a, Health Nee MED I CARE PROGRAMS
Health Net Seniority Plus Employer (HMO) 2021 Classic 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 21470, Version Number 15
This formulary was updated on 09/01/2021. For more recent information or other questions, please contact Health Net Seniority Plus Employer (HMO) at 1-800-275-4737 or, for TTY users, 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, or visit healthnet.com.
Y0020_21_19401EGFRMLY_C_22029_FINAL_07202020 09/01/2021 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 Health Net of California, Inc. and Health Net Community Solutions Inc. When it refers to “plan” or “our plan,” it means Health Net Seniority Plus Employer (HMO). This document includes a list of the drugs (formulary) for our plan which is current as of 09/01/2021. 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, 2022, and from time to time during the year.
What is the Health Net Seniority Plus Employer (HMO) 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 the 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 Health Net Seniority Plus Employer (HMO) 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
i Updated 09/01/2021 immediately remove the drug from our formulary and provide notice to members who take the drug.
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 both. 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 or move a drug to a higher cost-sharing tier, 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 Health Net Seniority Plus Employer (HMO) Formulary?”
Changes that will not affect you if you are currently taking the drug. Generally, if you are taking a drug on our 2021 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2021 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. You will not get direct notice this year about changes that do not affect you. However, on January 1 of the next year, such changes would affect you, and it is important to check the Drug List for the new benefit year for any changes to drugs. The enclosed formulary is current as of 09/01/2021. 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.
ii Updated 09/01/2021 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.
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 Health Net Seniority Plus Employer (HMO) Formulary?” on page iv for information about how to request an exception.
iii Updated 09/01/2021 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.
How do I request an exception to the Health Net Seniority Plus Employer (HMO) 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 cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug.
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, the lower cost-sharing drug 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.
iv Updated 09/01/2021 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.
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.
v Updated 09/01/2021 Health Net Seniority Plus Employer (HMO) 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.
vi Updated 09/01/2021 Abbreviations The abbreviations below may appear 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 This drug may be covered under Medicare Part B or Part D B 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. GC Additional We provide additional coverage of this prescription drug in the Gap coverage gap. Please refer to your Evidence of Coverage for more Coverage information about this coverage. GC* Additional Only for some Health Net Seniority Plus Employer (HMO) Gap plans: Coverage We provide additional coverage of this prescription drug in the coverage gap. Please refer to your Evidence of Coverage for more information about this coverage. LA Limited This prescription may be available only at certain pharmacies. For Access 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. NT Non-TrOOP Only for some Health Net Seniority Plus Employer (HMO) (Not Part D) plans: This prescription drug is not normally covered in a Medicare Prescription Drug Plan. The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. Quantity limits may apply. 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 This drug has a limit on the amount that we will cover. For example, Limit 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.
vii Updated 09/01/2021 Abbreviation Definition Description RX/OTC Prescription This drug is available both in a prescription form and in an OTC and Over-the- form. Other than some insulins and insulin supplies, only Counter prescription drugs are covered by our Medicare Part D plans. (OTC) 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. 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. ^ Non- This prescription drug may only be available for up to a one month Extended supply. Call Member Services to ask if the drug is available as an Day Supply extended supply.
viii Updated 09/01/2021 Formulary tier descriptions Prescription drugs are grouped into one of five tiers. To find out which tier your drug is in, look in the Drug Tier column of the formulary that begins on page 1. 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) unless otherwise noted:
Tier Copayment/ Description Coinsurance Tier 1 Tier 1 copayment Includes preferred generic drugs. (Preferred Generic Drugs) Tier 2 Tier 2 copayment Includes preferred brand drugs. (Preferred Brand Drugs) Tier 3 Tier 3 copayment Includes non-preferred brand and non-preferred (Non-Preferred Drugs) generic drugs. Tier 4 Tier 4 copayment Includes injectable drugs that do not meet the CMS (Injectable Drugs) cost threshold required to be placed on Tier 5. Tier 5 Tier 5 copayment Includes high cost brand and generic drugs. Drugs (Specialty Tier) or coinsurance in this tier are not eligible for exceptions for payment at a lower tier.
ix Updated 09/01/2021 dP HealthNer
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Y0020_20_13607MLI_C_07222019 Section 1557 Non-Discrimination Language Multi-Language Interpreter Services
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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. 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. FLY0301742M00 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; SL(1 ea ADHD/ANTI-NARCOLEPSY/ANTI- SUNOSI TABS 150 MG 3 OBESITY/ANOREXIANTS - Drugs to Treat daily); MO; GC* ADHD, Sleep and Eating Disorders 3 PA; SL(2 ea SUNOSI TABS 75 MG daily); MO; GC* Amphetamines Histamine H3-Receptor Antagonist/Inverse amphetamine- 1 QL(4 ea daily); dextroamphetamine cp24 MO; GC WAKIX TABS 5^ PA; GC* amphetamine- 1 QL(4 ea daily); dextroamphetamine tabs MO; GC Stimulants - Misc. dextroamphetamine sulfate 1 QL(6 ea daily); armodafinil tabs 1 PA; MO; GC cp24 10 mg, 15 mg, 5 mg MO; GC dextroamphetamine sulfate QL(6 ea daily); DAYTRANA PTCH 3 MO; GC* tabs 2.5 mg, 7.5 mg, 10 1 MO; GC mg, 5 mg dexmethylphenidate hcl 1 SL(4 ea daily); SL(7 ea daily); cp24 10 mg MO; GC VYVANSE CAPS 10 MG 3 MO; GC* dexmethylphenidate hcl 1 SL(2.66 ea SL(3.5 ea cp24 15 mg daily); MO; GC VYVANSE CAPS 20 MG 3 daily); MO; GC* dexmethylphenidate hcl 1 SL(2 ea daily); SL(2.33 ea cp24 20 mg MO; GC VYVANSE CAPS 30 MG 3 daily); MO; GC* dexmethylphenidate hcl 1 SL(1.6 ea SL(1.75 ea cp24 25 mg daily); MO; GC VYVANSE CAPS 40 MG 3 daily); MO; GC* dexmethylphenidate hcl 1 SL(1.33 ea SL(1.4 ea cp24 30 mg daily); MO; GC VYVANSE CAPS 50 MG 3 daily); MO; GC* dexmethylphenidate hcl 1 SL(1.14 ea SL(1.16 ea cp24 35 mg daily); MO; GC VYVANSE CAPS 60 MG 3 daily); MO; GC* dexmethylphenidate hcl 1 SL(1 ea daily); SL(1 ea daily); cp24 40 mg MO; GC VYVANSE CAPS 70 MG 3 MO; GC* dexmethylphenidate hcl 1 SL(8 ea daily); cp24 5 mg MO; GC Attention-Deficit/Hyperactivity Disorder (ADHD) dexmethylphenidate hcl 1 MO; GC atomoxetine hcl caps 10 1 SL(10 ea daily); tabs 2.5 mg, 10 mg, 5 mg mg MO; GC methylphenidate hcl cp24 MO; GC atomoxetine hcl caps 100 1 SL(1 ea daily); 10 mg, 20 mg, 30 mg, 40 1 mg MO; GC mg, 60 mg atomoxetine hcl caps 18 SL(5.55 ea 1 methylphenidate hcl cpcr 1 QL(2 ea daily); mg daily); MO; GC 20 mg MO; GC atomoxetine hcl caps 25 SL(4 ea daily); 1 methylphenidate hcl cpcr 1 MO; GC mg MO; GC 30 mg atomoxetine hcl caps 40 1 SL(2.5 ea methylphenidate hcl cpcr QL(1 ea daily); mg daily); MO; GC 40 mg, 10 mg, 50 mg, 60 1 MO; GC atomoxetine hcl caps 60 1 SL(1.66 ea mg mg daily); MO; GC methylphenidate hcl tabs 1 QL(3 ea daily); atomoxetine hcl caps 80 1 SL(1.25 ea 10 mg, 20 mg, 5 mg MO; GC mg daily); MO; GC methylphenidate hcl tb24 Non-Osmotic AL(Up to 64 yrs guanfacine hcl (adhd) tb24 1 18 mg, 27 mg, 36 mg, 54 1 Release; GC old); MO; GC mg Dopamine and Norepinephrine Reuptake You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary Updated 09/01/2021 1 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits methylphenidate hcl tbcr 20 1 QL(3 ea daily); HUMIRA PEDIATRIC PA; GC* mg MO; GC CROHNS DISEASE 5^ STARTER PACK PSKT methylphenidate hcl tbcr 54 1 MO; GC mg, 18 mg, 27 mg, 36 mg HUMIRA PEN PNKT 5^ PA; GC* modafinil tabs 100 mg 1 PA; MO; GC HUMIRA PEN-CD/UC/HS 5^ PA; GC* PA; QL(1 ea STARTER PNKT modafinil tabs 200 mg 1 daily); MO; GC HUMIRA PEN-PEDIATRIC PA; GC* UC STARTER PACK 5^ ALLERGENIC EXTRACTS/BIOLOGICALS MISC PNKT Allergenic Extracts HUMIRA PEN-PS/UV 5^ PA; GC* STARTER PNKT PA; MO; GC* GRASTEK SUBL 3 HUMIRA PSKT 10 PA; GC* PA; MO; GC* MG/0.1ML, 20 MG/0.2ML, 5^ ORALAIR SUBL 3 40 MG/0.4ML, 40 MG/0.8ML AMINOGLYCOSIDES - Drugs to Treat Bacterial Infections SIMPONI ARIA SOLN 5^ PA; GC* Aminoglycosides SIMPONI SOAJ 5^ PA; GC* amikacin sulfate soln 4 MO; GC* SIMPONI SOSY 5^ PA; GC* ARIKAYCE SUSP 5^ PA; MO; GC* Antirheumatic - Enzyme Inhibitors gentamicin in saline soln 4 GC* PA; GC* 0.9 %-1 mg/ml OLUMIANT TABS 5^ MO; GC* gentamicin sulfate soln 4 RINVOQ TB24 5^ PA; GC* MO; GC neomycin sulfate tabs 1 XELJANZ SOLN 5^ PA; GC* MO; GC paromomycin sulfate caps 1 XELJANZ TABS 5^ PA; GC* GC* TOBI PODHALER CAPS 5^ XELJANZ XR TB24 5^ PA; GC* tobramycin nebu 300 5^ B/D; GC* Antirheumatic Antimetabolites mg/4ml OTREXUP SOAJ 4 PA; GC* tobramycin nebu 300 1 B/D; GC mg/5ml RASUVO SOAJ 4 PA; GC* tobramycin sulfate soln 1.2 4 MO; GC* gm/30ml, 80 mg/2ml Gold Compounds tobramycin sulfate solr 1.2 4 GC* gm RIDAURA CAPS 5^ MO; GC* ANALGESICS - ANTI-INFLAMMATORY - Drugs Interleukin-1 Blockers to Treat Pain, Swelling, Muscle and Joint Conditions ARCALYST SOLR 5^ LA; GC* Anti-TNF-alpha - Monoclonal Antibodies Interleukin-1 Receptor Antagonist (IL-1Ra) KINERET SOSY 5^ PA; LA; MO; GC* You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary 2 Updated 09/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AL(Up to 64 yrs Interleukin-1beta Blockers indomethacin cpcr 75 mg 1 old); MO; GC ILARIS SOLN 5^ PA; LA; GC* ketoprofen cp24 200 mg 1 MO; GC Interleukin-6 Receptor Inhibitors ketorolac tromethamine 4 AL(Up to 64 yrs ACTEMRA SOLN 5^ PA; GC* soln ij 15 mg/ml, 30 mg/ml old); MO; GC* ketorolac tromethamine AL(Up to 64 yrs ACTEMRA SOSY 5^ PA; GC* soln im 30 mg/ml, 60 4 old); MO; GC* mg/2ml KEVZARA SOAJ 5^ PA; GC* ketorolac tromethamine 1 AL(Up to 64 yrs tabs or 10 mg old); MO; GC KEVZARA SOSY 5^ PA; GC* meclofenamate sodium 1 MO; GC caps 100 mg Nonsteroidal Anti-inflammatory Agents (NSAIDs) MO; GC celecoxib caps 1 MO; GC mefenamic acid caps 1 MO; GC meloxicam tabs 15 mg, 7.5 1 MO; GC diclofenac potassium tabs 1 mg MO; GC diclofenac sodium tb24 1 MO; GC nabumetone tabs 1 MO; GC NAPRELAN TB24 750 MG 3 MO; GC* diclofenac sodium tbec 1 (naproxen sodium) MO; GC diclofenac w/ misoprostol 1 MO; GC naproxen sodium tabs 1 tbec MO; GC DUEXIS TABS (ibuprofen- 5^ PA; MO; GC* naproxen sodium tb24 1 famotidine) MO; GC naproxen tabs 250 mg, 375 1 MO; GC etodolac caps 1 mg, 500 mg MO; GC naproxen tbec 375 mg, 500 1 MO; GC etodolac tabs 1 mg naproxen-esomeprazole PA; MO; GC* etodolac tb24 1 MO; GC 5^ magnesium tbec MO; GC flurbiprofen tabs 100 mg 1 oxaprozin tabs 1 MO; GC RX/OTC; MO; ibuprofen susp 100 mg/5ml 1 piroxicam caps 1 MO; GC GC SL(8 ea daily); MO; GC ibuprofen tabs 400 mg 1 sulindac tabs 1 MO; GC SL(5.33 ea tolmetin sodium caps 400 MO; GC ibuprofen tabs 600 mg 1 1 daily); MO; GC mg SL(4 ea daily); MO; GC* ibuprofen tabs 800 mg 1 ZIPSOR CAPS 3 MO; GC Phosphodiesterase 4 (PDE4) Inhibitors ibuprofen-famotidine tabs 5^ PA; MO; GC* OTEZLA TABS 5^ PA; GC* INDOCIN SUSP OR 25 3 AL(Up to 64 yrs MG/5ML old); MO; GC* OTEZLA TBPK 5^ PA; GC* indomethacin caps 25 mg, 1 AL(Up to 64 yrs 50 mg old); MO; GC Pyrimidine Synthesis Inhibitors You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary Updated 09/01/2021 3 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits leflunomide tabs 1 MO; GC fentanyl citrate tabs bu 200 5^ PA; QL(8 ea mcg daily); MO; GC* Selective Costimulation Modulators fentanyl citrate tabs bu 400 5^ PA; QL(4 ea mcg, 600 mcg, 800 mcg daily); MO; GC* ORENCIA CLICKJECT 5^ PA; GC* SOAJ Limit 10 PA; GC* fentanyl pt72 100 mcg/hr, patches per ORENCIA SOLR 5^ 12 mcg/hr, 25 mcg/hr, 50 1 month;QL(0.34 PA; GC* mcg/hr, 75 mcg/hr ea daily); MO; ORENCIA SOSY 5^ GC Soluble Tumor Necrosis Factor Receptor Agents FENTORA TABS 100 MCG 5^ PA; QL(16 ea (fentanyl citrate) daily); MO; GC* ENBREL MINI SOCT 5^ PA; GC* FENTORA TABS 200 MCG 5^ PA; QL(8 ea (fentanyl citrate) daily); MO; GC* PA; GC* ENBREL SOLN 5^ FENTORA TABS 400 PA; QL(4 ea PA; GC* MCG, 600 MCG, 800 MCG 5^ daily); MO; GC* ENBREL SOLR 5^ (fentanyl citrate) PA; GC* hydrocodone bitartrate 1 PA; QL(3 ea ENBREL SOSY 5^ cp12 or 10 mg, 15 mg daily); MO; GC ENBREL SURECLICK 5^ PA; GC* hydrocodone bitartrate PA; QL(2 ea SOAJ cp12 or 20 mg, 30 mg, 40 1 daily); MO; GC ANALGESICS - NonNarcotic - Drugs to Treat mg, 50 mg Pain, Muscle and Joint Conditions hydrocodone bitartrate t24a 1 PA; QL(1 ea or 100 mg, 120 mg, 80 mg daily); MO; GC Salicylates hydrocodone bitartrate t24a PA; QL(2 ea diflunisal tabs 1 MO; GC or 20 mg, 30 mg, 40 mg, 60 1 daily); MO; GC mg ANALGESICS - OPIOID - Drugs to Treat Pain, hydromorphone hcl liqd or 1 QL(50 ml Muscle and Joint Conditions 1 mg/ml daily); MO; GC Opioid Agonists hydromorphone hcl soln ij GC* PA; QL(16 ea 10 mg/ml, 50 mg/5ml, 500 4 ABSTRAL SUBL 100 MCG 3 daily); GC* mg/50ml hydromorphone hcl soln ij 2 Preservative ABSTRAL SUBL 200 MCG 5^ PA; QL(8 ea 4 daily); GC* mg/ml Free; GC* SL(24 ea daily); hydromorphone hcl soln ij 4 MO; GC* codeine sulfate tabs 15 mg 1 4 MO; GC mg/ml, 1 mg/ml, 2 mg/ml SL(12 ea daily); hydromorphone hcl tabs or QL(9 ea daily); codeine sulfate tabs 30 mg 1 1 MO; GC 2 mg, 4 mg MO; GC SL(6 ea daily); hydromorphone hcl tabs or QL(6.25 ea codeine sulfate tabs 60 mg 1 1 MO; GC 8 mg daily); MO; GC fentanyl citrate lpop bu PA; QL(4 ea hydromorphone hcl tb24 or 1 QL(4.17 ea 1200 mcg, 1600 mcg, 400 5^ daily); MO; GC* 12 mg daily); MO; GC mcg, 600 mcg, 800 mcg hydromorphone hcl tb24 or 1 QL(3.14 ea 16 mg daily); MO; GC fentanyl citrate lpop bu 200 5^ PA; QL(8 ea mcg daily); MO; GC* hydromorphone hcl tb24 or 1 QL(1.57 ea 32 mg daily); MO; GC fentanyl citrate tabs bu 100 5^ PA; QL(16 ea mcg daily); MO; GC* hydromorphone hcl tb24 or 1 QL(6.27 ea 8 mg daily); MO; GC You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary 4 Updated 09/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits morphine sulfate soln or QL(10 ml KADIAN CP24 200 MG 3 PA; QL(2 ea 1 daily); GC* 100 mg/5ml, 20 mg/ml daily); MO; GC LAZANDA SOLN 100 5^ PA; QL(1 ea morphine sulfate soln or 20 1 QL(50 ml MCG/ACT daily); MO; GC* mg/5ml daily); MO; GC PA; Limit 8 morphine sulfate tabs or 15 1 QL(13.34 ea bottles per mg daily); MO; GC LAZANDA SOLN 400 5^ month;QL(0.27 MCG/ACT morphine sulfate tabs or 30 1 QL(6.67 ea ea daily); MO; mg daily); MO; GC GC* morphine sulfate tbcr or 1 QL(2 ea daily); methadone hcl conc or 10 1 QL(6.67 ml 100 mg, 200 mg MO; GC mg/ml daily); MO; GC morphine sulfate tbcr or 15 1 QL(3 ea daily); methadone hcl soln or 10 1 QL(33.34 ml mg, 30 mg, 60 mg MO; GC mg/5ml daily); MO; GC SL(7 ea daily); NUCYNTA TABS 100 MG 3 methadone hcl soln or 5 1 QL(15 ml MO; GC* mg/5ml daily); MO; GC SL(14 ea daily); NUCYNTA TABS 50 MG 3 methadone hcl tabs or 5 1 QL(6 ea daily); MO; GC* mg, 10 mg MO; GC SL(9.33 ea NUCYNTA TABS 75 MG 3 morphine sulfate beads 1 QL(1.67 ea daily); MO; GC* cp24 120 mg daily); MO; GC QL(6 ea daily); oxycodone hcl caps 5 mg 1 morphine sulfate beads 1 QL(6.67 ea MO; GC cp24 30 mg daily); MO; GC oxycodone hcl conc 100 1 QL(6 ml daily); morphine sulfate beads 1 QL(4.44 ea mg/5ml MO; GC cp24 45 mg daily); MO; GC oxycodone hcl tabs 10 mg, 1 QL(6 ea daily); morphine sulfate beads 1 QL(3.34 ea 20 mg, 15 mg, 5 mg MO; GC cp24 60 mg daily); MO; GC QL(4.44 ea oxycodone hcl tabs 30 mg 1 morphine sulfate beads 1 QL(2.67 ea daily); MO; GC cp24 75 mg daily); MO; GC oxymorphone hcl tabs 10 1 QL(6 ea daily); morphine sulfate beads 1 QL(2.24 ea mg, 5 mg MO; GC cp24 90 mg daily); MO; GC oxymorphone hcl tb12 10 1 QL(3 ea daily); morphine sulfate cp24 or QL(3 ea daily); mg MO; GC 10 mg, 20 mg, 30 mg, 50 1 MO; GC mg oxymorphone hcl tb12 15 1 QL(4.44 ea mg daily); MO; GC morphine sulfate cp24 or 5^ QL(2 ea daily); 100 mg MO; GC* oxymorphone hcl tb12 20 1 QL(3.34 ea mg daily); MO; GC morphine sulfate cp24 or 1 PA; QL(3 ea 40 mg daily); MO; GC oxymorphone hcl tb12 30 1 QL(2.22 ea mg daily); MO; GC morphine sulfate cp24 or 1 QL(3.34 ea 60 mg daily); MO; GC oxymorphone hcl tb12 40 1 QL(2 ea daily); mg MO; GC morphine sulfate cp24 or 1 QL(2.5 ea 80 mg daily); MO; GC oxymorphone hcl tb12 5 1 QL(13.34 ea mg daily); MO; GC morphine sulfate soln ij 0.5 4 GC* mg/ml oxymorphone hcl tb12 7.5 1 QL(8.89 ea mg daily); MO; GC morphine sulfate soln ij 1 4 MO; GC* mg/ml SUBSYS LIQD 100 MCG 5^ PA; QL(16 ea daily); MO; GC* morphine sulfate soln or 10 1 QL(100 ml mg/5ml daily); MO; GC SUBSYS LIQD 1200 MCG 5^ PA; QL(2 ea daily); GC* You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary Updated 09/01/2021 5 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SUBSYS LIQD 1600 MCG, PA; QL(4 ea oxycodone w/ SL(6 ea daily); 400 MCG, 600 MCG, 800 5^ daily); MO; GC* acetaminophen tabs 10 1 MO; GC MCG mg-325 mg oxycodone w/ SL(12.3 ea SUBSYS LIQD 200 MCG 5^ PA; QL(8 ea daily); MO; GC* acetaminophen tabs 2.5 1 daily); MO; GC SL(8 ea daily); mg-325 mg tramadol hcl tabs 50 mg 1 MO; GC oxycodone w/ SL(12 ea daily); SL(3 ea daily); acetaminophen tabs 5 mg- 1 MO; GC tramadol hcl tb24 100 mg 1 MO; GC 325 mg SL(1.5 ea oxycodone w/ SL(8 ea daily); tramadol hcl tb24 200 mg 1 daily); MO; GC acetaminophen tabs 7.5 1 MO; GC mg-325 mg SL(1 ea daily); tramadol hcl tb24 300 mg 1 SL(12.3 ea MO; GC oxycodone-aspirin tabs 1 daily); MO; GC Opioid Combinations tramadol-acetaminophen 1 SL(8 ea daily); Limit 4500mls tabs MO; GC acetaminophen w/ codeine per soln 12 mg/5ml-120 1 month;SL(150 Opioid Partial Agonists mg/5ml ml daily); MO; BUNAVAIL FILM 0.7 MG- 3 QL(2 ea daily); GC 4.2 MG GC* acetaminophen w/ codeine 1 SL(13.3 ea buprenorphine hcl subl sl 2 1 QL(3 ea daily); tabs 15 mg-300 mg daily); MO; GC mg, 8 mg MO; GC acetaminophen w/ codeine 1 SL(12 ea daily); buprenorphine hcl- QL(3 ea daily); tabs 30 mg-300 mg MO; GC naloxone hcl dihydrate film 1 MO; GC 0.5 mg-2 mg, 1 mg-4 mg, 2 acetaminophen w/ codeine 1 SL(6 ea daily); tabs 60 mg-300 mg MO; GC mg-8 mg AL(Up to 64 yrs buprenorphine hcl- QL(2 ea daily); butalbital-acetaminophen- 1 old); SL(6 ea naloxone hcl dihydrate film 1 MO; GC caffeine w/ codeine caps daily); MO; GC 3 mg-12 mg AL(Up to 64 yrs buprenorphine hcl- QL(3 ea daily); butalbital-aspirin-caffeine 1 old); SL(6 ea naloxone hcl dihydrate subl 1 MO; GC w/cod caps daily); MO; GC 0.5 mg-2 mg, 2 mg-8 mg hydrocodone- Limit 5535mls Limit 8 patches acetaminophen soln 2.5 per per 28 buprenorphine ptwk 10 1 days;SL(0.29 mg/5ml-108 mg/5ml, 5 1 month;SL(184. mcg/hr mg/10ml-217 mg/10ml, 7.5 5 ml daily); MO; ea daily); MO; mg/15ml-325 mg/15ml GC GC hydrocodone- SL(13.3 ea Limit 5 patches acetaminophen tabs 10 daily); MO; GC per 28 1 buprenorphine ptwk 15 1 days;SL(0.19 mg-300 mg, 5 mg-300 mg, mcg/hr 7.5 mg-300 mg ea daily); MO; GC hydrocodone- SL(12.3 ea acetaminophen tabs 10 daily); MO; GC Limit 4 patches 1 per 28 mg-325 mg, 5 mg-325 mg, buprenorphine ptwk 20 7.5 mg-325 mg 1 days;SL(0.15 mcg/hr ea daily); MO; hydrocodone-ibuprofen QL(5 ea daily); GC tabs 10 mg-200 mg, 5 mg- 1 MO; GC 200 mg, 7.5 mg-200 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary 6 Updated 09/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 16 testosterone gel td 40.5 MO; GC patches per 28 mg/2.5gm, 1.62 %, 20.25 1 buprenorphine ptwk 5 1 days;SL(0.58 mcg/hr mg/1.25gm, 25 mg/2.5gm, ea daily); MO; 1 %, 50 mg/5gm GC testosterone soln td 30 1 MO; GC Limit 10 mg/act patches per 28 buprenorphine ptwk 7.5 1 days;SL(0.39 ANORECTAL AND RELATED PRODUCTS - mcg/hr ea daily); MO; Rectal Drugs to Treat Pain, Swelling and Itching GC Intrarectal Steroids butorphanol tartrate soln ij 4 MO; GC* CORTIFOAM FOAM 3 MO; GC* 2 mg/ml Limit 210mls hydrocortisone (intrarectal) 1 MO; GC enem butorphanol tartrate soln na 1 per month;QL(7 10 mg/ml ml daily); MO; UCERIS FOAM RE 2 3 MO; GC* GC MG/ACT Limit 10 Rectal Steroids patches per 28 BUTRANS PTWK 7.5 2 MO; GC ) days;SL(0.39 hydrocortisone (rectal) crea 1 MCG/HR (buprenorphine ea daily); MO; GC* Vasodilating Agents ZUBSOLV SUBL 0.18 MG- QL(3 ea daily); RECTIV OINT 3 MO; GC* 0.7 MG, 0.36 MG-1.4 MG, 3 MO; GC* 0.71 MG-2.9 MG, 1.4 MG- ANTHELMINTICS - Drugs to Treat Worm 5.7 MG Infections ZUBSOLV SUBL 2.1 MG- QL(2 ea daily); 3 Anthelmintics 8.6 MG MO; GC* albendazole tabs 1 MO; GC ZUBSOLV SUBL 2.9 MG- 3 QL(1 ea daily); 11.4 MG MO; GC* ivermectin tabs or 3 mg 1 MO; GC ANDROGENS-ANABOLIC - Drugs to Regulate Hormones praziquantel tabs 1 MO; GC Anabolic Steroids MO; GC* ANTI-INFECTIVE AGENTS - MISC. - Drugs to oxandrolone tabs 10 mg 5^ Treat Bacterial Infections oxandrolone tabs 2.5 mg 1 MO; GC Anti-infective Agents - Misc. IMPAVIDO CAPS 5^ MO; GC* Androgens LA; GC* metronidazole caps or 375 1 SL(10.6 ea AVEED SOLN 3 mg daily); MO; GC danazol caps 1 MO; GC metronidazole in nacl soln GC* 0.79 %-5 mg/ml, 0.79 %- 4 methyltestosterone caps 1 MO; GC 500 mg/100ml metronidazole tabs or 250 1 SL(16 ea daily); testosterone cypionate soln 4 MO; GC* mg MO; GC im 100 mg/ml, 200 mg/ml metronidazole tabs or 500 1 SL(8 ea daily); testosterone enanthate 4 MO; GC* mg MO; GC soln im You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary Updated 09/01/2021 7 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits pentamidine isethionate 4 MO; GC* DALVANCE SOLR 5^ GC* solr ij FIRVANQ SOLR 25 GC* pentamidine isethionate 1 B/D; MO; GC 3 solr in MG/ML MO; GC FIRVANQ SOLR 50 3 MO; GC* tinidazole tabs 1 MG/ML trimethoprim tabs 1 MO; GC ORBACTIV SOLR 5^ MO; GC* XIFAXAN TABS 200 MG 5^ MO; GC* vancomycin hcl caps or 3 PA; QL(4 ea 125 mg daily); MO; GC* QL(3 ea daily); XIFAXAN TABS 550 MG 5^ vancomycin hcl caps or 5^ PA; QL(8 ea MO; GC* 250 mg daily); MO; GC* Anti-infective Misc. - Combinations vancomycin hcl solr iv 10 GC* sulfamethoxazole- MO; GC* gm, 5 gm, 750 mg, 1 gm, 4 trimethoprim soln iv 80 4 1000 mg mg/5ml-400 mg/5ml vancomycin hcl solr iv 500 4 MO; GC* sulfamethoxazole- MO; GC mg trimethoprim susp or 40 1 VANCOMYCIN MO; GC* mg/5ml-200 mg/5ml HYDROCHLORIDE SOLR 3 sulfamethoxazole- MO; GC OR 250 MG/5ML trimethoprim tabs or 160 1 VANCOMYCIN GC* mg-800 mg, 80 mg-400 mg HYDROCHLORIDE/DEXT ROSE SOLN 1 GM/200ML- 4 Antiprotozoal Agents 5 %, 5 %-500 MG/100ML, atovaquone susp 5^ MO; GC* 5 %-750 MG/150ML Leprostatics nitazoxanide tabs or 1 MO; GC dapsone tabs 1 MO; GC Carbapenems Lincosamides ertapenem sodium solr 4 MO; GC* clindamycin hcl caps 1 MO; GC imipenem-cilastatin solr MO; GC 250 mg-250 mg, 500 mg- 1 clindamycin palmitate 1 MO; GC 500 mg hydrochloride solr MO; GC* clindamycin phosphate in 4 GC* meropenem solr 1 gm 4 d5w soln meropenem solr 500 mg 1 GC clindamycin