Passport Advantage (HMO SNP) 2017 Formulary List of Covered Drugs PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission ID 00017497, Version Number 16 This formulary was updated on 08/01/2017. For more recent information or other questions, please contact,passport Advantage Member Services, at (844) 859-6152 or, for TTY users, 711, Monday through Friday 8 a.m. to 8 p.m. Eastern Time from February 15 to September 30 and 7 days a week from 8 a.m. to 8 p.m. Eastern Time from October 1 to February 14, or visit http://www.passportadvantage.com. H9870_ADVG001004 Accepted 05/05/2017
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 Passport Advantage. When it refers to plan or our plan, it means Passport Advantage. This document includes list of the drugs (formulary) for our plan which is current as of formulary revision date. 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, 2018, and from time to time during the year. What is the Passport Advantage (HMO SNP) Formulary? A formulary is a list of covered drugs selected by Passport Advantage 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. Passport Advantage will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Passport Advantage 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 2017 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2017 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, or add prior authorization, quantity limits and/or step therapy restrictions on a drug, 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 formulary date. To get updated information about the drugs covered by Passport Advantage, please contact us. Our contact information appears on the front and back cover pages. i
In the event that Passport Advantage has CMS-approved non-maintenance changes to the formulary throughout the plan year (i.e. remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug), we will update our formulary and post it on our website. You will also be notified in writing if you are affected by the changes via errata sheets. We also maintain and update our online formulary on a monthly basis. 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. 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 168. 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? Passport Advantage 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: Prior Authorization: Passport Advantage 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 Limits: For certain drugs, Passport Advantage limits the amount of the drug that we will cover. For example, Passport Advantage provides 9 tablets per prescription for ii
sumatriptan succinate tab. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, Passport Advantage 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, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we 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 Passport Advantage 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 Passport Advantage s formulary? on this page 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 Passport Advantage does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by Passport Advantage. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Passport Advantage. You can ask Passport Advantage 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 Passport Advantage s Formulary? You can ask Passport Advantage 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. iii
You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Passport Advantage 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, Passport Advantage will only approve your request for an exception if the alternative drugs included on the plan s formulary, 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, or utilization restriction exception. When you request a formulary 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 a 91 to 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. In addition, all members who experience a level-of-care change are eligible for a transition supply. A levelof-care change is when a member changes from one treatment setting to another. For example, if a member is discharged from an inpatient facility to home on a non-formulary medication, the member will be eligible for a transition supply of that non-formulary medication. You can receive up to a 31-day supply of the medication (unless you have a prescription written for fewer days) after being discharged, to allow time for you and your physician to switch to a formulary alternative or request an exception. After your first 31-day iv
