Story Transcript
SCAN Health Plan®
2016
SCAN Health Plan Formulary (List of Covered Drugs)
This formulary was updated on 08/01/2015. For more recent information or other questions, please contact SCAN Health Plan Member Services at 1-800-559-3500 (Medicare and Medi-Cal eligible members should call 1-866-722-6725) 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.scanhealthplan.com. Este formulario se actualizó en 08/01/2015. Para obtener información más reciente o si tiene dudas, comuníquese con Servicios para Miembros de SCAN Health Plan al 1-800-559-3500 (los miembros elegibles para Medicare y Medi-Cal deben llamar al 1-866-722-6725) 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.scanhealthplan.com.
G9318 08/15 Y0057_SCAN_9189_2015F File & Use Accepted 08232015
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SCAN Health Plan 2016 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN 16400, 6 This formulary was updated on 08/01/2015. For more recent information or other questions, please contact SCAN Health Plan Member Services at 1-800-559-3500 (Medicare and Medi-Cal eligible members should call 1-866-722-6725) 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.scanhealthplan.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 SCAN Classic (HMO), SCAN Classic II (HMO), Scripps Classic offered by SCAN Health Plan (HMO), Scripps Signature offered by SCAN Health Plan (HMO), SCAN Healthy at Home (HMO SNP), Heart First (HMO SNP), Scripps Heart First offered by SCAN Health Plan (HMO SNP), SCAN Balance (HMO SNP), SCAN Connections (HMO SNP), SCAN Connections at Home (HMO SNP). This document includes a list of the drugs (formulary) for our plan which is current as of August 2015. 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 SCAN Health Plan Member Services at 1-800-559-3500 (Medicare and Medi-Cal eligible members should call 1-866-722-6725), 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. SCAN Health Plan is an HMO 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 1-800-559-3500, 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.
SCAN Health Plan | 2016 Formulary
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Esta información está disponible gratuitamente en otros idiomas. Llame nuestro número de Servicios para Miembros al 1-800-559-3500, 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. 本資訊有其他語言版本供免費索取。請撥打1-800-559-3500聯絡我們的會員服務部，服務時間：10月1日 至2月14日，每週七天，每天上午8點至晚上8點；2月15日至9月30日：週一至週五，上午8點到晚上8點； 週六上午9點到下午4點。（在節假日及我們的非工作時間內收到的郵件將會在一個工作日內退回）。聽障和 語障用戶請撥打711。
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SCAN Health Plan | 2016 Formulary
TABLE OF CONTENTS What is the SCAN Health Plan 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 SCAN Health Plan 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 SCAN Health Plan’s Formulary............................................................................................................. XXX Formulary Drugs Arranged by Therapeutic Class........................................................................................1 Formulary Drugs with Quantity Limits.....................................................................................................27 Index...................................................................................................................................................30
SCAN Health Plan | 2016 Formulary
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SCAN Health Plan | 2016 Formulary
What is the SCAN Health Plan Formulary? A formulary is a list of covered drugs selected by SCAN Health Plan 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. SCAN Health Plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a SCAN Health Plan 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 August 2015. To get updated information about the drugs covered by SCAN Health Plan, 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 30. 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? SCAN Health Plan 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. SCAN Health Plan | 2016 Formulary
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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: SCAN Health Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from SCAN Health Plan before you fill your prescriptions. If you don’t get approval, SCAN Health Plan may not cover the drug. • Quantity Limits: For certain drugs, SCAN Health Plan limits the amount of the drug that SCAN Health Plan will cover. For example, SCAN Health Plan 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, SCAN Health Plan 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, SCAN Health Plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, SCAN Health Plan 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 SCAN Health Plan 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 SCAN Health Plan 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 SCAN Health Plan does not cover your drug, you have two options: • You can ask Member Services for a list of similar drugs that are covered by SCAN Health Plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by SCAN Health Plan. • You can ask SCAN Health Plan 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 SCAN Health Plan Formulary? You can ask SCAN Health Plan 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 cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. • You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, SCAN Health Plan 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.
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SCAN Health Plan | 2016 Formulary
Generally, SCAN Health Plan will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering, or utilization restriction exception. When you request a formulary, tiering 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 SCAN Health Plan prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about SCAN Health Plan, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.
SCAN Health Plan | 2016 Formulary
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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.
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SCAN Health Plan | 2016 Formulary
The charts below list 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. SCAN Classic (HMO)†: Los Angeles County Standard Retail & Mail Order cost-sharing (in-network) (30-day supply)
Standard Retail cost-sharing (in-network) (90-day supply)
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
$0 copayment
$0 copayment
$0 copayment
$0 copayment
2
Generic Drugs
$10 copayment
$20 copayment
$20 copayment
$10 copayment
3
Preferred Brand Drugs
$47 copayment
$141 copayment
$131 copayment
$47 copayment
4
Non-Preferred Brand Drugs
$100 copayment
$300 copayment
$290 copayment
$100 copayment
5
Specialty Tier Drugs
33% coinsurance
N/A
N/A
33% coinsurance
6
Select Care Drugs
$11 copayment
$33 copayment
$23 copayment
$11 copayment
*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. †We provide additional coverage of prescription drugs in tiers 1 and 2 in the Coverage Gap. Please refer to your Evidence of Coverage for more information about this coverage.
SCAN Health Plan | 2016 Formulary
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SCAN Classic (HMO)†: Orange County Standard Retail & Mail Order cost-sharing (in-network) (30-day supply)
Standard Retail cost-sharing (in-network) (90-day supply)
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
$0 copayment
$0 copayment
$0 copayment
$0 copayment
2
Generic Drugs
$10 copayment
$20 copayment
$20 copayment
$10 copayment
3
Preferred Brand Drugs
$47 copayment
$141 copayment
$131 copayment
$47 copayment
4
Non-Preferred Brand Drugs
$100 copayment
$300 copayment
$290 copayment
$100 copayment
5
Specialty Tier Drugs
33% coinsurance
N/A
N/A
33% coinsurance
6
Select Care Drugs
$11 copayment
$33 copayment
$23 copayment
$11 copayment
*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. †We provide additional coverage of prescription drugs in tiers 1 and 2 in the Coverage Gap. Please refer to your Evidence of Coverage for more information about this coverage.
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SCAN Health Plan | 2016 Formulary
SCAN Classic (HMO)†: Riverside & San Bernardino Counties Standard Retail & Mail Order cost-sharing (in-network) (30-day supply)
Standard Retail cost-sharing (in-network) (90-day supply)
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
$5 copayment
$10 copayment
$10 copayment
$5 copayment
2
Generic Drugs
$12 copayment
$24 copayment
$24 copayment
$12 copayment
3
Preferred Brand Drugs
$47 copayment
$141 copayment
$131 copayment
$47 copayment
4
Non-Preferred Brand Drugs
$100 copayment
$300 copayment
$290 copayment
$100 copayment
5
Specialty Tier Drugs
33% coinsurance
N/A
N/A
33% coinsurance
6
Select Care Drugs
$11 copayment
$33 copayment
$23 copayment
$11 copayment
*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. †We provide additional coverage of prescription drugs in tiers 1 and 2 in the Coverage Gap. Please refer to your Evidence of Coverage for more information about this coverage.
SCAN Health Plan | 2016 Formulary
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SCAN Classic II (HMO)†: Riverside & San Bernardino Counties Standard Retail & Mail Order cost-sharing (in-network) (30-day supply)
Standard Retail cost-sharing (in-network) (90-day supply)
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
$7 copayment
$14 copayment
$14 copayment
$7 copayment
2
Generic Drugs
$12 copayment
$24 copayment
$24 copayment
$12 copayment
3
Preferred Brand Drugs
$47 copayment
$141 copayment
$131 copayment
$47 copayment
4
Non-Preferred Brand Drugs
$100 copayment
$300 copayment
$290 copayment
$100 copayment
5
Specialty Tier Drugs
33% coinsurance
N/A
N/A
33% coinsurance
6
Select Care Drugs
$11 copayment
$33 copayment
$23 copayment
$11 copayment
*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. †We provide additional coverage of prescription drugs in tier 1 in the Coverage Gap. Please refer to your Evidence of Coverage for more information about this coverage.
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SCAN Health Plan | 2016 Formulary
Scripps Classic offered by SCAN Health Plan (HMO): San Diego County Standard Retail & Mail Order cost-sharing (in-network) (30-day supply)
Standard Retail cost-sharing (in-network) (90-day supply)
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
$5 copayment
$10 copayment
$10 copayment
$5 copayment
2
Generic Drugs
$10 copayment
$20 copayment
$20 copayment
$10 copayment
3
Preferred Brand Drugs
$47 copayment
$141 copayment
$131 copayment
$47 copayment
4
Non-Preferred Brand Drugs
$95 copayment
$285 copayment
$275 copayment
$95 copayment
5
Specialty Tier Drugs
33% coinsurance
N/A
N/A
33% coinsurance
6
Select Care Drugs
$10 copayment
$30 copayment
$20 copayment
$10 copayment
*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.
SCAN Health Plan | 2016 Formulary
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Scripps Signature offered by SCAN Health Plan (HMO)†: San Diego County Standard Retail & Mail Order cost-sharing (in-network) (30-day supply)
Standard Retail cost-sharing (in-network) (90-day supply)
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
$5 copayment
$10 copayment
$10 copayment
$5 copayment
2
Generic Drugs
$8 copayment
$16 copayment
$16 copayment
$8 copayment
3
Preferred Brand Drugs
$47 copayment
$141 copayment
$131 copayment
$47 copayment
4
Non-Preferred Brand Drugs
$95 copayment
$285 copayment
$275 copayment
$95 copayment
5
Specialty Tier Drugs
33% coinsurance
N/A
N/A
33% coinsurance
6
Select Care Drugs
$10 copayment
$30 copayment
$20 copayment
$10 copayment
*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. †We provide additional coverage of prescription drugs in tiers 1 and 2 in the Coverage Gap. Please refer to your Evidence of Coverage for more information about this coverage.
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SCAN Health Plan | 2016 Formulary
SCAN Classic (HMO): Ventura County Standard Retail & Mail Order cost-sharing (in-network) (30-day supply)
Standard Retail cost-sharing (in-network) (90-day supply)
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
$7 copayment
$14 copayment
$14 copayment
$7 copayment
2
Generic Drugs
$10 copayment
$20 copayment
$20 copayment
$10 copayment
3
Preferred Brand Drugs
$47 copayment
$141 copayment
$131 copayment
$47 copayment
4
Non-Preferred Brand Drugs
$100 copayment
$300 copayment
$290 copayment
$100 copayment
5
Specialty Tier Drugs
33% coinsurance
N/A
N/A
33%coinsurance
6
Select Care Drugs
$11 copayment
$33 copayment
$23 copayment
$11 copayment
*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.
SCAN Health Plan | 2016 Formulary
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SCAN Classic (HMO): San Francisco & Santa Clara Counties Standard Retail & Mail Order cost-sharing (in-network) (30-day supply)
Standard Retail cost-sharing (in-network) (90-day supply)
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
$5 copayment
$10 copayment
$10 copayment
$5 copayment
2
Generic Drugs
$10 copayment
$20 copayment
$20 copayment
$10 copayment
3
Preferred Brand Drugs
$47 copayment
$141 copayment
$131 copayment
$47 copayment
4
Non-Preferred Brand Drugs
$100 copayment
$300 copayment
$290 copayment
$100 copayment
5
Specialty Tier Drugs
33% coinsurance
N/A
N/A
33% coinsurance
6
Select Care Drugs
$11 copayment
$33 copayment
$23 copayment
$11 copayment
*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.
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SCAN Health Plan | 2016 Formulary
SCAN Classic (HMO): Marin County Standard Retail & Mail Order cost-sharing (in-network) (30-day supply)
Standard Retail cost-sharing (in-network) (90-day supply)
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
$6 copayment
$6 copayment
$3 copayment
2
Generic Drugs
$7 copayment
$14 copayment
$14 copayment
$7 copayment
3
Preferred Brand Drugs
$45 copayment
$135 copayment
$125 copayment
$45 copayment
4
Non-Preferred Brand Drugs
$85 copayment
$255 copayment
$245 copayment
$85 copayment
5
Specialty Tier Drugs
33% coinsurance
N/A
N/A
33% coinsurance
6
Select Care Drugs
$10 copayment
$30 copayment
$20 copayment
$10 copayment
*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.
SCAN Health Plan | 2016 Formulary
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SCAN Classic (HMO): Napa & Sonoma Counties Standard Retail & Mail Order cost-sharing (in-network) (30-day supply)
Standard Retail cost-sharing (in-network) (90-day supply)
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
$5 copayment
$10 copayment
$10 copayment
$5 copayment
2
Generic Drugs
$15 copayment
$30 copayment
$30 copayment
$15 copayment
3
Preferred Brand Drugs
$47 copayment
$141 copayment
$131 copayment
$47 copayment
4
Non-Preferred Brand Drugs
$100 copayment
$300 copayment
$290 copayment
$100 copayment
5
Specialty Tier Drugs
33% coinsurance
N/A
N/A
33% coinsurance
6
Select Care Drugs
$11 copayment
$33 copayment
$23 copayment
$11 copayment
*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.
XVIII
SCAN Health Plan | 2016 Formulary
SCAN Classic (HMO)†: San Joaquin County Standard Retail & Mail Order cost-sharing (in-network) (30-day supply)
Standard Retail cost-sharing (in-network) (90-day supply)
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
$7 copayment
$14 copayment
$14 copayment
$7 copayment
2
Generic Drugs
$10 copayment
$20 copayment
$20 copayment
$10 copayment
3
Preferred Brand Drugs
$47 copayment
$141 copayment
$131 copayment
$47 copayment
4
Non-Preferred Brand Drugs
$100 copayment
$300 copayment
$290 copayment
$100 copayment
5
Specialty Tier Drugs
33% coinsurance
N/A
N/A
33% coinsurance
6
Select Care Drugs
$11 copayment
$33 copayment
$23 copayment
$11 copayment
*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. †We provide additional coverage of prescription drugs in tier 1 in the Coverage Gap. Please refer to your Evidence of Coverage for more information about this coverage.
SCAN Health Plan | 2016 Formulary
XIX
SCAN Healthy At Home (HMO SNP)†: Los Angeles, Orange, Riverside & San Bernardino Counties Standard Retail & Mail Order cost-sharing (in-network) (30-day supply)
Standard Retail cost-sharing (in-network) (90-day supply)
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
$6 copayment
$3 copayment
2
Generic Drugs
$10 copayment
$30 copayment
$20 copayment
$10 copayment
3
Preferred Brand Drugs
$47 copayment
$141 copayment
$131 copayment
$47 copayment
4
Non-Preferred Brand Drugs
$100 copayment
$300 copayment
$290 copayment
$100 copayment
5
Specialty Tier Drugs
33% coinsurance
N/A
N/A
33% coinsurance
6
Select Care Drugs
$11 copayment
$33 copayment
$23 copayment
$11 copayment
*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. †We provide additional coverage of prescription drugs in tier 1 in the Coverage Gap. Please refer to your Evidence of Coverage for more information about this coverage.
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SCAN Health Plan | 2016 Formulary
Heart First (HMO SNP)†: Orange County Standard Retail & Mail Order cost-sharing (in-network) (30-day supply)
Standard Retail cost-sharing (in-network) (90-day supply)
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
$6 copayment
$6 copayment
$3 copayment
2
Generic Drugs
$7 copayment
$14 copayment
$14 copayment
$7 copayment
3
Preferred Brand Drugs
$47 copayment
$141 copayment
$131 copayment
$47 copayment
4
Non-Preferred Brand Drugs
$100 copayment
$300 copayment
$290 copayment
$100 copayment
5
Specialty Tier Drugs
33% coinsurance
N/A
N/A
33% coinsurance
6
Select Care Drugs
$0 copayment
$0 copayment
$0 copayment
$0 copayment
*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. †We provide additional coverage of prescription drugs in tiers 1, 2 and 6 in the Coverage Gap. Please refer to your Evidence of Coverage for more information about this coverage.
