCRINE DISORDER - FERTILITY ENDOCRINE DISORDER - OTHER ENDOCRINE DISORDER - THYROID EYE - GENERAL DISORDERS EYE - GLAUCOMA EYE - MISCELLANEOUS GOUT AND RELATED DISEASES HEMATOLOGICAL DISORDERS HORMONAL DEFICIENCY IMMUNIZATION... 69

6 IMMUNOSUPPRESSION/MODULATION INFECTIOUS DISEASE - BACTERIAL INFECTIOUS DISEASE - FUNGAL INFECTIOUS DISEASE - MISCELLANEOUS INFECTIOUS DISEASE - PARASITIC INFECTIOUS DISEASE - VIRAL INFLAMMATORY DISEASE LOCAL ANESTHESIA LOWER GASTROINTESTINAL DISORDERS - BOWEL INFLAMMAT LOWER GASTROINTESTINAL DISORDERS - OTHER MISCELLANEOUS AGENTS NEOPLASTIC DISEASE NEUROLOGICAL DISEASE - MISCELLANEOUS ORAL/PHARYNGEAL DISORDERS OTHER DRUGS OTHER RESPIRATORY DISORDERS PAIN MANAGEMENT - ANALGESICS PARKINSONS DISEASE SEIZURE DISORDER SKELETAL MUSCLE DISORDER UPPER GASTROINTESTINAL DISORDERS - DIGESTIVE UPPER GASTROINTESTINAL DISORDERS - SPASTIC DISEASE UPPER GASTROINTESTINAL DISORDERS - ULCER DISEASE URINARY TRACT - FUNCTIONAL DISORDERS VAGINAL DISORDERS VITAMIN AND/OR MINERAL DEFICIENCY

7 1 ALLERGY arbinoxa LIQUID 1 arbinoxa TABLET 1 ASTEPRO SPRAY/PUMP 3 azelastine hcl 137 MCG SPRAY/PUMP 1 azelastine hcl 205.5MCG SPRAY/PUMP 3 BECONASE AQ SPRAY 3 budesonide SPRAY/PUMP 3 carbinoxamine maleate LIQUID 1 carbinoxamine maleate TABLET 1 cetirizine hcl SOLUTION 3 CLARINEX SYRUP 3 CLARINEX TABLET 3 CLARINEX-D 12 HOUR TBMP 12HR 3 clemastine fumarate SYRUP 1 clemastine fumarate TABLET 1 cyproheptadine hcl SYRUP 1 cyproheptadine hcl TABLET 1 desloratadine TAB RAPDIS 1 desloratadine TABLET 1 DICOPANOL SUSP RECON 3 diphenhydramine hcl ELIXIR 3 DYMISTA SPRAY/PUMP 3 fexofenadine hcl TABLET 3 fexofenadine-pse er TAB ER 24H 3 flunisolide SPRAY 1 fluticasone propionate SPRAY SUSP 1 hydroxyzine hcl SYRUP 1 hydroxyzine hcl TABLET 1 HYDROXYZINE PAMOATE CAPSULE 3 hydroxyzine pamoate CAPSULE 1 KARBINAL ER SUS ER 12H 3 levocetirizine dihydrochloride SOLUTION 1 levocetirizine dihydrochloride TABLET 1 NASONEX SPRAY/PUMP 3

8 2 olopatadine hcl SPRAY/PUMP 3 OMNARIS SPRAY/PUMP 3 PATANASE SPRAY/PUMP 3 promethazine hcl SYRUP 1 promethazine hcl TABLET 1 QNASL HFA AER AD 3 QNASL CHILDREN HFA AER AD 3 RHINOCORT AQUA SPRAY/PUMP 3 SEMPREX-D CAPSULE 3 triamcinolone acetonide SPRAY 3 VERAMYST SPRAY SUSP 3 VISTARIL CAPSULE 3 XYZAL SOLUTION 3 XYZAL TABLET 3 ZETONNA HFA AER AD 3 ANTIEMESIS/ANTIVERTIGO AKYNZEO CAPSULE 3 ANTIVERT TABLET 3 ANZEMET TABLET 3 CESAMET CAPSULE 3 COMPAZINE SUPP.RECT 2 COMPAZINE TABLET 3 compro SUPP.RECT 1 DICLEGIS TABLET DR 3 dronabinol CAPSULE 1 EMEND CAP DS PK 2 EMEND 125 MG CAPSULE 2 EMEND 40 MG CAPSULE 3 EMEND 80 MG CAPSULE 2 granisetron hcl TABLET 3 MARINOL CAPSULE 3 meclizine hcl TABLET 3 ondansetron hcl SOLUTION 1

9 3 ondansetron hcl TABLET 1 ondansetron odt TAB RAPDIS 1 phenadoz SUPP.RECT 1 PHENERGAN SUPP.RECT 2 prochlorperazine maleate SUPP.RECT 1 prochlorperazine maleate TABLET 1 promethazine hcl SUPP.RECT 1 promethegan SUPP.RECT 1 SANCUSO PATCH TDWK 3 TIGAN CAPSULE 3 TRANSDERM-SCOP PATCH TD72 3 trimethobenzamide hcl CAPSULE 3 ZOFRAN SOLUTION 3 ZOFRAN TABLET 3 ZOFRAN ODT TAB RAPDIS 3 ZUPLENZ FILM 3 ASTHMA ACCOLATE TABLET 3 ADVAIR DISKUS MCG BLST W/DEV 2 PA ADVAIR DISKUS MCG BLST W/DEV 2 PA ADVAIR DISKUS MCG BLST W/DEV 2 PA ADVAIR HFA MCG HFA AER AD 2 PA ADVAIR HFA MCG HFA AER AD 2 PA ADVAIR HFA 45-21MCG HFA AER AD 2 PA AEROSPAN HFA AER AD 3 albuterol sulfate SOLUTION 1 albuterol sulfate SYRUP 1 albuterol sulfate TAB ER 12H 3 albuterol sulfate TABLET 1 albuterol sulfate 0.63MG/3ML VIAL-NEB 3 albuterol sulfate 1.25MG/3ML VIAL-NEB 3 albuterol sulfate 2.5 MG/0.5 VIAL-NEB 1 albuterol sulfate 2.5 MG/3ML VIAL-NEB 1

