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NetResults A-Series Prescription Drug GuideOctober 2021Please consider talking to your doctor about prescribing covered medications. Preferred medications (G and P)will help reduce your out-of-pocket costs compared to non-preferred medications (NP). This list may help guideyou and your doctor in selecting an appropriate medication for you.The drug list, also known as a formulary, is regularly updated. This list is subject to change.ContentsTherapeutic Class Drug ListIntroduction . ICoverage considerations . IPrior Authorization . IStep Therapy . IQuantity Limits . IISpecialty Drugs. IINotice . IIAbbreviation key . IIAnti-Infective Agents . 1Biologicals . 9Antineoplastic Agents . 12Endocrine and Metabolic Drugs . 18Cardiovascular Agents . 32Respiratory Agents . 45Gastrointestinal Agents . 50Genitourinary Agents. 54Central Nervous System Drugs. 55Analgesics and Anesthetics . 69Neuromuscular Drugs . 79Nutritional Products . 86Hematological Agents . 91Topical Products. 100Miscellaneous Products . 110Index . 116To search for a drug name within this PDF document, use the Control and F keys on your keyboard, or go toEdit in the drop-down menu and select Find/Search. Type in the word or phrase you are looking for andclick on Search.2060-1A Prime Therapeutics LLC 10/21
IntroductionThe Prime Therapeutics NetResults A-Series Prescription Drug Guide contains covered drugs for a broad rangeof diseases.Generics drugs are shown in lower-case boldface type. Most generic drugs are followed by a reference branddrug in (parentheses). Some generic products have no reference brand.Brand prescription drugs are shown in capital letters followed by the generic name.The Prime Therapeutics NetResults A-Series Prescription Drug Guide is organized into broad categories (e.g.Anti-Infective drugs). Within most categories, drugs are sub-grouped by drug class (e.g. Penicillins) or by use fora specific medical condition (e.g. Diabetes).To save the most money on prescription drugs, take this drug list with you each time you visit your physician.Consider asking your physician to prescribe generic (G) and preferred (P) formulary medications, if appropriate.Decisions about the need for a prescription drug and dosage of a prescription drug must be made solely by youand your physician in accordance with the patient/physician relationship.G genericsP preferred brands (formulary brands)NP non-preferred brands (non-formulary brands)S specialtyCoverage considerationsMost prescription drug benefit plans provide coverage for up to a 30-day supply of medication, with someexceptions. Your plan may also provide coverage for up to a 90-day supply of maintenance medications.Maintenance medications are those drugs you may take on an ongoing basis for conditions such as high bloodpressure, diabetes or high cholesterol. Some plans may exclude coverage for certain agents or drug categories,like those used for erectile dysfunction, weight loss or infertility.Over-the-counter exclusions: The NetResults Formulary may not provide coverage for prescription medicationsthat have an over-the-counter version. You should refer to your benefit plan material for details about yourparticular benefits.Repackaged medications: Repackaged versions of medications already available on the market are notcovered.Prior AuthorizationSome drugs require