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1 2018 SCAN Health Plan Formulary List of Covered Drugs SCAN Health Plan 處方集承保藥物清單 SCAN Health Plan... This formulary was updated on 02/01/2018. For more recent information or other questions, please contact SCAN Health Plan Member Services at (Medicare and Medi-Cal eligible members should call ) or, for TTY users, 711, 8 a.m. to 8 p.m., 7 days a week from October 1 to February 14. From February 15 to September 30, hours are 8 a.m. to 8 p.m. Monday through Friday (messages received on holidays and outside of our business hours will be returned within one business day), or visit 本處方集更新於 2018 年 2 月 1 日 如欲瞭解更多最新資訊或有其他問題, 請聯絡 SCAN Health Plan 會員服務部, 電話 : ( 符合 Medicare 和 Medi-Cal 資格的會員應撥打 ),TTY 用戶 :711, 服務時間為 10 月 1 日至次年 2 月 14 日, 每週七天, 上午 8 時至晚上 8 時 ;2 月 15 日至 9 月 30 日, 週一至週五, 上午 8 時至晚上 8 時 ( 假日和下班時間接到的留言會在下一個工作日回電 ), 或者瀏覽 18C-FOR900CH

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3 SCAN Health Plan 2018 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN 18423, 8 This formulary was updated on 02/01/2018. For more recent information or other questions, please contact SCAN Health Plan Member Services, at (Medicare and Medi-Cal eligible members should call ) or, for TTY users, 711, 8 a.m. to 8 p.m., 7 days a week from October 1 to February 14. From February 15 to September 30, hours are 8 a.m. to 8 p.m. Monday through Friday (messages received on holidays and outside of our business hours will be returned within one business day), or visit 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 SCAN Health Plan. When it refers to plan or our plan, it means SCAN Classic (HMO), SCAN Classic II (HMO), Scripps Classic offered by SCAN Health Plan (HMO), Scripps Signature offered by SCAN Health Plan (HMO), SCAN Healthy at Home (HMO SNP), Heart First (HMO SNP), Scripps Heart First offered by SCAN Health Plan (HMO SNP), SCAN Balance (HMO SNP), SCAN Plus (HMO), Scripps Plus offered by SCAN Health Plan (HMO), SCAN Connections (HMO SNP), or SCAN Connections at Home (HMO SNP). This document includes a list of the drugs (formulary) for our plan which is current as of February, 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, 2019, and from time to time during the year. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. You can get prescription drugs shipped to your home through our network mail-order delivery program. Typically, you should expect to receive your prescription drugs within 14 days from the time that the mail-order pharmacy receives the order. If you do not receive your prescription drug(s) within this time, please contact SCAN Health Plan Member Services at (Medicare and Medi-Cal eligible members should call ), 8 a.m. to 8 p.m., 7 days a week from October 1 to February 14. From February 15 to September 30, hours are 8 a.m. to 8 p.m. Monday through Friday (messages received on holidays and outside of our business hours will be returned within one business day). TTY users should call

4 SCAN Health Plan is an HMO plan with a Medicare contract. Enrollment in SCAN Health Plan depends on contract renewal. ATTENTION: If you speak another language, language assistance services, free of charge, are available to you. Call (TTY: 711). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 711). 注意 : 如果您使用中文, 您可以免費獲得語言援助服務 請致電 (TTY: 711) Y0057_SCAN_10440_2017F File & Use Accepted

5 Table of Contents.... What is the SCAN Health Plan Formulary?... 5 Can the Formulary (drug list) change?... 5 How do I use the Formulary?... 5 What are generic drugs?... 6 Are there any restrictions on my coverage?... 6 What if my drug is not on the Formulary?... 6 How do I request an exception to the SCAN Health Plan Formulary?... 7 What do I do before I can talk to my doctor about changing my drugs or requesting an exception?... 7 For more information... 8 SCAN Health Plan s Formulary Formulary Drugs Arranged by Therapeutic Class Formulary Drugs with Quantity Limits Index

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7 What is the SCAN Health Plan Formulary? A formulary is a list of covered drugs selected by SCAN Health Plan 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. SCAN Health Plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a SCAN Health Plan 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 2018 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2018 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 February, To get updated information about the drugs covered by SCAN Health Plan, please contact us. Our contact information appears on the front and back cover pages. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 69. 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 number 69. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 98. 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. 5

8 What are generic drugs? SCAN Health Plan 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: SCAN Health Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from SCAN Health Plan before you fill your prescriptions. If you don t get approval, SCAN Health Plan may not cover the drug. Quantity Limits: For certain drugs, SCAN Health Plan limits the amount of the drug that SCAN Health Plan will cover. For example, SCAN Health Plan provides 30 tablets per prescription for Rozerem. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, SCAN Health Plan 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, SCAN Health Plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, SCAN Health Plan 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 69. 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 SCAN Health Plan 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 SCAN Health Plan formulary? on page 7 for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered. If you learn that SCAN Health Plan does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by SCAN Health Plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by SCAN Health Plan. You can ask SCAN Health Plan to make an exception and cover your drug. See below for information about how to request an exception. 6

9 How do I request an exception to the SCAN Health Plan Formulary? You can ask SCAN Health Plan 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, SCAN Health Plan 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, SCAN Health Plan 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 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with at least a 91 and may be up to a 98-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. 7

10 If you are a current member transitioning to a different level of care, you may be prescribed medications not on our formulary or your ability to get your drugs may be limited. In these instances, you need to talk with your doctor about the appropriate alternative therapies available on our formulary. If there are no appropriate alternative therapies on our formulary, you or your doctor can request an exception and ask the plan to cover the drug or remove restrictions from the drug. While you are talking with your doctor to determine the course of action, you are eligible to receive a 30-day transition supply of the drug if you are moving from a long-term care (LTC) facility or a hospital stay to home or a 31-day transition supply of the drug if you are moving from home or a hospital stay to a long-term care (LTC) facility. For more information For more detailed information about your SCAN Health Plan prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about SCAN Health Plan, 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 MEDICARE ( ) 24 hours a day/7 days a week. TTY users should call Or, visit 8

11 The charts below list what you will pay as your share of the costs for covered prescription drugs when you are in the Initial Coverage Stage. Please refer to your Evidence of Coverage for more information. SCAN Classic (HMO): Los Angeles County Drug Tier Tier Name Retail & Mail-Order (innetwork) (30-day Retail (innetwork) (30-day Retail & Mail- Order cost-sharing (60-day Retail (60-day Retail & Mail-Order (innetwork) (90-day Retail (innetwork) (90-day 1 Generic $0 $0 $0 $0 $0 $0 2 Generic $5 $10 $10 $20 $10 $20 3 Brand $42 $47 $84 $94 $116 $131 4 Non- Drug $95 $100 $190 $200 $275 $290 5 Specialty Tier 33% 33% N/A N/A N/A N/A Please refer to your Evidence of Coverage for information about the costs at Long-Term Care (LTC) pharmacies or out-of-network pharmacies. cost-sharing is lower cost-sharing that may be available to you for certain covered Part D drugs at certain network pharmacies. For more information, please visit our online searchable Pharmacy Directory at or call Member Services. Our contact information appears on the front and back cover pages. We provide additional coverage of prescription drugs in tiers 1 and 2 in the Coverage Gap. Please refer to your Evidence of Coverage for more information about this coverage. 9

12 SCAN Classic II (HMO): Los Angeles County Drug Tier Tier Name Retail & Mail-Order (innetwork) (30-day Retail (innetwork) (30-day Retail & Mail- Order cost-sharing (60-day Retail (60-day Retail & Mail-Order (innetwork) (90-day Retail (innetwork) (90-day 1 Generic $0 $5 $0 $10 $0 $0 2 Generic $5 $10 $10 $20 $10 $20 3 Brand $42 $47 $84 $94 $116 $131 4 Non- Drug $95 $100 $190 $200 $275 $290 5 Specialty Tier 33% 33% N/A N/A N/A N/A Please refer to your Evidence of Coverage for information about the costs at Long-Term Care (LTC) pharmacies or out-of-network pharmacies. cost-sharing is lower cost-sharing that may be available to you for certain covered Part D drugs at certain network pharmacies. For more information, please visit our online searchable Pharmacy Directory at or call Member Services. Our contact information appears on the front and back cover pages. We provide additional coverage of prescription drugs in tiers 1 and 2 in the Coverage Gap. Please refer to your Evidence of Coverage for more information about this coverage. 10

13 SCAN Classic (HMO): Orange County Drug Tier Tier Name Retail & Mail-Order (innetwork) (30-day Retail (innetwork) (30-day Retail & Mail- Order cost-sharing (60-day Retail (60-day Retail & Mail-Order (innetwork) (90-day Retail (innetwork) (90-day 1 Generic $0 $0 $0 $0 $0 $0 2 Generic $5 $10 $10 $20 $10 $20 3 Brand $42 $47 $84 $94 $116 $131 4 Non- Drug $95 $100 $190 $200 $275 $290 5 Specialty Tier 33% 33% N/A N/A N/A N/A Please refer to your Evidence of Coverage for information about the costs at Long-Term Care (LTC) pharmacies or out-of-network pharmacies. cost-sharing is lower cost-sharing that may be available to you for certain covered Part D drugs at certain network pharmacies. For more information, please visit our online searchable Pharmacy Directory at or call Member Services. Our contact information appears on the front and back cover pages. We provide additional coverage of prescription drugs in tiers 1 and 2 in the Coverage Gap. Please refer to your Evidence of Coverage for more information about this coverage. 11

14 SCAN Classic (HMO): Riverside and San Bernardino Counties Drug Tier Tier Name Retail & Mail-Order (innetwork) (30-day Retail (innetwork) (30-day Retail & Mail- Order cost-sharing (60-day Retail (60-day Retail & Mail-Order (innetwork) (90-day Retail (innetwork) (90-day 1 Generic $0 $5 $0 $10 $0 $10 2 Generic $7 $12 $14 $24 $14 $24 3 Brand $42 $47 $84 $94 $116 $131 4 Non- Drug $95 $100 $190 $200 $275 $290 5 Specialty Tier 33% 33% N/A N/A N/A N/A Please refer to your Evidence of Coverage for information about the costs at Long-Term Care (LTC) pharmacies or out-of-network pharmacies. cost-sharing is lower cost-sharing that may be available to you for certain covered Part D drugs at certain network pharmacies. For more information, please visit our online searchable Pharmacy Directory at or call Member Services. Our contact information appears on the front and back cover pages. We provide additional coverage of prescription drugs in tiers 1 and 2 in the Coverage Gap. Please refer to your Evidence of Coverage for more information about this coverage. 12

15 SCAN Classic II (HMO): Riverside and San Bernardino Counties Drug Tier Tier Name Retail & Mail-Order (innetwork) (30-day Retail (innetwork) (30-day Retail & Mail- Order cost-sharing (60-day Retail (60-day Retail & Mail-Order (innetwork) (90-day Retail (innetwork) (90-day 1 Generic $2 $7 $4 $14 $4 $14 2 Generic $7 $12 $14 $24 $14 $24 3 Brand $42 $47 $84 $94 $116 $131 4 Non- Drug $95 $100 $190 $200 $275 $290 5 Specialty Tier 33% 33% N/A N/A N/A N/A Please refer to your Evidence of Coverage for information about the costs at Long-Term Care (LTC) pharmacies or out-of-network pharmacies. cost-sharing is lower cost-sharing that may be available to you for certain covered Part D drugs at certain network pharmacies. For more information, please visit our online searchable Pharmacy Directory at or call Member Services. Our contact information appears on the front and back cover pages. We provide additional coverage of prescription drugs in tier 1 in the Coverage Gap. Please refer to your Evidence of Coverage for more information about this coverage. 13

16 Scripps Classic offered by SCAN Health Plan (HMO): San Diego County Drug Tier Tier Name Retail & Mail-Order (innetwork) (30-day Retail (innetwork) (30-day Retail & Mail- Order cost-sharing (60-day Retail (60-day Retail & Mail-Order (innetwork) (90-day Retail (innetwork) (90-day 1 Generic $0 $5 $0 $10 $0 $10 2 Generic $5 $10 $10 $20 $10 $20 3 Brand $42 $47 $84 $94 $116 $131 4 Non- Drug $95 $100 $190 $200 $275 $290 5 Specialty Tier 33% 33% N/A N/A N/A N/A Please refer to your Evidence of Coverage for information about the costs at Long-Term Care (LTC) pharmacies or out-of-network pharmacies. cost-sharing is lower cost-sharing that may be available to you for certain covered Part D drugs at certain network pharmacies. For more information, please visit our online searchable Pharmacy Directory at or call Member Services. Our contact information appears on the front and back cover pages. 14

17 Scripps Signature offered by SCAN Health Plan (HMO): San Diego County Drug Tier Tier Name Retail & Mail-Order (innetwork) (30-day Retail (innetwork) (30-day Retail & Mail- Order cost-sharing (60-day Retail (60-day Retail & Mail-Order (innetwork) (90-day Retail (innetwork) (90-day 1 Generic $0 $5 $0 $10 $0 $10 2 Generic $3 $8 $6 $16 $6 $16 3 Brand $42 $47 $84 $94 $116 $131 4 Non- Drug $95 $100 $190 $200 $275 $290 5 Specialty Tier 33% 33% N/A N/A N/A N/A Please refer to your Evidence of Coverage for information about the costs at Long-Term Care (LTC) pharmacies or out-of-network pharmacies. cost-sharing is lower cost-sharing that may be available to you for certain covered Part D drugs at certain network pharmacies. For more information, please visit our online searchable Pharmacy Directory at or call Member Services. Our contact information appears on the front and back cover pages. We provide additional coverage of prescription drugs in tiers 1 and 2 in the Coverage Gap. Please refer to your Evidence of Coverage for more information about this coverage. 15

18 SCAN Classic (HMO): Ventura County Drug Tier Tier Name Retail & Mail-Order (innetwork) (30-day Retail (innetwork) (30-day Retail & Mail- Order cost-sharing (60-day Retail (60-day Retail & Mail-Order (innetwork) (90-day Retail (innetwork) (90-day 1 Generic $2 $7 $4 $14 $4 $14 2 Generic $5 $12 $10 $24 $10 $24 3 Brand $42 $47 $84 $94 $116 $131 4 Non- Drug $95 $100 $190 $200 $275 $290 5 Specialty Tier 33% 33% N/A N/A N/A N/A Please refer to your Evidence of Coverage for information about the costs at Long-Term Care (LTC) pharmacies or out-of-network pharmacies. cost-sharing is lower cost-sharing that may be available to you for certain covered Part D drugs at certain network pharmacies. For more information, please visit our online searchable Pharmacy Directory at or call Member Services. Our contact information appears on the front and back cover pages. 16

19 SCAN Classic (HMO): San Francisco and Santa Clara Counties Drug Tier Tier Name Retail & Mail-Order (innetwork) (30-day Retail (innetwork) (30-day Retail & Mail- Order cost-sharing (60-day Retail (60-day Retail & Mail-Order (innetwork) (90-day Retail (innetwork) (90-day 1 Generic $3 $8 $6 $16 $6 $16 2 Generic $5 $10 $10 $20 $10 $20 3 Brand $42 $47 $84 $94 $116 $131 4 Non- Drug $95 $100 $190 $200 $275 $290 5 Specialty Tier 33% 33% N/A N/A N/A N/A Please refer to your Evidence of Coverage for information about the costs at Long-Term Care (LTC) pharmacies or out-of-network pharmacies. cost-sharing is lower cost-sharing that may be available to you for certain covered Part D drugs at certain network pharmacies. For more information, please visit our online searchable Pharmacy Directory at or call Member Services. Our contact information appears on the front and back cover pages. 17

20 SCAN Classic (HMO): Marin County Drug Tier Tier Name Retail & Mail-Order (innetwork) (30-day Retail (innetwork) (30-day Retail & Mail- Order cost-sharing (60-day Retail (60-day Retail & Mail-Order (innetwork) (90-day Retail (innetwork) (90-day 1 Generic $0 $3 $0 $6 $0 $6 2 Generic $2 $7 $4 $14 $4 $14 3 Brand $40 $45 $80 $90 $110 $125 4 Non- Drug $80 $85 $160 $170 $230 $245 5 Specialty Tier 33% 33% N/A N/A N/A N/A Please refer to your Evidence of Coverage for information about the costs at Long-Term Care (LTC) pharmacies or out-of-network pharmacies. cost-sharing is lower cost-sharing that may be available to you for certain covered Part D drugs at certain network pharmacies. For more information, please visit our online searchable Pharmacy Directory at or call Member Services. Our contact information appears on the front and back cover pages. 18

21 SCAN Classic (HMO): Napa and Sonoma Counties Drug Tier Tier Name Retail & Mail-Order (innetwork) (30-day Retail (innetwork) (30-day Retail & Mail- Order cost-sharing (60-day Retail (60-day Retail & Mail-Order (innetwork) (90-day Retail (innetwork) (90-day 1 Generic $0 $5 $0 $10 $0 $10 2 Generic $10 $15 $20 $30 $20 $30 3 Brand $42 $47 $84 $94 $116 $131 4 Non- Drug $95 $100 $190 $200 $275 $290 5 Specialty Tier 33% 33% N/A N/A N/A N/A Please refer to your Evidence of Coverage for information about the costs at Long-Term Care (LTC) pharmacies or out-of-network pharmacies. cost-sharing is lower cost-sharing that may be available to you for certain covered Part D drugs at certain network pharmacies. For more information, please visit our online searchable Pharmacy Directory at or call Member Services. Our contact information appears on the front and back cover pages. 19

22 SCAN Healthy At Home (HMO SNP): Los Angeles, Orange, Riverside and San Bernardino Counties Drug Tier Tier Name Retail & Mail-Order (innetwork) (30-day Retail (innetwork) (30-day Retail & Mail- Order cost-sharing (60-day Retail (60-day Retail & Mail-Order (innetwork) (90-day Retail (innetwork) (90-day 1 Generic $0 $3 $0 $6 $0 $9 2 Generic $5 $10 $10 $20 $15 $30 3 Brand $42 $47 $84 $94 $126 $141 4 Non- Drug $95 $100 $190 $200 $285 $300 5 Specialty Tier 33% 33% N/A N/A N/A N/A Please refer to your Evidence of Coverage for information about the costs at Long-Term Care (LTC) pharmacies or out-of-network pharmacies. cost-sharing is lower cost-sharing that may be available to you for certain covered Part D drugs at certain network pharmacies. For more information, please visit our online searchable Pharmacy Directory at or call Member Services. Our contact information appears on the front and back cover pages. We provide additional coverage of prescription drugs in tier 1 in the Coverage Gap. Please refer to your Evidence of Coverage for more information about this coverage. 20

23 Heart First (HMO SNP): Orange County Drug Tier Tier Name Retail & Mail-Order (innetwork) (30-day Retail (innetwork) (30-day Retail & Mail- Order cost-sharing (60-day Retail (60-day Retail & Mail-Order (innetwork) (90-day Retail (innetwork) (90-day 1 Generic $0 $3 $0 $6 $0 $6 2 Generic $2 $7 $4 $14 $4 $14 3 Brand $42 $47 $84 $94 $116 $131 4 Non- Drug $95 $100 $190 $200 $275 $290 5 Specialty Tier 33% 33% N/A N/A N/A N/A Please refer to your Evidence of Coverage for information about the costs at Long-Term Care (LTC) pharmacies or out-of-network pharmacies. cost-sharing is lower cost-sharing that may be available to you for certain covered Part D drugs at certain network pharmacies. For more information, please visit our online searchable Pharmacy Directory at or call Member Services. Our contact information appears on the front and back cover pages. We provide additional coverage of prescription drugs in tiers 1 and 2 in the Coverage Gap. Please refer to your Evidence of Coverage for more information about this coverage. 21

24 Heart First (HMO SNP): Marin County Drug Tier Tier Name Retail & Mail-Order (innetwork) (30-day Retail (innetwork) (30-day Retail & Mail- Order cost-sharing (60-day Retail (60-day Retail & Mail-Order (innetwork) (90-day Retail (innetwork) (90-day 1 Generic $0 $3 $0 $6 $0 $6 2 Generic $2 $7 $4 $14 $4 $14 3 Brand $40 $45 $80 $90 $110 $125 4 Non- Drug $90 $95 $180 $190 $260 $275 5 Specialty Tier 33% 33% N/A N/A N/A N/A Please refer to your Evidence of Coverage for information about the costs at Long-Term Care (LTC) pharmacies or out-of-network pharmacies. cost-sharing is lower cost-sharing that may be available to you for certain covered Part D drugs at certain network pharmacies. For more information, please visit our online searchable Pharmacy Directory at or call Member Services. Our contact information appears on the front and back cover pages. We provide additional coverage of prescription drugs in tiers 1 and 2 in the Coverage Gap. Please refer to your Evidence of Coverage for more information about this coverage. 22

25 Heart First (HMO SNP): Riverside and San Bernardino Counties Drug Tier Tier Name Retail & Mail-Order (innetwork) (30-day Retail (innetwork) (30-day Retail & Mail- Order cost-sharing (60-day Retail (60-day Retail & Mail-Order (innetwork) (90-day Retail (innetwork) (90-day 1 Generic $0 $5 $0 $10 $0 $10 2 Generic $7 $12 $14 $24 $14 $24 3 Brand $42 $47 $84 $94 $116 $131 4 Non- Drug $95 $100 $190 $200 $275 $290 5 Specialty Tier 33% 33% N/A N/A N/A N/A Please refer to your Evidence of Coverage for information about the costs at Long-Term Care (LTC) pharmacies or out-of-network pharmacies. cost-sharing is lower cost-sharing that may be available to you for certain covered Part D drugs at certain network pharmacies. For more information, please visit our online searchable Pharmacy Directory at or call Member Services. Our contact information appears on the front and back cover pages. We provide additional coverage of prescription drugs in tiers 1 and 2 in the Coverage Gap. Please refer to your Evidence of Coverage for more information about this coverage. 23

26 Scripps Heart First offered by SCAN Health Plan (HMO SNP): San Diego County Drug Tier Tier Name Retail & Mail-Order (30-day Retail (30-day Retail & Mail- Order cost-sharing (60-day Retail (60-day Retail & Mail-Order (90-day Retail (90-day 1 Generic $0 $5 $0 $10 $0 $10 2 Generic $5 $10 $10 $20 $10 $20 3 Brand $42 $47 $84 $94 $116 $131 4 Non- Drug $95 $100 $190 $200 $275 $290 5 Specialty Tier 33% 33% N/A N/A N/A N/A Please refer to your Evidence of Coverage for information about the costs at Long-Term Care (LTC) pharmacies or out-of-network pharmacies. cost-sharing is lower cost-sharing that may be available to you for certain covered Part D drugs at certain network pharmacies. For more information, please visit our online searchable Pharmacy Directory at or call Member Services. Our contact information appears on the front and back cover pages. We provide additional coverage of prescription drugs in tier 1 in the Coverage Gap. Please refer to your Evidence of Coverage for more information about this coverage. 24

27 Heart First (HMO SNP): Napa and Sonoma Counties Drug Tier Tier Name Retail & Mail-Order (30-day Retail (30-day Retail & Mail- Order cost-sharing (60-day Retail (60-day Retail & Mail-Order (90-day Retail (90-day 1 Generic $0 $5 $0 $10 $0 $10 2 Generic $10 $15 $20 $30 $20 $30 3 Brand $42 $47 $84 $94 $116 $131 4 Non- Drug $95 $100 $190 $200 $275 $290 5 Specialty Tier 33% 33% N/A N/A N/A N/A Please refer to your Evidence of Coverage for information about the costs at Long-Term Care (LTC) pharmacies or out-of-network pharmacies. cost-sharing is lower cost-sharing that may be available to you for certain covered Part D drugs at certain network pharmacies. For more information, please visit our online searchable Pharmacy Directory at or call Member Services. Our contact information appears on the front and back cover pages. We provide additional coverage of prescription drugs in tier 1 in the Coverage Gap. Please refer to your Evidence of Coverage for more information about this coverage. 25

28 SCAN Balance (HMO SNP): Los Angeles and Orange Counties Drug Tier Tier Name Retail & Mail-Order (30-day Retail (30-day Retail & Mail- Order cost-sharing (60-day Retail (60-day Retail & Mail-Order (90-day Retail (90-day 1 Generic $0 $3 $0 $6 $0 $6 2 Generic $2 $7 $4 $14 $4 $14 3 Brand $30 $35 $60 $70 $80 $95 4 Non- Drug $95 $100 $190 $200 $275 $290 5 Specialty Tier 33% 33% N/A N/A N/A N/A Please refer to your Evidence of Coverage for information about the costs at Long-Term Care (LTC) pharmacies or out-of-network pharmacies. cost-sharing is lower cost-sharing that may be available to you for certain covered Part D drugs at certain network pharmacies. For more information, please visit our online searchable Pharmacy Directory at or call Member Services. Our contact information appears on the front and back cover pages. We provide additional coverage of prescription drugs in tiers 1 and 2 in the Coverage Gap. Please refer to your Evidence of Coverage for more information about this coverage. 26

29 SCAN Balance (HMO SNP): Marin County Drug Tier Tier Name Retail & Mail-Order (30-day Retail (30-day Retail & Mail- Order cost-sharing (60-day Retail (60-day Retail & Mail-Order (90-day Retail (90-day 1 Generic $0 $3 $0 $6 $0 $6 2 Generic $2 $7 $4 $14 $4 $14 3 Brand $40 $45 $80 $90 $110 $125 4 Non- Drug $90 $95 $180 $190 $260 $275 5 Specialty Tier 33% 33% N/A N/A N/A N/A Please refer to your Evidence of Coverage for information about the costs at Long-Term Care (LTC) pharmacies or out-of-network pharmacies. cost-sharing is lower cost-sharing that may be available to you for certain covered Part D drugs at certain network pharmacies. For more information, please visit our online searchable Pharmacy Directory at or call Member Services. Our contact information appears on the front and back cover pages. We provide additional coverage of prescription drugs in tiers 1 and 2 in the Coverage Gap. Please refer to your Evidence of Coverage for more information about this coverage. 27

30 SCAN Balance (HMO SNP): Napa and Sonoma Counties Drug Tier Tier Name Retail & Mail-Order (30-day Retail (30-day Retail & Mail- Order cost-sharing (60-day Retail (60-day Retail & Mail-Order (90-day Retail (90-day 1 Generic $0 $5 $0 $10 $0 $10 2 Generic $10 $15 $20 $30 $20 $30 3 Brand $42 $47 $84 $94 $116 $131 4 Non- Drug $95 $100 $190 $200 $275 $290 5 Specialty Tier 33% 33% N/A N/A N/A N/A Please refer to your Evidence of Coverage for information about the costs at Long-Term Care (LTC) pharmacies or out-of-network pharmacies. cost-sharing is lower cost-sharing that may be available to you for certain covered Part D drugs at certain network pharmacies. For more information, please visit our online searchable Pharmacy Directory at or call Member Services. Our contact information appears on the front and back cover pages. We provide additional coverage of prescription drugs in tier 1 in the Coverage Gap. Please refer to your Evidence of Coverage for more information about this coverage. 28

