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Updated: April 1, 2022Classic Plan (HMO-POS)Value Plan (HMO)Rewards Plan (HMO)Health First Health Plans2022 FormularyList of Covered DrugsPLEASE READ: THIS DOCUMENT CONTAINS INFORMATIONABOUT THE DRUGS WE COVER IN THIS PLANFormulary ID 22464, Version Number 10This formulary was updated on 4/01/2022. For more recent information or other questions, please contactyour Health First Health Plans Care team at 800-716-7737, Monday - Friday 8 a.m. - 8 p.m. ET and Saturday8 a.m. - 12 p.m. ET between April 1 and September 30, then Monday - Sunday 8 a.m. - 8 p.m. ET betweenOctober 1 and March 31. TTY users should call 800-955-8771. You can also visit myHFHP.org.Note to existing members: This formulary has changed since last year. Please review this document tomake sure that it still contains the drugs you take.When this drug list (formulary) refers to “we,” “us”, or “our,” it means Health First Health Plans. When itrefers to “plan” or “our plan,” it means Classic Plan (HMO-POS), Value Plan (HMO), or Rewards Plan(HMO.This document includes a list of the drugs (formulary) for our plan which is current as of 4/01/2022. For anupdated formulary, please contact us. Our contact information, along with the date we last updated theformulary, appears above.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, 2022 and from time to timeduring the year.Last Updated: April 1, 2022Y0089 MPINFO9458 C (08/2021)1
What is the Health First Health Plans Formulary?A formulary is a list of covered drugs selected by Health First Health Plans in consultation with a team ofhealth care providers, which represents the prescription therapies believed to be a necessary part of a qualitytreatment program. Health First Health Plans will generally cover the drugs listed in our formulary as longas the drug is medically necessary, the prescription is filled at a Health First Health Plans network pharmacy,and other plan rules are followed. For more information on how to fill your prescriptions, please reviewyour Evidence of Coverage.Can the Formulary (drug list) change?Most changes in drug coverage happen on January 1, but we may add or remove drugs on the Drug Listduring the year, move them to different cost-sharing tiers, or add new restrictions. We must follow theMedicare rules in making these changes.Changes that can affect you this year: In the below cases, you will be affected by coverage changesduring the year: New generic drugs. We may immediately remove a brand name drug on our Drug List if we arereplacing it with a new generic drug that will appear on the same or lower cost sharing tier and withthe same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep thebrand name drug on our Drug List, but immediately move it to a different cost-sharing tier or addnew restrictions. If you are currently taking that brand name drug, we may not tell you in advancebefore we make that change, but we will later provide you with information about the specificchange(s) we have made.o If we make such a change, you or your prescriber can ask us to make an exception andcontinue to cover the brand name drug for you. The notice we provide you will also includeinformation on how to request an exception, and you can find information in the sectionbelow titled “How do I request an exception to the Health First Health Plans Formulary?” Drugs removed from the market. If the Food and Drug Administration deems a drug on ourformulary to be unsafe or the drug’s manufacturer