3-Tier Drug List
California3 Tier Drug ListThe 3 Tier Drug List (formulary) includes a list of drugs covered by Health Net. The drug list isupdated at least monthly and is subject to change. All previous versions are no longer in effect. Youcan view the most current drug list by going to our website at www.healthnet.com. Refer to Evidenceof Coverage or Certificate of Insurance for specific cost share information.California Large Group membersGo toDrug List - Use the “3 Tier” FormularyNOTE: To search the drug list online, open the (pdf) document. Hold down the “Control” (Ctrl)and “F” keys. When the search box appears, type the name of your drug and press the “Enter”key. If you have questions or need more information call us toll free.If you have questions about your pharmacy coverage call Customer Service at 1-800-522-0088Hours of Operation8:00am – 6:00pm Monday through FridayUpdated June 1, 2020Health Net of California, Inc. and Health Net Life Insurance Company are subsidiaries of Health Net,LLC and Centene Corporation. Health Net is a registered service mark of Health Net, LLC.
Table of ContentsWhat If I Have Questions Regarding My Pharmacy Benefit? iiWhat is the Drug List?. iiHow do I find a drug on the Drug List?. iiHow are the drugs listed in the categorical list? iiHow much will I pay for my drugs?. iiiTier description tableAre there any limits on my drug coverage? . .ivAbbreviations tableHow often does the Drug List change? . vHow can I get prior authorization or an exception to the rules for drug coverage?vAre all contraceptives covered? . viWhat blood glucose supplies are covered? . viWhat drugs are under my medical benefit? . viCan I go to any pharmacy? . viCan I use a mail order pharmacy? . viiHow can I save money on my prescription drugs?.viiDefinitions. viiiCategorical list of prescription drugs.1Alphabetical index of prescription drugs . Index 1i
Welcome to Health NetWhat If I Have Questions Regarding My Pharmacy Benefit?If you have questions about your pharmacy coverage contact Customer Service at the phonenumber listed on your Health Net ID card or on the cover of this book. Customer Service can helpyou with questions about your prescription drug benefits, including, but not limited to: information about drugs covered under the medical benefit the processes for submitting an exception request, requesting prior authorization and steptherapy exceptions actual dollar amounts of cost sharing for drugs including drugs subject to coinsuranceWhat is the Drug List?The drug list is a complete list of covered drugs used to treat common diseases or health problems.The drug list is selected by a committee of doctors and pharmacists who meet regularly to decidewhich drugs should be included. The committee reviews new drugs and new information aboutexisting drugs and chooses drugs based on: Safety Effectiveness Side effects Value (if two drugs are equally effective, the less costly drug will be preferred)How do I find a drug in the Drug List?You can search for a drug by using the search tool, alphabetical index or by categorical list. There arethree ways to find out if your drug is covered.Search Tool: Open the List of Drugs (PDF). Hold down the “Control” (Ctrl) and “F” keys. Whenthe search box appears, type the name of your drug. Press the “Enter” key.Alphabetical Index: The index at the end of the PDF lists the names of generic and brand namedrugs from A to Z. Once you find a drug name, go to the page number listed to see if the drug iscovered.Categorical list: The drugs are grouped into categorical or therapeutic categories. If you knowwhat therapeutic category and class your drug is in look through the list to find the category.Then look under the category and class for your drug.If a generic equivalent for a brand name drug is not available in the market or not covered, thegeneric drug will not be listed separately. The presence of a drug on the drug list does not guaranteethat your doctor will prescribe the drug for a particular medical condition.How are the drugs listed in the categorical list?A drug is listed alphabetically by its brand and generic names in its therapeutic category and class.ii