prior authorization (PA) to ensure appropriate use. This means that your doctor will need tosubmit a PA request for coverage. Coverage may be approved after certain criteria are met. If a PA is required fora drug listed in this document, it will be noted next to the drug with a dot under the PA column.Step TherapyA step therapy (ST) program means you may need to try an alternative drug before coverage may be available forthe requested drug included in the ST program. ST programs help redirect members to safe, effective and lessexpensive alternatives. If a ST is required for a drug listed in this document, it will be noted next to the drug with adot under the ST column.Prime Therapeutics NetResults A-Series October 2021 Prescription Drug GuideI
Quantity LimitsQuantity Limits (QL) help encourage drug use as intended by the Food and Drug Administration. The QL is themaximum quantity that can be dispensed over a given period of time. These limits help encourage safe andproper use. If a QL is required for a drug listed in this document, it will be noted next to the drug with a dot underthe QL column.Specialty DrugsSpecialty drugs require special handling, patient monitoring, and unique education prior to use.NoticeThe purpose of the Prime Therapeutics NetResults Prescription Drug List is to provide a guide to coverage.Decisions about the need for a prescription drug and dosage of a prescription drug must be made solely by youand your physician in accordance with the patient/physician relationship.Abbreviation keyaer.aerosolnebu . nebulizercap . capsulesodt. . orally disintegrating tabschew . chewableoint . ointmentconc .concentrateophth .ophthalmiccr. controlled releaseosm . osmotic releasedr . delayed releasepack .packetsec . enteric coatedpowd . powderequiv . equivalentpttw . twice-weekly patcher. extended releasesl . sublingualgm. gramsoln .solutioninhal .inhalersuppos . suppositoriesinj . injectionsusp . suspensionliqd. liquidtab . tabletsmg. milligramtd . transdermalml . milliliterw/.withPrime Therapeutics NetResults A-Series October 2021 Prescription Drug GuideII
ANTI-INFECTIVE AGENTSPENICILLINSAMOXICILLIN- amoxicillin (trihydrate)chew tab 125 mgNPAMOXICILLIN- amoxicillin (trihydrate)chew tab 250 mgNPamoxicillin (trihydrate) cap 250 mgGamoxicillin (trihydrate) cap 500 mgamoxicillin (trihydrate) for susp125 mg/5mlamoxicillin (trihydrate) for susp200 mg/5mlamoxicillin (trihydrate) for susp250 mg/5mlamoxicillin (trihydrate) for susp400 mg/5mlamoxicillin (trihydrate) tab 500 mgamoxicillin (trihydrate) tab 875 mgamoxicillin & k clavulanate for susp200-28.5 mg/5mlamoxicillin & k clavulanate for susp250-62.5 mg/5ml (Augmentin)amoxicillin & k clavulanate for susp400-57 mg/5mlamoxicillin & k clavulanate for susp600-42.9 mg/5ml (Augmentines-600)amoxicillin & k clavulanate tab250-125 mgamoxicillin & k clavulanate tab500-125 mg (Augmentin)amoxicillin & k clavulanate tab875-125 mgGGGGGGAMOXICILLIN/CLAVULANATE Pamoxicillin & k clavulanate tab er12hr 1000-62.5 mgNPAMPICILLIN- ampicillin cap 500 mgNPAUGMENTIN- amoxicillin& k clavulanate for susp125-31.25 mg/5mlNPdicloxacillin sodium cap 250 mgdicloxacillin sodium cap 500 mgGpenicillin v potassium tab 500 mgGDispensing LimitsStep TherapyPENICILLIN V POTASSIUM- penicillin NPv potassium for soln 125 mg/5mlPENICILLIN V POTASSIUM- penicillin NPv potassium for soln 250 mg/5mlGpenicillin v potassium tab 