Paramount Commercial Open preferred and restricted drug list

Paramount Commercial Open preferred and restricted drug listParamount Commercial Open preferred and restricted drug list
Welcome We cover both brand name drugs and generic drugs. Generic drugs have the same active-ingredient
formula as a brand name drug. Generic drugs usually cost less than brand name drugs and are
rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs
How to use this drug list This is not a complete list of all drugs that are covered. This list shows drugs that are preferred,
preventive, medical, or require prior authorization (PA) or step therapy (ST). Refer to the Legend for
tier explanations. If a drug is not preferred, but is covered without any restrictions such as ST or PA
it will not appear on the printed list. Using the search box, these will be designated as non-preferred
(NP). These drugs are covered, but non-preferred brand drugs may pay at a higher copay than
preferred drugs, depending on your benefit design.
Excluded drugs Some drugs that are not covered are listed on the not covered tier. In addition, certain categories of
drugs are considered a not covered benefit for most plans. These may not specifically appear on the
excluded drug tier on this list. Refer to you summary of benefits for any riders that may apply.
Categories of drugs that are typically excluded from coverage include convenience/therapy paks,
compounds/compounding kits, dietary supplements, over the counter (OTC medications), non-FDA
approved medications, topical products for cosmetic use, sexual dysfunction treatments, growth
hormones, fertility treatments, and weight loss medications. Injectable medications may be covered
under the medical benefit.
How to search this document for drugs 1. With the PDF open, press and hold Ctrl+F on your keyboard 2. In the “Find Box”, type the name of the medication 3. Click Find Next button until you find the medication you’re looking for
LEGEND
Drugs
TYPE DESCRIPTION
QL Quantity Limit There is a limit on the amount of this drug that is covered per
prescription, or within a specific time frame.
PA Prior Authorization
You (or your physician) are required to get prior authorization before
you fill your prescription for this drug. Without prior approval, we may
not cover this drug.
ST Step Therapy
In some cases, you may be required to first try certain drugs to treat
your medical condition before we will cover another drug for that
condition.
S Specialty Drug
Specialty drugs are high-cost drugs used to treat complex or rare
conditions, such as multiple sclerosis, rheumatoid arthritis, hepatitis
C, and hemophilia.
MED Medical Drug Medical drugs.
QLC Quantity Limit (Custom) There is a limit on the amount of this drug that is covered per
prescription, or within a specific time frame.
PAGE 2 LAST UPDATED 10/2021
LIST OF COVERED PRESCRIPTION MEDICATIONS PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANALGESICS
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS
aspirin (chew tab 81 mg, tab delayed release 81 mg, tab release 81 mg)
0 QL 100 / 30 [days]
CAMBIA 4 C alternative = generic oral diclofenac tabs
diclofenac sodium (tab delayed release 50 mg, tab delayed release 75 mg, tab er 24hr 100 mg, tab release 50 mg, tab release 75 mg)
1
ibuprofen and famotidine covered separately
ibuprofen (tab 400 mg, tab 600 mg, tab 800 mg) 1
indomethacin (cap 25 mg, cap 50 mg, cap cr 75 mg, cap er 75 mg)
1
meloxicam (tab 7.5 mg, tab 15 mg) 1
naproxen (tab 250 mg, tab 375 mg, tab 500 mg) 1
RELAFEN DS 4
sulindac (tab 150 mg, tab 200 mg) 1
VIMOVO 4 C
VIVLODEX 4 C generic oral meloxicam covered
ZIPSOR 4 C generic diclofenac covered
OPIOID ANALGESICS, LONG-ACTING
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
LEVORPHANOL TARTRATE (2 MG TAB, TAB 2 MG, TAB 3 MG)
4
RYZOLT 4
tramadol hcl (tab er 24hr 100 mg, tab er 24hr 200 mg, tab er 24hr 300 mg)
4
QDOLO 3
RYBIX ODT 4 C
TRAMADOL HCL 100 MG TAB 4
XODOL 4 C
ANESTHETICS
ENOVARX-LIDOCAINE HCL 4 C use FDA approved topical products
lidocaine oint 5% 4
lidocaine-prilocaine cream kit 2.5-2.5% 4 C combinations are avaialable OTC
LIDOTRAL 4 C use generic topical lidocaine products
NAYZILAM 3 QL 6 / 1 month
QUTENZA 4 C OTC capsaicin products available
RENUU 4 C
VELMA PAIN RELIEF 4 C OTC products available
ZTLIDO 3
ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS
OPIOID REVERSAL AGENTS
EVZIO 4 C
LIFEMS NALOXONE 4
SMOKING CESSATION AGENTS
bupropion hcl (smoking deterrent) (tab er 150 mg, tab sr 150 mg)
0
CHANTIX CONTINUING MONTH PAK 0
CHANTIX STARTING MONTH PAK 0
nicotine (patch 24hr 14 mg/24hr, patch 24hr 21 mg/24hr, patch 24hr 7 mg/24hr)
0
nicotine polacrilex (gum 2 mg, gum 4 mg, lozenge 2 mg, lozenge 4 mg)
0
NICOTROL NS 0 QL 2856 / 365 [days]
ANTIBACTERIALS
metronidazole (tab 250 mg, tab 500 mg) 1
nitrofurantoin macrocrystal (cap 50 mg, cap 100 mg) 1
nitrofurantoin monohyd macro 1
XENLETA (150 MG/15ML SOLUTION, 600 MG TAB) 3
QL 10 / 30 days
BETA-LACTAM, PENICILLINS
MOXATAG 4 C alt = generic amoxicillin
penicillin v potassium (250 mg/5ml recon soln, for soln 250 mg/5ml, tab 250 mg, tab 500 mg)
1
QUINOLONES
1
TETRACYCLINES
ADOXA 150 MG CAP 4 C generic doxycycline products covered
DORYX (50 MG TAB DR, 75 MG TAB DR, 100 MG TAB DR, 150 MG TAB DR, 200 MG TAB DR)
4 C generics available
DORYX MPC 4 C
generic doxycycline products available