10 4 ALVESCO HFA AER AD 3 ARCAPTA NEOHALER CAP W/DEV 3 ASMANEX AER POW BA 2 ST ASMANEX HFA HFA AER AD 2 ST ATROVENT HFA HFA AER AD 2 BROVANA VIAL-NEB 3 budesonide AMPUL-NEB 1 caffeine citrate SOLUTION 1 COMBIVENT RESPIMAT MIST INHAL 2 cromolyn sodium AMPUL-NEB 1 cromolyn sodium SOLUTION 3 DALIRESP TABLET 3 DULERA HFA AER AD 2 elixophyllin ELIXIR 3 FLOVENT DISKUS 100 MCG BLST W/DEV 2 PA FLOVENT DISKUS 250 MCG BLST W/DEV 2 PA FLOVENT DISKUS 50 MCG BLST W/DEV 2 PA FLOVENT HFA AER W/ADAP 2 FLOVENT HFA 110 MCG AER W/ADAP 2 PA FLOVENT HFA 220 MCG AER W/ADAP 2 PA FORADIL CAP W/DEV 3 GASTROCROM SOLUTION 3 ipratropium bromide SOLUTION 1 ipratropium-albuterol AMPUL-NEB 1 levalbuterol concentrate VIAL-NEB 3 levalbuterol hcl VIAL-NEB 3 LUFYLLIN TABLET 3 metaproterenol sulfate SYRUP 1 metaproterenol sulfate TABLET 1 montelukast sodium GRAN PACK 1 montelukast sodium TAB CHEW 1 montelukast sodium TABLET 1 PERFOROMIST VIAL-NEB 3 PROAIR HFA 90 MCG HFA AER AD 2 QL PROVENTIL HFA 90 MCG HFA AER AD 3 QL PULMICORT 0.25MG/2ML AMPUL-NEB 3

11 5 PULMICORT 0.5 MG/2ML AMPUL-NEB 3 PULMICORT 1 MG/2 ML AMPUL-NEB 2 PULMICORT FLEXHALER AER POW BA 3 QVAR AER W/ADAP 2 SEREVENT DISKUS BLST W/DEV 2 SINGULAIR GRAN PACK 3 SINGULAIR TAB CHEW 3 SINGULAIR TABLET 3 SPIRIVA CAP W/DEV 2 SPIRIVA RESPIMAT MIST INHAL 3 STRIVERDI RESPIMAT MIST INHAL 3 SYMBICORT MCG HFA AER AD 3 PA SYMBICORT MCG HFA AER AD 3 PA terbutaline sulfate TABLET 1 terbutaline sulfate VIAL 3 THEO-24 CAP ER 24H 3 theochron TAB ER 12H 1 theophylline SOLUTION 1 theophylline TABLET ER 1 theophylline anhydrous TAB ER 12H 1 TUDORZA PRESSAIR AER POW BA 3 VENTOLIN HFA 90 MCG HFA AER AD 3 QL VOSPIRE ER TAB ER 12H 3 XOPENEX VIAL-NEB 3 XOPENEX CONCENTRATE VIAL-NEB 3 XOPENEX HFA 45 MCG HFA AER AD 3 QL zafirlukast TABLET 3 ZYFLO TABLET 3 ZYFLO CR TBMP 12HR 3 AUTONOMIC NERVOUS SYSTEM DISORDERS ARICEPT TABLET 3 donepezil hcl 10 MG TABLET 1 donepezil hcl 23 MG TABLET 3

12 6 donepezil hcl 5 MG TABLET 1 donepezil hcl odt TAB RAPDIS 3 EXELON CAPSULE 3 EXELON PATCH TD24 3 galantamine hbr CAP24H PEL 1 galantamine hbr TABLET 1 galantamine hydrobromide SOLUTION 1 memantine TABLET 1 MESTINON SYRUP 2 MESTINON TABLET 3 MESTINON TABLET ER 2 NAMENDA SOLUTION 2 NAMENDA TAB DS PK 2 NAMENDA TABLET 2 NAMENDA XR CAP SPR 24 3 NAMENDA XR CAP24 DSPK 3 pyridostigmine bromide TABLET 1 RAZADYNE TABLET 3 RAZADYNE ER CAP24H PEL 3 rivastigmine CAPSULE 1 BEHAVIORAL HEALTH - ANTIDEPRESSANTS amitriptyline hcl TABLET 1 amoxapine TABLET 1 ANAFRANIL CAPSULE 3 APLENZIN TAB ER 24H 3 BRINTELLIX 10 MG TABLET 3 PA,DS BRINTELLIX 20 MG TABLET 3 PA,DS BRINTELLIX 5 MG TABLET 3 PA,DS BRISDELLE CAPSULE 3 bupropion hcl TABLET 1 bupropion hcl sr TABLET ER 1 bupropion xl TAB ER 24H 1 CELEXA TABLET 3

13 7 chlordiazepoxide-amitriptyline TABLET 3 citalopram hbr SOLUTION 1 citalopram hbr TABLET 1 clomipramine hcl CAPSULE 1 CYMBALTA CAPSULE DR 3 desipramine hcl TABLET 1 DESVENLAFAXINE ER 100 MG TAB ER 24H 3 PA DESVENLAFAXINE ER 50 MG TAB ER 24H 3 PA desvenlafaxine er 100 MG TAB ER 24 3 PA desvenlafaxine er 50 MG TAB ER 24 3 PA DESVENLAFAXINE FUMARATE ER 100 MG TAB ER 24 3 PA DESVENLAFAXINE FUMARATE ER 50 MG TAB ER 24 3 PA doxepin hcl CAPSULE 1 doxepin hcl ORAL CONC 1 duloxetine hcl CAPSULE DR 1 EFFEXOR XR CAP ER 24H 3 escitalopram oxalate SOLUTION 1 escitalopram oxalate TABLET 1 FETZIMA 120 MG CAP SA 24H 3 PA FETZIMA 20 MG CAP SA 24H 3 PA FETZIMA 40 MG CAP SA 24H 3 PA FETZIMA 80 MG CAP SA 24H 3 PA FETZIMA 20-40MG CAP24HDSPK 3 PA fluoxetine dr CAPSULE DR 3 FLUOXETINE HCL TABLET 3 fluoxetine hcl CAPSULE 1 fluoxetine hcl SOLUTION 1 fluoxetine hcl TABLET 1 fluvoxamine maleate TABLET 1 fluvoxamine maleate er CAP ER 24H 3 FORFIVO XL 450 MG TAB ER 24H 3 PA imipramine hcl TABLET 1 imipramine pamoate CAPSULE 3 KHEDEZLA 100 MG TAB ER 24 3 PA KHEDEZLA 50 MG TAB ER 24 3 PA LEXAPRO SOLUTION 3

14 8 LEXAPRO TABLET 3 maprotiline hcl TABLET 1 MARPLAN TABLET 3 mirtazapine TAB RAPDIS 3 mirtazapine TABLET 1 NARDIL TABLET 3 nefazodone hcl TABLET 3 NORPRAMIN TABLET 3 nortriptyline hcl CAPSULE 1 nortriptyline hcl SOLUTION 1 OLEPTRO ER TAB ER 24H 3 PAMELOR CAPSULE 3 PARNATE TABLET 3 paroxetine hcl TAB ER 24H 3 paroxetine hcl TABLET 1 PAXIL ORAL SUSP 2 PAXIL TABLET 3 PAXIL CR TAB ER 24H 3 perphenazine-amitriptyline TABLET 1 PEXEVA TABLET 3 phenelzine sulfate TABLET 1 PRISTIQ ER 100 MG TAB ER 24H 3 PA PRISTIQ ER 50 MG TAB ER 24H 3 PA protriptyline hcl TABLET 1 PROZAC CAPSULE 3 PROZAC WEEKLY CAPSULE DR 3 REMERON TAB RAPDIS 3 REMERON TABLET 3 SARAFEM TABLET 3 sertraline hcl ORAL CONC 1 sertraline hcl TABLET 1 SURMONTIL CAPSULE 3 TOFRANIL TABLET 3 TOFRANIL-PM CAPSULE 3 tranylcypromine sulfate TABLET 1 trazodone hcl TABLET 1

