Commercial Preventive Drug List
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- Melina Morton
- 5 years ago
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1 Commercial Preventive Drug List The presence of a drug on this list does not guarantee coverage. Your benefit plan determines coverage of medications. Where differences are noted between this reference guide and your benefit plan documents, the benefit plan documents will govern. All medications listed are still subject to Formulary management such as prior authorization, step-edits, quantity limits, and tier placement. This list is subject to change and may include additional drugs based on your plan benefits. bsneny.com A division of HealthNow New York Inc., an independent licensee of the BlueCross BlueShield Association _NENY_11_18 DL
2 Ace Inhibitors BENAZEPRIL HCL... GENERIC CAPTOPRIL... GENERIC ENALAPRIL MALEATE... GENERIC FOSINOPRIL SODIUM... GENERIC LISINOPRIL... GENERIC MOEXIPRIL HCL... GENERIC PERINDOPRIL ERBUMINE... GENERIC QUINAPRIL HCL... GENERIC RAMIPRIL... GENERIC TRANDOLAPRIL... GENERIC Adrenergic Agonist MIDODRINE HCL... GENERIC Adrenergic Antagonists and Related Drugs CLONIDINE... GENERIC CLONIDINE HCL... GENERIC DOXAZOSIN MESYLATE... GENERIC GUANFACINE HCL... GENERIC METHYLDOPA... GENERIC METHYLDOPA-HYDROCHLOROTHIAZIDE... GENERIC PHENOXYBENZAMINE HCL... GENERIC PRAZOSIN HCL... GENERIC RESERPINE... GENERIC TERAZOSIN HCL... GENERIC Angiotensin II Receptor Blockers and Renin Inhibitors VALSARTAN-HYDROCHLOROTHIAZIDE... GENERIC Anticoagulants/Antithrombotics ANAGRELIDE HCL... GENERIC ASPIRIN-DIPYRIDAMOLE ER... GENERIC CLOPIDOGREL... GENERIC DIPYRIDAMOLE... GENERIC ENOXAPARIN SODIUM... GENERIC FONDAPARINUX SODIUM... GENERIC JANTOVEN... GENERIC PRASUGREL HCL... GENERIC TICLOPIDINE HCL... GENERIC WARFARIN SODIUM... GENERIC Antiemetics APREPITANT... GENERIC COMPRO... GENERIC DRONABINOL... GENERIC GRANISETRON HCL... GENERIC MECLIZINE HCL... GENERIC ONDANSETRON HCL... GENERIC ONDANSETRON ODT... GENERIC PHENADOZ... GENERIC PROCHLORPERAZINE... GENERIC PROCHLORPERAZINE EDISYLATE... GENERIC PROCHLORPERAZINE MALEATE... GENERIC PROMETHAZINE HCL... GENERIC PROMETHEGAN... GENERIC SCOPOLAMINE... GENERIC TRIMETHOBENZAMIDE HCL... GENERIC Antihypertensive, Other CANDESARTAN CILEXETIL... GENERIC CANDESARTAN-HYDROCHLOROTHIAZID... GENERIC EPROSARTAN MESYLATE... GENERIC IRBESARTAN... GENERIC IRBESARTAN-HYDROCHLOROTHIAZIDE... GENERIC LOSARTAN POTASSIUM... GENERIC LOSARTAN-HYDROCHLOROTHIAZIDE... GENERIC OLMESARTAN MEDOXOMIL... GENERIC OLMESARTAN-HYDROCHLOROTHIAZIDE... GENERIC TELMISARTAN... GENERIC TELMISARTAN-HYDROCHLOROTHIAZID... GENERIC