Value Based Benefit Drugs - Ecommunity
Value Based Benefit DrugsBrand NameEffective 5/1/2021Generic Name and StrengthValue Based DrugAsthma COPDBronchodilators AnticholinergicsATROVENT HFAIpratropium Bromide HFA Inhal Aerosol 17 MCG/ACTYes 0IPRATROPIUM BROMIDEIpratropium Bromide Inhal Soln 0.02%Yes 0SPIRIVA RESPIMATTiotropium Bromide Monohydrate Inhal Aerosol 1.25 MCG/ACTYes*SPIRIVA RESPIMATTiotropium Bromide Monohydrate Inhal Aerosol 2.5 MCG/ACTYes*SPIRIVA HANDIHALERTiotropium Bromide Monohydrate Inhal Cap 18 MCG (Base Equiv)YesINCRUSE ELLIPTAUmeclidinium Br Aero Powd Breath Act 62.5 MCG/INH (Base Eq)Yes 0MONTELUKAST SODIUMMontelukast Sodium Chew Tab 4 MG (Base Equiv)Yes 0MONTELUKAST SODIUMMontelukast Sodium Chew Tab 5 MG (Base Equiv)Yes 0MONTELUKAST SODIUMMontelukast Sodium Tab 10 MG (Base Equiv)Yes 0ZAFIRLUKASTZafirlukast Tab 10 MGYes 0ZAFIRLUKASTZafirlukast Tab 20 MGYes 0*Respiratory Therapy Supplies Devices***Respiratory Therapy Supplies Devices**Yes 0*Spacer/Aerosol Holding Chamber Supplies Bags****Spacer/Aerosol Holding Chamber Supplies Bags***Yes 0Leukotriene ModulatorsRespiratory Therapy Supplies*Spacer/Aerosol Holding Chamber Supplies Masks*** *Spacer/Aerosol Holding Chamber Supplies Masks***Yes 0*Spacer/Aerosol Holding Chambers Device****Spacer/Aerosol Holding Chambers Device***Yes 0Peak Flow MeterPeak Flow MeterYes 0Peak Flow Meter w/Inhaler Assist Device KitPeak Flow Meter w/Inhaler Assist Device KitYes 0QVAR REDIHALERBeclomethasone Diprop HFA Breath Act Inh Aer 40 MCG/ACTYes 0Steroid Inhalants# The Value Based Drug list applies to the PPO and HSA plans only and these drugs will bypass the deductible.If Value Based Drug Yes 0 then drug is available at no cost to you, if Value Based Drug Yes* (with an asterisk) you must call the PBM at (844) 547 0399 to get assistance lowering the costof your medication.Page 1 of 20To see the full CHN Formulary File, go to https://www/ecommunity.com/community health direct/membersPrint version: 6 1 2021
Brand NameGeneric Name and StrengthValue Based DrugAsthma COPDQVAR REDIHALERBeclomethasone Diprop HFA Breath Act Inh Aer 80 MCG/ACTYes 0BUDESONIDEBudesonide Inhalation Susp 0.25 MG/2MLYes 0BUDESONIDEBudesonide Inhalation Susp 0.5 MG/2MLYes 0BUDESONIDEBudesonide Inhalation Susp 1 MG/2MLYes 0ARNUITY ELLIPTAFluticasone Furoate Aerosol Powder Breath Activ 100 MCG/ACTYes 0ARNUITY ELLIPTAFluticasone Furoate Aerosol Powder Breath Activ 200 MCG/ACTYes 0ARNUITY ELLIPTAFluticasone Furoate Aerosol Powder Breath Activ 50 MCG/ACTYes 0FLOVENT DISKUSFluticasone Propionate Aer Pow BA 100 MCG/BLISTERYes 0FLOVENT DISKUSFluticasone Propionate Aer Pow BA 250 MCG/BLISTERYes 0FLOVENT DISKUSFluticasone Propionate Aer Pow BA 50 MCG/BLISTERYes 0FLOVENT HFAFluticasone Propionate HFA Inhal Aer 110 MCG/ACT (125/Valve)Yes 0FLOVENT HFAFluticasone Propionate HFA Inhal Aer 220 MCG/ACT (250/Valve)Yes 0FLOVENT HFAFluticasone Propionate HFA Inhal Aero 44 MCG/ACT (50/Valve)Yes 0ALBUTEROL SULFATE HFAAlbuterol Sulfate Inhal Aero 108 MCG/ACT (90MCG Base Equiv)Yes 0ALBUTEROL SULFATEAlbuterol Sulfate Soln Nebu 0.083% (2.5 MG/3ML)Yes 0ALBUTEROL SULFATEAlbuterol Sulfate Soln Nebu 0.5% (5 MG/ML)Yes 0ALBUTEROL SULFATEAlbuterol Sulfate Soln Nebu 0.63 MG/3ML (Base Equiv)Yes 0ALBUTEROL SULFATEAlbuterol Sulfate Soln Nebu 1.25 MG/3ML (Base Equiv)Yes 0BUDESONIDE/FORMOTEROL FUMBudesonide Formoterol Fumarate Dihyd Aerosol 160 4.5 MCG/ACTYes 0BUDESONIDE/FORMOTEROL FUMBudesonide Formoterol Fumarate Dihyd Aerosol 80 4.5 MCG/ACTYes 0FLUTICASONE PROPIONATE/SAFluticasone Salmeterol Aer Powder BA 100 50 MCG/DOSEYes 0WIXELA INHUBFluticasone Salmeterol Aer Powder BA 100 50 MCG/DOSEYes 0FLUTICASONE PROPIONATE/SAFluticasone Salmeterol Aer Powder BA 113 14 MCG/ACTYes 0FLUTICASONE PROPIONATE/SAFluticasone Salmeterol Aer Powder BA 232 14 MCG/ACTYes 0FLUTICASONE PROPIONATE/SAFluticasone Salmeterol Aer Powder BA 250 50 MCG/DOSEYes 0Sympathomimetics# The Value Based Drug list applies to the PPO and HSA plans only and these drugs will bypass the deductible.If Value Based Drug Yes 0 then drug is available at no cost to you, if Value Based Drug Yes* (with an asterisk) you must call the PBM at (844) 547 0399 to get assistance lowering the costof your medication.Page 2 of 20To see the full CHN Formulary File, go to https://www/ecommunity.com/community health direct/membersPrint version: 6 1 2021
