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Heartlandplainshealth.com

2015 Comprehensive Formulary
HeartlandPlains Health
2015 Formulary
List of Covered Drugs
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION
ABOUT THE DRUGS WE COVER IN THIS PLAN
We have made no changes to this formulary since 10/15/15. For more recent information or other questions, please contact HeartlandPlains Health (HMO) Customer Service, at 1-866-792-0184or, for TTY users, 711, 8:00 am to 8:00 pm, Monday-Friday and 8:00 am to 8:00 pm, Monday-Sunday October 1 through February 14, or visit www.HeartlandPlainsHealth.com. 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 HeartlandPlains Health. When it refers to "plan" or "our plan," it means Classic Plus Rx (HMO) This document includes a list of the drugs (formulary) for our plan which is current as of December 1, 2015. 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, and/or copayments/coinsurance may change on January 1, 2016, and from time to time during the year. H3765_FullFormulary2015 Formulary ID: 15481, Version Number: 17 Effective Date: December 1, 2015 Last Updated: October 15, 2015 2015 Comprehensive Formulary

What is the HeartlandPlains Health Formulary?
A formulary is a list of covered drugs selected by HeartlandPlains 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. HeartlandPlains Health will generally cover the drugs listed in our formulary as long as
the drug is medically necessary, the prescription is filled at a HeartlandPlains 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 December 1, 2015. To get updated information
about the drugs covered by HeartlandPlains Health, please contact us. Our contact information appears on
the front and back cover pages. In the event of mid-year non-maintenance formulary changes, we will
update this formulary with a future formulary change insert sent with your monthly Explanation of Benefits
mailing.
How do I use the Formulary?
There are two ways to find your drug within the formulary: Medical Condition
The formulary begins on page 14. 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 14. Then look under the category name for your drug. 2015 Comprehensive Formulary

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. 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?
HeartlandPlains 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: HeartlandPlains Health requires you or your physician to get prior
authorization for certain drugs. This means that you will need to get approval from HeartlandPlains
Health before you fill your prescriptions. If you don't get approval, HeartlandPlains Health may not
cover the drug.


 Quantity Limits: For certain drugs, HeartlandPlains Health limits the amount of the drug that we
will cover. For example, HeartlandPlains Health provides 18 tablets per prescription for sumatriptan. This may be in addition to a standard one-month or three-month supply.  Step Therapy: In some cases, HeartlandPlains 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, HeartlandPlains Health may not cover Drug B unless you try Drug A first. If Drug A does not work for you, HeartlandPlains 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 14. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask HeartlandPlains 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 HeartlandPlains formulary?" on page 5 for information about how to request an exception. 2015 Comprehensive Formulary

What are over-the counter (OTC) drugs?
OTC drugs are non-prescription drugs that are not normally covered by a Medicare Prescription Drug Plan. HeartlandPlains Health pays for certain OTC drugs. HeartlandPlains Health will provide these OTC drugs at no cost to you. The cost to us of these OTC drugs will not count toward your total Part D drug costs (that is, the amount you pay does not count for the coverage gap.) COVERED OVER-THE-COUNTER (OTC) DRUGS
Dosage Form
Generic Name
(Reference Brand Name)
cetirizine hydrochloride Chewable Tablets, Solution, Tablets cetirizine hydrochloride/ pseudoephedrine hydrochloride loratadine Tablets, Solution loratadine/ pseudoephedrine sulfate ketotifen fumarate 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 HeartlandPlains 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 HeartlandPlains 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 HeartlandPlains Health.  You can ask HeartlandPlains Health to make an exception and cover your drug. See below for information about how to request an exception. 2015 Comprehensive Formulary

How do I request an exception to the HeartlandPlains Health Formulary?
You can ask HeartlandPlains 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 a 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, HeartlandPlains 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, HeartlandPlains 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. 2015 Comprehensive Formulary
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 93-day transition supply, consistent with 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. Current members who are outside of their transition period may experience circumstances that involve changing from one treatment setting to another (level of care change). For example, you are moved from a hospital to a skilled nursing facility and are accompanied by a discharge list of medications from the hospital formulary. If you experience a level of care change beyond the first 90 days of membership and need a drug that is not on our formulary or if your ability to get your drugs is limited, we may cover a 31-day emergency supply while you pursue a formulary exception. This policy only applies to "Part D covered Drugs" covered by a network pharmacy unless you qualify for out-of-network access.
For more information
For more detailed information about your HeartlandPlains Health prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about HeartlandPlains Health, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov.
HeartlandPlains Health Formulary
The formulary that begins on page 14 provides coverage information about the drugs covered by HeartlandPlains Health. If you have trouble finding your drug in the list, turn to the Index that begins on page I-1. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., ADVAIR DISKUS) and generic drugs are listed in lower-case italics (e.g., cortisone acetate). The information in the Requirements/Limits column tells you if HeartlandPlains Health has any special requirements for coverage of your drug. 2015 Comprehensive Formulary

Drugs are grouped into one of five Tiers – 1, 2, 3, 4, or 5.
Tiers for Classic Plus Rx (HMO) for a 31-day supply:
Tier 1: Preferred Generic Drugs – $2 Tier 2: Non-Preferred Generic Drugs – $10 Tier 3: Preferred Brand Drugs – $35 Tier 4: Non-Preferred Brand Drugs – 25% Tier 5: Specialty Tier Drugs – 33% 2015 Comprehensive Formulary
COVERAGE NOTES ABBREVIATIONS
DESCRIPTION
EXPLANATION
Utilization Management Restrictions
The reference brand name in parenthesis is provided for information only to assist in identifying the generic generic (Brand) medication and does NOT indicate formulary status or coverage. You (or your physician) are required to get prior Prior Authorization authorization from HeartlandPlains Health before you fill your prescription for this drug. Without prior approval, HeartlandPlains Health may not cover this drug. HeartlandPlains Health limits the amount of this drug that is covered per prescription, or within a specific time frame. Before HeartlandPlains Health will provide coverage for this drug, you must first try another drug(s) to treat your Step Therapy Restriction medical condition. This drug may only be covered if the other drug(s) does not work for you. This drug may be eligible for payment under Medicare Part Prior Authorization B or Part D. You (or your physician) are required to get prior authorization from HeartlandPlains Health to Part B versus Part D determine that this drug is covered under Medicare Part D before you fill your prescription for this drug. Without prior approval, HeartlandPlains Health may not cover this drug. This drug has been deemed by CMS to be potentially harmful and therefore, a High Risk Medication for Medicare Prior Authorization beneficiaries 65 years or older. Members age 65 yrs or older are required to get prior authorization from High Risk Medications HeartlandPlains Health before you fill your prescription for this drug. Without prior approval, HeartlandPlains Health may not cover this drug. If you are a new member or if you have not taken this drug previously, you (or your physician) are required to get prior Prior Authorization authorization from HeartlandPlains Health before you fill your prescription for this drug. Without prior approval, HeartlandPlains Health may not cover this drug. 2015 Comprehensive Formulary
DESCRIPTION
EXPLANATION
Other Special Requirements for Coverage
This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Customer Service at 1-866-792-0184 or 8:00 am to 8:00 pm, Monday - Friday and 8:00 am to 8:00 Limited Access Drug pm, Monday - Sunday October 1 through February 14. You may reach a voicemail on weekends and holidays; please leave a message and your call will be returned the next business day. TTY/TDD users should call 711. 2015 Comprehensive Formulary
STRENGTH AND DOSAGE FORM ABBREVIATIONS
DESCRIPTION
aerosol, breath activated aerosol powder, breath activated aerosol with adapter bulk bag injection capsule, delayed release multiphasic capsule, dose pack capsule, 12 hour extended release capsule, 24 hour extended release capsule, extended release degradable capsule, extended release pellets capsule, multiphasic capsule, 24 hour sustained action capsule, 12 hour sustained release capsule, 24 hour sustained release capsule, 24 hour controlled-onset pellets capsule, 24 hour sustained release pellets capsule, sprinkle capsule sustained release pellets capsule with device capsule, delayed release capsule, extended release capsule, sustained action combination: capsule, pad combination: ointment, foam combination: ointment, lotion combination: tablet, pad combination package capsule, 12 hour multiphasic capsule, 24 hour multiphasic capsule, multiphasic, 30%-70% capsule, multiphasic, 50%-50% cream(g), cream(gm) cream (milliliters) cream with applicator cream, extended release (grams) di(2-ethylhexyl)phthalate free bag disposable needle disk with inhalation device 2015 Comprehensive Formulary
DESCRIPTION
disposable syringe drops, suspension drops, hyperviscous emulsion adhesive emulsion (grams) foam with applicator frozen piggyback gel with prefilled applicator gel (milliliters) gel in metered dose pump gel with applicator hfa aerosol adapter intraperitoneal solution irrigating solution intravenous solution jelly with applicator jelly with pre-filled applicator kit: cleanser and cream kit: cream, lotion emollient kit: lotion, cream emollient kit: ointment, lotion emollient lotion, extended release medicated heated patch mucoadhesive buccal tablet mucoadhesive system, 12 hour extended release needle for injection nail film suspension oint. (g), oint.(gm) ointment (grams) oral concentrate 2015 Comprehensive Formulary
DESCRIPTION
patch, 24 hour transdermal patch, 72 hour transdermal patch, biweekly transdermal patch, weekly transdermal patient-controlled analgesic syringe patient-controlled analgesic vial pen injector kit piggyback bottle solution with multi-dose pump solution with applicator solution with pre-filled applicator solution, gel-forming solution, reconstituted solution (grams) spray, suspension suppository, rectal suppository, vaginal suspension, 24 hour extended release suspension, extended release reconstituted suspension, microcapsule reconstituted suspension, delayed release packet suspension, reconstituted tablet, chewable tablet, 12 hour extended release tablet, 24 hour extended release tablet, extended release particles tablet, extended release sequels tablet, dispersible tablet, dose pack tablet, 24 hour extended release tablet, multiphasic tablet, particles tablet, rapid disintegrating delayed release tablet, rapid disintegrating tablet, sublingual tablet, 12 hour sustained release 2015 Comprehensive Formulary
DESCRIPTION
tablet, 24 hour sustained release tablet, 24 hour gradual extended release tablet, delayed release tablet, extended release tablet, effervescent tablet, sustained action tablet, extended release dose pack tablet, multiphasic dose pack tablet, rapid disintegrating dose pack tablet, 3-month dose pack tablet, 12 hour multiphasic tablet, 24 hour multiphasic 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
Analgesics
Analgesics, Miscellaneous
acetaminophen-codeine oral solution (Acetaminophen with QL (2700 per 30 days) acetaminophen-codeine oral tablet 300-15 (Tylenol-Codeine No.3) QL (360 per 30 days) mg, 300-30 mg acetaminophen-codeine oral tablet 300-60 (Tylenol-Codeine No.3) QL (180 per 30 days) mg buprenorphine hcl injection (Buprenorphine HCl) butalb-acetaminophen-caffeine oral PA-HRM; QL (180 per capsule 50-325-40 mg (Fioricet with Codeine) PA-HRM; QL (180 per 30 days) PA-HRM; QL (180 per 30 days) butalbital-acetaminophen-caff oral tablet PA-HRM; QL (180 per 50-325-40 mg butalbital-aspirin-caffeine oral capsule PA-HRM; QL (180 per 30 days) butorphanol tartrate nasal (Butorphanol Tartrate) QL (5 per 28 days) QL (4 per 28 days) codeine sulfate oral tablet (Codeine Sulfate) QL (180 per 30 days) codeine-butalbital-asa-caffein oral (Fiorinal with Codeine PA-HRM; QL (180 per capsule 30-50-325-40 mg fentanyl citrate PA; QL (120 per 30 days) fentanyl transdermal patch 72 hour 100 PA; QL (20 per 30 days) mcg/hr fentanyl transdermal patch 72 hour 12 PA; QL (10 per 30 days) mcg/hr, 25 mcg/hr, 37.5 mcg/hour, 50 mcg/hr, 62.5 mcg/hour, 75 mcg/hr, 87.5 mcg/hour hydrocodone-acetaminophen oral solution (Hycet) QL (2700 per 30 days) hydrocodone-acetaminophen oral tablet (includes Vicodin, 10-300 mg, 5-300 mg, 7.5-300 mg Vicodin ES and Vicodin HP); QL (390 per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
