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ComprehensiveDrug List2017New York State of Health Marketplace (NYSOH)Healthfirst Leaf Premier Plans:Platinum, Gold, Silver, and BronzeHealthfirst Leaf Plans:Platinum, Gold, Silver, Bronze, and GreenHealthfirst HMO Plans:HMO A-VAD, HMO B-VAD, HMO C-VAD, HMO D-VAD,HMO A, HMO B, HMO C, HMO D, and HMO EHealthfirst Essential Plans PlusVision and Dental:Essential Plan 1 Plus Vision and DentalEssential Plan 2 Plus Vision and DentalHealthfirst Essential Plans:Essential Plans 1, 2, 3, and 4
Healthfirst Comprehensive Drug ListThis list is a guide to all of the drugs Healthfirst covers on your prescription benefit plan.You and your covered family members must use network pharmacies to get all prescription medicines.Your benefits, drug list, and/or pharmacy network, may change at times.Listed products are for informational purposes only and are not intended to replace the clinical judgmentof the prescriber.This list represents a summary of prescription coverage. It is not inclusive and does not guaranteecoverage. Any brand-name medicine for which a generic product becomes available may require priorauthorization or may not be covered. Unless specifically indicated, list products will include all oral dosageforms, except for orally disintegrating formulations. This list represents brand-name products in CAPSand generic products in lowercase italics. This is not an all-inclusive list. Listed products may be availablegenerically in certain strengths or dosage forms. Dosage forms on this list will be consistent with thecategory and use where listed. Log in to www.healthfirst.org to check coverage.This document contains references to brand-name prescription drugs that are trademarks or registeredtrademarks of pharmaceutical manufacturers not affiliated with Healthfirst.Effective October 2017
Frequently Asked QuestionsQ: What is the Healthfirst ComprehensiveDrug List?A: The Comprehensive Drug List is a list ofmedicines covered by your benefit plan.Healthfirst Plans work with a team of doctorsand pharmacists to choose medicines thatprovide quality treatment. Healthfirst willcover medicines on this list, as long as: The medicine is medically necessaryIf you are affected by a change, we will tell you atleast 60 days before the change goes into effect.Q: What else could result in changes to thecovered medicines on the list?A: We take medicine off our list and let affectedmembers know right away when: The prescription is filled at a Healthfirstnetwork pharmacy The FDA (US Food and Drug Administration)decides a product is unsafe Other plan rules are followed The company that makes the medicineremoves it from the marketPlease review your Subscriber Contract for moreinformation on coverage and how to fill yourprescriptions.Q: Can the Comprehensive Drug List change?A: Yes, the list can change. Reasons include: Removing medicine from our list ofcovered treatments Adding the need for Prior Approval orAuthorization (when your doctor mustexplain and give medical reasons why youneed a certain medicine and why a coveredoption will not work for you) Adding Quantity Limits (when you canonly get a certain amount of medicine atone time) Adding Step Therapy rules (when you haveto try one type of medicine as a first step intreating your condition, before you can tryanother type of medicine)i Moving a medicine to a higher Cost-SharingTier (when you have to pay more of theprescription cost)Q: How do I use the Comprehensive Drug List?A: Use the list to check if your current medicinesare covered options. If not, ask your doctor if amedicine on the list is right for you. Also, takethe list with you each time you or your familyvisits a doctor.There are 2 ways to find your medicine on thislist. Medicines are listed by the body systemor health condition they commonly treat andalphabetically.1. Body System or Health ConditionThe list starts on page 1. The medicines aregrouped by the body system or conditionthey are commonly used to treat. If you know what your medicine is usedfor, look for the heading on the list thatstarts on page 1 Then look under the heading foryour medicine
