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Peoples Health Choices 65 #14 (HMO)
Peoples Health Choices Gold (HMO-POS)
Peoples Health Group Medicare (HMO-POS)
2019 Formulary
(List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN
00019352, Version Number 6
This formulary was updated on 10/10/2018. For more recent information or other questions, please contact Peoples Health member services at 1-800-222-8600 or, for TTY users, 1-800-846-5277, seven days a week, from 8 a.m. to 8 p.m., or visit http://www.peopleshealth.com. If you contact us on a weekend or holiday, we will reach out to you within one business day.
Peoples Health is a Medicare Advantage organization with a Medicare contract to offer HMO plans. Enrollment depends on annual Medicare contract renewal.
H1961_19CF_FINAL_NOVEMBER OE Populated Template_C
http://www.peopleshealth.com/
Peoples Health 2019 Formulary (HMO and HMO-POS) – List of Covered Drugs
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 Peoples Health. When it refers to
“plan” or “our plan,” it means Peoples Health Choices 65 #14 (HMO), Peoples Health Choices Gold (HMO-
POS) or Peoples Health Group Medicare (HMO-POS).
This document includes a list of the drugs (formulary) for our plan, which is current as of the date printed on
the front and back cover pages. 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, copayments and coinsurance may change on January 1, 2020, and from time to time
during the year.
What is the Peoples Health formulary? A formulary is a list of covered drugs selected by Peoples Health 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 Peoples Health network pharmacy, and other plan rules are followed.
For more information on how to fill your prescriptions, please review the Evidence of Coverage.
Can the formulary (drug list) change? Generally, if you are taking a drug on our 2019 formulary that was covered at the beginning of the year, we
will not discontinue or reduce coverage of the drug during the 2019 coverage year except when a new, less
expensive generic drug becomes available, when new information about the safety or effectiveness of a drug
is released, or the drug is removed from the market. (See bullets below for more information on changes that
affect members currently taking the drug.) Other types of formulary changes, such as removing a drug from
our formulary, will not affect members who are currently taking the drug. It will remain available at the same
cost-sharing for those members taking it for the remainder of the coverage year. Below are changes to the
drug list that will also affect members currently taking a drug:
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 willimmediately 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 new generic drug to replace a brand name drug currently on the formulary or
add new restrictions to the brand name drug or move it to a different cost-sharing tier. Or we may
make changes based on new clinical guidelines. If we remove drugs from our formulary, add prior
authorization, quantity limits 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
1
Peoples Health 2019 Formulary (HMO and HMO-POS) – List of Covered Drugs
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.
The enclosed formulary is current as of the date printed on the front and back cover pages. To get updated
information about the drugs covered by our plans, please contact us. Our contact information appears on the
front and back cover pages. In the event of a mid-year, nonmaintenance formulary change, we will notify
you in writing of certain changes that may affect you.
How do I use the formulary? The formulary begins after this introduction. 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 have “Cardiovascular” listed in the Therapeutic Category column. Look in the Therapeutic Category column for the category name of what your drug is used for.
What are generic drugs? Peoples Health 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: Peoples Health 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, Peoples Health limits the amount of the drug that we will cover. For example, we provide 12 tablets per prescription for 30 days of naratriptan. This may be in
addition to a standard one-month or three-month supply.
Step Therapy: In some cases, Peoples Health 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 after this introduction. You can also get more information about the restrictions applied to specific
covered drugs by visiting our website. We have posted online 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.
2
Peoples Health 2019 Formulary (HMO and HMO-POS) – List of Covered Drugs
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 Peoples Health formulary?” below for information about how to request an exception.
What if my drug is not on the formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact member
services and ask if your drug is covered.
If you learn that Peoples Health 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 plans. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered
by our plans.
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 Peoples Health 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 predetermined 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, we limit 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, tiering or utilization
restriction exception. When you request a formulary, tiering 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
3
Peoples Health 2019 Formulary (HMO and HMO-POS) – List of Covered Drugs
waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no
later than 24 hours after we get a supporting statement from your doctor or other prescriber.
What do I do before I can talk to my doctor about changing my drugs or requesting an
exception? As a new or continuing member in our plan, you may be taking drugs that are not on our formulary. Or, you
may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need
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.
Peoples Health provides a transition process for members who experience a level-of-care change and are
currently on a medication regimen that contains non-formulary drugs or formulary drugs with restrictions.
This transition process will occur when the coverage determination processing time frames could interrupt
the prescribed drug regimen. We will cover up to a 31-day temporary supply of these non-formulary drugs or
formulary drugs with restrictions. Level-of-care changes include discharges from hospitals or psychiatric
facilities; admissions to or discharges from long-term care facilities; giving up hospice status; or exceeding
the limit for days covered during a skilled nursing facility stay.
For more information For more detailed information about your plan’s prescription drug coverage, please review the Evidence of Coverage and other plan materials.
If you have questions about Peoples Health, 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.
4
http://www.medicare.gov/
Peoples Health 2019 Formulary (HMO and HMO-POS) – List of Covered Drugs
Peoples Health formulary The formulary that begins after this introduction provides coverage information about the drugs covered by
Peoples Health.
During the initial coverage stage at network pharmacies, you pay the following, depending on your plan:
Peoples Health Choices 65 #14 (HMO) and Peoples Health Choices Gold (HMO-POS)
Drug Tier 30-Day Supply at a
Retail Pharmacy
90-Day Supply at a
Retail Pharmacy
Supply at a Mail-Order
Pharmacy
Tier 1 – Preferred Generic Tier $0 $0 $0 (90-day)
Tier 2 – Generic Tier $10 $30 $0 (90-day)
Tier 3 – Preferred Brand Tier $30 $90 $90 (90-day)
Tier 4 – Nonpreferred Drug Tier $80 $240 $240 (90-day)
Tier 5 – Specialty Tier 33% coinsurance Not covered
33% coinsurance
(30-day supply)
Peoples Health Group Medicare (HMO-POS)
Drug Tier 30-Day Supply at a
Retail Pharmacy
90-Day Supply at a
Retail Pharmacy With
Preferred Cost-
Sharing or a Mail-
Order Pharmacy
90-Day Supply
at a Retail
Pharmacy With
Standard
Cost-Sharing
Tier 1 – Preferred Generic Tier $3 $0 $9
Tier 2 – Generic Tier $10 $0 $30
Tier 3 – Preferred Brand Tier $25 $50 $75
Tier 4 – Nonpreferred Drug Tier $50 $100 $150
Tier 5 – Specialty Tier 20% coinsurance
5
Peoples Health 2019 Formulary (HMO and HMO-POS) – List of Covered Drugs
Peoples Health Group Medicare (HMO-POS) for Office of Group Benefits
Drug Tier 30-Day Supply at a
Retail Pharmacy
90-Day Supply at a
Retail Pharmacy With
Preferred Cost-
Sharing or a Mail-
Order Pharmacy
90-Day Supply
at a Retail
Pharmacy With
Standard
Cost-Sharing
Tier 1 – Preferred Generic Tier $0 $0 $0
Tier 2 – Generic Tier $0 $0 $0
Tier 3 – Preferred Brand Tier $20 $40 $60
Tier 4 – Nonpreferred Drug Tier $40 $80 $120
Tier 5 – Specialty Tier 20% coinsurance
6
Peoples Health 2019 Formulary (HMO and HMO-POS) – List of Covered Drugs
KEY
This formulary provides information about the drugs covered by Peoples Health. The first column of the chart lists the drug name. Other columns in this chart provide more information
about the drug, including if there are any special requirements for coverage of the drug. Below is an explanation of what these columns mean.
Coverage Gap (CG): If this column is marked "yes," we provide additional coverage for the drug in the coverage gap. Peoples Health Group Medicare (HMO-POS) members have coverage
through the gap for all tiers. Please refer to the Evidence of Coverage for more information.
Mail Order: If this column is marked "yes," the drug is available through our mail-order pharmacy.
Prior Authorization (PA): If this column is marked "yes," we require you or your physician to get prior authorization for the drug. This means that you will need to get approval from us before
you fill a prescription for the drug. If you don’t get approval, we may not cover the drug.
Step Therapy (ST): In some cases, we require 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. If this column is marked "yes," we require you
to first try certain other drugs to treat your medical condition before we will cover the drug.
Limited Access (LA): If this column is marked "yes," the drug may be available only at certain pharmacies. For more information, see the Provider Directory or call member services at the
number on the front and back cover pages of this formulary.
Quantity Limits (QL): For some drugs, there is a limit on the amount of the drug you can have. For example, there may be limits to how many refills you can get, or how much of the drug you
can get each time you fill your prescription (if it is normally considered safe to take only one pill per day for a certain drug, we may limit coverage for your prescription to no more than one pill
per day). If this column is marked "yes," we limit the amount of the drug that we will cover. For example, we provide 12 tablets per prescription for 30 days of naratriptan. This may be in
addition to a standard one-month or three-month supply.
Home Infusion (HI): If this column is marked "yes," the drug is covered under our medical benefit. For more information, call member services at the number on the front and back cover pages.
