2021-2022 Drug Formulary - Kaiser Permanente
Effective January 20222022 Drug FormularyFor members covered through large employer groups with a 1-tier or 2-tier in-networkpharmacy benefit and no out-of-network pharmacy benefitAllianceCoreAll plans offered and underwritten by Kaiser Foundation Health Plan of Washingtonor Kaiser Foundation Health Plan of Washington Options, Inc.XB0001338-50-17
Drug FormularyINTRODUCTIONWhat is a formulary?A formulary is a list of generic, brand, and specialty drugs. It is used by practitioners toidentify drugs that offer the best overall value, considering effectiveness, safety, andcost.How is the drug formulary developed?The formulary is developed by the Kaiser Permanente Pharmacy and Therapeutics(P&T) Committee. The P&T Committee is composed of physicians from variousmedical specialties, pharmacists, and a consumer member. The P&T Committeereviews and selects the most appropriate drugs in each class for the formulary basedon safety, effectiveness, and cost. The P&T Committee meets quarterly to review newand existing drugs to ensure that the formulary remains responsive to the needs ofmembers and providers.How do I search the formulary?Drugs on the formulary are listed by therapeutic class. An alphabetical index is includedat the end of this document to assist in locating specific drugs.Drugs are listed by generic name if a generic is available. If there is no genericavailable, drugs are listed by the brand name. Drugs are organized by class and drugformulary tier. Drugs administered in a provider’s office or in a clinic (e.g., drugs givenintravenously) may not be listed on the formulary. For coverage of these drugs, refer toyour Benefit Booklet.How do I use the formulary to understand my drug coverage?Drug coverage is based on an individual’s contracted benefit. Coverage for a specificdrug is subject to each member’s medical coverage agreement. Please consult yourBenefit Booklet or call Member Service if you have questions about your drug coverage.Kaiser Permanente will only cover FDA-approved drugs used for non-experimentaltherapies. Most plans exclude experimental and investigational drugs, over-the-counterdrugs, drugs used in the treatment of sexual dysfunction disorders, drugs for anticipatedillnesses while traveling, or drugs used for cosmetic purposes. Please consult yourBenefit Booklet for limitations and exclusions.Medications not listed in this document are not on the formulary at the time ofpublication. The most current information is online at www.kp.org/wa/ formulary. Nonformulary drugs are not covered unless approved by the health plan as a coverageexception. The prescriber must contact Kaiser Permanente to determine the medicalnecessity of the non-formulary medication. An alternative formulary medication will berecommended when clinically appropriate. If a coverage exception is not approved, thepatient is responsible for the full price of the drug.Prior authorization, step therapy and nonformulary requests are considered based on
coverage criteria requirements approved by the P&T Committee. To request review of anexception to Kaiser Permanente requirements for coverage of prescription drugs, you or yourprescriber may contact Kaiser Permanente Member Services at 1-888-630-4636 and request anexception. If the evidence your prescriber provides meets medical necessity, an exception may beapproved. Exceptions to required therapy that may be approved include: contraindications, clinicalfactors associated with adverse reactions, clinical factors reducing effect, other risks of clinicalharm, and barriers to compliance with clinical care. Your prescriber may also request temporarycoverage while the exception request is being processed.Generic drugs are substituted when available and allowed by your prescriber. When ageneric is available, the brand-name drug is generally considered non-formulary and subject to ahigher cost share.The drug formulary is updated periodically and is subject to change. If a drug will beremoved from the formulary, members who filled the drug in the prior three months will be notifiedby letter of the upcoming change. A formulary change notice will also be posted on the memberwebsite at least 60 days prior to the effective date.What are the methods that Kaiser Permanente uses toensure appropriate and safe use of formulary drugs?Prior Authorization (PA)The P&T Committee determines that certain drugs should require prior authorizationbefore they will be covered. These drugs most often have alternatives on the formulary,safety concerns, or a high potential for inappropriate use. To request coverage for priorauthorization drugs, you or your prescriber must contact Kaiser Permanente. Drugsrequiring prior authorization are indicated with a “PA” superscript next to the drug name.Step Therapy (ST)Step therapy requires you to try certain preferred drugs before receiving coverage for thedrug you were prescribed. Step therapy is added by the P&T Committee. Step therapyautomatically looks at your prescription history when you fill the drug you were prescribed.If you have tried the preferred drugs required by step therapy, the drug you wereprescribed will automatically be covered. To request step therapy exceptions, you or yourprescriber must contact Kaiser Permanente. Drugs requiring step therapy are indicatedwith a “ST” superscript next to the drug name.Quantity Limit (QL)A quantity limit defines how much of a particular drug you can get during a specific timeperiod or the maximum days supply that you can get at once. The P&T Committeedetermines if a drug should have a quantity limit. To request exceptions to quantitylimits, your prescriber must contact Kaiser Permanente. Drugs with quantity limits areindicated with “QL” superscript next to the drug name.High Dose Pain Medicine Prescriber ReviewMembers on high doses of certain pain medicines will need their prescriber to confirmsafety standards are in place annually to continue coverage of therapy.Drugs Limited to Select PharmaciesSome drugs are required to be dispensed from a preferred specialty pharmacy vendor.
