october 2017 hmsa control formularyrelease to the market. ... synthetic clomiphene §...

CVS Caremark® is an independent company providing pharmacy benefit management services on behalf of HMSA. Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit www.hmsa.com or contact a CVS Caremark Customer Care representative.

October 2017

HMSA Control Formulary

The HMSA Control Formulary is a guide within select therapeutic categories for clients, plan members and health care providers. Generics should be considered the first line of prescribing. If there is no generic available, there may be more than one brand-name

medicine to treat a condition. These preferred brand-name medicines are listed to help identify products that are clinically appropriate and cost-effective. Generics listed in therapeutic categories are for representational purposes only. This is not an all-inclusive list. This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics.

PLAN MEMBER

Your benefit plan provides you with a prescription benefit program administered by CVS Caremark

®. Ask your doctor to consider

prescribing, when medically appropriate, a preferred medicine from this list. Take this list along when you or a covered family member sees a doctor.

Please note:

• Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. Products recently approved by the U.S. Food and Drug Administration (FDA) may not be covered upon release to the market.

• You will be responsible for the full cost of products that are excluded from coverage.

• For specific information regarding your prescription benefit coverage and copay

1 information, please visit www.hmsa.com

or contact a CVS Caremark Customer Care representative.

• CVS Caremark may contact your doctor after receiving your prescription to request consideration of a drug list product or generic equivalent. This may result in your doctor prescribing, when medically appropriate, a different brand-name product or generic equivalent in place of your original prescription.

• In most instances, a brand-name drug for which a generic product becomes available will be designated as a non-preferred option upon release of the generic product to the market.

HEALTH CARE PROVIDER

Your patient is covered under a prescription benefit plan administered by CVS Caremark. As a way to help manage health care costs, authorize generic substitution whenever possible. If you believe a brand-name product is necessary, consider prescribing a brand-name on this list.

Please note:

• Generics should be considered the first line of prescribing.

• This drug list represents a summary of prescription coverage. It is not all-inclusive and does not guarantee coverage. The member’s specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. Products recently approved by the FDA may not be covered upon release to the market.

• The member's prescription benefit plan may have a different copay

1 for specific products on the list.

• Unless specifically indicated, drug list products will include all dosage forms.

• Log in to www.hmsa.com to check coverage and

copay1 information for a specific medicine.

ANALGESICS

§ NSAIDs

diclofenac sodium

ibuprofen

meloxicam

naproxen

§ NSAIDs, COMBINATIONS

diclofenac sodium-misoprostol

§ NSAIDs, TOPICAL

diclofenac sodium solution

VOLTAREN GEL

§ COX-2 INHIBITORS

celecoxib

§ GOUT

allopurinol colchicine tablet probenecid

COLCRYS

ULORIC

§ OPIOID ANALGESICS

codeine-acetaminophen

fentanyl transdermal fentanyl transmucosal

lozenge

hydrocodone-acetaminophen

hydromorphone

methadone

morphine

morphine ext-rel morphine suppository

oxycodone

oxycodone-acetaminophen

tramadol tramadol ext-rel FENTORA

HYSINGLA ER

NUCYNTA

NUCYNTA ER

OPANA ER

OXYCONTIN

SUBSYS

ANTI-INFECTIVES

ANTIBACTERIALS

§ CEPHALOSPORINS

cefdinir cefprozil cefuroxime axetil cephalexin

SUPRAX

§ ERYTHROMYCINS / MACROLIDES

azithromycin

clarithromycin

clarithromycin ext-rel erythromycins

DIFICID

§ FLUOROQUINOLONES

ciprofloxacin

ciprofloxacin ext-rel levofloxacin

moxifloxacin

§ PENICILLINS

amoxicillin

amoxicillin-clavulanate

dicloxacillin

penicillin VK

§ TETRACYCLINES

doxycycline hyclate

minocycline

tetracycline

§ ANTIFUNGALS

fluconazole

itraconazole

terbinafine tablet ONMEL

ANTIRETROVIRAL AGENTS

§ ANTIRETROVIRAL COMBINATIONS

abacavir-lamivudine

lamivudine-zidovudine

ATRIPLA

COMPLERA

DESCOVY

EVOTAZ

GENVOYA

ODEFSEY

PREZCOBIX

STRIBILD

TRIUMEQ

TRUVADA

INTEGRASE INHIBITORS

ISENTRESS

TIVICAY

§ NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS

nevirapine

nevirapine ext-rel EDURANT

INTELENCE

SUSTIVA

Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit www.hmsa.com or contact a CVS Caremark Customer Care representative.

§ NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS

abacavir tablet didanosine

lamivudine

stavudine

zidovudine

EMTRIVA

NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS

VIREAD

§ PROTEASE INHIBITORS

lopinavir-ritonavir solution

KALETRA TABLET

NORVIR

PREZISTA

REYATAZ

§ ANTITUBERCULAR AGENTS

ethambutol isoniazid

pyrazinamide

rifampin

ANTIVIRALS

§ CYTOMEGALOVIRUS AGENTS

valganciclovir

§ HEPATITIS B AGENTS

entecavir tablet lamivudine

BARACLUDE SOLUTION

VEMLIDY

§ HEPATITIS C AGENTS

ribavirin

EPCLUSA (genotypes 2, 3)

HARVONI (genotypes 1, 4, 5, 6)

§ HERPES AGENTS

acyclovir valacyclovir

INFLUENZA AGENTS

RELENZA

TAMIFLU

§ MISCELLANEOUS

clindamycin

ivermectin

metronidazole

nitrofurantoin

sulfamethoxazole-trimethoprim

SIVEXTRO

XIFAXAN 550 MG

CARDIOVASCULAR

§ ACE INHIBITORS

fosinopril lisinopril quinapril

ramipril

§ ACE INHIBITOR / DIURETIC COMBINATIONS

fosinopril-hydrochlorothiazide

lisinopril-hydrochlorothiazide

quinapril-hydrochlorothiazide

§ ADRENOLYTICS, CENTRAL

clonidine

clonidine transdermal guanfacine

§ ALDOSTERONE RECEPTOR ANTAGONISTS

eplerenone

spironolactone

§ ALPHA BLOCKERS

doxazosin

terazosin

§ ANGIOTENSIN II RECEPTOR ANTAGONISTS / DIURETIC COMBINATIONS

candesartan / candesartan-hydrochlorothiazide

eprosartan

irbesartan / irbesartan-hydrochlorothiazide

losartan / losartan-hydrochlorothiazide

telmisartan / telmisartan-hydrochlorothiazide

valsartan / valsartan-hydrochlorothiazide

BENICAR / BENICAR HCT

§ ANGIOTENSIN II RECEPTOR ANTAGONIST / CALCIUM CHANNEL BLOCKER COMBINATIONS

amlodipine-telmisartan

amlodipine-valsartan

AZOR

§ ANGIOTENSIN II RECEPTOR ANTAGONIST / CALCIUM CHANNEL BLOCKER / DIURETIC COMBINATIONS

amlodipine-valsartan-hydrochlorothiazide

TRIBENZOR

§ ANTIARRHYTHMICS

sotalol MULTAQ

ANTILIPEMICS

§ BILE ACID RESINS

cholestyramine

WELCHOL

§ CHOLESTEROL ABSORPTION INHIBITORS

ezetimibe

§ FIBRATES

fenofibrate

fenofibric acid

§ HMG-CoA REDUCTASE INHIBITORS / COMBINATIONS

atorvastatin

fluvastatin

lovastatin

pravastatin

rosuvastatin

simvastatin

VYTORIN

MICROSOMAL TRIGLYCERIDE TRANSFER PROTEIN INHIBITORS

JUXTAPID

§ NIACINS

niacin ext-rel

§ OMEGA-3 FATTY ACIDS

omega-3 acid ethyl esters

§ BETA-BLOCKERS

atenolol carvedilol metoprolol succinate ext-rel metoprolol tartrate

nadolol propranolol propranolol ext-rel BYSTOLIC

§ BETA-BLOCKER / DIURETIC COMBINATIONS

atenolol-chlorthalidone

bisoprolol-hydrochlorothiazide

metoprolol-hydrochlorothiazide

§ CALCIUM CHANNEL BLOCKERS

amlodipine

diltiazem ext-rel 2

nifedipine ext-rel verapamil ext-rel

§ CALCIUM CHANNEL BLOCKER / ANTILIPEMIC COMBINATIONS

amlodipine-atorvastatin

§ DIGITALIS GLYCOSIDES

digoxin

DIRECT RENIN INHIBITORS / DIURETIC COMBINATIONS

TEKTURNA / TEKTURNA HCT

§ DIURETICS

amiloride

furosemide

hydrochlorothiazide

metolazone

spironolactone-hydrochlorothiazide

torsemide

triamterene-hydrochlorothiazide

HEART FAILURE

BIDIL

CORLANOR

ENTRESTO

§ NITRATES

nitroglycerin lingual spray

nitroglycerin sublingual NITROLINGUAL

PULMONARY ARTERIAL HYPERTENSION

ENDOTHELIN RECEPTOR ANTAGONISTS

LETAIRIS

TRACLEER

§ PHOSPHODIESTERASE INHIBITORS

sildenafil

PROSTAGLANDIN VASODILATORS

ORENITRAM

MISCELLANEOUS

RANEXA

CENTRAL NERVOUS

SYSTEM

ANTIANXIETY

§ BENZODIAZEPINES

alprazolam

clonazepam tablet diazepam

lorazepam

oxazepam

§ MISCELLANEOUS

buspirone

clomipramine

fluvoxamine

§ ANTICONVULSANTS

carbamazepine

carbamazepine ext-rel diazepam rectal gel divalproex sodium

divalproex sodium ext-rel ethosuximide

gabapentin

lamotrigine

lamotrigine ext-rel levetiracetam

levetiracetam ext-rel oxcarbazepine

phenobarbital phenytoin

phenytoin sodium extended

primidone

tiagabine

topiramate

valproic acid

zonisamide

FYCOMPA

OXTELLAR XR

QUDEXY XR

TROKENDI XR

VIMPAT

§ ANTIDEMENTIA

donepezil galantamine

galantamine ext-rel memantine

rivastigmine

rivastigmine transdermal NAMENDA XR

NAMZARIC

ANTIDEPRESSANTS

§ SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs)

