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VillageHealth® (HMO-POS SNP) | Riverside and San Bernardino Counties
2016
VillageHealth (HMO-POS SNP) Formulary
(List of Covered Drugs)
Riverside and San Bernardino Counties
This formulary was updated on 03/2016. For more recent information or other questions, please contact
VillageHealth Member Services at 1-800-399-7226 or, for TTY users, 711, 8 a.m. to 8 p.m., 7 days a week
from October 1 to February 14. From February 15 to September 30, hours are 8 a.m. to 8 p.m. Monday through
Friday, and 9 a.m. to 4 p.m. on Saturday (messages received on holidays and outside of our business hours will
be returned within one business day), or visit www.villagehealthca.com.
Este formulario se actualizó en 03/2016. Para obtener información más reciente o si tiene dudas, comuníquese
con Servicios para Miembros de VillageHealth al 1-800-399-7226 o, para los usuarios de TTY, 711, de 8 a.m.
a 8 p.m., los 7 días de la semana, desde el 1 de octubre hasta el 14 de febrero. Desde el 15 de febrero
al 30 de septiembre, el horario es de 8 a.m. a 8 p.m., de lunes a viernes, y de 9 a.m. a 4 p.m. los sábados
(los mensajes recibidos en días festivos y fuera del horario hábil se devolverán en un día hábil). O visite
www.villagehealthca.com.
G9319 08/15
Y0057_SCAN_9190_2015F File & Use Accepted 08232015
16-FORVH1
VillageHealth (HMO-POS SNP)
2016 Formulary (List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER
IN THIS PLAN
16400, 7
This formulary was updated on 03/2016. For more recent information or other questions, please contact
VillageHealth Member Services at 1-800-399-7226 or, for TTY users, 711, 8 a.m. to 8 p.m., 7 days a week
from October 1 to February 14. From February 15 to September 30, hours are 8 a.m. to 8 p.m. Monday
through Friday, and 9 a.m. to 4 p.m. on Saturday (messages received on holidays and outside of our business
hours will be returned within one business day), or visit www.villagehealthca.com.
Note to existing members: This formulary has changed since last year. Please review this document to make
sure that it still contains the drugs you take.
When this drug list (formulary) refers to “we,” “us,” or “our,” it means SCAN Health Plan. When it refers to
“plan” or “our plan,” it means VillageHealth (HMO-POS SNP).
This document includes a list of the drugs (formulary) for our plan which is current as of March 2016. For
an updated formulary, please contact us. Our contact information, along with the date we last updated the
formulary, appears on the front and back cover pages.
You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary,
pharmacy network, and/or copayments/coinsurance may change on January 1, 2017, and from time to time
during the year.
This information is not a complete description of benefits. Contact the plan for more information.
Limitations, copayments, and restrictions may apply. The Formulary, pharmacy network, and/or provider
network may change at any time. You will receive notice when necessary.
You can get prescription drugs shipped to your home through our network mail order delivery program.
Typically, you should expect to receive your prescription drugs within 14 days from the time that the mail
order pharmacy receives the order. If you do not receive your prescription drug(s) within this time, please
contact VillageHealth Member Services at 1-800-399-7226, 8 a.m. to 8 p.m., 7 days a week from October
1 to February 14. From February 15 to September 30, hours are 8 a.m. to 8 p.m. Monday through Friday,
and 9 a.m. to 4 p.m. on Saturday (messages received on holidays and outside of our business hours will be
returned within one business day). TTY users should call 711.
VillageHealth (HMO-POS SNP) is an HMO plan; and is a Point of Service (POS) plan with a Medicare
contract. Enrollment in SCAN Health Plan depends on contract renewal.
This information is available for free in other languages. Please call our Member Services number at
1-800-399-7226, 8 a.m. to 8 p.m., 7 days a week from October 1 to February 14. From February 15 to
September 30, hours are 8 a.m. to 8 p.m. Monday through Friday, and 9 a.m. to 4 p.m. on Saturday (messages
received on holidays and outside of our business hours will be returned within one business day). TTY users
call 711.
Esta información está disponible gratuitamente en otros idiomas. Llame nuestro número de Servicios para
Miembros al 1-800-399-7226, de 8 a.m. a 8 p.m., los siete días de la semana del 1 de octubre al 14 de
febrero. Del 15 de febrero al 30 de septiembre el horario es de 8 a.m. a 8 p.m. de lunes a viernes, y de
9 a.m. a 4 p.m. el sábado (los mensajes recibidos en días festivos o fuera de nuestras horas de oficina serán
contestados dentro de un día hábil. Los usuarios de TTY llamen al 711.
VillageHealth | 2016 Formulary
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II
VillageHealth | 2016 Formulary
TABLE OF CONTENTS
What is the VillageHealth Formulary?.......................................................................................................V
Can the Formulary (drug list) change?......................................................................................................V
How do I use the Formulary?...................................................................................................................V
What are generic drugs?..........................................................................................................................V
Are there any restrictions on my coverage?...............................................................................................VI
What if my drug is not on the Formulary?................................................................................................VI
How do I request an exception to the VillageHealth Formulary?.................................................................VI
What do I do before I can talk to my doctor about changing my drugs or requesting an exception?..............VII
For more information............................................................................................................................VII
VillageHealth’s Formulary.......................................................................................................................IX
Formulary Drugs Arranged by Therapeutic Class........................................................................................1
Formulary Drugs with Quantity Limits.....................................................................................................28
Index...................................................................................................................................................31
VillageHealth | 2016 Formulary
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IV
VillageHealth | 2016 Formulary
What is the VillageHealth Formulary?
A formulary is a list of covered drugs selected by VillageHealth in consultation with a team of health care
providers, which represents the prescription therapies believed to be a necessary part of a quality treatment
program. VillageHealth will generally cover the drugs listed in our formulary as long as the drug is medically
necessary, the prescription is filled at a VillageHealth network pharmacy, and other plan rules are followed.
For more information on how to fill your prescriptions, please review your Evidence of Coverage.
Can the Formulary (drug list) change?
Generally, if you are taking a drug on our 2016 formulary that was covered at the beginning of the year, we
will not discontinue or reduce coverage of the drug during the 2016 coverage year except when a new, less
expensive generic drug becomes available or when new adverse information about the safety or effectiveness
of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not
affect members who are currently taking the drug. It will remain available at the same cost-sharing for those
members taking it for the remainder of the coverage year. We feel it is important that you have continued
access for the remainder of the coverage year to the formulary drugs that were available when you chose our
plan, except for cases in which you can save additional money or we can ensure your safety.
If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy
restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of
the change at least 60 days before the change becomes effective, or at the time the member requests a
refill of the drug, at which time the member will receive a 60-day supply of the drug. 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. The enclosed formulary is current as of March 2016. To get updated information about
the drugs covered by VillageHealth, please contact us. Our contact information appears on the front and back
cover pages.
How do I use the Formulary?
There are two ways to find your drug within the formulary:
Medical Condition
The formulary begins on page 1. The drugs in this formulary are grouped into categories depending
on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart
condition are listed under the category, “Cardiovascular Agents.” If you know what your drug is used
for, look for the category name in the list that begins on page number 1. Then look under the category
name for your drug.
Alphabetical Listing
If you are not sure what category to look under, you should look for your drug in the Index that begins
on page 31. The Index provides an alphabetical list of all of the drugs included in this document. Both
brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next
to your drug, you will see the page number where you can find coverage information. Turn to the page
listed in the Index and find the name of your drug in the first column of the list.
What are generic drugs?
VillageHealth covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as
having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand
name drugs.
VillageHealth | 2016 Formulary
V
Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These requirements and limits
may include:
• Prior Authorization: VillageHealth requires you or your physician to get prior authorization for
certain drugs. This means that you will need to get approval from VillageHealth before you fill your
prescriptions. If you don’t get approval, VillageHealth may not cover the drug.
• Quantity Limits: For certain drugs, VillageHealth limits the amount of the drug that VillageHealth will
cover. For example, VillageHealth provides 31 tablets per prescription for Rozerem. This may be in
addition to a standard one-month or three-month supply.
• Step Therapy: In some cases, VillageHealth requires you to first try certain drugs to treat your medical
condition before we will cover another drug for that condition. For example, if Drug A and Drug B
both treat your medical condition, VillageHealth may not cover Drug B unless you try Drug A first. If
Drug A does not work for you, VillageHealth will then cover Drug B.
You can find out if your drug has any additional requirements or limits by looking in the formulary that
begins on page 1. You can also get more information about the restrictions applied to specific covered drugs
by visiting our Web site. We have posted on line documents that explain our prior authorization and step
therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we
last updated the formulary, appears on the front and back cover pages.
You can ask VillageHealth 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 the
VillageHealth formulary?” on page VI 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 Member Services
and ask if your drug is covered.
If you learn that VillageHealth does not cover your drug, you have two options:
• You can ask Member Services for a list of similar drugs that are covered by VillageHealth. When you
receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered
by VillageHealth.
• You can ask VillageHealth to make an exception and cover your drug. See below for information about
how to request an exception.
How do I request an exception to the VillageHealth Formulary?
You can ask VillageHealth to make an exception to our coverage rules. There are several types of 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 be covered
at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a
lower cost-sharing level.
• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs,
VillageHealth limits the amount of the drug that we will cover. If your drug has a quantity limit, you
can ask us to waive the limit and cover a greater amount.
Generally, VillageHealth will only approve your request for an exception if the alternative drugs included on
the plan’s formulary or additional utilization restrictions would not be as effective in treating your condition
and/or would cause you to have adverse medical effects.
VI
VillageHealth | 2016 Formulary
You should contact us to ask us for an initial coverage decision for a formulary or utilization restriction
exception. When you request a formulary or utilization restriction exception you should submit a statement
from your prescriber or physician supporting your request. Generally, we must make our decision 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 to 72 hours for a decision.
If your request to expedite is granted, we must give you a decision no later than 24 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
an exception?
As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you
may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need
a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if
you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover
the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover
your drug in certain cases during the first 90 days you are a member of our plan.
For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover
a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network
pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been 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 have
provided you with at least a 91 and may be up to a 98-day transition supply, consistent with dispensing
increment (unless you have a prescription written for fewer days). We will cover more than one refill of these
drugs for the first 90 days you are a member of our plan. 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 of that drug (unless you have a prescription for fewer days) while you
pursue a formulary exception.
If you are a current member transitioning to a different level of care, you may be prescribed medications not
on our formulary or your ability to get your drugs may be limited. In these instances, you need to talk with
your doctor about the appropriate alternative therapies available on our formulary. If there are no appropriate
alternative therapies on our formulary, you or your doctor can request an exception and ask the plan to cover
the drug or remove restrictions from the drug. While you are talking with your doctor to determine the course
of action, you are eligible to receive a 30-day transition supply of the drug if you are moving from a longterm care (LTC) facility or a hospital stay to home or a 31-day transition supply of the drug if you are moving
from home or a hospital stay to a long-term care (LTC) facility.
For more information
For more detailed information about your VillageHealth prescription drug coverage, please review your
Evidence of Coverage and other plan materials.
If you have questions about VillageHealth, please contact us. Our contact information, along with the date
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 1-800-MEDICARE (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.
VillageHealth | 2016 Formulary
VII
The chart below lists what you will pay as your share of the costs for covered prescription drugs when you are
in the Initial Coverage Stage. Please refer to your Evidence of Coverage for more information.
VillageHealth (HMO-POS SNP):
Riverside & San Bernardino Counties*
Standard Retail & Mail
Order cost-sharing
(in-network)
(30-day supply)
Standard Retail & Mail
Order cost-sharing
(in-network)
(90-day supply)
Out-of-network Retail
cost-sharing
(30-day supply)**
Drug
Tier
Tier Name
1
Preferred Generic
Drugs
$3 copayment
$9 copayment
$3 copayment
2
Generic Drugs
$16 copayment
$48 copayment
$16 copayment
3
Preferred Brand
Drugs
25% coinsurance
25% coinsurance
25% coinsurance
4
Non-Preferred
Brand Drugs
25% coinsurance
25% coinsurance
25% coinsurance
5
Specialty Tier
Drugs
25% coinsurance
N/A
25% coinsurance
6
Select Care
Drugs
$11 copayment
$33 copayment
$11 copayment
*If you receive “Extra Help,” your share of the cost for covered prescription drugs may vary based on the
level of Extra Help you receive.
**For out-of-network fills, you will be responsible for the in-network cost-sharing plus a differential between
the out-of-network billed amount and in-network allowable.
VIII
VillageHealth | 2016 Formulary
VillageHealth’s Formulary
The formulary that begins on page 1 provides coverage information about the drugs covered by VillageHealth.
If you have trouble finding your drug in the list, turn to the Index that begins on page 31.
The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., BENICAR) and
generic drugs are listed in lower-case italics (e.g., lisinopril).
The information in the Requirements/Limits column tells you if VillageHealth has any special requirements
for coverage of your drug.
• The symbol [PA] indicates that prior authorization applies.
• The symbol [B vs D] indicates that this drug may be covered under Medicare Part B or
Part D depending upon the circumstances. Information may need to be submitted describing the use
and setting of the drug to make the determination.
• The symbol [ST] indicates that step therapy applies.
• The symbol [QL] indicates that quantities dispensed are limited. To see the quantity limit amount for
the formulary drugs with quantity limits, turn to the page 28.
• The symbol [90D] indicates that the drug is available for a 90-day supply at mail order and select
retail pharmacies.
• The symbol [LD] indicates that limited distribution applies. This prescription may be available only at
certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at
1-800-399-7226, 8 a.m. to 8 p.m., 7 days a week from October 1 to February 14. From February 15
to September 30, hours are 8 a.m. to 8 p.m. Monday through Friday, and 9 a.m. to 4 p.m. on Saturday
(messages received on holidays and outside of our business hours will be returned within one
business day). TTY users should call 711.
VillageHealth | 2016 Formulary
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VillageHealth | 2016 Formulary
Formulario para 2016 (Lista de medicamentos cubiertos)
de VillageHealth (HMO-POS SNP)
POR FAVOR, LEA: ESTE DOCUMENTO CONTIENE INFORMACIÓN ACERCA DE LOS
MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN
16400, 7
Este formulario se actualizó en 03/2016. Para obtener información más reciente o si tiene dudas,
comuníquese con Servicios para Miembros de VillageHealth al 1-800-399-7226 o, para los usuarios de TTY,
711, de 8 a.m. a 8 p.m., los 7 días de la semana, desde el 1 de octubre hasta el 14 de febrero. Desde el
15 de febrero al 30 de septiembre, el horario es de 8 a.m. a 8 p.m., de lunes a viernes, y de 9 a.m. a 4 p.m.
los sábados (los mensajes recibidos en días festivos y fuera del horario hábil se devolverán en un día hábil).
O visite www.villagehealthca.com.
Nota para los miembros actuales: Este formulario ha cambiado desde el año pasado. Revise este documento
para asegurarse de que todavía incluye los medicamentos que toma.
Cuando esta lista de medicamentos (formulario) usa “nosotros” o “nuestro” se refiere a SCAN Health Plan.
Cuando se usa “plan” o “nuestro plan,” se refiere a VillageHealth (HMO-POS SNP).
Este documento incluye una lista de los medicamentos (formulario) de nuestro plan que está vigente al
mes de marzo del 2016. Para obtener una lista actualizada de medicamentos, comuníquese con nosotros.
Nuestra información de contacto, junto con la fecha de la última actualización de la lista de medicamentos,
aparece en la portada y en la contraportada.
Por lo general, debe utilizar las farmacias de la red para utilizar su beneficio de recetados. Los beneficios, la
lista de medicamentos, la red de farmacias o los copagos/coseguro pueden cambiar el 1 de enero de 2017 y
de vez en cuando durante el año.
Esta información no es una descripción completa de los beneficios. Para obtener más información, póngase
en contacto con el plan. Limitaciones, copagos y restricciones pueden aplicar. La lista de medicamentos,
la red de farmacias o la red de proveedores pueden cambiar en cualquier momento. Usted recibirá un aviso
cuando sea necesario.
Puede obtener medicamentos recetados enviados a su casa, a través de nuestro servicio de entrega de
pedidos por correo de la red. Por lo general, debe esperar recibir sus medicamentos recetados dentro de los
siguientes 14 días desde el momento en que la farmacia de pedidos por correo recibe el pedido. Si no recibe
sus medicamentos recetados en este plazo, comuníquese a Servicios para Miembros de VillageHealth, al
1-800-399-7226, de 8 a.m. a 8 p.m., los 7 días de la semana, del 1 de octubre al 14 de febrero. Desde el
15 de febrero al 30 de septiembre, el horario es de 8 a.m. a 8 p.m., de lunes a viernes, y de 9 a.m. a 4 p.m.
los sábados (los mensajes recibidos en días festivos y fuera del horario hábil se devolverán en un día hábil).
Los usuarios de TTY deben llamar al 711.
VillageHealth (HMO-POS SNP) es un plan HMO; y es un plan de punto de servicio (Point of Service, POS)
con un contrato de Medicare. La inscripción en SCAN Health Plan depende de la renovación del contrato.
This information is available for free in other languages. Please call our Member Services number at
1-800-399-7226, 8 a.m. to 8 p.m., 7 days a week from October 1 to February 14. From February 15 to
September 30, hours are 8 a.m. to 8 p.m. Monday through Friday, and 9 a.m. to 4 p.m. on Saturday (messages
received on holidays and outside of our business hours will be returned within one business day). TTY users
call 711.
VillageHealth | Formulario 2016
XI
Esta información está disponible gratuitamente en otros idiomas. Llame nuestro número de Servicios para
Miembros al 1-800-399-7226, de 8 a.m. a 8 p.m., los siete días de la semana del 1 de octubre al 14 de
febrero. Del 15 de febrero al 30 de septiembre el horario es de 8 a.m. a 8 p.m. de lunes a viernes, y de
9 a.m. a 4 p.m. el sábado (los mensajes recibidos en días festivos o fuera de nuestras horas de oficina serán
contestados dentro de un día hábil. Los usuarios de TTY llamen al 711.
Y0057_SCAN_9190_2015F_SP File & Use Accepted 08232015
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VillageHealth | 2016 Formulary
TABLA DE CONTENIDOS
¿Qué es el Formulario de VillageHealth?................................................................................................. XV
¿El Formulario (lista de medicamentos) puede cambiar?.......................................................................... XV
¿Cómo utilizo el Formulario?.................................................................................................................. XV
¿Qué son los medicamentos genéricos?................................................................................................. XVI
¿Hay alguna restricción en mi cobertura?............................................................................................... XVI
¿Qué sucede si mi medicamento no está en el Formulario?..................................................................... XVI
¿Cómo solicito una excepción al formulario de VillageHealth?.................................................................XVII
¿Qué debo hacer antes de poder hablar con mi médico sobre un cambio en mis medicamentos o
solicitar una excepción?......................................................................................................................XVII
Para obtener más información............................................................................................................XVIII
Formulario de VillageHealth................................................................................................................... XX
Medicamentos del formulario coordinados por la clase terapéutica..............................................................1
Medicamentos del formulario con límites de cantidad..............................................................................28
Índice..................................................................................................................................................31
VillageHealth | Formulario 2016
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XIV
VillageHealth | Formulario 2016
¿Qué es el Formulario de VillageHealth?
Un formulario es una lista de medicamentos cubiertos seleccionados por VillageHealth en consulta con un
equipo de proveedores de atención médica, que representa las terapias prescritas que son parte necesaria de
un programa de tratamiento de calidad. VillageHealth generalmente cubrirá los medicamentos descritos en
nuestra lista de medicamentos siempre que el medicamento sea médicamente necesario, la receta médica
se surta en una farmacia de la red de VillageHealth y se sigan otras reglas del plan. Para obtener más
información acerca de cómo surtir sus recetas, consulte su Evidencia de cobertura.
¿El Formulario (lista de medicamentos) puede cambiar?
Por lo general, si está tomando un medicamento de nuestro formulario para 2016 que estaba cubierto al
inicio del año, no interrumpiremos ni reduciremos la cobertura del medicamento durante el año de cobertura
2016 excepto cuando esté disponible un medicamento genérico de menos costo o si se publica nueva
información adversa sobre la seguridad o efectividad de un medicamento. Otros tipos de cambios a la lista
de medicamentos aprobados, como la eliminación de un medicamento de nuestro formulario, no afectará
a los miembros que actualmente están tomando el medicamento. Permanecerá disponible al mismo costo
compartido para los miembros que lo tomen por el resto del año de cobertura. Creemos que es importante
que tenga acceso continuo por el resto del año de cobertura a los medicamentos del formulario que estaban
disponibles cuando eligió nuestro plan, excepto en los casos en que usted puede ahorrar más dinero o que
podamos garantizar su seguridad.
Si retiramos medicamentos de nuestro formulario, agregamos una autorización previa, restricciones de
límites de cantidad o terapia de pasos a un medicamento o movemos un medicamento a un nivel de costo
compartido superior, debemos notificar a los miembros afectados sobre el cambio por lo menos 60 días
antes de que el cambio entre en vigencia, o en el momento en que el miembro solicita una reposición del
medicamento, momento en el cual el miembro recibirá un suministro para 60 días del medicamento. Si la
Administración de Alimentos y Medicamentos considera que un medicamento de nuestro formulario no es
seguro o el fabricante del medicamento lo retira del mercado, inmediatamente retiraremos el medicamento
de nuestro formulario y notificaremos a los miembros que toman el medicamento. El formulario adjunto
está vigente al mes de marzo del 2016. Para obtener información actualizada acerca de los medicamentos
cubiertos por VillageHealth, comuníquese con nosotros. Nuestra información de contacto aparece en la
portada y en la contraportada.
¿Cómo utilizo el Formulario?
Hay dos maneras de encontrar su medicamento en el formulario:
Afección médica
El formulario comienza en la página 1. Los medicamentos en este formulario están agrupados en
categorías de acuerdo con el tipo de afecciones médicas que se utilizan para el tratamiento. Por
ejemplo, los medicamentos que se usan para tratar una afección cardíaca se muestran en la categoría
“Agentes cardiovasculares.” Si sabe para qué se usa su medicamento, busque el nombre de la categoría
en la lista que inicia en la página 1. Luego busque bajo el nombre de la categoría de su medicamento.