31 SCAN Plus (HMO): Los Angeles, Riverside, San Bernardino and San Francisco Counties Drug Tier Tier Name Retail & Mail-Order (30-day Retail (30-day Retail & Mail- Order cost-sharing (60-day Retail (60-day Retail & Mail-Order (90-day Retail (90-day 1 Generic $0 $8.50 $0 $17 $0 $ Generic 25% 25% 25% 25% 25% 25% 3 Brand 25% 25% 25% 25% 25% 25% 4 Non- Drug 25% 25% 25% 25% 25% 25% 5 Specialty Tier 25% 25% N/A N/A N/A N/A Please refer to your Evidence of Coverage for information about the costs at Long-Term Care (LTC) pharmacies or out-of-network pharmacies. cost-sharing is lower cost-sharing that may be available to you for certain covered Part D drugs at certain network pharmacies. For more information, please visit our online searchable Pharmacy Directory at or call Member Services. Our contact information appears on the front and back cover pages. If you receive Extra Help, your share of the cost for covered prescription drugs may vary based on the level of Extra Help you receive. For more information about your drug costs, look at the "LIS Rider". 29

32 SCAN Plus (HMO): Orange County Drug Tier Tier Name Retail & Mail-Order (30-day Retail (30-day Retail & Mail- Order cost-sharing (60-day Retail (60-day Retail & Mail-Order (90-day Retail (90-day 1 Generic $0 $7.50 $0 $15 $0 $ Generic 25% 25% 25% 25% 25% 25% 3 Brand 25% 25% 25% 25% 25% 25% 4 Non- Drug 25% 25% 25% 25% 25% 25% 5 Specialty Tier 25% 25% N/A N/A N/A N/A Please refer to your Evidence of Coverage for information about the costs at Long-Term Care (LTC) pharmacies or out-of-network pharmacies. cost-sharing is lower cost-sharing that may be available to you for certain covered Part D drugs at certain network pharmacies. For more information, please visit our online searchable Pharmacy Directory at or call Member Services. Our contact information appears on the front and back cover pages. If you receive Extra Help, your share of the cost for covered prescription drugs may vary based on the level of Extra Help you receive. For more information about your drug costs, look at the "LIS Rider 30

33 Scripps Plus offered by SCAN Health Plan (HMO): San Diego County Drug Tier Tier Name Retail & Mail-Order (30-day Retail (30-day Retail & Mail- Order cost-sharing (60-day Retail (60-day Retail & Mail-Order (90-day Retail (90-day 1 Generic $0 $6 $0 $12 $0 $18 2 Generic 25% 25% 25% 25% 25% 25% 3 Brand 25% 25% 25% 25% 25% 25% 4 Non- Drug 25% 25% 25% 25% 25% 25% 5 Specialty Tier 25% 25% N/A N/A N/A N/A Please refer to your Evidence of Coverage for information about the costs at Long-Term Care (LTC) pharmacies or out-of-network pharmacies. cost-sharing is lower cost-sharing that may be available to you for certain covered Part D drugs at certain network pharmacies. For more information, please visit our online searchable Pharmacy Directory at or call Member Services. Our contact information appears on the front and back cover pages. If you receive Extra Help, your share of the cost for covered prescription drugs may vary based on the level of Extra Help you receive. For more information about your drug costs, look at the "LIS Rider". 31

34 The chart below is for Medicare and Medi-Cal eligible members only. It lists what you will pay as your share of the cost for covered prescription drugs when you are in the Initial Coverage Stage. For information about your costs in the Coverage Gap Stage or the Catastrophic Coverage Stage, please refer to your Evidence of Coverage. Co-pays may vary based on the level of Extra Help you receive. Please contact Member Services for further details. Our contact information appears on the front and back cover pages. SCAN Connections (HMO SNP) Medicare and Medi-Cal eligible members only: Los Angeles, Riverside and San Bernardino Counties SCAN Connections at Home (HMO SNP) Medicare and Medi-Cal eligible members only: Los Angeles, Riverside, and San Bernardino Counties Drug Tier Tier Name Retail and Mail-Order cost-sharing ) Retail cost-sharing 1 Generic (One - three month $0 $0 or $1.25 or $ Generic (One - three month Brand (One - three month Non- Drug (One - three month Specialty Tier (One month supply only) You pay: For generic drugs (including brand drugs treated as generic), either: $0 or $1.25 or $3.35 For all other drugs, either: $0 or $3.70 or $8.35 Please refer to your Evidence of Coverage for information about the costs at Long-Term Care (LTC) pharmacies or out-of-network pharmacies. cost-sharing is lower cost-sharing that may be available to you for certain covered Part D drugs at certain network pharmacies. For more information, please visit our online searchable Pharmacy Directory at or call Member Services. Our contact information appears on the front and back cover pages. 32

35 SCAN Health Plan s Formulary The formulary that begins on page 69 provides coverage information about the drugs covered by SCAN Health Plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 98. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., JANUVIA) and generic drugs are listed in lower-case italics (e.g., metformin). The information in the Requirements/Limits column tells you if SCAN Health Plan has any special requirements for coverage of your drug. o o o o o o The symbol [PA] indicates that prior authorization applies. The symbol [B vs D] indicates that this drug may be covered under Medicare Part B or Part D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. The symbol [ST] indicates that step therapy applies. The symbol [QL] indicates that quantities dispensed are limited. To see the quantity limit amount for the formulary drugs with quantity limits, turn to the page 95. The symbol [90D] indicates that the drug is available for a 90-day supply at mail-order and select retail pharmacies. The symbol [LD] indicates that limited distribution applies. This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at (Medicare and Medi-Cal eligible members should call ), 8 a.m. to 8 p.m., 7 days a week from October 1 to February 14. From February 15 to September 30, hours are 8 a.m. to 8 p.m. Monday through Friday (messages received on holidays and outside of our business hours will be returned within one business day). TTY users should call

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37 SCAN Health Plan 2018 年處方集 ( 承保藥物清單 ) 請詳閱 : 本文件包含我們在該計劃中承保的藥物的資訊 18423, 8 本處方集更新於 2018 年 2 月 1 日 如欲瞭解更多近期資訊或有其他問題, 請聯絡 SCAN Health Plan 會員服務部, 電話 : ( 符合 Medicare 和 Medi-Cal 計劃資格的會員應撥打 ),TTY 用戶 :711, 服務時間為 10 月 1 日至次年 2 月 14 日, 每週七天, 上午 8 時至晚上 8 時 ;2 月 15 日至 9 月 30 日, 週一至週五上午 8 時至晚上 8 時 ( 假日和下班時間接到的留言會在下一個工作日回電 ), 或者瀏覽 現有會員請注意 : 本處方集自去年起已有所變更 請瀏覽本文件, 以確保其中仍包含您所服用的藥物 本藥物清單 ( 處方集 ) 提及的 我們 或 我們的 一律是指 SCAN Health Plan 提及 計劃 或 我們的計劃 時, 則是指 SCAN Classic (HMO) SCAN Classic II (HMO) Scripps Classic offered by SCAN Health Plan (HMO) Scripps Signature offered by SCAN Health Plan (HMO) SCAN Healthy at Home (HMO SNP) Heart First (HMO SNP) Scripps Heart First offered by SCAN Health Plan (HMO SNP) SCAN Balance (HMO SNP) SCAN Plus (HMO) Scripps Plus offered by SCAN Health Plan (HMO) SCAN Connections (HMO SNP) 或 SCAN Connections at Home (HMO SNP) 本文件包括我們計劃截至 2018 年 2 月的最新藥物清單 ( 處方集 ) 如需更新的處方集, 請與我們聯絡 我們的聯絡資訊以及我們上次更新處方集的日期印在封面頁和封底頁上 一般而言, 您必須使用服務網內的藥房才能獲得處方藥物福利 福利 處方集 藥房網路及 / 或共付額 / 共保額可能會從 2019 年 1 月 1 日起一年內不時變更 本資訊並非所有福利的完整描述 如欲瞭解詳細資訊, 請向計劃洽詢 可能有限額 共付額和限制 處方集 藥房網路和 / 或醫療服務提供者網路可能隨時會有變更 必要時, 您會收到通知 您可以透過我們的網路郵購遞送計劃將處方藥寄到您家裡 一般而言, 您會在郵購藥房接到訂單後的 14 天內收到處方藥 如果您沒有在這段時間內收到處方藥, 請聯絡 SCAN Health Plan 會員服務部, 電話 : ( 符合 Medicare 和 Medi-Cal 資格的會員應撥打 ), 服務時間為 10 月 1 日至次年 2 月 14 日, 每週七天, 上午 8 時至晚上 8 時 ;2 月 15 日至 9 月 30 日, 週一至週五上午 8 時至晚上 8 時 ( 假日和下班時間接到的留言會在下一個工作日回電 ) TTY 用戶應撥打

38 SCAN Health Plan 是簽署了 Medicare 合同的 HMO 計劃 參加 SCAN Health Plan 取決於是否續約 ATTENTION: If you speak another language, language assistance services, free of charge, are available to you. Call (TTY: 711). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 711). 注意 : 如果您使用中文, 您可以免費獲得語言援助服務 請致電 (TTY: 711) Y0057_SCAN_10440_2017F_CH 文件及用途獲得批准

39 目錄.... 何謂 SCAN Health Plan 處方集? 處方集 ( 藥物清單 ) 會有變化嗎? 我該如何使用處方集? 何謂副廠藥? 我的承保有任何限制嗎? 若所需藥物不在處方集上該怎麼辦? 如何提出 SCAN Health Plan 處方集例外處理申請? 在跟醫師討論換藥或提出例外處理申請之前我應該先做些什麼? 更多資訊 SCAN Health Plan 處方集 治療課堂安排的處方集藥物 有數量限制的處方集藥物 索引

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41 何謂 SCAN Health Plan 處方集? 處方集是在諮詢醫療護理提供者團體之後, 由 SCAN Health Plan 選定的承保藥物清單, 其中所載的處方藥物通常是優質治療計劃中不可或缺的一部分 SCAN Health Plan 一般會承保處方集列出的藥物, 只要該藥物具有醫療必要性 是在 SCAN Health Plan 網路藥房配藥, 而且遵守其他計劃規定 如需配領處方藥的詳情, 請參閱 承保證明書 處方集 ( 藥物清單 ) 會有變化嗎? 一般而言, 若您服用的是本公司 2018 年處方集在年初承保的藥物, 我們不會在 2018 年承保年度期間中斷藥物承保, 但有較新 費用較低的副廠藥上市時, 或發出某項藥物的新安全性或藥物負面資訊時除外 其他類型的處方集變更 ( 例如從處方集中刪除某種藥物 ) 不會對目前正在服用該藥物的會員造成影響 正在服用的會員在承保年度的剩餘時間裡, 將以相同的費用分攤方式持續獲得該藥物 我們認為您在承保年度剩餘期間仍能獲得您選擇本計劃時可取得的處方集藥物至關重要, 但是當您可節省額外費用或我們可確保您的安全時, 則另當別論 如果我們將藥物從我們的處方集中移除, 增加一種藥的預先授權 數量上限和 ( 或 ) 逐步療法限制, 或是把一種藥移到費用分攤較高的層級, 我們必須在變更開始生效至少 60 天以前通知受影響的會員, 或在會員要求續配藥物時通知並提供其該藥物 60 天的份量 如果美國食品和藥物管理局認為我們處方集的某種藥物不安全, 或藥物製造商將藥物撤出市場, 我們將立即從處方集刪除該藥物, 並通知服用這種藥的會員 隨附的處方集是截至 2018 年 2 月的最新版本 如需 SCAN Health Plan 承保藥物的更新資訊, 請與我們聯絡 我們的聯絡資訊印在封面頁和封底頁上 我該如何使用處方集? 有兩種方式可在處方集中找到您所需的藥物 : 醫療病況 處方集可在第 69 頁開始查找 處方集中的藥物視其治療的病症類型分門別類 例如, 治療心臟病的藥物列在 心血管藥物 類別下 若您知道藥物的用途, 請在清單中尋找從第 69 頁開始的分類名稱 然後在該分類名稱下尋找您的藥物 依字母順序排列的清單 如果您不確定要在哪個類別下尋找, 可從第 98 頁開始的索引中進行尋找 索引會按字母順序列出本文件包含的所有藥物 原廠藥和副廠藥均列在索引中 請搜尋索引, 找到所需的藥物 您的藥物旁有一個頁碼, 您可翻到該頁查閱承保資訊 翻到索引列出的頁碼, 在清單中的第一欄找到您的藥物名稱 39

42 何謂副廠藥? SCAN Health Plan 為原廠藥和副廠藥提供承保 副廠藥是經 FDA 核准, 具有與原廠藥相同活性成分的藥物 一般而言, 副廠藥的費用低於原廠藥 我的承保有任何限制嗎? 有些承保藥物可能有額外的承保規定或限制 這些規定及限制可能包括 : 預先授權 :SCAN Health Plan 要求您或您的醫師取得某些藥物的預先授權 亦即您需先取得 SCAN Health Plan 的核准才能配藥 若您未取得核准,SCAN Health Plan 可能不會承保該藥物 數量限制 :SCAN Health Plan 針對某些承保的藥物設有承保數量限制 例如, 針對每一張 Rozerem 處方箋,SCAN Health Plan 提供 30 錠的數量 這可能會在一個月或三個月的標準藥量之外提供 逐步治療 : 在某些情況下,SCAN Health Plan 會要求您先試用一種藥物來治療病症, 然後才會承保治療該病症的另一種藥物 例如, 若 A 藥物與 B 藥物均能治療您的病症,SCAN Health Plan 可能不會承保 B 藥物, 除非您先使用 A 藥物來治療 若 A 藥物對您沒有效,SCAN Health Plan 才會承保 B 藥物 請查閱從第 69 頁開始的處方集, 即可找到您的藥物是否有額外規定或限制 您也可以在我們的網站找到有關特定承保藥物限制的詳細資訊 我們已刊載線上文件, 解釋我們的預先授權和逐步治療的限制 您也可以要求我們寄一份副本給您 我們的聯絡資訊以及我們上次更新處方集的日期印在封面頁和封底頁上 您可以要求 SCAN Health Plan 對這些限制或限定進行例外處理, 或是索取一份可以治療您的醫療病況的其他類似藥物清單 如欲瞭解如何提出例外處理申請的資訊, 請參閱第 41 頁的 如何提出 SCAN Health Plan 處方集例外處理申請? 一節 若所需藥物不在處方集上該怎麼辦? 如果處方集 ( 承保藥物清單 ) 中沒有您的藥物, 您應該先向會員服務部洽詢, 確認所需藥物是否可獲得承保 若您得知您的藥物不在 SCAN Health Plan 的承保範圍內, 您有兩個選擇 : 您可向會員服務部索取 SCAN Health Plan 承保的類似藥物清單 收到該清單後, 出示給您的醫師, 並要求醫師開立 SCAN Health Plan 承保的類似藥物 您可要求 SCAN Health Plan 採取例外方式處理, 並承保所需藥物 如需有關如何要求例外處理的資訊, 請參閱下文 40

43 如何提出 SCAN Health Plan 處方集例外處理申請? 您可要求 SCAN Health Plan 對承保規定進行例外處理 您可要求我們進行幾種類型的例外處理 即使您的藥物沒有列在我們的處方集中, 您仍可要求我們承保 如果獲得核准, 此藥物會以預設的費用分攤層級承保, 您將不能要求我們以較低的費用分攤層級承保此藥物 如果處方集藥物不是特殊藥物, 您可要求我們以較低的費用分攤層級承保此藥物 如果獲得核准, 將會降低您必須支付藥物的金額 您可要求我們免除所需藥物的承保限制 例如,SCAN Health Plan 對於某些藥物設有承保的藥物數量限制 如果您的藥物有數量限制, 您可要求我們免除限制並承保更多藥量 一般而言, 僅當計劃處方集內的替代藥物 分攤費用較低的藥物或其他使用限制無法有效治療您的病症, 且 ( 或 ) 會導致您產生不良副作用時,SCAN Health Plan 才會核准例外處理要求 您應與我們聯絡, 要求我們進行處方集的初始承保判定, 或使用限制例外處理 提出處方集 分級或使用限制例外處理申請時, 請提交處方醫師或主治醫師的佐證聲明 一般而言, 我們必須在收到處方醫師佐證聲明後的 72 小時內做出決定 如果您或醫師認為等候 72 小時的判定時間可能嚴重危及您的健康, 您可提出加快 ( 快速 ) 例外處理申請 如果我們受理您的加快處理申請, 我們必須在取得醫師或其他處方醫師佐證聲明後的 24 小時內做出決定 在跟醫師討論換藥或提出例外處理申請之前我應該先做些什麼? 若您為計劃的新會員或續約會員, 您可能正在服用未列在我們處方集上的藥物 或者, 您可能正在服用列在處方集上的藥物, 但您取得該藥物的能力受到限制 例如, 您可能需要得到我們的預先授權才能去配藥 如果您想改用我們承保的另一種藥物, 或提出處方集例外處理申請以要求我們承保您服用的藥物, 請先與醫師討論 某些特定情況下, 在您與醫師討論以決定採取適宜措施期間, 我們可能在您投保後的最初 90 天內承保您的藥物 針對未列在我們處方集上的所用藥物, 或若您取得所需藥物的能力受到限制, 我們會在您前往網路藥房配藥時, 承保暫時性的 30 天份 ( 除非處方箋開立天數更少 ) 藥物 第一次領取 30 天份藥物後, 即使您投保不到 90 天, 我們也將不再承保這些藥物 如果您住在長期護理機構中, 我們會讓您續配處方藥, 直到我們已根據配藥間隔為您提供最少 91 天的轉換期藥物用量, 最多 98 天的轉換期藥物用量為止 ( 除非處方箋開立的天數較少 ) 在您投保後的最初 90 天, 我們會對這些藥物承保一次以上的續配費用 如果您需要未列在我們處方集上的藥物, 或是您取得所需藥物的能力受到限制, 但您投保已超過 90 天, 我們將會在您提出處方集例外處理申請時, 承保 31 天份的緊急藥量 ( 除非處方箋開立的天數較少 ) 若您是轉換到另一等級護理的現任會員, 醫師可能會開立不在處方集的藥物給您, 或您取得所需藥物的能力可能受到限制 在此情況下, 您需與醫師討論改服用處方集中的適當替代藥物 若處方集上沒有適當的替代藥物, 您或您的醫師可提出例外處理, 並且要求計劃承保藥物或取消藥物限制 在您與醫師討論該採取什麼樣的行動時, 如果您搬出長期護理 (LTC) 機構或出院回家, 可獲得 30 天份的轉換期藥物用量, 如果是從家裡搬出或出院入住長期護理 (LTC) 機構, 則可獲得 31 天份的轉換期藥物用量 洽詢詳情 如需有關 SCAN Health Plan 處方藥承保的詳細資訊, 請參閱您的 承保證明書 及其他計劃資料 41

44 如果您對 SCAN Health Plan 有任何問題, 請與我們聯絡 我們的聯絡資訊以及我們上次更新處方集的日期印在封面頁和封底頁上 如果您對 Medicare 處方藥承保有一般性的問題, 請致電 Medicare, 電話 :1-800-MEDICARE ( ), 一週 7 天, 一天 24 小時服務 TTY 用戶請撥 或者瀏覽網站 42

45 下表列出您在初始承保階段針對承保處方藥應支付的分攤費用 詳情請參閱您的 承保證明書 SCAN Classic (HMO): Los Angeles 郡 藥物層級 層級名稱 首選零售與郵購費用分攤 (30 天供應量 ) 標準零售費用分攤 (30 天供應量 ) 首選零售與郵標準零售費用購費用分攤分攤 (60 天供應 (60 天供應量 ) 量 ) 首選零售與郵購費用分攤 (90 天供應量 ) 標準零售費用分攤 (90 天供應量 ) 1 首選副廠藥 $0 $0 $0 $0 $0 $0 2 副廠藥 $5 $10 $10 $20 $10 $20 3 首選原廠藥 $42 $47 $84 $94 $116 $131 4 非首選藥物 $95 $100 $190 $200 $275 $290 5 特殊藥物 33% 33% 不適用不適用不適用不適用 請參考您的 承保證明書 上有關長期護理 (LTC) 藥房或網路外藥房費用的資訊 在某些網路藥房, 可為 Part D 的某些承保藥物提供費用較低的首選費用分攤 瞭解更多資訊, 請訪問我們的線上搜索藥物目錄 或者致電會員服務部 我們的聯絡資訊印在封面頁和封底頁上 承保缺口期間, 我們針對第 1 級及第 2 級處方藥提供額外的保險承保 有關此項承保的詳細資訊, 請參閱您的 承保證明書 43

46 SCAN Classic II (HMO): Los Angeles 郡 藥物層級 層級名稱 首選零售與郵購費用分攤 (30 天供應量 ) 標準零售費用分攤 (30 天供應量 ) 首選零售與郵標準零售費用購費用分攤分攤 (60 天供應 (60 天供應量 ) 量 ) 首選零售與郵購費用分攤 (90 天供應量 ) 標準零售費用分攤 (90 天供應量 ) 1 首選副廠藥 $0 $5 $0 $10 $0 $0 2 副廠藥 $5 $10 $10 $20 $10 $20 3 首選原廠藥 $42 $47 $84 $94 $116 $131 4 非首選藥物 $95 $100 $190 $200 $275 $290 5 特殊藥物 33% 33% 不適用不適用不適用不適用 請參考您的 承保證明書 上有關長期護理 (LTC) 藥房或網路外藥房費用的資訊 在某些網路藥房, 可為 Part D 的某些承保藥物提供費用較低的首選費用分攤 瞭解更多資訊, 請訪問我們的線上搜索藥物目錄 或者致電會員服務部 我們的聯絡資訊印在封面頁和封底頁上 承保缺口期間, 我們針對第 1 級及第 2 級處方藥提供額外的保險承保 有關此項承保的詳細資訊, 請參閱您的 承保證明書 44

47 SCAN Classic (HMO): Orange 郡 藥物層級 層級名稱 首選零售與郵購費用分攤 (30 天供應量 ) 標準零售費用分攤 (30 天供應量 ) 首選零售與郵標準零售費用購費用分攤分攤 (60 天供應 (60 天供應量 ) 量 ) 首選零售與郵購費用分攤 (90 天供應量 ) 標準零售費用分攤 (90 天供應量 ) 1 首選副廠藥 $0 $0 $0 $0 $0 $0 2 副廠藥 $5 $10 $10 $20 $10 $20 3 首選原廠藥 $42 $47 $84 $94 $116 $131 4 非首選藥物 $95 $100 $190 $200 $275 $290 5 特殊藥物 33% 33% 不適用不適用不適用不適用 請參考您的 承保證明書 上有關長期護理 (LTC) 藥房或網路外藥房費用的資訊 在某些網路藥房, 可為 Part D 的某些承保藥物提供費用較低的首選費用分攤 瞭解更多資訊, 請訪問我們的線上搜索藥物目錄 或者致電會員服務部 我們的聯絡資訊印在封面頁和封底頁上 承保缺口期間, 我們針對第 1 級及第 2 級處方藥提供額外的保險承保 有關此項承保的詳細資訊, 請參閱您的 承保證明書 45

48 SCAN Classic (HMO): Riverside 郡和 San Bernardino 郡 藥物層級 層級名稱 首選零售與郵購費用分攤 (30 天供應量 ) 標準零售費用分攤 (30 天供應量 ) 首選零售與郵標準零售費用購費用分攤分攤 (60 天供應 (60 天供應量 ) 量 ) 首選零售與郵購費用分攤 (90 天供應量 ) 標準零售費用分攤 (90 天供應量 ) 1 首選副廠藥 $0 $5 $0 $10 $0 $10 2 副廠藥 $7 $12 $14 $24 $14 $24 3 首選原廠藥 $42 $47 $84 $94 $116 $131 4 非首選藥物 $95 $100 $190 $200 $275 $290 5 特殊藥物 33% 33% 不適用不適用不適用不適用 請參考您的 承保證明書 上有關長期護理 (LTC) 藥房或網路外藥房費用的資訊 在某些網路藥房, 可為 Part D 的某些承保藥物提供費用較低的首選費用分攤 瞭解更多資訊, 請訪問我們的線上搜索藥物目錄 或者致電會員服務部 我們的聯絡資訊印在封面頁和封底頁上 承保缺口期間, 我們針對第 1 級及第 2 級處方藥提供額外的保險承保 有關此項承保的詳細資訊, 請參閱您的 承保證明書 46

49 SCAN Classic II (HMO): Riverside 郡和 San Bernardino 郡 藥物層級 層級名稱 首選零售與郵購費用分攤 (30 天供應量 ) 標準零售費用分攤 (30 天供應量 ) 首選零售與郵標準零售費用購費用分攤分攤 (60 天供應 (60 天供應量 ) 量 ) 首選零售與郵購費用分攤 (90 天供應量 ) 標準零售費用分攤 (90 天供應量 ) 1 首選副廠藥 $2 $7 $4 $14 $4 $14 2 副廠藥 $7 $12 $14 $24 $14 $24 3 首選原廠藥 $42 $47 $84 $94 $116 $131 4 非首選藥物 $95 $100 $190 $200 $275 $290 5 特殊藥物 33% 33% 不適用不適用不適用不適用 請參考您的 承保證明書 上有關長期護理 (LTC) 藥房或網路外藥房費用的資訊 在某些網路藥房, 可為 Part D 的某些承保藥物提供費用較低的首選費用分攤 瞭解更多資訊, 請訪問我們的線上搜索藥物目錄 或者致電會員服務部 我們的聯絡資訊印在封面頁和封底頁上 承保缺口期間, 我們針對第 1 級處方藥提供額外的保險承保 有關此項承保的詳細資訊, 請參閱您的 承保證明書 47

50 Scripps Classic offered by SCAN Health Plan (HMO): San Diego 郡 藥物層級 層級名稱 首選零售與郵購費用分攤 (30 天供應量 ) 標準零售費用分攤 (30 天供應量 ) 首選零售與郵標準零售費用購費用分攤分攤 (60 天供應 (60 天供應量 ) 量 ) 首選零售與郵購費用分攤 (90 天供應量 ) 標準零售費用分攤 (90 天供應量 ) 1 首選副廠藥 $0 $5 $0 $10 $0 $10 2 副廠藥 $5 $10 $10 $20 $10 $20 3 首選原廠藥 $42 $47 $84 $94 $116 $131 4 非首選藥物 $95 $100 $190 $200 $275 $290 5 特殊藥物 33% 33% 不適用不適用不適用不適用 請參考您的 承保證明書 上有關長期護理 (LTC) 藥房或網路外藥房費用的資訊 在某些網路藥房, 可為 Part D 的某些承保藥物提供費用較低的首選費用分攤 瞭解更多資訊, 請訪問我們的線上搜索藥物目錄 或者致電會員服務部 我們的聯絡資訊印在封面頁和封底頁上 48

51 Scripps Signature offered by SCAN Health Plan (HMO): San Diego 郡 藥物層級 層級名稱 首選零售與郵購費用分攤 (30 天供應量 ) 標準零售費用分攤 (30 天供應量 ) 首選零售與郵標準零售費用購費用分攤分攤 (60 天供應 (60 天供應量 ) 量 ) 首選零售與郵購費用分攤 (90 天供應量 ) 標準零售費用分攤 (90 天供應量 ) 1 首選副廠藥 $0 $5 $0 $10 $0 $10 2 副廠藥 $3 $8 $6 $16 $6 $16 3 首選原廠藥 $42 $47 $84 $94 $116 $131 4 非首選藥物 $95 $100 $190 $200 $275 $290 5 特殊藥物 33% 33% 不適用不適用不適用不適用 請參考您的 承保證明書 上有關長期護理 (LTC) 藥房或網路外藥房費用的資訊 在某些網路藥房, 可為 Part D 的某些承保藥物提供費用較低的首選費用分攤 瞭解更多資訊, 請訪問我們的線上搜索藥物目錄 或者致電會員服務部 我們的聯絡資訊印在封面頁和封底頁上 承保缺口期間, 我們針對第 1 級及第 2 級處方藥提供額外的保險承保 有關此項承保的詳細資訊, 請參閱您的 承保證明書 49