citalopram

escitalopram

fluoxetine

paroxetine

paroxetine ext-rel sertraline

TRINTELLIX

VIIBRYD

§ SEROTONIN NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIs)

duloxetine

venlafaxine

venlafaxine ext-rel capsule

PRISTIQ

§ TRICYCLIC ANTIDEPRESSANTS (TCAs)

amitriptyline

desipramine

doxepin

imipramine HCl nortriptyline

§ MISCELLANEOUS AGENTS

bupropion

bupropion ext-rel mirtazapine

trazodone

§ ANTIPARKINSONIAN AGENTS

amantadine

carbidopa-levodopa

carbidopa-levodopa ext-rel carbidopa-levodopa-

entacapone

entacapone

pramipexole

ropinirole

ropinirole ext-rel selegiline

AZILECT


MIRAPEX ER

NEUPRO

ANTIPSYCHOTICS

§ ATYPICALS

aripiprazole

clozapine

olanzapine

quetiapine

risperidone

ziprasidone

SEROQUEL XR

§ MISCELLANEOUS

chlorpromazine

fluphenazine

haloperidol perphenazine

thiothixene

trifluoperazine

§ ATTENTION DEFICIT HYPERACTIVITY DISORDER

amphetamine-dextroamphetamine mixed salts ext-rel

dexmethylphenidate

dexmethylphenidate ext-rel dextroamphetamine

dextroamphetamine ext-rel guanfacine ext-rel methylphenidate

methylphenidate ext-rel APTENSIO XR

QUILLIVANT XR

STRATTERA

VYVANSE

FIBROMYALGIA

LYRICA

SAVELLA

§ HUNTINGTON'S DISEASE AGENTS

tetrabenazine

HYPNOTICS

§ BENZODIAZEPINES

temazepam

§ NONBENZODIAZEPINES

zolpidem

zolpidem ext-rel zolpidem sublingual

MIGRAINE

§ SELECTIVE SEROTONIN AGONISTS

naratriptan

rizatriptan

sumatriptan

zolmitriptan

RELPAX

ZOMIG NASAL SPRAY

§ MOOD STABILIZERS

lithium carbonate

lithium carbonate ext-rel tablet 300 mg


MULTIPLE SCLEROSIS AGENTS

AUBAGIO

GILENYA

TECFIDERA

§ MUSCULOSKELETAL THERAPY AGENTS

baclofen

carisoprodol chlorzoxazone

cyclobenzaprine

dantrolene

metaxalone

methocarbamol orphenadrine-aspirin-caffeine

tizanidine

§ MYASTHENIA GRAVIS

pyridostigmine

MESTINON TIMESPAN

§ NARCOLEPSY

armodafinil

POSTHERPETIC NEURALGIA (PHN)

HORIZANT

PSYCHOTHERAPEUTIC - MISCELLANEOUS

§ ALCOHOL DETERRENTS

acamprosate calcium

disulfiram

§ OPIOID ANTAGONISTS

naltrexone

NARCAN NASAL SPRAY

§ PARTIAL OPIOID AGONIST / OPIOID ANTAGONIST COMBINATIONS

buprenorphine-naloxone sublingual tablet

SUBOXONE FILM

VASOMOTOR SYMPTOM AGENTS

BRISDELLE

ENDOCRINE AND

METABOLIC

§ ANDROGENS

testosterone gel 2%

ANDRODERM

AXIRON

ANTIDIABETICS

§ ALPHA-GLUCOSIDASE INHIBITORS

acarbose

§ BIGUANIDES

metformin

metformin ext-rel 3

§ BIGUANIDE / SULFONYLUREA COMBINATIONS

glipizide-metformin

DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS

JANUVIA

TRADJENTA

DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITOR / BIGUANIDE COMBINATIONS

JANUMET

JANUMET XR

JENTADUETO

JENTADUETO XR

INCRETIN MIMETIC AGENTS

TRULICITY

VICTOZA

INSULINS

BASAGLAR

HUMULIN R U-500

LEVEMIR

NOVOLIN 70/30

NOVOLIN N

NOVOLIN R

NOVOLOG

NOVOLOG MIX 70/30

TRESIBA

§ INSULIN SENSITIZERS

pioglitazone

§ INSULIN SENSITIZER / BIGUANIDE COMBINATIONS

pioglitazone-metformin

§ INSULIN SENSITIZER / SULFONYLUREA COMBINATIONS

pioglitazone-glimepiride

§ MEGLITINIDES

nateglinide

repaglinide

SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS

FARXIGA

JARDIANCE

SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITOR / BIGUANIDE COMBINATIONS

XIGDUO XR

§ SULFONYLUREAS

glimepiride

glipizide

glipizide ext-rel

SUPPLIES

BD ULTRAFINE INSULIN SYRINGES AND NEEDLES

ONETOUCH ULTRA TEST STRIPS

ONETOUCH VERIO TEST STRIPS

CALCIUM REGULATORS

§ BISPHOSPHONATES

alendronate

ibandronate

risedronate

ATELVIA

§ CALCITONINS

calcitonin-salmon

§ CARNITINE DEFICIENCY AGENTS

levocarnitine

CONTRACEPTIVES

§ MONOPHASIC

ethinyl estradiol-drospirenone

BEYAZ

LO LOESTRIN FE

MINASTRIN 24 FE

SAFYRAL

§ TRIPHASIC

ethinyl estradiol-norgestimate

FOUR PHASE

NATAZIA

§ EXTENDED CYCLE

ethinyl estradiol-levonorgestrel

§ PROGESTIN ONLY

norethindrone

§ TRANSDERMAL

ethinyl estradiol-norelgestromin

VAGINAL

NUVARING

ESTROGENS

§ ORAL

estradiol estropipate

PREMARIN

§ TRANSDERMAL

estradiol DIVIGEL

EVAMIST

MINIVELLE

VAGINAL

ESTRACE CREAM

PREMARIN CREAM

VAGIFEM

ESTROGEN / PROGESTINS

§ ORAL

estradiol-norethindrone

PREMPHASE

PREMPRO

TRANSDERMAL

CLIMARA PRO

FERTILITY REGULATORS

§ OVULATION STIMULANTS, SYNTHETIC

clomiphene

§ GLUCOCORTICOIDS

dexamethasone

methylprednisolone

prednisone

GLUCOSE ELEVATING AGENTS

GLUCAGEN HYPOKIT

GLUCAGON EMERGENCY KIT

§ HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS

calcitriol (1,25-D3) doxercalciferol paricalcitol

§ PHOSPHATE BINDER AGENTS

calcium acetate

PHOSLYRA

RENVELA

VELPHORO

POTASSIUM-REMOVING AGENTS

VELTASSA

PROGESTINS

§ ORAL

medroxyprogesterone

progesterone, micronized

MEGACE ES

VAGINAL

ENDOMETRIN

§ SELECTIVE ESTROGEN RECEPTOR MODULATORS

raloxifene

OSPHENA

SELECTIVE ESTROGEN RECEPTOR MODULATOR COMBINATIONS

DUAVEE

THYROID AGENTS

§ ANTITHYROID AGENTS

methimazole

propylthiouracil


§ THYROID SUPPLEMENTS

levothyroxine

§ VASOPRESSINS

desmopressin spray, tablet

§ MISCELLANEOUS

cabergoline

GASTROINTESTINAL

§ ANTIDIARRHEALS

diphenoxylate-atropine

loperamide

§ ANTIEMETICS

dronabinol granisetron

meclizine

metoclopramide

ondansetron

prochlorperazine

promethazine

trimethobenzamide

VARUBI

§ ANTISPASMODICS

chlordiazepoxide-clidinium

dicyclomine

§ CHOLELITHOLYTICS

ursodiol

§ H2 RECEPTOR ANTAGONISTS

ranitidine

INFLAMMATORY BOWEL DISEASE

§ ORAL AGENTS

balsalazide

budesonide capsule

sulfasalazine

sulfasalazine delayed-rel APRISO

LIALDA

PENTASA

UCERIS

§ RECTAL AGENTS

hydrocortisone enema

mesalamine rectal suspension

CANASA

CORTIFOAM

IRRITABLE BOWEL SYNDROME

AMITIZA

LINZESS

LOTRONEX

VIBERZI

§ LAXATIVES

lactulose

peg 3350-electrolytes

SUPREP

OPIOID-INDUCED CONSTIPATION

MOVANTIK

PANCREATIC ENZYMES

CREON

VIOKACE

ZENPEP

§ PROSTAGLANDINS

misoprostol

§ PROTON PUMP INHIBITORS

esomeprazole

lansoprazole

omeprazole

pantoprazole

DEXILANT

§ SALIVA STIMULANTS

cevimeline

pilocarpine tablet

STEROIDS, RECTAL

PROCTOFOAM-HC

§ ULCER THERAPY COMBINATIONS

lansoprazole + amoxicillin + clarithromycin

PYLERA

§ MISCELLANEOUS

sucralfate

GENITOURINARY

§ BENIGN PROSTATIC HYPERPLASIA

alfuzosin ext-rel doxazosin

dutasteride

dutasteride-tamsulosin

finasteride

tamsulosin

terazosin

CARDURA XL

CIALIS 5 MG

RAPAFLO

§ URINARY ANTISPASMODICS

darifenacin ext-rel oxybutynin ext-rel tolterodine

tolterodine ext-rel trospium

trospium ext-rel MYRBETRIQ

TOVIAZ

VESICARE

HEMATOLOGIC

ANTICOAGULANTS

§ ORAL

warfarin

ELIQUIS

XARELTO

§ PLATELET AGGREGATION INHIBITORS

clopidogrel dipyridamole ext-rel-aspirin

BRILINTA

EFFIENT

§ PLATELET SYNTHESIS INHIBITORS

anagrelide

§ MISCELLANEOUS

cilostazol

IMMUNOLOGIC

AGENTS

ALLERGENIC EXTRACTS

GRASTEK

ORALAIR

RAGWITEK

§ DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs)

