2019 Formulary (List of Covered Drugs)

Transcription

1 Health Net Gold Select (H), Health Net Healthy Heart (H), Health Net Jade (H SNP), Health Net Ruby (H), Health Net Ruby Select (H), Health Net Ruby Select II (H), Health Net Seniority Plus Amber I (H SNP), Health Net Seniority Plus Amber II (H SNP), Health Net Seniority Plus Amber II Premier (H SNP), Health Net Seniority Plus Ruby (H), Health Net Seniority Plus Sapphire (H), Health Net Seniority Plus Sapphire Premier (H), Health Net Seniority Plus Sapphire Premier II (H), Health Net Violet (PPO), Health Net Violet (PPO), and Health Net Violet (PPO) 09 Formulary (List of Covered s) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission ID 99, Version Number This formulary was updated on 0/0/09. For more recent information or other questions, please contact Health Net Gold Select (H), Health Net Healthy Heart (H), Health Net Jade (H SNP), Health Net Ruby (H), Health Net Ruby Select (H), Health Net Ruby Select II (H), Health Net Seniority Plus Amber I (H SNP), Health Net Seniority Plus Amber II (H SNP), Health Net Seniority Plus Amber II Premier (H SNP), Health Net Seniority Plus Ruby (H), Health Net Seniority Plus Sapphire (H), Health Net Seniority Plus Sapphire Premier (H), Health Net Seniority Plus Sapphire Premier II (H), Health Net Violet (PPO), Health Net Violet (PPO), and Health Net Violet (PPO) at: State Phone Number California (H Plans) California (All Other H SNP Plans) Health Net Seniority Plus Sapphire (H) Health Net Seniority Plus Sapphire Premier (H) Health Net Seniority Plus Sapphire Premier II (H) Oregon/Washington or, for TTY users, 7, from October March, seven days a week, 8 a.m. to 8 p.m., from April - September 0, Monday through Friday, 8 a.m. to 8 p.m. A messaging system is used after hours, on weekends, and on federal holidays, or visit ALL_9_80FRMLY_C_67_08008

2 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 Health Net of California, Health Net Community Solutions Inc., Health Net Life Insurance Company, and Health Net Health Plan of Oregon, Inc. When it refers to plan or our plan, it means Health Net Gold Select (H), Health Net Healthy Heart (H), Health Net Jade (H SNP), Health Net Ruby (H), Health Net Ruby Select (H), Health Net Ruby Select II (H), Health Net Seniority Plus Amber I (H SNP), Health Net Seniority Plus Amber II (H SNP), Health Net Seniority Plus Amber II Premier (H SNP), Health Net Seniority Plus Ruby (H), Health Net Seniority Plus Sapphire (H), Health Net Seniority Plus Sapphire Premier (H), Health Net Seniority Plus Sapphire Premier II (H), Health Net Violet (PPO), Health Net Violet (PPO), and Health Net Violet (PPO). This document includes a list of the drugs (formulary) for our plan which is current as of 0/0/09. 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, 00, and from time to time during the year. What is the Health Net Gold Select (H), Health Net Healthy Heart (H), Health Net Jade (H SNP), Health Net Ruby (H), Health Net Ruby Select (H), Health Net Ruby Select II (H), Health Net Seniority Plus Amber I (H SNP), Health Net Seniority Plus Amber II (H SNP), Health Net Seniority Plus Amber II Premier (H SNP), Health Net Seniority Plus Ruby (H), Health Net Seniority Plus Sapphire (H), Health Net Seniority Plus Sapphire Premier (H), Health Net Seniority Plus Sapphire Premier II (H), Health Net Violet (PPO), Health Net Violet (PPO), and Health Net Violet (PPO) Formulary? A formulary is a list of covered drugs selected by our 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. We will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a 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 09 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 09 coverage year except when a ii

3 new, less expensive generic drug becomes available, when new information about the safety or effectiveness of a drug is released, or the drug is removed from the market (see bullets below for more information on changes that affect members currently taking the drug). 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. Below are changes to the drug list that will also affect members currently taking a drug: New generic drugs. We may immediately remove a brand name drug on our List if we are replacing it with a new generic drug that will appear on the same or lower cost sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our List, but immediately move it to a different cost-sharing tier or add new restrictions. If you are currently taking that brand name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made. o If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on the steps you may take to request an exception, and you can also find information in the section below entitled How do I request an exception to the Health Net Gold Select (H), Health Net Healthy Heart (H), Health Net Jade (H SNP), Health Net Ruby (H), Health Net Ruby Select (H), Health Net Ruby Select II (H), Health Net Seniority Plus Amber I (H SNP), Health Net Seniority Plus Amber II (H SNP), Health Net Seniority Plus Amber II Premier (H SNP), Health Net Seniority Plus Ruby (H), Health Net Seniority Plus Sapphire (H), Health Net Seniority Plus Sapphire Premier (H), Health Net Seniority Plus Sapphire Premier II (H), Health Net Violet (PPO), Health Net Violet (PPO), and Health Net Violet (PPO) Formulary? s removed from the market. If the Food and 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. Other changes. We may make other changes that affect members currently taking a drug. For instance, we may add a generic drug that is not new to market to replace a brand name drug currently on the formulary or add new restrictions to the brand name drug or move it to a different cost-sharing tier. Or we may make changes based on new clinical guidelines. 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 0 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 0-day supply of the drug. iii

4 The enclosed formulary is current as of 0/0/09. To get updated information about the drugs covered by Health Net Gold Select (H), Health Net Healthy Heart (H), Health Net Jade (H SNP), Health Net Ruby (H), Health Net Ruby Select (H), Health Net Ruby Select II (H), Health Net Seniority Plus Amber I (H SNP), Health Net Seniority Plus Amber II (H SNP), Health Net Seniority Plus Amber II Premier (H SNP), Health Net Seniority Plus Ruby (H), Health Net Seniority Plus Sapphire (H), Health Net Seniority Plus Sapphire Premier (H), Health Net Seniority Plus Sapphire Premier II (H), Health Net Violet (PPO), Health Net Violet (PPO), and Health Net Violet (PPO) please contact us. Our contact information appears on the front and back cover pages. If we make any other negative changes to a drug you are taking, we will notify you via mail. We will also post the changes on our website. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page. 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-MISC. - s to Treat Heart and Circulation Conditions. If you know what your drug is used for, look for the category name in the list that begins on page. 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 Index. 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? Our 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. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: iv

