SAN FRANCISCO HEALTH PLAN Healthy Workers Formulary
San Francisco Health Plan Healthy Workers FormularyAS OF May 17, 2017SAN FRANCISCO HEALTH PLANHealthyWorkersFormularyAs of May 17, 2017
San Francisco Health Plan Healthy Workers FormularyAS OF May 17, 2017San Francisco Health Plan Healthy Workers FormularyThe San Francisco Health Plan (SFHP), with the direction from the Pharmacy and TherapeuticsCommittee (P&T), has developed a formulary to be used by members, clinicians, and pharmacists. TheP&T Committee is composed of the SFHP Chief Medical Officer, the SFHP Pharmacy Director, physiciansfrom various medical specialties and clinics, and community clinical pharmacists. The P&T meetsquarterly to review formulary changes based on quality of care considerations and soundpharmacoeconomic principles.The formulary is a list of drug products designed to reflect the most appropriate, high quality and costeffective drug therapies. The formulary is updated regularly and is subject to change without notice.The formulary requires the continuous support of all our providers and pharmacists. Please contact us at(415) 547-7818 x 7085 option 3 or medpharm@sfhp.org if you have any questions regarding theformulary. The SFHP Formulary can be easily accessed online from our websiteat lary/.Request for Addition or Deletion of a Drug to the FormularySFHP providers may request evaluation of drugs for addition to or deletion from the Formulary bysubmitting the Formulary Modification Request Form available on our websiteat orization-requests/.Request for Non-Preferred MedicationsNon-preferred or non-formulary medications may be authorized when there is clinical justification fordoing so. Clinicians can submit a prior authorization (PA) request in one of three different ways:1. Online: Submit using the Online Pharmacy Prior Authorization Request Form.2. Fax: Download a Prior Authorization Request Form and fax to 1(855) 811-9331 for both standardand urgent requests. Urgent requests should be clearly labeled “URGENT” at the top of the priorauthorization request form.3. Phone: Pharmacy Benefits Manager (PBM) PerformRx at (888) 989-0091 to submit a verbalrequest.The Prior Authorization Request Form and the Online Pharmacy Prior Authorization Request Form canbe accessed from our website at orizationrequests/.
San Francisco Health Plan Healthy Workers FormularyAS OF May 17, 2017Brand Medication PolicySFHP has a mandatory generic policy and requires generic substitution when an equivalent genericproduct is available. Dispensing of brand name medications when generic equivalent is available will beallowed only in the following cases: Pharmacy bills brand medication as DAW 5 (i.e. billed as a generic product) Pharmacy bills brand medication as DAW 8 (i.e. generic formulation is not currently available) Pharmacy is dispensing one of the following narrow therapeutic index drugs: Armour Thyroid,Coumadin, Dilantin, SynthroidIn all other cases, a prior authorization (PA) request should be submitted using the instructions above.Detailed PA criteria for brand name medication requests can be foundat r Auth Criteria.pdf under “Brand MedicationRequests” section.Healthy Workers Formulary ExclusionsThe following drug classes are excluded from the Healthy Workers formulary: Over-the-counter (OTC) medications except:o OTC insulin and diabetic testing supplies including test strips, lancets, insulin needlesand syringes, urine ketone testing stripso OTC nicotine replacement productso OTC prenatal vitamins, folic acid and fluoride preparationsCopaymentsThe following copayments apply to Healthy Workers formulary: 5 - generic medications 10 - brand medicationsDay Supply PolicySFHP standard day supply policy is 30 day supply for most brand medications and 90 day supply forgeneric medications with some exceptions. Refills are allowed when 75% of the medication has beenused, except for opioid pain medications where refills are allowed when 90% of the medication has beenused.Exceptions to the 30 day supply policy for brand medications are as follows: Up to 100 day supply is allowed for test strips, lancets, insulin syringes and urine ketone testingstrips Up to 90 day supply is allowed for select medications used for treatment of chronic conditions.Examples include but are not limited to antidiabetic medications including insulin,anticonvulsants, anticoagulants, antidepressants, antihyperlipidemics, antihypertensives, andinhaled steroids.
