VillageHealth®
2017
VillageHealth (HMO-POS SNP) Formulary
List of Covered Drugs
Formulario de VillageHealth (HMO-POS SNP) para 2017
Lista de medicamentos cubiertos
This formulary was updated on 06/01/2017. For more recent information or other questions, please contact
VillageHealth Member Services at 1-800-399-7226 or, for TTY users, 711, 8 a.m.–8 p.m., 7 days a week from
October 1 to February 14. From February 15 to September 30, hours are 8 a.m. to 8 p.m. Monday through Friday
(messages received on holidays and outside of our business hours will be returned within one business day), or
visit www.villagehealthca.com.
Este formulario se actualizó en 06/01/2017. Para obtener información más reciente o si tiene dudas,
comuníquese con Servicios para Miembros de VillageHealth al 1-800-399-7226 o, para los usuarios de TTY,
711, de 8 a.m. a 8 p.m., los 7 días de la semana, desde el 1 de octubre hasta el 14 de febrero. Desde el 15
de febrero al 30 de septiembre, el horario es de 8 a.m. a 8 p.m., de lunes a viernes (los mensajes recibidos en
días festivos y fuera del horario hábil se devolverán en un día hábil). O visite www.villagehealthca.com.
17C-FORVH
VillageHealth (HMO-POS SNP)
2017 Formulary (List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER
IN THIS PLAN
17395, 11
This formulary was updated on 06/01/2017. For more recent information or other questions, please contact
VillageHealth Member Services, at 1-800-399-7226 or, for TTY users, 711, 8 a.m.–8 p.m., 7 days a week
from October 1 to February 14. From February 15 to September 30, hours are 8 a.m. to 8 p.m. Monday
through Friday (messages received on holidays and outside of our business hours will be returned within one
business day), or visit www.villagehealthca.com.
Note to existing members: This formulary has changed since last year. Please review this document to make
sure that it still contains the drugs you take.
When this drug list (formulary) refers to “we,” “us”, or “our,” it means SCAN Health Plan. When it refers to
“plan” or “our plan,” it means VillageHealth (HMO-POS SNP).
This document includes a list of the drugs (formulary) for our plan which is current as of June 2017. For
an updated formulary, please contact us. Our contact information, along with the date we last updated the
formulary, appears on the front and back cover pages.
You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary,
pharmacy network, and/or copayments/coinsurance may change on January 1, 2018, and from time to time
during the year.
This information is not a complete description of benefits. Contact the plan for more information.
Limitations, copayments, and restrictions may apply. The Formulary, pharmacy network, and/or provider
network may change at any time. You will receive notice when necessary.
You can get prescription drugs shipped to your home through our network mail order delivery program.
Typically, you should expect to receive your prescription drugs within 14 days from the time that the mail
order pharmacy receives the order. If you do not receive your prescription drug(s) within this time, please
contact VillageHealth Member Services at 1-800-399-7226, 8 a.m.–8 p.m., 7 days a week from October
1 to February 14. From February 15 to September 30, hours are 8 a.m. to 8 p.m. Monday through Friday
(messages received on holidays and outside of our business hours will be returned within one business day).
TTY users should call 711.
VillageHealth (HMO-POS SNP) is an HMO plan; and is a Point of Service (POS) plan with a Medicare
contract. Enrollment in SCAN Health Plan depends on contract renewal.
I
ATTENTION: If you speak a language other than English, language assistance services, free of charge, are
available to you. Call 1-800-399-7226 (TTY: 711).
ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al
1-800-399-7226 (TTY: 711).
注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-800-399-7226（聽障專線：711）。
Y0057_SCAN_9797_2016F File & Use Accepted 08102016
II
TABLE OF CONTENTS
What is the VillageHealth Formulary?.......................................................................................................V
Can the Formulary (drug list) change?......................................................................................................V
How do I use the Formulary?...................................................................................................................V
What are generic drugs?..........................................................................................................................V
Are there any restrictions on my coverage?...............................................................................................VI
What if my drug is not on the Formulary?................................................................................................VI
How do I request an exception to the VillageHealth Formulary?.................................................................VI
What do I do before I can talk to my doctor about changing my drugs or requesting an exception?..............VII
For more information...........................................................................................................................VIII
VillageHealth’s Formulary.......................................................................................................................XI
Formulary Drugs Arranged by Therapeutic Class........................................................................................1
Formulary Drugs with Quantity Limits.....................................................................................................27
Index...................................................................................................................................................30
III
IV
What is the VillageHealth Formulary?
A formulary is a list of covered drugs selected by VillageHealth in consultation with a team of health care
providers, which represents the prescription therapies believed to be a necessary part of a quality treatment
program. VillageHealth will generally cover the drugs listed in our formulary as long as the drug is medically
necessary, the prescription is filled at a VillageHealth network pharmacy, and other plan rules are followed.
For more information on how to fill your prescriptions, please review your Evidence of Coverage.
Can the Formulary (drug list) change?
Generally, if you are taking a drug on our 2017 formulary that was covered at the beginning of the year, we
will not discontinue or reduce coverage of the drug during the 2017 coverage year except when a new, less
expensive generic drug becomes available or when new adverse information about the safety or effectiveness
of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not
affect members who are currently taking the drug. It will remain available at the same cost-sharing for those
members taking it for the remainder of the coverage year. We feel it is important that you have continued
access for the remainder of the coverage year to the formulary drugs that were available when you chose our
plan, except for cases in which you can save additional money or we can ensure your safety.
If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy
restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of
the change at least 60 days before the change becomes effective, or at the time the member requests a
refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug
Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug
from the market, we will immediately remove the drug from our formulary and provide notice to members
who take the drug. The enclosed formulary is current as of June 2017. To get updated information about the
drugs covered by VillageHealth, please contact us. Our contact information appears on the front and back
cover pages.
How do I use the Formulary?
There are two ways to find your drug within the formulary:
Medical Condition
The formulary begins on page 1. The drugs in this formulary are grouped into categories depending
on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart
condition are listed under the category, “Cardiovascular Agents”. If you know what your drug is used
for, look for the category name in the list that begins on page number 1. Then look under the category
name for your drug.
Alphabetical Listing
If you are not sure what category to look under, you should look for your drug in the Index that begins
on page 30. The Index provides an alphabetical list of all of the drugs included in this document. Both
brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next
to your drug, you will see the page number where you can find coverage information. Turn to the page
listed in the Index and find the name of your drug in the first column of the list.
What are generic drugs?
VillageHealth covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as
having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand
name drugs.
V
Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These requirements and limits
may include:
• Prior Authorization: VillageHealth requires you or your physician to get prior authorization for
certain drugs. This means that you will need to get approval from VillageHealth before you fill your
prescriptions. If you don’t get approval, VillageHealth may not cover the drug.
• Quantity Limits: For certain drugs, VillageHealth limits the amount of the drug that VillageHealth will
cover. For example, VillageHealth provides 30 tablets per prescription for Rozerem. This may be in
addition to a standard one-month or three-month supply.
• Step Therapy: In some cases, VillageHealth requires you to first try certain drugs to treat your medical
condition before we will cover another drug for that condition. For example, if Drug A and Drug B
both treat your medical condition, VillageHealth may not cover Drug B unless you try Drug A first. If
Drug A does not work for you, VillageHealth will then cover Drug B.
You can find out if your drug has any additional requirements or limits by looking in the formulary that
begins on page 1. You can also get more information about the restrictions applied to specific covered drugs
by visiting our Web site. We have posted on line documents that explain our prior authorization and step
therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we
last updated the formulary, appears on the front and back cover pages.
You can ask VillageHealth to make an exception to these restrictions or limits or for a list of other, similar
drugs that may treat your health condition. See the section, “How do I request an exception to the
VillageHealth formulary?” on page VI for information about how to request an exception
What if my drug is not on the Formulary?
If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services
and ask if your drug is covered.
If you learn that VillageHealth does not cover your drug, you have two options:
• You can ask Member Services for a list of similar drugs that are covered by VillageHealth. When you
receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered
by VillageHealth.
• You can ask VillageHealth to make an exception and cover your drug. See below for information about
how to request an exception.
How do I request an exception to the VillageHealth Formulary?
You can ask VillageHealth to make an exception to our coverage rules. There are several types of exceptions
that you can ask us to make.
• You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered
at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a
lower cost-sharing level.
• You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the
specialty tier. If approved this would lower the amount you must pay for your drug.
• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs,
VillageHealth limits the amount of the drug that we will cover. If your drug has a quantity limit, you
can ask us to waive the limit and cover a greater amount.
VI
Generally, VillageHealth will only approve your request for an exception if the alternative drugs included on
the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective
in treating your condition and/or would cause you to have adverse medical effects.
You should contact us to ask us for an initial coverage decision for a formulary, tiering, or utilization
restriction exception. When you request a formulary, tiering, or utilization restriction exception, you should
submit a statement from your prescriber or physician supporting your request. Generally, we must make our
decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited
(fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72
hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24
hours after we get a supporting statement from your doctor or other prescriber.
What do I do before I can talk to my doctor about changing my drugs or requesting
an exception?
As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you
may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need
a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if
you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover
the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover
your drug in certain cases during the first 90 days you are a member of our plan.
For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover
a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network
pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of
the plan less than 90 days.
If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have
provided you with at least a 91 and may be up to a 98-day transition supply, consistent with dispensing
increment (unless you have a prescription written for fewer days). We will cover more than one refill of these
drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or
if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we
will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you
pursue a formulary exception.
If you are a current member transitioning to a different level of care, you may be prescribed medications not
on our formulary or your ability to get your drugs may be limited. In these instances, you need to talk with
your doctor about the appropriate alternative therapies available on our formulary. If there are no appropriate
alternative therapies on our formulary, you or your doctor can request an exception and ask the plan to cover
the drug or remove restrictions from the drug. While you are talking with your doctor to determine the course
of action, you are eligible to receive a 30-day transition supply of the drug if you are moving from a longterm care (LTC) facility or a hospital stay to home or a 31-day transition supply of the drug if you are moving
from home or a hospital stay to a long-term care (LTC) facility.
VII
For more information
For more detailed information about your VillageHealth prescription drug coverage, please review your
Evidence of Coverage and other plan materials.
If you have questions about VillageHealth, please contact us. Our contact information, along with the date
we last updated the formulary, appears on the front and back cover pages.
If you have general questions about Medicare prescription drug coverage, please call Medicare
at 1-800-MEDICARE (1-800-633-4227), 24 hours a day/7 days a week. TTY users should call
1-877-486-2048. Or, visit http://www.medicare.gov.
VIII
The charts below list what you will pay as your share of the costs for covered prescription drugs when you are
in the Initial Coverage Stage. For information about your costs in the Coverage Gap Stage or the Catastrophic
Coverage Stage, please refer to your Evidence of Coverage.
VillageHealth (HMO-POS SNP):
Los Angeles and Orange Counties
Drug
Tier
Tier Name
Preferred Retail
& Mail Order
cost-sharing
(in-network)
(30-day supply)
Standard Retail
cost-sharing
(in-network)
(30-day supply)
Preferred Retail
& Mail Order
cost-sharing
(in-network)
(90-day supply)
Standard Retail
cost-sharing
(in-network)
(90-day supply)
1
Preferred
Generic
$0
$3.50
$0
$10.50
2
Generic
25%
25%
25%
25%
3
Preferred
Brand
25%
25%
25%
25%
4
Non-Preferred
Drug
25%
25%
25%
25%
5
Specialty Tier
25%
25%
N/A
N/A
6
Select Care
Drugs
$11
$11
$33
$33
Please refer to your Evidence of Coverage for information about the costs at Long-Term Care (LTC)
pharmacies or out-of-network pharmacies.
Preferred cost-sharing is lower cost-sharing that may be available to you for certain covered Part D drugs at
certain network pharmacies. For more information, please visit our online searchable Pharmacy Directory at
www.villagehealthca.com or call Member Services. Our contact information appears on the front and back
cover pages.
If you receive “Extra Help,” your share of the cost for covered prescription drugs may vary based on the level
of Extra Help you receive. For more information about your drug costs, look at the "LIS Rider".
IX
VillageHealth (HMO-POS SNP):
Riverside and San Bernardino Counties
Drug
Tier
Tier Name
Preferred Retail
& Mail Order
cost-sharing
(in-network)
(30-day supply)
Standard Retail
cost-sharing
(in-network)
(30-day supply)
Preferred Retail
& Mali Order
cost-sharing
(in-network)
(90-day supply)
Standard Retail
cost-sharing
(in-network)
(90-day supply)
1
Preferred
Generic
$0
$3
$0
$9
2
Generic
$8
$13
$24
$39
3
Preferred Brand
25%
25%
25%
25%
4
Non-Preferred
Drug
25%
25%
25%
25%
5
Specialty Tier
25%
25%
N/A
N/A
6
Select Care
Drugs
$11
$11
$33
$33
Please refer to your Evidence of Coverage for information about the costs at Long-Term Care (LTC)
pharmacies or out-of-network pharmacies.
Preferred cost-sharing is lower cost-sharing that may be available to you for certain covered Part D drugs at
certain network pharmacies. For more information, please visit our online searchable Pharmacy Directory at
www.villagehealthca.com or call Member Services. Our contact information appears on the front and back
cover pages.
If you receive “Extra Help,” your share of the cost for covered prescription drugs may vary based on the level
of Extra Help you receive. For more information about your drug costs, look at the "LIS Rider".
X
VillageHealth’s Formulary
The formulary that begins on page 1 provides coverage information about the drugs covered by VillageHealth.
If you have trouble finding your drug in the list, turn to the Index that begins on page 30.
The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., JANUVIA) and
generic drugs are listed in lower-case italics (e.g., metformin).
The information in the Requirements/Limits column tells you if VillageHealth has any special requirements
for coverage of your drug.
• The symbol [PA] indicates that prior authorization applies.
• The symbol [B vs D] indicates that this drug may be covered under Medicare Part B or
Part D depending upon the circumstances. Information may need to be submitted describing the use
and setting of the drug to make the determination.
• The symbol [ST] indicates that step therapy applies.
• The symbol [QL] indicates that quantities dispensed are limited. To see the quantity limit amount for
the formulary drugs with quantity limits, turn to the page 27.
• The symbol [90D] indicates that the drug is available for a 90-day supply at mail order and select
retail pharmacies.
• The symbol [LD] indicates that limited distribution applies. This prescription may be available only at
certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at
1-800-399-7226, 8 a.m.–8 p.m., 7 days a week from October 1 to February 14. From February 15 to
September 30, hours are 8 a.m. to 8 p.m. Monday through Friday (messages received on holidays and
outside of our business hours will be returned within one business day). TTY users should call 711.
XI
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XII
VillageHealth (HMO-POS SNP)
Formulario 2017 (Lista de medicamentos cubiertos)
POR FAVOR, LEA: ESTE DOCUMENTO CONTIENE INFORMACIÓN ACERCA DE LOS
MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN
17395, 11
Este formulario se actualizó el 1 de junio de 2017. Para obtener información más reciente o si tiene
preguntas, comuníquese a Servicios para Miembros de VillageHealth, al 1-800-399-7226, o, para los
usuarios de TTY, 711, de 8 a. m. a 8 p. m., los 7 días de la semana, desde el 1 de octubre hasta el 14 de
febrero. Del 15 de febrero al 30 de septiembre el horario es de 8 a. m. a 8 p. m. de lunes a viernes (los
mensajes recibidos en días festivos y fuera del horario hábil se devolverán
en un día hábil). O visite www.villagehealthca.com.
Nota para los miembros actuales: Este formulario ha cambiado desde el año pasado. Revise este documento
para asegurarse de que todavía incluye los medicamentos que toma.
Cuando esta lista de medicamentos (formulario) usa “nosotros” o “nuestro” se refiere a SCAN Health Plan.
Cuando se refiere a “plan” o “nuestro plan”, significa VillageHealth (HMO-POS SNP).
Este documento incluye una lista de los medicamentos (formulario) de nuestro plan que está vigente
al mes de junio de 2017. Para obtener un formulario actualizado, comuníquese con nosotros. Nuestra
información de contacto, junto con la fecha en que se actualizó el formulario por última vez, aparece en
la portada y contraportada.
Por lo general, debe utilizar las farmacias de la red para utilizar su beneficio de medicamentos con receta
médica. Los beneficios, la lista de medicamentos, la red de farmacias o los copagos/coaseguro pueden
cambiar el 1 de enero de 2018 y de vez en cuando durante el año.
Esta información no es una descripción completa de los beneficios. Para obtener más información, póngase
en contacto con el plan. Pueden aplicarse limitaciones, copagos y restricciones. La lista de medicamentos,
la red de farmacias o la red de proveedores pueden cambiar en cualquier momento. Recibirá un aviso
cuando sea necesario.
Puede obtener medicamentos recetados enviados a su casa, a través de nuestro programa de entrega de
pedidos por correo de la red. Por lo general, debe esperar recibir sus medicamentos recetados dentro de los
siguientes 14 días desde el momento en que la farmacia de pedidos por correo recibe el pedido. Si no recibe
sus medicamentos recetados en este plazo, comuníquese a Servicios para Miembros de VillageHealth, al
1-800-399-7226, de 8 a. m. a 8 p. m., los 7 días de la semana, del 1 de octubre al 14 de febrero. Del 15
de febrero al 30 de septiembre el horario es de 8 a. m. a 8 p. m. de lunes a viernes (los mensajes recibidos
en días festivos y fuera del horario hábil se devolverán en un día hábil).
Los usuarios de TTY deben llamar al 711.
VillageHealth (HMO-POS SNP) es un plan HMO; y es un plan de punto de servicio (Point of Service, POS)
con un contrato de Medicare. La inscripción en SCAN Health Plan depende de la renovación del contrato.
XIII
ATTENTION: If you speak a language other than English, language assistance services, free of charge, are
available to you. Call 1-800-399-7226 (TTY: 711).
ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al
1-800-399-7226 (TTY: 711).
注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-800-399-7226（聽障專線：711）。
Y0057_SCAN_9797_2016F_SP File & Use Accepted 08102016
XIV
TABLA DE CONTENIDOS
¿Qué es el Formulario de VillageHealth?...............................................................................................XVII
¿El Formulario (lista de medicamentos) puede cambiar?........................................................................XVII
¿Cómo utilizo el Formulario? ...............................................................................................................XVII
¿Qué son los medicamentos genéricos?...............................................................................................XVIII
¿Hay alguna restricción en mi cobertura?.............................................................................................XVIII
¿Qué sucede si mi medicamento no está en el Formulario?...................................................................XVIII
¿Cómo solicito una excepción al formulario de VillageHealth?.................................................................. XIX
¿Qué debo hacer antes de poder hablar con mi médico sobre un cambio en mis medicamentos o
solicitar una excepción?....................................................................................................................... XIX
Para obtener más información............................................................................................................... XX
Formulario de VillageHealth................................................................................................................XXIII
Medicamentos del formulario coordinados por la clase terapéutica..............................................................1
Medicamentos del formulario con límites de cantidad..............................................................................27
Índice..................................................................................................................................................30
XV
XVI
¿Qué es el Formulario de VillageHealth?
Un formulario es una lista de medicamentos cubiertos seleccionados por VillageHealth en consulta con un
equipo de proveedores de atención médica, que representa las terapias prescritas que se cree son parte
necesaria de un programa de tratamiento de calidad. VillageHealth generalmente cubrirá los medicamentos
descritos en nuestra lista de medicamentos siempre que el medicamento sea médicamente necesario, la
receta médica se surta en una farmacia de la red de VillageHealth y se sigan otras reglas del plan. Para
obtener más información sobre cómo surtir sus recetas, revise su Evidencia de cobertura.
¿El Formulario (lista de medicamentos) puede cambiar?
Por lo general, si usted está tomando un medicamento que aparece en nuestro formulario de 2017 que
estaba cubierto al inicio del año, no interrumpiremos ni reduciremos la cobertura del medicamento durante la
cobertura de 2017 excepto cuando esté disponible un nuevo medicamento genérico más económico, o cuando
se publique nueva información adversa sobre la seguridad o eficacia de un medicamento. Otros tipos de
cambios en el formulario, como eliminar un medicamento de nuestro formulario, no afectarán a los miembros
que están tomando el medicamento actualmente. Permanecerá disponible al mismo costo compartido para
los miembros que lo tomen por el resto del año de cobertura. Creemos que es importante que tenga acceso
continuo por el resto del año de cobertura a los medicamentos del formulario que estaban disponibles
cuando eligió nuestro plan, excepto en los casos en que usted pueda ahorrar más dinero o que podamos
garantizar su seguridad.
Si retiramos medicamentos de nuestro formulario, agregamos una autorización previa, restricciones de
límites de cantidad o terapia de pasos a un medicamento o movemos un medicamento a un nivel de costo
compartido superior, debemos notificar a los miembros afectados sobre el cambio por lo menos 60 días
antes de que el cambio entre en vigencia, o en el momento en que el miembro solicita una reposición del
medicamento, momento en el cual el miembro recibirá un suministro para 60 días del medicamento. Si la
Administración de Alimentos y Medicamentos considera que un medicamento de nuestro formulario no es
seguro o el fabricante del medicamento lo retira del mercado, inmediatamente retiraremos el medicamento
de nuestro formulario y notificaremos a los miembros que toman el medicamento. El formulario adjunto
está vigente al mes de junio de 2017. Para obtener información actualizada acerca de los medicamentos
cubiertos por VillageHealth, comuníquese con nosotros. Nuestra información de contacto aparece en la
portada y contraportada.
¿Cómo utilizo el Formulario?
Hay dos maneras de encontrar su medicamento en el formulario:
Afección médica
El formulario comienza en la página 1. Los medicamentos en este formulario están agrupados en categorías
dependiendo del tipo de afecciones médicas para el cual se utilizan. Por ejemplo, los medicamentos que se
usan para tratar una afección cardíaca se muestran en la categoría “Agentes cardiovasculares”. Si sabe para
qué se usa su medicamento, busque el nombre de la categoría en la lista que inicia en la página 1. Luego
busque en el nombre de la categoría de su medicamento.
Lista alfabética
Si usted no está seguro en qué categoría buscar, debe buscar su medicamento en el Índice que inicia en
la página 30. El Índice proporciona una lista en orden alfabético de todos los medicamentos incluidos en
este documento. Los medicamentos de marca y genéricos se incluyen en el índice. Busque en el índice
y encuentre su medicamento. Al lado de su medicamento, usted verá el número de página donde puede
XVII
encontrar la información de cobertura. Vaya a la página que aparece en el índice y encuentre el nombre de
su medicamento en la primera columna de la lista.
¿Qué son los medicamentos genéricos?
VillageHealth cubre tanto medicamentos de marca como medicamentos genéricos Un medicamento genérico
es aprobado por la Administración de Alimentos y Medicamentos (FDA) ya que tiene el mismo ingrediente
activo que el medicamento de marca. Por lo general, los medicamentos genéricos cuestan menos que los
medicamentos de marca.
¿Hay alguna restricción en mi cobertura?