hydrocodone-acetaminophen oral tablet QL (360 per 30 days) 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg hydrocodone-ibuprofen QL (150 per 30 days) hydromorphone (pf) injection solution 10 hydromorphone (pf) injection solution 4 mg/ml hydromorphone injection solution (Hydromorphone HCl) hydromorphone injection syringe 2 mg/ml (Hydromorphone HCl) hydromorphone oral liquid QL (1200 per 30 days) hydromorphone oral tablet 2 mg, 4 mg QL (180 per 30 days) hydromorphone oral tablet 8 mg QL (240 per 30 days) PA; QL (30 per 30 days) levorphanol tartrate (Levorphanol Tartrate) QL (180 per 30 days) methadone hcl oral tablet,soluble 40 mg QL (90 per 30 days) methadone injection methadone oral QL (1800 per 30 days) methadone oral QL (360 per 30 days) morphine concentrate oral solution QL (200 per 30 days) morphine concentrate oral syringe (Morphine Sulfate) morphine injection solution 15 mg/ml, 8 (Morphine Sulfate) mg/ml morphine injection syringe 10 mg/ml, 2 (Morphine Sulfate) mg/ml morphine intramuscular (Morphine Sulfate) morphine intravenous (Morphine Sulfate) morphine intravenous solution 25 mg/ml, (Morphine Sulfate) 50 mg/ml morphine intravenous (Morphine Sulfate) morphine oral solution 10 mg/5 ml QL (700 per 30 days) morphine oral solution 20 mg/5 ml QL (300 per 30 days) MORPHINE ORAL TABLET QL (180 per 30 days) morphine oral tablet extended release 100 (MS Contin) QL (120 per 30 days) mg, 30 mg, 60 mg morphine oral tablet extended release 15 QL (180 per 30 days) mg, 200 mg You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
morphine rectal (Morphine Sulfate) QL (181 per 30 days) QL (60 per 30 days) oxycodone hcl-acetaminophen oral QL (1800 per 30 days) solution 5-325 mg/5 ml HCl/Acetaminophen) oxycodone hcl-acetaminophen oral tablet QL (360 per 30 days) 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg oxycodone hcl-aspirin QL (360 per 30 days) oxycodone oral concentrate QL (180 per 30 days) oxycodone oral solution QL (1300 per 30 days) oxycodone oral tablet QL (180 per 30 days) oxycodone-acetaminophen oral tablet 10- QL (360 per 30 days) 325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg oxycodone-acetaminophen oral tablet 10- QL (180 per 30 days) 650 mg oxycodone-acetaminophen oral tablet 7.5- QL (240 per 30 days) 500 mg oxycodone-aspirin QL (360 per 30 days) OXYCONTIN ORAL TABLET,ORAL QL (60 per 30 days) ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG OXYCONTIN ORAL TABLET,ORAL QL (120 per 30 days) ONLY,EXT.REL.12 HR 80 MG oxymorphone oral tablet QL (180 per 30 days) oxymorphone oral tablet extended release (Opana ER) QL (60 per 30 days) 12 hr 10 mg, 15 mg, 20 mg, 5 mg, 7.5 mg oxymorphone oral tablet extended release (Opana ER) QL (120 per 30 days) 12 hr 30 mg, 40 mg tramadol oral tablet QL (240 per 30 days) QL (240 per 30 days) QL (150 per 30 days) Nonsteroidal Anti-Inflammatory Agents
CALDOLOR INTRAVENOUS RECON SOLN celecoxib QL (60 per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
choline,magnesium salicylate (Choline Sal/Mag COMFORT PAC-IBUPROFEN COMFORT PAC-MELOXICAM COMFORT PAC-NAPROXEN diclofenac potassium diclofenac sodium oral tablet extended release 24 hr diclofenac sodium oral tablet,delayed (Diclofenac Sodium) release (dr/ec) diclofenac sodium topical gel diflunisal etodolac oral capsule etodolac oral tablet etodolac oral tablet extended release 24 hr (Etodolac) fenoprofen oral tablet (Fenoprofen Calcium) flurbiprofen ibuprofen oral ibuprofen oral tablet 400 mg, 600 mg, 800 (Ibuprofen) mg indomethacin oral capsule 25 mg PA-HRM; QL (240 per 30 days) indomethacin oral capsule 50 mg PA-HRM; QL (120 per 30 days) indomethacin oral capsule, extended PA-HRM; QL (60 per 30 indomethacin sodium ketoprofen oral capsule ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg ketorolac injection cartridge 15 mg/ml QL (40 per 30 days) ketorolac injection cartridge 30 mg/ml QL (20 per 30 days) ketorolac injection solution 15 mg/ml QL (40 per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
ketorolac injection solution 30 mg/ml (1 QL (20 per 30 days) ketorolac intramuscular solution QL (20 per 30 days) ketorolac oral QL (20 per 30 days) mefenamic acid meloxicam oral suspension meloxicam oral tablet nabumetone naproxen oral suspension naproxen oral tablet naproxen oral tablet,delayed release (dr/ec) naproxen sodium oral tablet 275 mg, 550 mg piroxicam salsalate sulindac oral (Tolmetin Sodium) VOLTAREN TOPICAL Anesthetics
Local Anesthetics
lidocaine (pf) injection solution PA BvD; (PA for ESRD Only) lidocaine hcl injection solution PA BvD; (PA for ESRD Only) lidocaine hcl laryngotracheal lidocaine hcl mucous membrane gel lidocaine hcl mucous membrane jelly in applicator lidocaine hcl mucous membrane solution lidocaine hcl urethral lidocaine topical adhesive patch,medicated You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
lidocaine topical ointment PA BvD; (PA for ESRD Only) lidocaine-prilocaine topical PA BvD; (PA for ESRD Only) lidocaine-prilocaine topical kit Anti-Addiction/Substance Abuse Treatment Agents
Anti-Addiction/Substance Abuse Treatment Agents
acamprosate buprenorphine hcl sublingual PA; QL (90 per 30 days) PA; QL (90 per 30 days) HCl/Naloxone HCl) bupropion hcl sr 150 mg tablet f/c QL (168 per 84 days) CHANTIX CONTINUING MONTH QL (56 per 28 days) BOX CHANTIX CONTINUING MONTH PAK QL (56 per 28 days) CHANTIX STARTING MONTH BOX QL (53 per 28 days) disulfiram naltrexone hcl naltrexone ZUBSOLV SUBLINGUAL TABLET 1.4- PA; QL (120 per 30 ZUBSOLV SUBLINGUAL TABLET PA; QL (30 per 30 days) 11.4-2.9 MG ZUBSOLV SUBLINGUAL TABLET 2.9- PA; QL (60 per 30 days) 0.71 MG, 8.6-2.1 MG ZUBSOLV SUBLINGUAL TABLET 5.7- PA; QL (90 per 30 days) Antianxiety Agents
alprazolam oral tablet QL (90 per 30 days) alprazolam oral tablet extended release 24 (Xanax XR) QL (90 per 30 days) hr 0.5 mg You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
alprazolam oral tablet extended release 24 (Xanax XR) QL (60 per 30 days) hr 1 mg, 2 mg, 3 mg alprazolam oral tablet,disintegrating QL (90 per 30 days) chlordiazepoxide hcl (Chlordiazepoxide HCl) QL (120 per 30 days) clonazepam oral tablet 0.5 mg, 1 mg QL (90 per 30 days) clonazepam oral tablet 2 mg QL (300 per 30 days) clonazepam oral tablet,disintegrating QL (90 per 30 days) 0.125 mg, 0.25 mg, 0.5 mg, 1 mg clonazepam oral tablet,disintegrating 2 QL (300 per 30 days) mg clorazepate dipotassium oral tablet 15 mg (Tranxene T-Tab) QL (120 per 30 days) clorazepate dipotassium oral tablet 3.75 (Tranxene T-Tab) QL (60 per 30 days) mg, 7.5 mg DIASTAT ACUDIAL RECTAL KIT 12.5-15-17.5-20 MG diazepam injection QL (10 per 28 days) diazepam intensol QL (1200 per 30 days) diazepam oral solution QL (1200 per 30 days) diazepam oral tablet QL (120 per 30 days) diazepam rectal (Diastat Acudial) estazolam oral tablet 1 mg PA-HRM; (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); QL (60 per 30 days) estazolam oral tablet 2 mg PA-HRM; (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); QL (30 per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
flurazepam oral capsule 15 mg (Flurazepam HCl) PA-HRM; (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); QL (60 per 30 days) flurazepam oral capsule 30 mg (Flurazepam HCl) PA-HRM; (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); QL (30 per 30 days) lorazepam oral solution QL (150 per 30 days) lorazepam injection solution QL (2 per 30 days) lorazepam injection syringe QL (2 per 30 days) lorazepam oral tablet QL (90 per 30 days) midazolam (pf) injection (Midazolam HCl/PF) QL (2 per 30 days) midazolam (pf) injection syringe 2 mg/2 (Midazolam HCl/PF) QL (2 per 30 days) ml (1 mg/ml) midazolam oral syrup 2 mg/ml QL (10 per 30 days) ONFI ORAL SUSPENSION PA NSO; QL (480 per 30 days) ONFI ORAL TABLET 10 MG, 20 MG PA NSO; QL (60 per 30 days) temazepam oral capsule 15 mg, 22.5 mg, PA-HRM; (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); QL (30 per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
temazepam oral capsule 7.5 mg PA-HRM; (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); QL (120 per 30 days) triazolam oral tablet 0.125 mg PA-HRM; (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); QL (120 per 30 days) triazolam oral tablet 0.25 mg PA-HRM; (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); QL (60 per 30 days) gentamicin in nacl (iso-osm) intravenous (Gentamicin In Nacl, piggyback gentamicin injection solution gentamicin sulfate (ped) (pf) (Gentamicin Sulfate/PF) gentamicin sulfate (pf) intravenous (Gentamicin Sulfate/PF) solution neomycin (Neomycin Sulfate) streptomycin intramuscular (Streptomycin Sulfate) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
TOBI PODHALER INHALATION QL (224 per 28 days) tobramycin in 0.225 % nacl tobramycin in 0.9 % nacl (Tobramycin/Sodium tobramycin sulfate injection solution 10 mg/ml tobramycin sulfate injection solution 40 Antibacterials, Miscellaneous
bacitracin intramuscular chloramphenicol sod succinate (Chloramphenicol Sod clindamycin hcl clindamycin in 5 % dextrose (Cleocin Phosphate In clindamycin palmitate hcl (Cleocin Palmitate) clindamycin phosphate injection (Cleocin Phosphate) clindamycin phosphate intravenous (Cleocin Phosphate) solution colistin (colistimethate na) linezolid methenamine hippurate methenamine mandelate oral tablet 1 nitrofurantoin macrocrystal oral capsule (Macrodantin/Macrobid) PA-HRM; QL (120 per nitrofurantoin macrocrystal oral capsule (Macrodantin/Macrobid) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (120 per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
nitrofurantoin monohyd/m-cryst PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (120 per 30 days) trimethoprim vancomycin in d5w intravenous piggyback (Vancomycin vancomycin intravenous recon soln 1,000 (Vancomycin HCl) mg, 10 gram, 750 mg vancomycin intravenous recon soln 500 vancomycin oral capsule XIFAXAN ORAL TABLET 200 MG PA; QL (9 per 30 days) XIFAXAN ORAL TABLET 550 MG ST; QL (60 per 30 days) cefaclor oral capsule cefaclor oral suspension for reconstitution (Cefaclor) 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml cefadroxil oral capsule cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet cefazolin in dextrose (iso-os) intravenous (Cefazolin Sodium) piggyback 1 gram/50 ml cefazolin in dextrose (iso-os) intravenous piggyback 2 gram/50 ml Sodium/Dextrose, Iso) cefazolin injection recon soln cefazolin injection recon soln 100 gram, (Cefazolin Sodium) 300 g cefazolin intravenous (Cefazolin Sodium) cefditoren pivoxil You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
CEFEPIME IN DEXTROSE 5 % CEFEPIME IN DEXTROSE,ISO-OSM INTRAVENOUS PIGGYBACK cefotaxime cefoxitin cefoxitin in dextrose, iso-osm intravenous piggyback 2 gram/50 ml Sodium/Dextrose, Iso) cefpodoxime oral suspension for (Cefpodoxime Proxetil) reconstitution 100 mg/5 ml cefpodoxime oral suspension for (Cefpodoxime Proxetil) reconstitution 50 mg/5 ml cefpodoxime oral tablet (Cefpodoxime Proxetil) cefprozil ceftazidime ceftazidime injection recon soln 2 gram, 6 (Fortaz) gram ceftibuten ceftriaxone in dextrose,iso-os intravenous piggyback 1 gram/50 ml Na/Dextrose, Iso) CEFTRIAXONE IN DEXTROSE,ISO-OS INTRAVENOUS PIGGYBACK 2 GRAM/50 ML ceftriaxone injection recon soln ceftriaxone intravenous recon soln 1 gram (Ceftriaxone Na/Dextrose, Iso) CEFTRIAXONE INTRAVENOUS RECON SOLN 2 GRAM cefuroxime axetil oral tablet cefuroxime sodium injection recon soln 1.5 gram, 750 mg cefuroxime sodium intravenous cefuroxime-dextrose (iso-osm) Sodium/Dextrose, Iso) cephalexin oral capsule cephalexin oral suspension for reconstitution You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
cephalexin oral tablet MEFOXIN IN DEXTROSE (ISO-OSM) SUPRAX ORAL TABLET SUPRAX ORAL TABLET,CHEWABLE Macrolides
azithromycin clarithromycin oral suspension for reconstitution clarithromycin oral tablet clarithromycin oral tablet extended release 24 hr DIFICID QL (20 per 10 days) erythromycin base oral tablet,delayed (Erythromycin Base) release (dr/ec) 250 mg, 500 mg ERYTHROMYCIN BASE ORAL TABLET,DELAYED RELEASE (DR/EC) 333 MG erythromycin ethylsuccinate oral suspension for reconstitution 200 mg/5 ml erythromycin ethylsuccinate oral tablet erythromycin oral capsule,delayed (Erythromycin Base) release(dr/ec) erythromycin oral tablet (Erythromycin Base) erythromycin stearate oral tablet 250 mg (Erythromycin Stearate) Miscellaneous B-Lactam Antibiotics
aztreonam meropenem Penicillins
amoxicillin oral capsule amoxicillin oral suspension for reconstitution You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
amoxicillin oral tablet amoxicillin oral tablet,chewable 125 mg, 250 mg amoxicillin-pot clavulanate oral suspension for reconstitution amoxicillin-pot clavulanate oral tablet amoxicillin-pot clavulanate oral tablet extended release 12 hr amoxicillin-pot clavulanate oral (Amoxicillin/Potassium tablet,chewable ampicillin (Ampicillin Trihydrate) ampicillin sodium injection recon soln ampicillin sodium intravenous recon soln ampicillin-sulbactam injection recon soln 1.5 gram, 3 gram ampicillin-sulbactam injection recon soln 15 gram ampicillin-sulbactam intravenous recon soln BICILLIN C-R dicloxacillin (Dicloxacillin Sodium) nafcillin in dextrose iso-osm Dextrose,Iso-Osm) nafcillin injection nafcillin intravenous recon soln oxacillin in dextrose(iso-osm) Sodium/Dextrose, Iso) oxacillin injection recon soln (Oxacillin Sodium) oxacillin intravenous recon soln (Oxacillin Sodium) penicillin g pot in dextrose (Pen G Pot/Dextrose- penicillin g potassium (Penicillin G Potassium) penicillin g procaine (Penicillin G Procaine) penicillin v potassium (Penicillin V Potassium) Quinolones
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
ciprofloxacin ciprofloxacin hcl oral ciprofloxacin in 5 % dextrose ciprofloxacin lactate intravenous solution 400 mg/40 ml levofloxacin in d5w intravenous piggyback (Levaquin) levofloxacin intravenous levofloxacin oral solution levofloxacin oral tablet moxifloxacin ofloxacin oral sulfadiazine oral intravenous sulfamethoxazole-trimethoprim oral suspension sulfamethoxazole-trimethoprim oral tablet (Bactrim) sulfasalazine sulfatrim sulfazine sulfazine ec doxycycline hyclate oral capsule 100 mg doxycycline hyclate 100 mg tab f/c doxycycline hyclate intravenous (Doxycycline Hyclate) doxycycline hyclate oral capsule 100 mg doxycycline hyclate oral capsule 50 mg doxycycline hyclate oral tablet 100 mg, 50 (Adoxa) mg doxycycline hyclate oral tablet 20 mg doxycycline mono 100 mg cap doxycycline mono 100 mg tablet doxycycline monohydrate oral capsule 150 (Adoxa) mg, 75 mg You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
doxycycline monohydrate oral capsule 50 mg doxycycline monohydrate oral suspension (Vibramycin) for reconstitution doxycycline monohydrate oral tablet 150 mg, 75 mg doxycycline monohydrate oral tablet 50 mg minocycline oral capsule minocycline oral tablet (Minocycline HCl) tetracycline Anticancer Agents
Anticancer Agents