SCAN Health Plan | 2016 Formulary
XXI
Heart First (HMO SNP)†: Marin County Standard Retail & Mail Order cost-sharing (in-network) (30-day supply)
Standard Retail cost-sharing (in-network) (90-day supply)
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
$6 copayment
$6 copayment
$3 copayment
2
Generic Drugs
$7 copayment
$14 copayment
$14 copayment
$7 copayment
3
Preferred Brand Drugs
$45 copayment
$135 copayment
$125 copayment
$45 copayment
4
Non-Preferred Brand Drugs
$95 copayment
$285 copayment
$275 copayment
$95 copayment
5
Specialty Tier Drugs
33% coinsurance
N/A
N/A
33% coinsurance
6
Select Care Drugs
$0 copayment
$0 copayment
$0 copayment
$0 copayment
*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. †We provide additional coverage of prescription drugs in tiers 1, 2 and 6 in the Coverage Gap. Please refer to your Evidence of Coverage for more information about this coverage.
XXII
SCAN Health Plan | 2016 Formulary
Heart First (HMO SNP)†: Riverside & San Bernardino Counties Standard Retail & Mail Order cost-sharing (in-network) (30-day supply)
Standard Retail cost-sharing (in-network) (90-day supply)
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
$5 copayment
$10 copayment
$10 copayment
$5 copayment
2
Generic Drugs
$12 copayment
$24 copayment
$24 copayment
$12 copayment
3
Preferred Brand Drugs
$47 copayment
$141 copayment
$131 copayment
$47 copayment
4
Non-Preferred Brand Drugs
$100 copayment
$300 copayment
$290 copayment
$100 copayment
5
Specialty Tier Drugs
33% coinsurance
N/A
N/A
33% coinsurance
6
Select Care Drugs
$11 copayment
$33 copayment
$23 copayment
$11 copayment
*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. †We provide additional coverage of prescription drugs in tiers 1 and 2 in the Coverage Gap. Please refer to your Evidence of Coverage for more information about this coverage.
SCAN Health Plan | 2016 Formulary
XXIII
Scripps Heart First offered by SCAN Health Plan (HMO SNP)†: San Diego County Standard Retail & Mail Order cost-sharing (in-network) (30-day supply)
Standard Retail cost-sharing (in-network) (90-day supply)
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
$5 copayment
$10 copayment
$10 copayment
$5 copayment
2
Generic Drugs
$10 copayment
$20 copayment
$20 copayment
$10 copayment
3
Preferred Brand Drugs
$47 copayment
$141 copayment
$131 copayment
$47 copayment
4
Non-Preferred Brand Drugs
$100 copayment
$300 copayment
$290 copayment
$100 copayment
5
Specialty Tier Drugs
33% coinsurance
N/A
N/A
33% coinsurance
6
Select Care Drugs
$0 copayment
$0 copayment
$0 copayment
$0 copayment
*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. †We provide additional coverage of prescription drugs in tiers 1 and 6 in the Coverage Gap. Please refer to your Evidence of Coverage for more information about this coverage.
XXIV
SCAN Health Plan | 2016 Formulary
Heart First (HMO SNP)†: Napa & Sonoma Counties Standard Retail & Mail Order cost-sharing (in-network) (30-day supply)
Standard Retail cost-sharing (in-network) (90-day supply)
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
$5 copayment
$10 copayment
$10 copayment
$5 copayment
2
Generic Drugs
$15 copayment
$30 copayment
$30 copayment
$15 copayment
3
Preferred Brand Drugs
$47 copayment
$141 copayment
$131 copayment
$47 copayment
4
Non-Preferred Brand Drugs
$100 copayment
$300 copayment
$290 copayment
$100 copayment
5
Specialty Tier Drugs
33% coinsurance
N/A
N/A
33% coinsurance
6
Select Care Drugs
$0 copayment
$0 copayment
$0 copayment
$0 copayment
*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. †We provide additional coverage of prescription drugs in tiers 1 and 6 in the Coverage Gap. Please refer to your Evidence of Coverage for more information about this coverage.
SCAN Health Plan | 2016 Formulary
XXV
SCAN Balance (HMO SNP)†: Los Angeles & Orange Counties Standard Retail & Mail Order cost-sharing (in-network) (30-day supply)
Standard Retail cost-sharing (in-network) (90-day supply)
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
$6 copayment
$6 copayment
$3 copayment
2
Generic Drugs
$7 copayment
$14 copayment
$14 copayment
$7 copayment
3
Preferred Brand Drugs
$47 copayment
$141 copayment
$131 copayment
$47 copayment
4
Non-Preferred Brand Drugs
$100 copayment
$300 copayment
$290 copayment
$100 copayment
5
Specialty Tier Drugs
33% coinsurance
N/A
N/A
33% coinsurance
6
Select Care Drugs
$0 copayment
$0 copayment
$0 copayment
$0 copayment
*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. †We provide additional coverage of prescription drugs in tiers 1, 2 and 6 in the Coverage Gap. Please refer to your Evidence of Coverage for more information about this coverage.
XXVI
SCAN Health Plan | 2016 Formulary
SCAN Balance (HMO SNP)†: Marin County Standard Retail & Mail Order cost-sharing (in-network) (30-day supply)
Standard Retail cost-sharing (in-network) (90-day supply)
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
$6 copayment
$6 copayment
$3 copayment
2
Generic Drugs
$7 copayment
$14 copayment
$14 copayment
$7 copayment
3
Preferred Brand Drugs
$45 copayment
$135 copayment
$125 copayment
$45 copayment
4
Non-Preferred Brand Drugs
$95 copayment
$285 copayment
$275 copayment
$95 copayment
5
Specialty Tier Drugs
33% coinsurance
N/A
N/A
33% coinsurance
6
Select Care Drugs
$0 copayment
$0 copayment
$0 copayment
$0 copayment
*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. †We provide additional coverage of prescription drugs in tiers 1, 2 and 6 in the Coverage Gap. Please refer to your Evidence of Coverage for more information about this coverage.
SCAN Health Plan | 2016 Formulary
XXVII
SCAN Balance (HMO SNP)†: Napa, & Sonoma Counties Standard Retail & Mail Order cost-sharing (in-network) (30-day supply)
Standard Retail cost-sharing (in-network) (90-day supply)
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
$5 copayment
$10 copayment
$10 copayment
$5 copayment
2
Generic Drugs
$15 copayment
$30 copayment
$30 copayment
$15 copayment
3
Preferred Brand Drugs
$47 copayment
$141 copayment
$131 copayment
$47 copayment
4
Non-Preferred Brand Drugs
$100 copayment
$300 copayment
$290 copayment
$100 copayment
5
Specialty Tier Drugs
33% coinsurance
N/A
N/A
33% coinsurance
6
Select Care Drugs
$0 copayment
$0 copayment
$0 copayment
$0 copayment
*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. †We provide additional coverage of prescription drugs in tiers 1 and 6 in the Coverage Gap. Please refer to your Evidence of Coverage for more information about this coverage.
XXVIII
SCAN Health Plan | 2016 Formulary
The chart below is for Medicare and Medi-Cal eligible members only. It lists what you will pay as your share of the cost for covered prescription drugs when you are in the Initial Coverage Stage. Please refer to your Evidence of Coverage for more information. Co-pays may vary based on the level of Extra Help you receive. Please contact Member Services for further details. Our contact information appears on the front and back cover pages. SCAN Connections (HMO SNP)—Medicare and Medi-Cal eligible members only: Los Angeles, Riverside, San Bernardino, & San Joaquin Counties SCAN Connections at Home (HMO SNP)—Medicare and Medi-Cal eligible members only: Los Angeles, 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 Pharmacy cost-sharing (30-day supply)*
Drug Tier
Tier Name
1
Preferred Generic Drugs
$0 or $1.20 or $2.95
$0 or $1.20 or $2.95
$0 or $1.20 or $2.95
2
Generic Drugs
$0 or $1.20 or $2.95
$0 or $1.20 or $2.95
$0 or $1.20 or $2.95
3
Preferred Brand Drugs
$0 or $1.20 or $2.95 or $3.60 or $7.40
$0 or $1.20 or $2.95 or $3.60 or $7.40
$0 or $1.20 or $2.95 or $3.60 or $7.40
4
Non-Preferred Brand Drugs
$0 or $3.60 or $7.40
$0 or $3.60 or $7.40
$0 or $3.60 or $7.40
5
Specialty Tier Drugs
$0 or $1.20 or $2.95 or $3.60 or $7.40
N/A
$0 or $1.20 or $2.95 or $3.60 or $7.40
6
Select Care Drugs
$0 or $3.60 or $7.40
$0 or $3.60 or $7.40
$0 or $3.60 or $7.40
*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.
SCAN Health Plan | 2016 Formulary
XXIX
SCAN Health Plan’s Formulary The formulary that begins on page 1 provides coverage information about the drugs covered by SCAN Health Plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 30. 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 SCAN Health Plan 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 27. • 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 1-800-559-3500 (Medicare and Medi-Cal eligible members should call 1-866-722-6725), 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.
XXX
SCAN Health Plan | 2016 Formulary
SCAN Health Plan | 2016 Formulary
XXXI
XXXII
SCAN Health Plan | 2016 Formulary
Formulario para 2016 (Lista de medicamentos cubiertos) de SCAN Health Plan POR FAVOR, LEA: ESTE DOCUMENTO CONTIENE INFORMACIÓN ACERCA DE LOS MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN 16400, 6 Este formulario se actualizó en 08/01/2015. Para obtener información más reciente o si tiene dudas, comuníquese con Servicios para Miembros de SCAN Health Plan al 1-800-559-3500 (los miembros elegibles para Medicare y Medi-Cal deben llamar al 1-866-722-6725) 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.scanhealthplan.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 SCAN Classic (HMO), SCAN Classic II (HMO), Scripps Classic offered by SCAN Health Plan (HMO), Scripps Signature offered by SCAN Health Plan (HMO), SCAN Healthy at Home (HMO SNP), Heart First (HMO SNP), Scripps Heart First offered by SCAN Health Plan (HMO SNP), SCAN Balance (HMO SNP), SCAN Connections (HMO SNP), SCAN Connections at Home (HMO SNP). Este documento incluye una lista de los medicamentos (formulario) de nuestro plan que está vigente al mes de agosto del 2015. 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 SCAN Health Plan, al 1-800-559-3500 (los miembros elegibles para Medicare y Medi-Cal deben llamar al 1-866-722-6725) o, para usuarios de TTY, 711, 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. SCAN Health Plan es un plan HMO con un contrato de Medicare. La inscripción en SCAN Health Plan depende de la renovación del contrato.
SCAN Health Plan | Formulario 2016
XXXIII
This information is available for free in other languages. Please call our Member Services number at 1-800-559-3500, 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 1-800-559-3500, 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. 本資訊有其他語言版本供免費索取。請撥打1-800-559-3500聯絡我們的會員服務部，服務時間：10月1日 至2月14日，每週七天，每天上午8點至晚上8點；2月15日至9月30日：週一至週五，上午8點到晚上8點； 週六上午9點到下午4點。（在節假日及我們的非工作時間內收到的郵件將會在一個工作日內退回）。聽障和 語障用戶請撥打711。
XXXIV
SCAN Health Plan | 2016 Formulary
TABLA DE CONTENIDOS ¿Qué es el Formulario de SCAN Health Plan?.................................................................................... XXXVII ¿El Formulario (lista de medicamentos) puede cambiar?.................................................................... XXXVII ¿Cómo utilizo el Formulario?............................................................................................................ XXXVII ¿Qué son los medicamentos genéricos?........................................................................................... XXXVIII ¿Hay alguna restricción en mi cobertura?......................................................................................... XXXVIII ¿Qué sucede si mi medicamento no está en el Formulario?............................................................... XXXVIII ¿Cómo solicito una excepción al formulario de SCAN Health Plan?...................................................... XXXIX ¿Qué debo hacer antes de poder hablar con mi médico sobre un cambio en mis medicamentos o solicitar una excepción?................................................................................................................... XXXIX Para obtener más información............................................................................................................... XL Formulario de SCAN Health Plan.........................................................................................................LXII Medicamentos del formulario coordinados por la clase terapéutica..............................................................1 Medicamentos del formulario con límites de cantidad..............................................................................27 Índice..................................................................................................................................................30
SCAN Health Plan | Formulario 2016
XXXV
XXXVI
SCAN Health Plan | Formulario 2016
¿Qué es el Formulario de SCAN Health Plan? Un formulario es una lista de medicamentos cubiertos seleccionados por SCAN Health Plan 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. SCAN Health Plan 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 SCAN Health Plan 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 agosto del 2015. Para obtener información actualizada acerca de los medicamentos cubiertos por SCAN Health Plan, 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 30. 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. SCAN Health Plan | Formulario 2016
XXXVII
¿Qué son los medicamentos genéricos? SCAN Health Plan 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: SCAN Health Plan requiere que usted o su médico obtengan una autorización previa para ciertos medicamentos. Esto significa que necesitará obtener aprobación de SCAN Health Plan antes de surtir sus recetas médicas. Si no obtiene la aprobación, es posible que SCAN Health Plan no cubra el medicamento. • Límites de cantidad: Para ciertos medicamentos, SCAN Health Plan limita la cantidad del medicamento que SCAN Health Plan cubrirá. Por ejemplo, SCAN Health Plan 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, SCAN Health Plan 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 SCAN Health Plan no cubra el medicamento B a menos que pruebe primero el medicamento A. Si el medicamento A no funciona para usted, SCAN Health Plan 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 SCAN Health Plan 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 SCAN Health Plan?” en la página XXXIX, 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 SCAN Health Plan no cubre su medicamento, tiene dos opciones: • Puede solicitar a Servicios para Miembros una lista de medicamentos similares que SCAN Health Plan cubre. Cuando reciba la lista, muéstrela a su médico y pídale que le recete un medicamento similar que esté cubierto por SCAN Health Plan. • Puede solicitar que SCAN Health Plan haga una excepción y cubra su medicamento. Consulte a continuación para obtener información sobre cómo solicitar una excepción.
XXXVIII
SCAN Health Plan | Formulario 2016
¿Cómo solicito una excepción al formulario de SCAN Health Plan? Puede solicitar SCAN Health Plan 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, SCAN Health Plan 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, SCAN Health Plan 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 SCAN Health Plan | Formulario 2016
XXXIX
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 SCAN Health Plan, consulte su Evidencia de cobertura y otros materiales del plan. Si tiene alguna pregunta acerca de SCAN Health Plan, 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.
XL
SCAN Health Plan | Formulario 2016
Los cuadros a continuación enumeran 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. SCAN Classic (HMO)†: Condado de los Ángeles
Nivel del medicamento
Nombre del nivel
Costo compartido en farmacia minorista estándar y de pedidos por correo (dentro de la red) (suministro para 30 días)
Costo compartido en farmacia minorista estándar y de pedidos por correo (dentro de la red) (suministro para 90 días)
Costo compartido en farmacia de pedidos por correo (dentro de la red) (suministro para 90 días)
Costo compartido en farmacia de pedidos por correo (suministro para 30 días)*
1
Medicamentos genéricos preferidos
$0 de copago
$0 de copago
$0 de copago
$0 de copago
2
Medicamentos genéricos
$10 de copago
$20 de copago
$20 de copago
$10 de copago
3
Medicamentos de marca preferidos
$47 de copago
$141 de copago $131 de copago
$47 de copago
4
Medicamentos de marca no preferidos
$100 de copago $300 de copago $290 de copago $100 de copago
5
Medicamentos de nivel de especialidad
33% de coseguro
N/A
N/A
33% de coseguro
6
Medicamentos para tratamientos seleccionados
$11 de copago
$33 de copago
$23 de copago
$11 de copago
*Para las reposiciones 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. †Le proporcionaremos cobertura adicional de medicamentos recetados en los niveles 1 y 2 en el Vacío de cobertura. Consulte su Evidencia de cobertura para obtener más información acerca de esta cobertura.