5 Prior Authorization: Our plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from us before you fill your prescriptions. If you don t get approval, we may not cover the drug. Quantity : For certain drugs, our plan limits the amount of the drug that we will cover. For example, our plan provides one tablet per day per prescription for simvastatin 0. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, our 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 A and B both treat your medical condition, we may not cover B unless you try A first. If A does not work for you, we will then cover B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted online 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 us 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 Health Net Gold Select (H), Health Net Healthy Heart (H), Health Net Jade (H SNP), Health Net Ruby (H), Health Net Ruby Select (H), Health Net Ruby Select II (H), Health Net Seniority Plus Amber I (H SNP), Health Net Seniority Plus Amber II (H SNP), Health Net Seniority Plus Amber II Premier (H SNP), Health Net Seniority Plus Ruby (H), Health Net Seniority Plus Sapphire (H), Health Net Seniority Plus Sapphire Premier (H), Health Net Seniority Plus Sapphire Premier II (H), Health Net Violet (PPO), Health Net Violet (PPO), and Health Net Violet (PPO) 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 our 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 our 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 us. You can ask us to make an exception and cover your drug. See below for information about how to request an exception. v

6 How do I request an exception to the Health Net Gold Select (H), Health Net Healthy Heart (H), Health Net Jade (H SNP), Health Net Ruby (H), Health Net Ruby Select (H), Health Net Ruby Select II (H), Health Net Seniority Plus Amber I (H SNP), Health Net Seniority Plus Amber II (H SNP), Health Net Seniority Plus Amber II Premier (H SNP), Health Net Seniority Plus Ruby (H), Health Net Seniority Plus Sapphire (H), Health Net Seniority Plus Sapphire Premier (H), Health Net Seniority Plus Sapphire Premier II (H), Health Net Violet (PPO), Health Net Violet (PPO), and Health Net Violet (PPO) Formulary? You can ask us 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, our 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. Generally, we 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 7 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 7 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 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 vi

7 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 0-day supply. If your prescription is written for fewer days, we ll allow refills to provide up to a maximum 0-day supply of medication. After your first 0-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 and 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 -day emergency supply of that drug while you pursue a formulary exception. Level of care changes If you experience a change in your level of care, we will cover a transition supply of your drugs. A level of care change occurs when you are discharged from a hospital or moved to or from a long-term care facility. If you move home from a long-term care facility or hospital and need a transition supply, we will cover one 0-day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a total of a 0-day supply. If you move from home or a hospital to a long-term care facility and need a transition supply, we will cover one -day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a total of a -day supply. For more information For more detailed information about your plan s prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about our plan, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) hours a day/7 days a week. TTY users should call Or, visit Health Net Gold Select (H), Health Net Healthy Heart (H), Health Net Jade (H SNP), Health Net Ruby (H), Health Net Ruby Select (H), Health Net Ruby Select II (H), Health Net Seniority Plus Amber I (H SNP), Health Net Seniority Plus Amber II (H SNP), Health Net Seniority Plus Amber II Premier vii

8 (H SNP), Health Net Seniority Plus Ruby (H), Health Net Seniority Plus Sapphire (H), Health Net Seniority Plus Sapphire Premier (H), Health Net Seniority Plus Sapphire Premier II (H), Health Net Violet (PPO), Health Net Violet (PPO), and Health Net Violet (PPO) Formulary The formulary that begins on page provides coverage information about the drugs covered by our plan. If you have trouble finding your drug in the list, turn to the Index that begins on page Index. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., ELIQUIS TABS) and generic drugs are listed in lower-case italics (e.g., warfarin sodium tabs). The information in the column tells you if our plan has any special requirements for coverage of your drug. Abbreviations The abbreviations below may appear in the Requirement/ column on the formulary. Abbreviation Definition Description AL Age Limit This drug may require prior authorization if your age does not meet manufacturer, FDA, or clinical recommendations. B/D Medicare Part B vs. Part D 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. LA Limited Access This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services from October March, 7 days a week, 8 a.m. to 8 p.m. From April - September 0, Monday through Friday, 8 a.m. to 8 p.m. Our contact information appears on the front and back covers. TTY users should call 7. Mail Order This drug is available at our mail order pharmacy in addition to other network pharmacies. Non-Extended Day Supply This prescription drug may not be available for an extended day supply. Call Member Services to ask if the drug is available as an extended supply. viii

9 Abbreviation Definition Description PA Prior Authorization This drug requires prior authorization. This means that you or your prescriber must get approval from us before you fill your prescription. If you don t get approval, we may not cover the drug. QL Quantity Limit This drug has a limit on the amount that we will cover. For example, we cover one tablet per day per prescription for simvastatin 0. This may be in addition to a standard onemonth or three-month supply limit. RX/OTC Prescription and Over-the- Counter (OTC) This drug is available both in a prescription form and in an OTC form. Other than some insulins and insulin supplies, only prescription drugs are covered by our Medicare Part D plans. SL Safety Limit This drug has a maximum daily dose limit for safety supported by the FDA. This means that we will not cover more than the maximum daily dose. For example, the FDA maximum daily dose of ibuprofen is 00. Therefore, we will only cover four tablets per day for ibuprofen 800. ST Step Therapy This drug requires step therapy. This means that you must first try certain drugs to treat your medical condition before we cover another drug for that condition. For example, if A and B both treat your medical condition, we may not cover B unless you try A first. If A does not work for you, we will then cover B. Additional Gap Coverage Only for Health Net Gold Select (H), Health Net Healthy Heart (H) plans in Los Angeles, Orange, Riverside and San Bernardino Counties, and Health Net Jade (H SNP) plans in Kern, Los Angeles and Orange Counties: We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. ix