250 mgCEPHALOSPORINSNPGCEFACLOR- cefaclor cap 500 mgNPGCEFACLOR- cefaclor for susp125 mg/5mlNPGCEFACLOR- cefaclor for susp250 mg/5mlNPGCEFACLOR- cefaclor for susp375 mg/5mlNPGCEFACLOR ER- cefaclormonohydrate tab er 12hr 500 mgNPCEFADROXIL- cefadroxil tab 1 gmNPcefadroxil cap 500 mgGcefadroxil for susp 250 mg/5mlGcefdinir cap 300 mgNPAMOXICILLIN/CLAVULANATE Pamoxicillin & k clavulanate chew tab200-28.5 mgNPAMOXICILLIN/CLAVULANATE Pamoxicillin & k clavulanate chew tab400-57 mgPrior AuthorizationGCEFACLOR- cefaclor cap 250 mgGSpecialtyDrug NameTier DesignationDispensing LimitsStep TherapyPrior AuthorizationSpecialtyDrug NameTier Designation2021cefadroxil for susp 500 mg/5mlcefdinir for susp 125 mg/5mlcefdinir for susp 250 mg/5mlcefixime cap 400 mg (Suprax)cefixime for susp 100 mg/5ml(Suprax)cefixime for susp 200 mg/5ml(Suprax)Prime Therapeutics NetResults A-Series October 2021 Prescription Drug GuideGGGGGGGGG1
cefpodoxime proxetil for susp50 mg/5mlcefpodoxime proxetil for susp100 mg/5mlcefpodoxime proxetil tab 100 mgcefpodoxime proxetil tab 200 mgcefprozil for susp 125 mg/5mlcefprozil for susp 250 mg/5mlcefprozil tab 250 mgcefprozil tab 500 mgcefuroxime axetil tab 250 mgGGGclarithromycin tab 250 mgclarithromycin tab 500 mgNPGDIFICID- fidaxomicin tab 200 mgNPGE.E.S. 400- erythromycinethylsuccinate tab 400 mgNPGGGGGGSUPRAX- cefixime chew tab 200 mgPSUPRAX- cefixime for susp500 mg/5mlPERYTHROCIN STEARATEerythromycin stearate tab 250 mgNPERYTHROMYCIN ETHYLSUCCINAerythromycin ethylsuccinate tab400 mgNPerythromycin ethylsuccinate forsusp 200 mg/5ml (E.e.s. granules)Gerythromycin ethylsuccinate forsusp 400 mg/5ml (Eryped 400)erythromycin tab delayed release250 mgerythromycin tab delayed release333 mgPerythromycin tab delayed release500 mgazithromycin for susp 100 mg/5ml(Zithromax)Gerythromycin tab 250 mgazithromycin tab 600 mgCLARITHROMYCIN- clarithromycinfor susp 125 mg/5mlerythromycin tab 500 mgGZITHROMAX- azithromycin powdpack for susp 1 gmGTETRACYCLINESGGNPdemeclocycline hcl tab 150 mgdemeclocycline hcl tab 300 mgdoxycycline hyclate cap 50 mgdoxycycline hyclate cap 100 mg(Vibramycin)doxycycline hyclate tab 20 mgPrime Therapeutics NetResults A-Series October 2021 Prescription Drug GuideDispensing LimitsStep TherapyPrior AuthorizationSpecialtyPERYTHROMYCIN- erythromycinw/ delayed release particles cap250 mgAZITHROMYCIN- azithromycin powdpack for susp 1 gmazithromycin tab 500 mg(Zithromax)GDIFICID- fidaxomicin for susp 40 mg/mlSUPRAX- cefixime chew tab 100 mgazithromycin tab 250 mg(Zithromax)GGPazithromycin for susp 200 mg/5ml(Zithromax)Tier Designationclarithromycin tab er 24hr 500 mgGMACROLIDESDispensing LimitsGcephalexin cap 250 mg (Keflex)cephalexin for susp 250 mg/5mlStep TherapyNPCEPHALEXIN- cephalexin tab 250 mg NPCEPHALEXIN- cephalexin tab 500 mg NPcephalexin for susp 125 mg/5mlPrior AuthorizationCLARITHROMYCIN- clarithromycinfor susp 250 mg/5mlGcephalexin cap 750 mg (Keflex)Drug NameGcefuroxime axetil tab 500 mgcephalexin cap 500 mg (Keflex)SpecialtyDrug NameTier Designation2021GGGGGGNPGGGGG2