supply, we will not pay for the drug, unless an exception was approved. Our transition policy applies only to those drugs that are Part D drugs. The transition policy cannot be used to cover non-part D drugs. For more information For more detailed information about your Passport Advantage prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Passport Advantage, 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 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. Passport Advantage s Formulary The formulary that begins on page 12 provides coverage information about the drugs covered by Passport Advantage. If you have trouble finding your drug in the list, turn to the Index that begins on page 168. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., LIDODERM) and generic drugs are listed in lower-case italics (e.g., lidocaine). The information in the Requirements/Limits column tells you if Passport Advantage has any special requirements for coverage of your drug. Prior Authorization (): The abbreviation in the Requirements/Limits column indicates that prior authorization may apply. 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 Limits (QL): The abbreviation QL in the Requirements/Limits column indicates that quantities dispensed may be limited. For certain drugs, Passport Advantage limits the amount of the drug that we will cover. Step Therapy (ST): The abbreviation ST in the Requirements/Limits column indicates that step therapy may apply. In some cases, Passport Advantage 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, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. Part B vs Part D Determination (B/D): The abbreviation B/D in the Requirements/Limits column indicates that the drug may be eligible for payment under Medicare Part B or Part D. Limited Access (LA): The abbreviation LA in the Requirements/Limits column indicates that the drug is only available from certain pharmacies. v
Non-Mail Order (NM): The abbreviation NM in the Requirements/Limits column indicates that the drug is not available via your mail-order benefit. (NDS): The abbreviation NDS in the Requirements/Limits column indicates that the drug is not eligible for extended days supply. Nondiscrimination Notice Passport Advantage (HMO-SNP) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Passport Advantage (HMO- SNP) does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Passport Advantage (HMO-SNP): Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages If you believe that Passport Advantage (HMO-SNP) 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 file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Tracy Bertram is available to help you. Tracy Bertram, Director of Compliance, can be contacted by Mail: 5100 Commerce Crossings Drive, Louisville, KY 40229, Telephone Number: 502-212-6767, TTY 771, Fax Number: 502-213-8905, or Email: Tracy.bertram@passporthealthplan.com. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. vi
Nondiscrimination Statement English: Passport Advantage complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Spanish: Passport Advantage cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. French: Passport Advantage respecte les lois fédérales en vigueur relatives aux droits civiques et ne pratique aucune discrimination basée sur la race, la couleur de peau, l'origine nationale, l'âge, le sexe ou un handicap. French Creole: Passport Advantage konfòm ak lwa sou dwa sivil Federal ki aplikab yo e li pa fè diskriminasyon sou baz ras, koulè, peyi orijin, laj, enfimite oswa sèks. Italian: Passport Advantage è conforme a tutte le leggi federali vigenti in materia di diritti civili e non pone in essere discriminazioni sulla base di razza, colore, origine nazionale, età, disabilità o sesso. Portuguese: Passport Advantage cumpre as leis de direitos civis federais aplicáveis e não exerce discriminação com base na raça, cor, nacionalidade, idade, deficiência ou sexo. German: Passport Advantage erfüllt geltenden bundesstaatliche Menschenrechtsgesetze und lehnt jegliche Diskriminierung aufgrund von Rasse, Hautfarbe, Herkunft, Alter, Behinderung oder Geschlecht ab. Norwegian: Passport Advantage overholder gjeldende føderale lover om borgerrettigheter og diskriminerer ikke på grunnlag av etnisitet, farge, nasjonal opprinnelse, alder, funksjonshemning eller kjønn. Russian: Passport Advantage соблюдает применимое федеральное законодательство в области гражданских прав и не допускает дискриминации по признакам расы, цвета кожи, национальной принадлежности, возраста, инвалидности или пола. Persian: vwwwxن } zwwwق م یاز zwwwا~{ wwwwww~ ˆ wwwwwwطz Œx و ی vwwwwwwرال vwwwwww Passport Advantage wwwwwwwww~ ˆ یھ~ wwwwwwwwwz wwww~ x ا wwww ~ wwwwšz ر œwwww žwwwwاد س اwwwwš ی Œwwww ˆ zان wwww یwwwwš { ا Œwwwwwاد ~wwwww wwwww wwww wwww ی. zwwد Greek: Passport Advantage συµµορφώνεται µε τους ισχύοντες οµοσπονδιακούς νόµους για τα ατοµικά δικαιώµατα και δεν προβαίνει σε διακρίσεις µε βάση τη φυλή, το χρώµα, την vii