10 Formulary tier descriptions Prescription drugs are grouped into one of six tiers. To find out which tier your drug is in, look in the column of the formulary that begins on page. The table below tells you the copayment or coinsurance amount (i.e., the share of the drug's cost that you will pay during the initial coverage stage) for a one-month supply of drugs in each tier. For more detailed information about your out-of-pocket costs for prescriptions, including any deductible that may apply, please refer to your Evidence of Coverage and other plan materials. The table shows your standard retail 0-day supply copayment or coinsurance amount: State Plan Name 6 Preferred Generic (includes preferred generic drugs) Generic (includes generic drugs) Preferred Brand (includes preferred brand drugs and may include some generic drugs) Nonpreferred s (includes nonpreferred brand drugs and nonpreferred generic drugs) Specialty (includes high cost brand and generic drugs) Select Care s (includes some generic and may include some brand drugs used to treat specific chronic conditions) CA CA CA Health Net Gold Select (H) Health Net Healthy Heart (H) in Fresno and San Diego Counties Health Net Healthy Heart (H) in Alameda and Stanislaus Counties $ $0 $7 $00 % $0 $0 $0 $7 $00 % $0 $0 $0 $7 $00 8% $0 x

11 State Plan Name 6 Preferred Generic (includes preferred generic drugs) Generic (includes generic drugs) Preferred Brand (includes preferred brand drugs and may include some generic drugs) Nonpreferred s (includes nonpreferred brand drugs and nonpreferred generic drugs) Specialty (includes high cost brand and generic drugs) Select Care s (includes some generic and may include some brand drugs used to treat specific chronic conditions) CA CA CA CA Health Net Healthy Heart (H) in Los Angeles, Orange, Riverside, and San Bernardino Counties Health Net Healthy Heart (H) in Placer and Sacramento Counties Health Net Healthy Heart (H) in San Francisco County Health Net Healthy Heart (H) in Yolo County $0 $0 $7 $00 % $0 $8 $8 $7 $00 % $0 $ $8 $7 $00 % $0 $ $9 $7 $00 % $0 xi

12 State Plan Name 6 Preferred Generic (includes preferred generic drugs) Generic (includes generic drugs) Preferred Brand (includes preferred brand drugs and may include some generic drugs) Nonpreferred s (includes nonpreferred brand drugs and nonpreferred generic drugs) Specialty (includes high cost brand and generic drugs) Select Care s (includes some generic and may include some brand drugs used to treat specific chronic conditions) CA CA CA CA CA CA Health Net Jade (H SNP) in Kern, Los Angeles, and Orange Counties Health Net Jade (H SNP) in San Diego County Health Net Ruby Select (H) in Alameda and San Francisco Counties Health Net Ruby Select (H) in Fresno County Health Net Ruby Select (H) in Yolo County Health Net Ruby Select II (H) $ $ $7 $00 % $0 $0 $0 $7 $00 % $0 $8 $ $7 $00 % $0 $0 $0 $7 $00 % $0 $ $0 $7 $00 % $0 $8 $ $7 $00 % $0 xii

13 State Plan Name 6 Preferred Generic (includes preferred generic drugs) Generic (includes generic drugs) Preferred Brand (includes preferred brand drugs and may include some generic drugs) Nonpreferred s (includes nonpreferred brand drugs and nonpreferred generic drugs) Specialty (includes high cost brand and generic drugs) Select Care s (includes some generic and may include some brand drugs used to treat specific chronic conditions) CA CA CA CA CA Health Net Seniority Plus Amber I (H SNP) Health Net Seniority Plus Amber II (H SNP) Health Net Seniority Plus Amber II Premier (H SNP) Health Net Seniority Plus Ruby (H) Health Net Seniority Plus Sapphire (H) $0 $0 $7 $00 6% $0 $0 $0 $7 $00 7% $0 $0 $0 $7 $00 7% $0 $ $0 $7 $00 % $0 $0 $0 $7 $00 6% $0 xiii

14 State Plan Name 6 Preferred Generic Preferred Non- Specialty Select Care Generic (includes Brand preferred (includes s (includes generic (includes s high cost (includes preferred generic drugs) drugs) brand and generic drugs) preferred brand drugs and may include some generic drugs) (includes nonpreferred brand drugs and nonpreferred generic drugs) some generic and may include some brand drugs used to treat specific chronic conditions) CA CA CA Health Net Seniority Plus Sapphire Premier (H) in Alameda, Fresno, Kern, Los Angeles, Orange, San Diego, San Francisco, and Tulare Counties Health Net Seniority Plus Sapphire Premier (H) in Imperial, Riverside, and San Bernardino Counties Health Net Seniority Plus Sapphire Premier II (H) in Alameda, Fresno, Kern, Los Angeles, Orange, San Diego, San Francisco, and Tulare Counties $0 $0 $7 $00 7% $0 $0 $0 $7 $00 9% $0 $0 $0 $7 $00 7% $0 xiv

15 State Plan Name 6 Preferred Generic (includes preferred generic drugs) Generic (includes generic drugs) Preferred Brand (includes preferred brand drugs and may include some generic drugs) Nonpreferred s (includes nonpreferred brand drugs and nonpreferred generic drugs) Specialty (includes high cost brand and generic drugs) Select Care s (includes some generic and may include some brand drugs used to treat specific chronic conditions) CA OR OR/ WA OR/ WA Health Net Seniority Plus Sapphire Premier II (H) in Imperial, Riverside, and San Bernardino Counties Health Net Ruby (H) Health Net Violet (PPO) Health Net Violet (PPO) $0 $0 $7 $00 8% $0 $8 $ $7 $00 0% $0 $0 $0 $7 $00 % $0 $0 $0 $7 $00 0% $0 OR Health Net Violet (PPO) $0 $0 $7 $00 9% $0 s in this tier are not eligible for exceptions for payment at a lower tier. We provide additional coverage of these prescription drugs in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. Note: If NF is displayed in the column, this means the drug is not covered on the formulary. You may request an exception from us to cover these non-formulary drugs. If an exception request is approved for a non-formulary drug; the copayment applies. You may not ask us to provide the drug at a lower cost-sharing level. xv

16 Section 7 Non-Discrimination Language Notice of Non-Discrimination Health Net complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Health Net does not exclude people or treat them diferently because of race, color, national origin, age, disability, or sex. Health Net: Provides free aids and services to people with disabilities to communicate efectively with us, such as qualifed sign language interpreters and written information in other formats (large print, accessible electronic formats, other formats). Provides free language services to people whose primary language is not English, such as qualifed interpreters and information written in other languages. If you need these services, contact Health Net s Customer Contact Center at California: (Jade, Sapphire, Amber, and H SNP), (all other H); Oregon: (H and PPO) (TTY: 7). From October to March, you can call us 7 days a week from 8 a.m. to 8 p.m. From April to September 0, you can call us Monday through Friday from 8 a.m. to 8 p.m. A messaging system is used after hours, weekends, and on federal holidays. If you believe that Health Net has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can fle a grievance by calling the number above and telling them you need help fling a grievance; Health Net s Customer Contact Center is available to help you. You can also fle a civil rights complaint with the U.S. Department of Health and Human Services, Ofce for Civil Rights, electronically through the Ofce for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services, 00 Independence Avenue SW, Room 09F, HHH Building, Washington, DC 00, (TDD: ). Complaint forms are available at Health Net is contracted with Medicare for H, H SNP and PPO plans, and with some state Medicaid programs. Enrollment in Health Net depends on contract renewal. FLY00EK00 (8/8) CA_OR_9_8MLI_C 07008

