ExcellusBCBS.comB-4588/ 12295-18FLRX
INDIVIDUAL & FAMILY METAL PLANS, BASE AND ESSENTIAL PLANS FORMULARY GUIDEIncludes generic and brand-name medications
A nonprofit independent licensee of the Blue Cross Blue Shield Association
January 2019
Dear Member,
The prescription drug benefit is one of the most important and frequently
utilized elements of health plan coverage. To help you identify which
medications are covered under your plan, we are pleased to provide the
3-Tier Formulary Guide. This booklet provides you with easy to understand
information about your prescription drug coverage including descriptions of
prescription drug safety and cost-saving programs.
The 3-Tier Formulary Guide lists commonly prescribed medications and their
tier classifications. The medications listed have been approved by the Food
and Drug Administration (FDA) as safe and effective and were selected in
consultation with a team of health care professionals because they meet our
criteria for safety, quality and value. We continually review and update
our formulary.
The drugs listed in the formulary and program descriptions may not apply to all plans.
This booklet includes the Formulary Guide and prescription drug benefit information. Please refer to this booklet when you see your healthcare practioner or are prescribed a medication.
The drugs listed in the formulary and program descriptions may not apply to all plans. Please see your plan documents for a complete description of your pharmacy benefit.
If you have questions or need additional information, please visit our website, ExcellusBCBS.com or contact the Pharmacy Help Desk at 1-800-499-1275.
What is a Formulary?A formulary is a list of brand-name and generic drugs that are covered under your prescription drug benefit.
How is the Formulary Developed?Drugs listed on the formulary were selected by our independent Pharmacy and Therapeutics (P&T) Committee, which is made up of practicing health care providers and clinical pharmacists. The P&T Committee reviews each drug based upon scientific evidence, findings by federal government agencies, professional medical associations and journals to help ensure that the medications covered meet criteria for safety, effectiveness and value.
How do I use the Formulary?There are two ways to find your drug within the formulary:
Medical ConditionDrugs are listed in alphabetical order according to drug categories. For example, drugs used to treat heart conditions are listed under the category “Cardiovascular.” Drugs are listed in alphabetical order by condition.
Alphabetical ListingIf you are not sure what category to look under, look for your drug in the Index that follows the formulary. The Index provides an alphabetical listing of all of the drugs included in the formulary and the page where they can be found in the formulary.
3-Tier Drug BenefitYour 3-tier prescription drug benefit allows you to make informed choices and encourages value when choosing your prescription medications. Your copayment will vary depending on the tier in which your prescription drug is placed.
• Tier One drugs are typically generics and have the lowest copayment amount.
• Tier Two drugs are brand drugs that have unique, significant clinical advantages and offer overall greater value over the other products in the same drug class.
• Tier Three drugs are all other brand drugs, including new brand drugs and drugs that have generic equivalents. Tier Three drugs have the highest copayment amount.
The 3-Tier Formulary Guide lists commonly used medications and their tier designations. Because there are thousands of medications included in your pharmacy benefit, we list only the most commonly prescribed.
Your plan may not cover all medications listed in this booklet. Please see your plan documents for a complete description of your pharmacy benefit, or call the Pharmacy Help Desk at 1-800-499-1275.
Can the Formulary Change?Our P&T Committee regularly reviews the drugs on our formulary to be sure they meet the criteria for safety, effectiveness and value. The list is subject to change. Drugs may be added, removed, or change tier designation at any time.
Generics Are Real MedicineGeneric drugs: safe, effective, affordable! To help keep your prescription drug costs down, choose a generic drug over a brand. Generics are as safe and effective as their brand-name counterparts – they just cost a lot less.
In fact, you’ll save money when you choose a generic because generics have the lowest copay. That means you’ll always pay the lowest out-of-pocket amount for a generic.
Generic drugs treat your illness or condition with the same effectiveness and safety as their brand-name equivalents because they have to meet the same rigorous FDA requirements as brand-name drugs.
Experience has shown that more than 90 percent of members who start on a generic will stay on a generic. So the next time you need your brand prescription filled, ask your doctor or pharmacist if a generic is right for you.
Where Can I Purchase My Prescription Medications?You have access to more than 65,000 participating pharmacies in our nationwide Pharmacy Network, including national chains and most independents. Just show your Member Card at any participating pharmacy; it identifies you as having prescription drug coverage. A list of participating pharmacies in your area is available on our website, ExcellusBCBS.com
Mail Service PharmacyGet your prescriptions delivered right to your door!
When you use Express Scripts Home Delivery PharmacySM or Wegmans® Home Delivery Pharmacy, you get the convenience of home delivery and the ease of ordering new prescriptions and refills either by phone or via our website, ExcellusBCBS.com. Some benefits offer
copay savings for ordering prescriptions through Express Scripts Home Delivery PharmacySM
or Wegmans® Home Delivery Pharmacy.
