(List Of Covered Drugs) - MDA Programs
SilverScript2017 Formulary(List of Covered Drugs)PLEASE READ: THIS DOCUMENT CONTAINSINFORMATION ABOUT THE DRUGS WE COVER IN THIS PLANFormulary File 17255, Version 6This formulary was updated on August 1, 2016. For more recent information or other questions, pleasecontact SilverScript at 1-866-235-5660 or, for TTY users, 711, 24 hours a day, 7 days a week, or visitwww.silverscript.com.Note to existing members: This formulary has changed since last year. Please review this document tomake sure that it still contains the drugs you take.When this drug list (formulary) refers to “we,” “us,” or “our,” it means SilverScript Insurance Company. Whenit refers to “plan” or “our plan,” it means SilverScript Choice (PDP).This document includes a list of the drugs (formulary) for our plan which is current as ofJanuary 1, 2017. For an updated formulary, please contact us. Our contact information, along with the datewe 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 timeduring the year.Y0080 62001 FORM COMP 2017 AcceptedFRM-CM-CHC-9110-17
What is the SilverScriptFormulary?A formulary is a list of covered drugs selected bySilverScript Choice (PDP) in consultation with ateam of health care providers, which representsthe prescription therapies believed to be anecessary part of a quality treatment program.Our plan will generally cover the drugs listed inour formulary as long as the drug is medicallynecessary, the prescription is filled at a plannetwork pharmacy, and other plan rules arefollowed. For more information on how to fill yourprescriptions, please review your Evidence ofCoverage.Can the Formulary (drug list)change?Generally, if you are taking a drug on our 2017formulary that was covered at the beginning ofthe year, we will not discontinue or reducecoverage of the drug during the 2017 coverageyear except when a new, less expensive genericdrug becomes available or when new adverseinformation about the safety or effectiveness of adrug is released.Other types of formulary changes, such asremoving a drug from our formulary, will not affectmembers who are currently taking the drug. It willremain available at the same cost-sharing forthose members taking it for the remainder of thecoverage year.We feel it is important that you have continuedaccess for the remainder of the coverage year tothe formulary drugs that were available when youchose our plan, except for cases in which you cansave additional money or we can ensure yoursafety.If the Food and Drug Administration deems adrug on our formulary to be unsafe or the drug’smanufacturer removes the drug from the market,we will immediately remove the drug from ourformulary and provide notice to members whotake the drug.The enclosed formulary is current as of January1, 2017. To get updated information about thedrugs covered by SilverScript Choice (PDP),please contact us. Our contact informationappears on the front and back cover pages.If we have other types of mid-yearnon-maintenance formulary changes unrelated tothe reasons stated above (e.g. remove drugsfrom our formulary, add prior authorizationrequirements, quantity limits and/or step therapyrestrictions on a drug, or move a drug to a highercost-sharing tier), we will notify you by mail. Wewill also update our formulary with the newinformation. The updated formulary may beobtained from our website or by calling us. Ourcontact information appears on the front and backcover pages.How do I use the Formulary?There are two ways to find your drug within theformulary:Medical ConditionThe formulary begins on page 7. The drugs in thisformulary are grouped into categories dependingon the type of medical conditions that they areused to treat. For example, drugs used to treat aheart condition are listed under the category,“Cardiovascular”. If you know what your drug isused for, look for the category name in the listthat begins on page 7. Then look under thecategory name for your drug.If we remove drugs from our formulary, add priorauthorization, quantity limits and/or step therapyrestrictions on a drug, or move a drug to a highercost-sharing tier, we must notify affectedmembers of the change at least 60 days beforethe change becomes effective, or at the time themember requests a refill of the drug, at whichtime the member will receive a 60-day supply ofthe drug.1