PA NSO; QL (4 per 21 days) AFINITOR DISPERZ PA NSO; QL (112 per 28 days) AFINITOR ORAL TABLET 10 MG PA NSO; QL (56 per 28 days) AFINITOR ORAL TABLET 2.5 MG, 5 PA NSO; QL (28 per 28 ALIMTA INTRAVENOUS RECON SOLN anastrozole azacitidine bexarotene PA NSO; QL (420 per 30 days) bicalutamide bleomycin (Bleomycin Sulfate) PA NSO; QL (140 per 365 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
BOSULIF ORAL TABLET 100 MG PA NSO; QL (120 per 30 days) BOSULIF ORAL TABLET 500 MG PA NSO; QL (30 per 30 days) CAPRELSA ORAL TABLET 100 MG PA NSO; QL (60 per 30 days) CAPRELSA ORAL TABLET 300 MG PA NSO; QL (30 per 30 days) carboplatin intravenous solution cisplatin PA NSO; QL (112 per 28 days) cyclophosphamide intravenous recon soln (Cyclophosphamide) CYCLOPHOSPHAMIDE ORAL CAPSULE cyclophosphamide oral tablet (Cyclophosphamide) cytarabine cytarabine (pf) injection recon soln cytarabine (pf) injection solution dacarbazine intravenous recon soln dactinomycin decitabine doxorubicin hcl intravenous recon soln 10 (Doxorubicin HCl) mg doxorubicin hcl peg-liposomal intravenous (Doxil) suspension 2 mg/ml doxorubicin, peg-liposomal ELIGARD SUBCUTANEOUS SYRINGE QL (1 per 84 days) 22.5 MG (3 MONTH) ELIGARD SUBCUTANEOUS SYRINGE QL (1 per 112 days) 30 MG (4 MONTH) ELIGARD SUBCUTANEOUS SYRINGE QL (1 per 168 days) 45 MG (6 MONTH) ELIGARD SUBCUTANEOUS SYRINGE QL (1 per 28 days) 7.5 MG (1 MONTH) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
epirubicin intravenous solution 50 mg/25 ml ERBITUX PA NSO; QL (30 per 30 days) etoposide intravenous exemestane PA NSO; QL (6 per 21 days) FIRMAGON KIT W DILUENT SYRINGE floxuridine fludarabine fluorouracil intravenous solution 2.5 gram/50 ml, 5 gram/100 ml, 500 mg/10 ml flutamide PA NSO; QL (40 per 28 days) gemcitabine intravenous recon soln 1 gram GILOTRIF PA NSO; QL (30 per 30 days) GLEEVEC ORAL TABLET 100 MG PA NSO; QL (90 per 30 days) GLEEVEC ORAL TABLET 400 MG PA NSO; QL (60 per 30 days) PA NSO; QL (24 per 28 days) hydroxyurea PA NSO; QL (21 per 28 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
ICLUSIG ORAL TABLET 15 MG PA NSO; QL (60 per 30 days) ICLUSIG ORAL TABLET 45 MG PA NSO; QL (30 per 30 days) ifosfamide intravenous recon soln ifosfamide intravenous solution ifosfamide-mesna (Ifosfamide/Mesna) PA NSO; QL (120 per 30 days) INLYTA ORAL TABLET 1 MG PA NSO; QL (180 per 30 days) INLYTA ORAL TABLET 5 MG PA NSO; QL (60 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (6 per 28 days) letrozole leuprolide (Leuprolide Acetate) lomustine QL (1 per 28 days) LUPRON DEPOT (3 MONTH) QL (1 per 84 days) LUPRON DEPOT (4 MONTH) QL (1 per 84 days) LUPRON DEPOT (6 MONTH) QL (1 per 168 days) LUPRON DEPOT-PED QL (1 per 28 days) LUPRON DEPOT-PED (3 MONTH) QL (1 per 84 days) INTRAMUSCULAR SYRINGE KIT You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
PA NSO; QL (480 per 30 days) PA NSO; QL (4 per 28 days) megestrol oral suspension megestrol oral suspension 625 mg/5 ml megestrol oral tablet (Megestrol Acetate) MEKINIST ORAL TABLET 0.5 MG PA NSO; QL (90 per 30 days) MEKINIST ORAL TABLET 2 MG PA NSO; QL (30 per 30 days) melphalan hcl intravenous mercaptopurine methotrexate sodium (pf) injection recon methotrexate sodium (pf) injection (Methotrexate Sodium) solution methotrexate sodium injection (Methotrexate Sodium) methotrexate sodium oral (Methotrexate Sodium) mitomycin intravenous recon soln mitoxantrone (Mitoxantrone HCl) PA NSO; QL (120 per 30 days) OPDIVO INTRAVENOUS SOLUTION 40 MG/4 ML oxaliplatin intravenous solution 100 mg/20 ml paclitaxel PA NSO; QL (21 per 28 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
PA NSO; LA; QL (21 per 28 days) SPRYCEL ORAL TABLET 100 MG, 140 PA NSO; QL (30 per 30 MG, 50 MG, 70 MG, 80 MG SPRYCEL ORAL TABLET 20 MG PA NSO; QL (60 per 30 days) PA NSO; QL (84 per 28 days) PA NSO; QL (30 per 30 days) PA NSO; QL (28 per 28 days) PA NSO; QL (120 per 30 days) tamoxifen (Tamoxifen Citrate) TARCEVA ORAL TABLET 100 MG, 25 PA NSO; QL (60 per 30 TARCEVA ORAL TABLET 150 MG PA NSO; QL (90 per 30 days) TARGRETIN TOPICAL PA NSO; QL (60 per 28 days) PA NSO; QL (112 per 28 days) TEMODAR INTRAVENOUS PA NSO; (vial only) toposar intravenous topotecan intravenous PA BvD; QL (4 per 28 days) TREANDA INTRAVENOUS RECON You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
TREANDA INTRAVENOUS SOLUTION TRELSTAR INTRAMUSCULAR QL (1 per 168 days) SUSPENSION FOR RECONSTITUTION TRELSTAR INTRAMUSCULAR QL (1 per 84 days) SYRINGE 11.25 MG/2 ML TRELSTAR INTRAMUSCULAR QL (1 per 168 days) SYRINGE 22.5 MG/2 ML TRELSTAR INTRAMUSCULAR QL (1 per 28 days) SYRINGE 3.75 MG/2 ML tretinoin (chemotherapy) vinblastine intravenous (Vinblastine Sulfate) vincristine (Vincristine Sulfate) vincristine sulfate intravenous solution 1 (Vincristine Sulfate) mg/ml vinorelbine intravenous solution PA NSO; QL (120 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (120 per 30 days) ZALTRAP INTRAVENOUS SOLUTION PA NSO; QL (240 per 30 days) ZOLADEX SUBCUTANEOUS QL (1 per 84 days) IMPLANT 10.8 MG ZOLADEX SUBCUTANEOUS QL (1 per 28 days) IMPLANT 3.6 MG ZOLINZA You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
PA NSO; QL (60 per 30 days) PA NSO; QL (140 per 28 days) PA NSO; QL (120 per 30 days) Anticholinergic Agents
atropine injection solution 0.4 mg/ml (Atropine Sulfate) atropine injection syringe 0.05 mg/ml, 0.1 (Atropine Sulfate) mg/ml propantheline (Propantheline Bromide) carbamazepine carbamazepine oral capsule, er multiphase 12 hr carbamazepine oral suspension carbamazepine oral tablet extended release 12 hr carbamazepine oral tablet,chewable CELONTIN ORAL CAPSULE 300 MG DILANTIN CAPSULE 30 MG divalproex oral capsule, sprinkle (Depakote Sprinkle) divalproex oral tablet extended release 24 (Depakote ER) hr divalproex oral tablet,delayed release (dr/ec) ethosuximide oral capsule ethosuximide oral solution felbamate fosphenytoin FYCOMPA ORAL TABLET gabapentin oral capsule You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
gabapentin oral solution gabapentin oral tablet 600 mg, 800 mg GABITRIL ORAL TABLET 12 MG, 16 MG LAMICTAL ORAL TABLET, CHEWABLE DISPERSIBLE 2 MG lamotrigine oral tablet lamotrigine oral tablet extended release 24hr lamotrigine oral tablet, chewable dispersible lamotrigine oral tablets,dose pack 25 mg (Lamictal (Blue)) (35) levetiracetam intravenous levetiracetam oral solution levetiracetam oral tablet levetiracetam oral tablet extended release (Keppra XR) 24 hr LYRICA ORAL CAPSULE QL (90 per 30 days) LYRICA ORAL SOLUTION QL (900 per 30 days) oxcarbazepine oral suspension oxcarbazepine oral tablet phenobarbital oral elixir QL (1500 per 30 days) phenobarbital oral tablet 100 mg, 15 mg, QL (90 per 30 days) 16.2 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg phenobarbital oral tablet 30 mg QL (200 per 30 days) phenobarbital sodium injection solution (Phenobarbital Sodium) QL (2 per 30 days) phenytoin oral suspension 125 mg/5 ml phenytoin oral phenytoin sodium (Phenytoin Sodium) phenytoin sodium extended POTIGA ORAL TABLET 200 MG, 300 ST ; QL (90 per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
POTIGA ORAL TABLET 50 MG ST ; QL (270 per 30 days) primidone tiagabine topiramate topiramate oral capsule, sprinkle topiramate oral capsule,sprinkle,er 24hr TRILEPTAL ORAL SUSPENSION valproate sodium valproic acid valproic acid (as sodium salt) oral solution 250 mg/5 ml VIMPAT INTRAVENOUS ST ; QL (200 per 5 days) VIMPAT ORAL SOLUTION ST ; QL (1200 per 30 days) VIMPAT ORAL TABLET ST ; QL (60 per 30 days) zonisamide Antidementia Agents
Antidementia Agents
donepezil oral tablet 10 mg, 5 mg QL (30 per 30 days) donepezil oral tablet 23 mg QL (30 per 30 days) donepezil oral tablet,disintegrating QL (30 per 30 days) EXELON TRANSDERMAL QL (30 per 30 days) galantamine oral capsule,ext rel. pellets QL (30 per 30 days) 24 hr galantamine oral solution QL (200 per 30 days) galantamine oral tablet QL (60 per 30 days) memantine oral tablet QL (60 per 30 days) memantine oral tablets,dose pack QL (49 per 28 days) NAMENDA ORAL SOLUTION QL (360 per 30 days) NAMENDA ORAL TABLET QL (60 per 30 days) NAMENDA TITRATION PAK QL (49 per 28 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
QL (28 per 28 days) CAP,SPRINKLE,ER 24HR DOSE PACK NAMENDA XR ORAL QL (30 per 30 days) CAPSULE,SPRINKLE,ER 24HR NAMZARIC rivastigmine tartrate QL (60 per 30 days) amitriptyline (Amitriptyline HCl) amoxapine bupropion hcl oral tablet bupropion hcl oral tablet extended release (Wellbutrin SR) , 150 mg bupropion hcl oral tablet extended release (Wellbutrin XL) 24 hr citalopram oral solution citalopram oral tablet QL (30 per 30 days) clomipramine desipramine oral doxepin oral duloxetine oral capsule,delayed QL (60 per 30 days) release(dr/ec) 20 mg, 60 mg duloxetine oral capsule,delayed QL (30 per 30 days) release(dr/ec) 30 mg duloxetine oral capsule,delayed QL (30 per 30 days) release(dr/ec) 40 mg EMSAM QL (30 per 30 days) escitalopram oxalate fluoxetine oral capsule fluoxetine oral capsule,delayed release(dr/ec) fluoxetine oral solution (Fluoxetine HCl) fluoxetine oral tablet 10 mg, 20 mg (Fluoxetine HCl) FLUOXETINE ORAL TABLET 60 MG You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
fluvoxamine oral capsule,extended release (Luvox CR) 24hr fluvoxamine oral tablet (Fluvoxamine Maleate) imipramine hcl imipramine pamoate QL (30 per 30 days) ST ; QL (30 per 30 days) maprotiline (Maprotiline HCl) mirtazapine nefazodone (Nefazodone HCl) nortriptyline oral capsule nortriptyline oral solution (Nortriptyline HCl) paroxetine hcl oral tablet paroxetine hcl oral tablet extended release (Paxil CR) 24 hr PAXIL ORAL SUSPENSION phenelzine ST ; QL (30 per 30 days) protriptyline sertraline oral concentrate sertraline oral tablet QL (30 per 30 days) tranylcypromine trazodone venlafaxine oral capsule,extended release 24hr venlafaxine oral tablet (Venlafaxine HCl) venlafaxine oral tablet extended release (Venlafaxine HCl) 24hr 150 mg, 37.5 mg, 75 mg VIIBRYD Antidiabetic Agents
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
Antidiabetic Agents, Miscellaneous
QL (90 per 30 days) QL (4 per 28 days) BYETTA SUBCUTANEOUS PEN QL (2.4 per 28 days) INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML BYETTA SUBCUTANEOUS PEN QL (1.2 per 28 days) INJECTOR 5 MCG/DOSE (250 MCG/ML) 1.2 ML CYCLOSET QL (180 per 30 days) QL (30 per 30 days) INVOKAMET ORAL TABLET 150- ST; QL (60 per 30 days) 1,000 MG, 150-500 MG, 50-1,000 MG INVOKAMET ORAL TABLET 50-500 ST; QL (120 per 30 INVOKANA ORAL TABLET 100 MG ST; QL (60 per 30 days) INVOKANA ORAL TABLET 300 MG ST; QL (30 per 30 days) QL (60 per 30 days) JANUMET XR ORAL TABLET, ER QL (30 per 30 days) MULTIPHASE 24 HR 100-1,000 MG, 50-500 MG JANUMET XR ORAL TABLET, ER QL (60 per 30 days) MULTIPHASE 24 HR 50-1,000 MG JANUVIA QL (30 per 30 days) ST; QL (30 per 30 days) QL (60 per 30 days) PA; QL (112 per 28 days) metformin oral tablet 1,000 mg QL (60 per 30 days) metformin oral tablet 500 mg QL (120 per 30 days) metformin oral tablet 850 mg QL (90 per 30 days) metformin oral tablet extended release 24 QL (120 per 30 days) hr 500 mg metformin oral tablet extended release 24 QL (90 per 30 days) hr 750 mg metformin oral tablet extended release QL (60 per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
nateglinide QL (90 per 30 days) pioglitazone QL (30 per 30 days) QL (30 per 30 days) QL (90 per 30 days) QL (150 per 30 days) repaglinide QL (240 per 30 days) PA; QL (10.8 per 28 days) PA; QL (6 per 28 days) QL (30 per 30 days) QL (4 per 28 days) PA; QL (9 per 28 days) Insulins
QL (30 per 28 days) SUBCUTANEOUS INSULIN PEN 100 UNIT/ML HUMALOG KWIKPEN QL (12 per 28 days) SUBCUTANEOUS INSULIN PEN 200 UNIT/ML (3 ML) HUMALOG MIX 50-50 QL (40 per 28 days) HUMALOG MIX 50-50 KWIKPEN QL (30 per 28 days) HUMALOG MIX 75-25 QL (40 per 28 days) HUMALOG MIX 75-25 KWIKPEN QL (30 per 28 days) HUMALOG SUBCUTANEOUS QL (30 per 28 days) CARTRIDGE HUMALOG SUBCUTANEOUS QL (40 per 28 days) QL (40 per 28 days) HUMULIN 70/30 KWIKPEN QL (30 per 28 days) QL (40 per 28 days) HUMULIN N KWIKPEN QL (30 per 28 days) QL (40 per 28 days) QL (40 per 28 days) (CONCENTRATED) LANTUS QL (40 per 28 days) QL (30 per 28 days) QL (40 per 28 days) QL (40 per 28 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
QL (40 per 28 days) QL (40 per 28 days) QL (30 per 28 days) NOVOLOG MIX 70-30 QL (40 per 28 days) NOVOLOG MIX 70-30 FLEXPEN QL (30 per 28 days) QL (30 per 28 days) QL (7.5 per 28 days) glimepiride oral tablet 1 mg, 2 mg QL (30 per 30 days) glimepiride oral tablet 4 mg QL (60 per 30 days) glipizide oral tablet 10 mg QL (120 per 30 days) glipizide oral tablet 5 mg QL (60 per 30 days) glipizide oral tablet extended release 24hr (Glucotrol XL) QL (60 per 30 days) 10 mg glipizide oral tablet extended release 24hr (Glucotrol XL) QL (30 per 30 days) 2.5 mg, 5 mg glipizide-metformin oral tablet 2.5-250 mg (Glipizide/Metformin QL (60 per 30 days) glipizide-metformin oral tablet 2.5-500 (Glipizide/Metformin QL (120 per 30 days) mg, 5-500 mg glyburide micronized oral tablet 1.5 mg PA-HRM; QL (400 per 30 days) glyburide micronized oral tablet 3 mg PA-HRM; QL (180 per 30 days) glyburide micronized oral tablet 6 mg PA-HRM; QL (120 per 30 days) glyburide oral tablet 1.25 mg PA-HRM; QL (280 per 30 days) glyburide oral tablet 2.5 mg PA-HRM; QL (240 per 30 days) glyburide oral tablet 5 mg PA-HRM; QL (120 per 30 days) glyburide-metformin oral tablet 1.25-250 PA-HRM; QL (240 per glyburide-metformin oral tablet 2.5-500 PA-HRM; QL (120 per mg, 5-500 mg tolazamide oral tablet 250 mg QL (120 per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
tolazamide oral tablet 500 mg QL (60 per 30 days) tolbutamide QL (180 per 30 days) Antifungals
Antifungals
amphotericin b (Amphotericin B) ciclopirox topical cream ciclopirox topical gel ciclopirox topical shampoo ciclopirox topical solution ciclopirox topical suspension (Ciclopirox Olamine) clotrimazole mucous membrane clotrimazole topical cream clotrimazole topical solution clotrimazole-betamethasone topical cream (Lotrisone) clotrimazole-betamethasone topical lotion (Clotrimazole/Betameth econazole topical (Econazole Nitrate) fluconazole fluconazole in dextrose(iso-o) intravenous (Fluconazole In piggyback fluconazole in nacl (iso-osm) intravenous piggyback flucytosine griseofulvin microsize oral tablet itraconazole ketoconazole oral ketoconazole topical cream ketoconazole topical shampoo miconazole nitrate vaginal suppository 200 mg NOXAFIL ORAL You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