San Francisco Health Plan Healthy Workers FormularyAS OF May 17, 2017Exceptions to the 90 day supply policy for generic medications are as follows: 30 day supply only is allowed for all opiate medications except tramadolExceptions to the 30 and 90 days supply policy for brand and generic medications are as follows: Up to a year supply of self-administered hormonal contraceptives (i.e. up to 364 pills, 12 vaginalrings, and 36 patches) is allowed with patient request and a valid prescription for the correctquantity. For the 12 month supply, refills are allowed only when 90% of the medication hasbeen used.Exceptions to the 90 day supply policy for generic medications are as follows: 30 day supply only is allowed for all opiate medications except tramadolExceptions to the 30 and 90 days supply policy for brand and generic medications are as follows: Up to a year supply of self-administered hormonal contraceptives (i.e. up to 364 pills, 12 vaginalrings, and 36 patches) is allowed with patient request and a valid prescription for the correctquantity. For the 12 month supply, refills are allowed only when 90% of the medication hasbeen used.Formulary Restrictions (DUR edits)Standard formulary restrictions applicable to SFHP formulary are medication quantity and agelimitations. All formulary restrictions are based on FDA approved indications, standards of practice andsafety and abuse potential considerations.Step Therapy (ST)Step Therapy (ST) medications will process at point of sale at the pharmacy if there are paid prescriptionclaims for preferred medications. If there are no paid prescription claims, a prior authorization (PA)request must be submitted for consideration of coverage. Visit our websiteat lary/ for detailed information on all active steptherapy rules.Therapeutic Interchange PolicyPer American College of Clinical Pharmacy (AACP), therapeutic interchange is defined as the dispensingof a drug that is therapeutically equivalent to but chemically different from the drug originallyprescribed by a physician or other authorized prescriber. SFHP follows ACCP’s definition of therapeuticinterchange and will only employ therapeutic interchange with prescriber’s approval. Criteria forconsideration in therapeutic interchange include availability of agents within a therapeutic class,therapeutic equivalence, safety data, and costs.Diabetic SuppliesThe following diabetic supplies are covered:
San Francisco Health Plan Healthy Workers FormularyAS OF May 17, 2017 Glucometers: ACCU-CHEK Nano SmartView, ACCU-CHEK Aviva Plus, Accu-Chek Designer Care Kit,1 glucometer per 365 daysTest strips: ACCU-CHEK SmartView (for Nano) and ACCU-CHEK Aviva Plus test strips with thefollowing quantity limits:o 400 per 100 days for all memberso 800 per 100 days for members with gestational diabetesLancets: ACCU-CHEK FastClix, Multiclix, SoftClix lancets, 100 day supplyRespiratory SuppliesThe following respiratory supplies are covered as a pharmacy benefit for a quantity of 2 per 365 days: Inhalers and inhaler assist devices Nebulizers Peak flow metersFormulary Document DetailsThe SFHP formulary document is listed by drug class and the following information: drug name, dosageform, drug tier, quantity limit and prior authorization or step therapy requirements. Brand products arelisted in all uppercase letters and generic products are listed in all lowercase letters. Tier 1 drugs areformulary and will pay at the point of sale, if quantity limits and age limitations are met (see “FormularyRestrictions” above). Tier 2 drugs may require a Prior Authorization (see “Request for Non-PreferredMedications” above) or Step Therapy (see “Step Therapy (ST)” above).**Some medications may be listed as both Tier 1 and Tier 2 due to a particular strength being formularyand another strength of the same medication requiring a prior authorization.
