Selection

Results

Brand Name Generic Name	Therapeutic Class Sub-Class	Dose/Strength	Status	Notes & Restrictions
COSENTYX (2 SYRINGES) SUBCUTANEOUS SYRINGE 150 MG/ML Dermatological Antipsoriatic Agents-Interleukin-17 (Il-17) Antagonist, Mc Antibody	Dermatological Antipsoriatic Agents-Interleukin-17 (Il-17) Antagonist, Mc Antibody	SYRINGE 150 mg/mL
COSENTYX PEN (2 PENS) SUBCUTANEOUS PEN INJECTOR 150 MG/ML Dermatological Antipsoriatic Agents-Interleukin-17 (Il-17) Antagonist, Mc Antibody	Dermatological Antipsoriatic Agents-Interleukin-17 (Il-17) Antagonist, Mc Antibody	PEN INJECTOR 150 mg/mL
COSENTYX PEN SUBCUTANEOUS PEN INJECTOR 150 MG/ML Dermatological Antipsoriatic Agents-Interleukin-17 (Il-17) Antagonist, Mc Antibody	Dermatological Antipsoriatic Agents-Interleukin-17 (Il-17) Antagonist, Mc Antibody	PEN INJECTOR 150 mg/mL
COSENTYX SUBCUTANEOUS SYRINGE 150 MG/ML Dermatological Antipsoriatic Agents-Interleukin-17 (Il-17) Antagonist, Mc Antibody	Dermatological Antipsoriatic Agents-Interleukin-17 (Il-17) Antagonist, Mc Antibody	SYRINGE 150 mg/mL
COSENTYX SUBCUTANEOUS SYRINGE 75 MG/0.5 ML Dermatological Antipsoriatic Agents-Interleukin-17 (Il-17) Antagonist, Mc Antibody	Dermatological Antipsoriatic Agents-Interleukin-17 (Il-17) Antagonist, Mc Antibody	SYRINGE 75 mg/0.5 mL
SILIQ SUBCUTANEOUS SYRINGE 210 MG/1.5 ML Dermatological Antipsoriatic Agents-Interleukin-17 (Il-17) Antagonist, Mc Antibody	Dermatological Antipsoriatic Agents-Interleukin-17 (Il-17) Antagonist, Mc Antibody	SYRINGE 210 mg/1.5 mL
TALTZ AUTOINJECTOR (2 PACK) SUBCUTANEOUS AUTO-INJECTOR 80 MG/ML Dermatological Antipsoriatic Agents-Interleukin-17 (Il-17) Antagonist, Mc Antibody	Dermatological Antipsoriatic Agents-Interleukin-17 (Il-17) Antagonist, Mc Antibody	AUTO-INJECTOR 80 mg/mL
TALTZ AUTOINJECTOR (3 PACK) SUBCUTANEOUS AUTO-INJECTOR 80 MG/ML Dermatological Antipsoriatic Agents-Interleukin-17 (Il-17) Antagonist, Mc Antibody	Dermatological Antipsoriatic Agents-Interleukin-17 (Il-17) Antagonist, Mc Antibody	AUTO-INJECTOR 80 mg/mL
TALTZ AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 80 MG/ML Dermatological Antipsoriatic Agents-Interleukin-17 (Il-17) Antagonist, Mc Antibody	Dermatological Antipsoriatic Agents-Interleukin-17 (Il-17) Antagonist, Mc Antibody	AUTO-INJECTOR 80 mg/mL
TALTZ SYRINGE SUBCUTANEOUS SYRINGE 80 MG/ML Dermatological Antipsoriatic Agents-Interleukin-17 (Il-17) Antagonist, Mc Antibody	Dermatological Antipsoriatic Agents-Interleukin-17 (Il-17) Antagonist, Mc Antibody	SYRINGE 80 mg/mL

Definition of Status

Icon	Status	Definition
	Tier 1	This is the lowest cost sharing tier that includes preferred generic drugs. Details about your specific benefit for each tier are included in your Summary of Benefits.
	Tier 2	This tier includes generic drugs. Details about your specific benefit for each tier are included in your Summary of Benefits.
	Tier 3	This tier includes preferred brand name drugs and some higher cost generic drugs. Details about your specific benefit for each tier are included in your Summary of Benefits.
	Tier 4	This tier includes brand name drugs and some higher cost generic drugs. Some plans may be limited to a 30 day supply. Details about your specific benefit for each tier are included in your Summary of Benefits.
	Tier 5	This tier includes Specialty Drugs (SP) that must be obtained from Health First Family Pharmacy when possible and are limited to a 30-day supply. Details about your specific benefit for each tier are included in your Summary of Benefits.
	No Cost Share (NCS)	This tier includes some select preventive products, prescription medications and specific over-the-counter (OTC) medications available to you at no cost-sharing ($0) when applicable conditions are met.
	Non-Formulary	Your drug is not listed on the Formulary (Drug List). You can try to find a covered formulary alternative in the same therapeutic class. If this is not an option you can request an exception. To find out how to request a formulary exception please call Customer Service toll-free at 1.855.443.4735 (TTY/TDD relay: 1.800.955.8771) Monday through Friday from 8 a.m. to 6 p.m. for Health First Health Plans' or 1.844.522.5279 (TTY/TDD relay: 1.800.955.8771) Monday through Friday from 8 a.m. to 5 p.m. for Florida Hospital Care Advantage members.

Definition of Restrictions

Icon	Restriction	Definition
	Additional details	Click for additional information
	Age Restriction	Age Restriction
	Generic Indicator	This is a generic drug. 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.
	Limited Access	Limited Access
	MD	You may be taking these drugs on a long-term basis. Maintenance medications are generally those used to treat chronic conditions and long-term conditions.
	Prior Authorization	The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from The Plan before you fill your prescriptions. If you do not get approval, The Plan may not cover the drug.
	Prior Authorization - New Starts	The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from The Plan before you fill your prescriptions. If you do not get approval, The Plan may not cover the drug. Prior authorization for this drug applies to new starts only.
	Quantity Limit	For certain drugs, The Plan limits the amount of the drug that will be covered. For example, “30 EA per 30 days” would mean your coverage of this drug is limited to 30 pills every 30 days, or 1 pill per day.
	Step Therapy	In some cases, The 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 1 and Drug 2 both treat your medical condition, The Plan may not cover Drug 2 unless you try Drug 1 first. If Drug 1 does not work for you, The Plan will then cover Drug 2.