Example:Drug Requirements/Tier LimitsDrug NameMAVYRET (glecaprevirpibrentasvir) TABSphentermine hcl caps31PAPAThe generic drug name for a brand drug is included after the brand name in parentheses and allbold italicized lowercase letters.Brand Drug Example: MAVYRET (glecaprevir-pibrentasvir) TABSIf a generic equivalent for a brand name drug is both available and covered, the generic drug will belisted separately from the brand name drug in all bold and italicized lowercase letters.Generic Drug Example: terbutaline sulfate tabsIf a generic drug is marketed under a proprietary, trademark-protected brand name, the brandname will be listed after the generic name in parentheses and regular typeface in all CAPITALletters.Generic Drug Marketed Under A Proprietary Brand Name Example: levothyroxine sodium(LEVOXYL) TABSHow much will I pay for my drugs?To see how much you will pay for a drug, check the abbreviations in the Drug Tier column on theformulary. The copayment or coinsurance for each tier is defined in your Summary of Benefits orother plan documents.DrugClass/PlanOral Cancer DrugsAll other (non-oralcancer) DrugsBronze Plan MembersBenefit PhaseDeductible MetDeductible MetMaximum Cost Share 250 250Deductible Met 500Days Supply30 Days30 Days30 DaysBelow is a description for each tier. Refer to Evidence of Coverage or Certificate of Insurance forspecific cost share information.TierDescription1Drugs in this tier include preferred generic drugs.2Drugs in this tier include preferred brand drugs34Drugs in this tier are non-preferred brand drugs, covered drugs not on the druglist and covered brand drugs that are approved as medically necessary byHealth Net.Drugs indicated as “tier 4” are self-injectable drugs and coverage may differbased on your benefits. Please refer to your plan documents for specificcoverage.iii
GPGeneric drugs are preferred. To get a brand drug that has a generic available,your doctor must request prior authorization to show medical necessity. If weapprove the request, the drug may be covered at a higher copayment. Refer toyour plan documents for coverage details.Are there any limits on my drug coverage?Some drugs have limits on coverage. The table below provides a description of abbreviations that mayappear in the Limits column on the drug list:Abbreviation DefinitionDescriptionALAge LimitThese drugs may require prior authorization if your agedoes not fall within manufacturer, FDA, or clinicalrecommendations.ACAnti-cancerLALimited AccessThese oral cancer drugs are subject to a maximum 250 copayment for a one-month supply, after anydeductible has been met, per state law (or 750maximum for a three-month supply through mailorder).Some drugs may be subject to limited access orrestricted access. This means that a drug may onlybe available at select pharmacies. Limited accessmay be due to the following reasons: The FDA or the manufacturer has restricteddistribution of a drug to certain facilities, pharmacies orprescribers, or Certain drugs require special handling, coordination ofcare, or patient education that cannot be provided at aretail pharmacy.PAIf the drug is approved, we will let you know how to getlimited access drugs.Prior Authorization These drugs require prior approval. This means that youor your doctor must get approval from us before you fillyour prescription. If you don’t get approval, we may notcover the drugQLQuantity LimitRX/OTCPrescription &Over-theCounter (OTC)These drugs have a limit on the amount that will becovered. Your doctor must request approval for a higherquantity of the drug from Health Net. Health Net coversa 12-month supply when dispensed at one time of allself-administered hormonal contraceptives on theFormulary.Certain drugs are available both in a prescription formand in an OTC form. Only prescription drugs arecovered by your plan with the exception of someinsulin, insulin supplies and some covered preventivedrugs. OTC drugs on the drug list, including OTCpreventive drugs and contraceptives, require aprescription to be covered.iv