DrugGeneric drugs lowercaseitalicsBrand name drugs UPPERCASETierT1 Formulary, GenericT2 Formulary, BrandT3 Formulary, PriorAuthorization or Step TherapyT4 Specialty Pharmacy, PriorAuthorizationDrugTierNotesAL Age LimitPA Prior AuthorizationQL Quantity LimitST Step TherapyNotesAntihistamine DrugsEthanolamine Derivativesclemastine oral syrupT1First Gen. Antihist. Derivatives, Misc.cyproheptadineT1First Generation Antihistaminesclemastine oral syrupT1cyproheptadineT1Phenothiazine DerivativesPHENADOZ RECTAL SUPPOSITORY 12.5 MGT1AL (Min 2 Years)promethazine oralT1AL (Min 2 Years)promethazine rectal suppository 25 mgT1AL (Min 2 Years)PROMETHAZINE VCT1AL (Min 2 Years)promethazine-dmT1AL (Min 2 Years)PROMETHEGAN RECTAL SUPPOSITORY 50MGT3PAPiperazine Derivativeshydroxyzine hcl oral solution 10 mg/5 mlT1hydroxyzine hcl oral tabletT1hydroxyzine pamoateT1meclizine oral tablet 12.5 mg, 25 mgT1Second Generation Antihistaminesdesloratadine oral tabletT3PAlevocetirizine oral tabletT1QL (30 EA per 30 days)1
DrugTierNotesAnti-Infective AgentsAdamantanesamantadine hcl oral solutionT1amantadine hcl oral tabletT1rimantadineT1Allylaminesterbinafine hcl oralT1QL (180 EA per 365 days)Amebicidesmetronidazole oral tabletT1AminoglycosidesKITABIS PAKT3neomycinT1paromomycinT1tobramycin in 0.225 % naclT3PAPAAminopenicillinsamoxicillin oral capsuleT1amoxicillin oral suspension for reconstitutionT1amoxicillin oral tabletT1amoxicillin oral tablet,chewable 125 mg, 250 mgT1amoxicillin-pot clavulanate oral suspension forreconstitution 200-28.5 mg/5 ml, 250-62.5 mg/5ml, 400-57 mg/5 mlT1amoxicillin-pot clavulanate oral suspension forreconstitution 600-42.9 mg/5 mlT1amoxicillin-pot clavulanate oral tabletT1amoxicillin-pot clavulanate oral tablet extendedrelease 12 hrT1amoxicillin-pot clavulanate oral tablet,chewableT1ampicillin oral capsuleT1ampicillin oral suspension for reconstitutionT1AL (Max 12 Years)AUGMENTIN ORAL SUSPENSION FORRECONSTITUTION 125-31.25 MG/5 MLT2AL (Max 12 Years)T2QL (4 EA per 365 days)AL (Max 12 Years)AnthelminticsALBENZA2
DrugTierBILTRICIDET2ivermectin oralT1NotesQL (30 EA per 365 days)Antifungals, Miscellaneousgriseofulvin microsizeT1griseofulvin ultramicrosizeT1Anti-Infective guanilT1chloroquine phosphate oralT1DARAPRIMT3hydroxychloroquine oralT1mefloquineT1primaquineT1quinidine gluconate oralT1quinidine sulfateT1QL (180 EA per 365 days)PAAntimycobacterials, MiscellaneousdapsoneT1Antiprotozoals, MiscellaneousALINIAT2QL (30 ML per 365 days)atovaquoneT1dapsoneT1metronidazole oral tabletT1NEBUPENTT3PAPENTAMT3PAtinidazoleT1QL (30 EA per 365 days)ciprofloxacinT1AL (Max 12 Years)ciprofloxacin hcl oralT1clarithromycin oral tabletT1cycloserineT1Antituberculosis AgentsQL (60 EA per 30 days)3
DrugTierethambutolT1isoniazid oral solutionT1isoniazid oral tabletT1levofloxacin oral solutionT1levofloxacin oral T1rifabutinT1rifampin oralT1RIFATERT2SIRTUROT3TRECATORT2NotesAL (Max 12 Years)AL (Max 12 azole oralT1ONMELT3PAvoriconazole 1First Generation Cephalosporinscefadroxil oral capsuleT3PAcefadroxil oral suspension for reconstitution 250mg/5 ml, 500 mg/5 mlT3PAcefadroxil oral tabletT3PAcephalexin oral capsule 250 mg, 500 mgT1cephalexin oral suspension for reconstitutionT1Glycopeptidesvancomycin intravenous recon soln 1,000 mg, 5gram, 500 mgT1vancomycin oral capsuleT34ST; QL (40 QY per 10 DYs)