15 9 venlafaxine hcl TABLET 1 VENLAFAXINE HCL ER TAB ER 24 3 venlafaxine hcl er CAP ER 24H 1 venlafaxine hcl er TAB ER 24 3 VIIBRYD MG TAB DS PK 3 PA VIIBRYD 10 MG TABLET 3 PA VIIBRYD 20 MG TABLET 3 PA VIIBRYD 40 MG TABLET 3 PA WELLBUTRIN TABLET 3 WELLBUTRIN SR TABLET ER 3 WELLBUTRIN XL TAB ER 24H 3 ZOLOFT ORAL CONC 3 ZOLOFT TABLET 3 BEHAVIORAL HEALTH - OTHER ABILIFY 1 MG/ML SOLUTION 2 PA ABILIFY 10 MG TABLET 2 PA ABILIFY 15 MG TABLET 2 PA ABILIFY 2 MG TABLET 2 PA ABILIFY 20 MG TABLET 2 PA ABILIFY 30 MG TABLET 2 PA ABILIFY 5 MG TABLET 2 PA ABILIFY DISCMELT 10 MG TAB RAPDIS 3 PA ABILIFY DISCMELT 15 MG TAB RAPDIS 3 PA ABILIFY MAINTENA 300 MG SUSER SYR 3 PA,DS ABILIFY MAINTENA 400 MG SUSER SYR 3 PA,DS ABILIFY MAINTENA 300 MG SUSER VIAL 3 PA,DS ABILIFY MAINTENA 400 MG SUSER VIAL 3 PA,DS acamprosate calcium TABLET DR 1 ADDERALL TABLET 3 ADDERALL XR CAP ER 24H 1 QL alprazolam TABLET 1 alprazolam er TAB ER 24H 3 ALPRAZOLAM INTENSOL ORAL CONC 3

16 10 alprazolam odt TAB RAPDIS 3 alprazolam xr TAB ER 24H 3 AMBIEN TABLET 3 AMBIEN CR TAB MPHASE 3 amphetamine salt combo TABLET 1 ANTABUSE TABLET 3 aripiprazole 10MG TABLET 1 PA aripiprazole 15MG TABLET 1 PA aripiprazole 2MG TABLET 1 PA aripiprazole 20MG TABLET 1 PA aripiprazole 30MG TABLET 1 PA aripiprazole 5MG TABLET 1 PA ATIVAN TABLET 3 BELSOMRA TABLET 3 PA buspirone hcl 10 MG TABLET 1 buspirone hcl 15 MG TABLET 1 buspirone hcl 30 MG TABLET 1 buspirone hcl 5 MG TABLET 1 buspirone hcl 7.5 MG TABLET 3 BUTISOL SODIUM TABLET 3 chlordiazepoxide hcl CAPSULE 1 chlorpromazine hcl TABLET 1 clonidine hcl er TAB ER 12H 3 clorazepate dipotassium TABLET 1 clozapine 100 MG TABLET 1 clozapine 200 MG TABLET 3 clozapine 25 MG TABLET 1 clozapine 50 MG TABLET 3 clozapine odt TAB RAPDIS 3 CLOZARIL TABLET 3 CONCERTA TAB ER 24 3 QL DAYTRANA PATCH TD24 3 QL depade TABLET 1 DESOXYN TABLET 3 DEXEDRINE CAPSULE ER 3 PA,QL dexmethylphenidate hcl TABLET 1

17 11 dexmethylphenidate hcl er CPBP QL dextroamphetamine sulfate SOLUTION 3 dextroamphetamine sulfate TABLET 1 dextroamphetamine sulfate er CAPSULE ER 1 QL diazepam ORAL CONC 3 diazepam SOLUTION 3 diazepam TABLET 1 disulfiram TABLET 1 EDLUAR TAB SUBL 3 EMSAM PATCH TD24 3 EQUETRO CPMP 12HR 3 estazolam TABLET 3 eszopiclone TABLET 3 EVEKEO 10 MG TABLET 3 PA EVEKEO 5 MG TABLET 3 PA FANAPT MG TAB DS PK 3 ST FANAPT 1 MG TABLET 3 ST FANAPT 10 MG TABLET 3 ST FANAPT 12 MG TABLET 3 ST FANAPT 2 MG TABLET 3 ST FANAPT 4 MG TABLET 3 ST FANAPT 6 MG TABLET 3 ST FANAPT 8 MG TABLET 3 ST FAZACLO TAB RAPDIS 3 fluphenazine hcl ELIXIR 1 fluphenazine hcl ORAL CONC 1 fluphenazine hcl TABLET 1 flurazepam hcl CAPSULE 1 FOCALIN TABLET 3 FOCALIN XR CPBP PA,QL GEODON CAPSULE 3 guanfacine hcl er TAB ER 24H 3 HALCION TABLET 3 haloperidol TABLET 1 haloperidol lactate ORAL CONC 1 HETLIOZ 20 MG CAPSULE 3 PA,DS

18 12 INTERMEZZO TAB SUBL 3 INTUNIV TAB ER 24H 3 INVEGA 1.5 MG TAB ER 24 3 ST INVEGA 3 MG TAB ER 24 3 ST INVEGA 6 MG TAB ER 24 3 ST INVEGA 9 MG TAB ER 24 3 ST INVEGA SUSTENNA 117MG/0.75 SYRINGE 3 PA INVEGA SUSTENNA 156 MG/ML SYRINGE 3 PA INVEGA SUSTENNA 234MG/1.5 SYRINGE 3 PA INVEGA SUSTENNA 39MG/0.25 SYRINGE 3 PA INVEGA SUSTENNA 78MG/0.5ML SYRINGE 3 PA KAPVAY TAB ER 12H 3 LATUDA 120 MG TABLET 3 ST LATUDA 20 MG TABLET 3 ST LATUDA 40 MG TABLET 3 ST LATUDA 60 MG TABLET 3 ST LATUDA 80 MG TABLET 3 ST lithium SOLUTION 1 lithium carbonate CAPSULE 1 lithium carbonate TABLET 1 lithium carbonate er TABLET ER 1 LITHOBID TABLET ER 3 lorazepam ORAL CONC 1 lorazepam TABLET 1 lorazepam intensol ORAL CONC 1 loxapine CAPSULE 1 LUNESTA TABLET 3 meprobamate TABLET 3 METADATE CD CPBP QL METADATE ER TABLET ER 3 QL methamphetamine hcl TABLET 3 QL METHYLIN SOLUTION 3 QL METHYLIN TAB CHEW 3 QL methylphenidate er CPBP QL methylphenidate er TAB ER 24 1 QL methylphenidate er TABLET ER 1 QL