SCAN Health Plan | Formulario 2016
XLI
SCAN Classic (HMO)†: Condado de Orange
Nivel del medicamento
Nombre del nivel
Costo compartido en farmacia minorista estándar y de pedidos por correo (dentro de la red) (suministro para 30 días)
Costo compartido en farmacia minorista estándar y de pedidos por correo (dentro de la red) (suministro para 90 días)
Costo compartido en farmacia de pedidos por correo (dentro de la red) (suministro para 90 días)
Costo compartido en farmacia de pedidos por correo (suministro para 30 días)*
1
Medicamentos genéricos preferidos
$0 de copago
$0 de copago
$0 de copago
$0 de copago
2
Medicamentos genéricos
$10 de copago
$20 de copago
$20 de copago
$10 de copago
3
Medicamentos de marca preferidos
$47 de copago
$141 de copago $131 de copago
$47 de copago
4
Medicamentos de marca no preferidos
$100 de copago $300 de copago $290 de copago $100 de copago
5
Medicamentos de nivel de especialidad
33% de coseguro
N/A
N/A
33% de coseguro
6
Medicamentos para tratamientos seleccionados
$11 de copago
$33 de copago
$23 de copago
$11 de copago
*Para las reposiciones 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. †Le proporcionaremos cobertura adicional de medicamentos recetados en los niveles 1 y 2 en el Vacío de cobertura. Consulte su Evidencia de cobertura para obtener más información acerca de esta cobertura.
XLII
SCAN Health Plan | Formulario 2016
SCAN Classic (HMO)†: Condados de Riverside y San Bernardino
Nivel del medicamento
Nombre del nivel
Costo compartido en farmacia minorista estándar y de pedidos por correo (dentro de la red) (suministro para 30 días)
Costo compartido en farmacia minorista estándar y de pedidos por correo (dentro de la red) (suministro para 90 días)
Costo compartido en farmacia de pedidos por correo (dentro de la red) (suministro para 90 días)
Costo compartido en farmacia de pedidos por correo (suministro para 30 días)*
1
Medicamentos genéricos preferidos
$5 de copago
$10 de copago
$10 de copago
$5 de copago
2
Medicamentos genéricos
$12 de copago
$24 de copago
$24 de copago
$12 de copago
3
Medicamentos de marca preferidos
$47 de copago
$141 de copago $131 de copago
$47 de copago
4
Medicamentos de marca no preferidos
$100 de copago $300 de copago $290 de copago $100 de copago
5
Medicamentos de nivel de especialidad
33% de coseguro
N/A
N/A
33% de coseguro
6
Medicamentos para tratamientos seleccionados
$11 de copago
$33 de copago
$23 de copago
$11 de copago
*Para las reposiciones 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. †Le proporcionaremos cobertura adicional de medicamentos recetados en los niveles 1 y 2 en el Vacío de cobertura. Consulte su Evidencia de cobertura para obtener más información acerca de esta cobertura.
SCAN Health Plan | Formulario 2016
XLIII
SCAN Classic II (HMO)†: Condados de Riverside y San Bernardino
Nivel del medicamento
Nombre del nivel
Costo compartido en farmacia minorista estándar y de pedidos por correo (dentro de la red) (suministro para 30 días)
Costo compartido en farmacia minorista estándar y de pedidos por correo (dentro de la red) (suministro para 90 días)
Costo compartido en farmacia de pedidos por correo (dentro de la red) (suministro para 90 días)
Costo compartido en farmacia de pedidos por correo (suministro para 30 días)*
1
Medicamentos genéricos preferidos
$7 de copago
$14 de copago
$14 de copago
$7 de copago
2
Medicamentos genéricos
$12 de copago
$24 de copago
$24 de copago
$12 de copago
3
Medicamentos de marca preferidos
$47 de copago
$141 de copago $131 de copago
$47 de copago
4
Medicamentos de marca no preferidos
$100 de copago $300 de copago $290 de copago $100 de copago
5
Medicamentos de nivel de especialidad
33% de coseguro
N/A
N/A
33% de coseguro
6
Medicamentos para tratamientos seleccionados
$11 de copago
$33 de copago
$23 de copago
$11 de copago
*Para las reposiciones 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. †Le proporcionaremos cobertura adicional de medicamentos recetados en el nivel 1 en el Vacío de cobertura. Consulte su Evidencia de cobertura para obtener más información acerca de esta cobertura.
XLIV
SCAN Health Plan | Formulario 2016
Scripps Classic offered by SCAN Health Plan (HMO): Condado de San Diego
Nivel del medicamento
Nombre del nivel
Costo compartido en farmacia minorista estándar y de pedidos por correo (dentro de la red) (suministro para 30 días)
Costo compartido en farmacia minorista estándar y de pedidos por correo (dentro de la red) (suministro para 90 días)
Costo compartido en farmacia de pedidos por correo (dentro de la red) (suministro para 90 días)
Costo compartido en farmacia de pedidos por correo (suministro para 30 días)*
1
Medicamentos genéricos preferidos
$5 de copago
$10 de copago
$10 de copago
$5 de copago
2
Medicamentos genéricos
$10 de copago
$20 de copago
$20 de copago
$10 de copago
3
Medicamentos de marca preferidos
$47 de copago
$141 de copago $131 de copago
$47 de copago
4
Medicamentos de marca no preferidos
$95 de copago
$285 de copago $275 de copago
$95 de copago
5
Medicamentos de nivel de especialidad
33% de coseguro
N/A
N/A
33% de coseguro
6
Medicamentos para tratamientos seleccionados
$10 de copago
$30 de copago
$20 de copago
$10 de copago
*Para las reposiciones 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.
SCAN Health Plan | Formulario 2016
XLV
Scripps Signature offered by SCAN Health Plan (HMO)†: Condado de San Diego
Nivel del medicamento
Nombre del nivel
Costo compartido en farmacia minorista estándar y de pedidos por correo (dentro de la red) (suministro para 30 días)
Costo compartido en farmacia minorista estándar y de pedidos por correo (dentro de la red) (suministro para 90 días)
Costo compartido en farmacia de pedidos por correo (dentro de la red) (suministro para 90 días)
Costo compartido en farmacia de pedidos por correo (suministro para 30 días)*
1
Medicamentos genéricos preferidos
$5 de copago
$10 de copago
$10 de copago
$5 de copago
2
Medicamentos genéricos
$8 de copago
$16 de copago
$16 de copago
$8 de copago
3
Medicamentos de marca preferidos
$47 de copago
$141 de copago $131 de copago
$47 de copago
4
Medicamentos de marca no preferidos
$95 de copago
$285 de copago $275 de copago
$95 de copago
5
Medicamentos de nivel de especialidad
33% de coseguro
N/A
N/A
33% de coseguro
6
Medicamentos para tratamientos seleccionados
$10 de copago
$30 de copago
$20 de copago
$10 de copago
*Para las reposiciones 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. †Le proporcionaremos cobertura adicional de medicamentos recetados en los niveles 1 y 2 en el Vacío de cobertura. Consulte su Evidencia de cobertura para obtener más información acerca de esta cobertura.
XLVI
SCAN Health Plan | Formulario 2016
SCAN Classic (HMO): Condado de Ventura
Nivel del medicamento
Nombre del nivel
Costo compartido en farmacia minorista estándar y de pedidos por correo (dentro de la red) (suministro para 30 días)
Costo compartido en farmacia minorista estándar y de pedidos por correo (dentro de la red) (suministro para 90 días)
Costo compartido en farmacia de pedidos por correo (dentro de la red) (suministro para 90 días)
Costo compartido en farmacia de pedidos por correo (suministro para 30 días)*
1
Medicamentos genéricos preferidos
$7 de copago
$14 de copago
$14 de copago
$7 de copago
2
Medicamentos genéricos
$10 de copago
$20 de copago
$20 de copago
$10 de copago
3
Medicamentos de marca preferidos
$47 de copago
$141 de copago $131 de copago
$47 de copago
4
Medicamentos de marca no preferidos
$100 de copago $300 de copago $290 de copago $100 de copago
5
Medicamentos de nivel de especialidad
33% de coseguro
N/A
N/A
33% de coseguro
6
Medicamentos para tratamientos seleccionados
$11 de copago
$33 de copago
$23 de copago
$11 de copago
*Para las reposiciones 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.
SCAN Health Plan | Formulario 2016
XLVII
SCAN Classic (HMO): Condados de San Francisco y Santa Clara
Nivel del medicamento
Nombre del nivel
Costo compartido en farmacia minorista estándar y de pedidos por correo (dentro de la red) (suministro para 30 días)
Costo compartido en farmacia minorista estándar y de pedidos por correo (dentro de la red) (suministro para 90 días)
Costo compartido en farmacia de pedidos por correo (dentro de la red) (suministro para 90 días)
Costo compartido en farmacia de pedidos por correo (suministro para 30 días)*
1
Medicamentos genéricos preferidos
$5 de copago
$10 de copago
$10 de copago
$5 de copago
2
Medicamentos genéricos
$10 de copago
$20 de copago
$20 de copago
$10 de copago
3
Medicamentos de marca preferidos
$47 de copago
$141 de copago $131 de copago
$47 de copago
4
Medicamentos de marca no preferidos
$100 de copago $300 de copago $290 de copago $100 de copago
5
Medicamentos de nivel de especialidad
33% de coseguro
N/A
N/A
33% de coseguro
6
Medicamentos para tratamientos seleccionados
$11 de copago
$33 de copago
$23 de copago
$11 de copago
*Para las reposiciones 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.
XLVIII
SCAN Health Plan | Formulario 2016
SCAN Classic (HMO): Condado de Marin
Nivel del medicamento
Nombre del nivel
Costo compartido en farmacia minorista estándar y de pedidos por correo (dentro de la red) (suministro para 30 días)
Costo compartido en farmacia minorista estándar y de pedidos por correo (dentro de la red) (suministro para 90 días)
Costo compartido en farmacia de pedidos por correo (dentro de la red) (suministro para 90 días)
Costo compartido en farmacia de pedidos por correo (suministro para 30 días)*
1
Medicamentos genéricos preferidos
$3 de copago
$6 de copago
$6 de copago
$3 de copago
2
Medicamentos genéricos
$7 de copago
$14 de copago
$14 de copago
$7 de copago
3
Medicamentos de marca preferidos
$45 de copago
$135 de copago $125 de copago
$45 de copago
4
Medicamentos de marca no preferidos
$85 de copago
$255 de copago $245 de copago
$85 de copago
5
Medicamentos de nivel de especialidad
33% de coseguro
N/A
N/A
33% de coseguro
6
Medicamentos para tratamientos seleccionados
$10 de copago
$30 de copago
$20 de copago
$10 de copago
*Para las reposiciones 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.
SCAN Health Plan | Formulario 2016
XLIX
SCAN Classic (HMO): Condados de Napa y Sonoma
Nivel del medicamento
Nombre del nivel
Costo compartido en farmacia minorista estándar y de pedidos por correo (dentro de la red) (suministro para 30 días)
Costo compartido en farmacia minorista estándar y de pedidos por correo (dentro de la red) (suministro para 90 días)
Costo compartido en farmacia de pedidos por correo (dentro de la red) (suministro para 90 días)
Costo compartido en farmacia de pedidos por correo (suministro para 30 días)*
1
Medicamentos genéricos preferidos
$5 de copago
$10 de copago
$10 de copago
$5 de copago
2
Medicamentos genéricos
$15 de copago
$30 de copago
$30 de copago
$15 de copago
3
Medicamentos de marca preferidos
$47 de copago
$141 de copago $131 de copago
$47 de copago
4
Medicamentos de marca no preferidos
$100 de copago $300 de copago $290 de copago $100 de copago
5
Medicamentos de nivel de especialidad
33% de coseguro
N/A
N/A
33% de coseguro
6
Medicamentos para tratamientos seleccionados
$11 de copago
$33 de copago
$23 de copago
$11 de copago
*Para las reposiciones 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.
L
SCAN Health Plan | Formulario 2016
SCAN Classic (HMO)†: Condado de San Joaquín
Nivel del medicamento
Nombre del nivel
Costo compartido en farmacia minorista estándar y de pedidos por correo (dentro de la red) (suministro para 30 días)
Costo compartido en farmacia minorista estándar y de pedidos por correo (dentro de la red) (suministro para 90 días)
Costo compartido en farmacia de pedidos por correo (dentro de la red) (suministro para 90 días)
Costo compartido en farmacia de pedidos por correo (suministro para 30 días)*
1
Medicamentos genéricos preferidos
$7 de copago
$14 de copago
$14 de copago
$7 de copago
2
Medicamentos genéricos
$10 de copago
$20 de copago
$20 de copago
$10 de copago
3
Medicamentos de marca preferidos
$47 de copago
$141 de copago $131 de copago
$47 de copago
4
Medicamentos de marca no preferidos
$100 de copago $300 de copago $290 de copago $100 de copago
5
Medicamentos de nivel de especialidad
33% de coseguro
N/A
N/A
33% de coseguro
6
Medicamentos para tratamientos seleccionados
$11 de copago
$33 de copago
$23 de copago
$11 de copago
*Para las reposiciones 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. †Le proporcionaremos cobertura adicional de medicamentos recetados en el nivel 1 en el Vacío de cobertura. Consulte su Evidencia de cobertura para obtener más información acerca de esta cobertura.
SCAN Health Plan | Formulario 2016
LI
SCAN Healthy At Home (HMO SNP)†: Condados de Los Angeles, Orange, Riverside y San Bernardino
Nivel del medicamento
Nombre del nivel
Costo compartido en farmacia minorista estándar y de pedidos por correo (dentro de la red) (suministro para 30 días)
Costo compartido en farmacia minorista estándar y de pedidos por correo (dentro de la red) (suministro para 90 días)
Costo compartido en farmacia de pedidos por correo (dentro de la red) (suministro para 90 días)
Costo compartido en farmacia de pedidos por correo (suministro para 30 días)*
1
Medicamentos genéricos preferidos
$3 de copago
$9 de copago
$6 de copago
$3 de copago
2
Medicamentos genéricos
$10 de copago
$30 de copago
$20 de copago
$10 de copago
3
Medicamentos de marca preferidos
$47 de copago
$141 de copago $131 de copago
$47 de copago
4
Medicamentos de marca no preferidos
$100 de copago $300 de copago $290 de copago $100 de copago
5
Medicamentos de nivel de especialidad
33% de coseguro
N/A
N/A
33% de coseguro
6
Medicamentos para tratamientos seleccionados
$11 de copago
$33 de copago
$23 de copago
$11 de copago
*Para las reposiciones 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. †Le proporcionaremos cobertura adicional de medicamentos recetados en el nivel 1 en el Vacío de cobertura. Consulte su Evidencia de cobertura para obtener más información acerca de esta cobertura.
LII
SCAN Health Plan | Formulario 2016
Heart First (HMO SNP)†: Condado de Orange
Nivel del medicamento
Nombre del nivel
Costo compartido en farmacia minorista estándar y de pedidos por correo (dentro de la red) (suministro para 30 días)
Costo compartido en farmacia minorista estándar y de pedidos por correo (dentro de la red) (suministro para 90 días)
Costo compartido en farmacia de pedidos por correo (dentro de la red) (suministro para 90 días)
Costo compartido en farmacia de pedidos por correo (suministro para 30 días)*
1
Medicamentos genéricos preferidos
$3 de copago
$6 de copago
$6 de copago
$3 de copago
2
Medicamentos genéricos
$7 de copago
$14 de copago
$14 de copago
$7 de copago
3
Medicamentos de marca preferidos
$47 de copago
4
Medicamentos de marca no preferidos
$100 de copago $300 de copago $290 de copago $100 de copago
5
Medicamentos de nivel de especialidad
33% de coseguro
N/A
N/A
33% de coseguro
6
Medicamentos para tratamientos seleccionados
$0 de copago
$0 de copago
$0 de copago
$0 de copago
$141 de copago $131 de copago
$47 de copago
*Para las reposiciones 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. †Le proporcionaremos cobertura adicional de medicamentos recetados en los niveles 1, 2 y 6 en el Vacío de cobertura. Consulte su Evidencia de cobertura para obtener más información acerca de esta cobertura.