doxycycline hyclate (cap 50 mg, cap 100 mg, tab 50 mg) 4 C most generic doxycycline covered
MONODOX 4 C most generic doxycycline covered
MORGIDOX 4 C most generic doxycycline covered
ORACEA 4 C most generic doxycycline covered
SEYSARA 3 PA
VIBRAMYCIN 100 MG CAP 4 C tablets are covered
ANTICONVULSANTS
ANTICONVULSANTS, OTHER
levetiracetam (oral soln 100 mg/ml, tab 250 mg, tab 500 mg, tab 750 mg, tab 1000 mg, tab er 24hr 500 mg, tab er 24hr 750 mg, tab sr 24hr 500 mg, tab sr 24hr 750 mg)
1
CALCIUM CHANNEL MODIFYING AGENTS
zonisamide (cap 25 mg, cap 50 mg, cap 100 mg) 1
GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS
divalproex sodium (cap delayed release sprinkle 125 mg, tab delayed release 125 mg, tab delayed release 250 mg, tab delayed release 500 mg, tab er 24 hr 250 mg, tab er 24 hr 500 mg, tab release 125 mg, tab release 250 mg, tab release 500 mg, tab sr 24 hr 250 mg, tab sr 24 hr 500 mg)
1
gabapentin (cap 100 mg, cap 300 mg, cap 400 mg, oral soln 250 mg/5ml, tab 600 mg, tab 800 mg)
1
VALTOCO 10 MG DOSE 3 QL 6 / 1 month
GLUTAMATE REDUCING AGENTS
lamotrigine (tab 25 mg, tab 100 mg, tab 150 mg, tab 200 mg) 1
topiramate (tab 25 mg, tab 50 mg, tab 100 mg, tab 200 mg) 1
SODIUM CHANNEL AGENTS
carbamazepine (chew tab 100 mg, tab 200 mg) 1
oxcarbazepine (tab 150 mg, tab 300 mg, tab 600 mg) 1
phenytoin sodium extended cap 100 mg 1
ANTIDEMENTIA AGENTS
CHOLINESTERASE INHIBITORS
ANTIDEPRESSANTS
C bupropion (IR,SR,XL)
bupropion hcl (tab 75 mg, tab 100 mg, tab er 12hr 100 mg, tab er 12hr 150 mg, tab er 12hr 200 mg, tab er 24hr 150 mg, tab er 24hr 300 mg, tab sr 12hr 100 mg, tab sr 12hr 150 mg, tab sr 12hr 200 mg, tab sr 24hr 150 mg, tab sr 24hr 300 mg)
1
mirtazapine (tab 15 mg, tab 30 mg, tab 45 mg) 1
SSRIS/SNRIS (SELECTIVE SEROTONIN REUPTAKE INHIBITORS/SEROTONIN AND NOREPINEPHRINE REUPTAKE INHIBITORS)
BRISDELLE 3
step 1: citalopram,escita lopram, fluoxetine,fluvox amine, paroxetine(&CR) ,sertraline
citalopram hydrobromide (tab 10 mg, tab 20 mg, tab 40 mg) 1
EFFEXOR 3
EFFEXOR XR 3
C generic equivalent
escitalopram oxalate (tab 5 mg, tab 10 mg, tab 20 mg) 1
FETZIMA 3
step 1: duloxetine,desve nlafaxine, venlafaxine (& ER caps)
fluoxetine hcl (cap 10 mg, cap 20 mg, cap 40 mg, solution 20 mg/5ml)
1
KHEDEZLA 3
OLEPTRO 4 C alt = generic trazodone
paroxetine hcl (tab 10 mg, tab 20 mg, tab 30 mg, tab 40 mg) 1
paroxetine mesylate (vasomotor) 3
PEXEVA 4 C alt = generic paroxetine
PRAMLYTE 4 C use ingredients separately as indicated
PRISTIQ 3
step 1: duloxetine,desve nlafaxine, venlafaxine (& ER caps)
sertraline hcl (tab 25 mg, tab 50 mg, tab 100 mg) 1
TRINTELLIX 2
step 1: citalopram,escita lopram, fluoxetine,fluvox amine, paroxetine(&CR) ,sertraline
venlafaxine hcl (cap er 24hr 150 mg (base equivalent), cap er 24hr 37.5 mg (base equivalent), cap er 24hr 75 mg (base equivalent), cap sr 24hr 150 mg (base equivalent), cap sr 24hr 37.5 mg (base equivalent), cap sr 24hr 75 mg (base equivalent), tab 25 mg, tab 25 mg (base equivalent), tab 37.5 mg, tab 37.5 mg (base equivalent), tab 50 mg, tab 50 mg (base equivalent), tab 75 mg, tab 75 mg (base equivalent), tab 100 mg, tab 100 mg (base equivalent))
1
venlafaxine hcl (tab er 24hr 150 mg, tab er 24hr 225 mg, tab er 24hr 37.5 mg, tab er 24hr 75 mg)
3
ST
C
VENLAFAXINE HCL ER 3
step 1: duloxetine, desvenlafaxine, venlafaxine (& ER caps)
VIIBRYD (10 & 20 & 40 MG KIT, 10 MG TAB, 20 MG TAB, 40 MG TAB)
2
ST
C
VIIBRYD STARTER PACK 2
TRICYCLICS
amitriptyline hcl (tab 10 mg, tab 25 mg, tab 50 mg, tab 75 mg, tab 100 mg, tab 150 mg)
1
imipramine hcl (tab 10 mg, tab 25 mg, tab 50 mg) 1
nortriptyline hcl (cap 10 mg, cap 25 mg, cap 50 mg, cap 75 mg) 1
ANTIEMETICS
meclizine hcl (tab 12.5 mg, tab 25 mg) 1
metoclopramide hcl (tab 5 mg, tab 5 mg (base equivalent), tab 10 mg, tab 10 mg (base equivalent))
1
EMETOGENIC THERAPY ADJUNCTS
MED Medical Drug
ondansetron 1
ondansetron hcl (oral soln 4 mg/5ml, tab 4 mg, tab 8 mg) 1
SUSTOL 6 PA
MED Medical Drug
terconazole vaginal (cream 0.4%, cream 0.8%) 1
ANTIGOUT AGENTS
KRYSTEXXA 6 PA
MED Medical Drug
ANTIMIGRAINE AGENTS
AJOVY 225 MG/1.5ML SOLN PRSYR 2 PA
EMGALITY (120 MG/ML SOLN A-INJ, 120 MG/ML SOLN PRSYR)
2 PA
REYVOW 3 QL 8 / 1 month
PA
SUMAVEL DOSEPRO 4 C alt = generic sumatriptan injections
TREXIMET 4 C alt = sumatriptan and naproxen separately
ZECUITY 4 C alts = oral, injectable, nasal sumatriptan
ZEMBRACE SYMTOUCH 4 C alt = generic sumatriptan injections
ANTIMYCOBACTERIALS
ANTITUBERCULARS
ANTINEOPLASTICS
MED Medical Drug
BENDEKA 6 PA
MED Medical Drug
TREANDA (25 MG RECON SOLN, 45 MG/0.5ML SOLUTION, 100 MG RECON SOLN, 180 MG/2ML SOLUTION)
6 PA
PA
PA
ANTIESTROGENS/MODIFIERS
ANTIMETABOLITES
ABRAXANE 6 PA
MED Medical Drug
AYVAKIT (100 MG TAB, 200 MG TAB, 300 MG TAB) 5 PA
S Specialty Drug
FUSILEV 6 PA
MED Medical Drug
HALAVEN 6 PA
MED Medical Drug
ONIVYDE 6 PA
MED Medical Drug
PROVENGE 6 PA
MED Medical Drug
QINLOCK 5 PA
S Specialty Drug
SYNRIBO 6 PA
MED Medical Drug
TAZVERIK 5 PA
S Specialty Drug
ZALTRAP 6 PA
MED Medical Drug
AROMATASE INHIBITORS, 3RD GENERATION
MOLECULAR TARGET INHIBITORS
BELEODAQ 6 PA
MED Medical Drug
CYRAMZA 6 PA
MED Medical Drug
JEVTANA 6 PA
MED Medical Drug
KOSELUGO 5 PA
S Specialty Drug
KYPROLIS 6 PA
MED Medical Drug
MONOCLONAL ANTIBODY/ANTIBODY-DRUG CONJUGATE
ADCETRIS 6 PA
MED Medical Drug
ARZERRA 6 PA
MED Medical Drug
AVASTIN 6 PA
MED Medical Drug
BAVENCIO 6 PA