Brand NameGeneric Name and StrengthValue Based DrugAsthma COPDWIXELA INHUBFluticasone Salmeterol Aer Powder BA 250 50 MCG/DOSEYes 0FLUTICASONE PROPIONATE/SAFluticasone Salmeterol Aer Powder BA 500 50 MCG/DOSEYes 0WIXELA INHUBFluticasone Salmeterol Aer Powder BA 500 50 MCG/DOSEYes 0FLUTICASONE PROPIONATE/SAFluticasone Salmeterol Aer Powder BA 55 14 MCG/ACTYes 0TRELEGY ELLIPTAFluticasone Umeclidinium Vilanterol AEPB 100 62.5 25 MCG/INHYes*PERFOROMISTFormoterol Fumarate Soln Nebu 20 MCG/2MLYes*COMBIVENT RESPIMATIpratropium Albuterol Inhal Aerosol Soln 20 100 MCG/ACTYes*IPRATROPIUM BROMIDE/ALBUTIpratropium Albuterol Nebu Soln 0.5 2.5(3) MG/3MLYes 0LEVALBUTEROL HCLLevalbuterol HCl Soln Nebu 0.31 MG/3ML (Base Equiv)Yes 0LEVALBUTEROL HYDROCHLORIDLevalbuterol HCl Soln Nebu 0.31 MG/3ML (Base Equiv)Yes 0LEVALBUTEROL HCLLevalbuterol HCl Soln Nebu 0.63 MG/3ML (Base Equiv)Yes 0LEVALBUTEROL HYDROCHLORIDLevalbuterol HCl Soln Nebu 0.63 MG/3ML (Base Equiv)Yes 0LEVALBUTEROL HCLLevalbuterol HCl Soln Nebu 1.25 MG/3ML (Base Equiv)Yes 0LEVALBUTEROL HYDROCHLORIDLevalbuterol HCl Soln Nebu 1.25 MG/3ML (Base Equiv)Yes 0LEVALBUTEROLLevalbuterol HCl Soln Nebu Conc 1.25 MG/0.5ML (Base Equiv)Yes 0LEVALBUTEROL TARTRATE HFALevalbuterol Tartrate Inhal Aerosol 45 MCG/ACT (Base Equiv)Yes 0ANORO ELLIPTAUmeclidinium Vilanterol Aero Powd BA 62.5 25 MCG/INHYes*BENAZEPRIL HCLBenazepril HCl Tab 10 MGYes 0BENAZEPRIL HYDROCHLORIDEBenazepril HCl Tab 20 MGYes 0BENAZEPRIL HCLBenazepril HCl Tab 40 MGYes 0BENAZEPRIL HCLBenazepril HCl Tab 5 MGYes 0ENALAPRIL MALEATEEnalapril Maleate Tab 10 MGYes 0ENALAPRIL MALEATEEnalapril Maleate Tab 2.5 MGYes 0ENALAPRIL MALEATEEnalapril Maleate Tab 20 MGYes 0CardiovascularACE Inhibitors# The Value Based Drug list applies to the PPO and HSA plans only and these drugs will bypass the deductible.If Value Based Drug Yes 0 then drug is available at no cost to you, if Value Based Drug Yes* (with an asterisk) you must call the PBM at (844) 547 0399 to get assistance lowering the costof your medication.Page 3 of 20To see the full CHN Formulary File, go to https://www/ecommunity.com/community health direct/membersPrint version: 6 1 2021
Brand NameGeneric Name and StrengthValue Based DrugCardiovascularENALAPRIL MALEATEEnalapril Maleate Tab 5 MGYes 0FOSINOPRIL SODIUMFosinopril Sodium Tab 10 MGYes 0FOSINOPRIL SODIUMFosinopril Sodium Tab 20 MGYes 0FOSINOPRIL SODIUMFosinopril Sodium Tab 40 MGYes 0LISINOPRILLisinopril Tab 10 MGYes 0LISINOPRILLisinopril Tab 2.5 MGYes 0LISINOPRILLisinopril Tab 20 MGYes 0LISINOPRILLisinopril Tab 30 MGYes 0LISINOPRILLisinopril Tab 40 MGYes 0LISINOPRILLisinopril Tab 5 MGYes 0QUINAPRIL HYDROCHLORIDEQuinapril HCl Tab 10 MGYes 0QUINAPRIL HCLQuinapril HCl Tab 20 MGYes 0QUINAPRIL HYDROCHLORIDEQuinapril HCl Tab 20 MGYes 0QUINAPRIL HCLQuinapril HCl Tab 40 MGYes 0QUINAPRIL HYDROCHLORIDEQuinapril HCl Tab 40 MGYes 0QUINAPRIL HCLQuinapril HCl Tab 5 MGYes 0QUINAPRIL HYDROCHLORIDEQuinapril HCl Tab 5 MGYes 0RAMIPRILRamipril Cap 1.25 MGYes 0RAMIPRILRamipril Cap 10 MGYes 0RAMIPRILRamipril Cap 2.5 MGYes 0RAMIPRILRamipril Cap 5 MGYes 0TRANDOLAPRILTrandolapril Tab 1 MGYes 0TRANDOLAPRILTrandolapril Tab 2 MGYes 0TRANDOLAPRILTrandolapril Tab 4 MGYes 0CARVEDILOL PHOSPHATECarvedilol Phosphate Cap ER 24HR 10 MGYes 0Alpha Beta Blockers# The Value Based Drug list applies to the PPO and HSA plans only and these drugs will bypass the deductible.If Value Based Drug Yes 0 then drug is available at no cost to you, if Value Based Drug Yes* (with an asterisk) you must call the PBM at (844) 547 0399 to get assistance lowering the costof your medication.Page 4 of 20To see the full CHN Formulary File, go to https://www/ecommunity.com/community health direct/membersPrint version: 6 1 2021
