Preferred Drug List. (List of Covered Drugs) This document includes Passport Health Plan s complete 2015 formulary.
|
|
- Richard Gilbert
- 8 years ago
- Views:
Transcription
1 Drug List (List of Covered Drugs) This document includes Passport Health Plan s complete 2015 formulary.
2 What is the Passport Health Plan formulary? The formulary is a list of preferred drugs covered by Passport. To get a drug on our formulary, you must: The formulary is not a complete list of covered drugs by Passport. Some drugs not listed may be covered, if medically necessary. These drugs may or may not need prior-authorization. How do I find my drug on the formulary?. Are there any limits to the drugs you have been prescribed? Some covered drugs may have limits on them. This could include: Prior-Authorization: not cover the drug. Quantity Limits: standard one month supply. Step Therapy: Too Early to Refill: 30 days has passed. What if my drug is not on the formulary? i
3 Can the formulary change? What are generic drugs? How much are my copays? ii
4 Table of Contents Table of Contents... 1 ANTI-INFECTIVES... 6 PENICILLINS... 6 TETRACYCLINES... 6 FIRST GENERATION CEPHALOSPOSINS... 7 SECOND GENERATION CEPHALOSPORINS... 8 THIRD GENERATION CEPHALOSPORINS... 8 ERYTHROMYCINS & OTHER MACROLIDES... 9 FLUOROQUINOLONES SULFAS & RELATED AGENTS URINARY TRACT AGENTS MISCELLANEOUS ANTIVIRALS HIV/AIDS THERAPY ANTIFUNGAL AGENTS VANCOMYCIN MISCELLANEOUS ANTIINFECTIVES ANTIPARASITICS ANTIMALARIALS ANTIMYCOBACTERIALS ANTINEOPLASTIC & IMMUNOSUPPRESANT DRUGS ALKYLATING AGENTS ANTIMETABOLITES HORMONES ANTIESTROGENS ANTIANDROGENS IMMUNOSUPPRESSANT DRUGS MISCELLANEOUS ANTINEOPLASTIC DRUGS ADJUNCTIVE AGENTS AUTONOMIC & CNS DRUGS, NEUROLOGY, & PSYCH NARCOTIC ANALGESICS NARCOTICS COMBINATION NARCOTIC /ANALGESICS NON-NARCOTIC ANALGESICS NSAIDS NSAIDS- SPECIFIC COX-II INHIBITORS SALICYLATES MISCELLANEOUS ANALGESICS Page 1 Magellan Pharmacy Solutions Effective 1/1/15
5 NARCOTIC ANTAGONISTS MIGRAINE & CLUSTER HEADACHE THERAPY HEADACHE THERAPY ANTIPARKINSONISM AGENTS ANTICONVULSANTS MISCELLANEOUS NEUROLOGICAL THERAPY MUSCLE RELAXANTS & ANTISPASMODIC AGENTS MYASTHENIA GRAVIS HYPNOTIC AGENTS TRICYCLICS MISCELLANEOUS ANTIDEPRESSANTS MAO INHIBITORS SELECTIVE SEROTONIN REUPTAKE INHIBITORS PHENOTHIAZINES BUTYROPHENONES MISCELLANEOUS ANTIPSYCHOTICS MISCELLANEOUS PSYCHOTHERAPEUTIC AGENTS ANXIOLYTICS CARDIOVASCULAR, HYPERTENSION, & LIPIDS ANTIARRHYTHMIC AGENTS CARDIAC GLYCOSIDES NITRATES RAPID ACTING NITRATES LONG ACTING NITRATES COAGULATION THERAPY ANTICOAGULANTS ANTIPLATELET DRUGS HEPARIN VITAMIN K HEMOSTATICS MISCELLANEOUS COAGULATION AGENTS ANTIHYPERTENSIVE THERAPY THIAZIDE & RELATED DIURETICS BETA BLOCKERS CALCIUM CHANNEL BLOCKERS/NON-DIHYDROPYRIDINES CALCIUM CHANNEL BLOCKERS/DIHYDROPYRIDINES ACE INHIBITORS ADRENERGIC ANTAGONISTS & RELATED DRUGS AGENTS FOR PHEOCHROMOCYTOMA VASODILATORS is always preferred unless otherwise stated. Brand is nonpreferred if a generic is available unless otherwise stated. 2 ST-Step Therapy, PA Prior Authorization, QL Quantity Limit, SP Specialty pharmacy
6 OTHER ANTIHYPERTENSIVE COMBINATIONS ANGIOTENSIN II RECEPTOR BLOCKERS & RENIN INHIBITOR LIPID/CHOLESTEROL LOWERING AGENTS DERMATOLOGICAL/TOPICAL THERAPY TOPICAL CORTICOSTEROIDS TOPICAL CORTICOSTEROIDS VERY HIGH POTENCY TOPICAL CORTICOSTEROIDS HIGH POTENCY TOPICAL CORTICOSTEROIDS MEDIUM POTENCY TOPICAL CORTICOSTEROIDS LOW POTENCY TOPICAL ANESTHETICS THERAPY FOR ACNE TOPICAL ANTIBACTERIALS TOPICAL ANTIFUNGALS TOPICAL ANTIVIRALS BURN THERAPY TOPICAL ENZYMES KERATOLYTICS ANTIPSORIATIC / ANTISEBORRHEIC TOPICAL SCABICIDES / PEDICULICIDES MISCELLANEOUS DERMATOLOGICALS DIAGNOSTICS & MISCELLANEOUS AGENTS MISCELLANEOUS AGENTS SMOKING DETERRENTS ANOREXIANTS EAR, NOSE, & THROAT MEDICATIONS MISCELLANEOUS OTIC PREPARATIONS OTIC STEROID / ANTIBIOTIC MISCELLANEOUS AGENTS ENDOCRINE/DIABETES ANTITHYROID AGENTS THYROID HORMONES ADRENAL HORMONES ANDROGENS MISCELLANEOUS AGENTS DIABETES THERAPY INSULIN THERAPY NON-INSULIN HYPOGLYCEMIC AGENTS GLUCOSE ELEVATING AGENTS
7 INSULIN BLOOD GLUCOSE MONITORING DEVICES & SUPPLIES INSULIN SYRINGES/MISCELLANEOUS GASTROENTEROLOGY H2 ANTAGONISTS PROSTAGLANDINS OTHER ULCER THERAPY PROTON PUMP INHIBITORS ANTIDIARRHEALS ANTISPASMODICS COMBINATION ANTICHOLINERGICS BILE ACIDS DIGESTIVE ENZYMES MISCELLANEOUS GASTROINTESTINAL AGENTS ANTIVERTIGO & ANTIEMETIC AGENTS BOWEL EVACUANTS IMMUNOLOGY, VACCINES, & BIOTECHNOLOGY ERYTHROID STIMULANTS INTERFERONS GROWTH HORMONES INTERLEUKINS VACCINES & MISCELLANEOUS IMMUNOLOGICALS MUSCULOSKELETAL & RHEUMATOLOGY GOUT THERAPY MISCELLANEOUS RHEUMATOLOGICAL AGENTS OSTEOPOROSIS THERAPY OBSTETRICS & GYNECOLOGY MONOPHASIC /BIPHASIC /TRIPHASIC AGENTS OXYTOCICS ESTROGENS & PROGESTINS PROGESTINS ESTROGENS ESTROGEN COMBINATIONS MISCELLANEOUS OB/GYN VAGINAL CLEANSER /ANTIINFECTIVE VAGINAL ANTIFUNGALS SPECIALIZED OB/GYN DRUGS OPHTHALMOLOGY BETA-BLOCKERS CHOLINESTERASE INHIBITOR MIOTICS DIRECT ACTING MIOTICS is always preferred unless otherwise stated. Brand is nonpreferred if a generic is available unless otherwise stated. 4 ST-Step Therapy, PA Prior Authorization, QL Quantity Limit, SP Specialty pharmacy