removes the drug from the market, we willimmediately 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. Forinstance, we may add a generic drug that is not new to market to replace a brand name drug currentlyon the formulary; or add new restrictions to the brand name drug or move it to a different cost sharingtier or both. Or we may make changes based on new clinical guidelines. If we remove drugs fromour formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug, ormove a drug to a higher cost-sharing tier, we must notify affected members of the change at least 30days before the change becomes effective, or at the time the member requests a refill of the drug, atwhich time the member will receive a 30-day supply of the drug.o If we make these other changes, you or your prescriber can ask us to make an exception andcontinue to cover the brand name drug for you. The notice we provide you will also includeinformation on how to request an exception, and you can also find information in the sectionbelow entitled “How do I request an exception to the Health First Health Plans Formulary?”Changes that will not affect you if you are currently taking the drug.Generally, if you are taking a drug on our 2022 formulary that was covered at the beginning of the year, wewill not discontinue or reduce coverage of the drug during the 2022 coverage year except as described above.This means these drugs will remain available at the same cost sharing and with no new restrictions for thoseLast Updated: April 1, 2022Y0089 MPINFO9458 C (08/2021)2
members taking them for the remainder of the coverage year. You will not get direct notice this year aboutchanges that do not affect you. However, on January 1 of the next year, such changes would affect you, andit is important to check the Drug List for the new benefit year for any changes to drugs.The enclosed formulary is current as of 4/01/2022. To get updated information about the drugs covered byHealth First Health Plans and/or to request a hard copy of the formulary, please contact us. Our contactinformation appears on the front page. We update hard copies of our formulary every month. We also postinformation about certain changes we have made to our formulary every month at myHFHP.org.How do I use the Formulary?There are two ways to find your drug within the formulary:Medical ConditionThe formulary begins on page 7. The drugs in this formulary are grouped into categories depending onthe type of medical conditions that they are used to treat. For example, drugs used to treat a heartcondition are listed under the category, ANTI-ARRYTHMICS. If you know what your drug is used for,look for the category name in the list that begins on page 7. Then look under the category name for yourdrug.Alphabetical ListingIf you are not sure what category to look under, you should look for your drug in the Index that beginson page 79. The Index provides an alphabetical list of all of the drugs included in this document. Bothbrand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Nextto your drug, you will see the page number where you can find coverage information. Turn to the pagelisted in the Index and find the name of your drug in the first column of the list.What are generic drugs?Health First Health Plans covers both brand name drugs and generic drugs. A generic drug is approved bythe FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost lessthan brand name drugs.Are there any restrictions on my coverage?Some covered drugs may