MED Medical Drug
BLINCYTO 6 PA
MED Medical Drug
DARZALEX 6 PA
MED Medical Drug
EMPLICITI 6 PA
MED Medical Drug
ERBITUX 6 PA
MED Medical Drug
GAZYVA 6 PA
MED Medical Drug
HERCEPTIN 6 PA
MED Medical Drug
IMFINZI 6 PA
MED Medical Drug
KADCYLA 6 PA
MED Medical Drug
KEYTRUDA (50 MG RECON SOLN, 100 MG/4ML SOLUTION) 6 PA
MED Medical Drug
OPDIVO 6 PA
MED Medical Drug
PERJETA 6 PA
MED Medical Drug
PORTRAZZA 6 PA
MED Medical Drug
RITUXAN 6 PA
MED Medical Drug
YERVOY 6 PA
MED Medical Drug
ANTIPARKINSON AGENTS
DOPAMINE AGONISTS
pramipexole dihydrochloride (tab 0.125 mg, tab 0.25 mg, tab 0.5 mg, tab 0.75 mg, tab 1 mg, tab 1.5 mg)
1
ropinirole hydrochloride (tab 0.25 mg, tab 0.5 mg, tab 1 mg, tab 2 mg, tab 3 mg, tab 4 mg, tab 5 mg)
1
DOPAMINE PRECURSORS/L-AMINO ACID DECARBOXYLASE INHIBITORS
carbidopa-levodopa (carbidopa & levodopa orally disintegrating tab 10-100 mg, carbidopa & levodopa orally disintegrating tab 25-100 mg, carbidopa & levodopa orally disintegrating tab 25- 250 mg, carbidopa & levodopa tab 10-100 mg, carbidopa & levodopa tab 25-100 mg, carbidopa & levodopa tab 25-250 mg, carbidopa & levodopa tab cr 25-100 mg, carbidopa & levodopa tab cr 50-200 mg, carbidopa & levodopa tab er 25-100 mg, carbidopa & levodopa tab er 50-200 mg, carbidopa-levodopa 10-100 mg tab disp, carbidopa-levodopa 25-100 mg tab disp, carbidopa-levodopa 25-250 mg tab disp)
1
ANTIPSYCHOTICS
LATUDA 2
olanzapine (tab 2.5 mg, tab 5 mg, tab 10 mg, tab 15 mg) 1
quetiapine fumarate (tab 25 mg, tab 50 mg, tab 100 mg, tab 200 mg, tab 300 mg, tab 400 mg)
1
C both Latuda and Vraylar first
risperidone (tab 0.25 mg, tab 0.5 mg, tab 1 mg, tab 2 mg, tab 3 mg)
1
VRAYLAR (1.5 & 3 MG CAP THPK, 1.5 MG CAP, 3 MG CAP, 4.5 MG CAP, 6 MG CAP)
2
ANTISPASTICITY AGENTS
ANTIVIRALS
MAVYRET 5
GENVOYA 2
ISENTRESS (25 MG CHEW TAB, 100 MG CHEW TAB, 400 MG TAB)
2
ATRIPLA 2
COMPLERA 2
EDURANT 2
INTELENCE 2
abacavir sulfate (soln 20 mg/ml, tab 300 mg) 1
abacavir sulfate-lamivudine 1
abacavir sulfate-lamivudine-zidovudine 1
ANTI-HIV AGENTS, OTHER
SYMFI LO 2
KALETRA (100-25 MG TAB, 200-50 MG TAB) 2
LEXIVA (50 MG/ML SUSPENSION, 700 MG TAB) 2
NORVIR (80 MG/ML SOLUTION, 100 MG CAP) 2
PREZISTA (75 MG TAB, 100 MG/ML SUSPENSION, 150 MG TAB, 600 MG TAB, 800 MG TAB)
2
ANTI-INFLUENZA AGENTS
oseltamivir phosphate (cap 30 mg, cap 45 mg, cap 75 mg, for susp 6 mg/ml)
1
ANTIHERPETIC AGENTS
acyclovir (cap 200 mg, tab 400 mg, tab 800 mg) 1
SITAVIG 4
ANXIOLYTICS
ANXIOLYTICS, OTHER
buspirone hcl (tab 5 mg, tab 7.5 mg, tab 10 mg, tab 15 mg, tab 30 mg)
1
BIPOLAR AGENTS
MOOD STABILIZERS
lithium carbonate (cap 150 mg, 300 mg cap, cap 300 mg, cap 600 mg, tab 300 mg, tab cr 450 mg, tab er 300 mg, tab er 450 mg)
1
ANTIDIABETIC AGENTS
acarbose (tab 25 mg, tab 50 mg, tab 100 mg) 1
ADLYXIN 3
BYDUREON (2 MG PEN, 2 MG SRER) 3
ST
C
BYDUREON BCISE 3
step 1 metformin, step 2 Tulicity, Victoza, Ozempic
BYETTA 10 MCG PEN (10 MCG PEN 10 MCG/0.04ML SOLN PEN, 10 MCG PEN 10 MCG/0.04ML SOPN)
3
ST
C
BYETTA 5 MCG PEN 3
ST
C
FARXIGA 2
FORTAMET 4 C
glimepiride 1
glipizide (tab 5 mg, tab 10 mg, tab er 24hr 10 mg, tab er 24hr 2.5 mg, tab er 24hr 5 mg, tab sr 24hr 10 mg, tab sr 24hr 2.5 mg, tab sr 24hr 5 mg)
1
GLUMETZA 4 C metformin ER (non-osmotic)is covered
glyburide (tab 1.25 mg, tab 2.5 mg, tab 5 mg) 1
glyburide micronized 1
glyburide-metformin 1
GLYXAMBI 2
INVOKAMET 3
INVOKAMET XR 3
INVOKANA 3
JANUMET 2
JANUMET XR 2
JANUVIA 2
JARDIANCE 2
JENTADUETO 3
JENTADUETO XR 3
KAZANO 3
KOMBIGLYZE XR 3
METAGLIP 2.5-250 MG TAB 1
metformin hcl (tab 500 mg, tab 850 mg, tab 1000 mg, tab er 24hr 500 mg, tab er 24hr 750 mg, tab sr 24hr 500 mg, tab sr 24hr 750 mg)
1
ONGLYZA 3
OSENI 3
OZEMPIC (0.25 OR 0.5 MG/DOSE) 2
ST
OZEMPIC (1 MG/DOSE) 2 MG/1.5ML SOLN PEN 2
ST
pioglitazone hcl 1
QTERN 3
repaglinide 1
RYBELSUS 2
SEGLUROMET 3
STEGLATRO 3
STEGLUJAN 3
SYMLINPEN 120 2
SYMLINPEN 60 2
C metformin 2Gm/day x 90 days first
SYNJARDY XR (5-1000 MG TAB ER 24H, 10-1000 MG TAB ER 24H, 12.5-1000 MG TAB ER 24H)
2
ST
SYNJARDY XR 25-1000 MG TAB ER 24H 2 ST
C fluticasone first
TRIJARDY XR 2
TRULICITY (0.75 MG/0.5ML SOLN PEN, 1.5 MG/0.5ML SOLN PEN)
2
ST
TRULICITY (3 MG/0.5ML SOLN PEN, 4.5 MG/0.5ML SOLN PEN)
2
ST
C
metformin 2gm/day x 90 days first; follow dose titration schedule
VICTOZA 2
XIGDUO XR 2
GLYCEMIC AGENTS
BAQSIMI TWO PACK 2
QL 2 / 90 days
glucagon (rdna) 1
GVOKE HYPOPEN 2-PACK 3
QL 2 / 90 days
GVOKE PFS 3
INSULINS
3 ST
C step 1: Novolog
C step 1: Novolog
C step 1: Novolog
HUMALOG PEN 3 ST
C step 1: Novolog
HUMULIN 50/50 3 ST
C step 1: Novolin
HUMULIN N 3 ST
C step 1: Novolin
HUMULIN R 3 ST
C step 1: Novolin
LANTUS 3
LANTUS SOLOSTAR (100 UNIT/ML SOLN PEN, 100 UNIT/ML SOPN)
3
ST
LEVEMIR 2
NOVOLOG MIX 70/30 2
NOVOLOG PENFILL 2
3
ST
SOLIQUA 2
TOUJEO SOLOSTAR 3 C all step 1 first: Basaglar, Levemir, Tresiba
TRESIBA 2
ANTICOAGULANTS
COUMADIN (1 MG TAB, 2 MG TAB, 2.5 MG TAB, 3 MG TAB, 4 MG TAB, 5 MG TAB, 6 MG TAB, 7.5 MG TAB, 10 MG TAB)
2
PRADAXA 3
SAVAYSA 3
C Eliquis and Xarelto first
warfarin sodium (tab 1 mg, tab 2 mg, tab 3 mg, tab 4 mg, tab 5 mg, tab 6 mg, tab 7.5 mg, tab 10 mg)
1
FULPHILA 6 PA
MED Medical Drug
GRANIX (300 MCG/0.5ML SOLN PRSYR, 300 MCG/ML SOLUTION, 480 MCG/0.8ML SOLN PRSYR, 480 MCG/1.6ML SOLUTION)
6 PA
MED Medical Drug
LEUKINE (250 MCG RECON SOLN, 250 MCG SOLR, 500 MCG/ML SOLN, 500 MCG/ML SOLUTION)
6 PA
MED Medical Drug