Alphabetical ListingStep Therapy (ST)If you are not sure what category to look under,you should look for your drug in the Index thatbegins on page 52. The Index provides analphabetical list of all of the drugs included in thisdocument. Both brand name drugs and genericdrugs are listed in the Index. Look in the Indexand find your drug. Next to your drug, you will seethe page number where you can find coverageinformation. Turn to the page listed in the Indexand find the name of your drug in the first columnof the list.In some cases, SilverScript Choice (PDP)requires you to first try certain drugs to treat yourmedical condition before we will cover anotherdrug for that condition. For example, if Drug Aand Drug B both treat your medical condition, wemay not cover Drug B unless you try Drug A first.If Drug A does not work for you, we will thencover Drug B.What are generic drugs?SilverScript Choice (PDP) covers both brandname drugs and generic drugs. A generic drug isapproved by the FDA as having the same activeingredient as the brand name drug. Generally,generic drugs cost less than brand name drugs.Are there any restrictions onmy coverage?Some covered drugs may have additionalrequirements or limits on coverage. Theserequirements and limits may include:Prior Authorization (PA)You can find out if your drug has any additionalrequirements or limits by looking in the formularythat begins on page 7. You can also get moreinformation about the restrictions applied tospecific covered drugs by visiting our website. Wehave posted on line documents that explain ourprior authorization and step therapy restrictions.You may also ask us to send you a copy. Ourcontact information, along with the date we lastupdated the formulary, appears on the front andback cover pages.You can ask us to make an exception to theserestrictions or limits or for a list of other, similardrugs that may treat your health condition. Seethe section, “How do I request an exception to theSilverScript formulary?” on page 3 for informationabout how to request an exception.SilverScript Choice (PDP) requires you or yourphysician to get prior authorization for certaindrugs. This means that you will need to getapproval from us before you fill yourprescriptions. If you don’t get approval, we maynot cover the drug.What if my drug is not on theFormulary?Quantity Limits (QL)If you learn that SilverScript Choice (PDP) doesnot cover your drug, you have two options:For certain drugs, SilverScript Choice (PDP)limits the amount of the drug that we will cover.For example, our plan provides up to 30 tabletsper prescription for doxazosin. This may be inaddition to a standard one-month or three-monthsupply.If your drug is not included in this formulary (list ofcovered drugs), you should first contact CustomerCare and ask if your drug is covered. You can ask Customer Care for a list ofsimilar drugs that are covered by our plan.When you receive the list, show it to yourdoctor and ask him or her to prescribe asimilar drug that is covered by our plan. You can ask us to make an exception andcover your drug. See below forinformation about how to request anexception.2