NYSTATIN (BULK) POWDER 1 BILLION UNIT nystatin oral nystatin oral nystatin topical (Nystatin/Triamcin) terbinafine hcl oral voriconazole intravenous voriconazole oral clemastine oral syrup (Clemastine Fumarate) clemastine oral tablet 2.68 mg (Clemastine Fumarate) cyproheptadine (Cyproheptadine HCl) diphenhydramine hcl injection solution 50 (Diphenhydramine HCl) mg/ml diphenhydramine hcl injection syringe (Diphenhydramine HCl) levocetirizine oral solution levocetirizine oral tablet promethazine oral syrup (Promethazine HCl) Anti-Infectives (Skin And Mucous Membrane)
Anti-Infectives (Skin And Mucous Membrane)
clindamycin phosphate vaginal metronidazole vaginal (Metrogel-Vaginal) terconazole vaginal cream terconazole vaginal suppository Antimigraine Agents
Antimigraine Agents
dihydroergotamine injection QL (30 per 28 days) dihydroergotamine nasal QL (4 per 28 days) QL (40 per 28 days) naratriptan QL (18 per 28 days) rizatriptan oral tablet QL (18 per 28 days) rizatriptan oral tablet,disintegrating QL (18 per 28 days) sumatriptan nasal spray QL (12 per 28 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
sumatriptan oral tablet QL (18 per 28 days) sumatriptan succinate subcutaneous QL (4 per 28 days) cartridge sumatriptan succinate subcutaneous pen QL (4 per 28 days) injector sumatriptan succinate subcutaneous QL (4 per 28 days) solution zolmitriptan oral tablet QL (12 per 28 days) zolmitriptan oral tablet,disintegrating QL (12 per 28 days) ethambutol isoniazid oral pyrazinamide rifabutin PA; QL (188 per 168 days) Antinausea Agents
Antinausea Agents
dimenhydrinate injection solution (Dimenhydrinate) dronabinol EMEND INTRAVENOUS QL (2 per 28 days) EMEND ORAL CAPSULE 125 MG PA BvD; QL (1 per 1 day) EMEND ORAL CAPSULE 40 MG QL (1 per 1 day) EMEND ORAL CAPSULE 80 MG PA BvD; QL (2 per 1 day) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
EMEND ORAL CAPSULE,DOSE PACK PA BvD; QL (3 per 1 day) granisetron (pf) intravenous solution (Granisetron HCl/PF) granisetron hcl intravenous solution 1 mg/ml (1 ml) granisetron hcl oral (Granisetron HCl) meclizine oral tablet 12.5 mg, 25 mg ondansetron ondansetron hcl (pf) (Ondansetron HCl/PF) ondansetron hcl oral solution ondansetron hcl oral tablet prochlorperazine prochlorperazine edisylate injection solution prochlorperazine maleate prochlorperazine maleate oral promethazine hcl promethazine oral tablet (Promethazine HCl) promethazine rectal QL (10 per 30 days) Antiparasite Agents
Antiparasite Agents
atovaquone chloroquine phosphate oral (Aralen Phosphate) hydroxychloroquine oral ivermectin oral mefloquine (Mefloquine HCl) metronidazole in nacl (iso-os) (Metronidazole/Sodium metronidazole oral capsule You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
metronidazole oral tablet paromomycin (Paromomycin Sulfate) QL (90 per 30 days) quinine sulfate PA; QL (42 per 7 days) Antiparkinsonian Agents
Antiparkinsonian Agents
amantadine hcl (Amantadine HCl) QL (60 per 30 days) benztropine oral (Benztropine Mesylate) bromocriptine cabergoline carbidopa carbidopa-levodopa oral tablet carbidopa-levodopa oral tablet extended entacapone ST; QL (30 per 30 days) pramipexole oral tablet ropinirole oral tablet ropinirole oral tablet extended release 24 hr selegiline hcl oral capsule selegiline hcl oral tablet (Selegiline HCl) trihexyphenidyl (Trihexyphenidyl HCl) Antipsychotic Agents
Antipsychotic Agents
ABILIFY DISCMELT ORAL QL (90 per 30 days) TABLET,DISINTEGRATING 10 MG ABILIFY DISCMELT ORAL QL (60 per 30 days) TABLET,DISINTEGRATING 15 MG ABILIFY INTRAMUSCULAR QL (161.2 per 28 days) ABILIFY MAINTENA QL (1 per 28 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
ABILIFY ORAL SOLUTION QL (900 per 30 days) aripiprazole oral solution QL (900 per 30 days) aripiprazole oral tablet 10 mg, 15 mg, 20 QL (30 per 30 days) mg, 30 mg, 5 mg aripiprazole oral tablet 2 mg QL (60 per 30 days) chlorpromazine injection (Chlorpromazine HCl) chlorpromazine oral (Chlorpromazine HCl) clozapine oral tablet 100 mg QL (270 per 30 days) clozapine oral tablet 200 mg QL (135 per 30 days) clozapine oral tablet 25 mg, 50 mg QL (90 per 30 days) clozapine oral tablet,disintegrating 100 ST ; QL (90 per 30 days) mg, 12.5 mg, 25 mg clozapine oral tablet,disintegrating 150 clozapine oral tablet,disintegrating 200 FANAPT ORAL TABLET ST ; QL (60 per 30 days) FANAPT ORAL TABLETS,DOSE ST ; QL (8 per 28 days) PACK fluphenazine decanoate fluphenazine hcl (Fluphenazine HCl) GEODON INTRAMUSCULAR QL (6 per 28 days) haloperidol haloperidol decanoate intramuscular (Haloperidol Decanoate) solution 100 mg/ml haloperidol decanoate intramuscular (Haldol Decanoate 50) solution 50 mg/ml haloperidol lactate (Haloperidol Lactate) INVEGA ORAL TABLET EXTENDED ST ; QL (30 per 30 days) RELEASE 24HR 1.5 MG, 3 MG, 9 MG INVEGA ORAL TABLET EXTENDED ST ; QL (60 per 30 days) RELEASE 24HR 6 MG INVEGA SUSTENNA QL (0.75 per 28 days) INTRAMUSCULAR SYRINGE 117 MG/0.75 ML You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
QL (1 per 28 days) INTRAMUSCULAR SYRINGE 156 MG/ML INVEGA SUSTENNA QL (1.5 per 28 days) INTRAMUSCULAR SYRINGE 234 MG/1.5 ML INVEGA SUSTENNA QL (0.25 per 28 days) INTRAMUSCULAR SYRINGE 39 MG/0.25 ML INVEGA SUSTENNA QL (0.5 per 28 days) INTRAMUSCULAR SYRINGE 78 MG/0.5 ML INVEGA TRINZA INTRAMUSCULAR QL (0.875 per 84 days) SYRINGE 273 MG/0.875 ML INVEGA TRINZA INTRAMUSCULAR QL (1.315 per 84 days) SYRINGE 410 MG/1.315 ML INVEGA TRINZA INTRAMUSCULAR QL (1.75 per 84 days) SYRINGE 546 MG/1.75 ML INVEGA TRINZA INTRAMUSCULAR QL (2.625 per 84 days) SYRINGE 819 MG/2.625 ML LATUDA ORAL TABLET 120 MG, 20 ST ; QL (30 per 30 days) MG, 40 MG, 60 MG LATUDA ORAL TABLET 80 MG ST ; QL (60 per 30 days) loxapine succinate olanzapine intramuscular QL (30 per 30 days) olanzapine oral tablet QL (30 per 30 days) olanzapine oral tablet,disintegrating 10 QL (30 per 30 days) mg, 15 mg, 5 mg olanzapine oral tablet,disintegrating 20 QL (31 per 30 days) paliperidone oral tablet extended release QL (30 per 30 days) 24hr 1.5 mg, 3 mg, 9 mg paliperidone oral tablet extended release QL (60 per 30 days) 24hr 6 mg perphenazine quetiapine QL (90 per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
REXULTI ORAL TABLET 0.25 MG ST ; QL (120 per 30 days) REXULTI ORAL TABLET 0.5 MG ST ; QL (60 per 30 days) REXULTI ORAL TABLET 1 MG, 2 MG, ST ; QL (30 per 30 days) 3 MG, 4 MG RISPERDAL CONSTA QL (4 per 28 days) risperidone oral solution QL (480 per 30 days) risperidone oral tablet QL (60 per 30 days) risperidone oral tablet,disintegrating 0.25 (Risperdal M-Tab) QL (60 per 30 days) mg, 0.5 mg, 1 mg, 2 mg risperidone oral tablet,disintegrating 3 (Risperdal M-Tab) QL (120 per 30 days) mg, 4 mg SAPHRIS (BLACK CHERRY) ST ; QL (60 per 30 days) SEROQUEL XR ORAL TABLET ST ; QL (60 per 30 days) EXTENDED RELEASE 24 HR 150 MG, 300 MG, 400 MG, 50 MG SEROQUEL XR ORAL TABLET ST ; QL (30 per 30 days) EXTENDED RELEASE 24 HR 200 MG thioridazine (Thioridazine HCl) thiothixene trifluoperazine (Trifluoperazine HCl) ST ; QL (540 per 30 days) ziprasidone hcl QL (60 per 30 days) ZYPREXA RELPREVV QL (2 per 28 days) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG, 405 MG Antivirals (Systemic)
APTIVUS ORAL CAPSULE APTIVUS ORAL SOLUTION CRIXIVAN ORAL CAPSULE 200 MG, You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
didanosine EPIVIR HBV ORAL SOLUTION FUZEON SUBCUTANEOUS INTELENCE ORAL TABLET 100 MG, 200 MG INTELENCE ORAL TABLET 25 MG ISENTRESS ORAL POWDER IN PACKET ISENTRESS ORAL TABLET TABLET,CHEWABLE KALETRA ORAL SOLUTION KALETRA ORAL TABLET 100-25 MG KALETRA ORAL TABLET 200-50 MG lamivudine LEXIVA ORAL SUSPENSION LEXIVA ORAL TABLET nevirapine oral suspension nevirapine oral tablet nevirapine oral tablet extended release 24 (Viramune XR) hr NORVIR PREZISTA ORAL SUSPENSION PREZISTA ORAL TABLET 150 MG, 75 MG PREZISTA ORAL TABLET 400 MG, 600 MG, 800 MG RESCRIPTOR RETROVIR INTRAVENOUS You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG REYATAZ ORAL POWDER IN PACKET SELZENTRY stavudine VIDEX 2 GRAM PEDIATRIC VIDEX 4 GRAM PEDIATRIC VIRACEPT ORAL TABLET VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 100 MG VIREAD ZIAGEN ORAL SOLUTION zidovudine oral capsule zidovudine oral syrup zidovudine oral tablet Antivirals, Miscellaneous
foscarnet RELENZA DISKHALER rimantadine TAMIFLU ORAL CAPSULE 30 MG QL (84 per 180 days) TAMIFLU ORAL CAPSULE 45 MG QL (48 per 180 days) TAMIFLU ORAL CAPSULE 75 MG QL (42 per 180 days) TAMIFLU ORAL SUSPENSION FOR QL (540 per 180 days) Hcv Antivirals
PA; QL (28 per 28 days) PA; QL (30 per 30 days) PA; QL (28 per 28 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
PA; QL (28 per 28 days) PA; QL (56 per 28 days) PA; QL (112 per 28 days) Interferons
INTRON A INJECTION PEGASYS PROCLICK PEGINTRON REDIPEN PA NSO; QL (4 per 28 days) Nucleosides And Nucleotides
acyclovir oral capsule acyclovir oral suspension 200 mg/5 ml acyclovir oral tablet acyclovir sodium intravenous recon soln (Acyclovir Sodium) acyclovir sodium intravenous solution (Acyclovir Sodium) entecavir famciclovir ganciclovir sodium ribavirin oral capsule 200 mg ribavirin oral tablet 200 mg, 400 mg, 600 mg TYZEKA valacyclovir valganciclovir Blood Products/Modifiers/Volume Expanders
CEPROTIN (BLUE BAR) enoxaparin subcutaneous solution QL (36 per 30 days) enoxaparin subcutaneous syringe 100 QL (36 per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
enoxaparin subcutaneous syringe 120 QL (27.2 per 30 days) mg/0.8 ml enoxaparin subcutaneous syringe 150 QL (34 per 30 days) mg/ml enoxaparin subcutaneous syringe 30 QL (18 per 30 days) mg/0.3 ml enoxaparin subcutaneous syringe 40 QL (13.6 per 30 days) mg/0.4 ml enoxaparin subcutaneous syringe 60 QL (20.4 per 30 days) mg/0.6 ml enoxaparin subcutaneous syringe 80 QL (27.2 per 30 days) mg/0.8 ml fondaparinux subcutaneous syringe 10 QL (24 per 30 days) mg/0.8 ml fondaparinux subcutaneous syringe 2.5 QL (15 per 30 days) mg/0.5 ml fondaparinux subcutaneous syringe 5 QL (12 per 30 days) mg/0.4 ml fondaparinux subcutaneous syringe 7.5 QL (18 per 30 days) mg/0.6 ml heparin (porcine) in 5 % dex intravenous (Heparin Sodium in 5% parenteral solution 12,500 unit/250 ml, 20,000 unit/500 ml (40 unit/ml) HEPARIN (PORCINE) IN 5 % DEX INTRAVENOUS PARENTERAL SOLUTION 25,000 UNIT/250 ML(100 UNIT/ML), 25,000 UNIT/500 ML (50 UNIT/ML) heparin (porcine) in nacl (pf) intravenous parenteral solution 1,000 unit/500 ml Sodium,Porcine/Ns/PF) heparin (porcine) injection solution 1,000 (Heparin PA BvD; (PA for ESRD heparin (porcine) injection solution PA BvD; (PA for ESRD 10,000 unit/ml, 20,000 unit/ml, 5,000 unit/ml heparin, porcine (pf) injection solution 5,000 unit/0.5 ml Sodium,Porcine/PF) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
heparin, porcine (pf) injection (Monoject Prefill PA BvD; (PA for ESRD heparin, porcine (pf) intravenous syringe (Monoject Prefill 100 unit/ml HEPARIN-0.45% NACL 25,000 UNITS/250 ML (100 UNITS/ML) BAG LATEX-FREE, OUTER HEPARIN-0.45% NACL 25,000 UNITS/500 ML (50 UNITS/ML) BAG LATEX-FREE, OUTER heparin-d5w 25,000 units/250 ml (100 (Heparin Sodium in 5% units/ml) bag excel container heparin-d5w 25,000 units/500 ml (50 (Heparin Sodium in 5% units/ml) bag excel container PA; QL (24 per 28 days) QL (60 per 30 days) Blood Formation Modifiers
EPOGEN INJECTION SOLUTION PA; QL (12 per 28 days) 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML GRANIX LEUKINE INJECTION RECON SOLN PA; QL (0.6 per 28 days) NEULASTA SUBCUTANEOUS PROCRIT INJECTION SOLUTION PA; QL (12 per 28 days) 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 3,000 UNIT/ML, 4,000 UNIT/ML PROCRIT INJECTION SOLUTION PA; QL (12 per 28 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
PROCRIT INJECTION SOLUTION PA; QL (6 per 28 days) 40,000 UNIT/ML PROMACTA PA; QL (30 per 30 days) Hematologic Agents, Miscellaneous
aminocaproic acid oral solution (Aminocaproic Acid) aminocaproic acid oral tablet anagrelide protamine (Protamine Sulfate) PA BvD; (PA for ESRD Only) tranexamic acid intravenous (Tranexamic Acid) tranexamic acid oral QL (30 per 30 days) Platelet-Aggregation Inhibitors
QL (60 per 30 days) cilostazol clopidogrel QL (30 per 30 days) pentoxifylline (Pentoxifylline) Volume Expanders
ALBUMIN, HUMAN 25 % ALBUMIN, HUMAN 5 % ALBURX (HUMAN) 5 % You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
Caloric Agents
Caloric Agents
AMINO ACIDS 15 % AMINOSYN 7 % WITH ELECTROLYTES AMINOSYN 8.5 % AMINOSYN 8.5 %-ELECTROLYTES AMINOSYN II 10 % AMINOSYN II 15 % AMINOSYN II 8.5 % AMINOSYN II 8.5 %-ELECTROLYTES AMINOSYN M 3.5 % AMINOSYN-PF 10 % AMINOSYN-PF 7 % (SULFITE-FREE) AMINOSYN-RF 5.2 % CLINIMIX 5%/D15W SULFITE FREE CLINIMIX 5%/D25W SULFITE-FREE CLINIMIX 2.75%/D5W SULFIT FREE CLINIMIX 4.25%/D10W SULF FREE CLINIMIX 4.25%/D5W SULFIT FREE CLINIMIX 4.25%-D20W SULF-FREE CLINIMIX 4.25%-D25W SULF-FREE CLINIMIX 5%-D20W(SULFITE-FREE) CLINIMIX E 2.75%/D10W SUL FREE CLINIMIX E 2.75%/D5W SULF FREE CLINIMIX E 4.25%/D10W SUL FREE CLINIMIX E 4.25%/D25W SUL FREE CLINIMIX E 4.25%/D5W SULF FREE CLINIMIX E 5%/D15W SULFIT FREE CLINIMIX E 5%/D20W SULFIT FREE You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
CLINIMIX E 5%/D25W SULFIT FREE CLINISOL SF 15 % cysteine (l-cysteine) intravenous solution d10 % & 0.45 % sodium chloride (Dextrose 10 % and 0.45 d10 %-0.9 % sodium chloride (Dextrose 10 % and 0.9 d2.5 %-0.45 % sodium chloride (Dextrose 2.5 % and d5 % and 0.9 % sodium chloride (Dextrose 5 % and 0.9 % d5 %-0.45 % sodium chloride (Dextrose 5 %-0.45 % dextrose 10 % and 0.2 % nacl (Dextrose 10 % and 0.2 dextrose 10 % in water (d10w) (Dextrose 10 % in intravenous dextrose 2.5 % in water(d2.5w) (Dextrose 2.5 % in dextrose 20 % in water (d20w) (Dextrose 20 % in dextrose 25 % in water (d25w) (Dextrose 25 % in dextrose 40 % in water (d40w) (Dextrose 40 % in dextrose 5 % in ringers dextrose 5 % in water (d5w) intravenous (Dextrose 5 % in Water) dextrose 5 %-lactated ringers (Dextrose 5%-Lactated dextrose 5%-0.2 % sod chloride (Dextrose 5 %-0.2 % dextrose 5%-0.3 % sod.chloride (Dextrose 5 % and 0.3 % dextrose 50 % in water (d50w) (Dextrose 50 % in dextrose 70 % in water (d70w) (Dextrose 70 % in You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
dextrose with sodium chloride (Dextrose 5 %-0.2 % FREAMINE HBC 6.9 % FREAMINE III 10 % glucose oral tablet,chewable INTRALIPID INTRAVENOUS EMULSION 20 %, 30 % KABIVEN NEPHRAMINE 5.4 % potassium chloride in lr-d5 intravenous (Potassium Chloride In parenteral solution Cardiovascular Agents
Alpha-Adrenergic Agents
clonidine hcl oral tablet clonidine hcl-chlorthalidone HCl/Chlorthalidone) clonidine transdermal patch weekly 0.1 (Catapres-Tts 1) QL (4 per 28 days) mg/24 hr, 0.2 mg/24 hr clonidine transdermal patch weekly 0.3 (Catapres-Tts 1) QL (8 per 28 days) mg/24 hr doxazosin guanfacine oral tablet midodrine You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