doxycycline hyclate tab 75 mg(Acticlate)doxycycline hyclate tab 100 mgdoxycycline hyclate tab 150 mg(Acticlate)doxycycline monohydrate cap50 mgdoxycycline monohydrate cap75 mgdoxycycline monohydrate cap100 mgdoxycycline monohydrate cap150 mgdoxycycline monohydrate for susp25 mg/5ml (Vibramycin)doxycycline monohydrate tab50 mgdoxycycline monohydrate tab75 mgdoxycycline monohydrate tab100 mgdoxycycline monohydrate tab150 mgminocycline hcl cap 50 mgminocycline hcl cap 75 mgminocycline hcl cap 100 mgminocycline hcl tab er 24hr 55 mg(Solodyn)minocycline hcl tab er 24hr 65 mg(Solodyn)minocycline hcl tab er 24hr 80 mg(Solodyn)minocycline hcl tab er 24hr 105 mg(Solodyn)minocycline hcl tab er 24hr 115 mg(Solodyn)minocycline hcl tab 50 mgminocycline hcl tab 75 mgminocycline hcl tab 100 mgGNUZYRA- omadacycline tosylate tab150 mg (base equivalent)SGtetracycline hcl cap 250 mgGGGGGGGGGGtetracycline hcl cap 500 mgFLUOROQUINOLONESNPCIPRO- ciprofloxacin for oral susp250 mg/5ml (5%) (5 gm/100ml)NPCIPRO- ciprofloxacin for oral susp500 mg/5ml (10%) (10 gm/100ml)NPCIPROFLOXACIN HCL- ciprofloxacinhcl tab 100 mg (base equiv)NPciprofloxacin hcl tab 250 mg (baseequiv) (Cipro)Gciprofloxacin hcl tab 750 mg (baseequiv)levofloxacin oral soln 25 mg/mlGlevofloxacin tab 250 mgGlevofloxacin tab 750 mgGmoxifloxacin hcl tab 400 mg (baseequiv)GGlevofloxacin tab 500 mgGGGGGGOFLOXACIN- ofloxacin tab 300 mgPofloxacin tab 400 mgGAMINOGLYCOSIDESSGARIKAYCE- amikacin sulfate liposomeinhal susp 590 mg/8.4ml (base eq) SGKITABIS PAK- tobramycin nebu soln300 mg/5ml neomycin sulfate tab 500 mgGGGGparomomycin sulfate cap 250 mgGTOBI PODHALER- tobramycin inhalcap 28 mgS TOBRAMYCIN- tobramycin nebu soln300 mg/5mlS Prime Therapeutics NetResults A-Series October 2021 Prescription Drug GuideDispensing LimitsGGGStep TherapyPrior Authorization GBAXDELA- delafloxacin megluminetab 450 mg (base equiv)ciprofloxacin hcl tab 500 mg (baseequiv) (Cipro)SpecialtyDrug NameTier DesignationDispensing LimitsStep TherapyPrior AuthorizationSpecialtyDrug NameTier Designation2021 3
tobramycin nebu soln 300 mg/5ml(Tobi)tobramycin nebu soln 300 mg/4ml(Bethkis)SULFONAMIDESSULFADIAZINE- sulfadiazine tab500 mgANTIMYCOBACTERIAL AGENTSCYCLOSERINE- cycloserine cap250 mgethambutol hcl tab 100 mgethambutol hcl tab 400 mg(Myambutol)fluconazole tab 150 mg (Diflucan)flucytosine cap 250 mg (Ancobon)flucytosine cap 500 mg (Ancobon)griseofulvin microsize susp125 mg/5mlNPgriseofulvin microsize tab 500 mggriseofulvin ultramicrosize tab125 mgGGNPgriseofulvin ultramicrosize tab250 mgitraconazole cap 100 mg(Sporanox)itraconazole oral soln 10 mg/ml(Sporanox)GPASER- aminosalicylic acider granules packet 4 gmNPPRETOMANID- pretomanid tab200 mgNPPRIFTIN- rifapentine tab 150 mgPpyrazinamide tab 500 mgPrifampin cap 300 mg (Rifadin)fluconazole tab 100 mg (Diflucan)PISONIAZID- isoniazid tab 100 mgrifampin cap 150 mg (Rifadin)fluconazole tab 50 mg (Diflucan)fluconazole tab 200 mg (Diflucan)NPrifabutin cap 150 mg (Mycobutin)ketoconazole tab 200 mgGSIRTURO- bedaquiline fumarate tab20 mg (base equiv)SIRTURO- bedaquiline fumarate tab100 mg (base equiv)Svoriconazole tab 50 mg (Vfend)voriconazole tab 200 mg (Vfend)ANTIVIRALSTRECATOR- ethionamide tab 250 mg NPCRESEMBA- isavuconazoniumsulfate cap 186 mg (isavuconazole100 mg)fluconazole for susp 10 mg/ml(Diflucan)fluconazole for susp 40 mg/ml(Diflucan)NPGG abacavir sulfate soln 20 mg/ml(base equiv) (Ziagen)abacavir sulfate tab 300 mg (baseequiv) (Ziagen)abacavir sulfate-lamivudine tab600-300 mg (Epzicom)abacavir sulfate-lamivudinezidovudine tab 300-150-300 mg(Trizivir)Prime Therapeutics NetResults A-Series October 2021 Prescription Drug GuideDispensing LimitsStep TherapyPrior AuthorizationSpecialtyGGGGGGGGGGGvoriconazole for susp 40 mg/ml(Vfend) Gnystatin tab 500000 unitTOLSURA- itraconazole cap 65 mg GPterbinafine hcl tab 250 mgGGNOXAFIL- posaconazole susp 40 mg/mlposaconazole tab delayed release100 mg (Noxafil)GSANTIFUNGALSDrug NameTier Designation Dispensing LimitsSStep Therapy Prior AuthorizationSISONIAZID- isoniazid syrup50 mg/5mlisoniazid tab 300 mgSpecialtyDrug NameTier Designation2021G GNPG G GG G G G 4
