rillium ADVANTAGE'
Trillium Advantage Dual (HMO D-SNP)
2020 Formulary (List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN
HPMS Approved Formulary File Submission ID 20447, Version Number 21
This formulary was updated on 12/01/2020. For more recent information or other questions, please contact Trillium Advantage Dual (HMO D-SNP) at 1-844-867-1156 or, for TTY users, 711, from October 1 – March 31, seven days a week, 8 a.m. to 8 p.m., from April 1 - September 30, Monday through Friday, 8 a.m. to 8 p.m. A messaging system is used after hours, on weekends, and on federal holidays, or visit trilliumadvantage.com.
Y0020_20_14287FRMLY_C_FINAL_14802_08062019 Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to “we,” “us”, or “our,” it means Trillium Community Health Plan. When it refers to “plan” or “our plan,” it means Trillium Advantage Dual (HMO D-SNP). This document includes a list of the drugs (formulary) for our plan which is current as of 12/01/2020. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2021, and from time to time during the year.
What is the Trillium Advantage Dual (HMO D-SNP) Formulary? A formulary is a list of covered drugs selected by our plan in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. We will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a plan network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.
Can the Formulary (drug list) change? Most changes in drug coverage happen on January 1, but we may add or remove drugs on the Drug List during the year, move them to different cost-sharing tiers, or add new restrictions. We must follow Medicare rules in making these changes. Changes that can affect you this year: In the below cases, you will be affected by coverage changes during the year: • New generic drugs. We may immediately remove a brand name drug on our Drug List if we are replacing it with a new generic drug that will appear on the same or lower cost sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our Drug List, but immediately move it to a different cost-sharing tier or add new restrictions. If you are currently taking that brand name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made. o If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on how to request an exception, and you can also find information in the section below entitled “How do I request an exception to the Trillium Advantage Dual (HMO D-SNP) Formulary?”
• Drugs removed from the market. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug.
i • Other changes. We may make other changes that affect members currently taking a drug. For instance, we may add a generic drug that is not new to market to replace a brand name drug currently on the formulary or add new restrictions to the brand name drug or move it to a different cost-sharing tier. Or we may make changes based on new clinical guidelines. If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug, we must notify affected members of the change at least 30 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 30-day supply of the drug. o If we make these other changes, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on how to request an exception, and you can also find information in the section below entitled “How do I request an exception to the Trillium Advantage Dual (HMO D-SNP) Formulary?”
Changes that will not affect you if you are currently taking the drug. Generally, if you are taking a drug on our 2020 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2020 coverage year except as described above. This means these drugs will remain available at the same cost-sharing and with no new restrictions for those members taking them for the remainder of the coverage year. The enclosed formulary is current as of 12/01/2020. To get updated information about the drugs covered by our plan, please contact us. Our contact information appears on the front and back cover pages. If we make any other negative changes to a drug you are taking, we will notify you via mail. We will also post the changes on our website.
How do I use the Formulary? There are two ways to find your drug within the formulary:
Medical Condition The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “CARDIOVASCULAR AGENTS-MISC. - Drugs to Treat Heart and Circulation Conditions”. If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug.
Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page Index 1. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.
ii What are generic drugs? Our plan covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.
Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:
• Prior Authorization: Our plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from us before you fill your prescriptions. If you don’t get approval, we may not cover the drug.
• Quantity Limits: For certain drugs, our plan limits the amount of the drug that we will cover. For example, our plan provides one tablet per day per prescription for simvastatin 40 mg. This may be in addition to a standard one-month or three-month supply.
• Step Therapy: In some cases, our plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.
You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.
You can ask us to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the Trillium Advantage Dual (HMO D-SNP) Formulary?” on page iv for information about how to request an exception.
What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered. If you learn that our plan does not cover your drug, you have two options:
• You can ask Member Services for a list of similar drugs that are covered by our plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by us. • You can ask us to make an exception and cover your drug. See below for information about how to request an exception.
iii How do I request an exception to the Trillium Advantage Dual (HMO D-SNP) Formulary? You can ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. • You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.
• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, our plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.
Generally, we will only approve your request for an exception if the alternative drugs included on the plan’s formulary or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
You should contact us to ask us for an initial coverage decision for a formulary or utilization restriction exception. When you request a formulary or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.
What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.
For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply. If your prescription is written for fewer days, we’ll allow refills to provide up to a maximum 30-day supply of medication. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.
If you are a resident of a long-term care facility and you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug while you pursue a formulary exception.
iv Level of care changes If you experience a change in your level of care, we will cover a transition supply of your drugs. A level of care change occurs when you are discharged from a hospital or moved to or from a long-term care facility. • If you move home from a long-term care facility or hospital and need a transition supply, we will cover one 30-day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a total of a 30-day supply. • If you move from home or a hospital to a long-term care facility and need a transition supply, we will cover one 31-day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a total of a 31-day supply.
For more information For more detailed information about your plan’s prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about our plan, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486- 2048. Or, visit http://www.medicare.gov.
Trillium Advantage Dual (HMO D-SNP) Formulary The formulary that begins on page 1 provides coverage information about the drugs covered by our plan. If you have trouble finding your drug in the list, turn to the Index that begins on page Index 1. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., ELIQUIS TABS) and generic drugs are listed in lower-case italics (e.g., warfarin sodium tabs). The information in the Requirements/Limits column tells you if our plan has any special requirements for coverage of your drug.
v Abbreviations The abbreviations below may appear in the Requirements/Limits column on the formulary.
Abbreviation Definition Description
AL Age Limit This drug may require prior authorization if your age does not meet manufacturer, FDA, or clinical recommendations.
B/D Medicare Part B This drug may be covered under Medicare Part B or Part D vs. Part D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.
LA Limited Access This prescription may be available only at certain pharmacies. For more information consult your Provider and Pharmacy Directory or call Member Services from October 1 – March 31, 7 days a week, 8 a.m. to 8 p.m. From April 1 - September 30, Monday through Friday, 8 a.m. to 8 p.m. Our contact information appears on the front and back covers. TTY users should call 711.
MO Mail Order This drug is available at our mail order pharmacy in addition to other network pharmacies.
NDS Non-Extended This prescription drug may not be available for an extended day Day Supply supply. Call Member Services to ask if the drug is available as an extended supply.
PA Prior This drug requires prior authorization. This means that you or your Authorization prescriber must get approval from us before you fill your prescription. If you don’t get approval, we may not cover the drug.
QL Quantity Limit This drug has a limit on the amount that we will cover. For example, we cover one tablet per day per prescription for simvastatin 40 mg. This may be in addition to a standard one- month or three-month supply limit. RX/OTC Prescription and This drug is available both in a prescription form and in an OTC Over-the- form. Other than some insulins and insulin supplies, only Counter (OTC) prescription drugs are covered by our Medicare Part D plans.
SL Safety Limit This drug has a maximum daily dose limit for safety supported by the FDA. This means that we will not cover more than the maximum daily dose. For example, the FDA maximum daily dose of ibuprofen is 3200 mg. Therefore, we will only cover four tablets per day for ibuprofen 800 mg.
vi Abbreviation Definition Description
ST Step Therapy This drug requires step therapy. This means that you must first try certain drugs to treat your medical condition before we cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.
Formulary tier descriptions Our plan covers both brand-name drugs and generic drugs. Generally, generic drugs cost less than brand-name drugs. For more detailed information about your out-of-pocket costs for prescriptions, including any deductible that may apply, please refer to your Evidence of Coverage and other plan materials.
The table below shows the standard retail 30-day supply copayment or coinsurance amount (i.e., the share of the drug's cost that you will pay during the initial coverage stage):
State Plan Name Tier 1 Generic and Brand (includes generic drugs and brand drugs) OR Trillium Advantage 25% Dual (HMO D-SNP) - OR – $0, $1.30, $3.60 copay or 15% of the total cost for generic drugs $0, $3.90, $8.95 copay or 15% of the total cost for brand name drugs (depending upon your level of Extra Help)
vii Section 1557 Non-Discrimination Language Notice of Non-Discrimination
Trillium Medicare Advantage complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Trillium Medicare Advantage does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Trillium Medicare Advantage: . Provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print, audio, accessible electronic formats, other formats). . Provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages.
If you need these services, contact Trillium Medicare Advantage's Member Services at: 1-844-867-1156 (HMO SNP), (TTY: 711). From October 1 to March 31, you can call us 7 days a week from 8 a.m. to 8 p.m. From April 1 to September 30, you can call us Monday through Friday from 8 a.m. to 8 p.m. A messaging system is used after hours, weekends, and on federal holidays.
If you believe that Trillium Medicare Advantage 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 by calling the number above and telling them you need help filing a grievance; Trillium Medicare Advantage’s 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, DC 20201, 1-800-368-1019 (TDD: 1-800-537-7697).
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
FLY0301912M00
Y0020_20_13607MLI_C_07222019 Oregon | For Medicare: 1-844-867-1156, (TTY: 711) English: Language assistance services, auxiliary aids and services, and other alternative formats are available to you free of charge. To obtain this, please call the number above. Espa ol (Spanish): Servicios de asistencia de idiomas, ayudas y servicios auxiliares, y otros formatos alternativos están disponibles para usted sin ning n costo. Para obtener esto, llame al n mero de arriba.
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日本語 (Japanese): 言語支援サービス、補助器具と補助サービス、その他のオプション形式を無料で ご利用いただけます。ご利用をお考えの方は、上記の番号にお電話ください。 (Arabic) : ﻟك ﻣﺟﺎﻧﺎ. ﻟﻠﺣﺻول ﻋﻠﯾﮭﺎ ﺧدﻣﺎت اﻟﻣﺳﺎﻋدة اﻟﻠﻐوﯾﺔ واﻟﻣﻌﯾﻧﺎت واﻟﺧدﻣﺎت اﻹﺿﺎﻓﯾﺔ وﻏﯾرھﺎ ﻣن اﻷﺷﻛﺎل اﻟﺑدﯾﻠﺔ ﻣﺗﺎﺣﺔ، اﻟﻌرﺑﯾﺔ .ﯾرﺟﻰ اﻻﺗﺻﺎل ﺑﺎﻟرﻗم أﻋﻼه Română (Romanian): Servicii de asistență lingvistică, ajutoare și servicii auxiliare, precum și alte formate alternative vă stau la dispoziție în mod gratuit. Pentru a le obține, apelați numărul de mai sus.
Cushite (Cushite): Tajaajila qarqaarsa afaanii, qarqaarsa deeggarsaa fi tajaajilaa, fi qarqaarsi akkaataa biroo bilisaan siif laatama. Tajaajila kanniin argachuuf maaloo lakkoofsa asii olii bilbili. Deutsch (German): Sprachunterst tzung, Hilfen und Dienste f r H rbehinderte und Geh rlose sowie weitere alternative Formate werden Ihnen kostenlos zur Verf gung gestellt. Um eines dieser Serviceangebote zu nutzen, wählen Sie die o. a. Rufnummer.
ﻲﺳرﻓﺎ (Persian): ﮫﺟﻣرﺗتﺎدﻣﺧ ، تﺎﯾﺣﻣ ھﺎ وی تﺎدﻣﺧ ﻣﮑﮐ ﯽ ﺧ؛ ﺷردط ﺗت ر ﻣﻲﺟرﺗو ھﻲﺎﻔﺷ ﺳو ﺎﯾر اعواﻧ رﯾﮕد تﺎدﻣﺧ ﺑ روﺻﮫ ت را نﺎﯾﮕ ﺧﺗارد ﯾﺎر ﻣﺎﺷ ارﻗر ﻣ ﮔﯽ درﻧﯾ . ﺑ ار ی ﯾتﺳد ﺑﻲﺎﺑ ،تﺎدﻣﺧناﯾﮫ ﻔﺎطﻟ هﻣﺎرﺷﺑﺎ نﻠﻔﺗ ﺎﻻﺑ ﺗﻣ درﯾﮕﯾﺑسﺎ . Français (French) : Des services gratuits d’assistance linguistique, ainsi que des services d’assistance supplémentaires et d’autres formats sont à votre disposition. Pour y accéder, veuillez appeler le numéro ci-dessus.
ไทย (Thai): บริการช่วยเหลือด้านภาษา อุปกรณ์และบริการเสริม รวมทั้งรูปแบบทางเลือกอื่น ๆ มีให้ท่านใช้ได้โดยไม่เสียค่าใช้จ่าย หากต้องการขอรับบริการเหล่านี้ กรุณาติดต่อทางโทรศัพท์ที่หมายเลขข้างต้น
Y0020_20_13607MLI_C_07222019 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADHD/ANTI-NARCOLEPSY/ANTI- dexmethylphenidate hcl 1 SL(2.66 ea OBESITY/ANOREXIANTS - Drugs to Treat cp24 15 mg daily); MO ADHD, Sleep and Eating Disorders dexmethylphenidate hcl 1 SL(2 ea daily); cp24 20 mg MO Amphetamines dexmethylphenidate hcl SL(1.6 ea amphetamine- 1 MO 1 dextroamphetamine cp24 cp24 25 mg daily); MO dexmethylphenidate hcl SL(1.33 ea amphetamine- 1 MO 1 dextroamphetamine tabs cp24 30 mg daily); MO dexmethylphenidate hcl SL(1.14 ea dextroamphetamine sulfate 1 MO 1 cp24 10 mg, 15 mg, 5 mg cp24 35 mg daily); MO dexmethylphenidate hcl SL(1 ea daily); dextroamphetamine sulfate 1 MO 1 tabs 10 mg, 5 mg cp24 40 mg MO PA; MO dexmethylphenidate hcl 1 SL(8 ea daily); methamphetamine hcl tabs 1 cp24 5 mg MO dexmethylphenidate hcl 1 MO Attention-Deficit/Hyperactivity Disorder (ADHD) tabs 10 mg, 2.5 mg, 5 mg atomoxetine hcl caps 10 1 SL(10 ea daily); methylphenidate hcl cp24 MO mg MO 10 mg, 20 mg, 30 mg, 40 1 atomoxetine hcl caps 100 1 SL(1 ea daily); mg, 60 mg mg MO methylphenidate hcl cpcr 1 QL(2 ea daily); atomoxetine hcl caps 18 1 SL(5.55 ea 20 mg MO mg daily); MO methylphenidate hcl cpcr 1 MO atomoxetine hcl caps 25 1 SL(4 ea daily); 30 mg mg MO methylphenidate hcl cpcr QL(1 ea daily); atomoxetine hcl caps 40 1 SL(2.5 ea 40 mg, 10 mg, 50 mg, 60 1 MO mg daily); MO mg atomoxetine hcl caps 60 SL(1.66 ea 1 methylphenidate hcl tabs 1 QL(3 ea daily); mg daily); MO 20 mg, 10 mg, 5 mg MO atomoxetine hcl caps 80 SL(1.25 ea 1 methylphenidate hcl tb24 1 Non-Osmotic mg daily); MO 27 mg, 36 mg Release MO clonidine hcl (adhd) tb12 1 methylphenidate hcl tbcr 18 1 MO mg, 27 mg, 36 mg, 54 mg AL(Up to 64 yrs guanfacine hcl (adhd) tb24 1 methylphenidate hcl tbcr 20 1 QL(3 ea daily); old); MO mg MO Dopamine and Norepinephrine Reuptake modafinil tabs 100 mg 1 PA; MO PA; SL(1 ea SUNOSI TABS 150 MG 1 PA; QL(1 ea daily); MO modafinil tabs 200 mg 1 PA; SL(2 ea daily); MO SUNOSI TABS 75 MG 1 daily); MO AMINOGLYCOSIDES - Drugs to Treat Bacterial Histamine H3-Receptor Antagonist/Inverse Infections WAKIX TABS 1 PA; NDS Aminoglycosides amikacin sulfate soln 1 MO Stimulants - Misc. PA; NDS;MO dexmethylphenidate hcl 1 SL(4 ea daily); ARIKAYCE SUSP 1 cp24 10 mg MO
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 1 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BETHKIS NEBU 1 B/D; NDS XELJANZ TABS 1 PA; NDS (tobramycin) gentamicin in saline soln 1 Antirheumatic Antimetabolites 0.9 %-1 mg/ml OTREXUP SOAJ 1 PA gentamicin sulfate soln 40 1 MO mg/ml RASUVO SOAJ 1 PA neomycin sulfate tabs 1 MO Gold Compounds MO paromomycin sulfate caps 1 RIDAURA CAPS 1 NDS;MO NDS TOBI PODHALER CAPS 1 Interleukin-1 Blockers NDS;LA tobramycin nebu 300 1 B/D; NDS ARCALYST SOLR 1 mg/4ml Interleukin-1beta Blockers tobramycin nebu 300 1 B/D mg/5ml ILARIS SOLN 1 PA; NDS;LA tobramycin sulfate soln 1.2 1 MO gm/30ml, 80 mg/2ml Interleukin-6 Receptor Inhibitors tobramycin sulfate solr 1.2 1 ACTEMRA SOSY SC 162 1 PA; NDS gm MG/0.9ML ANALGESICS - ANTI-INFLAMMATORY - Drugs KEVZARA SOAJ 1 PA; NDS to Treat Pain, Swelling, Muscle and Joint Conditions KEVZARA SOSY 1 PA; NDS Anti-TNF-alpha - Monoclonal Antibodies HUMIRA PEDIATRIC PA; NDS Nonsteroidal Anti-inflammatory Agents (NSAIDs) CROHNS DISEASE 1 celecoxib caps 1 MO STARTER PACK PSKT MO HUMIRA PEN PNKT 1 PA; NDS diclofenac potassium tabs 1 diclofenac sodium tb24 1 MO HUMIRA PEN-CD/UC/HS 1 PA; NDS STARTER PNKT diclofenac sodium tbec 1 MO HUMIRA PEN-PS/UV 1 PA; NDS STARTER PNKT diclofenac w/ misoprostol 1 MO HUMIRA PSKT 1 PA; NDS tbec etodolac caps 1 MO SIMPONI ARIA SOLN 1 PA; NDS etodolac tabs 1 MO SIMPONI SOAJ 1 PA; NDS etodolac tb24 1 MO SIMPONI SOSY 1 PA; NDS MO Antirheumatic - Enzyme Inhibitors flurbiprofen tabs 100 mg 1 OLUMIANT TABS 1 PA; NDS ibuprofen susp 100 mg/5ml 1 RX/OTC; MO SL(8 ea daily); RINVOQ TB24 1 PA; NDS ibuprofen tabs 400 mg 1 MO
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 2 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SL(5.33 ea ibuprofen tabs 600 mg 1 ANALGESICS - NonNarcotic - Drugs to Treat daily); MO Pain, Muscle and Joint Conditions SL(4 ea daily); ibuprofen tabs 800 mg 1 Salicylates MO diflunisal tabs 1 MO indomethacin caps 25 mg, 1 AL(Up to 64 yrs 50 mg old); MO AL(Up to 64 yrs ANALGESICS - OPIOID - Drugs to Treat Pain, indomethacin cpcr 75 mg 1 old); MO Muscle and Joint Conditions Opioid Agonists ketorolac tromethamine 1 AL(Up to 64 yrs soln ij 15 mg/ml, 30 mg/ml old); MO fentanyl citrate lpop bu PA; NDS;QL(4 ketorolac tromethamine AL(Up to 64 yrs 1200 mcg, 1600 mcg, 400 1 ea daily); MO soln im 30 mg/ml, 60 1 old); MO mcg, 600 mcg, 800 mcg mg/2ml fentanyl citrate lpop bu 200 1 PA; NDS;QL(8 mcg ea daily); MO mefenamic acid caps 1 MO Limit 10 fentanyl pt72 100 mcg/hr, meloxicam tabs 1 MO 1 patches per 12 mcg/hr, 25 mcg/hr, 50 month;QL(0.34 mcg/hr, 75 mcg/hr ea daily); MO nabumetone tabs 1 MO hydrocodone bitartrate 1 PA; QL(3 ea naproxen sodium tabs 550 1 MO cp12 10 mg, 15 mg daily); MO mg, 275 mg hydrocodone bitartrate PA; QL(2 ea naproxen tabs 250 mg, 375 1 MO cp12 20 mg, 30 mg, 40 mg, 1 daily); MO mg, 500 mg 50 mg naproxen tbec 375 mg, 500 MO 1 hydromorphone hcl liqd or 1 QL(50 ml mg 1 mg/ml daily); MO MO oxaprozin tabs 1 hydromorphone hcl soln ij 1 1 MO mg/ml, 2 mg/ml piroxicam caps 1 MO hydromorphone hcl soln ij 10 mg/ml, 50 mg/5ml, 500 1 sulindac tabs 1 MO mg/50ml hydromorphone hcl tabs or 1 QL(9 ea daily); tolmetin sodium caps 400 1 MO 2 mg, 4 mg MO mg hydromorphone hcl tabs or 1 QL(6.25 ea Pyrimidine Synthesis Inhibitors 8 mg daily); MO MO leflunomide tabs 1 LAZANDA SOLN 100 1 PA; NDS;QL(1 MCG/ACT ea daily); MO Soluble Tumor Necrosis Factor Receptor Agents PA; NDS; Limit PA; NDS LAZANDA SOLN 300 1 15 boxes per ENBREL MINI SOCT 1 MCG/ACT month ;QL(0.5 ea daily); MO ENBREL SOLN 1 PA; NDS PA; NDS; Limit ENBREL SOLR 1 PA; NDS LAZANDA SOLN 400 1 8 bottles per MCG/ACT month;QL(0.27 ea daily); MO ENBREL SOSY 1 PA; NDS methadone hcl soln or 10 1 QL(33.34 ml ENBREL SURECLICK 1 PA; NDS mg/5ml daily); MO SOAJ
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2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 3 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits methadone hcl soln or 5 QL(15 ml 1 SUBSYS LIQD 1200 MCG 1 PA; NDS;QL(2 mg/5ml daily); MO ea daily) methadone hcl tabs or 5 1 QL(6 ea daily); SUBSYS LIQD 1600 MCG, PA; NDS;QL(4 mg, 10 mg MO 400 MCG, 600 MCG, 800 1 ea daily); MO morphine sulfate cp24 or QL(3 ea daily); MCG 10 mg, 20 mg, 30 mg, 50 1 MO SUBSYS LIQD 200 MCG 1 PA; NDS;QL(8 mg ea daily); MO NDS;QL(2 ea SL(8 ea daily); morphine sulfate cp24 or 1 tramadol hcl tabs 50 mg 1 100 mg daily); MO MO QL(3.34 ea SL(3 ea daily); morphine sulfate cp24 or 1 tramadol hcl tb24 100 mg 1 60 mg daily); MO MO QL(2.5 ea SL(1.5 ea morphine sulfate cp24 or 1 tramadol hcl tb24 200 mg 1 80 mg daily); MO daily); MO SL(1 ea daily); morphine sulfate soln ij 0.5 1 tramadol hcl tb24 300 mg 1 mg/ml MO morphine sulfate soln ij 1 1 MO Opioid Combinations mg/ml acetaminophen w/ codeine SL(150 ml morphine sulfate soln or 10 1 QL(100 ml soln 12 mg/5ml-120 1 daily); MO mg/5ml daily); MO mg/5ml morphine sulfate soln or QL(10 ml 1 acetaminophen w/ codeine 1 SL(13.3 ea 100 mg/5ml, 20 mg/ml daily); MO tabs 15 mg-300 mg daily); MO morphine sulfate soln or 20 QL(50 ml 1 acetaminophen w/ codeine 1 SL(12 ea daily); mg/5ml daily); MO tabs 30 mg-300 mg MO morphine sulfate tabs or 15 QL(13.34 ea 1 acetaminophen w/ codeine 1 SL(6 ea daily); mg, 30 mg daily); MO tabs 300 mg-60 mg MO morphine sulfate tbcr or 1 QL(2 ea daily); AL(Up to 64 yrs 100 mg, 200 mg MO butalbital-aspirin-caffeine 1 old); SL(6 ea w/cod caps daily); MO morphine sulfate tbcr or 15 1 QL(3 ea daily); mg, 30 mg, 60 mg MO hydrocodone- Limit 5535mls QL(6 ea daily); acetaminophen soln 108 per oxycodone hcl caps 5 mg 1 MO mg/5ml-2.5 mg/5ml, 217 1 month;SL(184. mg/10ml-5 mg/10ml, 325 5 ml daily); MO oxycodone hcl conc 100 1 QL(6 ml daily); mg/5ml MO mg/15ml-7.5 mg/15ml hydrocodone- SL(13.3 ea oxycodone hcl tabs 10 mg, 1 QL(6 ea daily); 20 mg, 15 mg, 5 mg MO acetaminophen tabs 10 1 daily); MO mg-300 mg, 300 mg-5 mg, QL(4.44 ea oxycodone hcl tabs 30 mg 1 300 mg-7.5 mg daily); MO hydrocodone- SL(12.3 ea oxymorphone hcl tabs 10 QL(6 ea daily); 1 acetaminophen tabs 10 1 daily); MO mg, 5 mg MO mg-325 mg, 325 mg-5 mg, oxymorphone hcl tb12 15 1 QL(4.44 ea 325 mg-7.5 mg mg daily); MO hydrocodone-ibuprofen QL(5 ea daily); oxymorphone hcl tb12 7.5 1 QL(8.89 ea tabs 200 mg-7.5 mg, 10 1 MO mg daily); MO mg-200 mg, 200 mg-5 mg PA; oxycodone w/ 1 SL(12.3 ea SUBSYS LIQD 100 MCG 1 NDS;QL(16 ea acetaminophen tabs daily); MO daily); MO
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2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 4 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SL(12.3 ea MO oxycodone-aspirin tabs 1 hydrocortisone (intrarectal) 1 daily); MO enem tramadol-acetaminophen 1 SL(8 ea daily); UCERIS FOAM RE 2 1 MO tabs MO MG/ACT Opioid Partial Agonists Rectal Steroids buprenorphine hcl subl sl 2 1 QL(3 ea daily); hydrocortisone (rectal) crea 1 MO mg, 8 mg MO buprenorphine hcl- QL(3 ea daily); Vasodilating Agents naloxone hcl dihydrate subl 1 MO MO 0.5 mg-2 mg, 2 mg-8 mg RECTIV OINT 1 butorphanol tartrate soln ij 1 MO ANTHELMINTICS - Drugs to Treat Worm 2 mg/ml Infections Limit 210mls butorphanol tartrate soln na 1 per month;QL(7 Anthelmintics 10 mg/ml ml daily); MO albendazole tabs 1 MO ANDROGENS-ANABOLIC - Drugs to Regulate MO Hormones ivermectin tabs or 3 mg 1 Anabolic Steroids ANTI-INFECTIVE AGENTS - MISC. - Drugs to ANADROL-50 TABS 1 NDS;MO Treat Bacterial Infections Anti-infective Agents - Misc. oxandrolone tabs 10 mg 1 NDS;MO IMPAVIDO CAPS 1 NDS;MO oxandrolone tabs 2.5 mg 1 MO metronidazole caps or 375 1 SL(10.6 ea mg daily); MO Androgens metronidazole in nacl soln ANDRODERM PT24 1 MO 0.79 %-5 mg/ml, 0.79 %- 1 500 mg/100ml AVEED SOLN 1 LA metronidazole tabs or 250 1 SL(16 ea daily); mg MO danazol caps 1 MO metronidazole tabs or 500 1 SL(8 ea daily); mg MO methyltestosterone caps 1 MO pentamidine isethionate 1 MO solr ij testosterone cypionate soln 1 MO im 100 mg/ml, 200 mg/ml pentamidine isethionate 1 B/D; MO solr in testosterone enanthate 1 MO soln im tinidazole tabs 1 MO testosterone gel td 1.62 %, MO MO 20.25 mg/1.25gm, 25 1 trimethoprim tabs 1 mg/2.5gm, 40.5 mg/2.5gm, 1 %, 1 %, 50 mg/5gm vancomycin hcl solr iv 1000 1 mg testosterone soln td 30 1 MO mg/act XIFAXAN TABS 550 MG 1 NDS;MO ANORECTAL AND RELATED PRODUCTS - Rectal Drugs to Treat Pain, Swelling and Itching Anti-infective Misc. - Combinations Intrarectal Steroids You can find information on what the symbols and abbreviations on this table mean by going to page vi.
