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Moda Health Plan, Inc.
Please read: this document contains information about the drugs we cover in this planNote 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. Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1 of each year. Moda Health Plan, Inc. is a PPO and HMO plan with a Medicare contract. Enrollment in Moda Health Plan, Inc. depends on contract renewal.To receive this document in an alternate format or language, please contact Pharmacy Customer Service at 1-888-786-7509 from 7 am to 8 pm, Pacific time, seven days a week.
H3813-004 H3813-005 H3813-006 H8506-001
2015 Comprehensive Formulary (complete list of covered drugs)
H3813_108515A Accepted
The Centers for Medicare and Medicaid Services (CMS) require that we send you important plan documents every year.These documents contain information specific to your Moda Health plan:
> Combined Annual Notice of Changes (ANOC) and Evidence of Coverage (EOC)
> Comprehensive formulary (if applicable) > Provider and/or pharmacy directory (if applicable)
That’s a lot of paper to clutter your home. Luckily, all of these documents are available electronically through your myModa account. To receive an email from Moda Health when new materials are available, simply log in to your myModa account by visiting www.modahealth.com. The myModa log in is on the right side of your screen. You can also create an account on this page. Once logged in, select the “Account” tab. Next, click on “Change account settings.” From here, you can update your email and make your electronic delivery preference.Once you request electronic delivery, you will no longer receive these documents in the mail.
Next year, you can get plan documents delivered to you online
Online documents give you easy access to all your Medicare information.
Cut down on more paper — sign up for ODS eBill today!Now you can pay your premium online with eBill. Using eBill, you can view invoices online and set up your preferred payment methods (credit card, debit card, checking or savings) and set a recurring payment using our AutoPay feature. To access eBill, log in to myModa and click on the eBill tab.
903239 (8/13) MDCR-1432
Questions? Call us at 877-299-9062.
www.modahealth.com
Health plans in Oregon, Washington and Alaska provided by Moda Health Plan, Inc. Dental plans in Oregon provided by Oregon Dental Service. Dental plans in Alaska provided by Oregon Dental Service doing business as Delta Dental of Alaska.
English: We have free interpreter services to answer any questions you may
have about our health or drug plan. To get an interpreter, just call us at 1- 877-299-9062. Someone who speaks English can help you. This is a free
service.
Spanish: Tenemos servicios de intérprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o
medicamentos. Para hablar con un intérprete, por favor llame al 1-877-299-9062. Alguien que hable español le podrá ayudar. Este es un servicio
gratuito.
Chinese Mandarin: 我们提供免费的翻译服务,帮助您解答关于健康或药物保险的任何疑
问。如果您需要此翻译服务,请致电 1-877-299-9062。我们的中文工作人员很乐意帮助您
。 这是一项免费服务。
Chinese Cantonese: 您對我們的健康或藥物保險可能存有疑問,為此我們提供免費的翻譯
服務。如需翻譯服務,請致電 1-877-299-9062。我們講中文的人員將樂意為您提供幫助。
這 是一項免費服務。
Tagalog: Mayroon kaming libreng serbisyo sa pagsasaling-wika upang
masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot. Upang makakuha ng tagasaling-wika,
tawagan lamang kami sa 1-877-299-9062. Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog. Ito ay libreng serbisyo.
French: Nous proposons des services gratuits d'interprétation pour répondre
à toutes vos questions relatives à notre régime de santé ou d'assurance-
médicaments. Pour accéder au service d'interprétation, il vous suffit de nous appeler au 1-877-299-9062. Un interlocuteur parlant Français pourra vous
aider. Ce service est gratuit.
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viên xin gọi 1-877-299-9062 sẽ có nhân viên nói tiếng Việt giúp đỡ quí vị. Đây là dịch vụ miễn phí .
German: Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen
zu unserem Gesundheits- und Arzneimittelplan. Unsere Dolmetscher erreichen Sie unter 1-877-299-9062. Man wird Ihnen dort auf Deutsch
weiterhelfen. Dieser Service ist kostenlos.
Korean: 당사는 의료 보험 또는 약품 보험에 관한 질문에 답해 드리고자 무료 통역
서비스를 제공하고 있습니다. 통역 서비스를 이용하려면 전화 1-877-299-9062.번으로
문의해 주십시오. 한국어를 하는 담당자가 도와 드릴 것입니다. 이 서비스는 무료로
운영됩니다.
Russian: Если у вас возникнут вопросы относительно страхового или
медикаментного плана, вы можете воспользоваться нашими бесплатными услугами переводчиков. Чтобы воспользоваться услугами переводчика,
позвоните нам по телефону 1-877-299-9062. Вам окажет помощь сотрудник, который говорит по-pусски. Данная услуга бесплатная.
Arabic:
. لدينا األدوية جدول أو بالصحة تتعلق أسئلة أي عن لإلجابة المجانية الفوري المترجم خدمات نقدم إننا ما شخص سيقوم. 2609-922-788-1على بنا االتصال سوى عليك ليس فوري، مترجم على للحصول
العربية يتحدث مجانية خدمة هذه. بمساعدتك .
Hindi: हमारे स्वास््य या दवा की योजना के बारे में आपके ककसी भी प्रश्न के जवाब देने के लिए हमारेपास मुफ्त दभुाषिया सेवाए ँउपिब्ध हैं. एक दभुाषिया प्राप्त करने के लिए, बस हमें 1-877-299-9062. परफोन करें. कोई व्यक्तत जो हहन्दी बोिता है आपकी मदद कर सकता है. यह एक मुफ्त सेवा है.
Italian: È disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande sul nostro piano sanitario e farmaceutico. Per un
interprete, contattare il numero 1-877-299-9062. Un nostro incaricato che parla Italianovi fornirà l'assistenza necessaria. È un servizio gratuito.
Portugués: Dispomos de serviços de interpretação gratuitos para responder
a qualquer questão que tenha acerca do nosso plano de saúde ou de medicação. Para obter um intérprete, contacte-nos através do número 1-
877-299-9062. Irá encontrar alguém que fale o idioma Português para o
ajudar. Este serviço é gratuito.
French Creole: Nou genyen sèvis entèprèt gratis pou reponn tout kesyon ou
ta genyen konsènan plan medikal oswa dwòg nou an. Pou jwenn yon
entèprèt, jis rele nou nan 1-877-299-9062. Yon moun ki pale Kreyòl kapab ede w. Sa a se yon sèvis ki gratis.
Polish: Umożliwiamy bezpłatne skorzystanie z usług tłumacza ustnego,
który pomoże w uzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania leków. Aby skorzystać z pomocy tłumacza znającego język
polski, należy zadzwonić pod numer 1-877-299-9062. Ta usługa jest bezpłatna.
Japanese: 当社の健康 健康保険と薬品 処方薬プランに関するご質問にお答えするため に
、無料の通訳サービスがありますございます。通訳をご用命になるには、1-877-299-
9062.にお電話ください。日本語を話す人 者 が支援いたします。これは無料のサー ビス
です。
H3813_403615A Accepted
Salem Health Medicare, powered by Moda Health (PPO)
Legacy Health Medicare, powered by Moda Health (PPO)
Moda Health PPORX (PPO)
Moda Health HMO
2015 Comprehensive Formulary
(Complete List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE
COVER IN THIS PLAN
This formulary was updated on September 1, 2014. For more recent information or other questions, please
contact Moda Health Customer Service, at 1-888-786-7509 or, for TTY users 711, from 7 am to 8 pm Pacific
time seven days a week, from October 1st to February14th (After February 15th, your call will be handled by
our automated phone system Saturdays, Sundays and holidays.) or visit www.modahealth.com/medicare.
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 Moda Health Plan, Inc. When it
refers to “plan” or “our plan,” it means Salem Health Medicare, powered by Moda Health; Legacy Health
Medicare, powered by Moda Health; Moda Health PPORX or Moda Health HMO.
This document includes a list of the drugs (formulary) for our plan which is current as of September 1, 2014.
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, premium and/or copayments/coinsurance may change on January 1, 2016, and from time
to time during the year.
Moda Health Plan, Inc. is a PPO and an HMO plan with a Medicare contract. Enrollment in Moda Health
Plan, Inc. depends on contract renewal.
This information is available for free in other languages. Please call our Customer Service number at 1-888-
786-7509. TTY users call 711. Customer Service is available from 7 am to 8 pm Pacific time, seven days a
week.
Esta información está disponible en otros idiomas, sin costo. Por favor comuníquese al departamento de
servicios a los miembros al 1-888-786-7509. Usuarios de TTY (teléfono de texto), llamen al 711. El
departamento de servicios a los miembros está disponible de 7 a.m. a 8 p.m., hora oficial del Pacífico, los
siete días de la semana.
Last updated September 1, 2014
Formulary ID 00015472, Version 5
H3813_108515A Accepted
What is the Moda Health Formulary?
A formulary is a list of covered drugs selected by Moda 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. Moda Health will generally cover the drugs listed in our formulary as long as the
drug is medically necessary, the prescription is filled at a Moda Health network pharmacy, and other
plan rules are followed. For more information on how to fill your prescriptions, please review your
Evidence of Coverage.
Can the Formulary (drug list) change?
Generally, if you are taking a drug on our 2015 formulary that was covered at the beginning of the year,
we will not discontinue or reduce coverage of the drug during the 2015 coverage year except when a
new, less expensive generic drug becomes available or when new adverse information about the safety
or effectiveness of a drug is released. 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. We feel it is
important that you have continued access for the remainder of the coverage year to the formulary drugs
that were available when you chose our plan, except for cases in which you can save additional money
or we can ensure your safety.
If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy
restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of
the change at least 60 days before the change becomes effective, or at the time the member requests a
refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and
Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes
the drug from the market, we will immediately remove the drug from our formulary and provide notice
to members who take the drug. The enclosed formulary is current as of September 1, 2014. To get
updated information about the drugs covered by Moda Health, please contact us. Our contact
information appears on the front and back cover pages.
How do I use the Formulary?
There are two ways to find your drug within the formulary:
Medical Condition
The formulary begins on page 1. The drugs in this formulary are grouped into categories depending
on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart
condition are listed under the category Cardiovascular Agents. If you know what your drug is used
for, look for the category name in the list that begins on page 1. Then look under the category name
for your drug.
Alphabetical Listing
If you are not sure what category to look under, you should look for your drug in the Index that
begins on page I-1 (at the back of this booklet). The Index provides an alphabetical list of all of the
drugs included in this document. Both brand name drugs and generic drugs are listed in the Index.
Look in the Index and find your drug. Next to your drug, you will see the page number where you
can find coverage information. Turn to the page listed in the Index and find the name of your drug
in the first column of the list.
What are generic drugs?
Moda 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: Moda Health requires you or your physician to get prior authorization for
certain drugs. This means that you will need to get approval from Moda Health before you fill
your prescriptions. If you don’t get approval, Moda Health may not cover the drug.
Quantity Limits: For certain drugs, Moda Health limits the amount of the drug that Moda
Health will cover. For example, Moda Health provides 18 tablets in 28 days per prescription for
sumatriptan (Imitrex) tablets. This may be in addition to a standard one month or three month
supply.
Step Therapy: In some cases, Moda 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, Moda Health may not cover Drug B unless you
try Drug A first. If Drug A does not work for you, Moda Health will then cover Drug B.
You can find out if your drug has any additional requirements or limits by looking in the formulary that
begins on page 1. You can also get more information about the restrictions applied to specific covered
drugs by visiting our Web site. You may also ask us to send you a copy. Our contact information, along
with the date we last updated the formulary, appears on the front and back cover pages.
You can ask Moda Health 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
Moda Health formulary?” on page IV 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 Customer
Service and ask if your drug is covered.
If you learn that Moda Health does not cover your drug, you have two options:
You can ask Customer Service for a list of similar drugs that are covered by Moda Health.
When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug
that is covered by Moda Health.
You can ask Moda Health 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 Moda Health Formulary? You can ask Moda Health 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 your drug even if it is not on our formulary. If approved, this drug will
be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide
the drug at a lower cost-sharing level.
You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the
specialty tier. If approved this would lower the amount you must pay for your drug.
You can ask us to waive coverage restrictions or limits on your drug. For example, for certain
drugs, Moda Health limits the amount of the drug that we will cover. If your drug has a quantity
limit, you can ask us to waive the limit and cover a greater amount.
Generally, Moda Health 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 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 a prior authorization from us before you can fill your prescription. You should talk to your
doctor to decide if you should switch to an appropriate drug that we cover or request a formulary
exception so that we will cover the drug you take. While you talk to your doctor to determine the right
course of action for you, we may cover your drug in certain cases during the first 90 days you are a
member of our plan.
For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will
cover a temporary 31-day supply (unless you have a prescription written for fewer days) when you go to
a network pharmacy. After your first 31-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, we will allow you to refill your prescription until we
have provided you with a 93-day transition supply, consistent with the dispensing increment, (unless
you have a prescription written for fewer days). We will cover more than one refill of these drugs for the
first 90 days you are a member of our plan. If 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 (unless you have a prescription for fewer days) while you
pursue a formulary exception.
If you have a level of care change, (going into or coming out of a skilled nursing facility or long term
care home) we will provide you with a 31-day transition supply (unless you have a prescription written
for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member
of our plan. If 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 (unless you have a prescription for fewer days) while you pursue a formulary exception.
For more information
For more detailed information about your Moda Health prescription drug coverage, please review your
Evidence of Coverage and other plan materials.
If you have questions about Moda 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 www.medicare.gov.
Moda Health Formulary
The formulary that begins on page 1 provides coverage information about the drugs covered by Moda
Health. If you have trouble finding your drug in the list, turn to the Index that begins on page I-1 (at the
back of this booklet).
The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., CELEBREX)
and generic drugs are listed in lower-case italics (e.g., sumatriptan).
The information in the Requirements/Limits column tells you if Moda Health has any special
requirements for coverage of your drug.
o LA – This prescription may be available only at certain pharmacies. For more information call
Customer Service at 1-888-786-7509 from 7 am to 8 pm, Pacific time, seven days a week, from
October 1st to February14th (After February 15th, your call will be handled by our automated
phone system Saturdays, Sundays and holidays.). TTY users should call 711.
o PA – Prior authorization is required for these drugs. This means you or your provider will need
to get approval from Moda Health before you can fill your prescription. If you don’t get
approval, Moda Health may not cover the drug. See page IV for how to request an exception. If
you need help requesting an exception please call Customer Service at 1-888-786-7509 from 7
am to 8 pm, Pacific time, seven days a week, from October 1st to February14th (After February
15th, your call will be handled by our automated phone system Saturdays, Sundays and
holidays.). TTY users should call 711.
o PA- HRM – Prior Authorization Restriction for High Risk Medication. The Centers for
Medicare and Medicaid Services (CMS) considers this medication to be high risk for patients 65
years old or older. Please contact your provider for more information.
o PA BvD - This drug may be covered under Medicare Part B or Part D depending upon the
circumstances. Information may need to be submitted describing the use and setting of the drug
to make the determination. If you need help requesting an exception please call Customer
Service at 1-888-786-7509 from 7 am to 8 pm, Pacific time, seven days a week, from October 1st
to February14th (After February 15th, your call will be handled by our automated phone system
Saturdays, Sundays and holidays.). TTY users should call 711.
o PA for ESRD only – These drugs are also prescribed for members who have End-Stage Renal
Disease (ESRD). If you have ESRD then you may need to receive these drugs from your dialysis
facility. If you don’t have ESRD, see page IV for how to request an exception. If you need help
requesting an exception please call Customer Service at 1-888-786-7509 from 7 am to 8 pm,
Pacific time, seven days a week, from October 1st to February14th (After February 15th, your
call will be handled by our automated phone system Saturdays, Sundays and holidays.). TTY
users should call 711.
o PA NSO - Prior Authorization Restriction for New Starts Only. If you are a new member or
taking this drug for the first time, you or your physician are required to get prior authorization
from Moda Health before you fill your prescription for this drug. Without prior approval, Moda
Health may not cover this drug. See page IV for how to request an exception. If you need help
requesting an exception please call Customer Service at 1-888-786-7509 from 7 am to 8 pm,
Pacific time, seven days a week, from October 1st to February14th (After February 15th, your
call will be handled by our automated phone system Saturdays, Sundays and holidays.). TTY
users should call 711.
o QL – These drugs have a quantity limit. This means you will receive a limited amount of these
drugs unless you or your provider asks for an exception to the quantity limit. See page IV for
how to request an exception. The maximum dosage allowed for the drug is noted first, then the
days supply (e.g., sumatriptan tablets QL 18 in 28 days, this means a maximum of 18 tablets are
allowed within 28 days). If you need help asking for an exception please call Customer Service
at 1-888-786-7509 from 7 am to 8 pm, Pacific time, seven days a week, from October 1st to
February14th (After February 15th, your call will be handled by our automated phone system
Saturdays, Sundays and holidays.) TTY users should call 711.
o Rx Product Only - This drug is now available as a generic over-the-counter (OTC) medication.
OTC products are not covered under your Part D benefit. The prescription strength is only
covered under your Part D benefit. If you have questions please call Customer Service at 1-888-
786-7509 from 7 am to 8 pm, Pacific time, seven days a week, from October 1st to February14th
(After February 15th, your call will be handled by our automated phone system Saturdays,
Sundays and holidays.). TTY users should call 711.
o ST – These drugs require you to first try certain other drugs to treat your medical condition
before we will cover this drug. See page IV for how to request an exception. If you need help
asking for an exception please call Customer Service at 1-888-786-7509 from 7 am to 8 pm,
Pacific time, seven days a week, from October 1st to February14th (After February 15th, your
call will be handled by our automated phone system Saturdays, Sundays and holidays.). TTY
users should call 711.
Below is your cost sharing by plan and tier.