How do I request an exceptionto the SilverScript Formulary?You can ask us to make an exception to ourcoverage rules. There are several types ofexceptions that you can ask us to make. You can ask us to cover a drug even if it isnot on our formulary. If approved, thisdrug will be covered at a pre-determinedcost-sharing level, and you would not beable to ask us to provide the drug at alower cost-sharing level. You can ask us to cover a formulary drugat a lower cost-sharing level if this drug isnot on the specialty tier. If approved thiswould lower the amount you must pay foryour drug. You can ask us to waive coveragerestrictions or limits on your drug. Forexample, for certain drugs, our plan limitsthe amount of the drug that we will cover.If your drug has a quantity limit, you canask us to waive the limit and cover agreater amount.Generally, SilverScript Choice (PDP) will onlyapprove your request for an exception if thealternative drugs included on the plan’s formulary,the lower cost-sharing drug or additionalutilization restrictions would not be as effective intreating your condition and/or would cause you tohave adverse medical effects.You should contact us to ask us for an initialcoverage decision for a formulary, tiering orutilization restriction exception. When yourequest a formulary, tiering or utilizationrestriction exception you should submit astatement from your prescriber or physiciansupporting your request.Generally, we must make our decision within 72hours of getting your prescriber’s supportingstatement. You can request an expedited (fast)exception if you or your doctor believe that yourhealth could be seriously harmed by waiting up to72 hours for a decision.If your request to expedite is granted, we mustgive you a decision no later than 24 hours afterwe get a supporting statement from your doctoror other prescriber.What do I do before I can talkto my doctor about changingmy drugs or requesting anexception?As a new or continuing member in our plan youmay be taking drugs that are not on ourformulary. Or, you may be taking a drug that is onour formulary but your ability to get it is limited.For example, you may need a prior authorizationfrom us before you can fill your prescription. Youshould talk to your doctor to decide if you shouldswitch to an appropriate drug that we cover orrequest a formulary exception so that we willcover the drug you take.While you talk to your doctor to determine theright course of action for you, we may cover yourdrug in certain cases during the first 90 days youare a member of our plan.For each of your drugs that is not on ourformulary or if your ability to get your drugs islimited, we will cover a temporary 30-day supply(unless you have a prescription written for fewerdays) when you go to a network pharmacy.After your first 30-day supply, we will not pay forthese drugs, even if you have been a member ofthe 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 wehave provided you with a 102-day transitionsupply, consistent with the dispensing increment,(unless you have a prescription written for fewerdays). We will cover more than one refill of thesedrugs for the first 90 days you are a member ofour plan. If you need a drug that is not on ourformulary or if your ability to get your drugs islimited, but you are past the first 90 days ofmembership in our plan, we will cover a 34-dayemergency supply of that drug (unless you havea prescription for fewer days) while you pursue aformulary exception.3
If you experience a change in your level of care,such as a move from a home to a long-term caresetting, and need a drug that is not on ourformulary (or if your ability to get your drugs islimited), we may cover a one-time temporarysupply from a network pharmacy for up to 34 daysunless you have a prescription for fewer days.You should use the plan's exception process ifyou wish to have continued coverage of the drugafter the temporary supply is finished.For more informationFor more detailed information about yourSilverScript Choice (PDP) prescription drugcoverage, please review your Evidence ofCoverage and other plan materials.If you have questions about our plan, pleasecontact us. Our contact information, along withthe date we last updated the formulary, appearson the front and back cover pages.If you have