Transcription
Trusted Health Plan Formulary
ContentsIntroduction . 3The Trusted Health Plan, District of Columbia Pharmacy and Therapeutics Committee(P&T) . 3Notice . 3Preface . 3Product Selection Criteria . 3Formulary Components . 4Generic Substitution . 4Covered Medications without Authorization . 4Non-Covered Benefits . 4Prior Authorization . 4Step Therapy . 4Specialty Medications . 4Quantity Limits . 5Benefit Exception . 5Pharmacy Benefit Management . 5Therapeutic Categories . 62020 Trusted Health Plan, District of Columbia Medicaid Formulary List . 9Index . 64
IntroductionTrusted Health Plan, District of Columbia is pleased to provide an updated 2020 Medicaid Formularyas a reference and informational tool for physicians, pharmacists and patients. The Trusted HealthPlan, District of Columbia Formulary is designed to assist practitioners in selecting clinically appropriateand cost-effective products for their patients.The Trusted Health Plan, District of Columbia Pharmacy and TherapeuticsCommittee (P&T)The medications on this formulary have been reviewed by the Trusted Health Plan, District of ColumbiaP&T Committee. The Committee includes physicians, pharmacists and health professionals. Theclinical information within the formulary is primarily derived from medical literature and is reviewed andapproved by the P&T Committee.NoticeThe information contained in this formulary is provided by Trusted Health Plan, District of Columbia,solely for the convenience of medical providers. This formulary is not intended to be a substitute for theknowledge, expertise, skill and judgment of the medical provider in their choice of prescription drugs.Trusted Health Plan, District of Columbia assumes no responsibility for the actions or omissions of anymedical provider based upon reliance, in whole or in part, on the information contained herein. Themedical provider should consult the drug manufacturer’s product literature or standard references formore detailed information.PrefaceThe Trusted Health Plan, District of Columbia formulary is organized by sections. Each section includestherapeutic groups identified by either drug class or disease state. Products are listed by its dispensablename. Brand names are included as a reference to assist in product recognition. Trusted Health Plan,District of Columbia will not cover prescription drugs that are prescribed for experimental,investigational or non-FDA approved indications, dosages, or routes of administration. Trusted HealthPlan, District of Columbia does not cover any medication excluded by District of Columbia Medicaid(https://dc.fhsc.com/ downloads/providers/dcrx pdl listing.pdf).Product Selection CriteriaThe Trusted Health Plan, District of Columbia P&T Committee considers clinical information on new tomarket drugs that are typically included in an outpatient pharmacy benefit. The primary goal of theTrusted Health Plan, District of Columbia P&T Committee is to preserve and evaluate the TrustedHealth Plan, District of Columbia formulary based upon an objective analysis of the safety, efficacy,approved indications, adverse effects, contraindications, patient administration/complianceconsiderations and cost effectiveness. When a new drug is considered for formulary inclusion, it will bereviewed relative to similar drugs currently included in the Trusted Health Plan, District of ColumbiaFormulary. Formulary decisions are communicated quarterly on the Trusted Health Plan, District ofColumbia website. Therapeutic substitution occurs when a preferred drug is approved for use becauseit has similar treatment effects but is not identical to a non-preferred drug.Trusted Health Plan District of ColumbiaVersion: 1Page 3 of 74Update Date: 1/2020