VALSARTAN... GENERIC 2 AMLODIPINE BESYLATE-BENAZEPRIL... GENERIC AMLODIPINE-OLMESARTAN... GENERIC AMLODIPINE-VALSARTAN... GENERIC AMLODIPINE-VALSARTAN-HCTZ... GENERIC ATENOLOL-CHLORTHALIDONE... GENERIC BENAZEPRIL-HYDROCHLOROTHIAZIDE... GENERIC BISOPROLOL-HYDROCHLOROTHIAZIDE... GENERIC CAPTOPRIL-HYDROCHLOROTHIAZIDE... GENERIC ENALAPRIL-HYDROCHLOROTHIAZIDE... GENERIC FOSINOPRIL-HYDROCHLOROTHIAZIDE... GENERIC HYDRALAZINE HCL... GENERIC LISINOPRIL-HYDROCHLOROTHIAZIDE... GENERIC
3 METOPROLOL-HYDROCHLOROTHIAZIDE... GENERIC MOEXIPRIL-HYDROCHLOROTHIAZIDE... GENERIC NADOLOL-BENDROFLUMETHIAZIDE... GENERIC OLMESARTAN-AMLODIPINE-HCTZ... GENERIC PROPRANOLOL-HYDROCHLOROTHIAZID... GENERIC QUINAPRIL-HYDROCHLOROTHIAZIDE... GENERIC TELMISARTAN-AMLODIPINE... GENERIC TRANDOLAPRIL-VERAPAMIL ER... GENERIC Antivirals ACYCLOVIR... GENERIC ATOVAQUONE... GENERIC ATOVAQUONE-PROGUANIL HCL... GENERIC CHLOROQUINE PHOSPHATE... GENERIC FAMCICLOVIR... GENERIC HYDROXYCHLOROQUINE SULFATE... GENERIC MEFLOQUINE HCL... GENERIC OSELTAMIVIR PHOSPHATE... GENERIC QUININE SULFATE... GENERIC RIMANTADINE HCL... GENERIC VALACYCLOVIR... GENERIC VALGANCICLOVIR HCL... GENERIC Beta Blockers ACEBUTOLOL HCL... GENERIC ATENOLOL... GENERIC BETAXOLOL HCL... GENERIC BISOPROLOL FUMARATE... GENERIC CARVEDILOL... GENERIC CARVEDILOL ER... GENERIC LABETALOL HCL... GENERIC METOPROLOL SUCCINATE... GENERIC METOPROLOL TARTRATE... GENERIC NADOLOL... GENERIC PINDOLOL... GENERIC PROPRANOLOL HCL... GENERIC PROPRANOLOL HCL ER... GENERIC TIMOLOL MALEATE... GENERIC Calcium Channel Blockers AFEDITAB CR... GENERIC AMLODIPINE BESYLATE... GENERIC CARTIA XT... GENERIC DILT-XR... GENERIC 3 DILTIAZEM 12HR ER... GENERIC DILTIAZEM 24HR CD... GENERIC DILTIAZEM 24HR ER... GENERIC DILTIAZEM ER... GENERIC FELODIPINE ER... GENERIC ISRADIPINE... GENERIC MATZIM LA... GENERIC NICARDIPINE HCL... GENERIC NIFEDICAL XL... GENERIC NIFEDIPINE... GENERIC NIFEDIPINE ER... GENERIC NISOLDIPINE... GENERIC TAZTIA XT... GENERIC VERAPAMIL ER... GENERIC VERAPAMIL ER PM... GENERIC VERAPAMIL HCL... GENERIC VERAPAMIL SR... GENERIC Contraceptives ALTAVERA... GENERIC ALYACEN... GENERIC AMETHIA... GENERIC AMETHIA LO... GENERIC AMETHYST... GENERIC APRI... GENERIC ARANELLE... GENERIC ASHLYNA... GENERIC AUBRA... GENERIC AUBRA EQ... GENERIC AVIANE... GENERIC AZURETTE... GENERIC BALZIVA... GENERIC BEKYREE... GENERIC BLISOVI 24 FE... GENERIC BLISOVI FE... GENERIC BRIELLYN... GENERIC CAMILA... GENERIC CAMRESE... GENERIC CAMRESE LO... GENERIC CAZIANT... GENERIC CHATEAL... GENERIC CHATEAL EQ... GENERIC CRYSELLE... GENERIC CYCLAFEM... GENERIC CYRED... GENERIC CYRED EQ... GENERIC
