Requesting an Exception to the Formulary You can ask Network Health Insurance Corporation to make an exception to our coverage rules. Generally, we will only approve your request for an exception if alternative formulary drugs would not be as effective in treating your condition and would have a negative effect on your health. Contact us to ask for an initial coverage decision for a formulary, tier or utilization restriction (specific criteria) exception. When you re requesting an exception, please submit a statement from your physician supporting your request. For more detailed information about your Network Health Insurance Corporation prescription drug coverage, please review your Evidence of Coverage and other plan materials. Rasuvo 27.5 mg/0.55 March 1 st, Rasuvo 25 mg/0.5 ml 4 ml Clindamax 1% March 1 st, Clindamycin 1% 2 Zazole 0.8% Vaginal March 1 st, Terconazole 0.8% Cream 2 Lokara 0.05% Lotion March 1 st, Desowen 0.05% Lotion 4 Acetasol HC Ear Drops March 1 st, Hydrocortison-Acetic Acid Sol. 2 Aminosyn II 7% IV March 1 st, Contact your prescriber Sol. Ampicillin 125 mg/5ml March 1 st, Amoxicillin 125 mg/5 ml 2 Ampicillin 250 mg March 1 st, Amoxicillin 250 mg Cap 2 Cap. Ampicillin 250 mg/5ml March 1 st, Amoxicillin 250 mg/5 ml 2 Axiron 30 mg/act Sol. March 1 st, Testosterone 30 mg/1.5 ml Pump 3 Bromfenac Sod 0.09% March 1 st, Prolensa 0.07% Eye Drop 4 Eye Drop Budesonide 32 mcg March 1 st, Fluticasone Prop 50 mcg Spray 2 Nasal Spray Doribax 500 mg vial March 1 st, Doripenem 500 mg vial 4 Engerix-B 10 March 1 st, Engerix-B Pedi 10 mcg/0.5 Syr. 3 mcg/0.5ml Eliphos 667 mg Tab March 1 st, Calcium Acetate 667 mg Tab 2 Fortaz 1 gm Twistvial March 1 st, Ceftazidime 1 gm Vial 2 Updated 8/ 1
Fortaz 2 gm Twistvial March 1 st, Ceftazidime 2 gm Vial 4 Fortaz 6 gm Twistvial March 1 st, Ceftazidime 6 gm Vial 2 Lioresal IT 0.05 mg/ml March 1 st, amp. Contact your prescriber Lortab 10-325 mg Tab March 1 st, Hydrocodone-Acetaminophen 10-2 325 mg Tab Lortab 5-325 mg Tab March 1 st, Hydrocodone-Acetaminophen 5-2 325 mg Tab Lortab 7.5-325 mg Tab March 1 st, Hydrocodone-Acetaminophen 2 7.5-325 mg Tab Gavilyte-H and March 1 st, Contact your prescriber Bisacodyl Kit Menomune-A-C-Y-W- March 1 st, Contact your prescriber 135 w-diluent Lomedia 24 FE 1 mg- March 1 st, Junel FE 24 Tab 2 20 mcg Tab Primsol 50 mg/5ml March 1 st, Oral Sol. Contact your prescriber 2 Sumatriptan 6 mg/0.5 March 1 st, Sumatriptan 6 mg/0.5 ml Refill 2 ml Syringe Zamicet 10-325 mg/15 March 1 st, Hydrocodone-Acetaminophen 10-2 ml Sol. 325 mg/15 ml Sol. Opana ER 10 