san bernardino county scan classic (hmo) scan prime …...jan 01, 2021 · san bernardino county...

San Bernardino County

SCAN Classic (HMO)SCAN Prime (HMO)

2021 Enrollment KitMedicare Advantage Plan

SCAN_38692_21C-SKB501_R1373_ClsPrm_SB_ENG_v6a.pdf

TABLE OF CONTENTS

SECTION I

Summary of Benefits

SECTION II

Additional Plan Information

SECTION III

Pharmacy Benefit

SECTION IV

Enrolling in SCAN Health PlanThe SCAN Story Keeping Seniors Healthy and Independent. That’s been the SCAN mission since the organization was founded in 1977.

We began when a group of senior activists in Long Beach, California got together, determined to improve access to the care and services they needed so they could stay as independent as possible. They brought together experts in medicine, gerontology, psychology and social services and formed the not-for-profit Senior Care Action Network, now known as SCAN.

More than forty years later, seniors are still at the heart of all we do — and they always will be. You can count on SCAN to help you stay healthy, vibrant and connected for years to come.

SCAN_38692_2021_TOC_v2_PR.pdf

Y0057_SCAN_11591_2019_C 07232020 R1535 08/20 SCAN-SCOPEFORM

Sales Appointment ConfirmationPlease initial below beside the type of product(s) you want the agent to discuss.The Centers for Medicare and Medicaid Services (CMS) requires agents to document the scope of a marketing appointment prior to any sales meeting to ensure understanding of what will be discussed between the agent and the Medicare beneficiary (or their authorized representative).

Medicare Advantage Plans (Part C) and Cost PlansMedicare Health Maintenance Organization (HMO) — A Medicare Advantage Plan that provides all Original Medicare Part A and Part B health coverage and sometimes covers Part D prescription drug coverage. In most HMOs, you can only get your care from doctors or hospitals in the plan’s network (except in emergencies).

Medicare Special Needs Plan (SNP) — A Medicare Advantage Plan that has a benefit package designed for people with special health care needs. Examples of the specific groups served include people who have both Medicare and Medicaid, people who reside in nursing homes, and people who have certain chronic medical conditions.

Optional Supplemental Dental Plans — Administered by Delta Dental Insurance Company

By signing this form, you agree to a meeting with a sales agent to discuss the types of products you initialed above.

Agreeing to this appointment does not affect your current or future Medicare enrollment status and there is no obligation to enroll. In addition, completing this confirmation will not automatically enroll you in a Medicare Advantage Plan, Prescription Drug Plan, or other Medicare Plan.Beneficiary or Authorized Representative Signature and Signature Date:

__________________________________________________________ __________________________Signature Signature Date

If you are the authorized representative, please sign above and print below:

Representative’s Name: __________________________________________________________________

Your Relationship to the Beneficiary: ________________________________________________________

Plan Use Only: To be completed by Agent

Agent Name: Agent Phone:

Beneficiary Name: Beneficiary Phone (Optional):

Beneficiary Address:

Initial Method of Contact: (Indicate here if beneficiary was a walk-in.)

Agent’s Signature: Date Appointment Completed:

Plan(s) the agent represented during this meeting:

If the form was signed by the beneficiary at time of appointment, provide explanation why Sales Appointment Confirmation was not documented prior to meeting:

Sales Appointment Confirmation (Scope of Appointment Form) documentation is subject to CMS record retention requirements.

SCAN-SCOPEFORM.pdf

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This page is intentionally blank_ENG.pdf

Summary of Benefits

SCAN_35253_2020_ENROLLMENT_KIT_DIVIDERS_SCAN_v1a.pdf

TRIM_MARKS_ONLY.pdf

2021

Summary of BenefitsSCAN Classic (HMO)

and SCAN Prime (HMO)San Bernardino County

January 1, 2021 ‑ December 31, 2021

SCAN Classic (HMO) and SCAN Prime (HMO) are HMO plans with Medicare contracts. Enrollment in SCAN Health Plan depends on contract renewal.

The benefit information provided does not list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, please request the “Evidence of Coverage” by calling our Member Services Department at the phone number listed in this document or online at www.scanhealthplan.com.

Y0057_SCAN_12099_2020F_M R1373 8/20 21C‑SMB501

SCAN_38692_21C-SMB501_ClsPrm_SB_T2-INS_v4_18p.pdf

SCAN_38692_21C-SMB501_ClsPrm_SB_T2-INS_v4_18p.pdf:2

I – 2

PREMIUM AND BENEFITS SCAN CLASSIC SCAN PRIME WHAT YOU SHOULD KNOW

Monthly Health Plan Premium

You pay $0 per month

You pay $23 per month

You must continue to pay your Medicare Part B premium.

Deductible You pay $0 You pay $0 This plan does not have a deductible.

Maximum Out‑of‑Pocket Responsibility (this does not include prescription drugs)

$999 annually $699 annually The most you pay for copays and coinsurance for Medicare‑covered medical services for the year.

Inpatient Hospital Coverage You pay $0 You pay $0 Our plan covers an unlimited number of days for an inpatient hospital stay. Prior authorization rules apply.

Outpatient Hospital Services

• Ambulatory Surgical Center

• Outpatient Hospital

You pay $0

You pay $0‑$100 copay per visit

You pay $0

You pay $0‑$100 copay per visit

Prior authorization rules apply for outpatient hospital services.

Doctor Visits

• Primary Care

• Specialists

You pay $0

You pay $0

You pay $0

You pay $0 Prior authorization rules apply for specialist visits.

Preventive Care You pay $0 You pay $0 Any additional preventive services approved by Medicare during the contract year will be covered. Prior authorization rules apply.

Emergency Care You pay $90 copay per visit

You pay $90 copay per visit

The emergency room copay will be waived if you are immediately admitted to the hospital.

You are covered for worldwide emergency services.

SUMMARY OF BENEFITS JANUARY 1, 2021 – DECEMBER 31, 2021


I – 3


Urgently Needed Services You pay $0 You pay $0 You are covered for worldwide urgent care services.

Diagnostic Services/Labs/Imaging

• Lab services

• Diagnostic tests and procedures

• Outpatient X‑rays

• Therapeutic radiology

• Diagnostic radiology (e.g., MRI, CT)

You pay $0

You pay $0

You pay $0



You pay $0

You pay $0

You pay $0



Prior authorization rules apply for diagnostic, lab, and imaging services.


I – 4


Hearing Services

• Medicare‑covered diagnostic hearing and balance exam

• Non‑Medicare‑covered (routine) hearing exam

• Non‑Medicare‑covered (routine) hearing aids

You pay $0

You pay $0 for up to 1 visit every 12 months

You pay $450 copay per aid for a TruHearing Advanced hearing aid or $750 copay per aid for a TruHearing Premium hearing aid

You are covered for up to 2 hearing aids every 12 months

You pay $0


Your benefit includes 3 options:

1) A $200 copay per aid for TruHearing Advanced hearing aids,

or

2) a $400 copay per aid for TruHearing Premium hearing aids,

or

3) a $3,000 allowance toward the purchase of any hearing aid from the TruHearing Choice product line.

You are covered for up to 2 hearing aids every 12 months

Prior authorization rules apply for Medicare‑covered diagnostic hearing and balance exams.

You must go to a SCAN‑contracted provider to obtain a routine hearing exam and hearing aids.


I – 5


Dental Services

• Medicare‑covered dental services

• Non‑Medicare‑covered (routine) oral exam

• Non‑Medicare‑covered (routine) dental cleaning

• Non‑Medicare‑covered (routine) dental X‑rays

You pay $0

You pay $0 for up to 2 visits every 12 months

You pay $0 for up to 2 visits every 12 months

You pay $0 for up to 2 series every 12 months

You pay $0

You pay $10 copay for up to 2 visits every 12 months

You pay $5 copay for up to 2 visits every 12 months

You pay $15 copay for up to 1 series every 6 months

Prior authorization rules apply for Medicare‑covered dental services.

Routine dental benefits are available with an additional premium. See the “Optional Supplemental Benefits” chart at the end of this document.

Vision Services

• Medicare‑covered vision exam to diagnose/treat diseases of the eye

• Medicare‑covered glasses after cataract surgery

• Non‑Medicare‑covered (routine) vision exam

• Non‑Medicare‑covered (routine) glasses or contact lenses

• Non‑Medicare‑covered (routine) vision coverage limit

You pay $0

You pay $0


You pay $10 copay per pair every 24 months

You are covered for up to $135 for frames or contact lenses every 24 months

You pay $0

You pay $0


You pay $30 copay per pair every 24 months

You are covered for up to $175 for frames or contact lenses every 24 months

Prior authorization rules apply for Medicare‑covered vision exam and glasses after cataract surgery.

Routine vision services do not require prior authorization.

You must go to a SCAN‑contracted vision provider to obtain routine vision services.


I – 6


Mental Health Services

• Inpatient visit

• Outpatient individual/group therapy visit

• Outpatient individual/group therapy visit with a psychiatrist

You pay $0 per day for days 1‑90


You pay $0



You pay $0

Prior authorization rules apply for inpatient mental health hospitalization. You are covered for up to 90 days per benefit period.*

Prior authorization rules apply for outpatient mental health services.

Skilled Nursing Facility You pay $0 per day for days 1‑20

You pay $100 copay per day for days 21‑100


You pay $100 copay per day for days 21‑100

Prior authorization rules apply for skilled nursing facility services. You are covered for up to 100 days per benefit period.*

No prior hospitalization is required.

Physical Therapy You pay $0 You pay $0 Prior authorization rules apply for outpatient physical therapy services.

Ambulance You pay $200 copay per one‑way trip

You pay $200 copay per one‑way trip

Transportation (Non‑Medicare‑ covered—routine)

You pay $0 for up to 24 one‑way trips per year

75‑mile limit applies to each one‑way trip

You pay $0 for up to 24 one‑way trips per year

75‑mile limit applies to each one‑way trip

Prior authorization rules apply for routine transportation services. You must use a SCAN‑contracted provider to obtain routine transportation services.

Medicare Part B Drugs You pay 20% of the total cost for chemotherapy and other Part B drugs

You pay 20% of the total cost for chemotherapy and other Part B drugs

Prior authorization rules apply to select drugs.

* A benefit period begins the day you go into a hospital or SNF. The benefit period ends when you haven’t received any inpatient hospital or SNF care for 60 days in a row.