SPSpecialty DrugSpecialty drugs are required to be provided through aHealth Net contracted Specialty Pharmacy. Once HealthNet approves the medication, our contracted Specialtypharmacy will contact you to arrange for delivery.PVPrevention DrugIncludes preventive benefit drugs, includingcontraceptives, covered at no cost to members under theAffordable Care Act. A deductible does not apply.STStep TherapyStep therapy is when you are required to use one drugbefore another, in a stepwise fashion. Unless an exceptionis made, one or more preferred drugs must be tried firstbefore progressing to a drug that is subject to step therapy.How often does the Drug List change?The formulary will be updated with changes on a monthly basis. The types of changes may include thefollowing: Removal of a drug or dosage form of a drug from the formulary;Any change in tier placement of a drug that results in an increase in cost sharing;Adding or changing utilization management procedures applicable to a drug.If these changes occur, you will be notified at least 60 days in advance of the change, unless thedrug is removed for safety reasons.How can I get prior authorization or an exception to the rules for drug coverage?Requests for prior authorization may be submitted electronically, by phone at 1-800-548-5524, or byfax at 1-800-314-6223. Once your doctor’s request is received, we will notify your doctor of ourdecision within 72 hours. If Health Net fails to respond to a completed prior authorization or steptherapy exception request within 72 hours of receiving a non-urgent request and 24 hours ofreceiving a request based on exigent circumstances, the request is deemed approved and the healthinsurer may not deny the request thereafter.If your doctor believes that waiting 72 hours for a standard decision could seriously harm your health,your doctor can ask for a fast (expedited) decision. This applies only to requests for drugs that youhave not already received. We must make expedited decisions within 24 hours after we get yourdoctor’s supporting statement.If we approve your drug’s exception, the approval continues until the end of the plan year. To keep theexception in place for the plan year, you must remain enrolled in our plan, your doctor must continueto prescribe your drug, and your drug must be safe for treating your conditionIn some cases, our plan requires you to first try certain drugs to treat your medical condition before wewill cover another drug for that condition. This is called step therapy. Step therapy is when you arerequired to use one drug before another, in a stepwise fashion. The required first step drug or preferreddrug is a proven, cost-effective medication. Unless an exception is made, one or more preferred drugsmust be tried before progressing to a drug that is subject to step therapy.You or your doctor can request an exception if your health may be harmed by waiting. Your doctorv
must submit a supporting statement to us explaining why you need the drug. You or your doctor mayappeal the denial of an exception request. The denial documents provide more information on appealrights and procedures if there is a medical need to use a second step drug without trying a first stepdrug, an exception to coverage may be requested by the prescriber. A request for an exception to a steptherapy requirement may be submitted in the same manner as a request for prior authorization. Therequest shall be treated in the same manner, and shall be responded to in the same manner, as a requestfor prior authorization for