Algunos medicamentos cubiertos pueden tener requisitos adicionales o límites de cobertura. Estos requisitos
y límites pueden incluir:
• Autorización previa: VillageHealth requiere que usted o su médico obtengan una autorización previa
para ciertos medicamentos. Esto significa que necesitará obtener aprobación de VillageHealth antes
de surtir sus recetas médicas. Si no obtiene la aprobación, es posible que VillageHealth no cubra el
medicamento.
• Límites de cantidad: Para ciertos medicamentos, VillageHealth limita la cantidad del medicamento
que VillageHealth cubrirá. Por ejemplo, VillageHealth proporciona 30 tabletas por receta médica para
Rozerem. Esto puede ser además de un suministro estándar para un mes o tres meses.
• Terapia de pasos: En algunos casos, VillageHealth requiere que primero pruebe ciertos medicamentos
para tratar su afección médica antes de que nosotros cubramos otro medicamento para esa afección.
Por ejemplo, si tanto el medicamento A como el medicamento B tratan su afección médica, es
posible que VillageHealth no cubra el medicamento B a menos que pruebe primero el medicamento
A. Si el medicamento A no funciona para usted, VillageHealth cubrirá el medicamento B.
Para averiguar si su medicamento tiene requisitos adicionales o límites revise el formulario que comienza
en la página 1. También puede obtener más información acerca de las restricciones que aplican a
medicamentos específicos cubiertos al visitar nuestro sitio web. Hemos publicado en línea documentos que
explican nuestras restricciones de autorización previa y terapia de pasos. También puede pedirnos que le
enviemos una copia. Nuestra información de contacto, junto con la fecha en que se actualizó el formulario
por última vez, aparece en la portada y contraportada.
Puede solicitar a VillageHealth que haga una excepción a estas restricciones o límites, o una lista de
medicamentos similares que pueden tratar su afección de salud. Consulte la sección “¿Cómo solicito una
excepción al formulario de VillageHealth?” en la página XIX para obtener información sobre cómo solicitar
una excepción.
¿Qué sucede si mi medicamento no está en el Formulario?
Si su medicamento no está incluido en este Formulario (lista de medicamentos cubiertos), primero debe
comunicarse con Servicios para Miembros y preguntar si su medicamento está cubierto.
Si descubre que VillageHealth no cubre su medicamento, tiene dos opciones:
• Puede solicitar a Servicios para Miembros una lista de medicamentos similares que VillageHealth
cubre. Cuando reciba la lista, muéstrela a su médico y pídale que le recete un medicamento similar
que esté cubierto por VillageHealth.
• Puede solicitar que VillageHealth haga una excepción y cubra su medicamento. Consulte a
continuación para obtener información sobre cómo solicitar una excepción.
XVIII
¿Cómo solicito una excepción al formulario de VillageHealth?
Puede solicitar a VillageHealth que haga una excepción a nuestras reglas de cobertura. Existen varios tipos
de excepciones que puede solicitarnos que hagamos.
• Puede solicitarnos que cubramos un medicamento, incluso si no está incluido en nuestro formulario.
Si se aprueba, este medicamento estará cubierto con un nivel de costo compartido predeterminado,
y usted no podrá solicitarnos que proporcionemos el medicamento a un nivel de costo compartido
inferior.
• Puede solicitarnos que cubramos un medicamento del formulario a un nivel de costo compartido
inferior si este medicamento no está incluido en el nivel de especialidades. Si se aprueba, esto
reducirá el monto que debe pagar por su medicamento.
• Puede solicitarnos que exoneremos las restricciones de cobertura o límites de su medicamento.
Por ejemplo, para ciertos medicamentos, VillageHealth limita la cantidad del medicamento que
cubriremos. Si su medicamento tiene un límite de cantidad, puede solicitarnos que exoneremos el
límite y cubramos una cantidad mayor.
Por lo general, VillageHealth solo aprobará su solicitud de excepción si los medicamentos alternativos incluidos
en el formulario del plan, el medicamento de costo compartido inferior o las restricciones adicionales de uso
pudieran no ser tan efectivos al tratar su afección y/o pudieran provocarle efectos médicos adversos.
Debe comunicarse con nosotros para pedirnos una decisión inicial de cobertura para una excepción de
restricción de uso, de nivel o al formulario. Cuando solicite una excepción de restricción de uso, de nivel o al
formulario, debe enviar una declaración de apoyo de su médico o la persona que receta que respalde su solicitud.
Por lo general, debemos tomar nuestra decisión dentro de las siguientes 72 horas después de recibir la
declaración de apoyo de la persona que receta. Puede solicitar una excepción expedita (rápida) si usted o su
médico consideran que su salud podría dañarse seriamente si espera hasta por 72 horas para una decisión.
Si se autoriza su solicitud expedita, debemos proporcionarle una decisión no después de 24 horas después
de haber recibido una declaración de apoyo de su médico u otra persona que recete.
¿Qué debo hacer antes de poder hablar con mi médico sobre un cambio en mis medicamentos o
solicitar una excepción?
Como miembro nuevo o existente en nuestro plan, puede tomar medicamentos que no se encuentran en
nuestro formulario. O bien, puede estar tomando un medicamento que está en nuestro formulario pero su
capacidad para obtenerlo es limitada. Por ejemplo, puede necesitar una autorización previa de nuestra parte
antes de que pueda surtir su receta médica. Debe hablar con su médico para decidir si deben cambiar a
un medicamento apropiado que cubramos o solicitar una excepción al formulario para que cubramos el
medicamento que toma. Mientras que habla con su médico para determinar el curso correcto de acción para
usted, podemos cubrir su medicamento en ciertos casos durante los primeros 90 días, que usted es miembro
de nuestro plan.
Para cada uno de sus medicamentos que no está incluido en nuestro formulario o si su capacidad de
obtener sus medicamentos es limitada, cubriremos un suministro temporal de 30 días (a menos que tenga
una receta médica para menos días) cuando vaya a una farmacia de la red de servicios. Después de su
primer suministro para 30 días, no pagaremos por estos medicamentos, incluso si ha sido un miembro del
plan por menos de 90 días.
Si es un residente de un centro de atención a largo plazo, le permitiremos que realice la reposición de su
receta médica hasta que le hayamos proporcionado por lo menos un suministro de transición para 91 y
es posible que para hasta 98 días, consistente con el incremento de despacho (a menos que tenga una
receta médica para menos días). Cubriremos más de un surtido de estos medicamentos dentro de los
primeros 90 días de ser miembro de nuestro plan. Si necesita un medicamento que no está incluido en
XIX
nuestro formulario o si su capacidad de obtener sus medicamentos es limitada, pero está más allá de los
primeros 90 días de la membresía en nuestro plan, cubriremos un suministro de emergencia de 31 días de
ese medicamento (a menos que tenga una receta médica para menos días) mientras tramita una excepción al
formulario.
Si es un miembro actual que está en la transición a un nivel diferente de atención, se le pueden prescribir
medicamentos no incluidos en nuestro formulario o su capacidad de obtener sus medicamentos podría
estar limitada. En estos casos, debe hablar con su médico acerca de las terapias alternativas apropiadas
y disponibles en nuestro formulario. Si no hubiera terapias alternativas apropiadas en nuestro formulario,
usted o su médico pueden solicitar una excepción y solicitar al plan que cubra el medicamento o eliminar
las restricciones de los medicamentos. Mientras habla con su médico para determinar el curso de acción,
es elegible para recibir un suministro de transición de 30 días del medicamento si se muda a un centro
de atención a largo plazo (long-term care, LTC) o de una estadía en el hospital a casa, o un suministro de
transición de 31 días del medicamento si se muda de la casa o de una estadía en el hospital a un centro de
atención a largo plazo (LTC).
Para obtener más información
Para obtener información más detallada sobre la cobertura de medicamentos recetados de VillageHealth,
consulte su Evidencia de cobertura y otros materiales del plan.
Si tiene alguna pregunta acerca de VillageHealth, comuníquese con nosotros. Nuestra información de
contacto, junto con la fecha en que se actualizó el formulario por última vez, aparece en la portada
y contraportada.
Si tiene preguntas generales acerca de la cobertura de medicamento recetados de Medicare, llame a
Medicare al 1-800-MEDICARE (1-800-633-4227) las 24 horas del día, los 7 días de la semana. Los
usuarios de TTY deben llamar al 1-877-486-2048. O bien, visite http://www.medicare.gov.
XX
Los cuadros a continuación enumeran lo que pagará como su parte de los costos de medicamentos
recetados cubiertos cuando se encuentra en la Etapa de cobertura inicial. Para obtener información acerca
de sus costos en la Etapa de vacío de cobertura o la Etapa de cobertura catastrófica, consulte su Evidencia
de cobertura.
VillageHealth (HMO-POS SNP):
Condados de Los Ángeles y Orange
Costo compartido
en farmacia
Costo compartido
minorista preferida en farmacia minorista
Nivel del
y de pedidos por
estándar
Nombre del nivel
medicamento
correo
(dentro de la red)
(dentro de la red) (suministro para 30
(suministro para 30
días)
días)
Costo compartido
Costo compartido
en farmacia
en farmacia
minorista preferida
minorista
y de pedidos por
estándar
correo
(dentro de la red)
(dentro de la red)
(suministro para
(suministro para 90
90 días)
días)
1
Genérico
preferido
$0
$3.50
$0
$10.50
2
Genérico
25 %
25 %
25 %
25 %
3
De marca
preferida
25 %
25 %
25 %
25 %
4
Medicamento no
preferido
25 %
25 %
25 %
25 %
5
Nivel de
especialidad
25 %
25 %
N/A
N/A
6
Medicamentos
de atención
seleccionada
$11
$11
$33
$33
Consulte su Evidencia de cobertura para obtener información acerca de los costos en farmacias de Atención
de largo plazo (LTC) o farmacias fuera de la red.
El costo compartido preferido es menor que el costo compartido que puede estar disponible para usted para
ciertos medicamentos cubiertos de la Parte D en ciertas farmacias de la red. Para obtener más información,
visite nuestro Directorio de farmacias de búsqueda en línea en www.villagehealthca.com o llame a Servicios
para Miembros. Nuestra información de contacto aparece en la portada y contraportada.
Si recibe “Ayuda adicional”, su parte del costo de los medicamentos recetados cubiertos puede variar
con base en el nivel de Ayuda adicional que reciba. Para obtener más información acerca del costo de los
medicamentos, conuslte el Anexo LIS.
XXI
VillageHealth (HMO-POS SNP):
Condados de Riverside y San Bernardino
Nivel del
Nombre del
medicamento
nivel
Costo compartido
Costo compartido
en farmacia
Costo compartido
en farmacia minorista
minorista preferida en farmacia minorista
preferida y de
y de pedidos por
estándar
pedidos por correo
correo
(dentro de la red)
(dentro de la red)
(dentro de la red) (suministro para 30
(suministro para 90
(suministro para 30
días)
días)
días)
Costo compartido
en farmacia
minorista estándar
(dentro de la red)
(suministro para
90 días)
1
Genérico
preferido
$0
$3
$0
$9
2
Genérico
$8
$13
$24
$39
3
De marca
preferida
25 %
25 %
25 %
25 %
4
Medicamento
no preferido
25 %
25 %
25 %
25 %
5
Nivel de
especialidad
25 %
25 %
N/A
N/A
6
Medicamentos
de atención
seleccionada
$11
$11
$33
$33
Consulte su Evidencia de cobertura para obtener información acerca de los costos en farmacias de Atención
de largo plazo (LTC) o farmacias fuera de la red.
El costo compartido preferido es menor que el costo compartido que puede estar disponible para usted para
ciertos medicamentos cubiertos de la Parte D en ciertas farmacias de la red. Para obtener más información,
visite nuestro Directorio de farmacias de búsqueda en línea en www.villagehealthca.com o llame a Servicios
para Miembros. Nuestra información de contacto aparece en la portada y contraportada.
Si recibe “Ayuda adicional”, su parte del costo de los medicamentos recetados cubiertos puede variar
con base en el nivel de Ayuda adicional que reciba. Para obtener más información acerca del costo de los
medicamentos, conuslte el Anexo LIS.
XXII
Formulario de VillageHealth
El formulario que comienza en la página 1 proporciona información sobre los medicamentos que cubre
VillageHealth. Si tiene dificultades para encontrar su medicamento en la lista, diríjase al índice que inicia en
la página 30.
La primera columna del cuadro muestra el nombre del medicamento. Los medicamentos de marca están en
mayúsculas (por ejemplo, JANUVIA) y los medicamentos genéricos están en minúsculas itálicas (por ejemplo,
metformin).
La información en la columna de Requisitos/límites le indica si VillageHealth tiene algún requisito especial
para la cobertura de su medicamento.
• El símbolo [PA] indica que se requiere una autorización previa.
• El símbolo [B vs D] indica que este medicamento puede estar cubierto por la Parte B o la Parte D de
Medicare, dependiendo de las circunstancias. Para hacer la determinación, es posible que se necesite
enviar información que describa el uso y ajuste del medicamento.
• El símbolo [ST] indica que se requiere terapia de pasos.
• El símbolo [QL] indica que las cantidades despachadas están limitadas. Para saber la cantidad
de límite de cantidad para los medicamentos del formulario con límites de cantidad, consulte la
página 27.
• El símbolo [90D] indica que los medicamentos están disponibles para un suministro para 90 días en
farmacias de pedido por correo y farmacias minoristas seleccionadas.
•
El símbolo [LD] indica que se aplica la distribución limitada. Esta receta médica puede estar
disponible únicamente en ciertas farmacias. Para obtener más información, consulte su Directorio de
Farmacias o llame a Servicios para Miembros al 1-800-399-7226, de 8 a. m. a 8 p. m., los 7 días
de la semana, desde el 1 de octubre hasta el 14 de febrero. Del 15 de febrero al 30 de septiembre el
horario es de 8 a. m. a 8 p. m. de lunes a viernes (los mensajes recibidos en días festivos y fuera del
horario hábil se devolverán en un día hábil). Los usuarios de TTY deben llamar al 711.
XXIII
Esta página se dejó en blanco intencionalmente
XXIV
FORMULARY DRUGS ARRANGED BY THERAPEUTIC CLASS
MEDICAMENTOS DEL FORMULARIO COORDINADOS POR LA CLASE TERAPÉUTICA
Formulary ID: 17395 (Version 11)
ID de Formulario: 17395 (Versión 11)
Drug Name
Nombre del Medicamento
Updated: 6/2017
Actualizado: 6/2017
Drug Requirements/
Tier Limits
Requisitos/
Nivel
Límites
ANALGESICS
Opioid Analgesics, Long-acting
2
duramorph inj
3
fentanyl patches
12mcg/hr, 25mcg/hr,
50mcg/hr, 75mcg/hr,
100mcg/hr
2
methadone oral
2
methadone inj
3
morphine sulfate er tabs
OXYCODONE ER
4
OXYCONTIN
4
3
oxymorphone er
2
tramadol er tabs
Opioid Analgesics, Short-acting
2
acetaminophen & codeine
2
butorphanol tartrate inj
2
butorphanol tartrate nasal
2
codeine
3
endocet 5-325mg, 7.5325mg, 10-325mg
3
fentanyl citrate lozenges
200mcg
5
fentanyl citrate lozenges
400mcg, 600mcg,
800mcg, 1200mcg &
1600mcg
2
hydrocodone &
acetaminophen soln 7.5325mg/15mL
2
hydrocodone &
acetaminophen tabs
5-325mg, 7.5-325mg,
10-325mg
2
hydrocodone & ibuprofen
Drug Name
Nombre del Medicamento
hydromorphone
immediate-release oral
soln & tabs
hydromorphone inj
LAZANDA
lorcet tabs 5-325mg
lorcet hd tabs 10-325mg
lorcet plus tabs 7.5-325mg
lortab tabs 5-325mg, 7.5325mg, 10-325mg
morphine sulfate inj vial
morphine sulfate oral
oxycodone immediaterelease
oxycodone oral soln
oxycodone &
acetaminophen 2.5325mg, 5-325mg, 7.5325mg, 10-325mg
oxycodone & aspirin
oxycodone & ibuprofen
reprexain
tramadol
tramadol & acetaminophen
zamicet
ANESTHETICS
Local Anesthetics
lidocaine hcl inj
lidocaine ointment
lidocaine patch
lidocaine topical gel &
solution
lidocaine & prilocaine
[90D]
[QL] [90D]
[90D]
[90D]
[QL] [90D]
[QL] [90D]
[QL] [90D]
[QL] [90D]
[QL] [90D]
[QL] [90D]
[90D]
[QL] [90D]
[90D]
[QL] [90D]
[PA] [90D]
[PA]
[QL] [90D]
[QL] [90D]
Drug Requirements/
Tier Limits
Requisitos/
Nivel
Límites
2
[90D]
2
5
2
2
2
2
[90D]
[PA]
[QL] [90D]
[QL] [90D]
[QL] [90D]
[QL] [90D]
2
2
2
[90D]
[90D]
[90D]
2
3
[90D]
[QL] [90D]
2
2
2
2
2
2
[QL] [90D]
[QL] [90D]
[90D]
[90D]
[QL] [90D]
[QL] [90D]
2
3
3
2
[90D]
[90D]
[PA] [90D]
[90D]
2
[90D]
[QL] [90D]
[PA] = Prior Authorization [B vs D] = B versus D [QL] = Quantity Limit [ST] = Step Therapy [90D] = 90-Day Supply
[LD] = Limited Distribution
You can find information on what the symbols and abbreviations on this table mean by going to page XI.
1
Drug Requirements/
Tier Limits
Requisitos/
Nombre del Medicamento
Nivel
Límites
ANTI-ADDICTION/SUBSTANCE ABUSE
TREATMENT AGENTS
Alcohol Deterrents/Anti-Craving
2
[90D]
acamprosate calcium dr
2
[90D]
disulfiram
Opioid Dependence Treatments
2
[90D]
buprenorphine inj
2
[90D]
buprenorphine oral
2
[90D]
buprenorphine & naloxone
sublingual tabs
2
[90D]
naltrexone
Opioid Reversal Agents
2
[90D]
naloxone inj
NARCAN
3
[90D]
Smoking Cessation Agents
2
[90D]
bupropion sr 150mg
CHANTIX
4
[ST] [90D]
CHANTIX STARTING &
4
[ST] [90D]
CONTINUING MONTH
PAK
NICOTROL INHALER
3
[90D]
NICOTROL NASAL
3
[90D]
ANTI-INFLAMMATORY AGENTS
Nonsteroidal Anti-inflammatory Drugs
2
[ST] [90D]
celecoxib
1
[90D]
diclofenac potassium
1
[90D]
diclofenac sodium dr
1
[90D]
diclofenac sodium er
2
[90D]
diflunisal
2
[90D]
etodolac
2
[90D]
etodolac er
1
[90D]
ibuprofen
2
[PA] [90D]
indomethacin er
2
[PA] [90D]
indomethacin ir caps
2
[PA] [90D]
ketorolac oral
2
[PA] [90D]
ketorolac inj
1
[90D]
meloxicam tabs
2
[90D]
nabumetone
1
[90D]
naproxen
1
[90D]
naproxen dr
1
[90D]
naproxen sodium ir
2
[90D]
piroxicam
Drug Name
Drug Name
Nombre del Medicamento
sulindac
ANTIBACTERIALS
Aminoglycosides
amikacin inj
gentamicin cream 0.1% &
oint 0.1%
gentamicin inj
neomycin sulfate oral
paromomycin
streptomycin inj
tobramycin sulfate inj
Antibacterials, Other
BACTROBAN CREAM
BACTROBAN NASAL
chloramphenicol sodium
succinate inj
CLEOCIN VAGINAL
clindamycin oral
clindamycin phosphate inj
colistimethate inj
CORTISPORIN CREAM &
OINT
daptomycin inj
linezolid inj
linezolid oral
methenamine hippurate
metronidazole inj
metronidazole oral
metronidazole topical
metronidazole vaginal
mupirocin
nitrofurantoin caps
silver sulfadiazine
SIVEXTRO
ssd
SYNERCID INJ
trimethoprim
TYGACIL INJ
vancomycin oral
vancomycin inj
vandazole
XIFAXAN TABS 200MG
Drug Requirements/
Tier Limits
Requisitos/
Nivel
Límites
2
[90D]
2
2
[90D]
[90D]
2
2
2
2
2
[90D]
[90D]
[90D]
[90D]
[90D]
3
3
2
[90D]
[90D]
[90D]
3
2
2
2
3
[90D]
[90D]
[90D]
[90D]
[90D]
5
5
5
2
2
2
3
2
2
2
2
5
2
5
2
5
5
2
2
3
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[PA]
[90D]
[90D]
[QL] [90D]
[PA] = Autorización Previa [B vs D] = B versus D [QL] = Límite de Cantidad [ST] = Tratamiento Escalonado
[90D] = Suministro para 90 Días [LD] = Distribución Limitada
Puede encontrar información sobre el significado de los símbolos y abreviaturas de esta tabla en la página XXIII.
2
Drug Requirements/
Tier Limits
Requisitos/
Nombre del Medicamento
Nivel
Límites
XIFAXAN TABS 550MG
5
Beta-lactam, Cephalosporins
2
[90D]
cefaclor
2
[90D]
cefaclor er
2
[90D]
cefadroxil caps & tabs
2
[90D]
cefazolin inj
2
[90D]
cefdinir
2
[90D]
cefepime inj
2
[90D]
cefixime
2
[90D]
cefoxitin sodium
2
[90D]
cefpodoxime tabs
2
[90D]
cefprozil
2
[90D]
ceftazidime inj 1gm, 2gm
& 6gm
2
[90D]
ceftriaxone inj
2
[90D]
cefuroxime oral
2
[90D]
cefuroxime inj
1
[90D]
cephalexin caps & tabs
250mg & 500mg
1
[90D]
cephalexin oral susp
SUPRAX CAPS &
3
[90D]
CHEWABLE TABS
SUPRAX ORAL SUSP
3
[90D]
500MG/5ML
2
[90D]
tazicef inj
TEFLARO INJ
5
ZERBAXA INJ
5
Beta-lactam, Other
2
[90D]
aztreonam inj 1gm
2
[90D]
cilastatin/imipenem inj
INVANZ INJ
4
[90D]
2
[90D]
meropenem inj 500mg
Beta-lactam, Penicillins
1
[90D]
amoxicillin
2
[90D]
amoxicillin & clavulanate
potassium
2
[90D]
amoxicillin & clavulanate
potassium er
2
[90D]
ampicillin & sulbactam inj
10-5gm, 2-1gm, & 1-0.5gm
2
[90D]
ampicillin inj
Drug Name
Drug Name
Nombre del Medicamento
ampicillin oral
BICILLIN L-A INJ
dicloxacillin sodium
nafcillin sodium inj
penicillin g inj 5 million
units
penicillin v potassium
piperacillin/tazobactam inj
3gm/0.375gm &
4gm/0.5gm & 12gm/1.5gm
ZOSYN GALAXY INJ
2GM/0.25GM &
3GM/0.375GM
Macrolides
AZASITE
azithromycin tabs & oral
susp
azithromycin inj
clarithromycin
clarithromycin er
ERYTHROCIN
LACTOBIONATE INJ
erythrocin stearate
erythromycin oral
erythromycin topical gel &
soln
Quinolones
ciprofloxacin inj
ciprofloxacin oral susp
ciprofloxacin tabs
immediate-release
ciprofloxacin tabs er
levofloxacin inj
levofloxacin oral soln
levofloxacin tabs
moxifloxacin oral
ofloxacin oral
Sulfonamides
sulfadiazine
sulfamethoxazole &
trimethoprim tabs
Drug Requirements/
Tier Limits
Requisitos/
Nivel
Límites
2
[90D]
3
[90D]
2
[90D]
2
[90D]
2
[90D]
2
2
[90D]
[90D]
4
[90D]
3
2
[90D]
[90D]
2
2
2
4
[90D]
[90D]
[90D]
[90D]
2
2
2
[90D]
[90D]
[90D]
2
2
1
[90D]
[90D]
[90D]
2
2
2
1
2
2
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
2
1
[90D]
[90D]
[PA] = Prior Authorization [B vs D] = B versus D [QL] = Quantity Limit [ST] = Step Therapy [90D] = 90-Day Supply
[LD] = Limited Distribution
You can find information on what the symbols and abbreviations on this table mean by going to page XI.
