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11705 HCR Essential Closed State Exchange

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11705 HCR Essential Closed State Exchange HCR Essential Key Notes BE = This medication is not covered in Pennsylvania under the Health Care Reform Comprehensive and Health Care Reform Progressive Formularies for Individual Plans and may not be covered for Group Plans. Contact Member Services for more information. EX = This medication is not covered in Pennsylvania or West Virginia under the Health Care Reform Comprehensive and Health Care Reform Progressive Formularies for Individual Plans and may not be covered for Group Plans. Contact Member Services for more information. PA = Coverage of this drug is subject to review by the plan and is based on Pharmacy policy. QL = Limits the amount of drug that a beneficiary may receive in a certain period. SP = To assist in the management of select specialty medications, some pharmacy benefit designs require the Status use of a preferred specialty $0 = Preventative Medication pharmacy. Please call the number on 1 = Tier 1 the back of your member ID card for 2 = Tier 2 assistance. 3 = Tier 3 ST = For a step therapy drug to be 4 = Tier 4 covered, the beneficiary will be first lowercase italics = Generic drugs NF = Non-Formulary required to try a therapeutically UPPERCASE = Brand name drugs Special Tier = Special Tier equivalent medication. Drug Status Notes Analgesic, Anti-Inflammatory Or Antipyretic Analgesic Opioid Agonists PA; ST; QL (120 UNITS per 25 ACTIQ NF days) PA; ST; QL (14 DAY SUPPLY ALFENTA NF per 30 days) Last Approved Date: 09/24/2021 Formulary Version: 92 1 Drug Status Notes PA; ST; QL (14 DAY SUPPLY alfentanil NF per 30 days) ARYMO ER Special Tier PA; ST; QL (90 MG per 1 day) ASTRAMORPH-PF INJECTION SOLUTION 1 PA; ST; QL (14 DAY SUPPLY 3 MG/ML per 30 days) PA; ST; QL (186 TABLETS per codeine sulfate 1 25 days) CONZIP NF PA; ST; QL (90 MG per 1 day) DEMEROL (PF) INJECTION SOLUTION 50 PA; ST; QL (14 DAY SUPPLY NF MG/ML per 30 days) PA; ST; QL (14 DAY SUPPLY DEMEROL (PF) INJECTION SYRINGE NF per 30 days) DEMEROL INJECTION SOLUTION 100 PA; ST; QL (14 DAY SUPPLY NF MG/ML per 30 days) PA; ST; QL (248 TABLETS per DEMEROL ORAL TABLET 100 MG NF 25 days) PA; ST; QL (14 DAY SUPPLY DILAUDID (PF) INJECTION SOLUTION NF per 30 days) DILAUDID (PF) INJECTION SYRINGE 0.5 NF PA; ST MG/0.5 ML, 1 MG/ML, 2 MG/ML DILAUDID INJECTION NF PA; ST PA; ST; QL (2480 ML per 25 DILAUDID ORAL LIQUID NF days) PA; ST; QL (186 TABLETS per DILAUDID ORAL TABLET NF 25 days) PA; ST; QL (248 TABLETS per DISKETS NF 25 days) PA; ST; QL (248 TABLETS per DOLOPHINE ORAL NF 25 days) PA; ST; QL (20 PATCHES per 25 DURAGESIC NF days) PA; ST; QL (14 DAY SUPPLY DURAMORPH (PF) NF per 30 days) PA; ST; QL (60 TABLETS per 25 EXALGO ER NF days) PA; ST; QL (120 UNITS per 25 fentanyl citrate buccal lozenge on a handle 3 days) PA; ST; QL (120 units per 25 fentanyl citrate buccal tablet, effervescent NF days) Last Approved Date: 09/24/2021 Formulary Version: 92 2 Drug Status Notes fentanyl transdermal patch 72 hour 100 mcg/hr, PA; ST; QL (20 PATCHES per 25 2 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr days) fentanyl transdermal patch 72 hour 37.5 PA; ST; QL (20 PATCHES per 25 