have additional requirements or limits on coverage. These requirements and limitsmay include: Prior Authorization: Health First Health Plans requires you or your physician to get priorauthorization for certain drugs. This means that you will need to get approval from us before you fillyour prescriptions. If you don’t get approval, Health First Health Plans may not cover the drug. Quantity Limits: For certain drugs, Health First Health Plans limits the amount of the drug that wewill cover. For example, we provide 60 tablets per month supply for ELIQUIS. This may be inaddition to a standard one-month or three-month supply. Step Therapy: In some cases, Health First Health Plans requires you to first try certain drugs to treatyour medical condition before we will cover another drug for that condition. For example, if Drug Aand Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first.If Drug A does not work for you, we will then cover Drug B.Last Updated: April 1, 2022Y0089 MPINFO9458 C (08/2021)3
You can find out if your drug has any additional requirements or limits by looking in the formulary thatbegins on page 7. You can also get more information about the restrictions applied to specific covered drugsby visiting our Web site. We have posted online documents that explain our prior authorization and steptherapy restrictions. You may also ask us to send you a copy. Our contact information, along with the datewe last updated the formulary, appears on the front page.You can ask Health First Health Plans to make an exception to these restrictions or limits or for a list ofother, similar drugs that may treat your health condition. See the section, “How do I request an exception tothe Health First Health Plans formulary?” on page 4 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 your Care teamand ask if your drug is covered.If you learn that Health First Health Plans does not cover your drug, you have two options: You can ask your Care team for a list of similar drugs that are covered by Health First Health Plans.When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that iscovered by our plan. You can ask us to make an exception and cover your drug. See below for information about how torequest an exception.How do I request an exception to the Health First Health Plans Formulary?You can ask us to make an exception to our coverage rules. There are several types of exceptions that youcan 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 becovered at a pre-determined cost-sharing level, and you would not be able to ask us to provide thedrug at a lower cost-sharing level. You can ask us to cover a formulary drug at lower cost-sharing level, unless the drug is on thespecialty tier. 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,our plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you canask us to waive the limit and cover a greater amount.Generally, Health First Health Plans will only approve your request for an exception if the alternative drugsincluded on the plan’s formulary or additional utilization restrictions would not be as effective in treatingyour 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 restrictionexception. When you request a formulary or utilization restriction exception you should submit astatement from your prescriber or physician supporting your request. Generally, we must make ourdecision 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 72hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24hours after we get a supporting statement from your doctor or other prescriber.Last Updated: April 1, 2022Y0089 MPINFO9458 C (08/2021)4