phosphate soln GC* ij 300 mg/2ml, 9 gm/60ml, 4 VABOMERE SOLR 4 GC* 9000 mg/60ml clindamycin phosphate soln 4 MO; GC* Chloramphenicols ij 600 mg/4ml, 900 mg/6ml MO; GC* chloramphenicol sodium 4 GC* lincomycin hcl soln 4 succinate solr Cyclic Lipopeptides Monobactams MO; GC* daptomycin solr 500 mg 5^ MO; GC* aztreonam solr 4 PA; LA; GC* Glycopeptides CAYSTON SOLR 5^ You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary 8 Updated 09/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Oxazolidinones isosorbide dinitrate tabs 40 5^ MO; GC* mg linezolid in sodium chloride 5^ GC* soln isosorbide mononitrate tabs 1 MO; GC linezolid soln iv 600 5^ GC* mg/300ml isosorbide mononitrate 1 MO; GC tb24 linezolid susr or 100 5^ MO; GC* mg/5ml NITRO-DUR PT24 0.3 3 MO; GC* MG/HR, 0.8 MG/HR linezolid tabs or 600 mg 1 MO; GC nitroglycerin oint td 2 % 1 MO; GC GC* SIVEXTRO SOLR IV 5^ nitroglycerin pt24 td 0.1 MO; GC mg/hr, 0.2 mg/hr, 0.4 1 MO; GC* SIVEXTRO TABS OR 5^ mg/hr, 0.6 mg/hr nitroglycerin soln tl 0.4 MO; GC ZYVOX SOLN IV 200 5^ GC* 1 MG/100ML mg/spray nitroglycerin subl sl 0.3 mg, 1 MO; GC Pleuromutilins 0.4 mg, 0.6 mg XENLETA TABS OR 600 PA; MO; GC* 5^ NITROSTAT SUBL 2 MO; GC* MG (nitroglycerin) Polymyxins ANTIANXIETY AGENTS - Drugs to Treat Anxiety colistimethate sodium solr 4 MO; GC* Antianxiety Agents - Misc. GC* polymyxin b sulfate solr 4 buspirone hcl tabs 1 MO; GC Streptogramins hydroxyzine hcl soln im 50 4 AL(Up to 64 yrs SYNERCID SOLR 5^ GC* mg/ml old); MO; GC* hydroxyzine hcl syrp or 10 1 AL(Up to 64 yrs Urinary Anti-infectives mg/5ml old); MO; GC hydroxyzine hcl tabs or 10 AL(Up to 64 yrs methenamine hippurate 1 MO; GC 1 tabs mg, 25 mg, 50 mg old); MO; GC hydroxyzine pamoate caps AL(Up to 64 yrs nitrofurantoin macrocrystal 1 MO; GC 1 caps 25 mg, 50 mg old); MO; GC AL(Up to 64 yrs nitrofurantoin monohyd 1 MO; GC meprobamate tabs 1 macro caps old); MO; GC nitrofurantoin susp 1 MO; GC Benzodiazepines alprazolam tabs 1 MO; GC ANTIANGINAL AGENTS - Drugs to Treat Chest Pain alprazolam tb24 1 MO; GC Antianginals-Other alprazolam tbdp 1 MO; GC ranolazine tb12 1 MO; GC clorazepate dipotassium 1 MO; GC Nitrates tabs MO; GC* DILATRATE SR CPCR 3 diazepam conc or 5 mg/ml 1 MO; GC isosorbide dinitrate tabs 30 MO; GC 1 diazepam soln ij 5 mg/ml, 1 MO; GC mg, 10 mg, 20 mg, 5 mg 50 mg/10ml You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary Updated 09/01/2021 9 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits diazepam soln or 5 mg/5ml 1 MO; GC cromolyn sodium nebu 1 B/D; MO; GC diazepam tabs or 10 mg, 2 1 MO; GC Antiasthmatic - Monoclonal Antibodies mg, 5 mg CINQAIR SOLN 5^ PA; LA; GC* lorazepam conc 1 MO; GC FASENRA SOSY 5^ PA; GC* lorazepam soln 1 MO; GC NUCALA SOLR 100 MG 5^ PA; LA; GC* lorazepam tabs 1 MO; GC XOLAIR SOLR 5^ PA; LA; GC* ANTIARRHYTHMICS - Drugs to treat abnormal heart rhythms XOLAIR SOSY 5^ PA; LA; GC* Antiarrhythmics Type I-A Bronchodilators - Anticholinergics disopyramide phosphate 1 AL(Up to 64 yrs caps old); MO; GC Limit 2 inhalers per NORPACE CR CP12 3 AL(Up to 64 yrs old); MO; GC* ATROVENT HFA AERS 3 month;QL(0.86 gm daily); MO; quinidine gluconate tbcr 1 MO; GC GC* MO; GC INCRUSE ELLIPTA AEPB 2 SL(1 ea daily); quinidine sulfate tabs 1 MO; GC* B/D; MO; GC Antiarrhythmics Type I-B ipratropium bromide soln 1 MO; GC mexiletine hcl caps 1 SPIRIVA HANDIHALER 2 SL(1 ea daily); CAPS MO; GC* Antiarrhythmics Type I-C Limit 1 inhaler per month (60 flecainide acetate tabs 100 1 SL(4 ea daily); SPIRIVA RESPIMAT mg MO; GC 2 actuations);SL( AERS 0.14 gm daily); flecainide acetate tabs 150 1 SL(2.66 ea mg daily); MO; GC MO; GC* Leukotriene Modulators flecainide acetate tabs 50 1 SL(8 ea daily); mg MO; GC montelukast sodium chew 1 QL(1 ea daily); propafenone hcl cp12 1 MO; GC 4 mg, 5 mg MO; GC montelukast sodium tabs 1 QL(1 ea daily); propafenone hcl tabs 1 MO; GC 10 mg MO; GC zafirlukast tabs 1 MO; GC Antiarrhythmics Type III SL(4 ea daily); amiodarone hcl tabs or 100 1 MO; GC zileuton tb12 5^ mg, 200 mg, 400 mg MO; GC* dofetilide caps 1 GC Selective Phosphodiesterase 4 (PDE4) Inhibitors QL(1 ea daily); DALIRESP TABS 3 MULTAQ TABS 2 MO; GC* MO; GC* Steroid Inhalants ANTIASTHMATIC AND BRONCHODILATOR AGENTS - Drugs to Treat Lung Conditions Anti-Inflammatory Agents You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary 10 Updated 09/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 2 inhalers Limit 2 inhalers ALVESCO AERS 160 per ASMANEX TWISTHALER per 3 month;SL(0.41 60 METERED DOSES 2 month;SL(0.07 MCG/ACT gm daily); MO; AEPB ea daily); MO; GC* GC* Limit 4 inhalers limit 35 inhalers ALVESCO AERS 80 per ASMANEX TWISTHALER per 3 month;SL(0.82 7 METERED DOSES 2 month;SL(1.17 MCG/ACT gm daily); MO; AEPB ea daily); MO; GC* GC* budesonide (inhalation) B/D; QL(8 ml ARNUITY ELLIPTA AEPB 2 SL(1 ea daily); 1 MO; GC* susp 0.25 mg/2ml daily); MO; GC Limit 2 inhalers budesonide (inhalation) 1 B/D; QL(4 ml per susp 0.5 mg/2ml daily); MO; GC ASMANEX HFA AERO 100 2 month;SL(0.87 MCG/ACT budesonide (inhalation) 1 B/D; QL(2 ml gm daily); MO; susp 1 mg/2ml daily); MO; GC GC* FLOVENT DISKUS AEPB 2 SL(20 ea daily); Limit 1 inhaler 100 MCG/BLIST MO; GC* per ASMANEX HFA AERO 200 2 month;SL(0.44 FLOVENT DISKUS AEPB 2 SL(8 ea daily); MCG/ACT gm daily); MO; 250 MCG/BLIST MO; GC* GC* FLOVENT DISKUS AEPB 2 SL(40 ea daily); Limit 4 inhalers 50 MCG/BLIST MO; GC* per Limit 2 inhalers ASMANEX HFA AERO 50 2 month;SL(1.74 per MCG/ACT FLOVENT HFA AERO 110 2 month;QL(0.8 gm daily); MO; MCG/ACT, 220 MCG/ACT GC* gm daily); MO; Limit 1 inhaler GC* ASMANEX TWISTHALER per Limit 1 inhaler 120 METERED DOSES 2 month;SL(0.04 per FLOVENT HFA AERO 44 2 month;QL(0.36 AEPB ea daily); MO; MCG/ACT GC* gm daily); MO; Limit 8 inhalers GC* ASMANEX TWISTHALER per Limit 2 inhalers 14 METERED DOSES 2 month;SL(0.29 per PULMICORT FLEXHALER 3 month;SL(0.07 AEPB ea daily); MO; AEPB 180 MCG/ACT GC* ea daily); MO; Limit 8 inhalers GC* ASMANEX TWISTHALER per Limit 8 inhalers 30 METERED DOSES 2 month;SL(0.27 per PULMICORT FLEXHALER 3 month;SL(0.27 AEPB 110 MCG/INH ea daily); MO; AEPB 90 MCG/ACT GC* ea daily); MO; Limit 4 inhalers GC* ASMANEX TWISTHALER per Sympathomimetics 30 METERED DOSES 2 month;SL(0.14 ADVAIR HFA AERO 21 QL(4 gm daily); AEPB 220 MCG/INH ea daily); MO; MCG/ACT-115 MCG/ACT, 2 MO; GC* GC* 21 MCG/ACT-45 MCG/ACT You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary Updated 09/01/2021 11 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 1 Inhaler fluticasone-salmeterol aepb SL(2 ea daily); per 50 mcg/dose-500 MO; GC ADVAIR HFA AERO 21 2 month;QL(0.4 mcg/dose, 50 mcg/act-100 MCG/ACT-230 MCG/ACT gm daily); MO; mcg/act, 50 mcg/act-250 1 GC* mcg/act, 50 mcg/dose-100 Limit 2 inhalers mcg/dose, 50 mcg/dose- per month 250 mcg/dose ADVAIR HFA AERO 21 (Institutional B/D; SL(4 ml 2 formoterol fumarate nebu 1 MCG/ACT-230 MCG/ACT Pack);QL(0.54 daily); MO; GC gm daily); MO; B/D; MO; GC GC* ipratropium-albuterol soln 1 albuterol sulfate nebu in B/D; MO; GC levalbuterol hcl nebu 1 B/D; MO; GC 0.63 mg/3ml, 1.25 mg/3ml, 1 0.083 %, 0.5 %, 2.5 MO; GC* mg/0.5ml levalbuterol tartrate aero 3 PERFOROMIST NEBU B/D; SL(4 ml albuterol sulfate syrp or 2 1 MO; GC 3 mg/5ml (formoterol fumarate) daily); MO; GC* PROAIR HFA AERS MO; GC* albuterol sulfate tabs or 2 1 MO; GC 2 mg, 4 mg (albuterol sulfate) PROAIR RESPICLICK MO; GC* ANORO ELLIPTA AEPB 2 QL(2 ea daily); 2 MO; GC* AEPB arformoterol tartrate nebu 1 B/D; MO; GC PROVENTIL HFA AERS 2 MO; GC* (albuterol sulfate) BREO ELLIPTA AEPB 25 Limit 1 inhaler SEREVENT DISKUS 2 QL(2 ea daily); MCG/INH-100 MCG/INH, 2 per month;SL(2 AEPB MO; GC* 25 MCG/INH-200 ea daily); MO; Limit 1 inhaler MCG/INH GC* per Limit 2 inhalers STIOLTO RESPIMAT 2 month;SL(0.14 BREO ELLIPTA AEPB 25 AERS MCG/INH-100 MCG/INH, per month gm daily); MO; 2 (Institutional GC* 25 MCG/INH-200 Pack);SL(2 ea MCG/INH Limit 1 inhaler daily); MO; GC* per month (60 STRIVERDI RESPIMAT BROVANA NEBU 3 B/D; MO; GC* 2 actuations);SL( (arformoterol tartrate) AERS 0.14 gm daily); Limit 3 inhalers MO; GC* per 2 COMBIVENT RESPIMAT Limit 2 inhalers 3 months;SL(0.2 SYMBICORT AERO 4.5 per month AERS gm daily); MO; MCG/ACT-160 MCG/ACT 3 (Institutional GC* (budesonide-formoterol Pack);SL(0.4 Limit 2 inhalers fumarate dihydrate) gm daily); MO; DULERA AERO 5 per GC* MCG/ACT-100 MCG/ACT, 2 5 MCG/ACT-200 month;SL(0.59 SYMBICORT AERO 4.5 Limit 1 inhaler MCG/ACT gm daily); MO; MCG/ACT-160 MCG/ACT, per GC* 4.5 MCG/ACT-80 3 month;SL(0.34 DULERA AERO 5 Limit 1 inhaler MCG/ACT (budesonide- gm daily); MO; MCG/ACT-100 MCG/ACT, per formoterol fumarate GC* 5 MCG/ACT-200 2 month;SL(0.44 dihydrate) MCG/ACT, 5 MCG/ACT-50 gm daily); MO; MCG/ACT GC* You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary 12 Updated 09/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 2 inhalers enoxaparin sodium soln sc MO; GC SYMBICORT AERO 4.5 per month 100 mg/ml, 120 mg/0.8ml, 1 MCG/ACT-80 MCG/ACT 3 (Institutional 60 mg/0.6ml, 80 mg/0.8ml (budesonide-formoterol Pack);SL(0.46 enoxaparin sodium soln sc MO; GC* fumarate dihydrate) gm daily); MO; 150 mg/ml, 30 mg/0.3ml, 4 GC* 40 mg/0.4ml terbutaline sulfate tabs or 1 MO; GC fondaparinux sodium soln MO; GC* 2.5 mg, 5 mg 10 mg/0.8ml, 5 mg/0.4ml, 5^ TRELEGY ELLIPTA AEPB MO; GC* 7.5 mg/0.6ml 25 MCG/INH-62.5 2 fondaparinux sodium soln 1 MO; GC MCG/INH-100 MCG/INH 2.5 mg/0.5ml TRELEGY ELLIPTA AEPB SL(2 ea daily); FRAGMIN SOLN 10000 MO; GC* 25 MCG/INH-62.5 2 MO; GC* UNIT/ML, 2500 3 MCG/INH-200 MCG/INH UNIT/0.2ML, 5000 VENTOLIN HFA AERS 3 MO; GC* UNIT/0.2ML (albuterol sulfate) FRAGMIN SOLN 12500 MO; GC* Xanthines UNIT/0.5ML, 15000 UNIT/0.6ML, 18000 5^ aminophylline soln 4 GC* UNT/0.72ML, 7500 UNIT/0.3ML, 95000 theophylline tb12 300 mg, 1 MO; GC UNIT/3.8ML 450 mg heparin sodium (porcine) 4 MO; GC* theophylline tb24 400 mg, 1 MO; GC soln 600 mg HEPARIN SODIUM SOLN 4 GC* ANTICOAGULANTS - Blood Thinners 5000 UNIT/ML Coumarin Anticoagulants Thrombin Inhibitors MO; GC argatroban soln 250 4 GC* warfarin sodium tabs 1 mg/2.5ml Direct Factor Xa Inhibitors PRADAXA CAPS 2 QL(2 ea daily); MO; GC* ELIQUIS STARTER PACK 3 QL(2 ea daily); TBPK MO; GC* ANTICONVULSANTS - Drugs to Treat Seizures ELIQUIS TABS 3 QL(2 ea daily); MO; GC* AMPA Glutamate Receptor Antagonists MO; GC* SAVAYSA TABS 3 QL(1 ea daily); FYCOMPA SUSP 3 MO; GC* FYCOMPA TABS 3 MO; GC* XARELTO STARTER 2 QL(1.7 ea PACK TBPK daily); MO; GC* Anticonvulsants - Benzodiazepines XARELTO TABS 10 MG, 2 QL(1 ea daily); 15 MG, 20 MG MO; GC* clobazam susp 1 MO; GC XARELTO TABS 2.5 MG 2 QL(2 ea daily); MO; GC* clobazam tabs 1 MO; GC Heparins And Heparinoid-Like Agents SL(40 ea daily); clonazepam tabs 0.5 mg 1 MO; GC enoxaparin sodium soln ij 4 MO; GC* 300 mg/3ml SL(20 ea daily); clonazepam tabs 1 mg 1 MO; GC You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary Updated 09/01/2021 13 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SL(10 ea daily); MO; GC clonazepam tabs 2 mg 1 carbamazepine cp12 1 MO; GC clonazepam tbdp 0.125 MO; GC carbamazepine susp 1 MO; GC mg, 0.25 mg, 0.5 mg, 1 mg, 1 2 mg carbamazepine tabs 1 MO; GC DIASTAT ACUDIAL GEL MO; GC* (diazepam 3 carbamazepine tb12 1 MO; GC (anticonvulsant)) DIASTAT PEDIATRIC GEL MO; GC* CARBATROL CP12 3 MO; GC* (diazepam 3 (carbamazepine) (anticonvulsant)) DIACOMIT CAPS 5^ PA; MO; GC* diazepam (anticonvulsant) 3 MO; GC* gel 10 mg DIACOMIT PACK 5^ PA; MO; GC* diazepam (anticonvulsant) 1 MO; GC PA; GC* gel 2.5 mg, 20 mg EPIDIOLEX SOLN 5^ PA; SL(0.34 ea NAYZILAM SOLN 5^ PA; SL(11.82 daily); MO; GC* FINTEPLA SOLN 5^ ml daily); MO; GC* SYMPAZAN FILM 10 MG, 5^ PA; MO; GC* 20 MG gabapentin caps 1 MO; GC SYMPAZAN FILM 5 MG 3 PA; MO; GC* gabapentin soln 1 MO; GC PA; SL(0.34 ea VALTOCO LIQD 5^ daily); MO; GC* gabapentin tabs 1 MO; GC PA; SL(0.34 ea VALTOCO LQPK 5^ daily); MO; GC* LAMICTAL XR KIT 3 MO; GC* Anticonvulsants - Misc. lamotrigine chew 25 mg, 5 1 MO; GC APTIOM TABS 200 MG 3 MO; GC* mg lamotrigine kit 25 mg 1 MO; GC APTIOM TABS 400 MG, 5^ MO; GC* 600 MG, 800 MG lamotrigine tabs 100 mg, 1 MO; GC BRIVIACT SOLN IV 50 5^ SL(20 ml daily); 150 mg, 200 mg, 25 mg MG/5ML GC* lamotrigine tb24 100 mg, MO; GC BRIVIACT SOLN OR 10 5^ PA; SL(20 ml 200 mg, 250 mg, 300 mg, 1 MG/ML daily); MO; GC* 25 mg, 50 mg BRIVIACT TABS OR 10 PA; SL(20 ea 5^ lamotrigine tbdp 100 mg, 1 MO; GC MG daily); MO; GC* 200 mg, 25 mg, 50 mg BRIVIACT TABS OR 100 PA; SL(2 ea 5^ levetiracetam in sodium 4 GC* MG daily); MO; GC* chloride soln BRIVIACT TABS OR 25 PA; SL(8 ea 5^ levetiracetam soln iv 500 4 GC* MG daily); MO; GC* mg/5ml BRIVIACT TABS OR 50 PA; SL(4 ea 5^ levetiracetam soln or 100 1 MO; GC MG daily); MO; GC* mg/ml, 500 mg/5ml BRIVIACT TABS OR 75 5^ PA; SL(2.67 ea levetiracetam tabs or 250 MO; GC MG daily); MO; GC* mg, 1000 mg, 750 mg, 500 1 mg carbamazepine chew 1 MO; GC You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary 14 Updated 09/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits levetiracetam tb24 or 500 1 MO; GC zonisamide caps 1 MO; GC mg, 750 mg oxcarbazepine susp 1 MO; GC Carbamates felbamate susp 1 MO; GC oxcarbazepine tabs 1 MO; GC felbamate tabs 1 MO; GC pregabalin caps 100 mg, 1 QL(3 ea daily); 25 mg, 50 mg, 75 mg MO; GC XCOPRI TABS 100 MG, 5^ PA; MO; GC* pregabalin caps 150 mg, 1 QL(2 ea daily); 150 MG, 200 MG, 50 MG 200 mg, 225 mg MO; GC PA; 12.5-25 SL(2 ea daily); XCOPRI TBPK 3 pregabalin caps 300 mg 1 MG;MO; GC* MO; GC PA; 50-200 SL(30 ml daily); XCOPRI TBPK 5^ pregabalin soln 20 mg/ml 1 MG;MO; GC* MO; GC PA; 50-100 XCOPRI TBPK 5^ primidone tabs 1 MO; GC MG;MO; GC* PA; 350 MG rufinamide susp 40 mg/ml 1 MO; GC XCOPRI TBPK 5^ Daily Dose; GC* rufinamide tabs 200 mg 1 MO; GC XCOPRI TBPK 5^ PA; 150-200 MG ;MO; GC* MO; GC* rufinamide tabs 400 mg 5^ PA; 100-150 XCOPRI TBPK 5^ PA; SL(3 ea MG; GC* SPRITAM TB3D 1000 MG 3 daily); MO; GC* GABA Modulators SPRITAM TB3D 250 MG 3 PA; SL(12 ea tiagabine hcl tabs 1 MO; GC daily); MO; GC* LA; MO; GC* SPRITAM TB3D 500 MG 3 PA; SL(6 ea vigabatrin pack 5^ daily); MO; GC* LA; GC* SPRITAM TB3D 750 MG 3 PA; SL(4 ea vigabatrin tabs 5^ daily); MO; GC* Hydantoins TEGRETOL SUSP 3 MO; GC* (carbamazepine) DILANTIN CAPS 3 MO; GC* TEGRETOL TABS 3 MO; GC* (carbamazepine) DILANTIN INFATABS 3 MO; GC* CHEW (phenytoin) TEGRETOL-XR TB12 3 MO; GC* (carbamazepine) DILANTIN-125 SUSP 3 MO; GC* (phenytoin) topiramate cpsp 15 mg, 25 1 MO; GC mg fosphenytoin sodium soln 4 GC* 100 mg pe/2ml topiramate tabs 100 mg, 1 MO; GC 200 mg, 25 mg, 50 mg fosphenytoin sodium soln 4 MO; GC* 500 mg pe/10ml VIMPAT SOLN IV 200 4 GC* MG/20ML PEGANONE TABS 3 MO; GC* VIMPAT SOLN OR 10 3 MO; GC* MG/ML phenytoin chew 1 MO; GC VIMPAT TABS OR 100 MO; GC* phenytoin sodium extended 1 MO; GC MG, 150 MG, 200 MG, 50 3 caps MG You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary Updated 09/01/2021 15 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GC* SL(6 ea daily); phenytoin sodium soln 4 bupropion hcl tabs 75 mg 1 MO; GC MO; GC SL(4 ea daily); phenytoin susp 1 bupropion hcl tb12 100 mg 1 MO; GC Succinimides SL(2.66 ea bupropion hcl tb12 150 mg 1 daily); MO; GC CELONTIN CAPS 3 MO; GC* SL(2 ea daily); bupropion hcl tb12 200 mg 1 ethosuximide caps 1 MO; GC MO; GC SL(3 ea daily); bupropion hcl tb24 150 mg 1 ethosuximide soln 1 MO; GC MO; GC SL(1.5 ea bupropion hcl tb24 300 mg 1 Valproic Acid daily); MO; GC DEPAKOTE ER TB24 3 MO; GC* ST; MO; GC (divalproex sodium) bupropion hcl tb24 450 mg 1 DEPAKOTE SPRINKLES MO; GC* 3 FORFIVO XL TB24 3 ST; MO; GC* CSDR (divalproex sodium) (bupropion hcl) DEPAKOTE TBEC 3 MO; GC* maprotiline hcl tabs 1 MO; GC (divalproex sodium) divalproex sodium csdr 1 MO; GC GABA Receptor Modulator - Neuroactive Steroid ZULRESSO SOLN 5^ PA; GC* divalproex sodium tb24 1 MO; GC Monoamine Oxidase Inhibitors (MAOIs) divalproex sodium tbec 1 MO; GC EMSAM PT24 5^ MO; GC* valproate sodium soln iv 4 GC* 100 mg/ml, 500 mg/5ml MARPLAN TABS 3 MO; GC* valproate sodium soln or 1 MO; GC 250 mg/5ml phenelzine sulfate tabs 1 MO; GC MO; GC valproic acid caps 1 tranylcypromine sulfate 1 MO; GC tabs ANTIDEPRESSANTS - Drugs to Treat Depression N-Methyl-D-aspartic acid (NMDA) Receptor SPRAVATO 56MG DOSE 5^ PA; MO; GC* Alpha-2 Receptor Antagonists (Tetracyclics) SOPK MO; GC mirtazapine tabs 1 SPRAVATO 84MG DOSE 5^ PA; MO; GC* SOPK MO; GC mirtazapine tbdp 1 Selective Serotonin Reuptake Inhibitors (SSRIs) Antidepressants - Misc. citalopram hydrobromide 1 SL(20 ml daily); soln 10 mg/5ml MO; GC ST; SL(3 ea APLENZIN TB24 174 MG 3 daily); MO; GC* citalopram hydrobromide 1 SL(4 ea daily); tabs 10 mg MO; GC ST; SL(1.5 ea APLENZIN TB24 348 MG 3 daily); MO; GC* citalopram hydrobromide 1 SL(2 ea daily); tabs 20 mg MO; GC ST; SL(1 ea APLENZIN TB24 522 MG 3 daily); MO; GC* citalopram hydrobromide 1 SL(1 ea daily); tabs 40 mg MO; GC SL(4.5 ea bupropion hcl tabs 100 mg 1 daily); MO; GC escitalopram oxalate soln 1 MO; GC You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary 16 Updated 09/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits escitalopram oxalate tabs 1 MO; GC DRIZALMA SPRINKLE 3 PA; SL(4 ea CSDR 30 MG daily); MO; GC* MO; GC fluoxetine hcl caps 1 DRIZALMA SPRINKLE 3 PA; SL(3 ea CSDR 40 MG daily); MO; GC* MO; GC fluoxetine hcl cpdr 1 DRIZALMA SPRINKLE 3 PA; SL(2 ea CSDR 60 MG daily); MO; GC* fluoxetine hcl soln 1 MO; GC duloxetine hcl cpep 20 mg, 1 MO; GC 60 mg, 30 mg fluoxetine hcl tabs 1 MO; GC FETZIMA CP24 120 MG, 3 ST; QL(1 ea 40 MG, 80 MG daily); MO; GC* fluvoxamine maleate cp24 1 MO; GC FETZIMA CP24 20 MG 3 ST; QL(2 ea daily); MO; GC* fluvoxamine maleate tabs 1 MO; GC FETZIMA TITRATION 3 ST; MO; GC* paroxetine hcl tabs 1 MO; GC PACK C4PK venlafaxine hcl cp24 150 1 SL(1.5 ea paroxetine hcl tb24 1 MO; GC mg daily); MO; GC venlafaxine hcl cp24 37.5 1 SL(6 ea daily); PAXIL SUSP 10 MG/5ML 3 MO; GC* mg MO; GC SL(3 ea daily); ST; MO; GC* venlafaxine hcl cp24 75 mg 1 PEXEVA TABS 3 MO; GC MO; GC venlafaxine hcl tabs 100 1 SL(3.75 ea sertraline hcl conc 1 mg daily); MO; GC SL(15 ea daily); sertraline hcl tabs 1 MO; GC venlafaxine hcl tabs 25 mg 1 MO; GC Serotonin Modulators venlafaxine hcl tabs 37.5 1 SL(10 ea daily); mg MO; GC nefazodone hcl tabs 1 MO; GC SL(7.5 ea venlafaxine hcl tabs 50 mg 1 daily); MO; GC trazodone hcl tabs 1 MO; GC SL(5 ea daily); venlafaxine hcl tabs 75 mg 1 TRINTELLIX TABS 10 MG 3 ST; QL(2 ea MO; GC daily); MO; GC* venlafaxine hcl tb24 150 1 SL(1.5 ea TRINTELLIX TABS 20 MG 3 ST; QL(1 ea mg daily); MO; GC daily); MO; GC* venlafaxine hcl tb24 225 1 ST; SL(1 ea TRINTELLIX TABS 5 MG 3 ST; QL(4 ea mg daily); MO; GC daily); MO; GC* venlafaxine hcl tb24 37.5 1 SL(6 ea daily); VIIBRYD STARTER PACK 3 ST; MO; GC* mg MO; GC KIT SL(3 ea daily); venlafaxine hcl tb24 75 mg 1 VIIBRYD TABS 3 ST; MO; GC* MO; GC Tricyclic Agents Serotonin-Norepinephrine Reuptake Inhibitors AL(Up to 64 yrs amitriptyline hcl tabs 1 DESVENLAFAXINE ER 3 ST; MO; GC* old); MO; GC TB24 amoxapine tabs 1 MO; GC desvenlafaxine succinate 1 MO; GC tb24 AL(Up to 64 yrs clomipramine hcl caps 1 DRIZALMA SPRINKLE 3 PA; SL(6 ea old); MO; GC CSDR 20 MG daily); MO; GC* You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary Updated 09/01/2021 17 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits desipramine hcl tabs 1 MO; GC alogliptin-pioglitazone tabs PA; SL(1 ea 12.5 mg-45 mg, 15 mg-25 3 daily); MO; GC* AL(Up to 64 yrs mg, 25 mg-30 mg, 25 mg- doxepin hcl caps 1 old); MO; GC 45 mg AL(Up to 64 yrs glipizide-metformin hcl tabs SL(8 ea daily); doxepin hcl conc 1 1 old); MO; GC 2.5 mg-250 mg MO; GC AL(Up to 64 yrs glipizide-metformin hcl tabs SL(4 ea daily); imipramine hcl tabs 1 old); MO; GC 2.5 mg-500 mg, 5 mg-500 1 MO; GC AL(Up to 64 yrs mg imipramine pamoate caps 1 old); MO; GC AL(Up to 64 yrs glyburide-metformin tabs 1 old); SL(8 ea MO; GC 1.25 mg-250 mg nortriptyline hcl caps 1 daily); MO; GC MO; GC glyburide-metformin tabs AL(Up to 64 yrs nortriptyline hcl soln 1 2.5 mg-500 mg, 5 mg-500 1 old); SL(4 ea mg daily); MO; GC protriptyline hcl tabs 1 MO; GC INVOKAMET TABS 150 SL(2 ea daily); AL(Up to 64 yrs MG-1000 MG, 150 MG-500 2 MO; GC* trimipramine maleate caps 1 old); MO; GC MG, 50 MG-1000 MG ANTIDIABETICS - Drugs to Regulate Blood INVOKAMET TABS 50 2 SL(4 ea daily); Sugar MG-500 MG MO; GC* INVOKAMET XR TB24 150 SL(2 ea daily); Alpha-Glucosidase Inhibitors MG-1000 MG, 150 MG-500 2 MO; GC* QL(3 ea daily); acarbose tabs 1 MG, 50 MG-1000 MG MO; GC INVOKAMET XR TB24 50 SL(4 ea daily); QL(3 ea daily); 2 miglitol tabs 1 MG-500 MG MO; GC* MO; GC SL(2 ea daily); JANUMET TABS 2 Antidiabetic - Amylin Analogs MO; GC* PA; Limit 12mls JANUMET XR TB24 100 2 SL(1 ea daily); per MG-1000 MG MO; GC* SYMLINPEN 120 SOPN 4 month;QL(0.4 JANUMET XR TB24 50 SL(2 ea daily); ml daily); MO; MG-1000 MG, 50 MG-500 2 MO; GC* GC* MG PA; Limit 12mls JENTADUETO TABS 2 SL(2 ea daily); per MO; GC* SYMLINPEN 60 SOPN 4 month;QL(0.4 ml daily); MO; JENTADUETO XR TB24 2 SL(2 ea daily); 2.5 MG-1000 MG MO; GC* GC* JENTADUETO XR TB24 5 2 SL(1 ea daily); Antidiabetic Combinations MG-1000 MG MO; GC* alogliptin-metformin hcl PA; SL(2 ea 3 KAZANO TABS (alogliptin- 3 PA; SL(2 ea tabs daily); MO; GC* metformin hcl) daily); MO; GC* alogliptin-pioglitazone tabs PA; SL(2 ea 3 KOMBIGLYZE XR TB24 3 PA; SL(2 ea 12.5 mg-15 mg daily); MO; GC* 2.5 MG-1000 MG daily); MO; GC* alogliptin-pioglitazone tabs 3 PA; SL(1.5 ea KOMBIGLYZE XR TB24 5 PA; SL(1 ea 12.5 mg-30 mg daily); MO; GC* MG-1000 MG, 5 MG-500 3 daily); MO; GC* MG OSENI TABS 12.5 MG-15 3 PA; SL(2 ea MG (alogliptin-pioglitazone) daily); MO; GC* You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary 18 Updated 09/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits OSENI TABS 12.5 MG-30 3 PA; SL(1.5 ea BAQSIMI TWO PACK 3 MO; GC* MG (alogliptin-pioglitazone) daily); MO; GC* POWD OSENI TABS 12.5 MG-45 PA; SL(1 ea diazoxide susp 1 MO; GC MG, 15 MG-25 MG, 25 3 daily); MO; GC* MG-30 MG, 25 MG-45 MG GLUCAGEN HYPOKIT 2 MO; GC* (alogliptin-pioglitazone) SOLR pioglitazone hcl-glimepiride 1 SL(1.5 ea glucagon (rdna) kit 1 MO; GC tabs daily); MO; GC GVOKE HYPOPEN 1- MO; GC* pioglitazone hcl-metformin 1 SL(3 ea daily); 3 hcl tabs MO; GC PACK SOAJ SYNJARDY TABS 12.5 SL(2 ea daily); GVOKE HYPOPEN 2- 3 MO; GC* MG-1000 MG, 5 MG-1000 2 MO; GC* PACK SOAJ MG GVOKE PFS SOSY 3 MO; GC* SYNJARDY TABS 12.5 SL(4 ea daily); MG-500 MG, 5 MG-500 2 MO; GC* PA; SL(4 ea MG KORLYM TABS 3 daily); LA; MO; SYNJARDY XR TB24 10 SL(2 ea daily); GC* MG-1000 MG, 12.5 MG- 2 MO; GC* Dipeptidyl Peptidase-4 (DPP-4) Inhibitors 1000 MG, 5 MG-1000 MG alogliptin benzoate tabs 3 PA; QL(2 ea SYNJARDY XR TB24 25 2 SL(1 ea daily); 12.5 mg daily); MO; GC* MG-1000 MG MO; GC* alogliptin benzoate tabs 25 3 PA; QL(1 ea XIGDUO XR TB24 10 MG- 3 SL(1 ea daily); mg daily); MO; GC* 1000 MG, 10 MG-500 MG MO; GC* alogliptin benzoate tabs 3 PA; QL(4 ea XIGDUO XR TB24 2.5 MG- SL(2 ea daily); 6.25 mg daily); MO; GC* 1000 MG, 5 MG-1000 MG, 3 MO; GC* JANUVIA TABS 100 MG 2 QL(1 ea daily); 5 MG-500 MG MO; GC* Biguanides JANUVIA TABS 25 MG 2 QL(4 ea daily); MO; GC* metformin hcl soln 500 1 SL(25.5 ml mg/5ml daily); MO; GC JANUVIA TABS 50 MG 2 QL(2 ea daily); MO; GC* metformin hcl tabs 1000 1 SL(2.55 ea mg daily); MO; GC NESINA TABS 12.5 MG 3 PA; QL(2 ea SL(5.1 ea (alogliptin benzoate) daily); MO; GC* metformin hcl tabs 500 mg 1 daily); MO; GC NESINA TABS 25 MG 3 PA; QL(1 ea SL(3 ea daily); (alogliptin benzoate) daily); MO; GC* metformin hcl tabs 850 mg 1 MO; GC NESINA TABS 6.25 MG 3 PA; QL(4 ea (GLUCOPHAG (alogliptin benzoate) daily); MO; GC* metformin hcl tb24 500 mg 1 E XR);SL(4 ea ONGLYZA TABS 2.5 MG 3 PA; QL(2 ea daily); MO; GC daily); MO; GC* (GLUCOPHAG PA; QL(1 ea ONGLYZA TABS 5 MG 3 1 E XR);SL(2.66 daily); MO; GC* metformin hcl tb24 750 mg ea daily); MO; GC TRADJENTA TABS 2 QL(1 ea daily); MO; GC* Diabetic Other Dopamine Receptor Agonists - Antidiabetic