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HEALTH NETMEDICARE PART D2011 5-Tier Employer Group Formulary(List of Covered Drugs)THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WECOVER IN THIS PLANNote to existing members: This formulary has changed since last year. Pleasereview this document to make sure that it still contains the drugs you take. To getupdated information about the drugs covered by Health Net, please visit ourwebsite at www.healthnet.com.This document includes Health Net’s formulary as of December 1, 2011.Beneficiaries must use network pharmacies to access their prescription drug benefit.Benefits, formulary, pharmacy network, premium and/or copayments/coinsurancemay change on January 1, 2012.A Medicare Advantage organization with a Medicare contract. A stand-aloneprescription drug plan with a Medicare contract.6022581 (9/10)Material ID # Y0035 EG 2011 0028(H0351, H0562, H5439, H5520, S5678)Compliance Approved 08272010
If you would like to contact Health Net Customer Service, please find the contact information for yourstate below:ARIZONACALIFORNIAFOR MEDICAL PLANS:FOR MEDICAL PLANS:Health Net of ArizonaCustomer Contact CenterP.O. Box 904Shelton, CT 06484Health Net Seniority Plus andHealth Net Options PlusP.O. Box 10198Van Nuys, CA 91410-0198FOR HEALTH NET ORANGE,PART D PRESCRIPTION DRUG PLANS:FOR HEALTH NET ORANGE,PART D PRESCRIPTION DRUG PLANS:Health Net Medicare EnrollmentP.O. Box 6500Rensselaer, NY 12144-6500Health Net Medicare EnrollmentP.O. Box 6500Rensselaer, NY 12144-6500Fax– 1-888-268-2393Fax– 1-888-268-2393Hours are: 8:00 a.m. – 8:00 p.m., 7 days a week.Hours are: 8:00 a.m. – 8:00 p.m., 7 days a week.Current Members:Current Members:All Medical Plans1-800-977-7522, TTY 1-800-977-6757Health Net Seniority Plus (HMO)(For MAPDs and SNPs)1-800-275-4737, TTY 1-800-929-9955Health Net Orange (PDP)Prescription Drug Plans1-800-806-8811, TTY 1-800-929-9955Health Net Options Plus (PPO)1-800-960-4638, TTY 1-800-929-9955Health Net Orange (PDP)Prescription Drug Plans1-800-806-8811, TTY 1-800-929-9955Prospective Members:All Medical Plans1-800-333-3930, TTY 1-800-977-6757Prospective Members:Health Net OrangePrescription Drug Plans1-800-865-9431, TTY 1-800-929-9955HMO Plans1-800-977-6738, TTY 1-800-929-9955PPO Plans1-800-579-9096, TTY 1-800-929-9955Health Net OrangePrescription Drug Plans1-800-865-9431, TTY 1-800-929-9955i
ALL OTHER STATESFOR HEALTH NET ORANGE, PART DPRESCRIPTION DRUG PLANS:Health Net Medicare EnrollmentP.O. Box 6500Rensselaer, NY 12144-6500Fax– 1-888-268-2393Hours are: 8:00 a.m. – 8:00 p.m., 7 days a week.Current Members:Health Net Orange (PDP)Prescription Drug Plans1-800-806-8811, TTY 1-800-929-9955Prospective Members:Health Net OrangePrescription Drug Plans1-800-865-9431, TTY 1-800-929-9955ii
Welcome toHealth Netthe year. We feel it is important that you havecontinued access for the remainder of the year tothe formulary drugs that were available when youchose our plan.We are glad you have chosen us to be your planof choice for your prescription needs. This easyto-read formulary provides you with valuableinformation about the formulary (also knownas a “drug list”) that applies to your benefit,the prescription drugs we cover, copayment orcoinsurance levels and details on how to use yourbenefit. To quickly find your drug, turn to theindex at the end of this booklet. For detailedinformation on how to read the formulary, turn topage viii.However, in some cases, these types of formularychanges may affect you. If a formulary changewill affect you, we will notify you in advance ofthe change. You will receive notification at least60 days before the change becomes effective,or you may receive a 60-day supply when yourequest a refill of the drug which will act