NEUPOGEN (300 MCG/0.5ML SOLN PRSYR, 300 MCG/ML SOLUTION, 480 MCG/0.8ML SOLN PRSYR, 480 MCG/1.6ML SOLUTION)
6 PA
MED Medical Drug
NIVESTYM (300 MCG/0.5ML SOLN PRSYR, 300 MCG/ML SOLUTION, 480 MCG/0.8ML SOLN PRSYR, 480 MCG/1.6ML SOLUTION)
6 PA
RETACRIT (2000 UNIT/ML SOLUTION, 3000 UNIT/ML SOLUTION, 4000 UNIT/ML SOLUTION, 10000 UNIT/ML SOLUTION, 40000 UNIT/ML SOLUTION)
6 PA
AFSTYLA 6 PA
MED Medical Drug
ALPHANATE 6 PA
MED Medical Drug
MED Medical Drug
ALPHANINE SD (500 RECON SOLN, 500 SOLR, 1000 RECON SOLN, 1000 SOLR, 1500 RECON SOLN, 1500 SOLR)
6 PA
MED Medical Drug
BENEFIX (250 KIT, 250 RECON SOLN, 250 SOLR, 500 KIT, 500 RECON SOLN, 500 SOLR, 1000 KIT, 1000 RECON SOLN, 1000 SOLR, 2000 KIT, 2000 RECON SOLN, 3000 KIT)
6 PA
MED Medical Drug
HELIXATE FS 6 PA
MED Medical Drug
HEMLIBRA 6 PA
MED Medical Drug
HEMOFIL M (HEOFIL 220-400 RECON SOLN, HEOFIL 250 RECON SOLN, HEOFIL 401-800 RECON SOLN, HEOFIL 401- 800 SOLR, HEOFIL 500 RECON SOLN, HEOFIL 801-1500 RECON SOLN, HEOFIL 801-1700 SOLR, HEOFIL 1000 RECON SOLN, HEOFIL 1501-2000 RECON SOLN, HEOFIL 1700 RECON SOLN, HEOFIL 1701-2000 RECON SOLN)
6 PA
MED Medical Drug
KOVALTRY 6 PA
MED Medical Drug
MONOCLATE-P 6 PA
MED Medical Drug
MONONINE 6 PA
MED Medical Drug
NOVOEIGHT 6 PA
MED Medical Drug
NOVOSEVEN 6 PA
MED Medical Drug
MED Medical Drug
NUWIQ (250 KIT, 250 RECON SOLN, 500 KIT, 500 RECON SOLN, 1000 KIT, 1000 RECON SOLN, 2000 KIT, 2000 RECON SOLN, 2500 KIT, 2500 RECON SOLN, 3000 KIT, 3000 RECON SOLN, 4000 KIT, 4000 RECON SOLN)
6 PA
MED Medical Drug
OBIZUR 6 PA
MED Medical Drug
PROFILNINE 6 PA
MED Medical Drug
PROFILNINE SD (500 RECON SOLN, 500 SOLR, 1000 SOLR, 1500 SOLR)
6 PA
MED Medical Drug
REBINYN 6 PA
MED Medical Drug
RECOMBINATE 6 PA
MED Medical Drug
REFACTO 6 PA
MED Medical Drug
RIXUBIS 6 PA
MED Medical Drug
TRETTEN 6 PA
MED Medical Drug
VONVENDI 6 PA
MED Medical Drug
WILATE (450-450 RECON SOLN, 500-500 KIT, 500-500 RECON SOLN, 900-900 RECON SOLN, 1000-1000 KIT, 1000- 1000 RECON SOLN)
6 PA
XYNTHA 6 PA
MED Medical Drug
dipyridamole tab 25 mg 1
DURLAZA 4 C generic aspirin products are covered
EFFIENT 2
CARDIOVASCULAR AGENTS
ALPHA-ADRENERGIC AGONISTS
clonidine hcl (tab 0.1 mg, tab 0.2 mg, tab 0.3 mg) 1
guanfacine hcl (tab 1 mg, tab 2 mg) 1
METHYLDOPA (250 MG TAB, TAB 250 MG) 1
ALPHA-ADRENERGIC BLOCKING AGENTS
doxazosin mesylate (tab 1 mg, tab 2 mg, tab 4 mg, tab 8 mg) 1
ANGIOTENSIN II RECEPTOR ANTAGONISTS
irbesartan 1
losartan potassium (tab 25 mg, tab 50 mg, tab 100 mg) 1
valsartan 1
ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS
benazepril hcl (tab 5 mg, tab 10 mg, tab 20 mg, tab 40 mg) 1
enalapril maleate (tab 2.5 mg, tab 5 mg, tab 10 mg, tab 20 mg) 1
EPANED (1 MG/ML RECON SOLN, 1 MG/ML SOLUTION) 4 C covered under certain circumstances
fosinopril sodium 1
lisinopril (tab 2.5 mg, tab 5 mg, tab 10 mg, tab 20 mg, tab 30 mg, tab 40 mg)
1
quinapril hcl 1
ANTIARRHYTHMICS
amiodarone hcl (tab 100 mg, tab 200 mg, tab 400 mg) 1
flecainide acetate 1
BETA-ADRENERGIC BLOCKING AGENTS
atenolol (tab 25 mg, tab 50 mg, tab 100 mg) 1
bisoprolol fumarate (tab 5 mg, tab 10 mg) 1
BYSTOLIC 2
carvedilol 1
labetalol hcl (tab 100 mg, tab 200 mg, tab 300 mg) 1
metoprolol succinate 1
metoprolol tartrate (tab 25 mg, tab 37.5 mg, tab 50 mg, tab 75 mg, tab 100 mg)
1
propranolol hcl (tab 10 mg, tab 20 mg, tab 40 mg, tab 60 mg, tab 80 mg)
1
CALCIUM CHANNEL BLOCKING AGENTS
amlodipine besylate (tab 2.5 mg, tab 2.5 mg (base equivalent), tab 5 mg, tab 5 mg (base equivalent), tab 10 mg, tab 10 mg (base equivalent))
1
diltiazem hcl (cap er 12hr 120 mg, cap er 12hr 60 mg, cap er 12hr 90 mg, cap er 24hr 120 mg, cap er 24hr 180 mg, cap er 24hr 240 mg, cap sr 24hr 240 mg, tab 30 mg, tab 60 mg, tab 90 mg, tab 120 mg)
1
diltiazem hcl coated beads (beads cap er 24hr 120 mg, beads cap er 24hr 180 mg, beads cap er 24hr 240 mg, beads cap er 24hr 300 mg, beads cap er 24hr 360 mg, beads cap sr 24hr 120 mg, beads cap sr 24hr 180 mg, beads cap sr 24hr 240 mg, beads cap sr 24hr 300 mg, beads tab er 24hr 180 mg, beads tab er 24hr 240 mg, beads tab er 24hr 300 mg, beads tab er 24hr 360 mg, beads tab er 24hr 420 mg, beads tab sr 24hr 180 mg, beads tab sr 24hr 240 mg, beads tab sr 24hr 300 mg, beads tab sr 24hr 360 mg, beads tab sr 24hr 420 mg)
1
diltiazem hcl extended release beads (beads cap er 24hr 120 mg, beads cap er 24hr 180 mg, beads cap er 24hr 240 mg, beads cap er 24hr 300 mg, beads cap er 24hr 360 mg, beads cap er 24hr 420 mg, beads cap sr 24hr 120 mg, beads cap sr 24hr 180 mg, beads cap sr 24hr 240 mg, beads cap sr 24hr 300 mg, beads cap sr 24hr 360 mg, beads cap sr 24hr 420 mg)
1
nifedipine (tab er 24hr 30 mg, tab er 24hr 60 mg, tab er 24hr 90 mg, tab er 24hr osmotic release 30 mg, tab er 24hr osmotic release 60 mg, tab er 24hr osmotic release 90 mg, tab sr 24hr 30 mg, tab sr 24hr 60 mg, tab sr 24hr 90 mg, tab sr 24hr osmotic 30 mg, tab sr 24hr osmotic 60 mg, tab sr 24hr osmotic 90 mg)
1
verapamil hcl (tab 40 mg, tab 80 mg, tab 120 mg, tab cr 120 mg, tab cr 180 mg, tab cr 240 mg, tab er 120 mg, tab er 180 mg, tab er 240 mg)
1
CONSENSI 4
CORLANOR (5 MG TAB, 5 MG/5ML SOLUTION, 7.5 MG TAB) 3
digoxin (tab 125 mcg (0.125, tab 250 mcg (0.25) 1
enalapril maleate & hydrochlorothiazide 1
losartan potassium & hydrochlorothiazide 1
pentoxifylline (tab cr 400 mg, tab er 400 mg) 1
quinapril-hydrochlorothiazide (tab 20-12.5 mg, tab 20-25 mg) 1
spironolactone & hydrochlorothiazide 1