4 DASETTA... GENERIC DAYSEE... GENERIC DEBLITANE... GENERIC DELYLA... GENERIC DESOGESTR-ETH ESTRAD ETH ESTRA... GENERIC DESOGESTREL-ETHINYL ESTRADIOL... GENERIC DROSPIRENONE-ETH ESTRA-LEVOMEF... GENERIC DROSPIRENONE-ETHINYL ESTRADIOL... GENERIC ELINEST... GENERIC EMOQUETTE... GENERIC ENPRESSE... GENERIC ENSKYCE... GENERIC ERRIN... GENERIC ESTARYLLA... GENERIC ETHYNODIOL-ETHINYL ESTRADIOL... GENERIC FALMINA... GENERIC FAYOSIM... GENERIC FEMYNOR... GENERIC GIANVI... GENERIC GILDAGIA... GENERIC GILDESS... GENERIC GILDESS 24 FE... GENERIC GILDESS FE... GENERIC HEATHER... GENERIC HYDROXYPROGESTERONE CAPROATE... GENERIC INCASSIA... GENERIC INTROVALE... GENERIC ISIBLOOM... GENERIC JENCYCLA... GENERIC JOLESSA... GENERIC JOLIVETTE... GENERIC JULEBER... GENERIC JUNEL... GENERIC JUNEL FE... GENERIC JUNEL FE GENERIC KAITLIB FE... GENERIC KARIVA... GENERIC KELNOR GENERIC KELNOR GENERIC KIMIDESS... GENERIC KURVELO... GENERIC LARIN... GENERIC LARIN 24 FE... GENERIC LARIN FE... GENERIC LARISSIA... GENERIC LAYOLIS FE... GENERIC LEENA... GENERIC LESSINA... GENERIC 4 LEVONEST... GENERIC LEVONORG-ETH ESTRAD ETH ESTRAD... GENERIC LEVONORGESTREL-ETH ESTRADIOL... GENERIC LEVORA GENERIC LILLOW... GENERIC LOMEDIA 24 FE... GENERIC LORYNA... GENERIC LOW-OGESTREL... GENERIC LUTERA... GENERIC LYZA... GENERIC MARLISSA... GENERIC MEDROXYPROGESTERONE ACETATE... GENERIC MELODETTA 24 FE... GENERIC MIBELAS 24 FE... GENERIC MICROGESTIN... GENERIC MICROGESTIN FE... GENERIC MILI... GENERIC MONO-LINYAH... GENERIC MONONESSA... GENERIC MYZILRA... GENERIC NECON... GENERIC NIKKI... GENERIC NORA-BE... GENERIC NORETHIN-ETH ESTRA-FERROUS FUM... GENERIC NORETHINDRON-ETHINYL ESTRADIOL... GENERIC NORETHINDRONE... GENERIC NORETHINDRONE ACETATE... GENERIC NORGESTIMATE-ETHINYL ESTRADIOL... GENERIC NORGESTREL-ETHINY ESTRA... GENERIC NORLYDA... GENERIC NORLYROC... GENERIC NORTREL... GENERIC OCELLA... GENERIC OGESTREL... GENERIC ORSYTHIA... GENERIC PHILITH... GENERIC PIMTREA... GENERIC PIRMELLA... GENERIC PORTIA... GENERIC PREVIFEM... GENERIC PROGESTERONE... GENERIC PROGESTERONE IN OIL... GENERIC QUASENSE... GENERIC RAJANI... GENERIC RECLIPSEN... GENERIC RIVELSA... GENERIC SETLAKIN... GENERIC SHAROBEL... GENERIC
5 SPRINTEC... GENERIC SRONYX... GENERIC SYEDA... GENERIC TARINA FE... GENERIC TARINA FE 1-20 EQ... GENERIC TILIA FE... GENERIC TRI FEMYNOR... GENERIC TRI-ESTARYLLA... GENERIC TRI-LEGEST FE... GENERIC TRI-LINYAH... GENERIC TRI-LO-ESTARYLLA... GENERIC TRI-LO-MARZIA... GENERIC TRI-LO-SPRINTEC... GENERIC TRI-MILI... GENERIC TRI-PREVIFEM... GENERIC TRI-SPRINTEC... GENERIC TRI-VYLIBRA... GENERIC TRINESSA... GENERIC TRINESSA