Lista alfabética
Si no está seguro de qué categoría buscar, deberá buscar su medicamento en el índice que inicia en la
página 31. El índice proporciona una lista en orden alfabético de todos los medicamentos incluidos en
este documento. Los medicamentos de marca y genéricos se incluyen en el índice. Busque en el índice
y encuentre su medicamento. Al lado de su medicamento, usted verá el número de página donde puede
encontrar la información de cobertura. Vaya a la página que aparece en el índice y encuentre el nombre
de su medicamento en la primera columna de la lista.
VillageHealth | Formulario 2016
XV
¿Qué son los medicamentos genéricos?
VillageHealth cubre tanto medicamentos de marca como medicamentos genéricos Un medicamento genérico
es aprobado por la Administración de Alimentos y Medicamentos (FDA) ya que tiene el mismo ingrediente
activo que el medicamento de marca. Por lo general, los medicamentos genéricos cuestan menos que los
medicamentos de marca.
¿Hay alguna restricción en mi cobertura?
Algunos medicamentos cubiertos pueden tener requisitos adicionales o límites de cobertura. Estos requisitos
y límites pueden incluir:
• Autorización previa: VillageHealth requiere que usted o su médico obtengan una autorización previa
para ciertos medicamentos. Esto significa que necesitará obtener aprobación de VillageHealth antes
de surtir sus recetas médicas. Si no obtiene la aprobación, es posible que VillageHealth no cubra
el medicamento.
• Límites de cantidad: Para ciertos medicamentos, VillageHealth limita la cantidad del medicamento
que VillageHealth cubrirá. Por ejemplo, VillageHealth proporciona 31 tabletas por receta médica para
Rozerem. Esto puede ser además de un suministro estándar para un mes o tres meses.
• Terapia de pasos: En algunos casos, VillageHealth requiere que primero pruebe ciertos
medicamentos para tratar su afección médica antes de que nosotros cubramos otro medicamento
para esa afección. Por ejemplo, si tanto el medicamento A como el medicamento B tratan su
afección médica, es posible que VillageHealth no cubra el medicamento B a menos que pruebe
primero el medicamento A. Si el medicamento A no funciona para usted, VillageHealth cubrirá el
medicamento B.
Para averiguar si su medicamento tiene requisitos adicionales o límites revise el formulario que comienza
en la página 1. También puede obtener más información acerca de las restricciones que aplican a
medicamentos específicos cubiertos al visitar nuestro sitio web. Hemos publicado en línea documentos que
explican nuestras restricciones de autorización previa y terapia de pasos. También puede pedirnos que le
enviemos una copia. Nuestra información de contacto, junto con la fecha de la última actualización de la
lista de medicamentos, aparece en la portada y en la contraportada.
Puede solicitar a VillageHealth que haga una excepción a estas restricciones o límites, o una lista de
medicamentos similares que pueden tratar su afección de salud. Consulte la sección “¿Cómo solicito una
excepción al formulario de VillageHealth?” en la página XVII, para obtener información sobre cómo solicitar
una excepción.
¿Qué sucede si mi medicamento no está en el Formulario?
Si su medicamento no está incluido en este Formulario (lista de medicamentos cubiertos), primero debe
comunicarse con Servicios para Miembros y preguntar si su medicamento está cubierto.
Si descubre que VillageHealth no cubre su medicamento, tiene dos opciones:
• Puede solicitar a Servicios para Miembros una lista de medicamentos similares que VillageHealth
cubre. Cuando reciba la lista, muéstrela a su médico y pídale que le recete un medicamento similar
que esté cubierto por VillageHealth.
• Puede solicitar que VillageHealth haga una excepción y cubra su medicamento. Consulte a
continuación para obtener información sobre cómo solicitar una excepción.
XVI
VillageHealth | Formulario 2016
¿Cómo solicito una excepción al formulario de VillageHealth?
Puede solicitar VillageHealth que haga una excepción a nuestras reglas de cobertura. Existen varios tipos de
excepciones que puede solicitarnos que hagamos.
• Puede solicitarnos que cubramos un medicamento, incluso si no está incluido en nuestro
formulario. Si se aprueba, este medicamento estará cubierto en un determinado nivel de costo
compartido, y usted no podrá solicitarnos que proporcionemos el medicamento a un nivel de costo
compartido inferior.
• Puede solicitarnos que cubramos un medicamento del formulario a un nivel de costo compartido
inferior si este medicamento no está incluido en el nivel de especialidades. Si se aprueba, esto
reducirá el monto que debe pagar por su medicamento.
• Puede solicitarnos que exoneremos las restricciones de cobertura o límites de su medicamento.
Por ejemplo, para ciertos medicamentos, VillageHealth limita la cantidad del medicamento que
cubriremos. Si su medicamento tiene un límite de cantidad, puede solicitarnos que exoneremos el
límite y cubramos una cantidad mayor.
Por lo general, VillageHealth solo aprobará su solicitud de excepción si los medicamentos alternativos
incluidos en el formulario del plan, el medicamento de costo compartido inferior o las restricciones
adicionales de uso pudieran no ser tan efectivos al tratar su afección y/o pudieran provocarle efectos
médicos adversos.
Debe comunicarse con nosotros para pedirnos una decisión inicial de cobertura para una excepción de
restricción de uso, de nivel o al formulario. Cuando solicite una excepción de restricción de uso, de nivel
o al formulario, debe enviar una declaración de apoyo de su médico o la persona que receta que respalde
su solicitud. Por lo general, debemos tomar nuestra decisión dentro de las siguientes 72 horas después de
recibir la declaración de apoyo de la persona que receta. Puede solicitar una excepción expedita (rápida) si
usted o su médico consideran que su salud podría dañarse seriamente si espera hasta por 72 horas para una
decisión. Si se autoriza su solicitud expedita, debemos proporcionarle una decisión no después de 24 horas
después de haber recibido una declaración de apoyo de su médico u otra persona que recete.
¿Qué debo hacer antes de poder hablar con mi médico sobre un cambio en mis medicamentos o
solicitar una excepción?
Como miembro nuevo o existente en nuestro plan puede tomar medicamentos que no se encuentran en
nuestro formulario. O bien, puede estar tomando un medicamento que está en nuestro formulario pero su
capacidad para obtenerlo es limitada. Por ejemplo, puede necesitar una autorización previa de nuestra parte
antes de que pueda surtir su receta médica. Debe hablar con su médico para decidir si deben cambiar a
un medicamento apropiado que cubramos o solicitar una excepción al formulario para que cubramos el
medicamento que toma. Mientras que habla con su médico para determinar el curso correcto de acción para
usted, podemos cubrir su medicamento en ciertos casos durante los primeros 90 días, que usted es miembro
de nuestro plan.
Para cada uno de sus medicamentos que no está incluido en nuestro formulario o si su capacidad de obtener
sus medicamentos es limitada, cubriremos un suministro temporal de 30 días (a menos que tenga una
receta médica para menos días) cuando vaya a una farmacia de la red de servicios. Después de su primer
suministro para 30 días, no pagaremos por estos medicamentos, incluso si ha sido un miembro del plan
menos de 90 días.
Si es un residente de un centro de atención a largo plazo, le permitiremos que realice la reposición de su
receta médica hasta que le hayamos proporcionado por lo menos un suministro de transición para 91 y es
posible que para hasta 98 días, consistente con el incremento de despacho (a menos que tenga una receta
médica para menos días). Cubriremos más de un reabastecimiento de estos medicamentos durante los
VillageHealth | Formulario 2016
XVII
primeros 90 días en que sea miembro de nuestro plan. Si necesita un medicamento que no está incluido
en nuestro formulario o si su capacidad de obtener sus medicamentos es limitada, pero está más allá de los
primeros 90 días de la membresía en nuestro plan, cubriremos un suministro de emergencia de 31 días de
ese medicamento (a menos que tenga una receta médica para menos días) mientras tramita una excepción
al formulario.
Si es un miembro actual que está en la transición a un nivel diferente de atención, se le pueden prescribir
medicamentos no incluidos en nuestro formulario o su capacidad de obtener sus medicamentos podría
estar limitada. En estos casos, debe hablar con su médico acerca de las terapias alternativas apropiadas
y disponibles en nuestro formulario. Si no hubiera terapias alternativas apropiadas en nuestro formulario,
usted o su médico pueden solicitar una excepción y solicitar al plan que cubra el medicamento o eliminar
las restricciones de los medicamentos. Mientras habla con su médico para determinar el curso de acción,
es elegible para recibir un suministro de transición de 30 días del medicamento si se muda a un centro
de atención a largo plazo (long-term care, LTC) o de una estadía en el hospital a casa, o un suministro de
transición de 31 días del medicamento si se muda de la casa o de una estadía en el hospital a un centro de
atención a largo plazo (LTC).
Para obtener más información
Para obtener información más detallada sobre la cobertura de medicamentos recetados de VillageHealth,
consulte su Evidencia de cobertura y otros materiales del plan.
Si tiene alguna pregunta acerca de VillageHealth, comuníquese con nosotros. Nuestra información de
contacto, junto con la fecha de la última actualización de la lista de medicamentos, aparece en la portada y
en la contraportada.
Si tiene preguntas generales acerca de la cobertura de medicamentos recetados de Medicare, llame a
Medicare al 1-800-MEDICARE (1-800-633-4227), las 24 horas del día, los 7 días a la semana. Los
usuarios de TTY deben llamar al 1. O bien, visite http://www.medicare.gov.
XVIII
VillageHealth | Formulario 2016
El siguiente cuadro enumera lo que pagará como su parte de los costos de medicamentos recetados
cubiertos cuando se encuentra en la Etapa de cobertura inicial. Consulte su Evidencia de cobertura para
obtener más información.
VillageHealth (HMO-POS SNP):
Condados de Riverside y San Bernardino*
Nivel del medicamento
Nombre del nivel
Costo compartido &
Costo compartido en
farmacia de pedidos
por correo
(dentro de la red)
(suministro para 30
días)
1
Medicamentos
genéricos
preferidos
$3 de copago
$9 de copago
$3 de copago
2
Medicamentos
genéricos
$16 de copago
$48 de copago
$16 de copago
3
Medicamentos de
marca preferidos
25% de coseguro
25% de coseguro
25% de coseguro
4
Medicamentos
de marca no
preferidos
25% de coseguro
25% de coseguro
25% de coseguro
5
Medicamentos
de nivel de
especialidad
25% de coseguro
N/A
25% de coseguro
6
Medicamentos
para tratamientos
seleccionados
$11 de copago
$33 de copago
$11 de copago
Costo compartido en
farmacia de pedidos
por correo
(dentro de la red)
(suministro para 90
días)
Costo compartido en
farmacia minorista
fuera de la red
(suministro para 30
días)**
*Si recibe “Ayuda adicional,” su parte del costo de los medicamentos recetados cubiertos puede variar con
base en el nivel de Ayuda adicional que recibe.
**Para los surtidos fuera de la red, usted será responsable por el costo compartido dentro de la red más la
diferencia entre el monto facturado fuera de la red y el monto permitido dentro de la red.
VillageHealth | Formulario 2016
XIX
Formulario de VillageHealth
El formulario que comienza en la página 1 proporciona información sobre los medicamentos que cubre
VillageHealth. Si tiene dificultades para encontrar su medicamento en la lista, diríjase al índice que inicia en
la página 31.
La primera columna del cuadro muestra el nombre del medicamento. Los medicamentos de marca están
en mayúsculas (por ejemplo, BENICAR) y los medicamentos genéricos están en minúsculas itálicas (por
ejemplo, lisinopril).
La información en la columna de Requisitos/límites le indica si VillageHealth tiene algún requisito especial
para la cobertura de su medicamento.
• El símbolo [PA] indica que se requiere una autorización previa.
• El símbolo [B vs D] indica que este medicamento puede estar cubierto por la Parte B o la Parte D de
Medicare, dependiendo de las circunstancias. Para hacer la determinación, es posible que se necesite
enviar información que describa el uso y ajuste del medicamento.
• El símbolo [ST] indica que se requiere terapia de pasos.
• El símbolo [QL] indica que cantidades surtidas están limitadas. Para saber la cantidad de límite de
cantidad para los medicamentos del formulario, consulte la página 28.
• El símbolo [90D] indica que los medicamentos están disponibles para un suministro para 90 días en
farmacias de pedido por correo y farmacias minoristas seleccionadas.
• El símbolo [LD] indica que se aplica la distribución limitada. Esta receta médica puede estar
disponible únicamente en ciertas farmacias. Para obtener más información, consulte su Directorio de
Farmacias o llame a Servicios para Miembros al 1-800-399-7226, de 8 a.m. a 8 p.m., los 7 días de la
semana, desde el 1 de octubre hasta el 14 de febrero. Desde el 15 de febrero al 30 de septiembre,
el horario es de 8 a.m. a 8 p.m., de lunes a viernes, y de 9 a.m. a 4 p.m. los sábados (los mensajes
recibidos en días festivos y fuera del horario hábil se devolverán en un día hábil). Los usuarios de TTY
deben llamar al 711.
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VillageHealth | Formulario 2016
FORMULARY DRUGS ARRANGED BY THERAPEUTIC CLASS
MEDICAMENTOS DEL FORMULARIO COORDINADOS POR LA CLASE TERAPÉUTICA
Formulary ID: 16400 (Version 7)
ID de Formulario: 16400 (Versión 7)
Updated: 03/2016
Actualizado: 03/2016
Drug Name
Drug Requirements/
Tier Limits
Nombre del Medicamento
Nivel
ANALGESICS
Opioid Analgesics, Long-acting
duramorph inj
2
fentanyl patches
3
12mcg/hr, 25mcg/hr,
50mcg/hr, 75mcg/hr,
100mcg/hr
methadone oral
2
methadone inj
2
morphine sulfate er tabs
3
OXYCONTIN
4
oxymorphone er
2
tramadol er tabs
2
Opioid Analgesics, Short-acting
acetaminophen & codeine
2
butorphanol tartrate inj
2
butorphanol tartrate nasal
2
codeine
2
endocet 5-325mg, 7.52
325mg, 10-325mg
endodan
2
fentanyl citrate lozenges
3
200mcg
fentanyl citrate lozenges
5
400mcg, 600mcg,
800mcg, 1200mcg &
1600mcg
hydrocodone &
2
acetaminophen soln 7.5325mg/15mL
hydrocodone &
2
acetaminophen tabs
5-325mg, 7.5-325mg,
10-325mg
hydrocodone & ibuprofen
2
Requisitos/
Límites
Drug Name
Drug Requirements/
Tier Limits
Nombre del Medicamento
Nivel
hydromorphone
immediate-release oral
soln & tabs
hydromorphone inj
LAZANDA
lorcet tabs 5-325mg
lorcet hd tabs 10-325mg
lorcet plus tabs 7.5-325mg
lortab tabs 5-325mg, 7.5325mg, 10-325mg
morphine sulfate inj vial
morphine sulfate oral
oxycodone immediaterelease
oxycodone oral soln
oxycodone &
acetaminophen 2.5325mg, 5-325mg, 7.5325mg, 10-325mg
oxycodone & aspirin
oxycodone & ibuprofen
reprexain
tramadol
tramadol & acetaminophen
zamicet
ANESTHETICS
Local Anesthetics
lidocaine patch
lidocaine hcl topical
lidocaine hcl inj
lidocaine & prilocaine
[90D]
[QL] [90D]
[90D]
[90D]
[QL] [90D]
[QL] [90D]
[QL] [90D]
[QL] [90D]
[QL] [90D]
[90D]
[QL] [90D]
[90D]
[QL] [90D]
[QL] [90D]
[PA] [90D]
[PA]
[QL] [90D]
[QL] [90D]
2
Requisitos/
Límites
[90D]
2
5
2
2
2
2
[90D]
[PA]
[QL] [90D]
[QL] [90D]
[QL] [90D]
[QL] [90D]
2
2
2
[90D]
[90D]
[90D]
2
2
[90D]
[QL] [90D]
2
2
2
2
2
2
[QL] [90D]
[QL] [90D]
[90D]
[90D]
[QL] [90D]
[QL] [90D]
3
2
2
2
[PA] [90D]
[90D]
[90D]
[90D]
[QL] [90D]
[PA] = Prior Authorization [B vs D] = B versus D [QL] = Quantity Limit [ST] = Step Therapy [90D] = 90-Day Supply
[LD] = Limited Distribution
You can find information on what the symbols and abbreviations on this table mean by going to page XXIX.
1
Drug Name
Drug Requirements/
Tier Limits
Requisitos/
Límites
ANTI-ADDICTION/SUBSTANCE ABUSE
TREATMENT AGENTS
Alcohol Deterrents/Anti-Craving
acamprosate calcium dr
2
[90D]
disulfiram
2
[90D]
Opioid Dependence Treatments
buprenorphine inj
3
[90D]
buprenorphine oral
3
[90D]
buprenorphine & naloxone
3
[90D]
sublingual tabs
naltrexone
2
[90D]
Opioid Reversal Agents
EVZIO
4
[90D]
naloxone inj
2
[90D]
NARCAN
3
[90D]
Smoking Cessation Agents
buproban
2
[90D]
CHANTIX
4
[ST] [90D]
CHANTIX STARTING &
4
[ST] [90D]
CONTINUING MONTH
PAK
NICOTROL INHALER
3
[90D]
NICOTROL NASAL
3
[90D]
ANTI-INFLAMMATORY AGENTS
Nonsteroidal Anti-inflammatory Drugs
celecoxib
2
[ST] [90D]
diclofenac potassium
1
[90D]
diclofenac sodium dr
1
[90D]
diclofenac sodium er
1
[90D]
diflunisal
2
[90D]
etodolac
2
[90D]
etodolac er
2
[90D]
ibuprofen
1
[90D]
indomethacin er
2
[PA] [90D]
indomethacin ir caps
2
[PA] [90D]
ketorolac oral
2
[PA] [90D]
ketorolac inj
2
[PA] [90D]
meloxicam oral susp
2
[90D]
Nombre del Medicamento
Nivel
Drug Name
Drug Requirements/
Tier Limits
Nombre del Medicamento
Nivel
meloxicam tabs
nabumetone
naproxen
naproxen dr
naproxen sodium ir
piroxicam
sulindac
ANTIBACTERIALS
Aminoglycosides
amikacin inj
gentamicin cream 0.1% &
oint 0.1%
gentamicin inj
neomycin sulfate oral
paromomycin
streptomycin inj
tobramycin sulfate inj
tobramycin sulfate &
sodium chloride inj
Antibacterials, Other
BACTROBAN CREAM
BACTROBAN NASAL
chloramphenicol sodium
succinate inj
CLEOCIN VAGINAL
clindamycin oral
clindamycin phosphate inj
colistimethate inj
CORTISPORIN CREAM &
OINT
CUBICIN INJ
linezolid inj
linezolid oral
methenamine hippurate
metronidazole inj
metronidazole oral
metronidazole topical
metronidazole vaginal
mupirocin
1
2
1
1
1
2
2
Requisitos/
Límites
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
2
2
[90D]
[90D]
2
2
2
2
2
2
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
3
3
2
[90D]
[90D]
[90D]
3
2
2
2
3
[90D]
[90D]
[90D]
[90D]
[90D]
5
5
5
2
2
2
2
2
2
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[PA] = Autorización Previa [B vs D] = B versus D [QL] = Límite de Cantidad [ST] = Tratamiento Escalonado
[90D] = Suministro para 90 Días [LD] = Distribución Limitada
Puede encontrar información sobre el significado de los símbolos y abreviaturas de esta tabla en la página LX.
2
Drug Name
Drug Requirements/
Tier Limits
Nombre del Medicamento
Nivel
nitrofurantoin caps
2
silver sulfadiazine
2
SIVEXTRO
5
ssd
2
SYNERCID INJ
5
trimethoprim
2
TYGACIL INJ
5
vancomycin oral
5
vancomycin inj
2
vandazole
2
XIFAXAN TABS 200MG
3
XIFAXAN TABS 550MG
5
ZYVOX ORAL SUSP
5
Beta-lactam, Cephalosporins
cefaclor
2
cefaclor er
2
cefadroxil caps & tabs
2
cefazolin inj
2
cefdinir
2
cefepime inj
2
cefixime
2
cefoxitin sodium
2
cefpodoxime tabs
2
cefprozil
2
ceftazidime inj 1gm, 2gm
2
& 6gm
ceftriaxone inj
2
cefuroxime oral
2
cefuroxime inj
2
cephalexin caps & tabs
1
250mg & 500mg
cephalexin oral susp
1
SUPRAX CAPS &
3
CHEWABLE TABS
SUPRAX ORAL SUSP
3
500MG/5ML
tazicef inj
2
TEFLARO INJ
4
Requisitos/
Límites
[PA]
[90D]
Drug Name
Drug Requirements/
Tier Limits
Nombre del Medicamento
Nivel
ZERBAXA INJ
Beta-lactam, Other
aztreonam inj 1gm
cilastatin/imipenem inj
INVANZ INJ
meropenem inj 500mg
Beta-lactam, Penicillins
amoxicillin
amoxicillin & clavulanate
potassium
amoxicillin & clavulanate
potassium er
ampicillin & sulbactam inj
10-5gm, 2-1gm, & 1-0.5gm
ampicillin inj
ampicillin oral
BICILLIN L-A INJ
dicloxacillin sodium
nafcillin sodium inj
penicillin g inj 5 million
units
penicillin v potassium
piperacillin/tazobactam inj
3gm/0.375gm &
4gm/0.5gm
ZOSYN GALAXY INJ
2GM/0.25GM &
3GM/0.375GM
Macrolides
azithromycin tabs & oral
susp
azithromycin inj
clarithromycin
clarithromycin er
ERYTHROCIN
LACTOBIONATE INJ
erythrocin stearate
erythromycin oral
erythromycin topical gel &
soln
[90D]
[90D]
[PA]
[90D]
[90D]
[QL] [90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
Requisitos/
Límites
5
2
2
4
2
[90D]
[90D]
[90D]
[90D]
1
2
[90D]
[90D]
2
[90D]
2
[90D]
2
2
3
2
2
2
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
2
2
[90D]
[90D]
4
[90D]
2
[90D]
2
2
2
4
[90D]
[90D]
[90D]
[90D]
2
2
2
[90D]
[90D]
[90D]
[PA] = Prior Authorization [B vs D] = B versus D [QL] = Quantity Limit [ST] = Step Therapy [90D] = 90-Day Supply
[LD] = Limited Distribution
You can find information on what the symbols and abbreviations on this table mean by going to page XXIX.
