Mercy Care Advantage (HMO SNP) 2020 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Formulary ID 00020345, Version 13 This formulary was updated on 08/01/2020. For more recent informaton or other questons, please contact Mercy Care Advantage (HMO SNP) Member Services at 602‑586‑1730 or 1‑877‑436‑5288 or, for TTY users, 711, 8:00 a.m. – 8:00 p.m., 7 days a week, or visit www.MercyCareAZ.org. Mercy Care Advantage (HMO SNP) Formulario para 2020 (Lista de Medicamentos Cubiertos) POR FAVOR LEA: ESTE DOCUMENTO CONTIENE INFORMACIÓN SOBRE LOS MEDICAMENTOS QUE CUBRIMOS BAJO ESTE PLAN Identfcación del Formulario 00020345, Versión 13 Este formulario fue actualizado en 08/01/2020. Para la información más reciente o para otras preguntas, por favor llame a Servicios al Miembro de Mercy Care Advantage (HMO SNP) al 602‑586‑1730 ó al 1‑877‑436‑5288, ó para los usuarios de TTY al 711, de 8:00 a.m. – 8:00 p.m., 7 días de la semana, ó visite www.MercyCareAZ.org. Visit/Viste www.MercyCareAZ.org AZ-19-06-01
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Mercy Care Advantage (HMO SNP) 2020 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN
Formulary ID 00020345, Version 13
This formulary was updated on 08/01/2020. For more recent information or other questions, please contact Mercy Care Advantage (HMO SNP) Member Services at 602‑586‑1730 or 1‑877‑436‑5288 or, for TTY users, 711, 8:00 a.m. – 8:00 p.m., 7 days a week, or visit www.MercyCareAZ.org.
Mercy Care Advantage (HMO SNP) Formulario para 2020 (Lista de Medicamentos Cubiertos) POR FAVOR LEA: ESTE DOCUMENTO CONTIENE INFORMACIÓN SOBRE LOS MEDICAMENTOS QUE CUBRIMOS BAJO ESTE PLAN
Identificación del Formulario 00020345, Versión 13
Este formulario fue actualizado en 08/01/2020. Para la información más reciente o para otras preguntas, por favor llame a Servicios al Miembro de Mercy Care Advantage (HMO SNP) al 602‑586‑1730 ó al 1‑877‑436‑5288, ó para los usuarios de TTY al 711, de 8:00 a.m. – 8:00 p.m., 7 días de la semana, ó visite www.MercyCareAZ.org.
Mercy Care Advantage (HMO SNP) 2020 Formulary (List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Formulary ID 00020345, Version 13
This formulary was updated on 08/01/2020. For more recent information or other questions, please contact Mercy Care Advantage (HMO SNP) Member Services at 602-586-1730 or 1-877-436-5288 or, for TTY users, 711, 8:00 a.m. – 8:00 p.m., 7 days a week, or visit www.MercyCareAZ.org.
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 Mercy Care. When it refers to “plan” or “our plan,” it means Mercy Care Advantage.
This document includes a list of the drugs (formulary) for our plan which is current as of 08/01/2020. 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, 2021, and from time to time during the year.
The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.
What is the Mercy Care Advantage (HMO SNP) Formulary? A formulary is a list of covered drugs selected by Mercy Care 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. Mercy Care Advantage will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Mercy Care 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? Most changes in drug coverage happen on January 1, but Mercy Care Advantage 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. o 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 Mercy Care Advantage (HMO SNP)’s 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.
• 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 name 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 31-day supply of the drug. o 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 Mercy Care Advantage (HMO SNP)’s Formulary?”
Changes that will not affect you if you are currently taking the drug. Generally, if you are taking a drug on our 2020 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.
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The enclosed formulary is current as of 08/01/2020. To get updated information about the drugs covered by Mercy Care Advantage, please contact us. Our contact information appears on the front and back cover pages. If we update the formulary during 2020 due to a non-maintenance formulary change, an updated version of the formulary and the notice issued to affected members will be posted on our website at www.MercyCareAZ.org. Printed formularies will be updated with the changes using an errata notice.
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 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.
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 52. 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? Mercy Care 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: Mercy Care Advantage requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Mercy Care Advantage before you fill your prescriptions. If you don’t get approval, Mercy Care Advantage may not cover the drug.
• Quantity Limits: For certain drugs, Mercy Care Advantage limits the amount of the drug that Mercy Care Advantage will cover. For example, Mercy Care Advantage provides 30 EA per 30 days per prescription for simvastatin. This may be in addition to a standard one-month or three-month supply.
• Step Therapy: In some cases, Mercy Care 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, Mercy Care Advantage may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Mercy Care Advantage 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 website. 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, appears on the front and back cover pages.
You can ask Mercy Care 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 Mercy Care Advantage’s formulary?” on page IV 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 Mercy Care 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 Mercy Care 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 Mercy Care Advantage.
• You can ask Mercy Care 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 Mercy Care Advantage (HMO SNP) Formulary? You can ask Mercy Care 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.
• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Mercy Care 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, Mercy Care 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.
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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 31-day supply. If your prescription is written for fewer days, we’ll allow refills to provide up to a maximum 31-day supply of medication. After your first 31-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.
If you are admitted to or discharged from a long-term care facility, you will be allowed to refill a prescription upon admission or discharge.
For more information For more detailed information about your Mercy Care Advantage prescription drug coverage, please review your Evidence of Coverage and other plan materials.
If you have questions about Mercy Care 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.
Mercy Care Advantage’s Formulary The formulary that begins on page 1 provides coverage information about the drugs covered by Mercy Care Advantage. If you have trouble finding your drug in the list, turn to the Index that begins on page 52.
The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., SYNTHROID) and generic drugs are listed in lower-case italics (e.g., levothyroxine).
The “Drug Tier” column of the chart lists the category of each drug. Your cost sharing amounts depend on which category the drug is in:
Category Cost-sharing amount
Generic drugs (including brand drugs treated as generic) $0/$1.30/$3.60 copay
All other drugs $0/$3.90/$8.95 copay
Your copays may be less, depending on the level of “Extra Help” you are receiving. The Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs (LIS Rider) lists the amount you will pay for your prescription drugs. You can also call Member Services to find out your cost sharing amount. Phone numbers for Member Services are on the front and back cover pages.
The information in the Requirements/Limits column tells you if Mercy Care Advantage has any special requirements for coverage of your drug.
Abbreviation Requirements/Limits
B/D Covered under Medicare Part B or Part D. Most drugs are covered under Part D, but there are some drugs that can be covered under both Part B or Part D depending on what the drug is used for and how it is administered.
EA Each. Medications listed with EA indicates number of pills dispensed.
LA Limited access. This prescription may be available only at certain pharmacies. For more information consult the Pharmacy Directory.
NM Not available at mail-order.
PA Prior authorization. You or your provider need to get approval from our plan before we will agree to cover the drug.
QL Quantity limits. The amount per fill or refill is shown.
ST Step therapy. This prescription drug requires that you’ve tried another drug first, which did not work for you.
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Mercy Care Advantage (HMO SNP) Formulario para 2020 (Lista de Medicamentos Cubiertos)
POR FAVOR LEA: ESTE DOCUMENTO CONTIENE INFORMACIÓN SOBRE LOS MEDICAMENTOS QUE CUBRIMOS BAJO ESTE PLAN Identificación del Formulario 00020345, Versión 13
Este formulario fue actualizado en el 1 de agosto de 2020. Para la información más reciente o para otras preguntas, por favor llame a Servicios al Miembro de Mercy Care Advantage (HMO SNP) al 602-586-1730 ó al 1-877-436-5288, ó para los usuarios de TTY al 711, de 8:00 a.m. – 8:00 p.m., 7 días de la semana, ó visite www.MercyCareAZ.org.
Nota para los miembros actuales: Este formulario cambió desde el año pasado. Por favor revisen este documento para asegurarse de que todavía contenga los medicamentos que usted toma.
Cuando esta lista de medicamentos (formulario) se refiere a “nosotros” o a “nuestros”, esto significa Mercy Care. Cuando se refiere al “plan” o a “nuestro plan”, esto significa Mercy Care Advantage.
Este documento incluye una lista de los medicamentos (formulario) de nuestro plan, la cual está actualizada a la fecha de el 1 de agosto de 2020. Para un formulario actualizado, por favor contáctenos. Nuestra información de contacto, junto con la fecha en la que actualizamos por último el formulario, aparece en la portada y la contraportada.
Generalmente usted debe usar farmacias de la red para usar su beneficio de medicamentos de prescripción. Los beneficios, el formulario, la red de farmacias, y/o los copagos/el coseguro pueden cambiar el 1º de enero de 2021, y de tiempo en tiempo durante el año.
El formulario, la red de farmacias, y/o la red de proveedores pueden cambiar en cualquier momento. Usted recibirá aviso cuando sea necesario.
¿Qué es el Formulario de Mercy Care Advantage (HMO SNP)? Un formulario es una lista de medicamentos cubiertos seleccionados por Mercy Care Advantage en consulta con un equipo de proveedores del cuidado de la salud, el cual representa las terapias de prescripción/receta que se considera son una parte necesaria de un programa de tratamiento de calidad. Generalmente, Mercy Care Advantage cubrirá los medicamentos listados en nuestro formulario, siempre y cuando el medicamento sea médicamente necesario, la prescripción/receta sea surtida en una farmacia de la red de Mercy Care Advantage, y se sigan otras reglas del plan. Para más información sobre cómo surtir sus prescripciones/recetas, por favor revise su Evidencia de Cobertura.
¿El Formulario (lista de medicamentos) puede cambiar? La mayoría de los cambios en la cobertura de medicamentos ocurren el 1º de enero, pero Mercy Care Advantage puede agregar o eliminar medicamentos en la Lista de Medicamentos durante el año, cambiarlos a niveles de costo compartido distintos o agregar nuevas restricciones. Nosotros debemos seguir las reglas de Medicare para hacer estos cambios.
Cambios que pueden afectarle este año: En los casos a continuación, usted se verá afectado/a por los cambios a la cobertura durante el año:
• Nuevos medicamentos genéricos. Nosotros podemos eliminar inmediatamente un medicamento de marca de nuestra Lista de Medicamentos si lo estamos reemplazando con un medicamento genérico nuevo que aparecerá en el mismo nivel o en un nivel más bajo de costo compartido y con las mismas o menos restricciones. Además, al agregar el nuevo medicamento genérico, nosotros podemos decidir retener el medicamento de marca en nuestra Lista de Medicamentos, pero cambiarlo inmediatamente a un nivel de costo compartido distinto o agregar nuevas restricciones. Si actualmente usted está tomando dicho medicamento de marca, es posible que nosotros no le informemos por adelantado que haremos dicho cambio, pero más tarde le proveeremos información sobre el/los cambio/s específico/s que hayamos hecho. o Si nosotros hacemos dicho cambio, usted o la persona prescribiéndole pueden pedirnos que hagamos una excepción y que continuemos cubriendo el medicamento de marca para usted. El aviso que nosotros le proveeremos también incluirá información sobre cómo solicitar una excepción, y usted también puede encontrar información en la sección a continuación titulada “¿Cómo solicito una excepción al Formulario de Mercy Care Advantage (HMO SNP)?”
• Medicamentos retirados del mercado. Si la Administración de Alimentos y Medicamentos considera que un medicamento en nuestro formulario no es seguro, o si el fabricante del medicamento retira el medicamento del mercado, nosotros inmediatamente retiraremos el medicamento de nuestro formulario y les proveeremos un aviso a los miembros que estén tomando dicho medicamento.
• Otros cambios. Nosotros podemos hacer otros cambios que afecten a los miembros que actualmente toman un medicamento. Por ejemplo, nosotros podemos agregar un medicamento genérico que no sea nuevo en el mercado para reemplazar un medicamento de marca actualmente en el formulario o agregar nuevas restricciones al medicamento de marca o cambiarlo a un nivel de costo compartido distinto. O podemos hacer cambios basados en nuevas directrices clínicas. Si retiramos medicamentos de nuestro formulario, o agregamos autorización previa, límites de cantidad y/o restricciones de terapia a pasos en un medicamento, nosotros debemos notificárselo a los miembros afectados por el cambio por lo menos 360 días antes de que el cambio entre en vigor, ó cuando el miembro pida que se le vuelva a surtir el medicamento, en cuyo momento, el miembro recibirá un suministro para 31 días del medicamento.
