2020 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: 20543 Version #: 14 This formulary was updated on 07/01/2020. For more recent information or other questions, please contact AmeriHealth Caritas VIP Care at 1-866-533-5490 or, for TTY users, 711, seven days a week, 8 a.m. to 8 p.m., or visit www.amerihealthcaritasvipcare.com. Y0093_FOR_660550_C_7
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2020 Formulary - AmeriHealth Caritas VIP Care (HMO SNP) · 6/1/2020 · AmeriHealth Caritas VIP Care will then cover Drug B. You can find out if your drug has any additional requirements
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2020 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: 20543 Version #: 14
This formulary was updated on 07/01/2020. For more recent information or other questions, please contact AmeriHealth Caritas VIP Care at 1-866-533-5490 or, for TTY users, 711, seven days a week, 8 a.m. to 8 p.m., or visit www.amerihealthcaritasvipcare.com.
Y0093_FOR_660550_C_7
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AmeriHealth Caritas VIP Care2020 Formulary
(List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN
Formulary ID: 20543, Version Number 14
This formulary was updated on 07/01/2020. For more recent information or other questions, please contact AmeriHealth Caritas VIP Care at 1-866-533-5490 or, for TTY users, 711, seven days a week, 8 a.m. to 8 p.m., or visit www.amerihealthcaritasvipcare.com.
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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 Vista Health Plan. When it refers to “plan” or “our plan,” it means AmeriHealth Caritas VIP Care.
This document includes a list of the drugs (formulary) for our plan, which is current as of 07/01/2020. 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, 2020, and from time to time during the year.
What is the AmeriHealth Caritas VIP Care Formulary?A formulary is a list of covered drugs selected by AmeriHealth Caritas VIP Care 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. AmeriHealth Caritas VIP Care will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at an AmeriHealth Caritas VIP Care 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?Most changes in drug coverage happen on January 1, but AmeriHealth Caritas VIP Care may add or remove drugs on the Drug List during the year, move them to different cost-sharing tiers, or add new restrictions. We must follow Medicare rules in making these changes.
Changes that can affect you this year: In the below cases, you will be affected by coverage changes during the year:
• New generic drugs. We may immediately remove a brand name drug on our Drug 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 Drug 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.
○ 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 how to request an exception, and you can also find information in the section below entitled “How do I request an exception to the AmeriHealth Caritas VIP Care Formulary?”
• Drugs removed from the market. 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.
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• 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 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, or add prior authorization, quantity limits, and/or step therapy restrictions on a drug, we must notify affected members of the change at least 30 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 we make these other changes, 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 how to request an exception, and you can also find information in the section below entitled “How do I request an exception to the AmeriHealth Caritas VIP Care Formulary?”
Changes that will not affect you if you are currently taking the drug. Generally, if you are taking a drug on our 2019 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2020 coverage year except as described above. This means these drugs will remain available at the same cost-sharing and with no new restrictions for those members taking them for the remainder of the coverage year. As long as the drug was not removed from the market or has not been deemed unsafe, it will remain on the formulary.
The enclosed formulary is current as of 07/01/2020. To get updated information about the drugs covered by AmeriHealth Caritas VIP Care, please contact us. Our contact information appears on the front and back cover pages.
The formulary is updated monthly throughout the year, and the list of drugs may change. If there are negative changes to the formulary outside of routine maintenance updates, such as removing a drug from our formulary; adding prior authorization, quantity limits, and/or step therapy restrictions to a drug; or changing a tiered cost-sharing status, our plan will mail you a written notice.
How do I use the Formulary? There are two ways to find your drug within the formulary:
Medical ConditionThe 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 Agents”. If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug.
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Alphabetical ListingIf you are not sure what category to look under, you should look for your drug in the Index that begins on page 104. 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?AmeriHealth Caritas VIP Care 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: AmeriHealth Caritas VIP Care requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from AmeriHealth Caritas VIP Care before you fill your prescriptions. If you don’t get approval, AmeriHealth Caritas VIP Care may not cover the drug.
• Quantity Limits: For certain drugs, AmeriHealth Caritas VIP Care limits the amount of the drug that AmeriHealth Caritas VIP Care will cover. For example, AmeriHealth Caritas VIP Care allows 30 tablets per 30 day supply of a prescription for digoxin. This may be in addition to a standard one-month or three-month supply.
• Step Therapy: In some cases, AmeriHealth Caritas VIP Care 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, AmeriHealth Caritas VIP Care may not cover Drug B unless you try Drug A first. If Drug A does not work for you, AmeriHealth Caritas VIP Care 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 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, appear on the front and back cover pages.
You can ask AmeriHealth Caritas VIP Care 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 AmeriHealth Caritas VIP Care formulary?” on page v for information about how to request an exception.
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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 AmeriHealth Caritas VIP Care does not cover your drug, you have two options:
• You can ask Member Services for a list of similar drugs that are covered by AmeriHealth Caritas VIP Care. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by AmeriHealth Caritas VIP Care.
• You can ask AmeriHealth Caritas VIP Care 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 AmeriHealth Caritas VIP Care Formulary?You can ask AmeriHealth Caritas VIP Care 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 predetermined 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 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, AmeriHealth Caritas VIP Care 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, AmeriHealth Caritas VIP Care 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 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.
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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. If your prescription is written for fewer days, we’ll allow refills to provide up to a maximum 30 day supply of medication. 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 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 31-day emergency supply of that drug while you pursue a formulary exception.
Members who have a change in level of care (setting) will be allowed up to a one-time 30-day transition supply per drug. For example, members who:
• Enter long-term care (LTC) facilities from hospitals are sometimes accompanied by a discharge list of medications from the hospital formulary, with very short-term planning taken into account (often under 8 hours).
• Are discharged from a hospital to home.
• End their skilled nursing facility Medicare Part A stay (where payments include all pharmacy charges) and who need to revert to their Part D plan formulary.
• End a long-term care facility stay and return to the community.
If a member has more than one change in level of care in a month, the pharmacy will have to call our plan to request an extension of the transition policy.
For more informationFor more detailed information about your AmeriHealth Caritas VIP Care prescription drug coverage, please review your Evidence of Coverage and other plan materials.
If you have questions about AmeriHealth Caritas VIP Care, 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/seven days a week. TTY users should call 1-877-486-2048. Or visit https://www.medicare.gov.
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AmeriHealth Caritas VIP Care’s FormularyThe formulary that begins on the next page provides coverage information about the drugs covered by AmeriHealth Caritas VIP Care. If you have trouble finding your drug in the list, turn to the Index that begins on page 104.
The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., COUMADIN) and generic drugs are listed in lower-case italics (e.g., warfarin).
The information in the Requirements/Limits column tells you if AmeriHealth Caritas VIP Care has any special requirements for coverage of your drug.
List of AbbreviationsB/D: This prescription drug has a Part B versus D administrative prior authorization requirement. This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.