2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 5 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits sulfamethoxazole- 1 MO vancomycin hcl solr iv 500 1 MO trimethoprim soln mg sulfamethoxazole- 1 MO VANCOMYCIN MO trimethoprim susp HYDROCHLORIDE SOLR 1 OR 250 MG/5ML sulfamethoxazole- 1 MO trimethoprim tabs VANCOMYCIN HYDROCHLORIDE/DEXT Antiprotozoal Agents ROSE SOLN 1 GM/200ML- 1 ALINIA TABS 500 MG 1 MO 5 %, 5 %-500 MG/100ML, 5 %-750 MG/150ML NDS;MO atovaquone susp 1 Leprostatics Carbapenems dapsone tabs or 100 mg, 1 MO 25 mg MO ertapenem sodium solr 1 Lincosamides imipenem-cilastatin solr MO clindamycin hcl caps 1 MO 250 mg-250 mg, 500 mg- 1 500 mg clindamycin palmitate 1 MO hydrochloride solr meropenem solr 1 gm 1 MO clindamycin phosphate in 1 meropenem solr 500 mg 1 d5w soln clindamycin phosphate soln VABOMERE SOLR 1 ij 300 mg/2ml, 9 gm/60ml, 1 9000 mg/60ml Chloramphenicols clindamycin phosphate soln 1 MO ij 600 mg/4ml, 900 mg/6ml chloramphenicol sodium 1 succinate solr clindamycin phosphate soln Cyclic Lipopeptides iv 300 mg/2ml, 600 mg/4ml, 1 900 mg/6ml daptomycin solr 500 mg 1 NDS;MO lincomycin hcl soln 1 MO Glycopeptides Monobactams DALVANCE SOLR 1 NDS aztreonam solr 1 MO FIRVANQ SOLR 25 1 MG/ML CAYSTON SOLR 1 PA; NDS;LA FIRVANQ SOLR 50 1 MO MG/ML Oxazolidinones NDS;MO linezolid in sodium chloride 1 NDS ORBACTIV SOLR 1 soln linezolid soln iv 600 NDS vancomycin hcl caps or 1 PA; MO 1 125 mg mg/300ml linezolid susr or 100 NDS;MO vancomycin hcl caps or 1 PA; NDS;MO 1 250 mg mg/5ml vancomycin hcl solr iv 5 linezolid tabs or 600 mg 1 MO gm, 10 gm, 750 mg, 1 gm, 1 1000 mg SIVEXTRO SOLR IV 1 NDS
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2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 6 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SIVEXTRO TABS OR 1 NDS;MO Antianxiety Agents - Misc. buspirone hcl tabs 1 MO ZYVOX SOLN IV 200 1 NDS MG/100ML hydroxyzine hcl soln im 50 1 AL(Up to 64 yrs Pleuromutilins mg/ml old); MO XENLETA TABS OR 600 1 PA; NDS;MO hydroxyzine hcl syrp or 10 1 AL(Up to 64 yrs MG mg/5ml old); MO Polymyxins hydroxyzine hcl tabs or 10 1 AL(Up to 64 yrs mg, 25 mg, 50 mg old); MO colistimethate sodium solr 1 MO hydroxyzine pamoate caps 1 AL(Up to 64 yrs 25 mg, 50 mg old); MO polymyxin b sulfate solr 1 Benzodiazepines Streptogramins alprazolam tabs 1 MO SYNERCID SOLR 1 NDS alprazolam tb24 1 MO Urinary Anti-infectives alprazolam tbdp 1 MO methenamine hippurate 1 MO tabs clorazepate dipotassium 1 MO nitrofurantoin macrocrystal 1 MO tabs caps diazepam conc or 5 mg/ml 1 MO nitrofurantoin monohyd 1 MO macro caps diazepam soln or 5 mg/5ml 1 MO ANTIANGINAL AGENTS - Drugs to Treat Chest Pain diazepam tabs or 10 mg, 2 1 MO mg, 5 mg Antianginals-Other lorazepam conc 1 MO ranolazine tb12 1 MO MO Nitrates lorazepam soln 1 isosorbide dinitrate tabs 30 1 MO lorazepam tabs 1 MO mg, 10 mg, 20 mg, 5 mg oxazepam caps 30 mg, 10 MO isosorbide mononitrate 1 MO 1 tabs mg, 15 mg isosorbide mononitrate 1 MO ANTIARRHYTHMICS - Drugs to treat abnormal tb24 heart rhythms nitroglycerin pt24 td 0.1 MO Antiarrhythmics Type I-A mg/hr, 0.2 mg/hr, 0.4 1 mg/hr, 0.6 mg/hr disopyramide phosphate 1 AL(Up to 64 yrs caps old); MO nitroglycerin soln tl 0.4 1 MO mg/spray quinidine gluconate tbcr or 1 MO 324 mg nitroglycerin subl sl 0.3 mg, 1 MO 0.4 mg, 0.6 mg quinidine sulfate tabs 1 MO NITROSTAT SUBL 1 MO (nitroglycerin) Antiarrhythmics Type I-B mexiletine hcl caps 1 MO ANTIANXIETY AGENTS - Drugs to Treat Anxiety
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2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 7 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Antiarrhythmics Type I-C Limit 1 inhaler per month (60 flecainide acetate tabs 100 1 SL(4 ea daily); SPIRIVA RESPIMAT 1 MO actuations);SL( mg AERS 0.14 gm daily); flecainide acetate tabs 150 1 SL(2.66 ea MO mg daily); MO Limit 1 inhaler flecainide acetate tabs 50 1 SL(8 ea daily); per month (60 mg MO TUDORZA PRESSAIR 1 actuations);QL( AEPB propafenone hcl cp12 1 MO 0.04 ea daily); MO propafenone hcl tabs 1 MO Limit 2 inhalers per month (30 TUDORZA PRESSAIR Antiarrhythmics Type III 1 actuations);QL( AEPB 0.07 ea daily); amiodarone hcl tabs or 100 1 MO mg, 200 mg, 400 mg MO Leukotriene Modulators dofetilide caps 1 montelukast sodium chew 1 QL(1 ea daily); MULTAQ TABS 1 MO 4 mg, 5 mg MO montelukast sodium tabs 1 QL(1 ea daily); ANTIASTHMATIC AND BRONCHODILATOR 10 mg MO AGENTS - Drugs to Treat Lung Conditions zafirlukast tabs 1 MO Anti-Inflammatory Agents NDS;SL(4 ea B/D; MO zileuton tb12 1 cromolyn sodium nebu 1 daily); MO Antiasthmatic - Monoclonal Antibodies Selective Phosphodiesterase 4 (PDE4) Inhibitors PA; NDS;LA DALIRESP TABS 1 QL(1 ea daily); CINQAIR SOLN 1 MO FASENRA SOSY 1 PA; NDS Steroid Inhalants SL(1 ea daily); ARNUITY ELLIPTA AEPB 1 NUCALA SOLR 100 MG 1 PA; NDS;LA MO budesonide (inhalation) 1 B/D; QL(8 ml XOLAIR SOLR 1 PA; NDS;LA susp 0.25 mg/2ml daily); MO PA; NDS;LA budesonide (inhalation) 1 B/D; QL(4 ml XOLAIR SOSY 1 susp 0.5 mg/2ml daily); MO Bronchodilators - Anticholinergics FLOVENT DISKUS AEPB 1 SL(20 ea daily); 100 MCG/BLIST MO Limit 2 inhalers FLOVENT DISKUS AEPB SL(8 ea daily); 1 per 1 ATROVENT HFA AERS month;QL(0.86 250 MCG/BLIST MO gm daily); MO FLOVENT DISKUS AEPB 1 SL(40 ea daily); 50 MCG/BLIST MO ipratropium bromide soln 1 B/D; MO Limit 2 inhalers FLOVENT HFA AERO 110 per SPIRIVA HANDIHALER 1 QL(1 ea daily); 1 CAPS MO MCG/ACT, 220 MCG/ACT month;QL(0.8 gm daily); MO
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2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 8 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 1 inhaler SEREVENT DISKUS 1 QL(2 ea daily); FLOVENT HFA AERO 44 1 per AEPB MO MCG/ACT month;QL(0.36 Limit 1 inhaler gm daily); MO STIOLTO RESPIMAT 1 per Sympathomimetics AERS month;SL(0.14 gm daily); MO ADVAIR HFA AERO 1 QL(4 gm daily); MO Limit 1 inhaler albuterol sulfate nebu in B/D; MO per month (60 STRIVERDI RESPIMAT 1 actuations);SL( 0.083 %, 0.63 mg/3ml, 1.25 1 AERS mg/3ml, 0.5 %, 2.5 0.14 gm daily); MO mg/0.5ml MO Limit 2 inhalers albuterol sulfate syrp or 2 1 SYMBICORT AERO 160 per month mg/5ml MCG/ACT-4.5 MCG/ACT 1 (Institutional albuterol sulfate tabs or 2 MO (budesonide-formoterol 1 fumarate dihydrate) Pack);QL(0.4 mg, 4 mg gm daily); MO albuterol sulfate tb12 or 4 1 MO SYMBICORT AERO 160 Limit 1 inhaler mg, 8 mg MCG/ACT-4.5 MCG/ACT, per 4.5 MCG/ACT-80 month;QL(0.34 ANORO ELLIPTA AEPB 1 QL(2 ea daily); 1 MO MCG/ACT (budesonide- gm daily); MO BREO ELLIPTA AEPB 100 Limit 1 inhaler formoterol fumarate MCG/INH-25 MCG/INH, per month;SL(2 dihydrate) 1 Limit 2 inhalers 200 MCG/INH-25 ea daily); MO SYMBICORT AERO 4.5 MCG/INH MCG/ACT-80 MCG/ACT per month Limit 2 inhalers 1 (Institutional BREO ELLIPTA AEPB 100 (budesonide-formoterol per month fumarate dihydrate) Pack);QL(0.46 MCG/INH-25 MCG/INH, 1 (Institutional gm daily); MO 200 MCG/INH-25 terbutaline sulfate tabs or MO MCG/INH Pack);SL(2 ea 1 daily); MO 2.5 mg, 5 mg Limit 3 inhalers TRELEGY ELLIPTA AEPB MO 100 MCG/INH-25 1 COMBIVENT RESPIMAT 1 per 2 AERS months;SL(0.2 MCG/INH-62.5 MCG/INH gm daily); MO Xanthines fluticasone-salmeterol aepb SL(2 ea daily); 100 mcg/dose-50 MO aminophylline soln 1 mcg/dose, 250 mcg/dose- 1 50 mcg/dose, 50 theophylline tb12 300 mg, 1 MO mcg/dose-500 mcg/dose 450 mg B/D; MO theophylline tb24 400 mg, 1 MO ipratropium-albuterol soln 1 600 mg levalbuterol hcl nebu 1 B/D; MO ANTICOAGULANTS - Blood Thinners levalbuterol tartrate aero 1 MO Coumarin Anticoagulants warfarin sodium tabs 1 MO PROAIR HFA AERS 1 MO (albuterol sulfate) Direct Factor Xa Inhibitors PROAIR RESPICLICK 1 MO QL(1 ea daily) AEPB BEVYXXA CAPS 40 MG 1
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2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 9 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NDS;MO BEVYXXA CAPS 80 MG 1 QL(1 ea daily); clobazam tabs 20 mg 1 MO SL(40 ea daily); ELIQUIS STARTER PACK 1 MO clonazepam tabs 0.5 mg 1 TBPK MO SL(20 ea daily); MO clonazepam tabs 1 mg 1 ELIQUIS TABS 1 MO XARELTO STARTER MO SL(10 ea daily); 1 clonazepam tabs 2 mg 1 PACK TBPK MO XARELTO TABS 1 MO clonazepam tbdp 0.125 MO mg, 0.25 mg, 0.5 mg, 1 mg, 1 Heparins And Heparinoid-Like Agents 2 mg MO DIASTAT ACUDIAL GEL MO enoxaparin sodium soln 1 (diazepam 1 fondaparinux sodium soln NDS;MO (anticonvulsant)) 10 mg/0.8ml, 5 mg/0.4ml, 1 DIASTAT PEDIATRIC GEL MO 7.5 mg/0.6ml (diazepam 1 (anticonvulsant)) fondaparinux sodium soln 1 MO 2.5 mg/0.5ml diazepam (anticonvulsant) 1 MO FRAGMIN SOLN 10000 MO gel PA; UNIT/ML, 2500 1 UNIT/0.2ML, 5000 NAYZILAM SOLN 1 NDS;SL(0.34 UNIT/0.2ML ea daily); MO FRAGMIN SOLN 12500 NDS;MO SYMPAZAN FILM 10 MG, 1 PA; NDS;MO UNIT/0.5ML, 15000 20 MG UNIT/0.6ML, 18000 1 PA; MO UNT/0.72ML, 7500 SYMPAZAN FILM 5 MG 1 UNIT/0.3ML, 95000 PA; UNIT/3.8ML VALTOCO LIQD 1 NDS;SL(0.34 ea daily); MO heparin sodium (porcine) 1 MO soln PA; Thrombin Inhibitors VALTOCO LQPK 1 NDS;SL(0.34 ea daily); MO argatroban soln 250 1 mg/2.5ml Anticonvulsants - Misc. PRADAXA CAPS 1 MO APTIOM TABS 200 MG 1 MO
APTIOM TABS 400 MG, 1 NDS;MO ANTICONVULSANTS - Drugs to Treat Seizures 600 MG, 800 MG AMPA Glutamate Receptor Antagonists BANZEL SUSP 40 MG/ML 1 MO (rufinamide) FYCOMPA SUSP 1 MO BANZEL TABS 200 MG 1 MO FYCOMPA TABS 1 MO BANZEL TABS 400 MG 1 NDS;MO Anticonvulsants - Benzodiazepines BRIVIACT SOLN IV 50 1 NDS;SL(20 ml clobazam susp 2.5 mg/ml 1 MO MG/5ML daily) MO BRIVIACT SOLN OR 10 1 PA; NDS;SL(20 clobazam tabs 10 mg 1 MG/ML ml daily); MO
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2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 10 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BRIVIACT TABS OR 10 1 PA; NDS;SL(20 levetiracetam tabs or 250 MO MG ea daily); MO mg, 1000 mg, 500 mg, 750 1 mg BRIVIACT TABS OR 100 1 PA; NDS;SL(2 MG ea daily); MO levetiracetam tb24 or 500 1 MO mg, 750 mg BRIVIACT TABS OR 25 1 PA; NDS;SL(8 MG ea daily); MO oxcarbazepine susp 1 MO BRIVIACT TABS OR 50 1 PA; NDS;SL(4 MG ea daily); MO oxcarbazepine tabs 1 MO PA; BRIVIACT TABS OR 75 1 pregabalin caps 100 mg, QL(3 ea daily); MG NDS;SL(2.67 1 ea daily); MO 25 mg, 50 mg, 75 mg MO MO pregabalin caps 150 mg, 1 QL(2 ea daily); carbamazepine chew 1 200 mg, 225 mg MO SL(2 ea daily); MO pregabalin caps 300 mg 1 carbamazepine cp12 1 MO MO SL(30 ml daily); carbamazepine susp 1 pregabalin soln 20 mg/ml 1 MO MO carbamazepine tabs 1 primidone tabs 1 MO MO carbamazepine tb12 1 rufinamide susp 1 MO PA; NDS EPIDIOLEX SOLN 1 SPRITAM TB3D 1000 MG 1 PA; SL(3 ea daily); MO PA; SPRITAM TB3D 250 MG 1 PA; SL(12 ea FINTEPLA SOLN 1 NDS;SL(11.82 daily); MO ml daily); MO PA; SL(6 ea SPRITAM TB3D 500 MG 1 gabapentin caps 1 MO daily); MO MO SPRITAM TB3D 750 MG 1 PA; SL(4 ea gabapentin soln 1 daily); MO MO topiramate cpsp 15 mg, 25 1 MO gabapentin tabs 1 mg LAMICTAL XR KIT 1 MO topiramate tabs 100 mg, 1 MO 200 mg, 25 mg, 50 mg lamotrigine chew 25 mg, 5 MO 1 VIMPAT SOLN IV 200 1 mg MG/20ML lamotrigine tabs 100 mg, MO 1 VIMPAT SOLN OR 10 1 MO 150 mg, 200 mg, 25 mg MG/ML lamotrigine tb24 100 mg, MO VIMPAT TABS OR 100 MO 200 mg, 250 mg, 300 mg, 1 MG, 150 MG, 200 MG, 50 1 25 mg, 50 mg MG levetiracetam in sodium 1 MO chloride soln zonisamide caps 1 levetiracetam soln iv 500 1 Carbamates mg/5ml felbamate susp 1 MO levetiracetam soln or 100 1 MO mg/ml, 500 mg/5ml felbamate tabs 1 MO
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2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 11 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MO XCOPRI TABS 100 MG 1 PA; NDS;SL(4 ethosuximide caps 1 ea daily); MO PA; ethosuximide soln 1 MO XCOPRI TABS 150 MG 1 NDS;SL(2.67 ea daily); MO Valproic Acid XCOPRI TABS 200 MG 1 PA; NDS;SL(2 MO ea daily); MO divalproex sodium csdr 1 MO XCOPRI TABS 50 MG 1 PA; NDS;SL(8 divalproex sodium tb24 1 ea daily); MO PA; 12.5-25 MO XCOPRI TBPK 1 divalproex sodium tbec 1 MG;MO valproate sodium soln iv XCOPRI TBPK 1 PA; NDS; 350 1 MG Daily Dose 100 mg/ml, 500 mg/5ml valproate sodium soln or MO XCOPRI TBPK 1 PA; NDS; 250 1 MG Daily Dose 250 mg/5ml valproic acid caps 1 MO XCOPRI TBPK 1 PA; NDS, 50- 100 MG;MO ANTIDEPRESSANTS - Drugs to Treat XCOPRI TBPK 1 PA; NDS, 150- 200 MG ;MO Depression GABA Modulators Alpha-2 Receptor Antagonists (Tetracyclics) MO tiagabine hcl tabs 1 MO mirtazapine tabs 1 MO vigabatrin pack 1 NDS;LA; MO mirtazapine tbdp 1 Antidepressants - Misc. vigabatrin tabs 1 NDS;LA SL(4.5 ea bupropion hcl tabs 100 mg 1 Hydantoins daily); MO SL(6 ea daily); DILANTIN INFATABS 1 MO bupropion hcl tabs 75 mg 1 CHEW (phenytoin) MO SL(4 ea daily); fosphenytoin sodium soln 1 bupropion hcl tb12 100 mg 1 100 mg pe/2ml MO SL(2.66 ea fosphenytoin sodium soln 1 MO bupropion hcl tb12 150 mg 1 500 mg pe/10ml daily); MO SL(2 ea daily); MO bupropion hcl tb12 200 mg 1 PEGANONE TABS 1 MO SL(3 ea daily); phenytoin chew 1 MO bupropion hcl tb24 150 mg 1 MO phenytoin sodium extended MO SL(1.5 ea 1 bupropion hcl tb24 300 mg 1 caps daily); MO phenytoin sodium soln 1 bupropion hcl tb24 450 mg 1 ST; MO MO phenytoin susp 1 FORFIVO XL TB24 1 ST; MO (bupropion hcl) Succinimides maprotiline hcl tabs 1 MO CELONTIN CAPS 1 MO GABA Receptor Modulator - Neuroactive Steroid You can find information on what the symbols and abbreviations on this table mean by going to page vi.
2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 12 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ZULRESSO SOLN 1 PA; NDS sertraline hcl conc 1 MO
Monoamine Oxidase Inhibitors (MAOIs) sertraline hcl tabs 1 MO NDS;MO EMSAM PT24 1 Serotonin Modulators MARPLAN TABS 1 MO nefazodone hcl tabs 1 MO phenelzine sulfate tabs 1 MO trazodone hcl tabs 1 MO tranylcypromine sulfate MO ST; QL(2 ea 1 TRINTELLIX TABS 10 MG 1 tabs daily); MO N-Methyl-D-aspartic acid (NMDA) Receptor TRINTELLIX TABS 20 MG 1 ST; QL(1 ea daily); MO SPRAVATO 56MG DOSE 1 PA; NDS;MO SOPK TRINTELLIX TABS 5 MG 1 ST; QL(4 ea daily); MO SPRAVATO 84MG DOSE 1 PA; NDS;MO SOPK VIIBRYD STARTER PACK 1 ST; MO KIT Selective Serotonin Reuptake Inhibitors (SSRIs) VIIBRYD TABS 1 ST; MO citalopram hydrobromide 1 SL(20 ml daily); soln 10 mg/5ml MO Serotonin-Norepinephrine Reuptake Inhibitors citalopram hydrobromide 1 SL(4 ea daily); tabs 10 mg MO DESVENLAFAXINE ER 1 ST; MO TB24 citalopram hydrobromide 1 SL(2 ea daily); tabs 20 mg MO desvenlafaxine succinate 1 MO tb24 citalopram hydrobromide 1 SL(1 ea daily); tabs 40 mg MO DRIZALMA SPRINKLE 1 ST; SL(6 ea CSDR 20 MG daily); MO escitalopram oxalate soln 1 MO DRIZALMA SPRINKLE 1 ST; SL(4 ea CSDR 30 MG daily); MO escitalopram oxalate tabs 1 MO DRIZALMA SPRINKLE 1 ST; SL(3 ea CSDR 40 MG daily); MO fluoxetine hcl caps 1 MO DRIZALMA SPRINKLE 1 ST; SL(2 ea CSDR 60 MG daily); MO fluoxetine hcl cpdr 1 MO duloxetine hcl cpep 20 mg, 1 MO fluoxetine hcl soln 1 MO 30 mg, 60 mg FETZIMA CP24 120 MG, 1 ST; QL(1 ea fluoxetine hcl tabs 1 MO 40 MG, 80 MG daily); MO FETZIMA CP24 20 MG 1 ST; QL(2 ea fluvoxamine maleate cp24 1 MO daily); MO MO FETZIMA TITRATION 1 ST; MO fluvoxamine maleate tabs 1 PACK C4PK MO venlafaxine hcl cp24 150 1 SL(1.5 ea paroxetine hcl tabs 1 mg daily); MO MO paroxetine hcl tb24 1 venlafaxine hcl cp24 37.5 1 SL(6 ea daily); mg MO MO SL(3 ea daily); PAXIL SUSP 10 MG/5ML 1 venlafaxine hcl cp24 75 mg 1 MO
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2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 13 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SL(3.75 ea QL(3 ea daily); venlafaxine hcl tabs 100 1 acarbose tabs 1 mg daily); MO MO SL(15 ea daily); QL(3 ea daily); venlafaxine hcl tabs 25 mg 1 miglitol tabs 1 MO MO venlafaxine hcl tabs 37.5 1 SL(10 ea daily); Antidiabetic - Amylin Analogs mg MO PA; Limit 12mls SL(7.5 ea venlafaxine hcl tabs 50 mg 1 1 per daily); MO SYMLINPEN 120 SOPN month;QL(0.4 SL(5 ea daily); ml daily); MO venlafaxine hcl tabs 75 mg 1 MO PA; Limit 12mls per venlafaxine hcl tb24 150 1 SL(1.5 ea SYMLINPEN 60 SOPN 1 mg daily); MO month;QL(0.4 ml daily); MO venlafaxine hcl tb24 225 1 ST; SL(1 ea mg daily); MO Antidiabetic Combinations venlafaxine hcl tb24 37.5 SL(6 ea daily); 1 glipizide-metformin hcl tabs 1 SL(8 ea daily); mg MO 2.5 mg-250 mg MO SL(3 ea daily); venlafaxine hcl tb24 75 mg 1 glipizide-metformin hcl tabs SL(4 ea daily); MO 2.5 mg-500 mg, 5 mg-500 1 MO Tricyclic Agents mg AL(Up to 64 yrs AL(Up to 64 yrs amitriptyline hcl tabs 1 glyburide-metformin tabs 1 old); SL(8 ea old); MO 1.25 mg-250 mg daily); MO MO amoxapine tabs 1 glyburide-metformin tabs AL(Up to 64 yrs AL(Up to 64 yrs 2.5 mg-500 mg, 5 mg-500 1 old); SL(4 ea clomipramine hcl caps 1 old); MO mg daily); MO MO INVOKAMET TABS 1000 SL(2 ea daily); desipramine hcl tabs 1 MG-150 MG, 1000 MG-50 1 MO AL(Up to 64 yrs MG, 150 MG-500 MG doxepin hcl caps 1 old); MO INVOKAMET TABS 50 1 SL(4 ea daily); AL(Up to 64 yrs MG-500 MG MO doxepin hcl conc 1 old); MO INVOKAMET XR TB24 SL(2 ea daily); AL(Up to 64 yrs 1000 MG-150 MG, 1000 MO imipramine hcl tabs 1 1 old); MO MG-50 MG, 150 MG-500 MG AL(Up to 64 yrs imipramine pamoate caps 1 old); MO INVOKAMET XR TB24 50 1 SL(4 ea daily); MG-500 MG MO nortriptyline hcl caps 1 MO JANUMET TABS 1 SL(2 ea daily); MO nortriptyline hcl soln 1 MO JANUMET XR TB24 100 1 SL(1 ea daily); MG-1000 MG MO 1 MO protriptyline hcl tabs JANUMET XR TB24 1000 SL(2 ea daily); AL(Up to 64 yrs MG-50 MG, 50 MG-500 1 MO trimipramine maleate caps 1 old); MO MG SL(2 ea daily); ANTIDIABETICS - Drugs to Regulate Blood JENTADUETO TABS 1 Sugar MO Alpha-Glucosidase Inhibitors You can find information on what the symbols and abbreviations on this table mean by going to page vi.
