VillageHealth (HMO-POS SNP) Formulary

VillageHealth® (HMO-POS SNP) | Los Angeles and Orange Counties
2016
VillageHealth (HMO-POS SNP) Formulary
(List of Covered Drugs)
Los Angeles and Orange Counties
This formulary was updated on 11/2016. For more recent information or other questions, please contact
VillageHealth Member Services at 1-800-399-7226 or, for TTY users, 711, 8 a.m. to 8 p.m., 7 days a week
from October 1 to February 14. From February 15 to September 30, hours are 8 a.m. to 8 p.m. Monday through
Friday, and 9 a.m. to 4 p.m. on Saturday (messages received on holidays and outside of our business hours will
be returned within one business day), or visit www.villagehealthca.com.
Este formulario se actualizó en 11/2016 Para obtener información más reciente o si tiene dudas, comuníquese
con Servicios para Miembros de VillageHealth al 1-800-399-7226 o, para los usuarios de TTY, 711, de 8 a.m.
a 8 p.m., los 7 días de la semana, desde el 1 de octubre hasta el 14 de febrero. Desde el 15 de febrero
al 30 de septiembre, el horario es de 8 a.m. a 8 p.m., de lunes a viernes, y de 9 a.m. a 4 p.m. los sábados
(los mensajes recibidos en días festivos y fuera del horario hábil se devolverán en un día hábil). O visite
www.villagehealthca.com.
G9530 10/16
Y0057_SCAN_9346_2015F File & Use Accepted 08232015
16-FORVH2
VillageHealth (HMO-POS SNP)
2016 Formulary (List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER
IN THIS PLAN
16400, 16
This formulary was updated on 11/2016. For more recent information or other questions, please contact
VillageHealth Member Services at 1-800-399-7226 or, for TTY users, 711, 8 a.m. to 8 p.m., 7 days a week
from October 1 to February 14. From February 15 to September 30, hours are 8 a.m. to 8 p.m. Monday
through Friday, and 9 a.m. to 4 p.m. on Saturday (messages received on holidays and outside of our business
hours will be returned within one business day), or visit www.villagehealthca.com.
Note to existing members: This formulary has changed since last year. Please review this document to make
sure that it still contains the drugs you take.
When this drug list (formulary) refers to “we,” “us,” or “our,” it means SCAN Health Plan. When it refers to
“plan” or “our plan,” it means VillageHealth (HMO-POS SNP).
This document includes a list of the drugs (formulary) for our plan which is current as of November 2016.
For an updated formulary, please contact us. Our contact information, along with the date we last updated
the formulary, appears on the front and back cover pages.
You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary,
pharmacy network, and/or copayments/coinsurance may change on January 1, 2017, and from time to time
during the year.
This information is not a complete description of benefits. Contact the plan for more information.
Limitations, copayments, and restrictions may apply. The Formulary, pharmacy network, and/or provider
network may change at any time. You will receive notice when necessary.
You can get prescription drugs shipped to your home through our network mail order delivery program.
Typically, you should expect to receive your prescription drugs within 14 days from the time that the mail
order pharmacy receives the order. If you do not receive your prescription drug(s) within this time, please
contact VillageHealth Member Services at 1-800-399-7226, 8 a.m. to 8 p.m., 7 days a week from October
1 to February 14. From February 15 to September 30, hours are 8 a.m. to 8 p.m. Monday through Friday,
and 9 a.m. to 4 p.m. on Saturday (messages received on holidays and outside of our business hours will be
returned within one business day). TTY users should call 711.
VillageHealth (HMO-POS SNP) is an HMO plan; and is a Point of Service (POS) plan with a Medicare
contract. Enrollment in SCAN Health Plan depends on contract renewal.
This information is available for free in other languages. Please call our Member Services number at
1-800-399-7226, 8 a.m. to 8 p.m., 7 days a week from October 1 to February 14. From February 15 to
September 30, hours are 8 a.m. to 8 p.m. Monday through Friday, and 9 a.m. to 4 p.m. on Saturday (messages
received on holidays and outside of our business hours will be returned within one business day). TTY users
call 711.
Esta información está disponible gratuitamente en otros idiomas. Llame nuestro número de Servicios para
Miembros al 1-800-399-7226, de 8 a.m. a 8 p.m., los siete días de la semana del 1 de octubre al 14 de
febrero. Del 15 de febrero al 30 de septiembre el horario es de 8 a.m. a 8 p.m. de lunes a viernes, y de
9 a.m. a 4 p.m. el sábado (los mensajes recibidos en días festivos o fuera de nuestras horas de oficina serán
contestados dentro de un día hábil). Los usuarios de TTY llamen al 711.
VillageHealth | 2016 Formulary
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VillageHealth | 2016 Formulary
TABLE OF CONTENTS
What is the VillageHealth Formulary?.......................................................................................................V
Can the Formulary (drug list) change?......................................................................................................V
How do I use the Formulary?...................................................................................................................V
What are generic drugs?..........................................................................................................................V
Are there any restrictions on my coverage?...............................................................................................VI
What if my drug is not on the Formulary?................................................................................................VI
How do I request an exception to the VillageHealth Formulary?.................................................................VI
What do I do before I can talk to my doctor about changing my drugs or requesting an exception?..............VII
For more information............................................................................................................................VII
VillageHealth’s Formulary.....................................................................................................................VIII
Formulary Drugs Arranged by Therapeutic Class........................................................................................1
Formulary Drugs with Quantity Limits.....................................................................................................27
Index...................................................................................................................................................30
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VillageHealth | 2016 Formulary
What is the VillageHealth Formulary?
A formulary is a list of covered drugs selected by VillageHealth in consultation with a team of health care
providers, which represents the prescription therapies believed to be a necessary part of a quality treatment
program. VillageHealth will generally cover the drugs listed in our formulary as long as the drug is medically
necessary, the prescription is filled at a VillageHealth network pharmacy, and other plan rules are followed.
For more information on how to fill your prescriptions, please review your Evidence of Coverage.
Can the Formulary (drug list) change?
Generally, if you are taking a drug on our 2016 formulary that was covered at the beginning of the year, we
will not discontinue or reduce coverage of the drug during the 2016 coverage year except when a new, less
expensive generic drug becomes available or when new adverse information about the safety or effectiveness
of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not
affect members who are currently taking the drug. It will remain available at the same cost-sharing for those
members taking it for the remainder of the coverage year. We feel it is important that you have continued
access for the remainder of the coverage year to the formulary drugs that were available when you chose our
plan, except for cases in which you can save additional money or we can ensure your safety.
If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy
restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of
the change at least 60 days before the change becomes effective, or at the time the member requests a
refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug
Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug
from the market, we will immediately remove the drug from our formulary and provide notice to members
who take the drug. The enclosed formulary is current as of November 2016. To get updated information
about the drugs covered by VillageHealth, 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 Condition
The formulary begins on page 1. The drugs in this formulary are grouped into categories depending
on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart
condition are listed under the category, “Cardiovascular Agents.” If you know what your drug is used
for, look for the category name in the list that begins on page number 1. Then look under the category
name for your drug.
Alphabetical Listing
If you are not sure what category to look under, you should look for your drug in the Index that begins
on page 30. The Index provides an alphabetical list of all of the drugs included in this document. Both
brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next
to your drug, you will see the page number where you can find coverage information. Turn to the page
listed in the Index and find the name of your drug in the first column of the list.
What are generic drugs?
VillageHealth covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as
having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand
name drugs.
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Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These requirements and limits
may include:
• Prior Authorization: VillageHealth requires you or your physician to get prior authorization for
certain drugs. This means that you will need to get approval from VillageHealth before you fill your
prescriptions. If you don’t get approval, VillageHealth may not cover the drug.
• Quantity Limits: For certain drugs, VillageHealth limits the amount of the drug that VillageHealth will
cover. For example, VillageHealth provides 31 tablets per prescription for Rozerem. This may be in
addition to a standard one-month or three-month supply.
• Step Therapy: In some cases, VillageHealth requires you to first try certain drugs to treat your medical
condition before we will cover another drug for that condition. For example, if Drug A and Drug B
both treat your medical condition, VillageHealth may not cover Drug B unless you try Drug A first. If
Drug A does not work for you, VillageHealth will then cover Drug B.
You can find out if your drug has any additional requirements or limits by looking in the formulary that
begins on page 1. You can also get more information about the restrictions applied to specific covered drugs
by visiting our Web site. We have posted on line documents that explain our prior authorization and step
therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we
last updated the formulary, appears on the front and back cover pages.
You can ask VillageHealth to make an exception to these restrictions or limits or for a list of other, similar
drugs that may treat your health condition. See the section, “How do I request an exception to the
VillageHealth formulary?” on page VI for information about how to request an exception.
What if my drug is not on the Formulary?
If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services
and ask if your drug is covered.
If you learn that VillageHealth does not cover your drug, you have two options:
• You can ask Member Services for a list of similar drugs that are covered by VillageHealth. When you
receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered
by VillageHealth.
• You can ask VillageHealth to make an exception and cover your drug. See below for information about
how to request an exception.
How do I request an exception to the VillageHealth Formulary?
You can ask VillageHealth to make an exception to our coverage rules. There are several types of exceptions
that you can ask us to make.
• You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered
at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a
lower cost-sharing level.
• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs,
VillageHealth limits the amount of the drug that we will cover. If your drug has a quantity limit, you
can ask us to waive the limit and cover a greater amount.
Generally, VillageHealth will only approve your request for an exception if the alternative drugs included on
the plan’s formulary or additional utilization restrictions would not be as effective in treating your condition
and/or would cause you to have adverse medical effects.
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VillageHealth | 2016 Formulary
You should contact us to ask us for an initial coverage decision for a formulary or utilization restriction
exception. When you request a formulary or utilization restriction exception you should submit a statement
from your prescriber or physician supporting your request. Generally, we must make our decision within 72
hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you
or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision.
If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a
supporting statement from your doctor or other prescriber.
What do I do before I can talk to my doctor about changing my drugs or requesting
an exception?
As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you
may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need
a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if
you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover
the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover
your drug in certain cases during the first 90 days you are a member of our plan.
For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover
a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network
pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of
the plan less than 90 days.
If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have
provided you with at least a 91 and may be up to a 98-day transition supply, consistent with dispensing
increment (unless you have a prescription written for fewer days). We will cover more than one refill of these
drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or
if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we
will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you
pursue a formulary exception.
If you are a current member transitioning to a different level of care, you may be prescribed medications not
on our formulary or your ability to get your drugs may be limited. In these instances, you need to talk with
your doctor about the appropriate alternative therapies available on our formulary. If there are no appropriate
alternative therapies on our formulary, you or your doctor can request an exception and ask the plan to cover
the drug or remove restrictions from the drug. While you are talking with your doctor to determine the course
of action, you are eligible to receive a 30-day transition supply of the drug if you are moving from a longterm care (LTC) facility or a hospital stay to home or a 31-day transition supply of the drug if you are moving
from home or a hospital stay to a long-term care (LTC) facility.
For more information
For more detailed information about your VillageHealth prescription drug coverage, please review your
Evidence of Coverage and other plan materials.
If you have questions about VillageHealth, please contact us. Our contact information, along with the date
we last updated the formulary, appears on the front and back cover pages.
If you have general questions about Medicare prescription drug coverage, please call Medicare
at 1-800-MEDICARE (1-800-633-4227), 24 hours a day/7 days a week. TTY users should call
1-877-486-2048. Or, visit http://www.medicare.gov.
VillageHealth | 2016 Formulary
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The chart below lists what you will pay as your share of the costs for covered prescription drugs when you are
in the Initial Coverage Stage. Please refer to your Evidence of Coverage for more information.
VillageHealth (HMO-POS SNP):
Los Angeles & Orange Counties
Cost-Sharing for Covered Prescription Drugs*
25% coinsurance
*If you receive “Extra Help,” your share of the cost for covered prescription drugs may vary based on the
level of Extra Help you receive.
VillageHealth’s Formulary
The formulary that begins on page 1 provides coverage information about the drugs covered by VillageHealth.
If you have trouble finding your drug in the list, turn to the Index that begins on page 30.
The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., BENICAR) and
generic drugs are listed in lower-case italics (e.g., lisinopril).
The information in the Requirements/Limits column tells you if VillageHealth has any special requirements
for coverage of your drug.
• The symbol [PA] indicates that prior authorization applies.
• The symbol [B vs D] indicates that this drug may be covered under Medicare Part B or
Part D depending upon the circumstances. Information may need to be submitted describing the use
and setting of the drug to make the determination.
• The symbol [ST] indicates that step therapy applies.
• The symbol [QL] indicates that quantities dispensed are limited. To see the quantity limit amount for
the formulary drugs with quantity limits, turn to the page 27.
• The symbol [90D] indicates that the drug is available for a 90-day supply at mail order and select
retail pharmacies.
• The symbol [LD] indicates that limited distribution applies. This prescription may be available only at
certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at
1-800-399-7226, 8 a.m. to 8 p.m., 7 days a week from October 1 to February 14. From February 15
to September 30, hours are 8 a.m. to 8 p.m. Monday through Friday, and 9 a.m. to 4 p.m. on Saturday
(messages received on holidays and outside of our business hours will be returned within one
business day). TTY users should call 711.
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VillageHealth | 2016 Formulary
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VillageHealth | 2016 Formulary
Formulario para 2016 (Lista de medicamentos cubiertos)
de VillageHealth (HMO-POS SNP)
POR FAVOR, LEA: ESTE DOCUMENTO CONTIENE INFORMACIÓN ACERCA DE LOS
MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN
16400, 16
Este formulario se actualizó en 11/2016 Para obtener información más reciente o si tiene dudas,
comuníquese con Servicios para Miembros de VillageHealth al 1-800-399-7226 o, para los usuarios de TTY,
711, de 8 a.m. a 8 p.m., los 7 días de la semana, desde el 1 de octubre hasta el 14 de febrero. Desde el
15 de febrero al 30 de septiembre, el horario es de 8 a.m. a 8 p.m., de lunes a viernes, y de 9 a.m. a 4 p.m.
los sábados (los mensajes recibidos en días festivos y fuera del horario hábil se devolverán en un día hábil).
O visite www.villagehealthca.com.
Nota para los miembros actuales: Este formulario ha cambiado desde el año pasado. Revise este documento
para asegurarse de que todavía incluye los medicamentos que toma.
Cuando esta lista de medicamentos (formulario) usa “nosotros” o “nuestro” se refiere a SCAN Health Plan.
Cuando se usa “plan” o “nuestro plan,” se refiere a VillageHealth (HMO-POS SNP).
Este documento incluye una lista de los medicamentos (formulario) de nuestro plan que está vigente al mes
de noviembre del 2016. Para obtener una lista actualizada de medicamentos, comuníquese con nosotros.
Nuestra información de contacto, junto con la fecha de la última actualización de la lista de medicamentos,
aparece en la portada y en la contraportada.
Por lo general, debe utilizar las farmacias de la red para utilizar su beneficio de recetados. Los beneficios, la
lista de medicamentos, la red de farmacias o los copagos/coseguro pueden cambiar el 1 de enero de 2017 y
de vez en cuando durante el año.
Esta información no es una descripción completa de los beneficios. Para obtener más información, póngase
en contacto con el plan. Limitaciones, copagos y restricciones pueden aplicar. La lista de medicamentos,
la red de farmacias o la red de proveedores pueden cambiar en cualquier momento. Usted recibirá un aviso
cuando sea necesario.
Puede obtener medicamentos recetados enviados a su casa, a través de nuestro servicio de entrega de
pedidos por correo de la red. Por lo general, debe esperar recibir sus medicamentos recetados dentro de los
siguientes 14 días desde el momento en que la farmacia de pedidos por correo recibe el pedido. Si no recibe
sus medicamentos recetados en este plazo, comuníquese a Servicios para Miembros de VillageHealth, al
1-800-399-7226, de 8 a.m. a 8 p.m., los 7 días de la semana, del 1 de octubre al 14 de febrero. Desde el
15 de febrero al 30 de septiembre, el horario es de 8 a.m. a 8 p.m., de lunes a viernes, y de 9 a.m. a 4 p.m.
los sábados (los mensajes recibidos en días festivos y fuera del horario hábil se devolverán en un día hábil).
Los usuarios de TTY deben llamar al 711.
VillageHealth (HMO-POS SNP) es un plan HMO; y es un plan de punto de servicio (Point of Service, POS)
con un contrato de Medicare. La inscripción en SCAN Health Plan depende de la renovación del contrato.
This information is available for free in other languages. Please call our Member Services number at
1-800-399-7226, 8 a.m. to 8 p.m., 7 days a week from October 1 to February 14. From February 15 to
September 30, hours are 8 a.m. to 8 p.m. Monday through Friday, and 9 a.m. to 4 p.m. on Saturday (messages
received on holidays and outside of our business hours will be returned within one business day). TTY users
call 711.
VillageHealth | Formulario 2016
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Esta información está disponible gratuitamente en otros idiomas. Llame nuestro número de Servicios para
Miembros al 1-800-399-7226, de 8 a.m. a 8 p.m., los siete días de la semana del 1 de octubre al 14 de
febrero. Del 15 de febrero al 30 de septiembre el horario es de 8 a.m. a 8 p.m. de lunes a viernes, y de
9 a.m. a 4 p.m. el sábado (los mensajes recibidos en días festivos o fuera de nuestras horas de oficina serán
contestados dentro de un día hábil. Los usuarios de TTY llamen al 711.
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TABLA DE CONTENIDOS
¿Qué es el Formulario de VillageHealth?................................................................................................. XV
¿El Formulario (lista de medicamentos) puede cambiar?.......................................................................... XV
¿Cómo utilizo el Formulario?.................................................................................................................. XV
¿Qué son los medicamentos genéricos?................................................................................................. XVI
¿Hay alguna restricción en mi cobertura?............................................................................................... XVI
¿Qué sucede si mi medicamento no está en el Formulario?..................................................................... XVI
¿Cómo solicito una excepción al formulario de VillageHealth?.................................................................. XVI
¿Qué debo hacer antes de poder hablar con mi médico sobre un cambio en mis medicamentos o
solicitar una excepción?......................................................................................................................XVII
Para obtener más información............................................................................................................XVIII
Formulario de VillageHealth.................................................................................................................. XIX
Medicamentos del formulario coordinados por la clase terapéutica..............................................................1
Medicamentos del formulario con límites de cantidad..............................................................................27
Índice..................................................................................................................................................30
VillageHealth | Formulario 2016
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VillageHealth | Formulario 2016
¿Qué es el Formulario de VillageHealth?
Un formulario es una lista de medicamentos cubiertos seleccionados por VillageHealth en consulta con un
equipo de proveedores de atención médica, que representa las terapias prescritas que son parte necesaria de
un programa de tratamiento de calidad. VillageHealth generalmente cubrirá los medicamentos descritos en
nuestra lista de medicamentos siempre que el medicamento sea médicamente necesario, la receta médica
se surta en una farmacia de la red de VillageHealth y se sigan otras reglas del plan. Para obtener más
información acerca de cómo surtir sus recetas, consulte su Evidencia de cobertura.
¿El Formulario (lista de medicamentos) puede cambiar?
Por lo general, si está tomando un medicamento de nuestro formulario para 2016 que estaba cubierto al
inicio del año, no interrumpiremos ni reduciremos la cobertura del medicamento durante el año de cobertura
2016 excepto cuando esté disponible un medicamento genérico de menos costo o si se publica nueva
información adversa sobre la seguridad o efectividad de un medicamento. Otros tipos de cambios a la lista
de medicamentos aprobados, como la eliminación de un medicamento de nuestro formulario, no afectará
a los miembros que actualmente están tomando el medicamento. Permanecerá disponible al mismo costo
compartido para los miembros que lo tomen por el resto del año de cobertura. Creemos que es importante
que tenga acceso continuo por el resto del año de cobertura a los medicamentos del formulario que estaban
disponibles cuando eligió nuestro plan, excepto en los casos en que usted puede ahorrar más dinero o que
podamos garantizar su seguridad.
Si retiramos medicamentos de nuestro formulario, agregamos una autorización previa, restricciones de
límites de cantidad o terapia de pasos a un medicamento o movemos un medicamento a un nivel de costo
compartido superior, debemos notificar a los miembros afectados sobre el cambio por lo menos 60 días
antes de que el cambio entre en vigencia, o en el momento en que el miembro solicita una reposición del
medicamento, momento en el cual el miembro recibirá un suministro para 60 días del medicamento. Si la
Administración de Alimentos y Medicamentos considera que un medicamento de nuestro formulario no es
seguro o el fabricante del medicamento lo retira del mercado, inmediatamente retiraremos el medicamento
de nuestro formulario y notificaremos a los miembros que toman el medicamento. El formulario adjunto está
vigente al mes de noviembre del 2016. Para obtener información actualizada acerca de los medicamentos
cubiertos por VillageHealth, comuníquese con nosotros. Nuestra información de contacto aparece en la
portada y en la contraportada.
