Transcription
Keystone 65 RxPersonal Choice 65 Rx2022 FormularySM(List of Covered Drugs)PLEASE READ:THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVERIN THIS PLANFID 22408, Version 7This formulary was updated on 4/1/2022. For more recent information or other questions, please contactKeystone 65 Rx at 1-800-645-3965 or Personal Choice 65 Rx at 1-888-718-3333 (TTY users should call711), seven days a week, 8 a.m. to 8 p.m. Please note that on weekends and holidays from April 1 throughSeptember 30, your call may be sent to voicemail. Or, visit www.ibxmedicare.com.Note to existing members: This formulary has changed since last year. Please review this document to makesure that it still contains the drugs you take.When this drug list (formulary) refers to “we,” “us,” or “our,” it means Independence Blue Cross.When it refers to “plan” or “our plan,” it means Keystone 65 Basic Rx HMO, Keystone 65 Select Rx HMO,Keystone 65 Preferred Rx HMO, Keystone 65 Focus Rx HMO-POS, Personal Choice 65 Rx PPO, PersonalChoice 65 Prime Rx PPO, Personal Choice 65 Elite Rx PPO, or Personal Choice 65 Saver Rx PPO.This document includes a list of the drugs (formulary) for our plan, which is current as of 4/1/2022.For an updated formulary, please contact us. Our contact information, along with the date we last updatedthe 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, 2023, and from time totime during the year.Y0041 HM C 22 99370
What is the Keystone 65 Rx, Personal Choice 65 Rx Formulary?A formulary is a list of covered drugs selected by our plan in consultation with a teamof health care providers, which represents the prescription therapies believed to be anecessary part of a quality treatment program. Our plan will generally cover the drugslisted in our formulary as long as the drug is medically necessary, the prescriptionis filled at a plan network pharmacy, and other plan rules are followed. For moreinformation 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 we may add or remove drugson the Drug List during the year, move them to different cost-sharing tiers, or add newrestrictions. We must follow the Medicare rules in making these changes.Changes that can affect you this yearIn 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 DrugList if we are replacing it with a new generic drug that will appear on the same orlower cost-sharing tier and with the same or fewer restrictions. Also, when adding thenew 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 youare currently taking that brand-name drug, we may not tell you in advance before wemake that change, but we will later provide you with information about the specificchange(s) we have made.- If we make such a change, you or your prescriber can ask us to make an exceptionand continue to cover the brand-name drug for you. The notice we provide youwill also include information on how to request an exception, and you can findinformation in the section below titled “How do I request an exception to theKeystone 65 Rx, Personal Choice 65 Rx’s Formulary?” Drugs removed from the market. If the Food and Drug Administration (FDA)deems a drug on our formulary to be unsafe or the drug’s manufacturer removesthe drug from the market, we will immediately remove the drug from our formularyand provide notice to members who take the drug.1