Formulary ComponentsThe Trusted Health Plan, District of Columbia Formulary contains the following components: Coveredmedications without authorization, medications that must meet Step Therapy Protocol, medications thatrequire Prior Authorization, Specialty medications and medications that are subject to Quantity Limits.Members will not be charged a co-pay when Trusted Health Plan, District of Columbia covers amedication.Generic SubstitutionTrusted Health Plan, District of Columbia is a mandatory generic plan. The brand and common nameslisted in the formulary are for reference only. Generic medication will be dispensed where available.Covered Medications without AuthorizationTrusted Health Plan, District of Columbia covers many medications without any authorization required.These medications include many prescription and over-the-counter medications (when ordered by aphysician).Non-Covered BenefitsThe following categories are not covered benefits: Medications used for cosmetic purposes, to promotefertility, for sexual dysfunction, for experimental or investigational purposes, or medications that are notlicensed for use in the United States.Prior AuthorizationDrugs indicated with "PA" require Prior Authorization for coverage. Details of the PA criteria are listednext to the drug name. Please call the Abarca Health Help Desk at 866-287-6156 or fax a completedPrior Authorization form to 866-839-2372. All requests must be accompanied by pertinent clinicalinformation and are reviewed within 24 hours.Step TherapyDrugs indicated with a "ST" require Step Therapy for coverage. The required step is listed next to thedrug name. Step Therapy ensures clinically appropriate and cost-effective drugs are used before otheralternatives.Specialty MedicationsAll specialty medications are handled by Abarca Health. To order a specialty medication by fax, sendthe prescription and a completed prior authorization form to 866-839-2372 or call Abarca Health HelpDesk at 866-287-6156.Trusted Health Plan District of ColumbiaVersion: 1Page 4 of 74Update Date: 1/2020
Quantity LimitsDrugs indicated with a "QL" have a set quantity limit imposed. These limits are based on FDArecommended dosing guidelines. The quantity limit is listed next to the drug name. All medications aresubject to a maximum of 30 days per prescription.Benefit ExceptionThe process for requesting non-formulary medication(s) requires faxing of a completed FormularyException form indicating the request for an exception to the formulary. This request will need to includepertinent clinical documentation showing trial and failure of all formulary agents. It should also containinformation showing the medication is the standard of care for the indication provided (Peer reviewedjournal articles may be required). Please call the Abarca Health Help Desk at 866-287-6156 or fax acompleted Formulary Exception form to 866-839-2372.Pharmacy Benefit ManagementTrusted Health Plan, District of Columbia utilizes Abarca Health to manage each member’s pharmacybenefit. Abarca Health provides Trusted Health Plan, District of Columbia with a pharmacy network,pharmacy claims management services, and claims adjudication. Abarca Health Help Desk can becontacted at 866-287-6156.Trusted Health Plan District of ColumbiaVersion: 1Page 5 of 74Update Date: 1/2020