Salem Health Medicare, powered by Moda Health (PPO)
Deductible $0.00
Drug Tier up to a 31-day supply up to a 93-day supply
Tier 1 $5.00 copay $15.00 copay
Tier 2 $12.00 copay $36.00 copay
Tier 3 $45.00 copay $135.00 copay
Tier 4 50% coinsurance 50% coinsurance
Tier 5 33% coinsurance drugs on this tier are limited to a 31-
day supply
Legacy Health Medicare, powered by Moda Health (PPO)
Deductible $0.00
Drug Tier up to a 31-day supply up to a 93-day supply
Tier 1 $5.00 copay $15.00 copay
Tier 2 $12.00 copay $36.00 copay
Tier 3 $45.00 copay $135.00 copay
Tier 4 50% coinsurance 50% coinsurance
Tier 5 33% coinsurance drugs on this tier are limited to a 31-
day supply
Moda Health PPORX (PPO)
Deductible $120.00
Drug Tier up to a 31-day supply up to a 93-day supply
Tier 1 $2.00 copay $6.00 copay
Tier 2 $10.00 copay $30.00 copay
Tier 3 $45.00 copay $135.00 copay
Tier 4 50% coinsurance 50% coinsurance
Tier 5 30% coinsurance drugs on this tier are limited to a 31-
day supply
Moda Health HMO
Deductible $120.00
Drug Tier up to a 31-day supply up to a 93-day supply
Tier 1 $5.00 copay $15.00 copay
Tier 2 $10.00 copay $30.00 copay
Tier 3 $45.00 copay $135.00 copay
Tier 4 $95.00 copay $285.00 copay
Tier 5 30% coinsurance drugs on this tier are limited to a 31-
day supply
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
document
1
Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
Analgesics Analgesics, Miscellaneous
acetaminophen with codeine solution (Acetaminophen with
Codeine)
2 QL: 2700 in 30 days
acetaminophen with codeine tablet: 300mg-
60mg
(Vopac) 2 QL: 180 in 30 days
acetaminophen with codeine tablet: 300mg-
15mg, 300mg-30mg
(Vopac) 2 QL: 360 in 30 days
buprenorphine hcl (Buprenorphine HCl) 2 (injectable)
butalb/acetaminophen/caffeine tablet (Esgic) 2 PA-HRM, QL: 180 in 30
days
butalbit/acetamin/caff/codeine (Fioricet with Codeine) 2 PA-HRM, QL: 180 in 30
days
butalbital/acetaminophen tablet: 50mg-
325mg
(Tencon) 2 PA-HRM, QL: 180 in 30
days
butalbital/aspirin/caffeine (Fiorinal) 2 PA-HRM, QL: 180 in 30
days
butorphanol tartrate spray (Butorphanol Tartrate) 2 QL: 5 in 28 days
BUTRANS 3 QL: 4 in 28 days
codeine sulfate tablet (Codeine Sulfate) 2 QL: 180 in 30 days
codeine/butalbital/asa/caffein (Fiorinal w/Codeine
#3)
2 PA-HRM, QL: 180 in 30
days
DURAMORPH 4
fentanyl citrate (Actiq) 5 PA, QL: 120 in 30 days
fentanyl patch td72: 12mcg/hr, 25mcg/hr,
50mcg/hr, 75mcg/hr
(Duragesic) 2 PA, QL: 10 in 30 days
fentanyl patch td72: 100mcg/hr (Duragesic) 2 PA, QL: 20 in 30 days
hydrocodone/acetaminophen solution: 2.5-
167/5
(Hycet) 2 QL: 2700 in 30 days
hydrocodone/acetaminophen solution: 7.5-
325/15
(Hycet) 2 QL: 2700 in 30 days
hydrocodone/acetaminophen tablet: 2.5-
325mg
(Norco) 2 QL: 360 in 30 days
hydrocodone/acetaminophen tablet: 5mg-
325mg, 7.5-325mg, 10mg-325mg
(Norco) 2 QL: 360 in 30 days
hydrocodone/acetaminophen tablet: 5mg-
300mg, 7.5-300mg, 10mg-300mg
(Norco) 2 QL: 390 in 30 days
hydrocodone/ibuprofen (Ibudone) 2 QL: 150 in 30 days
hydromorphone hcl liquid (Dilaudid) 2 QL: 1200 in 30 days
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
document
2
Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
hydromorphone hcl tablet: 2mg, 4mg (Dilaudid) 2 QL: 180 in 30 days
hydromorphone hcl tablet: 8mg (Dilaudid) 2 QL: 240 in 30 days
hydromorphone hcl syringe, vial (Hydromorphone HCl) 2
hydromorphone hcl/pf ampul (Dilaudid) 2
hydromorphone hcl/pf vial (Hydromorphone HCl/
PF)
2
LAZANDA 5 PA, QL: 30 in 30 days
levorphanol tartrate (Levo-dromoran) 2 QL: 180 in 30 days
methadone hcl tablet sol (Diskets) 2 QL: 90 in 30 days
methadone hcl vial (Methadone HCl) 2
methadone hcl solution (Methadone HCl) 2 QL: 1800 in 30 days
methadone hcl tablet (Methadose) 2 QL: 360 in 30 days
morphine sulfate cartridge: 2mg/ml, 4mg/
ml
(Morphine Sulfate) 2
morphine sulfate various dosage and/or
strengths are available
(Morphine Sulfate) 2
morphine sulfate tablet er: 30mg, 60mg,
100mg
(MS Contin) 2 QL: 120 in 30 days
morphine sulfate tablet er: 15mg, 200mg (MS Contin) 2 QL: 180 in 30 days
morphine sulfate solution: 100mg/5ml (MSIR) 2 QL: 200 in 30 days
morphine sulfate solution: 20mg/5ml (MSIR) 2 QL: 300 in 30 days
morphine sulfate solution: 10mg/5ml (MSIR) 2 QL: 700 in 30 days
MORPHINE SULFATE tablet 2 QL: 180 in 30 days
NUCYNTA ER 3 QL: 60 in 30 days
NUCYNTA 3 QL: 181 in 30 days
oxycodone hcl oral conc, tablet (Dazidox) 2 QL: 180 in 30 days
oxycodone hcl solution (Oxycodone HCl) 2 QL: 1300 in 30 days
oxycodone hcl/acetaminophen tablet:
10mg-650mg
(Alcet) 2 QL: 180 in 30 days
oxycodone hcl/acetaminophen tablet: 5mg-
500mg, 7.5-500mg
(Alcet) 2 QL: 240 in 30 days
oxycodone hcl/acetaminophen tablet: 2.5-
325mg, 5mg-325mg, 7.5-325mg, 10mg-
325mg
(Alcet) 2 QL: 360 in 30 days
oxycodone hcl/acetaminophen solution (Oxycodone HCl/
acetaminophen)
2 QL: 1800 in 30 days
oxycodone hcl/aspirin (Endodan) 2 QL: 360 in 30 days
OXYCONTIN tab er 12h: 80mg 3 QL: 120 in 30 days
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
document
3
Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
OXYCONTIN tab er 12h: 10mg, 15mg,
20mg, 30mg, 40mg, 60mg
3 QL: 60 in 30 days
oxymorphone hcl tablet (Opana) 2 QL: 180 in 30 days
oxymorphone hcl tab er 12h: 30mg, 40mg (Oxymorphone HCl) 2 QL: 120 in 30 days
oxymorphone hcl tab er 12h: 5mg, 7.5mg,
10mg, 15mg, 20mg
(Oxymorphone HCl) 2 QL: 60 in 30 days
tramadol hcl tablet (Ultram) 2 QL: 240 in 30 days
tramadol hcl/acetaminophen (Ultracet) 2 QL: 240 in 30 days
Nonsteroidal Anti-inflammatory Agents
CALDOLOR 4
CELEBREX 3 ST, QL: 60 in 30 days
choline sal/mag salicylate (Choline Sal/mag
Salicylate)
2
diclofenac potassium (Cataflam) 2
diclofenac sodium gel (gram) (Solaraze) 5
diclofenac sodium tab er 24h, tablet dr (Voltaren) 2
diclofenac sodium/misoprostol (Arthrotec 50) 2
diflunisal (Diflunisal) 2
etodolac (Etodolac) 2
fenoprofen calcium (Fenoprofen Calcium) 2
FLECTOR 3 PA
flurbiprofen (Ansaid) 2
ibuprofen oral susp (Ibuprofen) 2
ibuprofen tablet (Motrin) 1
indomethacin sodium (Indocin I.v.) 2 PA-HRM
indomethacin capsule er (Indocin SR) 2 PA-HRM, QL: 60 in 30
days
indomethacin capsule: 50mg (Indomethacin) 2 PA-HRM, QL: 120 in 30
days
indomethacin capsule: 25mg (Indomethacin) 2 PA-HRM, QL: 240 in 30
days
ketoprofen (Ketoprofen) 2
ketorolac tromethamine vial: 15mg/ml (Ketorolac
Tromethamine)
2 QL: 40 in 30 days
ketorolac tromethamine cartridge: 30mg/ml (Toradol) 2 QL: 20 in 30 days
ketorolac tromethamine tablet, vial: 30mg/
ml
(Toradol) 2 QL: 20 in 30 days
ketorolac tromethamine cartridge: 15mg/ml (Toradol) 2 QL: 40 in 30 days
mefenamic acid (Ponstel) 2
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
document
4
Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
meloxicam tablet (Mobic) 1
meloxicam oral susp (Mobic) 2
nabumetone (Relafen) 2
naproxen sodium (Anaprox) 1
naproxen tablet (Naprosyn) 1
naproxen oral susp, tablet dr (Naprosyn) 2
piroxicam (Feldene) 2
salsalate (Salflex) 2
sulindac (Clinoril) 2
tolmetin sodium (Tolmetin Sodium) 2
VOLTAREN 3 (Topical Gel)
Anesthetics Local Anesthetics
lidocaine hcl disp syrin, solution: 4% (Xylocaine) 2
lidocaine hcl jel (ml), jel/pf app, solution:
2%, 40mg/ml
(Xylocaine) 2
lidocaine hcl vial (Xylocaine) 2 PA BvD (PA for ESRD
Only)
lidocaine hcl/pf ampul: 15mg/ml, 40mg/ml (Xylocaine-MPF) 2 PA BvD (PA for ESRD
Only)
lidocaine hcl/pf vial: 5mg/ml (Xylocaine-MPF) 2 PA BvD (PA for ESRD
Only)
lidocaine oint. (g) (Lidocaine) 2 PA BvD (PA for ESRD
Only)
lidocaine/prilocaine (EMLA) 2 PA BvD (PA for ESRD
Only)
LIDODERM 4 PA
Anti-addiction/substance Abuse Treatment Agents Anti-addiction/substance Abuse Treatment Agents
acamprosate calcium (Campral) 2
buprenorphine hcl (Subutex) 2 PA, QL: 90 in 30 days
buprenorphine hcl/naloxone hcl (Suboxone) 2 PA, QL: 90 in 30 days
CHANTIX tablet: 0.5mg, 1mg 3 QL: 168 in 84 days
CHANTIX tab ds pk 3 QL: 53 in 28 days
CHANTIX tablet: 1mg 3 QL: 56 in 28 days
disulfiram (Antabuse) 2
naloxone hcl syringe: 0.4mg/ml; vial (Naloxone HCl) 2
naloxone hcl syringe: 1mg/ml (Naloxone HCl) 2
naltrexone hcl (Revia) 2
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
document
5
Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
NICOTROL 4
ZUBSOLV 3 PA, QL: 90 in 30 days
Antianxiety Agents Benzodiazepines
alprazolam tab er 24h: 1mg, 2mg, 3mg (Xanax XR) 2 QL: 60 in 30 days
alprazolam tab er 24h: 0.5mg; tab rapdis,
tablet
(Xanax) 2 QL: 90 in 30 days
chlordiazepoxide hcl (Librium) 2 QL: 120 in 30 days
clonazepam tab rapdis: 2mg; tablet: 2mg (Klonopin) 2 QL: 300 in 30 days
clonazepam tab rapdis: 0.125mg, 0.25mg,
0.5mg, 1mg; tablet: 0.5mg, 1mg
(Klonopin) 2 QL: 90 in 30 days
clorazepate dipotassium tablet: 15mg (Tranxene T-tab) 2 QL: 120 in 30 days
clorazepate dipotassium tablet: 3.75mg,
7.5mg
(Tranxene T-tab) 2 QL: 60 in 30 days
DIASTAT ACUDIAL kit: 12.5-15-20 4
diazepam kit (Diastat) 2
diazepam oral conc, solution (Diazepam) 2 QL: 1200 in 30 days
diazepam vial (Diazepam) 2 QL: 2 in 28 days
diazepam tablet (Valium) 2 QL: 120 in 30 days
estazolam tablet: 2mg (Prosom) 2 PA-HRM, QL: 30 in 30
days
estazolam tablet: 1mg (Prosom) 2 PA-HRM, QL: 60 in 30
days
flurazepam hcl capsule: 30mg (Dalmane) 2 PA-HRM, QL: 30 in 30
days
flurazepam hcl capsule: 15mg (Dalmane) 2 PA-HRM, QL: 60 in 30
days
lorazepam syringe, vial (Ativan) 2 QL: 2 in 30 days
lorazepam tablet (Ativan) 2 QL: 90 in 30 days
lorazepam oral conc (Lorazepam) 2 QL: 150 in 30 days
midazolam hcl syrup (Midazolam HCl) 2 QL: 10 in 30 days
midazolam hcl vial (Midazolam HCl) 2 QL: 2 in 30 days
midazolam hcl/pf (Midazolam HCl/PF) 2 QL: 2 in 30 days
ONFI oral susp 4 PA NSO, QL: 480 in 30
days
ONFI tablet 4 PA NSO, QL: 60 in 30
days
temazepam capsule: 7.5mg (Restoril) 2 PA-HRM, QL: 120 in 30
days
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
document
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Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
temazepam capsule: 15mg, 22.5mg, 30mg (Restoril) 2 PA-HRM, QL: 30 in 30
days
triazolam tablet: 0.125mg (Halcion) 2 PA-HRM, QL: 120 in 30
days
triazolam tablet: 0.25mg (Halcion) 2 PA-HRM, QL: 60 in 30
days
Antibacterials Aminoglycosides
BETHKIS 5 PA BvD
gentamicin in nacl, iso-osm piggyback:
100mg/50ml
(Gentamicin In Nacl,
Iso-osm)
2
gentamicin in nacl, iso-osm piggyback:
70mg/50ml, 80mg/100ml, 80mg/50ml,
90mg/100ml, 100mg/0.1l, 120mg/0.1l
(Gentamicin In Nacl,
Iso-osm)
2
gentamicin sulfate (Garamycin) 2
neomycin sulfate (Neomycin Sulfate) 2
streptomycin sulfate (Streptomycin Sulfate) 2
TOBI PODHALER 5 QL: 224 in 28 days
tobramycin in 0.225% nacl (Tobi) 5 PA BvD
tobramycin sulfate (Nebcin) 2
tobramycin/sodium chloride piggyback:
60mg/50ml
(Tobramycin/sodium
Chloride)
2
tobramycin/sodium chloride piggyback:
80mg/100ml
(Tobramycin/sodium
Chloride)
2
Antibacterials, Miscellaneous
bacitracin vial: 50000unit (Bacitracin) 2
chloramphenicol sod succ (Chloramphenicol Sod
Succ)
2
clindamycin hcl (Cleocin HCl) 2
clindamycin palmitate hcl (Cleocin Palmitate) 2
clindamycin phosphate vial port (Cleocin Phosphate) 2
clindamycin phosphate/d5w (Cleocin Phosphate In
D5w)
2
colistin (colistimethate na) (Coly-mycin M
Parenteral)
2
CUBICIN 5 PA BvD (PA for ESRD
Only)
methenamine hippurate (Urex) 2
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
document
7
Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
nitrofurantoin macrocrystal (Macrodantin) 2 PA-HRM, QL: 120 in 30
days (High Risk Med.
QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use of
nitrofurantoin drugs)
SYNERCID 5
trimethoprim (Trimethoprim) 2
vancomycin hcl capsule (Vancocin HCl) 5
vancomycin hcl vial: 5g, 10g (Vancomycin HCl) 2 PA BvD (PA for ESRD
Only)
vancomycin hcl vial: 750mg (Vancomycin HCl) 2 PA BvD (PA for ESRD
Only)
vancomycin hcl/d5w (Vancomycin HCl/
D5W)
2
VANCOMYCIN HCL 4
XIFAXAN tablet: 200mg 5 PA, QL: 9 in 30 days
XIFAXAN tablet: 550mg 5 ST, QL: 60 in 30 days
ZYVOX 5
Cephalosporins
cefaclor capsule, susp recon (Ceclor) 2
cefadroxil (Cefadroxil) 2
cefazolin sodium (Ancef) 2
cefazolin sodium/dextrose,iso (Cefazolin Sodium/
dextrose, Iso)
2
cefdinir (Omnicef) 2
cefepime hcl (Maxipime) 2
CEFEPIME 4
CEFEPIME-DEXTROSE 4
cefotaxime sodium (Claforan) 2
cefoxitin sodium (Mefoxin) 2
cefoxitin sodium/dextrose,iso (Cefoxitin Sodium/
dextrose, Iso)
2
cefpodoxime proxetil (Vantin) 2
cefprozil (Cefzil) 2
ceftazidime pentahydrate vial (Fortaz) 2
ceftazidime pentahydrate vial port (Fortaz) 2
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
document
8
Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
ceftibuten dihydrate (Cedax) 2
ceftriaxone na/dextrose,iso (Ceftriaxone Na/
dextrose, Iso)
2
ceftriaxone sodium (Rocephin) 2
cefuroxime axetil (Ceftin) 2
cefuroxime sodium (Zinacef) 2
cefuroxime sodium/dextrose,iso (Cefuroxime Sodium/
dextrose, Iso)
2
cephalexin monohydrate (Cephalexin
Monohydrate)
1
cephalexin (Keflex) 1
MEFOXIN froz.piggy 4
SUPRAX tab chew, tablet 4
TAZICEF IN DEXTROSE 4
TEFLARO 4
Macrolides
azithromycin (Zithromax) 2
clarithromycin (Biaxin) 2
DIFICID 5 QL: 20 in 10 days
ery e-succ/sulfisoxazole (Pediazole) 2
ERY-TAB 2
ERYTHROCIN LACTOBIONATE vial
port: 1g
4
ERYTHROCIN LACTOBIONATE vial
port: 500mg
4
erythromycin base capsule dr (Eryc) 2
erythromycin base tablet, tablet dr (Erythromycin Base) 2
erythromycin ethylsuccinate susp recon (Erythromycin
Ethylsuccinate)
2
erythromycin ethylsuccinate tablet (Erythromycin
Ethylsuccinate)
2
erythromycin stearate (Erythromycin
Stearate)
2
Miscellaneous B-lactam Antibiotics
aztreonam (Azactam) 2
CAYSTON 5 LA
imipenem/cilastatin sodium (Primaxin) 2
INVANZ vial 4
INVANZ vial port 4
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
document
9
Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
meropenem (Merrem) 2
Penicillins
amoxicillin trihydrate (Amoxicillin
Trihydrate)
1
amoxicillin (Amoxil) 1
amoxicillin/potassium clav (Augmentin) 2
ampicillin sodium vial (Totacillin-N) 2
ampicillin sodium vial port (Totacillin-N) 2
ampicillin sodium/sulbactam na vial (Unasyn) 2
ampicillin sodium/sulbactam na vial port (Unasyn) 2
ampicillin trihydrate (Ampicillin Trihydrate) 1
BICILLIN C-R 4
BICILLIN L-A 4
dicloxacillin sodium (Dicloxacillin Sodium) 2
NAFCILL IN DEXTROSE 4
nafcillin sodium vial (Unipen) 2
nafcillin sodium vial port (Unipen) 2
oxacillin sodium (Oxacillin Sodium) 2
oxacillin sodium/dextrose,iso (Oxacillin Sodium/
dextrose, Iso)
2
pen g pot/dextrose-water froz.piggy: 1mm/
50ml
(Pen G Pot/dextrose-
water)
2
pen g pot/dextrose-water froz.piggy: 2mm/
50ml, 3mm/50ml
(Pen G Pot/dextrose-
water)
2
penicillin g potassium (Penicillin G
Potassium)
2
penicillin g potassium/d5w (Penicillin G
Potassium/D5W)
2
penicillin g procaine syringe: 1.2mm/2ml (Penicillin G Procaine) 2
penicillin g procaine syringe: 600000/ml (Penicillin G Procaine) 2
penicillin v potassium (Veetids 500) 2
piperacillin sodium/tazobactam (Zosyn) 2
Quinolones
ciprofloxacin hcl (Cipro) 1
ciprofloxacin lactate (Cipro I.V.) 2
ciprofloxacin lactate/d5w (Cipro I.V.) 2
ciprofloxacin (Ciprofloxacin) 2
levofloxacin tablet (Levaquin) 1
levofloxacin solution, vial (Levaquin) 2
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
document
10
Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
levofloxacin/d5w (Levaquin) 2
moxifloxacin hcl (Avelox) 2
nalidixic acid (Nalidixic Acid) 2
ofloxacin (Floxin) 2
Sulfonamides
sulfadiazine (Sulfadiazine) 2
sulfamethoxazole/trimethoprim tablet (Septra) 1
sulfamethoxazole/trimethoprim oral susp,
vial
(Sulfamethoxazole/
trimethoprim)
2
sulfasalazine (Azulfidine) 2
Tetracyclines
doxycycline hyclate capsule, tablet: 20mg;
vial
(Morgidox) 2
doxycycline hyclate tablet: 100mg (Periostat) 2
doxycycline monohydrate (Adoxa) 2
minocycline hcl capsule, tablet (Dynacin) 2
tetracycline hcl capsule (Ala-tet) 2
tetracycline hcl oral susp (Tetracycline HCl) 2
TYGACIL 5
Anticancer Agents Anticancer Agents
ABRAXANE 5
ADCETRIS 5 PA NSO, QL: 4 in 21
days
AFINITOR DISPERZ 5 PA NSO, QL: 112 in 28
days
AFINITOR tablet: 2.5mg, 5mg, 7.5mg 5 PA NSO, QL: 28 in 28
days
AFINITOR tablet: 10mg 5 PA NSO, QL: 56 in 28
days
ALIMTA 5
anastrozole (Arimidex) 2
ARRANON 5
ARZERRA 5 PA NSO
AVASTIN 5 PA NSO
azacitidine (Vidaza) 5
bicalutamide (Casodex) 2
bleomycin sulfate (Bleomycin Sulfate) 2 PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
document
11
Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
BOSULIF tablet: 100mg 5 PA NSO, QL: 120 in 30
days
BOSULIF tablet: 500mg 5 PA NSO, QL: 30 in 30
days
CAPRELSA tablet: 300mg 5 PA NSO, QL: 30 in 30
days
CAPRELSA tablet: 100mg 5 PA NSO, QL: 60 in 30
days
carboplatin (Carboplatin) 2
cisplatin (Cisplatin) 2
COMETRIQ 5 PA NSO, QL: 112 in 28
days
cyclophosphamide tablet (Cyclophosphamide) 2 PA BvD, ST
cyclophosphamide vial (Cytoxan) 2 PA BvD
CYCLOPHOSPHAMIDE 4 PA BvD, ST
cytarabine (Tarabine Pfs) 2 PA BvD
cytarabine/pf (Cytarabine/PF) 2 PA BvD
dacarbazine (Dtic-Dome IV) 2
dactinomycin (Cosmegen) 2
decitabine (Dacogen) 5
doxorubicin hcl peg-liposomal (Doxil) 5 PA BvD
doxorubicin hcl vial: 10mg (Adriamycin RDF) 2 PA BvD
DROXIA 3
ELIGARD syringe: 30mg 4 QL: 1 in 112 days
ELIGARD syringe: 7.5mg 4 QL: 1 in 28 days
ELIGARD syringe: 22.5mg 4 QL: 1 in 84 days
ELIGARD syringe: 45mg 5 QL: 1 in 168 days
EMCYT 3
epirubicin hcl (Ellence) 2
ERBITUX 5 PA NSO
ERIVEDGE 5 PA NSO, QL: 30 in 30
days
ETOPOPHOS 4
etoposide (Etoposide) 2
exemestane (Aromasin) 2
FARESTON 5
FASLODEX 5
FIRMAGON 4
floxuridine (FUDR) 2 PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
document
12
Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
fludarabine phosphate (Fludara) 3
fluorouracil vial: 500mg/10ml (Fluorouracil) 2 PA BvD
fluorouracil vial: 5g/100ml (Fluorouracil) 2 PA BvD
flutamide (Flutamide) 2
GAZYVA 5 PA NSO, QL: 40 in 28
days
gemcitabine hcl (Gemzar) 5
GILOTRIF 5 PA NSO, QL: 30 in 30
days
GLEEVEC tablet: 400mg 5 PA NSO, QL: 60 in 30
days
GLEEVEC tablet: 100mg 5 PA NSO, QL: 90 in 30
days
HALAVEN 5 PA NSO, QL: 24 in 28
days
HERCEPTIN 5 PA NSO
HEXALEN 5
hydroxyurea (Hydrea) 2
ICLUSIG tablet: 45mg 5 PA NSO, QL: 30 in 30
days
ICLUSIG tablet: 15mg 5 PA NSO, QL: 60 in 30
days
ifosfamide (Ifex) 2 PA BvD
ifosfamide/mesna kit: 1g-1g, 3g-1g (Ifex-mesnex) 5 PA BvD
IMBRUVICA 5 PA NSO, QL: 120 in 30
days
INLYTA tablet: 1mg 5 PA NSO, QL: 180 in 30
days
INLYTA tablet: 5mg 5 PA NSO, QL: 60 in 30
days
ISTODAX 5 PA NSO
IXEMPRA 5
JAKAFI 5 PA NSO, QL: 60 in 30
days
JEVTANA 5
KADCYLA 5 PA NSO
KYPROLIS 5 PA NSO, QL: 6 in 28
days
letrozole (Femara) 2
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
document
13
Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
LEUKERAN 4
leuprolide acetate (Leuprolide Acetate) 2
lomustine (Ceenu) 2
