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metroplusFormulary 2020.GOLDOUR HEALTH PLAN FOR NEW YORK CITY EMPLOYEES
MetroPlus Health Plan2020 Gold Formulary(Prescription Drug Guide)PLEASE READ: THIS DOCUMENT CONTAINS INFORMATIONABOUT THE DRUGS WE COVER IN THIS PLANThis formulary was updated on August 1 For more recent information or other questions, please contactMetroPlus Health Plan Member Services, at 1-877-475-3795 (TTY: 711), 8am-8pm, Monday-Saturday, orvisit www.metroplus.org.Note to existing members: This formulary has changed since last year. Please review this document tomake sure that it still contains the drugs you take.This document includes list of the drugs for our plan. For an updated formulary, please contact us.You must use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacynetwork, and/or copayments/coinsurance may change on January 1, 2021, and from time to time during theyear.What is the MetroPlus Health Plan Formulary?A formulary is a list of covered drugs selected by MetroPlus Health Plan in consultation with a team ofhealth care providers, which represents the prescription therapies believed to be a necessary part of a qualitytreatment program. MetroPlus Health Plan will generally cover the drugs listed in our formulary as long asthe drug is medically necessary, the prescription is filled at a MetroPlus network pharmacy, and other planrules are followed. For more information on how to fill your prescriptions, please review your Certificate ofCoverage.Can the Formulary change?Generally, if you are taking a drug on our formulary that was covered at the beginning of the year, we willnot discontinue or reduce coverage of the drug during the coverage year except when a new, less expensivegeneric drug becomes available or when new adverse information about the safety or effectiveness of a drugis released. Other types of formulary changes, such as removing a drug from our formulary, will not affectmembers who are currently taking the drug. It will remain available at the same cost-sharing for thosemembers taking it for the remainder of the coverage year. We feel it is important that you have continuedMBR 16.381I
access for the remainder of the coverage year to the formulary drugs that were available when you chose ourplan, except for cases in which you can save additional money or we can ensure your safety.If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturerremoves the drug from the market, we will immediately remove the drug from our formulary and providenotice to members who take the drug. To get updated information about the drugs covered by MetroPlusHealth Plan, please contact us. Our contact information appears on the front and back cover pages.How do I use the Formulary?There are two ways to find your drug within the formulary:Medical ConditionThe formulary begins on page 1. The drugs in this formulary are grouped into categories depending onthe type of medical conditions that they are used to treat. For example, drugs used to treat a heartcondition are listed under the category, “Cardiovascular”. If you know what your drug is used for, lookfor the category name in the list that begins on page 1. 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 Index that begins onpage 110. The Index provides an alphabetical list of all of the drugs included in this document. Bothbrand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Nextto your drug, you will see the page number where you can find coverage information. Turn to the pagelisted in the Index and find the name of your drug in the first column of the list.MBR 16.381II