I – 7

OUTPATIENT PRESCRIPTION DRUGS (PART D DRUGS):

You pay the following:

SCAN CLASSIC

Drug Tier

Retail Mail‑Order

Preferred Standard Preferred Standard

30‑day supply

100‑day supply

30‑day supply

100‑day supply

100‑day supply

100‑day supply

Initial Coverage Stage

Tier 1 (Preferred Generic)

You pay $0

You pay $0

You pay $9

You pay $18

You pay $0

You pay $18

Tier 2 (Generic)

You pay $7

You pay $14

You pay $15

You pay $30

You pay $0

You pay $30

Tier 3 (Preferred Brand)

Select Insulins

You pay $25

You pay $55

You pay $35

You pay $85

You pay $55

You pay $85

Other DrugsYou pay

$37You pay

$91You pay

$47You pay $121

You pay $91

You pay $121

Tier 4 (Non‑Preferred Drug)

You pay $95

You pay $265

You pay $100

You pay $280

You pay $265

You pay $280

Tier 5 (Specialty Tier)

You pay 33%

Not available

You pay 33%

Not available

Not available

Not available

Coverage Gap Stage Begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $4,130.

You pay the same copays as in the Initial Coverage Stage for Tier 1, Tier 2 drugs and Tier 3 (select insulins only). For drugs in other tiers, you pay 25% of the negotiated price (and a portion of the dispensing fee) for your brand name drugs and 25% of the cost for your generic drugs.

Catastrophic Coverage Stage After your yearly out‑of‑pocket drug costs reach $6,550, you pay the greater of:

– 5% of the cost, or– $3.70 copay for generic (including drugs that are treated

like a generic) and $9.20 copay for all other drugs.

These copays for select insulins apply to members who do not qualify for a program that helps pay for your drugs (“Extra Help”). Select insulins are all insulin pens and vials in Tier 3 covered on our most recent Drug List we provided electronically. If you have questions about the Drug List, you can call Member Services.


I – 8

Some of our network pharmacies have preferred cost‑sharing. You may pay less for certain drugs if you use these pharmacies. Your cost‑sharing may vary depending on the pharmacy you choose (e.g., Preferred Retail, Standard Retail, Preferred Mail‑Order, Standard Mail‑Order, Long Term Care (LTC), Home infusion, etc.) or whether you receive a one‑month or a three‑month supply or when you enter another phase of the Part D benefit or if you receive “Extra Help.” For more information, please call our Member Services Department at the number provided in this document or access your Evidence of Coverage online.If you reside in a long‑term care facility, your cost‑sharing for a 31‑day supply is the same as at a standard retail pharmacy for a 30‑day supply. You may get drugs from an out‑of‑network pharmacy, but may pay more than you pay at an in‑network pharmacy.

You can get prescription drugs shipped to your home through our network mail‑order delivery program. Express Scripts PharmacySM is our Preferred mail order pharmacy. While you can fill your prescription medications at any of our network mail order pharmacies, you may pay less at the Preferred mail order pharmacy. Typically, you should expect to receive your prescription drugs within 14 days from the time that Express Scripts mail order pharmacy receives the order. If you do not receive your prescription drug(s) within this time, please contact SCAN Health Plan’s Member Services. For your mail order prescriptions, you have the option to sign up for an automatic refill program by contacting Express Scripts Pharmacy at 1‑866‑553‑4125, 24 hours a day, 7 days a week. TTY users call 711. You may opt out of automatic deliveries at any time. Other pharmacies are available in our network. Other pharmacies are available in our network.


I – 9

OUTPATIENT PRESCRIPTION DRUGS (PART D DRUGS):

You pay the following:

SCAN PRIME

Drug Tier

Retail Mail‑Order

Preferred Standard Preferred Standard

30‑day supply

100‑day supply

30‑day supply

100‑day supply

100‑day supply

100‑day supply

Initial Coverage Stage

Tier 1 (Preferred Generic)

You pay $0

You pay $0

You pay $7

You pay $14

You pay $0

You pay $14

Tier 2 (Generic)

You pay $7

You pay $14

You pay $14

You pay $28

You pay $0

You pay $28

Tier 3 (Preferred Brand)

Select Insulins

You pay $25

You pay $55

You pay $35

You pay $85

You pay $55

You pay $85

Other DrugsYou pay

$37You pay

$91You pay

$47You pay $121

You pay $91

You pay $121

Tier 4 (Non‑Preferred Drug)

You pay $95

You pay $265

You pay $100

You pay $280

You pay $265

You pay $280

Tier 5 (Specialty Tier)

You pay 33%

Not available

You pay 33%

Not available

Not available

Not available

Coverage Gap Stage Begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $4,130.

You pay the same copays as in the Initial Coverage Stage for Tier 1, Tier 2 drugs and Tier 3 (select insulins only). For drugs in other tiers, you pay 25% of the negotiated price (and a portion of the dispensing fee) for your brand name drugs and 25% of the cost for your generic drugs.

Catastrophic Coverage Stage After your yearly out‑of‑pocket drug costs reach $6,550, you pay the greater of:

– 5% of the cost, or– $3.70 copay for generic (including drugs that are treated

like a generic) and $9.20 copay for all other drugs.

These copays for select insulins apply to members who do not qualify for a program that helps pay for your drugs (“Extra Help”). Select insulins are all insulin pens and vials in Tier 3 covered on our most recent Drug List we provided electronically. If you have questions about the Drug List, you can call Member Services.


I – 10

Some of our network pharmacies have preferred cost‑sharing. You may pay less for certain drugs if you use these pharmacies. Your cost‑sharing may vary depending on the pharmacy you choose (e.g., Preferred Retail, Standard Retail, Preferred Mail‑Order, Standard Mail‑Order, Long Term Care (LTC), Home infusion, etc.) or whether you receive a one‑month or a three‑month supply or when you enter another phase of the Part D benefit or if you receive “Extra Help.” For more information, please call our Member Services Department at the number provided in this document or access your Evidence of Coverage online.If you reside in a long‑term care facility, your cost‑sharing for a 31‑day supply is the same as at a standard retail pharmacy for a 30‑day supply. You may get drugs from an out‑of‑network pharmacy, but may pay more than you pay at an in‑network pharmacy.

You can get prescription drugs shipped to your home through our network mail‑order delivery program. Express Scripts PharmacySM is our Preferred mail order pharmacy. While you can fill your prescription medications at any of our network mail order pharmacies, you may pay less at the Preferred mail order pharmacy. Typically, you should expect to receive your prescription drugs within 14 days from the time that Express Scripts mail order pharmacy receives the order. If you do not receive your prescription drug(s) within this time, please contact SCAN Health Plan’s Member Services. For your mail order prescriptions, you have the option to sign up for an automatic refill program by contacting Express Scripts Pharmacy at 1‑866‑553‑4125, 24 hours a day, 7 days a week. TTY users call 711. You may opt out of automatic deliveries at any time. Other pharmacies are available in our network.


I – 11

Plans may offer supplemental benefits in addition to Part C benefits and Part D benefits.

BENEFITS SCAN CLASSIC SCAN PRIME WHAT YOU SHOULD KNOW

Acupuncture Services You pay $15 copay for up to 30 visits per year combined with routine chiropractic services

You pay $0 for up to 20 visits per year combined with routine chiropractic services

You do not need a referral for an initial acupuncture visit. Any subsequent visits require prior authorization.

Chiropractic Services

• Medicare‑covered chiropractic care

• Routine chiropractic care

You pay $0

You pay $15 copay for up to 30 visits per year combined with acupuncture services

You pay $0

You pay $0 for up to 20 visits per year combined with acupuncture services

Prior authorization rules apply

You do not need a referral for an initial routine chiropractor visit. Any subsequent visits require prior authorization.

Home Health Care (Medicare‑covered)

You pay $0 You pay $0 Prior authorization rules apply

Medical Equipment/Supplies

• Durable Medical Equipment (e.g., wheelchairs, oxygen)

• Prosthetics (e.g., braces, artificial limbs)

• Diabetic supplies

You pay 0% to 20% of the total cost


You pay $0



You pay $0

Prior authorization rules apply for covered durable medical equipment, prosthetic devices, and certain diabetic supplies.

SCAN covers diabetic supplies such as glucose monitors, test strips, and control solution from a select manufacturer. Lancets are also covered and are available from all manufacturers.

ADDITIONAL BENEFITS


I – 12

ADDITIONAL BENEFITS

BENEFITS SCAN CLASSIC SCAN PRIME WHAT YOU SHOULD KNOW

Telehealth Services You pay $0 You pay $0 A visit with a board‑certified doctor in the comfort of your own home. This benefit is for non‑life threatening conditions such as, but not limited to, cough, flu, nausea, sore throat, fever, and allergies.

Visits with doctors can be conducted either by telephone or secure video capabilities from your computer or smart phone.


I – 13

OPTIONAL SUPPLEMENTAL BENEFITS

DENTAL SERVICES – SCAN CLASSIC ONLY

Essential Dental Plan

Monthly Premium $10 per month

• Access to a large network of Delta Dental DHMO providers• Over 290 dental procedures included• Predictable copayments• Additional comprehensive dental coverage• Only available in the SCAN Classic Plan


I – 14

SCAN Classic and SCAN Prime have a network of doctors, hospitals, pharmacies, and other providers. If you use the providers that are not in our network, the plan may not pay for these services.

ABOUT SCAN CLASSIC AND SCAN PRIME

Who can join? You must:

– have both Medicare Part A and Part B– live in the plan service area (San Bernardino County,

California)– be a United States citizen or be lawfully present in the

United States

Phone Number (Members)

Phone Number (Non‑Members)

TTY

1‑800‑559‑3500

1‑877‑870‑4867

Calling this number will direct you to a licensed insurance agent.

711

Hours of Operation October 1 to March 31:8 a.m. to 8 p.m., 7 days a week

April 1 to September 30:8 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.

Website http://www.scanhealthplan.com

To get more information about the coverage and costs of Original Medicare, look in your current “Medicare & You” handbook. View it online at https://www.medicare.gov or get a copy by calling 1‑800‑MEDICARE (1‑800‑633‑4227), 24 hours a day, 7 days a week. TTY users call 1‑877‑486‑2048.

This information is not a complete description of benefits. Call 1‑800‑559‑3500 (TTY: 711) for more information.

You can get prescription drugs shipped to your home through our network mail‑order delivery program, which is called Express Scripts Pharmacy.SM 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’s Member Services at 1‑800‑559‑3500, 8 a.m. to 8 p.m., 7 days a week from October 1 to March 31. From April 1 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: 711.


I – 15

Pre‑Enrollment ChecklistBefore making an enrollment decision, it is important that you fully understand our benefits and rules. If you have any questions, you can call and speak to a customer service representative at 1‑877‑870‑4867 (TTY users call 711) Hours are 8 a.m. to 8 p.m., seven days a week from October 1 to March 31. From April 1 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.

