Cambios Anuales de Rx3 2017
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GCHJLC7SP 1016 Page 1 of 27 To view in English, click here. Para ver la Lista de medicamentos completa, haga clic aquí. Fecha de entrada en vigor: 01/01/2017 Humana.com ¡Bienvenido a Humana! Los cambios al formulario adjunto, o Lista de medicamentos, entran en vigor el 1 de enero de 2017. Visite Humana.com e inicie sesión en MyHumana –su cuenta en línea segura y personal– a partir de la fecha de su renovación para ver los beneficios de medicamentos recetados específicos, incluidos los copagos o el costo compartido, las limitaciones y las exclusiones. También puede consultar su Certificado de cobertura/seguro o su Descripción resumida del plan/Póliza de seguro. Si tiene preguntas: : • Posibles afiliados: llamar a Atención al Cliente al número que aparece en los materiales de inscripción • Afiliados actuales: llamar al número indicado al reverso de su tarjeta de identificación de Humana Cómo leer los cambios a su Lista de medicamentos anual Algunos medicamentos cubiertos pueden tener requisitos adicionales o límites en la cobertura. Hable con su médico o proveedor de atención médica si su medicamento tiene un requisito adicional. Estos requisitos y límites pueden incluir: Estatus de la cobertura (CVG, por sus siglas en inglés): Ciertos medicamentos que anteriormente no estaban cubiertos en virtud de los beneficios de su plan se agregarán a su Lista de medicamentos para 2017, mientras que otros medicamentos que quizás estaban cubiertos en el pasado, se eliminarán. Tenga en cuenta que si usted surte o repite la receta de cualquier medicamento no cubierto en virtud de los beneficios de su plan, quizás deba pagar el costo total de su medicamento recetado. + CVG (incorporación); CVG (sin cambios); - CVG (eliminación) Autorización previa (PA, por sus siglas en inglés): Algunos medicamentos deben ser aprobados por anticipado para que su plan de farmacia los cubra. Para que estén cubiertos estos medicamentos, su médico debe obtener la aprobación o autorización previa de Humana. Los beneficios del plan no cubrirán este medicamento sin la autorización previa. En caso de que obtenga el medicamento primero sin la autorización previa, pagaría el precio completo. + PA (incorporación); +PA* (la incorporación se aplica únicamente a los nuevos medicamentos recetados); PA (sin cambios); - PA (eliminación) Límites de cantidad (QL, por sus siglas en inglés): Usted puede tener un límite en la cantidad que puede obtener de algunos medicamentos de una sola vez. Estos límites pueden aplicarse a algunos medicamentos, por motivos de seguridad o servicios de salud, y ayudan a evitar el uso inapropiado de estos medicamentos. + QL (incorporación); QL (sin cambios); - QL (eliminación) Cambios Anuales de Rx3 2017
Transcript of Cambios Anuales de Rx3 2017
GCHJLC7SP 1016 Page 1 of 27
To view in English, click here. Para ver la Lista de medicamentos completa, haga clic aquí.
Fecha de entrada en vigor: 01/01/2017
Humana.com
¡Bienvenido a Humana! Los cambios al formulario adjunto, o Lista de medicamentos, entran en vigor el 1 de enero de 2017.
Visite Humana.com e inicie sesión en MyHumana –su cuenta en línea segura y personal– a partir de la fecha de su renovación para ver los beneficios de medicamentos recetados específicos, incluidos los copagos o el costo compartido, las limitaciones y las exclusiones. También puede consultar su Certificado de cobertura/seguro o su Descripción resumida del plan/Póliza de seguro.
Si tiene preguntas: : • Posibles afiliados: llamar a Atención al Cliente al número que aparece en los materiales de inscripción
• Afiliados actuales: llamar al número indicado al reverso de su tarjeta de identificación de Humana
Cómo leer los cambios a su Lista de medicamentos anual Algunos medicamentos cubiertos pueden tener requisitos adicionales o límites en la cobertura. Hable con su médico o proveedor de atención médica si su medicamento tiene un requisito adicional. Estos requisitos y límites pueden incluir:
Estatus de la cobertura (CVG, por sus siglas en inglés): Ciertos medicamentos que anteriormente no estaban cubiertos en virtud de los beneficios de su plan se agregarán a su Lista de medicamentos para 2017, mientras que otros medicamentos que quizás estaban cubiertos en el pasado, se eliminarán. Tenga en cuenta que si usted surte o repite la receta de cualquier medicamento no cubierto en virtud de los beneficios de su plan, quizás deba pagar el costo total de su medicamento recetado. + CVG (incorporación); CVG (sin cambios); - CVG (eliminación)
Autorización previa (PA, por sus siglas en inglés): Algunos medicamentos deben ser aprobados por anticipado para que su plan de farmacia los cubra. Para que estén cubiertos estos medicamentos, su médico debe obtener la aprobación o autorización previa de Humana. Los beneficios del plan no cubrirán este medicamento sin la autorización previa. En caso de que obtenga el medicamento primero sin la autorización previa, pagaría el precio completo. + PA (incorporación); +PA* (la incorporación se aplica únicamente a los nuevos medicamentos recetados); PA (sin cambios); - PA (eliminación)
Límites de cantidad (QL, por sus siglas en inglés): Usted puede tener un límite en la cantidad que puede obtener de algunos medicamentos de una sola vez. Estos límites pueden aplicarse a algunos medicamentos, por motivos de seguridad o servicios de salud, y ayudan a evitar el uso inapropiado de estos medicamentos. + QL (incorporación); QL (sin cambios); - QL (eliminación)
Cambios Anuales de Rx3 2017
GCHJLC7SP 1016 Page 2 of 27
Terapia por fases (ST, por sus siglas en inglés): A veces, más de un medicamento es eficaz para tratar una afección médica. Algunos medicamentos pueden costar menos pero aun así funcionan para usted. Antes de que una receta de medicamento sea surtida con un medicamento que cueste más, se le puede pedir que pruebe al menos con un medicamento diferente primero. + ST (incorporación); + ST* (la incorporación se aplica únicamente a los nuevos medicamentos recetados); ST (sin cambios); - ST (eliminación)
Medicamentos especializados (SP, por sus siglas en inglés): Los medicamentos especializados son, generalmente, medicamentos de alto costo/alta tecnología que requieren condiciones especiales de despacho y control. La cobertura de medicamentos especializados varía según el plan. + SP (incorporación); SP (sin cambios); - SP (eliminación)
Nombre del medicamento Estatus del formulario
Alternativas
ACD solution -CVG Consult Your PhysicianACD-A solution -CVG Consult Your Physicianacetic acid irrigation solution -CVG Consult Your Physicianacetic acid-aluminum acetate ear drops -CVG Consult Your PhysicianActemra subcutaneous syringe CVG; PA; QL; SP Consult Your PhysicianActhar H.P. injection gel CVG; PA; QL; SP Consult Your PhysicianActimmune subcutaneous solution CVG; PA; QL; SP Consult Your PhysicianAczone topical gel -CVG Consult Your Physicianadapalene topical cream -CVG Consult Your Physicianadapalene topical gel -CVG Consult Your Physicianadapalene topical gel with pump -CVG Consult Your PhysicianAdasuve breath activated CVG; PA; QL; SP Consult Your PhysicianAdcirca tablet CVG; PA; QL; SP Consult Your PhysicianAdempas tablet CVG; PA; QL; SP Consult Your PhysicianAdrenalin nasal solution -CVG Consult Your PhysicianAdvanced DNA Medicated Collection mucosal kit -CVG Consult Your PhysicianAero Otic HC ear drops -CVG Consult Your PhysicianAfinitor Disperz tablet for oral suspension CVG; PA; QL; SP Consult Your PhysicianAfinitor tablet CVG; PA; QL; SP Consult Your PhysicianAkne-Mycin topical ointment -CVG Consult Your PhysicianAlagesic LQ oral solution -CVG Consult Your PhysicianAla-Quin topical cream -CVG Consult Your PhysicianAlcortin A topical gel -CVG Consult Your PhysicianAlcortin A topical gel packet -CVG Consult Your PhysicianAldactazide tablet -CVG Consult Your PhysicianAloquin topical gel -CVG Consult Your PhysicianAltacaine eye drops -CVG Consult Your PhysicianAltafluor eye drops -CVG Consult Your PhysicianAlvesco aerosol inhaler -CVG Consult Your Physicianamcinonide lotion -CVG Consult Your Physicianamcinonide topical cream -CVG Consult Your Physicianamcinonide topical ointment -CVG Consult Your Physicianaminocaproic acid oral solution CVG; -SP Consult Your Physicianaminocaproic acid tablet CVG; -SP Consult Your Physicianamlodipine-atorvastatin tablet -CVG Consult Your Physician
GCHJLC7SP 1016 Page 3 of 27
Nombre del medicamento Estatus del formulario
Alternativas