general questions about Medicareprescription drug coverage, please call Medicareat 1-800-MEDICARE (1-800-633-4227), 24 hoursa day, 7 days a week. TTY users should call1-877-486-2048. Or, visithttp://www.medicare.gov.SilverScript Choice (PDP)’sFormularyThe formulary that begins on page 7 providescoverage information about the drugs covered byour plan. If you have trouble finding your drug inthe list, turn to the Index that begins on page 52.The first column of the chart lists the drug name.Brand name drugs are capitalized (e.g.,SYNTHROID) and generic drugs are listed inlower-case italics (e.g., levothyroxine).4The information in the Requirements/Limitscolumn tells you if our plan has any specialrequirements for coverage of your drug.PA – Prior authorization.QL – Drug has quantity limit.ST – Step therapy required.NM – Not available at our mail-order pharmacies.NDS – Non-extended day supply. Not availablefor an extended (long-term) supply.LA – Limited access. This prescription may beavailable only at certain pharmacies. For moreinformation consult your Pharmacy Directory orcall Customer Care at 1-866-235-5660, 24 hoursa day, 7 days a week. TTY users should call 711.HR – High Risk Drug. According to medicalexperts, these drugs may cause more side effectsif you are 65 years of age or older. If you aretaking one of these drugs, ask your doctor if thereare safer options available.B/D – This drug may be covered under MedicarePart B or Part D depending upon thecircumstances. Information may need to besubmitted describing the use and setting of thedrug to make the determination.GC – We provide additional coverage of thisprescription drug in the coverage gap. Pleaserefer to our Evidence of Coverage for moreinformation about this coverage.
The Tier column of the drug list that begins on page 7 tells you which tier your drug is in. The table belowtells you the copayment or coinsurance amount (i.e., the share of the drug's cost that you will pay during theinitial coverage stage) for up to a one-month supply of drugs in each tier.Initial Coverage Stage Copayment / Coinsurance LevelsStandard retail cost-sharing (in-network) (Up to a 30-day supply)Tier 1(PreferredGeneric)State(includes lowcost preferredgeneric drugs)Tier 2(Generic)Tier 3(PreferredBrand)Tier 4(Non-PreferredDrug)(includes(includesgeneric and(includesnon-preferredsome low cost preferred brandbrand andpreferredand non-preferred non-preferredbrand drugs)generic drugs) generic drugs)Tier 5(SpecialtyTier)(includes highcost genericand branddrugs)Alabama 3.00 13.00 45.0050%33%Alaska 1.00 4.0015%35%25%Arizona 7.00 20.00 47.0050%33%Arkansas 3.00 13.00 46.0050%33%California 3.00 17.00 47.0048%33%Colorado 3.00 20.00 47.0050%33%Connecticut 3.00 13.00 42.0044%33%Delaware 3.00 19.00 47.0050%33%District of Columbia 3.00 19.00 47.0050%33%Florida 4.00 20.00 47.0050%33%Georgia 3.00 13.00 46.0050%33%Hawaii 1.00 4.0017%36%25%Idaho 3.00 14.00 45.0050%33%Illinois 3.00 18.00 46.0050%33%Indiana 3.00 14.00 45.0050%33%Iowa 3.00 14.00 42.0048%33%Kansas 3.00 14.00 45.0050%33%Kentucky 3.00 14.00 45.0050%33%Louisiana 3.00 12.00 43.0047%33%Maine 3.00 17.00 46.0050%33%Maryland 3.00 19.00 47.0050%33%Massachusetts 3.00 13.00 42.0044%33%Michigan 3.00 14.00 45.0049%33%Minnesota 3.00 14.00 42.0048%33%Mississippi 3.00 14.00 45.0050%33%Missouri 3.00 12.00 43.0047%33%Montana 3.00 14.00 42.0048%33%Nebraska 3.00 14.00 42.0048%33%5