εθνική καταγωγή, την ηλικία, την αναπηρία ή το φύλο. Serbo-Croatian: Passport Advantage pridržava se važećih saveznih zakona o građanskim pravima i ne pravi diskriminaciju po osnovu rase, boje kože, nacionalnog porijekla, godina starosti, invaliditeta ili pola. Urdu: Passport Advantage اط Ëwww Ëwww wwwww اور wwwwwwww~é ˆ wwwwwwwˆœ ÇwÊ یک zwwwwwwwwا~{ Çwww } zwwwق ی ŒÆwww یو wwww ق ق ~ wwwwww د Œwwwwww اwwwwww~Òx ز Ñwwwwww~Æ wwwwwwˆœ ی Ðwww ک www یر œww Îww xور ŒwwÉÏ ww~xz Hindi: Passport Advantage ल ग ह न य य स घ य न गरक अधक र क़ न न क प लन करत ह और ज त, र ग, र य म ल, आय, वकल गत, य ल ग क आध र पर भ दभ व नह करत ह Chinese: Passport Advantage 遵守適用的聯邦民權法律規定, 不因種族 膚色 民族 血統 年齡 殘障或性別而歧視任何人 Japanese: Passport Advantage は適用される連邦公民権法を遵守し 人種 肌の色 出身国 年齢 障害または性別に基づく差別をいたしません Korean: Passport Advantage 은 ( 는 ) 관련연방공민권법을준수하며인종, 피부색, 출신국가, 연령, 장애또는성별을이유로차별하지않습니다. Vietnamese: Passport Advantage tuân thủ luật dân quyền hiện hành của Liên bang và không phân biệt đối xử dựa trên chủng tộc, màu da, nguồn gốc quốc gia, độ tuổi, khuyết tật, hoặc giới tính. Tagalog: Sumusunod ang Passport Advantage sa mga naaangkop na Pederal na batas sa karapatang sibil at hindi nandidiskrimina batay sa lahi, kulay, bansang pinagmulan, edad, kapansanan o kasarian. viii
Multi-Language Interpreter Services ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-844-859-6152 (TTY: 711). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-844-859-6152 (TTY: 711). 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 1-844-859-6152 (TTY: 711). ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-844-859-6152 (TTY: 711). CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-844-859-6152 (TTY: 711). 2516 (Œww{x-958-448-1 ة ر وˆ wwww wwwwñ óéب wwww. Òwwwwôõ سیŒwwww{xب ةدwwÏ óww öو wwww ˆ Ò vwwwwø رÎwwwwñا ةówwww ö úwwwwف vwwwwxخ ˆ ówwwwx.اذإ :ةظzwww : ówwwww xو.(117 wwwwwò ówwwwwôx ھ OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite 1-844-859-6152 (TTY: 711). 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます 1-844-859-6152 (TTY:711) まで お電話にてご連絡ください ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-844-859-6152 (TTY:711). 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다. 1-844-859-6152 (TTY: 711) 번으로전화해주십시오. Wann du [Deitsch (Pennsylvania German / Dutch)] schwetzscht, kannscht du mitaus Koschte ebber gricke, ass dihr helft mit die englisch Schprooch. Ruf selli Nummer uff: Call 1-844-859-6152 (TTY: 711).!य न दन ह स: तप इ ल न प ल ब %नह&छ भन तप इ क न(त भ ष सह यत सव ह* न श%क *पम उपल.ध छ फ न गन ह सर 1-844-859-6152 ( ट टव इ: 711) ix
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SSPORT effective 08/01/2017 Drug Name ANTI - INFECTIVES ANTIFUNGAL AGENTS ABELCET INJ 5MG/ML 1 NDS, B/D AMBISOME INJ 50MG 1 NDS, B/D amphotericin b for inj 50 mg 1 B/D CANCIDAS INJ 50MG 1 NDS, B/D CANCIDAS INJ 70MG 1 NDS, B/D clotrimazole troche 10 mg 1 CRESEMBA CAP 186 MG 1 NDS CRESEMBA INJ 372MG 1 NDS ERAXIS INJ 50MG 1 ERAXIS INJ 100MG 1 fluconazole for susp 10 mg/ml 1 fluconazole for susp 40 mg/ml 1 fluconazole in nacl 0.9% inj 200 mg/100ml 1 fluconazole in nacl 0.9% inj 400 mg/200ml 1 fluconazole tab 50 mg 1 fluconazole tab 100 mg 1 fluconazole tab 150 mg 1 fluconazole tab 200 mg 1 flucytosine cap 250 mg 1 NDS flucytosine cap 500 mg 1 NDS griseofulvin microsize susp 125 mg/5ml 1 griseofulvin microsize tab 500 mg 1 griseofulvin ultramicrosize tab 125 mg 1 griseofulvin ultramicrosize tab 250 mg 1 itraconazole cap 100 mg 1 QL (120 caps / 30 days), ketoconazole tab 200 mg 1 MYCAMINE INJ 50MG 1 NDS MYCAMINE INJ 100MG 1 NDS NOXAFIL SUS 40MG/ML 1 NDS, NOXAFIL TAB 100MG 1 NDS, QL (93 tabs / 30 days), nystatin susp 100000 unit/ml 1 nystatin tab 500000 unit 1 ONMEL TAB 200MG 1 QL (30 tabs / 30 days), terbinafine hcl tab 250 mg 1 voriconazole for inj 200 mg 1 voriconazole for susp 40 mg/ml 1 NDS voriconazole tab 50 mg 1 NDS - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available 1
voriconazole tab 200 mg 1 NDS ANTIVIRALS abacavir sulfate tab 300 mg (base equiv) 1 abacavir sulfate-lamivudine tab 600-300 mg 1 NDS abacavir sulfate-lamivudine-zidovudine tab 1 NDS 300-150-300 mg acyclovir cap 200 mg 1 acyclovir sodium iv soln 50 mg/ml 1 B/D acyclovir susp 200 mg/5ml 1 acyclovir tab 400 mg 1 acyclovir tab 800 mg 1 adefovir dipivoxil tab 10 mg 1 NDS, amantadine hcl cap 100 mg 1 amantadine hcl syrup 50 mg/5ml 1 amantadine hcl tab 100 mg 1 APTIVUS CAP 250MG 1 NDS APTIVUS SOL 1 NDS ATRIPLA TAB 1 NDS BARACLUDE SOL.05MG/ML 1 cidofovir iv inj 75 mg/ml 1 NDS, B/D COMPLERA TAB 1 NDS CRIXIVAN CAP 200MG 1 CRIXIVAN CAP 400MG 1 DESCOVY TAB 200/25 1 NDS didanosine delayed release capsule 125 mg 1 didanosine delayed release capsule 200 mg 1 didanosine delayed release capsule 250 mg 1 didanosine delayed release capsule 400 mg 1 EDURANT TAB 25MG 1 NDS EMTRIVA CAP 200MG 1 EMTRIVA SOL 10MG/ML 1 entecavir tab 0.5 mg 1 NDS, entecavir tab 1 mg 1 NDS, EPCLUSA TAB 400-100 1 NDS, QL (28 tabs / 28 EPIVIR HBV SOL 5MG/ML 1 EVOTAZ TAB 300-150 1 NDS famciclovir tab 125 mg 1 famciclovir tab 250 mg 1 famciclovir tab 500 mg 1 foscarnet sodium inj 24 mg/ml 1 B/D FUZEON INJ 90MG 1 NDS, NM ganciclovir sodium for inj 500 mg 1 B/D GENVOYA TAB 1 NDS - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available 2