8 OTHER GLAUCOMA DRUGS ORAL DRUGS FOR GLAUCOMA CYCLOPLEGIC MYDRIATICS NON-STEROIDAL ANTI-INFLAMMATORY AGENTS VASOCONSTRICTOR DECONGESTANTS ANTIBIOTICS SULFONAMIDES STEROIDS STEROID-ANTIBIOTIC COMBINATIONS SYMPATHOMIMETICS MISCELLANEOUS OPHTHALMOLOGICS ANTIVIRALS RESPIRATORY, ALLERGY, COUGH, & COLD ANTIHISTAMINES & ANTIALLERGENIC AGENTS ANTIHISTAMINES ADRENERGICS COUGH & COLD THERAPY ANTITUSSIVE COMBINATIONS EXPECTORANT COMBINATIONS DECONGESTANT / ANTIHISTAMINES XANTHINES BETA AGONISTS ORAL BETA AGONISTS INHALERS INHALED CORTICOSTEROIDS INTRANASAL STEROIDS MISCELLANEOUS PULMONARY AGENTS MISCELLANEOUS EQUIPMENT PEAK FLOW METERS SPACERS UROLOGICALS CHOLINERGIC STIMULANTS ANTICHOLINERGICS & ANTISPASMODICS URINARY ANESTHETICS MISCELLANEOUS UROLOGICALS BENIGN PROSTATIC HYPERPLASIA (BPH) THERAPY VITAMINS, HEMATINICS, & ELECTROLYTES VITAMINS & HEMATINICS
9 / TRADE NAME NAME DOSE DESCRIPTION PA ST ANTI-INFECTIVES PENICILLINS Amox Tr/Potassium Clavulanate Amoxicillin/ Potassium Clav Suspension; Reconstituted; Oral (Ml) Amox Tr/Potassium Clavulanate Amoxicillin/ Potassium Clav Amox Tr/Potassium Clavulanate Amoxicillin/ Potassium Clav ; Chewable Amoxicillin Amoxicillin Amoxicillin Amoxicillin Suspension; Reconstituted; Oral (Ml) Amoxicillin Amoxicillin Amoxicillin Amoxicillin ; Chewable Amoxicillin- Clavulanate Er Ampicillin Trihydrate Ampicillin Trihydrate AUGMENTIN AUGMENTIN AUGMENTIN ES AUGMENTIN XR Dicloxacillin Sodium Penicillin G Procaine Penicillin V Potassium Penicillin V Potassium TETRACYCLINES ADOXA Avidoxy Demeclocycline Hcl DORYX Amoxicillin/ Potassium Clav Ampicillin Trihydrate Ampicillin Trihydrate AMOXICILLIN/ POTASSIUM CLAV AMOXICILLIN/ POTASSIUM CLAV AMOXICILLIN/ POTASSIUM CLAV AMOXICILLIN/ POTASSIUM CLAV Dicloxacillin Sodium Penicillin G Procaine Penicillin V Potassium Penicillin V Potassium DOXYCYCLINE MONOHYDRATE Doxycycline Monohydrate Demeclocycline Hcl DOXYCYCLINE HYCLATE ; Extended Release 12 Hr Suspension; Reconstituted; Oral (Ml) SUSPENSION; RECONSTITUTED ; ORAL (ML) SUSPENSION; RECONSTITUTED ; ORAL (ML) ; EXTENDED RELEASE 12 HR Syringe (Ml) Solution; Reconstituted; Oral CAPSULE ; ENTERIC is always preferred unless otherwise stated. Brand is nonpreferred if a generic is available unless otherwise stated. 6 ST-Step Therapy, PA Prior Authorization, QL Quantity Limit, SP Specialty pharmacy
10 / TRADE NAME NAME DOSE DESCRIPTION PA ST Doxycycline Hyclate Doxycycline Hyclate Doxycycline Hyclate Doxycycline Monohydrate Doxycycline Monohydrate Doxycycline Monohydrate Doxycycline Hyclate Doxycycline Hyclate Doxycycline Hyclate Doxycycline Monohydrate Doxycycline Monohydrate Doxycycline Monohydrate COATED ; Enteric Coated Suspension; Reconstituted; Oral (Ml) DYNACIN MINOCYCLINE HCL MINOCIN MINOCYCLINE HCL CAPSULE Minocycline Hcl Minocycline Hcl Minocycline Hcl Minocycline Hcl Minocycline Hcl Minocycline Hcl MONODOX Morgidox Ocudox PERIOSTAT SOLODYN DOXYCYCLINE MONOHYDRATE Doxycycline Hyclate Doxy/Eyelid Clns #3/Eye Eml #1 DOXYCYCLINE HYCLATE MINOCYCLINE HCL ; Extended Release 24 Hr CAPSULE Kit Tetracycline Hcl Tetracycline Hcl VIBRAMYCIN VIBRAMYCIN FIRST GENERATION CEPHALOSPOSINS DOXYCYCLINE MONOHYDRATE DOXYCYCLINE HYCLATE Cefadroxil Cefadroxil Hydrate ; EXTENDED RELEASE 24 HR SUSPENSION; RECONSTITUTED ; ORAL (ML) CAPSULE Cefadroxil Cefadroxil Hydrate Suspension; Reconstituted Oral (Ml) Cefadroxil Cefadroxil Hydrate Cephalexin Cephalexin 7
11 / TRADE NAME NAME DOSE DESCRIPTION PA ST Cephalexin Cephalexin Suspension; Reconstitutedoral (Ml) Cephalexin Cephalexin KEFLEX CEPHALEXIN CAPSULE SECOND GENERATION CEPHALOSPORINS Cefaclor Cefaclor Cefaclor Cefaclor Cefaclor Er Cefaclor Cefpodoxime Proxetil Cefpodoxime Proxetil Cefpodoxime Proxetil Cefpodoxime Proxetil Suspension; Reconstituted; Oral (Ml) ; Extended Release 12 Hr Suspension; Reconstitutedoral (Ml) Cefprozil Cefprozil Cefprozil Cefprozil CEFTIN CEFUROXIME AXETIL Cefuroxime Axetil Cefuroxime Axetil Suspension; Reconstitutedoral (Ml) Suspension; Reconstitutedoral (Ml) Cefuroxime Axetil Cefuroxime Axetil THIRD GENERATION CEPHALOSPORINS CEDAX CEDAX CEFTIBUTEN DIHYDRATE CEFTIBUTEN DIHYDRATE Cefdinir Cefdinir CAPSULE SUSPENSION; RECONSTITUTED ORAL (ML) Suspension; Reconstituted Oral (Ml) Cefdinir Cefdinir Cefditoren Pivoxil Cefditoren Pivoxil is always preferred unless otherwise stated. Brand is nonpreferred if a generic is available unless otherwise stated. 8 ST-Step Therapy, PA Prior Authorization, QL Quantity Limit, SP Specialty pharmacy