Tier 1(PreferredGeneric)Tier 2(Generic)Tier 3(PreferredBrand)Tier 4(Non-PreferredDrug)(includes(includesgeneric andnon-preferred(includessome low cost preferred brandbrand andpreferredand non-preferred non-preferredbrand drugs)generic drugs) generic drugs)Tier 5(SpecialtyTier)(includes highcost genericand branddrugs)State(includes lowcost preferredgeneric drugs)Nevada 7.00 20.00 47.0050%33%New Hampshire 3.00 17.00 46.0050%33%New Jersey 3.00 15.00 47.0049%33%New Mexico 3.00 15.00 47.0050%33%New York 3.00 13.00 46.0048%33%North Carolina 3.00 14.00 45.0050%33%North Dakota 3.00 14.00 42.0048%33%Ohio 3.00 17.00 46.0049%33%Oklahoma 3.00 12.00 43.0049%33%Oregon 3.00 12.00 44.0048%33%Pennsylvania 3.00 13.00 45.0050%33%Rhode Island 3.00 13.00 42.0044%33%South Carolina 3.00 17.00 47.0050%33%South Dakota 3.00 14.00 42.0048%33%Tennessee 3.00 13.00 45.0050%33%Texas 3.00 20.00 47.0050%33%Utah 3.00 14.00 45.0050%33%Vermont 3.00 13.00 42.0044%33%Virginia 3.00 18.00 47.0050%33%Washington 3.00 12.00 44.0048%33%West Virginia 3.00 13.00 45.0050%33%Wisconsin 3.00 12.00 43.0046%33%Wyoming 3.00 14.00 42.0048%33%You can find complete cost-sharing information, including costs for long-term supplies and mail-order,long-term care, and out-of-network pharmacy pricing, in your Evidence of Coverage.6
2017 SSI Choice 17255 v6 eff 01/01/2017Drug NameDrug Requirements/TierLimitsANALGESICSGOUTallopurinol tab (generic ofZYLOPRIM)colchicine w/ probenecidCOLCRYSQL (120 tabs / 30 days)probenecidULORIC233QLDrug Requirements/TierLimitsnaproxen sodium TABS275mgnaproxen sodium (generic ofANAPROX DS) TABS550mgsulindac TABS442OPIOID ANALGESICS33ST4QL4QL4QLNSAIDScelecoxib (generic ofCELEBREX) CAPS 50mgQL (240 caps / 30 days)celecoxib (generic ofCELEBREX) CAPS 100mgQL (120 caps / 30 days)celecoxib (generic ofCELEBREX) CAPS 200mgQL (60 caps / 30 days)celecoxib (generic ofCELEBREX) CAPS 400mgQL (30 caps / 30 days)diclofenac potassiumQL (120 tabs / 30 days)diclofenac sodium TB24diclofenac sodium TBECdiflunisaletodolac CAPS; TABSflurbiprofen TABSibuprofen SUSPibuprofen TABS 400mg,600mg, 800mgketoprofen CAPSMELOXICAM SUSPmeloxicam (generic ofMOBIC) TABSnabumetone TABSnaproxen (generic ofNAPROSYN) SUSPnaproxen (generic ofNAPROSYN) TABS 250mg,500mgnaproxen TABS 375mgnaproxen (generic ofEC-NAPROSYN) TBECDrug Name4QL3QL224433234123112acetaminophen w/ codeineSOLNQL (5000 mL / 30 days)acetaminophen w/ codeineTABSQL (400 tabs / 30 days)acetaminophen w/ codeine(generic ofTYLENOL/CODEINE #3)TABSQL (400 tabs / 30 days)acetaminophen w/ codeine(generic ofTYLENOL/CODEINE #4)TABSQL (400 tabs / 30 days)butorphanol tartrate SOLN1mg/ml, 2mg/mlBUTRANS 5mcg/hrQL (16 patches / 28days)BUTRANS 10mcg/hrQL (8 patches / 28 days)BUTRANS 15mcg/hr,20mcg/hrQL (4 patches / 28 days)BUTRANS 7.5MCG/HRQL (8 patches / 28 days)nalbuphine hcl (generic ofNUBAIN) SOLN 10mg/mlnalbuphine hcl SOLN20mg/mltramadol hcl (generic ofULTRAM) TABSQL (240 tabs / 30 days)tramadol-acetaminophen(generic of ULTRACET)QL (240 tabs / 30 days)2QL2QL2QL2QL43QL3QL3QL3QL442QL3QL4B/DOPIOID ANALGESICS, CIIDURAMORPHPA - Prior AuthorizationQL - Quantity LimitsST - Step TherapyNM - Not available atmail-orderB/D - Covered under Medicare B or DLA - Limited AccessNDS Non-Extended Days SupplyHR - High Risk Medication7
2017 SSI Choice 17255 v6 eff 01/01/2017Drug NameDrug Requirements/TierLimitsEMBEDAQL (60 caps / 30 days)endocet (generic ofPERCOCET)QL (360 tabs / 30 days)fentanyl citrate (generic ofACTIQ) LPOPQL (120 lozenges / 30days)fentanyl patch 12 mcg/hr(generic of DURAGESIC)QL (10 patches / 30days)fentanyl patch 25 mcg/hr(generic of DURAGESIC)QL (10 patches / 30days)fentanyl patch 50 mcg/hr(generic of DURAGESIC)QL (10 patches / 30days)fentanyl patch 75 mcg/hr(generic of DURAGESIC)QL (10 patches / 30days)fentanyl patch 100 mcg/hr(generic of DURAGESIC)QL (10 patches / 30days)FENTORAQL (120 tabs / 30 days)hydroco/apap tab 5-325mg(generic of NORCO)QL (360 tabs / 30 days)hydroco/apap tab 7.5-325mg(generic of NORCO)QL (360 tabs / 30 days)hydroco/apap tab 10-325mg(generic of NORCO)QL (360 tabs / 30 days)hydrocodone-acetaminophen7.5-325 mg/15ml (generic ofHYCET)QL (5400 mL / 30 days)hydrocodone-ibuprofen7.5-200mg (generic ofVICOPROFEN)QL (150 tabs / 30 days)3QL3QL5 NDS QL PA44QLQL4QL4QL4QL5 NDS QL PA22243QLQLQLQLQLDrug NameDrug Requirements/TierLimitshydromorphone hcl (genericof DILAUDID) LIQDhydromorphone hcl SOLN10mg/ml, 50mg/5ml,500mg/50mlhydromorphone hcl (genericof DILAUDID) TABSQL (270 tabs / 30 days)HYSINGLA ER 20mg, 