Moda Health Rx (PDP) 2021 Comprehensive Formulary .

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Moda Health Rx (PDP)2021 ComprehensiveFormulary (complete listof covered drugs)Please read: this documentcontains information about thedrugs we cover in this planNote to existing members: This formulary has changed sincelast year. Please review this document to make sure that itstill contains the drugs you take.For more recent information or other questions, pleasevisit modahealth.com/pers or contact Moda Health Plan,Inc. Customer Service at 1-888-786-7509 from 7 a.m. to 8p.m., Pacific Rx (PDP), seven days a week from October 1through March 31. (After March 31, your call will be handledby our automated phone systems Saturdays, Sundays, andholidays.) TTY users should call 711.Y0115 CFPERS21A C

Moda Health Rx (PDP)2021 Comprehensive Formulary(List of Covered Drugs)PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THEDRUGS WE COVER IN THIS PLANFormulary ID 00021545 Version 17This formulary was updated on December 1, 2021. For more recent information or other questions,please contact Moda Health at 1-888-786-7509 or, for TTY users, 711, from 7 a.m. to 8 p.m., PacificTime, seven days a week from October 1 through March 31 (After April 1, your call will be handledby our automated phone system Saturdays, Sundays and holidays), or visitwww.modahealth.com/pers.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 Moda Health Plan, Inc. When itrefers to “plan” or “our plan,” it means Moda Health Rx (PDP).This document includes a list of the drugs (formulary) for our plan which is current as of December 1,2021. For an updated formulary, please contact us. Our contact information, along with the date welast 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, 2022, and from time totime during the year. The formulary may change at any time. You will receive notice when necessary.Moda Health Plan, Inc. is a PPO and PDP with Medicare contracts. Enrollment in Moda Health Plan,Inc. depends on contract renewal.Formulary ID 00021545 Version 17Y0115 CFPERS21A Cii

What is the Moda Health Formulary?A formulary is a list of covered drugs selected by Moda Health in consultation with a team of health careproviders, which represents the prescription therapies believed to be a necessary part of a qualitytreatment program. Moda Health will generally cover the drugs listed in our formulary as long as the drugis medically necessary, the prescription is filled at a Moda Health network pharmacy, and other plan rulesare followed. For more information on how to fill your prescriptions, please review your Evidence ofCoverage.Can the Formulary (drug list) change?Most changes in drug coverage happen on January 1, 2021, but Moda Health may add or remove drugs onthe Drug List during the year, move them to different cost-sharing tiers, or add new restrictions.Changes that can affect you this year: In the below cases, you will be affected by coverage changesduring the year: New generic drugs. We may immediately remove a brand name drug on our Drug List if we arereplacing it with a new generic drug that will appear on the same or lower cost sharing tier andwith the same or fewer restrictions. Also, when adding the new generic drug, we may decide tokeep the brand name drug on our Drug List, but immediately move it to a different cost-sharingtier or add new restrictions. If you are currently taking that brand name drug, we may not tellyou in advance before we make that change, but we will later provide you with informationabout the specific change(s) we have made.o If we make such a change, you or your prescriber can ask us to make an exception andcontinue to cover the brand name drug for you. The notice we provide you will alsoinclude information on how to request an exception, and you can also find information inthe section below entitled “How do I request an exception to the Moda HealthFormulary?” Drugs removed from the market. If the Food and Drug Administration deems a drug on ourformulary to be unsafe or the drug’s manufacturer removes the drug from the market, we willimmediately remove the drug from our formulary and provide notice to members who takethe drug. Other changes. We may make other changes that affect members currently taking a drug. Forinstance, we may add a new generic drug to replace a brand name drug currently on theformulary or add new restrictions to the brand name drug or move it to a different costsharing tier. Or we may make changes based on new clinical guidelines. If we remove drugsfrom our formulary, or add prior authorization, quantity limits and/or step therapy restrictionson a drug or move a drug to a higher cost- sharing tier, we must notify affected members ofthe change at least 30 days before the change becomes effective, or at the time the memberrequests a refill of the drug, at which time the member will receive a 31-day supply of thedrug.o If we make these other changes, you or your prescriber can ask us to make an exceptionand continue to cover the brand name drug for you. The notice we provide you will alsoinclude information on how to request an exception, and you can also find informationiii