BAQSIMI ONE PACK 3 MO; GC* POWD CYCLOSET TABS 3 QL(6 ea daily); MO; GC* You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary Updated 09/01/2021 19 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Incretin Mimetic Agents (GLP-1 Receptor Limit 45mls per HUMALOG KWIKPEN month;QL(1.5 MO; GC* 2 BYDUREON BCISE AUIJ 2 SOPN ml daily); MO; GC* GC* BYDUREON PEN PEN 2 Limit 45mls per MO; GC* HUMALOG MIX 50/50 2 month;QL(1.5 BYETTA SOPN 3 KWIKPEN SUPN ml daily); MO; GC* OZEMPIC SOPN 2 2 1MG/Dose; MG/1.5ML GC* Limit 45mls per HUMALOG MIX 50/50 month;QL(1.5 OZEMPIC SOPN 2 2 MO; GC* 2 MG/1.5ML, 4 MG/3ML SUSP ml daily); MO; GC* MO; GC* RYBELSUS TABS 2 Limit 45mls per HUMALOG MIX 75/25 2 month;QL(1.5 TRULICITY SOPN 2 MO; GC* KWIKPEN SUPN ml daily); MO; GC* Limit 9mls per month;QL(0.3 Limit 45mls per VICTOZA SOPN 2 ml daily); MO; HUMALOG MIX 75/25 2 month;QL(1.5 GC* SUSP ml daily); MO; GC* Insulin Sensitizing Agents Limit 45mls per SL(4 ea daily); AVANDIA TABS 2 MG 2 2 month;QL(1.5 MO; GC* HUMALOG SOCT ml daily); MO; SL(2 ea daily); GC* AVANDIA TABS 4 MG 2 MO; GC* Limit 45mls per SL(3 ea daily); month;QL(1.5 pioglitazone hcl tabs 15 mg 1 HUMALOG SOLN 2 MO; GC ml daily); MO; SL(1.5 ea GC* pioglitazone hcl tabs 30 mg 1 daily); MO; GC Limit 45mls per SL(1 ea daily); HUMULIN 70/30 KWIKPEN month;QL(1.5 pioglitazone hcl tabs 45 mg 1 2 MO; GC SUPN ml daily); MO; GC* Insulin Limit 45mls per QL(18 ea AFREZZA POWD 12 UNIT, 5^ 2 month;QL(1.5 daily); MO; GC* HUMULIN 70/30 SUSP ml daily); MO; GC* AFREZZA POWD 4 UNIT, 3 QL(18 ea 8 UNIT, daily); MO; GC* Limit 45mls per Limit 45mls per HUMULIN N KWIKPEN 2 month;QL(1.5 SUPN ml daily); MO; 3 month;QL(1.5 APIDRA SOLN ml daily); MO; GC* GC* Limit 45mls per Limit 45mls per 2 month;QL(1.5 HUMULIN N SUSP ml daily); MO; APIDRA SOLOSTAR 3 month;QL(1.5 SOPN ml daily); MO; GC* GC* Limit 45mls per Limit 45mls per 2 month;QL(1.5 HUMULIN R SOLN ml daily); MO; HUMALOG JUNIOR 2 month;QL(1.5 KWIKPEN SOPN ml daily); MO; GC* GC* You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary 20 Updated 09/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 45mls per Limit 45mls per HUMULIN R U-500 2 month;QL(1.5 LANTUS SOLOSTAR 2 month;QL(1.5 (CONCENTRATED) SOLN ml daily); MO; SOPN ml daily); MO; GC* GC* Limit 45mls per Limit 45mls per HUMULIN R U-500 2 month;QL(1.5 LEVEMIR FLEXTOUCH 2 month;QL(1.5 KWIKPEN SOPN ml daily); MO; SOPN ml daily); MO; GC* GC* Limit 45mls per Limit 45mls per INSULIN ASPART month;QL(1.5 3 LEVEMIR SOLN 2 month;QL(1.5 FLEXPEN SOPN ml daily); MO; ml daily); MO; GC* GC* Limit 45mls per Limit 45mls per INSULIN ASPART 3 month;QL(1.5 NOVOLIN 70/30 FLEXPEN 3 month;QL(1.5 PENFILL SOCT ml daily); MO; RELION SUPN ml daily); MO; GC* GC* Limit 45mls per Limit 45mls per INSULIN ASPART PROTAMINE/INSULIN 3 month;QL(1.5 NOVOLIN 70/30 FLEXPEN 3 month;QL(1.5 ml daily); MO; SUPN ml daily); MO; ASPART FLEXPEN SUPN GC* GC* Limit 45mls per Limit 45mls per INSULIN ASPART PROTAMINE/INSULIN 3 month;QL(1.5 NOVOLIN 70/30 RELION 3 month;QL(1.5 ml daily); MO; SUSP ml daily); MO; ASPART SUSP GC* GC* Limit 45mls per Limit 45mls per INSULIN ASPART SOLN 3 month;QL(1.5 3 month;QL(1.5 ml daily); MO; NOVOLIN 70/30 SUSP ml daily); MO; GC* GC* Limit 45mls per Limit 45mls per INSULIN LISPRO JUNIOR 2 month;QL(1.5 NOVOLIN N FLEXPEN 3 month;QL(1.5 KWIKPEN SOPN ml daily); MO; RELION SUPN ml daily); MO; GC* GC* Limit 45mls per Limit 45mls per INSULIN LISPRO 2 month;QL(1.5 NOVOLIN N FLEXPEN 3 month;QL(1.5 KWIKPEN SOPN ml daily); MO; SUPN ml daily); MO; GC* GC* Limit 45mls per Limit 45mls per INSULIN LISPRO PROTAMINE/INSULIN 2 month;QL(1.5 NOVOLIN N RELION 3 month;QL(1.5 ml daily); MO; SUSP ml daily); MO; LISPRO KWIKPEN SUPN GC* GC* Limit 45mls per Limit 45mls per INSULIN LISPRO SOLN 2 month;QL(1.5 3 month;QL(1.5 ml daily); MO; NOVOLIN N SUSP ml daily); MO; GC* GC* Limit 45mls per NOVOLIN R FLEXPEN 3 QL(1.5 ml 2 month;QL(1.5 RELION SOPN daily); MO; GC* LANTUS SOLN ml daily); MO; GC* You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary Updated 09/01/2021 21 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 45mls per Limit 15mls per NOVOLIN R FLEXPEN 3 month;QL(1.5 TOUJEO MAX SOLOSTAR 2 month;QL(0.5 SOPN ml daily); MO; SOPN ml daily); MO; GC* GC* Limit 45mls per Limit 15mls per NOVOLIN R RELION 3 month;QL(1.5 TOUJEO SOLOSTAR 2 month;QL(0.5 SOLN ml daily); MO; SOPN ml daily); MO; GC* GC* Limit 45mls per Limit 45mls per month;QL(1.5 TRESIBA FLEXTOUCH month;QL(1.5 NOVOLIN R SOLN 3 2 ml daily); MO; SOPN 100 UNIT/ML ml daily); MO; GC* GC* Limit 45mls per Limit 27mls per NOVOLOG FLEXPEN 3 month;QL(1.5 TRESIBA FLEXTOUCH 2 month;QL(0.9 RELION SOPN ml daily); MO; SOPN 200 UNIT/ML ml daily); MO; GC* GC* Limit 45mls per Limit 45mls per NOVOLOG FLEXPEN month;QL(1.5 month;QL(1.5 3 TRESIBA SOLN 2 SOPN ml daily); MO; ml daily); MO; GC* GC* NOVOLOG MIX 70/30 Limit 45mls per Meglitinide Analogues 3 month;QL(1.5 QL(3 ea daily); PREFILLED FLEXPEN ml daily); MO; nateglinide tabs 1 RELION SUPN MO; GC GC* 1 SL(32 ea daily); Limit 45mls per repaglinide tabs 0.5 mg MO; GC NOVOLOG MIX 70/30 month;QL(1.5 PREFILLED FLEXPEN 3 SL(16 ea daily); SUPN ml daily); MO; repaglinide tabs 1 mg 1 GC* MO; GC SL(8 ea daily); Limit 45mls per repaglinide tabs 2 mg 1 MO; GC NOVOLOG MIX 70/30 3 month;QL(1.5 RELION SUSP ml daily); MO; Sodium-Glucose Co-Transporter 2 (SGLT2) GC* MO; GC* Limit 45mls per FARXIGA TABS 3 NOVOLOG MIX 70/30 3 month;QL(1.5 MO; GC* SUSP ml daily); MO; INVOKANA TABS 2 GC* MO; GC* Limit 45mls per JARDIANCE TABS 2 NOVOLOG PENFILL month;QL(1.5 3 Sulfonylureas SOCT ml daily); MO; GC* AL(Up to 64 yrs glimepiride tabs 1 mg 1 old); SL(8 ea Limit 45mls per daily); MO; GC 3 month;QL(1.5 NOVOLOG RELION SOLN ml daily); MO; AL(Up to 64 yrs GC* glimepiride tabs 2 mg 1 old); SL(4 ea daily); MO; GC Limit 45mls per AL(Up to 64 yrs 3 month;QL(1.5 NOVOLOG SOLN ml daily); MO; glimepiride tabs 4 mg 1 old); SL(2 ea GC* daily); MO; GC You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary 22 Updated 09/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SL(4 ea daily); glipizide tabs 10 mg 1 Antidotes - Chelating Agents MO; GC MO; GC* SL(8 ea daily); CHEMET CAPS 3 glipizide tabs 5 mg 1 MO; GC deferasirox pack 5^ GC* SL(2 ea daily); glipizide tb24 10 mg 1 MO; GC deferasirox tabs 5^ GC* SL(8 ea daily); glipizide tb24 2.5 mg 1 MO; GC deferasirox tbso 5^ GC* SL(4 ea daily); glipizide tb24 5 mg 1 PA; LA; MO; MO; GC deferiprone tabs 5^ GC* AL(Up to 64 yrs glyburide micronized tabs 1 old); SL(8 ea FERRIPROX TABS 1000 PA; LA; MO; 1.5 mg 5^ daily); MO; GC MG GC* AL(Up to 64 yrs FERRIPROX TWICE-A- 5^ PA; MO; GC* glyburide micronized tabs 3 1 old); SL(4 ea DAY TABS mg daily); MO; GC Antidotes and Specific Antagonists AL(Up to 64 yrs MO; GC* glyburide micronized tabs 6 1 old); SL(2 ea VISTOGARD PACK 5^ mg daily); MO; GC Opioid Antagonists AL(Up to 64 yrs glyburide tabs 1.25 mg 1 old); SL(16 ea EVZIO SOAJ 3 PA; GC* daily); MO; GC naloxone hcl soaj 2 1 PA; GC AL(Up to 64 yrs mg/0.4ml glyburide tabs 2.5 mg 1 old); SL(8 ea daily); MO; GC naloxone hcl sosy 2 1 GC mg/2ml AL(Up to 64 yrs glyburide tabs 5 mg 1 old); SL(4 ea naltrexone hcl tabs 1 MO; GC daily); MO; GC 1box=15DS, SL(6 ea daily); tolbutamide tabs 1 2boxes=30DS, MO; GC Max 4 NARCAN LIQD 3 ANTIDIARRHEAL/PROBIOTIC AGENTS - Drugs ea/month;QL(0. to Treat Diarrhea 134 ea daily); MO; GC* Antidiarrheal - Chloride Channel Antagonists ANTIEMETICS - Drugs to Treat Nausea and MYTESI TBEC 3 PA; QL(2 ea daily); MO; GC* Vomiting Antiperistaltic Agents 5-HT3 Receptor Antagonists granisetron hcl tabs or 1 B/D; MO; GC diphenoxylate w/ atropine 1 MO; GC 1 tabs 0.025 mg-2.5 mg mg RX/OTC; MO; ondansetron hcl soln ij 40 MO; GC* loperamide hcl caps 1 4 GC mg/20ml, 4 mg/2ml MO; GC* ondansetron hcl soln or 4 1 MO; GC MOTOFEN TABS 3 mg/5ml MO; GC ondansetron hcl tabs or 24 1 GC opium tincture tinc 1 mg ANTIDOTES AND SPECIFIC ANTAGONISTS ondansetron hcl tabs or 4 1 MO; GC mg, 8 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary Updated 09/01/2021 23 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ondansetron tbdp 1 MO; GC amphotericin b solr 4 PA; MO; GC* SANCUSO PTCH 5^ MO; GC* flucytosine caps 1 MO; GC Antiemetics - Anticholinergic griseofulvin microsize susp 1 MO; GC meclizine hcl tabs 12.5 mg, 1 RX/OTC; MO; 25 mg GC griseofulvin microsize tabs 1 MO; GC MO; GC scopolamine pt72 1 griseofulvin ultramicrosize 1 MO; GC tabs TIGAN SOLN IM 100 4 MO; GC* MG/ML nystatin tabs 1 MO; GC trimethobenzamide hcl 1 MO; GC MO; GC caps terbinafine hcl tabs 1 Antiemetics - Miscellaneous Imidazole-Related Antifungals AKYNZEO CAPS OR 0.5 B/D; GC* 3 CRESEMBA CAPS OR 5^ MO; GC* MG-300 MG 186 MG SL(2 ea daily); BONJESTA TBCR 3 CRESEMBA SOLR IV 372 5^ GC* MO; GC* MG B/D; MO; GC dronabinol caps 1 fluconazole in nacl soln 4 GC* B/D; MO; GC* SYNDROS SOLN 5^ fluconazole susr 1 MO; GC Substance P/Neurokinin 1 (NK1) Receptor fluconazole tabs 1 MO; GC aprepitant caps 125 mg, 80 1 B/D; MO; GC mg itraconazole caps 100 mg 1 MO; GC aprepitant caps 40 mg 1 PA; MO; GC itraconazole soln 10 mg/ml 5^ MO; GC* aprepitant misc 1 B/D; MO; GC ketoconazole tabs 1 MO; GC VARUBI TBPK 3 B/D; GC* NOXAFIL SOLN IV 300 5^ GC* MG/16.7ML ANTIFUNGALS - Drugs to Treat Fungal Infections NOXAFIL SUSP OR 40 5^ MO; GC* MG/ML Antifungal - Glucan Synthesis Inhibitors posaconazole tbec 5^ MO; GC* ERAXIS SOLR 4 GC* TOLSURA CAPS 5^ PA; MO; GC* micafungin sodium solr 100 5^ GC* mg voriconazole solr iv 200 mg 1 PA; GC micafungin sodium solr 50 5^ MO; GC* mg voriconazole susr or 40 1 QL(20 ml Antifungals mg/ml daily); MO; GC PA; GC* voriconazole tabs or 200 5^ QL(4 ea daily); ABELCET SUSP 4 mg MO; GC* PA; GC* QL(4 ea daily); AMBISOME SUSR 4 voriconazole tabs or 50 mg 1 MO; GC You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary 24 Updated 09/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ezetimibe-simvastatin tabs 1 QL(4 ea daily); ANTIHISTAMINES - Drugs to Treat Allergies 10 mg-20 mg MO; GC Antihistamines - Ethanolamines ezetimibe-simvastatin tabs 1 QL(2 ea daily); 10 mg-40 mg MO; GC carbinoxamine maleate 1 AL(Up to 64 yrs soln 4 mg/5ml old); MO; GC ezetimibe-simvastatin tabs 1 QL(1 ea daily); 10 mg-80 mg MO; GC carbinoxamine maleate 1 AL(Up to 64 yrs tabs 4 mg old); MO; GC Antihyperlipidemics - Misc. clemastine fumarate tabs 1 AL(Up to 64 yrs ST; MO; GC 2.68 mg old); MO; GC icosapent ethyl caps 1 diphenhydramine hcl soln 4 MO; GC* omega-3-acid ethyl esters 1 MO; GC caps Antihistamines - Non-Sedating VASCEPA CAPS 0.5 GM 3 ST; MO; GC* cetirizine hcl soln 1 mg/ml, 1 RX/OTC; MO; 5 mg/5ml GC Bile Acid Sequestrants desloratadine tabs 5 mg 1 MO; GC cholestyramine light pack 1 MO; GC desloratadine tbdp 5 mg 1 MO; GC cholestyramine light powd 1 MO; GC levocetirizine RX/OTC; MO; cholestyramine pack 1 MO; GC dihydrochloride soln 2.5 1 GC mg/5ml cholestyramine powd 1 MO; GC levocetirizine 1 RX/OTC; MO; dihydrochloride tabs 5 mg GC colesevelam hcl pack 1 MO; GC Antihistamines - Phenothiazines colesevelam hcl tabs 1 MO; GC promethazine hcl soln ij 50 4 AL(Up to 64 yrs mg/ml, 25 mg/ml old); MO; GC* colestipol hcl gran 1 MO; GC promethazine hcl soln or 1 AL(Up to 64 yrs 6.25 mg/5ml old); MO; GC colestipol hcl pack 1 MO; GC promethazine hcl supp re 1 AL(Up to 64 yrs 12.5 mg, 25 mg old); MO; GC colestipol hcl tabs 1 MO; GC promethazine hcl syrp or 1 AL(Up to 64 yrs 6.25 mg/5ml old); MO; GC Fibric Acid Derivatives SL(4.33 ea promethazine hcl tabs or 1 AL(Up to 64 yrs ANTARA CAPS 30 MG 3 25 mg, 12.5 mg, 50 mg old); MO; GC daily); MO; GC* Antihistamines - Piperidines ANTARA CAPS 90 MG 3 SL(1.44 ea daily); MO; GC* AL(Up to 64 yrs cyproheptadine hcl syrp 1 old); MO; GC choline fenofibrate cpdr 1 MO; GC AL(Up to 64 yrs cyproheptadine hcl tabs 1 old); MO; GC fenofibrate caps 150 mg, 1 MO; GC 50 mg ANTIHYPERLIPIDEMICS - Drugs to Treat High fenofibrate micronized caps 1 SL(1 ea daily); Cholesterol 130 mg MO; GC Antihyperlipidemics - Combinations fenofibrate micronized caps 1 MO; GC 134 mg, 200 mg, 67 mg ezetimibe-simvastatin tabs 1 QL(8 ea daily); 10 mg-10 mg MO; GC fenofibrate micronized caps 1 SL(3.02 ea 43 mg daily); MO; GC You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary Updated 09/01/2021 25 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits fenofibrate tabs 120 mg, 40 MO; GC PA; SL(12 ea mg, 145 mg, 48 mg, 54 mg, 1 JUXTAPID CAPS 5 MG 5^ daily); LA; MO; 160 mg GC* gemfibrozil tabs 1 MO; GC Nicotinic Acid Derivatives niacin (antihyperlipidemic) MO; GC LIPOFEN CAPS 3 MO; GC* tbcr 1000 mg, 500 mg, 750 1 (fenofibrate) mg HMG CoA Reductase Inhibitors Proprotein Convertase Subtilisin/Kexin Type 9 ALTOPREV TB24 3 MO; GC* PA; Limit 2mls per 28 PRALUENT SOAJ 150 atorvastatin calcium tabs 1 MO; GC 4 days;SL(0.08 MG/ML ml daily); MO; fluvastatin sodium caps 20 1 QL(3 ea daily); GC* mg MO; GC PA; Limit 4mls fluvastatin sodium caps 40 1 QL(2 ea daily); per 28 mg MO; GC PRALUENT SOAJ 75 4 days;SL(0.15 MG/ML ml daily); MO; fluvastatin sodium tb24 80 1 MO; GC mg GC* LIVALO TABS 3 MO; GC* REPATHA PUSHTRONEX 4 PA; MO; GC* SYSTEM SOCT lovastatin tabs 10 mg, 20 1 QL(1 ea daily); PA; MO; GC* mg MO; GC REPATHA SOSY 4 QL(2 ea daily); REPATHA SURECLICK PA; MO; GC* lovastatin tabs 40 mg 1 4 MO; GC SOAJ QL(1 ea daily); pravastatin sodium tabs 1 ANTIHYPERTENSIVES - Drugs to Treat High MO; GC Blood Pressure QL(1 ea daily); rosuvastatin calcium tabs 1 ACE Inhibitors MO; GC benazepril hcl tabs 1 MO; GC simvastatin tabs 5 mg, 10 1 QL(1 ea daily); mg, 20 mg, 40 mg MO; GC MO; GC SL(1 ea daily); captopril tabs 1 simvastatin tabs 80 mg 1 MO; GC enalapril maleate tabs 10 1 SL(4 ea daily); Intestinal Cholesterol Absorption Inhibitors mg MO; GC QL(1 ea daily); enalapril maleate tabs 2.5 SL(16 ea daily); ezetimibe tabs 1 1 MO; GC mg MO; GC Microsomal Triglyceride Transfer Protein (MTP) enalapril maleate tabs 20 1 SL(2 ea daily); mg MO; GC PA; SL(6 ea SL(8 ea daily); JUXTAPID CAPS 10 MG 5^ daily); LA; MO; enalapril maleate tabs 5 mg 1 GC* MO; GC PA; SL(3 ea fosinopril sodium tabs 1 MO; GC JUXTAPID CAPS 20 MG 5^ daily); LA; MO; GC* lisinopril tabs 1 MO; GC PA; SL(2 ea JUXTAPID CAPS 30 MG 5^ daily); LA; MO; moexipril hcl tabs 1 MO; GC GC* You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary 26 Updated 09/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits perindopril erbumine tabs 2 1 SL(8 ea daily); Antihypertensive Combinations mg MO; GC amlodipine besylate- 1 MO; GC perindopril erbumine tabs 4 1 SL(4 ea daily); benazepril hcl caps mg MO; GC amlodipine besylate- 1 MO; GC perindopril erbumine tabs 8 1 SL(2 ea daily); olmesartan medoxomil tabs MO; GC mg amlodipine besylate- SL(1 ea daily); MO; GC quinapril hcl tabs 1 valsartan tabs 10 mg-160 1 MO; GC mg, 10 mg-320 mg, 5 mg- ramipril caps 1 MO; GC 320 mg amlodipine besylate- SL(2 ea daily); trandolapril tabs 1 MO; GC valsartan tabs 5 mg-160 1 MO; GC mg Agents for Pheochromocytoma amlodipine-valsartan- SL(1 ea daily); metyrosine caps 5^ MO; GC* hydrochlorothiazide tabs 10 MO; GC mg-12.5 mg-160 mg, 10 1 mg-25 mg-160 mg, 10 mg- phenoxybenzamine hcl 1 MO; GC caps 25 mg-320 mg, 5 mg-25 mg-160 mg Angiotensin II Receptor Antagonists amlodipine-valsartan- SL(2 ea daily); candesartan cilexetil tabs 1 MO; GC hydrochlorothiazide tabs 5 1 MO; GC mg-12.5 mg-160 mg QL(1 ea daily); EDARBI TABS 3 MO; GC* atenolol & chlorthalidone 1 MO; GC tabs irbesartan tabs 1 MO; GC benazepril & 1 MO; GC hydrochlorothiazide tabs losartan potassium tabs or 1 MO; GC 100 mg, 25 mg, 50 mg bisoprolol & 1 MO; GC hydrochlorothiazide tabs olmesartan medoxomil tabs 1 MO; GC candesartan cilexetil- 1 MO; GC hydrochlorothiazide tabs telmisartan tabs 1 MO; GC QL(1 ea daily); EDARBYCLOR TABS 3 valsartan tabs 1 MO; GC MO; GC* enalapril maleate & 1 MO; GC Antiadrenergic Antihypertensives hydrochlorothiazide tabs MO; GC fosinopril sodium & 1 MO; GC clonidine hcl tabs 1 hydrochlorothiazide tabs MO; GC clonidine ptwk 1 irbesartan- 1 MO; GC hydrochlorothiazide tabs MO; GC doxazosin mesylate tabs 1 lisinopril & 1 MO; GC hydrochlorothiazide tabs AL(Up to 64 yrs guanfacine hcl tabs 1 losartan potassium & 1 MO; GC old); MO; GC hydrochlorothiazide tabs AL(Up to 64 yrs methyldopa tabs 1 metoprolol & 1 MO; GC old); MO; GC hydrochlorothiazide tabs prazosin hcl caps 1 MO; GC olmesartan medoxomil- MO; GC amlodipine- 1 terazosin hcl caps 1 MO; GC hydrochlorothiazide tabs You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary Updated 09/01/2021 27 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits olmesartan medoxomil- 1 MO; GC hydroxychloroquine sulfate 1 MO; GC hydrochlorothiazide tabs tabs MO; GC propranolol & 1 KRINTAFEL TABS 3 QL(0.14 ea hydrochlorothiazide tabs daily); GC* quinapril- 1 MO; GC mefloquine hcl tabs 1 MO; GC hydrochlorothiazide tabs MO; GC TEKTURNA HCT TABS 2 MO; GC* primaquine phosphate tabs 1 MO; GC PRIMAQUINE MO; GC* telmisartan-amlodipine tabs 1 PHOSPHATE TABS 3 (primaquine phosphate) telmisartan- 1 MO; GC hydrochlorothiazide tabs pyrimethamine tabs 1 MO; GC trandolapril-verapamil hcl MO; GC tbcr 2 mg-240 mg, 4 mg- 1 quinine sulfate caps 1 PA; MO; GC 240 mg valsartan- SL(2 ea daily); ANTIMYASTHENIC/CHOLINERGIC AGENTS hydrochlorothiazide tabs 1 MO; GC 12.5 mg-160 mg, 12.5 mg- Antimyasthenic/Cholinergic Agents 80 mg PA; SL(8 ea valsartan- SL(1 ea daily); FIRDAPSE TABS 5^ daily); LA; MO; GC* hydrochlorothiazide tabs 1 MO; GC 12.5 mg-320 mg, 25 mg- GC* 160 mg, 25 mg-320 mg GUANIDINE HCL TABS 2 Direct Renin Inhibitors pyridostigmine bromide 1 MO; GC tabs 60 mg aliskiren fumarate tabs 1 MO; GC pyridostigmine bromide tbcr 1 MO; GC 180 mg Selective Aldosterone Receptor Antagonists RUZURGI TABS 5^ PA; SL(10 ea eplerenone tabs 1 MO; GC daily); MO; GC* Vasodilators ANTIMYCOBACTERIAL AGENTS - Drugs to Treat Tuberculosis (Bacterial Infections) hydralazine hcl tabs or 100 1 MO; GC mg, 25 mg, 50 mg, 10 mg Antimycobacterial Agents minoxidil tabs 1 MO; GC CAPASTAT SULFATE 4 GC* SOLR ANTIMALARIALS - Drugs to Treat Malaria ethambutol hcl tabs 1 MO; GC (Parasitic Infections) isoniazid tabs or 100 mg, 1 MO; GC Antimalarial Combinations 300 mg atovaquone-proguanil hcl 1 MO; GC MO; GC* tabs PASER PACK 3 MO; GC* COARTEM TABS 3 PRETOMANID TABS 3 PA; GC* Antimalarials PRIFTIN TABS 3 MO; GC* chloroquine phosphate 1 MO; GC tabs 250 mg, 500 mg pyrazinamide tabs 1 MO; GC You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary 28 Updated 09/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits rifabutin caps 5^ MO; GC* melphalan tabs 1 B/D; MO; GC rifampin caps or 150 mg, 1 MO; GC oxaliplatin soln 200 1 GC 300 mg mg/40ml, 100 mg/20ml rifampin solr iv 600 mg 4 GC* oxaliplatin soln 50 mg/10ml 4 GC* SIRTURO TABS 5^ LA; GC* oxaliplatin solr 100 mg, 50 5^ GC* mg MO; GC* TRECATOR TABS 3 PEPAXTO SOLR 5^ MO; GC* ANTINEOPLASTICS AND ADJUNCTIVE TEMODAR SOLR 5^ GC* THERAPIES - Drugs to Treat Cancer GC* Alkylating Agents thiotepa solr 15 mg 5^ GC* BENDEKA SOLN 5^ TREANDA SOLR 5^ GC* GC* busulfan soln 4 YONDELIS SOLR 5^ LA; GC* carboplatin soln 1000 4 GC* MO; GC* mg/100ml ZANOSAR SOLR 4 carboplatin soln 450 GC Antimetabolites mg/45ml, 50 mg/5ml, 600 1 mg/60ml, 150 mg/15ml ALIMTA SOLR 5^ GC* GC* carmustine solr 4 ARRANON SOLN 5^ GC* cisplatin soln 100 GC* GC* mg/100ml, 200 mg/200ml, 4 azacitidine susr 5^ 50 mg/50ml cladribine soln 4 PA; GC* cyclophosphamide caps or 1 B/D; MO; GC 25 mg, 50 mg clofarabine soln 4 GC* CYCLOPHOSPHAMIDE GC* SOLN IV 1 GM/5ML, 500 5^ PA; GC* MG/2.5ML cytarabine soln 4 GC CYCLOPHOSPHAMIDE 3 B/D; GC* decitabine solr 1 TABS OR 25 MG, 50 MG GC* fludarabine phosphate solr 1 GC EVOMELA SOLR 5^ 50 mg IFEX SOLR 3 GM 4 GC* fluorouracil soln 4 PA; GC* GC* ifosfamide soln 1 gm/20ml, 4 GC* FOLOTYN SOLN 5^ 3 gm/60ml GC* gemcitabine hcl soln 1 GC ifosfamide solr 1 gm 4 gm/10ml, 2 gm/20ml, 200 1 mg/2ml IFOSFAMIDE SOLR 3 GM 4 GC* gemcitabine hcl soln 1 GC* MO; GC* gm/26.3ml, 2 gm/52.6ml, 5^ LEUKERAN TABS 3 200 mg/5.26ml melphalan hcl solr 4 GC* You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary Updated 09/01/2021 29 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits gemcitabine hcl solr 2 gm, 1 GC LENVIMA 8 MG DAILY 5^ PA; GC* 1 gm DOSE CPPK gemcitabine hcl solr 200 4 GC* MVASI SOLN 5^ GC* mg PA; GC* INFUGEM SOLN 5^ GC* ZALTRAP SOLN 5^ GC* mercaptopurine tabs 1 MO; GC ZIRABEV SOLN 5^ methotrexate sodium soln ij 4 GC* Antineoplastic - Anti-HER2 Agents 1 gm/40ml HERCEPTIN SOLR 5^ PA; GC* methotrexate sodium soln ij 4 MO; GC* 250 mg/10ml, 50 mg/2ml KANJINTI SOLR 5^ PA; GC* methotrexate sodium solr ij 4 GC* 1 gm OGIVRI SOLR 5^ GC* methotrexate sodium tabs 1 MO; GC or 2.5 mg PERJETA SOLN 5^ GC* ONUREG TABS 5^ PA; GC* TRAZIMERA SOLR 420 5^ GC* MG PURIXAN SUSP 5^ PA; GC* TUKYSA TABS 5^ PA; MO; GC* TABLOID TABS 2 MO; GC* Antineoplastic - Antibodies MO; GC* TREXALL TABS 3 ARZERRA CONC 5^ GC* PA; MO; GC* XATMEP SOLN 3 BAVENCIO SOLN 5^ GC* Antineoplastic - Angiogenesis Inhibitors BESPONSA SOLR 5^ GC* AVASTIN SOLN 5^ PA; GC* BLENREP SOLR 5^ MO; GC* CYRAMZA SOLN 5^ LA; GC* BLINCYTO SOLR 5^ GC* INLYTA TABS 5^ PA; GC* DARZALEX SOLN 5^ GC* LENVIMA 10 MG DAILY 5^ PA; GC* DOSE CPPK EMPLICITI SOLR 5^ GC* LENVIMA 12MG DAILY 5^ PA; GC* DOSE CPPK ENHERTU SOLR 5^ GC* LENVIMA 14 MG DAILY 5^ PA; GC* GC* DOSE CPPK GAZYVA SOLN 5^ LENVIMA 18 MG DAILY 5^ PA; GC* GC* DOSE CPPK IMFINZI SOLN 5^ GC* LENVIMA 20 MG DAILY 5^ PA; GC* JEMPERLI SOLN 5^ DOSE CPPK PA; GC* LENVIMA 24 MG DAILY 5^ PA; GC* KADCYLA SOLR 5^ DOSE CPPK PA; GC* LENVIMA 4 MG DAILY 5^ PA; GC* KEYTRUDA SOLN 5^ DOSE CPPK You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary 30 Updated 09/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LIBTAYO SOLN 5^ MO; GC* PORTRAZZA SOLN 5^ GC* LUMOXITI SOLR 5^ GC* TAGRISSO TABS 5^ PA; GC* MONJUVI SOLR 5^ MO; GC* VECTIBIX SOLN 5^ GC* MYLOTARG SOLR 5^ GC* VIZIMPRO TABS 5^ PA; GC* OPDIVO SOLN 5^ GC* Antineoplastic - Hedgehog Pathway Inhibitors DAURISMO TABS 5^ PA; GC* PADCEV SOLR 20 MG 5^ SL(7 ea daily); GC* ERIVEDGE CAPS 5^ LA; GC* PADCEV SOLR 30 MG 5^ SL(5 ea daily); GC* ODOMZO CAPS 5^ PA; LA; GC* POLIVY SOLR 5^ GC* Antineoplastic - Hormonal and Related Agents POTELIGEO SOLN 5^ GC* abiraterone acetate tabs 5^ PA; GC* RITUXAN SOLN 5^ PA; GC* anastrozole tabs 1 MO; GC RUXIENCE SOLN 5^ GC* bicalutamide tabs 1 MO; GC RYBREVANT SOLN 5^ GC* ELIGARD KIT 4 GC* SARCLISA SOLN 5^ GC* EMCYT CAPS 3 MO; GC* TECENTRIQ SOLN 5^ PA; GC* ERLEADA TABS 5^ PA; GC* TRUXIMA SOLN 5^ PA; GC* exemestane tabs 1 MO; GC YERVOY SOLN 5^ PA; GC* FIRMAGON SOLR 120 5^ GC* MG/VIAL ZYNLONTA SOLR 5^ MO; GC* FIRMAGON SOLR 80 MG 4 GC* Antineoplastic - BCL-2 Inhibitors flutamide caps 1 MO; GC VENCLEXTA STARTING 2 PA; LA; MO; PACK TBPK GC* fulvestrant soln 5^ MO; GC* PA; LA; MO; VENCLEXTA TABS 2 GC* hydroxyprogesterone GC* Antineoplastic - EGFR Inhibitors caproate (antineoplastic) 5^ soln ERBITUX SOLN 5^ GC* letrozole tabs 1 MO; GC erlotinib hcl tabs 5^ PA; GC* leuprolide acetate kit 4 GC* GILOTRIF TABS 5^ PA; MO; GC* LUPRON DEPOT (1- 5^ GC* MONTH) KIT IRESSA TABS 5^ GC* You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary Updated 09/01/2021 31 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LUPRON DEPOT (3- 5^ GC* XPOVIO 40 MG TWICE 5^ PA; MO; GC* MONTH) KIT WEEKLY TBPK LUPRON DEPOT (4- 5^ GC* XPOVIO 60 MG ONCE 5^ PA; MO; GC* MONTH) KIT WEEKLY TBPK LUPRON DEPOT (6- 5^ GC* XPOVIO 60 MG TWICE 5^ PA; MO; GC* MONTH) KIT WEEKLY TBPK LYSODREN TABS 2 GC* XPOVIO 80 MG ONCE 5^ PA; MO; GC* WEEKLY TBPK AL(Up to 64 yrs megestrol acetate susp 1 XPOVIO 80 MG TWICE 5^ PA; MO; GC* old); MO; GC WEEKLY TBPK AL(Up to 64 yrs megestrol acetate tabs 1 PA; MO; GC* old); MO; GC XPOVIO TBPK 5^ nilutamide tabs 1 MO; GC Antineoplastic Antibiotics bleomycin sulfate solr 4 PA; GC* NUBEQA TABS 5^ PA; GC* dactinomycin solr 4 GC* ORGOVYX TABS 5^ PA; MO; GC* daunorubicin hcl soln 4 