HARVONI TAB 90-400MG 1 NDS, QL (28 tabs / 28 INTELENCE TAB 25MG 1 INTELENCE TAB 100MG 1 NDS INTELENCE TAB 200MG 1 NDS INVIRASE CAP 200MG 1 INVIRASE TAB 500MG 1 NDS ISENTRESS CHW 25MG 1 ISENTRESS CHW 100MG 1 ISENTRESS POW 100MG 1 ISENTRESS TAB 400MG 1 NDS KALETRA SOL 1 NDS KALETRA TAB 100-25MG 1 KALETRA TAB 200-50MG 1 NDS lamivudine oral soln 10 mg/ml 1 lamivudine tab 100 mg (hbv) 1 lamivudine tab 150 mg 1 lamivudine tab 300 mg 1 lamivudine-zidovudine tab 150-300 mg 1 LEXIVA SUS 50MG/ML 1 LEXIVA TAB 700MG 1 NDS lopinavir-ritonavir soln 400-100 mg/5ml 1 (80-20 mg/ml) MODERIBA K 600/DAY 1 NDS, NM MODERIBA K 800/DAY 1 NDS, NM MODERIBA K 1000/DAY 1 NDS, NM MODERIBA K 1200/DAY 1 NDS, NM moderiba tab 200mg 1 NM nevirapine susp 50 mg/5ml 1 nevirapine tab 200 mg 1 nevirapine tab er 24hr 100 mg 1 nevirapine tab er 24hr 400 mg 1 NORVIR CAP 100MG 1 NORVIR SOL 80MG/ML 1 NORVIR TAB 100MG 1 ODEFSEY TAB 1 NDS oseltamivir phosphate cap 30 mg (base 1 QL (84 caps / 180 days) equiv) oseltamivir phosphate cap 45 mg (base 1 QL (42 caps / 180 days) equiv) oseltamivir phosphate cap 75 mg (base 1 QL (42 caps / 180 days) equiv) PREZCOBIX TAB 800-150 1 NDS PREZISTA SUS 100MG/ML 1 PREZISTA TAB 75MG 1 - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available 3
PREZISTA TAB 150MG 1 PREZISTA TAB 600MG 1 NDS PREZISTA TAB 800MG 1 NDS REBETOL SOL 40MG/ML 1 NDS, NM RELENZA MIS DISKHALE 1 QL (120 blisters / 365 days) RESCRIPTOR TAB 100 MG 1 RESCRIPTOR TAB 200MG 1 RETROVIR INJ 10MG/ML 1 REYATAZ CAP 150MG 1 NDS REYATAZ CAP 200MG 1 NDS REYATAZ CAP 300MG 1 NDS REYATAZ POW 50MG 1 NDS ribasphere cap 200mg 1 NM ribasphere tab 200mg 1 NM ribasphere tab 400mg 1 NM ribasphere tab 600mg 1 NDS, NM ribavirin cap 200 mg 1 NM ribavirin tab 200 mg 1 NM rimantadine hydrochloride tab 100 mg 1 SELZENTRY TAB 25MG 1 SELZENTRY TAB 75MG 1 NDS SELZENTRY TAB 150MG 1 NDS SELZENTRY TAB 300MG 1 NDS SOVALDI TAB 400MG 1 NDS, QL (30 tabs / 30 stavudine cap 15 mg 1 stavudine cap 20 mg 1 stavudine cap 30 mg 1 stavudine cap 40 mg 1 STRIBILD TAB 1 NDS SUSTIVA CAP 50MG 1 SUSTIVA CAP 200MG 1 SUSTIVA TAB 600MG 1 NDS SYNAGIS INJ 50MG 1 NDS, NM, LA, SYNAGIS INJ 100MG/ML 1 NDS, NM, LA, TAMIFLU SUS 6MG/ML 1 QL (525ml / 180 days) TIVICAY TAB 10MG 1 TIVICAY TAB 25MG 1 TIVICAY TAB 50MG 1 NDS TRIUMEQ TAB 1 NDS TRUVADA TAB 100-150 1 TRUVADA TAB 133-200 1 TRUVADA TAB 167-250 1 TRUVADA TAB 200-300 1 NDS - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available 4
TYBOST TAB 150MG 1 valacyclovir hcl tab 1 gm 1 valacyclovir hcl tab 500 mg 1 valganciclovir hcl for soln 50 mg/ml (base 1 NDS equiv) valganciclovir hcl tab 450 mg (base 1 NDS equivalent) VEMLIDY TAB 25MG 1 NDS, VIDEX SOL 2GM 1 VIRACEPT TAB 250MG 1 NDS VIRACEPT TAB 625MG 1 NDS VIREAD POW 40MG/GM 1 NDS VIREAD TAB 150MG 1 NDS VIREAD TAB 200MG 1 NDS VIREAD TAB 250MG 1 NDS VIREAD TAB 300MG 1 NDS ZERIT SOL 1MG/ML 1 ZIAGEN SOL 20MG/ML 1 zidovudine cap 100 mg 1 zidovudine syrup 10 mg/ml 1 zidovudine tab 300 mg 1 CEPHALOSPORINS AVYCAZ INJ 2-0.5GM 1 NDS cefaclor cap 250 mg 1 cefaclor cap 500 mg 1 CEFACLOR ER TAB 500MG 1 cefadroxil cap 500 mg 1 cefadroxil for susp 250 mg/5ml 1 cefadroxil for susp 500 mg/5ml 1 cefadroxil tab 1 gm 1 cefazolin sodium for inj 1 gm 1 cefazolin sodium for inj 10 gm 1 cefazolin sodium for inj 500 mg 1 cefdinir cap 300 mg 1 cefdinir for susp 125 mg/5ml 1 cefdinir for susp 250 mg/5ml 1 cefepime hcl for inj 1 gm 1 cefepime hcl for inj 2 gm 1 cefotaxime sodium for inj 1 gm 1 cefotaxime sodium for inj 2 gm 1 cefotaxime sodium for inj 10 gm 1 cefotaxime sodium for inj 500 mg 1 cefotetan disodium for inj 1 gm 1 cefotetan disodium for inj 2 gm 1 cefotetan disodium for inj 10 gm 1 - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available 5
cefoxitin sodium for inj 10 gm 1 cefoxitin sodium for iv soln 1 gm 1 cefoxitin sodium for iv soln 2 gm 1 cefpodoxime proxetil for susp 50 mg/5ml 1 cefpodoxime proxetil for susp 100 mg/5ml 1 cefpodoxime proxetil tab 100 mg 1 cefpodoxime proxetil tab 200 mg 1 cefprozil for susp 125 mg/5ml 1 cefprozil for susp 250 mg/5ml 1 cefprozil tab 250 mg 1 cefprozil tab 500 mg 1 ceftazidime for inj 1 gm 1 ceftazidime for inj 2 gm 1 ceftazidime for inj 6 gm 1 ceftibuten cap 400 mg 1 ceftibuten for susp 180 mg/5ml 1 ceftriaxone sodium for inj 10 gm 1 ceftriaxone sodium for inj 250 mg 1 ceftriaxone sodium for inj 500 mg 1 ceftriaxone sodium for iv soln 1 gm 1 ceftriaxone sodium for iv soln 2 gm 1 cefuroxime axetil tab 250 mg 1 cefuroxime axetil tab 500 mg 1 cefuroxime sodium for inj 1.5 gm 1 cefuroxime sodium for inj 750 mg 1 cephalexin cap 250 mg 1 cephalexin cap 500 mg 1 cephalexin cap 750 mg 1 cephalexin for susp 125 mg/5ml 1 cephalexin for susp 250 mg/5ml 1 cephalexin tab 250 mg 1 cephalexin tab 500 mg 1 FORTAZ INJ 1GM 1 FORTAZ INJ 2GM 1 SUPRAX CAP 400MG 1 SUPRAX CHW 100MG 1 SUPRAX CHW 200MG 1 TEFLARO INJ 400MG 1 TEFLARO INJ 600MG 1 NDS ZERBAXA INJ 1.5GM 1 NDS ERYTHROMYCINS / OTHER MACROLIDES azithromycin for susp 100 mg/5ml 1 azithromycin for susp 200 mg/5ml 1 azithromycin iv for soln 500 mg 1 - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available 6