2. Alphabetical ListingMedicines are listed in alphabetical order inthe Index. The Index starts on page 113.Generic and brand names are listedtogether by the first letter of the medicinename. This list can help you find yourcurrent medicine if you are unsure whatbody system or condition to look under. Look in the Index and find your medicine Next to your medicine is the page numberwhere you can find coverage information Turn to that page, locate the first columnof the list, and find the name of yourmedicine in that column Read across the second and third columnsto check the Cost-Sharing Tier andrestrictions/limitsQ: What are generic medicines?A: Healthfirst covers both brand-name andgeneric medicines. A generic medicine isapproved by the FDA. It must have the sameactive ingredient and perform the same asthe brand name. Generics usually cost lessthan brand names, but can provide the samequality of treatment.Q: Are there any restrictions on my coverage?A: Some covered medicines may have morecoverage requirements or limits. Theserequirements and limits may include: Prior Authorization: Healthfirst needs yourdoctor to submit and get Prior Approvalor Authorization for certain medicines.This means that you need to get approvalfrom Healthfirst before you can fill yourprescriptions. If you don’t get approval,Healthfirst may not cover the medicine. Quantity Limits: For certain medicines,Healthfirst limits the amount that it willcover. For example, Healthfirst covers 28Tamiflu 30 mg tablets every 180 days. Thismay be in addition to a standard 1-monthor 3-month supply. Step Therapy: Healthfirst requires you totry certain medicines as the first step intreating your condition before coveringanother option. For example, if Drug Aand Drug B both treat your condition,Healthfirst may not cover Drug B unless youtry Drug A first. If Drug A does not work foryou, Healthfirst will then cover Drug B.You can find out if your medicine has anyrequirements or limits by looking at the list onpage 1. You can also get more information aboutthe restrictions for specific covered options byvisiting www.healthfirst.org.You can ask Healthfirst to make an exceptionto these restrictions or limits. See the answerto question, “How do I ask for a coverageexception?” on page iii.Q: What are OTC (over-the counter)medicines?A: OTC medicines are nonprescription productsthat are not usually covered by a prescriptionbenefit plan. Healthfirst pays for certain OTCmedicines, but your cost may differ amongthem. Please see the Comprehensive Drug Listthat starts on page 1 for more information.ii
Q: Does my plan cover prescription medicinesthat are considered “Preventive Services”under the Affordable Care Act?A: The HHS (U.S. Department of Health andHuman Services) has adopted Guidelines forPreventive Services under the ACA (AffordableCare Act). Under the ACA, some prescriptionbenefit plans may provide a range ofpreventive services for 0 member cost shareand are designated as Tier 0 on this document.These items may include: Aspirin to prevent cardiovascular disease Fluoride and/or iron supplementationin children Folic acid supplementation for womenexpecting or planning to be pregnant Tobacco use counseling andcessation intervention Immunizations Women’s health preventive services (e.g.,contraceptives, emergency contraception)A list of the covered preventive servicesis available on our web site atwww.healthfirst.org, or will be mailed toyou upon request. You can request thelist by calling Member Services at1-888-250-2220, Monday-Friday, 8am-8pmor by calling the toll-free number on theback of your Member ID card.Q: What if my medicine is not on the list?A: If you learn that Healthfirst does not coveryour medicine, you have 2 choices: You can ask Member Services for a list ofalternative options that are covered byHealthfirst. When you get the list, show it toiiiyour doctor and ask him or her to prescribean alternative that is covered by Healthfirst. You can ask Healthfirst for an exceptionto cover your medicine. Read on forinformation about how to ask foran exception.Q: How do I ask for a coverage exception?A: You can ask Healthfirst to make an exceptionto our coverage rules. There are different typesof exceptions that you can ask us to make: You can ask us to cover your medicineif it is not on our Comprehensive Drug List. You can ask us to remove a restriction orlimit. For example, Healthfirst limits theamount of certain medicine that we willcover. If your medicine has this quantitylimit, you can ask us to removethe limit and cover a larger amount.Q: Will my request for an exception beapproved?A: Generally, Healthfirst will only approve yourrequest for an exception if the coveredoptions included on the plan would: Not be as effective in treating your condition. Cause you to have adverse medical effects.Q: How do I find out if my exception hasbeen approved?A: When you ask for a utilization restrictionexception, please send a statement from yourdoctor that supports your request. Then: We will make our decision within 3business days of receipt of your doctor’ssupporting statement.