amyl nitrite solution for inhalation -CVG Consult Your PhysicianAnacaine topical ointment -CVG Consult Your PhysicianAna-Lex Kit rectal kit -CVG Consult Your PhysicianAna-Lex rectal cream -CVG Consult Your PhysicianAnalpram Advanced kit -CVG Consult Your PhysicianAndroid capsule -CVG Consult Your Physiciananticoag citrate phos dextrose solution -CVG Consult Your Physicianantipyrine-benzocaine ear drops -CVG Consult Your PhysicianAnucort-HC suppository -CVG Consult Your PhysicianAnusol-HC suppository -CVG Consult Your PhysicianApexiCon E topical cream -CVG Consult Your PhysicianAplenzin tablet,extended release -CVG Consult Your PhysicianApligraf disk -CVG Consult Your PhysicianAPOKYN subcutaneous cartridge CVG; QL; SP Consult Your PhysicianAptivus capsule CVG; QL; SP Consult Your PhysicianAptivus oral solution CVG; QL; SP Consult Your PhysicianAqua Glycolic HC topical combo pack -CVG Consult Your PhysicianAranesp (in polysorbate) injection solution CVG; PA; QL; SP Consult Your PhysicianAranesp (in polysorbate) injection syringe CVG; PA; QL; SP Consult Your PhysicianArcalyst subcutaneous solution -CVG Consult Your PhysicianArcapta Neohaler capsule with inhalation device -CVG Consult Your PhysicianArmour Thyroid tablet CVG; Tier (2/3) Consult Your PhysicianArnuity Ellipta powder for inhalation +CVG; QL Consult Your PhysicianArtiss topical syringe -CVG Consult Your PhysicianAscomp with Codeine capsule -CVG Consult Your PhysicianAsmanex HFA aerosol inhaler -CVG Consult Your PhysicianAsmanex Twisthaler breath activated -CVG Consult Your Physicianaspirin-dipyridamole ER capsule,ext.release 12 hr multiphas
+CVG; +ST Consult Your Physician
Astringyn topical solution -CVG Consult Your PhysicianAtelvia tablet,delayed release -CVG Consult Your PhysicianAtrapro CP topical pack,cream and gel -CVG Consult Your PhysicianAtrapro Dermal Spray topical spray -CVG Consult Your PhysicianAtrapro Hydrogel topical -CVG Consult Your PhysicianATRIPLA tablet CVG; QL; SP Consult Your Physicianatropine eye ointment -CVG Consult Your PhysicianAubagio tablet -CVG Consult Your PhysicianAugmentin oral suspension -CVG Consult Your PhysicianAuroguard ear drops -CVG Consult Your PhysicianAurstat topical gel -CVG Consult Your PhysicianAuryxia tablet CVG; QL; SP Consult Your PhysicianAvar LS topical pads -CVG Consult Your PhysicianAvar topical cleanser -CVG Consult Your PhysicianAvar topical pads -CVG Consult Your Physician
GCHJLC7SP 1016 Page 4 of 27
Nombre del medicamento Estatus del formulario
Alternativas
Avar-E Green topical cream -CVG Consult Your PhysicianAvar-E topical cream -CVG Consult Your PhysicianAVC Vaginal cream -CVG Consult Your PhysicianAvidoxy DK kit -CVG Consult Your PhysicianAVO Cream topical emulsion -CVG Consult Your PhysicianAvonex (with albumin) intramuscular kit -CVG Consult Your PhysicianAvonex intramuscular pen injector -CVG Consult Your PhysicianAvonex intramuscular pen kit -CVG Consult Your PhysicianAvonex intramuscular syringe -CVG Consult Your PhysicianAvonex intramuscular syringe kit -CVG Consult Your PhysicianAzasan tablet -CVG Consult Your PhysicianAzelex topical cream -CVG Consult Your PhysicianBaraclude oral solution CVG; QL; SP Consult Your Physicianbelladonna alkaloids-opium rectal suppository -CVG Consult Your PhysicianBelladonna-Opium rectal suppository -CVG Consult Your PhysicianBensal HP topical ointment -CVG Consult Your PhysicianBenzac AC Wash topical cleanser -CVG Consult Your PhysicianBenzac W Wash topical cleanser -CVG Consult Your PhysicianBenzaclin Pump topical gel -CVG Consult Your PhysicianBenzamycinPak topical gel -CVG Consult Your PhysicianBenzePrO (microspheres) topical cleanser -CVG Consult Your PhysicianBenzePrO towelette -CVG Consult Your Physicianbenzoyl peroxide topical cleanser -CVG Consult Your Physicianbenzoyl peroxide topical foam -CVG Consult Your Physicianbetamethasone valerate topical foam -CVG Consult Your PhysicianBetaseron subcutaneous kit CVG; PA; QL; SP Consult Your PhysicianBetaseron subcutaneous solution CVG; PA; QL; SP Consult Your PhysicianBethkis solution for nebulization CVG; PA; QL; SP Consult Your PhysicianBetoptic S eye drops,suspension -CVG Consult Your Physicianbexarotene capsule +CVG; +PA*; QL; SP Consult Your PhysicianBinosto effervescent tablet -CVG Consult Your PhysicianBioGlo eye strips -CVG Consult Your PhysicianBionect topical cream -CVG Consult Your PhysicianBionect topical foam -CVG Consult Your PhysicianBionect topical gel -CVG Consult Your PhysicianBionect topical spray -CVG Consult Your PhysicianBosulif tablet CVG; PA; QL; SP Consult Your PhysicianBP 10-1 topical cleanser -CVG Consult Your PhysicianBP-50% Urea topical emulsion -CVG Consult Your PhysicianBPO topical gel -CVG Consult Your PhysicianBPO towelette -CVG Consult Your PhysicianBrintellix tablet -CVG Consult Your PhysicianBucalsep mucosal solution -CVG Consult Your PhysicianBucalsep mucosal spray -CVG Consult Your Physician
GCHJLC7SP 1016 Page 5 of 27
Nombre del medicamento Estatus del formulario
Alternativas
budesonide suspension for nebulization +CVG Consult Your PhysicianBupap tablet -CVG Consult Your PhysicianBuphenyl tablet -CVG Consult Your PhysicianButalbital Compound with Codeine capsule -CVG Consult Your Physicianbutalbital-acetaminophen-caffeine capsule -CVG Consult Your Physicianbutalbital-acetaminophen-caffeine-codeine capsule -CVG Consult Your PhysicianButisol tablet -CVG Consult Your Physiciancalcipotriene topical ointment -CVG Consult Your Physiciancalcipotriene-betamethasone topical ointment -CVG Consult Your PhysicianCalcitrene topical ointment -CVG Consult Your PhysicianCalcium-Folic Acid-Vitamin D oral wafer -CVG Consult Your Physiciancapecitabine tablet CVG; PA; QL; SP Consult Your PhysicianCaphosol mucosal solution -CVG Consult Your PhysicianCaprelsa tablet CVG; PA; QL; SP Consult Your PhysicianCarbaglu dispersible tablet -CVG Consult Your Physiciancarbidopa tablet -CVG Consult Your PhysicianCardizem LA tablet,extended release -CVG Consult Your PhysicianCarnitor Sugar-Free oral solution -CVG Consult Your PhysicianCarticel suspension for implantation -CVG Consult Your PhysicianCayston solution for nebulization CVG; PA; QL; SP Consult Your PhysicianCelacyn topical gel with pump -CVG Consult Your PhysicianCEM-Urea topical gel -CVG Consult Your PhysicianCentany AT ointment topical kit -CVG Consult Your PhysicianCentergy DM oral drops -CVG Consult Your PhysicianCentergy oral drops -CVG Consult Your PhysicianCerdelga capsule CVG; PA; QL; SP Consult Your PhysicianCervidil vaginal insert,controlled release -CVG Consult Your PhysicianCetacaine Anesthetic topical liquid -CVG Consult Your PhysicianCetacaine topical spray -CVG Consult Your Physicianchlordiazepoxide-clidinium capsule -CVG Consult Your PhysicianCholbam capsule CVG; PA; QL; SP Consult Your Physiciancholine and magnesium salicylate oral liquid -CVG Consult Your PhysicianCiprodex ear drops,suspension -CVG Consult Your PhysicianClaris Clarifying Wash topical cleanser -CVG Consult Your PhysicianCleansing Wash topical cleanser -CVG Consult Your PhysicianClimara Pro transdermal patch -CVG Consult Your PhysicianClindacin ETZ topical kit -CVG Consult Your PhysicianClindacin Pac topical kit -CVG Consult Your PhysicianClindagel topical -CVG Consult Your Physicianclindamycin topical foam -CVG Consult Your Physicianclocortolone pivalate topical cream -CVG Consult Your PhysicianClodan Kit topical kit, shampoo & cleanser -CVG Consult Your Physiciancocaine topical solution -CVG Consult Your Physiciancolchicine tablet -CVG Consult Your Physician
GCHJLC7SP 1016 Page 6 of 27
Nombre del medicamento Estatus del formulario
Alternativas
Colcrys tablet CVG; Tier (2/3); +ST; QL
Consult Your Physician
Colestid Flavored packet -CVG Consult Your PhysicianCometriq capsule CVG; PA; QL; SP Consult Your PhysicianComfort Pac-tizanidine kit -CVG Consult Your PhysicianComplera tablet CVG; QL; SP Consult Your PhysicianComplete Formulation D3000 capsule -CVG Consult Your PhysicianComplete Formulation Pediatric oral drops -CVG Consult Your PhysicianCompound 347 gas for inhalation -CVG Consult Your PhysicianConZip capsule, extended release -CVG Consult Your PhysicianConZip capsule,extended release (25-75) -CVG Consult Your PhysicianCopaxone subcutaneous syringe CVG; PA; QL; SP Consult Your PhysicianCordran lotion -CVG mometasone topical cream;
triamcinolone acetonide lotion; hydrocortisone lotion
Cordran topical cream -CVG Consult Your PhysicianCordran topical ointment -CVG Consult Your PhysicianCormax topical solution -CVG Consult Your PhysicianCortane-B Aqueous ear drops -CVG Consult Your PhysicianCortane-B ear drops -CVG Consult Your PhysicianCortane-B lotion -CVG Consult Your PhysicianCortifoam rectal -CVG Consult Your PhysicianCortisporin-TC ear drops,suspension -CVG Consult Your PhysicianCorvita 150 tablet -CVG Consult Your PhysicianCorvite 150 tablet -CVG Consult Your PhysicianCorvite FE tablet -CVG Consult Your PhysicianCosentyx (2 Syringes) subcutaneous syringe CVG; PA; QL; SP Consult Your PhysicianCosentyx Pen (2 Pens) subcutaneous pen injector CVG; PA; QL; SP Consult Your PhysicianCosentyx Pen subcutaneous pen injector CVG; PA; QL; SP Consult Your PhysicianCosentyx subcutaneous syringe CVG; PA; QL; SP Consult Your PhysicianCrestor tablet -CVG Consult Your PhysicianCryoserv solution -CVG Consult Your PhysicianCyclogyl eye drops -CVG Consult Your PhysicianCycloset tablet -CVG Consult Your PhysicianCystaran eye drops CVG; PA; QL; SP Consult Your PhysicianCysto-Conray II urethral solution -CVG Consult Your PhysicianCystografin urethral solution -CVG Consult Your PhysicianCystografin-Dilute urethral solution -CVG Consult Your PhysicianCytra-2 oral solution -CVG Consult Your PhysicianCytra-3 oral solution -CVG Consult Your PhysicianCytra-K oral solution -CVG Consult Your PhysicianDaklinza tablet CVG; PA; QL; SP Consult Your PhysicianDaraprim tablet -CVG Consult Your Physician