Other changes. We may make other changes that affect members currently taking adrug. For instance, we may add a generic drug that is not new to the market to replace abrand-name drug currently on the formulary; or add new restrictions to the brand-namedrug or move it to a different cost-sharing tier or both. Or, we may make changesbased on new clinical guidelines. If we remove drugs from our formulary, or add priorauthorization, quantity limits, and/or step therapy restrictions on a drug or move a drugto a higher cost-sharing tier, we must notify affected members of the change at least30 days before the change becomes effective, or at the time the member requests a refillof the drug, at which time the member will receive a 60-day supply of the drug.- If we make these other changes, you or your prescriber can ask us to make anexception and continue to cover the brand-name drug for you. The notice we provideyou will also include information on how to request an exception, and you can alsofind information in the section below entitled “How do I request an exception to theKeystone 65 Rx, Personal Choice 65 Rx’s Formulary?”Changes that will not affect you if you are currently taking the drugGenerally, if you are taking a drug on our 2022 formulary that was covered at thebeginning of the year, we will not discontinue or reduce coverage of the drug duringthe 2022 coverage year except as described above. This means these drugs will remainavailable at the same cost-sharing and with no new restrictions for those memberstaking them for the remainder of the coverage year. You will not get direct notice thisyear about changes that do not affect you. However, on January 1 of the next year, suchchanges would affect you, and it is important to check the Drug List for the new benefityear for any changes to drugs.The enclosed formulary is current as of 4/1/2022. To get updated information about thedrugs covered by the plan, please contact us. Our contact information appears on thefront and back cover pages. In the event of a midyear non-maintenance formularychange, all affected members will receive a notification of changes tothe formulary.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 categoriesdepending 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, “CardiovascularAgents.” If you know what your drug is used for, look for the category name in the listthat begins on page 7. Then, look under the category name for your drug.Alphabetical ListingIf you are not sure what category to look under, you should look for your drug in the Indexthat begins on page 101. The Index provides an alphabetical list of all the drugs includedin this document. Both brand-name drugs and generic drugs are listed in the Index. Lookin the Index and find your drug. Next to your drug, you will see the page number whereyou can find coverage information. Turn to the page listed in the Index and find the nameof your drug in the first column of the list.What are generic drugs?Our plan covers both brand-name drugs and generic drugs. A generic drug isapproved by the FDA as having the same active ingredient as the brand-name drug.Generally, generic drugs cost less than brand-name drugs.2
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: Our plan requires you or your physician to get prior authorizationfor certain drugs. This means that you will need to get approval from us before you fillyour prescriptions. If you don’t get approval, we may not cover the drug. Quantity Limits: For certain drugs, the plan limits the amount of the drug thatwe will cover. For example, our plan provides 60 per prescription for Glipizide ER10mg. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, the plan requires you to first try certain drugs totreat your medical condition before we will cover another drug for that condition.For example, if Drug A and Drug B both treat your medical condition, we may notcover Drug B unless you try Drug A first. If Drug A does not work for you, we willthen cover Drug B.You can find out if your drug has any additional requirements or limits by looking in theformulary that begins on page 7. You can also get more information about the restrictionsapplied to specific covered drugs by visiting our website. We have posted online documentsthat explain our prior authorization restriction and step therapy restrictions. You may alsoask us to send you a copy. Our contact information, along with the date we last updated theformulary, appears on the front and back cover pages.You can ask the plan to make an exception to these restrictions or limits or for a list of othersimilar drugs that may treat your health condition. See the section, “How do I request anexception to the Keystone 65 Rx and Personal Choice 65 Rx’s Formulary?” onpage 4 for information about how to request an exception.Other Special Coverage Rules:PDSS - Insulin Savings ProgramWith the Insulin Savings Program, you will pay a 35 copay for a 1-month supply of SelectInsulins during the initial coverage, and coverage gap or “donut hole” stages of yourbenefit. Your cost may be less if you receive “Extra Help” from Medicare.The Insulin Savings Program is available for Keystone 65 Focus HMO-POS, Keystone 65Preferred HMO, and Keystone 65 Select HMO members. For more information on theInsulin Savings Program, please refer to your Evidence of Coverage document.What are over-the-counter (OTC) drugs?OTC drugs are non-prescription drugs that are not normally covered by a MedicarePrescription Drug Plan. Our plan pays for certain OTC drugs, including bandages,cold and allergy medicines, pain relievers, vitamins, and more. Our plan will providethese OTC drugs at no cost to you. The cost to the plan of these OTC drugs will not counttoward your total Part D drug costs (that is, the cost of the OTC drugs does not countfor the coverage gap).What if my drug is not on the Formulary?If your drug is not included in this formulary (list of covered drugs), you should firstcontact our Member Help Team and ask if your drug is covered.If you learn that the plan does not cover your drug, you have two options: You can ask our Member Help Team for a list of similar drugs that are covered bythe plan. When you receive the list, show it to your doctor and ask him or her toprescribe a similar drug that is covered by the plan. You can ask us to make an exception and cover your drug. See below forinformation about how to request an exception.3
How do I request an exception to the Keystone 65 Rx, PersonalChoice 65 Rx’s Formulary?You can ask us to make an exception to our coverage rules. There are several types ofexceptions that you can ask us to make. Y ou can ask us to cover a drug even if it is not on our formulary. If approved, thisdrug will be covered at a predetermined cost-sharing level, and you would not beable to ask us to provide the drug at a lower cost-sharing level. Y ou can ask us to cover a formulary drug at a lower cost-sharing level, unless thedrug is on the specialty tier. If approved, this would lower the amount you must payfor your drug. Y ou can ask us to waive coverage restrictions or limits on your drug. For example,for certain drugs, the plan 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 covera greater amount.Generally, we will only approve your request for an exception if the alternative drugsincluded on the plan’s formulary, the lower cost-sharing drug, or additional utilizationrestrictions would not be as effective in treating your condition and/or would cause youto have adverse medical