You can ask for an expedited (fast)exception if your doctor believes thatyour health could be seriously harmedby waiting up to 3 business days fora decision. If your expedited (fast) request is granted,we will give you a decision no later than24 hours after we get your doctor’ssupporting statement.Q: How do I get more information about mybenefit plan and coverage?A: For more information about your Healthfirstprescription benefit plan and coverage, pleaselook at your Subscriber Contract and otherplan materials.If you have questions about Healthfirst Plans,please call Member Services at1-888-250-2220, Monday-Friday, 8am–8pm.TTY/TDD users, please call 1-888-542-3821.Or visit www.healthfirst.org.Q: Why do my diabetic drugs have adifferent copayment?Healthfirst Comprehensive Drug ListThe Comprehensive Drug List gives coverageinformation about all of the medicines onHealthfirst Plans. If you have trouble finding yourmedicine on the list, turn to the Index.The list is up to date as of October 2017.To get updated information about themedicines covered by Healthfirst, please visitwww.healthfirst.org or call Member Servicesat 1-888-250-2220, Monday-Friday, 8am-8pm.TTY/TDD users, please call 1-888-542-3821.The list is divided into 3 columns: Column 1 lists the medicine name. Brandname medicines are capitalized. For example,DIOVAN. Generic medicines are listed in lowercase italics. For example, simvastatin. Column 2 lists the Cost-Sharing Tier forthe medicine. Column 3 lists the coverage Requirementsand Limits Healthfirst has for the medicine.Please review the LEGEND to learn about eachRequirement or Limit.A: Some diabetic supplies, insulin, and oralmedications are provided as a part of aseparate benefit setup. This means that theamount you pay may differ from the otherdrugs listed on this formulary. These drugshave a ‘ ’ next to them on the drug list. Seeyour Summary of Benefits to find out howmuch you will pay for these drugs.iv
HEALTHFIRST COMPREHENSIVE DRUG LISTDrug NameDrug Tier Requirements/LimitsANALGESICSCOX-2 apcapcap50 mg100 mg200 mg400 mg1111GOUTallopurinol tab 100 mgallopurinol tab 300 mgcolchicine tab 0.6 mgcolchicine w/ probenecid tab 0.5-500 mgprobenecid tab 500 mgULORIC TAB 40MGULORIC TAB 80MG1111133ST; PA**ST; PA**11QL (720 mL / 25 days)QL (48 caps / 25 days)1QL (48 caps / 25 days)1QL (48 tabs / 25 days)1QL (48 caps / 25 days)1QL (48 tabs / 25 days)11QL (48 caps / 25 days)QL (48 tabs per 25days)NON-OPIOID ANALGESICSalagesic lq solbutalbital-acetaminophen-caffeine cap50-300-40 mgbutalbital-acetaminophen-caffeine cap50-325-40 mgbutalbital-acetaminophen-caffeine tab50-325-40 mgbutalbital-aspirin-caffeine cap 50-325-40mgbutalbital-aspirin-caffeine tab 50-325-40mgmargesic captencon tab 50-325mgNSAIDS, COMBINATIONSdiclofenac w/ misoprostol tab delayedrelease 50-0.2 mgdiclofenac w/ misoprostol tab delayedrelease 75-0.2 mg11NSAIDSdiclofenac potassium tab 50 mgdiclofenac sodium tab delayed release 25mgdiclofenac sodium tab delayed release 50mgdiclofenac sodium tab delayed release 75mgdiclofenac sodium tab er 24hr 100 mgetodolac cap 200 mgPA - Prior Authorization QL - Quantity LimitsCounter PA** - PA Applies if Step is Not Met111111ST - Step TherapyOTC - Over The - PCP copay applies1