GCHJLC7SP 1016 Page 7 of 27
Nombre del medicamento Estatus del formulario
Alternativas
Debacterol mucosal solution -CVG Consult Your PhysicianDebacterol mucosal swab -CVG Consult Your PhysicianDemser capsule -CVG Consult Your PhysicianDermasorb AF Complete Kit topical cream -CVG Consult Your PhysicianDermasorb HC Complete Kit topical,cleanser & lotion -CVG Consult Your PhysicianDermasorb TA Complete Kit topical cream -CVG Consult Your PhysicianDermasorb XM Complete Kit topical cream -CVG Consult Your PhysicianDermazene topical cream -CVG Consult Your Physiciandesoximetasone topical cream -CVG Consult Your Physiciandesoximetasone topical gel -CVG Consult Your Physiciandesoximetasone topical ointment -CVG Consult Your Physiciandesvenlafaxine fumarate ER tablet, extended release 24 hr
-CVG Consult Your Physician
Dex4 Glucose Bits chewable tablet -CVG Consult Your PhysicianDex4 Glucose chewable tablet -CVG Consult Your PhysicianDex4 Glucose oral gel -CVG Consult Your PhysicianDex4 Glucose oral gel packet -CVG Consult Your PhysicianDex4 Glucose oral liquid -CVG Consult Your PhysicianDex4 Glucose Pouch Pack chewable tablet -CVG Consult Your PhysicianDex4 Glucose Quick Dissolve chewable tablet -CVG Consult Your PhysicianDexilant capsule, delayed release -CVG Consult Your PhysicianDexPak 10 day tablets in a dose pack -CVG Consult Your PhysicianDexPak 13 Day tablets in a dose pack -CVG Consult Your PhysicianDexPak 6 Day tablets in a dose pack -CVG Consult Your Physiciandextrose oral liquid -CVG Consult Your PhysicianDIALYVITE 3000 tablet -CVG Consult Your PhysicianDialyvite 5000 tablet -CVG Consult Your PhysicianDialyvite Supreme D tablet -CVG Consult Your PhysicianDialyvite tablet -CVG Consult Your PhysicianDibenzyline capsule -CVG Consult Your Physiciandiclofenac topical drops -CVG Consult Your PhysicianDificid tablet CVG; +ST; QL Consult Your Physiciandiflorasone topical cream -CVG Consult Your Physiciandiflorasone topical ointment -CVG Consult Your PhysicianDipentum capsule -CVG Consult Your Physiciandoxycycline hyclate tablet +CVG Consult Your Physiciandoxycycline monohydrate capsule -CVG Consult Your Physiciandoxycycline monohydrate capsule,immediate & delay release
-CVG Consult Your Physician
doxycycline monohydrate tablet -CVG Consult Your PhysicianDrithocreme HP topical -CVG Consult Your PhysicianDulera HFA aerosol inhaler -CVG Consult Your PhysicianDymista nasal spray -CVG Consult Your PhysicianE.E.S. 400 tablet -CVG Consult Your PhysicianE.E.S. Granules oral suspension -CVG Consult Your Physician
GCHJLC7SP 1016 Page 8 of 27
Nombre del medicamento Estatus del formulario
Alternativas
Ecoza topical foam -CVG Consult Your PhysicianEdecrin tablet -CVG Consult Your PhysicianEdurant tablet CVG; QL; SP Consult Your PhysicianEgrifta subcutaneous solution CVG; PA; QL; SP Consult Your PhysicianElestrin transdermal gel pump -CVG Consult Your PhysicianEletone topical cream -CVG Consult Your PhysicianElidel topical cream CVG; Tier (3/2) Consult Your PhysicianElla tablet CVG; Tier (3/2); QL Consult Your PhysicianEmbeda capsule, extend release, oral only +CVG; QL Consult Your PhysicianEmulsion SB topical emulsion -CVG Consult Your PhysicianEnbrel subcutaneous solution CVG; PA; QL; SP Consult Your PhysicianEnbrel subcutaneous syringe CVG; PA; QL; SP Consult Your PhysicianEnbrel SureClick subcutaneous pen injector CVG; PA; QL; SP Consult Your PhysicianEndo Avitene topical sheets -CVG Consult Your PhysicianEnlyte (ferrous glycine cystein) capsule,immed,delay release
-CVG Consult Your Physician
entecavir tablet CVG; QL; SP Consult Your PhysicianEntero Vu oral liquid -CVG Consult Your PhysicianEntero Vu oral packet -CVG Consult Your PhysicianEpiCeram topical emulsion, extended release -CVG Consult Your PhysicianEpifoam topical -CVG Consult Your PhysicianEpisil gel forming solution -CVG Consult Your PhysicianEpivir oral solution -CVG Consult Your PhysicianEpogen injection solution CVG; PA; QL; SP Consult Your PhysicianEpzicom tablet CVG; QL; SP Consult Your PhysicianErivedge capsule CVG; PA; QL; SP Consult Your PhysicianErtaczo topical cream -CVG Consult Your PhysicianEryPed 200 oral suspension -CVG Consult Your PhysicianEryPed 400 oral suspension -CVG Consult Your PhysicianErythrocin (as stearate) tablet -CVG Consult Your Physicianerythromycin capsule,delayed release -CVG Consult Your Physicianerythromycin ethylsuccinate tablet -CVG Consult Your Physicianerythromycin tablet -CVG Consult Your PhysicianEsopho-Cat oral cream -CVG Consult Your Physicianethyl acetate liquid -CVG Consult Your Physicianethyl chloride topical spray -CVG Consult Your PhysicianEvotaz tablet CVG; QL; SP Consult Your PhysicianExelderm topical cream -CVG Consult Your PhysicianExelderm topical solution -CVG Consult Your PhysicianExelon transdermal patch -CVG Consult Your PhysicianExjade dispersible tablet CVG; PA; QL; SP Consult Your PhysicianExoderm lotion -CVG Consult Your PhysicianExotic-HC ear drops -CVG Consult Your PhysicianE-Z Disk tablet -CVG Consult Your Physician
GCHJLC7SP 1016 Page 9 of 27
Nombre del medicamento Estatus del formulario
Alternativas
E-Z-CAT DRY oral powder packet -CVG Consult Your PhysicianE-Z-Dose with Liquid Polibar Plus enema -CVG Consult Your PhysicianE-Z-HD Barium oral suspension -CVG Consult Your PhysicianE-Z-Paque oral powder for suspension -CVG Consult Your PhysicianE-Z-Paste oral cream -CVG Consult Your PhysicianFabior topical foam -CVG Consult Your PhysicianFareston tablet CVG; QL; SP Consult Your PhysicianFarydak capsule CVG; PA; QL; SP Consult Your PhysicianFemhrt Low Dose tablet -CVG Consult Your Physicianfenofibrate capsule -CVG Consult Your Physicianfenofibrate micronized capsule -CVG Consult Your Physicianfenofibric acid (choline) capsule,delayed release -CVG Consult Your Physicianfenofibric acid tablet -CVG Consult Your PhysicianFentora buccal tablet, effervescent -CVG Consult Your PhysicianFerriprox tablet CVG; PA; QL; SP Consult Your PhysicianFioricet capsule -CVG Consult Your PhysicianFioricet with Codeine capsule -CVG Consult Your PhysicianFirazyr subcutaneous syringe CVG; PA; QL; SP Consult Your PhysicianFlector transdermal 12 hour patch -CVG Consult Your PhysicianFloriva (fluoride-vitamin D3) oral drops -CVG Consult Your PhysicianFloriva chewable tablet -CVG Consult Your PhysicianFlucaine eye drops -CVG Consult Your Physicianfluocinonide topical cream -CVG Consult Your Physicianfluorescein-benoxinate eye drops -CVG Consult Your Physicianfluorescein-proparacaine eye drops -CVG Consult Your PhysicianFlurox eye drops -CVG Consult Your PhysicianFocalgin-B tablet -CVG Consult Your PhysicianFolbic tablet -CVG Consult Your PhysicianForadil Aerolizer capsule with inhalation device -CVG Consult Your PhysicianFormadon topical solution -CVG Consult Your PhysicianFormadon topical solution with applicator -CVG Consult Your Physicianformaldehyde topical solution with applicator -CVG Consult Your PhysicianForma-Ray solution -CVG Consult Your PhysicianForteo subcutaneous pen injector CVG; PA; QL; SP Consult Your PhysicianFosamax Plus D tablet -CVG Consult Your PhysicianFul-Glo eye strips -CVG Consult Your PhysicianFulyzaq tablet,delayed release -CVG Consult Your PhysicianFuzeon subcutaneous solution CVG; QL; SP Consult Your PhysicianGastroMARK oral suspension -CVG Consult Your PhysicianGattex 30-Vial subcutaneous kit CVG; PA; QL; SP Consult Your PhysicianGattex One-Vial subcutaneous kit CVG; PA; QL; SP Consult Your PhysicianGelclair mucosal gel packet -CVG Consult Your PhysicianGelfilm for the eye -CVG Consult Your PhysicianGelfilm implant -CVG Consult Your Physician
GCHJLC7SP 1016 Page 10 of 27
Nombre del medicamento Estatus del formulario
Alternativas