19 13 methylphenidate hcl SOLUTION 3 methylphenidate hcl TABLET 1 methylphenidate hcl cd CPBP QL methylphenidate la CPBP QL midazolam hcl SYRUP 3 modafinil 100 MG TABLET 1 ST modafinil 200 MG TABLET 1 ST naltrexone hcl TABLET 1 NUVIGIL 150 MG TABLET 2 ST NUVIGIL 200 MG TABLET 2 ST NUVIGIL 250 MG TABLET 2 ST NUVIGIL 50 MG TABLET 2 ST olanzapine TABLET 1 olanzapine odt TAB RAPDIS 3 olanzapine-fluoxetine hcl CAPSULE 3 ORAP TABLET 2 oxazepam CAPSULE 1 perphenazine TABLET 1 phenobarbital ELIXIR 1 phenobarbital TABLET 1 PROCENTRA SOLUTION 3 PROVIGIL 100 MG TABLET 3 ST PROVIGIL 200 MG TABLET 3 ST quetiapine fumarate TABLET 1 QUILLIVANT XR SU ER RC24 3 RESTORIL CAPSULE 3 REVIA TABLET 3 RISPERDAL SOLUTION 3 RISPERDAL TABLET 3 RISPERDAL M-TAB TAB RAPDIS 3 risperidone SOLUTION 1 risperidone TAB RAPDIS 3 risperidone TABLET 1 risperidone odt TAB RAPDIS 3 RITALIN TABLET 3 RITALIN LA CPBP QL

20 14 ROZEREM TABLET 3 SAPHRIS 10 MG TAB SUBL 3 ST SAPHRIS 5 MG TAB SUBL 3 ST SECONAL SODIUM CAPSULE 2 SEROQUEL TABLET 3 SEROQUEL XR 150 MG TAB ER 24H 3 ST SEROQUEL XR 200 MG TAB ER 24H 3 ST SEROQUEL XR 300 MG TAB ER 24H 3 ST SEROQUEL XR 400 MG TAB ER 24H 3 ST SEROQUEL XR 50 MG TAB ER 24H 3 ST SILENOR TABLET 3 SONATA CAPSULE 3 STRATTERA 10 MG CAPSULE 2 ST STRATTERA 100 MG CAPSULE 2 ST STRATTERA 18 MG CAPSULE 2 ST STRATTERA 25 MG CAPSULE 2 ST STRATTERA 40 MG CAPSULE 2 ST STRATTERA 60 MG CAPSULE 2 ST STRATTERA 80 MG CAPSULE 2 ST SYMBYAX CAPSULE 3 temazepam 15 MG CAPSULE 1 temazepam 22.5 MG CAPSULE 3 temazepam 30 MG CAPSULE 1 temazepam 7.5 MG CAPSULE 1 thioridazine hcl TABLET 3 thiothixene CAPSULE 1 TRANXENE T-TAB TABLET 3 triazolam TABLET 1 trifluoperazine hcl TABLET 1 VALIUM TABLET 3 VERSACLOZ ORAL SUSP 3 VYVANSE CAPSULE 3 PA, QL XANAX TABLET 3 XANAX XR TAB ER 24H 3 XYREM 500 MG/ML SOLUTION 3 PA,DS zaleplon CAPSULE 1

21 15 zenzedi TABLET 1 ziprasidone hcl CAPSULE 1 zolpidem TABLET 1 zolpidem tartrate TABLET 1 zolpidem tartrate er TAB MPHASE 1 ZOLPIMIST SPRAY/PUMP 3 ZYPREXA TABLET 3 ZYPREXA RELPREVV 210 MG VIAL 3 PA ZYPREXA RELPREVV 300 MG VIAL 3 PA ZYPREXA RELPREVV 405 MG VIAL 3 PA ZYPREXA ZYDIS TAB RAPDIS 3 CARDIOVASCULAR DISEASE - ARRHYTHMIA amiodarone hcl 100 MG TABLET 3 amiodarone hcl 200 MG TABLET 1 amiodarone hcl 400 MG TABLET 3 CORDARONE TABLET 3 disopyramide phosphate CAPSULE 1 flecainide acetate TABLET 1 mexiletine hcl CAPSULE 1 MULTAQ TABLET 3 NORPACE CAPSULE 3 NORPACE CR CAPSULE ER 2 pacerone 100 MG TABLET 3 pacerone 200 MG TABLET 1 pacerone 400 MG TABLET 3 propafenone hcl TABLET 1 propafenone hcl er CAP ER 12H 3 quinidine gluconate TABLET ER 1 quinidine sulfate TABLET 1 quinidine sulfate TABLET ER 1 RYTHMOL TABLET 3 RYTHMOL SR CAP ER 12H 3 TIKOSYN CAPSULE 3

22 16 CARDIOVASCULAR DISEASE - CARDIAC STIMULANT digitek TABLET 1 digox TABLET 1 DIGOXIN SOLUTION 2 digoxin TABLET 1 LANOXIN TABLET 3 CARDIOVASCULAR DISEASE - HYPERTENSION ACCUPRIL TABLET 3 ACCURETIC TABLET 3 acebutolol hcl CAPSULE 1 ACEON TABLET 3 ADALAT CC TABLET ER 3 ADCIRCA 20 MG TABLET 3 PA,DS ADEMPAS 0.5 MG TABLET 3 PA,DS ADEMPAS 1 MG TABLET 3 PA,DS ADEMPAS 1.5 MG TABLET 3 PA,DS ADEMPAS 2 MG TABLET 3 PA,DS ADEMPAS 2.5 MG TABLET 3 PA,DS afeditab cr TABLET ER 3 ALDACTAZIDE 25 MG-25MG TABLET 3 ALDACTAZIDE 50 MG-50MG TABLET 2 ALDACTONE TABLET 3 ALTACE CAPSULE 3 amiloride hcl TABLET 1 amiloride-hydrochlorothiazide TABLET 1 amlodipine besylate TABLET 1 amlodipine besylate-benazepril CAPSULE 1 amlodipine-valsartan 10MG-160MG TABLET 3 ST amlodipine-valsartan 10MG-320MG TABLET 3 ST amlodipine-valsartan 5MG-160MG TABLET 3 ST amlodipine-valsartan 5MG-320MG TABLET 3 ST

