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11699 HMK Progressive State Exchange HCR Progressive Key Notes $3-Copay = Beginning January 1, 2015, this medication may be eligible for a $3 copay depending on the Group's Plan. Contact Member Services for more information. BE = This medication is not covered in Pennsylvania under the Health Care Reform Comprehensive and Health Care Reform Progressive Formularies for Individual Plans and may not be covered for Group Plans. Contact Member Services for more information. EX = This medication is not covered in Pennsylvania or West Virginia under the Health Care Reform Comprehensive and Health Care Reform Progressive Formularies for Individual Plans and may not be covered for Group Plans. Contact Member Services for more information. PA = Coverage of this drug is subject to review by the plan and is based on Pharmacy policy. QL = Limits the amount of drug that a beneficiary may receive in a certain period. SP = To assist in the management of select specialty medications, some pharmacy benefit designs require the use of a preferred specialty Status pharmacy. Please call the number on $0 = Preventative Medication the back of your member ID card for 1 = Tier 1 assistance. 2 = Tier 2 SPT = This drug may incur a higher 3 = Tier 3 copay/coinsurance. Contact Member 4 = Tier 4 Services for more information. lowercase italics = Generic drugs NF = Non-Formulary ST = For a step therapy drug to be UPPERCASE = Brand name drugs Special Tier = Special Tier covered, the beneficiary will be first required to try a therapeutically equivalent medication. Last Approved Date: 09/23/2021 Formulary Version: 91 1 Drug Status Notes Alternative Therapy Alternative Therapy - Unclassified NUMOISYN MUCOUS MEMBRANE LIQUID 3 Analgesic, Anti-Inflammatory Or Antipyretic Analgesic - Neuronal (N)-Type Calcium Channel Blockers (Nccbs) PRIALT 3 PA Analgesic Opioid Agonists PA; ST; QL (120 UNITS per 25 ACTIQ 3 days) ALFENTA 3 PA alfentanil 3 PA ARYMO ER Special Tier PA PA; QL (186 TABLETS per 25 codeine sulfate 1 days) CONZIP 3 PA DEMEROL (PF) INJECTION SOLUTION 50 3 PA MG/ML DEMEROL (PF) INJECTION SYRINGE 3 PA DEMEROL INJECTION SOLUTION 100 3 PA MG/ML PA; QL (248 TABLETS per 25 DEMEROL ORAL TABLET 100 MG 3 days) DILAUDID (PF) INJECTION SOLUTION 3 PA DILAUDID (PF) INJECTION SYRINGE 0.5 3 PA MG/0.5 ML, 1 MG/ML, 2 MG/ML, 4 MG/ML DILAUDID INJECTION 3 PA DILAUDID ORAL LIQUID 3 PA; QL (2480 ML per 25 days) PA; QL (186 TABLETS per 25 DILAUDID ORAL TABLET 3 days) DILAUDID-HP (PF) 3 PA PA; QL (248 TABLETS per 25 DISKETS 1 days) PA; QL (248 TABLETS per 25 DOLOPHINE ORAL 3 days) Last Approved Date: 09/23/2021 Formulary Version: 91 2 Drug Status Notes PA; QL (20 PATCHES per 25 DURAGESIC 3 days) DURAMORPH (PF) 3 PA PA; QL (60 TABLETS per 25 EXALGO ER 3 days) PA; ST; QL (120 UNITS per 25 fentanyl citrate buccal lozenge on a handle 3 days) PA; ST; QL (120 units per 25 fentanyl citrate buccal tablet, effervescent 3 Dayss) fentanyl transdermal patch 72 hour 100 mcg/hr, PA; ST; QL (20 patches per 25 3 12 mcg/hr, 25 mcg/hr, 50 mcg/hr days) fentanyl transdermal patch 72 hour 37.5 PA; QL (20 PATCHES per 25 mcg/hour, 62.5 mcg/hour, 75 mcg/hr, 87.5 3 days) mcg/hour PA; ST; QL (120 UNITS per 25 FENTORA 