effects.You should contact us to ask us for an initial coverage decision for a formulary, tiering,or utilization restriction exception. When you request a formulary, tiering, orutilization restriction exception, you should submit a statement from yourprescriber or physician supporting your request. Generally, we must make ourdecision within 72 hours of getting your prescriber’s supporting statement. You canrequest an expedited (fast) exception if you or your doctor believe that your healthcould be seriously harmed by waiting up to 72 hours for a decision. If your request toexpedite is granted, we must give you a decision no later than 24 hours after we geta supporting statement from your doctor or other prescriber.4
What do I do before I can talk to my doctor about changing mydrugs or requesting an exception?As a new or continuing member in our plan, you may be taking drugs that are not onour formulary. Or, you may be taking a drug that is on our formulary but your ability toget it is limited.For example, you may need a prior authorization from us before you can fill yourprescription. You should talk to your doctor to decide if you should switch to anappropriate drug that we cover or request a formulary exception so that we will coverthe drug you take. While you talk to your doctor to determine the right course of actionfor you, we may cover your drug in certain cases during the first 90 days you are amember of our plan.For each of your drugs that is not on our formulary or if your ability to get your drugs islimited, we will cover a temporary 30-day supply. If your prescription is written for fewerdays, we’ll allow refills to provide up to a maximum 30-day supply of medication. Afteryour first 30-day supply, we will not pay for these drugs, even if you have been a memberof the plan less than 90 days.If you are a resident of a long-term care facility, we will allow you to refill yourprescription until we have provided you with a 98-day transition supply, consistent withdispensing increments (unless you have a prescription written for fewer days). We willcover more than one refill of these drugs for the first 90 days if you are a member of ourplan. If you need a drug that is not on our formulary or if your ability to get your drugsis limited, but you are past the first 90 days of membership in our plan, we will covera 31-day emergency supply of that drug (unless you have a prescription for fewer days)while you pursue a formulary exception.If a transition occurs due to a member changing setting, such as moving from a homeresidence to a long-term care facility and then back again, our plan has a methodin place to ensure that you have access to your medication. If your change of settingcannot be identified by the automated system, the pharmacy can notify our plan ofthe setting change and provide you with your needed medications. You will receivenotice that you must either switch to a therapeutically appropriate drug on the plan’sformulary or request an exception to continue taking the requested drug.For more informationFor more detailed information about your plan prescription drug coverage,please review your Evidence of Coverage and other plan materials.If you have questions about the plan, please contact us. Our contact information,along with the date we last updated the formulary, appears on the front and backcover pages.If you have general questions about Medicare prescription drug coverage, please callMedicare 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 www.medicare.gov.5