in the section below entitled “How do I request an exception to the Moda HealthFormulary?”Changes that will not affect you if you are currently taking the drug. Generally, if you are taking a drug onour 2020 formulary that was covered at the beginning of the year, we will not discontinue or reducecoverage of the drug during the 2021 coverage year except as described above. This means these drugswill remain available at the same cost-sharing and with no new restrictions for those members takingthem for the remainder of the coverage year.The enclosed formulary is current as of December 1, 2021. To get updated information about the drugscovered by Moda Health, please contact us. Our contact information appears on the front and back coverpages.Moda Health posts the future formulary update files on our website, www.modahealth.com/pers by thefirst of each month.How do I use the Formulary?There are two ways to find your drug within the formulary:Medical ConditionThe formulary begins on page 3. The drugs in this formulary are grouped into categories dependingon the type of medical conditions that they are used to treat. For example, drugs used to treat aheart condition are listed under the category, “Cardiovascular Agents”. If you know what your drugis used for, look for the category name in the list that begins on page 3. Then look under thecategory name for your drug.Alphabetical ListingIf you are not sure what category to look under, you should look for your drug in the Index that beginson page 99. The Index provides an alphabetical list of all of the drugs included in this document. Bothbrand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Nextto your drug, you will see the page number where you can find coverage information. Turn to the pagelisted in the Index and find the name of your drug in the first column of the list.What are generic drugs?Moda Health covers both brand name drugs and generic drugs. A generic drug is approved by the FDAas having the same active ingredient as the brand name drug. Generally, generic drugs cost lessthan brand name drugs.Are there any restrictions on my coverage?Some covered drugs may have additional requirements or limits on coverage. These requirements andlimits may include:iv

Prior Authorization: Moda Health requires you or your physician to get prior authorization forcertain drugs. This means that you will need to get approval from Moda Health before you fillyour prescriptions. If you don’t get approval, Moda Health may not cover the drug. Quantity Limits: For certain drugs, Moda Health limits the amount of the drug that ModaHealth will cover. For example, Moda Health provides 30 tablets in 30 days per prescription foratorvastatin. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, Moda Health requires you to first try certain drugs to treat yourmedical condition before we will cover another drug for that condition. For example, if Drug Aand Drug B both treat your medical condition, Moda Health may not cover Drug B unless youtry Drug A first. If Drug A does not work for you, Moda Health will then cover Drug B.You can find out if your drug has any additional requirements or limits by looking in the formulary thatbegins on page 3. You can also get more information about the restrictions applied to specific covereddrugs by visiting our Web site at modahealth.com/medicare. We have posted on line documents thatexplain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Ourcontact information, along with the date we last updated the formulary, appears on the front and backcover pages.You can ask Moda Health to make an exception to these restrictions or limits or for a list of other,similar drugs that may treat your health condition. See the section, “How do I request an exception to theModa Health’s formulary?” on page iv for information about how to request an exception.What if my drug is not on the Formulary?If your drug is not included in this formulary (list of covered drugs), you should first contact CustomerService and ask if your drug is covered.If you learn that Moda Health does not cover your drug, you have two options: You can ask Customer Service for a list of similar drugs that are covered by Moda Health. Whenyou receive the list, show it to your doctor and ask him or her to prescribe a similar drug that iscovered by Moda Health. You can ask Moda Health to make an exception and cover your drug. See belowfor information about how to request an exception.How do I request an exception to the Moda Health Formulary?You can ask Moda Health to make an exception to our coverage rules. There are several typesof exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will becovered at a pre-determined cost-sharing level, and you would not be able to ask us toprovide the drug at a lower cost-sharing level.v