Gelfoam Compressed Size 100 sponge -CVG Consult Your PhysicianGelfoam mucosal powder -CVG Consult Your PhysicianGelfoam sponge -CVG Consult Your PhysicianGelfoam Sponge Size 100 -CVG Consult Your PhysicianGelfoam Sponge Size 12-7mm -CVG Consult Your PhysicianGelfoam Sponge Size 200 -CVG Consult Your PhysicianGelfoam Sponge Size 50 -CVG Consult Your PhysiciangelX mucosal gel -CVG Consult Your PhysicianGenadur (with Lexinal) kit -CVG Consult Your PhysicianGenadur topical liquid -CVG Consult Your PhysicianGeneress Fe chewable tablet -CVG Consult Your PhysicianGenotropin MiniQuick subcutaneous syringe CVG; PA; QL; SP Consult Your PhysicianGenotropin subcutaneous cartridge CVG; PA; QL; SP Consult Your PhysicianGilenya capsule CVG; PA; QL; SP Consult Your PhysicianGilotrif tablet CVG; PA; QL; SP Consult Your PhysicianGlatopa subcutaneous syringe -CVG Consult Your PhysicianGleevec tablet -CVG Consult Your Physicianglucagon HCl solution for injection -CVG Consult Your PhysicianGluco Burst oral gel -CVG Consult Your PhysicianGluco Shot oral liquid -CVG Consult Your PhysicianGlucose Bits chewable tablet -CVG Consult Your Physicianglucose chewable tablet -CVG Consult Your PhysicianGlucose Gel oral gel -CVG Consult Your Physicianglutaraldehyde solution -CVG Consult Your Physicianglycine irrigation solution -CVG Consult Your PhysicianGlycine Urologic irrigation solution -CVG Consult Your PhysicianGordons Urea topical ointment -CVG Consult Your PhysicianGranulex topical spray -CVG Consult Your Physicianguaiacol liquid -CVG Consult Your PhysicianHalog topical cream -CVG Consult Your PhysicianHalog topical ointment -CVG Consult Your PhysicianHarvoni tablet CVG; PA; QL; SP Consult Your PhysicianHetlioz capsule CVG; PA; QL; SP Consult Your PhysicianHexalen capsule CVG; QL; SP Consult Your PhysicianHomatropaire eye drops -CVG Consult Your Physicianhomatropine eye drops -CVG Consult Your PhysicianHorizant ER tablet,extended release -CVG Consult Your PhysicianHPR Plus topical cream -CVG Consult Your PhysicianHPR Plus topical foam -CVG Consult Your PhysicianHPR Plus-MB HydroGel topical pack,gel & foam -CVG Consult Your PhysicianHPR topical foam -CVG Consult Your PhysicianHumalog KwikPen subcutaneous -CVG Consult Your PhysicianHumalog Mix 50-50 KwikPen subcutaneous -CVG Consult Your PhysicianHumalog Mix 50-50 subcutaneous suspension -CVG Consult Your Physician
GCHJLC7SP 1016 Page 11 of 27
Nombre del medicamento Estatus del formulario
Alternativas
Humalog Mix 75-25 KwikPen subcutaneous -CVG Consult Your PhysicianHumalog Mix 75-25 subcutaneous suspension -CVG Consult Your PhysicianHumalog subcutaneous cartridge -CVG Consult Your PhysicianHumalog subcutaneous solution -CVG Consult Your PhysicianHumira Pediatric Crohn's Starter subcutaneous syringe kit
CVG; PA; QL; SP Consult Your Physician
Humira Pen Crohn's-Ulc Col-Hidr Sup Starter subcutaneous kit
CVG; PA; QL; SP Consult Your Physician
Humira Pen Psoriasis Starter subcutaneous kit CVG; PA; QL; SP Consult Your PhysicianHumira Pen subcutaneous CVG; PA; QL; SP Consult Your PhysicianHumira subcutaneous syringe kit CVG; PA; QL; SP Consult Your PhysicianHumulin 70/30 KwikPen subcutaneous -CVG Consult Your PhysicianHumulin 70/30 subcutaneous suspension -CVG Consult Your PhysicianHumulin N KwikPen subcutaneous -CVG Consult Your PhysicianHumulin N subcutaneous suspension -CVG Consult Your PhysicianHumulin R injection solution -CVG Consult Your PhysicianHumulin R U-500 (Concentrated) Insulin subcutaneous solution
-CVG Consult Your Physician
Hycamtin capsule CVG; QL; SP Consult Your Physicianhydrocortisone acetate rectal suppository -CVG Consult Your Physicianhydrocortisone acetate-aloe vera topical gel -CVG Consult Your Physicianhydrocortisone topical cream -CVG Consult Your Physicianhydrocortisone-iodoquinol-aloe vera topical cream packet
-CVG Consult Your Physician
hydrocortisone-pramox-E-pram#1 kit,rectal cream, towelette
-CVG Consult Your Physician
hydrocortisone-pramoxine rectal cream -CVG Consult Your Physicianhydrocortisone-pramoxine topical cream -CVG Consult Your Physicianhydromorphone ER tablet,extended release 24 hr -CVG Consult Your Physicianhydroxocobalamin intramuscular solution CVG; Tier (2/1) Consult Your PhysicianHyophen tablet -CVG Consult Your PhysicianHypercare topical solution -CVG Consult Your PhysicianHyper-Sal solution for nebulization -CVG Consult Your PhysicianIbrance capsule CVG; PA; QL; SP Consult Your PhysicianIclusig tablet CVG; PA; QL; SP Consult Your PhysicianImbruvica capsule CVG; PA; QL; SP Consult Your PhysicianIncrelex subcutaneous solution CVG; PA; QL; SP Consult Your PhysicianInderal XL capsule,extended release -CVG Consult Your PhysicianIndiclor solution -CVG Consult Your PhysicianInfanate Balance capsule -CVG Consult Your PhysicianInfludo oral liquid -CVG Consult Your PhysicianInlyta tablet CVG; PA; QL; SP Consult Your PhysicianInnoPran XL capsule,extended release -CVG Consult Your PhysicianInova 4-1 topical combo pack -CVG Consult Your PhysicianInova 8-2 topical combo pack -CVG Consult Your Physician
GCHJLC7SP 1016 Page 12 of 27
Nombre del medicamento Estatus del formulario
Alternativas
Inova topical combo pack -CVG Consult Your PhysicianIntelence tablet CVG; QL; SP Consult Your PhysicianIntron A injection solution CVG; PA; QL; SP Consult Your PhysicianIntron A solution for injection CVG; PA; QL; SP Consult Your PhysicianInvirase capsule CVG; QL; SP Consult Your PhysicianInvirase tablet CVG; QL; SP Consult Your PhysicianIodoflex topical pads -CVG Consult Your Physicianiodoquinol-HC topical cream -CVG Consult Your PhysicianIodosorb topical gel -CVG Consult Your PhysicianIressa tablet CVG; PA; QL; SP Consult Your PhysicianIsentress chewable tablet CVG; QL; SP Consult Your PhysicianIsentress oral powder packet CVG; QL; SP Consult Your PhysicianIsentress tablet CVG; QL; SP Consult Your Physicianisoflurane inhalation liquid -CVG Consult Your Physicianisometheptene-caffeine-acetaminophen tablet -CVG Consult Your Physicianisometheptene-dichloralphenazone-acetaminophen capsule
-CVG Consult Your Physician
Isopto Hyoscine eye drops -CVG Consult Your Physicianisoxsuprine tablet -CVG Consult Your PhysicianIstalol eye drops -CVG Consult Your PhysicianIV Prep Wipes medicated -CVG Consult Your PhysicianJakafi tablet CVG; PA; QL; SP Consult Your PhysicianJuxtapid capsule CVG; PA; QL; SP Consult Your PhysicianKaletra tablet CVG; QL; SP Consult Your PhysicianKalydeco oral granules in packet CVG; PA; QL; SP Consult Your PhysicianKalydeco tablet CVG; PA; QL; SP Consult Your PhysicianKenalog topical aerosol -CVG Consult Your PhysicianKerafoam topical -CVG Consult Your PhysicianKeralyt Scalp Complete kit,shampoo and gel -CVG Consult Your Physicianketoconazole topical foam -CVG Consult Your PhysicianKetodan Kit topical combo pack -CVG Consult Your PhysicianKetodan topical foam -CVG Consult Your PhysicianKineret subcutaneous syringe -CVG Consult Your Physiciankit for preparation of Tc 99m-sodium thiosulfate solution
-CVG Consult Your Physician
Klor-Con M15 tablet,extended release CVG; Tier (1/2) Consult Your PhysicianKlor-Con oral packet -CVG Consult Your PhysicianKlor-Con/25 oral packet -CVG Consult Your PhysicianKorlym tablet CVG; PA; QL; SP Consult Your PhysicianK-Phos No 2 tablet CVG; Tier (2/3) Consult Your PhysicianK-Tab tablet,extended release -CVG Consult Your PhysicianKynamro subcutaneous syringe CVG; PA; QL; SP Consult Your PhysicianLacrisert eye inserts -CVG Consult Your Physicianlactated ringers irrigation solution -CVG Consult Your PhysicianLactic Acid E topical cream -CVG Consult Your Physician
GCHJLC7SP 1016 Page 13 of 27
Nombre del medicamento Estatus del formulario
Alternativas
lactic acid lotion -CVG Consult Your PhysicianLatrix topical suspension -CVG Consult Your PhysicianLatrix XM topical emulsion pump -CVG Consult Your PhysicianLenvima capsule CVG; PA; QL; SP Consult Your PhysicianLetairis tablet CVG; PA; QL; SP Consult Your PhysicianLeukine solution for injection CVG; PA; QL; SP Consult Your PhysicianLexiva oral suspension CVG; QL; SP Consult Your PhysicianLexiva tablet CVG; QL; SP Consult Your Physicianlidocaine HCl topical cream -CVG Consult Your Physicianlidocaine laryngotracheal solution -CVG Consult Your Physicianlidocaine lotion -CVG Consult Your Physicianlidocaine mucosal solution -CVG Consult Your Physicianlidocaine topical ointment -CVG Consult Your Physicianlidocaine-hydrocortisone rectal cream -CVG Consult Your Physicianlidocaine-hydrocortisone rectal gel -CVG Consult Your Physicianlidocaine-hydrocortisone rectal kit -CVG Consult Your Physicianlidocaine-hydrocortisone topical cream -CVG Consult Your Physicianlidocaine-hydrocortisone-aloe vera rectal gel -CVG Consult Your Physicianlidocaine-hydrocortisone-aloe vera rectal kit -CVG Consult Your Physicianlidocaine-prilocaine topical cream -CVG Consult Your Physicianlidocaine-prilocaine topical kit -CVG Consult Your Physicianlidocaine-tetracaine topical cream -CVG Consult Your PhysicianLipochol Plus tablet -CVG Consult Your PhysicianLiquid E-Z Paque oral suspension -CVG Consult Your PhysicianLiquid Polibar oral suspension -CVG Consult Your PhysicianLiquid Polibar Plus oral suspension -CVG Consult Your PhysicianLoestrin 1.5/30 (21) tablet -CVG Consult Your PhysicianLoestrin Fe 1.5/30 (28-Day) tablet -CVG Consult Your PhysicianLofibra capsule -CVG Consult Your PhysicianLofibra tablet -CVG Consult Your PhysicianLonsurf tablet CVG; PA; QL; SP Consult Your PhysicianLorzone tablet -CVG Consult Your PhysicianLotronex tablet -CVG Consult Your PhysicianLoutrex topical cream -CVG Consult Your PhysicianLupaneta Pack (1 month) kit,syringe & tablet CVG; PA; QL; SP Consult Your PhysicianLupaneta Pack (3 month) kit,syringe & tablet CVG; PA; QL; SP Consult Your PhysicianLuzu topical cream -CVG clotrimazole topical cream; econazole