SCAN Health Plan | Formulario 2016
LIII
Heart First (HMO SNP)†: Condado de Marin
Nivel del medicamento
Nombre del nivel
Costo compartido en farmacia minorista estándar y de pedidos por correo (dentro de la red) (suministro para 30 días)
Costo compartido en farmacia minorista estándar y de pedidos por correo (dentro de la red) (suministro para 90 días)
Costo compartido en farmacia de pedidos por correo (dentro de la red) (suministro para 90 días)
Costo compartido en farmacia de pedidos por correo (suministro para 30 días)*
1
Medicamentos genéricos preferidos
$3 de copago
$6 de copago
$6 de copago
$3 de copago
2
Medicamentos genéricos
$7 de copago
$14 de copago
$14 de copago
$7 de copago
3
Medicamentos de marca preferidos
$45 de copago
$135 de copago $125 de copago
$45 de copago
4
Medicamentos de marca no preferidos
$95 de copago
$285 de copago $275 de copago
$95 de copago
5
Medicamentos de nivel de especialidad
33% de coseguro
N/A
N/A
33% de coseguro
6
Medicamentos para tratamientos seleccionados
$0 de copago
$0 de copago
$0 de copago
$0 de copago
*Para las reposiciones 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. †Le proporcionaremos cobertura adicional de medicamentos recetados en los niveles 1, 2 y 6 en el Vacío de cobertura. Consulte su Evidencia de cobertura para obtener más información acerca de esta cobertura.
LIV
SCAN Health Plan | Formulario 2016
Heart First (HMO SNP)†: Condados de Riverside y San Bernardino
Nivel del medicamento
Nombre del nivel
Costo compartido en farmacia minorista estándar y de pedidos por correo (dentro de la red) (suministro para 30 días)
Costo compartido en farmacia minorista estándar y de pedidos por correo (dentro de la red) (suministro para 90 días)
Costo compartido en farmacia de pedidos por correo (dentro de la red) (suministro para 90 días)
Costo compartido en farmacia de pedidos por correo (suministro para 30 días)*
1
Medicamentos genéricos preferidos
$5 de copago
$10 de copago
$10 de copago
$5 de copago
2
Medicamentos genéricos
$12 de copago
$24 de copago
$24 de copago
$12 de copago
3
Medicamentos de marca preferidos
$47 de copago
$141 de copago $131 de copago
$47 de copago
4
Medicamentos de marca no preferidos
$100 de copago $300 de copago $290 de copago $100 de copago
5
Medicamentos de nivel de especialidad
33% de coseguro
N/A
N/A
33% de coseguro
6
Medicamentos para tratamientos seleccionados
$11 de copago
$33 de copago
$23 de copago
$11 de copago
*Para las reposiciones 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. †Le proporcionaremos cobertura adicional de medicamentos recetados en los niveles 1 y 2 en el Vacío de cobertura. Consulte su Evidencia de cobertura para obtener más información acerca de esta cobertura.
SCAN Health Plan | Formulario 2016
LV
Scripps Heart First offered by SCAN Health Plan (HMO SNP)†: Condado de San Diego
Nivel del medicamento
Nombre del nivel
Costo compartido en farmacia minorista estándar y de pedidos por correo (dentro de la red) (suministro para 30 días)
Costo compartido en farmacia minorista estándar y de pedidos por correo (dentro de la red) (suministro para 90 días)
Costo compartido en farmacia de pedidos por correo (dentro de la red) (suministro para 90 días)
Costo compartido en farmacia de pedidos por correo (suministro para 30 días)*
1
Medicamentos genéricos preferidos
$5 de copago
$10 de copago
$10 de copago
$5 de copago
2
Medicamentos genéricos
$10 de copago
$20 de copago
$20 de copago
$10 de copago
3
Medicamentos de marca preferidos
$47 de copago
$141 de copago $131 de copago
$47 de copago
4
Medicamentos de marca no preferidos
$100 de copago $300 de copago $290 de copago $100 de copago
5
Medicamentos de nivel de especialidad
33% de coseguro
N/A
N/A
33% de coseguro
6
Medicamentos para tratamientos seleccionados
$0 de copago
$0 de copago
$0 de copago
$0 de copago
*Para las reposiciones 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. †Le proporcionaremos cobertura adicional de medicamentos recetados en los niveles 1 y 6 en el Vacío de cobertura. Consulte su Evidencia de cobertura para obtener más información acerca de esta cobertura.
LVI
SCAN Health Plan | Formulario 2016
Heart First (HMO SNP)†: Condados de Napa y Sonoma
Nivel del medicamento
Nombre del nivel
Costo compartido en farmacia minorista estándar y de pedidos por correo (dentro de la red) (suministro para 30 días)
Costo compartido en farmacia minorista estándar y de pedidos por correo (dentro de la red) (suministro para 90 días)
Costo compartido en farmacia de pedidos por correo (dentro de la red) (suministro para 90 días)
Costo compartido en farmacia de pedidos por correo (suministro para 30 días)*
1
Medicamentos genéricos preferidos
$5 de copago
$10 de copago
$10 de copago
$5 de copago
2
Medicamentos genéricos
$15 de copago
$30 de copago
$30 de copago
$15 de copago
3
Medicamentos de marca preferidos
$47 de copago
$141 de copago $131 de copago
$47 de copago
4
Medicamentos de marca no preferidos
$100 de copago $300 de copago $290 de copago $100 de copago
5
Medicamentos de nivel de especialidad
33% de coseguro
N/A
N/A
33% de coseguro
6
Medicamentos para tratamientos seleccionados
$0 de copago
$0 de copago
$0 de copago
$0 de copago
*Para las reposiciones 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. †Le proporcionaremos cobertura adicional de medicamentos recetados en los niveles 1 y 6 en el Vacío de cobertura. Consulte su Evidencia de cobertura para obtener más información acerca de esta cobertura.
SCAN Health Plan | Formulario 2016
LVII
SCAN Balance (HMO SNP)†: Condados de Los Angeles y Orange
Nivel del medicamento
Nombre del nivel
Costo compartido en farmacia minorista estándar y de pedidos por correo (dentro de la red) (suministro para 30 días)
Costo compartido en farmacia minorista estándar y de pedidos por correo (dentro de la red) (suministro para 90 días)
Costo compartido en farmacia de pedidos por correo (dentro de la red) (suministro para 90 días)
Costo compartido en farmacia de pedidos por correo (suministro para 30 días)*
1
Medicamentos genéricos preferidos
$3 de copago
$6 de copago
$6 de copago
$3 de copago
2
Medicamentos genéricos
$7 de copago
$14 de copago
$14 de copago
$7 de copago
3
Medicamentos de marca preferidos
$47 de copago
4
Medicamentos de marca no preferidos
$100 de copago $300 de copago $290 de copago $100 de copago
5
Medicamentos de nivel de especialidad
33% de coseguro
N/A
N/A
33% de coseguro
6
Medicamentos para tratamientos seleccionados
$0 de copago
$0 de copago
$0 de copago
$0 de copago
$141 de copago $131 de copago
$47 de copago
*Para las reposiciones 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. †Le proporcionaremos cobertura adicional de medicamentos recetados en los niveles 1, 2 y 6 en el Vacío de cobertura. Consulte su Evidencia de cobertura para obtener más información acerca de esta cobertura.
LVIII
SCAN Health Plan | Formulario 2016
SCAN Balance (HMO SNP)†: Condado de Marin
Nivel del medicamento
Nombre del nivel
Costo compartido en farmacia minorista estándar y de pedidos por correo (dentro de la red) (suministro para 30 días)
Costo compartido en farmacia minorista estándar y de pedidos por correo (dentro de la red) (suministro para 90 días)
Costo compartido en farmacia de pedidos por correo (dentro de la red) (suministro para 90 días)
Costo compartido en farmacia de pedidos por correo (suministro para 30 días)*
1
Medicamentos genéricos preferidos
$3 de copago
$6 de copago
$6 de copago
$3 de copago
2
Medicamentos genéricos
$7 de copago
$14 de copago
$14 de copago
$7 de copago
3
Medicamentos de marca preferidos
$45 de copago
$135 de copago $125 de copago
$45 de copago
4
Medicamentos de marca no preferidos
$95 de copago
$285 de copago $275 de copago
$95 de copago
5
Medicamentos de nivel de especialidad
33% de coseguro
N/A
N/A
33% de coseguro
6
Medicamentos para tratamientos seleccionados
$0 de copago
$0 de copago
$0 de copago
$0 de copago
*Para las reposiciones 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. †Le proporcionaremos cobertura adicional de medicamentos recetados en los niveles 1, 2 y 6 en el Vacío de cobertura. Consulte su Evidencia de cobertura para obtener más información acerca de esta cobertura.
SCAN Health Plan | Formulario 2016
LIX
SCAN Balance (HMO SNP)†: Condados de Napa y Sonoma
Nivel del medicamento
Nombre del nivel
Costo compartido en farmacia minorista estándar y de pedidos por correo (dentro de la red) (suministro para 30 días)
Costo compartido en farmacia minorista estándar y de pedidos por correo (dentro de la red) (suministro para 90 días)
Costo compartido en farmacia de pedidos por correo (dentro de la red) (suministro para 90 días)
Costo compartido en farmacia de pedidos por correo (suministro para 30 días)*
1
Medicamentos genéricos preferidos
$5 de copago
$10 de copago
$10 de copago
$5 de copago
2
Medicamentos genéricos
$15 de copago
$30 de copago
$30 de copago
$15 de copago
3
Medicamentos de marca preferidos
$47 de copago
$141 de copago $131 de copago
$47 de copago
4
Medicamentos de marca no preferidos
$100 de copago $300 de copago $290 de copago $100 de copago
5
Medicamentos de nivel de especialidad
33% de coseguro
N/A
N/A
33% de coseguro
6
Medicamentos para tratamientos seleccionados
$0 de copago
$0 de copago
$0 de copago
$0 de copago
*Para las reposiciones 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. †Le proporcionaremos cobertura adicional de medicamentos recetados en los niveles 1 y 6 en el Vacío de cobertura. Consulte su Evidencia de cobertura para obtener más información acerca de esta cobertura.
LX
SCAN Health Plan | Formulario 2016
El siguiente cuadro es únicamente para miembros elegibles para Medicare y Medi-Cal. Indica lo que pagará como su parte del costo por medicamentos recetados cubiertos cuando se encuentra en la Etapa de cobertura inicial. Consulte su Evidencia de cobertura para obtener más información. Los copagos pueden variar con base en el nivel de Ayuda adicional que usted reciba. Comuníquese con Servicios para Miembros para obtener más detalles. Nuestra información de contacto aparece en la portada y en la contraportada. SCAN Connections (HMO SNP)—Únicamente para miembros elegibles para Medicare y Medi-Cal: Condados de Los Angeles, Riverside, San Bernardino y San Joaquín SCAN Connections at Home (HMO SNP)—Únicamente para miembros elegibles para Medicare y Medi-Cal: Condados de Los Angeles, Riverside y San Bernardino Costo compartido & Costo compartido en farmacia de pedidos por correo (dentro de la red) (suministro para 30 días)
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)*
Nivel del medicamento
Nombre del nivel
1
Medicamentos genéricos preferidos
$0 o $1.20 o $2.95 $0 o $1.20 o $2.95 $0 o $1.20 o $2.95
2
Medicamentos genéricos
$0 o $1.20 o $2.95 $0 o $1.20 o $2.95 $0 o $1.20 o $2.95
3
Medicamentos de marca preferidos
$0 o $1.20 o $2.95 $0 o $1.20 o $2.95 $0 o $1.20 o $2.95 o $3.60 o $7.40 o $3.60 o $7.40 o $3.60 o $7.40
4
Medicamentos de marca no preferidos
$0 o $3.60 o $7.40 $0 o $3.60 o $7.40 $0 o $3.60 o $7.40
5
Medicamentos de nivel de especialidad
$0 o $1.20 o $2.95 o $3.60 o $7.40
6
Medicamentos para tratamientos seleccionados
N/A
$0 o $1.20 o $2.95 o $3.60 o $7.40
$0 o $3.60 o $7.40 $0 o $3.60 o $7.40 $0 o $3.60 o $7.40
*Para las reposiciones 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.
SCAN Health Plan | Formulario 2016
LXI
Formulario de SCAN Health Plan El formulario que comienza en la página 1 proporciona información sobre los medicamentos que cubre SCAN Health Plan. Si tiene dificultades para encontrar su medicamento en la lista, diríjase al índice que inicia en la página 30. 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 SCAN Health Plan 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 27. • 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 1-800-559-3500 (los miembros elegibles para Medicare y Medi-Cal deben llamar al 1-866-722-6725), 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.
LXII
SCAN Health Plan | Formulario 2016
FORMULARY DRUGS ARRANGED BY THERAPEUTIC CLASS MEDICAMENTOS DEL FORMULARIO COORDINADOS POR LA CLASE TERAPÉUTICA Formulary ID: 16400 (Version 6) ID de Formulario: 16400 (Versión 6)
Updated: 08/2015 Actualizado: 08/2015
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 XXX.
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] 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] meloxicam tabs 1 [90D] Nombre del Medicamento
Nivel
Drug Name
Drug Requirements/ Tier Limits
Nombre del Medicamento
Nivel
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 nitrofurantoin caps
2 1 1 1 2 2
Requisitos/ Límites [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 2
[90D] [90D] [90D] [90D] [90D] [90D] [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 LXII.
2
Drug Name
Drug Requirements/ Tier Limits
Nombre del Medicamento
Nivel
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 ZERBAXA INJ 5
Requisitos/ Límites [90D]
Drug Name
Drug Requirements/ Tier Limits
Nombre del Medicamento
Nivel
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
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 XXX.
3
Drug Name
Drug Requirements/ Tier Limits
Nombre del Medicamento
Nivel
Drug Name
Requisitos/ Límites [90D]
erythromycin & 2 sulfisoxazole Quinolones ciprofloxacin inj 2 ciprofloxacin oral susp 2 ciprofloxacin tabs 1 immediate-release ciprofloxacin tabs er 2 levofloxacin inj 2 levofloxacin oral soln 2 levofloxacin tabs 1 moxifloxacin oral 2 ofloxacin oral 2 Sulfonamides sulfadiazine 2 sulfamethoxazole & 1 trimethoprim tabs sulfamethoxazole & 1 trimethoprim ds tabs sulfamethoxazole & 2 trimethoprim oral susp sulfamethoxazole & 2 trimethoprim inj Tetracyclines demeclocycline 3 doxy 100 inj 2 doxycycline immediate2 release tabs, caps & oral susp doxycycline inj 2 minocycline ir 2 tetracycline 2 ANTICONVULSANTS Anticonvulsants, Other FYCOMPA 4 levetiracetam er 2 levetiracetam oral 2 levetiracetam inj 2 POTIGA 4 Calcium Channel Modifying Agents
Drug Requirements/ Tier Limits
Requisitos/ Límites 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] carbamazepine tabs, 2 [90D] chewable tabs & oral susp Nombre del Medicamento
[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]
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 LXII.
4
Drug Name
Drug Requirements/ Tier Limits
Nombre del Medicamento
Nivel
Requisitos/ Límites [90D]
carbamazepine er tabs & 2 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] N-methyl-D-aspartate (NMDA) Receptor Antagonists memantine hcl immediate 2 [90D] release NAMENDA 3 [90D] NAMENDA ORAL SOLN 3 [90D]
Drug Name
Drug Requirements/ Tier Limits
Nombre del Medicamento
Nivel
Requisitos/ Límites [90D]
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] fluvoxamine 2 [90D] fluvoxamine er 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 XXX.
