Harmony Dual Access (HMO SNP) Dual Coverage (HMO SNP), Classic Care (HMO) In Control Drug Savings (HMO SNP) In Control Dual Access (HMO SNP) Bridges Drug Savings (HMO SNP) Bridges Dual Access (HMO SNP) Healthy Heart Drug Savings (HMO SNP) Healthy Heart Dual Access (HMO SNP) Hope Drug Savings (HMO SNP) Classic Choice for Medi-Medi (HMO) Formulario 2016 (Lista de medicamentos cubiertos) POR FAVOR, LEA: ESTE DOCUMENTO CONTIENE INFORMACIÓN SOBRE ALGUNOS DE LOS MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN
ID del Formulario 16493, Número de versión 9: This formulary was updated on 01/01/2016. “Este vademécum se actualizó el 01/01/2016. Para obtener información más reciente o si tiene otras preguntas, póngase en contacto con Brand New Day al 866-255-4795 o, para usuarios de TTY, al 866-321-5955. Horarios: del 1 de octubre al 14 de febrero: los 7 días de la semana, de 8:00 a. m. a 8:00 p. m. del 15 de febrero al 30 de septiembre: de lunes a viernes, de 8:00 a. m. a 8:00 p. m. o visite http://www.brandnewdayhmo.com/.
H0838_2016 Abridged Comp_SP
Nota para miembros existentes: Este formulario ha cambiado desde el año pasado. Por favor, revise este documento para asegurarse de que todavía incluye los medicamentos que toma. Cuando esta lista de medicamentos (formulario) se refiere a “nosotros”, “nos” o “nuestro”, significa Brand New Day. Cuando se refiere a “plan” o “nuestro plan”, significa Harmony Dual Access (HMO SNP), Dual Coverage (HMO SNP), Classic Care (HMO), In Control Drug Savings (HMO SNP), In Control Dual Access (HMO SNP), Bridges Drug Savings (HMO SNP), Bridges Dual Access (HMO SNP), Healthy Heart Drug Savings (HMO SNP), Healthy Heart Dual Access (HMO SNP), Hope Drug Savings (HMO SNP), Classic Choice for Medi-Medi (HMO). Este documento incluye una lista parcial de los medicamentos (formulario) para nuestro plan actualizada al 1 de enero de 2016. Para ver un formulario completo y actualizado, comuníquese con nosotros. Nuestra información de contacto, junto con la fecha de la última actualización del formulario, aparece en la portada y en la contraportada. Por lo general, se deben utilizar las farmacias de la red de servicios para utilizar su beneficio de medicamentos recetados. Los beneficios, formulario, red de farmacias y/o copagos/coseguro pueden cambiar el 1 de enero de 2017, y cada cierto tiempo durante el año.
¿Qué es el formulario abreviado de Brand New Day? Un formulario es una lista de medicamentos cubiertos seleccionados por Brand New Day en consulta con un equipo de proveedores de atención médica, que representa las terapias con receta que se cree son una parte necesaria de un programa de tratamiento de calidad. Por lo general, Brand New Day cubrirá los medicamentos descritos en nuestro formulario siempre que el medicamento sea médicamente necesario, la receta se surta en una farmacia de la red y se cumplan otras reglas del plan. Para obtener más información acerca de cómo surtir sus recetas, revise su Evidencia de Cobertura.
¿Puede cambiar el Formulario (lista de medicamentos)? Por lo general, si está tomando un medicamento de nuestro formulario 2016 que tenía cobertura a principios de año, no descontinuaremos ni reduciremos la cobertura del medicamento durante el año de cobertura 2016, excepto cuando esté disponible un medicamento genérico menos costoso o cuando se divulgue información nueva adversa acerca de la seguridad o efectividad de un medicamento. Otros tipos de cambios al formulario, como la eliminación de un medicamento de nuestro formulario, no afectará a los miembros que actualmente están tomando el medicamento. Permanecerá disponible al mismo costo compartido para los miembros que lo tomen por el resto del año de cobertura. Creemos que es importante que tenga acceso continuo por el resto del año de cobertura a los medicamentos del formulario que estaban disponibles cuando usted eligió nuestro plan, excepto en los casos en que pueda ahorrar más dinero o que no podamos garantizar su seguridad. Si eliminamos medicamentos de nuestro formulario, o añadimos una autorización previa, límites en cuanto a cantidad y/o restricciones de terapia de pasos a un medicamento o movemos un
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medicamento a un nivel de costo compartido superior, debemos notificar a los miembros afectados acerca del cambio al menos 60 días antes de que el cambio entre en vigencia, o al momento en que el miembro solicite un resurtido del medicamento, en cuyo momento el miembro recibirá un suministro para 60 días del medicamento. Si la Administración de Alimentos y Medicamentos considera que un medicamento de nuestro formulario es inseguro o el fabricante del medicamento lo retira del mercado, inmediatamente retiraremos el medicamento de nuestro formulario y notificaremos a los miembros que toman el medicamento. El formulario adjunto está vigente al 1 de enero de 2016. Para obtener información actualizada acerca de los medicamentos cubiertos por Brand New Day, comuníquese con nosotros. Nuestra información de contacto aparece en la portada y en la contraportada. En caso de que haya cambios a mediados de año en los medicamentos que no sean de mantenimiento, le enviaremos una carta notificándole los cambios. Publicaremos una versión actualizada del formulario de Brand New Day en nuestro sitio web en ww.brandnewdayhmo.com. Si desea recibir una versión impresa de las correcciones, se la enviaremos por correo si la solicita.
¿Cómo utilizo el Formulario? Hay dos maneras de encontrar su medicamento dentro del formulario: Afección médica El formulario comienza en la página 23. Los medicamentos en este formulario están agrupados en categorías según el tipo de afecciones médicas que se utilizan para el tratamiento. Por ejemplo, los medicamentos utilizados para tratar una afección del corazón aparecen bajo la categoría de Agentes cardiovasculares. Si sabe para qué se usa su medicamento, busque el nombre de la categoría en la lista que comienza en la página 23. Luego busque bajo el nombre de la categoría de su medicamento. Lista alfabética Si no está seguro de la categoría en la que debe buscar, debe buscar su medicamento en el Índice que comienza en la página I-1. El Índice proporciona una lista en orden alfabético de todos los medicamentos incluidos en este documento. Tanto los medicamentos de marca como los genéricos se incluyen en el Índice. Busque en el Índice y encuentre su medicamento. Al lado de su medicamento, 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? Brand New Day cubre medicamentos de marca y medicamentos genéricos. Un medicamento genérico es aprobado por la Administración de Alimentos y Medicamentos (Food and Drug
3
Administration, FDA), ya que tiene el mismo ingrediente activo que el medicamento de marca. Por lo general, los medicamentos genéricos cuestan menos que los medicamentos de marca. ¿Existe alguna restricción en mi cobertura? Algunos medicamentos cubiertos pueden tener requisitos adicionales o límites de cobertura. Estos requisitos y límites pueden incluir: •
Autorización previa: Brand New Day requiere que usted [o su médico] obtenga una autorización previa para ciertos medicamentos. Esto significa que deberá obtener la aprobación de Brand New Day antes de reponer sus recetas. Si no obtiene la aprobación, Brand New Day podría no cubrir el medicamento.
•
Límites de cantidad: Para ciertos medicamentos, Brand New Day limita la cantidad del medicamento que Brand New Day cubrirá. Por ejemplo, nuestro Plan proporciona 18 comprimidos por receta para succinato de sumatriptán oral. Esto puede ser adicional a un suministro estándar para un mes o tres meses.
•
Terapia de pasos: En algunos casos, Brand New Day requiere que primero pruebe ciertos medicamentos para tratar su afección médica antes de cubrir otro medicamento para esa afección. Por ejemplo, si tanto el medicamento A como el medicamento B tratan su afección médica, Brand New Day podría no cubrir el medicamento B a menos que primero intente usar el medicamento A. Si el medicamento A no funciona para usted, Brand New Day cubrirá el medicamento B.
Puede averiguar si su medicamento tiene requisitos adicionales o límites al revisar el formulario que comienza en la página 21. También puede obtener más información acerca de las restricciones que aplican a medicamentos específicos cubiertos al visitar nuestro sitio web. Hemos publicado documentos en línea que explican nuestra restricción sobre autorización previa y las restricciones de terapia de pasos. Usted también puede solicitar que le enviemos una copia. Nuestra información de contacto, junto con la fecha de la última actualización del Formulario, aparece en la portada y en la contraportada. Puede solicitar una excepción a estas restricciones o límites, o una lista de otros medicamentos similares, que traten la misma afección médica. Consulte la sección “¿Cómo solicito una excepción al Formulario de Brand New Day”? en la página 4 para obtener información sobre cómo solicitar una excepción.
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¿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 de Afiliados y preguntar si su medicamento está cubierto. Este documento incluye solo una lista parcial de los medicamentos cubiertos, por lo que Brand New Day puede cubrir su medicamento. Para obtener más información, comuníquese con nosotros. Nuestra información de contacto, junto con la fecha de la última actualización del Formulario, aparece en la portada y en la contraportada. Si se entera de que Brand New Day no cubre su medicamento, usted tiene dos opciones: •
Puede solicitar a Servicios de Afiliados una lista de medicamentos similares que están cubiertos por Brand New Day. Cuando usted reciba la lista, muéstresela a su médico y pídale que le recete un medicamento similar que esté cubierto por Brand New Day.
•
Usted puede solicitar a Brand New Day 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 Brand New Day? Puede solicitar a Brand New Day que haga una excepción a nuestras reglas de cobertura. Existen varios tipos de excepciones que puede solicitarnos que hagamos. •
Puede pedirnos que cubramos un medicamento incluso si no está en nuestro formulario. Si se aprueba, este medicamento estará cubierto a un nivel de costo compartido predeterminado, y usted no podría pedirnos que suministremos el medicamento a un nivel de costo compartido inferior.
•
Puede solicitarnos que cubramos un medicamento del formulario a un nivel de costo compartido inferior [si este medicamento no está en el nivel de especialidad]. Si se aprueba, esto bajaría la cantidad que usted paga por su medicamento.
•
Puede solicitarnos que exoneremos las restricciones de cobertura o límites de su medicamento. Por ejemplo, para algunos medicamentos, Brand New Day 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, Brand New Day solo aprobará su solicitud de excepción si los medicamentos alternativos incluidos en el formulario del plan, el medicamento de costo compartido inferior o las restricciones adicionales de uso pudieran no ser tan efectivos al tratar su afección o pudieran provocarle efectos médicos adversos.
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Debe comunicarse con nosotros para pedirnos una decisión inicial de cobertura de una excepción de restricción de formulario, de nivel o de utilización. Cuando solicite una excepción de restricción al formulario, de nivel o de utilización, debe presentar una declaración de su médico o persona autorizada para recetar que respalde su solicitud. Por lo general, debemos tomar nuestra decisión dentro de las siguientes 72 horas después de recibir la declaración de apoyo de su médico. Puede solicitar una excepción expedita (rápida) si usted o su médico consideran que su salud podría dañarse seriamente si espera hasta por 72 horas para una decisión. Si se autoriza su solicitud expedita, debemos proporcionarle una decisión a más tardar 24 horas después de haber recibido una declaración de apoyo de su médico u otra persona autorizada para recetar.
¿Qué debo hacer antes de que pueda hablar con mi médico sobre un cambio en mis medicamentos o de solicitar una excepción? Como miembro nuevo o continuado en nuestro plan, puede tomar medicamentos que no se encuentren en nuestro listado de medicamentos. O bien, usted puede estar tomando un medicamento que no está en nuestro formulario, pero su capacidad para obtenerlo es limitada. Por ejemplo, puede necesitar una autorización previa de nuestra parte antes de poder reponer su receta médica. Usted debe hablar con su médico para decidir si deben cambiar a un medicamento apropiado que cubramos o solicitar una excepción al formulario para que cubramos el medicamento que toma. Mientras que habla con su médico para determinar el curso correcto de acción para usted, podemos cubrir su medicamento en ciertos casos durante los primeros 90 días en que es miembro de nuestro plan. Para cada uno de sus medicamentos que no está incluido en nuestro formulario, o si su capacidad de obtener sus medicamentos es limitada, cubriremos un suministro temporal para 30 días (a menos que tenga una receta escrita para menos días) cuando vaya a una farmacia de la red de servicios. Después de su primer suministro para 30 días, nosotros no pagaremos por estos medicamentos, incluso si usted ha sido miembro del plan menos de 90 días. Si es un residente de un centro de atención a largo plazo, le permitiremos resurtir su receta médica hasta que le hayamos proporcionado un suministro de transición para 98 días, consistente con el incremento de despacho (a menos que tenga una receta escrita para menos días). Cubriremos más de un resurtido de estos medicamentos durante los primeros 90 días en que usted es miembro de nuestro plan. Si necesita un medicamento que no está en nuestro formulario o si su capacidad para obtener sus medicamentos es limitada, pero ha pasado los primeros 90 días de afiliación en nuestro plan, cubriremos un suministro de emergencia de 31 días de ese medicamento (a menos que tenga una receta por menos días) mientras solicita una excepción al formulario. Los afiliados que cambian los lugares de tratamiento debido a cambios en el nivel de atención también se consideran en transición. Estos afiliados recibirán un resurtido de transición adecuado.
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Para obtener más información Para obtener información más detallada acerca de su cobertura de medicamentos recetados de Brand New Day, consulte su Evidencia de Cobertura y otros materiales del plan. Si tiene preguntas sobre Brand New Day, comuníquese con nosotros. Nuestra información de contacto, junto con la fecha de la última actualización del Formulario, aparece en la portada y en la contraportada. Si tiene preguntas generales acerca de la cobertura de medicamentos recetados de Medicare, llame a Medicare al 1-800-MEDICARE (1-800-633-4227), las 24 horas del día, los 7 días de la semana. Los usuarios TTY deben llamar al 1-877-486-2048. O visite http://www.medicare.gov.
Formulario de Brand New Day El formulario que comienza en la página 21 proporciona información de cobertura sobre algunos de los medicamentos cubiertos por Brand New Day. Si tiene problemas para encontrar su medicamento en la lista, consulte el Índice que comienza en la página I-1. La primera columna del cuadro muestra el nombre del medicamento. Los medicamentos con nombre de marca están en mayúsculas (por ejemplo, CRESTOR) y los medicamentos genéricos están en minúsculas (por ejemplo, atorvastatin). La información en la columna de Requisitos/límites indica si Brand New Day tiene algún requisito especial para la cobertura de su medicamento.
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Las siguientes abreviaturas de Gestión de Utilización pueden encontrarse en este documento ABREVIATURAS DE NOTAS DE COBERTURA ABREVIATURA
DESCRIPCIÓN
EXPLICACIÓN
Restricciones de Gestión de Utilización
PA
Restricción de autorización previa
PA BvD
Restricción de autorización previa para Determinación de la Parte B vs. Parte D
PA-HRM
Restricción de Autorización previa para Medicamentos de alto riesgo
PA NSO
Restricción de Autorización previa para solo nuevos casos
QL
Restricción de límite de cantidad
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Usted (o su médico) debe obtener una autorización previa de Brand New Day antes de surtir su receta para este medicamento. Sin una aprobación previa, Brand New Day podría no cubrir este medicamento. Este medicamento puede ser elegible para el pago de la Parte B o la Parte D de Medicare. Usted (o su médico) debe obtener una autorización previa de Brand New Day para determinar que este medicamento está cubierto por la Parte D de Medicare antes de surtir su receta médica para este medicamento. Sin aprobación previa, Brand New Day podría no cubrir este medicamento. Los Centros de Servicios de Medicare y Medicaid (Centers for Medicare and Medicaid services, CMS) consideran que este medicamento es potencialmente dañino y, por lo tanto, un medicamento de alto riesgo para los beneficiarios de Medicare de 65 años o más. Los miembros de 65 años de edad o mayores deben obtener una autorización previa de Brand New Day antes de surtir su receta médica para este medicamento. Sin aprobación previa, Brand New Day podría no cubrir este medicamento. Si usted es un afiliado nuevo o si no ha tomado este medicamento antes, usted (o su médico) debe obtener una autorización previa de Brand New Day antes de surtir su receta para este medicamento. Sin aprobación previa, Brand New Day podría no cubrir este medicamento. Brand New Day limita la cantidad de este medicamento que está cubierta por receta médica, o dentro de un marco de tiempo
ABREVIATURA
ST
DESCRIPCIÓN
EXPLICACIÓN
específico. Antes de que Brand New Day le proporcione cobertura para este medicamento, primero debe intentar otro(s) medicamento(s) para tratar su Restricción de terapia de pasos afección médica. Este medicamento puede ser cubierto únicamente si el(los) otro medicamento(s) no funciona(n) para usted.
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Las siguientes abreviaturas de nota de cobertura adicional se pueden encontrar en este documento OTRO REQUISITO ESPECIAL PARA LA COBERTURA ABREVIATURAS
DESCRIPCIÓN
LA
Medicamento de acceso limitado
GC
Vacío de cobertura
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EXPLICACIÓN Esta receta médica puede estar disponible únicamente en ciertas farmacias. Para obtener más información, consulte su Directorio de Farmacias o llame a Servicios de Afiliados al 866-255-4795 Los usuarios de TTY deben llamar al 866-321-5955. Proporcionamos cobertura de este medicamento recetado en la etapa de vacío de cobertura. Por favor, consulte la Evidencia de Cobertura para obtener más información acerca de esta cobertura.
El siguiente es un breve resumen de los copagos/coaseguros de los planes de Brand New Day durante el Período de Cobertura Inicial. Las cantidades que aparecen son para farmacia minorista dentro de la red y farmacia de pedidos por correo Harmony Dual Access, Plan 020: Deducible de $360 (el deducible no se aplica a los niveles 1 y 6) Copago/coaseguro de pedidos por correo (suministro para 3 meses)
Nivel del medicamento
Nombre del nivel del medicamento
Copago/coaseguro minorista (suministro para 1 mes - 30 días)
Harmony Dual Access, Plan 020
1
Medicamentos genéricos preferidos
$0
$0
Harmony Dual Access, Plan 020
2
Medicamentos genéricos no preferidos
Copago de $13
Copago de $26
Harmony Dual Access, Plan 020
3
Medicamentos de marca preferidos
25 % de coaseguro
25 % de coaseguro
Harmony Dual Access, Plan 020
4
Medicamentos de marca no preferidos
25 % de coaseguro
25 % de coaseguro
Harmony Dual Access, Plan 020
5
Medicamentos especializados
25 % de coaseguro
25 % de coaseguro
Harmony Dual Access, Plan 020
6
Medicamentos seleccionados para la diabetes
Copago de $11
Copago de $22
Nombre del plan
11
Dual Coverage (HMO SNP), Plan 024: Sin deducible
Nombre del plan
Dual Coverage (HMO SNP), Plan 024
Dual Coverage (HMO SNP), Plan 024
Nivel del medica mento
Nombre del nivel del medicamento
Copago/coaseguro minorista (suministro para 1 mes -30 días)
Copago/coaseguro de pedidos por correo (suministro para 3 meses)
1
Medicamentos genéricos preferidos
Copago de $0
Copago de $0
2
Medicamentos genéricos no preferidos
Copago de $0
Copago de $0
(copago de $0; copago de $1.20; o copago de $2.95) Para todos los demás medicamentos: • copago de $0; o • copago de $3.60; o • copago de $7.40 (copago de $0; copago de $1.20; o copago de $2.95) Para todos los demás medicamentos: • copago de $0; o • copago de $3.60; o • copago de $7.40
(copago de $0; copago de $1.20; o copago de $2.95) Para todos los demás medicamentos: • copago de $0; o • copago de $3.60; o • copago de $7.40 (copago de $0; copago de $1.20; o copago de $2.95) Para todos los demás medicamentos: • copago de $0; o • copago de $3.60; o • copago de $7.40
Dual Coverage (HMO SNP), Plan 024
3
Medicamentos de marca preferidos
Dual Coverage (HMO SNP), Plan 024
4
Medicamentos de marca no preferidos
12
Nombre del plan
Dual Coverage (HMO SNP), Plan 024
Dual Coverage (HMO SNP), Plan 024
Nombre del nivel del medicamento
Copago/coaseguro minorista (suministro para 1 mes - 30 días)
Copago/coaseguro de pedidos por correo (suministro para 3 meses)
5
Medicamentos de especialidad
(copago de $0; copago de $1.20; o copago de $2.95) Para todos los demás medicamentos: • copago de $0; o • copago de $3.60; o • copago de $7.40
(copago de $0; copago d e$1.20; o copago de $2.95) Para todos los demás medicamentos: • copago de $0; o • copago de $3.60; o • copago de $7.40
6
Medicamentos seleccionados para la diabetes
Copago de $0
copago de $0
Nivel del medicamento
13
Classic Care (HMO), Plan 025: Sin deducible
Nivel del medicamento
Nombre del nivel del medicamento
Copago/coaseguro minorista (suministro para 1 mes - 30 días)
Copago/coaseguro de pedidos por correo (suministro para 3 meses)
1
Medicamentos genéricos preferidos
Copago de $0
Copago de $0
2
Medicamentos genéricos no preferidos
Copago de $9
Copago de $18
Classic Care (HMO), Plan 025
3
Medicamentos de marca preferidos
Copago de $45
Copago de $90
Classic Care (HMO), Plan 025
4
Medicamentos de marca no preferidos
Copago de $90
Copago de $180
Classic Care (HMO), Plan 025
5
Medicamentos de especialidad
33 % de coaseguro
33 % de coaseguro
Classic Care (HMO), Plan 025
6
Medicamentos seleccionados para la diabetes
Copago de $11
Copago de $22
Nombre del plan
Classic Care (HMO), Plan 025
Classic Care (HMO), Plan 025
14
In-Control Drug Savings,, (HMO SNP), Plan 026: Sin deducible
Copago/coaseguro minorista (suministro para 1 mes - 30 días)
Copago/coaseguro de pedidos por correo (suministro para 3 meses)
1
Medicamentos genéricos preferidos
Copago de $0
Copago de $0
2
Medicamentos genéricos no preferidos
Copago de $9
Copago de $18
In Control Drug Savings (HMO SNP) / 026
3
Medicamentos de marca preferidos
Copago de $45
Copago de $90
In Control Drug Savings (HMO SNP) / 026
4
Medicamentos de marca no preferidos
Copago de $90
Copago de $180
In Control Drug Savings (HMO SNP) / 026
5
Medicamentos de especialidad
33 % de coaseguro
33 % de coaseguro
In Control Drug Savings (HMO SNP) / 026
6
Medicamentos seleccionados para la diabetes
Copago de $9
Copago de $18
Nombre del plan
In Control Drug Savings (HMO SNP) 026 In Control Drug Savings (HMO SNP
Nivel del medicament o
Nombre del nivel del medicamento
15
In Control Dual Access (HMO SNP), Plan 027: Deducible de $360 (El deducible no se aplica al nivel 1, nivel 2, nivel 3 y nivel 6)
Nivel del medicament o
Nombre del nivel del medicamento
Copago/coaseguro minorista (suministro para 1 mes - 30 días)
Copago/coaseguro de pedidos por correo (suministro para 3 meses)
In Control Dual Access (HMO SNP) / Plan 027
1
Medicamentos genéricos preferidos
Copago de $0
Copago de $0
In Control Dual Access (HMO SNP) / Plan 027
2
Medicamentos genéricos no preferidos
Copago de $0
Copago de $0
In Control Dual Access (HMO SNP) / Plan 027
3
Medicamentos de marca preferidos
Copago de $0
Copago de $0
In Control Dual Access (HMO SNP) / Plan 027
4
Medicamentos de marca no preferidos
25 % de coaseguro
25 % de coaseguro
In Control Dual Access (HMO SNP) / Plan 027
5
Medicamentos de especialidad
25 % de coaseguro
25 % de coaseguro
In Control Dual Access (HMO SNP) / Plan 027
6
Medicamentos seleccionados para la diabetes
Copago de $0
Copago de $0
Nombre del plan
16
Bridges Drug Savings (HMO SNP), Plan 028: Sin deducible
Nivel del medicament o
Nombre del nivel del medicamento
Copago/coaseguro minorista (suministro para 1 mes - 30 días)
Copago/coaseguro de pedidos por correo (suministro para 3 meses)
1
Medicamentos genéricos preferidos
Copago de $0
Copago de $0
2
Medicamentos genéricos no preferidos
Copago de $9
Copago de $18
3
Medicamentos de marca preferidos
Copago de $45
Copago de $90
Bridges Drug Savings (HMO SNP) / Plan 028
4
Medicamentos de marca no preferidos
$90 de copago
$180 de copago
Bridges Drug Savings (HMO SNP) / Plan 028
5
Medicamentos de especialidad
33 % de coaseguro
Bridges Drug Savings (HMO SNP) / Plan 028
6
Medicamentos seleccionados para la diabetes
Copago de $11
Nombre del plan
Bridges Drug Savings (HMO SNP) / Plan 028 Bridges Drug Savings (HMO SNP) / Plan 028 Bridges Drug Savings (HMO SNP) / Plan 028
17
33 % de coaseguro
Copago de $22
Bridges Dual Access (HMO SNP), Plan 029: Deducible de $360 (El deducible no se aplica al nivel 1, nivel 2, nivel 3 y nivel 6)
Nombre del plan
Nivel del medicament o
Nombre del nivel del medicamento
Copago/coaseguro minorista (suministro para 1 mes - 30 días)
Copago/coaseguro de pedidos por correo (suministro para 3 meses)
Bridges Dual Access (HMO SNP) / Plan 029
1
Medicamentos genéricos preferidos
Copago de $0
Copago de $0
Bridges Dual Access (HMO SNP) / Plan 029
2
Medicamentos genéricos no preferidos
Copago de $0
Copago de $0
Bridges Dual Access (HMO SNP) / Plan 029
3
Medicamentos de marca preferidos
Copago de $0
Copago de $0
Bridges Dual Access (HMO SNP) / Plan 029
4
Medicamentos de marca no preferidos
25 % de coaseguro
25 % de coaseguro
Bridges Dual Access (HMO SNP) / Plan 029
5
Medicamentos de especialidad
25 % de coaseguro
25 % de coaseguro
6
Medicamentos seleccionados para la diabetes
Copago de $0
Copago de $0
Bridges Dual Access (HMO SNP) / Plan 029
18
