Learn About Your Formulary Your drug list, also called a formulary, is the list of drugs covered by St. Louis County Department of Health. Your plan with the St. Louis County Department of Health has specific guidelines you must follow to get prescription drug coverage. You must choose generic medications when they are Many drug companies offer programs to help people available. Generic medications have the same ingredients afford their drugs. We encourage you to ask your doctor as brand drugs, at lower prices. about manufacturer assistance programs. You must fill your prescription at participating pharmacies Drugs are listed on the formulary in alphabetical order by within the St. Louis area: name in the appropriate therapeutic category and class. > CVS > The Medicine Shoppe > Walmart > Schnucks Medications on the High Priority Drug List are covered for > Sam's Club > Beverly Hills Pharmacy ONLY two 30-day fills per year. > Dierbergs > If you are prescribed a High Priority Drug, contact the drug maker to request assistance in getting your medication at reduced or no cost. You must get your prescriptions from Department of > If you do not take this step, you will pay 100% of the Health Physicians discounted drug cost after getting two 30-day fills. > If a medication is prescribed by a non-panel doctor, a > The High Priority Drug List includes: special review is required and can be requested at the • Diabetes drugs: Lantus, Novolog and Novolin number below. • Asthma Inhalers: Atrovent, Spiriva, Ventolin, Proair, Respiclick, Symbicort, Advair, Flovent and Proventil Online Tools Who can I call if I have a question? Our Customer Service Center is available 24 hours a day, 7 Access your pharmacy beneft information through our days a week, 365 days a year to help answer any questions or portal, Members.EnvolveRx.com, and mobile app, concerns you have about your pharmacy benefit. Please call EnvolveRx. Our digital tools allow you to: us at 844.985.11188. > Access your digital ID cards on the EnvolveRx app > Compare prices for retail, mail, brand and generic medications How do I know if a drug is covered? > Find a pharmacy near you Review your formulary, below, or contact Envolve Pharmacy > Find generic alternatives to expensive brand name drugs Solutions’ Customer Service Center at 844.985.11188. > Check to see if a specifc drug is covered on your drug list > Review your claims history or print an Explanation of Benefts EnvolveRx.com © 2020 Envolve. All rights reserved. 02-20 844.985.11118 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADHD/ANTI-NARCOLEPSY/ANTI- diclofenac sodium tb24 F OBESITY/ANOREXIANTS - Drugs to Treat ADHD, Sleep and Eating Disorders diclofenac sodium tbec F Amphetamines ibuprofen susp 100 mg/5ml F RX/OTC amphetamine- F QL(2 ea daily) dextroamphetamine cp24 ibuprofen tabs 400 mg, 600 F MP mg, 800 mg amphetamine- F QL(2 ea daily) dextroamphetamine tabs INDOCIN SUPP F dextroamphetamine sulfate F QL(2 ea daily) cp24 5 mg, 10 mg, 15 mg INDOCIN SUSP F dextroamphetamine