Using a home delivery pharmacy is ideal for those who take prescription medication on a continuing basis. For more information on how to use Express Scripts Home Delivery PharmacySM or Wegmans® Home Delivery Pharmacy, please visit our website at ExcellusBCBS.com or contact the Pharmacy Help Desk at 1-800-499-1275.
Specialty PharmacySpecialty pharmacies focus on you and your individual health care needs. Because they work exclusively with specialty medications, they are experts in handling and administering these complex medications. Nationally recognized specialty pharmacy Accredo Health participates in our network. Accredo Health offers outstanding customer service and is dedicated to providing quality care to our members. With a single, toll-free phone call they take care of all the details – they will contact your doctor for your prescription and arrange delivery to your home. There are several local/regional specialty pharmacies also participating in our specialty pharmacy network. A complete listing of participating specialty pharmacies is available on our website, ExcellusBCBS.com
Are There Any Restrictions On Coverage?Some covered drugs may have additional requirements or limits for coverage. If a drug has requirements or limits, it will be noted in the formulary.
If your health-care practitioner determines that you need a medication that has a requirement or limit, we have an exception process in place. Your health-care practitioner must submit a request to the Health Plan supporting your need.
Coverage requirements or limits may include:
Prior Authorization Prior authorization helps ensure that a prescribed drug is safe and appropriate for your medical condition. Certain medications require that your doctor gets approval before the medication is covered. Our clinical pharmacists and physicians review medication requests to make sure that the choice of drug or dose is appropriately prescribed based
on FDA and manufacturer guidelines, medical literature, safety, use and benefit design.
Step Therapy In some cases you may be required to first try one or more drugs to treat your medical condition before another drug for that condition will be covered. The medication treatment moves along a series of “steps.” For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work, we will then cover Drug B.
Specialty Drug Benefit Specialty medications are designed for conditions like multiple sclerosis, rheumatoid arthritis, hepatitis C, and others that are difficult to treat with traditional medications. These medications are self-administered, either taken orally or by injection.
Your prescription drug benefit may require that you purchase certain specialty medications at a specialty pharmacy that participates in the Specialty Pharmacy Network in order to receive coverage. If a participating specialty pharmacy is not used, you may be responsible for the full cost of the prescription. A complete listing of participating specialty pharmacies can be found on our website, ExcellusBCBS.com
Quantity Limits For certain drugs, we limit the amount of the drug that we will cover. The amount of drug we cover is based on FDA approved dosing and usage guidelines.
Generic Advantage Program The Generic Advantage program promotes the use of generic medications. If you fill your prescription with a brand-name medication when there is a generic equivalent available, you will pay the difference between the pharmacy’s charge for the more costly brand-name medication and our price for the less expensive generic. Check your benefits summary to find out if the Generic Advantage program applies to your plan.
Key:
UPPERCASE – Brand name medicationlowercase – generic medication
PA = Prior Authorization required
QL = Quantity Limit applies
ST = Step Therapy required
MS = Drug must be purchased at a participating network specialty pharmacy for coverage