triamterene & hydrochlorothiazide (cap 37.5-25 mg, tab 37.5-25 mg, tab 75-50 mg)
1
PA
DIURETICS, LOOP
furosemide (tab 20 mg, tab 40 mg, tab 80 mg) 1
DIURETICS, POTASSIUM-SPARING
amiloride hcl tab 5 mg 1
spironolactone (tab 25 mg, tab 50 mg, tab 100 mg) 1
DIURETICS, THIAZIDE
chlorthalidone 1
hydrochlorothiazide (cap 12.5 mg, tab 12.5 mg, tab 25 mg, tab 50 mg)
1
DYSLIPIDEMICS, FIBRIC ACID DERIVATIVES
choline fenofibrate 1
fenofibrate (tab 48 mg, tab 54 mg, tab 160 mg) 1
fenofibrate micronized (cap 67 mg, cap 130 mg, cap 134 mg, cap 200 mg)
1
gemfibrozil tab 600 mg 1
DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS
atorvastatin calcium (tab 10 mg, tab 20 mg, tab 40 mg, tab 80 mg)
1
LIVALO 3 PA
lovastatin (tab 10 mg, tab 20 mg, tab 40 mg) 1
pravastatin sodium 1
rosuvastatin calcium 1
simvastatin (tab 5 mg, tab 10 mg, tab 20 mg, tab 40 mg, tab 80 mg)
1
NEXLIZET 2 PA
PRALUENT (75 MG/ML SOLN A-INJ, 75 MG/ML SOLN PRSYR, 150 MG/ML SOLN A-INJ, 150 MG/ML SOLN PRSYR)
2 PA
REPATHA 3
REPATHA PUSHTRONEX SYSTEM 3
REPATHA SURECLICK 3
VASCEPA 2
VASODILATORS, DIRECT-ACTING ARTERIAL
hydralazine hcl (tab 10 mg, tab 25 mg, tab 50 mg, tab 100 mg) 1
VASODILATORS, DIRECT-ACTING ARTERIAL/VENOUS
isosorbide mononitrate (tab er 24hr 30 mg, tab er 24hr 60 mg, tab sr 24hr 30 mg, tab sr 24hr 60 mg)
1
nitroglycerin (sl tab 0.3 mg, sl tab 0.4 mg, sl tab 0.6 mg) 1
NITROLINGUAL 4 C alt = generic
CENTRAL NERVOUS SYSTEM AGENTS
MYDAYIS 2
VYVANSE (10 MG CAP, 10 MG CHEW TAB, 20 MG CAP, 20 MG CHEW TAB, 30 MG CAP, 30 MG CHEW TAB, 40 MG CAP, 40 MG CHEW TAB, 50 MG CAP, 50 MG CHEW TAB, 60 MG CAP, 60 MG CHEW TAB, 70 MG CAP)
2
guanfacine hcl (adhd) 1
CENTRAL NERVOUS SYSTEM, OTHER
EVRYSDI 5 PA
S Specialty Drug
PHRENILIN FORTE 4 C alts = generic combination products
FIBROMYALGIA AGENTS
CYMBALTA (20 MG CP DR PART, 30 MG CP DR PART, 60 MG CP DR PART, 60 MG CPEP)
3
ST
SAVELLA 3
MULTIPLE SCLEROSIS AGENTS
BAFIERTAM 5
S Specialty Drug
S Specialty Drug
S Specialty Drug
S Specialty Drug
S Specialty Drug
MAVENCLAD (8 TABS) 5
S Specialty Drug
S Specialty Drug
S Specialty Drug
OCREVUS 6 PA
MED Medical Drug
TECFIDERA (120 & 240 MG MISC, 120 MG CAP DR, 240 MG CAP DR)
5
PA
ZEPOSIA 5
S Specialty Drug
PA
S Specialty Drug
S Specialty Drug
NAFRINSE DAILY/NEUTRAL 2
DERMATOLOGICAL AGENTS
COPASIL 4 C emollients & barrier creams available OTC
COSENTYX 150 MG/ML SOLN PRSYR 5
PA
PA
ELIDEL 3
EPICERAM 4 C
HYPERCARE 2
KLISYRI 3
must try 1 generic product first (fluorouracil, imiquimod, diclofenac 3%)
pimecrolimus 3
PROTOPIC 3
QBREXZA 3 PA
RENUU NL 4 C OTC products available
SKYRIZI (150 MG DOSE) 5
PA
C preferred specialty
S Specialty Drug
STELARA (45 MG/0.5ML SOLN PRSYR, 45 MG/0.5ML SOLUTION, 90 MG/ML SOLN PRSYR)
5
PA
PA
TREMFYA (100 MG/ML SOLN PEN, 100 MG/ML SOLN PRSYR)
5
PA
WYNZORA 4
ELECTROLYTES/MINERALS/METALS/VITAMINS
NIVA-FOL 1
potassium chloride (cap cr 10, cap er 10, tab cr 10, tab er 10, tab er 20 (1500 mg))
1
potassium chloride microencapsulated crystals cr 1
potassium chloride microencapsulated crystals er (crys er tab 10, crys er tab 20)
1
sodium chloride (inj, iv soln) 1
sodium fluoride (chew tab 0.25 mg f (from 0.55 mg naf), chew tab 0.5 mg f (from 1.1 mg naf), soln 0.125 mg/drop f (0.275 mg/drop naf), soln 0.5 mg/ml f (from 1.1 mg/ml naf), 1.1 (0.5 f) mg tab)
0
ELECTROLYTE/MINERAL/METAL MODIFIERS
JYNARQUE (15 MG TAB, 15 MG TAB THPK, 30 & 15 MG TAB THPK, 30 MG TAB, 45 & 15 MG TAB THPK, 60 & 30 MG TAB THPK, 90 & 30 MG TAB THPK)
5 PA
SPS 1
*b-complex w/ c & folic acid tab 1 mg*** 1
folic acid (cap 0.8 mg, tab 400 mcg, tab 800 mcg) 0 QL 100 / 30 [days]
folic acid tab 1 mg 1
folic acid-vitamin b6-vitamin b12 tab 2.5-25-1 mg 1
GASTROINTESTINAL AGENTS
ANTISPASMODICS, GASTROINTESTINAL
dicyclomine hcl (cap 10 mg, tab 20 mg) 1
hyoscyamine sulfate (sl tab 0.125 mg, tab 0.125 mg, tab disint 0.125 mg, tab disp 0.125 mg, tab er 12hr 0.375 mg, tab sl 0.125 mg, tab sr 12hr 0.375 mg)
1
ranitidine hcl syrup 15 mg/ml (75 mg/5ml) 1
IRRITABLE BOWEL SYNDROME AGENTS
CLENPIQ 0
lactulose (encephalopathy) solution 10 gm/15ml 1
MOVIPREP 0
PEG-PREP 0
PLENVU 0 C zero copay for preventive age 50-74
polyethylene glycol 3350 (3350 packet, 3350 packet 17 gm, 3350 powder, 3350 powder 17 gm/scoop)
1
PROTECTANTS
PROTON PUMP INHIBITORS
C 3 step 1 drugs first and duration criteria
esomeprazole magnesium (cap 20 mg, cap 40 mg) 4 C Nexium OTC is covered with PA
ESOMEPRAZOLE STRONTIUM 4 C Nexium OTC is covered with PA
lansoprazole (cap 15 mg, cap 30 mg, cap delayed 15 mg, cap delayed 30 mg)
1 PA
lansoprazole (tab 30 mg, tab delayed 15 mg) 1 PA
NEXIUM 10 MG PACKET 4 C alts = first- omeprazole,first- lansoprazole
NEXIUM 24HR 20 MG TAB DR 2 PA
C PA after 60 days
omeprazole (cap 20 mg, cap 40 mg) 1 PA
C PA after 60 days
omeprazole-sodium bicarbonate cap 40-1100 mg 4 C Zegerid OTC is covered with PA
pantoprazole sodium (ec tab 20 mg, ec tab 40 mg) 1 PA
C PA after 60 days
PREVACID (15 MG CAP DR, 15 MG CPDR) 2 PA
C PA after 60 days
PREVACID 24HR 2 PA
PROTONIX 40 MG PACKET 4 C
alternatives = generic tablets, first-omeprazole, first-lansoprazole
rabeprazole sodium (10 mg cap sprink, ec tab 20 mg) 3
PA
C
try 3 step 1 drugs and meet duration criteria after 60 days
ZEGERID 20-1100 MG CAP 4 C Zegerid OTC covered with PA
ZEGERID 40-1100 MG CAP 4 C Zegerid OTC is covered with PA
ZEGERID (20-1680 MG PACKET, 40-1680 MG PACKET) 4 C
alts = Zegerid OTC,first- omeprazole,first- lansoprazole