3
Drug Name
Drug Requirements/
Tier Limits
Nombre del Medicamento
Nivel
erythromycin &
sulfisoxazole
Quinolones
ciprofloxacin inj
ciprofloxacin oral susp
ciprofloxacin tabs
immediate-release
ciprofloxacin tabs er
levofloxacin inj
levofloxacin oral soln
levofloxacin tabs
moxifloxacin oral
ofloxacin oral
Sulfonamides
sulfadiazine
sulfamethoxazole &
trimethoprim tabs
sulfamethoxazole &
trimethoprim ds tabs
sulfamethoxazole &
trimethoprim oral susp
sulfamethoxazole &
trimethoprim inj
Tetracyclines
demeclocycline
doxy 100 inj
doxycycline immediaterelease tabs, caps & oral
susp
doxycycline inj
minocycline ir
tetracycline
ANTICONVULSANTS
Anticonvulsants, Other
FYCOMPA
levetiracetam er
levetiracetam oral
levetiracetam inj
POTIGA
2
Drug Name
Requisitos/
Límites
[90D]
2
2
1
[90D]
[90D]
[90D]
2
2
2
1
2
2
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
2
1
[90D]
[90D]
1
[90D]
2
[90D]
2
[90D]
3
2
2
[90D]
[90D]
[90D]
2
2
2
[90D]
[90D]
[90D]
4
2
2
2
4
[90D]
[90D]
[90D]
[90D]
[90D]
Drug Requirements/
Tier Limits
Requisitos/
Límites
Calcium Channel Modifying Agents
CELONTIN
4
[90D]
ethosuximide
2
[90D]
LYRICA
3
[PA] [90D]
zonisamide
2
[90D]
Gamma-aminobutyric Acid (GABA)
Augmenting Agents
clonazepam
2
[PA] [90D]
clonazepam odt
2
[PA] [90D]
clorazepate
2
[PA] [90D]
diazepam rectal gel
2
[PA] [90D]
divalproex sodium
2
[90D]
divalproex sodium dr
2
[90D]
divalproex sodium er
2
[90D]
gabapentin caps & oral
2
[90D]
soln
gabapentin tabs
3
[90D]
GABITRIL TABS 12MG &
4
[90D]
16MG
ONFI
4
[90D]
phenobarbital elixir
2
[PA] [90D]
phenobarbital tabs
2
[PA] [90D]
primidone
2
[90D]
SABRIL
5
[LD]
tiagabine
2
[90D]
valproate sodium inj
2
[90D]
valproic acid
2
[90D]
Glutamate Reducing Agents
felbamate tabs 400mg
2
[90D]
felbamate tabs 600mg &
5
oral susp 600mg/5ml
lamotrigine immediate2
[90D]
release tabs
topiramate immediate2
[90D]
release
Sodium Channel Agents
APTIOM
4
[90D]
BANZEL
4
[90D]
Nombre del Medicamento
Nivel
[PA] = Autorización Previa [B vs D] = B versus D [QL] = Límite de Cantidad [ST] = Tratamiento Escalonado
[90D] = Suministro para 90 Días [LD] = Distribución Limitada
Puede encontrar información sobre el significado de los símbolos y abreviaturas de esta tabla en la página LX.
4
Drug Name
Drug Requirements/
Tier Limits
Nombre del Medicamento
Nivel
Requisitos/
Límites
[90D]
carbamazepine tabs,
2
chewable tabs & oral susp
carbamazepine er tabs &
2
[90D]
caps
dilantin caps 100mg
2
[90D]
DILANTIN CAPS 30MG
3
[90D]
DILANTIN INFATABS
3
[90D]
DILANTIN SUSP
3
[90D]
epitol
2
[90D]
fosphenytoin sodium inj
2
[90D]
oxcarbazepine
2
[90D]
PEGANONE
4
[90D]
phenytoin chewable tabs
2
[90D]
phenytoin er
2
[90D]
phenytoin oral susp
2
[90D]
phenytoin inj
2
[90D]
TEGRETOL
3
[90D]
TEGRETOL XR
3
[90D]
TRILEPTAL
4
[90D]
VIMPAT ORAL
4
[90D]
VIMPAT INJ
4
[90D]
ANTIDEMENTIA AGENTS
Antidementia Agents, Other
ergoloid mesylates
3
[PA] [90D]
Cholinesterase Inhibitors
donepezil tabs 5mg &
2
[90D]
10mg
donepezil odt
2
[90D]
EXELON PATCHES
3
[QL] [90D]
galantamine
2
[QL] [90D]
galantamine er
2
[QL] [90D]
galantamine oral soln
2
[QL] [90D]
rivastigmine caps
2
[QL] [90D]
rivastigmine patches
3
[QL] [90D]
N-methyl-D-aspartate (NMDA) Receptor
Antagonists
memantine hcl immediate
2
[90D]
release
Drug Name
Drug Requirements/
Tier Limits
Nombre del Medicamento
Nivel
Requisitos/
Límites
[90D]
[90D]
[90D]
NAMENDA
3
NAMENDA ORAL SOLN
3
NAMENDA TITRATION
3
PAK
ANTIDEPRESSANTS
Antidepressants, Other
BRINTELLIX
4
[ST] [90D]
budeprion sr
2
[90D]
bupropion
2
[90D]
bupropion sr
2
[90D]
bupropion xl
2
[90D]
FORFIVO XL
3
[90D]
maprotiline
2
[90D]
mirtazapine
1
[90D]
mirtazapine odt
1
[90D]
nefazodone
2
[90D]
trazodone
1
[90D]
Monoamine Oxidase Inhibitors
EMSAM
4
[90D]
MARPLAN
4
[90D]
phenelzine
2
[90D]
tranylcypromine
2
[90D]
SSRIs/SNRIs (Selective Serotonin Reuptake
Inhibitors/Serotonin & Norepinephrine
Reuptake Inhibitors)
citalopram tabs
1
[90D]
citalopram oral soln
2
[90D]
DESVENLAFAXINE ER
4
[ST] [90D]
duloxetine hcl
3
[90D]
escitalopram
2
[90D]
FETZIMA
4
[ST] [90D]
FETZIMA TITRATION
4
[ST] [90D]
PACK
fluoxetine hcl caps 10mg,
2
[90D]
20mg & 40mg
fluoxetine hcl tabs 10mg &
2
[90D]
20mg
fluoxetine hcl oral soln
2
[90D]
[PA] = Prior Authorization [B vs D] = B versus D [QL] = Quantity Limit [ST] = Step Therapy [90D] = 90-Day Supply
[LD] = Limited Distribution
You can find information on what the symbols and abbreviations on this table mean by going to page XXIX.
5
Drug Name
Drug Requirements/
Tier Limits
Nombre del Medicamento
Nivel
fluvoxamine
fluvoxamine er
KHEDEZLA
paroxetine immediaterelease
paroxetine er
PAXIL 10MG/5ML SUSP
PRISTIQ
sertraline tabs
sertraline oral soln
venlafaxine ir tabs
venlafaxine er caps
VIIBRYD
Tricyclics
amitriptyline
amoxapine
clomipramine
desipramine
doxepin
imipramine hcl tabs
nortriptyline oral
perphenazine &
amitriptyline
protriptyline
SURMONTIL
trimipramine maleate
ANTIEMETICS
Antiemetics, Other
compro
meclizine
metoclopramide oral
tablets & soln
metoclopramide inj
phenadoz
phenergan suppositories
prochlorperazine inj
prochlorperazine oral
prochlorperazine
suppositories
2
2
4
1
Requisitos/
Límites
[90D]
[90D]
[ST] [90D]
[90D]
2
4
4
1
2
2
2
4
[90D]
[90D]
[ST] [90D]
[90D]
[90D]
[90D]
[90D]
[ST] [90D]
2
2
3
2
2
2
2
2
[PA] [90D]
[90D]
[PA] [90D]
[90D]
[PA] [90D]
[PA] [90D]
[90D]
[PA] [90D]
2
3
2
[90D]
[PA] [90D]
[PA] [90D]
2
2
2
[90D]
[90D]
[90D]
2
3
3
2
2
2
[90D]
[PA] [90D]
[PA] [90D]
[90D]
[90D]
[90D]
Drug Name
Drug Requirements/
Tier Limits
Nombre del Medicamento
Nivel
promethazine inj
3
promethazine
3
suppositories
promethazine syrup
2
promethazine tabs
2
12.5mg, 25mg & 50mg
promethegan
3
TRANSDERM-SCOP
3
Emetogenic Therapy Adjuncts
dronabinol
3
EMEND CAPS 80MG &
4
125MG
EMEND PACK
4
granisetron inj
2
granisetron oral
2
ondansetron odt
2
ondansetron oral soln
2
ondansetron inj
ondansetron tabs
2
2
ANTIFUNGALS
Antifungals
ABELCET INJ
AMBISOME INJ
amphotericin b inj
CANCIDAS INJ
ciclopirox 8% nail soln
ciclopirox cream, susp,
shampoo
clotrimazole &
betamethasone
clotrimazole 1% cream
clotrimazole 1% topical
soln
clotrimazole troche
CRESEMBA INJ
CRESEMBA ORAL
Requisitos/
Límites
[PA] [90D]
[PA] [90D]
[PA] [90D]
[PA] [90D]
[PA] [90D]
[90D]
[PA] [90D]
[PA] [90D]
[PA] [90D]
[90D]
[PA] [B vs D]
[90D]
[PA] [B vs D]
[90D]
[PA] [B vs D]
[90D]
[90D]
[PA] [B vs D]
[90D]
5
5
2
5
2
2
[90D]
[PA]
[90D]
[90D]
2
[90D]
2
2
[90D]
[90D]
2
5
5
[90D]
[PA]
[PA]
[PA] = Autorización Previa [B vs D] = B versus D [QL] = Límite de Cantidad [ST] = Tratamiento Escalonado
[90D] = Suministro para 90 Días [LD] = Distribución Limitada
Puede encontrar información sobre el significado de los símbolos y abreviaturas de esta tabla en la página LX.
6
Drug Name
Drug Requirements/
Tier Limits
Nombre del Medicamento
Nivel
Requisitos/
Límites
[90D]
[90D]
[90D]
econazole nitrate
3
fluconazole in dextrose inj
2
fluconazole oral
2
flucytosine
5
griseofulvin microsize
2
[90D]
itraconazole
3
[90D]
ketoconazole
2
[90D]
NOXAFIL ORAL
5
[PA]
nyamyc
2
[90D]
nystatin
2
[90D]
nystatin & triamcinolone
2
[90D]
ORAVIG
4
[90D]
SPORANOX ORAL SOLN
4
[90D]
terbinafine
2
[90D]
terconazole
2
[90D]
voriconazole inj
2
[90D]
voriconazole oral
5
ANTIGOUT AGENTS
Antigout Agents
allopurinol
1
[90D]
COLCHICINE
4
[QL] [90D]
COLCRYS
4
[QL] [90D]
probenecid
2
[90D]
probenecid & colchicine
2
[90D]
ULORIC
3
[ST] [90D]
ANTIMIGRAINE AGENTS
Ergot Alkaloids
dihydroergotamine
5
mesylate inj
ERGOMAR
3
[90D]
Serotonin (5-HT) 1b/1d Receptor Agonists
naratriptan
2
[QL] [90D]
rizatriptan
2
[90D]
rizatriptan odt
2
[90D]
sumatriptan nasal
3
[90D]
sumatriptan succinate inj
3
[90D]
sumatriptan succinate oral
2
[90D]
Drug Name
Drug Requirements/
Tier Limits
Nombre del Medicamento
Nivel
zolmitriptan tabs
zolmitriptan odt
ZOMIG NASAL
ANTIMYASTHENIC AGENTS
Parasympathomimetics
guanidine
MESTINON SYRUP
MESTINON TIMESPAN
pyridostigmine
pyridostigmine er
ANTIMYCOBACTERIALS
Antimycobacterials, Other
DAPSONE
rifabutin
Antituberculars
CAPASTAT INJ
ethambutol
isoniazid oral
PASER
PRIFTIN
pyrazinamide
rifampin oral
rifampin inj
RIFATER
SIRTURO
TRECATOR
ANTINEOPLASTICS
Alkylating Agents
cyclophosphamide caps
2
2
4
GLEOSTINE
HEXALEN
LEUKERAN
LOMUSTINE
MATULANE
VALCHLOR
4
5
3
4
5
5
Requisitos/
Límites
[90D]
[90D]
[QL] [90D]
2
3
3
2
2
[90D]
[90D]
[90D]
[90D]
[90D]
3
2
[90D]
[90D]
4
2
2
4
4
2
2
2
4
5
4
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
2
[PA] [B vs D]
[90D]
[90D]
[90D]
[PA] = Prior Authorization [B vs D] = B versus D [QL] = Quantity Limit [ST] = Step Therapy [90D] = 90-Day Supply
[LD] = Limited Distribution
You can find information on what the symbols and abbreviations on this table mean by going to page XXIX.
7
[90D]
[90D]
[PA]
Drug Name
Drug Requirements/
Tier Limits
Nombre del Medicamento
Nivel
Antiandrogens
bicalutamide
flutamide
NILANDRON
XTANDI
ZYTIGA
Antiangiogenic Agents
POMALYST
REVLIMID
THALOMID
Antiestrogens/Modifiers
EMCYT
FARESTON
FASLODEX INJ
SOLTAMOX
tamoxifen
Antimetabolites
ALIMTA INJ
hydroxyurea
LONSURF
mercaptopurine
PURIXAN
TABLOID
Antineoplastics, Other
amifostine inj
azacitidine inj
ERWINAZE INJ
leucovorin oral
leucovorin inj
levoleucovorin inj
LYNPARZA
MESNEX TABS
mitoxantrone inj
NINLARO
ONCASPAR INJ
paclitaxel inj
SYLATRON INJ
SYNRIBO INJ
Requisitos/
Límites
2
2
4
5
5
[90D]
[90D]
[90D]
[PA]
[PA]
5
5
5
[PA]
[PA] [LD]
[PA]
3
3
5
3
2
[90D]
[90D]
5
2
5
2
5
4
[PA]
[90D]
[PA]
[90D]
5
5
5
2
2
5
5
3
2
5
5
2
5
5
Drug Name
Drug Requirements/
Tier Limits
Requisitos/
Límites
VELCADE INJ
5
[PA]
Aromatase Inhibitors, 3rd Generation
anastrozole
2
[90D]
exemestane
3
[90D]
letrozole
2
[90D]
Enzyme Inhibitors
BELEODAQ
5
[PA]
etoposide inj
3
[90D]
FARYDAK
5
[PA]
ZOLINZA
5
[PA]
ZYDELIG
5
[PA]
Molecular Target Inhibitors
AFINITOR
5
[PA]
AFINITOR DISPERZ
5
[PA]
ALECENSA
5
[PA]
BOSULIF
5
[PA]
CAPRELSA
5
[PA]
COMETRIQ
5
[PA]
COTELLIC
5
[PA]
ERIVEDGE
5
[PA]
GILOTRIF
5
[PA]
GLEEVEC
5
[PA]
IBRANCE
5
[PA]
ICLUSIG
5
[PA]
IMBRUVICA
5
[PA]
INLYTA
5
[PA]
IRESSA
5
[PA]
JAKAFI
5
[PA]
LENVIMA
5
[PA]
MEKINIST
5
[PA]
NEXAVAR
5
[PA] [LD]
ODOMZO
5
[PA]
SPRYCEL
5
[PA]
STIVARGA
5
[PA]
SUTENT
5
[PA]
TAFINLAR
5
[PA]
TAGRISSO
5
[PA]
TARCEVA
5
Nombre del Medicamento
[90D]
[90D]
[PA] [90D]
[PA] [B vs D]
[PA] [B vs D]
[PA]
[90D]
[90D]
[PA]
[90D]
[PA] [90D]
[PA]
[PA]
[90D]
[PA]
[PA]
Nivel
[PA] = Autorización Previa [B vs D] = B versus D [QL] = Límite de Cantidad [ST] = Tratamiento Escalonado
[90D] = Suministro para 90 Días [LD] = Distribución Limitada
Puede encontrar información sobre el significado de los símbolos y abreviaturas de esta tabla en la página LX.
8
Drug Name
Drug Requirements/
Tier Limits
Nombre del Medicamento
Nivel
TASIGNA
TYKERB
VOTRIENT
XALKORI
ZELBORAF
ZYKADIA
Monoclonal Antibodies
AVASTIN INJ
HERCEPTIN INJ
KEYTRUDA INJ
RITUXAN INJ
YERVOY INJ
Retinoids
bexarotene
PANRETIN
TARGRETIN
tretinoin caps
ANTIPARASITICS
Anthelmintics
ALBENZA
ivermectin
Antiprotozoals
ALINIA
atovaquone
atovaquone/proguanil
chloroquine
COARTEM
DARAPRIM
hydroxychloroquine
mefloquine
NEBUPENT NEBULIZER
5
5
5
5
5
5
PENTAM INJ
PRIMAQUINE
quinine sulfate caps
324mg
4
3
2
Requisitos/
Límites
[PA]
[PA]
[PA]
[PA]
[PA]
[PA]
5
5
5
5
5
[PA]
[PA]
[PA]
[PA]
[PA]
5
5
5
2
[PA]
[PA]
[90D]
4
2
[90D]
[90D]
4
5
2
2
3
3
2
2
4
[90D]
Drug Name
Drug Requirements/
Tier Limits
Nombre del Medicamento
Nivel
Requisitos/
Límites
Pediculicides/Scabicides
EURAX
3
[90D]
malathion
2
[90D]
permethrin cream
2
[90D]
ANTIPARKINSON AGENTS
Anticholinergics
benztropine inj
2
[90D]
benztropine tabs
2
[PA] [90D]
trihexyphenidyl tabs
2
[PA] [90D]
trihexyphenidyl elixir
2
[PA] [90D]
Antiparkinson Agents, Other
amantadine
2
[90D]
entacapone
3
[90D]
Dopamine Agonists
APOKYN INJ
5
bromocriptine
2
[90D]
NEUPRO PATCH
4
[QL] [90D]
pramipexole ir
2
[90D]
ropinirole
2
[90D]
Dopamine Precursors/L-Amino Acid
Decarboxylase Inhibitors
carbidopa
3
[90D]
carbidopa & levodopa
2
[90D]
carbidopa & levodopa er
2
[90D]
carbidopa & levodopa odt
2
[90D]
carbidopa & levodopa &
3
[90D]
entacapone
Monoamine Oxidase B (MAO-B) Inhibitors
AZILECT
4
[90D]
selegiline
2
[90D]
ANTIPSYCHOTICS
1st Generation/Typical
molindone
2
[90D]
chlorpromazine oral
2
[90D]
chlorpromazine inj
2
[90D]
fluphenazine oral
2
[90D]
fluphenazine decanoate inj
2
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[PA] [B vs D]
[90D]
[90D]
[90D]
[PA] [90D]
[PA] = Prior Authorization [B vs D] = B versus D [QL] = Quantity Limit [ST] = Step Therapy [90D] = 90-Day Supply
[LD] = Limited Distribution
You can find information on what the symbols and abbreviations on this table mean by going to page XXIX.
9
Drug Name
Drug Requirements/
Tier Limits
Nombre del Medicamento
Nivel
fluphenazine inj
haloperidol tabs
haloperidol decanoate inj
haloperidol lactate oral
soln
haloperidol lactate inj
loxapine
ORAP
perphenazine
pimozide
thioridazine
thiothixene
trifluoperazine
2nd Generation/Atypical
ABILIFY ORAL SOLN
ABILIFY INJ
ABILIFY MAINTENA
aripiprazole odt
aripiprazole tabs 2mg,
5mg, 10mg, & 15mg
aripiprazole tabs 20mg &
30mg
FANAPT
FANAPT TITRATION
PACK
GEODON INJ
INVEGA ORAL
INVEGA SUSTENNA INJ
39MG & 78MG
INVEGA SUSTENNA INJ
117MG, 156MG & 234MG
LATUDA
2
2
2
2
4
[ST] [90D]
olanzapine tabs
olanzapine odt
olanzapine inj 10mg
paliperidone er
quetiapine
REXULTI
2
2
2
5
2
5
[90D]
[90D]
[90D]
[ST]
[90D]
[ST]
Requisitos/
Límites
[90D]
[90D]
[90D]
[90D]
2
2
4
2
2
2
2
2
[90D]
[90D]
[90D]
[90D]
[90D]
[PA] [90D]
[90D]
[90D]
4
4
5
2
2
[ST] [90D]
[90D]
5
[ST]
4
4
[ST] [90D]
[ST] [90D]
3
5
4
[90D]
[ST]
[90D]
Drug Name
Drug Requirements/
Tier Limits
Nombre del Medicamento
Nivel
Requisitos/
Límites
[90D]
RISPERDAL CONSTA INJ
12.5MG & 25MG
RISPERDAL CONSTA INJ
37.5MG & 50MG
risperidone
risperidone odt
SAPHRIS
4
2
2
4
[90D]
[90D]
[ST] [90D]
SEROQUEL XR
4
[ST] [90D]
ziprasidone oral
2
5
[90D]
5
ZYPREXA RELPREVV
210MG
Treatment-Resistant
clozapine
2
clozapine odt
2
FAZACLO
4
VERSACLOZ
4
ANTISPASTICITY AGENTS
Antispasticity Agents
baclofen
2
tizanidine
2
ANTIVIRALS
Anti-cytomegalovirus (CMV) Agents
ganciclovir inj
2
valganciclovir tabs
5
ZIRGAN
4
Anti-hepatitis B (HBV) Agents
adefovir dipivoxil
5
BARACLUDE ORAL
4
SOLN 0.05MG/ML
entecavir tabs
5
EPIVIR HBV SOLN
4
5MG/ML
INTRON-A INJ
4
lamivudine
2
TYZEKA
4
Anti-hepatitis C (HCV) Agents
DAKLINZA
5
HARVONI
5
[ST] [90D]
[ST] [90D]
5
[PA] = Autorización Previa [B vs D] = B versus D [QL] = Límite de Cantidad [ST] = Tratamiento Escalonado
[90D] = Suministro para 90 Días [LD] = Distribución Limitada
Puede encontrar información sobre el significado de los símbolos y abreviaturas de esta tabla en la página LX.
