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3 Tier Drug Formulary - 2021 DAKOTACARE-ONE 2021 3-Tier Drug Formulary

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3 Tier Drug Formulary - 2021 DAKOTACARE-ONE 2021 3-Tier Drug Formulary 3 Tier Drug Formulary - 2021 DAKOTACARE-ONE 2021 3-Tier Drug Formulary EFFECTIVE 04/01/2021 PLEASE READ: THIS DOCUMENT HAS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. Please refer to your Certificate of Coverage, Master Contract, Plan Document or other plan materials to determine if your drug is covered. The Drug Formulary does not guarantee coverage and is subject to change. The Drug Formulary is subject to change without notice. Members must use participating pharmacies to fill their prescription drugs. WHAT IS THE DAKOTACARE DRUG FORMULARY? .......................................................................................................................................... 4 CAN THE DRUG FORMULARY CHANGE?............................................................................................................................................................ 4 HOW DO I USE THE DRUG FORMULARY? .......................................................................................................................................................... 4 DAKOTACARE DRUG FORMULARY ..................................................................................................................................................................... 4 WHAT IF MY DRUG IS NOT ON THE DRUG FORMULARY? ............................................................................................................................... 5 HOW LIKELY IS IT THAT I WILL GET THE FORMULARY EXCEPTION? ........................................................................................................... 5 WHAT DO THE TIERS MEAN ON THE DRUG FORMULARY? ............................................................................................................................. 6 NOTICE ..................................................................................................................................................................................................................... 6 ANALGESICS........................................................................................................................................................................................................... 7 NSAIDs ........................................................................................................................................................................................................... 7 NSAIDs, COMBINATIONS ............................................................................................................................................................................. 7 NSAIDs, TOPICAL ......................................................................................................................................................................................... 7 COX-2 INHIBITORS ....................................................................................................................................................................................... 7 GOUT ............................................................................................................................................................................................................. 7 OPIOID ANALGESICS ................................................................................................................................................................................... 7 ANTI-INFECTIVES ................................................................................................................................................................................................... 8 ANTIBACTERIALS ......................................................................................................................................................................................... 8 ANTIFUNGALS .............................................................................................................................................................................................. 9 ANTIMALARIALS ........................................................................................................................................................................................... 9 ANTIRETROVIRAL AGENTS ........................................................................................................................................................................ 9 ANTITUBERCULAR AGENTS ..................................................................................................................................................................... 10 ANTIVIRALS................................................................................................................................................................................................. 11 MISCELLANEOUS ....................................................................................................................................................................................... 11 CARDIOVASCULAR .............................................................................................................................................................................................. 12 ACE INHIBITORS ........................................................................................................................................................................................ 12 ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS ........................................................................................................ 12 ACE INHIBITOR/DIURETIC COMBINATIONS ............................................................................................................................................ 12 ADRENOLYTICS, CENTRAL ....................................................................................................................................................................... 12 ALDOSTERONE RECEPTOR ANTAGONISTS .......................................................................................................................................... 12 ALPHA BLOCKERS ..................................................................................................................................................................................... 12 ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS ........................................................................................... 13 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS ......................................................... 13 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS ....................................... 13 ANTIARRHYTHMICS ................................................................................................................................................................................... 13 ANTILIPEMICS............................................................................................................................................................................................. 13 BETA-BLOCKERS ....................................................................................................................................................................................... 14 BETA-BLOCKER/DIURETIC COMBINATIONS ........................................................................................................................................... 15 CALCIUM CHANNEL BLOCKERS .............................................................................................................................................................. 15 CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS ............................................................................................................ 15 DIGITALIS GLYCOSIDES ............................................................................................................................................................................ 15 DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS ....................................................................................................................... 15 DIURETICS .................................................................................................................................................................................................. 15 HEART FAILURE ......................................................................................................................................................................................... 16 NITRATES .................................................................................................................................................................................................... 16 PULMONARY ARTERIAL HYPERTENSION .............................................................................................................................................. 16 MISCELLANEOUS ....................................................................................................................................................................................... 16 CENTRAL NERVOUS SYSTEM ............................................................................................................................................................................ 17 ANTIANXIETY .............................................................................................................................................................................................
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