prescription drugs. If you have already tried and failed the preferred drug(s),or if you are already taking a drug that is subject to step therapy when you switch to enrolled in aHealth Net plan, you will not have to undergo step therapy and the drug will be approved for coveragewhen medically necessary.If a drug is not on the drug list, and is not specifically excluded from coverage, your doctor can ask foran exception. To request an exception, your doctor can submit a prior authorization request along witha supporting statement explaining why you need the drug. Requests for prior authorization may besubmitted electronically or by telephone or fax. If we approve an exception for a drug that is not on thedrug list, the non-preferred brand drug tier (Tier 3) copayment applies.Health Net will cover all medically necessary drugs. If Health Net fails to respond to a completedprior authorization or step therapy exception request within 72 hours of receiving a non-urgentrequest and 24 hours of receiving an expedited request, the request will be approved and Health Netmay not deny the request thereafter.Are all contraceptives covered?Contraceptive benefits include coverage for a variety of U.S. Food and Drug Administration (FDA)approved prescription contraceptive methods. If your doctor determines that none of the coveredmethods on the drug list or if a covered therapeutic equivalent of a drug, device, or product is notavailable, and is medically necessary for you, Health Net will provide coverage. Coverage is subjectto limitations and restrictions. Prior authorization or step therapy may be required for some otherFDA-approved prescription contraceptive drugs, devices, or products prescribed by your doctor.What blood glucose supplies are covered?Specific brands of blood glucose monitors, blood glucose testing strips, lancets, ketone testing strips,pen delivery systems for injecting insulin and insulin needles and syringes are covered on the druglist. A prescription from your doctor is required to obtain these from a pharmacy. Insulin pumps andall related necessary supplies, podiatric devices to prevent or treat diabetes-related complications andvisual aids, excluding eyewear, to assist the visually impaired with proper dosing of insulin arecovered under the medical benefit.What drugs are covered under my medical benefit?Drugs that are not considered self-injectable and are administered by your doctor will be coveredunder your medical benefit. If your doctor does not have the drug, your doctor will give youinstructions on where you can receive the drug. Certain drugs that are self-administered are coveredunder your pharmacy benefit. Refer to your Evidence of Coverage or Certificate of Insurance forcoverage information and exceptions.Can I go to any pharmacy?Except in emergency and urgent situations, Health Net does not cover drugs dispensed by nonnetwork pharmacies. Health Net contracts with most U.S. chain pharmacies and many independentpharmacies.vi
These pharmacies are called in-network pharmacies. To find an in-network pharmacy near you, visitour website at Find a pharmacy or call us at the telephone number on your Health Net ID card orlisted on the front cover of this book.Some injectable and high cost drugs are considered specialty drugs. These drugs must be filled atan in-network specialty pharmacy. Specialty drugs are noted on the drug list in theRequirements/Limits column with the abbreviation “LA” or a statement indicating the drug must bedispensed from a network specialty pharmacy. After your drug has been approved, we will arrangefor the specialty pharmacy to contact you to set up delivery.Can I use a mail order pharmacy?For certain kinds of prescription drugs, you can use the contracted Mail Order Pharmacy. Generally,the drugs available through mail order are drugs that you take on a regular basis for a chronic or longterm medical condition. Specialty drugs