¿Cómo utilizo el Formulario?
Hay dos maneras de encontrar su medicamento en el formulario:
Afección médica
El formulario comienza en la página 1. Los medicamentos en este formulario están agrupados en
categorías de acuerdo con el tipo de afecciones médicas que se utilizan para el tratamiento. Por
ejemplo, los medicamentos que se usan para tratar una afección cardíaca se muestran en la categoría
“Agentes cardiovasculares.” Si sabe para qué se usa su medicamento, busque el nombre de la categoría
en la lista que inicia en la página 1. Luego busque bajo el nombre de la categoría de su medicamento.
Lista alfabética
Si no está seguro de qué categoría buscar, deberá buscar su medicamento en el índice que inicia en la
página 30. El índice proporciona una lista en orden alfabético de todos los medicamentos incluidos en
este documento. Los medicamentos de marca y genéricos se incluyen en el índice. Busque en el índice
y encuentre su medicamento. Al lado de su medicamento, usted verá el número de página donde puede
encontrar la información de cobertura. Vaya a la página que aparece en el índice y encuentre el nombre
de su medicamento en la primera columna de la lista.
VillageHealth | Formulario 2016
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¿Qué son los medicamentos genéricos?
VillageHealth cubre tanto medicamentos de marca como medicamentos genéricos Un medicamento genérico
es aprobado por la Administración de Alimentos y Medicamentos (FDA) ya que tiene el mismo ingrediente
activo que el medicamento de marca. Por lo general, los medicamentos genéricos cuestan menos que los
medicamentos de marca.
¿Hay alguna restricción en mi cobertura?
Algunos medicamentos cubiertos pueden tener requisitos adicionales o límites de cobertura. Estos requisitos
y límites pueden incluir:
• Autorización previa: VillageHealth requiere que usted o su médico obtengan una autorización previa
para ciertos medicamentos. Esto significa que necesitará obtener aprobación de VillageHealth antes
de surtir sus recetas médicas. Si no obtiene la aprobación, es posible que VillageHealth no cubra
el medicamento.
• Límites de cantidad: Para ciertos medicamentos, VillageHealth limita la cantidad del medicamento
que VillageHealth cubrirá. Por ejemplo, VillageHealth proporciona 31 tabletas por receta médica para
Rozerem. Esto puede ser además de un suministro estándar para un mes o tres meses.
• Terapia de pasos: En algunos casos, VillageHealth requiere que primero pruebe ciertos
medicamentos para tratar su afección médica antes de que nosotros cubramos otro medicamento
para esa afección. Por ejemplo, si tanto el medicamento A como el medicamento B tratan su
afección médica, es posible que VillageHealth no cubra el medicamento B a menos que pruebe
primero el medicamento A. Si el medicamento A no funciona para usted, VillageHealth cubrirá el
medicamento B.
Para averiguar si su medicamento tiene requisitos adicionales o límites revise el formulario que comienza
en la página 1. También puede obtener más información acerca de las restricciones que aplican a
medicamentos específicos cubiertos al visitar nuestro sitio web. Hemos publicado en línea documentos que
explican nuestras restricciones de autorización previa y terapia de pasos. También puede pedirnos que le
enviemos una copia. Nuestra información de contacto, junto con la fecha de la última actualización de la
lista de medicamentos, aparece en la portada y en la contraportada.
Puede solicitar a VillageHealth que haga una excepción a estas restricciones o límites, o una lista de
medicamentos similares que pueden tratar su afección de salud. Consulte la sección “¿Cómo solicito una
excepción al formulario de VillageHealth?” en la página XVI, para obtener información sobre cómo solicitar
una excepción.
¿Qué sucede si mi medicamento no está en el Formulario?
Si su medicamento no está incluido en este Formulario (lista de medicamentos cubiertos), primero debe
comunicarse con Servicios para Miembros y preguntar si su medicamento está cubierto.
Si descubre que VillageHealth no cubre su medicamento, tiene dos opciones:
• Puede solicitar a Servicios para Miembros una lista de medicamentos similares que VillageHealth
cubre. Cuando reciba la lista, muéstrela a su médico y pídale que le recete un medicamento similar
que esté cubierto por VillageHealth.
• Puede solicitar que VillageHealth haga una excepción y cubra su medicamento. Consulte a
continuación para obtener información sobre cómo solicitar una excepción.
¿Cómo solicito una excepción al formulario de VillageHealth?
Puede solicitar VillageHealth que haga una excepción a nuestras reglas de cobertura. Existen varios tipos de
excepciones que puede solicitarnos que hagamos.
XVI
VillageHealth | Formulario 2016
• Puede solicitarnos que cubramos un medicamento, incluso si no está incluido en nuestro formulario. Si
se aprueba, este medicamento estará cubierto en un determinado nivel de costo compartido, y usted no
podrá solicitarnos que proporcionemos el medicamento a un nivel de costo compartido inferior.
• Puede solicitarnos que exoneremos las restricciones de cobertura o límites de su medicamento. Por
ejemplo, para ciertos medicamentos, VillageHealth limita la cantidad del medicamento que cubriremos.
Si su medicamento tiene un límite de cantidad, puede solicitarnos que exoneremos el límite y cubramos
una cantidad mayor.
Por lo general, VillageHealth solo aprobará su solicitud de excepción si los medicamentos alternativos
incluidos en el formulario del plan, el medicamento de costo compartido inferior o las restricciones
adicionales de uso pudieran no ser tan efectivos al tratar su afección y/o pudieran provocarle efectos
médicos adversos.
Debe comunicarse con nosotros para pedirnos una decisión inicial de cobertura para una excepción de
restricción de uso, de nivel o al formulario. Cuando solicite una excepción de restricción de uso, de nivel
o al formulario, debe enviar una declaración de apoyo de su médico o la persona que receta que respalde
su solicitud. Por lo general, debemos tomar nuestra decisión dentro de las siguientes 72 horas después de
recibir la declaración de apoyo de la persona que receta. Puede solicitar una excepción expedita (rápida) si
usted o su médico consideran que su salud podría dañarse seriamente si espera hasta por 72 horas para una
decisión. Si se autoriza su solicitud expedita, debemos proporcionarle una decisión no después de 24 horas
después de haber recibido una declaración de apoyo de su médico u otra persona que recete.
¿Qué debo hacer antes de poder hablar con mi médico sobre un cambio en mis medicamentos o
solicitar una excepción?
Como miembro nuevo o existente en nuestro plan puede tomar medicamentos que no se encuentran en
nuestro formulario. O bien, puede estar tomando un medicamento que está en nuestro formulario pero su
capacidad para obtenerlo es limitada. Por ejemplo, puede necesitar una autorización previa de nuestra parte
antes de que pueda surtir su receta médica. Debe hablar con su médico para decidir si deben cambiar a
un medicamento apropiado que cubramos o solicitar una excepción al formulario para que cubramos el
medicamento que toma. Mientras que habla con su médico para determinar el curso correcto de acción para
usted, podemos cubrir su medicamento en ciertos casos durante los primeros 90 días, que usted es miembro
de nuestro plan.
Para cada uno de sus medicamentos que no está incluido en nuestro formulario o si su capacidad de obtener
sus medicamentos es limitada, cubriremos un suministro temporal de 30 días (a menos que tenga una
receta médica para menos días) cuando vaya a una farmacia de la red de servicios. Después de su primer
suministro para 30 días, no pagaremos por estos medicamentos, incluso si ha sido un miembro del plan
menos de 90 días.
Si es un residente de un centro de atención a largo plazo, le permitiremos que realice la reposición de su
receta médica hasta que le hayamos proporcionado por lo menos un suministro de transición para 91 y es
posible que para hasta 98 días, consistente con el incremento de despacho (a menos que tenga una receta
médica para menos días). Cubriremos más de un reabastecimiento de estos medicamentos durante los
primeros 90 días en que sea miembro de nuestro plan. Si necesita un medicamento que no está incluido
en nuestro formulario o si su capacidad de obtener sus medicamentos es limitada, pero está más allá de los
primeros 90 días de la membresía en nuestro plan, cubriremos un suministro de emergencia de 31 días de
ese medicamento (a menos que tenga una receta médica para menos días) mientras tramita una excepción
al formulario.
Si es un miembro actual que está en la transición a un nivel diferente de atención, se le pueden prescribir
medicamentos no incluidos en nuestro formulario o su capacidad de obtener sus medicamentos podría
VillageHealth | Formulario 2016
XVII
estar limitada. En estos casos, debe hablar con su médico acerca de las terapias alternativas apropiadas
y disponibles en nuestro formulario. Si no hubiera terapias alternativas apropiadas en nuestro formulario,
usted o su médico pueden solicitar una excepción y solicitar al plan que cubra el medicamento o eliminar
las restricciones de los medicamentos. Mientras habla con su médico para determinar el curso de acción,
es elegible para recibir un suministro de transición de 30 días del medicamento si se muda a un centro
de atención a largo plazo (long-term care, LTC) o de una estadía en el hospital a casa, o un suministro de
transición de 31 días del medicamento si se muda de la casa o de una estadía en el hospital a un centro de
atención a largo plazo (LTC).
Para obtener más información
Para obtener información más detallada sobre la cobertura de medicamentos recetados de VillageHealth,
consulte su Evidencia de cobertura y otros materiales del plan.
Si tiene alguna pregunta acerca de VillageHealth, comuníquese con nosotros. Nuestra información de
contacto, junto con la fecha de la última actualización de la lista de medicamentos, aparece en la portada y
en la contraportada.
Si tiene preguntas generales acerca de la cobertura de medicamentos recetados de Medicare, llame a
Medicare al 1-800-MEDICARE (1-800-633-4227), las 24 horas del día, los 7 días a la semana. Los
usuarios de TTY deben llamar al 1. O bien, visite http://www.medicare.gov.
XVIII
VillageHealth | Formulario 2016
El siguiente cuadro enumera lo que pagará como su parte de los costos de medicamentos recetados
cubiertos cuando se encuentra en la Etapa de cobertura inicial. Consulte su Evidencia de cobertura para
obtener más información.
VillageHealth (HMO-POS SNP):
Condados de Los Angeles y Orange
Costo compartido para medicamentos recetados
cubiertos*
25% de coseguro
*Si recibe “Ayuda adicional,” su parte del costo de los medicamentos recetados cubiertos puede variar con
base en el nivel de Ayuda adicional que recibe.
Formulario de VillageHealth
El formulario que comienza en la página 1 proporciona información sobre los medicamentos que cubre
VillageHealth. Si tiene dificultades para encontrar su medicamento en la lista, diríjase al índice que inicia en
la página 30.
La primera columna del cuadro muestra el nombre del medicamento. Los medicamentos de marca están
en mayúsculas (por ejemplo, BENICAR) y los medicamentos genéricos están en minúsculas itálicas (por
ejemplo, lisinopril).
La información en la columna de Requisitos/límites le indica si VillageHealth tiene algún requisito especial
para la cobertura de su medicamento.
• El símbolo [PA] indica que se requiere una autorización previa.
• El símbolo [B vs D] indica que este medicamento puede estar cubierto por la Parte B o la Parte D de
Medicare, dependiendo de las circunstancias. Para hacer la determinación, es posible que se necesite
enviar información que describa el uso y ajuste del medicamento.
• El símbolo [ST] indica que se requiere terapia de pasos.
• El símbolo [QL] indica que cantidades surtidas están limitadas. Para saber la cantidad de límite de
cantidad para los medicamentos del formulario, consulte la página 27.
• El símbolo [90D] indica que los medicamentos están disponibles para un suministro para 90 días en
farmacias de pedido por correo y farmacias minoristas seleccionadas.
• El símbolo [LD] indica que se aplica la distribución limitada. Esta receta médica puede estar
disponible únicamente en ciertas farmacias. Para obtener más información, consulte su Directorio de
Farmacias o llame a Servicios para Miembros al 1-800-399-7226, de 8 a.m. a 8 p.m., los 7 días de la
semana, desde el 1 de octubre hasta el 14 de febrero. Desde el 15 de febrero al 30 de septiembre,
el horario es de 8 a.m. a 8 p.m., de lunes a viernes, y de 9 a.m. a 4 p.m. los sábados (los mensajes
recibidos en días festivos y fuera del horario hábil se devolverán en un día hábil). Los usuarios de TTY
deben llamar al 711.
VillageHealth | Formulario 2016
XIX
FORMULARY DRUGS ARRANGED BY THERAPEUTIC CLASS
MEDICAMENTOS DEL FORMULARIO COORDINADOS POR LA CLASE TERAPÉUTICA
Formulary ID: 16400 (Version 16)
ID de Formulario: 16400 (Versión 16)
Updated: 11/2016
Actualizado: 11/2016
Drug Name
Requirements/
Limits
Drug Name
Nombre del Medicamento
Requisitos/
Límites
Nombre del Medicamento
ANALGESICS
Opioid Analgesics, Long-acting
duramorph inj
fentanyl patches 12mcg/hr,
25mcg/hr, 50mcg/hr, 75mcg/hr,
100mcg/hr
methadone oral
methadone inj
morphine sulfate er tabs
OXYCODONE ER
OXYCONTIN
oxymorphone er
tramadol er tabs
Opioid Analgesics, Short-acting
acetaminophen & codeine
butorphanol tartrate inj
butorphanol tartrate nasal
codeine
endocet 5-325mg, 7.5-325mg,
10-325mg
fentanyl citrate lozenges
200mcg
fentanyl citrate lozenges
400mcg, 600mcg, 800mcg,
1200mcg & 1600mcg
hydrocodone & acetaminophen
soln 7.5-325mg/15mL
hydrocodone & acetaminophen
tabs
5-325mg, 7.5-325mg,
10-325mg
hydrocodone & ibuprofen
hydromorphone immediaterelease oral soln & tabs
Requirements/
Limits
Requisitos/
Límites
hydromorphone inj
[90D]
LAZANDA
[PA]
lorcet tabs 5-325mg
[QL] [90D]
lorcet hd tabs 10-325mg
[QL] [90D]
lorcet plus tabs 7.5-325mg
[QL] [90D]
lortab tabs 5-325mg, 7.5-325mg,
[QL] [90D]
10-325mg
morphine sulfate inj vial
[90D]
morphine sulfate oral
[90D]
oxycodone immediate-release
[90D]
oxycodone oral soln
[90D]
oxycodone & acetaminophen
[QL] [90D]
2.5-325mg, 5-325mg, 7.5325mg, 10-325mg
oxycodone & aspirin
[QL] [90D]
oxycodone & ibuprofen
[QL] [90D]
reprexain
[90D]
tramadol
[90D]
tramadol & acetaminophen
[QL] [90D]
zamicet
[QL] [90D]
ANESTHETICS
Local Anesthetics
lidocaine patch
[PA] [90D]
lidocaine hcl topical
[90D]
lidocaine hcl inj
[90D]
lidocaine & prilocaine
[90D]
ANTI-ADDICTION/SUBSTANCE ABUSE
TREATMENT AGENTS
Alcohol Deterrents/Anti-Craving
acamprosate calcium dr
[90D]
disulfiram
[90D]
Opioid Dependence Treatments
buprenorphine inj
[90D]
[90D]
[QL] [90D]
[90D]
[90D]
[QL] [90D]
[QL] [90D]
[QL] [90D]
[QL] [90D]
[QL] [90D]
[QL] [90D]
[90D]
[QL] [90D]
[90D]
[QL] [90D]
[PA] [90D]
[PA]
[QL] [90D]
[QL] [90D]
[QL] [90D]
[90D]
[PA] = Prior Authorization [B vs D] = B versus D [QL] = Quantity Limit [ST] = Step Therapy [90D] = 90-Day Supply
[LD] = Limited Distribution
You can find information on what the symbols and abbreviations on this table mean by going to page XXIX.
1
Drug Name
Nombre del Medicamento
Requirements/
Limits
Requisitos/
Límites
[90D]
[90D]
buprenorphine oral
buprenorphine & naloxone
sublingual tabs
naltrexone
[90D]
Opioid Reversal Agents
EVZIO
[90D]
naloxone inj
[90D]
NARCAN
[90D]
Smoking Cessation Agents
bupropion sr tabs 150mg
[ST] [90D]
CHANTIX
[ST] [90D]
CHANTIX STARTING &
[ST] [90D]
CONTINUING MONTH PAK
NICOTROL INHALER
[90D]
NICOTROL NASAL
[90D]
ANTI-INFLAMMATORY AGENTS
Nonsteroidal Anti-inflammatory Drugs
celecoxib
[ST] [90D]
diclofenac potassium
[90D]
diclofenac sodium dr
[90D]
diclofenac sodium er
[90D]
diflunisal
[90D]
etodolac
[90D]
etodolac er
[90D]
ibuprofen
[90D]
indomethacin er
[PA] [90D]
indomethacin ir caps
[PA] [90D]
ketorolac oral
[PA] [90D]
ketorolac inj
[PA] [90D]
meloxicam oral susp
[90D]
meloxicam tabs
[90D]
nabumetone
[90D]
naproxen
[90D]
naproxen dr
[90D]
naproxen sodium ir
[90D]
piroxicam
[90D]
sulindac
[90D]
Drug Name
Requirements/
Limits
Nombre del Medicamento
Requisitos/
Límites
ANTIBACTERIALS
Aminoglycosides
amikacin inj
gentamicin cream 0.1% & oint
0.1%
gentamicin inj
neomycin sulfate oral
paromomycin
streptomycin inj
tobramycin sulfate inj
Antibacterials, Other
BACTROBAN CREAM
BACTROBAN NASAL
chloramphenicol sodium
succinate inj
CLEOCIN VAGINAL
clindamycin oral
clindamycin phosphate inj
colistimethate inj
CORTISPORIN CREAM & OINT
CUBICIN INJ
linezolid inj
linezolid oral
methenamine hippurate
metronidazole inj
metronidazole oral
metronidazole topical
metronidazole vaginal
mupirocin
nitrofurantoin caps
silver sulfadiazine
SIVEXTRO
ssd
SYNERCID INJ
trimethoprim
TYGACIL INJ
vancomycin oral
vancomycin inj
[PA] = Autorización Previa [B vs D] = B versus D [QL] = Límite de Cantidad [ST] = Tratamiento Escalonado
[90D] = Suministro para 90 Días [LD] = Distribución Limitada
Puede encontrar información sobre el significado de los símbolos y abreviaturas de esta tabla en la página LX.
2
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[PA]
[90D]
Drug Name
Nombre del Medicamento
vandazole
XIFAXAN TABS 200MG
XIFAXAN TABS 550MG
Beta-lactam, Cephalosporins
cefaclor
cefaclor er
cefadroxil caps & tabs
cefazolin inj
cefdinir
cefepime inj
cefixime
cefoxitin sodium
cefpodoxime tabs
cefprozil
ceftazidime inj 1gm, 2gm & 6gm
ceftriaxone inj
cefuroxime oral
cefuroxime inj
cephalexin caps & tabs 250mg
& 500mg
cephalexin oral susp
SUPRAX CAPS & CHEWABLE
TABS
SUPRAX ORAL SUSP
500MG/5ML
tazicef inj
TEFLARO INJ
ZERBAXA INJ
Beta-lactam, Other
aztreonam inj 1gm
cilastatin/imipenem inj
INVANZ INJ
meropenem inj 500mg
Beta-lactam, Penicillins
amoxicillin
amoxicillin & clavulanate
potassium
Requirements/
Limits
Drug Name
Requisitos/
Límites
[90D]
[QL] [90D]
Nombre del Medicamento
amoxicillin & clavulanate
potassium er
ampicillin & sulbactam inj 105gm, 2-1gm, & 1-0.5gm
ampicillin inj
ampicillin oral
BICILLIN L-A INJ
dicloxacillin sodium
nafcillin sodium inj
penicillin g inj 5 million units
penicillin v potassium
piperacillin/tazobactam inj
3gm/0.375gm & 4gm/0.5gm
ZOSYN GALAXY INJ
2GM/0.25GM & 3GM/0.375GM
Macrolides
azithromycin tabs & oral susp
azithromycin inj
clarithromycin
clarithromycin er
ERYTHROCIN
LACTOBIONATE INJ
erythrocin stearate
erythromycin oral
erythromycin topical gel & soln
erythromycin & sulfisoxazole
Quinolones
ciprofloxacin inj
ciprofloxacin oral susp
ciprofloxacin tabs immediaterelease
ciprofloxacin tabs er
levofloxacin inj
levofloxacin oral soln
levofloxacin tabs
moxifloxacin oral
ofloxacin oral
Sulfonamides
sulfadiazine
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
Requirements/
Limits
Requisitos/
Límites
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[PA] = Prior Authorization [B vs D] = B versus D [QL] = Quantity Limit [ST] = Step Therapy [90D] = 90-Day Supply
[LD] = Limited Distribution
You can find information on what the symbols and abbreviations on this table mean by going to page XXIX.