3
Drug Name
Nombre del Medicamento
Drug Requirements/
Tier Limits
Requisitos/
Nivel
Límites
1
[90D]
Drug Name
Nombre del Medicamento
Drug Requirements/
Tier Limits
Requisitos/
Nivel
Límites
4
[90D]
GABITRIL TABS 12MG &
16MG
ONFI
phenobarbital elixir
phenobarbital tabs
primidone
SABRIL
tiagabine
valproate sodium inj
valproic acid
Glutamate Reducing Agents
felbamate tabs 400mg
felbamate tabs 600mg &
oral susp 600mg/5ml
lamotrigine immediaterelease tabs
topiramate immediaterelease
Sodium Channel Agents
APTIOM
BANZEL
carbamazepine tabs,
chewable tabs & oral susp
carbamazepine er tabs &
caps
dilantin caps 100mg
DILANTIN CAPS 30MG
DILANTIN INFATABS
DILANTIN SUSP
epitol
fosphenytoin sodium inj
oxcarbazepine
PEGANONE
phenytoin chewable tabs
phenytoin er
phenytoin oral susp
phenytoin inj
TEGRETOL
TEGRETOL XR
TRILEPTAL
VIMPAT ORAL
VIMPAT INJ
sulfamethoxazole &
trimethoprim ds tabs
2
[90D]
sulfamethoxazole &
trimethoprim oral susp
2
[90D]
sulfamethoxazole &
trimethoprim inj
Tetracyclines
3
[90D]
demeclocycline
2
[90D]
doxy 100 inj
2
[90D]
doxycycline immediaterelease tabs, caps & oral
susp
2
[90D]
minocycline ir
2
[90D]
morgidox
2
[90D]
tetracycline
ANTICONVULSANTS
Anticonvulsants, Other
BRIVIACT INJ
4
[90D]
BRIVIACT ORAL SOLN
4
[90D]
BRIVIACT TABS
5
FYCOMPA
4
[90D]
2
[90D]
levetiracetam er
2
[90D]
levetiracetam oral
2
[90D]
levetiracetam inj
POTIGA
4
[90D]
SPRITAM
4
[90D]
Calcium Channel Modifying Agents
CELONTIN
4
[90D]
2
[90D]
ethosuximide
LYRICA
3
[PA] [90D]
2
[90D]
zonisamide
Gamma-aminobutyric Acid (GABA)
Augmenting Agents
2
[90D]
clonazepam
2
[90D]
clonazepam odt
2
[PA]
[90D]
clorazepate
2
[PA] [90D]
diazepam rectal gel
2
[90D]
divalproex sodium
2
[90D]
divalproex sodium dr
2
[90D]
divalproex sodium er
2
[90D]
gabapentin caps, tabs, &
oral soln
4
2
2
2
5
2
2
2
[90D]
[PA] [90D]
[PA] [90D]
[90D]
[LD]
[90D]
[90D]
[90D]
2
5
[90D]
2
[90D]
2
[90D]
4
4
2
[90D]
[90D]
[90D]
3
[90D]
2
3
3
3
2
2
2
4
2
2
2
2
3
3
4
4
4
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[PA] = Autorización Previa [B vs D] = B versus D [QL] = Límite de Cantidad [ST] = Tratamiento Escalonado
[90D] = Suministro para 90 Días [LD] = Distribución Limitada
Puede encontrar información sobre el significado de los símbolos y abreviaturas de esta tabla en la página XXIII.
4
Drug Name
Nombre del Medicamento
Drug Requirements/
Tier Limits
Requisitos/
Nivel
Límites
Drug Name
Nombre del Medicamento
ANTIDEMENTIA AGENTS
Antidementia Agents, Other
3
[PA] [90D]
ergoloid mesylates
Cholinesterase Inhibitors
2
[90D]
donepezil tabs 5mg &
10mg
2
[90D]
donepezil odt
2
[QL] [90D]
galantamine
2
[QL] [90D]
galantamine er
2
[QL] [90D]
galantamine oral soln
3
[QL] [90D]
rivastigmine caps
3
[QL] [90D]
rivastigmine patches
N-methyl-D-aspartate (NMDA) Receptor
Antagonists
2
[90D]
memantine hcl immediate
release
ANTIDEPRESSANTS
Antidepressants, Other
2
[90D]
bupropion
2
[90D]
bupropion sr
2
[90D]
bupropion xl
FORFIVO XL
3
[90D]
2
[90D]
maprotiline
1
[90D]
mirtazapine
1
[90D]
mirtazapine odt
2
[90D]
nefazodone
1
[90D]
trazodone
TRINTELLIX
4
[ST] [90D]
Monoamine Oxidase Inhibitors
EMSAM
4
[90D]
MARPLAN
4
[90D]
2
[90D]
phenelzine
2
[90D]
tranylcypromine
SSRIs/SNRIs (Selective Serotonin Reuptake
Inhibitors/Serotonin & Norepinephrine
Reuptake Inhibitors)
1
[90D]
citalopram tabs
2
[90D]
citalopram oral soln
DESVENLAFAXINE ER
4
[ST] [90D]
4
[ST] [90D]
desvenlafaxine succinate
er
duloxetine hcl
escitalopram
FETZIMA
FETZIMA TITRATION
PACK
fluoxetine hcl caps 10mg,
20mg & 40mg
fluoxetine hcl tabs 10mg &
20mg
fluoxetine hcl oral soln
fluvoxamine
fluvoxamine er
KHEDEZLA
paroxetine immediaterelease
paroxetine er
PAXIL 10MG/5ML SUSP
PRISTIQ
sertraline tabs
sertraline oral soln
venlafaxine ir tabs
venlafaxine er caps
VIIBRYD
VIIBRYD STARTER PACK
Tricyclics
amitriptyline
amoxapine
clomipramine
desipramine
doxepin
imipramine hcl tabs
nortriptyline oral
perphenazine &
amitriptyline
protriptyline
trimipramine maleate
ANTIEMETICS
Antiemetics, Other
compro
meclizine
Drug Requirements/
Tier Limits
Requisitos/
Nivel
Límites
3
[90D]
2
[90D]
4
[ST] [90D]
4
[ST] [90D]
2
[90D]
2
[90D]
2
2
2
4
1
[90D]
[90D]
[90D]
[ST] [90D]
[90D]
2
4
4
1
2
2
2
4
4
[90D]
[90D]
[ST] [90D]
[90D]
[90D]
[90D]
[90D]
[ST] [90D]
[ST] [90D]
2
2
4
2
2
2
2
2
[PA] [90D]
[90D]
[PA] [90D]
[90D]
[90D]
[PA] [90D]
[90D]
[PA] [90D]
2
2
[90D]
[PA] [90D]
2
2
[90D]
[90D]
[PA] = Prior Authorization [B vs D] = B versus D [QL] = Quantity Limit [ST] = Step Therapy [90D] = 90-Day Supply
[LD] = Limited Distribution
You can find information on what the symbols and abbreviations on this table mean by going to page XI.
5
Drug Name
Nombre del Medicamento
Drug Requirements/
Tier Limits
Requisitos/
Nivel
Límites
2
[90D]
metoclopramide oral
tablets & soln
2
metoclopramide inj
3
phenadoz
3
phenergan suppositories
2
prochlorperazine inj
2
prochlorperazine oral
2
prochlorperazine
suppositories
3
promethazine inj
3
promethazine
suppositories
2
promethazine syrup
2
promethazine tabs
12.5mg, 25mg & 50mg
3
promethegan
TRANSDERM-SCOP
3
Emetogenic Therapy Adjuncts
4
aprepitant caps 80mg &
125mg
4
aprepitant pack
3
dronabinol
2
granisetron inj
2
granisetron oral
ondansetron odt
2
ondansetron oral soln
2
ondansetron inj
ondansetron tabs
2
2
ANTIFUNGALS
Antifungals
ABELCET INJ
AMBISOME INJ
amphotericin b inj
5
5
2
CANCIDAS INJ
ciclopirox 8% nail soln
5
2
Drug Name
Nombre del Medicamento
ciclopirox cream, susp,
shampoo
clotrimazole &
betamethasone
clotrimazole 1% cream
clotrimazole 1% topical
soln
clotrimazole troche
CRESEMBA INJ
CRESEMBA ORAL
econazole nitrate
fluconazole in dextrose inj
fluconazole in sodium
chloride inj
fluconazole oral
flucytosine
griseofulvin microsize
itraconazole
ketoconazole
NOXAFIL ORAL
nyamyc
nyata
nystatin
nystatin & triamcinolone
ORAVIG
SPORANOX ORAL SOLN
terbinafine
terconazole
voriconazole inj
voriconazole oral
ANTIGOUT AGENTS
Antigout Agents
allopurinol
COLCHICINE
COLCRYS
probenecid
probenecid & colchicine
ULORIC
[90D]
[PA] [90D]
[PA] [90D]
[90D]
[90D]
[90D]
[PA] [90D]
[PA] [90D]
[PA] [90D]
[PA] [90D]
[PA] [90D]
[90D]
[PA] [90D]
[PA] [90D]
[PA] [90D]
[90D]
[PA] [B vs D]
[90D]
[PA] [B vs D]
[90D]
[PA] [B vs D]
[90D]
[90D]
[PA] [B vs D]
[90D]
[PA] [B vs D]
[PA] [B vs D]
[PA] [B vs D]
[90D]
[PA]
[90D]
Drug Requirements/
Tier Limits
Requisitos/
Nivel
Límites
2
[90D]
2
[90D]
2
2
[90D]
[90D]
2
5
5
3
2
2
[90D]
[PA]
[PA]
[90D]
[90D]
[90D]
2
5
2
4
2
5
2
2
2
3
4
4
2
2
2
5
[90D]
1
4
4
2
2
3
[90D]
[QL] [90D]
[QL] [90D]
[90D]
[90D]
[ST] [90D]
[90D]
[90D]
[90D]
[PA]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[PA] = Autorización Previa [B vs D] = B versus D [QL] = Límite de Cantidad [ST] = Tratamiento Escalonado
[90D] = Suministro para 90 Días [LD] = Distribución Limitada
Puede encontrar información sobre el significado de los símbolos y abreviaturas de esta tabla en la página XXIII.
6
Drug Name
Nombre del Medicamento
Drug Requirements/
Tier Limits
Requisitos/
Nivel
Límites
Drug Name
Nombre del Medicamento
GLEOSTINE
HEXALEN
LEUKERAN
MATULANE
VALCHLOR
Antiandrogens
bicalutamide
flutamide
nilutamide
XTANDI
ZYTIGA
Antiangiogenic Agents
POMALYST
REVLIMID
THALOMID
Antiestrogens/Modifiers
EMCYT
FARESTON
FASLODEX INJ
SOLTAMOX
tamoxifen
Antimetabolites
ALIMTA INJ
hydroxyurea
LONSURF
mercaptopurine
PURIXAN
TABLOID
Antineoplastics, Other
azacitidine inj
ERWINAZE INJ
KISQALI
leucovorin oral
leucovorin inj
levoleucovorin inj
LYNPARZA
MESNEX TABS
mitoxantrone inj
NINLARO
ONCASPAR INJ
ANTIMIGRAINE AGENTS
Ergot Alkaloids
5
dihydroergotamine
mesylate inj
4
[90D]
migergot suppository
Serotonin (5-HT) 1b/1d Receptor Agonists
2
[QL] [90D]
naratriptan
2
[90D]
rizatriptan
2
[90D]
rizatriptan odt
3
[90D]
sumatriptan nasal
3
[90D]
sumatriptan succinate inj
2
[90D]
sumatriptan succinate oral
2
[90D]
zolmitriptan tabs
2
[90D]
zolmitriptan odt
ZOMIG NASAL
4
[QL] [90D]
ANTIMYASTHENIC AGENTS
Parasympathomimetics
2
[90D]
guanidine
MESTINON SYRUP
3
[90D]
2
[90D]
pyridostigmine
2
[90D]
pyridostigmine er
ANTIMYCOBACTERIALS
Antimycobacterials, Other
DAPSONE
3
[90D]
2
[90D]
rifabutin
Antituberculars
CAPASTAT INJ
4
[90D]
2
[90D]
ethambutol
2
[90D]
isoniazid oral
PASER
4
[90D]
PRIFTIN
4
[90D]
2
[90D]
pyrazinamide
2
[90D]
rifampin oral
2
[90D]
rifampin inj
RIFATER
4
[90D]
SIRTURO
5
TRECATOR
4
[90D]
ANTINEOPLASTICS
Alkylating Agents
2
[PA] [B vs D]
cyclophosphamide caps
[90D]
Drug Requirements/
Tier Limits
Requisitos/
Nivel
Límites
4
[90D]
5
3
[90D]
5
5
[PA]
2
2
3
5
5
[90D]
[90D]
[90D]
[PA]
[PA]
5
5
5
[PA]
[PA] [LD]
[PA]
3
3
5
3
2
[90D]
[90D]
5
2
5
2
5
4
[PA]
[90D]
[PA]
[90D]
5
5
5
2
2
5
5
3
2
5
5
[90D]
[90D]
[PA] [90D]
[PA] [B vs D]
[PA]
[PA]
[90D]
[90D]
[PA]
[90D]
[PA] [90D]
[PA]
[PA]
[PA] = Prior Authorization [B vs D] = B versus D [QL] = Quantity Limit [ST] = Step Therapy [90D] = 90-Day Supply
[LD] = Limited Distribution
You can find information on what the symbols and abbreviations on this table mean by going to page XI.
7
Drug Name
Nombre del Medicamento
Drug Requirements/
Tier Limits
Requisitos/
Nivel
Límites
2
[90D]
5
[PA] [LD]
5
[PA]
5
[PA]
5
[PA]
4
[PA] [90D]
Drug Name
Nombre del Medicamento
MEKINIST
NEXAVAR
ODOMZO
SPRYCEL
STIVARGA
SUTENT
TAFINLAR
TAGRISSO
TARCEVA
TASIGNA
TYKERB
VOTRIENT
XALKORI
ZELBORAF
ZYKADIA
Monoclonal Antibodies
AVASTIN INJ
HERCEPTIN INJ
KEYTRUDA INJ
RITUXAN INJ
YERVOY INJ
Retinoids
bexarotene
PANRETIN
TARGRETIN GEL
tretinoin caps
ANTIPARASITICS
Anthelmintics
ALBENZA
ivermectin
Antiprotozoals
ALINIA
atovaquone
atovaquone/proguanil
chloroquine
COARTEM
DARAPRIM
hydroxychloroquine
mefloquine
NEBUPENT NEBULIZER
paclitaxel inj
RUBRACA
SYLATRON INJ
SYNRIBO INJ
VELCADE INJ
VENCLEXTA TABS 10MG
& 50MG
VENCLEXTA TABS
5
[PA]
100MG
VENCLEXTA STARTING
5
[PA]
PACK
ZEJULA
5
[PA]
Aromatase Inhibitors, 3rd Generation
2
[90D]
anastrozole
3
[90D]
exemestane
2
[90D]
letrozole
Enzyme Inhibitors
BELEODAQ
5
[PA]
3
[90D]
etoposide inj
FARYDAK
5
[PA]
ZOLINZA
5
[PA]
ZYDELIG
5
[PA]
Molecular Target Inhibitors
AFINITOR
5
[PA]
AFINITOR DISPERZ
5
[PA]
ALECENSA
5
[PA]
BOSULIF 100 MG TAB
3
[PA] [90D]
BOSULIF 500 MG TAB
5
[PA]
CABOMETYX
5
[PA]
CAPRELSA
5
[PA]
COMETRIQ
5
[PA]
COTELLIC
5
[PA]
ERIVEDGE
5
[PA]
GILOTRIF
5
[PA]
IBRANCE
5
[PA]
ICLUSIG
5
[PA]
5
[PA]
imatinib
IMBRUVICA
5
[PA]
INLYTA
5
[PA]
IRESSA
5
[PA]
JAKAFI
5
[PA]
LENVIMA
5
[PA]
Drug Requirements/
Tier Limits
Requisitos/
Nivel
Límites
5
[PA]
5
[PA] [LD]
5
[PA]
5
[PA]
5
[PA]
5
[PA]
5
[PA]
5
[PA]
5
5
[PA]
5
[PA]
5
[PA]
5
[PA]
5
[PA]
5
[PA]
5
5
5
5
5
[PA]
[PA]
[PA]
[PA]
[PA]
5
5
5
2
[PA]
[PA]
[90D]
4
2
[90D]
[90D]
4
5
2
2
3
5
2
2
4
[90D]
[90D]
[90D]
[90D]
[PA]
[90D]
[90D]
[PA] [B vs D]
[90D]
[PA] = Autorización Previa [B vs D] = B versus D [QL] = Límite de Cantidad [ST] = Tratamiento Escalonado
[90D] = Suministro para 90 Días [LD] = Distribución Limitada
Puede encontrar información sobre el significado de los símbolos y abreviaturas de esta tabla en la página XXIII.
8
Drug Name
Nombre del Medicamento
Drug Requirements/
Tier Limits
Requisitos/
Nivel
Límites
4
[90D]
3
[90D]
2
[PA] [90D]
Drug Name
Nombre del Medicamento
PENTAM INJ
PRIMAQUINE
quinine sulfate caps
324mg
Pediculicides/Scabicides
EURAX
3
[90D]
2
[90D]
malathion
2
[90D]
permethrin cream
ANTIPARKINSON AGENTS
Anticholinergics
2
[90D]
benztropine inj
2
[PA] [90D]
benztropine tabs
2
[PA] [90D]
trihexyphenidyl tabs
2
[PA] [90D]
trihexyphenidyl elixir
Antiparkinson Agents, Other
2
[90D]
amantadine
4
[90D]
entacapone
Dopamine Agonists
APOKYN INJ
5
[PA]
2
[90D]
bromocriptine
NEUPRO PATCH
4
[QL] [90D]
2
[90D]
pramipexole ir
2
[90D]
ropinirole
Dopamine Precursors/L-Amino Acid
Decarboxylase Inhibitors
4
[90D]
carbidopa
2
[90D]
carbidopa & levodopa
2
[90D]
carbidopa & levodopa er
2
[90D]
carbidopa & levodopa odt
3
[90D]
carbidopa & levodopa &
entacapone
Monoamine Oxidase B (MAO-B) Inhibitors
4
[90D]
rasagiline
2
[90D]
selegiline
ANTIPSYCHOTICS
1st Generation/Typical
3
[90D]
chlorpromazine oral
3
[90D]
chlorpromazine inj
2
[90D]
fluphenazine oral
2
[90D]
fluphenazine decanoate inj
2
[90D]
fluphenazine inj
haloperidol tabs
haloperidol decanoate inj
haloperidol lactate oral
soln
haloperidol lactate inj
loxapine
molindone
perphenazine
pimozide
thioridazine
thiothixene
trifluoperazine
2nd Generation/Atypical
ABILIFY INJ
ABILIFY MAINTENA
aripiprazole odt
aripiprazole tabs 2mg,
5mg, 10mg, & 15mg
aripiprazole tabs 20mg &
30mg
ARISTADA INJ
FANAPT
FANAPT TITRATION
PACK
GEODON INJ
INVEGA SUSTENNA INJ
39MG & 78MG
INVEGA TRINZA INJ
LATUDA
NUPLAZID
olanzapine tabs
olanzapine odt
olanzapine inj 10mg
paliperidone er
quetiapine
quetiapine er tabs
REXULTI
RISPERDAL CONSTA INJ
12.5MG & 25MG
Drug Requirements/
Tier Limits
Requisitos/
Nivel
Límites
2
[90D]
2
[90D]
2
[90D]
2
2
2
2
2
2
2
2
[90D]
[90D]
[90D]
[90D]
[90D]
[PA] [90D]
[90D]
[90D]
4
5
3
3
[90D]
[ST] [90D]
[ST] [90D]
5
[ST]
5
4
4
[ST] [90D]
[ST] [90D]
3
4
[90D]
[90D]
5
5
5
2
2
2
5
2
3
5
4
[ST]
[PA]
[90D]
[90D]
[90D]
[ST]
[90D]
[ST] [90D]
[ST]
[90D]
[PA] = Prior Authorization [B vs D] = B versus D [QL] = Quantity Limit [ST] = Step Therapy [90D] = 90-Day Supply
[LD] = Limited Distribution
You can find information on what the symbols and abbreviations on this table mean by going to page XI.