52 SCAN Classic (HMO): Ventura 郡 藥物層級 層級名稱 首選零售與郵購費用分攤 (30 天供應量 ) 標準零售費用分攤 (30 天供應量 ) 首選零售與郵標準零售費用購費用分攤分攤 (60 天供應 (60 天供應量 ) 量 ) 首選零售與郵購費用分攤 (90 天供應量 ) 標準零售費用分攤 (90 天供應量 ) 1 首選副廠藥 $2 $7 $4 $14 $4 $14 2 副廠藥 $5 $12 $10 $24 $10 $24 3 首選原廠藥 $42 $47 $84 $94 $116 $131 4 非首選藥物 $95 $100 $190 $200 $275 $290 5 特殊藥物 33% 33% 不適用不適用不適用不適用 請參考您的 承保證明書 上有關長期護理 (LTC) 藥房或網路外藥房費用的資訊 在某些網路藥房, 可為 Part D 的某些承保藥物提供費用較低的首選費用分攤 瞭解更多資訊, 請訪問我們的線上搜索藥物目錄 或者致電會員服務部 我們的聯絡資訊印在封面頁和封底頁上 50

53 SCAN Classic (HMO): San Francisco 郡和 Santa Clara 郡 藥物層級 層級名稱 首選零售與郵購費用分攤 (30 天供應量 ) 標準零售費用分攤 (30 天供應量 ) 首選零售與郵標準零售費用購費用分攤分攤 (60 天供應 (60 天供應量 ) 量 ) 首選零售與郵購費用分攤 (90 天供應量 ) 標準零售費用分攤 (90 天供應量 ) 1 首選副廠藥 $3 $8 $6 $16 $6 $16 2 副廠藥 $5 $10 $10 $20 $10 $20 3 首選原廠藥 $42 $47 $84 $94 $116 $131 4 非首選藥物 $95 $100 $190 $200 $275 $290 5 特殊藥物 33% 33% 不適用不適用不適用不適用 請參考您的 承保證明書 上有關長期護理 (LTC) 藥房或網路外藥房費用的資訊 在某些網路藥房, 可為 Part D 的某些承保藥物提供費用較低的首選費用分攤 瞭解更多資訊, 請訪問我們的線上搜索藥物目錄 或者致電會員服務部 我們的聯絡資訊印在封面頁和封底頁上 51

54 SCAN Classic (HMO): Marin 郡 藥物層級 層級名稱 首選零售與郵購費用分攤 (30 天供應量 ) 標準零售費用分攤 (30 天供應量 ) 首選零售與郵標準零售費用購費用分攤分攤 (60 天供應 (60 天供應量 ) 量 ) 首選零售與郵購費用分攤 (90 天供應量 ) 標準零售費用分攤 (90 天供應量 ) 1 首選副廠藥 $0 $3 $0 $6 $0 $6 2 副廠藥 $2 $7 $4 $14 $4 $14 3 首選原廠藥 $40 $45 $80 $90 $110 $125 4 非首選藥物 $80 $85 $160 $170 $230 $245 5 特殊藥物 33% 33% 不適用不適用不適用不適用 請參考您的 承保證明書 上有關長期護理 (LTC) 藥房或網路外藥房費用的資訊 在某些網路藥房, 可為 Part D 的某些承保藥物提供費用較低的首選費用分攤 瞭解更多資訊, 請訪問我們的線上搜索藥物目錄 或者致電會員服務部 我們的聯絡資訊印在封面頁和封底頁上 52

55 SCAN Classic (HMO): Napa 郡和 Sonoma 郡 藥物層級 層級名稱 首選零售與郵購費用分攤 (30 天供應量 ) 標準零售費用分攤 (30 天供應量 ) 首選零售與郵標準零售費用購費用分攤分攤 (60 天供應 (60 天供應量 ) 量 ) 首選零售與郵購費用分攤 (90 天供應量 ) 標準零售費用分攤 (90 天供應量 ) 1 首選副廠藥 $0 $5 $0 $10 $0 $10 2 副廠藥 $10 $15 $20 $30 $20 $30 3 首選原廠藥 $42 $47 $84 $94 $116 $131 4 非首選藥物 $95 $100 $190 $200 $275 $290 5 特殊藥物 33% 33% 不適用不適用不適用不適用 請參考您的 承保證明書 上有關長期護理 (LTC) 藥房或網路外藥房費用的資訊 在某些網路藥房, 可為 Part D 的某些承保藥物提供費用較低的首選費用分攤 瞭解更多資訊, 請訪問我們的線上搜索藥物目錄 或者致電會員服務部 我們的聯絡資訊印在封面頁和封底頁上 53

56 SCAN Healthy At Home (HMO SNP): Los Angeles 郡 Orange 郡 Riverside 郡和 San Bernardino 郡 藥物層級 層級名稱 首選零售與郵購費用分攤 (30 天供應量 ) 標準零售費用分攤 (30 天供應量 ) 首選零售與郵標準零售費用購費用分攤分攤 (60 天供應 (60 天供應量 ) 量 ) 首選零售與郵購費用分攤 (90 天供應量 ) 標準零售費用分攤 (90 天供應量 ) 1 首選副廠藥 $0 $3 $0 $6 $0 $9 2 副廠藥 $5 $10 $10 $20 $15 $30 3 首選原廠藥 $42 $47 $84 $94 $126 $141 4 非首選藥物 $95 $100 $190 $200 $285 $300 5 特殊藥物 33% 33% 不適用不適用不適用不適用 請參考您的 承保證明書 上有關長期護理 (LTC) 藥房或網路外藥房費用的資訊 在某些網路藥房, 可為 Part D 的某些承保藥物提供費用較低的首選費用分攤 瞭解更多資訊, 請訪問我們的線上搜索藥物目錄 或者致電會員服務部 我們的聯絡資訊印在封面頁和封底頁上 承保缺口期間, 我們針對第 1 級處方藥提供額外的保險承保 有關此項承保的詳細資訊, 請參閱您的 承保證明書 54

57 Heart First (HMO SNP): Orange 郡 藥物層級 層級名稱 首選零售與郵購費用分攤 (30 天供應量 ) 標準零售費用分攤 (30 天供應量 ) 首選零售與郵標準零售費用購費用分攤分攤 (60 天供應 (60 天供應量 ) 量 ) 首選零售與郵購費用分攤 (90 天供應量 ) 標準零售費用分攤 (90 天供應量 ) 1 首選副廠藥 $0 $3 $0 $6 $0 $6 2 副廠藥 $2 $7 $4 $14 $4 $14 3 首選原廠藥 $42 $47 $84 $94 $116 $131 4 非首選藥物 $95 $100 $190 $200 $275 $290 5 特殊藥物 33% 33% 不適用不適用不適用不適用 請參考您的 承保證明書 上有關長期護理 (LTC) 藥房或網路外藥房費用的資訊 在某些網路藥房, 可為 Part D 的某些承保藥物提供費用較低的首選費用分攤 瞭解更多資訊, 請訪問我們的線上搜索藥物目錄 或者致電會員服務部 我們的聯絡資訊印在封面頁和封底頁上 承保缺口期間, 我們針對第 1 級及第 2 級處方藥提供額外的保險承保 有關此項承保的詳細資訊, 請參閱您的 承保證明書 55

58 Heart First (HMO SNP): Marin 郡 藥物層級 層級名稱 首選零售與郵購費用分攤 (30 天供應量 ) 標準零售費用分攤 (30 天供應量 ) 首選零售與郵標準零售費用購費用分攤分攤 (60 天供應 (60 天供應量 ) 量 ) 首選零售與郵購費用分攤 (90 天供應量 ) 標準零售費用分攤 (90 天供應量 ) 1 首選副廠藥 $0 $3 $0 $6 $0 $6 2 副廠藥 $2 $7 $4 $14 $4 $14 3 首選原廠藥 $40 $45 $80 $90 $110 $125 4 非首選藥物 $90 $95 $180 $190 $260 $275 5 特殊藥物 33% 33% 不適用不適用不適用不適用 請參考您的 承保證明書 上有關長期護理 (LTC) 藥房或網路外藥房費用的資訊 在某些網路藥房, 可為 Part D 的某些承保藥物提供費用較低的首選費用分攤 瞭解更多資訊, 請訪問我們的線上搜索藥物目錄 或者致電會員服務部 我們的聯絡資訊印在封面頁和封底頁上 承保缺口期間, 我們針對第 1 級及第 2 級處方藥提供額外的保險承保 有關此項承保的詳細資訊, 請參閱您的 承保證明書 56

59 Heart First (HMO SNP): Riverside 郡和 San Bernardino 郡 藥物層級 層級名稱 首選零售與郵購費用分攤 (30 天供應量 ) 標準零售費用分攤 (30 天供應量 ) 首選零售與郵標準零售費用購費用分攤分攤 (60 天供應 (60 天供應量 ) 量 ) 首選零售與郵購費用分攤 (90 天供應量 ) 標準零售費用分攤 (90 天供應量 ) 1 首選副廠藥 $0 $5 $0 $10 $0 $10 2 副廠藥 $7 $12 $14 $24 $14 $24 3 首選原廠藥 $42 $47 $84 $94 $116 $131 4 非首選藥物 $95 $100 $190 $200 $275 $290 5 特殊藥物 33% 33% 不適用不適用不適用不適用 請參考您的 承保證明書 上有關長期護理 (LTC) 藥房或網路外藥房費用的資訊 在某些網路藥房, 可為 Part D 的某些承保藥物提供費用較低的首選費用分攤 瞭解更多資訊, 請訪問我們的線上搜索藥物目錄 或者致電會員服務部 我們的聯絡資訊印在封面頁和封底頁上 承保缺口期間, 我們針對第 1 級及第 2 級處方藥提供額外的保險承保 有關此項承保的詳細資訊, 請參閱您的 承保證明書 57

60 Scripps Heart First offered by SCAN Health Plan (HMO SNP): San Diego 郡 藥物層級 層級名稱 首選零售與郵購費用分攤 (30 天供應量 ) 標準零售費用分攤 (30 天供應量 ) 首選零售與郵購費用分攤 (60 天供應量 ) 標準零售費用分攤 (60 天供應量 ) 首選零售與郵購費用分攤 (90 天供應量 ) 標準零售費用分攤 (90 天供應量 ) 1 首選副廠藥 $0 $5 $0 $10 $0 $10 2 副廠藥 $5 $10 $10 $20 $10 $20 3 首選原廠藥 $42 $47 $84 $94 $116 $131 4 非首選藥物 $95 $100 $190 $200 $275 $290 5 特殊藥物 33% 33% 不適用不適用不適用不適用 請參考您的 承保證明書 上有關長期護理 (LTC) 藥房或網路外藥房費用的資訊 在某些網路藥房, 可為 Part D 的某些承保藥物提供費用較低的首選費用分攤 瞭解更多資訊, 請訪問我們的線上搜索藥物目錄 或者致電會員服務部 我們的聯絡資訊印在封面頁和封底頁上 承保缺口期間, 我們針對第 1 級處方藥提供額外的保險承保 有關此項承保的詳細資訊, 請參閱您的 承保證明書 58

61 Heart First (HMO SNP): Napa 郡和 Sonoma 郡 藥物層級 層級名稱 首選零售與郵購費用分攤 (30 天供應量 ) 標準零售費用分攤 (30 天供應量 ) 首選零售與郵購費用分攤 (60 天供應量 ) 標準零售費用分攤 (60 天供應量 ) 首選零售與郵購費用分攤 (90 天供應量 ) 標準零售費用分攤 (90 天供應量 ) 1 首選副廠藥 $0 $5 $0 $10 $0 $10 2 副廠藥 $10 $15 $20 $30 $20 $30 3 首選原廠藥 $42 $47 $84 $94 $116 $131 4 非首選藥物 $95 $100 $190 $200 $275 $290 5 特殊藥物 33% 33% 不適用不適用不適用不適用 請參考您的 承保證明書 上有關長期護理 (LTC) 藥房或網路外藥房費用的資訊 在某些網路藥房, 可為 Part D 的某些承保藥物提供費用較低的首選費用分攤 瞭解更多資訊, 請訪問我們的線上搜索藥物目錄 或者致電會員服務部 我們的聯絡資訊印在封面頁和封底頁上 承保缺口期間, 我們針對第 1 級處方藥提供額外的保險承保 有關此項承保的詳細資訊, 請參閱您的 承保證明書 59

62 SCAN Balance (HMO SNP): Los Angeles 郡和 Orange 郡 藥物層級 層級名稱 首選零售與郵購費用分攤 (30 天供應量 ) 標準零售費用分攤 (30 天供應量 ) 首選零售與郵購費用分攤 (60 天供應量 ) 標準零售費用分攤 (60 天供應量 ) 首選零售與郵購費用分攤 (90 天供應量 ) 標準零售費用分攤 (90 天供應量 ) 1 首選副廠藥 $0 $3 $0 $6 $0 $6 2 副廠藥 $2 $7 $4 $14 $4 $14 3 首選原廠藥 $30 $35 $60 $70 $80 $95 4 非首選藥物 $95 $100 $190 $200 $275 $290 5 特殊藥物 33% 33% 不適用不適用不適用不適用 請參考您的 承保證明書 上有關長期護理 (LTC) 藥房或網路外藥房費用的資訊 在某些網路藥房, 可為 Part D 的某些承保藥物提供費用較低的首選費用分攤 瞭解更多資訊, 請訪問我們的線上搜索藥物目錄 或者致電會員服務部 我們的聯絡資訊印在封面頁和封底頁上 承保缺口期間, 我們針對第 1 級及第 2 級處方藥提供額外的保險承保 有關此項承保的詳細資訊, 請參閱您的 承保證明書 60

63 SCAN Balance (HMO SNP): Marin 郡 藥物層級 層級名稱 首選零售與郵購費用分攤 (30 天供應量 ) 標準零售費用分攤 (30 天供應量 ) 首選零售與郵購費用分攤 (60 天供應量 ) 標準零售費用分攤 (60 天供應量 ) 首選零售與郵購費用分攤 (90 天供應量 ) 標準零售費用分攤 (90 天供應量 ) 1 首選副廠藥 $0 $3 $0 $6 $0 $6 2 副廠藥 $2 $7 $4 $14 $4 $14 3 首選原廠藥 $40 $45 $80 $90 $110 $125 4 非首選藥物 $90 $95 $180 $190 $260 $275 5 特殊藥物 33% 33% 不適用不適用不適用不適用 請參考您的 承保證明書 上有關長期護理 (LTC) 藥房或網路外藥房費用的資訊 在某些網路藥房, 可為 Part D 的某些承保藥物提供費用較低的首選費用分攤 瞭解更多資訊, 請訪問我們的線上搜索藥物目錄 或者致電會員服務部 我們的聯絡資訊印在封面頁和封底頁上 承保缺口期間, 我們針對第 1 級及第 2 級處方藥提供額外的保險承保 有關此項承保的詳細資訊, 請參閱您的 承保證明書 61

64 SCAN Balance (HMO SNP): Napa 郡和 Sonoma 郡 藥物層級 層級名稱 首選零售與郵購費用分攤 (30 天供應量 ) 標準零售費用分攤 (30 天供應量 ) 首選零售與郵購費用分攤 (60 天供應量 ) 標準零售費用分攤 (60 天供應量 ) 首選零售與郵購費用分攤 (90 天供應量 ) 標準零售費用分攤 (90 天供應量 ) 1 首選副廠藥 $0 $5 $0 $10 $0 $10 2 副廠藥 $10 $15 $20 $30 $20 $30 3 首選原廠藥 $42 $47 $84 $94 $116 $131 4 非首選藥物 $95 $100 $190 $200 $275 $290 5 特殊藥物 33% 33% 不適用不適用不適用不適用 請參考您的 承保證明書 上有關長期護理 (LTC) 藥房或網路外藥房費用的資訊 在某些網路藥房, 可為 Part D 的某些承保藥物提供費用較低的首選費用分攤 瞭解更多資訊, 請訪問我們的線上搜索藥物目錄 或者致電會員服務部 我們的聯絡資訊印在封面頁和封底頁上 承保缺口期間, 我們針對第 1 級處方藥提供額外的保險承保 有關此項承保的詳細資訊, 請參閱您的 承保證明書 62

65 SCAN Plus (HMO): Los Angeles 郡 Riverside 郡 San Bernardino 郡和 San Francisco 郡 藥物層級 層級名稱 首選零售與郵購費用分攤 (30 天供應量 ) 標準零售費用分攤 (30 天供應量 ) 首選零售與郵購費用分攤 (60 天供應量 ) 標準零售費用分攤 (60 天供應量 ) 首選零售與郵購費用分攤 (90 天供應量 ) 標準零售費用分攤 (90 天供應量 ) 1 首選副廠藥 $0 $8.50 $0 $17 $0 $ 副廠藥 25% 25% 25% 25% 25% 25% 3 首選原廠藥 25% 25% 25% 25% 25% 25% 4 非首選藥物 25% 25% 25% 25% 25% 25% 5 特殊藥物 25% 25% 不適用不適用不適用不適用 請參考您的 承保證明書 上有關長期護理 (LTC) 藥房或網路外藥房費用的資訊 在某些網路藥房, 可為 Part D 的某些承保藥物提供費用較低的首選費用分攤 瞭解更多資訊, 請訪問我們的線上搜索藥物目錄 或者致電會員服務部 我們的聯絡資訊印在封面頁和封底頁上 如果您獲得 額外協助, 承保處方藥的費用分攤可能會因您獲得的額外協助級別而有所不同 如需更多有關您藥物費用的資訊, 請查閱 低收入補貼 (LIS) 附文 63

66 SCAN Plus (HMO): Orange 郡 藥物層級 層級名稱 首選零售與郵購費用分攤 (30 天供應量 ) 標準零售費用分攤 (30 天供應量 ) 首選零售與郵購費用分攤 (60 天供應量 ) 標準零售費用分攤 (60 天供應量 ) 首選零售與郵購費用分攤 (90 天供應量 ) 標準零售費用分攤 (90 天供應量 ) 1 首選副廠藥 $0 $7.50 $0 $15 $0 $ 副廠藥 25% 25% 25% 25% 25% 25% 3 首選原廠藥 25% 25% 25% 25% 25% 25% 4 非首選藥物 25% 25% 25% 25% 25% 25% 5 特殊藥物 25% 25% 不適用不適用不適用不適用 請參考您的 承保證明書 上有關長期護理 (LTC) 藥房或網路外藥房費用的資訊 在某些網路藥房, 可為 Part D 的某些承保藥物提供費用較低的首選費用分攤 瞭解更多資訊, 請訪問我們的線上搜索藥物目錄 或者致電會員服務部 我們的聯絡資訊印在封面頁和封底頁上 如果您獲得 額外協助, 承保處方藥的費用分攤可能會因您獲得的額外協助級別而有所不同 如需更多有關您藥物費用的資訊, 請查閱 低收入補貼 (LIS) 附文 64

67 Scripps Plus offered by SCAN Health Plan (HMO): San Diego 郡 藥物層級 層級名稱 首選零售與郵購費用分攤 (30 天供應量 ) 標準零售費用分攤 (30 天供應量 ) 首選零售與郵購費用分攤 (60 天供應量 ) 標準零售費用分攤 (60 天供應量 ) 首選零售與郵購費用分攤 (90 天供應量 ) 標準零售費用分攤 (90 天供應量 ) 1 首選副廠藥 $0 $6 $0 $12 $0 $18 2 副廠藥 25% 25% 25% 25% 25% 25% 3 首選原廠藥 25% 25% 25% 25% 25% 25% 4 非首選藥物 25% 25% 25% 25% 25% 25% 5 特殊藥物 25% 25% 不適用不適用不適用不適用 請參考您的 承保證明書 上有關長期護理 (LTC) 藥房或網路外藥房費用的資訊 在某些網路藥房, 可為 Part D 的某些承保藥物提供費用較低的首選費用分攤 瞭解更多資訊, 請訪問我們的線上搜索藥物目錄 或者致電會員服務部 我們的聯絡資訊印在封面頁和封底頁上 如果您獲得 額外協助, 承保處方藥的費用分攤可能會因您獲得的額外協助級別而有所不同 如需更多有關您藥物費用的資訊, 請查閱 低收入補貼 (LIS) 附文 65

68 下表僅列出 Medicare 與 Medi-Cal 合格會員適用的資訊 說明您在初始承保階段針對承保處方藥應支付的分攤費用 瞭解更多在 承保間隔階段 或 重病承保階段 的相關費用, 請參考您的 承保證明書 共付額可能會因為您所獲得的額外援助的級別而有所不同 請聯絡會員服務部洽詢詳情 我們的聯絡資訊印在封面頁和封底頁上 SCAN Connections (HMO SNP) 僅適用 Medicare 和 Medi-Cal 合格會員 : Los Angeles 郡 Riverside 郡和 San Bernardino 郡 SCAN Connections at Home (HMO SNP) 僅適用 Medicare 和 Medi-Cal 合格會員 : Los Angeles 郡 Riverside 郡和 San Bernardino 郡 藥物層級 層級名稱 首選零售與郵購費用分攤 標準零售費用分攤 1 首選副廠藥 ( 供應一到三個月 ) $0 $0 或 $1.25 或 $ 副廠藥 ( 供應一到三個月 ) 首選原廠藥 ( 供應一到三個月 ) 非首選藥物 ( 供應一到三個月 ) 特殊藥物 ( 只供應一個月 ) 由您支付 : 副廠藥物 ( 包括被視為副廠藥物的原廠藥物 ), 每種藥物 : $0 或 $1.25 或 $3.35 所有其他藥物, 每種藥物 : $0 或 $3.70 或 $8.35 請參考您的 承保證明書 上有關長期護理 (LTC) 藥房或網路外藥房費用的資訊 在某些網路藥房, 可為 Part D 的某些承保藥物提供費用較低的首選費用分攤 瞭解更多資訊, 請訪問我們的線上搜索藥物目錄 或者致電會員服務部 我們的聯絡資訊印在封面頁和封底頁上 66

69 SCAN Health Plan 處方集 從第 69 頁開始的藥方集會說明 SCAN Health Plan 承保的所有藥物的承保資訊 如果在清單中找不到您的藥物, 請翻到第 98 頁開始的索引 表格的第一欄列出藥物名稱 原廠藥以大寫表示 ( 例如 JANUVIA), 副廠藥則以小寫斜體列出 ( 例如 metformin) 規定 / 限制欄中的資訊說明 SCAN Health Plan 對您所需藥物承保是否有特殊規定 o o o [PA] 符號表示適用事先授權 [B vs D] 符號是指本藥物可能由 Medicare Part B 或 Part D 承保, 視情況而定 可能需要提交資訊說明藥物的使用和場合, 以供作出裁定 [ST] 符號表示適用逐步治療 o [QL] 符號表示配藥數量有限 若要查看處方集上具有數量限制藥物的數量限制值, 請翻到第 95 頁 o o [90D] 符號表示此藥可經由郵購及特定零售藥房取得 90 天份藥量 [LD] 符號表示適用銷售範圍限制 本處方藥僅在某些藥房出售 瞭解更多資訊, 請查閱您的藥物目錄或致電會員服務部, 電話 : ( 符合 Medicare 和 Medi-Cal 資格的會員應撥打 ), 服務時間為 10 月 1 日至次年 2 月 14 日, 每週七天, 上午 8 時至晚上 8 時 ; 2 月 15 日至 9 月 30 日, 週一至週五上午 8 時至晚上 8 時 ( 假日和下班時間接到的留言會在下一個工作日回電 ) TTY 用戶應撥打

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71 FORMULARY DRUGS ARRANGED BY THERAPEUTIC CLASS 處方藥一覽表上的藥物按照治療類別排列 Formulary ID: (Version 8) Updated: 02/2018 處方藥一覽表 : ( 版本 8) 更新於 : 02/2018 Drug Drug Name Tier 藥物藥物名稱等級 ANALGESICS Opioid Analgesics, Long-acting Requirements/ Limits 要求 / 限制 duramorph inj 2 [90D] fentanyl patches 12mcg/hr, 25mcg/hr, 50mcg/hr, 75mcg/hr, 100mcg/hr 3 [QL] [90D] methadone oral 2 [90D] methadone inj 2 [90D] morphine sulfate er tabs 3 [QL] [90D] OXYCODONE ER 4 [QL] [90D] OXYCONTIN 4 [QL] [90D] oxymorphone er 3 [QL] [90D] tramadol er tabs 2 [QL] [90D] Opioid Analgesics, Short-acting acetaminophen & codeine 2 [QL] [90D] butorphanol tartrate inj 2 [90D] butorphanol tartrate nasal 2 [QL] [90D] codeine 2 [90D] endocet 5-325mg, [QL] [90D] 325mg, mg fentanyl citrate lozenges 5 [PA] hydrocodone & acetaminophen soln mg/15mL 2 [QL] [90D] hydrocodone & acetaminophen tabs 5-325mg, mg, mg 2 [QL] [90D] hydrocodone & ibuprofen 2 [QL] [90D] hydromorphone immediate-release oral soln & tabs 2 [90D] hydromorphone inj 3 [90D] LAZANDA 5 [PA] lorcet tabs 5-325mg 2 [QL] [90D] Drug Name Drug Requirements/ Tier Limits 藥物名稱 藥物等級 要求 / 限制 lorcet hd tabs mg 2 [QL] [90D] lorcet plus tabs mg 2 [QL] [90D] lortab tabs 5-325mg, [QL] [90D] 325mg, mg morphine sulfate oral 2 [90D] oxycodone immediaterelease 2 [90D] oxycodone oral soln 2 [90D] oxycodone & 3 [QL] [90D] acetaminophen mg, 5-325mg, mg, mg oxycodone & aspirin 2 [QL] [90D] oxycodone & ibuprofen 2 [QL] [90D] tramadol 2 [90D] tramadol & acetaminophen 2 [QL] [90D] zamicet 2 [QL] [90D] ANESTHETICS Local Anesthetics lidocaine hcl inj 2 [90D] lidocaine ointment 3 [90D] lidocaine patch 3 [PA] [90D] lidocaine topical gel & 2 [90D] solution lidocaine & prilocaine 2 [90D] ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS Alcohol Deterrents/Anti-Craving acamprosate calcium dr 2 [90D] disulfiram 2 [90D] Opioid Dependence Treatments buprenorphine inj 2 [90D] buprenorphine oral 2 [90D] buprenorphine & naloxone 2 [90D] sublingual tabs naltrexone 2 [90D] [PA] = Prior Authorization [B vs D] = B versus D [QL] = Quantity Limit [ST] = Step Therapy [90D] = 90-Day Supply [LD] = Limited Distribution You can find information on what the symbols and abbreviations on this table mean by going to page