3
Drug Name
Nombre del Medicamento
Requirements/
Limits
Drug Name
Requisitos/
Límites
[90D]
Nombre del Medicamento
sulfamethoxazole &
trimethoprim tabs
sulfamethoxazole &
[90D]
trimethoprim ds tabs
sulfamethoxazole &
[90D]
trimethoprim oral susp
sulfamethoxazole &
[90D]
trimethoprim inj
Tetracyclines
demeclocycline
[90D]
doxy 100 inj
[90D]
doxycycline immediate-release
[90D]
tabs, caps & oral susp
doxycycline inj
[90D]
minocycline ir
[90D]
morgidox caps
[90D]
tetracycline
[90D]
ANTICONVULSANTS
Anticonvulsants, Other
BRIVIACT INJ
[90D]
BRIVIACT ORAL SOLN
[90D]
BRIVIACT TABS
FYCOMPA
[90D]
levetiracetam er
[90D]
levetiracetam oral
[90D]
levetiracetam inj
[90D]
POTIGA
[90D]
SPRITAM
[90D]
Calcium Channel Modifying Agents
CELONTIN
[90D]
ethosuximide
[90D]
LYRICA
[PA] [90D]
zonisamide
[90D]
Gamma-aminobutyric Acid (GABA)
Augmenting Agents
clonazepam
[PA] [90D]
clonazepam odt
[PA] [90D]
clorazepate
[PA] [90D]
diazepam rectal gel
[PA] [90D]
divalproex sodium
divalproex sodium dr
divalproex sodium er
gabapentin
GABITRIL TABS 12MG & 16MG
ONFI
phenobarbital elixir
phenobarbital tabs
primidone
SABRIL
tiagabine
valproate sodium inj
valproic acid
Glutamate Reducing Agents
felbamate tabs 400mg
felbamate tabs 600mg & susp
600mg/5ml
lamotrigine immediate-release
tabs
topiramate immediate-release
Sodium Channel Agents
APTIOM
BANZEL
carbamazepine tabs, chewable
tabs & oral susp
carbamazepine er tabs & caps
dilantin caps 100mg
DILANTIN CAPS 30MG
DILANTIN INFATABS
DILANTIN SUSP
epitol
fosphenytoin sodium inj
oxcarbazepine
PEGANONE
phenytoin chewable tabs
phenytoin er
phenytoin oral susp
phenytoin inj
Requirements/
Limits
Requisitos/
Límites
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[PA] [90D]
[PA] [90D]
[90D]
[LD]
[90D]
[90D]
[90D]
[PA] = Autorización Previa [B vs D] = B versus D [QL] = Límite de Cantidad [ST] = Tratamiento Escalonado
[90D] = Suministro para 90 Días [LD] = Distribución Limitada
Puede encontrar información sobre el significado de los símbolos y abreviaturas de esta tabla en la página LX.
4
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
Drug Name
Nombre del Medicamento
Requirements/
Limits
Drug Name
Requisitos/
Límites
[90D]
[90D]
[90D]
[90D]
[90D]
Requirements/
Limits
Requisitos/
Límites
SSRIs/SNRIs (Selective Serotonin Reuptake
Inhibitors/Serotonin & Norepinephrine
Reuptake Inhibitors)
citalopram tabs
[90D]
citalopram oral soln
[90D]
DESVENLAFAXINE ER
[ST] [90D]
duloxetine hcl
[90D]
escitalopram
[90D]
FETZIMA
[ST] [90D]
FETZIMA TITRATION PACK
[ST] [90D]
fluoxetine hcl caps 10mg, 20mg
[90D]
& 40mg
fluoxetine hcl tabs 10mg & 20mg
[90D]
fluoxetine hcl oral soln
[90D]
fluvoxamine
[90D]
fluvoxamine er
[90D]
KHEDEZLA
[ST] [90D]
paroxetine immediate-release
[90D]
paroxetine er
[90D]
PAXIL 10MG/5ML SUSP
[90D]
PRISTIQ
[ST] [90D]
sertraline tabs
[90D]
sertraline oral soln
[90D]
venlafaxine ir tabs
[90D]
venlafaxine er caps
[90D]
VIIBRYD
[ST] [90D]
VIIBRYD STARTER PACK
[ST] [90D]
Tricyclics
amitriptyline
[PA] [90D]
amoxapine
[90D]
clomipramine
[PA] [90D]
desipramine
[90D]
doxepin
[PA] [90D]
imipramine hcl tabs
[PA] [90D]
nortriptyline oral
[90D]
perphenazine & amitriptyline
[PA] [90D]
protriptyline
[90D]
trimipramine maleate
[PA] [90D]
Nombre del Medicamento
TEGRETOL
TEGRETOL XR
TRILEPTAL
VIMPAT ORAL
VIMPAT INJ
ANTIDEMENTIA AGENTS
Antidementia Agents, Other
ergoloid mesylates
[PA] [90D]
Cholinesterase Inhibitors
donepezil tabs 5mg & 10mg
[90D]
donepezil odt
[90D]
galantamine
[QL] [90D]
galantamine er
[QL] [90D]
galantamine oral soln
[QL] [90D]
rivastigmine caps & patches
[QL] [90D]
N-methyl-D-aspartate (NMDA) Receptor
Antagonists
memantine hcl immediate
[90D]
release
ANTIDEPRESSANTS
Antidepressants, Other
budeprion sr
[90D]
bupropion
[90D]
bupropion sr
[90D]
bupropion xl
[90D]
FORFIVO XL
[90D]
maprotiline
[90D]
mirtazapine
[90D]
mirtazapine odt
[90D]
nefazodone
[90D]
trazodone
[90D]
TRINTELLIX
[ST] [90D]
Monoamine Oxidase Inhibitors
EMSAM
[90D]
MARPLAN
[90D]
phenelzine
[90D]
tranylcypromine
[90D]
[PA] = Prior Authorization [B vs D] = B versus D [QL] = Quantity Limit [ST] = Step Therapy [90D] = 90-Day Supply
[LD] = Limited Distribution
You can find information on what the symbols and abbreviations on this table mean by going to page XXIX.
5
Drug Name
Requirements/
Limits
Drug Name
Nombre del Medicamento
Requisitos/
Límites
Nombre del Medicamento
ANTIEMETICS
Antiemetics, Other
compro
meclizine
metoclopramide oral tablets &
soln
metoclopramide inj
phenadoz
phenergan suppositories
prochlorperazine inj
prochlorperazine oral
prochlorperazine suppositories
promethazine inj
promethazine suppositories
promethazine syrup
promethazine tabs 12.5mg,
25mg & 50mg
promethegan
TRANSDERM-SCOP
Emetogenic Therapy Adjuncts
dronabinol
EMEND CAPS 80MG & 125MG
EMEND PACK
granisetron inj
granisetron oral
ondansetron odt
ondansetron oral soln
ondansetron inj
ondansetron tabs
ANTIFUNGALS
Antifungals
ABELCET INJ
AMBISOME INJ
amphotericin b inj
CANCIDAS INJ
ciclopirox 8% nail soln
ciclopirox cream, susp,
shampoo
clotrimazole & betamethasone
clotrimazole 1% cream
clotrimazole 1% topical soln
clotrimazole troche
CRESEMBA INJ
CRESEMBA ORAL
econazole nitrate
fluconazole in dextrose inj
fluconazole in sodium chloride
inj
fluconazole oral
flucytosine
griseofulvin microsize
itraconazole
ketoconazole
NOXAFIL ORAL
nyamyc
nystatin
nystatin & triamcinolone
ORAVIG
SPORANOX ORAL SOLN
terbinafine
terconazole
voriconazole inj
voriconazole oral
ANTIGOUT AGENTS
Antigout Agents
allopurinol
COLCHICINE
COLCRYS
probenecid
probenecid & colchicine
ULORIC
[90D]
[90D]
[90D]
[90D]
[PA] [90D]
[PA] [90D]
[90D]
[90D]
[90D]
[PA] [90D]
[PA] [90D]
[PA] [90D]
[PA] [90D]
[PA] [90D]
[90D]
[PA] [90D]
[PA] [90D]
[PA] [90D]
[90D]
[PA] [B vs D]
[90D]
[PA] [B vs D]
[90D]
[PA] [B vs D]
[90D]
[90D]
[PA] [B vs D]
[90D]
Requirements/
Limits
Requisitos/
Límites
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[PA]
[PA]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[PA]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[QL] [90D]
[QL] [90D]
[90D]
[90D]
[ST] [90D]
[90D]
[PA]
[PA] = Autorización Previa [B vs D] = B versus D [QL] = Límite de Cantidad [ST] = Tratamiento Escalonado
[90D] = Suministro para 90 Días [LD] = Distribución Limitada
Puede encontrar información sobre el significado de los símbolos y abreviaturas de esta tabla en la página LX.
6
Drug Name
Requirements/
Limits
Drug Name
Requirements/
Limits
Nombre del Medicamento
Requisitos/
Límites
Nombre del Medicamento
Requisitos/
Límites
ANTIMIGRAINE AGENTS
Ergot Alkaloids
dihydroergotamine mesylate inj
ERGOMAR
[90D]
Serotonin (5-HT) 1b/1d Receptor Agonists
naratriptan
[QL] [90D]
rizatriptan
[90D]
rizatriptan odt
[90D]
sumatriptan nasal
[90D]
sumatriptan succinate inj
[90D]
sumatriptan succinate oral
[90D]
zolmitriptan tabs
[90D]
zolmitriptan odt
[90D]
ZOMIG NASAL
[QL] [90D]
ANTIMYASTHENIC AGENTS
Parasympathomimetics
guanidine
[90D]
MESTINON SYRUP
[90D]
pyridostigmine
[90D]
pyridostigmine er
[90D]
ANTIMYCOBACTERIALS
Antimycobacterials, Other
DAPSONE
[90D]
rifabutin
[90D]
Antituberculars
CAPASTAT INJ
[90D]
ethambutol
[90D]
isoniazid oral
[90D]
PASER
[90D]
PRIFTIN
[90D]
pyrazinamide
[90D]
rifampin oral
[90D]
rifampin inj
[90D]
RIFATER
[90D]
SIRTURO
TRECATOR
[90D]
ANTINEOPLASTICS
Alkylating Agents
cyclophosphamide caps
GLEOSTINE
HEXALEN
LEUKERAN
MATULANE
VALCHLOR
Antiandrogens
bicalutamide
flutamide
NILANDRON
nilutamide
XTANDI
ZYTIGA
Antiangiogenic Agents
POMALYST
REVLIMID
THALOMID
Antiestrogens/Modifiers
EMCYT
FARESTON
FASLODEX INJ
SOLTAMOX
tamoxifen
Antimetabolites
ALIMTA INJ
hydroxyurea
LONSURF
mercaptopurine
PURIXAN
TABLOID
Antineoplastics, Other
amifostine inj
azacitidine inj
ERWINAZE INJ
[PA] [B vs D]
[90D]
[90D]
[90D]
[PA]
[90D]
[90D]
[90D]
[90D]
[PA]
[PA]
[PA]
[PA] [LD]
[PA]
[90D]
[90D]
[90D]
[90D]
[PA]
[90D]
[PA]
[90D]
[PA] [90D]
[PA] [B vs D]
[PA] [B vs D]
[PA]
[PA] = Prior Authorization [B vs D] = B versus D [QL] = Quantity Limit [ST] = Step Therapy [90D] = 90-Day Supply
[LD] = Limited Distribution
You can find information on what the symbols and abbreviations on this table mean by going to page XXIX.
7
Drug Name
Nombre del Medicamento
Requirements/
Limits
Drug Name
Requisitos/
Límites
[90D]
[90D]
Nombre del Medicamento
leucovorin oral
leucovorin inj
levoleucovorin inj
LYNPARZA
[PA]
MESNEX TABS
[90D]
mitoxantrone inj
[PA] [90D]
NINLARO
[PA]
ONCASPAR INJ
[PA]
paclitaxel inj
[90D]
SYLATRON INJ
[PA]
SYNRIBO INJ
[PA]
VELCADE INJ
[PA]
VENCLEXTA TABS 10MG &
[PA] [90D]
50MG
VENCLEXTA TABS 100MG
[PA]
VENCLEXTA STARTING PACK
[PA] [90D]
Aromatase Inhibitors, 3rd Generation
anastrozole
[90D]
exemestane
[90D]
letrozole
[90D]
Enzyme Inhibitors
BELEODAQ
[PA]
etoposide inj
[90D]
FARYDAK
[PA]
ZOLINZA
[PA]
ZYDELIG
[PA]
Molecular Target Inhibitors
AFINITOR
[PA]
AFINITOR DISPERZ
[PA]
ALECENSA
[PA]
BOSULIF
[PA]
CABOMETYX
[PA]
CAPRELSA
[PA]
COMETRIQ
[PA]
COTELLIC
[PA]
ERIVEDGE
[PA]
GILOTRIF
[PA]
GLEEVEC
[PA]
IBRANCE
ICLUSIG
IMATINIB
IMBRUVICA
INLYTA
IRESSA
JAKAFI
LENVIMA
MEKINIST
NEXAVAR
ODOMZO
SPRYCEL
STIVARGA
SUTENT
TAFINLAR
TAGRISSO
TARCEVA
TASIGNA
TYKERB
VOTRIENT
XALKORI
ZELBORAF
ZYKADIA
Monoclonal Antibodies
AVASTIN INJ
HERCEPTIN INJ
KEYTRUDA INJ
RITUXAN INJ
YERVOY INJ
Retinoids
bexarotene
PANRETIN
TARGRETIN
tretinoin caps
ANTIPARASITICS
Anthelmintics
ALBENZA
ivermectin
Requirements/
Limits
Requisitos/
Límites
[PA]
[PA]
[PA]
[PA]
[PA]
[PA]
[PA]
[PA]
[PA]
[PA] [LD]
[PA]
[PA]
[PA]
[PA]
[PA]
[PA]
[PA] = Autorización Previa [B vs D] = B versus D [QL] = Límite de Cantidad [ST] = Tratamiento Escalonado
[90D] = Suministro para 90 Días [LD] = Distribución Limitada
Puede encontrar información sobre el significado de los símbolos y abreviaturas de esta tabla en la página LX.
8
[PA]
[PA]
[PA]
[PA]
[PA]
[PA]
[PA]
[PA]
[PA]
[PA]
[PA]
[PA]
[PA]
[90D]
[90D]
[90D]
Drug Name
Requirements/
Limits
Drug Name
Nombre del Medicamento
Requisitos/
Límites
Nombre del Medicamento
Antiprotozoals
ALINIA
atovaquone
atovaquone/proguanil
chloroquine
COARTEM
DARAPRIM
hydroxychloroquine
mefloquine
NEBUPENT NEBULIZER
Requirements/
Limits
Requisitos/
Límites
[90D]
[90D]
[90D]
carbidopa & levodopa er
carbidopa & levodopa odt
carbidopa & levodopa &
entacapone
Monoamine Oxidase B (MAO-B) Inhibitors
AZILECT
[90D]
selegiline
[90D]
ANTIPSYCHOTICS
1st Generation/Typical
molindone
[90D]
chlorpromazine oral
[90D]
chlorpromazine inj
[90D]
fluphenazine oral
[90D]
fluphenazine decanoate inj
[90D]
fluphenazine inj
[90D]
haloperidol tabs
[90D]
haloperidol decanoate inj
[90D]
haloperidol lactate oral soln
[90D]
haloperidol lactate inj
[90D]
loxapine
[90D]
perphenazine
[90D]
pimozide
[90D]
thioridazine
[PA] [90D]
thiothixene
[90D]
trifluoperazine
[90D]
nd
2 Generation/Atypical
ABILIFY ORAL SOLN
[ST] [90D]
ABILIFY INJ
[90D]
ABILIFY MAINTENA
aripiprazole odt
[ST] [90D]
aripiprazole tabs 2mg, 5mg,
[ST] [90D]
10mg, & 15mg
aripiprazole tabs 20mg & 30mg
[ST]
ARISTADA INJ
FANAPT
[ST] [90D]
FANAPT TITRATION PACK
[ST] [90D]
GEODON INJ
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[PA] [B vs D]
[90D]
[90D]
[90D]
[PA] [90D]
PENTAM INJ
PRIMAQUINE
quinine sulfate caps 324mg
Pediculicides/Scabicides
EURAX
[90D]
malathion
[90D]
permethrin cream
[90D]
ANTIPARKINSON AGENTS
Anticholinergics
benztropine inj
[90D]
benztropine tabs
[PA] [90D]
trihexyphenidyl tabs
[PA] [90D]
trihexyphenidyl elixir
[PA] [90D]
Antiparkinson Agents, Other
amantadine
[90D]
entacapone
[90D]
Dopamine Agonists
APOKYN INJ
bromocriptine
[90D]
NEUPRO PATCH
[QL] [90D]
pramipexole ir
[90D]
ropinirole
[90D]
Dopamine Precursors/L-Amino Acid
Decarboxylase Inhibitors
carbidopa
[90D]
carbidopa & levodopa
[90D]
[PA] = Prior Authorization [B vs D] = B versus D [QL] = Quantity Limit [ST] = Step Therapy [90D] = 90-Day Supply
[LD] = Limited Distribution
You can find information on what the symbols and abbreviations on this table mean by going to page XXIX.
9
Drug Name
Nombre del Medicamento
INVEGA SUSTENNA INJ 39MG
& 78MG
INVEGA TRINZA INJ
LATUDA
Requirements/
Limits
Requisitos/
Límites
[90D]
[PA]
olanzapine tabs
olanzapine odt
olanzapine inj 10mg
paliperidone er
quetiapine
REXULTI
[90D]
[90D]
[90D]
[ST]
[90D]
[ST]
RISPERDAL CONSTA INJ
12.5MG & 25MG
RISPERDAL CONSTA INJ
37.5MG & 50MG
risperidone
risperidone odt
SAPHRIS
[90D]
[90D]
[90D]
[ST] [90D]
SEROQUEL XR
[ST] [90D]
VRAYLAR
[ST] [90D]
ziprasidone oral
ZYPREXA RELPREVV 210MG
Treatment-Resistant
clozapine
clozapine odt
FAZACLO
VERSACLOZ
ANTISPASTICITY AGENTS
Antispasticity Agents
baclofen
tizanidine
ANTIVIRALS
Anti-cytomegalovirus (CMV) Agents
ganciclovir inj
valganciclovir tabs
ZIRGAN
Requirements/
Limits
Nombre del Medicamento
Requisitos/
Límites
Anti-hepatitis B (HBV) Agents
adefovir dipivoxil
BARACLUDE ORAL SOLN
[90D]
0.05MG/ML
entecavir tabs
EPIVIR HBV SOLN 5MG/ML
[90D]
INTRON-A INJ
[90D]
lamivudine
[90D]
TYZEKA
[90D]
Anti-hepatitis C (HCV) Agents
DAKLINZA
[PA]
EPCLUSA
[PA]
HARVONI
[PA]
moderiba 200mg tabs
[90D]
moderiba dose pack
OLYSIO
[PA]
PEGASYS INJ
PEGASYS PROCLICK INJ
PEG-INTRON INJ
PEG-INTRON REDIPEN INJ
ribasphere
[90D]
ribasphere ribapak
ribavirin
[90D]
SOVALDI
[PA]
Antiherpetic Agents
acyclovir oral
[90D]
acyclovir oint 5%
[90D]
acyclovir inj
[90D]
DENAVIR
[90D]
famciclovir
[90D]
valacyclovir
[90D]
XERESE
[90D]
ZOVIRAX CREAM
Anti-HIV Agents, Integrase Inhibitors (INSTI)
GENVOYA
ISENTRESS CHEW TABS
[90D]
ISENTRESS ORAL POWDER
[90D]
ISENTRESS TABS
[ST] [90D]
NUPLAZID
Drug Name
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[PA] = Autorización Previa [B vs D] = B versus D [QL] = Límite de Cantidad [ST] = Tratamiento Escalonado
[90D] = Suministro para 90 Días [LD] = Distribución Limitada
Puede encontrar información sobre el significado de los símbolos y abreviaturas de esta tabla en la página LX.