hydroxychloroquine

leflunomide

methotrexate

IMMUNOSUPPRESSANTS

§ ANTIMETABOLITES

azathioprine

mycophenolate mofetil mycophenolate sodium

§ CALCINEURIN INHIBITORS

cyclosporine

cyclosporine, modified

tacrolimus

§ RAPAMYCIN DERIVATIVES

sirolimus tablet RAPAMUNE SOLUTION

NUTRITIONAL /

SUPPLEMENTS

§ ELECTROLYTES

potassium chloride ext-rel potassium chloride liquid

VITAMINS AND MINERALS

§ FOLIC ACID / COMBINATIONS

folic acid

folic acid-vitamin B6- vitamin B12

RESPIRATORY

§ ANAPHYLAXIS TREATMENT AGENTS

epinephrine auto-injector EPIPEN

EPIPEN JR

§ ANTICHOLINERGICS

ipratropium inhalation solution

SPIRIVA

ANTICHOLINERGIC / BETA AGONIST COMBINATIONS

§ SHORT ACTING

ipratropium-albuterol inhalation solution

COMBIVENT RESPIMAT

LONG ACTING

ANORO ELLIPTA

BEVESPI AEROSPHERE

§ ANTIHISTAMINES, LOW SEDATING

levocetirizine

§ ANTIHISTAMINES, SEDATING

clemastine 2.68 mg

cyproheptadine

§ ANTITUSSIVES

benzonatate

ANTITUSSIVE COMBINATIONS

§ OPIOID

codeine-chlorpheniramine-pseudoephedrine

codeine-guaifenesin liquid

codeine-guaifenesin-pseudoephedrine

codeine-promethazine

codeine-promethazine-phenylephrine

hydrocodone-homatropine

§ NON-OPIOID

dextromethorphan-brompheniramine-pseudoephedrine

dextromethorphan-promethazine

BETA AGONISTS, INHALANTS

§ SHORT ACTING

albuterol inhalation solution

PROAIR HFA

PROAIR RESPICLICK

LONG ACTING

Hand-held Active Inhalation

SEREVENT

STRIVERDI RESPIMAT

Nebulized Passive Inhalation

PERFOROMIST

§ CYSTIC FIBROSIS

tobramycin inhalation solution

BETHKIS

§ LEUKOTRIENE RECEPTOR ANTAGONISTS

montelukast zafirlukast

§ MAST CELL STABILIZERS

cromolyn solution

§ NASAL ANTIHISTAMINES

azelastine

olopatadine

§ NASAL STEROIDS / COMBINATIONS

flunisolide

fluticasone

mometasone

triamcinolone

DYMISTA

PHOSPHODIESTERASE-4 INHIBITORS

DALIRESP

PULMONARY FIBROSIS AGENTS

ESBRIET

OFEV

STEROID / BETA AGONIST COMBINATIONS

ADVAIR

DULERA

§ STEROID INHALANTS

budesonide inhalation suspension

ASMANEX

QVAR

TOPICAL

DERMATOLOGY

ACNE

§ Oral

isotretinoin

§ Topical

adapalene

clindamycin solution

clindamycin-benzoyl peroxide

erythromycin solution

erythromycin-benzoyl peroxide

tretinoin

ACANYA

ATRALIN

BENZACLIN

DIFFERIN CREAM

DIFFERIN GEL 0.3%

DIFFERIN LOTION

EPIDUO

RETIN-A MICRO

TAZORAC

§ ACTINIC KERATOSIS

fluorouracil cream 5%

fluorouracil solution


imiquimod

PICATO

§ ANTIBIOTICS

gentamicin

mupirocin

silver sulfadiazine

§ ANTIFUNGALS

ciclopirox

clotrimazole

econazole

ketoconazole

nystatin

oxiconazole

LUZU

NAFTIN

§ ANTIPSORIATICS

acitretin

calcipotriene

methoxsalen

§ ANTISEBORRHEICS

ketoconazole shampoo 2%

§ ATOPIC DERMATITIS

tacrolimus

ELIDEL

CORTICOSTEROIDS

§ Low Potency

desonide

hydrocortisone

§ Medium Potency

hydrocortisone butyrate

mometasone

triamcinolone

CLODERM

LOCOID LOTION

§ High Potency

desoximetasone

fluocinonide

§ Very High Potency

clobetasol cream, foam, gel, lotion, ointment, shampoo

§ EMOLLIENTS

ammonium lactate 12%

§ LOCAL ANALGESICS

lidocaine patch

§ LOCAL ANESTHETICS

lidocaine-prilocaine

§ ROSACEA

metronidazole

FINACEA

ORACEA

§ SCABICIDES AND PEDICULICIDES

malathion

permethrin 5%

§ MISCELLANEOUS SKIN AND MUCOUS MEMBRANE

imiquimod

podofilox

MOUTH / THROAT / DENTAL AGENTS

PROTECTANTS

MUGARD

OPHTHALMIC

§ ANTIALLERGICS

azelastine

cromolyn sodium

olopatadine

PATADAY

PAZEO

§ ANTI-INFECTIVES

ciprofloxacin

erythromycin

gentamicin

levofloxacin

ofloxacin

sulfacetamide

tobramycin

BESIVANCE

MOXEZA

VIGAMOX

§ ANTI-INFECTIVE / ANTI-INFLAMMATORY COMBINATIONS

neomycin-polymyxin B-bacitracin-hydrocortisone

neomycin-polymyxin B-dexamethasone

tobramycin-dexamethasone

TOBRADEX OINTMENT

TOBRADEX ST

ZYLET

ANTI-INFLAMMATORIES

§ Nonsteroidal

bromfenac

diclofenac

ketorolac

PROLENSA

§ Steroidal

dexamethasone

prednisolone acetate 1%

ALREX

LOTEMAX

§ ANTIVIRALS

trifluridine

BETA-BLOCKERS

§ Nonselective

timolol maleate solution

BETIMOL

Selective

BETOPTIC S

§ CARBONIC ANHYDRASE INHIBITORS

dorzolamide

AZOPT

§ CARBONIC ANHYDRASE INHIBITOR / BETA-BLOCKER COMBINATIONS

dorzolamide-timolol

DRY EYE DISEASE

XIIDRA

§ PROSTAGLANDINS

latanoprost TRAVATAN Z

ZIOPTAN

§ SYMPATHOMIMETICS

brimonidine

ALPHAGAN P

SYMPATHOMIMETIC / BETA-BLOCKER COMBINATIONS

COMBIGAN

OTIC

§ ANTI-INFECTIVES

acetic acid

acetic acid-aluminum acetate

ofloxacin otic

§ ANTI-INFECTIVE / ANTI-INFLAMMATORY COMBINATIONS

neomycin-polymyxin B-hydrocortisone

CIPRODEX

QUICK REFERENCE DRUG LIST

A

abacavir tablet abacavir-lamivudine

acamprosate calcium

ACANYA

acarbose

acetic acid

acetic acid-aluminum acetate

acitretin

acyclovir adapalene

ADVAIR

albuterol inhalation solution

alendronate

alfuzosin ext-rel allopurinol ALPHAGAN P

alprazolam

ALREX

amantadine

amiloride

AMITIZA

amitriptyline

amlodipine

amlodipine-atorvastatin

amlodipine-telmisartan

amlodipine-valsartan

amlodipine-valsartan-hydrochlorothiazide

ammonium lactate 12%

amoxicillin

amoxicillin-clavulanate

amphetamine-dextroamphetamine mixed salts ext-rel

anagrelide

ANDRODERM

ANORO ELLIPTA

APRISO

APTENSIO XR

aripiprazole

armodafinil ASMANEX

ATELVIA

atenolol atenolol-chlorthalidone

atorvastatin

ATRALIN

ATRIPLA

AUBAGIO

AXIRON

azathioprine

azelastine

AZILECT

azithromycin

AZOPT

AZOR

B

baclofen

balsalazide

BARACLUDE SOLUTION

BASAGLAR

BD ULTRAFINE INSULIN SYRINGES AND NEEDLES

BENICAR

BENICAR HCT

BENZACLIN

benzonatate

BESIVANCE

BETHKIS

BETIMOL

BETOPTIC S

BEVESPI AEROSPHERE

BEYAZ

BIDIL

bisoprolol-hydrochlorothiazide

BRILINTA

brimonidine

BRISDELLE

bromfenac

budesonide capsule

budesonide inhalation suspension

buprenorphine-naloxone sublingual tablet

bupropion

bupropion ext-rel buspirone

BYSTOLIC

C

cabergoline

calcipotriene

calcitonin-salmon

calcitriol (1,25-D3) calcium acetate

CANASA

candesartan

candesartan-hydrochlorothiazide

carbamazepine

carbamazepine ext-rel carbidopa-levodopa

carbidopa-levodopa ext-rel carbidopa-levodopa-

entacapone

CARDURA XL

carisoprodol carvedilol cefdinir cefprozil cefuroxime axetil

celecoxib

cephalexin

cevimeline

chlordiazepoxide-clidinium

chlorpromazine

chlorzoxazone

cholestyramine

CIALIS 5 MG

ciclopirox

cilostazol CIPRODEX

ciprofloxacin

ciprofloxacin ext-rel citalopram

clarithromycin

clarithromycin ext-rel clemastine 2.68 mg

CLIMARA PRO

clindamycin

clindamycin solution

clindamycin-benzoyl peroxide

clobetasol cream, foam, gel, lotion, ointment, shampoo

CLODERM

clomiphene

clomipramine

clonazepam tablet clonidine


clonidine transdermal clopidogrel clotrimazole

clozapine

codeine-acetaminophen

codeine-chlorpheniramine-pseudoephedrine

codeine-guaifenesin liquid

codeine-guaifenesin-pseudoephedrine

codeine-promethazine

codeine-promethazine-phenylephrine

colchicine tablet COLCRYS

COMBIGAN

COMBIVENT RESPIMAT

COMPLERA

CORLANOR

CORTIFOAM

CREON

cromolyn sodium