You can ask us to waive coverage restrictions or limits on your drug. For example, for certaindrugs, Moda Health limits the amount of the drug that we will cover. If your drug has a quantitylimit, you can ask us to waive the limit and cover a greater amount.Generally, Moda Health will only approve your request for an exception if the alternative drugsincluded on the plan’s formulary or additional utilization restrictions would not be as effective intreating your condition and/or would cause you to have adverse medical effects.You should contact us to ask us for an initial coverage decision for a formulary or utilization restrictionexception. When you request a formulary or utilization restriction exception you should submit astatement from your prescriber or physician supporting your request. Generally, we must make ourdecision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited(fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than24 hours after we get a supporting statement from your doctor or other prescriber.What do I do before I can talk to my doctor about changing my drugs or requesting anexception?As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, youmay be taking a drug that is on our formulary but your ability to get it is limited. For example, you mayneed a prior authorization from us before you can fill your prescription. You should talk to your doctor todecide if you should switch to an appropriate drug that we cover or request a formulary exception sothat we will cover the drug you take. While you talk to your doctor to determine the right course ofaction for you, we may cover your drug in certain cases during the first 90 days you are a member of ourplan.For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we willcover a temporary 31-day supply (unless you have a prescription written for fewer days) when you go toa network pharmacy. After your first 31-day supply, we will not pay for these drugs, even if you havebeen a member of the plan less than 90 days.If you are a resident of a long-term care facility, we will allow you to refill your prescription until we haveprovided you with up to a 31-day transition supply, consistent with dispensing increment, (unless youhave a prescription written for fewer days). We will cover more than one refill of these drugs for the first90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability toget your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue aformulary exception.If you have a level of care change (such as going into or coming out of a skilled nursing facility or long termcare home) we will cover a temporary 31-day transition supply (unless you have a prescription written forfewer days). If you need a drug that is not on our formulary or if your ability to get your drugs is limited,but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply ofthat drug (unless you have a prescription for fewer days) while you pursue a formulary exception.vi

For more informationFor more detailed information about your Moda Health prescription drug coverage, please review yourEvidence of Coverage and other plan materials.If you have questions about Moda Health, please contact us. Our contact information, along with thedate we last updated the formulary, appears on the front and back cover pages.If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or,visit http://www.medicare.gov.Moda Health FormularyThe formulary that begins on page 1 provides coverage information about the drugs covered by ModaHealth. If you have trouble finding your drug in the list, turn to the Index that begins on page 99.The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., LYRICA) andgeneric drugs are listed in lower-case italics (e.g., valsartan).The information in the Requirements/Limits column tells you if Moda Health has any specialrequirements for coverage of your drug.vii

Below is your cost sharing in the plan by drug tier:Drug Tierup to a 31-day supplyup to a 93-day supplyTier 1Tier 2Tier 3Tier 4 8 1540% up to 25040% up to 250Tier 540% up to 250 24 4540% up to 75040% up to 750drugs on this tier arelimited to a 31-day supplyup to a 93-day supply atMail Order 16 3040% up to 75040% up to 750drugs on this tier are limited to a31-day supplyTier 6 0drugs on this tier arelimited to a 31-day supplydrugs on this tier are limited to a31-day supplyviii

Utilization Management RestrictionsAbbreviationDescriptionNDSNon-Extended DaysSupplyPAPA BvDPrior AuthorizationRestrictionPrior AuthorizationRestrictionforPart B vs Part DDetermination1ExplanationThis prescription is limited to a 31-daysupply. For more information call CustomerService at 1-888-786-7509 from 7 a.m. to 8p.m., Pacific Time, seven days a week, fromOctober 1 to March 31 (after April 1, yourcall will be handled by our automatedphone system Saturdays, Sundays andholidays). TTY users call 711.You (or your physician) are required to getprior authorization from Moda Healthbefore you fill your prescription for thisdrug. Without prior approval, ModaHealth may not cover the drug. To requesta coverage determination, please callCustomer Service at 1-888-786-7509 from7 a.m. to 8 p.m., Pacific Time, seven daysa week, from October 1 to March 31(after April 1, your call will be handled byour automated phone system Saturdays,Sundays and holidays). TTY users call 711.This drug may be eligible for paymentunder Medicare Part B or Part D. You (oryour physician) are required to get priorauthorization from Moda Health todetermine that this drug is covered underMedicare Part D before you fill yourprescription for this drug. Without priorapproval, Moda Health may not cover thedrug. To request a coveragedetermination, please call CustomerService at 1-888-786-7509 from 7 a.m. to8 p.m., Pacific Time, seven days a week,from October 1 to March 31 (after April 1,your call will be handled by ourautomated phone system Saturdays,Sundays and holidays). TTY users call 711.