LO... GENERIC TRIVORA GENERIC TULANA... GENERIC TYDEMY... GENERIC VELIVET... GENERIC VESTURA... GENERIC VIENVA... GENERIC VIORELE... GENERIC VYFEMLA... GENERIC VYLIBRA... GENERIC WERA... GENERIC WYMZYA FE... GENERIC XULANE... GENERIC ZARAH... GENERIC ZENCHENT... GENERIC ZENCHENT FE... GENERIC ZEOSA... GENERIC ZOVIA 1-35E... GENERIC ZOVIA 1-50E... GENERIC EPLERENONE... GENERIC ETHACRYNIC ACID... GENERIC FUROSEMIDE... GENERIC HYDROCHLOROTHIAZIDE... GENERIC INDAPAMIDE... GENERIC METHAZOLAMIDE... GENERIC METHYCLOTHIAZIDE... GENERIC METOLAZONE... GENERIC SPIRONOLACTONE... GENERIC SPIRONOLACTONE-HCTZ... GENERIC TORSEMIDE... GENERIC TRIAMTERENE-HCTZ... GENERIC TRIAMTERENE-HYDROCHLOROTHIAZID... GENERIC Estrogens/Estrogen Combinations AMABELZ... GENERIC COVARYX... GENERIC COVARYX H.S.... GENERIC EEMT... GENERIC EEMT H.S.... GENERIC ESTRADIOL... GENERIC ESTRADIOL TRANSDERMAL PATCH... GENERIC ESTRADIOL VALERATE... GENERIC ESTRADIOL-NORETHINDRONE ACETAT... GENERIC ESTROGEN-METHYLTESTOSTERONE... GENERIC ESTROPIPATE... GENERIC FYAVOLV... GENERIC JEVANTIQUE LO... GENERIC JINTELI... GENERIC LOPREEZA... GENERIC MIMVEY... GENERIC MIMVEY LO... GENERIC NORETHINDRON-ETHINYL ESTRADIOL... GENERIC Gout Therapy Diuretics ACETAZOLAMIDE... GENERIC ACETAZOLAMIDE SODIUM... GENERIC AMILORIDE HCL... GENERIC AMILORIDE-HYDROCHLOROTHIAZIDE... GENERIC BUMETANIDE... GENERIC CHLOROTHIAZIDE... GENERIC CHLORTHALIDONE... GENERIC 5 ALLOPURINOL... GENERIC HIV/AIDS Therapy ABACAVIR... GENERIC ABACAVIR-LAMIVUDINE... GENERIC ABACAVIR-LAMIVUDINE-ZIDOVUDINE... GENERIC ATAZANAVIR SULFATE... GENERIC DIDANOSINE... GENERIC EFAVIRENZ... GENERIC
6 FOSAMPRENAVIR CALCIUM... GENERIC LAMIVUDINE... GENERIC LAMIVUDINE-ZIDOVUDINE... GENERIC LOPINAVIR-RITONAVIR... GENERIC NEVIRAPINE... GENERIC NEVIRAPINE ER... GENERIC RITONAVIR... GENERIC STAVUDINE... GENERIC TENOFOVIR DISOPROXIL FUMARATE... GENERIC ZIDOVUDINE... GENERIC Immunosuppressant Drugs AZATHIOPRINE... GENERIC AZATHIOPRINE SODIUM... GENERIC CYCLOSPORINE... GENERIC CYCLOSPORINE MODIFIED... GENERIC GENGRAF... GENERIC MYCOPHENOLATE MOFETIL... GENERIC MYCOPHENOLIC ACID... GENERIC SIROLIMUS... GENERIC TACROLIMUS... GENERIC Inhaled Corticosteroids BUDESONIDE... GENERIC ADVAIR DISKUS... BRAND ADVAIR HFA... BRAND AEROSPAN... BRAND AIRDUO RESPICLICK... BRAND ALVESCO... BRAND ARMONAIR RESPICLICK... BRAND ARNUITY ELLIPTA... BRAND ASMANEX... BRAND ASMANEX HFA... BRAND BREO ELLIPTA... BRAND DULERA... BRAND FLOVENT DISKUS... BRAND FLOVENT HFA... BRAND FLUTICASONE-SALMETEROL... BRAND PULMICORT... BRAND PULMICORT FLEXHALER... BRAND QVAR... BRAND QVAR REDIHALER... BRAND SYMBICORT... BRAND TRELEGY