2018 - scan health plan formulario se actualizó el 1 de abril de 2018. ... scan health plan member...

SCAN Health Plan®................

18C-FOR900

2018 SCAN Health Plan Formulary List of Covered Drugs

Formulario de SCAN Health Plan para 2018

Lista de medicamentos cubiertos

This formulary was updated on 06/01/2018. For more recent information or other questions, please contact SCAN Health Plan Member Services at 1-800-559-3500 (Medicare and Medi-Cal eligible members should call 1-866-722-6725) 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 (messages received on holidays and outside of our business hours will be returned within one business day), or visit www.scanhealthplan.com.

Este formulario se actualizó el 1 de junio de 2018. Para obtener información más reciente o si tiene dudas, comuníquese con Servicios para Miembros de SCAN Health Plan al 1-800-559-3500 (los miembros elegibles para Medicare y Medi-Cal deben llamar al 1-866-722-6725) 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 (los mensajes recibidos en días festivos y fuera del horario hábil se devolverán en un día hábil); o visite www.scanhealthplan.com.

http://www.scanhealthplan.com/

1

SCAN Health Plan 2018 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN 18423, 12 This formulary was updated on 06/01/2018. For more recent information or other questions, please contact SCAN Health Plan Member Services, at 1-800-559-3500 (Medicare and Medi-Cal eligible members should call 1-866-722-6725) 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 (messages received on holidays and outside of our business hours will be returned within one business day), or visit www.scanhealthplan.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 SCAN Classic (HMO), SCAN Classic II (HMO), Scripps Classic offered by SCAN Health Plan (HMO), Scripps Signature offered by SCAN Health Plan (HMO), SCAN Healthy at Home (HMO SNP), Heart First (HMO SNP), Scripps Heart First offered by SCAN Health Plan (HMO SNP), SCAN Balance (HMO SNP), SCAN Plus (HMO), Scripps Plus offered by SCAN Health Plan (HMO), SCAN Connections (HMO SNP), or SCAN Connections at Home (HMO SNP). This document includes a list of the drugs (formulary) for our plan which is current as of June 2018. 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, 2019, 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 SCAN Health Plan Member Services at 1-800-559-3500 (Medicare and Medi-Cal eligible members should call 1-866-722-6725), 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 (messages received on holidays and outside of our business hours will be returned within one business day). TTY users should call 711.

2

SCAN Health Plan is an HMO plan with a Medicare contract. Enrollment in SCAN Health Plan depends on

contract renewal.

ATTENTION: If you speak another language, language assistance services, free of charge, are available to

you. Call 1-800-559-3500 (TTY: 711).

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al

1-800-559-3500 (TTY: 711).

注意：如果您使用中文，您可以免費獲得語言援助服務。請致電 1-800-559-3500（聽障專線：711）。

Y0057_SCAN_10440_2017F File & Use Accepted 08112017

3

Table of Contents…… ……………………………………….………….…..

What is the SCAN Health Plan Formulary? ................................................................... 5

Can the Formulary (drug list) change? .......................................................................... 5

How do I use the Formulary? ........................................................................................ 5

What are generic drugs? ............................................................................................... 6

Are there any restrictions on my coverage? .................................................................. 6

What if my drug is not on the Formulary? ...................................................................... 6

How do I request an exception to the SCAN Health Plan Formulary? ........................... 7

What do I do before I can talk to my doctor about changing my drugs or requesting an exception? .................................................................................................................... 7

For more information ..................................................................................................... 8

SCAN Health Plan’s Formulary ................................................................................... 33

Formulary Drugs Arranged by Therapeutic Class ....................................................... 69

Formulary Drugs with Quantity Limits ......................................................................... 96

Index ........................................................................................................................... 99

4

This page is intentionally blank.

5

What is the SCAN Health Plan Formulary?

A formulary is a list of covered drugs selected by SCAN Health Plan 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. SCAN Health Plan will generally cover the drugs listed in our formulary as long as the drug is

medically necessary, the prescription is filled at a SCAN Health Plan 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 2018 formulary that was covered at the beginning of the year, we will

not discontinue or reduce coverage of the drug during the 2018 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 June, 2018. To get updated information about the drugs covered by SCAN

Health Plan, please contact us. Our contact information appears on the front and back cover pages.

How do I use the Formulary?

There are two ways to find your drug within the formulary:

Medical Condition

The formulary begins on page 69. 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 69. 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 99. 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.

6

What are generic drugs?

SCAN Health Plan 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.

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: SCAN Health Plan requires you or your physician to get prior authorization for

certain drugs. This means that you will need to get approval from SCAN Health Plan before you fill your

prescriptions. If you don’t get approval, SCAN Health Plan may not cover the drug.

Quantity Limits: For certain drugs, SCAN Health Plan limits the amount of the drug that SCAN Health

Plan will cover. For example, SCAN Health Plan provides 30 tablets per prescription for Rozerem. This

may be in addition to a standard one-month or three-month supply.

Step Therapy: In some cases, SCAN Health Plan 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, SCAN Health Plan may not cover Drug B unless you try Drug A

first. If Drug A does not work for you, SCAN Health Plan 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 69. 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 SCAN Health Plan 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 SCAN

Health Plan formulary?” on page 7 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 SCAN Health Plan does not cover your drug, you have two options:

You can ask Member Services for a list of similar drugs that are covered by SCAN Health Plan. When

you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered

by SCAN Health Plan.

You can ask SCAN Health Plan to make an exception and cover your drug. See below for information

about how to request an exception.

7

How do I request an exception to the SCAN Health Plan Formulary?

You can ask SCAN Health Plan 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 cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty

tier. If approved this would lower the amount you must pay for your drug.

You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs,

SCAN Health Plan 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, SCAN Health Plan will only approve your request for an exception if the alternative drugs included

on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as

effective in treating your condition and/or would cause you to have adverse medical effects.

You should contact us to ask us for an initial coverage decision for a formulary, tiering, or utilization restriction exception. When you request a formulary, tiering, 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.

8

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 long-term 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 SCAN Health Plan prescription drug coverage, please review your

Evidence of Coverage and other plan materials.

If you have questions about SCAN Health Plan, 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.

9

The charts below list 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.

SCAN Classic (HMO):

Los Angeles County

Drug

Tier Tier Name

Preferred

Retail &

Mail-Order

cost-

sharing

(in-

network)

(30-day

supply)

Standard

Retail

cost-

sharing

(in-

network)

(30-day

supply)

Preferred

Retail &

Mail-Order

cost-

sharing

(in-

network)

(60-day

supply)

Standard

Retail

cost-

sharing

(in-

network)

(60-day

supply)

Preferred

Retail &

Mail-Order

cost-

sharing

(in-

network)

(90-day

supply)

Standard

Retail

cost-

sharing

(in-

network)

(90-day

supply)

1 Preferred

Generic $0 $0 $0 $0 $0 $0

2 Generic $5 $10 $10 $20 $10 $20

3 Preferred

Brand $42 $47 $84 $94 $116 $131

4

Non-

Preferred

Drug

$95 $100 $190 $200 $275 $290

5 Specialty

Tier 33% 33% N/A N/A N/A N/A

Please refer to your Evidence of Coverage for information about the costs at Long-Term Care (LTC)

pharmacies or out-of-network pharmacies.

Preferred cost-sharing is lower cost-sharing that may be available to you for certain covered Part D drugs at

certain network pharmacies. For more information, please visit our online searchable Pharmacy Directory at

www.scanhealthplan.com or call Member Services. Our contact information appears on the front and back

cover pages.

We provide additional coverage of prescription drugs in tiers 1 and 2 in the Coverage Gap. Please refer to your

Evidence of Coverage for more information about this coverage.

10

SCAN Classic II (HMO):

Los Angeles County

Drug

Tier Tier Name

Preferred

Retail &

Mail-Order

cost-

sharing

(in-

network)

(30-day

supply)

Standard

Retail

cost-

sharing

(in-

network)

(30-day

supply)

Preferred

Retail &

Mail-Order

cost-

sharing

(in-

network)

(60-day

supply)

Standard

Retail

cost-

sharing

(in-

network)

(60-day

supply)

Preferred

Retail &

Mail-Order

cost-

sharing

(in-

network)

(90-day

supply)

Standard

Retail

cost-

sharing

(in-

network)

(90-day

supply)

1 Preferred

Generic $0 $5 $0 $10 $0 $0

2 Generic $5 $10 $10 $20 $10 $20

3 Preferred

Brand $42 $47 $84 $94 $116 $131

4

Non-

Preferred

Drug

$95 $100 $190 $200 $275 $290

5 Specialty







cover pages.



11

SCAN Classic (HMO):

Orange County

Drug

Tier Tier Name

Preferred

Retail &

Mail-Order

cost-

sharing

(in-

network)

(30-day

supply)

Standard

Retail

cost-

sharing

(in-

network)

(30-day

supply)

Preferred

Retail &

Mail-Order

cost-

sharing

(in-

network)

(60-day

supply)

Standard

Retail

cost-

sharing

(in-

network)

(60-day

supply)

Preferred

Retail &

Mail-Order

cost-

sharing

(in-

network)

(90-day

supply)

Standard

Retail

cost-

sharing

(in-

network)

(90-day

supply)

1 Preferred

Generic $0 $0 $0 $0 $0 $0

2 Generic $5 $10 $10 $20 $10 $20

3 Preferred

Brand $42 $47 $84 $94 $116 $131

4

Non-

Preferred

Drug

$95 $100 $190 $200 $275 $290

5 Specialty







cover pages.



12

SCAN Classic (HMO):

Riverside and San Bernardino Counties

Drug

Tier Tier Name

Preferred

Retail &

Mail-Order

cost-

sharing

(in-

network)

(30-day

supply)

Standard

Retail

cost-

sharing

(in-

network)

(30-day

supply)

Preferred

Retail &

Mail-Order

cost-

sharing

(in-

network)

(60-day

supply)

Standard

Retail

cost-

sharing

(in-

network)

(60-day

supply)

Preferred

Retail &

Mail-Order

cost-

sharing

(in-

network)

(90-day

supply)

Standard

Retail

cost-

sharing

(in-

network)

(90-day

supply)

1 Preferred

Generic $0 $5 $0 $10 $0 $10

2 Generic $7 $12 $14 $24 $14 $24

3 Preferred

Brand $42 $47 $84 $94 $116 $131

4

Non-

Preferred

Drug

$95 $100 $190 $200 $275 $290

5 Specialty







cover pages.



13



Drug

Tier Tier Name

Preferred

Retail &

Mail-Order

cost-

sharing

(in-

network)

(30-day

supply)

Standard

Retail

cost-

sharing

(in-

network)

(30-day

supply)

Preferred

Retail &

Mail-Order

cost-

sharing

(in-

network)

(60-day

supply)

Standard

Retail

cost-

sharing

(in-

network)

(60-day

supply)

Preferred

Retail &

Mail-Order

cost-

sharing

(in-

network)

(90-day

supply)

Standard

Retail

cost-

sharing

(in-

network)

(90-day

supply)

1 Preferred

Generic $2 $7 $4 $14 $4 $14

2 Generic $7 $12 $14 $24 $14 $24

3 Preferred

Brand $42 $47 $84 $94 $116 $131

4

Non-

Preferred

Drug

$95 $100 $190 $200 $275 $290

5 Specialty







cover pages.

We provide additional coverage of prescription drugs in tier 1 in the Coverage Gap. Please refer to your


14

Scripps Classic offered by SCAN Health Plan (HMO):

San Diego County

Drug

Tier Tier Name

Preferred

Retail &

Mail-Order

cost-

sharing

(in-

network)

(30-day

supply)

Standard

Retail

cost-

sharing

(in-

network)

(30-day

supply)

Preferred

Retail &

Mail-Order

cost-

sharing

(in-

network)

(60-day

supply)

Standard

Retail

cost-

sharing

(in-

network)

(60-day

supply)

Preferred

Retail &

Mail-Order

cost-

sharing

(in-

network)

(90-day

supply)

Standard

Retail

cost-

sharing

(in-

network)

(90-day

supply)

1 Preferred

Generic $0 $5 $0 $10 $0 $10

2 Generic $5 $10 $10 $20 $10 $20

3 Preferred

Brand $42 $47 $84 $94 $116 $131

4

Non-

Preferred

Drug

$95 $100 $190 $200 $275 $290

5 Specialty







cover pages.

15

Scripps Signature offered by SCAN Health Plan (HMO):

San Diego County

Drug

Tier Tier Name

Preferred

Retail &

Mail-Order

cost-

sharing

(in-

network)

(30-day

supply)

Standard

Retail

cost-

sharing

(in-

network)

(30-day

supply)

Preferred

Retail &

Mail-Order

cost-

sharing

(in-

network)

(60-day

supply)

Standard

Retail

cost-

sharing

(in-

network)

(60-day

supply)

Preferred

Retail &

Mail-Order

cost-

sharing

(in-

network)

(90-day

supply)

Standard

Retail

cost-

sharing

(in-

network)

(90-day

supply)

1 Preferred

Generic $0 $5 $0 $10 $0 $10

2 Generic $3 $8 $6 $16 $6 $16

3 Preferred

Brand $42 $47 $84 $94 $116 $131

4

Non-

Preferred

Drug

$95 $100 $190 $200 $275 $290

5 Specialty







cover pages.



16

SCAN Classic (HMO):

Ventura County

Drug

Tier Tier Name

Preferred

Retail &

Mail-Order

cost-

sharing

(in-

network)

(30-day

supply)

Standard

Retail

cost-

sharing

(in-

network)

(30-day

supply)

Preferred

Retail &

Mail-Order

cost-

sharing

(in-

network)

(60-day

supply)

Standard

Retail

cost-

sharing

(in-

network)

(60-day

supply)

Preferred

Retail &

Mail-Order

cost-

sharing

(in-

network)

(90-day

supply)

Standard

Retail

cost-

sharing

(in-

network)

(90-day

supply)

1 Preferred

Generic $2 $7 $4 $14 $4 $14

2 Generic $5 $12 $10 $24 $10 $24

3 Preferred

Brand $42 $47 $84 $94 $116 $131

4

Non-

Preferred

Drug

$95 $100 $190 $200 $275 $290

5 Specialty







cover pages.

17

SCAN Classic (HMO):

San Francisco and Santa Clara Counties

Drug

Tier Tier Name

Preferred

Retail &

Mail-Order

cost-

sharing

(in-

network)

(30-day

supply)

Standard

Retail

cost-

sharing

(in-

network)

(30-day

supply)

Preferred

Retail &

Mail-Order

cost-

sharing

(in-

network)

(60-day

supply)

Standard

Retail

cost-

sharing

(in-

network)

(60-day

supply)

Preferred

Retail &

Mail-Order

cost-

sharing

(in-

network)

(90-day

supply)

Standard

Retail

cost-

sharing

(in-

network)

(90-day

supply)

1 Preferred

Generic $3 $8 $6 $16 $6 $16

2 Generic $5 $10 $10 $20 $10 $20

3 Preferred

Brand $42 $47 $84 $94 $116 $131

4

Non-

Preferred

Drug

$95 $100 $190 $200 $275 $290

5 Specialty







cover pages.

18

SCAN Classic (HMO):

Marin County

Drug

Tier Tier Name

Preferred

Retail &

Mail-Order

cost-

sharing

(in-

network)

(30-day

supply)

Standard

Retail

cost-

sharing

(in-

network)

(30-day

supply)

Preferred

Retail &

Mail-Order

cost-

sharing

(in-

network)

(60-day

supply)

Standard

Retail

cost-

sharing

(in-

network)

(60-day

supply)

Preferred

Retail &

Mail-Order

cost-

sharing

(in-

network)

(90-day

supply)

Standard

Retail

cost-

sharing

(in-

network)

(90-day

supply)

1 Preferred

Generic $0 $3 $0 $6 $0 $6

2 Generic $2 $7 $4 $14 $4 $14

3 Preferred

Brand $40 $45 $80 $90 $110 $125

4

Non-

Preferred

Drug

$80 $85 $160 $170 $230 $245

5 Specialty







cover pages.

19

SCAN Classic (HMO):

Napa and Sonoma Counties

Drug

Tier Tier Name

Preferred

Retail &

Mail-Order

cost-

sharing

(in-

network)

(30-day

supply)

Standard

Retail

cost-

sharing

(in-

network)

(30-day

supply)

Preferred

Retail &

Mail-Order

cost-

sharing

(in-

network)

(60-day

supply)

Standard

Retail

cost-

sharing

(in-

network)

(60-day

supply)

Preferred

Retail &

Mail-Order

cost-

sharing

(in-

network)

(90-day

supply)

Standard

Retail

cost-

sharing

(in-

network)

(90-day

supply)

1 Preferred

Generic $0 $5 $0 $10 $0 $10

2 Generic $10 $15 $20 $30 $20 $30

3 Preferred

Brand $42 $47 $84 $94 $116 $131

4

Non-

Preferred

Drug

$95 $100 $190 $200 $275 $290

5 Specialty







cover pages.

20

SCAN Healthy At Home (HMO SNP):

Los Angeles, Orange, Riverside and San Bernardino Counties

Drug

Tier Tier Name

Preferred

Retail &

Mail-Order

cost-

sharing

(in-

network)

(30-day

supply)

Standard

Retail

cost-

sharing

(in-

network)

(30-day

supply)

Preferred

Retail &

Mail-Order

cost-

sharing

(in-

network)

(60-day

supply)

Standard

Retail

cost-

sharing

(in-

network)

(60-day

supply)

Preferred

Retail &

Mail-Order

cost-

sharing

(in-

network)

(90-day

supply)

Standard

Retail

cost-

sharing

(in-

network)

(90-day

supply)

1 Preferred

Generic $0 $3 $0 $6 $0 $9

2 Generic $5 $10 $10 $20 $15 $30

3 Preferred

Brand $42 $47 $84 $94 $126 $141

4

Non-

Preferred

Drug

$95 $100 $190 $200 $285 $300

5 Specialty







cover pages.



21

Heart First (HMO SNP):

Orange County

Drug

Tier Tier Name

Preferred

Retail &

Mail-Order

cost-

sharing

(in-

network)

(30-day

supply)

Standard

Retail

cost-

sharing

(in-

network)

(30-day

supply)

Preferred

Retail &

Mail-Order

cost-

sharing

(in-

network)

(60-day

supply)

Standard

Retail

cost-

sharing

(in-

network)

(60-day

supply)

Preferred

Retail &

Mail-Order

cost-

sharing

(in-

network)

(90-day

supply)

Standard

Retail

cost-

sharing

(in-

network)

(90-day

supply)

1 Preferred

Generic $0 $3 $0 $6 $0 $6

2 Generic $2 $7 $4 $14 $4 $14

3 Preferred

Brand $42 $47 $84 $94 $116 $131

4

Non-

Preferred

Drug

$95 $100 $190 $200 $275 $290

5 Specialty







cover pages.



22


Marin County

Drug

Tier Tier Name

Preferred

Retail &

Mail-Order

cost-

sharing

(in-

network)

(30-day

supply)

Standard

Retail

cost-

sharing

(in-

network)

(30-day

supply)

Preferred

Retail &

Mail-Order

cost-

sharing

(in-

network)

(60-day

supply)

Standard

Retail

cost-

sharing

(in-

network)

(60-day

supply)

Preferred

Retail &

Mail-Order

cost-

sharing

(in-

network)

(90-day

supply)

Standard

Retail

cost-

sharing

(in-

network)

(90-day

supply)

1 Preferred

Generic $0 $3 $0 $6 $0 $6

2 Generic $2 $7 $4 $14 $4 $14

3 Preferred

Brand $40 $45 $80 $90 $110 $125

4

Non-

Preferred

Drug

$90 $95 $180 $190 $260 $275

5 Specialty







cover pages.



23



Drug

Tier Tier Name

Preferred

Retail &

Mail-Order

cost-

sharing

(in-

network)

(30-day

supply)

Standard

Retail

cost-

sharing

(in-

network)

(30-day

supply)

Preferred

Retail &

Mail-Order

cost-

sharing

(in-

network)

(60-day

supply)

Standard

Retail

cost-

sharing

(in-

network)

(60-day

supply)

Preferred

Retail &

Mail-Order

cost-

sharing

(in-

network)

(90-day

supply)

Standard

Retail

cost-

sharing

(in-

network)

(90-day

supply)

1 Preferred

Generic $0 $5 $0 $10 $0 $10

2 Generic $7 $12 $14 $24 $14 $24

3 Preferred

Brand $42 $47 $84 $94 $116 $131

4

Non-

Preferred

Drug

$95 $100 $190 $200 $275 $290

5 Specialty







cover pages.



24

Scripps Heart First offered by SCAN Health Plan (HMO SNP):

San Diego County

Drug

Tier Tier Name

Preferred

Retail &

Mail-Order

cost-

sharing

(in-network)

(30-day

supply)

Standard

Retail cost-

sharing

(in-network)

(30-day

supply)

Preferred

Retail &

Mail-Order

cost-

sharing

(in-network)

(60-day

supply)

Standard

Retail cost-

sharing

(in-network)

(60-day

supply)

Preferred

Retail &

Mail-Order

cost-

sharing

(in-network)

(90-day

supply)

Standard

Retail cost-

sharing

(in-network)

(90-day

supply)

1 Preferred

Generic $0 $5 $0 $10 $0 $10

2 Generic $5 $10 $10 $20 $10 $20

3 Preferred

Brand $42 $47 $84 $94 $116 $131

4

Non-

Preferred

Drug

$95 $100 $190 $200 $275 $290

5 Specialty







cover pages.



25



Drug

Tier Tier Name

Preferred

Retail &

Mail-Order

cost-

sharing

(in-network)

(30-day

supply)

Standard

Retail cost-

sharing

(in-network)

(30-day

supply)

Preferred

Retail &

Mail-Order

cost-

sharing

(in-network)

(60-day

supply)

Standard

Retail cost-

sharing

(in-network)

(60-day

supply)

Preferred

Retail &

Mail-Order

cost-

sharing

(in-network)

(90-day

supply)

Standard

Retail cost-

sharing

(in-network)

(90-day

supply)

1 Preferred

Generic $0 $5 $0 $10 $0 $10

2 Generic $10 $15 $20 $30 $20 $30

3 Preferred

Brand $42 $47 $84 $94 $116 $131

4

Non-

Preferred

Drug

$95 $100 $190 $200 $275 $290

5 Specialty







cover pages.



26

SCAN Balance (HMO SNP):

Los Angeles and Orange Counties

Drug

Tier Tier Name

Preferred

Retail &

Mail-Order

cost-

sharing

(in-network)

(30-day

supply)

Standard

Retail cost-

sharing

(in-network)

(30-day

supply)

Preferred

Retail &

Mail-Order

cost-

sharing

(in-network)

(60-day

supply)

Standard

Retail cost-

sharing

(in-network)

(60-day

supply)

Preferred

Retail &

Mail-Order

cost-

sharing

(in-network)

(90-day

supply)

Standard

Retail cost-

sharing

(in-network)

(90-day

supply)

1 Preferred

Generic $0 $3 $0 $6 $0 $6

2 Generic $2 $7 $4 $14 $4 $14

3 Preferred

Brand $30 $35 $60 $70 $80 $95

4

Non-

Preferred

Drug

$95 $100 $190 $200 $275 $290

5 Specialty







cover pages.



27


Marin County

Drug

Tier Tier Name

Preferred

Retail &

Mail-Order

cost-

sharing

(in-network)

(30-day

supply)

Standard

Retail cost-

sharing

(in-network)

(30-day

supply)

Preferred

Retail &

Mail-Order

cost-

sharing

(in-network)

(60-day

supply)

Standard

Retail cost-

sharing

(in-network)

(60-day

supply)

Preferred

Retail &

Mail-Order

cost-

sharing

(in-network)

(90-day

supply)

Standard

Retail cost-

sharing

(in-network)

(90-day

supply)

1 Preferred

Generic $0 $3 $0 $6 $0 $6

2 Generic $2 $7 $4 $14 $4 $14

3 Preferred

Brand $40 $45 $80 $90 $110 $125

4

Non-

Preferred

Drug

$90 $95 $180 $190 $260 $275

5 Specialty







cover pages.



28



Drug

Tier Tier Name

Preferred

Retail &

Mail-Order

cost-

sharing

(in-network)

(30-day

supply)

Standard

Retail cost-

sharing

(in-network)

(30-day

supply)

Preferred

Retail &

Mail-Order

cost-

sharing

(in-network)

(60-day

supply)

Standard

Retail cost-

sharing

(in-network)

(60-day

supply)

Preferred

Retail &

Mail-Order

cost-

sharing

(in-network)

(90-day

supply)

Standard

Retail cost-

sharing

(in-network)

(90-day

supply)

1 Preferred

Generic $0 $5 $0 $10 $0 $10

2 Generic $10 $15 $20 $30 $20 $30

3 Preferred

Brand $42 $47 $84 $94 $116 $131

4

Non-

Preferred

Drug

$95 $100 $190 $200 $275 $290

5 Specialty







cover pages.



29

SCAN Plus (HMO):

Los Angeles, Riverside, San Bernardino and San Francisco Counties

Drug

Tier Tier Name

Preferred

Retail &

Mail-Order

cost-

sharing

(in-network)

(30-day

supply)

Standard

Retail cost-

sharing

(in-network)

(30-day

supply)

Preferred

Retail &

Mail-Order

cost-

sharing

(in-network)

(60-day

supply)

Standard

Retail cost-

sharing

(in-network)

(60-day

supply)

Preferred

Retail &

Mail-Order

cost-

sharing

(in-network)

(90-day

supply)

Standard

Retail cost-

sharing

(in-network)

(90-day

supply)

1 Preferred

Generic $0 $8.50 $0 $17 $0 $25.50

2 Generic 25% 25% 25% 25% 25% 25%

3 Preferred

Brand 25% 25% 25% 25% 25% 25%

4

Non-

Preferred

Drug

25% 25% 25% 25% 25% 25%

5 Specialty







cover pages.