30mg,40mg, 60mgQL (60 tabs / 30 days)HYSINGLA ER 80mg,100mg, 120mgQL (30 tabs / 30 days)lorcet plus tab 7.5-325(generic of NORCO)QL (360 tabs / 30 days)lorcet tab 5-325mg (generic ofNORCO)QL (360 tabs / 30 days)lortab tab 5-325mg (generic ofNORCO)QL (360 tabs / 30 days)lortab tab 7.5-325 (generic ofNORCO)QL (360 tabs / 30 days)lortab tab 10-325mg (genericof NORCO)QL (360 tabs / 30 days)methadone hcl (generic ofMETHADOSE) CONCQL (120 mL / 30 days)methadone hcl SOLN5mg/5ml, 10mg/5mlQL (600 mL / 30 days)methadone hcl 5mg (genericof DOLOPHINE)QL (240 tabs / 30 days)methadone hcl 10mg (genericof DOLOPHINE)QL (240 tabs / 30 days)morphine ext-rel tab (genericof MS CONTIN) 15mg,30mg, 60mg, 100mgQL (90 tabs / 30 days)morphine ext-rel tab (genericof MS CONTIN) 200mgQL (60 tabs / 30 QLPA - Prior AuthorizationQL - Quantity LimitsST - Step TherapyNM - Not available atmail-orderB/D - Covered under Medicare B or DLA - Limited AccessNDS Non-Extended Days SupplyHR - High Risk Medication8
2017 SSI Choice 17255 v6 eff 01/01/2017Drug NameDrug Requirements/TierLimitsMORPHINE SUL INJ1MG/MLMORPHINE SUL INJ2MG/MLMORPHINE SUL INJ4MG/MLMORPHINE SUL INJ10MG/MLMORPHINE SUL INJ15MG/MLmorphine sulfate (generic ofMORPHINE SULFATE)SOLN 4mg/ml, 8mg/mlMORPHINE SULFATESOLN 8mg/ml, 150mg/30mlmorphine sulfate SOLN.5mg/ml, 1mg/mlMORPHINE SULFATETABSQL (180 tabs / 30 days)MORPHINE SULFATE ORALSOLOPANA ER (CRUSHRESISTANT)QL (120 tabs / 30 days)oxycodone hcl CAPSQL (180 caps / 30 days)oxycodone hcl CONCOXYCODONE HCL SOLNoxycodone hcl (generic ofROXICODONE) TABS 5mg,15mg, 30mgQL (180 tabs / 30 days)oxycodone hcl TABS 10mg,20mgQL (180 tabs / 30 days)oxycodone w/ acetaminophen2.5-325mg (generic ofPERCOCET)QL (360 tabs / 30 days)oxycodone w/ acetaminophen5-325mg (generic ofPERCOCET)QL (360 tabs / 30 days)4B/D4B/D4B/D4B/D4B/D4B/D4B/D4B/D3QLDrug NameDrug Requirements/TierLimitsoxycodone w/ acetaminophen7.5-325mg (generic ofPERCOCET)QL (360 tabs / 30 days)oxycodone w/ acetaminophen10-325mg (generic ofPERCOCET)QL (360 tabs / 30 days)oxycodone w/ acetaminophensolnQL (1800 mL / 30 days)OXYCONTINQL (120 tabs / 30 days)roxicet solnQL (1800 mL / 30 days)roxicet tab 5-325mg (genericof PERCOCET)QL (360 tabs / 30 STHETICSLOCAL ANESTHETICS3344433QLQLQLQLlidocaine hcl (local anesth.)(generic ofXYLOCAINE-MPF) 1%lidocaine hcl (local anesth.)(generic of XYLOCAINE).5%lidocaine inj 0.5% (generic ofXYLOCAINE-MPF)lidocaine inj 1% (generic ofXYLOCAINE)lidocaine inj 1.5% (generic ofXYLOCAINE-MPF)lidocaine inj 2% (generic ofXYLOCAINE)ANTI-INFECTIVESANTI-BACTERIALS - MISCELLANEOUS3QL3QLamikacin sulfate SOLNgentamicin in salinegentamicin sulfate SOLNgentamicin sulfate/0.9% sneomycin sulfate TABSparomomycin sulfate CAPSstreptomycin sulfate SOLRsulfadiazine TABStobramycin (generic of TOBI)NEBU444434445 NDS NM PAPA - Prior AuthorizationQL - Quantity LimitsST - Step TherapyNM - Not available atmail-orderB/D - Covered under Medicare B or DLA - Limited AccessNDS Non-Extended Days SupplyHR - High Risk Medication9
2017 SSI Choice 17255 v6 eff 01/01/2017Drug NameDrug Requirements/TierLimitstobramycin inj 1.2 gm/30mltobramycin inj 1.2gmtobramycin inj 10mg/mltobramycin inj 40mg/mltobramycin inj 80mg/2ml45444NDSANTI-INFECTIVES - MISCELLANEOUSALBENZAALINIAatovaquone (generic ofMEPRON) SUSPAZACTAM IN ISO-OSMOTICDEAZACTAM/DEX INJ 2GMaztreonam (generic ofAZACTAM)BILTRICIDECAYSTONclindamycin cap 75mg(generic of CLEOCIN)clindamycin cap 300mg(generic of CLEOCIN)clindamycin hcl cap 150 mg(generic of CLEOCIN)clindamycin phosphate(generic of CLEOCINPHOSPHATE) SOLNclindamycin phosphate in d5w(generic of CLEOCIN IND5W)clindamycin phosphate inj(generic of CLEOCINPHOSPHATE)clindamycin sol 75mg/5ml(generic of CLEOCINPEDIATRIC GRANULE)colistimethate sodium(generic of COLY-MYCIN M)SOLRCUBICINdapsone TABSemvermimipenem-cilastatin (genericof PRIMAXIN IV)INVANZ545NDSNDS44335 NDS NM LAPA2224444453444NDSDrug NameDrug Requirements/TierLimitsivermectin (generic