10
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[PA]
[PA]
Drug Name
Drug Requirements/
Tier Limits
Nombre del Medicamento
Nivel
Requisitos/
Límites
[90D]
moderiba 200mg tabs
2
moderiba dose pack
5
OLYSIO
5
[PA]
PEGASYS INJ
5
PEGASYS PROCLICK INJ
5
PEG-INTRON INJ
5
PEG-INTRON REDIPEN
5
INJ
ribasphere
2
[90D]
ribasphere ribapak
5
ribavirin
2
[90D]
SOVALDI
5
[PA]
Antiherpetic Agents
acyclovir oral
2
[90D]
acyclovir oint 5%
3
[90D]
acyclovir inj
2
[90D]
DENAVIR
3
[90D]
famciclovir
2
[90D]
valacyclovir
2
[90D]
XERESE
3
[90D]
ZOVIRAX CREAM
5
Anti-HIV Agents, Integrase Inhibitors (INSTI)
GENVOYA
5
ISENTRESS CHEW TABS
3
[90D]
ISENTRESS ORAL
3
[90D]
POWDER
ISENTRESS TABS
5
TIVICAY
5
VITEKTA
5
Anti-HIV Agents, Non-nucleoside Reverse
Transcriptase Inhibitors (NNRTI)
ATRIPLA
5
COMPLERA
5
EDURANT
5
INTELENCE 25MG TAB
4
[90D]
INTELENCE 100MG &
5
200MG TABS
nevirapine er
2
[90D]
Drug Name
Drug Requirements/
Tier Limits
Nombre del Medicamento
Nivel
Requisitos/
Límites
[90D]
[90D]
[90D]
nevirapine oral susp
2
nevirapine tabs
2
RESCRIPTOR
3
STRIBILD
5
SUSTIVA
4
[90D]
VIRAMUNE TABS
4
[90D]
VIRAMUNE XR 100MG
4
[90D]
Anti-HIV Agents, Nucleoside and Nucleotide
Reverse Transcriptase Inhibitors (NRTI)
abacavir tabs
2
[90D]
abacavir & lamivudine &
5
zidovudine
didanosine
2
[90D]
EMTRIVA
4
[90D]
EPZICOM
5
lamivudine
2
[90D]
lamivudine & zidovudine
5
RETROVIR IV INJ
4
[90D]
stavudine
2
[90D]
stavudine oral soln
2
[90D]
TRIUMEQ
5
TRUVADA
5
VIDEX PEDIATRIC SOLN
4
[90D]
2GM
VIREAD TABS
5
VIREAD POWDER
4
[90D]
ZIAGEN SOLN
4
[90D]
zidovudine
2
[90D]
Anti-HIV Agents, Other
FUZEON INJ
3
[90D]
SELZENTRY
5
TYBOST
3
[90D]
Anti-HIV Agents, Protease Inhibitors
APTIVUS
5
CRIXIVAN
3
[90D]
EVOTAZ
5
INVIRASE
4
[90D]
[PA] = Prior Authorization [B vs D] = B versus D [QL] = Quantity Limit [ST] = Step Therapy [90D] = 90-Day Supply
[LD] = Limited Distribution
You can find information on what the symbols and abbreviations on this table mean by going to page XXIX.
11
Drug Name
Drug Requirements/
Tier Limits
Nombre del Medicamento
Nivel
KALETRA TABS 10025MG
KALETRA TABS 20050MG & SOLN 400100MG/5ML
LEXIVA ORAL SUSP
LEXIVA TABS
NORVIR
PREZCOBIX
PREZISTA SUSP
100MG/ML
PREZISTA TABS 75MG &
150MG
PREZISTA TABS 600MG
& 800MG
REYATAZ CAPS & ORAL
POWDER
VIRACEPT
Anti-influenza Agents
RELENZA DISKHALER
rimantadine
TAMIFLU CAPS 75MG
TAMIFLU SUSP
ANXIOLYTICS
Anxiolytics, Other
buspirone
Benzodiazepines
alprazolam tabs
alprazolam er tabs
alprazolam intensol
diazepam tabs & soln
diazepam intensol
lorazepam tabs
lorazepam intensol
oxazepam
BIPOLAR AGENTS
Mood Stabilizers
lithium carbonate
lithium carbonate er
4
Requisitos/
Límites
[90D]
[90D]
4
[90D]
[90D]
[90D]
5
5
5
3
2
3
3
[90D]
[90D]
[90D]
[90D]
2
[90D]
2
2
2
2
2
2
2
2
[PA] [90D]
[PA] [90D]
[PA] [90D]
[PA] [90D]
[PA] [90D]
[90D]
[90D]
[PA] [90D]
2
2
[90D]
[90D]
Drug Requirements/
Tier Limits
Nombre del Medicamento
Nivel
lithium citrate
2
BLOOD GLUCOSE REGULATORS
Antidiabetic Agents
acarbose
2
BYDUREON INJ
3
BYETTA INJ
3
CYCLOSET
3
FARXIGA
3
glimepiride
1
glimepiride & pioglitazone
2
glipizide
1
glipizide & metformin tabs
2
glipizide er
1
INVOKAMET
3
INVOKANA
3
JANUMET
3
JANUMET XR
3
JANUVIA
3
KOMBIGLYZE XR
3
metformin
1
metformin er tabs 500mg
1
& 750mg
nateglinide
2
ONGLYZA
3
pioglitazone
2
pioglitazone & metformin
2
repaglinide
2
SYMLINPEN INJ
3
VICTOZA INJ
3
XIGDUO XR
3
Glycemic Agents
GLUCAGON
3
EMERGENCY KIT INJ
PROGLYCEM
4
Insulins
HUMALOG CARTRIDGE
3
INJ
HUMALOG KWIKPEN INJ
3
5
4
5
4
5
4
Drug Name
Requisitos/
Límites
[90D]
[PA] = Autorización Previa [B vs D] = B versus D [QL] = Límite de Cantidad [ST] = Tratamiento Escalonado
[90D] = Suministro para 90 Días [LD] = Distribución Limitada
Puede encontrar información sobre el significado de los símbolos y abreviaturas de esta tabla en la página LX.
12
[90D]
[PA] [90D]
[PA] [90D]
[90D]
[ST] [90D]
[90D]
[QL] [90D]
[90D]
[90D]
[90D]
[ST] [90D]
[ST] [90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[PA] [90D]
[PA] [90D]
[ST] [90D]
[90D]
[90D]
[90D]
[90D]
Drug Name
Drug Requirements/
Tier Limits
Nombre del Medicamento
Nivel
Requisitos/
Límites
[90D]
HUMALOG MIX 50/50
3
KWIKPEN INJ
HUMALOG MIX 75/25
3
[90D]
KWIKPEN INJ
HUMALOG MIX 50/50
6
[90D]
VIAL INJ
HUMALOG MIX 75/25
6
[90D]
VIAL INJ
HUMALOG VIAL INJ
6
[90D]
HUMULIN 70/30
3
[90D]
KWIKPEN INJ
HUMULIN 70/30 VIAL INJ
6
[90D]
HUMULIN N KWIKPEN
3
[90D]
INJ
HUMULIN N VIAL INJ
6
[90D]
HUMULIN R U-500
6
[90D]
(CONCENTRATED) VIAL
INJ
HUMULIN R VIAL INJ
6
[90D]
LANTUS SOLOSTAR
3
[90D]
PEN INJ
LANTUS VIAL INJ
6
[90D]
BLOOD PRODUCTS/ MODIFIERS/ VOLUME
EXPANDERS
Anticoagulants
COUMADIN ORAL
3
[90D]
enoxaparin inj
3
[90D]
30mg/0.3ml, 40mg/0.4ml,
60mg/0.6ml, 80mg/0.8ml &
300mg/3ml
enoxaparin inj 100mg/ml,
5
120mg/0.8ml & 150mg/ml
fondaparinux inj
3
[90D]
heparin inj
2
[PA] [B vs D]
[90D]
jantoven
1
[90D]
PRADAXA
3
[90D]
warfarin
1
[90D]
XARELTO
3
[90D]
XARELTO STARTER
3
[90D]
PACK
Drug Name
Drug Requirements/
Tier Limits
Nombre del Medicamento
Nivel
Requisitos/
Límites
Blood Formation Modifiers
anagrelide
2
LEUKINE INJ
5
NEUPOGEN INJ
5
PROCRIT INJ
3
2000UNIT/ML
PROCRIT INJ
4
3000UNIT/ML,
4000UNIT/ML &
10000UNIT/ML
PROCRIT INJ
5
20000UNIT/ML &
40000UNIT/ML
PROMACTA
5
Coagulants
tranexamic acid inj
2
tranexamic acid tabs
2
Platelet Modifying Agents
AGGRENOX
4
BRILINTA
3
cilostazol
2
clopidogrel tabs 75mg
2
dipyridamole & aspirin
2
dipyridamole oral
2
CARDIOVASCULAR AGENTS
Alpha-adrenergic Agonists
clonidine patches
2
clonidine tabs immediate1
release
guanfacine
2
methyldopa
2
methyldopa &
2
hydrochlorothiazide
methyldopate inj
2
midodrine tabs
2
Alpha-adrenergic Blocking Agents
doxazosin
2
prazosin
2
terazosin
1
[90D]
[PA]
[PA]
[PA] [90D]
[PA] [90D]
[PA]
[PA] [LD]
[90D]
[90D]
[QL] [90D]
[QL] [90D]
[90D]
[90D]
[QL] [90D]
[PA] [90D]
[90D]
[90D]
[PA] [90D]
[PA] [90D]
[PA] [90D]
[PA] = Prior Authorization [B vs D] = B versus D [QL] = Quantity Limit [ST] = Step Therapy [90D] = 90-Day Supply
[LD] = Limited Distribution
You can find information on what the symbols and abbreviations on this table mean by going to page XXIX.
13
[90D]
[90D]
[90D]
[90D]
[90D]
Drug Name
Drug Requirements/
Tier Limits
Requisitos/
Límites
Angiotensin-converting Enzyme (ACE)
Inhibitors
benazepril
1
[90D]
benazepril &
1
[90D]
hydrochlorothiazide
captopril
1
[90D]
captopril &
1
[90D]
hydrochlorothiazide
enalapril
1
[90D]
enalapril &
1
[90D]
hydrochlorothiazide
fosinopril
1
[90D]
fosinopril &
1
[90D]
hydrochlorothiazide
lisinopril
1
[90D]
lisinopril &
1
[90D]
hydrochlorothiazide
moexipril
1
[90D]
moexipril &
1
[90D]
hydrochlorothiazide
perindopril
1
[90D]
quinapril
1
[90D]
quinapril &
1
[90D]
hydrochlorothiazide
ramipril
1
[90D]
trandolapril
1
[90D]
Angiotensin II Receptor Antagonists
AZOR
3
[ST] [90D]
BENICAR
3
[ST] [90D]
BENICAR HCT
3
[ST] [90D]
irbesartan
1
[90D]
irbesartan hct
1
[90D]
losartan
1
[90D]
losartan hct
1
[90D]
valsartan hct
2
[90D]
valsartan & amlodipine
2
[ST] [90D]
valsartan & amlodipine &
2
[ST] [90D]
hct
Nombre del Medicamento
Nivel
Drug Name
Drug Requirements/
Tier Limits
Nombre del Medicamento
Nivel
Requisitos/
Límites
Antiarrhythmics
amiodarone tabs 200mg &
2
400mg
disopyramide phosphate
2
flecainide acetate
2
mexiletine
2
pacerone tabs 200mg
2
procainamide inj
2
propafenone
2
quinidine gluconate cr
2
quinidine gluconate inj
2
quinidine sulfate
2
sorine
2
sotalol tabs
2
TIKOSYN
4
Beta-adrenergic Blocking Agents
acebutolol
2
atenolol
1
atenolol & chlorthalidone
1
bisoprolol
2
bisoprolol &
2
hydrochlorothiazide
carvedilol
1
COREG CR
3
DUTOPROL
3
labetalol oral
2
labetalol inj
2
metoprolol succinate er
2
metoprolol tartrate tabs
1
metoprolol &
2
hydrochlorothiazide
nadolol
2
nadolol &
2
bendroflumethiazide
pindolol
2
propranolol ir tabs
1
propranolol er caps
2
propranolol oral soln
2
propranolol inj
2
[PA] = Autorización Previa [B vs D] = B versus D [QL] = Límite de Cantidad [ST] = Tratamiento Escalonado
[90D] = Suministro para 90 Días [LD] = Distribución Limitada
Puede encontrar información sobre el significado de los símbolos y abreviaturas de esta tabla en la página LX.
14
[90D]
[PA] [90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
Drug Name
Drug Requirements/
Tier Limits
Nombre del Medicamento
Nivel
Requisitos/
Límites
[90D]
propranolol &
1
hydrochlorothiazide
timolol oral
1
Calcium Channel Blocking Agents
afeditab cr
2
amlodipine
1
amlodipine & atorvastatin
2
amlodipine & benazepril
2
cartia xt
2
diltiazem tabs
2
diltiazem cd caps 120mg,
2
180mg, 240mg, & 300mg
diltiazem er caps
2
diltiazem inj 50mg/10ml
2
dilt-xr
2
felodipine er
2
isradipine
2
nicardipine caps
2
nifedical xl
2
nifedipine
2
nifedipine er
2
nimodipine caps
2
nisoldipine
2
nisoldipine er
2
taztia xt
2
verapamil ir
1
verapamil er
2
verapamil sr
2
verapamil inj
2
Cardiovascular Agents, Other
DEMSER
5
digitek
2
digoxin oral
2
digoxin inj
2
LANOXIN INJ
3
LANOXIN ORAL
3
NORTHERA
5
Drug Name
Drug Requirements/
Tier Limits
Nombre del Medicamento
Nivel
Requisitos/
Límites
[90D]
[PA] [90D]
[PA]
[ST] [90D]
[ST] [90D]
pentoxifylline er
2
RANEXA
3
REPATHA INJ
5
TEKTURNA
3
TEKTURNA HCT
3
Diuretics, Loop
bumetanide oral
2
[90D]
furosemide oral
1
[90D]
furosemide inj
2
[90D]
torsemide oral
2
[90D]
Diuretics, Potassium-sparing
amiloride
2
[90D]
amiloride &
1
[90D]
hydrochlorothiazide
eplerenone
2
[90D]
spironolactone
1
[90D]
spironolactone &
1
[90D]
hydrochlorothiazide
triamterene &
1
[90D]
hydrochlorothiazide
Diuretics, Thiazide
chlorothiazide tabs
2
[90D]
chlorthalidone
1
[90D]
hydrochlorothiazide
1
[90D]
indapamide
1
[90D]
metolazone
2
[90D]
Dyslipidemics, Fibric Acid Derivatives
fenofibrate caps 43mg &
2
[QL] [90D]
130mg
fenofibrate micronized
2
[QL] [90D]
fenofibrate tabs
2
[QL] [90D]
fenofibric acid dr caps
2
[QL] [90D]
gemfibrozil
2
[90D]
Dyslipidemics, HMG CoA Reductase Inhibitors
ADVICOR
3
[QL] [90D]
atorvastatin
2
[90D]
lovastatin
1
[90D]
pravastatin
1
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[PA] [90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[PA]
[PA] [90D]
[PA] [90D]
[PA] [90D]
[PA] [90D]
[PA] [90D]
[PA]
[PA] = Prior Authorization [B vs D] = B versus D [QL] = Quantity Limit [ST] = Step Therapy [90D] = 90-Day Supply
[LD] = Limited Distribution
You can find information on what the symbols and abbreviations on this table mean by going to page XXIX.
15
Drug Name
Drug Requirements/
Tier Limits
Nombre del Medicamento
Nivel
Requisitos/
Límites
[90D]
[90D]
Drug Name
Drug Requirements/
Tier Limits
Nombre del Medicamento
Nivel
Requisitos/
Límites
[QL] [90D]
dextroamphetamine
2
sulfate er
zenzedi tabs 5mg & 10mg
2
[QL] [90D]
Attention Deficit Hyperactivity Disorder
Agents, Non-amphetamines
clonidine er
2
[PA] [90D]
dexmethylphenidate ir tabs
2
[90D]
metadate er
2
[90D]
methylphenidate er tabs
2
[90D]
10mg & 20mg
methylphenidate ir tabs
2
[90D]
5mg, 10mg & 20mg
STRATTERA
4
[PA] [90D]
Central nervous system, Other
HETLIOZ
5
[PA]
NUEDEXTA
3
[90D]
riluzole
3
[90D]
tetrabenazine
5
[PA]
XENAZINE
5
[PA]
Fibromyalgia Agents
SAVELLA
3
[90D]
SAVELLA TITRATION
3
[90D]
PACK
Multiple Sclerosis Agents
AMPYRA
5
[PA]
AVONEX INJ
5
[PA]
AVONEX PEN INJ
5
[PA]
BETASERON INJ
5
GILENYA
5
[PA]
glatopa inj
5
[PA]
PLEGRIDY INJ
5
[PA]
PLEGRIDY STARTER
5
[PA]
PACK INJ
REBIF INJ
5
[PA]
REBIF REBIDOSE INJ
5
[PA]
REBIF REBIDOSE
5
[PA]
TITRATION PACK INJ
REBIF TITRATION PACK
5
[PA]
INJ
TECFIDERA
5
[PA]
SIMCOR
3
simvastatin
1
Dyslipidemics, Other
cholestyramine
2
[90D]
cholestyramine light
2
[90D]
colestipol granules
2
[90D]
colestipol tabs
2
[90D]
JUXTAPID
5
[PA] [LD]
KYNAMRO
5
[PA] [LD]
niacin er tabs
2
[QL] [90D]
omega-3-acid ethyl esters
2
[90D]
prevalite
2
[90D]
WELCHOL
4
[90D]
ZETIA
3
[QL] [90D]
Vasodilators, Direct-acting Arterial
hydralazine oral
2
[90D]
hydralazine inj
2
[90D]
minoxidil
2
[90D]
Vasodilators, Direct-acting Arterial/Venous
isosorbide dinitrate
2
[90D]
isosorbide dinitrate er
2
[90D]
isosorbide mononitrate
2
[90D]
isosorbide mononitrate er
2
[90D]
minitran patches
2
[90D]
nitro-bid oint
2
[90D]
NITRO-DUR PATCHES
3
[90D]
nitroglycerin inj
2
[90D]
nitroglycerin lingual
2
[90D]
nitroglycerin patches
2
[90D]
NITROSTAT
3
[90D]
CENTRAL NERVOUS SYSTEM AGENTS
Attention Deficit Hyperactivity Disorder
Agents, Amphetamines
amphetamine &
2
[QL] [90D]
dextroamphetamine tabs
dexedrine tabs
2
[QL] [90D]
dextroamphetamine
2
[QL] [90D]
sulfate
[PA] = Autorización Previa [B vs D] = B versus D [QL] = Límite de Cantidad [ST] = Tratamiento Escalonado
[90D] = Suministro para 90 Días [LD] = Distribución Limitada
Puede encontrar información sobre el significado de los símbolos y abreviaturas de esta tabla en la página LX.
16
Drug Name
Drug Requirements/
Tier Limits
Nombre del Medicamento
Nivel
TECFIDERA STARTER
5
PACK
TYSABRI INJ
5
DENTAL AND ORAL AGENTS
Dental and Oral Agents
cevimeline
2
chlorhexidine gluconate
2
pilocarpine tabs
2
triamcinolone in orabase
2
DERMATOLOGICAL AGENTS
Dermatological Agents
acitretin
5
ammonium lactate topical
2
amnesteem
2
calcipotriene cream & oint
3
calcipotriene soln
3
calcipotriene &
5
betamethasone oint
CARAC
5
clindamycin topical cream,
2
gel, lotion, soln & swab
clindamycin & benzoyl
2
peroxide topical
diclofenac sodium gel
5
ELIDEL
4
FLUOROURACIL 0.5%
5
CREAM
fluorouracil 2% and 5%
3
topical
imiquimod
3
methoxsalen
2
podofilox
2
prudoxin
2
REGRANEX
5
SANTYL
3
selenium sulfide lotion
2
sulfacetamide sodium
2
susp 10%
tacrolimus oint
3
Drug Name
Requisitos/
Límites
[PA]
Drug Requirements/
Tier Limits
Requisitos/
Límites
TAZORAC
4
[QL] [90D]
TOLAK
3
[90D]
VOLTAREN GEL 1%
3
[90D]
ZONALON
3
[90D]
ENZYME REPLACEMENTS/ MODIFIERS
Enzyme Replacement/ Modifiers
ADAGEN INJ
5
[PA]
ALDURAZYME INJ
5
[PA]
BUPHENYL TABS
5
CERDELGA
5
[PA]
CREON DR
3
[90D]
CYSTADANE
4
[90D]
CYSTAGON
3
[90D]
FABRAZYME INJ
5
KUVAN
5
LUMIZYME INJ
5
[PA]
NAGLAZYME INJ
5
[PA] [LD]
ORFADIN
5
[PA] [LD]
RAVICTI
5
sodium phenylbutyrate
5
powder
SUCRAID
5
VPRIV INJ
5
[PA]
ZAVESCA
5
[PA] [LD]
GASTROINTESTINAL AGENTS
Antispasmodics, Gastrointestinal
atropine sulfate inj
2
[90D]
dicyclomine oral
2
[90D]
glycopyrrolate oral
2
[90D]
glycopyrrolate inj
2
[90D]
Gastrointestinal Agents, Other
amoxicillin &
3
[90D]
clarithromycin &
lansoprazole
cromolyn sodium oral
2
[90D]
diphenoxylate & atropine
2
[90D]
GATTEX INJ
5
[PA]
loperamide caps 2mg
2
[90D]
Nombre del Medicamento
[PA]
[90D]
[90D]
[90D]
[90D]
[PA]
[90D]
[90D]
[QL] [90D]
[90D]
[90D]
[90D]
[QL] [90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[QL]
[90D]
[90D]
[90D]
[90D]
Nivel
[PA] = Prior Authorization [B vs D] = B versus D [QL] = Quantity Limit [ST] = Step Therapy [90D] = 90-Day Supply
[LD] = Limited Distribution
You can find information on what the symbols and abbreviations on this table mean by going to page XXIX.