ELLIPTA... BRAND 6 Insulin Therapy ADMELOG... BRAND ADMELOG SOLOSTAR... BRAND AFREZZA... BRAND APIDRA... BRAND APIDRA SOLOSTAR... BRAND BASAGLAR KWIKPEN U BRAND FIASP... BRAND FIASP FLEXTOUCH... BRAND HUMALOG... BRAND HUMALOG JUNIOR KWIKPEN... BRAND HUMALOG KWIKPEN U BRAND HUMALOG KWIKPEN U BRAND HUMALOG MIX BRAND HUMALOG MIX KWIKPEN... BRAND HUMALOG MIX BRAND HUMALOG MIX KWIKPEN... BRAND HUMULIN BRAND HUMULIN 70/30 KWIKPEN... BRAND HUMULIN N... BRAND HUMULIN N KWIKPEN... BRAND HUMULIN R... BRAND HUMULIN R U BRAND HUMULIN R U-500 KWIKPEN... BRAND LANTUS... BRAND LANTUS SOLOSTAR... BRAND LEVEMIR... BRAND LEVEMIR FLEXTOUCH... BRAND NOVOLIN BRAND NOVOLIN FLEXPEN... BRAND NOVOLIN N... BRAND NOVOLIN R... BRAND NOVOLOG... BRAND NOVOLOG FLEXPEN... BRAND NOVOLOG MIX BRAND NOVOLOG MIX FLEXPEN... BRAND TOUJEO MAX SOLOSTAR... BRAND TOUJEO SOLOSTAR... BRAND TRESIBA FLEXTOUCH U BRAND TRESIBA FLEXTOUCH U BRAND Leukotriene Antagonists/Modifiers MONTELUKAST SODIUM... GENERIC ZAFIRLUKAST... GENERIC ZILEUTON ER... GENERIC
7 Lipid/Cholesterol Lowering Agents AMLODIPINE-ATORVASTATIN... GENERIC ATORVASTATIN CALCIUM... GENERIC CHOLESTYRAMINE... GENERIC CHOLESTYRAMINE LIGHT... GENERIC COLESEVELAM HCL... GENERIC COLESTIPOL HCL... GENERIC EZETIMIBE-SIMVASTATIN... GENERIC FLUVASTATIN ER... GENERIC FLUVASTATIN SODIUM... GENERIC LOVASTATIN... GENERIC PRAVASTATIN SODIUM... GENERIC PREVALITE... GENERIC ROSUVASTATIN CALCIUM... GENERIC SIMVASTATIN... GENERIC Non-Insulin Hypoglycemic Agents ACARBOSE... GENERIC CHLORPROPAMIDE... GENERIC GLIMEPIRIDE... GENERIC GLIPIZIDE... GENERIC GLIPIZIDE ER... GENERIC GLIPIZIDE XL... GENERIC GLIPIZIDE-METFORMIN... GENERIC GLYBURIDE... GENERIC GLYBURIDE MICRONIZED... GENERIC GLYBURIDE-METFORMIN HCL... GENERIC METFORMIN HCL... GENERIC METFORMIN HCL ER... GENERIC MIGLITOL... GENERIC NATEGLINIDE... GENERIC PIOGLITAZONE HCL... GENERIC PIOGLITAZONE-GLIMEPIRIDE... GENERIC PIOGLITAZONE-METFORMIN... GENERIC REPAGLINIDE... GENERIC REPAGLINIDE-METFORMIN HCL... GENERIC TOLAZAMIDE... GENERIC TOLBUTAMIDE... GENERIC ACTOPLUS MET... BRAND ACTOPLUS MET XR... BRAND ACTOS... BRAND ADLYXIN... BRAND ALOGLIPTIN... BRAND ALOGLIPTIN-METFORMIN... BRAND ALOGLIPTIN-PIOGLITAZONE... BRAND 7 AMARYL... BRAND AVANDAMET... BRAND AVANDIA... BRAND BYDUREON... BRAND BYDUREON BCISE... BRAND BYDUREON PEN... BRAND BYETTA... BRAND CYCLOSET... BRAND DIABETA... BRAND DM2... BRAND DUETACT... BRAND FARXIGA... BRAND FORTAMET... BRAND GLUCOPHAGE... BRAND GLUCOPHAGE XR... BRAND GLUCOTROL... BRAND GLUCOTROL XL... BRAND GLUCOVANCE... BRAND GLUMETZA... BRAND GLYNASE... BRAND GLYSET... BRAND GLYXAMBI... BRAND INVOKAMET... BRAND