LUPRON DEPOT syringekit: 45mg 5 QL: 1 in 168 days
LUPRON DEPOT syringekit: 3.75mg 5 QL: 1 in 28 days
LUPRON DEPOT syringekit: 11.25mg,
22.5mg
5 QL: 1 in 84 days
LUPRON DEPOT-PED syringekit 5 QL: 1 in 112 days
LUPRON DEPOT-PED kit 5 QL: 1 in 28 days
LYSODREN 3
MARQIBO 5 PA NSO, QL: 4 in 28
days
MATULANE 5
MEGACE ES 5
megestrol acetate (Megestrol Acetate) 2
MEKINIST tablet: 2mg 5 PA NSO, QL: 30 in 30
days
MEKINIST tablet: 0.5mg 5 PA NSO, QL: 90 in 30
days
melphalan hcl (Alkeran) 5
mercaptopurine (Purinethol) 2
methotrexate sodium (Methotrexate Sodium) 2 PA BvD, ST
methotrexate sodium/pf (Methotrexate Sodium/
PF)
2 PA BvD
mitomycin (Mitomycin) 2 PA BvD
mitoxantrone hcl (Novantrone) 2
MUSTARGEN 3
NEXAVAR 5 PA NSO, QL: 120 in 30
days
NILANDRON 3
ONCASPAR 5 PA
oxaliplatin (Oxaliplatin) 5
paclitaxel (Taxol) 2
PERJETA 5 PA NSO
POMALYST 5 PA NSO, QL: 21 in 28
days
PROLEUKIN 5
REVLIMID 5 LA, PA NSO, QL: 21 in
28 days
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
document
14
Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
RITUXAN 5 PA NSO
SOLTAMOX 4
SPRYCEL tablet: 50mg, 70mg, 80mg,
100mg, 140mg
5 PA NSO, QL: 30 in 30
days
SPRYCEL tablet: 20mg 5 PA NSO, QL: 60 in 30
days
STIVARGA 5 PA NSO, QL: 84 in 28
days
SUTENT 5 PA NSO, QL: 30 in 30
days
SYLVANT 5 PA
SYNRIBO 5 PA NSO, QL: 28 in 28
days
TABLOID 3
TAFINLAR 5 PA NSO, QL: 120 in 30
days
tamoxifen citrate (Nolvadex) 2
TARCEVA tablet: 25mg, 100mg 5 PA NSO, QL: 60 in 30
days
TARCEVA tablet: 150mg 5 PA NSO, QL: 90 in 30
days
TARGRETIN capsule 5 PA NSO, QL: 420 in 30
days
TARGRETIN gel (gram) 5 PA NSO, QL: 60 in 28
days
TASIGNA 5 PA NSO, QL: 112 in 28
days
TEMODAR 5 PA NSO (vial only)
topotecan hcl (Hycamtin) 5
TORISEL 5 PA BvD, QL: 4 in 28
days
TREANDA 5
TRELSTAR syringe: 22.5mg/2ml 5 QL: 1 in 168 days
TRELSTAR syringe: 3.75mg/2ml 5 QL: 1 in 28 days
TRELSTAR syringe: 11.25/2ml 5 QL: 1 in 84 days
tretinoin (Tretinoin) 5 (capsule: 10mg)
TREXALL 4 PA BvD, ST
TYKERB 5
VALSTAR 5
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
document
15
Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
VECTIBIX 5 PA NSO
VELCADE 5 PA NSO
vinblastine sulfate (Vinblastine Sulfate) 2 PA BvD
vincristine sulfate (Vincristine Sulfate) 2 PA BvD
vinorelbine tartrate (Navelbine) 2
VOTRIENT 5 PA NSO, QL: 120 in 30
days
XALKORI 5 PA NSO, QL: 60 in 30
days
XTANDI 5 PA NSO, QL: 120 in 30
days
YERVOY 5 PA NSO, QL: 80 in 21
days
ZALTRAP 5 PA NSO
ZELBORAF 5 PA NSO, QL: 240 in 30
days
ZOLADEX implant: 3.6mg 4 QL: 1 in 28 days
ZOLADEX implant: 10.8mg 4 QL: 1 in 84 days
ZOLINZA 5
ZYKADIA 5 PA NSO, QL: 140 in 28
days
ZYTIGA 5 PA NSO, QL: 120 in 30
days
Anticholinergic Agents Antimuscarinics/Antispasmodics
atropine sulfate syringe: 0.05mg/ml,
0.1mg/ml
(Atropine Sulfate) 2
atropine sulfate vial: 0.4mg/ml (Atropine Sulfate) 2
propantheline bromide (Propantheline
Bromide)
2
Anticonvulsants Anticonvulsants
APTIOM 4 ST
BANZEL 4 ST
carbamazepine (Tegretol) 2
CELONTIN 3
DILANTIN capsule: 30mg 3
divalproex sodium (Depakote ER) 2
ethosuximide (Zarontin) 2
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
document
16
Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
felbamate (Felbatol) 2
fosphenytoin sodium (Cerebyx) 2
FYCOMPA 4 ST
gabapentin (Neurontin) 2
GABITRIL tablet: 12mg, 16mg 3
LAMICTAL tb chw dsp: 2mg 4
lamotrigine tab ds pk (Lamictal (blue)) 2
lamotrigine tab er 24, tablet, tb chw dsp (Lamictal) 2
levetiracetam (Keppra) 2
LUMINAL SODIUM 4 QL: 2 in 30 days
LYRICA capsule 3 QL: 90 in 30 days
LYRICA solution 3 QL: 900 in 30 days
oxcarbazepine (Trileptal) 2
OXTELLAR XR 4 ST
PEGANONE 3
phenobarbital sodium (Phenobarbital Sodium) 2 QL: 2 in 30 days
phenobarbital elixir (Phenobarbital) 2 QL: 1500 in 30 days
phenobarbital tablet: 30mg (Phenobarbital) 2 QL: 200 in 30 days
phenobarbital tablet: 15mg, 16.2mg,
32.4mg, 60mg, 64.8mg, 97.2mg, 100mg
(Phenobarbital) 2 QL: 90 in 30 days
phenytoin sodium extended (Dilantin) 2
phenytoin sodium syringe (Phenytoin Sodium) 2
phenytoin sodium vial (Phenytoin Sodium) 2
phenytoin (Dilantin) 2
POTIGA tablet: 50mg 4 ST, QL: 270 in 30 days
POTIGA tablet: 200mg, 300mg, 400mg 4 ST, QL: 90 in 30 days
primidone (Mysoline) 2
QUDEXY XR 4 ST
SABRIL 5
tiagabine hcl (Gabitril) 2
topiramate cap sprink, tablet (Topamax) 2
TRILEPTAL oral susp 4
TROKENDI XR 4 ST
valproic acid (as sodium salt) (Depakene) 2
valproic acid (Depakene) 2
VIMPAT solution 4 ST, QL: 1200 in 30 days
VIMPAT vial 4 ST, QL: 200 in 5 days
VIMPAT tablet 4 ST, QL: 60 in 30 days
zonisamide (Zonegran) 2
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
document
17
Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
Antidementia Agents Antidementia Agents
donepezil hcl (Aricept) 2 QL: 30 in 30 days
galantamine hbr cap24h pel (Razadyne ER) 2 QL: 30 in 30 days
galantamine hbr solution (Razadyne) 2 QL: 200 in 30 days
galantamine hbr tablet (Razadyne) 2 QL: 60 in 30 days
NAMENDA XR cap24 dspk 3 QL: 28 in 28 days
NAMENDA XR cap spr 24 3 QL: 30 in 30 days
NAMENDA 3 QL: 360 in 30 days
rivastigmine tartrate (Exelon) 2 QL: 60 in 30 days
Antidepressants Antidepressants
amitriptyline hcl (Amitriptyline HCl) 2 PA-HRM
amoxapine (Amoxapine) 2
BRINTELLIX 4 ST
bupropion hcl (Wellbutrin XL) 2
citalopram hydrobromide tablet (Celexa) 1 QL: 30 in 30 days
citalopram hydrobromide solution (Celexa) 2
clomipramine hcl (Anafranil) 2 PA-HRM
desipramine hcl (Norpramin) 2
doxepin hcl (Doxepin HCl) 2 PA-HRM
duloxetine hcl capsule dr: 30mg (Cymbalta) 2 QL: 30 in 30 days
duloxetine hcl capsule dr: 20mg, 60mg (Cymbalta) 2 QL: 60 in 30 days
EMSAM 4 QL: 30 in 30 days
escitalopram oxalate tablet (Lexapro) 2 QL: 30 in 30 days
escitalopram oxalate solution (Lexapro) 2 QL: 697 in 30 days
FETZIMA 4 ST
fluoxetine hcl capsule (Prozac) 1
fluoxetine hcl capsule dr, solution, tablet (Rapiflux) 2
fluvoxamine maleate (Fluvoxamine Maleate) 2
imipramine hcl (Tofranil) 2 PA-HRM
imipramine pamoate (Tofranil-PM) 2 PA-HRM
KHEDEZLA 4 ST, QL: 30 in 30 days
maprotiline hcl (Maprotiline HCl) 2
MARPLAN 4
mirtazapine (Remeron) 2
nefazodone hcl (Nefazodone HCl) 2
nortriptyline hcl (Pamelor) 2
olanzapine/fluoxetine hcl (Symbyax) 2
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
document
18
Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
paroxetine hcl (Paxil) 2
PAXIL oral susp 4
perphenazine/amitriptyline hcl (Perphenazine/
amitriptyline HCl)
2 PA-HRM
phenelzine sulfate (Nardil) 2
PRISTIQ ER 4 ST, QL: 30 in 30 days
protriptyline hcl (Vivactil) 2
sertraline hcl tablet (Zoloft) 1
sertraline hcl oral conc (Zoloft) 2
SILENOR 3 QL: 30 in 30 days
SURMONTIL 4 PA-HRM
tranylcypromine sulfate (Parnate) 2
trazodone hcl (Trazodone HCl) 1
venlafaxine hcl (Effexor XR) 2
VIIBRYD 4
Antidiabetic Agents Antidiabetic Agents, Miscellaneous
acarbose (Precose) 2 QL: 90 in 30 days
BYDUREON 3 ST, QL: 4 in 28 days
BYETTA pen injctr: 5mcg/0.02 3 ST, QL: 1.2 in 28 days
BYETTA pen injctr: 10mcg/0.04 3 ST, QL: 2.4 in 28 days
CYCLOSET 4 QL: 180 in 30 days
INVOKANA tablet: 300mg 3 ST, QL: 30 in 30 days
INVOKANA tablet: 100mg 3 ST, QL: 60 in 30 days
JANUMET XR tbmp 24hr: 50mg-500mg,
100-1000mg
3 QL: 30 in 30 days
JANUMET XR tbmp 24hr: 50-1000mg 3 QL: 60 in 30 days
JANUMET 3 QL: 60 in 30 days
JANUVIA 3 QL: 30 in 30 days
JENTADUETO 3 QL: 60 in 30 days
KORLYM 5 PA, QL: 112 in 28 days
metformin hcl tab er 24h: 500mg (Fortamet) 2 QL: 120 in 30 days
metformin hcl tab er 24 (Fortamet) 2 QL: 60 in 30 days
metformin hcl tab er 24h: 750mg (Fortamet) 2 QL: 90 in 30 days
metformin hcl tablet: 500mg (Glucophage) 1 QL: 120 in 30 days
metformin hcl tablet: 1000mg (Glucophage) 1 QL: 60 in 30 days
metformin hcl tablet: 850mg (Glucophage) 1 QL: 90 in 30 days
nateglinide (Starlix) 2 QL: 90 in 30 days
pioglitazone hcl (Actos) 2 QL: 30 in 30 days
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
document
19
Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
pioglitazone hcl/glimepiride (Duetact) 2 QL: 30 in 30 days
pioglitazone hcl/metformin hcl (Actoplus Met) 2 QL: 90 in 30 days
PRANDIMET 3 QL: 150 in 30 days
repaglinide (Prandin) 2 QL: 240 in 30 days
SYMLINPEN 120 4 PA, QL: 10.8 in 28 days
SYMLINPEN 60 4 PA, QL: 6 in 28 days
TRADJENTA 3 QL: 30 in 30 days
VICTOZA 3-PAK 4 PA, QL: 9 in 28 days
Insulins
HUMALOG MIX 50-50 insuln pen 3 QL: 30 in 28 days
HUMALOG MIX 50-50 vial 3 QL: 40 in 28 days
HUMALOG MIX 75-25 insuln pen 3 QL: 30 in 28 days
HUMALOG MIX 75-25 vial 3 QL: 40 in 28 days
HUMALOG insuln pen 3 QL: 30 in 28 days
HUMALOG vial 3 QL: 40 in 28 days
HUMULIN 70/30 KWIKPEN 3 QL: 30 in 28 days
HUMULIN 70-30 3 QL: 40 in 28 days
HUMULIN N KWIKPEN 3 QL: 30 in 28 days
HUMULIN N 3 QL: 40 in 28 days
HUMULIN R 3 QL: 40 in 28 days
LANTUS SOLOSTAR 3 QL: 30 in 28 days
LANTUS 3 QL: 40 in 28 days
NOVOLIN 70-30 cartridge 3 QL: 30 in 28 days
NOVOLIN 70-30 vial 3 QL: 40 in 28 days
NOVOLIN N cartridge 3 QL: 30 in 28 days
NOVOLIN N vial 3 QL: 40 in 28 days
NOVOLIN R cartridge 3 QL: 30 in 28 days
NOVOLIN R vial 3 QL: 40 in 28 days
NOVOLOG FLEXPEN 3 QL: 30 in 28 days
NOVOLOG MIX 70-30 FLEXPEN 3 QL: 30 in 28 days
NOVOLOG MIX 70-30 3 QL: 40 in 28 days
NOVOLOG 3 QL: 40 in 28 days
Sulfonylureas
glimepiride tablet: 1mg, 2mg (Amaryl) 1 QL: 30 in 30 days
glimepiride tablet: 4mg (Amaryl) 1 QL: 60 in 30 days
glipizide tab er 24: 2.5mg, 5mg (Glucotrol XL) 2 QL: 30 in 30 days
glipizide tab er 24: 10mg (Glucotrol XL) 2 QL: 60 in 30 days
glipizide tablet: 10mg (Glucotrol) 1 QL: 120 in 30 days
glipizide tablet: 5mg (Glucotrol) 1 QL: 60 in 30 days
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
document
20
Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
glipizide/metformin hcl tablet: 2.5-500mg,
5mg-500mg
(Metaglip) 2 QL: 120 in 30 days
glipizide/metformin hcl tablet: 2.5-250mg (Metaglip) 2 QL: 60 in 30 days
glyburide tablet: 5mg (Micronase) 2 PA-HRM, QL: 120 in 30
days
glyburide tablet: 2.5mg (Micronase) 2 PA-HRM, QL: 240 in 30
days
glyburide tablet: 1.25mg (Micronase) 2 PA-HRM, QL: 280 in 30
days
glyburide,micronized tablet: 6mg (Glynase) 2 PA-HRM, QL: 120 in 30
days
glyburide,micronized tablet: 3mg (Glynase) 2 PA-HRM, QL: 180 in 30
days
glyburide,micronized tablet: 1.5mg (Glynase) 2 PA-HRM, QL: 400 in 30
days
glyburide/metformin hcl tablet: 2.5-500mg,
5mg-500mg
(Glucovance) 2 PA-HRM, QL: 120 in 30
days
glyburide/metformin hcl tablet: 1.25-250mg (Glucovance) 2 PA-HRM, QL: 240 in 30
days
tolazamide tablet: 250mg (Tolazamide) 2 QL: 120 in 30 days
tolazamide tablet: 500mg (Tolazamide) 2 QL: 60 in 30 days
tolbutamide (Tolbutamide) 2 QL: 180 in 30 days
Antifungals Antifungals
ABELCET 5 PA BvD
AMBISOME 5 PA BvD
amphotericin b (Amphotericin B) 2 PA BvD
CANCIDAS 5
ciclopirox olamine (Loprox) 2
ciclopirox (Penlac) 2
clotrimazole (Mycelex) 2
clotrimazole/betamethasone dip (Lotrisone) 2
econazole nitrate (Spectazole) 2
fluconazole in nacl,iso-osm (Diflucan in Saline) 2
fluconazole (Diflucan) 2
flucytosine (Ancobon) 5
griseofulvin, microsize tablet (Grifulvin V) 2
itraconazole (Sporanox) 2
ketoconazole (Kuric) 2
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
document
21
Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
miconazole nitrate (Monistat 3) 2
NOXAFIL oral susp, tablet dr 5
nystatin (Nystatin) 2
nystatin/triamcin (Mycogen II) 2
terbinafine hcl (Lamisil) 2
voriconazole vial (Vfend IV) 2
voriconazole susp recon, tablet (Vfend) 5
Antihistamines Antihistamines
clemastine fumarate syrup, tablet: 2.68mg (Clemastine Fumarate) 2 PA-HRM
clemastine fumarate tablet: 1.34mg (Clemastine Fumarate) 2 PA-HRM
cyproheptadine hcl (Cyproheptadine HCl) 2 PA-HRM
diphenhydramine hcl vial (Benadryl) 2
diphenhydramine hcl syringe (Diphenhydramine
HCl)
2
levocetirizine dihydrochloride (Xyzal) 2
p-epd tan/chlor-tan (P-epd Tan/chlor-tan) 2
promethazine hcl (Promethazine HCl) 2 PA-HRM
Anti-infectives (Skin and Mucous Membrane) Anti-infectives (Skin and Mucous Membrane)
AVC 3
clindamycin phosphate (Cleocin) 2
metronidazole (Metrogel-vaginal) 2
sod propion/inositol/aa14/urea (Sod Propion/inositol/
aa14/urea)
2
terconazole (Terazol 3) 2
Antimigraine Agents Antimigraine Agents
dihydroergotamine mesylate ampul (D.H.E. 45) 2 QL: 30 in 28 days
dihydroergotamine mesylate spray/pump (Migranal) 2 QL: 4 in 28 days
ERGOMAR 4 QL: 40 in 28 days
naratriptan hcl (Amerge) 2 QL: 18 in 28 days
rizatriptan benzoate (Maxalt Mlt) 2 QL: 18 in 28 days
sumatriptan succinate tablet (Imitrex) 2 QL: 18 in 28 days
sumatriptan succinate cartridge (Imitrex) 2 QL: 4 in 28 days
sumatriptan succinate pen injctr, vial (Imitrex) 2 QL: 4 in 28 days
sumatriptan (Imitrex) 2 QL: 12 in 28 days
zolmitriptan (Zomig) 2 QL: 12 in 28 days
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
document
22
Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
Antimycobacterials Antimycobacterials
CAPASTAT SULFATE 4
dapsone (Dapsone) 2
ethambutol hcl (Myambutol) 2
isoniazid tablet (Isoniazid) 1
isoniazid solution (Isoniazid) 2
PASER 4
PRIFTIN 4
pyrazinamide (Pyrazinamide) 2
rifabutin (Mycobutin) 2
rifampin (Rifadin) 2
RIFATER 4
SIRTURO 5 PA, QL: 188 in 168 days
TRECATOR 4
Antinausea Agents Antinausea Agents
dimenhydrinate (Dimenhydrinate) 2
dronabinol (Marinol) 2
EMEND capsule: 40mg, 125mg 4 PA BvD, QL: 1 per fill
EMEND capsule: 80mg 4 PA BvD, QL: 2 per fill
EMEND cap ds pk 4 PA BvD, QL: 3 per fill
EMEND vial 4 QL: 2 in 28 days
granisetron hcl vial (Kytril) 2
granisetron hcl tablet (Kytril) 2 PA BvD
granisetron hcl/pf (Kytril) 2
meclizine hcl (Antivert) 2
ondansetron hcl (Zofran) 2 PA BvD
ondansetron hcl/pf (Zofran) 2
ondansetron (Zofran Odt) 2 PA BvD
prochlorperazine edisylate (Compazine) 2
prochlorperazine maleate tablet (Compazine) 1
prochlorperazine maleate supp.rect (Compazine) 2
promethazine hcl supp.rect, tablet (Promethazine HCl) 2 PA-HRM
TRANSDERM-SCOP 4 QL: 10 in 30 days
Antiparasite Agents Antiparasite Agents
ALBENZA 4
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
document
23
Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
ALINIA 4
atovaquone (Mepron) 5
atovaquone/proguanil hcl (Malarone) 2
BILTRICIDE 4
chloroquine phosphate (Aralen Phosphate) 2
COARTEM 4
DARAPRIM 4
hydroxychloroquine sulfate (Plaquenil) 2
mefloquine hcl (Lariam) 2
metronidazole (Flagyl) 2
metronidazole/sodium chloride (Metro IV) 2
NEBUPENT 4 PA BvD
paromomycin sulfate (Paromomycin Sulfate) 2
PENTAM 300 4
pentamidine isethionate (Pentam 300) 2
PRIMAQUINE 4 QL: 90 in 30 days
quinine sulfate (Qualaquin) 2 PA, QL: 42 in 7 days
STROMECTOL 3
Antiparkinsonian Agents Antiparkinsonian Agents
amantadine hcl (Amantadine HCl) 2
APOKYN 5 QL: 60 in 30 days
AZILECT 3
benztropine mesylate tablet (Benztropine Mesylate) 2 PA-HRM
bromocriptine mesylate (Parlodel) 2
cabergoline (Cabergoline) 2
carbidopa (Lodosyn) 2
carbidopa/levodopa tablet, tablet er (Sinemet 10-100) 2
carbidopa/levodopa/entacapone (Stalevo 50) 2
entacapone (Comtan) 2
NEUPRO 3 ST, QL: 30 in 30 days
pramipexole di-hcl (Mirapex) 2
ropinirole hcl (Requip) 2
selegiline hcl (Eldepryl) 2
trihexyphenidyl hcl (Trihexyphenidyl HCl) 2 PA-HRM
Antipsychotic Agents Antipsychotic Agents
ABILIFY DISCMELT tab rapdis: 15mg 3 QL: 60 in 30 days
ABILIFY DISCMELT tab rapdis: 10mg 3 QL: 90 in 30 days
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
document
24
Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
ABILIFY MAINTENA 5 QL: 1 in 28 days
ABILIFY vial 3 QL: 161.2 in 28 days
ABILIFY tablet: 5mg, 10mg, 15mg, 20mg,
30mg
3 QL: 30 in 30 days
ABILIFY tablet: 2mg 3 QL: 60 in 30 days
ABILIFY solution 3 QL: 900 in 30 days
chlorpromazine hcl ampul, tablet (Chlorpromazine HCl) 2
chlorpromazine hcl oral conc. (Chlorpromazine HCl) 2
clozapine tablet: 200mg (Clozaril) 2 QL: 135 in 30 days
clozapine tablet: 100mg (Clozaril) 2 QL: 270 in 30 days
clozapine tablet: 25mg, 50mg (Clozaril) 2 QL: 90 in 30 days
clozapine tab rapdis (Fazaclo) 2 ST, QL: 90 in 30 days
FANAPT tablet 4 ST, QL: 60 in 30 days
FANAPT tab ds pk 4 ST, QL: 8 in 28 days
FAZACLO tab rapdis: 200mg 4 ST, QL: 120 in 30 days
FAZACLO tab rapdis: 150mg 4 ST, QL: 180 in 30 days
fluphenazine decanoate (Fluphenazine
Decanoate)
2
fluphenazine hcl (Fluphenazine HCl) 2
GEODON vial 4 QL: 6 in 28 days
haloperidol decanoate (Haloperidol
Decanoate)
2
haloperidol lactate (Haloperidol Lactate) 2
haloperidol (Haloperidol) 2
INVEGA SUSTENNA syringe: 39mg/0.25 3 QL: 0.25 in 28 days
INVEGA SUSTENNA syringe: 78mg/
0.5ml
3 QL: 0.5 in 28 days
INVEGA SUSTENNA syringe: 117mg/
0.75
5 QL: 0.75 in 28 days
INVEGA SUSTENNA syringe: 156mg/ml 5 QL: 1 in 28 days
INVEGA SUSTENNA syringe: 234mg/1.5 5 QL: 1.5 in 28 days
INVEGA tab er 24: 1.5mg, 3mg, 9mg 4 ST, QL: 30 in 30 days
INVEGA tab er 24: 6mg 4 ST, QL: 60 in 30 days
LATUDA tablet: 20mg, 40mg, 60mg,
120mg
4 ST, QL: 30 in 30 days
LATUDA tablet: 80mg 4 ST, QL: 60 in 30 days
loxapine succinate (Loxitane) 2
olanzapine tab rapdis: 20mg (Zyprexa Zydis) 2 QL: 31 in 30 days
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
document
25
Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
olanzapine tab rapdis: 5mg, 10mg, 15mg;
tablet, vial
(Zyprexa) 2 QL: 30 in 30 days
ORAP 4
perphenazine (Perphenazine) 2
quetiapine fumarate (Seroquel) 2 QL: 90 in 30 days
RISPERDAL CONSTA 4 QL: 4 in 28 days
risperidone tab rapdis: 3mg, 4mg (Risperdal M-tab) 2 QL: 120 in 30 days
risperidone solution (Risperdal) 2 QL: 480 in 30 days
risperidone tab rapdis: 0.25mg, 0.5mg,
1mg, 2mg; tablet
(Risperdal) 2 QL: 60 in 30 days
SAPHRIS 4 ST, QL: 60 in 30 days
SEROQUEL XR tab er 24h: 200mg 4 ST, QL: 30 in 30 days
SEROQUEL XR tab er 24h: 50mg,
150mg, 300mg, 400mg
4 ST, QL: 60 in 30 days
thioridazine hcl oral conc. (Thioridazine HCl) 2 PA-HRM
thioridazine hcl tablet (Thioridazine HCl) 2 PA-HRM
thiothixene (Navane) 2
trifluoperazine hcl (Trifluoperazine HCl) 2
VERSACLOZ 5 ST, QL: 540 in 30 days
ziprasidone hcl (Geodon) 2 QL: 60 in 30 days
ZYPREXA RELPREVV 5 QL: 2 in 28 days
Antivirals (Systemic) Antiretrovirals
abacavir sulfate (Ziagen) 2
abacavir/lamivudine/zidovudine (Trizivir) 5
APTIVUS solution 4
APTIVUS capsule 5
ATRIPLA 5
COMPLERA 5
CRIXIVAN 4
didanosine (Videx EC) 2
EDURANT 5
EMTRIVA 3
EPIVIR HBV solution 4
EPIVIR solution 4
EPZICOM 5
FUZEON 5
INTELENCE tablet: 25mg 3
INTELENCE tablet: 100mg, 200mg 5
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
document
26
Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
INVIRASE 5
ISENTRESS powd pack, tab chew 3
ISENTRESS tablet 5
KALETRA tablet: 100mg-25mg 3
KALETRA solution, tablet: 200mg-50mg 5
lamivudine (Epivir) 2
lamivudine/zidovudine (Combivir) 5
LEXIVA oral susp 3
LEXIVA tablet 5
nevirapine (Viramune) 2
NORVIR 4
PREZISTA tablet: 75mg, 150mg 3
PREZISTA oral susp 4
PREZISTA tablet: 400mg 5
PREZISTA tablet: 600mg, 800mg 5
RESCRIPTOR 4
