MetroPlus Health Plan (12/30/2020 v2) INTRODUCTION ...................................................................................................................................................................................................... 4 PREFACE ................................................................................................................................................................................................................. 4 DRUG LIST PRODUCT DESCRIPTIONS ................................................................................................................................................................ 4 GENERIC SUBSTITUTION ...................................................................................................................................................................................... 5 NON-COVERED MEDICATIONS ............................................................................................................................................................................. 5 OVER-THE-COUNTER DRUG COVERAGE ........................................................................................................................................................... 5 SPECIALTY PLAN DESIGN .................................................................................................................................................................................... 5 PLAN DESIGN.......................................................................................................................................................................................................... 6 LEGEND ................................................................................................................................................................................................................... 6 NOTICE ..................................................................................................................................................................................................................... 6 ANALGESICS........................................................................................................................................................................................................... 7 NSAIDs ........................................................................................................................................................................................................... 7 COX-2 INHIBITORS ....................................................................................................................................................................................... 7 GOUT ............................................................................................................................................................................................................. 7 OPIOID ANALGESICS ................................................................................................................................................................................... 7 NON-OPIOID ANALGESICS .......................................................................................................................................................................... 8 ANTI-INFECTIVES ................................................................................................................................................................................................... 8 ANTIBACTERIALS ......................................................................................................................................................................................... 8 ANTIFUNGALS .............................................................................................................................................................................................. 9 ANTIMALARIALS ........................................................................................................................................................................................... 9 ANTIRETROVIRAL AGENTS ........................................................................................................................................................................ 9 ANTITUBERCULAR AGENTS ..................................................................................................................................................................... 10 ANTIVIRALS................................................................................................................................................................................................. 11 MISCELLANEOUS ....................................................................................................................................................................................... 11 ANTINEOPLASTIC AGENTS ................................................................................................................................................................................ 11 ALKYLATING AGENTS ............................................................................................................................................................................... 11 ANTIMETABOLITES .................................................................................................................................................................................... 11 HORMONAL ANTINEOPLASTIC AGENTS ................................................................................................................................................. 12 IMMUNOMODULATORS ............................................................................................................................................................................. 12 KINASE INHIBITORS ................................................................................................................................................................................... 12 MISCELLANEOUS ....................................................................................................................................................................................... 13 CARDIOVASCULAR .............................................................................................................................................................................................. 13 ACE INHIBITORS ........................................................................................................................................................................................ 13 ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS ........................................................................................................ 13 ACE INHIBITOR/DIURETIC COMBINATIONS ............................................................................................................................................ 13 ADRENOLYTICS, CENTRAL ....................................................................................................................................................................... 14 ALDOSTERONE RECEPTOR ANTAGONISTS .......................................................................................................................................... 14 ALPHA BLOCKERS ..................................................................................................................................................................................... 14 ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS ........................................................................................... 14 ANTIARRHYTHMICS ................................................................................................................................................................................... 14 ANTILIPEMICS............................................................................................................................................................................................. 14 BETA-BLOCKERS ....................................................................................................................................................................................... 15 BETA-BLOCKER/DIURETIC COMBINATIONS ........................................................................................................................................... 15 CALCIUM CHANNEL BLOCKERS .............................................................................................................................................................. 15 DIGITALIS GLYCOSIDES ............................................................................................................................................................................ 16 DIURETICS .................................................................................................................................................................................................. 16 HEART FAILURE ......................................................................................................................................................................................... 16 NITRATES ...................................................................................................................................................................................................