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. For more information about your drug costs, look at the "LIS Rider".

30

SCAN Plus (HMO):

Orange County

Drug

Tier Tier Name

Preferred

Retail &

Mail-Order

cost-

sharing

(in-network)

(30-day

supply)

Standard

Retail cost-

sharing

(in-network)

(30-day

supply)

Preferred

Retail &

Mail-Order

cost-

sharing

(in-network)

(60-day

supply)

Standard

Retail cost-

sharing

(in-network)

(60-day

supply)

Preferred

Retail &

Mail-Order

cost-

sharing

(in-network)

(90-day

supply)

Standard

Retail cost-

sharing

(in-network)

(90-day

supply)

1 Preferred

Generic $0 $7.50 $0 $15 $0 $22.50

2 Generic 25% 25% 25% 25% 25% 25%

3 Preferred

Brand 25% 25% 25% 25% 25% 25%

4

Non-

Preferred

Drug

25% 25% 25% 25% 25% 25%

5 Specialty







cover pages.

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. For more information about your drug costs, look at the "LIS Rider

31

Scripps Plus offered by SCAN Health Plan (HMO):

San Diego County

Drug

Tier Tier Name

Preferred

Retail &

Mail-Order

cost-

sharing

(in-network)

(30-day

supply)

Standard

Retail cost-

sharing

(in-network)

(30-day

supply)

Preferred

Retail &

Mail-Order

cost-

sharing

(in-network)

(60-day

supply)

Standard

Retail cost-

sharing

(in-network)

(60-day

supply)

Preferred

Retail &

Mail-Order

cost-

sharing

(in-network)

(90-day

supply)

Standard

Retail cost-

sharing

(in-network)

(90-day

supply)

1 Preferred

Generic $0 $6 $0 $12 $0 $18

2 Generic 25% 25% 25% 25% 25% 25%

3 Preferred

Brand 25% 25% 25% 25% 25% 25%

4

Non-

Preferred

Drug

25% 25% 25% 25% 25% 25%

5 Specialty







cover pages.

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. For more information about your drug costs, look at the "LIS Rider".

32

The chart below is for Medicare and Medi-Cal eligible members only. It lists what you will pay as your share of

the cost for covered prescription drugs when you are in the Initial Coverage Stage. For information about your

costs in the Coverage Gap Stage or the Catastrophic Coverage Stage, please refer to your Evidence of

Coverage.

Co-pays may vary based on the level of Extra Help you receive. Please contact Member Services for further

details. Our contact information appears on the front and back cover pages.

SCAN Connections (HMO SNP) – Medicare and Medi-Cal eligible members only:

Los Angeles, Riverside and San Bernardino Counties

SCAN Connections at Home (HMO SNP) – Medicare and Medi-Cal eligible members only:

Los Angeles, Riverside, and San Bernardino Counties

Drug

Tier Tier Name

Preferred Retail and Mail-Order

cost-sharing

(in-network))

Standard Retail

cost-sharing

(in-network)

1 Preferred Generic

(One - three month supply) $0 $0 or $1.25 or $3.35

2 Generic

(One - three month supply)

You pay:

For generic drugs (including brand drugs treated as generic), either:

– $0 or $1.25 or $3.35

For all other drugs, either:

– $0 or $3.70 or $8.35

3 Preferred Brand


4 Non-Preferred Drug


5 Specialty Tier

(One month supply only)






cover pages.

33

SCAN Health Plan’s Formulary

The formulary that begins on page 69 provides coverage information about the drugs covered by SCAN Health

Plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 99.

The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., JANUVIA) and generic

drugs are listed in lower-case italics (e.g., metformin).

The information in the Requirements/Limits column tells you if SCAN Health Plan has any special requirements

for coverage of your drug.

o The symbol [PA] indicates that prior authorization applies.

o 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.

o The symbol [ST] indicates that step therapy applies.

o 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 96.

o The symbol [90D] indicates that the drug is available for a 90-day supply at mail-order and select retail

pharmacies.

o 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 1-800-559-3500 (Medicare and Medi-Cal eligible members should call 1-866-722-6725), 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 (messages received on holidays and outside of our business hours will be returned within one business day). TTY users should call 711.

34

This page is intentionally blank. Esta página se dejó en blanco intencionalmente

35

SCAN Health Plan Formulario 2018 (Lista de medicamentos cubiertos) LEA: ESTE DOCUMENTO CONTIENE INFORMACIÓN ACERCA DE LOS MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN 18423, 12 Este formulario se actualizó el 1 de junio de 2018. Para obtener información más reciente o si tiene otras preguntas, comuníquese con Servicios para Miembros de SCAN Health Plan llamando al 1-800-559-3500 (los miembros que cumplen los requisitos de Medicare y Medi-Cal deben llamar al 1-866-722-6725) o para usuarios de TTY, al 711, de 8 a. m. a 8 p. m., los 7 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 (los mensajes recibidos en días festivos y fuera de nuestro horario hábil se responderán en el plazo de un día hábil), o visite www.scanhealthplan.com. Nota para miembros existentes: Este formulario ha cambiado desde el año pasado. Revise este documento para asegurarse de que todavía contiene los medicamentos que toma. Cuando esta lista de medicamentos (formulario) usa “nosotros” o “nuestro” se refiere a SCAN Health Plan. Cuando se refiere a “plan” o “nuestro plan”, se refiere a SCAN Classic (HMO), SCAN Classic II (HMO), Scripps Classic offered by SCAN Health Plan (HMO), Scripps Signature offered by SCAN Health Plan (HMO), SCAN Healthy at Home (HMO SNP), Heart First (HMO SNP), Scripps Heart First offered by SCAN Health Plan (HMO SNP), SCAN Balance (HMO SNP), SCAN Plus (HMO), Scripps Plus offered by SCAN Health Plan (HMO), SCAN Connections (HMO SNP) o SCAN Connections at Home (HMO SNP). Este documento incluye una lista de los medicamentos (formulario) de nuestro plan que es válido a partir de junio de 2018. Para obtener un formulario actualizado, comuníquese con nosotros. Nuestra información de contacto, junto con la fecha en que se actualizó el formulario por última vez, aparece en la portada y contraportada. Por lo general, debe utilizar las farmacias de la red para utilizar su beneficio de medicamentos con receta médica. Los beneficios, la lista de medicamentos, la red de farmacias o los copagos/coseguros pueden cambiar el 1 de enero de 2019 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. Pueden aplicarse limitaciones, copagos y restricciones. La lista de medicamentos (formulario), la red de farmacias o la red de proveedores pueden cambiar en cualquier momento. Recibirá un aviso cuando sea necesario. Puede obtener medicamentos recetados enviados a su casa, a través de nuestro programa de entrega de pedidos por correo de nuestra red. Por lo general, debe esperar recibir sus medicamentos recetados en el plazo de 14 días desde el momento en que la farmacia de pedidos por correo recibe el pedido. Si no recibe sus medicamentos recetados en ese plazo, comuníquese con Servicios para Miembros de SCAN Health Plan, al 1-800-559-3500 (los miembros que cumplen los requisitos para Medicare y Medi-Cal deben llamar al 1-866-722-6725) o, para usuarios de TTY, 711, de 8 a. m. a 8 p. m., los 7 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 (los mensajes recibidos en días festivos y fuera de nuestro horario hábil se responderán en el plazo de un día hábil). Los usuarios de TTY deben llamar al 711.

36

SCAN Health Plan es un plan HMO con un contrato con Medicare. La inscripción en SCAN Health Plan

depende de la renovación del contrato.

ATTENTION: If you speak another language, language assistance services, free of charge, are available to

you. Call 1-800-559-3500 (TTY: 711).

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al

1-800-559-3500 (TTY: 711).

注意：如果您使用中文，您可以免費獲得語言援助服務。請致電 1-800-559-3500（聽障專線：711）。

Y0057_SCAN_10440_2017F_SP File & Use Accepted 08112017

37

.TABLA DE CONTENIDOS………………………………………….……..…

¿Qué es el Formulario de SCAN Health Plan? ........................................................... 39

¿Puede cambiar el Formulario (lista de medicamentos)? ........................................... 39

¿Cómo utilizo el Formulario? ...................................................................................... 39

¿Qué son los medicamentos genéricos? .................................................................... 40

¿Hay alguna restricción en mi cobertura? ................................................................... 40

¿Qué sucede si mi medicamento no está en el Formulario? ....................................... 41

¿Cómo solicito una excepción al formulario de SCAN Health Plan? ........................... 41

¿Qué debo hacer antes de poder hablar con mi médico sobre un cambio en mis medicamentos o solicitar una excepción? ................................................................... 41

Para obtener más información .................................................................................... 42

Formulario de SCAN Health Plan ................................................................................ 67

Medicamentos del formulario coordinados por la clase terapéutica ............................ 69

Medicamentos del formulario con límites de cantidad ................................................. 96

Índice .......................................................................................................................... 99

38

Esta página se dejó en blanco intencionalmente

39

¿Qué es el Formulario de SCAN Health Plan?

Un formulario es una lista de medicamentos cubiertos seleccionados por SCAN Health Plan en consulta con

un equipo de proveedores de atención médica, que representa las terapias prescritas que se cree son parte

necesaria de un programa de tratamiento de calidad. SCAN Health Plan 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 SCAN Health Plan y se sigan otras reglas

del plan. Para obtener más información sobre cómo surtir sus recetas, consulte su Evidencia de cobertura.

¿Puede cambiar el Formulario (lista de medicamentos)?

Por lo general, si usted toma un medicamento que aparece en nuestro formulario de 2018 que estaba cubierto

al inicio del año, no interrumpiremos ni reduciremos la cobertura del medicamento durante la cobertura de

2018, excepto cuando esté disponible un nuevo medicamento genérico más económico, o cuando se publique

nueva información adversa sobre la seguridad o eficacia de un medicamento. Otros tipos de cambios en el

formulario, como eliminar un medicamento de nuestro formulario, no afectarán a los miembros que toman el

medicamento actualmente. Permanecerá disponible al mismo gasto compartido para los miembros que lo

tomen durante el resto del año de cobertura. Creemos que es importante que tenga acceso continuo durante

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 escalonada a un medicamento o movemos un medicamento a un nivel de gasto

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 a partir de junio de 2018. Para obtener información actualizada acerca de los medicamentos cubiertos

por SCAN Health Plan, comuníquese con nosotros. Nuestra información de contacto aparece en la portada y

contraportada.

¿Cómo utilizo el Formulario?

Hay dos maneras de encontrar su medicamento en el formulario:

Afección médica

El formulario comienza en la página 69. Los medicamentos en este formulario están agrupados en

categorías dependiendo del tipo de afecciones médicas para el cual se utilizan. 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 69. Luego busque en el nombre de la categoría de su medicamento.

Lista alfabética

Si usted no está seguro de en qué categoría buscar, debe buscar su medicamento en el Índice que

inicia en la página 99. El Índice proporciona una lista en orden alfabético de todos los medicamentos

40

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.

¿Qué son los medicamentos genéricos?

SCAN Health Plan cubre tanto medicamentos de marca como medicamentos genéricos. Un medicamento

genérico es aprobado por la Administración de Alimentos y Medicamentos (Food and Drug Administration,

FDA) porque 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: SCAN Health Plan solicita que usted o su médico obtengan una autorización

previa para determinados medicamentos. Esto significa que necesitará obtener aprobación de SCAN

Health Plan antes de surtir sus recetas médicas. Si no obtiene la aprobación, es posible que SCAN

Health Plan no cubra el medicamento.

Límites de cantidad: Para determinados medicamentos, SCAN Health Plan limita la cantidad del

medicamento que SCAN Health Plan cubrirá. Por ejemplo, SCAN Health Plan proporciona 30 tabletas

por receta médica para Rozerem. Esto puede ser además de un suministro estándar para un mes o

tres meses.

Terapia escalonada: En algunos casos, SCAN Health Plan exige que primero pruebe determinados

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 SCAN Health Plan no cubra el medicamento B a menos que pruebe primero el

medicamento A. Si el medicamento A no funciona para usted, SCAN Health Plan cubrirá el

medicamento B.

Para averiguar si su medicamento tiene requisitos adicionales o límites, revise el formulario que comienza en

la página 69. También puede obtener más información acerca de las restricciones que se aplican a

medicamentos específicos cubiertos al visitar nuestro sitio web. Hemos publicado en línea documentos que

explican nuestras restricciones de autorización previa y terapia escalonada. También puede pedirnos que le

enviemos una copia. Nuestra información de contacto, junto con la fecha en que se actualizó el formulario por

última vez, aparece en la portada y contraportada.

Puede solicitar a SCAN Health Plan que haga una excepción a estas restricciones o límites, o una lista de

medicamentos similares que pueden tratar su afección médica. Consulte la sección “¿Cómo solicito una

excepción al formulario de SCAN Health Plan?” en la página 41 para obtener información sobre cómo solicitar

una excepción.

41

¿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 SCAN Health Plan no cubre su medicamento, tiene dos opciones:

Puede solicitar a Servicios para Miembros una lista de medicamentos similares que cubre SCAN

Health Plan. Cuando reciba la lista, muéstrela a su médico y pídale que le recete un medicamento

similar que esté cubierto por SCAN Health Plan.

Puede solicitar a SCAN Health Plan que 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 SCAN Health Plan?

Puede solicitar a SCAN Health Plan que haga una excepción a nuestras reglas de cobertura. Existen varios

tipos de excepciones que puede solicitar que hagamos.

Puede solicitarnos que cubramos un medicamento, incluso si no está incluido en nuestro formulario. Si

se aprueba, este medicamento estará cubierto con un nivel de gasto compartido predeterminado, y

usted no podrá solicitarnos que proporcionemos el medicamento a un nivel de gasto compartido

inferior.

Puede solicitarnos que cubramos un medicamento del formulario a un nivel de gasto compartido

inferior si este medicamento no está incluido en el nivel de especialidad. Si se aprueba, esto reducirá

el monto que debe pagar por su medicamento.

Puede solicitarnos que exoneremos las restricciones de cobertura o límites de su medicamento. Por

ejemplo, para determinados medicamentos, SCAN Health Plan 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, SCAN Health Plan solo aprobará su solicitud de excepción si los medicamentos alternativos

incluidos en el formulario del plan, el medicamento de gasto 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 en el plazo de 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 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

42

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 habla con su médico para determinar el curso correcto de acción para

usted, podemos cubrir su medicamento en determinados casos durante los primeros 90 días en que usted sea

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 estos medicamentos, incluso si ha sido un miembro del plan menos de 90 días.

Si usted es residente de un centro de atención a largo plazo, le permitiremos que surta su receta hasta que le

hayamos proporcionado un suministro de transición de al menos 91 días o hasta 98 días, consistente con el

aumento del despacho, (a menos que tenga una receta escrita para menos días). Cubriremos más de un

surtido de estos medicamentos dentro de los primeros 90 días de ser 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 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 que elimine 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 SCAN Health Plan,

consulte su Evidencia de cobertura y otros materiales del plan.

Si tiene alguna pregunta acerca de SCAN Health Plan, comuníquese con nosotros. Nuestra información de

contacto, junto con la fecha en que se actualizó el formulario por última vez, aparece en la portada y

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 de la semana. Los usuarios

de TTY deben llamar al 1-877-486-2048. O bien, visite http://www.medicare.gov.

43

Los cuadros a continuación enumeran 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.

SCAN Classic (HMO):

Condado de Los Angeles

Nivel

del

medica-

mento

Nombre del

nivel

Gasto

compartido

en

farmacia

minorista

preferida

y de

pedidos

por correo

(dentro de

la red)

(suministro

para 30

días)

Gasto

compartido

en farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 30

días)

Gasto

compartido

en farmacia

minorista

preferida

y de

pedidos por

correo

(dentro de

la red)

(suministro

para 60

días)

Gasto

compartido

en farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 60

días)

Gasto

compartido

en farmacia

minorista

preferida y

de pedidos

por correo

(dentro de

la red)

(suministro

para 90

días)

Gasto

compartido

en farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 90

días)

1 Genérico

preferido $0 $0 $0 $0 $0 $0

2 Genérico $5 $10 $10 $20 $10 $20

3 De marca

preferida $42 $47 $84 $94 $116 $131

4 Medicamento

no preferido $95 $100 $190 $200 $275 $290

5 Nivel de

especialidad 33 % 33 % N/A N/A N/A N/A

Consulte su Evidencia de cobertura para obtener información acerca de los costos en farmacias de Atención a

largo plazo (LTC) o farmacias fuera de la red.

El gasto compartido preferido es menor que el gasto compartido que puede estar disponible para usted para

determinados medicamentos cubiertos de la Parte D en determinadas farmacias de la red. Para obtener más

información, visite nuestro Directorio de farmacias de búsqueda en línea en www.scanhealthplan.com o llame

a Servicios para Miembros. Nuestra información de contacto aparece en la portada y contraportada.

44

Le proporcionamos cobertura adicional de medicamentos recetados en los niveles 1 y 2 de la Interrupción en

la cobertura. Consulte su Evidencia de cobertura para obtener más información acerca de esta cobertura.


Condado de Los Angeles

Nivel

del

medica-

mento

Nombre del

nivel

Gasto

compartido

en

farmacia

minorista

preferida

y de

pedidos

por correo

(dentro de

la red)

(suministro

para 30

días)

Gasto

compartido

en

farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 30

días)

Gasto

compartido

en

farmacia

minorista

preferida

y de

pedidos

por correo

(dentro de

la red)

(suministro

para 60

días)

Gasto

compartido

en

farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 60

días)

Gasto

compartido

en

farmacia

minorista

preferida y

de pedidos

por correo

(dentro de

la red)

(suministro

para 90

días)

Gasto

compartido

en

farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 90

días)

1 Genérico

preferido $0 $5 $0 $10 $0 $0

2 Genérico $5 $10 $10 $20 $10 $20

3 De marca

preferida $42 $47 $84 $94 $116 $131

4 Medicamento

no preferido $95 $100 $190 $200 $275 $290

5 Nivel de










45

SCAN Classic (HMO):

Condado de Orange

Nivel

del

medica-

mento

Nombre del

nivel

Gasto

compartido

en

farmacia

minorista

preferida y

de pedidos

por correo

(dentro de

la red)

(suministro

para 30

días)

Gasto

compartido

en

farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 30

días)

Gasto

compartido

en

farmacia

minorista

preferida

y de

pedidos

por correo

(dentro de

la red)

(suministro

para 60

días)

Gasto

compartido

en

farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 60

días)

Gasto

compartido

en

farmacia

minorista

preferida y

de pedidos

por correo

(dentro de

la red)

(suministro

para 90

días)

Gasto

compartido

en

farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 90

días)

1 Genérico

preferido $0 $0 $0 $0 $0 $0

2 Genérico $5 $10 $10 $20 $10 $20

3 De marca

preferida $42 $47 $84 $94 $116 $131

4 Medicamento

no preferido $95 $100 $190 $200 $275 $290

5 Nivel de










46

SCAN Classic (HMO):

Condados de Riverside y San Bernardino

Nivel

del

medica-

mento

Nombre del

nivel

Gasto

compartido

en

farmacia

minorista

preferida y

de pedidos

por correo

(dentro de

la red)

(suministro

para 30

días)

Gasto

compartido

en

farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 30

días)

Gasto

compartido

en

farmacia

minorista

preferida

y de

pedidos

por correo

(dentro de

la red)

(suministro

para 60

días)

Gasto

compartido

en

farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 60

días)

Gasto

compartido

en

farmacia

minorista

preferida y

de pedidos

por correo

(dentro de

la red)

(suministro

para 90

días)

Gasto

compartido

en

farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 90

días)

1 Genérico

preferido $0 $5 $0 $10 $0 $10

2 Genérico $7 $12 $14 $24 $14 $24

3 De marca

preferida $42 $47 $84 $94 $116 $131

4 Medicamento

no preferido $95 $100 $190 $200 $275 $290

5 Nivel de










47



Nivel

del

medica-

mento

Nombre del

nivel

Gasto

compartido

en

farmacia

minorista

preferida y

de pedidos

por correo

(dentro de

la red)

(suministro

para 30

días)

Gasto

compartido

en

farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 30

días)

Gasto

compartido

en

farmacia

minorista

preferida

y de

pedidos

por correo

(dentro de

la red)

(suministro

para 60

días)

Gasto

compartido

en

farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 60

días)

Gasto

compartido

en

farmacia

minorista

preferida y

de pedidos

por correo

(dentro de

la red)

(suministro

para 90

días)

Gasto

compartido

en

farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 90

días)

1 Genérico

preferido $2 $7 $4 $14 $4 $14

2 Genérico $7 $12 $14 $24 $14 $24

3 De marca

preferida $42 $47 $84 $94 $116 $131

4 Medicamento

no preferido $95 $100 $190 $200 $275 $290

5 Nivel de








Le proporcionamos cobertura adicional de medicamentos recetados en el nivel 1 de la Interrupción en la

cobertura. Consulte su Evidencia de cobertura para obtener más información acerca de esta cobertura.

48

Scripps Classic offered by SCAN Health Plan (HMO):

Condado de San Diego

Nivel

del

medica-

mento

Nombre del

nivel

Gasto

compartido

en

farmacia

minorista

preferida y

de pedidos

por correo

(dentro de

la red)

(suministro

para 30

días)

Gasto

compartido

en

farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 30

días)

Gasto

compartido

en

farmacia

minorista

preferida

y de

pedidos

por correo

(dentro de

la red)

(suministro

para 60

días)

Gasto

compartido

en

farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 60

días)

Gasto

compartido

en

farmacia

minorista

preferida y

de pedidos

por correo

(dentro de

la red)

(suministro

para 90

días)

Gasto

compartido

en

farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 90

días)

1 Genérico

preferido $0 $5 $0 $10 $0 $10

2 Genérico $5 $10 $10 $20 $10 $20

3 De marca

preferida $42 $47 $84 $94 $116 $131

4 Medicamento

no preferido $95 $100 $190 $200 $275 $290

5 Nivel de








49

Scripps Signature offered by SCAN Health Plan (HMO):


Nivel

del

medica-

mento

Nombre del

nivel

Gasto

compartido

en

farmacia

minorista

preferida y

de pedidos

por correo

(dentro de

la red)

(suministro

para 30

días)

Gasto

compartido

en

farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 30

días)

Gasto

compartido

en

farmacia

minorista

preferida

y de

pedidos

por correo

(dentro de

la red)

(suministro

para 60

días)

Gasto

compartido

en

farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 60

días)

Gasto

compartido

en

farmacia

minorista

preferida y

de pedidos

por correo

(dentro de

la red)

(suministro

para 90

días)

Gasto

compartido

en

farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 90

días)

1 Genérico

preferido $0 $5 $0 $10 $0 $10

2 Genérico $3 $8 $6 $16 $6 $16

3 De marca

preferida $42 $47 $84 $94 $116 $131

4 Medicamento

no preferido $95 $100 $190 $200 $275 $290

5 Nivel de










50

SCAN Classic (HMO):

Condado de Ventura

Nivel

del

medica-

mento

Nombre del

nivel

Gasto

compartido

en

farmacia

minorista

preferida y

de pedidos

por correo

(dentro de

la red)

(suministro

para 30

días)

Gasto

compartido

en

farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 30

días)

Gasto

compartido

en

farmacia

minorista

preferida

y de

pedidos

por correo

(dentro de

la red)

(suministro

para 60

días)

Gasto

compartido

en

farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 60

días)

Gasto

compartido

en

farmacia

minorista

preferida y

de pedidos

por correo

(dentro de

la red)

(suministro

para 90

días)

Gasto

compartido

en

farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 90

días)

1 Genérico

preferido $2 $7 $4 $14 $4 $14

2 Genérico $5 $12 $10 $24 $10 $24

3 De marca

preferida $42 $47 $84 $94 $116 $131

4 Medicamento

no preferido $95 $100 $190 $200 $275 $290

5 Nivel de








51

SCAN Classic (HMO):

Condados de San Francisco y Santa Clara

Nivel

del

medica-

mento

Nombre del

nivel

Gasto

compartido

en

farmacia

minorista

preferida y

de pedidos

por correo

(dentro de

la red)

(suministro

para 30

días)

Gasto

compartido

en

farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 30

días)

Gasto

compartido

en

farmacia

minorista

preferida

y de

pedidos

por correo

(dentro de

la red)

(suministro

para 60

días)

Gasto

compartido

en

farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 60

días)

Gasto

compartido

en

farmacia

minorista

preferida y

de pedidos

por correo

(dentro de

la red)

(suministro

para 90

días)

Gasto

compartido

en

farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 90

días)

1 Genérico

preferido $3 $8 $6 $16 $6 $16

2 Genérico $5 $10 $10 $20 $10 $20

3 De marca

preferida $42 $47 $84 $94 $116 $131

4 Medicamento

no preferido $95 $100 $190 $200 $275 $290

5 Nivel de








52

SCAN Classic (HMO):

Condado de Marin

Nivel

del

medica-

mento

Nombre del

nivel

Gasto

compartido

en

farmacia

minorista

preferida y

de pedidos

por correo

(dentro de

la red)

(suministro

para 30

días)

Gasto

compartido

en

farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 30

días)

Gasto

compartido

en

farmacia

minorista

preferida

y de

pedidos

por correo

(dentro de

la red)

(suministro

para 60

días)

Gasto

compartido

en

farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 60

días)

Gasto

compartido

en

farmacia

minorista

preferida y

de pedidos

por correo

(dentro de

la red)

(suministro

para 90

días)

Gasto

compartido

en

farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 90

días)

1 Genérico

preferido $0 $3 $0 $6 $0 $6

2 Genérico $2 $7 $4 $14 $4 $14

3 De marca

preferida $40 $45 $80 $90 $110 $125

4 Medicamento

no preferido $80 $85 $160 $170 $230 $245

5 Nivel de








53

SCAN Classic (HMO):