RETROVIR vial 3
REYATAZ 5
SELZENTRY 5
stavudine (Zerit) 2
STRIBILD 5
SUSTIVA capsule: 100mg 4
SUSTIVA capsule: 50mg, 200mg; tablet 4
TIVICAY 5
TRUVADA 5
VIDEX 3
VIRACEPT 4
VIRAMUNE XR tab er 24h: 100mg 3
VIREAD 5
ZIAGEN solution 4
zidovudine (Retrovir) 2
Antivirals, Miscellaneous
foscarnet sodium (Foscavir) 2 PA BvD
RELENZA 4
rimantadine hcl (Flumadine) 2
SYNAGIS 5
TAMIFLU capsule: 75mg 3 QL: 42 in 180 days
TAMIFLU capsule: 45mg 3 QL: 48 in 180 days
TAMIFLU susp recon 3 QL: 540 in 180 days
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
document
27
Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
TAMIFLU capsule: 30mg 3 QL: 84 in 180 days
Hcv Antivirals
OLYSIO 5 PA, QL: 28 in 28 days
SOVALDI 5 PA, QL: 28 in 28 days
Interferons
INTRON A pen ij kit, vial: 18mmunit,
50mmunit
4 PA NSO
INTRON A vial: 6mmunit/ml, 10mm/ml 4 PA NSO
PEGASYS PROCLICK 5 PA
PEGASYS 5 PA
PEGINTRON REDIPEN 5 PA
PEGINTRON 5 PA
SYLATRON 4-PACK 5 PA NSO, QL: 4 in 28
days
Nucleosides and Nucleotides
acyclovir sodium (Acyclovir Sodium) 2 PA BvD
acyclovir (Zovirax) 2
adefovir dipivoxil (Hepsera) 5
BARACLUDE tablet 5
famciclovir (Famvir) 2
ganciclovir sodium (Cytovene) 2 PA BvD
ribavirin capsule, tablet (Rebetol) 2
TYZEKA 5
valacyclovir hcl (Valtrex) 2
VALCYTE tablet 5
VIRAZOLE 5 PA BvD
Blood Products/modifiers/volume Expanders Anticoagulants
CEPROTIN 5
ELIQUIS 3
enoxaparin sodium syringe: 40mg/0.4ml (Lovenox) 2 QL: 13.6 in 30 days
enoxaparin sodium syringe: 30mg/0.3ml (Lovenox) 2 QL: 18 in 30 days
enoxaparin sodium syringe: 60mg/0.6ml (Lovenox) 2 QL: 20.4 in 30 days
enoxaparin sodium syringe: 80mg/0.8ml (Lovenox) 2 QL: 27.2 in 30 days
enoxaparin sodium vial (Lovenox) 2 QL: 36 in 30 days
enoxaparin sodium syringe: 120mg/.8ml (Lovenox) 5 QL: 27.2 in 30 days
enoxaparin sodium syringe: 150mg/ml (Lovenox) 5 QL: 34 in 30 days
enoxaparin sodium syringe: 100mg/ml (Lovenox) 5 QL: 36 in 30 days
fondaparinux sodium syringe: 5mg/0.4ml (Arixtra) 2 QL: 12 in 30 days
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
document
28
Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
fondaparinux sodium syringe: 2.5mg/0.5 (Arixtra) 2 QL: 15 in 30 days
fondaparinux sodium syringe: 7.5mg/0.6 (Arixtra) 2 QL: 18 in 30 days
fondaparinux sodium syringe: 10mg/0.8ml (Arixtra) 2 QL: 24 in 30 days
heparin sodium,porcine (Hep-lock) 2 PA BvD (PA for ESRD
Only)
heparin sodium,porcine/d5w (Heparin Sodium,
porcine/D5W)
2
heparin sodium,porcine/ns/pf (Heparin Sodium,
porcine/ns/PF)
2
heparin sodium,porcine/pf (Monoject Prefill
Advanced)
2 PA BvD (PA for ESRD
Only)
IPRIVASK 5 PA, QL: 24 in 28 days
PRADAXA 4 QL: 60 in 30 days
warfarin sodium (Coumadin) 1
XARELTO tablet: 10mg, 20mg 3 QL: 30 in 30 days
XARELTO tablet: 15mg 3 QL: 42 in 21 days
Blood Formation Modifiers
EPOGEN 3 PA, QL: 12 in 28 days
GRANIX 5
LEUKINE 5
MOZOBIL 5
NEULASTA 5
NEUMEGA 5
NEUPOGEN 5
PROCRIT vial: 2000/ml, 3000/ml, 4000/
ml, 20000/2ml
3 PA, QL: 12 in 28 days
PROCRIT vial: 20000/ml 5 PA, QL: 12 in 28 days
PROCRIT vial: 40000/ml 5 PA, QL: 6 in 28 days
PROMACTA 5 PA, QL: 30 in 30 days
Hematologic Agents, Miscellaneous
aminocaproic acid solution, tablet (Amicar) 2
anagrelide hcl (Agrylin) 2
protamine sulfate (Protamine Sulfate) 2 PA BvD (PA for ESRD
Only)
tranexamic acid tablet (Lysteda) 2 QL: 30 in 30 days
tranexamic acid vial (Tranexamic Acid) 2
Platelet-aggregation Inhibitors
AGGRENOX 4 QL: 60 in 30 days
BRILINTA 3
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
document
29
Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
cilostazol (Pletal) 2
clopidogrel bisulfate (Plavix) 2
EFFIENT 3 QL: 30 in 30 days
pentoxifylline (Trental) 2
Volume Expanders
ALBUKED-25 4
ALBUKED-5 4
ALBUMIN (HUMAN) 4
ALBUMINAR-25 4
ALBUMINAR-5 4
ALBURX 4
ALBUTEIN 4
BUMINATE 4
FLEXBUMIN 4
KEDBUMIN 4
PLASBUMIN-25 4
PLASBUMIN-5 4
STERILE DILUENT 4
Caloric Agents Caloric Agents
AMINO ACIDS 4 PA BvD
AMINOSYN II iv soln: 10% 4 PA BvD
AMINOSYN II iv soln: 15% 4 PA BvD
AMINOSYN II iv soln: 7% 4 PA BvD
AMINOSYN II iv soln: 8.5% 4 PA BvD
AMINOSYN II iv soln: 8.5% 4 PA BvD
AMINOSYN M 4 PA BvD
AMINOSYN with ELECTROLYTES 4 PA BvD
AMINOSYN iv soln: 10% 4 PA BvD
AMINOSYN iv soln: 3.5% 4 PA BvD
AMINOSYN iv soln: 7% 4 PA BvD
AMINOSYN iv soln: 8.5% 4 PA BvD
AMINOSYN iv soln: 8.5% 4 PA BvD
AMINOSYN-HBC 4 PA BvD
AMINOSYN-PF iv soln: 10% 4 PA BvD
AMINOSYN-PF iv soln: 7% 4 PA BvD
AMINOSYN-RF 4 PA BvD
CLINIMIX E iv soln: 2.75% 4 PA BvD
CLINIMIX E iv soln: 2.75% 4 PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
document
30
Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
CLINIMIX E iv soln: 4.25% 4 PA BvD
CLINIMIX E iv soln: 4.25% 4 PA BvD
CLINIMIX E iv soln: 4.25% 4 PA BvD
CLINIMIX E iv soln: 5% 4 PA BvD
CLINIMIX E iv soln: 5% 4 PA BvD
CLINIMIX E iv soln: 5% 4 PA BvD
CLINIMIX E iv soln: 5% 4 PA BvD
CLINIMIX iv soln: 2.75% 4 PA BvD
CLINIMIX iv soln: 4.25% 4 PA BvD
CLINIMIX iv soln: 4.25% 4 PA BvD
CLINIMIX iv soln: 4.25% 4 PA BvD
CLINIMIX iv soln: 4.25% 4 PA BvD
CLINIMIX iv soln: 5% 4 PA BvD
CLINIMIX iv soln: 5% 4 PA BvD
CLINIMIX iv soln: 5% 4 PA BvD
CLINISOL 4 PA BvD
cysteine hcl (Cysteine HCl) 2 PA BvD
dextrose 10 % and 0.2 % nacl dehp fr bg (Dextrose 10 % and 0.2
% NaCl)
2
dextrose 10 % and 0.2 % nacl iv soln (Dextrose 10 % and 0.2
% NaCl)
2
dextrose 10 % and 0.9 % nacl (Dextrose 10 % and 0.9
% NaCl)
2
dextrose 10 % in water (Dextrose 10 % in
Water)
2 PA BvD
dextrose 10%-0.5 normal saline (Dextrose 10%-0.5
Normal Saline)
2
dextrose 2.5 % in water (Dextrose 2.5 % in
Water)
2 PA BvD
dextrose 2.5% in half ringers (Dextrose 2.5% In Half
Ringers)
2
dextrose 2.5%-0.5normal saline (Dextrose 2.5%-0.5
Normal Saline)
2
dextrose 20%-water (Dextrose 20%-water) 2 PA BvD
dextrose 25 % in water (Dextrose 25 % in
Water)
2 PA BvD
dextrose 40%-water (Dextrose 40%-water) 2 PA BvD
dextrose 5 % and 0.3 % nacl (Dextrose 5 % and 0.3
% NaCl)
2
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
document
31
Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
dextrose 5 % and 0.9 % nacl (Dextrose 5 % and 0.9
% NaCl)
2
dextrose 5 % in water (Dextrose 5 % in
Water)
2
dextrose 5 %-0.2 % nacl (Dextrose 5 %-0.2 %
NaCl)
2
dextrose 5 %-0.45 % nacl (Dextrose 5 %-0.45 %
NaCl)
2
dextrose 5% in ringers (Dextrose 5% In
Ringers)
2
dextrose 5%-lactated ringers (Dextrose 5%-Lactated
Ringers)
2
dextrose 50 % in water (Dextrose 50 % in
Water)
2 PA BvD
dextrose 60 % in water (Dextrose 60 % in
Water)
2 PA BvD
dextrose 70%-water (Dextrose 70%-water) 2 PA BvD
FREAMINE HBC 4 PA BvD
FREAMINE III 4 PA BvD
fructose 10% (Fructose 10%) 2 PA BvD
HEPATAMINE 4 PA BvD
HEPATASOL 4 PA BvD
INTRALIPID emulsion: 10% 4 PA BvD
INTRALIPID emulsion: 20%, 30% 4 PA BvD
LIPOSYN II 4 PA BvD
LIPOSYN III emulsion: 10%, 20% 4 PA BvD
LIPOSYN III emulsion: 30% 4 PA BvD
NEPHRAMINE 4 PA BvD
NOVAMINE 4 PA BvD
potassium chloride in lr-d5 (Potassium Chloride In
Lr-d5)
2
PREMASOL iv soln: 10% 4 PA BvD
PREMASOL iv soln: 6% 4 PA BvD
PROCALAMINE 4 PA BvD
PROSOL 4 PA BvD
QUICK MIX with LYTES 4 PA BvD
TRAVAMULSION 4 PA BvD
TRAVASOL W/DEXTROSE 4 PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
document
32
Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
TRAVASOL W/ELECTROLYTES iv
soln.: 5.5%
4 PA BvD
TRAVASOL W/ELECTROLYTES iv
soln.: 8.5%
4 PA BvD
TRAVASOL with DEXTROSE iv soln:
8.5%
4 PA BvD
TRAVASOL with DEXTROSE iv soln:
8.5%
4 PA BvD
TRAVASOL with DEXTROSE iv soln:
8.5%
4 PA BvD
TRAVASOL with ELECTROLYTES 4 PA BvD
TRAVASOL iv soln. 4 PA BvD
TRAVASOL iv soln: 10% 4 PA BvD
TRAVASOL iv soln: 5.5% 4 PA BvD
TRAVASOL iv soln: 8.5% 4 PA BvD
TRAVERT IN NORMAL SALINE 4 PA BvD
TRAVERT iv soln: 10% 4 PA BvD
TRAVERT iv soln: 5% 4 PA BvD
TROPHAMINE iv soln: 10% 4 PA BvD
TROPHAMINE iv soln: 6% 4 PA BvD
Cardiovascular Agents Alpha-adrenergic Agents
clonidine hcl (Catapres) 1
clonidine hcl/chlorthalidone (Clonidine HCl/
chlorthalidone)
2
clonidine patch tdwk: 0.1mg/24hr, 0.2mg/
24hr
(Catapres-tts 1) 2 QL: 4 in 28 days
clonidine patch tdwk: 0.3mg/24hr (Catapres-tts 1) 2 QL: 8 in 28 days
doxazosin mesylate (Cardura) 2
guanfacine hcl (Tenex) 2 PA-HRM
midodrine hcl (Proamatine) 2
phenylephrine hcl (Vazculep) 2
prazosin hcl (Minipress) 2
Angiotensin II Receptor Antagonists
BENICAR HCT 3 ST
BENICAR 3 ST
candesartan cilexetil (Atacand) 2
candesartan/hydrochlorothiazid (Atacand HCT) 2
DIOVAN 3 ST
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
document
33
Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
irbesartan (Avapro) 2
irbesartan/hydrochlorothiazide (Avalide) 2
losartan potassium (Cozaar) 1
losartan/hydrochlorothiazide (Hyzaar) 2
telmisartan (Micardis) 2
telmisartan/hydrochlorothiazid (Micardis HCT) 2
TRIBENZOR 3 ST
valsartan/hydrochlorothiazide (Diovan HCT) 2
Angiotensin-Converting Enzyme Inhibitors
benazepril hcl (Lotensin) 1
benazepril/hydrochlorothiazide (Lotensin HCT) 2
captopril (Capoten) 2
captopril/hydrochlorothiazide (Capozide) 2
enalapril maleate (Vasotec) 1
enalapril/hydrochlorothiazide (Vaseretic) 2
enalaprilat dihydrate (Enalaprilat Dihydrate) 2
fosinopril sodium (Monopril) 2
fosinopril/hydrochlorothiazide (Monopril HCT) 2
lisinopril (Zestril) 1
lisinopril/hydrochlorothiazide (Prinzide) 1
moexipril hcl (Univasc) 2
moexipril/hydrochlorothiazide (Uniretic) 2
perindopril erbumine (Aceon) 2
quinapril hcl (Accupril) 2
quinapril/hydrochlorothiazide (Accuretic) 2
ramipril (Altace) 2
trandolapril (Mavik) 2
Antiarrhythmic Agents
amiodarone hcl tablet (Cordarone) 2
disopyramide phosphate (Norpace) 2
flecainide acetate (Tambocor) 2
lidocaine hcl (Lidocaine HCl) 2
lidocaine hcl/d5w/pf iv soln: 2mg/ml, 8mg/
ml
(Lidocaine HCl/d5w/
PF)
2
lidocaine hcl/pf syringe (Lidocaine HCl/PF) 2
mexiletine hcl (Mexitil) 2
MULTAQ 3
procainamide hcl capsule, tablet sa (Procainamide HCl) 2
procainamide hcl vial (Procainamide HCl) 2
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
document
34
Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
PRONESTYL 4
propafenone hcl (Rythmol) 2
quinidine gluconate tablet er (Quinidine Gluconate) 2
quinidine sulfate (Quinidine Sulfate) 2
TIKOSYN 3
Beta-Adrenergic Blocking Agents
acebutolol hcl (Sectral) 2
atenolol (Tenormin) 1
atenolol/chlorthalidone (Tenoretic 50) 1
betaxolol hcl (Kerlone) 2
bisoprolol fumarate (Zebeta) 2
bisoprolol fumarate/hctz (Ziac) 2
BYSTOLIC 3
carvedilol (Coreg) 1
esmolol hcl (Brevibloc) 2 PA BvD
labetalol hcl (Trandate) 2
metoprolol succinate (Toprol XL) 2
metoprolol tartrate tablet (Lopressor) 1
metoprolol tartrate vial (Metoprolol Tartrate) 2
metoprolol/hydrochlorothiazide (Lopressor HCT) 2
nadolol (Corgard) 2
pindolol (Pindolol) 2
propranolol hcl (Propranolol HCl) 2
propranolol/hydrochlorothiazid (Propranolol/
hydrochlorothiazid)
2
sotalol hcl (Betapace) 2
timolol maleate (Timolol Maleate) 2
Calcium-channel Blocking Agents
diltiazem hcl tablet (Cardizem CD) 1
diltiazem hcl cap er 12h, cap er 24h, cap er
deg, capsule er, tab er 24h, vial, vial port
(Cardizem CD) 2
verapamil hcl tablet (Calan) 1
verapamil hcl cap24h pct, cap24h pel,
tablet er
(Calan) 2
verapamil hcl syringe (Verapamil HCl) 2
Cardiovascular Agents, Miscellaneous
DEMSER 4
digoxin syringe (Digoxin) 2 PA-HRM
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
document
35
Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
digoxin tablet (Lanoxin) 2 PA-HRM, QL: 30 in 30
days (High Risk Med
for Ages 65 and Older
and Dose is Greater
Than 125mcg Per Day)
DIGOXIN 3 PA-HRM, QL: 300 in 30
days (High Risk Med
for Ages 65 and Older
and Dose is Greater
Than 125mcg Per Day)
dobutamine hcl (Dobutamine HCl) 2 PA BvD
dobutamine hcl/d5w (Dobutamine HCl/
D5W)
2 PA BvD
dopamine hcl (Dopamine HCl) 2 PA BvD
dopamine hcl/d5w (Dopamine HCl/D5W) 2 PA BvD
dopamine hcl/dextrose 5%-water (Dopamine HCl/
dextrose 5%-water)
2 PA BvD
ephedrine sulfate (Ephedrine Sulfate) 2
epinephrine auto injct, syringe (Adrenaclick) 2
epinephrine ampul (Epinephrine) 2
EPIPEN 2-PAK 3
EPIPEN JR 2-PAK 3
ethanolamine oleate (Ethanolamine Oleate) 2
FIRAZYR 5
hydralazine hcl (Apresoline) 2
hydralazine/hydrochlorothiazid (Hydralazine/
hydrochlorothiazid)
2
LANOXIN tablet: 62.5mcg, 187.5mcg 4 PA-HRM, QL: 30 in 30
days (High Risk Med
for Ages 65 and Older
and Dose is Greater
Than 125mcg Per Day)
milrinone lactate (Milrinone Lactate) 5 PA BvD
milrinone lactate/d5w (Primacor in 5%
Dextrose)
5 PA BvD
norepinephrine bitartrate (Levophed Bitartrate) 2 PA BvD
papaverine hcl (Papaverine HCl) 2 PA
RANEXA 3
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
document
36
Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
Dihydropyridines
amlodipine besylate (Norvasc) 1
amlodipine besylate/benazepril (Lotrel) 2
AZOR 3 ST
CLEVIPREX 4
felodipine (Plendil) 2
isradipine (Dynacirc) 2
nicardipine hcl capsule (Nicardipine HCl) 2
nifedipine tab er 24, tablet er (Procardia XL) 2
Diuretics
amiloride hcl (Midamor) 2
amiloride/hydrochlorothiazide (Amiloride/
hydrochlorothiazide)
2
bumetanide (Bumex) 2
chlorothiazide sodium (Sodium Diuril) 2
chlorothiazide (Chlorothiazide) 1
chlorthalidone (Chlorthalidone) 1
DYRENIUM 4
furosemide solution, vial (Furosemide) 2
furosemide syringe (Furosemide) 2
furosemide tablet (Lasix) 1
hydrochlorothiazide (Microzide) 1
indapamide (Lozol) 1
methyclothiazide (Methyclothiazide) 2
metolazone (Zaroxolyn) 2
torsemide tablet (Demadex) 2
triamterene/hydrochlorothiazid (Maxzide) 2
Dyslipidemics
amlodipine/atorvastatin (Caduet) 2
atorvastatin calcium (Lipitor) 2
cholestyramine (with sugar) (Questran) 2
cholestyramine/aspartame (Questran Light) 2
colestipol hcl (Colestid) 2
CRESTOR 3
fenofibrate nanocrystallized (Tricor) 2
fenofibrate tablet (Lofibra) 2
fenofibrate,micronized (Antara) 2
fenofibric acid (choline) (Trilipix) 2
fenofibric acid (Fibricor) 2
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
document
37
Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
gemfibrozil (Lopid) 2
lovastatin (Mevacor) 1
niacin tab er 24h, tablet: 500mg (Niaspan) 2
omega-3 acid ethyl esters (Lovaza) 2
pravastatin sodium (Pravachol) 1
simvastatin (Zocor) 1 QL: 30 in 30 days
VASCEPA 3
WELCHOL 3
ZETIA 4
Renin-Angiotensin-Aldosterone System Inhibitors
eplerenone (Inspra) 2
spironolact/hydrochlorothiazid (Aldactazide) 2
spironolactone (Aldactone) 2
Vasodilators
isosorbide dinitrate tablet, tablet er (Isordil) 2
isosorbide dinitrate tab subl (Isosorbide Dinitrate) 1
isosorbide mononitrate (Imdur) 2
minoxidil (Minoxidil) 2
NITRO-BID 3
nitroglycerin patch td24: 0.1mg/hr, 0.2mg/
hr, 0.6mg/hr
(Nitro-dur) 2 QL: 30 in 30 days
nitroglycerin patch td24: 0.4mg/hr (Nitro-dur) 2 QL: 60 in 30 days
nitroglycerin vial: 50mg/10ml (Nitroglycerin) 2
nitroglycerin vial: 5mg/ml (Nitroglycerin) 2
nitroglycerin/d5w (Nitroglycerin/D5W) 2
NITROSTAT 3
PROGLYCEM 4
Central Nervous System Agents Central Nervous System Agents
AMPYRA 5 PA, QL: 60 in 30 days
caffeine citrated (Cafcit) 2
caffeine/sodium benzoate (Caffeine/sodium
Benzoate)
2
clonidine hcl (Kapvay) 2
dexmethylphenidate hcl tablet (Focalin) 2 QL: 60 in 30 days
dextroamphetamine sulfate capsule er (Dexedrine) 2 QL: 120 in 30 days
dextroamphetamine sulfate tablet: 5mg,
10mg
(Dextrostat) 2 QL: 180 in 30 days
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
document
38
Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
dextroamphetamine/amphetamine cap er
24h: 5mg, 10mg, 15mg
(Adderall XR) 2 QL: 30 in 30 days
dextroamphetamine/amphetamine cap er
24h: 20mg, 25mg, 30mg; tablet
(Adderall) 2 QL: 60 in 30 days
flumazenil (Romazicon) 2
INTUNIV 4 QL: 30 in 30 days
lithium carbonate (Eskalith) 2
lithium citrate (Lithium Citrate) 2
methylphenidate hcl cpbp 30-70: 10mg,
20mg, 40mg, 50mg, 60mg; tab er 24:
18mg, 27mg, 54mg
(Concerta) 2 QL: 30 in 30 days
methylphenidate hcl cpbp 30-70: 30mg; tab
er 24: 36mg
(Concerta) 2 QL: 60 in 30 days
methylphenidate hcl solution (Methylin) 2 QL: 900 in 30 days
methylphenidate hcl tablet, tablet er (Ritalin) 2 QL: 90 in 30 days
NUEDEXTA 3 QL: 60 in 30 days
QUILLIVANT XR 3
riluzole (Rilutek) 2
SAVELLA 3 QL: 60 in 30 days
STRATTERA 3
XENAZINE 5 PA, QL: 112 in 28 days
Contraceptives Contraceptives
desog-e.estradiol/e.estradiol (Mircette) 2
desogestrel-ethinyl estradiol (Desogen) 2
ELLA 3
ethinyl estradiol/drospirenone (Yaz) 2
ethynodiol d-ethinyl estradiol (Demulen 1/50-28) 2
levonorgestrel (Plan B) 2
levonorgestrel-ethin estradiol tablet: 0.1-
0.02, 0.15-0.03, 6-5-10
(Nordette-28) 2
levonorgestrel-ethin estradiol tbdspk 3mo (Seasonale) 2 QL: 91 in 84 days
l-norgest-eth estr/ethin estra tbdspk 3mo:
100-20(84)
(Seasonique) 2 QL: 91 in 84 days
l-norgest-eth estr/ethin estra tbdspk 3mo:
150-30(84)
(Seasonique) 2 QL: 91 in 84 days
norelgestromin/ethin.estradiol (Ortho Evra) 2 QL: 3 in 28 days
noreth-ethinyl estradiol/iron (Femcon Fe) 2
norethindrone ac-eth estradiol (Loestrin) 2
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
document
39
Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
norethindrone (Nor-Q-D) 2
norethindrone-e.estradiol-iron (Loestrin Fe) 2
norethindrone-ethinyl estrad tablet: 0.4-
0.035, 0.5-0.035, 1mg-35mcg, 7-9-5,
7daysx3, 10-11
(Modicon) 2
norethindrone-mestranol (Ortho-novum) 2
norgestimate-ethinyl estradiol (Ortho-cyclen) 2
norgestrel-ethinyl estradiol (Ovral-21) 2
NUVARING 3 ST, QL: 1 in 28 days
Dental And Oral Agents Dental And Oral Agents
cevimeline hcl (Evoxac) 2
chlorhexidine gluconate (Peridex) 2
pilocarpine hcl (Salagen) 2
triamcinolone acetonide (Kenalog In Orabase) 2
Dermatological Agents Dermatological Agents, Other
8-MOP 4
acitretin (Soriatane) 5
acyclovir (Zovirax) 2 QL: 30 in 30 days
alcohol antiseptic pads (Alcohol Antiseptic
Pads)
1
aluminum chloride (Drysol) 2
ammonium lactate (Lac-hydrin) 2
ANACAINE 4
calcipotriene (Dovonex) 2
calcitriol (Vectical) 2
CONDYLOX gel (gram) 4
FLUOROPLEX 4
fluorouracil (Efudex) 2
imiquimod (Aldara) 2 PA NSO, QL: 24 in 30
days
isotretinoin capsule: 10mg, 20mg, 40mg (Accutane) 2
mafenide acetate (Sulfamylon) 2
methoxsalen, rapid (Oxsoralen-ultra) 5
PANRETIN 5
PICATO gel (ea): 0.05% 3 QL: 2 in 56 days
PICATO gel (ea): 0.015% 3 QL: 3 in 56 days
podofilox (Condylox) 2
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
document
40
Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
podophyllum resin (Pododerm) 2
potassium hydroxide (Potassium Hydroxide) 2
SANTYL 4
silver nitrate applicator (Silver Nitrate
Applicator)
2
VALCHLOR 5
ZOVIRAX cream (g) 3 QL: 15 in 30 days
Dermatological Antibacterials
clindamycin phosphate gel (gram), lotion,
med. swab, solution
(Cleocin T) 2
erythromycin base/ethanol (A-T-S) 2
gentamicin sulfate (Gentamicin Sulfate) 2
metronidazole (Nydamax) 2
mupirocin calcium (Bactroban) 2
mupirocin (Centany) 2
neomy sulf/polymyxin b sulfate (Neosporin G.U.