72 Drug Name 藥物名稱 Drug Tier 藥物等級 Requirements/ Limits 要求 / 限制 Opioid Reversal Agents naloxone inj 2 [90D] NARCAN 3 [90D] Smoking Cessation Agents bupropion sr 150mg 2 [90D] CHANTIX 4 [ST] [90D] CHANTIX STARTING & CONTINUING MONTH PAK 4 [ST] [90D] NICOTROL INHALER 3 [90D] NICOTROL NASAL 3 [90D] ANTI-INFLAMMATORY AGENTS Nonsteroidal Anti-inflammatory Drugs celecoxib 3 [ST] [90D] diclofenac potassium 1 [90D] diclofenac sodium dr 1 [90D] diclofenac sodium er 1 [90D] diflunisal 2 [90D] etodolac 2 [90D] etodolac er 2 [90D] ibuprofen 1 [90D] indomethacin er 2 [PA] [90D] indomethacin ir caps 2 [PA] [90D] ketorolac oral 2 [PA] [90D] ketorolac inj 2 [PA] [90D] meloxicam tabs 1 [90D] nabumetone 2 [90D] naproxen 1 [90D] naproxen dr 1 [90D] naproxen sodium ir 1 [90D] piroxicam 2 [90D] sulindac 2 [90D] ANTIBACTERIALS Aminoglycosides amikacin inj 2 [90D] gentamicin cream 0.1% & 2 [90D] oint 0.1% gentamicin inj 2 [90D] gentamicin ophthalmic 2 [90D] soln 0.3% neomycin sulfate oral 2 [90D] paromomycin 2 [90D] [PA] = 事先授權 [B vs D] = B 與 D [QL] = 數量限制 [ST] = 階段療法 [90D] = 90 天份量 [LD] = 限量分配您可以前往第 67 頁, 找到本表中的符號和縮寫詞所代表含義的相關資訊 70 Drug Name Drug Requirements/ Tier Limits 藥物名稱 藥物等級 要求 / 限制 streptomycin inj 2 [90D] TOBRADEX OINT 3 [90D] tobramycin ophthalmic 2 [90D] solution tobramycin & 2 [90D] dexamethasone ophthalmic suspension tobramycin sulfate inj 2 [90D] Antibacterials, Other bacitracin ointment 2 [90D] bacitracin & polymyxin b 2 [90D] ointment BACTROBAN CREAM 3 [90D] BACTROBAN NASAL 3 [90D] chloramphenicol sodium 2 [90D] succinate inj CLEOCIN VAGINAL 3 [90D] clindamycin oral 2 [90D] clindamycin phosphate inj 2 [90D] clindamycin topical cream, 2 [90D] gel, lotion, soln & swab colistimethate inj 2 [90D] CORTISPORIN CREAM & 3 [90D] OINT daptomycin inj 5 linezolid inj 5 linezolid oral 5 methenamine hippurate 2 [90D] metronidazole inj 2 [90D] metronidazole oral 2 [90D] metronidazole topical 3 [90D] metronidazole vaginal 2 [90D] mupirocin cream 3 [90D] mupirocin ointment 2 [90D] neomycin & bacitracin & 2 [90D] polymyxin b ophthalmic neomycin & polymyxin & 2 [90D] gramicidin ophthalmic nitrofurantoin caps 2 [90D]

73 Drug Name 藥物名稱 polymyxin b sulfate & trimethoprim sulfate ophthalmic soln Drug Requirements/ Tier Limits 藥物要求 / 限制等級 2 [90D] silver sulfadiazine 2 [90D] SIVEXTRO 5 ssd 2 [90D] SYNERCID INJ 5 TIGECYCLINE INJ 5 trimethoprim 2 [90D] TYGACIL INJ 5 vancomycin oral 5 [PA] vancomycin inj 3 [90D] vandazole 2 [90D] XIFAXAN TABS 200MG 3 [PA] [QL] [90D] XIFAXAN TABS 550MG 5 [PA] Beta-lactam, Cephalosporins cefaclor 2 [90D] cefaclor er 2 [90D] cefadroxil caps & tabs 2 [90D] cefazolin inj 2 [90D] cefdinir 2 [90D] cefepime inj 2 [90D] cefixime 2 [90D] cefoxitin sodium 2 [90D] cefpodoxime tabs 2 [90D] cefprozil 2 [90D] ceftazidime inj 1gm, 2gm 2 [90D] & 6gm ceftriaxone inj 2 [90D] cefuroxime oral 2 [90D] cefuroxime inj 2 [90D] cephalexin caps & tabs 1 [90D] 250mg & 500mg cephalexin oral susp 1 [90D] SUPRAX CAPS & 3 [90D] CHEWABLE TABS SUPRAX ORAL SUSP 3 [90D] 500MG/5ML tazicef inj 2 [90D] TEFLARO INJ 5 Drug Name Drug Requirements/ Tier Limits 藥物名稱 藥物等級 要求 / 限制 ZERBAXA INJ 5 Beta-lactam, Other aztreonam inj 1gm 2 [90D] cilastatin/imipenem inj 2 [90D] INVANZ INJ 4 [90D] meropenem inj 4 [90D] Beta-lactam, Penicillins amoxicillin 1 [90D] amoxicillin & clavulanate 2 [90D] potassium amoxicillin & clavulanate 2 [90D] potassium er ampicillin & sulbactam inj 2 [90D] 10-5gm, 2-1gm, & 1-0.5gm ampicillin inj 2 [90D] ampicillin oral 2 [90D] BICILLIN L-A INJ 3 [90D] dicloxacillin sodium 2 [90D] nafcillin sodium inj 4 [90D] penicillin g inj 5 million 2 [90D] units penicillin v potassium 2 [90D] piperacillin/tazobactam inj 3 [90D] ZOSYN GALAXY INJ 4 [90D] 2GM/0.25GM & 3GM/0.375GM Macrolides AZASITE 3 [90D] azithromycin tabs & oral 2 [90D] susp azithromycin inj 2 [90D] clarithromycin 2 [90D] clarithromycin er 2 [90D] ERYTHROCIN 4 [90D] LACTOBIONATE INJ erythrocin stearate 2 [90D] erythromycin oral 2 [90D] erythromycin 2 [90D] ethylsuccinate tabs erythromycin ophthalmic oint 2 [90D] [PA] = Prior Authorization [B vs D] = B versus D [QL] = Quantity Limit [ST] = Step Therapy [90D] = 90-Day Supply [LD] = Limited Distribution You can find information on what the symbols and abbreviations on this table mean by going to page

74 Drug Name Drug Requirements/ Tier Limits 藥物名稱 藥物等級 要求 / 限制 erythromycin topical gel & 2 [90D] soln Quinolones CIPRO HC 3 [90D] CIPRODEX 3 [90D] ciprofloxacin inj 2 [90D] ciprofloxacin ophthalmic 2 [90D] soln 0.3% ciprofloxacin oral susp 2 [90D] ciprofloxacin tabs 1 [90D] immediate-release ciprofloxacin tabs er 2 [90D] levofloxacin inj 2 [90D] levofloxacin oral soln 2 [90D] levofloxacin tabs 1 [90D] moxifloxacin oral 2 [90D] moxifloxacin hcl 3 [90D] ophthalmic ofloxacin oral 2 [90D] ofloxacin ophthalmic 2 [90D] ofloxacin otic 2 [90D] VIGAMOX 3 [90D] Sulfonamides sulfacetamide sodium ophthalmic oint & soln 10% sulfacetamide sodium topical susp 10% sulfacetamide sodium & prednisolone sodium phosphate ophthalmic 2 [90D] 2 [90D] 2 [90D] sulfadiazine 2 [90D] sulfamethoxazole & 1 [90D] trimethoprim tabs sulfamethoxazole & 1 [90D] trimethoprim ds tabs sulfamethoxazole & 2 [90D] trimethoprim oral susp sulfamethoxazole & 2 [90D] trimethoprim inj Tetracyclines demeclocycline 3 [90D] doxy 100 inj 2 [90D] [PA] = 事先授權 [B vs D] = B 與 D [QL] = 數量限制 [ST] = 階段療法 [90D] = 90 天份量 [LD] = 限量分配您可以前往第 67 頁, 找到本表中的符號和縮寫詞所代表含義的相關資訊 72 Drug Name 藥物名稱 doxycycline immediaterelease tabs, caps & oral susp Drug Requirements/ Tier Limits 藥物要求 / 限制等級 2 [90D] minocycline ir 2 [90D] morgidox 2 [90D] tetracycline 2 [90D] ANTICONVULSANTS Anticonvulsants, Other BRIVIACT INJ 4 [90D] BRIVIACT ORAL SOLN 4 [90D] BRIVIACT TABS 5 FYCOMPA 4 [90D] levetiracetam er 2 [90D] levetiracetam oral 2 [90D] levetiracetam inj 2 [90D] roweepra 2 [90D] SPRITAM 4 [90D] Calcium Channel Modifying Agents CELONTIN 4 [90D] ethosuximide 2 [90D] LYRICA 3 [PA] [90D] zonisamide 2 [90D] Gamma-aminobutyric Acid (GABA) Augmenting Agents clonazepam 2 [90D] clonazepam odt 2 [90D] DIASTAT 3 [90D] diazepam rectal 2 [90D] divalproex sodium 2 [90D] divalproex sodium dr 2 [90D] divalproex sodium er 2 [90D] gabapentin caps, tabs, & 2 [90D] oral soln GABITRIL TABS 12MG & 4 [90D] 16MG ONFI 4 [90D] phenobarbital elixir 2 [PA] [90D] phenobarbital tabs 2 [PA] [90D] primidone 2 [90D] SABRIL 5 [LD] tiagabine 2 [90D] valproate sodium inj 2 [90D]

75 Drug Name Drug Requirements/ Tier Limits 藥物名稱 藥物等級 要求 / 限制 valproic acid 2 [90D] vigabatrin 5 [LD] Glutamate Reducing Agents felbamate tabs 400mg 2 [90D] felbamate tabs 600mg 4 [90D] felbamate oral susp 5 600mg/5ml lamotrigine immediaterelease 2 [90D] tabs topiramate immediaterelease 2 [90D] Sodium Channel Agents APTIOM 4 [90D] BANZEL 4 [90D] carbamazepine tabs, 2 [90D] chewable tabs & oral susp carbamazepine er tabs & 3 [90D] caps dilantin caps 100mg 2 [90D] DILANTIN CAPS 30MG 3 [90D] DILANTIN INFATABS 3 [90D] DILANTIN SUSP 3 [90D] epitol 2 [90D] fosphenytoin sodium inj 2 [90D] oxcarbazepine 2 [90D] PEGANONE 4 [90D] phenytoin chewable tabs 2 [90D] phenytoin er 2 [90D] phenytoin oral susp 2 [90D] phenytoin inj 2 [90D] TEGRETOL 3 [90D] TEGRETOL XR 3 [90D] TRILEPTAL 4 [90D] VIMPAT ORAL 4 [90D] VIMPAT INJ 4 [90D] ANTIDEMENTIA AGENTS Antidementia Agents, Other ergoloid mesylates 3 [PA] [90D] [PA] = Prior Authorization [B vs D] = B versus D [QL] = Quantity Limit [ST] = Step Therapy [90D] = 90-Day Supply [LD] = Limited Distribution You can find information on what the symbols and abbreviations on this table mean by going to page Drug Name 藥物名稱 Cholinesterase Inhibitors donepezil tabs 5mg & 10mg Drug Tier 藥物等級 Requirements/ Limits 要求 / 限制 2 [90D] donepezil odt 2 [90D] galantamine 2 [QL] [90D] galantamine er 2 [QL] [90D] galantamine oral soln 2 [QL] [90D] rivastigmine caps 3 [QL] [90D] rivastigmine patches 4 [QL] [90D] N-methyl-D-aspartate (NMDA) Receptor Antagonists memantine hcl immediate release 2 [90D] memantine hcl soln 2 [90D] ANTIDEPRESSANTS Antidepressants, Other bupropion 2 [90D] bupropion sr 2 [90D] bupropion xl 2 [90D] FORFIVO XL 3 [90D] maprotiline 2 [90D] mirtazapine 1 [90D] mirtazapine odt 1 [90D] nefazodone 2 [90D] trazodone 1 [90D] TRINTELLIX 4 [ST] [90D] Monoamine Oxidase Inhibitors EMSAM 4 [90D] MARPLAN 4 [90D] phenelzine 2 [90D] tranylcypromine 2 [90D] SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin & Norepinephrine Reuptake Inhibitors) BRISDELLE 3 [90D] citalopram tabs 1 [90D] citalopram oral soln 2 [90D] DESVENLAFAXINE ER 4 [ST] [90D] desvenlafaxine succinate 3 [ST] [90D] er duloxetine hcl 3 [90D]

76 Drug Name Drug Requirements/ Tier Limits 藥物名稱 藥物等級 要求 / 限制 escitalopram 2 [90D] FETZIMA 4 [ST] [90D] FETZIMA TITRATION 4 [ST] [90D] PACK fluoxetine hcl caps 10mg, 2 [90D] 20mg & 40mg fluoxetine hcl tabs 10mg & 2 [90D] 20mg fluoxetine hcl oral soln 2 [90D] fluvoxamine 2 [90D] fluvoxamine er 2 [90D] KHEDEZLA 4 [ST] [90D] paroxetine hcl immediaterelease 1 [90D] paroxetine hcl er 2 [90D] paroxetine mesylate caps 3 [90D] PAXIL 10MG/5ML SUSP 4 [90D] sertraline tabs 1 [90D] sertraline oral soln 2 [90D] venlafaxine ir tabs 2 [90D] venlafaxine er caps 2 [90D] VIIBRYD 4 [ST] [90D] VIIBRYD STARTER PACK 4 [ST] [90D] Tricyclics amitriptyline 2 [PA] [90D] amoxapine 2 [90D] clomipramine 4 [PA] [90D] desipramine 2 [90D] doxepin 2 [90D] imipramine hcl tabs 2 [PA] [90D] nortriptyline oral 2 [90D] perphenazine & 2 [PA] [90D] amitriptyline protriptyline 2 [90D] trimipramine maleate 2 [PA] [90D] ANTIEMETICS Antiemetics, Other compro 2 [90D] meclizine 2 [90D] phenadoz 3 [PA] [90D] phenergan suppositories 3 [PA] [90D] prochlorperazine inj 2 [90D] [PA] = 事先授權 [B vs D] = B 與 D [QL] = 數量限制 [ST] = 階段療法 [90D] = 90 天份量 [LD] = 限量分配您可以前往第 67 頁, 找到本表中的符號和縮寫詞所代表含義的相關資訊 74 Drug Name Drug Requirements/ Tier Limits 藥物名稱 藥物等級 要求 / 限制 prochlorperazine oral 2 [90D] prochlorperazine 2 [90D] suppositories promethazine inj 3 [PA] [90D] promethazine 3 [PA] [90D] suppositories promethazine syrup 2 [PA] [90D] promethazine tabs 2 [PA] [90D] 12.5mg, 25mg & 50mg promethegan 3 [PA] [90D] scopolamine patch 3 [90D] TRANSDERM-SCOP 3 [90D] Emetogenic Therapy Adjuncts aprepitant caps 80mg & 4 [PA] [90D] 125mg aprepitant pack 4 [PA] [90D] dronabinol 4 [PA] [90D] granisetron inj 2 [90D] granisetron oral 2 [PA] [B vs D] [90D] ondansetron odt 2 [PA] [B vs D] [90D] ondansetron oral soln 2 [PA] [B vs D] [90D] ondansetron inj 2 [90D] ondansetron tabs 2 [PA] [B vs D] [90D] ANTIFUNGALS Antifungals ABELCET INJ 5 [PA] [B vs D] AMBISOME INJ 5 [PA] [B vs D] amphotericin b inj 2 [PA] [B vs D] [90D] CANCIDAS INJ 5 [PA] caspofungin inj 50mg 5 [PA] ciclopirox 8% nail soln 2 [90D] ciclopirox cream, susp, 2 [90D] shampoo clotrimazole 1% cream 2 [90D] clotrimazole 1% topical 2 [90D] soln clotrimazole troche 2 [90D]

77 Drug Name Drug Requirements/ Tier Limits 藥物名稱 藥物等級 要求 / 限制 CRESEMBA INJ 5 [PA] CRESEMBA ORAL 5 [PA] econazole nitrate 4 [90D] fluconazole in sodium 2 [90D] chloride inj fluconazole oral 2 [90D] flucytosine 5 griseofulvin microsize 2 [90D] itraconazole 4 [90D] ketoconazole tabs, cream, 2 [90D] shampoo NATACYN 4 [90D] NOXAFIL ORAL 5 [PA] nyamyc 2 [90D] nyata 2 [90D] nystatin 2 [90D] nystatin & triamcinolone 3 [90D] ORAVIG 4 [90D] SPORANOX ORAL SOLN 4 [90D] terbinafine 2 [90D] terconazole 2 [90D] voriconazole inj 2 [90D] voriconazole oral 5 ANTIGOUT AGENTS Antigout Agents allopurinol tab 1 [90D] COLCHICINE 4 [QL] [90D] COLCRYS 4 [QL] [90D] probenecid 2 [90D] probenecid & colchicine 2 [90D] ULORIC 3 [ST] [90D] ANTIMIGRAINE AGENTS Ergot Alkaloids caffeine-ergotamine 4 [90D] dihydroergotamine 5 mesylate inj migergot suppository 4 [90D] Serotonin (5-HT) 1b/1d Receptor Agonists naratriptan 2 [QL] [90D] rizatriptan 2 [90D] Drug Name Drug Requirements/ Tier Limits 藥物名稱 藥物等級 要求 / 限制 rizatriptan odt 2 [90D] sumatriptan nasal 4 [90D] sumatriptan succinate inj 4 [90D] sumatriptan succinate oral 2 [90D] zolmitriptan tabs 2 [90D] zolmitriptan odt 2 [90D] ZOMIG NASAL 4 [QL] [90D] ANTIMYASTHENIC AGENTS Parasympathomimetics guanidine 2 [90D] MESTINON SYRUP 3 [90D] pyridostigmine 2 [90D] pyridostigmine er 2 [90D] ANTIMYCOBACTERIALS Antimycobacterials, Other dapsone tabs 3 [90D] rifabutin 4 [90D] Antituberculars CAPASTAT INJ 4 [90D] ethambutol 2 [90D] isoniazid oral 2 [90D] PASER 4 [90D] PRIFTIN 4 [90D] pyrazinamide 2 [90D] rifampin oral 2 [90D] rifampin inj 2 [90D] RIFATER 4 [90D] SIRTURO 5 TRECATOR 4 [90D] ANTINEOPLASTICS Alkylating Agents cyclophosphamide caps 2 [PA] [B vs D] [90D] GLEOSTINE 4 [90D] HEXALEN 5 LEUKERAN 3 [90D] MATULANE 5 VALCHLOR 5 [PA] Antiandrogens bicalutamide 2 [90D] [PA] = Prior Authorization [B vs D] = B versus D [QL] = Quantity Limit [ST] = Step Therapy [90D] = 90-Day Supply [LD] = Limited Distribution You can find information on what the symbols and abbreviations on this table mean by going to page

78 Drug Name Drug Requirements/ Tier Limits 藥物名稱 藥物等級 要求 / 限制 flutamide 2 [90D] nilutamide 5 XTANDI 5 [PA] ZYTIGA 5 [PA] Antiangiogenic Agents POMALYST 5 [PA] [LD] REVLIMID 5 [PA] [LD] THALOMID 5 [PA] Antiestrogens/Modifiers EMCYT 3 [90D] FARESTON 3 [90D] FASLODEX INJ 5 SOLTAMOX 3 [90D] tamoxifen 2 [90D] Antimetabolites ALIMTA INJ 5 [PA] hydroxyurea 2 [90D] LONSURF 5 [PA] mercaptopurine 2 [90D] PURIXAN 5 TABLOID 4 [PA] [90D] Antineoplastics, Other azacitidine inj 5 [PA] [B vs D] ERWINAZE INJ 5 [PA] IBRANCE 5 [PA] KISQALI 5 [PA] KISQALI FEMARA CO- 5 [PA] PACK leucovorin oral 2 [90D] leucovorin inj 2 [90D] levoleucovorin 175mg vial 5 LYNPARZA 5 [PA] MESNEX TABS 3 [90D] mitoxantrone inj 2 [PA] [90D] NERLYNX 5 [PA] NINLARO 5 [PA] paclitaxel inj 2 [90D] RUBRACA 5 [PA] [LD] RYDAPT 5 [PA] SYLATRON INJ 5 [PA] SYNRIBO INJ 5 [PA] [PA] = 事先授權 [B vs D] = B 與 D [QL] = 數量限制 [ST] = 階段療法 [90D] = 90 天份量 [LD] = 限量分配您可以前往第 67 頁, 找到本表中的符號和縮寫詞所代表含義的相關資訊 76 Drug Name Drug Requirements/ Tier Limits 藥物名稱 藥物等級 要求 / 限制 VELCADE INJ 5 [PA] VENCLEXTA TABS 10MG 4 [PA] [90D] & 50MG VENCLEXTA TABS 5 [PA] 100MG VENCLEXTA STARTING 5 [PA] PACK VERZENIO 5 [PA] ZEJULA 5 [PA] Aromatase Inhibitors, 3rd Generation anastrozole 2 [90D] exemestane 3 [90D] letrozole 2 [90D] Enzyme Inhibitors BELEODAQ 5 [PA] etoposide inj 3 [90D] FARYDAK 5 [PA] ZOLINZA 5 [PA] ZYDELIG 5 [PA] Molecular Target Inhibitors AFINITOR 5 [PA] AFINITOR DISPERZ 5 [PA] ALECENSA 5 [PA] ALUNBRIG 5 [PA] BOSULIF 100 MG TAB 3 [PA] [90D] BOSULIF 500 MG TAB 5 [PA] CABOMETYX 5 [PA] CALQUENCE 5 [PA] CAPRELSA 5 [PA] COMETRIQ 5 [PA] COTELLIC 5 [PA] ERIVEDGE 5 [PA] GILOTRIF 5 [PA] ICLUSIG 5 [PA] IDHIFA 5 [PA] imatinib 5 [PA] IMBRUVICA 5 [PA] INLYTA 5 [PA] IRESSA 5 [PA] JAKAFI 5 [PA] LENVIMA 5 [PA] MEKINIST 5 [PA]

79 Drug Name Drug Requirements/ Tier Limits 藥物名稱 藥物等級 要求 / 限制 NEXAVAR 5 [PA] [LD] ODOMZO 5 [PA] SPRYCEL 5 [PA] STIVARGA 5 [PA] SUTENT 5 [PA] TAFINLAR 5 [PA] TAGRISSO 5 [PA] TARCEVA 5 [PA] TASIGNA 5 [PA] TYKERB 5 [PA] VOTRIENT 5 [PA] XALKORI 5 [PA] ZELBORAF 5 [PA] ZYKADIA 5 [PA] Monoclonal Antibody/Antibody-Drug Conjugate AVASTIN INJ 5 [PA] HERCEPTIN INJ 5 [PA] KEYTRUDA INJ 5 [PA] RITUXAN INJ 5 [PA] RITUXAN HYCELA INJ 5 [PA] YERVOY INJ 5 [PA] Retinoids bexarotene 5 [PA] PANRETIN 5 TARGRETIN GEL 5 [PA] tretinoin caps 5 ANTIPARASITICS Anthelmintics ALBENZA 4 [90D] ivermectin 2 [90D] Antiprotozoals ALINIA 5 atovaquone 5 atovaquone/proguanil 2 [90D] chloroquine 2 [90D] COARTEM 3 [90D] DARAPRIM 5 [PA] hydroxychloroquine 2 [90D] mefloquine 2 [90D] [PA] = Prior Authorization [B vs D] = B versus D [QL] = Quantity Limit [ST] = Step Therapy [90D] = 90-Day Supply [LD] = Limited Distribution You can find information on what the symbols and abbreviations on this table mean by going to page Drug Name Drug Requirements/ Tier Limits 藥物名稱 藥物等級 要求 / 限制 NEBUPENT NEBULIZER 4 [PA] [B vs D] [90D] PENTAM INJ 4 [90D] PRIMAQUINE 3 [90D] quinine sulfate caps 3 [PA] [90D] 324mg Pediculicides/Scabicides EURAX 3 [90D] malathion 2 [90D] permethrin cream 2 [90D] ANTIPARKINSON AGENTS Anticholinergics benztropine inj 2 [90D] benztropine tabs 2 [PA] [90D] trihexyphenidyl tabs 2 [PA] [90D] trihexyphenidyl elixir 2 [PA] [90D] Antiparkinson Agents, Other amantadine 2 [90D] entacapone 4 [90D] Dopamine Agonists APOKYN INJ 5 [PA] bromocriptine 2 [90D] NEUPRO PATCH 4 [QL] [90D] pramipexole ir 2 [90D] ropinirole 2 [90D] Dopamine Precursors/L-Amino Acid Decarboxylase Inhibitors carbidopa 4 [90D] carbidopa & levodopa 2 [90D] carbidopa & levodopa er 2 [90D] carbidopa & levodopa odt 2 [90D] carbidopa & levodopa & entacapone 4 [90D] Monoamine Oxidase B (MAO-B) Inhibitors rasagiline 4 [90D] selegiline 2 [90D] ANTIPSYCHOTICS 1 st Generation/Typical chlorpromazine oral 4 [90D] chlorpromazine inj 4 [90D] fluphenazine oral 2 [90D]

80 Drug Name Drug Requirements/ Tier Limits 藥物名稱 藥物等級 要求 / 限制 fluphenazine decanoate inj 2 [90D] fluphenazine inj 2 [90D] haloperidol tabs 2 [90D] haloperidol decanoate inj 2 [90D] haloperidol lactate oral 2 [90D] soln haloperidol lactate inj 2 [90D] loxapine 2 [90D] perphenazine 2 [90D] pimozide 2 [90D] thioridazine 2 [PA] [90D] thiothixene 2 [90D] trifluoperazine 2 [90D] 2 nd Generation/Atypical ABILIFY MAINTENA 5 aripiprazole odt 3 [ST] [90D] aripiprazole tabs 2mg, 3 [ST] [90D] 5mg, 10mg, & 15mg aripiprazole tabs 20mg & 5 [ST] 30mg ARISTADA INJ 5 FANAPT 4 [ST] [90D] FANAPT TITRATION 4 [ST] [90D] PACK GEODON INJ 3 [90D] INVEGA SUSTENNA INJ 4 [90D] 39MG & 78MG INVEGA SUSTENNA INJ 5 117MG, 156MG, & 234MG INVEGA TRINZA INJ 5 LATUDA 5 [ST] NUPLAZID 5 [PA] olanzapine tabs 2 [90D] olanzapine odt 2 [90D] olanzapine inj 10mg 2 [90D] paliperidone er 5 [ST] quetiapine 2 [90D] quetiapine er tabs 3 [ST] [90D] REXULTI 5 [ST] RISPERDAL CONSTA INJ 12.5MG & 25MG 4 [90D] Drug Name 藥物名稱 Drug Tier 藥物等級 5 Requirements/ Limits 要求 / 限制 RISPERDAL CONSTA INJ 37.5MG & 50MG risperidone 2 [90D] risperidone odt 2 [90D] SAPHRIS 4 [ST] [90D] SEROQUEL XR 4 [ST] [90D] VRAYLAR CAPSULES 5 [ST] VRAYLAR DOSE PACK 4 [ST] [90D] ziprasidone oral 2 [90D] ZYPREXA RELPREVV 4 [90D] 210MG INJ Treatment-Resistant clozapine 2 [90D] clozapine odt 4 [90D] FAZACLO 4 [90D] VERSACLOZ 4 [90D] ANTISPASTICITY AGENTS Antispasticity Agents baclofen 2 [90D] tizanidine 2 [90D] ANTIVIRALS Anti-cytomegalovirus (CMV) Agents ganciclovir inj 2 [PA] [B vs D] [90D] valganciclovir tabs 5 ZIRGAN 4 [90D] Anti-hepatitis B (HBV) Agents adefovir dipivoxil 5 BARACLUDE ORAL 4 [90D] SOLN 0.05MG/ML entecavir tabs 5 EPIVIR HBV SOLN 4 [90D] 5MG/ML INTRON-A INJ 4 [90D] lamivudine tabs 100mg 2 [90D] Anti-hepatitis C (HCV) Agents, Direct Acting Agents EPCLUSA 5 [PA] HARVONI 5 [PA] Anti-hepatitis C (HCV) Agents, Other moderiba 200mg tabs 3 [90D] moderiba dose pack 5 [PA] = 事先授權 [B vs D] = B 與 D [QL] = 數量限制 [ST] = 階段療法 [90D] = 90 天份量 [LD] = 限量分配您可以前往第 67 頁, 找到本表中的符號和縮寫詞所代表含義的相關資訊 78