2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 14 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits JENTADUETO XR TB24 1 SL(2 ea daily); GVOKE PFS SOSY 1 MO 1000 MG-2.5 MG MO PA; SL(4 ea JENTADUETO XR TB24 1 SL(1 ea daily); KORLYM TABS 1 1000 MG-5 MG MO daily); LA; MO pioglitazone hcl-glimepiride 1 SL(1.5 ea Dipeptidyl Peptidase-4 (DPP-4) Inhibitors tabs daily); MO QL(1 ea daily); JANUVIA TABS 100 MG 1 pioglitazone hcl-metformin 1 SL(3 ea daily); MO hcl tabs MO JANUVIA TABS 25 MG 1 QL(4 ea daily); SYNJARDY TABS 1000 SL(2 ea daily); MO MG-12.5 MG, 1000 MG-5 1 MO JANUVIA TABS 50 MG 1 QL(2 ea daily); MG MO SYNJARDY TABS 12.5 SL(4 ea daily); QL(1 ea daily); TRADJENTA TABS 1 MG-500 MG, 5 MG-500 1 MO MO MG SYNJARDY XR TB24 10 SL(2 ea daily); Dopamine Receptor Agonists - Antidiabetic QL(6 ea daily); MG-1000 MG, 1000 MG- 1 MO CYCLOSET TABS 1 12.5 MG, 1000 MG-5 MG MO SYNJARDY XR TB24 1000 1 SL(1 ea daily); Incretin Mimetic Agents (GLP-1 Receptor MG-25 MG MO BYDUREON BCISE AUIJ 1 MO Biguanides MO metformin hcl tabs 1000 1 SL(2.55 ea BYDUREON PEN PEN 1 mg daily); MO SL(5.1 ea BYDUREON SRER 1 metformin hcl tabs 500 mg 1 daily); MO MO SL(3 ea daily); BYETTA SOPN 1 metformin hcl tabs 850 mg 1 MO OZEMPIC SOPN 1 MO SL(4 ea daily); metformin hcl tb24 500 mg 1 MO TRULICITY SOPN 1 MO SL(2.66 ea metformin hcl tb24 750 mg 1 daily); MO Limit 9mls per VICTOZA SOPN 1 month;QL(0.3 Diabetic Other ml daily); MO BAQSIMI ONE PACK 1 MO POWD Insulin Sensitizing Agents SL(4 ea daily); BAQSIMI TWO PACK 1 MO AVANDIA TABS 2 MG 1 POWD MO MO AVANDIA TABS 4 MG 1 SL(2 ea daily); diazoxide susp 1 MO SL(3 ea daily); GLUCAGEN HYPOKIT 1 MO pioglitazone hcl tabs 15 mg 1 SOLR MO SL(1.5 ea MO pioglitazone hcl tabs 30 mg 1 glucagon (rdna) kit 1 daily); MO GVOKE HYPOPEN 1- MO SL(1 ea daily); 1 pioglitazone hcl tabs 45 mg 1 PACK SOAJ MO GVOKE HYPOPEN 2- 1 MO Insulin PACK SOAJ
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2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 15 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HUMALOG JUNIOR Limit 45mls per INSULIN LISPRO Limit 45mls per 1 month;QL(1.5 PROTAMINE/INSULIN 1 month;QL(1.5 KWIKPEN SOPN ml daily); MO LISPRO KWIKPEN SUPN ml daily); MO HUMALOG KWIKPEN Limit 45mls per Limit 45mls per 1 month;QL(1.5 LANTUS SOLN 1 month;QL(1.5 SOPN ml daily); MO ml daily); MO HUMALOG MIX 50/50 Limit 45mls per Limit 45mls per 1 month;QL(1.5 LANTUS SOLOSTAR 1 month;QL(1.5 KWIKPEN SUPN SOPN ml daily); MO ml daily); MO HUMALOG MIX 50/50 Limit 45mls per Limit 45mls per 1 month;QL(1.5 LEVEMIR FLEXTOUCH 1 month;QL(1.5 SUSP SOPN ml daily); MO ml daily); MO Limit 45mls per Limit 45mls per HUMALOG MIX 75/25 1 1 month;QL(1.5 KWIKPEN SUPN month;QL(1.5 LEVEMIR SOLN ml daily); MO ml daily); MO Limit 45mls per TOUJEO MAX SOLOSTAR Limit 15mls per HUMALOG MIX 75/25 1 month;QL(1.5 1 month;QL(0.5 SUSP SOPN ml daily); MO ml daily); MO Limit 45mls per TOUJEO SOLOSTAR Limit 15mls per HUMALOG SOCT 1 month;QL(1.5 1 month;QL(0.5 SOPN ml daily); MO ml daily); MO Limit 45mls per TRESIBA FLEXTOUCH Limit 45mls per HUMALOG SOLN 1 month;QL(1.5 1 month;QL(1.5 SOPN 100 UNIT/ML ml daily); MO ml daily); MO Limit 45mls per TRESIBA FLEXTOUCH Limit 27mls per HUMULIN 70/30 KWIKPEN 1 month;QL(1.5 1 month;QL(0.9 SUPN SOPN 200 UNIT/ML ml daily); MO ml daily); MO Limit 45mls per QL(1.5 ml TRESIBA SOLN 1 HUMULIN 70/30 SUSP 1 month;QL(1.5 daily); MO ml daily); MO Meglitinide Analogues Limit 45mls per QL(3 ea daily); HUMULIN N KWIKPEN 1 month;QL(1.5 nateglinide tabs 1 SUPN MO ml daily); MO SL(32 ea daily); Limit 45mls per repaglinide tabs 0.5 mg 1 MO HUMULIN N SUSP 1 month;QL(1.5 ml daily); MO 1 SL(16 ea daily); repaglinide tabs 1 mg MO Limit 45mls per SL(8 ea daily); HUMULIN R SOLN 1 month;QL(1.5 repaglinide tabs 2 mg 1 ml daily); MO MO Limit 45mls per Sodium-Glucose Co-Transporter 2 (SGLT2) HUMULIN R U-500 1 month;QL(1.5 (CONCENTRATED) SOLN MO ml daily); MO INVOKANA TABS 1 Limit 45mls per JARDIANCE TABS 1 MO HUMULIN R U-500 1 month;QL(1.5 KWIKPEN SOPN ml daily); MO Sulfonylureas Limit 45mls per INSULIN LISPRO JUNIOR 1 month;QL(1.5 KWIKPEN SOPN ml daily); MO You can find information on what the symbols and abbreviations on this table mean by going to page vi.
2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 16 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AL(Up to 64 yrs glimepiride tabs 1 mg 1 old); SL(8 ea ANTIDOTES AND SPECIFIC ANTAGONISTS daily); MO Antidotes - Chelating Agents AL(Up to 64 yrs NDS glimepiride tabs 2 mg 1 old); SL(4 ea deferasirox pack 1 daily); MO NDS AL(Up to 64 yrs deferasirox tabs 1 glimepiride tabs 4 mg 1 old); SL(2 ea NDS daily); MO deferasirox tbso 1 SL(4 ea daily); PA; NDS;LA; glipizide tabs 10 mg 1 deferiprone tabs 1 MO MO SL(8 ea daily); glipizide tabs 5 mg 1 FERRIPROX TABS 1000 1 PA; NDS;LA; MO MG MO SL(2 ea daily); glipizide tb24 10 mg 1 FERRIPROX TWICE-A- 1 PA; NDS;MO MO DAY TABS SL(8 ea daily); glipizide tb24 2.5 mg 1 Antidotes and Specific Antagonists MO NDS;MO SL(4 ea daily); VISTOGARD PACK 1 glipizide tb24 5 mg 1 MO Opioid Antagonists AL(Up to 64 yrs glyburide micronized tabs 1 old); SL(8 ea naloxone hcl sosy 2 1.5 mg 1 daily); MO mg/2ml AL(Up to 64 yrs naltrexone hcl tabs 1 MO glyburide micronized tabs 3 1 old); SL(4 ea mg daily); MO 1box=15DS, 2boxes=30DS, AL(Up to 64 yrs Max 4 glyburide micronized tabs 6 1 old); SL(2 ea NARCAN LIQD 1 mg ea/month;QL(0. daily); MO 134 ea daily); AL(Up to 64 yrs MO glyburide tabs 1.25 mg 1 old); SL(16 ea daily); MO ANTIEMETICS - Drugs to Treat Nausea and Vomiting AL(Up to 64 yrs glyburide tabs 2.5 mg 1 old); SL(8 ea 5-HT3 Receptor Antagonists daily); MO granisetron hcl tabs or 1 1 B/D; MO AL(Up to 64 yrs mg glyburide tabs 5 mg 1 old); SL(4 ea ondansetron hcl soln ij 40 1 MO daily); MO mg/20ml, 4 mg/2ml SL(6 ea daily); tolbutamide tabs 1 ondansetron hcl soln or 4 1 MO MO mg/5ml ANTIDIARRHEAL/PROBIOTIC AGENTS - Drugs ondansetron hcl tabs or 24 1 to Treat Diarrhea mg Antiperistaltic Agents ondansetron hcl tabs or 4 1 MO mg, 8 mg diphenoxylate w/ atropine 1 MO tabs 0.025 mg-2.5 mg ondansetron tbdp 1 MO RX/OTC; MO loperamide hcl caps 1 Antiemetics - Anticholinergic
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2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 17 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits meclizine hcl tabs 12.5 mg, 1 RX/OTC; MO terbinafine hcl tabs 1 MO 25 mg scopolamine pt72 1 MO Imidazole-Related Antifungals CRESEMBA CAPS OR 1 NDS;MO TRANSDERM SCOP PT72 1 MO 186 MG (scopolamine) CRESEMBA SOLR IV 372 1 NDS TRANSDERM-SCOP PT72 1 MO MG (scopolamine) fluconazole in nacl soln 1 Antiemetics - Miscellaneous MO dronabinol caps 1 B/D; MO fluconazole susr 1 MO SYNDROS SOLN 1 B/D; NDS;MO fluconazole tabs 1 Substance P/Neurokinin 1 (NK1) Receptor itraconazole caps 100 mg 1 MO aprepitant caps 125 mg, 80 1 B/D; MO MO mg ketoconazole tabs 1 PA; MO aprepitant caps 40 mg 1 NOXAFIL SOLN IV 300 1 NDS MG/16.7ML B/D VARUBI TBPK 1 NOXAFIL SUSP OR 40 1 NDS;MO MG/ML ANTIFUNGALS - Drugs to Treat Fungal Infections posaconazole tbec 1 NDS;MO Antifungal - Glucan Synthesis Inhibitors TOLSURA CAPS 1 PA; NDS;MO ERAXIS SOLR 1 voriconazole solr iv 200 mg 1 micafungin sodium solr 100 1 NDS mg voriconazole susr or 40 1 MO mg/ml micafungin sodium solr 50 1 NDS;MO mg voriconazole tabs or 200 1 NDS;MO Antifungals mg, 50 mg ABELCET SUSP 1 PA ANTIHISTAMINES - Drugs to Treat Allergies
AMBISOME SUSR 1 PA Antihistamines - Ethanolamines carbinoxamine maleate 1 AL(Up to 64 yrs amphotericin b solr 1 PA; MO soln 4 mg/5ml old); MO carbinoxamine maleate 1 AL(Up to 64 yrs flucytosine caps 1 MO tabs 4 mg old); MO AL(Up to 64 yrs clemastine fumarate tabs 1 griseofulvin microsize susp 1 MO old); MO MO diphenhydramine hcl soln ij 1 MO griseofulvin microsize tabs 1 50 mg/ml griseofulvin ultramicrosize 1 MO Antihistamines - Non-Sedating tabs cetirizine hcl soln 1 mg/ml 1 RX/OTC; MO nystatin tabs 1 MO desloratadine tabs 5 mg 1 MO
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2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 18 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits desloratadine tbdp 5 mg 1 MO cholestyramine light powd 1 MO levocetirizine 1 RX/OTC; MO cholestyramine pack 1 MO dihydrochloride soln MO levocetirizine 1 RX/OTC; MO cholestyramine powd 1 dihydrochloride tabs MO Antihistamines - Phenothiazines colesevelam hcl pack 1 promethazine hcl soln ij 50 1 AL(Up to 64 yrs MO mg/ml, 25 mg/ml old); MO colesevelam hcl tabs 1 promethazine hcl soln or 1 AL(Up to 64 yrs colestipol hcl gran 1 MO 6.25 mg/5ml old); MO MO promethazine hcl supp re 1 AL(Up to 64 yrs colestipol hcl pack 1 12.5 mg, 25 mg old); MO MO promethazine hcl syrp or 1 AL(Up to 64 yrs colestipol hcl tabs 1 6.25 mg/5ml old); MO Fibric Acid Derivatives promethazine hcl tabs or 1 AL(Up to 64 yrs 12.5 mg, 25 mg, 50 mg old); MO ANTARA CAPS 30 MG 1 SL(4.33 ea daily); MO Antihistamines - Piperidines SL(1.44 ea AL(Up to 64 yrs ANTARA CAPS 90 MG 1 cyproheptadine hcl syrp 1 daily); MO old); MO MO AL(Up to 64 yrs choline fenofibrate cpdr 1 cyproheptadine hcl tabs 1 old); MO fenofibrate micronized caps 1 SL(1 ea daily); ANTIHYPERLIPIDEMICS - Drugs to Treat High 130 mg MO Cholesterol fenofibrate micronized caps 1 MO Antihyperlipidemics - Combinations 134 mg, 200 mg, 67 mg fenofibrate micronized caps SL(3.02 ea ezetimibe-simvastatin tabs 1 QL(8 ea daily); 1 10 mg-10 mg MO 43 mg daily); MO fenofibrate tabs 145 mg, 48 MO ezetimibe-simvastatin tabs 1 QL(4 ea daily); 1 10 mg-20 mg MO mg, 54 mg, 160 mg MO ezetimibe-simvastatin tabs 1 QL(2 ea daily); gemfibrozil tabs 1 10 mg-40 mg MO HMG CoA Reductase Inhibitors ezetimibe-simvastatin tabs 1 QL(1 ea daily); 10 mg-80 mg MO atorvastatin calcium tabs 1 MO Antihyperlipidemics - Misc. fluvastatin sodium caps 20 1 QL(3 ea daily); icosapent ethyl caps 1 ST; MO mg MO fluvastatin sodium caps 40 QL(2 ea daily); omega-3-acid ethyl esters 1 MO 1 caps mg MO ST; MO fluvastatin sodium tb24 80 1 MO VASCEPA CAPS 0.5 GM 1 mg lovastatin tabs 10 mg, 20 QL(1 ea daily); VASCEPA CAPS 1 GM 1 ST; MO 1 (icosapent ethyl) mg MO QL(2 ea daily); Bile Acid Sequestrants lovastatin tabs 40 mg 1 MO cholestyramine light pack 1 MO
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2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 19 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1 ea daily); pravastatin sodium tabs 1 REPATHA SOSY 1 PA; MO MO QL(1 ea daily); REPATHA SURECLICK PA; MO rosuvastatin calcium tabs 1 1 MO SOAJ simvastatin tabs 10 mg, 20 1 QL(1 ea daily); ANTIHYPERTENSIVES - Drugs to Treat High mg, 40 mg, 5 mg MO Blood Pressure SL(1 ea daily); simvastatin tabs 80 mg 1 ACE Inhibitors MO benazepril hcl tabs 1 MO Intestinal Cholesterol Absorption Inhibitors QL(1 ea daily); MO ezetimibe tabs 1 captopril tabs 1 MO enalapril maleate tabs 10 1 SL(4 ea daily); Microsomal Triglyceride Transfer Protein (MTP) mg MO PA; NDS;SL(6 enalapril maleate tabs 2.5 1 SL(16 ea daily); JUXTAPID CAPS 10 MG 1 ea daily); LA; mg MO MO enalapril maleate tabs 20 1 SL(2 ea daily); PA; NDS;SL(3 mg MO JUXTAPID CAPS 20 MG 1 ea daily); LA; SL(8 ea daily); MO enalapril maleate tabs 5 mg 1 MO PA; NDS;SL(2 JUXTAPID CAPS 30 MG 1 ea daily); LA; fosinopril sodium tabs 1 MO MO PA; lisinopril tabs 1 MO JUXTAPID CAPS 40 MG 1 NDS;SL(1.5 ea daily); LA; MO moexipril hcl tabs 1 MO PA; NDS;SL(12 perindopril erbumine tabs 2 1 SL(8 ea daily); JUXTAPID CAPS 5 MG 1 ea daily); LA; mg MO MO perindopril erbumine tabs 4 1 SL(4 ea daily); PA; NDS;SL(1 mg MO JUXTAPID CAPS 60 MG 1 ea daily); LA; MO perindopril erbumine tabs 8 1 SL(2 ea daily); mg MO Nicotinic Acid Derivatives MO niacin (antihyperlipidemic) MO quinapril hcl tabs 1 tbcr 1000 mg, 500 mg, 750 1 MO mg ramipril caps 1 Proprotein Convertase Subtilisin/Kexin Type 9 trandolapril tabs 1 MO PA; Limit 2mls Agents for Pheochromocytoma PRALUENT SOAJ 150 1 per 28 MG/ML days;SL(0.08 DEMSER CAPS 1 NDS;MO ml daily); MO (metyrosine) PA; Limit 4mls metyrosine caps 1 NDS;MO PRALUENT SOAJ 75 1 per 28 MG/ML days;SL(0.15 phenoxybenzamine hcl 1 MO ml daily); MO caps REPATHA PUSHTRONEX 1 PA; MO SYSTEM SOCT Angiotensin II Receptor Antagonists
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2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 20 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits candesartan cilexetil tabs 1 MO nadolol & 1 bendroflumethiazide tabs MO irbesartan tabs 1 quinapril- 1 MO hydrochlorothiazide tabs MO losartan potassium tabs 1 TEKTURNA HCT TABS 1 MO valsartan tabs 1 MO valsartan- SL(2 ea daily); hydrochlorothiazide tabs 1 MO Antiadrenergic Antihypertensives 12.5 mg-80 mg, 12.5 mg- 160 mg clonidine hcl tabs 1 MO valsartan- SL(1 ea daily); clonidine ptwk 1 MO hydrochlorothiazide tabs 1 MO 160 mg-25 mg, 25 mg-320 mg, 12.5 mg-320 mg doxazosin mesylate tabs 1 MO Direct Renin Inhibitors AL(Up to 64 yrs guanfacine hcl tabs 1 old); MO aliskiren fumarate tabs 1 MO MO prazosin hcl caps 1 Selective Aldosterone Receptor Antagonists MO terazosin hcl caps 1 MO eplerenone tabs 1 Antihypertensive Combinations Vasodilators hydralazine hcl tabs or 10 MO amlodipine besylate- 1 MO 1 benazepril hcl caps mg, 100 mg, 50 mg, 25 mg MO atenolol & chlorthalidone 1 MO minoxidil tabs 1 tabs ANTIMALARIALS - Drugs to Treat Malaria benazepril & 1 MO hydrochlorothiazide tabs (Parasitic Infections) bisoprolol & 1 MO Antimalarial Combinations hydrochlorothiazide tabs atovaquone-proguanil hcl 1 MO candesartan cilexetil- 1 MO tabs hydrochlorothiazide tabs COARTEM TABS 1 MO captopril & 1 MO hydrochlorothiazide tabs Antimalarials enalapril maleate & MO 1 chloroquine phosphate tabs 1 MO hydrochlorothiazide tabs 250 mg, 500 mg fosinopril sodium & MO 1 hydroxychloroquine sulfate 1 MO hydrochlorothiazide tabs tabs irbesartan- MO 1 KRINTAFEL TABS 1 QL(0.067 ea hydrochlorothiazide tabs daily) lisinopril & 1 MO MO hydrochlorothiazide tabs mefloquine hcl tabs 1 losartan potassium & 1 MO MO hydrochlorothiazide tabs primaquine phosphate tabs 1 metoprolol & 1 MO PRIMAQUINE MO hydrochlorothiazide tabs PHOSPHATE TABS 1 (primaquine phosphate) You can find information on what the symbols and abbreviations on this table mean by going to page vi.
2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 21 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits pyrimethamine tabs 1 MO Alkylating Agents BENDEKA SOLN 1 NDS quinine sulfate caps 1 PA; MO busulfan soln 1 ANTIMYASTHENIC/CHOLINERGIC AGENTS Antimyasthenic/Cholinergic Agents carboplatin soln 1 PA; NDS;SL(8 carmustine solr 1 FIRDAPSE TABS 1 ea daily); LA; MO cisplatin soln 100 mg/100ml, 200 mg/200ml, 1 GUANIDINE HCL TABS 1 50 mg/50ml pyridostigmine bromide 1 MO cyclophosphamide caps or 1 B/D; MO tabs 60 mg 25 mg, 50 mg pyridostigmine bromide 1 MO CYCLOPHOSPHAMIDE NDS tbcr 180 mg SOLN IV 1 GM/5ML, 500 1 PA; NDS;SL(10 MG/2.5ML RUZURGI TABS 1 ea daily); MO EVOMELA SOLR 1 NDS ANTIMYCOBACTERIAL AGENTS - Drugs to Treat Tuberculosis (Bacterial Infections) GLEOSTINE CAPS 1 MO Antimycobacterial Agents IFEX SOLR 3 GM 1 aminosalicylic acid pack 1 MO ifosfamide soln 1 gm/20ml, 1 3 gm/60ml CAPASTAT SULFATE 1 SOLR ifosfamide solr 1 gm 1 ethambutol hcl tabs 1 MO IFOSFAMIDE SOLR 3 GM 1 isoniazid tabs or 100 mg, 1 MO 300 mg LEUKERAN TABS 1 MO PRETOMANID TABS 1 PA melphalan hcl solr 1 PRIFTIN TABS 1 MO melphalan tabs 1 B/D; MO pyrazinamide tabs 1 MO oxaliplatin soln 200 1 mg/40ml, 100 mg/20ml rifabutin caps 1 NDS;MO oxaliplatin soln 50 mg/10ml 1 NDS rifampin caps or 150 mg, 1 MO 300 mg oxaliplatin solr 100 mg, 50 1 NDS mg rifampin solr iv 600 mg 1 TEMODAR SOLR 1 NDS SIRTURO TABS 1 NDS;LA thiotepa solr 15 mg 1 NDS TRECATOR TABS 1 MO TREANDA SOLR 1 NDS ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES - Drugs to Treat Cancer
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2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 22 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits YONDELIS SOLR 1 NDS;LA methotrexate sodium solr ij 1 1 gm MO ZANOSAR SOLR 1 methotrexate sodium tabs 1 MO or 5 mg, 2.5 mg NDS ZEPZELCA SOLR 1 ONUREG TABS 1 PA; NDS Antimetabolites PURIXAN SUSP 1 PA; NDS ALIMTA SOLR 1 NDS TABLOID TABS 1 MO ARRANON SOLN 1 NDS TREXALL TABS 1 MO azacitidine susr 1 NDS XATMEP SOLN 1 PA; MO cladribine soln 1 PA Antineoplastic - Angiogenesis Inhibitors clofarabine soln 1 AVASTIN SOLN 1 NDS PA cytarabine soln 1 CYRAMZA SOLN 1 NDS;LA decitabine solr 1 MVASI SOLN 1 NDS fludarabine phosphate solr 1 PA; NDS 50 mg ZALTRAP SOLN 1 PA fluorouracil soln 1 ZIRABEV SOLN 1 NDS FOLOTYN SOLN 1 NDS Antineoplastic - Antibodies gemcitabine hcl soln 1 ARZERRA CONC 1 NDS gm/10ml, 2 gm/20ml, 200 1 mg/2ml BAVENCIO SOLN 1 NDS;LA gemcitabine hcl soln 200 NDS NDS mg/5.26ml, 1 gm/26.3ml, 2 1 BESPONSA SOLR 1 gm/52.6ml BLENREP SOLR 1 NDS;MO gemcitabine hcl solr 2 gm, 1 1 gm BLINCYTO SOLR 1 NDS gemcitabine hcl solr 200 1 NDS mg CAMPATH SOLN 1 NDS GEMCITABINE SOLN 1 NDS (gemcitabine hcl) DARZALEX SOLN 1 NDS;LA INFUGEM SOLN 1 NDS EMPLICITI SOLR 1 NDS mercaptopurine tabs 1 MO ENHERTU SOLR 1 NDS methotrexate sodium soln ij 1 1 gm/40ml ERBITUX SOLN 1 NDS methotrexate sodium soln ij MO 250 mg/10ml, 50 mg/2ml, 1 GAZYVA SOLN 1 NDS;LA 250 mg/10ml, 50 mg/2ml
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2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 23 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HERCEPTIN SOLR 150 1 PA; NDS TRODELVY SOLR 1 NDS;MO MG NDS HERCEPTIN SOLR 440 1 NDS TRUXIMA SOLN 1 MG NDS IMFINZI SOLN 1 NDS;LA VECTIBIX SOLN 1 PA; NDS KADCYLA SOLR 1 PA; NDS YERVOY SOLN 1 Antineoplastic - BCL-2 Inhibitors KANJINTI SOLR 1 NDS VENCLEXTA STARTING 1 PA; LA; MO KEYTRUDA SOLN 1 NDS PACK TBPK VENCLEXTA TABS 1 PA; LA; MO LARTRUVO SOLN 1 NDS;LA; MO Antineoplastic - Hedgehog Pathway Inhibitors LIBTAYO SOLN 1 NDS;LA; MO DAURISMO TABS 1 PA; NDS LUMOXITI SOLR 1 NDS;LA ERIVEDGE CAPS 1 NDS;LA MONJUVI SOLR 1 NDS;MO ODOMZO CAPS 1 PA; NDS;LA MYLOTARG SOLR 1 NDS Antineoplastic - Hormonal and Related Agents NDS OGIVRI SOLR 1 abiraterone acetate tabs 1 PA; NDS NDS OPDIVO SOLN 1 anastrozole tabs 1 MO
PADCEV SOLR 20 MG 1 NDS;SL(7 ea MO daily) bicalutamide tabs 1 MO PADCEV SOLR 30 MG 1 NDS;SL(5 ea DEPO-PROVERA SUSP 1 daily) PERJETA SOLN 1 NDS ELIGARD KIT 1 MO POLIVY SOLR 1 NDS EMCYT CAPS 1 PA; NDS PORTRAZZA SOLN 1 NDS ERLEADA TABS 1 MO POTELIGEO SOLN 1 NDS exemestane tabs 1 NDS FASLODEX SOLN 1 NDS;MO RITUXAN SOLN 1 (fulvestrant) RUXIENCE SOLN 1 NDS FIRMAGON SOLR 120 1 NDS MG/VIAL NDS SARCLISA SOLN 1 FIRMAGON SOLR 80 MG 1 PA; NDS TECENTRIQ SOLN 1 flutamide caps 1 MO NDS TRAZIMERA SOLR 1 fulvestrant soln 1 NDS;MO
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2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 24 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits hydroxyprogesterone NDS XPOVIO 100 MG ONCE 1 PA; NDS;MO caproate (antineoplastic) 1 WEEKLY TBPK soln XPOVIO 40 MG ONCE 1 PA; NDS;MO letrozole tabs 1 MO WEEKLY TBPK XPOVIO 40 MG TWICE 1 PA; NDS;MO leuprolide acetate kit 1 WEEKLY TBPK XPOVIO 60 MG ONCE 1 PA; NDS;MO LUPRON DEPOT (1- 1 NDS WEEKLY TBPK MONTH) KIT XPOVIO 60 MG TWICE 1 PA; NDS;MO LUPRON DEPOT (3- 1 NDS WEEKLY TBPK MONTH) KIT XPOVIO 80 MG ONCE 1 PA; NDS;MO LUPRON DEPOT (4- 1 NDS WEEKLY TBPK MONTH) KIT XPOVIO 80 MG TWICE 1 PA; NDS;MO LUPRON DEPOT (6- 1 NDS WEEKLY TBPK MONTH) KIT Antineoplastic Antibiotics LYSODREN TABS 1 bleomycin sulfate solr 1 PA AL(Up to 64 yrs megestrol acetate susp 1 old); MO dactinomycin solr 1 AL(Up to 64 yrs megestrol acetate tabs 1 old); MO daunorubicin hcl soln 1 MO nilutamide tabs 1 DAUNORUBICIN HYDROCHLORIDE SOLN 1 NUBEQA TABS 1 PA; NDS 20 MG/4ML (daunorubicin hcl) MO SOLTAMOX SOLN 1 DAUNORUBICIN MO HYDROCHLORIDE SOLN 1 tamoxifen citrate tabs 1 50 MG/10ML NDS;MO doxorubicin hcl liposomal 1 toremifene citrate tabs 1 inj doxorubicin hcl soln 2 TRELSTAR MIXJECT 1 NDS 1 SUSR mg/ml doxorubicin hcl solr 10 mg, VANTAS KIT 1 NDS 1 50 mg PA; NDS;LA XTANDI CAPS 1 epirubicin hcl soln 1 PA; NDS YONSA TABS 1 idarubicin hcl soln 1
ZOLADEX IMPL 1 mitomycin solr 1 PA; NDS ZYTIGA TABS 500 MG 1 mitoxantrone hcl conc 1
Antineoplastic - Immunomodulators valrubicin soln 1 NDS POMALYST CAPS 1 NDS;LA VALSTAR SOLN 1 NDS (valrubicin) Antineoplastic - XPO1 Inhibitors Antineoplastic Combinations You can find information on what the symbols and abbreviations on this table mean by going to page vi.