Members with an out-of-network benefit may use other pharmacies; however, they may paya higher cost share.Please consult your Benefit Booklet for limitations and exclusions. Drugs limited toselect pharmacies are listed on the www.kp.org/wa/formulary webpage.Covered Diabetic SuppliesSome diabetic supplies may be covered at a Tier 1 cost share if they are filled as aprescription. These items are: Preferred blood glucose strips:o One Touch Verioo One Touch Ultrao Prodigy – prior authorization requiredo Contour Next – prior authorization requiredo Freestyle – prior authorization required Disposable insulin syringes and needlesLancing devices and lancetsPreferred blood glucose meters are covered only when filled through mail order pharmacy.Mail Order Pharmacy ServiceMail order is convenient and efficiently utilizes Kaiser Permanente’s resources. This serviceworks best for drugs that must be taken on regular basis, such as birth control pills anddrugs for high blood pressure, high cholesterol, or other chronic conditions.To begin using mail order, ask your prescriber to send your prescription directly to theMail Order Pharmacy. To transfer an existing prescription from a retail pharmacy,contact the Mail Order Pharmacy.Address: Kaiser Permanente Mail Order PharmacyPO Box 34383Seattle, WA 98124-1383Phone: 800-245-RXRX (1-800-245-7979)Fax: 206-630-7950, or toll-free 1-800-350-1683Over-the-Counter (OTC) DrugsA few plans offer coverage for OTC drugs. For these plans, a list of covered OTCdrugs can be found in Appendix A. You may contact Member Service at 1-888-6304636 to find if you have OTC drug coverage.Preventative Medications and Preferred ContraceptivesIn accordance with the Affordable Care Act (ACA) requirements for preventive services,most plans cover preventative care medicines and contraceptives in full. If your plan offersACA benefits, all prescribed FDA approved contraceptive methods from the KaiserPermanente formulary list will be covered in full when obtained in-network. For plans without-of-network (OON) benefits, contraceptives will be subject to the OON cost-share. Thelist of the preventative medications covered in full is available on the
www.kp.org/wa/formulary webpage.Please consult your Benefit Booklet under “Preventive Services” or call Member Service ifyou have questions about your coverage for these drugs.If you request coverage for a non-preferred contraceptive, we will contact your provider torecommend a preferred generic or therapeutically equivalent product. If you and yourprovider determine that the preferred contraceptive(s) would be medically inappropriate,your provider must request a contraceptive waiver. If waiver is completed, the requestednon-preferred contraceptive will be covered in full.Excluded Prescription Products for Medications that have Over-TheCounter (OTC) AlternativesThere are certain prescription products that have the same or similar productsavailable over-the- counter (OTC) without a prescription. In certain cases, KaiserPermanente will not cover the prescription product. The following prescription drugproducts are excluded from coverage: esomeprazole magnesium (Nexium),omeprazole/sodium bicarbonate (Zegerid), budesonide nasal spray (RhinocortAqua), triamcinolone nasal spray (Nasacort), and fluticasone propionate nasalspray (Flonase).Medical Benefit Injectable DrugsSome drugs are given in a non-hospital setting such as home infusion, a medicaloffice, a physician's office, or an infusion suite. These drugs are covered under themedical benefit but may require prior authorization or a non-hospital setting. Thelist of medical benefit injectable drugs is available on the www.kp.org/wa/formularywebpage.How do I get additional information?Please contact Member Service at 1-888-630-4636 with any questions or concernsregarding the information contained in this document.The most current drug formulary is available at www.kp.org/wa/formulary.