cromolyn solution

cyclobenzaprine

cyclosporine

cyclosporine, modified

cyproheptadine

D

DALIRESP

dantrolene

darifenacin ext-rel DESCOVY

desipramine

desmopressin spray, tablet desonide

desoximetasone

dexamethasone

DEXILANT

dexmethylphenidate

dexmethylphenidate ext-rel dextroamphetamine

dextroamphetamine ext-rel dextromethorphan-

brompheniramine-pseudoephedrine

dextromethorphan-promethazine

diazepam

diazepam rectal gel diclofenac

diclofenac sodium

diclofenac sodium solution

diclofenac sodium-misoprostol

dicloxacillin

dicyclomine

didanosine

DIFFERIN CREAM

DIFFERIN GEL 0.3%

DIFFERIN LOTION

DIFICID

digoxin

diltiazem ext-rel 2

diphenoxylate-atropine

dipyridamole ext-rel-aspirin

disulfiram

divalproex sodium

divalproex sodium ext-rel DIVIGEL

donepezil dorzolamide

dorzolamide-timolol doxazosin

doxepin

doxercalciferol doxycycline hyclate

dronabinol DUAVEE

DULERA

duloxetine

dutasteride

dutasteride-tamsulosin

DYMISTA

E

econazole

EDURANT

EFFIENT

ELIDEL

ELIQUIS

EMTRIVA

ENDOMETRIN

entacapone

entecavir tablet ENTRESTO

EPCLUSA

EPIDUO

epinephrine auto-injector EPIPEN

EPIPEN JR

eplerenone

eprosartan

erythromycin

erythromycin solution

erythromycin-benzoyl peroxide

erythromycins

ESBRIET

escitalopram

esomeprazole

ESTRACE CREAM

estradiol estradiol-norethindrone

estropipate

ethambutol ethinyl estradiol-

drospirenone

ethinyl estradiol-levonorgestrel

ethinyl estradiol-norelgestromin

ethinyl estradiol-norgestimate

ethosuximide

EVAMIST

EVOTAZ

ezetimibe

F

FARXIGA

fenofibrate

fenofibric acid

fentanyl transdermal fentanyl transmucosal

lozenge

FENTORA

FINACEA

finasteride

fluconazole

flunisolide

fluocinonide

fluorouracil cream 5%

fluorouracil solution

fluoxetine

fluphenazine

fluticasone

fluvastatin

fluvoxamine

folic acid

folic acid-vitamin B6-vitamin B12

fosinopril fosinopril-hydrochlorothiazide

furosemide

FYCOMPA

G

gabapentin

galantamine

galantamine ext-rel gentamicin

GENVOYA

GILENYA

glimepiride

glipizide

glipizide ext-rel glipizide-metformin

GLUCAGEN HYPOKIT

GLUCAGON EMERGENCY KIT

granisetron

GRASTEK

guanfacine

guanfacine ext-rel

H

haloperidol HARVONI HORIZANT

HUMULIN R U-500

hydrochlorothiazide

hydrocodone-acetaminophen

hydrocodone-homatropine

hydrocortisone

hydrocortisone butyrate

hydrocortisone enema

hydromorphone

hydroxychloroquine

HYSINGLA ER

I

ibandronate

ibuprofen

imipramine HCl imiquimod

INTELENCE

ipratropium inhalation solution

ipratropium-albuterol inhalation solution

irbesartan

irbesartan-hydrochlorothiazide

ISENTRESS

isoniazid

isotretinoin

itraconazole

ivermectin

J

JANUMET

JANUMET XR

JANUVIA

JARDIANCE

JENTADUETO

JENTADUETO XR

JUXTAPID

K

KALETRA TABLET

ketoconazole

ketoconazole shampoo 2%

ketorolac

L

lactulose

lamivudine

lamivudine-zidovudine

lamotrigine

lamotrigine ext-rel lansoprazole

lansoprazole + amoxicillin + clarithromycin

latanoprost leflunomide

LETAIRIS

LEVEMIR

levetiracetam

levetiracetam ext-rel levocarnitine

levocetirizine

levofloxacin

levothyroxine

LIALDA

lidocaine patch

lidocaine-prilocaine

LINZESS

lisinopril lisinopril-hydrochlorothiazide

lithium carbonate



LO LOESTRIN FE

LOCOID LOTION

loperamide

lopinavir-ritonavir solution

lorazepam

losartan

losartan-hydrochlorothiazide

LOTEMAX

LOTRONEX

lovastatin

LUZU

LYRICA

M

malathion

meclizine

medroxyprogesterone

MEGACE ES

meloxicam

memantine

mesalamine rectal suspension

MESTINON TIMESPAN

metaxalone

metformin

metformin ext-rel 3

methadone

methimazole

methocarbamol methotrexate

methoxsalen

methylphenidate

methylphenidate ext-rel methylprednisolone

metoclopramide

metolazone

metoprolol succinate ext-rel metoprolol tartrate

metoprolol-hydrochlorothiazide

metronidazole

MINASTRIN 24 FE

MINIVELLE

minocycline

MIRAPEX ER

mirtazapine

misoprostol mometasone

montelukast morphine

morphine ext-rel morphine suppository

MOVANTIK

MOXEZA

moxifloxacin

MUGARD

MULTAQ

mupirocin

mycophenolate mofetil mycophenolate sodium

MYRBETRIQ

N

nadolol NAFTIN

naltrexone

NAMENDA XR

NAMZARIC

naproxen

naratriptan

NARCAN NASAL SPRAY

NATAZIA

nateglinide

neomycin-polymyxin B-bacitracin-hydrocortisone

neomycin-polymyxin B-dexamethasone

neomycin-polymyxin B-hydrocortisone

NEUPRO


nevirapine

nevirapine ext-rel niacin ext-rel nifedipine ext-rel nitrofurantoin

nitroglycerin lingual spray

nitroglycerin sublingual NITROLINGUAL

norethindrone

nortriptyline

NORVIR

NOVOLIN 70/30

NOVOLIN N

NOVOLIN R

NOVOLOG

NOVOLOG MIX 70/30

NUCYNTA

NUCYNTA ER

NUVARING

nystatin

O

ODEFSEY

OFEV

ofloxacin

ofloxacin otic

olanzapine

olopatadine

omega-3 acid ethyl esters

omeprazole

ondansetron

ONETOUCH ULTRA TEST STRIPS

ONETOUCH VERIO TEST STRIPS

ONMEL

OPANA ER

ORACEA

ORALAIR

ORENITRAM

orphenadrine-aspirin-caffeine

OSPHENA

oxazepam

oxcarbazepine

oxiconazole

OXTELLAR XR

oxybutynin ext-rel oxycodone

oxycodone-acetaminophen

OXYCONTIN

P

pantoprazole

paricalcitol paroxetine

paroxetine ext-rel PATADAY

PAZEO

peg 3350-electrolytes

penicillin VK

PENTASA

PERFOROMIST

permethrin 5%

perphenazine

phenobarbital phenytoin

phenytoin sodium extended

PHOSLYRA

PICATO

pilocarpine tablet pioglitazone

pioglitazone-glimepiride

pioglitazone-metformin

podofilox

potassium chloride ext-rel potassium chloride liquid

pramipexole

pravastatin

prednisolone acetate 1%

prednisone

PREMARIN

PREMARIN CREAM

PREMPHASE

PREMPRO

PREZCOBIX

PREZISTA

primidone

PRISTIQ

PROAIR HFA

PROAIR RESPICLICK

probenecid

prochlorperazine

PROCTOFOAM-HC

progesterone, micronized

PROLENSA

promethazine

propranolol propranolol ext-rel propylthiouracil PYLERA

pyrazinamide

pyridostigmine

Q

QUDEXY XR

quetiapine

QUILLIVANT XR

quinapril quinapril-hydrochlorothiazide

QVAR

R

RAGWITEK

raloxifene

ramipril RANEXA

ranitidine

RAPAFLO

RAPAMUNE SOLUTION

RELENZA

RELPAX

RENVELA

repaglinide

RETIN-A MICRO

REYATAZ

ribavirin

rifampin

risedronate

risperidone

rivastigmine

rivastigmine transdermal rizatriptan

ropinirole

ropinirole ext-rel rosuvastatin

S

SAFYRAL

SAVELLA

selegiline

SEREVENT

SEROQUEL XR

sertraline

sildenafil silver sulfadiazine

simvastatin

sirolimus tablet SIVEXTRO

sotalol SPIRIVA

spironolactone

spironolactone-hydrochlorothiazide

stavudine

STRATTERA

STRIBILD

STRIVERDI RESPIMAT

SUBOXONE FILM

SUBSYS

sucralfate

sulfacetamide

sulfamethoxazole-trimethoprim

sulfasalazine

sulfasalazine delayed-rel sumatriptan

SUPRAX

SUPREP

SUSTIVA

T

tacrolimus

TAMIFLU

tamsulosin

TAZORAC

TECFIDERA

TEKTURNA

TEKTURNA HCT

telmisartan

telmisartan-hydrochlorothiazide

temazepam

terazosin

terbinafine tablet testosterone gel 2%

tetrabenazine

tetracycline

thiothixene

tiagabine

timolol maleate solution

TIVICAY

tizanidine

TOBRADEX OINTMENT

TOBRADEX ST

tobramycin

tobramycin inhalation solution

tobramycin-dexamethasone