2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 25 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; NDS DARZALEX FASPRO 1 NDS;LA CABOMETYX TABS 1 SOLN PA; NDS;LA; HERCEPTIN HYLECTA 1 NDS CALQUENCE CAPS 1 SOLN MO PA; NDS;MO INQOVI TABS 1 PA; NDS CAPRELSA TABS 100 MG 1 PA; NDS;LA; KISQALI FEMARA 200 1 PA; NDS CAPRELSA TABS 300 MG 1 DOSE TBPK MO PA; NDS;LA KISQALI FEMARA 400 1 PA; NDS COMETRIQ KIT 1 DOSE TBPK PA; NDS;MO KISQALI FEMARA 600 1 PA; NDS COPIKTRA CAPS 1 DOSE TBPK COTELLIC TABS 1 PA; NDS;LA LONSURF TABS 1 PA; NDS erlotinib hcl tabs 1 PA; NDS PHESGO SOLN 1 NDS everolimus tabs 1 PA; NDS RITUXAN HYCELA SOLN 1 NDS FARYDAK CAPS 1 PA; NDS;LA VYXEOS SUSR 1 NDS;MO PA; NDS;MO Antineoplastic Enzyme Inhibitors GAVRETO CAPS 1 PA; NDS AFINITOR DISPERZ TBSO 1 GILOTRIF TABS 1 PA; NDS;LA; MO PA; NDS AFINITOR TABS 10 MG 1 IBRANCE CAPS 1 NDS;LA PA; NDS;LA ALECENSA CAPS 1 IBRANCE TABS 1 NDS;LA NDS;MO ALIQOPA SOLR 1 ICLUSIG TABS 15 MG, 45 1 PA; NDS;LA; MG MO PA; NDS;LA ALUNBRIG TABS 1 IDHIFA TABS 1 PA; NDS PA; NDS;LA ALUNBRIG TBPK 1 imatinib mesylate tabs 1 PA; NDS PA; NDS;MO PA; NDS;LA; AYVAKIT TABS 1 IMBRUVICA CAPS 1 MO PA; NDS;LA; BALVERSA TABS 1 MO IMBRUVICA TABS 1 PA; NDS;LA; MO BELEODAQ SOLR 1 PA; NDS INLYTA TABS 1 PA; NDS;LA BORTEZOMIB SOLR 1 NDS INREBIC CAPS 1 PA; NDS;LA BOSULIF TABS 1 PA; NDS IRESSA TABS 1 LA BRAFTOVI CAPS 75 MG 1 PA; NDS;MO ISTODAX (OVERFILL) 1 NDS SOLR BRUKINSA CAPS 1 PA; NDS;MO JAKAFI TABS 1 PA; NDS;LA
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2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 26 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KISQALI TBPK 1 PA; NDS RETEVMO CAPS 1 PA; NDS
KOSELUGO CAPS 1 PA; NDS;MO ROMIDEPSIN SOLN 27.5 1 NDS MG/5.5ML NDS KYPROLIS SOLR 1 ROMIDEPSIN SOLR 10 1 NDS MG NDS lapatinib ditosylate tabs 1 ROZLYTREK CAPS 1 PA; NDS LENVIMA 10 MG DAILY 1 PA; NDS PA; NDS;LA DOSE CPPK RUBRACA TABS 1 LENVIMA 12MG DAILY 1 PA; NDS PA; NDS DOSE CPPK RYDAPT CAPS 1 LENVIMA 14 MG DAILY 1 PA; NDS SPRYCEL TABS 1 PA; NDS DOSE CPPK PA; NDS;LA LENVIMA 18 MG DAILY 1 PA; NDS STIVARGA TABS 1 DOSE CPPK NDS LENVIMA 20 MG DAILY 1 PA; NDS SUTENT CAPS 1 DOSE CPPK TABRECTA TABS 1 PA; NDS LENVIMA 24 MG DAILY 1 PA; NDS DOSE CPPK TAFINLAR CAPS 1 NDS LENVIMA 4 MG DAILY 1 PA; NDS DOSE CPPK TAGRISSO TABS 1 PA; NDS;LA LENVIMA 8 MG DAILY 1 PA; NDS DOSE CPPK TALZENNA CAPS 1 PA; NDS LORBRENA TABS 1 PA; NDS TASIGNA CAPS 1 PA; NDS LYNPARZA TABS 1 PA; NDS;LA TAZVERIK TABS 1 PA; NDS;MO MEKINIST TABS 1 PA; NDS temsirolimus soln 1 NDS MEKTOVI TABS 1 PA; NDS TIBSOVO TABS 1 PA; NDS;LA NERLYNX TABS 1 PA; NDS;LA TUKYSA TABS 1 PA; NDS;MO NEXAVAR TABS 1 NDS;LA PA; NDS;LA; TURALIO CAPS 1 MO NINLARO CAPS 1 PA; NDS TYKERB TABS (lapatinib 1 NDS PEMAZYRE TABS 1 PA; NDS;MO ditosylate) VELCADE SOLR 1 NDS PIQRAY 200MG DAILY 1 PA; NDS DOSE TBPK VERZENIO TABS 1 PA; NDS PIQRAY 250MG DAILY 1 PA; NDS DOSE TBPK VITRAKVI CAPS 1 PA; NDS PIQRAY 300MG DAILY 1 PA; NDS DOSE TBPK VITRAKVI SOLN 1 PA; NDS QINLOCK TABS 1 PA; NDS;LA; MO You can find information on what the symbols and abbreviations on this table mean by going to page vi.
2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 27 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VIZIMPRO TABS 1 PA; NDS TICE BCG SUSR 1 NDS
VOTRIENT TABS 1 PA; NDS tretinoin (chemotherapy) 1 NDS;MO caps XALKORI CAPS 1 PA; NDS Chemotherapy Adjuncts NDS XOSPATA TABS 1 PA; NDS;LA; ELITEK SOLR 1 MO KEPIVANCE SOLR 1 NDS ZEJULA CAPS 1 PA; NDS;LA; MO Chemotherapy Rescue/Antidote Agents ZELBORAF TABS 1 PA; NDS;LA dexrazoxane hcl solr 1 ZOLINZA CAPS 1 NDS KHAPZORY SOLR 1 NDS PA; NDS;LA ZYDELIG TABS 1 leucovorin calcium solr ij PA; NDS;LA 100 mg, 200 mg, 350 mg, 1 ZYKADIA TABS 1 50 mg, 500 mg Antineoplastic Enzymes leucovorin calcium tabs or 1 MO 25 mg, 5 mg, 10 mg, 15 mg NDS ERWINAZE SOLR 1 levoleucovorin calcium soln NDS 250 mg/25ml, 175 1 Antineoplastics Misc. mg/17.5ml NDS;LA ACTIMMUNE SOLN 1 levoleucovorin calcium solr 1 50 mg NDS arsenic trioxide soln 1 mesna soln 1 bexarotene caps 1 NDS MESNEX TABS OR 400 1 NDS;MO MG dacarbazine solr 1 Mitotic Inhibitors MO hydroxyurea caps 1 ABRAXANE SUSR 1 NDS;MO INTRON A SOLN 10 NDS 1 docetaxel conc 20 mg/ml, 1 NDS MU/ML 80 mg/4ml INTRON A SOLN 6000000 1 docetaxel soln 160 NDS UNIT/ML mg/16ml, 20 mg/2ml, 80 1 mg/8ml INTRON A SOLR 10 MU, 1 NDS 18 MU, 50 MU ETOPOPHOS SOLR 1 MATULANE CAPS 1 NDS;LA etoposide soln 1 NIPENT SOLR 1 HALAVEN SOLN 1 NDS PROLEUKIN SOLR 1 NDS IXEMPRA KIT SOLR 1 NDS SYLATRON KIT 1 NDS JEVTANA SOLN 1 NDS SYNRIBO SOLR 1 NDS;MO
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2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 28 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MARQIBO SUSP 1 NDS;MO Antiparkinson Dopaminergics MO paclitaxel conc 150 amantadine hcl caps 1 mg/25ml, 100 mg/16.7ml, 1 MO 30 mg/5ml, 300 mg/50ml, 6 amantadine hcl syrp 1 mg/ml amantadine hcl tabs 1 MO vinblastine sulfate soln 1 PA; MO APOKYN SOCT 1 NDS;LA vincristine sulfate soln 1 PA; MO bromocriptine mesylate 1 MO vinorelbine tartrate soln 10 1 caps mg/ml bromocriptine mesylate 1 MO vinorelbine tartrate soln 50 1 MO tabs mg/5ml carbidopa-levodopa tabs 1 MO Oncolytic Viral Agents MO IMLYGIC SUSP 1 1000000 carbidopa-levodopa tbcr 1 Unit/ML;MO NDS; carbidopa-levodopa tbdp 1 MO IMLYGIC SUSP 1 100000000 Unit/ML;MO DUOPA SUSP 1 B/D; MO Topoisomerase I Inhibitors NEUPRO PT24 1 MO irinotecan hcl soln 1 pramipexole MO NDS;MO ONIVYDE INJ 1 dihydrochloride tabs 0.125 1 mg, 0.25 mg, 0.5 mg, 0.75 topotecan hcl solr 4 mg 1 mg, 1 mg, 1.5 mg ropinirole hydrochloride 1 MO ANTIPARKINSON AND RELATED THERAPY tabs AGENTS - Drugs to Treat Parkinson's Disease ropinirole hydrochloride 1 MO Antiparkinson Adjunctive Therapy tb24 carbidopa tabs 1 MO Antiparkinson Monoamine Oxidase Inhibitors rasagiline mesylate tabs 1 MO Antiparkinson Anticholinergics MO benztropine mesylate soln 1 MO selegiline hcl caps 1 ij 1 mg/ml selegiline hcl tabs 1 MO benztropine mesylate tabs 1 AL(Up to 64 yrs or 0.5 mg, 1 mg, 2 mg old); MO AL(Up to 64 yrs ANTIPSYCHOTICS/ANTIMANIC AGENTS - trihexyphenidyl hcl soln 1 old); MO Drugs to Treat Mood Disorders AL(Up to 64 yrs Antimanic Agents trihexyphenidyl hcl tabs 1 old); MO lithium carbonate caps 1 MO Antiparkinson COMT Inhibitors MO SL(8 ea daily); lithium carbonate tabs 1 entacapone tabs 1 MO lithium carbonate tbcr 1 MO tolcapone tabs 1 MO
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2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 29 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits lithium soln 1 MO INVEGA SUSTENNA NDS;MO SUSY 117 MG/0.75ML, 1 Antipsychotics - Misc. 156 MG/ML, 234 MG/1.5ML PA; NDS;MO CAPLYTA CAPS 1 INVEGA SUSTENNA MO MO SUSY 39 MG/0.25ML, 78 1 EQUETRO CP12 1 MG/0.5ML PA; INVEGA TRINZA SUSY 1 NDS LATUDA TABS 120 MG 1 NDS;SL(1.33 SL(8 ea daily); ea daily); MO paliperidone tb24 1.5 mg 1 PA; NDS;SL(8 MO LATUDA TABS 20 MG 1 SL(4 ea daily); ea daily); MO paliperidone tb24 3 mg 1 PA; NDS;SL(4 MO LATUDA TABS 40 MG 1 SL(2 ea daily); ea daily); MO paliperidone tb24 6 mg 1 PA; MO NDS;SL(1.33 LATUDA TABS 60 MG 1 NDS;SL(2.67 paliperidone tb24 9 mg 1 ea daily); MO ea daily); MO PA; NDS;SL(2 PA; NDS LATUDA TABS 80 MG 1 PERSERIS PRSY 1 ea daily); MO Limit 8 vials per NUPLAZID CAPS 34 MG 1 PA; NDS;LA RISPERDAL CONSTA 1 28 PA; NDS;LA SRER 12.5 MG days;SL(0.29 NUPLAZID TABS 10 MG 1 ea daily); MO Limit 4 vials per NUPLAZID TABS 17 MG 1 PA; NDS RISPERDAL CONSTA 1 28 SRER 25 MG days;SL(0.15 VRAYLAR CAPS 1.5 MG 1 PA; SL(4 ea daily); MO ea daily); MO PA; SL(2 ea NDS; Limit 4 VRAYLAR CAPS 3 MG 1 daily); MO RISPERDAL CONSTA 1 vials per 42 SRER 37.5 MG days;SL(0.1 ea VRAYLAR CAPS 4.5 MG 1 PA; SL(1.4 ea daily); MO daily); MO NDS; Limit 2 PA; SL(1 ea VRAYLAR CAPS 6 MG 1 RISPERDAL CONSTA 1 vials per 28 daily); MO SRER 50 MG days;SL(0.08 VRAYLAR CPPK 1 PA; MO ea daily); MO risperidone soln 1 MO ziprasidone hcl caps 1 MO risperidone tabs 1 MO ziprasidone mesylate solr 1 MO 1 MO Benzisoxazoles risperidone tbdp FANAPT TABS 1 MG, 10 1 MO Butyrophenones MG, 2 MG, 4 MG haloperidol decanoate soln 1 MO FANAPT TABS 12 MG, 6 1 NDS;MO MG, 8 MG haloperidol lactate conc 1 MO
haloperidol lactate soln 1 MO
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 30 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits haloperidol tabs 1 MO chlorpromazine hcl soln ij 1 50 mg/2ml Dibenzapines chlorpromazine hcl tabs or MO 10 mg, 200 mg, 25 mg, 100 1 clozapine tabs 100 mg, 200 1 mg, 25 mg, 50 mg mg, 50 mg fluphenazine decanoate MO clozapine tbdp 100 mg, 1 1 12.5 mg, 25 mg, 150 mg soln NDS fluphenazine hcl conc or 5 1 MO clozapine tbdp 200 mg 1 mg/ml fluphenazine hcl soln ij 2.5 MO CLOZARIL TABS 50 MG 1 1 (clozapine) mg/ml MO fluphenazine hcl tabs or 1 1 MO loxapine succinate caps 1 mg, 10 mg, 2.5 mg, 5 mg olanzapine solr 1 MO perphenazine tabs 1 MO MO olanzapine tabs 1 prochlorperazine edisylate 1 MO soln 10 mg/2ml MO olanzapine tbdp 1 prochlorperazine edisylate 1 soln 50 mg/10ml quetiapine fumarate tabs MO prochlorperazine maleate 1 MO 100 mg, 200 mg, 25 mg, 1 tabs 300 mg, 400 mg, 50 mg MO NDS;SL(2 ea prochlorperazine supp 1 SAPHRIS SUBL 10 MG 1 daily); MO thioridazine hcl tabs 1 MO SAPHRIS SUBL 2.5 MG 1 SL(8 ea daily); MO trifluoperazine hcl tabs 1 MO SL(4 ea daily); SAPHRIS SUBL 5 MG 1 MO Quinolinone Derivatives SECUADO PT24 3.8 1 PA; NDS;SL(2 NDS;MO MG/24HR ea daily) ABILIFY MAINTENA PRSY 1 PA; NDS;MO SECUADO PT24 5.7 1 NDS;SL(1.34 ABILIFY MAINTENA SRER 1 MG/24HR ea daily) SL(30 ml daily); aripiprazole soln 1 mg/ml 1 SECUADO PT24 7.6 1 PA; NDS;SL(1 MO MG/24HR ea daily) 1 SL(3 ea daily); PA; NDS;SL(18 aripiprazole tabs 10 mg MO VERSACLOZ SUSP 1 ml daily) SL(2 ea daily); aripiprazole tabs 15 mg 1 ZYPREXA RELPREVV 1 MO SUSR SL(15 ea daily); aripiprazole tabs 2 mg 1 Dihydroindolones MO SL(1.5 ea aripiprazole tabs 20 mg 1 molindone hcl tabs 1 daily); MO SL(1 ea daily); Phenothiazines aripiprazole tabs 30 mg 1 MO chlorpromazine hcl soln ij MO 1 SL(6 ea daily); 25 mg/ml aripiprazole tabs 5 mg 1 MO
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2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 31 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NDS;SL(3 ea NDS;MO aripiprazole tbdp 10 mg 1 CIMDUO TABS 1 daily); MO NDS;SL(2 ea NDS;MO aripiprazole tbdp 15 mg 1 COMPLERA TABS 1 daily); MO MO ARISTADA INITIO PRSY 1 NDS CRIXIVAN CAPS 1 NDS;MO ARISTADA PRSY 1 NDS DELSTRIGO TABS 1 NDS;MO REXULTI TABS 0.25 MG 1 PA; NDS;SL(16 DESCOVY TABS 1 ea daily); MO didanosine cpdr 1 MO REXULTI TABS 0.5 MG 1 PA; NDS;SL(8 ea daily); MO NDS;MO PA; NDS;SL(4 DOVATO TABS 1 REXULTI TABS 1 MG 1 ea daily); MO EDURANT TABS 1 NDS;MO REXULTI TABS 2 MG 1 PA; NDS;SL(2 ea daily); MO efavirenz caps 1 MO PA; REXULTI TABS 3 MG 1 NDS;SL(1.33 efavirenz tabs 1 MO ea daily); MO efavirenz-emtricitabine- NDS;MO REXULTI TABS 4 MG 1 PA; NDS;SL(1 ea daily); MO tenofovir disoproxil 1 fumarate tabs Thioxanthenes efavirenz-lamivudine- NDS;MO thiothixene caps 1 MO tenofovir disoproxil 1 fumarate tabs ANTIVIRALS - Drugs to Treat Viral Infections emtricitabine caps 1 MO Antiretrovirals emtricitabine-tenofovir 1 NDS;MO abacavir sulfate soln 1 MO disoproxil fumarate tabs EMTRIVA SOLN 10 1 MO abacavir sulfate tabs 1 MO MG/ML EVOTAZ TABS 1 NDS;MO abacavir sulfate-lamivudine 1 MO tabs fosamprenavir calcium tabs 1 NDS;MO abacavir sulfate- 1 NDS;MO lamivudine-zidovudine tabs FUZEON SOLR 1 NDS APTIVUS CAPS 250 MG 1 NDS;MO GENVOYA TABS 1 NDS;MO APTIVUS SOLN 100 1 MG/ML INTELENCE TABS 100 1 NDS;MO MG, 200 MG atazanavir sulfate caps 1 NDS;MO INTELENCE TABS 25 MG 1 ATRIPLA TABS (efavirenz- NDS;MO emtricitabine-tenofovir 1 INVIRASE TABS 500 MG 1 NDS;MO disoproxil fumarate) NDS;MO ISENTRESS CHEW 100 1 SL(6 ea daily); BIKTARVY TABS 1 MG MO
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2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 32 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RETROVIR IV INFUSION ISENTRESS CHEW 25 MG 1 SL(24 ea daily); 1 MO SOLN ISENTRESS HD TABS 1 NDS;MO REYATAZ PACK 50 MG 1 NDS;MO
ISENTRESS PACK 100 1 SL(2 ea daily); ritonavir tabs 1 MO MG MO NDS;MO ISENTRESS TABS 400 1 NDS;MO RUKOBIA TB12 1 MG NDS;MO SELZENTRY SOLN 20 1 JULUCA TABS 1 MG/ML SELZENTRY TABS 150 MO KALETRA TABS 100 MG- 1 MO 1 25 MG MG, 300 MG SELZENTRY TABS 25 KALETRA TABS 200 MG- 1 NDS;MO 1 50 MG MG, 75 MG MO lamivudine soln 1 MO stavudine caps 1 NDS;MO lamivudine tabs 1 MO STRIBILD TABS 1 SYMFI LO TABS NDS;MO lamivudine-zidovudine tabs 1 MO (efavirenz-lamivudine- 1 MO tenofovir disoproxil LEXIVA SUSP 50 MG/ML 1 fumarate) lopinavir-ritonavir soln 1 NDS;MO SYMFI TABS (efavirenz- NDS;MO lamivudine-tenofovir 1 disoproxil fumarate) nevirapine susp 50 mg/5ml 1 MO SYMTUZA TABS 1 NDS;MO nevirapine tabs 200 mg 1 MO TEMIXYS TABS 1 NDS;MO nevirapine tb24 100 mg 1 tenofovir disoproxil 1 MO nevirapine tb24 400 mg 1 MO fumarate tabs TIVICAY PD TBSO 1 MO NORVIR PACK 100 MG 1 MO TIVICAY TABS 10 MG 1 MO NORVIR SOLN 80 MG/ML 1 MO TIVICAY TABS 25 MG, 50 1 NDS;MO ODEFSEY TABS 1 NDS;MO MG TRIUMEQ TABS 1 NDS;MO PIFELTRO TABS 1 NDS;MO TROGARZO SOLN 1 NDS PREZCOBIX TABS 1 NDS;MO TRUVADA TABS 100 MG- NDS;MO PREZISTA SUSP 100 1 NDS;MO 150 MG, 133 MG-200 MG, 1 MG/ML 167 MG-250 MG PREZISTA TABS 150 MG, 1 NDS;MO TRUVADA TABS 200 MG- NDS;MO 600 MG, 800 MG 300 MG (emtricitabine- 1 PREZISTA TABS 75 MG 1 MO tenofovir disoproxil fumarate)
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2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 33 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TYBOST TABS 1 MO PEGASYS PROCLICK 1 NDS SOLN 180 MCG/0.5ML MO VIDEX EC CPDR 125 MG 1 PEGASYS SOLN 1 NDS VIDEXPEDIATRIC SOLR 2 1 MO NDS GM PEGINTRON KIT 1 VIRACEPT TABS 1 NDS;MO ribavirin (hepatitis c) caps 1 200 mg NDS;MO VIREAD POWD 40 MG/GM 1 ribavirin (hepatitis c) tabs 1 200 mg VIREAD TABS 150 MG, NDS;MO 1 SOVALDI TABS 200 MG, 1 PA; NDS 200 MG, 250 MG 400 MG MO zidovudine caps 1 VEMLIDY TABS 1 ST; NDS;MO MO zidovudine syrp 1 VOSEVI TABS 1 PA; NDS MO zidovudine tabs 1 ZEPATIER TABS 1 PA; NDS CMV Agents Herpes Agents NDS cidofovir soln 1 acyclovir caps 1 MO PA ganciclovir sodium solr 1 acyclovir sodium soln 1 PA PREVYMIS TABS OR 240 1 PA; NDS;MO MO MG, 480 MG acyclovir susp 1 valganciclovir hcl tabs 450 1 NDS;MO MO mg acyclovir tabs 1 Hepatitis Agents famciclovir tabs 1 MO adefovir dipivoxil tabs 1 NDS;MO valacyclovir hcl tabs 1 MO BARACLUDE SOLN 0.05 1 MO MG/ML Influenza Agents MO oseltamivir phosphate caps 1 QL(4 ea daily); entecavir tabs 1 30 mg MO EPCLUSA TABS 100 MG- 1 PA; NDS oseltamivir phosphate caps 1 MO 400 MG 45 mg, 75 mg EPIVIR HBV SOLN 5 1 MO oseltamivir phosphate susr 1 MO MG/ML 6 mg/ml HARVONI PACK 150 MG- 1 PA; NDS RELENZA DISKHALER 1 MO 33.75 MG, 200 MG-45 MG AEPB HARVONI TABS 200 MG- 1 PA; NDS rimantadine hydrochloride 1 MO 45 MG, 400 MG-90 MG tabs lamivudine (hbv) tabs 1 MO Respiratory Syncytial Virus (RSV) Agents ribavirin solr 1 MAVYRET TABS 1 PA; NDS BETA BLOCKERS - Drugs to Treat High Blood Pressure You can find information on what the symbols and abbreviations on this table mean by going to page vi.
2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 34 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Alpha-Beta Blockers amlodipine besylate tabs 1 SL(1 ea daily); 10 mg MO carvedilol phosphate cp24 1 MO amlodipine besylate tabs 1 SL(4 ea daily); SL(8 ea daily); 2.5 mg MO carvedilol tabs 12.5 mg 1 MO amlodipine besylate tabs 5 1 SL(2 ea daily); SL(4 ea daily); mg MO carvedilol tabs 25 mg 1 MO diltiazem hcl coated beads 1 MO SL(32 ea daily); cp24 carvedilol tabs 3.125 mg 1 MO diltiazem hcl coated beads 1 MO SL(16 ea daily); tb24 carvedilol tabs 6.25 mg 1 MO diltiazem hcl cp12 or 120 1 MO mg, 60 mg, 90 mg labetalol hcl tabs or 100 1 MO mg, 200 mg, 300 mg diltiazem hcl cp24 or 120 1 MO mg, 180 mg, 240 mg Beta Blockers Cardio-Selective diltiazem hcl extended 1 MO acebutolol hcl caps 1 MO release beads cp24 MO diltiazem hcl tabs or 120 1 MO atenolol tabs 1 mg, 60 mg, 30 mg, 90 mg MO betaxolol hcl tabs 1 MO felodipine tb24 1
MO nicardipine hcl caps or 20 1 MO bisoprolol fumarate tabs 1 mg, 30 mg MO metoprolol succinate tb24 1 nifedipine tb24 30 mg, 60 1 MO mg, 90 mg metoprolol tartrate tabs or 1 MO MO 100 mg, 25 mg, 50 mg nimodipine caps 1 Beta Blockers Non-Selective nisoldipine tb24 17 mg, 34 1 MO mg, 8.5 mg nadolol tabs 1 MO NYMALIZE SOLN 1 NDS MO pindolol tabs 1 verapamil hcl cp24 or 360 MO mg, 100 mg, 120 mg, 180 propranolol hcl cp24 or 120 1 MO 1 mg, 160 mg, 60 mg, 80 mg mg, 200 mg, 240 mg, 300 mg propranolol hcl tabs or 10 MO mg, 80 mg, 20 mg, 40 mg, 1 verapamil hcl tabs or 40 1 MO 60 mg mg, 120 mg, 80 mg MO verapamil hcl tbcr or 120 1 MO sotalol hcl (afib/afl) tabs 1 mg, 180 mg, 240 mg 1 MO VERELAN PM CP24 300 1 MO sotalol hcl tabs MG (verapamil hcl) SOTYLIZE SOLN 1 MO CARDIOTONICS - Drugs to Treat Heart Failure and Abnormal Heart Rhythm CALCIUM CHANNEL BLOCKERS - Drugs to Treat High Blood Pressure Cardiac Glycosides MO Calcium Channel Blockers digoxin soln or 0.05 mg/ml 1
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2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 35 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits digoxin tabs or 0.25 mg, MO tadalafil (pulmonary 1 PA; NDS 250 mcg, 0.125 mg, 125 1 hypertension) tabs mcg Pulmonary Hypertension - Prostacyclin Receptor LANOXIN TABS OR 62.5 1 MO PA; NDS;LA MCG UPTRAVI TABS 1 CARDIOVASCULAR AGENTS - MISC. - Drugs to UPTRAVI TBPK 1 PA; NDS;LA Treat Heart and Circulation Conditions Cardiovascular Agents Misc. - Combinations Pulmonary Hypertension - Sol Guanylate Cyclase PA; NDS;SL(15 amlodipine besylate- 1 MO ADEMPAS TABS 0.5 MG 1 atorvastatin calcium tabs ea daily) MO PA; ENTRESTO TABS 1 ADEMPAS TABS 1 MG 1 NDS;SL(7.5 ea Prostaglandin Vasodilators daily) PA; NDS;SL(5 ORENITRAM TBCR 0.125 1 PA ADEMPAS TABS 1.5 MG 1 MG ea daily) PA; ORENITRAM TBCR 0.25 1 PA; NDS MG, 1 MG, 2.5 MG, 5 MG ADEMPAS TABS 2 MG 1 NDS;SL(3.75 ea daily) treprostinil soln 1 B/D; NDS;LA ADEMPAS TABS 2.5 MG 1 PA; NDS;SL(3 ea daily) TYVASO REFILL SOLN 1 B/D; NDS;LA Sinus Node Inhibitors B/D; NDS;LA TYVASO SOLN 1 CORLANOR SOLN 5 1 SL(15 ml daily) MG/5ML B/D; NDS;LA TYVASO STARTER SOLN 1 CORLANOR TABS 5 MG 1 SL(3 ea daily); MO VENTAVIS SOLN 10 1 B/D; LA MCG/ML CORLANOR TABS 7.5 MG 1 SL(2 ea daily); MO VENTAVIS SOLN 20 1 B/D; NDS;LA MCG/ML Transthyretin Stabilizers Pulmonary Hypertension - Endothelin Receptor VYNDAMAX CAPS 1 PA; NDS;QL(1 ea daily) ambrisentan tabs 1 NDS;LA VYNDAQEL CAPS 1 PA; NDS;QL(4 ea daily) bosentan tabs 1 NDS;LA CEPHALOSPORINS - Drugs to Treat Bacterial Infections OPSUMIT TABS 1 PA; NDS Cephalosporins - 1st Generation TRACLEER TBSO 32 MG 1 NDS;LA cefadroxil caps 1 MO Pulmonary Hypertension - Phosphodiesterase cefadroxil susr 1 MO sildenafil citrate (pulmonary PA; NDS hypertension) soln iv 10 1 MO mg/12.5ml cefadroxil tabs 1 sildenafil citrate (pulmonary PA cefazolin sodium solr ij 500 1 MO hypertension) tabs or 20 1 mg, 1 gm, 10 gm mg cephalexin caps 750 mg, 1 MO 250 mg, 500 mg
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2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 36 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits cephalexin susr 125 1 MO ceftriaxone sodium solr iv 1 MO mg/5ml, 250 mg/5ml 10 gm Cephalosporins - 2nd Generation ceftriaxone sodium solr iv 2 1 SL(2 ea daily); gm MO cefaclor caps 250 mg, 500 1 MO mg Cephalosporins - 4th Generation cefoxitin sodium solr ij 10 1 cefepime hcl solr 1 MO gm cefoxitin sodium solr iv 1 1 CEFEPIME SOLN 1 gm, 2 gm Cephalosporins - 5th Generation cefprozil susr 1 MO TEFLARO SOLR 1 cefprozil tabs 1 MO CONTRACEPTIVES - Drugs to Prevent cefuroxime axetil tabs 1 MO Pregnancy Combination Contraceptives - Oral cefuroxime sodium solr ij 1 7.5 gm desogestrel & ethinyl 1 MO estradiol tabs cefuroxime sodium solr ij 1 MO 750 mg desogestrel-ethinyl 1 MO estradiol (biphasic) tabs cefuroxime sodium solr iv 1 1.5 gm drospirenone-ethinyl 1 MO estradiol tabs Cephalosporins - 3rd Generation ethynodiol diacet & eth 1 MO cefdinir caps 1 MO estrad tabs MO levonorgestrel & eth 1 MO cefdinir susr 1 estradiol tabs MO levonorgestrel-eth estradiol 1 MO cefixime caps 400 mg 1 (triphasic) tabs MO cefpodoxime proxetil susr 1 levonorgestrel-ethinyl 1 biphasic;MO estradiol (91-day) tabs MO cefpodoxime proxetil tabs 1 norethin acet & estrad-fe 1 24-Day;MO tabs 1 mg-20 mcg-75 mg ceftazidime solr ij 2 gm, 1 1 MO norethin acet & estrad-fe MO gm tabs 1.5 mg-30 mcg-75 mg, 1 ceftazidime solr ij 6 gm 1 1 mg-20 mcg-75 mg norethindrone & eth 1 MO ceftriaxone sodium solr ij 1 1 SL(4 ea daily); estradiol tabs gm MO norethindrone & ethinyl MO ceftriaxone sodium solr ij 2 1 SL(2 ea daily); estradiol-fe chew 0.4 mg- 1 gm MO 35 mcg ceftriaxone sodium solr ij SL(16 ea daily); 1 norethindrone acet & eth 1 MO 250 mg MO estra tabs ceftriaxone sodium solr ij SL(8 ea daily); 1 norethindrone-eth estradiol 1 MO 500 mg MO (triphasic) tabs ceftriaxone sodium solr iv 1 SL(4 ea daily) 1 norgestimate-ethinyl 1 MO gm estradiol (triphasic) tabs
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2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 37 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits norgestimate-ethinyl 1 MO dexamethasone soln 0.5 1 MO estradiol tabs mg/5ml norgestrel & ethinyl MO dexamethasone tabs 1 mg, MO estradiol tabs 0.3 mg-30 1 1.5 mg, 2 mg, 0.5 mg, 0.75 1 mcg mg, 4 mg, 6 mg Combination Contraceptives - Transdermal dexamethasone tbpk 1.5 1 MO mg, 1.5 mg norelgestromin-ethinyl 1 MO estradiol ptwk EMFLAZA SUSP 1 PA; NDS;MO Combination Contraceptives - Vaginal EMFLAZA TABS 1 PA; NDS;MO etonogestrel-ethinyl 1 MO estradiol ring hydrocortisone tabs 1 MO Emergency Contraceptives KENALOG-10 SUSP 1 MO ELLA TABS 1 MO Progestin Contraceptives - Injectable MEDROL TABS 2 MG 1 medroxyprogesterone MO methylprednisolone acetate 1 MO acetate (contraceptive) 1 susp 80 mg/ml, 40 mg/ml susp methylprednisolone sod 1 MO medroxyprogesterone MO succ solr acetate (contraceptive) 1 MO susy methylprednisolone tabs 1 Progestin Contraceptives - Oral methylprednisolone tbpk 1 MO norethindrone 1 MO (contraceptive) tabs MILLIPRED TABS 5 MG 1 MO CORTICOSTEROIDS - Steroid Hormone Drugs to prednisolone sodium MO Treat Systemic Swelling Conditions phosphate soln or 15 1 Glucocorticosteroids mg/5ml, 5 mg/5ml, 25 mg/5ml betamethasone sod 1 MO phosphate & acetate susp prednisolone sodium MO MO phosphate tbdp or 10 mg, 1 budesonide cpep 3 mg 1 15 mg, 30 mg MO cortisone acetate tabs 1 MO prednisolone soln 1 MO DEPO-MEDROL SUSP 20 1 MO prednisone conc 5 mg/ml 1 MG/ML prednisone soln 5 mg/5ml 1 MO dexamethasone elix 0.5 1 MO mg/5ml prednisone tabs 1 mg, 10 MO dexamethasone sodium 1 mg, 2.5 mg, 50 mg, 20 mg, 1 phosphate soln ij 10 mg/ml 5 mg dexamethasone sodium Preservative 1 prednisone tbpk 10 mg, 5 1 MO phosphate soln ij 10 mg/ml Free;MO mg, 5 mg dexamethasone sodium MO prednisone tbpk 5 mg 1 Dose Pack;MO phosphate soln ij 100 1 mg/10ml, 120 mg/30ml, 20 mg/5ml, 4 mg/ml You can find information on what the symbols and abbreviations on this table mean by going to page vi.