Condados de Napa y Sonoma

Nivel

del

medica-

mento

Nombre del

nivel

Gasto

compartido

en

farmacia

minorista

preferida y

de pedidos

por correo

(dentro de

la red)

(suministro

para 30

días)

Gasto

compartido

en

farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 30

días)

Gasto

compartido

en

farmacia

minorista

preferida

y de

pedidos

por correo

(dentro de

la red)

(suministro

para 60

días)

Gasto

compartido

en

farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 60

días)

Gasto

compartido

en

farmacia

minorista

preferida y

de pedidos

por correo

(dentro de

la red)

(suministro

para 90

días)

Gasto

compartido

en

farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 90

días)

1 Genérico

preferido $0 $5 $0 $10 $0 $10

2 Genérico $10 $15 $20 $30 $20 $30

3 De marca

preferida $42 $47 $84 $94 $116 $131

4 Medicamento

no preferido $95 $100 $190 $200 $275 $290

5 Nivel de








54

SCAN Healthy At Home (HMO SNP):

Condados de Los Angeles, Orange, Riverside y San Bernardino

Nivel

del

medica-

mento

Nombre del

nivel

Gasto

compartido

en

farmacia

minorista

preferida y

de pedidos

por correo

(dentro de

la red)

(suministro

para 30

días)

Gasto

compartido

en

farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 30

días)

Gasto

compartido

en

farmacia

minorista

preferida

y de

pedidos

por correo

(dentro de

la red)

(suministro

para 60

días)

Gasto

compartido

en

farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 60

días)

Gasto

compartido

en

farmacia

minorista

preferida y

de pedidos

por correo

(dentro de

la red)

(suministro

para 90

días)

Gasto

compartido

en

farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 90

días)

1 Genérico

preferido $0 $3 $0 $6 $0 $9

2 Genérico $5 $10 $10 $20 $15 $30

3 De marca

preferida $42 $47 $84 $94 $126 $141

4 Medicamento

no preferido $95 $100 $190 $200 $285 $300

5 Nivel de










55


Condado de Orange

Nivel

del

medica-

mento

Nombre del

nivel

Gasto

compartido

en

farmacia

minorista

preferida y

de pedidos

por correo

(dentro de

la red)

(suministro

para 30

días)

Gasto

compartido

en

farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 30

días)

Gasto

compartido

en

farmacia

minorista

preferida

y de

pedidos

por correo

(dentro de

la red)

(suministro

para 60

días)

Gasto

compartido

en

farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 60

días)

Gasto

compartido

en

farmacia

minorista

preferida y

de pedidos

por correo

(dentro de

la red)

(suministro

para 90

días)

Gasto

compartido

en

farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 90

días)

1 Genérico

preferido $0 $3 $0 $6 $0 $6

2 Genérico $2 $7 $4 $14 $4 $14

3 De marca

preferida $42 $47 $84 $94 $116 $131

4 Medicamento

no preferido $95 $100 $190 $200 $275 $290

5 Nivel de










56


Condado de Marin

Nivel

del

medica-

mento

Nombre del

nivel

Gasto

compartido

en

farmacia

minorista

preferida y

de pedidos

por correo

(dentro de

la red)

(suministro

para 30

días)

Gasto

compartido

en

farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 30

días)

Gasto

compartido

en

farmacia

minorista

preferida

y de

pedidos

por correo

(dentro de

la red)

(suministro

para 60

días)

Gasto

compartido

en

farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 60

días)

Gasto

compartido

en

farmacia

minorista

preferida y

de pedidos

por correo

(dentro de

la red)

(suministro

para 90

días)

Gasto

compartido

en

farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 90

días)

1 Genérico

preferido $0 $3 $0 $6 $0 $6

2 Genérico $2 $7 $4 $14 $4 $14

3 De marca

preferida $40 $45 $80 $90 $110 $125

4 Medicamento

no preferido $90 $95 $180 $190 $260 $275

5 Nivel de










57



Nivel

del

medica-

mento

Nombre del

nivel

Gasto

compartido

en

farmacia

minorista

preferida y

de pedidos

por correo

(dentro de

la red)

(suministro

para 30

días)

Gasto

compartido

en

farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 30

días)

Gasto

compartido

en

farmacia

minorista

preferida

y de

pedidos

por correo

(dentro de

la red)

(suministro

para 60

días)

Gasto

compartido

en

farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 60

días)

Gasto

compartido

en

farmacia

minorista

preferida y

de pedidos

por correo

(dentro de

la red)

(suministro

para 90

días)

Gasto

compartido

en

farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 90

días)

1 Genérico

preferido $0 $5 $0 $10 $0 $10

2 Genérico $7 $12 $14 $24 $14 $24

3 De marca

preferida $42 $47 $84 $94 $116 $131

4 Medicamento

no preferido $95 $100 $190 $200 $275 $290

5 Nivel de










58

Scripps Heart First offered by SCAN Health Plan (HMO SNP):


Nivel

del

medica-

mento

Nombre del

nivel

Gasto

compartido

en farmacia

minorista

preferida y

de pedidos

por correo

(dentro de

la red)

(suministro

para 30

días)

Gasto

compartido

en farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 30

días)

Gasto

compartido

en farmacia

minorista

preferida

y de

pedidos por

correo

(dentro de

la red)

(suministro

para 60

días)

Gasto

compartido

en farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 60

días)

Gasto

compartido

en farmacia

minorista

preferida y

de pedidos

por correo

(dentro de

la red)

(suministro

para 90

días)

Gasto

compartido

en farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 90

días)

1 Genérico

preferido $0 $5 $0 $10 $0 $10

2 Genérico $5 $10 $10 $20 $10 $20

3 De marca

preferida $42 $47 $84 $94 $116 $131

4 Medicamento

no preferido $95 $100 $190 $200 $275 $290

5 Nivel de










59



Nivel

del

medica-

mento

Nombre del

nivel

Gasto

compartido

en farmacia

minorista

preferida y

de pedidos

por correo

(dentro de

la red)

(suministro

para 30

días)

Gasto

compartido

en farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 30

días)

Gasto

compartido

en farmacia

minorista

preferida

y de

pedidos por

correo

(dentro de

la red)

(suministro

para 60

días)

Gasto

compartido

en farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 60

días)

Gasto

compartido

en farmacia

minorista

preferida y

de pedidos

por correo

(dentro de

la red)

(suministro

para 90

días)

Gasto

compartido

en farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 90

días)

1 Genérico

preferido $0 $5 $0 $10 $0 $10

2 Genérico $10 $15 $20 $30 $20 $30

3 De marca

preferida $42 $47 $84 $94 $116 $131

4 Medicamento

no preferido $95 $100 $190 $200 $275 $290

5 Nivel de










60


Condados de Los Angeles y Orange

Nivel

del

medica-

mento

Nombre del

nivel

Gasto

compartido

en farmacia

minorista

preferida y

de pedidos

por correo

(dentro de

la red)

(suministro

para 30

días)

Gasto

compartido

en farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 30

días)

Gasto

compartido

en farmacia

minorista

preferida

y de

pedidos por

correo

(dentro de

la red)

(suministro

para 60

días)

Gasto

compartido

en farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 60

días)

Gasto

compartido

en farmacia

minorista

preferida y

de pedidos

por correo

(dentro de

la red)

(suministro

para 90

días)

Gasto

compartido

en farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 90

días)

1 Genérico

preferido $0 $3 $0 $6 $0 $6

2 Genérico $2 $7 $4 $14 $4 $14

3 De marca

preferida $30 $35 $60 $70 $80 $95

4 Medicamento

no preferido $95 $100 $190 $200 $275 $290

5 Nivel de










61


Condado de Marin

Nivel

del

medica-

mento

Nombre del

nivel

Gasto

compartido

en farmacia

minorista

preferida y

de pedidos

por correo

(dentro de

la red)

(suministro

para 30

días)

Gasto

compartido

en farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 30

días)

Gasto

compartido

en farmacia

minorista

preferida

y de

pedidos por

correo

(dentro de

la red)

(suministro

para 60

días)

Gasto

compartido

en farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 60

días)

Gasto

compartido

en farmacia

minorista

preferida y

de pedidos

por correo

(dentro de

la red)

(suministro

para 90

días)

Gasto

compartido

en farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 90

días)

1 Genérico

preferido $0 $3 $0 $6 $0 $6

2 Genérico $2 $7 $4 $14 $4 $14

3 De marca

preferida $40 $45 $80 $90 $110 $125

4 Medicamento

no preferido $90 $95 $180 $190 $260 $275

5 Nivel de










62



Nivel

del

medica-

mento

Nombre del

nivel

Gasto

compartido

en farmacia

minorista

preferida y

de pedidos

por correo

(dentro de

la red)

(suministro

para 30

días)

Gasto

compartido

en farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 30

días)

Gasto

compartido

en farmacia

minorista

preferida

y de

pedidos por

correo

(dentro de

la red)

(suministro

para 60

días)

Gasto

compartido

en farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 60

días)

Gasto

compartido

en farmacia

minorista

preferida y

de pedidos

por correo

(dentro de

la red)

(suministro

para 90

días)

Gasto

compartido

en farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 90

días)

1 Genérico

preferido $0 $5 $0 $10 $0 $10

2 Genérico $10 $15 $20 $30 $20 $30

3 De marca

preferida $42 $47 $84 $94 $116 $131

4 Medicamento

no preferido $95 $100 $190 $200 $275 $290

5 Nivel de










63

SCAN Plus (HMO):

Condados de Los Angeles, Riverside, San Bernardino y San Francisco

Nivel

del

medica-

mento

Nombre del

nivel

Gasto

compartido

en farmacia

minorista

preferida y

de pedidos

por correo

(dentro de

la red)

(suministro

para 30

días)

Gasto

compartido

en farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 30

días)

Gasto

compartido

en farmacia

minorista

preferida

y de

pedidos por

correo

(dentro de

la red)

(suministro

para 60

días)

Gasto

compartido

en farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 60

días)

Gasto

compartido

en farmacia

minorista

preferida y

de pedidos

por correo

(dentro de

la red)

(suministro

para 90

días)

Gasto

compartido

en farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 90

días)

1 Genérico

preferido $0 $8.50 $0 $17 $0 $25.50

2 Genérico 25 % 25 % 25 % 25 % 25 % 25 %

3 De marca

preferida 25 % 25 % 25 % 25 % 25 % 25 %

4 Medicamento

no preferido 25 % 25 % 25 % 25 % 25 % 25 %

5 Nivel de








Si recibe “Ayuda adicional”, su parte del costo de los medicamentos recetados cubiertos puede variar con

base en el nivel de Ayuda adicional que reciba. Para obtener más información acerca de sus costos de

medicamentos, consulte la Clásula LIS (LIS Rider).

64

SCAN Plus (HMO):

Condado de Orange

Nivel

del

medica-

mento

Nombre del

nivel

Gasto

compartido

en farmacia

minorista

preferida y

de pedidos

por correo

(dentro de

la red)

(suministro

para 30

días)

Gasto

compartido

en farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 30

días)

Gasto

compartido

en farmacia

minorista

preferida

y de

pedidos por

correo

(dentro de

la red)

(suministro

para 60

días)

Gasto

compartido

en farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 60

días)

Gasto

compartido

en farmacia

minorista

preferida y

de pedidos

por correo

(dentro de

la red)

(suministro

para 90

días)

Gasto

compartido

en farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 90

días)

1 Genérico

preferido $0 $7.50 $0 $15 $0 $22.50

2 Genérico 25 % 25 % 25 % 25 % 25 % 25 %

3 De marca

preferida 25 % 25 % 25 % 25 % 25 % 25 %

4 Medicamento

no preferido 25 % 25 % 25 % 25 % 25 % 25 %

5 Nivel de








Si recibe “Ayuda adicional”, su parte del costo de los medicamentos recetados cubiertos puede variar con

base en el nivel de Ayuda adicional que reciba. Para obtener más información acerca de sus costos de

medicamentos, consulte la Clásula LIS (LIS Rider).

65

Scripps Plus offered by SCAN Health Plan (HMO):


Nivel

del

medica-

mento

Nombre del

nivel

Gasto

compartido

en farmacia

minorista

preferida y

de pedidos

por correo

(dentro de

la red)

(suministro

para 30

días)

Gasto

compartido

en farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 30

días)

Gasto

compartido

en farmacia

minorista

preferida

y de

pedidos por

correo

(dentro de

la red)

(suministro

para 60

días)

Gasto

compartido

en farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 60

días)

Gasto

compartido

en farmacia

minorista

preferida y

de pedidos

por correo

(dentro de

la red)

(suministro

para 90

días)

Gasto

compartido

en farmacia

minorista

estándar

(dentro de

la red)

(suministro

para 90

días)

1 Genérico

preferido $0 $6 $0 $12 $0 $18

2 Genérico 25 % 25 % 25 % 25 % 25 % 25 %

3 De marca

preferida 25 % 25 % 25 % 25 % 25 % 25 %

4 Medicamento

no preferido 25 % 25 % 25 % 25 % 25 % 25 %

5 Nivel de








Si recibe “Ayuda adicional”, su parte del costo de los medicamentos recetados cubiertos puede variar con base en el nivel de Ayuda adicional que reciba. Para obtener más información acerca de sus costos de medicamentos, consulte la Clásula LIS (LIS Rider).

66

El siguiente cuadro es únicamente para miembros que cumplen los requisitos para Medicare y Medi-Cal.

Enumera lo que pagará como su parte de los costos de medicamentos recetados cubiertos cuando se

encuentra en la Etapa de cobertura inicial. Para obtener información acerca de sus costos en la Etapa de

interrupción en la cobertura o la Etapa de cobertura catastrófica, consulte su Evidencia de cobertura.

Los copagos pueden variar con base en el nivel de Ayuda adicional que reciba. Comuníquese con Servicios

para Miembros para obtener más detalles. Nuestra información de contacto aparece en la portada y

contraportada.

SCAN Connections (HMO SNP) – Únicamente para miembros que cumplen los requisitos de Medicare

y Medi-Cal:

Condados de Los Angeles, Riverside y San Bernardino

SCAN Connections at Home (HMO SNP) – Únicamente para miembros que cumplen los requisitos de

Medicare y Medi-Cal:

Condados de Los Angeles, Riverside y San Bernardino

Nivel del

medicamento Nombre del nivel

Gasto compartido en farmacia

minorista preferida y de pedidos

por correo

(dentro de la red))

Gasto compartido

en farmacia minorista

estándar

(dentro de la red)

1

Genérico preferido

(Suministro para uno a tres

meses)

$0 $0 o $1.25 o $3.35

2

Genérico


meses)

Usted paga:

Para medicamentos genéricos (incluidos medicamentos de marca

tratados como genéricos), ya sea:

– $0 o $1.25 o $3.35

Para todos los otros medicamentos, ya sea:

– $0 o $3.70 u $8.35

3

De marca preferida


meses)

4

Medicamento no preferido


meses)

5

Nivel de especialidad

(Suministro para un mes

únicamente)





67



Formulario de SCAN Health Plan

El formulario que comienza en la página 69 proporciona información de cobertura sobre los medicamentos que

cubre SCAN Health Plan. Si tiene problemas para encontrar su medicamento en la lista, vaya al Índice que

comienza en la página 99.

La primera columna del cuadro muestra el nombre del medicamento. Los medicamentos de marca están en

mayúsculas (por ejemplo, JANUVIA) y los medicamentos genéricos están en minúsculas itálicas (por ejemplo,

metformin o metformina).

La información en la columna de Requisitos/límites le indica si SCAN Health Plan tiene algún requisito especial

para la cobertura de su medicamento.

o El símbolo [PA] indica que se necesita una autorización previa.

o 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.

o El símbolo [ST] indica que se aplica terapia escalonada.

o El símbolo [QL] indica que las cantidades despachadas están limitadas. Para saber la cantidad de límite

de cantidad para los medicamentos del formulario con límites de cantidad, consulte la página 96.

o El símbolo [90D] indica que el medicamento está disponible para un suministro para 90 días en

farmacias de pedido por correo y farmacias minoristas seleccionadas.

o El símbolo [LD] indica que se aplica la distribución limitada. Esta receta médica puede estar disponible únicamente en determinadas farmacias.

Para obtener más información consulte su Directorio de Farmacias o llame a Servicios para Miembros al 1-800-559-3500 (los miembros que cumplen los requisitos de Medicare y Medi-Cal deben llamar al 1-866-722-6725) de 8 a. m. a 8 p. m., los 7 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 (los mensajes recibidos en días festivos y fuera de nuestro horario hábil se responderán en el plazo de un día hábil). Los usuarios de TTY deben llamar al 711.

68

Esta página se dejó en blanco intencionalmente

[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 33.

69

FORMULARY DRUGS ARRANGED BY THERAPEUTIC CLASS

MEDICAMENTOS DEL FORMULARIO COORDINADOS POR LA CLASE TERAPÉUTICA

Formulary ID: 18423 (Version 12) Updated: 6/2018

ID de Formulario: 18423 (Versión 12) Actualizado: 6/2018

Drug Name Drug

Tier

Requirements/

Limits

Nombre del Medicamento Nivel Requisitos/

Límites

ANALGESICS

Opioid Analgesics, Long-acting

duramorph inj 2 [90D]

fentanyl patches 12mcg/hr, 25mcg/hr, 50mcg/hr, 75mcg/hr, 100mcg/hr

3 [QL] [90D]

methadone oral 2 [90D]

methadone inj 2 [90D]

morphine sulfate er tabs 3 [QL] [90D]

OXYCODONE ER 4 [QL] [90D]

OXYCONTIN 4 [QL] [90D]

oxymorphone er 3 [QL] [90D]

tramadol er tabs 2 [QL] [90D]

Opioid Analgesics, Short-acting

acetaminophen & codeine 2 [QL] [90D]

butorphanol tartrate inj 2 [90D]

butorphanol tartrate nasal 2 [QL] [90D]

codeine 2 [90D]

endocet 5-325mg, 7.5-325mg, 10-325mg

3 [QL] [90D]

fentanyl citrate lozenges 5 [PA]

hydrocodone & acetaminophen soln 7.5-325mg/15mL

2 [QL] [90D]

hydrocodone & acetaminophen tabs 5-325mg, 7.5-325mg, 10-325mg

2 [QL] [90D]

hydrocodone & ibuprofen 2 [QL] [90D]

hydromorphone immediate-release oral soln & tabs

2 [90D]

hydromorphone inj 3 [90D]

LAZANDA 5 [PA]

lorcet tabs 5-325mg 2 [QL] [90D]

lorcet hd tabs 10-325mg 2 [QL] [90D]

Drug Name Drug

Tier

Requirements/

Limits


Límites

lorcet plus tabs 7.5-325mg 2 [QL] [90D]

morphine sulfate oral 2 [90D]

oxycodone immediate-release

2 [90D]

oxycodone oral soln 2 [90D]

oxycodone & acetaminophen 2.5-325mg, 5-325mg, 7.5-325mg, 10-325mg

3 [QL] [90D]

oxycodone & aspirin 2 [QL] [90D]

oxycodone & ibuprofen 2 [QL] [90D]

tramadol 2 [90D]

tramadol & acetaminophen 2 [QL] [90D]

ANESTHETICS

Local Anesthetics

lidocaine hcl inj 2 [90D]

lidocaine ointment 3 [90D]

lidocaine patch 3 [PA] [90D]

lidocaine topical gel & solution

2 [90D]

lidocaine & prilocaine 2 [90D]

ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS

Alcohol Deterrents/Anti-Craving

acamprosate calcium dr 2 [90D]

disulfiram 2 [90D]

Opioid Dependence Treatments

buprenorphine inj 2 [90D]

buprenorphine oral 2 [90D]

buprenorphine & naloxone sublingual tabs

2 [90D]

naltrexone 2 [90D]

Opioid Reversal Agents

naloxone inj 2 [90D]

NARCAN 3 [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 67.

70

Drug Name Drug

Tier

Requirements/

Limits


Límites

Smoking Cessation Agents

bupropion sr 150mg 2 [90D]

CHANTIX 4 [ST] [90D]

CHANTIX STARTING & CONTINUING MONTH PAK

4 [ST] [90D]

NICOTROL INHALER 3 [90D]

NICOTROL NASAL 3 [90D]

ANTI-INFLAMMATORY AGENTS

Nonsteroidal Anti-inflammatory Drugs

celecoxib 3 [ST] [90D]

diclofenac potassium 1 [90D]

diclofenac sodium dr 1 [90D]

diclofenac sodium er 1 [90D]

diflunisal 2 [90D]

etodolac 2 [90D]

etodolac er 2 [90D]

ibu 1 [90D]

ibuprofen 1 [90D]

indomethacin er 2 [PA] [90D]

indomethacin ir caps 2 [PA] [90D]

ketorolac oral 2 [PA] [90D]

ketorolac inj 2 [PA] [90D]

meloxicam tabs 1 [90D]

nabumetone 2 [90D]

naproxen 1 [90D]

naproxen dr 1 [90D]

naproxen sodium ir 1 [90D]

piroxicam 2 [90D]

sulindac 2 [90D]

ANTIBACTERIALS

Aminoglycosides

amikacin inj 2 [90D]

gentamicin cream 0.1% & oint 0.1%

2 [90D]

gentamicin inj 40mg/mL 2 [90D]

gentamicin ophthalmic soln 0.3%

2 [90D]

neomycin sulfate oral 2 [90D]

paromomycin 2 [90D]

streptomycin inj 2 [90D]

Drug Name Drug

Tier

Requirements/

Limits


Límites

TOBRADEX OINT 3 [90D]

tobramycin ophthalmic solution

2 [90D]

tobramycin & dexamethasone ophthalmic suspension

2 [90D]

tobramycin sulfate inj 2 [90D]

Antibacterials, Other

bacitracin ointment 2 [90D]

bacitracin & polymyxin b ointment

2 [90D]

BACTROBAN CREAM 3 [90D]

BACTROBAN NASAL 3 [90D]

chloramphenicol sodium succinate inj

2 [90D]

CLEOCIN VAGINAL 3 [90D]

clindamycin oral 2 [90D]

clindamycin phosphate inj 2 [90D]

clindamycin topical cream, gel, lotion, soln & swab

2 [90D]

colistimethate inj 2 [90D]

CORTISPORIN CREAM & OINT

3 [90D]

daptomycin inj 5

linezolid inj 5

linezolid oral 5

methenamine hippurate 2 [90D]

metronidazole inj 2 [90D]

metronidazole oral 2 [90D]

metronidazole topical 3 [90D]

metronidazole vaginal 2 [90D]

mupirocin cream 3 [90D]

mupirocin ointment 2 [90D]

neomycin & bacitracin & polymyxin b ophthalmic

2 [90D]

neomycin & polymyxin & gramicidin ophthalmic

2 [90D]

nitrofurantoin caps 2 [90D]

polymyxin b sulfate & trimethoprim sulfate ophthalmic soln

2 [90D]

silver sulfadiazine 2 [90D]




71

Drug Name Drug

Tier

Requirements/

Limits


Límites

SIVEXTRO 5

ssd 2 [90D]

SYNERCID INJ 5

TIGECYCLINE INJ 5

trimethoprim 2 [90D]

TYGACIL INJ 5

vancomycin oral 5 [PA]

vancomycin inj 3 [90D]

vandazole 2 [90D]

XIFAXAN TABS 200MG 3 [PA] [90D]

XIFAXAN TABS 550MG 5 [PA]

Beta-lactam, Cephalosporins

cefaclor 2 [90D]

cefaclor er 2 [90D]

cefadroxil caps & tabs 2 [90D]

cefazolin inj 2 [90D]

cefdinir 2 [90D]

cefepime inj 2 [90D]

cefixime 2 [90D]

cefoxitin sodium 2 [90D]

cefpodoxime tabs 2 [90D]

cefprozil 2 [90D]

ceftazidime inj 1gm, 2gm & 6gm

2 [90D]

ceftriaxone inj 2 [90D]

cefuroxime oral 2 [90D]

cefuroxime inj 2 [90D]

cephalexin caps & tabs 250mg & 500mg

1 [90D]

cephalexin oral susp 1 [90D]

SUPRAX CAPS & CHEWABLE TABS

3 [90D]

SUPRAX ORAL SUSP 500MG/5ML

3 [90D]

tazicef inj 2 [90D]

TEFLARO INJ 5

ZERBAXA INJ 5

Beta-lactam, Other

aztreonam inj 1gm 2 [90D]

cilastatin/imipenem inj 2 [90D]

INVANZ INJ 4 [90D]

Drug Name Drug

Tier

Requirements/

Limits


Límites

meropenem inj 4 [90D]

Beta-lactam, Penicillins

amoxicillin 1 [90D]

amoxicillin & clavulanate potassium

2 [90D]

amoxicillin & clavulanate potassium er

2 [90D]

ampicillin & sulbactam inj 10-5gm, 2-1gm, & 1-0.5gm

2 [90D]

ampicillin inj 2 [90D]

ampicillin oral 2 [90D]

BICILLIN L-A INJ 3 [90D]

dicloxacillin sodium 2 [90D]

nafcillin sodium inj 4 [90D]

penicillin g inj 5 million units

2 [90D]

penicillin v potassium 2 [90D]

piperacillin/tazobactam inj 3 [90D]

ZOSYN GALAXY INJ 2GM/0.25GM & 3GM/0.375GM

4 [90D]

Macrolides

AZASITE 3 [90D]

azithromycin tabs & oral susp

2 [90D]

azithromycin inj 2 [90D]

clarithromycin 2 [90D]

clarithromycin er 2 [90D]

ERYTHROCIN LACTOBIONATE INJ

4 [90D]

erythrocin stearate 2 [90D]

erythromycin oral 2 [90D]

erythromycin ethylsuccinate tabs

2 [90D]

erythromycin ophthalmic oint

2 [90D]

erythromycin topical gel & soln

2 [90D]

Quinolones

CIPRO HC 3 [90D]

CIPRODEX 3 [90D]

ciprofloxacin inj 2 [90D]