topical cream; ketoconazole topical cream
Lycelle topical gel -CVG Consult Your PhysicianLynparza capsule CVG; PA; QL; SP Consult Your PhysicianMagneBind 400 tablet -CVG Consult Your PhysicianMB HydroGel (cyclomethicone) topical kit,cream and gel -CVG Consult Your PhysicianMB HydroGel topical kit,cream and gel -CVG Consult Your PhysicianMD-Gastroview oral solution -CVG Consult Your Physician
GCHJLC7SP 1016 Page 14 of 27
Nombre del medicamento Estatus del formulario
Alternativas
Medrol tablet -CVG Consult Your PhysicianMegace ES oral suspension -CVG Consult Your Physicianmegestrol oral suspension CVG; -ST Consult Your PhysicianMekinist tablet CVG; PA; QL; SP Consult Your PhysicianMe-PB-Hyos oral elixir -CVG Consult Your PhysicianMe-PB-Hyos tablet -CVG Consult Your PhysicianMephyton tablet -CVG Consult Your Physicianmesalamine with cleansing wipes rectal enema kit -CVG Consult Your PhysicianMestinon syrup -CVG Consult Your PhysicianMeter-Check solution +CVG Consult Your Physicianmethenamine hippurate tablet -CVG Consult Your Physicianmethenamine mandelate tablet -CVG Consult Your Physicianmethotrexate sodium (PF) injection solution +CVG Consult Your Physicianmethotrexate sodium injection solution +CVG Consult Your Physicianmethoxsalen rapid capsule CVG; +SP Consult Your PhysicianMethylin chewable tablet -CVG Consult Your PhysicianMetozolv ODT disintegrating tablet -CVG Consult Your PhysicianMigergot rectal suppository -CVG Consult Your PhysicianMigragesic IDA capsule -CVG Consult Your PhysicianMinocin Kit with Wipes combo pack -CVG Consult Your PhysicianMirapex ER tablet,extended release -CVG Consult Your PhysicianMitosol ophthalmic kit -CVG Consult Your PhysicianModeriba Dose Pack tablets CVG; QL; -SP Consult Your PhysicianMonsel's topical solution -CVG Consult Your PhysicianMonsel's topical solution with applicator -CVG Consult Your PhysicianMorgidox capsule -CVG doxycycline monohydrate capsule;
minocycline capsulemorphine ER capsule,ext.release24hr multiphase -CVG Consult Your Physicianmorphine ER capsule,extended release pellets -CVG Consult Your PhysicianMucotrol oral wafer -CVG Consult Your PhysicianMuGard mucosal solution -CVG Consult Your PhysicianMultaq tablet CVG; Tier (2/3); QL Consult Your PhysicianMuri-Lube oil -CVG Consult Your PhysicianMvc-Fluoride chewable tablet CVG; Tier (2/3); QL Consult Your PhysicianMyalept subcutaneous solution CVG; PA; QL; SP Consult Your PhysicianNaftin topical cream -CVG Consult Your PhysicianNaftin topical gel -CVG Consult Your PhysicianNalfon capsule -CVG Consult Your PhysicianNamenda oral solution -CVG Consult Your PhysicianNasonex Spray -CVG Consult Your PhysicianNebuSal solution for nebulization -CVG Consult Your PhysicianNeosalus lotion -CVG Consult Your PhysicianNeosalus topical cream -CVG Consult Your PhysicianNeosalus topical foam -CVG Consult Your Physician
GCHJLC7SP 1016 Page 15 of 27
Nombre del medicamento Estatus del formulario
Alternativas
Nephplex Rx tablet -CVG Consult Your PhysicianNephrocaps Qt disintegrating tablet -CVG Consult Your PhysicianNeuac topical gel -CVG Consult Your PhysicianNeulasta subcutaneous syringe CVG; PA; QL; SP Consult Your PhysicianNeulasta with wearable subcutaneous injector CVG; PA; QL; SP Consult Your PhysicianNeumega subcutaneous solution CVG; QL; SP Consult Your PhysicianNeupogen injection solution -CVG Consult Your PhysicianNeupogen injection syringe -CVG Consult Your PhysicianNeurin-SL sublingual tablet -CVG Consult Your PhysicianNeutrasal mucosal powder in packet -CVG Consult Your PhysicianNexavar tablet CVG; PA; QL; SP Consult Your PhysicianNexium Packet granules delayed release for susp -CVG Consult Your PhysicianNilandron tablet CVG; QL; SP Consult Your Physiciannimodipine capsule -CVG Consult Your Physiciannitroglycerin ER capsule,extended release -CVG Consult Your PhysicianNitro-Time capsule,extended release -CVG Consult Your PhysicianNiva-Fol tablet -CVG Consult Your PhysicianNivatopic Plus topical cream -CVG Consult Your PhysicianNodolor capsule -CVG Consult Your PhysicianNorinyl 1+50 (28) tablet CVG; Tier (3/2) Consult Your PhysicianNoritate topical cream -CVG Consult Your PhysicianNormlgel Ag topical -CVG Consult Your PhysicianNorthera capsule CVG; PA; QL; SP Consult Your PhysicianNovacort topical gel -CVG Consult Your PhysicianNovaFerrum oral solution -CVG Consult Your PhysicianNovolin 70/30 subcutaneous suspension +CVG Consult Your PhysicianNovolin N subcutaneous suspension +CVG Consult Your PhysicianNovolin R injection solution +CVG Consult Your PhysicianNovolog Flexpen subcutaneous +CVG Consult Your PhysicianNovolog Mix 70-30 FlexPen subcutaneous +CVG Consult Your PhysicianNovolog Mix 70-30 subcutaneous solution +CVG Consult Your PhysicianNovolog PenFill subcutaneous cartridge +CVG Consult Your PhysicianNovolog subcutaneous solution +CVG Consult Your PhysicianNucort lotion -CVG Consult Your PhysicianNucynta tablet -CVG Consult Your PhysicianNumoisyn lozenges -CVG Consult Your PhysicianNumoisyn oral mucosal liquid -CVG Consult Your PhysicianNuOx topical gel -CVG Consult Your PhysicianNutropin AQ Nuspin subcutaneous cartridge -CVG Consult Your PhysicianNutropin AQ subcutaneous cartridge -CVG Consult Your PhysicianNuvail nail film solution -CVG Consult Your PhysicianNuvigil tablet -CVG Consult Your PhysicianOdomzo capsule CVG; PA; QL; SP Consult Your Physician
GCHJLC7SP 1016 Page 16 of 27
Nombre del medicamento Estatus del formulario
Alternativas
Ofev capsule CVG; PA; QL; SP Consult Your PhysicianOleptro ER tablet,extended release -CVG Consult Your Physicianomeprazole-sodium bicarbonate capsule -CVG Consult Your PhysicianOmnaris nasal spray -CVG Consult Your PhysicianOpsumit tablet CVG; PA; QL; SP Consult Your PhysicianOracea capsule,immediate & delay release -CVG Consult Your PhysicianOracit oral solution -CVG Consult Your PhysicianOrafate mucosal paste -CVG Consult Your PhysicianOrap tablet -CVG Consult Your PhysicianOrenitram tablet,extended release CVG; PA; QL; SP Consult Your PhysicianOrkambi tablet CVG; PA; QL; SP Consult Your PhysicianOrtho Tri-Cyclen Lo (28) tablet -CVG Consult Your PhysicianOsphena tablet -CVG Consult Your PhysicianOtezla Starter tablets in a dose pack CVG; PA; QL; SP Consult Your PhysicianOtezla tablet CVG; PA; QL; SP Consult Your PhysicianOtic Care (antipyrine) ear drops -CVG Consult Your PhysicianOticin ear drops -CVG Consult Your PhysicianOticin HC (BAK free) ear drops -CVG Consult Your PhysicianOto-End 10 ear drops -CVG Consult Your PhysicianOtomax-HC ear drops -CVG Consult Your PhysicianOtozin ear drops -CVG Consult Your PhysicianOtrexup (PF) subcutaneous auto-injector -CVG Consult Your PhysicianOvace Plus lotion -CVG Consult Your PhysicianOvace Plus topical cleanser,extended release -CVG Consult Your PhysicianOvace Plus topical cream -CVG Consult Your PhysicianOxalis topical ointment -CVG Consult Your PhysicianOxistat lotion -CVG Consult Your PhysicianOxistat topical cream -CVG Consult Your PhysicianOxsoralen lotion -CVG Consult Your PhysicianOxtellar XR tablet,extended release -CVG Consult Your Physicianoxymorphone ER tablet,extended release,12 hr CVG; +ST; QL Consult Your PhysicianPacnex HP topical pads -CVG Consult Your PhysicianPacnex LP topical pads -CVG Consult Your PhysicianPacnex MX topical cleanser -CVG Consult Your PhysicianPandel topical cream -CVG Consult Your PhysicianPCE particles in tablet -CVG Consult Your PhysicianPediaderm AF topical cream -CVG Consult Your PhysicianPediaderm HC kit,lotion & cream,emollient -CVG Consult Your PhysicianPediaderm TA topical cream -CVG Consult Your PhysicianPediatric Multivitamins-A,B,D,E,K,Zn oral drops -CVG Consult Your PhysicianPegIntron Redipen subcutaneous kit CVG; PA; QL; SP Consult Your PhysicianPegIntron subcutaneous kit CVG; PA; QL; SP Consult Your PhysicianPennsaid topical soln in metered-dose pump -CVG Consult Your Physicianphenol liquid -CVG Consult Your Physician
GCHJLC7SP 1016 Page 17 of 27
Nombre del medicamento Estatus del formulario
Alternativas