12 / TRADE NAME NAME DOSE DESCRIPTION PA ST Ceftibuten Ceftibuten Ceftibuten Dihydrate Ceftibuten Dihydrate Suspension; Reconstitutedoral (Ml) SPECTRACEF ERYTHROMYCINS & OTHER MACROLIDES CEFDITOREN PIVOXIL Azithromycin Azithromycin Azithromycin Azithromycin Suspension; Reconstituted; Oral (Ml) tabs: 500mg:1/day 250mg:1/day Azithromycin Azithromycin Packet (Ea) BIAXIN CLARITHROMYCIN SUSPENSION; RECONSTITUTED ; ORAL (ML) 150ml/Rx BIAXIN CLARITHROMYCIN 2/day BIAXIN XL CLARITHROMYCIN Clarithromycin Clarithromycin Clarithromycin Clarithromycin Clarithromycin Er Clarithromycin PREFERRED E.E.S. E.E.S. PREFERRED ERYPED ERYTHROMYCIN ETHYLSUCCINATE Erythromycin Ethylsuccinate ERYTHROMYCIN ETHYLSUCCINATE Ery-Tab Erythromycin Base PREFERRED ERY-TAB Erythrocin Stearate ERYTHROMYCIN BASE Erythromycin Stearate ; EXTENDED RELEASE 24 HR Suspension; Reconstituted; Oral (Ml) ; Extended Release 24 Hr SUSPENSION; RECONSTITUTED ; ORAL (ML) SUSPENSION; RECONSTITUTED ; ORAL (ML) ; Enteric Coated ; ENTERIC COATED Erythromycin Erythromycin Base 2/day 250mg, 500mg tabs 20 qty/10 days 150ml/rx 9
13 / TRADE NAME NAME DOSE DESCRIPTION PA ST Erythromycin Erythromycin Base PREFERRED ERYTHROMYCIN Erythromycin Ethylsuccinate Erythromycin Ethylsuccinate ERYTHROMYCIN BASE Erythromycin Ethylsuccinate Erythromycin Ethylsuccinate ;Delayed Release (Enteric Coated) ; ENTERIC COATED Suspension; Reconstituted; Oral (Ml) Erythromycin Stearate FLUOROQUINOLONES Erythromycin W/Sulfisoxazole Erythromycin Stearate Ery E- Succ/Sulfisoxazole Suspension; Reconstituted; Oral (Ml) ZITHROMAX AZITHROMYCIN ZITHROMAX AZITHROMYCIN PACKET (EA) ZITHROMAX AVELOX AZITHROMYCIN MOXIFLOXACIN HCL PREFERRED CIPRO CIPROFLOXACIN CIPRO CIPRO XR Ciprofloxacin Er CIPROFLOXACIN HCL CIPROFLOXACIN/C IPROFLOXA HCL Ciprofloxacin/ Ciprofloxa Hcl SUSPENSION; RECONSTITUTED ; ORAL (ML) SUSPENSION; MICROCAPSULE RECONSTITUTED ;EXTEND ED RELEASE MULTIPHASE 24 HR ;Extended Release Multiphase 24 Hr tabs: 250mg: 6/30 days; 500mg 5/30 days tabs: 250mg: 6/30 days; 500mg 5/30 days 1/day 10mL/day 2 tabs/day 2 tabs/day 2 tabs/day Ciprofloxacin Hcl Ciprofloxacin Hcl 2 tabs/day LEVAQUIN LEVOFLOXACIN 5 tabs/30 days LEVAQUIN LEVOFLOXACIN SOLUTION; ORAL 480ml/Rx Levofloxacin Hemihydrate Levofloxacin Solution; Oral 480ml/rx is always preferred unless otherwise stated. Brand is nonpreferred if a generic is available unless otherwise stated. 10 ST-Step Therapy, PA Prior Authorization, QL Quantity Limit, SP Specialty pharmacy
14 / TRADE NAME NAME DOSE DESCRIPTION PA ST Levofloxacin Hemihydrate Levofloxacin 5 tabs/30 days Moxifloxacin Hcl Moxifloxacin Hcl 1/day SULFAS & RELATED AGENTS BACTRIM BACTRIM DS SEPTRA SEPTRA DS Smz-Tmp Ds SULFAMETHOXAZ OLE/TRIMETHOPR IM SULFAMETHOXAZ OLE/TRIMETHOPR IM SULFAMETHOXAZ OLE/TRIMETHOPR IM SULFAMETHOXAZ OLE/TRIMETHOPR IM Sulfamethoxazole/ Trimethoprim Sulfadiazine Sulfadiazine Sulfamethoxazole/Tri methoprim Sulfamethoxazole/ Trimethoprim URINARY TRACT AGENTS Sulfamethoxazole/Tri methoprim SULFATRIM FURADANTIN HIPREX MACROBID MACRODANTIN Sulfamethoxazole/ Trimethoprim SULFAMETHOXAZ OLE/TRIMETHOPR IM NITROFURANTOIN METHENAMINE HIPPURATE NITROFURANTOIN MONOHYD/M- CRYST NITROFURANTOIN MACROCRYSTAL Suspension; Oral (Final Dose Form) SUSPENSION; ORAL (FINAL DOSE FORM) SUSPENSION; ORAL (FINAL DOSE FORM) CAPSULE CAPSULE Methenamine Hippurate Methenamine Hippurate Methenamine Mandelate Methenamine Mandelate Methylene Blue Methylene Blue (Antidotes) Ampul (Ml) 11
15 / TRADE NAME NAME DOSE DESCRIPTION PA ST Nitrofurantoin Nitrofurantoin Suspension; Oral (Final Dose Form) Nitrofurantoin Nitrofurantoin Macrocrystal Nitrofurantoin Macrocrystal Nitrofurantoin Monohyd/M-Cryst Trimethoprim Trimethoprim UREX MISCELLANEOUS ANTIVIRALS METHENAMINE HIPPURATE Acyclovir Acyclovir Suspension; Oral (Final Dose Form) Acyclovir Acyclovir Acyclovir Acyclovir Adefovir Dipivoxil Adefovir Dipivoxil PA SP Amantadine Hcl Amantadine Hcl Amantadine Hcl Amantadine Hcl Syrup Amantadine Hcl Amantadine Hcl PREFERRED BARACLUDE ENTECAVIR PA SP PREFERRED BARACLUDE ENTECAVIR SOLUTION; ORAL PA SP COPEGUS RIBAVIRIN PA SP EPIVIR HBV LAMIVUDINE PREFERRED EPIVIR HBV LAMIVUDINE SOLUTION; ORAL Famciclovir Famciclovir FAMVIR FAMCICLOVIR FLUMADINE RIMANTADINE HCL is always preferred unless otherwise stated. Brand is nonpreferred if a generic is available unless otherwise stated. 12 ST-Step Therapy, PA Prior Authorization, QL Quantity Limit, SP Specialty pharmacy
16 / TRADE NAME NAME DOSE DESCRIPTION PA ST Ganciclovir Ganciclovir HEPSERA ADEFOVIR DIPIVOXIL PA SP PREFERRED INCIVEK TELAPREVIR PA SP Lamivudine Lamivudine Moderiba Ribavirin ; Dose Pack SP Moderiba Ribavirin SP PREFERRED OLYSIO SIMEPREVIR SODIUM CAPSULE REBETOL RIBAVIRIN CAPSULE PA SP PREFERRED RELENZA ZANAMIVIR DISK; WITH INHALATION DEVICE Ribapak Ribavirin ; Dose Pack SP PA SP; 1 tablet per day for a total duration of 12 weeks 20/10days; 10 days' supply Ribasphere Ribavirin SP Ribasphere Ribavirin SP RIBATAB RIBAVIRIN ; DOSE PACK PA SP Ribavirin Ribavirin SP Ribavirin Ribavirin SP Rimantadine Hcl Rimantadine Hcl PREFERRED SOVALDI SOFOSBUVIR PA SP;28/28 days PREFERRED SYNAGIS PALIVIZUMAB VIAL (ML) PA SP PREFERRED TAMIFLU OSELTAMIVIR PHOSPHATE SUSPENSION; RECONSTITUTED ; ORAL (ML) 25 ml/day 13