Keystone 65 Rx, Personal Choice 65 Rx’s FormularyThe formulary provides coverage information about the drugs covered by our plan.If you have trouble finding your drug in the list, turn to the Index that begins on page 101.The first column of the chart lists the drug name. Brand-name drugs are capitalized(e.g., LIPITOR ) and generic drugs are listed in lowercase italics (e.g., atorvastatin).The information in the Requirements/Limits column tells you if the plan has any specialrequirements for coverage of your drug. Prior Authorization (PA): Our plan requires you or your physician to get priorauthorization for certain drugs. This means that you will need to get approval from usbefore you fill your prescriptions. If you don’t get approval, we may not cover the drug. Quantity Limits (QL): For certain drugs, the plan limits the amount of the drug thatwe will cover. For example, our plan provides 60 per prescription for Glipizide ER10mg. This may be in addition to a standard one-month or three-month supply. Step Therapy (ST): In some cases, the plan requires you to first try certain drugs totreat your medical condition before we will cover another drug for that condition.For example, if Drug A and Drug B both treat your medical condition, we may notcover Drug B unless you try Drug A first. If Drug A does not work for you, we willthen cover Drug B. Non-Extended Day Supply (NDS): All prescription fills for opioid medications will belimited to a 30-day supply. FutureScripts Home Delivery requires that you must use90 percent of your opioid medication before it may be refilled. Please note that otherpharmacies may have additional limitations on opioid medications. Non-Formulary (NF): If your drug has a “Non-Formulary” status, this meansthat your drug is not covered under your plan. In this case, you may request aFormulary Exception.The Drug Tier column of the chart lists the drug tier. The drug tier is the level of formularycost-sharing for which the member is responsible. See your Evidence of Coverage for moreinformation about cost-sharing amounts.6
Drug NameTierRequirementsAntihistamine DrugsFirst Generation Antihistaminescarbinoxamine maleate oral solutionNFcarbinoxamine maleate oral tablet 4 mgNFclemastine fumarate oral syrupclemastine fumarate oral tablet 2.68 mg5PANFcyproheptadine hcl oral2promethazine hcl oral syrup2PApromethazine hcl oral tablet2PApromethazine hcl rectal suppository 12.5 mg, 25 mg2PApromethazine-phenylephrinePROMETHEGAN RECTAL SUPPOSITORY 25 MG, 50 MGNF2RYCLORA ORAL SOLUTIONNFRYVENTSecond Generation AntihistaminesNFcetirizine hcl oral solution 1 mg/mlNFCLARINEX ORAL TABLETNFCLARINEX-D 12 HOURNFdesloratadine oral tablet2desloratadine oral tablet dispersiblelevocetirizine dihydrochloride oralAnti-Infective AgentsPANF2Anthelminticsalbendazole oral5ALBENZANFBILTRICIDENFEMVERMNFivermectin oral2praziquantel amikacin sulfate injection solution 500 mg/2ml2amoxicillin oral capsule1amoxicillin oral suspension reconstituted1amoxicillin oral tablet1amoxicillin oral tablet chewable 125 mg, 250 mg1amoxicillin-pot clavulanate er2amoxicillin-pot clavulanate oral2QL (12 EA per 30 days)7
Drug NameTierampicillin oral capsule 500 mg2ampicillin sodium injection solution reconstituted 1 gm, 125mg2ampicillin sodium intravenous solution reconstituted 10 gm2ampicillin-sulbactam sodium injection solution reconstituted1.5 (1-0.5) gm, 3 (2-1) gm2ampicillin-sulbactam sodium intravenous solutionreconstituted 15 (10-5) gm2ARIKAYCE5AVYCAZ5AZACTAMPANFazithromycin intravenous2azithromycin oral packet2azithromycin oral suspension reconstituted2azithromycin oral tablet 250 mg, 500 mg, 600 mg2aztreonam injection solution reconstituted 1 gm3AZULFIDINENFAZULFIDINE EN-TABSNFBACTRIMNFBACTRIM DSNFBAXDELANFBETHKIS5BICILLIN C-R4BICILLIN C-R 900/3004BICILLIN L-A INTRAMUSCULAR SUSPENSION 2400000UNIT/4ML4CAYSTON5cefaclor2cefaclor er2cefadroxil2cefazolin sodium injection solution reconstituted 1 gm, 10gm, 500 mg2cefdinir2cefepime hcl injection3cefixime2cefotetan disodium injection solution reconstituted 1 gm, 2gm2cefoxitin sodium intravenous2cefpodoxime proxetil3cefprozil2ceftazidime injection solution reconstituted 1 gm, 6 gm38RequirementsPAPA