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o Si nosotros hacemos estos otros cambios, usted o la persona prescribiéndole pueden pedirnos que hagamos una excepción y que continuemos cubriendo el medicamento de marca para usted. El aviso que le proveeremos también incluirá información sobre cómo solicitar una excepción, y usted también puede encontrar información en la sección a continuación titulada “¿Cómo solicito una excepción al Formulario de Mercy Care Advantage (HMO SNP)?”
Cambios que no le afectarán si usted está tomando actualmente el medicamento. Generalmente, si usted está tomando un medicamento listado en nuestro Formulario de 2020 que fue cubierto a principios de año, nosotros no interrumpiremos ni reduciremos la cobertura del medicamento durante el año de cobertura 2020 excepto como se describió anteriormente. Esto significa que estos medicamentos permanecerán disponibles al mismo costo compartido y sin nuevas restricciones para aquellos miembros que los tomen durante el resto del año de la cobertura.
El formulario adjunto está vigente a partir de el 1 de agosto de 2020. Para obtener información actualizada sobre los medicamentos cubiertos por Mercy Care Advantage, por favor póngase en contacto con nosotros. Nuestra información de contacto aparece en la portada y la contraportada. Si nosotros actualizamos el formulario durante 2020 debido a un cambio al formulario que no sea de mantenimiento, se publicará una versión actualizada del formulario y se emitirá un aviso a los miembros afectados en nuestro sitio web www.MercyCareAZ.org. Los cambios a los formularios impresos se actualizarán por medio de un aviso de erratas.
¿Cómo uso el Formulario? Hay dos formas de encontrar su medicamento dentro del formulario:
Condición Médica El formulario empieza en la página 1. Los medicamentos en este formulario están agrupados en categorías, dependiendo del tipo de condiciones médicas para cuyo tratamiento de usan. Por ejemplo, los medicamentos usados para tratar una condición cardíaca están listados bajo la categoría de “Agentes Cardiovasculares”. Si usted sabe para qué se usa su medicamento, busque el nombre de la categoría en la lista que empieza en la página 1. Después busque en esa categoría el nombre de su medicamento.
Listado Alfabético Si usted no está seguro/a bajo qué categoría buscar, debería buscar su medicamento en el Índice que empieza en la página 52. El Índice provee una lista en orden alfabético de todos los medicamentos incluidos en este documento. Tanto los medicamentos de marca como los medicamentos genéricos están listados en el Índice. Busque en el Índice y encuentre su medicamento. Junto a su medicamento, usted encontrará el número de la página en la que podrá encontrar información sobre la cobertura. Pase a la página listada en el Índice y encuentre el nombre de su medicamento en la primera columna de la lista.
¿Qué son los medicamentos genéricos? Mercy Care Advantage cubre tanto a los medicamentos de marca como a los medicamentos genéricos. Un medicamento genérico es aprobado por la Administración de Alimentos y Medicamentos (FDA por sus siglas en inglés) por contar con el mismo ingrediente activo que el medicamento de marca. En general, los medicamentos genéricos cuestan menos que los medicamentos de marca.
¿Hay alguna restricción en mi cobertura? Algunos medicamentos cubiertos pueden contar con requerimientos adicionales o límites en la cobertura. Dichos requerimientos y límites pueden incluir:
• Autorización Previa: Mercy Care Advantage requiere que usted o su médico obtengan autorización previa para ciertos medicamentos. Esto significa que usted necesitará obtener la aprobación de Mercy Care Advantage antes de surtir sus prescripciones/recetas. Si usted no obtiene la aprobación, Mercy Care Advantage puede no cubrir el costo del medicamento.
• Límites de Cantidades: Para ciertos medicamentos, Mercy Care Advantage limita la cantidad del medicamento que Mercy Care Advantage cubrirá. Por ejemplo, Mercy Care Advantage provee 30 píldoras cada una para 30 días por cada prescripción de Simvastatin. Esto puede ser en adición al suministro estándar para un mes o tres meses.
• Terapia a Pasos: En algunos casos, Mercy Care Advantage requiere que usted pruebe primero ciertos medicamentos para tratar su condición médica antes de cubrir otro medicamento para dicha condición. Por ejemplo, si el Medicamento A y el Medicamento B tratan ambos su condición médica, Mercy Care Advantage puede no cubrir el Medicamento B a menos que usted pruebe primero el Medicamento A. Si el Medicamento A no le funciona, entonces Mercy Care Advantage cubrirá el Medicamento B.
Usted puede informarse si hay cualquier requerimiento o límite adicional para sus medicamentos consultando el formulario que empieza en la página 1. También puede obtener más información sobre las restricciones aplicadas a medicamentos cubiertos específicos visitando nuestro sitio web. Nosotros hemos publicado un documento en línea que explica nuestras restricciones sobre la autorización previa y la terapia a pasos. Usted también puede pedirnos que le enviemos a usted una copia. Nuestra información de contacto, junto con la fecha de la última vez que actualizamos el formulario, aparece en la portada y la contraportada.
Usted puede pedirle a Mercy Care Advantage que haga una excepción a estas restricciones o límites, o para una lista de otros medicamentos similares que puedan tratar su condición de salud. Vea la sección “¿Cómo solicito una excepción al formulario de Mercy Care Advantage?” en la página X para información sobre cómo solicitar una excepción.
¿Qué pasa si mi medicamento no está en el Formulario? Si su medicamento no está incluido en este formulario (lista de medicamentos cubiertos), primero usted debería comunicarse con Servicios al Miembro y preguntar si su medicamento está cubierto. Si usted descubre que Mercy Care Advantage no cubre su medicamento, tiene dos opciones:
• Usted puede pedirle a Servicios al Miembro una lista de medicamentos similares que estén cubiertos por Mercy Care Advantage. Cuando usted reciba la lista, muéstresela a su doctor y pídale que le prescriba un medicamento similar que esté cubierto por Mercy Care Advantage.
• Usted puede solicitar que Mercy Care Advantage haga una excepción y cubra su medicamento. Vea abajo cómo solicitar una excepción.
¿Cómo solicito una excepción al Formulario de Mercy Care Advantage (HMO SNP)? Usted puede pedirle a Mercy Care Advantage que haga una excepción a nuestras normas de cobertura. Hay varios tipos de excepciones que usted puede pedir que hagamos.
• Usted nos puede pedir que cubramos un medicamento, aún si no está en nuestro formulario. Si es aprobado, dicho medicamento será cubierto a un nivel de costo compartido predeterminado, y usted no podrá pedirnos que le proveamos dicho medicamento a un nivel de costo compartido más bajo.
• Usted puede pedir que no apliquemos las restricciones o los límites a la cobertura en su medicamento. Por ejemplo, para ciertos medicamentos, Mercy Care Advantage limita la cantidad del medicamento que nosotros cubriremos. Si su medicamento tiene un límite de cantidad, usted puede pedirnos que no apliquemos el límite y que cubramos una cantidad más grande.
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Generalmente, Mercy Care Advantage sólo aprobará su solicitud de excepción si los medicamentos alternos incluidos en el formulario del plan o las restricciones adicionales para su uso no serían tan efectivos tratando su condición y/o podrían ocasionarle efectos médicos adversos.
Usted se debería comunicar con nosotros para pedirnos una decisión inicial de cobertura para una excepción al formulario, o a la restricción de uso. Cuando usted solicite una excepción al formulario o a la restricción de uso, debería presentar una declaración de su médico o de la persona emitiendo la prescripción respaldando su solicitud. Generalmente, nosotros debemos tomar nuestra decisión dentro de 72 horas después de recibir la declaración de respaldo de la persona emitiendo la prescripción. Usted puede solicitar una excepción expedita (rápida) si usted o su doctor creen que su salud podría verse seriamente dañada por esperar 72 horas para una decisión. Si se le concede su solicitud de excepción expedita, nosotros debemos darle una decisión no más tarde de 24 horas después de recibir la declaración de respaldo de su doctor o de la otra persona emitiendo la prescripción.
¿Qué hago antes de que pueda hablar con mi doctor sobre cambiar mis medicamentos o solicitar una excepción? Como miembro nuevo o continuando de nuestro plan, usted puede estar tomando medicamentos que no estén en nuestro formulario. O usted puede estar tomando un medicamento que esté en nuestro formulario pero su capacidad para obtenerlo puede ser limitada. Por ejemplo, usted puede necesitar nuestra autorización previa antes de poder surtir su prescripción/receta. Usted debería hablar con su doctor para decidir si debería cambiar a un medicamento apropiado que nosotros cubramos, o solicitar una excepción al formulario para que nosotros cubramos el medicamento que usted toma. Mientras habla con su doctor para determinar el curso de acción apropiado para usted, en ciertos casos, nosotros podemos cubrir su medicamento durante los primeros 90 días en los que usted sea miembro de nuestro plan.
Para cada medicamento que no esté en nuestro formulario, o si su capacidad para obtener dicho medicamento es limitada, nosotros cubriremos un suministro temporal para 31 días. Si su prescripción ha sido emitida para menos días, nosotros permitiremos que la vuelva a surtir hasta que se le provea medicamento con un suministro máximo de 31 días. Después de su primer suministro para 31 días, nosotros ya no pagaremos por dichos medicamentos, aún si usted ha sido miembro del plan durante menos de 90 días.
Si usted es residente de una instalación de cuidado a largo plazo y necesita un medicamento que no esté en nuestro formulario o si su capacidad para obtener sus medicamentos es limitada, pero ya pasaron los primeros 90 días como miembro de nuestro plan, nosotros cubriremos un suministro de emergencia de dicho medicamento para 31 días, mientras usted trata de obtener una excepción al formulario.
Si a usted se le admite o se le da de alta de una instalación de cuidado a largo plazo, se le permitirá que se le surta una prescripción ante su admisión o dada de alta.
Para más información Para información más detallada sobre su cobertura de medicamentos de prescripción/receta de Mercy Care Advantage, por favor lea su Evidencia de Cobertura y otros materiales del plan.
Si tiene usted preguntas sobre Mercy Care Advantage, por favor contáctenos. Nuestra información de contacto, junto con la fecha en la que actualizamos por último el formulario, aparece en la portada y la contraportada.
Si tiene usted preguntas generales sobre la cobertura de medicamentos de prescripción/receta de Medicare, por favor llame a Medicare al 1-800-MEDICARE (1-800-633-4227) 24 horas al día, siete días de la semana. Los usuarios de TTY deberían llamar al 1-877-486-2048. Ó visite http://www.medicare.gov.
Formulario de Mercy Care Advantage El formulario que empieza en la página 1 provee información de cobertura sobre algunos de los medicamentos cubiertos por Mercy Care Advantage. Si usted tiene problemas para encontrar su medicamento en la lista, regrese al Índice que empieza en la página 52.
En la primera columna de la tabla aparece el nombre del medicamento. Los medicamentos de marca están escritos en mayúsculas (ejem.: SYNTHROID) y los medicamentos genéricos están escritos en cursivas minúsculas (ejem.: levothyroxine).
La columna del “Nivel del Medicamento” de la tabla lista la categoría de cada medicamento. Sus cantidades de costo compartido dependen de la categoría en la que se encuentre el medicamento:
Categoría Cantidad del costo compartido
Medicamentos genéricos (incluyendo medicamentos de marca tratados
como genéricos) Copago de $0/$1.30/$3.60
El resto de los otros medicamentos Copago de $0/$3.90/$8.95
Sus copagos pueden ser más bajos, dependiendo del nivel de “Ayuda Extra” que usted esté recibiendo. La Evidencia de Cobertura para Personas que Reciben Ayuda Extra para el Pago de Sus Medicamentos de Prescripción (Cláusula LIS) lista la cantidad que usted pagará por sus medicamentos de prescripción. Usted también puede llamar a Servicios al Miembro para informarse sobre la cantidad de su costo compartido. Los números telefónicos de Servicios al Miembro están en la portada y la contraportada de este folleto.