17 Section 7 Non-Discrimination Language Multi-Language Interpreter Services ARABIC California: (Jade, Sapphire, Amber, and H SNP), (all other H); Oregon: (H and PPO) ARMENIAN California: (Jade, Sapphire, Amber, and H SNP), (all other H) (TTY: 7). CHINESE California: (Jade, Sapphire, Amber, and H SNP), (all other H); Oregon: (H and PPO) (TTY: 7) CUSHITE (TTY: 7). Oregon: (H and PPO) FRENCH (TTY: 7). Oregon: (H and PPO) GERMAN (H and PPO) (TTY: 7). Oregon: HINDI California: (Jade, Sapphire, Amber, and H SNP), (all other H) (TTY: 7). HNG California: (Jade, Sapphire, Amber, and H SNP), (all other H) (TTY: 7). JAPANESE KOREAN California: (Jade, Sapphire, Amber, and H SNP), (all other H); Oregon: (H and PPO) (TTY: 7)

18 N-KHMER CAMBODIAN California: (Jade, Sapphire, Amber, and H SNP), (all other H); Oregon: (H and PPO) (TTY: 7) PERSIAN PUNJABI California: (Jade, Sapphire, Amber, and H SNP), (all other H) (TTY: 7) ROMANIAN Oregon: (H and PPO) (TTY: 7). RUSSIAN California: (Jade, Sapphire, Amber, and H SNP), (all other H); Oregon: (H and PPO) (TTY: 7). SPANISH California: (Jade, Sapphire, Amber, and H SNP), (all other H); Oregon: (H and PPO) (TTY: 7). TAGALOG THAI California: (Jade, Sapphire, Amber, and H SNP), (all other H) (TTY: 7). California: (Jade, Sapphire, Amber, and H SNP), (all other H); Oregon: (H and PPO) (TTY: 7). UKRAINIAN Oregon: (H and PPO) (TTY: 7). VIETNAMESE

19 ADHD/ANTI-NARCOLEPSY/ANTI- OBESITY/ANOREXIANTS - s to Treat ADHD, Sleep and Eating Disorders Amphetamines amphetaminedextroamphetamine cp ---, , , , , amphetaminedextroamphetamine ; tabs ---, , , , , , dextroamphetamine sulfate cp, 0, dextroamphetamine sulfate tabs, 0 methamphetamine hcl tabs PA; VYVANSE CAPS 0 MG SL(7 ea daily); VYVANSE CAPS 0 MG SL(. ea daily); VYVANSE CAPS 0 MG SL(. ea daily); VYVANSE CAPS 0 MG SL(.7 ea daily); VYVANSE CAPS 0 MG SL(. ea daily); VYVANSE CAPS 60 MG SL(.6 ea daily); VYVANSE CAPS 70 MG SL( ea daily); Attention-Deficit/Hyperactivity Disorder (ADHD) atomoxetine hcl caps 0 SL(0 ea daily); ; atomoxetine hcl caps 00 SL( ea daily); ; atomoxetine hcl caps 8 SL(. ea daily); ; atomoxetine hcl caps SL( ea daily); ; atomoxetine hcl caps 0 SL(. ea daily); ; atomoxetine hcl caps 60 SL(.66 ea daily); ; atomoxetine hcl caps 80 SL(. ea daily); ; clonidine hcl (adhd) tb guanfacine hcl (adhd) tb Stimulants - Misc. armodafinil tabs DAYTRANA PTCH dexmethylphenidate hcl cp, 0,, 0,, 0,, 0 dexmethylphenidate hcl tabs, 0,. methylphenidate hcl cp 0, 60 methylphenidate hcl cp 0, 0, 0 methylphenidate hcl cpcr 0, 0, 0, 60 methylphenidate hcl cpcr 0 methylphenidate hcl cpcr 0 methylphenidate hcl tabs, 0, 0 methylphenidate hcl tb 8, 7, 6, AL(Up to 6 yrs old); ; PA; ; QL( ea daily); QL( ea daily); QL( ea daily); Non-Osmotic Release 09 Health Net (Value) Formulary Updated 0/0/09

20 methylphenidate hcl tbcr 0 methylphenidate hcl tbcr 8, 7, 6, methylphenidate hcl tbcr 0 modafinil tabs 00 modafinil tabs 00 QL( ea daily); PA; ; PA; QL( ea daily); ; ALLERGENIC EXTRACTS/BIOLOGICALS MISC Allergenic Extracts ORALAIR SUBL Biologicals Misc ADAGEN SOLN PA; ;LA; AMINOGLYCOSIDES - s to Treat Bacterial Infections Aminoglycosides amikacin sulfate soln BETHKIS NEBU B/D; gentamicin in saline soln 0.9%-/ml gentamicin sulfate soln 0 ; /ml KITABIS PAK NEBU B/D; neomycin sulfate tabs paromomycin sulfate caps TOBI PODHALER CAPS tobramycin nebu B/D; tobramycin sulfate soln 0 /ml, 80 /ml,. gm/0ml tobramycin sulfate solr. gm ANALGESICS - ANTI-INFLAMMATORY - s to Treat Pain, Swelling, Muscle and Joint Conditions Anti-TNF-alpha - Monoclonal Antibodies HUMIRA PEDIATRIC CROHNS DISEASE PA; STARTER PACK PSKT HUMIRA PEN PNKT PA; HUMIRA PEN-CD/UC/HS STARTER PNKT HUMIRA PEN-PS/UV STARTER PNKT HUMIRA PSKT SIMPONI ARIA SOLN SIMPONI SOAJ SIMPONI SOSY Antirheumatic - Enzyme Inhibitors OLUMIANT TABS XELJANZ TABS XELJANZ XR TB Antirheumatic Antimetabolites OTREXUP SOAJ 0 MG/0.ML, MG/0.ML, 0 MG/0.ML, MG/0.ML,. MG/0.ML, 7. MG/0.ML,. MG/0.ML RASUVO SOAJ 0 MG/0.ML, MG/0.ML, MG/0.ML, 0 MG/0.6ML, 7. MG/0.ML,. MG/0.ML, 7. MG/0.ML,. MG/0.ML RASUVO SOAJ 0 MG/0.ML Gold Compounds PA; PA; PA; PA; PA; PA; PA; PA; PA; PA PA PA 09 Health Net (Value) Formulary Updated 0/0/09