9
Drug Name
Nombre del Medicamento
Drug Requirements/
Tier Limits
Requisitos/
Nivel
Límites
5
Drug Requirements/
Tier Limits
Requisitos/
Nombre del Medicamento
Nivel
Límites
PEGASYS INJ
5
PEGASYS PROCLICK INJ
5
PEG-INTRON INJ
5
PEG-INTRON REDIPEN
5
INJ
2
[90D]
ribasphere
5
ribasphere ribapak
2
[90D]
ribavirin
SOVALDI
5
[PA]
Antiherpetic Agents
2
[90D]
acyclovir oral
4
[90D]
acyclovir oint 5%
2
[PA] [B vs D]
acyclovir inj
[90D]
DENAVIR
3
[90D]
2
[90D]
famciclovir
2
[90D]
valacyclovir
XERESE
3
[90D]
ZOVIRAX CREAM
5
Anti-HIV Agents, Integrase Inhibitors (INSTI)
GENVOYA
5
ISENTRESS CHEW TABS
3
[90D]
ISENTRESS ORAL
3
[90D]
POWDER
ISENTRESS TABS
5
TIVICAY 10MG & 25MG
4
[90D]
TABS
TIVICAY 50MG TAB
5
Anti-HIV Agents, Non-nucleoside Reverse
Transcriptase Inhibitors (NNRTI)
ATRIPLA
5
COMPLERA
5
DESCOVY
5
EDURANT
5
INTELENCE 25MG TAB
4
[90D]
INTELENCE 100MG &
5
200MG TABS
2
[90D]
nevirapine er
2
[90D]
nevirapine oral susp
2
[90D]
nevirapine tabs
ODEFSEY
5
RESCRIPTOR
3
[90D]
Drug Name
RISPERDAL CONSTA INJ
37.5MG & 50MG
2
[90D]
risperidone
2
[90D]
risperidone odt
SAPHRIS
4
[ST] [90D]
SEROQUEL XR
4
[ST] [90D]
VRAYLAR CAPSULES
5
[ST]
VRAYLAR DOSE PACK
4
[ST] [90D]
2
[90D]
ziprasidone oral
ZYPREXA RELPREVV
4
[90D]
210MG INJ
Treatment-Resistant
2
[90D]
clozapine
2
[90D]
clozapine odt
FAZACLO
4
[90D]
VERSACLOZ
4
[90D]
ANTISPASTICITY AGENTS
Antispasticity Agents
2
[90D]
baclofen
2
[90D]
tizanidine
ANTIVIRALS
Anti-cytomegalovirus (CMV) Agents
2
[PA] [B vs D]
ganciclovir inj
[90D]
5
valganciclovir tabs
ZIRGAN
4
[90D]
Anti-hepatitis B (HBV) Agents
5
adefovir dipivoxil
BARACLUDE ORAL
4
[90D]
SOLN 0.05MG/ML
5
entecavir tabs
EPIVIR HBV SOLN
4
[90D]
5MG/ML
INTRON-A INJ
4
[90D]
2
[90D]
lamivudine
Anti-hepatitis C (HCV) Agents
DAKLINZA
5
[PA]
EPCLUSA
5
[PA]
HARVONI
5
[PA]
2
[90D]
moderiba 200mg tabs
5
moderiba dose pack
OLYSIO
5
[PA]
[PA] = Autorización Previa [B vs D] = B versus D [QL] = Límite de Cantidad [ST] = Tratamiento Escalonado
[90D] = Suministro para 90 Días [LD] = Distribución Limitada
Puede encontrar información sobre el significado de los símbolos y abreviaturas de esta tabla en la página XXIII.
10
Drug Requirements/
Tier Limits
Requisitos/
Nombre del Medicamento
Nivel
Límites
STRIBILD
5
SUSTIVA
4
[90D]
VIRAMUNE TABS
4
[90D]
Anti-HIV Agents, Nucleoside and Nucleotide
Reverse Transcriptase Inhibitors (NRTI)
2
[90D]
abacavir tabs
5
abacavir & lamivudine
5
abacavir & lamivudine &
zidovudine
2
[90D]
didanosine
EMTRIVA
4
[90D]
2
[90D]
lamivudine
2
[90D]
lamivudine & zidovudine
RETROVIR IV INJ
4
[90D]
2
[90D]
stavudine caps
TRIUMEQ
5
TRUVADA
5
VIDEX PEDIATRIC SOLN
4
[90D]
2GM
VIREAD TABS
5
VIREAD POWDER
4
[90D]
ZERIT SOLN
3
[90D]
ZIAGEN SOLN
4
[90D]
2
[90D]
zidovudine
Anti-HIV Agents, Other
FUZEON INJ
3
[90D]
SELZENTRY 25MG &
4
[90D]
75MG
SELZENTRY 150MG &
5
300MG
TYBOST
3
[90D]
Anti-HIV Agents, Protease Inhibitors
APTIVUS
5
CRIXIVAN
3
[90D]
EVOTAZ
5
INVIRASE
4
[90D]
KALETRA TABS 1004
[90D]
25MG
KALETRA TABS 2005
50MG & SOLN 400100MG/5ML
Drug Name
Drug Name
Nombre del Medicamento
Drug Requirements/
Tier Limits
Requisitos/
Nivel
Límites
4
[90D]
5
4
[90D]
4
[90D]
5
4
[90D]
LEXIVA ORAL SUSP
LEXIVA TABS
lopinavir & ritonavir soln
NORVIR
PREZCOBIX
PREZISTA SUSP
100MG/ML
PREZISTA TABS 75MG &
4
150MG
PREZISTA TABS 600MG
5
& 800MG
REYATAZ CAPS & ORAL
5
POWDER
VIRACEPT
5
Anti-influenza Agents
RELENZA DISKHALER
3
2
rimantadine
2
oseltamivir caps
TAMIFLU SUSP
3
ANXIOLYTICS
Anxiolytics, Other
2
buspirone
Benzodiazepines
2
alprazolam tabs
2
alprazolam er tabs
2
alprazolam intensol
2
diazepam tabs & soln
2
diazepam intensol
2
lorazepam tabs
2
lorazepam intensol
2
oxazepam
BIPOLAR AGENTS
Mood Stabilizers
2
lithium carbonate
2
lithium carbonate er
2
lithium citrate
BLOOD GLUCOSE REGULATORS
Antidiabetic Agents
2
acarbose
BYDUREON INJ
3
BYETTA INJ
3
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[PA] [90D]
[PA] [90D]
[PA] [90D]
[PA] [90D]
[PA] [90D]
[90D]
[90D]
[PA] [90D]
[90D]
[90D]
[90D]
[90D]
[PA] [90D]
[PA] [90D]
[PA] = Prior Authorization [B vs D] = B versus D [QL] = Quantity Limit [ST] = Step Therapy [90D] = 90-Day Supply
[LD] = Limited Distribution
You can find information on what the symbols and abbreviations on this table mean by going to page XI.
11
Drug Name
Nombre del Medicamento
CYCLOSET
FARXIGA
glimepiride
glimepiride & pioglitazone
glipizide
glipizide & metformin tabs
glipizide er
INVOKAMET
INVOKAMET XR
INVOKANA
JANUMET
JANUMET XR
JANUVIA
KOMBIGLYZE XR
metformin
metformin er uncoated
tabs 500mg & 750mg
nateglinide
ONGLYZA
pioglitazone
pioglitazone & metformin
repaglinide
SYMLINPEN INJ
VICTOZA INJ
XIGDUO XR
Glycemic Agents
GLUCAGON
EMERGENCY KIT INJ
PROGLYCEM
Insulins
HUMALOG CARTRIDGE
INJ
HUMALOG KWIKPEN INJ
HUMALOG MIX 50/50
KWIKPEN INJ
HUMALOG MIX 75/25
KWIKPEN INJ
HUMALOG MIX 50/50
VIAL INJ
HUMALOG MIX 75/25
VIAL INJ
HUMALOG VIAL INJ
Drug Requirements/
Tier Limits
Requisitos/
Nivel
Límites
3
[90D]
3
[ST] [90D]
1
[90D]
2
[QL] [90D]
1
[90D]
2
[90D]
1
[90D]
3
[ST] [90D]
3
[ST] [90D]
3
[ST] [90D]
3
[90D]
3
[90D]
3
[90D]
3
[90D]
1
[90D]
1
[90D]
2
3
1
2
2
3
3
3
[90D]
[90D]
[90D]
[90D]
[90D]
[PA] [90D]
[PA] [90D]
[ST] [90D]
3
[90D]
4
[90D]
3
[90D]
3
3
[90D]
[90D]
3
[90D]
6
[90D]
6
[90D]
6
[90D]
Drug Name
Nombre del Medicamento
Drug Requirements/
Tier Limits
Requisitos/
Nivel
Límites
3
[90D]
HUMULIN 70/30
KWIKPEN INJ
HUMULIN 70/30 VIAL INJ
6
[90D]
HUMULIN N KWIKPEN
3
[90D]
INJ
HUMULIN N VIAL INJ
6
[90D]
HUMULIN R U-500
3
[90D]
(CONCENTRATED)
KWIKPEN INJ
HUMULIN R U-500
3
[90D]
(CONCENTRATED) VIAL
INJ
HUMULIN R VIAL INJ
6
[90D]
LANTUS SOLOSTAR
3
[90D]
PEN INJ
LANTUS VIAL INJ
3
[90D]
TOUJEO SOLOSTAR
3
[90D]
BLOOD PRODUCTS/ MODIFIERS/ VOLUME
EXPANDERS
Anticoagulants
COUMADIN ORAL
3
[90D]
ELIQUIS
3
[90D]
3
[90D]
enoxaparin inj
30mg/0.3ml, 40mg/0.4ml,
60mg/0.6ml, 80mg/0.8ml,
100mg/ml, 120mg/0.8ml &
300mg/3ml
5
enoxaparin inj 150mg/ml
4
[90D]
fondaparinux inj
2.5mg/0.5ml & 5mg/0.4ml
5
fondaparinux inj
7.5mg/0.6ml & 10mg/0.8ml
2
[PA] [B vs D]
heparin inj
[90D]
1
[90D]
jantoven
PRADAXA
3
[90D]
1
[90D]
warfarin
XARELTO
3
[90D]
XARELTO STARTER
3
[90D]
PACK
Blood Formation Modifiers
2
[90D]
anagrelide
LEUKINE INJ
5
[PA]
[PA] = Autorización Previa [B vs D] = B versus D [QL] = Límite de Cantidad [ST] = Tratamiento Escalonado
[90D] = Suministro para 90 Días [LD] = Distribución Limitada
Puede encontrar información sobre el significado de los símbolos y abreviaturas de esta tabla en la página XXIII.
12
Drug Name
Nombre del Medicamento
Drug Requirements/
Tier Limits
Requisitos/
Nivel
Límites
5
[PA]
3
[PA] [90D]
Drug Name
Nombre del Medicamento
NEUPOGEN INJ
PROCRIT INJ
2000UNIT/ML
PROCRIT INJ
4
[PA] [90D]
3000UNIT/ML,
4000UNIT/ML &
10000UNIT/ML
PROCRIT INJ
5
[PA]
20000UNIT/ML &
40000UNIT/ML
PROMACTA
5
[PA] [LD]
Coagulants
2
[90D]
tranexamic acid inj
2
[90D]
tranexamic acid tabs
Platelet Modifying Agents
BRILINTA
3
[QL] [90D]
2
[90D]
cilostazol
2
[90D]
clopidogrel tabs 75mg
3
[QL] [90D]
dipyridamole er & aspirin
2
[PA] [90D]
dipyridamole oral
CARDIOVASCULAR AGENTS
Alpha-adrenergic Agonists
3
[90D]
clonidine patches
1
[90D]
clonidine tabs immediaterelease
2
[90D]
guanfacine
2
[PA] [90D]
methyldopa
2
[PA] [90D]
methyldopa &
hydrochlorothiazide
2
[90D]
methyldopate inj
2
[90D]
midodrine tabs
Alpha-adrenergic Blocking Agents
2
[90D]
doxazosin
2
[90D]
prazosin
1
[90D]
terazosin
Angiotensin-converting Enzyme (ACE)
Inhibitors
1
[90D]
benazepril
1
[90D]
benazepril &
hydrochlorothiazide
1
[90D]
captopril
Drug Requirements/
Tier Limits
Requisitos/
Nivel
Límites
1
[90D]
captopril &
hydrochlorothiazide
1
[90D]
enalapril
1
[90D]
enalapril &
hydrochlorothiazide
1
[90D]
fosinopril
1
[90D]
fosinopril &
hydrochlorothiazide
1
[90D]
lisinopril
1
[90D]
lisinopril &
hydrochlorothiazide
1
[90D]
moexipril
1
[90D]
moexipril &
hydrochlorothiazide
1
[90D]
perindopril
1
[90D]
quinapril
1
[90D]
quinapril &
hydrochlorothiazide
1
[90D]
ramipril
1
[90D]
trandolapril
Angiotensin II Receptor Antagonists
2
[ST] [90D]
amlodipine & olmesartan
1
[90D]
irbesartan
1
[90D]
irbesartan hct
1
[90D]
losartan
1
[90D]
losartan hct
3
[ST] [90D]
olmesartan
3
[ST] [90D]
olmesartan hct
1
[90D]
valsartan
1
[90D]
valsartan hct
2
[90D]
valsartan & amlodipine
2
[ST] [90D]
valsartan & amlodipine &
hct
Antiarrhythmics
2
[90D]
amiodarone tabs
2
[PA] [90D]
disopyramide phosphate
2
[90D]
dofetilide
2
[90D]
flecainide acetate
2
[90D]
mexiletine
2
[90D]
pacerone tabs 200mg
2
[90D]
procainamide inj
[PA] = Prior Authorization [B vs D] = B versus D [QL] = Quantity Limit [ST] = Step Therapy [90D] = 90-Day Supply
[LD] = Limited Distribution
You can find information on what the symbols and abbreviations on this table mean by going to page XI.
13
Drug Requirements/
Tier Limits
Requisitos/
Nombre del Medicamento
Nivel
Límites
2
[90D]
propafenone
2
[90D]
quinidine gluconate cr
2
[90D]
quinidine gluconate inj
2
[90D]
quinidine sulfate
2
[90D]
sorine
2
[90D]
sotalol tabs
Beta-adrenergic Blocking Agents
2
[90D]
acebutolol
1
[90D]
atenolol
1
[90D]
atenolol & chlorthalidone
2
[90D]
bisoprolol
2
[90D]
bisoprolol &
hydrochlorothiazide
1
[90D]
carvedilol
COREG CR
3
[90D]
DUTOPROL
3
[90D]
2
[90D]
labetalol oral
2
[90D]
labetalol inj
2
[90D]
metoprolol succinate er
1
[90D]
metoprolol tartrate tabs
2
[90D]
metoprolol &
hydrochlorothiazide
2
[90D]
nadolol
2
[90D]
nadolol &
bendroflumethiazide
2
[90D]
pindolol
1
[90D]
propranolol ir tabs
2
[90D]
propranolol er caps
2
[90D]
propranolol oral soln
2
[90D]
propranolol inj
1
[90D]
propranolol &
hydrochlorothiazide
1
[90D]
timolol oral
Calcium Channel Blocking Agents
2
[90D]
afeditab cr
1
[90D]
amlodipine
2
[90D]
amlodipine & atorvastatin
1
[90D]
amlodipine & benazepril
2
[90D]
cartia xt
2
[90D]
diltiazem tabs
Drug Name
Drug Name
Nombre del Medicamento
Drug Requirements/
Tier Limits
Requisitos/
Nivel
Límites
2
[90D]
diltiazem cd caps 120mg,
180mg, 240mg, & 300mg
2
diltiazem er caps
2
diltiazem inj 50mg/10ml
2
dilt-xr
2
felodipine er
2
isradipine
2
nicardipine caps
2
nifedipine
2
nifedipine er
2
nimodipine caps
2
nisoldipine er
2
taztia xt
1
verapamil ir
2
verapamil er
2
verapamil sr
2
verapamil inj
Cardiovascular Agents, Other
DEMSER
5
2
digitek
2
digoxin oral
2
digoxin inj
LANOXIN INJ
3
LANOXIN ORAL
3
NORTHERA
5
2
pentoxifylline er
RANEXA
3
REPATHA INJ
5
TEKTURNA
3
TEKTURNA HCT
3
Diuretics, Loop
2
bumetanide oral
1
furosemide oral
2
furosemide inj
2
torsemide oral
Diuretics, Potassium-sparing
2
amiloride
1
amiloride &
hydrochlorothiazide
2
eplerenone
1
spironolactone
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[PA] [90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[PA]
[PA] [90D]
[PA] [90D]
[PA] [90D]
[PA] [90D]
[PA] [90D]
[PA]
[90D]
[PA] [90D]
[PA]
[ST] [90D]
[ST] [90D]
[PA] = Autorización Previa [B vs D] = B versus D [QL] = Límite de Cantidad [ST] = Tratamiento Escalonado
[90D] = Suministro para 90 Días [LD] = Distribución Limitada
Puede encontrar información sobre el significado de los símbolos y abreviaturas de esta tabla en la página XXIII.
14
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
Drug Name
Nombre del Medicamento
Drug Requirements/
Tier Limits
Requisitos/
Nivel
Límites
1
[90D]
Drug Requirements/
Tier Limits
Requisitos/
Nombre del Medicamento
Nivel
Límites
Vasodilators, Direct-acting Arterial/Venous
2
[90D]
isosorbide dinitrate
2
[90D]
isosorbide dinitrate er
2
[90D]
isosorbide mononitrate
2
[90D]
isosorbide mononitrate er
2
[90D]
minitran patches
2
[90D]
nitro-bid oint
NITRO-DUR PATCHES
3
[90D]
2
[90D]
nitroglycerin inj
2
[90D]
nitroglycerin lingual
2
[90D]
nitroglycerin patches
2
[90D]
nitroglycerin sublingual
CENTRAL NERVOUS SYSTEM AGENTS
Attention Deficit Hyperactivity Disorder
Agents, Amphetamines
2
[QL] [90D]
amphetamine &
dextroamphetamine tabs
2
[QL] [90D]
dexedrine tabs
2
[QL] [90D]
dextroamphetamine
sulfate
2
[QL] [90D]
dextroamphetamine
sulfate er
2
[QL] [90D]
zenzedi tabs 5mg & 10mg
Attention Deficit Hyperactivity Disorder
Agents, Non-amphetamines
2
[PA] [90D]
clonidine er
2
[90D]
dexmethylphenidate ir tabs
2
[90D]
metadate er
2
[90D]
methylphenidate er tabs
10mg & 20mg
2
[90D]
methylphenidate ir tabs
5mg, 10mg & 20mg
STRATTERA
4
[PA] [90D]
Central Nervous System, Other
HETLIOZ
5
[PA]
NUEDEXTA
3
[90D]
3
[90D]
riluzole
5
[PA]
tetrabenazine
Fibromyalgia Agents
SAVELLA
3
[90D]
Drug Name
spironolactone &
hydrochlorothiazide
1
[90D]
triamterene &
hydrochlorothiazide
Diuretics, Thiazide
2
[90D]
chlorothiazide tabs
1
[90D]
chlorthalidone
1
[90D]
hydrochlorothiazide
1
[90D]
indapamide
2
[90D]
metolazone
Dyslipidemics, Fibric Acid Derivatives
2
[QL] [90D]
fenofibrate caps 43mg &
130mg
2
[QL] [90D]
fenofibrate micronized
2
[QL] [90D]
fenofibrate tabs
2
[QL] [90D]
fenofibric acid dr caps
2
[QL] [90D]
fenofibric acid tabs
2
[90D]
gemfibrozil
Dyslipidemics, HMG CoA Reductase Inhibitors
1
[90D]
atorvastatin
1
[90D]
lovastatin
1
[90D]
pravastatin
2
[ST] [90D]
rosuvastatin
1
[90D]
simvastatin
Dyslipidemics, Other
2
[90D]
cholestyramine
2
[90D]
cholestyramine light
2
[90D]
colestipol granules
2
[90D]
colestipol tabs
3
[90D]
ezetimibe
JUXTAPID
5
[PA] [LD]
KYNAMRO
5
[PA] [LD]
3
[QL] [90D]
niacin er tabs
3
[90D]
omega-3-acid ethyl esters
2
[90D]
prevalite
WELCHOL
4
[90D]
ZETIA
3
[90D]
Vasodilators, Direct-acting Arterial
2
[90D]
hydralazine oral
2
[90D]
hydralazine inj
2
[90D]
minoxidil
[PA] = Prior Authorization [B vs D] = B versus D [QL] = Quantity Limit [ST] = Step Therapy [90D] = 90-Day Supply
[LD] = Limited Distribution
You can find information on what the symbols and abbreviations on this table mean by going to page XI.
15
Drug Name
Nombre del Medicamento
Drug Requirements/
Tier Limits
Requisitos/
Nivel
Límites
3
[90D]
SAVELLA TITRATION
PACK
Multiple Sclerosis Agents
AMPYRA
5
AUBAGIO
5
AVONEX INJ
5
AVONEX PEN INJ
5
BETASERON INJ
5
COPAXONE INJ
5
40MG/ML
GILENYA
5
5
glatopa inj
PLEGRIDY INJ
5
PLEGRIDY STARTER
5
PACK INJ
REBIF INJ
5
REBIF REBIDOSE INJ
5
REBIF REBIDOSE
5
TITRATION PACK INJ
REBIF TITRATION PACK
5
INJ
TECFIDERA
5
TECFIDERA STARTER
5
PACK
TYSABRI INJ
5
DENTAL AND ORAL AGENTS
Dental and Oral Agents
2
cevimeline
2
chlorhexidine gluconate
3
pilocarpine tabs
2
triamcinolone in orabase
DERMATOLOGICAL AGENTS
Dermatological Agents
5
acitretin
2
ammonium lactate topical
4
calcipotriene cream & oint
4
calcipotriene soln
4
calcipotriene &
betamethasone oint
CARAC
5
4
claravis
Drug Name
Nombre del Medicamento
Drug Requirements/
Tier Limits
Requisitos/
Nivel
Límites
2
[90D]
clindamycin topical cream,
gel, lotion, soln & swab
2
[90D]
clindamycin & benzoyl
peroxide topical
3
[90D]
diclofenac sodium gel 1%
5
[PA]
diclofenac sodium gel 3%
3
[90D]
doxepin cream 5%
ELIDEL
4
[QL] [90D]
FLUOROURACIL 0.5%
5
CREAM
3
[90D]
fluorouracil 2% and 5%
topical
3
[90D]
imiquimod
2
[90D]
methoxsalen
4
[90D]
myorisan
2
[90D]
podofilox
3
[90D]
prudoxin
REGRANEX
5
[QL]
SANTYL
3
[90D]
2
[90D]
selenium sulfide lotion
2
[90D]
sulfacetamide sodium
susp 10%
3
[90D]
tacrolimus oint
4
[QL] [90D]
tazarotene
TAZORAC
4
[QL] [90D]
TOLAK
3
[90D]
4
[90D]
zenatane
ZONALON
3
[90D]
ENZYME REPLACEMENTS/ MODIFIERS
Enzyme Replacement/ Modifiers
ADAGEN INJ
5
[PA]
ALDURAZYME INJ
5
[PA]
BUPHENYL TABS
5
CERDELGA
5
[PA]
CREON DR
3
[90D]
CYSTADANE
4
[90D]
CYSTAGON
3
[90D]
FABRAZYME INJ
5
KUVAN
5
LUMIZYME INJ
5
[PA]
NAGLAZYME INJ
5
[PA] [LD]
ORFADIN
5
[PA] [LD]
[PA]
[PA]
[PA]
[PA]
[PA]
[PA]
[PA]
[PA]
[PA]
[PA]
[PA]
[PA]
[PA]
[PA]
[PA]
[PA]
[90D]
[90D]
[90D]
[90D]
[PA]
[90D]
[QL] [90D]
[90D]
[90D]
[90D]
[PA] = Autorización Previa [B vs D] = B versus D [QL] = Límite de Cantidad [ST] = Tratamiento Escalonado
[90D] = Suministro para 90 Días [LD] = Distribución Limitada
Puede encontrar información sobre el significado de los símbolos y abreviaturas de esta tabla en la página XXIII.