La información en la columna de Requerimientos/Límites le indica si Mercy Care Advantage tiene cualquier requerimiento especial para la cobertura de su medicamento.
Abreviación en Inglés Requerimientos/Límites
B/D Cubierto/a bajo la Parte B o la Parte D de Medicare. La mayoría de los medicamentos están cubiertos bajo la Parte D, pero hay algunos medicamentos que pueden estar cubiertos tanto bajo la Parte B como la Parte D dependiendo del motivo por el que se esté usando el medicamento y cómo es administrado.
EA Each / cada uno/a. Los medicamentos listados con EA indican el número de píldoras despachadas.
LA Limited access / acceso limitado. Esta prescripción puede estar disponible sólo en ciertas farmacias. Para más información consulte el Directorio de Farmacias.
NM No está disponible en pedidos por correo.
PA Prior authorization / autorización previa. Usted o su proveedor necesitan obtener la aprobación de nuestro plan antes de que nosotros accedamos a cubrir el medicamento.
QL Quantity limits / límites de cantidad. Se muestra la cantidad por suministro o cada vez que se surta el medicamento.
ST Step therapy / terapia a pasos. Este medicamento de prescripción requiere que usted haya probado otro medicamento antes, el cual no le haya funcionado.
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86.03.334.1-AZ
Nondiscrimination Notice
Mercy Care d/b/a Mercy Care 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. Mercy Care d/b/a Mercy Care Advantage (HMO SNP) does not exclude people or treat them differently because of race, color, national origin, age, disability or sex.
Mercy Care d/b/a Mercy Care 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 need a qualified interpreter, written information in other formats, translation or other services, call the number on your ID card.
If you believe that Mercy Care d/b/a Mercy Care 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 with our Civil Rights Coordinator at:
Address: Attn: Civil Rights Coordinator4500 East Cotton Center BoulevardPhoenix, AZ 85040
You can file a grievance in person or by mail or email. If you need help filing a grievance, our Civil Rights Coordinator is available to help you.
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, D.C. 20201, 1-800-368-1019, 1-800-537-7697 (TDD).
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Mercy Care, que realiza operaciones comerciales como Mercy Care Advantage (HMO SNP), cumple con las leyes federales de derechos civiles vigentes y no discrimina por cuestiones de raza, color, nacionalidad, edad, discapacidad o sexo. Mercy Care, que realiza operaciones comerciales como Mercy Care Advantage (HMO SNP), no excluye a las personas ni las trata de manera diferente debido a cuestiones de raza, color, nacionalidad, edad, discapacidad o sexo.
Mercy Care, que realiza operaciones comerciales como Mercy Care Advantage (HMO SNP):
• Brinda ayuda y servicios gratuitos a personas con discapacidades para que se comuniquen de manera eficaz con nosotros, como los siguientes: o Intérpretes de lenguaje de señas calificados o Información escrita en otros formatos (letra grande, audio, formatos electrónicos accesibles,
otros formatos) • Brinda servicios de idiomas gratuitos a las personas cuya lengua materna no sea inglés, como
los siguientes: o Intérpretes calificados o Información escrita en otros idiomas
Si necesita un intérprete calificado, información escrita en otros formatos, servicios de traducción u otros servicios, comuníquese con el número que aparece en su tarjeta de identificación.
Si considera que Mercy Care, que realiza operaciones comerciales como Mercy Care Advantage (HMO SNP), no le proporcionó estos servicios o lo discriminó de alguna otra manera por cuestiones de raza, color, nacionalidad, edad, discapacidad o sexo, puede presentar una queja ante nuestro Coordinador de Derechos Civiles:
Dirección: Attn: Civil Rights Coordinator4500 East Cotton Center BoulevardPhoenix, AZ 85040
Puede presentar una queja en persona o por correo, fax o correo electrónico. Si necesita ayuda para presentar una queja, nuestro Coordinador de Derechos Civiles está disponible para ayudarle.
También puede presentar un reclamo de derechos civiles ante el Departamento de Salud y Servicios Sociales de EE. UU., Oficina de Derechos Civiles, de manera electrónica a través del portal de reclamos de la Oficina de Derechos Civiles, disponible en https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, o por correo o teléfono a: U.S. Department of Health and Human Services, 200 Independence Avenue, SW Room 509F, HHH Building, Washington, D.C. 20201, 1-800-368-1019, 1-800-537-7697 (TDD).
Los formularios de reclamo están disponibles en http://www.hhs.gov/ocr/office/file/index.html.
Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-877-436-5288 (TTY: 711).
Arabic:
Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-877-436-5288 (TTY: 711).
Korean: 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-877-436-5288 (TTY: 711) 번으로 전화해 주십시오.
French: ATTENTION: Si vous parlez français, des services d’aide linguistique vous sont proposés gratuitement. Appelez le 1-877-436-5288 (ATS: 711).
German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-877-436-5288 (TTY: 711).
Russian: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. ЗвонитЗвоните 1-877-436-5288 (телетайп: 711).
Serbo-Croatian (Serbian): OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite 1-877-436-5288 (TTY- Telefon za osobe sa oštećenim govorom ili sluhom: 711).
Thai:
PA – Prior Authorization QL – Quantity Limits ST – Step Therapy NM – Not available at mail-order B/D – Covered under Medicare B or D LA – Limited Access Formulary ID 00020345 v13 08/01/2020
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2020 Formulary (List of Covered Drugs)
Drug Name Drug Tier Requirements/Limits ANALGESICS – DRUGS TO TREAT PAIN AND INFLAMMATION
PA – Prior Authorization QL – Quantity Limits ST – Step Therapy NM – Not available at mail-order B/D – Covered under Medicare B or D LA – Limited Access Formulary ID 00020345 v13 08/01/2020
PA – Prior Authorization QL – Quantity Limits ST – Step Therapy NM – Not available at mail-order B/D – Covered under Medicare B or D LA – Limited Access Formulary ID 00020345 v13 08/01/2020
PA – Prior Authorization QL – Quantity Limits ST – Step Therapy NM – Not available at mail-order B/D – Covered under Medicare B or D LA – Limited Access Formulary ID 00020345 v13 08/01/2020
PA – Prior Authorization QL – Quantity Limits ST – Step Therapy NM – Not available at mail-order B/D – Covered under Medicare B or D LA – Limited Access Formulary ID 00020345 v13 08/01/2020
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Drug Name Drug Tier Requirements/Limits COARTEM OTHER NMmefloquine hcl GENERIC primaquine phosphate 26.3mg GENERIC NMPRIMAQUINE PHOSPHATE 26.3mg OTHER NMquinine sulfate CAPS GENERIC NM, PA ANTIRETROVIRAL AGENTS – DRUGS TO SUPPRESS HIV/AIDS INFECTION abacavir sulfate GENERIC NMAPTIVUS OTHER NMatazanavir sulfate GENERIC NMCRIXIVAN OTHER NMdidanosine GENERIC NMEDURANT OTHER NMefavirenz GENERIC NMEMTRIVA OTHER NMfosamprenavir tab 700 mg GENERIC NMFUZEON OTHER NMINTELENCE OTHER NMINVIRASE OTHER NMISENTRESS OTHER NMISENTRESS HD OTHER NMlamivudine GENERIC NMLEXIVA SUSP OTHER NMnevirapine susp 50 mg/5ml GENERIC NMnevirapine tab 100mg er GENERIC NMnevirapine tab 200mg GENERIC NMnevirapine tab 400mg er GENERIC NMNORVIR PACK OTHER NMNORVIR SOLN OTHER NMPIFELTRO OTHER NMPREZISTA SUSP OTHER QL (400 mL / 30 days), NM PREZISTA TABS 75mg OTHER QL (480 tabs / 30 days), NM PREZISTA TABS 150mg OTHER QL (240 tabs / 30 days), NM PREZISTA TABS 600mg OTHER QL (60 tabs / 30 days), NM PREZISTA TABS 800mg OTHER QL (30 tabs / 30 days), NM REYATAZ PACK OTHER NMritonavir GENERIC NMSELZENTRY OTHER NMstavudine GENERIC NMtenofovir disoproxil fumarate GENERIC NMTIVICAY OTHER NMTROGARZO OTHER NM, LA TYBOST OTHER NMVIRACEPT OTHER NMVIREAD POWD OTHER NMVIREAD TABS 150mg, 200mg, 250mg OTHER NM
PA – Prior Authorization QL – Quantity Limits ST – Step Therapy NM – Not available at mail-order B/D – Covered under Medicare B or D LA – Limited Access Formulary ID 00020345 v13 08/01/2020