Therapeutic IANTS . 9AMINOGLYCOSIDES . 10ANALGESICS - ANTI-INFLAMMATORY . 10ANALGESICS - NONNARCOTIC . 11ANALGESICS - OPIOID . 12ANORECTAL AGENTS . 14ANTACIDS . 15ANTIANGINAL AGENTS . 15ANTIANXIETY AGENTS . 15ANTIARRHYTHMICS . 16ANTIASTHMATIC AND BRONCHODILATOR AGENTS . 16ANTICOAGULANTS . 18ANTICONVULSANTS . 18ANTIDEPRESSANTS . 20ANTIDIABETICS . 21ANTIDIARRHEAL/PROBIOTIC AGENTS. 23ANTIDOTES AND SPECIFIC ANTAGONISTS . 23ANTIEMETICS . 23ANTIFUNGALS . 24ANTIHISTAMINES . 24ANTIHYPERLIPIDEMICS . 26ANTIHYPERTENSIVES . 26ANTI-INFECTIVE AGENTS - MISC. . 28ANTIMALARIALS . 28ANTIMYASTHENIC/CHOLINERGIC AGENTS . 28ANTIMYCOBACTERIAL AGENTS . 28ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES . 28ANTIPARKINSON AND RELATED THERAPY AGENTS . 29ANTIPSYCHOTICS/ANTIMANIC AGENTS . 30ANTIVIRALS . 31BETA BLOCKERS . 32Trusted Health Plan District of ColumbiaVersion: 1Page 6 of 74Update Date: 1/2020
CALCIUM CHANNEL BLOCKERS . 32CARDIOTONICS . 33CARDIOVASCULAR AGENTS - MISC. . 33CEPHALOSPORINS . 33CONTRACEPTIVES . 34CORTICOSTEROIDS . 37COUGH/COLD/ALLERGY . 38DERMATOLOGICALS . 39DIAGNOSTIC PRODUCTS . 44DIGESTIVE AIDS . 44DIURETICS . 44ENDOCRINE AND METABOLIC AGENTS - MISC. 45ESTROGENS . 45FLUOROQUINOLONES . 45GASTROINTESTINAL AGENTS - MISC. . 46GENITOURINARY AGENTS - MISCELLANEOUS . 46GOUT AGENTS . 47HEMATOLOGICAL AGENTS - MISC. . 47HEMATOPOIETIC AGENTS. 47HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS . 48LAXATIVES . 48LOCAL ANESTHETICS-PARENTERAL. 49MACROLIDES . 49MEDICAL DEVICES AND SUPPLIES . 50MIGRAINE PRODUCTS . 52MINERALS & ELECTROLYTES. 52MISCELLANEOUS THERAPEUTIC CLASSES . 53MOUTH/THROAT/DENTAL AGENTS . 53MULTIVITAMINS . 53MUSCULOSKELETAL THERAPY AGENTS . 54NASAL AGENTS - SYSTEMIC AND TOPICAL . 54OPHTHALMIC AGENTS . 55OTIC AGENTS . 57Trusted Health Plan District of ColumbiaVersion: 1Page 7 of 74Update Date: 1/2020
OXYTOCICS . 57PASSIVE IMMUNIZING AND TREATMENT AGENTS . 57PENICILLINS . 57PROGESTINS . 58PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. . 58RESPIRATORY AGENTS - MISC. 59TETRACYCLINES . 59THYROID AGENTS . 59TOXOIDS . 60ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS . 60URINARY ANTI-INFECTIVES . 61URINARY ANTISPASMODICS . 61VACCINES . 61VAGINAL AND RELATED PRODUCTS . 62VASOPRESSORS . 63VITAMINS . 63Trusted Health Plan District of ColumbiaVersion: 1Page 8 of 74Update Date: 1/2020
2020 Trusted Health Plan, District of Columbia Medicaid Formulary ListDrug NameDrugTierReference NameTHERAPEUTIC CATEGORYTherapeutic Amphetaminesamphetamine-dextroamphet er 10mg cap er 24 hr, 15 mg cap er 24hr, 20 mg cap er 24 hr, 25 mg caper 24 hr, 30 mg cap er 24 hr, 5 mgcap er 24 hr1ADDERALL XRamphetamine-dextroamphetamine10 mg tab, 20 mg tab, 30 mg tab, 5mg tab1ADDERALLdextroamphetamine sulfate 10 mgtab, 5 mg tab1DEXEDRINEdextroamphetamine sulfate er 10mg cap er 24 hr, 15 mg cap er 24hr1DEXEDRINEAttention-deficit/hyperactivity Disorder (adhd) Agentsclonidine hcl er 0.1 mg tab er 12 hr1KAPVAYguanfacine hcl er 1 mg tab er 24 hr,2 mg tab er 24 hr, 3 mg tab er 24hr, 4 mg tab er 24 hr1INTUNIVStimulants - Misc.dexmethylphenidate hcl 10 mg tab,2.5 mg tab, 5 mg tab1FOCALINdexmethylphenidate hcl er 10 mgcap er 24 hr, 15 mg cap er 24 hr,20 mg cap er 24 hr, 25 mg cap er24 hr, 30 mg cap er 24 hr, 40 mgcap er 24 hr, 5 mg cap er 24 hr1FOCALIN XRmethylphenidate hcl 10 mg tab, 20mg tab, 5 mg tab1RITALINmethylphenidate hcl er 18 mg taber 24 hr, 27 mg tab er 24 hr, 36 mgtab er 24 hr, 54 mg tab er 24 hr1methylphenidate hcl er 18 mg taber, 27 mg tab er, 36 mg tab er, 54mg tab er1CONCERTAmethylphenidate hcl er 10 mg taber1METADATEmethylphenidate hcl er 20 mg taber1RITALIN SRRequirements/Limits1QL(60 / 30)PA Prior Authorization; QL Quantity Limit; AL Age Limit; SP Specialty MedicationPage 9 of 74Trusted Health Plan District of ColumbiaVersion: 1Update Date: 1/2020
Drug NameDrugTiermethylphenidate hcl er (la) 20 mgcap er 24 hr, 40 mg cap er 24 hr1modafinil 100 mg tab, 200 mg tab1AMINOGLYCOSIDESAminoglycosidestobramycin 300 mg/5ml inh nebsoln1ANALGESICS - ANTI-INFLAMMATORYAnti-tnf-alpha - Monoclonal AntibodiesHUMIRA 40 mg/0.8ml sc pfs kit1HUMIRA PEN 40 mg/0.8ml sc peninj kit1HUMIRA PEN-CD/UC/HSSTARTER 40 mg/0.8ml sc pen-injkit1HUMIRA PEN-PS/UV/ADOL HSSTART 40 mg/0.8ml sc pen-inj kit1Interleukin-1 Receptor Antagonist (il-1ra)KINERET 100 mg/0.67ml sc solnpfs1Nonsteroidal Anti-inflammatory Agents (nsaids)celecoxib 100 mg cap, 200 mg cap,400 mg cap1childrens ibuprofen 100 mg/5mlsusp1diclofenac sodium 25 mg tab dr, 50mg tab dr, 75 mg tab dr1diclofenac sodium er 100 mg tab er24 hr1gnp childrens ibuprofen 100mg/5ml susp1goodsense ibuprofen 200 mg tab1goodsense ibuprofen childrens 100mg/5ml susp1goodsense ibuprofen infants 50mg/1.25ml susp1hm ibuprofen childrens 100 mg/5mlsusp1ibu-200 200 mg tab1ibuprofen 200 mg cap, 200 mg tab1ibuprofen 400 mg tab, 600 mg tab,800 mg tab1ibuprofen 100 mg/5ml susp1ibuprofen childrens 100 mg/5mlsusp1Reference NameRequirements/Limits1RITALIN LAPROVIGILTOBIPASP, PASP, PASP, PASP, PASP, MOTRINMOTRINMOTRINPA Prior Authorization; QL Quantity Limit; AL Age Limit; SP Specialty MedicationPage 10 of 74Trusted Health Plan District of ColumbiaVersion: 1Update Date: 1/2020
Drug NameDrugTierReference Nameibuprofen infants 50 mg/1.25mlsusp1ibuprofen junior strength 100 mgtab chew1ketorolac tromethamine 10 mg tab1meloxicam 15 mg tab, 7.5 mg tab1nabumetone 500 mg tab, 750 mgtab1naproxen 250 mg tab, 375 mg tab,500 mg tab1naproxen 125 mg/5ml susp1naproxen dr 375 mg tab dr, 500 mgtab dr1naproxen sodium 275 mg tab, 550mg tab1naproxen sodium er 500 mg tab er24 hr1oxaprozin 600 mg tab1sm childrens ibuprofen 100 mg/5mlsusp1sm ibuprofen 200 mg tab1sm ibuprofen ib 100 mg tab chew,200 mg tab1sm infants ibuprofen 50 mg/1.25mlsusp1sulindac 150 mg tab, 200 mg tab1Pyrimidine Synthesis Inhibitorsleflunomide 10 mg tab, 20 mg tab1Soluble Tumor Necrosis Factor Receptor AgentsENBREL 50 mg/ml sc soln pfs1ENBREL SURECLICK 50 mg/ml scsoln auto-inj1ANALGESICS - NONNARCOTICAnalgesic Combinationsbutalbital-apap-caffeine 50-300-40mg cap1butalbital-aspirin-caffeine 50-32540 mg tab1Analgesics Otheracetaminophen 325 mg tab, 500mg tab1acetaminophen 160 mg/5ml liq1acetaminophen extra strength 500mg tab1ed-apap 160 mg/5ml ILARAVASP, PASP, PAFIORICETQL(45 / 25)QL(180 / 25)PA Prior Authorization; QL Quantity Limit; AL Age Limit; SP Specialty MedicationPage 11 of 74Trusted Health Plan District of ColumbiaVersion: 1Update Date: 1/2020