ZEGERID OTC 2 PA
GENETIC OR ENZYME DISORDER: REPLACEMENT, MODIFIERS, TREATMENT
CREON 2
KANUMA 6 PA
MED Medical Drug
PANCRELIPASE (LIP-PROT-AMYL) 2
C Myrbetriq preferred, must try first
MYRBETRIQ (25 MG TAB ER 24H, 50 MG TAB ER 24H) 2
oxybutynin chloride (tab er 24hr 10 mg, tab er 24hr 15 mg, tab er 24hr 5 mg)
1
tolterodine tartrate (cap er 24hr 2 mg, cap er 24hr 4 mg, tab 1 mg, tab 2 mg)
1
TOVIAZ 2
trospium chloride (cap er 24hr 60 mg, tab 20 mg) 1
BENIGN PROSTATIC HYPERTROPHY AGENTS
PA
PA
tamsulosin hcl 1
GENITOURINARY AGENTS, OTHER
TODAY SPONGE 0
0
DESONATE 4 C generic formulations available
dexamethasone (tab 0.5 mg, tab 0.75 mg, tab 1.5 mg, tab 4 mg)
1
IMPEKLO 4
PREDNISOLONE (15 MG/5ML SOLUTION, SYRUP 15 MG/5ML (USP SOLUTION EQUIVALENT))
1
prednisolone sodium phosphate (phosph soln 6.7 mg/5ml (5 mg/5ml base), phosphate soln 15 mg/5ml (base equiv))
1
prednisone (tab 1 mg, tab 2.5 mg, tab 5 mg, tab 10 mg, tab 20 mg, tab 50 mg)
1
RAYOS 4 C alt = generic prednisone
SERNIVO 4 C alts = betamethasone oint,cream,lotion
triamcinolone acetonide (topical) (cream 0.025%, cream 0.1%, cream 0.5%, lotion 0.025%, lotion 0.1%, oint 0.025%, oint 0.1%, oint 0.5%)
1
ULTRAVATE 0.05 % LOTION 4 C alt = halobetasol cream and ointment
ZCORT 7-DAY 4
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS)
ANDROGENS
BALCOLTRA 0
desogest-ethin est tab 0.1-0.025/0.125-0.025/0.15-0.025mg-mg 0
drospirenone-ethinyl estradiol (tab 3-0.02 mg, tab 3-0.03 mg) 0
drospirenone-ethinyl estradiol-levomefolate calcium (tab 3-0.02- 0.451 mg, tab 3-0.03-0.451 mg)
0
estradiol (tab 0.5 mg, tab 1 mg, tab 2 mg) 1
estropipate (tab 0.75 mg, tab 1.5 mg, tab 3 mg) 1
ethynodiol diacet & eth estrad (tab 1 mg-35 mcg, tab 1 mg-50 mcg)
0
etonogestrel-ethinyl estradiol va ring 0.120-0.015 mg/24hr 0 QL 13 / 300 [days]
levonorgestrel & eth estradiol (tab 0.1 mg-20 mcg, tab 0.15 mg- 30 mcg)
0
levonorgestrel-ethinyl estradiol (91-day) (levonor-eth tab 0.15- 0.02/0.025/0.03 mg &eth 0.01 mg, levonorg-eth tab 0.1- 0.02mg(84) & eth tab 0.01mg(7), levonorg-eth tab 0.15- 0.03mg(84) & eth tab 0.01mg(7), levonorgrel & ethinyl radiol (91-day) tab 0.15-0.03 mg)
0
LO LOESTRIN FE 0
LOESTRIN 24 FE 0
norelgestromin-ethinyl estradiol 0
norethin acet & estrad-fe (ace & ethinyl tab 1 mg-20 mcg, ace & ethinyl tab 1.5 mg-30 mcg, ace-eth chew tab 1 mg-20 mcg (24), ace-ethinyl tab 1 mg-20 mcg (24))
0
norethindrone & eth estradiol (tab 0.4 mcg, tab 0.5 mcg, tab 1 mcg)
0
norethindrone & ethinyl estradiol-fe (chew tab 0.4 mg-35 mcg, chew tab 0.8 mg-25 mcg)
0
norethindrone acet & eth estra (tab 1 mg-20 mcg, tab 1.5 mg-30 mcg)
0
norethindrone-eth estradiol (triphasic) (tab 0.5-35/0.75-35/1-35, tab 0.5-35/1-35/0.5-35)
0
norgestimate-ethinyl estradiol (triphasic) (tab 0.18-25/0.215- 25/0.25-25, tab 0.18-35/0.215-35/0.25-35)
0
norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg 0
OGESTREL 0
ORTHO TRI-CYCLEN LO 0
PREMARIN (0.3 MG TAB, 0.45 MG TAB, 0.625 MG TAB, 0.625 MG/GM CREAM, 0.9 MG TAB, 1.25 MG TAB)
2
ENDOMETRIN 3 PA
levonorgestrel tab 1.5 mg 0
LILETTA (52 MG) 0 QL 1 / 300 [days]
medroxyprogesterone acetate (tab 2.5 mg, tab 5 mg, tab 10 mg)
1
0 QL 4 / 300 [days]
megestrol acetate (tab 20 mg, tab 40 mg) 1
MIRENA (52 MG) 0 QL 1 / 300 [days]
NEXPLANON 0 QL 1 / 300 [days]
norethindrone tab 0.35 mg 0
SKYLA 0 QL 1 / 300 [days]
SLYND 0
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID)
levothyroxine sodium (tab 25 mcg, tab 50 mcg, tab 75 mcg, tab 88 mcg, tab 100 mcg, tab 112 mcg, tab 125 mcg, tab 137 mcg, tab 150 mcg, tab 175 mcg, tab 200 mcg, tab 300 mcg)
1
liothyronine sodium (tab 5 mcg, tab 25 mcg, tab 50 mcg) 1
THYROLAR-1 2
THYROLAR-1/2 2
THYROLAR-1/4 2
THYROLAR-2 2
THYROLAR-3 2
HORMONAL AGENTS, SUPPRESSANT (PITUITARY)
ELIGARD (7.5 MG KIT, 22.5 MG KIT, 30 MG KIT, 45 MG KIT) 6 PA
MED Medical Drug
ORILISSA 3 PA
MED Medical Drug
TRELSTAR DEPOT MIXJECT 6 MED Medical Drug
TRELSTAR LA MIXJECT 6 MED Medical Drug
TRELSTAR MIXJECT (3.75 MG RECON SUSP, 11.25 MG RECON SUSP)
6 MED Medical Drug
HORMONAL AGENTS, SUPPRESSANT (THYROID)
IMMUNOLOGICAL AGENTS
ANGIOEDEMA AGENTS
IMMUNE SUPPRESSANTS
ENBREL (25 MG RECON SOLN, 25 MG/0.5ML SOLN PRSYR, 50 MG/ML SOLN PRSYR)
5
PA
S Specialty Drug
ENTYVIO 6 PA
MED Medical Drug
HUMIRA (10 MG/0.1ML PREF SY KT, 10 MG/0.2ML PREF SY KT, 20 MG/0.2ML PREF SY KT, 20 MG/0.4ML PREF SY KT, 40 MG/0.4ML PREF SY KT, 40 MG/0.8ML PREF SY KT)
5
PA
S Specialty Drug
INFLECTRA 6 PA
MED Medical Drug
methotrexate sodium (inj 50 mg/2ml (25 mg/ml), tab 2.5 mg (base equiv))
1
RENFLEXIS 6 PA
MED Medical Drug
S Specialty Drug
SIMPONI (50 MG/0.5ML SOLN A-INJ, 50 MG/0.5ML SOLN PRSYR, 100 MG/ML SOLN A-INJ, 100 MG/ML SOLN PRSYR)
5
PA
PA
MED Medical Drug
CUVITRU (1 GM/5ML SOLUTION, 2 GM/10ML SOLUTION, 4 GM/20ML SOLUTION, 8 GM/40ML SOLUTION)
6 PA
6 PA
GAMMAGARD 6 PA
MED Medical Drug
MED Medical Drug
GAMMAKED 6 PA
MED Medical Drug
GAMMAPLEX 6 PA
MED Medical Drug
GAMUNEX 6 PA
MED Medical Drug
GAMUNEX-C 6 PA
MED Medical Drug
HIZENTRA (1 GM/5ML SOLUTION, 2 GM/10ML SOLUTION, 4 GM/20ML SOLUTION)
6 PA
MED Medical Drug
OCTAGAM (1 GM/20ML SOLUTION, 2 GM/20ML SOLUTION, 2.5 GM/50ML SOLUTION, 5 GM/100ML SOLUTION, 5 GM/50ML SOLUTION, 10 GM/100ML SOLUTION, 10 GM/200ML SOLUTION, 20 GM/200ML SOLUTION, 25 GM/500ML SOLUTION)
6 PA
IMMUNOMODULATORS
BENLYSTA (120 MG RECON SOLN, 200 MG/ML SOLN A-INJ, 200 MG/ML SOLN PRSYR, 400 MG RECON SOLN)