Peoples Health 2019 Formulary (HMO and HMO-POS) - List of Covered Drugs
Drug Name Tier
Level CG
Order PA PA Criteria Name ST ST Criteria LA QL
QL
Amount QL Days HI
Brand/
Generic Therapeutic Category
ALLOPURINOL TAB 100MG 1 Yes Yes No No No No No Generic ANALGESICS
ALLOPURINOL TAB 300MG 1 Yes Yes No No No No No Generic ANALGESICS
APAP/CODEINE SOL 120-12/5 2 Yes No No No No Yes 2700 30 No Generic ANALGESICS
APAP/CODEINE TAB 300-15MG 2 Yes No No No No Yes 400 30 No Generic ANALGESICS
APAP/CODEINE TAB 300-30MG 2 Yes No No No No Yes 360 30 No Generic ANALGESICS
APAP/CODEINE TAB 300-60MG 2 Yes No No No No Yes 180 30 No Generic ANALGESICS
BUTORPHANOL INJ 1MG/ML 4 No No No No No No No Generic ANALGESICS
BUTORPHANOL INJ 2MG/ML 4 No No No No No No No Generic ANALGESICS
CELECOXIB CAP 100 MG 2 Yes Yes No No No Yes 120 30 No Generic ANALGESICS
CELECOXIB CAP 200 MG 2 Yes Yes No No No Yes 60 30 No Generic ANALGESICS
CELECOXIB CAP 400 MG 2 Yes Yes No No No Yes 30 30 No Generic ANALGESICS
CELECOXIB CAP 50 MG 2 Yes Yes No No No Yes 240 30 No Generic ANALGESICS
COLCRYS TAB 0.6MG 3 No No No No No Yes 120 30 No Brand ANALGESICS
DICLOFENAC TAB 100MG XR 2 Yes Yes No No No No No Generic ANALGESICS
DICLOFENAC TAB 25MG EC 2 Yes Yes No No No No No Generic ANALGESICS
DICLOFENAC TAB 50MG EC 2 Yes Yes No No No No No Generic ANALGESICS
DICLOFENAC TAB 75MG DR 2 Yes Yes No No No No No Generic ANALGESICS
DICLOFENAC POT TAB 50MG 2 Yes Yes No No No Yes 120 30 No Generic ANALGESICS DICLOFENAC
SODIUM/MISOPROSTOL TAB 50-
0.2MG
2 Yes Yes No No No No No Generic ANALGESICS
DICLOFENAC
SODIUM/MISOPROSTOL TAB 75-
0.2 MG
2 Yes Yes No No No No No Generic ANALGESICS
DIFLUNISAL TAB 500MG 2 Yes Yes No No No No No Generic ANALGESICS
ENDOCET TAB 10-325MG 2 Yes No No No No Yes 180 30 No Generic ANALGESICS
ENDOCET TAB 5-325MG 2 Yes No No No No Yes 360 30 No Generic ANALGESICS
ENDOCET TAB 7.5-325M 2 Yes No No No No Yes 240 30 No Generic ANALGESICS
ENDOCET TAB 2.5-325 2 Yes No No No No Yes 360 30 No Generic ANALGESICS
Peoples Health 2019 Formulary (HMO and HMO-POS) - List of Covered Drugs
Drug Name Tier
Level CG
Order PA PA Criteria Name ST ST Criteria LA QL
QL
Amount QL Days HI
Brand/
Generic Therapeutic Category
ETODOLAC CAP 200MG 2 Yes Yes No No No No No Generic ANALGESICS
ETODOLAC CAP 300MG 2 Yes Yes No No No No No Generic ANALGESICS
ETODOLAC TAB 400MG 2 Yes Yes No No No No No Generic ANALGESICS
ETODOLAC TAB 500MG 2 Yes Yes No No No No No Generic ANALGESICS
ETODOLAC ER TAB 400MG 2 Yes Yes No No No No No Generic ANALGESICS
ETODOLAC ER TAB 500MG 2 Yes Yes No No No No No Generic ANALGESICS
ETODOLAC ER TAB 600MG 2 Yes Yes No No No No No Generic ANALGESICS
FENTANYL DIS 100MCG/H 2 Yes No Yes FENTANYL PATCH No No Yes 10 30 No Generic ANALGESICS
FENTANYL DIS 12MCG/HR 2 Yes No Yes FENTANYL PATCH No No Yes 10 30 No Generic ANALGESICS
FENTANYL DIS 25MCG/HR 2 Yes No Yes FENTANYL PATCH No No Yes 10 30 No Generic ANALGESICS
FENTANYL DIS 50MCG/HR 2 Yes No Yes FENTANYL PATCH No No Yes 10 30 No Generic ANALGESICS
FENTANYL DIS 75MCG/HR 2 Yes No Yes FENTANYL PATCH No No Yes 10 30 No Generic ANALGESICS FENTANYL CITRATE 0.2 MG
TRANSMUCOSAL LOZENGES 5 No No Yes
ORAL-INTRANASAL
FENTANYL No No Yes 120 30 No Generic ANALGESICS
FENTANYL CITRATE 0.4 MG
TRANSMUCOSAL LOZENGES 5 No No Yes
ORAL-INTRANASAL
FENTANYL No No Yes 120 30 No Generic ANALGESICS
FENTANYL CITRATE 0.6 MG
TRANSMUCOSAL LOZENGES 5 No No Yes
ORAL-INTRANASAL
FENTANYL No No Yes 120 30 No Generic ANALGESICS
FENTANYL CITRATE 0.8 MG
TRANSMUCOSAL LOZENGES 5 No No Yes
ORAL-INTRANASAL
FENTANYL No No Yes 120 30 No Generic ANALGESICS
FENTANYL CITRATE 1.2 MG
TRANSMUCOSAL LOZENGES 5 No No Yes
ORAL-INTRANASAL
FENTANYL No No Yes 120 30 No Generic ANALGESICS
FENTANYL CITRATE 1.6 MG
TRANSMUCOSAL LOZENGES 5 No No Yes
ORAL-INTRANASAL
FENTANYL No No Yes 120 30 No Generic ANALGESICS
FENTORA 100 MCG BUCCAL
TABLET 5 No No Yes
ORAL-INTRANASAL
FENTANYL No No Yes 120 30 No Brand ANALGESICS
FENTORA 200 MCG BUCCAL
TABLET 5 No No Yes
ORAL-INTRANASAL
FENTANYL No No Yes 120 30 No Brand ANALGESICS
Peoples Health 2019 Formulary (HMO and HMO-POS) - List of Covered Drugs
Drug Name Tier
Level CG
Order PA PA Criteria Name ST ST Criteria LA QL
QL
Amount QL Days HI
Brand/
Generic Therapeutic Category
FENTORA 400 MCG BUCCAL
TABLET 5 No No Yes
ORAL-INTRANASAL
FENTANYL No No Yes 120 30 No Brand ANALGESICS
FENTORA 600 MCG BUCCAL
TABLET 5 No No Yes
ORAL-INTRANASAL
FENTANYL No No Yes 120 30 No Brand ANALGESICS
FENTORA 800 MCG BUCCAL
TABLET 5 No No Yes
ORAL-INTRANASAL
FENTANYL No No Yes 120 30 No Brand ANALGESICS
FLURBIPROFEN TAB 100MG 2 Yes Yes No No No No No Generic ANALGESICS
FLURBIPROFEN TAB 50MG 2 Yes Yes No No No No No Generic ANALGESICS HYDROCODONE/APAP SOL 7.5-
325 2 Yes No No No No Yes 2700 30 No Generic ANALGESICS
HYDROCODONE/APAP TAB 10-
325MG 2 Yes No No No No Yes 180 30 No Generic ANALGESICS
HYDROCODONE/APAP TAB 5-
325MG 2 Yes No No No No Yes 240 30 No Generic ANALGESICS
HYDROCODONE/APAP TAB 7.5-
325 2 Yes No No No No Yes 180 30 No Generic ANALGESICS
HYDROCODONE/IBUPROFEN TAB
7.5-200 2 Yes No No No No Yes 150 30 No Generic ANALGESICS
HYDROMORPHONE INJ (PF)
10MG/ML 4 No No Yes B VS. D No No No No Generic ANALGESICS
HYDROMORPHONE INJ 50
MG/5ML (PF) INJ (10 MG/ML) 4 No No Yes B VS. D No No No No Generic ANALGESICS
HYDROMORPHONE INJ 500
MG/50ML (PF) INJ (10 MG/ML) 4 No No Yes B VS. D No No No No Generic ANALGESICS
HYDROMORPHONE LIQ 1MG/ML 2 Yes No No No No Yes 600 30 No Generic ANALGESICS
HYDROMORPHONE TAB 2MG 2 Yes No No No No Yes 180 30 No Generic ANALGESICS
HYDROMORPHONE TAB 4MG 2 Yes No No No No Yes 180 30 No Generic ANALGESICS
HYDROMORPHONE TAB 8MG 2 Yes No No No No Yes 180 30 No Generic ANALGESICS
Peoples Health 2019 Formulary (HMO and HMO-POS) - List of Covered Drugs
Drug Name Tier
Level CG
Order PA PA Criteria Name ST ST Criteria LA QL
QL
Amount QL Days HI
Brand/
Generic Therapeutic Category
HYSINGLA ER TAB 100 MG 3 No No Yes IR BEFORE ER No No Yes 30 30 No Brand ANALGESICS
HYSINGLA ER TAB 120 MG 3 No No Yes IR BEFORE ER No No Yes 30 30 No Brand ANALGESICS
HYSINGLA ER TAB 20 MG 3 No No Yes IR BEFORE ER No No Yes 30 30 No Brand ANALGESICS
HYSINGLA ER TAB 30 MG 3 No No Yes IR BEFORE ER No No Yes 30 30 No Brand ANALGESICS
HYSINGLA ER TAB 40 MG 3 No No Yes IR BEFORE ER No No Yes 30 30 No Brand ANALGESICS
HYSINGLA ER TAB 60 MG 3 No No Yes IR BEFORE ER No No Yes 30 30 No Brand ANALGESICS
HYSINGLA ER TAB 80 MG 3 No No Yes IR BEFORE ER No No Yes 30 30 No Brand ANALGESICS
IBU TAB 600MG 1 Yes Yes No No No No No Generic ANALGESICS
IBU TAB 800MG 1 Yes Yes No No No No No Generic ANALGESICS
IBUPROFEN SUS 100/5ML 2 Yes Yes No No No No No Generic ANALGESICS
IBUPROFEN TAB 400MG 1 Yes Yes No No No No No Generic ANALGESICS
IBUPROFEN TAB 600MG 1 Yes Yes No No No No No Generic ANALGESICS
IBUPROFEN TAB 800MG 1 Yes Yes No No No No No Generic ANALGESICS
LORCET TAB 5-325MG 2 Yes No No No No Yes 240 30 No Generic ANALGESICS
LORCET HD TAB 10-325MG 2 Yes No No No No Yes 180 30 No Generic ANALGESICS
LORCET PLUS TAB 7.5-325 2 Yes No No No No Yes 180 30 No Generic ANALGESICS
MELOXICAM TAB 15MG 1 Yes Yes No No No No No Generic ANALGESICS
MELOXICAM TAB 7.5MG 1 Yes Yes No No No No No Generic ANALGESICS
METHADONE CON 10MG/ML 2 Yes No Yes IR BEFORE ER No No Yes 90 30 No Generic ANALGESICS
METHADONE SOL 10MG/5ML 2 Yes No Yes IR BEFORE ER No No Yes 450 30 No Generic ANALGESICS
METHADONE SOL 5MG/5ML 2 Yes No Yes IR BEFORE ER No No Yes 450 30 No Generic ANALGESICS
METHADONE TAB 10MG 2 Yes No Yes IR BEFORE ER No No Yes 90 30 No Generic ANALGESICS
METHADONE TAB 5MG 2 Yes No Yes IR BEFORE ER No No Yes 90 30 No Generic ANALGESICS
MITIGARE CAP 0.6MG 3 No No No No No Yes 60 30 No Brand ANALGESICS
MORPHINE 1 MG/ML 4 No No Yes B VS. D No No No No Generic ANALGESICS
MORPHINE 8 MG/ML SYRINGE 4 No No Yes B VS. D No No No No Generic ANALGESICS MORPHINE SUL INJ 10MG/ML PF
SYRINGE 4 No No Yes B VS. D No No No No Generic ANALGESICS
Peoples Health 2019 Formulary (HMO and HMO-POS) - List of Covered Drugs
Drug Name Tier
Level CG
Order PA PA Criteria Name ST ST Criteria LA QL
QL
Amount QL Days HI
Brand/
Generic Therapeutic Category
MORPHINE SUL INJ 10MG/ML PF
SYRINGE (10) 4 No No Yes B VS. D No No No No Generic ANALGESICS
MORPHINE SUL INJ 10MG/ML PF
VIAL 4 No No Yes B VS. D No No No No Brand ANALGESICS
MORPHINE SUL INJ 150/30ML
(5MG/ML) 4 No No Yes B VS. D No No No No Brand ANALGESICS
MORPHINE SUL INJ 2MG/ML 4 No No Yes B VS. D No No No No Brand ANALGESICS MORPHINE SUL INJ 2MG/ML
SYRINGE 4 No No Yes B VS. D No No No No Brand ANALGESICS
MORPHINE SUL INJ 2MG/ML VIAL 4 No No Yes B VS. D No No No No Brand ANALGESICS
MORPHINE SUL INJ 4MG/ML 4 No No Yes B VS. D No No No No Generic ANALGESICS MORPHINE SUL INJ 4MG/ML
(SYRINGE) 4 No No Yes B VS. D No No No No Generic ANALGESICS
MORPHINE SUL INJ 4MG/ML PF
(SYRINGE) 4 No No Yes B VS. D No No No No Generic ANALGESICS
MORPHINE SUL INJ 4MG/ML PF
(VIAL) 4 No No Yes B VS. D No No No No Brand ANALGESICS