PA; QL (180 per 30 days) phenylephrine hcl injection prazosin oral Angiotensin Ii Receptor Antagonists
candesartan PA; QL (60 per 30 days) irbesartan telmisartan valsartan Angiotensin-Converting Enzyme Inhibitors
benazepril captopril enalapril maleate enalaprilat intravenous injectable (Enalaprilat Dihydrate) fosinopril (Fosinopril Sodium) lisinopril moexipril perindopril erbumine You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
quinapril trandolapril Antiarrhythmic Agents
amiodarone hcl oral tablet 100 mg, 200 mg, 400 mg amiodarone oral disopyramide phosphate oral capsule flecainide (Flecainide Acetate) lidocaine (pf) intravenous syringe 50 mg/5 (Lidocaine HCl/PF) ml (1 %) lidocaine in 5 % dextrose (pf) intravenous (Lidocaine parenteral solution 8 mg/ml (0.8 %) mexiletine (Mexiletine HCl) procainamide injection (Procainamide HCl) propafenone oral capsule,extended release (Rythmol SR) 12 hr propafenone oral tablet quinidine gluconate oral (Quinidine Gluconate) quinidine sulfate (Quinidine Sulfate) Beta-Adrenergic Blocking Agents
acebutolol betaxolol oral bisoprolol fumarate carvedilol esmolol intravenous labetalol intravenous solution labetalol oral metoprolol succinate You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
metoprolol ta-hydrochlorothiaz metoprolol tartrate intravenous (Metoprolol Tartrate) metoprolol tartrate oral propranolol intravenous (Propranolol HCl) propranolol oral capsule,extended release (Inderal LA) 24 hr propranolol oral solution (Propranolol HCl) propranolol oral tablet (Propranolol HCl) sotalol hcl oral tablet 120 mg, 160 mg, 240 mg, 80 mg sotalol oral timolol maleate oral (Timolol Maleate) Calcium-Channel Blocking Agents
cartia xt diltiazem hcl intravenous diltiazem hcl oral capsule, extended release 180 mg, 360 mg, 420 mg diltiazem hcl oral capsule,extended release 12 hr diltiazem hcl oral capsule,extended release 24hr diltiazem hcl oral tablet diltiazem hcl oral tablet extended release 24 hr dilt-xr matzim la taztia xt verapamil intravenous syringe verapamil oral capsule, 24 hr er pellet ct verapamil oral capsule,ext rel. pellets 24 hr verapamil oral tablet verapamil oral tablet extended release You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
Cardiovascular Agents, Miscellaneous
ADRENALIN 1 MG/ML VIAL SUV ADRENALIN INJECTION SOLUTION 1 MG/ML (1:1,000) adrenalin injection solution 1 mg/ml (1:1,000) (1ml) CORLANOR digitek oral tablet 125 mcg PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); QL (30 per 30 days) digitek oral tablet 250 mcg PA-HRM; QL (30 per 30 days) digoxin injection DIGOXIN ORAL SOLUTION PA-HRM; QL (300 per 30 days) digoxin oral tablet PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); QL (30 per 30 days) dobutamine in d5w intravenous parenteral (Dobutamine HCl/D5W) solution 1,000 mg/250 ml (4,000 mcg/ml), 250 mg/250 ml (1 mg/ml), 500 mg/250 ml (2,000 mcg/ml) dobutamine intravenous solution (Dobutamine HCl) dopamine in 5 % dextrose intravenous (Dopamine HCl/D5W) solution dopamine intravenous solution ephedrine sulfate injection solution (Ephedrine Sulfate) epinephrine 1 mg/ml ampul latex-free epinephrine hcl (pf) intravenous (Epinephrine HCl/PF) epinephrine injection auto-injector 0.15 mg/0.15 ml (1:1,000) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
epinephrine injection auto-injector 0.3 mg/0.3 ml (1:1,000) epinephrine injection syringe 0.1 mg/ml (1:10,000) EPIPEN 2-PAK ethamolin (Ethanolamine Oleate) hydralazine (Hydralazine HCl) LANOXIN ORAL TABLET 187.5 MCG, PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); QL (30 per 30 days) milrinone (Milrinone Lactate) milrinone in 5 % dextrose intravenous piggyback 40 mg/200 ml (200 mcg/ml) norepinephrine bitartrate (Levophed Bitartrate) papaverine injection solution (Papaverine HCl) papaverine oral (Papaverine HCl) amlodipine CLEVIPREX INTRAVENOUS EMULSION felodipine isradipine nicardipine oral (Nicardipine HCl) nifedipine oral tablet extended release 24hr 30 mg, 60 mg, 90 mg nifedipine oral tablet extended release 30 mg, 60 mg You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
Diuretics
amiloride oral bumetanide chlorothiazide (Chlorothiazide) chlorothiazide sodium chlorthalidone oral tablet 25 mg, 50 mg (Chlorthalidone) furosemide injection furosemide oral solution furosemide oral tablet hydrochlorothiazide oral capsule hydrochlorothiazide oral tablet (Hydrochlorothiazide) indapamide methyclothiazide (Methyclothiazide) metolazone torsemide oral triamterene-hydrochlorothiazid oral capsule triamterene-hydrochlorothiazid oral tablet (Maxzide) atorvastatin cholestyramine (with sugar) oral cholestyramine-aspartame oral powder 4 cholestyramine-aspartame oral powder in (Cholestyramine/Asparta packet 4 gram colestipol fenofibrate micronized fenofibrate nanocrystallized fenofibrate oral tablet fenofibric acid fenofibric acid (choline) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
gemfibrozil oral lovastatin niacin oral tablet extended release 24 hr omega-3 acid ethyl esters PA; QL (2 per 28 days) PRALUENT SYRINGE PA; QL (2 per 28 days) pravastatin REPATHA SURECLICK PA; QL (3 per 28 days) PA; QL (3 per 28 days) simvastatin QL (30 per 30 days) Renin-Angiotensin-Aldosterone System Inhibitors
eplerenone spironolactone isosorbide dinitrate oral isosorbide dinitrate sublingual (Isosorbide Dinitrate) isosorbide mononitrate oral tablet (Isosorbide Mononitrate) isosorbide mononitrate oral tablet extended release 24 hr minitran transdermal patch 24 hour 0.1 QL (30 per 30 days) mg/hr, 0.2 mg/hr, 0.6 mg/hr minitran transdermal patch 24 hour 0.4 QL (60 per 30 days) mg/hr minoxidil oral nitroglycerin in 5 % dextrose intravenous (Nitroglycerin/D5W) solution nitroglycerin intravenous nitroglycerin transdermal patch 24 hour QL (30 per 30 days) 0.1 mg/hr, 0.2 mg/hr, 0.6 mg/hr You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
nitroglycerin transdermal patch 24 hour QL (60 per 30 days) 0.4 mg/hr NITROSTAT Central Nervous System Agents
Central Nervous System Agents
amphetamine salt combo QL (60 per 30 days) PA; QL (60 per 30 days) caffeine citrated intravenous caffeine citrated oral caffeine-sodium benzoate (Caffeine/Sodium clonidine hcl oral tablet extended release 12 hr dexmethylphenidate oral tablet QL (60 per 30 days) dextroamphetamine oral capsule, extended (Dexedrine) QL (120 per 30 days) release dextroamphetamine oral tablet QL (180 per 30 days) dextroamphetamine-amphetamine oral QL (30 per 30 days) capsule,extended release 24hr 10 mg, 15 mg, 5 mg dextroamphetamine-amphetamine oral QL (60 per 30 days) capsule,extended release 24hr 20 mg, 25 mg, 30 mg flumazenil guanfacine oral tablet extended release 24 (Intuniv) hr lithium carbonate oral capsule lithium carbonate oral tablet lithium carbonate oral tablet extended release lithium citrate oral solution (Lithium Citrate) methylphenidate oral capsule, er biphasic (Metadate Cd) QL (30 per 30 days) 30-70 10 mg, 20 mg, 50 mg, 60 mg methylphenidate oral capsule, er biphasic (Metadate Cd) QL (60 per 30 days) 30-70 30 mg You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
methylphenidate oral capsule,er biphasic QL (30 per 30 days) 50-50 20 mg methylphenidate oral capsule,er biphasic QL (60 per 30 days) 50-50 30 mg methylphenidate oral capsule,er biphasic QL (30 per 30 days) 50-50 40 mg methylphenidate oral solution QL (900 per 30 days) methylphenidate oral tablet QL (90 per 30 days) methylphenidate oral tablet extended QL (90 per 30 days) release methylphenidate oral tablet extended QL (30 per 30 days) release 24hr 18 mg, 27 mg, 54 mg methylphenidate oral tablet extended QL (60 per 30 days) release 24hr 36 mg NUEDEXTA QL (60 per 30 days) QL (60 per 30 days) tetrabenazine PA; QL (112 per 28 days) PA; QL (112 per 28 days) QL (91 per 84 days) deblitane desogestrel-ethinyl estradiol oral tablet 0.1/.125/.15-25 mg-mcg, 0.15-0.03 mg drospirenone-ethinyl estradiol ethinyl estradiol/drospirenone ethynodiol d-ethinyl estradiol (Ethynodiol D-Ethinyl gildess 24 fe You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
junel fe 24 kimidess (28) l norgest/e.estradiol-e.estrad QL (91 per 84 days) larin 24 fe levonorgestrel (Plan B One-Step) levonorgestrel oral tablet 1.5 mg (Plan B One-Step) levonorgestrel-ethin estradiol oral tablet 0.1-20 mg-mcg, 0.15-0.03 mg, 50-30 (6)/75-40 (5)/125-30(10) levonorgestrel-ethin estradiol oral (Levonorgestrel-Ethin QL (91 per 84 days) tablets,dose pack,3 month 0.15-30 mg-mcg Estradiol) levonorgestrel-ethinyl estrad oral tablet levonorgestrel-ethinyl estrad oral (Levonorgestrel-Ethin QL (91 per 84 days) tablets,dose pack,3 month l-norgest-eth estr/ethin estra QL (91 per 84 days) QL (3 per 28 days) noreth-ethinyl estradiol/iron norethindrone norethindrone (contraceptive) norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg, 1.5-30 mg-mcg norethindrone-e.estradiol-iron norethindrone-e.estradiol-iron oral tablet 1-20(5)/1-30(7) /1mg-35mcg (9), 1.5 mg-30 mcg (21)/75 mg (7) norethindrone-ethinyl estrad oral tablet 0.4-35 mg-mcg, 0.5-35 mg-mcg, 0.5-35/1-35 mg-mcg/mg-mcg, 0.5/0.75/1 mg- 35 mcg, 0.5/1/0.5-35 mg-mcg, 1-35 mg-mcg norethindrone-mestranol norgestimate-ethinyl estradiol norgestrel-ethinyl estradiol (Norgestrel-Ethinyl ST; QL (1 per 28 days) (Levonorgestrel-Ethin QL (91 per 84 days) tarina fe You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
Dental And Oral Agents
Dental And Oral Agents
cevimeline chlorhexidine gluconate mucous membrane pilocarpine hcl oral triamcinolone acetonide dental Dermatological Agents
Dermatological Agents, Other
acitretin acyclovir topical QL (30 per 30 days) ALCOHOL PREP PADS aluminum chloride (Aluminum Chloride) ammonium lactate calcipotriene topical cream calcipotriene topical ointment calcipotriene topical solution calcitriol topical CONDYLOX TOPICAL GEL COSENTYX (2 SYRINGES) COSENTYX PEN (2 PENS) DRYSOL DAB-O-MATIC fluorouracil topical cream fluorouracil topical solution imiquimod PA NSO; QL (24 per 30 days) isotretinoin oral capsule 10 mg, 20 mg, 30 (Isotretinoin) mg, 40 mg mafenide acetate (Mafenide Acetate) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
methoxsalen rapid (Oxsoralen-Ultra) PICATO TOPICAL GEL 0.015 % QL (3 per 56 days) PICATO TOPICAL GEL 0.05 % QL (2 per 56 days) podofilox podophyllum resin (Podophyllum Resin) potassium hydroxide (Potassium Hydroxide) silver nitrate applicators ZOVIRAX TOPICAL CREAM QL (15 per 30 days) Dermatological Antibacterials
clindamycin phosphate topical gel clindamycin phosphate topical lotion clindamycin phosphate topical solution clindamycin phosphate topical swab erythromycin base-ethanol erythromycin with ethanol topical gel erythromycin with ethanol topical solution (Erythromycin erythromycin with ethanol topical swab gentamicin topical (Gentamicin Sulfate) metronidazole topical metronidazole topical metronidazole topical mupirocin mupirocin calcium neomycin-polymyxin b gu selenium sulfide (Selenium Sulfide) silver nitrate topical (Silver Nitrate) silver sulfadiazine topical cream 1 % sulfacetamide sodium (acne) Dermatological Anti-Inflammatory Agents
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
alclometasone topical cream alclometasone topical ointment betamethasone dipropionate topical cream (Diprosone) betamethasone dipropionate topical lotion (Betamethasone betamethasone dipropionate topical betamethasone valerate topical cream betamethasone valerate topical foam betamethasone valerate topical lotion betamethasone valerate topical ointment betamethasone, augmented topical cream betamethasone, augmented topical gel betamethasone, augmented topical lotion betamethasone, augmented topical ointment clobetasol propionate topical solution 0.05 (Clobetasol Propionate) % clobetasol topical cream clobetasol topical foam clobetasol topical gel clobetasol topical lotion clobetasol topical ointment clobetasol topical shampoo clobetasol topical solution (Clobetasol Propionate) clobetasol-emollient topical clocortolone pivalate CORDRAN TOPICAL OINTMENT desonide topical cream desonide topical ointment desoximetasone PA; AGE (Min 2 Years) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
fluocinonide topical cream 0.05 % fluocinonide topical gel fluocinonide topical ointment fluocinonide topical solution fluocinonide-emollient base fluticasone topical cream fluticasone topical ointment (Fluticasone Propionate) halobetasol propionate hydrocortisone 1% ointment carton (otc) (Hydrocortisone) hydrocortisone acet-aloe vera topical gel hydrocortisone acetate-urea hydrocortisone butyrate hydrocortisone butyr-emollient hydrocortisone rectal cream 1 % hydrocortisone rectal cream 2.5 % (Hydrocortisone) hydrocortisone rectal enema 100 mg/60 ml (Cortenema) hydrocortisone topical cream 1 %, 2.5 % hydrocortisone topical lotion 2 %, 2.5 % hydrocortisone topical ointment 1 %, 2.5 (Hydrocortisone) % hydrocortisone valerate topical cream hydrocortisone valerate topical ointment mometasone prednicarbate tacrolimus topical triamcinolone acetonide topical cream triamcinolone acetonide topical lotion triamcinolone acetonide topical ointment 0.025 %, 0.05 %, 0.1 %, 0.5 % triderm topical cream Dermatological Retinoids
adapalene topical cream You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
adapalene topical gel 0.1 % TAZORAC TOPICAL CREAM tretinoin microspheres tretinoin topical cream tretinoin topical gel 0.01 %, 0.025 % Scabicides And Pediculicides
malathion permethrin topical cream ASSURE ID INSULIN SAFETY SYRINGE BD INSULIN PEN NEEDLE UF SHORT BD INSULIN SYRINGE ULTRA-FINE SYRINGE 0.3 ML 31 X 5/16", 1 ML 31 X 5/16", 1/2 ML 31 X 5/16" BD LUER-LOK SYRINGE SYRINGE 1 ML 20 X 1" INSULIN SYRINGE NEEDLELESS INSULIN SYRINGE SYRINGE INSULIN SYRINGE-NEEDLE U-100 SYRINGE PEN NEEDLE, DIABETIC NEEDLE 31 SURE COMFORT INS. SYR. U-100 Enzyme Replacement/Modifiers
Enzyme Replacement/Modifiers
CEREZYME INTRAVENOUS RECON SOLN 400 UNIT CIMZIA CIMZIA POWDER FOR RECONST ELITEK INTRAVENOUS RECON You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
FABRAZYME INTRAVENOUS RECON QL (30 per 30 days) QL (90 per 30 days) Eye, Ear, Nose, Throat Agents
Eye, Ear, Nose, Throat Agents, Miscellaneous
altacaine apraclonidine atropine ophthalmic drops (Isopto Atropine) atropine ophthalmic ointment (Atropine Sulfate) azelastine nasal QL (30 per 25 days) azelastine ophthalmic carteolol cromolyn ophthalmic (Cromolyn Sodium) CYCLOGYL OPHTHALMIC DROPS 0.5 % cyclopentolate epinastine homatropine hbr (Isopto Homatropine) ipratropium bromide nasal spray,non- QL (30 per 28 days) aerosol 0.03 % You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