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, youmay be taking a drug that is on our formulary but your ability to get it is limited. For example, you may needa prior authorization from us before you can fill your prescription. You should talk to your doctor to decideif you should switch to an appropriate drug that we cover or request a formulary exception so that we willcover the drug you take. While you talk to your doctor to determine the right course of action for you, wemay 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 willcover a temporary 30-day supply. If your prescription is written for fewer days, we’ll allow refills to provideup to a maximum 30-day supply of medication. After your first 30-day supply, we will not pay for thesedrugs, 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 yourability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we willcover a 31-day emergency supply of that drug while you pursue a formulary exception.For members who move to or from a Long-Term Facility (LTC) after their first 90 days of enrollment, areallowed to fill an emergency supply of a non-formulary medication while you and your doctor work to eitherswitch to a covered drug or request a prior authorization.Limitations on Diabetic SuppliesRoche Diabetes Care is our exclusive diabetic supply manufacturer. We only cover monitors, test strips, andlancets manufactured by Roche Diabetes Care. You may use any of the following glucose monitors that aremanufactured by Roche Diabetes Care: Accu-Chek Aviva Plus Care Kit; Accu-Chek Guide Care Kit; AccuChek Nano SmartView Care Kit.For more informationFor more detailed information about your Health First Health Plans prescription drug coverage, pleasereview your Evidence of Coverage and other plan materials.If you have questions about your plan, please contact us. Our contact information, along with the date we lastupdated the formulary, appears on the front page.If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800MEDICARE (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.Health First Health Plans FormularyThe formulary below provides coverage information about the drugs covered by Health First Health Plans.If you have trouble finding your drug in the list, turn to the Index that begins on page 79.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 information in the Requirements/Limits column tells you if our any special requirements for coverage ofyour drug.Last Updated: April 1, 2022Y0089 MPINFO9458 C (08/2021)5
Drug TiersThe Drug Tier column indicates the drug’s tier. Your cost-share for each tier is described in your Evidence ofCoverage. Please note that we have 5 tiers:Tier 1: Preferred GenericTier 2: GenericTier 3: Preferred BrandTier 4: Non-Preferred BrandTier 5: SpecialtyRequirements/LimitsBelow is a description of the acronyms we list in the Requirements/Limits column.QL: Quantity LimitFor certain drugs, we limit the amount of the drug that you can have by limiting how much of a drug you canget each time you fill your prescription. For example, if it is normally considered safe to take only one pillperday for a certain drug, we may limit coverage for your prescription to no more than one pill per day.PA: Prior AuthorizationWe require you or your physician to get prior authorization for certain drugs. This means that you will needto get approval from us before