Kaiser Foundation Health Plan of WashingtonTable of ContentsAnalgesics - Drugs for Pain and Inflammation . 11Analgesics - Drugs for Pain . 11Anesthetics . 12Anti-Addiction / Substance Abuse Treatment Agents. 12Antibacterials . 12Anticoagulants . 14Anticonvulsants - Drugs for Seizures . 14Antidementia Agents - Drugs for Alzheimer's Disease and Dementia. 14Antidepressants . 14Antiemetics - Drugs for Nausea and Vomiting . 15Antifungals . 15Antigout Agents . 16Antimigraine Agents . 16Antimyasthenic Agents . 16Antimycobacterials . 16Antineoplastics - Drugs for Cancer . 16Antiparasitics . 17Antiparkinson Agents. 17Antiplatelets . 18Antipsychotics - Drugs for Mood Disorders . 18Antivirals . 18Anxiolytics - Drugs for Anxiety . 20Bipolar Agents - Drugs for Mood Disorders. 20Blood Products and Modifiers - Drugs for Blood Disorders . 20Cardiovascular Agents - Drugs for Heart and Circulation Conditions . 20Central Nervous System Agents - Drugs for Attention Deficit Disorder . 23Central Nervous System Agents - Drugs for Multiple Sclerosis. 23Central Nervous System Agents - Miscellaneous . 23Dental and Oral Agents - Drugs for Mouth and Throat Conditions . 23Dermatological Agents - Drugs for Skin Conditions . 23Diabetes - Antidiabetic Agents . 26Diabetes - Glucose Monitoring . 26Diabetes - Glycemic Agents . 27Diabetes - Insulins . 27Electrolytes / Minerals / Metals / Vitamins . 289
Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer . 29Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions . 29Genetic or Enzyme Disorder - Drugs for Replacement, Modification, Treatment . 30Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions . 30Genitourinary Agents - Drugs for Prostate Conditions. 30Hormonal Agents - Adrenal . 30Hormonal Agents - Men's Health . 31Hormonal Agents - Pituitary . 31Hormonal Agents - Selective Estrogen Receptor Modifying Agents . 31Hormonal Agents - Sex Hormones and Birth Control . 31Hormonal Agents - Thyroid. 34Immunological Agents - Drugs for Immune System Stimulation or Suppression . 34Immunological Agents - Drugs for Vaccination . 35Inflammatory Bowel Disease Agents . 36Metabolic Bone Disease Agents - Drugs for Osteoporosis . 36Metabolic Bone Disease Agents - Other . 36Miscellaneous Therapeutic Agents . 36Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation . 37Ophthalmic Agents - Drugs for Glaucoma . 38Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions . 38Otic Agents - Drugs for Ear Conditions. 39Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold . 39Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions. 40Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis . 40Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension . 40Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm . 41Sleep Disorder Agents . 41Index of Drugs . 4310