ipratropium bromide nasal spray,non- QL (15 per 10 days) aerosol 0.06 % LACRISERT naphazoline (Naphazoline HCl) olopatadine QL (30.5 per 30 days) phenylephrine hcl ophthalmic proparacaine (Proparacaine HCl) proparacaine hcl ophthalmic drops 0.5 % (Proparacaine HCl) proparacaine-fluorescein sod tetracaine hcl Eye, Ear, Nose, Throat Anti-Infectives Agents
acetic acid otic bacitracin ophthalmic bacitracin-polymyxin b ophthalmic (Bacitracin/Polymyxin B ciprofloxacin hcl ophthalmic ciprofloxacin hcl otic erythromycin ophthalmic gatifloxacin gentamicin ophthalmic gentamicin sulfate ophthalmic ointment 0.3 % (3 mg/gram) levofloxacin ophthalmic neomy sulf-bacitrac zn-poly-hc (Neomycin Su/Baci (Neomycin Su/Baci Su/Bacitra/Polymyxin) neomycin-polymyxin b-dexameth You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
ofloxacin ophthalmic ofloxacin otic polymyxin b sulf-trimethoprim sulfacetamide sodium (Sulfacetamide Sodium) sulfacetamide sodium ophthalmic drops 10 (Sulfacetamide Sodium) % sulfacetamide-prednisolone tobramycin trifluridine Eye, Ear, Nose, Throat Anti-Inflammatory Agents
bromfenac (Bromfenac Sodium) dexamethasone sodium phosphate ophthalmic diclofenac sodium ophthalmic (Diclofenac Sodium) fluorometholone flurbiprofen sodium fluticasone nasal QL (16 per 30 days) ketorolac ophthalmic QL (34 per 28 days) prednisolone acetate prednisolone sodium phosphate (Prednisolone Sod ophthalmic QL (60 per 30 days) Gastrointestinal Agents
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
Antiulcer Agents And Acid Suppressants
CARAFATE ORAL SUSPENSION cimetidine (Rx Product Only) cimetidine hcl oral (Cimetidine HCl) esomeprazole sodium famotidine (pf) famotidine (pf)-nacl (iso-os) (Famotidine In Nacl,Iso- famotidine oral tablet 20 mg, 40 mg (Rx Product Only) lansoprazole oral capsule,delayed (Rx Product Only) release(dr/ec) misoprostol omeprazole oral capsule,delayed release(dr/ec) pantoprazole intravenous (Pantoprazole Sodium) pantoprazole oral ranitidine hcl injection (Rx Product Only) ranitidine hcl oral syrup (Ranitidine HCl) (Rx Product Only) ranitidine hcl oral tablet 150 mg, 300 mg (Rx Product Only) sucralfate oral suspension sucralfate oral tablet Gastrointestinal Agents, Other
QL (60 per 30 days) BUPHENYL ORAL TABLET cromolyn oral dicyclomine oral capsule dicyclomine oral solution (Dicyclomine HCl) dicyclomine oral tablet diphenoxylate-atropine oral liquid diphenoxylate-atropine oral tablet glycopyrrolate glycopyrrolate lactulose oral solution You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
loperamide oral (Loperamide HCl) methscopolamine oral metoclopramide hcl injection metoclopramide hcl oral (Metoclopramide HCl) metoclopramide hcl oral QL (30 per 30 days) RELISTOR SUBCUTANEOUS PA; QL (28 per 28 days) RELISTOR SUBCUTANEOUS PA; QL (28 per 28 days) ursodiol oral capsule ursodiol oral tablet Laxatives
peg 3350-electrolytes peg 3350-na sulf,bicarb,cl-kcl peg-electrolyte soln (Nulytely with Flavor polyethylene glycol 3350 oral sodium chloride-nahco3-kcl-peg oral (Nulytely with Flavor recon soln 420 gram Phosphate Binders
calcium acetate oral capsule calcium acetate oral tablet 667 mg (Calcium Acetate) calcium carbonate-mag carb-fa Carbonate/Mag Carb/Fa) sodium polystyrene sulfonate oral powder (Sodium Polystyrene sodium polystyrene sulfonate oral (Sodium Polystyrene suspension 15 gram/60 ml sodium polystyrene sulfonate rectal enema (Sodium Polystyrene 30 gram/120 ml Genitourinary Agents
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
Antispasmodics, Urinary
oxybutynin chloride oral tablet (Oxybutynin Chloride) oxybutynin chloride oral tablet extended release 24hr tolterodine oral capsule,extended release 24hr tolterodine oral tablet trospium oral capsule,extended release 24hr trospium oral tablet Genitourinary Agents, Miscellaneous
alfuzosin tamsulosin terazosin Heavy Metal Antagonists
Heavy Metal Antagonists
deferoxamine injection recon soln EXJADE ORAL TABLET, DISPERSIBLE 125 MG EXJADE ORAL TABLET, DISPERSIBLE 250 MG, 500 MG FERRIPROX sodium thiosulfate intravenous solution 1 (Sodium Thiosulfate) gram/10 ml (100 mg/ml), 12.5 gram/50 ml (250 mg/ml) SYPRINE Hormonal Agents, Stimulant/Replacement/Modifying
Androgens
PA; QL (30 per 30 days) ANDROGEL TRANSDERMAL GEL IN PA; QL (300 per 30 METERED-DOSE PUMP 1.25 GRAM/ You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
ANDROGEL TRANSDERMAL GEL IN PA; QL (150 per 30 METERED-DOSE PUMP 20.25 MG/1.25 GRAM (1.62 %) ANDROGEL TRANSDERMAL GEL IN PA; QL (300 per 30 PACKET 1 % (25 MG/2.5GRAM), 1 % (50 MG/5 GRAM) ANDROGEL TRANSDERMAL GEL IN PA; QL (150 per 30 PACKET 1.62 % (20.25 MG/1.25 GRAM), 1.62 % (40.5 MG/2.5 GRAM) danazol oral fluoxymesterone (Fluoxymesterone) oxandrolone testosterone cypionate (Depo-Testosterone) testosterone enanthate PA; QL (5 per 28 days) testosterone transdermal gel in packet 1 % (Androgel) PA; QL (150 per 30 (25 mg/2.5gram) Estrogens And Antiestrogens
PA-HRM; QL (8 per 28 days) estradiol oral estradiol transdermal patch semiweekly PA-HRM; QL (8 per 28 days) estradiol transdermal patch weekly PA-HRM; QL (4 per 28 days) estradiol valerate estradiol/norethindrone acet estradiol-norethindrone acet PA-HRM; QL (97.44 per 28 days) estropipate QL (1 per 84 days) norethindrone ac-eth estradiol oral tablet 1-5 mg-mcg PREMARIN INJECTION You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
PREMARIN VAGINAL raloxifene QL (18 per 28 days) betamethasone acet,sod phos cortisone (Cortisone Acetate) dexamethasone oral dexamethasone oral dexamethasone sodium phosphate (Dexamethasone Sod injection fludrocortisone (Fludrocortisone hydrocortisone oral hydrocortisone sod succinate (Hydrocortisone Sod methylprednisolone acetate methylprednisolone sodium succ injection (A-Methapred) recon soln 125 mg, 40 mg methylprednisolone sodium succ intravenous prednisolone sodium phosphate oral solution prednisone SOLU-CORTEF (PF) INJECTION RECON SOLN 100 MG/2 ML triamcinolone acetonide injection Pituitary
desmopressin injection (Desmopressin Acetate) desmopressin nasal QL (15 per 30 days) desmopressin nasal (Desmopressin Acetate) QL (15 per 30 days) desmopressin oral You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.2 MG/0.25 ML GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.4 MG/0.25 ML, 0.6 MG/0.25 ML, 0.8 MG/0.25 ML, 1 MG/0.25 ML, 1.2 MG/0.25 ML, 1.4 MG/0.25 ML, 1.6 MG/0.25 ML, 1.8 MG/0.25 ML, 2 MG/0.25 ML HUMATROPE NORDITROPIN FLEXPRO NUTROPIN AQ NUSPIN NUTROPIN AQ SUBCUTANEOUS octreotide acetate injection solution 1,000 (Sandostatin) mcg/ml octreotide acetate injection solution 100 mcg/ml, 200 mcg/ml, 500 mcg/ml octreotide acetate injection solution 50 (Octreotide Acetate) mcg/ml octreotide acetate injection syringe (Octreotide Acetate) OMNITROPE SUBCUTANEOUS CARTRIDGE 10 MG/1.5 ML (6.7 MG/ML) OMNITROPE SUBCUTANEOUS CARTRIDGE 5 MG/1.5 ML (3.3 MG/ML) OMNITROPE SUBCUTANEOUS RECON SOLN PREGNYL SAIZEN CLICK.EASY SANDOSTATIN LAR DEPOT INTRAMUSCULAR KIT SEROSTIM SUBCUTANEOUS RECON You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
SOMATULINE DEPOT QL (1 per 28 days) QL (1 per 360 days) vasopressin Progestins
DEPO-PROVERA INTRAMUSCULAR QL (10 per 28 days) SOLUTION medroxyprogesterone intramuscular QL (1 per 84 days) suspension medroxyprogesterone intramuscular (Medroxyprogesterone QL (1 per 84 days) medroxyprogesterone oral norethindrone acetate progesterone progesterone micronized capsules Thyroid And Antithyroid Agents
levothyroxine intravenous (Levothyroxine Sodium) levothyroxine oral liothyronine oral methimazole oral tablet 10 mg, 5 mg propylthiouracil (Propylthiouracil) Immunological Agents
Immunological Agents
PA; QL (28 per 28 days) azathioprine azathioprine sodium (Azathioprine Sodium) CARIMUNE NF NANOFILTERED INTRAVENOUS RECON SOLN CELLCEPT INTRAVENOUS cyclosporine intravenous cyclosporine modified cyclosporine oral capsule You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
cyclosporine, modified ENBREL SURECLICK GAMMAGARD LIQUID GAMUNEX-C INJECTION SOLUTION HUMIRA PEN CROHN'S-UC-HS START HYPERRAB S/D (PF) IMOGAM RABIES-HT (PF) PA; QL (18.76 per 28 days) leflunomide mycophenolate mofetil oral capsule mycophenolate mofetil oral suspension for (Cellcept) reconstitution mycophenolate mofetil oral tablet mycophenolate sodium PA; QL (4 per 28 days) ORENCIA (WITH MALTOSE) PROGRAF INTRAVENOUS RAPAMUNE ORAL SOLUTION RAPAMUNE ORAL TABLET 1 MG, 2 sirolimus oral tablet 0.5 mg, 1 mg sirolimus oral tablet 2 mg You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
tacrolimus oral PA; LA; QL (15 per 28 days) ZORTRESS ORAL TABLET 0.25 MG PA BvD; QL (120 per 30 days) ZORTRESS ORAL TABLET 0.5 MG, PA BvD; QL (120 per 30 Vaccines
ADOLESN/ADULT)(PF) BCG VACCINE, LIVE (PF) CERVARIX VACCINE (PF) DAPTACEL (DTAP PEDIATRIC) (PF) ENGERIX-B PEDIATRIC (PF) HAVRIX (PF) INTRAMUSCULAR SUSPENSION HAVRIX (PF) INTRAMUSCULAR SYRINGE IMOVAX RABIES VACCINE (PF) INFANRIX (DTAP) (PF) INTRAMUSCULAR IPOL INJECTION SUSPENSION MENACTRA (PF) INTRAMUSCULAR SOLUTION MENHIBRIX (PF) MENOMUNE - A/C/Y/W-135 (PF) MENVEO A-C-Y-W-135-DIP (PF) MENVEO MENA COMPONENT (PF) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
MENVEO MENCYW-135 COMPNT (PF) M-M-R II (PF) PENTACEL ACTHIB COMPONENT (PF) PROQUAD (PF) RECOMBIVAX HB (PF) TENIVAC (PF) INTRAMUSCULAR TETANUS TOXOID,ADSORBED (PF) TETANUS,DIPHTHERIA TOX PED(PF) TETANUS-DIPHTHERIA TOXOIDS-TD QL (1 per 365 days) Inflammatory Bowel Disease Agents
Inflammatory Bowel Disease Agents
alosetron balsalazide budesonide oral Irrigating Solutions
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
Irrigating Solutions
acetic acid irrigation GLYCINE IRRIGATION LACTATED RINGERS IRRIGATION ringers irrigation sodium chloride irrigation (Sodium Chloride Irrig sorbitol irrigation (Sorbitol Solution) (Mannitol/Sorbitol water for irrigation, sterile Irrigation,Sterile) Metabolic Bone Disease Agents
Metabolic Bone Disease Agents
alendronate oral solution (Alendronate Sodium) QL (300 per 28 days) alendronate oral tablet 10 mg, 40 mg, 5 mg alendronate oral tablet 35 mg, 70 mg QL (4 per 28 days) calcitonin (salmon) QL (3.7 per 28 days) calcitriol intravenous solution 1 mcg/ml PA BvD; (PA for ESRD Only) calcitriol oral capsule PA BvD; (PA for ESRD Only) calcitriol oral solution PA BvD; (PA for ESRD Only) doxercalciferol intravenous (Doxercalciferol) PA BvD; (PA for ESRD Only) doxercalciferol oral PA BvD; (PA for ESRD Only) etidronate disodium (Etidronate Disodium) PA; QL (2.4 per 28 days) QL (3.7 per 28 days) ibandronate intravenous solution (Ibandronate Sodium) PA BvD; (PA for ESRD Only); QL (3 per 84 days) ibandronate intravenous syringe PA BvD; QL (3 per 84 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
ibandronate oral QL (1 per 28 days) MIACALCIN INJECTION PA BvD; (PA for ESRD Only) PA; QL (2 per 28 days) paricalcitol oral PA BvD; (PA for ESRD Only) QL (1 per 180 days) risedronate oral tablet 150 mg QL (1 per 28 days) PA; QL (1.7 per 28 days) ZEMPLAR INTRAVENOUS PA BvD; (PA for ESRD Only) zoledronic acid intravenous zoledronic acid-mannitol-water intravenous piggyback Acid/Mannitol and Water) zoledronic acid-mannitol-water QL (100 per 300 days) intravenous solution ZOMETA INTRAVENOUS SOLUTION Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
ACTEMRA INTRAVENOUS PA; QL (40 per 30 days) ACTEMRA SUBCUTANEOUS PA; QL (3.6 per 28 days) allopurinol amifostine crystalline (Amifostine Crystalline) anticoag citrate phos dextrose (Citrate Phosphate AVONEX (WITH ALBUMIN) AVONEX INTRAMUSCULAR AVONEX INTRAMUSCULAR BENLYSTA INTRAVENOUS RECON SOLN BETASERON SUBCUTANEOUS bethanechol chloride You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
BOTOX INJECTION RECON SOLN 100 PA; QL (4 per 90 days) UNIT BOTOX INJECTION RECON SOLN 200 PA; QL (1 per 90 days) UNIT buspirone colchicine oral tablet (Colchicine/Probenecid) COPAXONE SUBCUTANEOUS SYRINGE CURITY GAUZE TOPICAL BANDAGE 2 X 2 " CYSTADANE droperidol injection solution (Ergoloid Mesylates) EXTAVIA SUBCUTANEOUS finasteride oral tablet 5 mg fomepizole PA; QL (28 per 28 days) GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) guanidine hydroxyzine hcl intramuscular (Hydroxyzine HCl) hydroxyzine hcl oral solution 10 mg/5 ml (Hydroxyzine HCl) hydroxyzine hcl oral tablet (Hydroxyzine HCl) hydroxyzine pamoate QL (30 per 30 days) PA; QL (9.6 per 365 days) leucovorin calcium injection recon soln (Leucovorin Calcium) 100 mg, 200 mg, 350 mg leucovorin calcium oral (Leucovorin Calcium) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
levocarnitine (with sugar) (Levocarnitine (With PA BvD; (PA for ESRD levocarnitine oral PA BvD; (PA for ESRD Only) levoleucovorin calcium MESTINON ORAL SYRUP morrhuate sodium (Sodium Morrhuate) PA; QL (60 per 30 days) PA; QL (60 per 30 days) probenecid pyridostigmine bromide REBIF (WITH ALBUMIN) REBIF TITRATION PACK SENSIPAR ORAL TABLET 30 MG SENSIPAR ORAL TABLET 60 MG, 90 PA; QL (12 per 28 days) SIMPONI SUBCUTANEOUS PEN PA; QL (3 per 28 days) INJECTOR 100 MG/ML SIMPONI SUBCUTANEOUS PEN PA; QL (0.5 per 28 days) INJECTOR 50 MG/0.5 ML SIMPONI SUBCUTANEOUS SYRINGE PA; QL (3 per 28 days) 100 MG/ML SIMPONI SUBCUTANEOUS SYRINGE PA; QL (0.5 per 28 days) 50 MG/0.5 ML SOLIRIS STELARA SUBCUTANEOUS SYRINGE STERILE PADS TOPICAL BANDAGE 2 You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
PA; QL (14 per 30 days) CAPSULE,DELAYED RELEASE(DR/EC) 120 MG TECFIDERA ORAL PA; QL (60 per 30 days) CAPSULE,DELAYED RELEASE(DR/EC) 120 MG (14)- 240 MG (46), 240 MG THALOMID PA NSO; QL (60 per 30 days) QL (30 per 30 days) ST; QL (30 per 30 days) PA; QL (60 per 30 days) Ophthalmic Agents
Antiglaucoma Agents
acetazolamide oral capsule, extended (Diamox Sequels) release acetazolamide oral tablet acetazolamide sodium (Acetazolamide Sodium) ALPHAGAN P OPHTHALMIC DROPS betaxolol ophthalmic bimatoprost brimonidine (drops: 0.15%, 0.20%) dorzolamide latanoprost levobunolol LUMIGAN OPHTHALMIC DROPS 0.01 QL (2.5 per 25 days) % methazolamide oral metipranolol PHOSPHOLINE IODIDE pilocarpine hcl ophthalmic drops 1 %, 2 (Isopto Carpine) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
timolol maleate ophthalmic drops timolol maleate ophthalmic gel forming solution TRAVATAN Z QL (2.5 per 25 days) travoprost (benzalkonium) QL (2.5 per 25 days) Replacement Preparations
Replacement Preparations
calcium chloride intravenous (Calcium Chloride) calcium gluconate intravenous (Calcium Gluconate) PA BvD; (PA for ESRD Only) citric acid-sodium citrate (Citric Acid/Sodium electrolyte-48 in d5w IONOSOL-B IN D5W IONOSOL-MB IN D5W ISOLYTE M IN 5 % DEXTROSE ISOLYTE-H IN 5 % DEXTROSE ISOLYTE-P IN 5 % DEXTROSE klor-con 10 (Potassium Chloride) klor-con m10 (Potassium Chloride) klor-con m15 (Potassium Chloride) klor-con m20 (Potassium Chloride) klor-con sprinkle magnesium chloride injection (Magnesium Chloride) magnesium sulf in 0.45% nacl (Magnesium Sulf In magnesium sulfate in d5w intravenous piggyback 1 gram/100 ml, 4 gram/100 ml You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