INVOKAMET XR... BRAND INVOKANA... BRAND JANUMET... BRAND JANUMET XR... BRAND JANUVIA... BRAND JARDIANCE... BRAND JENTADUETO... BRAND JENTADUETO XR... BRAND KAZANO... BRAND KOMBIGLYZE XR... BRAND NESINA... BRAND ONGLYZA... BRAND OSENI... BRAND OZEMPIC... BRAND PRANDIMET... BRAND PRANDIN... BRAND PRECOSE... BRAND QTERN... BRAND RIOMET... BRAND SEGLUROMET... BRAND SOLIQUA BRAND STARLIX... BRAND STEGLATRO... BRAND STEGLUJAN... BRAND SYMLINPEN BRAND
8 SYMLINPEN BRAND SYNJARDY... BRAND SYNJARDY XR... BRAND TANZEUM... BRAND TRADJENTA... BRAND TRULICITY... BRAND VICTOZA 2-PAK... BRAND VICTOZA 3-PAK... BRAND XIGDUO XR... BRAND XULTOPHY BRAND Osteoporosis Therapy ALENDRONATE SODIUM... GENERIC CALCITONIN-SALMON... GENERIC ETIDRONATE DISODIUM... GENERIC FORTICAL... GENERIC RALOXIFENE HCL... GENERIC RISEDRONATE SODIUM... GENERIC RISEDRONATE SODIUM DR... GENERIC Phosphate Binding Agents LANTHANUM CARBONATE... GENERIC SEVELAMER CARBONATE... GENERIC Smoking Cessation BUPROBAN... GENERIC BUPROPION HCL SR... GENERIC NICORELIEF... GENERIC NICOTINE GUM... GENERIC NICOTINE PATCH... GENERIC NTS... GENERIC QUIT 2... GENERIC QUIT 4... GENERIC STOP SMOKING AID... GENERIC Vitamins/Minerals CALCITRIOL... GENERIC FOLIC ACID... GENERIC IRON... GENERIC POTASSIUM CHLORIDE... GENERIC PRESCRIPTION PRENATAL VITAMINS... GENERIC CALCIUM ACETATE... GENERIC ELIPHOS... GENERIC Revised November 9, Working File 8
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Medications & Mothers Milk 2017
See Monograph for Details Alesse, Aviane, Lessina, Levlite, Lutera, Sronyx Monophasic Ethinyl estradiol 20 mcg Levonorgestrel 0.1 mg Angeliq Monophasic Estradiol 1 mg Drospirenone 0.5 mg Approved in Europe
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GHC-SCW Mandated Coverage Alphabetical Index Last Updated 8/1/2018
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THERAPEUTIC AREA NAME STRENGTH DOSAGE FORM
Value Based Tier Drugs are selected for the management of Asthma, Diabetes, Hypertension and Hyperlipidemia. These drugs are covered at no charge or at a reduced cost share. Medications are under continual
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ASEBP and ARTA TARP Drugs and Reference Price by Categories
ASEBP Pantoprazole Sodium 40 mg (generic) $0.2016 ASEBP Dexlansoprazole 30 mg Dexlansoprazole 60 mg Esomeprazole 10 mg Esomeprazole 20 mg Esomeprazole 40 mg Lansoprazole 15 mg Lansoprazole 30 mg Omeprazole
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Please consult your Benefit Booklet under Preventive Services or call Member Service if you have questions about your coverage for these drugs.