5
Drug Name
Drug Requirements/ Tier Limits
Nombre del Medicamento
Nivel
KHEDEZLA paroxetine immediaterelease paroxetine er PAXIL 10MG/5ML SUSP PRISTIQ sertraline tabs sertraline oral soln venlafaxine ir tabs venlafaxine er caps VIIBRYD VIIBRYD TITRATION PACK Tricyclics amitriptyline amoxapine clomipramine desipramine doxepin imipramine hcl tabs nortriptyline oral perphenazine & amitriptyline protriptyline SURMONTIL ANTIEMETICS Antiemetics, Other compro meclizine metoclopramide oral tablets & soln metoclopramide inj phenadoz phenergan suppositories prochlorperazine inj prochlorperazine oral prochlorperazine suppositories promethazine inj
4 1
Requisitos/ Límites [ST] [90D] [90D]
2 4 4 1 2 2 2 4 4
[90D] [90D] [ST] [90D] [90D] [90D] [90D] [90D] [ST] [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
[90D] [PA] [90D]
2 2 2
[90D] [90D] [90D]
2 3 3 2 2 2
[90D] [PA] [90D] [PA] [90D] [90D] [90D] [90D]
3
[PA] [90D]
Drug Name
Drug Requirements/ Tier Limits
Nombre del Medicamento
Nivel
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 econazole nitrate fluconazole in dextrose inj
Requisitos/ Límites [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 3 2
[90D] [PA] [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 LXII.
6
Drug Name
Drug Requirements/ Tier Limits
Nombre del Medicamento
Nivel
Requisitos/ Límites [90D]
Drug Name
Drug Requirements/ Tier Limits
Nombre del Medicamento
Nivel
ANTIMYASTHENIC AGENTS Parasympathomimetics guanidine MESTINON SYRUP MESTINON TIMESPAN pyridostigmine 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
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] 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] zolmitriptan tabs 2 [90D] zolmitriptan odt 2 [90D] ZOMIG NASAL 4 [QL] [90D]
GLEOSTINE HEXALEN LEUKERAN LOMUSTINE MATULANE VALCHLOR Antiandrogens bicalutamide flutamide NILANDRON XTANDI
Requisitos/ Límites
2 3 3 2
[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]
4 5 3 4 5 5
[90D]
2 2 4 5
[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 XXX.
7
[90D] [90D] [PA] [90D] [90D] [90D] [PA]
Drug Name
Drug Requirements/ Tier Limits
Nombre del Medicamento
Nivel
Requisitos/ Límites [PA]
Drug Name
Drug Requirements/ Tier Limits
Nombre del Medicamento
Nivel
etoposide inj FARYDAK ZOLINZA ZYDELIG Molecular Target Inhibitors AFINITOR AFINITOR DISPERZ BOSULIF CAPRELSA COMETRIQ ERIVEDGE GILOTRIF GLEEVEC IBRANCE ICLUSIG IMBRUVICA INLYTA JAKAFI LENVIMA MEKINIST NEXAVAR SPRYCEL STIVARGA SUTENT TAFINLAR TARCEVA TASIGNA TYKERB VOTRIENT XALKORI ZELBORAF ZYKADIA Monoclonal Antibodies AVASTIN INJ HERCEPTIN INJ KEYTRUDA INJ RITUXAN INJ YERVOY INJ
ZYTIGA 5 Antiangiogenic Agents POMALYST 5 [PA] REVLIMID 5 [PA] [LD] THALOMID 5 [PA] Antiestrogens/Modifiers EMCYT 3 [90D] FARESTON 3 [90D] FASLODEX INJ 5 SOLTAMOX 3 [90D] tamoxifen 2 [90D] Antimetabolites ALIMTA INJ 5 [PA] hydroxyurea 2 [90D] mercaptopurine 2 [90D] PURIXAN 5 TABLOID 4 [PA] [90D] Antineoplastics, Other amifostine inj 5 [PA] [B vs D] azacitidine inj 5 [PA] [B vs D] ERWINAZE INJ 5 [PA] leucovorin oral 2 [90D] leucovorin inj 2 [90D] levoleucovorin inj 5 LYNPARZA 5 [PA] MESNEX TABS 3 [90D] mitoxantrone inj 2 [PA] [90D] ONCASPAR INJ 5 [PA] paclitaxel inj 2 [90D] SYLATRON INJ 5 [PA] SYNRIBO INJ 5 [PA] VELCADE INJ 5 [PA] Aromatase Inhibitors, 3rd Generation anastrozole 2 [90D] exemestane 3 [90D] letrozole 2 [90D] Enzyme Inhibitors BELEODAQ 5 [PA]
3 5 5 5
Requisitos/ Límites [90D] [PA] [PA] [PA]
5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5
[PA] [PA] [PA] [PA] [PA] [PA] [PA] [PA] [PA] [PA] [PA] [PA] [PA] [PA] [PA] [PA] [LD] [PA] [PA] [PA] [PA]
5 5 5 5 5
[PA] [PA] [PA] [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 LXII.
8
[PA] [PA] [PA] [PA] [PA] [PA]
Drug Name
Drug Requirements/ Tier Limits
Nombre del Medicamento
Nivel
Retinoids PANRETIN TARGRETIN tretinoin caps ANTIPARASITICS Anthelmintics ALBENZA ivermectin Antiprotozoals ALINIA atovaquone atovaquone/proguanil chloroquine COARTEM DARAPRIM hydroxychloroquine mefloquine NEBUPENT NEBULIZER
Requisitos/ Límites
5 5 2
[PA] [90D]
4 2
[90D] [90D]
4 5 2 2 3 3 2 2 4
[90D]
PENTAM INJ 4 PRIMAQUINE 3 quinine sulfate caps 2 324mg Pediculicides/Scabicides EURAX 3 malathion 2 permethrin cream 2 ANTIPARKINSON AGENTS Anticholinergics benztropine inj 2 benztropine tabs 2 trihexyphenidyl tabs 2 trihexyphenidyl elixir 2 Antiparkinson Agents, Other amantadine 2 entacapone 3 Dopamine Agonists
Drug Name
Drug Requirements/ Tier Limits
Nombre del Medicamento
Nivel
Requisitos/ Límites
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 chlorpromazine oral 2 [90D] chlorpromazine inj 2 [90D] fluphenazine oral 2 [90D] fluphenazine decanoate inj 2 [90D] fluphenazine inj 2 [90D] haloperidol tabs 2 [90D] haloperidol decanoate inj 2 [90D] haloperidol lactate oral 2 [90D] soln haloperidol lactate inj 2 [90D] loxapine 2 [90D] ORAP 4 [90D] perphenazine 2 [90D] thioridazine 2 [PA] [90D] thiothixene 2 [90D] trifluoperazine 2 [90D] nd 2 Generation/Atypical ABILIFY ORAL SOLN 4 [ST] [90D] ABILIFY DISCMELT 4 [ST] [90D] ABILIFY INJ 4 [90D]
[90D] [90D] [90D] [90D] [90D] [90D] [PA] [B vs D] [90D] [90D] [90D] [PA] [90D] [90D] [90D] [90D]
[90D] [PA] [90D] [PA] [90D] [PA] [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 XXX.
9
Drug Name
Drug Requirements/ Tier Limits
Nombre del Medicamento
Nivel
ABILIFY MAINTENA 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
5 2
[ST] [90D]
5
[ST]
4 4
[ST] [90D] [ST] [90D]
3 5 4
[90D] [ST] [90D]
4
[ST] [90D]
olanzapine tabs olanzapine odt olanzapine inj 10mg quetiapine RISPERDAL CONSTA INJ 12.5MG & 25MG RISPERDAL CONSTA INJ 37.5MG & 50MG risperidone risperidone odt SAPHRIS
2 2 2 2 4
[90D] [90D] [90D] [90D] [90D]
2 2 4
[90D] [90D] [ST] [90D]
SEROQUEL XR
4
[ST] [90D]
ziprasidone oral
2 5
[90D]
2 2 4 4
[90D] [90D] [90D] [90D]
2 2
[90D] [90D]
ZYPREXA RELPREVV 210MG Treatment-Resistant clozapine clozapine odt FAZACLO VERSACLOZ ANTISPASTICITY AGENTS Antispasticity Agents baclofen tizanidine
Requisitos/ Límites
Drug Name
Drug Requirements/ Tier Limits
Nombre del Medicamento
Nivel
Requisitos/ Límites
ANTIVIRALS Anti-cytomegalovirus (CMV) Agents foscarnet inj 2 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 HARVONI 5 moderiba 200mg tabs 2 moderiba dose pack 5 OLYSIO 5 PEGASYS INJ 5 PEGASYS PROCLICK INJ 5 PEG-INTRON INJ 5 PEG-INTRON REDIPEN 5 INJ ribasphere 2 ribasphere ribapak 5 ribavirin 2 SOVALDI 5 Antiherpetic Agents acyclovir oral 2 acyclovir oint 5% 3 acyclovir inj 2 DENAVIR 3 famciclovir 2 valacyclovir 2 XERESE 3
5
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 LXII.
10
[90D] [90D] [90D]
[90D] [90D] [90D] [90D] [90D] [PA] [90D] [PA]
[90D] [90D] [PA] [90D] [90D] [90D] [90D] [90D] [90D] [90D]
Drug Name
Drug Requirements/ Tier Limits
Nombre del Medicamento
Nivel
Requisitos/ Límites
ZOVIRAX CREAM 5 Anti-HIV Agents, Integrase Inhibitors (INSTI) 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] nevirapine oral susp 2 [90D] nevirapine tabs 2 [90D] RESCRIPTOR 3 [90D] 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
Drug Name
Drug Requirements/ Tier Limits
Nombre del Medicamento
Nivel
Requisitos/ Límites
TRUVADA 5 VIDEX PEDIATRIC SOLN 4 2GM VIREAD TABS 5 VIREAD POWDER 4 ZIAGEN SOLN 4 zidovudine 2 Anti-HIV Agents, Other FUZEON INJ 3 SELZENTRY 5 TYBOST 3 Anti-HIV Agents, Protease Inhibitors APTIVUS 5 CRIXIVAN 3 EVOTAZ 5 INVIRASE 4 KALETRA TABS 1004 25MG KALETRA TABS 2005 50MG & SOLN 400100MG/5ML LEXIVA ORAL SUSP 4 LEXIVA TABS 5 NORVIR 4 PREZCOBIX 5 PREZISTA SUSP 4 100MG/ML PREZISTA TABS 75MG & 4 150MG PREZISTA TABS 600MG 5 & 800MG REYATAZ CAPS & ORAL 5 POWDER VIRACEPT 5 Anti-influenza Agents RELENZA DISKHALER 3 rimantadine 2 TAMIFLU CAPS 75MG 3 TAMIFLU SUSP 3
[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 XXX.
11
[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
ANXIOLYTICS Anxiolytics, Other buspirone 2 Benzodiazepines alprazolam tabs 2 alprazolam er tabs 2 alprazolam intensol 2 diazepam tabs & soln 2 diazepam intensol 2 lorazepam tabs 2 lorazepam intensol 2 oxazepam 2 BIPOLAR AGENTS Mood Stabilizers lithium carbonate 2 lithium carbonate er 2 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
Requisitos/ Límites
Drug Name
Drug Requirements/ Tier Limits
Nombre del Medicamento
Nivel
nateglinide ONGLYZA pioglitazone pioglitazone & metformin repaglinide SYMLINPEN INJ VICTOZA INJ XIGDUO XR Glycemic Agents GLUCAGON EMERGENCY KIT INJ PROGLYCEM Insulins HUMALOG CARTRIDGE INJ HUMALOG KWIKPEN INJ HUMALOG MIX 50/50 KWIKPEN INJ HUMALOG MIX 75/25 KWIKPEN INJ HUMALOG MIX 50/50 VIAL INJ HUMALOG MIX 75/25 VIAL INJ HUMALOG VIAL INJ HUMULIN 70/30 KWIKPEN INJ HUMULIN 70/30 VIAL INJ HUMULIN N KWIKPEN INJ HUMULIN N VIAL INJ HUMULIN R U-500 (CONCENTRATED) VIAL INJ HUMULIN R VIAL INJ LANTUS SOLOSTAR PEN INJ LANTUS VIAL INJ
[90D] [PA] [90D] [PA] [90D] [PA] [90D] [PA] [90D] [PA] [90D] [90D] [90D] [PA] [90D]
[90D] [90D] [90D]
[90D] [PA] [90D] [PA] [90D] [90D] [ST] [90D] [90D] [QL] [90D] [90D] [90D] [90D] [ST] [90D] [ST] [90D] [90D] [90D] [90D] [90D] [90D] [90D]
2 3 2 2 2 3 3 3
Requisitos/ Límites [90D] [90D] [90D] [90D] [90D] [PA] [90D] [PA] [90D] [ST] [90D]
3
[90D]
4
[90D]
3
[90D]
3 3
[90D] [90D]
3
[90D]
6
[90D]
6
[90D]
6 3
[90D] [90D]
6 3
[90D] [90D]
6 6
[90D] [90D]
6 3
[90D] [90D]
6
[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 LXII.
12
Drug Name
Drug Requirements/ Tier Limits
Requisitos/ Límites 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 Blood Formation Modifiers anagrelide 2 [90D] LEUKINE INJ 5 [PA] NEUMEGA INJ 5 [PA] NEUPOGEN INJ 5 [PA] PROCRIT INJ 3 [PA] [90D] 2000UNIT/ML PROCRIT INJ 4 [PA] [90D] 3000UNIT/ML, 4000UNIT/ML & 10000UNIT/ML PROCRIT INJ 5 [PA] 20000UNIT/ML & 40000UNIT/ML PROMACTA 5 [PA] [LD] Coagulants tranexamic acid inj 2 [90D] tranexamic acid tabs 2 [90D] Platelet Modifying Agents AGGRENOX 4 [QL] [90D] BRILINTA 3 [QL] [90D] Nombre del Medicamento
Nivel
Drug Name
Drug Requirements/ Tier Limits
Nombre del Medicamento
Nivel
Requisitos/ Límites [90D] [90D] [PA] [90D]
cilostazol 2 clopidogrel tabs 75mg 2 dipyridamole oral 2 CARDIOVASCULAR AGENTS Alpha-adrenergic Agonists clonidine patches 2 [90D] clonidine tabs immediate1 [90D] release guanfacine 2 [PA] [90D] methyldopa 2 [PA] [90D] methyldopa & 2 [PA] [90D] hydrochlorothiazide methyldopate inj 2 [90D] midodrine tabs 2 [90D] Alpha-adrenergic Blocking Agents doxazosin 2 [90D] prazosin 2 [90D] terazosin 1 [90D] 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]
[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 XXX.
13
Drug Name
Drug Requirements/ Tier Limits
Nombre del Medicamento
Nivel
Requisitos/ Límites [90D] [90D]
quinapril 1 quinapril & 1 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 Antiarrhythmics amiodarone tabs 200mg & 2 [90D] 400mg disopyramide phosphate 2 [PA] [90D] flecainide acetate 2 [90D] mexiletine 2 [90D] pacerone tabs 200mg 2 [90D] procainamide inj 2 [90D] propafenone 2 [90D] quinidine gluconate cr 2 [90D] quinidine gluconate inj 2 [90D] quinidine sulfate 2 [90D] sorine 2 [90D] sotalol tabs 2 [90D] TIKOSYN 4 [90D] Beta-adrenergic Blocking Agents acebutolol 2 [90D] atenolol 1 [90D] atenolol & chlorthalidone 1 [90D] bisoprolol 2 [90D] bisoprolol & 2 [90D] hydrochlorothiazide
Drug Name
Drug Requirements/ Tier Limits
Nombre del Medicamento
Nivel
Requisitos/ Límites [90D] [90D] [90D] [90D] [90D] [90D] [90D] [90D]
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 [90D] nadolol & 2 [90D] bendroflumethiazide pindolol 2 [90D] propranolol ir tabs 1 [90D] propranolol er caps 2 [90D] propranolol oral soln 2 [90D] propranolol inj 2 [90D] propranolol & 1 [90D] hydrochlorothiazide timolol oral 1 [90D] Calcium Channel Blocking Agents afeditab cr 2 [90D] amlodipine 1 [90D] amlodipine & atorvastatin 2 [90D] amlodipine & benazepril 2 [90D] cartia xt 2 [90D] diltiazem tabs 2 [90D] diltiazem cd caps 120mg, 2 [90D] 180mg, 240mg, & 300mg diltiazem er caps 2 [90D] diltiazem inj 50mg/10ml 2 [90D] dilt-xr 2 [90D] felodipine er 2 [90D] isradipine 2 [90D] nicardipine caps 2 [90D] nifedical xl 2 [90D] nifedipine 2 [PA] [90D] nifedipine er 2 [90D] nimodipine caps 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 LXII.