phenoxybenzamine capsule CVG; +SP Consult Your PhysicianPhosphasal tablet -CVG Consult Your PhysicianPhysiolyte irrigation solution -CVG Consult Your PhysicianPhysiosol Irrigation solution -CVG Consult Your PhysicianPinnacaine ear drops -CVG Consult Your PhysicianPlexion Cleansing Cloths -CVG Consult Your PhysicianPliaglis topical cream -CVG Consult Your PhysicianPodocon topical liquid -CVG Consult Your PhysicianPolibar ACB enema -CVG Consult Your PhysicianPoly-Vi-Flor biphasic oral drops -CVG Consult Your PhysicianPoly-Vi-Flor chewable tablet -CVG Consult Your PhysicianPoly-Vi-Flor with Iron biphasic oral drops -CVG Consult Your PhysicianPoly-Vi-Flor with Iron chewable tablet -CVG Consult Your PhysicianPomalyst capsule CVG; PA; QL; SP Consult Your PhysicianPontocaine topical solution -CVG Consult Your Physicianpot & sod citrate-citric acid oral solution -CVG Consult Your Physicianpotassium chloride oral packet -CVG Consult Your Physicianpotassium citrate-citric acid oral solution -CVG Consult Your Physicianpotassium hydroxide topical solution -CVG Consult Your PhysicianPR Benzoyl Peroxide topical cleanser -CVG Consult Your PhysicianPR Cream topical -CVG Consult Your PhysicianPraluent Pen subcutaneous pen injector CVG; PA; QL; SP Consult Your PhysicianPraluent Syringe subcutaneous CVG; PA; QL; SP Consult Your PhysicianPramCort rectal cream -CVG Consult Your PhysicianPramosone E topical cream -CVG Consult Your PhysicianPramosone topical ointment -CVG Consult Your Physicianprednisolone disintegrating tablet -CVG Consult Your PhysicianPrepidil vaginal gel -CVG Consult Your PhysicianPresera topical foam -CVG Consult Your PhysicianPrezcobix tablet CVG; QL; SP Consult Your PhysicianPrezista oral suspension CVG; QL; SP Consult Your PhysicianPrezista tablet CVG; QL; SP Consult Your PhysicianPrismasol B22GK hemodialysis solution -CVG Consult Your PhysicianPrismasol BGK hemodialysis solution -CVG Consult Your PhysicianPrismasol BK hemodialysis solution -CVG Consult Your PhysicianProcort rectal cream -CVG Consult Your PhysicianProcrit injection solution CVG; PA; QL; SP Consult Your PhysicianProctofoam HC -CVG Consult Your PhysicianProcysbi capsule,delayed release sprinkle CVG; PA; QL; SP Consult Your PhysicianPromacta tablet CVG; PA; QL; SP Consult Your PhysicianPromiseb Complete top,cleanser and cream kit -CVG Consult Your PhysicianPromiseb topical cream -CVG Consult Your PhysicianProstin E2 vaginal suppository -CVG Consult Your PhysicianProThelial mucosal paste -CVG Consult Your Physician
GCHJLC7SP 1016 Page 18 of 27
Nombre del medicamento Estatus del formulario
Alternativas
Provida OB capsule CVG; Tier (3/2) Consult Your PhysicianProvocholine solution for inhalation -CVG Consult Your PhysicianPruClair topical cream -CVG Consult Your PhysicianPrudoxin topical cream -CVG Consult Your PhysicianPruMyx topical cream -CVG Consult Your PhysicianPruTect topical emulsion -CVG Consult Your PhysicianPsorcon topical cream -CVG Consult Your PhysicianPulmicort Flexhaler breath activated -CVG Consult Your PhysicianPulmosal solution for nebulization -CVG Consult Your PhysicianPulmozyme solution for inhalation CVG; QL; SP Consult Your PhysicianPyrogallic Acid topical ointment -CVG Consult Your PhysicianQNASL nasal aerosol spray -CVG Consult Your PhysicianQuartette tablets,3 month dose pack CVG; Tier (3/2); QL Consult Your PhysicianQuillivant XR oral suspension,extend release 24hr -CVG Consult Your PhysicianQutenza topical kit -CVG Consult Your PhysicianQvar Metered Aerosol Oral Inhaler -CVG Consult Your PhysicianRadiagel topical -CVG Consult Your PhysicianRadiaPlexRx topical gel -CVG Consult Your PhysicianRadigel Acemannan Hydrogel topical -CVG Consult Your PhysicianRavicti oral liquid -CVG Consult Your PhysicianRayos tablet,delayed release -CVG Consult Your PhysicianRea Lo 39 topical cream -CVG Consult Your PhysicianRea Lo 40 lotion -CVG Consult Your PhysicianRea Lo 40 topical cream -CVG Consult Your PhysicianReadi-Cat 2 oral suspension -CVG Consult Your PhysicianReadi-Cat oral suspension -CVG Consult Your PhysicianRebif (with albumin) subcutaneous syringe CVG; PA; QL; SP Consult Your PhysicianRebif Rebidose subcutaneous pen injector CVG; PA; QL; SP Consult Your PhysicianRebif Titration Pack subcutaneous syringe CVG; PA; QL; SP Consult Your PhysicianRecothrom Spray Kit topical solution -CVG Consult Your PhysicianRecothrom topical solution -CVG Consult Your PhysicianRectacort-HC rectal suppository -CVG Consult Your PhysicianRegenecare topical gel -CVG Consult Your PhysicianRegenecare with Aloe topical gel -CVG Consult Your PhysicianRelagard vaginal gel -CVG Consult Your PhysicianReliOn Glucose oral liquid -CVG Consult Your PhysicianRelistor subcutaneous solution -CVG Consult Your PhysicianRelistor subcutaneous syringe -CVG Consult Your PhysicianRemeven topical cream -CVG Consult Your PhysicianRenvela oral powder packet CVG; Tier (1/2); QL calcium acetate tablet; sevelamer
carbonate tabletRenvela tablet CVG; Tier (1/2); QL calcium acetate tablet; sevelamer
carbonate tabletReprexain tablet -CVG Consult Your PhysicianRevatio oral suspension CVG; PA; QL; SP Consult Your Physician
GCHJLC7SP 1016 Page 19 of 27
Nombre del medicamento Estatus del formulario
Alternativas
Revesta capsule -CVG Consult Your PhysicianRevlimid capsule CVG; PA; QL; SP Consult Your PhysicianReyataz capsule CVG; QL; SP Consult Your PhysicianRibasphere RibaPak tablets in a dose pack CVG; QL; -SP Consult Your Physicianriluzole tablet CVG; -SP Consult Your PhysicianRosadan top,cleanser and cream kit -CVG Consult Your PhysicianRosadan topical cleanser & gel kit -CVG Consult Your PhysicianRosanil topical cleanser -CVG Consult Your PhysicianRoxicet oral solution CVG; Tier (2/3); QL Consult Your PhysicianSabril oral powder packet CVG; PA; QL; SP Consult Your PhysicianSabril tablet CVG; PA; QL; SP Consult Your Physiciansaccharin powder -CVG Consult Your PhysicianSafyral tablet CVG; Tier (3/2) Consult Your PhysicianSalacyn lotion -CVG Consult Your PhysicianSalacyn topical cream -CVG Consult Your Physiciansalicylic acid ER lotion,extended release -CVG Consult Your Physiciansalicylic acid ER topical cream,extended release -CVG Consult Your Physiciansalicylic acid lotion -CVG Consult Your Physiciansalicylic acid shampoo -CVG Consult Your Physiciansalicylic acid SR-ceramides 1,3,6-11 top kit,clnsr,cream ER
-CVG Consult Your Physician
salicylic acid SR-ceramides 1,3,6-11 topical combo pack -CVG Consult Your Physiciansalicylic acid topical cream -CVG Consult Your Physiciansalicylic acid topical film-forming liquid -CVG Consult Your Physiciansalicylic acid topical foam -CVG Consult Your Physiciansalicylic acid topical gel -CVG Consult Your Physiciansalicylic acid topical liquid -CVG Consult Your PhysicianSalvax Duo Plus topical foam -CVG Consult Your PhysicianSalvax topical foam -CVG Consult Your PhysicianSamsca tablet CVG; QL; SP Consult Your PhysicianScalacort lotion -CVG Consult Your PhysicianSeb-Prev topical cleanser -CVG Consult Your PhysicianSeconal Sodium capsule -CVG Consult Your PhysicianSelect-OB + DHA oral pack +CVG Consult Your Physicianselenium sulfide shampoo -CVG Consult Your PhysicianSelRx shampoo -CVG Consult Your PhysicianSelzentry tablet CVG; QL; SP Consult Your PhysicianSeroquel XR tablet, ER 24 hr dose pack -CVG Consult Your PhysicianSeroquel XR tablet,extended release -CVG Consult Your PhysicianSerostim subcutaneous solution CVG; PA; QL; SP Consult Your Physiciansevoflurane inhalation liquid -CVG Consult Your PhysicianShohl's Modified oral solution -CVG Consult Your PhysicianSiderol oral liquid -CVG Consult Your PhysicianSignifor subcutaneous solution CVG; PA; QL; SP Consult Your Physician
GCHJLC7SP 1016 Page 20 of 27
Nombre del medicamento Estatus del formulario
Alternativas
Silenor tablet -CVG Consult Your Physiciansilver nitrate applicators topical stick -CVG Consult Your Physiciansilver nitrate topical ointment -CVG Consult Your Physiciansilver nitrate topical solution -CVG Consult Your PhysicianSilvrStat topical gel -CVG Consult Your PhysicianSimponi subcutaneous pen injector CVG; PA; QL; SP Consult Your PhysicianSimponi subcutaneous pen injector -CVG Consult Your PhysicianSimponi subcutaneous syringe CVG; PA; QL; SP Consult Your PhysicianSimponi subcutaneous syringe -CVG Consult Your PhysicianSitzmarks capsule -CVG Consult Your PhysicianSklice lotion -CVG Consult Your Physiciansodium citrate-citric acid oral solution -CVG Consult Your Physiciansodium polystyrene sulfonate oral suspension -CVG Consult Your Physiciansodium succinate powder -CVG Consult Your PhysicianSojourn inhalation liquid -CVG Consult Your PhysicianSomatuline Depot subcutaneous syringe CVG; PA; QL; SP Consult Your PhysicianSomavert subcutaneous solution CVG; PA; QL; SP Consult Your PhysicianSonafine topical emulsion -CVG Consult Your Physiciansorbitol irrigation solution -CVG Consult Your Physiciansorbitol solution -CVG Consult Your PhysicianSovaldi tablet CVG; PA; QL; SP Consult Your PhysicianSpray And Stretch topical -CVG Consult Your PhysicianSprycel tablet CVG; PA; QL; SP Consult Your PhysicianSS 10-2 topical cleanser -CVG Consult Your PhysicianSSS 10-5 topical cream -CVG Consult Your PhysicianSSS 10-5 topical foam -CVG Consult Your PhysicianStivarga tablet CVG; PA; QL; SP Consult Your PhysicianStriant buccal system,sustained release -CVG Consult Your PhysicianStribild tablet CVG; QL; SP Consult Your PhysicianSubsys sublingual spray -CVG Consult Your Physiciansulfacetamide sodium shampoo -CVG Consult Your Physiciansulfacetamide sodium topical cleanser -CVG Consult Your Physiciansulfacetamide sodium topical cleanser, gel -CVG Consult Your Physiciansulfacetamide sodium-sulfur lotion -CVG Consult Your Physiciansulfacetamide sodium-sulfur topical cleanser -CVG Consult Your Physiciansulfacetamide sodium-sulfur topical cream -CVG Consult Your Physiciansulfacetamide sodium-sulfur topical foam -CVG Consult Your Physiciansulfacetamide sodium-sulfur topical pads -CVG Consult Your Physiciansulfacetamide sodium-sulfur topical suspension -CVG Consult Your Physiciansulfacetamide sodium-sulfur-urea topical cleanser -CVG Consult Your Physiciansulfacetamide sodium-sulfur-urea topical gel -CVG Consult Your Physiciansulfacetamide-sulfur-skin cleanser no.23 topical kit -CVG Consult Your PhysicianSulfaCleanse 8-4 topical suspension -CVG Consult Your Physiciansulfact sod-sulfur-avobnz-octin-octyl sal top cpcc -CVG Consult Your Physician