GC* SOLTAMOX SOLN 3 MO; GC* DAUNORUBICIN GC* tamoxifen citrate tabs 1 MO; GC HYDROCHLORIDE SOLN 5^ 50 MG/10ML toremifene citrate tabs 5^ MO; GC* doxorubicin hcl liposomal 1 GC inj TRELSTAR MIXJECT 5^ GC* SUSR doxorubicin hcl soln 4 GC* VANTAS KIT 5^ GC* doxorubicin hcl solr 4 GC* XTANDI CAPS 40 MG 5^ PA; LA; GC* epirubicin hcl soln 4 GC* XTANDI TABS 40 MG, 80 5^ PA; GC* MG idarubicin hcl soln 4 GC* PA; GC* YONSA TABS 5^ mitomycin solr 4 GC* GC* ZOLADEX IMPL 3 mitoxantrone hcl conc 1 GC Antineoplastic - Immunomodulators valrubicin soln 5^ GC* POMALYST CAPS 5^ LA; GC* Antineoplastic Combinations Antineoplastic - PDGFR-alpha Inhibitors DARZALEX FASPRO 5^ LA; GC* AYVAKIT TABS 5^ PA; MO; GC* SOLN HERCEPTIN HYLECTA 5^ PA; GC* Antineoplastic - XPO1 Inhibitors SOLN PA; GC* XPOVIO 100 MG ONCE 5^ PA; MO; GC* INQOVI TABS 5^ WEEKLY TBPK KISQALI FEMARA 200 PA; GC* XPOVIO 40 MG ONCE 5^ PA; MO; GC* 5^ WEEKLY TBPK DOSE TBPK You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary 32 Updated 09/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KISQALI FEMARA 400 5^ PA; GC* everolimus tabs 5^ PA; GC* DOSE TBPK PA; LA; GC* KISQALI FEMARA 600 5^ PA; GC* FARYDAK CAPS 5^ DOSE TBPK PA; MO; GC* LONSURF TABS 5^ PA; GC* FOTIVDA CAPS 5^ PA; MO; GC* PHESGO SOLN 5^ GC* GAVRETO CAPS 5^ LA; GC* RITUXAN HYCELA SOLN 5^ PA; GC* IBRANCE CAPS 5^ LA; GC* VYXEOS SUSR 5^ GC* IBRANCE TABS 5^ ICLUSIG TABS 10 MG, 15 5^ PA; MO; GC* Antineoplastic Enzyme Inhibitors MG, 30 MG, 45 MG PA; GC* AFINITOR DISPERZ TBSO 5^ IDHIFA TABS 5^ PA; GC* PA; GC* AFINITOR TABS 10 MG 5^ imatinib mesylate tabs 5^ PA; GC* PA; GC* ALECENSA CAPS 5^ IMBRUVICA CAPS 5^ PA; MO; GC* MO; GC* ALIQOPA SOLR 5^ IMBRUVICA TABS 5^ PA; MO; GC* PA; GC* ALUNBRIG TABS 5^ INREBIC CAPS 5^ PA; LA; GC* PA; GC* ALUNBRIG TBPK 5^ ISTODAX (OVERFILL) 5^ GC* SOLR BALVERSA TABS 5^ PA; LA; MO; GC* JAKAFI TABS 5^ PA; LA; GC* PA; GC* BELEODAQ SOLR 5^ KISQALI TBPK 5^ PA; GC* GC* BORTEZOMIB SOLR 5^ KOSELUGO CAPS 5^ PA; MO; GC* PA; GC* BOSULIF TABS 5^ KYPROLIS SOLR 5^ GC* PA; GC* BRAFTOVI CAPS 5^ lapatinib ditosylate tabs 5^ GC* PA; MO; GC* BRUKINSA CAPS 5^ LORBRENA TABS 5^ PA; GC* PA; GC* CABOMETYX TABS 5^ LUMAKRAS TABS 5^ PA; GC* PA; MO; GC* CALQUENCE CAPS 5^ LYNPARZA TABS 5^ PA; LA; GC* PA; MO; GC* CAPRELSA TABS 5^ MEKINIST TABS 5^ PA; GC* PA; GC* COMETRIQ KIT 5^ MEKTOVI TABS 5^ PA; GC* PA; MO; GC* COPIKTRA CAPS 5^ NERLYNX TABS 5^ PA; GC* PA; LA; GC* COTELLIC TABS 5^ NEXAVAR TABS 5^ LA; GC* You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary Updated 09/01/2021 33 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NINLARO CAPS 5^ PA; GC* TURALIO CAPS 5^ PA; MO; GC* PEMAZYRE TABS 5^ PA; MO; GC* UKONIQ TABS 5^ PA; MO; GC* PIQRAY 200MG DAILY 5^ PA; GC* VELCADE SOLR 5^ GC* DOSE TBPK PA; GC* PIQRAY 250MG DAILY 5^ PA; GC* VERZENIO TABS 5^ DOSE TBPK PA; GC* PIQRAY 300MG DAILY 5^ PA; GC* VITRAKVI CAPS 5^ DOSE TBPK VITRAKVI SOLN 5^ PA; GC* QINLOCK TABS 5^ PA; MO; GC* VOTRIENT TABS 5^ PA; GC* RETEVMO CAPS 5^ PA; GC* XALKORI CAPS 5^ PA; GC* ROMIDEPSIN SOLN 27.5 5^ GC* MG/5.5ML XOSPATA TABS 5^ PA; MO; GC* ROMIDEPSIN SOLR 10 5^ GC* MG PA; LA; MO; ZEJULA CAPS 5^ ROZLYTREK CAPS 5^ PA; GC* GC* ZELBORAF TABS 5^ PA; LA; GC* RUBRACA TABS 5^ PA; LA; GC* ZOLINZA CAPS 5^ GC* RYDAPT CAPS 5^ PA; GC* ZYDELIG TABS 5^ PA; LA; GC* SPRYCEL TABS 5^ PA; GC* ZYKADIA TABS 5^ PA; GC* STIVARGA TABS 5^ PA; LA; GC* Antineoplastic Enzymes SUTENT CAPS 5^ GC* ASPARLAS SOLN 5^ GC* TABRECTA TABS 5^ PA; GC* ERWINAZE SOLR 5^ GC* TAFINLAR CAPS 5^ GC* ONCASPAR SOLN 5^ GC* TALZENNA CAPS 5^ PA; GC* Antineoplastics Misc. PA; GC* TASIGNA CAPS 5^ ACTIMMUNE SOLN 5^ LA; GC* PA; MO; GC* TAZVERIK TABS 5^ arsenic trioxide soln 5^ GC* GC* temsirolimus soln 5^ bexarotene caps 5^ GC* PA; MO; GC* TEPMETKO TABS 5^ dacarbazine solr 4 GC* PA; LA; GC* TIBSOVO TABS 5^ hydroxyurea caps 1 MO; GC PA; MO; GC* TRUSELTIQ CPPK 5^ INTRON A SOLN 10 5^ GC* MU/ML You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary 34 Updated 09/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits INTRON A SOLN 6000000 4 GC* ABRAXANE SUSR 5^ MO; GC* UNIT/ML docetaxel conc 20 mg/ml, GC* INTRON A SOLR 10 MU, 5^ GC* 5^ 18 MU, 50 MU 80 mg/4ml LA; MO; GC* docetaxel soln 160 GC* MATULANE CAPS 5^ mg/16ml, 20 mg/2ml, 80 5^ mg/8ml NIPENT SOLR 4 GC* ETOPOPHOS SOLR 4 GC* PROLEUKIN SOLR 5^ GC* etoposide soln 4 GC* SYLATRON KIT 5^ GC* HALAVEN SOLN 5^ GC* SYNRIBO SOLR 5^ GC* IXEMPRA KIT SOLR 5^ GC* TICE BCG SUSR 5^ GC* JEVTANA SOLN 5^ GC* tretinoin (chemotherapy) 5^ MO; GC* caps MARQIBO SUSP 5^ MO; GC* GC* UVADEX SOLN 4 paclitaxel conc 100 GC* mg/16.67ml, 150 mg/25ml, 4 Chemotherapy Adjuncts 100 mg/16.7ml, 30 mg/5ml, ELITEK SOLR 5^ GC* 300 mg/50ml, 6 mg/ml vinblastine sulfate soln 4 PA; MO; GC* KEPIVANCE SOLR 5^ GC* PA; GC* Chemotherapy Rescue/Antidote/Protective Agents vincristine sulfate soln 4 dexrazoxane hcl solr 4 GC* vinorelbine tartrate soln 10 4 GC* mg/ml GC* KHAPZORY SOLR 5^ vinorelbine tartrate soln 50 4 MO; GC* mg/5ml leucovorin calcium solr ij GC* 500 mg, 100 mg, 200 mg, 4 Oncolytic Viral Agents 350 mg, 50 mg 1000000 IMLYGIC SUSP 4 Unit/ML;MO; leucovorin calcium tabs or 1 MO; GC 10 mg, 15 mg, 25 mg, 5 mg GC* 100000000 levoleucovorin calcium soln 5^ GC* 175 mg/17.5ml IMLYGIC SUSP 5^ Unit/ML;MO; GC* levoleucovorin calcium soln 4 GC* 250 mg/25ml Topoisomerase I Inhibitors irinotecan hcl soln 300 GC* levoleucovorin calcium solr 4 GC* 4 50 mg mg/15ml GC* irinotecan hcl soln 500 GC mesna soln 4 mg/25ml, 100 mg/5ml, 40 1 mg/2ml MESNEX TABS OR 400 5^ MO; GC* MG ONIVYDE INJ 5^ GC* Mitotic Inhibitors topotecan hcl solr 4 mg 5^ GC* You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary Updated 09/01/2021 35 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRODELVY SOLR 5^ MO; GC* GOCOVRI CP24 5^ PA; MO; GC* ANTIPARKINSON AND RELATED THERAPY NEUPRO PT24 3 MO; GC* AGENTS - Drugs to Treat Parkinson's Disease OSMOLEX ER TB24 129 3 PA; SL(1 ea Antiparkinson Adjunctive Therapy MG, 193 MG, 258 MG daily); MO; GC* MO; GC carbidopa tabs 1 pramipexole 1 MO; GC dihydrochloride tabs NOURIANZ TABS 3 MO; GC* pramipexole 1 MO; GC dihydrochloride tb24 Antiparkinson Anticholinergics ropinirole hydrochloride 1 MO; GC benztropine mesylate soln 4 MO; GC* tabs ij 1 mg/ml ropinirole hydrochloride 1 MO; GC benztropine mesylate tabs 1 AL(Up to 64 yrs tb24 or 0.5 mg, 1 mg, 2 mg old); MO; GC MO; GC* AL(Up to 64 yrs RYTARY CPCR 3 trihexyphenidyl hcl soln 1 old); MO; GC STALEVO 100 TABS MO; GC* AL(Up to 64 yrs trihexyphenidyl hcl tabs 1 (carbidopa-levodopa- 3 old); MO; GC entacapone) Antiparkinson COMT Inhibitors STALEVO 125 TABS MO; GC* SL(8 ea daily); (carbidopa-levodopa- 3 entacapone tabs 1 MO; GC entacapone) MO; GC STALEVO 150 TABS MO; GC* tolcapone tabs 1 (carbidopa-levodopa- 3 entacapone) Antiparkinson Dopaminergics STALEVO 200 TABS MO; GC* amantadine hcl caps 1 MO; GC (carbidopa-levodopa- 3 entacapone) amantadine hcl syrp 1 MO; GC STALEVO 50 TABS MO; GC* (carbidopa-levodopa- 3 amantadine hcl tabs 1 MO; GC entacapone) PA; LA; GC* STALEVO 75 TABS MO; GC* APOKYN SOCT 5^ (carbidopa-levodopa- 3 entacapone) bromocriptine mesylate 1 MO; GC caps Antiparkinson Monoamine Oxidase Inhibitors MO; GC bromocriptine mesylate 1 MO; GC rasagiline mesylate tabs 1 tabs MO; GC carbidopa-levodopa tabs 1 MO; GC selegiline hcl caps 1 MO; GC carbidopa-levodopa tbcr 1 MO; GC selegiline hcl tabs 1 MO; GC* carbidopa-levodopa tbdp 1 MO; GC ZELAPAR TBDP 3 ANTIPSYCHOTICS/ANTIMANIC AGENTS - carbidopa-levodopa- 1 MO; GC entacapone tabs Drugs to Treat Mood Disorders DUOPA SUSP 3 B/D; GC* Antimanic Agents You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary 36 Updated 09/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits lithium carbonate caps 1 MO; GC FANAPT TITRATION 3 MO; GC* PACK TABS lithium carbonate tabs 1 MO; GC INVEGA SUSTENNA MO; GC* SUSY 117 MG/0.75ML, 5^ lithium carbonate tbcr 1 MO; GC 156 MG/ML, 234 MG/1.5ML LITHIUM SOLN 2 MO; GC* INVEGA SUSTENNA MO; GC* SUSY 39 MG/0.25ML, 78 4 Antipsychotics - Misc. MG/0.5ML CAPLYTA CAPS 5^ PA; MO; GC* INVEGA TRINZA SUSY 5^ GC* SL(8 ea daily); EQUETRO CP12 3 MO; GC* paliperidone tb24 1.5 mg 1 MO; GC PA; SL(1.33 ea SL(4 ea daily); LATUDA TABS 120 MG 5^ paliperidone tb24 3 mg 1 daily); MO; GC* MO; GC PA; SL(8 ea SL(2 ea daily); LATUDA TABS 20 MG 5^ paliperidone tb24 6 mg 1 daily); MO; GC* MO; GC PA; SL(4 ea SL(1.33 ea LATUDA TABS 40 MG 5^ paliperidone tb24 9 mg 5^ daily); MO; GC* daily); MO; GC* LATUDA TABS 60 MG 5^ PA; SL(2.67 ea PA; GC* daily); MO; GC* PERSERIS PRSY 5^ PA; SL(2 ea Limit 8 vials per LATUDA TABS 80 MG 5^ 28 daily); MO; GC* RISPERDAL CONSTA PA; LA; GC* 4 days;SL(0.29 NUPLAZID CAPS 5^ SRER 12.5 MG ea daily); MO; PA; LA; GC* GC* NUPLAZID TABS 5^ Limit 4 vials per 28 VRAYLAR CAPS 1.5 MG 3 PA; SL(4 ea RISPERDAL CONSTA daily); MO; GC* 4 days;SL(0.15 SRER 25 MG ea daily); MO; VRAYLAR CAPS 3 MG 3 PA; SL(2 ea daily); MO; GC* GC* PA; SL(1.4 ea Limit 4 vials per VRAYLAR CAPS 4.5 MG 3 daily); MO; GC* RISPERDAL CONSTA 5^ 42 days;SL(0.1 SRER 37.5 MG ea daily); MO; VRAYLAR CAPS 6 MG 3 PA; SL(1 ea GC* daily); MO; GC* Limit 2 vials per VRAYLAR CPPK 3 PA; MO; GC* 28 RISPERDAL CONSTA 5^ days;SL(0.08 SRER 50 MG ziprasidone hcl caps 1 MO; GC ea daily); MO; GC* MO; GC* ziprasidone mesylate solr 4 risperidone soln 1 MO; GC Benzisoxazoles risperidone tabs 1 MO; GC FANAPT TABS 1 MG, 10 3 MO; GC* MG, 2 MG, 4 MG risperidone tbdp 1 MO; GC FANAPT TABS 12 MG, 6 5^ MO; GC* MG, 8 MG Butyrophenones You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary Updated 09/01/2021 37 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits haloperidol decanoate soln 1 MO; GC SECUADO PT24 7.6 5^ PA; SL(1 ea MG/24HR daily); GC* MO; GC haloperidol lactate conc 1 VERSACLOZ SUSP 5^ PA; SL(18 ml daily); GC* MO; GC haloperidol lactate soln 1 ZYPREXA RELPREVV 4 GC* SUSR MO; GC haloperidol tabs 1 Dihydroindolones Dibenzapines molindone hcl tabs 1 GC asenapine maleate subl 10 5^ SL(2 ea daily); mg MO; GC* Phenothiazines chlorpromazine hcl soln ij MO; GC* asenapine maleate subl 2.5 1 SL(8 ea daily); 4 mg MO; GC 25 mg/ml chlorpromazine hcl soln ij GC* asenapine maleate subl 5 1 SL(4 ea daily); 4 mg MO; GC 50 mg/2ml chlorpromazine hcl tabs or MO; GC clozapine tabs 200 mg, 50 1 GC mg, 100 mg, 25 mg 10 mg, 100 mg, 200 mg, 25 1 mg, 50 mg clozapine tbdp 100 mg, 1 GC 12.5 mg, 150 mg, 25 mg fluphenazine decanoate 4 MO; GC* soln clozapine tbdp 200 mg 5^ GC* fluphenazine hcl conc or 5 1 MO; GC mg/ml loxapine succinate caps 1 MO; GC fluphenazine hcl soln ij 2.5 4 MO; GC* mg/ml olanzapine solr 1 MO; GC fluphenazine hcl tabs or 1 1 MO; GC olanzapine tabs 1 MO; GC mg, 10 mg, 2.5 mg, 5 mg perphenazine tabs 1 MO; GC olanzapine tbdp 1 MO; GC prochlorperazine edisylate 4 MO; GC* quetiapine fumarate tabs MO; GC soln 10 mg/2ml 100 mg, 200 mg, 25 mg, 1 300 mg, 400 mg, 50 mg prochlorperazine edisylate 4 GC* soln 50 mg/10ml quetiapine fumarate tb24 PA; MO; GC 150 mg, 200 mg, 300 mg, 1 prochlorperazine maleate 1 MO; GC 400 mg, 50 mg tabs prochlorperazine supp 1 MO; GC SAPHRIS SUBL 10 MG 5^ SL(2 ea daily); (asenapine maleate) MO; GC* thioridazine hcl tabs 1 MO; GC SAPHRIS SUBL 2.5 MG 3 SL(8 ea daily); (asenapine maleate) MO; GC* trifluoperazine hcl tabs 1 MO; GC SAPHRIS SUBL 5 MG 3 SL(4 ea daily); MO; GC* Quinolinone Derivatives SAPHRIS SUBL 5 MG 3 SL(4 ea daily); MO; GC* (asenapine maleate) MO; GC* ABILIFY MAINTENA PRSY 5^ SECUADO PT24 3.8 5^ PA; SL(2 ea MO; GC* MG/24HR daily); GC* ABILIFY MAINTENA SRER 5^ SECUADO PT24 5.7 PA; SL(1.34 ea SL(30 ml daily); 5^ aripiprazole soln 1 mg/ml 1 MG/24HR daily); MO; GC* MO; GC You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary 38 Updated 09/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SL(3 ea daily); MO; GC* aripiprazole tabs 10 mg 1 APTIVUS CAPS 250 MG 5^ MO; GC SL(2 ea daily); APTIVUS SOLN 100 GC* aripiprazole tabs 15 mg 1 2 MO; GC MG/ML SL(15 ea daily); MO; GC aripiprazole tabs 2 mg 1 atazanavir sulfate caps 1 MO; GC SL(1.5 ea MO; GC* aripiprazole tabs 20 mg 3 BIKTARVY TABS 5^ daily); MO; GC* MO; GC* SL(1 ea daily); CABENUVA SUER 5^ aripiprazole tabs 30 mg 3 MO; GC* MO; GC* SL(6 ea daily); CIMDUO TABS 5^ aripiprazole tabs 5 mg 1 MO; GC COMPLERA TABS 5^ MO; GC* SL(3 ea daily); aripiprazole tbdp 10 mg 5^ MO; GC* CRIXIVAN CAPS 3 MO; GC* SL(2 ea daily); aripiprazole tbdp 15 mg 5^ MO; GC* DELSTRIGO TABS 5^ MO; GC* ARISTADA INITIO PRSY 5^ GC* DESCOVY TABS 5^ MO; GC* ARISTADA PRSY 5^ GC* DOVATO TABS 5^ MO; GC* PA; SL(16 ea REXULTI TABS 0.25 MG 5^ daily); MO; GC* EDURANT TABS 5^ MO; GC* REXULTI TABS 0.5 MG 5^ PA; SL(8 ea daily); MO; GC* efavirenz caps 1 MO; GC REXULTI TABS 1 MG 5^ PA; SL(4 ea MO; GC daily); MO; GC* efavirenz tabs 1 PA; SL(2 ea REXULTI TABS 2 MG 5^ efavirenz-emtricitabine- MO; GC* daily); MO; GC* tenofovir disoproxil 5^ PA; SL(1.33 ea fumarate tabs REXULTI TABS 3 MG 5^ daily); MO; GC* efavirenz-lamivudine- MO; GC* tenofovir disoproxil 5^ REXULTI TABS 4 MG 5^ PA; SL(1 ea daily); MO; GC* fumarate tabs Thioxanthenes emtricitabine caps 1 MO; GC thiothixene caps 1 MO; GC emtricitabine-tenofovir 5^ MO; GC* disoproxil fumarate tabs ANTIVIRALS - Drugs to Treat Viral Infections EMTRIVA SOLN 10 3 MO; GC* MG/ML Antiretrovirals etravirine tabs 5^ MO; GC* abacavir sulfate soln 1 MO; GC EVOTAZ TABS 5^ MO; GC* abacavir sulfate tabs 1 MO; GC fosamprenavir calcium tabs 5^ MO; GC* abacavir sulfate-lamivudine 1 MO; GC tabs FUZEON SOLR 5^ MO; GC* abacavir sulfate- 5^ MO; GC* lamivudine-zidovudine tabs You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary Updated 09/01/2021 39 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GENVOYA TABS 5^ MO; GC* NORVIR SOLN 80 MG/ML 2 MO; GC* INTELENCE TABS 100 5^ MO; GC* ODEFSEY TABS 5^ MO; GC* MG, 200 MG (etravirine) MO; GC* INTELENCE TABS 25 MG 3 GC* PIFELTRO TABS 5^ MO; GC* INVIRASE TABS 5^ MO; GC* PREZCOBIX TABS 5^ PREZISTA SUSP 100 MO; GC* ISENTRESS CHEW 100 2 SL(6 ea daily); 5^ MG MO; GC* MG/ML PREZISTA TABS 150 MG, MO; GC* ISENTRESS CHEW 25 MG 2 SL(24 ea daily); 5^ MO; GC* 600 MG, 800 MG MO; GC* ISENTRESS HD TABS 5^ MO; GC* PREZISTA TABS 75 MG 3 RETROVIR IV INFUSION GC* ISENTRESS PACK 100 3 SL(2 ea daily); 4 MG MO; GC* SOLN MO; GC* ISENTRESS TABS 400 5^ MO; GC* REYATAZ PACK 50 MG 5^ MG MO; GC JULUCA TABS 5^ MO; GC* ritonavir tabs 1 MO; GC* KALETRA TABS 25 MG- 3 MO; GC* RUKOBIA TB12 5^ 100 MG (lopinavir-ritonavir) SELZENTRY SOLN 20 2 GC* KALETRA TABS 50 MG- 5^ MO; GC* MG/ML 200 MG (lopinavir-ritonavir) SELZENTRY TABS 150 2 MO; GC* lamivudine soln 1 MO; GC MG, 300 MG MO; GC SELZENTRY TABS 25 2 GC* lamivudine tabs 1 MG, 75 MG MO; GC stavudine caps 15 mg, 20 1 MO; GC lamivudine-zidovudine tabs 1 mg, 30 mg, 40 mg LEXIVA SUSP 50 MG/ML 2 MO; GC* STRIBILD TABS 5^ MO; GC* lopinavir-ritonavir soln 100 5^ MO; GC* SYMTUZA TABS 5^ MO; GC* mg/5ml-400 mg/5ml MO; GC* lopinavir-ritonavir tabs 25 1 MO; GC TEMIXYS TABS 5^ mg-100 mg tenofovir disoproxil MO; GC lopinavir-ritonavir tabs 50 5^ MO; GC* 1 mg-200 mg fumarate tabs MO; GC* nevirapine susp 50 mg/5ml 1 MO; GC TIVICAY PD TBSO 3 MO; GC* nevirapine tabs 200 mg 1 MO; GC TIVICAY TABS 10 MG 3 GC TIVICAY TABS 25 MG, 50 5^ MO; GC* nevirapine tb24 100 mg 1 MG MO; GC* nevirapine tb24 400 mg 1 MO; GC TRIUMEQ TABS 5^ MO; GC* NORVIR PACK 100 MG 3 MO; GC* TROGARZO SOLN 5^ You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary 40 Updated 09/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TYBOST TABS 3 MO; GC* PEGASYS SOLN 5^ GC* VIDEX EC CPDR 125 MG 3 MO; GC* PEGINTRON KIT 5^ GC* VIRACEPT TABS 5^ MO; GC* ribavirin (hepatitis c) caps 1 GC 200 mg MO; GC* VIREAD POWD 40 MG/GM 5^ ribavirin (hepatitis c) tabs 1 GC 200 mg VIREAD TABS 150 MG, MO; GC* 5^ SOVALDI TABS 200 MG, 5^ PA; GC* 200 MG, 250 MG 400 MG MO; GC zidovudine caps 1 VEMLIDY TABS 5^ ST; MO; GC* MO; GC zidovudine syrp 1 VOSEVI TABS 5^ PA; GC* MO; GC zidovudine tabs 1 ZEPATIER TABS 5^ PA; GC* CMV Agents Herpes Agents GC* cidofovir soln 5^ acyclovir caps 1 MO; GC PA; GC ganciclovir sodium solr 1 acyclovir sodium soln 4 PA; GC* PREVYMIS TABS OR 240 5^ PA; MO; GC* MO; GC MG, 480 MG acyclovir susp 1 MO; GC* valganciclovir hcl solr 5^ acyclovir tabs 1 MO; GC MO; GC* valganciclovir hcl tabs 5^ famciclovir tabs 1 MO; GC Hepatitis Agents valacyclovir hcl tabs 1 MO; GC adefovir dipivoxil tabs 5^ MO; GC* Influenza Agents BARACLUDE SOLN 0.05 MO; GC* 2 oseltamivir phosphate caps 1 QL(4 ea daily); MG/ML 30 mg MO; GC MO; GC entecavir tabs 1 oseltamivir phosphate caps 1 MO; GC 45 mg, 75 mg EPCLUSA TABS 100 MG- PA; GC* 5^ oseltamivir phosphate susr 1 MO; GC 400 MG, 50 MG-200 MG 6 mg/ml EPIVIR HBV SOLN 5 MO; GC* 2 RELENZA DISKHALER 3 MO; GC* MG/ML AEPB HARVONI PACK 33.75 PA; GC* rimantadine hydrochloride 1 MO; GC MG-150 MG, 45 MG-200 5^ tabs MG Respiratory Syncytial Virus (RSV) Agents HARVONI TABS 45 MG- 5^ PA; GC* 200 MG, 90 MG-400 MG ribavirin solr 1 GC lamivudine (hbv) tabs 1 MO; GC BETA BLOCKERS - Drugs to Treat High Blood Pressure MAVYRET TABS 5^ PA; GC* Alpha-Beta Blockers You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary Updated 09/01/2021 41 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits carvedilol phosphate cp24 1 MO; GC sotalol hcl tabs 1 MO; GC SL(8 ea daily); MO; GC* carvedilol tabs 12.5 mg 1 SOTYLIZE SOLN 3 MO; GC SL(4 ea daily); SL(6 ea daily); carvedilol tabs 25 mg 1 timolol maleate tabs 10 mg 1 MO; GC MO; GC SL(32 ea daily); SL(3 ea daily); carvedilol tabs 3.125 mg 1 timolol maleate tabs 20 mg 1 MO; GC MO; GC SL(16 ea daily); SL(12 ea daily); carvedilol tabs 6.25 mg 1 timolol maleate tabs 5 mg 1 MO; GC MO; GC labetalol hcl tabs or 100 1 MO; GC CALCIUM CHANNEL BLOCKERS - Drugs to mg, 200 mg, 300 mg Treat High Blood Pressure Beta Blockers Cardio-Selective Calcium Channel Blockers MO; GC acebutolol hcl caps 1 amlodipine besylate tabs 1 SL(1 ea daily); 10 mg MO; GC MO; GC atenolol tabs 1 amlodipine besylate tabs 1 SL(4 ea daily); 2.5 mg MO; GC betaxolol hcl tabs 1 MO; GC amlodipine besylate tabs 5 1 SL(2 ea daily); mg MO; GC bisoprolol fumarate tabs 1 MO; GC CARDIZEM LA TB24 120 2 MO; GC* MG BYSTOLIC TABS 10 MG, 3 QL(1 ea daily); 2.5 MG, 5 MG MO; GC* diltiazem hcl coated beads 1 MO; GC QL(2 ea daily); cp24 BYSTOLIC TABS 20 MG 3 MO; GC* diltiazem hcl coated beads 1 MO; GC tb24 metoprolol succinate tb24 1 MO; GC diltiazem hcl cp12 or 120 1 MO; GC metoprolol tartrate tabs or MO; GC mg, 60 mg, 90 mg 1 37.5 mg, 75 mg, 100 mg, diltiazem hcl cp24 or 120 1 MO; GC 25 mg, 50 mg mg, 180 mg, 240 mg Beta Blockers Non-Selective diltiazem hcl extended 1 MO; GC release beads cp24 HEMANGEOL SOLN 3 GC* diltiazem hcl tabs or 120 1 MO; GC mg, 30 mg, 60 mg, 90 mg nadolol tabs 1 MO; GC felodipine tb24 1 MO; GC pindolol tabs 1 MO; GC nicardipine hcl caps or 20 1 MO; GC propranolol hcl cp24 or 60 MO; GC mg, 30 mg mg, 80 mg, 120 mg, 160 1 AL(Up to 64 yrs nifedipine caps 20 mg 1 mg old); MO; GC propranolol hcl soln or 20 MO; GC 1 nifedipine tb24 30 mg, 60 1 MO; GC mg/5ml, 40 mg/5ml mg, 90 mg propranolol hcl tabs or 10 MO; GC MO; GC mg, 20 mg, 80 mg, 40 mg, 1 nimodipine caps 1 60 mg nisoldipine tb24 17 mg, 34 1 MO; GC sotalol hcl (afib/afl) tabs 1 MO; GC mg, 8.5 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary 42 Updated 09/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NYMALIZE SOLN 30 5^ GC* Check plan for MG/10ML, 60 MG/20ML coverage; Limit verapamil hcl cp24 or 100 MO; GC CAVERJECT SOLR 40 2 4 vials per MCG month;QL(0.14 mg, 300 mg, 360 mg, 120 1 mg, 180 mg, 200 mg, 240 29 ea daily); mg MO; NT; GC* Check plan for verapamil hcl tabs or 40 1 MO; GC mg, 120 mg, 80 mg coverage; Limit 4 boxes per EDEX KIT 2 verapamil hcl tbcr or 120 1 MO; GC month;QL(0.14 mg, 180 mg, 240 mg 29 ea daily); VERELAN PM CP24 300 1 MO; GC MO; NT; GC* MG (verapamil hcl) Check plan for CARDIOTONICS - Drugs to Treat Heart Failure coverage; Limit and Abnormal Heart Rhythm MUSE PLLT 2 4 boxes per month;QL(0.14 Cardiac Glycosides 29 ea daily); digoxin soln or 0.05 mg/ml 1 MO; GC MO; NT; GC* Check plan for digoxin tabs or 0.25 mg, MO; GC 1 coverage;QL(0. 250 mcg, 0.125 mg, 125 1 sildenafil citrate tabs 1429 ea daily); mcg MO; NT; GC LANOXIN PEDIATRIC 4 GC* Check plan for SOLN coverage;QL(0. tadalafil tabs 10 mg, 20 mg 1 LANOXIN TABS OR 62.5 3 MO; GC* 1429 ea daily); MCG MO; NT; GC Inotropes PA; Check plan GC* 1 for dobutamine hcl soln 4 tadalafil tabs 2.5 mg, 5 mg coverage;MO; GC CARDIOVASCULAR AGENTS - MISC. - Drugs to Treat Heart and Circulation Conditions Check plan for coverage;QL(0. vardenafil hcl tabs 1 Cardiovascular Agents Misc. - Combinations 1429 ea daily); MO; NT; GC amlodipine besylate- 1 MO; GC atorvastatin calcium tabs Check plan for MO; GC* 1 coverage;QL(0. BIDIL TABS 3 vardenafil hcl tbdp 1429 ea daily); MO; NT; GC ENTRESTO TABS 3 PA; MO; GC* Prostaglandin Vasodilators Impotence Agents ORENITRAM TBCR 0.125 3 PA; GC* Check plan for MG coverage; Limit ORENITRAM TBCR 0.25 5^ PA; GC* CAVERJECT IMPULSE 2 4 boxes per MG, 1 MG, 2.5 MG, 5 MG KIT month;QL(0.14 B/D; LA; GC* 29 ea daily); treprostinil soln 5^ MO; NT; GC* TYVASO REFILL SOLN 5^ B/D; LA; GC* TYVASO SOLN 5^ B/D; LA; GC* You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary Updated 09/01/2021 43 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TYVASO STARTER SOLN 5^ B/D; LA; GC* Transthyretin Stabilizers PA; QL(1 ea VYNDAMAX CAPS 5^ VENTAVIS SOLN 10 2 B/D; LA; GC* daily); GC* MCG/ML PA; QL(4 ea VYNDAQEL CAPS 5^ VENTAVIS SOLN 20 5^ B/D; LA; GC* daily); GC* MCG/ML CEPHALOSPORINS - Drugs to Treat Bacterial Pulmonary Hypertension - Endothelin Receptor Infections PA; LA; GC* ambrisentan tabs 5^ Cephalosporins - 1st Generation MO; GC bosentan tabs 5^ PA; LA; GC* cefadroxil caps 1 MO; GC OPSUMIT TABS 5^ PA; GC* cefadroxil susr 1 Pulmonary Hypertension - Phosphodiesterase cefadroxil tabs 1 MO; GC sildenafil citrate (pulmonary PA; GC* cefazolin sodium solr ij 500 4 MO; GC* hypertension) soln iv 10 5^ mg, 1 gm, 10 gm mg/12.5ml MO; GC sildenafil citrate (pulmonary PA; GC cephalexin caps 1 hypertension) tabs or 20 1 mg cephalexin susr 1 MO; GC tadalafil (pulmonary 5^ PA; GC* MO; GC hypertension) tabs cephalexin tabs 1 Pulmonary Hypertension - Prostacyclin Receptor Cephalosporins - 2nd Generation PA; LA; GC* UPTRAVI TABS 5^ cefaclor caps 250 mg, 500 1 MO; GC mg PA; LA; GC* UPTRAVI TBPK 5^ cefaclor monohydrate tb12 1 MO; GC Pulmonary Hypertension - Sol Guanylate Cyclase cefoxitin sodium solr ij 10 4 GC* gm ADEMPAS TABS 0.5 MG 5^ PA; SL(15 ea daily); GC* cefoxitin sodium solr iv 2 4 GC* gm, 1 gm ADEMPAS TABS 1 MG 5^ PA; SL(7.5 ea daily); GC* cefprozil susr 1 MO; GC PA; SL(5 ea ADEMPAS TABS 1.5 MG 5^ daily); GC* cefprozil tabs 1 MO; GC PA; SL(3.75 ea ADEMPAS TABS 2 MG 5^ daily); GC* cefuroxime axetil tabs 1 MO; GC PA; SL(3 ea ADEMPAS TABS 2.5 MG 5^ daily); GC* cefuroxime sodium solr ij 4 MO; GC* 750 mg Sinus Node Inhibitors cefuroxime sodium solr iv 4 GC* CORLANOR SOLN 5 3 SL(15 ml daily); 1.5 gm MG/5ML GC* Cephalosporins - 3rd Generation CORLANOR TABS 5 MG 3 SL(3 ea daily); MO; GC* cefdinir caps 1 MO; GC CORLANOR TABS 7.5 MG 3 SL(2 ea daily); MO; GC MO; GC* cefdinir susr 1 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary 44 Updated 09/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits cefixime caps 1 MO; GC drospirenone-ethinyl MO; GC estradiol-levomefolate 1 cefixime susr 1 MO; GC calcium tabs ethynodiol diacet & eth 1 MO; GC cefpodoxime proxetil susr 1 MO; GC estrad tabs levonorgestrel & eth GC cefpodoxime proxetil tabs 1 MO; GC estradiol chew 0.1 mg-20 1 mcg ceftazidime solr ij 2 gm, 1 4 MO; GC* levonorgestrel & eth MO; GC gm estradiol tabs 0.03 mg-0.15 1 ceftazidime solr ij 6 gm 4 GC* mg, 0.15 mg-30 mcg, 0.1 mg-20 mcg ceftriaxone sodium in SL(200 ml 4 levonorgestrel-eth estradiol 1 MO; GC dextrose soln 20 mg/ml daily); GC* (triphasic) tabs ceftriaxone sodium solr ij 1 SL(4 ea daily); 4 levonorgestrel-ethinyl 