10
Drug Name
Nombre del Medicamento
Requirements/
Limits
Drug Name
Requisitos/
Límites
[90D]
Nombre del Medicamento
TIVICAY 10MG TAB
TIVICAY 25MG & 50MG TABS
VITEKTA
Anti-HIV Agents, Non-nucleoside Reverse
Transcriptase Inhibitors (NNRTI)
ATRIPLA
COMPLERA
DESCOVY
EDURANT
INTELENCE 25MG TAB
[90D]
INTELENCE 100MG & 200MG
TABS
nevirapine er
[90D]
nevirapine oral susp
[90D]
nevirapine tabs
[90D]
ODEFSEY
RESCRIPTOR
[90D]
STRIBILD
SUSTIVA
[90D]
VIRAMUNE TABS
[90D]
Anti-HIV Agents, Nucleoside and Nucleotide
Reverse Transcriptase Inhibitors (NRTI)
abacavir tabs
[90D]
abacavir & lamivudine &
zidovudine
didanosine
[90D]
EMTRIVA
[90D]
EPZICOM
lamivudine
[90D]
lamivudine & zidovudine
RETROVIR IV INJ
[90D]
stavudine
[90D]
stavudine oral soln
[90D]
TRIUMEQ
TRUVADA
VIDEX PEDIATRIC SOLN 2GM
[90D]
VIREAD TABS
VIREAD POWDER
[90D]
Requirements/
Limits
Requisitos/
Límites
[90D]
[90D]
ZIAGEN SOLN
zidovudine
Anti-HIV Agents, Other
FUZEON INJ
[90D]
SELZENTRY
TYBOST
[90D]
Anti-HIV Agents, Protease Inhibitors
APTIVUS
CRIXIVAN
[90D]
EVOTAZ
INVIRASE
[90D]
KALETRA TABS 100-25MG
[90D]
KALETRA TABS 200-50MG &
SOLN 400-100MG/5ML
LEXIVA ORAL SUSP
[90D]
LEXIVA TABS
NORVIR
[90D]
PREZCOBIX
PREZISTA SUSP 100MG/ML
[90D]
PREZISTA TABS 75MG &
[90D]
150MG
PREZISTA TABS 600MG &
800MG
REYATAZ CAPS & ORAL
POWDER
VIRACEPT
Anti-influenza Agents
RELENZA DISKHALER
[90D]
rimantadine
[90D]
TAMIFLU CAPS 75MG
[90D]
TAMIFLU SUSP
[90D]
ANXIOLYTICS
Anxiolytics, Other
buspirone
[90D]
Benzodiazepines
alprazolam tabs
[PA] [90D]
alprazolam er tabs
[PA] [90D]
alprazolam intensol
[PA] [90D]
[PA] = Prior Authorization [B vs D] = B versus D [QL] = Quantity Limit [ST] = Step Therapy [90D] = 90-Day Supply
[LD] = Limited Distribution
You can find information on what the symbols and abbreviations on this table mean by going to page XXIX.
11
Drug Name
Nombre del Medicamento
Requirements/
Limits
Drug Name
Requisitos/
Límites
[PA] [90D]
[PA] [90D]
[90D]
[90D]
[PA] [90D]
diazepam tabs & soln
diazepam intensol
lorazepam tabs
lorazepam intensol
oxazepam
BIPOLAR AGENTS
Mood Stabilizers
lithium carbonate
lithium carbonate er
lithium citrate
BLOOD GLUCOSE REGULATORS
Antidiabetic Agents
acarbose
BYDUREON INJ
BYETTA INJ
CYCLOSET
FARXIGA
glimepiride
glimepiride & pioglitazone
glipizide
glipizide & metformin tabs
glipizide er
INVOKAMET
INVOKANA
JANUMET
JANUMET XR
JANUVIA
KOMBIGLYZE XR
metformin
metformin er tabs 500mg &
750mg
nateglinide
ONGLYZA
pioglitazone
pioglitazone & metformin
repaglinide
SYMLINPEN INJ
VICTOZA INJ
Nombre del Medicamento
Requirements/
Limits
Requisitos/
Límites
[ST] [90D]
XIGDUO XR
Glycemic Agents
GLUCAGON EMERGENCY KIT
[90D]
INJ
PROGLYCEM
[90D]
Insulins
HUMALOG CARTRIDGE INJ
[90D]
HUMALOG KWIKPEN INJ
[90D]
HUMALOG MIX 50/50
[90D]
KWIKPEN INJ
HUMALOG MIX 75/25
[90D]
KWIKPEN INJ
HUMALOG MIX 50/50 VIAL INJ
[90D]
HUMALOG MIX 75/25 VIAL INJ
[90D]
HUMALOG VIAL INJ
[90D]
HUMULIN 70/30 KWIKPEN INJ
[90D]
HUMULIN 70/30 VIAL INJ
[90D]
HUMULIN N KWIKPEN INJ
[90D]
HUMULIN N VIAL INJ
[90D]
HUMULIN R U-500
[90D]
(CONCENTRATED) KWIKPEN
INJ
HUMULIN R U-500
[90D]
(CONCENTRATED) VIAL INJ
HUMULIN R VIAL INJ
[90D]
LANTUS SOLOSTAR PEN INJ
[90D]
LANTUS VIAL INJ
[90D]
BLOOD PRODUCTS/ MODIFIERS/ VOLUME
EXPANDERS
Anticoagulants
COUMADIN ORAL
[90D]
ELIQUIS
[90D]
enoxaparin inj 30mg/0.3ml,
[90D]
40mg/0.4ml, 60mg/0.6ml,
80mg/0.8ml & 300mg/3ml
enoxaparin inj 100mg/ml,
120mg/0.8ml & 150mg/ml
fondaparinux inj
[90D]
[90D]
[90D]
[90D]
[90D]
[PA] [90D]
[PA] [90D]
[90D]
[ST] [90D]
[90D]
[QL] [90D]
[90D]
[90D]
[90D]
[ST] [90D]
[ST] [90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[PA] [90D]
[PA] [90D]
[PA] = Autorización Previa [B vs D] = B versus D [QL] = Límite de Cantidad [ST] = Tratamiento Escalonado
[90D] = Suministro para 90 Días [LD] = Distribución Limitada
Puede encontrar información sobre el significado de los símbolos y abreviaturas de esta tabla en la página LX.
12
Drug Name
Nombre del Medicamento
heparin inj
jantoven
PRADAXA
warfarin
XARELTO
XARELTO STARTER PACK
Blood Formation Modifiers
anagrelide
LEUKINE INJ
NEUPOGEN INJ
PROCRIT INJ 2000UNIT/ML,
3000UNIT/ML, 4000UNIT/ML &
10000UNIT/ML
PROCRIT INJ 20000UNIT/ML &
40000UNIT/ML
PROMACTA
Coagulants
tranexamic acid inj
tranexamic acid tabs
Platelet Modifying Agents
BRILINTA
cilostazol
clopidogrel tabs 75mg
dipyridamole & aspirin
dipyridamole oral
CARDIOVASCULAR AGENTS
Alpha-adrenergic Agonists
clonidine patches
clonidine tabs immediaterelease
guanfacine
methyldopa
methyldopa &
hydrochlorothiazide
methyldopate inj
midodrine tabs
Requirements/
Limits
Drug Name
Requisitos/
Límites
[PA] [B vs D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
Requirements/
Limits
Requisitos/
Límites
Alpha-adrenergic Blocking Agents
doxazosin
[90D]
prazosin
[90D]
terazosin
[90D]
Angiotensin-converting Enzyme (ACE)
Inhibitors
benazepril
[90D]
benazepril & hydrochlorothiazide
[90D]
captopril
[90D]
captopril & hydrochlorothiazide
[90D]
enalapril
[90D]
enalapril & hydrochlorothiazide
[90D]
fosinopril
[90D]
fosinopril & hydrochlorothiazide
[90D]
lisinopril
[90D]
lisinopril & hydrochlorothiazide
[90D]
moexipril
[90D]
moexipril & hydrochlorothiazide
[90D]
perindopril
[90D]
quinapril
[90D]
quinapril & hydrochlorothiazide
[90D]
ramipril
[90D]
trandolapril
[90D]
Angiotensin II Receptor Antagonists
AZOR
[ST] [90D]
BENICAR
[ST] [90D]
BENICAR HCT
[ST] [90D]
irbesartan
[90D]
irbesartan hct
[90D]
losartan
[90D]
losartan hct
[90D]
valsartan
[90D]
valsartan hct
[90D]
valsartan & amlodipine
[ST] [90D]
valsartan & amlodipine & hct
[ST] [90D]
Nombre del Medicamento
[90D]
[PA]
[PA]
[PA] [90D]
[PA]
[PA] [LD]
[90D]
[90D]
[QL] [90D]
[90D]
[90D]
[QL] [90D]
[PA] [90D]
[90D]
[90D]
[PA] [90D]
[PA] [90D]
[PA] [90D]
[90D]
[90D]
[PA] = Prior Authorization [B vs D] = B versus D [QL] = Quantity Limit [ST] = Step Therapy [90D] = 90-Day Supply
[LD] = Limited Distribution
You can find information on what the symbols and abbreviations on this table mean by going to page XXIX.
13
Drug Name
Requirements/
Limits
Drug Name
Nombre del Medicamento
Requisitos/
Límites
Nombre del Medicamento
Antiarrhythmics
amiodarone tabs 200mg &
400mg
disopyramide phosphate
dofetilide
flecainide acetate
mexiletine
pacerone tabs 200mg
procainamide inj
propafenone
quinidine gluconate cr
quinidine gluconate inj
quinidine sulfate
sorine
sotalol tabs
TIKOSYN
Beta-adrenergic Blocking Agents
acebutolol
atenolol
atenolol & chlorthalidone
bisoprolol
bisoprolol & hydrochlorothiazide
carvedilol
COREG CR
DUTOPROL
labetalol oral
labetalol inj
metoprolol succinate er
metoprolol tartrate tabs
metoprolol &
hydrochlorothiazide
nadolol
nadolol & bendroflumethiazide
pindolol
propranolol ir tabs
propranolol er caps
propranolol oral soln
propranolol inj
Requirements/
Limits
Requisitos/
Límites
[90D]
propranolol &
hydrochlorothiazide
timolol oral
[90D]
Calcium Channel Blocking Agents
afeditab cr
[90D]
amlodipine
[90D]
amlodipine & atorvastatin
[90D]
amlodipine & benazepril
[90D]
cartia xt
[90D]
diltiazem tabs
[90D]
diltiazem cd caps 120mg,
[90D]
180mg, 240mg, & 300mg
diltiazem er caps
[90D]
diltiazem inj 50mg/10ml
[90D]
dilt-xr
[90D]
felodipine er
[90D]
isradipine
[90D]
nicardipine caps
[90D]
nifedical xl
[90D]
nifedipine
[PA] [90D]
nifedipine er
[90D]
nimodipine caps
[90D]
nisoldipine
[90D]
nisoldipine er
[90D]
taztia xt
[90D]
verapamil ir
[90D]
verapamil er
[90D]
verapamil sr
[90D]
verapamil inj
[90D]
Cardiovascular Agents, Other
DEMSER
[PA]
digitek
[PA] [90D]
digoxin oral
[PA] [90D]
digoxin inj
[PA] [90D]
LANOXIN INJ
[PA] [90D]
LANOXIN ORAL
[PA] [90D]
NORTHERA
[PA]
pentoxifylline er
[90D]
[90D]
[PA] [90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[PA] = Autorización Previa [B vs D] = B versus D [QL] = Límite de Cantidad [ST] = Tratamiento Escalonado
[90D] = Suministro para 90 Días [LD] = Distribución Limitada
Puede encontrar información sobre el significado de los símbolos y abreviaturas de esta tabla en la página LX.
14
Drug Name
Nombre del Medicamento
Requirements/
Limits
Requisitos/
Límites
[PA] [90D]
[PA]
[ST] [90D]
[ST] [90D]
RANEXA
REPATHA INJ
TEKTURNA
TEKTURNA HCT
Diuretics, Loop
bumetanide oral
[90D]
furosemide oral
[90D]
furosemide inj
[90D]
torsemide oral
[90D]
Diuretics, Potassium-sparing
amiloride
[90D]
amiloride & hydrochlorothiazide
[90D]
eplerenone
[90D]
spironolactone
[90D]
spironolactone &
[90D]
hydrochlorothiazide
triamterene &
[90D]
hydrochlorothiazide
Diuretics, Thiazide
chlorothiazide tabs
[90D]
chlorthalidone
[90D]
hydrochlorothiazide
[90D]
indapamide
[90D]
metolazone
[90D]
Dyslipidemics, Fibric Acid Derivatives
fenofibrate caps 43mg & 130mg
[QL] [90D]
fenofibrate micronized
[QL] [90D]
fenofibrate tabs
[QL] [90D]
fenofibric acid dr caps
[QL] [90D]
fenofibric acid tabs
[QL] [90D]
gemfibrozil
[90D]
Dyslipidemics, HMG CoA Reductase
Inhibitors
atorvastatin
[90D]
lovastatin
[90D]
pravastatin
[90D]
rosuvastatin
[ST] [90D]
simvastatin
[90D]
Drug Name
Requirements/
Limits
Nombre del Medicamento
Requisitos/
Límites
Dyslipidemics, Other
cholestyramine
[90D]
cholestyramine light
[90D]
colestipol granules
[90D]
colestipol tabs
[90D]
JUXTAPID
[PA] [LD]
KYNAMRO
[PA] [LD]
niacin er tabs
[QL] [90D]
omega-3-acid ethyl esters
[90D]
prevalite
[90D]
WELCHOL
[90D]
ZETIA
[QL] [90D]
Vasodilators, Direct-acting Arterial
hydralazine oral
[90D]
hydralazine inj
[90D]
minoxidil
[90D]
Vasodilators, Direct-acting Arterial/Venous
isosorbide dinitrate
[90D]
isosorbide dinitrate er
[90D]
isosorbide mononitrate
[90D]
isosorbide mononitrate er
[90D]
minitran patches
[90D]
nitro-bid oint
[90D]
NITRO-DUR PATCHES
[90D]
nitroglycerin inj
[90D]
nitroglycerin lingual
[90D]
nitroglycerin patches
[90D]
NITROSTAT
[90D]
CENTRAL NERVOUS SYSTEM AGENTS
Attention Deficit Hyperactivity Disorder
Agents, Amphetamines
amphetamine &
[QL] [90D]
dextroamphetamine tabs
dexedrine tabs
[QL] [90D]
dextroamphetamine sulfate
[QL] [90D]
dextroamphetamine sulfate er
[QL] [90D]
zenzedi tabs 5mg & 10mg
[QL] [90D]
[PA] = Prior Authorization [B vs D] = B versus D [QL] = Quantity Limit [ST] = Step Therapy [90D] = 90-Day Supply
[LD] = Limited Distribution
You can find information on what the symbols and abbreviations on this table mean by going to page XXIX.
15
Drug Name
Requirements/
Limits
Requisitos/
Límites
Attention Deficit Hyperactivity Disorder
Agents, Non-amphetamines
clonidine er
[PA] [90D]
dexmethylphenidate ir tabs
[90D]
metadate er
[90D]
methylphenidate er tabs 10mg &
[90D]
20mg
methylphenidate ir tabs 5mg,
[90D]
10mg & 20mg
STRATTERA
[PA] [90D]
Central Nervous System, Other
HETLIOZ
[PA]
NUEDEXTA
[90D]
riluzole
[90D]
tetrabenazine
[PA]
Fibromyalgia Agents
SAVELLA
[90D]
SAVELLA TITRATION PACK
[90D]
Multiple Sclerosis Agents
AMPYRA
[PA]
AVONEX INJ
[PA]
AVONEX PEN INJ
[PA]
BETASERON INJ
COPAXONE INJ 40MG/ML
[PA]
GILENYA
[PA]
glatopa inj
[PA]
PLEGRIDY INJ
[PA]
PLEGRIDY STARTER PACK
[PA]
INJ
REBIF INJ
[PA]
REBIF REBIDOSE INJ
[PA]
REBIF REBIDOSE TITRATION
[PA]
PACK INJ
REBIF TITRATION PACK INJ
[PA]
TECFIDERA
[PA]
TECFIDERA STARTER PACK
[PA]
TYSABRI INJ
[PA]
Nombre del Medicamento
Drug Name
Requirements/
Limits
Nombre del Medicamento
Requisitos/
Límites
DENTAL AND ORAL AGENTS
Dental and Oral Agents
cevimeline
chlorhexidine gluconate
pilocarpine tabs
triamcinolone in orabase
DERMATOLOGICAL AGENTS
Dermatological Agents
acitretin
ammonium lactate topical
calcipotriene cream & oint
calcipotriene soln
calcipotriene & betamethasone
oint
CARAC
clindamycin topical cream, gel,
lotion, soln & swab
clindamycin & benzoyl peroxide
topical
diclofenac sodium gel 1%
diclofenac sodium gel 3%
doxepin cream 5%
ELIDEL
FLUOROURACIL 0.5% CREAM
fluorouracil 2% and 5% topical
imiquimod
methoxsalen
podofilox
prudoxin
REGRANEX
SANTYL
selenium sulfide lotion
sulfacetamide sodium susp 10%
tacrolimus oint
TAZORAC
TOLAK
ZONALON
[90D]
[90D]
[90D]
[90D]
[PA]
[90D]
[QL] [90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[QL] [90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[QL]
[90D]
[90D]
[90D]
[90D]
[QL] [90D]
[90D]
[90D]
[PA] = Autorización Previa [B vs D] = B versus D [QL] = Límite de Cantidad [ST] = Tratamiento Escalonado
[90D] = Suministro para 90 Días [LD] = Distribución Limitada
Puede encontrar información sobre el significado de los símbolos y abreviaturas de esta tabla en la página LX.
16
Drug Name
Requirements/
Limits
Drug Name
Requisitos/
Límites
ENZYME REPLACEMENTS/ MODIFIERS
Enzyme Replacement/ Modifiers
ADAGEN INJ
[PA]
ALDURAZYME INJ
[PA]
BUPHENYL TABS
CERDELGA
[PA]
CREON DR
[90D]
CYSTADANE
[90D]
CYSTAGON
[90D]
FABRAZYME INJ
KUVAN
LUMIZYME INJ
[PA]
NAGLAZYME INJ
[PA] [LD]
ORFADIN
[PA] [LD]
RAVICTI
sodium phenylbutyrate powder
SUCRAID
VPRIV INJ
[PA]
ZAVESCA
[PA] [LD]
GASTROINTESTINAL AGENTS
Antispasmodics, Gastrointestinal
atropine sulfate inj
[90D]
dicyclomine oral
[90D]
glycopyrrolate oral
[90D]
glycopyrrolate inj
[90D]
Gastrointestinal Agents, Other
amoxicillin & clarithromycin &
[90D]
lansoprazole
cromolyn sodium oral
[90D]
diphenoxylate & atropine
[90D]
GATTEX INJ
[PA]
loperamide caps 2mg
[90D]
MOVANTIK
[90D]
RELISTOR INJ
[PA] [90D]
RELISTOR TABS
[PA] [90D]
ursodiol
[90D]
Requirements/
Limits
Requisitos/
Límites
Histamine2 (H2) Receptor Antagonists
cimetidine oral
[90D]
famotidine tabs
[90D]
famotidine inj
[90D]
ranitidine oral
[90D]
Irritable Bowel Syndrome Agents
alosetron hcl tabs 0.5mg
[PA] [90D]
alosetron hcl tabs 1mg
[PA]
AMITIZA
[90D]
LINZESS
[90D]
Laxatives
constulose soln
[90D]
enulose
[90D]
gavilyte-c
[90D]
gavilyte-g
[90D]
gavilyte-h
[90D]
gavilyte-n
[90D]
generlac
[90D]
lactulose
[90D]
MOVIPREP
[90D]
OSMOPREP
[90D]
peg 3350 & electrolytes
[90D]
peg 3350 & sodium chloride &
[90D]
sodium bicarbonate & potassium
chloride
polyethylene glycol 3350
[90D]
PREPOPIK
[90D]
SUPREP BOWEL PREP
[90D]
Protectants
misoprostol
[90D]
sucralfate
[90D]
Proton Pump Inhibitors
esomeprazole magnesium dr
[ST] [90D]
caps
lansoprazole dr caps
[90D]
omeprazole caps
[90D]
pantoprazole inj & tabs
[90D]
PROTONIX INJ
[90D]
Nombre del Medicamento
Nombre del Medicamento
[PA] = Prior Authorization [B vs D] = B versus D [QL] = Quantity Limit [ST] = Step Therapy [90D] = 90-Day Supply
[LD] = Limited Distribution
You can find information on what the symbols and abbreviations on this table mean by going to page XXIX.