6 PA
COSENTYX SENSOREADY PEN 5
S Specialty Drug
KEVZARA (150 MG/1.14ML SOLN A-INJ, 150 MG/1.14ML SOLN PRSYR, 200 MG/1.14ML SOLN A-INJ, 200 MG/1.14ML SOLN PRSYR)
5
PA
S Specialty Drug
OTEZLA (10 & 20 & 30 MG TAB THPK, 30 MG TAB, 30 MG TABS)
5
PA
PALFORZIA (300 MG MAINTENANCE) 3 PA
PALFORZIA (300 MG TITRATION) 3 PA
PALFORZIA (40 MG DAILY DOSE) 3 PA
PALFORZIA INITIAL ESCALATION 3 PA
VACCINES
ACTHIB 0
ADACEL 0
AFLURIA QUADRIVALENT (0.25 ML SUSP PRSYR, 0.5 ML SUSP PRSYR, SUSPENSION)
0
BEXSERO 0
0
DIPHTHERIA-TETANUS TOXOIDS DT 0
ENGERIX-B (10 MCG/0.5ML SUSP, 10 MCG/0.5ML SUSPENSION, 20 MCG/ML SUSP, 20 MCG/ML SUSPENSION)
0
FLUZONE HIGH-DOSE 0.5 ML SUSP PRSYR 0
FLUZONE QUADRIVALENT (0.25 ML SUSP PRSYR, 0.5 ML SUSP PRSYR, 0.5 ML SUSPENSION, SUSPENSION)
0
GARDASIL 9 (9SUSPENSION, 9SUSPPRSYR) 0
HAVRIX (720 U/0.5ML SUSP, 720 U/0.5ML SUSPENSION, 1440 U/ML SUSP, 1440 U/ML SUSPENSION)
0
0
IPOL 0
0
0
PEDVAX HIB 0
VAQTA 0
VARIVAX 0
ZOSTAVAX 0
balsalazide disodium 1
mesalamine (cap er 24hr 0.375 gm, enema 4 gm, tab delayed release 1.2 gm)
1
GLUCOCORTICOIDS
budesonide delayed release particles cap 3 mg 1
budesonide tab er 24hr 9 mg 4 C 3mg ER capsules covered
CORTIFOAM 2
hydrocortisone (rectal) (perianal cream 1%, perianal cream 2.5%, rectal cream 1%, rectal cream 2.5%)
1
UCERIS 9 MG TAB ER 24H 4 C 3mg ER capsules covered
SULFONAMIDES
sulfasalazine (tab 500 mg, tab delayed release 500 mg) 1
METABOLIC BONE DISEASE AGENTS
alendronate sodium (tab 10 mg, tab 35 mg, tab 70 mg) 1
ergocalciferol (cap 1.25 mg (50000 unit), cap 50000 unit) 1
PROLIA 6 PA
MED Medical Drug
XGEVA 6 PA
MED Medical Drug
MISCELLANEOUS THERAPEUTIC AGENTS
ACCU-CHEK COMPACT PLUS 4
ACCU-CHEK SMARTVIEW 4
BD PEN NEEDLE NANO 2ND GEN 2
BD PEN NEEDLE NANO U/F 2
BD PEN NEEDLE ORIGINAL U/F 2
BD PEN NEEDLE SHORT U/F 2
CANDIDA ALBICANS EXTRACT (EXTRACT 10000 PNU/ML SOLUTION, EXTRACT 20000 PNU/ML SOLUTION)
4 C not a covered pharmacy benefit
CAYA 0 QL 1 / 300 [days]
CONTOUR NEXT TEST 2 QL 5 / 1 days
CONTOUR TEST 2 QL 5 / 1 days
cromolyn sodium (nasal) 3
DEXCOM G6 RECEIVER 2
DEXCOM G6 SENSOR 2
DEXCOM G6 TRANSMITTER 2
ENLITE GLUCOSE SENSOR 3 PA
C Dexcom first
C Dexcom first
FREESTYLE LIBRE 14 DAY READER 3 PA
C Dexcom first
C Dexcom first
C Dexcom first
C Dexcom first
C Dexcom first
C Dexcom first
C Dexcom first
C Dexcom first
C Dexcom first
MINIMED RESERVOIR 3ML 2 C mail order only
OMNIFLEX DIAPHRAGM 0 QL 1 / 300 [days]
OMNIPOD 10 PACK 2 PA
OMNIPOD 5 PACK 2 PA
OMNIPOD DASH 5 PACK PODS 2 PA
ONETOUCH LANCETS 2 QL 5 / 1 days
ONETOUCH TEST 2 QL 5 / 1 days
ONETOUCH ULTRA 2 QL 5 / 1 days
ONETOUCH VERIO STRIP 2 QL 5 / 1 days
PARAGARD INTRAUTERINE COPPER 0 QL 1 / 300 [days]
SAXENDA 4 C weight loss drugs are not covered
SOLIRIS 6 PA
MED Medical Drug
T:SLIM INSULIN PUMP 6 PA
T:SLIM X2 INSULIN PMP BASAL IQ 6 PA
TRUE METRIX BLOOD GLUCOSE TEST 4
V-GO 20 2 PA
V-GO 30 2 PA
V-GO 40 2 PA
OPHTHALMIC AGENTS
XIIDRA 2
OPHTHALMIC ANTI-ALLERGY AGENTS
EYSUVIS 3
OPHTHALMIC ANTIGLAUCOMA AGENTS
timolol maleate (ophth) (soln 0.25%, soln 0.5%) 1
OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS
latanoprost ophth soln 0.005% 1
OTIC AGENTS
CIPRODEX 2
1
ARMONAIR DIGIHALER 4
ARMONAIR RESPICLICK 113 3
ARNUITY ELLIPTA 2
ST
ASMANEX (14 METERED DOSES) 3
ST
ST
ST
ST
ASMANEX 30 METERED DOSES 3
ST
ASMANEX HFA 3
budesonide (nasal) 3
FLONASE SENSIMIST 4 C generic fluticasone covered
FLOVENT DISKUS 2
FLOVENT HFA 2
NASACORT ALLERGY 24HR (24HR 55 MCG/ACT AERO, 24HR 55 MCG/ACT AEROSOL)
4
ST
NASACORT ALLERGY 24HR CHILDREN 4
ST
NASACORT AQ 4 C alt = OTC products/Nasaco rt allergy
NASONEX 4 C alt = generic mometasone
PULMICORT FLEXHALER 2
QVAR REDIHALER 3
C all step 1 first: Arnuity, Flovent, Pulmicort
RHINOCORT AQUA 4 C alt = rhinocort allergy OTC
TRELEGY ELLIPTA 100-62.5-25 MCG/INH AER POW BA 2
triamcinolone acetonide nasal aerosol suspension 55 mcg/act 4 C alt = OTC products/Nasaco rt allergy
VERAMYST 4 C alt = generic fluticasone
ANTILEUKOTRIENES
montelukast sodium (chew tab 4 mg, chew tab 5 mg, tab 10 mg)
1
BRONCHODILATORS, ANTICHOLINERGIC
ipratropium bromide inhal soln 0.02% 1
ipratropium bromide (nasal) 1
BRONCHODILATORS, SYMPATHOMIMETIC
albuterol sulfate inhal aero 108 mcg/act (90mcg base equiv) 1
ALBUTEROL SULFATE HFA 1
epinephrine solution auto-injector 0.15 mg/0.3ml (1:2000) 1 C generic Epi-pen Jr. and generic Adrenaclick
epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000) 1
QL 8 / 1 years
PROAIR DIGIHALER 4
PROAIR RESPICLICK 2
SEREVENT DISKUS 2
CYSTIC FIBROSIS AGENTS
BRONCHITOL 5 PA
RESPIRATORY TRACT AGENTS, OTHER
ADVAIR HFA 3
AIRDUO DIGIHALER 4
ANORO ELLIPTA 2
ARALAST NP 6 MED Medical Drug
BREO ELLIPTA 3
BREZTRI AEROSPHERE 2
CINQAIR 6 PA
MED Medical Drug
COMBIVENT RESPIMAT 2
ipratropium-albuterol 1
6 MED Medical Drug
6 MED Medical Drug
PULMOZYME 5 PA
STIOLTO RESPIMAT 2
SKELETAL MUSCLE RELAXANTS
methocarbamol (tab 500 mg, tab 750 mg) 1
MYOBLOC 6 MED Medical Drug
orphenadrine citrate (tab er 100 mg, tab sr 100 mg) 1
XEOMIN 6 MED Medical Drug
SLEEP DISORDER AGENTS
GABA RECEPTOR MODULATORS
INTERMEZZO 4 C zolpidem tablets covered
RESTORIL (7.5 MG CAP, 22.5 MG CAP) 4 C alt = temazepam 15mg,30mg
temazepam (cap 7.5 mg, cap 22.5 mg) 4 C alt = temazepam 15mg,30mg
XYWAV 5 PA
S Specialty Drug
SLEEP DISORDER AGENTS, OTHERS
Uncategorized
Unclassified
PA
PLENITY 4 C weight loss drugs are not covered
PLENITY WELCOME KIT 4 C weight loss drugs are not covered