tolterodine

tolterodine ext-rel topiramate

torsemide

TOVIAZ

TRACLEER

TRADJENTA

tramadol tramadol ext-rel TRAVATAN Z

trazodone

TRESIBA

tretinoin

triamcinolone

triamterene-hydrochlorothiazide

TRIBENZOR

trifluoperazine

trifluridine

trimethobenzamide

TRINTELLIX

TRIUMEQ

TROKENDI XR

trospium

trospium ext-rel TRULICITY

TRUVADA

U

UCERIS

ULORIC

ursodiol

V

VAGIFEM

valacyclovir valganciclovir valproic acid

valsartan

valsartan-hydrochlorothiazide

VARUBI VELPHORO

VELTASSA

VEMLIDY

venlafaxine

venlafaxine ext-rel capsule

verapamil ext-rel VESICARE

VIBERZI VICTOZA

VIGAMOX

VIIBRYD

VIMPAT

VIOKACE

VIREAD

VOLTAREN GEL

VYTORIN

VYVANSE

W

warfarin

WELCHOL

X

XARELTO

XIFAXAN 550 MG

XIGDUO XR

XIIDRA

Z

zafirlukast ZENPEP

zidovudine

ZIOPTAN

ziprasidone

zolmitriptan

zolpidem

zolpidem ext-rel zolpidem sublingual ZOMIG NASAL SPRAY

zonisamide

ZYLET


PREFERRED OPTIONS FOR EXCLUDED MEDICATIONS 4

EXCLUDED DRUG NAME(S) PREFERRED OPTION(S)*

ABILIFY aripiprazole, clozapine, olanzapine, quetiapine, risperidone, ziprasidone, SEROQUEL XR

ABSTRAL fentanyl transmucosal lozenge, FENTORA, SUBSYS

ACCU-CHEK TEST STRIPS 5 ONETOUCH ULTRA TEST STRIPS, ONETOUCH VERIO TEST STRIPS

ACTICLATE doxycycline hyclate

ACTOS pioglitazone

ACUVAIL bromfenac, diclofenac, ketorolac, PROLENSA

ADCIRCA sildenafil

ADDERALL XR amphetamine-dextroamphetamine mixed salts ext-rel, dexmethylphenidate ext-rel, dextroamphetamine ext-rel, methylphenidate ext-rel, APTENSIO XR, QUILLIVANT XR, VYVANSE

ADRENACLICK epinephrine auto-injector, EPIPEN, EPIPEN JR

AEROSPAN ASMANEX, QVAR

ALCORTIN A hydrocortisone

ALLISON MEDICAL INSULIN SYRINGES 6

BD ULTRAFINE INSULIN SYRINGES

ALOQUIN hydrocortisone

ALORA estradiol, DIVIGEL, EVAMIST, MINIVELLE

ALTOPREV atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin, VYTORIN

ALVESCO ASMANEX, QVAR

AMRIX cyclobenzaprine

ANDROGEL testosterone gel 2%, ANDRODERM, AXIRON

APEXICON-E desoximetasone, fluocinonide

APIDRA NOVOLOG

APTIOM gabapentin, lamotrigine, lamotrigine ext-rel, levetiracetam, levetiracetam ext-rel, oxcarbazepine, tiagabine, topiramate, zonisamide, FYCOMPA

ARCAPTA SEREVENT, STRIVERDI RESPIMAT

ARTHROTEC celecoxib or diclofenac sodium, ibuprofen, meloxicam or naproxen WITH esomeprazole, lansoprazole, omeprazole, pantoprazole or DEXILANT

ASACOL HD balsalazide, sulfasalazine, sulfasalazine delayed-rel, APRISO, LIALDA, PENTASA

ASCENSIA TEST STRIPS 5 ONETOUCH ULTRA TEST STRIPS, ONETOUCH VERIO TEST STRIPS

ATACAND, ATACAND HCT candesartan, candesartan-hydrochlorothiazide, eprosartan, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide, BENICAR, BENICAR HCT

ATROVENT HFA ipratropium inhalation solution, SPIRIVA

AUVI-Q epinephrine auto-injector, EPIPEN, EPIPEN JR

AZASITE ciprofloxacin, erythromycin, gentamicin, levofloxacin, ofloxacin, sulfacetamide, tobramycin, BESIVANCE, MOXEZA, VIGAMOX


AZELEX adapalene, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, ACANYA, ATRALIN, BENZACLIN, DIFFERIN CREAM, DIFFERIN GEL 0.3%, DIFFERIN LOTION, EPIDUO, RETIN-A MICRO, TAZORAC

BECONASE AQ flunisolide, fluticasone, mometasone, triamcinolone, DYMISTA

BENSAL HP desonide, hydrocortisone

BEPREVE azelastine, cromolyn sodium, olopatadine, PATADAY, PAZEO

BETAPACE, BETAPACE AF sotalol

BREEZE 2 TEST STRIPS 5 ONETOUCH ULTRA TEST STRIPS, ONETOUCH VERIO TEST STRIPS

BROVANA PERFOROMIST

butalbital-acetaminophen-caffeine capsule

naratriptan, rizatriptan, sumatriptan, zolmitriptan, RELPAX, ZOMIG NASAL SPRAY

BYDUREON TRULICITY, VICTOZA

BYETTA TRULICITY, VICTOZA

CAFERGOT naratriptan, rizatriptan, sumatriptan, zolmitriptan, RELPAX, ZOMIG NASAL SPRAY

CARAC fluorouracil cream 5%, fluorouracil solution, imiquimod, PICATO

CARDIZEM diltiazem ext-rel (except generic CARDIZEM LA)

CARDIZEM CD diltiazem ext-rel (except generic CARDIZEM LA)

CARDIZEM LA (and its generics) diltiazem ext-rel (except generic CARDIZEM LA)

CARNITOR levocarnitine

CARNITOR SF levocarnitine

CELEBREX celecoxib, diclofenac sodium, ibuprofen, meloxicam, naproxen

clobetasol spray clobetasol foam

CLOBEX SPRAY clobetasol foam

COLAZAL balsalazide

COMBIPATCH CLIMARA PRO

CONTOUR NEXT TEST STRIPS 5 ONETOUCH ULTRA TEST STRIPS, ONETOUCH VERIO TEST STRIPS

CONTOUR TEST STRIPS 5 ONETOUCH ULTRA TEST STRIPS, ONETOUCH VERIO TEST STRIPS

CORDRAN TAPE clobetasol cream, clobetasol lotion, clobetasol ointment

COREG CR atenolol, carvedilol, metoprolol succinate ext-rel, metoprolol tartrate, nadolol, propranolol, propranolol ext-rel, BYSTOLIC

COSOPT PF dorzolamide-timolol

CRESTOR atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin, VYTORIN

CRINONE ENDOMETRIN

CYMBALTA duloxetine, venlafaxine, venlafaxine ext-rel capsule, PRISTIQ

DAKLINZA EPCLUSA (genotypes 2, 3), HARVONI (genotypes 1, 4, 5, 6)



DELZICOL balsalazide, sulfasalazine, sulfasalazine delayed-rel, APRISO, LIALDA, PENTASA

DESVENLAFAXINE ER duloxetine, venlafaxine, venlafaxine ext-rel capsule, PRISTIQ

DETROL LA darifenacin ext-rel, oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ, TOVIAZ, VESICARE

DEXPAK dexamethasone, methylprednisolone, prednisone

DILANTIN carbamazepine, carbamazepine ext-rel, lamotrigine, lamotrigine ext-rel, levetiracetam, levetiracetam ext-rel, phenytoin, phenytoin sodium extended, primidone, topiramate, FYCOMPA, QUDEXY XR, TROKENDI XR

DIOVAN, DIOVAN HCT candesartan, candesartan-hydrochlorothiazide, eprosartan, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide, BENICAR, BENICAR HCT

DUREZOL dexamethasone, prednisolone acetate 1%, LOTEMAX

DUTOPROL metoprolol succinate ext-rel WITH hydrochlorothiazide

DYRENIUM amiloride

ECOZA clotrimazole, econazole, ketoconazole, oxiconazole, LUZU, NAFTIN

EDARBI, EDARBYCLOR candesartan, candesartan-hydrochlorothiazide, eprosartan, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide, BENICAR, BENICAR HCT

EDLUAR zolpidem, zolpidem ext-rel, zolpidem sublingual

E.E.S. GRANULES erythromycins

EMBEDA morphine ext-rel, HYSINGLA ER, NUCYNTA ER, OPANA ER, OXYCONTIN

ENABLEX darifenacin ext-rel, oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ, TOVIAZ, VESICARE

ERYPED erythromycins

ESTROGEL estradiol, DIVIGEL, EVAMIST, MINIVELLE

EVZIO NARCAN NASAL SPRAY

EXALGO morphine ext-rel, HYSINGLA ER, NUCYNTA ER, OPANA ER, OXYCONTIN

EXFORGE amlodipine-telmisartan, amlodipine-valsartan, AZOR

EXFORGE HCT amlodipine-valsartan-hydrochlorothiazide, TRIBENZOR

FABIOR adapalene, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, ACANYA, ATRALIN, BENZACLIN, DIFFERIN CREAM, DIFFERIN GEL 0.3%, DIFFERIN LOTION, EPIDUO, RETIN-A MICRO, TAZORAC

FANAPT aripiprazole, clozapine, olanzapine, quetiapine, risperidone, ziprasidone, SEROQUEL XR

FEMHRT LOW DOSE estradiol-norethindrone, PREMPHASE, PREMPRO

FETZIMA duloxetine, venlafaxine, venlafaxine ext-rel capsule, PRISTIQ

FIORICET CAPSULE naratriptan, rizatriptan, sumatriptan, zolmitriptan, RELPAX, ZOMIG NASAL SPRAY