MORPHINE SUL INJ 5MG/ML 4 No No Yes B VS. D No No No No Brand ANALGESICS MORPHINE SUL INJ 8 MG/ML PF
SYRINGE 4 No No Yes B VS. D No No No No Brand ANALGESICS
MORPHINE SUL INJ 8 MG/ML PF
VIAL 4 No No Yes B VS. D No No No No Generic ANALGESICS
MORPHINE SUL INJ 8 MG/ML PF
VIAL (SSB) 4 No No Yes B VS. D No No No No Brand ANALGESICS
MORPHINE SUL SOL 10MG/5ML 2 Yes No No No No Yes 900 30 No Generic ANALGESICS
MORPHINE SUL SOL 20MG/5ML 2 Yes No No No No Yes 750 30 No Generic ANALGESICS
MORPHINE SUL SOL 20MG/ML 2 Yes No No No No Yes 180 30 No Generic ANALGESICS
Peoples Health 2019 Formulary (HMO and HMO-POS) - List of Covered Drugs
Drug Name Tier
Level CG
Order PA PA Criteria Name ST ST Criteria LA QL
QL
Amount QL Days HI
Brand/
Generic Therapeutic Category
MORPHINE SUL TAB 100MG ER 2 Yes No Yes IR BEFORE ER No No Yes 90 30 No Generic ANALGESICS
MORPHINE SUL TAB 15MG 2 Yes No No No No Yes 180 30 No Generic ANALGESICS
MORPHINE SUL TAB 15MG ER 2 Yes No Yes IR BEFORE ER No No Yes 90 30 No Generic ANALGESICS
MORPHINE SUL TAB 200MG ER 2 Yes No Yes IR BEFORE ER No No Yes 60 30 No Generic ANALGESICS
MORPHINE SUL TAB 30MG 2 Yes No No No No Yes 90 30 No Generic ANALGESICS
MORPHINE SUL TAB 30MG ER 2 Yes No Yes IR BEFORE ER No No Yes 90 30 No Generic ANALGESICS
MORPHINE SUL TAB 60MG ER 2 Yes No Yes IR BEFORE ER No No Yes 90 30 No Generic ANALGESICS MORPHINE SULFATE INJ 10
MG/ML SYRINGE 4 No No Yes B VS. D No No No No Generic ANALGESICS
MORPHINE SULFATE INJ PF 5
MG/ML 4 No No Yes B VS. D No No No No Brand ANALGESICS
NABUMETONE TAB 500MG 2 Yes Yes No No No No No Generic ANALGESICS
NABUMETONE TAB 750MG 2 Yes Yes No No No No No Generic ANALGESICS
NALBUPHINE INJ 10MG/ML 4 No No No No No No No Generic ANALGESICS
NALBUPHINE INJ 20MG/ML 4 No No No No No No No Generic ANALGESICS
NAPROXEN TAB 250MG 1 Yes Yes No No No No No Generic ANALGESICS
NAPROXEN TAB 375MG 1 Yes Yes No No No No No Generic ANALGESICS
NAPROXEN TAB 500MG 1 Yes Yes No No No No No Generic ANALGESICS
NAPROXEN DR TAB 375MG EC 1 Yes Yes No No No No No Generic ANALGESICS
NAPROXEN DR TAB 500MG EC 1 Yes Yes No No No No No Generic ANALGESICS
NAPROXEN SOD TAB 275MG 2 Yes Yes No No No No No Generic ANALGESICS
NAPROXEN SOD TAB 550MG 2 Yes Yes No No No No No Generic ANALGESICS
NUCYNTA ER TAB 100MG 3 No No Yes IR BEFORE ER No No Yes 60 30 No Brand ANALGESICS
NUCYNTA ER TAB 150MG 3 No No Yes IR BEFORE ER No No Yes 90 30 No Brand ANALGESICS
NUCYNTA ER TAB 200MG 3 No No Yes IR BEFORE ER No No Yes 60 30 No Brand ANALGESICS
NUCYNTA ER TAB 250MG 3 No No Yes IR BEFORE ER No No Yes 60 30 No Brand ANALGESICS
NUCYNTA ER TAB 50MG 3 No No Yes IR BEFORE ER No No Yes 60 30 No Brand ANALGESICS
Peoples Health 2019 Formulary (HMO and HMO-POS) - List of Covered Drugs
Drug Name Tier
Level CG
Order PA PA Criteria Name ST ST Criteria LA QL
QL
Amount QL Days HI
Brand/
Generic Therapeutic Category
OXAPROZIN TAB 600MG 2 Yes Yes No No No No No Generic ANALGESICS
OXYCODONE TAB 15MG 2 Yes No No No No Yes 180 30 No Generic ANALGESICS
OXYCODONE TAB 30MG 2 Yes No No No No Yes 180 30 No Generic ANALGESICS
OXYCODONE TAB 5MG 2 Yes No No No No Yes 180 30 No Generic ANALGESICS
OXYCODONE 5 MG CAPSULE 2 Yes No No No No Yes 180 30 No Generic ANALGESICS
OXYCODONE HCL 10 MG TABLET 2 Yes No No No No Yes 180 30 No Generic ANALGESICS
OXYCODONE HCL 20 MG TABLET 2 Yes No No No No Yes 180 30 No Generic ANALGESICS
OXYCODONE HCL 20 MG/ML SOL 2 Yes No No No No Yes 180 30 No Generic ANALGESICS
OXYCODONE HCL 5 MG/5 ML SOL 2 Yes No No No No Yes 900 30 No Generic ANALGESICS
OXYCODONE/APAP TAB 10-
325MG 2 Yes No No No No Yes 180 30 No Generic ANALGESICS
OXYCODONE/APAP TAB 2.5-325 2 Yes No No No No Yes 360 30 No Generic ANALGESICS
OXYCODONE/APAP TAB 5-
325MG 2 Yes No No No No Yes 360 30 No Generic ANALGESICS
OXYCODONE/APAP TAB 7.5-325 2 Yes No No No No Yes 240 30 No Generic ANALGESICS
PIROXICAM CAP 10MG 2 Yes Yes No No No No No Generic ANALGESICS
PIROXICAM CAP 20MG 2 Yes Yes No No No No No Generic ANALGESICS
PROBEN/COLCH TAB 500-0.5 2 Yes Yes No No No No No Generic ANALGESICS
PROBENECID TAB 500MG 2 Yes Yes No No No No No Generic ANALGESICS
SULINDAC TAB 150MG 1 Yes Yes No No No No No Generic ANALGESICS
SULINDAC TAB 200MG 1 Yes Yes No No No No No Generic ANALGESICS
TRAMADOL HCL TAB 50MG 2 Yes No No No No Yes 240 30 No Generic ANALGESICS
Peoples Health 2019 Formulary (HMO and HMO-POS) - List of Covered Drugs
Drug Name Tier
Level CG
Order PA PA Criteria Name ST ST Criteria LA QL
QL
Amount QL Days HI
Brand/
Generic Therapeutic Category
TRAMADOL/APAP TAB 37.5-325 2 Yes No No No No Yes 240 30 No Generic ANALGESICS
ULORIC 40 MG TABLET 3 No Yes No Yes
You must try
ALLOPURINOL
before ULORIC is
covered
No No No Brand ANALGESICS
ULORIC 80 MG TABLET 3 No Yes No Yes
You must try
ALLOPURINOL
before ULORIC is
covered
No No No Brand ANALGESICS
LIDOCAINE INJ 0.5% 2 Yes No Yes B VS. D No No No No Generic ANESTHETICS
LIDOCAINE INJ 0.5% (PF) 2 Yes No Yes B VS. D No No No No Generic ANESTHETICS
LIDOCAINE INJ 1% 2 Yes No Yes B VS. D No No No No Generic ANESTHETICS
LIDOCAINE INJ 2% 2 Yes No Yes B VS. D No No No No Generic ANESTHETICS
LIDOCAINE HCL 1% SYRINGE 2 Yes No Yes B VS. D No No No No Generic ANESTHETICS
LIDOCAINE HCL 1.5% AMPUL 2 Yes No Yes B VS. D No No No No Generic ANESTHETICS
ABACAVIR TAB 300MG 2 Yes Yes No No No No No Generic ANTI-INFECTIVES ABACAVIR SULFATE SOLN 20
MG/ML 2 Yes Yes No No No No No Generic ANTI-INFECTIVES
ABACAVIR SULFATE-LAMIVUDINE
TAB 600-300 MG 2 Yes Yes No No No No No Generic ANTI-INFECTIVES
ABACAVIR SULFATE-LAMIVUDINE-
ZIDOVUDINE TAB 300-150-300
MG
5 No Yes No No No No No Generic ANTI-INFECTIVES
ABELCET INJ 5MG/ML 5 No No Yes B VS. D No No No Yes Brand ANTI-INFECTIVES
ACYCLOVIR CAP 200MG 1 Yes No No No No No No Generic ANTI-INFECTIVES
ACYCLOVIR SUS 200/5ML 2 Yes No No No No No No Generic ANTI-INFECTIVES
ACYCLOVIR TAB 400MG 1 Yes No No No No No No Generic ANTI-INFECTIVES
ACYCLOVIR TAB 800MG 1 Yes No No No No No No Generic ANTI-INFECTIVES
Peoples Health 2019 Formulary (HMO and HMO-POS) - List of Covered Drugs
Drug Name Tier
Level CG
Order PA PA Criteria Name ST ST Criteria LA QL
QL
Amount QL Days HI
Brand/
Generic Therapeutic Category
ACYCLOVIR NA INJ 50MG/ML 2 Yes No Yes B VS. D No No No Yes Generic ANTI-INFECTIVES
ADEFOVIR DIPIVOXIL TAB 10 MG 5 No Yes No No No No No Generic ANTI-INFECTIVES
ALBENZA TAB 200MG 5 No No No No No No No Brand ANTI-INFECTIVES
ALINIA SUS 100MG/5M 5 No No No No No No No Brand ANTI-INFECTIVES
ALINIA TAB 500MG 5 No No No No No No No Brand ANTI-INFECTIVES
AMBISOME INJ 50MG 5 No No Yes B VS. D No No No Yes Brand ANTI-INFECTIVES
AMIKACIN INJ 1GM/4ML 2 Yes No No No No No No Generic ANTI-INFECTIVES
AMIKACIN INJ 500/2ML 2 Yes No No No No No No Generic ANTI-INFECTIVES
AMOXICILLIN & K CLAVULANATE
TAB SR 12HR 1000-62.5 MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
AMOXICILLIN CAP 250MG 1 Yes No No No No No No Generic ANTI-INFECTIVES
AMOXICILLIN CAP 500MG 1 Yes No No No No No No Generic ANTI-INFECTIVES
AMOXICILLIN CHW 125MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
AMOXICILLIN CHW 250MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
AMOXICILLIN SUS 125/5ML 1 Yes No No No No No No Generic ANTI-INFECTIVES
AMOXICILLIN SUS 200/5ML 1 Yes No No No No No No Generic ANTI-INFECTIVES
AMOXICILLIN SUS 250/5ML 1 Yes No No No No No No Generic ANTI-INFECTIVES
AMOXICILLIN SUS 400/5ML 1 Yes No No No No No No Generic ANTI-INFECTIVES
AMOXICILLIN TAB 500MG 1 Yes No No No No No No Generic ANTI-INFECTIVES
AMOXICILLIN TAB 875MG 1 Yes No No No No No No Generic ANTI-INFECTIVES AMOXICILLIN/K CLAV CHW
200MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
AMOXICILLIN/K CLAV CHW
400MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
AMOXICILLIN/K CLAV SUS
200/5ML 2 Yes No No No No No No Generic ANTI-INFECTIVES
Peoples Health 2019 Formulary (HMO and HMO-POS) - List of Covered Drugs
Drug Name Tier
Level CG
Order PA PA Criteria Name ST ST Criteria LA QL
QL
Amount QL Days HI
Brand/
Generic Therapeutic Category
AMOXICILLIN/K CLAV SUS
250/5ML 2 Yes No No No No No No Generic ANTI-INFECTIVES
AMOXICILLIN/K CLAV SUS
400/5ML 2 Yes No No No No No No Generic ANTI-INFECTIVES
AMOXICILLIN/K CLAV SUS
600/5ML 2 Yes No No No No No No Generic ANTI-INFECTIVES
AMOXICILLIN/K CLAV TAB
250MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
AMOXICILLIN/K CLAV TAB
500MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
AMOXICILLIN/K CLAV TAB
875MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
AMPHOTERICIN INJ 50MG 2 Yes No Yes B VS. D No No No Yes Generic ANTI-INFECTIVES AMPICILLIN & SULBACTAM
SODIUM FOR INJ 10-5 GM 2 Yes No No No No No Yes Generic ANTI-INFECTIVES
AMPICILLIN CAP 500MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
AMPICILLIN INJ 10GM 2 Yes No No No No No No Generic ANTI-INFECTIVES
AMPICILLIN INJ 125MG 2 Yes No No No No No Yes Generic ANTI-INFECTIVES
AMPICILLIN INJ 1GM 2 Yes No No No No No Yes Generic ANTI-INFECTIVES
AMPICILLIN INJ 250MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
AMPICILLIN INJ 2GM 2 Yes No No No No No No Generic ANTI-INFECTIVES
