drug formulary example lamictal


0000027668 00000 n It is displayed next to the equivalent Formulary Generic Drug that is available at the lowest copay.

4. 0000012543 00000 n

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0000012227 00000 n trailer 0000004355 00000 n 0000013201 00000 n 0000090649 00000 n 0000032781 00000 n For example a drug may be listed in tier 1 … 0000012617 00000 n

• Non-Bolded Drug = Formulary Brand available at middle copay • Drug in Parenthesis ( ) = Non-Formulary Brand Drug available at the highest copay. 0000091415 00000 n startxref 0000003945 00000 n 0000007081 00000 n 0000010502 00000 n

Generic drugs on the formulary may not have the equivalent brand name product listed. 0000090930 00000 n

��n�W�����?����� Y� � endstream endobj 804 0 obj <>/Metadata 18 0 R/Pages 17 0 R/StructTreeRoot 20 0 R/Type/Catalog/ViewerPreferences<>>> endobj 805 0 obj <>/Font<>/ProcSet[/PDF/Text]/Properties<>>>>>/Rotate 0/StructParents 0/TrimBox[0.0 0.0 612.0 792.0]/Type/Page>> endobj 806 0 obj <>stream

0000075684 00000 n 0000003806 00000 n 0000015564 00000 n 0000002075 00000 n 0000040735 00000 n

0000008809 00000 n

0000029155 00000 n

non-formulary/Tier 3 or may no longer be covered by your prescription drug plan. 0000033337 00000 n It is displayed next to the equivalent Formulary Generic Drug that is available at the lowest copay. 165 0 obj<>stream 0000033609 00000 n xref 803 0 obj <> endobj xref 803 44 0000000016 00000 n h�b```g``�������A�X��,-7[�0 �`��r���e�`�FGG���� +�I�AR@� �f`�����)�e�g�b��P���f���đ�v�ݐ×-�A����8�?�g�� ��#���(��)�Y?�&�0΅;���i�z����pQa��@��7 ��(� endstream endobj 845 0 obj <>/Filter/FlateDecode/Index[20 783]/Length 47/Size 803/Type/XRef/W[1 1 1]>>stream
* Unless specifically excluded from your contract. 0000002895 00000 n 0000016323 00000 n

endstream endobj 124 0 obj<> endobj 125 0 obj<> endobj 126 0 obj<>/Font<>/ProcSet[/PDF/Text]/ExtGState<>>> endobj 127 0 obj<> endobj 128 0 obj[/ICCBased 153 0 R] endobj 129 0 obj[/Separation/Black 128 0 R 154 0 R] endobj 130 0 obj[/Separation/PANTONE#20293#20CV 128 0 R 159 0 R] endobj 131 0 obj<>stream The brand-name medications below are excluded on the formulary. 123 0 obj <> endobj 0000031825 00000 n 0000002272 00000 n
0000001455 00000 n 0000017452 00000 n 0000062373 00000 n Drug Formulary (Comprehensive list of covered drugs) HPMS Approved Formulary File Submission ID 18119, Version Number 15 ... • You can ask us to waive coverage restrictions or limits on your drug. PA PRIOR AUTHORIZATION REQUIRED – Prior authorization is the process of obtaining approval of benefits before certain prescriptions may be filled.

H�\�ˊ�@@���Zv/�$U�V� ��\̃q�bR:�1����dž�ᘇ�܂����m�&�ޟ�]̡i�>^�׾�f�M����M5 Coordinated Services Program (CSP) The State of Ohio permits MCPs to develop and implement programs to assist certain members that have received drugs that are not medically necessary to establish and maintain a relationship with one provider and/or pharmacy to coordinate treatment. 0000003018 00000 n h��ѡ 0ð4�����7 For the most up-to-date information, please visit independenthealth.com. 0000014324 00000 n 0000074600 00000 n {��^A��W�+��ʚy�L�L� ��s�M87�܄s�M97�ܔ~�_�W��~�_�W��~�_�W��~�_iV��f�Y�Qx���h0���h0���h0���h0�34���1x���8C��34��8C��f��h6��3t���w��~���w��~���w��~���w��~���w��~���%�Ԣ�r�����\ST�!�8�8��V �wA}�t LW�t�q��.~�N��i��� �AA endstream endobj 807 0 obj <> endobj 808 0 obj <>stream

x�b```f``������Z� �� �@Q�)H��pFC�f�*���-L��L7X�����2�`c��|��>;�E�"qf��̾Lߙ'�x��fV`|���� u���U��ց�kkW��u5�+8�8"Q�ɱ�ղ�7�e��Ვ?y�&�\�[KcO޶?b�m!�@�8So�:u���޴�lP�wŢ;%�l2MN@C]��W��,�xBEuz�TM�i[cJ�?h!�l�,�d���@����`��Xw�K7�8���̥��� �Gu��8�|e�>��C�(����ybJp��p�((@�Kn��/��]�4▖���$���������8BJJ��dll��� ׀s��4�epĊ��� �VH�����\���ԋ0��]�����>ЌT�]���bS��*|L�6����5.g�l�l�`OPN�t��P�z��q �k�,�I�?B �L��� M�Lw8?\=\$��wC �G^��&�h6����2rS*�-��"Ɵ�pb; �b`�x-�f �+m 0000002270 00000 n %PDF-1.4 %���� Products are listed in their most represented tier. 0000005563 00000 n 0000020135 00000 n 0000020205 00000 n 0000001156 00000 n "�� .�q�4)��C��~��4=0B�GR��q�*�춻�C�}���8�S�5C�]�C�1��.+�д���k�__}�����m��]w�f�e����qx��us=��,�64qh�sx���?�|��?��1��j�xJ/�r�.1�Ӷ�]�����%����磏��~���&��C�Cw��r�>��|O�U����vC�,�x6K_)�!ϙ����y������ΜJ��Y�U�\ ��%r�\!� +�"�S�S9�#�V�V�V�V�2��,�� 0000075222 00000 n 0000005699 00000 n 0000004920 00000 n

0000001652 00000 n

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