Drug NameTierceftazidime intravenous3ceftriaxone sodium injection solution reconstituted 1 gm, 2gm, 250 mg, 500 mg2ceftriaxone sodium intravenous solution reconstituted 10 gm2cefuroxime axetil oral tablet2cefuroxime sodium injection solution reconstituted 750 mg2cefuroxime sodium intravenous solution reconstituted 1.5gm2cephalexin oral capsule2cephalexin oral suspension reconstituted2cephalexin oral tablet3CIPRO ORAL SUSPENSION RECONSTITUTEDNFCIPRO ORAL TABLET 250 MG, 500 MGNFciprofloxacin hcl oral2ciprofloxacin in d5w intravenous solution 200 mg/100ml2clarithromycin er3clarithromycin oral suspension reconstituted3clarithromycin oral tablet2CLEOCIN ORALNFCLEOCIN PHOSPHATE INJECTION SOLUTION 900MG/6MLNFclindamycin hcl oral2clindamycin palmitate hcl2clindamycin phosphate in d5w2clindamycin phosphate injection solution 300 mg/2ml, 600mg/4ml, 900 mg/6ml2colistimethate sodium eclocycline hcl oral2dicloxacillin sodium2DIFICID ORAL SUSPENSION RECONSTITUTED5QL (408 ML per 30 days)DIFICID ORAL TABLET5QL (60 EA per 30 days)DORYX MPCNFDORYX ORAL TABLET DELAYED RELEASE 200 MG, 50MGNFDOXY 1002doxycycline hyclate oral capsule2doxycycline hyclate oral tablet3PA9
Drug Namedoxycycline hyclate oral tablet delayed release 100 mg, 150mg, 200 mg, 50 mg, 75 mgdoxycycline hyclate oral tablet delayed release 80 mgdoxycycline monohydrate oralTier3NF3E.E.S. 400 ORAL TABLETNFE.E.S. GRANULESNFertapenem sodium4ERYPED 200NFERYPED 400NFERY-TABNFERYTHROCIN LACTOBIONATE INTRAVENOUSSOLUTION RECONSTITUTED 500 MG4ERYTHROCIN STEARATE ORAL TABLET 250 MG4erythromycin base oral capsule delayed release particles4erythromycin base oral tablet4erythromycin base oral tablet delayed release 333 mg, 500mg3erythromycin ethylsuccinate oral suspension reconstituted200 mg/5ml3erythromycin ethylsuccinate oral suspension reconstituted400 mg/5ml5erythromycin ethylsuccinate oral tablet3erythromycin oral tablet delayed release 250 mg3FIRVANQ ORAL SOLUTION RECONSTITUTED 25 MG/ML4FIRVANQ ORAL SOLUTION RECONSTITUTED 50 MG/MLNFgentamicin in saline intravenous solution 0.8-0.9 mg/ml-%,1-0.9 mg/ml-%, 1.2-0.9 mg/ml-%, 1.6-0.9 mg/ml-%2gentamicin sulfate injection solution 40 mg/ml2imipenem-cilastatin3INVANZ INJECTIONRequirementsNFlevofloxacin in d5w intravenous solution 500 mg/100ml, 750mg/150ml2levofloxacin intravenous2levofloxacin oral2linezolid intravenous solution 600 mg/300ml3linezolid oral suspension reconstituted5QL (1680 ML per 28 days)linezolid oral tablet3QL (56 EA per 28 days)meropenem4minocycline hcl er oral tablet extended release 24 hourminocycline hcl oralMINOLIRA10NF2NF
Drug NameTiermoxifloxacin hcl in nacl2moxifloxacin hcl oral2nafcillin sodium injection solution reconstituted 1 gm, 2 gm2nafcillin sodium intravenous solution reconstituted 10 gm2neomycin sulfate oral2NUZYRA5ofloxacin oral tablet 300 mg, 400 mg2oxacillin sodium in dextrose2oxacillin sodium injection solution reconstituted 1 gm, 2 gm2oxacillin sodium intravenous2penicillin g pot in dextrose intravenous solution 40000unit/ml, 60000 unit/ml2penicillin g potassium injection solution reconstituted20000000 unit2penicillin g procaine2penicillin g sodium5penicillin v potassium2piperacillin