GCHJLC7SP 1016 Page 21 of 27
Nombre del medicamento Estatus del formulario
Alternativas
Supervite oral liquid -CVG Consult Your PhysicianSuprax oral suspension -CVG Consult Your PhysicianSurfaxin intratracheal suspension -CVG Consult Your PhysicianSustiva capsule CVG; QL; SP Consult Your PhysicianSustiva tablet CVG; QL; SP Consult Your PhysicianSutent capsule CVG; PA; QL; SP Consult Your PhysicianSylatron 4-Pack subcutaneous kit CVG; PA; QL; SP Consult Your PhysicianSylatron subcutaneous kit CVG; PA; QL; SP Consult Your PhysicianSymax Duotab tablet,extended release -CVG Consult Your PhysicianSynarel nasal spray CVG; PA; QL; SP Consult Your PhysicianSyringe Avitene topical powder -CVG Consult Your PhysicianTabloid tablet CVG; Tier (2/3); QL Consult Your PhysicianTaclonex topical suspension -CVG Consult Your PhysicianTafinlar capsule CVG; PA; QL; SP Consult Your PhysicianTAGITOL V oral suspension -CVG Consult Your PhysicianTarceva tablet CVG; PA; QL; SP Consult Your PhysicianTargretin capsule +CVG; +PA*; QL; SP Consult Your PhysicianTasigna capsule CVG; PA; QL; SP Consult Your PhysicianTasmar tablet -CVG Consult Your PhysicianTazorac topical cream -CVG Consult Your PhysicianTazorac topical gel -CVG Consult Your PhysicianTecfidera capsule,delayed release -CVG Consult Your Physiciantelmisartan tablet CVG; -ST; QL Consult Your Physiciantemozolomide capsule CVG; PA; QL; SP Consult Your PhysicianTerrell inhalation liquid -CVG Consult Your PhysicianTersi Foam topical -CVG Consult Your PhysicianTestred capsule -CVG Consult Your PhysicianTetcaine eye drops -CVG Consult Your Physiciantetrabenazine tablet CVG; PA; QL; SP Consult Your Physiciantetracaine eye drops -CVG Consult Your Physiciantetracaine HCl (PF) eye drops -CVG Consult Your PhysicianTetravisc Forte hyperviscous drops -CVG Consult Your PhysicianTetravisc Forte hyperviscous eye dropperette -CVG Consult Your PhysicianTetravisc viscous eye drops -CVG Consult Your PhysicianTetravisc viscous eye drops in a dropperette -CVG Consult Your PhysicianTexacort topical solution -CVG Consult Your PhysicianThalomid capsule CVG; PA; QL; SP Consult Your PhysicianThrombi-Gel topical pads -CVG Consult Your PhysicianThrombin-JMI nasal spray syringe -CVG Consult Your PhysicianThrombin-JMI topical solution -CVG Consult Your PhysicianThrombin-JMI topical spray -CVG Consult Your PhysicianThrombin-JMI topical spray syringe -CVG Consult Your PhysicianTimoptic Ocudose (PF) eye drops in a dropperette -CVG Consult Your Physician
GCHJLC7SP 1016 Page 22 of 27
Nombre del medicamento Estatus del formulario
Alternativas
Tisseel VHSD topical kit -CVG Consult Your PhysicianTisseel VHSD topical syringe -CVG Consult Your PhysicianTivicay tablet CVG; QL; SP Consult Your Physiciantizanidine capsule -CVG Consult Your PhysicianTL G-Fol OS tablet -CVG Consult Your PhysicianTL Triseb (with telmesteine) topical cream -CVG Consult Your PhysicianTobi Podhaler capsule with inhalation device CVG; PA; QL; SP Consult Your PhysicianTobi Podhaler capsules for inhalation CVG; PA; QL; SP Consult Your Physiciantolcapone tablet -CVG Consult Your PhysicianTopicort topical cream -CVG Consult Your PhysicianTopicort topical ointment -CVG Consult Your PhysicianTopicort topical spray -CVG Consult Your PhysicianTracleer tablet CVG; PA; QL; SP Consult Your Physiciantravoprost (benzalkonium) eye drops -CVG Consult Your Physiciantretinoin (chemotherapy) capsule CVG; PA; QL; SP Consult Your Physiciantretinoin microspheres topical gel -CVG Consult Your Physiciantretinoin microspheres topical gel with pump -CVG Consult Your Physiciantriacetin liquid -CVG Consult Your Physiciantriamcinolone acetonide topical aerosol -CVG Consult Your PhysicianTrianex topical ointment -CVG Consult Your PhysicianTri-Chlor topical solution -CVG Consult Your Physiciantrichloroacetic acid topical powder for solution -CVG Consult Your PhysicianTricitrates oral solution -CVG Consult Your PhysicianTriglide tablet -CVG Consult Your PhysicianTriOxin ear drops,suspension -CVG Consult Your PhysicianTriumeq tablet CVG; QL; SP Consult Your PhysicianTri-Vi-Floro oral drops -CVG Consult Your PhysicianTrokendi XR capsule,extended release -CVG Consult Your PhysicianTropazone Cream topical -CVG Consult Your PhysicianTropazone Lotion topical -CVG Consult Your PhysicianTRUEplus Glucose chewable tablet -CVG Consult Your PhysicianTRUEplus Glucose oral gel -CVG Consult Your PhysicianTRUEplus Glucose oral liquid -CVG Consult Your PhysicianTruvada tablet CVG; QL; SP Consult Your PhysicianTussiCaps capsule,extended release -CVG Consult Your PhysicianTykerb tablet CVG; PA; QL; SP Consult Your PhysicianTyvaso Institutional Starter Kit solution for nebulization CVG; PA; QL; SP Consult Your PhysicianTyvaso Refill Kit solution for nebulization CVG; PA; QL; SP Consult Your PhysicianTyvaso solution for nebulization CVG; PA; QL; SP Consult Your PhysicianTyvaso Starter Kit solution for nebulization CVG; PA; QL; SP Consult Your PhysicianTyzeka tablet CVG; QL; SP Consult Your PhysicianU-Cort topical cream -CVG Consult Your PhysicianUltraSal-ER topical film-forming soln w/ appl -CVG Consult Your PhysicianUltravate X topical combo pack -CVG Consult Your Physician
GCHJLC7SP 1016 Page 23 of 27
Nombre del medicamento Estatus del formulario
Alternativas
Ultravate X topical pack,ointment and cream -CVG Consult Your PhysicianUmecta Nail Film Pen -CVG Consult Your PhysicianUmecta PD topical emulsion -CVG Consult Your PhysicianUmecta PD topical suspension -CVG Consult Your PhysicianUmecta topical emulsion -CVG Consult Your PhysicianUmecta topical foam -CVG Consult Your PhysicianUmecta topical suspension -CVG Consult Your PhysicianUnistik 2 Extra kit CVG; Tier (3/2) Consult Your PhysicianUR N-C tablet -CVG Consult Your PhysicianUramaxin topical foam -CVG Consult Your PhysicianUrea (with la & sal acid) topical suspension -CVG Consult Your PhysicianUrea 50% topical emulsion -CVG Consult Your Physicianurea lotion -CVG Consult Your Physicianurea nail film suspension -CVG Consult Your PhysicianUrea Nail Stick topical solution -CVG Consult Your Physicianurea topical cream -CVG Consult Your Physicianurea topical foam -CVG Consult Your Physicianurea topical gel -CVG Consult Your Physicianurea-hyaluronate sodium topical kit -CVG Consult Your PhysicianUrelle tablet -CVG Consult Your PhysicianUribel capsule -CVG Consult Your PhysicianURIMAR-T tablet -CVG Consult Your PhysicianUrin DS tablet -CVG Consult Your PhysicianUro-Blue tablet -CVG Consult Your PhysicianUro-L tablet -CVG Consult Your PhysicianUro-MP capsule -CVG Consult Your PhysicianUryl tablet -CVG Consult Your PhysicianUstell capsule -CVG Consult Your PhysicianUtira-C tablet -CVG Consult Your PhysicianUtopic topical cream -CVG Consult Your PhysicianValchlor topical gel CVG; PA; QL; SP Consult Your PhysicianVanatol LQ oral solution -CVG Consult Your PhysicianVanoxide-HC topical suspension -CVG Consult Your PhysicianVantas implant kit -CVG Consult Your PhysicianVaribar Honey oral suspension -CVG Consult Your PhysicianVaribar Nectar oral suspension -CVG Consult Your PhysicianVaribar Pudding oral paste -CVG Consult Your PhysicianVaribar Thin Honey oral suspension -CVG Consult Your PhysicianVaribar Thin Liquid oral powder -CVG Consult Your PhysicianVasolex topical ointment -CVG Consult Your PhysicianVenelex topical ointment -CVG Consult Your Physicianvenlafaxine ER tablet,extended release 24 hr -CVG Consult Your PhysicianVentavis solution for nebulization CVG; PA; QL; SP Consult Your Physician
GCHJLC7SP 1016 Page 24 of 27
Nombre del medicamento Estatus del formulario
Alternativas