magnesium sulfate in water intravenous (Magnesium Sulfate in piggyback 4 gram/100 ml (4 %), 4 gram/50 ml (8 %) magnesium sulfate injection (Magnesium Sulfate) NORMOSOL-M IN 5 % DEXTROSE NORMOSOL-R PH 7.4 phosphorus #1 (K-Phos Neutral) PLASMA-LYTE-56 IN 5 % DEXTROSE potassium acetate intravenous (Potassium Acetate) potassium bicarb and chloride (Pot Chloride/Pot potassium bicarb-citric acid potassium bicarbonate-cit ac oral tablet, effervescent 25 meq potassium chlorid-d5-0.45%nacl (Potassium Chloride/D5- potassium chloride in 0.9%nacl (Potassium Chloride In intravenous parenteral solution 20 meq/l, 40 meq/l potassium chloride in 5 % dex intravenous (Potassium Chloride In parenteral solution 20 meq/l, 30 meq/l, 40 D5w) meq/l potassium chloride intravenous (Potassium Chloride) potassium chloride oral capsule, extended (Micro-K) release potassium chloride oral liquid potassium chloride oral packet potassium chloride oral tablet extended release potassium chloride oral tablet,er particles/crystals 10 meq You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
potassium chloride oral tablet,er (Potassium Chloride) particles/crystals 20 meq potassium chloride-0.45 % nacl (Potassium Chloride- potassium chloride-d5-0.2%nacl (Potassium Chloride/D5- potassium chloride-d5-0.3%nacl (Potassium Chloride/D5- intravenous parenteral solution 20 meq/l potassium chloride-d5-0.9%nacl (Potassium Chloride/D5- potassium citrate-citric acid oral packet (Potassium Citrate/Citric 3,300-1,002 mg potassium citrate-citric acid oral solution (Potassium Citrate/Citric 1,100-334 mg/5 ml potassium phosphate m-/d-basic (Potassium Phos,M- ringers intravenous (Ringers Solution) sodium acetate intravenous (Sodium Acetate) sodium bicarbonate intravenous (Sodium Bicarbonate) sodium chloride 0.45 % intravenous (Sodium Chloride 0.45 sodium chloride 0.9 % injection solution sodium chloride 0.9 % intravenous sodium chloride 3 % (Sodium Chloride 3 %) sodium chloride 5 % (Sodium Chloride 5 %) sodium chloride intravenous (Sodium Chloride) sodium citrate-citric acid (Citric Acid/Sodium sodium lactate intravenous (Sodium Lactate) sodium phosphate (Sodium Phos,M-Basic- sod-pot-k cit-sod cit-cit acid (Sod/Pot/K Cit/Sod TPN ELECTROLYTES TPN ELECTROLYTES II You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
Respiratory Tract Agents
Anti-Inflammatories, Inhaled Corticosteroids
QL (60 per 30 days) QL (12 per 28 days) QL (60 per 30 days) QL (13 per 28 days) FLOVENT DISKUS INHALATION QL (60 per 30 days) BLISTER WITH DEVICE 100 MCG/ACTUATION, 50 MCG/ACTUATION FLOVENT DISKUS INHALATION QL (120 per 30 days) BLISTER WITH DEVICE 250 MCG/ACTUATION FLOVENT HFA INHALATION HFA QL (12 per 28 days) AEROSOL INHALER 110 MCG/ACTUATION FLOVENT HFA INHALATION HFA QL (24 per 28 days) AEROSOL INHALER 220 MCG/ACTUATION FLOVENT HFA INHALATION HFA QL (21.2 per 28 days) AEROSOL INHALER 44 MCG/ACTUATION QVAR QL (17.4 per 25 days) montelukast zafirlukast albuterol sulfate inhalation solution for (Albuterol Sulfate) nebulization albuterol sulfate oral syrup (Albuterol Sulfate) albuterol sulfate oral tablet (Albuterol Sulfate) albuterol sulfate oral tablet extended release 12 hr ANORO ELLIPTA QL (60 per 30 days) QL (25.8 per 28 days) COMBIVENT RESPIMAT QL (8 per 30 days) metaproterenol oral (Metaproterenol Sulfate) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
QL (17 per 25 days) PROAIR RESPICLICK QL (2 per 25 days) QL (60 per 30 days) SPIRIVA RESPIMAT INHALATION QL (4 per 30 days) MIST 2.5 MCG/ACTUATION SPIRIVA WITH HANDIHALER QL (30 per 30 days) STIOLTO RESPIMAT QL (4 per 28 days) STRIVERDI RESPIMAT terbutaline oral (Terbutaline Sulfate) terbutaline subcutaneous (Terbutaline Sulfate) theophylline anhydrous oral tablet extended release 12 hr 100 mg, 200 mg, 300 mg theophylline in dextrose 5 % intravenous (Theophylline/D5W) parenteral solution 200 mg/100 ml, 200 mg/50 ml, 400 mg/250 ml, 400 mg/500 ml, 800 mg/250 ml theophylline oral theophylline oral theophylline oral TUDORZA PRESSAIR QL (1 per 28 days) Respiratory Tract Agents, Other
acetylcysteine acetylcysteine cromolyn inhalation (Cromolyn Sodium) QL (30 per 30 days) PA; QL (270 per 30 days) PA; QL (60 per 30 days) PA; QL (60 per 30 days) PA; QL (120 per 30 days) PA; QL (6 per 28 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
Skeletal Muscle Relaxants
Skeletal Muscle Relaxants
carisoprodol PA-HRM; QL (120 per 30 days) chlorzoxazone (Parafon Forte DSC) COMFORT PAC-CYCLOBENZAPRINE COMFORT PAC-TIZANIDINE cyclobenzaprine oral tablet 10 mg, 5 mg dantrolene dantrolene sodium metaxalone methocarbamol oral tizanidine oral capsule tizanidine oral tablet Sleep Disorder Agents
Sleep Disorder Agents
PA-HRM; (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); QL (60 per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
zolpidem oral tablet PA-HRM; (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); QL (30 per 30 days) zolpidem oral tablet,ext release multiphase (Ambien CR) PA-HRM; (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); QL (30 per 30 days) Sympatholytic Adrenergic Blocking Agents
Alpha-Adrenergic Blocking Agents
phentolamine injection (Phentolamine Mesylate) Vasodilating Agents
Vasodilating Agents
PA; QL (60 per 30 days) PA; QL (90 per 30 days) epoprostenol (glycine) intravenous recon soln 0.5 mg epoprostenol (glycine) intravenous recon soln 1.5 mg LETAIRIS PA; QL (30 per 30 days) PA; QL (30 per 30 days) ORENITRAM ORAL TABLET EXTENDED RELEASE 0.125 MG ORENITRAM ORAL TABLET EXTENDED RELEASE 0.25 MG, 1 MG, 2.5 MG REMODULIN sildenafil intravenous PA; QL (37.5 per 1 day) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
Drug Name
Drug Tier Requirements/Limits
sildenafil oral PA; QL (90 per 30 days) PA; LA; QL (60 per 30 days) TYVASO REFILL KIT TYVASO STARTER KIT Vitamins And Minerals
Vitamins And Minerals
multivit-fluor 0.25 mg/ml drop 0.25 mg/ml (Pedi Mvi No.82 with prenatal vitamins oral tablet 27 mg iron- 1 (Pnv with (All Rx Prenatal Ca,No.72/Iron/Fa) Vitamins Covered) PRENATAL VITAMINS ORAL TABLET 29 MG IRON- 1 MG-25 MG sodium fluoride 1 mg (2.2 mg) (Sodium Fluoride) sodium fluoride oral tablet 1 mg fluoride (Pedi Mvi No.82 with You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
AFINITOR DISPERZ . 16 AMINOSYN 10 % . 45 AMINOSYN 3.5 % . 45 AMINOSYN 7 % . 45 AMINOSYN 7 % WITH ELECTROLYTES . 45 AMINOSYN 8.5 % . 45 ALBUMIN, HUMAN 25 % . 44 ABILIFY . 35, 36 ALBUMIN, HUMAN 5 % . 44 ELECTROLYTES . 45 ABILIFY DISCMELT . 35 ALBUMINAR 25 % . 44 AMINOSYN II 10 % . 45 ABILIFY MAINTENA . 35 ALBUMINAR 5 % . 44 AMINOSYN II 15 % . 45 ALBURX (HUMAN) 5 % . 44 AMINOSYN II 7 % . 45 ALBUTEIN 25 % . 44 AMINOSYN II 8.5 % . 45 acarbose . 27, 28 ALBUTEIN 5 % . 44 AMINOSYN II 8.5 %- albuterol sulfate . 84 ELECTROLYTES . 45 acetaminophen-codeine . 1 alclometasone . 59, 60 AMINOSYN M 3.5 % . 45 acetazolamide . 80 ALCOHOL PADS . 58 AMINOSYN-HBC 7% . 45 acetazolamide sodium . 80 ALCOHOL PREP PADS . 58 AMINOSYN-PF 10 % . 45 acetic acid . 64, 75, 76 acetylcysteine . 85 (SULFITE-FREE) . 45 alendronate . 76 AMINOSYN-RF 5.2 % . 45 ACTHIB (PF) . 74 amiodarone hcl . 49 acyclovir . 41, 58 allopurinol . 77 amitriptyline . 26 acyclovir sodium . 41 amlodipine-atorvastatin. 53 ADOLESN/ADULT)(PF) . 74 alprazolam . 6, 7 amlodipine-benazepril. 52 amlodipine-valsartan . 52 adapalene . 61, 62 aluminum chloride . 58 amantadine hcl . 35 ammonium lactate . 58 amifostine crystalline . 77 amoxicillin . 13, 14 ADVAIR DISKUS . 84 amoxicillin-pot clavulanate . 14 AMINO ACIDS 15 % . 45 amphetamine salt combo. 55 aminocaproic acid . 44 amphotericin b . 31 HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
ampicillin . 14 azacitidine . 16 ampicillin sodium . 14 azathioprine . 72 ampicillin-sulbactam . 14 azathioprine sodium . 72 bimatoprost . 80 bisoprolol fumarate . 49 azithromycin . 13 anastrozole . 16 ANDROGEL . 68, 69 BOOSTRIX TDAP . 74 ANORO ELLIPTA . 84 anticoag citrate phos dextrose 77 bacitracin . 10, 64 bacitracin-polymyxin b . 64 BREO ELLIPTA . 84 apraclonidine . 63 balsalazide . 75 brimonidine . 80 BCG VACCINE, LIVE (PF) . 74 BD INSULIN PEN NEEDLE bromocriptine . 35 aripiprazole . 36 BD INSULIN SYRINGE BUMINATE 25 % . 44 BD LUER-LOK SYRINGE . 62 BUMINATE 5 % . 44 buprenorphine hcl . 1, 6 aspirin-dipyridamole . 44 buprenorphine-naloxone . 6 ASSURE ID INSULIN bupropion hcl . 6, 26 ASTAGRAF XL . 72 BENICAR HCT . 48 butalb-acetaminophen-caffeine 1 butalbital-acetaminop-caf-cod . 1 atenolol-chlorthalidone. 49 benztropine . 35 butalbital-acetaminophen . 1 atorvastatin . 53 betamethasone acet,sod phos . 70 butalbital-acetaminophen-caff . 1 betamethasone dipropionate . 60 butalbital-aspirin-caffeine . 1 atovaquone-proguanil . 34 betamethasone valerate . 60 butorphanol tartrate . 1 betamethasone, augmented . 60 atropine . 23, 63 ATROVENT HFA . 84 betaxolol . 49, 80 bethanechol chloride . 77 AVC VAGINAL . 32 cabergoline . 35 BEXSERO (PF) . 74 caffeine citrated . 55 bicalutamide . 16 caffeine-sodium benzoate . 55 AVONEX (WITH ALBUMIN) BICILLIN C-R . 14 calcipotriene . 58 BICILLIN L-A . 14 calcitonin (salmon). 76 HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
calcitriol . 58, 76 cefoxitin in dextrose, iso-osm 12 cholestyramine (with sugar) . 53 calcium acetate . 67 cefpodoxime . 12 cholestyramine-aspartame . 53 calcium carbonate-mag carb-fa choline,magnesium salicylate . 4 ceftazidime . 12 calcium chloride . 81 calcium gluconate . 81 ceftriaxone . 12 CEFTRIAXONE . 12 ceftriaxone in dextrose,iso-os 12 candesartan . 48 cimetidine hcl . 66 DEXTROSE,ISO-OS . 12 cefuroxime axetil . 12 CIMZIA POWDER FOR cefuroxime sodium . 12 ciprofloxacin . 14, 15 captopril-hydrochlorothiazide 48 ciprofloxacin hcl . 15, 64 CELLCEPT INTRAVENOUS ciprofloxacin in 5 % dextrose 15 carbamazepine . 23 ciprofloxacin lactate . 15 carbidopa-levodopa . 35 cephalexin . 12, 13 CEPROTIN (BLUE BAR) . 41 citric acid-sodium citrate. 81 clarithromycin . 13 carboplatin . 17 CERVARIX VACCINE (PF) 74 NANOFILTERED . 72 clindamycin hcl . 10 carisoprodol . 86 clindamycin in 5 % dextrose . 10 CHANTIX CONTINUING clindamycin palmitate hcl . 10 clindamycin phosphate. 10, 32, CHANTIX CONTINUING CLINIMIX 5%/D15W CHANTIX STARTING SULFITE FREE . 45 CLINIMIX 5%/D25W chloramphenicol sod succinate SULFITE-FREE . 45 cefazolin in dextrose (iso-os) . 11 CLINIMIX 2.75%/D5W chlordiazepoxide hcl . 7 SULFIT FREE . 45 cefditoren pivoxil . 11 chlorhexidine gluconate . 58 CLINIMIX 4.25%/D10W SULF chloroquine phosphate . 34 CEFEPIME IN DEXTROSE 5 chlorothiazide . 53 CLINIMIX 4.25%/D5W chlorothiazide sodium. 53 SULFIT FREE . 45 chlorpromazine . 36 CLINIMIX 4.25%-D20W DEXTROSE,ISO-OSM. 12 chlorthalidone . 53 chlorzoxazone . 86 CLINIMIX 4.25%-D25W HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
D20W(SULFITE-FREE) . 45 CLINIMIX E 2.75%/D10W COMBIVENT RESPIMAT . 84 cysteine (l-cysteine) . 46 CLINIMIX E 2.75%/D5W cytarabine (pf) . 17 CYCLOBENZAPRINE . 86 CLINIMIX E 4.25%/D10W COMFORT PAC-IBUPROFEN d10 % & 0.45 % sodium CLINIMIX E 4.25%/D25W d10 %-0.9 % sodium chloride 46 d2.5 %-0.45 % sodium chloride CLINIMIX E 4.25%/D5W COMFORT PAC-NAPROXEN d5 % and 0.9 % sodium chloride CLINIMIX E 5%/D15W COMFORT PAC-TIZANIDINE d5 %-0.45 % sodium chloride 46 CLINIMIX E 5%/D20W dacarbazine . 17 COMVAX (PF) . 74 dactinomycin . 17 CLINIMIX E 5%/D25W CLINISOL SF 15 % . 46 clobetasol propionate. 60 dantrolene sodium . 86 clobetasol-emollient . 60 COSENTYX (2 SYRINGES) 58 clocortolone pivalate . 60 COSENTYX PEN . 58 clomipramine . 26 COSENTYX PEN (2 PENS) . 58 PEDIATRIC) (PF) . 74 clonidine hcl . 47, 55 clonidine hcl-chlorthalidone . 47 cromolyn . 63, 66, 85 deferoxamine. 68 clopidogrel . 44 clorazepate dipotassium . 7 CURITY GAUZE . 78 clotrimazole . 31 cyclobenzaprine . 86 DEPEN TITRATABS . 68 clotrimazole-betamethasone . 31 DEPO-PROVERA . 72 cyclopentolate . 63 desipramine . 26 cyclophosphamide . 17 desmopressin . 70 codeine sulfate . 1 CYCLOPHOSPHAMIDE . 17 desog-e.estradiol/e.estradiol . 56 codeine-butalbital-asa-caffein . 1 desogestrel-ethinyl estradiol . 56 cyclosporine . 72 colchicine-probenecid . 78 cyclosporine modified . 72 desoximetasone . 60 cyclosporine, modified . 73 dexamethasone . 70 cyproheptadine . 32 dexamethasone sodium colistin (colistimethate na) . 10 phosphate . 65, 70 COLY-MYCIN S . 64 dexmethylphenidate . 55 HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
dextroamphetamine . 55 DILANTIN CAPSULE 30 MG electrolyte-48 in d5w . 81 amphetamine . 55 diltiazem hcl . 50 dextrose 10 % and 0.2 % nacl 46 dextrose 10 % in water (d10w) dimenhydrinate . 33 dextrose 2.5 % in water(d2.5w) diphenhydramine hcl . 32 diphenoxylate-atropine . 66 dextrose 20 % in water (d20w) disopyramide phosphate . 49 dextrose 25 % in water (d25w) dextrose 40 % in water (d40w) dobutamine in d5w . 51 enalapril maleate . 48 enalaprilat . 48 dextrose 5 % in ringers . 46 enalapril-hydrochlorothiazide 48 dextrose 5 % in water (d5w) . 46 dopamine in 5 % dextrose . 51 dextrose 5 %-lactated ringers . 46 dorzolamide . 80 ENBREL SURECLICK . 73 dextrose 5%-0.2 % sod chloride dorzolamide-timolol . 80 ENGERIX-B (PF) . 74 ENGERIX-B PEDIATRIC (PF) dextrose 5%-0.3 % sod.chloride doxercalciferol . 76 enoxaparin . 41, 42 dextrose 50 % in water (d50w) doxorubicin hcl . 17 doxorubicin hcl peg-liposomal dextrose 70 % in water (d70w) doxorubicin, peg-liposomal . 17 ephedrine sulfate . 51 dextrose with sodium chloride47 doxycycline hyclate . 15 DIASTAT ACUDIAL . 7 doxycycline monohydrate 15, 16 epinephrine . 51, 52 epinephrine hcl (pf) . 51 diazepam intensol . 7 EPIPEN 2-PAK . 52 diclofenac potassium . 4 drospirenone-ethinyl estradiol 56 EPIPEN JR 2-PAK . 52 diclofenac sodium . 4, 65 diclofenac-misoprostol . 4 DRYSOL DAB-O-MATIC . 58 dicloxacillin . 14 dicyclomine . 66 epoprostenol (glycine) . 87 DURAMORPH (PF). 1 dihydroergotamine . 32 erythromycin . 13, 64 HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