21 RIDAURA CAPS Interleukin- Blockers ARCALYST SOLR Interleukin-beta Blockers ILARIS SOLN ILARIS SOLR Interleukin-6 Receptor Inhibitors ACTEMRA SOSY SC 6 MG/0.9ML KEVZARA SOAJ KEVZARA SOSY ; ;LA PA; ;LA PA; ;LA PA; PA; PA; Nonsteroidal Anti-inflammatory Agents (NSAIDs) celecoxib caps diclofenac potassium tabs diclofenac sodium tb 00 diclofenac sodium tbec, 0, 7 diclofenac w/ misoprostol tbec etodolac caps 00, 00 etodolac tabs 00, 00 etodolac tb 00, 00, 600 flurbiprofen tabs ibuprofen susp 00 /ml ibuprofen tabs 00 ibuprofen tabs 600 ibuprofen tabs 800 INDOCIN SUSP OR MG/ML ; RX/OTC; ; SL(8 ea daily); ; SL(. ea daily); ; SL( ea daily); ; AL(Up to 6 yrs old); indomethacin caps, 0 indomethacin cpcr 7 ketoprofen caps 7 ketoprofen cp 00 ketorolac tromethamine soln ij /ml, 0 /ml ketorolac tromethamine soln im 0 /ml, 60 /ml ketorolac tromethamine tabs or 0 mefenamic acid caps meloxicam tabs nabumetone tabs NAPRELAN TB 70 MG naproxen sodium tabs 7, 0 naproxen sodium tb 7, 00 naproxen tabs 0, 7, 00 naproxen tbec 7, 00 oxaprozin tabs piroxicam caps sulindac tabs tolmetin sodium caps 00 tolmetin sodium tabs 00 VIVO TBEC ZIPSOR CAPS Pyrimidine Synthesis Inhibitors AL(Up to 6 yrs old); ; AL(Up to 6 yrs old); AL(Up to 6 yrs old); AL(Up to 6 yrs old); AL(Up to 6 yrs old); ; ; ; ; ; PA; ; 09 Health Net (Value) Formulary Updated 0/0/09

22 leflunomide tabs Soluble Tumor Necrosis Factor Receptor Agents ENBREL MINI SOCT PA; ENBREL SOLR ENBREL SOSY PA; PA; ENBREL SURECLICK PA; SOAJ ANALGESICS - NonNarcotic - s to Treat Pain, Muscle and Joint Conditions Salicylates diflunisal tabs ; ANALGESICS - OPIOID - s to Treat Pain, Muscle and Joint Conditions Opioid Agonists ABSTRAL SUBL 00 MCG PA; QL(6 ea daily) ABSTRAL SUBL 00 MCG PA; ;QL(8 ea daily) ABSTRAL SUBL 00 MCG PA; ;QL(. ea daily) ABSTRAL SUBL 00 MCG, 600 MCG, 800 MCG PA; ;QL( ea daily) codeine sulfate tabs 0 SL( ea daily); ; codeine sulfate tabs 60 SL(6 ea daily); ; fentanyl citrate lpop bu 00 PA; ;QL(8 mcg fentanyl citrate lpop bu 00 mcg, 600 mcg, 800 mcg, 00 mcg, 600 mcg fentanyl pt7 mcg/hr, mcg/hr, 0 mcg/hr, 7 mcg/hr, 00 mcg/hr FENTORA TABS 00 MCG FENTORA TABS 00 MCG ea daily); PA; ;QL( ea daily); Limit 0 patches per month;ql(0. ea daily); PA; ;QL(6 ea daily); PA; ;QL(8 ea daily); FENTORA TABS 00 MCG, 600 MCG, 800 MCG hydromorphone hcl liqd or /ml hydromorphone hcl soln ij /ml hydromorphone hcl soln ij 0 /ml, 0 /ml, 00 /0ml hydromorphone hcl soln ij /ml hydromorphone hcl ta or hydromorphone hcl ta or 6 hydromorphone hcl ta or hydromorphone hcl ta or 8, 8 hydromorphone hcl tabs or, hydromorphone hcl tabs or 8 HYSINGLA ER TA 0 MG, 0 MG, 0 MG, 60 MG HYSINGLA ER TA 80 MG, 00 MG, 0 MG KADIAN CP 0 MG (Morphine Sulfate) LAZANDA SOLN 00 MCG/ACT LAZANDA SOLN 00 MCG/ACT LAZANDA SOLN 00 MCG/ACT meperidine hcl tabs or 00 meperidine hcl tabs or 0 methadone hcl soln or 0 /ml PA; ;QL( ea daily); QL(0 ml daily); QL(.7 ea daily); ; QL(. ea daily); ; QL(.7 ea daily); ; QL(6.7 ea daily); ; QL(9 ea daily); QL(6. ea daily); PA; QL( ea daily); PA; QL( ea daily); PA; QL( ea daily); PA; ;QL( ea daily); PA; ;QL(0. ea daily); PA; ;QL(0.7 ea daily); AL(Up to 6 yrs old); QL(0 ea daily); AL(Up to 6 yrs old); QL(0 ea daily); QL(. ml daily); ; 09 Health Net (Value) Formulary Updated 0/0/09