QL: Quantity Limit. For certain drugs, AmeriHealth Caritas VIP Care limits the amount of the drug that the plan will cover. For example, our plan provides twelve tablets per prescription for sumatriptan succinate.
ST: Step Therapy. In some cases, AmeriHealth Caritas VIP Care 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, AmeriHealth Caritas VIP Care may not cover drug B unless you try Drug A first. If Drug A does not work for you, AmeriHealth Caritas VIP Care will then cover Drug B.
PA: Prior Authorization. AmeriHealth Caritas VIP Care requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from AmeriHealth Caritas VIP Care before you fill your prescriptions. If you don't get approval, AmeriHealth Caritas VIP Care may not cover the drug.
LA: Limited Availability. This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at 1-866-533-5490, 8 a.m. to 8 p.m., seven days per week. TTY users should call 711.
MO: Mail Order. This prescription may be filled by an AmeriHealth Caritas VIP Care network mail order pharmacy. Please review your Pharmacy Directory for more information about which pharmacies offer mail order service. For more information consult your Pharmacy Directory or call our Member Services Department at 1-866-533-5490, from 8 a.m. to 8 p.m., seven days per week. TTY/TDD users should call 711.
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AmeriHealth Caritas VIP Care is an HMO-SNP plan with a Medicare contract and a contract with the Pennsylvania Medicaid program. Enrollment in AmeriHealth Caritas VIP Care depends on contract renewal.The pharmacy network and provider network may change at any time. You will receive notice when necessary.AmeriHealth Caritas VIP Care complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.Attention: If you speak a language other than English, language assistance services, free of charge, are available to you. Call 1-866-533-5490 (TTY 711).Atención: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-866-533-5490 (TTY 711).注意:如果您使用中文,您可以免費獲得語言援助服務。請致電 1-866-533-5490 (TTY 711)。Please contact Member Services if you require this document in an alternate format such as large font, Braille, or audio.
AmeriHealth Caritas VIP Care is an HMO-SNP plan with a Medicare contract and a contract with the Pennsylvania Medicaid program. Enrollment in AmeriHealth Caritas VIP Care depends on contract renewal.The pharmacy network and provider network may change at any time. You will receive notice when necessary.AmeriHealth Caritas VIP Care complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.Attention: If you speak a language other than English, language assistance services, free of charge, are available to you. Call 1-866-533-5490 (TTY 711).Atención: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-866-533-5490 (TTY 711).注意:如果您使用中文,您可以免費獲得語言援助服務。請致電 1-866-533-5490 (TTY 711)。Please contact Member Services if you require this document in an alternate format such as large font, Braille, or audio.
AmeriHealth Caritas VIP Care is an HMO-SNP plan with a Medicare contract and a contract with the Pennsylvania Medicaid program. Enrollment in AmeriHealth Caritas VIP Care depends on contract renewal.The pharmacy network and provider network may change at any time. You will receive notice when necessary.AmeriHealth Caritas VIP Care complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.Attention: If you speak a language other than English, language assistance services, free of charge, are available to you. Call 1-866-533-5490 (TTY 711).Atención: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-866-533-5490 (TTY 711).注意:如果您使用中文,您可以免費獲得語言援助服務。請致電 1-866-533-5490 (TTY 711)。Please contact Member Services if you require this document in an alternate format such as large font, Braille, or audio.
AmeriHealth Caritas VIP Care is an HMO-SNP plan with a Medicare contract and a contract with the Pennsylvania Medicaid program. Enrollment in AmeriHealth Caritas VIP Care depends on contract renewal.The pharmacy network and provider network may change at any time. You will receive notice when necessary.AmeriHealth Caritas VIP Care complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.Attention: If you speak a language other than English, language assistance services, free of charge, are available to you. Call 1-866-533-5490 (TTY 711).Atención: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-866-533-5490 (TTY 711).注意:如果您使用中文,您可以免費獲得語言援助服務。請致電 1-866-533-5490 (TTY 711)。Please contact Member Services if you require this document in an alternate format such as large font, Braille, or audio.
2020 2 Tier Standard- AmeriHealth Caritas VIP Care
Document: 2020 Member Formulary
Formulary ID: 20543
Last Updated: 06/2020
Effective Date: 07-01-2020
You can find information on what the symbols and abbreviations in this table mean by going to page vii.
1
CURRENT AS OF 7/1/2020
Name of Drug Drug Tier Necessary actions,
restrictions, or limits on use
Analgesics - Treatment Of Pain
Analgesics, Other
acetaminophen-codeine #2 oral tablet 300-15 mg 1
acetaminophen-codeine #3 oral tablet 300-30 mg 1
acetaminophen-codeine #4 oral tablet 300-60 mg 1
acetaminophen-codeine oral solution 120-12
mg/5ml 1
acetaminophen-codeine oral tablet 300-15 mg,
300-60 mg 1
ASCOMP-CODEINE ORAL CAPSULE 50-325-
40-30 MG 1 PA
butalbital-acetaminophen oral tablet 50-325 mg 1 PA
butalbital-apap-caff-cod oral capsule 50-325-40-
30 mg 1 PA
butalbital-apap-caffeine oral capsule 50-325-40
mg 1 PA
butalbital-apap-caffeine oral tablet 50-325-40 mg 1 PA
butalbital-asa-caff-codeine oral capsule 50-325-
40-30 mg 1 PA
butalbital-aspirin-caffeine oral capsule 50-325-
40 mg 1 PA
carisoprodol-aspirin oral tablet 200-325 mg 1 PA
carisoprodol-aspirin-codeine oral tablet 200-325-
16 mg 1 PA
ENDOCET ORAL TABLET 10-325 MG, 5-325
MG, 7.5-325 MG 1
hydrocodone-acetaminophen oral tablet 10-325
mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg 1
hydrocodone-ibuprofen oral tablet 10-200 mg, 5-
200 mg, 7.5-200 mg 1
IBU ORAL TABLET 600 MG, 800 MG 1
2
Name of Drug Drug Tier Necessary actions,
restrictions, or limits on use
oxycodone-acetaminophen oral tablet 10-325 mg,
2.5-325 mg, 5-325 mg, 7.5-325 mg 1
oxycodone-aspirin oral tablet 4.8355-325 mg 1
oxycodone-ibuprofen oral tablet 5-400 mg 1
pentazocine-naloxone hcl oral tablet 50-0.5 mg 1 PA
tramadol-acetaminophen oral tablet 37.5-325 mg 1
Nonsteroidal Anti-Inflammatory Drugs
celecoxib oral capsule 100 mg, 200 mg, 400 mg,
50 mg 1
diclofenac potassium oral tablet 50 mg 1
diclofenac sodium er oral tablet extended release
24 hour 100 mg 1
diclofenac sodium oral tablet delayed release 25
mg, 50 mg, 75 mg 1
diclozor transdermal therapy pack 1 % 1
diflunisal oral tablet 500 mg 1
ec-naproxen oral tablet delayed release 375 mg,
500 mg 1
etodolac er oral tablet extended release 24 hour
400 mg, 500 mg, 600 mg 1
etodolac oral capsule 200 mg, 300 mg 1
etodolac oral tablet 400 mg, 500 mg 1
flurbiprofen oral tablet 100 mg, 50 mg 1
IBUPROFEN COMFORT PAC
COMBINATION KIT 800 MG 1
ibuprofen oral suspension 100 mg/5ml 1
ibuprofen oral tablet 400 mg, 600 mg, 800 mg 1
indomethacin er oral capsule extended release 75
mg 1 PA
indomethacin oral capsule 25 mg, 50 mg 1 PA
ketorolac tromethamine oral tablet 10 mg 1 PA; QL (20 EA per 30 days)
meclofenamate sodium oral capsule 100 mg, 50
mg 1
MELOXICAM COMFORT PAC
COMBINATION KIT 15 MG 1
meloxicam oral tablet 15 mg, 7.5 mg 1
nabumetone oral tablet 500 mg, 750 mg 1
2020 2 Tier Standard- AmeriHealth Caritas VIP Care
Document: 2020 Member Formulary
Formulary ID: 20543
Last Updated: 06/2020
Effective Date: 07-01-2020
You can find information on what the symbols and abbreviations in this table mean by going to page vii.