as yournotification.If the United States Food and DrugAdministration (FDA) deems a drug on theformulary to be unsafe or if the manufacturerof the drug removes the drug from the market,we will immediately remove the drug from theformulary and provide notice to you if you arecurrently receiving the drug.w h at i s t h e h e a lt h n e tm e d i c a r e pa rt d f o r m u l a ry ?A formulary (also known as a “drug list”) is alist of covered drugs selected by Health Net inconsultation with a team of health care providers,which represents the prescription therapiesbelieved to be a necessary part of a qualitytreatment program. Health Net will generallycover the drugs listed on the formulary as long asthe drug is medically necessary, the prescriptionis filled at a Health Net network pharmacy, andother plan rules are followed. For information onhow to fill your prescriptions, please review yourEvidence of Coverage (EOC).To get the most up-to-date information aboutthe drugs covered by Health Net, please visitour website at www.healthnet.com and use thenew online drug search tool. The tool allows youto type in your drug name and instantly viewboth brand-name and available generic druginformation. You may also call our CustomerService department at the toll-free number listed atthe beginning of this booklet.w h at i f m y d ru g i s n ot o nt h e f o r m u l a ry ?If your drug is not included on the formulary, youshould first contact Customer Service and ask ifyour drug is covered. If you learn that Health Netdoes not cover your drug, you have two options:c a n t h e f o r m u l a ry c h a n g e ?Generally, if you are taking a drug on the 2011formulary that was covered at the beginning of theyear, we will not discontinue or reduce coverageof the drug during the 2011 coverage year exceptwhen a new, less expensive generic drug becomesavailable and is offered at a lower tier or lower costto you, or when new information about the safetyor effectiveness of a drug is released.In most cases, formulary changes such as applyinga new or revised restriction to a drug, moving adrug to a more expensive tier or removing a drugfrom the formulary, will not affect you if you arecurrently taking the drug. The drug will remainavailable at the same cost for the remainder of You can ask Customer Service for a list of similardrugs that are covered by Health Net. When youreceive the list, show it to your physician andask him or her to prescribe a similar drug that iscovered by Health Net. You can ask Health Net to make an exceptionand cover your drug. See below for informationabout how to request an exception.iii
a r e t h e r e a n y r e s t r i c t i o n s o n m y c ov e r a g e ?Some drugs may have additional restrictions or limits on coverage. You can find out if your drug has anyrestrictions or limits by looking in the Limits column on the formulary.The table below provides a description of abbreviations that may appear in the Limits column onthe formulary:AbbreviationDefinitionALAge LimitBMedicare Part BB/D-PAMedicare Part B vs. Part DGLGender LimitLDLimited DistributionDescriptionSome drugs may require prior authorization ifyour age does not meet manufacturer, FDA,or clinical recommendations.Some drugs listed on the formulary areonly covered under Medicare Part B. Thesedrugs may be obtained at a pharmacy if youhave Part B coverage through Health Net.Please refer to your plan documents for theappropriate copayment or coinsurance.Some drugs may be payable under theMedicare Part B or Part D benefit, dependingon the intended use and other Medicareguidelines. Your physician may need tosupply additional information to support thatthe drug qualifies for coverage under yourMedicare Part D benefit. If the drug qualifiesfor coverage