Brand NameGeneric Name and StrengthValue Based DrugCardiovascularCARVEDILOL PHOSPHATECarvedilol Phosphate Cap ER 24HR 20 MGYes 0CARVEDILOL PHOSPHATECarvedilol Phosphate Cap ER 24HR 40 MGYes 0CARVEDILOL PHOSPHATECarvedilol Phosphate Cap ER 24HR 80 MGYes 0CARVEDILOLCarvedilol Tab 12.5 MGYes 0CARVEDILOLCarvedilol Tab 25 MGYes 0CARVEDILOLCarvedilol Tab 3.125 MGYes 0CARVEDILOLCarvedilol Tab 6.25 MGYes 0LABETALOL HYDROCHLORIDELabetalol HCl Tab 100 MGYes 0LABETALOL HYDROCHLORIDELabetalol HCl Tab 200 MGYes 0LABETALOL HYDROCHLORIDELabetalol HCl Tab 300 MGYes 0IRBESARTANIrbesartan Tab 150 MGYes 0IRBESARTANIrbesartan Tab 300 MGYes 0IRBESARTANIrbesartan Tab 75 MGYes 0LOSARTAN POTASSIUMLosartan Potassium Tab 100 MGYes 0LOSARTAN POTASSIUMLosartan Potassium Tab 25 MGYes 0LOSARTAN POTASSIUMLosartan Potassium Tab 50 MGYes 0VALSARTANValsartan Tab 160 MGYes 0VALSARTANValsartan Tab 320 MGYes 0VALSARTANValsartan Tab 40 MGYes 0VALSARTANValsartan Tab 80 MGYes 0AMLODIPINE BESYLATE/BENAZAmlodipine Besylate Benazepril HCl Cap 10 20 MGYes 0AMLODIPINE BESYLATE/BENAZAmlodipine Besylate Benazepril HCl Cap 10 40 MGYes 0AMLODIPINE BESYLATE/BENAZAmlodipine Besylate Benazepril HCl Cap 2.5 10 MGYes 0AMLODIPINE BESYLATE/BENAZAmlodipine Besylate Benazepril HCl Cap 5 10 MGYes 0Angiotensin II Receptor AntagonistsAntihypertensive Combinations# The Value Based Drug list applies to the PPO and HSA plans only and these drugs will bypass the deductible.If Value Based Drug Yes 0 then drug is available at no cost to you, if Value Based Drug Yes* (with an asterisk) you must call the PBM at (844) 547 0399 to get assistance lowering the costof your medication.Page 5 of 20To see the full CHN Formulary File, go to https://www/ecommunity.com/community health direct/membersPrint version: 6 1 2021
Brand NameGeneric Name and StrengthValue Based DrugCardiovascularAMLODIPINE BESYLATE/BENAZAmlodipine Besylate Benazepril HCl Cap 5 20 MGYes 0AMLODIPINE BESYLATE/BENAZAmlodipine Besylate Benazepril HCl Cap 5 40 MGYes 0BISOPROLOL FUMARATE/HYDROBisoprolol & Hydrochlorothiazide Tab 10 6.25 MGYes 0BISOPROLOL FUMARATE/HYDROBisoprolol & Hydrochlorothiazide Tab 2.5 6.25 MGYes 0BISOPROLOL FUMARATE/HYDROBisoprolol & Hydrochlorothiazide Tab 5 6.25 MGYes 0ENALAPRIL MALEATE/HYDROCHEnalapril Maleate & Hydrochlorothiazide Tab 10 25 MGYes 0ENALAPRIL MALEATE/HYDROCHEnalapril Maleate & Hydrochlorothiazide Tab 5 12.5 MGYes 0IRBESARTAN/HYDROCHLOROTHIIrbesartan Hydrochlorothiazide Tab 150 12.5 MGYes 0IRBESARTAN/HYDROCHLOROTHIIrbesartan Hydrochlorothiazide Tab 300 12.5 MGYes 0LISINOPRIL/HYDROCHLOROTHILisinopril & Hydrochlorothiazide Tab 10 12.5 MGYes 0LISINOPRIL/HYDROCHLOROTHILisinopril & Hydrochlorothiazide Tab 20 12.5 MGYes 0LISINOPRIL/HYDROCHLOROTHILisinopril & Hydrochlorothiazide Tab 20 25 MGYes 0LOSARTAN POTASSIUM/HYDROCLosartan Potassium & Hydrochlorothiazide Tab 100 12.5 MGYes 0LOSARTAN POTASSIUM/HYDROCLosartan Potassium & Hydrochlorothiazide Tab 100 25 MGYes 0LOSARTAN POTASSIUM/HYDROCLosartan Potassium & Hydrochlorothiazide Tab 50 12.5 MGYes 0ATENOLOLAtenolol Tab 100 MGYes 0ATENOLOLAtenolol Tab 25 MGYes 0ATENOLOLAtenolol Tab 50 MGYes 0BISOPROLOL FUMARATEBisoprolol Fumarate Tab 10 MGYes 0BISOPROLOL FUMARATEBisoprolol Fumarate Tab 5 MGYes 0METOPROLOL SUCCINATE ERMetoprolol Succinate Tab ER 24HR 100 MG (Tartrate Equiv)Yes 0METOPROLOL SUCCINATE ERMetoprolol Succinate Tab ER 24HR 200 MG (Tartrate Equiv)Yes 0METOPROLOL SUCCINATE ERMetoprolol Succinate Tab ER 24HR 25 MG (Tartrate Equiv)Yes 0METOPROLOL SUCCINATE ERMetoprolol Succinate Tab ER 24HR 50 MG (Tartrate Equiv)Yes 0METOPROLOL TARTRATEMetoprolol Tartrate Tab 100 MGYes 0Beta Blockers Cardio Selective# The Value Based Drug list applies to the PPO and HSA plans only and these drugs will bypass the deductible.If Value Based Drug Yes 0 then drug is available at no cost to you, if Value Based Drug Yes* (with an asterisk) you must call the PBM at (844) 547 0399 to get assistance lowering the costof your medication.Page 6 of 20To see the full CHN Formulary File, go to https://www/ecommunity.com/community health direct/membersPrint version: 6 1 2021