FLECTOR diclofenac sodium, diclofenac sodium solution, ibuprofen, meloxicam, naproxen, VOLTAREN GEL

FLOVENT ASMANEX, QVAR

fluorouracil cream 0.5% fluorouracil cream 5%, fluorouracil solution, imiquimod, PICATO

FLUOXETINE 60 MG citalopram, escitalopram, fluoxetine, paroxetine, paroxetine ext-rel, sertraline, TRINTELLIX, VIIBRYD

FML dexamethasone, prednisolone acetate 1%, LOTEMAX

FORTAMET metformin, metformin ext-rel (except generic GLUMETZA)

FORTESTA testosterone gel 2%, ANDRODERM, AXIRON

FOSRENOL calcium acetate, PHOSLYRA, RENVELA, VELPHORO

FREESTYLE TEST STRIPS 5 ONETOUCH ULTRA TEST STRIPS, ONETOUCH VERIO TEST STRIPS

GELNIQUE darifenacin ext-rel, oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ, TOVIAZ, VESICARE

GLUMETZA (and its generic) metformin, metformin ext-rel (except generic GLUMETZA)

GRALISE gabapentin, HORIZANT

HALOG desoximetasone, fluocinonide

HUMALOG NOVOLOG

HUMALOG MIX 50/50 NOVOLOG MIX 70/30

HUMALOG MIX 75/25 NOVOLOG MIX 70/30

HUMULIN NOVOLIN

ILEVRO bromfenac, diclofenac, ketorolac, PROLENSA

INCRUSE ELLIPTA SPIRIVA

INNOPRAN XL atenolol, carvedilol, metoprolol succinate ext-rel, metoprolol tartrate, nadolol, propranolol, propranolol ext-rel, BYSTOLIC

INTERMEZZO zolpidem, zolpidem ext-rel, zolpidem sublingual

INTUNIV amphetamine-dextroamphetamine mixed salts ext-rel, dexmethylphenidate, dexmethylphenidate ext-rel, dextroamphetamine, dextroamphetamine ext-rel, guanfacine ext-rel, methylphenidate, methylphenidate ext-rel, APTENSIO XR, QUILLIVANT XR, STRATTERA, VYVANSE

INVOKAMET XIGDUO XR

INVOKANA FARXIGA, JARDIANCE

JALYN dutasteride-tamsulosin

JUBLIA terbinafine tablet, ONMEL

KADIAN morphine ext-rel, HYSINGLA ER, NUCYNTA ER, OPANA ER, OXYCONTIN

KAPVAY amphetamine-dextroamphetamine mixed salts ext-rel, dexmethylphenidate, dexmethylphenidate ext-rel, dextroamphetamine, dextroamphetamine ext-rel, guanfacine ext-rel, methylphenidate, methylphenidate ext-rel, APTENSIO XR, QUILLIVANT XR, STRATTERA, VYVANSE

KAZANO JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR

KENALOG hydrocortisone butyrate, mometasone, triamcinolone, CLODERM, LOCOID LOTION

KEPPRA levetiracetam



KEPPRA XR levetiracetam ext-rel

KERYDIN terbinafine tablet, ONMEL

KLOR-CON/25 potassium chloride liquid

KOMBIGLYZE XR JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR

LAMICTAL lamotrigine

LANOXIN TABLET (125 MCG and 250 MCG only)

digoxin

LANTUS BASAGLAR, LEVEMIR, TRESIBA

LASTACAFT azelastine, cromolyn sodium, olopatadine, PATADAY, PAZEO

LATUDA aripiprazole, clozapine, olanzapine, quetiapine, risperidone, ziprasidone, SEROQUEL XR

LAZANDA fentanyl transmucosal lozenge, morphine, oxycodone, FENTORA, SUBSYS

LESCOL XL atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin, VYTORIN

levorphanol morphine ext-rel, HYSINGLA ER, NUCYNTA ER, OPANA ER, OXYCONTIN

LIPITOR atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin, VYTORIN

LIVALO atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin, VYTORIN

LUMIGAN latanoprost, TRAVATAN Z, ZIOPTAN

LUNESTA zolpidem, zolpidem ext-rel, zolpidem sublingual

LUXIQ hydrocortisone butyrate, mometasone, triamcinolone, CLODERM, LOCOID LOTION

MACRODANTIN nitrofurantoin

Matzim LA diltiazem ext-rel (except generic CARDIZEM LA)

MENEST estradiol, estropipate, PREMARIN

MENOSTAR estradiol

meperidine hydromorphone, morphine, oxycodone

METADATE CD amphetamine-dextroamphetamine mixed salts ext-rel, dexmethylphenidate ext-rel, dextroamphetamine ext-rel, methylphenidate ext-rel, APTENSIO XR, QUILLIVANT XR, VYVANSE

METROGEL metronidazole, FINACEA

MIACALCIN INJECTION alendronate, calcitonin-salmon, ibandronate, risedronate, ATELVIA

MIACALCIN NASAL SPRAY calcitonin-salmon

MILLIPRED dexamethasone, methylprednisolone, prednisone

MINOCIN minocycline

NAPRELAN diclofenac sodium, ibuprofen, meloxicam, naproxen

NATESTO testosterone gel 2%, ANDRODERM, AXIRON

NESINA JANUVIA, TRADJENTA

NEVANAC bromfenac, diclofenac, ketorolac, PROLENSA

NEXIUM esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT

NITROMIST nitroglycerin lingual spray, nitroglycerin sublingual, NITROLINGUAL

NORITATE metronidazole, FINACEA


NORVASC amlodipine

NOVACORT hydrocortisone

NOVO NORDISK NEEDLES 6 BD ULTRAFINE NEEDLES

OLEPTRO trazodone

OLUX-E clobetasol foam

OLYSIO HARVONI (genotypes 1, 4, 5, 6)

OMNARIS flunisolide, fluticasone, mometasone, triamcinolone, DYMISTA

ONGLYZA JANUVIA, TRADJENTA

OPSUMIT LETAIRIS, TRACLEER

OSENI JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR

OWEN MUMFORD NEEDLES 6 BD ULTRAFINE NEEDLES

OXISTAT ciclopirox, clotrimazole, econazole, ketoconazole, oxiconazole, LUZU, NAFTIN

OXYTROL darifenacin ext-rel, oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ, TOVIAZ, VESICARE

PENNSAID diclofenac sodium, diclofenac sodium solution, ibuprofen, meloxicam, naproxen, VOLTAREN GEL

PERRIGO NEEDLES 6 BD ULTRAFINE NEEDLES

PLAVIX clopidogrel, dipyridamole ext-rel-aspirin, BRILINTA, EFFIENT

PRADAXA warfarin, ELIQUIS, XARELTO

PRECISION XTRA TEST STRIPS 5

ONETOUCH ULTRA TEST STRIPS, ONETOUCH VERIO TEST STRIPS

PRED FORTE dexamethasone, prednisolone acetate 1%, LOTEMAX

PRED MILD dexamethasone, prednisolone acetate 1%, LOTEMAX

PREVACID esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT

PROGRAF tacrolimus

PROTONIX esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT

PROVENTIL HFA PROAIR HFA, PROAIR RESPICLICK

PROVIGIL armodafinil

PULMICORT RESPULES budesonide inhalation suspension, ASMANEX, QVAR

QNASL flunisolide, fluticasone, mometasone, triamcinolone, DYMISTA

QUARTETTE NATAZIA

RAYOS dexamethasone, methylprednisolone, prednisone

RELION INSULIN NOVOLIN INSULIN

RESTASIS XIIDRA

REVATIO sildenafil

RHINOCORT AQUA flunisolide, fluticasone, mometasone, triamcinolone, DYMISTA

RIMSO-50 Consult doctor

RIOMET metformin, metformin ext-rel (except generic GLUMETZA)



RITALIN SR amphetamine-dextroamphetamine mixed salts ext-rel, dexmethylphenidate ext-rel, dextroamphetamine ext-rel, methylphenidate ext-rel, APTENSIO XR, QUILLIVANT XR, VYVANSE

ROWASA mesalamine rectal suspension

ROZEREM zolpidem, zolpidem ext-rel, zolpidem sublingual

SFROWASA mesalamine rectal suspension

SILENOR zolpidem, zolpidem ext-rel, zolpidem sublingual

SOLARAZE fluorouracil cream 5%, fluorouracil solution, imiquimod, PICATO

SONATA zolpidem, zolpidem ext-rel, zolpidem sublingual

SPORANOX CAPSULE itraconazole, terbinafine tablet, ONMEL

SPORANOX SOLUTION fluconazole

SUMAVEL DOSEPRO naratriptan, rizatriptan, sumatriptan, zolmitriptan, RELPAX, ZOMIG NASAL SPRAY

SYMBICORT ADVAIR, DULERA

TANZEUM TRULICITY, VICTOZA

TECHNIVIE HARVONI (genotypes 1, 4, 5, 6)

TESTIM testosterone gel 2%, ANDRODERM, AXIRON

testosterone gel 1% 7 testosterone gel 2%, ANDRODERM, AXIRON

TOBI tobramycin inhalation solution, BETHKIS

TOBI PODHALER tobramycin inhalation solution, BETHKIS

TOUJEO BASAGLAR, LEVEMIR, TRESIBA

TREXIMET diclofenac sodium, ibuprofen, meloxicam or naproxen WITH naratriptan, rizatriptan, sumatriptan, zolmitriptan, RELPAX or ZOMIG NASAL SPRAY