azithromycin powd pack for susp 1 gm 1 azithromycin tab 250 mg 1 azithromycin tab 500 mg 1 azithromycin tab 600 mg 1 clarithromycin for susp 125 mg/5ml 1 clarithromycin for susp 250 mg/5ml 1 clarithromycin tab 250 mg 1 clarithromycin tab 500 mg 1 clarithromycin tab er 24hr 500 mg 1 DIFICID TAB 200MG 1 NDS, QL (20 tabs / 10 days), ST e.e.s. 400 tab 400mg 1 E.E.S. GRAN SUS 200/5ML 1 ery-tab tab 250mg ec 1 ery-tab tab 333mg ec 1 ery-tab tab 500mg ec 1 ERYTHROCIN INJ 500MG 1 erythrocin tab 250mg 1 erythromycin ethylsuccinate for susp 200 1 mg/5ml erythromycin ethylsuccinate tab 400 mg 1 erythromycin tab 250 mg 1 erythromycin tab 500 mg 1 erythromycin w/ delayed release particles 1 cap 250 mg MISCELLANEOUS ANTIINFECTIVES ALBENZA TAB 200MG 1 ALINIA SUS 100/5ML 1 ALINIA TAB 500MG 1 QL (40 tabs / 30 days) amikacin sulfate inj 1 gm/4ml (250 mg/ml) 1 amikacin sulfate inj 500 mg/2ml (250 1 mg/ml) atovaquone susp 750 mg/5ml 1 NDS atovaquone-proguanil hcl tab 62.5-25 mg 1 atovaquone-proguanil hcl tab 250-100 mg 1 AZACTAM/DEX INJ 2GM 1 aztreonam for inj 1 gm 1 aztreonam for inj 2 gm 1 baciim inj 50000unt 1 bacitracin intramuscular for soln 50000 1 unit BETHKIS NEB 300/4ML 1 NDS, B/D, QL (224ml / 56 days), NM BILTRICIDE TAB 600MG 1 CASTAT SUL INJ 1GM 1 - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available 7
CAYSTON INH 75MG 1 NDS, QL (84 vials / 56 days), NM, LA chloramphenicol sodium succinate for iv inj 1 1 gm chloroquine phosphate tab 250 mg 1 chloroquine phosphate tab 500 mg 1 clindamycin hcl cap 75 mg 1 clindamycin hcl cap 150 mg 1 clindamycin hcl cap 300 mg 1 clindamycin palmitate hcl for soln 75 1 mg/5ml (base equiv) clindamycin phosphate in d5w iv soln 300 1 mg/50ml clindamycin phosphate in d5w iv soln 600 1 mg/50ml clindamycin phosphate in d5w iv soln 900 1 mg/50ml clindamycin phosphate iv soln 300 mg/2ml 1 clindamycin phosphate iv soln 900 mg/6ml 1 COARTEM TAB 20-120MG 1 colistimethate sodium for inj 150 mg 1 DALVANCE SOL 500MG 1 NDS dapsone tab 25 mg 1 dapsone tab 100 mg 1 daptomycin for iv soln 500 mg 1 NDS DARAPRIM TAB 25MG 1 DORIBAX INJ 500MG 1 ethambutol hcl tab 100 mg 1 ethambutol hcl tab 400 mg 1 gentamicin in saline inj 0.8 mg/ml 1 gentamicin in saline inj 1 mg/ml 1 gentamicin in saline inj 1.2 mg/ml 1 gentamicin in saline inj 1.6 mg/ml 1 gentamicin sulfate inj 40 mg/ml 1 hydroxychloroquine sulfate tab 200 mg 1 imipenem-cilastatin intravenous for soln 1 250 mg imipenem-cilastatin intravenous for soln 1 500 mg INVANZ INJ 1GM 1 isoniazid inj 100 mg/ml 1 isoniazid syrup 50 mg/5ml 1 isoniazid tab 100 mg 1 isoniazid tab 300 mg 1 ivermectin tab 3 mg 1 LINCOCIN INJ 300MG/ML 1 - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available 8
lincomycin hcl inj 300 mg/ml 1 linezolid for susp 100 mg/5ml 1 NDS linezolid iv soln 600 mg/300ml (2 mg/ml) 1 NDS linezolid tab 600 mg 1 NDS mefloquine hcl tab 250 mg 1 meropenem iv for soln 1 gm 1 meropenem iv for soln 500 mg 1 metronidazole cap 375 mg 1 metronidazole in nacl 0.79% iv soln 500 1 mg/100ml metronidazole tab 250 mg 1 metronidazole tab 500 mg 1 NEBUPENT INH 300MG 1 B/D neomycin sulfate tab 500 mg 1 ORBACTIV SOL 400MG 1 NDS paromomycin sulfate cap 250 mg 1 SER GRA 4GM 1 PENTAM 300 INJ 300MG 1 polymyxin b sulfate for inj 500000 unit 1 PRIFTIN TAB 150MG 1 PRIMAQUINE TAB 26.3MG 1 pyrazinamide tab 500 mg 1 quinine sulfate cap 324 mg 1 rifabutin cap 150 mg 1 RIFAMATE CAP 1 rifampin cap 150 mg 1 rifampin cap 300 mg 1 rifampin for inj 600 mg 1 RIFATER TAB 1 SIRTURO TAB 100MG 1 NDS, LA, SIVEXTRO INJ 200MG 1 NDS, QL (6 vials / 30 days) SIVEXTRO TAB 200MG 1 NDS, QL (6 tabs / 30 days) streptomycin sulfate for inj 1 gm 1 SYNERCID INJ 500MG 1 NDS tinidazole tab 250 mg 1 tinidazole tab 500 mg 1 TOBI PODHALR CAP 28MG 1 NDS, QL (224 caps / 56 days) tobramycin nebu soln 300 mg/5ml 1 NDS, B/D, QL (280ml / 56 days), NM tobramycin sulfate inj 10 mg/ml (base equivalent) 1 - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available 9
tobramycin sulfate inj 80 mg/2ml (40 1 mg/ml) (base equiv) TRECATOR TAB 250MG 1 TYGACIL INJ 50MG 1 NDS XIFAXAN TAB 200MG 1 QL (9 tabs / 3 days) XIFAXAN TAB 550MG 1 NDS, QL (60 tabs / 30 days), PENICILLINS amoxicillin & k clavulanate chew tab 200-1 28.5 mg amoxicillin & k clavulanate chew tab 400-1 57 mg amoxicillin & k clavulanate for susp 200-1 28.5 mg/5ml amoxicillin & k clavulanate for susp 250-62.5 mg/5ml 1 amoxicillin & k clavulanate for susp 400-57 1 mg/5ml amoxicillin & k clavulanate for susp 600-1 42.9 mg/5ml amoxicillin & k clavulanate tab 250-125 mg 1 amoxicillin & k clavulanate tab 500-125 mg 1 amoxicillin & k clavulanate tab 875-125 mg 1 amoxicillin & k clavulanate tab er 12hr 1 1000-62.5 mg amoxicillin (trihydrate) cap 250 mg 1 amoxicillin (trihydrate) cap 500 mg 1 amoxicillin (trihydrate) chew tab 125 mg 1 amoxicillin (trihydrate) chew tab 250 mg 1 amoxicillin (trihydrate) for susp 125 1 mg/5ml amoxicillin (trihydrate) for susp 200 1 mg/5ml amoxicillin (trihydrate) for susp 250 1 mg/5ml amoxicillin (trihydrate) for susp 400 1 mg/5ml amoxicillin (trihydrate) tab 500 mg 1 amoxicillin (trihydrate) tab 875 mg 1 ampicillin & sulbactam sodium for inj 1.5 1 (1-0.5) gm ampicillin & sulbactam sodium for inj 3 (2-1 1) gm ampicillin & sulbactam sodium for iv soln 1 15 (10-5) gm ampicillin cap 250 mg 1 - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available 10