Brand NameGeneric Name and StrengthValue Based DrugCardiovascularMETOPROLOL TARTRATEMetoprolol Tartrate Tab 25 MGYes 0METOPROLOL TARTRATEMetoprolol Tartrate Tab 37.5 MGYes 0METOPROLOL TARTRATEMetoprolol Tartrate Tab 50 MGYes 0METOPROLOL TARTRATEMetoprolol Tartrate Tab 75 MGYes 0PROPRANOLOL HYDROCHLORIDEPropranolol HCl Tab 10 MGYes 0PROPRANOLOL HYDROCHLORIDEPropranolol HCl Tab 20 MGYes 0PROPRANOLOL HCLPropranolol HCl Tab 40 MGYes 0PROPRANOLOL HYDROCHLORIDEPropranolol HCl Tab 40 MGYes 0PROPRANOLOL HCLPropranolol HCl Tab 60 MGYes 0PROPRANOLOL HYDROCHLORIDEPropranolol HCl Tab 60 MGYes 0PROPRANOLOL HYDROCHLORIDEPropranolol HCl Tab 80 MGYes 0AMLODIPINE BESYLATEAmlodipine Besylate Tab 10 MG (Base Equivalent)Yes 0AMLODIPINE BESYLATEAmlodipine Besylate Tab 2.5 MG (Base Equivalent)Yes 0AMLODIPINE BESYLATEAmlodipine Besylate Tab 5 MG (Base Equivalent)Yes 0DILTIAZEM HCL ERDiltiazem HCl Cap ER 12HR 120 MGYes 0DILTIAZEM HCL ERDiltiazem HCl Cap ER 12HR 60 MGYes 0DILTIAZEM HCL ERDiltiazem HCl Cap ER 12HR 90 MGYes 0DILTIAZEM HYDROCHLORIDE EDiltiazem HCl Cap ER 24HR 120 MGYes 0DILT XRDiltiazem HCl Cap ER 24HR 120 MGYes 0DILTIAZEM HYDROCHLORIDE EDiltiazem HCl Cap ER 24HR 180 MGYes 0DILT XRDiltiazem HCl Cap ER 24HR 180 MGYes 0DILTIAZEM HYDROCHLORIDE EDiltiazem HCl Cap ER 24HR 240 MGYes 0DILT XRDiltiazem HCl Cap ER 24HR 240 MGYes 0CARTIA XTDiltiazem HCl Coated Beads Cap ER 24HR 120 MGYes 0Beta Blockers Non SelectiveCalcium Channel Blockers# The Value Based Drug list applies to the PPO and HSA plans only and these drugs will bypass the deductible.If Value Based Drug Yes 0 then drug is available at no cost to you, if Value Based Drug Yes* (with an asterisk) you must call the PBM at (844) 547 0399 to get assistance lowering the costof your medication.Page 7 of 20To see the full CHN Formulary File, go to https://www/ecommunity.com/community health direct/membersPrint version: 6 1 2021
Brand NameGeneric Name and StrengthValue Based DrugCardiovascularDILTIAZEM HYDROCHLORIDE EDiltiazem HCl Coated Beads Cap ER 24HR 120 MGYes 0CARTIA XTDiltiazem HCl Coated Beads Cap ER 24HR 180 MGYes 0DILTIAZEM HYDROCHLORIDE EDiltiazem HCl Coated Beads Cap ER 24HR 180 MGYes 0CARTIA XTDiltiazem HCl Coated Beads Cap ER 24HR 240 MGYes 0DILTIAZEM HYDROCHLORIDE EDiltiazem HCl Coated Beads Cap ER 24HR 240 MGYes 0CARTIA XTDiltiazem HCl Coated Beads Cap ER 24HR 300 MGYes 0DILTIAZEM HYDROCHLORIDE EDiltiazem HCl Coated Beads Cap ER 24HR 300 MGYes 0DILTIAZEM HCL CDDiltiazem HCl Coated Beads Cap ER 24HR 360 MGYes 0DILTIAZEM HYDROCHLORIDE EDiltiazem HCl Coated Beads Cap ER 24HR 360 MGYes 0DILTIAZEM HCL ERDiltiazem HCl Extended Release Beads Cap ER 24HR 120 MGYes 0TAZTIA XTDiltiazem HCl Extended Release Beads Cap ER 24HR 120 MGYes 0TIADYLT ERDiltiazem HCl Extended Release Beads Cap ER 24HR 120 MGYes 0DILTIAZEM HCL ERDiltiazem HCl Extended Release Beads Cap ER 24HR 180 MGYes 0TAZTIA XTDiltiazem HCl Extended Release Beads Cap ER 24HR 180 MGYes 0TIADYLT ERDiltiazem HCl Extended Release Beads Cap ER 24HR 180 MGYes 0DILTIAZEM HCL ERDiltiazem HCl Extended Release Beads Cap ER 24HR 240 MGYes 0TAZTIA XTDiltiazem HCl Extended Release Beads Cap ER 24HR 240 MGYes 0TIADYLT ERDiltiazem HCl Extended Release Beads Cap ER 24HR 240 MGYes 0DILTIAZEM HYDROCHLORIDE EDiltiazem HCl Extended Release Beads Cap ER 24HR 300 MGYes 0TAZTIA XTDiltiazem HCl Extended Release Beads Cap ER 24HR 300 MGYes 0TIADYLT ERDiltiazem HCl Extended Release Beads Cap ER 24HR 300 MGYes 0DILTIAZEM HYDROCHLORIDE EDiltiazem HCl Extended Release Beads Cap ER 24HR 360 MGYes 0TAZTIA XTDiltiazem HCl Extended Release Beads Cap ER 24HR 360 MGYes 0TIADYLT ERDiltiazem