DrugTierNotesHcv Polymerase InhibitorsEPCLUSAT3PAHARVONIT3PASOVALDIT3PAVIEKIRA PAKT3PATECHNIVIET3PAVIEKIRA 3PATECHNIVIET3PAVIEKIRA PAKT3PAZEPATIERT3PAFUZEON SUBCUTANEOUS RECON SOLNT3PASELZENTRYT2Hcv Protease InhibitorsHcv Replication Complex InhibitorsHiv Entry And Fusion InhibitorsHiv Integrase RIUMEQT2VITEKTAT2Hiv Nonnucleoside Rev.Transcrip. apineT15
DrugTierODEFSEYT2RESCRIPTORT2SUSTIVAT2Hiv Nucleoside, Nucleotide Rt 2EPIVIR HBV ORAL T2TRUVADAT2VIDEX 2 GRAM PEDIATRICT2VIDEX 4 GRAM PEDIATRICT2VIREADT2ZIAGENT2zidovudineT1Hiv Protease InhibitorsAPTIVUST2CRIXIVAN ORAL CAPSULE 200 MG, 400 MGT2EVOTAZT2INVIRASET2KALETRAT2LEXIVAT26Notes
DrugTierNotesNORVIRT2PREZCOBIXT2PREZISTAT2REYATAZ ORAL CAPSULE 150 MG, 200 MG,300 MGT2REYATAZ ORAL POWDER IN PACKETT2TECHNIVIET3PAVIEKIRA PAKT3PAVIRACEPT ORAL TABLETT2InterferonsALFERON NT3PAINFERGENT3PAINTRON A INJECTIONT3PAPEGASYS CONVENIENCE PACKT3PASYLATRONT3PAT3PAKetolidesKETEK ORAL TABLET 400 MGLincomycinsclindamycin hcl oral capsule 150 mg, 300 mgT1clindamycin hcl oral capsule 75 mgT3PAclindamycin palmitate hclT1AL (Max 12 Years)ERYPED 400T2AL (Max 12 Years)ERY-TABT1ERYTHROCIN (AS STEARATE) ORALTABLET 250 MGT1QL (120 EA per 30 days)erythromycin ethylsuccinate oral suspension forreconstitutionT1AL (Max 12 Years)erythromycin ethylsuccinate oral tabletT1erythromycin oral capsule,delayed release(dr/ec)T1erythromycin oral tabletT1PCET2MacrolidesQL (120 EA per 30 days)Monobactams7
DrugCAYSTONTierT3NotesPANatural Penicillinspenicillin v potassiumT1Neuraminidase Inhibitorsoseltamivir oral capsule 30 mg, 45 mgT1AL (Max 12 Years)oseltamivir oral capsule 75 mgT1RELENZA DISKHALERT2QL (20 QY per 30 DYs)TAMIFLU ORAL SUSPENSION FORRECONSTITUTIONT2AL (Max 12 Years)acyclovir oral capsuleT1QL (150 QY per 30 DYs)acyclovir oral suspension 200 mg/5 mlT1acyclovir oral tabletT1QL (150 QY per 30 DYs)BARACLUDE ORAL SOLUTIONT2AL (Max 12 Years)entecavirT1QL (30 EA per 30 days)famciclovirT1REBETOL ORAL SOLUTIONT3ribavirin oral capsuleT1ribavirin oral tablet 200 mgT1TYZEKAT2QL (30 EA per 30 days)valacyclovirT1QL (90 QY per 30 DYs)VALCYTE ORAL TABLETT3PAvalganciclovir oral recon solnT3PAVIRAZOLET3PAazithromycin oral packetT1QL (2 FL per 90 DYs)azithromycin oral suspension for reconstitution100 mg/5 mlT1azithromycin oral suspension for reconstitution200 mg/5 mlT1QL (2 FL per 90 DYs)azithromycin oral tablet 250 mg, 600 mgT1QL (30 QY per 30 DYs)azithromycin oral tablet 500 mgT1QL (15 EA per 30 days)clarithromycin oral tabletT1QL (60 EA per 30 days)DIFICID8T3PANucleosides And NucleotidesPAOther Macrolides
DrugTierNotesOxazolidinoneslinezolid oral suspension for reconstitutionT1linezolid oral tabletT1AL (Max 12 Years)Penicillinase-Resistant PenicillinsdicloxacillinT1Polyenesnystatin oral powder 50 million unitT1nystatin oral suspensionT1nystatin oral tabletT1QuinolonesciprofloxacinT1ciprofloxacin hcl oralT1levofloxacin oral solutionT1levofloxacin oral tabletT1moxifloxacinT3AL (Max 12 Years)AL (Max 12 fampin oralT1RIFATERT2XIFAXAN ORAL TABLET 200 MGT3ST; QL (90 QY per 30 DYs)XIFAXAN ORAL TABLET 550 MGT3ST; QL (60 QY per 30 DYs)Second Generation Cephalosporinscefaclor oral capsuleT1cefaclor oral suspension for reconstitution 125mg/5 ml, 250 mg/5 ml, 375 mg/5 mlT1cefaclor oral tablet extended release 12 hrT1cefprozil oral suspension for reconstitutionT1cefprozil oral tabletT1CEFTIN ORAL SUSPENSION FORRECONSTITUTION 250 MG/5 MLT2AL (Max 12 Years)AL (Max 12 Years)AL (Max 12 Years)9