MetroPlus Gold FormularyThe formulary that begins on the next page provides coverage information about the drugs covered byMetroPlus Health Plan. If you have trouble finding your drug in the list, turn to the Index that begins onpage 110.The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., DURAMORPH))and generic drugs are listed in lower-case italics (e.g., endocet).The information in the Requirements/Limits column tells you if MetroPlus Health Plan has any specialrequirements for coverage of your drug. PA: MetroPlus requires your physician to get prior authorization for certain drugs. This means youwill need to get approval from MetroPlus before you fill your prescriptions. If you don’t get approval,MetroPlus may not cover the drug.ST: In some cases, MetroPlus requires you to first try certain drugs to treat your medical conditionbefore we will cover another drug for that condition. For example, if Drug A and Drug B both treatyour medical condition, MetroPlus may not cover Drug B unless you try Drug A first. If Drug A doesnot work for you, MetroPlus will then cover Drug B.PA**: If you do not go through the step therapy process, prior authorization is required for this drug.QL: For certain drugs, MetroPlus limits the amount of the drug that MetroPlus will cover. Forexample, MetroPlus provides one unit per day per prescription for pantoprazole. This may be inaddition to a standard one month or three month supply.OTC: This drug is not available over the counter.MBR 16.381III
EXCH CVSC 3T NY4 STND eff 08/01/2020Drug NameANALGESICSCOX-2 INHIBITORScelecoxib cap 50 m gcelecoxib cap 100 m gcelecoxib cap 200 m gGOUTallopurinol tab 100 m gallopurinol tab 300 m gcolchicine tab 0.6 m gcolchicine w/ probenecid tab 0.5-500 m gfebuxostat tab 40 m gfebuxostat tab 80 m gprobenecid tab 500 m gNON-OPIOID ANALGESICS§butalbital-acetaminophen-caffeine cap50-300-40 m gbutalbital-acetaminophen-caffeine cap50-325-40 m gbutalbital-acetaminophen-caffeine tab50-325-40 m gbutalbital-aspirin-caffeine cap 50-325-40mgtencon tab 50-325m gNSAIDS, COMBINATIONS§diclofenac w/ m isoprostol tab delayedrelease 50-0.2 m gdiclofenac w/ m isoprostol tab delayedrelease 75-0.2 m gNSAIDS§diclofenac potassium tab 50 m gdiclofenac sodium tab delayed release 25mgdiclofenac sodium tab delayed release 50mgdiclofenac sodium tab delayed release 75mgdiclofenac sodium tab er 24hr 100 m getodolac cap 200 m getodolac cap 300 m getodolac tab 400 m getodolac tab 500 m getodolac tab er 24hr 400 m getodolac tab er 24hr 500 m getodolac tab er 24hr 600 m gfenoprofen calcium tab 600 m gDrug Tier Requirements/Limits1111111111ST; PA**ST; PA**1QL (48 caps / 25 days)1QL (48 caps / 25 days)1QL (48 tabs / 25 days)1QL (48 caps / 25 days)1QL (48 tabs / 25 days)111111111111111PA - Prior Authorization QL - Quantity Limits ST - Step Therapy M - MedicalBenefit OTC - Over the counter PA** - PA Applies if Step is Not Met1
Drug NameDrug Tier Requirements/Limitsflurbiprofen tab 50 m g1flurbiprofen tab 100 m g1ibuprofen susp 100 m g/5ml1ibuprofen tab 400 m g1ibuprofen tab 600 m g1ibuprofen tab 800 m g1ketoprofen cap er 24hr 200 m g1ketorolac tromethamine im inj 60 m g/2ml1(30 m g/ml)ketorolac tromethamine inj 15 m g/m l1ketorolac tromethamine inj 30 m g/m l1ketorolac tromethamine tab 10 m g1QL (20 tabs / 25 days)m eclofenamate sodium cap 50 m g1m eclofenamate sodium cap 100 m g1m efenam ic acid cap 250 m g1m eloxicam tab 7.5 m g1m eloxicam tab 15 m g1nabum etone tab 500 m g1nabum etone tab 750 m g1naproxen tab 250 m g1naproxen tab 375 m g1naproxen tab 500 m g1oxaprozin tab 600 m g1piroxicam cap 10 m g1piroxicam cap 20 m g1sulindac tab 150 m g1sulindac tab 200 m g1tolm etin sodium cap 400 m g1tolm etin sodium tab 200 m g1tolm etin sodium tab 600 m g1OPIOID AGONIST/ANTAGONIST§buprenorphine hcl-naloxone hcl sl film2-0.5 m g (base equiv)buprenorphine hcl-naloxone hcl sl film 4-1m g (base