Understanding the Benefits

Review the full list of benefits found in the Evidence of Coverage (EOC), especially for those services for which you routinely see a doctor. Visit www.scanhealthplan.com or call 1‑877‑870‑4867 to view a copy of the EOC.

Review the provider directory (or ask your doctor) to make sure the doctors you see now are in the network. If they are not listed, it means you will likely have to select a new doctor.

Review the pharmacy directory to make sure the pharmacy you use for any prescription medicines is in the network. If the pharmacy is not listed, you will likely have to select a new pharmacy for your prescriptions.

Understanding Important Rules

In addition to your monthly plan premium, you must continue to pay your Medicare Part B premium. This premium is normally taken out of your Social Security check each month.

Benefits, premiums and/or copayments/co‑insurance may change on January 1, 2022.

Except in emergency or urgent situations, we do not cover services by out‑of‑network providers (doctors who are not listed in the provider directory).

MA


I – 16

SCAN Health Plan complies with applicable federal civil rights laws and does not discriminate, exclude people, or treat them differently on the basis of, or because of, race, color, national origin, age, disability, or sex.

SCAN Health Plan provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters, and written information in other formats (large print, audio, accessible electronic formats, other formats).

SCAN Health Plan provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages.

If you need these services, contact SCAN Member Services.

If you believe that SCAN Health Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance in person, by phone, mail, or fax, at:

SCAN Member ServicesAttention: Grievance and Appeals DepartmentP.O. Box 22616, Long Beach, CA 90801‑56161‑800‑559‑3500 (TTY: 711)FAX: 1‑562‑989‑5181

Or by filling out the “File a Grievance” form on our website at:

https://www.scanhealthplan.com/contact‑us/file‑a‑grievance

If you need help filing a grievance, SCAN Member Services is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services200 Independence Avenue, SWRoom 509F, HHH BuildingWashington, D.C. 202011‑800‑368‑1019 (TTY: 1‑800‑537‑7697)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

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


I – 17

English: ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call 1-800-559-3500. (TTY: 711). Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-559-3500. (TTY: 711).

Chinese Traditional: 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。(TTY: 711)。

Chinese Simplified: 注意：如果您使用中文，您可以免费获得语言援助服务，请致电 1-800-559-3500。(TTY: 711)。 Vietnamese: CHÚ Ý: Nếu quý vị nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho quý vị. Xin vui lòng gọi số 1-800-559-3500. (TTY: 711). Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-800-559-3500. (TTY: 711).

Korean: 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-800-559-3500 번으로 연락해 주십시오. (TTY: 711).

Armenian: ՈՒՇԱԴՐՈՒԹՅՈՒՆ՝ Եթե խոսում եք հայերեն, ապա Ձեզ անվճար կարող են տրամադրվել լեզվական աջակցության ծառայություններ: Զանգահարե'ք 1-800-559-3500 հեռախոսահամարով: Հեռատիպի համարն է՝ 711:

Persian: ت زبایی بوور ت راگگان گفتگو می کنید، تسهیال فارسیاگر به زبان :توجه .(TTY: 711) ماس بگیرگد.ت 3500-559-800-1شماره برای شما فراهم می باشد. با

Russian: ВНИМАНИЕ! Если вы говорите по-русски, вы можете бесплатно получить услуги перевод;а. Звоните по телефону 1-800-559-3500 (TTY: 711). Japanese: 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。お問合せ先�1-800-559-3500. (TTY: 711).

Arabic: المساعدة اللغوية تتوافر لك ، فإن خدمات العربيةملحوظة: إذا كنت تتحدث (.711)الهاتف النصي: .3500-559-800-1 برقم اتصل بالمجان.

Punjabi: ਧਿਆਨ ਧਿਓ: ਜੇ ਤੁਸੀਂ ਪੰਜਾਬੀ ਬੋਲਿੇ ਹੋ, ਤਾਂ ਭਾਸ਼ਾ ਧਵਿੱ ਚ ਸਹਾਇਤਾ ਸੇਵਾ ਤੁਹਾਡੇ ਲਈ ਮੁਫਤ ਉਪਲਬਿ ਹੈ। 1-800-559-3500 ਉੱਤੇ ਕਾਲ ਕਰੋ। (TTY: 711)। Mon-Khmer, Cambodian: សូមយកចិត្តទុកដាក់៖ ប ើសិនជាអ្នកនិយាយភាសាខ្មែរ បសវាជំនួយខ្ននកភាសា បដាយមិនគិត្ថ្លៃ អាចមានសំរា ់ ំបរ ើអ្នក។ សូមទូរស័ព្ទបៅបេម 1-800-559-3500 ។ (TTY: 711) ។ Hmong: LUS CEEV: Yog tias koj hais lus Hmoob (Ntawv Suav - Hmoob), muaj kev pab txhais lus pub dawb rau koj. Hu rau 1-800-559-3500. (TTY: 711). Hindi: ध्यान दें: यदद आप द िंदी बोलत े ैं तो आपके ललए मुफ्त में भाषा स ायता सेवाएिं उपलब्ध ैं। कॉल करें 1-800-559-3500, (TTY: 711)। Thai: โปรดทราบ: ถ้าคณุพดูภาษาไทย คณุสามารถใช้บริการชว่ยเหลือทางภาษาได้ฟรี โทร 1-800-559-3500 (TTY: 711) Lao: ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວ ້ າພາສາ ລາວ, ການບໍລິການຊ່ວຍເຫ ຼື ອດ້ານພາສາ, ໂດຍບ່ໍເສັຽຄ່າ, ແມ່ນມີພ້ອມໃຫ້ທ່ານ. ໂທຣ 1-800-559-3500 (TTY: 711).


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Additional Plan Information

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SCAN offers you benefits beyond what Original Medicare alone provides. For some of these benefits, we partner with companies that specialize in that type of care. We are pleased to be able to provide you added coverage through these programs.

For more information on these benefits

Call SCAN at 1-877-870-4867 (TTY: 711) October 1 to March 31: 8 a.m. to 8 p.m., seven days a week April 1 to September 30: 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.

You can also visit www.scanhealthplan.com/other-providers Or contact the companies directly – either call or visit their websites.

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

Benefits BeyondOriginal Medicare

Good health goes beyond the doctor’s office, so check out your “more than Original Medicare” benefits on the following pages.

These program offerings may vary based on plan and county. Please turn to the Summary of Benefits for a detailed description of your plan.

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Vision Services (routine)

Transportation Services (routine)

EyeMed Vision CareTo find an optometrist or optician near you, call:

1-844-226-2850 or go to:

www.eyemedvisioncare.com/locatorOctober 1–March 315 a.m.–8 p.m. (PT), seven days a week

April 1–September 305 a.m.–8 p.m. (PT), Monday–Saturday8 a.m.–5 p.m. (PT), Sunday

National MedTrans Network To schedule a ride: 1-844-714-2218 7 a.m. to 6 p.m. (PT), Monday–Friday

Where’s my Ride: 1-844-864-3359 Available 24 hours a day, 7 days a week

SCAN offers routine vision care services through the EyeMed Select optometry provider network:• Routine eye exam, limited to one every calendar year

• An eyewear allowance to apply towards the cost of standard frames or lenses

• Access to a large network of independent and retail locations

Please note SCAN Health Plan members are part of the EyeMed “SELECT” network when searching for a provider.

• Curb-to-curb transportation to medical appointments, pharmacies, and dentists

• Taxi, wheelchair vans and other modes to meet people’s physical needs

• 75-mile limit applies to each one-way trip

Core Extras

Dental Services (routine)

Delta Dental of CaliforniaTo find a dentist near you, call:

1-855-830-65835 a.m.–6 p.m. (PT), Monday−Friday

Or go to:

www.deltadentalins.com/SCAN/

Please note SCAN Health Plan members are part of the “DeltaCare® USA” network when searching for a provider.

• Offers routine dental coverage

• Low out-of-pocket costs for diagnostic and preventive services (such as professional cleanings and regular dental exams)

Receive dental care

Fill out thedental form

Select a DeltaCare USA dentist

Receive yourwelcome kit

Schedule an appointment

Discuss a treatment plan

Pay only yourcopayment to dentist

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Acupuncture, Chiropractic and Therapeutic Massage Services (routine)

American Specialty Health (ASH)To find a professional near you, call:

1-800-678-91335 a.m.–6 p.m. (PT), Monday–Friday

Or go to:

www.ashlink.com/ash/SCAN

• Access to routine acupuncture, chiropractic and therapeutic massage services

• Large network of providers

• Call a participating provider to schedule an initial examination

Therapeutic massage services available for SCAN Prime (HMO) plan.

Podiatry Services (routine)

Podiatry PlanTo find a podiatrist near you, call:


Or go to:

www.podiatryplan.com/ find-a-provider/

• Six self-referred visits for $0 copay per calendar year

• Comprehensive network of podiatrists

• Routine foot care services including toenail clipping, callus removal and treatment of corns

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Have questions about enrolling?1-855-830-6583 5 a.m. to 6 p.m., (PT), Monday through Friday. To search for a dentist, use the “Find a Dentist” tool at

www.deltadentalins.com/scanHow do I sign up?Just fill out the dental application.

Copyright ©2019 Delta Dental. All rights reserved.

With a DeltaCare® USA plan, you’ll enjoy:• Set copayments — so you always know what your out-of-pocket costs will be

• $0 copayment for office visits (unspecified diagnostic procedures)

• No deductibles or maximums for covered benefits

• Low out-of-pocket costs for diagnostic and preventive services

• $0–$5 cleanings (two cleanings every 12 months)

SCAN Classic (HMO) enrollees have the option to enroll in the Essential Dental plan.

Optional Dental Plan

ServiceYour copayment

Essential Plan

Monthly premium $10

Office visit $0

Cleaning (prophylaxis) and Scaling and root planing

Included in your routine dental benefit

Partial denture $120–$440

Optional Dental PlansOffered by Delta Dental of California

Receive dental care







Receive dental care







Compare the Basic and Enhanced Plans

ServiceYour copayment

Basic Plan Enhanced Plan

Monthly premium $6 $16

Office visit $8 No cost

Cleaning (prophylaxis)

$5 $5

Scaling and root planing

$101 $60

Partial denture $485 $325

How do I sign up?Just fill out the dental application found at the back of this kit.