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Drug Name Drug Tier Requirements/Limits zidovudine cap 100mg GENERIC NM zidovudine syp 50mg/5ml GENERIC NM zidovudine tab 300mg GENERIC NM ANTIRETROVIRAL COMBINATION AGENTS – DRUGS TO SUPPRESS HIV/AIDS INFECTION abacavir sulfate-lamivudine GENERIC NM abacavir sulfate-lamivudine-zidovudine GENERIC NM ATRIPLA OTHER NM BIKTARVY OTHER NM CIMDUO OTHER NM COMPLERA OTHER NM DELSTRIGO OTHER NM DESCOVY OTHER NM DOVATO OTHER NM EVOTAZ OTHER NM GENVOYA OTHER NM JULUCA OTHER NM KALETRA TAB 100-25MG OTHER NM KALETRA TAB 200-50MG OTHER NM lamivudine-zidovudine GENERIC NM lopinavir-ritonavir GENERIC NM ODEFSEY OTHER NM PREZCOBIX OTHER NM STRIBILD OTHER NM SYMFI OTHER NM SYMFI LO OTHER NM SYMTUZA OTHER NM TEMIXYS OTHER NM TRIUMEQ OTHER NM TRUVADA TAB 100-150 OTHER QL (30 tabs / 30 days), NM TRUVADA TAB 133-200 OTHER QL (30 tabs / 30 days), NM TRUVADA TAB 167-250 OTHER QL (30 tabs / 30 days), NM TRUVADA TAB 200-300 OTHER QL (30 tabs / 30 days), NM ANTITUBERCULAR AGENTS – DRUGS TO TREAT TUBERCULOSIS cycloserine CAPS GENERIC NM ethambutol hcl TABS GENERIC NM isoniazid TABS GENERIC isoniazid syp 50mg/5ml GENERIC paser d/r GENERIC NM PRIFTIN OTHER NM pyrazinamide TABS GENERIC NM rifabutin GENERIC NM rifampin CAPS; SOLR GENERIC NM RIFATER OTHER NM SIRTURO 100mg OTHER NM, LA, PA TRECATOR OTHER NM
PA – Prior Authorization QL – Quantity Limits ST – Step Therapy NM – Not available at mail-order B/D – Covered under Medicare B or D LA – Limited Access Formulary ID 00020345 v13 08/01/2020
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Drug Name Drug Tier Requirements/Limits ANTIVIRALS – DRUGS TO TREAT VIRAL INFECTIONS acyclovir CAPS; SUSP; TABS GENERIC NM acyclovir sodium GENERIC B/D, NM adefovir dipivoxil GENERIC NM BARACLUDE SOLN OTHER NM entecavir GENERIC NM EPCLUSA OTHER NM, PA EPIVIR HBV SOLN OTHER NM famciclovir TABS GENERIC NM ganciclovir sodium GENERIC B/D, NM HARVONI OTHER NM, PA lamivudine (hbv) GENERIC NM MAVYRET OTHER NM, PA oseltamivir phosphate CAPS 30mg GENERIC QL (168 caps / year), NM oseltamivir phosphate CAPS 45mg, 75mg GENERIC QL (84 caps / year), NM oseltamivir phosphate SUSR GENERIC QL (1080 mL / year), NM PEGASYS OTHER NM, PA PEGASYS PROCLICK OTHER NM, PA RELENZA DISKHALER OTHER QL (6 inhalers / year), NM ribavirin cap 200mg GENERIC NM ribavirin tab 200mg GENERIC NM rimantadine hydrochloride GENERIC NM valacyclovir hcl TABS GENERIC NM valganciclovir hcl GENERIC VEMLIDY OTHER NM VOSEVI OTHER NM, PA CEPHALOSPORINS – DRUGS TO TREAT INFECTIONS cefaclor GENERIC NM cefaclor er tab 500mg GENERIC NM cefadroxil GENERIC NM CEFAZOLIN IN DEXTROSE 2GM/100ML-4% OTHER NM cefazolin inj GENERIC NM cefazolin sodium SOLR 1gm GENERIC NM cefazolin sodium 1 gm/50ml GENERIC NM cefdinir GENERIC NM cefepime for inj GENERIC NM cefixime SUSR GENERIC NM cefoxitin for inj GENERIC NM cefpodoxime proxetil GENERIC NM cefprozil GENERIC NM ceftazidime SOLR GENERIC NM CEFTAZIDIME/DEXTROSE OTHER NM ceftriaxone sodium SOLR 1gm, 2gm, 10gm, 250mg, 500mg GENERIC NM cefuroxime axetil GENERIC NM cefuroxime sodium GENERIC NM
PA – Prior Authorization QL – Quantity Limits ST – Step Therapy NM – Not available at mail-order B/D – Covered under Medicare B or D LA – Limited Access Formulary ID 00020345 v13 08/01/2020
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Drug Name Drug Tier Requirements/Limits cephalexin CAPS 250mg, 500mg GENERIC NM cephalexin SUSR GENERIC NM tazicef SOLR GENERIC NM TEFLARO OTHER NM ERYTHROMYCINS/MACROLIDES – DRUGS TO TREAT INFECTIONS azithromycin PACK; SOLR; SUSR; TABS GENERIC NM clarithromycin TABS GENERIC NM clarithromycin er GENERIC NM clarithromycin for susp GENERIC NM DIFICID OTHER NM e.e.s. 400 GENERIC NM ery-tab GENERIC NM erythrocin lactobionate GENERIC NM erythrocin stearate GENERIC NM erythromycin base GENERIC NM erythromycin cap 250mg ec GENERIC NM erythromycin ethylsuccinate TABS GENERIC NM erythromycin tab ec GENERIC NM FLUOROQUINOLONES – DRUGS TO TREAT INFECTIONS CIPRO SUSR 500mg/5ml OTHER NM ciprofloxacin hcl tab GENERIC NM ciprofloxacin in d5w GENERIC NM levofloxacin TABS GENERIC NM levofloxacin in d5w GENERIC NM levofloxacin inj 25mg/ml GENERIC NM levofloxacin oral soln 25 mg/ml GENERIC NM moxifloxacin hcl TABS GENERIC NM PENICILLINS – DRUGS TO TREAT INFECTIONS amoxicillin GENERIC NM amoxicillin & pot clavulanate 200-28.5 chw tabs GENERIC NM amoxicillin & pot clavulanate 200/5ml susr GENERIC NM amoxicillin & pot clavulanate 250-125 tabs GENERIC NM amoxicillin & pot clavulanate 250/5ml susr GENERIC NM amoxicillin & pot clavulanate 400-57 chw tabs GENERIC NM amoxicillin & pot clavulanate 400/5ml susr GENERIC NM amoxicillin & pot clavulanate 500-125 tabs GENERIC NM amoxicillin & pot clavulanate 600/5ml susr GENERIC NM amoxicillin & pot clavulanate 875-125 tabs GENERIC NM amoxicillin & pot clavulanate er 12hr 1000-62.5 tabs GENERIC NM ampicillin & sulbactam sodium GENERIC NM ampicillin cap 500mg GENERIC NM ampicillin inj GENERIC NM ampicillin sodium GENERIC NM BICILLIN L-A OTHER NM dicloxacillin sodium GENERIC NM
PA – Prior Authorization QL – Quantity Limits ST – Step Therapy NM – Not available at mail-order B/D – Covered under Medicare B or D LA – Limited Access Formulary ID 00020345 v13 08/01/2020
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Drug Name Drug Tier Requirements/Limits nafcillin sodium for inj GENERIC NM nafcillin sodium for inj 10gm GENERIC NM oxacillin sodium SOLR GENERIC NM PENICILLIN G POT IN DEXTROSE 2MU OTHER NM PENICILLIN G POT IN DEXTROSE 3MU OTHER NM penicillin g procaine GENERIC NM penicillin g sodium GENERIC NM penicillin v potassium GENERIC NM penicilln gk inj 5mu GENERIC NM penicilln gk inj 20mu GENERIC NM pfizerpen-g inj 5mu GENERIC NM pfizerpen-g inj 20mu GENERIC NM piper/tazoba inj 2-0.25gm GENERIC NM piper/tazoba inj 3-0.375gm GENERIC NM piper/tazoba inj 4-0.5gm GENERIC NM piper/tazoba inj 12-1.5gm GENERIC NM piper/tazoba inj 36-4.5gm GENERIC NM TETRACYCLINES – DRUGS TO TREAT INFECTIONS doxy 100 GENERIC NM doxycycline (monohydrate) CAPS 50mg, 100mg GENERIC NM doxycycline (monohydrate) TABS 50mg, 75mg, 100mg GENERIC NM doxycycline hyclate CAPS; SOLR GENERIC NM doxycycline hyclate 20 mg GENERIC NM doxycycline hyclate 100 mg GENERIC NM minocycline hcl CAPS GENERIC NM mondoxyne nl cap 100mg GENERIC NM tetracycline hcl CAPS GENERIC NM ANTINEOPLASTIC AGENTS – DRUGS TO TREAT CANCER ALKYLATING AGENTS BENDEKA OTHER B/D, NM cyclophosphamide CAPS; SOLR GENERIC B/D, NM EMCYT OTHER NM GLEOSTINE OTHER NM LEUKERAN OTHER NM ANTHRACYCLINES adriamycin SOLN GENERIC B/D, NM doxorubicin hcl GENERIC B/D, NM doxorubicin hcl liposomal GENERIC B/D, NM epirubicin hcl GENERIC B/D, NM ANTIMETABOLITES adrucil inj GENERIC B/D, NM ALIMTA OTHER B/D, NM azacitidine GENERIC B/D, NM cytarabine 20mg/ml GENERIC B/D, NM fluorouracil SOLN GENERIC B/D, NM
PA – Prior Authorization QL – Quantity Limits ST – Step Therapy NM – Not available at mail-order B/D – Covered under Medicare B or D LA – Limited Access Formulary ID 00020345 v13 08/01/2020
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Drug Name Drug Tier Requirements/Limits gemcitabine inj soln GENERIC B/D, NM gemcitabine inj solr GENERIC B/D, NM mercaptopurine TABS GENERIC NM methotrexate sodium inj soln GENERIC B/D, NM methotrexate sodium inj solr GENERIC B/D, NM PURIXAN OTHER NM TABLOID OTHER NM ANTIMITOTIC, TAXOIDS ABRAXANE OTHER B/D, NM docetaxel CONC 20mg/ml, 80mg/4ml, 160mg/8ml, 200mg/10ml
GENERIC B/D, NM
DOCETAXEL CONC 80mg/4ml, 160mg/8ml OTHER B/D, NM docetaxel SOLN 20mg/2ml, 80mg/8ml, 160mg/16ml GENERIC B/D, NM DOCETAXEL SOLN 20mg/2ml, 80mg/8ml, 160mg/16ml OTHER B/D, NM paclitaxel GENERIC B/D, NM TAXOTERE OTHER B/D, NM ANTIMITOTIC, VINCA ALKALOIDS vincristine sulfate GENERIC B/D, NM vinorelbine tartrate GENERIC B/D, NM BIOLOGIC RESPONSE MODIFIERS AVASTIN OTHER NM, LA, PA BORTEZOMIB OTHER NM, PA DAURISMO OTHER NM, LA, PA ERIVEDGE OTHER NM, LA, PA FARYDAK OTHER NM, LA, PA HERCEPTIN OTHER NM, PA HERCEPTIN HYLECTA OTHER NM, PA HERZUMA OTHER NM, PA IBRANCE CAPS OTHER QL (21 caps / 28 days), NM, LA, PA IBRANCE TABS OTHER QL (21 tabs / 28 days), NM, LA, PA IDHIFA OTHER QL (30 tabs / 30 days), NM, LA, PA KADCYLA OTHER B/D, NM KANJINTI OTHER NM, PA KEYTRUDA OTHER NM, PA KISQALI OTHER NM, PA KISQALI FEMARA 200 DOSE OTHER NM, PA KISQALI FEMARA 400 DOSE OTHER NM, PA KISQALI FEMARA 600 DOSE OTHER NM, PA LYNPARZA OTHER NM, LA, PA MVASI OTHER NM, LA, PA NINLARO OTHER NM, PA ODOMZO OTHER NM, LA, PA OGIVRI OTHER NM, PA ONTRUZANT OTHER NM, PA RITUXAN OTHER NM, LA, PA
PA – Prior Authorization QL – Quantity Limits ST – Step Therapy NM – Not available at mail-order B/D – Covered under Medicare B or D LA – Limited Access Formulary ID 00020345 v13 08/01/2020
11