Irrigant)
2
selenium sulfide suspension (Selenium Sulfide) 2
selenium sulfide shampoo (Selseb) 2
silver nitrate (Silver Nitrate) 2
silver sulfadiazine (Silvadene) 2
sulfacetamide sodium (Klaron) 2
Dermatological Anti-inflammatory Agents
alclometasone dipropionate (Aclovate) 2
betamethasone dipropionate (Del-beta) 2
betamethasone valerate (Betamethasone
Valerate)
2
betamethasone/propylene glyc (Diprolene AF) 2
clobetasol propionate (Temovate) 2
clocortolone pivalate (Cloderm) 2
CORDRAN oint. (g) 4
desonide cream (g), oint. (g) (Desowen) 2
desoximetasone (Topicort) 2
ELIDEL 3 PA (PA for Ages < 2)
fluocinonide cream (g): 0.05%; gel (gram),
oint. (g), solution
(Vanos) 2
fluticasone propionate cream (g), oint. (g) (Cutivate) 2
halobetasol propionate (Ultravate) 2
hydrocortisone acetate/aloe v (Nuzon) 2
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
document
41
Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
hydrocortisone acetate/urea (Carmol HC) 2
hydrocortisone butyrate (Hydrocortisone
Butyrate)
2
hydrocortisone valerate (Hydrocortisone
Valerate)
2
hydrocortisone cream(gm) (Hydrocortisone) 2
hydrocortisone cream (g), cream/appl,
enema, lotion, oint. (g)
(Hytone) 2
mometasone furoate (Elocon) 2
prednicarbate (Dermatop) 2
PROTOPIC 4 PA (0.03%; PA for
Ages < 2)
PROTOPIC 4 PA (0.1%; PA for Ages
< 15)
triamcinolone acetonide cream (g), lotion,
oint. (g): 0.025%, 0.1%, 0.5%
(Triamcinolone
Acetonide)
2
triamcinolone acetonide oint. (g): 0.05% (Triderm) 2
Dermatological Retinoids
adapalene cream (g), gel (gram) (Differin) 2
TAZORAC cream (g) 4
tretinoin microspheres (Retin-a Micro) 2 PA
tretinoin cream (g): 0.025%, 0.05%, 0.1%;
gel (gram): 0.01%, 0.025%
(Retin-A) 2 PA
Scabicides and Pediculicides
malathion (Ovide) 2
permethrin (Elimite) 2
Devices Devices
needles, insulin disposable (Needles, Insulin
Disposable)
2
syring w-ndl,disp,insul,0.3ml (Syring W-
ndl,disp,insul,0.3ml)
2
syring w-ndl,disp,insul,0.5ml (Syring W-
ndl,disp,insul,0.5ml)
2
syringe & needle,insulin,1 ml (Syringe &
Needle,insulin,1 Ml)
2
Enzyme Replacement/modifiers Enzyme Replacement/modifiers
ADAGEN 5
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
document
42
Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
ALDURAZYME 5
CEREZYME 5
CIMZIA 5 PA
CREON 3
ELAPRASE 5
ELITEK 5
FABRAZYME 5
KRYSTEXXA 5
KUVAN 5
LINZESS 3 QL: 30 in 30 days
lipase/protease/amylase (Zenpep) 2
LOTRONEX 5
LUMIZYME 5
MYOZYME 5
NAGLAZYME 5
ORFADIN 5
PULMOZYME 5 PA BvD
VIMIZIM 5 PA
VPRIV 5
ZAVESCA 5 QL: 90 in 30 days
ZENPEP 3
Eye, Ear, Nose, Throat Agents Eye, Ear, Nose, Throat Agents, Miscellaneous
AKTEN 4
apraclonidine hcl (Iopidine) 2
atropine sulfate (Isopto Atropine) 2
azelastine hcl spray/pump (Astelin) 2 QL: 30 in 25 days
azelastine hcl drops (Optivar) 2
carteolol hcl (Carteolol HCl) 2
cromolyn sodium (Cromolyn Sodium) 2
CYCLOGYL drops: 0.5% 3
cyclopentolate hcl (Cyclogyl) 2
CYSTARAN 5
epinastine hcl (Elestat) 2
homatropine hbr (Isopto Homatropine) 2
ipratropium bromide spray: 42mcg (Atrovent) 2 QL: 15 in 10 days
ipratropium bromide spray: 21mcg (Atrovent) 2 QL: 30 in 28 days
LACRISERT 3
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
document
43
Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
naphazoline hcl/antazoline (Naphazoline HCl/
antazoline)
2
PATADAY 3 ST
PATANOL 3 ST
phenylephrine hcl (Mydfrin) 2
proparacaine hcl (Ophthetic) 2
proparacaine/fluorescein sod (Proparacaine/
fluorescein Sod)
2
tetracaine hcl (Tetcaine) 2
Eye, Ear, Nose, Throat Anti-infectives Agents
acetic acid (Vosol) 2
bacitracin (Bacitracin) 2
bacitracin/polymyxin b sulfate (Polycin-b) 2
CIPRODEX 4
ciprofloxacin hcl droperette (Cetraxal) 2
ciprofloxacin hcl drops (Ciloxan) 2
COLY-MYCIN S 4
erythromycin base (Ilotycin) 2
gatifloxacin (Zymaxid) 2
gentamicin sulfate (Garamycin) 2
levofloxacin (Quixin) 2
MOXEZA 3
NATACYN 3
neo/polymyx b sulf/dexameth (Maxitrol) 2
neomy sulf/bacitra/polymyxin b (Neo-polycin) 2
neomy sulf/bacitrac zn/poly/hc (Triple Antibiotic HC) 2
neomycin sulfate/dex na ph (Neomycin Sulfate/dex
Na Ph)
2
neomycin/polymyxin b sulf/hc (Oticin HC) 2
neomycin/polymyxn b/gramicidin (Neosporin) 2
ofloxacin (Floxin) 2
polymyxin b sulf/trimethoprim (Polytrim) 2
sulfacetamide sodium (Sulfac) 2
sulfacetamide/prednisolone sp (Sulfacetamide/
prednisolone Sp)
2
TOBRADEX ST 3
tobramycin sulfate (Tobramycin Sulfate) 2
trifluridine (Viroptic) 2
VIGAMOX 3
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
document
44
Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
ZYLET 3
Eye, Ear, Nose, Throat Anti-inflammatory Agents
ALREX 3
bromfenac sodium (Bromfenac Sodium) 2
dexamethasone sod phosphate (Ak-dex) 2
diclofenac sodium (Voltaren) 2
DUREZOL 3
fluorometholone (FML) 2
flurbiprofen sodium (Ocufen) 2
fluticasone propionate (Flonase) 2 QL: 16 in 30 days
ILEVRO 3
ketorolac tromethamine (Acular) 2
LOTEMAX 3
NASONEX 4 QL: 34 in 28 days
NEVANAC 3
prednisolone sod phosphate (Prednisol) 2
PROLENSA 3
RESTASIS 3 QL: 60 in 30 days
Gastrointestinal Agents Antiulcer Agents And Acid Suppressants
CARAFATE oral susp 3
cimetidine hcl (Cimetidine HCl) 2
cimetidine (Tagamet) 2 (Rx Product Only)
esomeprazole sodium (Nexium I.v.) 2
famotidine in nacl,iso-osm/pf (Famotidine In
Nacl,iso-osm/PF)
2
famotidine tablet (Pepcid) 1 (Rx Product Only)
famotidine tablet (Pepcid) 1
famotidine/pf (Famotidine/PF) 2
lansoprazole (Prevacid) 2 (Rx Product Only)
lansoprazole/amoxiciln/clarith (Prevpac) 2
misoprostol (Cytotec) 2
omeprazole (Prilosec) 2
pantoprazole sodium (Protonix) 2
ranitidine hcl tablet (Zantac) 1 (Rx Product Only)
ranitidine hcl syrup, vial (Zantac) 2 (Rx Product Only)
ranitidine hcl syrup, vial (Zantac) 2
sucralfate tablet (Carafate) 2
sucralfate oral susp (Sucralfate) 2
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
document
45
Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
Gastrointestinal Agents, Other
AMITIZA 3 QL: 60 in 30 days
BUPHENYL tablet 5
cromolyn sodium (Gastrocrom) 5
dicyclomine hcl (Bentyl) 2
diphenoxylate hcl/atropine (Lomotil) 2
glycopyrrolate (Robinul) 2
isopropamide/prochlorperazine (Isopropamide/
prochlorperazine)
2
lactulose solution: 10; syrup (Lactulose) 2
lactulose solution: 10g/15ml (Lactulose) 2
loperamide hcl (Loperamide HCl) 2
methscopolamine bromide (Pamine) 2
metoclopramide hcl solution, vial (Metoclopramide HCl) 2
metoclopramide hcl syringe (Metoclopramide HCl) 2
metoclopramide hcl tablet (Reglan) 1
NUTRESTORE 4
RELISTOR syringe: 12mg/0.6ml 4 PA, QL: 28 in 28 days
RELISTOR syringe: 8mg/0.4ml 4 PA, QL: 28 in 28 days
ursodiol (Actigall) 2
Laxatives
MOVIPREP 3
peg 3350/na sulf,bicarb,cl/kcl (Golytely) 2
polyethylene glycol 3350 (Miralax) 2
sodium chloride/nahco3/kcl/peg (Nulytely with Flavor
Packs)
2
Phosphate Binders
calcium acetate (Phoslo) 2
calcium carbonate/mag carb/fa (Calcium Carbonate/
mag Carb/fa)
2
PHOSLYRA 4
RENAGEL 3
RENVELA 3
sodium polystyrene sulfonate oral susp (Sodium Polystyrene
Sulfonate)
2
sodium polystyrene sulfonate enema (Sps) 2
Genitourinary Agents Antispasmodics, Urinary
oxybutynin chloride tab er 24, tablet (Ditropan) 2
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
document
46
Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
tolterodine tartrate (Detrol LA) 2
TOVIAZ 3
trospium chloride (Sanctura) 2
Genitourinary Agents, Miscellaneous
alfuzosin hcl (Uroxatral) 2
tamsulosin hcl (Flomax) 2
terazosin hcl (Hytrin) 1
Heavy Metal Antagonists Heavy Metal Antagonists
deferoxamine mesylate (Desferal) 2 PA BvD
DEPEN 4
edetate disodium (Edetate Disodium) 2
EXJADE tab disper: 125mg 4
EXJADE tab disper: 250mg, 500mg 5
FERRIPROX 5
sodium thiosulfate (Sodium Thiosulfate) 2
SYPRINE 5
Hormonal Agents, Stimulant/replacement/modifying Androgens
ANDRODERM 3 PA, QL: 30 in 30 days
ANDROGEL gel md pmp: 20.25/1.25 3 PA, QL: 150 in 30 days
ANDROGEL gel md pmp: 1.25g(1%) 3 PA, QL: 300 in 30 days
danazol (Danocrine) 2
fluoxymesterone (Fluoxymesterone) 2
oxandrolone (Oxandrin) 2
testosterone cypionate (Depo-testosterone) 2 PA
testosterone enanthate (Delatestryl) 2 PA, QL: 5 in 28 days
Estrogens and Antiestrogens
COMBIPATCH 3 PA-HRM, QL: 8 in 28
days
DUAVEE 3 PA-HRM
ESTRACE cream/appl 3
estradiol valerate vial: 10mg/ml (Delestrogen) 2
estradiol valerate vial: 20mg/ml, 40mg/ml (Delestrogen) 2
estradiol patch tdwk (Climara) 2 PA-HRM, QL: 4 in 28
days
estradiol tablet (Estrace) 2 PA-HRM
estradiol/norethindrone acet (Activella) 2 PA-HRM
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
document
47
Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
ESTRASORB 4 PA-HRM, QL: 97.44 in
28 days
estropipate (Ogen) 2 PA-HRM
FEMRING 4 QL: 1 in 84 days
MENEST 4 PA-HRM
norethindrone ac-eth estradiol (Femhrt) 2 PA-HRM
PREMARIN cream/appl, vial 3
PREMARIN tablet 3 PA-HRM
PREMPHASE 3 PA-HRM
PREMPRO 3 PA-HRM
raloxifene hcl (Evista) 2
VAGIFEM 3 QL: 18 in 28 days
VIVELLE-DOT 3 PA-HRM, QL: 8 in 28
days
Glucocorticoids/mineralocorticoids
A-HYDROCORT 4 PA BvD
betamet acet/betamet na ph (Celestone) 2 PA BvD
cortisone acetate (Cortisone Acetate) 2 PA BvD
dexamethasone acetate (Dexamethasone
Acetate)
2 PA BvD
dexamethasone sod phosphate (Dexamethasone Sod
Phosphate)
2 PA BvD
dexamethasone tablet (Dexamethasone) 1 PA BvD
dexamethasone elixir (Dexamethasone) 2 PA BvD
fludrocortisone acetate (Fludrocortisone
Acetate)
2
hydrocortisone sod succinate (Hydrocortisone Sod
Succinate)
2 PA BvD
hydrocortisone (Cortef) 2 PA BvD
methylprednisolone acetate (Depo-medrol) 2 PA BvD
methylprednisolone sod succ vial: 40mg,
125mg
(A-methapred) 2 PA BvD
methylprednisolone sod succ vial: 500mg,
1000mg
(A-methapred) 2 PA BvD
methylprednisolone (Medrol) 2 PA BvD
prednisolone acetate (Prednisolone Acetate) 2 PA BvD
prednisolone sod phosphate (Orapred) 2 PA BvD
prednisone tablet (Prednisone) 1 PA BvD
prednisone solution (Prednisone) 2 PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
document
48
Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
prednisone tab ds pk (Sterapred Ds) 2 PA BvD
SOLU-CORTEF vial: 100mg/2ml 4 PA BvD
triamcinolone acetonide (Triamcinolone
Acetonide)
2
Pituitary
desmopressin acetate tablet, vial (DDAVP) 2
desmopressin acetate solution (Desmopressin Acetate) 2 QL: 15 in 30 days
desmopressin acetate spray/pump (Desmopressin Acetate) 2 QL: 15 in 30 days
GENOTROPIN syringe: 0.2mg/0.25 4 PA
GENOTROPIN various dosage and/or
strengths are available
5 PA
HUMATROPE 5 PA
INCRELEX 5
NORDITROPIN FLEXPRO 5 PA
NORDITROPIN NORDIFLEX 5 PA
NUTROPIN AQ NUSPIN 5 PA
NUTROPIN 5 PA
octreotide acetate syringe, vial: 100mcg/
ml, 200mcg/ml
(Sandostatin) 2
octreotide acetate vial: 1000mcg/ml (Sandostatin) 5
OMNITROPE cartridge: 10mg/1.5ml 4 PA
OMNITROPE cartridge: 5mg/1.5ml; vial 5 PA
PREGNYL 4
SAIZEN cartridge, vial: 5mg 5 PA
SAIZEN vial: 8.8mg 5 PA
SANDOSTATIN LAR 5
SEROSTIM 5 PA
SOMATULINE DEPOT 5 QL: 1 in 28 days
SOMAVERT 5
SUPPRELIN LA 5 QL: 1 in 360 days
TEV-TROPIN 4 PA
vasopressin (Pitressin) 2
Progestins
DEPO-PROVERA vial: 400mg/ml 4 QL: 10 in 28 days
medroxyprogesterone acet (Medroxyprogesterone
Acet)
2
medroxyprogesterone acetate syringe (Depo-provera) 2 QL: 1 in 84 days
medroxyprogesterone acetate vial (Depo-provera) 2 QL: 1 in 84 days
medroxyprogesterone acetate tablet (Provera) 2
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
document
49
Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
norethindrone acetate (Aygestin) 2
progesterone (Progesterone) 2
progesterone,micronized (Prometrium) 2
Thyroid and Antithyroid Agents
levothyroxine sodium vial: 100mcg (Levothyroxine
Sodium)
2
levothyroxine sodium vial: 200mcg (Levothyroxine
Sodium)
2
levothyroxine sodium tablet (Levoxyl) 1
liothyronine sodium tablet (Cytomel) 2
methimazole tablet: 20mg (Tapazole) 2
methimazole tablet: 5mg, 10mg (Tapazole) 2
propylthiouracil (Propylthiouracil) 2
Immunological Agents Immunological Agents
ARCALYST 5
ASTAGRAF XL 4 PA BvD
AUBAGIO 5 PA, QL: 28 in 28 days
azathioprine sodium (Azathioprine Sodium) 2 PA BvD
azathioprine (Imuran) 2 PA BvD
CARIMUNE NF NANOFILTERED 5 PA BvD
CELLCEPT vial 4 PA BvD
CELLCEPT susp recon 5 PA BvD
cyclosporine (Sandimmune) 2 PA BvD
cyclosporine, modified (Neoral) 2 PA BvD
ENBREL pen injctr 5 PA, QL: 3.92 in 28 days
ENBREL vial 5 PA, QL: 8 in 28 days
ENBREL syringe 5 PA, QL: 8.16 in 28 days
FLEBOGAMMA DIF 5 PA BvD
GAMASTAN S-D 3 PA BvD
GAMMAGARD LIQUID 5 PA BvD
GAMMAPLEX 5 PA BvD
GAMUNEX-C 5 PA BvD
HUMIRA kit 5 PA, QL: 2 in 28 days
HUMIRA pen ij kit: 40mg/0.8ml 5 PA, QL: 6 in 28 days
(Starter Kit)
HUMIRA pen ij kit: 40mg/0.8ml 5 PA
HYPERRAB S-D 4
ILARIS 5 PA
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
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50
Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
IMOGAM RABIES-HT 4
KINERET 5 PA, QL: 18.76 in 28
days
leflunomide (Arava) 2
mycophenolate mofetil (Cellcept) 2 PA BvD
mycophenolate sodium (Myfortic) 2 PA BvD
NULOJIX 5 PA BvD
OCTAGAM 5 PA BvD
ORENCIA syringe 5 PA, QL: 4 in 28 days
ORENCIA vial 5 PA
PRIVIGEN 5 PA BvD
PROGRAF ampul 4 PA BvD
RAPAMUNE solution, tablet: 1mg, 2mg 5 PA BvD
RIDAURA 5
sirolimus (Rapamune) 2 PA BvD
tacrolimus (Hecoria) 2 PA BvD
TYSABRI 5 LA, PA, QL: 15 in 28
days
ZORTRESS tablet: 0.25mg 4 PA BvD, QL: 120 in 30
days
ZORTRESS tablet: 0.5mg, 0.75mg 5 PA BvD, QL: 120 in 30
days
Vaccines
ACTHIB 3
ADACEL TDAP syringe 3
ADACEL TDAP vial 3
BCG VACCINE (TICE STRAIN) 3 PA BvD
BOOSTRIX TDAP 3
CERVARIX 3
COMVAX 3
DAPTACEL DTAP 3
DIPHTHERIA-TETANUS TOXOIDS-
PED
3
ENGERIX-B ADULT 3 PA BvD
ENGERIX-B PEDIATRIC-
ADOLESCENT
3 PA BvD
GARDASIL syringe 3
GARDASIL vial 3
HAVRIX syringe: 1440/ml 3 PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
document
51
Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
HAVRIX syringe: 720/0.5ml 3 PA BvD
HAVRIX vial 3 PA BvD
IMOVAX RABIES VACCINE 3 PA BvD
INFANRIX DTAP 3
IPOL 3
IXIARO 3
KINRIX 3
MENACTRA 3
MENHIBRIX 3
MENOMUNE-A-C-Y-W-135 3
MENVEO A-C-Y-W-135-DIP 3
M-M-R II VACCINE 3
PEDIARIX 3
PEDVAXHIB 3
PENTACEL ACTHIB COMPONENT 3
PENTACEL DTAP-IPV COMPONENT 3
PENTACEL 3
PROQUAD 3
RABAVERT 3 PA BvD
RECOMBIVAX HB syringe, vial: 5mcg/
0.5ml
3 PA BvD
RECOMBIVAX HB vial: 10mcg/ml,
40mcg/ml
3 PA BvD
ROTARIX 3
ROTATEQ 3
TE ANATOXAL BERNA 3 PA BvD
TENIVAC 3
TETANUS DIPHTHERIA TOXOIDS 3
TETANUS TOXOID ADSORBED 3 PA BvD
TWINRIX syringe 3
TWINRIX vial 3
TYPHIM VI 3
VAQTA syringe, vial: 25/0.5ml 3 PA BvD
VAQTA vial: 50unit/ml 3 PA BvD
VARIVAX VACCINE 3
YF-VAX 3
ZOSTAVAX 3 QL: 1 in 365 days
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
document
52
Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
Inflammatory Bowel Disease Agents Inflammatory Bowel Disease Agents
APRISO 3
ASACOL HD 3 ST
balsalazide disodium (Colazal) 2
budesonide (Entocort EC) 5
DELZICOL 3 ST
DIPENTUM 4 ST
Irrigating Solutions Irrigating Solutions
acetic acid (Acetic Acid) 2
glycine (Glycine) 2
LACTATED RINGERS 3
mannitol/sorbitol solution (Mannitol/sorbitol
Solution)
2
ringers solution (Tis-u-sol) 2
sodium chloride irrig solution (Sodium Chloride Irrig
Solution)
2
sorbitol solution (Sorbitol Solution) 2
UROLOGIC SOLUTION G 3
water for irrigation,sterile (Water for Irrigation,
Sterile)
2
Metabolic Bone Disease Agents Metabolic Bone Disease Agents
alendronate sodium tablet: 5mg, 10mg,
40mg
(Fosamax) 1
alendronate sodium tablet: 35mg, 70mg (Fosamax) 1 QL: 4 in 28 days
alendronate sodium solution (Fosamax) 2 QL: 300 in 28 days
calcitonin,salmon,synthetic (Miacalcin) 2 QL: 3.7 in 28 days
calcitriol (Rocaltrol) 2 PA BvD (PA for ESRD
Only)
doxercalciferol (Hectorol) 2 PA BvD (PA for ESRD
Only)
etidronate disodium (Didronel) 2
FORTEO 4 PA, QL: 2.4 in 28 days
FORTICAL 4 QL: 3.7 in 28 days
ibandronate sodium tablet (Boniva) 2 QL: 1 in 28 days
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
document
53
Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
ibandronate sodium vial (Ibandronate Sodium) 2 PA BvD, QL: 3 in 84
days (PA for ESRD
Only)
MIACALCIN vial 3 PA BvD (PA for ESRD
Only)
paricalcitol (Zemplar) 2 PA BvD (PA for ESRD
Only)
PROLIA 3 QL: 1 in 180 days
risedronate sodium (Actonel) 2 QL: 1 in 28 days
XGEVA 5 PA, QL: 1.7 in 28 days
ZEMPLAR vial 3 PA BvD (PA for ESRD
Only)
zoledronic acid (Zometa) 2
zoledronic acid/mannitol&water infus. btl (Reclast) 2 QL: 100 in 300 days
zoledronic acid/mannitol&water piggyback (Zoledronic Acid/
mannitol&water)
2
ZOMETA infus. btl 5
Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents
ACTEMRA syringe 5 PA, QL: 3.6 in 28 days
ACTEMRA vial 5 PA, QL: 40 in 30 days
ACTIMMUNE 5
allopurinol (Zyloprim) 1
amifostine crystalline (Ethyol) 2
AVODART 3
AVONEX ADMINISTRATION PACK 5 ST
AVONEX 5 ST
BENLYSTA 5 PA
BETASERON 5 ST
bethanechol chloride (Urecholine) 2
BOTOX vial: 200unit 4 PA, QL: 1 in 90 days
BOTOX vial: 100unit 4 PA, QL: 4 in 90 days
buspirone hcl (Buspar) 2
citrate phosphate dextros soln (Citrate Phosphate
Dextros Soln)
2
colchicine/probenecid (Colchicine/
probenecid)
2
COLCRYS 3
COPAXONE 5
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
document
54
Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
CYSTADANE 5
droperidol (Inapsine) 2
ELMIRON 4
ergoloid mesylates tablet (Ergoloid Mesylates) 2
EXTAVIA 5 ST
finasteride (Proscar) 2
fomepizole (Antizol) 5
FUSILEV 5
gauze bandage (Dermacea) 1
GILENYA 5 PA, QL: 28 in 28 days
GLUCAGEN 3
GLUCAGON EMERGENCY KIT 4
glutethimide (Glutethimide) 2
guanidine hcl (Guanidine HCl) 2
hydroxyzine hcl (Hydroxyzine HCl) 2 PA-HRM
hydroxyzine pamoate (Vistaril) 2 PA-HRM
JALYN 3 QL: 30 in 30 days
leucovorin calcium (Leucovorin Calcium) 2
levocarnitine (with sugar) (Carnitor) 2 PA BvD (PA for ESRD
Only)
levocarnitine tablet (Carnitor) 2 PA BvD (PA for ESRD
Only)
mesna (Mesnex) 2
MESNEX tablet 5
MESTINON syrup, tablet er 4
OTEZLA 5 PA, QL: 60 in 30 days
probenecid (Probenecid) 2
PROCYSBI 5
pyridostigmine bromide (Mestinon) 2
REBIF REBIDOSE 5
REBIF 5
REMICADE 5 PA
SENSIPAR tablet: 30mg 3
SENSIPAR tablet: 60mg, 90mg 5
SIMPONI ARIA 5 PA, QL: 12 in 28 days
SIMPONI pen injctr: 50mg/0.5ml 5 PA, QL: 0.5 in 28 days
SIMPONI pen injctr: 100mg/ml 5 PA, QL: 1 in 28 days
sodium morrhuate (Sodium Morrhuate) 2
SOLIRIS 5
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
document
55
Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
STELARA syringe: 45mg/0.5ml 5 PA, QL: 10 in 360 days
STELARA syringe: 90mg/ml 5 PA, QL: 5 in 360 days
SYNAREL 5
TECFIDERA capsule dr: 120mg 5 PA, QL: 14 in 30 days
TECFIDERA capsule dr: 120-240mg,
240mg
5 PA, QL: 60 in 30 days
THALOMID 5 PA NSO, QL: 60 in 30
days
ULORIC 3 ST, QL: 30 in 30 days
XELJANZ 5 PA, QL: 60 in 30 days
Ophthalmic Agents Antiglaucoma Agents
acetazolamide sodium (Acetazolamide
Sodium)
2
acetazolamide (Acetazolamide) 2
ALPHAGAN P drops: 0.1% 3
AZOPT 3
betaxolol hcl (Betaxolol HCl) 2
brimonidine tartrate (Alphagan P) 2 (drops: 0.15%, 0.20%)
COMBIGAN 3
dorzolamide hcl (Trusopt) 2
dorzolamide hcl/timolol maleat (Cosopt) 2
ISOPTO CARPINE drops: 8% 3
latanoprost (Xalatan) 2
levobunolol hcl drops: 0.25% (Betagan) 2
levobunolol hcl drops: 0.5% (Betagan) 2
LUMIGAN 3 QL: 2.5 in 25 days
methazolamide (Neptazane) 2
metipranolol (Optipranolol) 2
PHOSPHOLINE IODIDE 3
pilocarpine hcl (Isopto Carpine) 2
SIMBRINZA 3
timolol maleate (Timoptic) 2
TRAVATAN Z 3 QL: 2.5 in 25 days
travoprost (benzalkonium) (Travatan) 2 QL: 2.5 in 25 days
Replacement Preparations Replacement Preparations
0.9 % sodium chloride (0.9 % Sodium
Chloride)
2
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
document
56
Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
calcium chloride (Calcium Chloride) 2
calcium gluconate (Calcium Gluconate) 2 PA BvD (PA for ESRD
Only)
citric acid/sodium citrate (Bicitra) 2
dex 2.5%-half str lact.ringers (Dex 2.5%-half Str
Lact.ringers)
2
DEXTROSE W/ELECTROLYTE A 4
DEXTROSE W/ELECTROLYTE B 4
electrolyte-48 solution/d5w (Electrolyte-48
Solution/D5W)
2
electrolyte-48/fructose 10% (Electrolyte-48/fructose
10%)
2
electrolyte-48/fructose 5% (Electrolyte-48/fructose
5%)
2
electrolyte-75 solution/d5w (Electrolyte-75
Solution/D5W)
2
electrolyte-75/fructose 5% (Electrolyte-75/fructose
5%)
2
HYPERLYTE CR 4
HYPERLYTE R 4
IONOSOL B with DEXTROSE 5% 4
IONOSOL MB-DEXTROSE 5% 4
IONOSOL T-DEXTROSE 5% 4
ISOLYTE E 4
ISOLYTE H W/DEXTROSE 4
ISOLYTE M W/DEXTROSE 4
ISOLYTE P with DEXTROSE 4
ISOLYTE S with DEXTROSE 4
ISOLYTE S 4
magnesium chloride (Magnesium Chloride) 2
magnesium sulfate piggyback, vial (Magnesium Sulfate) 2
magnesium sulfate syringe (Magnesium Sulfate) 2
magnesium sulfate/d5w (Magnesium Sulfate/
D5W)
2
NORMOSOL-M and DEXTROSE 4
NORMOSOL-R PH 7.4 4
NUTRILYTE II 4
NUTRILYTE 4
phosphorus #1 (K-phos Neutral) 2
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
document
57
Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
PLASMA-LYTE 148 4
PLASMA-LYTE 56 IN DEXTROSE 4
PLASMA-LYTE A PH 7.4 4
PLASMA-LYTE M IN DEXTROSE 4
pot chloride/pot bicarb/cit ac (Pot Chloride/pot
Bicarb/cit Ac)
2
potassium acetate (Potassium Acetate) 2
potassium bicarbonate/cit ac (Potassium
Bicarbonate/cit Ac)
2
potassium chlorid/d10-0.2%nacl (Potassium Chlorid/
d10-0.2%NaCl)
2
potassium chloride in 0.9%nacl (Potassium Chloride In
0.9%NaCl)
2
potassium chloride in d5w iv soln: 10meq/l,
30meq/l
(Potassium Chloride In
D5w)
2
potassium chloride in d5w iv soln: 20meq/l,
40meq/l
(Potassium Chloride In
D5w)
2
potassium chloride liquid, packet,
piggyback: 30meq/0.1l; tablet sa
(Kaochlor) 2
potassium chloride capsule er, piggyback:
10meq/0.1l, 10meq/50ml, 20meq/50ml; tab
er prt, tablet er, vial
(K-dur) 2
potassium chloride/d5-0.2%nacl iv soln:
10meq/l, 30meq/l, 40meq/l
(Potassium Chloride/
d5-0.2%NaCl)
2
potassium chloride/d5-0.2%nacl iv soln:
20meq/l
(Potassium Chloride/
d5-0.2%NaCl)
2
potassium chloride/d5-0.25ns (Potassium Chloride/
D5-0.25 NS)
2
potassium chloride/d5-0.3%nacl (Potassium Chloride/
d5-0.3%NaCl)
2
potassium chloride/d5-0.45nacl (Potassium Chloride/
d5-0.45NaCl)
2
potassium chloride/d5-0.9%nacl (Potassium Chloride/
d5-0.9%NaCl)
2
potassium chloride-0.45% nacl (Potassium Chloride-
0.45% NaCl)
2
potassium citrate/citric acid (Polycitra-k) 2
potassium gluconate (Potassium Gluconate) 2
potassium phos,m-basic-d-basic (Potassium Phos,m-
basic-d-basic)
2
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
document
58
Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
ringers solution (Ringers Solution) 2
sod/pot/k cit/sod cit/cit acid (Polycitra-lc) 2
sodium acetate (Sodium Acetate) 2
sodium bicarbonate (Sodium Bicarbonate) 2
sodium chloride 0.45 % (Sodium Chloride 0.45
%)
2