23 methadone hcl soln or /ml methadone hcl tabs or, 0 morphine sulfate beads cp 0 morphine sulfate beads cp 0 morphine sulfate beads cp morphine sulfate beads cp 60 morphine sulfate beads cp 7 morphine sulfate beads cp 90 morphine sulfate cp or 0, 0, 0, 0 morphine sulfate cp or 00 morphine sulfate cp or 0 morphine sulfate cp or 60 morphine sulfate cp or 80 morphine sulfate soln ij 0. /ml morphine sulfate soln ij /ml morphine sulfate soln or 0 /ml morphine sulfate soln or 0 /ml morphine sulfate soln or 0 /ml, 00 /ml morphine sulfate tbcr or 00, 00 morphine sulfate tbcr or, 0, 60 NUCYNTA ER TB 00 MG NUCYNTA ER TB 0 MG QL( ml daily); ; QL(6 ea daily); QL(.67 ea daily); ; QL(6.67 ea daily); ; QL(. ea daily); ; QL(. ea daily); ; QL(.67 ea daily); ; QL(. ea daily); ; QL( ea daily); ;QL( ea daily); PA; QL( ea daily); QL(. ea daily); QL(. ea daily); QL(00 ml daily); QL(0 ml daily); QL(0 ml daily); QL( ea daily); QL( ea daily); QL(6.67 ea daily); QL(. ea daily); NUCYNTA ER TB 00 MG NUCYNTA ER TB 0 MG NUCYNTA ER TB 0 MG NUCYNTA TABS 00 MG NUCYNTA TABS 0 MG NUCYNTA TABS 7 MG OPANA ER (CRUSH RESISTANT) TA 0 MG oxycodone hcl caps oxycodone hcl conc 00 /ml oxycodone hcl tabs 0 oxycodone hcl tabs, 0,, 0 oxymorphone hcl tabs, 0 oxymorphone hcl tb 0 oxymorphone hcl tb oxymorphone hcl tb 0 oxymorphone hcl tb 0 oxymorphone hcl tb 0 oxymorphone hcl tb oxymorphone hcl tb 7. SUBSYS LIQD 00 MCG SUBSYS LIQD 00 MCG SUBSYS LIQD 00 MCG QL(. ea daily); QL( ea daily); QL(. ea daily); QL(6.67 ea daily); QL(. ea daily); QL(8.88 ea daily); ;QL( ea daily) QL(6 ea daily); QL(6 ml daily); QL(. ea daily); QL(6 ea daily); QL(6 ea daily); QL( ea daily); QL(. ea daily); QL(. ea daily); QL(. ea daily); QL( ea daily); QL(. ea daily); QL(8.89 ea daily); PA; ;QL(6 ea daily); PA; ;QL( ea daily) PA; ;QL(8 ea daily); 09 Health Net (Value) Formulary Updated 0/0/09

24 SUBSYS LIQD 00 MCG, 600 MCG, 800 MCG, 600 MCG tramadol hcl tabs 0 tramadol hcl tb 00 tramadol hcl tb 00 tramadol hcl tb 00 ZOHYDRO ER CA 0 MG, MG ZOHYDRO ER CA 0 MG, 0 MG, 0 MG, 0 MG Opioid Combinations acetaminophen w/ codeine soln 0/ml-/ml acetaminophen w/ codeine tabs 00- acetaminophen w/ codeine tabs 00-0 acetaminophen w/ codeine tabs butalbital-acetaminophencaffeine w/ codeine caps butalbital-aspirin-caffeine w/cod caps hydrocodoneacetaminophen soln 0/ml-/ml hydrocodoneacetaminophen soln./ml-08/ml, /0ml-7/0ml, 7./ml-/ml hydrocodoneacetaminophen tabs - 00, 0-00, PA; ;QL( ea daily); SL(8 ea daily); ; SL( ea daily); SL(. ea daily); SL( ea daily); PA; QL( ea daily); PA; QL( ea daily); Limit 00mls per month;sl(0 ml daily); ; SL(. ea daily); ; SL( ea daily); ; SL(6 ea daily); ; AL(Up to 6 yrs old); SL(6 ea daily); AL(Up to 6 yrs old); SL(6 ea daily); Limit mls per month;sl(8. ml daily); ; Limit mls per month;sl(8. ml daily); SL(. ea daily); ; hydrocodoneacetaminophen tabs -, 0-, 7.- hydrocodone-ibuprofen tabs oxycodone w/ acetaminophen tabs 0- oxycodone w/ acetaminophen tabs -,.-, 7.- oxycodone-aspirin tabs tramadol-acetaminophen tabs Opioid Partial Agonists BUNAVAIL FILM.MG- 0.MG BUNAVAIL FILM.MG- 0.7MG BUNAVAIL FILM 6.MG- MG buprenorphine hcl subl sl buprenorphine hcl subl sl 8 buprenorphine hclnaloxone hcl dihydrate film - buprenorphine hclnaloxone hcl dihydrate film -, 8-, - 0. buprenorphine hclnaloxone hcl dihydrate subl -0. buprenorphine hclnaloxone hcl dihydrate subl 8- buprenorphine ptwk 0 mcg/hr SL(. ea daily); ; QL( ea daily); SL(. ea daily); SL(. ea daily); ; SL(8 ea daily); QL(6 ea daily) QL( ea daily); QL( ea daily); QL( ea daily); QL( ea daily); ; QL( ea daily); ; QL( ea daily); QL( ea daily); Limit 8 patches per 8 days;sl(0.9 ea daily); ; 09 Health Net (Value) Formulary Updated 0/0/09 6