NF mcg/hour, 62.5 mcg/hour, 87.5 mcg/hour days) PA; ST; QL (120 UNITS per 25 FENTORA NF days) hydrocodone bitartrate oral capsule, oral only, er PA; ST; QL (100 CAPSULES per NF 12hr 25 days) hydrocodone bitartrate oral tablet,oral PA; ST; QL (30 tablets per 25 1 only,ext.rel.24 hr days) hydromorphone (pf) injection syringe NF PA; ST hydromorphone in 0.9 % nacl intravenous patient NF PA control.analgesia soln 6 mg/30 ml hydromorphone in d5w (pf) intravenous syringe NF PA; ST PA; ST; QL (2480 ML per 25 hydromorphone oral liquid NF days) PA; ST; QL (186 TABLETS per hydromorphone oral tablet 1 25 days) PA; ST; QL (60 TABLETS per 25 hydromorphone oral tablet extended release 24 hr 3 days) PA; ST; QL (14 DAY SUPPLY hydromorphone rectal 2 per 30 days) PA; ST; QL (30 TABLETS per 25 HYSINGLA ER Special Tier days) INFUMORPH P/F INJECTION SOLUTION 10 PA; ST; QL (14 DAY SUPPLY NF MG/ML per 30 days) PA; ST; QL (14 DAY SUPPLY IONSYS NF per 30 days) KADIAN ORAL CAPSULE,EXTEND.RELEASE PELLETS 10 PA; ST; QL (62 CAPSULES per NF MG, 100 MG, 20 MG, 200 MG, 30 MG, 40 MG, 25 days) 50 MG, 60 MG, 80 MG LAZANDA NASAL SPRAY,NON-AEROSOL PA; ST; QL (30 BOTTLES per 25 NF 100 MCG/SPRAY, 400 MCG/SPRAY days) LAZANDA NASAL SPRAY,NON-AEROSOL NF PA; ST 300 MCG/SPRAY PA; ST; QL (186 TABLETS per levorphanol tartrate oral tablet 2 mg NF 25 days) PA; ST; QL (186 tablets per 25 levorphanol tartrate oral tablet 3 mg NF days) Last Approved Date: 09/24/2021 Formulary Version: 92 3 Drug Status Notes meperidine (pf) injection solution 100 mg/ml, 25 PA; ST; QL (14 DAY SUPPLY NF mg/ml, 50 mg/ml per 30 days) PA; ST; QL (2500 ML per 25 meperidine oral solution 1 days) PA; ST; QL (248 TABLETS per meperidine oral tablet 1 25 days) PA; ST; QL (14 DAY SUPPLY methadone injection solution NF per 30 days) methadone intravenous 3 PA; ST methadone oral concentrate 3 PA; ST; QL (248 ML per 25 days) PA; ST; QL (1240 ML per 25 methadone oral solution 10 mg/5 ml 1 days) PA; ST; QL (2480 ML per 25 methadone oral solution 5 mg/5 ml 1 days) methadone oral syringe 10 mg/ml 3 PA; ST PA; ST; QL (248 TABLETS per methadone oral tablet 1 25 days) PA; ST; QL (248 TABLETS per methadone oral tablet,soluble NF 25 days) METHADOSE ORAL CONCENTRATE 3 PA; ST; QL (248 ML per 25 days) PA; ST; QL (248 TABLETS per METHADOSE ORAL TABLET,SOLUBLE NF 25 days) PA; ST; QL (14 DAY SUPPLY morphine (pf) injection solution 1 mg/ml NF per 30 days) PA; ST; QL (14 DAY SUPPLY morphine concentrate oral solution 1 per 30 days) PA; ST; QL (14 DAY SUPPLY morphine injection solution 15 mg/ml NF per 30 days) PA; ST; QL (14 DAY SUPPLY morphine intravenous solution 10 mg/ml NF per 30 days) PA; ST; QL (14 DAY SUPPLY morphine intravenous syringe 4 mg/ml NF per 30 days) PA; ST; QL (62 CAPSULES per morphine oral capsule, er multiphase 24 hr NF 25 days) PA; ST; QL (62 CAPSULES per morphine oral capsule,extend.release pellets NF 25 days) PA; ST; QL (2800 ML per 25 morphine oral solution 10 mg/5 ml 1 days) PA; ST; QL (1400 ML per 25 morphine oral solution 20 mg/5 ml (4 mg/ml) 1 days) Last Approved Date: 09/24/2021 Formulary Version: 92 4 Drug Status Notes PA; ST; QL (186 TABLETS per morphine oral tablet 1 25 days) PA; ST; QL (100 TABLETS per morphine oral tablet extended release 2 25 days) PA; ST; QL (14 DAY SUPPLY morphine rectal NF