Drug Namegoodsense pain relief extra st 500mg tabsm pain reliever 325 mg tabsm pain reliever ex st 500 mg tabtactinal 325 mg tabSalicylatesadult aspirin regimen 81 mg tab draspirin 325 mg tab, 81 mg tabchew, 81 mg tab draspirin 81 81 mg tab draspirin adult low dose 81 mg tab draspirin adult low strength 81 mg tabchewaspirin ec 325 mg tab dr, 81 mg tabdraspirin ec low strength 81 mg tab draspirin low dose 81 mg tab chew,81 mg tab draspirin low strength 81 mg tabchewdiflunisal 500 mg tabgnp aspirin 81 mg tab drgnp aspirin low dose 81 mg tab drgoodsense aspirin 81 mg tab chewhm aspirin 81 mg tab chewhm aspirin ec low dose 81 mg tabdrsm aspirin 325 mg tabsm aspirin adult low strength 81 mgtab chew, 81 mg tab drsm aspirin ec 325 mg tab drsm aspirin low dose 81 mg tabchewsm childrens aspirin 81 mg tabchewANALGESICS - OPIOIDOpioid Agonistsfentanyl 100 mcg/hr td patch 72 hr,12 mcg/hr td patch 72 hr, 25 mcg/hrtd patch 72 hr, 50 mcg/hr td patch72 hr, 75 mcg/hr td patch 72 hrhydromorphone hcl 8 mg tabhydromorphone hcl 4 mg tabhydromorphone hcl 2 mg tabDrugTierReference 111111111DURAGESICDILAUDIDDILAUDIDDILAUDIDPA, QL(10 / 30)QL(60 / 30)QL(150 / 30)QL(330 / 30)PA Prior Authorization; QL Quantity Limit; AL Age Limit; SP Specialty MedicationPage 12 of 74Trusted Health Plan District of ColumbiaVersion: 1Update Date: 1/2020
Drug NameDrugTierReference NameRequirements/Limits1hydromorphone hcl er 12 mg tab er24 hr abuse-deterr, 8 mg tab er 24hr abuse-deterr1EXALGOPA, QL(30 / 30)morphine sulfate 30 mg tab1QL(90 / 30)morphine sulfate 15 mg tab1QL(180 / 30)morphine sulfate er 60 mg cap er24 hr1KADIANPA, QL(30 / 30)morphine sulfate er 20 mg cap er24 hr1KADIANPA, QL(120 / 30)morphine sulfate er 10 mg cap er24 hr1KADIANPA, QL(270 / 30)morphine sulfate er 100 mg tab er,60 mg tab er1MS CONTINPA, QL(30 / 30)morphine sulfate er 30 mg tab er1MS CONTINPA, QL(90 / 30)morphine sulfate er 15 mg tab er1MS CONTINPA, QL(120 / 30)oxycodone hcl 20 mg tab1QL(90 / 30)oxycodone hcl 10 mg tab1QL(180 / 30)oxycodone hcl 5 mg cap1QL(360 / 30)oxycodone hcl 30 mg tab1ROXICODONEQL(60 / 30)oxycodone hcl 15 mg tab1ROXICODONEQL(120 / 30)oxycodone hcl 5 mg tab1ROXICODONEQL(360 / 30)oxycodone hcl 5 mg/5ml soln1ROXICODONEQL(1800 / 30)tramadol hcl 50 mg tab1ULTRAMQL(240 / 30)tramadol hcl er 200 mg tab er 24 hr1ULTRAM ERPA, QL(30 / 25)tramadol hcl er 100 mg tab er 24 hr1ULTRAM ERPA, QL(90 / 30)Opioid Combinationsacetaminophen-codeine 300-60 mgTYLENOL WITHtab1CODEINEQL(180 / 30)acetaminophen-codeine 300-15 mgTYLENOL WITHtab1CODEINEQL(360 / 30)acetaminophen-codeine 120-12TYLENOL WITHmg/5ml soln1CODEINEQL(4500 / 30)acetaminophen-codeine #2 300-15TYLENOL WITHmg tab1CODEINEQL(360 / 30)acetaminophen-codeine #3 300-30TYLENOL WITHmg tab1CODEINEQL(360 / 30)acetaminophen-codeine #4 300-60TYLENOL WITHmg tab1CODEINEQL(180 / 30)butalbital-apap-caff-cod 50-300-40FIORICET WITH30 mg cap1CODEINEQL(45 / 25)butalbital-asa-caff-codeine 50-325FIORINAL WITH40-30 mg cap1CODEINEQL(360 / 30)hydrocodone-acetaminophen 5-325mg tab1NORCOQL(360 / 30)hydrocodone-acetaminophen 5-300mg tab1VICODINQL(390 / 30)PA Prior Authorization; QL Quantity Limit; AL Age Limit; SP Specialty MedicationPage 13 of 74Trusted Health Plan District of ColumbiaVersion: 1Update Date: 1/2020