sodium chloride 3% (Sodium Chloride 3%) 2
sodium chloride 5 % (Sodium Chloride 5 %) 2
sodium chloride vial: 2.5meq/ml (Sodium Chloride) 2
sodium chloride vial: 4meq/ml (Sodium Chloride) 2
sodium lactate iv soln (Sodium Lactate) 2
sodium lactate vial (Sodium Lactate) 2
sodium phos,m-basic-d-basic (Sodium Phos,m-basic-
d-basic)
2
TPN ELECTROLYTES II 4
TRAVERT-ELECTROLYTE NO.1 4
TRAVERT-ELECTROLYTE NO.2 iv
soln: 10%
4
TRAVERT-ELECTROLYTE NO.2 iv
soln: 5%
4
TRAVERT-ELECTROLYTE NO.3 4
TRAVERT-ELECTROLYTE NO.4 4
Respiratory Tract Agents Anti-inflammatories, Inhaled Corticosteroids
ADVAIR DISKUS 3 QL: 60 in 30 days
ADVAIR HFA 3 QL: 12 in 28 days
DULERA 3 QL: 13 in 28 days
FLOVENT DISKUS blst w/dev: 250mcg 3 QL: 120 in 30 days
FLOVENT DISKUS blst w/dev: 50mcg,
100mcg
3 QL: 60 in 30 days
FLOVENT HFA aer w/adap: 110mcg 3 QL: 12 in 28 days
FLOVENT HFA aer w/adap: 44mcg 3 QL: 21.2 in 28 days
FLOVENT HFA aer w/adap: 220mcg 3 QL: 24 in 28 days
QVAR 3 QL: 17.4 in 25 days
Antileukotrienes
montelukast sodium (Singulair) 2
zafirlukast (Accolate) 2
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
document
59
Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
Bronchodilators
albuterol sulfate solution, vial-neb:
0.63mg/3ml, 1.25mg/3ml, 2.5mg/3ml
(Accuneb) 2 PA BvD
albuterol sulfate syrup, tab er 12h, tablet (Albuterol Sulfate) 2
ANORO ELLIPTA 3 QL: 60 in 30 days
ATROVENT HFA 3 QL: 25.8 in 28 days
COMBIVENT RESPIMAT 3 QL: 8 in 30 days
metaproterenol sulfate (Metaproterenol
Sulfate)
2
PROAIR HFA 3 QL: 17 in 25 days
SEREVENT DISKUS 3 QL: 60 in 30 days
SPIRIVA 3 QL: 30 in 30 days
terbutaline sulfate (Brethine) 2
theophylline anhydrous solution, tab er
12h, tablet er
(Theochron) 2
theophylline/d5w (Theophylline/D5W) 2
TUDORZA PRESSAIR 3 QL: 1 in 28 days
Respiratory Tract Agents, Other
acetylcysteine (Acetadote) 2 PA BvD
ARALAST NP 5
cromolyn sodium (Intal) 2 PA BvD
DALIRESP 3 QL: 30 in 30 days
KALYDECO 5 PA, QL: 60 in 30 days
XOLAIR 5 PA, QL: 6 in 28 days
ZEMAIRA 5
Skeletal Muscle Relaxants Skeletal Muscle Relaxants
baclofen (Baclofen) 2
carisoprodol tablet: 250mg (Soma) 2 PA-HRM, QL: 120 in 30
days
carisoprodol tablet: 350mg (Soma) 2 PA-HRM, QL: 120 in 30
days
chlorzoxazone (Parafon Forte DSC) 2 PA-HRM
chlorzoxazone/acetaminophen (Chlorzoxazone/
acetaminophen)
2 PA-HRM
cyclobenzaprine hcl tablet: 5mg, 10mg (Fexmid) 2 PA-HRM
dantrolene sodium capsule (Dantrium) 2
dantrolene sodium vial (Dantrium) 2
metaxalone (Skelaxin) 2 PA-HRM
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
document
60
Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
methocarbamol (Robaxin) 2 PA-HRM
tizanidine hcl (Zanaflex) 2
Sleep Disorder Agents Sleep Disorder Agents
NUVIGIL tablet: 200mg 3 PA
NUVIGIL tablet: 50mg, 150mg, 250mg 3 PA
ROZEREM 3
XYREM 5 LA
zaleplon (Sonata) 2 PA-HRM, QL: 60 in 30
days (High Risk Med.
QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use with any
non-benzodiazepine
hypnotic drug)
zolpidem tartrate (Ambien) 2 PA-HRM, QL: 30 in 30
days (High Risk Med.
QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use with any
non-benzodiazepine
hypnotic drug)
Sympatholytic Adrenergic Blocking Agents Alpha-Adrenergic Blocking Agents
phentolamine mesylate (Phentolamine
Mesylate)
2 PA
Vasodilating Agents Vasodilating Agents
ADCIRCA 5 PA, QL: 60 in 30 days
ADEMPAS 5 PA, QL: 90 in 30 days
epoprostenol sodium (glycine) vial: 0.5mg (Flolan) 2 PA BvD
epoprostenol sodium (glycine) vial: 1.5mg (Flolan) 5 PA BvD
LETAIRIS 5 PA, QL: 30 in 30 days
OPSUMIT 5 PA, QL: 30 in 30 days
ORENITRAM ER tablet er: 0.125mg 3 PA
You can find information on what the symbols and abbreviations in this table mean by going to page VI of this
document
61
Moda Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
Drug Name Drug Tier Requirements/Limits
ORENITRAM ER tablet er: 0.25mg, 1mg,
2.5mg
5 PA
REMODULIN 5 PA BvD
REVATIO vial 5 PA, QL: 37.5 in 1 day
sildenafil citrate (Revatio) 2 PA, QL: 90 in 30 days
TRACLEER 5 LA, PA, QL: 60 in 30
days
TYVASO 5 PA
VENTAVIS 5 PA BvD
Vitamins and Minerals Vitamins and Minerals
ped mv a,c,d3 #21 w-fluoride (Ped Mv A,c,d3 #21
W-fluoride)
2
pnv with ca,no.72/iron/fa (Pnv with Ca,no.72/
iron/fa)
3 (All Rx Prenatal
Vitamins Covered)
I-1
MODA Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
INDEX
0.9 % sodium chloride .......... 55
8-MOP................................... 39
abacavir sulfate ..................... 25
abacavir/lamivudine/zidovudine
........................................... 25
ABELCET............................. 20
ABILIFY ............................... 24
ABILIFY DISCMELT .......... 23
ABILIFY MAINTENA ........ 24
ABRAXANE ........................ 10
acamprosate calcium .............. 4
acarbose ................................ 18
acebutolol hcl ........................ 34
acetaminophen with codeine ... 1
acetazolamide ....................... 55
acetazolamide sodium ........... 55
acetic acid ....................... 43, 52
acetylcysteine ........................ 59
acitretin ................................. 39
ACTEMRA ........................... 53
ACTHIB ................................ 50
ACTIMMUNE ...................... 53
acyclovir .......................... 27, 39
acyclovir sodium ................... 27
ADACEL TDAP ................... 50
ADAGEN .............................. 41
adapalene .............................. 41
ADCETRIS ........................... 10
ADCIRCA............................. 60
adefovir dipivoxil .................. 27
ADEMPAS ........................... 60
ADVAIR DISKUS................ 58
ADVAIR HFA ...................... 58
AFINITOR ............................ 10
AFINITOR DISPERZ ........... 10
AGGRENOX ........................ 28
A-HYDROCORT ................. 47
AKTEN ................................. 42
ALBENZA ............................ 22
ALBUKED-25 ...................... 29
ALBUKED-5 ........................ 29
ALBUMIN HUMAN ............ 29
ALBUMINAR-25 ................. 29
ALBUMINAR-5 ................... 29
ALBURX .............................. 29
ALBUTEIN........................... 29
albuterol sulfate .................... 59
alclometasone dipropionate .. 40
alcohol antiseptic pads ......... 39
ALDURAZYME................... 42
alendronate sodium ............... 52
alfuzosin hcl .......................... 46
ALIMTA ............................... 10
ALINIA ................................. 23
allopurinol............................. 53
ALPHAGAN P ..................... 55
alprazolam .............................. 5
ALREX ................................. 44
aluminum chloride ................ 39
amantadine hcl ...................... 23
AMBISOME ......................... 20
amifostine crystalline ............ 53
amiloride hcl ......................... 36
amiloride/hydrochlorothiazide
........................................... 36
AMINO ACIDS .................... 29
aminocaproic acid ................ 28
AMINOSYN ......................... 29
AMINOSYN II ..................... 29
AMINOSYN M .................... 29
AMINOSYN with
ELECTROLYTES ............ 29
AMINOSYN-HBC ............... 29
AMINOSYN-PF ................... 29
AMINOSYN-RF ................... 29
amiodarone hcl ..................... 33
AMITIZA .............................. 45
amitriptyline hcl .................... 17
amlodipine besylate .............. 36
amlodipine besylate/benazepril
........................................... 36
amlodipine/atorvastatin ........ 36
ammonium lactate ................. 39
amoxapine ............................. 17
amoxicillin............................... 9
amoxicillin trihydrate.............. 9
amoxicillin/potassium clav...... 9
amphotericin b ...................... 20
ampicillin sodium .................... 9
ampicillin sodium/sulbactam na
............................................. 9
ampicillin trihydrate ............... 9
AMPYRA ............................. 37
ANACAINE .......................... 39
anagrelide hcl ....................... 28
anastrozole ............................ 10
ANDRODERM ..................... 46
ANDROGEL......................... 46
ANORO ELLIPTA ............... 59
APOKYN .............................. 23
apraclonidine hcl .................. 42
APRISO ................................ 52
APTIOM ............................... 15
APTIVUS .............................. 25
ARALAST NP ...................... 59
ARCALYST ......................... 49
ARRANON ........................... 10
ARZERRA ............................ 10
ASACOL HD ........................ 52
ASTAGRAF XL ................... 49
atenolol ................................. 34
atenolol/chlorthalidone ......... 34
atorvastatin calcium.............. 36
atovaquone ............................ 23
atovaquone/proguanil hcl ..... 23
ATRIPLA .............................. 25
atropine sulfate ............... 15, 42
I-2
MODA Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
ATROVENT HFA ................ 59
AUBAGIO ............................ 49
AVASTIN ............................. 10
AVC ...................................... 21
AVODART ........................... 53
AVONEX .............................. 53
AVONEX
ADMINISTRATION PACK
........................................... 53
azacitidine ............................. 10
azathioprine .......................... 49
azathioprine sodium .............. 49
azelastine hcl ......................... 42
AZILECT .............................. 23
azithromycin ............................ 8
AZOPT .................................. 55
AZOR .................................... 36
aztreonam ................................ 8
bacitracin .......................... 6, 43
bacitracin/polymyxin b sulfate
........................................... 43
baclofen ................................. 59
balsalazide disodium ............. 52
BANZEL ............................... 15
BARACLUDE ...................... 27
BCG VACCINE TICE
STRAIN ............................ 50
benazepril hcl ........................ 33
benazepril/hydrochlorothiazide
........................................... 33
BENICAR ............................. 32
BENICAR HCT .................... 32
BENLYSTA .......................... 53
benztropine mesylate ............. 23
betamet acet/betamet na ph .. 47
betamethasone dipropionate . 40
betamethasone valerate ........ 40
betamethasone/propylene glyc
........................................... 40
BETASERON ....................... 53
betaxolol hcl .................... 34, 55
bethanechol chloride ............. 53
BETHKIS ................................ 6
bicalutamide .......................... 10
BICILLIN C-R ........................ 9
BICILLIN L-A ........................ 9
BILTRICIDE ........................ 23
bisoprolol fumarate ............... 34
bisoprolol fumarate/hctz ....... 34
bleomycin sulfate .................. 10
BOOSTRIX TDAP ............... 50
BOSULIF .............................. 11
BOTOX ................................. 53
BRILINTA ............................ 28
brimonidine tartrate .............. 55
BRINTELLIX ....................... 17
bromfenac sodium ................. 44
bromocriptine mesylate ......... 23
budesonide ............................ 52
bumetanide ............................ 36
BUMINATE ......................... 29
BUPHENYL ......................... 45
buprenorphine hcl ............... 1, 4
buprenorphine hcl/naloxone hcl
............................................. 4
bupropion hcl ........................ 17
buspirone hcl ......................... 53
butalb/acetaminophen/caffeine 1
butalbit/acetamin/caff/codeine 1
butalbital/acetaminophen ....... 1
butalbital/aspirin/caffeine ....... 1
butorphanol tartrate................ 1
BUTRANS .............................. 1
BYDUREON ........................ 18
BYETTA ............................... 18
BYSTOLIC ........................... 34
cabergoline ........................... 23
caffeine citrated .................... 37
caffeine/sodium benzoate ...... 37
calcipotriene ......................... 39
calcitonin,salmon,synthetic ... 52
calcitriol .......................... 39, 52
calcium acetate ..................... 45
calcium carbonate/mag carb/fa
........................................... 45
calcium chloride.................... 56
calcium gluconate ................. 56
CALDOLOR ........................... 3
CANCIDAS .......................... 20
candesartan cilexetil ............. 32
candesartan/hydrochlorothiazid
........................................... 32
CAPASTAT SULFATE ....... 22
CAPRELSA .......................... 11
captopril ................................ 33
captopril/hydrochlorothiazide
........................................... 33
CARAFATE ......................... 44
carbamazepine ...................... 15
carbidopa .............................. 23
carbidopa/levodopa .............. 23
carbidopa/levodopa/entacapone
........................................... 23
carboplatin ............................ 11
CARIMUNE NF
NANOFILTERED ............ 49
carisoprodol .......................... 59
carteolol hcl .......................... 42
carvedilol .............................. 34
CAYSTON .............................. 8
cefaclor ................................... 7
cefadroxil ................................ 7
cefazolin sodium...................... 7
cefazolin sodium/dextrose,iso . 7
cefdinir .................................... 7
CEFEPIME ............................. 7
cefepime hcl ............................ 7
CEFEPIME-DEXTROSE ....... 7
cefotaxime sodium ................... 7
cefoxitin sodium ...................... 7
cefoxitin sodium/dextrose,iso .. 7
cefpodoxime proxetil ............... 7
cefprozil................................... 7
ceftazidime pentahydrate ........ 7
ceftibuten dihydrate ................ 8
I-3
MODA Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
ceftriaxone na/dextrose,iso ..... 8
ceftriaxone sodium .................. 8
cefuroxime axetil ..................... 8
cefuroxime sodium .................. 8
cefuroxime sodium/dextrose,iso
............................................. 8
CELEBREX ............................ 3
CELLCEPT ........................... 49
CELONTIN........................... 15
cephalexin ............................... 8
cephalexin monohydrate ......... 8
CEPROTIN ........................... 27
CEREZYME ......................... 42
CERVARIX .......................... 50
cevimeline hcl........................ 39
CHANTIX............................... 4
chloramphenicol sod succ ....... 6
chlordiazepoxide hcl ............... 5
chlorhexidine gluconate ........ 39
chloroquine phosphate .......... 23
chlorothiazide ....................... 36
chlorothiazide sodium ........... 36
chlorpromazine hcl ............... 24
chlorthalidone ....................... 36
chlorzoxazone ....................... 59
chlorzoxazone/acetaminophen
........................................... 59
cholestyramine (with sugar) . 36
cholestyramine/aspartame .... 36
choline sal/mag salicylate ....... 3
ciclopirox .............................. 20
ciclopirox olamine ................ 20
cilostazol ............................... 29
cimetidine .............................. 44
cimetidine hcl ........................ 44
CIMZIA ................................ 42
CIPRODEX........................... 43
ciprofloxacin ........................... 9
ciprofloxacin hcl ............... 9, 43
ciprofloxacin lactate ............... 9
ciprofloxacin lactate/d5w........ 9
cisplatin ................................. 11
citalopram hydrobromide ..... 17
citrate phosphate dextros soln
........................................... 53
citric acid/sodium citrate ...... 56
clarithromycin ......................... 8
clemastine fumarate .............. 21
CLEVIPREX......................... 36
clindamycin hcl ....................... 6
clindamycin palmitate hcl ....... 6
clindamycin phosphate 6, 21, 40
clindamycin phosphate/d5w .... 6
CLINIMIX ............................ 30
CLINIMIX E ................... 29, 30
CLINISOL ............................ 30
clobetasol propionate............ 40
clocortolone pivalate ............ 40
clomipramine hcl .................. 17
clonazepam ............................. 5
clonidine ................................ 32
clonidine hcl .................... 32, 37
clonidine hcl/chlorthalidone . 32
clopidogrel bisulfate ............. 29
clorazepate dipotassium.......... 5
clotrimazole........................... 20
clotrimazole/betamethasone dip
........................................... 20
clozapine ............................... 24
COARTEM ........................... 23
codeine sulfate ........................ 1
codeine/butalbital/asa/caffein . 1
colchicine/probenecid ........... 53
COLCRYS ............................ 53
colestipol hcl ......................... 36
colistin (colistimethate na) ...... 6
COLY-MYCIN S .................. 43
COMBIGAN ......................... 55
COMBIPATCH .................... 46
COMBIVENT RESPIMAT .. 59
COMETRIQ .......................... 11
COMPLERA ......................... 25
COMVAX ............................. 50
CONDYLOX ........................ 39
COPAXONE ......................... 53
CORDRAN ........................... 40
cortisone acetate ................... 47
CREON ................................. 42
CRESTOR............................. 36
CRIXIVAN ........................... 25
cromolyn sodium ....... 42, 45, 59
CUBICIN ................................ 6
cyclobenzaprine hcl .............. 59
CYCLOGYL ......................... 42
cyclopentolate hcl ................. 42
cyclophosphamide ................. 11
CYCLOPHOSPHAMIDE..... 11
CYCLOSET .......................... 18
cyclosporine .......................... 49
cyclosporine, modified .......... 49
cyproheptadine hcl ................ 21
CYSTADANE ...................... 54
CYSTARAN ......................... 42
cysteine hcl ............................ 30
cytarabine ............................. 11
cytarabine/pf ......................... 11
dacarbazine ........................... 11
dactinomycin ......................... 11
DALIRESP ........................... 59
danazol .................................. 46
dantrolene sodium ................. 59
dapsone ................................. 22
DAPTACEL DTAP .............. 50
DARAPRIM ......................... 23
decitabine .............................. 11
deferoxamine mesylate .......... 46
DELZICOL ........................... 52
DEMSER .............................. 34
DEPEN .................................. 46
DEPO-PROVERA ................ 48
desipramine hcl ..................... 17
desmopressin acetate ............ 48
desog-e.estradiol/e.estradiol . 38
desogestrel-ethinyl estradiol . 38
desonide ................................ 40
desoximetasone ..................... 40
I-4
MODA Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
dex 2.5%-half str lact.ringers 56
dexamethasone ...................... 47
dexamethasone acetate ......... 47
dexamethasone sod phosphate
..................................... 44, 47
dexmethylphenidate hcl ......... 37
dextroamphetamine sulfate ... 37
dextroamphetamine/
amphetamine ..................... 38
dextrose 10 % and 0.2 % nacl
........................................... 30
dextrose 10 % and 0.9 % nacl
........................................... 30
dextrose 10 % in water ......... 30
dextrose 10%-0.5 normal saline
........................................... 30
dextrose 2.5 % in water ........ 30
dextrose 2.5% in half ringers 30
dextrose 2.5%-0.5normal saline
........................................... 30
dextrose 20%-water .............. 30
dextrose 25 % in water ......... 30
dextrose 40%-water .............. 30
dextrose 5 % and 0.3 % nacl 30
dextrose 5 % and 0.9 % nacl 31
dextrose 5 % in water ........... 31
dextrose 5 %-0.2 % nacl ....... 31
dextrose 5 %-0.45 % nacl ..... 31
dextrose 5% in ringers .......... 31
dextrose 5%-lactated ringers 31
dextrose 50 % in water ......... 31
dextrose 60 % in water ......... 31
dextrose 70%-water .............. 31
DEXTROSE W/
ELECTROLYTE A .......... 56
DEXTROSE W/
ELECTROLYTE B ........... 56
DIASTAT ACUDIAL ............ 5
diazepam ................................. 5
diclofenac potassium ............... 3
diclofenac sodium ............. 3, 44
diclofenac sodium/misoprostol 3
dicloxacillin sodium ................ 9
dicyclomine hcl ..................... 45
didanosine ............................. 25
DIFICID .................................. 8
diflunisal ................................. 3
digoxin............................. 34, 35
DIGOXIN ............................. 35
dihydroergotamine mesylate . 21
DILANTIN ........................... 15
diltiazem hcl .......................... 34
dimenhydrinate ..................... 22
DIOVAN ............................... 32
DIPENTUM .......................... 52
diphenhydramine hcl ............. 21
diphenoxylate hcl/atropine .... 45
DIPHTHERIA-TETANUS
TOXOIDS-PED ................ 50
disopyramide phosphate ....... 33
disulfiram ................................ 4
divalproex sodium ................. 15
dobutamine hcl ...................... 35
dobutamine hcl/d5w .............. 35
donepezil hcl ......................... 17
dopamine hcl ......................... 35
dopamine hcl/d5w ................. 35
dopamine hcl/dextrose 5%-
water ................................. 35
dorzolamide hcl ..................... 55
dorzolamide hcl/timolol maleat
........................................... 55
doxazosin mesylate................ 32
doxepin hcl ............................ 17
doxercalciferol ...................... 52
doxorubicin hcl ..................... 11
doxorubicin hcl peg-liposomal
........................................... 11
doxycycline hyclate ............... 10
doxycycline monohydrate ...... 10
dronabinol ............................. 22
droperidol ............................. 54
DROXIA ............................... 11
DUAVEE .............................. 46
DULERA .............................. 58
duloxetine hcl ........................ 17
DURAMORPH ....................... 1
DUREZOL ............................ 44
DYRENIUM ......................... 36
econazole nitrate ................... 20
edetate disodium ................... 46
EDURANT ........................... 25
EFFIENT............................... 29
ELAPRASE .......................... 42
electrolyte-48 solution/d5w ... 56
electrolyte-48/fructose 10% .. 56