Healthy Heart Drug Savings (HMO SNP), Plan 030: Sin deducible
Nombre del plan
Nivel del medicament o
Nombre del nivel del medicamento
Copago/coaseguro minorista (suministro para 1 mes - 30 días)
Copago/coaseguro de pedidos por correo (suministro para 3 meses)
Healthy Heart Drug Savings (HMO SNP) / Plan 030
1
Medicamentos genéricos preferidos
Copago de $0
Copago de $0
2
Medicamentos genéricos no preferidos
Copago de $9
Copago de $18
3
Medicamentos de marca preferidos
Copago de $45.00
Copago de $90
Healthy Heart Drug Savings (HMO SNP) / Plan 030
4
Medicamentos de marca no preferidos
Copago de $90
Copago de $180.00
Healthy Heart Drug Savings (HMO SNP) / Plan 030
5
Medicamentos de especialidad
33 % de coaseguro
33 % de coaseguro
6
Medicamentos seleccionados para la diabetes
Copago de $11
Copago de $22
Healthy Heart Drug Savings (HMO SNP) / 0 Plan 030 Healthy Heart Drug Savings (HMO SNP) / 0 Plan 30
Healthy Heart Drug Savings (HMO SNP) / Plan 030
19
Healthy Heart Dual Access (HMO SNP), Plan 031: Deducible de $360 (El deducible no se aplica al nivel 1, nivel 2, nivel 3, nivel 6)
Nivel del medicament o
Nombre del nivel del medicamento
Copago/coaseguro minorista (suministro para 1 mes - 30 días)
Copago/coaseguro de pedidos por correo (suministro para 3 meses)
Healthy Heart Dual Access (HMO SNP) / Plan 031
1
Medicamentos genéricos preferidos
Copago de $0
Copago de $0
Healthy Heart Dual Access (HMO SNP) / Plan 031
2
Medicamentos genéricos no preferidos
Copago de $0
Copago de $0
3
Medicamentos de marca preferidos
Copago de $0
Copago de $0
Healthy Heart Dual Access (HMO SNP) / Plan 031
4
Medicamentos de marca no preferidos
25 % de coaseguro
25 % de coaseguro
Healthy Heart Dual Access (HMO SNP) / Plan 031
5
Medicamentos de especialidad
25 % de coaseguro
25 % de coaseguro
6
Medicamentos seleccionados para la diabetes
Copago de $0
Copago de $0
Nombre del plan
Healthy Heart Dual Access (HMO SNP) / Plan 031
Healthy Heart Dual Access (HMO SNP) / Plan 031
20
Hope Drug Savings (HMO SNP), Plan 032: Sin deducible
Nombre del plan
Nivel del medicament o
Nombre del nivel del medicamento
Copago/coaseguro minorista (suministro para 1 mes - 30 días)
Copago/coaseguro de pedidos por correo (suministro para 3 meses)
Hope Drug Savings (HMO SNP) / Plan 032
1
Medicamentos genéricos preferidos
Copago de $0
Copago de $0
2
Medicamentos genéricos no preferidos
Copago de $9
Copago de $18
Hope Drug Savings (HMO SNP) / Plan 032
3
Medicamentos de marca preferidos
Copago de $45
Copago de $90
Hope Drug Savings (HMO SNP) / Plan 032
4
Medicamentos de marca no preferidos
Copago de $90
Copago de $180
Hope Drug Savings (HMO SNP) / Plan 032
5
Medicamentos de especialidad
33 % de coaseguro
33 % de coaseguro
Hope Drug Savings (HMO SNP) / Plan 032
6
Medicamentos seleccionados para la diabetes
Copago de $11
Copago de $22
Hope Drug Savings (HMO SNP) / Plan 032
21
Classic Choice for Medi-Medi (HMO), Plan 033: Deducible de $360 (El deducible no se aplica al nivel 1, nivel 2, nivel 3, nivel 6)
Nombre del plan
Nivel del medicament o
Nombre del nivel del medicamento
Copago/coaseguro minorista (suministro para 1 mes - 30 días)
Copago/coaseguro de pedidos por correo (suministro para 3 meses)
Classic Choice for Medi-Medi (HMO), Plan 033
1
Medicamentos genéricos preferidos
Copago de $0
Copago de $0
Classic Choice for Medi-Medi (HMO), Plan 033
2
Medicamentos genéricos no preferidos
Copago de $0
Copago de $0
Classic Choice for Medi-Medi (HMO), Plan 033
3
Medicamentos de marca preferidos
Copago de $0
Copago de $0
Classic Choice for Medi-Medi (HMO), Plan 033
4
Medicamentos de marca no preferidos
25 % de coaseguro
25 % de coaseguro
Classic Choice for Medi-Medi (HMO), Plan 033
5
Medicamentos de especialidad
25 % de coaseguro
25 % de coaseguro
6
Medicamentos seleccionados para la diabetes
Copago de $0
Copago de $0
Classic Choice for Medi-Medi (HMO), Plan 033
22
Drug Name
Drug Tier
Requirements/Limits
(Acetaminophen with Codeine) acetaminophen-codeine oral tablet 300-15 (Tylenol-Codeine No.3) mg, 300-30 mg acetaminophen-codeine oral tablet 300-60 (Tylenol-Codeine No.3) mg buprenorphine hcl injection (Buprenorphine HCl) butalb-acetaminophen-caffeine oral (Esgic) capsule 50-325-40 mg butalbital-acetaminop-caf-cod (Fioricet with Codeine)
2
butalbital-acetaminophen
(Tencon)
2
butalbital-acetaminophen-caff oral capsule 50-325-40 mg butalbital-acetaminophen-caff oral tablet 50-325-40 mg butalbital-aspirin-caffeine oral capsule
(Esgic)
2
(Esgic)
2
(Fiorinal)
2
BUTRANS codeine sulfate oral tablet
(Codeine Sulfate)
3 2
codeine-butalbital-asa-caffein oral capsule 30-50-325-40 mg fentanyl
(Fiorinal with Codeine #3) (Duragesic)
2
fentanyl citrate
(Actiq)
5
hydrocodone-acetaminophen oral solution (Hycet)
2
hydrocodone-acetaminophen oral tablet 10-300 mg, 5-300 mg, 7.5-300 mg
(Norco)
2
hydrocodone-acetaminophen oral tablet (Norco) 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg
2
GC; QL (2700 per 30 days) GC; QL (360 per 30 days) GC; QL (180 per 30 days) GC PA-HRM; GC; QL (180 per 30 days) PA-HRM; GC; QL (180 per 30 days) PA-HRM; GC; QL (180 per 30 days) PA-HRM; GC; QL (180 per 30 days) PA-HRM; GC; QL (180 per 30 days) PA-HRM; GC; QL (180 per 30 days) QL (4 per 28 days) GC; QL (180 per 30 days) PA-HRM; GC; QL (180 per 30 days) PA; GC; QL (10 per 30 days) PA; QL (120 per 30 days) GC; QL (2700 per 30 days) (includes Vicodin, Vicodin ES and Vicodin HP); GC; QL (390 per 30 days) GC; QL (360 per 30 days)
Analgesics Analgesics, Miscellaneous acetaminophen-codeine oral solution
2 2 2 2 2
2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 23 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name
Drug Tier
Requirements/Limits
hydrocodone-ibuprofen
(Ibudone)
2
hydromorphone (pf) injection solution 10 mg/ml hydromorphone (pf) injection solution 4 mg/ml hydromorphone injection solution hydromorphone injection syringe 2 mg/ml hydromorphone oral liquid
(Hydromorphone HCl/PF) (Dilaudid)
2
GC; QL (150 per 30 days) GC
2
GC
(Hydromorphone HCl) (Hydromorphone HCl) (Dilaudid)
2 2 2
hydromorphone oral tablet 2 mg, 4 mg
(Dilaudid)
2
hydromorphone oral tablet 8 mg
(Dilaudid)
2
LAZANDA methadone hcl oral tablet,soluble 40 mg methadone injection methadone oral
(Diskets) (Methadone HCl) (Methadone HCl)
5 2 2 2
methadone oral
(Diskets)
2
morphine concentrate oral solution
(Morphine Sulfate)
2
morphine concentrate oral syringe morphine in dextrose 5 % injection pt controlled analgesia syring 50 mg/25 ml (2 mg/ml) morphine injection solution 15 mg/ml, 8 mg/ml morphine injection syringe 10 mg/ml morphine intramuscular morphine intravenous morphine intravenous solution 25 mg/ml, 50 mg/ml morphine intravenous morphine oral solution 10 mg/5 ml
(Morphine Sulfate) (Morphine Sulfate/D5W)
2 2
GC GC GC; QL (1200 per 30 days) GC; QL (180 per 30 days) GC; QL (240 per 30 days) PA; QL (30 per 30 days) GC; QL (90 per 30 days) GC GC; QL (1800 per 30 days) GC; QL (360 per 30 days) GC; QL (200 per 30 days) GC GC
(Morphine Sulfate)
2
GC
(Morphine Sulfate) (Morphine Sulfate) (Morphine Sulfate) (Morphine Sulfate)
2 2 2 2
GC GC GC GC
(Morphine Sulfate) (Morphine Sulfate)
2 2
morphine oral solution 20 mg/5 ml
(Morphine Sulfate)
2
GC GC; QL (700 per 30 days) GC; QL (300 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 24 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name
Drug Tier
MORPHINE ORAL TABLET morphine oral tablet extended release 100 mg, 30 mg, 60 mg morphine oral tablet extended release 15 mg, 200 mg morphine rectal NUCYNTA NUCYNTA ER oxycodone hcl-acetaminophen oral solution 5-325 mg/5 ml oxycodone hcl-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg oxycodone hcl-aspirin
(MS Contin)
4 2
(MS Contin)
2
(Morphine Sulfate)
2 3 3 2
(Oxycodone HCl/Acetaminophen) (Xolox)
2
(Percodan)
2
oxycodone oral concentrate
(Oxycodone HCl)
2
oxycodone oral solution
(Oxycodone HCl)
2
oxycodone oral tablet
(Roxicodone)
2
oxycodone-acetaminophen oral tablet 10325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg oxycodone-acetaminophen oral tablet 10650 mg oxycodone-acetaminophen oral tablet 7.5500 mg oxycodone-aspirin
(Xolox)
2
(Xolox)
2
(Xolox)
2
(Percodan)
2
OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 80 MG oxymorphone oral tablet oxymorphone oral tablet extended release 12 hr 10 mg, 15 mg, 20 mg, 5 mg, 7.5 mg
Requirements/Limits QL (180 per 30 days) GC; QL (120 per 30 days) GC; QL (180 per 30 days) GC QL (181 per 30 days) QL (60 per 30 days) GC; QL (1800 per 30 days) GC; QL (360 per 30 days) GC; QL (360 per 30 days) GC; QL (180 per 30 days) GC; QL (1300 per 30 days) GC; QL (180 per 30 days) GC; QL (360 per 30 days)
3
GC; QL (180 per 30 days) GC; QL (240 per 30 days) GC; QL (360 per 30 days) QL (60 per 30 days)
3
QL (120 per 30 days)
(Opana)
2
(Opana ER)
2
GC; QL (180 per 30 days) GC; QL (60 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 25 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name
Drug Tier
oxymorphone oral tablet extended release 12 hr 30 mg, 40 mg tramadol oral tablet
(Opana ER)
2
(Ultram)
2
tramadol-acetaminophen
(Ultracet)
2
xylon 10
(Ibudone)
2
Nonsteroidal Anti-Inflammatory Agents CALDOLOR INTRAVENOUS RECON SOLN celecoxib (Celebrex) choline,magnesium salicylate (Choline Sal/Mag Salicylate) diclofenac potassium (Diclofenac Potassium) diclofenac sodium oral tablet extended (Voltaren-XR) release 24 hr diclofenac sodium oral tablet,delayed (Diclofenac Sodium) release (dr/ec) diclofenac sodium topical gel (Solaraze) diclofenac-misoprostol (Arthrotec 50) diflunisal (Diflunisal) etodolac (Etodolac) fenoprofen oral tablet (Fenoprofen Calcium) FLECTOR flurbiprofen (Flurbiprofen) ibuprofen oral (Ibuprofen) ibuprofen oral tablet 400 mg, 600 mg, 800 (Ibuprofen) mg indomethacin oral capsule 25 mg (Indomethacin)
Requirements/Limits GC; QL (120 per 30 days) GC; QL (240 per 30 days) GC; QL (240 per 30 days) GC; QL (150 per 30 days)
4 2 2
GC; QL (60 per 30 days) GC
2 2
GC GC
2
GC
5 2 2 2 2 3 2 2 1
GC GC GC GC PA GC GC GC
2
indomethacin oral capsule 50 mg
(Indomethacin)
2
indomethacin oral capsule, extended release indomethacin sodium ketoprofen oral capsule
(Indomethacin)
2
(Indomethacin Sodium) (Ketoprofen)
2 2
PA-HRM; GC; QL (240 per 30 days) PA-HRM; GC; QL (120 per 30 days) PA-HRM; GC; QL (60 per 30 days) PA-HRM; GC GC
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 26 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg ketorolac oral
Drug Tier
Requirements/Limits
(Ketoprofen)
2
GC
(Ketorolac Tromethamine) (Ponstel) (Mobic) (Mobic) (Nabumetone) (Naprosyn) (Naprosyn) (Ec-Naprosyn)
2
GC; QL (20 per 30 days)
2 2 1 2 2 1 2
GC GC GC GC GC GC GC
(Anaprox)
1
GC
(Feldene) (Salsalate) (Sulindac) (Tolmetin Sodium)
2 2 2 2 3
GC GC GC GC
Local Anesthetics glydo lidocaine (pf) injection solution
(Lidocaine HCl) (Xylocaine-MPF)
2 2
lidocaine hcl injection solution
(Xylocaine)
2
lidocaine hcl laryngotracheal lidocaine hcl mucous membrane gel lidocaine hcl mucous membrane jelly in applicator lidocaine hcl mucous membrane solution lidocaine hcl urethral lidocaine topical adhesive patch,medicated lidocaine topical ointment
(Xylocaine) (Lidocaine HCl) (Lidocaine HCl)
2 2 2
GC PA BvD; (PA for ESRD Only); GC PA BvD; (PA for ESRD Only); GC GC GC GC
(Xylocaine) (Lidocaine HCl) (Lidoderm)
2 2 2
GC GC PA; GC
(Lidocaine)
2
lidocaine-prilocaine topical
(EMLA)
2
PA BvD; (PA for ESRD Only); GC PA BvD; (PA for ESRD Only); GC
mefenamic acid meloxicam oral suspension meloxicam oral tablet nabumetone naproxen oral suspension naproxen oral tablet naproxen oral tablet,delayed release (dr/ec) naproxen sodium oral tablet 275 mg, 550 mg piroxicam salsalate sulindac oral tolmetin VOLTAREN TOPICAL
Anesthetics
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 27 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name lidocaine-prilocaine topical kit
Drug Tier (Relador Pak)
RELADOR PAK
2 2
Requirements/Limits (PA for ESRD Only); GC (PA for ESRD Only); GC
Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate (Acamprosate Calcium) buprenorphine hcl sublingual (Subutex)
2 2
buprenorphine-naloxone
2 2 3 3
GC PA; GC; QL (90 per 30 days) PA; GC; QL (90 per 30 days) GC QL (168 per 84 days) QL (56 per 28 days)
(Antabuse) (Naloxone HCl) (Revia) (Revia)
3 3 2 2 2 2 4 3
QL (56 per 28 days) QL (53 per 28 days) GC GC GC GC QL (1008 per 90 days) PA; QL (90 per 30 days)
Benzodiazepines alprazolam oral tablet
(Xanax)
2
chlordiazepoxide hcl
(Chlordiazepoxide HCl)
2
clonazepam oral tablet 0.5 mg, 1 mg clonazepam oral tablet 2 mg
(Klonopin) (Klonopin)
2 2
clonazepam oral tablet,disintegrating 0.125 mg, 0.25 mg, 0.5 mg, 1 mg clonazepam oral tablet,disintegrating 2 mg
(Clonazepam)
2
GC; QL (120 per 30 days) GC; QL (120 per 30 days) GC; QL (90 per 30 days) GC; QL (300 per 30 days) GC; QL (90 per 30 days)
(Clonazepam)
2
bupropion hcl sr 150 mg tablet f/c CHANTIX CHANTIX CONTINUING MONTH BOX CHANTIX CONTINUING MONTH PAK CHANTIX STARTING MONTH BOX disulfiram naloxone naltrexone hcl naltrexone NICOTROL ZUBSOLV
(Buprenorphine HCl/Naloxone HCl) (Zyban)
Antianxiety Agents
GC; QL (300 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 28 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name
Drug Tier
Requirements/Limits GC; QL (120 per 30 days) GC; QL (60 per 30 days)
clorazepate dipotassium oral tablet 15 mg
(Tranxene T-Tab)
2
clorazepate dipotassium oral tablet 3.75 mg, 7.5 mg diazepam injection diazepam intensol
(Tranxene T-Tab)
2
(Diazepam) (Diazepam)
2 2
diazepam oral solution 5 mg/5 ml (1 mg/ml) diazepam oral tablet
(Diazepam)
2
(Valium)
2
diazepam rectal lorazepam oral tablet ONFI ORAL SUSPENSION
(Diastat) (Ativan)
2 2 4
ONFI ORAL TABLET 10 MG, 20 MG
4
GC; QL (10 per 28 days) GC; QL (1200 per 30 days) GC; QL (1200 per 30 days) GC; QL (120 per 30 days) GC GC; QL (90 per 30 days) PA NSO; QL (480 per 30 days) PA NSO; QL (60 per 30 days)
Antibacterials Aminoglycosides BETHKIS gentamicin in nacl (iso-osm) intravenous piggyback gentamicin injection solution gentamicin sulfate (ped) (pf) gentamicin sulfate (pf) intravenous solution neomycin streptomycin intramuscular TOBI PODHALER INHALATION tobramycin in 0.225 % nacl tobramycin in 0.9 % nacl tobramycin sulfate injection solution Antibacterials, Miscellaneous bacitracin intramuscular chloramphenicol sod succinate clindamycin hcl
(Gentamicin In Nacl, Iso-Osm) (Gentamicin Sulfate) (Gentamicin Sulfate/PF) (Gentamicin Sulfate/PF) (Neomycin Sulfate) (Streptomycin Sulfate) (Tobi) (Tobramycin/Sodium Chloride) (Tobramycin Sulfate) (Bacitracin) (Chloramphenicol Sod Succ) (Cleocin HCl)
5 2
PA BvD GC
2 2 2
GC GC GC
2 2 5 5 2
GC GC QL (224 per 28 days) PA BvD GC
2
GC
2 2
GC GC
2
GC
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 29 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name clindamycin in 5 % dextrose clindamycin palmitate hcl clindamycin phosphate injection clindamycin phosphate intravenous solution colistin (colistimethate na) CUBICIN linezolid methenamine hippurate methenamine mandelate metronidazole in nacl (iso-os) metronidazole oral nitrofurantoin macrocrystal oral capsule 100 mg nitrofurantoin macrocrystal oral capsule 25 mg nitrofurantoin macrocrystal oral capsule
Drug Tier
Requirements/Limits
(Cleocin Phosphate In D5w) (Cleocin Palmitate) (Cleocin Phosphate) (Cleocin Phosphate)
2
GC
2 2 2
GC GC GC
(Coly-Mycin M Parenteral)
5
(Zyvox) (Hiprex) (Methenamine Mandelate) (Metronidazole/Sodium Chloride) (Flagyl) (Macrodantin/Macrobid)
5 5 2 2
GC GC
2
GC
2 2
GC PA-HRM; GC; QL (120 per 30 days) PA-HRM; GC; QL (120 per 30 days) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); GC; QL (120 per 30 days) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); GC; QL (120 per 30 days) GC
(Macrodantin)
2
(Macrodantin/Macrobid)
2
nitrofurantoin monohyd/m-cryst
(Macrobid)
2
polymyxin b sulfate
(Polymyxin B Sulfate)
2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 30 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name SYNERCID trimethoprim (Trimethoprim) vancomycin in d5w intravenous piggyback (Vancomycin HCl/D5W) vancomycin intravenous recon soln 1,000 (Vancomycin HCl) mg, 10 gram, 750 mg vancomycin intravenous recon soln 500 (Vancomycin mg HCl/D5W) vancomycin oral (Vancocin HCl) XIFAXAN ORAL TABLET 200 MG XIFAXAN ORAL TABLET 550 MG ZYVOX ORAL SUSPENSION FOR RECONSTITUTION Cephalosporins cefaclor oral capsule (Cefaclor) cefaclor oral suspension for reconstitution (Cefaclor) 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml cefadroxil oral capsule (Cefadroxil) cefadroxil oral suspension for (Cefadroxil) reconstitution 250 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet (Cefadroxil) CEFAZOLIN IN DEXTROSE (ISO-OS) INTRAVENOUS PIGGYBACK 1 GRAM/50 ML cefazolin in dextrose (iso-os) intravenous (Cefazolin piggyback 2 gram/50 ml Sodium/Dextrose, Iso) cefazolin injection recon soln 1 gram, 10 (Cefazolin Sodium) gram, 100 gram, 300 g, 500 mg cefdinir (Cefdinir) cefditoren pivoxil (Spectracef) cefepime (Maxipime) CEFEPIME IN DEXTROSE 5 % CEFEPIME IN DEXTROSE,ISO-OSM INTRAVENOUS PIGGYBACK cefotaxime (Claforan) cefoxitin (Cefoxitin Sodium) cefoxitin in dextrose, iso-osm intravenous (Cefoxitin piggyback 2 gram/50 ml Sodium/Dextrose, Iso)
Drug Tier
Requirements/Limits
5 2 2
GC GC
2
GC
2
GC
5 5 5 5
PA; QL (9 per 30 days) PA; QL (60 per 30 days)
2 2
GC GC
2 2
GC GC
2 2
GC GC
2
GC
2
GC
2 2 2 4 4
GC GC GC
2 2 2
GC GC GC
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 31 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name cefpodoxime cefprozil ceftazidime injection recon soln 2 gram, 6 gram ceftibuten ceftriaxone in dextrose,iso-os intravenous piggyback 1 gram/50 ml CEFTRIAXONE IN DEXTROSE,ISO-OS INTRAVENOUS PIGGYBACK 2 GRAM/50 ML ceftriaxone injection recon soln ceftriaxone intravenous recon soln 1 gram CEFTRIAXONE INTRAVENOUS RECON SOLN 2 GRAM cefuroxime axetil oral tablet cefuroxime sodium injection recon soln 1.5 gram, 750 mg cefuroxime sodium intravenous cephalexin oral capsule cephalexin oral suspension for reconstitution cephalexin oral tablet MEFOXIN IN DEXTROSE (ISO-OSM) SUPRAX ORAL TABLET,CHEWABLE TEFLARO Macrolides azithromycin clarithromycin oral suspension for reconstitution clarithromycin oral tablet clarithromycin oral tablet extended release 24 hr DIFICID ERYTHROCIN erythromycin base oral tablet,delayed release (dr/ec) 250 mg, 500 mg
Drug Tier
Requirements/Limits
(Cefpodoxime Proxetil) (Cefprozil) (Fortaz)
2 2 2
GC GC GC
(Cedax) (Ceftriaxone Na/Dextrose, Iso)
2 2
GC GC
2
GC
2 2
GC GC
2
GC
(Ceftin) (Zinacef)
2 2
GC GC
(Zinacef) (Keflex) (Cephalexin)
2 1 1
GC GC GC
(Cephalexin)
1 4 4 4
GC
(Zithromax) (Biaxin)
2 2
GC GC
(Biaxin) (Clarithromycin)
2 2
GC GC QL (20 per 10 days)
(Erythromycin Base)
5 4 2
(Rocephin) (Ceftriaxone Na/Dextrose, Iso)
GC
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 32 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name
Drug Tier
ERYTHROMYCIN BASE ORAL TABLET,DELAYED RELEASE (DR/EC) 333 MG erythromycin ethylsuccinate oral suspension for reconstitution 200 mg/5 ml erythromycin ethylsuccinate oral tablet 400 mg erythromycin oral capsule,delayed release(dr/ec) erythromycin oral tablet erythromycin stearate oral tablet 250 mg Miscellaneous B-Lactam Antibiotics aztreonam injection recon soln 1 gram CAYSTON imipenem-cilastatin INVANZ meropenem meropenem-0.9% sodium chloride
4
Penicillins amoxicillin oral capsule amoxicillin oral suspension for reconstitution amoxicillin oral tablet amoxicillin oral tablet,chewable 125 mg, 250 mg amoxicillin-pot clavulanate oral suspension for reconstitution amoxicillin-pot clavulanate oral tablet amoxicillin-pot clavulanate oral tablet extended release 12 hr amoxicillin-pot clavulanate oral tablet,chewable ampicillin ampicillin sodium injection recon soln ampicillin sodium intravenous recon soln ampicillin-sulbactam injection
Requirements/Limits
(Eryped 200)
2
GC
(Erythromycin Ethylsuccinate) (Erythromycin Base)
2
GC
2
GC
(Erythromycin Base) (Erythromycin Stearate)
2 2
GC GC
(Azactam)
2 5 2 4 2 2
GC LA GC
(Amoxicillin) (Amoxicillin)
1 1
GC GC
(Amoxicillin) (Amoxicillin)
1 1
GC GC
(Augmentin)
2
GC
(Augmentin) (Augmentin XR)
2 2
GC GC
(Amoxicillin/Potassium Clav) (Ampicillin Trihydrate) (Ampicillin Sodium) (Ampicillin Sodium) (Unasyn)
2
GC
1 2 2 2
GC GC GC GC
(Primaxin) (Merrem) (Meropenem-0.9% Sodium Chloride)
GC GC
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 33 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name ampicillin-sulbactam intravenous recon soln BICILLIN C-R BICILLIN L-A dicloxacillin nafcillin injection nafcillin intravenous recon soln oxacillin in dextrose(iso-osm)
Drug Tier (Unasyn)
(Dicloxacillin Sodium) (Nafcillin Sodium) (Nafcillin Sodium) (Oxacillin Sodium/Dextrose, Iso) oxacillin injection recon soln 10 gram (Oxacillin Sodium) oxacillin intravenous (Oxacillin Sodium) penicillin g pot in dextrose (Pen G Pot/DextroseWater) penicillin g potassium injection recon soln (Penicillin G Potassium) 20 million unit penicillin g procaine (Penicillin G Procaine) penicillin v potassium (Penicillin V Potassium) piperacillin-tazobactam (Zosyn) Quinolones ciprofloxacin (Cipro) ciprofloxacin hcl oral (Cipro) ciprofloxacin in 5 % dextrose (Cipro I.V.) ciprofloxacin lactate (Ciprofloxacin Lactate) levofloxacin in d5w intravenous piggyback (Levaquin) levofloxacin intravenous (Levofloxacin) levofloxacin oral solution (Levaquin) levofloxacin oral tablet (Levaquin) moxifloxacin (Avelox) ofloxacin oral tablet 400 mg (Ofloxacin) Sulfonamides sulfadiazine oral (Sulfadiazine) sulfamethoxazole-trimethoprim (Sulfamethoxazole/Trim intravenous ethoprim) sulfamethoxazole-trimethoprim oral (Sulfamethoxazole/Trim suspension ethoprim) sulfamethoxazole-trimethoprim oral tablet (Bactrim) sulfasalazine (Azulfidine)
Requirements/Limits
2
GC
4 4 2 2 2 2
GC GC GC GC
2 2 2
GC GC GC
2
GC
2 2 2
GC GC GC
2 1 2 2 2 2 2 1 2 2
GC GC GC GC GC GC GC GC GC GC
2 2
GC GC
2
GC
1 2
GC GC
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 34 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name sulfatrim sulfazine sulfazine ec Tetracyclines doxycycline hyclate oral capsule 100 mg doxycycline hyclate 100 mg tab f/c doxycycline hyclate intravenous doxycycline hyclate oral capsule 100 mg doxycycline hyclate oral capsule 50 mg doxycycline hyclate oral tablet 100 mg, 50 mg doxycycline hyclate oral tablet 20 mg doxycycline monohydrate oral capsule doxycycline monohydrate oral suspension for reconstitution doxycycline monohydrate oral tablet minocycline oral capsule minocycline oral tablet tetracycline TYGACIL
Drug Tier
Requirements/Limits
(Sulfamethoxazole/Trim ethoprim) (Azulfidine) (Azulfidine)
2
GC
2 2
GC GC
(Morgidox) (Doryx) (Doxycycline Hyclate) (Adoxa) (Morgidox) (Avidoxy)
2 2 2 2 2 2
GC GC GC GC GC GC
(Doryx) (Adoxa) (Vibramycin)
2 2 2
GC GC GC
(Avidoxy) (Minocin) (Minocycline HCl) (Tetracycline HCl)
2 2 2 2 5
GC GC GC GC
Anticancer Agents Anticancer Agents ABRAXANE ADCETRIS
5 5
AFINITOR DISPERZ
5
AFINITOR ORAL TABLET 10 MG
5
AFINITOR ORAL TABLET 2.5 MG, 5 MG, 7.5 MG ALIMTA INTRAVENOUS RECON SOLN anastrozole AVASTIN azacitidine BELEODAQ
5
PA NSO; QL (4 per 21 days) PA NSO; QL (112 per 28 days) PA NSO; QL (56 per 28 days) PA NSO; QL (28 per 28 days)
5 (Arimidex) (Vidaza)
2 5 5 5
GC PA NSO PA NSO
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 35 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name
Drug Tier
Requirements/Limits PA NSO; QL (420 per 30 days) GC PA BvD; GC PA NSO; QL (140 per 365 days) PA NSO; QL (120 per 30 days) PA NSO; QL (30 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (30 per 30 days) PA NSO; QL (112 per 28 days) PA NSO; QL (63 per 28 days) PA BvD; GC PA BvD; ST
bexarotene
(Targretin)
5
bicalutamide bleomycin BLINCYTO
(Casodex) (Bleomycin Sulfate)
2 2 5
BOSULIF ORAL TABLET 100 MG
5
BOSULIF ORAL TABLET 500 MG
5
CAPRELSA ORAL TABLET 100 MG
5
CAPRELSA ORAL TABLET 300 MG
5
COMETRIQ
5
COTELLIC
5
cyclophosphamide intravenous recon soln CYCLOPHOSPHAMIDE ORAL CAPSULE cyclophosphamide oral tablet CYRAMZA dactinomycin DARZALEX decitabine doxorubicin hcl intravenous recon soln 10 mg doxorubicin hcl peg-liposomal intravenous suspension 2 mg/ml doxorubicin, peg-liposomal DROXIA ELIGARD SUBCUTANEOUS SYRINGE 22.5 MG (3 MONTH) ELIGARD SUBCUTANEOUS SYRINGE 30 MG (4 MONTH) ELIGARD SUBCUTANEOUS SYRINGE 45 MG (6 MONTH)
(Cyclophosphamide)
2 4
(Cyclophosphamide)
PA BvD; ST; GC PA NSO GC PA NSO
(Dacogen) (Doxorubicin HCl)
2 5 2 5 5 2
(Doxil)
5
PA BvD
(Doxil)
5 3 4
PA BvD
4
QL (1 per 112 days)
4
QL (1 per 168 days)
(Dactinomycin)
PA BvD; GC
QL (1 per 84 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 36 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name
Drug Tier
ELIGARD SUBCUTANEOUS SYRINGE 7.5 MG (1 MONTH) EMCYT EMPLICITI ERIVEDGE
4
ETOPOPHOS etoposide intravenous exemestane FARESTON FARYDAK FASLODEX floxuridine fluorouracil intravenous solution 2.5 gram/50 ml, 5 gram/100 ml, 500 mg/10 ml flutamide GAZYVA GILOTRIF
4 2 2 5 5 5 2 2
3 5 5
(Etoposide) (Aromasin)
(Floxuridine) (Fluorouracil) (Flutamide)
2 5 5
GLEEVEC ORAL TABLET 100 MG
5
GLEEVEC ORAL TABLET 400 MG
5
HERCEPTIN HEXALEN hydroxyurea IBRANCE
5 5 2 5
(Hydrea)
ICLUSIG ORAL TABLET 15 MG
5
ICLUSIG ORAL TABLET 45 MG
5
ifosfamide intravenous recon soln ifosfamide intravenous solution ifosfamide-mesna IMBRUVICA IMLYGIC INJECTION SUSPENSION 10EXP6 (1 MILLION) PFU/ML
(Ifex) (Ifex) (Ifosfamide/Mesna)
2 2 5 5 5
Requirements/Limits
PA NSO PA NSO; QL (30 per 30 days) GC GC PA NSO PA BvD; GC PA BvD; GC GC PA NSO PA NSO; QL (30 per 30 days) PA NSO; QL (90 per 30 days) PA NSO; QL (60 per 30 days) PA NSO GC PA NSO; QL (21 per 28 days) PA NSO; QL (60 per 30 days) PA NSO; QL (30 per 30 days) PA BvD; GC PA BvD; GC PA BvD PA NSO PA NSO; QL (4 per 365 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 37 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name
Drug Tier
Requirements/Limits
IMLYGIC INJECTION SUSPENSION 10EXP8 (100 MILLION) PFU/ML INLYTA ORAL TABLET 1 MG
5
INLYTA ORAL TABLET 5 MG
5
IRESSA
5
PA NSO; QL (8 per 28 days) PA NSO; QL (180 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (60 per 30 days)
IXEMPRA JAKAFI
5 5
KEYTRUDA KYPROLIS
5 5
LENVIMA letrozole LEUKERAN leuprolide subcutaneous kit lomustine LONSURF ORAL TABLET 15-6.14 MG
5 2 4 2 2 5
5
(Femara) (Leuprolide Acetate) (Gleostine)
LONSURF ORAL TABLET 20-8.19 MG
5
LUPRON DEPOT LUPRON DEPOT (3 MONTH) LUPRON DEPOT (4 MONTH) LUPRON DEPOT (6 MONTH) LYNPARZA
5 5 5 5 5
LYSODREN MATULANE megestrol oral suspension 625 mg/5 ml megestrol oral tablet MEKINIST ORAL TABLET 0.5 MG