Veramyst nasal spray,suspension -CVG fluticasone nasal spray,suspension; flunisolide nasal spray; Nasonex Spray
Verdeso topical foam -CVG Consult Your PhysicianViracept tablet CVG; QL; SP Consult Your PhysicianViramune XR tablet,extended release -CVG Consult Your PhysicianViread oral powder CVG; QL; SP Consult Your PhysicianViread tablet CVG; QL; SP Consult Your PhysicianVirti-Sulf topical cream -CVG Consult Your PhysicianVirtrate-2 oral solution -CVG Consult Your PhysicianVirtrate-3 oral solution -CVG Consult Your PhysicianVirtrate-K oral solution -CVG Consult Your PhysicianVirt-Vite Forte tablet -CVG Consult Your PhysicianVirt-Vite Plus tablet CVG; Tier (2/3) Consult Your PhysicianVitekta tablet CVG; QL; SP Consult Your PhysicianVoltaren topical gel CVG; Tier (1/2) diclofenac sodium tablet,delayed
release; naproxen tablet; meloxicam tablet
Volumen oral suspension -CVG Consult Your PhysicianVotrient tablet CVG; PA; QL; SP Consult Your PhysicianVusion topical ointment -CVG Consult Your PhysicianVytone topical cream packet -CVG Consult Your PhysicianVytorin 10-10 tablet CVG; +ST; QL Consult Your PhysicianVytorin 10-20 tablet CVG; +ST; QL Consult Your PhysicianVytorin 10-40 tablet CVG; +ST; QL Consult Your PhysicianVytorin 10-80 tablet CVG; +ST; QL Consult Your Physicianwater for irrigation, sterile solution -CVG Consult Your PhysicianXalkori capsule CVG; PA; QL; SP Consult Your PhysicianXclair topical cream -CVG Consult Your PhysicianXeljanz tablet CVG; PA; QL; SP Consult Your PhysicianXenazine tablet -CVG Consult Your PhysicianXolegel topical -CVG Consult Your PhysicianXopenex HFA aerosol inhaler CVG; +ST; QL Consult Your PhysicianXtandi capsule CVG; PA; QL; SP Consult Your PhysicianX-VIATE lotion -CVG Consult Your PhysicianX-VIATE topical cream -CVG Consult Your PhysicianX-VIATE topical gel -CVG Consult Your PhysicianXyrem oral solution CVG; PA; QL; SP Consult Your PhysicianYodoxin tablet -CVG Consult Your PhysicianZarxio injection syringe CVG; PA; QL; SP Consult Your PhysicianZavesca capsule -CVG Consult Your PhysicianZelapar disintegrating tablet -CVG Consult Your PhysicianZelboraf tablet CVG; PA; QL; SP Consult Your PhysicianZencia topical cleanser -CVG Consult Your PhysicianZenzedi tablet -CVG Consult Your Physician
GCHJLC7SP 1016 Page 25 of 27
Nombre del medicamento Estatus del formulario
Alternativas
Zetonna nasal HFA inhaler -CVG Consult Your PhysicianZithranol shampoo -CVG Consult Your PhysicianZithranol-RR topical cream rapid release -CVG Consult Your PhysicianZolinza capsule CVG; PA; QL; SP Consult Your PhysicianZonatuss capsule -CVG Consult Your PhysicianZorbtive subcutaneous solution CVG; PA; QL; SP Consult Your PhysicianZovirax topical cream -CVG Consult Your PhysicianZuplenz oral soluble film -CVG Consult Your PhysicianZyclara topical cream packet -CVG Consult Your PhysicianZyclara topical cream pump -CVG Consult Your PhysicianZydelig tablet CVG; PA; QL; SP Consult Your PhysicianZykadia capsule CVG; PA; QL; SP Consult Your PhysicianZytiga tablet CVG; PA; QL; SP Consult Your PhysicianZyvox oral suspension -CVG Consult Your PhysicianZyvox tablet -CVG Consult Your Physician
Humana.com
Humana Plans are offered by the Family of Insurance and Health Plan Companies including Humana Medical Plan, Inc., Humana Employers Health Plan of Georgia, Inc., Humana Health Plan, Inc., Humana Health Benefit Plan of Louisiana, Inc., Humana Health Plans of Michigan, Inc., Humana Health Plan of Ohio, Inc., Humana Health Plans of Puerto Rico, Inc. License # 00235-0008, Humana Wisconsin Health Organization Insurance Corporation, or Humana Health Plan of Texas, Inc. – A Health Maintenance Organization or insured by Humana Health Insurance Company of Florida, Inc., Humana Health Plan, Inc., Humana Health Benefit Plan of Louisiana, Inc., Humana Insurance Company, Humana Insurance Company of Kentucky, Emphesys Insurance Company, or Humana Insurance of Puerto Rico, Inc. License # 00187-0009 or administered by Humana Insurance Company or Humana Health Plan, Inc.
For Arizona Residents: Offered by Humana Health Plan, Inc. or insured by Emphesys Insurance Company or insured or administered by Humana Insurance Company or Humana Health Plan, Inc.
Please refer to your Benefit Plan Document (Certificate of Coverage/Insurance or Summary Plan Description) for more information on the company providing your benefits.
Our health benefit plans have limitations and exclusions.
GCHJLC7SP 1016 Page 26 of 27
La discriminación es contra la ley Humana Inc. y sus filiales (“Humana”) cumplen con todas las leyes aplicables de derechos civiles federales y no discriminan por motivos de raza, color de la piel, origen nacional, edad, discapacidad o sexo. Humana no excluye ni trata de manera diferente a nadie por motivos de raza, color de la piel, origen nacional, edad, discapacidad o sexo. Humana proporciona:
Ayudas y servicios auxiliares gratuitos, como por ejemplo intérpretes acreditados para hablar por señas, interpretación remota por video e información escrita en otros formatos para personas con discapacidades cuando dichas ayudas y servicios auxiliares sean necesarios para garantizar la igualdad de oportunidades de participación.
Servicios gratuitos de idiomas para personas cuyo idioma principal no es el inglés, cuando dichos servicios sean necesarios para proporcionar acceso útil, tales como documentos traducidos o interpretación oral.
Si necesita estos servicios, llame al número que figura en su tarjeta de identificación o envíe un correo electrónico a [email protected]; si utiliza un TTY, llame al 711.
Si usted cree que Humana ha fallado en proveer estos servicios o discriminado de otra forma por motivos de raza, color de la piel, origen nacional, edad, discapacidad o sexo, puede presentar una queja formal ante: Discrimination Grievances P.O. Box 14618 Lexington, KY 40512 - 4618 Si necesita ayuda para presentar una queja formal, llame al número que figura en su tarjeta de identificación o bien, si utiliza un TTY, llame al 711. También puede presentar una queja de derechos civiles ante el Departamento de Salud y Servicios Humanos de los Estados Unidos, Oficina de Derechos Civiles, por medios electrónicos a través del portal de quejas de la Oficina de Derechos Civiles, disponible en https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, o por correo postal o por teléfono a: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD) Los formularios para quejas están disponibles en http://www.hhs.gov/ocr/office/file/index.html
GCHJLC7SP 1016 Page 27 of 27
Multi-Language Interpreter ServicesEnglish: ATTENTION: If you do not speak English, language assistance services, free of charge, are available to you. Call the number on your ID card (TTY: 711).
Español (Spanish): ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al número que figura en su tarjeta de identificación (TTY: 711).
繁體中文 (Chinese): 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電會員卡上的電話號碼（TTY： 711）。Tiếng Việt (Vietnamese): CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số điện thoại ghi trên thẻ ID của quý vị (TTY: 711).
한국어 (Korean): 주의 : 한국어를 사용하시는 경우 , 언어 지원 서비스를 무료로 이용하실 수 있습니다 . ID 카드에 적혀 있는 번호로 전화해 주십시오 (TTY: 711).
Tagalog (Tagalog – Filipino): PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tawagan ang numero na nasa iyong ID card (TTY: 711).
Русский (Russian): ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Наберите номер, указанный на вашей карточке-удостоверении (телетайп: 711).
Kreyòl Ayisyen (French Creole): ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele nimewo ki sou kat idantite manm ou (TTY: 711).
Français (French): ATTENTION : Si vous parlez français, des services d’aide linguistique vous sont proposés gratuitement. Appelez le numéro figurant sur votre carte de membre (ATS : 711).
Polski (Polish): UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Proszę zadzwonić pod numer podany na karcie identyfikacyjnej (TTY: 711).
Português (Portuguese): ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para o número presente em seu cartão de identificação (TTY: 711).
Italiano (Italian): ATTENZIONE: In caso la lingua parlata sia l’italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero che appare sulla tessera identificativa (TTY: 711).
Deutsch (German): ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Wählen Sie die Nummer, die sich auf Ihrer Versicherungskarte befindet (TTY: 711).
日本語 (Japanese): 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。お手持ちの ID カードに記載されている電話番号までご連絡ください (TTY：711)。
:(Farsi) فارسی توجه: اگر به زبان فارسی گفتگو می کنید، تسهیلات زبانی بصورت رایگان برای شما فراھم می باشد.
.(TTY: 711) با شماره تلفن روی کارت شناسایی تان تماس بگیرید
:(Arabic) العربيةملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم الهاتف
الموجود على بطاقة الهوية الخاصة بك )رقم هاتف الصم والبكم: 711).