equiv)buprenorphine hcl-naloxone hcl sl film 8-2m g (base equiv)buprenorphine hcl-naloxone hcl sl film 12-3m g (base equiv)buprenorphine hcl-naloxone hcl sl tab2-0.5 m g (base equiv)buprenorphine hcl-naloxone hcl sl tab 8-2m g (base equiv)ZUBSOLV SUB 0.7-0.18ZUBSOLV SUB 1.4-0.36ZUBSOLV SUB 2.9-0.711QL (90 units / 25 days)1QL (90 units / 25 days)1QL (90 units / 25 days)1QL (60 units / 25 days)0QL (90 tabs / 25 days); 0 copayQL (90 tabs / 25 days); 0 copayQL (90 units / 25 days)QL (90 units / 25 days)QL (90 units / 25 days)0222PA - Prior Authorization QL - Quantity Limits ST - Step Therapy M - MedicalBenefit OTC - Over the counter PA** - PA Applies if Step is Not Met2
Drug NameZUBSOLV SUB 5.7-1.4ZUBSOLV SUB 8.6-2.1ZUBSOLV SUB 11.4-2.9OPIOID ANALGESICS§Drug Tier222acetam inophen w/ codeine soln 120-12m g/5ml1acetam inophen w/ codeine tab 300-15 m g1acetam inophen w/ codeine tab 300-30 m g1acetam inophen w/ codeine tab 300-60 m g1butalbital-acetaminophen-caff w/ cod cap50-300-40-30 m gbutorphanol tartrate nasal soln 10 m g/mlCODEINE SULF TAB 60MG1codeine sulfate tab 30 m g1EMBEDA CAP 20-0.8MG2EMBEDA CAP 30-1.2MG2EMBEDA CAP 50-2MG2EMBEDA CAP 60-2.4MG2EMBEDA CAP 80-3.2MG2EMBEDA CAP 100-4MG2endocet tab 2.5-3251endocet tab 5-325m g1endocet tab 7.5-325111Requirements/LimitsQL (90 units / 25 days)QL (60 units / 25 days)QL (30 units / 25 days)QL (2700 ml / 25 days),ST; Subject to initial7-day limitQL (400 tabs / 25 days),ST; Subject to initial7-day limitQL (360 tabs / 25 days),ST; Subject to initial7-day limitQL (180 tabs / 25 days),ST; Subject to initial7-day limitQL (48 caps / 25 days)QL (2 bottles / 25 days)QL (42 tabs / 25 days),ST; Subject to initial7-day limitQL (42 tabs / 25 days),ST; Subject to initial7-day limitQL (60 caps / 25 days),STQL (60 caps / 25 days),STQL (30 caps / 25 days),STQL (30 caps / 25 days),STQL (30 caps / 25 days),STPA, ST; High StrengthRequires PAQL (360 tabs / 25 days),ST; Subject to initial7-day limitQL (360 tabs / 25 days),ST; Subject to initial7-day limitQL (240 tabs / 25 days),ST; Subject to initial7-day limitPA - Prior Authorization QL - Quantity Limits ST - Step Therapy M - MedicalBenefit OTC - Over the counter PA** - PA Applies if Step is Not Met3
Drug Nameendocet tab 10-325m gDrug Tier Requirements/Limits1QL (180 tabs / 25 days),ST; Subject to initial7-day limitfentanyl citrate lozenge on a handle 2001QL (120 lozenges / 25m cgdays), PAfentanyl citrate lozenge on a handle 4001QL (120 lozenges / 25m cgdays), PAfentanyl citrate lozenge on a handle 6001QL (120 lozenges / 25m cgdays), PAfentanyl citrate lozenge on a handle 8001QL (120 lozenges / 25m cgdays), PAfentanyl citrate lozenge on a handle 12001QL (120 lozenges / 25m cgdays), PAfentanyl citrate lozenge on a handle 16001QL (120 lozenges / 25m cgdays), PAfentanyl td patch 72hr 12 m cg/hr1QL (10 patches / 25days), STfentanyl td patch 72hr 25 m cg/hr1QL (10 patches / 25days), STfentanyl td patch 72hr 50 m cg/hr1PA, ST; High StrengthRequires PAfentanyl td patch 72hr 75 m cg/hr1PA, ST; High StrengthRequires PAfentanyl td patch 72hr 100 m cg/hr1PA, ST; High StrengthRequires PAhydrocodone-acetaminophen soln 7.5-3251QL (2700 ml / 25 days),m g/15mlST; Subject to initial7-day limithydrocodone-acetaminophen tab 5-325 m g1QL (240 tabs / 25 days),ST; Subject to initial7-day limithydrocodone-acetaminophen tab 7.5-3251QL (180 tabs / 25 days),mgST; Subject to initial7-day limithydrocodone-acetaminophen tab 10-3251QL (180 tabs / 25 days),mgST; Subject to initial7-day limithydrocodone-ibuprofen tab 10-200 m g1QL (50 tabs / 25 days),ST; Subject to initial7-day limitHYDROMORPHON SUP 3MG3QL (120 suppositories /25 days), ST; Subject toinitial 7-day limithydrom orphone hcl tab 2 m g1QL (180 tabs / 25 days),ST; Subject to initial7-day limitPA - Prior Authorization QL - Quantity Limits ST - Step Therapy M - MedicalBenefit OTC - Over the counter PA** - PA Applies if Step is Not Met4