Drug Name Drug Tier Requirements/Limits RITUXAN HYCELA OTHER NM, LA, PA RUBRACA OTHER NM, LA, PA RUXIENCE OTHER NM, PA TALZENNA OTHER NM, LA, PA TECENTRIQ OTHER NM, LA, PA TIBSOVO OTHER NM, LA, PA TRAZIMERA OTHER NM, PA TRUXIMA OTHER NM, PA VELCADE OTHER NM, PA VENCLEXTA OTHER NM, LA, PA VENCLEXTA STARTING PACK OTHER NM, LA, PA VERZENIO OTHER NM, LA, PA ZEJULA OTHER NM, LA, PA ZIRABEV OTHER NM, PA ZOLINZA OTHER NM, PA HORMONAL ANTINEOPLASTIC AGENTS abiraterone acetate GENERIC NM, PA anastrozole TABS GENERIC bicalutamide GENERIC NM DEPO-PROVERA INJ 400/ML OTHER B/D, NM ERLEADA OTHER NM, LA, PA exemestane GENERIC flutamide GENERIC NM fulvestrant GENERIC B/D, NM letrozole TABS GENERIC leuprolide inj 1mg/0.2 GENERIC NM, PA LUPRON DEPOT (1-MONTH) 3.75mg OTHER NM, PA LUPRON DEPOT INJ 11.25MG (3-MONTH) OTHER NM, PA LYSODREN OTHER NM megestrol ac sus 40mg/ml GENERIC NM megestrol ac tab 20mg GENERIC NM megestrol ac tab 40mg GENERIC NM megestrol sus 625mg/5ml GENERIC PA nilutamide GENERIC NM NUBEQA OTHER NM, LA, PA SOLTAMOX OTHER tamoxifen citrate TABS GENERIC toremifene citrate GENERIC TRELSTAR DEP INJ 3.75MG OTHER NM, PA TRELSTAR LA INJ 11.25MG OTHER NM, PA XTANDI OTHER NM, LA, PA ZYTIGA 500mg OTHER NM, LA, PA IMMUNOMODULATORS POMALYST 1mg, 2mg OTHER QL (21 caps / 21 days), NM, LA, PA POMALYST 3mg, 4mg OTHER QL (21 caps / 28 days), NM, LA, PA
PA – Prior Authorization QL – Quantity Limits ST – Step Therapy NM – Not available at mail-order B/D – Covered under Medicare B or D LA – Limited Access
Formulary ID 00020345 v13 08/01/2020
12
Drug Name Drug Tier Requirements/Limits REVLIMID OTHER QL (28 caps / 28 days), NM, LA, PA THALOMID 50mg, 100mg OTHER QL (28 caps / 28 days), NM, PA THALOMID 150mg, 200mg OTHER QL (56 caps / 28 days), NM, PA KINASE INHIBITORS AFINITOR 10mg OTHER QL (30 tabs / 30 days), NM, PA AFINITOR DISPERZ 2mg OTHER QL (150 tabs / 30 days), NM, PA AFINITOR DISPERZ 3mg OTHER QL (90 tabs / 30 days), NM, PA AFINITOR DISPERZ 5mg OTHER QL (60 tabs / 30 days), NM, PA ALECENSA OTHER NM, LA, PA ALUNBRIG OTHER NM, LA, PA AYVAKIT OTHER QL (30 tabs / 30 days), NM, LA, PA BALVERSA OTHER NM, LA, PA BOSULIF OTHER NM, PA BRAFTOVI OTHER NM, LA, PA BRUKINSA OTHER NM, LA, PA CABOMETYX OTHER QL (30 tabs / 30 days), NM, LA, PA CALQUENCE OTHER NM, LA, PA CAPRELSA OTHER NM, LA, PA COMETRIQ OTHER NM, LA, PA COPIKTRA OTHER NM, LA, PA COTELLIC OTHER NM, LA, PA erlotinib hcl 25mg GENERIC QL (90 tabs / 30 days), NM, PA erlotinib hcl 100mg, 150mg GENERIC QL (30 tabs / 30 days), NM, PA everolimus GENERIC QL (30 tabs / 30 days), NM, PA GILOTRIF TAB 20MG OTHER NM, LA, PA GILOTRIF TAB 30MG OTHER NM, LA, PA GILOTRIF TAB 40MG OTHER NM, LA, PA ICLUSIG OTHER NM, LA, PA imatinib mesylate 100mg GENERIC QL (90 tabs / 30 days), NM, PA imatinib mesylate 400mg GENERIC QL (60 tabs / 30 days), NM, PA IMBRUVICA OTHER NM, LA, PA INLYTA 1mg OTHER QL (180 tabs / 30 days), NM, LA, PA INLYTA 5mg OTHER QL (120 tabs / 30 days), NM, LA, PA INREBIC OTHER NM, LA, PA IRESSA OTHER NM, LA, PA JAKAFI OTHER QL (60 tabs / 30 days), NM, LA, PA LENVIMA 4 MG DAILY DOSE OTHER NM, LA, PA LENVIMA 8 MG DAILY DOSE OTHER NM, LA, PA LENVIMA 10 MG DAILY DOSE OTHER NM, LA, PA LENVIMA 12MG DAILY DOSE OTHER NM, LA, PA LENVIMA 14 MG DAILY DOSE OTHER NM, LA, PA LENVIMA 18 MG DAILY DOSE OTHER NM, LA, PA LENVIMA 20 MG DAILY DOSE OTHER NM, LA, PA LENVIMA 24 MG DAILY DOSE OTHER NM, LA, PA LORBRENA OTHER NM, LA, PA
PA – Prior Authorization QL – Quantity Limits ST – Step Therapy NM – Not available at mail-order B/D – Covered under Medicare B or D LA – Limited Access
Formulary ID 00020345 v13 08/01/2020
13
Drug Name Drug Tier Requirements/Limits MEKINIST OTHER NM, LA, PA MEKTOVI OTHER NM, LA, PA NERLYNX OTHER NM, LA, PA NEXAVAR OTHER NM, LA, PA PEMAZYRE OTHER NM, LA, PA PIQRAY 200MG DAILY DOSE OTHER NM, PA PIQRAY 250MG DAILY DOSE OTHER NM, PA PIQRAY 300MG DAILY DOSE OTHER NM, PA ROZLYTREK OTHER NM, LA, PA RYDAPT OTHER NM, PA SPRYCEL OTHER NM, PA STIVARGA OTHER NM, LA, PA SUTENT OTHER QL (30 caps / 30 days), NM, PA TAFINLAR OTHER NM, LA, PA TAGRISSO OTHER QL (30 tabs / 30 days), NM, LA, PA TASIGNA OTHER NM, PA TUKYSA OTHER NM, LA, PA TURALIO OTHER NM, LA, PA TYKERB OTHER NM, LA, PA VITRAKVI OTHER NM, LA, PA VIZIMPRO OTHER NM, LA, PA VOTRIENT OTHER NM, LA, PA XALKORI OTHER NM, LA, PA XOSPATA OTHER NM, LA, PA ZELBORAF OTHER NM, LA, PA ZYDELIG OTHER NM, LA, PA ZYKADIA OTHER NM, LA, PA MISCELLANEOUS bexarotene GENERIC NM, PA hydroxyurea CAPS GENERIC NM LONSURF OTHER NM, PA MATULANE OTHER NM, LA SYLATRON OTHER NM, PA SYNRIBO OTHER NM, PA TAZVERIK OTHER NM, LA, PA tretinoin (chemotherapy) GENERIC NM XPOVIO 60 MG ONCE WEEKLY OTHER NM, LA, PA XPOVIO 80 MG ONCE WEEKLY OTHER NM, LA, PA XPOVIO 80 MG TWICE WEEKLY OTHER NM, LA, PA XPOVIO 100 MG ONCE WEEKLY OTHER NM, LA, PA PLATINUM-BASED AGENTS carboplatin GENERIC B/D, NM cisplatin SOLN GENERIC B/D, NM oxaliplatin inj 50mg GENERIC B/D, NM oxaliplatin inj 50mg/10ml GENERIC B/D, NM
PA – Prior Authorization QL – Quantity Limits ST – Step Therapy NM – Not available at mail-order B/D – Covered under Medicare B or D LA – Limited Access
PA – Prior Authorization QL – Quantity Limits ST – Step Therapy NM – Not available at mail-order B/D – Covered under Medicare B or D LA – Limited Access
PA – Prior Authorization QL – Quantity Limits ST – Step Therapy NM – Not available at mail-order B/D – Covered under Medicare B or D LA – Limited Access
Formulary ID 00020345 v13 08/01/2020
Drug Name Drug Tier Requirements/Limits ANTILIPEMICS, MISCELLANEOUS – DRUGS TO TREAT HIGH CHOLESTEROL cholestyramine GENERIC cholestyramine light pack GENERIC cholestyramine light powd GENERIC colesevelam hcl GENERIC colestipol hcl gran GENERIC colestipol hcl pack GENERIC colestipol hcl tabs GENERIC ezetimibe GENERIC ezetimibe-simvastatin GENERIC fenofibrate TABS 48mg, 54mg, 145mg, 160mg GENERIC fenofibrate micronized 67mg, 134mg, 200mg GENERIC gemfibrozil TABS GENERIC JUXTAPID OTHER NM, LA, PA niacin (antihyperlipidemic) GENERIC NM niacin er (antihyperlipidemic) 500mg GENERIC QL (60 tabs / 30 days) niacin er (antihyperlipidemic) 750mg, 1000mg GENERIC niacor GENERIC NM PRALUENT OTHER NM, PA prevalite GENERIC VASCEPA OTHER BETA-BLOCKER/DIURETIC COMBINATIONS – DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS atenolol & chlorthalidone GENERIC bisoprolol & hydrochlorothiazide GENERIC metoprolol & hydrochlorothiazide GENERIC propranolol & hydrochlorothiazide GENERIC BETA-BLOCKERS – DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS acebutolol hcl CAPS GENERIC atenolol TABS GENERIC betaxolol hcl GENERIC bisoprolol fumarate GENERIC BYSTOLIC 2.5mg, 5mg, 10mg OTHER QL (30 tabs / 30 days) BYSTOLIC 20mg OTHER QL (60 tabs / 30 days) carvedilol GENERIC labetalol hcl TABS GENERIC metoprolol succinate GENERIC metoprolol tartrate SOCT GENERIC NM metoprolol tartrate SOLN GENERIC NM metoprolol tartrate TABS 25mg, 50mg, 100mg GENERIC nadolol TABS GENERIC pindolol GENERIC propranolol cap er GENERIC propranolol hcl TABS GENERIC propranolol oral sol GENERIC timolol maleate TABS GENERIC
16
PA – Prior Authorization QL – Quantity Limits ST – Step Therapy NM – Not available at mail-order B/D – Covered under Medicare B or D LA – Limited Access Formulary ID 00020345 v13 08/01/2020
17
Drug Name Drug Tier Requirements/Limits
CALCIUM CHANNEL BLOCKERS – DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS amlodipine besylate TABS GENERIC cartia xt GENERIC dilt-xr cap GENERIC diltiazem cap 240mg cd GENERIC diltiazem cap 360mg cd GENERIC diltiazem cap er/12hr GENERIC diltiazem hcl TABS GENERIC diltiazem hcl coated beads CP24 GENERIC diltiazem hcl coated beads cap sr 24hr GENERIC diltiazem hcl extended release beads cap sr GENERIC diltiazem inj GENERIC NM felodipine GENERIC isradipine GENERIC nicardipine hcl CAPS GENERIC nifedipine TB24 GENERIC nifedipine er GENERIC nimodipine CAPS GENERIC NM NYMALIZE OTHER NM taztia xt GENERIC tiadylt er GENERIC verapamil cap er GENERIC verapamil hcl SOLN GENERIC NM verapamil hcl TABS; TBCR GENERIC verapamil tab er GENERIC DIGITALIS GLYCOSIDES – DRUGS TO TREAT HEART CONDITIONS digitek .25mg GENERIC PA; PA if 70 years and older digitek .125mg GENERIC QL (30 tabs / 30 days) digox 125mcg GENERIC QL (30 tabs / 30 days) digox 250mcg GENERIC PA; PA if 70 years and older digoxin TABS 125mcg GENERIC QL (30 tabs / 30 days) digoxin TABS 250mcg GENERIC PA; PA if 70 years and older digoxin inj GENERIC NM digoxin sol 50mcg/ml GENERIC PA; PA if 70 years and older DIURETICS – DRUGS TO TREAT HEART CONDITIONS acetazolamide CP12; TABS GENERIC amiloride & hydrochlorothiazide GENERIC amiloride hcl TABS GENERIC bumetanide inj 0.25/ml GENERIC NM bumetanide tab GENERIC chlorothiazide TABS GENERIC chlorthalidone GENERIC furosemide SOLN; TABS GENERIC furosemide inj GENERIC NM hydrochlorothiazide CAPS; TABS GENERIC
PA – Prior Authorization QL – Quantity Limits ST – Step Therapy NM – Not available at mail-order B/D – Covered under Medicare B or D LA – Limited Access
Formulary ID 00020345 v13 08/01/2020
18