TRICOR fenofibrate, fenofibric acid

TRIVIDIA INSULIN SYRINGES 6 BD ULTRAFINE INSULIN SYRINGES

TUDORZA SPIRIVA

ULTIMED INSULIN SYRINGES 6 BD ULTRAFINE INSULIN SYRINGES

ULTIMED NEEDLES 6 BD ULTRAFINE NEEDLES

UROXATRAL alfuzosin ext-rel, tamsulosin

VALCYTE valganciclovir

VALTREX acyclovir, valacyclovir

VASCEPA omega-3 acid ethyl esters


VELTIN adapalene, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, ACANYA, ATRALIN, BENZACLIN, DIFFERIN CREAM, DIFFERIN GEL 0.3%, DIFFERIN LOTION, EPIDUO, RETIN-A MICRO, TAZORAC

venlafaxine ext-rel tablet (except 225 mg)

duloxetine, venlafaxine, venlafaxine ext-rel capsule, PRISTIQ

VENLAFAXINE EXT-REL TABLET (except 225 MG)

duloxetine, venlafaxine, venlafaxine ext-rel capsule, PRISTIQ

VENTOLIN HFA PROAIR HFA, PROAIR RESPICLICK

VERDESO desonide, hydrocortisone

VEREGEN imiquimod, podofilox

VIEKIRA PAK HARVONI (genotypes 1, 4, 5, 6)

VIEKIRA XR HARVONI (genotypes 1, 4, 5, 6)

VOGELXO testosterone gel 2%, ANDRODERM, AXIRON

XENAZINE tetrabenazine

XERESE acyclovir (except ointment), valacyclovir

XIFAXAN 200 MG sulfamethoxazole-trimethoprim

XOPENEX HFA PROAIR HFA, PROAIR RESPICLICK

ZEGERID esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT

ZEPATIER HARVONI (genotypes 1, 4, 5, 6)

ZETONNA flunisolide, fluticasone, mometasone, triamcinolone, DYMISTA

ZOHYDRO ER morphine ext-rel, HYSINGLA ER, NUCYNTA ER, OPANA ER, OXYCONTIN

ZOLPIMIST zolpidem, zolpidem ext-rel, zolpidem sublingual

ZONEGRAN zonisamide

ZUBSOLV buprenorphine-naloxone sublingual tablet, SUBOXONE FILM

ZYCLARA fluorouracil 5% cream, fluorouracil solution, imiquimod, PICATO

ZYMAXID ciprofloxacin, erythromycin, gentamicin, levofloxacin, ofloxacin, sulfacetamide, tobramycin, BESIVANCE, MOXEZA, VIGAMOX

ZYVOX SIVEXTRO


FOR YOUR INFORMATION: Generics should be considered the first line of prescribing. This drug list represents a summary of prescription coverage. It is not all-inclusive and does not guarantee coverage. New-to-market products and new variations of products already in the marketplace will not be added to the formulary immediately. Each product will be evaluated for clinical appropriateness and cost-effectiveness. Recommended additions to the formulary will be presented to the CVS Caremark National Pharmacy and Therapeutics Committee (or other appropriate reviewing body) for review and approval. In most instances, a brand-name drug for which a generic product becomes available will be designated as a non-preferred option upon release of the generic product to the market. Specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. The member's prescription benefit plan may have a different copay1 for specific products on the list. Unless specifically indicated, drug list products will include all dosage forms. This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. Generics listed in therapeutic categories are for representational purposes only. Listed products may be available generically in certain strengths or dosage forms. Dosage forms on this list will be consistent with the category and use where listed. Log in to www.hmsa.com to check coverage and copay1 information for a specific medicine.

* The preferred options in this list are a broad representation within therapeutic categories of available treatment options and do not necessarily represent clinical equivalency.

§ Generics are available in this class and should be considered the first line of prescribing. 1 Copayment, copay or coinsurance means the amount a member is required to pay for a prescription in accordance with a Plan, which may be a deductible, a percentage of the prescription

price, a fixed amount or other charge, with the balance, if any, paid by a Plan. 2 Listing does not include generic CARDIZEM LA. 3 Listing does not include generic GLUMETZA 4 An exception process is in place for specific clinical or regulatory circumstances that may require coverage of an excluded medication. 5 ONETOUCH brand test strips are the only preferred options. 6 BD ULTRAFINE syringes and needles are the only preferred options. 7 Listing reflects the authorized generics for TESTIM and VOGELXO.

Plan member privacy is important to us. Our employees are trained regarding the appropriate way to handle members' private health information. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers. Listed products are for informational purposes only and are not intended to replace the clinical judgment of the prescriber. The document is subject to state-specific regulations and rules, including, but not limited to, those regarding generic substitution, controlled substance schedules, preference for brands and mandatory generics whenever applicable.


The status of a drug on this list is current as of the date of this publication. The list serves as a guide to product selection for our providers and members. The list is subject to change. Participating pharmacies have the most up-to-date formulary information at the time prescriptions are filled. New drugs, strengths, forms, and/or therapeutic categories introduced in the marketplace will be reflected in the formulary, as applicable, following the completion of HMSA’s review process. Brand-name drugs not listed should be considered Other Brand drugs. Not all generic drugs may be listed. Coverage of a drug will depend on your drug plan.

HMSA's mission is to provide the people of Hawaii access to a sustainable, quality health care system that improves the overall health and well-being of our state.

HMSA CENTERS Convenient evening and Saturday hours: HMSA Center @ Honolulu 818 Keeaumoku St. | Monday through Friday, 8 a.m. - 6 p.m. | Saturday, 9 a.m. - 2 p.m. HMSA Center @ Pearl City Pearl City Gateway | 1132 Kuala St., Suite 400 Monday through Friday, 9 a.m. - 7 p.m. | Saturday, 9 a.m. - 2 p.m. HMSA Center @ Hilo Waiakea Center | 303A E. Makaala St. Monday through Friday, 9 a.m. - 7 p.m. | Saturday, 9 a.m. - 2 p.m. OFFICES Visit your local HMSA office Monday through Friday, 8 a.m. - 4 p.m.: Kailua-Kona, Hawaii Island | 75-1029 Henry St., Suite 301 | Phone: 329-5291 Kahului, Maui | 33 Lono Ave., Suite 350 | Phone: 871-6295 Lihue, Kauai | 4366 Kukui Grove St., Suite 103 | Phone: 245-3393 PHONE 948-6372 on Oahu If you are calling from the U.S. Mainland, please call 1 (800) 776-4672. If you need to call a local Hawaii telephone number from the Mainland, the area code is 808. Check hmsa.com/contact for our holiday schedule. The information contained in this document is proprietary. The information may not be copied in whole or in part without written permission. ©2017. All rights reserved. 106-1059890-1-100117 www.hmsa.com

Important Information About Your Health Plan

HMSA doesn’t discriminateWe comply with applicable federal civil rights laws. We don’t discriminate, exclude people, or treat people diff erently because of things like:

• Race.• Color.• Nati onal origin.• Age.• Disability.• Sex.

Services that HMSA providesTo bett er communicate with people who have disabiliti es or whose primary language isn’t English, HMSA provides services at no cost when reasonable, such as:

• Language services and translati ons.• Text relay services.• Informati on writt en in other languages or formats.

If you need these services, please call 1 (800) 776-4672 toll-free. TTY 711.

How to fi le a discriminati on-related grievance or complaintIf you believe that we’ve failed to provide these services or discriminated against you in some way, you can fi le a grievance in any of the following ways:

• Phone: 1 (800) 776-4672 toll-free• TTY: 711• Email: [email protected]• Fax: (808) 948-6414 on Oahu• Mail: 818 Keeaumoku St., Honolulu, HI 96814

You can also fi le a civil rights complaint with the U.S. Department of Health and Human Services, Offi ce for Civil Rights, in any of the following ways:

• Online: ocrportal.hhs.gov/ocr/portal/lobby.jsf• Phone: 1 (800) 368-1019 toll-free; TDD users, call 1 (800) 537-7697 toll-free• Mail: U.S. Department of Health and Human Services, 200 Independence Ave. S.W.,

Room 509F, HHH Building, Washington, DC 20201For complaint forms, please go to hhs.gov/ocr/offi ce/fi le/index.html.

Federal law requires HMSA to provide you with this noti ce.

1000-8689A 7.17 LE

C

H3832_4036_2025_1157_v4 AcceptedH7317_4036_2025_1157 Accepted

English: This notice has important information about your HMSA application or plan benefits. It may also include key dates. You may need to take action by certain dates to keep your health plan or to get help with costs. If you or someone you’re helping has questions about HMSA, you have the right to get this notice and other help in your language at no cost. To talk to an interpreter, please call 1 (800) 776-4672 toll-free. TTY 711.Hawaiian: He ʻike koʻikoʻi ko kēia hoʻolaha pili i kou ʻinikua a i ʻole palapala noi ʻinikua HMSA. Aia paha he mau lā koʻikoʻi ma kēia hoʻolaha. Pono paha ʻoe e hana i kekahi mea ma mua o kekahi lā no ka hoʻomau i kou ʻinikua a i ʻole ka ʻimi kōkua me ka uku. Inā he mau nīnau kou no HMSA, he kuleana ko mākou no ka hāʻawi manuahi i kēia hoʻolaha a me nā kōkua ʻē aʻe ma kou ʻōlelo ponoʻī. No ke kamaʻilio me kekahi mea unuhi, e kelepona manuahi iā 1 (800) 776-4672. TTY 711.Bisayan - Visayan: Kini nga pahibalo adunay importanteng impormasyon mahitungod sa imong aplikasyon sa HMSA o mga benepisyo sa plano. Mahimo sab nga aduna kini mga importanteng petsa. Mahimong kinahanglan kang magbuhat og aksyon sa mga partikular nga petsa aron mapabilin ang imong plano sa panglawas o aron mangayo og tabang sa mga gastos.Kung ikaw o ang usa ka tawo nga imong gitabangan adunay mga pangutana mahitungod sa HMSA, aduna kay katungod nga kuhaon kini nga pahibalo ug ang uban pang tabang sa imong lengguwahe nga walay bayad. Aron makig-istorya sa usa ka tighubad, palihug tawag sa 1 (800) 776-4672 nga walay toll. TTY 711.Chinese: 本通告包含關於您的 HMSA 申請或計劃福利的重要資訊。也可能包含關鍵日期。您可能需要在某確定日期前採取行動，以維持您的健康計劃或者獲取費用幫助。