Drug NameDrugTierNotesAnalgesics - Drugs for Pain andInflammationDrug NameDrugTierbutalbital-apap-caffeineoral tablet1Notescelecoxib oral1butalbital-aspirin-caffeine1diclofenac potassium oraltablet 50 mg1butalbital-aspirin-caffeineoral tablet 50-325-40 mg1diclofenac sodium er1codeine sulfate1QLdiclofenac sodium oral1endocet1QLdiflunisal oral1etodolac11PA; QLflurbiprofen oral1ibuprofen oral tablet 400mg, 600 mg, 800 mgfentanyl transdermalpatch 72 hour 100mcg/hr, 12 mcg/hr, 25mcg/hr, 50 mcg/hr, 75mcg/hr1indomethacin er11QLindomethacin oral capsule25 mg, 50 mghydrocodoneacetaminophen oralsolution1ketorolac tromethamineinjection1hydrocodoneacetaminophen oral tablet10-325 mg, 5-325 mg,7.5-325 mg1QLketorolac tromethamineintramuscular1hydromorphone hcl oral1QLmeclofenamate sodiumoralhydromorphone hcl rectal1QL1levorphanol tartrate oral1PA; QLmeloxicam oral tablet1lorcet hd oral tablet 10325 mg1QLnabumetone oral1lorcet oral tablet 5-325 mg1QLnaproxen oral suspension1naproxen oral tablet1lorcet plus oral tablet 7.5325 mg1QLnaproxen sodium oraltablet 275 mg, 550 mg1methadone hcl oralsolution1ST; QLpiroxicam oral1methadone hcl oral tablet1ST; QLsalsalate oral11ST; QLsulindac oral1methadone hcl oral tabletsolubletolmetin sodium oralcapsule 400 mg1methadose oral tabletsoluble1ST; QLmorphine sulfate(concentrate) oral solution100 mg/5ml, 20 mg/ml1QLmorphine sulfate er oraltablet extended release1ST; QLmorphine sulfate oral1QLmorphine sulfate rectal1QLOXYCODONE HCL ER2ST; QLoxycodone hcl oralconcentrate 100 mg/5ml1QLAnalgesics - Drugs for e#41QLbac1Effective Date: 01/01/202211
DrugTierNotesoxycodone hcl oralsolution1QLoxycodone hcl oral tablet1QLoxycodoneacetaminophen oral tablet10-325 mg, 2.5-325 mg,5-325 mg, 7.5-325 mg1QLoxycodone-aspirin oraltablet 4.8355-325 mg1QLOXYCONTIN2ST; QLtramadol hcl ir1QLtramadol-acetaminophen1QLDrug NameAnestheticsDrug NameDrugTierCHANTIX STARTINGMONTH PAK ORALTABLET 0.5 MG X 11 & 1MG X 422disulfiram oral1goodsense nicotinemouth/throat lozenge 4mg2habitrol1naloxone hcl injection1naltrexone hcl oral1NARCAN1NICORETTEMOUTH/THROAT GUM 2MG2NICORETTEMOUTH/THROATLOZENGE 4 MG2nicotine polacrilex mini2nicotine polacrilexmouth/throat2nicotine step 11glydo1lidocaine external patch 5%1lidocaine hcl (pf) injectionsolution 1 %, 2 %1lidocaine hcl injectionsolution1lidocaine hclurethral/mucosal1lidocaine-prilocaine1nicotine step 21prilovix ultralite1nicotine step 31prilovix ultralite plus1nicotine transdermal kit1varenicline tartrate1VIVITROL2Anti-Addiction / Substance AbuseTreatment Agentsacamprosate calcium1APO-VARENICLINE2buprenorphine hclsublingual1buprenorphine hclnaloxone hcl sublingualtablet sublingual1bupropion hcl er n-potassiumclavulanate1QLampicillin111CHANTIX CONTINUINGMONTH PAK ORALTABLET 1 MGampicillin sodium injectionsolution reconstituted 1gm, 125 mg, 250 mg, 500mg2avidoxy1azithromycin oral1CHANTIX ORAL TABLET0.5 MG, 1 MG2BICILLIN L-A2cefadroxil1Effective Date: 01/01/202212NotesQL
Drug NameDrugTiercefazolin sodium injectionsolution reconstituted 1gm1cefdinir1cefixime1cefprozil1ceftazidime injectionsolution reconstituted 1gm1NotesDrug NameDrugTiergentamicin sulfateexternal1gentamicin sulfateinjection solution 40mg/ml1levofloxacin oral1linezolid oral suspensionreconstituted1linezolid oral tablet1methenamine hippurate1metronidazole oral tablet1metronidazole vaginal1ceftriaxone sodiuminjection solutionreconstituted 1 gm, 2 gm,250 mg, 500 mg1cefuroxime axetil11cephalexin oral capsule250 mg, 500 mgminocycline hcl oralcapsule1mondoxyne nl1cephalexin oralsuspension reconstituted1morgidox oral capsule100 mg1moxifloxacin hcl oral1mupirocin calcium1mupirocin external1CIPRO ORALSUSPENSIONRECONSTITUTED 250MG/5ML (5%)2ciprofloxacin