81 Drug Name Drug Requirements/ Tier Limits 藥物名稱 藥物等級 要求 / 限制 PEGASYS INJ 5 PEGASYS PROCLICK INJ 5 ribasphere 3 [90D] ribasphere ribapak 5 ribavirin 3 [90D] Antiherpetic Agents acyclovir oral 2 [90D] acyclovir oint 5% 4 [90D] acyclovir inj 2 [PA] [B vs D] [90D] DENAVIR 3 [90D] famciclovir 2 [90D] trifluridine 2 [90D] valacyclovir 2 [90D] XERESE 3 [90D] ZOVIRAX CREAM 5 Anti-HIV Agents, Integrase Inhibitors (INSTI) GENVOYA 5 ISENTRESS CHEW TABS 3 [90D] ISENTRESS ORAL 3 [90D] POWDER ISENTRESS TABS 5 ISENTRESS HD TABS 5 STRIBILD 5 TIVICAY 10MG & 25MG 4 [90D] TABS TIVICAY 50MG TAB 5 Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI) ATRIPLA 5 COMPLERA 5 EDURANT 5 INTELENCE 25MG TAB 4 [90D] INTELENCE 100MG & 5 200MG TABS nevirapine er 2 [90D] nevirapine oral susp 2 [90D] nevirapine tabs 2 [90D] ODEFSEY 5 RESCRIPTOR 3 [90D] Drug Name Drug Requirements/ Tier Limits 藥物名稱 藥物等級 要求 / 限制 SUSTIVA 50MG & 200MG 4 [90D] CAPS SUSTIVA 600MG TABS 5 VIRAMUNE TABS 4 [90D] Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI) abacavir soln 4 [90D] abacavir tabs 2 [90D] abacavir & lamivudine 5 abacavir & lamivudine & 5 zidovudine DESCOVY 5 didanosine 2 [90D] EMTRIVA 4 [90D] lamivudine tabs 150mg & 2 [90D] 300mg lamivudine soln 2 [90D] lamivudine & zidovudine 2 [90D] RETROVIR IV INJ 4 [90D] stavudine caps 2 [90D] TRIUMEQ 5 TRUVADA 5 VIDEX PEDIATRIC SOLN 4 [90D] 2GM VIREAD TABS 5 VIREAD POWDER 4 [90D] ZERIT SOLN 3 [90D] ZIAGEN SOLN 4 [90D] zidovudine 2 [90D] Anti-HIV Agents, Other FUZEON INJ 3 [90D] SELZENTRY SOLN 4 [90D] SELZENTRY 25MG & 4 [90D] 75MG SELZENTRY 150MG & 5 [PA] = Prior Authorization [B vs D] = B versus D [QL] = Quantity Limit [ST] = Step Therapy [90D] = 90-Day Supply [LD] = Limited Distribution You can find information on what the symbols and abbreviations on this table mean by going to page MG TYBOST 3 [90D] Anti-HIV Agents, Protease Inhibitors APTIVUS 5 CRIXIVAN 3 [90D] EVOTAZ 5

82 Drug Name Drug Requirements/ Tier Limits 藥物名稱 藥物等級 要求 / 限制 fosamprenavir tabs 5 INVIRASE 4 [90D] KALETRA TABS [90D] 25MG KALETRA TABS MG LEXIVA ORAL SUSP 4 [90D] LEXIVA TABS 5 lopinavir & ritonavir soln 4 [90D] NORVIR 4 [90D] PREZCOBIX 5 PREZISTA SUSP 4 [90D] 100MG/ML PREZISTA TABS 75MG & 4 [90D] 150MG PREZISTA TABS 600MG 5 & 800MG REYATAZ CAPS & ORAL 5 POWDER VIRACEPT 5 Anti-influenza Agents oseltamivir caps 2 [90D] oseltamivir susp 3 [90D] RELENZA DISKHALER 3 [90D] rimantadine 2 [90D] TAMIFLU SUSP 3 [90D] ANXIOLYTICS Anxiolytics, Other buspirone 2 [90D] meprobamate 4 [PA] [90D] Benzodiazepines alprazolam tabs 2 [PA] [90D] alprazolam er tabs 2 [PA] [90D] alprazolam intensol 2 [PA] [90D] clorazepate 2 [PA] [90D] diazepam tabs & soln 2 [PA] [90D] diazepam intensol 2 [PA] [90D] lorazepam tabs 2 [90D] lorazepam intensol 2 [90D] oxazepam 2 [PA] [90D] Drug Name 藥物名稱 Drug Tier 藥物等級 Requirements/ Limits 要求 / 限制 BIPOLAR AGENTS Mood Stabilizers lithium carbonate 2 [90D] lithium carbonate er 2 [90D] lithium citrate 2 [90D] BLOOD GLUCOSE REGULATORS Antidiabetic Agents acarbose 2 [90D] BYDUREON INJ 3 [PA] [90D] BYETTA INJ 3 [PA] [90D] CYCLOSET 3 [90D] FARXIGA 3 [ST] [90D] glimepiride 1 [90D] glimepiride & pioglitazone 2 [QL] [90D] glipizide 1 [90D] glipizide & metformin tabs 2 [90D] glipizide er 1 [90D] INVOKAMET 3 [ST] [90D] INVOKAMET XR 3 [ST] [90D] INVOKANA 3 [ST] [90D] JANUMET 3 [90D] JANUMET XR 3 [90D] JANUVIA 3 [90D] KOMBIGLYZE XR 3 [90D] metformin 1 [90D] metformin er uncoated 1 [90D] tabs 500mg & 750mg nateglinide 2 [90D] ONGLYZA 3 [90D] pioglitazone 1 [90D] pioglitazone & metformin 2 [90D] repaglinide 2 [90D] SYMLINPEN INJ 3 [PA] [90D] VICTOZA INJ 3 [PA] [90D] XIGDUO XR 3 [ST] [90D] Glycemic Agents GLUCAGON EMERGENCY KIT INJ 3 [90D] PROGLYCEM 4 [90D] [PA] = 事先授權 [B vs D] = B 與 D [QL] = 數量限制 [ST] = 階段療法 [90D] = 90 天份量 [LD] = 限量分配您可以前往第 67 頁, 找到本表中的符號和縮寫詞所代表含義的相關資訊 80

83 Drug Name 藥物名稱 Insulins HUMALOG CARTRIDGE INJ HUMALOG JUNIOR KWIKPEN INJ Drug Tier 藥物等級 Requirements/ Limits 要求 / 限制 3 [90D] 3 [90D] HUMALOG KWIKPEN INJ 3 [90D] HUMALOG MIX 50/50 3 [90D] KWIKPEN INJ HUMALOG MIX 75/25 3 [90D] KWIKPEN INJ HUMALOG MIX 50/50 3 [90D] VIAL INJ HUMALOG MIX 75/25 3 [90D] VIAL INJ HUMALOG VIAL INJ 3 [90D] HUMULIN 70/30 3 [90D] KWIKPEN INJ HUMULIN 70/30 VIAL INJ 3 [90D] HUMULIN N KWIKPEN 3 [90D] INJ HUMULIN N VIAL INJ 3 [90D] HUMULIN R U-500 (CONCENTRATED) KWIKPEN INJ 3 [90D] HUMULIN R U-500 (CONCENTRATED) VIAL INJ 3 [90D] HUMULIN R VIAL INJ 3 [90D] LANTUS SOLOSTAR 3 [90D] PEN INJ LANTUS VIAL INJ 3 [90D] TOUJEO SOLOSTAR 3 [90D] BLOOD PRODUCTS/ MODIFIERS/ VOLUME EXPANDERS Anticoagulants COUMADIN ORAL 3 [90D] ELIQUIS 3 [90D] enoxaparin inj 4 [90D] fondaparinux inj 2.5mg/0.5ml & 5mg/0.4ml fondaparinux inj 7.5mg/0.6ml & 10mg/0.8ml 4 [90D] 5 Drug Name Drug Requirements/ Tier Limits 藥物名稱 藥物等級 要求 / 限制 heparin inj 2 [PA] [B vs D] [90D] jantoven 1 [90D] PRADAXA 4 [90D] warfarin 1 [90D] XARELTO 3 [90D] XARELTO STARTER 3 [90D] PACK Blood Formation Modifiers anagrelide 2 [90D] LEUKINE INJ 5 [PA] MOZOBIL INJ 5 [PA] NEUPOGEN INJ 5 [PA] PROCRIT INJ 3 [PA] [90D] 2000UNIT/ML PROCRIT INJ 4 [PA] [90D] 3000UNIT/ML, 4000UNIT/ML & 10000UNIT/ML PROCRIT INJ 5 [PA] 20000UNIT/ML & 40000UNIT/ML PROMACTA 5 [PA] [LD] Hemostasis Agents tranexamic acid inj 2 [90D] tranexamic acid tabs 2 [90D] Platelet Modifying Agents BRILINTA 3 [QL] [90D] cilostazol 2 [90D] clopidogrel tabs 75mg 2 [90D] dipyridamole er & aspirin 3 [QL] [90D] dipyridamole oral 2 [PA] [90D] CARDIOVASCULAR AGENTS Alpha-adrenergic Agonists clonidine patches 3 [90D] clonidine tabs immediaterelease 1 [90D] guanfacine 2 [90D] methyldopa 2 [PA] [90D] [PA] = Prior Authorization [B vs D] = B versus D [QL] = Quantity Limit [ST] = Step Therapy [90D] = 90-Day Supply [LD] = Limited Distribution You can find information on what the symbols and abbreviations on this table mean by going to page

84 Drug Name Drug Requirements/ Tier Limits 藥物名稱 藥物等級 要求 / 限制 methyldopa & 2 [PA] [90D] hydrochlorothiazide methyldopate inj 2 [90D] midodrine tabs 2 [90D] Alpha-adrenergic Blocking Agents doxazosin 2 [90D] prazosin 2 [90D] terazosin 1 [90D] Angiotensin-converting Enzyme (ACE) Inhibitors benazepril 1 [90D] benazepril & 1 [90D] hydrochlorothiazide captopril 1 [90D] captopril & 1 [90D] hydrochlorothiazide enalapril 1 [90D] enalapril & 1 [90D] hydrochlorothiazide fosinopril 1 [90D] fosinopril & 1 [90D] hydrochlorothiazide lisinopril 1 [90D] lisinopril & 1 [90D] hydrochlorothiazide moexipril 1 [90D] moexipril & 1 [90D] hydrochlorothiazide perindopril 1 [90D] quinapril 1 [90D] quinapril & 1 [90D] hydrochlorothiazide ramipril 1 [90D] trandolapril 1 [90D] Angiotensin II Receptor Antagonists irbesartan 1 [90D] irbesartan hct 1 [90D] losartan 1 [90D] losartan hct 1 [90D] olmesartan 3 [ST] [90D] olmesartan & amlodipine 2 [ST] [90D] olmesartan hct 3 [ST] [90D] Drug Name Drug Requirements/ Tier Limits 藥物名稱 藥物等級 要求 / 限制 valsartan 1 [90D] valsartan hct 1 [90D] valsartan & amlodipine 2 [90D] valsartan & amlodipine & 2 [ST] [90D] hct Antiarrhythmics amiodarone tabs 2 [90D] disopyramide phosphate 2 [PA] [90D] dofetilide 2 [90D] flecainide acetate 2 [90D] mexiletine 2 [90D] pacerone tabs 200mg 2 [90D] procainamide inj 2 [90D] propafenone 2 [90D] quinidine gluconate cr 4 [90D] quinidine gluconate inj 4 [90D] quinidine sulfate 2 [90D] sorine 2 [90D] sotalol tabs 2 [90D] Beta-adrenergic Blocking Agents acebutolol 2 [90D] atenolol 1 [90D] atenolol & chlorthalidone 1 [90D] bisoprolol 2 [90D] bisoprolol & 2 [90D] hydrochlorothiazide BYSTOLIC 4 [90D] carvedilol 1 [90D] COREG CR 3 [90D] DUTOPROL 3 [90D] labetalol oral 2 [90D] labetalol inj 2 [90D] metoprolol succinate er 2 [90D] metoprolol tartrate tabs 1 [90D] metoprolol & 2 [90D] hydrochlorothiazide nadolol 2 [90D] nadolol & 2 [90D] bendroflumethiazide pindolol 2 [90D] propranolol ir tabs 1 [90D] propranolol er caps 2 [90D] [PA] = 事先授權 [B vs D] = B 與 D [QL] = 數量限制 [ST] = 階段療法 [90D] = 90 天份量 [LD] = 限量分配您可以前往第 67 頁, 找到本表中的符號和縮寫詞所代表含義的相關資訊 82

85 Drug Name Drug Requirements/ Tier Limits 藥物名稱 藥物等級 要求 / 限制 propranolol oral soln 2 [90D] propranolol inj 2 [90D] propranolol & 1 [90D] hydrochlorothiazide timolol oral 1 [90D] Calcium Channel Blocking Agents afeditab cr 2 [90D] amlodipine 1 [90D] amlodipine & atorvastatin 2 [90D] amlodipine & benazepril 1 [90D] cartia xt 2 [90D] diltiazem tabs 2 [90D] diltiazem cd caps 2 [90D] diltiazem er caps 2 [90D] diltiazem inj 50mg/10ml 2 [90D] dilt-xr 2 [90D] felodipine er 2 [90D] isradipine 2 [90D] nicardipine caps 2 [90D] nifedipine 2 [PA] [90D] nifedipine er 2 [90D] nimodipine caps 4 [90D] nisoldipine er 2 [90D] taztia xt 2 [90D] verapamil ir 1 [90D] verapamil er 2 [90D] verapamil sr 2 [90D] verapamil inj 2 [90D] Cardiovascular Agents, Other CORLANOR 4 [PA] [90D] DEMSER 5 [PA] digitek 2 [PA] [90D] digoxin oral 2 [PA] [90D] digoxin inj 2 [PA] [90D] ENTRESTO 4 [PA] [90D] LANOXIN INJ 3 [PA] [90D] LANOXIN ORAL 3 [PA] [90D] NORTHERA 5 [PA] pentoxifylline er 2 [90D] RANEXA 3 [PA] [90D] [PA] = Prior Authorization [B vs D] = B versus D [QL] = Quantity Limit [ST] = Step Therapy [90D] = 90-Day Supply [LD] = Limited Distribution You can find information on what the symbols and abbreviations on this table mean by going to page Drug Name Drug Requirements/ Tier Limits 藥物名稱 藥物等級 要求 / 限制 REPATHA INJ 5 [PA] TEKTURNA 3 [ST] [90D] TEKTURNA HCT 3 [ST] [90D] Diuretics, Loop bumetanide oral 2 [90D] furosemide oral 1 [90D] furosemide inj 2 [90D] torsemide oral 2 [90D] Diuretics, Potassium-sparing amiloride 2 [90D] amiloride & 1 [90D] hydrochlorothiazide eplerenone 3 [90D] spironolactone 1 [90D] spironolactone & 1 [90D] hydrochlorothiazide triamterene & 1 [90D] hydrochlorothiazide Diuretics, Thiazide chlorothiazide tabs 2 [90D] chlorthalidone 1 [90D] hydrochlorothiazide 1 [90D] indapamide 1 [90D] metolazone 2 [90D] Dyslipidemics, Fibric Acid Derivatives fenofibrate caps 43mg & 2 [QL] [90D] 130mg fenofibrate micronized 2 [QL] [90D] fenofibrate tabs 48mg, 2 [QL] [90D] 54mg, 145mg, 160mg fenofibric acid dr caps 3 [QL] [90D] fenofibric acid tabs 2 [90D] gemfibrozil 2 [90D] Dyslipidemics, HMG CoA Reductase Inhibitors atorvastatin 1 [90D] lovastatin 1 [90D] pravastatin 1 [90D] rosuvastatin 2 [ST] [90D] simvastatin 1 [90D] Dyslipidemics, Other cholestyramine 2 [90D]

86 Drug Name Drug Requirements/ Tier Limits 藥物名稱 藥物等級 要求 / 限制 cholestyramine light 2 [90D] colestipol granules 2 [90D] colestipol tabs 2 [90D] ezetimibe 3 [90D] JUXTAPID 5 [PA] [LD] KYNAMRO 5 [PA] [LD] niacin er tabs 3 [QL] [90D] omega-3-acid ethyl esters 3 [90D] prevalite 2 [90D] WELCHOL 4 [90D] Vasodilators, Direct-acting Arterial hydralazine oral 2 [90D] hydralazine inj 2 [90D] minoxidil 2 [90D] Vasodilators, Direct-acting Arterial/Venous isosorbide dinitrate 2 [90D] isosorbide dinitrate er 2 [90D] isosorbide mononitrate 2 [90D] isosorbide mononitrate er 2 [90D] minitran patches 2 [90D] nitro-bid oint 2 [90D] NITRO-DUR PATCHES 3 [90D] nitroglycerin inj 2 [90D] nitroglycerin lingual 2 [90D] nitroglycerin patches 2 [90D] nitroglycerin sublingual 2 [90D] CENTRAL NERVOUS SYSTEM AGENTS Attention Deficit Hyperactivity Disorder Agents, Amphetamines amphetamine & 2 [QL] [90D] dextroamphetamine tabs dextroamphetamine 2 [QL] [90D] sulfate dextroamphetamine 2 [QL] [90D] sulfate er zenzedi tabs 5mg & 10mg 2 [QL] [90D] Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines atomoxetine 3 [PA] [90D] clonidine er 2 [PA] [90D] dexmethylphenidate ir tabs 2 [90D] metadate er 2 [90D] Drug Name Drug Requirements/ Tier Limits 藥物名稱 藥物等級 要求 / 限制 methylphenidate er tabs 2 [90D] 10mg & 20mg methylphenidate ir tabs 5mg, 10mg & 20mg 2 [90D] Central Nervous System, Other AUSTEDO 5 [PA] HETLIOZ 5 [PA] NUEDEXTA 3 [90D] riluzole 3 [90D] Fibromyalgia Agents SAVELLA 3 [90D] SAVELLA TITRATION 3 [90D] PACK Multiple Sclerosis Agents AMPYRA 5 [PA] AUBAGIO 5 [PA] AVONEX INJ 5 [PA] AVONEX PEN INJ 5 [PA] BETASERON INJ 5 COPAXONE INJ 5 [PA] 40MG/ML GILENYA 5 [PA] glatopa inj 5 [PA] PLEGRIDY INJ 5 [PA] PLEGRIDY STARTER 5 [PA] PACK INJ REBIF INJ 5 [PA] REBIF REBIDOSE INJ 5 [PA] REBIF REBIDOSE 5 [PA] TITRATION PACK INJ REBIF TITRATION PACK 5 [PA] INJ TECFIDERA 5 [PA] [LD] TECFIDERA STARTER 5 [PA] [LD] PACK TYSABRI INJ 5 [PA] DENTAL AND ORAL AGENTS Dental and Oral Agents cevimeline 3 [90D] chlorhexidine gluconate 2 [90D] pilocarpine tabs 3 [90D] triamcinolone in orabase 2 [90D] [PA] = 事先授權 [B vs D] = B 與 D [QL] = 數量限制 [ST] = 階段療法 [90D] = 90 天份量 [LD] = 限量分配您可以前往第 67 頁, 找到本表中的符號和縮寫詞所代表含義的相關資訊 84

87 Drug Name Drug Requirements/ Tier Limits 藥物名稱 藥物等級 要求 / 限制 DERMATOLOGICAL AGENTS Dermatological Agents acitretin 5 [PA] adapalene 4 [90D] ammonium lactate topical 2 [90D] amnesteem caps 4 [90D] calcipotriene cream & oint 4 [QL] [90D] calcipotriene soln 4 [90D] calcipotriene & 4 [90D] betamethasone oint CARAC 5 claravis 4 [90D] clindamycin & benzoyl 2 [90D] peroxide topical diclofenac sodium gel 1% 3 [90D] diclofenac sodium gel 3% 5 [PA] doxepin cream 5% 3 [90D] ELIDEL 4 [QL] [90D] FLUOROURACIL 0.5% 5 CREAM fluorouracil 2% and 5% 3 [90D] topical imiquimod 3 [90D] methoxsalen 5 myorisan 4 [90D] podofilox 2 [90D] prudoxin 3 [90D] REGRANEX 5 [QL] SANTYL 3 [90D] selenium sulfide lotion 2 [90D] tacrolimus oint 3 [90D] tazarotene 4 [90D] TAZORAC 0.05% CREAM 4 [90D] TAZORAC GEL 4 [QL] [90D] TOLAK 3 [90D] tretinoin cream, gel 3 [PA] [90D] zenatane 4 [90D] ZONALON 3 [90D] Drug Name Drug Requirements/ Tier Limits 藥物名稱 藥物等級 要求 / 限制 ELECTROLYTES/MINERALS/METALS/ VITAMINS Electrolyte/Mineral/Metal Modifiers CARBAGLU 5 [PA] [LD] CUPRIMINE 4 [90D] DEPEN TITRATABS 4 [90D] EXJADE 5 [PA] JADENU 5 [PA] JADENU SPRINKLE 5 [PA] kionex 2 [90D] sodium polystyrene 2 [90D] sulfonate SYPRINE 5 VELTASSA 3 [PA] [90D] Electrolyte/Mineral Replacement AMINOSYN INJ 3 [PA] [B vs D] [90D] AMINOSYN & ELECTROLYTES INJ 3 [PA] [B vs D] [90D] CLINISOL SF INJ 4 [PA] [B vs D] [90D] dextrose inj 2 [90D] dextrose & sodium 2 [90D] chloride inj dextrose & lactated ringers 2 [90D] inj klor-con 2 [90D] klor-con sprinkle 2 [90D] lactated ringers inj 2 [90D] magnesium sulfate inj 2 [90D] plenamine inj 2 [PA] [B vs D] [90D] potassium chloride oral 2 [90D] soln potassium chloride er 2 [90D] potassium chloride inj 2 [90D] potassium chloride & dextrose & lactated ringers inj 2 [90D] [PA] = Prior Authorization [B vs D] = B versus D [QL] = Quantity Limit [ST] = Step Therapy [90D] = 90-Day Supply [LD] = Limited Distribution You can find information on what the symbols and abbreviations on this table mean by going to page

88 Drug Name 藥物名稱 potassium chloride & dextrose & sodium chloride inj 20mEq/5%/0.45% & 30mEq/5%/0.45% potassium chloride viaflex Drug Requirements/ Tier Limits 藥物要求 / 限制等級 2 [90D] 2 [90D] inj potassium citrate er 2 [90D] PROSOL INJ 4 [PA] [B vs D] [90D] sodium chloride inj 2 [90D] TPN ELECTROLYTES INJ 3 [90D] TRAVASOL INJ 4 [PA] [B vs D] [90D] Phosphate Binders calcium acetate 2 [90D] eliphos 2 [90D] FOSRENOL 3 [90D] lanthanum carbonate 3 [90D] RENVELA TABS 3 [90D] sevelamer carbonate 3 [90D] powder sevelamer carbonate tabs 3 [90D] Vitamins prenatal multi-vitamin 2 [90D] GASTROINTESTINAL AGENTS Antispasmodics, Gastrointestinal atropine sulfate inj 2 [90D] dicyclomine oral 2 [90D] glycopyrrolate 1mg & 2mg 2 [90D] tabs glycopyrrolate inj 2 [90D] Gastrointestinal Agents, Other cromolyn sodium oral 4 [90D] diphenoxylate & atropine 2 [90D] GATTEX INJ 5 [PA] loperamide caps 2mg 2 [90D] metoclopramide inj 2 [90D] metoclopramide oral tablets & soln MOVANTIK 3 [90D] RELISTOR INJ 5 [PA] 2 [90D] [PA] = 事先授權 [B vs D] = B 與 D [QL] = 數量限制 [ST] = 階段療法 [90D] = 90 天份量 [LD] = 限量分配您可以前往第 67 頁, 找到本表中的符號和縮寫詞所代表含義的相關資訊 86 Drug Name Drug Requirements/ Tier Limits 藥物名稱 藥物等級 要求 / 限制 RELISTOR TABS 4 [PA] [90D] ursodiol 3 [90D] Histamine2 (H2) Receptor Antagonists cimetidine oral 2 [90D] famotidine tabs 1 [90D] famotidine inj 2 [90D] ranitidine caps, syrup & inj 2 [90D] ranitidine tabs 1 [90D] Irritable Bowel Syndrome Agents alosetron hcl tabs 5 [PA] AMITIZA 3 [90D] LINZESS 3 [90D] Laxatives constulose soln 2 [90D] enulose 2 [90D] gavilyte-c 2 [90D] gavilyte-g 2 [90D] gavilyte-h 2 [90D] gavilyte-n 2 [90D] generlac 2 [90D] lactulose 2 [90D] MOVIPREP 3 [90D] OSMOPREP 3 [90D] peg 3350 & electrolytes 2 [90D] peg 3350 & sodium chloride & sodium bicarbonate & potassium 2 [90D] chloride polyethylene glycol [90D] PREPOPIK 3 [90D] SUPREP BOWEL PREP 3 [90D] Protectants misoprostol 2 [90D] sucralfate 2 [90D] Proton Pump Inhibitors esomeprazole magnesium dr caps 3 [ST] [90D] lansoprazole dr caps 2 [90D] omeprazole caps 2 [90D] pantoprazole inj 3 [90D] pantoprazole tabs 2 [90D] PROTONIX INJ 3 [90D]

89 Drug Name Drug Requirements/ Tier Limits 藥物名稱 藥物等級 要求 / 限制 GENETIC OR ENZYME DISORDER: REPLACEMENT, MODIFIERS, TREATMENT Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment ADAGEN INJ 5 [PA] ALDURAZYME INJ 5 [PA] BUPHENYL TABS 5 CERDELGA 5 [PA] CREON DR 3 [90D] CYSTADANE 4 [90D] CYSTAGON 3 [90D] FABRAZYME INJ 5 KUVAN 5 LUMIZYME INJ 5 [PA] NAGLAZYME INJ 5 [PA] [LD] ORFADIN 5 [PA] [LD] RAVICTI 5 sodium phenylbutyrate 5 powder & tabs SUCRAID 5 VPRIV INJ 5 [PA] ZAVESCA 5 [PA] [LD] GENITOURINARY AGENTS Antispasmodics, Urinary flavoxate 2 [90D] GELNIQUE 3 [90D] MYRBETRIQ 3 [90D] oxybutynin 2 [90D] oxybutynin er 2 [QL] [90D] OXYTROL 4 [90D] tolterodine tartrate er 2 [QL] [90D] TOVIAZ 3 [90D] VESICARE 3 [90D] Benign Prostatic Hypertrophy Agents alfuzosin hcl er 2 [90D] dutasteride 3 [90D] dutasteride & tamsulosin 3 [90D] finasteride tabs 5mg 2 [90D] tamsulosin 2 [90D] Drug Name Drug Requirements/ Tier Limits 藥物名稱 藥物等級 要求 / 限制 Genitourinary Agents, Other bethanechol 2 [90D] ELMIRON 4 [90D] THIOLA 3 [90D] HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (ADRENAL) Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) alclometasone 2 [90D] dipropionate betamethasone 2 [90D] dipropionate betamethasone 2 [90D] dipropionate augmented betamethasone valerate 2 [90D] cream, oint, lotion CAPEX SHAMPOO 4 [90D] clobetasol propionate 4 [90D] cream, foam, gel, oint, soln clotrimazole & 2 [90D] betamethasone cormax scalp application 4 [90D] cortisone 2 [90D] desonide 3 [90D] desoximetasone 3 [90D] dexamethasone tabs 2 [90D] dexamethasone elixir 2 [90D] dexamethasone inj 2 [90D] dexpak 2 [90D] diflorasone diacetate 2 [90D] fludrocortisone acetate 2 [90D] fluocinolone acetonide 3 [90D] fluocinonide-e 2 [90D] fluocinonide gel, oint & 2 [90D] soln fluticasone propionate 2 [90D] cream & oint halobetasol 2 [90D] hydrocortisone 2.5% cream, lotion, oint 2 [90D] [PA] = Prior Authorization [B vs D] = B versus D [QL] = Quantity Limit [ST] = Step Therapy [90D] = 90-Day Supply [LD] = Limited Distribution You can find information on what the symbols and abbreviations on this table mean by going to page