17
Drug Name
Requirements/
Limits
Drug Name
Nombre del Medicamento
Requisitos/
Límites
Nombre del Medicamento
betamethasone valerate cream,
oint, lotion
CAPEX SHAMPOO
clobetasol propionate foam, gel,
oint, soln
clobetasol propionate emollient
cream
cormax scalp application
cortisone
desonide
desoximetasone
dexamethasone tabs
dexamethasone elixir
dexamethasone inj
dexpak
diflorasone diacetate
fludrocortisone acetate
fluocinolone acetonide
fluocinonide cream 0.05%
fluocinonide-e
fluocinonide gel, oint & soln
fluticasone propionate cream &
oint
halobetasol
hydrocortisone 2.5% cream,
lotion, oint
hydrocortisone butyrate oint &
soln
hydrocortisone oral
hydrocortisone valerate
methylprednisolone oral
methylprednisolone sodium
succinate inj
mometasone cream & oint
prednicarbate
prednisolone oral soln
prednisone tabs
prednisone oral soln
procto-med hc
GENITOURINARY AGENTS
Antispasmodics, Urinary
flavoxate
[90D]
GELNIQUE
[90D]
MYRBETRIQ
[90D]
oxybutynin
[90D]
oxybutynin er
[QL] [90D]
OXYTROL
[90D]
tolterodine tartrate er
[QL] [90D]
TOVIAZ
[90D]
VESICARE
[90D]
Benign Prostatic Hypertrophy Agents
alfuzosin hcl er
[90D]
doxazosin
[90D]
dutasteride
[90D]
dutasteride & tamsulosin
[90D]
finasteride tabs 5mg
[90D]
prazosin
[90D]
tamsulosin
[90D]
terazosin
[90D]
Genitourinary Agents, Other
bethanechol
[90D]
ELMIRON
[90D]
THIOLA
[90D]
Phosphate Binders
calcium acetate
[90D]
eliphos
[90D]
FOSRENOL
[90D]
RENVELA
[90D]
sevelamer carbonate
[90D]
HORMONAL AGENTS, STIMULANT/
REPLACEMENT/ MODIFYING (ADRENAL)
Glucocorticoids/ Mineralocorticoids
alclometasone dipropionate
[90D]
betamethasone dipropionate
[90D]
betamethasone dipropionate
[90D]
augmented
Requirements/
Limits
Requisitos/
Límites
[90D]
[PA] = Autorización Previa [B vs D] = B versus D [QL] = Límite de Cantidad [ST] = Tratamiento Escalonado
[90D] = Suministro para 90 Días [LD] = Distribución Limitada
Puede encontrar información sobre el significado de los símbolos y abreviaturas de esta tabla en la página LX.
18
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
Drug Name
Nombre del Medicamento
Requirements/
Limits
Requisitos/
Límites
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
procto-pak
proctosol hc
proctozone-hc
SOLU-CORTEF INJ
triamcinolone acetonide inj
triamcinolone acetonide topical
cream, lotion & oint
triderm
[90D]
HORMONAL AGENTS, STIMULANT/
REPLACEMENT/ MODIFYING (PITUITARY)
Hormonal Agents, Stimulant/ Replacement/
Modifying (Pituitary)
desmopressin acetate nasal
[90D]
desmopressin acetate oral
[90D]
desmopressin acetate inj
[90D]
GENOTROPIN INJ
[PA]
GENOTROPIN MINIQUICK INJ
[PA] [90D]
0.2MG, 0.4MG, 0.6MG, 0.8MG
GENOTROPIN MINIQUICK INJ
[PA]
1MG, 1.2MG, 1.4MG, 1.6MG,
1.8MG, & 2MG
HUMATROPE INJ 6MG
[PA] [90D]
CARTRIDGE
HUMATROPE INJ 5MG VIAL,
[PA]
12MG & 24MG CARTRIDGE
INCRELEX INJ
[PA]
STIMATE
[90D]
HORMONAL AGENTS, STIMULANT/
REPLACEMENT/ MODIFYING
(PROSTAGLANDINS)
Hormonal Agents, Stimulant/ Replacement/
Modifying (Prostaglandins)
KORLYM
[PA]
HORMONAL AGENTS, STIMULANT/
REPLACEMENT/ MODIFYING (SEX
HORMONES/ MODIFIERS)
Anabolic Steroids
ANADROL-50
[PA]
oxandrolone
[90D]
Drug Name
Requirements/
Limits
Nombre del Medicamento
Requisitos/
Límites
Androgens
ANDROGEL 1.62%
danazol
testosterone cypionate inj
testosterone enanthate inj
testosterone gel 1%
Estrogens
ALORA
apri
aranelle
aubra
aviane
bekyree
blisovi fe 1/20 & 1.5/30
briellyn
caziant
cesia
cyclafem 1/35
cyclafem 7/7/7
delyla
desogestrel & ethinyl estradiol
emoquette
enpresse-28
ESTRACE VAGINAL
estradiol oral
estradiol patches
estradiol & norethindrone
acetate
estropipate
falmina
fyavolv
gildagia
gildess
introvale
jinteli
junel
kariva
[90D]
[90D]
[90D]
[90D]
[90D]
[PA] [90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[PA] [90D]
[PA] [90D]
[PA] [90D]
[PA] [90D]
[90D]
[PA] [90D]
[90D]
[90D]
[90D]
[PA] [90D]
[90D]
[90D]
[PA] = Prior Authorization [B vs D] = B versus D [QL] = Quantity Limit [ST] = Step Therapy [90D] = 90-Day Supply
[LD] = Limited Distribution
You can find information on what the symbols and abbreviations on this table mean by going to page XXIX.
19
Drug Name
Requirements/
Limits
Requisitos/
Límites
kimidess
[90D]
larin
[90D]
larin fe
[90D]
larissia
[90D]
levonest
[90D]
levonorgestrel & ethinyl estradiol
[90D]
0.1-0.02mg, 0.15-0.03mg, &
0.125-0.03mg packs
levora
[90D]
low-ogestrel
[90D]
marlissa 28 day
[90D]
MENEST
[PA] [90D]
microgestin 1/20 & 1.5/30
[90D]
mimvey
[PA] [90D]
mimvey lo
[PA] [90D]
necon
[90D]
norgestimate-ethinyl estradiol
[90D]
orsythia 28 day
[90D]
pimtrea
[90D]
pirmella 1/35
[90D]
PREMARIN ORAL
[PA] [90D]
PREMARIN VAGINAL
[90D]
PREMPHASE
[PA] [90D]
PREMPRO
[PA] [90D]
setlakin
[90D]
tarina fe
[90D]
tri-lo-estarylla
[90D]
tri-lo-sprintec
[90D]
tri-sprintec
[90D]
trivora-28
[90D]
VAGIFEM
[90D]
velivet
[90D]
vienva
[90D]
vyfemla
[90D]
wymzya fe
[90D]
zenchent
[90D]
zenchent fe
[90D]
zovia
[90D]
Nombre del Medicamento
Drug Name
Requirements/
Limits
Nombre del Medicamento
Requisitos/
Límites
Progestins
deblitane
[90D]
DEPO-PROVERA INJ
[90D]
400MG/ML
hydroxyprogesterone caproate
inj
lyza
[90D]
medroxyprogesterone acetate
[90D]
inj
medroxyprogesterone acetate
[90D]
tabs
megestrol acetate oral susp
[90D]
megestrol tabs
[90D]
norethindrone
[90D]
norlyroc
[90D]
progesterone caps
[90D]
sharobel
[90D]
Selective Estrogen Receptor Modifying
Agents
raloxifene hcl
[QL] [90D]
HORMONAL AGENTS, STIMULANT/
REPLACEMENT/ MODIFYING (THYROID)
Hormonal Agents, Stimulant/ Replacement/
Modifying (Thyroid)
CYTOMEL
[90D]
levothyroxine tabs
[90D]
levoxyl
[90D]
liothyronine tabs
[90D]
SYNTHROID
[90D]
THYROLAR
[90D]
unithroid
[90D]
HORMONAL AGENTS, SUPPRESSANT
(ADRENAL)
Hormonal Agents, Suppressant (Adrenal)
LYSODREN
[90D]
HORMONAL AGENTS, SUPPRESSANT
(PARATHYROID)
Hormonal Agents, Suppressant (Parathyroid)
SENSIPAR TABS 30MG
[QL] [90D]
[PA] = Autorización Previa [B vs D] = B versus D [QL] = Límite de Cantidad [ST] = Tratamiento Escalonado
[90D] = Suministro para 90 Días [LD] = Distribución Limitada
Puede encontrar información sobre el significado de los símbolos y abreviaturas de esta tabla en la página LX.
20
Drug Name
Requirements/
Limits
Drug Name
Nombre del Medicamento
Requisitos/
Límites
Nombre del Medicamento
gengraf
SENSIPAR TABS 60MG &
90MG
HORMONAL AGENTS, SUPPRESSANT
(PITUITARY)
Hormonal Agents, Suppressant (Pituitary)
cabergoline
[90D]
ELIGARD INJ
[90D]
leuprolide acetate inj
[90D]
LUPRON DEPOT INJ 7.5MG,
11.25MG, 22.5MG, 30MG &
45MG
octreotide inj 50mcg/ml,
[90D]
100mcg/ml & 200mcg/ml
octreotide inj 500mcg/ml &
1000mcg/ml
SIGNIFOR INJ
[PA]
SOMATULINE DEPOT INJ
[PA]
SOMAVERT INJ
[PA]
SYNAREL
[90D]
HORMONAL AGENTS, SUPPRESSANT
(THYROID)
Antithyroid Agents
methimazole
[90D]
propylthiouracil
[90D]
IMMUNOLOGICAL AGENTS
Angioedema (HAE) Agents
CINRYZE INJ
[PA] [B vs D]
FIRAZYR INJ
[PA]
Immune Suppressants
azathioprine inj
[90D]
azathioprine oral
[PA] [B vs D]
[90D]
BENLYSTA INJ
[PA]
cyclosporine modified
[PA] [B vs D]
[90D]
cyclosporine oral
[PA] [B vs D]
[90D]
ENBREL INJ
[PA]
ENBREL SURECLICK INJ
[PA]
HUMIRA INJ
HUMIRA PEDIATRIC CROHNS
INJ
HUMIRA PEN-CROHNS INJ
HUMIRA PEN INJ
HUMIRA PEN PSORIASIS
STARTER KIT INJ
KINERET INJ
methotrexate inj
methotrexate oral
mycophenolate mofetil caps &
tabs
mycophenolate mofetil oral susp
mycophenolic acid dr
NEORAL
NULOJIX INJ
RAPAMUNE SOLN
REMICADE INJ
SANDIMMUNE ORAL SOLN
100MG/ML
SANDIMMUNE CAPS 25MG &
100MG
sirolimus tabs
tacrolimus caps 0.5mg & 1mg
tacrolimus caps 5mg
ZORTRESS TABS 0.25MG
ZORTRESS TABS 0.5MG &
0.75MG
Immunizing Agents, Passive
ATGAM INJ
GAMMAGARD INJ
GAMUNEX-C INJ
Requirements/
Limits
Requisitos/
Límites
[PA] [B vs D]
[90D]
[PA]
[PA]
[PA]
[PA]
[PA]
[PA]
[90D]
[90D]
[PA] [B vs D]
[90D]
[PA] [B vs D]
[PA] [B vs D]
[90D]
[PA] [B vs D]
[90D]
[PA]
[PA] [B vs D]
[90D]
[PA]
[PA] [B vs D]
[90D]
[PA] [B vs D]
[90D]
[PA] [B vs D]
[90D]
[PA] [B vs D]
[90D]
[PA] [B vs D]
[PA] [B vs D]
[90D]
[PA] [B vs D]
[PA]
[PA] [B vs D]
[PA] [B vs D]
[PA] = Prior Authorization [B vs D] = B versus D [QL] = Quantity Limit [ST] = Step Therapy [90D] = 90-Day Supply
[LD] = Limited Distribution
You can find information on what the symbols and abbreviations on this table mean by going to page XXIX.
21
Drug Name
Requirements/
Limits
Drug Name
Nombre del Medicamento
Requisitos/
Límites
Nombre del Medicamento
Immunomodulators
ACTIMMUNE INJ
ARCALYST INJ
ILARIS INJ
leflunomide
OTEZLA
OTEZLA STARTER
RIDAURA
SYNAGIS INJ
XELJANZ
XELJANZ XR
Vaccines
ACTHIB INJ
ADACEL INJ
BEXSERO INJ
BOOSTRIX INJ
CERVARIX INJ
DAPTACEL INJ
DIPHTHERIA & TETANUS
TOXOIDS PEDIATRIC INJ
ENGERIX-B INJ
GARDASIL INJ
GARDASIL 9 INJ
HAVRIX INJ
HIBERIX INJ
IMOVAX RABIES INJ
INFANRIX INJ
IPOL INACTIVATED IPV INJ
IXIARO INJ
MENACTRA INJ
MENHIBRIX INJ
MENOMUNE-A/C/Y/W-135 INJ
MENVEO-A/C/Y/W-135 INJ
M-M-R II INJ
PEDVAX HIB INJ
PROQUAD INJ
QUADRACEL INJ
RABAVERT INJ
[PA]
[PA]
[QL] [90D]
[PA]
[PA]
RECOMBIVAX HB INJ
Requirements/
Limits
Requisitos/
Límites
[90D]
[PA] [B vs D]
[90D]
[PA] [B vs D]
[90D]
[90D]
[90D]
[90D]
[90D]
ROTARIX
ROTATEQ
TENIVAC
TETANUS & DIPHTHERIA
TOXOIDS-ADSORBED ADULT
INJ
TRUMENBA INJ
[90D]
TWINRIX INJ
[90D]
TYPHIM VI INJ
[90D]
VAQTA INJ
[90D]
VARIVAX INJ
[90D]
YF-VAX INJ
[90D]
ZOSTAVAX INJ
[90D]
INFLAMMATORY BOWEL DISEASE AGENTS
Aminosalicylates
APRISO
[QL] [90D]
balsalazide
[90D]
DELZICOL
[QL] [90D]
DIPENTUM
mesalamine enema kit
[90D]
PENTASA
[QL] [90D]
Glucocorticoids
budesonide ec caps
[PA]
hydrocortisone enema
[90D]
prednisone tabs
[90D]
prednisone oral soln
[90D]
Sulfonamides
sulfasalazine
[90D]
sulfazine
[90D]
sulfazine ec
[90D]
METABOLIC BONE DISEASE AGENTS
Metabolic Bone Disease Agents
alendronate tabs
[90D]
[PA]
[PA]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[PA] [B vs D]
[90D]
[90D]
[90D]
[90D]
[90D]
[PA] [B vs D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[PA] = Autorización Previa [B vs D] = B versus D [QL] = Límite de Cantidad [ST] = Tratamiento Escalonado
[90D] = Suministro para 90 Días [LD] = Distribución Limitada
Puede encontrar información sobre el significado de los símbolos y abreviaturas de esta tabla en la página LX.
22
Drug Name
Nombre del Medicamento
alendronate oral soln
calcitonin-salmon nasal
calcitriol caps
doxercalciferol oral
doxercalciferol inj
etidronate
FORTEO INJ
fortical nasal
ibandronate inj
ibandronate oral
MIACALCIN INJ
pamidronate inj
paricalcitol caps
Requirements/
Limits
Drug Name
Requisitos/
Límites
[90D]
[90D]
[PA] [B vs D]
[90D]
[PA] [B vs D]
[90D]
[PA] [B vs D]
[90D]
[90D]
[PA]
[90D]
[PA] [B vs D]
[90D]
[ST] [90D]
[PA] [B vs D]
[90D]
[PA] [B vs D]
[90D]
[PA] [B vs D]
[90D]
[PA] [90D]
[ST] [90D]
[ST] [90D]
[PA]
[90D]
[PA] [90D]
Nombre del Medicamento
levocarnitine oral
levocarnitine inj
NATPARA
OPHTHALMIC AGENTS
Ophthalmic Agents, Other
atropine sulfate soln
bacitracin
bacitracin & polymyxin b
ciprofloxacin soln 0.3%
erythromycin oint
gentamicin oint 0.3% & soln
0.3%
ilotycin oint
LACRISERT
neomycin & bacitracin &
polymyxin b
neomycin & polymyxin &
gramicidin
ofloxacin
polymyxin b sulfate &
trimethoprim sulfate soln
RESTASIS
PROLIA
risedronate sodium
risedronate sodium dr
XGEVA INJ
zoledronic acid inj 4mg/5ml
zoledronic acid inj 5mg/100ml
ZOMETA INJ 4MG/100ML
MISCELLANEOUS THERAPEUTIC AGENTS
Miscellaneous Therapeutic Agents
alcohol pads
[90D]
bd insulin syringe ultrafine
[90D]
bd insulin syringe safetyglide
[90D]
bd pen needle ultrafine
[90D]
BRISDELLE
[90D]
FERRIPROX
[PA]
gauze pads 2"x2"
[90D]
Requirements/
Limits
Requisitos/
Límites
[PA] [B vs D]
[90D]
[PA] [B vs D]
[90D]
[PA] [LD]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[90D]
[PA] [QL]
[90D]
[90D]
sulfacetamide sodium oint &
soln 10%
tobramycin sulfate
[90D]
trifluridine
[90D]
VIGAMOX
[90D]
Ophthalmic Anti-allergy Agents
azelastine
[90D]
cromolyn sodium
[90D]
olopatadine soln 0.1%
[QL] [90D]
PATADAY
[90D]
Ophthalmic Antiglaucoma Agents
acetazolamide tabs
[90D]
acetazolamide er caps
[90D]
ALPHAGAN P 0.1%
[90D]
[PA] = Prior Authorization [B vs D] = B versus D [QL] = Quantity Limit [ST] = Step Therapy [90D] = 90-Day Supply
[LD] = Limited Distribution
You can find information on what the symbols and abbreviations on this table mean by going to page XXIX.
23
Drug Name
Nombre del Medicamento
Requirements/
Limits
Requisitos/
Límites
[90D]
[90D]
betaxolol soln
brimonidine tartrate soln 0.15%
& 0.2%
carteolol
[90D]
COMBIGAN
[ST] [90D]
dorzolamide
[90D]
dorzolamide & timolol maleate
[90D]
levobunolol
[90D]
methazolamide
[90D]
metipranolol
[90D]
PHOSPHOLINE IODIDE
[90D]
pilocarpine soln
[90D]
timolol ophthalmic gel forming
[90D]
timolol soln
[90D]
Ophthalmic Anti-inflammatories
BLEPHAMIDE
[90D]
BLEPHAMIDE S.O.P.
[90D]
dexamethasone soln
[90D]
diclofenac sodium soln
[90D]
DUREZOL
[90D]
fluorometholone
[90D]
ketorolac soln 0.4% & 0.5%
[90D]
neomycin & polymyxin &
[90D]
dexamethasone
neomycin & polymyxin &
[90D]
bacitracin & hydrocortisone
PRED MILD
[90D]
prednisolone acetate
[90D]
prednisolone sodium phosphate
[90D]
sulfacetamide sodium &
[90D]
prednisolone sodium phosphate
TOBRADEX OINT
[90D]
tobramycin & dexamethasone
[90D]
Ophthalmic Prostaglandin and Prostamide
Analogs
latanoprost
[90D]
LUMIGAN
[ST] [QL]
[90D]
Drug Name
Requirements/
Limits
Nombre del Medicamento
Requisitos/
Límites
OTIC AGENTS
Otic Agents
acetasol hc
[90D]
acetic acid & hydrocortisone
[90D]
CIPRO HC
[90D]
CIPRODEX
[90D]
neomycin & polymyxin &
[90D]
hydrocortisone
ofloxacin
[90D]
RESPIRATORY TRACT/PULMONARY
AGENTS
Antihistamines
azelastine nasal
[90D]
cyproheptadine
[PA] [90D]
desloratadine
[90D]
desloratadine odt
[90D]
diphenhydramine hcl inj
[90D]
levocetirizine
[90D]
Anti-inflammatories, Inhaled Corticosteroids
ADVAIR DISKUS
[90D]
ADVAIR HFA
[90D]
ASMANEX HFA
[90D]
ASMANEX TWISTHALER
[90D]
BREO ELLIPTA
[90D]
budesonide nebulizer
[PA] [B vs D]
[90D]
DULERA
[90D]
flunisolide nasal
[QL] [90D]
fluticasone propionate nasal
[QL] [90D]
mometasone furoate nasal
[QL] [90D]
QVAR
[90D]
Antileukotrienes
montelukast
[90D]
zafirlukast
[QL] [90D]
ZYFLO CR
[QL] [90D]
Bronchodilators, Anticholinergic
ATROVENT HFA
[QL] [90D]
COMBIVENT RESPIMAT
[90D]
[PA] = Autorización Previa [B vs D] = B versus D [QL] = Límite de Cantidad [ST] = Tratamiento Escalonado
[90D] = Suministro para 90 Días [LD] = Distribución Limitada
Puede encontrar información sobre el significado de los símbolos y abreviaturas de esta tabla en la página LX.