Drug Nameetodolac cap 300 mgetodolac tab 400 mgetodolac tab 500 mgetodolac tab er 24hr 400 mgetodolac tab er 24hr 500 mgetodolac tab er 24hr 600 mgfenoprofen calcium cap 400 mgfenoprofen calcium tab 600 mgflurbiprofen tab 50 mgflurbiprofen tab 100 mgibuprofen susp 100 mg/5mlibuprofen tab 400 mgibuprofen tab 600 mgibuprofen tab 800 mgketoprofen cap 50 mgketoprofen cap 75 mgketoprofen cap er 24hr 200 mgketorolac tromethamine im inj 60 mg/2ml(30 mg/ml)ketorolac tromethamine inj 15 mg/mlketorolac tromethamine inj 30 mg/mlketorolac tromethamine inj 60 mg/2ml (30mg/ml)ketorolac tromethamine inj 300 mg/10ml(30 mg/ml)ketorolac tromethamine tab 10 mgmeclofenamate sodium cap 50 mgmeclofenamate sodium cap 100 mgmefenamic acid cap 250 mgmeloxicam susp 7.5 mg/5mlmeloxicam tab 7.5 mgmeloxicam tab 15 mgnabumetone tab 500 mgnabumetone tab 750 mgnaproxen dr tab 375mgnaproxen dr tab 500mgnaproxen sodium tab 275 mgnaproxen sodium tab 550 mgnaproxen susp 125 mg/5mlnaproxen tab 250 mgnaproxen tab 375 mgnaproxen tab 500 mgoxaprozin tab 600 mgpiroxicam cap 10 mgpiroxicam cap 20 mgsulindac tab 150 mgPA - Prior Authorization QL - Quantity LimitsCounter PA** - PA Applies if Step is Not MetDrug Tier 111111111111ST - Step TherapyQL (20 tabs / 25 days)OTC - Over The - PCP copay applies2
Drug Namesulindac tab 200 mgtolmetin sodium cap 400 mgtolmetin sodium tab 200 mgtolmetin sodium tab 600 mgDrug Tier Requirements/Limits1111OPIOID AGONIST/ANTAGONISTbuprenorphine hcl-naloxone hcl sl tab12-0.5 mg (base equiv)buprenorphine hcl-naloxone hcl sl tab 8-2 1mg (base equiv)SUBOXONE MIS 2-0.5MG2SUBOXONE MIS 4-1MG2SUBOXONE MIS 8-2MG2SUBOXONE MIS 12-3MG2QL (90 tabs /25 days)QL (90 tabs /25 days)QLQLQLQL(90(90(90(60unitsunitsunitsunits/ 25 days)/ 25 days)/ 25 days)/ 25 days)OPIOID ANALGESICSacetaminophen w/ codeine soln 120-121mg/5mlacetaminophen w/ codeine tab 300-15 mg 1acetaminophen w/ codeine tab 300-30 mg 1acetaminophen w/ codeine tab 300-60 mg 1butorphanol tartrate nasal soln 10 mg/mlCAPITAL/COD SUS 120-12/513CODEINE SULF SOL 30MG/5MLcodeine sulfate tab 15 mg21codeine sulfate tab 30 mg1codeine sulfate tab 60 mg1EMBEDA CAP 20-0.8MG3EMBEDA CAP 30-1.2MG3EMBEDA CAP 50-2MG3EMBEDA CAP 60-2.4MG3EMBEDA CAP 80-3.2MG3EMBEDA CAP 100-4MG3endocet tab 2.5-3251PA - Prior Authorization QL - Quantity LimitsCounter PA** - PA Applies if Step is Not MetST - Step TherapyQL (2700 ml per 25days)QL (400 tablets per 25days)QL (360 tablets per 25days)QL (180 tablets per 25days)QL (2 bottles / 25 days)QL (2700 ml per 25days)QL (210 ml per 25 days)QL (42 tablets per 25days)QL (42 tablets per 25days)QL (42 tablets per 25days)QL (120 capsules per 25days)QL (120 capsules per 25days)QL (120 capsules per 25days)QL (120 capsules per 25days)QL (120 capsules per 25days)QL (120 capsules per 25days)QL (360 tablets per 25days)OTC - Over The - PCP copay applies3
Drug Nameendocet tab 5-325mgDrug Tier Requirements/Limits1QL (360 tablets per 25days)endocet tab 7.5-3251QL (240 tablets per 25days)endocet tab 10-325mg1QL (180 tablets per 25days)fentanyl citrate lozenge on a handle 2001QL (120 lozenges / 25mcgdays), PAfentanyl citrate lozenge on a handle 4001QL (120 lozenges / 25mcgdays), PAfentanyl citrate lozenge on a handle 6001QL (120 lozenges / 25mcgdays), PAfentanyl citrate lozenge on a handle 8001QL (120 lozenges / 25mcgdays), PAfentanyl citrate lozenge on a handle 1200 1QL (120 lozenges / 25mcgdays), PAfentanyl citrate lozenge on a handle 1600 1QL (120 lozenges / 25mcgdays), PAfentanyl td patch 72hr 12 mcg/hr1QL (10 patches per 25days)fentanyl td patch 72hr 25 mcg/hr1QL (10 patches per 25days)fentanyl td patch 72hr 50 mcg/hr1QL (10 patches