17
Drug Name
Drug Requirements/
Tier Limits
Requisitos/
Límites
MOVANTIK
3
[90D]
RELISTOR INJ
4
[PA] [90D]
ursodiol
3
[90D]
Histamine2 (H2) Receptor Antagonists
cimetidine oral
2
[90D]
famotidine tabs
1
[90D]
famotidine inj
2
[90D]
ranitidine caps & syrup
2
[90D]
ranitidine tabs
1
[90D]
ranitidine inj
2
[90D]
Irritable Bowel Syndrome Agents
alosetron hcl tabs 0.5mg
3
[PA] [90D]
alosetron hcl tabs 1mg
5
[PA]
AMITIZA
3
[90D]
LINZESS
3
[90D]
Laxatives
constulose soln
2
[90D]
enulose
2
[90D]
gavilyte-c
2
[90D]
gavilyte-g
2
[90D]
gavilyte-n
2
[90D]
generlac
2
[90D]
lactulose
2
[90D]
MOVIPREP
3
[90D]
OSMOPREP
3
[90D]
peg 3350 & electrolytes
2
[90D]
peg 3350 & sodium
2
[90D]
chloride & sodium
bicarbonate & potassium
chloride
polyethylene glycol 3350
2
[90D]
PREPOPIK
3
[90D]
SUPREP BOWEL PREP
3
[90D]
Protectants
misoprostol
2
[90D]
sucralfate
2
[90D]
Nombre del Medicamento
Nivel
Drug Name
Drug Requirements/
Tier Limits
Nombre del Medicamento
Nivel
Requisitos/
Límites
Proton Pump Inhibitors
esomeprazole magnesium
2
[ST] [QL]
dr caps
[90D]
lansoprazole dr caps
2
[QL] [90D]
omeprazole caps
2
[90D]
pantoprazole tabs
2
[90D]
PROTONIX INJ
3
[90D]
GENITOURINARY AGENTS
Antispasmodics, Urinary
flavoxate
2
[90D]
GELNIQUE
3
[90D]
MYRBETRIQ
3
[90D]
oxybutynin
2
[90D]
oxybutynin er
2
[QL] [90D]
OXYTROL
4
[90D]
tolterodine tartrate er
2
[QL] [90D]
TOVIAZ
3
[90D]
VESICARE
3
[90D]
Benign Prostatic Hypertrophy Agents
alfuzosin hcl er
2
[90D]
doxazosin
2
[90D]
dutasteride
2
[90D]
dutasteride & tamsulosin
2
[90D]
finasteride tabs 5mg
2
[90D]
prazosin
2
[90D]
tamsulosin
2
[90D]
terazosin
1
[90D]
Genitourinary Agents, Other
bethanechol
2
[90D]
ELMIRON
4
[90D]
THIOLA
3
[90D]
Phosphate Binders
calcium acetate
2
[90D]
eliphos
2
[90D]
FOSRENOL
3
[90D]
RENVELA
3
[90D]
sevelamer carbonate
2
[90D]
[PA] = Autorización Previa [B vs D] = B versus D [QL] = Límite de Cantidad [ST] = Tratamiento Escalonado
[90D] = Suministro para 90 Días [LD] = Distribución Limitada
Puede encontrar información sobre el significado de los símbolos y abreviaturas de esta tabla en la página LX.
18
Drug Name
Drug Requirements/
Tier Limits
Requisitos/
Límites
HORMONAL AGENTS, STIMULANT/
REPLACEMENT/ MODIFYING (ADRENAL)
Glucocorticoids/ Mineralocorticoids
alclometasone
2
[90D]
dipropionate
betamethasone
2
[90D]
dipropionate
betamethasone
2
[90D]
dipropionate augmented
betamethasone valerate
2
[90D]
cream, oint, lotion
CAPEX SHAMPOO
4
[90D]
clobetasol propionate
3
[90D]
foam, gel, oint, soln
clobetasol propionate
3
[90D]
emollient cream
cormax scalp application
3
[90D]
cortisone
2
[90D]
desonide
2
[90D]
desoximetasone
2
[90D]
dexamethasone tabs
2
[90D]
dexamethasone elixir
2
[90D]
dexamethasone inj
2
[90D]
dexpak
2
[90D]
diflorasone diacetate
2
[90D]
fludrocortisone acetate
2
[90D]
fluocinolone acetonide
2
[90D]
fluocinonide cream 0.05%
2
[90D]
fluocinonide-e
2
[90D]
fluocinonide gel, oint &
2
[90D]
soln
fluticasone propionate
2
[90D]
cream & oint
halobetasol
2
[90D]
hydrocortisone 2.5%
2
[90D]
cream, lotion, oint
hydrocortisone butyrate
2
[90D]
oint & soln
hydrocortisone oral
2
[90D]
hydrocortisone valerate
2
[90D]
Nombre del Medicamento
Nivel
Drug Name
Drug Requirements/
Tier Limits
Nombre del Medicamento
Nivel
Requisitos/
Límites
[90D]
[90D]
methylprednisolone oral
2
methylprednisolone
2
sodium succinate inj
mometasone cream & oint
2
[90D]
prednicarbate
2
[90D]
prednisolone oral soln
2
[90D]
prednisone tabs
1
[90D]
prednisone oral soln
2
[90D]
procto-pak
2
[90D]
proctosol hc
2
[90D]
proctozone-hc
2
[90D]
SOLU-CORTEF INJ
4
[90D]
triamcinolone acetonide inj
2
[90D]
triamcinolone acetonide
2
[90D]
topical cream, lotion & oint
triderm
2
[90D]
HORMONAL AGENTS, STIMULANT/
REPLACEMENT/ MODIFYING (PITUITARY)
Hormonal Agents, Stimulant/ Replacement/
Modifying (Pituitary)
desmopressin acetate
2
[90D]
nasal
desmopressin acetate oral
2
[90D]
desmopressin acetate inj
2
[90D]
GENOTROPIN INJ
5
[PA]
GENOTROPIN
4
[PA] [90D]
MINIQUICK INJ 0.2MG,
0.4MG, 0.6MG, 0.8MG
GENOTROPIN
5
[PA]
MINIQUICK INJ 1MG,
1.2MG, 1.4MG, 1.6MG,
1.8MG, & 2MG
HUMATROPE INJ 6MG
4
[PA] [90D]
CARTRIDGE
HUMATROPE INJ 5MG
5
[PA]
VIAL, 12MG & 24MG
CARTRIDGE
INCRELEX INJ
5
[PA]
STIMATE
4
[90D]
[PA] = Prior Authorization [B vs D] = B versus D [QL] = Quantity Limit [ST] = Step Therapy [90D] = 90-Day Supply
[LD] = Limited Distribution
You can find information on what the symbols and abbreviations on this table mean by going to page XXIX.
19
Drug Name
Drug Requirements/
Tier Limits
Requisitos/
Límites
HORMONAL AGENTS, STIMULANT/
REPLACEMENT/ MODIFYING
(PROSTAGLANDINS)
Hormonal Agents, Stimulant/ Replacement/
Modifying (Prostaglandins)
KORLYM
5
[PA]
HORMONAL AGENTS, STIMULANT/
REPLACEMENT/ MODIFYING (SEX
HORMONES/ MODIFIERS)
Anabolic Steroids
ANADROL-50
5
[PA]
oxandrolone
2
[90D]
Androgens
ANDROGEL
3
[90D]
danazol
2
[90D]
testosterone cypionate inj
2
[90D]
testosterone enanthate inj
2
[90D]
testosterone gel 1%
3
[90D]
Estrogens
ALORA
3
[PA] [90D]
apri
2
[90D]
aranelle
2
[90D]
aubra
2
[90D]
aviane
2
[90D]
bekyree
2
[90D]
blisovi fe 1/20
2
[90D]
briellyn
2
[90D]
cesia
2
[90D]
cyclafem 1/35
2
[90D]
cyclafem 7/7/7
2
[90D]
delyla
2
[90D]
desogestrel & ethinyl
2
[90D]
estradiol
emoquette
2
[90D]
enpresse-28
2
[90D]
ESTRACE VAGINAL
3
[90D]
estradiol oral
2
[PA] [90D]
estradiol patches
3
[PA] [90D]
Nombre del Medicamento
Nivel
Drug Name
Drug Requirements/
Tier Limits
Nombre del Medicamento
Nivel
estradiol & norethindrone
acetate
estropipate
falmina
gildagia
gildess
introvale
jinteli
junel
kariva
kimidess
larin
larin fe
leena
levonest
levonorgestrel & ethinyl
estradiol 0.1-0.02mg, 0.150.03mg, & 0.125-0.03mg
packs
levora
low-ogestrel
marlissa 28 day
MENEST
microgestin 1/20 & 1.5/30
mimvey
mimvey lo
necon
orsythia 28 day
pimtrea
pirmella 1/35
PREMARIN ORAL
PREMARIN VAGINAL
PREMPHASE
PREMPRO
setlakin
tarina fe
tri-sprintec
trivora-28
3
Requisitos/
Límites
[PA] [90D]
2
2
2
2
2
3
2
2
2
2
2
2
2
2
[PA] [90D]
[90D]
[90D]
[90D]
[90D]
[PA] [90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
2
2
2
4
2
3
3
2
2
2
2
4
3
4
4
2
2
2
2
[90D]
[90D]
[90D]
[PA] [90D]
[90D]
[PA] [90D]
[PA] [90D]
[90D]
[90D]
[90D]
[90D]
[PA] [90D]
[90D]
[PA] [90D]
[PA] [90D]
[90D]
[90D]
[90D]
[90D]
[PA] = Autorización Previa [B vs D] = B versus D [QL] = Límite de Cantidad [ST] = Tratamiento Escalonado
[90D] = Suministro para 90 Días [LD] = Distribución Limitada
Puede encontrar información sobre el significado de los símbolos y abreviaturas de esta tabla en la página LX.
20
Drug Name
Drug Requirements/
Tier Limits
Nombre del Medicamento
Nivel
Drug Name
Requisitos/
Límites
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
Drug Requirements/
Tier Limits
Requisitos/
Límites
HORMONAL AGENTS, SUPPRESSANT
(ADRENAL)
Hormonal Agents, Suppressant (Adrenal)
LYSODREN
3
[90D]
HORMONAL AGENTS, SUPPRESSANT
(PARATHYROID)
Hormonal Agents, Suppressant (Parathyroid)
SENSIPAR TABS 30MG
3
[QL] [90D]
SENSIPAR TABS 60MG &
5
90MG
HORMONAL AGENTS, SUPPRESSANT
(PITUITARY)
Hormonal Agents, Suppressant (Pituitary)
cabergoline
2
[90D]
ELIGARD INJ
4
[90D]
leuprolide acetate inj
2
[90D]
LUPRON DEPOT INJ
5
7.5MG, 11.25MG,
22.5MG, 30MG & 45MG
octreotide inj 50mcg/ml,
2
[90D]
100mcg/ml & 200mcg/ml
octreotide inj 500mcg/ml &
5
1000mcg/ml
SIGNIFOR INJ
5
[PA]
SOMATULINE DEPOT
5
[PA]
INJ
SOMAVERT INJ
5
[PA]
SYNAREL
4
[90D]
HORMONAL AGENTS, SUPPRESSANT
(THYROID)
Antithyroid Agents
methimazole
2
[90D]
propylthiouracil
2
[90D]
IMMUNOLOGICAL AGENTS
Angioedema (HAE) Agents
CINRYZE INJ
5
[PA] [B vs D]
FIRAZYR INJ
5
[PA]
Immune Suppressants
azathioprine oral
2
[PA] [B vs D]
[90D]
Nombre del Medicamento
VAGIFEM
3
velivet
2
vyfemla
2
wymzya fe
2
zenchent
2
zenchent fe
2
zovia
2
Progestins
deblitane
2
[90D]
DEPO-PROVERA INJ
4
[90D]
400MG/ML
lyza
2
[90D]
medroxyprogesterone
2
[90D]
acetate inj
medroxyprogesterone
2
[90D]
acetate tabs
megestrol acetate oral
2
[90D]
susp
megestrol tabs
2
[90D]
norethindrone
2
[90D]
norlyroc
2
[90D]
progesterone caps
2
[90D]
sharobel
2
[90D]
Selective Estrogen Receptor Modifying Agents
raloxifene hcl
2
[QL] [90D]
HORMONAL AGENTS, STIMULANT/
REPLACEMENT/ MODIFYING (THYROID)
Hormonal Agents, Stimulant/ Replacement/
Modifying (Thyroid)
CYTOMEL
3
[90D]
levothyroxine tabs
1
[90D]
levoxyl
1
[90D]
liothyronine tabs
2
[90D]
SYNTHROID
3
[90D]
THYROLAR
3
[90D]
unithroid
1
[90D]
Nivel
[PA] = Prior Authorization [B vs D] = B versus D [QL] = Quantity Limit [ST] = Step Therapy [90D] = 90-Day Supply
[LD] = Limited Distribution
You can find information on what the symbols and abbreviations on this table mean by going to page XXIX.
21
Drug Name
Drug Requirements/
Tier Limits
Nombre del Medicamento
Nivel
BENLYSTA INJ
cyclosporine modified
5
2
cyclosporine oral
2
ENBREL INJ
ENBREL SURECLICK INJ
gengraf
5
5
2
HUMIRA INJ
HUMIRA PEN-CROHNS
INJ
KINERET INJ
methotrexate inj
methotrexate oral
mycophenolate mofetil
caps & tabs
mycophenolate mofetil oral
susp
mycophenolic acid dr
5
5
NEORAL
4
NULOJIX INJ
RAPAMUNE SOLN
5
4
REMICADE INJ
SANDIMMUNE ORAL
SOLN 100MG/ML
SANDIMMUNE CAPS
25MG & 100MG
sirolimus tabs
5
4
5
2
2
2
5
3
4
3
tacrolimus caps 0.5mg &
3
1mg
tacrolimus caps 5mg
5
ZORTRESS TABS
4
0.25MG
ZORTRESS TABS 0.5MG
5
& 0.75MG
Immunizing Agents, Passive
ATGAM INJ
5
Requisitos/
Límites
[PA]
[PA] [B vs D]
[90D]
[PA] [B vs D]
[90D]
[PA]
[PA]
[PA] [B vs D]
[90D]
[PA]
[PA]
[PA]
[90D]
[90D]
[PA] [B vs D]
[90D]
[PA] [B vs D]
[PA] [B vs D]
[90D]
[PA] [B vs D]
[90D]
[PA]
[PA] [B vs D]
[90D]
[PA]
[PA] [B vs D]
[90D]
[PA] [B vs D]
[90D]
[PA] [B vs D]
[90D]
[PA] [B vs D]
[90D]
[PA] [B vs D]
[PA] [B vs D]
[90D]
[PA] [B vs D]
[PA]
Drug Name
Drug Requirements/
Tier Limits
Nombre del Medicamento
Nivel
GAMMAGARD INJ
GAMUNEX-C INJ
Immunomodulators
ACTIMMUNE INJ
ARCALYST INJ
ILARIS INJ
leflunomide
OTEZLA
OTEZLA STARTER
RIDAURA
SYNAGIS INJ
XELJANZ
Vaccines
ACTHIB INJ
ADACEL INJ
BEXSERO INJ
BOOSTRIX INJ
CERVARIX INJ
COMVAX INJ
DAPTACEL INJ
DIPHTHERIA & TETANUS
TOXOIDS PEDIATRIC INJ
ENGERIX-B INJ
5
5
GARDASIL INJ
GARDASIL 9 INJ
HAVRIX INJ
IMOVAX RABIES INJ
4
4
3
3
INFANRIX INJ
IPOL INACTIVATED IPV
INJ
IXIARO INJ
MENACTRA INJ
MENOMUNE-A/C/Y/W135 INJ
MENVEO-A/C/Y/W-135
INJ
M-M-R II INJ
Requisitos/
Límites
[PA] [B vs D]
[PA] [B vs D]
5
5
5
2
5
5
5
5
5
[PA]
[PA]
[QL] [90D]
[PA]
[PA]
[PA]
3
3
3
3
4
3
3
3
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
3
3
3
[PA] [B vs D]
[90D]
[90D]
[90D]
[90D]
[PA] [B vs D]
[90D]
[90D]
[90D]
4
3
3
[90D]
[90D]
[90D]
3
[90D]
3
[90D]
[PA] = Autorización Previa [B vs D] = B versus D [QL] = Límite de Cantidad [ST] = Tratamiento Escalonado
[90D] = Suministro para 90 Días [LD] = Distribución Limitada
Puede encontrar información sobre el significado de los símbolos y abreviaturas de esta tabla en la página LX.
22
Drug Name
Drug Requirements/
Tier Limits
Nombre del Medicamento
Nivel
PEDVAX HIB INJ
PROQUAD INJ
QUADRACEL INJ
RABAVERT INJ
3
3
3
3
RECOMBIVAX HB INJ
3
Drug Name
Requisitos/
Límites
[90D]
[90D]
[90D]
[PA] [B vs D]
[90D]
[PA] [B vs D]
[90D]
[90D]
[90D]
[90D]
[90D]
Drug Requirements/
Tier Limits
Requisitos/
Límites
METABOLIC BONE DISEASE AGENTS
Metabolic Bone Disease Agents
alendronate tabs
1
[90D]
alendronate oral soln
2
[90D]
calcitonin-salmon nasal
2
[90D]
calcitriol caps
2
[PA] [B vs D]
[90D]
doxercalciferol oral
3
[PA] [B vs D]
[90D]
doxercalciferol inj
3
[PA] [B vs D]
[90D]
etidronate
2
[90D]
FORTEO INJ
5
[PA]
fortical nasal
2
[90D]
ibandronate inj
2
[PA] [B vs D]
[90D]
ibandronate oral
2
[ST] [90D]
MIACALCIN INJ
4
[PA] [B vs D]
[90D]
pamidronate inj
2
[PA] [B vs D]
[90D]
paricalcitol caps
2
[PA] [B vs D]
[90D]
PROLIA
4
[PA] [90D]
risedronate sodium
3
[ST] [90D]
risedronate sodium dr
3
[ST] [90D]
XGEVA INJ
5
[PA]
zoledronic acid inj
3
[90D]
4mg/5ml
zoledronic acid inj
2
[PA] [90D]
5mg/100ml
ZOMETA INJ 4MG/100ML
5
MISCELLANEOUS THERAPEUTIC AGENTS
Miscellaneous Therapeutic Agents
alcohol pads
2
[90D]
bd insulin syringe ultrafine
2
[90D]
bd insulin syringe
2
[90D]
safetyglide
bd pen needle ultrafine
2
[90D]
BRISDELLE
3
[90D]
Nombre del Medicamento
ROTARIX
3
ROTATEQ
3
TENIVAC
3
TETANUS & DIPHTHERIA
3
TOXOIDS-ADSORBED
ADULT INJ
TRUMENBA INJ
3
[90D]
TWINRIX INJ
3
[90D]
TYPHIM VI INJ
3
[90D]
VAQTA INJ
3
[90D]
VARIVAX INJ
3
[90D]
YF-VAX INJ
3
[90D]
ZOSTAVAX INJ
4
[90D]
INFLAMMATORY BOWEL DISEASE AGENTS
Aminosalicylates
APRISO
4
[QL] [90D]
balsalazide
2
[90D]
DELZICOL
4
[QL] [90D]
DIPENTUM
5
mesalamine enema kit
3
[90D]
PENTASA
4
[QL] [90D]
Glucocorticoids
budesonide ec caps
5
[PA]
hydrocortisone enema
2
[90D]
prednisone tabs
1
[90D]
prednisone oral soln
2
[90D]
Sulfonamides
sulfasalazine
2
[90D]
sulfazine
2
[90D]
sulfazine ec
2
[90D]
Nivel
[PA] = Prior Authorization [B vs D] = B versus D [QL] = Quantity Limit [ST] = Step Therapy [90D] = 90-Day Supply
[LD] = Limited Distribution
You can find information on what the symbols and abbreviations on this table mean by going to page XXIX.
23
Drug Name
Drug Requirements/
Tier Limits
Nombre del Medicamento
Nivel
FERRIPROX
gauze pads 2"x2"
levocarnitine oral
5
2
2
levocarnitine inj
2
NATPARA
OPHTHALMIC AGENTS
Ophthalmic Agents, Other
atropine sulfate soln
bacitracin
bacitracin & polymyxin b
ciprofloxacin soln 0.3%
erythromycin oint
garamycin soln
gentamicin oint 0.3% &
soln 0.3%
ilotycin oint
LACRISERT
neomycin & bacitracin &
polymyxin b
neomycin & polymyxin &
gramicidin
ofloxacin
polymyxin b sulfate &
trimethoprim sulfate soln
RESTASIS
5
Requisitos/
Límites
[PA]
[90D]
[PA] [B vs D]
[90D]
[PA] [B vs D]
[90D]
[PA] [LD]
2
2
2
2
2
2
2
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
2
4
2
[90D]
[90D]
[90D]
2
[90D]
2
2
[90D]
[90D]
3
[PA] [QL]
[90D]
[90D]
sulfacetamide sodium oint
2
& soln 10%
tobramycin sulfate
2
trifluridine
2
VIGAMOX
3
Ophthalmic Anti-allergy Agents
azelastine
2
cromolyn sodium
2
olopatadine soln 0.1%
2
PATADAY
3
PATANOL
3
Drug Name
Drug Requirements/
Tier Limits
Nombre del Medicamento
Nivel
Requisitos/
Límites
Ophthalmic Antiglaucoma Agents
acetazolamide tabs
2
[90D]
acetazolamide er caps
2
[90D]
ALPHAGAN P 0.1%
3
[90D]
betaxolol soln
2
[90D]
brimonidine tartrate soln
2
[90D]
0.15% & 0.2%
carteolol
1
[90D]
COMBIGAN
3
[ST] [90D]
dorzolamide
2
[90D]
dorzolamide & timolol
2
[90D]
maleate
levobunolol
2
[90D]
methazolamide
2
[90D]
metipranolol
2
[90D]
PHOSPHOLINE IODIDE
3
[90D]
pilocarpine soln
2
[90D]
timolol ophthalmic gel
2
[90D]
forming
timolol soln
1
[90D]
Ophthalmic Anti-inflammatories
BLEPHAMIDE
3
[90D]
BLEPHAMIDE S.O.P.