Utilization Management RestrictionsAbbreviationDescriptionPA NSOPrior AuthorizationRestrictionforNew Starts OnlyQLSTExplanationIf you are a new member or if you have nottaken this drug before, you (or yourphysician) are required to get priorauthorization from Moda Health beforeyou fill your prescription for this drug.Without prior approval, Moda Health maynot cover the drug. To request a coveragedetermination, please call CustomerService at 1-888-786-7509 from 7 a.m. to 8p.m., Pacific Time, seven days a week, fromOctober 1 to March 31 (after April1, your call will be handled by ourautomated phone system Saturdays,Sundays and holidays). TTY users call 711.Quantity Limit RestrictionStep Therapy Restriction2Moda Health limits the amount of this drugthat is covered per prescription, or within aspecific time frame. Without priorapproval, Moda Health may not cover thedrug. To request a coveragedetermination, please call CustomerService at 1-888-786-7509 from 7 a.m. to 8p.m., Pacific Time, seven days a week fromOctober 1 to March 31 (after April 1, yourcall will be handled by our automatedphone system Saturdays, Sundays andholidays). TTY users call 711.Before Moda Health will provide coveragefor this drug, you must first try anotherdrug(s) to treat your medical condition.This drug may only be covered if the otherdrug(s) does not work for you. To requesta coverage determination, please callCustomer Service at 1-888-786-7509 from7 a.m. to 8 p.m., Pacific Time, seven daysa week, from October 1 to March 31(after April 1, your call will be handled byour automated phone systemSaturdays, Sundays and holidays). TTYusers call 711.

DRUG NAMEDRUG phetamine 10mg ER cap2amphetamine-dextroamphetamine 10mg tab2amphetamine-dextroamphetamine 12.5mg tab2amphetamine-dextroamphetamine 15mg ER cap2amphetamine-dextroamphetamine 15mg tab2amphetamine-dextroamphetamine 20mg ER cap2amphetamine-dextroamphetamine 20mg tab2amphetamine-dextroamphetamine 25mg ER cap2amphetamine-dextroamphetamine 30mg ER cap2amphetamine-dextroamphetamine 30mg tab2amphetamine-dextroamphetamine 5mg ER cap2amphetamine-dextroamphetamine 5mg tab2amphetamine-dextroamphetamine 7.5mg tab2dextroamphetamine sulfate 10mg er cap2dextroamphetamine sulfate 10mg tab2dextroamphetamine sulfate 15mg er cap2dextroamphetamine sulfate 1mg/ml oral soln2dextroamphetamine sulfate 5mg er cap2dextroamphetamine sulfate 5mg tab2procentra 5mg/5ml oral soln2ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD) AGENTSatomoxetine 100mg capQL 60 EA/30 Days2atomoxetine 10mg capQL 60 EA/30 Days2atomoxetine 18mg capQL 60 EA/30 Days2atomoxetine 25mg capQL 60 EA/30 Days2atomoxetine 40mg capQL 60 EA/30 Days2atomoxetine 60mg capQL 60 EA/30 Days2atomoxetine 80mg capQL 60 EA/30 Days2clonidine 0.1mg er tab2guanfacine 1mg er tab2guanfacine 2mg er tab2guanfacine 3mg er tab2guanfacine 4mg er tab2DOPAMINE AND NOREPINEPHRINE REUPTAKE INHIBITORS (DNRIS)SUNOSI 150MG TABPA QL 30 EA/30 Days3SUNOSI 75MG TABPA QL 30 EA/30 Days3HISTAMINE H3-RECEPTOR ANTAGONIST/INVERSE AGONISTSWAKIX 17.8MG TABNDS PA QL 60 EA/30 Days5WAKIX 4.45MG TABNDS PA QL 60 EA/30 Days5STIMULANTS - MISC.armodafinil 150mg tabPA QL 30 EA/30 Days2armodafinil 200mg tabPA QL 30 EA/30 Days2armodafinil 250mg tabPA QL 30 EA/30 Days2armodafinil 50mg tabPA QL 30 EA/30 Days2You can find information on what the symbols and abbreviations on this table mean by going to thebeginning of this table.3