hcl oral1neomycin sulfate oral1clarithromycin oral1nitrofurantoin1clindamycin hcl oral11clindamycin palmitate hcl1nitrofurantoinmacrocrystalclindamycin phosphateinjection solution lindamycin phosphatevaginalokebo oral capsule 75 mg11penicillin v potassium1dicloxacillin sodium1PRIMSOL2doxycycline hyclate oralcapsule1silver sulfadiazineexternal1SIVEXTRO ORAL2doxycycline hyclate oraltablet 100 mg, 150 mg, 50mg, 75 mg1ssd1doxycycline monohydrateoral capsule1sulfamethoxazoletrimethoprim oral1doxycycline monohydrateoral tabletsulfatrim pediatric11FIRVANQ2SUPRAX ORALSUSPENSIONRECONSTITUTED 500MG/5ML2Effective Date: 01/01/202213NotesQLQL
Drug NameDrugTierNotesDrug NameDrugTiertazicef injection1levetiracetam oral1trimethoprim oral1NAYZILAM2vancomycin hcl oralcapsule1oxcarbazepine1vancomycin hcl oralsolution reconstitutedphenobarbital oral111vandazole1phenobarbital oralsolution 20 mg/5mlphenobarbital sodiuminjection solution 130mg/ml1phenytoin infatabs1phenytoin oral1QLAnticoagulantsenoxaparin sodium1QLfondaparinux sodium1QLheparin sodium (porcine)injection solution 1000unit/ml, 10000 unit/ml,5000 unit/ml1phenytoin sodiumextended oral capsule100 mg1heparin sodium (porcine)pf1phenytoin sodiuminjection1jantoven1primidone oral1LOVENOX1roweepra1PRADAXA2warfarin sodium oral11XARELTO2PAroweepra xr oral tabletextended release 24 hour500 mg, 750 mgXARELTO STARTERPACKsubvenite12PAtopiramate oral1valproic acid oral1QLAnticonvulsants - Drugs for Seizurescarbamazepine er1VALTOCO2carbamazepine oral1zonisamide oral1CELONTIN2DIASTAT PEDIATRIC1QLAntidementia Agents - Drugs forAlzheimer's Disease and Dementiadiazepam rectal1QLDILANTIN ORALCAPSULE 30 MGdonepezil hcl oral tablet10 mg, 5 mg12galantaminehydrobromide1divalproex sodium er1divalproex sodium oral1galantaminehydrobromide er1epitol11ethosuximide oral1memantine hcl oral tablet10 mg, 5 mggabapentin oral1rivastigmine tartrate1lamotrigine oral tablet1lamotrigine oral tabletchewablelevetiracetam erAntidepressantsamitriptyline hcl oral11amoxapine11bupropion hcl er (sr)1Effective Date: 01/01/202214NotesPA; QLQLPA; QL
Drug NameDrugTierbupropion hcl er (xl) oraltablet extended release24 hour 150 mg, 300 mg1bupropion hcl oralNotesDrug NameDrugTieraprepitant oral11aprepitant oral capsule125 mg, 80 & 125 mg, 80mg1citalopram hydrobromide1compro1clomipramine hcl oral1dimenhydrinate injection1desipramine hcl oral1dronabinol1doxepin hcl oral capsule1doxepin hcl oralconcentrate11metoclopramide hclinjectionduloxetine hcl oralcapsule delayed releaseparticles 20 mg, 30 mg,60 mgmetoclopramide hcl oralsolution11metoclopramide hcl oraltablet1ondansetron hcl injection1escitalopram oxalate1ondansetron hcl oral1fluoxetine hcl oral capsule1ondansetron odt1fluoxetine hcl oral solution1perphenazine oral1fluvoxamine maleate1prochlorperazine1imipramine hcl oral1maprotiline hcl oral tablet25 mg, 50 mg, 75 mg11prochlorperazineedisylate injectionmirtazapine oral1prochlorperazine maleateoral1nortriptyline hcl oral1Antifungalsparoxetine hcl1ciclodan1PAXIL ORALSUSPENSION2ciclopirox external gel1perphenazineamitriptyline11ciclopirox externalsolutionphenelzine sulfate oral1ciclopirox olamineexternal1protriptyline hcl1clotrimazole mouth/throat1sertraline hcl ne hcl oral tablet1CRESEMBA ORAL2tranylcypromine sulfate1fluconazole oral1trazodone hcl oral1flucytosine oral2venlafaxine hcl1griseofulvin microsize oral1griseofulvin ultramicrosize1itraconazole oral1ketoconazole externalcream1venlafaxine hcl er oralcapsule extended release24 hour1Antiemetics - Drugs for Nausea andVomitingEffective Date: 01/01/202215NotesPA; QLQLPA