HCl Extended Release Beads Cap ER 24HR 360 MGYes 0DILTIAZEM HCL ERDiltiazem HCl Extended Release Beads Cap ER 24HR 420 MGYes 0TIADYLT ERDiltiazem HCl Extended Release Beads Cap ER 24HR 420 MGYes 0# The Value Based Drug list applies to the PPO and HSA plans only and these drugs will bypass the deductible.If Value Based Drug Yes 0 then drug is available at no cost to you, if Value Based Drug Yes* (with an asterisk) you must call the PBM at (844) 547 0399 to get assistance lowering the costof your medication.Page 8 of 20To see the full CHN Formulary File, go to https://www/ecommunity.com/community health direct/membersPrint version: 6 1 2021
Brand NameGeneric Name and StrengthValue Based DrugCardiovascularDILTIAZEM HCLDiltiazem HCl Tab 120 MGYes 0DILTIAZEM HYDROCHLORIDEDiltiazem HCl Tab 120 MGYes 0DILTIAZEM HCLDiltiazem HCl Tab 30 MGYes 0DILTIAZEM HYDROCHLORIDEDiltiazem HCl Tab 30 MGYes 0DILTIAZEM HCLDiltiazem HCl Tab 60 MGYes 0DILTIAZEM HYDROCHLORIDEDiltiazem HCl Tab 60 MGYes 0DILTIAZEM HCLDiltiazem HCl Tab 90 MGYes 0DILTIAZEM HYDROCHLORIDEDiltiazem HCl Tab 90 MGYes 0FELODIPINE ERFelodipine Tab ER 24HR 10 MGYes 0FELODIPINE ERFelodipine Tab ER 24HR 2.5 MGYes 0FELODIPINE ERFelodipine Tab ER 24HR 5 MGYes 0NIFEDIPINE ERNifedipine Tab ER 24HR 30 MGYes 0NIFEDIPINE ERNifedipine Tab ER 24HR 60 MGYes 0NIFEDIPINE ERNifedipine Tab ER 24HR 90 MGYes 0NIFEDIPINE ERNifedipine Tab ER 24HR Osmotic Release 30 MGYes 0NIFEDIPINE ERNifedipine Tab ER 24HR Osmotic Release 60 MGYes 0NIFEDIPINE ERNifedipine Tab ER 24HR Osmotic Release 90 MGYes 0VERAPAMIL HCL ERVerapamil HCl Cap ER 24HR 100 MGYes 0VERAPAMIL HCL ERVerapamil HCl Cap ER 24HR 120 MGYes 0VERAPAMIL HCL SRVerapamil HCl Cap ER 24HR 120 MGYes 0VERAPAMIL HCL ERVerapamil HCl Cap ER 24HR 180 MGYes 0VERAPAMIL HCL SRVerapamil HCl Cap ER 24HR 180 MGYes 0VERAPAMIL HYDROCHLORIDE EVerapamil HCl Cap ER 24HR 200 MGYes 0VERAPAMIL HCL ERVerapamil HCl Cap ER 24HR 240 MGYes 0VERAPAMIL HCL SRVerapamil HCl Cap ER 24HR 240 MGYes 0VERAPAMIL HCL ERVerapamil HCl Cap ER 24HR 300 MGYes 0# The Value Based Drug list applies to the PPO and HSA plans only and these drugs will bypass the deductible.If Value Based Drug Yes 0 then drug is available at no cost to you, if Value Based Drug Yes* (with an asterisk) you must call the PBM at (844) 547 0399 to get assistance lowering the costof your medication.Page 9 of 20To see the full CHN Formulary File, go to https://www/ecommunity.com/community health direct/membersPrint version: 6 1 2021
Brand NameGeneric Name and StrengthValue Based DrugCardiovascularVERAPAMIL HCL SRVerapamil HCl Cap ER 24HR 360 MGYes 0VERAPAMIL HYDROCHLORIDEVerapamil HCl Tab 120 MGYes 0VERAPAMIL HCLVerapamil HCl Tab 40 MGYes 0VERAPAMIL HCLVerapamil HCl Tab 80 MGYes 0VERAPAMIL HCL ERVerapamil HCl Tab ER 120 MGYes 0VERAPAMIL HCL ERVerapamil HCl Tab ER 180 MGYes 0VERAPAMIL HYDROCHLORIDE EVerapamil HCl Tab ER 180 MGYes 0VERAPAMIL HCL ERVerapamil HCl Tab ER 240 MGYes 0VERAPAMIL HYDROCHLORIDE EVerapamil HCl Tab ER 240 MGYes 0JANTOVENWarfarin Sodium Tab 1 MGYes 0WARFARIN SODIUMWarfarin Sodium Tab 1 MGYes 0JANTOVENWarfarin Sodium Tab 10 MGYes 0WARFARIN SODIUMWarfarin Sodium Tab 10 MGYes 0JANTOVENWarfarin Sodium Tab 2 MGYes 0WARFARIN SODIUMWarfarin Sodium Tab 2 MGYes 0JANTOVENWarfarin Sodium Tab 2.5 MGYes 0WARFARIN SODIUMWarfarin Sodium Tab 2.5 MGYes 0JANTOVENWarfarin Sodium Tab 3 MGYes 0WARFARIN SODIUMWarfarin Sodium Tab 3 MGYes 0JANTOVENWarfarin Sodium Tab 4 MGYes 0WARFARIN SODIUMWarfarin Sodium Tab 4 MGYes 0JANTOVENWarfarin Sodium Tab 5 MGYes 0WARFARIN SODIUMWarfarin Sodium Tab 5 MGYes 0JANTOVENWarfarin Sodium Tab 6 MGYes 0WARFARIN SODIUMWarfarin Sodium Tab 6 MGYes 0Coumarin Anticoagulants# The Value Based Drug list applies to the PPO and HSA plans only and these drugs will bypass the deductible.If Value Based Drug Yes 0 then drug is available at no cost to you, if Value Based Drug Yes* (with an asterisk) you must call the PBM at (844) 547 0399 to get assistance lowering the costof your medication.Page 10 of 20To see the full CHN Formulary File, go to https://www/ecommunity.com/community health direct/membersPrint version: 6 1 2021