24
Drug Name
Requirements/
Limits
Requisitos/
Límites
ipratropium bromide nasal
[QL] [90D]
ipratropium bromide nebulizer
[PA] [B vs D]
[90D]
ipratropium bromide & albuterol
[PA] [B vs D]
sulfate nebulizer
[90D]
SPIRIVA HANDIHALER
[90D]
SPIRIVA RESPIMAT
[90D]
TUDORZA PRESSAIR
[90D]
Phosphodiesterase Inhibitors, Airways
Disease
aminophylline inj
[90D]
DALIRESP
[90D]
theophylline cr & er tabs
[90D]
Bronchodilators, Sympathomimetic
albuterol sulfate nebulizer
[PA] [B vs D]
[90D]
albuterol sulfate er
[90D]
albuterol sulfate syrup
[90D]
albuterol sulfate tabs
[90D]
EPIPEN INJ
[90D]
EPIPEN-JR INJ
[90D]
levalbuterol nebulizer
[PA] [B vs D]
[90D]
PROAIR HFA
[90D]
PROAIR RESPICLICK
[90D]
SEREVENT DISKUS
[90D]
STRIVERDI RESPIMAT
[90D]
terbutaline sulfate oral
[90D]
terbutaline sulfate inj
[90D]
Cystic Fibrosis Agents
CAYSTON
[PA] [LD]
KALYDECO
[PA]
ORKAMBI
[PA]
PULMOZYME
[PA] [B vs D]
TOBI PODHALER
tobramycin nebulizer
[PA] [B vs D]
Mast Cell Stabilizers
cromolyn sodium nebulizer soln
[PA] [B vs D]
[90D]
Nombre del Medicamento
Drug Name
Requirements/
Limits
Nombre del Medicamento
Requisitos/
Límites
Pulmonary Antihypertensives
ADCIRCA
[PA]
ADEMPAS
[PA] [LD]
LETAIRIS
[PA] [LD]
OPSUMIT
[PA] [LD]
REMODULIN INJ
[PA]
sildenafil tabs 20mg
[PA]
TRACLEER
[PA] [LD]
UPTRAVI
[PA]
Respiratory Tract Agents, Other
acetylcysteine nebulizer
[PA] [B vs D]
[90D]
ANORO ELLIPTA
[90D]
ESBRIET
[PA]
OFEV
[PA]
PROLASTIN C INJ
[PA] [LD]
VIRAZOLE
SKELETAL MUSCLE RELAXANTS
Skeletal Muscle Relaxants
chlorzoxazone
[PA] [90D]
cyclobenzaprine hcl
[PA] [90D]
methocarbamol
[PA] [90D]
SLEEP DISORDER AGENTS
GABA Receptor Modulators
estazolam
[90D]
flurazepam
[90D]
temazepam
[90D]
triazolam
[90D]
zolpidem tabs 5mg & 10mg
[PA]
Sleep Disorders, Other
BELSOMRA
[QL] [90D]
modafinil
[PA] [90D]
ROZEREM
[QL] [90D]
SILENOR
[QL] [90D]
XYREM
[LD]
[PA] = Prior Authorization [B vs D] = B versus D [QL] = Quantity Limit [ST] = Step Therapy [90D] = 90-Day Supply
[LD] = Limited Distribution
You can find information on what the symbols and abbreviations on this table mean by going to page XXIX.
25
Drug Name
Requirements/
Limits
Drug Name
Requisitos/
Límites
THERAPEUTIC NUTRIENTS/ MINERALS/
ELECTROLYTES
Electrolyte/Mineral Modifiers
CARBAGLU
[PA] [LD]
CUPRIMINE
[90D]
DEPEN TITRATABS
[90D]
EXJADE
[PA]
JADENU
[PA]
kionex
[90D]
sodium polystyrene sulfonate
[90D]
SYPRINE
VELTASSA
[PA] [90D]
Electrolyte/Mineral Replacement
AMINOSYN INJ
[PA] [B vs D]
[90D]
AMINOSYN & ELECTROLYTES [PA] [B vs D]
INJ
[90D]
CLINISOL SF INJ
[PA] [B vs D]
[90D]
dextrose inj
[90D]
dextrose & sodium chloride inj
[90D]
dextrose & lactated ringers inj
[90D]
INTRALIPID INJ
[PA] [B vs D]
[90D]
klor-con
[90D]
klor-con sprinkle
[90D]
lactated ringers inj
[90D]
magnesium sulfate inj
[90D]
MOZOBIL INJ
[PA]
plenamine inj
[PA] [B vs D]
[90D]
potassium chloride oral soln
[90D]
potassium chloride er
[90D]
potassium chloride inj
[90D]
potassium chloride & dextrose &
[90D]
lactated ringers inj
potassium chloride & dextrose &
[90D]
sodium chloride inj
20mEq/5%/0.45% &
30mEq/5%/0.45%
Nombre del Medicamento
Nombre del Medicamento
potassium chloride viaflex inj
potassium citrate er
PROSOL INJ
sodium chloride inj
TPN ELECTROLYTES INJ
TRAVASOL INJ
Requirements/
Limits
Requisitos/
Límites
[90D]
[90D]
[PA] [B vs D]
[90D]
[90D]
[90D]
[PA] [B vs D]
[90D]
Vitamins
prenatal multi-vitamin
[PA] = Autorización Previa [B vs D] = B versus D [QL] = Límite de Cantidad [ST] = Tratamiento Escalonado
[90D] = Suministro para 90 Días [LD] = Distribución Limitada
Puede encontrar información sobre el significado de los símbolos y abreviaturas de esta tabla en la página LX.
26
[90D]
FORMULARY DRUGS WITH QUANTITY LIMITS
MEDICAMENTOS DEL FORMULARIO CON LÍMITES DE CANTIDAD
Drugs with Quantity Limits
Medicamentos con Límites de Cantidad
Drug Name
Nombre del Medicamento
acetaminophen & codeine #2 & #3 tabs
acetaminophen & codeine #4 tabs
acetaminophen & codeine elixir
amphetamine & dextroamphetamine
APRISO
ATROVENT HFA
BELSOMRA
BRILINTA
butorphanol tartrate nasal
calcipotriene cream
calcipotriene oint
COLCHICINE
COLCRYS
DELZICOL CAPS 400MG
dexedrine tabs
dextroamphetamine sulfate
dextroamphetamine sulfate er
dipyridamole & aspirin
ELIDEL
endocet tabs 5-325mg, 7.5-325mg, 10-325mg
fenofibrate
fenofibrate micronized
fenofibric acid
fenofibric acid dr
Quantity Limits
Límites de Cantidad
372 tabs per 31 days
186 tabs per 31 days
5166ml per 31 days
62 tabs per 31 days
124 caps per 31 days
2 inhalers per 31 days
31 tabs per 31 days
62 tabs per 31 days
4 bottles per 31 days
120gm: 1 tube per 31 days
60gm: 2 tubes per 31 days
124 caps or tabs per 31 days
124 tabs per 31 days
186 caps per 31 days
5mg: 124 tabs per 31 days; 10mg: 186 tabs per 31 days
5mg: 124 tabs per 31 days; 10mg: 186 tabs per 31 days
5mg: 31 caps per 31 days; 10mg & 15mg: 124 caps per
31 days
62 caps per 31 days
100gm: 2 tubes per 31 days
5-325mg: 372 tabs per 31 days; 7.5-325mg: 248 tabs
per 31 days; 10-325mg: 186 tabs per 31 days
31 caps or tabs per 31 days
31 caps per 31 days
35mg: 62 tabs per 31 days; 105mg: 31 tabs per 31 days
45mg: 62 caps per 31 days; 135mg: 31 caps per 31
days
15 patches per 31 days
2 bottles per 31 days
2 bottles per 31 days
62 tabs per 31 days
31 caps per 31 days
200ml per 31 days
31 tabs per 31 days
2790ml per 31 days
fentanyl patches
flunisolide nasal
fluticasone propionate nasal
galantamine
galantamine er
galantamine oral soln
glimepiride & pioglitazone tabs
hydrocodone & acetaminophen soln 7.5325mg/15ml
hydrocodone & acetaminophen tabs 55-325mg: 372 tabs per 31 days; 7.5-325mg & 10-325mg:
VillageHealth | 2016 Formulary
27
Drugs with Quantity Limits
Medicamentos con Límites de Cantidad
Drug Name
Nombre del Medicamento
325mg,7.5-325mg, & 10-325mg
hydrocodone & ibuprofen tabs 5-200mg, 7.5200mg, & 10-200mg
ipratropium bromide nasal
leflunomide
lorcet hd tabs 10-325mg
lorcet plus tabs 7.5-325mg
lorcet tabs 5-325mg
lortab tabs 5-325mg,7.5-325mg, & 10-325mg
LUMIGAN
mometasone furoate nasal
morphine sulfate er tabs
naratriptan
NEUPRO PATCH
niacin er tabs
olopatadine soln 0.1%
oxybutynin er
oxycodone & acetaminophen tabs 2.5-325mg,
5-325mg, 7.5-325mg, & 10-325mg
oxycodone & aspirin tabs
oxycodone & ibuprofen tabs
OXYCODONE ER
OXYCONTIN
oxymorphone er
PENTASA
raloxifene hcl
REGRANEX
RESTASIS
rivastigmine caps
rivastigmine patches
ROZEREM
SENSIPAR TABS 30MG
SILENOR
TAZORAC
tolterodine tartrate er
tramadol & acetaminophen 37.5-325mg tabs
Quantity Limits
Límites de Cantidad
186 tabs per 31 days
155 tabs per 31 days
1 bottle per 31 days
31 tabs per 31 days
186 tabs per 31 days
186 tabs per 31 days
372 tabs per 31 days
5-325mg: 372 tabs per 31 days; 7.5-325mg & 10-325mg:
186 tabs per 31 days
1 bottle per 31 days
3 bottles per 31 days
124 tabs per 31 days
9 tabs per 31 days
30 patches per 30 days
500mg: 93 tabs per 31 days; 750mg & 1000mg: 62 tabs
per 31 days
3 bottles per 31 days
5mg: 31 tabs per 31 days; 10mg & 15mg: 62 tabs per 31
days
2.5-325mg & 5-325mg: 372 tabs per 31 days; 7.5325mg: 248 tabs per 31 days; 10-325mg: 186 tabs per
31 days
372 tabs per 31 days
124 tabs per 31 days
10mg, 15mg, 20mg, 30mg, 40mg, 60mg: 62 tabs per 31
days; 80mg: 124 tabs per 31 days
10mg, 15mg, 20mg, 30mg, 40mg, 60mg: 62 tabs per 31
days; 80mg: 124 tabs per 31 days
62 tabs per 31 days
248 caps per 31 days
31 tabs per 31 days
2 tubes per 31 days
60 vials per 30 days
62 caps per 31 days
30 patches per 30 days
31 tabs per 31 days
62 tabs per 31 days
31 tabs per 31 days
60gm & 100gm: 1 tube per 31 days
31 caps per 31 days
248 tabs per 31 days
VillageHealth | 2016 Formulary
28
Drugs with Quantity Limits
Medicamentos con Límites de Cantidad
Drug Name
Nombre del Medicamento
tramadol er
XIFAXAN TABS 200MG
zafirlukast
zamicet
zenzedi tabs 5mg & 10mg
ZETIA
ZOMIG NASAL
ZYFLO CR
Quantity Limits
Límites de Cantidad
31 tabs per 31 days
9 tabs per 3 days
62 tabs per 31 days
2790ml per 31 days
5mg: 124 tabs per 31 days; 10mg: 186 tabs per 31 days
31 tabs per 31 days
2.5mg: 18 single use units per 31 days; 5mg: 12 single
use units per 31 days
124 tabs per 31 days
VillageHealth | 2016 Formulary
29
INDEX
ÍNDICE
abacavir & lamivudine & zidovudine, 11
ALECENSA, 8
abacavir tabs, 11
alendronate oral soln, 23
alendronate tabs, 22
ABELCET INJ, 6
alfuzosin hcl er, 18
ABILIFY INJ, 9
ABILIFY MAINTENA, 9
ALIMTA INJ, 7
ALINIA, 9
ABILIFY ORAL SOLN, 9
acamprosate calcium dr, 1
allopurinol, 6
acarbose, 12
ALORA, 19
alosetron hcl tabs 0.5mg, 17
acebutolol, 14
alosetron hcl tabs 1mg, 17
acetaminophen & codeine, 1, 27
acetasol hc, 24
ALPHAGAN P 0.1%, 23
acetazolamide, 23
alprazolam er tabs, 11
alprazolam intensol, 11
acetazolamide er caps, 23
alprazolam tabs, 11
acetazolamide tabs, 23
acetic acid & hydrocortisone, 24
amantadine, 9
acetylcysteine nebulizer, 25
AMBISOME INJ, 6
amifostine inj, 7
acitretin, 16
amikacin inj, 2
ACTHIB INJ, 22
amiloride, 15
ACTIMMUNE INJ, 22
amiloride & hydrochlorothiazide, 15
acyclovir inj, 10
aminophylline inj, 25
acyclovir oint 5%, 10
acyclovir oral, 10
AMINOSYN & ELECTROLYTES INJ, 26
AMINOSYN INJ, 26
ADACEL INJ, 22
amiodarone tabs 200mg & 400mg, 14
ADAGEN INJ, 17
AMITIZA, 17
ADCIRCA, 25
amitriptyline, 5
adefovir dipivoxil, 10
amlodipine, 14
ADEMPAS, 25
amlodipine & atorvastatin, 14
ADVAIR DISKUS, 24
amlodipine & benazepril, 14
ADVAIR HFA, 24
ammonium lactate topical, 16
afeditab cr, 14
amoxapine, 5
AFINITOR, 8
amoxicillin, 3
AFINITOR DISPERZ, 8
amoxicillin & clarithromycin & lansoprazole, 17
ALBENZA, 8
amoxicillin & clavulanate potassium, 3
albuterol sulfate er, 25
albuterol sulfate nebulizer, 25
amoxicillin & clavulanate potassium er, 3
amphetamine & dextroamphetamine, 27
albuterol sulfate syrup, 25
amphetamine & dextroamphetamine tabs, 15
albuterol sulfate tabs, 25
amphotericin b inj, 6
alclometasone dipropionate, 18
ampicillin & sulbactam inj 10-5gm, 2-1gm, & 1alcohol pads, 23
0.5gm, 3
ALDURAZYME INJ, 17
VillageHealth | 2016 Formulary
30
ampicillin inj, 3
ampicillin oral, 3
AMPYRA, 16
ANADROL-50, 19
anagrelide, 13
anastrozole, 8
ANDROGEL 1.62%, 19
ANORO ELLIPTA, 25
APOKYN INJ, 9
apri, 19
APRISO, 22, 27
APTIOM, 4
APTIVUS, 11
aranelle, 19
ARCALYST INJ, 22
aripiprazole, 9
aripiprazole 20mg & 30mg, 9
aripiprazole odt, 9
ARISTADA INJ, 9
ASMANEX HFA, 24
ASMANEX TWISTHALER, 24
atenolol, 14
atenolol & chlorthalidone, 14
ATGAM INJ, 21
atorvastatin, 15
atovaquone, 9
atovaquone/proguanil, 9
ATRIPLA, 11
atropine sulfate inj, 17
atropine sulfate soln, 23
ATROVENT HFA, 24, 27
aubra, 19
AVASTIN INJ, 8
aviane, 19
AVONEX INJ, 16
AVONEX PEN INJ, 16
azacitidine inj, 7
azathioprine inj, 21
azathioprine oral, 21
azelastine, 23
azelastine nasal, 24
AZILECT, 9
azithromycin inj, 3
azithromycin tabs & oral susp, 3
AZOR, 13
aztreonam inj 1gm, 3
bacitracin, 23
bacitracin & polymyxin b, 23
baclofen, 10
BACTROBAN CREAM, 2
BACTROBAN NASAL, 2
balsalazide, 22
BANZEL, 4
BARACLUDE ORAL SOLN 0.05MG/ML, 10
bd insulin syringe safetyglide, 23
bd insulin syringe ultrafine, 23
bd pen needle ultrafine, 23
bekyree, 19
BELEODAQ, 8
BELSOMRA, 25, 27
benazepril, 13
benazepril & hydrochlorothiazide, 13
BENICAR, 13
BENICAR HCT, 13
BENLYSTA INJ, 21
benztropine inj, 9
benztropine tabs, 9
betamethasone dipropionate, 18
betamethasone dipropionate augmented, 18
betamethasone valerate cream, oint, lotion, 18
BETASERON INJ, 16
betaxolol soln, 24
bethanechol, 18
bexarotene, 8
BEXSERO INJ, 22
bicalutamide, 7
BICILLIN L-A INJ, 3
bisoprolol, 14
bisoprolol & hydrochlorothiazide, 14
BLEPHAMIDE, 24
BLEPHAMIDE S.O.P., 24
blisovi fe 1/20 & 1.5/30, 19
BOOSTRIX INJ, 22
BOSULIF, 8
BREO ELLIPTA, 24
briellyn, 19
VillageHealth | 2016 Formulary
31
carbamazepine tabs, chewable tabs & oral susp,
4
carbidopa, 9
carbidopa & levodopa, 9
carbidopa & levodopa & entacapone, 9
carbidopa & levodopa er, 9
carbidopa & levodopa odt, 9
carteolol, 24
cartia xt, 14
carvedilol, 14
CAYSTON, 25
caziant, 19
cefaclor, 3
cefaclor er, 3
cefadroxil caps & tabs, 3
cefazolin inj, 3
cefdinir, 3
cefepime inj, 3
cefixime, 3
cefoxitin sodium, 3
cefpodoxime tabs, 3
cefprozil, 3
ceftazidime inj 1gm, 2gm & 6gm, 3
ceftriaxone inj, 3
cefuroxime inj, 3
cefuroxime oral, 3
celecoxib, 2
CELONTIN, 4
cephalexin caps & tabs 250mg & 500mg, 3
cephalexin oral susp, 3
CERDELGA, 17
CERVARIX INJ, 22
cesia, 19
cevimeline, 16
CHANTIX, 2
CHANTIX STARTING MONTH PAK, 2
chloramphenicol sodium succinate inj, 2
chlorhexidine gluconate, 16
chloroquine, 9
chlorothiazide tabs, 15
chlorpromazine inj, 9
chlorpromazine oral, 9
chlorthalidone, 15
chlorzoxazone, 25
BRILINTA, 13, 27
brimonidine tartrate soln 0.15% & 0.2%, 24
BRISDELLE, 23
BRIVIACT INJ, 4
BRIVIACT ORAL SOLN, 4
BRIVIACT TABS, 4
bromocriptine, 9
budeprion sr, 5
budesonide ec caps, 22
budesonide nebulizer, 24
bumetanide oral, 15
BUPHENYL TABS, 17
buprenorphine & naloxone sublingual tabs, 2
buprenorphine inj, 1
buprenorphine oral, 2
bupropion, 5
bupropion sr, 5
bupropion sr tabs 150mg, 2
bupropion xl, 5
buspirone, 11
butorphanol tartrate inj, 1
butorphanol tartrate nasal, 1, 27
BYDUREON INJ, 12
BYETTA INJ, 12
cabergoline, 21
CABOMETYX, 8
calcipotriene & betamethasone oint, 16
calcipotriene cream, 27
calcipotriene cream & oint, 16
calcipotriene oint, 27
calcipotriene soln, 16
calcitonin-salmon nasal, 23
calcitriol caps, 23
calcium acetate, 18
CANCIDAS INJ, 6
CAPASTAT INJ, 7
CAPEX SHAMPOO, 18
CAPRELSA, 8
captopril, 13
captopril & hydrochlorothiazide, 13
CARAC, 16
CARBAGLU, 26
carbamazepine er tabs & caps, 4
VillageHealth | 2016 Formulary
32
cholestyramine, 15
cholestyramine light, 15
ciclopirox 8% nail soln, 6
ciclopirox cream, susp, shampoo, 6
cilastatin/imipenem inj, 3
cilostazol, 13
cimetidine oral, 17
CINRYZE INJ, 21
CIPRO HC, 24
CIPRODEX, 24
ciprofloxacin inj, 3
ciprofloxacin oral susp, 3
ciprofloxacin soln 0.3%, 23
ciprofloxacin tabs er, 3
ciprofloxacin tabs immediate-release, 3
citalopram oral soln, 5
citalopram tabs, 5
clarithromycin, 3
clarithromycin er, 3
CLEOCIN VAGINAL, 2
clindamycin & benzoyl peroxide topical, 16