under Medicare Part B andyou do not have Medicare Part B coveragethrough Health Net, the claim will be deniedfor coverage under Health Net.Some drugs are only covered for males orfemales based on manufacturer, FDA, orclinical recommendations.Some drugs may be subject to limiteddistribution or restricted access. This means thata drug may only be available at one or a limitednumber of pharmacies. Limited distribution maybe due to the following reasons: The FDA has restricted distribution of adrug to certain facilities, pharmacies orphysicians, or Certain drugs require special handling,coordination of care, or patient educationthat cannot be received at a retail pharmacy.You should talk to your doctor or pharmacistfor details about acquiring limited distributiondrugs.iv
AbbreviationDefinitionNTNon-TrOOPPAPrior AuthorizationQLQuantity LimitST30DSDescriptionHealth Net covers some drugs that theCenters for Medicare and Medicaid Services(CMS) exclude from coverage under PartD. The amount paid for these drugs will notaccrue toward your true out-of-pocket costs(TrOOP) or Initial Coverage Limit.Some drugs require prior authorization dueto coverage, clinical effectiveness, or safetyconsiderations. This means that you or yourphysician must request approval fromHealth Net before the drug will be covered.For some drugs, Health Net limits the amountof the drug covered based on manufacturer,FDA, clinical dosing or treatmentrecommendations.This may replace your standard days supplylimit.In some cases, Health Net requires you tofirst try certain drugs to treat your medicalcondition before covering another drug forthat condition.Step TherapyFor example, if Drug A and Drug B both treatyour medical condition, Health Net may notcover Drug B unless you try Drug A first. IfDrug A is found in your recent Health Netprescription claims history Drug B will beautomatically approved.Certain drugs will not be covered for morethan a 30-day supply. This limitation applies atretail, mail order, specialty and home infusionpharmacies.30-day supplyYou can ask Health Net to make an exception to these restrictions or limits. See the section, “How doI request an exception to the Health Net Medicare Part D Formulary?” for information about how torequest an exception.v
H ow d o I r e qu e s t a ne xc e p t i o n to t h e H e a lt h N e tM e d i c a r e Pa rt D f o r m u l a ry ?You can ask us to make an exception to our coveragerules. There are several types of exceptions that youcan ask us to make.Generally, Health Net will only approve yourrequest for an exception if preferred alternativedrugs or utilization restrictions would not be aseffective in treating your condition and/or wouldcause you to have adverse medical effects.You may contact us to request an exception. Whenrequesting an exception we require a statement fromyour physician supporting your request. Generally,we must make our decision within 72 hours ofreceiving your prescribing physician’s supportingstatement. You or your physician may request anexpedited (fast) exception if you or your physicianbelieve that your health could be seriously harmedby waiting up to 72 hours for a decision. If yourrequest to expedite is granted, we must give youa decision no later than 24 hours after we receiveyour prescriber or prescribing physician’s supportingstatement. You can ask us to cover your drug even if it is noton the formulary. You can ask us to waive coverage restrictions orlimits on your drug. For example, for certaindrugs, Health Net may limit the amount of thedrug that will be covered. If your drug has aquantity limit, you can ask us to waive the limitand cover more. You can ask us to provide a higher level ofcoverage for your drug. If your drug is on thenon-preferred tier or Tier 4, you can ask us tocover it for a preferred tier copayment. Pleasenote, if we grant your request to cover a drug thatis not on the formulary, the drug will be availablefor a non-preferred copayment. A higher level ofcoverage for the drug will not be approved. Also,a higher level of coverage for drugs on Tier 5 willnot be approved.vi