sulfate F QL(60 ml daily) soln 5 mg/5ml indomethacin caps F dextroamphetamine sulfate F QL(2 ea daily) tabs 10 mg indomethacin cpcr F dextroamphetamine sulfate F ketorolac tromethamine F QL(20 ea per tabs 5 mg tabs 30 days retail) Stimulants - Misc. meloxicam tabs F MP methylphenidate hcl chew F 5 mg, 10 mg, 2.5 mg nabumetone tabs F methylphenidate hcl cp24 F QL(2 ea daily) 10 mg, 20 mg, 30 mg naproxen sodium tabs F MP methylphenidate hcl cp24 F QL(1 ea daily) 40 mg naproxen tabs F MP methylphenidate hcl cpcr MP 10 mg, 40 mg, 50 mg, 60 F naproxen tbec F mg sulindac tabs F methylphenidate hcl cpcr F QL(2 ea daily) 20 mg, 30 mg ANALGESICS - NonNarcotic - Drugs to Treat methylphenidate hcl tabs 5 F QL(2 ea daily) Pain, Muscle and Joint Conditions mg, 10 mg, 20 mg methylphenidate hcl tbcr 10 QL(1 ea daily) Salicylates mg, 18 mg, 20 mg, 27 mg, F aspirin chew F MP 54 mg MP methylphenidate hcl tbcr 36 F QL(2 ea daily) aspirin tabs F mg MP AMINOGLYCOSIDES - Drugs to Treat Bacterial aspirin tbec F Infections ANALGESICS - OPIOID - Drugs to Treat Pain, Aminoglycosides Muscle and Joint Conditions neomycin sulfate tabs F Opioid Agonists ANALGESICS - ANTI-INFLAMMATORY - Drugs hydromorphone hcl tabs F to Treat Pain, Swelling, Muscle and Joint morphine sulfate tabs 15 F Conditions mg, 30 mg Nonsteroidal Anti-inflammatory Agents (NSAIDs) tramadol hcl tabs F QL(8 ea daily) Updated April 1, 2020 F-Formulary drug, QL-Quantity limit, RX/OTC-both Rx and OTC NDCs, MP-Maintenance Product 1 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Opioid Combinations sulfamethoxazole- F trimethoprim susp acetaminophen w/ codeine F soln sulfamethoxazole- F trimethoprim tabs acetaminophen w/ codeine F tabs Lincosamides hydrocodone- clindamycin hcl caps F acetaminophen tabs 2.5 F mg-325 mg ANTIANGINAL AGENTS - Drugs to Treat Chest hydrocodone- QL(240 ea per Pain acetaminophen tabs 5 mg- F fill retail) 325 mg, 10 mg-325 mg, Nitrates 7.5 mg-325 mg ISOSORBIDE DINITRATE F MP ER TBCR hydrocodone-ibuprofen F tabs isosorbide dinitrate tabs F MP oxycodone w/ F acetaminophen tabs isosorbide mononitrate tabs F MP tramadol-acetaminophen F isosorbide mononitrate F MP tabs tb24 Opioid Partial Agonists nitroglycerin cpcr F buprenorphine hcl subl F nitroglycerin subl F buprenorphine hcl- PA Required naloxone hcl dihydrate film F after 30 days 8 mg-2 mg, 2 mg-0.5 mg ANTIANXIETY AGENTS - Drugs to Treat Anxiety buprenorphine hcl- Antianxiety Agents - Misc. naloxone hcl dihydrate subl F MP 8 mg-2 mg, 2 mg-0.5 mg buspirone hcl tabs F ANORECTAL AGENTS - Rectal Drugs to Treat hydroxyzine hcl tabs 10 mg F Pain, Swelling and Itching hydroxyzine hcl tabs 25 F MP Rectal Steroids mg, 50 mg hydrocortisone (rectal) crea F HYDROXYZINE F PAMOATE CAPS 100 MG hydrocortisone acetate F (rectal) supp hydroxyzine pamoate caps F 25 mg ANTI-INFECTIVE AGENTS - MISC. - Drugs to hydroxyzine pamoate caps F MP Treat Bacterial Infections 50 mg Anti-infective Agents - Misc. Benzodiazepines metronidazole caps F alprazolam tabs F metronidazole tabs F