AMPICILLIN INJ 500MG 2 Yes No No No No No No Generic ANTI-INFECTIVES AMPICILLIN INJ FOR IV SOLN
10GM 2 Yes No No No No No Yes Generic ANTI-INFECTIVES
AMPICILLIN INJ FOR IV SOLN
1GM 2 Yes No No No No No No Generic ANTI-INFECTIVES
AMPICILLIN INJ FOR IV SOLN
2GM 2 Yes No No No No No No Generic ANTI-INFECTIVES
Peoples Health 2019 Formulary (HMO and HMO-POS) - List of Covered Drugs
Drug Name Tier
Level CG
Order PA PA Criteria Name ST ST Criteria LA QL
QL
Amount QL Days HI
Brand/
Generic Therapeutic Category
AMPICILLIN-SULBACTAM 1.5 GM
VL 2 Yes No No No No No Yes Generic ANTI-INFECTIVES
AMPICILLIN-SULBACTAM INJ
15GM 2 Yes No No No No No No Generic ANTI-INFECTIVES
AMPICILLIN-SULBACTAM INJ
3GM (2-1 GM) 2 Yes No No No No No Yes Generic ANTI-INFECTIVES
APTIVUS CAP 250MG 5 No Yes No No No No No Brand ANTI-INFECTIVES
APTIVUS SOL 5 No Yes No No No No No Brand ANTI-INFECTIVES ATAZANAVIR SULFATE CAP 150
MG 5 No Yes No No No No No Generic ANTI-INFECTIVES
ATAZANAVIR SULFATE CAP 200
MG 5 No Yes No No No No No Generic ANTI-INFECTIVES
ATAZANAVIR SULFATE CAP 300
MG 5 No Yes No No No No No Generic ANTI-INFECTIVES
ATOVAQUONE SUS 750/5ML 5 No No No No No No No Generic ANTI-INFECTIVES ATOVAQUONE/ PROGUANIL 250-
100 MG TABLET 2 Yes No No No No No No Generic ANTI-INFECTIVES
ATOVAQUONE-PROGUANIL HCL
TAB 62.5-25 MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
ATRIPLA TAB 5 No Yes No No No No No Brand ANTI-INFECTIVES
AUGMENTIN SUS 125/5ML 4 No No No No No No No Brand ANTI-INFECTIVES
AZACTAM INJ 2GM 4 No No No No No No Yes Brand ANTI-INFECTIVES
AZACTAM 1 GM VIAL 4 No No No No No No Yes Brand ANTI-INFECTIVES
AZACTAM/DEX INJ 1GM 4 No No No No No No No Brand ANTI-INFECTIVES
AZACTAM/DEX INJ 2GM 4 No No No No No No No Brand ANTI-INFECTIVES AZITHROMYCIN 1 GM PWD
PACKET 2 Yes No No No No No No Generic ANTI-INFECTIVES
AZITHROMYCIN INJ 500MG VIAL
(2 MG/ML) 2 Yes No No No No No Yes Generic ANTI-INFECTIVES
Peoples Health 2019 Formulary (HMO and HMO-POS) - List of Covered Drugs
Drug Name Tier
Level CG
Order PA PA Criteria Name ST ST Criteria LA QL
QL
Amount QL Days HI
Brand/
Generic Therapeutic Category
AZITHROMYCIN SUS 100/5ML 2 Yes No No No No No No Generic ANTI-INFECTIVES
AZITHROMYCIN SUS 200/5ML 2 Yes No No No No No No Generic ANTI-INFECTIVES
AZITHROMYCIN TAB 250MG 1 Yes No No No No No No Generic ANTI-INFECTIVES AZITHROMYCIN TAB 250MG
PACK 1 Yes No No No No No No Generic ANTI-INFECTIVES
AZITHROMYCIN TAB 500MG 1 Yes No No No No No No Generic ANTI-INFECTIVES AZITHROMYCIN TAB 500MG
PACK 1 Yes No No No No No No Generic ANTI-INFECTIVES
AZITHROMYCIN TAB 600MG 1 Yes No No No No No No Generic ANTI-INFECTIVES
AZTREONAM INJ 1GM 2 Yes No No No No No Yes Generic ANTI-INFECTIVES
AZTREONAM INJ 2GM 2 Yes No No No No No No Generic ANTI-INFECTIVES
BARACLUDE SOL .05MG/ML 5 No Yes No No No No No Brand ANTI-INFECTIVES
BICILLIN L-A INJ 1200000 4 No No No No No No No Brand ANTI-INFECTIVES
BICILLIN L-A INJ 2400000 4 No No No No No No No Brand ANTI-INFECTIVES
BICILLIN L-A INJ 600000 4 No No No No No No No Brand ANTI-INFECTIVES
BIKTARVY TAB 5 No Yes No No No No No Brand ANTI-INFECTIVES
BILTRICIDE TAB 600MG 3 No No No No No No No Brand ANTI-INFECTIVES CASPOFUNGIN ACETATE FOR IV
SOLN 50 MG 5 No No No No No No Yes Generic ANTI-INFECTIVES
CASPOFUNGIN ACETATE FOR IV
SOLN 70 MG 5 No No No No No No Yes Generic ANTI-INFECTIVES
CAYSTON INH 75MG 5 No No Yes CAYSTON No Yes No No Brand ANTI-INFECTIVES
CEFACLOR CAP 250MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
CEFACLOR CAP 500MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
CEFACLOR SUS 125/5ML 2 Yes No No No No No No Generic ANTI-INFECTIVES
CEFACLOR SUS 250/5ML 2 Yes No No No No No No Generic ANTI-INFECTIVES
CEFACLOR SUS 375/5ML 2 Yes No No No No No No Generic ANTI-INFECTIVES
CEFACLOR ER TAB 500MG 4 No No No No No No No Generic ANTI-INFECTIVES
CEFADROXIL CAP 500MG 1 Yes No No No No No No Generic ANTI-INFECTIVES
Peoples Health 2019 Formulary (HMO and HMO-POS) - List of Covered Drugs
Drug Name Tier
Level CG
Order PA PA Criteria Name ST ST Criteria LA QL
QL
Amount QL Days HI
Brand/
Generic Therapeutic Category
CEFADROXIL SUS 250/5ML 2 Yes No No No No No No Generic ANTI-INFECTIVES
CEFADROXIL SUS 500/5ML 2 Yes No No No No No No Generic ANTI-INFECTIVES
CEFADROXIL TAB 1GM 2 Yes No No No No No No Generic ANTI-INFECTIVES
CEFAZOLIN INJ 1GM 2 Yes No No No No No Yes Generic ANTI-INFECTIVES
CEFAZOLIN INJ 1GM/50ML 3 No No No No No No No Generic ANTI-INFECTIVES
CEFAZOLIN INJ 500MG 2 Yes No No No No No Yes Generic ANTI-INFECTIVES
CEFAZOLIN INJ 10GM 2 Yes No No No No No Yes Generic ANTI-INFECTIVES
CEFAZOLIN INJ 20GM 2 Yes No No No No No No Generic ANTI-INFECTIVES
CEFAZOLIN INJ FOR IV SOLN 1GM 2 Yes No No No No No No Generic ANTI-INFECTIVES
CEFAZOLIN SODIUM-DEXTROSE
IV SOLUTION 2 GM/100ML-4% 3 No No No No No No No Brand ANTI-INFECTIVES
CEFDINIR CAP 300MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
CEFDINIR SUS 125/5ML 2 Yes No No No No No No Generic ANTI-INFECTIVES
CEFDINIR SUS 250/5ML 2 Yes No No No No No No Generic ANTI-INFECTIVES
CEFEPIME INJ 1GM 2 Yes No No No No No Yes Generic ANTI-INFECTIVES
CEFEPIME INJ 2GM 2 Yes No No No No No Yes Generic ANTI-INFECTIVES
CEFIXIME FOR SUSP 100 MG/5ML 2 Yes No No No No No No Generic ANTI-INFECTIVES
CEFIXIME FOR SUSP 200 MG/5ML 2 Yes No No No No No No Generic ANTI-INFECTIVES
CEFOTAXIME INJ 2GM 2 Yes No No No No No Yes Generic ANTI-INFECTIVES
CEFOTAXIME INJ 500MG 2 Yes No No No No No Yes Generic ANTI-INFECTIVES
CEFOTAXIME INJ 1GM 2 Yes No No No No No Yes Generic ANTI-INFECTIVES
CEFOXITIN INJ 10GM 2 Yes No No No No No Yes Generic ANTI-INFECTIVES
CEFOXITIN INJ 1GM 2 Yes No No No No No Yes Generic ANTI-INFECTIVES
CEFOXITIN INJ 2GM 2 Yes No No No No No Yes Generic ANTI-INFECTIVES
CEFPODOXIME TAB 100MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
CEFPODOXIME TAB 200MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
Peoples Health 2019 Formulary (HMO and HMO-POS) - List of Covered Drugs
Drug Name Tier
Level CG
Order PA PA Criteria Name ST ST Criteria LA QL
QL
Amount QL Days HI
Brand/
Generic Therapeutic Category
CEFPODOXIME PROX SUS
100/5ML 2 Yes No No No No No No Generic ANTI-INFECTIVES
CEFPODOXIME PROX SUS
50MG/5ML 2 Yes No No No No No No Generic ANTI-INFECTIVES
CEFPROZIL SUS 125/5ML 2 Yes No No No No No No Generic ANTI-INFECTIVES
CEFPROZIL SUS 250/5ML 2 Yes No No No No No No Generic ANTI-INFECTIVES
CEFPROZIL TAB 250MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
CEFPROZIL TAB 500MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
CEFTAZIDIME INJ 1GM 2 Yes No No No No No Yes Generic ANTI-INFECTIVES
CEFTAZIDIME INJ 2GM 2 Yes No No No No No Yes Generic ANTI-INFECTIVES
CEFTAZIDIME INJ 6GM 2 Yes No No No No No Yes Generic ANTI-INFECTIVES
CEFTAZIDIME/ SOL D5W 1GM 4 No No No No No No No Brand ANTI-INFECTIVES
CEFTAZIDIME/ SOL D5W 2 GM 4 No No No No No No No Brand ANTI-INFECTIVES
CEFTRIAXONE INJ 10GM 2 Yes No No No No No Yes Generic ANTI-INFECTIVES
CEFTRIAXONE INJ 250MG 2 Yes No No No No No Yes Generic ANTI-INFECTIVES
CEFTRIAXONE INJ 500MG 2 Yes No No No No No Yes Generic ANTI-INFECTIVES
CEFTRIAXONE 1 GM VIAL 2 Yes No No No No No Yes Generic ANTI-INFECTIVES
CEFTRIAXONE 2 GM VIAL 2 Yes No No No No No Yes Generic ANTI-INFECTIVES
CEFTRIAXONE/DEX INJ 1GM 2 Yes No No No No No No Generic ANTI-INFECTIVES
CEFTRIAXONE/DEX INJ 2GM 2 Yes No No No No No No Generic ANTI-INFECTIVES
CEFUROXIME INJ 1.5GM 2 Yes No No No No No Yes Generic ANTI-INFECTIVES
CEFUROXIME INJ 7.5GM 2 Yes No No No No No Yes Generic ANTI-INFECTIVES
CEFUROXIME INJ 750MG 2 Yes No No No No No Yes Generic ANTI-INFECTIVES
CEFUROXIME TAB 250MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
CEFUROXIME TAB 500MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
CEFUROXIME INJ 1.5GM 2 Yes No No No No No No Generic ANTI-INFECTIVES
CEPHALEXIN CAP 250MG 1 Yes No No No No No No Generic ANTI-INFECTIVES
CEPHALEXIN CAP 500MG 1 Yes No No No No No No Generic ANTI-INFECTIVES
CEPHALEXIN SUS 125/5ML 2 Yes No No No No No No Generic ANTI-INFECTIVES
Peoples Health 2019 Formulary (HMO and HMO-POS) - List of Covered Drugs
Drug Name Tier
Level CG
Order PA PA Criteria Name ST ST Criteria LA QL
QL
Amount QL Days HI
Brand/
Generic Therapeutic Category
CEPHALEXIN SUS 250/5ML 2 Yes No No No No No No Generic ANTI-INFECTIVES
CHLOROQUINE TAB 250MG 2 Yes Yes No No No No No Generic ANTI-INFECTIVES
CHLOROQUINE TAB 500MG 2 Yes Yes No No No No No Generic ANTI-INFECTIVES
CIMDUO TAB 300MG-300MG 5 No Yes No No No No No Brand ANTI-INFECTIVES
CIPROFLOXACIN 200 MG/100 ML 2 Yes No No No No No Yes Generic ANTI-INFECTIVES
CIPROFLOXACIN 400 MG/200 ML 2 Yes No No No No No No Generic ANTI-INFECTIVES
CIPROFLOXACIN FOR ORAL SUSP
250 MG/5ML (5%) (5 GM/100ML) 2 Yes No No No No No No Generic ANTI-INFECTIVES
CIPROFLOXACIN FOR ORAL SUSP
500 MG/5ML (10%) (10
GM/100ML)
2 Yes No No No No No No Generic ANTI-INFECTIVES
CIPROFLOXACIN TAB 100MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
CIPROFLOXACIN TAB 250MG 1 Yes No No No No No No Generic ANTI-INFECTIVES