With a DeltaCare® USA plan, you’ll enjoy:• Set copayments — so you always know

what your out-of-pocket costs will be• $0–8 copayment for office visits

(unspecified diagnostic procedures)• No deductibles or maximums for covered

benefits• Low out-of-pocket costs for diagnostic

and preventive services (such as cleanings and exams)

Nearly 250 procedures are covered, including:• $5 cleanings (2 cleanings every 12 months)• Tooth-colored fillings• Root canals• Porcelain crowns• Dentures• Bridges• Bleaching

Offered by Delta Dental of CaliforniaSCAN Health Plan® Optional Dental Plans

Phone Website

1-855-830-6583 5 am to 6 pm, Pacific Time, Monday through Friday

To search for a dentist, use the “Find a Dentist” tool at deltadentalins.com/scan.

Have questions about enrolling?

Copyright © 2018 Delta Dental. All rights reserved. SCAN #114169 (rev. 7/18)

We keep you smiling® deltadentalins.com/scan

Pay only your copayment to dentist

Receive dental care

Fill out the dental form


Receive your welcome kit



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TruHearing

Personalized Care

• Guidance and assistance from a TruHearing Hearing Consultant

• Professional exam from a local, licensed provider

• Three follow-up visits for fitting and adjustments

Next-Generation Sound

• Coverage for up to two Advanced or Premium hearing aids per year

• Powerful hearing aids to hear what matters most, wherever you are

• Automatically adjusting device sensors, for a natural sound even while you’re moving

Devices for Your Lifestyle

• Bluetooth® connectivity for streaming your favorite music, TV and phone calls straight to your ears1

• A “smart app” that acts as a hearing aid remote control, allows you to interface with your provider and even tracks your physical activity2

N

S

Your hearing aid benefit includes:

Your 2021 Hearing Coverage:Your Plan TruHearing Advanced TruHearing Premium Your benefit also includes:

SCAN Classic (HMO)

$450 per aid $750 per aidRisk-free 45-day trial period

+ 48 free batteries with non-rechargeable models

+ Full 3-year manufacturer warranty

SCAN Prime (HMO)

$200 per aid

or $3,000 allowance for

$400 per aid

up to 2 hearing aids

*Rechargeable battery option is available on select styles for an additional $50 per hearing aid.

Think you might have hearing loss? Try our free, fast online screening, visit: TruHearing.com/SCAN Call to learn more: 1-844-255-7148 | (TTY 711) Hours: 5 a.m.–6 p.m. (PT), Monday–Friday1 Smartphone-compatible hearing aids connect directly to iPhone,® iPad,® and iPod®

Touch devices. Connectivity also available to many Android® phones with use of an accessory. TV streaming available through most TVs with use of an accessory.

2 In- app interfacing requires provider activation. All content ©2020 TruHearing, Inc. All Rights Reserved. TruHearing® is a registered trademark of TruHearing, Inc. Three follow-up visits must be used within one year after the date of initial purchase. Free battery offer is not applicable to the purchase of rechargeable hearing aid models. Three-year warranty includes repairs and one-time loss and damage replacement. Hearing aid repairs and replacements are subject to provider and manufacturer fees. For questions regarding fees, contact a TruHearing hearing consultant.

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Featured Extras

Request a telehealth visit today.

Call 1-888-993-4087 (TTY: 1-800-770-5531),

24 hours a day, 7 days a week.

Or go to: www.mdlive.com/scanhealthplan.com

When it’s not an emergency, you don’t have an appointment to see your primary care physician (PCP) or when you just want a convenient alternative to an urgent care center, your telehealth benefit offers care 24 hours a day, 7 days a week, 365 days a year.

• The doctor can diagnose your non-emergency symptoms and send medically necessary prescriptions to your SCAN network pharmacy

• Speak with a Board Certified medical doctor in the comfort of your own home for non-life-threatening conditions

• The visit can be conducted either by telephone or secure video capabilities from your computer or smart phone

Telehealth - MDLive

To access technology support assistance please call:

1-833-437-0555 (TTY: 711) 24 hours a day, 7 days a week.

A technology support line to provide education and training on how to use your computer, tablet or smartphone to access health care and health care related information.

SCAN HEALTHtech Technology Support Assistance

Areas where Healthtech can help you• Skype/Zoom/FaceTime training for physician visits

• Telehealth visit overview, setup on personal equipment (phone, tablet, or computer)

• Prescription delivery setup

• Email account creation for health care communication

• Setting up your medical group’s online portal access

• SCAN Health Plan Member Portal registration

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To access any of these benefits, call SCAN Health Plan 1-800-559-3500

SCAN goes where you go.Life can take you many places, so SCAN goes where you go. Whether you’re out of town or across the country, you can count on SCAN to be there,

too, with benefits to help you stay healthy and safe. And if you need care, we’re there with coverage you can count on.

Benefits available on the go include:• Personal Emergency

Reponse System

• CVS MinuteClinic®

• Prescription refills

• Eyeglasses

• Emergency dental

• SilverSneakers®

• Travel Assurance

• Urgent care

• Emergency care

• Telehealth benefit

• Hearing aids

Benefits may vary by plan and must be obtained by contracted providers.

At home or on the go, we’ve got you covered.

SCAN on the go

To access this benefit, call SCAN Health Plan 1-800-559-3500

With SCAN you can travel with confidence, knowing your SCAN coverage travels with you anywhere you go. Members will have access to resources that facilitate the reimbursement of approved claims.

The SCAN Travel Assurance kit includes:• Step-by-step instructions on what to do if you need to see a

doctor while traveling

• Room to store helpful health information, such as your medication list or vaccination record, and hold your passport

• A copy of your SCAN Member ID card

• A claim form so you can be repaid for any covered out-of-pocket costs when you return home

Have safe and confident travels with SCAN Travel Assurance!

SCAN Travel Assurance Worldwide Coverage

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Solutions For Healthy Living

To learn more about this benefit call: 1-877-494-2892 (TTY: 711)5 a.m.–8 p.m. (PT), Monday–Friday

You will be mailed an OTC catalog or go to: otc.scanhealthplan.com

As a member of SCAN Health Plan you will receive a quarterly over-the-counter (OTC) benefit that allows you to purchase commonly used OTC health products.

To place your quarterly OTC order you can:• Call and speak to an OTC Advocate at 1-877-494-2892

• Order online at https://otc.scanhealthplan.com, or

• Mail your OTC order form in the self-addressed, stamped envelope

• Up to 2 orders every quarter can be placed for non-prescription medication and products

• Unused allowances roll over each quarter for each benefit year

SilverSneakers® Fitness Program To find a SilverSneakers location or get your SilverSneakers ID Number, call:


Or go to: www.SilverSneakers.com

SilverSneakers is a health and fitness program that provides gym access, fitness classes and programs.

SilverSneakers members:• Have access to a no cost gym membership with access to all

basic amenities

• Thousands of gyms, community centers, and other participating fitness locations across the nation

• Exercise classes designed for seniors of all fitness levels and led by trained instructors

• Access to SilverSneakers Live virtual classes and hundreds of On-Demand classes at SilverSneakers.com

Health Club Membership

Over-the-Counter (OTC)

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To start using BrainHQ, please go to www.scan.brainhq.com

For additional questions you can call: 1-888-844-6598 (TTY: 711)7:30 a.m.–4 p.m.Monday–Friday

Exercise your mind with BrainHQ, an online brain health program. Keeping your mind “physically fit” is important. Brain fitness helps strengthen connections in order to maintain important brain functions. Exercising the brain should be on every adult’s daily to-do list.

BrainHQ is offered at no-cost to SCAN members.

Features include: • Mental games that focus on attention, memory, brain speed,

intelligence, navigation, and people skills exercises

• A useful and meaningful workout tailored to your unique brain. Using a special method, each exercise adapts in difficulty as you use it so you’re always working at your optimum level—where you are most likely to improve your performance

BrainHQ

To access this benefit, call SCAN Health Plan 1-800-559-3500

or go to: www.scanhealthplan.com/Fitbit

Fitbit Activity Tracker Benefit:Fitbit is a fitness tracker for every day that helps you build healthy habits. Your Fitbit can help you take ‘steps’ toward better health.

• Members receive a Fitbit brand activity tracker every two years at no cost

• Features include all day activity tracking, sleep tracking, calories burned, reminders to get up and move, text and calendar alerts and goal celebrations

• Activity trackers have up to 5 days of battery life

Fitbit® - Fitness Tracker

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To access this benefit, call SCAN Health Plan

1-800-559-3500

Returning to Home is designed to help with support and personal care services immediately following a discharge from a hospital or skilled nursing facility (SNF). Within seven days of

being discharged, you, a family member or your doctor can request services by calling SCAN Health Plan.

Returning to Home services include:• Personal in-home care: up to ten visits (40 hours total per

year) to help with activities of daily living such as bathing, dressing, laundry, care-giver relief, etc.

• Home-delivered meals for up to 28 days (84 meals maximum per year)

• Ongoing personal phone support services from a SCAN Care Navigator

SCAN Respite Care Services

SCAN Returning to Home

Solutions for Independence

To access this benefit,call SCAN Health Plan1-800-559-3500

Members who experience a debilitating health condition and have a full time unpaid caregiver can access the SCAN Respite Care benefit.

Your benefit includes:• Up to 40 hours per year of in-home respite care to

relieve full-time caregivers. This service must be used in 4-hour increments

• Services must be delivered in the member’s home

• Criteria and restrictions apply, please call SCAN Member Services

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Emergency Response System

To access this benefit, call SCAN Health Plan

1-800-559-3500Get the help you need wherever life takes you with a GPS enabled Personal Emergency Response System (PERS).

PERS enables you to remain at home, living safely and independently.

Your PERS includes:• A water resistant, two-way voice wearable mobile device

and charging cradle

• GPS to identify your location if you need help

• Just press the button on the mobile device and our response center operator will respond immediately

Safety at your fingertips!

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Pharmacy Benefit

TRIM_MARKS_ONLY.pdf

Save Money on Your Medications1

INSULIN CD 3-FOR-2

Low Insulin CopaysIf you have diabetes, we understand how hard that can be on your budget. That’s why many SCAN plans offer all insulin pens and vials covered on our Drug List (i.e., Humalog, Humulin, Lantus, Lyumjev, Toujeo) for a $25 copay per one-month supply, including gap coverage, at any of our SCAN Preferred pharmacies*

*This insulin copay applies to members who do not qualify for a program that helps pay for prescription drugs (such as Extra Help). Insulin copays may vary by SCAN plan and county. Check your Evidence of Coverage for details.