are not available through mail order.To use the mail order pharmacy, your doctor must provide a new prescription that allows up to a 90day supply of each drug. Mail order forms are available on our website at Find forms and brochuresor you may call us at the telephone number on your Health Net ID card or on the front cover of thisbook to request a form.How can I save money on my prescription drugs?You can save time and money with these simple steps: Ask your doctor about generic drugs that may work for you. Fill prescriptions at in-network pharmacies. Be sure your doctor prescribes drugs on the drug list. Fill your maintenance drugs through our mail order pharmacy program.DefinitionsBrand drug: Is a drug that is marketed under a proprietary, trademark-protected name. A brand drugis listed in this formulary in all CAPITAL letters.Coinsurance: Is a percentage of the cost of a covered health care benefit that you pay after you havepaid the deductible, if a deductible applies to the health care benefit.Copayment: Is a fixed dollar amount that you pay for a covered health care benefit after you havepaid the deductible, if a deductible applies to the health care benefit.Deductible: Is the amount you pay for covered health care benefits that are subject to the deductiblebefore your health insurer begins to pay. If the plan has a deductible, it may have either onedeductible or separate deductibles for medical benefits and prescription drug benefits. After you payyour deductible, you usually pay only a copayment or coinsurance for covered health care benefits.The plan pays the rest.Drug Tier: Is a group of prescription drugs that correspond to a specified cost sharing tier. The drugtier in which a prescription drug is placed determines your portion of the cost for the drug.Enrollee: Is a person enrolled in a health plan who is entitled to receive services from the plan. Allreferences to enrollees in this formulary template shall also include subscribers as defined in thissection below.vii
Exception request: Is a request for coverage of a non-formulary drug. If you, your designee, or yourdoctor submits a request for coverage of a non-formulary drug, the plan must cover the nonformulary drug when it is medically necessary for you to take the drug.Exigent circumstances: Is when you are suffering from a medical condition that may seriouslyjeopardize your life, health, or ability to regain maximum function, or when you are undergoing acurrent course of treatment using a non-formulary drug.Formulary or prescription drug list: Is the list of drugs that is covered by the plan under theprescription drug benefit of the policy.Generic drug: Is a drug that is the same as its brand name drug equivalent in dosage, strength,effect, how it is taken, quality, safety, and intended use. A generic drug is listed in the drug list inbold and italicized lowercase letters.Medically Necessary: Is a health care benefit needed to diagnose, treat, or prevent a medicalcondition or its symptoms and that meet accepted standards of medicine. Plans usually do not coverhealth care benefits that are not medically necessary.Non-formulary drug: Is a prescription drug that is not listed on the drug list.Out-of-pocket costs: Are your expenses for health care benefits that aren't reimbursed by the plan.Out-of-pocket costs include deductibles, copayments, and coinsurance for covered health carebenefits, plus all costs for health care benefits that are paid by the Member and not covered by theplan.Prescribing provider: This is a health care provider who can write a prescription for a drug todiagnose, treat, or prevent a medical condition.Prescription: Is an oral, written, or electronic order from a prescribing provider authorizing aprescription drug to be provided to a specific individual.Prior Authorization: Is a decision by the plan that a health care benefit is medically necessary foryou. If a prescription