CIPROFLOXACIN TAB 500MG 1 Yes No No No No No No Generic ANTI-INFECTIVES
CIPROFLOXACIN TAB 750MG 1 Yes No No No No No No Generic ANTI-INFECTIVES
CLARITHROMYCIN SUS 125/5ML 2 Yes No No No No No No Generic ANTI-INFECTIVES
CLARITHROMYCIN SUS 250/5ML 2 Yes No No No No No No Generic ANTI-INFECTIVES
CLARITHROMYCIN TAB 250MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
CLARITHROMYCIN TAB 500MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
CLARITHROMYCIN TAB 500MG ER 2 Yes No No No No No No Generic ANTI-INFECTIVES
CLINDAMYCIN INJ 600MG 2 Yes No No No No No Yes Generic ANTI-INFECTIVES
CLINDAMYCIN INJ 300MG 2 Yes No No No No No Yes Generic ANTI-INFECTIVES
Peoples Health 2019 Formulary (HMO and HMO-POS) - List of Covered Drugs
Drug Name Tier
Level CG
Order PA PA Criteria Name ST ST Criteria LA QL
QL
Amount QL Days HI
Brand/
Generic Therapeutic Category
CLINDAMYCIN INJ 900MG 2 Yes No No No No No Yes Generic ANTI-INFECTIVES
CLINDAMYCIN CAP 150MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
CLINDAMYCIN CAP 300MG 2 Yes No No No No No No Generic ANTI-INFECTIVES CLINDAMYCIN INJ 150MG/ML IV
SOLUTION 2 Yes No No No No No Yes Generic ANTI-INFECTIVES
CLINDAMYCIN HCL CAP 75 MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
CLINDAMYCIN INJ 150MG/ML 2 Yes No No No No No No Generic ANTI-INFECTIVES CLINDAMYCIN PED SOL
75MG/5ML 2 Yes No No No No No No Generic ANTI-INFECTIVES
CLINDAMYCIN PHOSPHATE IN
D5W IV SOLN 600 MG/50ML 2 Yes No No No No No No Generic ANTI-INFECTIVES
CLINDAMYCIN PHOSPHATE IN
NACL 0.9% IV SOLN 300
MG/50ML
4 No No No No No No No Brand ANTI-INFECTIVES
CLINDAMYCIN PHOSPHATE IN
NACL 0.9% IV SOLN 600
MG/50ML
4 No No No No No No No Brand ANTI-INFECTIVES
CLINDAMYCIN PHOSPHATE IN
NACL 0.9% IV SOLN 900
MG/50ML
4 No No No No No No No Brand ANTI-INFECTIVES
CLINDAMYCIN PHOSPHATE INJ
300 MG/2ML 2 Yes No No No No No Yes Generic ANTI-INFECTIVES
CLINDAMYCIN PHOSPHATE INJ 9
GM/60ML 2 Yes No No No No No No Generic ANTI-INFECTIVES
CLINDAMYCIN PHOSPHATE INJ
900 MG/6ML 2 Yes No No No No No Yes Generic ANTI-INFECTIVES
CLINDAMYCIN PHOSPHATE IV INJ
900 MG/6ML 2 Yes No No No No No No Generic ANTI-INFECTIVES
Peoples Health 2019 Formulary (HMO and HMO-POS) - List of Covered Drugs
Drug Name Tier
Level CG
Order PA PA Criteria Name ST ST Criteria LA QL
QL
Amount QL Days HI
Brand/
Generic Therapeutic Category
COARTEM 20 MG/ 120 MG
TABLET 4 No No No No No No No Brand ANTI-INFECTIVES
COLISTIMETHATE INJ 150MG 2 Yes No No No No No Yes Generic ANTI-INFECTIVES
COMPLERA TAB 5 No Yes No No No No No Brand ANTI-INFECTIVES
CRIXIVAN CAP 200MG 4 No Yes No No No No No Brand ANTI-INFECTIVES
CRIXIVAN CAP 400MG 4 No Yes No No No No No Brand ANTI-INFECTIVES
CYCLOSERINE CAP 250 MG 5 No No No No No No No Generic ANTI-INFECTIVES
DAPSONE TAB 100MG 2 Yes Yes No No No No No Generic ANTI-INFECTIVES
DAPSONE TAB 25MG 2 Yes Yes No No No No No Generic ANTI-INFECTIVES DAPTOMYCIN FOR IV SOLN 500
MG 5 No No No No No No Yes Generic ANTI-INFECTIVES
DESCOVY TAB 200/25 5 No Yes No No No No No Brand ANTI-INFECTIVES
DICLOXACILLIN CAP 250MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
DICLOXACILLIN CAP 500MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
DIDANOSINE CAP 200MG 2 Yes Yes No No No No No Generic ANTI-INFECTIVES
DIDANOSINE CAP 250MG 2 Yes Yes No No No No No Generic ANTI-INFECTIVES
DIDANOSINE CAP 400MG 2 Yes Yes No No No No No Generic ANTI-INFECTIVES
DIFICID TAB 200MG 5 No No No No No No No Brand ANTI-INFECTIVES
DOXY 100 INJ 100MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
DOXYCYCLINE TAB 20MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
DOXYCYCLINE HYC CAP 100MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
DOXYCYCLINE HYC CAP 50MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
DOXYCYCLINE HYC INJ 100MG 2 Yes No No No No No No Generic ANTI-INFECTIVES DOXYCYCLINE HYCLATE TAB
100MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
DOXYCYCLINE MONO 100 MG
CAP 2 Yes No No No No No No Generic ANTI-INFECTIVES
DOXYCYCLINE MONO 50 MG CAP 2 Yes No No No No No No Generic ANTI-INFECTIVES
Peoples Health 2019 Formulary (HMO and HMO-POS) - List of Covered Drugs
Drug Name Tier
Level CG
Order PA PA Criteria Name ST ST Criteria LA QL
QL
Amount QL Days HI
Brand/
Generic Therapeutic Category
DOXYCYCLINE MONO TAB 100
MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
DOXYCYCLINE MONO TAB 150MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
DOXYCYCLINE MONO TAB 50MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
DOXYCYCLINE MONO TAB 75MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
E.E.S. 400 TAB 400MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
EDURANT TAB 25MG 5 No Yes No No No No No Brand ANTI-INFECTIVES
EFAVIRENZ CAP 200 MG 5 No Yes No No No No No Generic ANTI-INFECTIVES
EFAVIRENZ CAP 50 MG 2 Yes Yes No No No No No Generic ANTI-INFECTIVES
EFAVIRENZ TAB 600 MG 5 No Yes No No No No No Generic ANTI-INFECTIVES
EMTRIVA CAP 200MG 3 No Yes No No No No No Brand ANTI-INFECTIVES
EMTRIVA SOL 10MG/ML 3 No Yes No No No No No Brand ANTI-INFECTIVES
EMVERM CHW 100MG 5 No No No No No No No Brand ANTI-INFECTIVES
ENTECAVIR TAB 0.5 MG 5 No Yes No No No No No Generic ANTI-INFECTIVES
ENTECAVIR TAB 1 MG 5 No Yes No No No No No Generic ANTI-INFECTIVES
EPCLUSA TAB 400-100 5 No No Yes EPCLUSA No No No No Brand ANTI-INFECTIVES
EPIVIR HBV SOL 5MG/ML 4 No Yes No No No No No Brand ANTI-INFECTIVES
ERTAPENEM INJ 1GM 2 Yes No No No No No No Generic ANTI-INFECTIVES
ERY-TAB TAB 250MG EC 2 Yes No No No No No No Generic ANTI-INFECTIVES
ERY-TAB TAB 333MG EC 2 Yes No No No No No No Generic ANTI-INFECTIVES
ERY-TAB TAB 500MG EC 2 Yes No No No No No No Generic ANTI-INFECTIVES
ERYTHROCIN INJ 500MG 4 No No No No No No Yes Brand ANTI-INFECTIVES
ERYTHROCIN TAB 250MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
ERYTHROM ETH TAB 400MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
ERYTHROMYCIN 250 MG CAP EC 2 Yes No No No No No No Generic ANTI-INFECTIVES
Peoples Health 2019 Formulary (HMO and HMO-POS) - List of Covered Drugs
Drug Name Tier
Level CG
Order PA PA Criteria Name ST ST Criteria LA QL
QL
Amount QL Days HI
Brand/
Generic Therapeutic Category
ERYTHROMYCIN TAB 250MG BS 2 Yes No No No No No No Generic ANTI-INFECTIVES
ERYTHROMYCIN TAB 500MG BS 2 Yes No No No No No No Generic ANTI-INFECTIVES
ETHAMBUTOL TAB 100MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
ETHAMBUTOL TAB 400MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
EVOTAZ TAB 300-150 5 No Yes No No No No No Brand ANTI-INFECTIVES
FAMCICLOVIR TAB 125MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
FAMCICLOVIR TAB 250MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
FAMCICLOVIR TAB 500MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
FLUCONAZOLE SUS 10MG/ML 2 Yes No No No No No No Generic ANTI-INFECTIVES
FLUCONAZOLE SUS 40MG/ML 2 Yes No No No No No No Generic ANTI-INFECTIVES
FLUCONAZOLE TAB 100MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
FLUCONAZOLE TAB 150MG 1 Yes No No No No No No Generic ANTI-INFECTIVES
FLUCONAZOLE TAB 200MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
FLUCONAZOLE TAB 50MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
FLUCONAZOLE/ INJ DEX 400 2 Yes No No No No No No Generic ANTI-INFECTIVES FLUCONAZOLE-DEXT 200 MG/100
ML 2 Yes No No No No No No Generic ANTI-INFECTIVES
FLUCONAZOLE-NS 200 MG/100
ML 2 Yes No No No No No Yes Generic ANTI-INFECTIVES
FLUCONAZOLE-NS 400 MG/200
ML 2 Yes No No No No No Yes Generic ANTI-INFECTIVES
FLUCYTOSINE CAP 250 MG 5 No No No No No No No Generic ANTI-INFECTIVES
FLUCYTOSINE CAP 500 MG 5 No No No No No No No Generic ANTI-INFECTIVES FOSAMPRENAVIR CALCIUM TAB
700 MG (BASE EQUIV) 5 No Yes No No No No No Generic ANTI-INFECTIVES
FUZEON INJ 90MG 5 No Yes No No No No No Brand ANTI-INFECTIVES GANCICLOVIR SODIUM FOR INJ
500 MG 2 Yes No Yes B VS. D No No No No Generic ANTI-INFECTIVES
GENTAM/NACL INJ 100MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
Peoples Health 2019 Formulary (HMO and HMO-POS) - List of Covered Drugs
Drug Name Tier
Level CG
Order PA PA Criteria Name ST ST Criteria LA QL
QL
Amount QL Days HI
Brand/
Generic Therapeutic Category
GENTAMICIN INJ 40MG/ML 2 Yes No No No No No No Generic ANTI-INFECTIVES GENTAMICIN PED 10 MG/ML
VIAL 2 Yes No No No No No No Generic ANTI-INFECTIVES
GENTAMICIN/NACL INJ 100MG 2 Yes No No No No No No Generic ANTI-INFECTIVES GENTAMICIN/NACL INJ 60MG 50
ML (1.2 MG/ML) 2 Yes No No No No No No Generic ANTI-INFECTIVES
GENTAMICIN/NACL INJ 80MG
100 ML (0.8 MG/ML) 2 Yes No No No No No No Generic ANTI-INFECTIVES
GENTAMICIN/NACL INJ 80MG/
50 ML (1.6 MG/ML) 2 Yes No No No No No No Generic ANTI-INFECTIVES
GENVOYA TAB 5 No Yes No No No No No Brand ANTI-INFECTIVES GRISEOFULVIN MICROSIZE TAB
500 MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
GRISEOFULVIN SUS 125/5ML 2 Yes No No No No No No Generic ANTI-INFECTIVES
GRISEOFULVIN TAB ULTR 125 2 Yes No No No No No No Generic ANTI-INFECTIVES