17 / TRADE NAME NAME DOSE DESCRIPTION PA ST PREFERRED TAMIFLU OSELTAMIVIR PHOSPHATE CAPSULE PREFERRED TYZEKA TELBIVUDINE SP Valacyclovir Valacyclovir Hcl PREFERRED VALCYTE PREFERRED VALCYTE VALGANCICLOVIR HCL VALGANCICLOVIR HCL SOLUTION; RECONSTITUTED ; ORAL VALTREX VALACYCLOVIR HCL PREFERRED VICTRELIS BOCEPREVIR CAPSULE PA SP HIV/AIDS THERAPY ZOVIRAX ACYCLOVIR ZOVIRAX ACYCLOVIR SUSPENSION; ORAL (FINAL DOSE FORM) ZOVIRAX ACYCLOVIR CAPSULE Abacavir Abacavir Sulfate Abacavir-Lamivudine- Zidovudine Abacavir/ Lamivudine/ Zidovudine PREFERRED APTIVUS TIPRANAVIR CAPSULE PREFERRED APTIVUS PREFERRED ATRIPLA COMBIVIR PREFERRED COMPLERA TIPRANAVIR/ VITAMIN E TPGS EFAVIRENZ/ EMTRICITAB/ TENOFOVIR LAMIVUDINE/ZID OVUDINE EMTRICITAB/RILP IVIRINE/TENOFOV SOLUTION; ORAL PREFERRED CRIXIVAN INDINAVIR SULFATE Didanosine Didanosine CAPSULE ;Delayed Release (Enteric Coated) is always preferred unless otherwise stated. Brand is nonpreferred if a generic is available unless otherwise stated. 14 ST-Step Therapy, PA Prior Authorization, QL Quantity Limit, SP Specialty pharmacy
18 / TRADE NAME NAME DOSE DESCRIPTION PA ST PREFERRED EDURANT RILPIVIRINE HCL PREFERRED EMTRIVA EMTRICITABINE SOLUTION; ORAL PREFERRED EMTRIVA EMTRICITABINE CAPSULE PREFERRED EPIVIR LAMIVUDINE SOLUTION; ORAL PREFERRED EPZICOM EPIVIR LAMIVUDINE ABACAVIR SULFATE/LAMIVU DINE PREFERRED FUZEON ENFUVIRTIDE KIT PA SP PREFERRED INTELENCE ETRAVIRINE PREFERRED INVIRASE PREFERRED INVIRASE PREFERRED ISENTRESS SAQUINAVIR MESYLATE SAQUINAVIR MESYLATE RALTEGRAVIR POTASSIUM CAPSULE PA SP PREFERRED ISENTRESS RALTEGRAVIR POTASSIUM ; CHEWABLE PA SP PREFERRED KALETRA LOPINAVIR/RITON AVIR SOLUTION; ORAL PREFERRED KALETRA LOPINAVIR/RITON AVIR Lamivudine Lamivudine Lamivudine- Zidovudine PREFERRED LEXIVA PREFERRED LEXIVA Lamivudine/ Zidovudine FOSAMPRENAVIR CALCIUM FOSAMPRENAVIR CALCIUM SUSPENSION; ORAL (FINAL DOSE FORM) Nevirapine Nevirapine Suspension; Oral (Final Dose Form) Nevirapine Nevirapine 15
19 / TRADE NAME NAME DOSE DESCRIPTION PA ST Nevirapine ER 400mg Nevirapine ER PREFERRED NORVIR RITONAVIR CAPSULE PREFERRED NORVIR RITONAVIR SOLUTION; ORAL PREFERRED NORVIR RITONAVIR PREFERRED PREZISTA PREFERRED PREZISTA PREFERRED RESCRIPTOR PREFERRED RESCRIPTOR DARUNAVIR ETHANOLATE DARUNAVIR ETHANOLATE DELAVIRDINE MESYLATE DELAVIRDINE MESYLATE SUSPENSION; ORAL (FINAL DOSE FORM) ; DISPERSIBLE RETROVIR ZIDOVUDINE CAPSULE RETROVIR ZIDOVUDINE RETROVIR ZIDOVUDINE SYRUP PREFERRED REYATAZ ATAZANAVIR SULFATE CAPSULE PREFERRED SELZENTRY MARAVIROC PA Stavudine Stavudine Stavudine Stavudine PREFERRED STRIBILD ELVITEGR/ COBICIST/ EMTRIC/TENOF Solution; Reconstituted; Oral PREFERRED SUSTIVA EFAVIRENZ CAPSULE PREFERRED SUSTIVA EFAVIRENZ PREFERRED TIVICAY DOLUTEGRAVIR SODIUM SP TRIZIVIR ABACAVIR/ LAMIVUDINE/ ZIDOVUDINE is always preferred unless otherwise stated. Brand is nonpreferred if a generic is available unless otherwise stated. 16 ST-Step Therapy, PA Prior Authorization, QL Quantity Limit, SP Specialty pharmacy
20 / TRADE NAME NAME DOSE DESCRIPTION PA ST PREFERRED TRUVADA EMTRICITABINE/ TENOFOVIR PREFERRED VIDEX DIDANOSINE VIDEX EC PREFERRED VIRACEPT VIRAMUNE DIDANOSINE NELFINAVIR MESYLATE NEVIRAPINE SOLUTION; RECONSTITUTED ; ORAL CAPSULE;DELAY ED RELEASE (ENTERIC COATED) SUSPENSION; ORAL (FINAL DOSE FORM) VIRAMUNE NEVIRAPINE PREFERRED VIRAMUNE XR NEVIRAPINE PREFERRED VIREAD VIRAMUNE XR 400MG ZERIT NEVIRAPINE TENOFOVIR DISOPROXIL FUMARATE STAVUDINE ; EXTENDED RELEASE 24 HR ; EXTENDED RELEASE 24 HR SOLUTION; RECONSTITUTED ; ORAL ZERIT STAVUDINE CAPSULE ZIAGEN ABACAVIR SULFATE PREFERRED ZIAGEN ABACAVIR SULFATE SOLUTION; ORAL Zidovudine Zidovudine Zidovudine Zidovudine Syrup Zidovudine Zidovudine ANTIFUNGAL AGENTS ANCOBON FLUCYTOSINE CAPSULE Clotrimazole Clotrimazole Troche DIFLUCAN FLUCONAZOLE SUSPENSION; 17
21 / TRADE NAME NAME DOSE DESCRIPTION PA ST RECONSTITUTED ; ORAL (ML) DIFLUCAN FLUCONAZOLE 150mg: 2 EA/7 days Fluconazole Fluconazole Fluconazole Fluconazole Suspension; Reconstituted; Oral (Ml) 150mg: 2 ea/7 days Flucytosine Flucytosine GRIFULVIN V GRISEOFULVIN; MICROSIZE Griseofulvin Griseofulvin Griseofulvin; Microsize Griseofulvin; Microsize Suspension; Oral (Final Dose Form) Griseofulvin Ultramicrosize Griseofulvin Ultramicrosize GRIS-PEG GRISEOFULVIN ULTRAMICROSIZE Itraconazole Itraconazole Ketoconazole Ketoconazole PA LAMISIL TERBINAFINE HCL PREFERRED LAMISIL TERBINAFINE HCL PREFERRED NOXAFIL POSACONAZOLE PREFERRED NOXAFIL POSACONAZOLE Nystatin Nystatin GRANULES IN PACKET (EA) SUSPENSION; ORAL (FINAL DOSE FORM) ; ENTERIC COATED Suspension; Oral (Final Dose Form) 250mg: 1 tab/day;84 days of therapy per 365 days 250mg: 1 tab/day;84 days of therapy per 365 days Nystatin Nystatin SPORANOX ITRACONAZOLE CAPSULE is always preferred unless otherwise stated. Brand is nonpreferred if a generic is available unless otherwise stated. 18 ST-Step Therapy, PA Prior Authorization, QL Quantity Limit, SP Specialty pharmacy