72

Drug Name Drug

Tier

Requirements/

Limits


Límites

ciprofloxacin ophthalmic soln 0.3%

2 [90D]

ciprofloxacin oral susp 2 [90D]

ciprofloxacin tabs immediate-release

1 [90D]

ciprofloxacin tabs er 2 [90D]

levofloxacin inj 2 [90D]

levofloxacin oral soln 2 [90D]

levofloxacin tabs 1 [90D]

moxifloxacin oral 2 [90D]

moxifloxacin hcl ophthalmic

3 [90D]

ofloxacin oral 2 [90D]

ofloxacin ophthalmic 2 [90D]

ofloxacin otic 2 [90D]

Sulfonamides

sulfacetamide sodium ophthalmic oint & soln 10%

2 [90D]

sulfacetamide sodium topical susp 10%

2 [90D]

sulfacetamide sodium & prednisolone sodium phosphate ophthalmic

2 [90D]

sulfadiazine 2 [90D]

sulfamethoxazole & trimethoprim tabs

1 [90D]

sulfamethoxazole & trimethoprim ds tabs

1 [90D]

sulfamethoxazole & trimethoprim oral susp

2 [90D]

sulfamethoxazole & trimethoprim inj

2 [90D]

Tetracyclines

demeclocycline 3 [90D]

doxy 100 inj 2 [90D]

doxycycline immediate-release tabs, caps & oral susp

2 [90D]

minocycline ir 2 [90D]

morgidox 2 [90D]

tetracycline 2 [90D]

Drug Name Drug

Tier

Requirements/

Limits


Límites

ANTICONVULSANTS

Anticonvulsants, Other

BRIVIACT INJ 4 [90D]

BRIVIACT ORAL SOLN 4 [90D]

BRIVIACT TABS 5

FYCOMPA 4 [90D]

levetiracetam er 2 [90D]

levetiracetam oral 2 [90D]

levetiracetam inj 2 [90D]

roweepra 2 [90D]

roweepra xr 2 [90D]

SPRITAM 4 [90D]

Calcium Channel Modifying Agents

CELONTIN 4 [90D]

ethosuximide 2 [90D]

LYRICA 3 [PA] [90D]

zonisamide 2 [90D]

Gamma-aminobutyric Acid (GABA) Augmenting Agents

clonazepam 2 [90D]

clonazepam odt 2 [90D]

DIASTAT 3 [90D]

diazepam rectal 2 [90D]

divalproex sodium 2 [90D]

divalproex sodium dr 2 [90D]

divalproex sodium er 2 [90D]

gabapentin caps, tabs, & oral soln

2 [90D]

GABITRIL TABS 12MG & 16MG

4 [90D]

ONFI 4 [90D]

phenobarbital elixir 2 [PA] [90D]

phenobarbital tabs 2 [PA] [90D]

primidone 2 [90D]

SABRIL TABS 5 [LD]

tiagabine tabs 2 [90D]

valproate sodium inj 2 [90D]

valproic acid 2 [90D]

vigabatrin powder for oral soln

5 [LD]

Glutamate Reducing Agents

felbamate tabs 400mg 2 [90D]




73

Drug Name Drug

Tier

Requirements/

Limits


Límites

felbamate tabs 600mg 4 [90D]

felbamate oral susp 600mg/5ml

5

lamotrigine immediate-release tabs

2 [90D]

lamotrigine starter kit 4 [90D]

topiramate immediate-release

2 [90D]

Sodium Channel Agents

APTIOM 4 [90D]

BANZEL 4 [90D]

carbamazepine tabs, chewable tabs & oral susp

2 [90D]

carbamazepine er tabs & caps

3 [90D]

dilantin caps 100mg 2 [90D]

DILANTIN CAPS 30MG 3 [90D]

DILANTIN INFATABS 3 [90D]

DILANTIN SUSP 3 [90D]

epitol 2 [90D]

fosphenytoin sodium inj 2 [90D]

oxcarbazepine 2 [90D]

PEGANONE 4 [90D]

phenytoin chewable tabs 2 [90D]

phenytoin er 2 [90D]

phenytoin oral susp 2 [90D]

phenytoin inj 2 [90D]

TEGRETOL 3 [90D]

TEGRETOL XR 3 [90D]

TRILEPTAL 4 [90D]

VIMPAT ORAL 4 [90D]

VIMPAT INJ 4 [90D]

ANTIDEMENTIA AGENTS

Antidementia Agents, Other

ergoloid mesylates 3 [PA] [90D]

Cholinesterase Inhibitors

donepezil tabs 5mg & 10mg

2 [90D]

donepezil odt 2 [90D]

galantamine 2 [QL] [90D]

galantamine er 2 [QL] [90D]

Drug Name Drug

Tier

Requirements/

Limits


Límites

galantamine oral soln 2 [QL] [90D]

rivastigmine caps 3 [QL] [90D]

rivastigmine patches 4 [QL] [90D]

N-methyl-D-aspartate (NMDA) Receptor Antagonists

memantine hcl immediate release

2 [90D]

memantine hcl soln 2 [90D]

ANTIDEPRESSANTS

Antidepressants, Other

bupropion 2 [90D]

bupropion sr 2 [90D]

bupropion xl 2 [90D]

FORFIVO XL 3 [90D]

maprotiline 2 [90D]

mirtazapine 1 [90D]

mirtazapine odt 1 [90D]

nefazodone 2 [90D]

trazodone 1 [90D]

TRINTELLIX 4 [ST] [90D]

Monoamine Oxidase Inhibitors

EMSAM 4 [90D]

MARPLAN 4 [90D]

phenelzine 2 [90D]

tranylcypromine 2 [90D]

SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin & Norepinephrine Reuptake Inhibitors)

citalopram tabs 1 [90D]

citalopram oral soln 2 [90D]

DESVENLAFAXINE ER 4 [ST] [90D]

desvenlafaxine succinate er

3 [ST] [90D]

duloxetine hcl 3 [90D]

escitalopram 2 [90D]

FETZIMA 4 [ST] [90D]

FETZIMA TITRATION PACK

4 [ST] [90D]

fluoxetine hcl caps 10mg, 20mg & 40mg

2 [90D]




74

Drug Name Drug

Tier

Requirements/

Limits


Límites

fluoxetine hcl tabs 10mg & 20mg

2 [90D]

fluoxetine hcl oral soln 2 [90D]

fluvoxamine 2 [90D]

fluvoxamine er 2 [90D]

KHEDEZLA 4 [ST] [90D]

paroxetine hcl immediate-release

1 [90D]

paroxetine hcl er 2 [90D]

PAXIL 10MG/5ML SUSP 4 [90D]

sertraline tabs 1 [90D]

sertraline oral soln 2 [90D]

venlafaxine ir tabs 2 [90D]

venlafaxine er caps 2 [90D]

VIIBRYD 4 [ST] [90D]

VIIBRYD STARTER PACK 4 [ST] [90D]

Tricyclics

amitriptyline 2 [PA] [90D]

amoxapine 2 [90D]

clomipramine 4 [PA] [90D]

desipramine 2 [90D]

doxepin 2 [90D]

imipramine hcl tabs 2 [PA] [90D]

nortriptyline oral 2 [90D]

perphenazine & amitriptyline

2 [PA] [90D]

protriptyline 2 [90D]

trimipramine maleate 2 [PA] [90D]

ANTIEMETICS

Antiemetics, Other

compro 2 [90D]

meclizine 2 [90D]

phenadoz 3 [PA] [90D]

phenergan suppositories 3 [PA] [90D]

prochlorperazine inj 2 [90D]

prochlorperazine oral 2 [90D]

prochlorperazine suppositories

2 [90D]

promethazine inj 3 [PA] [90D]

promethazine suppositories

3 [PA] [90D]

promethazine syrup 2 [PA] [90D]

Drug Name Drug

Tier

Requirements/

Limits


Límites

promethazine tabs 12.5mg, 25mg & 50mg

2 [PA] [90D]

promethegan 3 [PA] [90D]

scopolamine patch 3 [90D]

Emetogenic Therapy Adjuncts

aprepitant caps 80mg & 125mg

4 [PA] [90D]

aprepitant pack 4 [PA] [90D]

dronabinol 4 [PA] [90D]

granisetron inj 2 [90D]

granisetron oral 2 [PA] [B vs D] [90D]

ondansetron odt 2 [PA] [B vs D] [90D]

ondansetron oral soln 2 [PA] [B vs D] [90D]

ondansetron inj 2 [90D]

ondansetron tabs 2 [PA] [B vs D] [90D]

ANTIFUNGALS

Antifungals

ABELCET INJ 5 [PA] [B vs D]

AMBISOME INJ 5 [PA] [B vs D]

amphotericin b inj 2 [PA] [B vs D] [90D]

caspofungin inj 5 [PA]

ciclopirox 8% nail soln 2 [90D]

ciclopirox cream, susp, shampoo

2 [90D]

clotrimazole 1% cream 2 [90D]

clotrimazole 1% topical soln

2 [90D]

clotrimazole troche 2 [90D]

CRESEMBA INJ 5 [PA]

CRESEMBA ORAL 5 [PA]

econazole nitrate 4 [90D]

fluconazole in sodium chloride inj

2 [90D]

fluconazole oral 2 [90D]

flucytosine 5

griseofulvin microsize 2 [90D]

itraconazole 4 [90D]




75

Drug Name Drug

Tier

Requirements/

Limits


Límites

ketoconazole tabs, cream, shampoo

2 [90D]

NATACYN 4 [90D]

NOXAFIL ORAL 5 [PA]

nyamyc 2 [90D]

nystatin 2 [90D]

nystatin & triamcinolone 3 [90D]

ORAVIG 4 [90D]

SPORANOX ORAL SOLN 4 [90D]

terbinafine 2 [90D]

terconazole 2 [90D]

voriconazole inj 2 [90D]

voriconazole oral 5

ANTIGOUT AGENTS

Antigout Agents

allopurinol tab 1 [90D]

COLCHICINE 4 [QL] [90D]

COLCRYS 4 [QL] [90D]

probenecid 2 [90D]

probenecid & colchicine 2 [90D]

ULORIC 3 [ST] [90D]

ANTIMIGRAINE AGENTS

Ergot Alkaloids

caffeine-ergotamine 4 [90D]

dihydroergotamine mesylate inj

5

migergot suppository 4 [90D]

Serotonin (5-HT) 1b/1d Receptor Agonists

naratriptan 2 [QL] [90D]

rizatriptan 2 [90D]

rizatriptan odt 2 [90D]

sumatriptan nasal 4 [90D]

sumatriptan succinate inj 4 [90D]

sumatriptan succinate oral 2 [90D]

zolmitriptan tabs 2 [90D]

zolmitriptan odt 2 [90D]

ZOMIG NASAL 4 [QL] [90D]

ANTIMYASTHENIC AGENTS

Parasympathomimetics

guanidine 2 [90D]

MESTINON SYRUP 3 [90D]

Drug Name Drug

Tier

Requirements/

Limits


Límites

pyridostigmine 2 [90D]

pyridostigmine er 2 [90D]

ANTIMYCOBACTERIALS

Antimycobacterials, Other

dapsone tabs 3 [90D]

rifabutin 4 [90D]

Antituberculars

CAPASTAT INJ 4 [90D]

ethambutol 2 [90D]

isoniazid oral 2 [90D]

PASER 4 [90D]

PRIFTIN 4 [90D]

pyrazinamide 2 [90D]

rifampin oral 2 [90D]

rifampin inj 2 [90D]

RIFATER 4 [90D]

SIRTURO 5

TRECATOR 4 [90D]

ANTINEOPLASTICS

Alkylating Agents

cyclophosphamide caps 2 [PA] [B vs D] [90D]

GLEOSTINE 4 [90D]

HEXALEN 5

LEUKERAN 3 [90D]

MATULANE 5

VALCHLOR 5 [PA]

Antiandrogens

bicalutamide 2 [90D]

ERLEADA 5 [PA]

flutamide 2 [90D]

nilutamide 5

XTANDI 5 [PA]

ZYTIGA 5 [PA]

Antiangiogenic Agents

POMALYST 5 [PA] [LD]

REVLIMID 5 [PA] [LD]

THALOMID 5 [PA]

Antiestrogens/Modifiers

EMCYT 3 [90D]




76

Drug Name Drug

Tier

Requirements/

Limits


Límites

FARESTON 3 [90D]

FASLODEX INJ 5

SOLTAMOX 3 [90D]

tamoxifen 2 [90D]

Antimetabolites

ALIMTA INJ 5 [PA]

hydroxyurea 2 [90D]

LONSURF 5 [PA]

mercaptopurine 2 [90D]

PURIXAN 5

TABLOID 4 [PA] [90D]

Antineoplastics, Other

azacitidine inj 5 [PA] [B vs D]

ERWINAZE INJ 5 [PA]

IBRANCE 5 [PA]

KISQALI 5 [PA]

KISQALI FEMARA CO-PACK

5 [PA]

leucovorin oral 2 [90D]

leucovorin inj 2 [90D]

levoleucovorin 50mg vial 4 [90D]

levoleucovorin 175mg vial 5

LYNPARZA 5 [PA]

MESNEX TABS 3 [90D]

mitoxantrone inj 2 [PA] [90D]

NERLYNX 5 [PA]

NINLARO 5 [PA]

paclitaxel inj 2 [90D]

RUBRACA 5 [PA] [LD]

RYDAPT 5 [PA]

SYLATRON INJ 5 [PA]

SYNRIBO INJ 5 [PA]

VELCADE INJ 5 [PA]

VENCLEXTA TABS 10MG & 50MG

4 [PA] [90D]

VENCLEXTA TABS 100MG

5 [PA]

VENCLEXTA STARTING PACK

5 [PA]

VERZENIO 5 [PA]

ZEJULA 5 [PA]

Drug Name Drug

Tier

Requirements/

Limits


Límites

Aromatase Inhibitors, 3rd Generation

anastrozole 2 [90D]

exemestane 3 [90D]

letrozole 2 [90D]

Enzyme Inhibitors

BELEODAQ 5 [PA]

etoposide inj 3 [90D]

FARYDAK 5 [PA]

ZOLINZA 5 [PA]

ZYDELIG 5 [PA]

Molecular Target Inhibitors

AFINITOR 5 [PA]

AFINITOR DISPERZ 5 [PA]

ALECENSA 5 [PA]

ALUNBRIG 5 [PA]

ALUNBRIG INITIATION PACK

5 [PA]

BOSULIF TAB 100MG 3 [PA] [90D]

BOSULIF TABS 400MG & 500MG

5 [PA]

CABOMETYX 5 [PA]

CALQUENCE 5 [PA]

CAPRELSA 5 [PA]

COMETRIQ 5 [PA]

COTELLIC 5 [PA]

ERIVEDGE 5 [PA]

GILOTRIF 5 [PA]

ICLUSIG 5 [PA]

IDHIFA 5 [PA]

imatinib 5 [PA]

IMBRUVICA 5 [PA]

INLYTA 5 [PA]

IRESSA 5 [PA]

JAKAFI 5 [PA]

LENVIMA 5 [PA]

MEKINIST 5 [PA]

NEXAVAR 5 [PA] [LD]

ODOMZO 5 [PA]

SPRYCEL 5 [PA]

STIVARGA 5 [PA]

SUTENT 5 [PA]




77

Drug Name Drug

Tier

Requirements/

Limits


Límites

TAFINLAR 5 [PA]

TAGRISSO 5 [PA]

TARCEVA 5 [PA]

TASIGNA 5 [PA]

TYKERB 5 [PA]

VOTRIENT 5 [PA]

XALKORI 5 [PA]

ZELBORAF 5 [PA]

ZYKADIA 5 [PA]

Monoclonal Antibody/Antibody-Drug Conjugate

AVASTIN INJ 5 [PA]

HERCEPTIN INJ 5 [PA]

KEYTRUDA INJ 5 [PA]

RITUXAN INJ 5 [PA]

RITUXAN HYCELA INJ 5 [PA]

YERVOY INJ 5 [PA]

Retinoids

bexarotene 5 [PA]

PANRETIN 5

TARGRETIN GEL 5 [PA]

tretinoin caps 5

ANTIPARASITICS

Anthelmintics

ALBENZA 4 [90D]

ivermectin 2 [90D]

Antiprotozoals

ALINIA 5

atovaquone 5

atovaquone/proguanil 2 [90D]

chloroquine 2 [90D]

COARTEM 3 [90D]

DARAPRIM 5 [PA]

hydroxychloroquine 2 [90D]

mefloquine 2 [90D]

NEBUPENT NEBULIZER 4 [PA] [B vs D] [90D]

PENTAM INJ 4 [90D]

PRIMAQUINE 3 [90D]

Drug Name Drug

Tier

Requirements/

Limits


Límites

quinine sulfate caps 324mg

3 [PA] [90D]

Pediculicides/Scabicides

EURAX 3 [90D]

malathion 2 [90D]

permethrin cream 2 [90D]

ANTIPARKINSON AGENTS

Anticholinergics

benztropine inj 2 [90D]

benztropine tabs 2 [PA] [90D]

trihexyphenidyl tabs 2 [PA] [90D]

trihexyphenidyl elixir 2 [PA] [90D]

Antiparkinson Agents, Other

amantadine 2 [90D]

entacapone 4 [90D]

Dopamine Agonists

APOKYN INJ 5 [PA]

bromocriptine 2 [90D]

NEUPRO PATCH 4 [QL] [90D]

pramipexole ir 2 [90D]

ropinirole 2 [90D]

Dopamine Precursors/L-Amino Acid Decarboxylase Inhibitors

carbidopa 4 [90D]

carbidopa & levodopa 2 [90D]

carbidopa & levodopa er 2 [90D]

carbidopa & levodopa odt 2 [90D]

carbidopa & levodopa & entacapone

4 [90D]

Monoamine Oxidase B (MAO-B) Inhibitors

rasagiline 4 [90D]

selegiline 2 [90D]

ANTIPSYCHOTICS

1st Generation/Typical

chlorpromazine oral 4 [90D]

chlorpromazine inj 4 [90D]

fluphenazine oral 2 [90D]

fluphenazine decanoate inj 2 [90D]

fluphenazine inj 2 [90D]

haloperidol tabs 2 [90D]

haloperidol decanoate inj 2 [90D]




78

Drug Name Drug

Tier

Requirements/

Limits


Límites

haloperidol lactate oral soln

2 [90D]

haloperidol lactate inj 2 [90D]

loxapine 2 [90D]

perphenazine 2 [90D]

pimozide 2 [90D]

thioridazine 2 [PA] [90D]

thiothixene 2 [90D]

trifluoperazine 2 [90D]

2nd Generation/Atypical

ABILIFY MAINTENA 5

aripiprazole odt 3 [ST] [90D]

aripiprazole soln 1mg/ml 3 [90D]

aripiprazole tabs 2mg, 5mg, 10mg, & 15mg

3 [ST] [90D]

aripiprazole tabs 20mg & 30mg

5 [ST]

ARISTADA INJ 5

FANAPT 4 [ST] [90D]

FANAPT TITRATION PACK

4 [ST] [90D]

GEODON INJ 3 [90D]

INVEGA SUSTENNA INJ 39MG & 78MG

4 [90D]

INVEGA SUSTENNA INJ 117MG, 156MG, & 234MG

5

INVEGA TRINZA INJ 5

LATUDA 5 [ST]

NUPLAZID 5 [PA]

olanzapine tabs 2 [90D]

olanzapine odt 2 [90D]

olanzapine inj 10mg 2 [90D]

paliperidone er 5 [ST]

quetiapine 2 [90D]

quetiapine er tabs 3 [ST] [90D]

REXULTI 5 [ST]

RISPERDAL CONSTA INJ 12.5MG & 25MG

4 [90D]

RISPERDAL CONSTA INJ 37.5MG & 50MG

5

risperidone 2 [90D]

risperidone odt 2 [90D]

Drug Name Drug

Tier

Requirements/

Limits


Límites

SAPHRIS 4 [ST] [90D]

SEROQUEL XR 4 [ST] [90D]

VRAYLAR CAPSULES 5 [ST]

VRAYLAR DOSE PACK 4 [ST] [90D]

ziprasidone oral 2 [90D]

ZYPREXA RELPREVV 210MG INJ

4 [90D]

Treatment-Resistant

clozapine 2 [90D]

clozapine odt 4 [90D]

FAZACLO 4 [90D]

VERSACLOZ 4 [90D]

ANTISPASTICITY AGENTS

Antispasticity Agents

baclofen 2 [90D]

tizanidine 2 [90D]

ANTIVIRALS

Anti-cytomegalovirus (CMV) Agents

ganciclovir inj 2 [PA] [B vs D] [90D]

valganciclovir tabs 5

ZIRGAN 4 [90D]

Anti-hepatitis B (HBV) Agents

adefovir dipivoxil 5

BARACLUDE ORAL SOLN 0.05MG/ML

4 [90D]

entecavir tabs 5

EPIVIR HBV SOLN 5MG/ML

4 [90D]

INTRON-A INJ 4 [90D]

lamivudine tabs 100mg 2 [90D]

Anti-hepatitis C (HCV) Agents, Direct Acting Agents

EPCLUSA 5 [PA]

HARVONI 5 [PA]

Anti-hepatitis C (HCV) Agents, Other

moderiba 200mg tabs 3 [90D]

moderiba dose pack 5

PEGASYS INJ 5

PEGASYS PROCLICK INJ 5

ribasphere 3 [90D]

ribasphere ribapak 5




79

Drug Name Drug

Tier

Requirements/

Limits


Límites

ribavirin 3 [90D]

Antiherpetic Agents

acyclovir oral 2 [90D]

acyclovir oint 5% 4 [90D]

acyclovir inj 2 [PA] [B vs D] [90D]

DENAVIR 3 [90D]

famciclovir 2 [90D]

trifluridine 2 [90D]

valacyclovir 2 [90D]

XERESE 3 [90D]

ZOVIRAX CREAM 5

Anti-HIV Agents, Integrase Inhibitors (INSTI)

BIKTARVY 5

GENVOYA 5

ISENTRESS CHEW TABS 3 [90D]

ISENTRESS ORAL POWDER

3 [90D]

ISENTRESS TABS 5

ISENTRESS HD TABS 5

JULUCA 5

STRIBILD 5

TIVICAY 10MG & 25MG TABS

4 [90D]

TIVICAY 50MG TAB 5

Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)

ATRIPLA 5

COMPLERA 5

EDURANT 5

efavirenz caps 4 [90D]

efavirenz tab 5

INTELENCE 25MG TAB 4 [90D]

INTELENCE 100MG & 200MG TABS

5

nevirapine er 2 [90D]

nevirapine tabs 2 [90D]

ODEFSEY 5

RESCRIPTOR 3 [90D]

SUSTIVA 200MG CAPS 4 [90D]

SUSTIVA 600MG TABS 5

Drug Name Drug

Tier

Requirements/

Limits


Límites

SYMFI LO 5

VIRAMUNE ORAL SUSP 3 [90D]

VIRAMUNE TABS 4 [90D]

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI)

abacavir soln 4 [90D]

abacavir tabs 2 [90D]

abacavir & lamivudine 5

abacavir & lamivudine & zidovudine

5

DESCOVY 5

didanosine 2 [90D]

EMTRIVA 4 [90D]

lamivudine tabs 150mg & 300mg

2 [90D]

lamivudine soln 2 [90D]

lamivudine & zidovudine 2 [90D]

RETROVIR IV INJ 4 [90D]

stavudine caps 2 [90D]

tenofovir disoproxil fumarate tabs

5

TRIUMEQ 5

TRUVADA 5

VIDEX EC 125MG 3 [90D]

VIDEX PEDIATRIC SOLN 4 [90D]

VIREAD TABS 5

VIREAD POWDER 4 [90D]

ZERIT SOLN 3 [90D]

ZIAGEN SOLN 4 [90D]

zidovudine 2 [90D]

Anti-HIV Agents, Other

FUZEON INJ 3 [90D]

SELZENTRY SOLN 4 [90D]

SELZENTRY 25MG & 75MG

4 [90D]

SELZENTRY 150MG & 300MG

5

TYBOST 3 [90D]

Anti-HIV Agents, Protease Inhibitors

APTIVUS 5




80

Drug Name Drug

Tier

Requirements/

Limits


Límites

atazanavir sulfate caps 150mg & 200mg

4 [90D]

atazanavir sulfate caps 300mg

5

CRIXIVAN 3 [90D]

EVOTAZ 5

fosamprenavir tabs 5

INVIRASE 4 [90D]

KALETRA TABS 100-25MG

4 [90D]

KALETRA TABS 200-50MG

5

LEXIVA ORAL SUSP 4 [90D]

lopinavir & ritonavir soln 4 [90D]

NORVIR 4 [90D]

PREZCOBIX 5

PREZISTA SUSP 100MG/ML

4 [90D]

PREZISTA TABS 75MG & 150MG

4 [90D]

PREZISTA TABS 600MG & 800MG

5

REYATAZ CAPS & ORAL POWDER

5

ritonavir tabs 4 [90D]

VIRACEPT 5

Anti-influenza Agents

oseltamivir caps 2 [90D]

oseltamivir susp 3 [90D]

RELENZA DISKHALER 3 [90D]

rimantadine 2 [90D]

ANXIOLYTICS

Anxiolytics, Other

buspirone 2 [90D]

meprobamate 4 [PA] [90D]

Benzodiazepines

alprazolam tabs 2 [PA] [90D]

alprazolam er tabs 2 [PA] [90D]

alprazolam intensol 2 [PA] [90D]

clorazepate 2 [PA] [90D]

diazepam tabs & soln 2 [PA] [90D]

diazepam intensol 2 [PA] [90D]

Drug Name Drug

Tier

Requirements/

Limits


Límites

lorazepam tabs 2 [90D]

lorazepam intensol 2 [90D]

oxazepam 2 [PA] [90D]