GRISEOFULVIN TAB ULTR 250 2 Yes No No No No No No Generic ANTI-INFECTIVES
HARVONI TAB 90-400MG 5 No No Yes HARVONI No No No No Brand ANTI-INFECTIVES IMIPENEM/CILASTATIN INJ
250MG 2 Yes No No No No No Yes Generic ANTI-INFECTIVES
IMIPENEM/CILASTATIN INJ
500MG 2 Yes No No No No No Yes Generic ANTI-INFECTIVES
INTELENCE TAB 100MG 5 No Yes No No No No No Brand ANTI-INFECTIVES
INTELENCE TAB 200MG 5 No Yes No No No No No Brand ANTI-INFECTIVES
INTELENCE TAB 25MG 4 No Yes No No No No No Brand ANTI-INFECTIVES
INVANZ INJ 1GM 4 No No No No No No Yes Brand ANTI-INFECTIVES
INVANZ INJ 1GM FOR IV 4 No No No No No No No Brand ANTI-INFECTIVES
INVIRASE CAP 200MG 5 No Yes No No No No No Brand ANTI-INFECTIVES
INVIRASE TAB 500MG 5 No Yes No No No No No Brand ANTI-INFECTIVES
ISENTRESS SUSP 100MG 3 No Yes No No No No No Brand ANTI-INFECTIVES
Peoples Health 2019 Formulary (HMO and HMO-POS) - List of Covered Drugs
Drug Name Tier
Level CG
Order PA PA Criteria Name ST ST Criteria LA QL
QL
Amount QL Days HI
Brand/
Generic Therapeutic Category
ISENTRESS TAB 400MG 5 No Yes No No No No No Brand ANTI-INFECTIVES
ISENTRESS CHEW 100 MG 5 No Yes No No No No No Brand ANTI-INFECTIVES
ISENTRESS CHEW 25 MG 3 No Yes No No No No No Brand ANTI-INFECTIVES
ISENTRESS HD TAB 600MG 5 No Yes No No No No No Brand ANTI-INFECTIVES
ISONIAZID SYP 50MG/5ML 2 Yes Yes No No No No No Generic ANTI-INFECTIVES
ISONIAZID TAB 100MG 1 Yes Yes No No No No No Generic ANTI-INFECTIVES
ISONIAZID TAB 300MG 1 Yes Yes No No No No No Generic ANTI-INFECTIVES
ITRACONAZOLE CAP 100MG 2 Yes No Yes ITRACONAZOLE No No No No Generic ANTI-INFECTIVES
IVERMECTIN TAB 3 MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
JULUCA TAB 50-25MG 5 No Yes No No No No No Brand ANTI-INFECTIVES
KALETRA TAB 100-25MG 4 No Yes No No No No No Brand ANTI-INFECTIVES
KALETRA TAB 200-50MG 5 No Yes No No No No No Brand ANTI-INFECTIVES
KETOCONAZOLE TAB 200MG 2 Yes No Yes KETOCONAZOLE No No No No Generic ANTI-INFECTIVES
LAMIVUDINE TAB 100MG 2 Yes Yes No No No No No Generic ANTI-INFECTIVES LAMIVUDINE ORAL SOLN 10
MG/ML 2 Yes Yes No No No No No Generic ANTI-INFECTIVES
LAMIVUDINE TAB 150 MG 2 Yes Yes No No No No No Generic ANTI-INFECTIVES
LAMIVUDINE TAB 300 MG 2 Yes Yes No No No No No Generic ANTI-INFECTIVES LAMIVUDINE-ZIDOVUDINE TAB
150-300 MG 2 Yes Yes No No No No No Generic ANTI-INFECTIVES
LEVOFLOXACIN 250 MG TABLET 1 Yes No No No No No No Generic ANTI-INFECTIVES
LEVOFLOXACIN 500 MG TABLET 1 Yes No No No No No No Generic ANTI-INFECTIVES
LEVOFLOXACIN 750 MG TABLET 1 Yes No No No No No No Generic ANTI-INFECTIVES LEVOFLOXACIN IN D5W IV SOLN
250 MG/50ML 2 Yes No No No No No No Generic ANTI-INFECTIVES
LEVOFLOXACIN IN D5W IV SOLN
500 MG/100ML 2 Yes No No No No No Yes Generic ANTI-INFECTIVES
LEVOFLOXACIN IN D5W IV SOLN
750 MG/150ML 2 Yes No No No No No Yes Generic ANTI-INFECTIVES
Peoples Health 2019 Formulary (HMO and HMO-POS) - List of Covered Drugs
Drug Name Tier
Level CG
Order PA PA Criteria Name ST ST Criteria LA QL
QL
Amount QL Days HI
Brand/
Generic Therapeutic Category
LEVOFLOXACIN INJ 25MG/ML 2 Yes No No No No No Yes Generic ANTI-INFECTIVES LEVOFLOXACIN ORAL SOLN 25
MG/ML 2 Yes No No No No No No Generic ANTI-INFECTIVES
LEXIVA SUS 50MG/ML 4 No Yes No No No No No Brand ANTI-INFECTIVES
LINEZOLID TAB 600MG 5 No No No No No No No Generic ANTI-INFECTIVES LINEZOLID FOR SUSP 100
MG/5ML 5 No No No No No No No Generic ANTI-INFECTIVES
LINEZOLID IN SODIUM CHLORIDE
IV SOLN 600 MG/300ML-0.9% 4 No No No No No No No Generic ANTI-INFECTIVES
LINEZOLID IV SOLN 600
MG/300ML (2 MG/ML) 2 Yes No No No No No Yes Generic ANTI-INFECTIVES
LOPINAVIR-RITONAVIR SOLN 400-
100 MG/5ML (80-20 MG/ML) 2 Yes Yes No No No No No Generic ANTI-INFECTIVES
MAVYRET TAB 100-40MG 5 No No Yes MAVYRET No No No No Brand ANTI-INFECTIVES
MEFLOQUINE TAB 250MG 2 Yes Yes No No No No No Generic ANTI-INFECTIVES
MEROPENEM INJ 500MG 2 Yes No No No No No Yes Generic ANTI-INFECTIVES MEROPENEM IV FOR SOLN 1000
MG 2 Yes No No No No No Yes Generic ANTI-INFECTIVES
METHENAMINE HIP TAB 1GM 2 Yes No No No No No No Generic ANTI-INFECTIVES
METRONIDAZOLE TAB 250MG 1 Yes No No No No No No Generic ANTI-INFECTIVES
METRONIDAZOLE TAB 500MG 1 Yes No No No No No No Generic ANTI-INFECTIVES METRONIDAZOLE/NACL INJ
500MG 2 Yes No No No No No Yes Generic ANTI-INFECTIVES
MINOCYCLINE CAP 100MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
MINOCYCLINE CAP 50MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
MINOCYCLINE CAP 75MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
MODERIBA TAB 200MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
Peoples Health 2019 Formulary (HMO and HMO-POS) - List of Covered Drugs
Drug Name Tier
Level CG
Order PA PA Criteria Name ST ST Criteria LA QL
QL
Amount QL Days HI
Brand/
Generic Therapeutic Category
MONDOXYNE NL CAP 100MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
MONDOXYNE NL CAP 50MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
MORGIDOX CAP 1X50MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
MORGIDOX CAP 2X100MG 2 Yes No No No No No No Generic ANTI-INFECTIVES MOXIFLOXACIN HCL 400
MG/250ML INJ 4 No No No No No No No Brand ANTI-INFECTIVES
MOXIFLOXACIN HCL 400
MG/250ML IN SODIUM
CHLORIDE 0.8% INJ
2 Yes No No No No No No Generic ANTI-INFECTIVES
MOXIFLOXACIN TAB 400MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
MYCAMINE INJ 100MG 5 No No No No No No Yes Brand ANTI-INFECTIVES
MYCAMINE INJ 50MG 5 No No No No No No Yes Brand ANTI-INFECTIVES
NAFCILLIN INJ 10GM 5 No No No No No No Yes Generic ANTI-INFECTIVES
NAFCILLIN INJ 1GM 2 Yes No No No No No Yes Generic ANTI-INFECTIVES
NAFCILLIN INJ 2GM 2 Yes No No No No No No Generic ANTI-INFECTIVES
NAFCILLIN INJ FOR IV SOLN 1GM 2 Yes No No No No No No Generic ANTI-INFECTIVES
NAFCILLIN INJ FOR IV SOLN 2GM 2 Yes No No No No No No Generic ANTI-INFECTIVES
NEBUPENT INH 300MG 4 No No Yes B VS. D No No No No Brand ANTI-INFECTIVES
NEOMYCIN TAB 500MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
NEVIRAPINE TAB 400MG ER 2 Yes Yes No No No No No Generic ANTI-INFECTIVES
NEVIRAPINE SUSP 50 MG/5ML 2 Yes Yes No No No No No Generic ANTI-INFECTIVES
NEVIRAPINE TAB 200MG 2 Yes Yes No No No No No Generic ANTI-INFECTIVES NEVIRAPINE TAB SR 24HR 100
MG 2 Yes Yes No No No No No Generic ANTI-INFECTIVES
NITROFURANTOIN MAC CAP
50MG 3 No No Yes HRM-NITROFURANTOIN No No No No Generic ANTI-INFECTIVES
Peoples Health 2019 Formulary (HMO and HMO-POS) - List of Covered Drugs
Drug Name Tier
Level CG
Order PA PA Criteria Name ST ST Criteria LA QL
QL
Amount QL Days HI
Brand/
Generic Therapeutic Category
NITROFURANTOIN MONO-MAC
CAP 100MG 3 No No Yes HRM-NITROFURANTOIN No No No No Generic ANTI-INFECTIVES
NITROFURANTOIN-MACRO 100
MG 3 No No Yes HRM-NITROFURANTOIN No No No No Generic ANTI-INFECTIVES
NORVIR CAP 100MG 3 No Yes No No No No No Brand ANTI-INFECTIVES
NORVIR POW 100MG 4 No Yes No No No No No Brand ANTI-INFECTIVES
NORVIR SOL 80MG/ML 4 No Yes No No No No No Brand ANTI-INFECTIVES
NOXAFIL SUS 40MG/ML 5 No Yes No No No Yes 630 30 No Brand ANTI-INFECTIVES
NOXAFIL TAB 100MG 5 No Yes No No No Yes 93 30 No Brand ANTI-INFECTIVES
NYSTATIN TAB 500000 2 Yes No No No No No No Generic ANTI-INFECTIVES
ODEFSEY TAB 5 No Yes No No No No No Brand ANTI-INFECTIVES OSELTAMIVIR PHOSPHATE CAP
30 MG 2 Yes No No No No Yes 168 365 No Generic ANTI-INFECTIVES
OSELTAMIVIR PHOSPHATE CAP
45 MG 2 Yes No No No No Yes 84 365 No Generic ANTI-INFECTIVES
OSELTAMIVIR PHOSPHATE CAP
75 MG 2 Yes No No No No Yes 84 365 No Generic ANTI-INFECTIVES
OSELTAMIVIR PHOSPHATE FOR
SUSP 6 MG/ML (BASE EQUIV) 2 Yes No No No No Yes 1080 365 No Generic ANTI-INFECTIVES
OXACILLIN INJ 10GM 5 No No No No No No Yes Generic ANTI-INFECTIVES
OXACILLIN INJ 1GM 2 Yes No No No No No Yes Generic ANTI-INFECTIVES
OXACILLIN INJ 2GM 2 Yes No No No No No Yes Generic ANTI-INFECTIVES
PAROMOMYCIN CAP 250MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
PASER GRA 4GM 4 No No No No No No No Brand ANTI-INFECTIVES
PEGASYS 180 MCG/ML VIAL 5 No No Yes PEGASYS No No No No Brand ANTI-INFECTIVES PEGASYS INJ 180 MCG/0.5ML
SYRINGE 5 No No Yes PEGASYS No No No No Brand ANTI-INFECTIVES
Peoples Health 2019 Formulary (HMO and HMO-POS) - List of Covered Drugs
Drug Name Tier
Level CG
Order PA PA Criteria Name ST ST Criteria LA QL
QL
Amount QL Days HI
Brand/
Generic Therapeutic Category
PEGASYS INJ PROCLICK 180
MCG/0.5ML 5 No No Yes PEGASYS No No No No Brand ANTI-INFECTIVES
PENICILLIN G PROC INJ 600000 4 No No No No No No No Generic ANTI-INFECTIVES
PENICILLIN G SOD INJ 5000000 2 Yes No No No No No Yes Generic ANTI-INFECTIVES
PENICILLIN GK INJ 20MU 2 Yes No No No No No Yes Generic ANTI-INFECTIVES
PENICILLIN GK INJ 5MU 2 Yes No No No No No No Generic ANTI-INFECTIVES
PENICILLIN GK/ INJ DEX 2MU 4 No No No No No No Yes Brand ANTI-INFECTIVES
PENICILLIN GK/ INJ DEX 3MU 4 No No No No No No Yes Brand ANTI-INFECTIVES
PENICILLIN VK SOL 125/5ML 2 Yes No No No No No No Generic ANTI-INFECTIVES
PENICILLIN VK SOL 250/5ML 2 Yes No No No No No No Generic ANTI-INFECTIVES