sod-tazobactam so intravenous solutionreconstituted 2.25 (2-0.25) gm, 3.375 (3-0.375) gm, 4.5 (40.5) gm, 40.5 (36-4.5) gm4polymyxin b sulfate injection2PRIMAXIN IV INTRAVENOUS SOLUTIONRECONSTITUTED 500-500 MGNFSEYSARANFSIVEXTRO5SOLODYN ORAL TABLET EXTENDED RELEASE 24HOUR 105 MG, 115 MG, 55 MG, 65 MG, 80 MG2sulfadiazine oral2sulfamethoxazole-trimethoprim oral suspension 200-40mg/5ml1sulfamethoxazole-trimethoprim oral tablet1sulfasalazine oral2SUPRAX ORAL CAPSULENFSUPRAX ORAL SUSPENSION RECONSTITUTED 100MG/5ML, 200 MG/5MLNFSUPRAX ORAL SUSPENSION RECONSTITUTED 500MG/5ML4SUPRAX ORAL TABLET CHEWABLE4TAZICEF INJECTION SOLUTION RECONSTITUTED 1 GMPAPA; QL (6 EA per 30 days)NFstreptomycin sulfate intramuscularTARGADOXRequirementsNF311
Drug NameTierTAZICEF INTRAVENOUS SOLUTION RECONSTITUTED2 GM, 6 GM3TEFLARO5tetracycline hcl oral2tigecycline3TOBIRequirementsNFTOBI PODHALER5PAtobramycin inhalation5PAtobramycin sulfate injection solution 10 mg/ml, 80 mg/2ml2TYGACILNFUNASYN INJECTION SOLUTION RECONSTITUTED 3 (21) GMNFUNASYN INTRAVENOUS SOLUTION RECONSTITUTED15 (10-5) GMNFVABOMERENFVANCOCINNFvancomycin hcl intravenous solution reconstituted 1 gm, 10gm, 500 mg, 750 mg2vancomycin hcl oral capsule4vancomycin hcl oral solution reconstituted2VIBRAMYCINNFXENLETA ORAL5PA; QL (10 EA per 30 days)XIFAXAN ORAL TABLET 200 MG5QL (9 EA per 30 days)XIFAXAN ORAL TABLET 550 MG5PAZEMDRI5PAZERBAXANFZITHROMAX INTRAVENOUSNFZITHROMAX ORAL PACKETNFZITHROMAX ORAL SUSPENSION RECONSTITUTEDNFZITHROMAX ORAL TABLET 250 MG, 500 MGNFZITHROMAX TRI-PAKNFZITHROMAX Z-PAKNFZOSYN INTRAVENOUS SOLUTION 2-0.25 GM/50ML, 30.375 GM/50MLNFZYVOX INTRAVENOUS SOLUTION 600 MG/300MLNFZYVOX ORALAntifungalsNFABELCET4PAAMBISOME5PAamphotericin b intravenous2PAANCOBON12NF
Drug NameTierCANCIDASNFcaspofungin acetate intravenous solution reconstituted 50mg5caspofungin acetate intravenous solution reconstituted 70mg3CRESEMBA ORAL5DIFLUCANRequirementsPANFERAXIS5fluconazole in sodium chloride intravenous solution 200-0.9mg/100ml-%, 400-0.9 mg/200ml-%2fluconazole oral2flucytosine oral5griseofulvin microsize oral2griseofulvin ultramicrosize2itraconazole oral capsule2itraconazole oral solution5ketoconazole oral2micafungin sodium intravenous solution reconstituted 100mg3micafungin sodium intravenous solution reconstituted 50 mg5NOXAFIL ORAL5nystatin mouth/throat2nystatin oral tablet2posaconazole5SPORANOXNFterbinafine hcl oral2tolsura5VFENDNFVFEND IVNFvoriconazole intravenous5voriconazole oral suspension reconstituted5voriconazole oral tabletAntimycobacterials4dapsone oral2ethambutol hcl oral2isoniazid oral2MYAMBUTOL ORAL TABLET 400 MGNFMYCOBUTINNFPASER4pretomanid4PRIFTIN4PAPAPAPA13
Drug NameTierpyrazinamide oral2rifabutin2rifampin intravenous2rifampin oral2SIRTURO5TRECATORAntiprotozoals4atovaquone oral5atovaquone-proguanil hcl3benznidazole4chloroquine phosphate oral2COARTEM4DARAPRIMNFFLAGYL ORAL CAPSULENFHUMATINNFhydroxychloroquine sulfate oral2IMPAVIDO5KRINTAFEL4LAMPIT4MALARONEmefloquine hclMEPRONNFmetronidazole oral tablet2NFnitazoxanide oral5paromomycin sulfate oral2NFpentamidine isethionate inhalation2pentamidine isethionate injection2PLAQUENIL2pyrimethamine oral5quinine sulfate oralSOLOSECNF2PANFtinidazole oralAntivirals2abacavir sulfate oral solution2abacavir sulfate oral tablet214PANFprimaquine phosphate oral tablet 26.3 (15 base) mgQUALAQUINQL (84 EA per 28 days)24PENTAMPANFmetronidazole oral capsuleNEBUPENTRequirementsQL (60 EA per 30 days)