ampicillin cap 500 mg 1 ampicillin for susp 125 mg/5ml 1 ampicillin for susp 250 mg/5ml 1 ampicillin sodium for inj 1 gm 1 ampicillin sodium for inj 2 gm 1 ampicillin sodium for inj 125 mg 1 ampicillin sodium for inj 250 mg 1 ampicillin sodium for inj 500 mg 1 ampicillin sodium for iv soln 2 gm 1 ampicillin sodium for iv soln 10 gm 1 BACTOCILL INJ DEX 1GM 1 BACTOCILL INJ DEX 2GM 1 NDS BICILLIN C-R INJ 900/300 1 BICILLIN C-R INJ 1200000 1 BICILLIN L-A INJ 600000 1 BICILLIN L-A INJ 1200000 1 BICILLIN L-A INJ 2400000 1 dicloxacillin sodium cap 250 mg 1 dicloxacillin sodium cap 500 mg 1 nafcillin sodium for inj 1 gm 1 nafcillin sodium for inj 2 gm 1 nafcillin sodium for inj 10 gm 1 NDS nafcillin sodium for iv soln 2 gm 1 oxacillin sodium for inj 1 gm 1 oxacillin sodium for inj 10 gm 1 NDS PEN G PROC INJ 600000 1 PENICILL GK/ INJ DEX 2MU 1 PENICILL GK/ INJ DEX 3MU 1 penicillin g potassium for inj 5000000 unit 1 penicillin g sodium for inj 5000000 unit 1 NDS penicillin v potassium for soln 125 mg/5ml 1 penicillin v potassium for soln 250 mg/5ml 1 penicillin v potassium tab 250 mg 1 penicillin v potassium tab 500 mg 1 pfizerpen-g inj 20mu 1 piperacillin sod-tazobactam na for inj 3.3751 gm (3-0.375 gm) piperacillin sod-tazobactam sod for inj 2.25 1 gm (2-0.25 gm) piperacillin sod-tazobactam sod for inj 4.5 1 gm (4-0.5 gm) piperacillin sod-tazobactam sod for inj 40.5 1 gm (36-4.5 gm) ZOSYN SOL 2-0.25GM 1 ZOSYN SOL 3-0.375G 1 - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available 11
ZOSYN SOL 4-0.50GM 1 QUINOLONES AVELOX INJ 1 ciprofloxacin 200 mg/100ml in d5w 1 ciprofloxacin 400 mg/200ml in d5w 1 ciprofloxacin hcl tab 100 mg (base equiv) 1 ciprofloxacin hcl tab 250 mg (base equiv) 1 ciprofloxacin hcl tab 500 mg (base equiv) 1 ciprofloxacin hcl tab 750 mg (base equiv) 1 ciprofloxacin iv soln 200 mg/20ml (1%) 1 ciprofloxacin iv soln 400 mg/40ml (1%) 1 ciprofloxacin-ciprofloxacin hcl tab er 24hr 1 QL (28 tabs / 30 days) 500 mg (base eq) ciprofloxacin-ciprofloxacin hcl tab er 24hr 1 QL (14 tabs / 30 days) 1000 mg(base eq) levofloxacin in d5w iv soln 250 mg/50ml 1 levofloxacin in d5w iv soln 500 mg/100ml 1 levofloxacin in d5w iv soln 750 mg/150ml 1 levofloxacin iv soln 25 mg/ml 1 levofloxacin oral soln 25 mg/ml 1 levofloxacin tab 250 mg 1 levofloxacin tab 500 mg 1 levofloxacin tab 750 mg 1 moxifloxacin hcl tab 400 mg (base equiv) 1 MOXIFLOXACIN INJ 1 ofloxacin tab 300 mg 1 ofloxacin tab 400 mg 1 SULFA'S / RELATED AGENTS SULFADIAZINE TAB 500MG 1 sulfamethoxazole-trimethoprim iv soln 1 400-80 mg/5ml sulfamethoxazole-trimethoprim susp 200-1 40 mg/5ml sulfamethoxazole-trimethoprim tab 400-80 1 mg sulfamethoxazole-trimethoprim tab 800-1 160 mg TETRACYCLINES doxy 100 inj 100mg 1 doxycycline hyclate cap 50 mg 1 doxycycline hyclate cap 100 mg 1 doxycycline hyclate tab 20 mg 1 doxycycline hyclate tab 100 mg 1 doxycycline monohydrate cap 50 mg 1 doxycycline monohydrate cap 100 mg 1 - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available 12
doxycycline monohydrate for susp 25 1 mg/5ml doxycycline monohydrate tab 50 mg 1 doxycycline monohydrate tab 75 mg 1 doxycycline monohydrate tab 100 mg 1 doxycycline monohydrate tab 150 mg 1 minocycline hcl cap 50 mg 1 minocycline hcl cap 75 mg 1 minocycline hcl cap 100 mg 1 morgidox cap 1x50mg 1 tetracycline hcl cap 250 mg 1 tetracycline hcl cap 500 mg 1 VIBRAMYCIN SYP 50MG/5ML 1 URINARY TRACT AGENTS methenamine hippurate tab 1 gm 1 methenamine mandelate tab 0.5 gm 1 methenamine mandelate tab 1 gm 1 MONUROL K GRANULES 1 nitrofurantoin macrocrystalline cap 50 mg 1 QL (180 caps / year) nitrofurantoin macrocrystalline cap 100 mg 1 QL (90 caps / year) nitrofurantoin monohydrate 1 QL (90 caps / year) macrocrystalline cap 100 mg trimethoprim tab 100 mg 1 VANCOMYCIN vancomycin hcl cap 125 mg 1 NDS vancomycin hcl cap 250 mg 1 NDS vancomycin hcl for inj 10 gm 1 vancomycin hcl for inj 500 mg 1 vancomycin hcl for inj 1000 mg 1 VIBATIV INJ 750MG 1 NDS ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS dexrazoxane for inj 250 mg 1 NDS dexrazoxane for inj 500 mg 1 ELITEK INJ 1.5MG 1 NDS ELITEK INJ 7.5MG 1 FUSILEV INJ 50MG 1 NDS, NM KEPIVANCE INJ 6.25MG 1 NDS, LA leucovorin calcium for inj 100 mg 1 leucovorin calcium for inj 350 mg 1 leucovorin calcium tab 5 mg 1 leucovorin calcium tab 10 mg 1 leucovorin calcium tab 15 mg 1 leucovorin calcium tab 25 mg 1 - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available 13