2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 38 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SOLU-CORTEF SOLR 100 1 MO erythromycin (acne aid) 1 MO MG, 250 MG, 500 MG soln SOLU-CORTEF SOLR 1 isotretinoin caps 1 1000 MG triamcinolone acetonide MO sulfacetamide sodium 1 MO susp 40 mg/ml, 400 1 (acne) lotn mg/10ml tretinoin crea 0.05 %, 0.1 1 MO Mineralocorticoids %, 0.025 % tretinoin gel 0.01 %, 0.025 MO fludrocortisone acetate 1 MO 1 tabs % MO COUGH/COLD/ALLERGY - Drugs to Treat tretinoin microsphere gel 1 Cough, Cold and Allergy Symptoms Anti-inflammatory Agents - Topical Cough/Cold/Allergy Combinations DICLOFENAC 1 PA; MO CLARINEX-D 12 HOUR 1 MO EPOLAMINE PTCH TB12 diclofenac epolamine ptch 1 PA; MO promethazine & 1 AL(Up to 64 yrs phenylephrine syrp old); MO SL(33.34 gm diclofenac sodium (topical) 1 daily); RX/OTC; Mucolytics gel 1 % MO acetylcysteine soln 1 B/D; MO FLECTOR PTCH 1 PA; MO DERMATOLOGICALS - Drugs to Treat Skin FLECTOR PTCH 1 PA; MO Conditions (diclofenac epolamine) Acne Products PA; NDS;QL(8 PENNSAID SOLN 1 adapalene crea 0.1 % 1 MO gm daily); MO Antibiotics - Topical adapalene gel 0.1 % 1 RX/OTC; MO gentamicin sulfate (topical) 1 MO crea benzoyl peroxide- 1 MO erythromycin gel mupirocin calcium (topical) 1 QL(1 gm daily); clindamycin phosphate MO crea MO 1 QL(0.74 gm (topical) foam mupirocin oint 1 daily); MO clindamycin phosphate 1 MO (topical) gel Antifungals - Topical clindamycin phosphate 1 MO ciclopirox gel 0.77 % 1 MO (topical) lotn MO clindamycin phosphate 1 QL(2 ml daily); ciclopirox olamine crea 1 (topical) soln MO MO clindamycin phosphate 1 MO ciclopirox olamine susp 1 (topical) swab clindamycin phosphate- MO ciclopirox sham 1 % 1 MO benzoyl peroxide 1 (refrigerate) gel ciclopirox soln 8 % 1 MO clindamycin phosphate- MO RX/OTC; MO benzoyl peroxide gel 1 %-5 1 clotrimazole (topical) crea 1 % You can find information on what the symbols and abbreviations on this table mean by going to page vi.
2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 39 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RX/OTC; MO clotrimazole (topical) soln 1 TARGRETIN GEL EX 1 % 1 PA; NDS;QL(2 gm daily) clotrimazole w/ 1 MO PA; NDS;MO betamethasone crea VALCHLOR GEL 1 clotrimazole w/ 1 MO Antipruritics - Topical betamethasone lotn doxepin hcl (antipruritic) PA; QL(1.5 gm QL(3 gm daily); 1 econazole nitrate crea 1 crea daily); MO MO PRUDOXIN CREA PA; QL(1.5 gm QL(2 gm daily); 1 ketoconazole (topical) crea 1 (doxepin hcl (antipruritic)) daily); MO MO ZONALON CREA (doxepin PA; QL(1.5 gm QL(3.34 gm 1 ketoconazole (topical) foam 1 hcl (antipruritic)) daily); MO daily); MO Antipsoriatics ketoconazole (topical) 1 QL(4 ml daily); sham MO acitretin caps 10 mg, 25 mg 1 MO naftifine hcl crea 2 % 1 MO acitretin caps 17.5 mg 1 NDS;MO MO naftifine hcl gel 1 % 1 QL(4 gm daily); calcipotriene crea 1 MO NAFTIN GEL 1 % (naftifine 1 MO hcl) calcipotriene oint 1 MO NAFTIN GEL 2 % 1 MO calcipotriene soln 1 MO QL(2 gm daily); nystatin (topical) crea 1 MO ILUMYA SOSY 1 PA; NDS QL(2 gm daily); nystatin (topical) oint 1 NDS;MO MO methoxsalen rapid caps 1 QL(2 gm daily); nystatin (topical) powd 1 PA; NDS MO SILIQ SOSY 1 nystatin-triamcinolone crea 1 MO SKYRIZI PSKT 1 PA; NDS nystatin-triamcinolone oint 1 MO STELARA SOLN 1 PA; NDS
Antineoplastic or Premalignant Lesion Agents - STELARA SOSY 1 PA; NDS CARAC CREA (fluorouracil 1 NDS;MO (topical)) tazarotene crea 1 MO diclofenac sodium (actinic 1 PA; QL(3.34 MO keratoses) gel gm daily); MO TAZORAC CREA 0.05 % 1 fluorouracil (topical) crea NDS;MO 1 TAZORAC GEL 0.05 %, 1 MO 0.5 % 0.1 % fluorouracil (topical) crea 5 1 MO PA; NDS % TREMFYA SOPN 1 PA; NDS fluorouracil (topical) soln 2 1 MO TREMFYA SOSY 1 %, 5 % PANRETIN GEL 1 NDS Antiseborrheic Products selenium sulfide lotn 2.5 % 1 MO PICATO GEL 1 NDS;MO
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2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 40 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Antivirals - Topical clobetasol propionate crea 1 MO acyclovir topical crea 1 NDS;MO clobetasol propionate 1 MO emollient base crea acyclovir topical oint 1 MO clobetasol propionate 1 MO emulsion foam DENAVIR CREA 1 NDS;MO clobetasol propionate foam 1 MO Burn Products clobetasol propionate gel 1 MO silver sulfadiazine crea 1 MO clobetasol propionate lotn 1 MO SULFAMYLON CREA 85 1 MO MG/GM clobetasol propionate oint 1 MO Corticosteroids - Topical MO alclometasone dipropionate 1 MO clobetasol propionate sham 1 crea MO alclometasone dipropionate 1 MO clobetasol propionate soln 1 oint QL(2 gm daily); desonide crea 1 amcinonide crea 1 MO MO QL(3.94 ml betamethasone 1 MO desonide lotn 1 dipropionate (topical) crea daily); MO QL(2 gm daily); betamethasone 1 MO desonide oint 1 dipropionate (topical) lotn MO desoximetasone crea 0.25 MO betamethasone 1 MO 1 dipropionate (topical) oint % betamethasone MO desoximetasone gel 0.05 % 1 MO dipropionate augmented 1 crea desoximetasone oint 0.25 1 MO % betamethasone MO dipropionate augmented 1 diflorasone diacetate oint 1 MO gel betamethasone MO fluocinolone acetonide crea 1 MO dipropionate augmented 1 lotn fluocinolone acetonide oil 1 MO betamethasone MO MO dipropionate augmented 1 fluocinolone acetonide oint 1 oint fluocinolone acetonide soln 1 MO betamethasone valerate 1 MO crea fluocinonide crea 0.05 % 1 MO betamethasone valerate 1 MO foam fluocinonide emulsified 1 MO base crea betamethasone valerate 1 MO lotn fluocinonide gel 0.05 % 1 MO betamethasone valerate 1 MO oint fluocinonide oint 0.05 % 1 MO
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2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 41 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits fluocinonide soln 0.05 % 1 MO triamcinolone acetonide MO (topical) lotn 0.025 %, 0.1 1 fluticasone propionate crea 1 MO % triamcinolone acetonide MO fluticasone propionate lotn 1 MO (topical) oint 0.025 %, 0.1 1 %, 0.5 % MO fluticasone propionate oint 1 Emollients lactic acid (ammonium RX/OTC; MO halobetasol propionate 1 MO 1 crea lactate) crea MO lactic acid (ammonium 1 RX/OTC; MO halobetasol propionate oint 1 lactate) lotn hydrocortisone (topical) 1 RX/OTC; MO Enzymes - Topical crea 1 % SANTYL OINT 1 MO hydrocortisone (topical) 1 MO crea 2.5 % Immunomodulating Agents - Topical hydrocortisone (topical) 1 MO NDS;MO lotn 2.5 % imiquimod crea 3.75 % 1 hydrocortisone (topical) 1 RX/OTC; MO MO oint 1 % imiquimod crea 5 % 1 hydrocortisone (topical) MO 1 ZYCLARA CREA 1 NDS;MO oint 2.5 % (imiquimod) hydrocortisone butyrate QL(1.5 gm 1 ZYCLARA PUMP CREA 1 NDS;MO crea daily); MO 2.5 % hydrocortisone butyrate QL(1.5 gm 1 ZYCLARA PUMP CREA 1 NDS;MO hydrophilic lipo base crea daily); MO 3.75 % (imiquimod) hydrocortisone butyrate 1 QL(1.5 gm Immunosuppressive Agents - Topical oint daily); MO pimecrolimus crea 1 PA; MO hydrocortisone butyrate 1 QL(2 ml daily); soln MO tacrolimus (topical) oint 1 PA; MO hydrocortisone valerate 1 MO crea Keratolytic/Antimitotic Agents hydrocortisone valerate 1 MO MO oint podofilox soln 1 mometasone furoate crea 1 MO Local Anesthetics - Topical QL(4 ml daily); MO lidocaine hcl gel ex 2 % 1 mometasone furoate oint 1 MO MO mometasone furoate soln 1 MO lidocaine hcl prsy ex 2 % 1 QL(6.67 ml MO lidocaine hcl soln ex 4 % 1 prednicarbate crea 1 daily); MO triamcinolone acetonide MO QL(5 gm daily); 1 lidocaine oint 1 (topical) aers 0.147 mg/gm MO triamcinolone acetonide MO lidocaine ptch 1 PA; SL(3 ea (topical) crea 0.025 %, 0.5 1 daily); MO %, 0.1 %
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 42 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(2 gm daily); MO lidocaine-prilocaine crea 1 triamterene & 1 MO hydrochlorothiazide caps Rosacea Agents triamterene & 1 MO hydrochlorothiazide tabs azelaic acid gel 1 MO Loop Diuretics metronidazole (topical) MO 1 bumetanide tabs or 0.5 mg, 1 MO crea 1 mg, 2 mg MO metronidazole (topical) gel 1 furosemide soln ij 10 mg/ml 1 MO MO metronidazole (topical) lotn 1 furosemide soln or 10 1 MO mg/ml PA; MO MIRVASO GEL 1 furosemide tabs or 20 mg, 1 MO 40 mg, 80 mg Scabicides & Pediculicides torsemide tabs 1 MO malathion lotn 1 MO Potassium Sparing Diuretics permethrin crea 1 MO amiloride hcl tabs 1 MO Wound Care Products spironolactone tabs 1 MO REGRANEX GEL 1 NDS;MO Thiazides and Thiazide-Like Diuretics DIGESTIVE AIDS - Drugs to Treat Low Digestive MO Enzymes chlorothiazide tabs 500 mg 1 Digestive Enzymes chlorthalidone tabs 1 MO CREON CPEP 1 MO hydrochlorothiazide caps 1 MO PANCREAZE CPEP 1 MO hydrochlorothiazide tabs 1 MO SUCRAID SOLN 1 LA; MO indapamide tabs 1 MO DIURETICS - Drugs to Treat Heart, Circulation MO Conditions and Blood Pressure metolazone tabs 1 Carbonic Anhydrase Inhibitors ENDOCRINE AND METABOLIC AGENTS - acetazolamide cp12 1 MO MISC. - Drugs to Treat Bone Disease and Regulate Hormones acetazolamide tabs 1 MO Bone Density Regulators MO alendronate sodium tabs 1 MO methazolamide tabs 1 10 mg Diuretic Combinations alendronate sodium tabs 1 QL(0.15 ea 35 mg, 70 mg daily); MO amiloride & 1 MO hydrochlorothiazide tabs alendronate sodium tabs 5 1 mg spironolactone & 1 MO hydrochlorothiazide tabs calcitonin (salmon) soln 1 MO
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2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 43 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; NDS; Limit NUTROPIN AQ NUSPIN 1 PA; NDS 1 2.4mls per 28 20 SOPN FORTEO SOPN days;QL(0.09 ml daily) Hormone Receptor Modulators OSPHENA TABS 1 MO ibandronate sodium soln iv 1 QL(0.036 ml 3 mg/3ml daily); MO QL(1 ea daily); raloxifene hcl tabs 1 Limit 1 tab per MO ibandronate sodium tabs or 1 28 days (3 per 150 mg 84);QL(0.036 Insulin-Like Growth Factors (Somatomedins) ea daily); MO INCRELEX SOLN 1 LA MIACALCIN SOLN 1 MO LHRH/GnRH Agonist Analog Pituitary PA; NDS;LA NATPARA CART 1 FENSOLVI KIT 1 MO PROLIA SOSY 1 PA; QL(0.006 NDS ml daily) LUPANETA PACK KIT 1 TYMLOS SOPN 1 PA; NDS LUPRON DEPOT-PED (1- NDS MONTH) KIT 11.25 MG, 1 NDS; Limit 7.5 MG 6.8mls per 28 XGEVA SOLN 1 LUPRON DEPOT-PED (1- 1 days;QL(0.243 MONTH) KIT 15 MG ml daily) LUPRON DEPOT-PED (3- 1 NDS zoledronic acid conc 4 1 MONTH) KIT mg/5ml NDS;MO Limit 1 dose SYNAREL SOLN 1 zoledronic acid soln 5 1 per NDS;MO mg/100ml year;QL(0.28 TRIPTODUR SRER 1 ml daily) Metabolic Modifiers Fertility Regulators calcitriol caps or 0.25 mcg, 1 MO CHORIONIC 1 PA 0.5 mcg GONADOTROPIN SOLR calcitriol soln or 1 mcg/ml 1 MO NOVAREL SOLR 1 PA LA; MO PREGNYL W/DILUENT PA CARBAGLU TABS 1 BENZYLALCOHOL/NACL 1 SOLR cinacalcet hcl tabs 30 mg 1 GnRH/LHRH Antagonists cinacalcet hcl tabs 60 mg, 1 NDS 90 mg ORILISSA TABS 1 PA; NDS;MO CRYSVITA SOLN 1 PA; NDS;LA Growth Hormone Receptor Antagonists FABRAZYME SOLR 1 NDS;LA SOMAVERT SOLR 1 PA; NDS;LA PA; NDS;LA Growth Hormones GALAFOLD CAPS 1 NORDITROPIN FLEXPRO PA; NDS KANUMA SOLN 1 NDS;LA SOPN 10 MG/1.5ML, 5 1 MG/1.5ML KUVAN PACK (sapropterin 1 PA; NDS;LA dihydrochloride) You can find information on what the symbols and abbreviations on this table mean by going to page vi.
2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 44 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KUVAN TBSO (sapropterin 1 PA; NDS;LA octreotide acetate soln 100 dihydrochloride) mcg/ml, 500 mcg/ml, 1000 1 mcg/ml, 50 mcg/ml, 1000 levocarnitine (metabolic 1 MO modifiers) tabs 330 mg mcg/5ml, 200 mcg/ml NDS;LA SANDOSTATIN LAR 1 NDS LUMIZYME SOLR 1 DEPOT KIT MYALEPT SOLR 1 NDS;LA; MO NDS; Limit 6 vials per 28 SIGNIFOR LAR SRER 10 NDS;LA 1 days;SL(0.22 NAGLAZYME SOLN 1 MG ea daily); LA; MO nitisinone caps 1 MO NDS; Limit 3 ORFADIN CAPS 20 MG 1 LA; MO vials per 28 SIGNIFOR LAR SRER 20 1 days;SL(0.11 MG PA; NDS;LA ea daily); LA; PALYNZIQ SOSY 1 MO paricalcitol caps or 1 mcg, 1 MO NDS; Limit 2 2 mcg, 4 mcg vials per 28 SIGNIFOR LAR SRER 30 LA 1 days;SL(0.08 RAVICTI LIQD 1 MG ea daily); LA; MO RAYALDEE CPCR 1 PA; MO NDS; Limit 3 vials per 56 REVCOVI SOLN 1 PA; NDS;LA; SIGNIFOR LAR SRER 40 MO 1 days;SL(0.054 MG ea daily); LA; sapropterin dihydrochloride 1 PA; NDS;LA pack MO NDS; Limit 1 sapropterin dihydrochloride 1 PA; NDS;LA tbso vial per 28 SIGNIFOR LAR SRER 60 1 days;SL(0.036 PA; NDS;LA; MG STRENSIQ SOLN 1 ea daily); LA; MO MO NDS;LA VIMIZIM SOLN 1 SIGNIFOR SOLN 1 NDS;LA; MO NDS;SL(4 ea XURIDEN PACK 1 SOMATULINE DEPOT 1 NDS daily); MO SOLN Posterior Pituitary Hormones Vasopressin Receptor Antagonists MO desmopressin acetate soln 1 JYNARQUE TABS 15 MG, 1 NDS;MO 30 MG desmopressin acetate 1 MO spray refrigerated soln JYNARQUE TBPK 1 PA; NDS;LA desmopressin acetate MO 1 JYNARQUE TBPK 15 MG 1 PA; NDS;LA; spray soln MO MO desmopressin acetate tabs 1 SAMSCA TABS 15 MG 1 NDS;MO Prolactin Inhibitors tolvaptan tabs 15 mg, 30 1 NDS;MO mg cabergoline tabs 1 MO ESTROGENS - Hormone Replacement/Modifying Somatostatic Agents Drugs You can find information on what the symbols and abbreviations on this table mean by going to page vi.
2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 45 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Estrogen Combinations GASTROINTESTINAL AGENTS - MISC. - Miscellaneous Gastrointestinal Drugs estradiol & norethindrone 1 AL(Up to 64 yrs acetate tabs old); MO Farnesoid X Receptor (FXR) Agonists norethindrone acetate- AL(Up to 64 yrs OCALIVA TABS 10 MG 1 PA; NDS;SL(1 ethinyl estradiol tabs 0.5 1 old); MO ea daily) mg-2.5 mcg PA; NDS;SL(2 OCALIVA TABS 5 MG 1 PREMPHASE TABS 1 AL(Up to 64 yrs ea daily) old); MO AL(Up to 64 yrs Gallstone Solubilizing Agents PREMPRO TABS 1 old); MO CHENODAL TABS 1 NDS;LA Estrogens ursodiol caps 1 MO AL(Up to 64 yrs DIVIGEL GEL 1 old); MO ursodiol tabs 1 MO estradiol ptwk td 0.05 AL(Up to 64 yrs mg/24hr, 0.06 mg/24hr, old); MO Gastrointestinal Antiallergy Agents 0.075 mg/24hr, 0.1 1 cromolyn sodium 1 MO mg/24hr, 37.5 mcg/24hr, (mastocytosis) conc 0.025 mg/24hr Gastrointestinal Stimulants estradiol tabs or 0.5 mg, 1 1 AL(Up to 64 yrs mg, 2 mg old); MO metoclopramide hcl soln ij 1 MO 5 mg/ml estradiol valerate oil 1 MO metoclopramide hcl soln or 1 MO PREMARIN TABS OR 0.3 AL(Up to 64 yrs 10 mg/10ml, 5 mg/5ml MG, 0.45 MG, 0.625 MG, 1 old); MO metoclopramide hcl tabs or 1 MO 0.9 MG, 1.25 MG 5 mg, 10 mg FLUOROQUINOLONES - Drugs to Treat Bacterial Inflammatory Bowel Agents Infections balsalazide disodium caps 1 MO Fluoroquinolones NDS;MO BAXDELA SOLR IV 300 1 PA; NDS DIPENTUM CAPS 1 MG ENTYVIO SOLR 1 PA; NDS BAXDELA TABS OR 450 1 ST; NDS;MO MG INFLECTRA SOLR 1 PA; NDS ciprofloxacin hcl tabs 1 MO mesalamine cp24 or 0.375 1 MO ciprofloxacin in d5w soln 1 gm 200 mg/100ml-5 % mesalamine cpdr or 400 1 MO ciprofloxacin in d5w soln 1 MO mg 400 mg/200ml-5 % mesalamine enem re 4 gm 1 MO levofloxacin in d5w soln 1 mesalamine tbec or 1.2 1 MO levofloxacin soln iv 25 1 gm, 800 mg mg/ml mesalamine w/ cleanser kit 1 MO levofloxacin soln or 25 1 MO mg/ml REMICADE SOLR 1 PA; NDS levofloxacin tabs or 250 1 MO mg, 500 mg, 750 mg You can find information on what the symbols and abbreviations on this table mean by going to page vi.