Make the SwitchOnce your SCAN membership begins, contact:

• Express Scripts Personal Enrollment Specialist at 1-877-842-9792 (TTY: 711)

OR

• Your doctor’s office and ask about home delivery for your maintenance medications. They can send your 3-month prescriptions right to Express Scripts Pharmacy

A 3-month supply of Tier 1 and Tier 2 drugs is $0 through Express Scripts PharmacyMany other medications get Preferred Pharmacy pricing. So if low cost, convenience and great service are at the top of your list, you’ll want to make it mail-order..

Take advantage of the savings and convenience of home delivery, plus the added benefits of:

Online TrackingEasily manage your medications on the Express Scripts website or app.

Have Questions?24/7 telephone access to a pharmacist at 1-866-553-4125 (TTY: 711).

Automatic RefillsSign up for automatic refills with Express Scripts Pharmacy, they’ll remember so you don’t have to.

Payment FlexibilityExpress Scripts Pharmacy offers payment options that work with your budget.

Make it Mail-OrderSome of the lowest prices are available through Mail Order from Express Scripts PharmacySM The easy way to fill your maintenance medications. Make fewer trips to the pharmacy by having your 3-month supply delivered right to you and right on time. And standard shipping is free!

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Keeping Prescription Medications AffordableWe know how important it is to keep the cost of medications low. Here are even more ways to save with SCAN Health Plan.

PREFERRED-STANDARD

Preferred Pharmacies = Lower Copayments!If you prefer to fill your prescriptions at a local pharmacy but still want to save money, we have you covered. Just use a SCAN Preferred pharmacy. These are pharmacies in the SCAN network that generally offer lower copayments than Standard pharmacies for most drugs.

While you can fill your prescriptions at any of the pharmacies listed below, you may pay less at a Preferred pharmacy.

CVS Costco Safeway

Rite Aid Ralphs Albertsons

Walmart Home Delivery from Express Scripts PharmacySelect independent pharmacies

Walgreens Medicine Shoppe Select independent pharmacies

3-Month Supply = SavingsSave money and time by getting 3-month supply of the medications you take on an ongoing basis. The amount you save will depend on the tier your medication is on and what pharmacy you use (e.g., Preferred or Standard). Specialty tier (Tier 5) drugs are not available for a 3-month supply.

100

Preferred Pharmacies

Standard Pharmacies

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Brand name drugs are capitalized (e.g., JANUVIA) and generic drugs are listed in lower-case italics (e.g., metformin).

Drug NameDrug Tier

Aabacavir & lamivudine 5abacavir & lamivudine & zidovudine 5abacavir soln 4abacavir tabs 4ABELCET INJ 4ABILIFY MAINTENA 5abiraterone acetate 5acamprosate calcium dr 2acarbose 2acebutolol 2acetaminophen & codeine 2acetazolamide er caps 2acetazolamide tabs 2acetic acid & hydrocortisone 2acetylcysteine nebulizer soln 2acitretin 4ACTHIB INJ 3ACTIMMUNE INJ 5acyclovir caps & tabs 2acyclovir cream & oint 5% 4acyclovir inj 2acyclovir oral susp 4ADACEL INJ 3adapalene cream 0.1% 4adapalene gel 0.1% & 0.3% 4adefovir dipivoxil 5ADEMPAS 5ADVAIR HFA 3AFINITOR DISPERZ 5

Drug NameDrug Tier

AFINITOR TAB 10MG 5AIMOVIG 4albendazole 4albuterol sulfate er 3albuterol sulfate hfa 6.7gm inhaler 2albuterol sulfate hfa 8.5gm inhaler 2albuterol sulfate nebulizer 2albuterol sulfate syrup 2albuterol sulfate tabs 3alclometasone dipropionate 2alcohol pads 2ALECENSA 5alendronate oral soln 2alendronate tabs 1alfuzosin hcl er 2ALINIA SUSP 4ALINIA TABS 5aliskiren 3allopurinol tab 1ALORA 3alosetron hcl tabs 5ALPHAGAN P 0.1% 3alprazolam er tabs 2alprazolam intensol 2alprazolam tabs 2altavera 2ALTRENO 3ALUNBRIG 5ALUNBRIG INITIATION PACK 5alyacen 1/35 2

About this list:This is not a complete list of drugs covered by our plan. For a complete and updated list of drugs, please refer to the 2021 SCAN Health Plan Formulary or visit our website at www.scanhealthplan.com. The Formulary will also note if there are any restrictions to the medication.

This list of drugs is current as of August 2020 and is subject to change. Generally, you must use network pharmacies to use your prescription drug benefit. The Formulary may change at any time. You will receive notice when necessary.

SCAN Health Plan 2021 Drug Listing

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III – 3


Drug NameDrug Tier

alyq 5amabelz 3amantadine 2AMBISOME INJ 5ambrisentan 5amikacin inj 2amiloride 2amiloride & hydrochlorothiazide 1AMINOSYN INJ 3amiodarone tabs 2AMITIZA 3amitriptyline 2amlodipine 1amlodipine & atorvastatin 2amlodipine & benazepril 1ammonium lactate topical 2amnesteem caps 4amoxapine 2amoxicillin 1amoxicillin & clavulanate potassium 2amoxicillin & clavulanate potassium er 2amphetamine & dextroamphetamine tabs 2amphotericin b inj 2ampicillin & sulbactam inj 10-5gm, 2-1gm, & 1-0.5gm

2

ampicillin inj 2ampicillin oral 2ANADROL-50 3anagrelide 2anastrozole 2ANORO ELLIPTA 3APOKYN INJ 5aprepitant caps 80mg & 125mg 4aprepitant pack 4apri 2APTIOM 5APTIVUS 5aranelle 2ARCALYST INJ 5aripiprazole odt 5aripiprazole soln 1mg/ml 3

Drug NameDrug Tier

aripiprazole tabs 3ARISTADA INITIO INJ 4ARISTADA INJ 5armodafinil 3ASMANEX HFA 3ASMANEX TWISTHALER 3ASTAGRAF XL 4atazanavir sulfate caps 4atenolol 1atenolol & chlorthalidone 1atomoxetine 3atorvastatin 1atovaquone 5atovaquone/proguanil 2ATRIPLA 5atropine sulfate soln 2ATROVENT HFA 3AUBAGIO 5aubra 2AURYXIA 5AUSTEDO 5aviane 2AVONEX INJ 5AVONEX PEN INJ 5AYVAKIT 5AZASAN 4AZASITE 3azathioprine oral 2azelastine 0.05% 2azelastine nasal 0.1% 2azelastine nasal 0.15% 2azithromycin inj 2azithromycin tabs & oral susp 2aztreonam inj 1gm 4Bbacitracin & polymyxin b ointment 2bacitracin ophthalmic ointment 2baclofen 2balsalazide 3BALVERSA 5BANZEL 4

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Drug NameDrug Tier

BAQSIMI 3BARACLUDE ORAL SOLN 0.05MG/ML 4BCG INJ 3bd insulin syringe safetyglide 2bd insulin syringe ultrafine 2bd pen needle ultrafine 2BELSOMRA 3benazepril 1benazepril & hydrochlorothiazide 1BENLYSTA INJ 200MG/ML 5benztropine tabs 2betamethasone dipropionate 2betamethasone dipropionate augmented 2betamethasone valerate cream, oint, lotion

2

BETASERON INJ 5betaxolol soln 2bethanechol 2BETHKIS 5BEVESPI AEROSPHERE 3bexarotene 5BEXSERO INJ 3bicalutamide 2BICILLIN L-A INJ 3BIKTARVY 5bisoprolol 2bisoprolol & hydrochlorothiazide 2BLEPHAMIDE 3BLEPHAMIDE S.O.P. 3blisovi fe 1.5/30 2BOOSTRIX INJ 3bosentan 62.5mg & 125mg tab 5BOSULIF TABS 5BRAFTOVI 5BREO ELLIPTA 3briellyn 2BRILINTA 3brimonidine tartrate soln 0.15% 3brimonidine tartrate soln 0.2% 2BRIVIACT ORAL SOLN 4BRIVIACT TABS 5

Drug NameDrug Tier

bromocriptine 2BROVANA NEBULIZER 4BRUKINSA 5budesonide ec caps 4budesonide er tabs 9mg 5budesonide nebulizer 3bumetanide oral 2buprenorphine & naloxone sublingual film 2buprenorphine & naloxone sublingual tabs 2buprenorphine oral 1bupropion 2bupropion sr 2bupropion sr 150mg 2bupropion xl 150mg, 300mg 2bupropion xl 450mg 3buspirone 2butorphanol tartrate nasal 2BYDUREON BCISE INJ 3BYDUREON INJ 3BYETTA INJ 3BYSTOLIC 4

Ccabergoline 2CABOMETYX 5caffeine-ergotamine 3calcipotriene cream & oint 4calcipotriene soln 4calcitonin-salmon nasal 2calcitriol caps 2calcium acetate 2CALQUENCE 5CAPEX SHAMPOO 4CAPLYTA 5CAPRELSA 5captopril 1captopril & hydrochlorothiazide 1CARAC 5CARBAGLU 5carbamazepine er tabs & caps 3carbamazepine tabs, chewable tabs & oral susp

2


III – 5


Drug NameDrug Tier

carbidopa 4carbidopa & levodopa 2carbidopa & levodopa & entacapone 4carbidopa & levodopa er 2carbidopa & levodopa odt 2carteolol 1cartia xt 2carvedilol 1carvedilol phosphate er 4caspofungin inj 5CAYSTON 5caziant 2cefaclor 2cefaclor er 2cefadroxil caps & tabs 2cefazolin inj 2cefdinir 2cefepime inj 2cefixime caps 3cefixime susp 4cefoxitin sodium 2cefpodoxime tabs 2cefprozil 2ceftazidime inj 1gm, 2gm & 6gm 2ceftriaxone inj 2cefuroxime inj 2cefuroxime oral 2celecoxib 3CELLCEPT CAPS 4CELLCEPT ORAL SUSPENSION & TABS 5CELONTIN 4cephalexin caps & tabs 250mg & 500mg 1cephalexin oral susp 1CERDELGA 5cevimeline 3CHANTIX 4CHANTIX STARTING & CONTINUING MONTH PAK

4

chlorhexidine gluconate 2chloroquine 2chlorpromazine oral 4

Drug NameDrug Tier

chlorthalidone 1chlorzoxazone tabs 500mg 2cholestyramine 2cholestyramine light 2ciclopirox 8% nail soln 2ciclopirox cream & susp 2ciclopirox gel & shampoo 2cilastatin/imipenem inj 2cilostazol 2CIMDUO 5cimetidine oral 2cinacalcet tabs 30mg 3cinacalcet tabs 60mg & 90mg 5CINRYZE INJ 5CIPRO HC 3CIPRODEX 3ciprofloxacin in d5w inj 2ciprofloxacin ophthalmic soln 0.3% 2ciprofloxacin tabs immediate-release 250mg, 500mg, 750mg