3
Name of Drug Drug Tier Necessary actions,
restrictions, or limits on use
NAPROXEN COMFORT PAC COMBINATION
KIT 500 MG 1
naproxen dr oral tablet delayed release 375 mg,
500 mg 1
naproxen oral suspension 125 mg/5ml 1
naproxen oral tablet 250 mg, 375 mg, 500 mg 1
naproxen sodium oral tablet 275 mg, 550 mg 1
piroxicam oral capsule 10 mg, 20 mg 1
sulindac oral tablet 150 mg, 200 mg 1
Opioid Analgesics, Long-Acting
buprenorphine transdermal patch weekly 10
mcg/hr, 15 mcg/hr, 20 mcg/hr, 5 mcg/hr, 7.5
mcg/hr
1 QL (4 EA per 28 days)
fentanyl transdermal patch 72 hour 100 mcg/hr 1 PA
fentanyl transdermal patch 72 hour 12 mcg/hr, 25
mcg/hr, 37.5 mcg/hr, 50 mcg/hr, 62.5 mcg/hr, 75
mcg/hr, 87.5 mcg/hr
1 QL (10 EA per 30 days)
methadone hcl oral solution 10 mg/5ml 1 QL (1200 ML per 30 days)
methadone hcl oral solution 5 mg/5ml 1 QL (2400 ML per 30 days)
methadone hcl oral tablet 10 mg 1 PA
methadone hcl oral tablet 5 mg 1 QL (180 EA per 30 days)
morphine sulfate er oral tablet extended release
100 mg, 200 mg 1 PA
morphine sulfate er oral tablet extended release
15 mg, 30 mg, 60 mg 1 QL (60 EA per 30 days)
oxycodone hcl er oral tablet er 12 hour abuse-
deterrent 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 60
mg, 80 mg
1 PA
Opioid Analgesics, Short-Acting
butorphanol tartrate nasal solution 10 mg/ml 1 QL (5 ML per 30 days)
2020 2 Tier Standard- AmeriHealth Caritas VIP Care
Document: 2020 Member Formulary
Formulary ID: 20543
Last Updated: 06/2020
Effective Date: 07-01-2020
109
HETLIOZ ............................. 103
HEXALEN ............................. 28
HIBERIX ................................ 92
HUMALOG ........................... 50
HUMALOG JUNIOR
KWIKPEN ......................... 50
HUMALOG KWIKPEN ........ 50
HUMALOG MIX 50/50......... 50
HUMALOG MIX 50/50
KWIKPEN ......................... 50
HUMALOG MIX 75/25......... 50
HUMALOG MIX 75/25
KWIKPEN ......................... 50
HUMATROPE ....................... 85
HUMIRA ................................ 89
HUMIRA PEDIATRIC
CROHNS START .............. 88
HUMIRA PEN ....................... 88
HUMIRA PEN-CD/UC/HS
STARTER .......................... 88
HUMIRA PEN-PS/UV/ADOL
HS START ......................... 88
HUMULIN 70/30 ................... 51
HUMULIN N ......................... 51
HUMULIN R ......................... 51
HUMULIN R U-500
(CONCENTRATED) ......... 51
HUMULIN R U-500
KWIKPEN ......................... 51
hydralazine hcl ....................... 62
hydrochlorothiazide ................ 61
hydrocodone-acetaminophen ... 1
hydrocodone-ibuprofen ............ 1
hydrocortisone ............ 25, 76, 94
hydrocortisone butyrate .......... 25
hydrocortisone valerate .... 25, 26
hydrocortisone-acetic acid...... 97
hydromorphone hcl .................. 4
hydromorphone hcl pf .............. 4
hydroxychloroquine sulfate .... 34
hydroxyurea ............................ 29
hydroxyzine hcl ...................... 98
hydroxyzine pamoate ............. 45
HYPERRAB........................... 90
HYPERRAB S/D ................... 90
I ibandronate sodium ................ 94
ibrance .................................... 31
IBRANCE .............................. 31
IBU ........................................... 1
ibuprofen .................................. 2
IBUPROFEN COMFORT PAC
.............................................. 2
icatibant acetate ...................... 88
ICLUSIG ................................ 32
IDHIFA .................................. 32
imatinib mesylate ................... 32
IMBRUVICA ......................... 32
imipenem-cilastatin ................ 11
imipramine hcl ........................ 20
imipramine pamoate ............... 20
imiquimod .............................. 67
IMOVAX RABIES ................ 92
INCASSIA.............................. 83
INCRELEX ............................ 85
INCRUSE ELLIPTA .............. 99
indapamide ............................. 61
indomethacin ............................ 2
indomethacin er ........................ 2
INFANRIX ............................. 92
INGREZZA ............................ 65
INLYTA ................................. 32
INREBIC ................................ 32
insulin asp prot & asp flexpen 51
insulin aspart........................... 51
insulin aspart flexpen.............. 51
insulin aspart penfill ............... 51
insulin aspart prot & aspart .... 51
insulin lispro ........................... 51
insulin lispro (1 unit dial) ....... 51
insulin lispro junior kwikpen .. 51
insulin lispro prot & lispro ..... 51
insulin syringe ........................ 50
INTELENCE .......................... 42
INTRALIPID.......................... 69
INTRON A ............................. 41
INTROVALE ......................... 80
INVEGA SUSTENNA ........... 38
INVEGA TRINZA ................. 38
INVIRASE ............................. 44
INVOKAMET ........................ 47
INVOKAMET XR ................. 48
INVOKANA........................... 48
IPOL ....................................... 92
ipratropium bromide ....... 99, 102
ipratropium-albuterol ............ 102
irbesartan ................................ 55
irbesartan-hydrochlorothiazide
............................................ 59
IRESSA .................................. 32
ISENTRESS ........................... 42
ISENTRESS HD .................... 42
ISIBLOOM ............................. 80
ISOLYTE-P IN D5W ............. 69
ISOLYTE-S ............................ 69
ISOLYTE-S PH 7.4 ................ 69
isoniazid .................................. 27
isosorbide dinitrate ................. 63
isosorbide mononitrate ........... 63
isosorbide mononitrate er ....... 63
isotretinoin .............................. 67
isradipine ................................ 58
itraconazole............................. 23
ivermectin ............................... 34
IXIARO .................................. 92
J JADENU................................. 70
JADENU SPRINKLE ............ 71
JAKAFI .................................. 32
JANTOVEN ........................... 53
JANUMET ............................. 48
JANUMET XR ....................... 48
JANUVIA ............................... 48
JARDIANCE .......................... 48
JENTADUETO ...................... 48
JENTADUETO XR ................ 48
JINTELI .................................. 80
JOLIVETTE ........................... 80
JULEBER ............................... 80
JULUCA ................................. 42
JUNEL 1.5/30 ......................... 80
JUNEL 1/20 ............................ 80
110
JUNEL FE 1.5/30 ................... 80
JUNEL FE 1/20 ...................... 80
JUXTAPID ............................. 62
JYNARQUE ........................... 71
K KALETRA ............................. 44
KALLIGA .............................. 80
KALYDECO ........................ 100
KARIVA ................................ 80
kcl in dextrose-nacl ................ 69
kedrab ..................................... 92
KELNOR 1/35........................ 80
KELNOR 1/50........................ 80
ketoconazole ........................... 23
ketorolac tromethamine ...... 2, 97
KEVEYIS ............................... 60
KIMIDESS ............................. 80
KINERET ............................... 89
KINRIX .................................. 92
KIONEX................................. 71
KISQALI (200 MG DOSE) ... 32
KISQALI (400 MG DOSE) ... 32