Drug Name Drug Tier Requirements/Limits indapamide GENERIC methazolamide TABS GENERIC metolazone GENERIC spironolactone & hydrochlorothiazide GENERIC torsemide tabs GENERIC triamterene & hydrochlorothiazide cap 37.5-25 mg GENERIC triamterene & hydrochlorothiazide tabs GENERIC MISCELLANEOUS aliskiren fumarate GENERIC clonidine hcl TABS GENERIC clonidine hcl ptwk GENERIC CORLANOR OTHER DEMSER OTHER NM, PA hydralazine hcl SOLN GENERIC NM hydralazine hcl TABS GENERIC midodrine hcl GENERIC NM minoxidil TABS GENERIC NORTHERA 100mg OTHER QL (90 caps / 30 days), NM, LA, PA NORTHERA 200mg, 300mg OTHER QL (180 caps / 30 days), NM, LA, PA ranolazine GENERIC NITRATES – DRUGS TO TREAT HEART CONDITIONS isosorb mononitrate tab GENERIC isosorbide dinitrate 5mg, 10mg, 20mg, 30mg GENERIC isosorbide mononitrate er GENERIC minitran GENERIC nitro-bid GENERIC NITRO-DUR DIS 0.3MG/HR OTHER NITRO-DUR DIS 0.8MG/HR OTHER nitroglycerin SOLN .4mg/spray GENERIC nitroglycerin SUBL GENERIC nitroglycerin td patch GENERIC PULMONARY ARTERIAL HYPERTENSION – DRUGS TO TREAT PULMONARY HYPERTENSION ADEMPAS OTHER QL (90 tabs / 30 days), NM, LA, PA ambrisentan GENERIC QL (30 tabs / 30 days), NM, LA, PA bosentan 62.5mg GENERIC QL (120 tabs / 30 days), NM, LA, PA bosentan 125mg GENERIC QL (60 tabs / 30 days), NM, LA, PA OPSUMIT OTHER QL (30 tabs / 30 days), NM, LA, PA sildenafil citrate tab 20 mg (pulmonary hypertension) GENERIC QL (90 tabs / 30 days), NM, PA treprostinil GENERIC NM, LA, PA VENTAVIS OTHER NM, PA CENTRAL NERVOUS SYSTEM – DRUGS TO TREAT NERVOUS SYSTEM DISORDERS ANTIANXIETY – DRUGS TO TREAT ANXIETY alprazolam tab 0.5mg GENERIC QL (150 tabs / 30 days), NM alprazolam tab 0.25mg GENERIC QL (150 tabs / 30 days), NM alprazolam tab 1mg GENERIC QL (150 tabs / 30 days), NM
PA – Prior Authorization QL – Quantity Limits ST – Step Therapy NM – Not available at mail-order B/D – Covered under Medicare B or D LA – Limited Access
Formulary ID 00020345 v13 08/01/2020
19
Drug Name Drug Tier Requirements/Limits alprazolam tab 2 mg GENERIC QL (150 tabs / 30 days), NM buspirone hcl TABS GENERIC NM fluvoxamine maleate TABS GENERIC lorazepam SOLN GENERIC NM lorazepam TABS GENERIC QL (150 tabs / 30 days), NM lorazepam intensol GENERIC QL (150 mL / 30 days), NM ANTICONVULSANTS – DRUGS TO TREAT SEIZURES APTIOM OTHER QL (60 tabs / 30 days) BANZEL SUS 40MG/ML OTHER PA BANZEL TAB 200MG OTHER PA BANZEL TAB 400MG OTHER PA BRIVIACT INJ 50MG/5ML OTHER NM, PA BRIVIACT SOL 10MG/ML OTHER PA BRIVIACT TAB 10MG OTHER PA BRIVIACT TAB 25MG OTHER PA BRIVIACT TAB 50MG OTHER PA BRIVIACT TAB 75MG OTHER PA BRIVIACT TAB 100MG OTHER PA carbamazepine CHEW; CP12; SUSP; TABS; TB12 GENERIC CELONTIN OTHER clobazam GENERIC PA clonazepam TABS 2mg GENERIC QL (300 tabs / 30 days), NM clonazepam TABS .5mg, 1mg GENERIC QL (90 tabs / 30 days), NM clonazepam TBDP 2mg GENERIC QL (300 tabs / 30 days), NM clonazepam TBDP .125mg, .25mg, .5mg, 1mg GENERIC QL (90 tabs / 30 days), NM clorazepate dipotassium GENERIC QL (180 tabs / 30 days), NM, PA;
PA if 65 years and older DIASTAT ACUDIAL OTHER NM DIASTAT PEDIATRIC OTHER NM diazepam TABS GENERIC QL (120 tabs / 30 days), NM, PA;
PA if 65 years and older diazepam gel GENERIC NM diazepam inj GENERIC NM diazepam intensol GENERIC QL (240 mL / 30 days), NM, PA;
PA if 65 years and older diazepam oral soln 1 mg/ml GENERIC QL (1200 mL / 30 days), NM, PA;
PA if 65 years and older dilantin cap 30mg GENERIC dilantin cap 100mg GENERIC dilantin chew tab 50mg GENERIC DILANTIN-125 SUSP OTHER divalproex sodium CSDR; TB24; TBEC GENERIC EPIDIOLEX OTHER QL (600 mL / 30 days), NM, LA, PAepitol GENERIC ethosuximide CAPS; SOLN GENERIC
PA – Prior Authorization QL – Quantity Limits ST – Step Therapy NM – Not available at mail-order 20 B/D – Covered under Medicare B or D LA – Limited Access
Formulary ID 00020345 v13 08/01/2020
Drug Name Drug Tier Requirements/Limits felbamate GENERIC FYCOMPA SUSP OTHER QL (720 mL / 30 days), PA FYCOMPA TABS 2mg, 4mg, 6mg OTHER QL (60 tabs / 30 days), PA FYCOMPA TABS 8mg, 10mg, 12mg OTHER QL (30 tabs / 30 days), PA gabapentin CAPS 100mg GENERIC QL (1080 caps / 30 days) gabapentin CAPS 300mg GENERIC QL (360 caps / 30 days) gabapentin CAPS 400mg GENERIC QL (270 caps / 30 days) gabapentin SOLN GENERIC QL (2160 mL / 30 days) gabapentin TABS 600mg GENERIC QL (180 tabs / 30 days) gabapentin TABS 800mg GENERIC QL (120 tabs / 30 days) lamotrigine CHEW; TABS; TB24 GENERIC levetiracetam SOLN GENERIC NM levetiracetam TABS; TB24 GENERIC levetiracetam in sodium chloride GENERIC NM levetiracetam oral soln 100 mg/ml GENERIC NAYZILAM OTHER NMoxcarbazepine GENERIC PEGANONE OTHER phenobarbital ELIX; TABS GENERIC PA; PA if 70 years and older phenobarbital sodium SOLN GENERIC NM, PA; PA if 70 years and older phenytek GENERIC
PA – Prior Authorization QL – Quantity Limits ST – Step Therapy NM – Not available at mail-order 22 B/D – Covered under Medicare B or D LA – Limited Access
Formulary ID 00020345 v13 08/01/2020
Drug Name Drug Tier Requirements/Limits escitalopram oxalate GENERIC FETZIMA 20mg, 40mg OTHER QL (60 caps / 30 days), PA FETZIMA 80mg, 120mg OTHER QL (30 caps / 30 days), PA FETZIMA TITRATION PACK OTHER NM, PA fluoxetine cap 10mg GENERIC fluoxetine cap 20mg GENERIC fluoxetine cap 40mg GENERIC fluoxetine hcl SOLN GENERIC imipramine hcl TABS GENERIC maprotiline hcl GENERIC MARPLAN TAB 10MG OTHER QL (180 tabs / 30 days)
APOKYN OTHER QL (20 cartridges / 30 days), NM, LA, PA
benztropine mesylate inj GENERIC NM benztropine mesylate tab 0.5mg GENERIC PA; PA if 70 years and older
benztropine mesylate tab 1mg GENERIC PA; PA if 70 years and older benztropine mesylate tab 2mg GENERIC PA; PA if 70 years and older bromocriptine mesylate CAPS; TABS GENERIC
trifluoperazine hcl GENERIC VERSACLOZ OTHER QL (600 mL / 30 days), NM, PA
VRAYLAR 1.5mg OTHER QL (60 caps / 30 days), PA VRAYLAR 3mg, 4.5mg, 6mg OTHER QL (30 caps / 30 days), PA VRAYLAR THERAPY PACK OTHER NM, PA ziprasidone hcl GENERIC QL (60 caps / 30 days) ziprasidone mesylate GENERIC QL (6 injections / 3 days), NM
PA – Prior Authorization QL – Quantity Limits ST – Step Therapy NM – Not available at mail-order 25 B/D – Covered under Medicare B or D LA – Limited Access
Formulary ID 00020345 v13 08/01/2020
Drug Name Drug Tier Requirements/Limits ZYPREXA RELPREVV 300mg OTHER QL (2 vials / 28 days), NM, PA ZYPREXA RELPREVV 405mg OTHER QL (1 vial / 28 days), NM, PA ZYPREXA RELPREVV INJ 210MG OTHER QL (2 vials / 28 days), NM, PA ATTENTION DEFICIT HYPERACTIVITY DISORDER – DRUGS TO TREAT ADHD
MULTIPLE SCLEROSIS AGENTS – DRUGS TO TREAT MULTIPLE SCLEROSIS BETASERON OTHER QL (14 syringes / 28 days), NM,
PA dalfampridine TB12 GENERIC NM, PA
GILENYA OTHER QL (28 caps / 28 days), NM, PA
PA – Prior Authorization QL – Quantity Limits ST – Step Therapy NM – Not available at mail-order B/D – Covered under Medicare B or D LA – Limited Access
Formulary ID 00020345 v13 08/01/2020
26
PA – Prior Authorization QL – Quantity Limits ST – Step Therapy NM – Not available at mail-order B/D – Covered under Medicare B or D LA – Limited Access
Formulary ID 00020345 v13 08/01/2020
27
Drug Name Drug Tier Requirements/Limits glatiramer acetate 20mg/ml GENERIC QL (30 syringes / 30 days), NM, PA
VIVITROL OTHER NM ENDOCRINE AND METABOLIC – DRUGS TO TREAT DIABETES AND REGULATE HORMONES ANDROGENS – DRUGS TO REGULATE MALE HORMONES
ANADROL-50 OTHER NM, PA ANDRODERM OTHER QL (30 patches / 30 days), PA
oxandrolone tab 2.5mg GENERIC NM, PA oxandrolone tab 10mg GENERIC NM, PA testosterone GEL 1%, 25mg/2.5gm, 50mg/5gm GENERIC QL (300 grams / 30 days), PA
testosterone cypionate SOLN GENERIC NM, PA
PA – Prior Authorization QL – Quantity Limits ST – Step Therapy NM – Not available at mail-order B/D – Covered under Medicare B or D LA – Limited Access
Formulary ID 00020345 v13 08/01/2020
2
Drug Name Drug Tier Requirements/Limits testosterone enanthate SOLN GENERIC NM, PA ANTIDIABETICS, INJECTABLE – DRUGS TO TREAT DIABETESBASAGLAR KWIKPEN OTHER BD ALCOHOL SWABS OTHER NMBD ULTRAFINE INSULIN SYRINGE OTHER NMBD ULTRAFINE/NANO PEN NEEDLES OTHER NMBYDUREON BCISE OTHER QL (4 pens / 28 days)
BYDUREON PEN OTHER QL (4 pens / 28 days)BYETTA OTHER QL (1 pen / 30 days)
FIASP OTHER FIASP FLEXTOUCH OTHER FIASP PENFILL OTHER
GAUZE PADS 2" X 2" OTHER NM HUMULIN R INJ U-500 OTHER B/D HUMULIN R U-500 KWIKPEN OTHER INSULIN PEN NEEDLE OTHER NM
INSULIN SAFETY NEEDLES OTHER NM INSULIN SYRINGE OTHER NM LEVEMIR OTHER LEVEMIR FLEXTOUCH OTHER
NOVOLIN 70/30 OTHER (brand RELION not covered) NOVOLIN 70/30 FLEXPEN OTHER (brand RELION not covered)
NOVOLIN N OTHER (brand RELION not covered) NOVOLIN N FLEXPEN OTHER (brand RELION not covered)
NOVOLIN R OTHER (brand RELION not covered) NOVOLIN R FLEXPEN OTHER (brand RELION not covered)
NOVOLOG OTHER NOVOLOG 70/30 FLEXPEN OTHER NOVOLOG FLEXPEN OTHER NOVOLOG MIX 70/30 OTHER NOVOLOG PENFILL OTHER
OZEMPIC INJ 0.25 OR 0.5MG/DOSE OTHER QL (1 pen / 28 days) OZEMPIC INJ 1MG/DOSE OTHER QL (2 pens / 28 days) SOLIQUA 100/33 OTHER QL (10 pens / 30 days)
TRESIBA FLEXTOUCH OTHER TRESIBA INJ OTHER
TRULICITY OTHER QL (4 pens / 28 days) VICTOZA OTHER QL (3 pens / 30 days)
XULTOPHY 100/3.6 OTHER QL (5 pens / 30 days) ANTIDIABETICS, ORAL – DRUGS TO TREAT DIABETES