formulary tier descriptionsTo determine how much you will be required to pay for a drug, the abbreviations in the table below appearin the Brand Tier and Generic Tier columns on the formulary. The copayment or coinsurance level youwill be required to pay is displayed in the copayment/coinsurance column. If you do not know your copayment or coinsurance for each tier, please refer to your Summary of Benefits or EOC.Abbreviation Copayment/ CoinsuranceDescription1Tier 1 copaymentGenerally includes preferred generic drugs.May include some preferred brand drugs.2Tier 2 copaymentGenerally includes preferred brand drugs.May include some generic drugs.3Tier 3 copaymentNon-preferred generic and brand drugs.4Tier 4 copayment orIncludes injectable drugs that do not meetthe Centers for Medicare and Medicaid(Injectable Tier) coinsuranceServices (CMS) minimum cost thresholdrequired to be placed on the SpecialtyTier (Tier 5). These drugs are limited to amaximum 30-day supply per fill.5Tier 5 copayment orHigh cost drugs. These drugs are limited to(Specialty Tier) coinsurancea maximum 30-day supply per fill and are noteligible for exceptions for payment at a lowertier.NFNon-formulary – If Health Net Drugs not covered on Health Net’s Medicareapproves an exception request Part D formulary. You may request anfor a non-formulary drug, theexception from Health Net to cover theseTier 3 copayment will apply.drugs. See the section, “How do I request anexception to the Health Net Medicare PartD formulary?” for information about how torequest an exception.H ow d o I u s e t h e f o r m u l a ry ?The index at the end of this booklet provides an alphabetical list of all of the drugs included in theformulary. Both brand-name drugs and generic drugs are listed in the index. Next to your drug, you willsee the page number where you can find coverage information. Turn to the page listed in the index and findthe name of your drug.vii
H ow d o I r e a d t h e f o r m u l a ry ?If you have trouble finding your drug, turn to theindex at the end of this booklet.B r a n d a n d G e n e r i c D ru gNamesThe name of each drug can be found in the firstcolumn. Brand-name drugs are in uppercase(example: ZOCOR) and generic drugs are inlowercase (example: simvastatin). When thereis a brand-name drug with a generic equivalentavailable, the drugs will be listed on the same linewith the generic drug in parentheses, for example:ZOCOR (simvastatin).T i e r S tat u sThe tier status is shown to the right of the drugname. Generally, when there is a brand-name drugwith a generic equivalent available, the brand-namedrug will be non-preferred or non-formulary.LimitsThe information in the Limits column tells you ifthere are any limits or restrictions on your drug. Fora complete description of abbreviations found inthe Limits column please refer to the Abbreviationstable beginning on page iv. Choosing generic drugs may significantly loweryour out-of-pocket costs because generic drugs aregenerally lower in cost than brand-name drugs. The FDA thoroughly reviews all generic drugsto ensure they are safe and effective. A genericdrug has the same active ingredients as the brandname counterpart, but may differ in size, shape,and/or color because it is made by a differentmanufacturer.Note: Example onlybrand drugBrand Tier(generic drug)Therapeutic Category NameTherapeutic Class Name –BRAND NAME2(generic name)BRAND NAME3Generic Tier1LimitsQL, PA, B/D-PA, 30DSLD, STBrand drug only;generic not availableSample of abbreviations; Turnto pages iv-v for a completedescription of abbreviationsviii