you fill your prescriptions. If you don’t get approval, we may not cover thedrug.ST: Step TherapyIn some cases, we require you to first try certain drugs to treat your medical condition before we will coveranother drug for that condition. For example, if Drug A and Drug B both treat your medical condition, wemay not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover DrugB.LA: Limited AccessThis prescription may be available only at certain pharmacies. For more information, consult your PharmacyDirectory at myHFHP.org or call us. Our contact information appears on the front page.MO: Mail-Order DrugThis prescription drug is available through our mail-order service, as well as through our retail networkpharmacies.NM: Not Available via Mail OrderThis drug is not available through mail order.B/D: Part B vs. Part DThis drug could be covered under your Part B (medical) benefit or your Part D (drug) benefit depending onhow you will use it. We need to decide how we will cover the drug before you get it. You or your physicianmust ask us to make this decision before you get this drug. Your cost-share for the drug under your Part Bbenefit will be different than your cost-share for the drug under your Part D benefit. You will pay 20% ofthe cost for drugs covered under your Part B benefit.Last Updated: April 1, 2022Y0089 MPINFO9458 C (08/2021)6
HEALTH FIRST FL CY22 CORE PRINT eff 04/01/2022Drug NameDrug Tier Requirements/LimitsANALGESICSGOUTallopurinol TABS 100mg, 300mgcolchicine TABS .6mgcolchicine w/ probenecid tab 0.5-500 mgfebuxostat TABS 40mg, 80mgMITIGARE CAPS .6mgprobenecid TABS 500mg122232QL (120 tabs / 30 days)PAQL (60 caps / 30 days)NSAIDScelecoxib CAPS 50mgcelecoxib CAPS 100mgcelecoxib CAPS 200mgcelecoxib CAPS 400mgdiclofenac potassium TABS 50mgdiclofenac sodium TB24 100mg; TBEC25mg, 50mg, 75mgdiclofenac w/ misoprostol tab delayedrelease 50-0.2 mgdiclofenac w/ misoprostol tab delayedrelease 75-0.2 mgdiflunisal TABS 500mgec-naproxen TBEC 375mgec-naproxen TBEC 500mgetodolac CAPS 200mg, 300mg; TABS400mg, 500mg; TB24 400mg, 500mg,600mgflurbiprofen TABS 100mgibu TABS 600mg, 800mgibuprofen SUSP 100mg/5mlibuprofen TABS 400mg, 600mg, 800mgmeloxicam TABS 7.5mg, 15mgnabumetone TABS 500mg, 750mgnaproxen TABS 250mg, 375mg, 500mgnaproxen TBEC 375mgnaproxen TBEC 500mgnaproxen sodium TABS 275mg, 550mgoxaprozin TABS 600mgpiroxicam CAPS 10mg, 20mgsulindac TABS 150mg, 200mg222222QLQLQLQLQL(240 caps / 30 days)(120 caps / 30 days)(60 caps / 30 days)(30 caps / 30 days)(120 tabs / 30 days)2222222121111222222QL (120 tabs / 30 days)QL (90 tabs / 30 days)QL (120 tabs / 30 days)QL (90 tabs / 30 days)OPIOID ANALGESICS, LONG-ACTINGfentanyl PT72 12mcg/hr, 25mcg/hr,50mcg/hr, 75mcg/hr, 100mcg/hrhydrocodone bitartrate T24A 20mg,30mg, 40mg, 60mg22QL (10 patches / 30days), PAQL (30 tabs / 30 days),PA7
Drug NameDrug Tierhydrocodone bitartrate T24A 80mg,3100mg, 120mgHYSINGLA ER T24A 20mg, 30mg, 40mg,360mg, 80mg, 100mg, 120mgmethadone hcl SOLN 5mg/5ml, 10mg/5ml2methadone hcl TABS 5mg, 10mg2methadone hydrochloride i CONC10mg/mlmorphine sulfate TBCR 15mg, 30mg,60mg, 100mg, 200mg22Requirements/LimitsQL (30 tabs / 30 days),PAQL (30 tabs / 30 days),PAQL (450 mL / 30 days),PAQL (90 tabs / 30 days),PAQL (90 mL / 30 days),PAQL (90 tabs / 30 days),PAOPIOID ANALGESICS, SHORT-ACTINGacetaminophen w/ codeine soln 120-12mg/5mlacetaminophen w/ codeine tab 300-15 mgacetaminophen w/ codeine tab 300-30 mgacetaminophen w/ codeine tab 300-60 mgbutorphanol tartrate SOLN 1mg/ml,2mg/mlendocet tab 2.5-325mgendocet