Drug Namehydrom orphone hcl tab 4 m gDrug Tier Requirements/Limits1QL (150 tabs / 25 days),ST; Subject to initial7-day limithydrom orphone hcl tab 8 m g1QL (60 tabs / 25 days),ST; Subject to initial7-day limithydrom orphone hcl tab er 24hr deter 8 m g1QL (30 tabs / 25 days),SThydrom orphone hcl tab er 24hr deter 121QL (30 tabs / 25 days),mgSThydrom orphone hcl tab er 24hr deter 161QL (30 tabs / 25 days),mgSThydrom orphone hcl tab er 24hr deter 321PA, ST; High StrengthmgRequires PAHYSINGLA ER TAB 20 MG3QL (30 tabs / 25 days),STHYSINGLA ER TAB 30 MG3QL (30 tabs / 25 days),STHYSINGLA ER TAB 40 MG3QL (30 tabs / 25 days),STHYSINGLA ER TAB 60 MG3QL (30 tabs / 25 days),STHYSINGLA ER TAB 80 MG3QL (30 tabs / 25 days),STHYSINGLA ER TAB 100 MG3PA, ST; High StrengthRequires PAHYSINGLA ER TAB 120 MG3PA, ST; High StrengthRequires PAm ethadone con 10mg/ml1QL (60 mL / 25 days),ST; (generic ofMethadone Intensol,indicated for pain)m ethadone hcl conc 10 m g/ml1QL (30 ml / 25 days);(indicated for opioidaddiction)m ethadone hcl soln 5 m g/5m l1QL (450 ml / 25 days),STm ethadone hcl soln 10 m g/5ml1QL (300 mL / 25 days),STm ethadone hcl tab 5 m g1QL (90 tabs / 25 days),STm ethadone hcl tab 10 m g1QL (60 tabs / 25 days),STm ethadone hcl tab for oral susp 40 m g1QL (9 tabs / 25 days)m ethadose tab 40m g1QL (9 tabs / 25 days)m orphine sulfate beads cap er 24hr 30 m g1QL (30 caps / 25 days),STPA - Prior Authorization QL - Quantity Limits ST - Step Therapy M - MedicalBenefit OTC - Over the counter PA** - PA Applies if Step is Not Met5
Drug NameDrug Tier Requirements/Limitsm orphine sulfate beads cap er 24hr 45 m g1QL (30 caps / 25 days),STm orphine sulfate beads cap er 24hr 60 m g1QL (30 caps / 25 days),STm orphine sulfate beads cap er 24hr 75 m g1QL (30 caps / 25 days),STm orphine sulfate beads cap er 24hr 90 m g1QL (30 caps / 25 days),STm orphine sulfate beads cap er 24hr 1201PA, ST; High StrengthmgRequires PAm orphine sulfate cap er 24hr 10 m g1QL (60 caps / 25 days),STm orphine sulfate cap er 24hr 20 m g1QL (60 caps / 25 days),STm orphine sulfate cap er 24hr 30 m g1QL (60 caps / 25 days),STm orphine sulfate cap er 24hr 50 m g1QL (30 caps / 25 days),STm orphine sulfate cap er 24hr 60 m g1QL (30 caps / 25 days),STm orphine sulfate cap er 24hr 80 m g1QL (30 caps / 25 days),STm orphine sulfate cap er 24hr 100 m g1PA, ST; High StrengthRequires PAm orphine sulfate oral soln 10 m g/5ml1QL (900 ml / 25 days),ST; Subject to initial7-day limitm orphine sulfate oral soln 20 m g/5ml1QL (675 mL / 25 days),ST; Subject to initial7-day limitm orphine sulfate oral soln 100 m g/5m l (201QL (135 mL / 25 days),m g/m l)ST; Subject to initial7-day limitm orphine sulfate suppos 5 m g1QL (180 suppositories /25 days), ST; Subject toinitial 7-day limitm orphine sulfate suppos 10 m g1QL (180 suppositories /25 days), ST; Subject toinitial 7-day limitm orphine sulfate suppos 20 m g1QL (120 supp / 25days), ST; Subject toinitial 7-day limitm orphine sulfate suppos 30 m g1QL (90 supp / 25 days),ST; Subject to initial7-day limitm orphine sulfate tab 15 m g1QL (180 tabs / 25 days),ST; Subject to initial7-day limitPA - Prior Authorization QL - Quantity Limits ST - Step Therapy M - MedicalBenefit OTC - Over the counter PA** - PA Applies if Step is Not Met6