per 25days)fentanyl td patch 72hr 75 mcg/hr1QL (10 patches per 25days)fentanyl td patch 72hr 100 mcg/hr1QL (10 patches per 25days)hydrocodone-acetaminophen soln 7.5-325 1QL (2700 ml per 25mg/15mldays)hydrocodone-acetaminophen soln 10-325 1QL (2700 ml per 25mg/15mldays)hydrocodone-acetaminophen tab 2.5-325 1QL (360 tablets per 25mgdays)hydrocodone-acetaminophen tab 5-300 mg 1QL (240 tablets per 25days)hydrocodone-acetaminophen tab 5-325 mg 1QL (240 tablets per 25days)hydrocodone-acetaminophen tab 7.5-300 1QL (180 tablets per 25mgdays)hydrocodone-acetaminophen tab 7.5-325 1QL (180 tablets per 25mgdays)hydrocodone-acetaminophen tab 10-300 1QL (180 tablets per 25mgdays)hydrocodone-acetaminophen tab 10-325 1QL (180 tablets per 25mgdays)HYDROMORPHON SUP 3MG3QL (120 suppositoriesper 25 days)PA - Prior Authorization QL - Quantity LimitsCounter PA** - PA Applies if Step is Not MetST - Step TherapyOTC - Over The - PCP copay applies4
Drug Namehydromorphone hcl liqd 1 mg/mlhydromorphone hcl tab 2 mgDrug Tier Requirements/Limits1QL (600 ml per 25 days)1QL (180 tablets per 25days)hydromorphone hcl tab 4 mg1QL (180 tablets per 25days)hydromorphone hcl tab 8 mg1QL (180 tablets per 25days)hydromorphone hcl tab er 24hr deter 8 mg 1QL (60 tablets per 25days)hydromorphone hcl tab er 24hr deter 121QL (60 tablets per 25mgdays)hydromorphone hcl tab er 24hr deter 161QL (60 tablets per 25mgdays)hydromorphone hcl tab er 24hr deter 321QL (60 tablets per 25mgdays)levorphanol tartrate tab 2 mg1QL (120 tablets per 25days)lortab tab 10-325mg1QL (180 tablets per 25days)methadone hcl conc 10 mg/ml1QL (30 ml per 25 days)methadone hcl soln 5 mg/5ml1QL (450 ml per 25 days)methadone hcl soln 10 mg/5ml1QL (450 ml per 25 days)methadone hcl tab 5 mg1QL (90 tablets per 25days)methadone hcl tab 10 mg1QL (90 tablets per 25days)methadone hcl tab for oral susp 40 mg1QL (9 tablets per 25days)methadose tab 40mg1QL (9 tablets per 25days)MORPHINE SUL SUP 30MG2QL (180 suppositoriesper 25 days)morphine sulfate beads cap er 24hr 30 mg 1QL (30 capsules per 25days)morphine sulfate beads cap er 24hr 45 mg 1QL (30 capsules per 25days)morphine sulfate beads cap er 24hr 60 mg 1QL (30 capsules per 25days)morphine sulfate beads cap er 24hr 75 mg 1QL (30 capsules per 25days)morphine sulfate beads cap er 24hr 90 mg 1QL (30 capsules per 25days)morphine sulfate beads cap er 24hr 1201QL (30 capsules per 25mgdays)morphine sulfate cap er 24hr 10 mg1QL (120 capsules per 25days)morphine sulfate cap er 24hr 20 mg1QL (120 capsules per 25days)PA - Prior Authorization QL - Quantity LimitsCounter PA** - PA Applies if Step is Not MetST - Step TherapyOTC - Over The - PCP copay applies5
Drug Namemorphine sulfate cap er 24hr 30 mgmorphine sulfatemorphine sulfatemorphine sulfatemorphine tesulfatesulfateDrug Tier Requirements/Limits1QL (120 capsules per 25days)cap er 24hr 50 mg1QL (120 capsules per 25days)cap er 24hr 60 mg1QL (120 capsules per 25days)cap er 24hr 80 mg1QL (120 capsules per 25days)cap er 24hr 100 mg1QL (120 capsules per 25days)oral soln 10 mg/5ml1QL (900 ml per 25 days)oral soln 20 mg/5ml1QL (900 ml per 25 days)oral soln 100 mg/5ml (20 1QL (180 ml per 25 days)sulfate suppos 5 mg1morphine sulfate suppos 10 mg1morphine sulfate suppos 20 mg1morphine sulfate tab 15 mg1morphine sulfate tab 30 mg1morphine sulfate tab er 15 mg1morphine sulfate tab er 30 mg1morphine sulfate tab er 60 mg1morphine sulfate tab er 100 mg1morphine sulfate tab