mg Tab March 1 st, Oxymorphone ER 10 mg Tab 2 Opana ER 15 mg Tab March 1 st, Oxymorphone ER 15 mg Tab 2 Opana ER 20 mg Tab March 1 st, Oxymorphone ER 20 mg Tab 2 Opana ER 30 mg Tab March 1 st, Oxymorphone ER 30 mg Tab 2 Opana ER 40 mg Tab March 1 st, Oxymorphone ER 40 mg Tab 2 Opana ER 5 mg Tab March 1 st, Oxymorphone ER 5 mg Tab 2 Opana ER 7.5 mg Tab March 1 st, Oxymorphone ER 7.5 mg Tab 2 Talwin 30 mg/ml Vial March 1 st, Talwin 30 mg/ml amp 4 Twinrix Vaccine Vial March 1 st, Twinrix Vaccine Syringe 3 Nuvessa Vaginal 1.3% March 1 st, Vandazole Vaginal 0.75% 2 Zenchent FE Tab Chew March 1 st, Noret-Estr-FE 0.4-0.035 (21)-75 2 Updated 8/ 2
Necon 10-11-28 Tab March 1 st, Contact your prescriber Necon 1-50-28 Tab March 1 st, Contact your prescriber Neosporin Eye Drops March 1 st, Neomyc-Polym-Gramicid Eye Drop 2 Zamicet 10-325 mg/15 March 1 st, Hydrocodone-Acetaminophen 10-2 ml Sol. 325 mg/15 ml Sol. Xodol 10-300 mg Tab March 1 st, Hydrocodone-Acetaminophen 10-2 300 mg Tab Xodol 5-300 mg Tab March 1 st, Hydrocodone-Acetaminophen 5-2 300 mg Tab Xodol 7.5-300 mg Tab March 1 st, Hydrocodone-Acetaminophen 2 7.5-300 mg Tab Opana ER 10 mg Tab March 1 st, Oxymorphone ER 10 mg Tab 2 Opana ER 15 mg Tab March 1 st, Oxymorphone ER 15 mg Tab 2 Opana ER 20 mg Tab March 1 st, Oxymorphone ER 20 mg Tab 2 Opana ER 30 mg Tab March 1 st, Oxymorphone ER 30 mg Tab 2 Opana ER 40 mg Tab March 1 st, Oxymorphone ER 40 mg Tab 2 Opana ER 5 mg Tab March 1 st, Oxymorphone ER 5 mg Tab 2 Opana ER 7.5 mg Tab March 1 st, Oxymorphone ER 7.5 mg Tab 2 Ponstel 250 mg Kap. March 1 st, Mefenamic Acid 250 mg Cap 2 Talwin 30 mg/ml Vial March 1 st, Talwin 30 mg/ml amp 4 Risperdal M-Tab 2 mg March 1 st, ODT Risperidone 2 mg ODT 2 Twinrix Vaccine Vial March 1 st, Twinrix Vaccine Syringe 3 Nuvessa Vaginal 1.3% March 1 st, Vandazole Vaginal 0.75% 2 Zenchent FE Tab Chew March 1 st, Noret-Estr-FE 0.4-0.035 (21)-75 2 Norinyl 1-35 28 Tab March 1 st, Nortrel 1-35 28 Tab 2 Necon 10-11-28 Tab March 1 st, Contact your prescriber Necon 1-50-28 Tab March 1 st, Contact your prescriber Neosporin Eye Drops March 1 st, Neomyc-Polym-Gramicid Eye Drop 2 Updated 8/ 3
Ocufen 0.03% Eye March 1 st, Drops Flurbiprofen 0.03% Eye Drops 2 Cormax 0.5 mg/ml April 1 st, Clobetasol 0.05% Solution 2 Nyata 100 unit/mg April 1 st, Nystatin Powder 2 Ragwitek April 1 st, Contact your prescriber Grastek 2800 BAU Sub April 1 st, Contact your prescriber Tablet Trisenox 1mg/ml Inj May 1 st, Trisenox 12 mg/6 ml Vial 5 Synalgos-DC May 1 st, Aspirin-Caffeine-Dihydrocodeine Cap 2 Didanosine 125 mg Cap May 