Kansas Health Advantage (HMO SNP) 2018 Formulary Quantity Limit Criteria
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1 APREPITANT Kansas Health Advantage (HMO SNP) 2018 Formulary Aprepitant Oral Capsule 125, 40, 80 Aprepitant Oral Capsule 80 & 125 Quantity Limit: 8 EA Per 30 Days Quantity Limit: 12 EA Per 30 Days ARMODAFINIL Armodafinil Oral Tablet 150, 200, 250, 50 BUPAP Bupap Oral Tablet BUPRENORPHINE HCL Buprenorphine HCl Sublingual Tablet Sublingual 2 Buprenorphine HCl Sublingual Tablet Sublingual 8 Quantity Limit: 240 EA Per 30 Days BUTALBITAL-ACETAMINOPHEN Butalbital-Acetaminophen Oral Tablet BUTALBITAL-APAP-CAFF-COD Butalbital-APAP-Caff-Cod Oral Capsule BUTALBITAL-APAP-CAFFEINE Butalbital-APAP-Caffeine Oral Tablet BUTALBITAL-ASA-CAFF-CODEINE Butalbital-ASA-Caff-Codeine Oral Capsule
2 BUTORPHANOL TARTRATE Butorphanol Tartrate Nasal Solution 10 /ML Quantity Limit: 10 ML Per 30 Days CELECOXIB Celecoxib Oral Capsule 100, 200, 400, 50 CYSTARAN Cystaran Ophthalmic Solution 0.44 % Quantity Limit: 60 ML Per 30 Days DIGITEK Digitek Oral Tablet 125 MCG DIGOX Digox Oral Tablet 125 MCG DIGOXIN Digoxin Oral Tablet 125 MCG DIHYDROERGOTAMINE MESYLATE Dihydroergotamine Mesylate Nasal Solution 4 /ML Quantity Limit: 24 ML Per 28 Days DRONABINOL Dronabinol Oral Capsule 10, 2.5, 5 ELETRIPTAN HYDROBROMIDE Eletriptan Hydrobromide Oral Tablet 20, 40 Quantity Limit: 9 EA Per 30 Days EPINEPHRINE EPINEPHrine Injection Solution Auto-Injector 0.15 /0.3ML, 0.3 /0.3ML 2
3 ERGOTAMINE-CAFFEINE Ergotamine-Caffeine Oral Tablet Quantity Limit: 40 EA Per 28 Days FLURAZEPAM HCL Flurazepam HCl Oral Capsule 15 Flurazepam HCl Oral Capsule 30 GRANISETRON HCL Granisetron HCl Oral Tablet 1 LATANOPROST Latanoprost Ophthalmic Solution % Quantity Limit: 2.5 ML Per 25 Days LIDOCAINE Lidocaine External Patch 5 % LIDOCAINE-PRILOCAINE Lidocaine-Prilocaine External Cream % Quantity Limit: 30 GM Per 30 Days MODAFINIL Modafinil Oral Tablet 100, 200 MONUROL Monurol Oral Packet 3 GM NARATRIPTAN HCL Naratriptan HCl Oral Tablet 1, 2.5 Quantity Limit: 12 EA Per 30 Days NARCAN Narcan Nasal Liquid 4 /0.1ML 3
4 ONDANSETRON HCL Ondansetron HCl Oral Tablet 24 Ondansetron HCl Oral Tablet 4 Ondansetron HCl Oral Tablet 8 ONDANSETRON Ondansetron Oral Tablet Dispersible 4 Ondansetron Oral Tablet Dispersible 8 PROAIR HFA ProAir HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT Quantity Limit: 17 GM Per 30 Days PROAIR RESPICLICK ProAir RespiClick Inhalation Aerosol Powder Breath Activated 108 (90 Base) MCG/ACT ROZEREM Rozerem Oral Tablet 8 SPRITAM Spritam Oral Tablet Disintegrating Soluble 1000 Spritam Oral Tablet Disintegrating Soluble 250, 500, 750 SUBOXONE Suboxone Sublingual Film 12-3, 2-0.5, 4-1 Suboxone Sublingual Film 8-2 4
5 SUMATRIPTAN SUCCINATE SUMAtriptan Succinate Oral Tablet 100, 25, 50 Quantity Limit: 9 EA Per 30 Days TEMAZEPAM Temazepam Oral Capsule 15, 22.5, 30 Temazepam Oral Capsule 7.5 TOBI PODHALER Tobi Podhaler Inhalation Capsule 28 Quantity Limit: 224 EA Per 56 Days TRAMADOL HCL TraMADol HCl Oral Tablet 50 Quantity Limit: 240 EA Per 30 Days TRAMADOL-ACETAMINOPHEN Tramadol-Acetaminophen Oral Tablet Quantity Limit: 240 EA Per 30 Days VALCHLOR Valchlor External Gel % Quantity Limit: 60 GM Per 30 Days VARUBI Varubi Oral Tablet 90 Quantity Limit: 8 EA Per 30 Days VRAYLAR Vraylar Oral Capsule 1.5 Vraylar Oral Capsule 3 Vraylar Oral Capsule 4.5, 6 XGEVA Xgeva Subcutaneous Solution 120 /1.7ML Quantity Limit: 1.7 ML Per 28 Days 5