3 5 2 2 5
(Megestrol Acetate) (Megestrol Acetate)
MEKINIST ORAL TABLET 2 MG mercaptopurine
5 (Mercaptopurine)
2
PA NSO; QL (60 per 30 days) PA NSO PA NSO; QL (6 per 28 days) PA NSO GC GC GC PA NSO; QL (100 per 28 days) PA NSO; QL (80 per 28 days) QL (1 per 84 days) QL (1 per 84 days) QL (1 per 168 days) PA NSO; QL (480 per 30 days)
GC GC PA NSO; QL (90 per 30 days) PA NSO; QL (30 per 30 days) GC
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 38 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name methotrexate sodium (pf) injection recon soln methotrexate sodium (pf) injection solution methotrexate sodium injection methotrexate sodium oral mitoxantrone NEXAVAR
Drug Tier
Requirements/Limits
(Methotrexate Sodium/PF) (Methotrexate Sodium)
2
PA BvD; GC
2
PA BvD; GC
(Methotrexate Sodium) (Methotrexate Sodium) (Mitoxantrone HCl)
2 2 2 5
PA BvD; GC PA BvD; ST; GC GC PA NSO; QL (120 per 30 days)
NILANDRON NINLARO
3 5
ODOMZO ONCASPAR OPDIVO INTRAVENOUS SOLUTION 40 MG/4 ML POMALYST
5 5 5
PROLEUKIN PURIXAN REVLIMID RITUXAN SOLTAMOX SPRYCEL ORAL TABLET 100 MG, 140 MG, 50 MG, 70 MG, 80 MG SPRYCEL ORAL TABLET 20 MG
5 5 5 5 4 5
STIVARGA
5
SUTENT
5
SYLVANT SYNRIBO
5 5
TABLOID TAFINLAR
3 5
5
5
PA NSO; QL (3 per 28 days) PA NSO PA NSO PA NSO PA NSO; QL (21 per 28 days)
PA NSO; LA PA NSO PA NSO; QL (30 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (84 per 28 days) PA NSO; QL (30 per 30 days) PA NSO PA NSO; QL (28 per 28 days) PA NSO; QL (120 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 39 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name TAGRISSO tamoxifen TARCEVA ORAL TABLET 100 MG, 25 MG TARCEVA ORAL TABLET 150 MG
(Tamoxifen Citrate)
Drug Tier
Requirements/Limits
5
PA NSO; QL (30 per 30 days) GC PA NSO; QL (60 per 30 days) PA NSO; QL (90 per 30 days) PA NSO; QL (420 per 30 days) PA NSO; QL (60 per 28 days) PA NSO; QL (112 per 28 days) PA NSO; (vial only) GC
2 5 5
TARGRETIN ORAL
5
TARGRETIN TOPICAL
5
TASIGNA
5
TEMODAR INTRAVENOUS toposar intravenous (Etoposide) TREANDA TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION TRELSTAR INTRAMUSCULAR SYRINGE 11.25 MG/2 ML TRELSTAR INTRAMUSCULAR SYRINGE 22.5 MG/2 ML TRELSTAR INTRAMUSCULAR SYRINGE 3.75 MG/2 ML tretinoin (chemotherapy) (Tretinoin) TREXALL TYKERB UNITUXIN VALSTAR VELCADE vinorelbine intravenous solution (Navelbine) VOTRIENT
5 2 5 5
XALKORI
5
XTANDI
5
YERVOY INTRAVENOUS SOLUTION
5
QL (1 per 168 days)
5
QL (1 per 84 days)
5
QL (1 per 168 days)
5 5 4 5 5 5 5 2 5
(capsule: 10mg) PA BvD; ST PA NSO PA NSO GC PA NSO; QL (120 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (120 per 30 days) PA NSO
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 40 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name
Drug Tier
Requirements/Limits
YONDELIS ZELBORAF
5 5
ZOLADEX SUBCUTANEOUS IMPLANT 10.8 MG ZOLADEX SUBCUTANEOUS IMPLANT 3.6 MG ZOLINZA ZYDELIG
4
PA NSO PA NSO; QL (240 per 30 days) QL (1 per 84 days)
4
QL (1 per 28 days)
ZYKADIA
5
ZYTIGA
5
5 5
PA NSO; QL (60 per 30 days) PA NSO; QL (140 per 28 days) PA NSO; QL (120 per 30 days)
Anticholinergic Agents Antimuscarinics/Antispasmodics atropine injection solution 0.4 mg/ml (Atropine Sulfate) atropine injection syringe 0.05 mg/ml, 0.1 (Atropine Sulfate) mg/ml propantheline (Propantheline Bromide) STIOLTO RESPIMAT
2 2
GC GC
2 3
GC QL (4 per 28 days)
(Tegretol) (Carbatrol)
4 4 2 2
ST ST GC GC
(Tegretol) (Tegretol XR)
2 2
GC GC
(Carbamazepine)
2 3 3 2 2
GC
Anticonvulsants Anticonvulsants APTIOM BANZEL carbamazepine carbamazepine oral capsule, er multiphase 12 hr carbamazepine oral suspension carbamazepine oral tablet extended release 12 hr carbamazepine oral tablet,chewable CELONTIN ORAL CAPSULE 300 MG DILANTIN CAPSULE 30 MG divalproex oral capsule, sprinkle divalproex oral tablet extended release 24 hr
(Depakote Sprinkle) (Depakote ER)
GC GC
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 41 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name
Drug Tier
Requirements/Limits
divalproex oral tablet,delayed release (dr/ec) ethosuximide felbamate fosphenytoin FYCOMPA ORAL TABLET gabapentin oral capsule gabapentin oral solution gabapentin oral tablet 600 mg, 800 mg GABITRIL ORAL TABLET 12 MG, 16 MG LAMICTAL ORAL TABLET, CHEWABLE DISPERSIBLE 2 MG lamotrigine oral tablet lamotrigine oral tablet extended release 24hr lamotrigine oral tablet, chewable dispersible lamotrigine oral tablets,dose pack 25 mg (35) levetiracetam intravenous levetiracetam oral solution levetiracetam oral tablet levetiracetam oral tablet extended release 24 hr LYRICA ORAL CAPSULE LYRICA ORAL SOLUTION oxcarbazepine OXTELLAR XR PEGANONE phenobarbital oral elixir
(Depakote)
2
GC
(Zarontin) (Felbatol) (Cerebyx)
2 2 2 4 2 2 2 3
GC GC GC ST GC GC GC
(Neurontin) (Neurontin) (Neurontin)
4 (Lamictal) (Lamictal XR)
2 2
GC GC
(Lamictal)
2
GC
(Lamictal (Blue))
2
GC
(Keppra) (Keppra) (Keppra) (Keppra XR)
2 2 2 2
GC GC GC GC QL (90 per 30 days) QL (900 per 30 days) GC ST
(Phenobarbital)
3 3 2 4 3 2
phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg phenobarbital oral tablet 30 mg
(Phenobarbital)
2
(Phenobarbital)
2
phenobarbital sodium injection solution
(Phenobarbital Sodium)
2
(Trileptal)
GC; QL (1500 per 30 days) GC; QL (90 per 30 days)
GC; QL (200 per 30 days) GC; QL (2 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 42 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name phenytoin oral suspension 125 mg/5 ml phenytoin oral phenytoin sodium phenytoin sodium extended POTIGA ORAL TABLET 200 MG, 300 MG, 400 MG POTIGA ORAL TABLET 50 MG primidone SABRIL tiagabine topiramate oral capsule, sprinkle topiramate oral capsule,sprinkle,er 24hr TROKENDI XR valproate sodium valproic acid valproic acid (as sodium salt) oral solution 250 mg/5 ml VIMPAT INTRAVENOUS VIMPAT ORAL SOLUTION VIMPAT ORAL TABLET zonisamide
Drug Tier (Dilantin-125) (Dilantin) (Phenytoin Sodium) (Dilantin)
Requirements/Limits
2 2 2 2 4
GC GC GC GC QL (90 per 30 days) QL (270 per 30 days) GC
(Depacon) (Depakene) (Depakene)
4 2 5 2 2 2 4 2 2 2
(Zonegran)
4 4 4 2
QL (200 per 5 days) QL (1200 per 30 days) QL (60 per 30 days) GC
(Razadyne ER)
2 2 2 2
GC; QL (30 per 30 days) GC; QL (30 per 30 days) GC; QL (30 per 30 days) GC; QL (30 per 30 days)
(Galantamine Hbr)
2
(Razadyne) (Namenda)
2 2
memantine oral tablet (Namenda) memantine oral tablets,dose pack (Namenda) NAMENDA XR ORAL CAP,SPRINKLE,ER 24HR DOSE PACK
2 2 3
GC; QL (200 per 30 days) GC; QL (60 per 30 days) GC; QL (360 per 30 days) GC; QL (60 per 30 days) GC; QL (49 per 28 days) QL (28 per 28 days)
(Mysoline) (Gabitril) (Topamax) (Qudexy XR)
GC GC GC ST GC GC GC
Antidementia Agents Antidementia Agents donepezil oral tablet donepezil oral tablet,disintegrating EXELON TRANSDERMAL galantamine oral capsule,ext rel. pellets 24 hr galantamine oral solution galantamine oral tablet memantine oral solution
(Aricept) (Donepezil HCl)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 43 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 24HR NAMZARIC rivastigmine tartrate
Drug Tier
Requirements/Limits
3
QL (30 per 30 days)
3 2
GC; QL (60 per 30 days)
(Wellbutrin) (Wellbutrin SR)
2 2 4 2 2
PA NSO-HRM; GC GC ST GC GC
(Wellbutrin XL)
2
GC
(Citalopram Hydrobromide) (Celexa) (Anafranil) (Norpramin) (Doxepin HCl) (Duloxetine)
2
GC
1 2 2 2 2
(Duloxetine)
2
(Duloxetine)
2
(Prozac) (Prozac Weekly)
4 2 4 1 2
GC; QL (30 per 30 days) PA NSO-HRM; GC GC PA NSO-HRM; GC (Cymbalta); GC; QL (60 per 30 days) (Cymbalta); GC; QL (30 per 30 days) (Irenka); GC; QL (30 per 30 days) QL (30 per 30 days) GC ST GC GC
(Fluoxetine HCl) (Fluoxetine HCl) (Fluvoxamine Maleate) (Tofranil) (Tofranil-Pm) (Maprotiline HCl)
2 2 2 2 2 2
GC GC GC PA NSO-HRM; GC PA NSO-HRM; GC GC
(Exelon)
Antidepressants Antidepressants amitriptyline amoxapine BRINTELLIX bupropion hcl oral tablet bupropion hcl oral tablet extended release , 150 mg bupropion hcl oral tablet extended release 24 hr citalopram oral solution citalopram oral tablet clomipramine desipramine oral doxepin oral duloxetine oral capsule,delayed release(dr/ec) 20 mg, 60 mg duloxetine oral capsule,delayed release(dr/ec) 30 mg duloxetine oral capsule,delayed release(dr/ec) 40 mg EMSAM escitalopram oxalate FETZIMA fluoxetine oral capsule fluoxetine oral capsule,delayed release(dr/ec) fluoxetine oral solution fluoxetine oral tablet 10 mg, 20 mg fluvoxamine imipramine hcl imipramine pamoate maprotiline
(Amitriptyline HCl) (Amoxapine)
(Lexapro)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 44 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name
Drug Tier
MARPLAN mirtazapine nefazodone nortriptyline oral capsule nortriptyline oral solution olanzapine-fluoxetine paroxetine hcl oral tablet paroxetine hcl oral tablet extended release 24 hr PAXIL ORAL SUSPENSION perphenazine-amitriptyline
4 2 2 2 2 2 2 2
GC GC GC GC GC GC GC
4 2
PA NSO-HRM; GC
(Parnate) (Trazodone HCl) (Trimipramine Maleate) (Effexor XR)
2 4 2 2 1 3 4 2 1 2 2
GC ST; QL (30 per 30 days) GC GC GC QL (30 per 30 days) PA NSO-HRM GC GC PA NSO-HRM; GC GC
(Venlafaxine HCl) (Venlafaxine HCl)
2 2
GC GC
phenelzine PRISTIQ protriptyline sertraline oral concentrate sertraline oral tablet SILENOR SURMONTIL tranylcypromine trazodone trimipramine venlafaxine oral capsule,extended release 24hr venlafaxine oral tablet venlafaxine oral tablet extended release 24hr 150 mg, 37.5 mg, 75 mg VIIBRYD
(Remeron) (Nefazodone HCl) (Pamelor) (Nortriptyline HCl) (Symbyax) (Paxil) (Paxil CR)
(Perphenazine/Amitripty line HCl) (Nardil) (Protriptyline HCl) (Zoloft) (Zoloft)
Requirements/Limits
4
Antidiabetic Agents Antidiabetic Agents, Miscellaneous acarbose CYCLOSET GLYXAMBI INVOKAMET ORAL TABLET 1501,000 MG, 150-500 MG, 50-1,000 MG INVOKAMET ORAL TABLET 50-500 MG
(Precose)
2 4 3 3
GC; QL (90 per 30 days) QL (180 per 30 days) ST; QL (30 per 30 days) ST; QL (60 per 30 days)
3
ST; QL (120 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 45 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name
Drug Tier
Requirements/Limits
INVOKANA ORAL TABLET 100 MG INVOKANA ORAL TABLET 300 MG JANUMET JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG, 50500 MG JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 50-1,000 MG JANUVIA JARDIANCE JENTADUETO KORLYM
3 3 3 3
ST; QL (60 per 30 days) ST; QL (30 per 30 days) QL (60 per 30 days) QL (30 per 30 days)
3
QL (60 per 30 days)
3 3 3 5
metformin oral tablet 1,000 mg metformin oral tablet 500 mg
(Glucophage) (Glucophage)
1 1
metformin oral tablet 850 mg metformin oral tablet extended release 24 hr 500 mg metformin oral tablet extended release 24 hr 750 mg metformin oral tablet extended release 24hr nateglinide pioglitazone pioglitazone-glimepiride pioglitazone-metformin PRANDIMET repaglinide
(Glucophage) (Glucophage XR)
1 2
(Glucophage XR)
2
QL (30 per 30 days) ST; QL (30 per 30 days) QL (60 per 30 days) PA; QL (112 per 28 days) GC; QL (60 per 30 days) GC; QL (150 per 30 days) GC; QL (90 per 30 days) GC; QL (120 per 30 days) GC; QL (90 per 30 days)
(Fortamet)
2
GC; QL (60 per 30 days)
(Starlix) (Actos) (Duetact) (Actoplus Met) (Prandin)
2 2 2 2 3 2
repaglinide-metformin
(Prandimet)
2
GC; QL (90 per 30 days) GC; QL (30 per 30 days) GC; QL (30 per 30 days) GC; QL (90 per 30 days) QL (150 per 30 days) GC; QL (240 per 30 days) GC; QL (150 per 30 days) PA; QL (10.8 per 28 days) PA; QL (6 per 28 days) ST; QL (60 per 30 days) QL (30 per 30 days) ST; QL (4 per 28 days)
SYMLINPEN 120
4
SYMLINPEN 60 SYNJARDY TRADJENTA TRULICITY
4 3 3 3
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 46 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name VICTOZA Insulins HUMULIN R U-500 (CONCENTRATED) LANTUS LANTUS SOLOSTAR NOVOLIN 70/30 NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX 70-30 NOVOLOG MIX 70-30 FLEXPEN NOVOLOG PENFILL TOUJEO SOLOSTAR Sulfonylureas glimepiride oral tablet 1 mg, 2 mg glimepiride oral tablet 4 mg glipizide oral tablet 10 mg
Drug Tier
Requirements/Limits
3
ST; QL (9 per 28 days)
3
QL (40 per 28 days)
6 6 6 6 6 6 6 6 6 6 6
GC; QL (40 per 28 days) GC; QL (30 per 28 days) GC; QL (40 per 28 days) GC; QL (40 per 28 days) GC; QL (40 per 28 days) GC; QL (40 per 28 days) GC; QL (30 per 28 days) GC; QL (40 per 28 days) GC; QL (30 per 28 days) GC; QL (30 per 28 days) GC
(Amaryl) (Amaryl) (Glucotrol)
1 1 1
(Glucotrol) (Glucotrol XL)
1 2
GC; QL (30 per 30 days) GC; QL (60 per 30 days) GC; QL (120 per 30 days) GC; QL (60 per 30 days) GC; QL (60 per 30 days)
(Glucotrol XL)
2
GC; QL (30 per 30 days)
2
glipizide-metformin oral tablet 2.5-500 mg, 5-500 mg glyburide micronized oral tablet 1.5 mg
(Glipizide/Metformin HCl) (Glipizide/Metformin HCl) (Glynase)
glyburide micronized oral tablet 3 mg
(Glynase)
2
glyburide micronized oral tablet 6 mg
(Glynase)
2
glyburide oral tablet 1.25 mg
(Glyburide)
2
GC; QL (240 per 30 days) GC; QL (120 per 30 days) PA-HRM; GC; QL (400 per 30 days) PA-HRM; GC; QL (180 per 30 days) PA-HRM; GC; QL (120 per 30 days) PA-HRM; GC; QL (280 per 30 days)
glipizide oral tablet 5 mg glipizide oral tablet extended release 24hr 10 mg glipizide oral tablet extended release 24hr 2.5 mg, 5 mg glipizide-metformin oral tablet 2.5-250 mg
2 2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 47 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name
Drug Tier
Requirements/Limits PA-HRM; GC; QL (240 per 30 days) PA-HRM; GC; QL (120 per 30 days) PA-HRM; GC; QL (240 per 30 days) PA-HRM; GC; QL (120 per 30 days) GC; QL (120 per 30 days) GC; QL (60 per 30 days) GC; QL (180 per 30 days)
glyburide oral tablet 2.5 mg
(Glyburide)
2
glyburide oral tablet 5 mg
(Glyburide)
2
glyburide-metformin oral tablet 1.25-250 mg glyburide-metformin oral tablet 2.5-500 mg, 5-500 mg tolazamide oral tablet 250 mg
(Glucovance)
2
(Glucovance)
2
(Tolazamide)
2
tolazamide oral tablet 500 mg tolbutamide
(Tolazamide) (Tolbutamide)
2 2
Antifungals Antifungals ABELCET AMBISOME amphotericin b CANCIDAS ciclopirox topical cream ciclopirox topical gel ciclopirox topical shampoo ciclopirox topical solution ciclopirox topical suspension ciclopirox-ure-camph-menth-euc clotrimazole mucous membrane clotrimazole topical cream clotrimazole topical solution clotrimazole-betamethasone topical cream clotrimazole-betamethasone topical lotion econazole topical fluconazole fluconazole in dextrose(iso-o) intravenous piggyback fluconazole in nacl (iso-osm) intravenous piggyback 400 mg/200 ml flucytosine
(Amphotericin B) (Ciclodan) (Loprox) (Loprox) (Penlac) (Ciclopirox Olamine) (Ciclodan) (Clotrimazole) (Clotrimazole) (Lotrimin) (Lotrisone) (Clotrimazole/Betameth asone Dip) (Econazole Nitrate) (Diflucan) (Fluconazole In Nacl,Iso-Osm) (Fluconazole In Nacl,Iso-Osm) (Ancobon)
5 5 2 5 2 2 2 2 2 2 2 2 2 2 2
PA BvD PA BvD PA BvD; GC
2 2 2
GC GC GC
2
GC
GC GC GC GC GC GC GC GC GC GC GC
5
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 48 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name griseofulvin microsize oral tablet itraconazole ketoconazole oral ketoconazole topical cream ketoconazole topical shampoo miconazole nitrate vaginal suppository 200 mg NOXAFIL ORAL NYSTATIN (BULK) POWDER 1 BILLION UNIT, 10 BILLION UNIT nystatin oral nystatin oral nystatin topical nystatin topical powder 100,000 unit/gram nystatin-triamcinolone terbinafine hcl oral voriconazole intravenous voriconazole oral
Drug Tier (Grifulvin V) (Sporanox) (Ketoconazole) (Ketoconazole) (Nizoral) (Monistat 3)
Requirements/Limits
2 2 2 2 2 2
GC GC GC GC GC GC
5 2
GC
(Nystatin) (Nystatin) (Nystatin) (Nystatin) (Nystatin/Triamcin) (Lamisil) (Vfend IV) (Vfend)
2 2 2 2 2 2 2 5
GC GC GC GC GC GC GC
(Cyproheptadine HCl) (Diphenhydramine HCl)
2 2
GC GC
(Xyzal) (Promethazine HCl)
2 2
GC PA-HRM; GC
(Cleocin) (Metrogel-Vaginal) (Terazol 7) (Terconazole)
3 2 2 2 2
GC GC GC GC
(D.H.E.45)
2
GC; QL (30 per 28 days)
Antihistamines Antihistamines cyproheptadine diphenhydramine hcl injection solution 50 mg/ml levocetirizine promethazine oral syrup
Anti-Infectives (Skin And Mucous Membrane) Anti-Infectives (Skin And Mucous Membrane) AVC VAGINAL clindamycin phosphate vaginal metronidazole vaginal terconazole vaginal cream terconazole vaginal suppository
Antimigraine Agents Antimigraine Agents dihydroergotamine injection
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 49 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name dihydroergotamine nasal ERGOMAR naratriptan rizatriptan oral tablet rizatriptan oral tablet,disintegrating sumatriptan nasal spray sumatriptan 6 mg/0.5 ml inject 2 autoinjector,outer sumatriptan oral tablet sumatriptan succinate subcutaneous cartridge sumatriptan succinate subcutaneous pen injector 4 mg/0.5 ml sumatriptan succinate subcutaneous pen injector 6 mg/0.5 ml sumatriptan succinate subcutaneous solution zolmitriptan oral tablet zolmitriptan oral tablet,disintegrating
Drug Tier
Requirements/Limits
(Amerge) (Maxalt) (Maxalt Mlt) (Imitrex) (Sumatriptan Succinate)
2 4 2 2 2 2 2
GC; QL (8 per 28 days) QL (40 per 28 days) GC; QL (18 per 28 days) GC; QL (18 per 28 days) GC; QL (18 per 28 days) GC; QL (12 per 28 days) GC; QL (4 per 28 days)
(Imitrex) (Imitrex)
2 2
GC; QL (18 per 28 days) GC; QL (4 per 28 days)
(Sumatriptan Succinate)
2
GC; QL (4 per 28 days)
(Imitrex)
2
GC; QL (4 per 28 days)
(Imitrex)
2
GC; QL (4 per 28 days)
(Zomig) (Zomig Zmt)
2 2
GC; QL (12 per 28 days) GC; QL (12 per 28 days)
(Migranal)
Antimycobacterials Antimycobacterials CAPASTAT dapsone ethambutol isoniazid oral solution isoniazid oral tablet PASER PRIFTIN pyrazinamide rifabutin rifampin rifampin RIFATER SIRTURO TRECATOR
(Dapsone) (Myambutol) (Isoniazid) (Isoniazid)
(Pyrazinamide) (Mycobutin) (Rifadin) (Rifadin)
4 2 2 2 1 4 4 2 2 2 2 4 5
GC GC GC GC
GC GC GC GC PA; QL (188 per 168 days)
4
Antinausea Agents Antinausea Agents You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 50 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name AKYNZEO dimenhydrinate injection solution dronabinol EMEND INTRAVENOUS EMEND ORAL granisetron (pf) intravenous solution granisetron hcl intravenous solution 1 mg/ml (1 ml) granisetron hcl oral meclizine oral tablet 12.5 mg, 25 mg ondansetron ondansetron hcl (pf) ondansetron hcl oral prochlorperazine prochlorperazine edisylate injection solution prochlorperazine maleate oral promethazine hcl promethazine oral tablet promethazine rectal TRANSDERM-SCOP
Drug Tier (Dimenhydrinate) (Marinol)
(Granisetron HCl/PF) (Granisetron HCl) (Granisetron HCl) (Antivert) (Zofran Odt) (Ondansetron HCl/PF) (Zofran) (Compazine) (Prochlorperazine Edisylate) (Compazine) (Phenergan) (Promethazine HCl) (Phenergan)
Requirements/Limits
3 2 2 4 4 2 2
PA BvD GC GC QL (2 per 28 days) PA BvD GC GC
2 2 2 2 2 2 2
PA BvD; GC GC PA BvD; GC GC PA BvD; GC GC GC
1 2 2 2 4
GC PA-HRM; GC PA-HRM; GC PA-HRM; GC QL (10 per 30 days)
Antiparasite Agents Antiparasite Agents ALBENZA ALINIA atovaquone atovaquone-proguanil chloroquine phosphate oral COARTEM DARAPRIM hydroxychloroquine oral ivermectin oral mefloquine NEBUPENT paromomycin PENTAM PRIMAQUINE
(Mepron) (Malarone) (Chloroquine Phosphate)
(Plaquenil) (Stromectol) (Mefloquine HCl) (Paromomycin Sulfate)
4 4 5 2 2 4 4 2 2 2 4 2 4 4
GC GC
GC GC GC PA BvD GC QL (90 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 51 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name quinine sulfate
Drug Tier
Requirements/Limits
(Qualaquin)
2
PA; GC; QL (42 per 7 days)
(Amantadine HCl)
2 5 3 2 2 2 2 2 2
GC QL (60 per 30 days)
(Mirapex) (Requip) (Requip XL)
2 2 3 2 2 2
GC GC ST; QL (30 per 30 days) GC GC GC
(Eldepryl) (Selegiline HCl) (Trihexyphenidyl HCl)
2 2 2
GC GC PA-HRM; GC
3
QL (90 per 30 days)
Antiparkinsonian Agents Antiparkinsonian Agents amantadine hcl APOKYN AZILECT benztropine oral bromocriptine cabergoline carbidopa carbidopa-levodopa oral tablet carbidopa-levodopa oral tablet extended release carbidopa-levodopa-entacapone entacapone NEUPRO pramipexole oral tablet ropinirole oral tablet ropinirole oral tablet extended release 24 hr selegiline hcl oral capsule selegiline hcl oral tablet trihexyphenidyl
(Benztropine Mesylate) (Parlodel) (Cabergoline) (Lodosyn) (Sinemet CR) (Sinemet CR) (Stalevo 50) (Comtan)
PA-HRM; GC GC GC GC GC GC
Antipsychotic Agents Antipsychotic Agents ABILIFY DISCMELT ORAL TABLET,DISINTEGRATING 10 MG ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 300 MG ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 400 MG
5
5
QL (1 per 28 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 52 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING aripiprazole oral solution
Drug Tier
Requirements/Limits
5
QL (1 per 28 days)
(Abilify)
2
aripiprazole oral tablet 10 mg, 15 mg, 20 mg, 30 mg, 5 mg aripiprazole oral tablet 2 mg aripiprazole oral tablet,disintegrating 10 mg aripiprazole oral tablet,disintegrating 15 mg ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 441 MG/1.6 ML ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 662 MG/2.4 ML ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 882 MG/3.2 ML chlorpromazine clozapine oral tablet 100 mg
(Abilify)
2
GC; QL (900 per 30 days) GC; QL (30 per 30 days)
(Abilify) (Abilify Discmelt)
2 2
GC; QL (60 per 30 days) GC; QL (90 per 30 days)
(Abilify Discmelt)
2
GC; QL (60 per 30 days)
5
QL (1.6 per 28 days)
5
QL (2.4 per 28 days)
5
QL (3.2 per 28 days)
(Chlorpromazine HCl) (Clozaril)
2 2
clozapine oral tablet 200 mg
(Clozaril)
2
clozapine oral tablet 25 mg, 50 mg clozapine oral tablet,disintegrating FANAPT ORAL TABLET FANAPT ORAL TABLETS,DOSE PACK fluphenazine decanoate
(Clozaril) (Fazaclo)
2 2 4 4
GC GC; QL (270 per 30 days) GC; QL (135 per 30 days) GC; QL (90 per 30 days) ST; GC ST; QL (60 per 30 days) ST; QL (8 per 28 days)
(Fluphenazine Decanoate) (Fluphenazine HCl)
2
GC
2 4 2 2
GC QL (6 per 28 days) GC GC
fluphenazine hcl GEODON INTRAMUSCULAR haloperidol haloperidol decanoate intramuscular solution 100 mg/ml
(Haloperidol) (Haloperidol Decanoate)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 53 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name
Drug Tier
Requirements/Limits
haloperidol decanoate intramuscular solution 50 mg/ml haloperidol lactate INVEGA ORAL TABLET EXTENDED RELEASE 24HR 1.5 MG, 3 MG, 9 MG INVEGA ORAL TABLET EXTENDED RELEASE 24HR 6 MG INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG/0.75 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 156 MG/ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 234 MG/1.5 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 39 MG/0.25 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 78 MG/0.5 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.875 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 410 MG/1.315 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 546 MG/1.75 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 819 MG/2.625 ML LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG LATUDA ORAL TABLET 80 MG loxapine succinate molindone oral tablet 10 mg
(Haldol Decanoate 50)
2
GC
(Haloperidol Lactate)
2 4
GC ST; QL (30 per 30 days)
4
ST; QL (60 per 30 days)
5
QL (0.75 per 28 days)
5
QL (1 per 28 days)
5
QL (1.5 per 28 days)
3
QL (0.25 per 28 days)
3
QL (0.5 per 28 days)
5
QL (0.875 per 84 days)
5
QL (1.315 per 84 days)
5
QL (1.75 per 84 days)
5
QL (2.625 per 84 days)
4
ST; QL (30 per 30 days)
(Loxapine Succinate) (Moban)
4 2 2
molindone oral tablet 25 mg
(Moban)
2
ST; QL (60 per 30 days) GC GC; QL (240 per 30 days) GC; QL (270 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 54 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name
Drug Tier
Requirements/Limits
molindone oral tablet 5 mg
(Moban)
2
olanzapine intramuscular olanzapine oral tablet olanzapine oral tablet,disintegrating 10 mg, 15 mg, 5 mg olanzapine oral tablet,disintegrating 20 mg ORAP paliperidone oral tablet extended release 24hr 1.5 mg, 3 mg, 9 mg paliperidone oral tablet extended release 24hr 6 mg perphenazine pimozide quetiapine REXULTI ORAL TABLET 0.25 MG REXULTI ORAL TABLET 0.5 MG REXULTI ORAL TABLET 1 MG, 2 MG, 3 MG, 4 MG RISPERDAL CONSTA risperidone oral solution
(Zyprexa) (Zyprexa) (Zyprexa Zydis)
2 2 2
GC; QL (120 per 30 days) GC; QL (30 per 30 days) GC; QL (30 per 30 days) GC; QL (30 per 30 days)
(Zyprexa Zydis)
2
GC; QL (31 per 30 days)
(Invega)
4 2
GC; QL (30 per 30 days)
(Invega)
2
GC; QL (60 per 30 days)
(Perphenazine) (Orap) (Seroquel)
2 2 2 5 5 5
GC GC GC; QL (90 per 30 days) QL (120 per 30 days) QL (60 per 30 days) QL (30 per 30 days)
(Risperdal)
4 2
risperidone oral tablet risperidone oral tablet,disintegrating 0.25 mg, 0.5 mg, 1 mg, 2 mg risperidone oral tablet,disintegrating 3 mg, 4 mg SAPHRIS (BLACK CHERRY) thioridazine thiothixene trifluoperazine VERSACLOZ
(Risperdal) (Risperdal M-Tab)
2 2
QL (4 per 28 days) GC; QL (480 per 30 days) GC; QL (60 per 30 days) GC; QL (60 per 30 days)
(Risperdal M-Tab)
2
(Thioridazine HCl) (Thiothixene) (Trifluoperazine HCl)
4 2 2 2 5
ziprasidone hcl (Geodon) ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG, 405 MG
2 5
GC; QL (120 per 30 days) ST; QL (60 per 30 days) PA NSO-HRM; GC GC GC ST; QL (540 per 30 days) GC; QL (60 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 55 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name
Drug Tier
Requirements/Limits
Antivirals (Systemic) Antiretrovirals abacavir abacavir-lamivudine-zidovudine APTIVUS ORAL CAPSULE APTIVUS ORAL SOLUTION ATRIPLA COMPLERA CRIXIVAN ORAL CAPSULE 200 MG, 400 MG didanosine EDURANT EMTRIVA EPIVIR HBV ORAL SOLUTION EPZICOM EVOTAZ FUZEON SUBCUTANEOUS GENVOYA INTELENCE ORAL TABLET 100 MG, 200 MG INTELENCE ORAL TABLET 25 MG INVIRASE ISENTRESS ORAL POWDER IN PACKET ISENTRESS ORAL TABLET ISENTRESS ORAL TABLET,CHEWABLE KALETRA ORAL SOLUTION KALETRA ORAL TABLET 100-25 MG KALETRA ORAL TABLET 200-50 MG lamivudine lamivudine-zidovudine LEXIVA ORAL SUSPENSION LEXIVA ORAL TABLET nevirapine oral suspension nevirapine oral tablet nevirapine oral tablet extended release 24 hr
(Ziagen) (Trizivir)
2 5 5 4 5 5 4
GC
(Videx EC)
2 5 3 4 5 5 5 5 5
GC
3 5 3 5 3
(Epivir) (Combivir)
(Viramune) (Viramune) (Viramune XR)
5 3 5 2 5 3 5 2 2 2
GC
GC GC GC
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 56 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name
Drug Tier