22 / TRADE NAME NAME DOSE DESCRIPTION PA ST PREFERRED SPORANOX ITRACONAZOLE SOLUTION; ORAL Terbinafine Terbinafine Hcl Terbinafine Terbinafine Hcl VFEND VORICONAZOLE VFEND VORICONAZOLE Voriconazole Voriconazole SUSPENSION; RECONSTITUTED ; ORAL (ML) Suspension; Reconstituted; Oral (Ml) 250mg: 1 tab/day;84 days of therapy per 365 days 250mg: 1 tab/day;84 days of therapy per 365 days Voriconazole Voriconazole VANCOMYCIN VANCOCIN HCL VANCOMYCIN HCL CAPSULE Vancomycin Hcl Vancomycin Hcl MISCELLANEOUS ANTIINFECTIVES Amikacin Sulfate Amikacin Sulfate Syringe (Ml) PREFERRED CAYSTON AZTREONAM LYSINE VIAL; NEBULIZER (ML) PA SP; 3 vials per day CLEOCIN HCL CLINDAMYCIN HCL CAPSULE CLEOCIN PALMITATE CLINDAMYCIN PALMITATE HCL SOLUTION; RECONSTITUTED ; ORAL Clindamycin Hcl Clindamycin Hcl Clindamycin Palmitate Hcl Clindamycin Pediatric Clindamycin Palmitate Hcl Clindamycin Palmitate Hcl Solution; Reconstituted; Oral Solution; Reconstituted; Oral PREFERRED DAPSONE DAPSONE Neomycin Sulfate Neomycin Sulfate 19
23 / TRADE NAME NAME DOSE DESCRIPTION PA ST TOBI TOBRAMYCIN IN 0.225% NACL PREFERRED TOBI PODHALER TOBRAMYCIN AMPUL FOR NEBULIZATION (ML) CAPSULE; WITH INHALATION DEVICE PA PA SP Tobramycin Sulfate Tobramycin In 0.225% Nacl Ampul For Nebulization (Ml) PA PREFERRED XIFAXAN RIFAXIMIN PREFERRED ZYVOX LINEZOLID SUSPENSION; RECONSTITUTED ; ORAL (ML) PA PREFERRED ZYVOX LINEZOLID PA ANTIPARASITICS PREFERRED ALBENZA ALBENDAZOLE PREFERRED ALINIA NITAZOXANIDE SUSPENSION; RECONSTITUTED ; ORAL (ML) PREFERRED ALINIA NITAZOXANIDE Atovaquone Atovaquone Suspension; Oral (Final Dose Form) NON- PREFERRED BILTRICIDE PRAZIQUANTEL PA FLAGYL METRONIDAZOLE CAPSULE FLAGYL METRONIDAZOLE generic preferred mebendazole mebendazole tablet; chewable MEPRON ATOVAQUONE SUSPENSION; ORAL (FINAL DOSE FORM) Metronidazole Metronidazole Metronidazole Metronidazole Paromomycin Sulfate Paromomycin Sulfate PREFERRED STROMECTOL IVERMECTIN TINDAMAX TINIDAZOLE Tinidazole Tinidazole ANTIMALARIALS ARALEN PHOSPHATE Atovaquone-Proguanil Hcl CHLOROQUINE PHOSPHATE Atovaquone/Progu anil Hcl Allow to bypass denial if provider inserts ICD-9 diagnosis code of is always preferred unless otherwise stated. Brand is nonpreferred if a generic is available unless otherwise stated. 20 ST-Step Therapy, PA Prior Authorization, QL Quantity Limit, SP Specialty pharmacy
24 / TRADE NAME NAME DOSE DESCRIPTION PA ST Chloroquine Chloroquine Phosphate Phosphate PREFERRED COARTEM ARTEMETHER/LU MEFANTRINE PREFERRED DARAPRIM PYRIMETHAMINE Hydroxychloroquine Sulfate MALARONE Hydroxychloroquine Sulfate ATOVAQUONE/PR OGUANIL HCL Mefloquine Hcl Mefloquine Hcl PLAQUENIL HYDROXYCHLORO QUINE SULFATE QUALAQUIN QUININE SULFATE CAPSULE Quinine Sulfate Quinine Sulfate ANTIMYCOBACTERIALS Ethambutol Hcl Ethambutol Hcl Isonarif Rifampin/Isoniazid Isoniazid Isoniazid Isoniazid Isoniazid Solution; Oral MYAMBUTOL ETHAMBUTOL HCL PREFERRED MYCOBUTIN RIFABUTIN CAPSULE PREFERRED PRIFTIN RIFAPENTINE Pyrazinamide Pyrazinamide RIFADIN RIFAMPIN CAPSULE RIFAMATE RIFAMPIN/ISONIA ZID CAPSULE Rifampin Rifampin PREFERRED SIRTURO BEDAQUILINE FUMARATE 21
25 / TRADE NAME NAME DOSE DESCRIPTION PA ST ANTINEOPLASTIC & IMMUNOSUPPRESANT DRUGS ALKYLATING AGENTS PREFERRED ALKERAN MELPHALAN SP PREFERRED CEENU LOMUSTINE CAPSULE SP Cyclophosphamide Cyclophosphamide PREFERRED LEUKERAN CHLORAMBUCIL SP PREFERRED LOMUSTINE LOMUSTINE CAPSULE PREFERRED MYLERAN BUSULFAN SP TEMODAR TEMOZOLOMIDE CAPSULE SP Temozolomide Temozolomide SP ANTIMETABOLITES Capecitabine Capecitabine PA SP Mercaptopurine Mercaptopurine Methotrexate Methotrexate Methotrexate Sodium PREFERRED OFORTA Methotrexate Sodium Methotrexate Sodium Methotrexate Sodium FLUDARABINE PHOSPHATE ; Dose Pack PURINETHOL MERCAPTOPURINE PREFERRED TABLOID THIOGUANINE SP PREFERRED TREXALL METHOTREXATE SODIUM XELODA CAPECITABINE PA SP is always preferred unless otherwise stated. Brand is nonpreferred if a generic is available unless otherwise stated. 22 ST-Step Therapy, PA Prior Authorization, QL Quantity Limit, SP Specialty pharmacy
26 / TRADE NAME NAME DOSE DESCRIPTION PA ST HORMONES MEGACE MEGESTROL ACETATE Megestrol Acetate Megestrol Acetate SUSPENSION; ORAL (FINAL DOSE FORM) Suspension; Oral (Final Dose Form) Megestrol Acetate Megestrol Acetate ANTIESTROGENS Anastrozole Anastrozole ARIMIDEX ANASTROZOLE AROMASIN EXEMESTANE SP Exemestane Exemestane SP PREFERRED FARESTON TOREMIFENE CITRATE SP FEMARA LETROZOLE Letrozole Letrozole Tamoxifen Citrate Tamoxifen Citrate ANTIANDROGENS Bicalutamide Bicalutamide CASODEX BICALUTAMIDE Flutamide Flutamide PREFERRED NILANDRON NILUTAMIDE SP PREFERRED XTANDI ENZALUTAMIDE CAPSULE SP PREFERRED ZYTIGA ABIRATERONE ACETATE SP 23
27 / TRADE NAME NAME DOSE DESCRIPTION PA ST IMMUNOSUPPRESSANT DRUGS PREFERRED AZASAN AZATHIOPRINE Azathioprine Azathioprine PREFERRED CELLCEPT CELLCEPT MYCOPHENOLATE MOFETIL MYCOPHENOLATE MOFETIL SUSPENSION; RECONSTITUTED ; ORAL (ML) CELLCEPT MYCOPHENOLATE MOFETIL CAPSULE Cyclosporine Cyclosporine Cyclosporine Cyclosporine Solution; Oral Cyclosporine Cyclosporine Gengraf Gengraf Cyclosporine; Modified Cyclosporine; Modified Cyclosporine; Modified Cyclosporine; Modified Solution; Oral Solution; Oral Hecoria Tacrolimus IMURAN AZATHIOPRINE Mycophenolate Mofetil Mycophenolate Mofetil Mycophenolate Mofetil Mycophenolate Mofetil Mycophenolic Acid MYFORTIC Mycophenolate Sodium MYCOPHENOLATE SODIUM ; Enteric Coated ; ENTERIC COATED PROGRAF TACROLIMUS CAPSULE PREFERRED RAPAMUNE SIROLIMUS SOLUTION; ORAL SP PREFERRED RAPAMUNE SIROLIMUS SP is always preferred unless otherwise stated. Brand is nonpreferred if a generic is available unless otherwise stated. 24 ST-Step Therapy, PA Prior Authorization, QL Quantity Limit, SP Specialty pharmacy