H e a lt h N e t ’ s t r a n s i t i o np ro g r a mThe transition program is designed to ensurecontinuity of care for new members, existingmembers who may be subject to formulary changes,and members who experience a level of carechange. A level of care change occurs when you aredischarged from a hospital or moved to or froma Long Term Care (LTC) facility. The programalso allows members in LTC facilities access to atemporary transition supply of drugs.During this time, if your drug is not on theformulary or if your ability to get your drug islimited, we will cover a one-time temporary 30-daytransition supply (unless you have a prescriptionwritten for fewer days) when you go to a networkpharmacy.If you are a resident of a long-term care facility, wewill cover a temporary 34-day transition supply(unless you have a prescription written for fewerdays). We will cover more than one refill of thesedrugs for the first 90 days you are a member of ourplan. If you need a drug that is not on the formularyor your ability to get your drug is limited, but youare past the first 90 days of membership in our plan,we will cover a 34-day emergency supply of thatdrug (unless you have a prescription written forfewer days) while you pursue an exception.If you are a new member in our plan, you may betaking drugs that are not on the formulary, or youmay be taking a drug that is on the formulary withrestrictions or limits. For example, you may need aprior authorization from us before your prescriptioncan be filled. You should talk to your physician todecide if you should change to a drug that we coveror request an exception so that we will cover thedrug you take. While you talk to your physicianto determine the right course of action for you, wemay cover your drug in certain cases during thefirst 90 days you are a member of our plan. Thismay also apply if you are a renewing member andexperience a change in formulary upon annualbenefit renewal.You may view additional information about thetransition program at www.healthnet.com.ix
For more informationFor more detailed information about your Health Net prescription drug coverage,please review your EOC and other plan materials.If you have questions about Health Net, please call our Customer Servicedepartment at the toll-free number listed at the beginning of this booklet, or visitwww.healthnet.com.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/TDD users should call 1-877-486-2048. Or, visit www.medicare.gov.x
BRAND DRUG (generic Y/ANTI-OBESITY/ANOREXIANTSADDERALL TAB 10 MG, 12.5 MG, 15 MG,20 MG, 30 MG, 5 MG, 7.5 MG3ADDERALL XR 24 HR CAP(amphetamine-dextroamphetamine) 10 MG,15 MG, 20 MG, 25 MG, 30 MG, 5 MG3AMPHETAMINE SALT COMBO TAB 10 MG,12.5 MG, 15 MG, 20 MG, 30 MG, 5 MG, 7.5MG1CONCERTA 24 HR TAB (methylphenidate)18 MG, 27 MG, 36 MG, 54 MG2DAYTRANA DAILY PATCH 10 MG/9 HR, 15MG/9 HR, 20 MG/9 HR, 30 MG/9 HR3DESOXYN TAB (methamphetamine) 5 MG33DEXEDRINE SPANSULE CAP(dextroamphetamine) 10 MG, 15 MG, 5 MG31dextroamphetamine tab 10 mg, 5 mg321FOCALIN TAB (dexmethylphenidate) 10 MG,2.5 MG, 5 MG3FOCALIN XR CAP 10 MG, 15 MG, 20 MG,25 MG, 30 MG, 35 MG, 40 MG, 5 MG3INTUNIV ER 24 HR TAB 1 MG, 2 MG, 3 MG,4 MG3KAPVAY 12 HR TAB 0.1 MG3LIQUADD ORAL SOLN 5 MG/5 ML33Please refer to pages iv - v for a complete description of abbreviations.AL Age Limit B Medicare Part B B/D-PA Medicare Part Bvs.D GL Gender LimitLD Limited Distribution NT Non-TrOOP PA Prior AuthorizationQL Quantity Limit ST Step Therapy 30DS 30-Day Supplywww.healthnet.com1