NORVIR PREZCOBIX PREZISTA ORAL SUSPENSION PREZISTA ORAL TABLET 150 MG, 75 MG PREZISTA ORAL TABLET 400 MG, 600 MG, 800 MG RESCRIPTOR RETROVIR INTRAVENOUS REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG REYATAZ ORAL POWDER IN PACKET SELZENTRY stavudine STRIBILD SUSTIVA TIVICAY TRIUMEQ TRUVADA VIDEX 2 GRAM PEDIATRIC VIDEX 4 GRAM PEDIATRIC VIRACEPT ORAL TABLET VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 100 MG VIREAD VITEKTA ZIAGEN ORAL SOLUTION zidovudine oral capsule zidovudine oral syrup zidovudine oral tablet Antivirals, Miscellaneous foscarnet RELENZA DISKHALER rimantadine SYNAGIS TAMIFLU ORAL CAPSULE 30 MG TAMIFLU ORAL CAPSULE 45 MG
3 5 4 3
Requirements/Limits
5 4 3 5 5
(Zerit)
(Retrovir) (Retrovir) (Zidovudine) (Foscavir) (Flumadine)
5 2 5 4 5 5 5 3 3 4 3 5 5 4 2 2 2 2 4 2 5 3 3
GC
GC GC GC PA BvD; GC GC QL (84 per 180 days) QL (48 per 180 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 57 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name
Drug Tier
TAMIFLU ORAL CAPSULE 75 MG TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION Hcv Antivirals DAKLINZA HARVONI OLYSIO SOVALDI TECHNIVIE Interferons INTRON A INJECTION PEGASYS PEGASYS PROCLICK PEGINTRON SYLATRON Nucleosides And Nucleotides acyclovir oral capsule acyclovir oral suspension 200 mg/5 ml acyclovir oral tablet acyclovir sodium intravenous solution adefovir entecavir famciclovir ganciclovir sodium ribavirin oral capsule 200 mg ribavirin oral tablet 200 mg, 400 mg, 600 mg TYZEKA valacyclovir valganciclovir VIRAZOLE
Requirements/Limits
3 3
QL (42 per 180 days) QL (540 per 180 days)
5 5 5 5 5
PA; QL (28 per 28 days) PA; QL (30 per 30 days) PA; QL (28 per 28 days) PA; QL (28 per 28 days) PA; QL (56 per 28 days)
4 5 5 5 5
PA NSO PA PA PA PA NSO; QL (4 per 28 days)
(Zovirax) (Zovirax) (Zovirax) (Acyclovir Sodium) (Hepsera) (Baraclude) (Famvir) (Cytovene) (Rebetol) (Copegus)
2 2 2 2 5 5 2 2 2 2
GC GC GC PA BvD; GC
(Valtrex) (Valcyte)
5 2 5 5
GC PA BvD; GC GC GC
GC PA BvD
Blood Products/Modifiers/Volume Expanders Anticoagulants CEPROTIN (BLUE BAR) ELIQUIS enoxaparin subcutaneous solution
(Lovenox)
5 3 2
GC; QL (36 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 58 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name enoxaparin subcutaneous syringe 100 mg/ml enoxaparin subcutaneous syringe 120 mg/0.8 ml enoxaparin subcutaneous syringe 150 mg/ml enoxaparin subcutaneous syringe 30 mg/0.3 ml enoxaparin subcutaneous syringe 40 mg/0.4 ml enoxaparin subcutaneous syringe 60 mg/0.6 ml enoxaparin subcutaneous syringe 80 mg/0.8 ml fondaparinux subcutaneous syringe 10 mg/0.8 ml fondaparinux subcutaneous syringe 2.5 mg/0.5 ml fondaparinux subcutaneous syringe 5 mg/0.4 ml fondaparinux subcutaneous syringe 7.5 mg/0.6 ml heparin (porcine) in 5 % dex intravenous parenteral solution 12,500 unit/250 ml, 20,000 unit/500 ml (40 unit/ml), 25,000 unit/500 ml (50 unit/ml) heparin (porcine) in 5 % dex intravenous parenteral solution 25,000 unit/250 ml(100 unit/ml) heparin (porcine) in nacl (pf) intravenous parenteral solution 1,000 unit/500 ml heparin (porcine) injection solution 1,000 unit/ml, 20,000 unit/ml, 5,000 unit/ml heparin (porcine) injection solution 10,000 unit/ml heparin sodium,porcine-pf intravenous syringe 10 unit/ml heparin, porcine (pf) injection solution 5,000 unit/0.5 ml
Drug Tier
Requirements/Limits
(Lovenox)
5
QL (36 per 30 days)
(Lovenox)
5
QL (27.2 per 30 days)
(Lovenox)
5
QL (34 per 30 days)
(Lovenox)
2
GC; QL (18 per 30 days)
(Lovenox)
2
(Lovenox)
2
(Lovenox)
2
(Arixtra)
2
GC; QL (13.6 per 30 days) GC; QL (20.4 per 30 days) GC; QL (27.2 per 30 days) GC; QL (24 per 30 days)
(Arixtra)
2
GC; QL (15 per 30 days)
(Arixtra)
2
GC; QL (12 per 30 days)
(Arixtra)
2
GC; QL (18 per 30 days)
(Heparin Sodium,Porcine/D5W)
2
GC
(Heparin Sod,Pork In 0.45% NaCl)
2
GC
(Heparin Sodium,Porcine/Ns/PF) (Heparin Sodium,Porcine) (Heparin Sodium,Porcine) (Monoject Prefill Advanced) (Heparin Sodium,Porcine/PF)
2
GC
2 2
PA BvD; (PA for ESRD Only); GC PA BvD; GC
2
GC
2
PA BvD; (PA for ESRD Only); GC
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 59 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name heparin, porcine (pf) injection heparin, porcine (pf) intravenous syringe heparin-0.45% nacl 25,000 units/250 ml (100 units/ml) bag latex-free, inner heparin-d5w 25,000 units/250 ml (100 units/ml) bag excel container IPRIVASK jantoven PRADAXA warfarin XARELTO Blood Formation Modifiers CINRYZE EPOGEN INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML GRANIX LEUKINE INJECTION RECON SOLN MIRCERA INJECTION SYRINGE 100 MCG/0.3 ML, 50 MCG/0.3 ML, 75 MCG/0.3 ML MOZOBIL NEULASTA NEUMEGA NEUPOGEN PROCRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 3,000 UNIT/ML, 4,000 UNIT/ML PROCRIT INJECTION SOLUTION 20,000 UNIT/ML PROCRIT INJECTION SOLUTION 40,000 UNIT/ML PROMACTA ZARXIO
(Monoject Prefill Advanced) (Monoject Prefill Advanced) (Heparin Sod,Pork In 0.45% NaCl) (Heparin Sodium,Porcine/D5W) (Coumadin) (Coumadin)
Drug Tier
Requirements/Limits
2 2
PA BvD; (PA for ESRD Only); GC GC
2
GC
2
GC
5 1 4 1 3
PA; QL (24 per 28 days) GC ST; QL (60 per 30 days) GC
5 3
PA PA; QL (12 per 28 days)
5 5 4
PA; QL (0.6 per 28 days)
5 5 5 5 3
PA; QL (12 per 28 days)
5
PA; QL (12 per 28 days)
5
PA; QL (6 per 28 days)
5 5
PA; QL (30 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 60 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name Hematologic Agents, Miscellaneous aminocaproic acid oral anagrelide protamine tranexamic acid intravenous tranexamic acid oral Platelet-Aggregation Inhibitors AGGRENOX aspirin-dipyridamole BRILINTA cilostazol clopidogrel EFFIENT pentoxifylline Volume Expanders ALBUKED-25 ALBUKED-5 ALBUMIN, HUMAN 25 % ALBUMIN, HUMAN 5 % ALBUMINAR 25 % ALBUMINAR 5 % ALBURX (HUMAN) 5 % ALBUTEIN 25 % ALBUTEIN 5 % BUMINATE 25 % BUMINATE 5 % FLEXBUMIN 25 % FLEXBUMIN 5 % KEDBUMIN PLASBUMIN 25 % PLASBUMIN 5 %
Drug Tier
Requirements/Limits
(Aminocaproic Acid) (Agrylin) (Protamine Sulfate)
2 2 2
(Tranexamic Acid) (Lysteda)
2 2
GC GC PA BvD; (PA for ESRD Only); GC GC GC; QL (30 per 30 days)
(Aggrenox) (Pletal) (Plavix) (Pentoxifylline)
4 2 3 2 2 3 2
QL (60 per 30 days) GC GC GC QL (30 per 30 days) GC
4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4
Caloric Agents Caloric Agents AMINO ACIDS 15 % AMINOSYN 10 %
4 4
PA BvD PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 61 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name
Drug Tier
AMINOSYN 3.5 % AMINOSYN 7 % AMINOSYN 7 % WITH ELECTROLYTES AMINOSYN 8.5 % AMINOSYN 8.5 %-ELECTROLYTES AMINOSYN II 10 % AMINOSYN II 15 % AMINOSYN II 7 % AMINOSYN II 8.5 % AMINOSYN II 8.5 %-ELECTROLYTES AMINOSYN M 3.5 % AMINOSYN-HBC 7% AMINOSYN-PF 10 % AMINOSYN-PF 7 % (SULFITE-FREE) AMINOSYN-RF 5.2 % CLINIMIX 5%/D15W SULFITE FREE CLINIMIX 5%/D25W SULFITE-FREE CLINIMIX 2.75%/D5W SULFIT FREE CLINIMIX 4.25%/D10W SULF FREE CLINIMIX 4.25%/D5W SULFIT FREE CLINIMIX 4.25%-D20W SULF-FREE CLINIMIX 4.25%-D25W SULF-FREE CLINIMIX 5%-D20W(SULFITE-FREE) CLINIMIX E 2.75%/D10W SUL FREE CLINIMIX E 2.75%/D5W SULF FREE CLINIMIX E 4.25%/D10W SUL FREE CLINIMIX E 4.25%/D25W SUL FREE CLINIMIX E 4.25%/D5W SULF FREE CLINIMIX E 5%/D15W SULFIT FREE CLINIMIX E 5%/D20W SULFIT FREE CLINIMIX E 5%/D25W SULFIT FREE CLINISOL SF 15 % cysteine (l-cysteine) intravenous solution d10 %-0.9 % sodium chloride
4 4 4
PA BvD PA BvD PA BvD
4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 2 2
PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD; GC GC
(Cysteine HCl) (Dextrose 10 % and 0.9 % NaCl)
Requirements/Limits
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 62 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name dextrose 10 % in water (d10w) dextrose 2.5 % in water(d2.5w) dextrose 20 % in water (d20w) dextrose 25 % in water (d25w) dextrose 40 % in water (d40w) dextrose 5 % in ringers dextrose 5 % in water (d5w) intravenous dextrose 50 % in water (d50w) dextrose 70 % in water (d70w) FREAMINE HBC 6.9 % FREAMINE III 10 % HEPATAMINE 8% HEPATASOL 8 % INTRALIPID INTRAVENOUS EMULSION 20 %, 30 % KABIVEN LIPOSYN II LIPOSYN III NEPHRAMINE 5.4 % NUTRILIPID PERIKABIVEN PREMASOL 10 % PREMASOL 6 % PROCALAMINE 3% PROSOL 20 % TRAVASOL 10 % TROPHAMINE 10 % TROPHAMINE 6%
Drug Tier (Dextrose 10 % in Water) (Dextrose 2.5 % in Water) (Dextrose 20 % in Water) (Dextrose 25 % in Water) (Dextrose 40 % in Water) (Dextrose 5% In Ringers) (Dextrose 5 % in Water) (Dextrose 50 % in Water) (Dextrose 70 % in Water)
Requirements/Limits
2
PA BvD; GC
2
PA BvD; GC
2
PA BvD; GC
2
PA BvD; GC
2
PA BvD; GC
2
GC
2 2
GC PA BvD; GC
2
PA BvD; GC
4 4 4 4 4
PA BvD PA BvD PA BvD PA BvD PA BvD
4 4 4 4 4 4 4 4 4 4 4 4 4
PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD
Cardiovascular Agents Alpha-Adrenergic Agents You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 63 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name clonidine hcl oral tablet clonidine hcl-chlorthalidone clonidine transdermal patch weekly 0.1 mg/24 hr, 0.2 mg/24 hr clonidine transdermal patch weekly 0.3 mg/24 hr doxazosin guanfacine oral tablet midodrine NORTHERA phenylephrine hcl injection prazosin oral Angiotensin Ii Receptor Antagonists BENICAR BENICAR HCT candesartan candesartan-hydrochlorothiazid ENTRESTO irbesartan irbesartan-hydrochlorothiazide losartan losartan-hydrochlorothiazide telmisartan telmisartan-hydrochlorothiazid TRIBENZOR valsartan valsartan-hydrochlorothiazide Angiotensin-Converting Enzyme Inhibitors benazepril benazepril-hydrochlorothiazide captopril captopril-hydrochlorothiazide enalapril maleate
Drug Tier
Requirements/Limits
(Catapres) (Clonidine HCl/Chlorthalidone) (Catapres-Tts 1)
1 2
GC GC
2
GC; QL (4 per 28 days)
(Catapres-Tts 1)
2
GC; QL (8 per 28 days)
(Cardura) (Tenex) (Midodrine HCl)
2 2 2 5
(Vazculep) (Minipress)
2 2
GC PA-HRM; GC GC PA; QL (180 per 30 days) GC GC
3 3 2 2 3 2 2 1 2 2 2 3 2 2
ST ST GC GC PA; QL (60 per 30 days) GC GC GC GC GC GC ST GC GC
1 2 2 2
GC GC GC GC
1
GC
(Atacand) (Atacand HCT) (Avapro) (Avalide) (Cozaar) (Hyzaar) (Micardis) (Micardis HCT) (Diovan) (Diovan HCT)
(Lotensin) (Lotensin HCT) (Captopril) (Captopril/Hydrochlorot hiazide) (Vasotec)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 64 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name enalaprilat intravenous solution enalapril-hydrochlorothiazide fosinopril fosinopril-hydrochlorothiazide lisinopril lisinopril-hydrochlorothiazide moexipril moexipril-hydrochlorothiazide perindopril erbumine quinapril quinapril-hydrochlorothiazide ramipril trandolapril Antiarrhythmic Agents amiodarone hcl oral tablet 100 mg, 200 mg, 400 mg amiodarone oral disopyramide phosphate oral capsule flecainide lidocaine (pf) intravenous syringe 50 mg/5 ml (1 %) lidocaine in 5 % dextrose (pf) intravenous parenteral solution 8 mg/ml (0.8 %) mexiletine MULTAQ procainamide injection propafenone oral capsule,extended release 12 hr propafenone oral tablet quinidine gluconate oral quinidine sulfate TIKOSYN Beta-Adrenergic Blocking Agents acebutolol atenolol atenolol-chlorthalidone
Drug Tier
Requirements/Limits
(Enalaprilat Dihydrate) (Vaseretic) (Fosinopril Sodium) (Fosinopril/Hydrochloro thiazide) (Zestril) (Zestoretic) (Moexipril HCl) (Moexipril/Hydrochlorot hiazide) (Aceon) (Accupril) (Accuretic) (Altace) (Mavik)
2 2 2 2
GC GC GC GC
1 1 2 2
GC GC GC GC
2 2 2 2 2
GC GC GC GC GC
(Cordarone)
2
GC
(Cordarone) (Norpace) (Tambocor) (Lidocaine HCl/PF)
2 2 2 2
GC GC GC GC
(Lidocaine HCl/D5w/PF) (Mexiletine HCl)
2
GC
2 3 2 2
GC
(Rythmol) (Quinidine Gluconate) (Quinidine Sulfate)
2 2 2 3
GC GC GC
(Sectral) (Tenormin) (Tenoretic 50)
2 1 1
GC GC GC
(Procainamide HCl) (Rythmol SR)
GC GC
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 65 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name betaxolol oral bisoprolol fumarate bisoprolol-hydrochlorothiazide BYSTOLIC carvedilol esmolol intravenous labetalol intravenous solution labetalol oral metoprolol succinate metoprolol ta-hydrochlorothiaz metoprolol tartrate intravenous metoprolol tartrate oral nadolol pindolol propranolol intravenous propranolol oral capsule,extended release 24 hr propranolol oral solution propranolol oral tablet propranolol-hydrochlorothiazid sotalol hcl oral tablet 120 mg, 160 mg, 240 mg, 80 mg sotalol oral timolol maleate oral Calcium-Channel Blocking Agents cartia xt diltiazem hcl intravenous diltiazem hcl oral capsule, extended release 180 mg, 360 mg, 420 mg diltiazem hcl oral capsule,extended release 12 hr diltiazem hcl oral capsule,extended release 24hr diltiazem hcl oral tablet diltiazem hcl oral tablet extended release 24 hr
Drug Tier (Kerlone) (Zebeta) (Ziac)
Requirements/Limits
2 2 2 3 1 2 2 2 2 2 2 1 2 2 2 2
GC GC GC
(Propranolol HCl) (Propranolol HCl) (Propranolol/Hydrochlor othiazid) (Betapace)
2 2 2
GC GC GC
2
GC
(Betapace) (Timolol Maleate)
2 2
GC GC
(Cardizem CD) (Cardizem CD) (Cardizem CD)
2 2 2
GC GC GC
(Cardizem CD)
2
GC
(Cardizem CD)
2
GC
(Cardizem CD) (Cardizem LA)
1 2
GC GC
(Coreg) (Esmolol HCl) (Labetalol HCl) (Trandate) (Toprol XL) (Lopressor HCT) (Lopressor) (Lopressor) (Corgard) (Pindolol) (Propranolol HCl) (Inderal LA)
GC PA BvD; GC GC GC GC GC GC GC GC GC GC GC
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 66 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name
Drug Tier
Requirements/Limits
dilt-xr matzim la taztia xt verapamil intravenous syringe verapamil oral capsule, 24 hr er pellet ct verapamil oral capsule,ext rel. pellets 24 hr verapamil oral tablet verapamil oral tablet extended release Cardiovascular Agents, Miscellaneous CORLANOR DEMSER digitek oral tablet 125 mcg
(Cardizem CD) (Cardizem CD) (Cardizem CD) (Verapamil HCl) (Verelan Pm) (Verelan)
2 2 2 2 2 2
GC GC GC GC GC GC
(Calan) (Calan SR)
1 2
GC GC
ST
(Lanoxin)
3 5 2
digitek oral tablet 250 mcg
(Lanoxin)
2
digoxin injection DIGOXIN ORAL SOLUTION
(Digoxin)
2 3
digoxin oral tablet
(Lanoxin)
2
dobutamine in d5w intravenous parenteral solution 1,000 mg/250 ml (4,000 mcg/ml), 250 mg/250 ml (1 mg/ml), 500 mg/250 ml (2,000 mcg/ml) dobutamine intravenous solution dopamine in 5 % dextrose intravenous solution dopamine intravenous solution ephedrine sulfate injection solution
(Dobutamine HCl/D5W)
2
PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); GC; QL (30 per 30 days) PA-HRM; GC; QL (30 per 30 days) PA-HRM; GC PA-HRM; QL (300 per 30 days) PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); GC; QL (30 per 30 days) PA BvD; GC
(Dobutamine HCl) (Dopamine HCl/D5W)
2 2
PA BvD; GC PA BvD; GC
(Dopamine HCl) (Ephedrine Sulfate)
2 2
PA BvD; GC GC
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 67 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name
Drug Tier
epinephrine hcl (pf) intravenous epinephrine injection auto-injector epinephrine injection solution epinephrine injection syringe 0.1 mg/ml (1:10,000) EPIPEN 2-PAK EPIPEN JR 2-PAK ethamolin FIRAZYR hydralazine LANOXIN ORAL TABLET 187.5 MCG, 62.5 MCG
(Epinephrine HCl/PF) (Adrenaclick) (Epinephrine) (Epinephrine)
milrinone milrinone in 5 % dextrose intravenous piggyback 40 mg/200 ml (200 mcg/ml) norepinephrine bitartrate papaverine injection solution papaverine oral RANEXA Dihydropyridines amlodipine amlodipine-benazepril amlodipine-valsartan amlodipine-valsartan-hcthiazid AZOR CLEVIPREX INTRAVENOUS EMULSION felodipine isradipine nicardipine oral nifedipine oral tablet extended release 24hr 30 mg, 60 mg, 90 mg nifedipine oral tablet extended release 30 mg, 60 mg
(Milrinone Lactate) (Milrinone Lactate/D5W) (Levophed Bitartrate) (Papaverine HCl) (Papaverine HCl)
5 5 2 2 2 3
PA BvD; GC PA; GC PA; GC
(Norvasc) (Lotrel) (Exforge) (Exforge HCT)
1 2 2 2 3 4
GC GC GC GC ST
(Felodipine) (Isradipine) (Nicardipine HCl) (Procardia XL)
2 2 2 2
GC GC GC GC
(Adalat CC)
2
GC
(Ethanolamine Oleate) (Hydralazine HCl)
2 2 2 2
Requirements/Limits
3 3 2 5 2 4
GC GC GC GC
GC GC PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); QL (30 per 30 days) PA BvD PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 68 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name Diuretics amiloride oral amiloride-hydrochlorothiazide bumetanide chlorothiazide chlorothiazide sodium chlorthalidone oral tablet 25 mg, 50 mg DYRENIUM furosemide injection furosemide oral solution furosemide oral tablet hydrochlorothiazide oral capsule hydrochlorothiazide oral tablet indapamide methyclothiazide metolazone torsemide oral triamterene-hydrochlorothiazid oral capsule triamterene-hydrochlorothiazid oral tablet Dyslipidemics amlodipine-atorvastatin atorvastatin cholestyramine (with sugar) oral cholestyramine-aspartame oral powder 4 gram cholestyramine-aspartame oral powder in packet 4 gram colestipol CRESTOR fenofibrate micronized fenofibrate nanocrystallized fenofibrate oral tablet fenofibric acid fenofibric acid (choline) gemfibrozil oral JUXTAPID
Drug Tier (Midamor) (Amiloride/Hydrochloro thiazide) (Bumetanide) (Chlorothiazide) (Sodium Diuril) (Chlorthalidone)
Requirements/Limits
2 2
GC GC GC GC GC GC
(Furosemide) (Furosemide) (Lasix) (Microzide) (Hydrochlorothiazide) (Indapamide) (Methyclothiazide) (Zaroxolyn) (Demadex) (Dyazide)
2 1 2 1 4 2 2 1 1 1 1 2 2 2 2
(Maxzide)
2
GC
(Caduet) (Lipitor) (Questran) (Cholestyramine/Asparta me) (Questran)
2 2 2 2
GC GC GC GC
2
GC
(Colestid)
2 3 2 2 2 2 2 2 5
GC
(Lofibra) (Tricor) (Lofibra) (Fibricor) (Trilipix) (Lopid)
GC GC GC GC GC GC GC GC GC GC
GC GC GC GC GC GC PA
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 69 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name
Drug Tier
Requirements/Limits
KYNAMRO lovastatin niacin oral tablet extended release 24 hr omega-3 acid ethyl esters PRALUENT PEN PRALUENT SYRINGE pravastatin REPATHA SURECLICK REPATHA SYRINGE simvastatin VASCEPA ZETIA Renin-Angiotensin-Aldosterone System Inhibitors eplerenone spironolactone spironolacton-hydrochlorothiaz Vasodilators isosorbide dinitrate oral isosorbide dinitrate sublingual isosorbide mononitrate oral tablet isosorbide mononitrate oral tablet extended release 24 hr minitran transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.6 mg/hr minitran transdermal patch 24 hour 0.4 mg/hr minoxidil oral NITRO-BID nitroglycerin in 5 % dextrose intravenous solution nitroglycerin intravenous nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.6 mg/hr nitroglycerin transdermal patch 24 hour 0.4 mg/hr NITROSTAT PROGLYCEM
5 1 2 2 5 5 1 5 5 1 3 4
PA; QL (4 per 28 days) GC GC GC PA; QL (2 per 28 days) PA; QL (2 per 28 days) GC PA; QL (3 per 28 days) PA; QL (3 per 28 days) GC; QL (30 per 30 days)
(Inspra) (Aldactone) (Aldactazide)
2 2 2
GC GC GC
(Isochron) (Isosorbide Dinitrate) (Isosorbide Mononitrate) (Imdur)
2 1 2 2
GC GC GC GC
(Nitro-Dur)
2
GC; QL (30 per 30 days)
(Nitro-Dur)
2
GC; QL (60 per 30 days)
(Minoxidil)
GC
(Nitroglycerin/D5W)
2 3 2
(Nitroglycerin) (Nitro-Dur)
2 2
GC GC; QL (30 per 30 days)
(Nitro-Dur)
2
GC; QL (60 per 30 days)
(Mevacor) (Niaspan) (Lovaza)
(Pravachol)
(Zocor)
GC
3 4
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 70 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name
Drug Tier
Requirements/Limits
2 5 2 2 2
GC; QL (60 per 30 days) PA; QL (60 per 30 days) GC GC GC
clonidine hcl oral tablet extended release 12 hr dexmethylphenidate oral tablet (Focalin) dextroamphetamine oral capsule, extended (Dexedrine) release dextroamphetamine oral tablet (Dexedrine)
2
GC
2 2
dextroamphetamine-amphetamine oral capsule,extended release 24hr 10 mg, 15 mg, 5 mg dextroamphetamine-amphetamine oral capsule,extended release 24hr 20 mg, 25 mg, 30 mg flumazenil guanfacine oral tablet extended release 24 hr lithium carbonate oral capsule lithium carbonate oral tablet lithium carbonate oral tablet extended release lithium citrate oral solution methylphenidate oral capsule, er biphasic 30-70 10 mg, 20 mg, 40 mg, 50 mg, 60 mg methylphenidate oral capsule, er biphasic 30-70 30 mg methylphenidate oral capsule,er biphasic 50-50 20 mg, 40 mg methylphenidate oral capsule,er biphasic 50-50 30 mg methylphenidate oral solution
(Adderall XR)
2
GC; QL (60 per 30 days) GC; QL (120 per 30 days) GC; QL (180 per 30 days) GC; QL (30 per 30 days)
(Adderall XR)
2
GC; QL (60 per 30 days)
(Romazicon) (Intuniv)
2 2
GC GC
(Lithium Carbonate) (Lithobid) (Lithobid)
2 2 2
GC GC GC
(Lithium Citrate) (Metadate Cd)
2 2
GC GC; QL (30 per 30 days)
(Metadate Cd)
2
GC; QL (60 per 30 days)
(Metadate Cd)
2
GC; QL (30 per 30 days)
(Metadate Cd)
2
GC; QL (60 per 30 days)
(Methylin)
2
GC; QL (900 per 30 days)
Central Nervous System Agents Central Nervous System Agents amphetamine salt combo AMPYRA caffeine citrated intravenous caffeine citrated oral caffeine-sodium benzoate
(Adderall) (Cafcit) (Cafcit) (Caffeine/Sodium Benzoate) (Kapvay)
2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 71 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name methylphenidate oral tablet methylphenidate oral tablet extended release methylphenidate oral tablet extended release 24hr 18 mg, 27 mg, 54 mg methylphenidate oral tablet extended release 24hr 36 mg NUEDEXTA QUILLIVANT XR riluzole SAVELLA STRATTERA tetrabenazine
Drug Tier
Requirements/Limits
(Ritalin) (Methylphenidate HCl)
2 2
GC; QL (90 per 30 days) GC; QL (90 per 30 days)
(Concerta)
2
GC; QL (30 per 30 days)
(Concerta)
2
GC; QL (60 per 30 days)
3 3 2 3 3 5
QL (60 per 30 days)
(Rilutek)
(Xenazine)
XENAZINE
5
GC QL (60 per 30 days) PA; QL (112 per 28 days) PA; QL (112 per 28 days)
Contraceptives Contraceptives ashlyna bekyree (28) blisovi 24 fe blisovi fe 1/20 (28) cyred deblitane desog-e.estradiol/e.estradiol desogestrel-ethinyl estradiol oral tablet 0.1/.125/.15-25 mg-mcg, 0.15-0.03 mg drospirenone-ethinyl estradiol ELLA ethinyl estradiol/drospirenone ethynodiol d-ethinyl estradiol gildess 1/20 (21) gildess 24 fe gildess fe 1/20 (28) juleber junel fe 24 kimidess (28) l norgest/e.estradiol-e.estrad
(Seasonique) (Mircette) (Loestrin Fe) (Loestrin Fe) (Desogen) (Nor-Q-D) (Mircette) (Desogen)
2 2 2 2 2 2 2 2
GC GC GC GC GC GC GC GC
(Yaz)
2 4 2 2 2 2 2 2 2 2 2
GC QL (6 per 365 days) GC GC GC GC GC GC GC GC GC; QL (91 per 84 days)
(Yaz) (Demulen 1-50-21) (Loestrin) (Loestrin Fe) (Loestrin Fe) (Desogen) (Loestrin Fe) (Mircette) (Seasonique)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 72 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name
Drug Tier
Requirements/Limits
larin 24 fe larin fe 1/20 (28) levonorgestrel oral tablet 0.75 mg
(Loestrin Fe) (Loestrin Fe) (Plan B One-Step)
2 2 2
levonorgestrel oral tablet 1.5 mg levonorgestrel-ethin estradiol oral tablet 0.1-20 mg-mcg, 0.15-0.03 mg, 50-30 (6)/75-40 (5)/125-30(10) levonorgestrel-ethin estradiol oral tablets,dose pack,3 month 0.15-30 mg-mcg levonorgestrel-ethinyl estrad oral tablet levonorgestrel-ethinyl estrad oral tablet 0.15-0.03 mg levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month l-norgest-eth estr/ethin estra norelgestromin/ethin.estradiol norethindrone norethindrone (contraceptive) norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg, 1.5-30 mg-mcg norethindrone-e.estradiol-iron oral tablet 1 mg-20 mcg (21)/75 mg (7), 1 mg-20 mcg (24)/75 mg (4), 1-20(5)/1-30(7) /1mg35mcg (9), 1.5 mg-30 mcg (21)/75 mg (7) norethindrone-ethinyl estrad oral tablet 0.4-35 mg-mcg, 0.5-35 mg-mcg, 0.5-35/135 mg-mcg/mg-mcg, 0.5/0.75/1 mg- 35 mcg, 0.5/1/0.5-35 mg-mcg, 1-35 mg-mcg norethindrone-mestranol norgestimate-ethinyl estradiol norgestrel-ethinyl estradiol
(Plan B One-Step) (Amethyst)
2 2
GC GC GC; QL (12 per 365 days) GC; QL (6 per 365 days) GC
(Levonorgestrel-Ethin Estradiol) (Amethyst) (Amethyst)
2
GC; QL (91 per 84 days)
2 2
GC GC; QL (91 per 84 days)
(Amethyst)
2
GC; QL (91 per 84 days)
(Seasonique) (Ortho Evra) (Nor-Q-D) (Nor-Q-D) (Loestrin)
2 2 2 2 2
GC; QL (91 per 84 days) GC; QL (3 per 28 days) GC GC GC
(Loestrin Fe)
2
GC
(Modicon)
2
GC
(Norinyl 1+50) (Ortho-Cyclen) (Norgestrel-Ethinyl Estradiol)
2 2 2
GC GC GC
3 2
ST; QL (1 per 28 days) GC; QL (91 per 84 days)
2
GC
NUVARING setlakin tarina fe 1/20 (28)
(Levonorgestrel-Ethin Estradiol) (Loestrin Fe)
Dental And Oral Agents Dental And Oral Agents You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 73 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name cevimeline chlorhexidine gluconate mucous membrane mouthwash 0.12 % pilocarpine hcl oral sodium fluoride oral tablet,chewable 0.25 mg fluorid (0.55 mg) triamcinolone acetonide dental
Drug Tier
Requirements/Limits
(Evoxac) (Peridex)
2 2
GC GC
(Salagen) (Sodium Fluoride)
2 2
GC GC
(Triamcinolone Acetonide)
2
GC
Dermatological Agents Dermatological Agents, Other 8-MOP acitretin acyclovir topical ALCOHOL PADS ALCOHOL PREP PADS ammonium lactate ANACAINE calcipotriene scalp calcipotriene topical cream calcipotriene topical ointment calcitriol topical CONDYLOX TOPICAL GEL COSENTYX (2 SYRINGES) COSENTYX PEN COSENTYX PEN (2 PENS) FLUOROPLEX fluorouracil topical cream fluorouracil topical solution imiquimod isotretinoin oral capsule 10 mg, 20 mg, 30 mg, 40 mg methoxsalen rapid PANRETIN PICATO TOPICAL GEL 0.015 % PICATO TOPICAL GEL 0.05 % podofilox podophyllum resin
(Carac) (Fluorouracil) (Aldara)
4 5 2 1 1 2 4 2 2 2 2 4 5 5 5 4 2 2 2
(Isotretinoin)
2
GC GC PA NSO; GC; QL (24 per 30 days) GC
(Oxsoralen-Ultra)
5 5 3 3 2 2
QL (3 per 56 days) QL (2 per 56 days) GC GC
(Soriatane) (Zovirax)
(Lac-Hydrin) (Calcipotriene) (Dovonex) (Calcipotriene) (Vectical)
(Condylox) (Podophyllum Resin)
GC; QL (30 per 30 days) GC GC GC GC GC GC GC PA PA PA
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 74 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name potassium hydroxide SANTYL TOLAK VALCHLOR ZOVIRAX TOPICAL CREAM Dermatological Antibacterials clindamycin phosphate topical gel clindamycin phosphate topical lotion clindamycin phosphate topical solution clindamycin phosphate topical swab erythromycin base-ethanol
Drug Tier (Potassium Hydroxide)
(Cleocin T) (Cleocin T) (Cleocin T) (Cleocin T) (Erythromycin Base/Ethanol) erythromycin with ethanol topical gel (Emgel) erythromycin with ethanol topical solution (Erythromycin Base/Ethanol) erythromycin with ethanol topical swab (Erythromycin Base/Ethanol) gentamicin topical (Gentamicin Sulfate) metronidazole topical (Metrocream) metronidazole topical (Rosadan) metronidazole topical (Metrolotion) mupirocin (Centany) mupirocin calcium (Bactroban) neomycin-polymyxin b gu (Neosporin G.U. Irrigant) selenium sulfide (Selenium Sulfide) silver nitrate applicators (Silver Nitrate Applicator) silver nitrate topical (Silver Nitrate) silver sulfadiazine topical cream 1 % (Silvadene) sulfacetamide sodium (acne) (Klaron) Dermatological AntiInflammatory Agents alclometasone (Alclometasone Dipropionate) betamethasone dipropionate (Betamethasone Dipropionate)
Requirements/Limits
2 4 4 5 3
GC
2 2 2 2 2