DrugTiercefuroxime axetil oral suspension forreconstitution 125 mg/5 mlT1cefuroxime axetil oral tabletT1NotesAL (Max 12 Years)Sulfonamides (Systemic)sulfadiazine oralT1sulfamethoxazole-trimethoprim oralT1sulfasalazineT1Tetracyclinesdoxycycline hyclate oral capsuleT1QL (60 EA per 30 days)doxycycline hyclate oral tablet 100 mgT1QL (60 EA per 30 days)doxycycline monohydrate oral capsule 100 mg, 50mgT1QL (60 EA per 30 days)doxycycline monohydrate oral tablet 100 mgT1QL (60 EA per 30 days)minocycline oral capsule 100 mg, 50 mgT1QL (60 EA per 30 days)tetracyclineT1QL (120 QY per 30 DYs)CEDAX ORAL SUSPENSION FORRECONSTITUTIONT3PAcefdinir oral capsuleT1QL (60 EA per 30 days)cefdinir oral suspension for reconstitutionT1AL (Max 12 Years)cefditoren pivoxilT3PAcefixime oral suspension for reconstitution 100mg/5 mlT1AL (Max 12 Years)cefixime oral suspension for reconstitution 200mg/5 mlT1AL (Min 12 Years)cefpodoxime oral suspension for reconstitutionT1AL (Max 12 Years)cefpodoxime oral tablet 100 mgT1QL (60 QY per 30 DYs)cefpodoxime oral tablet 200 mgT1ceftibutenT3PASUPRAX ORAL CAPSULET2QL (28 EA per 28 days)SUPRAX ORAL TABLET,CHEWABLET2AL (Max 12 Years)Third Generation CephalosporinsUrinary Anti-Infectivesnitrofurantoin macrocrystalT1nitrofurantoin monohyd/m-crystT110
DrugTiernitrofurantoin oralT1trimethoprimT1NotesAntineoplastic AgentsAntineoplastic AgentsAFINITORT3PAAFINITOR DISPERZT3PAALECENSAT3PAALFERON NT3PAALKERAN ORALT3PAanastrozoleT1QL (30 QY per 30 LLICT3PAcyclophosphamide oral capsuleT3PAELIGARDT3PAELIGARD (3 MONTH)T3PAELIGARD (4 MONTH)T3PAELIGARD (6 TONT3PAFARYDAKT3PAFIRMAGON KIT W DILUENT ALENT3PA11
DrugTierNotesHYCAMTIN 3PAIMBRUVICAT3PAINLYTAT3PAINTRON A 3PALUPRON DEPOT-PEDT3PALUPRON DEPOT-PED (3 strol oral suspension 400 mg/10 ml (10 ml),400 mg/10 ml (40 mg/ml)T1megestrol oral tabletT1MEKINISTT3mercaptopurineT1methotrexate sodium (pf) injection solutionT1QL (16 ML per 28 days)methotrexate sodium injectionT1QL (16 ML per 28 days)methotrexate sodium 2PAPA
GNAT3PAtemozolomideT3PAtretinoin PAVENCLEXTA STARTING 3PAZOLINZAT3PAZYDELIGT3PAZYKADIAT3PAZYTIGA ORAL TABLET 250 MGT3PAAntitoxins,Immune Glob,Toxoids,VaccinesToxoids13
DrugTierNotesADACEL(TDAP ADOLESN/ADULT)(PF)T2QL (0.5 ML per 1 fill); AL (Min 19Years)BOOSTRIX TDAPT2QL (0.5 ML per 1 fill); AL (Min 19Years)TENIVAC (PF)T2QL (0.5 ML per 1 fill); AL (Min 19Years)epinephrine injection auto-injectorT1QL (6 EA per 365 days)REZIRAT3PAAutonomic DrugsAlpha- And Beta-Adrenergic AgonistsAlpha-Adrenergic Agonistsclonidine hclT1clonidine transdermal patch weekly 0.1 mg/24 hrT1QL (4 EA per 28 days)clonidine transdermal patch weekly 0.2 mg/24 hr,0.3 mg/24 hrT1QL (8 EA per 28 days)KAPVAY DOSE PACKT2AL (Min 5 Years and Max 24 midodrineT1PROMETHAZINE VCT1AL (Min 2 Years)ATROVENT HFAT2QL (25.8 QY per 30 DYs)chlordiazepoxide-clidiniumT1COMBIVENT RESPIMATT2dicyclomine oral capsuleT1dicyclomine oral tabletT1diphenoxylate-atropineT1glycopyrrolate oralT1hyoscyamine sulfate oral tabletT1hyoscyamine sulfate oral tablet extended release12 hrT1hyoscyamine sulfate sublingualT1ipratropium bromide inhalationT1QL (312.5 QY per 30 DYs)ipratropium-albuterolT1QL (570 QY per 30 DYs)Antimuscarinics/Antispasmodics14QL (4 QY per 20 DYs)
DrugTierNotesSPIRIVA RESPIMATT2QL (4 GM per 30 days)SPIRIVA WITH HANDIHALERT2QL (30 QY per 30 DYs)TUDORZA PRESSAIRT2QL (1 QY per 30 DYs)Antiparkinsonian Agentsbenztropine oralT1trihexyphenidylT1Autonomic Drugs, MiscellaneousCHANTIX ORAL TABLET 0.5 MGT2QL (360 QY per 365 DYs)CHANTIX ORAL TABLET 1 MGT2QL (224 EA per 365 days)CHANTIX STARTING MONTH BOXT2QL (106 QY per 365 DYs)nicotine (polacrilex) buccal gumT1QL (360 QY per 30 DYs)nicotine (polacrilex) buccal lozengeT1QL (360 EA per 30 days)nicotine transdermal patch 24 hour 14 mg/24 hr,21 mg/24 hr, 7 mg/24 hrT1QL (30 QY per 30 DYs)NICOTROLT3PANICOTROL NST3PAcyclobenzaprine oral tablet 10 mg, 5 mgT1QL (90 QY per 30 DYs)methocarbamol oralT1QL (120 EA per 30 days)tizanidine oral tabletT1QL (90 QY per 30 DYs)Centrally Acting Skeletal Muscle RelaxntGaba-Derivative Skeletal Muscle RelaxantbaclofenT1Non-Sel. Beta-Adrenergic Blocking AgentscarvedilolT1labetalol oralT1nadololT1pindololT1propranolol oralT1sotalol oralT1Non-Sel.Alpha-1-Adrenergic Blocking AgtsdoxazosinT1prazosin oralT1terazosinT115