drug is subject to prior authorization in the drug list, your doctor must requestapproval from the plan to cover the drug before you fill your prescription. The plan must grant aprior authorization request when it is medically necessary for you to take the drug.Step therapy: Is a specific sequence in which prescription drugs for a particular medical conditionmust be tried. If a drug is subject to step therapy in the drug list, you may have to try one or moreother drugs before the plan will cover that drug for your medical condition. If your doctor submits arequest for an exception to the step therapy requirement, the plan must grant the request when it ismedically necessary for you to take the drug.Subscriber: Means the person who is responsible for payment to a plan or whose employment or other status,except for family dependency, is the basis for eligibility for membership in the plan.viii
Drug NameDrug Requirements/Tier LimitsDrug NameADHD/ANTI-NARCOLEPSY/ANTIOBESITY/ANOREXIANTS - Drugs to TreatADHD, Sleep and Eating DisordersDEXEDRINE mphetamineSulfate) PROCENTRASOLN(DextroamphetamineSulfate) ZENZEDI TABS 5MG, 10 MGADDERALL TABS(amphetaminedextroamphetamine)ADDERALL XR esulfate cp24 5 mg, 10mg, 15 mgdextroamphetaminesulfate soln 5 mg/5mldextroamphetaminesulfate tabs 5 mg, 10mgmethamphetamine hcltabsamphetaminedextroamphetaminecp24 5 mg-5 mg-5 mg5 mg, 2.5 mg-2.5 mg2.5 mg-2.5 mg, 7.5 mg7.5 mg-7.5 mg-7.5 mg,1.25 mg-1.25 mg-1.25mg-1.25 mg, 3.75 mg3.75 mg-3.75 mg-3.75mg, 6.25 mg-6.25 mg6.25 mg-6.25 mgamphetaminedextroamphetaminetabs 5 mg-5 mg-5 mg-5mg, 2.5 mg-2.5 mg-2.5mg-2.5 mg, 7.5 mg-7.5mg-7.5 mg-7.5 mg,1.25 mg-1.25 mg-1.25mg-1.25 mg, 3.75 mg3.75 mg-3.75 mg-3.75mg, 1.875 mg-1.875mg-1.875 mg-1.875mg, 3.125 mg-3.125mg-3.125 mg-3.125 mgDESOXYN TABS(methamphetamine hcl)31GPQL(2 eaGP daily,90 day(s)limit)QL(2 eadaily,90 day(s)limit)1VYVANSE CAPS 10 MG,20 MG, 30 MG, 40 MG, 50MG, 60 MG, 70 MG(lisdexamfetaminedimesylate)VYVANSE CHEW 10 MG,20 MG, 30 MG, 40 MG, 50MG, 60 MG(lisdexamfetaminedimesylate)ZENZEDI TABS 15 MG, 20MG, 30 MG, 2.5 MG, 7.5MG(dextroamphetaminesulfate)Drug Requirements/Tier LimitsGP1313PA; ST;QL(1 ea daily)22Limited to 1 perday;QL(1 eadaily)3Analepticscaffeine citrate soln1Anorexiants Non-Amphetamine1ADIPEX-P CAPS(phentermine hcl)BENZPHETAMINE HCLTABS (benzphetaminehcl)GPPA; ST;LOMAIRA TABS(phentermine hcl)PA; NotGP availablethrough MailOrderPA; Not3 availablethrough MailOrderPA31 Preferred Generics 2 Preferred Brands/High Cost Generics 3 Non-Preferred Brand Drugs4 High Cost DrugsGP Generic PreferredPV Preventive DrugsAL Age LimitPA Prior AuthorizationQL Quantity LimitST Step TherapyAC Anti-CancerLA Limited AccessRX/OTC Prescription & Over-the-Counter1
Drug Namephentermine hcl capsQSYMIA CP24(phentermine hcltopiramate)REGIMEX TABS(benzphetamine hcl)Drug Requirements/Tier LimitsPA; Not3 availablethrough MailOrderPA; Notavailable3 through MailOrder;QL(1 eadaily)PA; NotGP availablethrough MailOrderAnti-Obesity AgentsCONTRAVE TB12(naltrexone hclbupropion hcl)XENICAL CAPS (orlistat)33PA; Notavailablethrough MailOrderPA; Notavailablethrough MailOrderAttention-Deficit/Hyperactivity Disorder (ADHD)QL(2 ea daily)atomoxetine hcl caps110 mg, 18 mg, 25 mg,40 mgatomoxetine hcl caps60 mg, 80 mg, 100 mgguanfacine hcl (adhd)tb2411QL(1 ea daily)QL(1 ea daily)INTUNIV TB24QL(1 ea daily)GP(guanfacine hcl (adhd))STRATTERA CAPS 10QL(2 ea daily)MG, 18 MG, 25 MG, 40 MG GP(atomoxetine hcl)STRATTERA CAPS 60QL(1 ea daily)MG, 80 MG, 100 MGGP(atomoxetine hcl)Stimulants - Misc.