KISQALI (600 MG DOSE) ... 32
KISQALI FEMARA (400 MG
DOSE) ................................ 32
KISQALI FEMARA (600 MG
DOSE) ................................ 32
KISQALI FEMARA(200 MG
DOSE) ................................ 32
KLOR-CON ........................... 69
KLOR-CON 10 ...................... 69
KLOR-CON M10 ................... 69
KLOR-CON M15 ................... 69
KLOR-CON M20 ................... 69
KLOR-CON SPRINKLE ....... 70
KORLYM............................... 48
KRISTALOSE ....................... 73
K-SOL .................................... 70
KURVELO ............................. 80
KUVAN ................................. 74
L labetalol hcl ............................ 57
lactulose .................................. 73
lamivudine .............................. 41
lamivudine-zidovudine ........... 43
lamotrigine ....................... 16, 46
lamotrigine er ......................... 16
lamotrigine starter kit-blue ..... 46
lamotrigine starter kit-green ... 46
lamotrigine starter kit-orange . 46
lansoprazole ............................ 73
lanthanum carbonate............... 71
LANTUS ................................ 51
LANTUS SOLOSTAR........... 51
LARIN 1.5/30 ......................... 80
LARIN 1/20 ............................ 80
LARIN FE 1.5/30 ................... 80
LARIN FE 1/20 ...................... 80
LARISSIA .............................. 80
latanoprost .............................. 95
LATUDA................................ 38
LAZANDA ............................... 4
LEENA ................................... 80
leflunomide ............................. 91
LENVIMA (10 MG DAILY
DOSE) ................................ 32
LENVIMA (12 MG DAILY
DOSE) ................................ 32
LENVIMA (14 MG DAILY
DOSE) ................................ 32
LENVIMA (18 MG DAILY
DOSE) ................................ 32
LENVIMA (20 MG DAILY
DOSE) ................................ 32
LENVIMA (24 MG DAILY
DOSE) ................................ 32
LENVIMA (4 MG DAILY
DOSE) ................................ 32
LENVIMA (8 MG DAILY
DOSE) ................................ 33
LESSINA................................ 80
letrozole .................................. 30
leucovorin calcium ................. 29
LEUKERAN .......................... 28
LEUKINE ............................... 54
leuprolide acetate .................... 86
LEVA SET/OCCLUSIVE
DRESSING .......................... 4
levalbuterol hcl ....................... 99
LEVEMIR .............................. 51
LEVEMIR FLEXTOUCH ..... 51
levetiracetam .......................... 14
levetiracetam er ...................... 14
levobunolol hcl ....................... 96
levocarnitine ........................... 70
levocarnitine sf ....................... 70
levocetirizine dihydrochloride 98
levofloxacin ............................ 13
levofloxacin in d5w ................ 13
LEVONEST ........................... 80
levonorgest-eth estrad 91-day. 80
levonorgestrel-ethinyl estrad .. 80
LEVORA 0.15/30 (28) ........... 80
LEVO-T .................................. 85
levothyroxine sodium ............. 86
LEVOXYL ............................. 86
LEXIVA ................................. 44
lidocaine ................................... 4
lidocaine hcl.............................. 4
lidocaine hcl urethral/mucosal .. 4
lidocaine viscous hcl................. 4
lidocaine-prilocaine .................. 4
lidopac ...................................... 4
lidopril ...................................... 5
lidopril xr .................................. 5
LIDO-PRILO CAINE PACK ... 5
LILLOW ................................. 80
lindane .................................... 35
linezolid .................................... 8
linezolid in sodium chloride ..... 8
LINZESS ................................ 73
liothyronine sodium ................ 86
LIPROZONEPAK .................... 5
lisinopril .................................. 56
lisinopril-hydrochlorothiazide 60
lithium..................................... 46
lithium carbonate .................... 46
lithium carbonate er ................ 46
LIVIXIL PAK .......................... 5
LOESTRIN 1.5/30 (21) .......... 81
LONSURF .............................. 29
loperamide hcl ........................ 72
lopinavir-ritonavir................... 44
LOPREEZA ............................ 81
lorazepam ............................... 46
LORAZEPAM INTENSOL ... 46
LORBRENA........................... 33
losartan potassium .................. 55
losartan potassium-hctz .......... 60
lovastatin................................. 61
LOW-OGESTREL ................. 81
loxapine succinate .................. 36
LUCEMYRA ............................ 5
LUCENTIS ....................... 95, 96
LUMIGAN ............................. 95
LUPRON DEPOT (1-MONTH)
............................................ 86
LUPRON DEPOT (3-MONTH)
............................................ 86
2020 2 Tier Standard- AmeriHealth Caritas VIP Care
Document: 2020 Member Formulary
Formulary ID: 20543
Last Updated: 06/2020
Effective Date: 07-01-2020
111
LUPRON DEPOT (4-MONTH)
............................................ 86
LUPRON DEPOT (6-MONTH)
............................................ 86
LUPRON DEPOT-PED (1-
MONTH) ............................ 87
LUPRON DEPOT-PED (3-
MONTH) ............................ 87
LUTERA ................................ 81
LYNPARZA........................... 29
LYSODREN........................... 34
LYZA ..................................... 83
M MACUGEN ............................ 96
magnesium sulfate .................. 70
malathion ................................ 35
maprotiline hcl........................ 20
marlissa................................... 81
MARPLAN ............................ 19
MATULANE ......................... 28
MAVYRET ............................ 41
MAYZENT ............................ 66
meclizine hcl .......................... 21
meclofenamate sodium ............. 2
MEDOLOR PAK ..................... 5
medroxyprogesterone acetate 83,
84
mefloquine hcl ........................ 34
megestrol acetate .................... 84
MEKINIST ............................. 33
MEKTOVI ............................. 33
meloxicam ................................ 2
MELOXICAM COMFORT
PAC ...................................... 2
memantine hcl ........................ 18
memantine hcl er .................... 18
MENACTRA ......................... 92
MENEST ................................ 77
MENTAX ............................... 23
MENVEO ............................... 92
meperidine hcl .......................... 4
mercaptopurine ....................... 29
meropenem ............................. 11
meropenem-sodium chloride .. 11
mesalamine ............................. 94
mesalamine-cleanser .............. 94
MESNEX................................ 29
metaproterenol sulfate ............ 99
metaxalone............................ 102
metformin hcl ......................... 48
metformin hcl er ..................... 48
methadone hcl........................... 3
methazolamide........................ 60
methenamine hippurate ............ 8
methimazole ........................... 87
methocarbamol ..................... 102
methotrexate ........................... 89
methotrexate sodium .............. 89
methotrexate sodium (pf) ....... 89