3
[90D]
dexamethasone soln
2
[90D]
diclofenac sodium soln
2
[90D]
DUREZOL
3
[90D]
fluorometholone
2
[90D]
ketorolac soln 0.4% &
2
[QL] [90D]
0.5%
neomycin & polymyxin &
2
[90D]
dexamethasone
neomycin & polymyxin &
2
[90D]
bacitracin &
hydrocortisone
PRED MILD
3
[90D]
prednisolone acetate
2
[90D]
prednisolone sodium
2
[90D]
phosphate
[90D]
[90D]
[90D]
[90D]
[90D]
[QL] [90D]
[90D]
[QL] [90D]
[PA] = Autorización Previa [B vs D] = B versus D [QL] = Límite de Cantidad [ST] = Tratamiento Escalonado
[90D] = Suministro para 90 Días [LD] = Distribución Limitada
Puede encontrar información sobre el significado de los símbolos y abreviaturas de esta tabla en la página LX.
24
Drug Name
Drug Requirements/
Tier Limits
Nombre del Medicamento
Nivel
Requisitos/
Límites
[90D]
sulfacetamide sodium &
2
prednisolone sodium
phosphate
TOBRADEX OINT
3
[90D]
tobramycin &
2
[90D]
dexamethasone
Ophthalmic Prostaglandin and Prostamide
Analogs
latanoprost
1
[90D]
LUMIGAN
3
[ST] [QL]
[90D]
OTIC AGENTS
Otic Agents
acetasol hc
2
[90D]
acetic acid &
2
[90D]
hydrocortisone
CIPRO HC
3
[90D]
CIPRODEX
3
[90D]
neomycin & polymyxin &
2
[90D]
hydrocortisone
ofloxacin
2
[90D]
RESPIRATORY TRACT/PULMONARY AGENTS
Antihistamines
azelastine nasal
2
[90D]
cyproheptadine
2
[PA] [90D]
desloratadine
2
[90D]
desloratadine odt
2
[90D]
diphenhydramine hcl inj
2
[90D]
levocetirizine
2
[QL] [90D]
Anti-inflammatories, Inhaled Corticosteroids
ADVAIR DISKUS
3
[90D]
ADVAIR HFA
3
[90D]
ASMANEX HFA
3
[90D]
ASMANEX TWISTHALER
3
[90D]
BREO ELLIPTA
3
[90D]
budesonide nebulizer
2
[PA] [B vs D]
[90D]
DULERA
3
[90D]
flunisolide nasal
2
[QL] [90D]
Drug Name
Drug Requirements/
Tier Limits
Nombre del Medicamento
Nivel
Requisitos/
Límites
[QL] [90D]
fluticasone propionate
2
nasal
NASONEX
3
[QL] [90D]
QVAR
3
[90D]
Antileukotrienes
montelukast
2
[90D]
zafirlukast
2
[QL] [90D]
ZYFLO CR
3
[QL] [90D]
Bronchodilators, Anticholinergic
ATROVENT HFA
3
[QL] [90D]
COMBIVENT RESPIMAT
3
[QL] [90D]
ipratropium bromide nasal
2
[QL] [90D]
ipratropium bromide
2
[PA] [B vs D]
nebulizer
[90D]
ipratropium bromide &
2
[PA] [B vs D]
albuterol sulfate nebulizer
[90D]
SPIRIVA HANDIHALER
3
[90D]
SPIRIVA RESPIMAT
3
[90D]
TUDORZA PRESSAIR
3
[90D]
Phosphodiesterase Inhibitors, Airways
Disease
aminophylline inj
2
[90D]
DALIRESP
3
[90D]
theophylline cr & er tabs
2
[90D]
Bronchodilators, Sympathomimetic
albuterol sulfate nebulizer
2
[PA] [B vs D]
[90D]
albuterol sulfate er
3
[90D]
albuterol sulfate syrup
2
[90D]
albuterol sulfate tabs
3
[90D]
AUVI-Q INJ
3
[90D]
EPIPEN INJ
3
[90D]
EPIPEN-JR INJ
3
[90D]
FORADIL AEROLIZER
3
[90D]
levalbuterol nebulizer
2
[PA] [B vs D]
[90D]
PROAIR HFA
3
[90D]
PROAIR RESPICLICK
3
[90D]
SEREVENT DISKUS
3
[90D]
[PA] = Prior Authorization [B vs D] = B versus D [QL] = Quantity Limit [ST] = Step Therapy [90D] = 90-Day Supply
[LD] = Limited Distribution
You can find information on what the symbols and abbreviations on this table mean by going to page XXIX.
25
Drug Name
Drug Requirements/
Tier Limits
Nombre del Medicamento
Nivel
STRIVERDI RESPIMAT
3
terbutaline sulfate oral
2
terbutaline sulfate inj
2
Cystic Fibrosis Agents
CAYSTON
5
KALYDECO
5
ORKAMBI
5
PULMOZYME
5
TOBI PODHALER
5
tobramycin nebulizer
5
Mast Cell Stabilizers
cromolyn sodium nebulizer
2
soln
Pulmonary Antihypertensives
ADCIRCA
5
ADEMPAS
5
LETAIRIS
5
OPSUMIT
5
REMODULIN INJ
5
sildenafil tabs 20mg
3
TRACLEER
5
Respiratory Tract Agents, Other
acetylcysteine nebulizer
2
Requisitos/
Límites
[90D]
[90D]
[90D]
Drug Name
Drug Requirements/
Tier Limits
Nombre del Medicamento
Nivel
Requisitos/
Límites
[90D]
[90D]
[PA]
temazepam
2
triazolam
2
zolpidem tabs 5mg &
2
10mg
Sleep Disorders, Other
BELSOMRA
3
[QL] [90D]
modafinil
3
[PA] [90D]
ROZEREM
3
[QL] [90D]
SILENOR
3
[QL] [90D]
XYREM
5
[LD]
THERAPEUTIC NUTRIENTS/ MINERALS/
ELECTROLYTES
Electrolyte/Mineral Modifiers
CARBAGLU
5
[PA] [LD]
CUPRIMINE
4
[90D]
DEPEN TITRATABS
4
[90D]
EXJADE
5
[PA]
JADENU
5
[PA]
kionex
2
[90D]
sodium polystyrene
2
[90D]
sulfonate
SYPRINE
5
Electrolyte/Mineral Replacement
AMINOSYN INJ
3
[PA] [B vs D]
[90D]
AMINOSYN &
3
[PA] [B vs D]
ELECTROLYTES INJ
[90D]
CLINISOL SF INJ
4
[PA] [B vs D]
[90D]
dextrose inj
2
[90D]
dextrose & sodium
2
[90D]
chloride inj
dextrose & lactated ringers
2
[90D]
inj
INTRALIPID INJ
4
[PA] [B vs D]
[90D]
klor-con
2
[90D]
klor-con sprinkle
2
[90D]
lactated ringers inj
2
[90D]
magnesium sulfate inj
2
[90D]
[PA] [LD]
[PA]
[PA]
[PA] [B vs D]
[PA] [B vs D]
[PA] [B vs D]
[90D]
[PA]
[PA] [LD]
[PA] [LD]
[PA] [LD]
[PA]
[PA]
[PA] [LD]
[PA] [B vs D]
[90D]
[90D]
[PA]
[PA]
[PA] [LD]
ANORO ELLIPTA
3
ESBRIET
5
OFEV
5
PROLASTIN C INJ
5
VIRAZOLE
5
SKELETAL MUSCLE RELAXANTS
Skeletal Muscle Relaxants
chlorzoxazone
2
[PA] [90D]
cyclobenzaprine hcl
2
[PA] [90D]
methocarbamol
2
[PA] [90D]
SLEEP DISORDER AGENTS
GABA Receptor Modulators
estazolam
2
[90D]
flurazepam
2
[90D]
[PA] = Autorización Previa [B vs D] = B versus D [QL] = Límite de Cantidad [ST] = Tratamiento Escalonado
[90D] = Suministro para 90 Días [LD] = Distribución Limitada
Puede encontrar información sobre el significado de los símbolos y abreviaturas de esta tabla en la página LX.
26
Drug Name
Drug Requirements/
Tier Limits
Nombre del Medicamento
Nivel
MOZOBIL INJ
plenamine inj
5
2
potassium chloride oral
soln
potassium chloride er
potassium chloride inj
potassium chloride &
dextrose & lactated ringers
inj
potassium chloride &
dextrose & sodium
chloride inj
20mEq/5%/0.45% &
30mEq/5%/0.45%
potassium chloride viaflex
inj
potassium citrate er
PROSOL INJ
2
Requisitos/
Límites
[PA]
[PA] [B vs D]
[90D]
[90D]
2
2
2
[90D]
[90D]
[90D]
2
[90D]
2
[90D]
2
4
sodium chloride inj
TPN ELECTROLYTES INJ
TRAVASOL INJ
2
3
4
[90D]
[PA] [B vs D]
[90D]
[90D]
[90D]
[PA] [B vs D]
[90D]
Vitamins
prenatal multi-vitamin
2
[90D]
[PA] = Prior Authorization [B vs D] = B versus D [QL] = Quantity Limit [ST] = Step Therapy [90D] = 90-Day Supply
[LD] = Limited Distribution
You can find information on what the symbols and abbreviations on this table mean by going to page XXIX.
27
FORMULARY DRUGS WITH QUANTITY LIMITS
MEDICAMENTOS DEL FORMULARIO CON LÍMITES DE CANTIDAD
Drugs with Quantity Limits
Medicamentos con Límites de Cantidad
Drug Name
Nombre del Medicamento
acetaminophen & codeine #2 & #3 tabs
acetaminophen & codeine #4 tabs
acetaminophen & codeine elixir
ADVICOR
AGGRENOX
amphetamine & dextroamphetamine
APRISO
ATROVENT HFA
BELSOMRA
BRILINTA
butorphanol tartrate nasal
calcipotriene cream
calcipotriene oint
COLCHICINE
COLCRYS
COMBIVENT RESPIMAT
DELZICOL CAPS 400MG
dexedrine tabs
dextroamphetamine sulfate
dextroamphetamine sulfate er
dipyridamole & aspirin
ELIDEL
endocet tabs 5-325mg, 7.5-325mg, 10-325mg
endodan
esomeprazole magnesium dr caps
EXELON PATCHES
fenofibrate
fenofibrate micronized
fenofibric acid dr
fentanyl patches
flunisolide nasal
fluticasone propionate nasal
galantamine
galantamine er
Quantity Limits
Límites de Cantidad
372 tabs per 31 days
186 tabs per 31 days
5166ml per 31 days
31 tabs per 31 days
62 caps per 31 days
62 tabs per 31 days
124 caps per 31 days
2 inhalers per 31 days
31 tabs per 31 days
62 tabs per 31 days
4 bottles per 31 days
120gm: 1 tube per 31 days
60gm: 2 tubes per 31 days
124 caps or tabs per 31 days
124 tabs per 31 days
2 inhalers per 31 days
186 caps per 31 days
5mg: 124 tabs per 31 days; 10mg: 186 tabs per 31 days
5mg: 124 tabs per 31 days; 10mg: 186 tabs per 31 days
5mg: 31 caps per 31 days; 10mg & 15mg: 124 caps per
31 days
62 caps per 31 days
100gm: 2 tubes per 31 days
5-325mg: 372 tabs per 31 days; 7.5-325mg: 248 tabs
per 31 days; 10-325mg: 186 tabs per 31 days
372 tabs per 31 days
31 caps per 31 days
30 patches per 30 days
31 caps or tabs per 31 days
31 caps per 31 days
45mg: 62 caps per 31 days; 135mg: 31 caps per 31
days
15 patches per 31 days
2 bottles per 31 days
2 bottles per 31 days
62 tabs per 31 days
31 caps per 31 days
VillageHealth | 2016 Formulary
28
Drugs with Quantity Limits
Medicamentos con Límites de Cantidad
Drug Name
Nombre del Medicamento
galantamine oral soln
glimepiride & pioglitazone tabs
hydrocodone & acetaminophen soln 7.5325mg/15ml
hydrocodone & acetaminophen tabs 5325mg,7.5-325mg, & 10-325mg
hydrocodone & ibuprofen tabs 5-200mg, 7.5200mg, & 10-200mg
ipratropium bromide nasal
ketorolac ophth soln 0.4%
ketorolac ophth soln 0.5%
lansoprazole dr caps
leflunomide
levocetirizine
lorcet hd tabs 10-325mg
lorcet plus tabs 7.5-325mg
lorcet tabs 5-325mg
lortab tabs 5-325mg,7.5-325mg, & 10-325mg
LUMIGAN
morphine sulfate er tabs
naratriptan
NASONEX
NEUPRO PATCH
niacin er tabs
olopatadine soln 0.1%
oxybutynin er
oxycodone & acetaminophen tabs 2.5-325mg,
5-325mg, 7.5-325mg, & 10-325mg
oxycodone & aspirin tabs
oxycodone & ibuprofen tabs
OXYCONTIN
oxymorphone er
PATANOL
PENTASA
raloxifene hcl
REGRANEX
Quantity Limits
Límites de Cantidad
200ml per 31 days
31 tabs per 31 days
2790ml per 31 days
5-325mg: 372 tabs per 31 days; 7.5-325mg & 10-325mg:
186 tabs per 31 days
155 tabs per 31 days
1 bottle per 31 days
3 bottles per 31 days
2 bottles per 31 days
62 caps per 31 days
31 tabs per 31 days
31 tabs per 31 days; 296ml per 28 days
186 tabs per 31 days
186 tabs per 31 days
372 tabs per 31 days
5-325mg: 372 tabs per 31 days; 7.5-325mg & 10-325mg:
186 tabs per 31 days
1 bottle per 31 days
124 tabs per 31 days
9 tabs per 31 days
3 bottles per 31 days
30 patches per 30 days
500mg: 93 tabs per 31 days; 750mg & 1000mg: 62 tabs
per 31 days
3 bottles per 31 days
5mg: 31 tabs per 31 days; 10mg & 15mg: 62 tabs per 31
days
2.5-325mg & 5-325mg: 372 tabs per 31 days; 7.5325mg: 248 tabs per 31 days; 10-325mg: 186 tabs per
31 days
372 tabs per 31 days
124 tabs per 31 days
10mg, 15mg, 20mg, 30mg, 40mg, 60mg: 62 tabs per 31
days; 80mg: 124 tabs per 31 days
62 tabs per 31 days
3 bottles per 31 days
248 caps per 31 days
31 tabs per 31 days
2 tubes per 31 days
VillageHealth | 2016 Formulary
29
Drugs with Quantity Limits
Medicamentos con Límites de Cantidad
Drug Name
Nombre del Medicamento
RESTASIS
rivastigmine caps
rivastigmine patches
ROZEREM
SENSIPAR TABS 30MG
SILENOR
TAZORAC
tolterodine tartrate er
tramadol & acetaminophen 37.5-325mg tabs
tramadol er
XIFAXAN TABS 200MG
zafirlukast
zamicet
zenzedi tabs 5mg & 10mg
ZETIA
ZOMIG NASAL
ZYFLO CR
Quantity Limits
Límites de Cantidad
60 vials per 30 days
62 caps per 31 days
30 patches per 30 days
31 tabs per 31 days
62 tabs per 31 days
31 tabs per 31 days
60gm & 100gm: 1 tube per 31 days
31 caps per 31 days
248 tabs per 31 days
31 tabs per 31 days
9 tabs per 3 days
62 tabs per 31 days
2790ml per 31 days
5mg: 124 tabs per 31 days; 10mg: 186 tabs per 31 days
31 tabs per 31 days
2.5mg: 18 single use units per 31 days; 5mg: 12 single
use units per 31 days
124 tabs per 31 days
VillageHealth | 2016 Formulary
30
INDEX
ÍNDICE
abacavir & lamivudine & zidovudine, 11
abacavir tabs, 11
ABELCET INJ, 6
ABILIFY INJ, 10
ABILIFY MAINTENA, 10
ABILIFY ORAL SOLN, 10
acamprosate calcium dr, 2
acarbose, 12
acebutolol, 14
acetaminophen & codeine, 1, 28
acetasol hc, 25
acetazolamide, 24
acetazolamide er caps, 24
acetazolamide tabs, 24
acetic acid & hydrocortisone, 25
acetylcysteine nebulizer, 26
acitretin, 17
ACTHIB INJ, 22
ACTIMMUNE INJ, 22
acyclovir inj, 11
acyclovir oint 5%, 11
acyclovir oral, 11
ADACEL INJ, 22
ADAGEN INJ, 17
ADCIRCA, 26
adefovir dipivoxil, 10
ADEMPAS, 26
ADVAIR DISKUS, 25
ADVAIR HFA, 25
ADVICOR, 15, 28
afeditab cr, 15
AFINITOR, 8
AFINITOR DISPERZ, 8
AGGRENOX, 13, 28
ALBENZA, 9
albuterol sulfate er, 25
albuterol sulfate nebulizer, 25
albuterol sulfate syrup, 25
albuterol sulfate tabs, 25
alclometasone dipropionate, 19
alcohol pads, 23
ALDURAZYME INJ, 17
ALECENSA, 8
alendronate oral soln, 23
alendronate tabs, 23
alfuzosin hcl er, 18
ALIMTA INJ, 8
ALINIA, 9
allopurinol, 7
ALORA, 20
alosetron hcl tabs 0.5mg, 18
alosetron hcl tabs 1mg, 18
ALPHAGAN P 0.1%, 24
alprazolam er tabs, 12
alprazolam intensol, 12
alprazolam tabs, 12
amantadine, 9
AMBISOME INJ, 6
amifostine inj, 8
amikacin inj, 2
amiloride, 15
amiloride & hydrochlorothiazide, 15
aminophylline inj, 25
AMINOSYN & ELECTROLYTES INJ, 26
AMINOSYN INJ, 26
amiodarone tabs 200mg & 400mg, 14
AMITIZA, 18
amitriptyline, 6
amlodipine, 15
amlodipine & atorvastatin, 15
amlodipine & benazepril, 15
ammonium lactate topical, 17
amnesteem, 17
amoxapine, 6
amoxicillin, 3
amoxicillin & clarithromycin & lansoprazole, 17
amoxicillin & clavulanate potassium, 3
amoxicillin & clavulanate potassium er, 3
VillageHealth | 2016 Formulary
31
amphetamine & dextroamphetamine, 28
amphetamine & dextroamphetamine tabs, 16
amphotericin b inj, 6
ampicillin & sulbactam inj 10-5gm, 2-1gm, & 10.5gm, 3
ampicillin inj, 3
ampicillin oral, 3
AMPYRA, 16
ANADROL-50, 20
anagrelide, 13
anastrozole, 8
ANDROGEL, 20
ANORO ELLIPTA, 26
APOKYN INJ, 9
apri, 20
APRISO, 23, 28
APTIOM, 4
APTIVUS, 11
aranelle, 20
ARCALYST INJ, 22
aripiprazole, 10
aripiprazole 20mg & 30mg, 10
aripiprazole odt, 10
ASMANEX HFA, 25
ASMANEX TWISTHALER, 25
atenolol, 14
atenolol & chlorthalidone, 14
ATGAM INJ, 22
atorvastatin, 15
atovaquone, 9
atovaquone/proguanil, 9
ATRIPLA, 11
atropine sulfate inj, 17
atropine sulfate soln, 24
ATROVENT HFA, 25, 28
aubra, 20
AUVI-Q INJ, 25
AVASTIN INJ, 9
aviane, 20
AVONEX INJ, 16
AVONEX PEN INJ, 16
azacitidine inj, 8
azathioprine oral, 21
azelastine, 24
azelastine nasal, 25
AZILECT, 9
azithromycin inj, 3
azithromycin tabs & oral susp, 3
AZOR, 14
aztreonam inj 1gm, 3
bacitracin, 24
bacitracin & polymyxin b, 24
baclofen, 10
BACTROBAN CREAM, 2
BACTROBAN NASAL, 2
balsalazide, 23
BANZEL, 4
BARACLUDE ORAL SOLN 0.05MG/ML, 10
bd insulin syringe safetyglide, 23
bd insulin syringe ultrafine, 23
bd pen needle ultrafine, 23
bekyree, 20
BELEODAQ, 8
BELSOMRA, 26, 28
benazepril, 14
benazepril & hydrochlorothiazide, 14
BENICAR, 14
BENICAR HCT, 14
BENLYSTA INJ, 22
benztropine inj, 9
benztropine tabs, 9
betamethasone dipropionate, 19
betamethasone dipropionate augmented, 19
betamethasone valerate cream, oint, lotion, 19
BETASERON INJ, 16
betaxolol soln, 24
bethanechol, 18
bexarotene, 9
BEXSERO INJ, 22
bicalutamide, 8
BICILLIN L-A INJ, 3
bisoprolol, 14
bisoprolol & hydrochlorothiazide, 14
BLEPHAMIDE, 24
BLEPHAMIDE S.O.P., 24
blisovi fe 1/20, 20
BOOSTRIX INJ, 22
BOSULIF, 8
VillageHealth | 2016 Formulary
32
carbamazepine tabs, chewable tabs & oral susp,
5
carbidopa, 9
carbidopa & levodopa, 9
carbidopa & levodopa & entacapone, 9
carbidopa & levodopa er, 9
carbidopa & levodopa odt, 9
carteolol, 24
cartia xt, 15
carvedilol, 14
CAYSTON, 26
cefaclor, 3
cefaclor er, 3
cefadroxil caps & tabs, 3
cefazolin inj, 3
cefdinir, 3
cefepime inj, 3
cefixime, 3
cefoxitin sodium, 3
cefpodoxime tabs, 3
cefprozil, 3
ceftazidime inj 1gm, 2gm & 6gm, 3
ceftriaxone inj, 3
cefuroxime inj, 3
cefuroxime oral, 3
celecoxib, 2
CELONTIN, 4