6 ZALEPLON Kansas Health Advantage (HMO SNP) 2018 Formulary Zaleplon Oral Capsule 5 ZOLPIDEM TARTRATE Zolpidem Tartrate Oral Tablet 5 6
7 Alphabetical Listing A Aprepitant... 1 Armodafinil... 1 B Bupap... 1 Buprenorphine HCl... 1 Butalbital-Acetaminophen... 1 Butalbital-APAP-Caff-Cod... 1 Butalbital-APAP-Caffeine... 1 Butalbital-ASA-Caff-Codeine... 1 Butorphanol Tartrate... 2 C Celecoxib... 2 Cystaran... 2 D Digitek... 2 Digox... 2 Digoxin... 2 Dihydroergotamine Mesylate... 2 Dronabinol... 2 E Eletriptan Hydrobromide... 2 EPINEPHrine... 2 Ergotamine-Caffeine... 3 F Flurazepam HCl... 3 G Granisetron HCl... 3 L Latanoprost... 3 Lidocaine... 3 Lidocaine-Prilocaine... 3 M Modafinil... 3 Monurol... 3 N Naratriptan HCl... 3 Narcan... 3 O Ondansetron... 4 Ondansetron HCl... 4 P ProAir HFA... 4 ProAir RespiClick... 4 R Rozerem... 4 S Spritam... 4 Suboxone... 4 SUMAtriptan Succinate... 5 T Temazepam... 5 Tobi Podhaler... 5 TraMADol HCl... 5 Tramadol-Acetaminophen... 5 V Valchlor... 5 Varubi... 5 Vraylar... 5 X Xgeva... 5 Z Zaleplon... 6 Zolpidem Tartrate
Tribute 2018 Formulary 2018 Quantity Limit Criteria
APREPITANT Aprepitant Oral Capsule 125, 40, 80 Aprepitant Oral Capsule 80 & 125 Quantity Limit: 8 EA Per 30 Days Quantity Limit: 12 EA Per 30 Days ARMODAFINIL Armodafinil Oral Tablet 150, 200, 250, 50
Tribute 2018 Formulary 2018 Quantity Limit Criteria
APREPITANT Aprepitant ORAL CAPSULE 125, 40, 80 Aprepitant Oral CAPSULE 80 & 125 Quantity Limit: 8 EA Per 30 Days Quantity Limit: 12 EA Per 30 Days ARMODAFINIL Armodafinil ORAL TABLET 150, 200, 250, 50
APREPITANT ARMODAFINIL BELSOMRA BUPAP BUPRENORPHINE HCL BUTALBITAL-ACETAMINOPHEN BUTALBITAL-APAP-CAFF-COD BUTALBITAL-APAP-CAFFEINE
APREPITANT Aprepitant Oral Capsule 125, 40, 80 Aprepitant Oral Capsule 80 & 125 Quantity Limit: 8 EA Per 30 Days Quantity Limit: 12 EA Per 30 Days ARMODAFINIL Armodafinil Oral Tablet 150, 200, 250, 50
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ALPHA BLOCKERS. Products Affected Step 1: Details. Step 2: Rapaflo 4 mg capsule Rapaflo 8 mg capsule
CHRISTUS Health Plan Generations (HMO) CHRISTUS Health Plan Generations Plus (HMO) 2018 Premier Performance Standard Step Therapy PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT SOME OF THE DRUGS
ANTIDEPRESSANTS. Details. dose pack Viibryd 10 mg tablet Viibryd 20 mg tablet Viibryd 40 mg tablet. Criteria
ANTIDEPRESSANTS Trintellix 10 mg tablet Trintellix 20 mg tablet Trintellix 5 mg tablet Viibryd 10 mg (7)-20 mg (23) tablets in a dose pack Viibryd 10 mg tablet Viibryd 20 mg tablet Viibryd 40 mg tablet
2016 Step Therapy (ST) Criteria
2016 Step Therapy (ST) Some drugs require step therapy pre-approval. This means that your doctor must have you first try a different drug to treat your medical condition before we will cover a drug that
2018 Formulary. (List of Covered Drugs)
Capital Health Plan Advantage Plus (HMO) Capital Health Plan Preferred Advantage (HMO) 2018 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN
2014 Medicare Part D Formulary Formulary Additions
Formulary Additions Used For Coverage Tier Bromday Ophthalmic Anti-inflammatory Invokana 100 mg Invokana 300 mg Namenda 14 mg ER Dementia Namenda 28 Titration Pack Dementia Namenda 21 mg ER Dementia Namenda