PA – Prior Authorization QL – Quantity Limits ST – Step Therapy NM – Not available at mail-order B/D – Covered under Medicare B or D LA – Limited Access
Formulary ID 00020345 v13 08/01/2020
29
Drug Name Drug Tier Requirements/Limits glip/metform tab 2.5-500mg GENERIC QL (120 tabs / 30 days) glip/metform tab 5-500mg GENERIC QL (120 tabs / 30 days)
PA – Prior Authorization QL – Quantity Limits ST – Step Therapy NM – Not available at mail-order 30 B/D – Covered under Medicare B or D LA – Limited Access
Formulary ID 00020345 v13 08/01/2020
Drug Name Drug Tier Requirements/Limits repaglinide 2mg GENERIC QL (240 tabs / 30 days) repaglinide .5mg, 1mg GENERIC QL (120 tabs / 30 days) RYBELSUS OTHER QL (30 tabs / 30 days) SYNJARDY TAB 5-500MG OTHER QL (120 tabs / 30 days) SYNJARDY TAB 5-1000MG OTHER QL (60 tabs / 30 days) SYNJARDY TAB 12.5-500MG OTHER QL (60 tabs / 30 days) SYNJARDY TAB 12.5-1000MG OTHER QL (60 tabs / 30 days) SYNJARDY XR TAB 5-1000MG OTHER QL (60 tabs / 30 days) SYNJARDY XR TAB 10-1000MG OTHER QL (60 tabs / 30 days) SYNJARDY XR TAB 12.5-1000MG OTHER QL (60 tabs / 30 days) SYNJARDY XR TAB 25-1000MG OTHER QL (30 tabs / 30 days) TRADJENTA OTHER QL (30 tabs / 30 days) TRIJARDY XR TAB ER 24HR 5-2.5-1000MG OTHER QL (60 tabs / 30 days) TRIJARDY XR TAB ER 24HR 10-5-1000 MG OTHER QL (30 tabs / 30 days) TRIJARDY XR TAB ER 24HR 12.5-2.5-1000MG OTHER QL (60 tabs / 30 days) TRIJARDY XR TAB ER 24HR 25-5-1000 MG OTHER QL (30 tabs / 30 days) XIGDUO XR TAB 2.5-1000MG OTHER QL (60 tabs / 30 days) XIGDUO XR TAB 5-500MG OTHER QL (60 tabs / 30 days) XIGDUO XR TAB 5-1000MG OTHER QL (60 tabs / 30 days) XIGDUO XR TAB 10-500MG OTHER QL (30 tabs / 30 days) XIGDUO XR TAB 10-1000MG OTHER QL (30 tabs / 30 days) BISPHOSPHONATES – DRUGS TO TREAT BONE LOSS alendronate sodium soln 70mg/75ml GENERIC alendronate sodium tab 5 mg GENERIC alendronate sodium tab 10 mg GENERIC alendronate sodium tab 35 mg GENERIC
PA – Prior Authorization QL – Quantity Limits ST – Step Therapy NM – Not available at mail-order 31 B/D – Covered under Medicare B or D LA – Limited Access
Formulary ID 00020345 v13 08/01/2020
Drug Name Drug Tier Requirements/Limits penicillamine TABS GENERIC NM sodium polystyrene sulfonate powder GENERIC NM sodium polystyrene sulfonate susp GENERIC NM sps susp 15gm/60ml GENERIC NM trientine hcl GENERIC NM, PA VELTASSA OTHER LA, PA CONTRACEPTIVES – DRUGS FOR BIRTH CONTROL altavera tab GENERIC alyacen 1/35 GENERIC amethia GENERIC amethia lo GENERIC apri GENERIC aranelle GENERIC
larin 1.5/30 GENERIC larin 1/20 GENERIC larin fe 1.5/30 GENERIC larin fe 1/20 GENERIC
larissia tab GENERIC layolis fe GENERIC
leena tab GENERIC lessina GENERIC
levonest GENERIC levonor-eth est tab 0.15-0.02/0.025/0.03mg & eth est 0.01mg
GENERIC
levonor/ethi tab GENERIC levonorg-eth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7)
GENERIC
levonorg-eth est tab 0.15-0.03mg (84) & eth est tab 0.01mg(7)
GENERIC
levonorgestrel & eth estradiol GENERIC levonorgestrel-ethinyl estradiol 0.15-0.03mg (91-day) GENERIC
levora 0.15/30-28 GENERIC loryna GENERIC
low-ogestrel GENERIC lutera GENERIC
lyza GENERIC
PA – Prior Authorization QL – Quantity Limits ST – Step Therapy NM – Not available at mail-order 33 B/D – Covered under Medicare B or D LA – Limited Access
Formulary ID 00020345 v13 08/01/2020
Drug Name Drug Tier Requirements/Limits marlissa GENERIC
medroxyprogesterone acetate (contraceptive) GENERIC NM melodetta 24 fe GENERIC mibelas 24 fe GENERIC
tri-estarylla GENERIC tri-legest fe GENERIC tri-linyah GENERIC
PA – Prior Authorization QL – Quantity Limits ST – Step Therapy B/D – Covered under Medicare B or D LA – Limited Access
NM – Not available at mail-order 34
Formulary ID 00020345 v13 08/01/2020
Drug Name Drug Tier Requirements/Limits tri-lo marzia GENERIC
tri-lo-estarylla GENERIC tri-lo-sprintec GENERIC
tri-mili GENERIC tri-previfem GENERIC
tri-sprintec GENERIC tri-vylibra GENERIC tri-vylibra lo GENERIC trivora-28 GENERIC
tulana GENERIC tydemy GENERIC
velivet GENERIC vienva GENERIC viorele GENERIC
vyfemla GENERIC vylibra GENERIC
wymzya fe GENERIC xulane dis 150-35 GENERIC zarah GENERIC zovia 1/35e GENERIC ENDOMETRIOSIS danazol CAPS GENERIC NM SYNAREL OTHER NM ENZYME REPLACEMENTS – DRUGS TO TREAT ENZYME DEFICIENCIES ALDURAZYME OTHER NM, LA, PA CARBAGLU OTHER NM, LA, PA CERDELGA OTHER NM, PA CEREZYME OTHER NM, LA, PA CYSTADANE OTHER NM, LA CYSTAGON OTHER NM, LA, PA FABRAZYME OTHER NM, LA, PA KUVAN OTHER NM, LA, PA levocarnitine (metabolic modifiers) GENERIC B/D LUMIZYME OTHER NM, LA, PA miglustat GENERIC NM, PA NAGLAZYME OTHER NM, LA, PA nitisinone GENERIC NM, PA NITYR OTHER NM, LA, PA ORFADIN OTHER NM, LA, PA sodium phenylbutyrate GENERIC NM, PA ESTROGENS – DRUGS TO REGULATE FEMALE HORMONES DELESTROGEN 10mg/ml OTHER NM estradiol PTWK; TABS GENERIC estradiol vaginal cream GENERIC estradiol vaginal tab GENERIC
PA – Prior Authorization QL – Quantity Limits ST – Step Therapy NM – Not available at mail-order 35 B/D – Covered under Medicare B or D LA – Limited Access
Formulary ID 00020345 v13 08/01/2020
Drug Name Drug Tier Requirements/Limits estradiol valerate inj GENERIC NM
fyavolv GENERIC jinteli GENERIC
norethindrone acetate-ethinyl estradiol GENERIC yuvafem vaginal tablet 10 mcg GENERIC
GLUCOCORTICOIDS – DRUGS TO TREAT INFLAMMATORY RESPONSE
PA – Prior Authorization QL – Quantity Limits ST – Step Therapy B/D – Covered under Medicare B or D LA – Limited Access
NM – Not available at mail-order 36
Formulary ID 00020345 v13 08/01/2020
Drug Name Drug Tier Requirements/Limits FORTEO OTHER NM, PA
GENOTROPIN OTHER NM, PA GENOTROPIN MINIQUICK OTHER NM, PA
INCRELEX OTHER NM, LA, PAKORLYM OTHER NM, LA, PA
LUPRON DEP-PED INJ 7.5MG OTHER NM, PA LUPRON DEP-PED INJ 11.25MG (3-MONTH) OTHER NM, PA LUPRON DEPOT-PED (1-MONTH) OTHER NM, PA LUPRON DEPOT-PED (3-MONTH) OTHER NM, PA
NATPARA OTHER NM, PA octreotide acetate GENERIC NM, PA OSPHENA OTHER PA
PROLIA OTHER QL (1 injection / 180 days), NM raloxifene tab 60mg GENERIC SIGNIFOR OTHER NM, LA, PA
SOMATULINE DEPOT OTHER NM, PA SOMAVERT OTHER NM, LA, PA
TYMLOS OTHER NM, PA XGEVA OTHER NM, PA
PHOSPHATE BINDER AGENTS – DRUGS TO REGULATE CALCIUM AND PHOSPHORUS LEVELS
desmopressin inj 4mcg/ml GENERIC NM STIMATE OTHER NM
PA – Prior Authorization QL – Quantity Limits ST – Step Therapy NM – Not available at mail-order B/D – Covered under Medicare B or D LA – Limited Access
Formulary ID 00020345 v13 08/01/2020
37
Drug Name Drug Tier Requirements/Limits GASTROINTESTINAL – DRUGS TO TREAT STOMACH AND INTESTINAL DISORDERS ANTIEMETICS – DRUGS FOR NAUSEA AND VOMITING
omeprazole cap 10mg GENERIC omeprazole cap 20mg GENERIC omeprazole cap 40mg GENERIC
pantoprazole sodium SOLR GENERIC NM
PA – Prior Authorization QL – Quantity Limits ST – Step Therapy NM – Not available at mail-order 39 B/D – Covered under Medicare B or D LA – Limited Access
Formulary ID 00020345 v13 08/01/2020
Drug Name Drug Tier Requirements/Limits pantoprazole sodium tbec GENERIC rabeprazole sodium GENERIC QL (30 tabs / 30 days)
IMMUNOLOGIC AGENTS – DRUGS TO TREAT DISORDERS OF THE IMMUNE SYSTEM DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) – DRUGS TO TREAT RHEUMATOID ARTHRITIS
ENBREL SOLR OTHER QL (16 vials / 28 days), NM, PA ENBREL SOSY 25mg/0.5ml OTHER QL (16 syringes / 28 days), NM, PA ENBREL SOSY 50mg/ml OTHER QL (8 syringes / 28 days), NM, PA ENBREL MINI OTHER QL (8 injections / 28 days), NM, PA ENBREL SURECLICK OTHER QL (8 injections / 28 days), NM, PA HUMIRA 10mg/0.1ml, 20mg/0.2ml OTHER QL (2 injections / 28 days), NM, PA HUMIRA 40mg/0.4ml OTHER QL (6 injections / 28 days), NM, PA HUMIRA INJ 10MG/0.2ML OTHER QL (2 syringes / 28 days), NM, PA HUMIRA KIT 20MG/0.4ML OTHER QL (2 syringes / 28 days), NM, PA HUMIRA KIT 40MG/0.8ML OTHER QL (6 syringes / 28 days), NM, PA HUMIRA PEDIATRIC CROHNS DISEASE OTHER NM, PA HUMIRA PEN OTHER QL (6 pens / 28 days), NM, PA
HUMIRA PEN CD/UC/HS STARTER OTHER NM, PA HUMIRA PEN INJ CD/UC/HS STARTER OTHER NM, PA HUMIRA PEN INJ PS/UV STARTER OTHER NM, PA
PA – Prior Authorization QL – Quantity Limits ST – Step Therapy NM – Not available at mail-order B/D – Covered under Medicare B or D LA – Limited Access
Formulary ID 00020345 v13 08/01/2020
41
Drug Name Drug Tier Requirements/Limits HUMIRA PEN-PS/UV STARTER OTHER NM, PA
Drug Name Drug Tier Requirements/Limits tacrolimus CAPS GENERIC B/D, NM ZORTRESS TAB 0.5MG OTHER B/D, NM ZORTRESS TAB 0.25MG OTHER B/D, NM ZORTRESS TAB 0.75MG OTHER B/D, NM ZORTRESS TAB 1MG OTHER B/D, NM VACCINES
ACTHIB OTHER NM ADACEL OTHER NM
BCG VACCINE OTHER NM BEXSERO OTHER NM BOOSTRIX OTHER NM DAPTACEL OTHER NM
DIPHTHERIA/TETANUS TOXOID OTHER B/D, NM ENGERIX-B SUSP OTHER B/D, NM
GARDASIL 9 OTHER NM HAVRIX OTHER NM HIBERIX OTHER NM
IMOVAX RABIES (H.D.C.V.) OTHER B/D, NM INFANRIX OTHER NM
IPOL INACTIVATED IPV OTHER NM IXIARO OTHER NM KINRIX OTHER NM