1 (QUARTETTE); gm MO; GC* estradiol (91-day) tabs MO; GC ceftriaxone sodium solr ij 2 SL(2 ea daily); 4 levonorgestrel-ethinyl 1 biphasic;MO; gm MO; GC* estradiol (91-day) tabs GC ceftriaxone sodium solr ij SL(16 ea daily); 4 levonorgestrel-ethinyl 1 MO; GC 250 mg MO; GC* estradiol (continuous) tabs ceftriaxone sodium solr ij 4 SL(8 ea daily); MO; GC* 500 mg MO; GC* LO LOESTRIN FE TABS 3 ceftriaxone sodium solr iv 1 SL(4 ea daily); 4 norethin acet & estrad-fe 1 MO; GC gm GC* caps 1 mg-20 mcg-75 mg ceftriaxone sodium solr iv MO; GC* 4 norethin acet & estrad-fe 1 MO; GC 10 gm chew 1 mg-20 mcg-75 mg ceftriaxone sodium solr iv 2 4 SL(2 ea daily); norethin acet & estrad-fe MO; GC gm MO; GC* tabs 1 mg-20 mcg-75 mg, 1 Cephalosporins - 4th Generation 1.5 mg-30 mcg-75 mg MO; GC* norethindrone & eth 1 MO; GC cefepime hcl solr 4 estradiol tabs norethindrone & ethinyl MO; GC CEFEPIME SOLN 4 GC* 1 estradiol-fe chew Cephalosporins - 5th Generation norethindrone acet & eth 1 MO; GC estra tabs TEFLARO SOLR 4 GC* norethindrone-eth estradiol 1 MO; GC CONTRACEPTIVES - Drugs to Prevent (triphasic) tabs Pregnancy norgestimate-ethinyl 1 MO; GC estradiol (triphasic) tabs Combination Contraceptives - Oral norgestimate-ethinyl 1 MO; GC desogestrel & ethinyl 1 MO; GC estradiol tabs estradiol tabs norgestrel & ethinyl MO; GC desogestrel-ethinyl 1 MO; GC estradiol tabs 0.3 mg-30 1 estradiol (biphasic) tabs mcg drospirenone-ethinyl 1 MO; GC estradiol tabs Combination Contraceptives - Transdermal You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary Updated 09/01/2021 45 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits norelgestromin-ethinyl 1 MO; GC dexamethasone soln 0.5 1 MO; GC estradiol ptwk mg/5ml Combination Contraceptives - Vaginal dexamethasone tabs 1 mg, MO; GC 1 MO; GC 1.5 mg, 2 mg, 4 mg, 0.5 etonogestrel-ethinyl 1 mg, 0.75 mg, 6 mg estradiol ring dexamethasone tbpk 1.5 1 MO; GC Emergency Contraceptives mg GC* ELLA TABS 2 EMFLAZA SUSP 5^ PA; GC* Progestin Contraceptives - Injectable EMFLAZA TABS 5^ PA; GC* DEPO-SUBQ PROVERA 4 MO; GC* 104 SUSY hydrocortisone tabs 1 MO; GC medroxyprogesterone MO; GC* acetate (contraceptive) 4 KENALOG-10 SUSP 4 MO; GC* susp MO; GC* medroxyprogesterone MO; GC* MEDROL TABS 2 MG 2 acetate (contraceptive) 4 susy methylprednisolone acetate 1 MO; GC susp 80 mg/ml, 40 mg/ml Progestin Contraceptives - Oral methylprednisolone sod 1 MO; GC norethindrone 1 MO; GC succ solr (contraceptive) tabs methylprednisolone tabs 1 MO; GC SLYND TABS 3 MO; GC* methylprednisolone tbpk 1 MO; GC CORTICOSTEROIDS - Steroid Hormone Drugs to Treat Systemic Swelling Conditions prednisolone sodium MO; GC phosphate soln or 15 1 Glucocorticosteroids mg/5ml, 25 mg/5ml, 5 betamethasone sod 4 MO; GC* mg/5ml, 6.7 mg/5ml phosphate & acetate susp prednisolone sodium MO; GC budesonide cpep 3 mg 1 MO; GC phosphate tbdp or 10 mg, 1 15 mg, 30 mg MO; GC* budesonide tb24 9 mg 5^ prednisolone soln 15 1 MO; GC mg/5ml cortisone acetate tabs 1 MO; GC prednisolone tabs 5 mg 1 MO; GC DEPO-MEDROL SUSP 20 MO; GC* 4 PREDNISONE INTENSOL MO; GC* MG/ML 3 CONC dexamethasone elix 0.5 MO; GC 1 MO; GC mg/5ml prednisone soln 1 dexamethasone sodium 4 GC* MO; GC phosphate soln ij 10 mg/ml prednisone tabs 1 dexamethasone sodium 4 Preservative MO; GC phosphate soln ij 10 mg/ml Free;MO; GC* prednisone tbpk 1 dexamethasone sodium MO; GC* SOLU-CORTEF SOLR 100 4 MO; GC* MG, 250 MG, 500 MG phosphate soln ij 100 4 mg/10ml, 120 mg/30ml, 20 SOLU-CORTEF SOLR 4 GC* mg/5ml, 4 mg/ml 1000 MG You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary 46 Updated 09/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SOLU-MEDROL SOLR 2 4 GC* CLEOCIN-T GEL MO; GC* GM (clindamycin phosphate 3 triamcinolone acetonide MO; GC* (topical)) susp 200 mg/5ml, 40 4 CLINDAGEL GEL MO; GC* mg/ml, 400 mg/10ml (clindamycin phosphate 3 (topical)) Mineralocorticoids MO; GC clindamycin phosphate 1 MO; GC fludrocortisone acetate 1 (topical) foam tabs clindamycin phosphate 1 MO; GC COUGH/COLD/ALLERGY - Drugs to Treat (topical) gel Cough, Cold and Allergy Symptoms clindamycin phosphate 1 MO; GC Antitussives (topical) lotn benzonatate caps 150 mg, MO; NT; GC 1 clindamycin phosphate 1 QL(2 ml daily); 200 mg, 100 mg (topical) soln MO; GC Cough/Cold/Allergy Combinations clindamycin phosphate 1 MO; GC (topical) swab CLARINEX-D 12 HOUR 3 MO; GC* TB12 clindamycin phosphate- MO; GC hydrocodone polistirex- AL(Up to 64 yrs benzoyl peroxide 1 chlorpheniramine polistirex 1 old); MO; NT; (refrigerate) gel suer GC clindamycin phosphate- 1 MO; GC benzoyl peroxide gel promethazine & 1 AL(Up to 64 yrs phenylephrine syrp old); MO; GC clindamycin phosphate- 1 MO; GC promethazine- AL(Up to 64 yrs tretinoin gel phenylephrine-codeine 1 old); MO; NT; erythromycin (acne aid) gel 1 MO; GC syrp GC erythromycin (acne aid) 1 MO; GC Mucolytics soln acetylcysteine soln 1 B/D; MO; GC Limit 100gms per DERMATOLOGICALS - Drugs to Treat Skin FABIOR FOAM 3 month;QL(3.34 Conditions gm daily); MO; Acne Products GC* ABSORICA CAPS 10 MG, GC* isotretinoin caps 1 GC 20 MG, 40 MG 3 (isotretinoin) RETIN-A MICRO PUMP 3 QL(1.67 gm GEL 0.08 % daily); MO; GC* adapalene crea 0.1 % 1 MO; GC sulfacetamide sodium 1 MO; GC RX/OTC; MO; (acne) lotn adapalene gel 0.1 % 1 GC Limit 100gms MO; GC per adapalene gel 0.3 % 1 TAZAROTENE FOAM 3 month;QL(3.34 gm daily); MO; adapalene-benzoyl 1 MO; GC GC* peroxide gel QL(1.5 gm tretinoin crea 1 AZELEX CREA 3 MO; GC* daily); MO; GC QL(1.5 gm benzoyl peroxide- 1 MO; GC tretinoin gel 1 erythromycin gel daily); MO; GC You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary Updated 09/01/2021 47 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(1.67 gm MO; GC tretinoin microsphere gel 1 luliconazole crea 1 daily); MO; GC Anti-inflammatory Agents - Topical LUZU CREA (luliconazole) 3 MO; GC* PA; MO; GC diclofenac epolamine ptch 1 MENTAX CREA 2 RX/OTC; MO; GC* SL(33.34 gm diclofenac sodium (topical) 1 daily); RX/OTC; naftifine hcl crea 2 %, 1 % 1 MO; GC gel 1 % MO; GC naftifine hcl gel 1 % 1 MO; GC diclofenac sodium (topical) 1 QL(15 ml soln 1.5 % daily); MO; GC NAFTIN GEL 1 % (naftifine 3 MO; GC* FLECTOR PTCH 3 PA; MO; GC* hcl) (diclofenac epolamine) MO; GC* PA; QL(8 gm NAFTIN GEL 2 % 3 PENNSAID SOLN 5^ daily); MO; GC* QL(2 gm daily); nystatin (topical) crea 1 Antibiotics - Topical MO; GC QL(2 gm daily); CENTANY OINT 3 QL(0.74 gm nystatin (topical) oint 1 daily); MO; GC* MO; GC QL(2 gm daily); gentamicin sulfate (topical) 1 MO; GC nystatin (topical) powd 1 crea MO; GC QL(0.74 gm MO; GC mupirocin oint 1 nystatin-triamcinolone crea 1 daily); MO; GC MO; GC Antifungals - Topical nystatin-triamcinolone oint 1 MO; GC QL(3 gm daily); ciclopirox gel 0.77 % 1 oxiconazole nitrate crea 1 MO; GC MO; GC ciclopirox olamine crea 1 OXISTAT LOTN 3 QL(2 ml daily); MO; GC* ciclopirox olamine susp 1 MO; GC tavaborole soln 1 PA; MO; GC MO; GC ciclopirox sham 1 % 1 Antineoplastic or Premalignant Lesion Agents - RX/OTC; MO; CARAC CREA (fluorouracil MO; GC* clotrimazole (topical) crea 1 5^ GC (topical)) RX/OTC; MO; PA; QL(3.34 clotrimazole (topical) soln 1 diclofenac sodium (actinic 3 gm daily); MO; GC keratoses) gel QL(3 gm daily); GC* econazole nitrate crea 1 MO; GC fluorouracil (topical) crea 5^ MO; GC* 0.5 % ERTACZO CREA 3 MO; GC* fluorouracil (topical) crea 5 1 MO; GC % JUBLIA SOLN 3 PA; MO; GC* fluorouracil (topical) soln 2 MO; GC QL(2 gm daily); 1 ketoconazole (topical) crea 1 %, 5 % MO; GC PANRETIN GEL 5^ GC* QL(3.34 gm ketoconazole (topical) foam 1 daily); MO; GC PICATO GEL 5^ GC* ketoconazole (topical) 1 QL(4 ml daily); sham MO; GC You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary 48 Updated 09/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; GC* TARGRETIN GEL EX 1 % 5^ PA; QL(2 gm TALTZ SOAJ 5^ daily); GC* PA; GC* VALCHLOR GEL 5^ PA; MO; GC* TALTZ SOSY 5^ Antipruritics - Topical tazarotene crea 1 MO; GC doxepin hcl (antipruritic) 3 PA; QL(1.5 gm MO; GC* crea daily); MO; GC* TAZORAC CREA 0.05 % 2 PRUDOXIN CREA PA; QL(1.5 gm 3 TAZORAC GEL 0.05 %, 2 MO; GC* (doxepin hcl (antipruritic)) daily); MO; GC* 0.1 % ZONALON CREA (doxepin 3 PA; QL(1.5 gm PA; GC* hcl (antipruritic)) daily); MO; GC* TREMFYA SOPN 5^ Antipsoriatics TREMFYA SOSY 5^ PA; GC* acitretin caps 10 mg, 25 1 MO; GC mg VECTICAL OINT (calcitriol 3 MO; GC* (topical)) MO; GC* acitretin caps 17.5 mg 5^ Antiseborrheic Products QL(4 gm daily); calcipotriene crea 1 selenium sulfide lotn 2.5 % 1 MO; GC MO; GC QL(4 gm daily); calcipotriene foam 1 Antivirals - Topical MO; GC QL(1 gm daily); QL(4 gm daily); acyclovir topical crea 5^ calcipotriene oint 1 MO; GC* MO; GC acyclovir topical oint 1 MO; GC QL(4 ml daily); calcipotriene soln 1 MO; GC DENAVIR CREA 5^ MO; GC* calcitriol (topical) oint 1 MO; GC XERESE CREA 3 MO; GC* COSENTYX 5^ PA; LA; GC* SENSOREADY PEN SOAJ Burn Products COSENTYX SOSY 150 5^ PA; LA; GC* MO; GC MG/ML silver sulfadiazine crea 1 SULFAMYLON CREA 85 MO; GC* COSENTYX SOSY 150 5^ PA; GC* 3 MG/ML, 75 MG/0.5ML MG/GM ILUMYA SOSY 5^ PA; GC* Corticosteroids - Topical alclometasone dipropionate 1 MO; GC methoxsalen rapid caps 5^ MO; GC* crea PA; GC* alclometasone dipropionate 1 MO; GC SILIQ SOSY 5^ oint MO; GC SKYRIZI PSKT 75 5^ PA; GC* amcinonide crea 1 MG/0.83ML betamethasone MO; GC SORILUX FOAM 3 QL(4 gm daily); 1 MO; GC* dipropionate (topical) crea PA; GC* betamethasone 1 MO; GC STELARA SOLN 5^ dipropionate (topical) lotn PA; GC* betamethasone 1 MO; GC STELARA SOSY 5^ dipropionate (topical) oint You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary Updated 09/01/2021 49 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MO; GC SL(7.15 ml betamethasone clobetasol propionate soln 1 dipropionate augmented 1 daily); MO; GC crea clocortolone pivalate crea 1 MO; GC betamethasone MO; GC dipropionate augmented 1 CLODERM CREA 3 MO; GC* gel (clocortolone pivalate) betamethasone MO; GC CORDRAN TAPE 4 3 MO; GC* dipropionate augmented 1 MCG/SQCM lotn QL(2 gm daily); desonide crea 1 betamethasone MO; GC MO; GC dipropionate augmented 1 QL(3.94 ml desonide lotn 1 oint daily); MO; GC betamethasone valerate MO; GC QL(2 gm daily); 1 desonide oint 1 crea MO; GC betamethasone valerate MO; GC 1 desoximetasone crea 0.05 1 QL(3.34 gm foam %, 0.25 % daily); MO; GC betamethasone valerate 1 MO; GC MO; GC lotn desoximetasone gel 0.05 % 1 betamethasone valerate MO; GC 1 desoximetasone liqd 0.25 1 MO; GC oint % calcipotriene- SL(14.29 gm desoximetasone oint 0.05 1 MO; GC betamethasone 5^ daily); MO; GC* %, 0.25 % dipropionate oint MO; GC calcipotriene- SL(14.29 gm diflorasone diacetate crea 1 betamethasone 5^ daily); MO; GC* QL(2 gm daily); diflorasone diacetate oint 1 dipropionate susp MO; GC MO; GC* CAPEX SHAM 3 ENSTILAR FOAM 5^ QL(4 gm daily); MO; GC* SL(7.15 gm clobetasol propionate crea 1 MO; GC daily); MO; GC fluocinolone acetonide crea 1 clobetasol propionate 1 SL(7.15 gm MO; GC emollient base crea daily); MO; GC fluocinolone acetonide oil 1 Non- fluocinolone acetonide oint 1 MO; GC emulsion;SL(7. clobetasol propionate foam 1 15 gm daily); MO; GC MO; GC fluocinolone acetonide soln 1 SL(7.15 gm MO; GC clobetasol propionate gel 1 fluocinonide crea 0.05 % 1 daily); MO; GC SL(8.43 ml fluocinonide emulsified MO; GC clobetasol propionate liqd 1 1 daily); MO; GC base crea SL(7.15 ml MO; GC clobetasol propionate lotn 1 fluocinonide gel 0.05 % 1 daily); MO; GC SL(7.15 gm fluocinonide oint 0.05 % 1 MO; GC clobetasol propionate oint 1 daily); MO; GC MO; GC SL(7.15 ml fluocinonide soln 0.05 % 1 clobetasol propionate sham 1 daily); MO; GC flurandrenolide crea 1 MO; GC You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary 50 Updated 09/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(4 ml daily); TACLONEX SUSP SL(14.29 gm flurandrenolide lotn 1 MO; GC (calcipotriene- 5^ daily); MO; GC* MO; GC betamethasone fluticasone propionate crea 1 dipropionate) fluticasone propionate lotn 1 MO; GC triamcinolone acetonide 1 MO; GC (topical) aers 0.147 mg/gm fluticasone propionate oint 1 MO; GC triamcinolone acetonide MO; GC (topical) crea 0.025 %, 0.5 1 halcinonide crea 1 MO; GC %, 0.1 % triamcinolone acetonide MO; GC halobetasol propionate 1 QL(1.67 gm (topical) lotn 0.025 %, 0.1 1 crea daily); MO; GC % halobetasol propionate oint 1 MO; GC triamcinolone acetonide MO; GC (topical) oint 0.025 %, 0.1 1 hydrocortisone (topical) 1 RX/OTC; MO; %, 0.5 % crea 1 % GC ULTRAVATE LOTN 5^ PA; MO; GC* hydrocortisone (topical) 1 MO; GC crea 2.5 % Emollients hydrocortisone (topical) MO; GC 1 lactic acid (ammonium 1 RX/OTC; MO; lotn 2.5 % lactate) crea GC hydrocortisone (topical) RX/OTC; MO; 1 lactic acid (ammonium 1 RX/OTC; MO; oint 1 % GC lactate) lotn GC hydrocortisone (topical) 1 MO; GC oint 2.5 % Enzymes - Topical MO; GC* hydrocortisone butyrate 1 QL(1.5 gm SANTYL OINT 3 crea daily); MO; GC Immunomodulating Agents - Topical hydrocortisone butyrate 1 QL(1.5 gm hydrophilic lipo base crea daily); MO; GC imiquimod crea 3.75 % 5^ MO; GC* hydrocortisone butyrate 1 QL(3.94 ml lotn daily); MO; GC imiquimod crea 5 % 1 MO; GC hydrocortisone butyrate 1 QL(1.5 gm oint daily); MO; GC ZYCLARA CREA 5^ MO; GC* (imiquimod) hydrocortisone butyrate 1 QL(2 ml daily); soln MO; GC ZYCLARA PUMP CREA 5^ MO; GC* 2.5 % hydrocortisone valerate 1 MO; GC crea ZYCLARA PUMP CREA 5^ MO; GC* 3.75 % (imiquimod) hydrocortisone valerate 1 MO; GC oint Immunosuppressive Agents - Topical MO; GC PA; QL(3.34 mometasone furoate crea 1 pimecrolimus crea 1 gm daily); MO; GC mometasone furoate oint 1 MO; GC tacrolimus (topical) oint 1 PA; MO; GC mometasone furoate soln 1 MO; GC Keratolytic/Antimitotic Agents TACLONEX SUSP 5^ SL(14.29 gm MO; GC* daily); MO; GC* CONDYLOX GEL 3 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary Updated 09/01/2021 51 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits podofilox soln 1 MO; GC DIGESTIVE AIDS - Drugs to Treat Low Digestive Enzymes Local Anesthetics - Topical Digestive Enzymes QL(4 ml daily); lidocaine hcl gel ex 2 % 1 CREON CPEP 12000 MO; GC* MO; GC UNIT-38000 UNIT-60000 lidocaine hcl prsy ex 2 % 1 MO; GC UNIT, 3000 UNIT-9500 UNIT-15000 UNIT, 36000 2 QL(6.67 ml lidocaine hcl soln ex 4 % 1 UNIT-114000 UNIT-180000 daily); MO; GC UNIT, 6000 UNIT-19000 QL(3 gm daily); UNIT-30000 UNIT lidocaine oint ex 5 % 1 MO; GC CREON CPEP 24000 MO; GC* PA; SL(3 ea UNIT-76000 UNIT-120000 3 lidocaine ptch ex 5 % 1 daily); MO; GC UNIT QL(1 gm daily); LA; MO; GC* lidocaine-prilocaine crea 1 SUCRAID SOLN 3 MO; GC ZENPEP CPEP 10000 MO; GC* Rosacea Agents UNIT-32000 UNIT-42000 azelaic acid gel 1 MO; GC UNIT, 15000 UNIT-47000 UNIT-63000 UNIT, 20000 MO; GC doxycycline (rosacea) cpdr 1 UNIT-63000 UNIT-84000 3 UNIT, 25000 UNIT-79000 FINACEA FOAM 3 MO; GC* UNIT-105000 UNIT, 3000 UNIT-10000 UNIT-14000 MO; GC UNIT, 5000 UNIT-17000 ivermectin (rosacea) crea 1 UNIT-24000 UNIT metronidazole (topical) 1 MO; GC ZENPEP CPEP 40000 MO; GC* crea UNIT-126000 UNIT-168000 5^ UNIT metronidazole (topical) gel 1 MO; GC DIURETICS - Drugs to Treat Heart, Circulation metronidazole (topical) lotn 1 MO; GC Conditions and Blood Pressure Carbonic Anhydrase Inhibitors MIRVASO GEL 3 PA; MO; GC* acetazolamide cp12 1 MO; GC NORITATE CREA 5^ MO; GC* acetazolamide tabs 1 MO; GC ORACEA CPDR MO; GC* 3 PA; SL(4 ea (doxycycline (rosacea)) KEVEYIS TABS 5^ daily); MO; GC* Scabicides & Pediculicides methazolamide tabs 1 MO; GC crotamiton lotn 1 MO; GC Diuretic Combinations malathion lotn 1 MO; GC ALDACTAZIDE TABS 50 2 MO; GC* MG-50 MG permethrin crea 1 MO; GC amiloride & 1 MO; GC Wound Care Products hydrochlorothiazide tabs MO; GC* spironolactone & 1 MO; GC REGRANEX GEL 5^ hydrochlorothiazide tabs You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary 52 Updated 09/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits triamterene & 1 MO; GC calcitonin (salmon) soln na 1 MO; GC hydrochlorothiazide caps 200 unit/act triamterene & 1 MO; GC EVENITY SOSY 5^ PA; GC* hydrochlorothiazide tabs Loop Diuretics PA; Limit 2.4mls per 28 FORTEO SOPN 5^ bumetanide tabs or 0.5 mg, 1 MO; GC days;QL(0.09 1 mg, 2 mg ml daily); GC* MO; GC ethacrynic acid tabs 1 FOSAMAX PLUS D TABS 3 QL(0.15 ea daily); MO; GC* furosemide soln ij 10 mg/ml 4 MO; GC* ibandronate sodium soln iv 4 QL(0.036 ml 3 mg/3ml daily); MO; GC* furosemide soln or 10 1 MO; GC mg/ml Limit 1 tab per 28 days (3 per ibandronate sodium tabs or furosemide tabs or 20 mg, 1 MO; GC 1 84);QL(0.036 40 mg, 80 mg 150 mg ea daily); MO; torsemide tabs 1 MO; GC GC NATPARA CART 5^ PA; LA; GC* Potassium Sparing Diuretics amiloride hcl tabs 1 MO; GC PROLIA SOSY 2 PA; QL(0.006 ml daily); GC* MO; GC spironolactone tabs 1 risedronate sodium tabs 1 QL(0.04 ea 150 mg daily); MO; GC MO; GC triamterene caps 1 risedronate sodium tabs 30 1 QL(1 ea daily); mg, 5 mg MO; GC Thiazides and Thiazide-Like Diuretics risedronate sodium tabs 35 1 QL(0.15 ea chlorthalidone tabs 1 MO; GC mg daily); MO; GC risedronate sodium tbec 35 1 QL(0.15 ea hydrochlorothiazide caps 1 MO; GC mg daily); MO; GC PA; Limit MO; GC hydrochlorothiazide tabs 1 5^ 2.4mls per 28 TERIPARATIDE SOPN days;QL(0.09 indapamide tabs 1 MO; GC ml daily); GC* TYMLOS SOPN 5^ PA; GC* metolazone tabs 1 MO; GC PA; Limit ENDOCRINE AND METABOLIC AGENTS - 5^ 6.8mls per 28 MISC. - Drugs to Treat Bone Disease and XGEVA SOLN days;QL(0.243 Regulate Hormones ml daily); GC* Bone Density Regulators zoledronic acid conc 4 4 GC* mg/5ml alendronate sodium tabs 1 MO; GC 10 mg Limit 1 dose zoledronic acid soln 5 per alendronate sodium tabs 1 QL(0.15 ea 1 70 mg, 35 mg daily); MO; GC mg/100ml year;QL(0.28 ml daily); GC calcitonin (salmon) soln ij 4 MO; GC* 200 unit/ml Corticotropin You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary Updated 09/01/2021 53 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; LA; GC* QL(1 ea daily); ACTHAR GEL 5^ raloxifene hcl tabs 1 MO; GC Fertility Regulators Insulin-Like Growth Factor Receptor Inhibitors CHORIONIC 4 PA; GC* PA; GC* GONADOTROPIN SOLR TEPEZZA SOLR 5^ NOVAREL SOLR 4 PA; GC* Insulin-Like Growth Factors (Somatomedins) LA; GC* PREGNYL W/DILUENT PA; GC* INCRELEX SOLN 4 BENZYLALCOHOL/NACL 4 SOLR LHRH/GnRH Agonist Analog Pituitary GC* GnRH/LHRH Antagonists FENSOLVI KIT 4 PA; MO; GC* ORILISSA TABS 5^ LUPANETA PACK KIT 5^ GC* Growth Hormone Receptor Antagonists LUPRON DEPOT-PED (1- GC* PA; LA; GC* MONTH) KIT 11.25 MG, 5^ SOMAVERT SOLR 5^ 7.5 MG Growth Hormone Releasing Hormones (GHRH) LUPRON DEPOT-PED (1- 4 GC* MONTH) KIT 15 MG EGRIFTA SV SOLR 5^ GC* LUPRON DEPOT-PED (3- 5^ GC* MONTH) KIT Growth Hormones SYNAREL SOLN 5^ MO; GC* GENOTROPIN MINIQUICK 4 PA; GC* SOLR 0.4 MG TRIPTODUR SRER 5^ MO; GC* GENOTROPIN SOLR 5 4 PA; GC* MG Metabolic Modifiers HUMATROPE COMBO 5^ PA; GC* PACK SOLR calcitriol caps or 0.25 mcg, 1 MO; GC 0.5 mcg HUMATROPE SOLR 12 5^ PA; GC* MG, 24 MG calcitriol soln or 1 mcg/ml 1 MO; GC PA; GC* HUMATROPE SOLR 6 MG 4 CARBAGLU TABS 5^ LA; MO; GC* NORDITROPIN FLEXPRO PA; GC* GC SOPN 10 MG/1.5ML, 5 5^ cinacalcet hcl tabs 30 mg 1 MG/1.5ML cinacalcet hcl tabs 60 mg, 5^ GC* NUTROPIN AQ NUSPIN 5^ PA; GC* 90 mg 20 SOPN CRYSVITA SOLN 5^ PA; LA; GC* OMNITROPE SOCT 10 5^ PA; GC* MG/1.5ML, 5 MG/1.5ML CYSTADANE POWD 3 LA; MO; GC* SEROSTIM SOLR 4 MG, 6 5^ PA; GC* MG doxercalciferol caps or 0.5 1 MO; GC mcg, 1 mcg, 2.5 mcg ZOMACTON SOLR 5 MG 4 PA; GC* FABRAZYME SOLR 5^ LA; GC* Hormone Receptor Modulators PA; LA; GC* OSPHENA TABS 3 MO; GC* GALAFOLD CAPS 5^ KANUMA SOLN 5^ LA; GC* You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary 54 Updated 09/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KUVAN TABS 100 MG PA; GC* cabergoline tabs 1 MO; GC (sapropterin 5^ dihydrochloride) Somatostatic Agents levocarnitine (metabolic 1 MO; GC octreotide acetate soln 100 GC* modifiers) tabs 330 mg mcg/ml, 500 mcg/ml, 50 4 LUMIZYME SOLR 5^ LA; GC* mcg/ml, 1000 mcg/ml, 200 mcg/ml LA; MO; GC* MYALEPT SOLR 5^ SANDOSTATIN LAR 5^ GC* DEPOT KIT NAGLAZYME SOLN 5^ LA; GC* Limit 6 vials per 28 SIGNIFOR LAR SRER 10 nitisinone caps 1 MO; GC 5^ days;SL(0.22 MG ea daily); LA; ORFADIN CAPS 20 MG 2 LA; MO; GC* MO; GC* Limit 3 vials per PALYNZIQ SOSY 5^ PA; LA; GC* 28 SIGNIFOR LAR SRER 20 5^ days;SL(0.11 MG paricalcitol caps or 1 mcg, 1 MO; GC ea daily); LA; 2 mcg, 4 mcg MO; GC* SL(17.5 ml RAVICTI LIQD 3 Limit 2 vials per daily); LA; GC* 28 SIGNIFOR LAR SRER 30 RAYALDEE CPCR 3 PA; MO; GC* 5^ days;SL(0.08 MG ea daily); LA; PA; LA; MO; MO; GC* REVCOVI SOLN 5^ GC* Limit 3 vials per sapropterin dihydrochloride PA; GC* 5^ SIGNIFOR LAR SRER 40 56 pack 5^ days;SL(0.054 MG ea daily); LA; sapropterin dihydrochloride 5^ PA; GC* tabs MO; GC* Limit 1 vial per STRENSIQ SOLN 5^ PA; LA; MO; GC* 28 SIGNIFOR LAR SRER 60 5^ days;SL(0.036 VIMIZIM SOLN 5^ LA; GC* MG ea daily); LA; MO; GC* SL(4 ea daily); XURIDEN PACK 5^ MO; GC* SIGNIFOR SOLN 5^ LA; MO; GC* Posterior Pituitary Hormones SOMATULINE DEPOT 5^ GC* SOLN desmopressin acetate soln 4 MO; GC* ij 4 mcg/ml Vasopressin Receptor Antagonists desmopressin acetate MO; GC 1 JYNARQUE TABS 15 MG, 5^ MO; GC* spray refrigerated soln 30 MG desmopressin acetate 1 MO; GC PA; LA; GC* spray soln JYNARQUE TBPK 5^ desmopressin acetate tabs MO; GC 1 JYNARQUE TBPK 15 MG, 5^ PA; LA; MO; or 0.1 mg, 0.2 mg GC* GC* STIMATE SOLN 3 SAMSCA TABS 15 MG 5^ MO; GC* (tolvaptan) Prolactin Inhibitors You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary Updated 09/01/2021 55 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits tolvaptan tabs 15 mg, 30 5^ MO; GC* PREMARIN TABS OR 0.3 AL(Up to 64 yrs mg MG, 0.45 MG, 0.625 MG, 3 old); MO; GC* 0.9 MG, 1.25 MG ESTROGENS - Hormone Replacement/Modifying Drugs FLUOROQUINOLONES - Drugs to Treat Bacterial Infections Estrogen Combinations AL(Up to 64 yrs Fluoroquinolones CLIMARA PRO PTWK 3 old); MO; GC* BAXDELA SOLR IV 300 5^ PA; GC* AL(Up to 64 yrs MG COMBIPATCH PTTW 3 old); MO; GC* BAXDELA TABS OR 450 5^ ST; MO; GC* AL(Up to 64 yrs MG DUAVEE TABS 3 old); MO; GC* CIPRO SUSR 5 3 MO; GC* GM/100ML, 500 MG/5ML estradiol & norethindrone 1 AL(Up to 64 yrs acetate tabs old); MO; GC ciprofloxacin hcl tabs 1 MO; GC norethindrone acetate- AL(Up to 64 yrs ethinyl estradiol tabs 0.5 1 old); MO; GC ciprofloxacin in d5w soln 5 4 GC* mg-2.5 mcg %-200 mg/100ml ciprofloxacin in d5w soln 5 MO; GC* PREMPHASE TABS 3 AL(Up to 64 yrs 4 old); MO; GC* %-400 mg/200ml MO; GC PREMPRO TABS 3 AL(Up to 64 yrs ciprofloxacin susr 1 old); MO; GC* GC* Estrogens levofloxacin in d5w soln 4 DELESTROGEN OIL 10 MO; GC* 4 levofloxacin soln iv 25 4 GC* MG/ML mg/ml AL(Up to 64 yrs DIVIGEL GEL 3 levofloxacin soln or 25 1 MO; GC old); MO; GC* mg/ml AL(Up to 64 yrs ELESTRIN GEL 3 levofloxacin tabs or 250 1 MO; GC old); MO; GC* mg, 500 mg, 750 mg estradiol pttw td 0.025 AL(Up to 64 yrs moxifloxacin hcl tabs 1 MO; GC mg/24hr, 0.0375 mg/24hr, 1 old); MO; GC 0.05 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr GASTROINTESTINAL AGENTS - MISC. - Miscellaneous Gastrointestinal Drugs estradiol ptwk td 0.025 AL(Up to 64 yrs mg/24hr, 0.075 mg/24hr, old); MO; GC Farnesoid X Receptor (FXR) Agonists 0.1 mg/24hr, 0.05 mg/24hr, 1 PA; SL(1 ea OCALIVA TABS 10 MG 5^ 0.06 mg/24hr, 37.5 daily); GC* mcg/24hr PA; SL(2 ea OCALIVA TABS 5 MG 5^ estradiol tabs or 0.5 mg, 1 1 AL(Up to 64 yrs daily); GC* mg, 2 mg old); MO; GC Gallstone Solubilizing Agents estradiol valerate oil 4 MO; GC* CHENODAL TABS 5^ LA; MO; GC* EVAMIST SOLN 3 AL(Up to 64 yrs old); MO; GC* ursodiol caps 1 MO; GC MENOSTAR PTWK 3 AL(Up to 64 yrs MO; GC old); MO; GC* ursodiol tabs 1 Gastrointestinal Antiallergy Agents You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary 56 Updated 09/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits cromolyn sodium 1 MO; GC Intestinal Acidifiers (mastocytosis) conc lactulose (encephalopathy) 1 MO; GC Gastrointestinal Chloride Channel