90 Drug Name Drug Requirements/ Tier Limits 藥物名稱 藥物等級 要求 / 限制 hydrocortisone butyrate 2 [90D] oint & soln hydrocortisone oral 2 [90D] hydrocortisone valerate 2 [90D] methylprednisolone oral 2 [90D] methylprednisolone 2 [90D] sodium succinate inj mometasone cream & oint 2 [90D] prednicarbate 2 [90D] prednisolone oral soln 2 [90D] prednisone dose pack 1 [90D] procto-med hc 2 [90D] procto-pak 2 [90D] proctosol hc 2 [90D] proctozone-hc 2 [90D] SOLU-CORTEF INJ 4 [90D] triamcinolone acetonide 2 [90D] topical cream, lotion & oint triderm 2 [90D] HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (PITUITARY) Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary) desmopressin acetate nasal 2 [90D] desmopressin acetate oral 2 [90D] desmopressin acetate inj 2 [90D] GENOTROPIN INJ 5 [PA] GENOTROPIN MINIQUICK INJ 0.2MG, 0.4MG, 0.6MG, 0.8MG GENOTROPIN MINIQUICK INJ 1MG, 1.2MG, 1.4MG, 1.6MG, 1.8MG, & 2MG HUMATROPE INJ 6MG CARTRIDGE HUMATROPE INJ 5MG VIAL, 12MG & 24MG CARTRIDGE 4 [PA] [90D] 5 [PA] 4 [PA] [90D] 5 [PA] INCRELEX INJ 5 [PA] STIMATE 4 [90D] Drug Name Drug Tier 藥物名稱 藥物等級 要求 / 限制 HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (SEX HORMONES/ MODIFIERS) Anabolic Steroids ANADROL-50 5 [PA] oxandrolone 4 [90D] Androgens ANDROGEL 1% GEL PACKET 50MG/5GM Requirements/ Limits 3 [PA] [90D] ANDROGEL 1.62% 3 [PA] [90D] danazol 2 [90D] testosterone cypionate inj 2 [PA] [90D] testosterone enanthate inj 2 [PA] [90D] testosterone gel 3 [PA] [90D] 25mg/2.5g Estrogens ALORA 3 [PA] [90D] alyacen 1/35 2 [90D] amabelz 3 [PA] [90D] apri 2 [90D] aranelle 2 [90D] aubra 2 [90D] aviane 2 [90D] bekyree 2 [90D] blisovi fe 1/20 & 1.5/30 2 [90D] briellyn 2 [90D] caziant 2 [90D] cyclafem 1/35 2 [90D] cyclafem 7/7/7 2 [90D] delyla 2 [90D] desogestrel & ethinyl 2 [90D] estradiol emoquette 2 [90D] enpresse-28 2 [90D] ESTRACE VAGINAL 3 [90D] estradiol oral 2 [PA] [90D] estradiol patches 3 [PA] [90D] estradiol vaginal tabs 3 [90D] estradiol & norethindrone acetate 5mcg/1mg & 2.5mcg-0.5mg 3 [PA] [90D] estropipate 2 [PA] [90D] [PA] = 事先授權 [B vs D] = B 與 D [QL] = 數量限制 [ST] = 階段療法 [90D] = 90 天份量 [LD] = 限量分配您可以前往第 67 頁, 找到本表中的符號和縮寫詞所代表含義的相關資訊 88

91 Drug Name Drug Requirements/ Tier Limits 藥物名稱 藥物等級 要求 / 限制 ethinyl estradiol & 2 [90D] ethynodiol ethinyl estradiol, ferrous 2 [90D] fumarate & norethindrone falmina 2 [90D] femynor 2 [90D] fyavolv 3 [PA] [90D] gildagia 2 [90D] introvale 2 [90D] isibloom 2 [90D] jinteli 3 [PA] [90D] junel 2 [90D] kariva 2 [90D] kimidess 2 [90D] larin 2 [90D] larin fe 2 [90D] larissia 2 [90D] leena 2 [90D] levonest 2 [90D] levonorgestrel & ethinyl 2 [90D] estradiol mg, mg packs levora 2 [90D] low-ogestrel 2 [90D] marlissa 28 day 2 [90D] MENEST 4 [PA] [90D] microgestin 1/20 & 1.5/30 2 [90D] mimvey 3 [PA] [90D] mimvey lo 3 [PA] [90D] necon 2 [90D] norgestimate-ethinyl 2 [90D] estradiol orsythia 28 day 2 [90D] pimtrea 2 [90D] pirmella 1/35 2 [90D] PREMARIN ORAL 4 [PA] [90D] PREMARIN VAGINAL 3 [90D] PREMPHASE 4 [PA] [90D] PREMPRO 4 [PA] [90D] setlakin 2 [90D] tarina fe 2 [90D] [PA] = Prior Authorization [B vs D] = B versus D [QL] = Quantity Limit [ST] = Step Therapy [90D] = 90-Day Supply [LD] = Limited Distribution You can find information on what the symbols and abbreviations on this table mean by going to page Drug Name Drug Requirements/ Tier Limits 藥物名稱 藥物等級 要求 / 限制 tri-lo-estarylla 2 [90D] tri-lo-sprintec 2 [90D] tri-sprintec 2 [90D] trivora-28 2 [90D] velivet 2 [90D] vienva 2 [90D] vyfemla 2 [90D] wymzya fe 2 [90D] yuvafem 3 [90D] zenchent 2 [90D] zenchent fe 2 [90D] zovia 2 [90D] Progesterone Agonists/Antagonists KORLYM 5 [PA] Progestins deblitane 2 [90D] DEPO-PROVERA INJ 4 [90D] 400MG/ML hydroxyprogesterone 5 caproate lyza 2 [90D] medroxyprogesterone 2 [90D] acetate inj medroxyprogesterone 2 [90D] acetate tabs megestrol acetate oral 2 [90D] susp 40mg/ml megestrol tabs 2 [90D] norethindrone 2 [90D] norlyroc 2 [90D] progesterone caps 2 [90D] sharobel 2 [90D] Selective Estrogen Receptor Modifying Agents raloxifene hcl 3 [QL] [90D] HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (THYROID) Hormonal Agents, Stimulant/ Replacement/ Modifying (Thyroid) CYTOMEL 3 [90D] levothyroxine tabs 1 [90D] levoxyl 1 [90D]

92 Drug Name Drug Requirements/ Tier Limits 藥物名稱 藥物等級 要求 / 限制 liothyronine tabs 2 [90D] SYNTHROID 3 [90D] THYROLAR 3 [90D] TYMLOS 5 [PA] unithroid 1 [90D] HORMONAL AGENTS, SUPPRESSANT (ADRENAL) Hormonal Agents, Suppressant (Adrenal) LYSODREN 3 [90D] HORMONAL AGENTS, SUPPRESSANT (PITUITARY) Hormonal Agents, Suppressant (Pituitary) cabergoline 2 [90D] ELIGARD INJ 4 [PA] [90D] leuprolide acetate inj 2 [PA] [90D] LUPRON DEPOT INJ 5 [PA] octreotide inj 50mcg/ml, 2 [90D] 100mcg/ml & 200mcg/ml octreotide inj 500mcg/ml & mcg/ml SIGNIFOR INJ 5 [PA] SOMATULINE DEPOT 5 [PA] INJ SOMAVERT INJ 5 [PA] SYNAREL 4 [90D] TRELSTAR MIXJECT 5 [PA] HORMONAL AGENTS, SUPPRESSANT (THYROID) Antithyroid Agents methimazole 2 [90D] propylthiouracil 2 [90D] IMMUNOLOGICAL AGENTS Angioedema Agents CINRYZE INJ 5 [PA] [B vs D] FIRAZYR INJ 5 [PA] Immune Suppressants azathioprine inj 2 [PA] [B vs D] [90D] azathioprine oral 2 [PA] [B vs D] [90D] BENLYSTA INJ 5 [PA] Drug Name Drug Requirements/ Tier Limits 藥物名稱 藥物等級 要求 / 限制 cyclosporine modified 2 [PA] [B vs D] [90D] cyclosporine oral 2 [PA] [B vs D] [90D] ENBREL INJ 5 [PA] ENBREL MINI 5 [PA] CARTRIDGE ENBREL SURECLICK INJ 5 [PA] gengraf 2 [PA] [B vs D] [90D] HUMIRA INJ 5 [PA] HUMIRA PEDIATRIC 5 [PA] CROHNS INJ HUMIRA PEN-CROHNS 5 [PA] INJ HUMIRA PEN- 5 [PA] PSORIASIS INJ HUMIRA PEN INJ 5 [PA] KINERET INJ 5 [PA] methotrexate inj 2 [90D] methotrexate oral 2 [90D] mycophenolate mofetil caps & tabs 2 [PA] [B vs D] [90D] mycophenolate mofetil inj 4 [PA] [B vs D] [90D] mycophenolate mofetil oral 5 [PA] [B vs D] susp mycophenolic acid dr 4 [PA] [B vs D] [90D] NEORAL 4 [PA] [B vs D] [90D] NULOJIX INJ 5 [PA] RAPAMUNE SOLN 4 [PA] [B vs D] [90D] REMICADE INJ 5 [PA] SANDIMMUNE ORAL SOLN 100MG/ML 4 [PA] [B vs D] [90D] SANDIMMUNE CAPS 25MG & 100MG 4 [PA] [B vs D] [90D] sirolimus tabs 4 [PA] [B vs D] [90D] tacrolimus caps 0.5mg & 1mg 3 [PA] [B vs D] [90D] [PA] = 事先授權 [B vs D] = B 與 D [QL] = 數量限制 [ST] = 階段療法 [90D] = 90 天份量 [LD] = 限量分配您可以前往第 67 頁, 找到本表中的符號和縮寫詞所代表含義的相關資訊 90

93 Drug Name Drug Requirements/ Tier Limits 藥物名稱 藥物等級 要求 / 限制 tacrolimus caps 5mg 4 [PA] [B vs D] [90D] XATMEP 4 [90D] ZORTRESS TABS 0.25MG 4 [PA] [B vs D] [90D] ZORTRESS TABS 0.5MG & 0.75MG 5 [PA] [B vs D] Immunizing Agents, Passive ATGAM INJ 5 [PA] GAMMAGARD INJ 5 [PA] [B vs D] GAMUNEX-C INJ 5 [PA] [B vs D] Immunomodulators ACTIMMUNE INJ 5 ARCALYST INJ 5 [PA] ILARIS INJ 5 [PA] leflunomide 2 [QL] [90D] OTEZLA 5 [PA] OTEZLA STARTER 5 [PA] RIDAURA 5 SYNAGIS INJ 5 XELJANZ 5 [PA] XELJANZ XR 5 [PA] Vaccines ACTHIB INJ 3 [90D] ADACEL INJ 3 [90D] BCG INJ 3 [90D] BEXSERO INJ 3 [90D] BOOSTRIX INJ 3 [90D] DAPTACEL INJ 3 [90D] DIPHTHERIA & TETANUS 3 [90D] TOXOIDS PEDIATRIC INJ ENGERIX-B INJ 3 [PA] [B vs D] [90D] GARDASIL 9 INJ 4 [90D] HAVRIX INJ 3 [90D] HIBERIX INJ 3 [90D] IMOVAX RABIES INJ 3 [90D] INFANRIX INJ 3 [90D] IPOL INACTIVATED IPV 3 [90D] INJ IXIARO INJ 4 [90D] [PA] = Prior Authorization [B vs D] = B versus D [QL] = Quantity Limit [ST] = Step Therapy [90D] = 90-Day Supply [LD] = Limited Distribution You can find information on what the symbols and abbreviations on this table mean by going to page Drug Name Drug Requirements/ Tier Limits 藥物名稱 藥物等級 要求 / 限制 KINRIX INJ 3 [90D] MENACTRA INJ 3 [90D] MENOMUNE-A/C/Y/W- 3 [90D] 135 INJ MENVEO-A/C/Y/W [90D] INJ M-M-R II INJ 3 [90D] PEDIARIX INJ 3 [90D] PEDVAX HIB INJ 3 [90D] PROQUAD INJ 3 [90D] QUADRACEL INJ 3 [90D] RABAVERT INJ 3 [90D] RECOMBIVAX HB INJ 3 [PA] [B vs D] [90D] ROTARIX 3 [90D] ROTATEQ 3 [90D] SHINGRIX 3 [90D] TENIVAC 3 [90D] TETANUS & DIPHTHERIA 3 [90D] TOXOIDS-ADSORBED ADULT INJ TRUMENBA INJ 3 [90D] TWINRIX INJ 3 [90D] TYPHIM VI INJ 3 [90D] VAQTA INJ 3 [90D] VARIVAX INJ 3 [90D] VARIZIG INJ 4 [90D] YF-VAX INJ 3 [90D] ZOSTAVAX INJ 4 [90D] INFLAMMATORY BOWEL DISEASE AGENTS Aminosalicylates APRISO 4 [QL] [90D] balsalazide 3 [90D] DELZICOL 3 [90D] DIPENTUM 5 mesalamine enema kit 4 [90D] PENTASA 4 [QL] [90D] Glucocorticoids budesonide ec caps 5 [PA] hydrocortisone enema 2 [90D] prednisone tabs 1 [90D]

94 Drug Name Drug Requirements/ Tier Limits 藥物名稱 藥物等級 要求 / 限制 prednisone oral soln 2 [90D] Sulfonamides sulfasalazine 2 [90D] METABOLIC BONE DISEASE AGENTS Metabolic Bone Disease Agents alendronate tabs 1 [90D] alendronate oral soln 2 [90D] calcitonin-salmon nasal 2 [90D] calcitriol caps 2 [PA] [B vs D] [90D] doxercalciferol oral 3 [PA] [B vs D] [90D] doxercalciferol inj 3 [PA] [B vs D] [90D] etidronate 2 [90D] FORTEO INJ 5 [PA] ibandronate inj 2 [PA] [B vs D] [90D] ibandronate oral 2 [90D] MIACALCIN INJ 4 [PA] [B vs D] [90D] pamidronate inj 2 [PA] [B vs D] [90D] paricalcitol caps 2 [PA] [B vs D] [90D] PROLIA 4 [PA] [90D] risedronate sodium 3 [ST] [90D] risedronate sodium dr 3 [ST] [90D] SENSIPAR TABS 30MG 3 [PA] [B vs D] [QL] [90D] SENSIPAR TABS 60MG & 5 [PA] [B vs D] 90MG XGEVA INJ 5 [PA] zoledronic acid inj 4 [90D] 4mg/5ml zoledronic acid inj 2 [PA] [90D] 5mg/100ml ZOMETA INJ 4MG/100ML 5 MISCELLANEOUS THERAPEUTIC AGENTS Miscellaneous Therapeutic Agents alcohol pads 2 [90D] bd insulin syringe ultrafine 2 [90D] Drug Name Drug Requirements/ Tier Limits 藥物名稱 藥物等級 要求 / 限制 bd insulin syringe 2 [90D] safetyglide bd pen needle ultrafine 2 [90D] FERRIPROX 5 [PA] gauze pads 2"x2" 2 [90D] INTRALIPID INJ 4 [PA] [B vs D] [90D] levocarnitine oral 2 [PA] [B vs D] [90D] NATPARA 5 [PA] [LD] OPHTHALMIC AGENTS Ophthalmic Agents, Other atropine sulfate soln 2 [90D] CYSTARAN 5 LACRISERT 4 [90D] RESTASIS 3 [PA] [90D] XIIDRA 4 [PA] [90D] Ophthalmic Anti-allergy Agents azelastine 2 [90D] cromolyn sodium 2 [90D] ophthalmic soln olopatadine soln 0.1% 2 [QL] [90D] olopatadine soln 0.2% 3 [90D] Ophthalmic Anti-inflammatories BLEPHAMIDE 3 [90D] BLEPHAMIDE S.O.P. 3 [90D] dexamethasone 2 [90D] ophthalmic soln diclofenac sodium 2 [90D] ophthalmic soln DUREZOL 3 [90D] fluorometholone 2 [90D] ketorolac soln 0.4% & 2 [90D] 0.5% neomycin & polymyxin & 2 [90D] dexamethasone neomycin & polymyxin & 2 [90D] bacitracin & hydrocortisone PRED MILD 3 [90D] prednisolone acetate 2 [90D] [PA] = 事先授權 [B vs D] = B 與 D [QL] = 數量限制 [ST] = 階段療法 [90D] = 90 天份量 [LD] = 限量分配您可以前往第 67 頁, 找到本表中的符號和縮寫詞所代表含義的相關資訊 92

95 Drug Name Drug Requirements/ Tier Limits 藥物名稱 藥物等級 要求 / 限制 prednisolone sodium phosphate 2 [90D] Ophthalmic Antiglaucoma Agents acetazolamide tabs 2 [90D] acetazolamide er caps 2 [90D] ALPHAGAN P 0.1% 3 [90D] betaxolol soln 2 [90D] brimonidine tartrate soln 2 [90D] 0.15% & 0.2% carteolol 1 [90D] COMBIGAN 3 [ST] [90D] dorzolamide 2 [90D] dorzolamide & timolol 2 [90D] maleate levobunolol 2 [90D] methazolamide 4 [90D] metipranolol 2 [90D] PHOSPHOLINE IODIDE 3 [90D] pilocarpine soln 2 [90D] timolol ophthalmic gel 2 [90D] forming timolol soln 1 [90D] Ophthalmic Prostaglandin and Prostamide Analogs latanoprost 1 [90D] LUMIGAN 3 [ST] [90D] OTIC AGENTS Otic Agents acetasol hc 2 [90D] acetic acid & 2 [90D] hydrocortisone neomycin & polymyxin & hydrocortisone 2 [90D] RESPIRATORY TRACT/PULMONARY AGENTS Antihistamines azelastine nasal 2 [90D] cyproheptadine 2 [PA] [90D] desloratadine 2 [90D] desloratadine odt 2 [90D] diphenhydramine hcl inj 2 [90D] hydroxyzine hcl tabs 2 [PA] [90D] [PA] = Prior Authorization [B vs D] = B versus D [QL] = Quantity Limit [ST] = Step Therapy [90D] = 90-Day Supply [LD] = Limited Distribution You can find information on what the symbols and abbreviations on this table mean by going to page Drug Name Drug Requirements/ Tier Limits 藥物名稱 藥物等級 要求 / 限制 levocetirizine 2 [90D] Anti-inflammatories, Inhaled Corticosteroids ADVAIR DISKUS 3 [90D] ADVAIR HFA 3 [90D] ASMANEX HFA 3 [90D] ASMANEX TWISTHALER 3 [90D] BREO ELLIPTA 3 [90D] budesonide nebulizer 2 [PA] [B vs D] [90D] DULERA 3 [90D] flunisolide nasal 2 [QL] [90D] fluticasone propionate 2 [QL] [90D] nasal mometasone furoate nasal 3 [QL] [90D] PULMICORT NEBULIZER 4 [PA] [B vs D] [90D] QVAR 3 [90D] Antileukotrienes montelukast 2 [90D] zafirlukast 2 [QL] [90D] zileuton er 5 Bronchodilators, Anticholinergic ATROVENT HFA 3 [QL] [90D] COMBIVENT RESPIMAT 3 [90D] ipratropium bromide nasal 2 [QL] [90D] ipratropium bromide 2 [PA] [B vs D] nebulizer [90D] ipratropium bromide & 2 [PA] [B vs D] albuterol sulfate nebulizer [90D] SPIRIVA HANDIHALER 3 [90D] SPIRIVA RESPIMAT 3 [90D] TUDORZA PRESSAIR 3 [90D] Bronchodilators, Sympathomimetic albuterol sulfate nebulizer 2 [PA] [B vs D] [90D] albuterol sulfate er 3 [90D] albuterol sulfate syrup 2 [90D] albuterol sulfate tabs 3 [90D] BEVESPI AEROSPHERE 3 [90D] BROVANA NEBULIZER 4 [PA] [B vs D] [90D]

96 Drug Name 藥物名稱 EPINEPHRINE AUTO- INJECTOR 0.15MG/0.3ML & 0.3MG/0.3ML Drug Requirements/ Tier Limits 藥物要求 / 限制等級 3 [90D] levalbuterol nebulizer 2 [PA] [B vs D] [90D] PERFOROMIST NEBULIZER 4 [PA] [B vs D] [90D] PROAIR HFA 3 [90D] PROAIR RESPICLICK 3 [90D] SEREVENT DISKUS 3 [90D] STRIVERDI RESPIMAT 3 [90D] terbutaline sulfate oral 2 [90D] terbutaline sulfate inj 2 [90D] XOPENEX NEBULIZER 4 [PA] [B vs D] [90D] Cystic Fibrosis Agents BETHKIS 5 [PA] [B vs D] CAYSTON 5 [PA] [LD] KALYDECO 5 [PA] ORKAMBI 5 [PA] PULMOZYME 5 [PA] [B vs D] TOBI 5 [PA] [B vs D] TOBI PODHALER 5 tobramycin nebulizer 5 [PA] [B vs D] Mast Cell Stabilizers cromolyn sodium nebulizer soln 4 [PA] [B vs D] [90D] Phosphodiesterase Inhibitors, Airways Disease aminophylline inj 2 [90D] DALIRESP 3 [90D] theophylline cr & er tabs 2 [90D] Pulmonary Antihypertensives ADCIRCA 5 [PA] ADEMPAS 5 [PA] [LD] LETAIRIS 5 [PA] [LD] OPSUMIT 5 [PA] [LD] REMODULIN INJ 5 [PA] sildenafil tabs 20mg 3 [PA] [90D] TRACLEER 5 [PA] [LD] UPTRAVI 5 [PA] VENTAVIS 5 [PA] [B vs D] Drug Name Drug Requirements/ Tier Limits 藥物名稱 藥物等級 要求 / 限制 Pulmonary Fibrosis Agents ESBRIET 5 [PA] OFEV 5 [PA] Respiratory Tract Agents, Other acetylcysteine nebulizer 2 [PA] [B vs D] [90D] ANORO ELLIPTA 3 [90D] PROLASTIN C INJ 5 [PA] [LD] STIOLTO RESPIMAT 3 [90D] SKELETAL MUSCLE RELAXANTS Skeletal Muscle Relaxants chlorzoxazone 500mg tabs 2 [PA] [90D] cyclobenzaprine hcl 2 [PA] [90D] methocarbamol tabs 2 [PA] [90D] SLEEP DISORDER AGENTS GABA Receptor Modulators estazolam 2 [90D] flurazepam 2 [90D] temazepam 2 [90D] triazolam 2 [90D] zolpidem tabs 5mg & 2 [PA] [90D] 10mg Sleep Disorders, Other BELSOMRA 3 [QL] [90D] modafinil 4 [PA] [90D] ROZEREM 3 [QL] [90D] SILENOR 3 [QL] [90D] XYREM 5 [PA] [LD] [PA] = 事先授權 [B vs D] = B 與 D [QL] = 數量限制 [ST] = 階段療法 [90D] = 90 天份量 [LD] = 限量分配您可以前往第 67 頁, 找到本表中的符號和縮寫詞所代表含義的相關資訊 94

97 FORMULARY DRUGS WITH QUANTITY LIMITS 有數量限制的藥物 Drugs with Quantity Limits 有數量限制的藥物 Drug Name 藥物名稱 Quantity Limits 數量限制 acetaminophen & codeine #2 & #3 tabs 360 tabs per 30 days acetaminophen & codeine #4 tabs 180 tabs per 30 days acetaminophen & codeine elixir 5000ml per 30 days amphetamine & dextroamphetamine 60 tabs per 30 days APRISO 120 caps per 30 days ATROVENT HFA 2 inhalers per 30 days BELSOMRA 30 tabs per 30 days BRILINTA 60 tabs per 30 days butorphanol tartrate nasal 4 bottles per 30 days calcipotriene cream 60gm: 2 tube per 30 days; 120gm: 1 tube per 30 days calcipotriene oint 60gm: 2 tubes per 30 days COLCHICINE 120 caps or tabs per 30 days COLCRYS 120 tabs per 30 days dextroamphetamine sulfate 5mg: 120 tabs per 30 days; 10mg: 180 tabs per 30 days dextroamphetamine sulfate er 5mg: 30 caps per 30 days; 10mg & 15mg: 120 caps per 30 days dipyridamole er & aspirin 60 caps per 30 days ELIDEL 100gm: 2 tubes per 30 days endocet tabs 5-325mg, mg, mg 5-325mg: 360 tabs per 30 days; mg: 240 tabs per 30 days; mg: 180 tabs per 30 days fenofibrate 30 caps or tabs per 30 days fenofibrate micronized 30 caps per 30 days fenofibric acid dr 45mg: 60 caps per 30 days; 135mg: 30 caps per 30 days fentanyl patches 15 patches per 30 days flunisolide nasal 2 bottles per 30 days fluticasone propionate nasal 2 bottles per 30 days galantamine 60 tabs per 30 days galantamine er 30 caps per 30 days galantamine oral soln 200ml per 30 days glimepiride & pioglitazone tabs 30 tabs per 30 days hydrocodone & acetaminophen soln ml per 30 days 325mg/15ml hydrocodone & acetaminophen tabs 5-325mg, mg, & mg 5-325mg: 360 tabs per 30 days; mg & mg: 180 tabs per 30 days SCAN Health Plan 2018 Formulary 95