ofSTROMECTOL) TABSlinezolid (generic of ZYVOX)SOLNLINEZOLID SUSR; TABSLINEZOLID IN SODIUMCHLORIDEmeropenem (generic ofMERREM)methenamine hippurate(generic of HIPREX)metronidazole (generic ofFLAGYL) TABSmetronidazole in naclNEBUPENTnitrofurantoin macrocrystal(generic of MACRODANTIN)50mg, 100mgPA applies if 70 years andolder after a 90 day supplyin a calendar year; HRnitrofurantoin monohyd macro(generic of MACROBID)PA applies if 70 years andolder after a 90 day supplyin a calendar year; HRPENTAM 300SIVEXTROsulfamethoxazole-trimethopds (generic of BACTRIM DS)sulfamethoxazole-trimethoprim injsulfamethoxazole-trimethoprim suspsulfamethoxazole-trimethoprim tab (generic of BACTRIM)SYNERCIDtrimethoprim TABSTYGACILvancomycin hcl (generic ofVANCOCIN HCL) CAPSvancomycin hcl SOLRVANCOMYCIN IN NDS44ANTIFUNGALSABELCETAMBISOME54NDS B/DB/DPA - Prior AuthorizationQL - Quantity LimitsST - Step TherapyNM - Not available atmail-orderB/D - Covered under Medicare B or DLA - Limited AccessNDS Non-Extended Days SupplyHR - High Risk Medication10
2017 SSI Choice 17255 v6 eff 01/01/2017Drug NameDrug Requirements/TierLimitsamphotericin b SOLRCANCIDASfluconazole (generic ofDIFLUCAN) SUSRfluconazole (generic ofDIFLUCAN) TABSfluconazole in dextrosefluconazole inj nacl 100fluconazole inj nacl 200fluconazole inj nacl 400flucytosine (generic ofANCOBON) CAPSgriseofulvin microsize SUSPgriseofulvin microsize TABSgriseofulvin ultramicrosize(generic of GRIS-PEG)itraconazole (generic ofSPORANOX) CAPSketoconazole TABSMYCAMINENOXAFIL SUSP; TBECnystatin TABSterbinafine hcl (generic ofLAMISIL) TABSvoriconazole (generic ofVFEND IV) SOLRvoriconazole (generic ofVFEND) SUSR; MALARIALSatovaquone-proguanil hcl(generic of MALARONE)chloroquine phosphateTABS 250mgchloroquine phosphate(generic of ARALEN) TABS500mgCOARTEMmefloquine hclPRIMAQUINE PHOSPHATEquinine sulfate (generic ofQUALAQUIN) CAPS4334334PAANTIRETROVIRAL AGENTSabacavir sulfate (generic ofZIAGEN)APTIVUS35NDSDrug NameDrug Requirements/TierLimitsCRIXIVANdidanosine (generic of VIDEXEC)EDURANTEMTRIVAFUZEONINTELENCE 25mgINTELENCE 100mg, 200mgINVIRASEISENTRESS CHEW 25mgISENTRESS CHEW 100mgISENTRESS PACKISENTRESS TABSlamivudine (generic ofEPIVIR)LEXIVA SUSPLEXIVA TABSNEVIRAPINE SUSP 50MG/5MLnevirapine tab 100mg(generic of VIRAMUNE XR)nevirapine tab 200mg(generic of VIRAMUNE)nevirapine tb24 (generic ofVIRAMUNE XR)NORVIRPREZISTA SUSPPREZISTA TABS 75mg,150mgPREZISTA TABS 600mg,800mgRESCRIPTORRETROVIR IV INFUSIONREYATAZSELZENTRYstavudine (generic of ZERIT)SUSTIVA CAPS 50mgSUSTIVA CAPS 200mgSUSTIVA TABSTIVICAY 10mgTIVICAY 25mg, 50mgTYBOSTVIDEX PEDIATRICVIRACEPTVIREAD4453545535553NDSNDS PA - Prior AuthorizationQL - Quantity LimitsST - Step TherapyNM - Not available atmail-orderB/D - Covered under Medicare B or DLA - Limited AccessNDS Non-Extended Days SupplyHR - High Risk MedicationNDSNDSNDSNDSNDSNDSNDS11
2017 SSI Choice 17255 v6 eff 01/01/2017Drug NameDrug Requirements/TierLimitsVITEKTAZIAGEN SOLNzidovudine (generic ofRETROVIR) CAPS; SYRPzidovudine TABS534NDS3ANTIRETROVIRAL dine(generic of AKALETRA SOLKALETRA TAB 100-25MGKALETRA TAB 200-50MGlamivudine-zidovudine(generic of COMBIVIR)ODEFSEYPREZCOBIXSTRIBILDTRIUMEQTRUVADA TAB 100-150QL (60 tabs / 30 days)TRUVADA TAB 133-200QL (30 tabs / 30 days)TRUVADA TAB 167-250QL (30 tabs / 30 days)TRUVADA TAB 200-300QL (30 tabs / 30 days)5NDSDrug Requirements/TierLimitsrifabutin (generic ofMYCOBUTIN)rifampin (generic of RIFADIN)CAPSrifampin (generic of RIFADIN)SOLRRIFATERSIRTUROTRECATOR43445 NDS LA DSNDSNDSNDSNDS QL5NDS QL5NDS QL5NDS QLNDSANTITUBERCULAR AGENTSCAPASTAT SULFATEcycloserine CAPSethambutol hcl (generic ofMYAMBUTOL) TABSisoniazid TABSisoniazid inj 100 mg/mlisoniazid syp 50mg/5mlpaser d/rPRIFTINpyrazinamide TABSDrug Name454244344NDSacyclovir (generic ofZOVIRAX) CAPSacyclovir (generic ofZOVIRAX) SUSPacyclovir (generic ofZOVIRAX) TABSacyclovir sodium SOLNacyclovir sodium SOLR500mgadefovir dipivoxil (generic ofHEPSERA)BARACLUDE SOLNDAKLINZAentecavir (generic ofBARACLUDE)EPIVIR HBV SOLNfamciclovir (generic ofFAMVIR) TABSganciclovir inj 500mg (genericof CYTOVENE)lamivudine (hbv) (generic ofEPIVIR HBV)moderiba tab 200mg (genericof COPEGUS)PEGASYSPEGASYS PROCLICKREBETOL SOL 40MG/MLRELENZA DISKHALERribasphere (generic ofREBETOL) CAPSribasphere (generic ofCOPEGUS) TABS 200mgribasphere TABS 400mg,600mgribavirin cap 200mg (genericof REBETOL)24244B/DB/D5NDS5NDS5 NDS NM PA5NDS433B/D44NM5 NDS NM PA5 NDS NM PA5 NDS NM33NM4NM5NDS NM3NMPA - Prior AuthorizationQL - Quantity LimitsST - Step TherapyNM - Not available atmail-orderB/D - Covered under Medicare B or DLA - Limited AccessNDS Non-Extended Days SupplyHR - High Risk Medication12
2017 SSI Choice 17255 v6 eff 01/01/2017Drug NameDrug Requirements/TierLimitsribavirin tab 200mg (genericof COPEGUS)rimantadine hydrochloride(generic of FLUMADINE)SOVALDITAMIFLUTYZEKAvalacyclovir hcl (generic ofVALTREX) TABSVALCYTE SOLRvalganciclovir hcl (generic ofVALCYTE)445 NDS NM PA35NDS355CEPHALOSPORINScefaclor CAPScefaclor SUSRcefaclor er tab 500mgcefadroxil CAPScefadroxil SUSRcefadroxil TABSCEFAZOLIN IN DEXTROSE2GM/100ML-4%cefazolin injcefazolin sodium 1gm, 20gmcefazolin sodium 1 gm/50mlcefdinir CAPScefdinir SUSRcefepime hcl (generic ofMAXIPIME)cefixime (generic of SUPRAX)cefotaxime sodium (generic ofCLAFORAN) 1gm, 2gm,500mgcefoxitin sodiumcefpodoxime proxetilcefprozil SUSRcefprozil TABSceftazidime (generic ofFORTAZ)CEFTAZIDIME/DEXTROSEceftriaxone sodium (generic ofROCEPHIN) SOLR 1gmceftriaxone sodium SOLR1gm, 2gm, 10gm, 250mg,500mgNM34423444443444444434444NDSNDSDrug NameDrug Requirements/TierLimitscefuroxime axetil (generic ofCEFTIN)cefuroxime sodium (generic ofZINACEF) 1.5gm, 7.
Aug 01, 2016 · 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 January 1, 2017. To get updated informat
Drugs in this tier are non-preferred brand drugs, covered drugs not on the drug list and covered brand drugs that are approved as medically necessary by Health Net. 4 Drugs indicated as "tier 4" are self-injectable drugs and coverage may differ based on your benefits. Please refer to your plan documents for specific
NOTE: Sybase 12.5.0.3 users should make sure their MDA tables are properly configured so they can see all available statistics. Please refer to the instructions for enabling MDA tables. Enabling MDA Tables In ASE 12.5.0.3, a new feature called "MDA tables" wa
Sep 09, 2021 · Dennis O. Steinacker Buddy Boy, Inc. t/a The Gardener of Bel Air PFA 0821 MDA-F 0266 Edward J. Chmelewski Buffalo Construction Company, Inc. PFA 0797 MDA-F 0543 David J. Kardos Burning Tree Club PFA 1027 MDA-F 0452 Thomas C. Warfield C & C Custom Lawn Care, Inc. PFA 1519 MDA-F 0602 Matthew
Drugs Affecting Autonomic Nervous System, 2. Drugs Affecting Central Nervous System, 3. Drugs Affecting Cardiovascular System, 4. Drugs Affecting Haemostasis and Thrombosis, 5. Drugs Affecting Renal Function, 6. Drugs Affecting Endocrine System, 7. Drugs Affecting Respiratory System, 8. Drugs Affecting Gastr
NDC labeler code 47335 (Sun Pharmaceutical Industries, Inc.) only. drugs cdl p1a 3 Part 2 – Drugs: Contract Drugs Lists Part 1 – Prescription Drugs (A through D) Page u
The UCare formulary is a list of generic and brand drugs that are covered by this plan(s). To be covered, the drug must be on our formulary. The most current list of covered drugs can be found on the UCare . Express Scripts for review/copay override. Contraceptives Women u
What are generic drugs? Premera Blue Cross Medicare Advantage Plans cover 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. Are there any restrictions on my coverage?
These include drugs affecting the autonomic nervous system; anesthetics and analgesics; drugs to treat the heart and diseases of the cardiovascular system; drugs affecting the pulmonary system; antibiotics; drugs used to treat psychiatric disorders; drugs of abuse and drugs use to treat addiction; drugs that affect the immune