GC GC GC GC GC
2 2
GC GC
2
GC
2 2 2 2 2 2 2
GC GC GC GC GC GC GC
2 2
GC GC
2 2 2
GC GC GC
2
GC
2
GC
QL (15 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 75 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name betamethasone valerate topical cream betamethasone valerate topical foam betamethasone valerate topical lotion betamethasone valerate topical ointment betamethasone, augmented topical cream betamethasone, augmented topical gel betamethasone, augmented topical lotion betamethasone, augmented topical ointment clobetasol propionate scalp solution 0.05 % clobetasol scalp clobetasol topical cream clobetasol topical foam clobetasol topical gel clobetasol topical lotion clobetasol topical ointment clobetasol topical shampoo clobetasol-emollient topical clocortolone pivalate desonide topical cream desonide topical ointment desoximetasone ELIDEL fluocinonide topical cream 0.05 % fluocinonide topical gel fluocinonide topical ointment fluocinonide topical solution fluocinonide-emollient base fluticasone topical cream fluticasone topical ointment halobetasol propionate hydrocortisone 1% ointment carton (otc)
Drug Tier
Requirements/Limits
(Betamethasone Valerate) (Luxiq) (Betamethasone Valerate) (Betamethasone Valerate) (Diprolene AF) (Betamethasone Dipropionate) (Diprolene) (Diprolene)
2
GC
2 2
GC GC
2
GC
2 2
GC GC
2 2
GC GC
(Clobetasol Propionate)
2
GC
(Clobetasol Propionate) (Temovate) (Olux) (Clobetasol Propionate) (Clobex) (Temovate) (Clobex) (Temovate) (Cloderm) (Desowen) (Desonide) (Topicort)
2 2 2 2 2 2 2 2 2 2 2 2 3 2 2 2 2 2 2 2 2 2
GC GC GC GC GC GC GC GC GC GC GC GC
(Vanos) (Fluocinonide) (Fluocinonide) (Fluocinonide) (Vanos) (Cutivate) (Fluticasone Propionate) (Ultravate) (Hydrocortisone)
GC GC GC GC GC GC GC GC GC
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 76 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name
Drug Tier
hydrocortisone acet-aloe vera topical gel
2
GC
2
GC
2
GC
2 2 2
GC GC GC
2 2 2 2 2 2
GC GC GC GC GC GC
2
GC
2 2 2 2 2
GC GC GC GC GC
2
GC
2
GC
2 2 4 2 2
GC GC
2 2
GC GC
(Hydrocortisone Acetate/Aloe V) hydrocortisone acetate-urea (Hydrocortisone Acetate/Urea) hydrocortisone butyrate topical cream (Hydrocortisone Butyrate) hydrocortisone butyrate topical ointment (Locoid) hydrocortisone butyrate topical solution (Locoid) hydrocortisone butyr-emollient (Hydrocortisone Butyrate) hydrocortisone rectal cream 1 % (Anusol-HC) hydrocortisone rectal cream 2.5 % (Hydrocortisone) hydrocortisone rectal enema 100 mg/60 ml (Cortenema) hydrocortisone topical cream 1 %, 2.5 % (Anusol-HC) hydrocortisone topical lotion 2 %, 2.5 % (Scalacort) hydrocortisone topical ointment 1 %, 2.5 (Hydrocortisone) % hydrocortisone valerate topical cream (Hydrocortisone Valerate) hydrocortisone valerate topical ointment (Westcort) mometasone (Elocon) prednicarbate (Dermatop) tacrolimus topical (Protopic) triamcinolone acetonide topical cream (Triamcinolone Acetonide) triamcinolone acetonide topical lotion (Triamcinolone Acetonide) triamcinolone acetonide topical ointment (Triamcinolone 0.025 %, 0.1 %, 0.5 % Acetonide) Dermatological Retinoids adapalene topical cream (Differin) adapalene topical gel 0.1 % (Differin) TAZORAC TOPICAL CREAM tretinoin microspheres (Retin-A Micro) tretinoin topical (Retin-A) Scabicides And Pediculicides malathion (Ovide) permethrin topical cream (Elimite)
Requirements/Limits
PA; GC PA; GC
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 77 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name
Drug Tier
Requirements/Limits
Devices Devices ASSURE ID INSULIN SAFETY SYRINGE BD ECLIPSE LUER-LOK SYRINGE 1 ML 27 X 1/2" BD INSULIN PEN NEEDLE UF SHORT BD INSULIN SYRINGE ULTRA-FINE SYRINGE 0.3 ML 31 X 5/16", 1 ML 31 X 5/16", 1/2 ML 31 X 5/16" INSULIN SYRINGE-NEEDLE U-100 SYRINGE 0.3 ML 29, 1 ML 29 X 1/2", 1/2 ML 28 PEN NEEDLE, DIABETIC NEEDLE 29 GAUGE X 1/2 " VGO 40
2
GC
2
GC
2 2
GC GC
2
GC
2
GC
2
GC
Enzyme Replacement/Modifiers Enzyme Replacement/Modifiers ADAGEN ALDURAZYME CEREZYME INTRAVENOUS RECON SOLN 400 UNIT CREON ELAPRASE ELITEK INTRAVENOUS RECON SOLN FABRAZYME INTRAVENOUS RECON SOLN KRYSTEXXA KUVAN ORAL TABLET,SOLUBLE lipase-protease-amylase (Lipase/Protease/Amylas e) MYOZYME NAGLAZYME ORFADIN PULMOZYME STRENSIQ VIMIZIM
5 5 5 3 5 5 5 5 5 2
GC
5 5 5 5 5 5
PA BvD PA PA
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 78 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name
Drug Tier
VPRIV ZAVESCA ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,000-34,000 55,000 UNIT, 15,000-51,000 -82,000 UNIT, 20,000-68,000 -109,000 UNIT, 25,000-85,000- 136,000 UNIT, 3,00010,000- 16,000 UNIT, 40,000-136,000218,000 UNIT
Requirements/Limits
5 5 3
QL (90 per 30 days)
4 2 2 2 2 2 2 2 2 2 3
GC GC GC GC GC GC; QL (30 per 25 days) GC GC GC
Eye, Ear, Nose, Throat Agents Eye, Ear, Nose, Throat Agents, Miscellaneous AKTEN (PF) altacaine apraclonidine atropine ophthalmic drops atropine ophthalmic ointment atropine sulfate ophthalmic drops 1 % azelastine nasal aerosol,spray 137 mcg azelastine ophthalmic carteolol cromolyn ophthalmic CYCLOGYL OPHTHALMIC DROPS 0.5 % cyclopentolate CYSTARAN epinastine homatropine hbr ipratropium bromide nasal spray,nonaerosol 0.03 % ipratropium bromide nasal spray,nonaerosol 0.06 % LACRISERT naphazoline olopatadine ophthalmic phenylephrine hcl ophthalmic proparacaine proparacaine hcl ophthalmic drops 0.5 %
(Tetcaine) (Iopidine) (Isopto Atropine) (Atropine Sulfate) (Isopto Atropine) (Astepro) (Azelastine HCl) (Carteolol HCl) (Cromolyn Sodium)
(Cyclogyl)
GC
(Elestat) (Isopto Homatropine) (Atrovent)
2 5 2 2 2
(Atrovent)
2
GC; QL (15 per 10 days)
(Naphazoline HCl) (Patanol) (Mydfrin) (Proparacaine HCl) (Proparacaine HCl)
3 1 2 2 2 2
GC GC GC GC GC
GC GC GC; QL (30 per 28 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 79 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name proparacaine-fluorescein sod tetracaine hcl (pf) ophthalmic Eye, Ear, Nose, Throat AntiInfectives Agents acetic acid otic bacitracin ophthalmic bacitracin-polymyxin b ophthalmic CIPRODEX ciprofloxacin hcl ophthalmic ciprofloxacin hcl otic COLY-MYCIN S erythromycin ophthalmic gatifloxacin gentamicin ophthalmic gentamicin sulfate ophthalmic ointment 0.3 % (3 mg/gram) levofloxacin ophthalmic MOXEZA NATACYN neomy sulf-bacitrac zn-poly-hc neomycin-bacitracin-poly-hc neomycin-bacitracin-polymyxin neomycin-polymyxin b-dexameth neomycin-polymyxin-gramicidin neomycin-polymyxin-hc ophthalmic neomycin-polymyxin-hc otic drops,suspension neomycin-polymyxin-hc otic solution neo-polycin ofloxacin ophthalmic ofloxacin otic
Drug Tier
Requirements/Limits
(Proparacaine/Fluorescei n Sod) (Tetracaine HCl/PF)
2
GC
2
GC
(Acetic Acid) (Bacitracin) (Bacitracin/Polymyxin B Sulfate)
2 2 2
GC GC GC
(Ciloxan) (Cetraxal) (Ilotycin) (Zymaxid) (Garamycin) (Garamycin) (Levofloxacin)
(Neomycin Su/Baci Zn/Poly/HC) (Neomycin Su/Baci Zn/Poly/HC) (Neomycin Su/Bacitra/Polymyxin) (Maxitrol) (Neosporin) (Neomycin/Polymyxin B Sulf/HC) (Neomycin/Polymyxin B Sulf/HC) (Cortisporin) (Neomycin Su/Bacitra/Polymyxin) (Ocuflox) (Ocuflox)
3 2 2 4 2 2 2 2
GC GC GC GC GC GC
2 3 3 2
GC
2
GC
2
GC
2 2 2
GC GC GC
2
GC
2 2
GC GC
2 2
GC GC
GC
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 80 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name polymyxin b sulf-trimethoprim sulfacetamide sodium sulfacetamide sodium ophthalmic drops 10 % sulfacetamide-prednisolone TOBRADEX ST tobramycin trifluridine VIGAMOX ZIRGAN ZYLET Eye, Ear, Nose, Throat AntiInflammatory Agents ALREX bromfenac dexamethasone sodium phosphate ophthalmic diclofenac sodium ophthalmic DUREZOL flunisolide nasal spray,non-aerosol 25 mcg (0.025 %) fluorometholone flurbiprofen sodium fluticasone nasal ILEVRO ketorolac ophthalmic LOTEMAX NEVANAC prednisolone acetate prednisolone sodium phosphate ophthalmic PROLENSA RESTASIS
Drug Tier
Requirements/Limits
(Polytrim) (Sulfacetamide Sodium) (Sulfacetamide Sodium)
2 2 2
GC GC GC
(Sulfacetamide/Predniso lone Sp)
2
GC
(Tobrex) (Viroptic)
(Bromfenac Sodium) (Dexasol) (Diclofenac Sodium) (Flunisolide) (FML) (Ocufen) (Fluticasone Propionate) (Acular)
(Omnipred) (Prednisolone Sod Phosphate)
3 2 2 3 4 3
GC GC
3 2 2
ST GC GC
2 3 2
GC
2 2 1 3 2 3 3 2 2
GC GC GC; QL (16 per 30 days)
GC; QL (50 per 25 days)
GC
GC GC
3 3
QL (60 per 30 days)
2
GC
Gastrointestinal Agents Antiulcer Agents And Acid Suppressants amoxicil-clarithromy-lansopraz
(Prevpac)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 81 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name CARAFATE ORAL SUSPENSION cimetidine cimetidine hcl oral esomeprazole sodium famotidine (pf) famotidine (pf)-nacl (iso-os) famotidine intravenous famotidine oral tablet 20 mg, 40 mg lansoprazole oral capsule,delayed release(dr/ec) misoprostol omeprazole oral capsule,delayed release(dr/ec) pantoprazole oral ranitidine hcl injection ranitidine hcl oral syrup ranitidine hcl oral tablet 150 mg, 300 mg sucralfate oral suspension sucralfate oral tablet Gastrointestinal Agents, Other AMITIZA BUPHENYL ORAL TABLET CARBAGLU cromolyn oral dicyclomine oral capsule dicyclomine oral solution dicyclomine oral tablet diphenoxylate-atropine oral liquid diphenoxylate-atropine oral tablet GATTEX 30-VIAL GATTEX ONE-VIAL glycopyrrolate glycopyrrolate lactulose LINZESS loperamide oral
Drug Tier
Requirements/Limits
3 2 2 2 2 2
(Rx Product Only); GC GC GC GC GC
2 1 2
GC (Rx Product Only); GC (Rx Product Only); GC
(Cytotec) (Prilosec)
2 2
GC GC
(Protonix) (Zantac) (Ranitidine HCl) (Zantac) (Sucralfate) (Carafate)
2 2 2 1 2 2
GC (Rx Product Only); GC (Rx Product Only); GC (Rx Product Only); GC GC GC
3 5 5 5 2 2 2 2
QL (60 per 30 days)
2 5 5 2 2 2 3 2
GC PA PA GC GC GC QL (30 per 30 days) GC
(Cimetidine) (Cimetidine HCl) (Nexium I.V.) (Famotidine) (Famotidine In Nacl,IsoOsm/PF) (Famotidine) (Pepcid) (Prevacid)
(Gastrocrom) (Bentyl) (Dicyclomine HCl) (Bentyl) (Diphenoxylate HCl/Atropine) (Lomotil)
(Robinul) (Robinul) (Lactulose) (Loperamide HCl)
GC GC GC GC
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 82 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name LOTRONEX methscopolamine oral metoclopramide hcl injection metoclopramide hcl oral metoclopramide hcl oral MOVANTIK NUTRESTORE RAVICTI RELISTOR SUBCUTANEOUS RELISTOR SUBCUTANEOUS sodium polystyrene sulfonate oral powder
Drug Tier (Methscopolamine Bromide) (Metoclopramide HCl) (Metoclopramide HCl) (Reglan)
(Sodium Polystyrene Sulfonate) sodium polystyrene sulfonate oral (Sodium Polystyrene suspension 15 gram/60 ml Sulfonate) sodium polystyrene sulfonate rectal enema (Sodium Polystyrene 30 gram/120 ml Sulfonate) ursodiol oral capsule (Actigall) ursodiol oral tablet (Urso) Laxatives MOVIPREP peg 3350-electrolytes (Golytely) PEG 3350-GRX peg 3350-na sulf,bicarb,cl-kcl (Golytely) peg-electrolyte soln (Nulytely with Flavor Packs) polyethylene glycol 3350 oral (Gavilyte-N) sodium chloride-nahco3-kcl-peg oral (Nulytely with Flavor recon soln 420 gram Packs) Phosphate Binders calcium acetate oral capsule (Phoslo) calcium acetate oral tablet 667 mg (Calcium Acetate) calcium carbonate-mag carb-fa (Calcium Carbonate/Mag Carb/Fa) PHOSLYRA RENAGEL RENVELA
5 2
Requirements/Limits GC
2 2 1 3 4 5 4 4 2
GC GC GC QL (30 per 30 days)
2
GC
2
GC
2 2
GC GC
3 2 2 2 2
GC GC GC GC
2 2
GC GC
2 2 2
GC GC GC
PA PA; QL (28 per 28 days) PA; QL (28 per 28 days) GC
4 3 3
Genitourinary Agents You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 83 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name Antispasmodics, Urinary MYRBETRIQ oxybutynin chloride oral tablet oxybutynin chloride oral tablet extended release 24hr tolterodine oral capsule,extended release 24hr tolterodine oral tablet TOVIAZ trospium Genitourinary Agents, Miscellaneous alfuzosin tamsulosin terazosin
Drug Tier
Requirements/Limits
(Oxybutynin Chloride) (Ditropan XL)
3 2 2
GC GC
(Detrol LA)
2
GC
(Detrol)
GC
(Trospium Chloride)
2 3 2
(Uroxatral) (Flomax) (Terazosin HCl)
2 2 1
GC GC GC
2 5 4
PA BvD; GC
GC
Heavy Metal Antagonists Heavy Metal Antagonists deferoxamine injection recon soln (Desferal) DEPEN TITRATABS EXJADE ORAL TABLET, DISPERSIBLE 125 MG EXJADE ORAL TABLET, DISPERSIBLE 250 MG, 500 MG FERRIPROX sodium thiosulfate intravenous solution 1 (Sodium Thiosulfate) gram/10 ml (100 mg/ml), 12.5 gram/50 ml (250 mg/ml) SYPRINE
5 5 2
GC
5
Hormonal Agents, Stimulant/Replacement/Modifying Androgens ANDRODERM ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 20.25 MG/1.25 GRAM (1.62 %) ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM), 1.62 % (40.5 MG/2.5 GRAM)
3 3
PA; QL (30 per 30 days) PA; QL (150 per 30 days)
3
PA; QL (150 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 84 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name danazol oral fluoxymesterone oxandrolone testosterone cypionate testosterone enanthate
(Danazol) (Fluoxymesterone) (Oxandrin) (Depo-Testosterone) (Delatestryl)
Drug Tier
Requirements/Limits
2 2 2 2 2
GC GC GC PA; GC PA; GC; QL (5 per 28 days) PA; GC; QL (300 per 30 days)
testosterone transdermal gel in packet 1 % (Androgel) (25 mg/2.5gram) Estrogens And Antiestrogens COMBIPATCH
2
DUAVEE ESTRACE VAGINAL estradiol oral estradiol transdermal patch semiweekly
(Estrace) (Vivelle-Dot)
3 3 2 2
estradiol transdermal patch weekly
(Climara)
2
estradiol valerate (Delestrogen) estradiol/norethindrone acet (Activella) estradiol-norethindrone acet (Activella) estropipate (Ogen) FEMRING MENEST PREMARIN INJECTION PREMARIN ORAL PREMARIN VAGINAL PREMPHASE PREMPRO raloxifene (Evista) VAGIFEM Glucocorticoids/Mineralocorticoid betamethasone acet,sod phos (Celestone) cortisone (Cortisone Acetate) dexamethasone oral (Dexamethasone) dexamethasone oral (Dexamethasone) dexamethasone sodium phosphate (Dexamethasone Sod injection solution Phosphate)
3
2 2 2 2 4 4 3 3 3 3 3 2 3 2 2 2 1 2
PA-HRM; QL (8 per 28 days) PA-HRM PA-HRM; GC PA-HRM; GC; QL (8 per 28 days) PA-HRM; GC; QL (4 per 28 days) GC PA-HRM; GC PA-HRM; GC PA-HRM; GC QL (1 per 84 days) PA-HRM PA-HRM PA-HRM PA-HRM GC QL (18 per 28 days) GC PA BvD; GC PA BvD; GC PA BvD; GC GC
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 85 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name fludrocortisone hydrocortisone oral hydrocortisone sod succinate methylprednisolone methylprednisolone acetate methylprednisolone sodium succ injection recon soln 125 mg, 40 mg methylprednisolone sodium succ intravenous prednisolone sodium phosphate oral solution prednisone oral solution prednisone oral tablet prednisone oral tablets,dose pack SOLU-CORTEF (PF) INJECTION RECON SOLN 100 MG/2 ML triamcinolone acetonide injection Pituitary desmopressin injection desmopressin nasal desmopressin nasal desmopressin oral GENOTROPIN GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.2 MG/0.25 ML GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.4 MG/0.25 ML, 0.6 MG/0.25 ML, 0.8 MG/0.25 ML, 1 MG/0.25 ML, 1.2 MG/0.25 ML, 1.4 MG/0.25 ML, 1.6 MG/0.25 ML, 1.8 MG/0.25 ML, 2 MG/0.25 ML INCRELEX LUPRON DEPOT-PED
Drug Tier
Requirements/Limits
(Fludrocortisone Acetate) (Cortef) (Hydrocortisone Sod Succinate) (Medrol) (Depo-Medrol) (A-Methapred)
2
GC
2 2
PA BvD; GC GC
2 2 2
PA BvD; GC GC GC
(A-Methapred)
2
GC
(Pediapred)
2
PA BvD; GC
(Prednisone) (Prednisone) (Prednisone)
2 1 2 4
PA BvD; GC PA BvD; GC PA BvD; GC
(Triamcinolone Acetonide)
2
GC
(Desmopressin Acetate) (DDAVP) (Desmopressin Acetate) (DDAVP)
2 2 2 2 5 4
GC GC; QL (15 per 30 days) GC; QL (15 per 30 days) GC PA PA
5
PA
5 5
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 86 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name
Drug Tier
LUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR SYRINGE KIT NORDITROPIN FLEXPRO NORDITROPIN NORDIFLEX octreotide acetate injection solution 1,000 mcg/ml octreotide acetate injection solution 100 mcg/ml, 200 mcg/ml, 500 mcg/ml octreotide acetate injection solution 50 mcg/ml octreotide acetate injection syringe SAIZEN SAIZEN CLICK.EASY SANDOSTATIN LAR DEPOT INTRAMUSCULAR KIT SEROSTIM SUBCUTANEOUS RECON SOLN 4 MG, 5 MG, 6 MG SOMATULINE DEPOT SOMAVERT SUPPRELIN LA Progestins DEPO-PROVERA INTRAMUSCULAR SOLUTION medroxyprogesterone intramuscular medroxyprogesterone oral MEGACE ES megestrol oral suspension norethindrone acetate progesterone progesterone micronized capsules Thyroid And Antithyroid Agents levothyroxine intravenous levothyroxine oral liothyronine oral methimazole oral tablet 10 mg, 5 mg propylthiouracil
5
QL (1 per 84 days) PA PA
(Sandostatin)
5 5 5
(Sandostatin)
2
GC
(Octreotide Acetate)
2
GC
(Octreotide Acetate)
2 5 5 5
GC PA PA
5
PA
5 5 5
QL (1 per 28 days)
4
QL (10 per 28 days) GC; QL (1 per 84 days) GC
(Megace Es) (Aygestin) (Progesterone) (Prometrium)
2 2 5 2 2 2 2
(Levothyroxine Sodium) (Levoxyl) (Cytomel) (Tapazole) (Propylthiouracil)
2 1 2 2 2
GC GC GC GC GC
(Depo-Provera) (Provera)
Requirements/Limits
QL (1 per 360 days)
GC GC GC GC
Immunological Agents Immunological Agents You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 87 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name ARCALYST ASTAGRAF XL AUBAGIO azathioprine azathioprine sodium CARIMUNE NF NANOFILTERED INTRAVENOUS RECON SOLN CELLCEPT INTRAVENOUS CIMZIA CIMZIA POWDER FOR RECONST cyclosporine intravenous cyclosporine modified cyclosporine oral capsule cyclosporine, modified ENBREL ENBREL SURECLICK FLEBOGAMMA DIF GAMASTAN S/D GAMMAGARD LIQUID GAMMAPLEX HUMIRA HUMIRA PEN HUMIRA PEN CROHN'S-UC-HS START HYPERRAB S/D (PF) HYQVIA ILARIS (PF) IMOGAM RABIES-HT (PF) KINERET leflunomide mycophenolate mofetil oral capsule mycophenolate mofetil oral suspension for reconstitution mycophenolate mofetil oral tablet mycophenolate sodium NULOJIX OCTAGAM
(Imuran) (Azathioprine Sodium)
(Sandimmune) (Neoral) (Sandimmune) (Neoral)
Drug Tier
Requirements/Limits
5 4 5 2 2 5
PA BvD PA; QL (28 per 28 days) PA BvD; GC PA BvD; GC PA BvD
4 5 5 2 2 2 2 5 5 5 3 5 5 5 5 5
PA BvD PA PA PA BvD; GC PA BvD; GC PA BvD; GC PA BvD; GC PA PA PA BvD PA BvD PA BvD PA BvD PA PA PA
4 5 5 4 5
PA BvD PA
(Arava) (Cellcept) (Cellcept)
2 2 5
PA; QL (18.76 per 28 days) GC PA BvD; GC PA BvD
(Cellcept) (Myfortic)
2 2 5 5
PA BvD; GC PA BvD; GC PA BvD PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 88 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name ORENCIA ORENCIA (WITH MALTOSE) PRIVIGEN PROGRAF INTRAVENOUS RAPAMUNE ORAL SOLUTION RIDAURA sirolimus oral tablet 0.5 mg, 1 mg sirolimus oral tablet 2 mg tacrolimus oral TYSABRI
Drug Tier
(Rapamune) (Rapamune) (Hecoria)
5 5 5 4 5 5 2 5 2 5
ZORTRESS ORAL TABLET 0.25 MG
4
ZORTRESS ORAL TABLET 0.5 MG, 0.75 MG Vaccines ACTHIB (PF) ADACEL(TDAP ADOLESN/ADULT)(PF) BCG VACCINE, LIVE (PF) BEXSERO (PF) BOOSTRIX TDAP CERVARIX VACCINE (PF) COMVAX (PF) DAPTACEL (DTAP PEDIATRIC) (PF) ENGERIX-B (PF)
5
ENGERIX-B PEDIATRIC (PF)
3
GARDASIL (PF) GARDASIL 9 (PF) HAVRIX (PF) INTRAMUSCULAR SUSPENSION HAVRIX (PF) INTRAMUSCULAR SYRINGE IMOVAX RABIES VACCINE (PF) INFANRIX (DTAP) (PF) INTRAMUSCULAR
3 3 3
Requirements/Limits PA PA PA BvD PA BvD PA BvD PA BvD; GC PA BvD PA BvD; GC PA; LA; QL (15 per 28 days) PA BvD; QL (120 per 30 days) PA BvD; QL (120 per 30 days)
3 3 3 3 3 3 3 3 3
PA BvD
PA BvD; QL (3 per 365 days) PA BvD; QL (3 per 365 days) QL (1.5 per 365 days) QL (1.5 per 365 days)
3 3 3
PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 89 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name
Drug Tier
IPOL INJECTION SUSPENSION IXIARO (PF) KINRIX (PF) MENACTRA (PF) INTRAMUSCULAR SOLUTION MENHIBRIX (PF) MENOMUNE - A/C/Y/W-135 (PF) MENVEO A-C-Y-W-135-DIP (PF) MENVEO MENA COMPONENT (PF) MENVEO MENCYW-135 COMPNT (PF) M-M-R II (PF) PEDIARIX (PF) PEDVAX HIB (PF) PENTACEL (PF) PENTACEL ACTHIB COMPONENT (PF) PROQUAD (PF) QUADRACEL (PF) RABAVERT (PF) RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 MCG/ML, 40 MCG/ML RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE ROTARIX ROTATEQ VACCINE TENIVAC (PF) INTRAMUSCULAR TETANUS TOXOID,ADSORBED (PF) TETANUS,DIPHTHERIA TOX PED(PF) TETANUS-DIPHTHERIA TOXOIDS-TD TICE BCG TRUMENBA TWINRIX (PF) TYPHIM VI VAQTA (PF) VARIVAX (PF) YF-VAX (PF)
3 3 3 3
Requirements/Limits
3 3 3 3 3 3 3 3 3 3
QL (2 per 365 days)
3 3 3 3
QL (2 per 365 days)
3
PA BvD; QL (3 per 365 days)
3 3 3 3 3 3 3 3 3 3 3 3 3
PA BvD PA BvD; QL (3 per 365 days)
PA BvD
PA BvD
QL (2 per 365 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 90 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name
Drug Tier
ZOSTAVAX (PF)
3
Requirements/Limits QL (1 per 365 days)
Inflammatory Bowel Disease Agents Inflammatory Bowel Disease Agents APRISO ASACOL HD balsalazide budesonide oral DELZICOL DIPENTUM
(Colazal) (Entocort EC)
3 3 2 5 3 4
GC
ST
Irrigating Solutions Irrigating Solutions acetic acid irrigation LACTATED RINGERS IRRIGATION ringers irrigation sodium chloride irrigation
2 3 2 2
GC
2 2
GC GC
2
GC
(Alendronate Sodium)
2
alendronate oral tablet 10 mg, 40 mg, 5 mg alendronate oral tablet 35 mg, 70 mg calcitonin (salmon)
(Fosamax)
1
GC; QL (300 per 28 days) GC
(Fosamax) (Miacalcin)
1 2
calcitriol intravenous solution 1 mcg/ml
(Calcitriol)
2
calcitriol oral
(Rocaltrol)
2
doxercalciferol intravenous
(Doxercalciferol)
2
sorbitol irrigation sorbitol-mannitol water for irrigation, sterile
(Acetic Acid) (Ringers Solution) (Sodium Chloride Irrig Solution) (Sorbitol Solution) (Mannitol/Sorbitol Solution) (Water For Irrigation,Sterile)
GC GC
Metabolic Bone Disease Agents Metabolic Bone Disease Agents alendronate oral solution
GC; QL (4 per 28 days) GC; QL (3.7 per 28 days) PA BvD; (PA for ESRD Only); GC PA BvD; (PA for ESRD Only); GC PA BvD; (PA for ESRD Only); GC
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 91 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name
Drug Tier
Requirements/Limits
(Hectorol)
2
FORTEO FORTICAL ibandronate intravenous solution
(Ibandronate Sodium)
4 4 2
ibandronate intravenous syringe
(Boniva)
2
ibandronate oral MIACALCIN INJECTION
(Boniva)
2 3
PA BvD; (PA for ESRD Only); GC PA; QL (2.4 per 28 days) QL (3.7 per 28 days) PA BvD; (PA for ESRD Only); GC; QL (3 per 84 days) PA BvD; GC; QL (3 per 84 days) GC; QL (1 per 28 days) PA BvD; (PA for ESRD Only) PA; QL (2 per 28 days) PA BvD; (PA for ESRD Only); GC QL (1 per 180 days) GC; QL (1 per 28 days) GC; QL (30 per 28 days) PA BvD; (PA for ESRD Only) GC GC
doxercalciferol oral
NATPARA paricalcitol oral PROLIA risedronate oral tablet 150 mg risedronate oral tablet 30 mg, 5 mg ZEMPLAR INTRAVENOUS zoledronic acid intravenous zoledronic acid-mannitol-water intravenous piggyback zoledronic acid-mannitol-water intravenous solution ZOMETA INTRAVENOUS SOLUTION 4 MG/100 ML
(Zemplar)
(Actonel) (Actonel)
(Zometa) (Zoledronic Acid/Mannitol and Water) (Reclast)
5 2 3 2 2 3 2 2
2 5
GC; QL (100 per 300 days) PA BvD
5
PA
5 5 2 2
PA
Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents ACTEMRA INTRAVENOUS SOLUTION 200 MG/10 ML (20 MG/ML) ACTEMRA SUBCUTANEOUS ACTIMMUNE allopurinol (Zyloprim) amifostine crystalline (Amifostine Crystalline)
GC GC
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 92 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name anticoag citrate phos dextrose AVONEX (WITH ALBUMIN) AVONEX INTRAMUSCULAR AVONEX INTRAMUSCULAR BENLYSTA INTRAVENOUS RECON SOLN BETASERON SUBCUTANEOUS bethanechol chloride buspirone CERDELGA colchicine oral tablet colchicine-probenecid COPAXONE SUBCUTANEOUS SYRINGE CYSTADANE droperidol injection solution dutasteride dutasteride-tamsulosin ELMIRON ergoloid EXTAVIA SUBCUTANEOUS finasteride oral tablet 5 mg fomepizole FUSILEV GAUZE PAD TOPICAL BANDAGE 2 X 2" GILENYA GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) guanidine hydroxyzine hcl intramuscular hydroxyzine hcl oral solution 10 mg/5 ml hydroxyzine hcl oral tablet hydroxyzine pamoate JALYN
Drug Tier (Citrate Phosphate Dextros Soln)
(Urecholine) (Buspirone HCl) (Colcrys) (Colchicine/Probenecid)
(Droperidol) (Avodart) (Jalyn) (Ergoloid Mesylates) (Proscar) (Fomepizole)
(Guanidine HCl) (Hydroxyzine HCl) (Hydroxyzine HCl) (Hydroxyzine HCl) (Vistaril)
Requirements/Limits
2
GC
5 5 5 5
ST ST ST PA
5 2 2 5 2 2 5
ST GC GC PA GC GC
5 2 2 2 4 2 5 2 5 5 1
GC GC GC; QL (30 per 30 days) GC ST GC
GC
5 3 4
PA; QL (28 per 28 days)
2 2 2 2 2 3
GC PA-HRM; GC PA-HRM; GC PA-HRM; GC PA-HRM; GC QL (30 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 93 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name
Drug Tier
Requirements/Limits
KEVEYIS
5
LEMTRADA leucovorin calcium injection recon soln 100 mg, 200 mg, 350 mg leucovorin calcium oral levocarnitine (with sugar)
5 2
PA NSO; QL (120 per 30 days) PA GC
levocarnitine oral mesna MESNEX ORAL MESTINON ORAL SYRUP MESTINON TIMESPAN morrhuate sodium OTEZLA OTEZLA STARTER OTREXUP (PF) PLEGRIDY probenecid PROCYSBI pyridostigmine bromide oral tablet RASUVO (PF) REBIF (WITH ALBUMIN) REBIF REBIDOSE REBIF TITRATION PACK REMICADE SENSIPAR ORAL TABLET 30 MG SENSIPAR ORAL TABLET 60 MG, 90 MG SIGNIFOR SIMPONI ARIA SIMPONI SUBCUTANEOUS PEN INJECTOR 100 MG/ML SIMPONI SUBCUTANEOUS PEN INJECTOR 50 MG/0.5 ML SIMPONI SUBCUTANEOUS SYRINGE
(Leucovorin Calcium) (Leucovorin Calcium) (Levocarnitine (With Sugar)) (Carnitor)
2 2
(Mesnex)
2 5 4 4 2 5 5 3 5 2 5 2 3 5 5 5 5 3 5
(Sodium Morrhuate)
(Probenecid) (Mestinon)
2
GC PA BvD; (PA for ESRD Only); GC PA BvD; (PA for ESRD Only); GC GC
GC PA; QL (60 per 30 days) PA; QL (60 per 30 days) ST GC GC
PA
5 5 5
QL (60 per 30 days) PA PA; QL (3 per 28 days)
5
PA; QL (0.5 per 28 days)
5
PA
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 94 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name
Drug Tier
Requirements/Limits
STELARA SUBCUTANEOUS SYRINGE STERILE PADS TOPICAL BANDAGE 2 X2" SYNAREL TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG (14)- 240 MG (46), 240 MG THALOMID
5
PA
1
GC
5 5
PA; QL (14 per 30 days)
5
PA; QL (60 per 30 days)
5
TYBOST ULORIC XELJANZ
4 3 5
PA NSO; QL (60 per 30 days) QL (30 per 30 days) ST; QL (30 per 30 days) PA; QL (60 per 30 days)
(Diamox Sequels)
2
GC
(Acetazolamide) (Acetazolamide Sodium)
2 2 3
GC GC
Ophthalmic Agents Antiglaucoma Agents acetazolamide oral capsule, extended release acetazolamide oral tablet acetazolamide sodium ALPHAGAN P OPHTHALMIC DROPS 0.1 % AZOPT betaxolol ophthalmic bimatoprost brimonidine COMBIGAN dorzolamide dorzolamide-timolol latanoprost levobunolol LUMIGAN OPHTHALMIC DROPS 0.01 % methazolamide oral
(Betaxolol HCl) (Bimatoprost) (Alphagan P)
3 2 2 2
GC GC (drops: 0.15%, 0.20%); GC
(Trusopt) (Cosopt) (Xalatan) (Betagan)