(Methylphenidate Hcl)METADATE ER TBCR1APTENSIO XR CP24(methylphenidate hcl)3QL(1 eadaily,90 day(s)limit)PA; QL(1 eadaily)Drug Namearmodafinil tabsCONCERTA TBCR 18 MG,27 MG, 36 MG(methylphenidate hcl)CONCERTA TBCR 54 MG(methylphenidate hcl)DAYTRANA PTCH(methylphenidate)dexmethylphenidate hclcp24 5 mg, 10 mg, 15mg, 20 mg, 25 mg, 30mg, 35 mg, 40 mgdexmethylphenidate hcltabs 5 mg, 10 mg, 2.5mgFOCALIN TABS(dexmethylphenidatehcl)FOCALIN XR CP24(dexmethylphenidatehcl)METHYLIN SOLN(methylphenidate hcl)METHYLPEHNIDATEHYDROCHLORIDE ERCP24 (methylphenidatehcl)methylphenidate hclchew 5 mg, 10 mg, 2.5mgmethylphenidate hclcp24 10 mg, 20 mg, 30mg, 40 mgmethylphenidate hclcp24 60 mgmethylphenidate hclcpcr 10 mg, 20 mg, 30mg, 40 mg, 50 mg, 60mgmethylphenidate hclsoln 10 mg/5mlDrug Requirements/Tier Limits1 PA; STQL(1 ea daily)GPGPQL(2 ea daily)3QL(1 ea daily)3QL(2 ea daily)1QL(2 ea daily)GPQL(1 ea daily)GPGP3PA; QL(1 eadaily)333QL(1 eadaily,90 ea perfill retail)QL(1 ea daily)131 Preferred Generics 2 Preferred Brands/High Cost Generics 3 Non-Preferred Brand Drugs4 High Cost DrugsGP Generic PreferredPV Preventive DrugsAL Age LimitPA Prior AuthorizationQL Quantity LimitST Step TherapyAC Anti-CancerLA Limited AccessRX/OTC Prescription & Over-the-Counter2
Drug Namemethylphenidate hclsoln 5 mg/5mlmethylphenidate hcltabs 20 mgmethylphenidate hcltabs 5 mg, 10 mgmethylphenidate hcltb24 18 mg, 27 mg, 54mgmethylphenidate hcltb24 36 mgmethylphenidate hcltb24 54 mgmethylphenidate hcltbcr 10 mgmethylphenidate hcltbcr 18 mg, 27 mg, 36mgmethylphenidate hcltbcr 20 mgmethylphenidate hcltbcr 54 mgMETHYLPHENIDATEHYDROCHLORIDE ERCP24 10 MG, 15 MG, 20MG, 30 MG, 40 MG, 50 MG(methylphenidate hcl)METHYLPHENIDATEHYDROCHLORIDE ERTBCR 72 MG(methylphenidate hcl)modafinil tabsNUVIGIL TABS(armodafinil)PROVIGIL TABS(modafinil)QUILLICHEW ER CHER(methylphenidate hcl)Drug Requirements/Tier Limits11QL(3 ea daily)11111QL(1 eadaily,90 day(s)limit)QL(2 eadaily,90 day(s)limit)QL(1 eadaily,90 ea perfill retail)QL(1 eadaily,90 ea perfill retail)QL(1 ea daily)111QL(1 eadaily,90 day(s)limit)QL(2 ea daily)PA; QL(1 eadaily)3QL(1 ea daily)33GPST; QL(1 eadaily)PA; STST; QL(1 eaGP daily)PA3Drug NameQUILLIVANT XR SRER(methylphenidate hcl)RELEXXII TBCR(methylphenidate hcl)RITALIN LA CP24(methylphenidate hcl)RITALIN TABS 20 MG(methylphenidate hcl)RITALIN TABS 5 MG, 10MG (methylphenidatehcl)Drug Requirements/Tier LimitsPA; ST;QL(123 ml daily)QL(1 ea daily)3GPGPQL(3 ea daily)GPAMINOGLYCOSIDES - Drugs to Treat AMYCININHALATION SOLUTIONPAK NEBUARIKAYCE SUSP(amikacin sulfateliposome)BETHKIS NEBU(tobramycin)KITABIS PAK NEBU(tobramycin)neomycin sulfate tabsparomomycin sulfatecapsPAROMOMYCINSULFATE CAPS(paromomycin sulfate)TOBI NEBU (tobramycin)TOBI PODHALER CAPS(tobramycin)1PA; Must useAcariaHlth SpRx 1-844-5384661PA332PAPA; Must useAcariaHlth SpRx 1-844-5384661112PA; Must useGP AcariaHlth SpRx 1-844-5384661PA; Must use3 AcariaHlth SpRx 1-844-53846611 Preferred Generics 2 Preferred Brands/High Cost Generics 3 Non-Preferred Brand Drugs4 High Cost DrugsGP Generic PreferredPV Preventive DrugsAL Age LimitPA Prior AuthorizationQL Quantity LimitST Step TherapyAC Anti-CancerLA Limited AccessRX/OTC Prescription & Over-the-Counter3
Drug Nametobramycin nebuTOBRAMYCIN NEBU(tobramycin)Drug Requirements/Tier LimitsPA; Must use1 AcariaHlth SpRx 1-844-5384661PA; Must use2 AcariaHlth SpRx 1-844-5384661ANALGESICS - ANTI-INFLAMMATORY - Drugsto Treat Pain, Swelling, Muscle and JointConditionsAnti-TNF-alpha - Monoclonal AntibodiesHUMIRA PEDIATRICPACROHNS DISEASE4STARTER PACK PSKT(adalimumab)HUMIRA PEDIATRICPA; ST; CheckCROHNS DISEASEplan4 documents forSTARTER PACK PSKT 40coverageMG/0.8ML (adalimumab)HUMIRA PEDIATRICPA; STCROHNS DISEASE4STARTER PACK PSKT 80MG/0.8ML (adalimumab)HUMIRA PEN PNKT 40PA; ST4MG/0.4ML (adalimumab)PA; ST; CheckHUMIRA PEN PNKT 404 plandocuments forMG/0.8ML (adalimumab)coveragePA; ST; CheckHUMIRA PEN-CD/UC/HSSTARTER PNKT4 plandocuments for(adalimumab)coverageHUMIRA PEN-PS/UVSTARTER PNKT(adalimumab)HUMIRA PSKT 10MG/0.1ML, 20 MG/0.2ML,40 MG/0.4ML(adalimumab)HUMIRA PSKT 10MG/0.2ML, 20 MG/0.4ML,40 MG/0.8ML(adalimumab)4PA; ST; Checkplandocuments forcoveragePA; ST44PA; ST; Checkplandocuments forcoverageDrug NameDrug Requirements/Tier LimitsAntirheumatic - Enzyme InhibitorsRINVOQ TB243(upadacitinib)XELJANZ TABS 10 MG3(tofacitinib