er 200 mg1nalbuphine hcl inj 10 mg/mlnalbuphine hcl inj 20 mg/mlNUCYNTA ER TAB 50MG112NUCYNTA ER TAB 100MG2NUCYNTA ER TAB 150MG2NUCYNTA ER TAB 200MG2NUCYNTA ER TAB 250MG2NUCYNTA TAB 50MG2PA - Prior Authorization QL - Quantity LimitsCounter PA** - PA Applies if Step is Not MetST - Step TherapyQL (180 suppositoriesper 25 days)QL (180 suppositoriesper 25 days)QL (180 suppositoriesper 25 days)QL (180 tablets per 25days)QL (180 tablets per 25days)QL (90 tablets per 25days)QL (90 tablets per 25days)QL (90 tablets per 25days)QL (90 tablets per 25days)QL (90 tablets per 25days)QL (300 tablets per 25days)QL (150 tablets per 25days)QL (90 tablets per 25days)QL (60 tablets per 25days)QL (60 tablets per 25days)QL (360 tablets per 25days)OTC - Over The - PCP copay applies6
Drug NameNUCYNTA TAB 75MGDrug Tier Requirements/Limits2QL (240 tablets per 25days)2QL (180 tablets per 25days)1QL (180 capsules per 25days)1QL (180 ml per 25 days)NUCYNTA TAB 100MGoxycodone hcl cap 5 mgoxycodone hcl conc 100 mg/5ml (20mg/ml)oxycodone hcl soln 5 mg/5mloxycodone hcl tab 5 mg11oxycodone hcl tab 10 mg1oxycodone hcl tab 15 mg1oxycodone hcl tab 20 mg1oxycodone hcl tab 30 mg1oxycodone hcl tab er 12hr deter 10 mg1oxycodone hcl tab er 12hr deter 15 mg1oxycodone hcl tab er 12hr deter 20 mg1oxycodone hcl tab er 12hr deter 30 mg1oxycodone hcl tab er 12hr deter 40 mg1oxycodone hcl tab er 12hr deter 60 mg1oxycodone hcl tab er 12hr deter 80 mg1oxycodone w/ acetaminophen soln 5-325mg/5mloxycodone w/ acetaminophen tab 2.5-325mgoxycodone w/ acetaminophen tab 5-325mgoxycodone w/ acetaminophen tab 7.5-325mgoxycodone w/ acetaminophen tab 10-325mgoxycodone-aspirin tab 4.8355-325 mg1oxycodone-ibuprofen tab 5-400 mg1PA - Prior Authorization QL - Quantity LimitsCounter PA** - PA Applies if Step is Not Met11111ST - Step TherapyQL (900 ml per 25 days)QL (180 tablets per 25days)QL (180 tablets per 25days)QL (180 tablets per 25days)QL (180 tablets per 25days)QL (180 tablets per 25days)QL (120 tablets per 25days)QL (120 tablets per 25days)QL (120 tablets per 25days)QL (120 tablets per 25days)QL (120 tablets per 25days)QL (120 tablets per 25days)QL (120 tablets per 25days)QL (1800 ml per 25days)QL (360 tablets per 25days)QL (360 tablets per 25days)QL (240 tablets per 25days)QL (180 tablets per 25days)QL (360 tablets per 25days)QL (28 tabs per 25days)OTC - Over The - PCP copay applies7
Drug NameOXYCONTIN TAB 10MG CROXYCONTIN TAB 15MG CROXYCONTIN TAB 20MG CROXYCONTIN TAB 30MG CROXYCONTIN TAB 40MG CROXYCONTIN TAB 60MG CROXYCONTIN TAB 80MG CRoxymorphone hcl tab 5 mgoxymorphone hcl tab 10 mgoxymorphone hcl tab er 12hr 5 mgoxymorphone hcl tab er 12hr 7.5 mgoxymorphone hcl tab er 12hr 10 mgoxymorphone hcl tab er 12hr 15 mgoxymorphone hcl tab er 12hr 20 mgoxymorphone hcl tab er 12hr 30 mgoxymorphone hcl tab er 12hr 40 mgPRIMLEV TAB 5-300MGPRIMLEV TAB 7.5-300PRIMLEV TAB 10-300MGroxicet tab 5-325mgtramadol hcl tab 50 mgtramadol hcl tab er 24hr 100 mgtramadol hcl tab er 24hr 200 mgtramadol hcl tab er 24hr 300 mgPA - Prior Authorization QL - Quantity LimitsCounter PA** - PA Applies if Step is Not MetDrug Tier Requirements/Limits2QL (120 tablets per 25days)2QL (120 tablets per 25days)2QL (120 tablets per 25days)2QL (120 tablets per 25days)2QL (120 tablets per 25days)2QL (120 tablets per 25days)2QL (120 tablets per 25days)1QL (180 tablets per 25days)1QL (180 tablets per 25days)1QL (120 tablets per 25days)1QL (120 tablets per 25days)1QL (120 tablets per 25days)1QL (120 tablets per 25days)1QL (120 tablets per 25days)1QL (120 tablets per 25days)1QL (120 tablets per 25days)3QL (360 tablets per 25days)3QL (240 tablets per 25days)3QL (180 tablets per 25days)1QL (360 tablets per 25days)1QL (180 tablets per 25days)1QL (30 tablets per 25days)1QL (30 tablets per 25days)1QL (30 tablets per 25days)ST - Step TherapyOTC - Over The - PCP copay applies8