Activators soln AMITIZA CAPS 2 MO; GC* Irritable Bowel Syndrome (IBS) Agents (lubiprostone) alosetron hcl tabs 5^ PA; MO; GC* lubiprostone caps 1 MO; GC LINZESS CAPS 2 MO; GC* Gastrointestinal Stimulants PA; MO; GC* metoclopramide hcl soln ij 4 MO; GC* VIBERZI TABS 5^ 5 mg/ml Peripheral Opioid Receptor Antagonists metoclopramide hcl soln or 1 MO; GC 10 mg/10ml, 5 mg/5ml MOVANTIK TABS 3 MO; GC* metoclopramide hcl tabs or 1 MO; GC 10 mg, 5 mg RELISTOR SOLN SC 12 5^ MO; GC* MG/0.6ML, 8 MG/0.4ML Inflammatory Bowel Agents RELISTOR TABS OR 150 5^ PA; MO; GC* balsalazide disodium caps 1 MO; GC MG Phosphate Binder Agents CIMZIA KIT 5^ PA; GC* calcium acetate (phosphate 1 MO; GC CIMZIA STARTER KIT KIT 5^ PA; GC* binder) caps calcium acetate (phosphate 1 RX/OTC; MO; ENTYVIO SOLR 5^ PA; GC* binder) tabs GC lanthanum carbonate chew 5^ MO; GC* INFLECTRA SOLR 5^ PA; GC* sevelamer carbonate pack 5^ MO; GC* mesalamine cp24 or 0.375 1 MO; GC 0.8 gm, 2.4 gm gm sevelamer carbonate tabs 1 MO; GC mesalamine cpdr or 400 1 MO; GC 800 mg mg Short Bowel Syndrome (SBS) Agents mesalamine enem re 4 gm 1 MO; GC GATTEX KIT 5^ PA; LA; GC* mesalamine supp re 1000 5^ MO; GC* mg Tryptophan Hydroxylase Inhibitors mesalamine tbec or 1.2 MO; GC 1 XERMELO TABS 5^ PA; LA; MO; gm, 800 mg GC* mesalamine w/ cleanser kit 1 MO; GC GENITOURINARY AGENTS - MISCELLANEOUS - Miscellaneous Drugs to Treat Reproductive REMICADE SOLR 5^ PA; GC* Organs and Urinary System Alkalinizers RENFLEXIS SOLR 5^ PA; GC* potassium citrate 1 MO; GC STELARA SOLN 5^ PA; GC* (alkalinizer) tbcr Cystinosis Agents sulfasalazine tabs 1 MO; GC CYSTAGON CAPS 3 GC* sulfasalazine tbec 1 MO; GC You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary Updated 09/01/2021 57 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PROCYSBI CPDR 25 MG, 3 GC* Aminolevulinate Synthase 1-Directed siRNA 75 MG GIVLAARI SOLN 5^ PA; MO; GC* Genitourinary Irrigants acetic acid soln 1 MO; GC Bradykinin B2 Receptor Antagonists icatibant acetate soln 5^ PA; GC* neomycin/polymyxin b gu 1 MO; GC soln Complement Inhibitors sodium chloride (gu 1 MO; GC irrigant) soln BERINERT KIT 5^ PA; LA; GC* Interstitial Cystitis Agents CINRYZE SOLR 5^ PA; LA; GC* ELMIRON CAPS 3 MO; GC* HAEGARDA SOLR 5^ PA; GC* Prostatic Hypertrophy Agents RUCONEST SOLR 5^ GC* alfuzosin hcl tb24 1 MO; GC Hemataologic - Tyrosine Kinase Inhibitors CARDURA XL TB24 3 MO; GC* TAVALISSE TABS 5^ PA; GC* dutasteride caps 1 MO; GC Hematorheologic Agents dutasteride-tamsulosin hcl 1 MO; GC MO; GC caps pentoxifylline tbcr 1 finasteride tabs 1 MO; GC Plasma Kallikrein Inhibitors GC* silodosin caps 1 MO; GC KALBITOR SOLN 5^ PA; GC* tamsulosin hcl caps 1 MO; GC TAKHZYRO SOLN 5^ Platelet Aggregation Inhibitors GOUT AGENTS - Drugs to Treat Gout anagrelide hcl caps 1 MO; GC Gout Agent Combinations aspirin-dipyridamole cp12 1 MO; GC colchicine w/ probenecid 1 MO; GC tabs MO; GC* Gout Agents BRILINTA TABS 2 SL(8 ea daily); PA; MO; GC* allopurinol tabs 100 mg 1 CABLIVI KIT 5^ MO; GC SL(2.66 ea MO; GC allopurinol tabs 300 mg 1 cilostazol tabs 1 daily); MO; GC MO; GC colchicine tabs 1 MO; GC clopidogrel bisulfate tabs 1 AL(Up to 64 yrs MO; GC dipyridamole tabs 1 febuxostat tabs 1 old); MO; GC Uricosurics prasugrel hcl tabs 1 MO; GC MO; GC probenecid tabs 1 ZONTIVITY TABS 2 MO; GC* HEMATOLOGICAL AGENTS - MISC. - Drugs to Treat Blood Disorders You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary 58 Updated 09/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HEMATOPOIETIC AGENTS - Drugs to Treat ARANESP ALBUMIN PA; GC* Blood Disorders FREE SOSY 100 MCG/0.5ML, 150 5^ Agents for Gaucher Disease MCG/0.3ML, 200 CERDELGA CAPS 5^ PA; GC* MCG/0.4ML, 300 MCG/0.6ML, 500 MCG/ML PA; LA; GC* CEREZYME SOLR 5^ DOPTELET TABS 5^ PA; LA; GC* GC* ELELYSO SOLR 5^ EPOGEN SOLN 10000 3 PA; GC* UNIT/ML miglustat caps 5^ LA; MO; GC* EPOGEN SOLN 2000 PA; GC* UNIT/ML, 3000 UNIT/ML, 4 VPRIV SOLR 5^ GC* 4000 UNIT/ML EPOGEN SOLN 20000 5^ PA; GC* Agents for Sickle Cell Disease UNIT/ML PA; GC* ADAKVEO SOLN 5^ MULPLETA TABS 5^ PA; GC* DROXIA CAPS 3 MO; GC* PROCRIT SOLN 10000 PA; GC* UNIT/ML, 2000 UNIT/ML, 2 ENDARI PACK 5^ PA; MO; GC* 3000 UNIT/ML, 4000 UNIT/ML PA; LA; GC* OXBRYTA TABS 5^ PROCRIT SOLN 20000 5^ PA; GC* UNIT/ML, 40000 UNIT/ML Cobalamins PROMACTA PACK 12.5 5^ PA; SL(12 ea cyanocobalamin soln 4 MO; NT; GC* MG daily); LA; GC* PA; SL(6 ea PROMACTA PACK 25 MG 5^ NASCOBAL SOLN 3 MO; NT; GC* daily); LA; GC* PROMACTA TABS 12.5 5^ PA; SL(12 ea Folic Acid/Folates MG daily); LA; GC* RX/OTC; MO; folic acid tabs 1 PROMACTA TABS 25 MG 5^ PA; SL(6 ea NT; GC daily); LA; GC* PA; SL(3 ea Hematopoietic Growth Factors PROMACTA TABS 50 MG 5^ ARANESP ALBUMIN PA; GC* daily); LA; GC* PA; SL(2 ea FREE SOLN 100 MCG/ML, 5^ PROMACTA TABS 75 MG 5^ 200 MCG/ML, 300 daily); LA; GC* MCG/ML REBLOZYL SOLR 5^ PA; GC* ARANESP ALBUMIN PA; GC* FREE SOLN 25 MCG/ML, 4 RETACRIT SOLN 10000 PA; GC* 40 MCG/ML, 60 MCG/ML UNIT/ML, 2000 UNIT/ML, ARANESP ALBUMIN PA; GC* 20000 UNIT/2ML, 3000 4 FREE SOSY 10 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML MCG/0.4ML, 25 4 MCG/0.42ML, 40 RETACRIT SOLN 20000 4 GC* MCG/0.4ML, 60 UNIT/ML MCG/0.3ML ZARXIO SOSY 5^ PA; GC* Stem Cell Mobilizers You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary Updated 09/01/2021 59 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MOZOBIL SOLN 5^ PA; GC* zolpidem tartrate tbcr or 1 SL(1 ea daily); 12.5 mg MO; GC HEMOSTATICS - Drugs to Stop Bleeding/Treat zolpidem tartrate tbcr or 1 SL(2 ea daily); Blood Disorders 6.25 mg MO; GC Hemostatics - Systemic Orexin Receptor Antagonists PA; SL(2 ea aminocaproic acid soln or 5^ MO; GC* BELSOMRA TABS 10 MG 3 0.25 gm/ml daily); MO; GC* PA; SL(1.33 ea aminocaproic acid tabs or 5^ MO; GC* BELSOMRA TABS 15 MG 3 1000 mg daily); MO; GC* PA; SL(1 ea aminocaproic acid tabs or 1 MO; GC BELSOMRA TABS 20 MG 3 500 mg daily); MO; GC* PA; SL(4 ea tranexamic acid soln iv 1 GC BELSOMRA TABS 5 MG 3 1000 mg/10ml daily); MO; GC* tranexamic acid tabs or 1 MO; GC Selective Melatonin Receptor Agonists 650 mg HETLIOZ CAPS 5^ PA; MO; GC* HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS SL(1 ea daily); ramelteon tabs 1 MO; GC Barbiturate Hypnotics AL(Up to 64 yrs phenobarbital elix 1 LAXATIVES - Bowel Treatment Drugs old); MO; GC AL(Up to 64 yrs Laxative Combinations phenobarbital soln 1 old); MO; GC CLENPIQ SOLN 3 MO; GC* AL(Up to 64 yrs phenobarbital tabs 1 old); MO; GC GOLYTELY SOLR 2.82 GC* GM-5.53 GM-6.36 GM-21.5 3 Hypnotics - Tricyclic Agents GM-227.1 GM doxepin hcl (sleep) tabs 3 1 QL(2 ea daily); peg 3350-kcl-nacl-na MO; GC mg MO; GC sulfate-na ascorbate- 1 ascorbic acid solr doxepin hcl (sleep) tabs 6 1 QL(1 ea daily); mg MO; GC peg 3350-kcl-sod bicarb- MO; GC Non-Barbiturate Hypnotics sod chloride-sod sulfate 1 solr MO; GC eszopiclone tabs 1 peg 3350-potassium MO; GC MO; GC chloride-sod bicarbonate- 1 temazepam caps 1 sod chloride solr MO; GC* zaleplon caps 1 MO; GC PLENVU SOLR 3 SUPREP BOWEL PREP MO; GC* zolpidem tartrate subl sl 1 SL(2 ea daily); 3 1.75 mg MO; GC KIT SOLN Laxatives - Miscellaneous zolpidem tartrate subl sl 3.5 1 SL(1 ea daily); mg MO; GC lactulose soln 10 gm/15ml, 1 MO; GC 20 gm/30ml zolpidem tartrate tabs or 10 1 SL(1 ea daily); mg MO; GC Saline Laxatives zolpidem tartrate tabs or 5 1 SL(2 ea daily); MO; GC* mg MO; GC OSMOPREP TABS 3 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary 60 Updated 09/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LOCAL ANESTHETICS-Parenteral - Drugs for MEDICAL DEVICES AND SUPPLIES Numbing Local Anesthetics - Amides Bandages-Dressings-Tape RX/OTC; MO; lidocaine hcl (local anesth.) 4 GC* gauze pads 2" x 2" 1 soln GC MACROLIDES - Drugs to Treat Bacterial Misc. Devices Infections ALCOHOL PADS 2 RX/OTC; MO; GC* Azithromycin Parenteral Therapy Supplies azithromycin pack or 1 gm 1 MO; GC INSULIN SYRINGES AND 2 RX/OTC; MO; PEN NEEDLES GC* azithromycin solr iv 500 mg 4 MO; GC* MIGRAINE PRODUCTS - Drugs to Treat Migraine azithromycin susr or 100 1 MO; GC Headaches mg/5ml, 200 mg/5ml Calcitonin Gene-Related Peptide (CGRP) azithromycin tabs or 250 1 MO; GC mg, 500 mg, 600 mg AIMOVIG SOAJ 4 PA; MO; GC* ZITHROMAX PACK OR 1 2 MO; GC* PA; MO; GC* GM (azithromycin) AJOVY SOSY 4 Clarithromycin EMGALITY SOAJ 120 4 PA; MO; GC* MG/ML clarithromycin susr 250 1 MO; GC mg/5ml EMGALITY SOSY 100 5^ PA; MO; GC* MG/ML clarithromycin tabs 250 mg, 1 MO; GC 500 mg EMGALITY SOSY 120 4 PA; MO; GC* MG/ML clarithromycin tb24 500 mg 1 MO; GC Migraine Combinations Erythromycins ergotamine w/ caffeine 1 MO; GC supp ERYTHROCIN 4 SL(8 ea daily); LACTOBIONATE SOLR GC* ergotamine w/ caffeine tabs 1 MO; GC erythromycin base cpep 1 SL(16 ea daily); 250 mg MO; GC sumatriptan-naproxen 1 MO; GC sodium tabs erythromycin base tabs 1 SL(16 ea daily); 250 mg MO; GC Migraine Products - NSAIDs erythromycin base tabs 1 SL(8 ea daily); MO; GC* 500 mg MO; GC CAMBIA PACK 3 erythromycin SL(100 ml Migraine Products ethylsuccinate susr 200 1 daily); MO; GC mg/5ml dihydroergotamine 1 MO; GC mesylate soln ij 1 mg/ml erythromycin SL(50 ml daily); ethylsuccinate susr 400 1 MO; GC dihydroergotamine 5^ MO; GC* mg/5ml mesylate soln na 4 mg/ml GC erythromycin 1 SL(10 ea daily); ergotamine tartrate subl 1 ethylsuccinate tabs 400 mg MO; GC MIGRANAL SOLN MO; GC* Fidaxomicin (dihydroergotamine 5^ ) DIFICID TABS 200 MG 5^ MO; GC* mesylate You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary Updated 09/01/2021 61 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SL(4 ea daily); Serotonin Agonists zolmitriptan tabs or 2.5 mg 1 QL(0.4 ea MO; GC almotriptan malate tabs 1 daily); MO; GC 1 SL(2 ea daily); zolmitriptan tabs or 5 mg MO; GC eletriptan hydrobromide QL(0.2 ea 1 SL(4 ea daily); tabs daily); MO; GC zolmitriptan tbdp or 2.5 mg 1 QL(0.6 ea MO; GC frovatriptan succinate tabs 1 SL(2 ea daily); daily); MO; GC zolmitriptan tbdp or 5 mg 1 QL(0.3 ea MO; GC naratriptan hcl tabs 1 daily); MO; GC ZOMIG SOLN NA 2.5 MG 3 SL(4 ea daily); ) QL(0.4 ea (zolmitriptan MO; GC* rizatriptan benzoate tabs 1 daily); MO; GC ZOMIG SOLN NA 5 MG 3 SL(2 ea daily); ( ) QL(0.4 ea zolmitriptan MO; GC* rizatriptan benzoate tbdp 1 daily); MO; GC MINERALS & ELECTROLYTES Limit 12 inhalers per Electrolyte Mixtures sumatriptan soln 20 mg/act 1 month;QL(0.4 dextrose in lactated ringers 4 GC* ea daily); MO; soln GC dextrose w/ sodium GC* Limit 18 chloride soln 0.2 %-5 %, 4 inhalers per 0.33 %-5 %, 0.45 %-2.5 %, sumatriptan soln 5 mg/act 1 month;QL(0.6 0.45 %-5 % ea daily); MO; dextrose w/ sodium 4 MO; GC* GC chloride soln 0.9 %-5 % Auto-injector; lactated ringer's soln 20 GC* Limit 4mls per mg/100ml-30 mg/100ml- sumatriptan succinate soaj 4 month;QL(0.14 sc 4 mg/0.5ml, 6 mg/0.5ml 310 mg/100ml-600 4 ml daily); MO; mg/100ml, 3 meq/l-4 meq/l- GC* 28 meq/l-109 meq/l-130 Solution meq/l cartridge;Limit parenteral electrolytes conc 4 B/D; GC* sumatriptan succinate soct 4 4mls per sc 4 mg/0.5ml, 6 mg/0.5ml month;QL(0.14 potassium chloride in GC* ml daily); MO; dextrose & sodium chloride 4 GC* soln 0.45 %-5 %-20 meq/l Limit 4mls per TPN ELECTROLYTES 4 B/D; GC* sumatriptan succinate soln 4 month;QL(0.14 CONC sc 6 mg/0.5ml ml daily); MO; GC* Magnesium magnesium sulfate soln ij GC* sumatriptan succinate tabs 1 QL(0.3 ea 4 or 50 mg, 100 mg, 25 mg daily); MO; GC 50 % ZEMBRACE SYMTOUCH 4 SL(2 ml daily); Potassium SOAJ MO; GC* K-TAB TBCR 8 MEQ MO; GC* SL(4 ea daily); 3 zolmitriptan soln na 2.5 mg 1 (potassium chloride) MO; GC potassium chloride cpcr or MO; GC SL(2 ea daily); 1 zolmitriptan soln na 5 mg 1 10 meq, 8 meq MO; GC You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary 62 Updated 09/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits potassium chloride MO; GC cyclosporine caps or 100 1 B/D; MO; GC microencapsulated crystals 1 mg, 25 mg er tbcr 20 meq, 10 meq cyclosporine modified (for 1 B/D; MO; GC potassium chloride soln iv 4 MO; GC* microemulsion) caps 2 meq/ml cyclosporine modified (for 1 B/D; MO; GC potassium chloride soln or 1 MO; GC microemulsion) soln 20 %, 10 % cyclosporine soln iv 50 4 B/D; MO; GC* potassium chloride tbcr or 1 MO; GC mg/ml 20 meq, 10 meq, 8 meq ENVARSUS XR TB24 3 B/D; MO; GC* Sodium everolimus B/D; MO; GC sodium chloride soln iv 4 GC* 0.45 % (immunosuppressant) tabs 1 0.25 mg sodium chloride soln iv 3 4 MO; GC* %, 5 %, 0.9 % everolimus B/D; MO; GC* (immunosuppressant) tabs 5^ Zinc 0.5 mg, 0.75 mg MO; NT; GC* GALZIN CAPS 3 mycophenolate mofetil 1 B/D; MO; GC caps 250 mg MO; NT; GC* WILZIN CAPS 3 mycophenolate mofetil hcl 4 B/D; MO; GC* solr MISCELLANEOUS THERAPEUTIC CLASSES mycophenolate mofetil susr 5^ B/D; MO; GC* 200 mg/ml Chelating Agents mycophenolate mofetil tabs 1 B/D; MO; GC penicillamine tabs 1 GC 500 mg mycophenolate sodium B/D; MO; GC SL(2 ea daily); 1 trientine hcl caps 5^ tbec GC* NULOJIX SOLR 5^ B/D; GC* Enzymes XIAFLEX SOLR 5^ GC* PROGRAF PACK OR 0.2 3 B/D; MO; GC* MG, 1 MG Immunomodulators PROGRAF SOLN IV 5 4 B/D; GC* MG/ML REVLIMID CAPS 5^ PA; LA; GC* SANDIMMUNE SOLN OR 3 B/D; MO; GC* 100 MG/ML THALOMID CAPS 5^ GC* SIMULECT SOLR 5^ GC* Immunosuppressive Agents B/D; MO; GC ASTAGRAF XL CP24 3 B/D; MO; GC* sirolimus soln 1 mg/ml 1 B/D; MO; GC ATGAM INJ 4 B/D; GC* sirolimus tabs 0.5 mg, 1 mg 1 B/D; MO; GC* AZASAN TABS 3 B/D; MO; GC* sirolimus tabs 2 mg 5^ tacrolimus caps 1 B/D; MO; GC AZATHIOPRINE SOLR IJ 4 B/D; GC* 100 MG THYMOGLOBULIN SOLR 2 B/D; GC* azathioprine tabs or 50 mg 1 B/D; MO; GC You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary Updated 09/01/2021 63 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ZORTRESS TABS 1 MG 5^ B/D; MO; GC* cevimeline hcl caps 1 MO; GC Irrigation Solutions pilocarpine hcl (oral) tabs 1 MO; GC irrigation solutions, 1 GC physiological soln MULTIVITAMINS water for irrigation, sterile 1 MO; GC soln Ped MV w/ Fluoride pediatric vitamins acd w/ RX/OTC; MO; Potassium Removing Agents fluoride soln 0.25 mg/ml-35 1 GC LOKELMA PACK 3 ST; MO; GC* mg/ml-400 unit/ml-1500 unit/ml sodium polystyrene 1 MO; GC pediatric vitamins acd w/ MO; GC sulfonate powd fluoride soln 0.5 mg/ml-35 1 sodium polystyrene 1 MO; GC mg/ml-400 unit/ml-1500 sulfonate susp unit/ml ST; SL(1.5 ea VELTASSA PACK 16.8 GM 3 Prenatal Vitamins daily); MO; GC* TRINATAL RX 1 TABS 3 MO; GC* VELTASSA PACK 25.2 GM 3 ST; SL(1 ea daily); MO; GC* MUSCULOSKELETAL THERAPY AGENTS - VELTASSA PACK 8.4 GM 5^ ST; SL(3 ea Drugs to Treat Spasms daily); MO; GC* Central Muscle Relaxants Systemic Lupus Erythematosus Agents SL(8 ea daily); baclofen tabs or 10 mg 1 BENLYSTA SOAJ 5^ PA; GC* MO; GC SL(4 ea daily); PA; GC* baclofen tabs or 20 mg 1 BENLYSTA SOLR 5^ MO; GC SL(16 ea daily); PA; GC* baclofen tabs or 5 mg 1 BENLYSTA SOSY 5^ MO; GC AL(Up to 64 yrs carisoprodol tabs 1 MOUTH/THROAT/DENTAL AGENTS old); MO; GC AL(Up to 64 yrs Anesthetics Topical Oral chlorzoxazone tabs 500 mg 1 lidocaine hcl (mouth-throat) MO; GC old); MO; GC 1 AL(Up to 64 yrs soln 2 % cyclobenzaprine hcl cp24 1 old); MO; GC Anti-infectives - Throat AL(Up to 64 yrs cyclobenzaprine hcl tabs 1 clotrimazole troc 1 MO; GC old); MO; GC AL(Up to 64 yrs nystatin (mouth-throat) 1 QL(24 ml metaxalone tabs 1 susp daily); MO; GC old); MO; GC methocarbamol tabs or 500 1 AL(Up to 64 yrs Antiseptics - Mouth/Throat mg, 750 mg old); MO; GC chlorhexidine gluconate MO; GC 1 orphenadrine citrate tb12 or 1 AL(Up to 64 yrs (mouth-throat) soln 100 mg old); MO; GC Steroids - Mouth/Throat/Dental SL(18 ea daily); tizanidine hcl caps 2 mg 1 MO; GC triamcinolone acetonide 1 MO; GC (mouth) pste SL(9 ea daily); tizanidine hcl caps 4 mg 1 Throat Products - Misc. MO; GC You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary 64 Updated 09/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SL(6 ea daily); tizanidine hcl caps 6 mg 1 ALS Agents MO; GC PA; GC* SL(18 ea daily); RADICAVA SOLN 5^ tizanidine hcl tabs 2 mg 1 MO; GC riluzole tabs 1 MO; GC SL(9 ea daily); tizanidine hcl tabs 4 mg 1 MO; GC Muscular Dystrophy Agents Direct Muscle Relaxants EXONDYS 51 SOLN 5^ PA; LA; MO; GC* dantrolene sodium caps 1 MO; GC PA; LA; MO; VYONDYS 53 SOLN 5^ Muscle Relaxant Combinations GC* carisoprodol w/ aspirin & 1 AL(Up to 64 yrs Neuromuscular Blocking Agent - Neurotoxins codeine tabs old); MO; GC BOTOX SOLR 100 UNIT 4 PA; GC* NASAL AGENTS - SYSTEMIC AND TOPICAL - Drugs to treat the Nose or Sinus BOTOX SOLR 200 UNIT 3 PA; GC* Nasal Agent Combinations XEOMIN SOLR 4 PA; MO; GC* azelastine hcl-fluticasone 1 MO; GC propionate susp NUTRIENTS Nasal Antiallergy Carbohydrates azelastine hcl soln 1 MO; GC dextrose soln 5 % 4 B/D; MO; GC* olopatadine hcl (nasal) soln 1 MO; GC dextrose soln 50 %, 10 %, 4 B/D; GC* Nasal Anticholinergics 70 % ipratropium bromide (nasal) 1 MO; GC Lipids soln fat emulsion plant based 4 B/D; GC* Nasal Steroids emul BECONASE AQ SUSP 3 MO; GC* Proteins amino acid infusion 15% 4 B/D; MO; GC* flunisolide (nasal) soln 1 MO; GC CLINIMIX B/D; GC* fluticasone propionate 1 RX/OTC; MO; 4.25%/DEXTROSE 5% 4 (nasal) susp GC SOLN mometasone furoate 1 MO; GC B/D; GC* (nasal) susp PROSOL SOLN 4 MO; GC* OMNARIS SUSP 3 OPHTHALMIC AGENTS - Drugs to Treat the Eye QNASL AERS 3 MO; GC* Beta-blockers - Ophthalmic betaxolol hcl (ophth) soln 1 MO; GC QNASL CHILDRENS 3 MO; GC* AERS BETIMOL SOLN 3 MO; GC* ZETONNA AERS 3 MO; GC* BETOPTIC-S SUSP 2 MO; GC* NEUROMUSCULAR AGENTS - Drugs to Relax/Paralyze Muscles carteolol hcl (ophth) soln 1 MO; GC You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary Updated 09/01/2021 65 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits COMBIGAN SOLN 3 MO; GC* ciprofloxacin hcl (ophth) 1 MO; GC soln dorzolamide hcl-timolol MO; GC QL(0.5 gm 1 erythromycin (ophth) oint 1 maleate soln daily); MO; GC MO; GC levobunolol hcl soln 1 gatifloxacin (ophth) soln 1 MO; GC timolol maleate (ophth) MO; GC 1 gentamicin sulfate (ophth) 1 MO; GC solg oint timolol maleate (ophth) MO; GC 1 gentamicin sulfate (ophth) 1 MO; GC soln soln TIMOPTIC OCUDOSE 3 MO; GC* MO; GC SOLN 0.25 % levofloxacin (ophth) soln 1 TIMOPTIC-XE SOLG 0.25 3 MO; GC* MOXEZA SOLN 2 MO; GC* % (timolol maleate (ophth)) (moxifloxacin hcl (ophth)) Cycloplegic Mydriatics moxifloxacin hcl (ophth) 1 MO; GC soln cyclopentolate hcl soln 1 MO; GC NATACYN SUSP 2 MO; GC* Miotics neomycin-bacitracin zn- 1 MO; GC pilocarpine hcl soln 1 MO; GC polymyxin oint neomycin-polymyxin- 1 MO; GC Ophthalmic - Angiogenesis Inhibitors gramicidin soln PA; GC* BEOVU SOLN 5^ ofloxacin (ophth) soln 1 MO; GC PA; LA; GC* EYLEA SOLN 5^ polymyxin b-trimethoprim 1 MO; GC soln EYLEA SOSY 5^ PA; LA; GC* sulfacetamide sodium 1 MO; GC (ophth) oint Ophthalmic Adrenergic Agents sulfacetamide sodium 1 MO; GC ALPHAGAN P SOLN 0.1 % 2 MO; GC* (ophth) soln tobramycin (ophth) soln 1 MO; GC apraclonidine hcl soln 1 MO; GC TOBREX OINT 3 MO; GC* brimonidine tartrate soln 1 MO; GC trifluridine soln 1 MO; GC SIMBRINZA SUSP 3 MO; GC* ZIRGAN GEL 3 MO; GC* Ophthalmic Anti-infectives AZASITE SOLN 3 MO; GC* Ophthalmic Immunomodulators RESTASIS EMUL 2 MO; GC* bacitracin (ophthalmic) oint 1 MO; GC RESTASIS MULTIDOSE 2 MO; GC* bacitracin-polymyxin b 1 MO; GC EMUL (ophth) oint Ophthalmic Kinase Inhibitors BESIVANCE SUSP 3 MO; GC* ROCKLATAN SOLN 3 MO; GC* CILOXAN OINT 3 MO; GC* You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary 66 Updated 09/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Ophthalmic Local Anesthetics TOBRADEX ST SUSP 3 QL(0.67 ml daily); MO; GC* proparacaine hcl soln 1 MO; GC tobramycin- 1 QL(0.67 ml dexamethasone susp daily); MO; GC Ophthalmic Nerve Growth Factors ZYLET SUSP 2 MO; GC* OXERVATE SOLN 5^ PA; MO; GC* Ophthalmics - Misc. Ophthalmic Steroids ACUVAIL SOLN 3 QL(4 ea daily); ALREX SUSP 3 MO; GC* MO; GC* MO; GC* bacitracin-poly-neomycin- 1 MO; GC ALOCRIL SOLN 3 hc oint ALOMIDE SOLN 3 MO; GC* BLEPHAMIDE SUSP 3 MO; GC* azelastine hcl (ophth) soln 1 MO; GC dexamethasone sodium 1 MO; GC phosphate (ophth) soln AZOPT SUSP 2 MO; GC* DUREZOL EMUL 2 MO; GC* (brinzolamide) bepotastine besilate soln 1 MO; GC FLAREX SUSP 2 MO; GC* BEPREVE SOLN 3 MO; GC* fluorometholone (ophth) 1 MO; GC (bepotastine besilate) susp bromfenac sodium (ophth) 1 Once daily FML FORTE SUSP 2 MO; GC* soln dosing;MO; GC MO; GC* cromolyn sodium (ophth) 1 MO; GC FML OINT 2 soln MO; GC* Limit 60mls per LOTEMAX OINT 3 28 MO; GC* CYSTARAN SOLN 3 days;QL(2.15 LOTEMAX SM GEL 3 ml daily); LA; MO; GC* loteprednol etabonate gel 1 MO; GC diclofenac sodium (ophth) 1 MO; GC soln loteprednol etabonate susp 1 MO; GC dorzolamide hcl soln 1 MO; GC MAXIDEX SUSP 3 MO; GC* epinastine hcl (ophth) soln 1 MO; GC neomycin-polymy- 1 MO; GC dexameth oint flurbiprofen sodium soln 1 MO; GC neomycin-polymy- 1 MO; GC dexameth susp ILEVRO SUSP 2 MO; GC* PRED MILD SUSP 2 MO; GC* ketorolac tromethamine 1 QL(0.34 ml (ophth) soln daily); MO; GC prednisolone acetate 1 MO; GC (ophth) susp LASTACAFT SOLN 3 MO; GC* sulfacetamide sod- 1 MO; GC prednisolone soln NEVANAC SUSP 2 MO; GC* QL(0.5 gm TOBRADEX OINT 3 RX/OTC; MO; daily); MO; GC* olopatadine hcl soln 1 GC You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary Updated 09/01/2021 67 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PROLENSA SOLN 3 MO; GC* methylergonovine maleate 1 MO; GC tabs Prostaglandins - Ophthalmic PASSIVE IMMUNIZING AND TREATMENT bimatoprost soln 1 MO; GC AGENTS - Antibody Drugs to Treat Low Immune System latanoprost soln 1 MO; GC Immune Serums B/D; GC* LUMIGAN SOLN 2 MO; GC* BIVIGAM SOLN 5^ MO; GC CUVITRU SOLN 1 3 B/D; LA; GC* travoprost soln 1 GM/5ML MO; GC* CUVITRU SOLN 10 5^ B/D; GC* ZIOPTAN SOLN 3 GM/50ML CUVITRU SOLN 2 B/D; LA; GC* OTIC AGENTS - Drugs to Treat the Ear GM/10ML, 4 GM/20ML, 8 5^ Otic Agents - Miscellaneous GM/40ML MO; GC FLEBOGAMMA DIF SOLN B/D; GC* acetic acid (otic) soln 1 0.5 GM/10ML, 10 GM/100ML, 10 GM/200ML, 5^ Otic Anti-infectives 2.5 GM/50ML, 20 CETRAXAL SOLN 3 MO; GC* GM/200ML, 20 GM/400ML, (ciprofloxacin hcl (otic)) 5 GM/100ML MO; GC ciprofloxacin hcl (otic) soln 1 FLEBOGAMMA DIF SOLN 5^ B/D; 5 GM/50 5 GM/50ML ML; GC* MO; GC ofloxacin (otic) soln 1 GAMASTAN INJ 4 B/D; GC* Otic Combinations GAMMAGARD LIQUID 5^ B/D; GC* SOLN CIPRO HC SUSP 3 MO; GC* GAMMAKED SOLN 5^ B/D; GC* CIPRODEX SUSP MO; GC* (ciprofloxacin- 2 GAMMAPLEX SOLN 5^ B/D; GC* dexamethasone) B/D; GC* CORTISPORIN-TC SUSP 3 MO; GC* GAMUNEX-C SOLN 5^ HIZENTRA SOLN 1 B/D; LA; GC* neomycin-polymyxin-hc 1 MO; GC 3 (otic) soln GM/5ML HIZENTRA SOLN 10 B/D; GC* neomycin-polymyxin-hc 1 MO; GC 5^ (otic) susp GM/50ML Otic Steroids HIZENTRA SOLN 2 5^ B/D; LA; GC* GM/10ML, 4 GM/20ML fluocinolone acetonide 1 MO; GC (otic) oil HIZENTRA SOSY 1 B/D; GC* GM/5ML, 2 GM/10ML, 4 5^ hydrocortisone w/acetic 1 MO; GC GM/20ML acid soln HYPERRAB S/D SOLN 4 GC* OXYTOCICS - Drugs to Prevent/Control Uterine Bleeding IMOGAM RABIES-HT 4 GC* Oxytocics SOLN You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary 68 Updated 09/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KEDRAB SOLN 4 GC* amoxicillin & pot 1 MO; GC clavulanate chew B/D; GC* OCTAGAM SOLN 5^ amoxicillin & pot 1 MO; GC clavulanate susr B/D; GC* PRIVIGEN SOLN 5^ amoxicillin & pot 1 MO; GC clavulanate tabs VARIZIG SOLN 5^ GC* amoxicillin & pot 1 MO; GC clavulanate tb12 Monoclonal Antibodies ampicillin & sulbactam 4 GC* SYNAGIS SOLN 5^ GC* sodium solr ij 0.5 gm-1 gm ampicillin & sulbactam 4 MO; GC* ZINPLAVA SOLN 5^ PA; GC* sodium solr ij 1 gm-2 gm ampicillin & sulbactam 4 GC* Passive Immunizing Agents - Combinations sodium solr iv 5 gm-10 gm B/D; GC* HYQVIA KIT 5^ piperacillin sodium- 4 GC* tazobactam sodium solr PENICILLINS - Drugs to Treat Bacterial Infections ZOSYN SOLN 0.25 GC* GM/50ML-2 GM/50ML-5 %, Aminopenicillins 0.375 GM/50ML-3 4 amoxicillin caps 1 MO; GC GM/50ML-5 %, 0.5 GM/100ML-4 GM/100ML-5 amoxicillin chew 1 MO; GC % Penicillinase-Resistant Penicillins amoxicillin susr 1 