acyclovir cap 200 mgacyclovir susp 200 mg/5ml(Zovirax)acyclovir tab 400 mgacyclovir tab 800 mgadefovir dipivoxil tab 10 mg(Hepsera)APTIVUS- tipranavir cap 250 mgatazanavir sulfate cap 150 mg (baseequiv) (Reyataz)atazanavir sulfate cap 200 mg (baseequiv) (Reyataz)GGefavirenz-lamivudine-tenofovir dftab 600-300-300 mg (Symfi)Gemtricitabine caps 200 mg(Emtriva)emtricitabine-tenofovir disoproxilfumarate tab 100-150 mg(Truvada)GGG emtricitabine-tenofovir disoproxilfumarate tab 133-200 mg(Truvada)G G emtricitabine-tenofovir disoproxilfumarate tab 167-250 mg(Truvada)NPBARACLUDE- entecavir oral soln0.05 mg/mlPemtricitabine-tenofovir disoproxilfumarate tab 200-300 mg(Truvada)BIKTARVY- bictegravir-emtricitabinetenofovir af tab 50-200-25 mgP EMTRIVA- emtricitabine soln 10 mg/mlCIMDUO- lamivudine-tenofovirdisoproxil fumarate tab 300-300 mgP entecavir tab 1 mg (Baraclude)COMPLERA- emtricitabine-rilpivirinetenofovir df tab 200-25-300 mgNPCRIXIVAN- indinavir sulfate cap400 mgNPatazanavir sulfate cap 300 mg (baseequiv) (Reyataz)Dispensing LimitsStep TherapyPrior AuthorizationG G NP GG EPIVIR HBV- lamivudine oral soln5 mg/ml (hbv)NPetravirine tab 100 mg (Intelence)G NP efavirenz-lamivudine-tenofovir dftab 400-300-300 mg (Symfi lo) Pefavirenz-emtricitabine-tenofovir dftab 600-200-300 mg (Atripla)GSDOVATO- dolutegravir sodiumlamivudine tab 50-300 mg (base eq)G G G EPCLUSA- sofosbuvir-velpatasvir tab400-100 mg efavirenz tab 600 mg (Sustiva)G PG DESCOVY- emtricitabine-tenofoviralafenamide fumarate tab200-25 mgefavirenz cap 200 mg (Sustiva)G G SPefavirenz cap 50 mg (Sustiva)GEPCLUSA- sofosbuvir-velpatasvir tab200-50 mgDELSTRIGO- doravirine-lamivudinetenofovir df tab 100-300-300 mgEDURANT- rilpivirine hcl tab 25 mg(base equivalent)entecavir tab 0.5 mg (Baraclude)SpecialtyDrug NameTier DesignationDispensing LimitsStep TherapyPrior AuthorizationSpecialtyDrug NameTier Designation2021etravirine tab 200 mg (Intelence)GEVOTAZ- atazanavir sulfate-cobicistattab 300-150 mg (base equiv)Pfamciclovir tab 125 mgGfamciclovir tab 250 mgfamciclovir tab 500 mgfosamprenavir calcium tab 700 mg(base equiv) (Lexiva)GG GFUZEON- enfuvirtide for inj 90 mgSGENVOYA- elvitegrav-cobicemtricitab-tenofov af tab150-150-200-10 mgPHARVONI- ledipasvir-sofosbuvir pelletpack 33.75-150 mgSPrime Therapeutics NetResults A-Series October 2021 Prescription Drug Guide 5
S HARVONI- ledipasvir-sofosbuvir tab90-400 mgS INTELENCE- etravirine tab 25 mgPINTELENCE- etravirine tab 100 mgPINTELENCE- etravirine tab 200 mgPINVIRASE- saquinavir mesylate tab500 mgNP ISENTRESS- raltegravir potassiumchew tab 25 mg (base equiv)P ISENTRESS- raltegravir potassiumchew tab 100 mg (base equiv)PISENTRESS- raltegravir potassiumpacket for susp 100 mg (base equiv)PISENTRESS- raltegravir potassiumtab 400 mg (base equiv)PISENTRESS HD- raltegravirpotassium tab 600 mg (base equiv)PJULUCA- dolutegravir sodiumrilpivirine hcl tab 50-25 mg (base eq)PKALETRA- lopinavir-ritonavir tab100-25 mgPKALETRA- lopinavir-ritonavir tab200-50 mgPlamivudine