Drug Namevicodin es tab 7.5-300Drug Tier Requirements/Limits1QL (180 tablets per 25days)1QL (180 tablets per 25days)1QL (240 tablets per 25days)1QL (50 tablets per 25days)vicodin hp tab 10-300mgvicodin tab 5-300mgxylon tab 10-200mgOPIOID PARTIAL AGONISTSbuprenorphine hcl sl tab 2 mg (base equiv) 1buprenorphine hcl sl tab 8 mg (base equiv) 1QL (90 tabs/25 days; 21tabs/75 days InductionTherapy), PAQL (90 tabs/25 days; 21tabs/75 days InductionTherapy), PASALICYLATESaspirin chew tab 81 mg0aspirin low tab 81mg ec0aspirin tab 81 mg0diflunisal tab 500 mgST JOSEPH CHW 75MG ADU10QL (100 tabs / 30 days);OTC; 0 copay-age andgender restrictions applyQL (100 tabs / 30 days);OTC; 0 copay-age andgender restrictions applyQL (100 tabs / 30 days);OTC; 0 copay-age andgender restrictions applyQL (100 tabs / 30 days);OTC; 0 copay-age andgender restrictions applyANTI-INFECTIVESANTI-BACTERIALS - MISCELLANEOUSe.s.p. sus 200-600KETEK TAB 300MGKETEK TAB 400MGMONUROL PAK GRANULESparomomycin sulfate cap 250 mgstreptomycin sulfate for inj 1 gmSULFADIAZINE TAB 500MGtinidazole tab 250 mgtinidazole tab 500 mgtobramycin nebu soln 300 mg/5mlVIBATIV INJ 250MGVIBATIV INJ 750MG133311311133PAANTI-INFECTIVES - MISCELLANEOUSALBENZA TAB 200MGALINIA SUS 100/5MLPA - Prior Authorization QL - Quantity LimitsCounter PA** - PA Applies if Step is Not Met22ST - Step TherapyOTC - Over The - PCP copay applies9
Drug NameALINIA TAB 500MGatovaquone susp 750 mg/5mlaztreonam for inj 1 gmaztreonam for inj 2 gmBILTRICIDE TAB 600MGCAYSTON INH 75MGclindamycin hcl cap 75 mgclindamycin hcl cap 150 mgclindamycin hcl cap 300 mgclindamycin palmitate hcl for soln 75mg/5ml (base equiv)dapsone tab 25 mgdapsone tab 100 mgdaptomycin for iv soln 500 mgDARAPRIM TAB 25MGdoripenem for iv infusion 250 mgdoripenem for iv infusion 500 mgivermectin tab 3 mglinezolid for susp 100 mg/5mllinezolid tab 600 mgmethenamine hippurate tab 1 gmmetronidazole cap 375 mgmetronidazole tab 250 mgmetronidazole tab 500 mgNEBUPENT INH 300MGnitrofurantoin macrocrystalline cap 25 mgDrug Tier ofurantoin macrocrystalline cap 50 mg 1nitrofurantoin macrocrystalline cap 100 mg 1nitrofurantoin monohydratemacrocrystalline cap 100 mg1PENTAM 300 INJ 300MGPRIMSOL SOL 50MG/5MLSIVEXTRO INJ 200MGSIVEXTRO TAB 200MGsulfamethoxazole-trimethoprim susp200-40 mg/5ml32331PA - Prior Authorization QL - Quantity LimitsCounter PA** - PA Applies if Step is Not MetST - Step TherapyPA; High RiskMedications require PAfor members age 65 andolderPA; High RiskMedications require PAfor members age 65 andolderPA; High RiskMedications require PAfor members age 65 andolderPA; High RiskMedications require PAfor members age 65 andolderOTC - Over The - PCP copay applies10