14
Drug Name
Drug Requirements/ Tier Limits
Nombre del Medicamento
Nivel
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 pentoxifylline er 2 RANEXA 3 TEKTURNA 3 TEKTURNA HCT 3 Diuretics, Loop bumetanide oral 2 furosemide oral 1 furosemide inj 2 torsemide oral 2 Diuretics, Potassium-sparing amiloride 2 amiloride & 1 hydrochlorothiazide eplerenone 2 spironolactone 1 spironolactone & 1 hydrochlorothiazide triamterene & 1 hydrochlorothiazide Diuretics, Thiazide chlorothiazide tabs 2 chlorthalidone 1 hydrochlorothiazide 1
Drug Name
Requisitos/ Límites [90D] [90D] [90D] [90D] [90D] [90D] [90D]
Drug Requirements/ Tier Limits
Requisitos/ Límites 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] SIMCOR 3 [90D] simvastatin 1 [90D] 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] Nombre del Medicamento
[PA] [PA] [90D] [PA] [90D] [PA] [90D] [PA] [90D] [PA] [90D] [PA] [90D] [PA] [90D] [ST] [90D] [ST] [90D] [90D] [90D] [90D] [90D] [90D] [90D] [90D] [90D] [90D] [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 XXX.
15
Drug Name
Drug Requirements/ Tier Limits
Requisitos/ Límites 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 dextroamphetamine 2 [QL] [90D] 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] XENAZINE 5 [PA] Fibromyalgia Agents SAVELLA 3 [90D] SAVELLA TITRATION 3 [90D] PACK Multiple Sclerosis Agents AMPYRA 5 [PA] AVONEX INJ 5 [PA] Nombre del Medicamento
Nivel
Drug Name
Drug Requirements/ Tier Limits
Nombre del Medicamento
Nivel
AVONEX PEN INJ 5 BETASERON INJ 5 GILENYA 5 glatopa inj 5 PLEGRIDY INJ 5 PLEGRIDY STARTER 5 PACK INJ REBIF INJ 5 REBIF REBIDOSE INJ 5 REBIF REBIDOSE 5 TITRATION PACK INJ REBIF TITRATION PACK 5 INJ TECFIDERA 5 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
Requisitos/ Límites [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 LXII.
16
[PA] [PA] [PA] [PA] [PA] [PA] [PA] [PA] [PA] [PA] [PA]
[90D] [90D] [90D] [90D]
[PA] [90D] [90D] [QL] [90D] [90D]
[90D] [90D] [QL] [90D]
Drug Name
Drug Requirements/ Tier Limits
Nombre del Medicamento
Nivel
Requisitos/ Límites
Drug Name
Drug Requirements/ Tier Limits
Nombre del Medicamento
Nivel
Requisitos/ Límites
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] 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]
FLUOROURACIL 0.5% 5 CREAM fluorouracil 2% and 5% 3 [90D] topical imiquimod 3 [90D] methoxsalen 2 [90D] podofilox 2 [90D] prudoxin 2 [90D] REGRANEX 5 [QL] SANTYL 3 [90D] selenium sulfide lotion 2 [90D] sulfacetamide sodium 2 [90D] susp 10% tacrolimus oint 3 [90D] TAZORAC 4 [QL] [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]
[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 XXX.
17
Drug Name
Drug Requirements/ Tier Limits
Nombre del Medicamento
Nivel
Requisitos/ Límites [90D] [90D] [90D] [90D] [90D] [90D] [90D]
MOVIPREP 3 OSMOPREP 3 peg 3350 & electrolytes 2 polyethylene glycol 3350 2 PREPOPIK 3 SUCLEAR BOWEL PREP 3 SUPREP BOWEL PREP 3 Protectants misoprostol 2 [90D] sucralfate 2 [90D] 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] finasteride tabs 5mg 2 [90D] prazosin 2 [90D] tamsulosin 2 [90D] terazosin 1 [90D] Genitourinary Agents, Other bethanechol 2 [90D] ELMIRON 4 [90D]
Drug Name
Drug Requirements/ Tier Limits
Nombre del Medicamento
Nivel
Requisitos/ Límites [90D]
THIOLA 3 Phosphate Binders calcium acetate 2 [90D] eliphos 2 [90D] FOSRENOL 3 [90D] RENVELA 3 [90D] sevelamer carbonate 2 [90D] 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
[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 LXII.
18
Drug Name
Drug Requirements/ Tier Limits
Nombre del Medicamento
Nivel
Requisitos/ Límites [90D] [90D]
halobetasol 2 hydrocortisone 2.5% 2 cream, lotion, oint hydrocortisone butyrate 2 [90D] oint & soln hydrocortisone oral 2 [90D] hydrocortisone valerate 2 [90D] methylprednisolone oral 2 [90D] methylprednisolone 2 [90D] 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
Drug Name
Drug Requirements/ Tier Limits
Nombre del Medicamento
Nivel
Requisitos/ Límites [PA] [90D]
HUMATROPE INJ 6MG 4 CARTRIDGE HUMATROPE INJ 5MG 5 [PA] VIAL, 12MG & 24MG CARTRIDGE INCRELEX INJ 5 [PA] STIMATE 4 [90D] 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] Estrogens ALORA 3 [PA] [90D] apri 2 [90D] aranelle 2 [90D] aubra 2 [90D] aviane 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]
[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 XXX.
19
Drug Name
Drug Requirements/ Tier Limits
Nombre del Medicamento
Nivel
ESTRACE VAGINAL estradiol oral estradiol patches estradiol & norethindrone acetate estropipate falmina gildagia gildess introvale jinteli junel kariva larin larin fe leena levonest levonorgestrel & ethinyl estradiol 0.1-0.02mg, 0.150.03mg 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 tarina fe tri-sprintec trivora-28
3 2 3 3
Requisitos/ Límites [90D] [PA] [90D] [PA] [90D] [PA] [90D]
2 2 2 2 2 3 2 2 2 2 2 2 2
[PA] [90D] [90D] [90D] [90D] [90D] [PA] [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
[90D] [90D] [90D] [PA] [90D] [90D] [PA] [90D] [PA] [90D] [90D] [90D] [90D] [90D] [PA] [90D] [90D] [PA] [90D] [PA] [90D] [90D] [90D] [90D]
Drug Name
Drug Requirements/ Tier Limits
Nombre del Medicamento
Nivel
Requisitos/ Límites [90D] [90D] [90D] [90D] [90D] [90D] [90D]
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 [PA] [90D] susp megestrol tabs 2 [PA] [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]
[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 LXII.
20
Drug Name
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
Nivel
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
tacrolimus caps 0.5mg & 1mg tacrolimus caps 5mg ZORTRESS TABS 0.25MG ZORTRESS TABS 0.5MG & 0.75MG
3
5 2 2 2 5 3
4 3
5 4 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] = 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 XXX.
21
Drug Name
Drug Requirements/ Tier Limits
Nombre del Medicamento
Nivel
Immunizing Agents, Passive ATGAM INJ 5 GAMMAGARD INJ 5 GAMUNEX-C INJ 5 Immunomodulators ACTIMMUNE INJ 5 ARCALYST INJ 5 ILARIS INJ 5 leflunomide 2 OTEZLA 5 OTEZLA STARTER 5 RIDAURA 5 SYNAGIS INJ 5 XELJANZ 5 Vaccines ACTHIB INJ 3 ADACEL INJ 3 BEXSERO INJ 3 BOOSTRIX INJ 3 CERVARIX INJ 4 COMVAX INJ 3 DAPTACEL INJ 3 DIPHTHERIA & TETANUS 3 TOXOIDS PEDIATRIC INJ ENGERIX-B INJ 3
Requisitos/ Límites [PA] [PA] [B vs D] [PA] [B vs D]
[PA] [PA] [QL] [90D] [PA] [PA]
[90D] [90D] [90D] [90D] [90D] [90D] [90D] [90D]
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
3 3 4 3 3
[90D] [90D] [90D]
Drug Requirements/ Tier Limits
Nombre del Medicamento
Nivel
MENVEO-A/C/Y/W-135 INJ M-M-R II INJ PEDVAX HIB INJ PROQUAD INJ QUADRACEL INJ RABAVERT INJ
3
RECOMBIVAX HB INJ
3
3 3 3 3 3
Requisitos/ Límites [90D] [90D] [90D] [90D] [90D] [PA] [B vs D] [90D] [PA] [B vs D] [90D] [90D] [90D] [90D] [90D]
ROTARIX 3 ROTATEQ 3 TENIVAC 3 TETANUS & DIPHTHERIA 3 TOXOIDS-ADSORBED ADULT INJ TETANUS TOXOID 3 [PA] [B vs D] ADSORBED INJ [90D] 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]
[PA]
[PA] [B vs D] [90D] [90D] [90D] [90D] [PA] [B vs D] [90D] [90D] [90D]
Drug Name
[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 LXII.
22
Drug Name
Drug Requirements/ Tier Limits
Nombre del Medicamento
Nivel
Requisitos/ Límites
Sulfonamides sulfasalazine 2 [90D] sulfazine 2 [90D] sulfazine ec 2 [90D] 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]
Drug Name
Drug Requirements/ Tier Limits
Nombre del Medicamento
Nivel
bd insulin syringe ultrafine bd insulin syringe safetyglide bd pen needle ultrafine BRISDELLE FERRIPROX gauze pads 2"x2" levocarnitine oral
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
[90D] [90D] [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
sulfacetamide sodium oint & soln 10% tobramycin sulfate trifluridine VIGAMOX
2
[PA] [QL] [90D] [90D]
2 2 3
[90D] [90D] [90D]
2 3 5 2 2
Requisitos/ Límites [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 XXX.
23
Drug Name
Drug Requirements/ Tier Limits
Nombre del Medicamento
Nivel
Requisitos/ Límites
Ophthalmic Anti-allergy Agents azelastine 2 [90D] cromolyn sodium 2 [90D] PATADAY 3 [90D] PATANOL 3 [QL] [90D] 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
Drug Name
Drug Requirements/ Tier Limits
Nombre del Medicamento
Nivel
Requisitos/ Límites [90D] [90D] [90D]
PRED MILD 3 prednisolone acetate 2 prednisolone sodium 2 phosphate sulfacetamide sodium & 2 [90D] 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]
[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 LXII.
24
Drug Name
Drug Requirements/ Tier Limits
Nombre del Medicamento
Nivel
budesonide nebulizer
2
Requisitos/ Límites [PA] [B vs D] [90D] [90D] [QL] [90D] [QL] [90D]
Drug Name
Drug Requirements/ Tier Limits
Nombre del Medicamento
Nivel
levalbuterol nebulizer
DULERA 3 flunisolide nasal 2 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]
2
PROAIR HFA 3 PROAIR RESPICLICK 3 SEREVENT DISKUS 3 STRIVERDI RESPIMAT 3 terbutaline sulfate oral 2 terbutaline sulfate inj 2 Cystic Fibrosis Agents CAYSTON 5 KALYDECO 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 [PA] [B vs D] [90D] [90D] [90D] [90D] [90D] [90D] [90D] [PA] [LD] [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]
[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 XXX.
25
Drug Name
Drug Requirements/ Tier Limits
Nombre del Medicamento
Nivel
Requisitos/ Límites
SLEEP DISORDER AGENTS GABA Receptor Modulators estazolam 2 [90D] flurazepam 2 [90D] temazepam 2 [90D] triazolam 2 [90D] zolpidem tabs 5mg & 2 [PA] 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]
Drug Name
Drug Requirements/ Tier Limits
Nombre del Medicamento
Nivel
klor-con lactated ringers inj magnesium sulfate inj MOZOBIL INJ 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 2 2 5 2
sodium chloride inj TPN ELECTROLYTES INJ TRAVASOL INJ
2 3 4
Vitamins prenatal multi-vitamin
2
Requisitos/ Límites [90D] [90D] [90D] [PA] [90D]
2 2 2
[90D] [90D] [90D]
2
[90D]
2
[90D]
2 4
[90D] [PA] [B vs D] [90D] [90D] [90D] [PA] [B vs D] [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 LXII.