1

citalopram oral soln 2citalopram tabs 1claravis 4clarithromycin 2clarithromycin er 2CLEOCIN VAGINAL SUPP 3clindamycin & benzoyl peroxide gel 5%-1% & 5%-1.2%

3

clindamycin oral 2clindamycin phosphate inj 2clindamycin topical gel, lotion, soln & swab

2

clindamycin vaginal cream 2CLINISOL SF INJ 4clobazam 4clobetasol propionate cream, foam, gel, oint, soln

4

clobetasol propionate emollient 4clomipramine 4clonazepam 2clonazepam odt 2clonidine er 2


III – 6


Drug NameDrug Tier

clonidine patches 4clonidine tabs immediate-release 1clopidogrel tabs 75mg 2clorazepate 2clotrimazole & betamethasone 2clotrimazole 1% cream 2clotrimazole 1% topical soln 2clotrimazole troche 2clozapine 2clozapine odt 4COARTEM 3codeine sulfate 2COLCHICINE 4COLCRYS 4colesevelam 4colestipol granules 2colestipol tabs 2colistimethate inj 2COMBIGAN 3COMBIVENT RESPIMAT 3COMETRIQ 5COMPLERA 5compro 2constulose soln 2COPAXONE INJ 40MG/ML 5COPIKTRA 5CORLANOR 4cortisone 2CORTISPORIN CREAM 3CORTISPORIN OINT 3COSENTYX 5COSENTYX SENSOREADY PEN 5COTELLIC 5CREON DR 3CRESEMBA ORAL 5CRIXIVAN 3cromolyn sodium nebulizer soln 4cromolyn sodium ophthalmic soln 2cromolyn sodium oral 4cyclafem 1/35 2cyclafem 7/7/7 2

Drug NameDrug Tier

cyclobenzaprine hcl ir 2cyclophosphamide caps 4CYCLOSET 3cyclosporine caps 3cyclosporine modified 2cyproheptadine 2cyred eq 2CYSTADANE 4CYSTAGON 3CYSTARAN 5CYTOMEL 3dalfampridine er 5DDALIRESP 3danazol 3dapsone tabs 3DAPTACEL INJ 3daptomycin inj 5DAURISMO 5deblitane 2deferasirox 5DELSTRIGO 5demeclocycline 4DEMSER 5DENAVIR 5DEPO-PROVERA INJ 400MG/ML 4DESCOVY 5desipramine 2desloratadine tabs 2desmopressin acetate nasal 4desmopressin acetate oral 2desogestrel & ethinyl estradiol 2desonide 3desoximetasone topical cream, & oint 0.25%

3

desoximetasone topical cream, gel & oint 0.05%

4

DESVENLAFAXINE ER 4desvenlafaxine succinate er 3dexamethasone dose pack 2dexamethasone elixir 2


III – 7


Drug NameDrug Tier

dexamethasone ophthalmic soln 2dexamethasone tabs 2dexmethylphenidate ir tabs 2dextroamphetamine sulfate er 4dextroamphetamine sulfate tabs 3dextrose (10%, 5% or 2.5%) & sodium chloride inj

2

dextrose inj 2DIAZEPAM RECTAL GEL 3diazepam tabs & soln 2diazoxide 4diclofenac potassium 1diclofenac sodium dr 1diclofenac sodium er 1diclofenac sodium gel 1% 3diclofenac sodium gel 3% 4diclofenac sodium ophthalmic soln 0.1% 2dicloxacillin sodium 2dicyclomine oral 2didanosine 2diflorasone diacetate 4diflunisal 2digitek 2digox 2digoxin oral 2dihydroergotamine mesylate nasal 5DILANTIN CAPS 100MG 3DILANTIN CAPS 30MG 3DILANTIN INFATABS 3DILANTIN SUSP 3diltiazem er caps 2diltiazem tabs 2dilt-xr 2DIPENTUM 5diphenoxylate & atropine 2DIPHTHERIA & TETANUS TOXOIDS PEDIATRIC INJ

3

dipyridamole er & aspirin 3dipyridamole oral 2disopyramide phosphate 4disulfiram 2

Drug NameDrug Tier

divalproex sodium 2divalproex sodium dr 2divalproex sodium er 2dofetilide 4donepezil odt 2donepezil tabs 5mg & 10mg 2dorzolamide 2dorzolamide & timolol maleate 2dotti 3DOVATO 5doxazosin 2doxepin caps 2doxepin oral soln 2doxepin tabs 3doxercalciferol oral 3doxy 100 inj 2doxycycline immediate-release tabs, caps & oral susp

2

DRIZALMA SPRINKLE 4dronabinol 4DUAVEE 3DULERA 3duloxetine hcl 2duramorph inj 2DUREZOL 3dutasteride 3dutasteride & tamsulosin 3Eeconazole nitrate 4EDURANT 5efavirenz caps 4efavirenz tab 5ELIGARD INJ 4ELIQUIS 3ELIQUIS STARTER PACK 3ELMIRON 4EMCYT 3emoquette 2EMSAM 5EMTRIVA 4enalapril 1


III – 8


Drug NameDrug Tier

enalapril & hydrochlorothiazide 1ENBREL INJ 5ENBREL MINI 5ENBREL SURECLICK INJ 5endocet 5-325mg, 7.5-325mg, 10-325mg

3

ENGERIX-B INJ 3enoxaparin inj syringe 30mg/0.3ml, 40mg/0.4ml, 60mg/0.6ml, 80mg/0.8ml 100mg/ml, 120mg/0.8ml, & 150mg/ml

4

enpresse-28 2enskyce 2entacapone 4entecavir tabs 4ENTRESTO 3enulose 2ENVARSUS XR 4EPCLUSA 5EPIDIOLEX 5EPINEPHRINE AUTO-INJECTOR 0.15MG/0.3ML & 0.3MG/0.3ML

3

epitol 2EPIVIR HBV SOLN 5MG/ML 4eplerenone 3ergoloid mesylates 3ERIVEDGE 5ERLEADA 5erlotinib 5ertapenem inj 4ERYTHROCIN LACTOBIONATE INJ 4erythrocin stearate 3erythromycin caps & tabs 3erythromycin dr 3erythromycin ophthalmic oint 2erythromycin topical gel & soln 2ESBRIET 5escitalopram 2esomeprazole magnesium dr caps 3estarylla 2estazolam 2estradiol & norethindrone acetate 0.5mg/0.1mg & 1mg/0.5mg

3

Drug NameDrug Tier

estradiol oral 2estradiol patches 3estradiol vaginal cream 3estradiol vaginal tabs 3ethambutol 2ethinyl estradiol & ethynodiol 2ethinyl estradiol & norethindrone acetate 5mcg/1mg & 2.5mcg-0.5mg

3

ethosuximide 2etodolac 2etodolac er 2everolimus 0.25mg 4everolimus 0.5mg, 0.75mg 5everolimus tabs 2.5mg, 5mg & 7.5mg 5EVOTAZ 5exemestane 3ezetimibe 2ezetimibe & simvastatin 3Ffalmina 2famciclovir 2famotidine tabs 1FANAPT 4FANAPT TITRATION PACK 4FARXIGA 3FARYDAK 5FASENRA 5febuxostat 3felbamate oral susp 600mg/5ml 5felbamate tabs 400mg 2felbamate tabs 600mg 4felodipine er 2femynor 2fenofibrate caps 43mg, 130mg, 134mg 2fenofibrate micronized 2fenofibrate tabs 48mg, 54mg, 145mg, 160mg

2

fenofibric acid dr caps 3fentanyl citrate lozenges 5fentanyl patches 12mcg/hr, 25mcg/hr, 50mcg/hr, 75mcg/hr, 100mcg/hr

3


III – 9


Drug NameDrug Tier

FERRIPROX 5FETZIMA 4FETZIMA TITRATION PACK 4finasteride tabs 5mg 2flavoxate 2flecainide acetate 2fluconazole in sodium chloride inj 2fluconazole oral 2flucytosine 5fludrocortisone acetate 2flunisolide nasal 2fluocinolone acetonide cream, oint, soln 3fluocinolone acetonide otic soln 3fluocinolone acetonide scalp oil 3fluocinonide emulsified base cream 2fluocinonide gel & oint 2fluocinonide soln 2fluorometholone 2fluorouracil 2% and 5% topical 3fluoxetine hcl caps 10mg, 20mg & 40mg 2fluoxetine hcl oral soln 2fluoxetine hcl tabs 10mg & 20mg 2fluphenazine decanoate inj 2fluphenazine inj 2fluphenazine oral 2flurazepam 2flutamide 2fluticasone propionate cream & oint 2fluticasone propionate nasal 2fluticasone propionate/salmeterol diskus 100mcg-50mcg, 250mcg-50mcg & 500mcg-50mcg

3

fluvoxamine 2fluvoxamine er 4fondaparinux inj 2.5mg/0.5ml & 5mg/0.4ml

4

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

5

FORFIVO XL 3FORTEO INJ 5fosamprenavir tabs 5fosinopril 1

Drug NameDrug Tier

fosinopril & hydrochlorothiazide 1furosemide inj 2furosemide oral 1FUZEON INJ 3fyavolv 3FYCOMPA 4

Ggabapentin caps, tabs, & oral soln 2galantamine 2galantamine er 2galantamine oral soln 4GAMMAGARD INJ 5GAMUNEX-C INJ 5GARDASIL 9 INJ 4GATTEX INJ 5gauze pads 2”x2” 2gavilyte-c 2gavilyte-g 2gavilyte-n 2GELNIQUE 3gemfibrozil 2generlac 2gengraf 2GENOTROPIN INJ 5GENOTROPIN MINIQUICK INJ 0.2MG, 0.4MG, 0.6MG, 0.8MG

4

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

5

gentamicin cream 0.1% & oint 0.1% 2gentamicin inj 40mg/mL 2gentamicin ophthalmic soln 0.3% 2GENVOYA 5GILENYA 5GILOTRIF 5glatiramer acetate inj 5glatopa inj 5glimepiride 1glimepiride & pioglitazone 2glipizide 1glipizide & metformin tabs 1glipizide er 1