25 BUPRENORPHINE PTWK 0 MCG/HR buprenorphine ptwk mcg/hr BUPRENORPHINE PTWK MCG/HR BUPRENORPHINE PTWK 0 MCG/HR buprenorphine ptwk 0 mcg/hr buprenorphine ptwk mcg/hr BUPRENORPHINE PTWK MCG/HR BUPRENORPHINE PTWK 7. MCG/HR butorphanol tartrate soln ij /ml butorphanol tartrate soln na 0 /ml BUTRANS PTWK 0 MCG/HR (Buprenorphine) BUTRANS PTWK MCG/HR (Buprenorphine) Limit 8 patches per 8 days;sl(0.9 ea daily); Limit patches per 8 days;sl(0.9 ea daily); ; Limit patches per 8 days;sl(0.9 ea daily); Limit patches per 8 days;sl(0. ea daily); Limit patches per 8 days;sl(0. ea daily); ; Limit 6 patches per 8 days;sl(0.8 ea daily); ; Limit 6 patches per 8 days;sl(0.8 ea daily); Limit 0 patches per 8 days;sl(0.9 ea daily); Limit 0mls per month;ql(7 ml daily); Limit 8 patches per 8 days;sl(0.9 ea daily); Limit patches per 8 days;sl(0.9 ea daily); BUTRANS PTWK 0 MCG/HR (Buprenorphine) BUTRANS PTWK MCG/HR (Buprenorphine) BUTRANS PTWK 7. MCG/HR pentazocine w/ naloxone tabs SUBOXONE FILM MG- MG (Buprenorphine HCl- Naloxone HCl Dihydrate) SUBOXONE FILM MG- MG, 8MG-MG, MG- 0.MG (Buprenorphine HCl-Naloxone HCl Dihydrate) ZUBSOLV SUBL 0.7MG- 0.8MG ZUBSOLV SUBL.MG- 0.6MG,.MG-.9MG,.9MG-0.7MG ZUBSOLV SUBL.7MG-.MG ZUBSOLV SUBL 8.6MG-.MG Limit patches per 8 days;sl(0. ea daily); Limit 6 patches per 8 days;sl(0.8 ea daily); Limit 0 patches per 8 days;sl(0.9 ea daily); AL(Up to 6 yrs old); QL(9.07 ea daily); QL( ea daily); QL( ea daily); QL( ea daily); QL( ea daily); QL( ea daily); ANDROGENS-ANABOLIC - s to Regulate Hormones Anabolic Steroids ANADROL-0 TABS ; oxandrolone tabs 0 ; oxandrolone tabs. ; Androgens ANDRODERM PT AVEED SOLN LA 09 Health Net (Value) Formulary Updated 0/0/09 7

26 danazol caps fluoxymesterone tabs ; FORTESTA GEL (Testosterone) methyltestosterone caps ; testosterone cypionate soln ; 00 /ml, 00 /ml testosterone enanthate soln testosterone gel %, 0 /gm, /.gm testosterone gel.6 %, 0. /.gm, 0. /.gm testosterone gel 0 /act ; testosterone soln 0 /act ANORECTAL AGENTS - Rectal s to Treat Pain, Swelling and Itching Intrarectal Steroids CORTIFOAM FOAM hydrocortisone (intrarectal) enem UCERIS FOAM RE MG/ACT Rectal Steroids hydrocortisone (rectal) crea ; Vasodilating Agents RECTIV OINT ANTHELMINTICS - s to Treat Worm Infections Anthelmintics albendazole tabs ; ALBENZA TABS (Albendazole) BILTRICIDE TABS (Praziquantel) ivermectin tabs praziquantel tabs ; ANTI-INFECTIVE AGENTS - MISC. - s to Treat Bacterial Infections Anti-infective Agents - Misc. colistimethate sodium solr IMPAVIDO CAPS ; metronidazole caps or 7 SL(0.6 ea daily); metronidazole in nacl soln metronidazole tabs or 0 metronidazole tabs or 00 NEBUPENT SOLR PENTAM 00 SOLR tinidazole tabs trimethoprim tabs SL(6 ea daily); ; SL(8 ea daily); ; B/D; ; Anti-infective Misc. - Combinations sulfamethoxazoletrimethoprim soln iv ; 80/ml-00/ml sulfamethoxazoletrimethoprim susp or 0/ml-00/ml sulfamethoxazoletrimethoprim tabs or 80- ; 00, Antiprotozoal Agents ALINIA TABS 00 MG atovaquone susp Carbapenems DORIBAX SOLR DORIPENEM SOLR ; 09 Health Net (Value) Formulary Updated 0/0/09 8

27 ertapenem sodium solr imipenem-cilastatin solr 0-0 imipenem-cilastatin solr INVANZ SOLR IJ (Ertapenem Sodium) meropenem solr gm meropenem solr 00 VABOMERE SOLR Chloramphenicols chloramphenicol sodium succinate solr Cyclic Lipopeptides daptomycin solr 00 Glycopeptides ORBACTIV SOLR vancomycin hcl caps or vancomycin hcl caps or 0 VANCOMYCIN HCL IN DEXTROSE SOLN %- GM/00ML, %- 00MG/00ML, %- 70MG/0ML vancomycin hcl solr iv gm, gm, 0 gm, 70, 000 vancomycin hcl solr iv 00 Glycylcyclines tigecycline solr TIGECYCLINE SOLR Leprostatics dapsone tabs Lincosamides ; ; PA; PA; ; ; clindamycin hcl caps clindamycin palmitate hydrochloride solr clindamycin phosphate in dw soln clindamycin phosphate soln ij 600 /ml, 900 /6ml clindamycin phosphate soln ij 9 gm/60ml, 00 /ml, 9000 /60ml clindamycin phosphate soln iv 00 /ml, 900 /6ml clindamycin phosphate soln iv 600 /ml lincomycin hcl soln Monobactams aztreonam solr CAYSTON SOLR Oxazolidinones linezolid soln iv 600 /00ml LINEZOLID SOLN IV 600MG/00ML-0.9% linezolid susr or 00 /ml linezolid tabs or 600 SIVEXTRO SOLR IV SIVEXTRO TABS OR ZYVOX SOLN IV 00 MG/00ML Polymyxins polymyxin b sulfate solr Streptogramins SYNERCID SOLR ; ; PA; ;LA ; ; ; ANTIANGINAL AGENTS - s to Treat Chest Pain 09 Health Net (Value) Formulary Updated 0/0/09 9