BIPOLAR AGENTS

Mood Stabilizers

lithium carbonate 2 [90D]

lithium carbonate er 2 [90D]

lithium citrate 2 [90D]

BLOOD GLUCOSE REGULATORS

Antidiabetic Agents

acarbose 2 [90D]

BYDUREON BCISE INJ 3 [PA] [90D]

BYDUREON INJ 3 [PA] [90D]

BYETTA INJ 3 [PA] [90D]

CYCLOSET 3 [90D]

FARXIGA 3 [ST] [90D]

glimepiride 1 [90D]

glimepiride & pioglitazone 2 [QL] [90D]

glipizide 1 [90D]

glipizide & metformin tabs 1 [90D]

glipizide er 1 [90D]

INVOKAMET 3 [ST] [90D]

INVOKAMET XR 3 [ST] [90D]

INVOKANA 3 [ST] [90D]

JANUMET 3 [90D]

JANUMET XR 3 [90D]

JANUVIA 3 [90D]

KOMBIGLYZE XR 3 [90D]

metformin 1 [90D]

metformin er uncoated tabs 500mg & 750mg

1 [90D]

nateglinide 2 [90D]

ONGLYZA 3 [90D]

OZEMPIC 3 [PA] [90D]

pioglitazone 1 [90D]

pioglitazone & metformin 2 [90D]

repaglinide 2 [90D]

SYMLINPEN INJ 3 [PA] [90D]

VICTOZA INJ 3 [PA] [90D]

XIGDUO XR 3 [ST] [90D]




81

Drug Name Drug

Tier

Requirements/

Limits


Límites

Glycemic Agents

GLUCAGON EMERGENCY KIT INJ

3 [90D]

PROGLYCEM 4 [90D]

Insulins

HUMALOG CARTRIDGE INJ

3 [90D]

HUMALOG JUNIOR KWIKPEN INJ

3 [90D]

HUMALOG KWIKPEN INJ 3 [90D]

HUMALOG MIX 50/50 KWIKPEN INJ

3 [90D]

HUMALOG MIX 75/25 KWIKPEN INJ

3 [90D]

HUMALOG MIX 50/50 VIAL INJ

3 [90D]

HUMALOG MIX 75/25 VIAL INJ

3 [90D]

HUMALOG VIAL INJ 3 [90D]

HUMULIN 70/30 KWIKPEN INJ

3 [90D]

HUMULIN 70/30 VIAL INJ 3 [90D]

HUMULIN N KWIKPEN INJ

3 [90D]

HUMULIN N VIAL INJ 3 [90D]

HUMULIN R U-500 (CONCENTRATED) KWIKPEN INJ

3 [90D]

HUMULIN R U-500 (CONCENTRATED) VIAL INJ

3 [90D]

HUMULIN R VIAL INJ 3 [90D]

LANTUS SOLOSTAR PEN INJ

3 [90D]

LANTUS VIAL INJ 3 [90D]

TOUJEO SOLOSTAR 3 [90D]

BLOOD PRODUCTS/ MODIFIERS/ VOLUME EXPANDERS

Anticoagulants

COUMADIN ORAL 3 [90D]

ELIQUIS 3 [90D]

ELIQUIS STARTER PACK 3 [90D]

Drug Name Drug

Tier

Requirements/

Limits


Límites

enoxaparin inj 4 [90D]

fondaparinux inj 2.5mg/0.5ml & 5mg/0.4ml

4 [90D]

fondaparinux inj 7.5mg/0.6ml & 10mg/0.8ml

5

heparin inj 2 [PA] [B vs D] [90D]

jantoven 1 [90D]

PRADAXA 4 [90D]

warfarin 1 [90D]

XARELTO 3 [90D]

XARELTO STARTER PACK

3 [90D]

Blood Formation Modifiers

anagrelide 2 [90D]

LEUKINE INJ 5 [PA]

MOZOBIL INJ 5 [PA]

NEUPOGEN INJ 5 [PA]

PROCRIT INJ 2000UNIT/ML

3 [PA] [90D]

PROCRIT INJ 3000UNIT/ML, 4000UNIT/ML & 10000UNIT/ML

4 [PA] [90D]

PROCRIT INJ 20000UNIT/ML & 40000UNIT/ML

5 [PA]

PROMACTA 5 [PA] [LD]

Hemostasis Agents

tranexamic acid inj 2 [90D]

tranexamic acid tabs 2 [90D]

Platelet Modifying Agents

BRILINTA 3 [QL] [90D]

cilostazol 2 [90D]

clopidogrel tabs 75mg 2 [90D]

dipyridamole er & aspirin 3 [QL] [90D]

dipyridamole oral 2 [PA] [90D]

CARDIOVASCULAR AGENTS

Alpha-adrenergic Agonists

clonidine patches 3 [90D]




82

Drug Name Drug

Tier

Requirements/

Limits


Límites

clonidine tabs immediate-release

1 [90D]

guanfacine 2 [90D]

methyldopa 2 [PA] [90D]

methyldopa & hydrochlorothiazide

2 [PA] [90D]

methyldopate inj 2 [90D]

midodrine tabs 2 [90D]

Alpha-adrenergic Blocking Agents

doxazosin 2 [90D]

prazosin 2 [90D]

terazosin 1 [90D]

Angiotensin-converting Enzyme (ACE) Inhibitors

benazepril 1 [90D]

benazepril & hydrochlorothiazide

1 [90D]

captopril 1 [90D]

captopril & hydrochlorothiazide

1 [90D]

enalapril 1 [90D]

enalapril & hydrochlorothiazide

1 [90D]

fosinopril 1 [90D]

fosinopril & hydrochlorothiazide

1 [90D]

lisinopril 1 [90D]

lisinopril & hydrochlorothiazide

1 [90D]

moexipril 1 [90D]

moexipril & hydrochlorothiazide

1 [90D]

perindopril 1 [90D]

quinapril 1 [90D]

quinapril & hydrochlorothiazide

1 [90D]

ramipril 1 [90D]

trandolapril 1 [90D]

Angiotensin II Receptor Antagonists

irbesartan 1 [90D]

irbesartan hct 1 [90D]

losartan 1 [90D]

Drug Name Drug

Tier

Requirements/

Limits


Límites

losartan hct 1 [90D]

olmesartan 2 [90D]

olmesartan & amlodipine 2 [ST] [90D]

olmesartan hct 2 [90D]

valsartan 1 [90D]

valsartan hct 1 [90D]

valsartan & amlodipine 1 [90D]

valsartan & amlodipine & hct

2 [ST] [90D]

Antiarrhythmics

amiodarone tabs 2 [90D]

disopyramide phosphate 2 [PA] [90D]

dofetilide 2 [90D]

flecainide acetate 2 [90D]

mexiletine 2 [90D]

pacerone tabs 200mg 2 [90D]

procainamide inj 2 [90D]

propafenone 2 [90D]

quinidine gluconate cr 4 [90D]

quinidine gluconate inj 4 [90D]

quinidine sulfate 2 [90D]

sorine 2 [90D]

sotalol tabs 2 [90D]

Beta-adrenergic Blocking Agents

acebutolol 2 [90D]

atenolol 1 [90D]

atenolol & chlorthalidone 1 [90D]

bisoprolol 2 [90D]

bisoprolol & hydrochlorothiazide

2 [90D]

BYSTOLIC 4 [90D]

carvedilol 1 [90D]

carvedilol phosphate er 3 [90D]

DUTOPROL 3 [90D]

labetalol oral 2 [90D]

labetalol inj 2 [90D]

metoprolol succinate er 2 [90D]

metoprolol tartrate tabs 1 [90D]

metoprolol & hydrochlorothiazide

2 [90D]

nadolol 2 [90D]




83

Drug Name Drug

Tier

Requirements/

Limits


Límites

nadolol & bendroflumethiazide

2 [90D]

pindolol 2 [90D]

propranolol ir tabs 1 [90D]

propranolol er caps 2 [90D]

propranolol oral soln 2 [90D]

propranolol inj 2 [90D]

propranolol & hydrochlorothiazide

1 [90D]

timolol oral 1 [90D]

Calcium Channel Blocking Agents

afeditab cr 2 [90D]

amlodipine 1 [90D]

amlodipine & atorvastatin 2 [90D]

amlodipine & benazepril 1 [90D]

cartia xt 2 [90D]

diltiazem tabs 2 [90D]

diltiazem cd caps 2 [90D]

diltiazem er caps 2 [90D]

diltiazem inj 50mg/10ml 2 [90D]

dilt-xr 2 [90D]

felodipine er 2 [90D]

isradipine 2 [90D]

nicardipine caps 2 [90D]

nifedipine 2 [PA] [90D]

nifedipine er 2 [90D]

nimodipine caps 4 [90D]

nisoldipine er 2 [90D]

taztia xt 2 [90D]

verapamil ir 1 [90D]

verapamil er 2 [90D]

verapamil sr 2 [90D]

verapamil inj 2 [90D]

Cardiovascular Agents, Other

CORLANOR 4 [PA] [90D]

DEMSER 5 [PA]

digitek 2 [PA] [90D]

digox 2 [PA] [90D]

digoxin oral 2 [PA] [90D]

digoxin inj 2 [PA] [90D]

ENTRESTO 4 [PA] [90D]

Drug Name Drug

Tier

Requirements/

Limits


Límites

LANOXIN INJ 3 [PA] [90D]

LANOXIN ORAL 3 [PA] [90D]

NORTHERA 5 [PA]

pentoxifylline er 2 [90D]

RANEXA 3 [PA] [90D]

REPATHA INJ 5 [PA]

TEKTURNA 3 [ST] [90D]

TEKTURNA HCT 3 [ST] [90D]

Diuretics, Loop

bumetanide oral 2 [90D]

furosemide oral 1 [90D]

furosemide inj 2 [90D]

torsemide oral 2 [90D]

Diuretics, Potassium-sparing

amiloride 2 [90D]

amiloride & hydrochlorothiazide

1 [90D]

eplerenone 3 [90D]

spironolactone 1 [90D]

spironolactone & hydrochlorothiazide

1 [90D]

triamterene & hydrochlorothiazide

1 [90D]

Diuretics, Thiazide

chlorothiazide tabs 2 [90D]

chlorthalidone 1 [90D]

hydrochlorothiazide 1 [90D]

indapamide 1 [90D]

metolazone 2 [90D]

Dyslipidemics, Fibric Acid Derivatives

fenofibrate caps 43mg & 130mg

2 [QL] [90D]

fenofibrate micronized 2 [QL] [90D]

fenofibrate tabs 48mg, 54mg, 145mg, 160mg

2 [QL] [90D]

fenofibric acid dr caps 3 [QL] [90D]

fenofibric acid tabs 2 [90D]

gemfibrozil 2 [90D]

Dyslipidemics, HMG CoA Reductase Inhibitors

atorvastatin 1 [90D]

lovastatin 1 [90D]




84

Drug Name Drug

Tier

Requirements/

Limits


Límites

pravastatin 1 [90D]

rosuvastatin 2 [ST] [90D]

simvastatin 1 [90D]

Dyslipidemics, Other

cholestyramine 2 [90D]

cholestyramine light 2 [90D]

colestipol granules 2 [90D]

colestipol tabs 2 [90D]

ezetimibe 3 [90D]

JUXTAPID 5 [PA] [LD]

KYNAMRO 5 [PA] [LD]

niacin er tabs 3 [QL] [90D]

omega-3-acid ethyl esters 3 [90D]

prevalite 2 [90D]

WELCHOL 4 [90D]

Vasodilators, Direct-acting Arterial

hydralazine oral 2 [90D]

hydralazine inj 2 [90D]

minoxidil 2 [90D]

Vasodilators, Direct-acting Arterial/Venous

isosorbide dinitrate 2 [90D]

isosorbide dinitrate er 2 [90D]

isosorbide mononitrate 2 [90D]

isosorbide mononitrate er 2 [90D]

minitran patches 2 [90D]

nitro-bid oint 2 [90D]

NITRO-DUR PATCHES 3 [90D]

nitroglycerin inj 2 [90D]

nitroglycerin lingual 2 [90D]

nitroglycerin patches 2 [90D]

nitroglycerin sublingual 2 [90D]

CENTRAL NERVOUS SYSTEM AGENTS

Attention Deficit Hyperactivity Disorder Agents, Amphetamines

amphetamine & dextroamphetamine tabs

2 [QL] [90D]

dextroamphetamine sulfate

2 [QL] [90D]

dextroamphetamine sulfate er

2 [QL] [90D]

zenzedi tabs 5mg & 10mg 2 [QL] [90D]

Drug Name Drug

Tier

Requirements/

Limits


Límites

Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines

atomoxetine 3 [PA] [90D]

clonidine er 2 [PA] [90D]

dexmethylphenidate ir tabs 2 [90D]

metadate er 2 [90D]

methylphenidate er tabs 10mg & 20mg

2 [90D]

methylphenidate ir tabs 5mg, 10mg & 20mg

2 [90D]

Central Nervous System, Other

AUSTEDO 5 [PA]

HETLIOZ 5 [PA]

NUEDEXTA 3 [90D]

riluzole 3 [90D]

Fibromyalgia Agents

SAVELLA 3 [90D]

SAVELLA TITRATION PACK

3 [90D]

Multiple Sclerosis Agents

AMPYRA 5 [PA]

AUBAGIO 5 [PA]

AVONEX INJ 5 [PA]

AVONEX PEN INJ 5 [PA]

BETASERON INJ 5

COPAXONE INJ 40MG/ML

5 [PA]

GILENYA 5 [PA]

glatiramer acetate inj 5 [PA]

glatopa inj 5 [PA]

PLEGRIDY INJ 5 [PA]

PLEGRIDY STARTER PACK INJ

5 [PA]

REBIF INJ 5 [PA]

REBIF REBIDOSE INJ 5 [PA]

REBIF REBIDOSE TITRATION PACK INJ

5 [PA]

REBIF TITRATION PACK INJ

5 [PA]

TECFIDERA 5 [PA] [LD]

TECFIDERA STARTER PACK

5 [PA] [LD]




85

Drug Name Drug

Tier

Requirements/

Limits


Límites

TYSABRI INJ 5 [PA]

DENTAL AND ORAL AGENTS

Dental and Oral Agents

cevimeline 3 [90D]

chlorhexidine gluconate 2 [90D]

pilocarpine tabs 3 [90D]

triamcinolone in orabase 2 [90D]

DERMATOLOGICAL AGENTS

Dermatological Agents

acitretin 5 [PA]

adapalene 4 [90D]

ammonium lactate topical 2 [90D]

amnesteem caps 4 [90D]

calcipotriene cream & oint 4 [QL] [90D]

calcipotriene soln 4 [90D]

calcipotriene & betamethasone oint

4 [90D]

CARAC 5

claravis 4 [90D]

clindamycin & benzoyl peroxide topical

2 [90D]

COSENTYX 5 [PA]

COSENTYX SENSOREADY PEN

5 [PA]

diclofenac sodium gel 1% 3 [90D]

diclofenac sodium gel 3% 5 [PA]

doxepin cream 5% 3 [90D]

ELIDEL 4 [QL] [90D]

FLUOROURACIL 0.5% CREAM

5

fluorouracil 2% and 5% topical

3 [90D]

imiquimod 3 [90D]

isotretinoin caps 4 [90D]

methoxsalen 5

myorisan 4 [90D]

podofilox 2 [90D]

prudoxin 3 [90D]

REGRANEX 5 [QL]

SANTYL 3 [90D]

selenium sulfide lotion 2 [90D]

Drug Name Drug

Tier

Requirements/

Limits


Límites

STELARA INJ 45MG/0.5ML, 90MG/ML

5 [PA]

tacrolimus oint 3 [90D]

tazarotene 4 [90D]

TAZORAC 0.05% CREAM 4 [90D]

TAZORAC GEL 4 [QL] [90D]

TOLAK 3 [90D]

tretinoin cream, gel 3 [PA] [90D]

zenatane 4 [90D]

ZONALON 3 [90D]

ELECTROLYTES/MINERALS/METALS/ VITAMINS

Electrolyte/Mineral/Metal Modifiers

CARBAGLU 5 [PA] [LD]

CUPRIMINE 4 [90D]

DEPEN TITRATABS 4 [90D]

EXJADE 5 [PA]

JADENU 5 [PA]

JADENU SPRINKLE 5 [PA]

kionex 2 [90D]

sodium polystyrene sulfonate

2 [90D]

SYPRINE 5

trientine 5

VELTASSA 3 [PA] [90D]

Electrolyte/Mineral Replacement

AMINOSYN INJ 3 [PA] [B vs D] [90D]

AMINOSYN & ELECTROLYTES INJ

3 [PA] [B vs D] [90D]

CLINISOL SF INJ 4 [PA] [B vs D] [90D]

dextrose inj 2 [90D]

dextrose & sodium chloride inj

2 [90D]

dextrose & lactated ringers inj

2 [90D]

klor-con 2 [90D]

klor-con sprinkle 2 [90D]

lactated ringers inj 2 [90D]

magnesium sulfate inj 2 [90D]




86

Drug Name Drug

Tier

Requirements/

Limits


Límites

plenamine inj 2 [PA] [B vs D] [90D]

potassium chloride oral soln

2 [90D]

potassium chloride er 2 [90D]

potassium chloride inj 2 [90D]

potassium chloride & dextrose & lactated ringers inj

2 [90D]

potassium chloride & dextrose & sodium chloride inj 20mEq/5%/0.45% & 30mEq/5%/0.45%

2 [90D]

potassium chloride viaflex inj

2 [90D]

potassium citrate er 2 [90D]

PROSOL INJ 4 [PA] [B vs D] [90D]

sodium chloride inj 2 [90D]

TPN ELECTROLYTES INJ 3 [90D]

TRAVASOL INJ 4 [PA] [B vs D] [90D]

Phosphate Binders

calcium acetate 2 [90D]

FOSRENOL ORAL POWDER

3 [90D]

lanthanum carbonate 3 [90D]

sevelamer carbonate powder

3 [90D]

sevelamer carbonate tabs 3 [90D]

Vitamins

prenatal multi-vitamin 2 [90D]

GASTROINTESTINAL AGENTS

Antispasmodics, Gastrointestinal

atropine sulfate inj 2 [90D]

dicyclomine oral 2 [90D]

glycopyrrolate 1mg & 2mg tabs

2 [90D]

glycopyrrolate inj 2 [90D]

Gastrointestinal Agents, Other

cromolyn sodium oral 4 [90D]

diphenoxylate & atropine 2 [90D]

Drug Name Drug

Tier

Requirements/

Limits


Límites

GATTEX INJ 5 [PA]

loperamide caps 2mg 2 [90D]

metoclopramide inj 2 [90D]

metoclopramide oral tablets & soln

2 [90D]

MOVANTIK 3 [90D]

RELISTOR INJ 5 [PA]

RELISTOR TABS 4 [PA] [90D]

ursodiol 3 [90D]

Histamine2 (H2) Receptor Antagonists

cimetidine oral 2 [90D]

famotidine tabs 1 [90D]

famotidine inj 2 [90D]

ranitidine caps, syrup & inj 2 [90D]

ranitidine tabs 1 [90D]

Irritable Bowel Syndrome Agents

alosetron hcl tabs 5 [PA]

AMITIZA 3 [90D]

LINZESS 3 [90D]

Laxatives

constulose soln 2 [90D]

enulose 2 [90D]

gavilyte-c 2 [90D]

gavilyte-g 2 [90D]

gavilyte-n 2 [90D]

generlac 2 [90D]

lactulose 2 [90D]

MOVIPREP 3 [90D]

OSMOPREP 3 [90D]

peg 3350 & electrolytes 2 [90D]

peg 3350 & sodium chloride & sodium bicarbonate & potassium chloride

2 [90D]

polyethylene glycol 3350 2 [90D]

PREPOPIK 3 [90D]

SUPREP BOWEL PREP 3 [90D]

Protectants

misoprostol 2 [90D]

sucralfate 2 [90D]




87

Drug Name Drug

Tier

Requirements/

Limits


Límites

Proton Pump Inhibitors

esomeprazole magnesium dr caps

3 [ST] [90D]

lansoprazole dr caps 2 [90D]

omeprazole caps 2 [90D]

pantoprazole inj 3 [90D]

pantoprazole tabs 2 [90D]

PROTONIX INJ 3 [90D]

GENETIC OR ENZYME DISORDER: REPLACEMENT, MODIFIERS, TREATMENT

Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment

ADAGEN INJ 5 [PA]

ALDURAZYME INJ 5 [PA]

BUPHENYL TABS 5

CERDELGA 5 [PA]

CREON DR 3 [90D]

CYSTADANE 4 [90D]

CYSTAGON 3 [90D]

FABRAZYME INJ 5

KUVAN 5

LUMIZYME INJ 5 [PA]

NAGLAZYME INJ 5 [PA] [LD]

ORFADIN 5 [PA] [LD]

RAVICTI 5

sodium phenylbutyrate powder & tabs

5

SUCRAID 5

VPRIV INJ 5 [PA]

ZAVESCA 5 [PA] [LD]

GENITOURINARY AGENTS

Antispasmodics, Urinary

flavoxate 2 [90D]

GELNIQUE 3 [90D]

MYRBETRIQ 3 [90D]

oxybutynin 2 [90D]

oxybutynin er 2 [QL] [90D]

OXYTROL 4 [90D]

tolterodine tartrate er 2 [QL] [90D]

TOVIAZ 3 [90D]

VESICARE 3 [90D]

Drug Name Drug

Tier

Requirements/

Limits


Límites

Benign Prostatic Hypertrophy Agents

alfuzosin hcl er 2 [90D]

dutasteride 3 [90D]

dutasteride & tamsulosin 3 [90D]

finasteride tabs 5mg 2 [90D]

tamsulosin 2 [90D]

Genitourinary Agents, Other

bethanechol 2 [90D]

ELMIRON 4 [90D]

THIOLA 3 [90D]

HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (ADRENAL)

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)

alclometasone dipropionate

2 [90D]

betamethasone dipropionate

2 [90D]

betamethasone dipropionate augmented

2 [90D]

betamethasone valerate cream, oint, lotion

2 [90D]

CAPEX SHAMPOO 4 [90D]

clobetasol propionate cream, foam, gel, oint, soln

4 [90D]

clotrimazole & betamethasone

2 [90D]

cortisone 2 [90D]

desonide 3 [90D]

desoximetasone 3 [90D]

dexamethasone tabs 2 [90D]

dexamethasone elixir 2 [90D]

dexamethasone inj 2 [90D]

dexpak 2 [90D]

diflorasone diacetate 2 [90D]

fludrocortisone acetate 2 [90D]

fluocinolone acetonide 3 [90D]

fluocinonide-e 2 [90D]




88

Drug Name Drug

Tier

Requirements/

Limits


Límites

fluocinonide gel, oint & soln

2 [90D]

fluticasone propionate cream & oint

2 [90D]

halobetasol 2 [90D]

hydrocortisone 2.5% cream, lotion, oint

2 [90D]

hydrocortisone butyrate cream, oint & soln

2 [90D]

hydrocortisone oral 2 [90D]

hydrocortisone valerate 2 [90D]

methylprednisolone oral 2 [90D]

methylprednisolone sodium succinate inj

2 [90D]

mometasone cream & oint 2 [90D]

prednicarbate 2 [90D]

prednisolone oral soln 2 [90D]

prednisone dose pack 1 [90D]

procto-med hc 2 [90D]

procto-pak 2 [90D]

proctosol hc 2 [90D]

proctozone-hc 2 [90D]

SOLU-CORTEF INJ 4 [90D]

triamcinolone acetonide topical cream, inj, lotion & oint

2 [90D]

triderm 2 [90D]

HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (PITUITARY)

Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary)

desmopressin acetate nasal

2 [90D]

desmopressin acetate oral 2 [90D]

desmopressin acetate inj 2 [90D]

GENOTROPIN INJ 5 [PA]

GENOTROPIN MINIQUICK INJ 0.2MG, 0.4MG, 0.6MG, 0.8MG

4 [PA] [90D]

Drug Name Drug

Tier

Requirements/

Limits


Límites

GENOTROPIN MINIQUICK INJ 1MG, 1.2MG, 1.4MG, 1.6MG, 1.8MG, & 2MG

5 [PA]

HUMATROPE INJ 6MG CARTRIDGE

4 [PA] [90D]

HUMATROPE INJ 5MG VIAL, 12MG & 24MG CARTRIDGE

5 [PA]

INCRELEX INJ 5 [PA]

STIMATE 4 [90D]

HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (SEX HORMONES/ MODIFIERS)

Anabolic Steroids

ANADROL-50 5 [PA]

oxandrolone 4 [90D]

Androgens

ANDROGEL 1% GEL PACKET 50MG/5GM

3 [PA] [90D]

ANDROGEL 1.62% 3 [PA] [90D]

danazol 2 [90D]

testosterone cypionate inj 2 [PA] [90D]

testosterone enanthate inj 2 [PA] [90D]

testosterone gel 25mg/2.5g & 50mg/5g

3 [PA] [90D]

testosterone gel 1% pump 3 [PA] [90D]

Estrogens

ALORA 3 [PA] [90D]

altavera 2 [90D]

alyacen 1/35 2 [90D]

amabelz 3 [PA] [90D]

apri 2 [90D]

aranelle 2 [90D]

aubra 2 [90D]

aviane 2 [90D]

bekyree 2 [90D]

blisovi fe 1/20 & 1.5/30 2 [90D]

briellyn 2 [90D]

caziant 2 [90D]

cyclafem 1/35 2 [90D]

cyclafem 7/7/7 2 [90D]




89

Drug Name Drug

Tier

Requirements/

Limits


Límites

delyla 2 [90D]

desogestrel & ethinyl estradiol

2 [90D]

emoquette 2 [90D]

enpresse-28 2 [90D]

enskyce 2 [90D]