clindamycin oral, 2
clindamycin phosphate inj, 2
clindamycin topical cream, gel, lotion, soln &
swab, 16
CLINISOL SF INJ, 26
clobetasol propionate emollient cream, 18
clobetasol propionate foam, gel, oint, soln, 18
clomipramine, 5
clonazepam, 4
clonazepam odt, 4
clonidine er, 16
clonidine patches, 13
clonidine tabs immediate-release, 13
clopidogrel tabs 75mg, 13
clorazepate, 4
clotrimazole & betamethasone, 6
clotrimazole 1% cream, 6
clotrimazole 1% topical soln, 6
clotrimazole troche, 6
clozapine, 10
clozapine odt, 10
COARTEM, 9
codeine, 1
COLCHICINE, 6
COLCHICINE, 27
COLCRYS, 6, 27
colestipol granules, 15
colestipol tabs, 15
colistimethate inj, 2
COMBIGAN, 24
COMBIVENT RESPIMAT, 24
COMETRIQ, 8
COMPLERA, 11
compro, 6
constulose soln, 17
COPAXONE INJ 40MG/ML, 16
COREG CR, 14
cormax scalp application, 18
cortisone, 18
CORTISPORIN CREAM & OINT, 2
COTELLIC, 8
COUMADIN ORAL, 12
CREON DR, 17
CRESEMBA INJ, 6
CRESEMBA ORAL, 6
CRIXIVAN, 11
cromolyn sodium, 23, 25
cromolyn sodium nebulizer soln, 25
cromolyn sodium oral, 17
CUBICIN INJ, 2
CUPRIMINE, 26
cyclafem 1/35, 19
cyclafem 7/7/7, 19
cyclobenzaprine hcl, 25
cyclophosphamide caps, 7
CYCLOSET, 12
cyclosporine modified, 21
cyclosporine oral, 21
cyproheptadine, 24
CYSTADANE, 17
CYSTAGON, 17
CYTOMEL, 20
DAKLINZA, 10
DALIRESP, 25
danazol, 19
VillageHealth | 2016 Formulary
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diclofenac sodium gel 3%, 16
diclofenac sodium soln, 24
dicloxacillin sodium, 3
dicyclomine oral, 17
didanosine, 11
diflorasone diacetate, 18
diflunisal, 2
digitek, 14
digoxin inj, 14
digoxin oral, 14
dihydroergotamine mesylate inj, 7
dilantin caps 100mg, 4
DILANTIN CAPS 30MG, 4
DILANTIN INFATABS, 4
DILANTIN SUSP, 4
diltiazem cd caps 120mg, 180mg, 240mg, &
300mg,, 14
diltiazem er caps, 14
diltiazem inj 50mg/10ml, 14
diltiazem tabs, 14
dilt-xr, 14
DIPENTUM, 22
diphenhydramine hcl inj, 24
diphenoxylate & atropine, 17
DIPHTHERIA & TETANUS TOXOIDS
PEDIATRIC INJ, 22
dipyridamole & aspirin, 27
dipyridamole & aspirin, 13
dipyridamole oral, 13
disopyramide phosphate, 14
disulfiram, 1
divalproex sodium, 4
divalproex sodium dr, 4
divalproex sodium er, 4
dofetilide, 14
donepezil odt, 5
donepezil tabs 5mg & 10mg, 5
dorzolamide, 24
dorzolamide & timolol maleate, 24
doxazosin, 13, 18
doxepin, 5
doxepin cream 5%, 16
doxercalciferol inj, 23
doxercalciferol oral, 23
DAPSONE, 7
DAPTACEL INJ, 22
DARAPRIM, 9
deblitane, 20
delyla, 19
DELZICOL, 22
DELZICOL CAPS 400MG, 27
demeclocycline, 4
DEMSER, 14
DENAVIR, 10
DEPEN TITRATABS, 26
DEPO-PROVERA INJ 400MG/ML, 20
DESCOVY, 11
desipramine, 5
desloratadine, 24
desloratadine odt, 24
desmopressin acetate inj, 19
desmopressin acetate nasal, 19
desmopressin acetate oral, 19
desogestrel & ethinyl estradiol, 19
desonide, 18
desoximetasone, 18
DESVENLAFAXINE ER, 5
dexamethasone elixir, 18
dexamethasone inj, 18
dexamethasone soln, 24
dexamethasone tabs, 18
dexedrine tabs, 15
dexedrine tabs, 27
dexmethylphenidate ir tabs, 16
dexpak, 18
dextroamphetamine sulfate, 15, 27
dextroamphetamine sulfate er, 15, 27
dextrose & lactated ringers inj, 26
dextrose & sodium chloride inj, 26
dextrose inj, 26
diazepam intensol, 12
diazepam rectal gel, 4
diazepam tabs & soln, 12
diclofenac potassium, 2
diclofenac sodium, 2, 24
diclofenac sodium dr, 2
diclofenac sodium er, 2
diclofenac sodium gel 1%, 16
VillageHealth | 2016 Formulary
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doxy 100 inj, 4
doxycycline immediate-release tabs, caps & oral
susp, 4
doxycycline inj, 4
dronabinol, 6
DULERA, 24
duloxetine hcl, 5
duramorph inj, 1
DUREZOL, 24
dutasteride, 18
dutasteride & tamsulosin, 18
DUTOPROL, 14
econazole nitrate, 6
EDURANT, 11
ELIDEL, 16, 27
ELIGARD INJ, 21
eliphos, 18
ELIQUIS, 12
ELMIRON, 18
EMCYT, 7
EMEND, 6
emoquette, 19
EMSAM, 5
EMTRIVA, 11
enalapril, 13
enalapril & hydrochlorothiazide, 13
ENBREL INJ, 21
ENBREL SURECLICK INJ, 21
endocet, 1
endocet, 27
ENGERIX-B INJ, 22
enoxaparin inj 30mg/0.3ml, 40mg/0.4ml,
60mg/0.6ml, 80mg/0.8ml & 300mg/3ml, 12
enoxaparin inj100mg/ml, 120mg/0.8ml &
150mg/ml, 12
enpresse-28, 19
entacapone, 9
entecavir tabs, 10
enulose, 17
EPCLUSA, 10
EPIPEN INJ, 25
EPIPEN-JR INJ, 25
epitol, 4
EPIVIR HBV SOLN 5MG/ML, 10
eplerenone, 15
EPZICOM, 11
ergoloid mesylates, 5
ERGOMAR, 7
ERIVEDGE, 8
ERWINAZE INJ, 7
ERYTHROCIN LACTOBIONATE INJ, 3
erythrocin stearate, 3
erythromycin & sulfisoxazole, 3
erythromycin oint, 23
erythromycin oral, 3
erythromycin topical gel & soln, 3
ESBRIET, 25
escitalopram, 5
esomeprazole magnesium dr caps, 17
estazolam, 25
ESTRACE VAGINAL, 19
estradiol & norethindrone acetate, 19
estradiol oral, 19
estradiol patches, 19
estropipate, 19
ethambutol, 7
ethosuximide, 4
etidronate, 23
etodolac, 2
etodolac er, 2
etoposide inj, 8
EURAX, 9
EVOTAZ, 11
EVZIO, 2
exemestane, 8
EXJADE, 26
FABRAZYME INJ, 17
falmina, 19
famciclovir, 10
famotidine inj, 17
famotidine tabs, 17
FANAPT, 9
FANAPT TITRATION PACK, 9
FARESTON, 7
FARXIGA, 12
FARYDAK, 8
VillageHealth | 2016 Formulary
35
flurazepam, 25
flutamide, 7
fluticasone propionate cream & oint, 18
fluticasone propionate nasal, 24, 27
fluvoxamine, 5
fluvoxamine er, 5
fondaparinux inj, 12
FORFIVO XL, 5
FORTEO INJ, 23
fortical nasal, 23
fosinopril, 13
fosinopril & hydrochlorothiazide, 13
fosphenytoin sodium inj, 4
FOSRENOL, 18
furosemide inj, 15
furosemide oral, 15
FUZEON INJ, 11
fyavolv, 19
FYCOMPA, 4
gabapentin, 4
GABITRIL TABS 12MG & 16MG, 4
galantamine, 5, 27
galantamine er, 5, 27
galantamine oral soln, 5, 27
GAMMAGARD INJ, 21
GAMUNEX-C INJ, 21
ganciclovir inj, 10
GARDASIL 9 INJ, 22
GARDASIL INJ, 22
GATTEX INJ, 17
gauze pads 2x2, 23
gavilyte-c, 17
gavilyte-g, 17
gavilyte-h, 17
gavilyte-n, 17
GELNIQUE, 18
gemfibrozil, 15
generlac, 17
gengraf, 21
GENOTROPIN INJ, 19
GENOTROPIN MINIQUICK INJ 0.2MG, 0.4MG,
0.6MG, 0.8MG, 19
GENOTROPIN MINIQUICK INJ 1MG, 1.2MG,
1.4MG, 1.6MG, 1.8MG, & 2MG, 19
FASLODEX INJ, 7
FAZACLO, 10
felbamate tabs 400mg, 4
felbamate tabs 600mg & oral susp 600mg/5ml, 4
felodipine er, 14
fenofibrate, 15, 27
fenofibrate caps 43mg & 130mg, 15
fenofibrate micronized, 15, 27
fenofibrate tabs, 15
fenofibric acid dr caps, 15
fenofibric acid tabs, 15
fentanyl citrate lozenges 200mcg, 1
fentanyl citrate lozenges 400mcg, 600mcg,
800mcg, 1200mcg & 1600mcg, 1
fentanyl patches, 27
fentanyl patches 12mcg/hr, 25mcg/hr, 50mcg/hr,
75mcg/hr, 100mcg/hr, 1
FERRIPROX, 23
FETZIMA, 5
FETZIMA TITRATION PACK, 5
finasteride tabs 5mg, 18
FIRAZYR INJ, 21
flavoxate, 18
flecainide acetate, 14
fluconazole in dextrose inj, 6
fluconazole in sodium chloride inj, 6
fluconazole oral, 6
flucytosine, 6
fludrocortisone acetate, 18
flunisolide nasal, 24, 27
fluocinolone acetonide, 18
fluocinonide, 18
fluocinonide cream 0.05%, 18
fluocinonide gel, oint & soln, 18
fluocinonide-e, 18
fluorometholone, 24
FLUOROURACIL 0.5% CREAM, 16
fluorouracil topical, 16
fluoxetine hcl caps 10mg, 20mg & 40mg, 5
fluoxetine hcl oral soln, 5
fluoxetine hcl tabs 10mg & 20mg, 5
fluphenazine decanoate inj, 9
fluphenazine inj, 9
fluphenazine oral, 9
VillageHealth | 2016 Formulary
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gentamicin cream 0.1% & oint 0.1%, 2
gentamicin inj, 2
gentamicin oint 0.3% & soln 0.3%, 23
GENVOYA, 10
GEODON INJ, 9
gildagia, 19
gildess, 19
GILENYA, 16
GILOTRIF, 8
glatopa inj, 16
GLEEVEC, 8
GLEOSTINE, 7
glimepiride, 12
glimepiride & pioglitazone, 12
glimepiride & pioglitazone tabs, 27
glipizide, 12
glipizide & metformin tabs, 12
glipizide er, 12
GLUCAGON EMERGENCY KIT INJ, 12
glycopyrrolate inj, 17
glycopyrrolate oral, 17
granisetron inj, 6
granisetron oral, 6
griseofulvin microsize, 6
guanfacine, 13
guanidine, 7
halobetasol, 18
haloperidol decanoate inj, 9
haloperidol lactate inj, 9
haloperidol lactate oral soln, 9
haloperidol tabs, 9
HARVONI, 10
HAVRIX INJ, 22
heparin inj, 13
HERCEPTIN INJ, 8
HETLIOZ, 16
HEXALEN, 7
HIBERIX INJ, 22
HUMALOG CARTRIDGE INJ, 12
HUMALOG KWIKPEN INJ, 12
HUMALOG MIX 50/50 KWIKPEN INJ, 12
HUMALOG MIX 50/50 VIAL INJ, 12
HUMALOG MIX 75/25 KWIKPEN INJ, 12
HUMALOG MIX 75/25 VIAL INJ, 12
HUMALOG VIAL INJ, 12
HUMATROPE INJ 5MG VIAL, 12MG & 24MG
CARTRIDGE, 19
HUMATROPE INJ 6MG CARTRIDGE, 19
HUMIRA INJ, 21
HUMIRA PEDIATRIC CROHNS INJ, 21
HUMIRA PEN INJ, 21
HUMIRA PEN PSORIASIS STARTER KIT INJ, 21
HUMIRA PEN-CROHNS INJ, 21
HUMULIN 70/30 KWIKPEN INJ, 12
HUMULIN 70/30 VIAL INJ, 12
HUMULIN N KWIKPEN INJ, 12
HUMULIN N VIAL INJ, 12
HUMULIN R U-500 (CONCENTRATED)
KWIKPEN INJ, 12
HUMULIN R U-500 (CONCENTRATED) VIAL
INJ, 12
HUMULIN R VIAL INJ, 12
hydralazine inj, 15
hydralazine oral, 15
hydrochlorothiazide, 15
hydrocodone & acetaminophen soln, 1, 27
hydrocodone & acetaminophen tabs, 1, 27
hydrocodone & ibuprofen, 1, 28
hydrocortisone 2.5% cream, lotion, oint, 18
hydrocortisone butyrate oint & soln, 18
hydrocortisone enema, 22
hydrocortisone oral, 18
hydrocortisone valerate, 18
hydromorphone immediate-release oral soln &
tabs, 1
hydromorphone inj, 1
hydroxychloroquine, 9
hydroxyprogesterone caproate inj, 20
hydroxyurea, 7
ibandronate inj, 23
ibandronate oral, 23
IBRANCE, 8
ibuprofen, 2
ICLUSIG, 8
ILARIS INJ, 22
ilotycin oint, 23
VillageHealth | 2016 Formulary
37
IMATINIB, 8
IMBRUVICA, 8
imipramine hcl tabs, 5
imiquimod, 16
IMOVAX RABIES INJ, 22
INCRELEX INJ, 19
indapamide, 15
indomethacin, 2
indomethacin er, 2
indomethacin ir caps, 2
INFANRIX INJ, 22
INLYTA, 8
INTELENCE 100MG & 200MG TABS, 11
INTELENCE 25MG TAB, 11
INTRALIPID INJ, 26
INTRON-A INJ, 10
introvale, 19
INVANZ INJ, 3
INVEGA SUSTENNA 39MG & 78MG, 10
INVEGA TRINZA INJ, 10
INVIRASE, 11
INVOKAMET, 12
INVOKANA, 12
IPOL INACTIVATED IPV INJ, 22
ipratropium bromide & albuterol sulfate nebulizer,
25
ipratropium bromide nasal, 25, 28
ipratropium bromide nebulizer, 25
irbesartan, 13
irbesartan hct, 13
IRESSA, 8
ISENTRESS CHEW TABS, 10
ISENTRESS ORAL POWDER, 10
ISENTRESS TABS, 10
isoniazid oral, 7
isosorbide dinitrate, 15
isosorbide dinitrate er, 15
isosorbide mononitrate, 15
isosorbide mononitrate er, 15
isradipine, 14
itraconazole, 6
ivermectin, 8
IXIARO INJ, 22
JADENU, 26
JAKAFI, 8
jantoven, 13
JANUMET, 12
JANUMET XR, 12
JANUVIA, 12
jinteli, 19
junel, 19
JUXTAPID, 15
KALETRA TABS 100-25MG, 11
KALETRA TABS 200MG-50MG & SOLN 400100MG/5ML, 11
KALYDECO, 25
kariva, 19
ketoconazole, 6
ketorolac inj, 2
ketorolac oral, 2
ketorolac soln 0.4% & 0.5%, 24
KEYTRUDA INJ, 8
KHEDEZLA, 5
kimidess, 20
KINERET INJ, 21
kionex, 26
klor-con, 26
klor-con sprinkle, 26
KOMBIGLYZE XR, 12
KORLYM, 19
KUVAN, 17
KYNAMRO, 15
labetalol inj, 14
labetalol oral, 14
LACRISERT, 23
lactated ringers inj, 26
lactulose, 17
lamivudine, 10, 11
lamivudine & zidovudine, 11
lamotrigine immediate-release tabs, 4
LANOXIN INJ, 14
LANOXIN ORAL, 14
lansoprazole dr caps, 17
LANTUS SOLOSTAR PEN INJ, 12
LANTUS VIAL INJ, 12
larin, 20
larin fe, 20
larissia, 20
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latanoprost, 24
LATUDA, 10
LAZANDA, 1
leflunomide, 22, 28
LENVIMA, 8
LETAIRIS, 25
letrozole, 8
leucovorin inj, 8
leucovorin oral, 8
LEUKERAN, 7
LEUKINE INJ, 13
leuprolide acetate inj, 21
levalbuterol nebulizer, 25
levetiracetam er, 4
levetiracetam inj, 4
levetiracetam oral, 4
levobunolol, 24
levocarnitine inj, 23
levocarnitine oral, 23
levocetirizine, 24
levofloxacin inj, 3
levofloxacin oral soln, 3
levofloxacin tabs, 3
levoleucovorin inj, 8
levonest, 20
levonorgestrel & ethinyl estradiol 0.1-0.02mg,
0.15-0.03mg, & 0.125-0.03mg packs, 20
levora, 20
levothyroxine tabs, 20
levoxyl, 20
LEXIVA ORAL SUSP, 11
LEXIVA TABS, 11
lidocaine & prilocaine, 1
lidocaine hcl inj, 1
lidocaine hcl topical, 1
lidocaine patch, 1
linezolid inj, 2
linezolid oral, 2
LINZESS, 17
liothyronine tabs, 20
lisinopril, 13
lisinopril & hydrochlorothiazide, 13
lithium carbonate, 12
lithium carbonate er, 12
lithium citrate, 12
LONSURF, 7
loperamide caps 2mg, 17
lorazepam intensol, 12
lorazepam tabs, 12
lorcet hd tabs, 1, 28
lorcet plus tabs, 1, 28
lorcet tabs, 1, 28
lortab tabs, 1, 28
losartan, 13
losartan hct, 13
lovastatin, 15
low-ogestrel, 20
loxapine, 9
LUMIGAN, 24, 28
LUMIZYME INJ, 17
LUPRON DEPOT INJ 7.5MG, 11.25MG, 22.5MG,
30MG & 45MG, 21
LYNPARZA, 8
LYRICA, 4
LYSODREN, 20
lyza, 20
magnesium sulfate inj, 26
malathion, 9
maprotiline, 5
marlissa 28 day, 20
MARPLAN, 5
MATULANE, 7
meclizine, 6
medroxyprogesterone acetate inj, 20
medroxyprogesterone acetate tabs, 20
mefloquine, 9
megestrol acetate oral susp, 20
megestrol tabs, 20
MEKINIST, 8
meloxicam oral susp, 2
meloxicam tabs, 2
memantine hcl immediate release, 5
MENACTRA INJ, 22
MENEST, 20
MENHIBRIX INJ, 22
MENOMUNE-A/C/Y/W-135 INJ, 22
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minoxidil, 15
mirtazapine, 5
mirtazapine odt, 5
misoprostol, 17
mitoxantrone inj, 8
M-M-R II INJ, 22
modafinil, 25
moderiba 200mg tabs, 10
moderiba dose pack, 10
moexipril, 13
moexipril & hydrochlorothiazide, 13
molindone, 9
mometasone cream & oint, 18
mometasone furoate nasal, 24, 28
montelukast, 24
morgidox caps, 4
morphine sulfate er tabs, 1, 28
morphine sulfate inj vial, 1
morphine sulfate oral, 1
MOVANTIK, 17
MOVIPREP, 17
moxifloxacin oral, 3
MOZOBIL INJ, 26
mupirocin, 2
mycophenolate mofetil caps & tabs, 21
mycophenolate mofetil oral susp, 21
mycophenolic acid dr, 21
MYRBETRIQ, 18
nabumetone, 2
nadolol, 14
nadolol & bendroflumethiazide, 14
nafcillin sodium inj, 3
NAGLAZYME INJ, 17
naloxone inj, 2
naltrexone, 2
naproxen, 2
naproxen dr, 2
naproxen sodium ir, 2
naratriptan, 7, 28
NARCAN, 2
nateglinide, 12
NATPARA, 23
NEBUPENT NEBULIZER, 9
necon, 20
MENVEO-A/C/Y/W-135 INJ, 22
mercaptopurine, 7
meropenem inj, 3
mesalamine enema kit, 22
MESNEX TABS, 8
MESTINON SYRUP, 7
metadate er, 16
metformin, 12
metformin er tabs 500mg & 750mg, 12
methadone inj, 1
methadone oral, 1
methazolamide, 24
methenamine hippurate, 2
methimazole, 21
methocarbamol, 25
methotrexate inj, 21
methotrexate oral, 21
methoxsalen, 16
methyldopa, 13
methyldopa & hydrochlorothiazide, 13
methyldopate inj, 13
methylphenidate er tabs 10mg & 20mg, 16
methylphenidate ir tabs 5mg, 10mg & 20mg, 16
