Commercial Triple Tier 4th Tier Applicabl e Traditional Detailed s 2 films - DESCOVY 2 2 1 tablet NARCAN 2 2 ODEFSEY 2 2 1 tablet REPATHA 2 2 HoFH: 3 ml per 28 ROSUVASTATIN 1 1 - UPTRAVI 3 2 - Alternatives abacavir/lamivudine, zidovudine, Epzicom, Truvada sildenafil*, Orenitram*, Tyvaso*, Ventavis*, Letairis*, Opsumit*, Tracleer, Adcirca*, Adempas* VELTASSA 3 2 1 packet sodium polystyrene sulfonate VENCLEXTA 3 2 tablets 10 mg tablet: 2 50 mg tablet: 1 tablet 100 mg tablet: 4 1 capsule release, fenoprofen, flurbiprofen, ibuprofen, indomethacin, indomethacin sustained release, ketoprofen, ketorolac, VRAYLAR 3 2 1 capsule ZEPATIER 2 2 1 tablet, 28 day supply per fill Kaletra, rvir, Aptivus, Viramune, Viramune XR, Videx, Videx EC, Zerit, Evotaz, Reyataz, Sustiva, Fuzeon, Invirase, Atripla, Complera, Emtriva, Genvoya, Stribild, Truvada, Tybost, Viread, Viekta, Edurant, Intelence, Prezcobix, Prezista, Crixivan, Isentress, Combivir, Epivir, Epzicom, Lexiva, Rescriptor, Retrovir, Selzentry, Tivicay,, Trizivir, Viracept, and Ziagen
CHIP Tier Detailed s - 2 films - - Alternatives DESCOVY 2 1 tablet abacavir/lamivudine, zidovudine, Epzicom, Truvada NARCAN 2 ODEFSEY 2 1 tablet REPATHA 2 HoFH: 3 ml ROSUVASTATIN 2 - UPTRAVI 2 - sildenafil*, Orenitram*, Tyvaso*, Ventavis*, Letairis*, Opsumit*, Tracleer, Adcirca*, Adempas* VELTASSA 2 1 packet sodium polystyrene sulfonate VENCLEXTA 2 tablets 10 mg tablet: 2 tablets 50 mg tablet: 1 tablet 100 mg tablet: 4 tablets - 1 capsule release, fenoprofen, flurbiprofen, ibuprofen, indomethacin, indomethacin sustained release, ketoprofen, ketorolac, VRAYLAR 2 1 capsule ZEPATIER 2 1 tablet, 28 day supply per fill Kaletra, rvir, Aptivus, Viramune, Viramune XR, Videx, Videx EC, Zerit, Evotaz, Reyataz, Sustiva, Fuzeon, Invirase, Atripla, Complera, Emtriva, Genvoya, Stribild, Truvada, Tybost, Viread, Viekta, Edurant, Intelence, Prezcobix, Prezista, Crixivan, Isentress, Combivir, Epivir, Epzicom, Lexiva, Rescriptor, Retrovir, Selzentry, Tivicay,, Trizivir, Viracept, and Ziagen
GHP Family GHP Family Tier Detailed s 2 films daily DESCOVY Brand one tablet daily Alternative(s) abacavir/ Epzicom, Trizivir, Truvada NARCAN Brand 4 naloxone syringe ODEFSEY Brand 1 tablet daily REPATHA Brand ROSUVASTATIN Generic UPTRAVI ASCVS or HeFH: 2 ml HoFH:3 ml per 28 Praluent*, atorvastatin, rosuvastatin, Zetia, cholestyramine, Prevalite, colestipol, fenofibrate, fenofibric acid, gemfibrozil atorvastatin,, lovastatin, pravastatin sildenafil*, Letairis*, Tracleer* VELTASSA Brand one packet daily sodium polystyrene sulfonate VENCLEXTA Brand tablets per 28 Ongoing therapy: four tablets per day Imbruvica*, Revlimid* one capsule daily celecoxib*, diclofenac, difunisal, etodolac, fenoprofen, flurbiprofen, ibuprofen, indomethacin, ketoprofen, ketorolac, meloxicam, nabumetone, naproxen, oxaprozin, piroxicam, sulindac, VRAYLAR ZEPATIER Brand one capsule daily one tablet daily for 28 aripiprazole*, clozapine, olanzapine, quetiapine, risperidone, ziprasidone Sovaldi*, Viekira Pak*
Geisinger Gold $0 Deductible DESCOVY Specialty NARCAN Brand ODEFSEY Specialty REPATHA Brand UPTRAVI Specialty VELTASSA Brand VENCLEXTA Specialty Standard Detailed s 2 films/day 1 tablet/day 4 nasal sprays/30 1 tablet/day 3 ml/28 Alternative(s) fentanyl patches, morphine sulfate ER, abacavir/ Epzicom, Truvada naloxone syringes/vials Atripla, Complera, Genvoya, Stribild, Praulent*, atorvastatin, rosuvastatin, Zetia sildenafil*, Orenitram*, Tyvaso*, Ventavis*, Opsumit*, Letairis*, Tracleer*, Adcirca*, Adempas*, epoprostenol, Veletri* 1 packet/day sodium polystyrene sulfonate 10 mg tablets = 2/day; 50 mg tablets = 1/day; 100 mg tablets = 4 /day, 30 day supply per fill Arzerra*, Gazyva*, Imbruvica*, Revlimid*, Rituxan*, Zydelig* 1 capsule/day celecoxib, diclofenac sodium, diflunisal, etodolac, fenoprofen, flurbiprofen, ibuprofen, meloxicam, nabumetone, naproxen sodium, oxaprozin, VRAYLAR Specialty 1 capsule/day aripiprazole, olanzapine, quetiapine, risperidone, ziprasidone ZEPATIER Specialty 1 tablet/day Viekira*, Sovaldi*, ribavirin, Pegasys, Pegintron
Marketplace Tier Detailed s - 2 films - - DESCOVY 3 1 tablet NARCAN 3 ODEFSEY 3 1 tablet REPATHA 3 HoFH: 3 ml per 28 ROSUVASTATIN 2 - UPTRAVI 5 - Alternatives abacavir/lamivudine, zidovudine, Epzicom, Truvada sildenafil*, Orenitram*, Tyvaso*, Ventavis*, Letairis*, Opsumit*, Tracleer, Adcirca*, Adempas* VELTASSA 4 1 packet sodium polystyrene sulfonate VENCLEXTA 5 tablets 10 mg tablet: 2 50 mg tablet: 1 tablet 100 mg tablet: 4-1 capsule release, fenoprofen, flurbiprofen, ibuprofen, indomethacin, indomethacin sustained release, ketoprofen, ketorolac, VRAYLAR 4 1 capsule ZEPATIER 5 1 tablet, 28 day supply per fill Kaletra, rvir, Aptivus, Viramune, Viramune XR, Videx, Videx EC, Zerit, Evotaz, Reyataz, Sustiva, Fuzeon, Invirase, Atripla, Complera, Emtriva, Genvoya, Stribild, Truvada, Tybost, Viread, Viekta, Edurant, Intelence, Prezcobix, Prezista, Crixivan, Isentress, Combivir, Epivir, Epzicom, Lexiva, Rescriptor, Retrovir, Selzentry, Tivicay,, Trizivir, Viracept, and Ziagen