M-M-R II OTHER NM MENACTRA OTHER NM
MENVEO OTHER NM PEDIARIX OTHER NM
PEDVAX HIB OTHER NM PENTACEL OTHER NM PROQUAD OTHER NM
QUADRACEL OTHER NM RABAVERT OTHER B/D, NM
RECOMBIVAX HB OTHER B/D, NM ROTARIX OTHER NM ROTATEQ OTHER NM SHINGRIX OTHER QL (2 vials per lifetime), NM
TDVAX OTHER B/D, NM TENIVAC OTHER B/D, NM
TRUMENBA OTHER NM
TWINRIX INJ OTHER NM TYPHIM VI OTHER NM
VAQTA OTHER NM VARIVAX OTHER NM
YF-VAX OTHER NM ZOSTAVAX OTHER QL (1 vial per lifetime), NM
PA – Prior Authorization QL – Quantity Limits ST – Step Therapy NM – Not available at mail-order B/D – Covered under Medicare B or D LA – Limited Access
Formulary ID 00020345 v13 08/01/2020
42
PA – Prior Authorization QL – Quantity Limits ST – Step Therapy NM – Not available at mail-order 43 B/D – Covered under Medicare B or D LA – Limited Access
Formulary ID 00020345 v13 08/01/2020
Drug Name Drug Tier Requirements/Limits NUTRITIONAL/SUPPLEMENTS – VITAMINS AND SUPPLEMENTS ELECTROLYTES
premasol 10% GENERIC B/D, NM PROCALAMINE OTHER B/D, NM
PROSOL OTHER B/D, NM
PA – Prior Authorization QL – Quantity Limits ST – Step Therapy NM – Not available at mail-order B/D – Covered under Medicare B or D LA – Limited Access
Formulary ID 00020345 v13 08/01/2020
Drug Name Drug Tier Requirements/Limits TRAVASOL OTHER B/D, NM
TROPHAMINE INJ 10% OTHER B/D, NM IV REPLACEMENT SOLUTIONS
PA – Prior Authorization QL – Quantity Limits ST – Step Therapy NM – Not available at mail-order 45 B/D – Covered under Medicare B or D LA – Limited Access
Formulary ID 00020345 v13 08/01/2020
Drug Name Drug Tier Requirements/Limits VITAMINS calcitriol CAPS GENERIC B/D calcitriol inj GENERIC B/D, NM calcitriol oral soln 1 mcg/ml GENERIC B/D M-NATAL PLUS OTHER NM paricalcitol CAPS GENERIC B/D PNV FOLIC ACID + IRON MUL OTHER NM PRENATAL OTHER NM PRENATAL PLUS OTHER NM PRENATAL PLUS LOW IRON OTHER NM RAYALDEE OTHER TRICARE OTHER NM OPHTHALMIC – DRUGS TO TREAT EYE CONDITIONS ANTI-INFECTIVE/ANTI-INFLAMMATORY – DRUGS TO TREAT INFECTIONS AND INFLAMMATION
latanoprost SOLN GENERIC levobunolol hcl GENERIC LUMIGAN OTHER
PHOSPHOLINE IODIDE OTHER pilocarpine hcl SOLN GENERIC RHOPRESSA OTHER
SIMBRINZA OTHERtimolol maleate (ophth) soln GENERICtimolol maleate gel G ENERIC
PA – Prior Authorization QL – Quantity Limits ST – Step Therapy NM – Not available at mail-order 47 B/D – Covered under Medicare B or D LA – Limited Access
Formulary ID 00020345 v13 08/01/2020
Drug Name Drug Tier Requirements/Limits timolol maleate ophth soln 0.5% (once-daily) GENERIC travoprost GENERIC MISCELLANEOUS ATROPINE SULFATE SOLN 1% OTHER CYSTARAN OTHER NM, LA, PA proparacaine hcl SOLN GENERIC NM
RESTASIS OTHER QL (60 single use vials / 30 days) RESTASIS MULTIDOSE OTHER QL (1 bottle / 30 days)
RESPIRATORY – DRUGS TO TREAT BREATHING DISORDERS ANTICHOLINERGIC/BETA AGONIST COMBINATIONS – DRUGS TO TREAT COPD ANORO ELLIPTA OTHER QL (60 blisters / 30 days)BEVESPI AEROSPHERE OTHER QL (1 inhaler / 30 days)COMBIVENT RESPIMAT OTHER QL (2 inhalers / 30 days)ipratropium-albuterol nebu GENERIC B/D
TRELEGY ELLIPTA OTHER QL (60 blisters / 30 days)ANTICHOLINERGICS – DRUGS TO TREAT COPD ATROVENT HFA OTHER QL (2 inhalers / 30 days) INCRUSE ELLIPTA OTHER QL (30 blisters / 30 days) ipratropium bromide SOLN GENERIC B/D ipratropium bromide (nasal) GENERIC ANTIHISTAMINES – DRUGS TO TREAT ALLERGIES azelastine spr 0.1% GENERIC NM azelastine spr 0.15% GENERIC NM cetirizine syrup GENERIC NM cyproheptadine hcl SYRP; TABS GENERIC NM, PA; PA if 70 years and older diphenhydramine hcl inj 50mg/ml GENERIC NM hydroxyzine hcl SYRP; TABS GENERIC NM, PA; PA if 70 years and older hydroxyzine hcl inj GENERIC NM, PA; PA if 70 years and older hydroxyzine pamoate CAPS 25mg, 50mg GENERIC NM, PA; PA if 70 years and older levocetirizine dihydrochloride GENERIC NM BETA AGONISTS – DRUGS TO TREAT ASTHMA AND COPD albuterol sulfate AERS 108mcg/act GENERIC QL (2 inhalers / 30 days);
PA – Prior Authorization QL – Quantity Limits ST – Step Therapy NM – Not available at mail-order 48 B/D – Covered under Medicare B or D LA – Limited Access
Formulary ID 00020345 v13 08/01/2020
Drug Name Drug Tier Requirements/Limits VENTOLIN HFA OTHER QL (2 inhalers / 30 days) LEUKOTRIENE MODULATORS montelukast sodium CHEW; PACK; TABS GENERIC zafirlukast GENERIC MAST CELL STABILIZERS – DRUGS TO TREAT ALLERGIES cromolyn sod neb 20mg/2ml GENERIC B/D MISCELLANEOUS acetylcysteine SOLN 10%, 20% GENERIC B/D, NM ARALAST NP OTHER NM, LA, PA DALIRESP OTHER epinephrine (anaphylaxis) .15mg/0.3ml, .3mg/0.3ml GENERIC NM; (generic of EpiPen) epinephrine (anaphylaxis) .15mg/0.15ml, .3mg/0.3ml GENERIC NM; (generic of Adrenaclick) ESBRIET OTHER NM, PA FASENRA OTHER NM, LA, PA FASENRA PEN OTHER NM, LA, PA KALYDECO OTHER NM, PA NUCALA OTHER NM, LA, PA OFEV OTHER NM, PA ORKAMBI OTHER NM, PA PROLASTIN-C OTHER NM, LA, PA PULMOZYME OTHER NM, PA SYMDEKO OTHER NM, LA, PA
SYMJEPI OTHER NM theo-24 GENERIC
theophylline GENERICtheophylline tab er 12hr 300 mg GENERICtheophylline tab er 12hr 450 mg GENERICtheophylline tab sr 24hr GENERICTRIKAFTA OTHER NM, LA, PA XOLAIR OTHER NM, LA, PA ZEMAIRA OTHER NM, LA, PA NASAL STEROIDS – DRUGS TO TREAT ALLERGIES flunisolide (nasal) GENERIC QL (3 bottles / 30 days), NM fluticasone propionate (nasal) GENERIC QL (1 bottle / 30 days), NM STEROID INHALANTS – DRUGS TO TREAT ASTHMA
ARNUITY ELLIPTA OTHER QL (30 inhalations / 30 days)
PULMICORT FLEXHALER OTHER QL (2 inhalers / 30 days)STEROID/BETA-AGONIST COMBINATIONS – DRUGS TO TREAT ASTHMA AND COPD ADVAIR DISKUS OTHER QL (60 inhalations / 30 days)
ADVAIR HFA OTHER QL (1 inhaler / 30 days)
PA – Prior Authorization QL – Quantity Limits ST – Step Therapy NM – Not available at mail-order 49 B/D – Covered under Medicare B or D LA – Limited Access
Formulary ID 00020345 v13 08/01/2020
Drug Name Drug Tier Requirements/Limits BREO ELLIPTA OTHER QL (60 blisters / 30 days) SYMBICORT OTHER QL (1 inhaler / 30 days) TOPICAL – DRUGS TO TREAT EAR AND SKIN CONDITIONS DERMATOLOGY, ACNE amnesteem GENERIC NM, PA avita GENERIC QL (45 grams / 30 days), NM, PA benzoyl peroxide-erythromycin GENERIC NM claravis GENERIC NM, PA clindamycin phosphate (topical) GEL GENERIC QL (75 grams / 30 days), NM clindamycin phosphate (topical) LOTN GENERIC NM clindamycin phosphate (topical) SOLN GENERIC QL (60 mL / 30 days), NM ery pad 2% GENERIC NM erythromycin (acne aid) GENERIC NM isotretinoin CAPS GENERIC NM, PA
myorisan GENERIC NM, PA sulfacetamide sodium (acne) GENERIC NM
tretinoin CREA GENERIC QL (45 grams / 30 days), NM, PA tretinoin GEL .01%, .025% GENERIC QL (45 grams / 30 days), NM, PA zenatane GENERIC NM, PA
PA – Prior Authorization QL – Quantity Limits ST – Step Therapy NM – Not available at mail-order B/D – Covered under Medicare B or D LA – Limited Access
Formulary ID 00020345 v13 08/01/2020
50
Drug Name Drug Tier Requirements/Limits DERMATOLOGY, ANTISEBORRHEICS
PA – Prior Authorization QL – Quantity Limits ST – Step Therapy NM – Not available at mail-order B/D – Covered under Medicare B or D LA – Limited Access
sod chloride 38PEGANONE 20PEGASYS 7PEGASYS PROCLICK 7PEMAZYRE 13penicillamine 31PENICILLIN G POT IN DEXTROSE 2MU 9PENICILLIN G POT IN DEXTROSE 3MU 9penicillin g procaine 9penicillin g sodium 9penicillin v potassium 9penicilln gk inj 20mu 9
Mercy Care Advantage (HMO SNP) Member Services Call 602‑586‑1730 or 1‑877‑436‑5288
Calls to these numbers are free. 8:00 a.m. – 8:00 p.m., 7 days a week.
Member Services also has free language interpreter services available for non-English speakers.
TTY 711 Calls to this number are free. 8:00 a.m. – 8:00 p.m., 7 days a week.
Write Mercy Care Advantage (HMO SNP) 4755 S. 44th Place Phoenix, AZ 85040
Website www.MercyCareAZ.org
This formulary was updated on 08/01/2020. For more recent information or other questions, please contact Mercy Care Advantage (HMO SNP) Member Services at 602‑586‑1730 or 1‑877‑436‑5288 or, for TTY users, 711, 8:00 a.m. – 8:00 p.m., 7 days a week, or visit www.MercyCareAZ.org.
Servicios al Miembro de Mercy Care Advantage (HMO SNP) Llame 602‑586‑1730 o 1‑877‑436‑5288
Las llamadas a estos números son gratis. 8:00 a.m. a 8:00 p.m., 7 días de la semana.
Servicios al Miembro también tiene servicios gratuitos de interpretación de idiomas disponibles para personas que no hablan inglés.
TTY 711 Las llamadas a este número son gratis. 8:00 a.m. a 8:00 p.m., 7 días de la semana.
Escriba Mercy Care Advantage (HMO SNP) 4755 S. 44th Place Phoenix, AZ 85040
Sitio Web www.MercyCareAZ.org
Este formulario fue actualizado en 08/01/2020. Para la información más reciente o para otras preguntas, por favor llame a Servicios al Miembro de Mercy Care Advantage (HMO SNP) al 602‑586‑1730 ó al 1‑877‑436‑5288, ó para los usuarios de TTY al 711, de 8:00 a.m. – 8:00 p.m., 7 días de la semana, ó visite www.MercyCareAZ.org.