methylprednisolone oral, 18
methylprednisolone sodium succinate inj, 18
metipranolol, 24
metoclopramide inj, 6
metoclopramide tablets & oral soln, 6
metolazone, 15
metoprolol & hydrochlorothiazide, 14
metoprolol succinate er, 14
metoprolol tartrate tabs, 14
metronidazole inj, 2
metronidazole oral, 2
metronidazole topical, 2
metronidazole vaginal, 2
mexiletine, 14
MIACALCIN INJ, 23
microgestin, 20
midodrine tabs, 13
mimvey, 20
mimvey lo, 20
minitran patches, 15
minocycline ir, 4
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nefazodone, 5
neomycin & bacitracin & polymyxin b, 23
neomycin & polymyxin & bacitracin &
hydrocortisone, 24
neomycin & polymyxin & dexamethasone, 24
neomycin & polymyxin & gramicidin, 23
neomycin & polymyxin & hydrocortisone, 24
neomycin sulfate oral, 2
NEORAL, 21
NEUPOGEN INJ, 13
NEUPRO PATCH, 9
NEUPRO PATCH, 28
nevirapine er, 11
nevirapine oral susp, 11
nevirapine tabs, 11
NEXAVAR, 8
niacin er tabs, 15, 28
nicardipine caps, 14
NICOTROL INHALER, 2
NICOTROL NASAL, 2
nifedical xl, 14
nifedipine, 14
nifedipine er, 14
NILANDRON, 7
nilutamide, 7
nimodipine caps, 14
NINLARO, 8
nisoldipine, 14
nisoldipine er, 14
nitro-bid oint, 15
NITRO-DUR PATCHES, 15
nitrofurantoin caps, 2
nitroglycerin inj, 15
nitroglycerin lingual, 15
nitroglycerin patches, 15
NITROSTAT, 15
norethindrone, 20
norgestimate-ethinyl estradiol, 20
norlyroc, 20
NORTHERA, 14
nortriptyline oral, 5
NORVIR, 11
NOXAFIL ORAL, 6
NUEDEXTA, 16
NULOJIX INJ, 21
NUPLAZID, 10
nyamyc, 6
nystatin, 6
nystatin & triamcinolone, 6
octreotide inj 500mcg/ml & 1000mcg/ml, 21
octreotide inj 50mcg/ml, 100mcg/ml & 200mcg/ml,
21
ODEFSEY, 11
ODOMZO, 8
OFEV, 25
ofloxacin, 23, 24
ofloxacin oral, 3
olanzapine inj 10mg, 10
olanzapine odt, 10
olanzapine tabs, 10
olopatadine soln 0.1%, 23
olopatadine soln 0.1%, 28
OLYSIO, 10
omega-3-acid ethyl esters, 15
omeprazole caps, 17
ONCASPAR INJ, 8
ondansetron inj, 6
ondansetron odt, 6
ondansetron oral soln, 6
ondansetron tabs, 6
ONFI, 4
ONGLYZA, 12
OPSUMIT, 25
ORAVIG, 6
ORFADIN, 17
ORKAMBI, 25
orsythia 28 day, 20
OSMOPREP, 17
OTEZLA, 22
OTEZLA STARTER, 22
oxandrolone, 19
oxazepam, 12
oxcarbazepine, 4
oxybutynin, 18, 28
oxybutynin er, 18, 28
oxycodone, 1
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oxycodone & acetaminophen, 1, 28
oxycodone & aspirin, 1, 28
oxycodone & ibuprofen, 1
oxycodone & ibuprofen tabs, 28
OXYCODONE ER, 1
oxycodone immediate-release, 1
oxycodone oral soln, 1
OXYCONTIN, 1, 28
oxymorphone er, 1, 28
OXYTROL, 18
pacerone tabs 200mg, 14
paclitaxel inj, 8
paliperidone er, 10
pamidronate inj, 23
PANRETIN, 8
pantoprazole inj & tabs, 17
paricalcitol caps, 23
paromomycin, 2
paroxetine er, 5
paroxetine immediate-release, 5
PASER, 7
PATADAY, 23
PAXIL 10MG/5ML SUSP, 5
PEDVAX HIB INJ, 22
peg 3350 & electrolytes, 17
peg 3350 & sodium chloride & sodium
bicarbonate & potassium chloride, 17
PEGANONE, 4
PEGASYS INJ, 10
PEGASYS PROCLICK INJ, 10
PEG-INTRON INJ, 10
PEG-INTRON REDIPEN INJ, 10
penicillin g inj 5 million units, 3
penicillin v potassium, 3
PENTAM INJ, 9
PENTASA, 22, 28
pentoxifylline er, 14
perindopril, 13
permethrin cream, 9
perphenazine, 5, 9
perphenazine & amitriptyline, 5
phenadoz, 6
phenelzine, 5
phenergan suppositories, 6
phenobarbital elixir, 4
phenobarbital tabs, 4
phenytoin chewable tabs, 4
phenytoin er, 4
phenytoin inj, 4
phenytoin oral susp, 4
PHOSPHOLINE IODIDE, 24
pilocarpine soln, 24
pilocarpine tabs, 16
pimozide, 9
pimtrea, 20
pindolol, 14
pioglitazone, 12
pioglitazone & metformin, 12
piperacillin/tazobactam inj 3gm/0.375gm &
4gm/0.5gm, 3
pirmella 1/35, 20
piroxicam, 2
PLEGRIDY INJ, 16
PLEGRIDY STARTER PACK INJ, 16
plenamine inj, 26
podofilox, 16
polyethylene glycol 3350, 17
polymyxin b sulfate & trimethoprim sulfate soln,
23
POMALYST, 7
potassium chloride & dextrose & lactated ringers
inj, 26
potassium chloride & dextrose & sodium chloride
inj 20mEq/5%/0.45% & 30mEq/5%/0.45%, 26
potassium chloride er, 26
potassium chloride inj, 26
potassium chloride oral soln, 26
potassium chloride viaflex inj, 26
potassium citrate er, 26
POTIGA, 4
PRADAXA, 13
pramipexole ir, 9
pravastatin, 15
prazosin, 13, 18
PRED MILD, 24
prednicarbate, 18
prednisolone, 24
prednisolone acetate, 24
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prednisolone oral soln, 18
prednisolone sodium phosphate, 24
prednisone oral soln, 18, 22
prednisone tabs, 18, 22
PREMARIN ORAL, 20
PREMARIN VAGINAL, 20
PREMPHASE, 20
PREMPRO, 20
prenatal multi-vitamin, 26
PREPOPIK, 17
prevalite, 15
PREZCOBIX, 11
PREZISTA SUSP 100MG/ML, 11
PREZISTA TABS 600MG & 800MG, 11
PREZISTA TABS 75MG & 150MG, 11
PRIFTIN, 7
PRIMAQUINE, 9
primidone, 4
PRISTIQ, 5
PROAIR HFA, 25
PROAIR RESPICLICK, 25
probenecid, 6
probenecid & colchicine, 6
procainamide inj, 14
prochlorperazine inj, 6
prochlorperazine oral, 6
prochlorperazine suppositories, 6
PROCRIT INJ 20000UNIT/ML & 40000UNIT/ML,
13
PROCRIT INJ 3000UNIT/ML, 4000UNIT/ML &
10000UNIT/ML, 13
procto-med hc, 18
procto-pak, 19
proctosol hc, 19
proctozone-hc, 19
progesterone caps, 20
PROGLYCEM, 12
PROLASTIN C INJ, 25
PROLIA, 23
PROMACTA, 13
promethazine inj, 6
promethazine suppositories, 6
promethazine syrup, 6
promethazine tabs 12.5mg, 25mg & 50mg, 6
promethegan, 6
propafenone, 14
propranolol & hydrochlorothiazide, 14
propranolol er caps, 14
propranolol inj, 14
propranolol ir tabs, 14
propranolol oral soln, 14
propylthiouracil, 21
PROQUAD INJ, 22
PROSOL INJ, 26
PROTONIX INJ, 17
protriptyline, 5
prudoxin, 16
PULMOZYME, 25
PURIXAN, 7
pyrazinamide, 7
pyridostigmine, 7
pyridostigmine er, 7
QUADRACEL INJ, 22
quetiapine, 10
quinapril, 13
quinapril & hydrochlorothiazide, 13
quinidine gluconate cr, 14
quinidine gluconate inj, 14
quinidine sulfate, 14
quinine sulfate caps 324mg, 9
QVAR, 24
RABAVERT INJ, 22
raloxifene hcl, 20, 28
ramipril, 13
RANEXA, 15
ranitidine oral, 17
RAPAMUNE SOLN, 21
RAVICTI, 17
REBIF INJ, 16
REBIF REBIDOSE INJ, 16
REBIF REBIDOSE TITRATION PACK INJ, 16
REBIF TITRATION PACK INJ, 16
RECOMBIVAX HB INJ, 22
REGRANEX, 16, 28
RELENZA DISKHALER, 11
RELISTOR INJ, 17
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SAPHRIS, 10
SAVELLA, 16
SAVELLA TITRATION PACK, 16
selegiline, 9
selenium sulfide lotion, 16
SELZENTRY, 11
SENSIPAR TABS 30MG, 20, 28
SENSIPAR TABS 60MG & 90MG, 21
SEREVENT DISKUS, 25
SEROQUEL XR, 10
sertraline oral soln, 5
sertraline tabs, 5
setlakin, 20
sevelamer carbonate, 18
sharobel, 20
sildenafil tabs 20mg, 25
SILENOR, 25, 28
silver sulfadiazine, 2
simvastatin, 15
sirolimus tabs, 21
SIRTURO, 7
SIVEXTRO, 2
sodium chloride inj, 26
sodium phenylbutyrate powder, 17
sodium polystyrene sulfonate, 26
SOLTAMOX, 7
SOLU-CORTEF INJ, 19
SOMATULINE DEPOT INJ, 21
SOMAVERT INJ, 21
sorine, 14
sotalol tabs, 14
SOVALDI, 10
SPIRIVA HANDIHALER, 25
SPIRIVA RESPIMAT, 25
spironolactone, 15
spironolactone & hydrochlorothiazide, 15
SPORANOX ORAL SOLN, 6
SPRITAM, 4
SPRYCEL, 8
ssd, 2
stavudine, 11
stavudine oral soln, 11
STIMATE, 19
STIVARGA, 8
RELISTOR TABS, 17
REMICADE INJ, 21
REMODULIN INJ, 25
RENVELA, 18
repaglinide, 12
REPATHA INJ, 15
reprexain, 1
RESCRIPTOR, 11
RESTASIS, 23, 28
RETROVIR IV INJ, 11
REVLIMID, 7
REXULTI, 10
REYATAZ CAPS & ORAL POWDER, 11
ribasphere, 10
ribasphere ribapak, 10
ribavirin, 10
RIDAURA, 22
rifabutin, 7
rifampin inj, 7
rifampin oral, 7
RIFATER, 7
riluzole, 16
rimantadine, 11
risedronate sodium, 23
risedronate sodium dr, 23
RISPERDAL CONSTA INJ 12.5MG & 25MG, 10
RISPERDAL CONSTA INJ 37.5MG & 50MG, 10
risperidone, 10
risperidone odt, 10
RITUXAN INJ, 8
rivastigmine caps, 28
rivastigmine caps & patches, 5
rivastigmine patches, 28
rizatriptan, 7
rizatriptan odt, 7
ropinirole, 9
rosuvastatin, 15
ROTARIX, 22
ROTATEQ, 22
ROZEREM, 25, 28
SABRIL, 4
SANDIMMUNE CAPS 25MG & 100MG, 21
SANDIMMUNE ORAL SOLN 100MG/ML, 21
SANTYL, 16
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STRATTERA, 16
streptomycin inj, 2
STRIBILD, 11
STRIVERDI RESPIMAT, 25
SUCRAID, 17
sucralfate, 17
sulfacetamide sodium, 24
sulfacetamide sodium & prednisolone sodium
phosphate, 24
sulfacetamide sodium oint & soln 10%, 23
sulfacetamide sodium susp 10%, 16
sulfadiazine, 3
sulfamethoxazole & trimethoprim, 4
sulfamethoxazole & trimethoprim ds tabs, 4
sulfamethoxazole & trimethoprim inj, 4
sulfamethoxazole & trimethoprim oral susp, 4
sulfamethoxazole & trimethoprim tabs, 4
sulfasalazine, 22
sulfazine, 22
sulfazine ec, 22
sulindac, 2
sumatriptan nasal, 7
sumatriptan succinate inj, 7
sumatriptan succinate oral, 7
SUPRAX CAPS & CHEWABLE TABS, 3
SUPRAX ORAL SUSP 500MG/5ML, 3
SUPREP BOWEL PREP, 17
SUSTIVA, 11
SUTENT, 8
SYLATRON INJ, 8
SYMLINPEN INJ, 12
SYNAGIS INJ, 22
SYNAREL, 21
SYNERCID INJ, 2
SYNRIBO INJ, 8
SYNTHROID, 20
SYPRINE, 26
TABLOID, 7
tacrolimus caps 0.5mg & 1mg, 21
tacrolimus caps 5mg, 21
tacrolimus oint, 16
TAFINLAR, 8
TAGRISSO, 8
TAMIFLU CAPS 75MG, 11
TAMIFLU SUSP, 11
tamoxifen, 7
tamsulosin, 18
TARCEVA, 8
TARGRETIN, 8
tarina fe, 20
TASIGNA, 8
tazicef inj, 3
TAZORAC, 16, 28
taztia xt, 14
TECFIDERA, 16
TECFIDERA STARTER PACK, 16
TEFLARO INJ, 3
TEGRETOL, 5
TEGRETOL XR, 5
TEKTURNA, 15
TEKTURNA HCT, 15
temazepam, 25
TENIVAC, 22
terazosin, 13, 18
terbinafine, 6
terbutaline sulfate inj, 25
terbutaline sulfate oral, 25
terconazole, 6
testosterone cypionate inj, 19
testosterone enanthate inj, 19
testosterone gel 1%, 19
TETANUS & DIPHTHERIA TOXOIDSADSORBED ADULT INJ, 22
tetrabenazine, 16
tetracycline, 4
THALOMID, 7
theophylline, 25
theophylline cr & er tabs, 25
THIOLA, 18
thioridazine, 9
thiothixene, 9
THYROLAR, 20
tiagabine, 4
TIKOSYN, 14
timolol ophthalmic gel forming, 24
timolol oral, 14
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timolol soln, 24
TIVICAY 10MG TAB, 11
TIVICAY 25MG & 50MG TABS, 11
tizanidine, 10
TOBI PODHALER, 25
TOBRADEX OINT, 24
tobramycin, 24
tobramycin & dexamethasone, 24
tobramycin nebulizer, 25
tobramycin sulfate, 23
tobramycin sulfate inj, 2
TOLAK, 16
tolterodine tartrate, 28
tolterodine tartrate er, 18
topiramate immediate-release, 4
torsemide oral, 15
TOVIAZ, 18
TPN ELECTROLYTES INJ, 26
TRACLEER, 25
tramadol, 1, 28, 29
tramadol & acetaminophen, 1, 28
tramadol er, 29
tramadol er tabs, 1
trandolapril, 13
tranexamic acid inj, 13
tranexamic acid tabs, 13
TRANSDERM-SCOP, 6
tranylcypromine, 5
TRAVASOL INJ, 26
trazodone, 5
TRECATOR, 7
tretinoin caps, 8
triamcinolone, 16
triamcinolone acetonide inj, 19
triamcinolone acetonide topical cream, lotion &
oint, 19
triamcinolone in orabase, 16
triamterene & hydrochlorothiazide, 15
triazolam, 25
triderm, 19
trifluoperazine, 9
trifluridine, 23
trihexyphenidyl elixir, 9
trihexyphenidyl tabs, 9
TRILEPTAL, 5
tri-lo-estarylla, 20
tri-lo-sprintec, 20
trimethoprim, 2
trimipramine maleate, 5
TRINTELLIX, 5
tri-sprintec, 20
TRIUMEQ, 11
trivora-28, 20
TRUMENBA INJ, 22
TRUVADA, 11
TUDORZA PRESSAIR, 25
TWINRIX INJ, 22
TYBOST, 11
TYGACIL INJ, 2
TYKERB, 8
TYPHIM VI INJ, 22
TYSABRI INJ, 16
TYZEKA, 10
ULORIC, 6
unithroid, 20
UPTRAVI, 25
ursodiol, 17
VAGIFEM, 20
valacyclovir, 10
VALCHLOR, 7
valganciclovir tabs, 10
valproate sodium inj, 4
valproic acid, 4
valsartan, 13
valsartan & amlodipine, 13
valsartan & amlodipine & hct, 13
valsartan hct, 13
vancomycin inj, 2
vancomycin oral, 2
vandazole, 3
VAQTA INJ, 22
VARIVAX INJ, 22
VELCADE INJ, 8
velivet, 20
VELTASSA, 26
VENCLEXTA STARTING PACK, 8
VENCLEXTA TABS 100MG, 8
VENCLEXTA TABS 10MG & 50MG, 8
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venlafaxine er caps, 5
venlafaxine ir tabs, 5
verapamil er, 14
verapamil inj, 14
verapamil ir, 14
verapamil sr, 14
VERSACLOZ, 10
VESICARE, 18
VICTOZA INJ, 12
VIDEX PEDIATRIC SOLN 2GM, 11
vienva, 20
VIGAMOX, 23
VIIBRYD, 5
VIIBRYD STARTER PACK, 5
VIMPAT INJ, 5
VIMPAT ORAL, 5
VIRACEPT, 11
VIRAMUNE TABS, 11
VIRAZOLE, 25
VIREAD POWDER, 11
VIREAD TABS, 11
VITEKTA, 11
voriconazole inj, 6
voriconazole oral, 6
VOTRIENT, 8
VPRIV INJ, 17
VRAYLAR, 10
vyfemla, 20
warfarin, 13
WELCHOL, 15
wymzya fe, 20
XALKORI, 8
XARELTO, 13
XARELTO STARTER PACK, 13
XELJANZ, 22
XELJANZ XR, 22
XERESE, 10
XGEVA INJ, 23
XIFAXAN TABS 200MG, 3, 29
XIFAXAN TABS 550MG, 3
XIGDUO XR, 12
XTANDI, 7
XYREM, 25
YERVOY INJ, 8
YF-VAX INJ, 22
zafirlukast, 24, 29
zamicet, 1, 29
ZAVESCA, 17
ZELBORAF, 8
zenchent, 20
zenchent fe, 20
zenzedi tabs 5mg & 10mg, 15, 29
ZERBAXA INJ, 3
ZETIA, 15, 29
ZIAGEN SOLN, 11
zidovudine, 11
ziprasidone oral, 10
ZIRGAN, 10
zoledronic acid 4mg/5ml inj, 23
zoledronic acid 5mg/100ml inj, 23
ZOLINZA, 8
zolmitriptan odt, 7
zolmitriptan tabs, 7
zolpidem tabs 5mg & 10mg, 25
ZOMETA INJ 4MG/100ML, 23
ZOMIG NASAL, 7, 29
ZONALON, 16
zonisamide, 4
ZORTRESS TABS 0.25MG, 21
ZORTRESS TABS 0.5MG & 0.75MG, 21
ZOSTAVAX INJ, 22
ZOSYN GALAXY INJ 2GM/0.25GM &
3GM/0.375GM, 3
zovia, 20
ZOVIRAX CREAM, 10
ZYDELIG, 8
ZYFLO CR, 24, 29
ZYKADIA, 8
ZYPREXA RELPREVV 210MG, 10
ZYTIGA, 7
VillageHealth | 2016 Formulary
47
3800 Kilroy Airport Way, Suite 100
Long Beach, CA 90806
This formulary was updated on 11/2016. For more recent information or other questions, please contact
VillageHealth Member Services at 1-800-399-7226 or, for TTY users, 711, 8 a.m. to 8 p.m., 7 days a week
from October 1 to February 14. From February 15 to September 30, hours are 8 a.m. to 8 p.m. Monday through
Friday, and 9 a.m. to 4 p.m. on Saturday (messages received on holidays and outside of our business hours will
be returned within one business day), or visit www.villagehealthca.com.
Este formulario se actualizó en 11/2016. Para obtener información más reciente o si tiene dudas, comuníquese
con Servicios para Miembros de VillageHealth al 1-800-399-7226 o, para los usuarios de TTY, 711, de 8 a.m.
a 8 p.m., los 7 días de la semana, desde el 1 de octubre hasta el 14 de febrero. Desde el 15 de febrero
al 30 de septiembre, el horario es de 8 a.m. a 8 p.m., de lunes a viernes, y de 9 a.m. a 4 p.m. los sábados
(los mensajes recibidos en días festivos y fuera del horario hábil se devolverán en un día hábil). O visite
www.villagehealthca.com.
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