cephalexin caps & tabs 250mg & 500mg, 3
cephalexin oral susp, 3
CERDELGA, 17
CERVARIX INJ, 22
cesia, 20
cevimeline, 17
CHANTIX, 2
CHANTIX STARTING MONTH PAK, 2
chloramphenicol sodium succinate inj, 2
chlorhexidine gluconate, 17
chloroquine, 9
chlorothiazide tabs, 15
chlorpromazine inj, 9
chlorpromazine oral, 9
chlorthalidone, 15
chlorzoxazone, 26
BREO ELLIPTA, 25
briellyn, 20
BRILINTA, 13, 28
brimonidine tartrate soln 0.15% & 0.2%, 24
BRINTELLIX, 5
BRISDELLE, 23
bromocriptine, 9
budeprion sr, 5
budesonide ec caps, 23
budesonide nebulizer, 25
bumetanide oral, 15
BUPHENYL TABS, 17
buprenorphine & naloxone sublingual tabs, 2
buprenorphine inj, 2
buprenorphine oral, 2
buproban, 2
bupropion, 5
bupropion sr, 5
bupropion xl, 5
buspirone, 12
butorphanol tartrate inj, 1
butorphanol tartrate nasal, 1, 28
BYDUREON INJ, 12
BYETTA INJ, 12
cabergoline, 21
calcipotriene & betamethasone oint, 17
calcipotriene cream, 28
calcipotriene cream & oint, 17
calcipotriene oint, 28
calcipotriene soln, 17
calcitonin-salmon nasal, 23
calcitriol caps, 23
calcium acetate, 18
CANCIDAS INJ, 6
CAPASTAT INJ, 7
CAPEX SHAMPOO, 19
CAPRELSA, 8
captopril, 14
captopril & hydrochlorothiazide, 14
CARAC, 17
CARBAGLU, 26
carbamazepine er tabs & caps, 5
VillageHealth | 2016 Formulary
33
cholestyramine, 16
cholestyramine light, 16
ciclopirox 8% nail soln, 6
ciclopirox cream, susp, shampoo, 6
cilastatin/imipenem inj, 3
cilostazol, 13
cimetidine oral, 18
CINRYZE INJ, 21
CIPRO HC, 25
CIPRODEX, 25
ciprofloxacin inj, 4
ciprofloxacin oral susp, 4
ciprofloxacin soln 0.3%, 24
ciprofloxacin tabs er, 4
ciprofloxacin tabs immediate-release, 4
citalopram oral soln, 5
citalopram tabs, 5
clarithromycin, 3
clarithromycin er, 3
CLEOCIN VAGINAL, 2
clindamycin & benzoyl peroxide topical, 17
clindamycin oral, 2
clindamycin phosphate inj, 2
clindamycin topical cream, gel, lotion, soln &
swab, 17
CLINISOL SF INJ, 26
clobetasol propionate emollient cream, 19
clobetasol propionate foam, gel, oint, soln, 19
clomipramine, 6
clonazepam, 4
clonazepam odt, 4
clonidine er, 16
clonidine patches, 13
clonidine tabs immediate-release, 13
clopidogrel tabs 75mg, 13
clorazepate, 4
clotrimazole & betamethasone, 6
clotrimazole 1% cream, 6
clotrimazole 1% topical soln, 6
clotrimazole troche, 6
clozapine, 10
clozapine odt, 10
COARTEM, 9
codeine, 1
COLCHICINE, 7
COLCHICINE, 28
COLCRYS, 7, 28
colestipol granules, 16
colestipol tabs, 16
colistimethate inj, 2
COMBIGAN, 24
COMBIVENT RESPIMAT, 25, 28
COMETRIQ, 8
COMPLERA, 11
compro, 6
COMVAX INJ, 22
constulose soln, 18
COREG CR, 14
cormax scalp application, 19
cortisone, 19
CORTISPORIN CREAM & OINT, 2
COTELLIC, 8
COUMADIN ORAL, 13
CREON DR, 17
CRESEMBA INJ, 6
CRESEMBA ORAL, 6
CRIXIVAN, 11
cromolyn sodium, 24, 26
cromolyn sodium nebulizer soln, 26
cromolyn sodium oral, 17
CUBICIN INJ, 2
CUPRIMINE, 26
cyclafem 1/35, 20
cyclafem 7/7/7, 20
cyclobenzaprine hcl, 26
cyclophosphamide caps, 7
CYCLOSET, 12
cyclosporine modified, 22
cyclosporine oral, 22
cyproheptadine, 25
CYSTADANE, 17
CYSTAGON, 17
CYTOMEL, 21
DAKLINZA, 10
DALIRESP, 25
danazol, 20
DAPSONE, 7
DAPTACEL INJ, 22
VillageHealth | 2016 Formulary
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dicyclomine oral, 17
didanosine, 11
diflorasone diacetate, 19
diflunisal, 2
digitek, 15
digoxin inj, 15
digoxin oral, 15
dihydroergotamine mesylate inj, 7
dilantin caps 100mg, 5
DILANTIN CAPS 30MG, 5
DILANTIN INFATABS, 5
DILANTIN SUSP, 5
diltiazem cd caps 120mg, 180mg, 240mg, &
300mg,, 15
diltiazem er caps, 15
diltiazem inj 50mg/10ml, 15
diltiazem tabs, 15
dilt-xr, 15
DIPENTUM, 23
diphenhydramine hcl inj, 25
diphenoxylate & atropine, 17
DIPHTHERIA & TETANUS TOXOIDS
PEDIATRIC INJ, 22
dipyridamole & aspirin, 28
dipyridamole & aspirin, 13
dipyridamole oral, 13
disopyramide phosphate, 14
disulfiram, 2
divalproex sodium, 4
divalproex sodium dr, 4
divalproex sodium er, 4
donepezil odt, 5
donepezil tabs 5mg & 10mg, 5
dorzolamide, 24
dorzolamide & timolol maleate, 24
doxazosin, 13, 18
doxepin, 6
doxercalciferol inj, 23
doxercalciferol oral, 23
doxy 100 inj, 4
doxycycline immediate-release tabs, caps & oral
susp, 4
doxycycline inj, 4
DARAPRIM, 9
deblitane, 21
delyla, 20
DELZICOL, 23
DELZICOL CAPS 400MG, 28
demeclocycline, 4
DEMSER, 15
DENAVIR, 11
DEPEN TITRATABS, 26
DEPO-PROVERA INJ 400MG/ML, 21
desipramine, 6
desloratadine, 25
desloratadine odt, 25
desmopressin acetate inj, 19
desmopressin acetate nasal, 19
desmopressin acetate oral, 19
desogestrel & ethinyl estradiol, 20
desonide, 19
desoximetasone, 19
DESVENLAFAXINE ER, 5
dexamethasone elixir, 19
dexamethasone inj, 19
dexamethasone soln, 24
dexamethasone tabs, 19
dexedrine tabs, 16
dexedrine tabs, 28
dexmethylphenidate ir tabs, 16
dexpak, 19
dextroamphetamine sulfate, 16, 28
dextroamphetamine sulfate er, 16, 28
dextrose & lactated ringers inj, 26
dextrose & sodium chloride inj, 26
dextrose inj, 26
diazepam intensol, 12
diazepam rectal gel, 4
diazepam tabs & soln, 12
diclofenac potassium, 2
diclofenac sodium, 2, 24
diclofenac sodium dr, 2
diclofenac sodium er, 2
diclofenac sodium gel, 17
diclofenac sodium soln, 24
dicloxacillin sodium, 3
VillageHealth | 2016 Formulary
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dronabinol, 6
DULERA, 25
duloxetine hcl, 5
duramorph inj, 1
DUREZOL, 24
dutasteride, 18
dutasteride & tamsulosin, 18
DUTOPROL, 14
econazole nitrate, 7
EDURANT, 11
ELIDEL, 17, 28
ELIGARD INJ, 21
eliphos, 18
ELMIRON, 18
EMCYT, 8
EMEND, 6
emoquette, 20
EMSAM, 5
EMTRIVA, 11
enalapril, 14
enalapril & hydrochlorothiazide, 14
ENBREL INJ, 22
ENBREL SURECLICK INJ, 22
endocet, 1
endocet, 28
endodan, 1
endodan, 28
ENGERIX-B INJ, 22
enoxaparin inj 30mg/0.3ml, 40mg/0.4ml,
60mg/0.6ml, 80mg/0.8ml & 300mg/3ml, 13
enoxaparin inj100mg/ml, 120mg/0.8ml &
150mg/ml, 13
enpresse-28, 20
entacapone, 9
entecavir tabs, 10
enulose, 18
EPIPEN INJ, 25
EPIPEN-JR INJ, 25
epitol, 5
EPIVIR HBV SOLN 5MG/ML, 10
eplerenone, 15
EPZICOM, 11
ergoloid mesylates, 5
ERGOMAR, 7
ERIVEDGE, 8
ERWINAZE INJ, 8
ERYTHROCIN LACTOBIONATE INJ, 3
erythrocin stearate, 3
erythromycin & sulfisoxazole, 4
erythromycin oint, 24
erythromycin oral, 3
erythromycin topical gel & soln, 3
ESBRIET, 26
escitalopram, 5
esomeprazole magnesium dr caps, 18
esomeprazole magnesium dr caps, 28
estazolam, 26
ESTRACE VAGINAL, 20
estradiol & norethindrone acetate, 20
estradiol oral, 20
estradiol patches, 20
estropipate, 20
ethambutol, 7
ethosuximide, 4
etidronate, 23
etodolac, 2
etodolac er, 2
etoposide inj, 8
EURAX, 9
EVOTAZ, 11
EVZIO, 2
EXELON PATCHES, 5, 28
exemestane, 8
EXJADE, 26
FABRAZYME INJ, 17
falmina, 20
famciclovir, 11
famotidine inj, 18
famotidine tabs, 18
FANAPT, 10
FANAPT TITRATION PACK, 10
FARESTON, 8
FARXIGA, 12
FARYDAK, 8
FASLODEX INJ, 8
FAZACLO, 10
felbamate tabs 400mg, 4
felbamate tabs 600mg & oral susp 600mg/5ml, 4
VillageHealth | 2016 Formulary
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felodipine er, 15
fenofibrate, 15, 28
fenofibrate caps 43mg & 130mg, 15
fenofibrate micronized, 15, 28
fenofibrate tabs, 15
fenofibric acid dr caps, 15
fentanyl citrate lozenges 200mcg, 1
fentanyl citrate lozenges 400mcg, 600mcg,
800mcg, 1200mcg & 1600mcg, 1
fentanyl patches, 28
fentanyl patches 12mcg/hr, 25mcg/hr, 50mcg/hr,
75mcg/hr, 100mcg/hr, 1
FERRIPROX, 24
FETZIMA, 5
FETZIMA TITRATION PACK, 5
finasteride tabs 5mg, 18
FIRAZYR INJ, 21
flavoxate, 18
flecainide acetate, 14
fluconazole in dextrose inj, 7
fluconazole oral, 7
flucytosine, 7
fludrocortisone acetate, 19
flunisolide nasal, 25, 28
fluocinolone acetonide, 19
fluocinonide, 19
fluocinonide cream 0.05%, 19
fluocinonide gel, oint & soln, 19
fluocinonide-e, 19
fluorometholone, 24
FLUOROURACIL 0.5% CREAM, 17
fluorouracil topical, 17
fluoxetine hcl caps 10mg, 20mg & 40mg, 5
fluoxetine hcl oral soln, 5
fluoxetine hcl tabs 10mg & 20mg, 5
fluphenazine decanoate inj, 9
fluphenazine inj, 10
fluphenazine oral, 9
flurazepam, 26
flutamide, 8
fluticasone propionate cream & oint, 19
fluticasone propionate nasal, 25, 28
fluvoxamine, 6
fluvoxamine er, 6
fondaparinux inj, 13
FORADIL AEROLIZER, 25
FORFIVO XL, 5
FORTEO INJ, 23
fortical nasal, 23
fosinopril, 14
fosinopril & hydrochlorothiazide, 14
fosphenytoin sodium inj, 5
FOSRENOL, 18
furosemide inj, 15
furosemide oral, 15
FUZEON INJ, 11
FYCOMPA, 4
gabapentin caps & oral soln, 4
gabapentin tabs, 4
GABITRIL TABS 12MG & 16MG, 4
galantamine, 5, 28
galantamine er, 5, 28
galantamine oral soln, 5, 29
GAMMAGARD INJ, 22
GAMUNEX-C INJ, 22
ganciclovir inj, 10
garamycin soln, 24
GARDASIL 9 INJ, 22
GARDASIL INJ, 22
GATTEX INJ, 17
gauze pads 2x2, 24
gavilyte-c, 18
gavilyte-g, 18
gavilyte-n, 18
GELNIQUE, 18
gemfibrozil, 15
generlac, 18
gengraf, 22
GENOTROPIN INJ, 19
GENOTROPIN MINIQUICK INJ 0.2MG, 0.4MG,
0.6MG, 0.8MG, 19
GENOTROPIN MINIQUICK INJ 1MG, 1.2MG,
1.4MG, 1.6MG, 1.8MG, & 2MG, 19
gentamicin cream 0.1% & oint 0.1%, 2
gentamicin inj, 2
gentamicin oint 0.3% & soln 0.3%, 24
VillageHealth | 2016 Formulary
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GENVOYA, 11
GEODON INJ, 10
gildagia, 20
gildess, 20
GILENYA, 16
GILOTRIF, 8
glatopa inj, 16
GLEEVEC, 8
GLEOSTINE, 7
glimepiride, 12
glimepiride & pioglitazone, 12
glimepiride & pioglitazone tabs, 29
glipizide, 12
glipizide & metformin tabs, 12
glipizide er, 12
GLUCAGON EMERGENCY KIT INJ, 12
glycopyrrolate inj, 17
glycopyrrolate oral, 17
granisetron inj, 6
granisetron oral, 6
griseofulvin microsize, 7
guanfacine, 13
guanidine, 7
halobetasol, 19
haloperidol decanoate inj, 10
haloperidol lactate inj, 10
haloperidol lactate oral soln, 10
haloperidol tabs, 10
HARVONI, 10
HAVRIX INJ, 22
heparin inj, 13
HERCEPTIN INJ, 9
HETLIOZ, 16
HEXALEN, 7
HUMALOG CARTRIDGE INJ, 12
HUMALOG KWIKPEN INJ, 12
HUMALOG MIX 50/50 KWIKPEN INJ, 13
HUMALOG MIX 50/50 VIAL INJ, 13
HUMALOG MIX 75/25 KWIKPEN INJ, 13
HUMALOG MIX 75/25 VIAL INJ, 13
HUMALOG VIAL INJ, 13
HUMATROPE INJ 5MG VIAL, 12MG & 24MG
CARTRIDGE, 19
HUMATROPE INJ 6MG CARTRIDGE, 19
HUMIRA INJ, 22
HUMIRA PEN-CROHNS INJ, 22
HUMULIN 70/30 KWIKPEN INJ, 13
HUMULIN 70/30 VIAL INJ, 13
HUMULIN N KWIKPEN INJ, 13
HUMULIN N VIAL INJ, 13
HUMULIN R U-500 (CONCENTRATED) VIAL
INJ, 13
HUMULIN R VIAL INJ, 13
hydralazine inj, 16
hydralazine oral, 16
hydrochlorothiazide, 15
hydrocodone & acetaminophen soln, 1, 29
hydrocodone & acetaminophen tabs, 1, 29
hydrocodone & ibuprofen, 1, 29
hydrocortisone 2.5% cream, lotion, oint, 19
hydrocortisone butyrate oint & soln, 19
hydrocortisone enema, 23
hydrocortisone oral, 19
hydrocortisone valerate, 19
hydromorphone immediate-release oral soln &
tabs, 1
hydromorphone inj, 1
hydroxychloroquine, 9
hydroxyurea, 8
ibandronate inj, 23
ibandronate oral, 23
IBRANCE, 8
ibuprofen, 2
ICLUSIG, 8
ILARIS INJ, 22
ilotycin oint, 24
IMBRUVICA, 8
imipramine hcl tabs, 6
imiquimod, 17
IMOVAX RABIES INJ, 22
INCRELEX INJ, 19
indapamide, 15
indomethacin, 2
indomethacin er, 2
indomethacin ir caps, 2
INFANRIX INJ, 22
INLYTA, 8
INTELENCE 100MG & 200MG TABS, 11
VillageHealth | 2016 Formulary
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KALETRA TABS 200MG-50MG & SOLN 400100MG/5ML, 12
KALYDECO, 26
kariva, 20
ketoconazole, 7
ketorolac inj, 2
ketorolac oral, 2
ketorolac soln 0.4%, 29
ketorolac soln 0.4% & 0.5%, 24
ketorolac soln 0.5%, 29
KEYTRUDA INJ, 9
KHEDEZLA, 6
kimidess, 20
KINERET INJ, 22
kionex, 26
klor-con, 26
klor-con sprinkle, 26
KOMBIGLYZE XR, 12
KORLYM, 20
KUVAN, 17
KYNAMRO, 16
labetalol inj, 14
labetalol oral, 14
LACRISERT, 24
lactated ringers inj, 26
lactulose, 18
lamivudine, 10, 11
lamivudine & zidovudine, 11
lamotrigine immediate-release tabs, 4
LANOXIN INJ, 15
LANOXIN ORAL, 15
lansoprazole dr caps, 18, 29
LANTUS SOLOSTAR PEN INJ, 13
LANTUS VIAL INJ, 13
larin, 20
larin fe, 20
latanoprost, 25
LATUDA, 10
LAZANDA, 1
leena, 20
leflunomide, 22, 29
LENVIMA, 8
LETAIRIS, 26
INTELENCE 25MG TAB, 11
INTRALIPID INJ, 26
INTRON-A INJ, 10
introvale, 20
INVANZ INJ, 3
INVEGA ORAL, 10
INVEGA SUSTENNA 117MG, 156MG & 234MG,
10
INVEGA SUSTENNA 39MG & 78MG, 10
INVIRASE, 11
INVOKAMET, 12
INVOKANA, 12
IPOL INACTIVATED IPV INJ, 22
ipratropium bromide & albuterol sulfate nebulizer,
25
ipratropium bromide nasal, 25, 29
ipratropium bromide nebulizer, 25
irbesartan, 14
irbesartan hct, 14
IRESSA, 8
ISENTRESS CHEW TABS, 11
ISENTRESS ORAL POWDER, 11
ISENTRESS TABS, 11
isoniazid oral, 7
isosorbide dinitrate, 16
isosorbide dinitrate er, 16
isosorbide mononitrate, 16
isosorbide mononitrate er, 16
isradipine, 15
itraconazole, 7
ivermectin, 9
IXIARO INJ, 22
JADENU, 26
JAKAFI, 8
jantoven, 13
JANUMET, 12
JANUMET XR, 12
JANUVIA, 12
jinteli, 20
junel, 20
JUXTAPID, 16
KALETRA TABS 100-25MG, 12
VillageHealth | 2016 Formulary
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letrozole, 8
leucovorin inj, 8
leucovorin oral, 8
LEUKERAN, 7
LEUKINE INJ, 13
leuprolide acetate inj, 21
levalbuterol nebulizer, 25
levetiracetam er, 4
levetiracetam inj, 4
levetiracetam oral, 4
levobunolol, 24
levocarnitine inj, 24
levocarnitine oral, 24
levocetirizine, 25, 29
levofloxacin inj, 4
levofloxacin oral soln, 4
levofloxacin tabs, 4
levoleucovorin inj, 8
levonest, 20
levonorgestrel & ethinyl estradiol 0.1-0.02mg,
0.15-0.03mg, & 0.125-0.03mg packs, 20
levora, 20
levothyroxine tabs, 21
levoxyl, 21
LEXIVA ORAL SUSP, 12
LEXIVA TABS, 12
lidocaine & prilocaine, 1
lidocaine hcl inj, 1
lidocaine hcl topical, 1
lidocaine patch, 1
linezolid inj, 2
linezolid oral, 2
LINZESS, 18
liothyronine tabs, 21
lisinopril, 14
lisinopril & hydrochlorothiazide, 14
lithium carbonate, 12
lithium carbonate er, 12
lithium citrate, 12
LOMUSTINE, 7
LONSURF, 8
loperamide caps 2mg, 17
lorazepam intensol, 12
lorazepam tabs, 12
lorcet hd tabs, 1, 29
lorcet plus tabs, 1, 29
lorcet tabs, 1, 29
lortab tabs, 1, 29
losartan, 14
losartan hct, 14
lovastatin, 15
low-ogestrel, 20
loxapine, 10
LUMIGAN, 25, 29
LUMIZYME INJ, 17
LUPRON DEPOT INJ 7.5MG, 11.25MG, 22.5MG,
30MG & 45MG, 21
LYNPARZA, 8
LYRICA, 4
LYSODREN, 21
lyza, 21
magnesium sulfate inj, 26
malathion, 9
maprotiline, 5
marlissa 28 day, 20
MARPLAN, 5
MATULANE, 7
meclizine, 6
medroxyprogesterone acetate inj, 21
medroxyprogesterone acetate tabs, 21
mefloquine, 9
megestrol acetate oral susp, 21
megestrol tabs, 21
MEKINIST, 8
meloxicam oral susp, 2
meloxicam tabs, 2
memantine hcl immediate release, 5
MENACTRA INJ, 22
MENEST, 20
MENOMUNE-A/C/Y/W-135 INJ, 22
MENVEO-A/C/Y/W-135 INJ, 22
mercaptopurine, 8
meropenem inj, 3
mesalamine enema kit, 23
MESNEX TABS, 8
MESTINON SYRUP, 7
MESTINON TIMESPAN, 7
metadate er, 16
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metformin, 12
metformin er tabs 500mg & 750mg, 12
methadone inj, 1
methadone oral, 1
methazolamide, 24
methenamine hippurate, 2
methimazole, 21
methocarbamol, 26
methotrexate inj, 22
methotrexate oral, 22
methoxsalen, 17
methyldopa, 13
methyldopa & hydrochlorothiazide, 13