Drug Namem orphine sulfate tab 30 m gm orphine sulfate tab er 15 m gm orphine sulfate tab er 30 m gm orphine sulfate tab er 60 m gm orphine sulfate tab er 100 m gm orphine sulfate tab er 200 m gnalbuphine hcl inj 10 m g/mlnalbuphine hcl inj 20 m g/mlNUCYNTA ER TAB 50MGNUCYNTA ER TAB 100MGNUCYNTA ER TAB 150MGNUCYNTA ER TAB 200MGNUCYNTA ER TAB 250MGNUCYNTA TAB 50MGNUCYNTA TAB 75MGNUCYNTA TAB 100MGoxycodone hcl cap 5 m goxycodone hcl conc 100 m g/5ml (20m g/m l)oxycodone hcl soln 5 m g/5mloxycodone hcl tab 5 m gDrug Tier Requirements/Limits1QL (90 tabs / 25 days),ST; Subject to initial7-day limit1QL (90 tabs / 25 days),ST1QL (90 tabs / 25 days),ST1PA, ST; High StrengthRequires PA1PA, ST; High StrengthRequires PA1PA, ST; High StrengthRequires PA112QL (60 tabs / 25 days),ST2QL (60 tabs / 25 days),ST2PA, ST; High StrengthRequires PA2PA, ST; High StrengthRequires PA2PA, ST; High StrengthRequires PA2QL (120 tabs / 25 days),ST; Subject to initial7-day limit2QL (90 tabs / 25 days),ST; Subject to initial7-day limit2QL (60 tabs / 25 days),ST; Subject to initial7-day limit1QL (180 caps / 25days), ST; Subject toinitial 7-day limit1QL (90 mL / 25 days),ST; Subject to initial7-day limit1QL (900 ml / 25 days),ST; Subject to initial7-day limit1QL (180 tabs / 25 days),ST; Subject to initial7-day limitPA - Prior Authorization QL - Quantity Limits ST - Step Therapy M - MedicalBenefit OTC - Over the counter PA** - PA Applies if Step is Not Met7
Drug Nameoxycodone hcl tab 10 m gDrug Tier Requirements/Limits1QL (180 tabs / 25 days),ST; Subject to initial7-day limitoxycodone hcl tab 15 m g1QL (120 tabs / 25 days),ST; Subject to initial7-day limitoxycodone hcl tab 20 m g1QL (90 tabs / 25 days),ST; Subject to initial7-day limitoxycodone hcl tab 30 m g1QL (60 tabs / 25 days),ST; Subject to initial7-day limitoxycodone hcl tab er 12hr deter 10 m g1QL (60 tabs / 25 days),SToxycodone hcl tab er 12hr deter 15 m g1QL (60 tabs / 25 days),SToxycodone hcl tab er 12hr deter 20 m g1QL (60 tabs / 25 days),SToxycodone hcl tab er 12hr deter 30 m g1QL (60 tabs / 25 days),SToxycodone hcl tab er 12hr deter 40 m g1PA, ST; High StrengthRequires PAoxycodone hcl tab er 12hr deter 60 m g1PA, ST; High StrengthRequires PAoxycodone hcl tab er 12hr deter 80 m g1PA, ST; High StrengthRequires PAoxycodone w/ acetam inophen soln 5-3251QL (1800 ml / 25 days),m g/5mlST; Subject to initial7-day limitoxycodone w/ acetam inophen tab 2.5-3251QL (360 tabs / 25 days),mgST; Subject to initial7-day limitoxycodone w/ acetam inophen tab 5-3251QL (360 tabs / 25 days),mgST; Subject to initial7-day limitoxycodone w/ acetam inophen tab 7.5-3251QL (240 tabs / 25 days),mgST; Subject to initial7-day limitoxycodone w/ acetam inophen tab 10-3251QL (180 tabs / 25 days),mgST; Subject to initial7-day limitoxycodone-aspirin tab 4.8355-325 m g1QL (360 tabs / 25 days),ST; Subject to initial7-day limitoxycodone-ibuprofen tab 5-400 m g1QL (28 tabs / 25 days),ST; Subject to initial7-day limitOXYCONTIN TAB 10MG CR3QL (60 tabs / 25 days),STPA - Prior Authorization QL - Quantity Limits ST - Step Therapy M - MedicalBenefit OTC - Over the counter PA** - PA Applies if Step is Not Met8
Drug NameOXYCONTIN TAB 15MG CRDrug Tier Requirements/Limits3QL (60 tabs / 25 days),STOXYCONTIN TAB 20MG CR3QL (60 tabs / 25 days),STOXYCONTIN TAB 30MG CR3QL (60 tabs / 25 days),STOXYCONTIN TAB 40MG CR3PA, ST; High StrengthRequires PAOXYCONTIN TAB 60MG CR3PA, ST; High StrengthRequires PAOXYCONTIN TAB 80MG CR3PA, ST; High StrengthRequires PAoxym orphone hcl tab 5 m g1QL (180 tabs / 25 days),ST; Subject to initial7-day limitoxym orphone hcl tab 10 m g1QL (90 tabs / 25 days),ST; Subject to initial7-day limitoxym orphone hcl tab er 12hr 5 m g1QL (60 tabs / 25 days),SToxym orphone hcl tab er 12hr 7.5 m g1QL (60 tabs / 25 days),SToxym orphone hcl tab er 12hr 10 m g1QL (60 tabs / 25 days),SToxym orphone hcl tab er 12hr 15 m g1QL (60 tabs / 25 days),SToxym orphone hcl tab er 12hr 20 m g1PA, ST; High StrengthRequires PAoxym orphone hcl tab er 12hr 30 m g1PA, ST; High StrengthRequires PAoxym orphone hcl tab er 12hr 40 m g1PA, ST; High StrengthRequires