PENICILLIN VK TAB 250MG 1 Yes No No No No No No Generic ANTI-INFECTIVES
PENICILLIN VK TAB 500MG 1 Yes No No No No No No Generic ANTI-INFECTIVES
PENTAM 300 INJ 300MG 4 No No No No No No Yes Brand ANTI-INFECTIVES
PFIZERPEN-G INJ 20MU 2 Yes No No No No No No Generic ANTI-INFECTIVES
PFIZERPEN-G INJ 5MU 2 Yes No No No No No No Generic ANTI-INFECTIVES
PIPERACILLIN / TAZOBACTAM 12-
1.5 GRAM INJECTABLE SOLUTION 4 No No No No No No No Brand ANTI-INFECTIVES
PIPERACILLIN 200 MG/ML /
TAZOBACTAM 25 MG/ML
INJECTABLE SOLUTION
2 Yes No No No No No Yes Generic ANTI-INFECTIVES
PIPERACILLIN SODIUM-
TAZOBACTAM SODIUM FOR INJ
36-4.5 GM
2 Yes No No No No No Yes Generic ANTI-INFECTIVES
PIPERACILLIN SODIUM-
TAZOBACTAM SODIUM FOR INJ 4-
0.5 GM
2 Yes No No No No No Yes Generic ANTI-INFECTIVES
Peoples Health 2019 Formulary (HMO and HMO-POS) - List of Covered Drugs
Drug Name Tier
Level CG
Order PA PA Criteria Name ST ST Criteria LA QL
QL
Amount QL Days HI
Brand/
Generic Therapeutic Category
PIPERACILLIN/TAZOBABACTAM
INJ 3-0.375G 2 Yes No No No No No Yes Generic ANTI-INFECTIVES
PRAZIQUANTEL TAB 600 MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
PREZCOBIX TAB 800-150 5 No Yes No No No No No Brand ANTI-INFECTIVES
PREZISTA TAB 150MG 5 No Yes No No No Yes 240 30 No Brand ANTI-INFECTIVES
PREZISTA TAB 600MG 5 No Yes No No No Yes 60 30 No Brand ANTI-INFECTIVES
PREZISTA TAB 75MG 3 No Yes No No No Yes 480 30 No Brand ANTI-INFECTIVES
PREZISTA TAB 800MG 5 No Yes No No No Yes 30 30 No Brand ANTI-INFECTIVES PREZISTA ORAL SUSPENSION
100MG/ML 5 No Yes No No No Yes 400 30 No Brand ANTI-INFECTIVES
PRIFTIN TAB 150MG 4 No No No No No No No Brand ANTI-INFECTIVES
PRIMAQUINE TAB 26.3MG 3 No No No No No No No Brand ANTI-INFECTIVES
PYRAZINAMIDE TAB 500MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
QUININE SULFATE 324 MG CAP 2 Yes No Yes QUININE SULFATE No No No No Generic ANTI-INFECTIVES
REBETOL SOL 40MG/ML 5 No No No No No No No Brand ANTI-INFECTIVES
RELENZA MIS DISKHALE 3 No No No No No Yes 120 365 No Brand ANTI-INFECTIVES
RESCRIPTOR TAB 100 MG 4 No Yes No No No No No Brand ANTI-INFECTIVES
RESCRIPTOR TAB 200MG 4 No Yes No No No No No Brand ANTI-INFECTIVES REYATAZ POWDER FOR
SUSPENSION 50 MG 5 No Yes No No No No No Brand ANTI-INFECTIVES
RIBASPHERE CAP 200MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
RIBASPHERE TAB 200MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
RIBASPHERE TAB 400MG 5 No No No No No No No Generic ANTI-INFECTIVES
RIBASPHERE TAB 600MG 5 No No No No No No No Generic ANTI-INFECTIVES
RIBAVIRIN CAP 200MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
RIBAVIRIN TAB 200MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
RIFABUTIN CAP 150MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
RIFAMPIN CAP 150MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
RIFAMPIN CAP 300MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
Peoples Health 2019 Formulary (HMO and HMO-POS) - List of Covered Drugs
Drug Name Tier
Level CG
Order PA PA Criteria Name ST ST Criteria LA QL
QL
Amount QL Days HI
Brand/
Generic Therapeutic Category
RIFAMPIN INJ 600 MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
RIFATER TAB 4 No No No No No No No Brand ANTI-INFECTIVES
RIMANTADINE TAB 100MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
RITONAVIR TAB 100 MG 2 Yes Yes No No No No No Generic ANTI-INFECTIVES
SELZENTRY TAB 150MG 5 No Yes No No No No No Brand ANTI-INFECTIVES
SELZENTRY TAB 25MG 4 No Yes No No No No No Brand ANTI-INFECTIVES
SELZENTRY TAB 300MG 5 No Yes No No No No No Brand ANTI-INFECTIVES
SELZENTRY TAB 75MG 5 No Yes No No No No No Brand ANTI-INFECTIVES
SELZENTRY SOL 20MG/ML 5 No Yes No No No No No Brand ANTI-INFECTIVES
SIRTURO TAB 100MG 5 No No Yes SIRTURO No Yes No No Brand ANTI-INFECTIVES
SIVEXTRO INJ 200MG 5 No No No No No No No Brand ANTI-INFECTIVES
SIVEXTRO TAB 200MG 5 No No No No No No No Brand ANTI-INFECTIVES
SMZ/TMP DS TAB 800-160 1 Yes No No No No No No Generic ANTI-INFECTIVES
SMZ-TMP INJ 400-80/5 2 Yes No No No No No No Generic ANTI-INFECTIVES
SMZ-TMP TAB 400-80MG 1 Yes No No No No No No Generic ANTI-INFECTIVES
SMZ-TMP SUS 200-40/5 2 Yes No No No No No No Generic ANTI-INFECTIVES
STAVUDINE CAP 15MG 2 Yes Yes No No No No No Generic ANTI-INFECTIVES
STAVUDINE CAP 20MG 2 Yes Yes No No No No No Generic ANTI-INFECTIVES
STAVUDINE CAP 30MG 2 Yes Yes No No No No No Generic ANTI-INFECTIVES
STAVUDINE CAP 40MG 2 Yes Yes No No No No No Generic ANTI-INFECTIVES
STREPTOMYCIN INJ 1GM 5 No No No No No No No Generic ANTI-INFECTIVES
STRIBILD TAB 5 No Yes No No No No No Brand ANTI-INFECTIVES
SULFADIAZINE TAB 500MG 4 No No No No No No No Generic ANTI-INFECTIVES
SULFATRIM PD SUS 200-40/5 2 Yes No No No No No No Generic ANTI-INFECTIVES
SUPRAX CAP 400MG 3 No No No No No No No Brand ANTI-INFECTIVES
SUPRAX CHW 100MG 4 No No No No No No No Brand ANTI-INFECTIVES
SUPRAX CHW 200MG 4 No No No No No No No Brand ANTI-INFECTIVES SUPRAX 500 MG/5 ML
SUSPENSION 3 No No No No No No No Brand ANTI-INFECTIVES
Peoples Health 2019 Formulary (HMO and HMO-POS) - List of Covered Drugs
Drug Name Tier
Level CG
Order PA PA Criteria Name ST ST Criteria LA QL
QL
Amount QL Days HI
Brand/
Generic Therapeutic Category
SYMFI TAB 5 No Yes No No No No No Brand ANTI-INFECTIVES
SYMFI LO TAB 5 No Yes No No No No No Brand ANTI-INFECTIVES
SYMTUZA TAB 5 No Yes No No No No No Brand ANTI-INFECTIVES
SYNERCID INJ 500MG 5 No No No No No No No Brand ANTI-INFECTIVES
TAZICEF INJ 1GM 2 Yes No No No No No Yes Generic ANTI-INFECTIVES TAZICEF INJ 1GM VIAL FOR
RECONSTITUTION 2 Yes No No No No No No Generic ANTI-INFECTIVES
TAZICEF INJ 2GM 2 Yes No No No No No Yes Generic ANTI-INFECTIVES TAZICEF INJ 2GM VIAL FOR
RECONSTITUTION 2 Yes No No No No No No Generic ANTI-INFECTIVES
TAZICEF INJ 6GM 2 Yes No No No No No Yes Generic ANTI-INFECTIVES
TEFLARO INJ 400MG 5 No No No No No No No Brand ANTI-INFECTIVES
TEFLARO INJ 600MG 5 No No No No No No No Brand ANTI-INFECTIVES TENOFOVIR DISOPROXIL
FUMARATE TAB 300 MG 5 No Yes No No No No No Generic ANTI-INFECTIVES
TERBINAFINE TAB 250MG 1 Yes No No No No Yes 90 365 No Generic ANTI-INFECTIVES
TETRACYCLINE CAP 250MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
TETRACYCLINE CAP 500MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
TIGECYCLINE FOR IV SOLN 50 MG 5 No No No No No No Yes Generic ANTI-INFECTIVES
TIVICAY TAB 10MG 3 No Yes No No No No No Brand ANTI-INFECTIVES
TIVICAY TAB 25MG 5 No Yes No No No No No Brand ANTI-INFECTIVES
TIVICAY TAB 50MG 5 No Yes No No No No No Brand ANTI-INFECTIVES
TOBRAMYCIN INJ 1.2/30ML 2 Yes No No No No No No Generic ANTI-INFECTIVES
TOBRAMYCIN INJ 1.2GM 5 No No No No No No No Generic ANTI-INFECTIVES
TOBRAMYCIN INJ 10MG/ML 2 Yes No No No No No No Generic ANTI-INFECTIVES
TOBRAMYCIN INJ 80MG/2ML 2 Yes No No No No No No Generic ANTI-INFECTIVES
TOBRAMYCIN INJ 40MG/ML 2 Yes No No No No No No Generic ANTI-INFECTIVES
Peoples Health 2019 Formulary (HMO and HMO-POS) - List of Covered Drugs
Drug Name Tier
Level CG
Order PA PA Criteria Name ST ST Criteria LA QL
QL
Amount QL Days HI
Brand/
Generic Therapeutic Category
TOBRAMYCIN NEBULIZATION
SOLN 300 MG/5ML 5 No No Yes TOBRAMYCIN No No No No Generic ANTI-INFECTIVES
TRECATOR TAB 250MG 4 No No No No No No No Brand ANTI-INFECTIVES
TRIMETHOPRIM TAB 100MG 1 Yes No No No No No No Generic ANTI-INFECTIVES
TRIUMEQ TAB 5 No Yes No No No No No Brand ANTI-INFECTIVES
TROGARZO INJ 150MG/ML 5 No Yes No No Yes No No Brand ANTI-INFECTIVES
TRUVADA TAB 100-150 5 No Yes No No No Yes 60 30 No Brand ANTI-INFECTIVES
TRUVADA TAB 133-200 5 No Yes No No No Yes 30 30 No Brand ANTI-INFECTIVES
TRUVADA TAB 167-250 5 No Yes No No No Yes 30 30 No Brand ANTI-INFECTIVES
TRUVADA TAB 200-300 5 No Yes No No No Yes 30 30 No Brand ANTI-INFECTIVES
TYBOST TAB 150MG 4 No Yes No No No No No Brand ANTI-INFECTIVES
VALACYCLOVIR TAB 1GM 2 Yes No No No No No No Generic ANTI-INFECTIVES
VALACYCLOVIR TAB 500MG 2 Yes No No No No No No Generic ANTI-INFECTIVES VALGANCICLOVIR HCL FOR SOLN
50 MG/ML (AG) 5 No Yes No No No No No Generic ANTI-INFECTIVES
VALGANCICLOVIR HCL TAB 450
MG 5 No Yes No No No No No Generic ANTI-INFECTIVES
VANCOMYCIN CAP 125MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
VANCOMYCIN CAP 250MG 5 No No No No No No No Generic ANTI-INFECTIVES
VANCOMYCIN INJ 1000MG 2 Yes No No No No No Yes Generic ANTI-INFECTIVES
VANCOMYCIN INJ 10GM 2 Yes No No No No No Yes Generic ANTI-INFECTIVES
VANCOMYCIN INJ 750MG 2 Yes No No No No No No Generic ANTI-INFECTIVES
VANCOMYCIN 5 GM VIAL 2 Yes No No No No No No Generic ANTI-INFECTIVES
VANCOMYCIN 500 MG VIAL 2 Yes No No No No No Yes Generic ANTI-INFECTIVES VANCOMYCIN/NACL 0.9% INJ
1000 MG/200ML 4 No No No No No No No Brand ANTI-INFECTIVES
VANCOMYCIN/NACL 0.9% INJ 500
MG/100ML 4 No No No No No No No Brand ANTI-INFECTIVES
Peoples Health 2019 Formulary (HMO and HMO-POS) - List of Covered Drugs
Drug Name Tier
Level CG
Order PA PA Criteria Name ST ST Criteria LA QL
QL
Amount QL Days HI
Brand/
Generic Therapeutic Category
VANCOMYCIN/NACL 0.9% INJ 750
MG/150ML 4 No No No No No No No Brand ANTI-INFECTIVES