methyldopate inj, 13
methylphenidate er tabs 10mg & 20mg, 16
methylphenidate ir tabs 5mg, 10mg & 20mg, 16
methylprednisolone oral, 19
methylprednisolone sodium succinate inj, 19
metipranolol, 24
metoclopramide inj, 6
metoclopramide tablets & oral soln, 6
metolazone, 15
metoprolol & hydrochlorothiazide, 14
metoprolol succinate er, 14
metoprolol tartrate tabs, 14
metronidazole inj, 2
metronidazole oral, 2
metronidazole topical, 2
metronidazole vaginal, 2
mexiletine, 14
MIACALCIN INJ, 23
microgestin, 20
midodrine tabs, 13
mimvey, 20
mimvey lo, 20
minitran patches, 16
minocycline ir, 4
minoxidil, 16
mirtazapine, 5
mirtazapine odt, 5
misoprostol, 18
mitoxantrone inj, 8
M-M-R II INJ, 22
modafinil, 26
moderiba 200mg tabs, 11
moderiba dose pack, 11
moexipril, 14
moexipril & hydrochlorothiazide, 14
molindone, 9
mometasone cream & oint, 19
montelukast, 25
morphine sulfate er tabs, 1, 29
morphine sulfate inj vial, 1
morphine sulfate oral, 1
MOVANTIK, 18
MOVIPREP, 18
moxifloxacin oral, 4
MOZOBIL INJ, 27
mupirocin, 2
mycophenolate mofetil caps & tabs, 22
mycophenolate mofetil oral susp, 22
mycophenolic acid dr, 22
MYRBETRIQ, 18
nabumetone, 2
nadolol, 14
nadolol & bendroflumethiazide, 14
nafcillin sodium inj, 3
NAGLAZYME INJ, 17
naloxone inj, 2
naltrexone, 2
NAMENDA, 5
NAMENDA ORAL SOLN, 5
NAMENDA TITRATION PAK, 5
naproxen, 2
naproxen dr, 2
naproxen sodium ir, 2
naratriptan, 7, 29
NARCAN, 2
NASONEX, 25, 29
nateglinide, 12
NATPARA, 24
NEBUPENT NEBULIZER, 9
necon, 20
nefazodone, 5
neomycin & bacitracin & polymyxin b, 24
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neomycin & polymyxin & bacitracin &
hydrocortisone, 24
neomycin & polymyxin & dexamethasone, 24
neomycin & polymyxin & gramicidin, 24
neomycin & polymyxin & hydrocortisone, 25
neomycin sulfate oral, 2
NEORAL, 22
NEUPOGEN INJ, 13
NEUPRO PATCH, 9
NEUPRO PATCH, 29
nevirapine er, 11
nevirapine oral susp, 11
nevirapine tabs, 11
NEXAVAR, 8
niacin er tabs, 16, 29
nicardipine caps, 15
NICOTROL INHALER, 2
NICOTROL NASAL, 2
nifedical xl, 15
nifedipine, 15
nifedipine er, 15
NILANDRON, 8
nimodipine caps, 15
NINLARO, 8
nisoldipine, 15
nisoldipine er, 15
nitro-bid oint, 16
NITRO-DUR PATCHES, 16
nitrofurantoin caps, 3
nitroglycerin inj, 16
nitroglycerin lingual, 16
nitroglycerin patches, 16
NITROSTAT, 16
norethindrone, 21
norlyroc, 21
NORTHERA, 15
nortriptyline oral, 6
NORVIR, 12
NOXAFIL ORAL, 7
NUEDEXTA, 16
NULOJIX INJ, 22
nyamyc, 7
nystatin, 7
nystatin & triamcinolone, 7
octreotide inj 500mcg/ml & 1000mcg/ml, 21
octreotide inj 50mcg/ml, 100mcg/ml & 200mcg/ml,
21
ODOMZO, 8
OFEV, 26
ofloxacin, 24, 25
ofloxacin oral, 4
olanzapine inj 10mg, 10
olanzapine odt, 10
olanzapine tabs, 10
olopatadine soln 0.1%, 24
olopatadine soln 0.1%, 29
OLYSIO, 11
omega-3-acid ethyl esters, 16
omeprazole caps, 18
ONCASPAR INJ, 8
ondansetron inj, 6
ondansetron odt, 6
ondansetron oral soln, 6
ondansetron tabs, 6
ONFI, 4
ONGLYZA, 12
OPSUMIT, 26
ORAP, 10
ORAVIG, 7
ORFADIN, 17
ORKAMBI, 26
orsythia 28 day, 20
OSMOPREP, 18
OTEZLA, 22
OTEZLA STARTER, 22
oxandrolone, 20
oxazepam, 12
oxcarbazepine, 5
oxybutynin, 18, 29
oxybutynin er, 18, 29
oxycodone, 1
oxycodone & acetaminophen, 1, 29
oxycodone & aspirin, 1, 29
oxycodone & ibuprofen, 1
oxycodone & ibuprofen tabs, 29
oxycodone immediate-release, 1
oxycodone oral soln, 1
OXYCONTIN, 1, 29
VillageHealth | 2016 Formulary
42
oxymorphone er, 1, 29
OXYTROL, 18
pacerone tabs 200mg, 14
paclitaxel inj, 8
paliperidone er, 10
pamidronate inj, 23
PANRETIN, 9
pantoprazole tabs, 18
paricalcitol caps, 23
paromomycin, 2
paroxetine er, 6
paroxetine immediate-release, 6
PASER, 7
PATADAY, 24
PATANOL, 24, 29
PAXIL 10MG/5ML SUSP, 6
PEDVAX HIB INJ, 23
peg 3350 & electrolytes, 18
peg 3350 & sodium chloride & sodium
bicarbonate & potassium chloride, 18
PEGANONE, 5
PEGASYS INJ, 11
PEGASYS PROCLICK INJ, 11
PEG-INTRON INJ, 11
PEG-INTRON REDIPEN INJ, 11
penicillin g inj 5 million units, 3
penicillin v potassium, 3
PENTAM INJ, 9
PENTASA, 23, 29
pentoxifylline er, 15
perindopril, 14
permethrin cream, 9
perphenazine, 6, 10
perphenazine & amitriptyline, 6
phenadoz, 6
phenelzine, 5
phenergan suppositories, 6
phenobarbital elixir, 4
phenobarbital tabs, 4
phenytoin chewable tabs, 5
phenytoin er, 5
phenytoin inj, 5
phenytoin oral susp, 5
PHOSPHOLINE IODIDE, 24
pilocarpine soln, 24
pilocarpine tabs, 17
pimozide, 10
pimtrea, 20
pindolol, 14
pioglitazone, 12
pioglitazone & metformin, 12
piperacillin/tazobactam inj 3gm/0.375gm &
4gm/0.5gm, 3
pirmella 1/35, 20
piroxicam, 2
PLEGRIDY INJ, 16
PLEGRIDY STARTER PACK INJ, 16
plenamine inj, 27
podofilox, 17
polyethylene glycol 3350, 18
polymyxin b sulfate & trimethoprim sulfate soln,
24
POMALYST, 8
potassium chloride & dextrose & lactated ringers
inj, 27
potassium chloride & dextrose & sodium chloride
inj 20mEq/5%/0.45% & 30mEq/5%/0.45%, 27
potassium chloride er, 27
potassium chloride inj, 27
potassium chloride oral soln, 27
potassium chloride viaflex inj, 27
potassium citrate er, 27
POTIGA, 4
PRADAXA, 13
pramipexole ir, 9
pravastatin, 15
prazosin, 13, 18
PRED MILD, 24
prednicarbate, 19
prednisolone, 24
prednisolone acetate, 24
prednisolone oral soln, 19
prednisolone sodium phosphate, 24
prednisone oral soln, 19, 23
prednisone tabs, 19, 23
PREMARIN ORAL, 20
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43
propranolol ir tabs, 14
propranolol oral soln, 14
propylthiouracil, 21
PROQUAD INJ, 23
PROTONIX INJ, 18
protriptyline, 6
prudoxin, 17
PULMOZYME, 26
PURIXAN, 8
pyrazinamide, 7
pyridostigmine, 7
pyridostigmine er, 7
QUADRACEL INJ, 23
quetiapine, 10
quinapril, 14
quinapril & hydrochlorothiazide, 14
quinidine gluconate cr, 14
quinidine gluconate inj, 14
quinidine sulfate, 14
quinine sulfate caps 324mg, 9
QVAR, 25
RABAVERT INJ, 23
raloxifene hcl, 21, 29
ramipril, 14
RANEXA, 15
ranitidine caps & syrup, 18
ranitidine inj, 18
ranitidine tabs, 18
RAPAMUNE SOLN, 22
RAVICTI, 17
REBIF INJ, 16
REBIF REBIDOSE INJ, 16
REBIF REBIDOSE TITRATION PACK INJ, 16
REBIF TITRATION PACK INJ, 16
RECOMBIVAX HB INJ, 23
REGRANEX, 17, 29
RELENZA DISKHALER, 12
RELISTOR INJ, 18
REMICADE INJ, 22
REMODULIN INJ, 26
RENVELA, 18
repaglinide, 12
REPATHA INJ, 15
reprexain, 1
PREMARIN VAGINAL, 20
PREMPHASE, 20
PREMPRO, 20
prenatal multi-vitamin, 27
PREPOPIK, 18
prevalite, 16
PREZCOBIX, 12
PREZISTA SUSP 100MG/ML, 12
PREZISTA TABS 600MG & 800MG, 12
PREZISTA TABS 75MG & 150MG, 12
PRIFTIN, 7
PRIMAQUINE, 9
primidone, 4
PRISTIQ, 6
PROAIR HFA, 25
PROAIR RESPICLICK, 25
probenecid, 7
probenecid & colchicine, 7
procainamide inj, 14
prochlorperazine inj, 6
prochlorperazine oral, 6
prochlorperazine suppositories, 6
PROCRIT INJ 20000UNIT/ML & 40000UNIT/ML,
13
PROCRIT INJ 2000UNIT/ML, 13
PROCRIT INJ 3000UNIT/ML, 4000UNIT/ML &
10000UNIT/ML, 13
procto-pak, 19
proctosol hc, 19
proctozone-hc, 19
progesterone caps, 21
PROGLYCEM, 12
PROLASTIN C INJ, 26
PROLIA, 23
PROMACTA, 13
promethazine inj, 6
promethazine suppositories, 6
promethazine syrup, 6
promethazine tabs 12.5mg, 25mg & 50mg, 6
promethegan, 6
propafenone, 14
propranolol & hydrochlorothiazide, 15
propranolol er caps, 14
propranolol inj, 14
VillageHealth | 2016 Formulary
44
SENSIPAR TABS 30MG, 21, 30
SENSIPAR TABS 60MG & 90MG, 21
SEREVENT DISKUS, 25
SEROQUEL XR, 10
sertraline oral soln, 6
sertraline tabs, 6
setlakin, 20
sevelamer carbonate, 18
sharobel, 21
sildenafil tabs 20mg, 26
SILENOR, 26, 30
silver sulfadiazine, 3
SIMCOR, 16
simvastatin, 16
sirolimus tabs, 22
SIRTURO, 7
SIVEXTRO, 3
sodium chloride inj, 27
sodium phenylbutyrate powder, 17
sodium polystyrene sulfonate, 26
SOLTAMOX, 8
SOLU-CORTEF INJ, 19
SOMATULINE DEPOT INJ, 21
SOMAVERT INJ, 21
sorine, 14
sotalol tabs, 14
SOVALDI, 11
SPIRIVA HANDIHALER, 25
SPIRIVA RESPIMAT, 25
spironolactone, 15
spironolactone & hydrochlorothiazide, 15
SPORANOX ORAL SOLN, 7
SPRYCEL, 8
ssd, 3
stavudine, 11
stavudine oral soln, 11
STIMATE, 19
STIVARGA, 8
STRATTERA, 16
streptomycin inj, 2
STRIBILD, 11
STRIVERDI RESPIMAT, 26
SUCRAID, 17
RESCRIPTOR, 11
RESTASIS, 24, 30
RETROVIR IV INJ, 11
REVLIMID, 8
REXULTI, 10
REYATAZ CAPS & ORAL POWDER, 12
ribasphere, 11
ribasphere ribapak, 11
ribavirin, 11
RIDAURA, 22
rifabutin, 7
rifampin inj, 7
rifampin oral, 7
RIFATER, 7
riluzole, 16
rimantadine, 12
risedronate sodium, 23
risedronate sodium dr, 23
RISPERDAL CONSTA INJ 12.5MG & 25MG, 10
RISPERDAL CONSTA INJ 37.5MG & 50MG, 10
risperidone, 10
risperidone odt, 10
RITUXAN INJ, 9
rivastigmine caps, 5
rivastigmine caps, 30
rivastigmine patches, 30
rivastigmine patches, 5
rizatriptan, 7
rizatriptan odt, 7
ropinirole, 9
ROTARIX, 23
ROTATEQ, 23
ROZEREM, 26, 30
SABRIL, 4
SANDIMMUNE CAPS 25MG & 100MG, 22
SANDIMMUNE ORAL SOLN 100MG/ML, 22
SANTYL, 17
SAPHRIS, 10
SAVELLA, 16
SAVELLA TITRATION PACK, 16
selegiline, 9
selenium sulfide lotion, 17
SELZENTRY, 11
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45
sucralfate, 18
sulfacetamide sodium, 25
sulfacetamide sodium & prednisolone sodium
phosphate, 25
sulfacetamide sodium oint & soln 10%, 24
sulfacetamide sodium susp 10%, 17
sulfadiazine, 4
sulfamethoxazole & trimethoprim, 4
sulfamethoxazole & trimethoprim ds tabs, 4
sulfamethoxazole & trimethoprim inj, 4
sulfamethoxazole & trimethoprim oral susp, 4
sulfamethoxazole & trimethoprim tabs, 4
sulfasalazine, 23
sulfazine, 23
sulfazine ec, 23
sulindac, 2
sumatriptan nasal, 7
sumatriptan succinate inj, 7
sumatriptan succinate oral, 7
SUPRAX CAPS & CHEWABLE TABS, 3
SUPRAX ORAL SUSP 500MG/5ML, 3
SUPREP BOWEL PREP, 18
SURMONTIL, 6
SUSTIVA, 11
SUTENT, 8
SYLATRON INJ, 8
SYMLINPEN INJ, 12
SYNAGIS INJ, 22
SYNAREL, 21
SYNERCID INJ, 3
SYNRIBO INJ, 8
SYNTHROID, 21
SYPRINE, 26
TABLOID, 8
tacrolimus caps 0.5mg & 1mg, 22
tacrolimus caps 5mg, 22
tacrolimus oint, 17
TAFINLAR, 8
TAGRISSO, 8
TAMIFLU CAPS 75MG, 12
TAMIFLU SUSP, 12
tamoxifen, 8
tamsulosin, 18
TARCEVA, 8
TARGRETIN, 9
tarina fe, 20
TASIGNA, 9
tazicef inj, 3
TAZORAC, 17, 30
taztia xt, 15
TECFIDERA, 16
TECFIDERA STARTER PACK, 17
TEFLARO INJ, 3
TEGRETOL, 5
TEGRETOL XR, 5
TEKTURNA, 15
TEKTURNA HCT, 15
temazepam, 26
TENIVAC, 23
terazosin, 13, 18
terbinafine, 7
terbutaline sulfate inj, 26
terbutaline sulfate oral, 26
terconazole, 7
testosterone cypionate inj, 20
testosterone enanthate inj, 20
testosterone gel 1%, 20
TETANUS & DIPHTHERIA TOXOIDSADSORBED ADULT INJ, 23
tetrabenazine, 16
tetracycline, 4
THALOMID, 8
theophylline, 25
theophylline cr & er tabs, 25
THIOLA, 18
thioridazine, 10
thiothixene, 10
THYROLAR, 21
tiagabine, 4
TIKOSYN, 14
timolol ophthalmic gel forming, 24
timolol oral, 15
timolol soln, 24
TIVICAY, 11
tizanidine, 10
TOBI PODHALER, 26
TOBRADEX OINT, 25
tobramycin, 25
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tobramycin & dexamethasone, 25
tobramycin nebulizer, 26
tobramycin sulfate, 24
tobramycin sulfate & sodium chloride inj, 2
tobramycin sulfate inj, 2
TOLAK, 17
tolterodine tartrate, 30
tolterodine tartrate er, 18
topiramate immediate-release, 4
torsemide oral, 15
TOVIAZ, 18
TPN ELECTROLYTES INJ, 27
TRACLEER, 26
tramadol, 1, 30
tramadol & acetaminophen, 1, 30
tramadol er, 30
tramadol er tabs, 1
trandolapril, 14
tranexamic acid inj, 13
tranexamic acid tabs, 13
TRANSDERM-SCOP, 6
tranylcypromine, 5
TRAVASOL INJ, 27
trazodone, 5
TRECATOR, 7
tretinoin caps, 9
triamcinolone, 17
triamcinolone acetonide inj, 19
triamcinolone acetonide topical cream, lotion &
oint, 19
triamcinolone in orabase, 17
triamterene & hydrochlorothiazide, 15
triazolam, 26
triderm, 19
trifluoperazine, 10
trifluridine, 24
trihexyphenidyl elixir, 9
trihexyphenidyl tabs, 9
TRILEPTAL, 5
trimethoprim, 3
trimipramine maleate, 6
tri-sprintec, 20
TRIUMEQ, 11
trivora-28, 20
TRUMENBA INJ, 23
TRUVADA, 11
TUDORZA PRESSAIR, 25
TWINRIX INJ, 23
TYBOST, 11
TYGACIL INJ, 3
TYKERB, 9
TYPHIM VI INJ, 23
TYSABRI INJ, 17
TYZEKA, 10
ULORIC, 7
unithroid, 21
ursodiol, 18
VAGIFEM, 21
valacyclovir, 11
VALCHLOR, 7
valganciclovir tabs, 10
valproate sodium inj, 4
valproic acid, 4
valsartan & amlodipine, 14
valsartan & amlodipine & hct, 14
valsartan hct, 14
vancomycin inj, 3
vancomycin oral, 3
vandazole, 3
VAQTA INJ, 23
VARIVAX INJ, 23
VELCADE INJ, 8
velivet, 21
venlafaxine er caps, 6
venlafaxine ir tabs, 6
verapamil er, 15
verapamil inj, 15
verapamil ir, 15
verapamil sr, 15
VERSACLOZ, 10
VESICARE, 18
VICTOZA INJ, 12
VIDEX PEDIATRIC SOLN 2GM, 11
VIGAMOX, 24
VIIBRYD, 6
VIMPAT INJ, 5
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VIMPAT ORAL, 5
VIRACEPT, 12
VIRAMUNE TABS, 11
VIRAMUNE XR 100MG, 11
VIRAZOLE, 26
VIREAD POWDER, 11
VIREAD TABS, 11
VITEKTA, 11
VOLTAREN GEL 1%, 17
voriconazole inj, 7
voriconazole oral, 7
VOTRIENT, 9
VPRIV INJ, 17
vyfemla, 21
warfarin, 13
WELCHOL, 16
wymzya fe, 21
XALKORI, 9
XARELTO, 13
XARELTO STARTER PACK, 13
XELJANZ, 22
XENAZINE, 16
XERESE, 11
XGEVA INJ, 23
XIFAXAN TABS 200MG, 3, 30
XIFAXAN TABS 550MG, 3
XIGDUO XR, 12
XTANDI, 8
XYREM, 26
YERVOY INJ, 9
YF-VAX INJ, 23
zafirlukast, 25, 30
zamicet, 1, 30
ZAVESCA, 17
ZELBORAF, 9
zenchent, 21
zenchent fe, 21
zenzedi tabs 5mg & 10mg, 16, 30
ZERBAXA INJ, 3
ZETIA, 16, 30
ZIAGEN SOLN, 11
zidovudine, 11
ziprasidone oral, 10
ZIRGAN, 10
zoledronic acid 4mg/5ml inj, 23
zoledronic acid 5mg/100ml inj, 23
ZOLINZA, 8
zolmitriptan odt, 7
zolmitriptan tabs, 7
zolpidem tabs 5mg & 10mg, 26
ZOMETA INJ 4MG/100ML, 23
ZOMIG NASAL, 7, 30
ZONALON, 17
zonisamide, 4
ZORTRESS TABS 0.25MG, 22
ZORTRESS TABS 0.5MG & 0.75MG, 22
ZOSTAVAX INJ, 23
ZOSYN GALAXY INJ 2GM/0.25GM &
3GM/0.375GM, 3
zovia, 21
ZOVIRAX CREAM, 11
ZYDELIG, 8
ZYFLO CR, 25, 30
ZYKADIA, 9
ZYPREXA RELPREVV 210MG, 10
ZYTIGA, 8
ZYVOX ORAL SUSP, 3
VillageHealth | 2016 Formulary
48
VillageHealth | Formulario 2016
XXI
3800 Kilroy Airport Way, Suite 100
Long Beach, CA 90806
This formulary was updated on 03/2016. For more recent information or other questions, please contact
VillageHealth Member Services at 1-800-399-7226 or, for TTY users, 711, 8 a.m. to 8 p.m., 7 days a week
from October 1 to February 14. From February 15 to September 30, hours are 8 a.m. to 8 p.m. Monday through
Friday, and 9 a.m. to 4 p.m. on Saturday (messages received on holidays and outside of our business hours will
be returned within one business day), or visit www.villagehealthca.com.
Este formulario se actualizó en 03/2016. Para obtener información más reciente o si tiene dudas, comuníquese
con Servicios para Miembros de VillageHealth al 1-800-399-7226 o, para los usuarios de TTY, 711, de 8 a.m.
a 8 p.m., los 7 días de la semana, desde el 1 de octubre hasta el 14 de febrero. Desde el 15 de febrero
al 30 de septiembre, el horario es de 8 a.m. a 8 p.m., de lunes a viernes, y de 9 a.m. a 4 p.m. los sábados
(los mensajes recibidos en días festivos y fuera del horario hábil se devolverán en un día hábil). O visite
www.villagehealthca.com.
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16-FORVH1