levoleucovorin calcium for iv inj 50 mg (base equiv) 1 NDS, NM levoleucovorin calcium inj 175 mg/17.5ml 1 NDS, NM (base equiv) mesna inj 100 mg/ml 1 MESNEX TAB 400MG 1 XGEVA INJ 1 NDS, QL (1 vial / 28 ZINECARD INJ 250MG 1 NDS ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ABRAXANE INJ 100MG 1 NDS adriamycin inj 20mg 1 adrucil inj 500/10ml 1 B/D AFINITOR DIS TAB 2MG 1 NDS, NM, AFINITOR DIS TAB 3MG 1 NDS, NM, AFINITOR DIS TAB 5MG 1 NDS, NM, AFINITOR TAB 2.5MG 1 NDS, QL (120 tabs / 30 AFINITOR TAB 5MG 1 NDS, QL (60 tabs / 30 AFINITOR TAB 7.5MG 1 NDS, QL (60 tabs / 30 AFINITOR TAB 10MG 1 NDS, QL (30 tabs / 30 ALECENSA CAP 150MG 1 NDS, QL (240 caps / 30 ALIMTA INJ 100MG 1 NDS ALIMTA INJ 500MG 1 NDS ALUNBRIG TAB 30MG 1 NDS, QL (180 tabs / 30 anastrozole tab 1 mg 1 ARRANON INJ 5MG/ML 1 NDS ARZERRA CON 100/5ML 1 NDS, B/D, NM AVASTIN INJ 1 NDS, NM AVASTIN INJ 400/16ML 1 NDS, NM azacitidine for inj 100 mg 1 NDS, NM AZATHIOPRINE INJ 100MG 1 B/D azathioprine tab 50 mg 1 B/D BAVENCIO INJ 20MG/ML 1 NDS, NM, BELEODAQ INJ 500MG 1 NDS, NM BENDEKA INJ 100/4ML 1 NDS, NM bexarotene cap 75 mg 1 NDS, NM, bicalutamide tab 50 mg 1 BICNU INJ 100MG 1 bleomycin sulfate for inj 15 unit 1 - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available 14
bleomycin sulfate for inj 30 unit 1 B/D BLINCYTO INJ 35MCG 1 NDS, NM BOSULIF TAB 100MG 1 NDS, QL (180 tabs / 30 BOSULIF TAB 500MG 1 NDS, QL (60 tabs / 30 busulfan inj 6 mg/ml 1 NDS BUSULFEX INJ 6MG/ML 1 NDS CABOMETYX TAB 20MG 1 QL (90 tabs / 30 days), NM, LA, CABOMETYX TAB 40MG 1 QL (60 tabs / 30 days), NM, LA, CABOMETYX TAB 60MG 1 QL (30 tabs / 30 days), NM, LA, CAMTH INJ 30MG/ML 1 NDS CAPRELSA TAB 100MG 1 QL (90 tabs / 30 days), NM, LA, CAPRELSA TAB 300MG 1 QL (30 tabs / 30 days), NM, LA, carboplatin iv soln 150 mg/15ml 1 CELLCEPT IV INJ 500MG 1 B/D cisplatin inj 100 mg/100ml (1 mg/ml) 1 cladribine iv soln 10 mg/10ml (1 mg/ml) 1 NDS, B/D clofarabine iv soln 1 mg/ml 1 NDS CLOLAR INJ 1MG/ML 1 NDS COMETRIQ KIT 60MG 1 NDS, QL (252 caps / 28 COMETRIQ KIT 100MG 1 NDS, QL (112 caps / 28 COMETRIQ KIT 140MG 1 NDS, QL (112 caps / 28 COTELLIC TAB 20MG 1 NDS, QL (63 tabs / 28 days), NM, LA, CYCLOPHOSPH CAP 25MG 1 B/D CYCLOPHOSPH CAP 50MG 1 B/D cyclophosphamide for inj 1 gm 1 B/D cyclophosphamide for inj 2 gm 1 B/D cyclophosphamide for inj 500 mg 1 B/D cyclosporine cap 25 mg 1 B/D cyclosporine cap 100 mg 1 B/D cyclosporine iv soln 50 mg/ml 1 B/D cyclosporine modified cap 25 mg 1 B/D cyclosporine modified cap 50 mg 1 B/D cyclosporine modified cap 100 mg 1 B/D cyclosporine modified oral soln 100 mg/ml 1 B/D CYRAMZA INJ 100/10ML 1 NDS, B/D, NM - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available 15
CYRAMZA INJ 500/50ML 1 NDS, B/D, NM cytarabine inj 20 mg/ml 1 B/D cytarabine inj pf 20 mg/ml 1 B/D cytarabine inj pf 100 mg/ml 1 B/D dacarbazine for inj 100 mg 1 dacarbazine for inj 200 mg 1 DARZALEX SOL 100MG/5M 1 NDS, NM, LA DARZALEX SOL 400MG/20 1 NDS, NM, LA daunorubicin hcl inj 5 mg/ml (base equiv) 1 decitabine for inj 50 mg 1 NDS, NM DOCETAXEL INJ 80MG/4ML 1 DOCETAXEL INJ 80MG/8ML 1 NDS doxorubicin hcl for inj 10 mg 1 doxorubicin hcl for inj 50 mg 1 doxorubicin hcl inj 2 mg/ml 1 doxorubicin hcl liposomal inj (for iv 1 infusion) 2 mg/ml ELIGARD INJ 7.5MG 1 QL (1 kit / 28 days), NM, ELIGARD INJ 22.5MG 1 QL (1 kit / 84 days), NM, ELIGARD INJ 30MG 1 QL (1 kit / 112 days), NM, ELIGARD INJ 45MG 1 QL (1 kit / 168 days), NM, EMCYT CAP 140MG 1 EMPLICITI INJ 300MG 1 NDS, B/D, NM EMPLICITI INJ 400MG 1 NDS, B/D, NM epirubicin hcl iv soln 50 mg/25ml (2 1 mg/ml) epirubicin hcl iv soln 200 mg/100ml (2 1 mg/ml) ERBITUX INJ 100MG 1 NDS, NM ERBITUX INJ 200MG 1 NDS, NM ERIVEDGE CAP 150MG 1 NDS, QL (30 caps / 30 ERWINAZE INJ 10000UNT 1 NDS, NM ETOPOPHOS INJ 100MG 1 etoposide inj 500 mg/25ml (20 mg/ml) 1 exemestane tab 25 mg 1 FARESTON TAB 60MG 1 NDS, FARYDAK CAP 10MG 1 NDS, QL (12 caps / 21 FARYDAK CAP 15MG 1 NDS, QL (12 caps / 21 - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available 16
FARYDAK CAP 20MG 1 NDS, QL (6 caps / 21 FASLODEX INJ 250MG 1 NDS FIRMAGON INJ 80MG 1 QL (12 vials / 28 days), NM, FIRMAGON INJ 120MG 1 NDS, QL (4 vials / 365 floxuridine for inj 0.5 gm 1 fludarabine phosphate for inj 50 mg 1 fludarabine phosphate inj 25 mg/ml 1 fluorouracil inj 1 gm/20ml (50 mg/ml) 1 fluorouracil inj 2.5 gm/50ml (50 mg/ml) 1 B/D flutamide cap 125 mg 1 FOLOTYN INJ 40MG/2ML 1 NDS, NM GAZYVA INJ 25MG/ML 1 NDS, NM gemcitabine hcl for inj 1 gm 1 NDS gemcitabine hcl for inj 2 gm 1 gemcitabine hcl for inj 200 mg 1 gemcitabine hcl inj 1 gm/26.3ml (38 1 mg/ml) (base equiv) gemcitabine hcl inj 2 gm/52.6ml (38 1 mg/ml) (base equiv) gemcitabine hcl inj 200 mg/5.26ml (38 1 mg/ml) (base equiv) gengraf cap 25mg 1 B/D gengraf cap 50mg 1 B/D gengraf cap 100mg 1 B/D gengraf sol 100mg/ml 1 B/D GILOTRIF TAB 20MG 1 NDS, QL (60 tabs / 30 GILOTRIF TAB 30MG 1 NDS, QL (60 tabs / 30 GILOTRIF TAB 40MG 1 NDS, QL (30 tabs / 30 GLEEVEC TAB 100MG 1 NDS, QL (240 tabs / 30 GLEEVEC TAB 400MG 1 NDS, QL (60 tabs / 30 GLEOSTINE CAP 5MG 1 GLEOSTINE CAP 10MG 1 GLEOSTINE CAP 40MG 1 GLEOSTINE CAP 100MG 1 HALAVEN INJ 1MG/2ML 1 NDS, NM HERCEPTIN INJ 440MG 1 NDS, NM HEXALEN CAP 50MG 1 NDS hydroxyurea cap 500 mg 1 - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available 17