Brand NameGeneric Name and StrengthValue Based DrugCardiovascularJANTOVENWarfarin Sodium Tab 7.5 MGYes 0WARFARIN SODIUMWarfarin Sodium Tab 7.5 MGYes 0ELIQUISApixaban Tab 2.5 MGYes*ELIQUISApixaban Tab 5 MGYes*ELIQUIS STARTER PACKApixaban Tab Starter Pack 5 MGYes*XARELTORivaroxaban Tab 10 MGYes*XARELTORivaroxaban Tab 15 MGYes*XARELTORivaroxaban Tab 2.5 MGYes*XARELTORivaroxaban Tab 20 MGYes*XARELTO STARTER PACKRivaroxaban Tab Starter Therapy Pack 15 MG & 20 MGYes*TRIAMTERENE/HYDROCHLOROTHTriamterene & Hydrochlorothiazide Cap 37.5 25 MGYes 0TRIAMTERENE/HYDROCHLOROTHTriamterene & Hydrochlorothiazide Tab 37.5 25 MGYes 0TRIAMTERENE/HYDROCHLOROTHTriamterene & Hydrochlorothiazide Tab 75 50 MGYes 0FOLIC ACIDFolic Acid Tab 1 MGYes 0ATORVASTATIN CALCIUMAtorvastatin Calcium Tab 10 MG (Base Equivalent)Yes 0ATORVASTATIN CALCIUMAtorvastatin Calcium Tab 20 MG (Base Equivalent)Yes 0ATORVASTATIN CALCIUMAtorvastatin Calcium Tab 40 MG (Base Equivalent)Yes 0ATORVASTATIN CALCIUMAtorvastatin Calcium Tab 80 MG (Base Equivalent)Yes 0FLUVASTATINFluvastatin Sodium Cap 20 MG (Base Equivalent)Yes 0FLUVASTATINFluvastatin Sodium Cap 40 MG (Base Equivalent)Yes 0LOVASTATINLovastatin Tab 10 MGYes 0Direct Factor Xa InhibitorsDiuretic CombinationsFolic Acid/FolatesHMG CoA Reductase Inhibitors# The Value Based Drug list applies to the PPO and HSA plans only and these drugs will bypass the deductible.If Value Based Drug Yes 0 then drug is available at no cost to you, if Value Based Drug Yes* (with an asterisk) you must call the PBM at (844) 547 0399 to get assistance lowering the costof your medication.Page 11 of 20To see the full CHN Formulary File, go to https://www/ecommunity.com/community health direct/membersPrint version: 6 1 2021
Brand NameGeneric Name and StrengthValue Based DrugCardiovascularLOVASTATINLovastatin Tab 20 MGYes 0LOVASTATINLovastatin Tab 40 MGYes 0PRAVASTATIN SODIUMPravastatin Sodium Tab 10 MGYes 0PRAVASTATIN SODIUMPravastatin Sodium Tab 20 MGYes 0PRAVASTATIN SODIUMPravastatin Sodium Tab 40 MGYes 0PRAVASTATIN SODIUMPravastatin Sodium Tab 80 MGYes 0ROSUVASTATIN CALCIUMRosuvastatin Calcium Tab 10 MGYes 0ROSUVASTATIN CALCIUMRosuvastatin Calcium Tab 20 MGYes 0ROSUVASTATIN CALCIUMRosuvastatin Calcium Tab 40 MGYes 0ROSUVASTATIN CALCIUMRosuvastatin Calcium Tab 5 MGYes 0SIMVASTATINSimvastatin Tab 10 MGYes 0SIMVASTATINSimvastatin Tab 20 MGYes 0SIMVASTATINSimvastatin Tab 40 MGYes 0SIMVASTATINSimvastatin Tab 5 MGYes 0SIMVASTATINSimvastatin Tab 80 MGYes 0BUMETANIDEBumetanide Tab 0.5 MGYes 0BUMETANIDEBumetanide Tab 1 MGYes 0BUMETANIDEBumetanide Tab 2 MGYes 0FUROSEMIDEFurosemide Tab 20 MGYes 0FUROSEMIDEFurosemide Tab 40 MGYes 0FUROSEMIDEFurosemide Tab 80 MGYes 0NITROGLYCERINNitroglycerin SL Tab 0.3 MGYes 0NITROGLYCERINNitroglycerin SL Tab 0.4 MGYes 0NITROGLYCERINNitroglycerin SL Tab 0.6 MGYes 0Loop DiureticsNitrates# The Value Based Drug list applies to the PPO and HSA plans only and these drugs will bypass the deductible.If Value Based Drug Yes 0 then drug is available at no cost to you, if Value Based Drug Yes* (with an asterisk) you must call the PBM at (844) 547 0399 to get assistance lowering the costof your medication.Page 12 of 20To see the full CHN Formulary File, go to https://www/ecommunity.com/community health direct/membersPrint version: 6 1 2021