BRAND DRUG (generic drug)BrandTierGenericLimitsTierMETADATE CD CAP 10 MG, 20 MG, 30 MG,40 MG, 50 MG, 60 MG3METADATE ER TAB (methylphenidate) 10MG31METADATE ER TAB (methylphenidate) 20MG11METHYLIN CHEWABLE TAB 10 MG, 2.5MG, 5 MG2METHYLIN ORAL SOLN (methylphenidate)10 MG/5 ML, 5 MG/5 ML21METHYLIN TAB (methylphenidate) 10 MG,20 MG, 5 MG11METHYLIN ER TAB (methylphenidate) 10MG, 20 MG11NUVIGIL TAB 150 MG, 250 MG, 50 MG2PROCENTRA ORAL SOLN 5 MG/5 ML3PROVIGIL TAB 100 MG, 200 MG2RITALIN TAB (methylphenidate) 10 MG, 20MG, 5 MG3RITALIN LA CAP 10 MG, 20 MG, 30 MG, 40MG3RITALIN SR TAB (methylphenidate) 20 MG3STRATTERA CAP 10 MG, 100 MG, 18 MG,25 MG, 40 MG, 60 MG, 80 MG2VYVANSE CAP 20 MG, 30 MG, 40 MG, 50MG, 60 MG, 70 MG3XENICAL CAP 120 MG3PAPA11AMINOGLYCOSIDESamikacin injection 1,000 mg/4 ml, 100 mg/2ml, 500 mg/2 ml4amikacin (pf) injection 1,000 mg/4 ml, 100mg/2 ml4gentamicin injection 10 mg/ml, 40 mg/ml4Please refer to pages iv - v for a complete description of abbreviations.AL Age Limit B Medicare Part B B/D-PA Medicare Part Bvs.D GL Gender LimitLD Limited Distribution NT Non-TrOOP PA Prior AuthorizationQL Quantity Limit ST Step Therapy 30DS 30-Day Supply2www.healthnet.com
BRAND DRUG (generic drug)BrandTierGenericLimitsTiergentamicin in sodium chloride(iso-osmotic) ivpiggy back 100 mg/100 ml, 100 mg/50 ml, 60mg/100 ml, 60 mg/50 ml, 70 mg/50 ml, 80mg/100 ml, 80 mg/50 ml, 90 mg/100 ml4gentamicin sulfate (pediatric) (pf) injection 20mg/2 ml4gentamicin sulfate (pf) iv 80 mg/8 ml4kanamycin injection 1 gram/3 ml4NEO-FRADIN ORAL SOLN 25 MG/ML2neomycin tab 500 mg1paromomycin cap 250 mg1streptomycin im 1 gram4TOBI NEB SOLUTION 300 MG/5 MLB/D-PA5tobramycin in ns iv piggy back 60 mg/50 ml,80 mg/100 ml4tobramycin injection 10 mg/ml, 40 mg/ml4tobramycin iv 80 mg/8ml4tobramycin solution for injection 1.2 g4ANALGESICS - ANTI-INFLAMMATORYACTEMRA IV 200 MG/10 ML (20 MG/ML),400 MG/20 ML (20 MG/ML), 80 MG/4 ML (20MG/ML)5ANAPROX TAB (naproxen sodium) 275 MG31ANAPROX DS TAB (naproxen sodium) 550MG31ANSAID TAB (flurbiprofen) 100 MG31ARAVA TAB (leflunomide) 10 MG, 20 MG31ARCALYST SUB-Q SOLN 220 MG5ARTHROTEC 50 TAB 50-200 MG-MCG3ARTHROTEC 75 TAB 75-200 MG-MCG3CATAFLAM TAB (diclofenac potassium) 50MG3LD1Please refer to pages iv - v for a complete description of abbreviations.AL Age Limit B Medicare Part B B/D-PA Medicare Part Bvs.D GL Gender LimitLD Limited Distribution NT Non-TrOOP PA Prior AuthorizationQL Quantity Limit ST Step Therapy 30DS 30-Day Supplywww.healthnet.com3
BRAND DRUG (generic drug)BrandTierGenericLimitsTierCELEBREX CAP 100 MG, 200 MG, 400 MG,50 MG2CLINORIL TAB (sulindac) 200 MG31DAYPRO TAB (oxaprozin) 600 MG31diclofenac sodium tab, delayed release 25mg, 50 mg1EC-NAPROSYN TAB (naproxen) 375 MG,500 MG3ENBREL SUB-Q KIT 25 MG (1 ML)5ENBREL SUB-Q SYRINGE 25 MG/0.5ML(0.51), 50 MG/ML (0.98 ML)51etodolac cap 200 mg, 300 mg1etodolac er 24 hr tab 400 mg, 500 mg, 600mg1etodolac tab 400 mg, 500 mg1FELDENE CAP (piroxicam) 10 MG, 20 MG31fenoprofen tab 600 mg3flurbiprofen tab 50 mg1HUMIRA SUB-Q KIT 20 MG/0.4 ML, 40MG/0.8 ML5HUMIRA CROHN'S DISEASE STARTERPACK SUBQ PEN KIT 40 MG/0.8 ML5ibuprofen oral susp 100 mg/5 ml1ibuprofen tab 400 mg, 600 mg, 800 mg1ILARIS (PF) SUB-Q SOLN 180 MG/1.2 ML(150 MG/ML)5INDOCIN ORAL SUSP 25 MG/5 ML2LDindomethacin cap 25 mg, 50 mg1indomethacin er cap 75 mg1ketoprofen cap 50 mg, 75 mg1ketoprofen er 24 hr cap 200 mg1Please refer to pages iv - v for a complete description of abbreviations.AL Age Limit B Medicare Part B B/D-PA Medicare Part Bvs.D GL Gender LimitLD Limited Distribution NT Non-TrOOP PA Prior AuthorizationQL Quantity Limit ST Step Therapy 30DS 30-Day Supply4www.healthnet.com