ESTRACE VAGINAL 3 [90D]

estradiol oral 2 [PA] [90D]

estradiol patches 3 [PA] [90D]

estradiol vaginal cream 3 [90D]

estradiol vaginal tabs 3 [90D]

estradiol & norethindrone acetate 5mcg/1mg & 2.5mcg-0.5mg

3 [PA] [90D]

estropipate 2 [PA] [90D]

ethinyl estradiol & ethynodiol

2 [90D]

ethinyl estradiol, ferrous fumarate & norethindrone

2 [90D]

falmina 2 [90D]

femynor 2 [90D]

fyavolv 3 [PA] [90D]

gildagia 2 [90D]

introvale 2 [90D]

isibloom 2 [90D]

jinteli 3 [PA] [90D]

junel 2 [90D]

kariva 2 [90D]

kelnor 1/35, 1/50 2 [90D]

kimidess 2 [90D]

kurvelo 2 [90D]

larin 2 [90D]

larin fe 2 [90D]

larissia 2 [90D]

leena 2 [90D]

levonest 2 [90D]

levonorgestrel & ethinyl estradiol 0.1-0.02mg, 0.15-0.03mg packs

2 [90D]

Drug Name Drug

Tier

Requirements/

Limits


Límites

levonorgestrel & ethinyl estradiol and ethinyl estradiol 0.1/0.02mg-0.01mg packs

2 [90D]

levora 2 [90D]

low-ogestrel 2 [90D]

marlissa 28 day 2 [90D]

MENEST 4 [PA] [90D]

microgestin 1/20 & 1.5/30 2 [90D]

mimvey 3 [PA] [90D]

mimvey lo 3 [PA] [90D]

necon 2 [90D]

norgestimate-ethinyl estradiol

2 [90D]

orsythia 28 day 2 [90D]

pimtrea 2 [90D]

pirmella 1/35 2 [90D]

PREMARIN ORAL 4 [PA] [90D]

PREMARIN VAGINAL 3 [90D]

PREMPHASE 4 [PA] [90D]

PREMPRO 4 [PA] [90D]

setlakin 2 [90D]

tarina fe 2 [90D]

tri-lo-estarylla 2 [90D]

tri-lo-sprintec 2 [90D]

tri-sprintec 2 [90D]

trivora-28 2 [90D]

velivet 2 [90D]

vienva 2 [90D]

vyfemla 2 [90D]

wymzya fe 2 [90D]

yuvafem 3 [90D]

zenchent 2 [90D]

zovia 2 [90D]

Progesterone Agonists/Antagonists

KORLYM 5 [PA]

Progestins

deblitane 2 [90D]

DEPO-PROVERA INJ 400MG/ML

4 [90D]




90

Drug Name Drug

Tier

Requirements/

Limits


Límites

hydroxyprogesterone caproate

5

lyza 2 [90D]

medroxyprogesterone acetate inj

2 [90D]

medroxyprogesterone acetate tabs

2 [90D]

megestrol acetate oral susp 40mg/ml

2 [90D]

megestrol tabs 2 [90D]

norethindrone 2 [90D]

norlyroc 2 [90D]

progesterone caps 2 [90D]

sharobel 2 [90D]

Selective Estrogen Receptor Modifying Agents

raloxifene hcl 3 [QL] [90D]

HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (THYROID)

Hormonal Agents, Stimulant/ Replacement/ Modifying (Thyroid)

CYTOMEL 3 [90D]

levothyroxine tabs 1 [90D]

levoxyl 1 [90D]

liothyronine tabs 2 [90D]

SYNTHROID 3 [90D]

THYROLAR 3 [90D]

unithroid 1 [90D]

HORMONAL AGENTS, SUPPRESSANT (ADRENAL)

Hormonal Agents, Suppressant (Adrenal)

LYSODREN 3 [90D]

HORMONAL AGENTS, SUPPRESSANT (PITUITARY)

Hormonal Agents, Suppressant (Pituitary)

cabergoline 2 [90D]

ELIGARD INJ 4 [PA] [90D]

leuprolide acetate inj 2 [PA] [90D]

LUPRON DEPOT INJ 5 [PA]

octreotide inj 50mcg/ml, 100mcg/ml & 200mcg/ml

2 [90D]

octreotide inj 500mcg/ml & 1000mcg/ml

5

Drug Name Drug

Tier

Requirements/

Limits


Límites

SIGNIFOR INJ 5 [PA]

SOMATULINE DEPOT INJ 5 [PA]

SOMAVERT INJ 5 [PA]

SYNAREL 4 [90D]

TRELSTAR MIXJECT 5 [PA]

HORMONAL AGENTS, SUPPRESSANT (THYROID)

Antithyroid Agents

methimazole 2 [90D]

propylthiouracil 2 [90D]

IMMUNOLOGICAL AGENTS

Angioedema Agents

CINRYZE INJ 5 [PA] [B vs D]

FIRAZYR INJ 5 [PA]

Immune Suppressants

azathioprine inj 2 [PA] [B vs D] [90D]

azathioprine oral 2 [PA] [B vs D] [90D]

BENLYSTA INJ 5 [PA]

cyclosporine modified 2 [PA] [B vs D] [90D]

cyclosporine oral 2 [PA] [B vs D] [90D]

ENBREL INJ 5 [PA]

ENBREL MINI CARTRIDGE

5 [PA]

ENBREL SURECLICK INJ 5 [PA]

gengraf 2 [PA] [B vs D] [90D]

HUMIRA INJ 5 [PA]

HUMIRA PEDIATRIC CROHNS INJ

5 [PA]

HUMIRA PEN-CROHNS INJ

5 [PA]

HUMIRA PEN-PSORIASIS INJ

5 [PA]

HUMIRA PEN INJ 5 [PA]

KINERET INJ 5 [PA]

methotrexate inj 2 [90D]

methotrexate oral 2 [90D]




91

Drug Name Drug

Tier

Requirements/

Limits


Límites

mycophenolate mofetil caps & tabs

2 [PA] [B vs D] [90D]

mycophenolate mofetil inj 4 [PA] [B vs D] [90D]

mycophenolate mofetil oral susp

5 [PA] [B vs D]

mycophenolic acid dr 4 [PA] [B vs D] [90D]

NEORAL 4 [PA] [B vs D] [90D]

NULOJIX INJ 5 [PA] [B vs D]

ORENCIA INJ PF SYRINGE

5 [PA]

ORENCIA CLICKJET 5 [PA]

RAPAMUNE SOLN 4 [PA] [B vs D] [90D]

REMICADE INJ 5 [PA]

SANDIMMUNE ORAL SOLN 100MG/ML

4 [PA] [B vs D] [90D]

SANDIMMUNE CAPS 25MG & 100MG

4 [PA] [B vs D] [90D]

sirolimus tabs 4 [PA] [B vs D] [90D]

tacrolimus caps 0.5mg & 1mg

3 [PA] [B vs D] [90D]

tacrolimus caps 5mg 4 [PA] [B vs D] [90D]

XATMEP 4 [90D]

ZORTRESS TABS 0.25MG

4 [PA] [B vs D] [90D]

ZORTRESS TABS 0.5MG & 0.75MG

5 [PA] [B vs D]

Immunizing Agents, Passive

ATGAM INJ 5 [PA]

GAMMAGARD INJ 5 [PA] [B vs D]

GAMUNEX-C INJ 5 [PA] [B vs D]

Immunomodulators

ACTIMMUNE INJ 5

ARCALYST INJ 5 [PA]

ILARIS INJ 5 [PA]

leflunomide 2 [QL] [90D]

OTEZLA 5 [PA]

Drug Name Drug

Tier

Requirements/

Limits


Límites

OTEZLA STARTER 5 [PA]

RIDAURA 5

SYNAGIS INJ 5

XELJANZ 5 [PA]

XELJANZ XR 5 [PA]

Vaccines

ACTHIB INJ 3 [90D]

ADACEL INJ 3 [90D]

BCG INJ 3 [90D]

BEXSERO INJ 3 [90D]

BOOSTRIX INJ 3 [90D]

DAPTACEL INJ 3 [90D]

DIPHTHERIA & TETANUS TOXOIDS PEDIATRIC INJ

3 [90D]

ENGERIX-B INJ 3 [PA] [B vs D] [90D]

GARDASIL 9 INJ 4 [90D]

HAVRIX INJ 3 [90D]

HIBERIX INJ 3 [90D]

IMOVAX RABIES INJ 3 [90D]

INFANRIX INJ 3 [90D]

IPOL INACTIVATED IPV INJ

3 [90D]

IXIARO INJ 4 [90D]

KINRIX INJ 3 [90D]

MENACTRA INJ 3 [90D]

MENVEO-A/C/Y/W-135 INJ

3 [90D]

M-M-R II INJ 3 [90D]

PEDIARIX INJ 3 [90D]

PEDVAX HIB INJ 3 [90D]

PROQUAD INJ 3 [90D]

QUADRACEL INJ 3 [90D]

RABAVERT INJ 3 [90D]

RECOMBIVAX HB INJ 3 [PA] [B vs D] [90D]

ROTARIX 3 [90D]

ROTATEQ 3 [90D]

SHINGRIX 3 [90D]

TENIVAC 3 [90D]




92

Drug Name Drug

Tier

Requirements/

Limits


Límites

TETANUS & DIPHTHERIA TOXOIDS-ADSORBED ADULT INJ

3 [90D]

TRUMENBA INJ 3 [90D]

TWINRIX INJ 3 [90D]

TYPHIM VI INJ 3 [90D]

VAQTA INJ 3 [90D]

VARIVAX INJ 3 [90D]

VARIZIG INJ 4 [90D]

YF-VAX INJ 3 [90D]

ZOSTAVAX INJ 4 [90D]

INFLAMMATORY BOWEL DISEASE AGENTS

Aminosalicylates

APRISO 4 [QL] [90D]

balsalazide 3 [90D]

DELZICOL 3 [90D]

DIPENTUM 5

mesalamine enema kit 4 [90D]

PENTASA 4 [QL] [90D]

Glucocorticoids

budesonide ec caps 5 [PA]

hydrocortisone enema 2 [90D]

prednisone tabs 1 [90D]

prednisone oral soln 2 [90D]

Sulfonamides

sulfasalazine 2 [90D]

METABOLIC BONE DISEASE AGENTS

Metabolic Bone Disease Agents

alendronate tabs 1 [90D]

alendronate oral soln 2 [90D]

calcitonin-salmon nasal 2 [90D]

calcitriol caps 2 [PA] [B vs D] [90D]

doxercalciferol oral 3 [PA] [B vs D] [90D]

doxercalciferol inj 3 [PA] [B vs D] [90D]

etidronate 2 [90D]

FORTEO INJ 5 [PA]

ibandronate inj 2 [PA] [B vs D] [90D]

ibandronate oral 2 [90D]

Drug Name Drug

Tier

Requirements/

Limits


Límites

MIACALCIN INJ 4 [PA] [B vs D] [90D]

pamidronate inj 2 [PA] [B vs D] [90D]

paricalcitol caps 2 [PA] [B vs D] [90D]

PROLIA 4 [PA] [90D]

risedronate sodium 3 [ST] [90D]

risedronate sodium dr 3 [ST] [90D]

SENSIPAR TABS 30MG 3 [PA] [B vs D] [90D]

SENSIPAR TABS 60MG & 90MG

5 [PA] [B vs D]

TYMLOS 5 [PA]

XGEVA INJ 5 [PA]

zoledronic acid inj 4mg/5ml

4 [90D]

zoledronic acid inj 5mg/100ml

2 [PA] [90D]

ZOMETA INJ 4MG/100ML 5

MISCELLANEOUS THERAPEUTIC AGENTS

Miscellaneous Therapeutic Agents

alcohol pads 2 [90D]

bd insulin syringe ultrafine 2 [90D]

bd insulin syringe safetyglide

2 [90D]

bd pen needle ultrafine 2 [90D]

FERRIPROX 5 [PA]

gauze pads 2"x2" 2 [90D]

INTRALIPID INJ 4 [PA] [B vs D] [90D]

levocarnitine oral 2 [PA] [B vs D] [90D]

paroxetine mesylate 3 [90D]

NATPARA 5 [PA] [LD]

OPHTHALMIC AGENTS

Ophthalmic Agents, Other

atropine sulfate soln 2 [90D]

CYSTARAN 5

LACRISERT 4 [90D]

RESTASIS 3 [PA] [90D]

XIIDRA 4 [PA] [90D]




93

Drug Name Drug

Tier

Requirements/

Limits


Límites

Ophthalmic Anti-allergy Agents

azelastine 2 [90D]

cromolyn sodium ophthalmic soln

2 [90D]

olopatadine soln 0.1% 2 [QL] [90D]

olopatadine soln 0.2% 3 [90D]

Ophthalmic Anti-inflammatories

BLEPHAMIDE 3 [90D]

BLEPHAMIDE S.O.P. 3 [90D]

dexamethasone ophthalmic soln

2 [90D]

diclofenac sodium ophthalmic soln

2 [90D]

DUREZOL 3 [90D]

fluorometholone 2 [90D]

ketorolac soln 0.4% & 0.5%

2 [90D]

neomycin & polymyxin & dexamethasone

2 [90D]

neomycin & polymyxin & bacitracin & hydrocortisone

2 [90D]

PRED MILD 3 [90D]

prednisolone acetate 2 [90D]

prednisolone sodium phosphate

2 [90D]

Ophthalmic Antiglaucoma Agents

acetazolamide tabs 2 [90D]

acetazolamide er caps 2 [90D]

ALPHAGAN P 0.1% 3 [90D]

betaxolol soln 2 [90D]

brimonidine tartrate soln 0.15% & 0.2%

2 [90D]

carteolol 1 [90D]

COMBIGAN 3 [ST] [90D]

dorzolamide 2 [90D]

dorzolamide & timolol maleate

2 [90D]

levobunolol 2 [90D]

methazolamide 4 [90D]

metipranolol 2 [90D]

Drug Name Drug

Tier

Requirements/

Limits


Límites

PHOSPHOLINE IODIDE 3 [90D]

pilocarpine soln 2 [90D]

timolol ophthalmic gel forming

2 [90D]

timolol soln 1 [90D]

Ophthalmic Prostaglandin and Prostamide Analogs

latanoprost 1 [90D]

LUMIGAN 3 [ST] [90D]

OTIC AGENTS

Otic Agents

acetic acid & hydrocortisone

2 [90D]

neomycin & polymyxin & hydrocortisone

2 [90D]

RESPIRATORY TRACT/PULMONARY AGENTS

Antihistamines

azelastine nasal 2 [90D]

cyproheptadine 2 [PA] [90D]

desloratadine 2 [90D]

desloratadine odt 2 [90D]

diphenhydramine hcl inj 2 [90D]

hydroxyzine hcl tabs 2 [PA] [90D]

levocetirizine 2 [90D]

Anti-inflammatories, Inhaled Corticosteroids

ADVAIR DISKUS 3 [90D]

ADVAIR HFA 3 [90D]

ASMANEX HFA 3 [90D]

ASMANEX TWISTHALER 3 [90D]

BREO ELLIPTA 3 [90D]

budesonide nebulizer 2 [PA] [B vs D] [90D]

DULERA 3 [90D]

flunisolide nasal 2 [QL] [90D]

fluticasone propionate nasal

2 [QL] [90D]

mometasone furoate nasal 3 [QL] [90D]

PULMICORT NEBULIZER 4 [PA] [B vs D] [90D]

QVAR 3 [90D]

QVAR REDIHALER 3 [90D]




94

Drug Name Drug

Tier

Requirements/

Limits


Límites

Antileukotrienes

montelukast 2 [90D]

zafirlukast 2 [QL] [90D]

zileuton er 5

Bronchodilators, Anticholinergic

ATROVENT HFA 3 [QL] [90D]

COMBIVENT RESPIMAT 3 [90D]

ipratropium bromide nasal 2 [QL] [90D]

ipratropium bromide nebulizer

2 [PA] [B vs D] [90D]

ipratropium bromide & albuterol sulfate nebulizer

2 [PA] [B vs D] [90D]

SPIRIVA HANDIHALER 3 [90D]

SPIRIVA RESPIMAT 3 [90D]

TUDORZA PRESSAIR 3 [90D]

Bronchodilators, Sympathomimetic

albuterol sulfate nebulizer 2 [PA] [B vs D] [90D]

albuterol sulfate er 3 [90D]

albuterol sulfate syrup 2 [90D]

albuterol sulfate tabs 3 [90D]

BEVESPI AEROSPHERE 3 [90D]

BROVANA NEBULIZER 4 [PA] [B vs D] [90D]

EPINEPHRINE AUTO-INJECTOR 0.15MG/0.3ML & 0.3MG/0.3ML

3 [90D]

levalbuterol nebulizer 2 [PA] [B vs D] [90D]

PERFOROMIST NEBULIZER

4 [PA] [B vs D] [90D]

PROAIR HFA 3 [90D]

PROAIR RESPICLICK 3 [90D]

SEREVENT DISKUS 3 [90D]

STRIVERDI RESPIMAT 3 [90D]

terbutaline sulfate oral 2 [90D]

terbutaline sulfate inj 2 [90D]

XOPENEX NEBULIZER 4 [PA] [B vs D] [90D]

Cystic Fibrosis Agents

BETHKIS 5 [PA] [B vs D]

CAYSTON 5 [PA] [LD]

Drug Name Drug

Tier

Requirements/

Limits


Límites

KALYDECO 5 [PA]

ORKAMBI 5 [PA]

PULMOZYME 5 [PA] [B vs D]

TOBI 5 [PA] [B vs D]

TOBI PODHALER 5

tobramycin nebulizer 5 [PA] [B vs D]

Mast Cell Stabilizers

cromolyn sodium nebulizer soln

4 [PA] [B vs D] [90D]

Phosphodiesterase Inhibitors, Airways Disease

aminophylline inj 2 [90D]

DALIRESP 3 [90D]

theophylline cr & er tabs 2 [90D]

Pulmonary Antihypertensives

ADCIRCA 5 [PA]

ADEMPAS 5 [PA] [LD]

LETAIRIS 5 [PA] [LD]

OPSUMIT 5 [PA] [LD]

REMODULIN INJ 5 [PA]

sildenafil tabs 20mg 3 [PA] [90D]

TRACLEER 5 [PA] [LD]

UPTRAVI 5 [PA]

VENTAVIS 5 [PA] [B vs D]

Pulmonary Fibrosis Agents

ESBRIET 5 [PA]

OFEV 5 [PA]

Respiratory Tract Agents, Other

acetylcysteine nebulizer 2 [PA] [B vs D] [90D]

ANORO ELLIPTA 3 [90D]

PROLASTIN C INJ 5 [PA] [LD]

STIOLTO RESPIMAT 3 [90D]

SKELETAL MUSCLE RELAXANTS

Skeletal Muscle Relaxants

chlorzoxazone 500mg tabs 2 [PA] [90D]

cyclobenzaprine hcl 2 [PA] [90D]

methocarbamol tabs 2 [PA] [90D]

SLEEP DISORDER AGENTS

GABA Receptor Modulators

estazolam 2 [90D]




95

Drug Name Drug

Tier

Requirements/

Limits


Límites

flurazepam 2 [90D]

temazepam 2 [90D]

triazolam 2 [90D]

zolpidem tabs 5mg & 10mg

2 [PA] [90D]

Sleep Disorders, Other

BELSOMRA 3 [QL] [90D]

modafinil 4 [PA] [90D]

ROZEREM 3 [QL] [90D]

SILENOR 3 [QL] [90D]

XYREM 5 [PA] [LD]

SCAN Health Plan | 2018 Formulary 96

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

Quantity Limits Límites de Cantidad

acetaminophen & codeine #2 & #3 tabs 360 tabs per 30 days

acetaminophen & codeine #4 tabs 180 tabs per 30 days

acetaminophen & codeine elixir 5000ml per 30 days

amphetamine & dextroamphetamine 60 tabs per 30 days

APRISO 120 caps per 30 days

ATROVENT HFA 2 inhalers per 30 days

BELSOMRA 30 tabs per 30 days

BRILINTA 60 tabs per 30 days

butorphanol tartrate nasal 4 bottles per 30 days

calcipotriene cream 60gm: 2 tube per 30 days; 120gm: 1 tube per 30 days

calcipotriene oint 60gm: 2 tubes per 30 days

COLCHICINE 120 caps or tabs per 30 days

COLCRYS 120 tabs per 30 days

dextroamphetamine sulfate 5mg: 120 tabs per 30 days; 10mg: 180 tabs per 30 days

dextroamphetamine sulfate er 5mg: 30 caps per 30 days; 10mg & 15mg: 120 caps per 30 days

dipyridamole er & aspirin 60 caps per 30 days

ELIDEL 100gm: 2 tubes per 30 days

endocet tabs 5-325mg, 7.5-325mg, 10-325mg 5-325mg: 360 tabs per 30 days; 7.5-325mg: 240 tabs per 30 days; 10-325mg: 180 tabs per 30 days

fenofibrate 30 caps or tabs per 30 days

fenofibrate micronized 30 caps per 30 days

fenofibric acid dr 45mg: 60 caps per 30 days; 135mg: 30 caps per 30 days

fentanyl patches 15 patches per 30 days

flunisolide nasal 2 bottles per 30 days

fluticasone propionate nasal 2 bottles per 30 days

galantamine 60 tabs per 30 days

galantamine er 30 caps per 30 days

galantamine oral soln 200ml per 30 days

glimepiride & pioglitazone tabs 30 tabs per 30 days

hydrocodone & acetaminophen soln 7.5-325mg/15ml

2700ml per 30 days

hydrocodone & acetaminophen tabs 5-325mg,7.5-325mg, & 10-325mg

5-325mg: 360 tabs per 30 days; 7.5-325mg & 10-325mg: 180 tabs per 30 days

SCAN Health Plan | 2018 Formulary

97

Drugs with Quantity Limits Medicamentos con Límites de Cantidad

Drug Name Nombre del Medicamento

Quantity Limits Límites de Cantidad

hydrocodone & ibuprofen tabs 5-200mg, 7.5-200mg, & 10-200mg

150 tabs per 30 days

ipratropium bromide nasal 1 bottle per 30 days

leflunomide 30 tabs per 30 days

lorcet hd tabs 10-325mg 180 tabs per 30 days

lorcet plus tabs 7.5-325mg 180 tabs per 30 days

lorcet tabs 5-325mg 360 tabs per 30 days

mometasone furoate nasal 3 bottles per 30 days

morphine sulfate er tabs 120 tabs per 30 days

naratriptan 9 tabs per 30 days

NEUPRO PATCH 30 patches per 30 days

niacin er tabs 500mg: 90 tabs per 30 days; 750mg & 1000mg: 60 tabs per 30 days

olopatadine soln 0.1% 3 bottles per 30 days

oxybutynin er 5mg: 30 tabs per 30 days; 10mg & 15mg: 60 tabs per 30 days

oxycodone & acetaminophen tabs 2.5-325mg, 5-325mg, 7.5-325mg, & 10-325mg

2.5-325mg & 5-325mg: 360 tabs per 30 days; 7.5-325mg: 240 tabs per 30 days; 10-325mg: 180 tabs per 30 days

oxycodone & aspirin tabs 360 tabs per 30 days

oxycodone & ibuprofen tabs 120 tabs per 30 days

OXYCODONE ER 60 tabs per 30 days

OXYCONTIN 60 tabs per 30 days

oxymorphone er 60 tabs per 30 days

PENTASA 240 caps per 30 days

raloxifene hcl 30 tabs per 30 days

REGRANEX 2 tubes per 30 days

rivastigmine caps 60 caps per 30 days

rivastigmine patches 30 patches per 30 days

ROZEREM 30 tabs per 30 days

SILENOR 30 tabs per 30 days

TAZORAC GEL 30gm: 3 tubes per 30 days; 100gm: 1 tube per 30 days

tolterodine tartrate er 30 caps per 30 days

tramadol & acetaminophen 37.5-325mg tabs 240 tabs per 30 days

tramadol er tabs 30 tabs per 30 days

zafirlukast 60 tabs per 30 days

zenzedi tabs 5mg & 10mg 5mg: 120 tabs per 30 days; 10mg: 180 tabs per 30 days

ZOMIG NASAL 2.5mg: 18 single use units per 30 days; 5mg: 12 single use units per 30 days