DRUG NAMEdexmethylphenidate 10mg tabdexmethylphenidate 2.5mg tabdexmethylphenidate 5mg tabmethylphenidate 10mg cr capmethylphenidate 10mg er tabmethylphenidate 10mg la capmethylphenidate 10mg tabmethylphenidate 1mg/ml oral solnmethylphenidate 20mg cr capmethylphenidate 20mg er tabmethylphenidate 20mg la capmethylphenidate 20mg tabmethylphenidate 2mg/ml oral solnmethylphenidate 30mg cr capmethylphenidate 30mg la capmethylphenidate 40mg cr capmethylphenidate 40mg la capmethylphenidate 50mg cr capmethylphenidate 5mg tabmethylphenidate 60mg cr capmethylphenidate 60mg la capmodafinil 100mg tabmodafinil 200mg tabDRUG TIERREQUIREMENTS/LIMITS222222222222222222222PA QL 60 EA/30 Days2PA QL 60 EA/30 Days2AMEBICIDESAMEBICIDESSOLOSEC 2GM GRANULESPA4AMINOGLYCOSIDESAMINOGLYCOSIDESamikacin 250mg/ml inj2ARIKAYCE 590MG/8.4ML INH SUSPNDS PA QL 252 ML/30 Days5GENTAMICIN 0.8MG/ML INJ2gentamicin 1.2mg/ml inj2GENTAMICIN 1.6MG/ML INJ2GENTAMICIN 1MG/ML INJ2gentamicin 40mg/ml inj2neomycin sulfate 500mg tab1paromomycin 250mg cap4STREPTOMYCIN 1000MG INJ4TOBI PODHALER KIT 28MG PACKNDS QL 224 EA/28 Days5TOBRAMYCIN 10MG/ML INJ2tobramycin 40mg/ml inj2tobramycin 60mg/ml inh solnNDS PA QL 300 ML/30 Days5tobramycin 75mg/ml neb2ANALGESICS - ANTI-INFLAMMATORYANTIRHEUMATIC - ENZYME INHIBITORSOLUMIANT 1MG TABNDS PA5You can find information on what the symbols and abbreviations on this table mean by going to thebeginning of this table.4