23 17 amlodipine-valsartan-hctz TABLET 3 AMTURNIDE TABLET 3 ST AMTURNIDE TABLET 3 ST AMTURNIDE TABLET 3 ST AMTURNIDE MG TABLET 3 ST AMTURNIDE 300MG-10MG TABLET 3 ST ATACAND TABLET 3 ATACAND HCT TABLET 3 atenolol TABLET 1 atenolol-chlorthalidone TABLET 1 AVALIDE TABLET 3 AVAPRO TABLET 3 AZOR 10 MG-20MG TABLET 3 ST AZOR 10 MG-40MG TABLET 3 ST AZOR 5 MG-20 MG TABLET 3 ST AZOR 5 MG-40 MG TABLET 3 ST benazepril hcl TABLET 1 benazepril-hydrochlorothiazide TABLET 1 BENICAR 20 MG TABLET 3 ST BENICAR 40 MG TABLET 3 ST BENICAR 5 MG TABLET 3 ST BENICAR HCT MG TABLET 3 ST BENICAR HCT 40 MG-25MG TABLET 3 ST BENICAR HCT MG TABLET 3 ST BETAPACE TABLET 3 BETAPACE AF TABLET 3 betaxolol hcl TABLET 1 BIDIL TABLET 3 bisoprolol fumarate TABLET 1 bisoprolol-hydrochlorothiazide TABLET 1 bumetanide TABLET 1 BYSTOLIC TABLET 3 CALAN TABLET 3 CALAN SR TABLET ER 3 candesartan cilexetil TABLET 3 candesartan-hydrochlorothiazid TABLET 3

24 18 captopril TABLET 1 captopril-hydrochlorothiazide TABLET 1 CARDENE SR CAPSULE ER 3 CARDIZEM TABLET 3 CARDIZEM CD CAP ER 24H 3 CARDIZEM LA TAB ER 24H 3 CARDURA TABLET 3 CARDURA XL TAB ER 24 3 cartia xt CAP ER 24H 1 carvedilol TABLET 1 CATAPRES TABLET 3 CATAPRES-TTS 1 PATCH TDWK 3 CATAPRES-TTS 2 PATCH TDWK 3 CATAPRES-TTS 3 PATCH TDWK 3 chlorothiazide TABLET 1 chlorthalidone TABLET 1 clonidine PATCH TDWK 1 clonidine hcl TABLET 1 clorpres TABLET 3 COREG TABLET 3 COREG CR CPMP 24HR 3 CORGARD TABLET 3 CORZIDE TABLET 3 COZAAR TABLET 3 DEMADEX TABLET 3 DEMSER CAPSULE 3 DIBENZYLINE CAPSULE 2 dilt-xr CAP ER DEG 1 diltiazem 12hr er CAP ER 12H 1 diltiazem 24hr cd CAP ER 24H 1 diltiazem 24hr er CAP ER 24H 1 diltiazem er CAP ER DEG 1 diltiazem er CAPSULE ER 3 diltiazem er TAB ER 24H 3 diltiazem hcl TABLET 1 DIOVAN TABLET 3

25 19 DIOVAN HCT TABLET 3 DIURIL ORAL SUSP 2 doxazosin mesylate TABLET 1 DUTOPROL TAB ER 24H 3 DYAZIDE CAPSULE 3 DYRENIUM CAPSULE 2 EDARBI 40 MG TABLET 3 ST EDARBI 80 MG TABLET 3 ST EDARBYCLOR 40 MG-25MG TABLET 3 ST EDARBYCLOR MG TABLET 3 ST EDECRIN TABLET 2 enalapril maleate TABLET 1 enalapril-hydrochlorothiazide TABLET 1 EPANED SOLN RECON 3 eplerenone TABLET 1 eprosartan mesylate 600 MG TABLET 3 ST EXFORGE 10MG-160MG TABLET 3 ST EXFORGE 10MG-320MG TABLET 3 ST EXFORGE 5MG-160MG TABLET 3 ST EXFORGE 5MG-320MG TABLET 3 ST EXFORGE HCT TABLET 3 felodipine er TAB ER 24H 1 fosinopril sodium TABLET 1 fosinopril-hydrochlorothiazide TABLET 1 furosemide SOLUTION 1 furosemide TABLET 1 guanfacine hcl TABLET 1 HEMANGEOL 4.28 MG/ML SOLUTION 3 PA hydralazine hcl TABLET 1 hydrochlorothiazide CAPSULE 1 hydrochlorothiazide TABLET 1 HYZAAR TABLET 3 indapamide TABLET 1 INDERAL LA CAP SA 24H 3 INDERAL XL CAP ER 24H 3 INNOPRAN XL CAP ER 24H 3

26 20 INSPRA TABLET 3 irbesartan TABLET 1 irbesartan-hydrochlorothiazide TABLET 1 isradipine CAPSULE 1 labetalol hcl TABLET 1 LASIX TABLET 3 LETAIRIS 10 MG TABLET 2 PA,DS LETAIRIS 5 MG TABLET 2 PA,DS LEVATOL TABLET 3 lisinopril TABLET 1 lisinopril-hydrochlorothiazide TABLET 1 LOPRESSOR TABLET 3 LOPRESSOR HCT TABLET 3 losartan potassium TABLET 1 losartan-hydrochlorothiazide TABLET 1 LOTENSIN TABLET 3 LOTENSIN HCT TABLET 3 LOTREL CAPSULE 3 matzim la TAB ER 24H 3 MAVIK TABLET 3 MAXZIDE TABLET 3 MAXZIDE-25 MG TABLET 3 methyclothiazide TABLET 1 methyldopa TABLET 1 methyldopa-hydrochlorothiazide TABLET 3 metolazone TABLET 1 metoprolol succinate TAB ER 24H 1 metoprolol tartrate TABLET 1 metoprolol-hydrochlorothiazide TABLET 1 MICARDIS TABLET 3 MICARDIS HCT TABLET 3 MICROZIDE CAPSULE 3 MINIPRESS CAPSULE 3 minoxidil TABLET 1 moexipril hcl TABLET 1 moexipril-hydrochlorothiazide TABLET 1

Traditional Prescription Drug List (PDL) 1,2,3 $0 Cost-share Medications & Products

Traditional Prescription Drug List (PDL) 1,2,3 $0 Cost-share Medications & Products For our members Preventive Care Medications Traditional Prescription Drug List (PDL) 1,2,3 $0 Cost-share Medications & Products U.S. Preventive Services Task Force A & B Recommendation Medications and

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

Traditional Prescription Drug List (PDL) 1,2,3,4 $0 Cost-share Medications & Products

Traditional Prescription Drug List (PDL) 1,2,3,4 $0 Cost-share Medications & Products For our clients Preventive Care Medications Traditional Prescription Drug List (PDL) 1,2,3,4 $0 Cost-share Medications & Products U.S. Preventive Services Task Force A & B Recommendation Medications 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

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

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

LET S TALK. Your no-cost preventive drugs. Tips for using the lists. Legend: September 2014

LET S TALK. Your no-cost preventive drugs. Tips for using the lists. Legend: September 2014 LET S TALK September 2014 Your no-cost preventive drugs Preventive services help you stay healthy. A doctor isn t someone to see only when you re sick. Doctors also provide services that help prevent medical

More information

EFFECTIVE OCTOBER 2015. 2015 Drug Formulary. For federal employees and retirees on the Federal Employees Health Benefits Program.