chlordiazepoxide hcl caps F trimethoprim tabs F diazepam tabs F Anti-infective Misc. - Combinations lorazepam tabs F Updated April 1, 2020 F-Formulary drug, QL-Quantity limit, RX/OTC-both Rx and OTC NDCs, MP-Maintenance Product 2 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ANTIARRHYTHMICS - Drugs to treat abnormal ADVAIR HFA AERO 21 QL(0.4 gm heart rhythms MCG/ACT-45 MCG/ACT, F daily)2 rtl MAX 21 MCG/ACT-115 fill,365 rtl Antiarrhythmics Type III MCG/ACT day(s) supply, amiodarone hcl tabs F MP QL(1.2 gm albuterol sulfate aers 108 F daily)2 rtl MAX ANTIASTHMATIC AND BRONCHODILATOR mcg/act fill,365 rtl AGENTS - Drugs to Treat Lung Conditions day(s) supply, Bronchodilators - Anticholinergics QL(1.2 gm ALBUTEROL SULFATE F daily)2 rtl MAX QL(0.86 gm HFA AERS fill,365 rtl ATROVENT HFA AERS F daily)2 rtl MAX day(s) supply, fill,365 rtl day(s) supply, albuterol sulfate nebu 0.63 2 rtl MAX mg/3ml, 0.083 %, 0.5 %, F fill,365 rtl 2 rtl MAX 1.25 mg/3ml, 2.5 mg/0.5ml day(s) supply, F fill,365 rtl ipratropium bromide soln day(s) supply,; QL(0.34 gm BUDESONIDE/FORMOTE daily)2 rtl MAX MP ROL FUMARATE F DIHYDRATE AERO fill,365 rtl QL(1 ea daily)2 day(s) supply, SPIRIVA HANDIHALER F rtl MAX fill,365 CAPS rtl day(s) QL(0.2 gm supply, COMBIVENT RESPIMAT F daily)2 rtl MAX AERS fill,365 rtl Steroid Inhalants day(s) supply, QL(20 ea QL(2 ea daily)2 FLOVENT DISKUS AEPB daily)2 rtl MAX F F rtl MAX fill,365 100 MCG/BLIST fill,365 rtl fluticasone-salmeterol aepb rtl day(s) day(s) supply, supply, QL(8 ea daily)2 QL(0.07 ea FLOVENT DISKUS AEPB rtl MAX fill,365 F PROAIR RESPICLICK F daily)2 rtl MAX 250 MCG/BLIST rtl day(s) AEPB fill,365 rtl supply, day(s) supply, QL(40 ea QL(1.2 gm FLOVENT DISKUS AEPB daily)2 rtl MAX F PROVENTIL HFA AERS F daily)2 rtl MAX 50 MCG/BLIST fill,365 rtl fill,365 rtl day(s) supply, day(s) supply, QL(0.8 gm QL(0.34 gm FLOVENT HFA AERO 110 daily)2 rtl MAX F SYMBICORT AERO F daily)2 rtl MAX MCG/ACT, 220 MCG/ACT fill,365 rtl fill,365 rtl day(s) supply, day(s) supply, QL(0.36 gm QL(1.2 gm FLOVENT HFA AERO 44 daily)2 rtl MAX F VENTOLIN HFA AERS F daily)2 rtl MAX MCG/ACT fill,365 rtl fill,365 rtl day(s) supply, day(s) supply, Sympathomimetics Xanthines 2 rtl MAX ADVAIR HFA AERO 21 F THEO-24 CP24 F MCG/ACT-230 MCG/ACT fill,365 rtl day(s) supply, THEOPHYLLINE ER TB12 F Updated April 1, 2020 F-Formulary drug, QL-Quantity limit, RX/OTC-both Rx and OTC NDCs, MP-Maintenance Product 3 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits theophylline tb12 F Hydantoins DILANTIN CAPS 30 MG F theophylline tb24 F phenytoin chew F ANTICOAGULANTS - Blood Thinners phenytoin sodium extended F Coumarin Anticoagulants caps MP warfarin sodium tabs F phenytoin susp F Heparins And Heparinoid-Like Agents Succinimides 1 rtl MAX enoxaparin sodium soln F fill,365 rtl ethosuximide caps F day(s) supply, ethosuximide soln F ANTICONVULSANTS - Drugs to Treat Seizures Valproic Acid Anticonvulsants - Benzodiazepines divalproex sodium tb24 F MP clonazepam tabs F divalproex sodium tbec F MP Anticonvulsants - Misc.