IBRANCE CAP 75MG 1 NDS, QL (42 caps / 28 IBRANCE CAP 100MG 1 NDS, QL (42 caps / 28 IBRANCE CAP 125MG 1 NDS, QL (21 caps / 28 ICLUSIG TAB 15MG 1 NDS, QL (90 tabs / 30 ICLUSIG TAB 45MG 1 NDS, QL (30 tabs / 30 idarubicin hcl iv inj 10 mg/10ml (1 mg/ml) 1 NDS ifosfamide for inj 1 gm 1 IFOSFAMIDE INJ 3GM 1 ifosfamide iv inj 1 gm/20ml (50 mg/ml) 1 ifosfamide iv inj 3 gm/60ml (50 mg/ml) 1 IMBRUVICA CAP 140MG 1 NDS, QL (120 caps / 30 IMFINZI INJ 120/2.4 1 NDS, NM IMFINZI INJ 500/10 1 NDS, NM INLYTA TAB 1MG 1 NDS, QL (600 tabs / 30 INLYTA TAB 5MG 1 NDS, QL (120 tabs / 30 IRESSA TAB 250MG 1 NDS, QL (30 tabs / 30 irinotecan hcl inj 40 mg/2ml (20 mg/ml) 1 irinotecan hcl inj 100 mg/5ml (20 mg/ml) 1 irinotecan hcl inj 500 mg/25ml (20 mg/ml) 1 ISTODAX OVR INJ 10MG 1 NDS, NM IXEMPRA KIT INJ 15MG 1 NDS, NM IXEMPRA KIT INJ 45MG 1 NDS, NM JAKAFI TAB 5MG 1 NDS, QL (300 tabs / 30 JAKAFI TAB 10MG 1 NDS, QL (180 tabs / 30 JAKAFI TAB 15MG 1 NDS, QL (120 tabs / 30 JAKAFI TAB 20MG 1 NDS, QL (120 tabs / 30 JAKAFI TAB 25MG 1 NDS, QL (60 tabs / 30 JEVTANA INJ 60/1.5ML 1 NDS, NM KADCYLA INJ 100MG 1 NDS, NM KADCYLA INJ 160MG 1 NDS, NM KEYTRUDA INJ 100MG/4M 1 NDS, NM KEYTRUDA SOL 50MG 1 NDS, NM - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available 18
KISQALI 200 K FEMARA 1 NDS, QL (49 tabs / 28 KISQALI 400 K FEMARA 1 NDS, QL (70 tabs / 28 KISQALI 600 K FEMARA 1 NDS, QL (91 tabs / 28 KISQALI TAB 200DOSE 1 NDS, QL (63 tabs / 28 KISQALI TAB 400DOSE 1 NDS, QL (63 tabs / 28 KISQALI TAB 600DOSE 1 NDS, QL (63 tabs / 28 KYPROLIS SOL 30MG 1 NDS, NM KYPROLIS SOL 60MG 1 NDS, NM LARTRUVO INJ 10MG/ML 1 NDS, NM, LA LENVIMA CAP 8 MG 1 QL (180 caps / 30 LENVIMA CAP 10 MG 1 NDS, QL (90 caps / 30 LENVIMA CAP 14 MG 1 NDS, QL (120 caps / 30 LENVIMA CAP 18 MG 1 QL (180 caps / 30 LENVIMA CAP 20 MG 1 NDS, QL (120 caps / 30 LENVIMA CAP 24 MG 1 NDS, QL (90 caps / 30 letrozole tab 2.5 mg 1 LEUKERAN TAB 2MG 1 leuprolide acetate inj kit 5 mg/ml 1 NM, LONSURF TAB 15-6.14 1 NDS, NM, LONSURF TAB 20-8.19 1 NDS, NM, LUPR DEP-PED INJ 11.25MG 1 NDS, QL (1 kit / 28 LUPR DEP-PED INJ 15MG 1 NDS, QL (1 kit / 28 LUPRON DEPOT INJ 3.75MG 1 NDS, QL (1 kit / 28 LUPRON DEPOT INJ 7.5MG 1 NDS, QL (1 kit / 28 LUPRON DEPOT INJ 11.25MG 1 NDS, QL (1 kit / 84 LUPRON DEPOT INJ 22.5MG 1 NDS, QL (1 kit / 84 LUPRON DEPOT INJ 30MG 1 NDS, QL (1 kit / 84 - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available 19
LUPRON DEPOT INJ 45MG 1 QL (1 kit / 168 days), NM, LYNRZA CAP 50MG 1 NDS, QL (480 caps / 30 LYSODREN TAB 500MG 1 NDS MATULANE CAP 50MG 1 NDS megestrol acetate susp 40 mg/ml 1 megestrol acetate tab 20 mg 1 megestrol acetate tab 40 mg 1 MEKINIST TAB 0.5MG 1 NDS, QL (120 tabs / 30 MEKINIST TAB 2MG 1 NDS, QL (30 tabs / 30 melphalan hcl for inj 50 mg (base equiv) 1 NDS mercaptopurine tab 50 mg 1 methotrexate sodium for inj 1 gm 1 B/D methotrexate sodium inj 25 mg/ml 1 B/D methotrexate sodium inj 50 mg/2ml (25 mg/ml) 1 B/D methotrexate sodium inj 250 mg/10ml (25 1 B/D mg/ml) methotrexate sodium inj pf 1000 mg/40ml 1 B/D (25 mg/ml) methotrexate sodium tab 2.5 mg (base 1 equiv) mitomycin for iv soln 5 mg 1 NDS mitomycin for iv soln 20 mg 1 NDS mitomycin for iv soln 40 mg 1 NDS mitoxantrone hcl inj conc 25 mg/12.5ml (2 1 NM mg/ml) MUSTARGEN INJ 10MG 1 mycophenolate mofetil cap 250 mg 1 B/D mycophenolate mofetil for oral susp 200 1 NDS, B/D mg/ml mycophenolate mofetil hcl for iv soln 500 1 B/D mg (base equiv) mycophenolate mofetil tab 500 mg 1 B/D mycophenolate sodium tab dr 180 mg 1 B/D (mycophenolic acid equiv) mycophenolate sodium tab dr 360 mg 1 B/D (mycophenolic acid equiv) NEXAVAR TAB 200MG 1 NDS, QL (120 tabs / 30 days), NM, LA, nilutamide tab 150 mg 1 NDS NINLARO CAP 2.3MG 1 NDS, QL (6 caps / 28 - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available 20
NINLARO CAP 3MG 1 NDS, QL (6 caps / 28 NINLARO CAP 4MG 1 NDS, QL (3 caps / 28 NIPENT INJ 10MG 1 NDS NULOJIX INJ 250MG 1 NDS, octreotide acetate inj 50 mcg/ml (0.05 1 NM mg/ml) octreotide acetate inj 100 mcg/ml (0.1 1 NM mg/ml) octreotide acetate inj 200 mcg/ml (0.2 1 NM mg/ml) octreotide acetate inj 500 mcg/ml (0.5 1 NDS, NM mg/ml) octreotide acetate inj 1000 mcg/ml (1 1 NDS, NM mg/ml) ODOMZO CAP 200MG 1 NDS, QL (30 caps / 30 days), NM, LA, OPDIVO INJ 40MG/4ML 1 NDS, NM OPDIVO INJ 100MG/10 1 NDS, NM oxaliplatin for iv inj 50 mg 1 oxaliplatin for iv inj 100 mg 1 oxaliplatin iv soln 50 mg/10ml 1 oxaliplatin iv soln 100 mg/20ml 1 paclitaxel iv conc 300 mg/50ml (6 mg/ml) 1 PERJETA INJ 420/14ML 1 NDS, NM POMALYST CAP 1MG 1 NDS, QL (84 caps / 28 POMALYST CAP 2MG 1 NDS, QL (42 caps / 28 POMALYST CAP 3MG 1 NDS, QL (42 caps / 28 POMALYST CAP 4MG 1 NDS, QL (21 caps / 28 PORTRAZZA INJ 800/50ML 1 NDS, B/D, NM PROGRAF INJ 5MG/ML 1 B/D PURIXAN SUS 20MG/ML 1 NDS, NM, RAMUNE SOL 1MG/ML 1 NDS, REVLIMID CAP 2.5MG 1 NDS, QL (210 caps / 28 days), NM, LA, REVLIMID CAP 5MG 1 NDS, QL (105 caps / 28 days), NM, LA, REVLIMID CAP 10MG 1 NDS, QL (63 caps / 28 days), NM, LA, REVLIMID CAP 15MG 1 NDS, QL (42 caps / 28 days), NM, LA, - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available 21