1 st, Videx EC 125 mg Cap 4 Gentamicin 10 mg/ml May 1 st, Inj Contact your prescriber Afrezza 90-60 (4Unit) May 1 st, Contact your prescriber Acetaminophen June 1 st, Contact your prescriber 65mg/ml-Oxycodone 1mg/ml oral solution Zenpep 40,000 Cap June 1 st, Zenpep DR 40,000 Cap 5 Zmax 33.3mg/ml June 1 st, Azithromycin 1 gm Packet 2 Ilaris 180 mg Inj. June 1 st, Ilaris 150 mg/ml Vial 5 Gengraf 50 mg Cap June 1 st, Cyclosporine Mod 50mg 2 Zinbryta 150mg/ml June 1 st, Contact your prescriber Syringe Evzio Auto-Injector June 1 st, Evzio 2 mg Auto-Injector 4 Nevirapine 10mg/ml June 1 st, Viramune 50 mg/5ml Susp 4 Oral Suspension Keytruda 50 mg Inj. June 1 st, Keytruda 100 mg/4ml Vial 5 Relpax 40 mg Tab June 1 st, Eletriptan 40 mg Tab 2 Effient 5 mg Tab June 1 st, Prasugrel 5 mg Tab 2 Renvela 800 mg Tab June 1 st, Sevelamer 800 mg Tab 5 Tamiflu 6 mg/ml Susp June 1 st, Oseltamavir 6 mg/ml Susp 2 Updated 8/ 4
Fosrenol 750 mg Chew June 1 st, Lanthanum 750 mg Chew Tab 3 Tab Sabril 50 mg/ml Oral June 1 st, Vigabatrin 50 mg/ml Oral 5 Solution Solution Fosrenol 1000 mg June 1 st, Lanthanum 1000 mg Chew Tab 3 Chew Tab Sustiva 50 mg Cap June 1 st, Efavirenz 50 mg Cap 2 Vigamox 5 mg/ml June 1 st, Moxifloxacin 5 mg/ml Ophth Sol. 2 Ophth Sol Aczone 0.05 mg/mg June 1 st, Dapsone 0.05 mg/mg 4 Coreg ER 80 mg Cap June 1 st, Carvedilol 80 mg ER Cap 3 Effient 10mg Tab June 1 st, Prasugrel 10mg Tab 2 Epiduo June 1 st, Adapalene 0.001mg/mg / Benzoyl 3 Peroxide 0.025mg/mg Relpax 20 mg Tab June 1 st, Eletriptan 20 mg Tab 2 Transderm Scop Patch June 1 st, Scopolamine 0.0139 mg/hr Patch 2 Fosrenol 500 mg Chew June 1 st, Lanthanum 500 mg Chew Tab 3 Tab Lexiva 700 mg Tab June 1 st, Fosamprenavir 700 mg Tab 5 Brisdelle 7.5mg Cap June 1 st, Paroxetine 7.5mg Cap 2 Clopidogrel 300 mg July 1 st, Clopidogrel 75 mg Tab 2 Tab Gildagia 0.4 mg-0.035 July 1 st, Contact your prescriber mg Tab Onmel 200 mg Tab July 1 st, Itraconazole 100 mg Cap 2 Gablofen 2 mg/ml Inj. August 1 st, Contact your prescriber Qvar 40 mcg Inhaler August 1 st, Qvar Redihaler 40 mcg 3 Ciprofloxacin 10 mg/ml August 1 st, Contact your prescriber PCE 333 mg Tab August 1 st, Erythromycin DR 250 mg Cap 2 Updated 8/ 5
PCE 500 mg Tab August 1 st, Erythromycin 500 mg Film Tab 2 Zovia 1/50 Tab August 1 st, Contact your prescriber Aerospan 0.08 mg/act August 1 st, Contact your prescriber Inh Triam/HCTZ 50/25 mg August 1 st, Triamterene/HCTZ 37.5/25 mg 2 Cap Cap Methotrexate 25 mg/ml August 1 st, Contact your prescriber Inj. 40 ml Renagel 400 mg Tab August 1 st, Sevelamer 800 mg Tab 5 Updated 8/ 6