EFFECTIVE OCTOBER 2015. 2015 Drug Formulary. For federal employees and retirees on the Federal Employees Health Benefits Program. EFFECTIVE OCTOBER 2015 2015 Drug Formulary For federal employees and retirees on the Federal Employees Health Benefits Program. Drug Formulary INTRODUCTION Development of the Drug Formulary At Group Health

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

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

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

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

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

$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

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

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

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

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

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

Advantage Prescription Drug List (PDL) 1,2,3 $0 Cost-share Medications & Products

Advantage Prescription Drug List (PDL) 1,2,3 $0 Cost-share Medications & Products For our members Preventive Care Medications Advantage Prescription Drug List (PDL) 1,2,3 $0 Cost-share Medications & Products U.S. Preventive Services Task Force A & B Recommendation Medications and Supplements

More information

South Carolina Department of Health and Human Services Post Office Box 8206 Columbia, South Carolina 29202-8206

South Carolina Department of Health and Human Services Post Office Box 8206 Columbia, South Carolina 29202-8206 South Carolina Department of Health and Human Services Post Office Box 8206 Columbia, South Carolina 29202-8206 Pharmacy and Therapeutics (P&T) Committee Meeting MINUTES 1. Call to Order A meeting of the

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

Advantage Prescription Drug List (PDL) 1,2,3 $0 Cost-share Medications & Products

Advantage Prescription Drug List (PDL) 1,2,3 $0 Cost-share Medications & Products For our members Preventive Care Medications Advantage Prescription Drug List (PDL) 1,2,3 $0 Cost-share Medications & Products U.S. Preventive Services Task Force A & B Recommendation Medications and Supplements

More information

How to use your pharmacy benefits for better health

How to use your pharmacy benefits for better health cholestyramine fenofibrate gemfibrozil lovastatin pravastatin sodium simvastatin Crestor Niaspan Simcor Tricor Vytorin Frequently Asked Questions about Preventive Care Drugs High Cholesterol alendronate

More information

Advantage Prescription Drug List (PDL) 1,2,3 $0 Cost-share Medications & Products

Advantage Prescription Drug List (PDL) 1,2,3 $0 Cost-share Medications & Products For our members Preventive Care Medications Advantage Prescription Drug List (PDL) 1,2,3 $0 Cost-share Medications & Products U.S. Preventive Services Task Force A & B Recommendation Medications and Supplements

More information

Trinity Clinic Whitehouse Automatic Refill Policy April, 2007

Trinity Clinic Whitehouse Automatic Refill Policy April, 2007 Trinity Clinic Whitehouse Automatic Refill Policy April, 2007 Overview The following pages contain details on how to administer our automatic refill policy. Our intent is to streamline, standardize and

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

GPI Description* Iron Supplements. GPI Description*

GPI Description* Iron Supplements. GPI Description* PREVENTIVE SERVICES: Interim Final Rules for Non-Grandfathered Group Health Plans and Health Insurance Issuers Coverage of Preventive Services Under the Patient Protection and Affordable Care Act July

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

Pharmacy Management Drug Policy

Pharmacy Management Drug Policy PAGE: Page 1 of 9 DESCRIPTION: Step Therapy encourages use of safe, cost-effective medications within different therapeutic drug categories. The entry of new generics and cost-effective therapeutic alternatives

More information

Reducing your out-of-pocket costs for the medicine you need Preventive Medicine List

Reducing your out-of-pocket costs for the medicine you need Preventive Medicine List Quality health plans & benefits Healthier living Financial well-being Intelligent solutions Reducing your out-of-pocket costs for the medicine you need Preventive Medicine List 05.03.393.1 G (10/14) Receive

More information

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

2014 Valley Baptist Medicare D Formulary Step Therapy Criteria

2014 Valley Baptist Medicare D Formulary Step Therapy Criteria 2014 Valley Baptist Medicare D Formulary Step Therapy Products Affected ACTONEL TAB Last Updated 11/1/2014 Requires a trial of alendronate. 1 APLENZIN TAB Patient must have tried bupropion SR or bupropion

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

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

$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

WV Public Employees Insurance Agency (PEIA)

WV Public Employees Insurance Agency (PEIA) Approved Changes for Plan Year 2013 (July 1, 2012 June 30, 2013) The WV PEIA Finance Board recommended several changes to the PEIA PPB Plan structure for the upcoming fiscal year, effective July 1, 2012,

More information

2014 Preventive Medicine List

2014 Preventive Medicine List Quality health plans & benefits Healthier living Financial well-being Intelligent solutions 2014 Preventive Medicine List 05.03.393.1 F (2/14) ACE inhibitors (hypertension, diabetes) benazepril benazepril/hctz

More information

Health Plan & Formulary A Simple Resource to Help You Understand Your Benefits. Comparison Guide

Health Plan & Formulary A Simple Resource to Help You Understand Your Benefits. Comparison Guide Health Plan & Formulary A Simple Resource to Help You Understand Your Benefits Comparison Guide Contents What Does Rx Formulary Mean?... 3 How To Use This Comparison Guide... 3 A Note To Members... 3 Health

More information

member education Dose Optimization

member education Dose Optimization member education Dose Optimization Do you take a prescription drug more than once each day? For some drugs, your doctor can prescribe a higher amount that you only have to take once a day. We call this

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

Women s Preventive Services

Women s Preventive Services Interim Final Rules for Non-Grandfathered Group Health Plans and Health Insurance Issuers Coverage of Preventive Services under the Patient Protection and Affordable Care Act Women s Preventive Services

More information

LET S TALK PREVENTION

LET S TALK PREVENTION LET S TALK PREVENTION July 2016 YOUR NO COST PREVENTIVE SERVICES Preventive services help you stay healthy. A doctor isn t someone to see only when you re sick. Doctors also provide services that help

More information

Medication Review. Cardiovascular Drugs. Pharmacy Technician Training Systems Passassured, LLC

Medication Review. Cardiovascular Drugs. Pharmacy Technician Training Systems Passassured, LLC Medication Review Cardiovascular Drugs Pharmacy Technician Training Systems Passassured, LLC Medication Review, Cardiovascular Drugs PassAssured's Pharmacy Technician Training Program Medication Review

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

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

Advantage Prescription Drug List (PDL) 1,2,3,4 $0 Cost-share Medications & Products

Advantage Prescription Drug List (PDL) 1,2,3,4 $0 Cost-share Medications & Products For our clients Preventive Care Medications Advantage Prescription Drug List (PDL) 1,2,3,4 $0 Cost-share Medications & Products U.S. Preventive Services Task Force A & B Recommendation Medications and

More information

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

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

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

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

Early Morning Waking Excessively Orderly or Perfectionistic

Early Morning Waking Excessively Orderly or Perfectionistic COLLEGE OF MEDICINE Jacksonville 580 W 8 th St T-2 6 th Fl Ste 6005 6266 Dupont Station Ct Department of Psychiatry Jacksonville, FL 32209 Jacksonville, Fl 32217 Division of Adult Psychiatry Phone 904-383-1038