Drug NameTierRequirementsabacavir sulfate-lamivudine2QL (30 EA per 30 days)abacavir-lamivudine-zidovudine5QL (60 EA per 30 days)acyclovir oral2acyclovir sodium intravenous solution2PAadefovir dipivoxil3QL (30 EA per 30 days)APTIVUS ORAL CAPSULE5QL (120 EA per 30 days)atazanavir sulfate oral capsule 150 mg, 300 mg4QL (30 EA per 30 days)atazanavir sulfate oral capsule 200 mg4QL (60 EA per 30 days)ATRIPLA5QL (30 EA per 30 days)BARACLUDENFBIKTARVY5CIMDUO5COMBIVIRQL (30 EA per 30 days)NFCOMPLERA5QL (30 EA per 30 days)DELSTRIGO5DESCOVY ORAL TABLET 200-25 MG5DOVATO5EDURANT5QL (30 EA per 30 days)efavirenz oral capsule 200 mg2QL (120 EA per 30 days)efavirenz oral capsule 50 mg2efavirenz oral tablet3QL (30 EA per 30 days)efavirenz-emtricitab-tenofovir5QL (30 EA per 30 QL (30 EA per 30 days)emtricitabine-tenofovir df5QL (30 EA per 30 days)QL (30 EA per 30 days)EMTRIVA ORAL CAPSULENFEMTRIVA ORAL SOLUTION4entecavir3QL (30 EA per 30 days)EPCLUSA ORAL PACKET 150-37.5 MG5PA; QL (84 EA per 365 days)EPCLUSA ORAL PACKET 200-50 MG5PA; QL (168 EA per 365 days)EPCLUSA ORAL TABLET 200-50 MG5PA; QL (168 EA per 365 days)EPCLUSA ORAL TABLET 400-100 MG5PA; QL (84 EA per 365 days)EPIVIREPIVIR HBV ORAL SOLUTIONNF4EPIVIR HBV ORAL TABLETNFEPZICOMNFetravirine oral tablet 100 mg5QL (120 EA per 30 days)etravirine oral tablet 200 mg5QL (60 EA per 30 days)EVOTAZ5QL (30 EA per 30 days)famciclovir oral415
Drug NameTierRequirementsfosamprenavir calcium5QL (120 EA per 30 days)FUZEON SUBCUTANEOUS SOLUTIONRECONSTITUTED5QL (60 EA per 30 days)GENVOYA5QL (30 EA per 30 days)HARVONI ORAL PACKET 33.75-150 MG5PA; QL (168 EA per 365 days)HARVONI ORAL PACKET 45-200 MG5PA; QL (336 EA per 365 days)HARVONI ORAL TABLET 90-400 MG5PA; QL (168 EA per 365 days)HEPSERANFINTELENCE ORAL TABLET 100 MG4QL (120 EA per 30 days)INTELENCE ORAL TABLET 200 MG5QL (60 EA per 30 days)INTELENCE ORAL TABLET 25 MG4ISENTRESS HD5ISENTRESS ORAL PACKET5ISENTRESS ORAL TABLET5ISENTRESS ORAL TABLET CHEWABLE 100 MG5ISENTRESS ORAL TABLET CHEWABLE 25 MG4JULUCA5KALETRA ORAL SOLUTIONQL (30 EA per 30 days)NFKALETRA ORAL TABLET 100-25 MG4QL (240 EA per 30 days)KALETRA ORAL TABLET 200-50 MG5QL (120 EA per 30 days)lamivudine oral solution2lamivudine oral tablet 100 mg2lamivudine oral tablet 150 mg2QL (60 EA per 30 days)lamivudine oral tablet 300 mg2QL (30 EA per 30 days)lamivudine-zidovudine4QL (60 EA per 30 days)ledipasvir-sofosbuvir5PA; QL (168 EA per 365 days)LEXIVA ORAL SUSPENSION4LEXIVA ORAL TABLETNFLIVTENCITYNFlopinavir-ritonavir oral solution3lopinavir-ritonavir oral tablet 100-25 mg4QL (240 EA per 30 days)lopinavir-ritonavir oral tablet 200-50 mg4QL (120 EA per 30 days)MAVYRET ORAL TABLET5PA; QL (336 EA per 365 days)nevirapine er oral tablet extended release 24 hour 100 mg2QL (90 EA per 30 days)nevirapine er oral tablet extended release 24 hour 400 mg2QL (30 EA per 30 days)nevirapine oral suspension2nevirapine oral tablet2NORVIR ORAL PACKET4NORVIR ORAL SOLUTION4NORVIR ORAL TABLET16NFQL (60 EA per 30 days)
Drug NameTierODEFSEY5QL (30 EA per 30 days)oseltamivir phosphate oral capsule 30 mg3QL (60 EA per 30 days)oseltamivir phosphate oral capsule 45 mg, 75 mg3QL (30 EA per 30 days)oseltamivir phosphate oral suspension reconstituted3QL (540 ML per 30 days)PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/ML5PEGASYS SUBCUTANEOUS SOLUTION PREFILLEDSYRINGE5PIFELTRO5PLEGRIDY SUBCUTANEOUS SOLUTION PENINJECTOR5PREVYMIS ORAL5PREZCOBIX5PREZISTA ORAL SUSPENSION5PREZISTA ORAL TABLET 150 MG5PREZISTA ORAL TABLET 600 MG5PREZISTA ORAL TABLET 75 MG4PREZISTA ORAL TABLET 800
Keystone 65 Preferred Rx HMO, Keystone 65 Focus Rx HMO-POS, Personal Choice 65 Rx PPO, Personal Choice 65 Prime Rx PPO, Personal Choice 65 Elite Rx PPO, or Personal Choice 65 Saver Rx PPO. This document includes a list of the drugs (formulary) for our plan, which is current as