tab 5-325mgendocet tab 7.5-325mgendocet tab 10-325mgfentanyl citrate LPOP 200mcg2QL (2700 mL / 30 days)2224QL (400 tabs / 30 days)QL (360 tabs / 30 days)QL (180 tabs / 30 days)22222fentanyl citrate LPOP 400mcg, 600mcg,800mcg, 1200mcg, 1600mcghydrocodone-acetaminophen soln 7.5-325mg/15mlhydrocodone-acetaminophen tab 5-325 mghydrocodone-acetaminophen tab 7.5-325mghydrocodone-acetaminophen tab 10-325mghydrocodone-ibuprofen tab 7.5-200 mghydromorphone hcl LIQD 1mg/mlhydromorphone hcl TABS 2mg, 4mg, 8mgmorphine sulfate SOLN 1mg/ml, 4mg/ml,10mg/mlMORPHINE SULFATE SOLN 2mg/ml,4mg/ml, 5mg/ml, 8mg/ml, 10mg/mlmorphine sulfate SOLN 10mg/5ml,20mg/5mlmorphine sulfate SOLN 100mg/5mlmorphine sulfate TABS 15mg, 30mgnalbuphine hcl SOLN 10mg/ml, 20mg/ml52QL (360 tabs / 30 days)QL (360 tabs / 30 days)QL (240 tabs / 30 days)QL (180 tabs / 30 days)QL (120 lozenges / 30days), PAQL (120 lozenges / 30days), PAQL (2700 mL / 30 days)22QL (240 tabs / 30 days)QL (180 tabs / 30 days)2QL (180 tabs / 30 days)2224QL (150 tabs / 30 days)QL (600 mL / 30 days)QL (180 tabs / 30 days)B/D4B/D2QL (900 mL / 30 days)224QL (180 mL / 30 days)QL (180 tabs / 30 days)8
Drug NameDrug Tieroxycodone hcl CAPS 5mg2oxycodone hcl CONC 100mg/5ml2oxycodone hcl SOLN 5mg/5ml2oxycodone hcl TABS 5mg, 10mg, 15mg,220mg, 30mgoxycodone w/ acetaminophen tab 2.5-3252mgoxycodone w/ acetaminophen tab 5-3252mgoxycodone w/ acetaminophen tab 7.5-3252mgoxycodone w/ acetaminophen tab 10-3252mgtramadol hcl TABS 50mg2tramadol-acetaminophen tab 37.5-325 mg2Requirements/LimitsQL (180 caps / 30 days)QL (180 mL / 30 days)QL (900 mL / 30 days)QL (180 tabs / 30 days)QL (360 tabs / 30 days)QL (360 tabs / 30 days)QL (240 tabs / 30 days)QL (180 tabs / 30 days)QL (240 tabs / 30 days)QL (240 tabs / 30 days)ANESTHETICSLOCAL ANESTHETICSlidocaine hcl (local anesth.) SOLN .5%,1%, 1.5%, 2%2B/DANTI-INFECTIVESANTI-INFECTIVES - MISCELLANEOUSalbendazole TABS 200mgamikacin sulfate SOLN 1gm/4ml,500mg/2mlatovaquone SUSP 750mg/5mlaztreonam SOLR 1gm, 2gmCAYSTON SOLR 75mgclindamycin hcl CAPS 75mg, 150mg,300mgclindamycin palmitate hydrochloride SOLR75mg/5mlclindamycin phosphate SOLN 300mg/2ml,600mg/4ml, 900mg/6ml, 9000mg/60mlclindamycin phosphate in d5w iv soln 300mg/50mlclindamycin phosphate in d5w iv soln 600mg/50mlclindamycin phosphate in d5w iv soln 900mg/50mlCLINDMYC/NAC INJ 300/50MLCLINDMYC/NAC INJ 600/50MLCLINDMYC/NAC INJ 900/50MLcolistimethate sodium SOLR 150mgdapsone TABS 25mg, 100mgDAPTOMYCIN SOLR 350mgdaptomycin SOLR 350mg, 500mgEMVERM CHEW 100mg522251NM, LA, PA2222244422555QL (12 tabs / year)9
Drug NameDrug Tierertapenem sodium SOLR 1gm2gentamicin in saline inj 0.8 mg/ml2gentamicin in saline inj 1 mg/ml2gentamicin in saline inj 1.2 mg/ml2gentamicin in saline inj 1.6 mg/ml2gentamicin in saline inj 2 mg/ml2gentamicin sulfate SOLN 10mg/ml,240mg/mlimipenem-cilastatin intravenous for soln2250 mgimipenem-cilastatin intravenous for soln2500 mgivermectin TABS 3mg2linezolid SOLN 600mg/300ml2linezolid SUSR 100mg/5ml5linezolid TABS 600mg2linezolid in sodium chloride iv soln 6002mg/300ml-0.9%meropenem SOLR 1gm, 500mg2methenamine hippurate TABS 1gm2metronidazole TABS 250mg, 500mg1metronidazole in nacl 0.79% iv soln 5002mg/100mlneomycin sulfate TABS 500mg2nitazoxanide TABS 500mg5nitrofurantoin macrocrystal CAPS 50mg,3100mgnitrofurantoin monohyd macro CAPS3100mgparomomycin sulfate CAPS 250mg2pentamidine isethionate inh SOLR 300mg2pentamidine isethionate inj SOLR 300mg2praziquantel TABS 600mg2SIVEXTRO SOLR 200mg; TABS 200mg5streptomycin sulfate SOLR 1gm2sulfadiazine TABS 500mg4sulfamethoxazole-trimethoprim iv soln2400-80 mg/5mlsulfamethoxazole-trimethoprim susp 200240 mg/5mlsulfamethoxazole-trimethoprim tab 400-801mgsulfamethoxazole-trimethoprim tab 8001160 mgSYNERCID INJ 500MG5tobramycin NEBU 300mg/5ml5Requirements/LimitsPAQL (1800 mL / 30 days)QL (60 tabs / 30 days)QL (6 tabs / 30 days)B/DNM, PA10