28 / TRADE NAME NAME DOSE DESCRIPTION PA ST Sirolimus Sirolimus Tacrolimus Tacrolimus PREFERRED ZORTRESS EVEROLIMUS SP MISCELLANEOUS ANTINEOPLASTIC DRUGS PREFERRED AFINITOR EVEROLIMUS SP PREFERRED AFINITOR DISPERZ EVEROLIMUS FOR SUSPENSION SP PREFERRED BOSULIF BOSUTINIB SP PREFERRED CAPRELSA VANDETANIB SP PREFERRED DROXIA HYDROXYUREA CAPSULE PREFERRED EMCYT ESTRAMUSTINE PHOSPHATE SODIUM CAPSULE SP PREFERRED ERIVEDGE VISMODEGIB CAPSULE SP Etoposide Etoposide PREFERRED GILOTRIF AFATINIB DIMALEATE SP PREFERRED GLEEVEC IMATINIB MESYLATE SP PREFERRED HEXALEN ALTRETAMINE CAPSULE SP PREFERRED HYCAMTIN TOPOTECAN HCL CAPSULE SP HYDREA HYDROXYUREA CAPSULE Hydroxyurea Hydroxyurea PREFERRED IMBRUVICA IBRUTINIB CAPSULE PA SP PREFERRED INLYTA AXITINIB SP 25
29 / TRADE NAME NAME DOSE DESCRIPTION PA ST PREFERRED IRESSA GEFITINIB SP PREFERRED JAKAFI RUXOLITINIB PHOSPHATE SP PREFERRED LYSODREN MITOTANE SP PREFERRED MATULANE PROCARBAZINE HCL CAPSULE SP PREFERRED MEKINIST TRAMETINIB DIMETHYL SULFOXIDE SP PREFERRED NEXAVAR SORAFENIB TOSYLATE SP PREFERRED POMALYST POMALIDOMIDE CAPSULE SP PREFERRED REVLIMID LENALIDOMIDE CAPSULE SP PREFERRED SIGNIFOR PASIREOTIDE DIASPARTATE AMPUL (ML) SP PREFERRED SPRYCEL DASATINIB SP PREFERRED STIVARGA REGORAFENIB SP PREFERRED SUTENT SUNITINIB MALATE CAPSULE SP PREFERRED TAFINLAR DABRAFENIB MESYLATE CAPSULE SP PREFERRED TARCEVA ERLOTINIB HCL SP PREFERRED TARGRETIN BEXAROTENE CAPSULE SP PREFERRED TARGRETIN BEXAROTENE GEL (GRAM) SP PREFERRED TASIGNA NILOTINIB HCL CAPSULE SP PREFERRED THALOMID THALIDOMIDE CAPSULE SP Tretinoin Tretinoin SP PREFERRED TYKERB LAPATINIB DITOSYLATE PA SP is always preferred unless otherwise stated. Brand is nonpreferred if a generic is available unless otherwise stated. 26 ST-Step Therapy, PA Prior Authorization, QL Quantity Limit, SP Specialty pharmacy
30 / TRADE NAME NAME DOSE DESCRIPTION PA ST PREFERRED VANDETANIB VANDETANIB PREFERRED VOTRIENT PAZOPANIB HCL SP PREFERRED XALKORI CRIZOTINIB CAPSULE SP PREFERRED ZELBORAF VEMURAFENIB SP PREFERRED ZOLINZA VORINOSTAT CAPSULE SP PREFERRED ZYKADIA CERITINIB ADJUNCTIVE AGENTS Leucovorin Calcium Leucovorin Calcium SP; 140 capsules per 28 days (5 capsules per day) PREFERRED MESNEX MESNA SP AUTONOMIC & CNS DRUGS, NEUROLOGY, & PSYCH NARCOTIC ANALGESICS NARCOTICS ACTIQ AVINZA Buprenorphine Hydrochloride FENTANYL CITRATE MORPHINE SULFATE LOZENGE ON A HANDLE CAPSULE; EXTENDED RELEASE MULTIPHASE 24HR Buprenorphine Hcl ; Sublingual PA 1/day Codeine Sulfate Codeine Sulfate DEMEROL MEPERIDINE HCL DILAUDID HYDROMORPHON E HCL DILAUDID HYDROMORPHON E HCL LIQUID (ML) Diskets Methadone Hcl ; Soluble DOLOPHINE HCL METHADONE HCL 27
31 / TRADE NAME NAME DOSE DESCRIPTION PA ST DURAGESIC EXALGO FENTANYL HYDROMORPHONE ER Fentanyl Fentanyl Fentanyl Citrate Fentanyl Citrate PATCH; TRANSDERMAL 72 HOURS Patch; Transdermal 72 Hours Lozenge On A Handle patch 12/28 days 3/day patch 12/28 days Hydromorphone Hcl Hydromorphone Hcl Suppository; Rectal Hydromorphone Hcl Hydromorphone Hcl Liquid (Ml) Hydromorphone Hcl Hydromorphone Hcl Hydromorphone Hcl ER Hydromorphone Hcl 3/day KADIAN MORPHINE SULFATE CAPSULE; EXTENDED RELEASE PELLETS PA 2/day Levorphanol Tartrate Levorphanol Tartrate Meperidine Hcl Meperidine Hcl Cartridge (Ml) Meperitab Meperidine Hcl Methadone Hcl Methadone Hcl Concentrate; Oral Methadone Hcl Methadone Hcl Solution; Oral Methadone Hcl Methadone Hcl Methadone Hcl Methadone Hcl ; Soluble Methadose Methadone Hcl Methadose Methadone Hcl Concentrate; Oral Methadose Methadone Hcl ; Soluble Morphine Sulfate Morphine Sulfate Solution; Oral is always preferred unless otherwise stated. Brand is nonpreferred if a generic is available unless otherwise stated. 28 ST-Step Therapy, PA Prior Authorization, QL Quantity Limit, SP Specialty pharmacy
How To Get A Drug Plan To Pay For A Prescription From Acpa
+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 informationFORMULARY. (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 information2015 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 informationProduct 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 informationAvMed 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 informationMarketplace 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 informationHIV 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(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 informationNorth 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 informationAbridged 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 informationAETNA 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 informationPROJECT 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 informationMagellan 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 informationCovered 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 information2016 Comprehensive. Formulary. Service To Seniors (HMO) OC Preferred (HMO) LIST OF COVERED DRUGS. It s Personal.