2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 46 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RENFLEXIS SOLR 1 PA; NDS Genitourinary Irrigants acetic acid soln 1 MO STELARA SOLN 1 PA; NDS neomycin/polymyxin b gu 1 MO sulfasalazine tabs 1 MO soln MO sodium chloride (gu 1 MO sulfasalazine tbec 1 irrigant) soln Intestinal Acidifiers Prostatic Hypertrophy Agents MO lactulose (encephalopathy) 1 MO alfuzosin hcl tb24 1 soln MO Irritable Bowel Syndrome (IBS) Agents dutasteride caps 1 PA; NDS;MO alosetron hcl tabs 1 dutasteride-tamsulosin hcl 1 MO caps MO LINZESS CAPS 1 finasteride tabs 1 MO Peripheral Opioid Receptor Antagonists tamsulosin hcl caps 1 MO MOVANTIK TABS 1 MO GOUT AGENTS - Drugs to Treat Gout RELISTOR SOLN SC 12 1 NDS;MO MG/0.6ML, 8 MG/0.4ML Gout Agent Combinations Phosphate Binder Agents colchicine w/ probenecid 1 MO tabs calcium acetate (phosphate 1 MO binder) caps Gout Agents MO SL(8 ea daily); lanthanum carbonate chew 1 allopurinol tabs 100 mg 1 MO sevelamer carbonate pack NDS;MO SL(2.66 ea 1 allopurinol tabs 300 mg 1 0.8 gm, 2.4 gm daily); MO sevelamer carbonate tabs 1 MO MO 800 mg colchicine tabs 1 Short Bowel Syndrome (SBS) Agents Uricosurics PA; NDS;LA GATTEX KIT 1 probenecid tabs 1 MO Tryptophan Hydroxylase Inhibitors HEMATOLOGICAL AGENTS - MISC. - Drugs to PA; NDS;LA; Treat Blood Disorders XERMELO TABS 1 MO Bradykinin B2 Receptor Antagonists GENITOURINARY AGENTS - MISCELLANEOUS PA; NDS - Miscellaneous Drugs to Treat Reproductive icatibant acetate soln 1 Organs and Urinary System Complement Inhibitors Alkalinizers CINRYZE SOLR 1 PA; NDS;LA potassium citrate 1 MO (alkalinizer) tbcr HAEGARDA SOLR 1 PA; NDS Cystinosis Agents Hemataologic - Tyrosine Kinase Inhibitors CYSTAGON CAPS 1
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2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 47 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TAVALISSE TABS 1 PA; NDS ENDARI PACK 1 PA; NDS;MO
Hematorheologic Agents OXBRYTA TABS 1 PA; NDS;LA MO pentoxifylline tbcr 1 Hematopoietic Growth Factors Plasma Kallikrein Inhibitors ARANESP ALBUMIN PA; NDS FREE SOLN 100 MCG/ML, 1 KALBITOR SOLN 1 NDS 200 MCG/ML, 300 MCG/ML PA; NDS TAKHZYRO SOLN 1 ARANESP ALBUMIN PA FREE SOLN 25 MCG/ML, 1 Platelet Aggregation Inhibitors 40 MCG/ML, 60 MCG/ML anagrelide hcl caps 1 MO ARANESP ALBUMIN PA FREE SOSY 10 MO aspirin-dipyridamole cp12 1 MCG/0.4ML, 25 1 MCG/0.42ML, 40 BRILINTA TABS 1 MO MCG/0.4ML, 60 MCG/0.3ML CABLIVI KIT 1 PA; NDS;MO ARANESP ALBUMIN PA; NDS FREE SOSY 100 MO cilostazol tabs 1 MCG/0.5ML, 150 1 MCG/0.3ML, 200 clopidogrel bisulfate tabs 1 MO MCG/0.4ML, 300 MCG/0.6ML, 500 MCG/ML AL(Up to 64 yrs dipyridamole tabs 1 PA; NDS;LA old); MO DOPTELET TABS 1 prasugrel hcl tabs 1 MO EPOGEN SOLN 10000 PA UNIT/ML, 2000 UNIT/ML, 1 ZONTIVITY TABS 1 MO 3000 UNIT/ML, 4000 UNIT/ML HEMATOPOIETIC AGENTS - Drugs to Treat EPOGEN SOLN 20000 1 PA; NDS Blood Disorders UNIT/ML Agents for Gaucher Disease GRANIX SOSY 300 PA; NDS PA; NDS MCG/0.5ML, 480 1 CERDELGA CAPS 1 MCG/0.8ML PA; NDS CEREZYME SOLR 1 PA; NDS;LA LEUKINE SOLR 1 PA; NDS ELELYSO SOLR 1 NDS MULPLETA TABS 1 NDS;LA; MO NEULASTA ONPRO KIT 1 PA; NDS miglustat caps 1 PSKT VPRIV SOLR 1 NDS NEULASTA SOSY 1 PA; NDS
Agents for Sickle Cell Disease NEUPOGEN SOLN 1 PA; NDS ADAKVEO SOLN 1 PA; NDS NEUPOGEN SOSY 1 PA; NDS DROXIA CAPS 1 MO
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2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 48 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NIVESTYM SOSY 300 PA; NDS Barbiturate Hypnotics 1 MCG/0.5ML, 480 AL(Up to 64 yrs MCG/0.8ML phenobarbital elix 1 old); MO PROCRIT SOLN 10000 PA 1 AL(Up to 64 yrs UNIT/ML, 2000 UNIT/ML, 1 phenobarbital soln old); MO 3000 UNIT/ML, 4000 AL(Up to 64 yrs UNIT/ML phenobarbital tabs 1 old); MO PROCRIT SOLN 20000 1 PA; NDS UNIT/ML, 40000 UNIT/ML Hypnotics - Tricyclic Agents PROMACTA PACK 12.5 1 PA; NDS;SL(12 doxepin hcl (sleep) tabs 3 1 QL(2 ea daily); MG ea daily); LA mg MO PA; NDS;SL(6 doxepin hcl (sleep) tabs 6 QL(1 ea daily); PROMACTA PACK 25 MG 1 1 ea daily); LA mg MO PROMACTA TABS 12.5 1 PA; NDS;SL(12 Non-Barbiturate Hypnotics MG ea daily); LA temazepam caps 1 MO PROMACTA TABS 25 MG 1 PA; NDS;SL(6 ea daily); LA triazolam tabs 1 MO PROMACTA TABS 50 MG 1 PA; NDS;SL(3 ea daily); LA zaleplon caps 1 MO PA; NDS;SL(2 PROMACTA TABS 75 MG 1 ea daily); LA zolpidem tartrate tabs or 10 1 SL(1 ea daily); mg MO REBLOZYL SOLR 1 PA; NDS zolpidem tartrate tabs or 5 1 SL(2 ea daily); RETACRIT SOLN 10000 PA mg MO UNIT/ML, 2000 UNIT/ML, 1 zolpidem tartrate tbcr or 1 SL(1 ea daily); 3000 UNIT/ML, 4000 12.5 mg MO UNIT/ML, 40000 UNIT/ML zolpidem tartrate tbcr or 1 SL(2 ea daily); ZARXIO SOSY 1 PA; NDS 6.25 mg MO Orexin Receptor Antagonists Stem Cell Mobilizers PA; SL(2 ea BELSOMRA TABS 10 MG 1 MOZOBIL SOLN 1 PA; NDS daily); MO BELSOMRA TABS 15 MG 1 PA; SL(1.33 ea HEMOSTATICS - Drugs to Stop Bleeding/Treat daily); MO Blood Disorders BELSOMRA TABS 20 MG 1 PA; SL(1 ea Hemostatics - Systemic daily); MO aminocaproic acid soln or NDS;MO 1 BELSOMRA TABS 5 MG 1 PA; SL(4 ea 0.25 gm/ml daily); MO aminocaproic acid tabs or 1 MO Selective Melatonin Receptor Agonists 500 mg HETLIOZ CAPS 1 PA; NDS;MO tranexamic acid soln iv 1 1000 mg/10ml ramelteon tabs 1 MO tranexamic acid tabs or 1 MO 650 mg LAXATIVES - Bowel Treatment Drugs HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS Laxative Combinations
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2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 49 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits bisacodyl-peg 3350-pot erythromycin base tabs 500 1 SL(8 ea daily); chloride-sod bicarb-sod 1 mg MO chloride kit erythromycin 1 SL(10 ea daily); peg 3350-kcl-sod bicarb- MO ethylsuccinate tabs 400 mg MO sod chloride-sod sulfate 1 erythromycin lactobionate 1 SL(8 ea daily) solr solr peg 3350-potassium MO chloride-sod bicarbonate- 1 Fidaxomicin sod chloride solr DIFICID TABS 1 NDS;MO SUPREP BOWEL PREP 1 MO KIT SOLN MEDICAL DEVICES AND SUPPLIES Laxatives - Miscellaneous Bandages-Dressings-Tape lactulose soln 10 gm/15ml, 1 MO RX/OTC; MO 20 gm/30ml gauze pads2"x2" 1 LOCAL ANESTHETICS-Parenteral - Drugs for Misc. Devices Numbing ALCOHOL PADS 1 RX/OTC; MO Local Anesthetics - Amides lidocaine hcl (local anesth.) Preservative Parenteral Therapy Supplies soln 0.5 %, 1 %, 1.5 %, 2 1 Free INSULIN SYRINGES AND 1 RX/OTC; MO % PEN NEEDLES lidocaine hcl (local anesth.) 1 soln 0.5 %, 1 %, 2 % MIGRAINE PRODUCTS - Drugs to Treat Migraine Headaches MACROLIDES - Drugs to Treat Bacterial Infections Calcitonin Gene-Related Peptide (CGRP) PA; MO Azithromycin AIMOVIG SOAJ 1 azithromycin solr iv 500 mg 1 MO AJOVY SOSY 1 PA; MO azithromycin susr or 100 MO 1 EMGALITY SOAJ 120 1 PA; MO mg/5ml, 200 mg/5ml MG/ML azithromycin tabs or 250 MO 1 EMGALITY SOSY 100 1 PA; NDS;MO mg, 500 mg MG/ML azithromycin tabs or 600 QL(0.29 ea 1 EMGALITY SOSY 120 1 PA; MO mg daily); MO MG/ML Clarithromycin Migraine Combinations clarithromycin susr 250 MO 1 ergotamine w/ caffeine 1 MO mg/5ml supp re 100 mg-2 mg clarithromycin tabs 250 mg, MO 1 sumatriptan-naproxen 1 MO 500 mg sodium tabs MO clarithromycin tb24 500 mg 1 TREXIMET TABS 10 MG- 1 60 MG Erythromycins Migraine Products erythromycin base tabs SL(16 ea daily); 1 dihydroergotamine 1 MO 250 mg MO mesylate soln ij 1 mg/ml
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 50 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits dihydroergotamine 1 NDS;MO dextrose w/ sodium 1 MO mesylate soln na 4 mg/ml chloride soln 0.9 %-5 % ERGOMAR SUBL 1 lactated ringer's soln 109 meq/l-130 meq/l-28 meq/l-3 MIGRANAL SOLN NDS;MO meq/l-4 meq/l, 20 1 (dihydroergotamine 1 mg/100ml-30 mg/100ml- mesylate) 310 mg/100ml-600 mg/100ml Serotonin Agonists parenteral electrolytes conc 1 B/D almotriptan malate tabs 1 MO potassium chloride in QL(0.3 ea naratriptan hcl tabs 1 dextrose & sodium chloride 1 daily); MO soln 0.15 %-0.45 %-5 %, QL(0.4 ea rizatriptan benzoate tabs 1 0.45 %-20 meq/l-5 % daily); MO Magnesium QL(0.4 ea rizatriptan benzoate tbdp 1 daily); MO magnesium sulfate soln ij 1 50 % Auto-injector; Potassium sumatriptan succinate soaj 1 Limit 4mls per sc 4 mg/0.5ml, 6 mg/0.5ml month;QL(0.14 K-TAB TBCR 20 MEQ 1 MO ml daily); MO (potassium chloride) Solution potassium chloride cpcr or 1 MO cartridge;Limit 10 meq, 8 meq sumatriptan succinate soct 1 4mls per sc 4 mg/0.5ml, 6 mg/0.5ml potassium chloride MO month;QL(0.14 microencapsulated crystals 1 ml daily); MO er tbcr 20 meq, 10 meq Limit 4mls per potassium chloride soln iv 2 MO sumatriptan succinate soln 1 month;QL(0.14 1 sc 6 mg/0.5ml meq/ml ml daily); MO potassium chloride soln or 1 MO sumatriptan succinate tabs 1 QL(0.3 ea 20 %, 10 % or 100 mg, 25 mg, 50 mg daily); MO potassium chloride tbcr or MO SL(4 ea daily); 1 zolmitriptan tabs 2.5 mg 1 20 meq, 10 meq, 8 meq MO SL(2 ea daily); Sodium zolmitriptan tabs 5 mg 1 MO sodium chloride soln iv 1 SL(4 ea daily); 0.45 % zolmitriptan tbdp 2.5 mg 1 MO sodium chloride soln iv 3 1 MO SL(2 ea daily); %, 5 %, 0.9 % zolmitriptan tbdp 5 mg 1 MO MISCELLANEOUS THERAPEUTIC CLASSES MINERALS & ELECTROLYTES Chelating Agents Electrolyte Mixtures penicillamine tabs 1 MO dextrose in lactated ringers 1 soln trientine hcl caps 1 NDS;MO dextrose w/ sodium Immunomodulators chloride soln 0.2 %-5 %, 1 0.45 %-2.5 %, 0.33 %-5 %, REVLIMID CAPS 1 PA; NDS;LA 0.45 %-5 % You can find information on what the symbols and abbreviations on this table mean by going to page vi.
2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 51 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits THALOMID CAPS 1 NDS sirolimus soln 1 mg/ml 1 B/D; MO
Immunosuppressive Agents sirolimus tabs 0.5 mg, 1 mg 1 B/D; MO ASTAGRAF XL CP24 1 B/D; MO sirolimus tabs 2 mg 1 B/D; NDS;MO AZATHIOPRINE SOLR IJ 1 B/D 100 MG tacrolimus caps 1 B/D; MO azathioprine tabs or 100 1 B/D; MO B/D mg, 50 mg, 75 mg THYMOGLOBULIN SOLR 1 B/D; MO cyclosporine caps 1 ZORTRESS TABS 1 MG 1 B/D; NDS;MO cyclosporine modified (for 1 B/D; MO Irrigation Solutions microemulsion) caps irrigation solutions, 1 cyclosporine modified (for 1 B/D; MO physiological soln microemulsion) soln water for irrigation, sterile 1 MO cyclosporine soln 1 B/D; MO soln Potassium Removing Agents ENVARSUS XR TB24 1 B/D; MO LOKELMA PACK 1 ST; MO everolimus B/D; MO (immunosuppressant) tabs 1 sodium polystyrene 1 MO 0.25 mg sulfonate powd or everolimus B/D; NDS;MO sodium polystyrene MO (immunosuppressant) tabs 1 sulfonate susp or 15 1 0.5 mg, 0.75 mg gm/60ml mycophenolate mofetil B/D; MO ST; SL(1.5 ea 1 VELTASSA PACK 16.8 GM 1 caps 250 mg daily); LA; MO mycophenolate mofetil hcl B/D; MO 1 VELTASSA PACK 25.2 GM 1 ST; SL(1 ea solr daily); LA; MO mycophenolate mofetil susr 1 B/D; NDS;MO ST; NDS;SL(3 200 mg/ml VELTASSA PACK 8.4 GM 1 ea daily); LA; MO mycophenolate mofetil tabs 1 B/D; MO 500 mg Systemic Lupus Erythematosus Agents mycophenolate sodium 1 B/D; MO PA; NDS tbec BENLYSTA SOAJ 1 B/D; NDS NULOJIX SOLR 1 BENLYSTA SOLR 1 PA; NDS
PROGRAF PACK OR 0.2 1 B/D; NDS;MO PA; NDS MG BENLYSTA SOSY 1 PROGRAF PACK OR 1 B/D; MO 1 MOUTH/THROAT/DENTAL AGENTS MG PROGRAF SOLN IV 5 1 B/D Anesthetics Topical Oral MG/ML lidocaine hcl (mouth-throat) 1 MO SANDIMMUNE SOLN OR 1 B/D; MO soln 2 % 100 MG/ML Anti-infectives - Throat SIMULECT SOLR 1 B/D; NDS
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2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 52 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits clotrimazole troc 1 MO NASAL AGENTS - SYSTEMIC AND TOPICAL - Drugs to treat the Nose or Sinus nystatin (mouth-throat) 1 MO susp Nasal Antiallergy MO Antiseptics - Mouth/Throat azelastine hcl soln 1 chlorhexidine gluconate 1 MO MO (mouth-throat) soln olopatadine hcl (nasal) soln 1 Steroids - Mouth/Throat/Dental Nasal Anticholinergics triamcinolone acetonide MO 1 ipratropium bromide (nasal) 1 MO (mouth) pste soln Throat Products - Misc. Nasal Steroids cevimeline hcl caps 1 MO flunisolide (nasal) soln 1 MO MO pilocarpine hcl (oral) tabs 1 fluticasone propionate 1 RX/OTC; MO (nasal) susp MUSCULOSKELETAL THERAPY AGENTS - NEUROMUSCULAR AGENTS - Drugs to Drugs to Treat Spasms Relax/Paralyze Muscles Central Muscle Relaxants ALS Agents SL(8 ea daily); baclofen tabs or 10 mg 1 PA; NDS MO RADICAVA SOLN 1 SL(4 ea daily); baclofen tabs or 20 mg 1 riluzole tabs 1 MO MO AL(Up to 64 yrs carisoprodol tabs 350 mg 1 Muscular Dystrophy Agents old); MO PA; NDS;LA; AL(Up to 64 yrs EXONDYS 51 SOLN 1 chlorzoxazone tabs 500 mg 1 MO old); MO PA; NDS;LA; VYONDYS 53 SOLN 1 cyclobenzaprine hcl tabs 1 AL(Up to 64 yrs MO 10 mg, 5 mg old); MO Neuromuscular Blocking Agent - Neurotoxins metaxalone tabs 400 mg, 1 AL(Up to 64 yrs 800 mg old); MO BOTOX SOLR 1 PA; MO methocarbamol tabs or 500 1 AL(Up to 64 yrs PA; MO mg, 750 mg old); MO XEOMIN SOLR 1 SL(18 ea daily); tizanidine hcl caps 2 mg 1 MO NUTRIENTS SL(9 ea daily); tizanidine hcl caps 4 mg 1 Carbohydrates MO dextrose soln 10 %, 70 %, B/D SL(6 ea daily); 1 tizanidine hcl caps 6 mg 1 50 % MO B/D; MO SL(18 ea daily); dextrose soln 5 % 1 tizanidine hcl tabs 2 mg 1 MO Lipids SL(9 ea daily); tizanidine hcl tabs 4 mg 1 MO fat emulsion plant based 1 B/D emul Direct Muscle Relaxants Proteins dantrolene sodium caps 1 MO
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2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 53 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits amino acid infusion 15% 1 B/D; MO SIMBRINZA SUSP 1 MO CLINIMIX B/D Ophthalmic Anti-infectives 4.25%/DEXTROSE 5% 1 MO SOLN AZASITE SOLN 1 OPHTHALMIC AGENTS - Drugs to Treat the Eye bacitracin (ophthalmic) oint 1 MO Beta-blockers - Ophthalmic bacitracin-polymyxin b 1 MO (ophth) oint betaxolol hcl (ophth) soln 1 MO ciprofloxacin hcl (ophth) 1 MO carteolol hcl (ophth) soln 1 MO soln erythromycin (ophth) oint 1 MO COMBIGAN SOLN 1 MO MO dorzolamide hcl-timolol MO gatifloxacin (ophth) soln 1 maleate soln 20 mg/ml-5 1 gentamicin sulfate (ophth) 1 MO mg/ml, 22.3 mg/ml-6.8 oint mg/ml gentamicin sulfate (ophth) 1 MO levobunolol hcl soln 1 MO soln levofloxacin (ophth) soln 1 MO timolol maleate (ophth) 1 MO solg 0.25 %, 0.5 % moxifloxacin hcl (ophth) 1 MO timolol maleate (ophth) 1 MO soln soln 0.25 %, 0.5 % NATACYN SUSP 1 MO TIMOPTIC-XE SOLG 0.25 1 MO % (timolol maleate (ophth)) neomycin-bacitracin zn- 1 MO Cycloplegic Mydriatics polymyxin oint MO neomycin-polymyxin- 1 MO cyclopentolate hcl soln 1 gramicidin soln Miotics ofloxacin (ophth) soln 1 MO PHOSPHOLINE IODIDE 1 SOLR polymyxin b-trimethoprim 1 MO soln pilocarpine hcl soln 1 MO sulfacetamide sodium 1 MO (ophth) soln Ophthalmic - Angiogenesis Inhibitors tobramycin (ophth) soln 1 MO BEOVU SOLN 1 PA; NDS trifluridine soln 1 MO EYLEA SOSY 1 PA; NDS;LA ZIRGAN GEL 1 MO Ophthalmic Adrenergic Agents ALPHAGAN P SOLN 0.1 % 1 MO Ophthalmic Immunomodulators RESTASIS EMUL 1 MO apraclonidine hcl soln 1 MO RESTASIS MULTIDOSE 1 MO brimonidine tartrate soln 1 MO EMUL Ophthalmic Local Anesthetics You can find information on what the symbols and abbreviations on this table mean by going to page vi.
2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 54 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits proparacaine hcl soln 1 MO Limit 60mls per 28 Ophthalmic Nerve Growth Factors CYSTARAN SOLN 1 days;QL(2.15 ml daily); LA; OXERVATE SOLN 1 PA; NDS;MO MO diclofenac sodium (ophth) 1 MO Ophthalmic Steroids soln MO ALREX SUSP 1 dorzolamide hcl soln 1 MO bacitracin-poly-neomycin- 1 MO MO hc oint epinastine hcl (ophth) soln 1 dexamethasone sodium 1 MO MO phosphate (ophth) soln flurbiprofen sodium soln 1 DUREZOL EMUL 1 MO ILEVRO SUSP 1 MO fluorometholone (ophth) 1 MO ketorolac tromethamine 1 MO susp (ophth) soln LOTEMAX GEL 1 MO NEVANAC SUSP 1 MO
LOTEMAX OINT 1 MO olopatadine hcl soln 0.2 % 1 RX/OTC; MO
LOTEMAX SM GEL 1 MO Prostaglandins - Ophthalmic bimatoprost soln 1 MO loteprednol etabonate susp 1 MO latanoprost soln 1 MO neomycin-polymy- 1 MO dexameth oint LUMIGAN SOLN 1 MO neomycin-polymy- 1 MO dexameth susp TRAVATAN Z SOLN 1 MO prednisolone acetate 1 MO (travoprost) (ophth) susp OTIC AGENTS - Drugs to Treat the Ear sulfacetamide sod- 1 MO prednisolone soln Otic Agents - Miscellaneous tobramycin- 1 MO MO dexamethasone susp acetic acid (otic) soln 1 Ophthalmics - Misc. Otic Anti-infectives MO azelastine hcl (ophth) soln 1 CETRAXAL SOLN 1 MO (ciprofloxacin hcl (otic)) MO AZOPT SUSP 1 ciprofloxacin hcl (otic) soln 1 MO bromfenac sodium (ophth) 1 Once daily MO soln dosing;MO ofloxacin (otic) soln 1 cromolyn sodium (ophth) 1 MO Otic Combinations soln ciprofloxacin- 1 MO dexamethasone susp neomycin-polymyxin-hc 1 MO (otic) soln
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2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 55 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits neomycin-polymyxin-hc 1 MO HIZENTRA SOLN 10 1 B/D; NDS (otic) susp GM/50ML Otic Steroids HIZENTRA SOLN 2 1 B/D; NDS;LA GM/10ML, 4 GM/20ML fluocinolone acetonide 1 MO (otic) oil HIZENTRA SOSY 1 B/D; NDS GM/5ML, 2 GM/10ML, 4 1 hydrocortisone w/acetic MO 1 GM/20ML acid soln OXYTOCICS - Drugs to Prevent/Control Uterine HYPERRAB S/D SOLN 1 Bleeding IMOGAM RABIES-HT 1 Oxytocics SOLN 300 UNIT/2ML methylergonovine maleate 1 MO KEDRAB SOLN 1 tabs B/D; NDS PASSIVE IMMUNIZING AND TREATMENT OCTAGAM SOLN 1 AGENTS - Antibody Drugs to Treat Low Immune B/D; NDS System PRIVIGEN SOLN 1 Immune Serums VARIZIG SOLN 1 NDS BIVIGAM SOLN 1 B/D; NDS Monoclonal Antibodies CUVITRU SOLN 1 1 B/D; LA NDS GM/5ML SYNAGIS SOLN 1 CUVITRU SOLN 10 B/D; NDS 1 ZINPLAVA SOLN 1 PA; NDS GM/50ML CUVITRU SOLN 2 B/D; NDS;LA Passive Immunizing Agents - Combinations GM/10ML, 4 GM/20ML, 8 1 B/D; NDS GM/40ML HYQVIA KIT 1 FLEBOGAMMA DIF SOLN B/D; NDS 0.5 GM/10ML, 10 PENICILLINS - Drugs to Treat Bacterial Infections GM/100ML, 10 GM/200ML, 1 2.5 GM/50ML, 20 Aminopenicillins GM/200ML, 20 GM/400ML, amoxicillin caps 250 mg, 1 MO 5 GM/100ML 500 mg amoxicillin susr 125 MO FLEBOGAMMA DIF SOLN 1 B/D; NDS; 5 5 GM/50ML GM/50 ML mg/5ml, 200 mg/5ml, 250 1 mg/5ml, 400 mg/5ml GAMASTAN INJ 1 B/D amoxicillin tabs 500 mg, 1 MO 875 mg GAMMAGARD LIQUID 1 B/D; NDS SOLN ampicillin caps 1 MO GAMMAKED SOLN 1 B/D; NDS ampicillin sodium solr ij 2 1 MO gm, 500 mg, 1 gm GAMMAPLEX SOLN 1 B/D; NDS ampicillin sodium solr ij 250 1 GAMUNEX-C SOLN 1 B/D; NDS mg ampicillin sodium solr iv 10 1 HIZENTRA SOLN 1 1 B/D; LA gm, 2 gm GM/5ML Natural Penicillins
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2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 56 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BICILLIN L-A SUSP 1 MO norethindrone acetate tabs 1 MO penicillin g potassium solr MO progesterone micronized 1 MO 5000000 unit, 20 mu, 1 caps 20000000 unit PSYCHOTHERAPEUTIC AND NEUROLOGICAL penicillin v potassium solr 1 MO AGENTS - MISC. - Drugs to Treat Mental and 250 mg/5ml Emotional Conditions penicillin v potassium tabs MO 1 Agents for Chemical Dependency 250 mg, 500 mg MO Penicillin Combinations acamprosate calcium tbec 1 amoxicillin & pot 1 MO disulfiram tabs 1 MO clavulanate chew PA; NDS;SL(16 amoxicillin & pot 1 MO LUCEMYRA TABS 1 clavulanate susr ea daily); MO amoxicillin & pot 1 MO Anti-Cataplectic Agents clavulanate tabs XYREM SOLN 1 NDS;LA; MO amoxicillin & pot 1 MO clavulanate tb12 Antidementia Agents ampicillin & sulbactam 1 donepezil hydrochloride 1 MO sodium solr ij 0.5 gm-1 gm tabs ampicillin & sulbactam MO 1 donepezil hydrochloride 1 MO sodium solr ij 1 gm-2 gm tbdp ampicillin & sulbactam 1 galantamine hydrobromide 1 MO sodium solr iv 10 gm-5 gm cp24 piperacillin sodium- 1 galantamine hydrobromide 1 MO tazobactam sodium solr soln Penicillinase-Resistant Penicillins galantamine hydrobromide 1 MO tabs dicloxacillin sodium caps 1 MO AL(At least 60 nafcillin sodium solr ij 1 gm 1 memantine hcl cp24 14 mg 1 yrs old); SL(2 ea daily); MO NAFCILLIN SODIUM 1 NDS AL(At least 60 SOLR IJ 10 GM yrs old); memantine hcl cp24 21 mg 1 nafcillin sodium solr ij 2 gm 1 MO SL(1.33 ea daily); MO nafcillin sodium solr iv 10 1 NDS AL(At least 60 gm memantine hcl cp24 28 mg 1 yrs old); SL(1 PROGESTINS - Hormone Replacement/Modifying ea daily); MO Drugs AL(At least 60 memantine hcl cp24 7 mg 1 yrs old); SL(4 Progestins ea daily); MO medroxyprogesterone MO 1 memantine hcl soln 10 1 AL(At least 60 acetate tabs mg/5ml, 2 mg/ml yrs old); MO megestrol acetate AL(Up to 64 yrs 1 memantine hcl tabs 10 mg, 1 MO (appetite) susp old); MO 5 mg