QELBREE (150 MG CAP ER 24H, 200 MG CAP ER 24H) 3 ST
C atomoxetine first
QL 1 / 1 days
XELJANZ 1 MG/ML SOLUTION 5
PA
3
Index of covered drugs A abacavir sulfate 18
abacavir sulfate-lamivudine 18
abacavir sulfate-lamivudine-zidovudine 18
ABILIFY MYCITE 17
abiraterone acetate 13
ACCU-CHEK SMARTVIEW 58
AIRDUO DIGIHALER 66
ASMANEX HFA 63
aspirin 3
ATENDIA 4
atenolol 33
BAFIERTAM 38
BALCOLTRA 48
BD PEN NEEDLE NANO 2ND GEN 58
BD PEN NEEDLE NANO U/F 58
BD PEN NEEDLE ORIGINAL U/F 58
BD PEN NEEDLE SHORT U/F 58
BEBULIN 29
buspirone hcl 19
BYSTOLIC 33
chlorothiazide 35
chlorthalidone 35
COSENTYX SENSOREADY PEN 55
DEXCOM G6 RECEIVER 59
DEXCOM G6 SENSOR 59
DEXCOM G6 TRANSMITTER 59
diltiazem hcl extended release beads 34
DIPHTHERIA-TETANUS TOXOIDS DT 56
ELIDEL 41
ELIGARD 51
ELIQUIS 27
ELLA 50
ELOCTATE 29
EMGALITY 12
EMPLICITI 16
etonogestrel-ethinyl estradiol 49
EVERSENSE SENSOR 59
FORTAMET 20
fosinopril sodium 33
FREESTYLE LIBRE 2 READER 59
FREESTYLE LIBRE 2 SENSOR 59
FREESTYLE LIBRE READER 60
FREESTYLE LITE TEST 60
GAMMAKED 54
GAMMAPLEX 54
GAMUNEX 54
GAMUNEX-C 54
GUARDIAN SENSOR (3) 60
HAVRIX 56
HUMALOG MIX 75/25 25
HUMALOG PEN 25
hydralazine hcl 36
ISENTRESS 18
isoniazid 12
LEVEMIR FLEXPEN 26
LEVEMIR FLEXTOUCH 26
MINIMED RESERVOIR 3ML 60
MIRENA (52 MG) 50
MYFEMBREE 68
MYOBLOC 67
MYRBETRIQ 46
NASACORT AQ 64
norethindrone acetate-ethinyl estradiol-fe 49
norethindrone-eth estradiol (triphasic) 49
NOVOLOG PENFILL 27
ofloxacin (ophth) 6
ofloxacin (otic) 6
ondansetron 11
ORACEA 7
ORAVIG 11
ORIAHNN 48
ORILISSA 51
OZEMPIC (1 MG/DOSE) 22
PALFORZIA (120 MG DAILY DOSE) 55
PALFORZIA (300 MG MAINTENANCE) 55
PALFORZIA (300 MG TITRATION) 55
PALFORZIA INITIAL ESCALATION 55
PRADAXA 27
PRALUENT 36
ropinirole hydrochloride 17
rosuvastatin calcium 36
SAVAYSA 27
SAVELLA 37
SAXENDA 60
SEGLUROMET 23
SEMGLEE 27
SLYND 50
SUSTOL 11
SYMBICORT 67
SYMFI 18
T:SLIM INSULIN PUMP 61
tacrolimus (topical) 42
TENIVAC 57
TRULANCE 44
TRULICITY 24
TRUMENBA 57
TRUVADA 18
VANTAS 51
VAQTA 57
VARIVAX 57
VASCEPA 36
VIOKACE 46
VIVLODEX 3
VONVENDI 31
VRAYLAR 17
VUMERITY 39
ZEPOSIA STARTER KIT 40
Albanian: KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në 1-800-462-3589 (TTY: 1-888- 740-5670). Arabic: :
) 9853-264-008-1 . (.0765-047-888-1 :
Bantu: ICITONDERWA: Nimba uvuga Ikirundi, uzohabwa serivisi zo gufasha mu ndimi, ku buntu. Woterefona 1-800-462-3589 (TTY: 1-888-740-5670).
Bengali: , ,

-800-462-3589 (TTY: -888-740-5670)
Chinese:
740-5670
Cushite: XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 1-800-462-3589 (TTY: 1-888- 740-5670). Dutch: AANDACHT: Als u nederlands spreekt, kunt u gratis gebruikmaken van de taalkundige diensten. Bel 1-800-462-3589 (TTY: 1-888-740-5670). French: ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-800-462-3589 (ATS : 1- 888-740-5670). German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1- 800-462-3589 (TTY: 1-888-740-5670). Italian: ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-800-462- 3589 (TTY: 1-888-740-5670).
Japanese:
. 1-800-462-
3589 (TTY: 1-888-740-5670) .
Nepali: :

1-800-462-3589 (: 1-888-740-
5670) Wann du [Deitsch (Pennsylvania German / Dutch)] schwetzscht, kannscht du mitaus Koschte ebber gricke, ass dihr helft mit die englisch Schprooch. Ruf selli Nummer uff: Call 1-800-462-3589 (TTY: 1-888- 740-5670). Polish: UWAGA: Jeeli mówisz po polsku, moesz skorzysta z bezpatnej pomocy jzykowej. Zadzwo pod numer 1-800-462-3589 (TTY: 1-888-740-5670). Romanian: ATENIE: Dac vorbii limba român, v stau la dispoziie servicii de asisten lingvistic, gratuit. Sunai la 1-800-462-3589 (TTY: 1-888-740- 5670). Russian: : , . 1-800-462-3589 (: 1- 888-740-5670). Serbo-Croatian: OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezike pomoi dostupne su vam besplatno. Nazovite 1-800-462-3589 (TTY- Telefon za osobe sa ošteenim govorom ili sluhom: 1-888-740-5670). Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-462-3589 (TTY: 1-888-740-5670). Syriac:
:

.
(TTY: 1-888-740-5670) 3589-462-800-1
Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-800-462-3589 (TTY: 1-888-740-5670). Ukrainian: ! , . 1-800-462-3589 (: 1-888-740-5670). Vietnamese: CHÚ Ý: Nu bn nói Ting Vit, có các dch v h tr ngôn ng min phí dành cho bn. Gi s 1-800-462-3589 (TTY: 1-888-740-5670).
Notice of Nondiscrimination and Accessibility: Discrimination is Against the Law Paramount complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Paramount does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Paramount provides:
• Free aids and services to people with disabilities to communicate effectively with us, such as:
Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats,
other formats) • Free language services to people whose primary language is not English, such as:
Qualified interpreters Information written in other languages If you need these services, contact Member Services at 1-800-462-3589.
If you believe that Paramount has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance. You can file a grievance in person or by mail, fax, or email.
Member Services 1901 Indian Wood Circle, Maumee OH 43537 Phone: 419-887-2525 Toll Free: 1-800-462-3589 TTY: 1-888-740-5670 Fax: 419-887-2047 Email: [email protected].
If you need help filing a grievance, Member Services is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
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