98 Drugs with Quantity Limits 有數量限制的藥物 Drug Name 藥物名稱 Quantity Limits 數量限制 hydrocodone & ibuprofen tabs 5-200mg, tabs per 30 days 200mg, & mg ipratropium bromide nasal 1 bottle per 30 days leflunomide 30 tabs per 30 days lorcet hd tabs mg 180 tabs per 30 days lorcet plus tabs mg 180 tabs per 30 days lorcet tabs 5-325mg 360 tabs per 30 days lortab tabs 5-325mg, mg, & mg 5-325mg: 360 tabs per 30 days; mg & mg: 180 tabs per 30 days mometasone furoate nasal 3 bottles per 30 days morphine sulfate er tabs 120 tabs per 30 days naratriptan 9 tabs per 30 days NEUPRO PATCH 30 patches per 30 days niacin er tabs 500mg: 90 tabs per 30 days; 750mg & 1000mg: 60 tabs per 30 days olopatadine soln 0.1% 3 bottles per 30 days oxybutynin er 5mg: 30 tabs per 30 days; 10mg & 15mg: 60 tabs per 30 days oxycodone & acetaminophen tabs mg, 5-325mg, mg, & mg mg & 5-325mg: 360 tabs per 30 days; mg: 240 tabs per 30 days; mg: 180 tabs per 30 days oxycodone & aspirin tabs 360 tabs per 30 days oxycodone & ibuprofen tabs 120 tabs per 30 days OXYCODONE ER 60 tabs per 30 days OXYCONTIN 60 tabs per 30 days oxymorphone er 60 tabs per 30 days PENTASA 240 caps per 30 days raloxifene hcl 30 tabs per 30 days REGRANEX 2 tubes per 30 days rivastigmine caps 60 caps per 30 days rivastigmine patches 30 patches per 30 days ROZEREM 30 tabs per 30 days SENSIPAR TABS 30MG 60 tabs per 30 days SILENOR 30 tabs per 30 days TAZORAC GEL 30gm: 3 tubes per 30 days; 100gm: 1 tube per 30 days tolterodine tartrate er 30 caps per 30 days tramadol & acetaminophen mg tabs 240 tabs per 30 days tramadol er 30 tabs per 30 days XIFAXAN TABS 200MG 9 tabs per 3 days zafirlukast 60 tabs per 30 days SCAN Health Plan 2018 Formulary 96

99 Drugs with Quantity Limits 有數量限制的藥物 Drug Name Quantity Limits 藥物名稱數量限制 zamicet 2700ml per 30 days zenzedi tabs 5mg & 10mg 5mg: 120 tabs per 30 days; 10mg: 180 tabs per 30 days ZOMIG NASAL 2.5mg: 18 single use units per 30 days; 5mg: 12 single use units per 30 days SCAN Health Plan 2018 Formulary 97

100 INDEX abacavir & lamivudine, 79 abacavir & lamivudine & zidovudine, 79 abacavir soln, 79 abacavir tabs, 79 ABELCET INJ, 74 ABILIFY MAINTENA, 78 acamprosate calcium dr, 69 acarbose, 80 acebutolol, 82 acetaminophen & codeine, 69, 95 acetasol hc, 93 acetazolamide, 93 acetazolamide er caps, 93 acetazolamide tabs, 93 acetic acid & hydrocortisone, 93 acetylcysteine nebulizer, 94 acitretin, 85 ACTHIB INJ, 91 ACTIMMUNE INJ, 91 acyclovir inj, 79 acyclovir oint 5%, 79 acyclovir oral, 79 ADACEL INJ, 91 ADAGEN INJ, 87 adapalene, 85 ADCIRCA, 94 adefovir dipivoxil, 78 ADEMPAS, 94 ADVAIR DISKUS, 93 ADVAIR HFA, 93 afeditab cr, 83 AFINITOR, 76 AFINITOR DISPERZ, 76 ALBENZA, 77 albuterol sulfate er, 93 albuterol sulfate nebulizer, 93 albuterol sulfate syrup, 93 albuterol sulfate tabs, 93 alclometasone dipropionate, 87 alcohol pads, 92 ALDURAZYME INJ, 87 ALECENSA, 76 alendronate oral soln, 92 alendronate tabs, 92 alfuzosin hcl er, 87 ALIMTA INJ, 76 ALINIA, 77 allopurinol tab, 75 ALORA, 88 alosetron hcl tabs, 86 ALPHAGAN P 0.1%, 93 alprazolam er tabs, 80 alprazolam intensol, 80 alprazolam tabs, 80 ALUNBRIG, 76 alyacen 1/35, 88 amabelz, 88 amantadine, 77 AMBISOME INJ, 74 amikacin inj, 70 amiloride, 83 amiloride & hydrochlorothiazide, 83 aminophylline inj, 94 AMINOSYN & ELECTROLYTES INJ, 85 AMINOSYN INJ, 85 amiodarone tabs, 82 AMITIZA, 86 amitriptyline, 74 amlodipine, 83 amlodipine & atorvastatin, 83 amlodipine & benazepril, 83 ammonium lactate topical, 85 amnesteem caps, 85 amoxapine, 74 amoxicillin, 71 amoxicillin & clavulanate potassium, 71 amoxicillin & clavulanate potassium er, 71 amphetamine & dextroamphetamine, 95 amphetamine & dextroamphetamine tabs, 84 amphotericin b inj, 74 SCAN Health Plan 2018 Formulary 98

101 ampicillin & sulbactam inj 10-5gm, 2-1gm, & 1-0.5gm, 71 ampicillin inj, 71 ampicillin oral, 71 AMPYRA, 84 ANADROL-50, 88 anagrelide, 81 anastrozole, 76 ANDROGEL 1% GEL PACKET 50MG/5GM, 88 ANDROGEL 1.62%, 88 ANORO ELLIPTA, 94 APOKYN INJ, 77 aprepitant caps 80mg & 125mg, 74 aprepitant pack, 74 apri, 88 APRISO, 91, 95 APTIOM, 73 APTIVUS, 79 aranelle, 88 ARCALYST INJ, 91 aripiprazole, 78 aripiprazole 20mg & 30mg, 78 aripiprazole odt, 78 ARISTADA INJ, 78 ASMANEX HFA, 93 ASMANEX TWISTHALER, 93 atenolol, 82 atenolol & chlorthalidone, 82 ATGAM INJ, 91 atomoxetine, 84 atorvastatin, 83 atovaquone, 77 atovaquone/proguanil, 77 ATRIPLA, 79 atropine sulfate inj, 86 atropine sulfate soln, 92 ATROVENT HFA, 93, 95 AUBAGIO, 84 aubra, 88 AUSTEDO, 84 AVASTIN INJ, 77 aviane, 88 AVONEX INJ, 84 AVONEX PEN INJ, 84 azacitidine inj, 76 AZASITE, 71 azathioprine inj, 90 azathioprine oral, 90 azelastine, 92 azelastine nasal, 93 azithromycin inj, 71 azithromycin tabs & oral susp, 71 aztreonam inj 1gm, 71 bacitracin & polymyxin b ointment, 70 bacitracin ointment, 70 baclofen, 78 BACTROBAN CREAM, 70 BACTROBAN NASAL, 70 balsalazide, 91 BANZEL, 73 BARACLUDE ORAL SOLN 0.05MG/ML, 78 BCG INJ, 91 bd insulin syringe safetyglide, 92 bd insulin syringe ultrafine, 92 bd pen needle ultrafine, 92 bekyree, 88 BELEODAQ, 76 BELSOMRA, 94, 95 benazepril, 82 benazepril & hydrochlorothiazide, 82 BENLYSTA INJ, 90 benztropine inj, 77 benztropine tabs, 77 betamethasone dipropionate, 87 betamethasone dipropionate augmented, 87 betamethasone valerate cream, oint, lotion, 87 BETASERON INJ, 84 betaxolol soln, 93 bethanechol, 87 BETHKIS, 94 BEVESPI AEROSPHERE, 93 bexarotene, 77 BEXSERO INJ, 91 bicalutamide, 75 BICILLIN L-A INJ, 71 bisoprolol, 82 SCAN Health Plan 2018 Formulary 99

102 bisoprolol & hydrochlorothiazide, 82 BLEPHAMIDE, 92 BLEPHAMIDE S.O.P., 92 blisovi fe 1/20 & 1.5/30, 88 BOOSTRIX INJ, 91 BOSULIF 100 MG TAB, 76 BOSULIF 500 MG TAB, 76 BREO ELLIPTA, 93 briellyn, 88 BRILINTA, 81, 95 brimonidine tartrate soln 0.15% & 0.2%, 93 BRISDELLE, 73 BRIVIACT INJ, 72 BRIVIACT ORAL SOLN, 72 BRIVIACT TABS, 72 bromocriptine, 77 BROVANA NEBULIZER, 93 budesonide ec caps, 91 budesonide nebulizer, 93 bumetanide oral, 83 BUPHENYL TABS, 87 buprenorphine & naloxone sublingual tabs, 69 buprenorphine inj, 69 buprenorphine oral, 69 bupropion, 73 bupropion sr, 73 bupropion sr 150mg, 70 bupropion xl, 73 buspirone, 80 butorphanol tartrate inj, 69 butorphanol tartrate nasal, 69, 95 BYDUREON INJ, 80 BYETTA INJ, 80 BYSTOLIC, 82 cabergoline, 90 CABOMETYX, 76 caffeine-ergotamine, 75 calcipotriene & betamethasone oint, 85 calcipotriene cream, 95 calcipotriene cream & oint, 85 calcipotriene oint, 95 calcipotriene soln, 85 calcitonin-salmon nasal, 92 calcitriol caps, 92 SCAN Health Plan 2018 Formulary 100 calcium acetate, 86 CALQUENCE, 76 CANCIDAS INJ, 74 CAPASTAT INJ, 75 CAPEX SHAMPOO, 87 CAPRELSA, 76 captopril, 82 captopril & hydrochlorothiazide, 82 CARAC, 85 CARBAGLU, 85 carbamazepine er tabs & caps, 73 carbamazepine tabs, chewable tabs & oral susp, 73 carbidopa, 77 carbidopa & levodopa, 77 carbidopa & levodopa & entacapone, 77 carbidopa & levodopa er, 77 carbidopa & levodopa odt, 77 carteolol, 93 cartia xt, 83 carvedilol, 82 caspofungin inj 50mg, 74 CAYSTON, 94 caziant, 88 cefaclor, 71 cefaclor er, 71 cefadroxil caps & tabs, 71 cefazolin inj, 71 cefdinir, 71 cefepime inj, 71 cefixime, 71 cefoxitin sodium, 71 cefpodoxime tabs, 71 cefprozil, 71 ceftazidime inj 1gm, 2gm & 6gm, 71 ceftriaxone inj, 71 cefuroxime inj, 71 cefuroxime oral, 71 celecoxib, 70 CELONTIN, 72 cephalexin caps & tabs 250mg & 500mg, 71 cephalexin oral susp, 71 CERDELGA, 87 cevimeline, 84

103 CHANTIX, 70 CHANTIX STARTING MONTH PAK, 70 chloramphenicol sodium succinate inj, 70 chlorhexidine gluconate, 84 chloroquine, 77 chlorothiazide tabs, 83 chlorpromazine inj, 77 chlorpromazine oral, 77 chlorthalidone, 83 chlorzoxazone 500mg tabs, 94 cholestyramine, 83, 84 cholestyramine light, 84 ciclopirox 8% nail soln, 74 ciclopirox cream, susp, shampoo, 74 cilastatin/imipenem inj, 71 cilostazol, 81 cimetidine oral, 86 CINRYZE INJ, 90 CIPRO HC, 72 CIPRODEX, 72 ciprofloxacin inj, 72 ciprofloxacin ophthalmic soln 0.3%, 72 ciprofloxacin oral susp, 72 ciprofloxacin tabs er, 72 ciprofloxacin tabs immediate-release, 72 citalopram oral soln, 73 citalopram tabs, 73 claravis, 85 clarithromycin, 71 clarithromycin er, 71 CLEOCIN VAGINAL, 70 clindamycin & benzoyl peroxide topical, 85 clindamycin oral, 70 clindamycin phosphate inj, 70 clindamycin topical cream, gel, lotion, soln & swab, 70 CLINISOL SF INJ, 85 clobetasol propionate cream, foam, gel, oint, soln, 87 clomipramine, 74 clonazepam, 72 clonazepam odt, 72 clonidine er, 84 clonidine patches, 81 clonidine tabs immediate-release, 81 clopidogrel tabs 75mg, 81 clorazepate, 80 clotrimazole & betamethasone, 87 clotrimazole 1% cream, 74 clotrimazole 1% topical soln, 74 clotrimazole troche, 74 clozapine, 78 clozapine odt, 78 COARTEM, 77 codeine, 69 COLCHICINE, 75 COLCHICINE, 95 COLCRYS, 75, 95 colestipol granules, 84 colestipol tabs, 84 colistimethate inj, 70 COMBIGAN, 93 COMBIVENT RESPIMAT, 93 COMETRIQ, 76 COMPLERA, 79 compro, 74 constulose soln, 86 COPAXONE INJ 40MG/ML, 84 COREG CR, 82 CORLANOR, 83 cormax scalp application, 87 cortisone, 87 CORTISPORIN CREAM & OINT, 70 COTELLIC, 76 COUMADIN ORAL, 81 CREON DR, 87 CRESEMBA INJ, 75 CRESEMBA ORAL, 75 CRIXIVAN, 79 cromolyn sodium nebulizer soln, 94 cromolyn sodium ophthalmic soln, 92 cromolyn sodium oral, 86 CUPRIMINE, 85 cyclafem 1/35, 88 cyclafem 7/7/7, 88 cyclobenzaprine hcl, 94 SCAN Health Plan 2018 Formulary 101

104 cyclophosphamide caps, 75 CYCLOSET, 80 cyclosporine modified, 90 cyclosporine oral, 90 cyproheptadine, 93 CYSTADANE, 87 CYSTAGON, 87 CYSTARAN, 92 CYTOMEL, 89 DALIRESP, 94 danazol, 88 dapsone tabs, 75 DAPTACEL INJ, 91 daptomycin inj, 70 DARAPRIM, 77 deblitane, 89 delyla, 88 DELZICOL, 91 demeclocycline, 72 DEMSER, 83 DENAVIR, 79 DEPEN TITRATABS, 85 DEPO-PROVERA INJ 400MG/ML, 89 DESCOVY, 79 desipramine, 74 desloratadine, 93 desloratadine odt, 93 desmopressin acetate inj, 88 desmopressin acetate nasal, 88 desmopressin acetate oral, 88 desogestrel & ethinyl estradiol, 88 desonide, 87 desoximetasone, 87 DESVENLAFAXINE ER, 73 desvenlafaxine succinate er, 73 dexamethasone elixir, 87 dexamethasone inj, 87 dexamethasone ophthalmic soln, 92 dexamethasone tabs, 87 dexmethylphenidate ir tabs, 84 dexpak, 87 dextroamphetamine sulfate, 84, 95 dextroamphetamine sulfate er, 84, 95 dextrose & lactated ringers inj, 85 SCAN Health Plan 2018 Formulary 102 dextrose & sodium chloride inj, 85 dextrose inj, 85 DIASTAT, 72 diazepam intensol, 80 diazepam rectal, 72 diazepam tabs & soln, 80 diclofenac potassium, 70 diclofenac sodium, 70 diclofenac sodium dr, 70 diclofenac sodium er, 70 diclofenac sodium gel 1%, 85 diclofenac sodium gel 3%, 85 diclofenac sodium ophthalmic soln, 92 dicloxacillin sodium, 71 dicyclomine oral, 86 didanosine, 79 diflorasone diacetate, 87 diflunisal, 70 digitek, 83 digoxin inj, 83 digoxin oral, 83 dihydroergotamine mesylate inj, 75 dilantin caps 100mg, 73 DILANTIN CAPS 30MG, 73 DILANTIN INFATABS, 73 DILANTIN SUSP, 73 diltiazem cd caps,, 83 diltiazem er caps, 83 diltiazem inj 50mg/10ml, 83 diltiazem tabs, 83 dilt-xr, 83 DIPENTUM, 91 diphenhydramine hcl inj, 93 diphenoxylate & atropine, 86 DIPHTHERIA & TETANUS TOXOIDS PEDIATRIC INJ, 91 dipyridamole er & aspirin, 95 dipyridamole er & aspirin, 81 dipyridamole oral, 81 disopyramide phosphate, 82 disulfiram, 69 divalproex sodium, 72 divalproex sodium dr, 72 divalproex sodium er, 72

105 dofetilide, 82 donepezil odt, 73 donepezil tabs 5mg & 10mg, 73 dorzolamide, 93 dorzolamide & timolol maleate, 93 doxazosin, 82 doxepin, 74 doxepin cream 5%, 85 doxercalciferol inj, 92 doxercalciferol oral, 92 doxy 100 inj, 72 doxycycline immediate-release tabs, caps & oral susp, 72 dronabinol, 74 DULERA, 93 duloxetine hcl, 73 duramorph inj, 69 DUREZOL, 92 dutasteride, 87 dutasteride & tamsulosin, 87 DUTOPROL, 82 econazole nitrate, 75 EDURANT, 79 ELIDEL, 85, 95 ELIGARD INJ, 90 eliphos, 86 ELIQUIS, 81 ELMIRON, 87 EMCYT, 76 emoquette, 88 EMSAM, 73 EMTRIVA, 79 enalapril, 82 enalapril & hydrochlorothiazide, 82 ENBREL INJ, 90 ENBREL MINI CARTRIDGE, 90 ENBREL SURECLICK INJ, 90 endocet, 69 endocet, 95 ENGERIX-B INJ, 91 enoxaparin inj, 81 enpresse-28, 88 entacapone, 77 entecavir tabs, 78 ENTRESTO, 83 enulose, 86 EPCLUSA, 78 EPINEPHRINE AUTO-INJECTOR 0.15MG/0.3ML & 0.3MG/0.3ML, 94 epitol, 73 EPIVIR HBV SOLN 5MG/ML, 78 eplerenone, 83 ergoloid mesylates, 73 ERIVEDGE, 76 ERWINAZE INJ, 76 ERYTHROCIN LACTOBIONATE INJ, 71 erythrocin stearate, 71 erythromycin ethylsuccinate tabs, 71 erythromycin ophthalmic oint, 71 erythromycin oral, 71 erythromycin topical gel & soln, 72 ESBRIET, 94 escitalopram, 74 esomeprazole magnesium dr caps, 86 estazolam, 94 ESTRACE VAGINAL, 88 estradiol & norethindrone acetate 5mcg/1mg & 2.5mcg-0.5mg, 88 estradiol oral, 88 estradiol patches, 88 estradiol vaginal tabs, 88 estropipate, 88 ethambutol, 75 ethinyl estradiol & ethynodiol, 89 ethinyl estradiol, ferrous fumarate & norethindrone, 89 ethosuximide, 72 etidronate, 92 etodolac, 70 etodolac er, 70 etoposide inj, 76 EURAX, 77 EVOTAZ, 79 exemestane, 76 EXJADE, 85 ezetimibe, 84 SCAN Health Plan 2018 Formulary 103

106 FABRAZYME INJ, 87 falmina, 89 famciclovir, 79 famotidine inj, 86 famotidine tabs, 86 FANAPT, 78 FANAPT TITRATION PACK, 78 FARESTON, 76 FARXIGA, 80 FARYDAK, 76 FASLODEX INJ, 76 FAZACLO, 78 felbamate oral susp 600mg/5ml, 73 felbamate tabs 400mg, 73 felbamate tabs 600mg, 73 felodipine er, 83 femynor, 89 fenofibrate, 83, 95 fenofibrate caps 43mg & 130mg, 83 fenofibrate micronized, 83, 95 fenofibrate tabs 48mg, 54mg, 145mg, 160mg, 83 fenofibric acid dr caps, 83 fenofibric acid tabs, 83 fentanyl citrate lozenges, 69 fentanyl patches, 95 fentanyl patches 12mcg/hr, 25mcg/hr, 50mcg/hr, 75mcg/hr, 100mcg/hr, 69 FERRIPROX, 92 FETZIMA, 74 FETZIMA TITRATION PACK, 74 finasteride tabs 5mg, 87 FIRAZYR INJ, 90 flavoxate, 87 flecainide acetate, 82 fluconazole in sodium chloride inj, 75 fluconazole oral, 75 flucytosine, 75 fludrocortisone acetate, 87 flunisolide nasal, 93, 95 fluocinolone acetonide, 87 fluocinonide, 87 fluocinonide gel, oint & soln, 87 fluocinonide-e, 87 SCAN Health Plan 2018 Formulary 104 fluorometholone, 92 FLUOROURACIL 0.5% CREAM, 85 fluorouracil topical, 85 fluoxetine hcl caps 10mg, 20mg & 40mg, 74 fluoxetine hcl oral soln, 74 fluoxetine hcl tabs 10mg & 20mg, 74 fluphenazine decanoate inj, 78 fluphenazine inj, 78 fluphenazine oral, 77 flurazepam, 94 flutamide, 76 fluticasone propionate cream & oint, 87 fluticasone propionate nasal, 93, 95 fluvoxamine, 74 fluvoxamine er, 74 fondaparinux inj 2.5mg/0.5ml & 5mg/0.4ml, 81 fondaparinux inj 7.5mg/0.6ml & 10mg/0.8ml, 81 FORFIVO XL, 73 FORTEO INJ, 92 fosamprenavir tabs, 80 fosinopril, 82 fosinopril & hydrochlorothiazide, 82 fosphenytoin sodium inj, 73 FOSRENOL, 86 furosemide inj, 83 furosemide oral, 83 FUZEON INJ, 79 fyavolv, 89 FYCOMPA, 72 gabapentin caps, tabs, & oral soln, 72 GABITRIL TABS 12MG & 16MG, 72 galantamine, 73, 95 galantamine er, 73, 95 galantamine oral soln, 73, 95 GAMMAGARD INJ, 91 GAMUNEX-C INJ, 91 ganciclovir inj, 78 GARDASIL 9 INJ, 91 GATTEX INJ, 86 gauze pads 2x2, 92 gavilyte-c, 86 gavilyte-g, 86 gavilyte-h, 86 gavilyte-n, 86

107 GELNIQUE, 87 gemfibrozil, 83 generlac, 86 gengraf, 90 GENOTROPIN INJ, 88 GENOTROPIN MINIQUICK INJ 0.2MG, 0.4MG, 0.6MG, 0.8MG, 88 GENOTROPIN MINIQUICK INJ 1MG, 1.2MG, 1.4MG, 1.6MG, 1.8MG, & 2MG, 88 gentamicin cream 0.1% & oint 0.1%, 70 gentamicin inj, 70 gentamicin ophthalmic soln 0.3%, 70 GENVOYA, 79 GEODON INJ, 78 gildagia, 89 GILENYA, 84 GILOTRIF, 76 glatopa inj, 84 GLEOSTINE, 75 glimepiride, 80 glimepiride & pioglitazone, 80 glimepiride & pioglitazone tabs, 95 glipizide, 80 glipizide & metformin tabs, 80 glipizide er, 80 GLUCAGON EMERGENCY KIT INJ, 80 glycopyrrolate 1mg & 2mg tabs, 86 glycopyrrolate inj, 86 granisetron inj, 74 granisetron oral, 74 griseofulvin microsize, 75 guanfacine, 81 guanidine, 75 halobetasol, 87 haloperidol decanoate inj, 78 haloperidol lactate inj, 78 haloperidol lactate oral soln, 78 haloperidol tabs, 78 HARVONI, 78 HAVRIX INJ, 91 heparin inj, 81 HERCEPTIN INJ, 77 HETLIOZ, 84 HEXALEN, 75 HIBERIX INJ, 91 HUMALOG CARTRIDGE INJ, 81 HUMALOG JUNIOR KWIKPEN INJ, 81 HUMALOG KWIKPEN INJ, 81 HUMALOG MIX 50/50 KWIKPEN INJ, 81 HUMALOG MIX 50/50 VIAL INJ, 81 HUMALOG MIX 75/25 KWIKPEN INJ, 81 HUMALOG MIX 75/25 VIAL INJ, 81 HUMALOG VIAL INJ, 81 HUMATROPE INJ 5MG VIAL, 12MG & 24MG CARTRIDGE, 88 HUMATROPE INJ 6MG CARTRIDGE, 88 HUMIRA INJ, 90 HUMIRA PEN INJ, 90 HUMIRA PEN-CROHNS INJ, 90 HUMIRA PEN-PSORIASIS INJ, 90 HUMULIN 70/30 KWIKPEN INJ, 81 HUMULIN 70/30 VIAL INJ, 81 HUMULIN N KWIKPEN INJ, 81 HUMULIN N VIAL INJ, 81 HUMULIN R U-500 (CONCENTRATED) KWIKPEN INJ, 81 HUMULIN R U-500 (CONCENTRATED) VIAL INJ, 81 HUMULIN R VIAL INJ, 81 hydralazine inj, 84 hydralazine oral, 84 hydrochlorothiazide, 83 hydrocodone & acetaminophen soln, 69, 95 hydrocodone & acetaminophen tabs, 69, 95 hydrocodone & ibuprofen, 69, 96 hydrocortisone 2.5% cream, lotion, oint, 87 hydrocortisone butyrate oint & soln, 88 hydrocortisone enema, 91 hydrocortisone oral, 88 hydrocortisone valerate, 88 hydromorphone immediate-release oral soln & tabs, 69 hydromorphone inj, 69 hydroxychloroquine, 77 hydroxyprogesterone caproate, 89 hydroxyurea, 76 SCAN Health Plan 2018 Formulary 105

108 hydroxyzine hcl tabs, 93 ibandronate inj, 92 ibandronate oral, 92 IBRANCE, 76 ibuprofen, 70 ICLUSIG, 76 IDHIFA, 76 ILARIS INJ, 91 imatinib, 76 IMBRUVICA, 76 imipramine hcl tabs, 74 imiquimod, 85 IMOVAX RABIES INJ, 91 INCRELEX INJ, 88 indapamide, 83 indomethacin, 70 indomethacin er, 70 indomethacin ir caps, 70 INFANRIX INJ, 91 INLYTA, 76 INTELENCE 100MG & 200MG TABS, 79 INTELENCE 25MG TAB, 79 INTRALIPID INJ, 92 INTRON-A INJ, 78 introvale, 89 INVANZ INJ, 71 INVEGA SUSTENNA 117MG, 156MG, & 234MG, 78 INVEGA SUSTENNA 39MG & 78MG, 78 INVEGA TRINZA INJ, 78 INVIRASE, 80 INVOKAMET, 80 INVOKAMET XR, 80 INVOKANA, 80 IPOL INACTIVATED IPV INJ, 91 ipratropium bromide & albuterol sulfate nebulizer, 93 ipratropium bromide nasal, 93, 96 ipratropium bromide nebulizer, 93 irbesartan, 82 irbesartan hct, 82 IRESSA, 76 ISENTRESS CHEW TABS, 79 ISENTRESS HD TABS, 79 SCAN Health Plan 2018 Formulary 106 ISENTRESS ORAL POWDER, 79 ISENTRESS TABS, 79 isibloom, 89 isoniazid oral, 75 isosorbide dinitrate, 84 isosorbide dinitrate er, 84 isosorbide mononitrate, 84 isosorbide mononitrate er, 84 isradipine, 83 itraconazole, 75 ivermectin, 77 IXIARO INJ, 91 JADENU, 85 JADENU SPRINKLE, 85 JAKAFI, 76 jantoven, 81 JANUMET, 80 JANUMET XR, 80 JANUVIA, 80 jinteli, 89 junel, 89 JUXTAPID, 84 KALETRA TABS MG, 80 KALETRA TABS 200MG-50MG, 80 KALYDECO, 94 kariva, 89 ketoconazole tabs, cream, shampoo, 75 ketorolac inj, 70 ketorolac oral, 70 ketorolac soln 0.4% & 0.5%, 92 KEYTRUDA INJ, 77 KHEDEZLA, 74 kimidess, 89 KINERET INJ, 90 KINRIX INJ, 91 kionex, 85 KISQALI, 76 KISQALI FEMARA CO-PACK, 76 klor-con, 85 klor-con sprinkle, 85 KOMBIGLYZE XR, 80 KORLYM, 89 KUVAN, 87 KYNAMRO, 84