28 Antianginals-Other RANEXA TB Nitrates DILATRATE SR CPCR ISORDIL TITRADOSE TABS 0 MG isosorbide dinitrate tabs 0 isosorbide dinitrate tabs, 0, 0 isosorbide dinitrate tbcr 0 isosorbide mononitrate tabs 0, 0 isosorbide mononitrate tb 0, 60, 0 NITRO-DUR PT 0. MG/HR, 0.8 MG/HR NITROGLYCERIN LINGUAL AERS nitroglycerin pt td 0. /hr, 0. /hr, 0. /hr, 0.6 /hr nitroglycerin soln tl 0. /spray nitroglycerin subl sl 0., 0., 0.6 NITROSTAT SUBL (Nitroglycerin) PA; ; ; ; ; ; ANTIANXIETY AGENTS - s to Treat Anxiety Antianxiety Agents - Misc. buspirone hcl tabs hydroxyzine hcl soln im 0 /ml hydroxyzine hcl syrp or 0 /ml hydroxyzine hcl tabs or 0,, 0 hydroxyzine pamoate caps, 0 meprobamate tabs ; AL(Up to 6 yrs old); ; AL(Up to 6 yrs old); AL(Up to 6 yrs old); AL(Up to 6 yrs old); ; AL(Up to 6 yrs old); Benzodiazepines alprazolam tabs 0., 0.,, alprazolam tb 0.,,, alprazolam tbdp 0., 0.,, chlordiazepoxide hcl caps clorazepate dipotassium tabs diazepam conc or /ml diazepam soln ij /ml diazepam soln or /ml diazepam tabs or,, 0 lorazepam conc or /ml ; ; ; ; ; ; ; lorazepam soln ij /ml, ; /ml, 0 /0ml lorazepam tabs or 0., ;, oxazepam caps 0,, 0 ANTIARRHYTHMICS - s to treat abnormal heart rhythms Antiarrhythmics Type I-A disopyramide phosphate AL(Up to 6 yrs caps old); NORPACE CR CP 00 AL(Up to 6 yrs MG old); quinidine gluconate tbcr or quinidine sulfate tabs ; Antiarrhythmics Type I-B lidocaine hcl (cardiac) soln mexiletine hcl caps Antiarrhythmics Type I-C flecainide acetate tabs 00 SL( ea daily); 09 Health Net (Value) Formulary Updated 0/0/09 0

29 flecainide acetate tabs 0 flecainide acetate tabs 0 propafenone hcl cp,, propafenone hcl tabs 0,, 00 Antiarrhythmics Type III amiodarone hcl tabs or 00, 00, 00 dofetilide caps MULTAQ TABS SL(.66 ea daily); SL(8 ea daily); ; ANTIASTHMATIC AND BRONCHODILATOR AGENTS - s to Treat Lung Conditions Anti-Inflammatory Agents cromolyn sodium nebu B/D; ; Antiasthmatic - Monoclonal Antibodies CINQAIR SOLN PA; ;LA FASENRA SOSY PA; NUCALA SOLR PA; ;LA XOLAIR SOLR 0 MG PA; ;LA Bronchodilators - Anticholinergics ATROVENT HFA AERS INCRUSE ELLIPTA AEPB ipratropium bromide soln SPIRIVA HANDIHALER CAPS SPIRIVA RESPIMAT AERS Limit inhalers per month;ql(0.86 gm daily); QL( ea daily); B/D; ; QL( ea daily); Limit inhaler per month (60 actuations);sl( 0. gm daily); TUDORZA PRESSAIR AEPB TUDORZA PRESSAIR AEPB Leukotriene Modulators montelukast sodium chew, montelukast sodium tabs 0 zafirlukast tabs Limit inhaler per month (60 actuations);ql( 0.0 ea daily); Limit inhalers per month (0 actuations);ql( 0.07 ea daily); QL( ea daily); QL( ea daily); ; zileuton tb ;SL( ea daily); Selective Phosphodiesterase (PDE) Inhibitors DALIRESP TABS QL( ea daily); Steroid Inhalants ARNUITY ELLIPTA AEPB SL( ea daily); budesonide (inhalation) B/D; QL(8 ml susp 0. /ml daily); budesonide (inhalation) B/D; QL( ml susp 0. /ml daily); budesonide (inhalation) B/D; QL( ml susp /ml daily); FLOVENT DISKUS AEPB 00 MCG/BLIST SL(0 ea daily); FLOVENT DISKUS AEPB 0 MCG/BLIST SL(8 ea daily); FLOVENT DISKUS AEPB 0 MCG/BLIST SL(0 ea daily); FLOVENT HFA AERO 0 MCG/ACT, 0 MCG/ACT Limit inhalers per month;ql(0.8 gm daily); FLOVENT HFA AERO MCG/ACT Limit inhaler per month;ql(0.6 gm daily); 09 Health Net (Value) Formulary Updated 0/0/09

30 PULMICORT FLEXHALER AEPB 80 MCG/ACT PULMICORT FLEXHALER AEPB 90 MCG/ACT Sympathomimetics ADVAIR HFA AERO albuterol sulfate nebu in 0.6 /ml, 0.08 %, 0. %,. /ml albuterol sulfate syrp or /ml albuterol sulfate tabs or, albuterol sulfate tb or, 8 ANORO ELLIPTA AEPB ARCAPTA NEOHALER CAPS BREO ELLIPTA AEPB MCG/INH-00MCG/INH, MCG/INH-00MCG/INH BREO ELLIPTA AEPB MCG/INH-00MCG/INH, MCG/INH-00MCG/INH BROVANA NEBU COMBIVENT RESPIMAT AERS fluticasone-salmeterol aepb 0mcg/dose-00mcg/dose, 0mcg/dose-0mcg/dose, 0mcg/dose-00mcg/dose ipratropium-albuterol soln levalbuterol hcl nebu levalbuterol tartrate aero Limit inhalers per month;ql(0.07 ea daily); Limit 8 inhalers per month;ql(0.7 ea daily); QL( gm daily); B/D; ; ; ; QL( ea daily); QL( ea daily); Limit inhalers per month (Institutional Pack);SL( ea daily); Limit inhaler per month;sl( ea daily); B/D; Limit inhaler per month;sl(0. gm daily); QL( ea daily); ; B/D; ; B/D; PERFOROMIST NEBU PROAIR HFA AERS PROAIR RESPICLICK AEPB SEREVENT DISKUS AEPB STIOLTO RESPIMAT AERS STRIVERDI RESPIMAT AERS SYMBICORT AERO.MCG/ACT- 60MCG/ACT SYMBICORT AERO.MCG/ACT-80MCG/ACT SYMBICORT AERO.MCG/ACT- 80MCG/ACT,.MCG/ACT- 60MCG/ACT terbutaline sulfate tabs or,. TRELEGY ELLIPTA AEPB Xanthines aminophylline soln theophylline tb 00, 00, 00, 0 theophylline tb 00, 600 B/D; QL( ml daily); QL( ea daily); Limit inhaler per month;sl(0. gm daily); Limit inhaler per month (60 actuations);sl( 0. gm daily); Limit inhalers per month (Institutional Pack);QL(0. gm daily); Limit inhalers per month (Institutional Pack);QL(0.6 gm daily); Limit inhaler per month;ql(0. gm daily); ; ANTICOAGULANTS - Blood Thinners Coumarin Anticoagulants 09 Health Net (Value) Formulary Updated 0/0/09