methoxsalen rapid................... 68
methyclothiazide .................... 61
methyldopa ............................. 55
methyldopa-hydrochlorothiazide
............................................ 60
methylphenidate hcl ............... 65
methylphenidate hcl er ..... 64, 65
methylphenidate hcl er (cd) .... 64
methylphenidate hcl er (la) ..... 64
methylprednisolone .......... 26, 94
methylprednisolone acetate .... 76
methyltestosterone .................. 77
metoclopramide hcl ................ 21
metolazone.............................. 61
metoprolol succinate er .......... 57
metoprolol tartrate .................. 57
metoprolol-hydrochlorothiazide
............................................ 57
metronidazole ........................... 8
metronidazole in nacl ............... 8
mexiletine hcl ......................... 56
micafungin sodium ................. 23
MICROGESTIN 1.5/30.......... 81
MICROGESTIN 1/20............. 81
MICROGESTIN FE 1.5/30 .... 81
MICROGESTIN FE 1/20 ....... 81
midodrine hcl .......................... 55
MILI ....................................... 81
MIMVEY ............................... 81
minocycline hcl ...................... 14
minoxidil................................. 62
mirtazapine ............................. 18
misoprostol ............................. 73
M-M-R II ................................ 92
modafinil............................... 103
moexipril hcl ........................... 56
molindone hcl ......................... 36
mometasone furoate.......... 26, 98
MONONESSA ....................... 81
montelukast sodium ................ 99
MORGIDOX .......................... 14
morphine sulfate ....................... 4
morphine sulfate er ................... 3
moxifloxacin hcl ..................... 13
moxifloxacin hcl in nacl ......... 13
MULTAQ ............................... 56
mupirocin .................................. 8
MYCAMINE .......................... 23
mycophenolate mofetil ........... 89
mycophenolate sodium ........... 89
MYORISAN ........................... 68
MYRBETRIQ......................... 75
N nabumetone............................... 2
nadolol .................................... 57
nafcillin sodium ...................... 12
nafcillin sodium in dextrose ... 12
nalbuphine hcl .......................... 4
naloxone hcl.......................... 5, 6
naltrexone hcl ........................... 5
NAMENDA XR TITRATION
PACK ................................. 18
naproxen ................................... 3
NAPROXEN COMFORT PAC
.............................................. 3
naproxen dr ............................... 3
naproxen sodium ...................... 3
NARCAN ................................. 6
NATACYN............................. 96
nateglinide .............................. 48
NATPARA ............................. 95
NAYZILAM ........................... 16
NECON 0.5/35 (28)................ 81
112
NECON 7/7/7 ......................... 81
nefazodone hcl........................ 18
neomycin sulfate ...................... 6
neomycin-bacitracin zn-
polymyx ................................ 8
neomycin-polymyxin-dexameth
.............................................. 8
neomycin-polymyxin-
gramicidin............................. 8
neomycin-polymyxin-hc .... 8, 97
NERLYNX ............................. 33
NEULASTA ........................... 54
NEULASTA ONPRO ............ 54
NEUPOGEN .......................... 54
NEUPRO ................................ 35
nevirapine ............................... 43
nevirapine er ........................... 42
NEXAVAR ............................ 33
NEXLETOL ........................... 62
niacin er (antihyperlipidemic) 62
NICOTROL .............................. 6
NICOTROL NS........................ 6
nifedipine ................................ 58
nifedipine er............................ 58
nifedipine er osmotic release .. 58
nilutamide ............................... 28
nimodipine .............................. 58
NINLARO .............................. 29
nitisinone ................................ 74
NITRO-BID ........................... 63
NITRO-DUR .......................... 63
nitrofurantoin macrocrystal ...... 8
nitrofurantoin monohyd macro. 8
nitroglycerin ........................... 63
NITYR .................................... 74
NIVESTYM ........................... 54
NOCTIVA .............................. 85
NORA-BE .............................. 84
NORDITROPIN FLEXPRO .. 85
norethin ace-eth estrad-fe ....... 81
norethindrone ......................... 84
norethindrone acetate ............. 84
norethindrone acet-ethinyl est 81
norethindrone-eth estradiol .... 81
norgestimate-eth estradiol ...... 81
norgestim-eth estrad triphasic 81
NORLYDA ............................ 81
NORLYROC .......................... 84
NORMOSOL-R ..................... 70
NORMOSOL-R PH 7.4 ......... 70
NORPACE CR ....................... 56
NORTHERA .......................... 55
NORTREL 0.5/35 (28) ........... 82
NORTREL 1/35 (21) .............. 82
NORTREL 1/35 (28) .............. 82
NORTREL 7/7/7 .................... 82
nortriptyline hcl ...................... 21
NORVIR ................................. 44
NOVOLIN 70/30 .................... 52
NOVOLIN 70/30 RELION .... 52
NOVOLIN N .......................... 52
NOVOLIN N RELION .......... 52
NOVOLIN R .......................... 52
NOVOLIN R RELION .......... 52
NOXAFIL .............................. 23
NUBEQA ............................... 28
NUCALA ............................... 91
NUEDEXTA .......................... 65
NULOJIX ............................... 89
NUPLAZID ............................ 38
nutrilipid ................................. 70
NUTROPIN AQ NUSPIN 10. 85
NUTROPIN AQ NUSPIN 20. 85
NUTROPIN AQ NUSPIN 5... 85
NYAMYC .............................. 23
nystatin ................................... 23
nystatin-triamcinolone ............ 68
NYSTOP ................................ 23
O OCALIVA .............................. 72
OCELLA ................................ 82
octreotide acetate .................... 87
ODEFSEY .............................. 43
ODOMZO .............................. 29
OFEV.................................... 101
ofloxacin ........................... 13, 97
olanzapine ............................... 38
olmesartan medoxomil ........... 55
olmesartan medoxomil-hctz ... 60
olmesartan-amlodipine-hctz ... 60
olopatadine hcl ....................... 96
omega-3-acid ethyl esters ....... 62
omeprazole ............................. 73
OMNITROPE ......................... 85
ondansetron ............................ 22
ondansetron hcl....................... 22
ORENCIA .............................. 89
ORENCIA CLICKJECT ........ 89
ORFADIN .............................. 74
ORILISSA .............................. 87
ORKAMBI ........................... 100
orphenadrine citrate er .......... 102
ORSYTHIA ............................ 82
oseltamivir phosphate ............. 45
OTEZLA................................. 91
oxandrolone ............................ 77
OXBRYTA ............................. 54
oxcarbazepine ......................... 17
OXERVATE........................... 96
oxybutynin chloride ................ 75
oxybutynin chloride er ............ 75
oxycodone hcl ........................... 4
oxycodone hcl er....................... 3
oxycodone-acetaminophen ....... 2