Drug NameDrugTierNotesDrug NameDrugTierketoconazole externalshampoo1ketoconazole oral1MESTINON ORALSOLUTION2nyamyc1pyridostigmine bromide er1nystatin external11nystatin mouth/throat1pyridostigmine bromideoralnystatin oral1nystatin-triamcinolone1nystop1terbinafine hcl oral1voriconazole oral1NotesAntimyasthenic AgentsAntimycobacterialsPAAntigout Agentsdapsone oral1ethambutol hcl oral1isoniazid oral1PRIFTIN2pyrazinamide oral1rifabutin1rifampin oral1allopurinol oral1COLCHICINE ORALCAPSULE1colchicine oral tablet1abiraterone acetate1QLcolchicine-probenecid1AFINITOR DISPERZ2PA; QLprobenecid1anastrozole oral1bicalutamide1BRUKINSA2PA; QLCALQUENCE2PA; QLcapecitabine1QLCOTELLIC2PA; QLAntineoplastics - Drugs for CancerAntimigraine Agentsdihydroergotaminemesylate injection1dihydroergotaminemesylate nasal1ERGOMAR2ergotamine-caffeine1cyclophosphamide oralcapsule1MIGERGOT2DROXIA2naratriptan hcl1erlotinib hcl1PArizatriptan benzoate1etoposide oral1QLsumatriptan nasal11PA; QLsumatriptan succinateoraleverolimus oral tablet 10mg, 2.5 mg, 5 mg, 7.5 mg11PA; QLsumatriptan succinaterefilleverolimus oral tabletsoluble1exemestane1sumatriptan 2hydroxyurea oral1imatinib mesylate1sumatriptan succinatesubcutaneous solutionprefilled syringe 6mg/0.5ml1zolmitriptan oral1QLEffective Date: 01/01/202216PA; QLQL
DrugTierNotesIMBRUVICA ORALCAPSULE2PA; QLIMBRUVICA ORALTABLET 140 MG, 420MG, 560 MG2PA; QLIRESSA2PA; QLlapatinib ditosylate1PA; QLletrozole oralDrug NameDrug NameDrugTierNotesAntiparasiticsalbendazole oral1ALINIA e phosphateoral1leucovorin calcium oral1crotan2LEUKERAN2MATULANE2QLEURAX EXTERNALCREAM 10 %2MEKINIST2PA; QL2melphalan1QLEURAX EXTERNALLOTION 10 %mercaptopurine oral1hydroxychloroquinesulfate oral1mesna1KRINTAFEL2MESNEX ORAL2nitazoxanide oral2MYLERAN2QLpermethrin external1NEXAVAR2PAREVLIMID2PA; QLpraziquantel oral1ROZLYTREK2PA; QLprimaquine phosphate1RYDAPT2PA; QLpyrimethamine oral1SPRYCEL2PA; QLULESFIA EXTERNALLOTION 5 %2STIVARGA2PAsunitinib malate1PA; QLSUTENT2PA; QLTABLOID2TAFINLAR2TAGRISSO2tamoxifen citrate oral1temozolomide1QLTHALOMID2PA; QLtretinoin oral1QLVENCLEXTA2PA; QLVENCLEXTA STARTINGPACK2PA; QLVOTRIENT2PA; QLXTANDI ORAL CAPSULE2PA; QLZELBORAF2PAZYDELIG2PA; QLPA; QLAntiparkinson Agentsamantadine hcl oral1benztropine mesylate1PA; QLbromocriptine mesylateoral1PA; QLcarbidopa oral1carbidopa-levodopa er1carbidopa-levodopa oraltablet1carbidopa-levodopa oraltablet dispersible 10-100mg, 25-100 ramipexoledihydrochloride1Effective Date: 01/01/202217PA