VEMLIDY TAB 25MG 5 No Yes No No No No No Brand ANTI-INFECTIVES
VIDEX SOL 2GM 4 No Yes No No No No No Brand ANTI-INFECTIVES
VIDEX 4 GM PEDIATRIC SOLN 4 No Yes No No No No No Brand ANTI-INFECTIVES
VIDEX EC CAP 125MG 4 No Yes No No No No No Brand ANTI-INFECTIVES
VIRACEPT TAB 250MG 5 No Yes No No No No No Brand ANTI-INFECTIVES
VIRACEPT TAB 625MG 5 No Yes No No No No No Brand ANTI-INFECTIVES
VIRAMUNE SUS 50MG/5ML 4 No Yes No No No No No Brand ANTI-INFECTIVES
VIREAD POW 40MG/GM 5 No Yes No No No No No Brand ANTI-INFECTIVES
VIREAD TAB 150MG 5 No Yes No No No No No Brand ANTI-INFECTIVES
VIREAD TAB 200MG 5 No Yes No No No No No Brand ANTI-INFECTIVES
VIREAD TAB 250MG 5 No Yes No No No No No Brand ANTI-INFECTIVES VORICONAZOLE FOR SUSP 40
MG/ML 5 No No No No No No No Generic ANTI-INFECTIVES
VORICONAZOLE INJ 200MG 2 Yes No No No No No Yes Generic ANTI-INFECTIVES
VORICONAZOLE TAB 200 MG 5 No No No No No No No Generic ANTI-INFECTIVES
VORICONAZOLE TAB 50 MG 5 No No No No No No No Generic ANTI-INFECTIVES
VOSEVI TAB 5 No No Yes VOSEVI No No No No Brand ANTI-INFECTIVES
ZEPATIER TAB 50-100MG 5 No No Yes ZEPATIER No No No No Brand ANTI-INFECTIVES
ZERIT SOL 1MG/ML 5 No Yes No No No No No Brand ANTI-INFECTIVES
ZIDOVUDINE CAP 100MG 2 Yes Yes No No No No No Generic ANTI-INFECTIVES
ZIDOVUDINE SYP 50MG/5ML 2 Yes Yes No No No No No Generic ANTI-INFECTIVES
ZIDOVUDINE TAB 300MG 2 Yes Yes No No No No No Generic ANTI-INFECTIVES
ABRAXANE INJ 100MG 5 No No Yes B VS. D No No No No Brand ANTINEOPLASTIC AGENTS ADRIAMYCIN INJ 2MG/ML (20
MG/ 10 ML) 2 Yes No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS
ADRUCIL INJ 500/10ML 2 Yes No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS
ADRUCIL INJ 2.5G/50M 2 Yes No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS
Peoples Health 2019 Formulary (HMO and HMO-POS) - List of Covered Drugs
Drug Name Tier
Level CG
Order PA PA Criteria Name ST ST Criteria LA QL
QL
Amount QL Days HI
Brand/
Generic Therapeutic Category
ADRUCIL INJ 5GM/100M 2 Yes No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS
AFINITOR TAB 10MG 5 No No Yes AFINITOR No No Yes 30 30 No Brand ANTINEOPLASTIC AGENTS
AFINITOR TAB 2.5MG 5 No No Yes AFINITOR No No Yes 30 30 No Brand ANTINEOPLASTIC AGENTS
AFINITOR TAB 5MG 5 No No Yes AFINITOR No No Yes 30 30 No Brand ANTINEOPLASTIC AGENTS
AFINITOR TAB 7.5MG 5 No No Yes AFINITOR No No Yes 30 30 No Brand ANTINEOPLASTIC AGENTS
AFINITOR DISPERZ TAB 2MG 5 No No Yes AFINITOR No No Yes 150 30 No Brand ANTINEOPLASTIC AGENTS
AFINITOR DISPERZ TAB 3MG 5 No No Yes AFINITOR No No Yes 90 30 No Brand ANTINEOPLASTIC AGENTS
AFINITOR DISPERZ TAB 5MG 5 No No Yes AFINITOR No No Yes 60 30 No Brand ANTINEOPLASTIC AGENTS
ALECENSA CAP 150MG 5 No No Yes ALECENSA No Yes No No Brand ANTINEOPLASTIC AGENTS
ALIMTA INJ 500MG 5 No No Yes B VS. D No No No No Brand ANTINEOPLASTIC AGENTS
ALIMTA 100MG VIAL 5 No No Yes B VS. D No No No No Brand ANTINEOPLASTIC AGENTS
ALUNBRIG TAB 180MG 5 No No Yes ALUNBRIG No Yes No No Brand ANTINEOPLASTIC AGENTS
ALUNBRIG TAB 30MG 5 No No Yes ALUNBRIG No Yes No No Brand ANTINEOPLASTIC AGENTS
ALUNBRIG TAB 90MG 5 No No Yes ALUNBRIG No Yes No No Brand ANTINEOPLASTIC AGENTS
ALUNBRIG PAK 5 No No Yes ALUNBRIG No Yes No No Brand ANTINEOPLASTIC AGENTS
ANASTROZOLE TAB 1 MG 2 Yes Yes No No No No No Generic ANTINEOPLASTIC AGENTS
AVASTIN INJ 5 No No Yes AVASTIN No Yes No No Brand ANTINEOPLASTIC AGENTS
AVASTIN 400 MG/16 ML VIAL 5 No No Yes AVASTIN No Yes No No Brand ANTINEOPLASTIC AGENTS
AZACITIDINE INJ 100MG 5 No No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS
BENDEKA INJ 100/4ML 5 No No Yes B VS. D No No No No Brand ANTINEOPLASTIC AGENTS
BEXAROTENE CAP 75 MG 5 No Yes Yes BEXAROTENE No No No No Generic ANTINEOPLASTIC AGENTS
BICALUTAMIDE TAB 50MG 2 Yes Yes No No No No No Generic ANTINEOPLASTIC AGENTS
BLEOMYCIN INJ 15UNIT 2 Yes No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS
BLEOMYCIN INJ 30UNIT 2 Yes No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS
BORTEZOMIB INJ 3.5MG 5 No No Yes VELCADE No No No No Brand ANTINEOPLASTIC AGENTS
BOSULIF TAB 100MG 5 No No Yes BOSULIF No No No No Brand ANTINEOPLASTIC AGENTS
BOSULIF TAB 400MG 5 No No Yes BOSULIF No No No No Brand ANTINEOPLASTIC AGENTS
BOSULIF TAB 500MG 5 No No Yes BOSULIF No No No No Brand ANTINEOPLASTIC AGENTS
BRAFTOVI CAP 50MG 5 No No Yes BRAFTOVI No Yes No No Brand ANTINEOPLASTIC AGENTS
Peoples Health 2019 Formulary (HMO and HMO-POS) - List of Covered Drugs
Drug Name Tier
Level CG
Order PA PA Criteria Name ST ST Criteria LA QL
QL
Amount QL Days HI
Brand/
Generic Therapeutic Category
BRAFTOVI CAP 75MG 5 No No Yes BRAFTOVI No Yes No No Brand ANTINEOPLASTIC AGENTS
CABOMETYX TAB 20MG 5 No No Yes CABOMETYX No Yes Yes 30 30 No Brand ANTINEOPLASTIC AGENTS
CABOMETYX TAB 40MG 5 No No Yes CABOMETYX No Yes Yes 30 30 No Brand ANTINEOPLASTIC AGENTS
CABOMETYX TAB 60MG 5 No No Yes CABOMETYX No Yes Yes 30 30 No Brand ANTINEOPLASTIC AGENTS
CALQUENCE CAP 100MG 5 No No Yes CALQUENCE No Yes No No Brand ANTINEOPLASTIC AGENTS
CAPRELSA TAB 100MG 5 No No Yes CAPRELSA No Yes No No Brand ANTINEOPLASTIC AGENTS
CAPRELSA TAB 300MG 5 No No Yes CAPRELSA No Yes No No Brand ANTINEOPLASTIC AGENTS
CARBOPLATIN INJ 150/15ML 2 Yes No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS CARBOPLATIN 450 MG/45 ML
VIAL 2 Yes No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS
CARBOPLATIN 50 MG/5 ML VIAL 2 Yes No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS
CARBOPLATIN 600 MG/60 ML
VIAL 2 Yes No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS
CISPLATIN INJ 100MG 2 Yes No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS
CISPLATIN INJ 200MG 2 Yes No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS
CISPLATIN INJ 50/50ML 2 Yes No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS
COMETRIQ KIT 100MG 5 No No Yes COMETRIQ No Yes No No Brand ANTINEOPLASTIC AGENTS
COMETRIQ KIT 140MG 5 No No Yes COMETRIQ No Yes No No Brand ANTINEOPLASTIC AGENTS
COMETRIQ KIT 60MG 5 No No Yes COMETRIQ No Yes No No Brand ANTINEOPLASTIC AGENTS
COTELLIC TAB 20MG 5 No No Yes COTELLIC No Yes No No Brand ANTINEOPLASTIC AGENTS
CYCLOPHOSPHAMIDE CAP 25MG 2 Yes No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS
CYCLOPHOSPHAMIDE CAP 50MG 2 Yes No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS
CYCLOPHOSPHAMIDE INJ 1GM 5 No No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS
CYCLOPHOSPHAMIDE INJ 500MG 5 No No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS
Peoples Health 2019 Formulary (HMO and HMO-POS) - List of Covered Drugs
Drug Name Tier
Level CG
Order PA PA Criteria Name ST ST Criteria LA QL
QL
Amount QL Days HI
Brand/
Generic Therapeutic Category
CYCLOPHOSPHAMIDE 2 GM VIAL 5 No No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS
CYTARABINE INJ 20MG/ML 2 Yes No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS
DACARBAZINE 100 MG VIAL 2 Yes No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS
DEPO-PROVERA INJ 400/ML 4 No Yes Yes B VS. D No No No No Brand ANTINEOPLASTIC AGENTS
DEXRAZOXANE INJ 500MG 5 No No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS
DOCETAXEL INJ 160/8ML 5 No No Yes B VS. D No No No No Brand ANTINEOPLASTIC AGENTS
DOCETAXEL INJ 20MG/2ML 5 No No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS DOCETAXEL INJ 20MG/2ML
(MSB) 5 No No Yes B VS. D No No No No Brand ANTINEOPLASTIC AGENTS
DOCETAXEL INJ (20MG/ML) 5 No No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS
DOCETAXEL INJ 160/16ML 5 No No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS
DOCETAXEL INJ 160/16ML (MSB) 5 No No Yes B VS. D No No No No Brand ANTINEOPLASTIC AGENTS
DOCETAXEL INJ 200/10 5 No No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS DOCETAXEL INJ 80 MG/4ML
(20MG/ML) 5 No No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS
DOCETAXEL INJ 80MG/4ML 5 No No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS
DOCETAXEL INJ 80MG/8ML 5 No No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS DOCETAXEL INJ 80MG/8ML
(MSB) 5 No No Yes B VS. D No No No No Brand ANTINEOPLASTIC AGENTS
DOXORUBICIN INJ 2MG/ML 2 Yes No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS
DOXORUBICIN 10 MG VIAL 2 Yes No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS
DOXORUBICIN 50 MG VIAL 2 Yes No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS
DOXORUBICIN HCL LIPOSOMAL
INJ (FOR IV INFUSION) 2 MG/ML 5 No No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS
EMCYT CAP 140MG 4 No No No No No No No Brand ANTINEOPLASTIC AGENTS
EPIRUBICIN INJ 50/25ML 2 Yes No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS
Peoples Health 2019 Formulary (HMO and HMO-POS) - List of Covered Drugs
Drug Name Tier
Level CG
Order PA PA Criteria Name ST ST Criteria LA QL
QL
Amount QL Days HI
Brand/
Generic Therapeutic Category
EPIRUBICIN 200 MG/100 ML VIAL 2 Yes No Yes B VS. D No No No No Generic ANTINEOPLASTIC AGENTS
ERIVEDGE CAP 150MG 5 No No Yes ERIVEDGE No Yes N
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