3 2 2 2 2 3
GC GC GC GC QL (2.5 per 25 days)
(Neptazane)
2
GC
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 95 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name metipranolol PHOSPHOLINE IODIDE pilocarpine hcl ophthalmic drops 1 %, 2 %, 4 % SIMBRINZA timolol maleate ophthalmic drops timolol maleate ophthalmic gel forming solution TRAVATAN Z travoprost (benzalkonium)
Drug Tier (Metipranolol) (Isopto Carpine)
2 3 2
(Timoptic) (Timoptic-Xe)
3 2 2
Requirements/Limits GC GC
GC GC
3 2
QL (2.5 per 25 days) GC; QL (2.5 per 25 days)
(Pyridostigmine Bromide)
2
GC
(Calcium Chloride) (Calcium Gluconate)
2 2
(Citric Acid/Sodium Citrate) (Dextrose 10 % and 0.45 % NaCl) (Dextrose 2.5 % and 0.45 % NaCl) (Dextrose 5 % and 0.9 % NaCl) (Dextrose 5 %-0.45 % NaCl) (Dextrose 10 % and 0.2 % NaCl) (Dextrose 5%-Lactated Ringers) (Dextrose 5 %-0.2 % NaCl)
2
GC PA BvD; (PA for ESRD Only); GC GC
2
GC
2
GC
2
GC
2
GC
2
GC
2
GC
2
GC
(Travoprost (Benzalkonium))
Parasympathomimetic (Cholinergic Agents) Parasympathomimetic (Cholinergic Agents) pyridostigmine bromide oral tablet extended release
Replacement Preparations Replacement Preparations calcium chloride intravenous calcium gluconate intravenous citric acid-sodium citrate d10 % & 0.45 % sodium chloride d2.5 %-0.45 % sodium chloride d5 % and 0.9 % sodium chloride d5 %-0.45 % sodium chloride dextrose 10 % and 0.2 % nacl dextrose 5 %-lactated ringers dextrose 5%-0.2 % sod chloride
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 96 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name dextrose 5%-0.3 % sod.chloride dextrose with sodium chloride electrolyte-48 in d5w HYPERLYTE CR IONOSOL-B IN D5W IONOSOL-MB IN D5W ISOLYTE M IN 5 % DEXTROSE ISOLYTE-H IN 5 % DEXTROSE ISOLYTE-P IN 5 % DEXTROSE ISOLYTE-S klor-con 10 klor-con m10 klor-con m15 klor-con m20 klor-con sprinkle magnesium chloride injection magnesium sulf in 0.45% nacl magnesium sulfate in d5w intravenous piggyback 1 gram/100 ml, 4 gram/100 ml magnesium sulfate in water magnesium sulfate injection NORMOSOL-M IN 5 % DEXTROSE NORMOSOL-R PH 7.4 NUTRILYTE NUTRILYTE II phosphorus #1 PLASMA-LYTE 148 PLASMA-LYTE A PLASMA-LYTE-56 IN 5 % DEXTROSE potassium acetate intravenous potassium bicarb and chloride potassium bicarb-citric acid
Drug Tier (Dextrose 5 % and 0.3 % NaCl) (Dextrose 5 %-0.2 % NaCl) (Electrolyte-48 Solution/D5W)
(Potassium Chloride) (Potassium Chloride) (Potassium Chloride) (Potassium Chloride) (Micro-K) (Magnesium Chloride) (Magnesium Sulf In 0.45% NaCl) (Magnesium Sulfate/D5W) (Magnesium Sulfate in Water) (Magnesium Sulfate)
(K-Phos Neutral)
(Potassium Acetate) (Pot Chloride/Pot Bicarb/Cit Ac) (Klor-Con-Ef)
Requirements/Limits
2
GC
2
GC
2
GC
4 4 4 4 4 4 4 2 2 2 2 2 2 2
GC GC GC GC GC GC GC
2
GC
2
GC
2 4 4 4 4 2 4 4 4 2 2
GC
2
GC
GC
GC GC
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 97 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name potassium bicarbonate-cit ac oral tablet, effervescent 25 meq potassium chlorid-d5-0.45%nacl potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 30 meq/l, 40 meq/l potassium chloride in lr-d5 intravenous parenteral solution potassium chloride intravenous potassium chloride oral capsule, extended release potassium chloride oral liquid potassium chloride oral packet potassium chloride oral tablet extended release potassium chloride oral tablet,er particles/crystals 10 meq potassium chloride oral tablet,er particles/crystals 20 meq potassium chloride-0.45 % nacl potassium chloride-d5-0.2%nacl potassium chloride-d5-0.3%nacl intravenous parenteral solution 20 meq/l potassium chloride-d5-0.9%nacl potassium citrate potassium citrate-citric acid oral packet potassium phosphate m-/d-basic ringers intravenous sodium acetate intravenous
Drug Tier
Requirements/Limits
(Klor-Con-Ef)
2
GC
(Potassium Chloride/D50.45nacl) (Potassium Chloride In 0.9%NaCl)
2
GC
2
GC
(Potassium Chloride In D5w)
2
GC
(Potassium Chloride In Lr-D5) (Potassium Chloride) (Micro-K)
2
GC
2 2
GC GC
(Potassium Chloride) (Klor-Con) (K-Tab ER)
2 2 2
GC GC GC
(K-Tab ER)
2
GC
(Potassium Chloride)
2
GC
(Potassium Chloride0.45% NaCl) (Potassium Chloride/D50.2%NaCl) (Potassium Chloride/D50.3%NaCl) (Potassium Chloride/D50.9%NaCl) (Urocit-K) (Potassium Citrate/Citric Acid) (Potassium Phos,MBasic-D-Basic) (Ringers Solution) (Sodium Acetate)
2
GC
2
GC
2
GC
2
GC
2 2
GC GC
2
GC
2 2
GC GC
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 98 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name sodium bicarbonate intravenous solution 1 (Sodium Bicarbonate) meq/ml (8.4 %) sodium bicarbonate intravenous syringe (Sodium Bicarbonate) sodium chloride 0.45 % intravenous (Sodium Chloride 0.45 %) sodium chloride 0.9 % injection solution (0.9 % Sodium Chloride) sodium chloride 0.9 % intravenous (0.9 % Sodium Chloride) sodium chloride 3 % (Sodium Chloride 3 %) sodium chloride 5 % (Sodium Chloride 5 %) sodium chloride intravenous (Sodium Chloride) sodium citrate-citric acid (Citric Acid/Sodium Citrate) sodium lactate (Sodium Lactate) sodium phosphate (Sodium Phos,M-BasicD-Basic) sod-pot-k cit-sod cit-cit acid (Sod/Pot/K Cit/Sod Cit/Cit Acid) TPN ELECTROLYTES TPN ELECTROLYTES II
Drug Tier
Requirements/Limits
2
GC
2 2
GC GC
2
GC
2
GC
2 2 2 2
GC GC GC GC
2 2
GC GC
2
GC
4 4
Respiratory Tract Agents Anti-Inflammatories, Inhaled Corticosteroids ADVAIR DISKUS ADVAIR HFA BREO ELLIPTA DULERA FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 50 MCG/ACTUATION FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION
3 3 3 3 3
QL (60 per 30 days) QL (12 per 28 days) QL (60 per 30 days) QL (13 per 28 days) QL (60 per 30 days)
3
QL (120 per 30 days)
3
QL (12 per 28 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 99 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name
Drug Tier
FLOVENT HFA INHALATION HFA AEROSOL INHALER 220 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ACTUATION QVAR Antileukotrienes montelukast zafirlukast Bronchodilators albuterol sulfate inhalation solution for nebulization albuterol sulfate oral syrup albuterol sulfate oral tablet albuterol sulfate oral tablet extended release 12 hr ATROVENT HFA COMBIVENT RESPIMAT metaproterenol oral PROAIR HFA PROAIR RESPICLICK SEREVENT DISKUS SPIRIVA RESPIMAT SPIRIVA WITH HANDIHALER STRIVERDI RESPIMAT terbutaline oral terbutaline subcutaneous theophylline anhydrous oral tablet extended release 12 hr 100 mg, 200 mg, 300 mg theophylline in dextrose 5 % intravenous parenteral solution 200 mg/100 ml, 200 mg/50 ml, 400 mg/250 ml, 400 mg/500 ml, 800 mg/250 ml theophylline oral
3
QL (24 per 28 days)
3
QL (21.2 per 28 days)
3
QL (17.4 per 25 days)
(Singulair) (Accolate)
2 2
GC GC
(Albuterol Sulfate)
2
PA BvD; GC
(Albuterol Sulfate) (Albuterol Sulfate) (Vospire ER)
2 2 2
GC GC GC
3 3 2 3 3 3 3 3 3 2 2 2
QL (25.8 per 28 days) QL (8 per 30 days) GC QL (17 per 25 days) QL (2 per 30 days) QL (60 per 30 days) QL (4 per 30 days) QL (30 per 30 days)
(Theophylline/D5W)
2
GC
(Theophylline Anhydrous) (Theophylline Anhydrous)
2
GC
2
GC
theophylline oral
(Metaproterenol Sulfate)
(Terbutaline Sulfate) (Terbutaline Sulfate) (Theophylline Anhydrous)
Requirements/Limits
GC GC GC
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 100 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name theophylline oral
Drug Tier (Theophylline Anhydrous)
Requirements/Limits
2
GC
TUDORZA PRESSAIR Respiratory Tract Agents, Other acetylcysteine (Acetadote) acetylcysteine (Acetadote) cromolyn inhalation (Cromolyn Sodium) DALIRESP ESBRIET
3
QL (1 per 28 days)
2 2 2 3 5
KALYDECO NUCALA OFEV ORKAMBI
5 5 5 5
PA BvD; GC PA BvD; GC PA BvD; GC QL (30 per 30 days) PA; QL (270 per 30 days) PA; QL (60 per 30 days) PA; QL (1 per 28 days) PA PA; QL (120 per 30 days)
PROLASTIN-C XOLAIR
5 5
PA
Skeletal Muscle Relaxants Skeletal Muscle Relaxants baclofen carisoprodol
(Baclofen) (Soma)
2 2
chlorzoxazone cyclobenzaprine oral tablet 10 mg, 5 mg dantrolene dantrolene sodium metaxall metaxalone methocarbamol oral tizanidine
(Parafon Forte DSC) (Fexmid) (Dantrium) (Dantrium) (Skelaxin) (Skelaxin) (Robaxin) (Zanaflex)
2 2 2 2 2 2 2 2
GC PA-HRM; GC; QL (120 per 30 days) PA-HRM; GC PA-HRM; GC GC GC PA-HRM; GC PA-HRM; GC PA-HRM; GC GC
Sleep Disorder Agents Sleep Disorder Agents
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 101 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name
Drug Tier
Requirements/Limits
BELSOMRA
3
HETLIOZ NUVIGIL ROZEREM XYREM zaleplon
(Sonata)
5 3 3 5 2
(High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (30 per 30 days) PA PA
zolpidem oral tablet
(Ambien)
2
zolpidem oral tablet,ext release multiphase (Ambien CR)
2
LA PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); GC; QL (60 per 30 days) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); GC; QL (30 per 30 days) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); GC; QL (30 per 30 days)
Vasodilating Agents You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 102 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
Drug Name Vasodilating Agents ADCIRCA ADEMPAS epoprostenol (glycine) intravenous recon soln 0.5 mg epoprostenol (glycine) intravenous recon soln 1.5 mg LETAIRIS OPSUMIT ORENITRAM ORAL TABLET EXTENDED RELEASE 0.125 MG ORENITRAM ORAL TABLET EXTENDED RELEASE 0.25 MG, 1 MG, 2.5 MG REMODULIN sildenafil intravenous sildenafil oral
Drug Tier
Requirements/Limits
(Flolan)
5 5 2
PA; QL (60 per 30 days) PA; QL (90 per 30 days) PA BvD; GC
(Flolan)
5
PA BvD
5 5 3
PA; QL (30 per 30 days) PA; QL (30 per 30 days) PA
5
PA
5 5 2
TRACLEER
5
TYVASO TYVASO REFILL KIT TYVASO STARTER KIT
5 5 5
PA BvD PA; QL (37.5 per 1 day) PA; GC; QL (90 per 30 days) PA; LA; QL (60 per 30 days) PA BvD PA BvD PA BvD
2
GC
3
(All Rx Prenatal Vitamins Covered) GC GC
(Revatio) (Revatio)
Vitamins And Minerals Vitamins And Minerals multivit-fluor 0.5 mg tab chew chewable, d/f, s/f 0.5 mg prenatal vitamins oral tablet 27 mg iron- 1 mg sodium fluoride 1 mg (2.2 mg) sodium fluoride oral tablet 1 mg fluoride (2.2 mg) VITAFOL FE+ (WITH DOCUSATE)
(Pedi M.Vit No.17 with Fluoride) (Pnv with Ca,No.72/Iron/Fa) (Sodium Fluoride) (Pedi M.Vit No.17 with Fluoride)
2 2 3
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document 103 Brand New Day HMO and SNPs 2016 Part D Formulary Effective: January 01, 2016 Formulary ID: 16493.000, Version: 9
INDEX
8 8-MOP .................................... 74 A abacavir .................................. 56 abacavir-lamivudine-zidovudine ............................................ 56 ABELCET .............................. 48 ABILIFY DISCMELT ........... 52 ABILIFY MAINTENA .... 52, 53 ABRAXANE.......................... 35 acamprosate ............................ 28 acarbose .................................. 45 acebutolol ............................... 65 acetaminophen-codeine .......... 23 acetazolamide ......................... 95 acetazolamide sodium ............ 95 acetic acid ......................... 80, 91 acetylcysteine ....................... 101 acitretin ................................... 74 ACTEMRA ............................ 92 ACTHIB (PF) ......................... 89 ACTIMMUNE ....................... 92 acyclovir ........................... 58, 74 acyclovir sodium .................... 58 ADACEL(TDAP ADOLESN/ADULT)(PF) .. 89 ADAGEN ............................... 78 adapalene ................................ 77 ADCETRIS ............................ 35 ADCIRCA .................... 102, 103 adefovir................................... 58 ADEMPAS ........................... 103 ADVAIR DISKUS ................. 99 ADVAIR HFA ....................... 99 AFINITOR ............................. 35 AFINITOR DISPERZ ............ 35 AGGRENOX ......................... 61 AKTEN (PF) .......................... 79
AKYNZEO ...................... 50, 51 ALBENZA............................. 51 ALBUKED-25 ....................... 61 ALBUKED-5 ......................... 61 ALBUMIN, HUMAN 25 % .. 61 ALBUMIN, HUMAN 5 % .... 61 ALBUMINAR 25 % .............. 61 ALBUMINAR 5 % ................ 61 ALBURX (HUMAN) 5 %..... 61 ALBUTEIN 25 % .................. 61 ALBUTEIN 5 % .................... 61 albuterol sulfate ................... 100 alclometasone ........................ 75 ALCOHOL PADS ................. 74 ALCOHOL PREP PADS ...... 74 ALDURAZYME ................... 78 alendronate............................. 91 alfuzosin................................. 84 ALIMTA ................................ 35 ALINIA ................................. 51 allopurinol .............................. 92 ALPHAGAN P ...................... 95 alprazolam ............................. 28 ALREX .................................. 81 altacaine ................................. 79 amantadine hcl ....................... 52 AMBISOME .......................... 48 amifostine crystalline ............. 92 amiloride ................................ 69 amiloride-hydrochlorothiazide ........................................... 69 AMINO ACIDS 15 % ........... 61 aminocaproic acid .................. 61 AMINOSYN 10 % ................ 61 AMINOSYN 3.5 % ............... 62 AMINOSYN 7 % .................. 62 AMINOSYN 7 % WITH ELECTROLYTES ............. 62
I-1 Brand New Day HMO and SNPs 2016 Part D Formulary Formulary ID: 16493.000, Version: 9
AMINOSYN 8.5 % ................ 62 AMINOSYN 8.5 %ELECTROLYTES ............. 62 AMINOSYN II 10 % ............. 62 AMINOSYN II 15 % ............. 62 AMINOSYN II 7 % ............... 62 AMINOSYN II 8.5 % ............ 62 AMINOSYN II 8.5 %ELECTROLYTES ............. 62 AMINOSYN M 3.5 % ........... 62 AMINOSYN-HBC 7% .......... 62 AMINOSYN-PF 10 % ........... 62 AMINOSYN-PF 7 % (SULFITE-FREE) .............. 62 AMINOSYN-RF 5.2 % ......... 62 amiodarone ............................. 65 amiodarone hcl ....................... 65 AMITIZA ............................... 82 amitriptyline ........................... 44 amlodipine.............................. 68 amlodipine-atorvastatin.......... 69 amlodipine-benazepril............ 68 amlodipine-valsartan .............. 68 amlodipine-valsartan-hcthiazid ............................................ 68 ammonium lactate .................. 74 amoxapine .............................. 44 amoxicil-clarithromy-lansopraz ............................................ 81 amoxicillin ............................. 33 amoxicillin-pot clavulanate .... 33 amphetamine salt combo........ 71 amphotericin b ....................... 48 ampicillin ............................... 33 ampicillin sodium................... 33 ampicillin-sulbactam ........ 33, 34 AMPYRA .............................. 71 ANACAINE ........................... 74
Effective: January 01, 2016
anagrelide ............................... 61 anastrozole.............................. 35 ANDRODERM ...................... 84 ANDROGEL .......................... 84 anticoag citrate phos dextrose 93 APOKYN ............................... 52 apraclonidine .......................... 79 APRISO.................................. 91 APTIOM................................. 41 APTIVUS ............................... 56 ARCALYST ..................... 87, 88 aripiprazole ............................. 53 ARISTADA............................ 53 ASACOL HD ......................... 91 ashlyna .................................... 72 aspirin-dipyridamole .............. 61 ASSURE ID INSULIN SAFETY ............................. 78 ASTAGRAF XL .................... 88 atenolol ................................... 65 atenolol-chlorthalidone........... 65 atorvastatin ............................. 69 atovaquone ............................. 51 atovaquone-proguanil ............. 51 ATRIPLA ............................... 56 atropine ............................. 41, 79 atropine sulfate ....................... 79 ATROVENT HFA ............... 100 AUBAGIO ............................. 88 AVASTIN .............................. 35 AVC VAGINAL .................... 49 AVONEX ............................... 93 AVONEX (WITH ALBUMIN) ............................................ 93 azacitidine............................... 35 azathioprine ............................ 88 azathioprine sodium ............... 88 azelastine ................................ 79 AZILECT ............................... 52 azithromycin ........................... 32 AZOPT ................................... 95 AZOR ..................................... 68
aztreonam............................... 33 B bacitracin ......................... 29, 80 bacitracin-polymyxin b .......... 80 baclofen ............................... 101 balsalazide ............................. 91 BANZEL ............................... 41 BCG VACCINE, LIVE (PF) . 89 BD ECLIPSE LUER-LOK .... 78 BD INSULIN PEN NEEDLE UF SHORT ........................ 78 BD INSULIN SYRINGE ULTRA-FINE .................... 78 bekyree (28) ........................... 72 BELEODAQ .......................... 35 BELSOMRA ............... 101, 102 benazepril............................... 64 benazepril-hydrochlorothiazide ........................................... 64 BENICAR .............................. 64 BENICAR HCT ..................... 64 BENLYSTA .......................... 93 benztropine ............................ 52 betamethasone acet,sod phos . 85 betamethasone dipropionate .. 75 betamethasone valerate .......... 76 betamethasone, augmented .... 76 BETASERON ........................ 93 betaxolol .......................... 66, 95 bethanechol chloride .............. 93 BETHKIS .............................. 29 bexarotene .............................. 36 BEXSERO (PF) ..................... 89 bicalutamide........................... 36 BICILLIN C-R ...................... 34 BICILLIN L-A ...................... 34 bimatoprost ............................ 95 bisoprolol fumarate ................ 66 bisoprolol-hydrochlorothiazide ........................................... 66 bleomycin .............................. 36 BLINCYTO ........................... 36
I-2 Brand New Day HMO and SNPs 2016 Part D Formulary Formulary ID: 16493.000, Version: 9
blisovi 24 fe............................ 72 blisovi fe 1/20 (28) ................. 72 BOOSTRIX TDAP ................ 89 BOSULIF ............................... 36 BREO ELLIPTA .................... 99 BRILINTA ............................. 61 brimonidine ............................ 95 BRINTELLIX ........................ 44 bromfenac .............................. 81 bromocriptine ......................... 52 budesonide ............................. 91 bumetanide ............................. 69 BUMINATE 25 % ................. 61 BUMINATE 5 % ................... 61 BUPHENYL .......................... 82 buprenorphine hcl ............ 23, 28 buprenorphine-naloxone ........ 28 bupropion hcl ................... 28, 44 buspirone ................................ 93 butalb-acetaminophen-caffeine ............................................ 23 butalbital-acetaminop-caf-cod 23 butalbital-acetaminophen ....... 23 butalbital-acetaminophen-caff 23 butalbital-aspirin-caffeine ...... 23 BUTRANS ............................. 23 BYSTOLIC ............................ 66 C cabergoline ............................. 52 caffeine citrated ...................... 71 caffeine-sodium benzoate ...... 71 calcipotriene ........................... 74 calcitonin (salmon)................. 91 calcitriol ........................... 74, 91 calcium acetate ....................... 83 calcium carbonate-mag carb-fa ............................................ 83 calcium chloride ..................... 96 calcium gluconate .................. 96 CALDOLOR .......................... 26 CANCIDAS ........................... 48 candesartan ............................. 64
Effective: January 01, 2016
candesartan-hydrochlorothiazid ............................................ 64 CAPASTAT ........................... 50 CAPRELSA ........................... 36 captopril .................................. 64 captopril-hydrochlorothiazide 64 CARAFATE ........................... 82 CARBAGLU .......................... 82 carbamazepine ........................ 41 carbidopa ................................ 52 carbidopa-levodopa ................ 52 carbidopa-levodopa-entacapone ............................................ 52 CARIMUNE NF NANOFILTERED ............. 88 carisoprodol .......................... 101 carteolol .................................. 79 cartia xt ................................... 66 carvedilol ................................ 66 CAYSTON ............................. 33 cefaclor ................................... 31 cefadroxil................................ 31 cefazolin ................................. 31 cefazolin in dextrose (iso-os) . 31 CEFAZOLIN IN DEXTROSE (ISO-OS) ............................ 31 cefdinir ................................... 31 cefditoren pivoxil ................... 31 cefepime ................................. 31 CEFEPIME IN DEXTROSE 5 %......................................... 31 CEFEPIME IN DEXTROSE,ISO-OSM...... 31 cefotaxime .............................. 31 cefoxitin.................................. 31 cefoxitin in dextrose, iso-osm 31 cefpodoxime ........................... 32 cefprozil .................................. 32 ceftazidime ............................. 32 ceftibuten ................................ 32 ceftriaxone .............................. 32 CEFTRIAXONE .................... 32
ceftriaxone in dextrose,iso-os 32 CEFTRIAXONE IN DEXTROSE,ISO-OS ........ 32 cefuroxime axetil ................... 32 cefuroxime sodium ................ 32 celecoxib ................................ 26 CELLCEPT INTRAVENOUS ........................................... 88 CELONTIN ........................... 41 cephalexin .............................. 32 CEPROTIN (BLUE BAR) .... 58 CERDELGA .......................... 93 CEREZYME .......................... 78 CERVARIX VACCINE (PF) 89 cevimeline ........................ 73, 74 CHANTIX ............................. 28 CHANTIX CONTINUING MONTH BOX ................... 28 CHANTIX CONTINUING MONTH PAK.................... 28 CHANTIX STARTING MONTH BOX ................... 28 chloramphenicol sod succinate ........................................... 29 chlordiazepoxide hcl .............. 28 chlorhexidine gluconate ......... 74 chloroquine phosphate ........... 51 chlorothiazide ........................ 69 chlorothiazide sodium............ 69 chlorpromazine ...................... 53 chlorthalidone ........................ 69 chlorzoxazone ...................... 101 cholestyramine (with sugar) .. 69 cholestyramine-aspartame ..... 69 choline,magnesium salicylate 26 ciclopirox ............................... 48 ciclopirox-ure-camph-mentheuc ...................................... 48 cilostazol ................................ 61 cimetidine .............................. 82 cimetidine hcl ........................ 82 CIMZIA ................................. 88
I-3 Brand New Day HMO and SNPs 2016 Part D Formulary Formulary ID: 16493.000, Version: 9
CIMZIA POWDER FOR RECONST ......................... 88 CINRYZE .............................. 60 CIPRODEX............................ 80 ciprofloxacin .......................... 34 ciprofloxacin hcl .............. 34, 80 ciprofloxacin in 5 % dextrose 34 ciprofloxacin lactate ............... 34 citalopram .............................. 44 citric acid-sodium citrate........ 96 clarithromycin ........................ 32 CLEVIPREX.......................... 68 clindamycin hcl ...................... 29 clindamycin in 5 % dextrose .. 30 clindamycin palmitate hcl ...... 30 clindamycin phosphate.... 30, 49, 75 CLINIMIX 5%/D15W SULFITE FREE ................. 62 CLINIMIX 5%/D25W SULFITE-FREE ................ 62 CLINIMIX 2.75%/D5W SULFIT FREE ................... 62 CLINIMIX 4.25%/D10W SULF FREE .................................. 62 CLINIMIX 4.25%/D5W SULFIT FREE ................... 62 CLINIMIX 4.25%-D20W SULF-FREE ....................... 62 CLINIMIX 4.25%-D25W SULF-FREE ....................... 62 CLINIMIX 5%D20W(SULFITE-FREE) ... 62 CLINIMIX E 2.75%/D10W SUL FREE ......................... 62 CLINIMIX E 2.75%/D5W SULF FREE ....................... 62 CLINIMIX E 4.25%/D10W SUL FREE ......................... 62 CLINIMIX E 4.25%/D25W SUL FREE ......................... 62
Effective: January 01, 2016
CLINIMIX E 4.25%/D5W SULF FREE ....................... 62 CLINIMIX E 5%/D15W SULFIT FREE.................... 62 CLINIMIX E 5%/D20W SULFIT FREE.................... 62 CLINIMIX E 5%/D25W SULFIT FREE.................... 62 CLINISOL SF 15 % ............... 62 clobetasol ................................ 76 clobetasol propionate.............. 76 clobetasol-emollient ............... 76 clocortolone pivalate .............. 76 clomipramine.......................... 44 clonazepam ............................. 28 clonidine ................................. 64 clonidine hcl ............... 63, 64, 71 clonidine hcl-chlorthalidone... 64 clopidogrel .............................. 61 clorazepate dipotassium ......... 29 clotrimazole ............................ 48 clotrimazole-betamethasone ... 48 clozapine................................. 53 COARTEM ............................ 51 codeine sulfate ........................ 23 codeine-butalbital-asa-caffein 23 colchicine ............................... 93 colchicine-probenecid ............ 93 colestipol ................................ 69 colistin (colistimethate na) ..... 30 COLY-MYCIN S ................... 80 COMBIGAN .......................... 95 COMBIPATCH...................... 85 COMBIVENT RESPIMAT . 100 COMETRIQ ........................... 36 COMPLERA .......................... 56 COMVAX (PF) ...................... 89 CONDYLOX ......................... 74 COPAXONE .......................... 93 CORLANOR .......................... 67 cortisone ................................. 85 COSENTYX (2 SYRINGES) 74