DrugTierNotesrasagiline mesylate oral1PAropinirole hclDrug NameDrug NameDrugTierRISPERDAL CONSTA21risperidone oral solution1selegiline hcl oral1risperidone oral tablet1trihexyphenidyl hcl1thiothixene1trifluoperazine hcl1AntiplateletsNotesaspirin-dipyridamole er1ziprasidone hcl1BRILINTA2ZYPREXA RELPREVV2cilostazol1Antiviralsclopidogrel bisulfate oral1abacavir sulfate1dipyridamole oral1prasugrel hcl1abacavir yclovir oral1adefovir dipivoxil1QLAPTIVUS2QLatazanavir sulfate1BARACLUDE ORALSOLUTION2QL2QLAntipsychotics - Drugs for Mood DisordersQLQLABILIFY MAINTENA2aripiprazole oral solution1aripiprazole oral tablet1ARISTADA2QLARISTADA INITIO2QLchlorpromazine hclinjection1chlorpromazine hcl oraltablet1BIKTARVY ORALTABLET 50-200-25 MG1CIMDUO2QLclozapine oral tabletCOMPLERA2PA; QLfluphenazine decanoateinjection12fluphenazine hcl1CRIXIVAN ORALCAPSULE 200 MG, 400MGhaloperidol decanoateintramuscular1DESCOVY2haloperidol lactate11haloperidol oral1didanosine oral capsuledelayed release 200 mg,250 mg, 400 mgINVEGA HAFYERA2DOVATO2INVEGA SUSTENNA2EDURANT2INVEGA TRINZA2efavirenz1loxapine mtricitabine1quetiapine fumarate1emtricitabine-tenofovir df1quetiapine fumarate er1QLQLEffective Date: 01/01/202218PA; QLQL
Drug NameDrugTierNotesEMTRIVA ORALSOLUTION2entecavir1EPCLUSA ORALPACKET 150-37.5 MG2PA; QLEPCLUSA ORALTABLET2PA; QLEPIVIR HBV ORALSOLUTION2etravirine1fosamprenavir calcium1GENVOYA2HARVONI2INTELENCE ORALTABLET 25 MG2QLPA; QLDrug NameDrugTierNotesPEGASYS2QLPEGASYS PROCLICKSUBCUTANEOUSSOLUTION AUTOINJECTOR 180MCG/0.5ML2QLPEGINTRONSUBCUTANEOUS KIT 50MCG/0.5ML2QLPREVYMIS ORAL2PA; QLPREZCOBIX2QLPREZISTA2RELENZA DISKHALER2RESCRIPTOR ORALTABLET 200 MG2REYATAZ ORALPACKET2ribavirin ora
Oct 01, 2021 · The drug formulary is updated periodically and is subject to change. If a drug will be removed from the formulary, members who filled the drug in the prior three months will be notified by letter of the upcoming change. A formulary change notice will also be posted on the mem
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.
Nov 01, 2019 · Anthem Blue MedicareRx Standard (PDP)’s Formulary?” Drugs removed from the market. 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 pr
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. Other changes. We may make other changes that affect members c
MDwise Formulary Introduction – Hoosier Healthwise (HHW) HHW members must use MDwise network pharmacies to access their prescription drug benefit. How do I use the formulary? There are two ways to find your drug within the formulary: Medical Condition Drugs in this formulary are grouped into categories depending on the type of medical
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. o If we make these other change
Blue Cross Blue Shield of North Dakota Drug Formulary . January 2021 Please consider talking to your doctor about prescribing formulary medications, which may help reduce your out-of-pocket costs. This list may help guide you and your doctor in selecting an appropriate medication for you. The drug formulary is regularly updated.
Die Zivilgerichtsklausur im Assessorexamen " Band II: Wiederholung und Vertiefung - Kaiser / Kaiser / Kaiser, Inhaltsverzeichnis Author: Horst Kaiser, Jan Kaiser, Torsten Kaiser - Verlag C.H. Beck Subject: Die Zivilgerichtsklausur im Assessorexamen " Band II: Wiederholung und Vertie
Un additif alimentaire est défini comme ‘’ n’importe quelle substance habituellement non consommée comme un aliment en soi et non employée comme un ingrédient caractéristique de l’aliment, qu’il ait un une valeur nutritionnelle ou non, dont l’addition intentionnelle à l’aliment pour un but technologique dans la fabrication, le traitement, la préparation, l’emballage, le .