DrugTierNotesNon-Sel.Alpha-Adrenergic Blocking AgentsphenoxybenzamineT3PAbethanechol chlorideT3PAdonepezilT1galantamineT1MESTINON ORAL SYRUPT2NAMZARICT2pilocarpine hcl oral tablet 5 mgT1PROSTIGMINT2pyridostigmine bromideT1rivastigmineT1rivastigmine tartrateT1Parasympathomimetic (Cholinergic Agents)QL (180 QY per 30 DYs)Selective Alpha-1-Adrenergic Block.AgentalfuzosinT1QL (30 EA per 30 days)carvedilolT1labetalol oralT1RAPAFLOT3PAtamsulosinT1QL (60 QY per 30 DYs)ADVAIR DISKUST2QL (60 EA per 30 days)ADVAIR HFAT3PAalbuterol sulfate inhalation solution fornebulization 1.25 mg/3 ml, 2.5 mg/0.5 mlT1albuterol sulfate inhalation solution fornebulization 2.5 mg /3 ml (0.083 %)T1QL (525 QY per 30 DYs)albuterol sulfate inhalation solution fornebulization 5 mg/mlT1QL (100 QY per 30 DYs)albuterol sulfate oral syrupT1QL (120 QY per 30 DYs); AL (Max 5Years)albuterol sulfate oral tabletT1QL (120 QY per 30 DYs)BREO ELLIPTAT3PACOMBIVENT RESPIMATT2QL (4 QY per 20 DYs)DULERAT2QL (13 QY per 30 DYs)Selective Beta-2-Adrenergic Agonists16
DrugTierNotesipratropium-albuterolT1QL (570 QY per 30 DYs)levalbuterol hcl inhalation solution fornebulization 0.31 mg/3 mlT3ST; QL (240 QY per 30 DYs)levalbuterol hcl inhalation solution fornebulization 0.63 mg/3 ml, 1.25 mg/3 mlT3ST; QL (360 QY per 30 DYs)levalbuterol hcl inhalation solution fornebulization 1.25 mg/0.5 mlT3ST; QL (150 QY per 30 DYs)levalbuterol tartrateT3ST; QL (30 GM per 30 days)PROAIR HFAT2QL (17 GM per 30 days)PROVENTIL HFAT3ST; QL (13.4 GM per 30 days)SEREVENT DISKUST3PASYMBICORTT2QL (10.2 QY per 30 DYs)terbutaline oralT1VENTOLIN HFAT2QL (36 QY per 30 DYs)Selective Beta-Adrenergic Blocking T1bisoprolol ol succinateT1metoprolol tartrate oral tablet 100 mg, 25 mg, 50mgT1Blood Formation, Coagulation, ThrombosisCoumarin DerivativeswarfarinT1Direct Factor Xa InhibitorsELIQUIST2QL (60 EA per 30 days)SAVAYSAT3PAXARELTO ORAL TABLET 10 MG, 20 MGT2QL (30 EA per 30 days)XARELTO ORAL TABLET 15 MGT2QL (60 EA per 30 days)XARELTO ORAL TABLETS,DOSE PACKT2QL (51 EA per 30 days)T3PADirect Thrombin InhibitorsPRADAXA17
DrugTierNotesHematopoietic AgentsARANESP (IN POLYSORBATE)T3PAEPOGEN INJECTION SOLUTION 10,000UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/ML,3,000 UNIT/MLT3PANEULASTA SUBCUTANEOUS SYRINGET3PAPROCRIT INJECTION SOLUTION 4,000UNIT/ML, 40,000 UNIT/MLT3PAPROMACTAT3PAZARXIOT3PAT1QL (90 QY per 30 DYs)Hemorrheologic AgentspentoxifyllineHemostaticsdesmopressin nasal spray,non-aerosolT1desmopressin oralT1STIMATET3PAenoxaparin subcutaneous solutionT1QL (6 QY per 10 DYs)enoxaparin subcutaneous syringe 100 mg/ml, 150mg/mlT1QL (20 QY per 10 DYs)enoxaparin subcutaneous syringe 120 mg/0.8 ml,80 mg/0.8 mlT1QL (16 QY per 10 DYs)enoxaparin subcutaneous syringe 30 mg/0.3 mlT1QL (6 QY per 10 DYs)enoxaparin subcutaneous syringe 40 mg/0.4 mlT1QL (8 QY per 10 DYs)enoxaparin subcutaneous syringe 60 mg/0.6 mlT1QL (12 QY per 10 DYs)heparin (porcine) injection cartridgeT1heparin (porcine) injection solution 10,000unit/ml, 20,000 unit/mlT1heparin, porcine (pf) injection solution 1,000unit/mlT1HeparinsIron PreparationsATABEX ECT2QL (30 QY per 30 DYs)BAL-CARE DHAT1QL (60 QY per 30 DYs)BAL-CARE DHA ESSENTIALT2QL (60 QY per 30 DYs)CAVAN-EC SOD DHAT1QL (60 QY per 30 DYs)18
