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Drug ID Drug Name Tier Level Value Limits
1053651ABSTRAL 100 MCG TAB SUBLINGUALTier 5: Specialty drugsQL
1053654ABSTRAL 200 MCG TAB SUBLINGUALTier 5: Specialty drugsQL
1053657ABSTRAL 300 MCG TAB SUBLINGUALTier 5: Specialty drugsQL
1053660ABSTRAL 400 MCG TAB SUBLINGUALTier 5: Specialty drugsQL
1053663ABSTRAL 600 MCG TAB SUBLINGUALTier 5: Specialty drugsQL
1053666ABSTRAL 800 MCG TAB SUBLINGUALTier 5: Specialty drugsQL
835726acamprosate calc dr 333 mg tabTier 2: Non-preferred generic drugs*
885133ACANYA GELTier 4: Non-preferred brand drugs^
199150acarbose 100 mg tabletTier 2: Non-preferred generic drugs*,STEP,QL,^
200132acarbose 25 mg tabletTier 2: Non-preferred generic drugs*,STEP,QL,^
199149acarbose 50 mg tabletTier 2: Non-preferred generic drugs*,STEP,QL,^
261313ACCOLATE 10 MG TABLETTier 4: Non-preferred brand drugs^
211776ACCOLATE 20 MG TABLETTier 4: Non-preferred brand drugs^
207892ACCUPRIL 10 MG TABLETTier 4: Non-preferred brand drugs^
207893ACCUPRIL 20 MG TABLETTier 4: Non-preferred brand drugs^
207895ACCUPRIL 40 MG TABLETTier 4: Non-preferred brand drugs^
207891ACCUPRIL 5 MG TABLETTier 4: Non-preferred brand drugs^
809854ACCURETIC 10-12.5 MG TABLETTier 4: Non-preferred brand drugs^
809858ACCURETIC 20-12.5 MG TABLETTier 4: Non-preferred brand drugs^
882559ACCURETIC 20-25 MG TABLETTier 4: Non-preferred brand drugs^

Drugs Alphabetically

Legend

  • *: Covered in the Gap for members in Network PlatinumPlus Pharmacy and Network PlatinumPremier Pharmacy
  • #: Limited Access Medication
  • MAIL: Available through Mail Order.
  • PA: Prior Authorization
  • QL: Quantity Limit
  • STEP: Step Therapy
  • ^: Non-Preferred Product

Brand-name drugs are capitalized (e.g., SINGULAIR) and generic drugs are listed in lower-case italics (e.g., warfarin).

About the Formulary

We may add or remove drugs from our formulary during the year. If we remove drugs, 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 members who take the drug of the change at least 60 days before the change becomes effective (or when a member requests a refill). These are recent changes to the formulary. 

Generic Drugs and Brand Name Drugs

Network Health Medicare Advantage plans cover both brand name and generic drugs. Generic drugs have the same active-ingredient formula as a brand name drug. Generic drugs usually cost less than brand name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs.

What Tiers Mean

When you find your drug, it will be listed with a tier level. This is the cost-level that your drug is on, and the higher the level, the more you’ll pay. Some drugs may fall into a different tier.

Tier 1Tier 2Tier 3Tier 4Tier 5
Preferred generic drugs Non-preferred generic drugs Preferred brand drugs Non-preferred brand drugs Specialty drugs

What Requirements and Limits Mean

Some drugs may have an abbreviation in the Requirements/Limits column. This tells you if your drug has any special requirements for it to be covered. These restrictions are used to help make sure certain drugs are used safely and effectively.

Exceptions to the Formulary

You can ask Network Health Medicare Advantage plans to make an exception to our prescription drug restrictions. To do so, you should submit a statement from your physician supporting your request. You can call us to ask for an exception, submit your request by using the link below or fax or mail the form found at the link below.

Submit a Request for a Drug Coverage Determination