oral soln 10 mg/ml(Epivir)Glamivudine tab 150 mg (Epivir)lamivudine tab 300 mg (Epivir)lamivudine-zidovudine tab150-300 mg (Combivir)LEXIVA- fosamprenavir calcium susp50 mg/ml (base equiv)lopinavir-ritonavir soln400-100 mg/5ml (80-20 mg/ml)(Kaletra) GGGGNPG lopinavir-ritonavir tab 100-25 mg(Kaletra)lopinavir-ritonavir tab 200-50 mg(Kaletra)Dispensing LimitsHARVONI- ledipasvir-sofosbuvir tab45-200 mglamivudine tab 100 mg (hbv) (Epivirhbv) Step Therapy Prior AuthorizationSSpecialtyHARVONI- ledipasvir-sofosbuvir pelletpack 45-200 mgDrug NameTier DesignationDispensing LimitsStep TherapyPrior AuthorizationSpecialtyDrug NameTier Designation2021G G MAVYRET- glecaprevir-pibrentasvirtab 100-40 mgSNEVIRAPINE ER- nevirapine tab er24hr 100 mgNP G G GNP ODEFSEY- emtricitabine-rilpivirinetenofovir af tab 200-25-25 mgP oseltamivir phosphate cap 30 mg(base equiv) (Tamiflu)G G G G nevirapine susp 50 mg/5ml(Viramune)nevirapine tab er 24hr 400 mg(Viramune xr)nevirapine tab 200 mg (Viramune)NORVIR- ritonavir oral soln 80 mg/mlNORVIR- ritonavir powder packet100 mgoseltamivir phosphate cap 45 mg(base equiv) (Tamiflu)oseltamivir phosphate cap 75 mg(base equiv) (Tamiflu)oseltamivir phosphate for susp6 mg/ml (base equiv) (Tamiflu)PPEGASYS- peginterferon alfa-2a inj180 mcg/mlS PEGASYS- peginterferon alfa-2a inj180 mcg/0.5mlS PREVYMIS- letermovir tab 240 mgNPPREVYMIS- letermovir tab 480 mgNPPREZCOBIX- darunavir-cobicistat tab800-150 mgP PREZISTA- darunavir ethanolate susp100 mg/ml (base equiv)P PREZISTA- darunavir ethanolate tab75 mg (base equiv)P PREZISTA- darunavir ethanolate tab150 mg (base equiv)P Prime Therapeutics NetResults A-Series October 2021 Prescription Drug Guide6
P RELENZA DISKHALER- zanamiviraero powder breath activated 5 mg/blisterNP REYATAZ- atazanavir sulfate oralpowder packet 50 mg (base equiv)NP ribavirin cap 200 mgribavirin for inhal soln 6 gm(Virazole)ribavirin tab 200 mgritonavir tab 100 mg (Norvir)S GS GRUKOBIA- fostemsavir tromethaminetab er 12hr 600 mgNPSELZENTRY- maraviroc oral soln20 mg/mlNPSELZENTRY- maraviroc tab 25 mgNPSELZENTRY- maraviroc tab 75 mgNPSELZENTRY- maraviroc tab 150 mgNPSELZENTRY- maraviroc tab 300 mgNPSITAVIG- acyclovir buccal tab 50 mgNP SOVALDI- sofosbuvir pellet pack150 mgS SOVALDI- sofosbuvir pellet pack200 mgS SOVALDI- sofosbuvir tab 200 mgSSOVALDI- sofosbuvir tab 400 mgS STAVUDINE- stavudine cap 15 mgGSTAVUDINE- stavudine cap 20 mgGSTAVUDINE- stavudine cap 30 mgGSTAVUDINE- stavudine cap 40 mgG STRIBILD- elvitegrav-cobic-emtricitab- NPtenofovdf tab 150-150-200-300 mgPSYMTUZA- darunavir-cobicemtricitab-tenofov af tab800-150-200-10 mg Dispensing LimitsPREZISTA- darunavir ethanolate tab800 mg (base equiv)Step Therapy Prior AuthorizationPSpecialtyPREZISTA- darunavir ethanolate tab600 mg (base equiv)Drug NameTier DesignationDispensing LimitsStep TherapyPrior AuthorizationSpecialtyDrug NameTier Designation2021TEMIXYS- lamivudine-tenofovirdisoproxil fumarate tab 300-300 mgP tenofovir disoproxil fumarate tab300 mg (Viread)G TIVICAY- dolutegravir sodium tab10 mg (base equiv)P TIVICAY- dolutegravir sodium tab25 mg (base equiv)P TIVICAY- dolutegravir sodium tab50 mg (base equiv)P TIVICAY PD- dolutegravir sodium tabfor oral susp 5 mg (base equiv)P TRIUMEQ- abacavir-dolutegravirlamivudine tab 600-50-300 mgP NP TYBOST- cobicistat tab 150 mgvalacyclovir hcl tab 500 mg(Valtrex)valacyclovir hcl tab 1 gm (Valtrex)valganciclovir