DrugTierNotesCENTRUM SPECIALIST PRENATALT2QL (60 QY per 30 DYs)CITRANATAL HARMONYT1QL (30 QY per 30 DYs)CLASSIC PRENATALT2DUET DHA BALANCED ORAL COMBOPACK 26 MG IRON- 1 MG-278 MGT2QL (60 QY per 30 DYs)DUET DHA EC-OM 3T2QL (60 QY per 30 DYs)DUET DHA WITH OMEGA-3T2QL (60 QY per 30 DYs)ELITE-OB 400T1QL (30 QY per 30 DYs)EXTRA-VIRT PLUS DHAT1FOLIVANE-EC CALCIUM DHA NFT1QL (60 EA per 30 days)FOLIVANE-OBT1QL (30 QY per 30 DYs)FOLIVANE-PRX DHA NFT2QL (30 QY per 30 DYs)HEMATOGEN FAT1HEMENATAL OBT1QL (30 QY per 30 DYs)HEMENATAL OB DHAT1QL (60 QY per 30 DYs)INATAL ULTRAT1QL (30 QY per 30 DYs)KPN ORAL TABLET 9 MG IRON- 267 MCGT2QL (30 QY per 30 DYs)L-METHYLFOLATE PNV DHAT1MACNATAL CN DHAT1QL (30 QY per 30 DYs)MARNATAL-FT2QL (30 QY per 30 DYs)MINI PRENATALT2QL (30 QY per 30 DYs)MYNATAL ORAL CAPSULET2QL (30 QY per 30 DYs)MYNATAL-ZT1QL (30 QY per 30 DYs)NATACHEW (FE BIS-GLYCINATE)T2QL (30 QY per 30 DYs)NATAFORT (NEW FORMULA 2011)T2QL (30 QY per 30 DYs)NATALVIRT CAT1QL (60 QY per 30 DYs)NATALVITT2QL (30 QY per 30 DYs)NATELLE ONET1QL (30 QY per 30 DYs)NEWGENT1QL (30 EA per 30 days)OB COMPLETE 400T2QL (30 QY per 30 DYs)OB COMPLETE ONET2QL (30 QY per 30 DYs)OB COMPLETE ORAL TABLET,CHEWABLET2QL (30 QY per 30 DYs)OB COMPLETE PREMIERT2QL (30 QY per 30 DYs)19
DrugTierNotesOBSTETRIX DHAT1QL (60 QY per 30 DYs)OBSTETRIX ECT2QL (60 QY per 30 DYs)OBTREXT2O-CAL FAT2QL (30 QY per 30 DYs)O-CAL PRENATALT2QL (30 QY per 30 DYs)ONE A DAY WOMEN'S PRENATAL DHAT1QL (60 QY per 30 DYs)PAIRE OB PLUS DHAT1PERRY PRENATALT2PNV 29-1T1PNV FOLIC ACID IRONT1PNV-OMEGAT1QL (30 QY per 30 DYs)PR NATAL 430T1QL (60 QY per 30 DYs)PR NATAL 430 ECT1QL (60 QY per 30 DYs)PRENA1T2QL (30 QY per 30 DYs)PRENA1 PLUST1QL (60 EA per 30 days)PRENAISSANCE 90 DHAT1QL (60 EA per 30 days)PRENAISSANCE DHA HARMONYT1QL (60 EA per 30 days)PRENATAT2QL (30 QY per 30 DYs)PRENATAL 19T1QL (30 QY per 30 DYs)PRENATAL 19 (WITH DOCUSATE)T1QL (30 QY per 30 DYs)PRENATAL DHA COMPLETE PRENATALT1QL (60 QY per 30 DYs)PRENATAL FORMULA ORAL TABLET 9 MGIRON- 267 MCGT1QL (30 QY per 30 DYs)PRENATAL LOW IRONT1QL (30 QY per 30 DYs)PRENATAL MULTI-DHA ORAL CAPSULE 27MG IRON-800 MCG-228 MGT1QL (60 QY per 30 DYs)PRENATAL ORAL TABLET 28 MG IRON- 800MCGT1QL (30 QY per 30 DYs)PRENATAL PLUST1QL (30 QY per 30 DYs)PRENATAL PLUS (CALCIUM CARB)T1PRENATAL VITAMIN WITH MINERALST1QL (30 QY per 30 DYs)prenatal vits96-iron fum-folicT1QL (30 QY per 30 DYs)PRENATAL-1T1QL (30 QY per 30 DYs)PRENATE DHAT2QL (30 QY per 30 DYs)20QL (30 QY per 30 DYs)
DrugTierNotesPRENATE ELITET2QL (30 QY per 30 DYs)PRENATE ESSENTIALT2QL (30 QY per 30 DYs)PRENATE MINIT2QL (30 QY per 30 DYs)PREQUE 10T2PROTECT NATALT2PROTECT PLUST1PUREFE OB PLUST2QL (30 QY per 30 DYs)RELNATE DHAT1QL (30 QY per 30 DYs)SELECT-OB (FOLIC ACID)T2QL (30 QY per 30 DYs)SE-TAN DHAT1QL (30 QY per 30 DYs)STROVITE FORTET2STUART PRENATAL PLUS DHAT2QL (60 QY per 30 DYs)TARON-BCT1QL (90 QY per 30 DYs)TARON-C DHAT1QL (30 QY per 30 DYs)THERANATAL COMPLETET2QL (60 QY per 30 DYs)TRIADVANCET1TRICARE PRENATAL DHA ONET2TRIGELS-F FORTET1TRINATAL GTT1QL (30 QY per 30 DYs)TRIVEEN-ONET1QL (30 QY per 30 DYs)TRIVEEN-PRX RNFT1QL (30 QY per 30 DYs)TRIVEEN-TENT1QL (60 QY per 30 DYs)ULTIMATECARE ONE NFT1QL (30 QY per 30 DYs)VENATAL-FAT1QL (30 QY per 30 DYs)VINACAL BT1VINATE AZT1VINATE IIT1VINATE ONET1QL (30 QY per 30 DYs)VIRT-SELECTT1QL (30 QY per 30 DYs)VITAFOLT2VITAFOL GUMMIEST2VOL-NATET1VP-ERA OB PLUST1QL (60 QY per 30 DYs)QL (30 QY per 30 DYs)QL (30 QY per 30 DYs)QL (30 QY per 30 DYs)21