16
Drug Name
Nombre del Medicamento
Drug Requirements/
Tier Limits
Requisitos/
Nivel
Límites
5
5
Drug Name
Nombre del Medicamento
RAVICTI
sodium phenylbutyrate
powder
SUCRAID
5
VPRIV INJ
5
[PA]
ZAVESCA
5
[PA] [LD]
GASTROINTESTINAL AGENTS
Antispasmodics, Gastrointestinal
2
[90D]
atropine sulfate inj
2
[90D]
dicyclomine oral
2
[90D]
glycopyrrolate oral
2
[90D]
glycopyrrolate inj
Gastrointestinal Agents, Other
2
[90D]
cromolyn sodium oral
2
[90D]
diphenoxylate & atropine
GATTEX INJ
5
[PA]
2
[90D]
loperamide caps 2mg
MOVANTIK
3
[90D]
RELISTOR INJ
5
[PA]
RELISTOR TABS
4
[PA] [90D]
3
[90D]
ursodiol
Histamine2 (H2) Receptor Antagonists
2
[90D]
cimetidine oral
1
[90D]
famotidine tabs
2
[90D]
famotidine inj
2
[90D]
ranitidine caps, syrup & inj
1
[90D]
ranitidine tabs
Irritable Bowel Syndrome Agents
3
[PA] [90D]
alosetron hcl tabs 0.5mg
5
[PA]
alosetron hcl tabs 1mg
AMITIZA
3
[90D]
LINZESS
3
[90D]
Laxatives
2
[90D]
constulose soln
2
[90D]
enulose
2
[90D]
gavilyte-c
2
[90D]
gavilyte-g
2
[90D]
gavilyte-h
2
[90D]
gavilyte-n
2
[90D]
generlac
2
[90D]
lactulose
Drug Requirements/
Tier Limits
Requisitos/
Nivel
Límites
3
[90D]
3
[90D]
2
[90D]
2
[90D]
MOVIPREP
OSMOPREP
peg 3350 & electrolytes
peg 3350 & sodium
chloride & sodium
bicarbonate & potassium
chloride
2
[90D]
polyethylene glycol 3350
PREPOPIK
3
[90D]
SUPREP BOWEL PREP
3
[90D]
Protectants
2
[90D]
misoprostol
2
[90D]
sucralfate
Proton Pump Inhibitors
3
[ST] [90D]
esomeprazole magnesium
dr caps
2
[90D]
lansoprazole dr caps
2
[90D]
omeprazole caps
3
[90D]
pantoprazole inj
2
[90D]
pantoprazole tabs
PROTONIX INJ
3
[90D]
GENITOURINARY AGENTS
Antispasmodics, Urinary
2
[90D]
flavoxate
GELNIQUE
3
[90D]
MYRBETRIQ
3
[90D]
2
[90D]
oxybutynin
2
[QL] [90D]
oxybutynin er
OXYTROL
4
[90D]
2
[QL] [90D]
tolterodine tartrate er
TOVIAZ
3
[90D]
VESICARE
3
[90D]
Benign Prostatic Hypertrophy Agents
2
[90D]
alfuzosin hcl er
2
[90D]
doxazosin
2
[90D]
dutasteride
2
[90D]
dutasteride & tamsulosin
2
[90D]
finasteride tabs 5mg
2
[90D]
prazosin
2
[90D]
tamsulosin
1
[90D]
terazosin
[PA] = Prior Authorization [B vs D] = B versus D [QL] = Quantity Limit [ST] = Step Therapy [90D] = 90-Day Supply
[LD] = Limited Distribution
You can find information on what the symbols and abbreviations on this table mean by going to page XI.
17
Drug Requirements/
Tier Limits
Requisitos/
Nombre del Medicamento
Nivel
Límites
Genitourinary Agents, Other
2
[90D]
bethanechol
ELMIRON
4
[90D]
THIOLA
3
[90D]
Phosphate Binders
2
[90D]
calcium acetate
2
[90D]
eliphos
FOSRENOL
3
[90D]
RENVELA
3
[90D]
HORMONAL AGENTS, STIMULANT/
REPLACEMENT/ MODIFYING (ADRENAL)
Glucocorticoids/ Mineralocorticoids
2
[90D]
alclometasone
dipropionate
2
[90D]
betamethasone
dipropionate
2
[90D]
betamethasone
dipropionate augmented
2
[90D]
betamethasone valerate
cream, oint, lotion
CAPEX SHAMPOO
4
[90D]
3
[90D]
clobetasol propionate
foam, gel, oint, soln
3
[90D]
clobetasol propionate
emollient cream
3
[90D]
cormax scalp application
2
[90D]
cortisone
3
[90D]
desonide
3
[90D]
desoximetasone
2
[90D]
dexamethasone tabs
2
[90D]
dexamethasone elixir
2
[90D]
dexamethasone inj
2
[90D]
dexpak
2
[90D]
diflorasone diacetate
2
[90D]
fludrocortisone acetate
3
[90D]
fluocinolone acetonide
2
[90D]
fluocinonide cream 0.05%
2
[90D]
fluocinonide-e
2
[90D]
fluocinonide gel, oint &
soln
Drug Name
Drug Name
Nombre del Medicamento
Drug Requirements/
Tier Limits
Requisitos/
Nivel
Límites
2
[90D]
fluticasone propionate
cream & oint
2
[90D]
halobetasol
2
[90D]
hydrocortisone 2.5%
cream, lotion, oint
2
[90D]
hydrocortisone butyrate
oint & soln
2
[90D]
hydrocortisone oral
2
[90D]
hydrocortisone valerate
2
[90D]
methylprednisolone oral
2
[90D]
methylprednisolone
sodium succinate inj
2
[90D]
mometasone cream & oint
2
[90D]
prednicarbate
2
[90D]
prednisolone oral soln
1
[90D]
prednisone tabs
2
[90D]
prednisone oral soln
2
[90D]
procto-med hc
2
[90D]
procto-pak
2
[90D]
proctosol hc
2
[90D]
proctozone-hc
SOLU-CORTEF INJ
4
[90D]
2
[90D]
triamcinolone acetonide inj
2
[90D]
triamcinolone acetonide
topical cream, lotion & oint
2
[90D]
triderm
HORMONAL AGENTS, STIMULANT/
REPLACEMENT/ MODIFYING (PITUITARY)
Hormonal Agents, Stimulant/ Replacement/
Modifying (Pituitary)
2
[90D]
desmopressin acetate
nasal
2
[90D]
desmopressin acetate oral
2
[90D]
desmopressin acetate inj
GENOTROPIN INJ
5
[PA]
GENOTROPIN
4
[PA] [90D]
MINIQUICK INJ 0.2MG,
0.4MG, 0.6MG, 0.8MG
GENOTROPIN
5
[PA]
MINIQUICK INJ 1MG,
1.2MG, 1.4MG, 1.6MG,
1.8MG, & 2MG
[PA] = Autorización Previa [B vs D] = B versus D [QL] = Límite de Cantidad [ST] = Tratamiento Escalonado
[90D] = Suministro para 90 Días [LD] = Distribución Limitada
Puede encontrar información sobre el significado de los símbolos y abreviaturas de esta tabla en la página XXIII.
18
Drug Name
Nombre del Medicamento
Drug Requirements/
Tier Limits
Requisitos/
Nivel
Límites
4
[PA] [90D]
Drug Name
Nombre del Medicamento
HUMATROPE INJ 6MG
CARTRIDGE
HUMATROPE INJ 5MG
5
[PA]
VIAL, 12MG & 24MG
CARTRIDGE
INCRELEX INJ
5
[PA]
STIMATE
4
[90D]
HORMONAL AGENTS, STIMULANT/
REPLACEMENT/ MODIFYING
(PROSTAGLANDINS)
Hormonal Agents, Stimulant/ Replacement/
Modifying (Prostaglandins)
KORLYM
5
[PA]
HORMONAL AGENTS, STIMULANT/
REPLACEMENT/ MODIFYING (SEX
HORMONES/ MODIFIERS)
Anabolic Steroids
ANADROL-50
5
[PA]
2
[90D]
oxandrolone
Androgens
ANDROGEL 1% GEL
3
[PA] [90D]
PACKET 50MG/5GM
ANDROGEL 1.62%
3
[PA] [90D]
2
[90D]
danazol
2
[PA] [90D]
testosterone cypionate inj
2
[PA] [90D]
testosterone enanthate inj
3
[PA] [90D]
testosterone gel 1%
Estrogens
ALORA
3
[PA] [90D]
2
[90D]
alyacen 1/35
3
[PA] [90D]
amabelz
2
[90D]
apri
2
[90D]
aranelle
2
[90D]
aubra
2
[90D]
aviane
2
[90D]
bekyree
2
[90D]
blisovi fe 1/20 & 1.5/30
2
[90D]
briellyn
2
[90D]
caziant
2
[90D]
cyclafem 1/35
2
[90D]
cyclafem 7/7/7
delyla
desogestrel & ethinyl
estradiol
emoquette
enpresse-28
ESTRACE VAGINAL
estradiol oral
estradiol patches
estradiol & norethindrone
acetate
estropipate
ethinyl estradiol &
ethynodiol
ethinyl estradiol, ferrous
fumarate & norethindrone
falmina
femynor
fyavolv
gildagia
introvale
jinteli
junel
kariva
kimidess
larin
larin fe
larissia
leena
levonest
levonorgestrel & ethinyl
estradiol 0.1-0.02mg, 0.150.03mg, & 0.125-0.03mg
packs
levora
low-ogestrel
marlissa 28 day
MENEST
microgestin 1/20 & 1.5/30
mimvey
mimvey lo
necon
Drug Requirements/
Tier Limits
Requisitos/
Nivel
Límites
2
[90D]
2
[90D]
2
2
3
2
3
3
[90D]
[90D]
[90D]
[PA] [90D]
[PA] [90D]
[PA] [90D]
2
2
[PA] [90D]
[90D]
2
[90D]
2
2
3
2
2
3
2
2
2
2
2
2
2
2
2
[90D]
[90D]
[PA] [90D]
[90D]
[90D]
[PA] [90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
2
2
2
4
2
3
3
2
[90D]
[90D]
[90D]
[PA] [90D]
[90D]
[PA] [90D]
[PA] [90D]
[90D]
[PA] = Prior Authorization [B vs D] = B versus D [QL] = Quantity Limit [ST] = Step Therapy [90D] = 90-Day Supply
[LD] = Limited Distribution
You can find information on what the symbols and abbreviations on this table mean by going to page XI.
19
Drug Name
Nombre del Medicamento
norgestimate-ethinyl
estradiol
orsythia 28 day
pimtrea
pirmella 1/35
PREMARIN ORAL
PREMARIN VAGINAL
PREMPHASE
PREMPRO
setlakin
tarina fe
tri-lo-estarylla
tri-lo-sprintec
tri-sprintec
trivora-28
velivet
vienva
vyfemla
wymzya fe
yuvafem
zenchent
zenchent fe
zovia
Progestins
deblitane
DEPO-PROVERA INJ
400MG/ML
hydroxyprogesterone
caproate
lyza
medroxyprogesterone
acetate inj
medroxyprogesterone
acetate tabs
megestrol acetate oral
susp
megestrol tabs
norethindrone
norlyroc
progesterone caps
sharobel
Drug Requirements/
Tier Limits
Requisitos/
Nivel
Límites
2
[90D]
2
2
2
4
3
4
4
2
2
2
2
2
2
2
2
2
2
3
2
2
2
[90D]
[90D]
[90D]
[PA] [90D]
[90D]
[PA] [90D]
[PA] [90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
2
4
[90D]
[90D]
Drug Requirements/
Tier Limits
Requisitos/
Nombre del Medicamento
Nivel
Límites
Selective Estrogen Receptor Modifying Agents
3
[QL] [90D]
raloxifene hcl
HORMONAL AGENTS, STIMULANT/
REPLACEMENT/ MODIFYING (THYROID)
Hormonal Agents, Stimulant/ Replacement/
Modifying (Thyroid)
CYTOMEL
3
[90D]
1
[90D]
levothyroxine tabs
1
[90D]
levoxyl
2
[90D]
liothyronine tabs
SYNTHROID
3
[90D]
THYROLAR
3
[90D]
1
[90D]
unithroid
HORMONAL AGENTS, SUPPRESSANT
(ADRENAL)
Hormonal Agents, Suppressant (Adrenal)
LYSODREN
3
[90D]
HORMONAL AGENTS, SUPPRESSANT
(PARATHYROID)
Hormonal Agents, Suppressant (Parathyroid)
SENSIPAR TABS 30MG
3
[QL] [90D]
SENSIPAR TABS 60MG &
5
90MG
HORMONAL AGENTS, SUPPRESSANT
(PITUITARY)
Hormonal Agents, Suppressant (Pituitary)
2
[90D]
cabergoline
ELIGARD INJ
4
[90D]
2
[90D]
leuprolide acetate inj
LUPRON DEPOT INJ
5
7.5MG, 11.25MG,
22.5MG, 30MG & 45MG
2
[90D]
octreotide inj 50mcg/ml,
100mcg/ml & 200mcg/ml
5
octreotide inj 500mcg/ml &
1000mcg/ml
SIGNIFOR INJ
5
[PA]
SOMATULINE DEPOT
5
[PA]
INJ
SOMAVERT INJ
5
[PA]
SYNAREL
4
[90D]
TRELSTAR
5
Drug Name
5
2
2
[90D]
[90D]
2
[90D]
2
[90D]
2
2
2
2
2
[90D]
[90D]
[90D]
[90D]
[90D]
[PA] = Autorización Previa [B vs D] = B versus D [QL] = Límite de Cantidad [ST] = Tratamiento Escalonado
[90D] = Suministro para 90 Días [LD] = Distribución Limitada
Puede encontrar información sobre el significado de los símbolos y abreviaturas de esta tabla en la página XXIII.
20
Drug Requirements/
Tier Limits
Requisitos/
Nombre del Medicamento
Nivel
Límites
HORMONAL AGENTS, SUPPRESSANT
(THYROID)
Antithyroid Agents
2
[90D]
methimazole
2
[90D]
propylthiouracil
IMMUNOLOGICAL AGENTS
Angioedema (HAE) Agents
CINRYZE INJ
5
[PA] [B vs D]
FIRAZYR INJ
5
[PA]
Immune Suppressants
2
[PA] [B vs D]
azathioprine inj
[90D]
2
[PA] [B vs D]
azathioprine oral
[90D]
BENLYSTA INJ
5
[PA]
2
[PA] [B vs D]
cyclosporine modified
[90D]
2
[PA] [B vs D]
cyclosporine oral
[90D]
ENBREL INJ
5
[PA]
ENBREL SURECLICK INJ
5
[PA]
2
[PA] [B vs D]
gengraf
[90D]
HUMIRA INJ
5
[PA]
HUMIRA PEDIATRIC
5
[PA]
CROHNS INJ
HUMIRA PEN-CROHNS
5
[PA]
INJ
HUMIRA PEN5
[PA]
PSORIASIS INJ
HUMIRA PEN INJ
5
[PA]
KINERET INJ
5
[PA]
2
[90D]
methotrexate inj
2
[90D]
methotrexate oral
2
[PA] [B vs D]
mycophenolate mofetil
[90D]
caps & tabs
3
[PA] [B vs D]
mycophenolate mofetil inj
[90D]
5
[PA] [B vs D]
mycophenolate mofetil oral
susp
3
[PA] [B vs D]
mycophenolic acid dr
[90D]
Drug Name
Drug Name
Nombre del Medicamento
NEORAL
NULOJIX INJ
RAPAMUNE SOLN
REMICADE INJ
SANDIMMUNE ORAL
SOLN 100MG/ML
SANDIMMUNE CAPS
25MG & 100MG
sirolimus tabs
tacrolimus caps 0.5mg &
1mg
tacrolimus caps 5mg
Drug Requirements/
Tier Limits
Requisitos/
Nivel
Límites
4
[PA] [B vs D]
[90D]
5
[PA]
4
[PA] [B vs D]
[90D]
5
[PA]
4
[PA] [B vs D]
[90D]
4
[PA] [B vs D]
[90D]
4
[PA] [B vs D]
[90D]
3
[PA] [B vs D]
[90D]
4
[PA] [B vs D]
[90D]
4
[PA] [B vs D]
[90D]
5
[PA] [B vs D]
ZORTRESS TABS
0.25MG
ZORTRESS TABS 0.5MG
& 0.75MG
Immunizing Agents, Passive
ATGAM INJ
5
GAMMAGARD INJ
5
GAMUNEX-C INJ
5
Immunomodulators
ACTIMMUNE INJ
5
ARCALYST INJ
5
ILARIS INJ
5
2
leflunomide
OTEZLA
5
OTEZLA STARTER
5
RIDAURA
5
SYNAGIS INJ
5
XELJANZ
5
XELJANZ XR
5
Vaccines
ACTHIB INJ
3
ADACEL INJ
3
BEXSERO INJ
3
BOOSTRIX INJ
3
DAPTACEL INJ
3
[PA]
[PA] [B vs D]
[PA] [B vs D]
[PA]
[PA]
[QL] [90D]
[PA]
[PA]
[PA]
[PA]
[90D]
[90D]
[90D]
[90D]
[90D]
[PA] = Prior Authorization [B vs D] = B versus D [QL] = Quantity Limit [ST] = Step Therapy [90D] = 90-Day Supply
[LD] = Limited Distribution
You can find information on what the symbols and abbreviations on this table mean by going to page XI.
21
Drug Requirements/
Tier Limits
Requisitos/
Nombre del Medicamento
Nivel
Límites
DIPHTHERIA & TETANUS
3
[90D]
TOXOIDS PEDIATRIC INJ
ENGERIX-B INJ
3
[PA] [B vs D]
[90D]
GARDASIL INJ
4
[90D]
GARDASIL 9 INJ
4
[90D]
HAVRIX INJ
3
[90D]
HIBERIX INJ
3
[90D]
IMOVAX RABIES INJ
3
[PA] [B vs D]
[90D]
INFANRIX INJ
3
[90D]
IPOL INACTIVATED IPV
3
[90D]
INJ
IXIARO INJ
4
[90D]
KINRIX INJ
3
[90D]
MENACTRA INJ
3
[90D]
MENHIBRIX INJ
3
[90D]
MENOMUNE-A/C/Y/W3
[90D]
135 INJ
MENVEO-A/C/Y/W-135
3
[90D]
INJ
M-M-R II INJ
3
[90D]
PEDIARIX INJ
3
[90D]
PEDVAX HIB INJ
3
[90D]
PROQUAD INJ
3
[90D]
QUADRACEL INJ
3
[90D]
RABAVERT INJ
3
[PA] [B vs D]
[90D]
RECOMBIVAX HB INJ
3
[PA] [B vs D]
[90D]
ROTARIX
3
[90D]
ROTATEQ
3
[90D]
TENIVAC
3
[90D]
TETANUS & DIPHTHERIA
3
[90D]
TOXOIDS-ADSORBED
ADULT INJ
TRUMENBA INJ
3
[90D]
TWINRIX INJ
3
[90D]
TYPHIM VI INJ
3
[90D]
VAQTA INJ
3
[90D]
VARIVAX INJ
3
[90D]
YF-VAX INJ
3
[90D]
Drug Requirements/
Tier Limits
Requisitos/
Nombre del Medicamento
Nivel
Límites
ZOSTAVAX INJ
4
[90D]
INFLAMMATORY BOWEL DISEASE AGENTS
Aminosalicylates
APRISO
4
[QL] [90D]
2
[90D]
balsalazide
DELZICOL
3
[90D]
DIPENTUM
5
4
[90D]
mesalamine enema kit
PENTASA
4
[QL] [90D]
Glucocorticoids
5
[PA]
budesonide ec caps
2
[90D]
hydrocortisone enema
1
[90D]
prednisone tabs
2
[90D]
prednisone oral soln
Sulfonamides
2
[90D]
sulfasalazine
METABOLIC BONE DISEASE AGENTS
Metabolic Bone Disease Agents
1
[90D]
alendronate tabs
2
[90D]
alendronate oral soln
2
[90D]
calcitonin-salmon nasal
2
[PA] [B vs D]
calcitriol caps
[90D]
3
[PA] [B vs D]
doxercalciferol oral
[90D]
3
[PA] [B vs D]
doxercalciferol inj
[90D]
2
[90D]
etidronate
FORTEO INJ
5
[PA]
2
[PA] [B vs D]
ibandronate inj
[90D]
2
[90D]
ibandronate oral
MIACALCIN INJ
4
[PA] [B vs D]
[90D]
2
[PA] [B vs D]
pamidronate inj
[90D]
2
[PA] [B vs D]
paricalcitol caps
[90D]
PROLIA
4
[PA] [90D]
3
[ST] [90D]
risedronate sodium
3
[ST] [90D]
risedronate sodium dr
XGEVA INJ
5
[PA]
Drug Name
Drug Name
[PA] = Autorización Previa [B vs D] = B versus D [QL] = Límite de Cantidad [ST] = Tratamiento Escalonado
[90D] = Suministro para 90 Días [LD] = Distribución Limitada
Puede encontrar información sobre el significado de los símbolos y abreviaturas de esta tabla en la página XXIII.
22
Drug Name
Nombre del Medicamento
Drug Requirements/
Tier Limits
Requisitos/
Nivel
Límites
4
[90D]
Drug Name
Nombre del Medicamento
zoledronic acid inj
4mg/5ml
2
[PA] [90D]
zoledronic acid inj
5mg/100ml
ZOMETA INJ 4MG/100ML
5
MISCELLANEOUS THERAPEUTIC AGENTS
Miscellaneous Therapeutic Agents
2
[90D]
alcohol pads
2
[90D]
bd insulin syringe ultrafine
2
[90D]
bd insulin syringe
safetyglide
2
[90D]
bd insulin syringe U-500
2
[90D]
bd pen needle ultrafine
BRISDELLE
3
[90D]
FERRIPROX
5
[PA]
2
[90D]
gauze pads 2"x2"
2
[PA] [B vs D]
levocarnitine oral
[90D]
2
[PA] [B vs D]
levocarnitine inj
[90D]
NATPARA
5
[PA] [LD]
OPHTHALMIC AGENTS
Ophthalmic Agents, Other
2
[90D]
atropine sulfate soln
2
[90D]
bacitracin ointment
2
[90D]
bacitracin & polymyxin b
2
[90D]
ciprofloxacin soln 0.3%
CYSTARAN
5
2
[90D]
erythromycin oint
2
[90D]
gentamicin oint 0.3% &
soln 0.3%
LACRISERT
4
[90D]
2
[90D]
neomycin & bacitracin &
polymyxin b
2
[90D]
neomycin & polymyxin &
gramicidin
2
[90D]
ofloxacin
2
[90D]
polymyxin b sulfate &
trimethoprim sulfate soln
RESTASIS
3
[PA] [90D]
Drug Requirements/
Tier Limits
Requisitos/
Nivel
Límites
2
[90D]
sulfacetamide sodium oint
& soln 10%
2
[90D]
tobramycin sulfate
2
[90D]
trifluridine
VIGAMOX
3
[90D]
Ophthalmic Anti-allergy Agents
2
[90D]
azelastine
2
[90D]
cromolyn sodium
2
[QL] [90D]
olopatadine soln 0.1%
PATADAY
3
[90D]
Ophthalmic Antiglaucoma Agents
2
[90D]
acetazolamide tabs
2
[90D]
acetazolamide er caps
ALPHAGAN P 0.1%
3
[90D]
2
[90D]
betaxolol soln
2
[90D]
brimonidine tartrate soln
0.15% & 0.2%
1
[90D]
carteolol
COMBIGAN
3
[ST] [90D]
2
[90D]
dorzolamide
2
[90D]
dorzolamide & timolol
maleate
2
[90D]
levobunolol
3
[90D]
methazolamide
2
[90D]
metipranolol
PHOSPHOLINE IODIDE
3
[90D]
2
[90D]
pilocarpine soln
2
[90D]
timolol ophthalmic gel
forming
1
[90D]
timolol soln
Ophthalmic Anti-inflammatories
BLEPHAMIDE
3
[90D]
BLEPHAMIDE S.O.P.