MO; GC dicloxacillin sodium caps 1 MO; GC amoxicillin tabs 1 MO; GC nafcillin sodium solr ij 1 gm 4 GC* ampicillin caps 1 MO; GC nafcillin sodium solr ij 2 gm 4 MO; GC* ampicillin sodium solr ij 1 4 MO; GC* gm, 2 gm, 500 mg nafcillin sodium solr iv 10 5^ GC* gm ampicillin sodium solr ij 250 4 GC* mg PROGESTINS - Hormone Replacement/Modifying Drugs ampicillin sodium solr iv 10 4 GC* gm, 2 gm Progestins Natural Penicillins medroxyprogesterone 1 MO; GC acetate tabs BICILLIN L-A SUSP 4 MO; GC* megestrol acetate 1 AL(Up to 64 yrs penicillin g potassium solr MO; GC* (appetite) susp old); MO; GC 5000000 unit, 20 mu, 4 norethindrone acetate tabs 1 MO; GC 20000000 unit progesterone caps or 100 MO; GC penicillin v potassium solr 1 MO; GC 1 250 mg/5ml mg, 200 mg penicillin v potassium tabs 1 MO; GC PSYCHOTHERAPEUTIC AND NEUROLOGICAL 250 mg, 500 mg AGENTS - MISC. - Drugs to Treat Mental and Penicillin Combinations Emotional Conditions Agents for Chemical Dependency You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary Updated 09/01/2021 69 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits acamprosate calcium tbec 1 MO; GC rivastigmine tartrate caps 1 MO; GC disulfiram tabs 1 MO; GC Combination Psychotherapeutics chlordiazepoxide- 1 AL(Up to 64 yrs LUCEMYRA TABS 5^ PA; SL(16 ea amitriptyline tabs old); MO; GC daily); MO; GC* olanzapine-fluoxetine hcl 1 MO; GC Anti-Cataplectic Agents caps LA; MO; GC* XYREM SOLN 5^ perphenazine-amitriptyline 1 AL(Up to 64 yrs tabs old); MO; GC Antidementia Agents Fibromyalgia Agents donepezil hydrochloride 1 MO; GC PA; MO; GC* tabs SAVELLA TABS 3 donepezil hydrochloride MO; GC 1 SAVELLA TITRATION 3 PA; MO; GC* tbdp PACK MISC galantamine hydrobromide 1 MO; GC Movement Disorder Drug Therapy cp24 PA; SL(4 ea AUSTEDO TABS 12 MG 5^ galantamine hydrobromide 1 MO; GC daily); LA; GC* soln PA; SL(8 ea AUSTEDO TABS 6 MG 5^ galantamine hydrobromide 1 MO; GC daily); LA; GC* tabs AUSTEDO TABS 9 MG 5^ PA; SL(5.33 ea AL(At least 60 daily); LA; GC* yrs old); SL(2 memantine hcl cp24 14 mg 1 PA; LA; MO; ea daily); MO; INGREZZA CAPS 5^ GC GC* PA; LA; MO; AL(At least 60 INGREZZA CPPK 5^ yrs old); GC* memantine hcl cp24 21 mg 1 PA; SL(8 ea SL(1.33 ea tetrabenazine tabs 12.5 mg 5^ daily); MO; GC daily); GC* PA; SL(4 ea AL(At least 60 tetrabenazine tabs 25 mg 5^ yrs old); SL(1 daily); GC* memantine hcl cp24 28 mg 1 ea daily); MO; Multiple Sclerosis Agents GC PA; GC* AL(At least 60 AUBAGIO TABS 5^ 1 yrs old); SL(4 memantine hcl cp24 7 mg ea daily); MO; PA; Limited to GC 5^ 1 box per 28 AVONEX PEN AJKT days;QL(0.036 AL(At least 60 ml daily); GC* memantine hcl soln 10 1 yrs old); MO; mg/5ml, 2 mg/ml GC PA; Limited to 1 box per 28 AVONEX PSKT 5^ memantine hcl tabs 10 mg, 1 MO; GC days;QL(0.036 5 mg ml daily); GC* AL(At least 60 PA; GC* NAMENDA XR TITRATION 3 BETASERON KIT 5^ PACK CP24 yrs old); MO; GC* COPAXONE SOSY 5^ PA; GC* rivastigmine pt24 1 MO; GC (glatiramer acetate) dalfampridine tb12 5^ PA; GC* You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary 70 Updated 09/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EXTAVIA KIT 5^ PA; GC* Psychotherapeutic and Neurological Agents - AL(Up to 64 yrs ergoloid mesylates tabs 1 GILENYA CAPS 0.5 MG 5^ PA; GC* old); MO; GC MO; GC LEMTRADA SOLN 5^ PA; LA; GC* pimozide tabs 1 Restless Leg Syndrome (RLS) Agents MAVENCLAD TBPK 5^ PA; 10 tabs; GC* HORIZANT TBCR 3 MO; GC* MAVENCLAD TBPK 5^ PA; LA; GC* Smoking Deterrents PA; GC* MAYZENT TABS 5^ APO-VARENICLINE TABS 3 MO; GC* PA; GC* OCREVUS SOLN 5^ bupropion hcl (smoking 1 SL(2 ea daily); deterrent) tb12 MO; GC PLEGRIDY SOPN 5^ PA; GC* CHANTIX CONTINUING 3 MO; GC* MONTHPAK TABS PLEGRIDY SOSY 5^ PA; GC* CHANTIX STARTING 3 MO; GC* MONTH PAK TABS PLEGRIDY STARTER 5^ PA; GC* PACK SOPN CHANTIX TABS 3 MO; GC* PLEGRIDY STARTER 5^ PA; GC* PACK SOSY Limit 3 boxes per REBIF REBIDOSE SOAJ 5^ PA; GC* NICOTROL INHALER 3 month;SL(16.8 INHA ea daily); MO; REBIF REBIDOSE 5^ PA; GC* GC* TITRATIONPACK SOAJ NICOTROL NS SOLN 2 MO; GC* REBIF SOSY 5^ PA; GC* Transthyretin Amyloidosis Agents REBIF TITRATION PACK 5^ PA; GC* SOSY TEGSEDI SOSY 5^ PA; LA; MO; GC* TECFIDERA CPDR 5^ PA; QL(2 ea (dimethyl fumarate) daily); GC* Vasomotor Symptom Agents TECFIDERA STARTER PA; GC* paroxetine mesylate 1 MO; GC PACK MISC (dimethyl 5^ (vasomotor) caps fumarate) RESPIRATORY AGENTS - MISC. - Drugs to TYSABRI CONC 5^ PA; GC* Treat Lung Conditions Alpha-Proteinase Inhibitor (Human) VUMERITY CPDR 5^ PA; QL(4 ea daily); GC* ARALAST NP SOLR 1000 5^ PA; LA; MO; MG GC* VUMERITY CPDR 5^ PA; Starter Bottle; GC* ARALAST NP SOLR 500 5^ PA; LA; GC* MG Postherpetic Neuralgia (PHN)/Neuropathic Pain GLASSIA SOLN 4 PA; LA; GC* GRALISE TABS 300 MG, 3 MO; GC* 600 MG PROLASTIN-C SOLN 5^ PA; LA; MO; Pseudobulbar Affect (PBA) Agents GC* PA; MO; GC* NUEDEXTA CAPS 3 PROLASTIN-C SOLR 5^ PA; LA; MO; GC* You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary Updated 09/01/2021 71 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits doxycycline (monohydrate) MO; GC ZEMAIRA SOLR 5^ PA; LA; MO; 1 GC* tabs Cystic Fibrosis Agents doxycycline hyclate caps or 1 QL(2 ea daily); 50 mg, 100 mg MO; GC KALYDECO PACK 5^ PA; MO; GC* doxycycline hyclate solr iv 4 QL(2 ea daily); 100 mg MO; GC* KALYDECO TABS 5^ PA; MO; GC* doxycycline hyclate tabs or 1 QL(2 ea daily); 100 mg, 20 mg MO; GC ORKAMBI PACK 5^ PA; LA; MO; GC* doxycycline hyclate tbec or 1 MO; GC 200 mg, 100 mg, 150 mg ORKAMBI TABS 5^ PA; LA; MO; GC* minocycline hcl caps 100 1 MO; GC mg, 50 mg, 75 mg PULMOZYME SOLN 5^ B/D; GC* minocycline hcl tabs 100 1 MO; GC SYMDEKO TBPK 5^ PA; LA; GC* mg, 50 mg, 75 mg tetracycline hcl caps 1 MO; GC TRIKAFTA TBPK 5^ PA; LA; MO; GC* VIBRAMYCIN SYRP 50 2 MO; GC* Pulmonary Fibrosis Agents MG/5ML ESBRIET CAPS 5^ PA; LA; GC* THYROID AGENTS - Drugs to Regulate Thyroid Hormones PA; LA; GC* ESBRIET TABS 5^ Antithyroid Agents MO; GC OFEV CAPS 5^ PA; LA; GC* methimazole tabs 1 MO; GC SULFONAMIDES - Drugs to Treat Bacterial propylthiouracil tabs 1 Infections Thyroid Hormones Sulfonamides levothyroxine sodium tabs MO; GC sulfadiazine tabs 1 MO; GC or 300 mcg, 100 mcg, 112 mcg, 125 mcg, 137 mcg, 1 TETRACYCLINES - Drugs to Treat Bacterial 150 mcg, 175 mcg, 200 Infections mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg Aminomethylcyclines liothyronine sodium tabs or 1 MO; GC NUZYRA TABS OR 150 5^ PA; MO; GC* 50 mcg, 25 mcg, 5 mcg MG SYNTHROID TABS 3 MO; GC* Glycylcyclines (levothyroxine sodium) GC* tigecycline solr 5^ TOXOIDS Tetracyclines Toxoid Combinations MO; GC demeclocycline hcl tabs 1 ADACEL SUSP 1 GC doxycycline (monohydrate) 1 MO; GC GC caps BOOSTRIX SUSP 1 doxycycline (monohydrate) 1 MO; GC DAPTACEL SUSP 4 GC* susr You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary 72 Updated 09/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DIPHTHERIA/TETANUS B/D; GC* RX/OTC; MO; famotidine tabs or 20 mg 1 TOXOIDS ADSORBED 4 GC PEDIATRIC SUSP famotidine tabs or 40 mg 1 MO; GC INFANRIX SUSP 4 GC* nizatidine caps 150 mg, 1 MO; GC KINRIX SUSP 4 GC* 300 mg Misc. Anti-Ulcer PEDIARIX SUSP 4 GC* sucralfate susp 1 MO; GC PENTACEL SUSR 4 GC* sucralfate tabs 1 MO; GC QUADRACEL SUSP 4 GC* Proton Pump Inhibitors B/D; GC* TDVAX SUSP 4 DEXILANT CPDR 2 ST; MO; GC* B/D; GC* TENIVAC INJ 4 esomeprazole magnesium 1 ST; RX/OTC; cpdr 20 mg MO; GC ULCER DRUGS - Drugs to Treat Bowel, Intestine esomeprazole magnesium 1 ST; MO; GC and Stomach Conditions cpdr 40 mg Antispasmodics esomeprazole sodium solr 4 GC* dicyclomine hcl caps or 10 MO; GC 40 mg 1 RX/OTC; MO; mg lansoprazole cpdr 15 mg 1 GC dicyclomine hcl tabs or 20 1 MO; GC mg lansoprazole cpdr 30 mg 1 MO; GC glycopyrrolate soln ij 0.2 MO; GC* RX/OTC; MO; mg/ml, 1 mg/5ml, 4 4 lansoprazole tbdd 15 mg 1 mg/20ml GC MO; GC glycopyrrolate soln ij 0.4 4 GC* lansoprazole tbdd 30 mg 1 mg/2ml omeprazole cpdr 10 mg, 40 MO; GC SL(8 ea daily); 1 glycopyrrolate tabs or 1 mg 1 mg MO; GC RX/OTC; MO; SL(4 ea daily); omeprazole cpdr 20 mg 1 glycopyrrolate tabs or 2 mg 1 GC MO; GC pantoprazole sodium solr iv 1 GC methscopolamine bromide 1 MO; GC 40 mg tabs pantoprazole sodium tbec 1 MO; GC H-2 Antagonists or 20 mg, 40 mg RX/OTC; MO; cimetidine tabs 200 mg 1 Ulcer Drugs - Prostaglandins GC misoprostol tabs 1 MO; GC cimetidine tabs 300 mg, 1 MO; GC 400 mg, 800 mg Ulcer Therapy Combinations famotidine soln iv 20 GC* mg/2ml, 200 mg/20ml, 40 4 amoxicillin-clarithromycin 3 MO; GC* mg/4ml w/ lansoprazole misc omeprazole-sodium RX/OTC; MO; famotidine susr or 40 1 MO; GC mg/5ml bicarbonate caps 20 mg- 1 GC 1100 mg You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary Updated 09/01/2021 73 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits omeprazole-sodium ST; 20MG- BEXSERO SUSY 4 GC* bicarbonate pack 20 mg- 1 1680 MG;MO; 1680 mg GC HIBERIX SOLR 4 GC* omeprazole-sodium MO; GC bicarbonate pack 40 mg- 1 MENACTRA INJ 4 GC* 1680 mg GC* PYLERA CAPS 3 MO; GC* MENQUADFI INJ 4 GC* URINARY ANTISPASMODICS - Drugs to Treat MENVEO SOLR 4 Miscellaneous Bladder Spasms PEDVAX HIB SUSP 4 GC* Urinary Antispasmodic - Antimuscarinics GC* darifenacin hydrobromide 1 MO; GC TRUMENBA SUSY 4 tb24 GC* oxybutynin chloride syrp 1 MO; GC TYPHIM VI SOLN 4 Viral Vaccines oxybutynin chloride tabs 1 MO; GC ENGERIX-B SUSP IJ 10 4 B/D; GC* oxybutynin chloride tb24 1 MO; GC MCG/0.5ML, 20 MCG/ML GARDASIL 9 SUSP 4 GC* solifenacin succinate tabs 1 MO; GC GARDASIL 9 SUSY 4 GC* tolterodine tartrate cp24 1 MO; GC HAVRIX SUSP 4 GC* tolterodine tartrate tabs 1 MO; GC IMOVAX RABIES 4 B/D; GC* TOVIAZ TB24 2 MO; GC* (H.D.C.V.) INJ IPOL INACTIVATED IPV 4 GC* trospium chloride cp24 1 MO; GC INJ GC* trospium chloride tabs 1 MO; GC IXIARO SUSP 4 GC* Urinary Antispasmodics - Beta-3 Adrenergic M-M-R II SOLR 4 MYRBETRIQ TB24 25 MG, 3 MO; GC* GC* 50 MG PROQUAD SUSR 4 Urinary Antispasmodics - Cholinergic Agonists RABAVERT SUSR 4 B/D; GC* bethanechol chloride tabs 1 MO; GC RECOMBIVAX HB SUSP 4 B/D; GC* Urinary Antispasmodics - Direct Muscle Relaxants ROTARIX SUSR 3 GC* flavoxate hcl tabs 1 MO; GC ROTATEQ SOLN 2 GC* VACCINES SHINGRIX SUSR 2 GC* Bacterial Vaccines GC* ACTHIB SOLR 4 GC* TWINRIX SUSY 4 GC* BCG VACCINE INJ 4 GC* VAQTA SUSP 4 You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary 74 Updated 09/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VARIVAX INJ 4 GC* Vasopressors midodrine hcl tabs 1 MO; GC YF-VAX INJ 4 GC* ZOSTAVAX SUSR 2 GC* VITAMINS Oil Soluble Vitamins VAGINAL AND RELATED PRODUCTS ergocalciferol caps 1.25 1 MO; NT; GC Vaginal Anti-infectives mg, 50000 unit MO; NT; GC CLEOCIN SUPP VA 100 3 MO; GC* phytonadione tabs 1 MG clindamycin phosphate 1 MO; GC vaginal crea metronidazole vaginal gel 1 MO; GC miconazole nitrate vaginal 1 MO; GC supp terconazole vaginal crea 1 MO; GC terconazole vaginal supp 1 MO; GC Vaginal Estrogens estradiol vaginal tabs 10 1 MO; GC mcg ESTRING RING 3 MO; GC* FEMRING RING 3 MO; GC* PREMARIN CREA VA 2 MO; GC* 0.625 MG/GM Vaginal Progestins CRINONE GEL 3 PA; MO; GC* VASOPRESSORS - Drugs to Treat Heart and Circulation Conditions Anaphylaxis Therapy Agents epinephrine (anaphylaxis) MO; GC soaj 0.15 mg/0.15ml, 0.15 1 mg/0.3ml, 0.3 mg/0.3ml Neurogenic Orthostatic Hypotension (NOH) - PA; SL(18 ea droxidopa caps 100 mg 5^ daily); GC* PA; SL(9 ea droxidopa caps 200 mg 5^ daily); GC* PA; SL(6 ea droxidopa caps 300 mg 5^ daily); GC* You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2021 Health Net Seniority Plus Employer (HMO) Classic Formulary Updated 09/01/2021 75 Index of Drugs abacavir sulfate 39 alendronate sodium 53 amphetamine- abacavir sulfate-lamivudine 39 alfuzosin hcl 58 dextroamphetamine 1 amphotericin b 24 abacavir sulfate-lamivudine- ALIMTA 29 ampicillin 69 zidovudine 39 ALIQOPA 33 ABELCET 24 ampicillin & sulbactam aliskiren fumarate 28 ABILIFY MAINTENA 38 sodium 69 allopurinol 58 ampicillin sodium 69 abiraterone acetate 31 almotriptan malate 62 anagrelide hcl 58 ABRAXANE 35 ALOCRIL 67 anastrozole 31 ABSORICA 47 alogliptin benzoate 19 ANORO ELLIPTA 12 ABSTRAL 4 alogliptin-metformin hcl 18 ANTARA 25 acamprosate calcium 70 alogliptin-pioglitazone 18 APIDRA 20 acarbose 18 ALOMIDE 67 APIDRA SOLOSTAR 20 acebutolol hcl 42 alosetron hcl 57 APLENZIN 16 acetaminophen w/ codeine 6 ALPHAGAN P 66 APO-VARENICLINE 71 acetazolamide 52 alprazolam 9 APOKYN 36 acetic acid 58 ALREX 67 apraclonidine hcl 66 acetic acid (otic) 68 ALTOPREV 26 aprepitant 24 acetylcysteine 47 ALUNBRIG 33 APTIOM 14 acitretin 49 ALVESCO 11 APTIVUS 39 ACTEMRA 3 amantadine hcl 36 ARALAST NP 71 ACTHAR 54 AMBISOME 24 ARANESP ALBUMIN FREE 59 ACTHIB 74 ambrisentan 44 ARCALYST 2 ACTIMMUNE 34 amcinonide 49 arformoterol tartrate 12 ACUVAIL 67 amikacin sulfate 2 argatroban 13 acyclovir 41 amiloride & ARIKAYCE 2 acyclovir sodium 41 hydrochlorothiazide 52 aripiprazole 38,39 acyclovir topical 49 amiloride hcl 53 ARISTADA 39 ADACEL 72 amino acid infusion 15% 65 ARISTADA INITIO 39 ADAKVEO 59 aminocaproic acid 60 armodafinil 1 adapalene 47 aminophylline 13 ARNUITY ELLIPTA 11 adapalene-benzoyl peroxide 47 amiodarone hcl 10 ARRANON 29 adefovir dipivoxil 41 AMITIZA 57 arsenic trioxide 34 ADEMPAS 44 amitriptyline hcl 17 ARZERRA 30 ADVAIR HFA 11,12 amlodipine besylate 42 asenapine maleate 38 AFINITOR 33 amlodipine besylate- ASMANEX HFA 11 AFINITOR DISPERZ 33 atorvastatin calcium 43 amlodipine besylate-benazepril ASMANEX TWISTHALER 120 AFREZZA 20 hcl 27 METERED DOSES 11 AIMOVIG 61 amlodipine besylate-olmesartan ASMANEX TWISTHALER 14 AJOVY 61 medoxomil 27 METERED DOSES 11 amlodipine besylate- ASMANEX TWISTHALER 30 AKYNZEO 24 valsartan 27 METERED DOSES 11 albendazole 7 amlodipine-valsartan- ASMANEX TWISTHALER 60 albuterol sulfate 12 hydrochlorothiazide 27 METERED DOSES 11 alclometasone dipropionate 49 amoxapine 17 ASMANEX TWISTHALER 7 amoxicillin 69 METERED DOSES 11 ALCOHOL PADS 61 ASPARLAS 34 ALDACTAZIDE 52 amoxicillin & pot clavulanate 69 aspirin-dipyridamole 58 ALECENSA 33 amoxicillin-clarithromycin w/ ASTAGRAF XL 63 lansoprazole 73 Index 1 Updated 09/01/2021 atazanavir sulfate 39 benazepril & BRAFTOVI 33 atenolol 42 hydrochlorothiazide 27 BREO ELLIPTA 12 benazepril hcl 26 atenolol & chlorthalidone 27 BRILINTA 58 BENDEKA 29 ATGAM 63 brimonidine tartrate 66 BENLYSTA 64 atomoxetine hcl 1 BRIVIACT 14 benzonatate 47 atorvastatin calcium 26 bromfenac sodium (ophth) 67 benzoyl peroxide- atovaquone 8 erythromycin 47 bromocriptine mesylate 36 atovaquone-proguanil hcl 28 benztropine mesylate 36 BROVANA 12 ATROVENT HFA 10 BEOVU 66 BRUKINSA 33 AUBAGIO 70 bepotastine besilate 67 budesonide 46 AUSTEDO 70 BEPREVE 67 budesonide (inhalation) 11 AVANDIA 20 BERINERT 58 bumetanide 53 AVASTIN 30 BESIVANCE 66 BUNAVAIL 6 AVEED 7 BESPONSA 30 buprenorphine 6,7 AVONEX 70 betamethasone dipropionate buprenorphine hcl 6 AVONEX PEN 70 (topical) 49 buprenorphine hcl-naloxone hcl betamethasone dipropionate AYVAKIT 32 dihydrate 6 augmented 50 bupropion hcl 16 azacitidine 29 betamethasone sod phosphate bupropion hcl (smoking AZASAN 63 & acetate 46 deterrent) 71 AZASITE 66 betamethasone valerate 50 buspirone hcl 9 AZATHIOPRINE 63 BETASERON 70 busulfan 29 azathioprine 63 betaxolol hcl 42 butalbital-acetaminophen- azelaic acid 52 betaxolol hcl (ophth) 65 caffeine w/ codeine 6 bethanechol chloride 74 butalbital-aspirin-caffeine azelastine hcl 65 w/cod 6 BETIMOL 65 azelastine hcl (ophth) 67 butorphanol tartrate 7 BETOPTIC-S 65 azelastine hcl-fluticasone BUTRANS 7 propionate 65 bexarotene 34 BYDUREON BCISE 20 AZELEX 47 BEXSERO 74 BYDUREON PEN 20 azithromycin 61 bicalutamide 31 BYETTA 20 AZOPT 67 BICILLIN L-A 69 BYSTOLIC 42 aztreonam 8 BIDIL 43 CABENUVA 39 bacitracin (ophthalmic) 66 BIKTARVY 39 cabergoline 55 bacitracin-poly-neomycin-hc 67 bimatoprost 68 CABLIVI 58 bacitracin-polymyxin b bisoprolol & (ophth) 66 hydrochlorothiazide 27 CABOMETYX 33 baclofen 64 bisoprolol fumarate 42 calcipotriene 49 balsalazide disodium 57 BIVIGAM 68 calcipotriene-betamethasone dipropionate 50 BALVERSA 33 BLENREP 30 calcitonin (salmon) 53 BAQSIMI ONE PACK 19 bleomycin sulfate 32 calcitriol 54 BAQSIMI TWO PACK 19 BLEPHAMIDE 67 BARACLUDE 41 calcitriol (topical) 49 BLINCYTO 30 calcium acetate (phosphate BAVENCIO 30 BONJESTA 24 binder) 57 BAXDELA 56 BOOSTRIX 72 CALQUENCE 33 BCG VACCINE 74 BORTEZOMIB 33 CAMBIA 61 BECONASE AQ 65 bosentan 44 candesartan cilexetil 27 BELEODAQ 33 BOSULIF 33 candesartan cilexetil- BELSOMRA 60 BOTOX 65 hydrochlorothiazide 27 Updated 09/01/2021 Index 2 CAPASTAT SULFATE 28 cephalexin 44 citalopram hydrobromide 16 CAPEX 50 CERDELGA 59 cladribine 29 CAPLYTA 37 CEREZYME 59 CLARINEX-D 12 HOUR 47 CAPRELSA 33 cetirizine hcl 25 clarithromycin 61 captopril 26 CETRAXAL 68 clemastine fumarate 25 CARAC 48 cevimeline hcl 64 CLENPIQ 60 CARBAGLU 54 CHANTIX 71 CLEOCIN 75 carbamazepine 14 CHANTIX CONTINUING CLEOCIN-T 47 CARBATROL 14 MONTHPAK 71 CLIMARA PRO 56 CHANTIX STARTING MONTH carbidopa 36 PAK 71 CLINDAGEL 47 carbidopa-levodopa 36 CHEMET 23 clindamycin hcl 8 carbidopa-levodopa-entacapone CHENODAL 56 clindamycin palmitate 36 chloramphenicol sodium hydrochloride 8 carbinoxamine maleate 25 succinate 8 clindamycin phosphate 8 carboplatin 29 chlordiazepoxide-amitriptyline clindamycin phosphate CARDIZEM LA 42 70 (topical) 47 chlorhexidine gluconate clindamycin phosphate in d5w8 CARDURA XL 58 (mouth-throat) 64 clindamycin phosphate carisoprodol 64 chloroquine phosphate 28 vaginal 75 carisoprodol w/ aspirin & chlorpromazine hcl 38 clindamycin phosphate-benzoyl codeine 65 peroxide 47 carmustine 29 chlorthalidone 53 clindamycin phosphate-benzoyl carteolol hcl (ophth) 65 chlorzoxazone 64 peroxide (refrigerate) 47 clindamycin phosphate- carvedilol 42 cholestyramine 25 cholestyramine light 25 tretinoin 47 carvedilol phosphate 42 CLINIMIX 4.25%/DEXTROSE CAVERJECT 43 choline fenofibrate 25 5% 65 CHORIONIC clobazam 13 CAVERJECT IMPULSE 43 GONADOTROPIN 54 clobetasol propionate 50 CAYSTON 8 ciclopirox 48 cefaclor 44 clobetasol propionate emollient ciclopirox olamine 48 base 50 cefaclor monohydrate 44 cidofovir 41 clocortolone pivalate 50 cefadroxil 44 cilostazol 58 CLODERM 50 cefazolin sodium 44 CILOXAN 66 clofarabine 29 cefdinir 44 CIMDUO 39 clomipramine hcl 17 CEFEPIME 45 cimetidine 73 clonazepam 13,14 cefepime hcl 45 CIMZIA 57 clonidine 27 cefixime 45 CIMZIA STARTER KIT 57 clonidine hcl 27 cefoxitin sodium 44 cinacalcet hcl 54 clopidogrel bisulfate 58 cefpodoxime proxetil 45 CINQAIR 10 clorazepate dipotassium 9 cefprozil 44 CINRYZE 58 clotrimazole 64 ceftazidime 45 CIPRO 56 clotrimazole (topical) 48 ceftriaxone sodium 45 CIPRO HC 68 clozapine 38 ceftriaxone sodium in CIPRODEX 68 dextrose 45 COARTEM 28 cefuroxime axetil 44 ciprofloxacin 56 codeine sulfate 4 cefuroxime sodium 44 ciprofloxacin hcl 56 colchicine 58 celecoxib 3 ciprofloxacin hcl (ophth) 66 colchicine w/ probenecid 58 CELONTIN 16 ciprofloxacin hcl (otic) 68 colesevelam hcl 25 CENTANY 48 ciprofloxacin in d5w 56 colestipol hcl 25 cisplatin 29 colistimethate sodium 9 Index 3 Updated 09/01/2021 COMBIGAN 66 DALVANCE 8 dexrazoxane hcl 35 COMBIPATCH 56 danazol 7 dextroamphetamine sulfate 1 COMBIVENT RESPIMAT 12 dantrolene sodium 65 dextrose 65 COMETRIQ 33 dapsone 8 dextrose in lactated ringers 62 COMPLERA 39 DAPTACEL 72 dextrose w/ sodium chloride 62 CONDYLOX 51 daptomycin 8 DIACOMIT 14 COPAXONE 70 darifenacin hydrobromide 74 DIASTAT ACUDIAL 14 COPIKTRA 33 DARZALEX 30 DIASTAT PEDIATRIC 14 CORDRAN 50 DARZALEX FASPRO 32 diazepam 9,10 CORLANOR 44 daunorubicin hcl 32 diazepam (anticonvulsant) 14 CORTIFOAM 7 DAUNORUBICIN diazoxide 19 cortisone acetate 46 HYDROCHLORIDE 32 diclofenac epolamine 48 DAURISMO 31 CORTISPORIN-TC 68 diclofenac potassium 3 DAYTRANA 1 COSENTYX 49 diclofenac sodium 3 COSENTYX SENSOREADY decitabine 29 diclofenac sodium (actinic PEN 49 deferasirox 23 keratoses) 48 COTELLIC 33 deferiprone 23 diclofenac sodium (ophth) 67 CREON 52 DELESTROGEN 56 diclofenac sodium (topical) 48 CRESEMBA 24 DELSTRIGO 39 diclofenac w/ misoprostol 3 CRINONE 75 demeclocycline hcl 72 dicloxacillin sodium 69 CRIXIVAN 39 DENAVIR 49 dicyclomine hcl 73 cromolyn sodium 10 DEPAKOTE 16 DIFICID 61 cromolyn sodium DEPAKOTE ER 16 diflorasone diacetate 50 (mastocytosis) 57 DEPAKOTE SPRINKLES 16 diflunisal 4 cromolyn sodium (ophth) 67 DEPO-MEDROL 46 digoxin 43 crotamiton 52 DEPO-SUBQ PROVERA dihydroergotamine mesylate 61 CRYSVITA 54 104 46 DILANTIN 15 CUVITRU 68 DESCOVY 39 DILANTIN INFATABS 15 cyanocobalamin 59 desipramine hcl 18 DILANTIN-125 15 cyclobenzaprine hcl 64 desloratadine 25 DILATRATE SR 9 cyclopentolate hcl 66 desmopressin acetate 55 diltiazem hcl 42 cyclophosphamide 29 desmopressin acetate diltiazem hcl coated beads 42 CYCLOPHOSPHAMIDE 29 spray 55 desmopressin acetate spray diltiazem hcl extended release CYCLOSET 19 refrigerated 55 beads 42 cyclosporine 63 desogestrel & ethinyl diphenhydramine hcl 25 cyclosporine modified (for estradiol 45 diphenoxylate w/ atropine 23 microemulsion) 63 desogestrel-ethinyl estradiol DIPHTHERIA/TETANUS cyproheptadine hcl 25 (biphasic) 45 TOXOIDS ADSORBED CYRAMZA 30 desonide 50 PEDIATRIC 73 CYSTADANE 54 desoximetasone 50 dipyridamole 58 CYSTAGON 57 DESVENLAFAXINE ER 17 disopyramide phosphate 10 CYSTARAN 67 desvenlafaxine succinate 17 disulfiram 70 cytarabine 29 dexamethasone 46 divalproex sodium 16 dexamethasone sodium DIVIGEL 56 dacarbazine 34 phosphate 46 dactinomycin 32 dexamethasone sodium dobutamine hcl 43 dalfampridine 70 phosphate (ophth) 67 docetaxel 35 DALIRESP 10 DEXILANT 73 dofetilide 10 dexmethylphenidate hcl 1 donepezil hydrochloride 70 Updated 09/01/2021 Index 4 DOPTELET 59 ELITEK 35 ertapenem sodium 8 dorzolamide hcl 67 ELLA 46 ERWINAZE 34 dorzolamide hcl-timolol ELMIRON 58 ERYTHROCIN maleate 66 EMCYT 31 LACTOBIONATE 61 DOVATO 39 erythromycin (acne aid) 47 EMFLAZA 46 doxazosin mesylate 27 erythromycin (ophth) 66 EMGALITY 61 doxepin hcl 18 erythromycin base 61 EMPLICITI 30 doxepin hcl (antipruritic) 49 erythromycin ethylsuccinate 61 EMSAM 16 doxepin hcl (sleep) 60 ESBRIET 72 emtricitabine 39 doxercalciferol 54 emtricitabine-tenofovir escitalopram oxalate 16 doxorubicin hcl 32 disoproxil fumarate 39 esomeprazole magnesium 73 doxorubicin hcl liposomal 32 EMTRIVA 39 esomeprazole sodium 73 doxycycline (monohydrate) 72 enalapril maleate 26 estradiol 56 doxycycline (rosacea) 52 enalapril maleate & estradiol & norethindrone doxycycline hyclate 72 hydrochlorothiazide 27 acetate 56 ENBREL 4 estradiol vaginal 75 DRIZALMA SPRINKLE 17 ENBREL MINI 4 estradiol valerate 56 dronabinol 24 drospirenone-ethinyl ENBREL SURECLICK 4 ESTRING 75 estradiol 45 ENDARI 59 eszopiclone 60 drospirenone-ethinyl estradiol- ENGERIX-B 74 ethacrynic acid 53 levomefolate calcium 45 ENHERTU 30 ethambutol hcl 28 DROXIA 59 enoxaparin sodium 13 ethosuximide 16 droxidopa 75 ENSTILAR 50 ethynodiol diacet & eth DUAVEE 56 entacapone 36 estrad 45 DUEXIS 3 etodolac 3 entecavir 41 DULERA 12 etonogestrel-ethinyl estradiol46 ENTRESTO 43 duloxetine hcl 17 ETOPOPHOS 35 ENTYVIO 57 DUOPA 36 etoposide 35 ENVARSUS XR 63 DUREZOL 67 etravirine 39 EPCLUSA 41 dutasteride 58 EVAMIST 56 EPIDIOLEX 14 dutasteride-tamsulosin hcl 58 EVENITY 53 epinastine hcl (ophth) 67 econazole nitrate 48 everolimus 33 epinephrine (anaphylaxis) 75 EDARBI 27 everolimus epirubicin hcl 32 EDARBYCLOR 27 (immunosuppressant) 63 EPIVIR HBV 41 EVOMELA 29 EDEX 43 eplerenone 28 EVOTAZ 39 EDURANT 39 EPOGEN 59 EVZIO 23 efavirenz 39 EQUETRO 37 efavirenz-emtricitabine-tenofovir exemestane 31 disoproxil fumarate 39 ERAXIS 24 EXONDYS 51 65 efavirenz-lamivudine-tenofovir ERBITUX 31 EXTAVIA 71 disoproxil fumarate 39 ergocalciferol 75 EYLEA 66 EGRIFTA SV 54 ergoloid mesylates 71 ezetimibe 26 ELELYSO 59 ergotamine tartrate 61 ezetimibe-simvastatin 25 ELESTRIN 56 ergotamine w/ caffeine 61 FABIOR 47 eletriptan hydrobromide 62 ERIVEDGE 31 FABRAZYME 54 ELIGARD 31 ERLEADA 31 famciclovir 41 ELIQUIS 13 erlotinib