PAtramadol hcl tab 50 m g1QL (180 tabs / 25 days),ST; Subject to initial7-day limittramadol hcl tab 100 m g1QL (90 tabs / 25 days),ST; Subject to initial7-day limittramadol hcl tab er 24hr 100 m g1QL (30 tabs / 25 days),STtramadol hcl tab er 24hr 200 m g1PA, ST; High StrengthRequires PAtramadol hcl tab er 24hr 300 m g1PA, ST; High StrengthRequires PAtramadol-acetaminophen tab 37.5-325 m g1QL (40 tabs / 25 days),ST; Subject to initial7-day limitPA - Prior Authorization QL - Quantity Limits ST - Step Therapy M - MedicalBenefit OTC - Over the counter PA** - PA Applies if Step is Not Met9
Drug Namexylon tab 10-200m gOPIOID PARTIAL AGONISTS§Drug Tier Requirements/Limits1QL (50 tabs / 25 days),ST; Subject to initial7-day limitBELBUCA MIS 75MCG2BELBUCA MIS 150MCG2BELBUCA MIS 300MCG2BELBUCA MIS 450MCG2BELBUCA MIS 600MCG2BELBUCA MIS 750MCG2BELBUCA MIS 900MCG2buprenorphine hcl sl tab 2 m g (base equiv)0buprenorphine hcl sl tab 8 m g (base equiv)0SUBLOCADE INJ 100/0.5SUBLOCADE INJ 300/1.533SALICYLATESaspirin chw 81m g0aspirin low tab 81m g ec0diflunisal tab 500 m g1ANTI-INFECTIVESANTI-BACTERIALS - MISCELLANEOUSMONUROL PAK GRANULESneom ycin sulfate tab 500 m gparom omycin sulfate cap 250 m gQL (60 films / 25 days),STQL (60 films / 25 days),STQL (60 films / 25 days),STQL (60 films / 25 days),STPA, ST; High StrengthRequires Prior AuthPA, ST; High StrengthRequires Prior AuthPA, ST; High StrengthRequires Prior AuthQL (90 tabs / 25 days); 0 copay; Must obtainapproval after the first30 day supplyQL (90 tabs / 25 days); 0 copay; Must obtainapproval after the first30 day supplyOTC, QL (100 tabs / 30days); 0 copay formembers age 50-59 ormembers at risk forpreeclampsia, otherwisenot coveredOTC, QL (100 tabs / 30days); 0 copay formembers age 50-59 ormembers at risk forpreeclampsia, otherwisenot covered311PA - Prior Authorization QL - Quantity Limits ST - Step Therapy M - MedicalBenefit OTC - Over the counter PA** - PA Applies if Step is Not Met10
Drug Namestreptomycin sulfate for inj 1 gmSULFADIAZINE TAB 500MGtinidazole tab 250 m gtinidazole tab 500 m gtobram ycin nebu soln 300 m g/5m lANTI-INFECTIVES - MISCELLANEOUSDrug Tier Requirements/Limits13113QL (280 mL / 28 days),PAALINIA SUS 100/5MLALINIA TAB 500MGatovaquone susp 750 m g/5m laztreonam for inj 1 gmaztreonam for inj 2 gmCAYSTON INH 75MG331113clindam ycin hcl cap 75 m gclindam ycin hcl cap 150 m gclindam ycin hcl cap 300 m gclindam ycin palm itate hcl for soln 75m g/5ml (base equiv)dapsone tab 25 m gdapsone tab 100 m gdaptom ycin for iv soln 500 m gDARAPRIM TAB 25MGdoripenem for iv infusion 250 m gdoripenem for iv infusion 500 m gEMVERM CHW 100MGiverm ectin tab 3 m glinezolid for susp 100 m g/5m llinezolid tab 600 m gm ethenamine hippurate tab 1 gmm etronidazole cap 375 m gm etronidazole tab 250 m gm etronidazole tab 500 m gnitrofurantoin m acrocrystalline cap 25 m g1111nitrofurantoin m acrocrystalline cap 50 m g1nitrofurantoin m acrocrystalline cap 100 m g1111311311111111QL (540mL / 25 days)QL (20 tabs / 25 days)QL (84 vials / 28 days),PAPAQL (12 tabs / 365 days)PA; High RiskMedications require PAfor members age 70 andolderPA; High RiskMedications require PAfor members age 70 andolderPA; High RiskMedications require PAfor members age 70 andolderPA - Prior Authorization QL - Quantity Limits ST - Step Therapy M - MedicalBenefit OTC - Over the counter PA** - PA Applies if Step is Not Met11