26
[90D]
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 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 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
SCAN Health Plan | 2016 Formulary 27
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 7.5-200mg 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 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 RESTASIS rivastigmine ROZEREM
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 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 60 vials per 30 days 62 caps per 31 days 31 tabs per 31 days
SCAN Health Plan | 2016 Formulary 28
Drugs with Quantity Limits Medicamentos con Límites de Cantidad Drug Name Nombre del Medicamento 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 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
SCAN Health Plan | 2016 Formulary 29
INDEX ÍNDICE abacavir & lamivudine & zidovudine, 11 alclometasone dipropionate, 18 abacavir tabs, 11 alcohol pads, 23 ABELCET INJ, 6 ALDURAZYME INJ, 17 alendronate oral soln, 23 ABILIFY DISCMELT, 9 alendronate tabs, 23 ABILIFY INJ, 9 alfuzosin hcl er, 18 ABILIFY MAINTENA, 10 ABILIFY ORAL SOLN, 9 ALIMTA INJ, 8 acamprosate calcium dr, 2 ALINIA, 9 acarbose, 12 allopurinol, 7 acebutolol, 14 ALORA, 19 acetaminophen & codeine, 1, 27 alosetron hcl tabs 0.5mg, 17 acetasol hc, 24 alosetron hcl tabs 1mg, 17 acetazolamide, 24 ALPHAGAN P 0.1%, 24 acetazolamide er caps, 24 alprazolam er tabs, 12 acetazolamide tabs, 24 alprazolam intensol, 12 acetic acid & hydrocortisone, 24 alprazolam tabs, 12 acetylcysteine nebulizer, 25 amantadine, 9 acitretin, 16 AMBISOME INJ, 6 amifostine inj, 8 ACTHIB INJ, 22 amikacin inj, 2 ACTIMMUNE INJ, 22 acyclovir inj, 10 amiloride, 15 acyclovir oint 5%, 10 amiloride & hydrochlorothiazide, 15 acyclovir oral, 10 aminophylline inj, 25 ADACEL INJ, 22 AMINOSYN & ELECTROLYTES INJ, 26 ADAGEN INJ, 17 AMINOSYN INJ, 26 amiodarone tabs 200mg & 400mg, 14 ADCIRCA, 25 adefovir dipivoxil, 10 AMITIZA, 17 amitriptyline, 6 ADEMPAS, 25 amlodipine, 14 ADVAIR DISKUS, 24 amlodipine & atorvastatin, 14 ADVAIR HFA, 24 amlodipine & benazepril, 14 ADVICOR, 15, 27 afeditab cr, 14 ammonium lactate topical, 16 amnesteem, 16 AFINITOR, 8 amoxapine, 6 AFINITOR DISPERZ, 8 amoxicillin, 3 AGGRENOX, 13, 27 amoxicillin & clarithromycin & lansoprazole, 17 ALBENZA, 9 albuterol sulfate er, 25 amoxicillin & clavulanate potassium, 3 albuterol sulfate nebulizer, 25 amoxicillin & clavulanate potassium er, 3 albuterol sulfate syrup, 25 amphetamine & dextroamphetamine, 27 albuterol sulfate tabs, 25 amphetamine & dextroamphetamine tabs, 16 SCAN Health Plan | 2016 Formulary 30
amphotericin b inj, 6 ampicillin & sulbactam inj 10-5gm, 2-1gm, & 10.5gm, 3 ampicillin inj, 3 ampicillin oral, 3 AMPYRA, 16 ANADROL-50, 19 anagrelide, 13 anastrozole, 8 ANDROGEL, 19 ANORO ELLIPTA, 25 APOKYN INJ, 9 apri, 19 APRISO, 22, 27 APTIOM, 4 APTIVUS, 11 aranelle, 19 ARCALYST INJ, 22 aripiprazole, 10 aripiprazole 20mg & 30mg, 10 ASMANEX HFA, 24 ASMANEX TWISTHALER, 24 atenolol, 14 atenolol & chlorthalidone, 14 ATGAM INJ, 22 atorvastatin, 15 atovaquone, 9 atovaquone/proguanil, 9 ATRIPLA, 11 atropine sulfate inj, 17 atropine sulfate soln, 23 ATROVENT HFA, 25, 27 aubra, 19 AUVI-Q INJ, 25 AVASTIN INJ, 8 aviane, 19 AVONEX INJ, 16 AVONEX PEN INJ, 16 azacitidine inj, 8 azathioprine oral, 21 azelastine, 24 azelastine nasal, 24 AZILECT, 9
azithromycin inj, 3 azithromycin tabs & oral susp, 3 AZOR, 14 aztreonam inj 1gm, 3 bacitracin, 23 bacitracin & polymyxin b, 23 baclofen, 10 BACTROBAN CREAM, 2 BACTROBAN NASAL, 2 balsalazide, 22 BANZEL, 4 BARACLUDE ORAL SOLN 0.05MG/ML, 10 bd insulin syringe safetyglide, 23 bd insulin syringe ultrafine, 23 bd pen needle ultrafine, 23 BELEODAQ, 8 BELSOMRA, 26, 27 benazepril, 13 benazepril & hydrochlorothiazide, 13 BENICAR, 14 BENICAR HCT, 14 BENLYSTA INJ, 21 benztropine inj, 9 benztropine tabs, 9 betamethasone dipropionate, 18 betamethasone dipropionate augmented, 18 betamethasone valerate cream, oint, lotion, 18 BETASERON INJ, 16 betaxolol soln, 24 bethanechol, 18 BEXSERO INJ, 22 bicalutamide, 7 BICILLIN L-A INJ, 3 bisoprolol, 14 bisoprolol & hydrochlorothiazide, 14 BLEPHAMIDE, 24 BLEPHAMIDE S.O.P., 24 BOOSTRIX INJ, 22 BOSULIF, 8 BREO ELLIPTA, 24 briellyn, 19 BRILINTA, 13, 27 brimonidine tartrate soln 0.15% & 0.2%, 24
SCAN Health Plan | 2016 Formulary 31
carbidopa & levodopa odt, 9 carteolol, 24 cartia xt, 14 carvedilol, 14 CAYSTON, 25 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, 19 cevimeline, 16 CHANTIX, 2 CHANTIX STARTING MONTH PAK, 2 chloramphenicol sodium succinate inj, 2 chlorhexidine gluconate, 16 chloroquine, 9 chlorothiazide tabs, 15 chlorpromazine inj, 9 chlorpromazine oral, 9 chlorthalidone, 15 chlorzoxazone, 25 cholestyramine, 15 cholestyramine light, 15 ciclopirox 8% nail soln, 6 ciclopirox cream, susp, shampoo, 6 cilastatin/imipenem inj, 3 cilostazol, 13 cimetidine oral, 17
BRINTELLIX, 5 BRISDELLE, 23 bromocriptine, 9 budeprion sr, 5 budesonide ec caps, 22 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, 27 BYDUREON INJ, 12 BYETTA INJ, 12 cabergoline, 21 calcipotriene & betamethasone oint, 16 calcipotriene cream, 27 calcipotriene cream & oint, 16 calcipotriene oint, 27 calcipotriene soln, 16 calcitonin-salmon nasal, 23 calcitriol caps, 23 calcium acetate, 18 CANCIDAS INJ, 6 CAPASTAT INJ, 7 CAPEX SHAMPOO, 18 CAPRELSA, 8 captopril, 13 captopril & hydrochlorothiazide, 13 CARAC, 16 CARBAGLU, 26 carbamazepine er tabs & caps, 5 carbamazepine tabs, chewable tabs & oral susp, 4 carbidopa, 9 carbidopa & levodopa, 9 carbidopa & levodopa & entacapone, 9 carbidopa & levodopa er, 9
SCAN Health Plan | 2016 Formulary 32
CINRYZE INJ, 21 CIPRO HC, 24 CIPRODEX, 24 ciprofloxacin inj, 4 ciprofloxacin oral susp, 4 ciprofloxacin soln 0.3%, 23 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, 16 clindamycin oral, 2 clindamycin phosphate inj, 2 clindamycin topical cream, gel, lotion, soln & swab, 16 CLINISOL SF INJ, 26 clobetasol propionate emollient cream, 18 clobetasol propionate foam, gel, oint, soln, 18 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, 27 COLCRYS, 7, 27 colestipol granules, 15 colestipol tabs, 15 colistimethate inj, 2
COMBIGAN, 24 COMBIVENT RESPIMAT, 25, 27 COMETRIQ, 8 COMPLERA, 11 compro, 6 COMVAX INJ, 22 constulose soln, 17 COREG CR, 14 cormax scalp application, 18 cortisone, 18 CORTISPORIN CREAM & OINT, 2 COUMADIN ORAL, 13 CREON DR, 17 CRESEMBA, 6 CRIXIVAN, 11 cromolyn sodium, 24, 25 cromolyn sodium nebulizer soln, 25 cromolyn sodium oral, 17 CUBICIN INJ, 2 CUPRIMINE, 26 cyclafem 1/35, 19 cyclafem 7/7/7, 19 cyclobenzaprine hcl, 25 cyclophosphamide caps, 7 CYCLOSET, 12 cyclosporine modified, 21 cyclosporine oral, 21 cyproheptadine, 24 CYSTADANE, 17 CYSTAGON, 17 CYTOMEL, 20 DALIRESP, 25 danazol, 19 DAPSONE, 7 DAPTACEL INJ, 22 DARAPRIM, 9 deblitane, 20 delyla, 19 DELZICOL, 22 DELZICOL CAPS 400MG, 27 demeclocycline, 4 DEMSER, 15 DENAVIR, 10
SCAN Health Plan | 2016 Formulary 33
DEPEN TITRATABS, 26 DEPO-PROVERA INJ 400MG/ML, 20 desipramine, 6 desloratadine, 24 desloratadine odt, 24 desmopressin acetate inj, 19 desmopressin acetate nasal, 19 desmopressin acetate oral, 19 desogestrel & ethinyl estradiol, 19 desonide, 18 desoximetasone, 18 DESVENLAFAXINE ER, 5 dexamethasone elixir, 18 dexamethasone inj, 18 dexamethasone soln, 24 dexamethasone tabs, 18 dexedrine tabs, 16 dexedrine tabs, 27 dexmethylphenidate ir tabs, 16 dexpak, 18 dextroamphetamine sulfate, 16, 27 dextroamphetamine sulfate er, 16, 27 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, 16 diclofenac sodium soln, 24 dicloxacillin sodium, 3 dicyclomine oral, 17 didanosine, 11 diflorasone diacetate, 18 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,, 14 diltiazem er caps, 14 diltiazem inj 50mg/10ml, 14 diltiazem tabs, 14 dilt-xr, 14 DIPENTUM, 22 diphenhydramine hcl inj, 24 diphenoxylate & atropine, 17 DIPHTHERIA & TETANUS TOXOIDS PEDIATRIC INJ, 22 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 dronabinol, 6 DULERA, 25 duloxetine hcl, 5 duramorph inj, 1 DUREZOL, 24 DUTOPROL, 14 econazole nitrate, 6 EDURANT, 11 ELIDEL, 16, 27 ELIGARD INJ, 21 eliphos, 18 ELMIRON, 18
SCAN Health Plan | 2016 Formulary 34
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, 27 exemestane, 8 EXJADE, 26 FABRAZYME INJ, 17 falmina, 20 famciclovir, 10 famotidine inj, 17 famotidine tabs, 17 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 felodipine er, 14 fenofibrate, 15, 27 fenofibrate caps 43mg & 130mg, 15 fenofibrate micronized, 15, 27 fenofibrate tabs, 15 fenofibric acid dr caps, 15 fentanyl citrate lozenges 200mcg, 1 fentanyl citrate lozenges 400mcg, 600mcg, 800mcg, 1200mcg & 1600mcg, 1 fentanyl patches, 27 fentanyl patches 12mcg/hr, 25mcg/hr, 50mcg/hr, 75mcg/hr, 100mcg/hr, 1
EMCYT, 8 EMEND, 6 emoquette, 19 EMSAM, 5 EMTRIVA, 11 enalapril, 13 enalapril & hydrochlorothiazide, 13 ENBREL INJ, 21 ENBREL SURECLICK INJ, 21 endocet, 1 endocet, 27 endodan, 1 endodan, 27 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, 19 entacapone, 9 entecavir tabs, 10 enulose, 17 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, 23 erythromycin oral, 3 erythromycin topical gel & soln, 3 ESBRIET, 25 escitalopram, 5 esomeprazole magnesium dr caps, 18 esomeprazole magnesium dr caps, 27 estazolam, 26
SCAN Health Plan | 2016 Formulary 35
FERRIPROX, 23 FETZIMA, 5 FETZIMA TITRATION PACK, 5 finasteride tabs 5mg, 18 FIRAZYR INJ, 21 flavoxate, 18 flecainide acetate, 14 fluconazole in dextrose inj, 6 fluconazole oral, 7 flucytosine, 7 fludrocortisone acetate, 18 flunisolide nasal, 25, 27 fluocinolone acetonide, 18 fluocinonide, 18 fluocinonide cream 0.05%, 18 fluocinonide gel, oint & soln, 18 fluocinonide-e, 18 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, 9 fluphenazine oral, 9 flurazepam, 26 flutamide, 7 fluticasone propionate cream & oint, 18 fluticasone propionate nasal, 25, 27 fluvoxamine, 5 fluvoxamine er, 5 fondaparinux inj, 13 FORADIL AEROLIZER, 25 FORFIVO XL, 5 FORTEO INJ, 23 fortical nasal, 23 foscarnet inj, 10 fosinopril, 13 fosinopril & hydrochlorothiazide, 13 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, 27 galantamine er, 5, 27 galantamine oral soln, 5, 28 GAMMAGARD INJ, 22 GAMUNEX-C INJ, 22 ganciclovir inj, 10 garamycin soln, 23 GARDASIL 9 INJ, 22 GARDASIL INJ, 22 GATTEX INJ, 17 gauze pads 2x2, 23 gavilyte-c, 17 gavilyte-g, 17 gavilyte-n, 17 GELNIQUE, 18 gemfibrozil, 15 generlac, 17 gengraf, 21 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%, 23 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, 28 glipizide, 12 glipizide & metformin tabs, 12
SCAN Health Plan | 2016 Formulary 36
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, 9 haloperidol lactate inj, 9 haloperidol lactate oral soln, 9 haloperidol tabs, 9 HARVONI, 10 HAVRIX INJ, 22 heparin inj, 13 HERCEPTIN INJ, 8 HETLIOZ, 16 HEXALEN, 7 HUMALOG CARTRIDGE INJ, 12 HUMALOG KWIKPEN INJ, 12 HUMALOG MIX 50/50 KWIKPEN INJ, 12 HUMALOG MIX 50/50 VIAL INJ, 12 HUMALOG MIX 75/25 KWIKPEN INJ, 12 HUMALOG MIX 75/25 VIAL INJ, 12 HUMALOG VIAL INJ, 12 HUMATROPE INJ 5MG VIAL, 12MG & 24MG CARTRIDGE, 19 HUMATROPE INJ 6MG CARTRIDGE, 19 HUMIRA INJ, 21 HUMIRA PEN-CROHNS INJ, 21 HUMULIN 70/30 KWIKPEN INJ, 12 HUMULIN 70/30 VIAL INJ, 12 HUMULIN N KWIKPEN INJ, 12 HUMULIN N VIAL INJ, 12 HUMULIN R U-500 (CONCENTRATED) VIAL INJ, 12 HUMULIN R VIAL INJ, 12 hydralazine inj, 15 hydralazine oral, 15 hydrochlorothiazide, 15 hydrocodone & acetaminophen soln, 1, 28
hydrocodone & acetaminophen tabs, 1, 28 hydrocodone & ibuprofen, 1, 28 hydrocortisone 2.5% cream, lotion, oint, 19 hydrocortisone butyrate oint & soln, 19 hydrocortisone enema, 22 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, 23 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 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
SCAN Health Plan | 2016 Formulary 37
IPOL INACTIVATED IPV INJ, 22 ipratropium bromide & albuterol sulfate nebulizer, 25 ipratropium bromide nasal, 25, 28 ipratropium bromide nebulizer, 25 irbesartan, 14 irbesartan hct, 14 ISENTRESS CHEW TABS, 11 ISENTRESS ORAL POWDER, 11 ISENTRESS TABS, 11 isoniazid oral, 7 isosorbide dinitrate, 15 isosorbide dinitrate er, 15 isosorbide mononitrate, 15 isosorbide mononitrate er, 15 isradipine, 14 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, 15 KALETRA TABS 100-25MG, 11 KALETRA TABS 200MG-50MG & SOLN 400100MG/5ML, 11 KALYDECO, 25 kariva, 20 ketoconazole, 7 ketorolac inj, 2 ketorolac oral, 2 ketorolac soln 0.4%, 28 ketorolac soln 0.4% & 0.5%, 24 ketorolac soln 0.5%, 28 KEYTRUDA INJ, 8 KHEDEZLA, 6 KINERET INJ, 21 kionex, 26 klor-con, 26