109 labetalol inj, 82 labetalol oral, 82 LACRISERT, 92 lactated ringers inj, 85 lactulose, 86 lamivudine & zidovudine, 79 lamivudine soln, 79 lamivudine tabs 100mg, 78 lamivudine tabs 150mg & 300mg, 79 lamotrigine immediate-release tabs, 73 LANOXIN INJ, 83 LANOXIN ORAL, 83 lansoprazole dr caps, 86 lanthanum carbonate, 86 LANTUS SOLOSTAR PEN INJ, 81 LANTUS VIAL INJ, 81 larin, 89 larin fe, 89 larissia, 89 latanoprost, 93 LATUDA, 78 LAZANDA, 69 leena, 89 leflunomide, 91, 96 LENVIMA, 76 LETAIRIS, 94 letrozole, 76 leucovorin inj, 76 leucovorin oral, 76 LEUKERAN, 75 LEUKINE INJ, 81 leuprolide acetate inj, 90 levalbuterol nebulizer, 94 levetiracetam er, 72 levetiracetam inj, 72 levetiracetam oral, 72 levobunolol, 93 levocarnitine oral, 92 levocetirizine, 93 levofloxacin inj, 72 levofloxacin oral soln, 72 levofloxacin tabs, 72 levoleucovorin 175mg vial, 76 levonest, 89 levonorgestrel & ethinyl estradiol mg, mg packs, 89 levora, 89 levothyroxine tabs, 89 levoxyl, 89 LEXIVA ORAL SUSP, 80 LEXIVA TABS, 80 lidocaine & prilocaine, 69 lidocaine hcl inj, 69 lidocaine ointment, 69 lidocaine patch, 69 lidocaine topical gel & solution, 69 linezolid inj, 70 linezolid oral, 70 LINZESS, 86 liothyronine tabs, 90 lisinopril, 82 lisinopril & hydrochlorothiazide, 82 lithium carbonate, 80 lithium carbonate er, 80 lithium citrate, 80 LONSURF, 76 loperamide caps 2mg, 86 lopinavir &ritonavir soln, 80 lorazepam intensol, 80 lorazepam tabs, 80 lorcet hd tabs, 69, 96 lorcet plus tabs, 69, 96 lorcet tabs, 69, 96 lortab tabs, 69, 96 losartan, 82 losartan hct, 82 lovastatin, 83 low-ogestrel, 89 loxapine, 78 LUMIGAN, 93 LUMIZYME INJ, 87 LUPRON DEPOT INJ, 90 LYNPARZA, 76 LYRICA, 72 LYSODREN, 90 lyza, 89 SCAN Health Plan 2018 Formulary 107

110 magnesium sulfate inj, 85 malathion, 77 maprotiline, 73 marlissa 28 day, 89 MARPLAN, 73 MATULANE, 75 meclizine, 74 medroxyprogesterone acetate inj, 89 medroxyprogesterone acetate tabs, 89 mefloquine, 77 megestrol acetate oral susp 40mg/ml, 89 megestrol tabs, 89 MEKINIST, 76 meloxicam tabs, 70 memantine hcl immediate release, 73 memantine hcl soln, 73 MENACTRA INJ, 91 MENEST, 89 MENOMUNE-A/C/Y/W-135 INJ, 91 MENVEO-A/C/Y/W-135 INJ, 91 meprobamate, 80 mercaptopurine, 76 meropenem inj, 71 mesalamine enema kit, 91 MESNEX TABS, 76 MESTINON SYRUP, 75 metadate er, 84 metformin, 80 metformin er uncoated tabs 500mg & 750mg, 80 methadone inj, 69 methadone oral, 69 methazolamide, 93 methenamine hippurate, 70 methimazole, 90 methocarbamol tabs, 94 methotrexate inj, 90 methotrexate oral, 90 methoxsalen, 85 methyldopa, 81, 82 methyldopa & hydrochlorothiazide, 82 methyldopate inj, 82 methylphenidate er tabs 10mg & 20mg, 84 methylphenidate ir tabs 5mg, 10mg & 20mg, 84 methylprednisolone oral, 88 SCAN Health Plan 2018 Formulary 108 methylprednisolone sodium succinate inj, 88 metipranolol, 93 metoclopramide inj, 86 metoclopramide oral tablets & soln, 86 metolazone, 83 metoprolol & hydrochlorothiazide, 82 metoprolol succinate er, 82 metoprolol tartrate tabs, 82 metronidazole inj, 70 metronidazole oral, 70 metronidazole topical, 70 metronidazole vaginal, 70 mexiletine, 82 MIACALCIN INJ, 92 microgestin, 89 midodrine tabs, 82 migergot suppository, 75 mimvey, 89 mimvey lo, 89 minitran patches, 84 minocycline ir, 72 minoxidil, 84 mirtazapine, 73 mirtazapine odt, 73 misoprostol, 86 mitoxantrone inj, 76 M-M-R II INJ, 91 modafinil, 94 moderiba 200mg tabs, 78 moderiba dose pack, 78 moexipril, 82 moexipril & hydrochlorothiazide, 82 mometasone cream & oint, 88 mometasone furoate nasal, 93 mometasone furoate nasal, 96 montelukast, 93 morgidox, 72 morphine sulfate er tabs, 69, 96 morphine sulfate oral, 69 MOVANTIK, 86 MOVIPREP, 86 moxifloxacin hcl ophthalmic, 72 moxifloxacin oral, 72 MOZOBIL INJ, 81

111 mupirocin cream, 70 mupirocin ointment, 70 mycophenolate mofetil caps & tabs, 90 mycophenolate mofetil inj, 90 mycophenolate mofetil oral susp, 90 mycophenolic acid dr, 90 myorisan, 85 MYRBETRIQ, 87 nabumetone, 70 nadolol, 82 nadolol & bendroflumethiazide, 82 nafcillin sodium inj, 71 NAGLAZYME INJ, 87 naloxone inj, 70 naltrexone, 69 naproxen, 70 naproxen dr, 70 naproxen sodium ir, 70 naratriptan, 75, 96 NARCAN, 70 NATACYN, 75 nateglinide, 80 NATPARA, 92 NEBUPENT NEBULIZER, 77 necon, 89 nefazodone, 73 neomycin & bacitracin & polymyxin b ophthalmic, 70 neomycin & polymyxin & bacitracin & hydrocortisone, 92 neomycin & polymyxin & dexamethasone, 92 neomycin & polymyxin & gramicidin ophthalmic, 70 neomycin & polymyxin & hydrocortisone, 93 neomycin sulfate oral, 70 NEORAL, 90 NERLYNX, 76 NEUPOGEN INJ, 81 NEUPRO PATCH, 77 NEUPRO PATCH, 96 nevirapine er, 79 nevirapine oral susp, 79 nevirapine tabs, 79 NEXAVAR, 77 niacin er tabs, 84, 96 nicardipine caps, 83 NICOTROL INHALER, 70 NICOTROL NASAL, 70 nifedipine, 83 nifedipine er, 83 nilutamide, 76 nimodipine caps, 83 NINLARO, 76 nisoldipine er, 83 nitro-bid oint, 84 NITRO-DUR PATCHES, 84 nitrofurantoin caps, 70 nitroglycerin inj, 84 nitroglycerin lingual, 84 nitroglycerin patches, 84 nitroglycerin sublingual, 84 norethindrone, 89 norgestimate-ethinyl estradiol, 89 norlyroc, 89 NORTHERA, 83 nortriptyline oral, 74 NORVIR, 80 NOXAFIL ORAL, 75 NUEDEXTA, 84 NULOJIX INJ, 90 NUPLAZID, 78 nyamyc, 75 nyata, 75 nystatin, 75 nystatin & triamcinolone, 75 octreotide inj 500mcg/ml & 1000mcg/ml, 90 octreotide inj 50mcg/ml, 100mcg/ml & 200mcg/ml, 90 ODEFSEY, 79 ODOMZO, 77 OFEV, 94 ofloxacin ophthalmic, 72 ofloxacin oral, 72 ofloxacin otic, 72 olanzapine inj 10mg, 78 olanzapine odt, 78 SCAN Health Plan 2018 Formulary 109

112 olanzapine tabs, 78 olmesartan, 82 olmesartan & amlodipine, 82 olmesartan hct, 82 olopatadine soln 0.1%, 92 olopatadine soln 0.1%, 96 olopatadine soln 0.2%, 92 omega-3-acid ethyl esters, 84 omeprazole caps, 86 ondansetron inj, 74 ondansetron odt, 74 ondansetron oral soln, 74 ondansetron tabs, 74 ONFI, 72 ONGLYZA, 80 OPSUMIT, 94 ORAVIG, 75 ORFADIN, 87 ORKAMBI, 94 orsythia 28 day, 89 oseltamivir caps, 80 oseltamivir susp, 80 OSMOPREP, 86 OTEZLA, 91 OTEZLA STARTER, 91 oxandrolone, 88 oxazepam, 80 oxcarbazepine, 73 oxybutynin, 87, 96 oxybutynin er, 87, 96 oxycodone, 69 oxycodone & acetaminophen, 69, 96 oxycodone & aspirin, 69, 96 oxycodone & ibuprofen, 69 oxycodone & ibuprofen tabs, 96 OXYCODONE ER, 69 OXYCODONE ER, 96 oxycodone immediate-release, 69 oxycodone oral soln, 69 OXYCONTIN, 69, 96 oxymorphone er, 69, 96 OXYTROL, 87 pacerone tabs 200mg, 82 paclitaxel inj, 76 SCAN Health Plan 2018 Formulary 110 paliperidone er, 78 pamidronate inj, 92 PANRETIN, 77 pantoprazole inj, 86 pantoprazole tabs, 86 paricalcitol caps, 92 paromomycin, 70 paroxetine hcl er, 74 paroxetine hcl immediate-release, 74 paroxetine mesylate caps, 74 PASER, 75 PAXIL 10MG/5ML SUSP, 74 PEDIARIX INJ, 91 PEDVAX HIB INJ, 91 peg 3350 & electrolytes, 86 peg 3350 & sodium chloride & sodium bicarbonate & potassium chloride, 86 PEGANONE, 73 PEGASYS INJ, 79 PEGASYS PROCLICK INJ, 79 penicillin g inj 5 million units, 71 penicillin v potassium, 71 PENTAM INJ, 77 PENTASA, 91, 96 pentoxifylline er, 83 PERFOROMIST NEBULIZER, 94 perindopril, 82 permethrin cream, 77 perphenazine, 74, 78 perphenazine & amitriptyline, 74 phenadoz, 74 phenelzine, 73 phenergan suppositories, 74 phenobarbital elixir, 72 phenobarbital tabs, 72 phenytoin chewable tabs, 73 phenytoin er, 73 phenytoin inj, 73 phenytoin oral susp, 73 PHOSPHOLINE IODIDE, 93 pilocarpine soln, 93 pilocarpine tabs, 84 pimozide, 78 pimtrea, 89

113 pindolol, 82 pioglitazone, 80 pioglitazone & metformin, 80 piperacillin/tazobactam inj, 71 pirmella 1/35, 89 piroxicam, 70 PLEGRIDY INJ, 84 PLEGRIDY STARTER PACK INJ, 84 plenamine inj, 85 podofilox, 85 polyethylene glycol 3350, 86 polymyxin b sulfate & trimethoprim sulfate ophthalmic soln, 71 POMALYST, 76 potassium chloride & dextrose & lactated ringers inj, 85 potassium chloride & dextrose & sodium chloride inj 20mEq/5%/0.45% & 30mEq/5%/0.45%, 86 potassium chloride er, 85 potassium chloride inj, 85 potassium chloride oral soln, 85 potassium chloride viaflex inj, 86 potassium citrate er, 86 PRADAXA, 81 pramipexole ir, 77 pravastatin, 83 prazosin, 82 PRED MILD, 92 prednicarbate, 88 prednisolone, 92, 93 prednisolone acetate, 92 prednisolone oral soln, 88 prednisolone sodium phosphate, 93 prednisone dose pack, 88 prednisone oral soln, 92 prednisone tabs, 91 PREMARIN ORAL, 89 PREMARIN VAGINAL, 89 PREMPHASE, 89 PREMPRO, 89 prenatal multi-vitamin, 86 PREPOPIK, 86 prevalite, 84 PREZCOBIX, 80 PREZISTA SUSP 100MG/ML, 80 PREZISTA TABS 600MG & 800MG, 80 PREZISTA TABS 75MG & 150MG, 80 PRIFTIN, 75 PRIMAQUINE, 77 primidone, 72 PROAIR HFA, 94 PROAIR RESPICLICK, 94 probenecid, 75 probenecid & colchicine, 75 procainamide inj, 82 prochlorperazine inj, 74 prochlorperazine oral, 74 prochlorperazine suppositories, 74 PROCRIT INJ 20000UNIT/ML & 40000UNIT/ML, 81 PROCRIT INJ 2000UNIT/ML, 81 PROCRIT INJ 3000UNIT/ML, 4000UNIT/ML & 10000UNIT/ML, 81 procto-med hc, 88 procto-pak, 88 proctosol hc, 88 proctozone-hc, 88 progesterone caps, 89 PROGLYCEM, 80 PROLASTIN C INJ, 94 PROLIA, 92 PROMACTA, 81 promethazine inj, 74 promethazine suppositories, 74 promethazine syrup, 74 promethazine tabs 12.5mg, 25mg & 50mg, 74 promethegan, 74 propafenone, 82 propranolol & hydrochlorothiazide, 83 propranolol er caps, 82 propranolol inj, 83 propranolol ir tabs, 82 propranolol oral soln, 83 propylthiouracil, 90 PROQUAD INJ, 91 SCAN Health Plan 2018 Formulary 111

114 PROSOL INJ, 86 PROTONIX INJ, 86 protriptyline, 74 prudoxin, 85 PULMICORT NEBULIZER, 93 PULMOZYME, 94 PURIXAN, 76 pyrazinamide, 75 pyridostigmine, 75 pyridostigmine er, 75 QUADRACEL INJ, 91 quetiapine, 78 quetiapine er tabs, 78 quinapril, 82 quinapril & hydrochlorothiazide, 82 quinidine gluconate cr, 82 quinidine gluconate inj, 82 quinidine sulfate, 82 quinine sulfate caps 324mg, 77 QVAR, 93 RABAVERT INJ, 91 raloxifene hcl, 89, 96 ramipril, 82 RANEXA, 83 ranitidine caps, syrup & inj, 86 ranitidine tabs, 86 RAPAMUNE SOLN, 90 rasagiline, 77 RAVICTI, 87 REBIF INJ, 84 REBIF REBIDOSE INJ, 84 REBIF REBIDOSE TITRATION PACK INJ, 84 REBIF TITRATION PACK INJ, 84 RECOMBIVAX HB INJ, 91 REGRANEX, 85, 96 RELENZA DISKHALER, 80 RELISTOR INJ, 86 RELISTOR TABS, 86 REMICADE INJ, 90 REMODULIN INJ, 94 RENVELA TABS, 86 repaglinide, 80 REPATHA INJ, 83 RESCRIPTOR, 79 SCAN Health Plan 2018 Formulary 112 RESTASIS, 92 RETROVIR IV INJ, 79 REVLIMID, 76 REXULTI, 78 REYATAZ CAPS & ORAL POWDER, 80 ribasphere, 79 ribasphere ribapak, 79 ribavirin, 79 RIDAURA, 91 rifabutin, 75 rifampin inj, 75 rifampin oral, 75 RIFATER, 75 riluzole, 84 rimantadine, 80 risedronate sodium, 92 risedronate sodium dr, 92 RISPERDAL CONSTA INJ 12.5MG & 25MG, 78 RISPERDAL CONSTA INJ 37.5MG & 50MG, 78 risperidone, 78 risperidone odt, 78 RITUXAN HYCELA INJ, 77 RITUXAN INJ, 77 rivastigmine caps, 73 rivastigmine caps, 96 rivastigmine patches, 96 rivastigmine patches, 73 rizatriptan, 75 rizatriptan odt, 75 ropinirole, 77 rosuvastatin, 83 ROTARIX, 91 ROTATEQ, 91 roweepra, 72 ROZEREM, 94, 96 RUBRACA, 76 RYDAPT, 76 SABRIL, 72 SANDIMMUNE CAPS 25MG & 100MG, 90 SANDIMMUNE ORAL SOLN 100MG/ML, 90 SANTYL, 85 SAPHRIS, 78 SAVELLA, 84 SAVELLA TITRATION PACK, 84

115 scopolamine patch, 74 selegiline, 77 selenium sulfide lotion, 85 SELZENTRY 150MG & 300MG, 79 SELZENTRY 25MG & 75MG, 79 SELZENTRY SOLN, 79 SENSIPAR TABS 30MG, 92, 96 SENSIPAR TABS 60MG & 90MG, 92 SEREVENT DISKUS, 94 SEROQUEL XR, 78 sertraline oral soln, 74 sertraline tabs, 74 setlakin, 89 sevelamer carbonate powder, 86 sevelamer carbonate tabs, 86 sharobel, 89 SHINGRIX, 91 sildenafil tabs 20mg, 94 SILENOR, 94, 96 silver sulfadiazine, 71 simvastatin, 83 sirolimus tabs, 90 SIRTURO, 75 SIVEXTRO, 71 sodium chloride inj, 86 sodium phenylbutyrate powder & tabs, 87 sodium polystyrene sulfonate, 85 SOLTAMOX, 76 SOLU-CORTEF INJ, 88 SOMATULINE DEPOT INJ, 90 SOMAVERT INJ, 90 sorine, 82 sotalol tabs, 82 SPIRIVA HANDIHALER, 93 SPIRIVA RESPIMAT, 93 spironolactone, 83 spironolactone & hydrochlorothiazide, 83 SPORANOX ORAL SOLN, 75 SPRITAM, 72 SPRYCEL, 77 ssd, 71 stavudine caps, 79 STIMATE, 88 STIOLTO RESPIMAT, 94 STIVARGA, 77 streptomycin inj, 70 STRIBILD, 79 STRIVERDI RESPIMAT, 94 SUCRAID, 87 sucralfate, 86 sulfacetamide sodium & prednisolone sodium phosphate ophthalmic, 72 sulfacetamide sodium ophthalmic oint & soln 10%, 72 sulfacetamide sodium topical susp 10%, 72 sulfadiazine, 72 sulfamethoxazole & trimethoprim, 72 sulfamethoxazole & trimethoprim ds tabs, 72 sulfamethoxazole & trimethoprim inj, 72 sulfamethoxazole & trimethoprim oral susp, 72 sulfamethoxazole & trimethoprim tabs, 72 sulfasalazine, 92 sulindac, 70 sumatriptan nasal, 75 sumatriptan succinate inj, 75 sumatriptan succinate oral, 75 SUPRAX CAPS & CHEWABLE TABS, 71 SUPRAX ORAL SUSP 500MG/5ML, 71 SUPREP BOWEL PREP, 86 SUSTIVA 50MG & 200MG CAPS, 79 SUSTIVA 600MG TABS, 79 SUTENT, 77 SYLATRON INJ, 76 SYMLINPEN INJ, 80 SYNAGIS INJ, 91 SYNAREL, 90 SYNERCID INJ, 71 SYNRIBO INJ, 76 SYNTHROID, 90 SYPRINE, 85 TABLOID, 76 tacrolimus caps 0.5mg & 1mg, 90 tacrolimus caps 5mg, 91 tacrolimus oint, 85 TAFINLAR, 77 TAGRISSO, 77 SCAN Health Plan 2018 Formulary 113

116 TAMIFLU SUSP, 80 tamoxifen, 76 tamsulosin, 87 TARCEVA, 77 TARGRETIN GEL, 77 tarina fe, 89 TASIGNA, 77 tazarotene, 85 tazicef inj, 71 TAZORAC 0.05% CREAM, 85 TAZORAC GEL, 85, 96 taztia xt, 83 TECFIDERA, 84 TECFIDERA STARTER PACK, 84 TEFLARO INJ, 71 TEGRETOL, 73 TEGRETOL XR, 73 TEKTURNA, 83 TEKTURNA HCT, 83 temazepam, 94 TENIVAC, 91 terazosin, 82 terbinafine, 75 terbutaline sulfate inj, 94 terbutaline sulfate oral, 94 terconazole, 75 testosterone cypionate inj, 88 testosterone enanthate inj, 88 testosterone gel 25mg/2.5g, 88 TETANUS & DIPHTHERIA TOXOIDS- ADSORBED ADULT INJ, 91 tetracycline, 72 THALOMID, 76 theophylline cr & er tabs, 94 THIOLA, 87 thioridazine, 78 thiothixene, 78 THYROLAR, 90 tiagabine, 72 TIGECYCLINE INJ, 71 timolol ophthalmic gel forming, 93 timolol oral, 83 timolol soln, 93 TIVICAY 10MG & 25MG TABS, 79 SCAN Health Plan 2018 Formulary 114 TIVICAY 50MG TAB, 79 tizanidine, 78 TOBI, 94 TOBI PODHALER, 94 TOBRADEX OINT, 70 tobramycin & dexamethasone ophthalmic suspension, 70 tobramycin nebulizer, 94 tobramycin ophthalmic solution, 70 tobramycin sulfate inj, 70 TOLAK, 85 tolterodine tartrate er, 87, 96 topiramate immediate-release, 73 torsemide oral, 83 TOUJEO SOLOSTAR, 81 TOVIAZ, 87 TPN ELECTROLYTES INJ, 86 TRACLEER, 94 tramadol, 69, 96 tramadol & acetaminophen, 69, 96 tramadol er, 96 tramadol er tabs, 69 trandolapril, 82 tranexamic acid inj, 81 tranexamic acid tabs, 81 TRANSDERM-SCOP, 74 tranylcypromine, 73 TRAVASOL INJ, 86 trazodone, 73 TRECATOR, 75 TRELSTAR MIXJECT, 90 tretinoin caps, 77 tretinoin cream, gel, 85 triamcinolone, 84 triamcinolone acetonide topical cream, lotion & oint, 88 triamcinolone in orabase, 84 triamterene & hydrochlorothiazide, 83 triazolam, 94 triderm, 88 trifluoperazine, 78 trifluridine, 79 trihexyphenidyl elixir, 77 trihexyphenidyl tabs, 77

117 TRILEPTAL, 73 tri-lo-estarylla, 89 tri-lo-sprintec, 89 trimethoprim, 71 trimipramine maleate, 74 TRINTELLIX, 73 tri-sprintec, 89 TRIUMEQ, 79 trivora-28, 89 TRUMENBA INJ, 91 TRUVADA, 79 TUDORZA PRESSAIR, 93 TWINRIX INJ, 91 TYBOST, 79 TYGACIL INJ, 71 TYKERB, 77 TYMLOS, 90 TYPHIM VI INJ, 91 TYSABRI INJ, 84 ULORIC, 75 unithroid, 90 UPTRAVI, 94 ursodiol, 86 valacyclovir, 79 VALCHLOR, 75 valganciclovir tabs, 78 valproate sodium inj, 72 valproic acid, 73 valsartan, 82 valsartan & amlodipine, 82 valsartan & amlodipine & hct, 82 valsartan hct, 82 vancomycin inj, 71 vancomycin oral, 71 vandazole, 71 VAQTA INJ, 91 VARIVAX INJ, 91 VARIZIG INJ, 91 VELCADE INJ, 76 velivet, 89 VELTASSA, 85 VENCLEXTA STARTING PACK, 76 VENCLEXTA TABS 100MG, 76 VENCLEXTA TABS 10MG & 50MG, 76 venlafaxine er caps, 74 venlafaxine ir tabs, 74 VENTAVIS, 94 verapamil er, 83 verapamil inj, 83 verapamil ir, 83 verapamil sr, 83 VERSACLOZ, 78 VERZENIO, 76 VESICARE, 87 VICTOZA INJ, 80 VIDEX PEDIATRIC SOLN 2GM, 79 vienva, 89 vigabatrin, 73 VIGAMOX, 72 VIIBRYD, 74 VIIBRYD STARTER PACK, 74 VIMPAT INJ, 73 VIMPAT ORAL, 73 VIRACEPT, 80 VIRAMUNE TABS, 79 VIREAD POWDER, 79 VIREAD TABS, 79 voriconazole inj, 75 voriconazole oral, 75 VOTRIENT, 77 VPRIV INJ, 87 VRAYLAR CAPSULES, 78 VRAYLAR DOSE PACK, 78 vyfemla, 89 warfarin, 81 WELCHOL, 84 wymzya fe, 89 XALKORI, 77 XARELTO, 81 XARELTO STARTER PACK, 81 XATMEP, 91 XELJANZ, 91 XELJANZ XR, 91 XERESE, 79 XGEVA INJ, 92 XIFAXAN TABS 200MG, 71, 96 SCAN Health Plan 2018 Formulary 115

118 XIFAXAN TABS 550MG, 71 XIGDUO XR, 80 XIIDRA, 92 XOPENEX NEBULIZER, 94 XTANDI, 76 XYREM, 94 YERVOY INJ, 77 YF-VAX INJ, 91 yuvafem, 89 zafirlukast, 93, 96 zamicet, 69, 97 ZAVESCA, 87 ZEJULA, 76 ZELBORAF, 77 zenatane, 85 zenchent, 89 zenchent fe, 89 zenzedi tabs 5mg & 10mg, 84, 97 ZERBAXA INJ, 71 ZERIT SOLN, 79 ZIAGEN SOLN, 79 zidovudine, 79 zileuton er, 93 ziprasidone oral, 78 ZIRGAN, 78 zoledronic acid 4mg/5ml inj, 92 zoledronic acid 5mg/100ml inj, 92 ZOLINZA, 76 zolmitriptan odt, 75 zolmitriptan tabs, 75 zolpidem tabs 5mg & 10mg, 94 ZOMETA INJ 4MG/100ML, 92 ZOMIG NASAL, 75, 97 ZONALON, 85 zonisamide, 72 ZORTRESS TABS 0.25MG, 91 ZORTRESS TABS 0.5MG & 0.75MG, 91 ZOSTAVAX INJ, 91 ZOSYN GALAXY INJ 2GM/0.25GM & 3GM/0.375GM, 71 zovia, 89 ZOVIRAX CREAM, 79 ZYDELIG, 76 ZYKADIA, 77 ZYPREXA RELPREVV 210MG INJ, 78 ZYTIGA, 76 SCAN Health Plan 2018 Formulary 116

119

120 .. This formulary was updated on 02/01/2018. For more recent information or other questions, please contact SCAN Health Plan Member Services at (Medicare and Medi-Cal eligible members should call ) or, for TTY users, 711, 8 a.m. to 8 p.m., 7 days a week from October 1 to February 14. From February 15 to September 30, hours are 8 A.M. to 8 P.M. Monday through Friday (messages received on holidays and outside of our business hours will be returned within one business day), or visit 本處方集更新於 2018 年 2 月 1 日 如欲瞭解更多最新資訊或有其他問題, 請聯絡 SCAN Health Plan 會員服務部, 電話 : ( 符合 Medicare 和 Medi-Cal 資格的會員應撥打 ),TTY 用戶 :711, 服務時間為 10 月 1 日至次年 2 月 14 日, 每週七天, 上午 8 時至晚上 8 時 ;2 月 15 日至 9 月 30 日, 週一至週五, 上午 8 時至晚上 8 時 ( 假日和下班時間接到的留言會在下一個工作日回電 ), 或者瀏覽 SCAN Health Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. SCAN Health Plan cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. SCAN Health Plan 遵守適用的聯邦民權法律規定, 不因種族 膚色 民族血統 年齡 殘障或性別而歧視任何人 ATTENTION: If you speak another language, language assistance services, free of charge, are available to you. Call (TTY: 711). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 711). (TTY: 711) 注意 : 如果您使用中文, 您可以免費獲得語言援助服務 請致電 ( 聽障專線 :711) Y0057_SCAN_10440_2017F_CH File & Use Accepted G /18 18C-FOR900CH