3
[90D]
2
[90D]
dexamethasone soln
2
[90D]
diclofenac sodium soln
DUREZOL
3
[90D]
2
[90D]
fluorometholone
2
[90D]
ketorolac soln 0.4% &
0.5%
2
[90D]
neomycin & polymyxin &
dexamethasone
[PA] = Prior Authorization [B vs D] = B versus D [QL] = Quantity Limit [ST] = Step Therapy [90D] = 90-Day Supply
[LD] = Limited Distribution
You can find information on what the symbols and abbreviations on this table mean by going to page XI.
23
Drug Name
Nombre del Medicamento
Drug Requirements/
Tier Limits
Requisitos/
Nivel
Límites
2
[90D]
Drug Name
Nombre del Medicamento
neomycin & polymyxin &
bacitracin &
hydrocortisone
PRED MILD
3
[90D]
2
[90D]
prednisolone acetate
2
[90D]
prednisolone sodium
phosphate
2
[90D]
sulfacetamide sodium &
prednisolone sodium
phosphate
TOBRADEX OINT
3
[90D]
2
[90D]
tobramycin &
dexamethasone
Ophthalmic Prostaglandin and Prostamide
Analogs
1
[90D]
latanoprost
LUMIGAN
3
[ST] [90D]
OTIC AGENTS
Otic Agents
2
[90D]
acetasol hc
2
[90D]
acetic acid &
hydrocortisone
CIPRO HC
3
[90D]
CIPRODEX
3
[90D]
2
[90D]
neomycin & polymyxin &
hydrocortisone
2
[90D]
ofloxacin
RESPIRATORY TRACT/PULMONARY AGENTS
Antihistamines
2
[90D]
azelastine nasal
2
[PA] [90D]
cyproheptadine
2
[90D]
desloratadine
2
[90D]
desloratadine odt
2
[90D]
diphenhydramine hcl inj
2
[PA] [90D]
hydroxyzine hcl tabs
2
[90D]
levocetirizine
Anti-inflammatories, Inhaled Corticosteroids
ADVAIR DISKUS
3
[90D]
ADVAIR HFA
3
[90D]
ASMANEX HFA
3
[90D]
ASMANEX TWISTHALER
3
[90D]
BREO ELLIPTA
3
[90D]
budesonide nebulizer
Drug Requirements/
Tier Limits
Requisitos/
Nivel
Límites
2
[PA] [B vs D]
[90D]
3
[90D]
2
[QL] [90D]
2
[QL] [90D]
DULERA
flunisolide nasal
fluticasone propionate
nasal
3
[QL] [90D]
mometasone furoate nasal
QVAR
3
[90D]
Antileukotrienes
2
[90D]
montelukast
2
[QL] [90D]
zafirlukast
3
[QL] [90D]
zileuton er
ZYFLO CR
3
[QL] [90D]
Bronchodilators, Anticholinergic
ATROVENT HFA
3
[QL] [90D]
COMBIVENT RESPIMAT
3
[90D]
2
[QL] [90D]
ipratropium bromide nasal
2
[PA] [B vs D]
ipratropium bromide
[90D]
nebulizer
2
[PA] [B vs D]
ipratropium bromide &
[90D]
albuterol sulfate nebulizer
SPIRIVA HANDIHALER
3
[90D]
SPIRIVA RESPIMAT
3
[90D]
TUDORZA PRESSAIR
3
[90D]
Phosphodiesterase Inhibitors, Airways
Disease
2
[90D]
aminophylline inj
DALIRESP
3
[90D]
2
[90D]
theophylline cr & er tabs
Bronchodilators, Sympathomimetic
2
[PA] [B vs D]
albuterol sulfate nebulizer
[90D]
3
[90D]
albuterol sulfate er
2
[90D]
albuterol sulfate syrup
3
[90D]
albuterol sulfate tabs
BEVESPI AEROSPHERE
3
[90D]
EPINEPHRINE AUTO3
[90D]
INJECTOR 0.15MG/0.3ML
& 0.3MG/0.3ML
EPIPEN INJ
3
[90D]
EPIPEN-JR INJ
3
[90D]
[PA] = Autorización Previa [B vs D] = B versus D [QL] = Límite de Cantidad [ST] = Tratamiento Escalonado
[90D] = Suministro para 90 Días [LD] = Distribución Limitada
Puede encontrar información sobre el significado de los símbolos y abreviaturas de esta tabla en la página XXIII.
24
Drug Name
Nombre del Medicamento
levalbuterol nebulizer
Drug Requirements/
Tier Limits
Requisitos/
Nivel
Límites
2
[PA] [B vs D]
[90D]
3
[90D]
3
[90D]
3
[90D]
3
[90D]
2
[90D]
2
[90D]
PROAIR HFA
PROAIR RESPICLICK
SEREVENT DISKUS
STRIVERDI RESPIMAT
terbutaline sulfate oral
terbutaline sulfate inj
Cystic Fibrosis Agents
CAYSTON
5
KALYDECO
5
ORKAMBI
5
PULMOZYME
5
TOBI PODHALER
5
5
tobramycin nebulizer
Mast Cell Stabilizers
2
cromolyn sodium nebulizer
soln
Pulmonary Antihypertensives
ADCIRCA
5
ADEMPAS
5
LETAIRIS
5
OPSUMIT
5
REMODULIN INJ
5
3
sildenafil tabs 20mg
TRACLEER
5
UPTRAVI
5
Respiratory Tract Agents, Other
2
acetylcysteine nebulizer
Drug Requirements/
Tier Limits
Requisitos/
Nombre del Medicamento
Nivel
Límites
SLEEP DISORDER AGENTS
GABA Receptor Modulators
2
[90D]
estazolam
2
[90D]
flurazepam
2
[90D]
temazepam
2
[90D]
triazolam
2
[PA]
zolpidem tabs 5mg &
10mg
Sleep Disorders, Other
BELSOMRA
3
[QL] [90D]
4
[PA] [90D]
modafinil
ROZEREM
3
[QL] [90D]
SILENOR
3
[QL] [90D]
XYREM
5
[LD]
THERAPEUTIC NUTRIENTS/ MINERALS/
ELECTROLYTES
Electrolyte/Mineral Modifiers
CARBAGLU
5
[PA] [LD]
CUPRIMINE
4
[90D]
DEPEN TITRATABS
4
[90D]
EXJADE
5
[PA]
JADENU
5
[PA]
2
[90D]
kionex
2
[90D]
sodium polystyrene
sulfonate
SYPRINE
5
VELTASSA
3
[PA] [90D]
Electrolyte/Mineral Replacement
AMINOSYN INJ
3
[PA] [B vs D]
[90D]
AMINOSYN &
3
[PA] [B vs D]
ELECTROLYTES INJ
[90D]
CLINISOL SF INJ
4
[PA] [B vs D]
[90D]
2
[90D]
dextrose inj
2
[90D]
dextrose & sodium
chloride inj
2
[90D]
dextrose & lactated ringers
inj
INTRALIPID INJ
4
[PA] [B vs D]
[90D]
2
[90D]
klor-con
Drug Name
[PA] [LD]
[PA]
[PA]
[PA] [B vs D]
[PA] [B vs D]
[PA] [B vs D]
[90D]
[PA]
[PA] [LD]
[PA] [LD]
[PA] [LD]
[PA]
[PA]
[PA] [LD]
[PA]
[PA] [B vs D]
[90D]
[90D]
[PA]
[PA]
[PA] [LD]
[90D]
ANORO ELLIPTA
3
ESBRIET
5
OFEV
5
PROLASTIN C INJ
5
STIOLTO RESPIMAT
3
VIRAZOLE
5
SKELETAL MUSCLE RELAXANTS
Skeletal Muscle Relaxants
2
[PA] [90D]
chlorzoxazone
2
[PA] [90D]
cyclobenzaprine hcl
2
[PA] [90D]
methocarbamol
[PA] = Prior Authorization [B vs D] = B versus D [QL] = Quantity Limit [ST] = Step Therapy [90D] = 90-Day Supply
[LD] = Limited Distribution
You can find information on what the symbols and abbreviations on this table mean by going to page XI.
25
Drug Name
Nombre del Medicamento
klor-con sprinkle
lactated ringers inj
magnesium sulfate inj
MOZOBIL INJ
plenamine inj
potassium chloride oral
soln
potassium chloride er
potassium chloride inj
potassium chloride &
dextrose & lactated ringers
inj
potassium chloride &
dextrose & sodium
chloride inj
20mEq/5%/0.45% &
30mEq/5%/0.45%
potassium chloride viaflex
inj
potassium citrate er
PROSOL INJ
Drug Requirements/
Tier Limits
Requisitos/
Nivel
Límites
2
[90D]
2
[90D]
2
[90D]
5
[PA]
2
[PA] [B vs D]
[90D]
2
[90D]
2
2
2
[90D]
[90D]
[90D]
2
[90D]
2
[90D]
2
4
[90D]
[PA] [B vs D]
[90D]
[90D]
[90D]
[PA] [B vs D]
[90D]
sodium chloride inj
TPN ELECTROLYTES INJ
TRAVASOL INJ
2
3
4
Vitamins
prenatal multi-vitamin
2
[90D]
[PA] = Autorización Previa [B vs D] = B versus D [QL] = Límite de Cantidad [ST] = Tratamiento Escalonado
[90D] = Suministro para 90 Días [LD] = Distribución Limitada
Puede encontrar información sobre el significado de los símbolos y abreviaturas de esta tabla en la página XXIII.
26
FORMULARY DRUGS WITH QUANTITY LIMITS
MEDICAMENTOS DEL FORMULARIO CON LÍMITES DE CANTIDAD
Drugs with Quantity Limits
Medicamentos con Límites de Cantidad
Drug Name
Nombre del Medicamento
acetaminophen & codeine #2 & #3 tabs
acetaminophen & codeine #4 tabs
acetaminophen & codeine elixir
amphetamine & dextroamphetamine
APRISO
ATROVENT HFA
BELSOMRA
BRILINTA
butorphanol tartrate nasal
calcipotriene cream
calcipotriene oint
COLCHICINE
COLCRYS
dexedrine tabs
dextroamphetamine sulfate
dextroamphetamine sulfate er
dipyridamole er & aspirin
ELIDEL
endocet tabs 5-325mg, 7.5-325mg, 10-325mg
fenofibrate
fenofibrate micronized
fenofibric acid
fenofibric acid dr
fentanyl patches
flunisolide nasal
fluticasone propionate nasal
galantamine
galantamine er
galantamine oral soln
glimepiride & pioglitazone tabs
Quantity Limits
Límites de Cantidad
360 tabs per 30 days
180 tabs per 30 days
5000ml per 30 days
60 tabs per 30 days
120 caps per 30 days
2 inhalers per 30 days
30 tabs per 30 days
60 tabs per 30 days
4 bottles per 30 days
120gm: 1 tube per 30 days
60gm: 2 tubes per 30 days
120 caps or tabs per 30 days
120 tabs per 30 days
5mg: 120 tabs per 30 days; 10mg: 180 tabs per 30
days
5mg: 120 tabs per 30 days; 10mg: 180 tabs per 30
days
5mg: 30 caps per 30 days; 10mg & 15mg: 120 caps
per 30 days
60 caps per 30 days
100gm: 2 tubes per 30 days
5-325mg: 360 tabs per 30 days; 7.5-325mg: 240 tabs
per 30 days; 10-325mg: 180 tabs per 30 days
30 caps or tabs per 30 days
30 caps per 30 days
35mg: 60 tabs per 30 days; 105mg: 30 tabs per 30
days
45mg: 60 caps per 30 days; 135mg: 30 caps per 30
days
15 patches per 30 days
2 bottles per 30 days
2 bottles per 30 days
60 tabs per 30 days
30 caps per 30 days
200ml per 30 days
30 tabs per 30 days
VillageHealth | 2017 Formulary
27
Drugs with Quantity Limits
Medicamentos con Límites de Cantidad
Drug Name
Nombre del Medicamento
hydrocodone & acetaminophen soln 7.5325mg/15ml
hydrocodone & acetaminophen tabs 5325mg,7.5-325mg, & 10-325mg
hydrocodone & ibuprofen tabs 5-200mg, 7.5200mg, & 10-200mg
ipratropium bromide nasal
leflunomide
lorcet hd tabs 10-325mg
lorcet plus tabs 7.5-325mg
lorcet tabs 5-325mg
lortab tabs 5-325mg,7.5-325mg, & 10-325mg
Quantity Limits
Límites de Cantidad
2700ml per 30 days
5-325mg: 360 tabs per 30 days; 7.5-325mg & 10325mg: 180 tabs per 30 days
150 tabs per 30 days
1 bottle per 30 days
30 tabs per 30 days
180 tabs per 30 days
180 tabs per 30 days
360 tabs per 30 days
5-325mg: 360 tabs per 30 days; 7.5-325mg & 10325mg: 180 tabs per 30 days
3 bottles per 30 days
mometasone furoate nasal
120 tabs per 30 days
morphine sulfate er tabs
9 tabs per 30 days
naratriptan
NEUPRO PATCH
30 patches per 30 days
500mg: 90 tabs per 30 days; 750mg & 1000mg: 60
niacin er tabs
tabs per 30 days
3 bottles per 30 days
olopatadine soln 0.1%
5mg: 30 tabs per 30 days; 10mg & 15mg: 60 tabs
oxybutynin er
per 30 days
oxycodone & acetaminophen tabs 2.5-325mg, 2.5-325mg & 5-325mg: 360 tabs per 30 days; 7.5325mg: 240 tabs per 30 days; 10-325mg: 180 tabs
5-325mg, 7.5-325mg, & 10-325mg
per 30 days
360 tabs per 30 days
oxycodone & aspirin tabs
120 tabs per 30 days
oxycodone & ibuprofen tabs
OXYCODONE ER
60 tabs per 30 days
OXYCONTIN
60 tabs per 30 days
60 tabs per 30 days
oxymorphone er
PENTASA
240 caps per 30 days
30 tabs per 30 days
raloxifene hcl
REGRANEX
2 tubes per 30 days
60 caps per 30 days
rivastigmine caps
30 patches per 30 days
rivastigmine patches
ROZEREM
30 tabs per 30 days
SENSIPAR TABS 30MG
60 tabs per 30 days
SILENOR
30 tabs per 30 days
60gm: 1 tube per 30 days
tazarotene
TAZORAC
60gm & 100gm: 1 tube per 30 days
30 caps per 30 days
tolterodine tartrate er
240 tabs per 30 days
tramadol & acetaminophen 37.5-325mg tabs
VillageHealth | 2017 Formulary
28
Drugs with Quantity Limits
Medicamentos con Límites de Cantidad
Drug Name
Nombre del Medicamento
tramadol er
XIFAXAN TABS 200MG
zafirlukast
zamicet
zenzedi tabs 5mg & 10mg
ZOMIG NASAL
zileuton er
ZYFLO CR
Quantity Limits
Límites de Cantidad
30 tabs per 30 days
9 tabs per 3 days
60 tabs per 30 days
2700ml per 30 days
5mg: 120 tabs per 30 days; 10mg: 180 tabs per 30
days
2.5mg: 18 single use units per 30 days; 5mg: 12
single use units per 30 days
120 tabs per 30 days
120 tabs per 30 days
VillageHealth | 2017 Formulary
29
INDEX
ÍNDICE
abacavir & lamivudine, 11
abacavir & lamivudine & zidovudine, 11
abacavir tabs, 11
ABELCET INJ, 6
ABILIFY INJ, 9
ABILIFY MAINTENA, 9
acamprosate calcium dr, 2
acarbose, 11
acebutolol, 14
acetaminophen & codeine, 1, 27
acetasol hc, 24
acetazolamide, 23
acetazolamide er caps, 23
acetazolamide tabs, 23
acetic acid & hydrocortisone, 24
acetylcysteine nebulizer, 25
acitretin, 16
ACTHIB INJ, 21
ACTIMMUNE INJ, 21
acyclovir inj, 10
acyclovir oint 5%, 10
acyclovir oral, 10
ADACEL INJ, 21
ADAGEN INJ, 16
ADCIRCA, 25
adefovir dipivoxil, 10
ADEMPAS, 25
ADVAIR DISKUS, 24
ADVAIR HFA, 24
afeditab cr, 14
AFINITOR, 8
AFINITOR DISPERZ, 8
ALBENZA, 8
albuterol sulfate er, 24
albuterol sulfate nebulizer, 24
albuterol sulfate syrup, 24
albuterol sulfate tabs, 24
alclometasone dipropionate, 18
alcohol pads, 23
ALDURAZYME INJ, 16
ALECENSA, 8
alendronate oral soln, 22
alendronate tabs, 22
alfuzosin hcl er, 17
ALIMTA INJ, 7
ALINIA, 8
allopurinol, 6
ALORA, 19
alosetron hcl tabs 0.5mg, 17
alosetron hcl tabs 1mg, 17
ALPHAGAN P 0.1%, 23
alprazolam er tabs, 11
alprazolam intensol, 11
alprazolam tabs, 11
alyacen 1/35, 19
amabelz, 19
amantadine, 9
AMBISOME INJ, 6
amikacin inj, 2
amiloride, 14
amiloride & hydrochlorothiazide, 14
aminophylline inj, 24
AMINOSYN & ELECTROLYTES INJ, 25
AMINOSYN INJ, 25
amiodarone tabs, 13
AMITIZA, 17
amitriptyline, 5
amlodipine, 14
amlodipine & atorvastatin, 14
amlodipine & benazepril, 14
amlodipine & olmesartan, 13
ammonium lactate topical, 16
amoxapine, 5
amoxicillin, 3
amoxicillin & clavulanate potassium, 3
amoxicillin & clavulanate potassium er, 3
amphetamine & dextroamphetamine, 27
amphetamine & dextroamphetamine tabs, 15
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amphotericin b inj, 6
ampicillin & sulbactam inj 10-5gm, 2-1gm, & 10.5gm, 3
ampicillin inj, 3
ampicillin oral, 3
AMPYRA, 16
ANADROL-50, 19
anagrelide, 12
anastrozole, 8
ANDROGEL 1% GEL PACKET 50MG/5GM, 19
ANDROGEL 1.62%, 19
ANORO ELLIPTA, 25
APOKYN INJ, 9
aprepitant caps 80mg & 125mg, 6
aprepitant pack, 6
apri, 19
APRISO, 22, 27
APTIOM, 4
APTIVUS, 11
aranelle, 19
ARCALYST INJ, 21
aripiprazole, 9
aripiprazole 20mg & 30mg, 9
aripiprazole odt, 9
ARISTADA INJ, 9
ASMANEX HFA, 24
ASMANEX TWISTHALER, 24
atenolol, 14
atenolol & chlorthalidone, 14
ATGAM INJ, 21
atorvastatin, 15
atovaquone, 8
atovaquone/proguanil, 8
ATRIPLA, 10
atropine sulfate inj, 17
atropine sulfate soln, 23
ATROVENT HFA, 24, 27
AUBAGIO, 16
aubra, 19
AVASTIN INJ, 8
aviane, 19
AVONEX INJ, 16
AVONEX PEN INJ, 16
azacitidine inj, 7
AZASITE, 3
azathioprine inj, 21
azathioprine oral, 21
azelastine, 23
azelastine nasal, 24
azithromycin inj, 3
azithromycin tabs & oral susp, 3
aztreonam inj 1gm, 3
bacitracin & polymyxin b, 23
bacitracin ointment, 23
baclofen, 10
BACTROBAN CREAM, 2
BACTROBAN NASAL, 2
balsalazide, 22
BANZEL, 4
BARACLUDE ORAL SOLN 0.05MG/ML, 10
bd insulin syringe safetyglide, 23
bd insulin syringe U-500, 23
bd insulin syringe ultrafine, 23
bd pen needle ultrafine, 23
bekyree, 19
BELEODAQ, 8
BELSOMRA, 25, 27
benazepril, 13
benazepril & hydrochlorothiazide, 13
BENLYSTA INJ, 21
benztropine inj, 9
benztropine tabs, 9
betamethasone dipropionate, 18
betamethasone dipropionate augmented, 18
betamethasone valerate cream, oint, lotion, 18
BETASERON INJ, 16
betaxolol soln, 23
bethanechol, 18
BEVESPI AEROSPHERE, 24
bexarotene, 8
BEXSERO INJ, 21
bicalutamide, 7
BICILLIN L-A INJ, 3
bisoprolol, 14
bisoprolol & hydrochlorothiazide, 14
BLEPHAMIDE, 23
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BLEPHAMIDE S.O.P., 23
captopril, 13
blisovi fe 1/20 & 1.5/30, 19
captopril & hydrochlorothiazide, 13
BOOSTRIX INJ, 21
CARAC, 16
BOSULIF 100 MG TAB, 8
CARBAGLU, 25
BOSULIF 500 MG TAB, 8
carbamazepine er tabs & caps, 4
BREO ELLIPTA, 24
carbamazepine tabs, chewable tabs & oral susp,
briellyn, 19
4
BRILINTA, 13, 27
carbidopa, 9
brimonidine tartrate soln 0.15% & 0.2%, 23
carbidopa & levodopa, 9
BRISDELLE, 23
carbidopa & levodopa & entacapone, 9
BRIVIACT INJ, 4
carbidopa & levodopa er, 9
BRIVIACT ORAL SOLN, 4
carbidopa & levodopa odt, 9
BRIVIACT TABS, 4
carteolol, 23
bromocriptine, 9
cartia xt, 14
budesonide ec caps, 22
carvedilol, 14
budesonide nebulizer, 24
CAYSTON, 25
bumetanide oral, 14
caziant, 19
BUPHENYL TABS, 16
cefaclor, 3
buprenorphine & naloxone sublingual tabs, 2
cefaclor er, 3
buprenorphine inj, 2
cefadroxil caps & tabs, 3
buprenorphine oral, 2
cefazolin inj, 3
bupropion, 5
cefdinir, 3
bupropion sr, 5
cefepime inj, 3
bupropion sr 150mg, 2
cefixime, 3
bupropion xl, 5
cefoxitin sodium, 3
buspirone, 11
cefpodoxime tabs, 3
butorphanol tartrate inj, 1
cefprozil, 3
butorphanol tartrate nasal, 1, 27
ceftazidime inj 1gm, 2gm & 6gm, 3
BYDUREON INJ, 11
ceftriaxone inj, 3
BYETTA INJ, 11
cefuroxime inj, 3
cabergoline, 20
cefuroxime oral, 3
CABOMETYX, 8
celecoxib, 2
calcipotriene & betamethasone oint, 16
CELONTIN, 4
calcipotriene cream, 27
cephalexin caps & tabs 250mg & 500mg, 3
calcipotriene cream & oint, 16
cephalexin oral susp, 3
CERDELGA, 16