KOMBIGLYZE XR, 12 KORLYM, 19 KUVAN, 17 KYNAMRO, 15 labetalol inj, 14 labetalol oral, 14 LACRISERT, 23 lactated ringers inj, 26 lactulose, 17 lamivudine, 10, 11 lamivudine & zidovudine, 11 lamotrigine immediate-release tabs, 4 LANOXIN INJ, 15 LANOXIN ORAL, 15 lansoprazole dr caps, 18, 28 LANTUS SOLOSTAR PEN INJ, 12 LANTUS VIAL INJ, 12 larin, 20 larin fe, 20 latanoprost, 24 LATUDA, 10 LAZANDA, 1 leena, 20 leflunomide, 22, 28 LENVIMA, 8 LETAIRIS, 25 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, 23 levocarnitine oral, 23 levocetirizine, 24, 28 levofloxacin inj, 4 levofloxacin oral soln, 4 levofloxacin tabs, 4 levoleucovorin inj, 8
SCAN Health Plan | 2016 Formulary 38
levonest, 20 levonorgestrel & ethinyl estradiol 0.1-0.02mg, 0.15-0.03mg, 20 levora, 20 levothyroxine tabs, 20 levoxyl, 20 LEXIVA ORAL SUSP, 11 LEXIVA TABS, 11 lidocaine & prilocaine, 1 lidocaine hcl inj, 1 lidocaine hcl topical, 1 lidocaine patch, 1 linezolid inj, 2 linezolid oral, 2 LINZESS, 17 liothyronine tabs, 20 lisinopril, 13 lisinopril & hydrochlorothiazide, 13 lithium carbonate, 12 lithium carbonate er, 12 lithium citrate, 12 LOMUSTINE, 7 loperamide caps 2mg, 17 lorazepam intensol, 12 lorazepam tabs, 12 lorcet hd tabs, 1, 28 lorcet plus tabs, 1, 28 lorcet tabs, 1, 28 lortab tabs, 1, 28 losartan, 14 losartan hct, 14 lovastatin, 15 low-ogestrel, 20 loxapine, 9 LUMIGAN, 24, 28 LUMIZYME INJ, 17 LUPRON DEPOT INJ 7.5MG, 11.25MG, 22.5MG, 30MG & 45MG, 21 LYNPARZA, 8 LYRICA, 4 LYSODREN, 21 lyza, 20 magnesium sulfate inj, 26
malathion, 9 maprotiline, 5 marlissa 28 day, 20 MARPLAN, 5 MATULANE, 7 meclizine, 6 medroxyprogesterone acetate inj, 20 medroxyprogesterone acetate tabs, 20 mefloquine, 9 megestrol acetate oral susp, 20 megestrol tabs, 20 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, 22 MESNEX TABS, 8 MESTINON SYRUP, 7 MESTINON TIMESPAN, 7 metadate er, 16 metformin, 12 metformin er tabs 500mg & 750mg, 12 methadone inj, 1 methadone oral, 1 methazolamide, 24 methenamine hippurate, 2 methimazole, 21 methocarbamol, 25 methotrexate inj, 21 methotrexate oral, 21 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
SCAN Health Plan | 2016 Formulary 39
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, 15 mirtazapine, 5 mirtazapine odt, 5 misoprostol, 18 mitoxantrone inj, 8 M-M-R II INJ, 22 modafinil, 26 moderiba 200mg tabs, 10 moderiba dose pack, 10 moexipril, 13 moexipril & hydrochlorothiazide, 13 mometasone cream & oint, 19 montelukast, 25 morphine sulfate er tabs, 1, 28 morphine sulfate inj vial, 1 morphine sulfate oral, 1 MOVANTIK, 17 MOVIPREP, 18 moxifloxacin oral, 4 MOZOBIL INJ, 26 mupirocin, 2 mycophenolate mofetil caps & tabs, 21 mycophenolate mofetil oral susp, 21 mycophenolic acid dr, 21
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, 28 NASONEX, 25, 28 nateglinide, 12 NATPARA, 23 NEBUPENT NEBULIZER, 9 necon, 20 nefazodone, 5 neomycin & bacitracin & polymyxin b, 23 neomycin & polymyxin & bacitracin & hydrocortisone, 24 neomycin & polymyxin & dexamethasone, 24 neomycin & polymyxin & gramicidin, 23 neomycin & polymyxin & hydrocortisone, 24 neomycin sulfate oral, 2 NEORAL, 21 NEUMEGA, 13 NEUPOGEN INJ, 13 NEUPRO PATCH, 9 NEUPRO PATCH, 28 nevirapine er, 11 nevirapine oral susp, 11 nevirapine tabs, 11 NEXAVAR, 8 niacin er tabs, 15, 28 nicardipine caps, 14 NICOTROL INHALER, 2 NICOTROL NASAL, 2 nifedical xl, 14 nifedipine, 14 nifedipine er, 14
SCAN Health Plan | 2016 Formulary 40
ORFADIN, 17 orsythia 28 day, 20 OSMOPREP, 18 OTEZLA, 22 OTEZLA STARTER, 22 oxandrolone, 19 oxazepam, 12 oxcarbazepine, 5 oxybutynin, 18, 28 oxybutynin er, 18, 28 oxycodone, 1 oxycodone & acetaminophen, 1, 28 oxycodone & aspirin, 1, 28 oxycodone & ibuprofen, 1 oxycodone & ibuprofen tabs, 28 oxycodone immediate-release, 1 oxycodone oral soln, 1 OXYCONTIN, 1, 28 oxymorphone er, 1, 28 OXYTROL, 18 pacerone tabs 200mg, 14 paclitaxel inj, 8 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, 28 PAXIL 10MG/5ML SUSP, 6 PEDVAX HIB INJ, 22 peg 3350 & electrolytes, 18 PEGANONE, 5 PEGASYS INJ, 10 PEGASYS PROCLICK INJ, 10 PEG-INTRON INJ, 10 PEG-INTRON REDIPEN INJ, 10 penicillin g inj 5 million units, 3 penicillin v potassium, 3 PENTAM INJ, 9
NILANDRON, 7 nimodipine caps, 14 nisoldipine, 15 nisoldipine er, 15 nitro-bid oint, 16 NITRO-DUR PATCHES, 16 nitrofurantoin caps, 2 nitroglycerin inj, 16 nitroglycerin lingual, 16 nitroglycerin patches, 16 NITROSTAT, 16 norethindrone, 20 norlyroc, 20 NORTHERA, 15 nortriptyline oral, 6 NORVIR, 11 NOXAFIL ORAL, 7 NUEDEXTA, 16 NULOJIX INJ, 21 nyamyc, 7 nystatin, 7 nystatin & triamcinolone, 7 octreotide inj 500mcg/ml & 1000mcg/ml, 21 octreotide inj 50mcg/ml, 100mcg/ml & 200mcg/ml, 21 OFEV, 25 ofloxacin, 23, 24 ofloxacin oral, 4 olanzapine inj 10mg, 10 olanzapine odt, 10 olanzapine tabs, 10 OLYSIO, 10 omega-3-acid ethyl esters, 15 omeprazole caps, 18 ONCASPAR INJ, 8 ondansetron inj, 6 ondansetron odt, 6 ondansetron oral soln, 6 ondansetron tabs, 6 ONFI, 4 ONGLYZA, 12 OPSUMIT, 25 ORAP, 9
SCAN Health Plan | 2016 Formulary 41
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, 22 prednisone tabs, 19, 22 PREMARIN ORAL, 20 PREMARIN VAGINAL, 20 PREMPHASE, 20 PREMPRO, 20 prenatal multi-vitamin, 26 PREPOPIK, 18 prevalite, 15 PREZCOBIX, 11 PREZISTA SUSP 100MG/ML, 11 PREZISTA TABS 600MG & 800MG, 11 PREZISTA TABS 75MG & 150MG, 11 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, 20 PROGLYCEM, 12
PENTASA, 22, 28 pentoxifylline er, 15 perindopril, 13 permethrin cream, 9 perphenazine, 6, 9 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, 16 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 podofilox, 17 polyethylene glycol 3350, 18 polymyxin b sulfate & trimethoprim sulfate soln, 23 POMALYST, 8 potassium chloride & dextrose & lactated ringers inj, 26 potassium chloride & dextrose & sodium chloride inj 20mEq/5%/0.45% & 30mEq/5%/0.45%, 26 potassium chloride er, 26 potassium chloride inj, 26 potassium chloride oral soln, 26 potassium chloride viaflex inj, 26 potassium citrate er, 26 POTIGA, 4 PRADAXA, 13
SCAN Health Plan | 2016 Formulary 42
REBIF REBIDOSE TITRATION PACK INJ, 16 REBIF TITRATION PACK INJ, 16 RECOMBIVAX HB INJ, 22 REGRANEX, 17, 28 RELENZA DISKHALER, 11 RELISTOR INJ, 17 REMICADE INJ, 21 REMODULIN INJ, 25 RENVELA, 18 repaglinide, 12 reprexain, 1 RESCRIPTOR, 11 RESTASIS, 23, 28 RETROVIR IV INJ, 11 REVLIMID, 8 REYATAZ CAPS & ORAL POWDER, 11 ribasphere, 10 ribasphere ribapak, 10 ribavirin, 10 RIDAURA, 22 rifabutin, 7 rifampin inj, 7 rifampin oral, 7 RIFATER, 7 riluzole, 16 rimantadine, 11 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, 8 rivastigmine, 5, 28 rizatriptan, 7 rizatriptan odt, 7 ropinirole, 9 ROTARIX, 22 ROTATEQ, 22 ROZEREM, 26, 28 SABRIL, 4 SANDIMMUNE CAPS 25MG & 100MG, 21 SANDIMMUNE ORAL SOLN 100MG/ML, 21
PROLASTIN C INJ, 25 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, 14 propranolol er caps, 14 propranolol inj, 14 propranolol ir tabs, 14 propranolol oral soln, 14 propylthiouracil, 21 PROQUAD INJ, 22 PROTONIX INJ, 18 protriptyline, 6 prudoxin, 17 PULMOZYME, 25 PURIXAN, 8 pyrazinamide, 7 pyridostigmine, 7 QUADRACEL INJ, 22 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, 22 raloxifene hcl, 20, 28 ramipril, 14 RANEXA, 15 ranitidine caps & syrup, 17 ranitidine inj, 17 ranitidine tabs, 17 RAPAMUNE SOLN, 21 RAVICTI, 17 REBIF INJ, 16 REBIF REBIDOSE INJ, 16
SCAN Health Plan | 2016 Formulary 43
SANTYL, 17 SAPHRIS, 10 SAVELLA, 16 SAVELLA TITRATION PACK, 16 selegiline, 9 selenium sulfide lotion, 17 SELZENTRY, 11 SENSIPAR TABS 30MG, 21, 29 SENSIPAR TABS 60MG & 90MG, 21 SEREVENT DISKUS, 25 SEROQUEL XR, 10 sertraline oral soln, 6 sertraline tabs, 6 sevelamer carbonate, 18 sharobel, 20 sildenafil tabs 20mg, 25 SILENOR, 26, 29 silver sulfadiazine, 3 SIMCOR, 15 simvastatin, 15 sirolimus tabs, 21 SIRTURO, 7 SIVEXTRO, 3 sodium chloride inj, 26 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, 10 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, 25 SUCLEAR BOWEL PREP, 18 SUCRAID, 17 sucralfate, 18 sulfacetamide sodium, 24 sulfacetamide sodium & prednisolone sodium phosphate, 24 sulfacetamide sodium oint & soln 10%, 23 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, 20 SYPRINE, 26 TABLOID, 8 tacrolimus caps 0.5mg & 1mg, 21 tacrolimus caps 5mg, 21 tacrolimus oint, 17 TAFINLAR, 8
SCAN Health Plan | 2016 Formulary 44
TAMIFLU CAPS 75MG, 11 TAMIFLU SUSP, 11 tamoxifen, 8 tamsulosin, 18 TARCEVA, 8 TARGRETIN, 9 tarina fe, 20 TASIGNA, 8 tazicef inj, 3 TAZORAC, 17, 29 taztia xt, 15 TECFIDERA, 16 TECFIDERA STARTER PACK, 16 TEFLARO INJ, 3 TEGRETOL, 5 TEGRETOL XR, 5 TEKTURNA, 15 TEKTURNA HCT, 15 temazepam, 26 TENIVAC, 22 terazosin, 13, 18 terbinafine, 7 terbutaline sulfate inj, 25 terbutaline sulfate oral, 25 terconazole, 7 testosterone cypionate inj, 19 testosterone enanthate inj, 19 TETANUS & DIPHTHERIA TOXOIDSADSORBED ADULT INJ, 22 TETANUS TOXOID ADSORBED INJ, 22 tetracycline, 4 THALOMID, 8 theophylline, 25 theophylline cr & er tabs, 25 THIOLA, 18 thioridazine, 9 thiothixene, 9 THYROLAR, 20 tiagabine, 4 TIKOSYN, 14 timolol ophthalmic gel forming, 24 timolol oral, 14 timolol soln, 24
TIVICAY, 11 tizanidine, 10 TOBI PODHALER, 25 TOBRADEX OINT, 24 tobramycin, 24 tobramycin & dexamethasone, 24 tobramycin nebulizer, 25 tobramycin sulfate, 23 tobramycin sulfate & sodium chloride inj, 2 tobramycin sulfate inj, 2 tolterodine tartrate, 29 tolterodine tartrate er, 18 topiramate immediate-release, 4 torsemide oral, 15 TOVIAZ, 18 TPN ELECTROLYTES INJ, 26 TRACLEER, 25 tramadol, 1, 29 tramadol & acetaminophen, 1, 29 tramadol er, 29 tramadol er tabs, 1 trandolapril, 14 tranexamic acid inj, 13 tranexamic acid tabs, 13 TRANSDERM-SCOP, 6 tranylcypromine, 5 TRAVASOL INJ, 26 trazodone, 5 TRECATOR, 7 tretinoin caps, 9 triamcinolone, 16 triamcinolone acetonide inj, 19 triamcinolone acetonide topical cream, lotion & oint, 19 triamcinolone in orabase, 16 triamterene & hydrochlorothiazide, 15 triazolam, 26 triderm, 19 trifluoperazine, 9 trifluridine, 23 trihexyphenidyl elixir, 9 trihexyphenidyl tabs, 9 TRILEPTAL, 5
SCAN Health Plan | 2016 Formulary 45
trimethoprim, 3 tri-sprintec, 20 TRIUMEQ, 11 trivora-28, 20 TRUMENBA INJ, 22 TRUVADA, 11 TUDORZA PRESSAIR, 25 TWINRIX INJ, 22 TYBOST, 11 TYGACIL INJ, 3 TYKERB, 8 TYPHIM VI INJ, 22 TYSABRI INJ, 16 TYZEKA, 10 ULORIC, 7 unithroid, 20 ursodiol, 17 VAGIFEM, 20 valacyclovir, 10 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, 22 VARIVAX INJ, 22 VELCADE INJ, 8 velivet, 20 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, 23
VIIBRYD, 6 VIIBRYD TITRATION PACK, 6 VIMPAT INJ, 5 VIMPAT ORAL, 5 VIRACEPT, 11 VIRAMUNE TABS, 11 VIRAMUNE XR 100MG, 11 VIRAZOLE, 25 VIREAD POWDER, 11 VIREAD TABS, 11 VITEKTA, 11 VOLTAREN GEL 1%, 17 voriconazole inj, 7 voriconazole oral, 7 VOTRIENT, 8 VPRIV INJ, 17 vyfemla, 20 warfarin, 13 WELCHOL, 15 wymzya fe, 20 XALKORI, 8 XARELTO, 13 XARELTO STARTER PACK, 13 XELJANZ, 22 XENAZINE, 16 XERESE, 10 XGEVA INJ, 23 XIFAXAN TABS 200MG, 3, 29 XIFAXAN TABS 550MG, 3 XIGDUO XR, 12 XTANDI, 7 XYREM, 26 YERVOY INJ, 8 YF-VAX INJ, 22 zafirlukast, 25, 29 zamicet, 1, 29 ZAVESCA, 17 ZELBORAF, 8 zenchent, 20 zenchent fe, 20 zenzedi tabs 5mg & 10mg, 16, 29 ZERBAXA INJ, 3 ZETIA, 15, 29 ZIAGEN SOLN, 11 SCAN Health Plan | 2016 Formulary 46
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, 29 ZONALON, 17 zonisamide, 4
ZORTRESS TABS 0.25MG, 21 ZORTRESS TABS 0.5MG & 0.75MG, 21 ZOSTAVAX INJ, 22 ZOSYN GALAXY INJ 2GM/0.25GM & 3GM/0.375GM, 3 zovia, 20 ZOVIRAX CREAM, 11 ZYDELIG, 8 ZYFLO CR, 25, 29 ZYKADIA, 8 ZYPREXA RELPREVV 210MG, 10 ZYTIGA, 8 ZYVOX ORAL SUSP, 3
SCAN Health Plan | 2016 Formulary 47
3800 Kilroy Airport Way, Suite 100 Long Beach, CA 90806
This formulary was updated on 08/01/2015. For more recent information or other questions, please contact SCAN Health Plan Member Services at 1-800-559-3500 (Medicare and Medi-Cal eligible members should call 1-866-722-6725) 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.scanhealthplan.com. Este formulario se actualizó en 08/01/2015. Para obtener información más reciente o si tiene dudas, comuníquese con Servicios para Miembros de SCAN Health Plan al 1-800-559-3500 (los miembros elegibles para Medicare y Medi-Cal deben llamar al 1-866-722-6725) 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.scanhealthplan.com.
G9318 08/15 Y0057_SCAN_9189_2015F File & Use Accepted 08232015
16-FOR900