99

INDEX

ÍNDICE

abacavir & lamivudine, 79

abacavir & lamivudine & zidovudine, 79

abacavir soln, 79

abacavir tabs, 79

ABELCET INJ, 74

ABILIFY MAINTENA, 78

acamprosate calcium dr, 69

acarbose, 80

acebutolol, 82

acetaminophen & codeine, 69, 96

acetazolamide, 93

acetazolamide er caps, 93

acetazolamide tabs, 93

acetic acid & hydrocortisone, 93

acetylcysteine nebulizer, 94

acitretin, 85

ACTHIB INJ, 91

ACTIMMUNE INJ, 91

acyclovir inj, 79

acyclovir oint 5%, 79

acyclovir oral, 79

ADACEL INJ, 91

ADAGEN INJ, 87

adapalene, 85

ADCIRCA, 94

adefovir dipivoxil, 78

ADEMPAS, 94

ADVAIR DISKUS, 93

ADVAIR HFA, 93

afeditab cr, 83

AFINITOR, 76

AFINITOR DISPERZ, 76

ALBENZA, 77

albuterol sulfate er, 94

albuterol sulfate nebulizer, 94

albuterol sulfate syrup, 94

albuterol sulfate tabs, 94

alclometasone dipropionate, 87

alcohol pads, 92

ALDURAZYME INJ, 87

ALECENSA, 76

alendronate oral soln, 92

alendronate tabs, 92

alfuzosin hcl er, 87

ALIMTA INJ, 76

ALINIA, 77

allopurinol tab, 75

ALORA, 88

alosetron hcl tabs, 86

ALPHAGAN P 0.1%, 93

alprazolam er tabs, 80

alprazolam intensol, 80

alprazolam tabs, 80

altavera, 88

ALUNBRIG, 76

ALUNBRIG INITIATION PACK, 76

alyacen 1/35, 88

amabelz, 88

amantadine, 77

AMBISOME INJ, 74

amikacin inj, 70

amiloride, 83

amiloride & hydrochlorothiazide, 83

aminophylline inj, 94

AMINOSYN & ELECTROLYTES INJ, 85

AMINOSYN INJ, 85

amiodarone tabs, 82

AMITIZA, 86

amitriptyline, 74

amlodipine, 83

amlodipine & atorvastatin, 83

amlodipine & benazepril, 83

ammonium lactate topical, 85

amnesteem caps, 85

amoxapine, 74

amoxicillin, 71

amoxicillin & clavulanate potassium, 71

amoxicillin & clavulanate potassium er, 71


amphetamine & dextroamphetamine, 96

amphetamine & dextroamphetamine tabs, 84

amphotericin b inj, 74

ampicillin & sulbactam inj 10-5gm, 2-1gm, & 1-

0.5gm, 71

ampicillin inj, 71

ampicillin oral, 71

AMPYRA, 84

ANADROL-50, 88

anagrelide, 81

anastrozole, 76

ANDROGEL 1% GEL PACKET 50MG/5GM, 88

ANDROGEL 1.62%, 88

ANORO ELLIPTA, 94

APOKYN INJ, 77

aprepitant caps 80mg & 125mg, 74

aprepitant pack, 74

apri, 88

APRISO, 92, 96

APTIOM, 73

APTIVUS, 79

aranelle, 88

ARCALYST INJ, 91

aripiprazole, 78

aripiprazole 20mg & 30mg, 78

aripiprazole odt, 78

aripiprazole soln 1mg/ml, 78

ARISTADA INJ, 78

ASMANEX HFA, 93

ASMANEX TWISTHALER, 93

atazanavir sulfate caps 150mg & 200mg, 80

atazanavir sulfate caps 300mg, 80

atenolol, 82

atenolol & chlorthalidone, 82

ATGAM INJ, 91

atomoxetine, 84

atorvastatin, 83

atovaquone, 77

atovaquone/proguanil, 77

ATRIPLA, 79

atropine sulfate inj, 86

atropine sulfate soln, 92

ATROVENT HFA, 94, 96

AUBAGIO, 84

aubra, 88

AUSTEDO, 84

AVASTIN INJ, 77

aviane, 88

AVONEX INJ, 84

AVONEX PEN INJ, 84

azacitidine inj, 76

AZASITE, 71

azathioprine inj, 90

azathioprine oral, 90

azelastine, 93

azelastine nasal, 93

azithromycin inj, 71

azithromycin tabs & oral susp, 71

aztreonam inj 1gm, 71

bacitracin & polymyxin b ointment, 70

bacitracin ointment, 70

baclofen, 78

BACTROBAN CREAM, 70

BACTROBAN NASAL, 70

balsalazide, 92

BANZEL, 73

BARACLUDE ORAL SOLN 0.05MG/ML, 78

BCG INJ, 91

bd insulin syringe safetyglide, 92

bd insulin syringe ultrafine, 92

bd pen needle ultrafine, 92

bekyree, 88

BELEODAQ, 76

BELSOMRA, 95, 96

benazepril, 82

benazepril & hydrochlorothiazide, 82

BENLYSTA INJ, 90

benztropine inj, 77

benztropine tabs, 77

betamethasone dipropionate, 87

betamethasone dipropionate augmented, 87

betamethasone valerate cream, oint, lotion, 87

BETASERON INJ, 84

betaxolol soln, 93

bethanechol, 87

BETHKIS, 94

BEVESPI AEROSPHERE, 94

bexarotene, 77


101

BEXSERO INJ, 91

bicalutamide, 75

BICILLIN L-A INJ, 71

BIKTARVY, 79

bisoprolol, 82

bisoprolol & hydrochlorothiazide, 82

BLEPHAMIDE, 93

BLEPHAMIDE S.O.P., 93

blisovi fe 1/20 & 1.5/30, 88

BOOSTRIX INJ, 91

BOSULIF TAB 100 MG, 76

BOSULIF TABS 400MG & 500 MG, 76

BREO ELLIPTA, 93

briellyn, 88

BRILINTA, 81, 96

brimonidine tartrate soln 0.15% & 0.2%, 93

BRIVIACT INJ, 72

BRIVIACT ORAL SOLN, 72

BRIVIACT TABS, 72

bromocriptine, 77

BROVANA NEBULIZER, 94

budesonide ec caps, 92

budesonide nebulizer, 93

bumetanide oral, 83

BUPHENYL TABS, 87

buprenorphine & naloxone sublingual tabs, 69

buprenorphine inj, 69

buprenorphine oral, 69

bupropion, 73

bupropion sr, 73

bupropion sr 150mg, 70

bupropion xl, 73

buspirone, 80

butorphanol tartrate inj, 69

butorphanol tartrate nasal, 69, 96

BYDUREON BCISE INJ, 80

BYDUREON INJ, 80

BYETTA INJ, 80

BYSTOLIC, 82

cabergoline, 90

CABOMETYX, 76

caffeine-ergotamine, 75

calcipotriene & betamethasone oint, 85

calcipotriene cream, 96

calcipotriene cream & oint, 85

calcipotriene oint, 96

calcipotriene soln, 85

calcitonin-salmon nasal, 92

calcitriol caps, 92

calcium acetate, 86

CALQUENCE, 76

CAPASTAT INJ, 75

CAPEX SHAMPOO, 87

CAPRELSA, 76

captopril, 82

captopril & hydrochlorothiazide, 82

CARAC, 85

CARBAGLU, 85

carbamazepine er tabs & caps, 73

carbamazepine tabs, chewable tabs & oral susp,

73

carbidopa, 77

carbidopa & levodopa, 77

carbidopa & levodopa & entacapone, 77

carbidopa & levodopa er, 77

carbidopa & levodopa odt, 77

carteolol, 93

cartia xt, 83

carvedilol, 82

carvedilol phosphate er, 82

caspofungin inj, 74

CAYSTON, 94

caziant, 88

cefaclor, 71

cefaclor er, 71

cefadroxil caps & tabs, 71

cefazolin inj, 71

cefdinir, 71

cefepime inj, 71

cefixime, 71

cefoxitin sodium, 71

cefpodoxime tabs, 71

cefprozil, 71

ceftazidime inj 1gm, 2gm & 6gm, 71

ceftriaxone inj, 71

cefuroxime inj, 71


cefuroxime oral, 71

celecoxib, 70

CELONTIN, 72

cephalexin caps & tabs 250mg & 500mg, 71

cephalexin oral susp, 71

CERDELGA, 87

cevimeline, 85

CHANTIX, 70

CHANTIX STARTING MONTH PAK, 70

chloramphenicol sodium succinate inj, 70

chlorhexidine gluconate, 85

chloroquine, 77

chlorothiazide tabs, 83

chlorpromazine inj, 77

chlorpromazine oral, 77

chlorthalidone, 83

chlorzoxazone 500mg tabs, 94

cholestyramine, 84

cholestyramine light, 84

ciclopirox 8% nail soln, 74

ciclopirox cream, susp, shampoo, 74

cilastatin/imipenem inj, 71

cilostazol, 81

cimetidine oral, 86

CINRYZE INJ, 90

CIPRO HC, 71

CIPRODEX, 71

ciprofloxacin inj, 71

ciprofloxacin ophthalmic soln 0.3%, 72

ciprofloxacin oral susp, 72

ciprofloxacin tabs er, 72

ciprofloxacin tabs immediate-release, 72

citalopram oral soln, 73

citalopram tabs, 73

claravis, 85

clarithromycin, 71

clarithromycin er, 71

CLEOCIN VAGINAL, 70

clindamycin & benzoyl peroxide topical, 85

clindamycin oral, 70

clindamycin phosphate inj, 70

clindamycin topical cream, gel, lotion, soln &

swab, 70

CLINISOL SF INJ, 85

clobetasol propionate cream, foam, gel, oint,

soln, 87

clomipramine, 74

clonazepam, 72

clonazepam odt, 72

clonidine er, 84

clonidine patches, 81

clonidine tabs immediate-release, 82

clopidogrel tabs 75mg, 81

clorazepate, 80

clotrimazole & betamethasone, 87

clotrimazole 1% cream, 74

clotrimazole 1% topical soln, 74

clotrimazole troche, 74

clozapine, 78

clozapine odt, 78

COARTEM, 77

codeine, 69

COLCHICINE, 75

COLCHICINE, 96

COLCRYS, 75, 96

colestipol granules, 84

colestipol tabs, 84

colistimethate inj, 70

COMBIGAN, 93

COMBIVENT RESPIMAT, 94

COMETRIQ, 76

COMPLERA, 79

compro, 74

constulose soln, 86

COPAXONE INJ 40MG/ML, 84

CORLANOR, 83

cortisone, 87

CORTISPORIN CREAM & OINT, 70

COSENTYX, 85

COSENTYX SENSOREADY PEN, 85

COTELLIC, 76

COUMADIN ORAL, 81

CREON DR, 87

CRESEMBA INJ, 74

CRESEMBA ORAL, 74

CRIXIVAN, 80

cromolyn sodium nebulizer soln, 94

cromolyn sodium ophthalmic soln, 93


103

cromolyn sodium oral, 86

CUPRIMINE, 85

cyclafem 1/35, 88

cyclafem 7/7/7, 88

cyclobenzaprine hcl, 94

cyclophosphamide caps, 75

CYCLOSET, 80

cyclosporine modified, 90

cyclosporine oral, 90

cyproheptadine, 93

CYSTADANE, 87

CYSTAGON, 87

CYSTARAN, 92

CYTOMEL, 90

DALIRESP, 94

danazol, 88

dapsone tabs, 75

DAPTACEL INJ, 91

daptomycin inj, 70

DARAPRIM, 77

deblitane, 89

delyla, 89

DELZICOL, 92

demeclocycline, 72

DEMSER, 83

DENAVIR, 79

DEPEN TITRATABS, 85

DEPO-PROVERA INJ 400MG/ML, 89

DESCOVY, 79

desipramine, 74

desloratadine, 93

desloratadine odt, 93

desmopressin acetate inj, 88

desmopressin acetate nasal, 88

desmopressin acetate oral, 88

desogestrel & ethinyl estradiol, 89

desonide, 87

desoximetasone, 87

DESVENLAFAXINE ER, 73

desvenlafaxine succinate er, 73

dexamethasone elixir, 87

dexamethasone inj, 87

dexamethasone ophthalmic soln, 93

dexamethasone tabs, 87

dexmethylphenidate ir tabs, 84

dexpak, 87

dextroamphetamine sulfate, 84, 96

dextroamphetamine sulfate er, 84, 96

dextrose & lactated ringers inj, 85

dextrose & sodium chloride inj, 85

dextrose inj, 85

DIASTAT, 72

diazepam intensol, 80

diazepam rectal, 72

diazepam tabs & soln, 80

diclofenac potassium, 70

diclofenac sodium, 70

diclofenac sodium dr, 70

diclofenac sodium er, 70

diclofenac sodium gel 1%, 85

diclofenac sodium gel 3%, 85

diclofenac sodium ophthalmic soln, 93

dicloxacillin sodium, 71

dicyclomine oral, 86

didanosine, 79

diflorasone diacetate, 87

diflunisal, 70

digitek, 83

digox, 83

digoxin inj, 83

digoxin oral, 83

dihydroergotamine mesylate inj, 75

dilantin caps 100mg, 73

DILANTIN CAPS 30MG, 73

DILANTIN INFATABS, 73

DILANTIN SUSP, 73

diltiazem cd caps,, 83

diltiazem er caps, 83

diltiazem inj 50mg/10ml, 83

diltiazem tabs, 83

dilt-xr, 83

DIPENTUM, 92

diphenhydramine hcl inj, 93

diphenoxylate & atropine, 86

DIPHTHERIA & TETANUS TOXOIDS

PEDIATRIC INJ, 91


dipyridamole er & aspirin, 96

dipyridamole er & aspirin, 81

dipyridamole oral, 81

disopyramide phosphate, 82

disulfiram, 69

divalproex sodium, 72

divalproex sodium dr, 72

divalproex sodium er, 72

dofetilide, 82

donepezil odt, 73

donepezil tabs 5mg & 10mg, 73

dorzolamide, 93

dorzolamide & timolol maleate, 93

doxazosin, 82

doxepin, 74

doxepin cream 5%, 85

doxercalciferol inj, 92

doxercalciferol oral, 92

doxy 100 inj, 72

doxycycline immediate-release tabs, caps & oral

susp, 72

dronabinol, 74

DULERA, 93

duloxetine hcl, 73

duramorph inj, 69

DUREZOL, 93

dutasteride, 87

dutasteride & tamsulosin, 87

DUTOPROL, 82

econazole nitrate, 74

EDURANT, 79

efavirenz caps, 79

efavirenz tab, 79

ELIDEL, 85, 96

ELIGARD INJ, 90

ELIQUIS, 81

ELIQUIS STARTER PACK, 81

ELMIRON, 87

EMCYT, 75

emoquette, 89

EMSAM, 73

EMTRIVA, 79

enalapril, 82

enalapril & hydrochlorothiazide, 82

ENBREL INJ, 90

ENBREL MINI CARTRIDGE, 90

ENBREL SURECLICK INJ, 90

endocet, 69

endocet, 96

ENGERIX-B INJ, 91

enoxaparin inj, 81

enpresse-28, 89

enskyce, 89

entacapone, 77

entecavir tabs, 78

ENTRESTO, 83

enulose, 86

EPCLUSA, 78

EPINEPHRINE AUTO-INJECTOR

0.15MG/0.3ML & 0.3MG/0.3ML, 94

epitol, 73

EPIVIR HBV SOLN 5MG/ML, 78

eplerenone, 83

ergoloid mesylates, 73

ERIVEDGE, 76

ERLEADA, 75

ERWINAZE INJ, 76

ERYTHROCIN LACTOBIONATE INJ, 71

erythrocin stearate, 71

erythromycin ethylsuccinate tabs, 71

erythromycin ophthalmic oint, 71

erythromycin oral, 71

erythromycin topical gel & soln, 71

ESBRIET, 94

escitalopram, 73

esomeprazole magnesium dr caps, 87

estazolam, 94

ESTRACE VAGINAL, 89

estradiol & norethindrone acetate 5mcg/1mg &

2.5mcg-0.5mg, 89

estradiol oral, 89

estradiol patches, 89

estradiol vaginal cream, 89

estradiol vaginal tabs, 89

estropipate, 89

ethambutol, 75

ethinyl estradiol & ethynodiol, 89


105

ethinyl estradiol, ferrous fumarate &

norethindrone, 89

ethosuximide, 72

etidronate, 92

etodolac, 70

etodolac er, 70

etoposide inj, 76

EURAX, 77

EVOTAZ, 80

exemestane, 76

EXJADE, 85

ezetimibe, 84

FABRAZYME INJ, 87

falmina, 89

famciclovir, 79

famotidine inj, 86

famotidine tabs, 86

FANAPT, 78

FANAPT TITRATION PACK, 78

FARESTON, 76

FARXIGA, 80

FARYDAK, 76

FASLODEX INJ, 76

FAZACLO, 78

felbamate oral susp 600mg/5ml, 73

felbamate tabs 400mg, 72

felbamate tabs 600mg, 73

felodipine er, 83

femynor, 89

fenofibrate, 83, 96

fenofibrate caps 43mg & 130mg, 83

fenofibrate micronized, 83, 96

fenofibrate tabs 48mg, 54mg, 145mg, 160mg,

83

fenofibric acid dr caps, 83

fenofibric acid tabs, 83

fentanyl citrate lozenges, 69

fentanyl patches, 96

fentanyl patches 12mcg/hr, 25mcg/hr, 50mcg/hr,

75mcg/hr, 100mcg/hr, 69

FERRIPROX, 92

FETZIMA, 73

FETZIMA TITRATION PACK, 73

finasteride tabs 5mg, 87

FIRAZYR INJ, 90

flavoxate, 87

flecainide acetate, 82

fluconazole in sodium chloride inj, 74

fluconazole oral, 74

flucytosine, 74

fludrocortisone acetate, 87

flunisolide nasal, 93, 96

fluocinolone acetonide, 87

fluocinonide, 87

fluocinonide gel, oint & soln, 88

fluocinonide-e, 87

fluorometholone, 93

FLUOROURACIL 0.5% CREAM, 85

fluorouracil topical, 85

fluoxetine hcl caps 10mg, 20mg & 40mg, 73

fluoxetine hcl oral soln, 74

fluoxetine hcl tabs 10mg & 20mg, 74

fluphenazine decanoate inj, 77

fluphenazine inj, 77

fluphenazine oral, 77

flurazepam, 95

flutamide, 75

fluticasone propionate cream & oint, 88

fluticasone propionate nasal, 93, 96

fluvoxamine, 74

fluvoxamine er, 74

fondaparinux inj 2.5mg/0.5ml & 5mg/0.4ml, 81

fondaparinux inj 7.5mg/0.6ml & 10mg/0.8ml, 81

FORFIVO XL, 73

FORTEO INJ, 92

fosamprenavir tabs, 80

fosinopril, 82

fosinopril & hydrochlorothiazide, 82

fosphenytoin sodium inj, 73

FOSRENOL ORAL POWDER, 86

furosemide inj, 83

furosemide oral, 83

FUZEON INJ, 79

fyavolv, 89

FYCOMPA, 72

gabapentin caps, tabs, & oral soln, 72


GABITRIL TABS 12MG & 16MG, 72

galantamine, 73, 96

galantamine er, 73, 96

galantamine oral soln, 73, 96

GAMMAGARD INJ, 91

GAMUNEX-C INJ, 91

ganciclovir inj, 78

GARDASIL 9 INJ, 91

GATTEX INJ, 86

gauze pads 2x2, 92

gavilyte-c, 86

gavilyte-g, 86

gavilyte-n, 86

GELNIQUE, 87

gemfibrozil, 83

generlac, 86

gengraf, 90

GENOTROPIN INJ, 88

GENOTROPIN MINIQUICK INJ 0.2MG, 0.4MG,

0.6MG, 0.8MG, 88

GENOTROPIN MINIQUICK INJ 1MG, 1.2MG,

1.4MG, 1.6MG, 1.8MG, & 2MG, 88

gentamicin cream 0.1% & oint 0.1%, 70

gentamicin inj 40mg/ml, 70

gentamicin ophthalmic soln 0.3%, 70

GENVOYA, 79

GEODON INJ, 78

gildagia, 89

GILENYA, 84

GILOTRIF, 76

glatiramer acetate inj, 84

glatopa inj, 84

GLEOSTINE, 75

glimepiride, 80

glimepiride & pioglitazone, 80

glimepiride & pioglitazone tabs, 96

glipizide, 80

glipizide & metformin tabs, 80

glipizide er, 80

GLUCAGON EMERGENCY KIT INJ, 81

glycopyrrolate 1mg & 2mg tabs, 86

glycopyrrolate inj, 86

granisetron inj, 74

granisetron oral, 74

griseofulvin microsize, 74

guanfacine, 82

guanidine, 75

halobetasol, 88

haloperidol decanoate inj, 77

haloperidol lactate inj, 78

haloperidol lactate oral soln, 78

haloperidol tabs, 77

HARVONI, 78

HAVRIX INJ, 91

heparin inj, 81

HERCEPTIN INJ, 77

HETLIOZ, 84

HEXALEN, 75

HIBERIX INJ, 91

HUMALOG CARTRIDGE INJ, 81

HUMALOG JUNIOR KWIKPEN INJ, 81

HUMALOG KWIKPEN INJ, 81

HUMALOG MIX 50/50 KWIKPEN INJ, 81

HUMALOG MIX 50/50 VIAL INJ, 81

HUMALOG MIX 75/25 KWIKPEN INJ, 81

HUMALOG MIX 75/25 VIAL INJ, 81

HUMALOG VIAL INJ, 81

HUMATROPE INJ 5MG VIAL, 12MG & 24MG

CARTRIDGE, 88

HUMATROPE INJ 6MG CARTRIDGE, 88

HUMIRA INJ, 90

HUMIRA PEN INJ, 90

HUMIRA PEN-CROHNS INJ, 90

HUMIRA PEN-PSORIASIS INJ, 90

HUMULIN 70/30 KWIKPEN INJ, 81

HUMULIN 70/30 VIAL INJ, 81

HUMULIN N KWIKPEN INJ, 81

HUMULIN N VIAL INJ, 81

HUMULIN R U-500 (CONCENTRATED)