It s Personal. 2016 Comprehensive Formulary Service To Seniors (HMO) OC Preferred (HMO) LIST OF COVERED DRUGS PLEASE READ: This document contains information about the drugs we cover in the Plans Service
More informationEffective 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 informationHIV 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 informationHPMS Approved Formulary File Submission ID: 00016311, Version Number 6.
UPMC for Life 2016 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. HPMS Approved Formulary File Submission ID: 00016311, Version
More informationPLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN.
01 Blue BCN Advantage HMO BCN Advantage HMO-POS Medicare and more Care Network of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. BCN Advantage
More informationFORMULARY. 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 informationAnthem 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 informationBeHealthy America, Inc. 2015 Formulary. (List of Covered Drugs)
BeHealthy America, Inc. 2015 Formulary (List of Covered Drugs) HPMS Approved Formulary File Submission ID: 15583 Version Number: 12 PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER
More informationDrug Class Review Drugs for Fibromyalgia
Drug Class Review Drugs for Fibromyalgia Final Original Report April 2011 The Agency for Healthcare Research and Quality has not yet seen or approved this report. The purpose of the is to summarize key
More information12629 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 informationFirst 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 informationPrescription Drug Guide
2012 Prescription Drug Guide Humana Group Medicare Formulary List of covered drugs Humana Group Medicare Plus 3 PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. Y0040_PDG12b_Final_522C
More informationQUANTITY 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 informationBlue MedicareRx Premier (PDP) 2015 Formulary (List of Covered Drugs)
Blue MedicareRx Premier (PDP) 0 Formulary (List of Covered s) Please read: This document contains information about some of the drugs we cover in this plan. This formulary was updated on October, 0. For
More informationMay 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 informationPLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN.
UPMC for Life 2015 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. HPMS Approved Formulary File Submission ID: 00015350, Version
More informationExpress Scripts Medicare (PDP) 2015 Formulary (List of Covered Drugs)
Value Express Scripts Medicare (PDP) 2015 Formulary (List of Covered s) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT SOME OF THE DRUGS WE COVER IN THIS PLAN Y0046_F00SNV5A Accepted, Formulary
More informationMVP 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 information2016 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 informationPalliative 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 informationSTATE HEALTH REFORM IMPACT MODELING PROJECT. Alabama
STATE HEALTH REFORM IMPACT MODELING PROJECT Alabama January 2013 Prepared by the Center for Health Law and Policy Innovation of Harvard Law School and the Treatment Access Expansion Project BACKGROUND
More information2016 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 informationState Health Reform Impact Modeling Project Tennessee
State Health Reform Impact Modeling Project Tennessee January 2013 Prepared by the Center for Health Law and Policy Innovation of Harvard Law School and the Treatment Access Expansion Project Background
More informationUPMC for You Advantage (HMO SNP) 2015 Formulary. (List of Covered Drugs)
UPMC for You Advantage (HMO SNP) 2015 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission ID:
More informationEmpire MediBlue Plus (HMO) 2015 Formulary (List of Covered Drugs)
Empire MediBlue Plus (H) 0 Formulary (List of Covered s) Please read: This document contains information about some of the drugs we cover in this plan. This formulary was updated on October, 0. For more
More informationPatient 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 informationicare Medicare Plan HMO SNP 2016 Abridged Formulary (Partial List of Covered Drugs)
icare Medicare Plan HMO SNP 016 Abridged Formulary (Partial List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT SOME OF THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary
More informationIllinois Department of Revenue Regulations TITLE 86: REVENUE CHAPTER I: DEPARTMENT OF REVENUE
Illinois Department of Revenue Regulations Title 86 Part 530 Section 530.110 Covered Prescription Drugs TITLE 86: REVENUE CHAPTER I: DEPARTMENT OF REVENUE PART 530 SENIOR CITIZENS AND DISABLED PERSONS
More informationMeasuring 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 informationPSYCHOSOMATIC 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 informationAvMed Medicare Choice. 2011 Formulary (List of Covered Drugs)
AvMed Medicare Choice 2011 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 has changed since
More informationDrug 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 informationAnthem Blue MedicareRx Standard (PDP) 2015 Formulary (List of Covered Drugs)
Anthem Blue MedicareRx Standard (PDP) 0 Formulary (List of Covered s) Please read: This document contains information about some of the drugs we cover in this plan. This formulary was updated on August,
More informationSporadic attacks of severe tension-type headaches may respond to analgesics.
MEDICATIONS While we are big advocates of non-drug treatments, many people do require the use of medications to control headaches. Headache medications are divided into two categories. Abortive drugs are
More informationOral Fluid Drug Testing March 23 rd, 2015
Oral Fluid Drug Testing March 23 rd, 2015 Drug Testing Options Breath Blood Meconium Vitreous Hair Sweat Urine Oral Drug Testing Options Oral Fluid and Blood and Breath Actual levels (immediate use, up
More informationPDL 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 informationSouth CarolinaJanuary 2013
STATE HEALTH REFORM IMPACT MODELING PROJECT South CarolinaJanuary 2013 Prepared by the Center for Health Law and Policy Innovation of Harvard Law School and the Treatment Access Expansion Project BACKGROUND
More informationExpress Scripts Medicare (PDP) 2016 Formulary (List of Covered Drugs)
Express Scripts Medicare (PDP) 2016 Formulary (List of Covered s) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT SOME OF THE DRUGS COVERED BY THIS PLAN Formulary ID Number: 16082, v5 This formulary
More informationUSP 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 informationState Health Reform Impact Modeling Project Florida
State Health Reform Impact Modeling Project Florida January 2013 Prepared by the Center for Health Law and Policy Innovation of Harvard Law School and the Treatment Access Expansion Project Questions may
More informationSTATE HEALTH REFORM IMPACT MODELING PROJECT. Georgia
STATE HEALTH REFORM IMPACT MODELING PROJECT Georgia January 2013 Prepared by the Center for Health Law and Policy Innovation of Harvard Law School and the Treatment Access Expansion Project BACKGROUND
More informationPhone (Home) Phone (Work or other) Primary Care Physician: PCP Address: Phone: Referring Physician (if different than PCP):
Addressograph or Patient Name and Medical Record Number Clinics Pain Mngmt New Patient Health Questionnaire Patient Name: Last First Middle Maiden Address: Street City State Zip Phone (Home) Phone (Work
More informationDrugs 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 informationOpioid Pain and Addiction Management Medications Drug. Interactions with HIV Antiretrovirals. A Drug Interaction Guide for Clinicians.