Brand NameGeneric Name and StrengthValue Based DrugCardiovascularPlatelet Aggregation InhibitorsCLOPIDOGRELClopidogrel Bisulfate Tab 300 MG (Base Equiv)Yes 0CLOPIDOGRELClopidogrel Bisulfate Tab 75 MG (Base Equiv)Yes 0AMILORIDE HCLAmiloride HCl Tab 5 MGYes 0SPIRONOLACTONESpironolactone Tab 100 MGYes 0SPIRONOLACTONESpironolactone Tab 25 MGYes 0SPIRONOLACTONESpironolactone Tab 50 MGYes 0CHLORTHALIDONEChlorthalidone Tab 25 MGYes 0CHLORTHALIDONEChlorthalidone Tab 50 MGYes 0HYDROCHLOROTHIAZIDEHydrochlorothiazide Cap 12.5 MGYes 0HYDROCHLOROTHIAZIDEHydrochlorothiazide Tab 12.5 MGYes 0HYDROCHLOROTHIAZIDEHydrochlorothiazide Tab 25 MGYes 0HYDROCHLOROTHIAZIDEHydrochlorothiazide Tab 50 MGYes 0INDAPAMIDEIndapamide Tab 1.25 MGYes 0INDAPAMIDEIndapamide Tab 2.5 MGYes 0METOLAZONEMetolazone Tab 10 MGYes 0METOLAZONEMetolazone Tab 2.5 MGYes 0METOLAZONEMetolazone Tab 5 MGYes 0ACARBOSEAcarbose Tab 100 MGYes 0ACARBOSEAcarbose Tab 25 MGYes 0ACARBOSEAcarbose Tab 50 MGYes 0Potassium Sparing DiureticsThiazides and Thiazide Like DiureticsDiabetesAlpha Glucosidase Inhibitors# The Value Based Drug list applies to the PPO and HSA plans only and these drugs will bypass the deductible.If Value Based Drug Yes 0 then drug is available at no cost to you, if Value Based Drug Yes* (with an asterisk) you must call the PBM at (844) 547 0399 to get assistance lowering the costof your medication.Page 13 of 20To see the full CHN Formulary File, go to https://www/ecommunity.com/community health direct/membersPrint version: 6 1 2021
Brand NameGeneric Name and StrengthValue Based DrugDiabetesAntidiabetic CombinationsINVOKAMETCanagliflozin Metformin HCl Tab 150 1000 MGYes*INVOKAMETCanagliflozin Metformin HCl Tab 150 500 MGYes*INVOKAMETCanagliflozin Metformin HCl Tab 50 1000 MGYes*INVOKAMETCanagliflozin Metformin HCl Tab 50 500 MGYes*INVOKAMET XRCanagliflozin Metformin HCl Tab ER 24HR 150 1000 MGYes*INVOKAMET XRCanagliflozin Metformin HCl Tab ER 24HR 150 500 MGYes*INVOKAMET XRCanagliflozin Metformin HCl Tab ER 24HR 50 1000 MGYes*INVOKAMET XRCanagliflozin Metformin HCl Tab ER 24HR 50 500 MGYes*SYNJARDYEmpagliflozin Metformin HCl Tab 12.5 1000 MGYes 0SYNJARDYEmpagliflozin Metformin HCl Tab 12.5 500 MGYes 0SYNJARDYEmpagliflozin Metformin HCl Tab 5 1000 MGYes 0SYNJARDYEmpagliflozin Metformin HCl Tab 5 500 MGYes 0SYNJARDY XREmpagliflozin Metformin HCl Tab ER 24HR 10 1000 MGYes 0SYNJARDY XREmpagliflozin Metformin HCl Tab ER 24HR 12.5 1000 MGYes 0SYNJARDY XREmpagliflozin Metformin HCl Tab ER 24HR 25 1000 MGYes 0SYNJARDY XREmpagliflozin Metformin HCl Tab ER 24HR 5 1000 MGYes 0GLIPIZIDE/METFORMIN HYDROGlipizide Metformin HCl Tab 2.5 250 MGYes 0GLIPIZIDE/METFORMIN HYDROGlipizide Metformin HCl Tab 2.5 500 MGYes 0GLIPIZIDE/METFORMIN HYDROGlipizide Metformin HCl Tab 5 500 MGYes 0GLYBURIDE/METFORMIN HYDROGlyburide Metformin Tab 1.25 250 MGYes 0GLYBURIDE/METFORMIN HYDROGlyburide Metformin Tab 2.5 500 MGYes 0GLYBURIDE/METFORMIN HYDROGlyburide Metformin Tab 5 500 MGYes 0PIOGLITAZONE HCL GLIMEPIRPioglitazone HCl Glimepiride Tab 30 2 MGYes 0PIOGLITAZONE HCL GLIMEPIRPioglitazone HCl Glimepiride Tab 30 4 MGYes 0PIOGLITAZONE HCL/METFORMIPioglitazone HCl Metformin HCl Tab 15 500 MGYes 0# The Value Based Drug list applies to the PPO and HSA plans only and these drugs will bypass the deductible.If Value Based Drug Yes 0 then drug is available at no cost to you, if Value Based Drug Yes* (with an asterisk) you must call the PBM at (844) 547 0399 to get assistance lowering the costof your medication.Page 14 of 20To see the full CHN Formulary File, go to https://www/ecommunity.com/community health direct/membersPrint version: 6 1 2021
Brand NameGeneric Name and StrengthValue Based DrugDiabetesPIOGLITAZONE HCL/METFORMIPioglitazone HCl Metformin HCl Tab 15 850 MGYes 0METFORMIN HYDROCHLORIDEMetformin HCl Oral Soln 500 MG/5MLYes 0METFORMIN HYDROCHLORIDEMetformin HCl Tab 1000 MGYes 0METFORMIN HYDROCHLORIDEMetformin HCl Tab 500 MGYes 0METFORMIN HYDROCHLORIDEMetformin HCl Tab 850 MGYes 0METFORMIN HYDROCHLORIDE EMetformin HCl Tab ER 24HR 500 MGYes 0METFORMIN HYDROCHLORIDE EMetformin HCl Tab ER 24HR 750 MGYes 0GLUCAGON EMERGENCY KITGlucagon (rDNA) For Inj Kit 1 MGYesGLUCAGEN HYPOKITGlucagon HCl (rDNA) For Inj 1 MG (Base Equiv)Yes*Lancets****Lancets***Yes 0CONTOUR BLOOD GLUCOSE TESGlucose Blood Test StripYes 0CONTOUR NEXT BLOOD GLUCOSGlucose Blood Test StripYes 0TRULICITYDulaglutide Soln Pen injector 0.75 MG/0.5MLYesTRULICITYDulaglutide