COSENTYX PEN ................. 74 COSENTYX PEN (2 PENS) . 74 COTELLIC ............................ 36 CREON.................................. 78 CRESTOR ............................. 69 CRIXIVAN ............................ 56 cromolyn .................. 79, 82, 101 CUBICIN ............................... 30 cyclobenzaprine ................... 101 CYCLOGYL ......................... 79 cyclopentolate ........................ 79 cyclophosphamide ................. 36 CYCLOPHOSPHAMIDE ..... 36 CYCLOSET........................... 45 cyclosporine ........................... 88 cyclosporine modified ........... 88 cyclosporine, modified .......... 88 cyproheptadine....................... 49 CYRAMZA ........................... 36 cyred ...................................... 72 CYSTADANE ....................... 93 CYSTARAN.......................... 79 cysteine (l-cysteine) ............... 62 D d10 % & 0.45 % sodium chloride .............................. 96 d10 %-0.9 % sodium chloride 62 d2.5 %-0.45 % sodium chloride ........................................... 96 d5 % and 0.9 % sodium chloride ........................................... 96 d5 %-0.45 % sodium chloride 96 dactinomycin ......................... 36 DAKLINZA........................... 58 DALIRESP .......................... 101 danazol ................................... 85 dantrolene ............................ 101 dantrolene sodium................ 101 dapsone .................................. 50 DAPTACEL (DTAP PEDIATRIC) (PF) ............. 89 DARAPRIM .......................... 51
I-4 Brand New Day HMO and SNPs 2016 Part D Formulary Formulary ID: 16493.000, Version: 9
DARZALEX .......................... 36 deblitane ................................. 72 decitabine ............................... 36 deferoxamine.......................... 84 DELZICOL ............................ 91 DEMSER ............................... 67 DEPEN TITRATABS ............ 84 DEPO-PROVERA ................. 87 desipramine ............................ 44 desmopressin .......................... 86 desog-e.estradiol/e.estradiol ... 72 desogestrel-ethinyl estradiol .. 72 desonide ................................. 76 desoximetasone ...................... 76 dexamethasone ....................... 85 dexamethasone sodium phosphate ..................... 81, 85 dexmethylphenidate ............... 71 dextroamphetamine ................ 71 dextroamphetamineamphetamine ...................... 71 dextrose 10 % and 0.2 % nacl 96 dextrose 10 % in water (d10w) ............................................ 63 dextrose 2.5 % in water(d2.5w) ............................................ 63 dextrose 20 % in water (d20w) ............................................ 63 dextrose 25 % in water (d25w) ............................................ 63 dextrose 40 % in water (d40w) ............................................ 63 dextrose 5 % in ringers .......... 63 dextrose 5 % in water (d5w) .. 63 dextrose 5 %-lactated ringers . 96 dextrose 5%-0.2 % sod chloride ............................................ 96 dextrose 5%-0.3 % sod.chloride ............................................ 97 dextrose 50 % in water (d50w) ............................................ 63
Effective: January 01, 2016
dextrose 70 % in water (d70w) ............................................ 63 dextrose with sodium chloride97 diazepam................................. 29 diazepam intensol ................... 29 diclofenac potassium .............. 26 diclofenac sodium ............ 26, 81 diclofenac-misoprostol ........... 26 dicloxacillin ............................ 34 dicyclomine ............................ 82 didanosine............................... 56 DIFICID ................................. 32 diflunisal ................................. 26 digitek ..................................... 67 digoxin.................................... 67 DIGOXIN ............................... 67 dihydroergotamine ........... 49, 50 DILANTIN CAPSULE 30 MG ............................................ 41 diltiazem hcl ........................... 66 dilt-xr ...................................... 67 dimenhydrinate ....................... 51 DIPENTUM ........................... 91 diphenhydramine hcl .............. 49 diphenoxylate-atropine ........... 82 disopyramide phosphate ......... 65 disulfiram ............................... 28 divalproex ......................... 41, 42 dobutamine ............................. 67 dobutamine in d5w ................. 67 donepezil ................................ 43 dopamine ................................ 67 dopamine in 5 % dextrose ...... 67 dorzolamide ............................ 95 dorzolamide-timolol ............... 95 doxazosin................................ 64 doxepin ................................... 44 doxercalciferol .................. 91, 92 doxorubicin hcl....................... 36 doxorubicin hcl peg-liposomal ............................................ 36 doxorubicin, peg-liposomal .... 36
doxycycline hyclate ............... 35 doxycycline monohydrate...... 35 dronabinol .............................. 51 droperidol............................... 93 drospirenone-ethinyl estradiol 72 DROXIA ................................ 36 DUAVEE ............................... 85 DULERA ............................... 99 duloxetine .............................. 44 DUREZOL............................. 81 dutasteride .............................. 93 dutasteride-tamsulosin ........... 93 DYRENIUM .......................... 69 E econazole ............................... 48 EDURANT ............................ 56 EFFIENT ............................... 61 ELAPRASE ........................... 78 electrolyte-48 in d5w ............. 97 ELIDEL ................................. 76 ELIGARD ........................ 36, 37 ELIQUIS ................................ 58 ELITEK ................................. 78 ELLA ..................................... 72 ELMIRON ............................. 93 EMCYT ................................. 37 EMEND ................................. 51 EMPLICITI ........................... 37 EMSAM................................. 44 EMTRIVA ............................. 56 enalapril maleate .................... 64 enalaprilat .............................. 65 enalapril-hydrochlorothiazide 65 ENBREL................................ 88 ENBREL SURECLICK ........ 88 ENGERIX-B (PF).................. 89 ENGERIX-B PEDIATRIC (PF) ........................................... 89 enoxaparin ....................... 58, 59 entacapone ............................. 52 entecavir................................. 58 ENTRESTO ........................... 64
I-5 Brand New Day HMO and SNPs 2016 Part D Formulary Formulary ID: 16493.000, Version: 9
ephedrine sulfate .................... 67 epinastine ............................... 79 epinephrine ............................. 68 epinephrine hcl (pf) ................ 68 EPIPEN 2-PAK ...................... 68 EPIPEN JR 2-PAK ................ 68 EPIVIR HBV ......................... 56 eplerenone .............................. 70 EPOGEN ................................ 60 epoprostenol (glycine) ......... 103 EPZICOM .............................. 56 ergoloid .................................. 93 ERGOMAR............................ 50 ERIVEDGE............................ 37 ERYTHROCIN ...................... 32 erythromycin .................... 33, 80 erythromycin base .................. 32 ERYTHROMYCIN BASE .... 33 erythromycin base-ethanol ..... 75 erythromycin ethylsuccinate .. 33 erythromycin stearate ............. 33 erythromycin with ethanol ..... 75 ESBRIET ............................. 101 escitalopram oxalate............... 44 esmolol ................................... 66 esomeprazole sodium ............. 82 ESTRACE .............................. 85 estradiol .................................. 85 estradiol valerate .................... 85 estradiol/norethindrone acet ... 85 estradiol-norethindrone acet... 85 estropipate .............................. 85 ethambutol.............................. 50 ethamolin................................ 68 ethinyl estradiol/drospirenone 72 ethosuximide .......................... 42 ethynodiol d-ethinyl estradiol 72 etodolac .................................. 26 ETOPOPHOS ........................ 37 etoposide ................................ 37 EVOTAZ................................ 56 EXELON................................ 43
Effective: January 01, 2016
exemestane ............................. 37 EXJADE ................................. 84 EXTAVIA .............................. 93 F FABRAZYME ....................... 78 famciclovir ............................. 58 famotidine............................... 82 famotidine (pf)........................ 82 famotidine (pf)-nacl (iso-os) . 82 FANAPT ................................ 53 FARESTON ........................... 37 FARYDAK............................. 37 FASLODEX ........................... 37 felbamate ................................ 42 felodipine................................ 68 FEMRING .............................. 85 fenofibrate .............................. 69 fenofibrate micronized ........... 69 fenofibrate nanocrystallized ... 69 fenofibric acid ........................ 69 fenofibric acid (choline) ......... 69 fenoprofen .............................. 26 fentanyl ................................... 23 fentanyl citrate ........................ 23 FERRIPROX .......................... 84 FETZIMA............................... 44 finasteride ............................... 93 FIRAZYR ............................... 68 FLEBOGAMMA DIF ............ 88 flecainide ................................ 65 FLECTOR .............................. 26 FLEXBUMIN 25 % ............... 61 FLEXBUMIN 5 % ................. 61 FLOVENT DISKUS .............. 99 FLOVENT HFA............. 99, 100 floxuridine .............................. 37 fluconazole ............................. 48 fluconazole in dextrose(iso-o) 48 fluconazole in nacl (iso-osm) . 48 flucytosine .............................. 48 fludrocortisone ....................... 86 flumazenil ............................... 71
flunisolide .............................. 81 fluocinonide ........................... 76 fluocinonide-emollient base .. 76 fluorometholone..................... 81 FLUOROPLEX ..................... 74 fluorouracil ...................... 37, 74 fluoxetine ............................... 44 fluoxymesterone .................... 85 fluphenazine decanoate.......... 53 fluphenazine hcl ..................... 53 flurbiprofen ............................ 26 flurbiprofen sodium ............... 81 flutamide ................................ 37 fluticasone ........................ 76, 81 fluvoxamine ........................... 44 fomepizole ............................. 93 fondaparinux .......................... 59 FORTEO ................................ 92 FORTICAL............................ 92 foscarnet................................. 57 fosinopril ................................ 65 fosinopril-hydrochlorothiazide ........................................... 65 fosphenytoin .......................... 42 FREAMINE HBC 6.9 % ....... 63 FREAMINE III 10 % ............ 63 furosemide ............................. 69 FUSILEV ............................... 93 FUZEON ............................... 56 FYCOMPA ............................ 42 G gabapentin .............................. 42 GABITRIL............................. 42 galantamine ............................ 43 GAMASTAN S/D ................. 88 GAMMAGARD LIQUID ..... 88 GAMMAPLEX ..................... 88 ganciclovir sodium ................ 58 GARDASIL (PF) ................... 89 GARDASIL 9 (PF) ................ 89 gatifloxacin ............................ 80 GATTEX 30-VIAL ............... 82
I-6 Brand New Day HMO and SNPs 2016 Part D Formulary Formulary ID: 16493.000, Version: 9
GATTEX ONE-VIAL ........... 82 GAUZE PAD ......................... 93 GAZYVA ............................... 37 gemfibrozil ............................. 69 GENOTROPIN ...................... 86 GENOTROPIN MINIQUICK 86 gentamicin .................. 29, 75, 80 gentamicin in nacl (iso-osm).. 29 gentamicin sulfate .................. 80 gentamicin sulfate (ped) (pf) .. 29 gentamicin sulfate (pf) ........... 29 GENVOYA ............................ 56 GEODON ............................... 53 gildess 1/20 (21) ..................... 72 gildess 24 fe ........................... 72 gildess fe 1/20 (28)................. 72 GILENYA .............................. 93 GILOTRIF ............................. 37 GLEEVEC ............................. 37 glimepiride ............................. 47 glipizide.................................. 47 glipizide-metformin ............... 47 GLUCAGEN HYPOKIT ....... 93 GLUCAGON EMERGENCY KIT (HUMAN) .................. 93 glyburide .......................... 47, 48 glyburide micronized ............. 47 glyburide-metformin .............. 48 glycopyrrolate ........................ 82 glydo ...................................... 27 GLYXAMBI .......................... 45 granisetron (pf)....................... 51 granisetron hcl ........................ 51 GRANIX ................................ 60 griseofulvin microsize............ 49 guanfacine ........................ 64, 71 guanidine ................................ 93 H halobetasol propionate ........... 76 haloperidol ............................. 53 haloperidol decanoate ...... 53, 54 haloperidol lactate .................. 54
Effective: January 01, 2016
HARVONI ............................. 58 HAVRIX (PF) ........................ 89 heparin (porcine) .................... 59 heparin (porcine) in 5 % dex . 59, 60 heparin (porcine) in nacl (pf) . 59 heparin sodium,porcine-pf ..... 59 heparin(porcine) in 0.45% nacl ............................................ 60 heparin, porcine (pf) ......... 59, 60 HEPATAMINE 8%................ 63 HEPATASOL 8 % ................. 63 HERCEPTIN .......................... 37 HETLIOZ ............................. 102 HEXALEN ............................. 37 homatropine hbr ..................... 79 HUMIRA................................ 88 HUMIRA PEN ....................... 88 HUMIRA PEN CROHN'S-UCHS START ......................... 88 HUMULIN R U-500 (CONCENTRATED) ......... 47 hydralazine ............................. 68 hydrochlorothiazide................ 69 hydrocodone-acetaminophen . 23 hydrocodone-ibuprofen .......... 24 hydrocortisone ............ 76, 77, 86 hydrocortisone acet-aloe vera. 77 hydrocortisone acetate-urea.... 77 hydrocortisone butyrate .......... 77 hydrocortisone butyr-emollient ............................................ 77 hydrocortisone sod succinate . 86 hydrocortisone valerate .......... 77 hydromorphone ...................... 24 hydromorphone (pf) ............... 24 hydroxychloroquine ............... 51 hydroxyurea ............................ 37 hydroxyzine hcl ...................... 93 hydroxyzine pamoate ............. 93 HYPERLYTE CR .................. 97 HYPERRAB S/D (PF) ........... 88
HYQVIA ............................... 88 I ibandronate ............................ 92 IBRANCE .............................. 37 ibuprofen ................................ 26 ICLUSIG ............................... 37 ifosfamide .............................. 37 ifosfamide-mesna................... 37 ILARIS (PF) .......................... 88 ILEVRO................................. 81 IMBRUVICA ........................ 37 imipenem-cilastatin ............... 33 imipramine hcl ....................... 44 imipramine pamoate .............. 44 imiquimod.............................. 74 IMLYGIC ........................ 37, 38 IMOGAM RABIES-HT (PF) 88 IMOVAX RABIES VACCINE (PF) .................................... 89 INCRELEX ........................... 86 indapamide............................. 69 indomethacin ......................... 26 indomethacin sodium ............. 26 INFANRIX (DTAP) (PF) ...... 89 INLYTA ................................ 38 INSULIN SYRINGE-NEEDLE U-100 ................................. 78 INTELENCE ......................... 56 INTRALIPID ......................... 63 INTRON A ............................ 58 INVANZ ................................ 33 INVEGA ................................ 54 INVEGA SUSTENNA .......... 54 INVEGA TRINZA ................ 54 INVIRASE............................. 56 INVOKAMET ....................... 45 INVOKANA .......................... 46 IONOSOL-B IN D5W ........... 97 IONOSOL-MB IN D5W ....... 97 IPOL ...................................... 90 ipratropium bromide .............. 79 IPRIVASK ............................. 60
I-7 Brand New Day HMO and SNPs 2016 Part D Formulary Formulary ID: 16493.000, Version: 9
irbesartan ................................ 64 irbesartan-hydrochlorothiazide ............................................ 64 IRESSA .................................. 38 ISENTRESS ........................... 56 ISOLYTE M IN 5 % DEXTROSE....................... 97 ISOLYTE-H IN 5 % DEXTROSE....................... 97 ISOLYTE-P IN 5 % DEXTROSE....................... 97 ISOLYTE-S ........................... 97 isoniazid ................................. 50 isosorbide dinitrate ................. 70 isosorbide mononitrate ........... 70 isotretinoin ............................. 74 isradipine ................................ 68 itraconazole ............................ 49 ivermectin .............................. 51 IXEMPRA.............................. 38 IXIARO (PF) ......................... 90 J JAKAFI .................................. 38 JALYN ................................... 93 jantoven .................................. 60 JANUMET ............................. 46 JANUMET XR ...................... 46 JANUVIA .............................. 46 JARDIANCE ......................... 46 JENTADUETO ...................... 46 juleber .................................... 72 junel fe 24 .............................. 72 JUXTAPID ............................ 69 K KABIVEN.............................. 63 KALETRA ............................. 56 KALYDECO........................ 101 KEDBUMIN .......................... 61 ketoconazole .......................... 49 ketoprofen ........................ 26, 27 ketorolac ........................... 27, 81 KEVEYIS .............................. 94
Effective: January 01, 2016
KEYTRUDA .......................... 38 kimidess (28) .......................... 72 KINERET ............................... 88 KINRIX (PF) .......................... 90 klor-con 10 ............................. 97 klor-con m10 .......................... 97 klor-con m15 .......................... 97 klor-con m20 .......................... 97 klor-con sprinkle .................... 97 KORLYM............................... 46 KRYSTEXXA........................ 78 KUVAN ................................. 78 KYNAMRO ........................... 70 KYPROLIS ............................ 38 L l norgest/e.estradiol-e.estrad... 72 labetalol .................................. 66 LACRISERT .......................... 79 LACTATED RINGERS ......... 91 lactulose.................................. 82 LAMICTAL ........................... 42 lamivudine .............................. 56 lamivudine-zidovudine ........... 56 lamotrigine ............................. 42 LANOXIN .............................. 68 lansoprazole............................ 82 LANTUS ................................ 47 LANTUS SOLOSTAR .......... 47 larin 24 fe ............................... 73 larin fe 1/20 (28) ..................... 73 latanoprost .............................. 95 LATUDA ............................... 54 LAZANDA............................. 24 leflunomide............................. 88 LEMTRADA.......................... 94 LENVIMA ............................. 38 LETAIRIS ............................ 103 letrozole .................................. 38 leucovorin calcium ................. 94 LEUKERAN .......................... 38 LEUKINE............................... 60 leuprolide................................ 38
levetiracetam .......................... 42 levobunolol ............................ 95 levocarnitine .......................... 94 levocarnitine (with sugar) ...... 94 levocetirizine ......................... 49 levofloxacin ..................... 34, 80 levofloxacin in d5w ............... 34 levonorgestrel ........................ 73 levonorgestrel-ethin estradiol 73 levonorgestrel-ethinyl estrad . 73 levothyroxine ......................... 87 LEXIVA ................................ 56 lidocaine................................. 27 lidocaine (pf).................... 27, 65 lidocaine hcl ........................... 27 lidocaine in 5 % dextrose (pf) 65 lidocaine-prilocaine ......... 27, 28 linezolid ................................. 30 LINZESS ............................... 82 liothyronine ............................ 87 lipase-protease-amylase ......... 78 LIPOSYN II........................... 63 LIPOSYN III ......................... 63 lisinopril ................................. 65 lisinopril-hydrochlorothiazide 65 lithium carbonate ................... 71 lithium citrate......................... 71 l-norgest-eth estr/ethin estra .. 73 lomustine ............................... 38 LONSURF ............................. 38 loperamide ............................. 82 lorazepam oral solution ......... 29 losartan................................... 64 losartan-hydrochlorothiazide . 64 LOTEMAX ............................ 81 LOTRONEX .......................... 83 lovastatin................................ 70 loxapine succinate.................. 54 LUMIGAN ............................ 95 LUPRON DEPOT ................. 38 LUPRON DEPOT (3 MONTH) ........................................... 38
I-8 Brand New Day HMO and SNPs 2016 Part D Formulary Formulary ID: 16493.000, Version: 9
LUPRON DEPOT (4 MONTH) ............................................ 38 LUPRON DEPOT (6 MONTH) ............................................ 38 LUPRON DEPOT-PED ......... 86 LUPRON DEPOT-PED (3 MONTH)............................ 87 LYNPARZA .......................... 38 LYRICA ................................. 42 LYSODREN .......................... 38 M magnesium chloride ............... 97 magnesium sulf in 0.45% nacl97 magnesium sulfate ................. 97 magnesium sulfate in d5w ..... 97 magnesium sulfate in water ... 97 malathion................................ 77 maprotiline ............................. 44 MARPLAN ............................ 45 MATULANE ......................... 38 matzim la................................ 67 meclizine ................................ 51 medroxyprogesterone ............. 87 mefenamic acid ...................... 27 mefloquine ............................. 51 MEFOXIN IN DEXTROSE (ISO-OSM) ........................ 32 MEGACE ES ......................... 87 megestrol .......................... 38, 87 MEKINIST ............................ 38 meloxicam .............................. 27 memantine .............................. 43 MENACTRA (PF) ................. 90 MENEST................................ 85 MENHIBRIX (PF) ................. 90 MENOMUNE - A/C/Y/W-135 (PF) .................................... 90 MENVEO A-C-Y-W-135-DIP (PF) .................................... 90 MENVEO MENA COMPONENT (PF)........... 90
Effective: January 01, 2016
MENVEO MENCYW-135 COMPNT (PF) ................... 90 mercaptopurine ....................... 38 meropenem ............................. 33 meropenem-0.9% sodium chloride ............................... 33 mesna...................................... 94 MESNEX ............................... 94 MESTINON ........................... 94 MESTINON TIMESPAN ...... 94 metaproterenol ...................... 100 metaxall ................................ 101 metaxalone ........................... 101 metformin ............................... 46 methadone .............................. 24 methadone hcl ........................ 24 methazolamide ....................... 95 methenamine hippurate .......... 30 methenamine mandelate ......... 30 methimazole ........................... 87 methocarbamol ..................... 101 methotrexate sodium .............. 39 methotrexate sodium (pf) ....... 39 methoxsalen rapid .................. 74 methscopolamine.................... 83 methyclothiazide .................... 69 methylphenidate ............... 71, 72 methylprednisolone ................ 86 methylprednisolone acetate .... 86 methylprednisolone sodium succ ............................................ 86 metipranolol ........................... 96 metoclopramide hcl ................ 83 metolazone ............................. 69 metoprolol succinate .............. 66 metoprolol ta-hydrochlorothiaz ............................................ 66 metoprolol tartrate .................. 66 metronidazole ............. 30, 49, 75 metronidazole in nacl (iso-os) 30 mexiletine ............................... 65 MIACALCIN ......................... 92
miconazole nitrate.................. 49 midodrine ............................... 64 milrinone................................ 68 milrinone in 5 % dextrose ...... 68 minitran .................................. 70 minocycline ........................... 35 minoxidil................................ 70 MIRCERA ............................. 60 mirtazapine ............................ 45 misoprostol ............................ 82 mitoxantrone .......................... 39 M-M-R II (PF) ....................... 90 moexipril................................ 65 moexipril-hydrochlorothiazide ........................................... 65 molindone ........................ 54, 55 mometasone ........................... 77 montelukast .......................... 100 morphine .......................... 24, 25 MORPHINE .......................... 25 morphine concentrate ............ 24 morphine in dextrose 5 % ...... 24 morrhuate sodium .................. 94 MOVANTIK ......................... 83 MOVIPREP ........................... 83 MOXEZA .............................. 80 moxifloxacin .......................... 34 MOZOBIL ............................. 60 MULTAQ .............................. 65 mupirocin ............................... 75 mupirocin calcium ................. 75 mycophenolate mofetil .......... 88 mycophenolate sodium .......... 88 MYOZYME........................... 78 MYRBETRIQ .................. 83, 84 N nabumetone ............................ 27 nadolol ................................... 66 nafcillin .................................. 34 NAGLAZYME ...................... 78 naloxone................................. 28 naltrexone .............................. 28
I-9 Brand New Day HMO and SNPs 2016 Part D Formulary Formulary ID: 16493.000, Version: 9