calcipotriene oint, 27
cevimeline, 16
calcipotriene soln, 16
CHANTIX, 2
calcitonin-salmon nasal, 22
CHANTIX STARTING MONTH PAK, 2
calcitriol caps, 22
chloramphenicol sodium succinate inj, 2
calcium acetate, 18
chlorhexidine gluconate, 16
CANCIDAS INJ, 6
chloroquine, 8
CAPASTAT INJ, 7
chlorothiazide tabs, 15
CAPEX SHAMPOO, 18
chlorpromazine inj, 9
CAPRELSA, 8
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chlorpromazine oral, 9
chlorthalidone, 15
chlorzoxazone, 25
cholestyramine, 15
cholestyramine light, 15
ciclopirox 8% nail soln, 6
ciclopirox cream, susp, shampoo, 6
cilastatin/imipenem inj, 3
cilostazol, 13
cimetidine oral, 17
CINRYZE INJ, 21
CIPRO HC, 24
CIPRODEX, 24
ciprofloxacin inj, 3
ciprofloxacin oral susp, 3
ciprofloxacin soln 0.3%, 23
ciprofloxacin tabs er, 3
ciprofloxacin tabs immediate-release, 3
citalopram oral soln, 5
citalopram tabs, 5
claravis, 16
clarithromycin, 3
clarithromycin er, 3
CLEOCIN VAGINAL, 2
clindamycin & benzoyl peroxide topical, 16
clindamycin oral, 2
clindamycin phosphate inj, 2
clindamycin topical cream, gel, lotion, soln &
swab, 16
CLINISOL SF INJ, 25
clobetasol propionate emollient cream, 18
clobetasol propionate foam, gel, oint, soln, 18
clomipramine, 5
clonazepam, 4
clonazepam odt, 4
clonidine er, 15
clonidine patches, 13
clonidine tabs immediate-release, 13
clopidogrel tabs 75mg, 13
clorazepate, 4
clotrimazole & betamethasone, 6
clotrimazole 1% cream, 6
clotrimazole 1% topical soln, 6
clotrimazole troche, 6
clozapine, 10
clozapine odt, 10
COARTEM, 8
codeine, 1
COLCHICINE, 6
COLCHICINE, 27
COLCRYS, 6, 27
colestipol granules, 15
colestipol tabs, 15
colistimethate inj, 2
COMBIGAN, 23
COMBIVENT RESPIMAT, 24
COMETRIQ, 8
COMPLERA, 10
compro, 5
constulose soln, 17
COPAXONE INJ 40MG/ML, 16
COREG CR, 14
cormax scalp application, 18
cortisone, 18
CORTISPORIN CREAM & OINT, 2
COTELLIC, 8
COUMADIN ORAL, 12
CREON DR, 16
CRESEMBA INJ, 6
CRESEMBA ORAL, 6
CRIXIVAN, 11
cromolyn sodium, 23, 25
cromolyn sodium nebulizer soln, 25
cromolyn sodium oral, 17
CUPRIMINE, 25
cyclafem 1/35, 19
cyclafem 7/7/7, 19
cyclobenzaprine hcl, 25
cyclophosphamide caps, 7
CYCLOSET, 12
cyclosporine modified, 21
cyclosporine oral, 21
cyproheptadine, 24
CYSTADANE, 16
CYSTAGON, 16
CYSTARAN, 23
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CYTOMEL, 20
diclofenac potassium, 2
DAKLINZA, 10
diclofenac sodium, 2, 23
DALIRESP, 24
diclofenac sodium dr, 2
danazol, 19
diclofenac sodium er, 2
DAPSONE, 7
diclofenac sodium gel 1%, 16
DAPTACEL INJ, 21
diclofenac sodium gel 3%, 16
daptomycin inj, 2
diclofenac sodium soln, 23
DARAPRIM, 8
dicloxacillin sodium, 3
deblitane, 20
dicyclomine oral, 17
delyla, 19
didanosine, 11
DELZICOL, 22
diflorasone diacetate, 18
demeclocycline, 4
diflunisal, 2
DEMSER, 14
digitek, 14
DENAVIR, 10
digoxin inj, 14
DEPEN TITRATABS, 25
digoxin oral, 14
DEPO-PROVERA INJ 400MG/ML, 20
dihydroergotamine mesylate inj, 7
DESCOVY, 10
dilantin caps 100mg, 4
desipramine, 5
DILANTIN CAPS 30MG, 4
desloratadine, 24
DILANTIN INFATABS, 4
desloratadine odt, 24
DILANTIN SUSP, 4
desmopressin acetate inj, 18
diltiazem cd caps 120mg, 180mg, 240mg, &
desmopressin acetate nasal, 18
300mg,, 14
desmopressin acetate oral, 18
diltiazem er caps, 14
desogestrel & ethinyl estradiol, 19
diltiazem inj 50mg/10ml, 14
desonide, 18
diltiazem tabs, 14
desoximetasone, 18
dilt-xr, 14
DESVENLAFAXINE ER, 5
DIPENTUM, 22
desvenlafaxine succinate er, 5
diphenhydramine hcl inj, 24
dexamethasone elixir, 18
diphenoxylate & atropine, 17
dexamethasone inj, 18
DIPHTHERIA & TETANUS TOXOIDS
dexamethasone soln, 23
PEDIATRIC INJ, 22
dexamethasone tabs, 18
dipyridamole er & aspirin, 27
dexedrine tabs, 15
dipyridamole er & aspirin, 13
dexedrine tabs, 27
dipyridamole oral, 13
dexmethylphenidate ir tabs, 15
disopyramide phosphate, 13
dexpak, 18
disulfiram, 2
divalproex sodium, 4
dextroamphetamine sulfate, 15, 27
divalproex sodium dr, 4
dextroamphetamine sulfate er, 15, 27
divalproex sodium er, 4
dextrose & lactated ringers inj, 25
dofetilide, 13
dextrose & sodium chloride inj, 25
donepezil odt, 5
dextrose inj, 25
donepezil tabs 5mg & 10mg, 5
diazepam intensol, 11
dorzolamide, 23
diazepam rectal gel, 4
dorzolamide & timolol maleate, 23
diazepam tabs & soln, 11
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doxazosin, 13, 17
doxepin, 5
doxepin cream 5%, 16
doxercalciferol inj, 22
doxercalciferol oral, 22
doxy 100 inj, 4
doxycycline immediate-release tabs, caps & oral
susp, 4
dronabinol, 6
DULERA, 24
duloxetine hcl, 5
duramorph inj, 1
DUREZOL, 23
dutasteride, 17
dutasteride & tamsulosin, 17
DUTOPROL, 14
econazole nitrate, 6
EDURANT, 10
ELIDEL, 16, 27
ELIGARD INJ, 20
eliphos, 18
ELIQUIS, 12
ELMIRON, 18
EMCYT, 7
emoquette, 19
EMSAM, 5
EMTRIVA, 11
enalapril, 13
enalapril & hydrochlorothiazide, 13
ENBREL INJ, 21
ENBREL SURECLICK INJ, 21
endocet, 1
endocet, 27
ENGERIX-B INJ, 22
enoxaparin inj 150mg/ml, 12
enoxaparin inj 30mg/0.3ml, 40mg/0.4ml,
60mg/0.6ml, 80mg/0.8ml, 100mg/ml,
120mg/0.8ml & 300mg/3ml, 12
enpresse-28, 19
entacapone, 9
entecavir tabs, 10
enulose, 17
EPCLUSA, 10
EPINEPHRINE AUTO-INJECTOR
0.15MG/0.3ML & 0.3MG/0.3ML, 24
EPIPEN INJ, 24
EPIPEN-JR INJ, 24
epitol, 4
EPIVIR HBV SOLN 5MG/ML, 10
eplerenone, 14
ergoloid mesylates, 5
ERIVEDGE, 8
ERWINAZE INJ, 7
ERYTHROCIN LACTOBIONATE INJ, 3
erythrocin stearate, 3
erythromycin oint, 23
erythromycin oral, 3
erythromycin topical gel & soln, 3
ESBRIET, 25
escitalopram, 5
esomeprazole magnesium dr caps, 17
estazolam, 25
ESTRACE VAGINAL, 19
estradiol & norethindrone acetate, 19
estradiol oral, 19
estradiol patches, 19
estropipate, 19
ethambutol, 7
ethinyl estradiol & ethynodiol, 19
ethinyl estradiol, ferrous fumarate &
norethindrone, 19
ethosuximide, 4
etidronate, 22
etodolac, 2
etodolac er, 2
etoposide inj, 8
EURAX, 9
EVOTAZ, 11
exemestane, 8
EXJADE, 25
ezetimibe, 15
FABRAZYME INJ, 16
falmina, 19
famciclovir, 10
famotidine inj, 17
famotidine tabs, 17
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FANAPT, 9
fluoxetine hcl caps 10mg, 20mg & 40mg, 5
FANAPT TITRATION PACK, 9
fluoxetine hcl oral soln, 5
FARESTON, 7
fluoxetine hcl tabs 10mg & 20mg, 5
FARXIGA, 12
fluphenazine decanoate inj, 9
FARYDAK, 8
fluphenazine inj, 9
FASLODEX INJ, 7
fluphenazine oral, 9
FAZACLO, 10
flurazepam, 25
felbamate tabs 400mg, 4
flutamide, 7
felbamate tabs 600mg & oral susp 600mg/5ml, 4
fluticasone propionate cream & oint, 18
felodipine er, 14
fluticasone propionate nasal, 24, 27
femynor, 19
fluvoxamine, 5
fenofibrate, 15, 27
fluvoxamine er, 5
fenofibrate caps 43mg & 130mg, 15
fondaparinux inj 2.5mg/0.5ml & 5mg/0.4ml, 12
fenofibrate micronized, 15, 27
fondaparinux inj 7.5mg/0.6ml & 10mg/0.8ml, 12
fenofibrate tabs, 15
FORFIVO XL, 5
fenofibric acid dr caps, 15
FORTEO INJ, 22
fenofibric acid tabs, 15
fosinopril, 13
fentanyl citrate lozenges 200mcg, 1
fosinopril & hydrochlorothiazide, 13
fosphenytoin sodium inj, 4
fentanyl citrate lozenges 400mcg, 600mcg,
800mcg, 1200mcg & 1600mcg, 1
FOSRENOL, 18
fentanyl patches, 27
furosemide inj, 14
furosemide oral, 14
fentanyl patches 12mcg/hr, 25mcg/hr, 50mcg/hr,
75mcg/hr, 100mcg/hr, 1
FUZEON INJ, 11
FERRIPROX, 23
fyavolv, 19
FETZIMA, 5
FYCOMPA, 4
FETZIMA TITRATION PACK, 5
gabapentin caps, tabs, & oral soln, 4
finasteride tabs 5mg, 17
GABITRIL TABS 12MG & 16MG, 4
FIRAZYR INJ, 21
galantamine, 5, 27
flavoxate, 17
galantamine er, 5, 27
flecainide acetate, 13
galantamine oral soln, 5, 27
fluconazole in dextrose inj, 6
GAMMAGARD INJ, 21
fluconazole in sodium chloride inj, 6
GAMUNEX-C INJ, 21
fluconazole oral, 6
ganciclovir inj, 10
GARDASIL 9 INJ, 22
flucytosine, 6
GARDASIL INJ, 22
fludrocortisone acetate, 18
GATTEX INJ, 17
flunisolide nasal, 24, 27
gauze pads 2x2, 23
fluocinolone acetonide, 18
gavilyte-c, 17
fluocinonide, 18
gavilyte-g, 17
fluocinonide cream 0.05%, 18
gavilyte-h, 17
fluocinonide gel, oint & soln, 18
gavilyte-n, 17
fluocinonide-e, 18
GELNIQUE, 17
fluorometholone, 23
gemfibrozil, 15
FLUOROURACIL 0.5% CREAM, 16
generlac, 17
fluorouracil topical, 16
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gengraf, 21
GENOTROPIN INJ, 18
GENOTROPIN MINIQUICK INJ 0.2MG, 0.4MG,
0.6MG, 0.8MG, 18
GENOTROPIN MINIQUICK INJ 1MG, 1.2MG,
1.4MG, 1.6MG, 1.8MG, & 2MG, 18
gentamicin cream 0.1% & oint 0.1%, 2
gentamicin inj, 2
gentamicin oint 0.3% & soln 0.3%, 23
GENVOYA, 10
GEODON INJ, 9
gildagia, 19
GILENYA, 16
GILOTRIF, 8
glatopa inj, 16
GLEOSTINE, 7
glimepiride, 12
glimepiride & pioglitazone, 12
glimepiride & pioglitazone tabs, 27
glipizide, 12
glipizide & metformin tabs, 12
glipizide er, 12
GLUCAGON EMERGENCY KIT INJ, 12
glycopyrrolate inj, 17
glycopyrrolate oral, 17
granisetron inj, 6
granisetron oral, 6
griseofulvin microsize, 6
guanfacine, 13
guanidine, 7
halobetasol, 18
haloperidol decanoate inj, 9
haloperidol lactate inj, 9
haloperidol lactate oral soln, 9
haloperidol tabs, 9
HARVONI, 10
HAVRIX INJ, 22
heparin inj, 12
HERCEPTIN INJ, 8
HETLIOZ, 15
HEXALEN, 7
HIBERIX INJ, 22
HUMALOG CARTRIDGE INJ, 12
HUMALOG KWIKPEN INJ, 12
HUMALOG MIX 50/50 KWIKPEN INJ, 12
HUMALOG MIX 50/50 VIAL INJ, 12
HUMALOG MIX 75/25 KWIKPEN INJ, 12
HUMALOG MIX 75/25 VIAL INJ, 12
HUMALOG VIAL INJ, 12
HUMATROPE INJ 5MG VIAL, 12MG & 24MG
CARTRIDGE, 19
HUMATROPE INJ 6MG CARTRIDGE, 19
HUMIRA INJ, 21
HUMIRA PEN INJ, 21
HUMIRA PEN-CROHNS INJ, 21
HUMIRA PEN-PSORIASIS INJ, 21
HUMULIN 70/30 KWIKPEN INJ, 12
HUMULIN 70/30 VIAL INJ, 12
HUMULIN N KWIKPEN INJ, 12
HUMULIN N VIAL INJ, 12
HUMULIN R U-500 (CONCENTRATED)
KWIKPEN INJ, 12
HUMULIN R U-500 (CONCENTRATED) VIAL
INJ, 12
HUMULIN R VIAL INJ, 12
hydralazine inj, 15
hydralazine oral, 15
hydrochlorothiazide, 15
hydrocodone & acetaminophen soln, 1, 28
hydrocodone & acetaminophen tabs, 1, 28
hydrocodone & ibuprofen, 1, 28
hydrocortisone 2.5% cream, lotion, oint, 18
hydrocortisone butyrate oint & soln, 18
hydrocortisone enema, 22
hydrocortisone oral, 18
hydrocortisone valerate, 18
hydromorphone immediate-release oral soln &
tabs, 1
hydromorphone inj, 1
hydroxychloroquine, 8
hydroxyprogesterone caproate, 20
hydroxyurea, 7
hydroxyzine hcl tabs, 24
ibandronate inj, 22
ibandronate oral, 22
IBRANCE, 8
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ibuprofen, 2
itraconazole, 6
ICLUSIG, 8
ivermectin, 8
ILARIS INJ, 21
IXIARO INJ, 22
imatinib, 8
JADENU, 25
IMBRUVICA, 8
JAKAFI, 8
imipramine hcl tabs, 5
jantoven, 12
imiquimod, 16
JANUMET, 12
IMOVAX RABIES INJ, 22
JANUMET XR, 12
INCRELEX INJ, 19
JANUVIA, 12
indapamide, 15
jinteli, 19
indomethacin, 2
junel, 19
indomethacin er, 2
JUXTAPID, 15
indomethacin ir caps, 2
KALETRA TABS 100-25MG, 11
INFANRIX INJ, 22
KALETRA TABS 200MG-50MG & SOLN 400INLYTA, 8
100MG/5ML, 11
INTELENCE 100MG & 200MG TABS, 10
KALYDECO, 25
INTELENCE 25MG TAB, 10
kariva, 19
INTRALIPID INJ, 25
ketoconazole, 6
INTRON-A INJ, 10
ketorolac inj, 2
introvale, 19
ketorolac oral, 2
INVANZ INJ, 3
ketorolac soln 0.4% & 0.5%, 23
INVEGA SUSTENNA 39MG & 78MG, 9
KEYTRUDA INJ, 8
INVEGA TRINZA INJ, 9
KHEDEZLA, 5
INVIRASE, 11
kimidess, 19
INVOKAMET, 12
KINERET INJ, 21
INVOKAMET XR, 12
KINRIX INJ, 22
INVOKANA, 12
kionex, 25
IPOL INACTIVATED IPV INJ, 22
KISQALI, 7
klor-con, 25
ipratropium bromide & albuterol sulfate
nebulizer, 24
klor-con sprinkle, 26
ipratropium bromide nasal, 24, 28
KOMBIGLYZE XR, 12
ipratropium bromide nebulizer, 24
KORLYM, 19
irbesartan, 13
KUVAN, 16
KYNAMRO, 15
irbesartan hct, 13
labetalol inj, 14
IRESSA, 8
labetalol oral, 14
ISENTRESS CHEW TABS, 10
LACRISERT, 23
ISENTRESS ORAL POWDER, 10
lactated ringers inj, 26
ISENTRESS TABS, 10
lactulose, 17
isoniazid oral, 7
lamivudine, 10, 11
isosorbide dinitrate, 15
lamivudine & zidovudine, 11
isosorbide dinitrate er, 15
lamotrigine immediate-release tabs, 4
isosorbide mononitrate, 15
LANOXIN INJ, 14
isosorbide mononitrate er, 15
LANOXIN ORAL, 14
isradipine, 14
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lansoprazole dr caps, 17
LANTUS SOLOSTAR PEN INJ, 12
LANTUS VIAL INJ, 12
larin, 19
larin fe, 19
larissia, 19
latanoprost, 24
LATUDA, 9
LAZANDA, 1
leena, 19
leflunomide, 21, 28
LENVIMA, 8
LETAIRIS, 25
letrozole, 8
leucovorin inj, 7
leucovorin oral, 7
LEUKERAN, 7
LEUKINE INJ, 12
leuprolide acetate inj, 20
levalbuterol nebulizer, 25
levetiracetam er, 4
levetiracetam inj, 4
levetiracetam oral, 4
levobunolol, 23
levocarnitine inj, 23
levocarnitine oral, 23
levocetirizine, 24
levofloxacin inj, 3
levofloxacin oral soln, 3
levofloxacin tabs, 3
levoleucovorin inj, 7
levonest, 19
levonorgestrel & ethinyl estradiol 0.1-0.02mg,
0.15-0.03mg, & 0.125-0.03mg packs, 19
levora, 19
levothyroxine tabs, 20
levoxyl, 20
LEXIVA ORAL SUSP, 11
LEXIVA TABS, 11
lidocaine & prilocaine, 1
lidocaine hcl inj, 1
lidocaine ointment, 1
lidocaine patch, 1
lidocaine topical gel & solution, 1
linezolid inj, 2
linezolid oral, 2
LINZESS, 17
liothyronine tabs, 20
lisinopril, 13
lisinopril & hydrochlorothiazide, 13
lithium carbonate, 11
lithium carbonate er, 11
lithium citrate, 11
LONSURF, 7
loperamide caps 2mg, 17
lopinavir &ritonavir soln, 11
lorazepam intensol, 11
lorazepam tabs, 11
lorcet hd tabs, 1, 28
lorcet plus tabs, 1, 28
lorcet tabs, 1, 28
lortab tabs, 1, 28
losartan, 13
losartan hct, 13
lovastatin, 15
low-ogestrel, 19
loxapine, 9
LUMIGAN, 24
LUMIZYME INJ, 16
LUPRON DEPOT INJ 7.5MG, 11.25MG,
22.5MG, 30MG & 45MG, 20
LYNPARZA, 7
LYRICA, 4
LYSODREN, 20
lyza, 20
magnesium sulfate inj, 26
malathion, 9
maprotiline, 5
marlissa 28 day, 19
MARPLAN, 5
MATULANE, 7
meclizine, 5
medroxyprogesterone acetate inj, 20
medroxyprogesterone acetate tabs, 20
mefloquine, 8
megestrol acetate oral susp, 20
VillageHealth | 2017 Formulary
39
megestrol tabs, 20
mexiletine, 13
MEKINIST, 8
MIACALCIN INJ, 22
meloxicam tabs, 2
microgestin, 19
memantine hcl immediate release, 5
midodrine tabs, 13
MENACTRA INJ, 22
migergot suppository, 7
MENEST, 19
mimvey, 19
MENHIBRIX INJ, 22
mimvey lo, 19
MENOMUNE-A/C/Y/W-135 INJ, 22
minitran patches, 15
MENVEO-A/C/Y/W-135 INJ, 22
minocycline ir, 4
mercaptopurine, 7
minoxidil, 15
meropenem inj, 3
mirtazapine, 5
mesalamine enema kit, 22
mirtazapine odt, 5
MESNEX TABS, 7
misoprostol, 17
MESTINON SYRUP, 7
mitoxantrone inj, 7
metadate er, 15
M-M-R II INJ, 22
metformin, 12
modafinil, 25
metformin er uncoated tabs 500mg & 750mg, 12
moderiba 200mg tabs, 10
methadone inj, 1
moderiba dose pack, 10
methadone oral, 1
moexipril, 13
methazolamide, 23
moexipril & hydrochlorothiazide, 13
methenamine hippurate, 2
molindone, 9
methimazole, 21
mometasone cream & oint, 18
methocarbamol, 25
mometasone furoate nasal, 24
methotrexate inj, 21
mometasone furoate nasal, 28
methotrexate oral, 21
montelukast, 24
methoxsalen, 16
morgidox, 4
methyldopa, 13
morphine sulfate er tabs, 1, 28
methyldopa & hydrochlorothiazide, 13
morphine sulfate inj vial, 1
methyldopate inj, 13
morphine sulfate oral, 1
methylphenidate er tabs 10mg & 20mg, 15
MOVANTIK, 17
methylphenidate ir tabs 5mg, 10mg & 20mg, 15
MOVIPREP, 17
moxifloxacin oral, 3
methylprednisolone oral, 18
MOZOBIL INJ, 26
methylprednisolone sodium succinate inj, 18
mupirocin, 2
metipranolol, 23
mycophenolate mofetil caps & tabs, 21
metoclopramide inj, 6
mycophenolate mofetil inj, 21
metoclopramide tablets & oral soln, 6
mycophenolate mofetil oral susp, 21
metolazone, 15
mycophenolic acid dr, 21
metoprolol & hydrochlorothiazide, 14
myorisan, 16
metoprolol succinate er, 14
MYRBETRIQ, 17
metoprolol tartrate tabs, 14
nabumetone, 2
metronidazole inj, 2
nadolol, 14
metronidazole oral, 2
nadolol & bendroflumethiazide, 14