per 30 days) PA; ST; QL (100 TABLETS per MS CONTIN NF 25 days) PA; ST; QL (186 TABS per 25 NUCYNTA NF days) PA; ST; QL (62 TABLETS per 25 NUCYNTA ER NF days) PA; ST; QL (100 TABLETS per OPANA ER NF 25 days) OPANA INJECTION NF PA; ST PA; ST; QL (180 TABLETS per OPANA ORAL NF 25 days) PA; ST; QL (100 TABLETS per ORAMORPH SR 3 25 days) PA; ST; QL (180 TABLET per 25 OXAYDO NF days) PA; ST; QL (180 CAPSULE per oxycodone oral capsule NF 25 days) oxycodone oral concentrate NF PA; ST; QL (180 ML per 25 days) PA; ST; QL (5600 ML per 25 oxycodone oral solution 3 days) PA; ST; QL (180 TABLET per 25 oxycodone oral tablet 1 days) oxycodone oral tablet,oral only,ext.rel.12 hr 10 PA; ST; QL (100 TABLETS per NF mg, 20 mg, 40 mg, 80 mg 25 days) PA; ST; QL (100 TABLETS per OXYCONTIN 3 25 days) PA; ST; QL (180 TABLETS per oxymorphone oral tablet NF 25 days) PA; ST; QL (100 TABLETS per oxymorphone oral tablet extended release 12 hr 2 25 days) QDOLO NF PA; ST PA; ST; QL (180 TABLET per 25 ROXICODONE NF days) Last Approved Date: 09/24/2021 Formulary Version: 92 5 Drug Status Notes PA; ST; QL (14 DAY SUPPLY ROXYBOND Special Tier per 30 days) PA; ST; QL (240 SPRAY UNITS SUBSYS NF per 25 days) tramadol oral capsule,er biphase 24 hr 17-83 NF PA; ST; QL (90 MG per 1 day) tramadol oral capsule,er biphase 24 hr 25-75 NF PA; ST; QL (90 MG per 1 day) PA; ST; QL (14 day supply per 30 tramadol oral tablet 100 mg NF dayss) PA; ST; QL (14 DAY SUPPLY tramadol oral tablet 50 mg 1 per 30 days) tramadol oral tablet extended release 24 hr 3 PA; ST; QL (90 MG per 1 day) tramadol oral tablet, er multiphase 24 hr 3 PA; ST; QL (90 MG per 1 day) PA; ST; QL (14 DAY SUPPLY ULTRAM NF per 30 days) ULTRAM ER ORAL TABLET EXTENDED NF PA; ST; QL (90 MG per 1 day) RELEASE 24 HR 300 MG PA; ST; QL (60 CAPSULES per XTAMPZA ER Special Tier 23 days) PA; ST; QL (100 CAPSULES per ZOHYDRO ER NF 25 days) Analgesic Opioid Codeine Combinations acetaminophen-codeine oral solution 120-12 PA; ST; QL (14 DAY SUPPLY 1 mg/5 ml per 30 days) PA; ST; QL (120 GM APAP acetaminophen-codeine oral tablet 1 COMP per 25 days) PA; ST; QL (14 DAY SUPPLY ASCOMP WITH CODEINE 3 per 30 days) PA; ST; QL (14 DAY SUPPLY BUTALBITAL COMPOUND W/CODEINE 3 per 30 days) PA; ST; QL (14 DAY SUPPLY BUTALBITAL COMPOUND-CODEINE 3 per 30 days) butalbital-acetaminop-caf-cod oral capsule 50- PA; ST; QL (120 GM APAP NF 300-40-30 mg COMP per 25 days) butalbital-acetaminop-caf-cod oral capsule 50- PA; ST; QL (120 GM APAP 3 325-40-30 mg COMP per 25 days) PA; ST; QL (14 DAY SUPPLY CAPITAL WITH CODEINE NF per 30 days) PA; ST; QL (14 DAY SUPPLY codeine-butalbital-asa-caff 3 per 30 days) Last Approved Date: 09/24/2021 Formulary Version: 92 6 Drug Status Notes FIORICET WITH CODEINE NF PA; ST; QL (120 GM per 25 days) PA; ST; QL (14 DAY SUPPLY FIORINAL-CODEINE #3 NF per 30 days) PA; ST; QL (120 GM APAP TYLENOL-CODEINE #3 NF COMP per 25 days) PA; ST; QL (120 GM APAP TYLENOL-CODEINE #4 NF COMP per 25 days) Analgesic Opioid Dihydrocodeine Combinations PA; ST; QL (14 DAY SUPPLY acetaminophen-caff-dihydrocod oral capsule NF per 30 days) PA; ST; QL (14 DAY SUPPLY aspirin-caffeine-dihydrocodein NF per 30 days) PA; ST; QL (300 TABLETS per PANLOR(ACETAM-CAFF-DIHYDROCOD) 3 25 days) PA; ST; QL (14
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