hcl for soln 50 mg/ml(base equiv) (Valcyte)valganciclovir hcl tab 450 mg (baseequivalent) (Valcyte)GGGGVEMLIDY- tenofovir alafenamidefumarate tab 25 mgNPVIRACEPT- nelfinavir mesylate tab250 mgNP VIRACEPT- nelfinavir mesylate tab625 mgNP VIREAD- tenofovir disoproxil fumarateoral powder 40 mg/gmP VIREAD- tenofovir disoproxil fumaratetab 150 mgP VIREAD- tenofovir disoproxil fumaratetab 200 mgP VIREAD- tenofovir disoproxil fumaratetab 250 mgP VOSEVI- sofosbuvir-velpatasvirvoxilaprevir tab 400-100-100 mgSXOFLUZA- baloxavir marboxil tabtherapy pack 2 x 20 mg (40 mgdose)NPPrime Therapeutics NetResults A-Series October 2021 Prescription Drug Guide 7
XOFLUZA- baloxavir marboxil tabtherapy pack 2 x 40 mg (80 mgdose)zidovudine cap 100 mg (Retrovir)zidovudine syrup 10 mg/ml(Retrovir)zidovudine tab 300 mgNPG G GANTIMALARIALSARAKODA- tafenoquine succinate tab NP100 mg (base equivalent)Gatovaquone-proguanil hcl tab62.5-25 mg (Malarone)Gatovaquone-proguanil hcl tab250-100 mg (Malarone)NPCHLOROQUINE PHOSPHATEchloroquine phosphate tab 500 mgchloroquine phosphate tab 250 mg GBENZNIDAZOLE- benznidazole tab100 mgPEMVERM- mebendazole chew tab100 mgNPivermectin tab 3 mg (Stromectol)Gpraziquantel tab 600 mg (Biltricide)ANTI-INFECTIVE AGENTS - MISC.AEMCOLO- rifamycin sodium tabdelayed release 194 mg (baseequiv)ALINIA- nitazoxanide for susp100 mg/5mlPatovaquone susp 750 mg/5ml(Mepron)GGNPclindamycin hcl cap 75 mg(Cleocin)Gclindamycin hcl cap 150 mg(Cleocin)KRINTAFEL- tafenoquine succinatetab 150 mg (base equivalent)NPclindamycin hcl cap 300 mg(Cleocin)MEFLOQUINE HCL- mefloquine hcltab 250 mgPclindamycin palmitate hcl for soln75 mg/5ml (base equiv) (Cleocinpediatric gr)primaquine phosphate tab 26.3 mg(15 mg base) (Primaquinephosphate)Gdapsone tab 25 mgpyrimethamine tab 25 mg(Daraprim)quinine sulfate cap 324 mg(Qualaquin)AMEBICIDESSOLOSEC- secnidazole granulespacket 2 gmANTHELMINTICSalbendazole tab 200 mg (Albenza)BENZNIDAZOLE- benznidazole tab12.5 mgdapsone tab 100 mgDispensing LimitsGGGNPGFIRVANQ- vancomycin hcl for oralsoln 50 mg/ml (base equivalent)NPGPfosfomycin tromethamine powdpack 3 gm (base equivalent)(Monurol)PLAMPIT- nifurtimox tab 30 mgNPGLAMPIT- nifurtimox tab 120 mgNPPlinezolid for susp 100 mg/5ml(Zyvox)GPrime Therapeutics NetResults A-Series October 2021 Prescription Drug Guide GFIRVANQ- vancomycin hcl for oralsoln 25 mg/ml (base equivalent)linezolid tab 600 mg (Zyvox) GGIMPAVIDO- miltefosine cap 50 mgStep TherapyNPShydroxychloroquine sulfate tab200 mg (Plaquenil)Prior AuthorizationGCAYSTON- aztreonam lysine for inhalsoln 75 mg (base equivalent)COARTEM- artemether-lumefantrinetab 20-120 mgSpecialty Drug NameTier DesignationDispensing LimitsStep TherapyPrior AuthorizationSpecialtyDrug NameTier Designation2021G8
methenamine hippurate tab 1 gm(Hiprex)metronidazole cap 375 mg (Flagyl)metronidazole tab 250 mg (Flagyl)metronidazole tab 500 mg (Flagyl)nitazoxanide tab 500 mg (Alinia)nitrofurantoin macrocrystalline cap25 mg (Macrodantin)nitrofurantoin macrocrystalline cap50 mg (Macrodantin)nitrofurantoin macrocrystalline cap100 mg (Macrodantin)nitrofurantoin monohydratemacrocrystalline cap 100 mg(Macrobid)nitrofurantoin susp 25 mg/5mlpentamidine isethionate fornebulization soln 300 mg(Nebupent)tinidazole tab 500 mgtrimethoprim tab 100 mgvancomycin hcl cap 125 mg (baseequivalent) (Vancocin hcl)vancomycin hcl cap 250 mg (baseequivalent) (Vancocin)VANCOMYCIN