BRAND DRUG (generic drug)BrandTierGenericLimitsTierketorolac im 60 mg/2 ml4ketorolac injection 15 mg/ml, 30 mg/ml, 30mg/ml (1 ml)4ketorolac injection, cartridge 30 mg/ml4ketorolac tab 10 mg1KINERET SUB-Q SYRINGE 100 MG/0.67ML5meclofenamate cap 100 mg, 50 mg3MOBIC ORAL SUSP (meloxicam) 7.5 MG/5ML31MOBIC TAB (meloxicam) 15 MG, 7.5 MG31nabumetone tab 500 mg, 750 mg1NALFON CAP 200 MG3NAPRELAN CR 24 HR TAB 375 MG, 500MG2NAPRELAN CR 24 HR TAB 750 MG3NAPRELAN CR DOSE CARD 24 HR TAB750 MG (6) 500 MG (14)3NAPROSYN ORAL SUSP (naproxen) 125MG/5 ML31NAPROSYN TAB (naproxen) 250 MG, 375MG, 500 MG31ORENCIA IV SOLUTION 250 MG5ORENCIA SUB-Q SYRINGE 125 MG/ML5PONSTEL CAP (mefenamic acid) 250 MG3RHEUMATREX TABS IN A DOSE PACK 2.5MG2RIDAURA CAP 3 MG2SIMPONI SUB-Q SYRINGE 50 MG/0.5 ML5SPRIX NASAL SPRAY 15.75 MG/SPRAY3sulindac tab 150 mg31Please refer to pages iv - v for a complete description of abbreviations.AL Age Limit B Medicare Part B B/D-PA Medicare Part Bvs.D GL Gender LimitLD Limited Distribution NT Non-TrOOP PA Prior AuthorizationQL Quantity Limit ST Step Therapy 30DS 30-Day Supplywww.healthnet.com5
BRAND DRUG (generic drug)BrandTierGenericLimitsTiertolmetin cap 400 mg1tolmetin tab 200 mg, 600 mg1VIMOVO MULTIPHASE, IMMED & DELAYREL TAB 375-20 MG, 500-20 MG3VOLTAREN TAB (diclofenac sodium) 75 MG31VOLTAREN-XR 24 HR TAB (diclofenacsodium) 100 MG33ZIPSOR CAP 25 MG3ANALGESICS - NONNARCOTICALAGESIC CAP(butalbital-acetaminophen-caff) 50-325-40MG11NTANOLOR 300 CAP(butalbital-acetaminophen-caff) 50-325-40MG11NTBUPAP TAB 50-650 MG1BUTALBITAL COMPOUND CAP(butalbital-aspirin-caffeine) 50-325-40 MG11NTBUTALBITAL COMPOUND TAB(butalbital-aspirin-caffeine) 50-325-40 MG11NTCAPACET CAP(butalbital-acetaminophen-caff) 50-325-40MG11NTCEPHADYN TAB 50-650 MG1NTNTclonidine (pf) epidural 1,000 mcg/10 ml,5,000 mcg/10 ml4diflunisal tab 500 mg3DOLGIC LQ ORAL SOLN 50-325-40 MG/15ML3NTDOLGIC PLUS TAB 50-750-40 MG3NTESGIC CAP (butalbital-acetaminophen-caff)50-325-40 MG31NTPlease refer to pages iv - v for a complete description of abbreviations.AL Age Limit B Medicare Part B B/D-PA Medicare Part Bvs.D GL Gender LimitLD Limited Distribution NT Non-TrOOP PA Prior AuthorizationQL Quantity Limit ST Step Therapy 30DS 30-Day Supply6www.healthnet.com
BRAND DRUG (generic drug)BrandTierGenericLimitsTierESGIC TAB (butalbital-acetaminophen-caff)50-325-40 MG3ESGIC-PLUS CAP 50-500-40 MG3ESGIC-PLUS TAB(butalbital-acetaminophen-caff) 50-500-40MG31NTFARBITAL CAP (butalbital-aspirin-caffeine)50-325-40 MG11NTFIORICET TAB(butalbital-acetaminophen-caff) 50-325-40MG31NTFIORINAL CAP (butalbital-aspirin-caffeine)50-325-40 MG31NTMARGESIC CAP(butalbital-acetaminophen-caff) 50-325-40MG11NTMARTEN-TAB TAB(butalbital-acetaminophen) 50-325 MG11NTORBIVAN CAP 50-300-40 MG3PHRENILIN TAB (butalbital-acetaminophen)50-325 MG3PHRENILIN FORTE CAP 50-650 MG3PRIALT INTRATHECAL 100 MCG/ML, 25MCG/ML5PROMACET TAB 50-650 MG1REPAN TAB (butalbital-acetaminophen-caff)50-325-40 MG1SEDAPAP TAB 50-650 MG3TRIAD CAP (butalbital-acetaminophen-caff)50-325-40 MG1ZEBUTAL CAP 50-500-40 MG11NTNTNT1NTNTNT1NTNT1NTNTPlease refer to pages iv - v for a complete description of abbreviations.AL Age Limit B Medicare Part B B/D-PA Medicare Part Bvs.D GL Gender LimitLD Limited Distribution NT Non-TrOOP PA Prior AuthorizationQL Quantity Limit ST Step Therapy 30DS 30-Day Supplywww.healthnet.com7
BRAND DRUG (generic drug)BrandTierGenericLimitsTierANALGESICS - OPIOIDABSTRAL SUBLINGUAL TAB 100 MCG, 200MCG, 300 MCG, 400 MCG, 600 MCG, 800MCG5acetaminophen-codeine elixir 120-12 mg/5ml1acetaminophen-codeine tab 300-15 mg1ACTIQ LOZENGE ON A HANDLE (fentanylcitrate) 1,200 MCG, 1,600 MCG, 200 MCG,400 MCG, 600 MCG, 800 MCG3ASCOMP W/CODEINE CAP 30-50-325-40MG3ASTRAMORPH-PF INJECTION (morphine(pf)) 0.5 MG/ML, 1 MG/ML4AVINZA 24 HR CAP 120 MG, 30 MG, 45MG, 60 MG, 75 MG, 90 MG2BUPRENEX INJECTION 0.3 MG/ML434buprenorphine syringe 0.3 mg/ml4butorphanol tartrate injection 1 mg/ml4butorphanol tartrate nasal