hcl 31 famotidine 73 ELIQUIS STARTER PACK 13 ERTACZO 48 FANAPT 37 Index 5 Updated 09/01/2021 FANAPT TITRATION PACK 37 fluphenazine decanoate 38 GAVRETO 33 FARXIGA 22 fluphenazine hcl 38 GAZYVA 30 FARYDAK 33 flurandrenolide 50 gemcitabine hcl 29,30 FASENRA 10 flurbiprofen 3 gemfibrozil 26 fat emulsion plant based 65 flurbiprofen sodium 67 GENOTROPIN 54 febuxostat 58 flutamide 31 GENOTROPIN MINIQUICK 54 felbamate 15 fluticasone propionate 51 gentamicin in saline 2 felodipine 42 fluticasone propionate gentamicin sulfate 2 FEMRING 75 (nasal) 65 gentamicin sulfate (ophth) 66 fluticasone-salmeterol 12 fenofibrate 25,26 gentamicin sulfate (topical) 48 fluvastatin sodium 26 fenofibrate micronized 25 GENVOYA 40 fluvoxamine maleate 17 FENSOLVI 54 GILENYA 71 FML 67 fentanyl 4 GILOTRIF 31 FML FORTE 67 fentanyl citrate 4 GIVLAARI 58 folic acid 59 FENTORA 4 GLASSIA 71 FOLOTYN 29 FERRIPROX 23 glimepiride 22 fondaparinux sodium 13 FERRIPROX TWICE-A-DAY 23 glipizide 23 FORFIVO XL 16 FETZIMA 17 glipizide-metformin hcl 18 formoterol fumarate 12 FETZIMA TITRATION PACK17 GLUCAGEN HYPOKIT 19 FORTEO 53 FINACEA 52 glucagon (rdna) 19 FOSAMAX PLUS D 53 finasteride 58 glyburide 23 fosamprenavir calcium 39 FINTEPLA 14 glyburide micronized 23 fosinopril sodium 26 FIRDAPSE 28 glyburide-metformin 18 fosinopril sodium & FIRMAGON 31 hydrochlorothiazide 27 glycopyrrolate 73 FIRVANQ 8 fosphenytoin sodium 15 GOCOVRI 36 FLAREX 67 FOTIVDA 33 GOLYTELY 60 flavoxate hcl 74 FRAGMIN 13 GRALISE 71 FLEBOGAMMA DIF 68 frovatriptan succinate 62 granisetron hcl 23 flecainide acetate 10 fulvestrant 31 GRASTEK 2 FLECTOR 48 furosemide 53 griseofulvin microsize 24 FLOVENT DISKUS 11 FUZEON 39 griseofulvin ultramicrosize 24 FLOVENT HFA 11 FYCOMPA 13 guanfacine hcl 27 fluconazole 24 gabapentin 14 guanfacine hcl (adhd) 1 fluconazole in nacl 24 GALAFOLD 54 GUANIDINE HCL 28 flucytosine 24 galantamine hydrobromide 70 GVOKE HYPOPEN 1-PACK 19 fludarabine phosphate 29 GALZIN 63 GVOKE HYPOPEN 2-PACK 19 fludrocortisone acetate 47 GAMASTAN 68 GVOKE PFS 19 flunisolide (nasal) 65 GAMMAGARD LIQUID 68 HAEGARDA 58 fluocinolone acetonide 50 GAMMAKED 68 HALAVEN 35 fluocinolone acetonide (otic) 68 GAMMAPLEX 68 halcinonide 51 fluocinonide 50 GAMUNEX-C 68 halobetasol propionate 51 fluocinonide emulsified base 50 ganciclovir sodium 41 haloperidol 38 fluorometholone (ophth) 67 GARDASIL 9 74 haloperidol decanoate 38 fluorouracil 29 gatifloxacin (ophth) 66 haloperidol lactate 38 fluorouracil (topical) 48 GATTEX 57 HARVONI 41 fluoxetine hcl 17 gauze pads 2" X 2" 61 HAVRIX 74 Updated 09/01/2021 Index 6 HEMANGEOL 42 hydrocortisone (topical) 51 INFANRIX 73 HEPARIN SODIUM 13 hydrocortisone butyrate 51 INFLECTRA 57 heparin sodium (porcine) 13 hydrocortisone butyrate INFUGEM 30 HERCEPTIN 30 hydrophilic lipo base 51 INGREZZA 70 hydrocortisone valerate 51 HERCEPTIN HYLECTA 32 INLYTA 30 hydrocortisone w/acetic HETLIOZ 60 acid 68 INQOVI 32 HIBERIX 74 hydromorphone hcl 4 INREBIC 33 HIZENTRA 68 hydroxychloroquine sulfate 28 INSULIN ASPART 21 HORIZANT 71 hydroxyprogesterone caproate INSULIN ASPART HUMALOG 20 (antineoplastic) 31 FLEXPEN 21 HUMALOG JUNIOR hydroxyurea 34 INSULIN ASPART PENFILL 21 KWIKPEN 20 hydroxyzine hcl 9 INSULIN ASPART HUMALOG KWIKPEN 20 PROTAMINE/INSULIN hydroxyzine pamoate 9 ASPART 21 HUMALOG MIX 50/50 20 HYPERRAB S/D 68 INSULIN ASPART HUMALOG MIX 50/50 HYQVIA 69 PROTAMINE/INSULIN ASPART KWIKPEN 20 ibandronate sodium 53 FLEXPEN 21 HUMALOG MIX 75/25 20 INSULIN LISPRO 21 IBRANCE 33 HUMALOG MIX 75/25 INSULIN LISPRO JUNIOR KWIKPEN 20 ibuprofen 3 KWIKPEN 21 HUMATROPE 54 ibuprofen-famotidine 3 INSULIN LISPRO KWIKPEN 21 HUMATROPE COMBO icatibant acetate 58 INSULIN LISPRO PACK 54 ICLUSIG 33 PROTAMINE/INSULIN LISPRO HUMIRA 2 icosapent ethyl 25 KWIKPEN 21 HUMIRA PEDIATRIC CROHNS INSULIN SYRINGES AND PEN DISEASE STARTER PACK 2 idarubicin hcl 32 NEEDLES 61 HUMIRA PEN 2 IDHIFA 33 INTELENCE 40 HUMIRA PEN-CD/UC/HS IFEX 29 INTRON A 34,35 STARTER 2 ifosfamide 29 INVEGA SUSTENNA 37 HUMIRA PEN-PEDIATRIC UC STARTER PACK 2 IFOSFAMIDE 29 INVEGA TRINZA 37 HUMIRA PEN-PS/UV ILARIS 3 INVIRASE 40 STARTER 2 ILEVRO 67 INVOKAMET 18 HUMULIN 70/30 20 ILUMYA 49 INVOKAMET XR 18 HUMULIN 70/30 KWIKPEN 20 imatinib mesylate 33 INVOKANA 22 HUMULIN N 20 IMBRUVICA 33 IPOL INACTIVATED IPV 74 HUMULIN N KWIKPEN 20 IMFINZI 30 ipratropium bromide 10 HUMULIN R 20 imipenem-cilastatin 8 ipratropium bromide (nasal) 65 HUMULIN R U-500 imipramine hcl 18 (CONCENTRATED) 21 ipratropium-albuterol 12 HUMULIN R U-500 imipramine pamoate 18 irbesartan 27 KWIKPEN 21 imiquimod 51 irbesartan-hydrochlorothiazide hydralazine hcl 28 IMLYGIC 35 27 IRESSA 31 hydrochlorothiazide 53 IMOGAM RABIES-HT 68 hydrocodone bitartrate 4 IMOVAX RABIES irinotecan hcl 35 hydrocodone polistirex- (H.D.C.V.) 74 irrigation solutions, chlorpheniramine polistirex 47 IMPAVIDO 7 physiological 64 ISENTRESS 40 hydrocodone-acetaminophen 6 INCRELEX 54 ISENTRESS HD 40 hydrocodone-ibuprofen 6 INCRUSE ELLIPTA 10 isoniazid 28 hydrocortisone 46 indapamide 53 isosorbide dinitrate 9 hydrocortisone (intrarectal) 7 INDOCIN 3 isosorbide mononitrate 9 hydrocortisone (rectal) 7 indomethacin 3 Index 7 Updated 09/01/2021 isotretinoin 47 KISQALI FEMARA 400 leucovorin calcium 35 ISTODAX (OVERFILL) 33 DOSE 33 LEUKERAN 29 KISQALI FEMARA 600 itraconazole 24 DOSE 33 leuprolide acetate 31 ivermectin 7 KOMBIGLYZE XR 18 levalbuterol hcl 12 ivermectin (rosacea) 52 KORLYM 19 levalbuterol tartrate 12 IXEMPRA KIT 35 KOSELUGO 33 LEVEMIR 21 IXIARO 74 KRINTAFEL 28 LEVEMIR FLEXTOUCH 21 JAKAFI 33 KUVAN 55 levetiracetam 14,15 JANUMET 18 KYPROLIS 33 levetiracetam in sodium chloride 14 JANUMET XR 18 labetalol hcl 42 levobunolol hcl 66 JANUVIA 19 lactated ringer's 62 levocarnitine (metabolic JARDIANCE 22 lactic acid (ammonium modifiers) 55 JEMPERLI 30 lactate) 51 levocetirizine dihydrochloride25 lactulose 60 JENTADUETO 18 levofloxacin 56 lactulose (encephalopathy)57 JENTADUETO XR 18 levofloxacin (ophth) 66 LAMICTAL XR 14 JEVTANA 35 levofloxacin in d5w 56 lamivudine 40 JUBLIA 48 levoleucovorin calcium 35 JULUCA 40 lamivudine (hbv) 41 levonorgestrel & eth JUXTAPID 26 lamivudine-zidovudine 40 estradiol 45 levonorgestrel-eth estradiol JYNARQUE 55 lamotrigine 14 LANOXIN 43 (triphasic) 45 K-TAB 62 levonorgestrel-ethinyl estradiol KADCYLA 30 LANOXIN PEDIATRIC 43 (91-day) 45 KADIAN 5 lansoprazole 73 levonorgestrel-ethinyl estradiol lanthanum carbonate 57 (continuous) 45 KALBITOR 58 levothyroxine sodium 72 KALETRA 40 LANTUS 21 LANTUS SOLOSTAR 21 LEXIVA 40 KALYDECO 72 LIBTAYO 31 KANJINTI 30 lapatinib ditosylate 33 LASTACAFT 67 lidocaine 52 KANUMA 54 lidocaine hcl 52 KAZANO 18 latanoprost 68 LATUDA 37 lidocaine hcl (local anesth.) 61 KEDRAB 69 lidocaine hcl (mouth-throat) 64 KENALOG-10 46 LAZANDA 5 leflunomide 4 lidocaine-prilocaine 52 KEPIVANCE 35 lincomycin hcl 8 ketoconazole 24 LEMTRADA 71 LENVIMA 10 MG DAILY linezolid 9 ketoconazole (topical) 48 DOSE 30 linezolid in sodium chloride 9 ketoprofen 3 LENVIMA 12MG DAILY LINZESS 57 DOSE 30 ketorolac tromethamine 3 liothyronine sodium 72 ketorolac tromethamine LENVIMA 14 MG DAILY (ophth) 67 DOSE 30 LIPOFEN 26 KEVEYIS 52 LENVIMA 18 MG DAILY lisinopril 26 DOSE 30 KEVZARA 3 lisinopril & LENVIMA 20 MG DAILY hydrochlorothiazide 27 KEYTRUDA 30 DOSE 30 LITHIUM 37 KHAPZORY 35 LENVIMA 24 MG DAILY DOSE 30 lithium carbonate 37 KINERET 2 LENVIMA 4 MG DAILY LIVALO 26 KINRIX 73 DOSE 30 LO LOESTRIN FE 45 LENVIMA 8 MG DAILY KISQALI 33 LOKELMA 64 KISQALI FEMARA 200 DOSE 30 DOSE 32 letrozole 31 LONSURF 33 Updated 09/01/2021 Index 8 loperamide hcl 23 medroxyprogesterone metoprolol & lopinavir-ritonavir 40 acetate 69 hydrochlorothiazide 27 medroxyprogesterone acetate metoprolol succinate 42 lorazepam 10 (contraceptive) 46 metoprolol tartrate 42 LORBRENA 33 mefenamic acid 3 metronidazole 7 losartan potassium 27 mefloquine hcl 28 metronidazole (topical) 52 losartan potassium & megestrol acetate 32 metronidazole in nacl 7 hydrochlorothiazide 27 megestrol acetate LOTEMAX 67 (appetite) 69 metronidazole vaginal 75 LOTEMAX SM 67 MEKINIST 33 metyrosine 27 loteprednol etabonate 67 MEKTOVI 33 mexiletine hcl 10 lovastatin 26 meloxicam 3 micafungin sodium 24 loxapine succinate 38 melphalan 29 miconazole nitrate vaginal 75 lubiprostone 57 melphalan hcl 29 midodrine hcl 75 LUCEMYRA 70 memantine hcl 70 miglitol 18 luliconazole 48 MENACTRA 74 miglustat 59 LUMAKRAS 33 MENOSTAR 56 MIGRANAL 61 LUMIGAN 68 MENQUADFI 74 minocycline hcl 72 LUMIZYME 55 MENTAX 48 minoxidil 28 LUMOXITI 31 MENVEO 74 mirtazapine 16 LUPANETA PACK 54 meprobamate 9 MIRVASO 52 LUPRON DEPOT (1- mercaptopurine 30 misoprostol 73 MONTH) 31 mitomycin 32 LUPRON DEPOT (3- meropenem 8 MONTH) 32 mesalamine 57 mitoxantrone hcl 32 LUPRON DEPOT (4- mesalamine w/ cleanser 57 modafinil 2 MONTH) 32 mesna 35 moexipril hcl 26 LUPRON DEPOT (6- MONTH) 32 MESNEX 35 molindone hcl 38 LUPRON DEPOT-PED (1- metaxalone 64 mometasone furoate 51 MONTH) 54 metformin hcl 19 mometasone furoate (nasal) 65 LUPRON DEPOT-PED (3- MONJUVI 31 MONTH) 54 methadone hcl 5 LUZU 48 methazolamide 52 montelukast sodium 10 LYNPARZA 33 methenamine hippurate 9 morphine sulfate 5 LYSODREN 32 methimazole 72 morphine sulfate beads 5 M-M-R II 74 methocarbamol 64 MOTOFEN 23 magnesium sulfate 62 methotrexate sodium 30 MOVANTIK 57 malathion 52 methoxsalen rapid 49 MOXEZA 66 maprotiline hcl 16 methscopolamine bromide 73 moxifloxacin hcl 56 MARPLAN 16 methyldopa 27 moxifloxacin hcl (ophth) 66 MARQIBO 35 methylergonovine maleate 68 MOZOBIL 60 MATULANE 35 methylphenidate hcl 1,2 MULPLETA 59 MAVENCLAD 71 methylprednisolone 46 MULTAQ 10 MAVYRET 41 methylprednisolone mupirocin 48 acetate 46 MUSE 43 MAXIDEX 67 methylprednisolone sod MAYZENT 71 succ 46 MVASI 30 meclizine hcl 24 methyltestosterone 7 MYALEPT 55 meclofenamate sodium 3 metoclopramide hcl 57 mycophenolate mofetil 63 MEDROL 46 metolazone 53 mycophenolate mofetil hcl 63 Index 9 Updated 09/01/2021 mycophenolate sodium 63 nimodipine 42 NOVOLIN N FLEXPEN MYLOTARG 31 NINLARO 34 RELION 21 NOVOLIN N RELION 21 MYRBETRIQ 74 NIPENT 35 NOVOLIN R 22 MYTESI 23 nisoldipine 42 NOVOLIN R FLEXPEN 22 nabumetone 3 nitazoxanide 8 NOVOLIN R FLEXPEN nadolol 42 nitisinone 55 RELION 21 nafcillin sodium 69 NITRO-DUR 9 NOVOLIN R RELION 22 naftifine hcl 48 nitrofurantoin 9 NOVOLOG 22 NAFTIN 48 nitrofurantoin macrocrystal 9 NOVOLOG FLEXPEN 22 NAGLAZYME 55 nitrofurantoin monohyd NOVOLOG FLEXPEN naloxone hcl 23 macro 9 RELION 22 nitroglycerin 9 naltrexone hcl 23 NOVOLOG MIX 70/30 22 NAMENDA XR TITRATION NITROSTAT 9 NOVOLOG MIX 70/30 70 nizatidine 73 PREFILLED FLEXPEN 22 PACK NOVOLOG MIX 70/30 NAPRELAN 3 NORDITROPIN FLEXPRO 54 PREFILLED FLEXPEN naproxen 3 norelgestromin-ethinyl RELION 22 naproxen sodium 3 estradiol 46 NOVOLOG MIX 70/30 naproxen-esomeprazole norethin acet & estrad-fe 45 RELION 22 magnesium 3 norethindrone & eth NOVOLOG PENFILL 22 naratriptan hcl 62 estradiol 45 NOVOLOG RELION 22 norethindrone & ethinyl NARCAN 23 estradiol-fe 45 NOXAFIL 24 NASCOBAL 59 norethindrone NUBEQA 32 NATACYN 66 (contraceptive) 46 NUCALA 10 norethindrone acet & eth nateglinide 22 estra 45 NUCYNTA 5 NATPARA 53 norethindrone acetate 69 NUEDEXTA 71 NAYZILAM 14 norethindrone acetate-ethinyl NULOJIX 63 nefazodone hcl 17 estradiol 56 NUPLAZID 37 neomycin sulfate 2 norethindrone-eth estradiol NUTROPIN AQ NUSPIN 20 54 (triphasic) 45 neomycin-bacitracin zn- norgestimate-ethinyl NUZYRA 72 polymyxin 66 estradiol 45 NYMALIZE 43 neomycin-polymy-dexameth 67 norgestimate-ethinyl estradiol nystatin 24 neomycin-polymyxin-gramicidin (triphasic) 45 66 norgestrel & ethinyl nystatin (mouth-throat) 64 neomycin-polymyxin-hc estradiol 45 nystatin (topical) 48 (otic) 68 NORITATE 52 nystatin-triamcinolone 48 neomycin/polymyxin b gu 58 NORPACE CR 10 OCALIVA 56 NERLYNX 33 nortriptyline hcl 18 OCREVUS 71 NESINA 19 NORVIR 40 OCTAGAM 69 NEUPRO 36 NOURIANZ 36 octreotide acetate 55 NEVANAC 67 NOVAREL 54 ODEFSEY 40 nevirapine 40 NOVOLIN 70/30 21 ODOMZO 31 NEXAVAR 33 NOVOLIN 70/30 OFEV 72 niacin (antihyperlipidemic) 26 FLEXPEN 21 ofloxacin (ophth) 66 nicardipine hcl 42 NOVOLIN 70/30 FLEXPEN RELION 21 ofloxacin (otic) 68 NICOTROL INHALER 71 NOVOLIN 70/30 RELION 21 OGIVRI 30 NICOTROL NS 71 NOVOLIN N 21 olanzapine 38 nifedipine 42 NOVOLIN N FLEXPEN 21 olanzapine-fluoxetine hcl 70 nilutamide 32 olmesartan medoxomil 27 Updated 09/01/2021 Index 10 olmesartan medoxomil- OXISTAT 48 perphenazine 38 amlodipine-hydrochlorothiazide oxybutynin chloride 74 perphenazine-amitriptyline 70 27 olmesartan medoxomil- oxycodone hcl 5 PERSERIS 37 hydrochlorothiazide 28 oxycodone w/ PEXEVA 17 olopatadine hcl 67 acetaminophen 6 phenelzine sulfate 16 oxycodone-aspirin 6 olopatadine hcl (nasal) 65 phenobarbital 60 oxymorphone hcl 5 OLUMIANT 2 phenoxybenzamine hcl 27 OZEMPIC 20 omega-3-acid ethyl esters 25 phenytoin 15 paclitaxel 35 omeprazole 73 phenytoin sodium 16 PADCEV 31 omeprazole-sodium phenytoin sodium extended 15 bicarbonate 73,74 paliperidone 37 PHESGO 33 OMNARIS 65 PALYNZIQ 55 phytonadione 75 OMNITROPE 54 PANRETIN 48 PICATO 48 ONCASPAR 34 pantoprazole sodium 73 PIFELTRO 40 ondansetron 24 parenteral electrolytes 62 pilocarpine hcl 66 ondansetron hcl 23 paricalcitol 55 pilocarpine hcl (oral) 64 ONGLYZA 19 paromomycin sulfate 2 pimecrolimus 51 ONIVYDE 35 paroxetine hcl 17 pimozide 71 ONUREG 30 paroxetine mesylate pindolol 42 OPDIVO 31 (vasomotor) 71 pioglitazone hcl 20 opium tincture 23 PASER 28 pioglitazone hcl-glimepiride 19 OPSUMIT 44 PAXIL 17 pioglitazone hcl-metformin ORACEA 52 PEDIARIX 73 pediatric vitamins acd w/ hcl 19 ORALAIR 2 fluoride 64 piperacillin sodium-tazobactam ORBACTIV 8 sodium 69 PEDVAX HIB 74 PIQRAY 200MG DAILY ORENCIA 4 peg 3350-kcl-nacl-na sulfate-na DOSE 34 ORENCIA CLICKJECT 4 ascorbate-ascorbic acid 60 PIQRAY 250MG DAILY ORENITRAM 43 peg 3350-kcl-sod bicarb-sod DOSE 34 chloride-sod sulfate 60 ORFADIN 55 PIQRAY 300MG DAILY peg 3350-potassium chloride- DOSE 34 ORGOVYX 32 sod bicarbonate-sod piroxicam 3 ORILISSA 54 chloride 60 PEGANONE 15 PLEGRIDY 71 ORKAMBI 72 PLEGRIDY STARTER orphenadrine citrate 64 PEGASYS 41 PACK 71 oseltamivir phosphate 41 PEGINTRON 41 PLENVU 60 OSENI 18,19 PEMAZYRE 34 podofilox 52 OSMOLEX ER 36 penicillamine 63 POLIVY 31 OSMOPREP 60 penicillin g potassium 69 polymyxin b sulfate 9 OSPHENA 54 penicillin v potassium 69 polymyxin b-trimethoprim 66 OTEZLA 3 PENNSAID 48 POMALYST 32 OTREXUP 2 PENTACEL 73 PORTRAZZA 31 oxaliplatin 29 pentamidine isethionate 8 posaconazole 24 oxandrolone 7 pentoxifylline 58 potassium chloride 62,63 oxaprozin 3 PEPAXTO 29 potassium chloride in dextrose & sodium chloride 62 OXBRYTA 59 PERFOROMIST 12 perindopril erbumine 27 potassium chloride oxcarbazepine 15 microencapsulated crystals OXERVATE 67 PERJETA 30 er 63 oxiconazole nitrate 48 permethrin 52 Index 11 Updated 09/01/2021 potassium citrate promethazine & REBIF TITRATION PACK 71 (alkalinizer) 57 phenylephrine 47 REBLOZYL 59 POTELIGEO 31 promethazine hcl 25 RECOMBIVAX HB 74 PRADAXA 13 promethazine-phenylephrine- RECTIV 7 PRALUENT 26 codeine 47 propafenone hcl 10 REGRANEX 52 pramipexole dihydrochloride 36 proparacaine hcl 67 RELENZA DISKHALER 41 prasugrel hcl 58 propranolol & RELISTOR 57 pravastatin sodium 26 hydrochlorothiazide 28 REMICADE 57 praziquantel 7 propranolol hcl 42 RENFLEXIS 57 prazosin hcl 27 propylthiouracil 72 repaglinide 22 PRED MILD 67 PROQUAD 74 REPATHA 26 prednisolone 46 PROSOL 65 REPATHA PUSHTRONEX prednisolone acetate (ophth) 67 protriptyline hcl 18 SYSTEM 26 prednisolone sodium PROVENTIL HFA 12 REPATHA SURECLICK 26 phosphate 46 PRUDOXIN 49 RESTASIS 66 prednisone 46 PULMICORT FLEXHALER11 RESTASIS MULTIDOSE 66 PREDNISONE INTENSOL 46 PULMOZYME 72 RETACRIT 59 pregabalin 15 RETEVMO 34 PREGNYL W/DILUENT PURIXAN 30 BENZYLALCOHOL/NACL 54 PYLERA 74 RETIN-A MICRO PUMP 47 PREMARIN 56,75 pyrazinamide 28 RETROVIR IV INFUSION 40 PREMPHASE 56 pyridostigmine bromide 28 REVCOVI 55 PREMPRO 56 pyrimethamine 28 REVLIMID 63 PRETOMANID 28 QINLOCK 34 REXULTI 39 PREVYMIS 41 QNASL 65 REYATAZ 40 PREZCOBIX 40 QNASL CHILDRENS 65 ribavirin 41 PREZISTA 40 QUADRACEL 73 ribavirin (hepatitis c) 41 PRIFTIN 28 quetiapine fumarate 38 RIDAURA 2 primaquine phosphate 28 quinapril hcl 27 rifabutin 29 PRIMAQUINE PHOSPHATE 28 quinapril-hydrochlorothiazide rifampin 29 primidone 15 28 riluzole 65 quinidine gluconate 10 PRIVIGEN 69 rimantadine hydrochloride 41 quinidine sulfate 10 PROAIR HFA 12 RINVOQ 2 quinine sulfate 28 PROAIR RESPICLICK 12 risedronate sodium 53 RABAVERT 74 probenecid 58 RISPERDAL CONSTA 37 RADICAVA 65 prochlorperazine 38 risperidone 37 raloxifene hcl 54 prochlorperazine edisylate 38 ritonavir 40 ramelteon 60 prochlorperazine maleate 38 RITUXAN 31 ramipril 27 PROCRIT 59 RITUXAN HYCELA 33 ranolazine 9 PROCYSBI 58 rivastigmine 70 rasagiline mesylate 36 progesterone 69 rivastigmine tartrate 70 RASUVO 2 PROGRAF 63 rizatriptan benzoate 62 RAVICTI 55 PROLASTIN-C 71 ROCKLATAN 66 RAYALDEE 55 PROLENSA 68 ROMIDEPSIN 34 REBIF 71 PROLEUKIN 35 ropinirole hydrochloride 36 REBIF REBIDOSE 71 PROLIA 53 rosuvastatin calcium 26 REBIF REBIDOSE PROMACTA 59 TITRATIONPACK 71 ROTARIX 74 Updated 09/01/2021 Index 12 ROTATEQ 74 simvastatin 26 sucralfate 73 ROZLYTREK 34 sirolimus 63 sulfacetamide sod- RUBRACA 34 SIRTURO 29 prednisolone 67 sulfacetamide sodium (acne)47 RUCONEST 58 SIVEXTRO 9 sulfacetamide sodium rufinamide 15 SKYRIZI 49 (ophth) 66 RUKOBIA 40 SLYND 46 sulfadiazine 72 RUXIENCE 31 sodium chloride 63 sulfamethoxazole- RUZURGI 28 sodium chloride (gu trimethoprim 8 RYBELSUS 20 irrigant) 58 SULFAMYLON 49 sodium polystyrene sulfasalazine 57 RYBREVANT 31 sulfonate 64 sulindac 3 RYDAPT 34 solifenacin succinate 74 sumatriptan 62 RYTARY 36 SOLTAMOX 32 sumatriptan succinate 62 SAMSCA 55 SOLU-CORTEF 46 sumatriptan-naproxen SANCUSO 24 SOLU-MEDROL 47 sodium 61 SANDIMMUNE 63 SOMATULINE DEPOT 55 SUNOSI 1 SANDOSTATIN LAR SOMAVERT 54 SUPREP BOWEL PREP KIT60 DEPOT 55 SORILUX 49 SANTYL 51 SUTENT 34 sotalol hcl 42 SAPHRIS 38 SYLATRON 35 sotalol hcl (afib/afl) 42 sapropterin dihydrochloride 55 SYMBICORT 12,13 SOTYLIZE 42 SARCLISA 31 SYMDEKO 72 SOVALDI 41 SAVAYSA 13 SYMLINPEN 120 18 SPIRIVA HANDIHALER 10 SAVELLA 70 SYMLINPEN 60 18 SAVELLA TITRATION SPIRIVA RESPIMAT 10 SYMPAZAN 14 PACK 70 spironolactone 53 SYMTUZA 40 scopolamine 24 spironolactone & SYNAGIS 69 hydrochlorothiazide 52 SECUADO 38 SYNAREL 54 SPRAVATO 56MG DOSE 16 selegiline hcl 36 SYNDROS 24 SPRAVATO 84MG DOSE 16 selenium sulfide 49 SYNERCID 9 SPRITAM 15 SELZENTRY 40 SYNJARDY 19 SPRYCEL 34 SEREVENT DISKUS 12 SYNJARDY XR 19 STALEVO 100 36 SEROSTIM 54 SYNRIBO 35 STALEVO 125 36 sertraline hcl 17 SYNTHROID 72 STALEVO 150 36 sevelamer carbonate 57 TABLOID 30 STALEVO 200 36 SHINGRIX 74 TABRECTA 34 STALEVO 50 36 SIGNIFOR 55 TACLONEX 51 STALEVO 75 36 SIGNIFOR LAR 55 tacrolimus 63 stavudine 40 sildenafil citrate 43 tacrolimus (topical) 51 STELARA 49 sildenafil citrate (pulmonary tadalafil 43 STIMATE 55 hypertension) 44 tadalafil (pulmonary SILIQ 49 STIOLTO RESPIMAT 12 hypertension) 44 silodosin 58 STIVARGA 34 TAFINLAR 34 silver sulfadiazine 49 STRENSIQ 55 TAGRISSO 31 SIMBRINZA 66 STRIBILD 40 TAKHZYRO 58 SIMPONI 2 STRIVERDI RESPIMAT 12 TALTZ 49 SIMPONI ARIA 2 SUBSYS 5,6 TALZENNA 34 SIMULECT 63 SUCRAID 52 tamoxifen citrate 32 Index 13 Updated 09/01/2021 tamsulosin hcl 58 tiagabine hcl 15 TREANDA 29 TARGRETIN 49 TIBSOVO 34 TRECATOR 29 TASIGNA 34 TICE BCG 35 TRELEGY ELLIPTA 13 tavaborole 48 TIGAN 24 TRELSTAR MIXJECT 32 TAVALISSE 58 tigecycline 72 TREMFYA 49 TAZAROTENE 47 timolol maleate 42 treprostinil 43 tazarotene 49 timolol maleate (ophth) 66 TRESIBA 22 TAZORAC 49 TIMOPTIC OCUDOSE 66 TRESIBA FLEXTOUCH 22 TAZVERIK 34 TIMOPTIC-XE 66 tretinoin 47 TDVAX 73 tinidazole 8 tretinoin (chemotherapy) 35 TECENTRIQ 31 TIVICAY 40 tretinoin microsphere 48 TECFIDERA 71 TIVICAY PD 40 TREXALL 30 TECFIDERA STARTER tizanidine hcl 64,65 triamcinolone acetonide 47 PACK 71 TOBI PODHALER 2 triamcinolone acetonide TEFLARO 45 TOBRADEX 67 (mouth) 64 TEGRETOL 15 triamcinolone acetonide TOBRADEX ST 67 TEGRETOL-XR 15 (topical) 51 tobramycin 2 triamterene 53 TEGSEDI 71 tobramycin (ophth) 66 triamterene & TEKTURNA HCT 28 tobramycin sulfate 2 hydrochlorothiazide 53 telmisartan 27 tobramycin- trientine hcl 63 telmisartan-amlodipine 28 dexamethasone 67 trifluoperazine hcl 38 telmisartan-hydrochlorothiazide TOBREX 66 trifluridine 66 28 tolbutamide 23 trihexyphenidyl hcl 36 temazepam 60 tolcapone 36 TRIKAFTA 72 TEMIXYS 40 tolmetin sodium 3 trimethobenzamide hcl 24 TEMODAR 29 TOLSURA 24 trimethoprim 8 temsirolimus 34 tolterodine tartrate 74 trimipramine maleate 18 TENIVAC 73 tolvaptan 56 TRINATAL RX 1 64 tenofovir disoproxil fumarate 40 topiramate 15 TRINTELLIX 17 TEPEZZA 54 topotecan hcl 35 TRIPTODUR 54 TEPMETKO 34 toremifene citrate 32 TRIUMEQ 40 terazosin hcl 27 torsemide 53 TRODELVY 36 terbinafine hcl 24 TOUJEO MAX TROGARZO 40 terbutaline sulfate 13 SOLOSTAR 22 trospium chloride 74 terconazole vaginal 75 TOUJEO SOLOSTAR 22 TRULICITY 20 TERIPARATIDE 53 TOVIAZ 74 TRUMENBA 74 testosterone 7 TPN ELECTROLYTES 62 TRUSELTIQ 34 testosterone cypionate 7 TRADJENTA 19 TRUXIMA 31 testosterone enanthate 7 tramadol hcl 6 TUKYSA 30 tetrabenazine 70 tramadol-acetaminophen 6 TURALIO 34 tetracycline hcl 72 trandolapril 27 TWINRIX 74 THALOMID 63 trandolapril-verapamil hcl 28 TYBOST 41 theophylline 13 tranexamic acid 60 TYMLOS 53 thioridazine hcl 38 tranylcypromine sulfate 16 TYPHIM VI 74 thiotepa 29 travoprost 68 TYSABRI 71 thiothixene 39 TRAZIMERA 30 TYVASO 43 THYMOGLOBULIN 63 trazodone hcl 17 Updated 09/01/2021 Index 14 TYVASO REFILL 43 VIBRAMYCIN 72 XIGDUO XR 19 TYVASO STARTER 44 VICTOZA 20 XOLAIR 10 UCERIS 7 VIDEX EC 41 XOSPATA 34 UKONIQ 34 vigabatrin 15 XPOVIO 32 ULTRAVATE 51 VIIBRYD 17 XPOVIO 100 MG ONCE UPTRAVI 44 VIIBRYD STARTER PACK 17 WEEKLY 32 XPOVIO 40 MG ONCE ursodiol 56 VIMIZIM 55 WEEKLY 32 UVADEX 35 VIMPAT 15 XPOVIO 40 MG TWICE VABOMERE 8 vinblastine sulfate 35 WEEKLY 32 XPOVIO 60 MG ONCE valacyclovir hcl 41 vincristine sulfate 35 WEEKLY 32 VALCHLOR 49 vinorelbine tartrate 35 XPOVIO 60 MG TWICE valganciclovir hcl 41 VIRACEPT 41 WEEKLY 32 valproate sodium 16 VIREAD 41 XPOVIO 80 MG ONCE WEEKLY 32 valproic acid 16 VISTOGARD 23 XPOVIO 80 MG TWICE valrubicin 32 VITRAKVI 34 WEEKLY 32 valsartan 27 VIZIMPRO 31 XTANDI 32 valsartan-hydrochlorothiazide voriconazole 24 XURIDEN 55 28 VOSEVI 41 XYREM 70 VALTOCO 14 VOTRIENT 34 YERVOY 31 vancomycin hcl 8 VPRIV 59 YF-VAX 75 VANCOMYCIN HYDROCHLORIDE 8 VRAYLAR 37 YONDELIS 29 VANCOMYCIN VUMERITY 71 YONSA 32 HYDROCHLORIDE/DEXTROSE VYNDAMAX 44 zafirlukast 10 8 VYNDAQEL 44 zaleplon 60 VANTAS 32 VYONDYS 53 65 ZALTRAP 30 VAQTA 74 VYVANSE 1 ZANOSAR 29 vardenafil hcl 43 VYXEOS 33 ZARXIO 59 VARIVAX 75 WAKIX 1 ZEJULA 34 VARIZIG 69 warfarin sodium 13 ZELAPAR 36 VARUBI 24 water for irrigation, sterile 64 ZELBORAF 34 VASCEPA 25 WILZIN 63 ZEMAIRA 72 VECTIBIX 31 XALKORI 34 ZEMBRACE SYMTOUCH 62 VECTICAL 49 XARELTO 13 ZENPEP 52 VELCADE 34 XARELTO STARTER ZEPATIER 41 VELTASSA 64 PACK 13 ZETONNA 65 VEMLIDY 41 XATMEP 30 zidovudine 41 VENCLEXTA 31 XCOPRI 15 zileuton 10 VENCLEXTA STARTING XELJANZ 2 PACK 31 ZINPLAVA 69 XELJANZ XR 2 venlafaxine hcl 17 ZIOPTAN 68 XENLETA 9 VENTAVIS 44 ziprasidone hcl 37 XEOMIN 65 VENTOLIN HFA 13 ziprasidone mesylate 37 XERESE 49 verapamil hcl 43 ZIPSOR 3 XERMELO 57 VERELAN PM 43 ZIRABEV 30 XGEVA 53 VERSACLOZ 38 ZIRGAN 66 XIAFLEX 63 VERZENIO 34 ZITHROMAX 61 XIFAXAN 8 VIBERZI 57 ZOLADEX 32 Index 15 Updated 09/01/2021 zoledronic acid 53 ZOLINZA 34 zolmitriptan 62 zolpidem tartrate 60 ZOMACTON 54 ZOMIG 62 ZONALON 49 zonisamide 15 ZONTIVITY 58 ZORTRESS 64 ZOSTAVAX 75 ZOSYN 69 ZUBSOLV 7 ZULRESSO 16 ZYCLARA 51 ZYCLARA PUMP 51 ZYDELIG 34 ZYKADIA 34 ZYLET 67 ZYNLONTA 31 ZYPREXA RELPREVV 38 ZYVOX 9 Updated 09/01/2021 Index 16 This formulary was updated on 09/01/2021. 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