3 days) hydrocodone bitartrate oral capsule, oral only, er PA; QL (100 capsules per 25 3 12hr dayss) hydrocodone bitartrate oral tablet,oral PA; ST; QL (30 tablets per 25 3 only,ext.rel.24 hr Dayss) hydromorphone (pf) injection syringe 3 PA hydromorphone (pf)-0.9 % nacl intravenous 3 PA syringe 1 mg/ml hydromorphone in 0.9 % nacl intravenous patient 3 PA control.analgesia soln 6 mg/30 ml hydromorphone in d5w (pf) intravenous syringe 3 PA hydromorphone injection syringe 0.5 mg/0.5 ml, 1 3 mg/ml, 2 mg/ml hydromorphone oral liquid 1 PA; QL (2480 ML per 25 days) PA; QL (186 TABLETS per 25 hydromorphone oral tablet 1 days) hydromorphone oral tablet extended release 24 hr 3 QL (60 TABLETS per 25 days) hydromorphone rectal 1 PA; QL (30 TABLETS per 25 HYSINGLA ER Special Tier days) INFUMORPH P/F 3 PA IONSYS 3 PA Last Approved Date: 09/23/2021 Formulary Version: 91 3 Drug Status Notes KADIAN ORAL CAPSULE,EXTEND.RELEASE PELLETS 10 PA; QL (62 CAPSULES per 25 3 MG, 100 MG, 20 MG, 200 MG, 30 MG, 50 MG, days) 60 MG, 80 MG KADIAN ORAL CAPSULE,EXTEND.RELEASE PELLETS 40 3 PA MG LAZANDA NASAL SPRAY,NON-AEROSOL PA; ST; QL (30 BOTTLES per 25 3 100 MCG/SPRAY, 400 MCG/SPRAY days) LAZANDA NASAL SPRAY,NON-AEROSOL 3 PA 300 MCG/SPRAY PA; ST; QL (14 day supply per 30 levorphanol tartrate oral tablet 2 mg 3 days) PA; ST; QL (186 tablets per 25 levorphanol tartrate oral tablet 3 mg 3 days) meperidine (pf) injection solution 100 mg/ml, 25 3 PA mg/ml, 50 mg/ml meperidine oral solution 1 PA; QL (2500 ML per 25 days) PA; QL (248 TABLETS per 25 meperidine oral tablet 1 days) methadone injection solution 3 PA METHADONE INTENSOL 1 QL (248 ML per 25 days) methadone intravenous 1 PA methadone oral concentrate 1 PA; QL (248 ML per 25 days) methadone oral solution 10 mg/5 ml 1 PA; QL (1240 ML per 25 days) methadone oral solution 5 mg/5 ml 1 PA; QL (2480 ML per 25 days) methadone oral syringe 10 mg/ml 1 PA PA; QL (248 TABLETS per 25 methadone oral tablet 1 days) methadone oral tablet,soluble 1 PA; QL (248 EA per 25 days) METHADOSE ORAL CONCENTRATE 1 PA; QL (248 ML per 25 days) PA; QL (248 TABLETS per 25 METHADOSE ORAL TABLET,SOLUBLE 1 days) morphine (pf) injection solution 0.5 mg/ml, 1 3 PA mg/ml morphine concentrate oral solution 1 QL (930 ML per 25 days) morphine concentrate oral syringe 3 morphine injection solution 10 mg/ml, 2 mg/ml, 4 3 PA mg/ml Last Approved Date: 09/23/2021 Formulary Version: 91 4 Drug Status Notes morphine injection solution 15 mg/ml, 8 mg/ml 1 PA morphine injection syringe 10 mg/ml, 2 mg/ml, 4 3 mg/ml, 5 mg/ml, 8 mg/ml morphine intramuscular 3 morphine intravenous solution 10 mg/ml 1 PA morphine intravenous syringe 4 mg/ml 3 PA morphine oral solution 10 mg/5 ml 1 PA; QL (2800 ML per 25 days) morphine oral solution 20 mg/5 ml (4 mg/ml) 1 PA; QL (1400 ML per 25 days) PA; QL (186 TABLETS per 25 morphine oral tablet 1 days) morphine oral tablet extended release 1 QL (100 TABLETS per 25 days) morphine rectal suppository 10 mg, 20 mg 1 PA morphine rectal suppository 30 mg, 5 mg 1 PA; QL (100 TABLETS per 25 MS CONTIN 3 days) NUCYNTA 3 PA; QL (186 TABS per 25 days) PA; QL (62 TABLETS per 25 NUCYNTA ER 3 days) OPANA ER ORAL TABLET EXTENDED 3 PA RELEASE 12 HR OPANA ER ORAL TABLET,ORAL 3 PA ONLY,EXT.REL.12 HR