Drug NameDrug Tier Requirements/Limitssulfamethoxazole-trimethoprim tab 400-80 1mgsulfamethoxazole-trimethoprim tab1800-160 mgtrimethoprim tab 100 mg1vancomycin hcl cap 125 mg1ST; PA**vancomycin hcl cap 250 mg1ST; PA**XIFAXAN TAB 200MG2XIFAXAN TAB 550MG2PAANTIFUNGALSABELCET INJ 5MG/MLAMPHOTEC INJ 50MGAMPHOTEC INJ 100MGamphotericin b for inj 50 mgBIO-STATIN CAP 500000BIO-STATIN CAP 1000000CANCIDAS INJ 50MGCANCIDAS INJ 70MGCRESEMBA CAP 186 MGERAXIS INJ 50MGERAXIS INJ 100MGfluconazole for susp 10 mg/mlfluconazole for susp 40 mg/mlfluconazole tab 50 mgfluconazole tab 100 mgfluconazole tab 150 mgfluconazole tab 200 mggriseofulvin microsize susp 125 mg/5mlgriseofulvin microsize tab 500 mggriseofulvin ultramicrosize tab 125 mggriseofulvin ultramicrosize tab 250 mgitraconazole cap 100 mgNOXAFIL SUS 40MG/MLNOXAFIL TAB 100MGnystatin oral powdernystatin tab 500000 unitSPORANOX SOL 10MG/MLterbinafine hcl tab 250 mgvoriconazole for susp 40 mg/mlvoriconazole tab 50 mgvoriconazole tab 200 ALARIALSatovaquone-proguanil hcl tab 62.5-25 mg 1atovaquone-proguanil hcl tab 250-100 mg 1chloroquine phosphate tab 250 mg1PA - Prior Authorization QL - Quantity LimitsCounter PA** - PA Applies if Step is Not MetST - Step TherapyOTC - Over The - PCP copay applies11
Drug Namechloroquine phosphate tab 500 mgCOARTEM TAB 20-120MGmefloquine hcl tab 250 mgPRIMAQUINE TAB 26.3MGquinine sulfate cap 324 mgquinine sulfate tab 260 mgDrug Tier Requirements/Limits131311ANTIRETROVIRAL AGENTSabacavir sulfate tab 300 mg (base equiv) 1APTIVUS CAP 250MG2APTIVUS SOL2CRIXIVAN CAP 200MG2CRIXIVAN CAP 400MG2didanosine delayed release capsule 125 mg 1didanosine delayed release capsule 200 mg 1didanosine delayed release capsule 250 mg 1didanosine delayed release capsule 400 mg 1EDURANT TAB 25MG2EMTRIVA CAP 200MG2EMTRIVA SOL 10MG/ML2FUZEON INJ 90MG3INTELENCE TAB 25MG2INTELENCE TAB 100MG2INTELENCE TAB 200MG2INVIRASE CAP 200MG2INVIRASE TAB 500MG2ISENTRESS CHW 25MG2ISENTRESS CHW 100MG2ISENTRESS POW 100MG2ISENTRESS TAB 400MG2lamivudine oral soln 10 mg/ml1lamivudine tab 150 mg1lamivudine tab 300 mg1LEXIVA SUS 50MG/ML2LEXIVA TAB 700MG2nevirapine susp 50 mg/5ml1nevirapine tab 200 mg1nevirapine tab er 24hr 100 mg1nevirapine tab er 24hr 400 mg1NORVIR CAP 100MG2NORVIR SOL 80MG/ML2NORVIR TAB 100MG2PREZISTA SUS 100MG/ML2PREZISTA TAB 75MG2PREZISTA TAB 150MG2PREZISTA TAB 400MG2PA - Prior Authorization QL - Quantity LimitsCounter PA** - PA Applies if Step is Not MetST - Step TherapyOTC - Over The - PCP copay applies12
Drug NamePREZISTA TAB 600MGPREZISTA TAB 800MGREYATAZ CAP 100MGREYATAZ CAP 150MGREYATAZ CAP 200MGREYATAZ CAP 300MGREYATAZ POW 50MGSELZENTRY SOL 20MG/MLSELZENTRY TAB 25MGSELZENTRY TAB 75MGSELZENTRY TAB 150MGSELZENTRY TAB 300MGstavudine cap 15 mgstavudine cap 20 mgstavudine cap 30 mgstavudine cap 40 mgstavudine for oral soln 1 mg/mlSUSTIVA CAP 50MGSUSTIVA CAP 200MGSUSTIVA TAB 600MGTIVICAY TAB 10MGTIVICAY TAB 25MGTIVICAY TAB 50MGTYBOST TAB 150MGVIDEX SOL 2GMVIDEX SOL 4GMVIRACEPT TAB 250MGVIRACEPT TAB 625MGVIREAD POW 40MG/GMVIREAD TAB 150MGVIREAD TAB 200MGVIREAD TAB 250MGVIREAD TAB 300MGVITEKTA TAB 85MGVITEKTA TAB 150MGZERIT SOL 1MG/MLZIAGEN SOL 20MG/MLzidovudine cap 100 mgzidovudine syrup 10 mg/mlzidovudine tab 300 mgDrug Tier 222222111ANTIRETROVIRAL COMBINATION AGENTSabacavir sulfate-lamivudine tab 600-3001mgabacavir sulfate-lamivudine-zidovudine tab 1300-150-300 mgATRIPLA TAB2PA - Prior Authorization QL - Quantity LimitsCounter PA** - PA Applies if Step is Not MetST - Step TherapyOTC - Over The - PCP
Healthfirst Leaf Premier Plans: Platinum, Gold, Silver, and Bronze Healthfirst Leaf Plans: Platinum, Gold, Silver, Bronze, and Green . This list is a guide to all of the drugs Healthfirst covers on your prescription benefit plan. You and your covered family members must