naltrexone hcl ......................... 28 NAMENDA XR............... 43, 44 NAMZARIC .......................... 44 naphazoline ............................ 79 naproxen ................................. 27 naproxen sodium .................... 27 naratriptan .............................. 50 NATACYN ............................ 80 nateglinide .............................. 46 NATPARA............................. 92 NEBUPENT ........................... 51 nefazodone ............................. 45 neomy sulf-bacitrac zn-poly-hc ............................................ 80 neomycin ................................ 29 neomycin-bacitracin-poly-hc . 80 neomycin-bacitracin-polymyxin ............................................ 80 neomycin-polymyxin b gu ..... 75 neomycin-polymyxin bdexameth ............................ 80 neomycin-polymyxingramicidin .......................... 80 neomycin-polymyxin-hc ........ 80 neo-polycin ............................ 80 NEPHRAMINE 5.4 % ........... 63 NEULASTA .......................... 60 NEUMEGA............................ 60 NEUPOGEN .......................... 60 NEUPRO................................ 52 NEVANAC ............................ 81 nevirapine ............................... 56 NEXAVAR ............................ 39 niacin ...................................... 70 nicardipine.............................. 68 NICOTROL ........................... 28 nifedipine ............................... 68 NILANDRON ........................ 39 NINLARO.............................. 39 NITRO-BID ........................... 70 nitrofurantoin macrocrystal .... 30
Effective: January 01, 2016
nitrofurantoin monohyd/m-cryst ............................................ 30 nitroglycerin ........................... 70 nitroglycerin in 5 % dextrose . 70 NITROSTAT.......................... 70 NORDITROPIN FLEXPRO .. 87 NORDITROPIN NORDIFLEX ............................................ 87 norelgestromin/ethin.estradiol 73 norepinephrine bitartrate ........ 68 norethindrone ......................... 73 norethindrone (contraceptive) 73 norethindrone acetate ............. 87 norethindrone ac-eth estradiol 73 norethindrone-e.estradiol-iron 73 norethindrone-ethinyl estrad .. 73 norethindrone-mestranol ........ 73 norgestimate-ethinyl estradiol 73 norgestrel-ethinyl estradiol..... 73 NORMOSOL-M IN 5 % DEXTROSE ....................... 97 NORMOSOL-R PH 7.4 ......... 97 NORTHERA .......................... 64 nortriptyline ............................ 45 NORVIR................................. 57 NOVOLIN 70/30.................... 47 NOVOLIN N .......................... 47 NOVOLIN R .......................... 47 NOVOLOG ............................ 47 NOVOLOG FLEXPEN.......... 47 NOVOLOG MIX 70-30 ......... 47 NOVOLOG MIX 70-30 FLEXPEN .......................... 47 NOVOLOG PENFILL ........... 47 NOXAFIL .............................. 49 NUCALA ............................. 101 NUCYNTA ............................ 25 NUCYNTA ER ...................... 25 NUEDEXTA .......................... 72 NULOJIX ............................... 88 NUTRESTORE ...................... 83 NUTRILIPID ......................... 63
NUTRILYTE ......................... 97 NUTRILYTE II ..................... 97 NUVARING .......................... 73 NUVIGIL............................. 102 nystatin................................... 49 NYSTATIN (BULK) ............. 49 nystatin-triamcinolone ........... 49 O OCTAGAM ........................... 88 octreotide acetate ................... 87 ODOMZO .............................. 39 OFEV ................................... 101 ofloxacin .......................... 34, 80 olanzapine .............................. 55 olanzapine-fluoxetine ............ 45 olopatadine............................. 79 OLYSIO................................. 58 omega-3 acid ethyl esters ...... 70 omeprazole............................. 82 ONCASPAR .......................... 39 ondansetron ............................ 51 ondansetron hcl ...................... 51 ondansetron hcl (pf) ............... 51 ONFI ...................................... 29 OPDIVO ................................ 39 OPSUMIT ............................ 103 ORAP..................................... 55 ORENCIA ............................. 89 ORENCIA (WITH MALTOSE) ........................................... 89 ORENITRAM ..................... 103 ORFADIN ............................. 78 ORKAMBI .......................... 101 OTEZLA ................................ 94 OTEZLA STARTER ............. 94 OTREXUP (PF) ..................... 94 oxacillin ................................. 34 oxacillin in dextrose(iso-osm) 34 oxandrolone ........................... 85 oxcarbazepine ........................ 42 OXTELLAR XR.................... 42 oxybutynin chloride ............... 84
I-10 Brand New Day HMO and SNPs 2016 Part D Formulary Formulary ID: 16493.000, Version: 9
oxycodone .............................. 25 oxycodone hcl-acetaminophen ............................................ 25 oxycodone hcl-aspirin ............ 25 oxycodone-acetaminophen .... 25 oxycodone-aspirin .................. 25 OXYCONTIN ........................ 25 oxymorphone ................... 25, 26 P paliperidone............................ 55 PANRETIN ............................ 74 pantoprazole ........................... 82 papaverine .............................. 68 paricalcitol.............................. 92 paromomycin ......................... 51 paroxetine hcl ......................... 45 PASER ................................... 50 PAXIL .................................... 45 pedi m.vit no.17 with fluoride .......................................... 103 PEDIARIX (PF) ..................... 90 PEDVAX HIB (PF) ............... 90 peg 3350-electrolytes ............. 83 PEG 3350-GRX ..................... 83 peg 3350-na sulf,bicarb,cl-kcl 83 PEGANONE .......................... 42 PEGASYS .............................. 58 PEGASYS PROCLICK ......... 58 peg-electrolyte soln ................ 83 PEGINTRON ......................... 58 PEN NEEDLE, DIABETIC ... 78 penicillin g pot in dextrose..... 34 penicillin g potassium ............ 34 penicillin g procaine ............... 34 penicillin v potassium ............ 34 PENTACEL (PF) ................... 90 PENTACEL ACTHIB COMPONENT (PF)........... 90 PENTAM ............................... 51 pentoxifylline ......................... 61 PERIKABIVEN ..................... 63 perindopril erbumine .............. 65
Effective: January 01, 2016
permethrin .............................. 77 perphenazine........................... 55 perphenazine-amitriptyline..... 45 phenelzine............................... 45 phenobarbital .......................... 42 phenobarbital sodium ............. 42 phenylephrine hcl ............. 64, 79 phenytoin ................................ 43 phenytoin sodium ................... 43 phenytoin sodium extended.... 43 PHOSLYRA ........................... 83 PHOSPHOLINE IODIDE ...... 96 phosphorus #1 ........................ 97 PICATO ................................. 74 pilocarpine hcl .................. 74, 96 pimozide ................................. 55 pindolol................................... 66 pioglitazone ............................ 46 pioglitazone-glimepiride ........ 46 pioglitazone-metformin .......... 46 piperacillin-tazobactam .......... 34 piroxicam................................ 27 PLASBUMIN 25 % ............... 61 PLASBUMIN 5 % ................. 61 PLASMA-LYTE 148 ............. 97 PLASMA-LYTE A ................ 97 PLASMA-LYTE-56 IN 5 % DEXTROSE ....................... 97 PLEGRIDY ............................ 94 podofilox ................................ 74 podophyllum resin .................. 74 polyethylene glycol 3350 ....... 83 polymyxin b sulfate ................ 30 polymyxin b sulf-trimethoprim ............................................ 81 POMALYST .......................... 39 potassium acetate.................... 97 potassium bicarb and chloride 97 potassium bicarb-citric acid ... 97 potassium bicarbonate-cit ac .. 98 potassium chlorid-d5-0.45%nacl ............................................ 98
potassium chloride ................. 98 potassium chloride in 0.9%nacl ........................................... 98 potassium chloride in 5 % dex98 potassium chloride in lr-d5 .... 98 potassium chloride-0.45 % nacl ........................................... 98 potassium chloride-d5-0.2%nacl ........................................... 98 potassium chloride-d5-0.3%nacl ........................................... 98 potassium chloride-d5-0.9%nacl ........................................... 98 potassium citrate .................... 98 potassium citrate-citric acid ... 98 potassium hydroxide .............. 75 potassium phosphate m-/d-basic ........................................... 98 POTIGA................................. 43 PRADAXA ............................ 60 PRALUENT PEN .................. 70 PRALUENT SYRINGE ........ 70 pramipexole ........................... 52 PRANDIMET ........................ 46 pravastatin .............................. 70 prazosin.................................. 64 prednicarbate ......................... 77 prednisolone acetate .............. 81 prednisolone sodium phosphate ..................................... 81, 86 prednisone .............................. 86 PREMARIN........................... 85 PREMASOL 10 %................. 63 PREMASOL 6 %................... 63 PREMPHASE........................ 85 PREMPRO............................. 85 prenatal vitamins.................. 103 PREZCOBIX ......................... 57 PREZISTA............................. 57 PRIFTIN ................................ 50 PRIMAQUINE ...................... 51 primidone ............................... 43
I-11 Brand New Day HMO and SNPs 2016 Part D Formulary Formulary ID: 16493.000, Version: 9
PRISTIQ ................................ 45 PRIVIGEN ............................. 89 PROAIR HFA ...................... 100 PROAIR RESPICLICK ....... 100 probenecid .............................. 94 procainamide .......................... 65 PROCALAMINE 3% ............ 63 prochlorperazine .................... 51 prochlorperazine edisylate ..... 51 prochlorperazine maleate ....... 51 PROCRIT ............................... 60 PROCYSBI ............................ 94 progesterone ........................... 87 progesterone micronized capsules .............................. 87 PROGLYCEM ....................... 70 PROGRAF ............................. 89 PROLASTIN-C.................... 101 PROLENSA ........................... 81 PROLEUKIN ......................... 39 PROLIA ................................. 92 PROMACTA ......................... 60 promethazine .................... 49, 51 promethazine hcl .................... 51 propafenone............................ 65 propantheline.......................... 41 proparacaine ........................... 79 proparacaine hcl ..................... 79 proparacaine-fluorescein sod . 80 propranolol ............................. 66 propranolol-hydrochlorothiazid ............................................ 66 propylthiouracil ...................... 87 PROQUAD (PF) .................... 90 PROSOL 20 % ....................... 63 protamine ............................... 61 protriptyline............................ 45 PULMOZYME ...................... 78 PURIXAN .............................. 39 pyrazinamide .......................... 50 pyridostigmine bromide ... 94, 96
Effective: January 01, 2016
Q QUADRACEL (PF) ............... 90 quetiapine ............................... 55 QUILLIVANT XR ................. 72 quinapril ................................. 65 quinapril-hydrochlorothiazide 65 quinidine gluconate ................ 65 quinidine sulfate ..................... 65 quinine sulfate ........................ 52 QVAR................................... 100 R RABAVERT (PF) .................. 90 raloxifene................................ 85 ramipril ................................... 65 RANEXA ............................... 68 ranitidine hcl ........................... 82 RAPAMUNE ......................... 89 RASUVO (PF) ....................... 94 RAVICTI................................ 83 REBIF (WITH ALBUMIN) ... 94 REBIF REBIDOSE ................ 94 REBIF TITRATION PACK .. 94 RECOMBIVAX HB (PF) ...... 90 RELADOR PAK .................... 28 RELENZA DISKHALER ...... 57 RELISTOR ............................. 83 REMICADE ........................... 94 REMODULIN ...................... 103 RENAGEL ............................. 83 RENVELA ............................. 83 repaglinide .............................. 46 repaglinide-metformin............ 46 REPATHA SURECLICK ...... 70 REPATHA SYRINGE ........... 70 RESCRIPTOR ........................ 57 RESTASIS ............................. 81 RETROVIR ............................ 57 REVLIMID ............................ 39 REXULTI ............................... 55 REYATAZ ............................. 57 ribavirin .................................. 58 RIDAURA.............................. 89
rifabutin ................................. 50 rifampin ................................. 50 RIFATER............................... 50 riluzole ................................... 72 rimantadine ............................ 57 ringers .............................. 91, 98 risedronate ............................. 92 RISPERDAL CONSTA ........ 55 risperidone ............................. 55 RITUXAN ............................. 39 rivastigmine tartrate ............... 44 rizatriptan ............................... 50 ropinirole ............................... 52 ROTARIX ............................. 90 ROTATEQ VACCINE .......... 90 ROZEREM .......................... 102 S SABRIL ................................. 43 SAIZEN ................................. 87 SAIZEN CLICK.EASY......... 87 salsalate .................................. 27 SANDOSTATIN LAR DEPOT ........................................... 87 SANTYL ............................... 75 SAPHRIS (BLACK CHERRY) ........................................... 55 SAVELLA ............................. 72 selegiline hcl .......................... 52 selenium sulfide ..................... 75 SELZENTRY ........................ 57 SENSIPAR ............................ 94 SEREVENT DISKUS ......... 100 SEROSTIM ........................... 87 sertraline ................................ 45 setlakin ................................... 73 SIGNIFOR ............................. 94 sildenafil oral tablet 20 mg .. 103 SILENOR .............................. 45 silver nitrate ........................... 75 silver nitrate applicators......... 75 silver sulfadiazine .................. 75 SIMBRINZA ......................... 96
I-12 Brand New Day HMO and SNPs 2016 Part D Formulary Formulary ID: 16493.000, Version: 9
SIMPONI ............................... 94 SIMPONI ARIA .................... 94 simvastatin ............................. 70 sirolimus................................. 89 SIRTURO .............................. 50 sodium acetate ........................ 98 sodium bicarbonate ................ 99 sodium chloride................ 91, 99 sodium chloride 0.45 % ......... 99 sodium chloride 0.9 % ........... 99 sodium chloride 3 % .............. 99 sodium chloride 5 % .............. 99 sodium chloride-nahco3-kcl-peg ............................................ 83 sodium citrate-citric acid........ 99 sodium fluoride .............. 74, 103 sodium lactate ........................ 99 sodium phosphate................... 99 sodium polystyrene sulfonate 83 sodium thiosulfate .................. 84 sod-pot-k cit-sod cit-cit acid .. 99 SOLTAMOX ......................... 39 SOLU-CORTEF (PF) ............ 86 SOMATULINE DEPOT ........ 87 SOMAVERT.......................... 87 sorbitol ................................... 91 sorbitol-mannitol .................... 91 sotalol ..................................... 66 sotalol hcl ............................... 66 SOVALDI .............................. 58 SPIRIVA RESPIMAT ......... 100 SPIRIVA WITH HANDIHALER ............... 100 spironolactone ........................ 70 spironolacton-hydrochlorothiaz ............................................ 70 SPRYCEL .............................. 39 stavudine ................................ 57 STELARA.............................. 95 STERILE PADS .................... 95 STIOLTO RESPIMAT .......... 41 STIVARGA ........................... 39
Effective: January 01, 2016
STRATTERA ......................... 72 STRENSIQ ............................. 78 streptomycin ........................... 29 STRIBILD .............................. 57 STRIVERDI RESPIMAT .... 100 sucralfate ................................ 82 sulfacetamide sodium ............. 81 sulfacetamide sodium (acne) .. 75 sulfacetamide-prednisolone.... 81 sulfadiazine............................. 34 sulfamethoxazole-trimethoprim ............................................ 34 sulfasalazine ........................... 34 sulfatrim ................................. 35 sulfazine ................................. 35 sulfazine ec ............................. 35 sulindac................................... 27 sumatriptan nasal spray .......... 50 sumatriptan succinate ............. 50 SUPPRELIN LA .................... 87 SUPRAX ................................ 32 SURMONTIL......................... 45 SUSTIVA ............................... 57 SUTENT................................. 39 SYLATRON........................... 58 SYLVANT ............................. 39 SYMLINPEN 120 .................. 46 SYMLINPEN 60 .................... 46 SYNAGIS............................... 57 SYNAREL ............................. 95 SYNERCID ............................ 31 SYNJARDY ........................... 46 SYNRIBO .............................. 39 SYPRINE ............................... 84 T TABLOID .............................. 39 tacrolimus ......................... 77, 89 TAFINLAR ............................ 39 TAGRISSO ............................ 40 TAMIFLU ........................ 57, 58 tamoxifen................................ 40 tamsulosin............................... 84
TARCEVA ............................ 40 TARGRETIN......................... 40 tarina fe 1/20 (28) .................. 73 TASIGNA .............................. 40 TAZORAC ............................ 77 taztia xt .................................. 67 TECFIDERA ......................... 95 TECHNIVIE .......................... 58 TEFLARO ............................. 32 telmisartan ............................. 64 telmisartan-hydrochlorothiazid ........................................... 64 TEMODAR ........................... 40 TENIVAC (PF)...................... 90 terazosin ................................. 84 terbinafine hcl ........................ 49 terbutaline ............................ 100 terconazole ............................. 49 testosterone ............................ 85 testosterone cypionate............ 85 testosterone enanthate ............ 85 TETANUS TOXOID,ADSORBED (PF) ........................................... 90 TETANUS,DIPHTHERIA TOX PED(PF)............................. 90 TETANUS-DIPHTHERIA TOXOIDS-TD ................... 90 tetrabenazine .......................... 72 tetracaine hcl (pf) ................... 80 tetracycline............................. 35 THALOMID .......................... 95 theophylline ................. 100, 101 theophylline anhydrous........ 100 theophylline in dextrose 5 % 100 thioridazine ............................ 55 thiothixene ............................. 55 tiagabine................................. 43 TICE BCG ............................. 90 TIKOSYN .............................. 65 timolol maleate ................ 66, 96 TIVICAY ............................... 57
I-13 Brand New Day HMO and SNPs 2016 Part D Formulary Formulary ID: 16493.000, Version: 9
tizanidine .............................. 101 TOBI PODHALER ................ 29 TOBRADEX ST .................... 81 tobramycin ............................. 81 tobramycin in 0.225 % nacl ... 29 tobramycin in 0.9 % nacl ....... 29 tobramycin sulfate .................. 29 TOLAK .................................. 75 tolazamide .............................. 48 tolbutamide ............................ 48 tolmetin .................................. 27 tolterodine .............................. 84 topiramate .............................. 43 toposar intravenous ................ 40 torsemide ................................ 69 TOUJEO SOLOSTAR ........... 47 TOVIAZ................................. 84 TPN ELECTROLYTES......... 99 TPN ELECTROLYTES II ..... 99 TRACLEER ......................... 103 TRADJENTA ........................ 46 tramadol ................................. 26 tramadol-acetaminophen ........ 26 trandolapril ............................. 65 tranexamic acid ...................... 61 TRANSDERM-SCOP............ 51 tranylcypromine ..................... 45 TRAVASOL 10 % ................. 63 TRAVATAN Z ...................... 96 travoprost (benzalkonium) ..... 96 trazodone ................................ 45 TREANDA ............................ 40 TRECATOR .......................... 50 TRELSTAR ........................... 40 tretinoin .................................. 77 tretinoin (chemotherapy) ........ 40 tretinoin microspheres ............ 77 TREXALL ............................. 40 triamcinolone acetonide .. 74, 77, 86 triamterene-hydrochlorothiazid ............................................ 69
Effective: January 01, 2016
TRIBENZOR ......................... 64 trifluoperazine ........................ 55 trifluridine............................... 81 trihexyphenidyl....................... 52 trimethoprim ........................... 31 trimipramine ........................... 45 TRIUMEQ.............................. 57 TROKENDI XR ..................... 43 TROPHAMINE 10 % ............ 63 TROPHAMINE 6% ............... 63 trospium.................................. 84 TRULICITY ........................... 46 TRUMENBA ......................... 90 TRUVADA ............................ 57 TUDORZA PRESSAIR ....... 101 TWINRIX (PF) ...................... 90 TYBOST ................................ 95 TYGACIL .............................. 35 TYKERB ................................ 40 TYPHIM VI ........................... 90 TYSABRI ............................... 89 TYVASO.............................. 103 TYVASO REFILL KIT ....... 103 TYVASO STARTER KIT ... 103 TYZEKA ................................ 58 U ULORIC ................................. 95 UNITUXIN ............................ 40 ursodiol ................................... 83 V VAGIFEM .............................. 85 valacyclovir ............................ 58 VALCHLOR .......................... 75 valganciclovir ......................... 58 valproate sodium .................... 43 valproic acid ........................... 43 valproic acid (as sodium salt) . 43 valsartan ................................. 64 valsartan-hydrochlorothiazide 64 VALSTAR ............................. 40
vancomycin ............................ 31 vancomycin in d5w ................ 31 VAQTA (PF) ......................... 90 VARIVAX (PF) ..................... 90 VASCEPA ............................. 70 VELCADE............................. 40 venlafaxine............................. 45 verapamil ............................... 67 VERSACLOZ........................ 55 VGO 40.................................. 78 VICTOZA .............................. 47 VIDEX 2 GRAM PEDIATRIC ........................................... 57 VIDEX 4 GRAM PEDIATRIC ........................................... 57 VIGAMOX ............................ 81 VIIBRYD............................... 45 VIMIZIM ............................... 78 VIMPAT ................................ 43 vinorelbine ............................. 40 VIRACEPT ............................ 57 VIRAMUNE XR ................... 57 VIRAZOLE ........................... 58 VIREAD ................................ 57 VITAFOL FE+ (WITH DOCUSATE)................... 103 VITEKTA .............................. 57 VOLTAREN .......................... 27 voriconazole........................... 49 VOTRIENT ........................... 40 VPRIV ................................... 79 W warfarin .................................. 60 water for irrigation, sterile ..... 91 X XALKORI ............................. 40 XARELTO............................. 60 XELJANZ.............................. 95 XENAZINE ........................... 72 XIFAXAN ............................. 31
I-14 Brand New Day HMO and SNPs 2016 Part D Formulary Formulary ID: 16493.000, Version: 9
XOLAIR .............................. 101 XTANDI ................................ 40 xylon 10 ................................. 26 XYREM ............................... 102 Y YERVOY ............................... 40 YF-VAX (PF) ........................ 90 YONDELIS............................ 41 Z zafirlukast ............................. 100 zaleplon ................................ 102 ZARXIO ................................ 60 ZAVESCA ............................. 79 ZELBORAF ........................... 41 ZEMPLAR ............................. 92 ZENPEP ................................. 79 ZETIA .................................... 70 ZIAGEN ................................. 57 zidovudine .............................. 57 ziprasidone hcl ....................... 55 ZIRGAN ................................ 81 ZOLADEX ............................. 41 zoledronic acid ....................... 92 zoledronic acid-mannitol-water ............................................ 92 ZOLINZA .............................. 41 zolmitriptan ............................ 50 zolpidem............................... 102 ZOMETA ............................... 92 zonisamide ............................. 43 ZORTRESS............................ 89 ZOSTAVAX (PF) .................. 91 ZOVIRAX.............................. 75 ZUBSOLV ............................. 28 ZYDELIG .............................. 41 ZYKADIA ............................. 41 ZYLET ................................... 81 ZYPREXA RELPREVV ....... 55 ZYTIGA ................................. 41 ZYVOX.................................. 31
Effective: January 01, 2016