DRUG NAMEDRUG TIERREQUIREMENTS/LIMITSOLUMIANT 2MG TABNDS PA5RINVOQ 15MG ER TABNDS PA5XELJANZ 10MG TABNDS PA5XELJANZ 1MG/ML ORAL SOLNNDS PA5XELJANZ 5MG TABNDS PA5XELJANZ XR 11MG TABNDS PA5XELJANZ XR 22MG TABNDS PA5ANTI-TNF-ALPHA - MONOCLONAL ANTIBODIESHUMIRA 10MG/0.1ML SYRINGENDS PA5HUMIRA 20MG/0.2ML SYRINGENDS PA5HUMIRA 40MG/0.4ML AUTO-INJECTORNDS PA5HUMIRA 40MG/0.4ML SYRINGENDS PA5HUMIRA 40MG/0.8ML AUTO-INJECTORNDS PA5HUMIRA 40MG/0.8ML SYRINGENDS PA5HUMIRA 80MG/0.8ML AUTO-INJECTORNDS PA5NDS PAHUMIRA PEDIATRIC CROHN'S STARTER PACK (3)580MG/0.8ML INJNDS PAHUMIRA PEDIATRIC CROHN'S STARTER PACK5SYRINGE (2) 40MG/0.4MLNDS PAHUMIRA PEN - CROHN'S STARTER PACK540MG/0.8ML INJNDS PAHUMIRA PEN - CROHN'S STARTER PACK580MG/0.8ML INJNDS PAHUMIRA PEN - PEDIATRIC UC STARTER PACK580MG/0.8ML INJNDS PAHUMIRA PEN - PSORIASIS STARTER PACK540MG/0.8ML INJNDS PAHUMIRA PEN - PSORIASIS STARTER PACK580MG/0.8ML INJSIMPONI 100MG/ML AUTO-INJECTORNDS PA5SIMPONI 100MG/ML SYRINGENDS PA5SIMPONI 50MG/0.5ML AUTO-INJECTORNDS PA5SIMPONI 50MG/0.5ML SYRINGENDS PA5GOLD COMPOUNDSRIDAURA 3MG CAPNDS5INTERLEUKIN-1 BLOCKERSARCALYST 220MG INJNDS PA5INTERLEUKIN-1 RECEPTOR ANTAGONIST (IL-1RA)KINERET 100MG/0.67ML SYRINGENDS PA5INTERLEUKIN-6 RECEPTOR INHIBITORSACTEMRA 162MG/0.9ML AUTO-INJECTORNDS PA5ACTEMRA 162MG/0.9ML SYRINGENDS PA5KEVZARA 150MG/1.14ML AUTO-INJECTORNDS PA5KEVZARA 150MG/1.14ML SYRINGENDS PA5KEVZARA 200MG/1.14ML AUTO-INJECTORNDS PA5KEVZARA 200MG/1.14ML SYRINGENDS PA5You can find information on what the symbols and abbreviations on this table mean by going to thebeginning of this table.5

DRUG NAMEDRUG TIERREQUIREMENTS/LIMITSNONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)celecoxib 100mg capQL 60 EA/30 Days2celecoxib 200mg capQL 60 EA/30 Days2celecoxib 400mg capQL 60 EA/30 Days2celecoxib 50mg capQL 60 EA/30 Days2diclofenac potassium 50mg tab2diclofenac sodium 100mg er tab2diclofenac sodium 25mg dr tab2diclofenac sodium 50mg dr tab2diclofenac sodium 75mg dr tab2etodolac 200mg cap2etodolac 300mg cap2etodolac 400mg er tab2etodolac 400mg tab2etodolac 500mg er tab2etodolac 500mg tab2etodolac 600mg er tab2flurbiprofen 100mg tab2ibu 600mg tab1ibu 800mg tab1ibuprofen 20mg/ml susp2ibuprofen 400mg tab1ibuprofen 600mg tab1ibuprofen 800mg tab1indomethacin 25mg cap2indomethacin 50mg cap2indomethacin 75mg er cap2ketorolac tromethamine 10mg tabQL 20 EA/5 Days2meloxicam 15mg tab1meloxicam 7.5mg tab1nabumetone 500mg tab2nabumetone 750mg tab2naproxen 250mg tab1naproxen 375mg dr tab2naproxen 375mg tab1naproxen 500mg dr tab2naproxen 500mg tab1naproxen sodium 275mg tab2naproxen sodium 550mg tab2oxaprozin 600mg tab2piroxicam 10mg cap2piroxicam 20mg cap2sulindac 150mg tab2sulindac 200mg tab2PHOSPHODIESTERASE 4 (PDE4) INHIBITORSOTEZLA 28-DAY STARTER PACKNDS PA5You can find information on what the symbols and abbreviations on this table mean by going to thebeginning of this table.6