Drug Namenitrofurantoin m onohydratem acrocrystalline cap 100 m gpentam idine isethionate for nebulizationsoln 300 m gpentam idine isethionate for soln 300 m gpraziquantel tab 600 m gPRIMSOL SOL 50MG/5MLSIVEXTRO INJ 200MGSIVEXTRO TAB 200MGsulfam ethoxazole-trimethoprim susp200-40 m g/5mlsulfam ethoxazole-trimethoprim tab 400-80mgsulfam ethoxazole-trimethoprim tab800-160 m gtrim ethoprim tab 100 m gvancom ycin hcl cap 125 m g (baseequivalent)vancom ycin hcl cap 250 m g (baseequivalent)XIFAXAN TAB 200MGXIFAXAN TAB 550MGANTIFUNGALSam photericin b for iv soln 50 m gBIO-STATIN CAP 500000BIO-STATIN CAP 1000000bio-statin powCRESEMBA CAP 186 MGfluconazole for susp 10 m g/mlfluconazole for susp 40 m g/mlfluconazole tab 50 m gfluconazole tab 100 m gfluconazole tab 150 m gfluconazole tab 200 m ggriseofulvin m icrosize susp 125 m g/5mlgriseofulvin m icrosize tab 500 m ggriseofulvin ultram icrosize tab 125 m ggriseofulvin ultram icrosize tab 250 m gitraconazole cap 100 m gitraconazole oral soln 10 m g/m lNOXAFIL SUS 40MG/MLnystatin tab 500000 unitposaconazole tab delayed release 100 m gterbinafine hcl tab 250 m gDrug Tier Requirements/Limits1PA; High RiskMedications require PAfor members age 70 andolder1112331QL (24 tabs / 365 days)1111QL (80 caps / 10 days)1QL (80 caps / 10 days)22QL (9 tabs / 25 days)PA122131111111111112111PAPAPAPAPAPA - Prior Authorization QL - Quantity Limits ST - Step Therapy M - MedicalBenefit OTC - Over the counter PA** - PA Applies if Step is Not Met12
Drug Namevoriconazole for susp 40 m g/mlvoriconazole tab 50 m gvoriconazole tab 200 m gDrug Tier333ANTIMALARIALSatovaquone-proguanil hcl tab 62.5-25 m gatovaquone-proguanil hcl tab 250-100 m gchloroquine phosphate tab 250 m gchloroquine phosphate tab 500 m gCOARTEM TAB 20-120MGm efloquine hcl tab 250 m gprim aquine phosphate tab 26.3 m g (15 m gbase)quinine sulfate cap 324 m gANTIRETROVIRAL AGENTSabacavir sulfate soln 20 m g/m l (baseequiv)abacavir sulfate tab 300 m g (base equiv)APTIVUS CAP 250MGAPTIVUS SOLatazanavir sulfate cap 150 m g (base equiv)atazanavir sulfate cap 200 m g (base equiv)atazanavir sulfate cap 300 m g (base equiv)CRIXIVAN CAP 200MGCRIXIVAN CAP 400MGdidanosine delayed release capsule 200 mgdidanosine delayed release capsule 250 mgdidanosine delayed release capsule 400 mgEDURANT TAB 25MGefavirenz cap 50 m gefavirenz cap 200 m gefavirenz tab 600 m gEMTRIVA CAP 200MGEMTRIVA SOL 10MG/MLfosam prenavir calcium tab 700 m g (baseequiv)FUZEON INJ 90MGINTELENCE TAB 25MGINTELENCE TAB 100MGINTELENCE TAB 200MGINVIRASE CAP 200MGINVIRASE TAB 500MGISENTRESS CHW 25MGISENTRESS CHW 100MGISENTRESS HD TAB 600MGISENTRESS POW 100MGRequirements/LimitsPAPAPA111131111QL (900 mL / 30 days)122111221112111221QL (60 tabs / 30 days)QL (120 caps / 30 days)QL (285 mL / 28 days)QL (30 caps / 30 days)QL (60 caps / 30 days)QL (30 caps / 30 days)QL (450 caps / 30 days)QL (180 caps / 30 days)QL (30 caps / 30 days)QL (30 caps / 30 days)QL (30 caps / 30 days)QL (60 tabs / 30 days)QL (90 caps / 30 days)QL (90 caps / 30 days)QL (30 tabs / 30 days)QL (30 caps / 30 days)QL (680 ml / 28 days)QL (120 tabs / 30 days)3222222222QL (60 vials / 30 days)QL (120 tabs / 30 days)QL (120 tabs / 30 days)QL (60 tabs / 30 days)QL (300 caps / 30 days)QL (120 tabs / 30 days)QL (180 tabs / 30 days)QL (180 tabs / 30 days)QL (60 tabs / 30 days)QL (60 packets / 30days)PA - Prior Authorization QL - Quantity Limits ST - Step Therapy M - MedicalBenefit OTC - Over the counter PA** - PA Applies if Step is Not Met13
Drug NameISENTRESS TAB 400MGlam ivudine oral soln 10 m g/m llam ivudine tab 150 m glam ivudine tab 300 m gLEXIVA SUS 50MG/MLnevirapine susp 50 m g/5mlnevirapine tab 200 m gnevirapine tab er 24hr 100 m gnevirapine tab er 24hr 400 m gNORVIR POW 100MGDrug Tier2111211112NORVIR SOL 80MG/MLPREZISTA SUS 100MG/MLPREZISTA TAB 75MGPREZISTA TAB 150MGPREZISTA TAB 600MGPREZISTA TAB 800MGREYATAZ POW 50MG2222222ritonavir tab 100 m gSELZENTRY SOL 20MG/MLSELZENTRY TAB 25MGSELZENTRY TAB 75MGSELZENTRY TAB 150MGSELZENTRY TAB 300MGstavudine cap 15 m gstavudine cap 20 m gstavudine cap 30 m gstavudine cap 40 m gtenofovir disoproxil fumarate tab 300 m gTIVICAY