More information

2014 Chronic and Preventive Medicine List

2014 Chronic and Preventive Medicine List Quality health plans & benefits Healthier living Financial well-being Intelligent solutions 2014 Chronic and Preventive Medicine List TIER ONE ACE inhibitors (hypertension, diabetes) benazepril benazepril/hctz

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

12629 LIBRIUM CHLORDIAZEPOXIDE HCL 12637 LIBRIUM CHLORDIAZEPOXIDE HCL 12645 LIBRIUM CHLORDIAZEPOXIDE HCL 13110 VALIUM DIAZEPAM 13277 VALIUM DIAZEPAM 24406 LITHANE LITHIUM CARBONATE 25836 SURMONTIL TRIMIPRAMINE

More information

PRESCRIPTION DRUG GUIDE

PRESCRIPTION DRUG GUIDE 2007 PRESCRIPTION DRUG GUIDE Humana Formulary (List of Covered Drugs) GH-21346 9/06 PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. 2 Welcome to Humana! PLEASE READ:

More information

Plan Year Allegian Advantage (HMO) Step Therapy Criteria (ST)

Plan Year Allegian Advantage (HMO) Step Therapy Criteria (ST) Plan Year 2015 Allegian Advantage (HMO) Step Therapy (ST) Step Therapy: In some cases, Allegian Advantage requires you to first try certain drugs to treat your medical condition before we will cover another

More information

MEDICATION(S) SUBJECT TO STEP THERAPY

MEDICATION(S) SUBJECT TO STEP THERAPY ACE/ARB COMBO AZOR 5-20 MG TABLET, AZOR 5-40 MG TABLET, BENICAR HCT, MICARDIS HCT, TARKA, TEKTURNA HCT, TELMISARTAN-HYDROCHLOROTHIAZID, TRIBENZOR Claims for formulary step 2 ACE Inhibitor combination products

More information

NO-COST PREVENTIVE CARE DRUGS

NO-COST PREVENTIVE CARE DRUGS NO-COST PREVENTIVE CARE DRUGS INFORMATION FOR NON-GRANDFATHERED ASO GROUPS The Affordable Care Act (ACA) requires that certain preventive care drugs and drug categories be covered at no cost to health

More information

Oral Contraceptive Reference Chart

Oral Contraceptive Reference Chart Generic Name (Tier 1) Brand Name Estrgen/Prgestin Cmpnent Aviane, Orsythia, Falmina, Lessina, Delyla, Aubra, Srnyx, Lutera, levnrgestrel/ee Apri, Slia, Reclipsen, Enskyce, Emquette, Desgestrel/EE Levra,

More information

GEORGIA MEDICAID FEE-FOR-SERVICE ASTHMA and COPD AGENTS PA SUMMARY

GEORGIA MEDICAID FEE-FOR-SERVICE ASTHMA and COPD AGENTS PA SUMMARY GEORGIA MEDICAID FEE-FOR-SERVICE ASTHMA and COPD AGENTS PA SUMMARY Preferred Anticholinergics and Combinations Atrovent HFA (ipratropium) Combivent Respimat (ipratropium/albuterol) Ipratropium neb inhalation

More information

2014 Chronic Medicine List

2014 Chronic Medicine List Quality health plans & benefits Healthier living Financial well-being Intelligent solutions 2014 Chronic Medicine List TIER ONE ACE inhibitors (hypertension, diabetes) benazepril benazepril/hctz captopril

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

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

Medications Requiring Prior Authorization for Medical Necessity

Medications Requiring Prior Authorization for Medical Necessity January 2015 Medications Requiring Medical Necessity Below is a list of medicines by drug class that will not be covered without a prior authorization for medical necessity, effective January 1, 2015.

More information

HEALTH PLAN & FORMULARY COMPARISON GUIDE. A Simple Resource to Help You Understand Your Benefits

HEALTH PLAN & FORMULARY COMPARISON GUIDE. A Simple Resource to Help You Understand Your Benefits HEALTH PLAN & FORMULARY COMPARISON GUIDE A Simple Resource to Help You Understand Your s Contents PAGE What Does Rx Formulary Mean?....................................3 How To Use This Comparison Guide.................................3

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

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

Table 4. Some Topical Drugs for Atopic Dermatitis (cont.) Drug. Table 4. Some Topical Drugs for Atopic Dermatitis Drug

Table 4. Some Topical Drugs for Atopic Dermatitis (cont.) Drug. Table 4. Some Topical Drugs for Atopic Dermatitis Drug Table 4. Some Topical Drugs for Atopic Dermatitis Drug Vehicle CALCINEURIN INHIBITORS Pimecrolimus 1% adel (Novartis) Tacrolimus 0.03% Protopic (Astellas) Tacrolimus 0.1% Protopic (Astellas) CORTICOSTEROIDS

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

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

Aspirin PREVENTIVE SERVICES: Introduction

Aspirin PREVENTIVE SERVICES: Introduction PREVENTIVE SERVICES: Interim Final Rules for Non-Grandfathered Group Health Plans and Health Insurance Issuers Coverage of Preventive Services Under the Patient Protection and Affordable Care Act Introduction

More information

2015 Drug Formulary. For members with individual and family plans or covered through small employer groups (1 50 employees)

2015 Drug Formulary. For members with individual and family plans or covered through small employer groups (1 50 employees) EFFECTIVE OCTOBER 2015 2015 Drug Formulary For members with individual and family plans or covered through small employer groups (1 50 employees) Connect / Alliant Plus Core / Group Health GHC Individual

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

Formulary Drug Removals

Formulary Drug Removals January 2015 Below is a list of medicines by drug class that have been removed from your plan s formulary. This list is effective January 1, 2015. If you continue using one of the drugs listed below and

More information

Burlington Scripts Vs. Current local purchase plan. Current Copays

Burlington Scripts Vs. Current local purchase plan. Current Copays Introduction: Burlington Scripts is a voluntary prescription drug program that is available to eligible Employees, Retirees and their Dependents of the Town of Burlington, MA. For your convenience, a list

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

Aspirin PREVENTIVE SERVICES: Introduction. Aspirin to Prevent Cardiovascular Disease (CVD): Men. CVS Caremark Recommendation

Aspirin PREVENTIVE SERVICES: Introduction. Aspirin to Prevent Cardiovascular Disease (CVD): Men. CVS Caremark Recommendation PREVENTIVE SERVICES: Interim Final Rules for Non-Grandfathered Group Health Plans and Health Insurance Issuers Coverage of Preventive Services Under the Patient Protection and Affordable Care Act July

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

If your drug is not on the list just give us a call for a price. Ask us for details on how to avoid the higher deductible generic price.