electrolyte-48/fructose 5% .... 56
electrolyte-75 solution/d5w ... 56
electrolyte-75/fructose 5% .... 56
ELIDEL................................. 40
ELIGARD ............................. 11
ELIQUIS ............................... 27
ELITEK................................. 42
ELLA .................................... 38
ELMIRON ............................ 54
EMCYT................................. 11
EMEND ................................ 22
EMSAM ................................ 17
EMTRIVA ............................ 25
enalapril maleate .................. 33
enalapril/hydrochlorothiazide
........................................... 33
enalaprilat dihydrate ............ 33
ENBREL ............................... 49
ENGERIX-B ADULT .......... 50
ENGERIX-B PEDIATRIC-
ADOLESCENT ................ 50
enoxaparin sodium ................ 27
entacapone ............................ 23
ephedrine sulfate ................... 35
epinastine hcl ........................ 42
epinephrine ........................... 35
EPIPEN 2-PAK ..................... 35
EPIPEN JR 2-PAK ............... 35
epirubicin hcl ........................ 11
EPIVIR .................................. 25
I-5
MODA Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
EPIVIR HBV ........................ 25
eplerenone ............................. 37
EPOGEN ............................... 28
epoprostenol sodium (glycine)
........................................... 60
EPZICOM ............................. 25
ERBITUX ............................. 11
ergoloid mesylates ................ 54
ERGOMAR........................... 21
ERIVEDGE........................... 11
ery e-succ/sulfisoxazole .......... 8
ERY-TAB ............................... 8
ERYTHROCIN
LACTOBIONATE .............. 8
erythromycin base ............. 8, 43
erythromycin base/ethanol .... 40
erythromycin ethylsuccinate ... 8
erythromycin stearate ............. 8
escitalopram oxalate ............. 17
esmolol hcl ............................ 34
esomeprazole sodium ............ 44
estazolam................................. 5
ESTRACE ............................. 46
estradiol ................................ 46
estradiol valerate .................. 46
estradiol/norethindrone acet . 46
ESTRASORB ....................... 47
estropipate............................. 47
ethambutol hcl ....................... 22
ethanolamine oleate .............. 35
ethinyl estradiol/drospirenone
........................................... 38
ethosuximide ......................... 15
ethynodiol d-ethinyl estradiol 38
etidronate disodium .............. 52
etodolac ................................... 3
ETOPOPHOS ....................... 11
etoposide ............................... 11
exemestane ............................ 11
EXJADE ............................... 46
EXTAVIA ............................. 54
FABRAZYME ...................... 42
famciclovir ............................ 27
famotidine ............................. 44
famotidine in nacl,iso-osm/pf 44
famotidine/pf ......................... 44
FANAPT ............................... 24
FARESTON .......................... 11
FASLODEX .......................... 11
FAZACLO ............................ 24
felbamate ............................... 16
felodipine............................... 36
FEMRING............................. 47
fenofibrate ............................. 36
fenofibrate nanocrystallized.. 36
fenofibrate,micronized .......... 36
fenofibric acid ....................... 36
fenofibric acid (choline) ........ 36
fenoprofen calcium.................. 3
fentanyl .................................... 1
fentanyl citrate ........................ 1
FERRIPROX......................... 46
FETZIMA ............................. 17
finasteride ............................. 54
FIRAZYR ............................. 35
FIRMAGON ......................... 11
FLEBOGAMMA DIF ........... 49
flecainide acetate .................. 33
FLECTOR ............................... 3
FLEXBUMIN ....................... 29
FLOVENT DISKUS ............. 58
FLOVENT HFA ................... 58
floxuridine ............................. 11
fluconazole ............................ 20
fluconazole in nacl,iso-osm ... 20
flucytosine ............................. 20
fludarabine phosphate .......... 12
fludrocortisone acetate ......... 47
flumazenil .............................. 38
fluocinonide........................... 40
fluorometholone .................... 44
FLUOROPLEX..................... 39
fluorouracil ..................... 12, 39
fluoxetine hcl ......................... 17
fluoxymesterone .................... 46
fluphenazine decanoate ......... 24
fluphenazine hcl .................... 24
flurazepam hcl ......................... 5
flurbiprofen ............................. 3
flurbiprofen sodium ............... 44
flutamide ............................... 12
fluticasone propionate .... 40, 44
fluvoxamine maleate ............. 17
fomepizole ............................. 54
fondaparinux sodium ...... 27, 28
FORTEO ............................... 52
FORTICAL ........................... 52
foscarnet sodium ................... 26
fosinopril sodium .................. 33
fosinopril/hydrochlorothiazide
........................................... 33
fosphenytoin sodium.............. 16
FREAMINE HBC ................. 31
FREAMINE III ..................... 31
fructose 10% ......................... 31
furosemide ............................. 36
FUSILEV .............................. 54
FUZEON ............................... 25
FYCOMPA ........................... 16
gabapentin............................. 16
GABITRIL ............................ 16
galantamine hbr .................... 17
GAMASTAN S-D ................ 49
GAMMAGARD LIQUID ..... 49
GAMMAPLEX ..................... 49
GAMUNEX-C ...................... 49
ganciclovir sodium ................ 27
GARDASIL .......................... 50
gatifloxacin ........................... 43
gauze bandage ...................... 54
GAZYVA .............................. 12
gemcitabine hcl ..................... 12
gemfibrozil ............................ 37
GENOTROPIN ..................... 48
gentamicin in nacl, iso-osm .... 6
gentamicin sulfate ....... 6, 40, 43
I-6
MODA Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
GEODON .............................. 24
GILENYA ............................. 54
GILOTRIF ............................ 12
GLEEVEC ............................ 12
glimepiride ............................ 19
glipizide ................................. 19
glipizide/metformin hcl ......... 20
GLUCAGEN......................... 54
GLUCAGON EMERGENCY
KIT .................................... 54
glutethimide........................... 54
glyburide ............................... 20
glyburide,micronized ............ 20
glyburide/metformin hcl ........ 20
glycine ................................... 52
glycopyrrolate ....................... 45
granisetron hcl ...................... 22
granisetron hcl/pf .................. 22
GRANIX ............................... 28
griseofulvin, microsize .......... 20
guanfacine hcl ....................... 32
guanidine hcl ......................... 54
HALAVEN ........................... 12
halobetasol propionate ......... 40
haloperidol ............................ 24
haloperidol decanoate .......... 24
haloperidol lactate ................ 24
HAVRIX ......................... 50, 51
heparin sodium,porcine ........ 28
heparin sodium,porcine/d5w. 28
heparin sodium,porcine/ns/pf 28
heparin sodium,porcine/pf .... 28
HEPATAMINE..................... 31
HEPATASOL ....................... 31
HERCEPTIN......................... 12
HEXALEN ............................ 12
homatropine hbr.................... 42
HUMALOG .......................... 19
HUMALOG MIX 50-50 ....... 19
HUMALOG MIX 75-25 ....... 19
HUMATROPE ...................... 48
HUMIRA .............................. 49
HUMULIN 70/30 KWIKPEN
........................................... 19
HUMULIN 70-30 ................. 19
HUMULIN N ........................ 19
HUMULIN N KWIKPEN .... 19
HUMULIN R ........................ 19
hydralazine hcl ...................... 35
hydralazine/hydrochlorothiazid
........................................... 35
hydrochlorothiazide .............. 36
hydrocodone/acetaminophen .. 1
hydrocodone/ibuprofen ........... 1
hydrocortisone ................ 41, 47
hydrocortisone acetate/aloe v 40
hydrocortisone acetate/urea . 41
hydrocortisone butyrate ........ 41
hydrocortisone sod succinate 47
hydrocortisone valerate ........ 41
hydromorphone hcl ............. 1, 2
hydromorphone hcl/pf ............. 2
hydroxychloroquine sulfate ... 23
hydroxyurea .......................... 12
hydroxyzine hcl ..................... 54
hydroxyzine pamoate ............ 54
HYPERLYTE CR ................. 56
HYPERLYTE R.................... 56
HYPERRAB S-D .................. 49
ibandronate sodium ........ 52, 53
ibuprofen ................................. 3
ICLUSIG ............................... 12
ifosfamide .............................. 12
ifosfamide/mesna................... 12
ILARIS .................................. 49
ILEVRO ................................ 44
IMBRUVICA ........................ 12
imipenem/cilastatin sodium .... 8
imipramine hcl ...................... 17
imipramine pamoate ............. 17
imiquimod ............................. 39
IMOGAM RABIES-HT........ 50
IMOVAX RABIES VACCINE
........................................... 51
INCRELEX ........................... 48
indapamide ............................ 36
indomethacin ........................... 3
indomethacin sodium .............. 3
INFANRIX DTAP ................ 51
INLYTA ................................ 12
INTELENCE......................... 25
INTRALIPID ........................ 31
INTRON A............................ 27
INTUNIV .............................. 38
INVANZ ................................. 8
INVEGA ............................... 24
INVEGA SUSTENNA ......... 24
INVIRASE ............................ 26
INVOKANA ......................... 18
IONOSOL B with DEXTROSE
5% ..................................... 56
IONOSOL MB-DEXTROSE
5% ..................................... 56
IONOSOL T-DEXTROSE 5%
........................................... 56
IPOL ...................................... 51
ipratropium bromide ............. 42
IPRIVASK ............................ 28
irbesartan .............................. 33
irbesartan/hydrochlorothiazide
........................................... 33
ISENTRESS .......................... 26
ISOLYTE E .......................... 56
ISOLYTE H W/DEXTROSE 56
ISOLYTE M W/DEXTROSE56
ISOLYTE P with DEXTROSE
........................................... 56
ISOLYTE S ........................... 56
ISOLYTE S with DEXTROSE
........................................... 56
isoniazid ................................ 22
isopropamide/prochlorperazine
........................................... 45
ISOPTO CARPINE .............. 55
isosorbide dinitrate ............... 37
isosorbide mononitrate ......... 37
I-7
MODA Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
isotretinoin ............................ 39
isradipine .............................. 36
ISTODAX ............................. 12
itraconazole........................... 20
IXEMPRA............................. 12
IXIARO................................. 51
JAKAFI ................................. 12
JALYN .................................. 54
JANUMET ............................ 18
JANUMET XR ..................... 18
JANUVIA ............................. 18
JENTADUETO ..................... 18
JEVTANA............................. 12
KADCYLA ........................... 12
KALETRA ............................ 26
KALYDECO......................... 59
KEDBUMIN ......................... 29
ketoconazole .......................... 20
ketoprofen ............................... 3
ketorolac tromethamine .... 3, 44
KHEDEZLA ......................... 17
KINERET ............................. 50
KINRIX................................. 51
KORLYM ............................. 18
KRYSTEXXA ...................... 42
KUVAN ................................ 42
KYPROLIS ........................... 12
labetalol hcl .......................... 34
LACRISERT ......................... 42
LACTATED RINGERS ....... 52
lactulose ................................ 45
LAMICTAL .......................... 16
lamivudine ............................. 26
lamivudine/zidovudine .......... 26
lamotrigine ............................ 16
LANOXIN ............................ 35
lansoprazole .......................... 44
lansoprazole/amoxiciln/clarith
........................................... 44
LANTUS ............................... 19
LANTUS SOLOSTAR ......... 19
latanoprost ............................ 55
LATUDA .............................. 24
LAZANDA ............................. 2
leflunomide ............................ 50
LETAIRIS ............................. 60
letrozole................................. 12
leucovorin calcium ................ 54
LEUKERAN ......................... 13
LEUKINE ............................. 28
leuprolide acetate.................. 13
levetiracetam ......................... 16
levobunolol hcl ...................... 55
levocarnitine ......................... 54
levocarnitine (with sugar) ..... 54
levocetirizine dihydrochloride
........................................... 21
levofloxacin ....................... 9, 43
levofloxacin/d5w ................... 10
levonorgestrel ....................... 38
levonorgestrel-ethin estradiol 38
levorphanol tartrate ................ 2
levothyroxine sodium ............ 49
LEXIVA ................................ 26
lidocaine .................................. 4
lidocaine hcl ...................... 4, 33
lidocaine hcl/d5w/pf .............. 33
lidocaine hcl/pf.................. 4, 33
lidocaine/prilocaine ................ 4
LIDODERM ........................... 4
LINZESS............................... 42
liothyronine sodium .............. 49
lipase/protease/amylase ........ 42
LIPOSYN II .......................... 31
LIPOSYN III ......................... 31
lisinopril ................................ 33
lisinopril/hydrochlorothiazide
........................................... 33
lithium carbonate .................. 38
lithium citrate ........................ 38
l-norgest-eth estr/ethin estra . 38
lomustine ............................... 13
loperamide hcl ...................... 45
lorazepam ................................ 5
losartan potassium ................ 33
losartan/hydrochlorothiazide 33
LOTEMAX ........................... 44
LOTRONEX ......................... 42
lovastatin ............................... 37
loxapine succinate ................. 24
LUMIGAN ............................ 55
LUMINAL SODIUM ........... 16
LUMIZYME ......................... 42
LUPRON DEPOT ................. 13
LUPRON DEPOT-PED ........ 13
LYRICA ................................ 16
LYSODREN ......................... 13
mafenide acetate ................... 39
magnesium chloride .............. 56
magnesium sulfate ................. 56
magnesium sulfate/d5w ......... 56
malathion .............................. 41
mannitol/sorbitol solution ..... 52
maprotiline hcl ...................... 17
MARPLAN ........................... 17
MARQIBO ............................ 13
MATULANE ........................ 13
meclizine hcl.......................... 22
medroxyprogesterone acet .... 48
medroxyprogesterone acetate 48
mefenamic acid ....................... 3
mefloquine hcl ....................... 23
MEFOXIN .............................. 8
MEGACE ES ........................ 13
megestrol acetate .................. 13
MEKINIST ........................... 13
meloxicam ............................... 4
melphalan hcl ........................ 13
MENACTRA ........................ 51
MENEST............................... 47
MENHIBRIX ........................ 51
MENOMUNE-A-C-Y-W-135
........................................... 51
MENVEO A-C-Y-W-135-DIP
........................................... 51
mercaptopurine ..................... 13
I-8
MODA Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
meropenem .............................. 9
mesna .................................... 54
MESNEX .............................. 54
MESTINON .......................... 54
metaproterenol sulfate .......... 59
metaxalone ............................ 59
metformin hcl ........................ 18
methadone hcl ......................... 2
methazolamide ...................... 55
methenamine hippurate ........... 6
methimazole .......................... 49
methocarbamol ..................... 60
methotrexate sodium ............. 13
methotrexate sodium/pf ......... 13
methoxsalen, rapid ................ 39
methscopolamine bromide .... 45
methyclothiazide ................... 36
methylphenidate hcl .............. 38
methylprednisolone ............... 47
methylprednisolone acetate .. 47
methylprednisolone sod succ 47
metipranolol .......................... 55
metoclopramide hcl ............... 45
metolazone ............................ 36
metoprolol succinate ............. 34
metoprolol tartrate ................ 34
metoprolol/hydrochlorothiazide
........................................... 34
metronidazole ............ 21, 23, 40
metronidazole/sodium chloride
........................................... 23
mexiletine hcl ........................ 33
MIACALCIN ........................ 53
miconazole nitrate ................. 21
midazolam hcl ......................... 5
midazolam hcl/pf ..................... 5
midodrine hcl ........................ 32
milrinone lactate ................... 35
milrinone lactate/d5w ........... 35
minocycline hcl ..................... 10
minoxidil ............................... 37
mirtazapine ........................... 17
misoprostol ............................ 44
mitomycin .............................. 13
mitoxantrone hcl ................... 13
M-M-R II VACCINE ............ 51
moexipril hcl ......................... 33
moexipril/hydrochlorothiazide
........................................... 33
mometasone furoate .............. 41
montelukast sodium ............... 58
morphine sulfate...................... 2
MORPHINE SULFATE ......... 2
MOVIPREP .......................... 45
MOXEZA ............................. 43
moxifloxacin hcl .................... 10
MOZOBIL ............................ 28
MULTAQ ............................. 33
mupirocin .............................. 40
mupirocin calcium ................ 40
MUSTARGEN ...................... 13
mycophenolate mofetil .......... 50
mycophenolate sodium .......... 50
MYOZYME .......................... 42
nabumetone ............................. 4
nadolol .................................. 34
NAFCILL IN DEXTROSE..... 9
nafcillin sodium ....................... 9
NAGLAZYME ..................... 42
nalidixic acid ......................... 10
naloxone hcl ............................ 4
naltrexone hcl.......................... 4
NAMENDA .......................... 17
NAMENDA XR.................... 17
naphazoline hcl/antazoline ... 43
naproxen ................................. 4
naproxen sodium ..................... 4
naratriptan hcl ...................... 21
NASONEX ........................... 44
NATACYN ........................... 43
nateglinide............................. 18
NEBUPENT .......................... 23
needles, insulin disposable.... 41
nefazodone hcl ...................... 17
neo/polymyx b sulf/dexameth 43
neomy sulf/bacitra/polymyxin b
........................................... 43
neomy sulf/bacitrac zn/poly/hc
........................................... 43
neomy sulf/polymyxin b sulfate
........................................... 40
neomycin sulfate...................... 6
neomycin sulfate/dex na ph ... 43
neomycin/polymyxin b sulf/hc 43
neomycin/polymyxn b/
gramicidin ......................... 43
NEPHRAMINE .................... 31
NEULASTA ......................... 28
NEUMEGA........................... 28
NEUPOGEN ......................... 28
NEUPRO............................... 23
NEVANAC ........................... 44
nevirapine ............................. 26
NEXAVAR ........................... 13
niacin..................................... 37
nicardipine hcl ...................... 36
NICOTROL ............................ 5
nifedipine............................... 36
NILANDRON ....................... 13
NITRO-BID .......................... 37
nitrofurantoin macrocrystal .... 7
nitroglycerin .......................... 37
nitroglycerin/d5w .................. 37
NITROSTAT ........................ 37
NORDITROPIN FLEXPRO . 48
NORDITROPIN NORDIFLEX
........................................... 48
norelgestromin/ethin.estradiol
........................................... 38
norepinephrine bitartrate...... 35
noreth-ethinyl estradiol/iron . 38
norethindrone ........................ 39
norethindrone acetate ........... 49
norethindrone ac-eth estradiol
..................................... 38, 47
I-9
MODA Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
norethindrone-e.estradiol-iron
........................................... 39
norethindrone-ethinyl estrad 39
norethindrone-mestranol ...... 39
norgestimate-ethinyl estradiol
........................................... 39
norgestrel-ethinyl estradiol ... 39
NORMOSOL-M and
DEXTROSE ...................... 56
NORMOSOL-R PH 7.4 ........ 56
nortriptyline hcl .................... 17
NORVIR ............................... 26
NOVAMINE ......................... 31
NOVOLIN 70-30 .................. 19
NOVOLIN N ........................ 19
NOVOLIN R ......................... 19
NOVOLOG ........................... 19
NOVOLOG FLEXPEN ........ 19
NOVOLOG MIX 70-30 ........ 19
NOVOLOG MIX 70-30
FLEXPEN ......................... 19
NOXAFIL ............................. 21
NUCYNTA ............................. 2
NUCYNTA ER ....................... 2
NUEDEXTA ......................... 38
NULOJIX .............................. 50
NUTRESTORE..................... 45
NUTRILYTE ........................ 56
NUTRILYTE II .................... 56
NUTROPIN .......................... 48
NUTROPIN AQ NUSPIN .... 48
NUVARING ......................... 39
NUVIGIL .............................. 60
nystatin .................................. 21