DRUG NAMEDRUG TIERREQUIREMENTS/LIMITSOTEZLA 30MG TABNDS PA5PYRIMIDINE SYNTHESIS INHIBITORSleflunomide 10mg tab2leflunomide 20mg tab2SELECTIVE COSTIMULATION MODULATORSORENCIA 125MG/ML AUTO-INJECTORNDS PA5ORENCIA 125MG/ML SYRINGENDS PA5ORENCIA 50MG/0.4ML SYRINGENDS PA5ORENCIA 87.5MG/0.7ML SYRINGENDS PA5SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTSENBREL 25MG INJNDS PA5ENBREL 25MG/0.5ML INJNDS PA5ENBREL 25MG/0.5ML SYRINGENDS PA5ENBREL 50MG/ML AUTO-INJECTORNDS PA5ENBREL 50MG/ML CARTRIDGENDS PA5ENBREL 50MG/ML SYRINGENDS PA5ANALGESICS - NONNARCOTICANALGESIC COMBINATIONSQL 180 EA/30 Daysacetaminophen 325mg/butalbital 50mg/caffeine 40mg2tabaspirin 325mg/butalbital 50mg/caffeine 40mg capQL 180 EA/30 Days2ANALGESICS - OPIOIDOPIOID AGONISTSCODEINE SULFATE 15MG TABQL 240 EA/30 Days3codeine sulfate 30mg tabQL 240 EA/30 Days2codeine sulfate 60mg tabQL 180 EA/30 Days2fentanyl 0.012mg/hr patchQL 10 EA/30 Days2fentanyl 0.025mg/hr patchQL 10 EA/30 Days2fentanyl 0.05mg/hr patchQL 10 EA/30 Days2fentanyl 0.075mg/hr patchQL 10 EA/30 Days2FENTANYL 0.1MG BUCCAL TABPA QL 120 EA/30 Days4fentanyl 0.1mg/hr patchQL 10 EA/30 Days2FENTANYL 0.2MG BUCCAL TABPA QL 120 EA/30 Days4fentanyl 0.2mg lozengePA QL 120 EA/30 Days2FENTANYL 0.4MG BUCCAL TABPA QL 120 EA/30 Days4fentanyl 0.4mg lozengeNDSPA QL 120 EA/30 Days5FENTANYL 0.6MG BUCCAL TABPA QL 120 EA/30 Days4fentanyl 0.6mg lozengeNDS PA QL 120 EA/30 Days5FENTANYL 0.8MG BUCCAL TABPA QL 120 EA/30 Days4fentanyl 0.8mg lozengeNDSPA QL 120 EA/30 Days5fentanyl 1.2mg lozengeNDS PA QL 120 EA/30 Days5fentanyl 1.6mg lozengeNDS PA QL 120 EA/30 Days5hydrocodone bitartrate 10mg er cap2hydrocodone bitartrate 15mg er cap2hydrocodone bitartrate 20mg er cap2hydrocodone bitartrate 30mg er cap2You can find information on what the symbols and abbreviations on this table mean by going to thebeginning of this table.7