Soln Pen injector 1.5 MG/0.5MLYesTRULICITYDulaglutide Soln Pen injector 3 MG/0.5MLYes*TRULICITYDulaglutide Soln Pen injector 4.5 MG/0.5MLYes*VICTOZALiraglutide Soln Pen injector 18 MG/3ML (6 MG/ML)YesOZEMPICSemaglutide Soln Pen inj 0.25 or 0.5 MG/DOSE (2 MG/1.5ML)Yes*OZEMPICSemaglutide Soln Pen inj 1 MG/DOSE (2 MG/1.5ML)Yes*OZEMPICSemaglutide Soln Pen inj 1 MG/DOSE (4 MG/3ML)Yes*BiguanidesDiabetic OtherDiabetic SuppliesDiagnostic TestsIncretin Mimetic Agents (GLP 1 Receptor Agonists)# The Value Based Drug list applies to the PPO and HSA plans only and these drugs will bypass the deductible.If Value Based Drug Yes 0 then drug is available at no cost to you, if Value Based Drug Yes* (with an asterisk) you must call the PBM at (844) 547 0399 to get assistance lowering the costof your medication.Page 15 of 20To see the full CHN Formulary File, go to https://www/ecommunity.com/community health direct/membersPrint version: 6 1 2021
Brand NameGeneric Name and StrengthValue Based DrugDiabetesInsulinFIASPInsulin Aspart (with Niacinamide) Inj 100 Unit/MLYes*FIASP FLEXTOUCHInsulin Aspart (with Niacinamide) Sol Pen inj 100 Unit/MLYes*FIASP PENFILLInsulin Aspart (with Niacinamide) Soln Cartridge 100 Unit/MLYes*INSULIN ASPARTInsulin Aspart Inj 100 Unit/MLYes 0NOVOLOGInsulin Aspart Inj 100 Unit/MLYes*INSULIN ASPART PROTAMINE/Insulin Aspart Prot & Aspart (Human) Inj 100 Unit/ML (70 30)Yes 0NOVOLOG MIX 70/30Insulin Aspart Prot & Aspart (Human) Inj 100 Unit/ML (70 30)Yes*INSULIN ASPART PROTAMINE/Insulin Aspart Prot & Aspart Sus Pen inj 100 Unit/ML (70 30)Yes 0NOVOLOG MIX 70/30 PREFILLInsulin Aspart Prot & Aspart Sus Pen inj 100 Unit/ML (70 30)Yes*INSULIN ASPART PENFILLInsulin Aspart Soln Cartridge 100 Unit/MLYes 0NOVOLOG PENFILLInsulin Aspart Soln Cartridge 100 Unit/MLYes*INSULIN ASPART FLEXPENInsulin Aspart Soln Pen injector 100 Unit/MLYes 0NOVOLOG FLEXPENInsulin Aspart Soln Pen inj
BUDESONIDE Budesonide Inhalation Susp 0.25 MG/2ML Yes 0 . FLOVENT HFA Fluticasone Propionate HFA Inhal Aero 44 MCG/ACT (50/Valve) Yes 0 . BUDESONIDE/FORMOTEROL FUM Budesonide Formoterol Fumarate Dihyd Aerosol 80 4.5 MCG/ACT Yes 0 FLUTICASONE PROPIONATE/SA Fluticasone Salmete
eCommunity is fully interoperable, ensuring quick and painless integration. eCommunity's interoperability and open APIs guarantee fast and accurate data transfer. The only solution that integrates with HealthRoster, making it the only end-to-end solution on the market. Automatic integration to HealthRoster ensures data uploaded is
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
Entrepreneurship eCommunity Loan Application Ellis County E-Community Program A partnership project of Grow Hays Hays Area Chamber of Commerce Downtown Hays Development Corporation Small Business Development Center - Fort Hays State University Kansas Department of Commerce E-Community Vision Fostering the entrepreneurial culture of Ellis County
eCommunity is an NHS designed tool to support the operational element of delivering care in the community, focusing on capacity and demand, smart rostering and visit allocation. This in turn ensures skill, continuity and patient choice and experience delivers safe and effective patient centric care.
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
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
b. Drugs acting on Central Nervous system: Analgesics, Nonsteroidal anti inflammatory drugs, Sedatives and Hypnotic, Anti convulsants and Antipsychotic drugs. Drugs used in parkinsonism. c. Drugs acting on Autonomic Nervous system: Drugs which influence the working of autonomic nervous system, Adrencrgic drugs
(e.g., cancer treatment drugs) These drugs usually have special shipping, storage or use instructions You pay less for these drugs than for Non-preferred specialty drugs Tier 5 Non-preferred specialty You'll pay more for these specialty drugs because there is a Preferred specialty available SO BO