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2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 57 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NAMENDA XR TITRATION 1 AL(At least 60 MAYZENT TABS 1 PA; NDS PACK CP24 yrs old); MO PA; NDS rivastigmine pt24 1 MO OCREVUS SOLN 1 PA; NDS rivastigmine tartrate caps 1 MO REBIF REBIDOSE SOAJ 1 Combination Psychotherapeutics REBIF REBIDOSE 1 PA; NDS TITRATIONPACK SOAJ chlordiazepoxide- 1 AL(Up to 64 yrs amitriptyline tabs old); MO REBIF SOSY 1 PA; NDS olanzapine-fluoxetine hcl MO 1 REBIF TITRATION PACK 1 PA; NDS caps SOSY perphenazine-amitriptyline AL(Up to 64 yrs 1 TECFIDERA CPDR 1 PA; NDS tabs old); MO (dimethyl fumarate) Movement Disorder Drug Therapy TECFIDERA STARTER PA; NDS PA; NDS;LA; PACK MISC (dimethyl 1 INGREZZA CAPS 1 MO fumarate) PA; NDS INGREZZA CPPK 1 PA; NDS;LA; TYSABRI CONC 1 MO PA; NDS; PA; NDS VUMERITY CPDR 1 tetrabenazine tabs 1 Starter Bottle Multiple Sclerosis Agents VUMERITY CPDR 1 PA; NDS;QL(4 ea daily) AUBAGIO TABS 1 PA; NDS Pseudobulbar Affect (PBA) Agents PA; NDS; NUEDEXTA CAPS 1 PA; MO Limited to 1 AVONEX PEN AJKT 1 box per 28 Psychotherapeutic and Neurological Agents - days;QL(0.036 AL(Up to 64 yrs ea daily) ergoloid mesylates tabs 1 old); MO PA; NDS; Limited to 1 pimozide tabs 1 MO AVONEX PSKT 1 box per 28 days;QL(0.036 Smoking Deterrents ml daily) bupropion hcl (smoking 1 SL(2 ea daily); BETASERON KIT 1 PA; NDS deterrent) tb12 MO CHANTIX CONTINUING 1 MO COPAXONE SOSY 1 PA; NDS MONTHPAK TABS (glatiramer acetate) CHANTIX STARTING 1 MO dalfampridine tb12 1 PA; NDS MONTH PAK TABS CHANTIX TABS 1 MO GILENYA CAPS 0.5 MG 1 PA; NDS Limit 3 boxes PA; NDS;LA LEMTRADA SOLN 1 NICOTROL INHALER 1 per INHA month;SL(16.8 MAVENCLAD TBPK 1 PA; NDS; 10 ea daily); MO Tabs NICOTROL NS SOLN 1 MO MAVENCLAD TBPK 1 PA; NDS;LA
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2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 58 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Transthyretin Amyloidosis Agents sulfadiazine tabs 1 MO TEGSEDI SOSY 1 PA; NDS;LA; MO TETRACYCLINES - Drugs to Treat Bacterial Infections Vasomotor Symptom Agents Aminomethylcyclines paroxetine mesylate 1 MO (vasomotor) caps NUZYRA TABS OR 150 1 PA; NDS;MO MG RESPIRATORY AGENTS - MISC. - Drugs to Treat Lung Conditions Glycylcyclines Alpha-Proteinase Inhibitor (Human) tigecycline solr 1 NDS ARALAST NP SOLR 1000 1 NDS;LA; MO MG Tetracyclines MO ARALAST NP SOLR 500 1 NDS;LA demeclocycline hcl tabs 1 MG doxycycline (monohydrate) 1 MO PROLASTIN-C SOLN 1000 1 PA; NDS;LA; caps MG/20ML MO doxycycline (monohydrate) 1 MO PROLASTIN-C SOLR 1000 1 NDS;LA; MO susr MG doxycycline (monohydrate) 1 MO ZEMAIRA SOLR 1 NDS;LA; MO tabs doxycycline hyclate caps or 1 MO Cystic Fibrosis Agents 50 mg, 100 mg PA; NDS;MO KALYDECO PACK 1 doxycycline hyclate solr iv 1 QL(2 ea daily); 100 mg MO KALYDECO TABS 1 PA; NDS;MO doxycycline hyclate tabs or 1 MO 100 mg, 20 mg PA; NDS;LA; ORKAMBI PACK 1 MO doxycycline hyclate tbec or 1 MO 150 mg PA; NDS;LA; ORKAMBI TABS 1 MO minocycline hcl caps 50 1 MO mg, 75 mg, 100 mg PULMOZYME SOLN 1 B/D; NDS minocycline hcl tabs 100 1 MO mg, 50 mg, 75 mg SYMDEKO TBPK 1 PA; NDS;LA tetracycline hcl caps 1 MO PA; NDS;LA; TRIKAFTA TBPK 1 MO THYROID AGENTS - Drugs to Regulate Thyroid Pulmonary Fibrosis Agents Hormones ESBRIET CAPS 1 PA; NDS;LA Antithyroid Agents methimazole tabs 1 MO ESBRIET TABS 1 PA; NDS;LA propylthiouracil tabs 1 MO OFEV CAPS 1 PA; NDS;LA Thyroid Hormones SULFONAMIDES - Drugs to Treat Bacterial Infections Sulfonamides
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2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 59 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MO SL(8 ea daily); levothyroxine sodium tabs glycopyrrolate tabs or 1 mg 1 or 300 mcg, 100 mcg, 112 MO mcg, 125 mcg, 137 mcg, SL(4 ea daily); 1 glycopyrrolate tabs or 2 mg 1 150 mcg, 175 mcg, 200 MO mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg methscopolamine bromide 1 MO tabs liothyronine sodium tabs or 1 MO 25 mcg, 5 mcg, 50 mcg H-2 Antagonists RX/OTC; MO TOXOIDS cimetidine tabs 200 mg 1 Toxoid Combinations cimetidine tabs 300 mg, 1 MO 400 mg, 800 mg ADACEL SUSP 1 famotidine soln iv 20 mg/2ml, 200 mg/20ml, 40 1 BOOSTRIX SUSP 1 mg/4ml famotidine susr or 40 1 MO DAPTACEL SUSP 1 mg/5ml DIPHTHERIA/TETANUS B/D famotidine tabs or 20 mg 1 RX/OTC; MO TOXOIDS ADSORBED 1 PEDIATRIC SUSP famotidine tabs or 40 mg 1 MO INFANRIX SUSP 1 nizatidine caps 150 mg, 1 MO 300 mg KINRIX SUSP 1 Misc. Anti-Ulcer PEDIARIX SUSP 1 sucralfate tabs 1 gm 1 MO PENTACEL SUSR 1 Proton Pump Inhibitors ST; MO QUADRACEL SUSP 1 DEXILANT CPDR 1 B/D esomeprazole magnesium 1 RX/OTC; MO TDVAX SUSP 1 cpdr 20 mg TENIVAC INJ 1 B/D esomeprazole magnesium 1 MO cpdr 40 mg ULCER DRUGS - Drugs to Treat Bowel, Intestine esomeprazole magnesium 1 ST; MO and Stomach Conditions pack 10 mg, 20 mg, 40 mg Antispasmodics esomeprazole sodium solr 1 40 mg dicyclomine hcl caps or 10 1 MO mg lansoprazole cpdr 15 mg 1 RX/OTC; MO dicyclomine hcl tabs or 20 1 MO MO mg lansoprazole cpdr 30 mg 1 glycopyrrolate soln ij 0.2 MO NEXIUM PACK 2.5 MG, 5 1 ST; MO mg/ml, 1 mg/5ml, 4 1 MG mg/20ml omeprazole cpdr 10 mg, 40 1 MO glycopyrrolate soln ij 0.4 1 mg mg/2ml omeprazole cpdr 20 mg 1 RX/OTC; MO
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2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 60 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits pantoprazole sodium solr iv 1 40 mg VACCINES pantoprazole sodium tbec 1 MO Bacterial Vaccines or 20 mg, 40 mg ACTHIB SOLR 1 Ulcer Drugs - Prostaglandins misoprostol tabs 1 MO BCG VACCINE INJ 1 Ulcer Therapy Combinations BEXSERO SUSY 1 amoxicillin-clarithromycin 1 MO w/ lansoprazole misc HIBERIX SOLR 1 omeprazole-sodium MO MENACTRA INJ 1 bicarbonate caps 1100 mg- 1 40 mg MENQUADFI INJ 1 URINARY ANTI-INFECTIVES - Drugs to Treat Bladder/Kidney Infections MENVEO SOLR 1 Urinary Anti-infectives PEDVAX HIB SUSP 1 nitrofurantoin monohyd 1 MO macro caps TRUMENBA SUSY 1 URINARY ANTISPASMODICS - Drugs to Treat Miscellaneous Bladder Spasms TYPHIM VI SOLN 1 Urinary Antispasmodic - Antimuscarinics Viral Vaccines oxybutynin chloride syrp 1 MO ENGERIX-B SUSP IJ 10 1 B/D MCG/0.5ML, 20 MCG/ML oxybutynin chloride tabs 1 MO GARDASIL 9 SUSP 1 oxybutynin chloride tb24 1 MO GARDASIL 9 SUSY 1 tolterodine tartrate cp24 1 MO HAVRIX SUSP 1 tolterodine tartrate tabs 1 MO IMOVAX RABIES 1 B/D (H.D.C.V.) INJ trospium chloride cp24 1 MO IPOL INACTIVATED IPV 1 INJ trospium chloride tabs 1 MO IXIARO SUSP 1 Urinary Antispasmodics - Beta-3 Adrenergic M-M-R II SOLR 1 MYRBETRIQ TB24 1 MO Urinary Antispasmodics - Cholinergic Agonists PROQUAD SUSR 1 bethanechol chloride tabs 1 MO RABAVERT SUSR 1 B/D
Urinary Antispasmodics - Direct Muscle Relaxants RECOMBIVAX HB SUSP 1 B/D flavoxate hcl tabs 1 MO ROTARIX SUSR 1
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2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 61 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ROTATEQ SOLN 1 NORTHERA CAPS 300 1 PA; NDS;SL(6 MG ea daily) SHINGRIX SUSR 1 Vasopressors
TWINRIX SUSP 1 dobutamine hcl soln 1 MO TWINRIX SUSY 1 midodrine hcl tabs 1
VAQTA SUSP 1
VARIVAX INJ 1
YF-VAX INJ 1
ZOSTAVAX SUSR 1
VAGINAL AND RELATED PRODUCTS Vaginal Anti-infectives clindamycin phosphate 1 MO vaginal crea metronidazole vaginal gel 1 MO terconazole vaginal crea 1 MO terconazole vaginal supp 1 MO Vaginal Estrogens estradiol vaginal crea 0.1 1 MO mg/gm PREMARIN CREA VA 1 MO 0.625 MG/GM VASOPRESSORS - Drugs to Treat Heart and Circulation Conditions Anaphylaxis Therapy Agents epinephrine (anaphylaxis) MO soaj 0.15 mg/0.15ml, 0.15 1 mg/0.3ml, 0.3 mg/0.3ml EPIPEN-JR 2-PAK SOAJ 1 MO (epinephrine (anaphylaxis)) Neurogenic Orthostatic Hypotension (NOH) - NORTHERA CAPS 100 1 PA; NDS;SL(18 MG ea daily) NORTHERA CAPS 200 1 PA; NDS;SL(9 MG ea daily)
You can find information on what the symbols and abbreviations on this table mean by going to page vi.
2020 Trillium Advantage Dual (HMO D-SNP) Formulary Updated 12/01/2020 62 Index of Drugs abacavir sulfate 32 alosetron hcl 47 ARANESP ALBUMIN FREE 48 abacavir sulfate-lamivudine 32 ALPHAGAN P 54 ARCALYST 2 abacavir sulfate-lamivudine- alprazolam 7 argatroban 10 zidovudine 32 ALREX 55 ARIKAYCE 1 ABELCET 18 ALUNBRIG 26 aripiprazole 31 ABILIFY MAINTENA 31 amantadine hcl 29 ARISTADA 32 abiraterone acetate 24 AMBISOME 18 ARISTADA INITIO 32 ABRAXANE 28 ambrisentan 36 ARNUITY ELLIPTA 8 acamprosate calcium 57 amcinonide 41 ARRANON 23 acarbose 14 amikacin sulfate 1 arsenic trioxide 28 acebutolol hcl 35 amiloride & ARZERRA 23 acetaminophen w/ codeine 4 hydrochlorothiazide 43 aspirin-dipyridamole 48 acetazolamide 43 amiloride hcl 43 ASTAGRAF XL 52 acetic acid 47 amino acid infusion 15% 54 atazanavir sulfate 32 acetic acid (otic) 55 aminocaproic acid 49 atenolol 35 acetylcysteine 39 aminophylline 9 atenolol & chlorthalidone 21 acitretin 40 aminosalicylic acid 22 atomoxetine hcl 1 ACTEMRA 2 amiodarone hcl 8 atorvastatin calcium 19 ACTHIB 61 amitriptyline hcl 14 atovaquone 6 ACTIMMUNE 28 amlodipine besylate 35 atovaquone-proguanil hcl 21 acyclovir 34 amlodipine besylate- ATRIPLA 32 acyclovir sodium 34 atorvastatin calcium 36 amlodipine besylate-benazepril ATROVENT HFA 8 acyclovir topical 41 hcl 21 AUBAGIO 58 ADACEL 60 amoxapine 14 AVANDIA 15 ADAKVEO 48 amoxicillin 56 AVASTIN 23 adapalene 39 amoxicillin & pot AVEED 5 adefovir dipivoxil 34 clavulanate 57 amoxicillin-clarithromycin w/ AVONEX 58 ADEMPAS 36 lansoprazole 61 AVONEX PEN 58 ADVAIR HFA 9 amphetamine- AYVAKIT 26 AFINITOR 26 dextroamphetamine 1 azacitidine 23 AFINITOR DISPERZ 26 amphotericin b 18 AZASITE 54 AIMOVIG 50 ampicillin 56 AZATHIOPRINE 52 AJOVY 50 ampicillin & sulbactam sodium 57 azathioprine 52 albendazole 5 ampicillin sodium 56 azelaic acid 43 albuterol sulfate 9 ANADROL-50 5 azelastine hcl 53 alclometasone dipropionate 41 anagrelide hcl 48 azelastine hcl (ophth) 55 ALCOHOL PADS 50 anastrozole 24 azithromycin 50 ALECENSA 26 ANDRODERM 5 AZOPT 55 alendronate sodium 43 ANORO ELLIPTA 9 aztreonam 6 alfuzosin hcl 47 ANTARA 19 bacitracin (ophthalmic) 54 ALIMTA 23 APOKYN 29 bacitracin-poly-neomycin-hc 55 ALINIA 6 apraclonidine hcl 54 bacitracin-polymyxin b ALIQOPA 26 aprepitant 18 (ophth) 54 aliskiren fumarate 21 APTIOM 10 baclofen 53 allopurinol 47 APTIVUS 32 balsalazide disodium 46 almotriptan malate 51 ARALAST NP 59 BALVERSA 26
Index 1 BANZEL 10 bosentan 36 CARBAGLU 44 BAQSIMI ONE PACK 15 BOSULIF 26 carbamazepine 11 BAQSIMI TWO PACK 15 BOTOX 53 carbidopa 29 BARACLUDE 34 BRAFTOVI 26 carbidopa-levodopa 29 BAVENCIO 23 BREO ELLIPTA 9 carbinoxamine maleate 18 BAXDELA 46 BRILINTA 48 carboplatin 22 BCG VACCINE 61 brimonidine tartrate 54 carisoprodol 53 BELEODAQ 26 BRIVIACT 10,11 carmustine 22 BELSOMRA 49 bromfenac sodium (ophth) 55 carteolol hcl (ophth) 54 benazepril & bromocriptine mesylate 29 carvedilol 35 hydrochlorothiazide 21 BRUKINSA 26 carvedilol phosphate 35 benazepril hcl 20 budesonide 38 CAYSTON 6 BENDEKA 22 budesonide (inhalation) 8 cefaclor 37 BENLYSTA 52 bumetanide 43 cefadroxil 36 benzoyl peroxide- erythromycin 39 buprenorphine hcl 5 cefazolin sodium 36 benztropine mesylate 29 buprenorphine hcl-naloxone hcl cefdinir 37 dihydrate 5 BEOVU 54 CEFEPIME 37 bupropion hcl 12 cefepime hcl 37 BESPONSA 23 bupropion hcl (smoking betamethasone dipropionate deterrent) 58 cefixime 37 (topical) 41 buspirone hcl 7 cefoxitin sodium 37 betamethasone dipropionate augmented 41 busulfan 22 cefpodoxime proxetil 37 betamethasone sod phosphate & butalbital-aspirin-caffeine cefprozil 37 acetate 38 w/cod 4 ceftazidime 37 betamethasone valerate 41 butorphanol tartrate 5 ceftriaxone sodium 37 BETASERON 58 BYDUREON 15 cefuroxime axetil 37 betaxolol hcl 35 BYDUREON BCISE 15 cefuroxime sodium 37 betaxolol hcl (ophth) 54 BYDUREON PEN 15 celecoxib 2 bethanechol chloride 61 BYETTA 15 CELONTIN 12 BETHKIS 2 cabergoline 45 cephalexin 36,37 BEVYXXA 9,10 CABLIVI 48 CERDELGA 48 bexarotene 28 CABOMETYX 26 CEREZYME 48 BEXSERO 61 calcipotriene 40 cetirizine hcl 18 bicalutamide 24 calcitonin (salmon) 43 CETRAXAL 55 BICILLIN L-A 57 calcitriol 44 cevimeline hcl 53 BIKTARVY 32 calcium acetate (phosphate binder) 47 CHANTIX 58 bimatoprost 55 CALQUENCE 26 CHANTIX CONTINUING bisacodyl-peg 3350-pot chloride- MONTHPAK 58 sod bicarb-sod chloride 50 CAMPATH 23 CHANTIX STARTING MONTH bisoprolol & candesartan cilexetil 21 PAK 58 hydrochlorothiazide 21 candesartan cilexetil- CHENODAL 46 bisoprolol fumarate 35 hydrochlorothiazide 21 chloramphenicol sodium BIVIGAM 56 CAPASTAT SULFATE 22 succinate 6 BLENREP 23 CAPLYTA 30 chlordiazepoxide-amitriptyline 58 bleomycin sulfate 25 CAPRELSA 26 chlorhexidine gluconate (mouth- BLINCYTO 23 captopril 20 throat) 53 BOOSTRIX 60 captopril & chloroquine phosphate 21 hydrochlorothiazide 21 BORTEZOMIB 26 chlorothiazide 43 CARAC 40
Index 2 chlorpromazine hcl 31 clofarabine 23 CYRAMZA 23 chlorthalidone 43 clomipramine hcl 14 CYSTAGON 47 chlorzoxazone 53 clonazepam 10 CYSTARAN 55 cholestyramine 19 clonidine 21 cytarabine 23 cholestyramine light 19 clonidine hcl 21 dacarbazine 28 choline fenofibrate 19 clonidine hcl (adhd) 1 dactinomycin 25 CHORIONIC clopidogrel bisulfate 48 dalfampridine 58 GONADOTROPIN 44 clorazepate dipotassium 7 DALIRESP 8 ciclopirox 39 clotrimazole 53 DALVANCE 6 ciclopirox olamine 39 clotrimazole (topical) 39 danazol 5 cidofovir 34 clotrimazole w/ dantrolene sodium 53 cilostazol 48 betamethasone 40 dapsone 6 CIMDUO 32 clozapine 31 DAPTACEL 60 cimetidine 60 CLOZARIL 31 daptomycin 6 cinacalcet hcl 44 COARTEM 21 DARZALEX 23 CINQAIR 8 colchicine 47 DARZALEX FASPRO 26 CINRYZE 47 colchicine w/ probenecid 47 daunorubicin hcl 25 ciprofloxacin hcl 46 colesevelam hcl 19 DAUNORUBICIN ciprofloxacin hcl (ophth) 54 colestipol hcl 19 HYDROCHLORIDE 25 ciprofloxacin hcl (otic) 55 colistimethate sodium 7 DAURISMO 24 ciprofloxacin in d5w 46 COMBIGAN 54 decitabine 23 ciprofloxacin-dexamethasone COMBIVENT RESPIMAT 9 deferasirox 17 55 COMETRIQ 26 deferiprone 17 cisplatin 22 COMPLERA 32 DELSTRIGO 32 citalopram hydrobromide 13 COPAXONE 58 demeclocycline hcl 59 cladribine 23 COPIKTRA 26 DEMSER 20 CLARINEX-D 12 HOUR 39 CORLANOR 36 DENAVIR 41 clarithromycin 50 cortisone acetate 38 DEPO-MEDROL 38 clemastine fumarate 18 COTELLIC 26 DEPO-PROVERA 24 clindamycin hcl 6 CREON 43 DESCOVY 32 clindamycin palmitate hydrochloride 6 CRESEMBA 18 desipramine hcl 14 clindamycin phosphate 6 CRIXIVAN 32 desloratadine 18 clindamycin phosphate cromolyn sodium 8 desmopressin acetate 45 (topical) 39 cromolyn sodium desmopressin acetate spray 45 clindamycin phosphate in d5w6 (mastocytosis) 46 desmopressin acetate spray clindamycin phosphate cromolyn sodium (ophth) 55 refrigerated 45 vaginal 62 CRYSVITA 44 desogestrel & ethinyl clindamycin phosphate-benzoyl CUVITRU 56 estradiol 37 peroxide 39 desogestrel-ethinyl estradiol clindamycin phosphate-benzoyl cyclobenzaprine hcl 53 (biphasic) 37 peroxide (refrigerate) 39 cyclopentolate hcl 54 desonide 41 CLINIMIX 4.25%/DEXTROSE cyclophosphamide 22 5% 54 desoximetasone 41 clobazam 10 CYCLOPHOSPHAMIDE 22 DESVENLAFAXINE ER 13 clobetasol propionate 41 CYCLOSET 15 desvenlafaxine succinate 13 clobetasol propionate emollient cyclosporine 52 dexamethasone 38 base 41 cyclosporine modified (for dexamethasone sodium clobetasol propionate microemulsion) 52 phosphate 38 emulsion 41 cyproheptadine hcl 19 dexamethasone sodium phosphate (ophth) 55
Index 3 DEXILANT 60 dofetilide 8 enalapril maleate 20 dexmethylphenidate hcl 1 donepezil hydrochloride 57 enalapril maleate & dexrazoxane hcl 28 DOPTELET 48 hydrochlorothiazide 21 ENBREL 3 dextroamphetamine sulfate 1 dorzolamide hcl 55 ENBREL MINI 3 dextrose 53 dorzolamide hcl-timolol ENBREL SURECLICK 3 dextrose in lactated ringers 51 maleate 54 DOVATO 32 ENDARI 48 dextrose w/ sodium chloride 51 doxazosin mesylate 21 ENGERIX-B 61 DIASTAT ACUDIAL 10 doxepin hcl 14 ENHERTU 23 DIASTAT PEDIATRIC 10 doxepin hcl (antipruritic) 40 enoxaparin sodium 10 diazepam 7 doxepin hcl (sleep) 49 entacapone 29 diazepam (anticonvulsant) 10 doxorubicin hcl 25 entecavir 34 diazoxide 15 doxorubicin hcl liposomal 25 ENTRESTO 36 DICLOFENAC EPOLAMINE 39 doxycycline (monohydrate)59 ENTYVIO 46 diclofenac epolamine 39 doxycycline hyclate 59 ENVARSUS XR 52 diclofenac potassium 2 DRIZALMA SPRINKLE 13 EPCLUSA 34 diclofenac sodium 2 diclofenac sodium (actinic dronabinol 18 EPIDIOLEX 11 keratoses) 40 drospirenone-ethinyl epinastine hcl (ophth) 55 diclofenac sodium (ophth) 55 estradiol 37 epinephrine (anaphylaxis) 62 DROXIA 48 diclofenac sodium (topical) 39 EPIPEN-JR 2-PAK 62 duloxetine hcl 13 diclofenac w/ misoprostol 2 epirubicin hcl 25 DUOPA 29 dicloxacillin sodium 57 EPIVIR HBV 34 DUREZOL 55 dicyclomine hcl 60 eplerenone 21 dutasteride 47 didanosine 32 EPOGEN 48 dutasteride-tamsulosin hcl 47 DIFICID 50 EQUETRO 30 econazole nitrate 40 diflorasone diacetate 41 ERAXIS 18 EDURANT 32 diflunisal 3 ERBITUX 23 efavirenz 32 digoxin 35,36 ergoloid mesylates 58 efavirenz-emtricitabine- dihydroergotamine tenofovir disoproxil ERGOMAR 51 mesylate 50,51 fumarate 32 ergotamine w/ caffeine 50 DILANTIN INFATABS 12 efavirenz-lamivudine-tenofovir ERIVEDGE 24 diltiazem hcl 35 disoproxil fumarate 32 ERLEADA 24 diltiazem hcl coated beads 35 ELELYSO 48 erlotinib hcl 26 diltiazem hcl extended release ELIGARD 24 ertapenem sodium 6 beads 35 ELIQUIS 10 ERWINAZE 28 DIPENTUM 46 ELIQUIS STARTER PACK 10 erythromycin (acne aid) 39 diphenhydramine hcl 18 ELITEK 28 erythromycin (ophth) 54 diphenoxylate w/ atropine 17 ELLA 38 DIPHTHERIA/TETANUS erythromycin base 50 EMCYT 24 TOXOIDS ADSORBED erythromycin ethylsuccinate 50 PEDIATRIC 60 EMFLAZA 38 erythromycin lactobionate 50 dipyridamole 48 EMGALITY 50 ESBRIET 59 disopyramide phosphate 7 EMPLICITI 23 escitalopram oxalate 13 disulfiram 57 EMSAM 13 esomeprazole magnesium 60 divalproex sodium 12 emtricitabine 32 esomeprazole sodium 60 DIVIGEL 46 emtricitabine-tenofovir estradiol 46 dobutamine hcl 62 disoproxil fumarate 32 EMTRIVA 32 estradiol & norethindrone docetaxel 28 acetate 46