citrate)XELJANZ TABS 5 MG3(tofacitinib citrate)XELJANZ XR TB24 11 MG3(tofacitinib citrate)XELJANZ XR TB24 22 MG3(tofacitinib citrate)PAPA; SPPA; QL(2 eadaily); SPPA; QL(1 eadaily); SPPA; SPAntirheumatic AntimetabolitesMETHOTREXATE TABS(methotrexate sodium2(antirheumatic))Gold CompoundsRIDAURA CAPS(auranofin)2Interleukin-6 Receptor InhibitorsKEVZARA SOAJ(sarilumab)4KEVZARA SOSY(sarilumab)4PA; ST; Notcovered by allplans under thepharmacybenefit;LAPA; ST; Notcovered by allplans under thepharmacybenefit;LANonsteroidal Anti-inflammatory Agents (NSAIDs)(Fenoprofen Calcium)1PROFENO TABS(Ibuprofen) IBU TABSANAPROX DS TABS(naproxen sodium)ARTHROTEC 50 TBEC(diclofenac w/misoprostol)ARTHROTEC 75 TBEC(diclofenac w/misoprostol)1GPGPGP1 Preferred Generics 2 Preferred Brands/High Cost Generics 3 Non-Preferred Brand Drugs4 High Cost DrugsGP Generic PreferredPV Preventive DrugsAL Age LimitPA Prior AuthorizationQL Quantity LimitST Step TherapyAC Anti-CancerLA Limited AccessRX/OTC Prescription & Over-the-Counter4
Drug NameCELEBREX CAPS 100 MG(celecoxib)CELEBREX CAPS 200 MG(celecoxib)CELEBREX CAPS 400 MG(celecoxib)CELEBREX CAPS 50 MG(celecoxib)celecoxib caps 100 mgcelecoxib caps 200 mgcelecoxib caps 400 mgcelecoxib caps 50 mgDAYPRO TABS(oxaprozin)diclofenac potassiumtabsdiclofenac sodium tb24100 mgdiclofenac sodium tbec25 mg, 50 m
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
Reading (R-CBM and Maze) Grade 1 Grade 2 R-CBM Maze R-CBM Maze Tier 2 Tier 1 Tier 2 Tier 1 Tier 2 Tier 1 Tier 2 Tier 1 Fall 0 1 21 55 1 4 Winter 14 30 1 3 47 80 4 9 Spring 24 53 3 7 61 92 8 14 Grade 3 Grade 4 R-CBM Maze R-CBM Maze Tier 2 Tier 1 Tier 2 Tier 1 Tier 2 Tier 1 Tier 2 Tier 1 Fa
Select 4 Tier Drug List. Drug list — Four Tier Drug Plan . Your prescription benefit comes with a drug list, which is also called a formulary. This list is made up of brand-name and generic prescription drugs approved by the U.S. Food & Drug Administration (FDA). The following is a list
coinsurance for covered health care benefits. Your insurance company pays the rest. Drug Tier means a group of Prescription Drug Products that correspond to a specified cost sharing tier in your health insurance policy. The drug tier in which a Prescription Drug Product is placed determines your portion of the cost for the drug.
136366 Tiger Mart #2 Cleburne Tier 1 140368 Parker Beverages Plano Tier 2 144550 J & J Quickstop Fort Worth Tier 1 145428 Diamond Food Mart Bay City Tier 1 149674 Town & Country Exxon Waller Tier 1 150655 Mini-Mart Bryan Tier 1 151132 Pinehurst Food Mart Baytown Tier 2 151411 Webb Chapel Beer & Wine Carrollton Tier 2 .
Pharmacy Benefit Drug List Changes - Effective on or after January 1, 2022 . Drug Name Drug Therapy Category Added to Coverage Removed from Coverage Tier Change 20 2 1 Drug Tier * 202 2 Drug Tier * Special Requirements ** 1/2 ML ALLERG KIT 27 G X 1/2" NEEDLE/SYRINGE/SUPPLIES X 03 N/A
benefits offered under this plan and compare these benefits to those offered by other plans. Information contained in this summary is designed to help you compare, both the value and scope . BCBSTX Health Insurance Marketplace 6 Tier Drug List May 2022 (Plan Year 2021) V Drugs by Cost-Sharing Tier: Tier Percentage of Drugs ACA 3.2% Tier 1 14.3%
404D-22 4 NA 2.2 84 x 100 51.0 hp at 3000 rpm 143 at 1800 Tier 3 & Tier 4 interim 184 kg 404D-22T 4 T 2.2 84 x 100 60.0 hp at 2800 rpm 190 at 1800 Tier 3 & Tier 4 interim 194 kg 404D-22TA 4 TA 2.2 84 x 100 66.0 hp at 2800 rpm 208 at 1800 Tier 3 & Tier 4 interim 194 kg 804D-33 4 NA 3.3 94 x 120 63.0 hp at 2600 rpm 200 at 1600 Tier 3 245 kg 804D-33T 4 TA 3.3 94 x 120 80.5 hp at 2600 rpm 253 at .
2 - DRUG LIST Updated 10/2018 Welcome to Humana-The Humana Drug List (also known as a formulary) is effective on January 1st unless otherwise specified. This is an all-inclusive list and may change throughout the year. What is the Drug List? The Drug List is a list of covered medicines s