如果您或您正在幫助的某人對 HMSA 存在疑問，您有權免費獲得以您母語表述的本通告及其他幫助。如需與口譯員通話，請撥打免費電話1 (800) 776-4672。TTY 711.Ilocano: Daytoy a pakaammo ket naglaon iti napateg nga impormasion maipanggep iti aplikasionyo iti HMSA wenno kadagiti benepisioyo iti plano. Mabalin nga adda pay nairaman a petsa. Mabalin a masapulyo ti mangaramid iti addang agpatingga kadagiti partikular a petsa tapno agtalinaed kayo iti plano wenno makaala kayo iti tulong kadagiti gastos. No addaan kayo wenno addaan ti maysa a tao a tultulonganyo iti saludsod maipanggep iti HMSA, karbenganyo a maala daytoy a pakaammo ken dadduma

pay a tulong iti bukodyo a pagsasao nga awan ti bayadna. Tapno makapatang ti maysa a mangipatarus ti pagsasao, tumawag kay koma iti 1 (800) 776-4672 toll-free. TTY 711.Japanese: 本通知書には、HMSAへの申請や医療給付に関する重要な情報や日付が記載されています。医療保険を利用したり、費用についてサポートを受けるには、本通知書に従って特定の日付に手続きしてください。

患者さん、または付き添いの方がHMSAについて質問がある場合は、母国語で無料で通知を受けとったり、他のサポートを受ける権利があります。通訳を希望する場合は、ダイヤルフリー電話1 (800) 776-4672 をご利用ください。TTY 711.

Laotian: ແຈງການສະບບນ ມ ຂ ມນທ ສ າຄນກຽວກບການສະມກ HMSAຂອງທານ ຫ ແຜນຜນປະໂຫຍດຈາກ HMSA. ອາດມ ຂ ມນກຽວກບວນທ ທ ສ າຄນ. ທານອາດຕອງໄດດ າເນ ນການໃນວນທ ໃດໜງເພອຮກສາແຜນສຂະພາບຂອງທານ ຫ ຮບການຊວຍເຫ ອຄາຮກສາ.

ຖາຫາກທານ ຫ ຜທ ທານຊວຍເຫ ອມ ຄ າຖາມກຽວກບHMSA, ທານມ ສ ດທ ຈະໄດຮບແຈງການສະບບນ ແລະການຊວຍເຫ ອອ ນໆເປນພາສາຂອງທານໂດຍບ ຕອງເສຍຄາ. ເພອໂທຫານາຍແປພາສາ, ກະລນາໂທໄປ1 (800) 776-4672 ໂດຍບ ເສຍຄາ. TTY 711.Marshallese: Kojella in ej boktok jet melele ko reaurok kin application ak jipan ko jen HMSA bwilan ne am. Emaron bar kwalok jet raan ko reaurok bwe kwon jela. Komaron aikiuj kommane jet bunten ne ko mokta jen detlain ko aer bwe kwon jab tum jen health bwilan en am ak bok jipan kin wonaan takto. Ne ewor kajjitok kin HMSA, jen kwe ak juon eo kwoj jipane, ewor am jimwe im maron nan am ba ren ukot kojjella in kab melele ko kin jipan ko jet nan kajin ne am ilo ejjelok wonaan. Bwe kwon kenono ippan juon ri-ukok, jouj im calle 1 (800) 776-4672 tollfree, enaj ejjelok wonaan. TTY 711.Micronesian - Pohnpeian: Kisin likou en pakair wet audaudki ire kesempwal me pid sapwelimwomwi aplikasin en HMSA de koasoandihn sawas en kapai kan. E pil kak audaudki rahn me pahn kesemwpwal ieng komwi. Komw pahn kakete anahne wia kemwekid ni rahn akan me koasoandi kan pwe komwi en kak kolokol sawas en roson mwahu de pil ale pweinen sawas pwukat. Ma komwi de emen aramas tohrohr me komw sewese ahniki kalelapak me pid duwen HMSA, komw ahniki pwuhng en ale pakair wet oh sawas teikan ni sapwelimwomwi mahsen ni soh isepe. Ma komw men mahsenieng souhn kawehwe, menlau eker telepohn 1 (800) 776-4672 ni soh isepe. TTY 711.

Korean: 이 통지서에는 HMSA 신청서 또는 보험 혜택에 대한 중요한 정보가 들어 있으며, 중요한 날짜가 포함되었을 수도 있습니다. 해당 건강보험을 그대로 유지하거나 보상비를 수령하려면 해당 기한 내에 조치를 취하셔야 합니다.신청자 본인 또는 본인의 도움을 받는 누군가가 HMSA에 대해 궁금한 사항이 있으면 본 통지서를받고 아무런 비용 부담 없이 모국어로 다른 도움을 받을 수 있습니다. 통역사를 이용하려면 수신자 부담 전화 1 (800) 776-4672번으로 연락해 주시기 바랍니다. TTY 711.Samoan - Fa’asamoa: O lenei fa’aliga tāua e fa’atatau i lau tusi talosaga ma fa’amanuiaga ‘e te ono agava’a ai, pe’ā fa’amanuiaina ‘oe i le polokalame o le HMSA. E aofia ai fo’i i lalo o lenei fa’aliga ia aso tāua. E ono mana’omia ‘oe e fa’atinoina ni galuega e fa’atonuina ai ‘oe i totonu o le taimi fa’atulagaina, ina ‘ia e agava’a ai pea mo fa’amanuiaga i le polokalame soifua maloloina ‘ua fa’ata’atia po’o se fesoasoani fo’i mo le totogi’ina. Afai e iai ni fesili e fa’atatau i le HMSA, e iai lou aiātatau e te talosaga ai e maua lenei fa’aliga i lau gagana e aunoa ma se totogi. A mana’omia le feasoasoani a se fa’aliliu ‘upu, fa’amolemole fa’afeso’ota’i le numera 1 (800) 776-4672 e leai se totogi o lenei ‘au’aunaga. TTY 711.Spanish: Este aviso contiene información importante sobre su solicitud a HMSA o beneficios del plan. También puede incluir fechas clave. Pueda que tenga que tomar medidas antes de determinadas fechas a fin de mantener su plan de salud u obtener ayuda con los gastos. Si usted o alguien a quien le preste ayuda tiene preguntas respecto a HMSA, usted tiene el derecho de recibir este aviso y otra ayuda en su idioma, sin ningún costo. Para hablar con un intérprete, llame al número gratuito 1 (800) 776-4672. TTY 711.Tagalog: Ang abiso na ito ay naglalaman ng mahalagang impormasyon tungkol sa inyong aplikasyon sa HMSA o mga benepisyo sa plano. Maaari ding kasama ditoang mga petsa. Maaaring kailangan ninyong gumawang hakbang bago sumapit ang mga partikular napetsa upang mapanatili ninyo ang inyong planongpangkalusugan o makakuha ng tulong sa mga gastos.

Kung kayo o isang taong tinutulungan ninyo ay may mga tanong tungkol sa HMSA, may karapatan kayong makuha ang abiso na ito at iba pang tulong sa inyong wika nang walang bayad. Upang makipag-usap sa isang tagapagsalin ng wika, mangyaring tumawag sa 1 (800) 776-4672 toll-free. TTY 711.Tongan - Fakatonga: Ko e fakatokanga mahu’inga eni fekau’aki mo ho’o kole ki he HMSA pe palani penefití. ‘E malava ke hā ai ha ngaahi ‘aho ‘oku mahu’inga. ‘E i ai e ngaahi ‘aho pau ‘e fiema’u ke ke fai e ‘ū me’a ‘uhiā ko ho’o palani mo’ui leleí pe ko ho’o ma’u ha tokoni fekau’aki mo e totongí. Kapau ‘oku ‘i ai ha’o fehu’i pe ha fehu’i ha’a taha ‘oku ke tokonia fekau’aki mo e HMSA, ‘oku totonu ke ke ma’u e fakatokanga ko ení pe ha toe tokoni pē ‘i ho’o lea faka-fonuá ta’e totongi. Ke talanoa ki ha taha fakatonulea, kātaki tā ta’etotongi ki he 1 (800) 776-4672. TTY 711.Trukese: Ei esinesin a kawor auchean porausen omw HMSA apilikeison me/ika omw kewe plan benefit. A pwan pachanong porausen ekoch ran mei auchea ngeni omw ei plan Ina epwe pwan auchea omw kopwe fori ekoch fofor me mwen ekei ran (mei pachanong) pwe omw health plan esap kouno, are/ika ren omw kopwe angei aninisin monien omw ei plan. Ika a wor omw kapas eis usun HMSA, ka tongeni tungoren aninis, iwe ka pwan tongeni tungoren ar repwe ngonuk eche kapin ei taropwe mei translatini non kapasen fonuom, ese kamo. Ika ka mwochen kapas ngeni emon chon chiakku, kosemochen kopwe kori 1 (800) 776-4672, ese kamo. TTY 711.Vietnamese: Thông báo này có thông tin quan trọng về đơn đăng ký HMSA hoặc phúc lợi chương trình của quý vị. Thông báo cũng có thể bao gồm những ngày quan trọng. Quý vị có thể cần hành động trước một số ngày để duy trì chương trình bảo hiểm sức khỏe của mình hoặc được giúp đỡ có tính phí. Nếu quý vị hoặc người quý vị đang giúp đỡ có thắc mắc về HMSA, quý vị có quyền nhận thông báo này và trợ giúp khác bằng ngôn ngữ của mình miễn phí. Để nói chuyện với một thông dịch viên, vui lòng gọi số miễn cước 1 (800) 776-4672. TTY 711.

october 2017 hmsa control formularyrelease to the market. ... synthetic clomiphene §...

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