Index 4 estradiol vaginal 62 FLECTOR 39 GAMMAGARD LIQUID 56 estradiol valerate 46 FLOVENT DISKUS 8 GAMMAKED 56 ethambutol hcl 22 FLOVENT HFA 8,9 GAMMAPLEX 56 ethosuximide 12 fluconazole 18 GAMUNEX-C 56 ethynodiol diacet & eth fluconazole in nacl 18 ganciclovir sodium 34 estrad 37 flucytosine 18 GARDASIL 9 61 etodolac 2 fludarabine phosphate 23 gatifloxacin (ophth) 54 etonogestrel-ethinyl estradiol38 fludrocortisone acetate 39 GATTEX 47 ETOPOPHOS 28 flunisolide (nasal) 53 gauze pads2"x2" 50 etoposide 28 fluocinolone acetonide 41 GAVRETO 26 everolimus 26 fluocinolone acetonide GAZYVA 23 everolimus (otic) 56 GEMCITABINE 23 (immunosuppressant) 52 fluocinonide 41 gemcitabine hcl 23 EVOMELA 22 fluocinonide emulsified EVOTAZ 32 base 41 gemfibrozil 19 exemestane 24 fluorometholone (ophth) 55 gentamicin in saline 2 EXONDYS 51 53 fluorouracil 23 gentamicin sulfate 2 EYLEA 54 fluorouracil (topical) 40 gentamicin sulfate (ophth) 54 ezetimibe 20 fluoxetine hcl 13 gentamicin sulfate (topical) 39 ezetimibe-simvastatin 19 fluphenazine decanoate 31 GENVOYA 32 FABRAZYME 44 fluphenazine hcl 31 GILENYA 58 famciclovir 34 flurbiprofen 2 GILOTRIF 26 famotidine 60 flurbiprofen sodium 55 GLEOSTINE 22 FANAPT 30 flutamide 24 glimepiride 17 FARYDAK 26 fluticasone propionate 42 glipizide 17 FASENRA 8 fluticasone propionate glipizide-metformin hcl 14 FASLODEX 24 (nasal) 53 GLUCAGEN HYPOKIT 15 fluticasone-salmeterol 9 fat emulsion plant based 53 glucagon (rdna) 15 fluvastatin sodium 19 felbamate 11 glyburide 17 fluvoxamine maleate 13 felodipine 35 glyburide micronized 17 FOLOTYN 23 fenofibrate 19 glyburide-metformin 14 fondaparinux sodium 10 fenofibrate micronized 19 glycopyrrolate 60 FORFIVO XL 12 FENSOLVI 44 granisetron hcl 17 FORTEO 44 fentanyl 3 GRANIX 48 fosamprenavir calcium 32 fentanyl citrate 3 griseofulvin microsize 18 fosinopril sodium 20 FERRIPROX 17 griseofulvin ultramicrosize 18 fosinopril sodium & FERRIPROX TWICE-A-DAY 17 hydrochlorothiazide 21 guanfacine hcl 21 FETZIMA 13 fosphenytoin sodium 12 guanfacine hcl (adhd) 1 FETZIMA TITRATION PACK13 FRAGMIN 10 GUANIDINE HCL 22 finasteride 47 fulvestrant 24 GVOKE HYPOPEN 1-PACK 15 FINTEPLA 11 furosemide 43 GVOKE HYPOPEN 2-PACK 15 FIRDAPSE 22 FUZEON 32 GVOKE PFS 15 FIRMAGON 24 FYCOMPA 10 HAEGARDA 47 FIRVANQ 6 gabapentin 11 HALAVEN 28 flavoxate hcl 61 GALAFOLD 44 halobetasol propionate 42 FLEBOGAMMA DIF 56 galantamine hydrobromide 57 haloperidol 31 flecainide acetate 8 GAMASTAN 56 haloperidol decanoate 30
Index 5 haloperidol lactate 30 hydromorphone hcl 3 INSULIN LISPRO HARVONI 34 hydroxychloroquine sulfate 21 PROTAMINE/INSULIN LISPRO KWIKPEN 16 HAVRIX 61 hydroxyprogesterone caproate INSULIN SYRINGES AND PEN heparin sodium (porcine) 10 (antineoplastic) 25 NEEDLES 50 hydroxyurea 28 HERCEPTIN 24 INTELENCE 32 hydroxyzine hcl 7 HERCEPTIN HYLECTA 26 INTRON A 28 hydroxyzine pamoate 7 HETLIOZ 49 INVEGA SUSTENNA 30 HYPERRAB S/D 56 HIBERIX 61 INVEGA TRINZA 30 HYQVIA 56 HIZENTRA 56 INVIRASE 32 ibandronate sodium 44 HUMALOG 16 INVOKAMET 14 HUMALOG JUNIOR IBRANCE 26 INVOKAMET XR 14 KWIKPEN 16 ibuprofen 2,3 INVOKANA 16 HUMALOG KWIKPEN 16 icatibant acetate 47 IPOL INACTIVATED IPV 61 HUMALOG MIX 50/50 16 ICLUSIG 26 ipratropium bromide 8 HUMALOG MIX 50/50 icosapent ethyl 19 ipratropium bromide (nasal) 53 KWIKPEN 16 idarubicin hcl 25 HUMALOG MIX 75/25 16 ipratropium-albuterol 9 IDHIFA 26 HUMALOG MIX 75/25 irbesartan 21 KWIKPEN 16 IFEX 22 irbesartan-hydrochlorothiazide HUMIRA 2 ifosfamide 22 21 HUMIRA PEDIATRIC CROHNS IFOSFAMIDE 22 IRESSA 26 DISEASE STARTER PACK 2 ILARIS 2 irinotecan hcl 29 HUMIRA PEN 2 ILEVRO 55 irrigation solutions, HUMIRA PEN-CD/UC/HS physiological 52 ILUMYA 40 STARTER 2 ISENTRESS 32,33 imatinib mesylate 26 HUMIRA PEN-PS/UV ISENTRESS HD 33 STARTER 2 IMBRUVICA 26 isoniazid 22 HUMULIN 70/30 16 IMFINZI 24 isosorbide dinitrate 7 HUMULIN 70/30 KWIKPEN 16 imipenem-cilastatin 6 isosorbide mononitrate 7 HUMULIN N 16 imipramine hcl 14 isotretinoin 39 HUMULIN N KWIKPEN 16 imipramine pamoate 14 ISTODAX (OVERFILL) 26 HUMULIN R 16 imiquimod 42 itraconazole 18 HUMULIN R U-500 IMLYGIC 29 (CONCENTRATED) 16 ivermectin 5 IMOGAM RABIES-HT 56 HUMULIN R U-500 IXEMPRA KIT 28 KWIKPEN 16 IMOVAX RABIES IXIARO 61 hydralazine hcl 21 (H.D.C.V.) 61 JAKAFI 26 hydrochlorothiazide 43 IMPAVIDO 5 JANUMET 14 hydrocodone bitartrate 3 INCRELEX 44 JANUMET XR 14 hydrocodone-acetaminophen 4 indapamide 43 JANUVIA 15 hydrocodone-ibuprofen 4 indomethacin 3 JARDIANCE 16 hydrocortisone 38 INFANRIX 60 JENTADUETO 14 hydrocortisone (intrarectal) 5 INFLECTRA 46 JENTADUETO XR 15 hydrocortisone (rectal) 5 INFUGEM 23 JEVTANA 28 hydrocortisone (topical) 42 INGREZZA 58 JULUCA 33 hydrocortisone butyrate 42 INLYTA 26 hydrocortisone butyrate INQOVI 26 JUXTAPID 20 hydrophilic lipo base 42 INREBIC 26 JYNARQUE 45 hydrocortisone valerate 42 INSULIN LISPRO JUNIOR K-TAB 51 hydrocortisone w/acetic acid 56 KWIKPEN 16 KADCYLA 24
Index 6 KALBITOR 48 LATUDA 30 lidocaine hcl (local anesth.) 50 KALETRA 33 LAZANDA 3 lidocaine hcl (mouth-throat) 52 KALYDECO 59 leflunomide 3 lidocaine-prilocaine 43 KANJINTI 24 LEMTRADA 58 lincomycin hcl 6 KANUMA 44 LENVIMA 10 MG DAILY linezolid 6 KEDRAB 56 DOSE 27 linezolid in sodium chloride 6 LENVIMA 12MG DAILY KENALOG-10 38 DOSE 27 LINZESS 47 KEPIVANCE 28 LENVIMA 14 MG DAILY liothyronine sodium 60 ketoconazole 18 DOSE 27 lisinopril 20 LENVIMA 18 MG DAILY ketoconazole (topical) 40 lisinopril & DOSE 27 hydrochlorothiazide 21 ketorolac tromethamine 3 LENVIMA 20 MG DAILY ketorolac tromethamine DOSE 27 lithium 30 (ophth) 55 LENVIMA 24 MG DAILY lithium carbonate 29 KEVZARA 2 DOSE 27 LOKELMA 52 KEYTRUDA 24 LENVIMA 4 MG DAILY LONSURF 26 DOSE 27 KHAPZORY 28 LENVIMA 8 MG DAILY loperamide hcl 17 KINRIX 60 DOSE 27 lopinavir-ritonavir 33 KISQALI 27 letrozole 25 lorazepam 7 KISQALI FEMARA 200 leucovorin calcium 28 LORBRENA 27 DOSE 26 LEUKERAN 22 losartan potassium 21 KISQALI FEMARA 400 DOSE 26 LEUKINE 48 losartan potassium & KISQALI FEMARA 600 leuprolide acetate 25 hydrochlorothiazide 21 DOSE 26 levalbuterol hcl 9 LOTEMAX 55 KORLYM 15 levalbuterol tartrate 9 LOTEMAX SM 55 KOSELUGO 27 LEVEMIR 16 loteprednol etabonate 55 KRINTAFEL 21 LEVEMIR FLEXTOUCH 16 lovastatin 19 KUVAN 44 levetiracetam 11 loxapine succinate 31 KYPROLIS 27 levetiracetam in sodium LUCEMYRA 57 labetalol hcl 35 chloride 11 LUMIGAN 55 lactated ringer's 51 levobunolol hcl 54 LUMIZYME 45 lactic acid (ammonium levocarnitine (metabolic LUMOXITI 24 modifiers) 45 lactate) 42 LUPANETA PACK 44 lactulose 50 levocetirizine dihydrochloride 19 LUPRON DEPOT (1- lactulose (encephalopathy) 47 levofloxacin 46 MONTH) 25 LAMICTAL XR 11 LUPRON DEPOT (3- levofloxacin (ophth) 54 MONTH) 25 lamivudine 33 levofloxacin in d5w 46 LUPRON DEPOT (4- lamivudine (hbv) 34 levoleucovorin calcium 28 MONTH) 25 lamivudine-zidovudine 33 levonorgestrel & eth LUPRON DEPOT (6- lamotrigine 11 estradiol 37 MONTH) 25 LUPRON DEPOT-PED (1- LANOXIN 36 levonorgestrel-eth estradiol (triphasic) 37 MONTH) 44 lansoprazole 60 levonorgestrel-ethinyl estradiol LUPRON DEPOT-PED (3- lanthanum carbonate 47 (91-day) 37 MONTH) 44 LANTUS 16 levothyroxine sodium 60 LYNPARZA 27 LANTUS SOLOSTAR 16 LEXIVA 33 LYSODREN 25 lapatinib ditosylate 27 LIBTAYO 24 M-M-R II 61 LARTRUVO 24 lidocaine 42 magnesium sulfate 51 latanoprost 55 lidocaine hcl 42 malathion 43 maprotiline hcl 12
Index 7 MARPLAN 13 methylprednisolone sod mycophenolate sodium 52 MARQIBO 29 succ 38 MYLOTARG 24 methyltestosterone 5 MATULANE 28 MYRBETRIQ 61 metoclopramide hcl 46 MAVENCLAD 58 nabumetone 3 metolazone 43 MAVYRET 34 nadolol 35 metoprolol & MAYZENT 58 hydrochlorothiazide 21 nadolol & bendroflumethiazide 21 meclizine hcl 18 metoprolol succinate 35 nafcillin sodium 57 MEDROL 38 metoprolol tartrate 35 NAFCILLIN SODIUM 57 medroxyprogesterone metronidazole 5 acetate 57 nafcillin sodium 57 metronidazole (topical) 43 medroxyprogesterone acetate naftifine hcl 40 metronidazole in nacl 5 (contraceptive) 38 NAFTIN 40 mefenamic acid 3 metronidazole vaginal 62 NAGLAZYME 45 mefloquine hcl 21 metyrosine 20 naloxone hcl 17 megestrol acetate 25 mexiletine hcl 7 naltrexone hcl 17 megestrol acetate (appetite) 57 MIACALCIN 44 NAMENDA XR TITRATION MEKINIST 27 micafungin sodium 18 PACK 58 MEKTOVI 27 midodrine hcl 62 naproxen 3 meloxicam 3 miglitol 14 naproxen sodium 3 melphalan 22 miglustat 48 naratriptan hcl 51 melphalan hcl 22 MIGRANAL 51 NARCAN 17 memantine hcl 57 MILLIPRED 38 NATACYN 54 MENACTRA 61 minocycline hcl 59 nateglinide 16 MENQUADFI 61 minoxidil 21 NATPARA 44 MENVEO 61 mirtazapine 12 NAYZILAM 10 mercaptopurine 23 MIRVASO 43 nefazodone hcl 13 meropenem 6 misoprostol 61 neomycin sulfate 2 mesalamine 46 mitomycin 25 neomycin-bacitracin zn- mesalamine w/ cleanser 46 mitoxantrone hcl 25 polymyxin 54 neomycin-polymy-dexameth 55 mesna 28 modafinil 1 neomycin-polymyxin-gramicidin MESNEX 28 moexipril hcl 20 54 metaxalone 53 molindone hcl 31 neomycin-polymyxin-hc metformin hcl 15 mometasone furoate 42 (otic) 55 methadone hcl 3,4 MONJUVI 24 neomycin/polymyxin b gu 47 methamphetamine hcl 1 montelukast sodium 8 NERLYNX 27 methazolamide 43 morphine sulfate 4 NEULASTA 48 methenamine hippurate 7 MOVANTIK 47 NEULASTA ONPRO KIT 48 methimazole 59 moxifloxacin hcl (ophth) 54 NEUPOGEN 48 methocarbamol 53 MOZOBIL 49 NEUPRO 29 methotrexate sodium 23 MULPLETA 48 NEVANAC 55 methoxsalen rapid 40 MULTAQ 8 nevirapine 33 methscopolamine bromide 60 mupirocin 39 NEXAVAR 27 methylergonovine maleate 56 mupirocin calcium (topical) 39 NEXIUM 60 methylphenidate hcl 1 MVASI 23 niacin (antihyperlipidemic) 20 methylprednisolone 38 MYALEPT 45 nicardipine hcl 35 methylprednisolone acetate 38 mycophenolate mofetil 52 NICOTROL INHALER 58 mycophenolate mofetil hcl 52 NICOTROL NS 58
Index 8 nifedipine 35 nystatin-triamcinolone 40 OZEMPIC 15 nilutamide 25 OCALIVA 46 paclitaxel 29 nimodipine 35 OCREVUS 58 PADCEV 24 NINLARO 27 OCTAGAM 56 paliperidone 30 NIPENT 28 octreotide acetate 45 PALYNZIQ 45 nisoldipine 35 ODEFSEY 33 PANCREAZE 43 nitisinone 45 ODOMZO 24 PANRETIN 40 nitrofurantoin macrocrystal 7 OFEV 59 pantoprazole sodium 61 nitrofurantoin monohyd macro 7 ofloxacin (ophth) 54 parenteral electrolytes 51 nitroglycerin 7 ofloxacin (otic) 55 paricalcitol 45 NITROSTAT 7 OGIVRI 24 paromomycin sulfate 2 NIVESTYM 49 olanzapine 31 paroxetine hcl 13 nizatidine 60 olanzapine-fluoxetine hcl 58 paroxetine mesylate NORDITROPIN FLEXPRO 44 olopatadine hcl 55 (vasomotor) 59 PAXIL 13 norelgestromin-ethinyl olopatadine hcl (nasal) 53 PEDIARIX 60 estradiol 38 OLUMIANT 2 norethin acet & estrad-fe 37 PEDVAX HIB 61 omega-3-acid ethyl esters 19 norethindrone & eth estradiol37 peg 3350-kcl-sod bicarb-sod omeprazole 60 norethindrone & ethinyl estradiol- chloride-sod sulfate 50 fe 37 omeprazole-sodium peg 3350-potassium chloride-sod norethindrone bicarbonate 61 bicarbonate-sod chloride 50 (contraceptive) 38 ondansetron 17 PEGANONE 12 norethindrone acet & eth ondansetron hcl 17 PEGASYS 34 estra 37 ONIVYDE 29 PEGASYS PROCLICK 34 norethindrone acetate 57 ONUREG 23 PEGINTRON 34 norethindrone acetate-ethinyl estradiol 46 OPDIVO 24 PEMAZYRE 27 norethindrone-eth estradiol OPSUMIT 36 penicillamine 51 (triphasic) 37 ORBACTIV 6 penicillin g potassium 57 norgestimate-ethinyl ORENITRAM 36 estradiol 38 penicillin v potassium 57 norgestimate-ethinyl estradiol ORFADIN 45 PENNSAID 39 (triphasic) 37 ORILISSA 44 PENTACEL 60 norgestrel & ethinyl estradiol 38 ORKAMBI 59 pentamidine isethionate 5 NORTHERA 62 oseltamivir phosphate 34 pentoxifylline 48 nortriptyline hcl 14 OSPHENA 44 perindopril erbumine 20 NORVIR 33 OTREXUP 2 PERJETA 24 NOVAREL 44 oxaliplatin 22 permethrin 43 NOXAFIL 18 oxandrolone 5 perphenazine 31 NUBEQA 25 oxaprozin 3 perphenazine-amitriptyline 58 NUCALA 8 oxazepam 7 PERSERIS 30 NUEDEXTA 58 OXBRYTA 48 phenelzine sulfate 13 NULOJIX 52 oxcarbazepine 11 phenobarbital 49 NUPLAZID 30 OXERVATE 55 phenoxybenzamine hcl 20 NUTROPIN AQ NUSPIN 20 44 oxybutynin chloride 61 phenytoin 12 NUZYRA 59 oxycodone hcl 4 phenytoin sodium 12 NYMALIZE 35 oxycodone w/ phenytoin sodium extended 12 acetaminophen 4 nystatin 18 PHESGO 26 oxycodone-aspirin 5 nystatin (mouth-throat) 53 PHOSPHOLINE IODIDE 54 nystatin (topical) 40 oxymorphone hcl 4
Index 9 PICATO 40 PREMARIN 46,62 quinidine gluconate 7 PIFELTRO 33 PREMPHASE 46 quinidine sulfate 7 pilocarpine hcl 54 PREMPRO 46 quinine sulfate 22 pilocarpine hcl (oral) 53 PRETOMANID 22 RABAVERT 61 pimecrolimus 42 PREVYMIS 34 RADICAVA 53 pimozide 58 PREZCOBIX 33 raloxifene hcl 44 pindolol 35 PREZISTA 33 ramelteon 49 pioglitazone hcl 15 PRIFTIN 22 ramipril 20 pioglitazone hcl-glimepiride 15 primaquine phosphate 21 ranolazine 7 pioglitazone hcl-metformin PRIMAQUINE rasagiline mesylate 29 hcl 15 PHOSPHATE 21 RASUVO 2 piperacillin sodium-tazobactam primidone 11 RAVICTI 45 sodium 57 PRIVIGEN 56 PIQRAY 200MG DAILY RAYALDEE 45 PROAIR HFA 9 DOSE 27 REBIF 58 PIQRAY 250MG DAILY PROAIR RESPICLICK 9 REBIF REBIDOSE 58 DOSE 27 probenecid 47 PIQRAY 300MG DAILY REBIF REBIDOSE DOSE 27 prochlorperazine 31 TITRATIONPACK 58 piroxicam 3 prochlorperazine edisylate 31 REBIF TITRATION PACK 58 podofilox 42 prochlorperazine maleate 31 REBLOZYL 49 POLIVY 24 PROCRIT 49 RECOMBIVAX HB 61 polymyxin b sulfate 7 progesterone micronized 57 RECTIV 5 polymyxin b-trimethoprim 54 PROGRAF 52 REGRANEX 43 POMALYST 25 PROLASTIN-C 59 RELENZA DISKHALER 34 PORTRAZZA 24 PROLEUKIN 28 RELISTOR 47 posaconazole 18 PROLIA 44 REMICADE 46 potassium chloride 51 PROMACTA 49 RENFLEXIS 47 potassium chloride in dextrose & promethazine & repaglinide 16 sodium chloride 51 phenylephrine 39 REPATHA 20 potassium chloride promethazine hcl 19 REPATHA PUSHTRONEX microencapsulated crystals propafenone hcl 8 SYSTEM 20 er 51 proparacaine hcl 55 REPATHA SURECLICK 20 potassium citrate (alkalinizer) 47 propranolol hcl 35 RESTASIS 54 POTELIGEO 24 propylthiouracil 59 RESTASIS MULTIDOSE 54 PRADAXA 10 PROQUAD 61 RETACRIT 49 PRALUENT 20 protriptyline hcl 14 RETEVMO 27 pramipexole dihydrochloride 29 PRUDOXIN 40 RETROVIR IV INFUSION 33 prasugrel hcl 48 PULMOZYME 59 REVCOVI 45 pravastatin sodium 20 PURIXAN 23 REVLIMID 51 prazosin hcl 21 pyrazinamide 22 REXULTI 32 prednicarbate 42 pyridostigmine bromide 22 REYATAZ 33 prednisolone 38 pyrimethamine 22 ribavirin 34 prednisolone acetate (ophth) 55 QINLOCK 27 ribavirin (hepatitis c) 34 prednisolone sodium QUADRACEL 60 RIDAURA 2 phosphate 38 quetiapine fumarate 31 rifabutin 22 prednisone 38 quinapril hcl 20 rifampin 22 pregabalin 11 quinapril-hydrochlorothiazide riluzole 53 PREGNYL W/DILUENT 21 BENZYLALCOHOL/NACL 44 rimantadine hydrochloride 34
Index 10 RINVOQ 2 SIMULECT 52 sulindac 3 RISPERDAL CONSTA 30 simvastatin 20 sumatriptan succinate 51 risperidone 30 sirolimus 52 sumatriptan-naproxen ritonavir 33 SIRTURO 22 sodium 50 SUNOSI 1 RITUXAN 24 SIVEXTRO 6 SUPREP BOWEL PREP KIT50 RITUXAN HYCELA 26 SKYRIZI 40 SUTENT 27 rivastigmine 58 sodium chloride 51 SYLATRON 28 rivastigmine tartrate 58 sodium chloride (gu SYMBICORT 9 rizatriptan benzoate 51 irrigant) 47 sodium polystyrene SYMDEKO 59 ROMIDEPSIN 27 sulfonate 52 SYMFI 33 ropinirole hydrochloride 29 SOLTAMOX 25 SYMFI LO 33 rosuvastatin calcium 20 SOLU-CORTEF 39 SYMLINPEN 120 14 ROTARIX 61 SOMATULINE DEPOT 45 SYMLINPEN 60 14 ROTATEQ 62 SOMAVERT 44 SYMPAZAN 10 ROZLYTREK 27 sotalol hcl 35 SYMTUZA 33 RUBRACA 27 sotalol hcl (afib/afl) 35 SYNAGIS 56 rufinamide 11 SOTYLIZE 35 SYNAREL 44 RUKOBIA 33 SOVALDI 34 SYNDROS 18 RUXIENCE 24 SPIRIVA HANDIHALER 8 SYNERCID 7 RUZURGI 22 SPIRIVA RESPIMAT 8 SYNJARDY 15 RYDAPT 27 spironolactone 43 SYNJARDY XR 15 SAMSCA 45 spironolactone & SYNRIBO 28 SANDIMMUNE 52 hydrochlorothiazide 43 SANDOSTATIN LAR SPRAVATO 56MG DOSE 13 TABLOID 23 DEPOT 45 SPRAVATO 84MG DOSE 13 TABRECTA 27 SANTYL 42 SPRITAM 11 tacrolimus 52 SAPHRIS 31 SPRYCEL 27 tacrolimus (topical) 42 sapropterin dihydrochloride 45 stavudine 33 tadalafil (pulmonary hypertension) 36 SARCLISA 24 STELARA 40 TAFINLAR 27 scopolamine 18 STIOLTO RESPIMAT 9 TAGRISSO 27 SECUADO 31 STIVARGA 27 TAKHZYRO 48 selegiline hcl 29 STRENSIQ 45 TALZENNA 27 selenium sulfide 40 STRIBILD 33 tamoxifen citrate 25 SELZENTRY 33 STRIVERDI RESPIMAT 9 tamsulosin hcl 47 SEREVENT DISKUS 9 SUBSYS 4 TARGRETIN 40 sertraline hcl 13 SUCRAID 43 TASIGNA 27 sevelamer carbonate 47 sucralfate 60 TAVALISSE 48 SHINGRIX 62 sulfacetamide sod- tazarotene 40 SIGNIFOR 45 prednisolone 55 sulfacetamide sodium TAZORAC 40 SIGNIFOR LAR 45 (acne) 39 TAZVERIK 27 sildenafil citrate (pulmonary sulfacetamide sodium hypertension) 36 (ophth) 54 TDVAX 60 SILIQ 40 sulfadiazine 59 TECENTRIQ 24 silver sulfadiazine 41 sulfamethoxazole- TECFIDERA 58 SIMBRINZA 54 trimethoprim 6 TECFIDERA STARTER SIMPONI 2 SULFAMYLON 41 PACK 58 TEFLARO 37 SIMPONI ARIA 2 sulfasalazine 47
Index 11 TEGSEDI 59 toremifene citrate 25 TRODELVY 24 TEKTURNA HCT 21 torsemide 43 TROGARZO 33 temazepam 49 TOUJEO MAX trospium chloride 61 TEMIXYS 33 SOLOSTAR 16 TRULICITY 15 TOUJEO SOLOSTAR 16 TEMODAR 22 TRUMENBA 61 TRACLEER 36 temsirolimus 27 TRUVADA 33 TRADJENTA 15 TENIVAC 60 TRUXIMA 24 tramadol hcl 4 tenofovir disoproxil fumarate 33 TUDORZA PRESSAIR 8 tramadol-acetaminophen 5 terazosin hcl 21 TUKYSA 27 trandolapril 20 terbinafine hcl 18 TURALIO 27 tranexamic acid 49 terbutaline sulfate 9 TWINRIX 62 TRANSDERM SCOP 18 terconazole vaginal 62 TYBOST 34 TRANSDERM-SCOP 18 testosterone 5 TYKERB 27 tranylcypromine sulfate 13 testosterone cypionate 5 TYMLOS 44 TRAVATAN Z 55 testosterone enanthate 5 TYPHIM VI 61 TRAZIMERA 24 tetrabenazine 58 TYSABRI 58 trazodone hcl 13 tetracycline hcl 59 TYVASO 36 TREANDA 22 THALOMID 52 TYVASO REFILL 36 TRECATOR 22 theophylline 9 TYVASO STARTER 36 TRELEGY ELLIPTA 9 thioridazine hcl 31 UCERIS 5 TRELSTAR MIXJECT 25 thiotepa 22 UPTRAVI 36 TREMFYA 40 thiothixene 32 ursodiol 46 treprostinil 36 THYMOGLOBULIN 52 VABOMERE 6 TRESIBA 16 tiagabine hcl 12 valacyclovir hcl 34 TRESIBA FLEXTOUCH 16 TIBSOVO 27 VALCHLOR 40 tretinoin 39 TICE BCG 28 valganciclovir hcl 34 tretinoin (chemotherapy) 28 tigecycline 59 valproate sodium 12 tretinoin microsphere 39 timolol maleate (ophth) 54 valproic acid 12 TREXALL 23 TIMOPTIC-XE 54 valrubicin 25 TREXIMET 50 tinidazole 5 valsartan 21 triamcinolone acetonide 39 TIVICAY 33 valsartan-hydrochlorothiazide triamcinolone acetonide TIVICAY PD 33 21 (mouth) 53 VALSTAR 25 tizanidine hcl 53 triamcinolone acetonide VALTOCO 10 TOBI PODHALER 2 (topical) 42 triamterene & vancomycin hcl 5,6 tobramycin 2 hydrochlorothiazide 43 VANCOMYCIN tobramycin (ophth) 54 triazolam 49 HYDROCHLORIDE 6 tobramycin sulfate 2 trientine hcl 51 VANCOMYCIN tobramycin-dexamethasone 55 HYDROCHLORIDE/DEXTROSE trifluoperazine hcl 31 6 tolbutamide 17 trifluridine 54 VANTAS 25 tolcapone 29 trihexyphenidyl hcl 29 VAQTA 62 tolmetin sodium 3 TRIKAFTA 59 VARIVAX 62 TOLSURA 18 trimethoprim 5 VARIZIG 56 tolterodine tartrate 61 trimipramine maleate 14 VARUBI 18 tolvaptan 45 TRINTELLIX 13 VASCEPA 19 topiramate 11 TRIPTODUR 44 VECTIBIX 24 topotecan hcl 29 TRIUMEQ 33 VELCADE 27
Index 12 VELTASSA 52 XENLETA 7 zolpidem tartrate 49 VEMLIDY 34 XEOMIN 53 ZONALON 40 VENCLEXTA 24 XERMELO 47 zonisamide 11 VENCLEXTA STARTING XGEVA 44 ZONTIVITY 48 PACK 24 XIFAXAN 5 ZORTRESS 52 venlafaxine hcl 13,14 XOLAIR 8 ZOSTAVAX 62 VENTAVIS 36 XOSPATA 28 ZULRESSO 13 verapamil hcl 35 XPOVIO 100 MG ONCE ZYCLARA 42 VERELAN PM 35 WEEKLY 25 ZYCLARA PUMP 42 VERSACLOZ 31 XPOVIO 40 MG ONCE ZYDELIG 28 VERZENIO 27 WEEKLY 25 XPOVIO 40 MG TWICE ZYKADIA 28 VICTOZA 15 WEEKLY 25 ZYPREXA RELPREVV 31 VIDEX EC 34 XPOVIO 60 MG ONCE ZYTIGA 25 VIDEXPEDIATRIC 34 WEEKLY 25 XPOVIO 60 MG TWICE ZYVOX 7 vigabatrin 12 WEEKLY 25 VIIBRYD 13 XPOVIO 80 MG ONCE VIIBRYD STARTER PACK 13 WEEKLY 25 VIMIZIM 45 XPOVIO 80 MG TWICE WEEKLY 25 VIMPAT 11 XTANDI 25 vinblastine sulfate 29 XURIDEN 45 vincristine sulfate 29 XYREM 57 vinorelbine tartrate 29 YERVOY 24 VIRACEPT 34 YF-VAX 62 VIREAD 34 YONDELIS 23 VISTOGARD 17 YONSA 25 VITRAKVI 27 zafirlukast 8 VIZIMPRO 28 zaleplon 49 voriconazole 18 ZALTRAP 23 VOSEVI 34 ZANOSAR 23 VOTRIENT 28 ZARXIO 49 VPRIV 48 ZEJULA 28 VRAYLAR 30 ZELBORAF 28 VUMERITY 58 ZEMAIRA 59 VYNDAMAX 36 ZEPATIER 34 VYNDAQEL 36 ZEPZELCA 23 VYONDYS 53 53 zidovudine 34 VYXEOS 26 zileuton 8 WAKIX 1 ZINPLAVA 56 warfarin sodium 9 ziprasidone hcl 30 water for irrigation, sterile 52 ziprasidone mesylate 30 XALKORI 28 ZIRABEV 23 XARELTO 10 ZIRGAN 54 XARELTO STARTER PACK 10 ZOLADEX 25 XATMEP 23 zoledronic acid 44 XCOPRI 12 ZOLINZA 28 XELJANZ 2 zolmitriptan 51
Index 13 This formulary was updated on 12/01/2020. For more recent information or other questions, please contact Trillium Advantage Dual (HMO D-SNP) at 1-844-867-1156 or, for TTY users, 711, from October 1 – March 31, seven days a week, 8 a.m. to 8 p.m., from April 1 - September 30, Monday through Friday, 8 a.m. to 8 p.m. A messaging system is used after hours, on weekends, and on federal holidays, or visit trilliumadvantage.com.
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