Drug NameLORCET 5-325 mg taboxycodone-acetaminophen 5-325mg tabtramadol-acetaminophen 37.5-325mg tabOpioid Partial AgonistsBUNAVAIL 6.3-1 mg bucc filmBUNAVAIL 4.2-0.7 mg bucc filmBUNAVAIL 2.1-0.3 mg bucc filmbuprenorphine hcl 8 mg tab sublbuprenorphine hcl 2 mg tab sublbuprenorphine hcl-naloxone hcl 123 mg subl filmbuprenorphine hcl-naloxone hcl 8-2mg subl filmbuprenorphine hcl-naloxone hcl 4-1mg subl filmbuprenorphine hcl-naloxone hcl 20.5 mg subl filmbuprenorphine hcl-naloxone hcl 8-2mg tab sublbuprenorphine hcl-naloxone hcl 20.5 mg tab sublSUBLOCADE 300 mg/1.5ml scsoln pfsSUBLOCADE 100 mg/0.5ml scsoln pfsSUBOXONE 12-3 mg subl filmSUBOXONE 8-2 mg subl filmSUBOXONE 4-1 mg subl filmSUBOXONE 2-0.5 mg subl filmZUBSOLV 11.4-2.9 mg tab sublZUBSOLV 8.6-2.1 mg tab sublZUBSOLV 5.7-1.4 mg tab sublZUBSOLV 2.9-0.71 mg tab sublZUBSOLV 1.4-0.36 mg tab sublZUBSOLV 0.7-0.18 mg tab sublANORECTAL AGENTSRectal Combinationshemorrhoidal 1-0.25-14.4-15 % rectcrmlidocaine-hydrocortisone ace 3-1 %rect kitRectal Steroidsanucort-hc 25 mg rect suppDrugTier1Reference NameRequirements/Limits1QL(360 / 30)1PERCOCETQL(360 / 30)1ULTRACETQL(300 / 30)SUBUTEXSUBUTEXQL(60 / 30)QL(90 / 30)QL(180 / 30)QL(90 / 30)QL(360 / 30)111111QL(60 / 30)1QL(90 / 30)1QL(180 / 30)1QL(360 / 30)1SUBOXONEQL(90 / 30)1SUBOXONEQL(360 / 30)1QL(1 / 30)11111111111QL(3 / 30)QL(60 / 30)QL(90 / 30)QL(180 / 30)QL(360 / 30)QL(30 / 30)QL(60 / 30)QL(90 / 30)QL(150 / 30)QL(330 / 30)QL(690 / 30)111PA Prior Authorization; QL Quantity Limit; AL Age Limit; SP Specialty MedicationPage 14 of 74Trusted Health Plan District of ColumbiaVersion: 1Update Date: 1/2020
Drug Namehydrocortisone 1 % rect crmhydrocortisone acetate 25 mg rectsupp, 30 mg rect suppANTACIDSAntacid Combinationsantacid 200-200-20 mg/5ml suspantacid anti-gas max strength 400400-40 mg/5ml suspantacid fast acting 200-200-20mg/5ml suspantacid maximum strength 400400-40 mg/5ml susphm antacid/antigas 200-200-20mg/5ml suspsm antacid advanced max st 400400-40 mg/5ml suspsm antacid/antigas 200-200-20mg/5ml suspAntacids - Aluminum Saltsaluminum hydroxide gel 320mg/5ml suspAntacids - Calcium Saltscalcium antacid 500 mg tab chewcalcium carbonate antacid 648 mgtabcalcium carbonate antacid 1250mg/5ml suspAntacids - Magnesium Saltsmagnesium oxide 400 mg tabANTIANGINAL AGENTSNitratesisosorbide dinitrate 10 mg tab, 20mg tab, 30 mg tab, 5 mg tabisosorbide mononitrate 10 mg tab,20 mg tabisosorbide mononitrate er 120 mgtab er 24 hr, 30 mg tab er 24 hr, 60mg tab er 24 hrnitroglycerin 0.2 mg/hr td patch24hr, 0.4 mg/hr td patch 24hrnitroglycerin 0.3 mg tab subl, 0.4mg tab sublANTIANXIETY AGENTSAntianxiety Agents - Misc.DrugTier1Reference KET1IMDUR1NITRO-DUR1NITROSTATPA Prior Authorization; QL Quantity Limit; AL Age Limit; SP Specialty MedicationPage 15 of 74Trusted Health Plan District of ColumbiaVersion: 1Update Date: 1/2020
Drug NameDrugTierRefer
Trusted Health Plan, District of Columbia is a mandatory generic plan. The brand and common names listed in the formulary are for reference only. Generic medication will be dispensed where available. Covered Medications without Authorization Trusted Health Plan, District of Columbia covers many medications without any authorization required.