oxycodone-aspirin .................... 2
oxycodone-ibuprofen ................ 2
OZEMPIC (0.25 OR 0.5
MG/DOSE) ......................... 48
OZEMPIC (1 MG/DOSE) ...... 48
P paliperidone er .................. 38, 39
PANRETIN ............................ 34
pantoprazole sodium ............... 74
paricalcitol .............................. 71
paromomycin sulfate ................ 6
paroxetine hcl ......................... 20
paroxetine hcl er ..................... 20
PASER .................................... 28
PAXIL .................................... 20
PEDIARIX ............................. 92
PEDVAX HIB ........................ 92
peg 3350/electrolytes .............. 73
peg 3350-kcl-na bicarb-nacl ... 73
peg-3350/electrolytes ............. 73
PEGANONE........................... 17
PEGASYS .............................. 41
PEGASYS PROCLICK.......... 41
penicillamine .......................... 89
penicillin g procaine ............... 12
penicillin g sodium ................. 12
penicillin v potassium ............. 12
PENTACEL ............................ 92
pentamidine isethionate .......... 34
PENTASA .............................. 94
pentazocine-naloxone hcl ......... 2
pentoxifylline er...................... 60
PERFOROMIST..................... 99
PERIOGARD ......................... 66
permethrin............................... 35
perphenazine ........................... 21
2020 2 Tier Standard- AmeriHealth Caritas VIP Care
Document: 2020 Member Formulary
Formulary ID: 20543
Last Updated: 06/2020
Effective Date: 07-01-2020
113
perphenazine-amitriptyline..... 18
PERSERIS .............................. 39
phenelzine sulfate ................... 19
phenobarbital .......................... 16
phenoxybenzamine hcl ........... 55
PHENYTEK ........................... 17
phenytoin ................................ 17
phenytoin sodium extended .... 17
PHOSPHOLINE IODIDE ...... 96
PIFELTRO ............................. 43
pilocarpine hcl .................. 66, 97
pimecrolimus .......................... 68
pimozide ................................. 37
PIMTREA .............................. 82
pindolol................................... 57
pioglitazone hcl ...................... 48
pioglitazone hcl-metformin hcl
............................................ 48
piperacillin sod-tazobactam so12
PIQRAY (200 MG DAILY
DOSE) ................................ 30
PIQRAY (250 MG DAILY
DOSE) ................................ 30
PIQRAY (300 MG DAILY
DOSE) ................................ 30
PIRMELLA 1/35 .................... 82
piroxicam .................................. 3
PLENAMINE ......................... 70
podofilox ................................ 68
polyethylene glycol 3350 ....... 73
polymyxin b sulfate .................. 8
polymyxin b-trimethoprim ....... 8
POMALYST .......................... 28
PORTIA-28 ............................ 82
posaconazole .......................... 23
potassium chloride.................. 70
potassium chloride crys er ...... 70
potassium chloride er ............. 70
potassium citrate er................. 70
PRADAXA............................. 53
PRALUENT ........................... 62
pramipexole dihydrochloride . 35
pramipexole dihydrochloride er
............................................ 35
prasugrel hcl ........................... 55
pravastatin sodium .................. 61
praziquantel ............................ 34
prazosin hcl............................. 55
prednicarbate .......................... 68
prednisolone ........................... 26
prednisolone acetate ............... 97
prednisolone sodium phosphate
...................................... 26, 97
prednisone .............................. 26
PREDNISONE INTENSOL... 76
preferred plus insulin syringe . 50
pregabalin ............................... 15
PREMARIN ........................... 77
PREMPHASE ........................ 82
PREMPRO ............................. 82
prenatal ................................... 71
pretomanid .............................. 28
PREVALITE .......................... 62
PREVIFEM ............................ 82
PREVYMIS ............................ 40
PREZCOBIX .......................... 44
PREZISTA ....................... 44, 45
PRIFTIN ................................. 28
prilolid ...................................... 5
prilovix lite ............................... 5
prilovix lite plus........................ 5
prilovix ultralite ........................ 5
prilovix ultralite plus ................ 5
primaquine phosphate............. 34
primidone................................ 16
PRIVIGEN ............................. 90
probenecid .............................. 24
prochlorperazine ..................... 21
prochlorperazine maleate ....... 21
PROCRIT ............................... 54
procto-med hc ......................... 76
procto-pak ............................... 76
PROCTOSOL HC .................. 76
PROCTOZONE-HC ............... 76
progesterone micronized ........ 84
PROGRAF.............................. 89
PROLASTIN-C ...................... 74
PROLIA.................................. 95
promacta ................................. 54
PROMACTA .......................... 54
promethazine hcl .............. 21, 98
promethazine vc plain........... 102
promethazine-phenylephrine 102
PROMETHEGAN .................. 21
propafenone hcl ...................... 56
proparacaine hcl...................... 96
propranolol hcl........................ 57
propranolol hcl er ................... 57
propranolol-hctz ..................... 60
propylthiouracil ...................... 87
PROQUAD ............................. 92
protriptyline hcl ...................... 21
PULMOZYME ..................... 100
PURIXAN .............................. 29
pyrazinamide .......................... 28
pyridostigmine bromide.......... 27
pyridostigmine bromide er ..... 27
pyrimethamine ........................ 34
Q QUADRACEL ....................... 92
QUASENSE ........................... 82
quetiapine fumarate ................ 39
quetiapine fumarate er ............ 39
quinapril hcl ............................ 56
quinapril-hydrochlorothiazide 60
quinidine gluconate er ............ 56
quinidine sulfate ..................... 56
quinine sulfate ........................ 34
QVAR ..................................... 98
QVAR REDIHALER ............. 98
R ra sterile .................................. 50
RABAVERT........................... 93
raloxifene hcl .......................... 84
ramelteon .............................. 103
ramipril ................................... 56
ranolazine er ........................... 60
rasagiline mesylate ................. 36
RAVICTI ................................ 74
REBIF ..................................... 66
REBIF REBIDOSE ................ 66
114
REBIF REBIDOSE
TITRATION PACK ........... 66
REBIF TITRATION PACK .. 66
RECLIPSEN........................... 82
RECOMBIVAX HB .............. 93
RECTIV ................................. 72
REGRANEX .......................... 68
RELENZA DISKHALER ...... 45
RELI-ON INSULIN SYRINGE
............................................ 50
RELISTOR ............................. 72
REMICADE ........................... 89
repaglinide .............................. 48
REPATHA ............................. 62
REPATHA PUSHTRONEX
SYSTEM ............................ 62
REPATHA SURECLICK ...... 62