DrugTierNotesVP-HEME ONET1QL (30 EA per 30 days)ZATEAN-CHT1ZATEAN-PNT1QL (30 QY per 30 DYs)aspirin-dipyridamoleT1QL (60 EA per 30 days)BRILINTAT2QL (60 EA per 30 days)butalbital-aspirin-caffeine oral capsuleT3PAcilostazolT1QL (60 QY per 30 DYs)clopidogrel oral tablet 75 mgT1dipyridamole oralT1EFFIENT ORAL TABLET 10 MGT3ST; QL (30 QY per 30 DYs)EFFIENT ORAL TABLET 5 MGT3ST; QL (60 EA per 30 days)Platelet-Aggregation InhibitorsPlatelet-Reducing AgentsanagrelideT1Thrombolytic Agentsbutalbital-aspirin-caffeine oral capsuleT3PACardiovascular DrugsAlpha-Adrenergic Blocking AgentscarvedilolT1doxazosinT1labetalol oralT1prazosin oralT1terazosinT1Alpha-Adrenergic Blocking Agt.(Hypoten)doxazosinT1labetalol oralT1prazosin oralT1terazosinT1Angiotensin Ii Receptor Antagon.(Hypotn)amlodipine-valsartanT1QL (30 EA per 30 T3ST22
DrugTierNotesirbesartanT1QL (30 EA per 30 days)irbesartan-hydrochlorothiazideT1QL (30 EA per 30 days)losartanT1QL (30 QY per 30 DYs)losartan-hydrochlorothiazideT1QL (30 QY per 30 DYs)telmisartanT1valsartan oral tablet 160 mg, 80 mgT1valsartan oral tablet 320 mg, 40 mgT1QL (30 EA per 30 days)valsartan-hydrochlorothiazideT1QL (30 EA per 30 days)amlodipine-valsartanT1QL (30 EA per 30 T3STENTRESTOT3STirbesartanT1QL (30 EA per 30 days)irbesartan-hydrochlorothiazideT1QL (30 EA per 30 days)losartanT1QL (30 QY per 30 DYs)losartan-hydrochlorothiazideT1QL (30 QY per 30 DYs)telmisartanT1valsartan oral tablet 160 mg, 80 mgT1valsartan oral tablet 320 mg, 40 mgT1QL (30 EA per 30 days)valsartan-hydrochlorothiazideT1QL (30 EA per 30 days)Angiotensin Ii Receptor AntagonistsAngiotensin-Convert.Enzyme nazepril-hydrochlorothiazideT1captoprilT1enalapril ndopril erbumineT1quinaprilT123
ting Enzyme epril-hydrochlorothiazideT1c
Glucometers: ACCU-CHEK Nano SmartView, ACCU-CHEK Aviva Plus, Accu-Chek Designer Care Kit, 1 glucometer per 365 days Test strips: ACCU-CHEK SmartView (for Nano) and ACCU-CHEK Aviva Plus test strips with the following quantity limits: o 400 per 100 days for all members
San Francisco Public Works Making San Francisco a beautiful, livable, vibrant, and sustainable city. City and County of San Francisco San Francisco Public Works INFRASTRUCTURE DIVISION Project Management & Construction 30 Van Ness, 5th Avenue San Francisco, Ca 94102 (415) 554-4045 www.SFPublicWorks.org Mark Farrell, Mayor
ford Chang (San Francisco), Dr. Daniel Beltran (San Fran-cisco), Dr. Keith Gualderama (Urban Eyes, San Francisco), . San Francisco), Carolyn Chu (Dr. Michael Chew, Daly City and San Rafael), Irina Volkova (Dr. Joanne Yee, San Francisco) PVI Top 5 dinners held on March 8th at Gary Danko’s on June 28th, at Asia de Cuba, and on September 16th .
San Francisco-San Mateo-San Rafael, California U.S. Department of Housing and Urban Development Office of Policy Development and Research As of January 1, 2016 Sonoma Solano Napa . 24. Fr P T ANAL YSIS 2 Table 1. Housing Demand in the San Francisco HMA* During the Forecast Period San Francisco HMA* San Fra
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City and County of San Francisco John Rahaim, Planning Director City and County of San Francisco Todd Rufo, Director, Economic and Workforce Development, Office of the Mayor City and County of San Francisco Mayor Wayne Lee City of Millbrae / San Mateo Mayor Pradeep Gupta City of South San Francisco / San Mate
City and County of San Francisco John Rahaim, Planning Director City and County of San Francisco Todd Rufo, Director, Economic and Workforce Development, Office of the Mayor City and County of San Francisco Mayor Wayne Lee City of Millbrae / San Mateo Mayor Pradeep Gupta City of South San Francisco / San Mate