DRUG NAMEhydrocodone bitartrate 40mg er caphydrocodone bitartrate 50mg er caphydromorphone 10mg/ml (1ml) injhydromorphone 10mg/ml (5ml) injhydromorphone 1mg/ml oral solnhydromorphone 2mg tabhydromorphone 4mg tabhydromorphone 8mg tabmethadone 10mg tabMETHADONE 1MG/ML ORAL SOLNMETHADONE 2MG/ML ORAL SOLNmethadone 5mg tabmorphine sulfate 100mg er tabmorphine sulfate 15mg er tabmorphine sulfate 15mg tabmorphine sulfate 200mg er tabmorphine sulfate 20mg/ml oral solnmorphine sulfate 2mg/ml oral solnmorphine sulfate 30mg er tabmorphine sulfate 30mg tabmorphine sulfate 4mg/ml oral solnmorphine sulfate 60mg er tabNUCYNTA 100MG ER TABNUCYNTA 150MG ER TABNUCYNTA 200MG ER TABNUCYNTA 250MG ER TABNUCYNTA 50MG ER TABOXYCODONE 10MG ER TABoxycodone 10mg tabOXYCODONE 15MG ER TABoxycodone 15mg taboxycodone 1mg/ml oral solnOXYCODONE 20MG ER TABoxycodone 20mg taboxycodone 20mg/ml oral solnOXYCODONE 30MG ER TABoxycodone 30mg tabOXYCODONE 40MG ER TABoxycodone 5mg capoxycodone 5mg tabOXYCODONE 60MG ER TABOXYCODONE 80MG ER TABoxymorphone 10mg taboxymorphone 5mg tabtramadol 100mg er tabtramadol 100mg er tab (matrix delivery)DRUG REQUIREMENTS/LIMITSQL 2400 ML/30 DaysQL 450 EA/30 DaysQL 240 EA/30 DaysQL 120 EA/30 DaysQL 360 EA/30 DaysQL 3600 ML/30 DaysQL 1800 ML/30 DaysQL 360 EA/30 DaysQL 120 EA/30 DaysQL 120 EA/30 DaysQL 180 EA/30 DaysQL 120 EA/30 DaysQL 180 ML/30 DaysQL 1800 ML/30 DaysQL 120 EA/30 DaysQL 180 EA/30 DaysQL 900 ML/30 DaysQL 120 EA/30 DaysQL 60 EA/30 DaysQL 60 EA/30 DaysQL 60 EA/30 DaysQL 60 EA/30 DaysQL 60 EA/30 DaysQL 60 EA/30 DaysQL 180 EA/30 DaysQL 60 EA/30 DaysQL 180 EA/30 DaysQL 5400 ML/30 DaysQL 60 EA/30 DaysQL 180 EA/30 DaysQL 270 ML/30 DaysQL 60 EA/30 DaysQL 180 EA/30 DaysQL 60 EA/30 DaysQL 360 EA/30 DaysQL 360 EA/30 DaysQL 60 EA/30 DaysQL 60 EA/30 DaysQL 360 EA/30 DaysQL 360 EA/30 DaysQL 60 EA/30 DaysQL 60 EA/30 DaysYou can find information on what the symbols and abbreviations on this table mean by going to thebeginning of this table.8

DRUG NAMEtramadol 200mg er tabtramadol 200mg er tab (matrix delivery)tramadol 300mg er tabtramadol 300mg er tab (matrix delivery)tramadol 50mg tabXTAMPZA 13.5MG ER CAPXTAMPZA 18MG ER CAPXTAMPZA 27MG ER CAPXTAMPZA 36MG ER CAPXTAMPZA 9MG ER CAPDRUG TIER2222133333OPIOID COMBINATIONSacetaminophen 21.7mg/ml/hydrocodone bitartrate20.5mg/ml oral solnacetaminophen 24mg/ml/codeine phosphate 2.4mg/ml2oral solnacetaminophen 300mg/codeine phosphate 15mg tab2acetaminophen 300mg/codeine phosphate 30mg tab2acetaminophen 300mg/codeine phosphate 60mg tab2acetaminophen 300mg/hydrocodone bitartrate 10mg2tabacetaminophen 300mg/hydrocodone bitartrate 5mg2tabacetaminophen 300mg/hydrocodone bitartrate 7.5mg2tabacetaminophen 325mg/hydrocodone bitartrate 10mg2tabacetaminophen 325mg/hydrocodone bitartrate 5mg2tabacetaminophen 325mg/hydrocodone bitartrate 7.5mg2tabacetaminophen 325mg/oxycodone 10mg tab2acetaminophen 325mg/oxycodone 2.5mg tab2acetaminophen 325mg/oxycodone 5mg tab2acetaminophen 325mg/oxycodone 7.5mg tab2acetaminophen 325mg/tramadol 37.5mg tab2endocet 325-10mg tab2endocet 325-5mg tab2endocet 325-7.5mg tab2hydrocodone bitartrate 10mg/ibupro

If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. o If we make these other change

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