metronidazole topical, 2
nafcillin sodium inj, 3
metronidazole vaginal, 2
VillageHealth | 2017 Formulary
40
NAGLAZYME INJ, 16
naloxone inj, 2
naltrexone, 2
naproxen, 2
naproxen dr, 2
naproxen sodium ir, 2
naratriptan, 7, 28
NARCAN, 2
nateglinide, 12
NATPARA, 23
NEBUPENT NEBULIZER, 8
necon, 19
nefazodone, 5
neomycin & bacitracin & polymyxin b, 23
neomycin & polymyxin & bacitracin &
hydrocortisone, 24
neomycin & polymyxin & dexamethasone, 23
neomycin & polymyxin & gramicidin, 23
neomycin & polymyxin & hydrocortisone, 24
neomycin sulfate oral, 2
NEORAL, 21
NEUPOGEN INJ, 13
NEUPRO PATCH, 9
NEUPRO PATCH, 28
nevirapine er, 10
nevirapine oral susp, 10
nevirapine tabs, 10
NEXAVAR, 8
niacin er tabs, 15, 28
nicardipine caps, 14
NICOTROL INHALER, 2
NICOTROL NASAL, 2
nifedipine, 14
nifedipine er, 14
nilutamide, 7
nimodipine caps, 14
NINLARO, 7
nisoldipine er, 14
nitro-bid oint, 15
NITRO-DUR PATCHES, 15
nitrofurantoin caps, 2
nitroglycerin inj, 15
nitroglycerin lingual, 15
nitroglycerin patches, 15
nitroglycerin sublingual, 15
norethindrone, 20
norgestimate-ethinyl estradiol, 20
norlyroc, 20
NORTHERA, 14
nortriptyline oral, 5
NORVIR, 11
NOXAFIL ORAL, 6
NUEDEXTA, 15
NULOJIX INJ, 21
NUPLAZID, 9
nyamyc, 6
nyata, 6
nystatin, 6
nystatin & triamcinolone, 6
octreotide inj 500mcg/ml & 1000mcg/ml, 20
octreotide inj 50mcg/ml, 100mcg/ml &
200mcg/ml, 20
ODEFSEY, 10
ODOMZO, 8
OFEV, 25
ofloxacin, 23, 24
ofloxacin oral, 3
olanzapine inj 10mg, 9
olanzapine odt, 9
olanzapine tabs, 9
olmesartan, 13
olmesartan hct, 13
olopatadine soln 0.1%, 23
olopatadine soln 0.1%, 28
OLYSIO, 10
omega-3-acid ethyl esters, 15
omeprazole caps, 17
ONCASPAR INJ, 7
ondansetron inj, 6
ondansetron odt, 6
ondansetron oral soln, 6
ondansetron tabs, 6
ONFI, 4
ONGLYZA, 12
OPSUMIT, 25
ORAVIG, 6
VillageHealth | 2017 Formulary
41
ORFADIN, 16
PEGASYS INJ, 10
ORKAMBI, 25
PEGASYS PROCLICK INJ, 10
orsythia 28 day, 20
PEG-INTRON INJ, 10
oseltamivir caps, 11
PEG-INTRON REDIPEN INJ, 10
OSMOPREP, 17
penicillin g inj 5 million units, 3
OTEZLA, 21
penicillin v potassium, 3
OTEZLA STARTER, 21
PENTAM INJ, 9
oxandrolone, 19
PENTASA, 22, 28
oxazepam, 11
pentoxifylline er, 14
oxcarbazepine, 4
perindopril, 13
oxybutynin, 17, 28
permethrin cream, 9
oxybutynin er, 17, 28
perphenazine, 5, 9
oxycodone, 1
perphenazine & amitriptyline, 5
oxycodone & acetaminophen, 1, 28
phenadoz, 6
oxycodone & aspirin, 1, 28
phenelzine, 5
oxycodone & ibuprofen, 1
phenergan suppositories, 6
oxycodone & ibuprofen tabs, 28
phenobarbital elixir, 4
OXYCODONE ER, 1
phenobarbital tabs, 4
OXYCODONE ER, 28
phenytoin chewable tabs, 4
oxycodone immediate-release, 1
phenytoin er, 4
oxycodone oral soln, 1
phenytoin inj, 4
OXYCONTIN, 1, 28
phenytoin oral susp, 4
oxymorphone er, 1, 28
PHOSPHOLINE IODIDE, 23
OXYTROL, 17
pilocarpine soln, 23
pacerone tabs 200mg, 13
pilocarpine tabs, 16
paclitaxel inj, 8
pimozide, 9
paliperidone er, 9
pimtrea, 20
pamidronate inj, 22
pindolol, 14
PANRETIN, 8
pioglitazone, 12
pantoprazole inj, 17
pioglitazone & metformin, 12
pantoprazole tabs, 17
piperacillin/tazobactam inj 3gm/0.375gm &
paricalcitol caps, 22
4gm/0.5gm & 12gm/1.5gm, 3
paromomycin, 2
pirmella 1/35, 20
paroxetine er, 5
piroxicam, 2
paroxetine immediate-release, 5
PLEGRIDY INJ, 16
PASER, 7
PLEGRIDY STARTER PACK INJ, 16
plenamine inj, 26
PATADAY, 23
podofilox, 16
PAXIL 10MG/5ML SUSP, 5
polyethylene glycol 3350, 17
PEDIARIX INJ, 22
polymyxin b sulfate & trimethoprim sulfate soln,
PEDVAX HIB INJ, 22
23
peg 3350 & electrolytes, 17
POMALYST, 7
peg 3350 & sodium chloride & sodium
bicarbonate & potassium chloride, 17
potassium chloride & dextrose & lactated ringers
inj, 26
PEGANONE, 4
VillageHealth | 2017 Formulary
42
prochlorperazine suppositories, 6
PROCRIT INJ 20000UNIT/ML &
40000UNIT/ML, 13
PROCRIT INJ 2000UNIT/ML, 13
PROCRIT INJ 3000UNIT/ML, 4000UNIT/ML &
10000UNIT/ML, 13
procto-med hc, 18
procto-pak, 18
proctosol hc, 18
proctozone-hc, 18
progesterone caps, 20
PROGLYCEM, 12
PROLASTIN C INJ, 25
PROLIA, 22
PROMACTA, 13
promethazine inj, 6
promethazine suppositories, 6
promethazine syrup, 6
promethazine tabs 12.5mg, 25mg & 50mg, 6
promethegan, 6
propafenone, 14
propranolol & hydrochlorothiazide, 14
propranolol er caps, 14
propranolol inj, 14
propranolol ir tabs, 14
propranolol oral soln, 14
propylthiouracil, 21
PROQUAD INJ, 22
PROSOL INJ, 26
PROTONIX INJ, 17
protriptyline, 5
prudoxin, 16
PULMOZYME, 25
PURIXAN, 7
pyrazinamide, 7
pyridostigmine, 7
pyridostigmine er, 7
QUADRACEL INJ, 22
quetiapine, 9
quetiapine er tabs, 9
quinapril, 13
quinapril & hydrochlorothiazide, 13
quinidine gluconate cr, 14
potassium chloride & dextrose & sodium
chloride inj 20mEq/5%/0.45% &
30mEq/5%/0.45%, 26
potassium chloride er, 26
potassium chloride inj, 26
potassium chloride oral soln, 26
potassium chloride viaflex inj, 26
potassium citrate er, 26
POTIGA, 4
PRADAXA, 12
pramipexole ir, 9
pravastatin, 15
prazosin, 13, 17
PRED MILD, 24
prednicarbate, 18
prednisolone, 24
prednisolone acetate, 24
prednisolone oral soln, 18
prednisolone sodium phosphate, 24
prednisone oral soln, 18, 22
prednisone tabs, 18, 22
PREMARIN ORAL, 20
PREMARIN VAGINAL, 20
PREMPHASE, 20
PREMPRO, 20
prenatal multi-vitamin, 26
PREPOPIK, 17
prevalite, 15
PREZCOBIX, 11
PREZISTA SUSP 100MG/ML, 11
PREZISTA TABS 600MG & 800MG, 11
PREZISTA TABS 75MG & 150MG, 11
PRIFTIN, 7
PRIMAQUINE, 9
primidone, 4
PRISTIQ, 5
PROAIR HFA, 25
PROAIR RESPICLICK, 25
probenecid, 6
probenecid & colchicine, 6
procainamide inj, 13
prochlorperazine inj, 6
prochlorperazine oral, 6
VillageHealth | 2017 Formulary
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quinidine gluconate inj, 14
risedronate sodium, 22
quinidine sulfate, 14
risedronate sodium dr, 22
quinine sulfate caps 324mg, 9
RISPERDAL CONSTA INJ 12.5MG & 25MG, 9
QVAR, 24
RISPERDAL CONSTA INJ 37.5MG & 50MG, 10
RABAVERT INJ, 22
risperidone, 10
raloxifene hcl, 20, 28
risperidone odt, 10
ramipril, 13
RITUXAN INJ, 8
RANEXA, 14
rivastigmine caps, 5
ranitidine caps, syrup & inj, 17
rivastigmine caps, 28
ranitidine tabs, 17
rivastigmine patches, 28
RAPAMUNE SOLN, 21
rivastigmine patches, 5
rasagiline, 9
rizatriptan, 7
RAVICTI, 17
rizatriptan odt, 7
REBIF INJ, 16
ropinirole, 9
REBIF REBIDOSE INJ, 16
rosuvastatin, 15
REBIF REBIDOSE TITRATION PACK INJ, 16
ROTARIX, 22
REBIF TITRATION PACK INJ, 16
ROTATEQ, 22
RECOMBIVAX HB INJ, 22
ROZEREM, 25, 28
REGRANEX, 16, 28
RUBRACA, 8
RELENZA DISKHALER, 11
SABRIL, 4
RELISTOR INJ, 17
SANDIMMUNE CAPS 25MG & 100MG, 21
RELISTOR TABS, 17
SANDIMMUNE ORAL SOLN 100MG/ML, 21
REMICADE INJ, 21
SANTYL, 16
REMODULIN INJ, 25
SAPHRIS, 10
RENVELA, 18
SAVELLA, 15
repaglinide, 12
SAVELLA TITRATION PACK, 16
REPATHA INJ, 14
selegiline, 9
reprexain, 1
selenium sulfide lotion, 16
RESCRIPTOR, 10
SELZENTRY 150MG & 300MG, 11
RESTASIS, 23
SELZENTRY 25MG & 75MG, 11
RETROVIR IV INJ, 11
SENSIPAR TABS 30MG, 20, 28
REVLIMID, 7
SENSIPAR TABS 60MG & 90MG, 20
REXULTI, 9
SEREVENT DISKUS, 25
REYATAZ CAPS & ORAL POWDER, 11
SEROQUEL XR, 10
sertraline oral soln, 5
ribasphere, 10
sertraline tabs, 5
ribasphere ribapak, 10
setlakin, 20
ribavirin, 10
sharobel, 20
RIDAURA, 21
sildenafil tabs 20mg, 25
rifabutin, 7
SILENOR, 25, 28
rifampin inj, 7
silver sulfadiazine, 2
rifampin oral, 7
simvastatin, 15
RIFATER, 7
sirolimus tabs, 21
riluzole, 15
SIRTURO, 7
rimantadine, 11
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SIVEXTRO, 2
sodium chloride inj, 26
sodium phenylbutyrate powder, 17
sodium polystyrene sulfonate, 25
SOLTAMOX, 7
SOLU-CORTEF INJ, 18
SOMATULINE DEPOT INJ, 20
SOMAVERT INJ, 20
sorine, 14
sotalol tabs, 14
SOVALDI, 10
SPIRIVA HANDIHALER, 24
SPIRIVA RESPIMAT, 24
spironolactone, 14, 15
spironolactone & hydrochlorothiazide, 15
SPORANOX ORAL SOLN, 6
SPRITAM, 4
SPRYCEL, 8
ssd, 2
stavudine caps, 11
STIMATE, 19
STIOLTO RESPIMAT, 25
STIVARGA, 8
STRATTERA, 15
streptomycin inj, 2
STRIBILD, 11
STRIVERDI RESPIMAT, 25
SUCRAID, 17
sucralfate, 17
sulfacetamide sodium, 24
sulfacetamide sodium & prednisolone sodium
phosphate, 24
sulfacetamide sodium oint & soln 10%, 23
sulfacetamide sodium susp 10%, 16
sulfadiazine, 3
sulfamethoxazole & trimethoprim, 4
sulfamethoxazole & trimethoprim ds tabs, 4
sulfamethoxazole & trimethoprim inj, 4
sulfamethoxazole & trimethoprim oral susp, 4
sulfamethoxazole & trimethoprim tabs, 3
sulfasalazine, 22
sulindac, 2
sumatriptan nasal, 7
sumatriptan succinate inj, 7
sumatriptan succinate oral, 7
SUPRAX CAPS & CHEWABLE TABS, 3
SUPRAX ORAL SUSP 500MG/5ML, 3
SUPREP BOWEL PREP, 17
SUSTIVA, 11
SUTENT, 8
SYLATRON INJ, 8
SYMLINPEN INJ, 12
SYNAGIS INJ, 21
SYNAREL, 20
SYNERCID INJ, 2
SYNRIBO INJ, 8
SYNTHROID, 20
SYPRINE, 25
TABLOID, 7
tacrolimus caps 0.5mg & 1mg, 21
tacrolimus caps 5mg, 21
tacrolimus oint, 16
TAFINLAR, 8
TAGRISSO, 8
TAMIFLU SUSP, 11
tamoxifen, 7
tamsulosin, 17
TARCEVA, 8
TARGRETIN GEL, 8
tarina fe, 20
TASIGNA, 8
tazarotene, 16, 28
tazicef inj, 3
TAZORAC, 16, 28
taztia xt, 14
TECFIDERA, 16
TECFIDERA STARTER PACK, 16
TEFLARO INJ, 3
TEGRETOL, 4
TEGRETOL XR, 4
TEKTURNA, 14
TEKTURNA HCT, 14
temazepam, 25
TENIVAC, 22
terazosin, 13, 17
terbinafine, 6
VillageHealth | 2017 Formulary
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terbutaline sulfate inj, 25
trandolapril, 13
terbutaline sulfate oral, 25
tranexamic acid inj, 13
terconazole, 6
tranexamic acid tabs, 13
testosterone cypionate inj, 19
TRANSDERM-SCOP, 6
testosterone enanthate inj, 19
tranylcypromine, 5
testosterone gel 1%, 19
TRAVASOL INJ, 26
TETANUS & DIPHTHERIA TOXOIDStrazodone, 5
ADSORBED ADULT INJ, 22
TRECATOR, 7
tetrabenazine, 15
TRELSTAR, 20
tetracycline, 4
tretinoin caps, 8
THALOMID, 7
triamcinolone, 16
theophylline, 24
triamcinolone acetonide inj, 18
theophylline cr & er tabs, 24
triamcinolone acetonide topical cream, lotion &
THIOLA, 18
oint, 18
thioridazine, 9
triamcinolone in orabase, 16
thiothixene, 9
triamterene & hydrochlorothiazide, 15
THYROLAR, 20
triazolam, 25
tiagabine, 4
triderm, 18
timolol ophthalmic gel forming, 23
trifluoperazine, 9
timolol oral, 14
trifluridine, 23
timolol soln, 23
trihexyphenidyl elixir, 9
TIVICAY 10MG & 25MG TABS, 10
trihexyphenidyl tabs, 9
TIVICAY 50MG TAB, 10
TRILEPTAL, 4
tizanidine, 10
tri-lo-estarylla, 20
TOBI PODHALER, 25
tri-lo-sprintec, 20
TOBRADEX OINT, 24
trimethoprim, 2
tobramycin, 24
trimipramine maleate, 5
tobramycin & dexamethasone, 24
TRINTELLIX, 5
tobramycin nebulizer, 25
tri-sprintec, 20
tobramycin sulfate, 23
TRIUMEQ, 11
tobramycin sulfate inj, 2
trivora-28, 20
TOLAK, 16
TRUMENBA INJ, 22
tolterodine tartrate, 28
TRUVADA, 11
tolterodine tartrate er, 17
TUDORZA PRESSAIR, 24
TWINRIX INJ, 22
topiramate immediate-release, 4
TYBOST, 11
torsemide oral, 14
TYGACIL INJ, 2
TOUJEO SOLOSTAR, 12
TYKERB, 8
TOVIAZ, 17
TYPHIM VI INJ, 22
TPN ELECTROLYTES INJ, 26
TYSABRI INJ, 16
TRACLEER, 25
ULORIC, 6
tramadol, 1, 28, 29
unithroid, 20
tramadol & acetaminophen, 1, 28
UPTRAVI, 25
tramadol er, 29
ursodiol, 17
tramadol er tabs, 1
VillageHealth | 2017 Formulary
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valacyclovir, 10
VALCHLOR, 7
valganciclovir tabs, 10
valproate sodium inj, 4
valproic acid, 4
valsartan, 13
valsartan & amlodipine, 13
valsartan & amlodipine & hct, 13
valsartan hct, 13
vancomycin inj, 2
vancomycin oral, 2
vandazole, 2
VAQTA INJ, 22
VARIVAX INJ, 22
VELCADE INJ, 8
velivet, 20
VELTASSA, 25
VENCLEXTA STARTING PACK, 8
VENCLEXTA TABS 100MG, 8
VENCLEXTA TABS 10MG & 50MG, 8
venlafaxine er caps, 5
venlafaxine ir tabs, 5
verapamil er, 14
verapamil inj, 14
verapamil ir, 14
verapamil sr, 14
VERSACLOZ, 10
VESICARE, 17
VICTOZA INJ, 12
VIDEX PEDIATRIC SOLN 2GM, 11
vienva, 20
VIGAMOX, 23
VIIBRYD, 5
VIIBRYD STARTER PACK, 5
VIMPAT INJ, 4
VIMPAT ORAL, 4
VIRACEPT, 11
VIRAMUNE TABS, 11
VIRAZOLE, 25
VIREAD POWDER, 11
VIREAD TABS, 11
voriconazole inj, 6
voriconazole oral, 6
VOTRIENT, 8
VPRIV INJ, 17
VRAYLAR CAPSULES, 10
VRAYLAR DOSE PACK, 10
vyfemla, 20
warfarin, 12
WELCHOL, 15
wymzya fe, 20
XALKORI, 8
XARELTO, 12
XARELTO STARTER PACK, 12
XELJANZ, 21
XELJANZ XR, 21
XERESE, 10
XGEVA INJ, 22
XIFAXAN TABS 200MG, 2, 29
XIFAXAN TABS 550MG, 3
XIGDUO XR, 12
XTANDI, 7
XYREM, 25
YERVOY INJ, 8
YF-VAX INJ, 22
yuvafem, 20
zafirlukast, 24, 29
zamicet, 1, 29
ZAVESCA, 17
ZEJULA, 8
ZELBORAF, 8
zenatane, 16
zenchent, 20
zenchent fe, 20
zenzedi tabs 5mg & 10mg, 15, 29
ZERBAXA INJ, 3
ZERIT SOLN, 11
ZETIA, 15
ZIAGEN SOLN, 11
zidovudine, 11
zileuton er, 24
ziprasidone oral, 10
ZIRGAN, 10
zoledronic acid 4mg/5ml inj, 23
zoledronic acid 5mg/100ml inj, 23
ZOLINZA, 8
VillageHealth | 2017 Formulary
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zolmitriptan odt, 7
zolmitriptan tabs, 7
zolpidem tabs 5mg & 10mg, 25
ZOMETA INJ 4MG/100ML, 23
ZOMIG NASAL, 7, 29
ZONALON, 16
zonisamide, 4
ZORTRESS TABS 0.25MG, 21
ZORTRESS TABS 0.5MG & 0.75MG, 21
ZOSTAVAX INJ, 22
ZOSYN GALAXY INJ 2GM/0.25GM &
3GM/0.375GM, 3
zovia, 20
ZOVIRAX CREAM, 10
ZYDELIG, 8
ZYFLO CR, 24, 29
ZYKADIA, 8
ZYPREXA RELPREVV 210MG INJ, 10
ZYTIGA, 7
VillageHealth | 2017 Formulary
48
3800 Kilroy Airport Way, Suite 100
Long Beach, CA 90806
SCAN Health Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race,
color, national origin, age, disability, or sex. SCAN Health Plan cumple con las leyes federales de derechos civiles
aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. SCAN Health Plan
遵守適用的聯邦民權法律規定，不因種族、膚色、民族血統、年齡、殘障或性別而歧視 任何人。
ATTENTION: If you speak a language other than English, language assistance services, free of charge, are
available to you. Call 1-800-399-7226. Hours are 8 a.m. to 8 p.m., seven days a week from October 1 to February
14. From February 15 to September 30 hours are 8 a.m. to 8 p.m. Monday through Friday. Messages received on
holidays and outside of our business hours will be returned within one business day. (TTY: 711). ATENCIÓN: si
habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-399-7226. El
horario es de 8 a. m. a 8 p. m., los siete días de la semana, del 1 de octubre al 14 de febrero. Del 15 de febrero
al 30 de septiembre, nuestro horario es de 8 a. m. a 8 p. m., de lunes a viernes. Los mensajes recibidos en días
festivos o fuera de nuestras horas de oficina serán contestados dentro de un día hábil. (TTY: 711). 注意：如果您
使用繁體中文，您可以免費獲得語言援助服務。請致電 1-800-399-7226. 。10 月 1 日至 2 月 14 日期間的
服務時間為早上 8 點至晚上 8 點，每週七天。2 月 15 日至 9 月 30 日期間的服務時間為週一至週五，早上 8
點至晚上 8 點。在節假日及營業時間之外收到的訊息將在一個工作日內回覆。（聽障專線：711）。
This formulary was updated on 06/01/2017. For more recent information or other questions, please contact
VillageHealth Member Services at 1-800-399-7226 or, for TTY users, 711, 8 a.m.–8 p.m., 7 days a week from
October 1 to February 14. From February 15 to September 30, hours are 8 a.m. to 8 p.m. Monday through Friday
(messages received on holidays and outside of our business hours will be returned within one business day), or
visit www.villagehealthca.com.
Este formulario se actualizó en 06/01/2017. Para obtener información más reciente o si tiene dudas,
comuníquese con Servicios para Miembros de VillageHealth al 1-800-399-7226 o, para los usuarios de TTY,
711, de 8 a.m. a 8 p.m., los 7 días de la semana, desde el 1 de octubre hasta el 14 de febrero. Desde el 15
de febrero al 30 de septiembre, el horario es de 8 a.m. a 8 p.m., de lunes a viernes (los mensajes recibidos en
días festivos y fuera del horario hábil se devolverán en un día hábil). O visite www.villagehealthca.com.
Y0057_SCAN_9797_2016F File & Use Accepted 08102016
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