Drug Nametobramycin sulfate SOLN 1.2gm/30ml,10mg/ml, 40mg/ml, 80mg/2mlTRIMETHOPRIM TABS 100mgvancomycin hcl CAPS 125mgvancomycin hcl CAPS 250mgvancomycin hcl SOLR 1gm, 5gm, 10gm,500mg, 750mgVANCOMYCIN INJ 1 GMVANCOMYCIN INJ 500MGVANCOMYCIN INJ 750MGDrug Tier Requirements/Limits2122QL (80 caps / 180 days)QL (160 caps / 180days)2444ANTIFUNGALSABELCET SUSP 5mg/mlAMBISOME SUSR 50mgamphotericin b SOLR 50mgcaspofungin acetate SOLR 50mg, 70mgfluconazole SUSR 10mg/ml, 40mg/ml;TABS 50mg, 100mg, 150mg, 200mgfluconazole in nacl 0.9% inj 200 mg/100mlfluconazole in nacl 0.9% inj 400 mg/200mlflucytosine CAPS 250mg, 500mggriseofulvin microsize SUSP 125mg/5ml;TABS 500mggriseofulvin ultramicrosize TABS 125mg,250mgitraconazole CAPS 100mgketoconazole TABS 200mgmicafungin sodium SOLR 50mg, 100mgNOXAFIL SUSP 40mg/ml45222nystatin TABS 500000unitposaconazole TBEC 100mg25terbinafine hcl TABS 250mgvoriconazole SOLR 200mg; SUSR40mg/mlvoriconazole TABS 50mg15voriconazole TABS 200mg22252B/DB/DB/DPA222552PAPAQL (630 mL / 30 days),PAQL (93 tabs / 30 days),PAQL (90 tabs / year)PAQL (480 tabs / 30 days),PAQL (120 tabs / 30 days),PAANTIMALARIALSatovaquone-proguanil hcl tab 62.5-25 mgatovaquone-proguanil hcl tab 250-100 mgchloroquine phosphate TABS 250mg,500mgCOARTEM TAB 20-120MGmefloquine hcl TABS 250mg2224211
Drug Nameprimaquine phosphate TABS 26.3mgPRIMAQUINE PHOSPHATE TABS 26.3mgquinine sulfate CAPS 324mgDrug Tier Requirements/Limits232PAANTIRETROVIRAL AGENTSabacavir sulfate SOLN 20mg/ml; TABS300mgAPTIVUS CAPS 250mgatazanavir sulfate CAPS 150mg, 200mg,300mgEDURANT TABS 25mgefavirenz CAPS 50mg, 200mg; TABS600mgemtricitabine CAPS 200mgEMTRIVA SOLN 10mg/mletravirine TABS 100mg, 200mgfosamprenavir calcium TABS 700mgFUZEON SOLR 90mgINTELENCE TABS 25mgINVIRASE TABS 500mgISENTRESS CHEW 25mg; PACK 100mgISENTRESS CHEW 100mg; TABS 400mgISENTRESS HD TABS 600mglamivudine SOLN 10mg/ml; TABS 150mg,300mgLEXIVA SUSP 50mg/mlmaraviroc TABS 150mg, 300mgNEVIRAPINE SUSP 50mg/5mlnevirapine TABS 200mg; TB24 100mg,400mgNORVIR PACK 100mg; SOLN 80mg/mlPIFELTRO TABS 100mgPREZISTA SUSP NMNMNM4522NMNMNMNM455PREZISTA TABS 75mg4PREZISTA TABS 150mg5PREZISTA TABS 600mg5PREZISTA TABS 800mg5REYATAZ PACK 50mgritonavir TABS 100mgRUKOBIA TB12 600mgSELZENTRY SOLN 20mg/ml; TABS 75mg,150mg, 300mgSELZENTRY TABS 25mg5255NMNMQL (400 mL / 30 days),NMQL (480 tabs / 30 days),NMQL (240 tabs / 30 days),NMQL (60 tabs / 30 days),NMQL (30 tabs / 30 days),NMNMNMNMNM3NM12
Drug NameDrug Tierstavudine CAPS 15mg, 20mg, 30mg,240mgtenofovir disoproxil fumarate TABS 300mg2TIVICAY TABS 10mg3TIVICAY TABS 25mg, 50mg5TIVICAY PD TBSO 5mg3TROGARZO SOLN 200mg/1.33ml5TYBOST TABS 150mg3VIRACEPT TABS 250mg, 625mg5VIREAD POWD 40mg/gm; TABS 150mg,5200mg, 250mgzidovudine CAPS 100mg; SYRP250mg/5ml; TABS 300mgRequirements/LimitsNMNMNMNMNMNM, LANMNMNMNMANTIRETROVIRAL COMBINATION AGENTSabacavir sulfate-lamivudine tab 600-300mgabacavir sulfate-lamivudine-zidovudine tab300-150-300 mgBIKTARVY TAB 30-120-15 MGBIKTARVY TAB 50-200-25 MGCIMDUO TAB 300-300COMPLERA TABDELSTRIGO TABDESCOVY TAB 200/25MGDOVATO TAB 50-300MGefavirenz-emtricitabine-tenofovir df tab600-200-300 mgefavirenz-lamivudine-tenofovir df tab 400300-300 