RESCRIPTOR ........................ 43
RESTASIS ............................. 96
RESTASIS MULTIDOSE ..... 96
RETACRIT ............................ 54
REVLIMID ............................ 28
REXULTI ............................... 39
REYATAZ ............................. 45
ribavirin .................................. 41
rifabutin .................................. 27
rifampin .................................. 28
RIFATER ............................... 28
riluzole .................................... 65
rimantadine hcl ....................... 45
risedronate sodium ................. 95
RISPERDAL CONSTA ......... 39
risperidone .............................. 39
ritonavir .................................. 45
rivastigmine ............................ 18
rivastigmine tartrate................ 18
rizatriptan benzoate ................ 27
ropinirole hcl .......................... 36
ropinirole hcl er ...................... 35
rosuvastatin calcium ............... 61
ROTARIX .............................. 93
ROTATEQ ............................. 93
ROWEEPRA .......................... 15
ROWEEPRA XR ................... 15
ROZLYTREK ........................ 33
RUBRACA............................. 33
RYBELSUS ........................... 48
RYDAPT ................................ 33
S SAMSCA ............................... 71
SANDIMMUNE .................... 89
SANTYL ................................ 68
SAPHRIS................................ 39
SAVELLA .............................. 65
SAVELLA TITRATION PACK
............................................ 65
scopolamine ............................ 21
secuado ................................... 39
SEGLUROMET ..................... 49
selegiline hcl ........................... 36
selenium sulfide ...................... 68
SELZENTRY ......................... 44
SEREVENT DISKUS .......... 100
SEROSTIM ............................ 72
sertraline hcl ........................... 20
SETLAKIN ............................ 82
sevelamer carbonate ............... 71
SHAROBEL ........................... 84
SHINGRIX ............................. 93
SIGNIFOR.............................. 87
sildenafil citrate .................... 101
silver sulfadiazine ................... 13
SIMBRINZA .......................... 97
SIMLIYA ............................... 82
SIMPONI.......................... 89, 90
simvastatin .............................. 62
sirolimus ................................. 90
SIRTURO ............................... 28
sodium chloride ...................... 70
sodium chloride (pf) ............... 70
sodium fluoride....................... 70
sodium phenylbutyrate ........... 74
sodium polystyrene sulfonate . 71
sofosbuvir-velpatasvir ............ 41
SOLIRIS ................................. 54
SOLTAMOX .......................... 29
SOMATULINE DEPOT ........ 87
SOMAVERT .......................... 87
SORINE.................................. 56
sotalol hcl ............................... 57
sotalol hcl (af) ......................... 56
SPIRIVA HANDIHALER ..... 99
SPIRIVA RESPIMAT ............ 99
spironolactone ........................ 61
spironolactone-hctz ................ 60
SPRAVATO (56 MG DOSE) 19
SPRAVATO (84 MG DOSE) 19
SPRINTEC 28 ........................ 82
SPRITAM ............................... 15
SPRYCEL .............................. 33
SPS ......................................... 71
SRONYX ................................ 82
SSD ......................................... 13
stavudine ................................. 43
STEGLATRO ......................... 49
STEGLUJAN ......................... 49
STELARA .............................. 68
STIOLTO RESPIMAT ......... 102
STIVARGA ............................ 33
streptomycin sulfate.................. 6
STRIBILD .............................. 42
STRIVERDI RESPIMAT .... 100
SUCRAID............................... 74
sucralfate................................. 73
sulfacetamide sodium ............. 14
sulfacetamide sodium (acne) .. 13
sulfacetamide-prednisolone .... 96
sulfadiazine ............................. 14
sulfamethoxazole-trimethoprim
............................................ 14
sulfasalazine ........................... 94
sulindac ..................................... 3
sumatriptan ............................. 27
sumatriptan succinate ............. 27
sumatriptan succinate refill ..... 27
SUTENT ................................. 33
SYLATRON ........................... 29
SYMDEKO .......................... 100
SYMFI .................................... 44
SYMFI LO.............................. 43
SYMLINPEN 120 .................. 49
SYMLINPEN 60 .................... 49
SYMPAZAN .......................... 16
SYMTUZA ............................. 44
SYNAREL .............................. 87
SYNDROS ............................. 22
SYNJARDY ........................... 49
SYNJARDY XR ..................... 49
SYNRIBO............................... 30
SYNTHROID ......................... 86
T TABLOID............................... 29
tacrolimus ......................... 68, 90
TAFINLAR ............................ 33
TAGRISSO............................. 33
TALZENNA ........................... 30
tamoxifen citrate ..................... 29
tamsulosin hcl ......................... 75
TARGRETIN ......................... 34
TARINA FE 1/20 ................... 82
2020 2 Tier Standard- AmeriHealth Caritas VIP Care
Document: 2020 Member Formulary
Formulary ID: 20543
Last Updated: 06/2020
Effective Date: 07-01-2020
115
TARINA FE 1/20 EQ ............. 82
TASIGNA .............................. 33
tazarotene ............................... 68
TAZICEF ............................... 10
TAZORAC ............................. 68
TAZTIA XT ........................... 58
TAZVERIK ............................ 30
TDVAX .................................. 93
TECFIDERA .......................... 66
TEFLARO .............................. 10
TEKTURNA HCT ................. 60
temazepam ............................ 103
TENIVAC .............................. 93
tenofovir disoproxil fumarate . 41
terazosin hcl............................ 55
terbinafine hcl ......................... 23
terbutaline sulfate ................. 100
terconazole ............................. 23
testosterone ............................. 77
testosterone cypionate ............ 77
testosterone enanthate ............ 77
tetrabenazine........................... 65
tetracycline hcl ....................... 14
THALOMID........................... 28
theophylline .......................... 100
theophylline er ...................... 100
THIOLA ................................. 76
THIOLA EC ........................... 76
thioridazine hcl ....................... 37
thiothixene .............................. 37
tiagabine hcl ........................... 16
TIBSOVO............................... 33
TICE BCG .............................. 93
timolol maleate ................. 57, 97
tinidazole .................................. 8
TIVICAY ............................... 42
TIZANIDINE COMFORT PAC
............................................ 40
tizanidine hcl .......................... 40
TOBRADEX ............................ 6
tobramycin ........................ 6, 100
tobramycin sulfate .................... 6
tobramycin-dexamethasone ...... 7
tolcapone ................................ 35