If your drug is not on the list just give us a call for a price. Ask us for details on how to avoid the higher deductible generic price. If your drug is not on the list just give us a call for a price. Ask us for details on how to avoid the higher deductible generic price. FREE SHIPPING TO AL, CT, DE, FL, GA, IN, KS, MA, MO, MS, NC, NH,

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

Monthly Copays. Union Copays Crestor 20MG - Tier 2,10% Eliquis 5mg - Tier 3, 20% Non-Union Copays Crestor 20MG - Tier 2, $25

Monthly Copays. Union Copays Crestor 20MG - Tier 2,10% Eliquis 5mg - Tier 3, 20% Non-Union Copays Crestor 20MG - Tier 2, $25 Introduction: MCSMeds is an international mail order option for eligible Employees, Retirees and Dependents of Muncie Community Schools. Your list of qualified maintenance medications is on the reverse.

More information

8 Types of Drugs That Can Cause Leg Cramps

8 Types of Drugs That Can Cause Leg Cramps Ask the Pharmacist 8 Types of Drugs That Can Cause Leg Cramps Pain may be a sign of an underlying medical problem by Dr. Armon B. Neel Jr., AARP, January 10, 2013 En Español l The older you are, the more

More information

Asthma, COPD and Diabetes Preferred Drug List Medications

Asthma, COPD and Diabetes Preferred Drug List Medications GPI Name Dexamethasone Tab 0.5 MG Dexamethasone Tab 0.75 MG Dexamethasone Tab 1 MG Dexamethasone Tab 1.5 MG Dexamethasone Tab 2 MG Dexamethasone Tab 4 MG Dexamethasone Tab 6 MG Dexamethasone Elixir 0.5

More information

CareATC Generic Formulary Medications Available (2015)

CareATC Generic Formulary Medications Available (2015) Allergic Reactions EPINEPHRINE** Ephinephrine, EpiPen CETIRIZINE 10MG Zyrtec FEXOFENADINE180MG TABS 100ct Allegra Allergies LORATADINE 10MG Claritin MONTELUKAST 4MG 30CT Singulair PROMETHAZINE 25MG AMP

More information

Formulary Drug Removals

Formulary Drug Removals January 2016 Below is a list of medicines by drug class that have been removed from your plan s formulary. This list is effective January 1, 2016. If you continue using one of the drugs listed below and

More information

Prescription Medications &Weight Gain What You Need to Know

Prescription Medications &Weight Gain What You Need to Know Prescription Medications & Weight Gain What You Need to Know by Ted Kyle, RPh, MBA, and Bonnie Kuehl, PhD How can I be gaining weight? I m eating smarter, I m walking more. What am I doing wrong? You might

More information

HEALTH PLAN & FORMULARY COMPARISON GUIDE. A Simple Resource to Help You Understand Your Benefits

HEALTH PLAN & FORMULARY COMPARISON GUIDE. A Simple Resource to Help You Understand Your Benefits HEALTH PLAN & FORMULARY COMPARISON GUIDE A Simple Resource to Help You Understand Your s Contents PAGE What Does Rx Formulary Mean?......................... 3 How To Use This Comparison Guide......................

More information

Insulin Injection, Rapid-Acting

Insulin Injection, Rapid-Acting IN-su-lin \*\*Illustration of how to give a subcutaneous shot with a syringe What are other names for this medicine? Type of medicine: antidiabetic Generic and brand names: rapid-acting insulin aspart,

More information

2014 Medicare Part D Formulary Change

2014 Medicare Part D Formulary Change 2014 Medicare Part D Formulary Change We may add or remove drugs from our formulary during the year. If we remove drugs from our formulary, or add prior authorizations, quantity limits and/or step therapy

More information

Angiotensin-converting enzyme (ACE) inhibitors Angiotensin II receptor blockers (ARBs) Beta-blockers Calcium channel blockers Diuretics

Angiotensin-converting enzyme (ACE) inhibitors Angiotensin II receptor blockers (ARBs) Beta-blockers Calcium channel blockers Diuretics Angiotensin-converting enzyme (ACE) inhibitors Angiotensin II receptor blockers (ARBs) Beta-blockers Calcium channel blockers Diuretics This brochure gives you information about high blood pressure and

More information

Provider Forum January 13, 2015 1:00 PM

Provider Forum January 13, 2015 1:00 PM Provider Forum January 13, 2015 1:00 PM Agenda Welcome and Updates Beth Lackey, Provider Network Director NCTRACKS and Taxonomies Gap Analysis/Needs Assessment IPRS Utilization Analysis B3 Funds PBHM Performance

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

HEALTH PLAN & FORMULARY COMPARISON GUIDE. A Simple Resource to Help You Understand Your Benefits

HEALTH PLAN & FORMULARY COMPARISON GUIDE. A Simple Resource to Help You Understand Your Benefits HEALTH PLAN & FORMULARY COMPARISON GUIDE A Simple Resource to Help You Understand Your s Contents PAGE What Does Formulary Mean?... 3 How To Use This Comparison Guide... 3 A Note To Members... 3 Health

More information

HEALTH PLAN & FORMULARY COMPARISON GUIDE. A Simple Resource to Help You Understand Your Benefits

HEALTH PLAN & FORMULARY COMPARISON GUIDE. A Simple Resource to Help You Understand Your Benefits HEALTH PLAN & FORMULARY COMPARISON GUIDE A Simple Resource to Help You Understand Your s Contents PAGE What Does Formulary Mean?... 3 How To Use This Comparison Guide... 3 A Note To Members... 3 Health

More information

May 31, 2013. Ms. Debra Lansey American College of Physicians 190 North Independence Mall West Philadelphia, PA 19106

May 31, 2013. Ms. Debra Lansey American College of Physicians 190 North Independence Mall West Philadelphia, PA 19106 P.O. Box 30449 Salt Lake City, UT 84130-0449 May 31, 2013 Ms. Debra Lansey American College of Physicians 190 North Independence Mall West Philadelphia, PA 19106 Re: Pharmacy Benefit Coverage Changes Effective

More information

Medications Requiring Prior Authorization for Medical Necessity

Medications Requiring Prior Authorization for Medical Necessity Medications Requiring Prior Medical Necessity July 2016 Below is a list of medicines by drug class that will not be covered without a prior authorization for medical necessity. If you continue using one

More information

Formulary Drug Removals

Formulary Drug Removals July 2016 Below is a list of medicines by drug class that have been removed from your plan s formulary. If you continue using one of the drugs listed below and identified as a Removal, you may be required

More information

Tier 1 Formulary Drug Quantity Limits 2016

Tier 1 Formulary Drug Quantity Limits 2016 Tier 1 Formulary Drug Quantity Limits 2016 Updated: 11/20/2015 Effective: 01/01/2016 What are Quantity Limits? For certain drugs, we limit the amount of the drug that you can have by limiting how much

More information

Health Plan & Formulary A Simple Resource to Help You Understand Your Benefits. Comparison Guide

Health Plan & Formulary A Simple Resource to Help You Understand Your Benefits. Comparison Guide Health Plan & Formulary A Simple Resource to Help You Understand Your s Comparison Guide Contents What Does Rx Formulary Mean?... 3 How To Use This Comparison Guide... 3 A Note To Members... 3 Health Plan

More information