mgefavirenz-lamivudine-tenofovir df tab 600300-300 mgemtricitabine-tenofovir disoproxil fumaratetab 100-150 mgemtricitabine-tenofovir disoproxil fumaratetab 133-200 mgemtricitabine-tenofovir disoproxil fumaratetab 167-250 mgemtricitabine-tenofovir disoproxil fumaratetab 200-300 mgEVOTAZ TAB 300-150GENVOYA TABJULUCA TAB 50-25MGlamivudine-zidovudine tab 150-300 mglopinavir-ritonavir soln 400-100 mg/5ml(80-20 mg/ml)lopinavir-ritonavir tab 100-25 mglopinavir-ritonavir tab 200-50 mg2NM5NM55555555NMNMNMNMNMNMNMNM5NM5NM555522QL (30NMQL (30NMQL (30NMQL (30NMNMNMNMNMNM25NMNM555tabs / 30 days),tabs / 30 days),tabs / 30 days),tabs / 30 days),13
Drug NameODEFSEY TABPREZCOBIX TAB 800-150STRIBILD TABSYMTUZA TABTEMIXYS TAB 300-300TRIUMEQ TABDrug CULAR AGENTScycloserine CAPS 250mgethambutol hcl TABS 100mg, 400mgisoniazid SYRP 50mg/5mlisoniazid TABS 100mg, 300mgPASER PACK 4gmPRIFTIN TABS 150mgpyrazinamide TABS 500mgrifabutin CAPS 150mgrifampin CAPS 150mg, 300mg; SOLR600mgSIRTURO TABS 20mg, 100mgTRECATOR TABS 250mg52214422254LA, PAANTIVIRALSacyclovir CAPS 200mg; TABS 400mg,800mgacyclovir SUSP 200mg/5mlacyclovir sodium SOLN 50mg/mladefovir dipivoxil TABS 10mgBARACLUDE SOLN .05mg/mlentecavir TABS .5mg, 1mgEPCLUSA PAK 150-37.5EPCLUSA PAK 200-50MGEPCLUSA TAB 200-50MGEPCLUSA TAB 400-100EPIVIR HBV SOLN 5mg/mlfamciclovir TABS 125mg, 250mg, 500mgganciclovir sodium SOLR 500mgHARVONI PAK 33.75-150MGHARVONI PAK 45-200MGHARVONI TAB 45-200MGHARVONI TAB 90-400MGlamivudine (hbv) TABS 100mgMAVYRET PAK 50-20MGMAVYRET TAB 100-40MGoseltamivir phosphate CAPS 30mgoseltamivir phosphate CAPS 45mg, 75mgoseltamivir phosphate SUSR 6mg/mlPEGASYS SOLN 180mcg/ml; M,NM,NM,NM,NMPAPAPAPAB/DNM, PANM, PANM, PANM, PANMNM, PANM, PAQL (168 caps / year)QL (84 caps / year)QL (1080 mL / year)NM, PA14
Drug NamePREVYMIS TABS 240mg, 480mgDrug Tier Requirements/Limits5QL (28 tabs / 28 days),PARELENZA DISKHALER AEPB 5mg/blister3QL (6 inhalers / year)ribavirin (hepatitis c) CAPS 200mg; TABS2NM200mgrimantadine hydrochloride TABS 100mg2valacyclovir hcl TABS 1gm, 500mg2valganciclovir hcl SOLR 50mg/ml5valganciclovir hcl TABS 450mg2VEMLIDY TABS 25mg5NM, PAVOSEVI TAB5NM, PACEPHALOSPORINScefaclor CAPS 250mg, 500mg; SUSR125mg/5ml, 250mg/5ml, 375mg/5mlCEFACLOR ER TB12 500mgcefadroxil CAPS 500mgcefadroxil SUSR 250mg/5ml, 500mg/5mlCEFAZOLIN INJ 1GM/50MLcefazolin sodium SOLR 1gm, 10gm,500mgCEFAZOLIN SOLN 2GM/100ML-4%cefdinir CAPS 300mg; SUSR 125mg/5ml,250mg/5mlcefepime hcl SOLR 1gm, 2gmcefixime SUSR 100mg/5ml, 200mg/5mlcefoxitin sodium SOLR 1gm, 2gm, 10gmcefpodoxime proxetil SUSR 50mg/5ml,100mg/5ml; TABS 100mg, 200mgcefprozil SUSR 125mg/5ml, 250mg/5ml;TABS 250mg, 500mgceftazidime SOLR 1gm, 2gm, 6gmCEFTAZIDIME/ SOL D5W 1GMCEFTAZIDIME/ SOL D5W 2GMceftriaxone sodium SOLR 1gm, 2gm,10gm, 250mg, 500mgcefuroxime axetil TABS 250mg, 500mgcefuroxime sodium SOLR 1.5gm, 7.5gm,750mgcephalexin CAPS 250mg, 500mgcephalexin SUSR 125mg/5ml, 250mg/5mltazicef SOLR 1gm, 2gmTAZICEF SOLR 6gmTEFLARO SOLR 400mg, DESazithromycin PACK 1gm; SOLR 500mg;SUSR 100mg/5ml, 200mg/5ml215
Drug NameDrug Tier Requirements/Limitsazithromycin TABS 250mg, 500mg,1600mgclarithromycin SUSR 125mg/5ml,2250mg/5ml; TABS 250mg, 500mg; TB24500mgDIFICID SUSR 40mg/ml; TABS 200mg5e.e.s. 400 TABS 400mg2ery-tab TBEC 250mg, 333mg, 500mg2ERYTHROCIN LACTOBIONATE SOLR5500mgerythrocin stearate TABS 250mg2erythromy
Oct 01, 2021 · Y0089_MPINFO9458_C (08/2021) 3 The enclosed formulary is current as of 10/01/2021. To get updated information about the drugs covered by Health First Health Plans and/o