tolterodine tartrate .................. 75
tolterodine tartrate er .............. 75
tolvaptan ................................. 71
topiramate ............................... 17
toremifene citrate .................... 29
torsemide ................................ 60
TOUJEO MAX SOLOSTAR . 52
TOUJEO SOLOSTAR ........... 52
TOVIAZ ................................. 75
TRADJENTA ......................... 49
tramadol hcl .............................. 4
tramadol-acetaminophen .......... 2
trandolapril ............................. 56
tranexamic acid....................... 54
tranylcypromine sulfate .......... 19
travoprost ................................ 95
travoprost (bak free) ............... 95
trazodone hcl .......................... 19
TRECATOR ........................... 28
TRELEGY ELLIPTA........... 102
TRELSTAR MIXJECT .......... 87
TREMFYA ............................. 68
tretinoin ............................ 34, 68
tretinoin (emollient) ................ 68
TREXALL .............................. 90
TRI FEMYNOR ..................... 82
triamcinolone acetonide ... 26, 66
triamterene-hctz ...................... 60
TRIDERM .............................. 26
trientine hcl ............................. 71
TRI-ESTARYLLA ................. 82
trifluoperazine hcl................... 37
trifluridine ............................... 42
trihexyphenidyl hcl ................. 35
TRIKAFTA .......................... 100
triklo ....................................... 62
TRI-LEGEST FE .................... 82
TRILYTE ............................... 73
trimethobenzamide hcl ........... 21
trimethoprim ............................. 9
TRI-MILI................................ 83
trimipramine maleate .............. 21
TRINESSA (28) ..................... 83
TRINTELLIX ......................... 20
TRI-PREVIFEM..................... 83
TRI-SPRINTEC ..................... 83
TRIUMEQ .............................. 42
TRIVORA (28) ....................... 83
TRI-VYLIBRA....................... 83
trospium chloride .................... 75
trospium chloride er ................ 75
TRULICITY ........................... 49
TRUMENBA .......................... 93
TRUVADA............................. 43
TULANA ................................ 84
TURALIO............................... 33
TWINRIX ............................... 93
TYBOST................................. 44
TYKERB ................................ 33
TYMLOS ................................ 95
TYPHIM VI............................ 93
U UNITHROID .......................... 86
ursodiol ................................... 72
V VABOMERE .......................... 11
valacyclovir hcl ...................... 42
VALCHLOR .......................... 28
valganciclovir hcl ................... 40
valproic acid ........................... 16
valsartan .................................. 55
valsartan-hydrochlorothiazide 60
valtoco 10 mg dose ................. 16
valtoco 15 mg dose ................. 16
valtoco 20 mg dose ................. 16
valtoco 5 mg dose ................... 16
valumark pen needles ............. 50
vancomycin hcl ......................... 9
VAQTA .................................. 93
VARIVAX .............................. 93
VARIZIG ................................ 93
VAXCHORA ......................... 93
VELIVET ............................... 83
VELPHORO ........................... 71
VEMLIDY .............................. 41
VENCLEXTA ........................ 30
VENCLEXTA STARTING
PACK ................................. 30
116
venlafaxine hcl ....................... 20
venlafaxine hcl er ................... 20
VENTAVIS .......................... 101
VENTOLIN HFA ................. 100
verapamil hcl .......................... 58
verapamil hcl er ...................... 58
VERSACLOZ ........................ 40
VERZENIO ............................ 33
VICTOZA .............................. 49
VIDEX ................................... 44
VIDEX EC ............................. 43
VIENVA................................. 83
vigabatrin ................................ 16
VIGADRONE ........................ 16
VIIBRYD ............................... 20
VIIBRYD STARTER PACK . 20
VIMPAT................................. 17
VIRACEPT ............................ 45
VIREAD ................................. 41
VITRAKVI............................. 33
VIZIMPRO............................. 30
voriconazole ........................... 23
VOSEVI ................................. 41
VOTRIENT ............................ 33
VRAYLAR............................. 39
VYFEMLA............................. 83
VYLIBRA .............................. 83
W warfarin sodium...................... 53
WIXELA INHUB ................ 102
X XALKORI .............................. 33
XARELTO ............................. 53
XARELTO STARTER PACK
............................................ 53
XATMEP................................ 90
XCOPRI ................................. 16
XCOPRI (250 MG DAILY
DOSE) ................................ 16
XCOPRI (350 MG DAILY
DOSE) ................................ 16
XELJANZ .............................. 91
XELJANZ XR ........................ 91
XERMELO ............................. 72
XGEVA .................................. 95
XIFAXAN .............................. 73
XIIDRA .................................. 96
XOLAIR ................................. 91
XOSPATA.............................. 33
XPOVIO (100 MG ONCE
WEEKLY) .......................... 30
XPOVIO (60 MG ONCE
WEEKLY) .......................... 30
XPOVIO (80 MG ONCE
WEEKLY) .......................... 30
XPOVIO (80 MG TWICE
WEEKLY) .......................... 30
XTANDI ................................. 28
XULANE................................ 83
XURIDEN .............................. 74
XYREM.................................. 99
Y YF-VAX ................................. 93
YONSA .................................. 28
YUVAFEM ............................ 77
Z zafirlukast ............................... 99
zaleplon................................. 103
ZARAH .................................. 83
ZARXIO ................................. 54
ZEJULA ................................. 33
ZELBORAF ........................... 33
ZEMAIRA .............................. 75
ZENATANE ........................... 68
ZENPEP ................................. 75
ZERIT ..................................... 44
zidovudine .............................. 44
ZIEXTENZO .......................... 54
ziprasidone hcl ........................ 39
ziprasidone mesylate .............. 39
ZIRGAN ................................. 40
ZOLINZA ............................... 30
zolpidem tartrate ................... 103
zolpidem tartrate er ............... 103
zonisamide .............................. 15
ZORTRESS ............................ 90
ZOSTAVAX........................... 93
ZOVIA 1/35E (28) ................. 83
ZTLIDO .................................... 5
ZYDELIG ............................... 30
ZYKADIA .............................. 34
ZYPREXA RELPREVV ........ 40
ZYTIGA ................................. 28
ix
This formulary was updated on 07/01/2020. For more recent information or other questions, please contact AmeriHealth Caritas VIP Care at 1-866-533-5490 or, for TTY users, 711, seven days a week, 8 a.m. to 8 p.m., or visit www.amerihealthcaritasvipcare.com.