TAB 10MGTIVICAY TAB 25MGTIVICAY TAB 50MGTROGARZO INJ 150MG/MLTYBOST TAB 150MGVIDEX EC CAP 125MGVIDEX SOL 2GMVIDEX SOL 4GMVIRACEPT TAB 250MGVIRACEPT TAB 625MGVIREAD POW 40MG/GMVIREAD TAB 150MGVIREAD TAB 200MGVIREAD TAB 250MGZERIT SOL 1MG/MLzidovudine cap 100 m g122222111112223222222222221Requirements/LimitsQL (120 tabs / 30 days)QL (900 ml / 30 days)QL (60 tabs / 30 days)QL (30 tabs / 30 days)QL (1575 mL / 28 days)QL (1200 mL / 30 days)QL (60 tabs / 30 days)QL (90 tabs / 30 days)QL (30 tabs / 30 days)QL (360 packets / 30days)QL (480 mL / 30 days)QL (400 ml / 30 days)QL (300 tabs / 30 days)QL (180 tabs / 30 days)QL (60 tabs / 30 days)QL (30 tabs / 30 days)QL (180 packets / 30days)QL (360 tabs / 30 days)QL (1840 mL / 30 days)QL (240 tabs / 30 days)QL (60 tabs / 30 days)QL (60 tabs / 30 days)QL (120 tabs / 30 days)QL (60 caps / 30 days)QL (60 caps / 30 days)QL (60 caps / 30 days)QL (60 caps / 30 days)QL (30 tabs / 30 days)QL (60 tabs / 30 days)QL (60 tabs / 30 days)QL (60 tabs / 30 days)NMQL (30 tabs / 30 days)QL (30 caps / 30 days)QL (1200 ml / 30 days)QL (1200 ml / 30 days)QL (300 tabs / 30 days)QL (120 tabs / 30 days)QL (240 gm / 30 days)QL (30 tabs / 30 days)QL (30 tabs / 30 days)QL (30 tabs / 30 days)QL (2400 ml / 30 days)QL (180 caps / 30 days)PA - Prior Authorization QL - Quantity Limits ST - Step Therapy M - MedicalBenefit OTC - Over the counter PA** - PA Applies if Step is Not Met14
Drug Namezidovudine syrup 10 m g/m lzidovudine tab 300 m gDrug Tier Requirements/Limits1QL (1800 ml / 30 days)1QL (60 tabs / 30 days)ANTIRETROVIRAL COMBINATION AGENTSabacavir sulfate-lam ivudine tab 600-300mgabacavir sulfate-lam ivudine-zidovudine tab300-150-300 m gBIKTARVY TABCIMDUO TAB 300-300COMPLERA TABDESCOVY TAB 200/251QL (30 tabs / 30 days)1QL (60 tabs / 30 days)2222DOVATO TAB 50-300MGEVOTAZ TAB 300-150GENVOYA TABKALETRA TAB 100-25MGKALETRA TAB 200-50MGlam ivudine-zidovudine tab 150-300 m glopinavir-ritonavir soln 400-100 m g/5ml(80-20 m g/m l)ODEFSEY TABPREZCOBIX TAB 800-150STRIBILD TABSYMFI LO TABSYMFI TABTEMIXYS TAB 300-300TRIUMEQ TABTRUVADA TAB 100-150TRUVADA TAB 133-200TRUVADA TAB 167-250TRUVADA TAB 200-3003222211QL (30 tabs / 30 days)QL (30 tabs / 30 days)QL (30 tabs / 30 days)QL (30 tabs / 30 days);Exception processavailable for 0 copaywhen medicallynecessary forpre-exposureprophylaxisQL (30 tabs / 30 days)QL (30 tabs / 30 days)QL (30 tabs / 30 days)QL (240 tabs / 30 days)QL (120 tabs / 30 days)QL (60 tabs / 30 days)QL (390 mL / 30 days)ANTITUBERCULAR AGENTScycloserine cap 250 m getham butol hcl tab 100 m getham butol hcl tab 400 m gisoniazid syrup 50 m g/5mlisoniazid tab 100 m g22222222220QL (30 tabs / 30 days)QL (30 tabs / 30 days)QL (30 tabs / 30 days)QL (30 tabs / 30 days)QL (30 tabs / 30 days)QL (30 tabs / 30 days)QL (30 tabs / 30 days)QL (30 tabs / 30 days)QL (30 tabs / 30 days)QL (30 tabs / 30 days)QL (30 tabs / 30 days),ST; PA**; 0 copay;coverage for pre andpost-exposureprophylaxis only11111PA - Prior Authorization QL - Quantity Limits ST - Step Therapy M - MedicalBenefit OTC - Over the counter PA** - PA Applies if Step is Not Met15
Drug Nameisoniazid tab 300 m gPASER GRA 4GMPRIFTIN TAB 150MGpyrazinam ide tab 500 m grifabutin cap 150 m gRIFAMATE CAPrifam pin cap 150 m grifam pin cap 300 m gRIFATER TABSIRTURO TAB 100MGTRECATOR TAB 250MGANTIVIRALS§Drug Tier Requirements/Limits13211211232acyclovir cap 200 m gacyclovir susp 200 m g/5mlac
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy M - Medical Benefit OTC - Over the counter PA** - PA Applies if Step is Not Met 2 Drug Name Drug Tier Requirements/Limits flurbiprofen tab 50 mg 1 flurbiprofen tab 100 mg 1 ibuprofen susp 100 mg/5ml 1 ibuprofen tab 400 mg 1 ibuprofen tab 600 mg 1 ibuprofen tab 800 mg 1 ketoprofen cap er 24hr 200 mg 1