OPANA INJECTION 3 PA PA; QL (180 TABLETS per 25 OPANA ORAL 3 days) PA; ST; QL (180 TABLET per 25 OXAYDO 3 days) PA; QL (180 CAPSULE per 25 oxycodone oral capsule 1 days) oxycodone oral concentrate 1 PA; QL (180 ML per 25 days) oxycodone oral solution 1 PA; QL (5600 ML per 25 days) oxycodone oral syringe 3 PA; QL (180 TABLET per 25 oxycodone oral tablet 1 days) OXYCONTIN ORAL TABLET EXTENDED 3 PA; QL (100 EA per 25 days) RELEASE 12 HR OXYCONTIN ORAL TABLET,ORAL 3 PA ONLY,EXT.REL.12 HR Last Approved Date: 09/23/2021 Formulary Version: 91 5 Drug Status Notes PA; QL (180 TABLETS per 25 oxymorphone oral tablet 1 days) PA; QL (100 TABLETS per 25 oxymorphone oral tablet extended release 12 hr 1 days) QDOLO 3 PA; ST PA; QL (180 TABLET per 25 ROXICODONE ORAL TABLET 15 MG, 30 MG 3 days) ROXICODONE ORAL TABLET 5 MG 3 PA ROXYBOND Special Tier QL (14 day supply per 30 dayss) SUBSYS SUBLINGUAL SPRAY,NON- AEROSOL 1,200 MCG (600 MCG/SPRAY X 2), 3 PA; ST; QL (240 EA per 25 days) 1,600 MCG (800 MCG/SPRAY X 2) SUBSYS SUBLINGUAL SPRAY,NON- AEROSOL 100 MCG/SPRAY, 200 PA; ST; QL (240 SPRAY UNITS 3 MCG/SPRAY, 400 MCG/SPRAY, 600 per 25 days) MCG/SPRAY, 800 MCG/SPRAY tramadol oral capsule,er biphase 24 hr 17-83 3 PA tramadol oral capsule,er biphase 24 hr 25-75 3 PA PA; ST; QL (14 day supply per 30 tramadol oral tablet 100 mg 3 dayss) tramadol oral tablet 50 mg 1 PA tramadol oral tablet extended release 24 hr 1 PA tramadol oral tablet, er multiphase 24 hr 1 PA ULTRAM 3 PA ULTRAM ER ORAL TABLET EXTENDED 3 PA RELEASE 24 HR 300 MG XTAMPZA ER Special Tier PA; QL (60 EA per 30 days) ZOHYDRO ER 3 PA; QL (100 CAPS per 25 days) Analgesic Opioid Codeine Combinations acetaminophen-codeine oral solution 1 acetaminophen-codeine oral tablet 300-15 mg, QL (120 GM APAP COMP per 25 1 300-60 mg days) PA; QL (120 GM APAP COMP acetaminophen-codeine oral tablet 300-30 mg 1 per 25 days) ASCOMP WITH CODEINE 1 PA BUTALBITAL COMPOUND W/CODEINE 1 PA BUTALBITAL COMPOUND-CODEINE 1 PA Last Approved Date: 09/23/2021 Formulary Version: 91 6 Drug Status Notes butalbital-acetaminop-caf-cod oral capsule 50- 1 PA 300-40-30 mg butalbital-acetaminop-caf-cod oral capsule 50- PA; QL (120 GM APAP COMP 1 325-40-30 mg per 25 days) CAPITAL WITH CODEINE 3 PA codeine-butalbital-asa-caff 1 PA FIORICET WITH CODEINE 3 PA FIORINAL-CODEINE #3 3 PA PA; QL (120 GM APAP COMP TYLENOL-CODEINE #3 3 per 25 days) PA; QL (120 GM APAP COMP TYLENOL-CODEINE #4 3 per 25 days) Analgesic Opioid Dihydrocodeine Combinations acetaminophen-caff-dihydrocod oral capsule 1 PA acetaminophen-caff-dihydrocod oral tablet NL PA aspirin-caffeine-dihydrocodein 1 PA DVORAH 1 PANLOR(ACETAM-CAFF-DIHYDROCOD) 1 PA SYNALGOS-DC 3 PA TREZIX 3 PA Analgesic Opioid Dihydrocodeine, Non- Salicylate Analgesic,Xanthine acetaminophen-caff-dihydrocod oral capsule 1 PA acetaminophen-caff-dihydrocod oral tablet NL PA DVORAH 1 PANLOR(ACETAM-CAFF-DIHYDROCOD) 1 PA TREZIX 3 PA Analgesic Opioid Dihydrocodeine, Salicylate Analgesic, Xanthine Comb aspirin-caffeine-dihydrocodein 1 PA SYNALGOS-DC 3 PA Analgesic Opioid Hydrocodone And Non-Salicylate Combinations hydrocodone-acetaminophen oral solution 3 Last Approved Date: 09/23/2021 Formulary Version: 91 7 Drug Status
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