857106_Pain Bro.qxd 6/11/13 7:49 AM Page 1 Opioid Pain and Addiction Management Medications Drug Interactions with HIV Antiretrovirals A Drug Interaction Guide for Clinicians Spring 2013 NY/NJ AIDS Education
More informationExpress Scripts Medicare (PDP) 2016 Formulary (List of Covered Drugs)
Value Express Scripts Medicare (PDP) 2016 Formulary (List of Covered s) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Formulary File Submission ID: 16337, V11 This
More informationFrequently Asked Questions: HB 341 Mandatory OARRS Registration and Requests
Frequently Asked Questions: HB 341 Mandatory OARRS Registration and Requests Q1) What is OARRS? Updated 12-18-2014 OARRS stands for the Ohio Automated Rx Reporting System. Established in 2006, OARRS is
More informationBest Practices for Patients With Pain. Commonly Used Over the Counter (OTC) Pain Relievers 5/15/2015
Faculty Best Practices for Patients With Pain Nancy Bishop, RPh Assistant State Pharmacy Director Alabama Department of Public Health Satellite Conference and Live Webcast Wednesday, May 20, 2015 2:00
More informationAn Analysis of Access to Anticonvulsants in Medicare Part D and Commercial Health Insurance Plans
An Analysis of Access to Anticonvulsants in Medicare Part D and Commercial Health Insurance Plans June 2013 Prepared by: Kelly Brantley Jacqueline Wingfield Bonnie Washington UCB provided funding for this
More informationNew Jersey. State Health Reform Impact Modeling Project
State Health Reform Impact Modeling Project New Jersey January 2013 Prepared by the Center for Health Law and Policy Innovation of Harvard Law School and the Treatment Access Expansion Project Background
More informationRocky Mountain Health Plans 2015 Premier Medicare Formulary (List of Covered Drugs)
Rocky Mountain Health Plans 015 Premier Medicare Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on November
More informationClinical Criteria Manual
Department of Vermont Health Access Pharmacy Benefit Management Program VERMONT PREFERRED DRUG LIST and DRUGS REQUIRING PRI AUTHIZATION Clinical Criteria Manual January 21, 2014 Department of Vermont Health
More informationAttachment 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 informationMUSC Opioid Analgesic Comparison Chart
MUSC Opioid Analgesic Comparison Chart Approved by the Pharmacy and Therapeutics Committee (February 2006, November 2009, March 2010, December 2011) Prepared by the MUSC Department of Pharmacy Services
More informationFirst 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 informationList of Covered Drugs (Formulary)
Amerigroup STAR+PLUS MMP (Medicare-Medicaid Plan) List of Covered Drugs (Formulary) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. Member Services: 1-855-878-1784
More informationSTATE HEALTH REFORM IMPACT MODELING PROJECT. North Carolina
STATE HEALTH REFORM IMPACT MODELING PROJECT North Carolina December 2012 Prepared by the Center for Health Law and Policy Innovation of Harvard Law School and the Treatment Access Expansion Project Questions
More informationPSYCHOPHARMACOLOGY 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 informationHow To Get A Generic Drug From A Pharmacy Benefit Manager
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 informationDosage Calculations INTRODUCTION. L earning Objectives CHAPTER
CHAPTER 5 Dosage Calculations L earning Objectives After completing this chapter, you should be able to: Solve one-step pharmaceutical dosage calculations. Set up a series of ratios and proportions to
More information$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 informationBC 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 informationBAPTIST HEALTH MEDICATION EXAMINATION INFORMATION SHEET
BAPTIST HEALTH MEDICATION EXAMINATION INFORMATION SHEET Before you begin employment in the role of RN or LPN, you are required to take a Medication Administration Exam. The exam may be administered at
More informationMaryland. State Health Reform Impact Modeling Project
State Health Reform Impact Modeling Project Maryland January 2013 Prepared by the Center for Health Law and Policy Innovation of Harvard Law School and the Treatment Access Expansion Project Background
More informationDosing information in renal impairment
No. Drug name Usual dose Adjustment for Renal failure estimated CrCl (ml/min) Aminoglycoside antibiotics 1 Amikacin 2 Gentamicin 7.5 mg /kg q 12 hr > 50-90 7.5 mg/kg q 12 hr 10-50 7.5 mg/kg q 24 hr < 10
More informationFORMULARY. Toll-Free 1-800-204-1002, TTY 711. 8 a.m. to 8 p.m. local time, 7 days a week. www.careimprovementplus.com
1 015 Comprehensive FORMULARY (Complete list of covered drugs) Care Improvement Plus Gold Rx (PPO SNP) Care Improvement Plus Gold Rx (Regional PPO SNP) Care Improvement Plus Medicare Advantage (PPO) Care
More informationMedicare-Medicaid Plan 2015 List of Covered Drugs (Formulary)
Medicare-Medicaid Plan 2015 List of Covered Drugs (Formulary) caid-mmaiformulary-1115 Version 25 November 1, 2015 H0073_14_11391a caid-mmaiformulary-1115 Version 25 November 1, 2015 H0773_14_11391a Health
More informationRetail 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 informationExtra 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 informationMay 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 informationExpress Scripts Medicare (PDP) 2016 Formulary (List of Covered Drugs)
Choice Express Scripts Medicare (PDP) 016 Formulary (List of Covered s) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Formulary File Submission ID: 16338, V1 This
More informationDate: November 30, 2010
Department of Health and Human Services Public Health Service Food and Drug Administration Center for Drug Evaluation and Research Date: November 30, 2010 To: Through: From: Subject: Drug Name(s): Application
More informationState of Louisiana. Department of Health and Hospitals Bureau of Health Services Financing
Bobby Jindal GOVERNOR Bruce D. Greenstein SECRETARY State of Louisiana Department of Health and Hospitals Bureau of Health Services Financing Re: Quantity Limits, Maximum Dosages and ICD-9-CM Diagnosis
More informationDistrict of Columbia
STATE HEALTH REFORM IMPACT MODELING PROJECT District of Columbia January 2013 Prepared by the Center for Health Law and Policy Innovation of Harvard Law School and the Treatment Access Expansion Project
More informationPsychiatric 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 informationFormulary. List of Covered Drugs. premera.com/ma. Version 17. PLEASE READ: This document contains information about the drugs we cover in this plan.
2015 Formulary List of Covered Drugs premera.com/ma Version 17 Premera Blue Cross Medicare Advantage (HMO) Premera Blue Cross Medicare Advantage Plus (HMO) Premera Blue Cross Medicare Advantage (HMO-POS)
More informationEarly 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 informationDrug Use Review. Edward Cox, M.D. Director Office of Antimicrobial Products
Department of Health and Human Services Public Health Service Food and Drug Administration Center for Drug Evaluation and Research Drug Use Review Date: April 5, 2012 To: Through: Edward Cox, M.D. Director
More informationArizona 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 informationFirstCarolinaCare Insurance Company
FirstCarolinaCare Insurance Company FirstMedicare Direct HMO Plus (HMO) and FirstMedicare Direct PPO Plus (PPO) 2015 Comprehensive Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS
More informationLamictal, lamotrigine Lithium, lithobid, eskalith Depakote, valproate Trileptal, oxcarbazepine Tegretol, equetro, carbamazepine Atypicals (aripiprazole, abilify, olanzapine, zyprexa, invega, risperdal,
More informationHelpful HIV Medication Tables for Pharmacists
861837_Pharmguide.qxd 2/5/14 12:55 PM Page 1 Helpful HIV Medication Tables for Pharmacists New York/New Jersey AIDS Education & Training Center (AETC) www.nynjaetc.org Winter 2014 861837_Pharmguide.qxd
More informationDrug Class Review Neuropathic Pain
Drug Class Review Neuropathic Pain Final Update 1 Report June 2011 The Agency for Healthcare Research and Quality has not yet seen or approved this report The purpose of the is to summarize key information
More informationAETNA BETTER HEALTH OF OHIO a MyCare Ohio plan
AETNA BETTER HEALTH OF OHIO a MyCare Ohio plan 2016 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 informationNEW PATIENTS' INFORMATION SHEET
NEW PATIENTS' INFORMATION SHEET Please print clearly. Please complete all information so that your claim can be processed quickly and efficiently. Thank you! PATIENT INFORMATION (First) (MI) (Last) Name
More information