III – 10


Drug NameDrug Tier

GLUCAGEN HYPOKIT 3GLUCAGON EMERGENCY KIT INJ 3glycopyrrolate 1mg & 2mg tabs 2granisetron oral 2griseofulvin microsize 2guanfacine ir 2guanidine 2Hhalobetasol propionate cream & ointment 2haloperidol decanoate inj 2haloperidol lactate inj 2haloperidol oral 2HARVONI 5HAVRIX INJ 3heparin inj vials 1000u/ml, 5000u/ml, 10000u/ml & 20000u/ml

2

HETLIOZ 5HIBERIX INJ 3HUMALOG CARTRIDGE INJ 3HUMALOG JUNIOR KWIKPEN INJ 3HUMALOG KWIKPEN INJ 3HUMALOG MIX 50/50 KWIKPEN INJ 3HUMALOG MIX 50/50 VIAL INJ 3HUMALOG MIX 75/25 KWIKPEN INJ 3HUMALOG MIX 75/25 VIAL INJ 3HUMALOG VIAL INJ 3HUMATROPE INJ 5MG VIAL, 12MG & 24MG CARTRIDGE

5

HUMATROPE INJ 6MG CARTRIDGE 4HUMIRA INJ 5HUMIRA PEDIATRIC CROHNS INJ 5HUMIRA PEN INJ 5HUMIRA PEN-CD/UC/HS STARTER 5HUMIRA PEN-PS/UV STARTER 5HUMULIN 70/30 KWIKPEN INJ 3HUMULIN 70/30 VIAL INJ 3HUMULIN N KWIKPEN INJ 3HUMULIN N VIAL INJ 3HUMULIN R U-500 (CONCENTRATED) KWIKPEN INJ

3

Drug NameDrug Tier

HUMULIN R U-500 (CONCENTRATED) VIAL INJ

3

HUMULIN R VIAL INJ 3hydralazine oral 2hydrochlorothiazide 1hydrocodone & acetaminophen soln 7.5-325mg/15ml

2

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

2

hydrocodone & ibuprofen 2hydrocortisone 2.5% cream, lotion, oint 2hydrocortisone butyrate cream, oint & soln

2

hydrocortisone enema 2hydrocortisone oral 2hydrocortisone valerate 2hydromorphone immediate-release oral soln & tabs

2

hydromorphone inj 3hydroxychloroquine 2hydroxyurea 2hydroxyzine hcl tabs 2Iibandronate oral 2IBRANCE CAPS 5IBRANCE TABS 5ibu 1ibuprofen 1icatibant inj 5ICLUSIG 5IDHIFA 5imatinib 5IMBRUVICA 5imipramine hcl tabs 2IMIQUIMOD CREAM 3.75% PUMP 5imiquimod cream 5% 3IMOVAX RABIES INJ 3IMURAN TABS 4incassia 2INCRELEX INJ 5indapamide 1indomethacin er 2


III – 11


Drug NameDrug Tier

indomethacin ir caps 2INFANRIX INJ 3INLYTA 5INREBIC 5INTELENCE 100MG & 200MG TABS 5INTELENCE 25MG TAB 4INTRALIPID INJ 4INTRON-A INJ 3introvale 2INVEGA SUSTENNA INJ 39MG 4INVEGA SUSTENNA INJ 78MG, 117MG, 156MG, & 234MG

5

INVEGA TRINZA INJ 5INVIRASE 4INVOKAMET 3INVOKAMET XR 3INVOKANA 3IPOL INACTIVATED IPV INJ 3ipratropium bromide & albuterol sulfate nebulizer

2

ipratropium bromide nasal 2ipratropium bromide nebulizer 2irbesartan 1irbesartan hct 1IRESSA 5ISENTRESS 100MG CHEW TABS 5ISENTRESS 25MG CHEW TABS 3ISENTRESS HD TABS 5ISENTRESS ORAL POWDER 5ISENTRESS TABS 5isibloom 2isoniazid oral 2isosorbide dinitrate tabs 5mg, 10mg, 20mg, & 30mg

2

isosorbide mononitrate 2isosorbide mononitrate er 2isotretinoin caps 4isradipine 2itraconazole 4ivermectin tabs 2IXIARO INJ 4

Drug NameDrug Tier

JJAKAFI 5jantoven 1JANUMET 3JANUMET XR 3JANUVIA 3jasmiel 2jinteli 3JULUCA 5junel 21 day 2JUXTAPID 5

KKALETRA TABS 100-25MG 4KALETRA TABS 200-50MG 5KALYDECO 5kariva 2kelnor 1/35, 1/50 2ketoconazole cream, shampoo, & tabs 2ketorolac oral tabs 2ketorolac soln 0.4% & 0.5% 2KINERET INJ 5KINRIX INJ 3kionex 2KISQALI 5KISQALI FEMARA CO-PACK 5klor-con pack 4klor-con tabs 2KOMBIGLYZE XR 3KORLYM 5kurvelo 2KUVAN 5

Llabetalol oral 2LACRISERT 4lactulose soln 10g/15ml 2lamivudine & zidovudine 2lamivudine soln 2lamivudine tabs 100mg 2lamivudine tabs 150mg & 300mg 2lamotrigine chewable tabs 2lamotrigine immediate-release tabs 2


III – 12


Drug NameDrug Tier

lamotrigine starter kit 4LANOXIN ORAL 3lansoprazole dr caps 2lanthanum carbonate 5LANTUS SOLOSTAR PEN INJ 3LANTUS VIAL INJ 3larin 2larin fe 2larissia 2latanoprost 1LATUDA 5LEDIPASVIR/SOFOSBUVIR 5leena 2leflunomide 2LENVIMA 5letrozole 2leucovorin oral 2LEUKERAN 3LEUKINE INJ 5leuprolide acetate inj 2levalbuterol nebulizer 2levetiracetam er 2levetiracetam oral 2levobunolol 2levocarnitine oral 2levocetirizine 2levofloxacin inj 2levofloxacin oral soln 2levofloxacin tabs 1levonest 2levonorgestrel & ethinyl estradiol 0.1-0.02mg & 0.15-0.03mg & triphasic packs

2

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

2

levora 2levothyroxine tabs 1levoxyl 1LEXIVA ORAL SUSP 4lidocaine & prilocaine 3lidocaine ointment 4

Drug NameDrug Tier

lidocaine patch 3lidocaine topical gel 2lidocaine topical soln 2lidocaine viscous soln 2linezolid inj 5linezolid oral susp 5linezolid tabs 4LINZESS 3liothyronine tabs 2lisinopril 1lisinopril & hydrochlorothiazide 1lithium carbonate 2lithium carbonate er 2lithium citrate soln 2LODINE TABS 2LONSURF 5loperamide caps 2mg 2lopinavir & ritonavir soln 4lorazepam oral soln 2lorazepam tabs 2LORBRENA 5lorcet hd tabs 10-325mg 2lorcet plus tabs 7.5-325mg 2lorcet tabs 5-325mg 2losartan 1losartan hct 1lovastatin 1low-ogestrel 2loxapine 2LUMIGAN 3LUPRON DEPOT INJ 5LYNPARZA 5LYSODREN 3LYUMJEV INJ 3LYUMJEV KWIKPEN 3lyza 2Mmagnesium sulfate inj 2malathion 4maprotiline 2marlissa 28 day 2


III – 13


Drug NameDrug Tier

MARPLAN 4MATULANE 5MAYZENT 5meclizine 2MEDROL TABS 4medroxyprogesterone acetate inj 2medroxyprogesterone acetate tabs 2mefloquine 2megestrol acetate oral susp 40mg/ml 2megestrol tabs 2MEKINIST 5MEKTOVI 5meloxicam tabs 1memantine hcl immediate release 2memantine hcl soln 2MENACTRA INJ 3MENEST 4MENVEO-A/C/Y/W-135 INJ 3meprobamate 4mercaptopurine 2meropenem inj 4mesalamine dr 400mg 3mesalamine enema kit 4mesalamine er caps 4MESNEX TABS 5metformin er uncoated tabs 500mg & 750mg

1

metformin tabs 1methadone oral 2methazolamide 4methenamine hippurate 2methimazole 2methocarbamol tabs 2methotrexate inj 50mg/2ml 2methotrexate oral 2methoxsalen 5methyldopa 2methyldopa& hydrochlorothiazide 2methylphenidate er tabs 10mg & 20mg 3methylphenidate ir tabs 5mg, 10mg & 20mg

2

Drug NameDrug Tier

methylprednisolone dose pack 2methylprednisolone oral 2metoclopramide oral tablets & soln 2metolazone 2metoprolol & hydrochlorothiazide 2metoprolol succinate er 2metoprolol tartrate 25mg, 50mg,100mg tabs

1

metronidazole inj 2metronidazole oral 2metronidazole topical 3metronidazole vaginal 2mexiletine 2microgestin 1/20 & 1.5/30 2midodrine tabs 3migergot suppository 4miglustat 5mili 2MILLIPRED 4mimvey 3minitran patches 2minocycline ir 2minoxidil 2mirtazapine 1mirtazapine odt 1misoprostol 2M-M-R II INJ 3modafinil 4moexipril 1molindone 2mometasone cream, oint & soln 2mometasone furoate nasal 3mondoxyne nl 2montelukast 2morphine sulfate er tabs 3morphine sulfate oral 2MOVANTIK 3MOVIPREP 3moxifloxacin hcl ophthalmic 2moxifloxacin oral 2mupirocin cream 4


III – 14


Drug NameDrug Tier

mupirocin ointment 2mycophenolate mofetil caps & tabs 2mycophenolate mofetil oral susp 5mycophenolic acid dr 4MYFORTIC 4myorisan 4MYRBETRIQ 3

Nnabumetone 2nadolol 2nafcillin sodium inj 4naloxone inj 0.4mg/ml & 2mg/2ml 2NALOXONE PEN INJ 3naltrexone 1naproxen dr tabs 1naproxen sodium ir tabs 1naproxen tabs 250mg, 375mg, 500mg 1naratriptan 2NARCAN 3NATACYN 4nateglinide 2NATPARA 5NAYZILAM 4NEBUPENT NEBULIZER 4necon 2nefazodone 2neomycin & polymyxin & bacitracin 2neomycin & polymyxin & bacitracin & hydrocortisone

2

neomycin & polymyxin & dexamethasone 2neomycin & polymyxin & gramicidin ophthalmic

2

neomycin & polymyxin & hydrocortisone 2neomycin & polymyxin & hydrocortisone 2neomycin sulfate oral 2NEORAL 4NERLYNX 5NEUPOGEN INJ 5NEUPRO PATCH 4nevirapine er 2nevirapine susp & tabs 2