ACA Drug List Preventative Medications and Preferred Contraceptives In accordance with the Affordable Care Act (ACA) requirements for preventive services, most plans cover preventative care medicines and
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Medication Therapy Management Drug & COPD & COPD, Other ATROVENT HFA cromolyn inhalation DALIRESP ORAL TABLET ipratropium bromide inhalation montelukast oral granules in packet montelukast oral tablet
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Complex contraception
Disclosures Complex contraception I have no relevant financial disclosures Jennifer Kerns, MD, MPH Assistant Professor, UCSF Obstetrics, Gynecology and Reproductive Sciences San Francisco General Hospital
ACA Preventive Drug List Effective January 1, 2018
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Health Partners Medicare Prime and Value (2017) Updates
March/April 2017 Effective Date Brand Name Name Type of Change Previous Value New Value SPS sodium polystyrene sulfonate/sorbitol solution ORKAMBI ADRENACLICK ADRENACLICK levalbuterol tartrate hfa EXONDYS
Step Therapy Requirements
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Alaska Medicaid 90 Day** Generic Prescription Medication List
1 ACYCLOVIR 200 MG CAPSULE BUPROPION HCL 150 MG TAB ER 24H ACYCLOVIR 200 MG/5ML BUPROPION HCL 150 MG TABLET ER ACYCLOVIR 400 MG TABLET BUPROPION HCL 150 MG TABLET ER ACYCLOVIR 800 MG TABLET BUPROPION HCL
QTY LIMIT COPAY (30 DAY/90 DAY) BENIGN PROSTATIC HYPERPLASIA FINASTERIDE $4/$8 $4/$8 $4/$8 $4/$8 $4/$8 $4/$8 $4/$8 $4/$8 $4/$8 $4/$8 $4/$8
2019 LiveWELL Health Plan PREVENTIVE DRUG LIST - GENERIC Names ( Copay) - ALPHABETICAL by DRUG CATEGORY You should always check with your prescriber and/or pharmacist to determine if these alternatives
Formulary Medical Necessity Program
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ACEBUTOLOL HCL 100MG TABLET GENERIC BETA BLOCKERS ALISKIREN 150MG TABLET RASILAZ RENIN INHIBITOR
S/N ME OF MEDICATIONS BRANDED/GENERIC DRUG CLASS * UNIT PRICE RANGE (SGD$) 1 ACEBUTOLOL HCL 100MG CAPSULE SECTRAL BETA BLOCKERS 0.50 2 ACEBUTOLOL HCL 100MG TABLET GENERIC BETA BLOCKERS 0.33 3 ALISKIREN
DIABETES (1 of 5) Generic. Generic $0 $5 $5-10 $0 $0 $0. Generic $0 $5 $5-10. Generic. Generic $0 $5 $5-10 $0 $0 $0. Generic $0 $5 $5-10 $0 $0 $0
Metformin DIABETES (1 of 5) Glucophage Glucophage XR ER $7 (500mg) $7 (500mg) $5 $5 500mg, 750mg only 500mg, 750mg only Sulfonylurea/Combinations Amaryl Glucotrol glimepiride glipizide $5 $5 Glucotrol
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Step Therapy Criteria 2019
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Step Therapy Requirements
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