spray 10 mg/ml3BUTRANS TRANSDERM PATCH 10MCG/HOUR, 20 MCG/HOUR, 5 MCG/HOUR3CAPITAL WITH CODEINE ORAL SUSP120-12 MG/5 ML3CO-GESIC TAB(hydrocodone-acetaminophen) 5-500 MG1codeine tab 15 mg, 30 mg, 60 mg11COMBUNOX TAB (ibuprofen-oxycodone)400-5 MG33DAZIDOX TAB (oxycodone) 20 MG21DEMEROL INJECTION 100 MG/ML, 50MG/ML4Please refer to pages iv - v for a complete description of abbreviations.AL Age Limit B Medicare Part B B/D-PA Medicare Part Bvs.D GL Gender LimitLD Limited Distribution NT Non-TrOOP PA Prior AuthorizationQL Quantity Limit ST Step Therapy 30DS 30-Day Supply8www.healthnet.com
BRAND DRUG (generic drug)BrandTierGenericLimitsTierDEMEROL TAB (meperidine) 100 MG, 50MG3DEMEROL (PF) INJECTION 100 MG/2 ML,25 MG/0.5 ML, 75 MG/1.5 ML4DEMEROL (PF) SYRINGE 100 MG/ML, 25MG/ML, 75 MG/ML4DEMEROL (PF) INJECTION (meperidine(pf)) 100 MG/ML44DILAUDID TAB (hydromorphone) 2 MG, 4MG, 8 MG31DILAUDID (PF) INJECTION 1 MG/ML, 2MG/ML, 4 MG/ML4DILAUDID-5 ORAL LIQUID 1 MG/ML2DILAUDID-HP SOLUTION FOR INJECTION250 MG4DILAUDID-HP INJECTION (hydromorphone(pf)) 10 MG/ML44DISKETS SOLUBLE TAB (methadone) 40MG33DOLOPHINE TAB (methadone) 10 MG, 5MG31DOLOREX FORTE CAP 5-500 MG1DURAGESIC TRANSDERM PATCH(fentanyl) 100 MCG/HR, 12 MCG/HR, 25MCG/HR, 50 MCG/HR, 75 MCG/HR31DURAMORPH INJECTION (morphine (pf))0.5 MG/ML, 1 MG/ML44EMBEDA CAP 100-4 MG, 20-0.8 MG, 30-1.2MG, 50-2 MG, 60-2.4 MG, 80-3.2 MG2ENDOCET TAB (oxycodone-acetaminophen)10-325 MG, 10-650 MG, 5-325 MG, 7.5-325MG, 7.5-500 MG11ENDODAN TAB (oxycodone-aspirin)4.8355-325 MG111Please refer to pages iv - v for a complete description of abbreviations.AL Age Limit B Medicare Part B B/D-PA Medicare Part Bvs.D GL Gender LimitLD Limited Distribution NT Non-TrOOP PA Prior AuthorizationQL Quantity Limit ST Step Therapy 30DS 30-Day Supplywww.healthnet.com9
BRAND DRUG (generic drug)EXALGO ER 24 HR TAB 12 MG, 16 MG, 8MGBrandTierGenericLimitsTier3fentanyl (pf) syringe 50 mcg/ml4FENTORA BUCCAL TAB, EFFERVESCENT100 MCG, 200 MCG, 300 MCG, 400 MCG,600 MCG, 800 MCG5FIORICET-CODEINE CAP(cod-butalbital-acetaminop-caf) 30-50-325-40MG3FIORINAL-CODEINE #3 CAP 30-50-325-40MG3HYCET ORAL SOLN(hydrocodone-acetaminophen) 7.5-325MG/15 ML333hydrocodone-acetaminophen oral soln 5-163mg/7.5ml(7.5ml)3hydrocodone-acetaminophen tab 2.5-500 mg1HYDROGESIC CAP 5-500 MG1IBUDONE TAB 10-200 MG, 5-200 MG3INFUMORPH P/F INJECTION 10 MG/ML, 25MG/ML4KADIAN CAP 10 MG, 100 MG, 20 MG, 200MG, 30 MG, 50 MG, 60 MG, 80 MG2levorphanol tartrate tab 2 mg3LORCET 10/650 TAB(hydrocodone-acetaminophen) 10-650 MG31LORCET PLUS TAB(hydrocodone-acetaminophen) 7.5-650 MG31LORTAB TAB (hydrocodone-acetaminophen)10-500 MG, 5-500 MG, 7.5-500 MG31LORTAB ELIXIR ORAL SOLN(hydrocodone-acetaminophen) 7.5-500MG/15 ML31Please refer to pages iv - v for a complete description of abbreviations.AL Age Limit B Medicare Part B B/D-PA Medicare Part Bvs.D GL Gender LimitLD Limited Distribution NT Non-TrOOP PA Prior AuthorizationQL Quantity Limit ST Step Therapy 30DS 30-Day Supply10 www.healthnet.com
BRAND DRUG (generic drug)BrandTierMAGNACET TAB 10-400 MG, 2.5-400 MG,5-400 MG, 7.5-400 MG3MARGESIC-H CAP 5-500 MG1MAXIDONE TAB(hydrocodone-acetaminophen) 10-750 MG3GenericLimitsTier1meperidine oral soln 50 mg/5 ml1meperidine (pf) injection 25 mg/ml, 50 mg/ml,75 mg/ml4meperidine (pf) pca syringe 500 mg/50 ml4methadone injection 10 mg/ml4methadone oral soln 10 mg/5 ml, 5 mg/5 ml1METHADONE INTENSOL ORALCONCENTRATE (methadone) 10 MG/ML31METHADOSE ORAL CONCENTRATE(methadon
Health Net Seniority Plus and Health Net Options Plus P.O. Box 10198 Van Nuys, CA 91410-0198 FOR HEALTH NET ORANGE, PART D PRESCRIPTION DRUG PLANS: Health Net Medicare Enrollment P.O. Box 6500 Rensselaer, NY 12144-6500 Fax– 1-888-268-2393 Hours are: 8:00 a.m. – 8:00 p.m., 7 days a week. Current