Drug NameDrug Tier

NEXAVAR 5niacin er tabs 3nicardipine caps 2NICOTROL INHALER 3NICOTROL NASAL 3nifedipine caps 2nifedipine er 2nilutamide 5nimodipine caps 4NINLARO 5nisoldipine er 4nitisinone 5nitro-bid oint 2NITRO-DUR PATCHES 0.3MG/HR & 0.8MG/HR

3

nitrofurantoin caps 2nitroglycerin lingual 2nitroglycerin patches 2nitroglycerin sublingual 2NIVESTYM 5norethindrone 2norethindrone, ethinyl estradiol, ferrous fumarate 0.4mg/0.035mg

2

norgestimate-ethinyl estradiol 2NORTHERA 5nortriptyline oral 2NORVIR PACK & SOLN 3NOXAFIL SUSPENSION 5NUBEQA 5NUEDEXTA 5NUPLAZID 5nyamyc 2nystatin 2nystatin & triamcinolone 3nystop 2Ooctreotide inj 500mcg/ml & 1000mcg/ml 5octreotide inj 50mcg/ml, 100mcg/ml & 200mcg/ml

2

ODEFSEY 5ODOMZO 5


III – 15


Drug NameDrug Tier

OFEV 5ofloxacin ophthalmic 2ofloxacin oral 2ofloxacin otic 2olanzapine inj 10mg 2olanzapine odt 2olanzapine tabs 2olmesartan 2olmesartan & amlodipine 2olmesartan hct 2olmesartan medoxomil & amlodipine & hydrochlorothiazide tabs

2

olopatadine soln 0.1% 2olopatadine soln 0.2% 2omega-3-acid ethyl esters 3omeprazole caps 2ondansetron odt 2ondansetron oral soln 2ondansetron tabs 2ONGLYZA 3OPSUMIT 5ORAPRED ODT 4ORAVIG 4ORENCIA CLICKJET 5ORENCIA INJ PF SYRINGE 5ORFADIN 5ORKAMBI 5orsythia 28 day 2oseltamivir caps 2oseltamivir susp 3OSMOPREP 3OTEZLA 5OTEZLA STARTER 5oxandrolone 10mg tabs 4oxandrolone 2.5mg tabs 3oxazepam 3oxcarbazepine susp 4oxcarbazepine tabs 2oxybutynin 2oxybutynin er 2

Drug NameDrug Tier

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

3

oxycodone & aspirin 2OXYCODONE ER 4oxycodone immediate-release 2oxycodone oral soln 2OXYTROL 4OZEMPIC 3

Ppacerone tabs 2paliperidone er 1.5mg, 3mg & 6mg tabs 4paliperidone er 9mg tabs 5pantoprazole tabs 2paricalcitol caps 3paromomycin 3paroxetine hcl er 2paroxetine hcl immediate-release 1paroxetine mesylate 3PASER 4PAXIL 10MG/5ML SUSP 4PEDIARIX INJ 3PEDVAX HIB INJ 3peg 3350 & electrolytes 2peg 3350 & sodium chloride & sodium bicarbonate & potassium chloride

2

PEGANONE 4PEGASYS INJ 5PEGASYS PROCLICK INJ 5PEMAZYRE 5penicillamine tabs 5penicillin g inj 2 million units, 5 million units

2

penicillin v potassium 2pentamidine inhalation soln 3pentamidine inj 4PENTASA 4pentoxifylline er 2PERFOROMIST NEBULIZER 4perindopril 1permethrin cream 2perphenazine 2


III – 16


Drug NameDrug Tier

perphenazine & amitriptyline 2PERSERIS 5phenelzine 2phenobarbital elixir 2phenobarbital tabs 2phenytek 2phenytoin chewable tabs 2phenytoin er 2phenytoin oral susp 2PHOSPHOLINE IODIDE 3PIFELTRO 5pilocarpine soln 2pilocarpine tabs 3pimecrolimus 4pimozide 2pimtrea 2pindolol 2pioglitazone 1pioglitazone & metformin 2piperacillin/tazobactam inj 3PIQRAY 5pirmella 1/35 2piroxicam 2PLEGRIDY INJ 5PLEGRIDY STARTER PACK INJ 5plenamine inj 2PLENVU 3podofilox 2polymyxin b sulfate & trimethoprim sulfate ophthalmic soln

2

POMALYST 5posaconazole dr tabs 5potassium chloride & dextrose & lactated ringers inj

2

potassium chloride & dextrose & sodium chloride inj 30mEq/5%/0.45% & 20mEq/5%/0.2%

2

potassium chloride & dextrose 20mEq/5% inj

2

potassium chloride er & cr 2potassium chloride inj 2potassium chloride oral soln 4

Drug NameDrug Tier

potassium chloride pack 20meq 4potassium citrate er 2PRADAXA 4pramipexole ir 2prasugrel 2pravastatin 1prazosin 2PRED MILD 3prednicarbate 2prednisolone acetate 2prednisolone odt 4prednisolone oral soln 2prednisolone sodium phosphate 2PREDNISONE INTENSOL 4prednisone oral soln 2prednisone tabs 1pregabalin 3PREMARIN ORAL 4PREMARIN VAGINAL CREAM 3PREMPHASE 4PREMPRO 4prenatal multi-vitamin 2prevalite 2PREVYMIS 5PREZCOBIX 5PREZISTA SUSP 100MG/ML 4PREZISTA TABS 600MG & 800MG 5PREZISTA TABS 75MG & 150MG 4PRIFTIN 4PRIMAQUINE 3primidone 2PROAIR RESPICLICK 3probenecid 2probenecid & colchicine 2prochlorperazine oral 2prochlorperazine suppositories 2PROCRIT INJ 20000UNIT/ML & 40000UNIT/ML

5

PROCRIT INJ 2000UNIT/ML 3PROCRIT INJ 3000UNIT/ML, 4000UNIT/ML & 10000UNIT/ML

4


III – 17


Drug NameDrug Tier

procto-med hc 2procto-pak 2proctosol hc 2proctozone-hc 2progesterone caps 2PROGRAF CAPS 4PROGRAF PACK 4PROLASTIN C INJ 5PROLIA 4PROMACTA 5promethazine suppositories 3promethazine syrup 2promethazine tabs 12.5mg, 25mg & 50mg

2

promethegan 3propafenone 2propranolol & hydrochlorothiazide 1propranolol er caps 2propranolol ir tabs 1propranolol oral soln 2propylthiouracil 2PROQUAD INJ 3PROSOL INJ 4protriptyline 2PULMICORT NEBULIZER 4PULMOZYME 5PURIXAN 5pyrazinamide 2pyridostigmine er tabs 180mg 4pyridostigmine soln 4pyridostigmine tabs 60mg 3pyrimethamine 5QQINLOCK 5QUADRACEL INJ 3quetiapine 2quetiapine er tabs 3quinapril 1quinapril & hydrochlorothiazide 1quinidine gluconate cr 4quinidine sulfate 2

Drug NameDrug Tier

quinine sulfate caps 324mg 3QVAR REDIHALER 3

RRABAVERT INJ 3raloxifene hcl 3ramelteon 3ramipril 1ranolazine er 4RAPAMUNE SOLN 5RAPAMUNE TABS 4rasagiline 4RAVICTI 5REBIF INJ 5REBIF REBIDOSE INJ 5REBIF REBIDOSE TITRATION PACK INJ 5REBIF TITRATION PACK INJ 5RECOMBIVAX HB INJ 3RECTIV 4REGRANEX 5RELENZA DISKHALER 3RELISTOR INJ 5RELISTOR TABS 5repaglinide 2REPATHA INJ 3RESTASIS 3RETACRIT INJ 2000UNIT/ML 3RETACRIT INJ 3000UNIT/ML, 4000UNIT/ML & 10000UNIT/ML

4

RETACRIT INJ 40000UNIT/ML 5RETEVMO 5REVLIMID 5REXULTI 5REYATAZ ORAL POWDER 5ribavirin 3RIDAURA 5rifabutin 4rifampin inj 2rifampin oral 2riluzole 3rimantadine 2RINVOQ 5


III – 18


Drug NameDrug Tier

risedronate sodium 3risedronate sodium dr 3RISPERDAL CONSTA INJ 12.5MG & 25MG

4

RISPERDAL CONSTA INJ 37.5MG & 50MG

5

risperidone 2risperidone odt 2ritonavir tabs 3rivastigmine caps 3rivastigmine patches 4rizatriptan 2rizatriptan odt 2ropinirole ir 2rosuvastatin 2ROTARIX 3ROTATEQ 3roweepra 2roweepra xr 2ROZLYTREK 5RUBRACA 5RYBELSUS 3RYDAPT 5

SSANDIMMUNE CAPS 25MG & 100MG 4SANDIMMUNE ORAL SOLN 100MG/ML 4SANTYL 3SAPHRIS 5SAVELLA 3SAVELLA TITRATION PACK 3scopolamine patch 3SECUADO 5SEGLUROMET 3selegiline 2selenium sulfide lotion 2SELZENTRY 150MG & 300MG 5SELZENTRY 25MG & 75MG 4SELZENTRY SOLN 4SEREVENT DISKUS 3SEROQUEL XR 4sertraline oral soln 2

Drug NameDrug Tier

sertraline tabs 1setlakin 2sevelamer carbonate powder 5sevelamer carbonate tabs 4sharobel 2SHINGRIX 3SIGNIFOR INJ 5sildenafil tab 20mg 3silver sulfadiazine 2simvastatin 1sirolimus soln 5sirolimus tabs 4SIRTURO 5SIVEXTRO 5SKYRIZI 5sodium chloride inj 2sodium phenylbutyrate powder & tabs 5sodium polystyrene sulfonate 2SOFOSBUVIR/VELPATASVIR 5solifenacin succinate 3SOLTAMOX 3SOMATULINE DEPOT INJ 5SOMAVERT INJ 5sorine 2sotalol tabs 2SPIRIVA HANDIHALER 3SPIRIVA RESPIMAT 3spironolactone 1spironolactone & hydrochlorothiazide 1SPRITAM 4SPRYCEL 5sps suspension 2ssd 2stavudine caps 2STEGLATRO 3STELARA INJ 45MG/0.5ML, & 90MG/ML 5STIMATE 4STIOLTO RESPIMAT 3STIVARGA 5streptomycin inj 2STRIBILD 5


III – 19


Drug NameDrug Tier

STRIVERDI RESPIMAT 3SUCRAID 5sucralfate tabs 2sulfacetamide sodium & prednisolone sodium phosphate ophthalmic

2

sulfacetamide sodium ophthalmic oint & soln

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