erythromycin base . 13 ERYTHROMYCIN BASE . 13 flurbiprofen . 4 erythromycin base-ethanol . 59 flurbiprofen sodium . 65 erythromycin ethylsuccinate . 13 fenofibrate . 53 erythromycin stearate . 13 fenofibrate micronized . 53 fluticasone . 61, 65 erythromycin with ethanol . 59 fenofibrate nanocrystallized . 53 fluvoxamine . 27 fenofibric acid . 53 escitalopram oxalate . 26 fenofibric acid (choline) . 53 fondaparinux . 42 esomeprazole sodium . 66 fentanyl citrate . 1 estradiol valerate . 69 finasteride . 78 estradiol/norethindrone acet . 69 fosphenytoin . 23 estradiol-norethindrone acet . 69 FIRMAGON KIT W DILUENT FREAMINE HBC 6.9 %. 47 FREAMINE III 10 % . 47 estropipate . 69 FLEBOGAMMA DIF . 73 ethinyl estradiol/drospirenone 56 FLEXBUMIN 25 %. 44 ethosuximide . 23 FLEXBUMIN 5 %. 44 ethynodiol d-ethinyl estradiol. 56 FLOVENT DISKUS. 84 gabapentin . 23, 24 etidronate disodium . 76 FLOVENT HFA . 84 floxuridine . 18 galantamine . 25 fluconazole . 31 GAMASTAN S/D . 73 fluconazole in dextrose(iso-o) 31 GAMMAGARD LIQUID . 73 fluconazole in nacl (iso-osm) 31 flucytosine . 31 fludarabine . 18 ganciclovir sodium . 41 fludrocortisone . 70 GARDASIL (PF) . 74 GARDASIL 9 (PF) . 74 fluocinonide . 61 gatifloxacin . 64 fluocinonide-emollient base . 61 famciclovir . 41 fluorometholone. 65 gemcitabine . 18 gemfibrozil . 54 famotidine (pf). 66 fluorouracil . 18, 58 famotidine (pf)-nacl (iso-os) . 66 GENOTROPIN MINIQUICK 71 gentamicin . 9, 59, 64 fluoxymesterone . 69 gentamicin in nacl (iso-osm) . 9 fluphenazine decanoate . 36 gentamicin sulfate . 64 fluphenazine hcl . 36 gentamicin sulfate (ped) (pf) . 9 HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
gentamicin sulfate (pf) . 9 heparin, porcine (pf) . 42, 43 hydroxyzine hcl . 78 HEPATAMINE 8% . 47 hydroxyzine pamoate . 78 gildess 24 fe . 56 HEPATASOL 8 %. 47 HYPERLYTE CR . 81 HYPERRAB S/D (PF) . 73 homatropine hbr . 63 glimepiride . 30 ibandronate . 76, 77 HUMALOG KWIKPEN . 29 glipizide-metformin . 30 HUMALOG MIX 50-50 . 29 GLUCAGEN HYPOKIT . 78 HUMALOG MIX 50-50 GLUCAGON EMERGENCY KIT (HUMAN) . 78 HUMALOG MIX 75-25 . 29 ifosfamide-mesna . 19 HUMALOG MIX 75-25 glyburide micronized. 30 glyburide-metformin . 30 imipenem-cilastatin . 13 imipramine hcl . 27 glycopyrrolate. 66 HUMIRA PEN CROHN'S-UC- imipramine pamoate. 27 HUMULIN 70/30 . 29 IMOGAM RABIES-HT (PF) 73 granisetron (pf) . 34 HUMULIN 70/30 KWIKPEN 29 IMOVAX RABIES VACCINE granisetron hcl . 34 HUMULIN N KWIKPEN . 29 griseofulvin microsize . 31 guanfacine . 47, 55 indomethacin . 4 (CONCENTRATED) . 29 indomethacin sodium . 4 hydralazine . 52 INFANRIX (DTAP) (PF) . 74 hydrochlorothiazide . 53 halobetasol propionate. 61 hydrocodone-acetaminophen 1, 2 INSULIN SYRINGE . 62 haloperidol . 36 hydrocodone-ibuprofen . 2 haloperidol decanoate . 36 hydrocortisone . 61, 70 haloperidol lactate . 36 hydrocortisone acet-aloe vera 61 INSULIN SYRINGE-NEEDLE hydrocortisone acetate-urea . 61 HAVRIX (PF) . 74 hydrocortisone butyrate . 61 heparin (porcine) . 42 heparin (porcine) in 5 % dex . 42, hydrocortisone sod succinate . 70 HEPARIN (PORCINE) IN 5 % hydrocortisone valerate . 61 hydromorphone . 2 INVEGA SUSTENNA . 36, 37 heparin (porcine) in nacl (pf) . 42 hydromorphone (pf) . 2 INVEGA TRINZA. 37 HEPARIN(PORCINE) IN hydroxychloroquine . 34 hydroxyurea . 18 HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
IONOSOL-B IN D5W . 81 IONOSOL-MB IN D5W . 81 leflunomide . 73 ipratropium bromide . 63, 64 ketoconazole . 31 leucovorin calcium . 78 ketorolac . 4, 5, 65 kimidess (28) . 57 levetiracetam . 24 ISOLYTE M IN 5 % levobunolol . 80 KINRIX (PF) . 74 levocarnitine . 79 ISOLYTE-H IN 5 % levocarnitine (with sugar) . 79 klor-con 10 . 81 levocetirizine . 32 ISOLYTE-P IN 5 % levofloxacin. 15, 64 klor-con m10. 81 levofloxacin in d5w. 15 klor-con m15. 81 levoleucovorin calcium . 79 klor-con m20. 81 levonorgestrel . 57 isosorbide dinitrate . 54 klor-con sprinkle . 81 levonorgestrel-ethin estradiol. 57 isosorbide mononitrate . 54 KLOR-CON/EF . 81 levonorgestrel-ethinyl estrad . 57 isotretinoin . 58 levorphanol tartrate . 2 levothyroxine . 72 itraconazole . 31 lidocaine . 5, 6 lidocaine (pf) . 5, 49 l norgest/e.estradiol-e.estrad . 57 lidocaine hcl . 5 IXIARO (PF) . 74 lidocaine in 5 % dextrose (pf) 49 lidocaine-prilocaine. 6 LACTATED RINGERS . 76 liothyronine . 72 lipase-protease-amylase . 63 lamivudine-zidovudine . 39 lamotrigine . 24 LIPOSYN III . 47 lansoprazole . 66 lisinopril-hydrochlorothiazide 48 lithium carbonate . 55 LANTUS SOLOSTAR . 29 lithium citrate . 55 junel fe 24 . 57 larin 24 fe . 57 l-norgest-eth estr/ethin estra . 57 latanoprost . 80 HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
loperamide . 67 metipranolol . 80 lorazepam oral solution . 8 metoclopramide hcl . 67 losartan-hydrochlorothiazide . 48 metoprolol succinate . 49 melphalan hcl intravenous . 20 MENACTRA (PF) . 74 metoprolol tartrate . 50 loxapine succinate . 37 metronidazole . 32, 34, 35, 59 MENHIBRIX (PF) . 74 metronidazole in nacl (iso-os) 34 MENOMUNE - A/C/Y/W-135 LUPRON DEPOT . 19 LUPRON DEPOT (3 MONTH) MENVEO A-C-Y-W-135-DIP miconazole nitrate . 31 LUPRON DEPOT (4 MONTH) midazolam (pf) . 8 COMPONENT (PF) . 74 LUPRON DEPOT (6 MONTH) MENVEO MENCYW-135 COMPNT (PF) . 75 milrinone in 5 % dextrose . 52 LUPRON DEPOT-PED . 19 mercaptopurine . 20 LUPRON DEPOT-PED (3 minocycline . 16 mirtazapine . 27 metaproterenol . 84 misoprostol . 66 mafenide acetate . 58 mitoxantrone . 20 magnesium chloride . 81 M-M-R II (PF) . 75 magnesium sulf in 0.45% nacl81 methadone hcl . 2 magnesium sulfate . 82 methazolamide . 80 magnesium sulfate in d5w . 81 methenamine hippurate . 10 magnesium sulfate in water . 82 methenamine mandelate . 10 methimazole . 72 montelukast . 84 maprotiline . 27 methocarbamol . 86 methotrexate sodium. 20 methotrexate sodium (pf) . 20 morphine concentrate . 2 methoxsalen rapid . 59 morrhuate sodium . 79 methscopolamine . 67 methyclothiazide . 53 medroxyprogesterone . 72 methylphenidate. 55, 56 mefenamic acid . 5 methylprednisolone . 70 moxifloxacin . 15 methylprednisolone acetate . 70 MEFOXIN IN DEXTROSE methylprednisolone sodium succ HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
mupirocin calcium . 59 mycophenolate mofetil . 73 NOVOLOG FLEXPEN . 30 mycophenolate sodium . 73 NOVOLOG MIX 70-30 . 30 NOVOLOG MIX 70-30 NOVOLOG PENFILL . 30 nicardipine . 52 nafcillin in dextrose iso-osm . 14 naltrexone hcl . 6 nitrofurantoin macrocrystal . 10 NAMENDA TITRATION PAK NUTRILYTE II . 82 nitroglycerin. 54, 55 nitroglycerin in 5 % dextrose. 54 NUTROPIN AQ NUSPIN . 71 NORDITROPIN FLEXPRO . 71 norelgestromin/ethin.estradiol 57 naproxen sodium . 5 norepinephrine bitartrate . 52 noreth-ethinyl estradiol/iron . 57 NYSTATIN (BULK) . 32 norethindrone . 57 nystatin-triamcinolone . 32 norethindrone (contraceptive) 57 nateglinide . 29 norethindrone acetate . 72 norethindrone ac-eth estradiol octreotide acetate . 71 norethindrone-e.estradiol-iron 57 ofloxacin . 15, 65 neomy sulf-bacitrac zn-poly-hc norethindrone-ethinyl estrad . 57 norethindrone-mestranol . 57 olanzapine-fluoxetine . 27 norgestimate-ethinyl estradiol 57 olopatadine . 64 neomycin-bacitracin-poly-hc . 64 norgestrel-ethinyl estradiol . 57 NORMOSOL-M IN 5 % omega-3 acid ethyl esters . 54 neomycin-polymyxin b gu . 59 neomycin-polymyxin b- NORMOSOL-R PH 7.4 . 82 ondansetron . 34 nortriptyline . 27 ondansetron hcl . 34 ondansetron hcl (pf) . 34 neomycin-polymyxin-hc . 65 NOVOLIN 70/30 . 29 NEPHRAMINE 5.4 % . 47 HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
peg 3350-na sulf,bicarb,cl-kcl 67 PLASBUMIN 25 % . 44 PLASBUMIN 5 % . 45 PLASMA-LYTE 148 . 82 ORENCIA (WITH MALTOSE) PEGASYS PROCLICK . 41 PLASMA-LYTE A . 82 peg-electrolyte soln . 67 PLASMA-LYTE-56 IN 5 % PEGINTRON REDIPEN . 41 PEN NEEDLE, DIABETIC . 62 penicillin g pot in dextrose . 14 podophyllum resin . 59 OTEZLA STARTER. 79 penicillin g potassium . 14 polyethylene glycol 3350 . 67 penicillin g procaine . 14 polymyxin b sulf-trimethoprim oxacillin in dextrose(iso-osm) 14 penicillin v potassium . 14 oxaliplatin . 20 PENTACEL (PF) . 75 oxandrolone . 69 potassium acetate . 82 oxcarbazepine . 24 COMPONENT (PF) . 75 potassium bicarb and chloride 82 OXTELLAR XR . 24 potassium bicarb-citric acid . 82 oxybutynin chloride. 67, 68 pentoxifylline . 44 potassium bicarbonate-cit ac . 82 oxycodone hcl-acetaminophen . 3 perindopril erbumine . 48 oxycodone hcl-aspirin . 3 potassium chloride . 82, 83 oxycodone-acetaminophen . 3 potassium chloride in 0.9%nacl oxycodone-aspirin . 3 perphenazine . 37 perphenazine-amitriptyline . 27 potassium chloride in 5 % dex82 potassium chloride in lr-d5 . 47 phenobarbital . 24 potassium chloride-0.45 % nacl phenobarbital sodium . 24 paliperidone . 37 phentolamine . 87 phenylephrine hcl . 48, 64 pantoprazole . 66 phenytoin sodium . 24 paricalcitol . 77 phenytoin sodium extended . 24 paromomycin . 35 paroxetine hcl . 27 PHOSPHOLINE IODIDE . 80 potassium citrate-citric acid . 83 phosphorus #1 . 82 potassium hydroxide . 59 potassium phosphate m-/d-basic pilocarpine hcl . 58, 80 pedi m.vit no.17 with fluoride 88 pioglitazone . 29 PEDIARIX (PF) . 75 pioglitazone-glimepiride . 29 PRALUENT PEN . 54 PEDVAX HIB (PF) . 75 pioglitazone-metformin . 29 PRALUENT SYRINGE . 54 peg 3350-electrolytes . 67 piperacillin-tazobactam . 14 PEG 3350-GRX. 67 HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
pravastatin . 54 promethazine hcl . 34 propafenone . 49 prednicarbate . 61 propantheline . 23 prednisolone acetate . 65 proparacaine . 64 prednisolone sodium phosphate proparacaine hcl . 64 proparacaine-fluorescein sod . 64 REPATHA SURECLICK . 54 REPATHA SYRINGE . 54 PREMARIN . 69, 70 PREMASOL 10 % . 47 propylthiouracil . 72 PREMASOL 6 % . 47 PROQUAD (PF) . 75 prenatal vitamins . 88 protriptyline . 27 PRENATAL VITAMINS . 88 pyrazinamide . 33 pyridostigmine bromide . 79 QUADRACEL (PF) . 75 rimantadine . 40 ringers . 76, 83 QUILLIVANT XR . 56 risedronate . 77 PROAIR RESPICLICK . 85 RISPERDAL CONSTA . 38 quinapril-hydrochlorothiazide 49 procainamide . 49 quinidine gluconate. 49 PROCALAMINE 3% . 47 quinidine sulfate . 49 rivastigmine tartrate . 26 prochlorperazine . 34 quinine sulfate. 35 rizatriptan . 32 prochlorperazine edisylate. 34 prochlorperazine maleate . 34 PROCRIT . 43, 44 RABAVERT (PF). 75 ROTATEQ VACCINE . 75 progesterone . 72 progesterone micronized ranitidine hcl . 66 SAIZEN CLICK.EASY . 71 REBIF (WITH ALBUMIN) . 79 REBIF REBIDOSE . 79 SANDOSTATIN LAR DEPOT REBIF TITRATION PACK . 79 RECOMBIVAX HB (PF) . 75 SAPHRIS (BLACK CHERRY) promethazine . 32, 34 RELENZA DISKHALER . 40 HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
selegiline hcl . 35 selenium sulfide. 59 sorbitol-mannitol . 76 SYMLINPEN 120 . 29 sotalol hcl . 50 SYMLINPEN 60 . 29 SEREVENT DISKUS . 85 SEROQUEL XR . 38 SPIRIVA RESPIMAT . 85 spironolactone . 54 sildenafil oral tablet 20 mg . 87, tacrolimus . 61, 74 silver nitrate . 59 silver nitrate applicators . 59 silver sulfadiazine . 59 STERILE PADS . 79 STIOLTO RESPIMAT . 85 SIMPONI ARIA . 79 simvastatin . 54 streptomycin . 9 STRIVERDI RESPIMAT. 85 sodium acetate . 83 sodium bicarbonate . 83 sulfacetamide sodium . 65 sodium chloride . 76, 83 sulfacetamide sodium (acne) . 59 sodium chloride 0.45 % . 83 sulfacetamide-prednisolone . 65 sodium chloride 0.9 % . 83 sulfadiazine . 15 telmisartan . 48 sodium chloride 3 % . 83 sodium chloride 5 % . 83 sulfasalazine . 15 temazepam . 8, 9 sodium citrate-citric acid . 83 TENIVAC (PF) . 75 sodium fluoride . 88 sulfazine ec . 15 sodium lactate . 83 terbinafine hcl . 32 sodium phosphate . 83 sumatriptan nasal spray . 32 terbutaline . 85 sodium polystyrene sulfonate . 67 sumatriptan succinate . 33 terconazole . 32 sodium thiosulfate . 68 SUPPRELIN LA. 72 testosterone . 69 sod-pot-k cit-sod cit-cit acid . 83 testosterone cypionate . 69 SURE COMFORT INS. SYR. testosterone enanthate . 69 SOLU-CORTEF (PF) . 70 TOXOID,ADSORBED (PF) SOMATULINE DEPOT . 72 HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
TETANUS,DIPHTHERIA TOX tramadol-acetaminophen . 3 trandolapril. 49 TETANUS-DIPHTHERIA tranexamic acid . 44 TYVASO REFILL KIT . 88 TRANSDERM-SCOP . 34 TYVASO STARTER KIT . 88 tetrabenazine. 56 tranylcypromine . 27 tetracaine hcl . 64 TRAVASOL 10 %. 47 tetracycline . 16 travoprost (benzalkonium) . 81 theophylline . 85 TREANDA . 21, 22 theophylline anhydrous . 85 theophylline in dextrose 5 % . 85 valacyclovir . 41 thioridazine . 38 thiothixene . 38 tretinoin (chemotherapy) . 22 valganciclovir . 41 tretinoin microspheres . 62 valproate sodium . 25 valproic acid . 25 triamcinolone acetonide . 58, 61, valproic acid (as sodium salt) 25 timolol maleate . 50, 81 valsartan-hydrochlorothiazide 48 TOBI PODHALER . 10 TOBRADEX ST . 65 vancomycin in d5w . 11 tobramycin in 0.225 % nacl . 10 trifluoperazine . 38 VARIVAX (PF) . 75 tobramycin in 0.9 % nacl. 10 trifluridine . 65 tobramycin sulfate . 10 trihexyphenidyl . 35 vasopressin . 72 tolazamide . 30, 31 tolbutamide . 31 trimethoprim . 11 venlafaxine . 27 TROKENDI XR . 25 TROPHAMINE 10 % . 47 toposar intravenous . 21 TROPHAMINE 6% . 47 VIDEX 2 GRAM PEDIATRIC TOUJEO SOLOSTAR . 30 VIDEX 4 GRAM PEDIATRIC TUDORZA PRESSAIR . 85 TPN ELECTROLYTES . 83 TWINRIX (PF) . 75 VIEKIRA PAK . 41 TPN ELECTROLYTES II . 83 HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 2015 Comprehensive Formulary
vinblastine . 22 ziprasidone hcl . 38 vincristine . 22 vincristine sulfate . 22 zoledronic acid . 77 vinorelbine . 22 VIRAMUNE XR . 40 zolmitriptan . 33 YF-VAX (PF) . 75 voriconazole . 32 zafirlukast . 84 ZOSTAVAX (PF) . 75 water for irrigation, sterile . 76 ZYPREXA RELPREVV . 38 HeartlandPlains Health 2015 Part D Formulary Effective: December 01, 2015 Formulary ID: 15481.002, Version: 17 We have made no changes to this formulary since 10/15/15. For more recent information or other questions, please contact HeartlandPlains Health (HMO) Customer Service, at 1-866-792-0184 or, for TTY users, 711, 8:00 am to 8:00 pm, Monday-Friday and 8:00 am to 8:00 pm, Monday-Sunday October 1 through February 14, or visit www.HeartlandPlainsHealth.com. HeartlandPlains Health Customer Service
Nebraska Senior Health Insurance
Information Program (SHIIP)
(TTY/TDD users should call 711) Calls to these numbers are free. (TTY/TDD 1-800-833-7352) HeartlandPlains Health is an HMO plan with a This number is only for people who have Medicare contract. Enrollment in Heartland- difficulties with hearing or speaking. Plains Health depends on contract renewal. HeartlandPlains Health hours of operation are 8:00am to 8:00pm, Monday - Friday and 8:00am Nebraska Department of Insurance Terminal to 8:00pm, Monday – Sunday October 1 through Building 941 O Street, Suite 400 Lincoln, NE February 14. You may reach a voicemail on weekends and holidays; please leave a message and your call will be returned the next business day. Customer Service also has free language interpreter services available for non-English
speakers.
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HeartlandPlains Health
PO Box 31457
Omaha, NE 68131
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