HYDROCHLORIDEvancomycin hcl for oral soln 50 mg/ml (base equivalent)XIFAXAN- rifaximin tab 200 mgNPGXIFAXAN- rifaximin tab 550 mgPGBIOLOGICALSGG VACCINESACTHIB- haemophilus bpolysaccharide conjugate vaccinefor injPAFLURIA QUADRIVALENT 2020influenza virus vac split quadrivalentsusp pref syr 0.25 mlPGAFLURIA QUADRIVALENT 2020influenza virus vac split quadrivalentsusp pref syr 0.5mlPGAFLURIA QUADRIVALENT 2020influenza virus vaccine splitquadrivalent im injPAFLURIA QUADRIVALENT 2021influenza virus vac split quadrivalentsusp pref syr 0.25 mlPAFLURIA QUADRIVALENT 2021influenza virus vac split quadrivalentsusp pref syr 0.5mlPAFLURIA QUADRIVALENT 2021influenza virus vaccine splitquadrivalent im injPBEXSERO- meningococcal vac b(recomb omv adjuv) inj prefilledsyringePENGERIX-B- hepatitis b vaccine(recombinant) susp 10 mcg/0.5mlPENGERIX-B- hepatitis b vaccine(recombinant) susp 20 mcg/mlPFLUAD QUADRIVALENT INFLUEinfluenza vac type a&b surface antadj quad pref syr 0.5 mlPFLUAD QUADRIVALENT 2021-2influenza vac type a&b surface antadj quad pref syr 0.5 mlPGGGGGGGGGGGNPPrime Therapeutics NetResults A-Series October 2021 Prescription Drug GuideDispensing LimitsStep Therapy Prior AuthorizationSpecialtyTier DesignationDispensing LimitsGNPtinidazole tab 250 mgStep TherapySSIVEXTRO- tedizolid phosphate tab200 mgsulfamethoxazole-trimethoprim tab800-160 mg (Bactrim ds)Prior AuthorizationXENLETA- lefamulin acetate tab600 mgNPsulfamethoxazole-trimethoprim tab400-80 mg (Bactrim)Drug NameGPRIMSOL- trimethoprim hcl oral soln50 mg/5ml (base equiv)sulfamethoxazole-trimethoprimsusp 200-40 mg/5mlSpecialtyDrug NameTier Designation20219
FLUAD 2020-2021- influenza vac typea&b surface ant adj susp pref syr0.5 mlPHIBERIX- haemophilus bpolysaccharide conjugate vac for inj10 mcgPFLUARIX QUADRIVALENT 2021influenza virus vac split quadrivalentsusp pref syr 0.5mlPIMOVAX RABIES (H.D.C.V.)- rabiesvirus vaccine, hdc injPPPFLUBLOK QUADRIVALENT 2021influenza vac recomb ha quad pfsoln pref syr 0.5 mlIPOL INACTIVATED IPV- poliovirusvaccine, ipv injectionPFLUCELVAX QUADRIVALENT 20influenza vac tiss-cult subunt quadsusp pref syr 0.5 mlPJANSSEN COVID-19 VACCINEcovid-19 (sars-cov-2) ad26 vectorvaccine-janssen im 0.5 mlPFLUCELVAX QUADRIVALENT 20influenza vac tissue-cultured subunitquadrivalent im suspPM-M-R II- measles-mumps-rubellavirus vaccines for inj solnMENACTRA- meningococcal (a, c, y,and w-135) conjugate vaccine injPFLULAVAL QUADRIVALENT 202influenza virus vac split quadrivalentsusp pref syr 0.5mlPMENQUADFI- meningococcal (a, c, y,and w-135) conjugate vaccine injPPFLUZONE HIGH-DOSE PF 2021influenza vac split high-dose quad pfsusp pref syr 0.7 mlPMENVEO- meningococcal (a, c, y, andw-135) oligo conj vac for injPFLUZONE QUADRIVALENT 2021influenza virus vac split quadrivalentsusp pref syr 0.5mlPMODERNA COVID-19 VACCINEcovid-19 (sars-cov-2)mrna vaccmoderna im susp 100 mcg/0.5mlPFLUZONE QUADRIVALENT 2021influenza virus vaccine splitquadrivalent im injPPEDVAX HIB- haemophilus bpolysaccharide conj vac im susp7.5 mcg/0.5 mlPFLUZONE QUADRIVALENT 2021influenza virus vaccine splitquadrivalent
NetResults A-Series Prescription Drug Guide . October 2021 Please consider talking to your doctor about prescribing covered medications . Preferred medications (G and P) will help reduce your out-of-pocket costs compared to non-preferred medications (NP ). This list may help guide you a