KWIKPEN INJ, 81

HUMULIN R U-500 (CONCENTRATED) VIAL

INJ, 81

HUMULIN R VIAL INJ, 81

hydralazine inj, 84

hydralazine oral, 84

hydrochlorothiazide, 83

hydrocodone & acetaminophen soln, 69, 96

hydrocodone & acetaminophen tabs, 69, 96


107

hydrocodone & ibuprofen, 69, 97

hydrocortisone 2.5% cream, lotion, oint, 88

hydrocortisone butyrate cream, oint & soln, 88

hydrocortisone enema, 92

hydrocortisone oral, 88

hydrocortisone valerate, 88

hydromorphone immediate-release oral soln &

tabs, 69

hydromorphone inj, 69

hydroxychloroquine, 77

hydroxyprogesterone caproate, 90

hydroxyurea, 76

hydroxyzine hcl tabs, 93

ibandronate inj, 92

ibandronate oral, 92

IBRANCE, 76

ibu, 70

ibuprofen, 70

ICLUSIG, 76

IDHIFA, 76

ILARIS INJ, 91

imatinib, 76

IMBRUVICA, 76

imipramine hcl tabs, 74

imiquimod, 85

IMOVAX RABIES INJ, 91

INCRELEX INJ, 88

indapamide, 83

indomethacin, 70

indomethacin er, 70

indomethacin ir caps, 70

INFANRIX INJ, 91

INLYTA, 76

INTELENCE 100MG & 200MG TABS, 79

INTELENCE 25MG TAB, 79

INTRALIPID INJ, 92

INTRON-A INJ, 78

introvale, 89

INVANZ INJ, 71

INVEGA SUSTENNA 117MG, 156MG, &

234MG, 78

INVEGA SUSTENNA 39MG & 78MG, 78

INVEGA TRINZA INJ, 78

INVIRASE, 80

INVOKAMET, 80

INVOKAMET XR, 80

INVOKANA, 80

IPOL INACTIVATED IPV INJ, 91

ipratropium bromide & albuterol sulfate

nebulizer, 94

ipratropium bromide nasal, 94, 97

ipratropium bromide nebulizer, 94

irbesartan, 82

irbesartan hct, 82

IRESSA, 76

ISENTRESS CHEW TABS, 79

ISENTRESS HD TABS, 79

ISENTRESS ORAL POWDER, 79

ISENTRESS TABS, 79

isibloom, 89

isoniazid oral, 75

isosorbide dinitrate, 84

isosorbide dinitrate er, 84

isosorbide mononitrate, 84

isosorbide mononitrate er, 84

isotretinoin caps, 85

isradipine, 83

itraconazole, 74

ivermectin, 77

IXIARO INJ, 91

JADENU, 85

JADENU SPRINKLE, 85

JAKAFI, 76

jantoven, 81

JANUMET, 80

JANUMET XR, 80

JANUVIA, 80

jinteli, 89

JULUCA, 79

junel, 89

JUXTAPID, 84

KALETRA TABS 100-25MG, 80

KALETRA TABS 200MG-50MG, 80

KALYDECO, 94

kariva, 89

kelnor 1/35, 1/50, 89


ketoconazole tabs, cream, shampoo, 75

ketorolac inj, 70

ketorolac oral, 70

ketorolac soln 0.4% & 0.5%, 93

KEYTRUDA INJ, 77

KHEDEZLA, 74

kimidess, 89

KINERET INJ, 90

KINRIX INJ, 91

kionex, 85

KISQALI, 76

KISQALI FEMARA CO-PACK, 76

klor-con, 85

klor-con sprinkle, 85

KOMBIGLYZE XR, 80

KORLYM, 89

kurvelo, 89

KUVAN, 87

KYNAMRO, 84

labetalol inj, 82

labetalol oral, 82

LACRISERT, 92

lactated ringers inj, 85

lactulose, 86

lamivudine & zidovudine, 79

lamivudine soln, 79

lamivudine tabs 100mg, 78

lamivudine tabs 150mg & 300mg, 79

lamotrigine immediate-release tabs, 73

lamotrigine starter kit, 73

LANOXIN INJ, 83

LANOXIN ORAL, 83

lansoprazole dr caps, 87

lanthanum carbonate, 86

LANTUS SOLOSTAR PEN INJ, 81

LANTUS VIAL INJ, 81

larin, 89

larin fe, 89

larissia, 89

latanoprost, 93

LATUDA, 78

LAZANDA, 69

leena, 89

leflunomide, 91, 97

LENVIMA, 76

LETAIRIS, 94

letrozole, 76

leucovorin inj, 76

leucovorin oral, 76

LEUKERAN, 75

LEUKINE INJ, 81

leuprolide acetate inj, 90

levalbuterol nebulizer, 94

levetiracetam er, 72

levetiracetam inj, 72

levetiracetam oral, 72

levobunolol, 93

levocarnitine oral, 92

levocetirizine, 93

levofloxacin inj, 72

levofloxacin oral soln, 72

levofloxacin tabs, 72

levoleucovorin 175mg vial, 76

levoleucovorin 50mg vial, 76

levonest, 89

levonorgestrel & ethinyl estradiol 0.1-0.02mg,

0.15-0.03mg packs, 89

levonorgestrel & ethinyl estradiol and ethinyl

estradiol 0.1/0.02mg-0.01mg packs, 89

levora, 89

levothyroxine tabs, 90

levoxyl, 90

LEXIVA ORAL SUSP, 80

lidocaine & prilocaine, 69

lidocaine hcl inj, 69

lidocaine ointment, 69

lidocaine patch, 69

lidocaine topical gel & solution, 69

linezolid inj, 70

linezolid oral, 70

LINZESS, 86

liothyronine tabs, 90

lisinopril, 82

lisinopril & hydrochlorothiazide, 82

lithium carbonate, 80

lithium carbonate er, 80

lithium citrate, 80

LONSURF, 76


109

loperamide caps 2mg, 86

lopinavir &ritonavir soln, 80

lorazepam intensol, 80

lorazepam tabs, 80

lorcet hd tabs, 69, 97

lorcet plus tabs, 69, 97

lorcet tabs, 69, 97

losartan, 82

losartan hct, 82

lovastatin, 83

low-ogestrel, 89

loxapine, 78

LUMIGAN, 93

LUMIZYME INJ, 87

LUPRON DEPOT INJ, 90

LYNPARZA, 76

LYRICA, 72

LYSODREN, 90

lyza, 90

magnesium sulfate inj, 85

malathion, 77

maprotiline, 73

marlissa 28 day, 89

MARPLAN, 73

MATULANE, 75

meclizine, 74

medroxyprogesterone acetate inj, 90

medroxyprogesterone acetate tabs, 90

mefloquine, 77

megestrol acetate oral susp 40mg/ml, 90

megestrol tabs, 90

MEKINIST, 76

meloxicam tabs, 70

memantine hcl immediate release, 73

memantine hcl soln, 73

MENACTRA INJ, 91

MENEST, 89

MENVEO-A/C/Y/W-135 INJ, 91

meprobamate, 80

mercaptopurine, 76

meropenem inj, 71

mesalamine enema kit, 92

MESNEX TABS, 76

MESTINON SYRUP, 75

metadate er, 84

metformin, 80

metformin er uncoated tabs 500mg & 750mg, 80

methadone inj, 69

methadone oral, 69

methazolamide, 93

methenamine hippurate, 70

methimazole, 90

methocarbamol tabs, 94

methotrexate inj, 90

methotrexate oral, 90

methoxsalen, 85

methyldopa, 82

methyldopa & hydrochlorothiazide, 82

methyldopate inj, 82

methylphenidate er tabs 10mg & 20mg, 84

methylphenidate ir tabs 5mg, 10mg & 20mg, 84

methylprednisolone oral, 88

methylprednisolone sodium succinate inj, 88

metipranolol, 93

metoclopramide inj, 86

metoclopramide oral tablets & soln, 86

metolazone, 83

metoprolol & hydrochlorothiazide, 82

metoprolol succinate er, 82

metoprolol tartrate tabs, 82

metronidazole inj, 70

metronidazole oral, 70

metronidazole topical, 70

metronidazole vaginal, 70

mexiletine, 82

MIACALCIN INJ, 92

microgestin, 89

midodrine tabs, 82

migergot suppository, 75

mimvey, 89

mimvey lo, 89

minitran patches, 84

minocycline ir, 72

minoxidil, 84

mirtazapine, 73

mirtazapine odt, 73


misoprostol, 86

mitoxantrone inj, 76

M-M-R II INJ, 91

modafinil, 95

moderiba 200mg tabs, 78

moderiba dose pack, 78

moexipril, 82

moexipril & hydrochlorothiazide, 82

mometasone cream & oint, 88

mometasone furoate nasal, 93

mometasone furoate nasal, 97

montelukast, 94

morgidox, 72

morphine sulfate er tabs, 69, 97

morphine sulfate oral, 69

MOVANTIK, 86

MOVIPREP, 86

moxifloxacin hcl ophthalmic, 72

moxifloxacin oral, 72

MOZOBIL INJ, 81

mupirocin cream, 70

mupirocin ointment, 70

mycophenolate mofetil caps & tabs, 91

mycophenolate mofetil inj, 91

mycophenolate mofetil oral susp, 91

mycophenolic acid dr, 91

myorisan, 85

MYRBETRIQ, 87

nabumetone, 70

nadolol, 82, 83

nadolol & bendroflumethiazide, 83

nafcillin sodium inj, 71

NAGLAZYME INJ, 87

naloxone inj, 69

naltrexone, 69

naproxen, 70

naproxen dr, 70

naproxen sodium ir, 70

naratriptan, 75, 97

NARCAN, 69

NATACYN, 75

nateglinide, 80

NATPARA, 92

NEBUPENT NEBULIZER, 77

necon, 89

nefazodone, 73

neomycin & bacitracin & polymyxin b

ophthalmic, 70

neomycin & polymyxin & bacitracin &

hydrocortisone, 93

neomycin & polymyxin & dexamethasone, 93

neomycin & polymyxin & gramicidin ophthalmic,

70

neomycin & polymyxin & hydrocortisone, 93

neomycin sulfate oral, 70

NEORAL, 91

NERLYNX, 76

NEUPOGEN INJ, 81

NEUPRO PATCH, 77

NEUPRO PATCH, 97

nevirapine er, 79

nevirapine tabs, 79

NEXAVAR, 76

niacin er tabs, 84, 97

nicardipine caps, 83

NICOTROL INHALER, 70

NICOTROL NASAL, 70

nifedipine, 83

nifedipine er, 83

nilutamide, 75

nimodipine caps, 83

NINLARO, 76

nisoldipine er, 83

nitro-bid oint, 84

NITRO-DUR PATCHES, 84

nitrofurantoin caps, 70

nitroglycerin inj, 84

nitroglycerin lingual, 84

nitroglycerin patches, 84

nitroglycerin sublingual, 84

norethindrone, 90

norgestimate-ethinyl estradiol, 89

norlyroc, 90

NORTHERA, 83

nortriptyline oral, 74

NORVIR, 80

NOXAFIL ORAL, 75

NUEDEXTA, 84


111

NULOJIX INJ, 91

NUPLAZID, 78

nyamyc, 75

nystatin, 75

nystatin & triamcinolone, 75

octreotide inj 500mcg/ml & 1000mcg/ml, 90

octreotide inj 50mcg/ml, 100mcg/ml &

200mcg/ml, 90

ODEFSEY, 79

ODOMZO, 76

OFEV, 94

ofloxacin ophthalmic, 72

ofloxacin oral, 72

ofloxacin otic, 72

olanzapine inj 10mg, 78

olanzapine odt, 78

olanzapine tabs, 78

olmesartan, 82

olmesartan & amlodipine, 82

olmesartan hct, 82

olopatadine soln 0.1%, 93



omega-3-acid ethyl esters, 84

omeprazole caps, 87

ondansetron inj, 74

ondansetron odt, 74

ondansetron oral soln, 74

ondansetron tabs, 74

ONFI, 72

ONGLYZA, 80

OPSUMIT, 94

ORAVIG, 75

ORENCIA CLICKJET, 91

ORENCIA INJ PF SYRINGE, 91

ORFADIN, 87

ORKAMBI, 94

orsythia 28 day, 89

oseltamivir caps, 80

oseltamivir susp, 80

OSMOPREP, 86

OTEZLA, 91

OTEZLA STARTER, 91

oxandrolone, 88

oxazepam, 80

oxcarbazepine, 73

oxybutynin, 87, 97

oxybutynin er, 87, 97

oxycodone, 69

oxycodone & acetaminophen, 69, 97

oxycodone & aspirin, 69, 97

oxycodone & ibuprofen, 69

oxycodone & ibuprofen tabs, 97

OXYCODONE ER, 69

OXYCODONE ER, 97

oxycodone immediate-release, 69

oxycodone oral soln, 69

OXYCONTIN, 69, 97

oxymorphone er, 69, 97

OXYTROL, 87

OZEMPIC, 80

pacerone tabs 200mg, 82

paclitaxel inj, 76

paliperidone er, 78

pamidronate inj, 92

PANRETIN, 77

pantoprazole inj, 87

pantoprazole tabs, 87

paricalcitol caps, 92

paromomycin, 70

paroxetine hcl er, 74

paroxetine hcl immediate-release, 74

paroxetine mesylate, 92

PASER, 75

PAXIL 10MG/5ML SUSP, 74

PEDIARIX INJ, 91

PEDVAX HIB INJ, 91

peg 3350 & electrolytes, 86

peg 3350 & sodium chloride & sodium

bicarbonate & potassium chloride, 86

PEGANONE, 73

PEGASYS INJ, 78

PEGASYS PROCLICK INJ, 78

penicillin g inj 5 million units, 71

penicillin v potassium, 71

PENTAM INJ, 77


PENTASA, 92, 97

pentoxifylline er, 83

PERFOROMIST NEBULIZER, 94

perindopril, 82

permethrin cream, 77

perphenazine, 74, 78

perphenazine & amitriptyline, 74

phenadoz, 74

phenelzine, 73

phenergan suppositories, 74

phenobarbital elixir, 72

phenobarbital tabs, 72

phenytoin chewable tabs, 73

phenytoin er, 73

phenytoin inj, 73

phenytoin oral susp, 73

PHOSPHOLINE IODIDE, 93

pilocarpine soln, 93

pilocarpine tabs, 85

pimozide, 78

pimtrea, 89

pindolol, 83

pioglitazone, 80

pioglitazone & metformin, 80

piperacillin/tazobactam inj, 71

pirmella 1/35, 89

piroxicam, 70

PLEGRIDY INJ, 84

PLEGRIDY STARTER PACK INJ, 84

plenamine inj, 86

podofilox, 85

polyethylene glycol 3350, 86

polymyxin b sulfate & trimethoprim sulfate

ophthalmic soln, 70

POMALYST, 75

potassium chloride & dextrose & lactated ringers

inj, 86

potassium chloride & dextrose & sodium

chloride inj 20mEq/5%/0.45% &

30mEq/5%/0.45%, 86

potassium chloride er, 86

potassium chloride inj, 86

potassium chloride oral soln, 86

potassium chloride viaflex inj, 86

potassium citrate er, 86

PRADAXA, 81

pramipexole ir, 77

pravastatin, 84

prazosin, 82

PRED MILD, 93

prednicarbate, 88

prednisolone, 93

prednisolone acetate, 93

prednisolone oral soln, 88

prednisolone sodium phosphate, 93

prednisone dose pack, 88

prednisone oral soln, 92

prednisone tabs, 92

PREMARIN ORAL, 89

PREMARIN VAGINAL, 89

PREMPHASE, 89

PREMPRO, 89

prenatal multi-vitamin, 86

PREPOPIK, 86

prevalite, 84

PREZCOBIX, 80

PREZISTA SUSP 100MG/ML, 80

PREZISTA TABS 600MG & 800MG, 80

PREZISTA TABS 75MG & 150MG, 80

PRIFTIN, 75

PRIMAQUINE, 77

primidone, 72

PROAIR HFA, 94

PROAIR RESPICLICK, 94

probenecid, 75

probenecid & colchicine, 75

procainamide inj, 82

prochlorperazine inj, 74

prochlorperazine oral, 74

prochlorperazine suppositories, 74

PROCRIT INJ 20000UNIT/ML &

40000UNIT/ML, 81

PROCRIT INJ 2000UNIT/ML, 81

PROCRIT INJ 3000UNIT/ML, 4000UNIT/ML &

10000UNIT/ML, 81

procto-med hc, 88

procto-pak, 88

proctosol hc, 88


113

proctozone-hc, 88

progesterone caps, 90

PROGLYCEM, 81

PROLASTIN C INJ, 94

PROLIA, 92

PROMACTA, 81

promethazine inj, 74

promethazine suppositories, 74

promethazine syrup, 74

promethazine tabs 12.5mg, 25mg & 50mg, 74

promethegan, 74

propafenone, 82

propranolol & hydrochlorothiazide, 83

propranolol er caps, 83

propranolol inj, 83

propranolol ir tabs, 83

propranolol oral soln, 83

propylthiouracil, 90

PROQUAD INJ, 91

PROSOL INJ, 86

PROTONIX INJ, 87

protriptyline, 74

prudoxin, 85

PULMICORT NEBULIZER, 93

PULMOZYME, 94

PURIXAN, 76

pyrazinamide, 75

pyridostigmine, 75

pyridostigmine er, 75

QUADRACEL INJ, 91

quetiapine, 78

quetiapine er tabs, 78

quinapril, 82

quinapril & hydrochlorothiazide, 82

quinidine gluconate cr, 82

quinidine gluconate inj, 82

quinidine sulfate, 82

quinine sulfate caps 324mg, 77

QVAR, 93

QVAR REDIHALER, 93

RABAVERT INJ, 91

raloxifene hcl, 90, 97

ramipril, 82

RANEXA, 83

ranitidine caps, syrup & inj, 86

ranitidine tabs, 86

RAPAMUNE SOLN, 91

rasagiline, 77

RAVICTI, 87

REBIF INJ, 84

REBIF REBIDOSE INJ, 84

REBIF REBIDOSE TITRATION PACK INJ, 84

REBIF TITRATION PACK INJ, 84

RECOMBIVAX HB INJ, 91

REGRANEX, 85, 97

RELENZA DISKHALER, 80

RELISTOR INJ, 86

RELISTOR TABS, 86

REMICADE INJ, 91

REMODULIN INJ, 94

repaglinide, 80

REPATHA INJ, 83

RESCRIPTOR, 79

RESTASIS, 92

RETROVIR IV INJ, 79

REVLIMID, 75

REXULTI, 78

REYATAZ CAPS & ORAL POWDER, 80

ribasphere, 78

ribasphere ribapak, 78

ribavirin, 79

RIDAURA, 91

rifabutin, 75

rifampin inj, 75

rifampin oral, 75

RIFATER, 75

riluzole, 84

rimantadine, 80

risedronate sodium, 92

risedronate sodium dr, 92

RISPERDAL CONSTA INJ 12.5MG & 25MG, 78

RISPERDAL CONSTA INJ 37.5MG & 50MG, 78

risperidone, 78

risperidone odt, 78

ritonavir tabs, 80

RITUXAN HYCELA INJ, 77


RITUXAN INJ, 77

rivastigmine caps, 73

rivastigmine caps, 97

rivastigmine patches, 97

rivastigmine patches, 73

rizatriptan, 75

rizatriptan odt, 75

ropinirole, 77

rosuvastatin, 84

ROTARIX, 91

ROTATEQ, 91

roweepra, 72

roweepra xr, 72

ROZEREM, 95, 97

RUBRACA, 76

RYDAPT, 76

SABRIL TABS, 72

SANDIMMUNE CAPS 25MG & 100MG, 91

SANDIMMUNE ORAL SOLN 100MG/ML, 91

SANTYL, 85

SAPHRIS, 78

SAVELLA, 84

SAVELLA TITRATION PACK, 84

scopolamine patch, 74

selegiline, 77

selenium sulfide lotion, 85

SELZENTRY 150MG & 300MG, 79

SELZENTRY 25MG & 75MG, 79

SELZENTRY SOLN, 79

SENSIPAR TABS 30MG, 92

SENSIPAR TABS 60MG & 90MG, 92

SEREVENT DISKUS, 94

SEROQUEL XR, 78

sertraline oral soln, 74

sertraline tabs, 74

setlakin, 89

sevelamer carbonate powder, 86

sevelamer carbonate tabs, 86

sharobel, 90

SHINGRIX, 91

sildenafil tabs 20mg, 94

SILENOR, 95, 97

silver sulfadiazine, 70

simvastatin, 84

sirolimus tabs, 91

SIRTURO, 75

SIVEXTRO, 71

sodium chloride inj, 86

sodium phenylbutyrate powder & tabs, 87

sodium polystyrene sulfonate, 85

SOLTAMOX, 76

SOLU-CORTEF INJ, 88

SOMATULINE DEPOT INJ, 90

SOMAVERT INJ, 90

sorine, 82

sotalol tabs, 82

SPIRIVA HANDIHALER, 94

SPIRIVA RESPIMAT, 94

spironolactone, 83

spironolactone & hydrochlorothiazide, 83

SPORANOX ORAL SOLN, 75

SPRITAM, 72

SPRYCEL, 76

ssd, 71

stavudine caps, 79

STELARA INJ 45MG/0.5ML, 90MG/ML, 85

STIMATE, 88

STIOLTO RESPIMAT, 94

STIVARGA, 76

streptomycin inj, 70

STRIBILD, 79

STRIVERDI RESPIMAT, 94

SUCRAID, 87

sucralfate, 86

sulfacetamide sodium & prednisolone sodium

phosphate ophthalmic, 72

sulfacetamide sodium ophthalmic oint & soln

10%, 72

sulfacetamide sodium topical susp 10%, 72

sulfadiazine, 72

sulfamethoxazole & trimethoprim, 72

sulfamethoxazole & trimethoprim ds tabs, 72

sulfamethoxazole & trimethoprim inj, 72

sulfamethoxazole & trimethoprim oral susp, 72

sulfamethoxazole & trimethoprim tabs, 72

sulfasalazine, 92

sulindac, 70

sumatriptan nasal, 75


115

sumatriptan succinate inj, 75

sumatriptan succinate oral, 75

SUPRAX CAPS & CHEWABLE TABS, 71

SUPRAX ORAL SUSP 500MG/5ML, 71

SUPREP BOWEL PREP, 86

SUSTIVA 200MG CAPS, 79

SUSTIVA 600MG TABS, 79

SUTENT, 76

SYLATRON INJ, 76

SYMFI LO, 79

SYMLINPEN INJ, 80

SYNAGIS INJ, 91

SYNAREL, 90

SYNERCID INJ, 71

SYNRIBO INJ, 76

SYNTHROID, 90

SYPRINE, 85

TABLOID, 76

tacrolimus caps 0.5mg & 1mg, 91

tacrolimus caps 5mg, 91

tacrolimus oint, 85

TAFINLAR, 77

TAGRISSO, 77

tamoxifen, 76

tamsulosin, 87

TARCEVA, 77

TARGRETIN GEL, 77

tarina fe, 89

TASIGNA, 77

tazarotene, 85

tazicef inj, 71

TAZORAC 0.05% CREAM, 85

TAZORAC GEL, 85, 97

taztia xt, 83

TECFIDERA, 84

TECFIDERA STARTER PACK, 84

TEFLARO INJ, 71

TEGRETOL, 73

TEGRETOL XR, 73

TEKTURNA, 83

TEKTURNA HCT, 83

temazepam, 95

TENIVAC, 91

tenofovir disoproxil fumarate tabs, 79

terazosin, 82

terbinafine, 75

terbutaline sulfate inj, 94

terbutaline sulfate oral, 94

terconazole, 75

testosterone cypionate inj, 88

testosterone enanthate inj, 88

testosterone gel 1% pump, 88

testosterone gel 25mg/2.5g & 50mg/5g, 88

TETANUS & DIPHTHERIA TOXOIDS-

ADSORBED ADULT INJ, 92

tetracycline, 72

THALOMID, 75

theophylline cr & er tabs, 94

THIOLA, 87

thioridazine, 78

thiothixene, 78

THYROLAR, 90

tiagabine tabs, 72

TIGECYCLINE INJ, 71

timolol ophthalmic gel forming, 93

timolol oral, 83

timolol soln, 93

TIVICAY 10MG & 25MG TABS, 79

TIVICAY 50MG TAB, 79

tizanidine, 78

TOBI, 94

TOBI PODHALER, 94

TOBRADEX OINT, 70

tobramycin & dexamethasone ophthalmic

suspension, 70

tobramycin nebulizer, 94

tobramycin ophthalmic solution, 70

tobramycin sulfate inj, 70

TOLAK, 85

tolterodine tartrate er, 87, 97

topiramate immediate-release, 73

torsemide oral, 83

TOUJEO SOLOSTAR, 81

TOVIAZ, 87

TPN ELECTROLYTES INJ, 86

TRACLEER, 94


tramadol, 69, 97

tramadol & acetaminophen, 69, 97

tramadol er tabs, 69, 97

trandolapril, 82

tranexamic acid inj, 81

tranexamic acid tabs, 81

tranylcypromine, 73

TRAVASOL INJ, 86

trazodone, 73

TRECATOR, 75

TRELSTAR MIXJECT, 90

tretinoin caps, 77

tretinoin cream, gel, 85

triamcinolone, 85

triamcinolone acetonide topical cream, inj, lotion

& oint, 88

triamcinolone in orabase, 85

triamterene & hydrochlorothiazide, 83

triazolam, 95

triderm, 88

trientine, 85

trifluoperazine, 78

trifluridine, 79

trihexyphenidyl elixir, 77

trihexyphenidyl tabs, 77

TRILEPTAL, 73

tri-lo-estarylla, 89

tri-lo-sprintec, 89

trimethoprim, 71

trimipramine maleate, 74

TRINTELLIX, 73

tri-sprintec, 89

TRIUMEQ, 79

trivora-28, 89

TRUMENBA INJ, 92

TRUVADA, 79

TUDORZA PRESSAIR, 94

TWINRIX INJ, 92

TYBOST, 79

TYGACIL INJ, 71

TYKERB, 77

TYMLOS, 92

TYPHIM VI INJ, 92

TYSABRI INJ, 85

ULORIC, 75

unithroid, 90

UPTRAVI, 94

ursodiol, 86

valacyclovir, 79

VALCHLOR, 75

valganciclovir tabs, 78

valproate sodium inj, 72

valproic acid, 72

valsartan, 82

valsartan & amlodipine, 82

valsartan & amlodipine & hct, 82

valsartan hct, 82

vancomycin inj, 71

vancomycin oral, 71

vandazole, 71

VAQTA INJ, 92

VARIVAX INJ, 92

VARIZIG INJ, 92

VELCADE INJ, 76

velivet, 89

VELTASSA, 85

VENCLEXTA STARTING PACK, 76

VENCLEXTA TABS 100MG, 76

VENCLEXTA TABS 10MG & 50MG, 76

venlafaxine er caps, 74

venlafaxine ir tabs, 74

VENTAVIS, 94

verapamil er, 83

verapamil inj, 83

verapamil ir, 83

verapamil sr, 83

VERSACLOZ, 78

VERZENIO, 76

VESICARE, 87

VICTOZA INJ, 80

VIDEX EC 125MG, 79

VIDEX PEDIATRIC SOLN, 79

vienva, 89

vigabatrin powder for oral soln, 72

VIIBRYD, 74

VIIBRYD STARTER PACK, 74

VIMPAT INJ, 73

VIMPAT ORAL, 73


117

VIRACEPT, 80

VIRAMUNE ORAL SUSP, 79

VIRAMUNE TABS, 79

VIREAD POWDER, 79

VIREAD TABS, 79

voriconazole inj, 75

voriconazole oral, 75

VOTRIENT, 77

VPRIV INJ, 87

VRAYLAR CAPSULES, 78

VRAYLAR DOSE PACK, 78

vyfemla, 89

warfarin, 81

WELCHOL, 84

wymzya fe, 89

XALKORI, 77

XARELTO, 81

XARELTO STARTER PACK, 81

XATMEP, 91

XELJANZ, 91

XELJANZ XR, 91

XERESE, 79

XGEVA INJ, 92

XIFAXAN TABS 200MG, 71

XIFAXAN TABS 550MG, 71

XIGDUO XR, 80

XIIDRA, 92

XOPENEX NEBULIZER, 94

XTANDI, 75

XYREM, 95

YERVOY INJ, 77

YF-VAX INJ, 92

yuvafem, 89

zafirlukast, 94, 97

ZAVESCA, 87

ZEJULA, 76

ZELBORAF, 77

zenatane, 85

zenchent, 89

zenzedi tabs 5mg & 10mg, 84, 97

ZERBAXA INJ, 71

ZERIT SOLN, 79

ZIAGEN SOLN, 79

zidovudine, 79

zileuton er, 94

ziprasidone oral, 78

ZIRGAN, 78

zoledronic acid 4mg/5ml inj, 92

zoledronic acid 5mg/100ml inj, 92

ZOLINZA, 76

zolmitriptan odt, 75

zolmitriptan tabs, 75

zolpidem tabs 5mg & 10mg, 95

ZOMETA INJ 4MG/100ML, 92

ZOMIG NASAL, 75, 97

ZONALON, 85

zonisamide, 72

ZORTRESS TABS 0.25MG, 91

ZORTRESS TABS 0.5MG & 0.75MG, 91

ZOSTAVAX INJ, 92

ZOSYN GALAXY INJ 2GM/0.25GM &

3GM/0.375GM, 71

zovia, 89

ZOVIRAX CREAM, 79

ZYDELIG, 76

ZYKADIA, 77

ZYPREXA RELPREVV 210MG INJ, 78

ZYTIGA, 75

………………..……

Y0057_SCAN_10440_2017F File & Use Accepted 08112017 G10505 06/18 18C-FOR900

This formulary was updated on 06/01/2018. For more recent information or other questions, please contact SCAN Health Plan Member Services at 1-800-559-3500 (Medicare and Medi-Cal eligible members should call 1-866-722-6725) 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 (messages received on holidays and outside of our business hours will be returned within one business day), or visit www.scanhealthplan.com.

Este formulario se actualizó el 1 de junio de 2018. Para obtener información más reciente o si tiene dudas, comuníquese con Servicios para Miembros de SCAN Health Plan al 1-800-559-3500 (los miembros elegibles para Medicare y Medi-Cal deben llamar al 1-866-722-6725) 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 (los mensajes recibidos en días festivos y fuera del horario hábil se devolverán en un día hábil); o visite www.scanhealthplan.com.

SCAN Health Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. SCAN Health Plan cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad,

discapacidad o sexo. SCAN Health Plan 遵守適用的聯邦民權法律規定，不因種族、膚色、民族血統、

年齡、殘障或性別而歧視任何人。

ATTENTION: If you speak another language, language assistance services, free of charge, are available to you. Call 1-800-559-3500. (TTY: 711). ATENCIÓN: si habla español, tiene a su disposición

servicios gratuitos de asistencia lingüística. Llame al 1-800-559-3500. (TTY: 711). 注意：如果您使用

中文，您可以免費獲得語言援助服務。請致電 1-800-559-3500。（聽障專線：711）。

http://www.scanhealthplan.com/

2018 - scan health plan formulario se actualizó el 1 de abril de 2018. ... scan health plan member...

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