nystatin/triamcin ................... 21
OCTAGAM .......................... 50
octreotide acetate .................. 48
ofloxacin .......................... 10, 43
olanzapine ....................... 24, 25
olanzapine/fluoxetine hcl ...... 17
OLYSIO ................................ 27
omega-3 acid ethyl esters...... 37
omeprazole ............................ 44
OMNITROPE ....................... 48
ONCASPAR ......................... 13
ondansetron........................... 22
ondansetron hcl ..................... 22
ondansetron hcl/pf ................ 22
ONFI ....................................... 5
OPSUMIT ............................. 60
ORAP .................................... 25
ORENCIA ............................. 50
ORENITRAM ER ........... 60, 61
ORFADIN ............................. 42
OTEZLA ............................... 54
oxacillin sodium ...................... 9
oxacillin sodium/dextrose,iso .. 9
oxaliplatin ............................. 13
oxandrolone .......................... 46
oxcarbazepine ....................... 16
OXTELLAR XR ................... 16
oxybutynin chloride ............... 45
oxycodone hcl.......................... 2
oxycodone hcl/acetaminophen 2
oxycodone hcl/aspirin ............. 2
OXYCONTIN ..................... 2, 3
oxymorphone hcl ..................... 3
paclitaxel ............................... 13
PANRETIN ........................... 39
pantoprazole sodium ............. 44
papaverine hcl ....................... 35
paricalcitol ............................ 53
paromomycin sulfate ............. 23
paroxetine hcl........................ 18
PASER .................................. 22
PATADAY ........................... 43
PATANOL ............................ 43
PAXIL ................................... 18
ped mv a,c,d3 #21 w-fluoride 61
PEDIARIX ............................ 51
PEDVAXHIB ....................... 51
peg 3350/na sulf,bicarb,cl/kcl 45
PEGANONE ......................... 16
PEGASYS ............................. 27
PEGASYS PROCLICK ........ 27
PEGINTRON ........................ 27
PEGINTRON REDIPEN ...... 27
pen g pot/dextrose-water......... 9
penicillin g potassium ............. 9
penicillin g potassium/d5w ..... 9
penicillin g procaine ............... 9
penicillin v potassium ............. 9
PENTACEL .......................... 51
PENTACEL ACTHIB
COMPONENT .................. 51
PENTACEL DTAP-IPV
COMPONENT .................. 51
PENTAM 300 ....................... 23
pentamidine isethionate ........ 23
pentoxifylline ......................... 29
p-epd tan/chlor-tan ............... 21
perindopril erbumine ............ 33
PERJETA .............................. 13
permethrin ............................. 41
perphenazine ......................... 25
perphenazine/amitriptyline hcl
........................................... 18
phenelzine sulfate .................. 18
phenobarbital ........................ 16
phenobarbital sodium ........... 16
phentolamine mesylate .......... 60
phenylephrine hcl ............ 32, 43
phenytoin ............................... 16
phenytoin sodium .................. 16
phenytoin sodium extended ... 16
PHOSLYRA ......................... 45
PHOSPHOLINE IODIDE .... 55
phosphorus #1 ....................... 56
PICATO ................................ 39
pilocarpine hcl ................ 39, 55
pindolol ................................. 34
pioglitazone hcl ..................... 18
pioglitazone hcl/glimepiride . 19
pioglitazone hcl/metformin hcl
........................................... 19
I-10
MODA Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
piperacillin sodium/tazobactam
............................................. 9
piroxicam ................................ 4
PLASBUMIN-25 .................. 29
PLASBUMIN-5 .................... 29
PLASMA-LYTE 148 ............ 57
PLASMA-LYTE 56 IN
DEXTROSE ...................... 57
PLASMA-LYTE A PH 7.4 ... 57
PLASMA-LYTE M IN
DEXTROSE ...................... 57
pnv with ca,no.72/iron/fa ...... 61
podofilox ............................... 39
podophyllum resin ................. 40
polyethylene glycol 3350....... 45
polymyxin b sulf/trimethoprim
........................................... 43
POMALYST ......................... 13
pot chloride/pot bicarb/cit ac 57
potassium acetate .................. 57
potassium bicarbonate/cit ac 57
potassium chlorid/d10-
0.2%nacl ........................... 57
potassium chloride ................ 57
potassium chloride in 0.9%nacl
........................................... 57
potassium chloride in d5w .... 57
potassium chloride in lr-d5 ... 31
potassium chloride/d5-
0.2%nacl ........................... 57
potassium chloride/d5-0.25ns 57
potassium chloride/d5-
0.3%nacl ........................... 57
potassium chloride/d5-0.45nacl
........................................... 57
potassium chloride/d5-
0.9%nacl ........................... 57
potassium chloride-0.45% nacl
........................................... 57
potassium citrate/citric acid . 57
potassium gluconate.............. 57
potassium hydroxide ............. 40
potassium phos,m-basic-d-basic
........................................... 57
POTIGA ................................ 16
PRADAXA ........................... 28
pramipexole di-hcl ................ 23
PRANDIMET ....................... 19
pravastatin sodium ................ 37
prazosin hcl ........................... 32
prednicarbate ........................ 41
prednisolone acetate ............. 47
prednisolone sod phosphate . 44,
47
prednisone ....................... 47, 48
PREGNYL ............................ 48
PREMARIN .......................... 47
PREMASOL ......................... 31
PREMPHASE ....................... 47
PREMPRO ............................ 47
PREZISTA ............................ 26
PRIFTIN ............................... 22
PRIMAQUINE ..................... 23
primidone .............................. 16
PRISTIQ ER ......................... 18
PRIVIGEN ............................ 50
PROAIR HFA ....................... 59
probenecid............................. 54
procainamide hcl .................. 33
PROCALAMINE .................. 31
prochlorperazine edisylate.... 22
prochlorperazine maleate ..... 22
PROCRIT .............................. 28
PROCYSBI ........................... 54
progesterone ......................... 49
progesterone,micronized ....... 49
PROGLYCEM ...................... 37
PROGRAF ............................ 50
PROLENSA .......................... 44
PROLEUKIN ........................ 13
PROLIA ................................ 53
PROMACTA ........................ 28
promethazine hcl ............. 21, 22
PRONESTYL ....................... 34
propafenone hcl .................... 34
propantheline bromide .......... 15
proparacaine hcl ................... 43
proparacaine/fluorescein sod 43
propranolol hcl ..................... 34
propranolol/hydrochlorothiazid
........................................... 34
propylthiouracil .................... 49
PROQUAD ........................... 51
PROSOL ............................... 31
protamine sulfate .................. 28
PROTOPIC ........................... 41
protriptyline hcl .................... 18
PULMOZYME ..................... 42
pyrazinamide ......................... 22
pyridostigmine bromide ........ 54
QUDEXY XR ....................... 16
quetiapine fumarate .............. 25
QUICK MIX with LYTES.... 31
QUILLIVANT XR................ 38
quinapril hcl .......................... 33
quinapril/hydrochlorothiazide
........................................... 33
quinidine gluconate ............... 34
quinidine sulfate .................... 34
quinine sulfate ....................... 23
QVAR ................................... 58
RABAVERT ......................... 51
raloxifene hcl ........................ 47
ramipril ................................. 33
RANEXA .............................. 35
ranitidine hcl ......................... 44
RAPAMUNE ........................ 50
REBIF ................................... 54
REBIF REBIDOSE ............... 54
RECOMBIVAX HB ............. 51
RELENZA ............................ 26
RELISTOR ........................... 45
REMICADE .......................... 54
REMODULIN....................... 61
RENAGEL ............................ 45
RENVELA ............................ 45
I-11
MODA Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
repaglinide ............................ 19
RESCRIPTOR ...................... 26
RESTASIS ............................ 44
RETROVIR........................... 26
REVATIO ............................. 61
REVLIMID ........................... 13
REYATAZ ............................ 26
ribavirin ................................ 27
RIDAURA ............................ 50
rifabutin................................. 22
rifampin ................................. 22
RIFATER .............................. 22
riluzole .................................. 38
rimantadine hcl ..................... 26
ringers solution ............... 52, 58
risedronate sodium................ 53
RISPERDAL CONSTA ........ 25
risperidone ............................ 25
RITUXAN............................. 14
rivastigmine tartrate ............. 17
rizatriptan benzoate .............. 21
ropinirole hcl ........................ 23
ROTARIX ............................. 51
ROTATEQ ............................ 51
ROZEREM ........................... 60
SABRIL ................................ 16
SAIZEN ................................ 48
salsalate .................................. 4
SANDOSTATIN LAR.......... 48
SANTYL ............................... 40
SAPHRIS .............................. 25
SAVELLA ............................ 38
selegiline hcl ......................... 23
selenium sulfide ..................... 40
SELZENTRY ........................ 26
SENSIPAR ............................ 54
SEREVENT DISKUS ........... 59
SEROQUEL XR ................... 25
SEROSTIM ........................... 48
sertraline hcl ......................... 18
sildenafil citrate .................... 61
SILENOR .............................. 18
silver nitrate .......................... 40
silver nitrate applicator ........ 40
silver sulfadiazine ................. 40
SIMBRINZA......................... 55
SIMPONI .............................. 54
SIMPONI ARIA ................... 54
simvastatin ............................ 37
sirolimus ................................ 50
SIRTURO ............................. 22
sod propion/inositol/aa14/urea
........................................... 21
sod/pot/k cit/sod cit/cit acid .. 58
sodium acetate ...................... 58
sodium bicarbonate ............... 58
sodium chloride ..................... 58
sodium chloride 0.45 % ........ 58
sodium chloride 3% .............. 58
sodium chloride 5 % ............. 58
sodium chloride irrig solution
........................................... 52
sodium chloride/nahco3/kcl/peg
........................................... 45
sodium lactate ....................... 58
sodium morrhuate ................. 54
sodium phos,m-basic-d-basic 58
sodium polystyrene sulfonate 45
sodium thiosulfate ................. 46
SOLIRIS ............................... 54
SOLTAMOX ........................ 14
SOLU-CORTEF ................... 48
SOMATULINE DEPOT ....... 48
SOMAVERT......................... 48
sorbitol solution .................... 52
sotalol hcl .............................. 34
SOVALDI ............................. 27
SPIRIVA ............................... 59
spironolact/hydrochlorothiazid
........................................... 37
spironolactone....................... 37
SPRYCEL ............................. 14
stavudine ............................... 26
STELARA............................. 55
STERILE DILUENT ............ 29
STIVARGA .......................... 14
STRATTERA ....................... 38
streptomycin sulfate ................ 6
STRIBILD............................. 26
STROMECTOL .................... 23
sucralfate............................... 44
sulfacetamide sodium ...... 40, 43
sulfacetamide/prednisolone sp
........................................... 43
sulfadiazine ........................... 10
sulfamethoxazole/trimethoprim
........................................... 10
sulfasalazine .......................... 10
sulindac ................................... 4
sumatriptan ........................... 21
sumatriptan succinate ........... 21
SUPPRELIN LA ................... 48
SUPRAX ................................. 8
SURMONTIL ....................... 18
SUSTIVA .............................. 26
SUTENT ............................... 14
SYLATRON 4-PACK .......... 27
SYLVANT ............................ 14
SYMLINPEN 120 ................. 19
SYMLINPEN 60 ................... 19
SYNAGIS ............................. 26
SYNAREL ............................ 55
SYNERCID............................. 7
SYNRIBO ............................. 14
SYPRINE .............................. 46
syring w-ndl,disp,insul,0.3ml 41
syring w-ndl,disp,insul,0.5ml 41
syringe & needle,insulin,1 ml 41
TABLOID ............................. 14
tacrolimus ............................. 50
TAFINLAR ........................... 14
TAMIFLU ....................... 26, 27
tamoxifen citrate ................... 14
tamsulosin hcl ....................... 46
TARCEVA ............................ 14
TARGRETIN ........................ 14
I-12
MODA Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
TASIGNA ............................. 14
TAZICEF IN DEXTROSE ..... 8
TAZORAC ............................ 41
TE ANATOXAL BERNA .... 51
TECFIDERA......................... 55
TEFLARO............................... 8
telmisartan ............................ 33
telmisartan/hydrochlorothiazid
........................................... 33
temazepam........................... 5, 6
TEMODAR ........................... 14
TENIVAC ............................. 51
terazosin hcl .......................... 46
terbinafine hcl ....................... 21
terbutaline sulfate ................. 59
terconazole ............................ 21
testosterone cypionate ........... 46
testosterone enanthate .......... 46
TETANUS DIPHTHERIA
TOXOIDS ......................... 51
TETANUS TOXOID
ADSORBED ..................... 51
tetracaine hcl ........................ 43
tetracycline hcl ...................... 10
TEV-TROPIN ....................... 48
THALOMID ......................... 55
theophylline anhydrous ......... 59
theophylline/d5w ................... 59
thioridazine hcl ..................... 25
thiothixene ............................. 25
tiagabine hcl.......................... 16
TIKOSYN ............................. 34
timolol maleate................ 34, 55
TIVICAY .............................. 26
tizanidine hcl ......................... 60
TOBI PODHALER ................. 6
TOBRADEX ST ................... 43
tobramycin in 0.225% nacl ..... 6
tobramycin sulfate ............. 6, 43
tobramycin/sodium chloride ... 6
tolazamide ............................. 20
tolbutamide ........................... 20
tolmetin sodium ....................... 4
tolterodine tartrate ................ 46
topiramate ............................. 16
topotecan hcl ......................... 14
TORISEL .............................. 14
torsemide ............................... 36
TOVIAZ ................................ 46
TPN ELECTROLYTES II .... 58
TRACLEER .......................... 61
TRADJENTA ....................... 19
tramadol hcl ............................ 3
tramadol hcl/acetaminophen .. 3
trandolapril ........................... 33
tranexamic acid ..................... 28
TRANSDERM-SCOP........... 22
tranylcypromine sulfate ........ 18
TRAVAMULSION............... 31
TRAVASOL ......................... 32
TRAVASOL W/DEXTROSE
........................................... 31
TRAVASOL W/
ELECTROLYTES ............ 32
TRAVASOL with DEXTROSE
........................................... 32
TRAVASOL with
ELECTROLYTES ............ 32
TRAVATAN Z ..................... 55
TRAVERT ............................ 32
TRAVERT IN NORMAL
SALINE ............................ 32
TRAVERT-ELECTROLYTE
NO.1 .................................. 58
TRAVERT-ELECTROLYTE
NO.2 .................................. 58
TRAVERT-ELECTROLYTE
NO.3 .................................. 58
TRAVERT-ELECTROLYTE
NO.4 .................................. 58
travoprost (benzalkonium) .... 55
trazodone hcl ......................... 18
TREANDA ........................... 14
TRECATOR ......................... 22
TRELSTAR .......................... 14
tretinoin ........................... 14, 41
tretinoin microspheres .......... 41
TREXALL ............................ 14
triamcinolone acetonide. 39, 41,
48
triamterene/hydrochlorothiazid
........................................... 36
triazolam ................................. 6
TRIBENZOR ........................ 33
trifluoperazine hcl ................. 25
trifluridine ............................. 43
trihexyphenidyl hcl ................ 23
TRILEPTAL ......................... 16
trimethoprim ........................... 7
TROKENDI XR.................... 16
TROPHAMINE .................... 32
trospium chloride .................. 46
TRUVADA ........................... 26
TUDORZA PRESSAIR ........ 59
TWINRIX ............................. 51
TYGACIL ............................. 10
TYKERB............................... 14
TYPHIM VI .......................... 51
TYSABRI ............................. 50
TYVASO .............................. 61
TYZEKA............................... 27
ULORIC ................................ 55
UROLOGIC SOLUTION G . 52
ursodiol ................................. 45
VAGIFEM ............................ 47
valacyclovir hcl ..................... 27
VALCHLOR ......................... 40
VALCYTE ............................ 27
valproic acid ......................... 16
valproic acid (as sodium salt) 16
valsartan/hydrochlorothiazide
........................................... 33
VALSTAR ............................ 14
vancomycin hcl........................ 7
VANCOMYCIN HCL ............ 7
vancomycin hcl/d5w ................ 7
I-13
MODA Health 2015 Part D Formulary Effective: January 01, 2015
Formulary ID: 15472.000, Version: 5
VAQTA................................. 51
VARIVAX VACCINE ......... 51
VASCEPA ............................ 37
vasopressin ............................ 48
VECTIBIX ............................ 15
VELCADE ............................ 15
venlafaxine hcl ...................... 18
VENTAVIS........................... 61
verapamil hcl ........................ 34
VERSACLOZ ....................... 25
VICTOZA 3-PAK ................. 19
VIDEX .................................. 26
VIGAMOX ........................... 43
VIIBRYD .............................. 18
VIMIZIM .............................. 42
VIMPAT ............................... 16
vinblastine sulfate ................. 15
vincristine sulfate .................. 15
vinorelbine tartrate ............... 15
VIRACEPT ........................... 26
VIRAMUNE XR .................. 26
VIRAZOLE........................... 27
VIREAD ............................... 26
VIVELLE-DOT .................... 47
VOLTAREN ........................... 4
voriconazole .......................... 21
VOTRIENT........................... 15
VPRIV................................... 42
warfarin sodium .................... 28
water for irrigation,sterile .... 52
WELCHOL ........................... 37
XALKORI............................. 15
XARELTO ............................ 28
XELJANZ ............................. 55
XENAZINE .......................... 38
XGEVA................................. 53
XIFAXAN............................... 7
XOLAIR ............................... 59
XTANDI ............................... 15
XYREM ................................ 60
YERVOY .............................. 15
YF-VAX ............................... 51
zafirlukast .............................. 58
zaleplon ................................. 60
ZALTRAP............................. 15
ZAVESCA ............................ 42
ZELBORAF .......................... 15
ZEMAIRA ............................ 59
ZEMPLAR ............................ 53
ZENPEP ................................ 42
ZETIA ................................... 37
ZIAGEN ................................ 26
zidovudine ............................. 26
ziprasidone hcl ...................... 25
ZOLADEX ............................ 15
zoledronic acid ...................... 53
zoledronic acid/
mannitol&water ................ 53
ZOLINZA ............................. 15
zolmitriptan ........................... 21
zolpidem tartrate ................... 60
ZOMETA .............................. 53
zonisamide............................. 16
ZORTRESS........................... 50
ZOSTAVAX ......................... 51
ZOVIRAX............................. 40
ZUBSOLV .............................. 5
ZYKADIA ............................ 15
ZYLET .................................. 44
ZYPREXA RELPREVV ...... 25
ZYTIGA ................................ 15
ZYVOX................................... 7
Moda Health Customer Service
CALL 1-888-786-7509
Calls to this number are free. Customer Service is available from 7
am to 8 pm Pacific time seven days a week, from October 1st to
February14th (After February 15th, your call will be handled by our
automated phone system Saturdays, Sundays and holidays. When
leaving a message, please include your name, number and the time
that you called, and a Customer Service representative will return
your call the next business day.)
Customer Service also has free language interpreter services available
for non-English speakers.
TTY 711
This number requires special telephone equipment and is only for
people who have difficulties with hearing or speaking.
Calls to this number are free. This number is available 24 hours a day
seven days a week.
FAX 1-800-207-8235
WRITE Moda Health Plan, Inc.
P.O. Box 40327
Portland OR 97240-0327
pharmacy@modahealth.com
WEB SITE www.modahealth.com/medicare
This formulary was updated on September 1, 2014. For more recent information or other questions,
please contact us.
Questions? Call 888-786-7509 (TTY users please dial 711) 601 S.W. Second Ave.
Portland, OR 97204-3156
www.modahealth.com/medicare
7830833 (9/14)
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