LIST OF COVERED PRESCRIPTION MEDICATIONS
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANALGESICS
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS
butalbital/aspirin/caffeine 50-325-40 capsule 1 QL
butalbital/aspirin/caffeine 50-325-40 tablet 1
CAMBIA 3
QL
ST
celecoxib (50 mg capsule, 100 mg capsule, 200 mg capsule, 400 mg capsule) 1 QL
choline salicylate/magnesium salicylate 1
diclofenac potassium 1
diclofenac sodium (1.5 % drops, 25 mg tablet dr, 50 mg tablet dr, 75 mg tabletdr, 100 mg tab er 24h)
1
diclofenac sodium/misoprostol 1 QL
DICLOPR 3
QL
PA
diflunisal 1
DITHOL 3
QL
PA
DUEXIS 3
QL
PA
etodolac 1
fenoprofen calcium (200 mg capsule, 400 mg capsule) 3 PA
fenoprofen calcium 600 mg tablet 1 PA
FENORTHO 3 PA
FLECTOR 3
QL
PA
flurbiprofen 1
IBU 1
ibuprofen (100 mg/5ml oral susp, 400 mg tablet, 600 mg tablet, 800 mg tablet) 1
indomethacin 1
ketoprofen 1
PAGE 5 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ketorolac tromethamine 10 mg tablet 1 QL
MECLOFENAMATE SODIUM 3
mefenamic acid 1
meloxicam (7.5 mg tablet, 15 mg tablet) 1
MELOXICAM 7.5 MG/5 ML ORAL SUSP 3
nabumetone (500 mg tablet, 750 mg tablet) 1 QL
naproxen (250 mg tablet, 375 mg tablet, 375 mg tablet dr, 500 mg tablet, 500mg tablet dr)
1
NAPROXEN 125 MG/5 ML ORAL SUSP 3
naproxen sodium (275 mg tablet, 375 mg tbmp 24hr, 500 mg tbmp 24hr, 550mg tablet)
1
oxaprozin 600 mg tablet 1 QL
PENNSAID 2% PUMP 3
QL
PA
piroxicam 1
PROFENO 1 PA
salsalate 1
SPRIX 3
QL
PA
sulindac 1
TIVORBEX 3
QL
PA
tolmetin sodium 1
VIMOVO 3
QL
PA
VIVLODEX 3 PA
ZIPSOR 3
QL
PA
ZORVOLEX 3
QL
PA
OPIOID ANALGESICS, LONG-ACTING
ARYMO ER (ER 15 MG TABLET, ER 30 MG TABLET, ER 60 MG TABLET) 3 PA
PAGE 6 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
BELBUCA (75 MCG FILM, 150 MCG FILM, 300 MCG FILM, 450 MCG FILM,600 MCG FILM, 750 MCG FILM, 900 MCG FILM)
3 PA
BUPRENORPHINE PATCH 3
QL
PA
BUTRANS (5 MCG/HR PATCH, 7.5 MCG/HR PATCH, 10 MCG/HR PATCH, 15MCG/HR PATCH, 20 MCG/HR PATCH)
3 PA
EMBEDA 3 PA
EXALGO 3 PA
fentanyl (12 mcg/hr patch td72, 25 mcg/hr patch td72, 50mcg/hr patch td72,75mcg/hr patch td72, 100 mcg/hr patch td72)
1 PA
FENTANYL (37.5MCG/HR PATCH TD72, 62.5MCG/HR PATCH TD72,87.5MCG/HR PATCH TD72)
1 PA
hydromorphone hcl (8 mg tab er 24h, 12 mg tab er 24h, 16 mg tab er 24h, 32mg tab er 24h)
1
QL
PA
HYSINGLA ER 3 PA
levorphanol tartrate 1 PA
methadone hcl (5 mg tablet, 5 mg/5 ml solution, 10 mg tablet, 10 mg/5 mlsolution, 10 mg/ml oral conc, 40 mg tablet sol)
1 PA
METHADONE INTENSOL 1 PA
METHADOSE 40 MG TABLET DISPR 1 PA
MORPHABOND ER 3 PA
morphine sulfate (10 mg cap er pel, 15 mg tablet er, 20 mg cap er pel, 30 mgcap er pel, 30 mg tablet er, 50 mg cap er pel, 60 mg cap er pel, 80 mg cap erpel, 100 mg cap er pel, 100 mg tablet er, 200 mg tablet er)
1 PA
morphine sulfate (30 mg cpmp 24hr, 45 mg cpmp 24hr, 60 mg cpmp 24hr, 75mg cpmp 24hr, 90 mg cpmp 24hr, 120 mg cpmp 24hr)
2 PA
morphine sulfate 60 mg tablet er 1
QL
PA
NUCYNTA ER (ER 50 MG TABLET, ER 100 MG TABLET, ER 150 MGTABLET, ER 200 MG TABLET, ER 250 MG TABLET)
2 PA
OXYCODONE HCL ER 3 PA
OXYCONTIN (10 MG TABLET, 15 MG TABLET, 20 MG TABLET, 30 MGTABLET, 40 MG TABLET, 60 MG TABLET, 80 MG TABLET)
3 PA
oxymorphone hcl (5 mg tab er 12h, 7.5 mg tab er 12h, 10 mg tab er 12h, 15 mgtab er 12h, 20 mg tab er 12h, 30 mg tab er 12h, 40 mg tab er 12h)
1 PA
TRAMADOL ER CAPS 3
QL
PA
tramadol hcl (100 mg tab er 24h, 200 mg tab er 24h, 300 mg tbmp 24hr) 1 PA
tramadol hcl (100 mg tbmp 24hr, 200 mg tbmp 24hr, 300 mg tab er 24h) 1
QL
PA
PAGE 7 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
XTAMPZA ER 3 PA
ZOHYDRO ER 3
QL
PA
OPIOID ANALGESICS, SHORT-ACTING
ABSTRAL 3
QL
PA
acetaminophen with codeine phosphate (120-12mg/5 solution, 300mg-15mgtablet, 300mg-30mg tablet, 300mg-60mg tablet, 300mg/12.5 solution)
1
acetaminophen/caff/dihydrocod 320.5-30mg capsule 1
ACTIQ 3
QL
PA
ASCOMP WITH CODEINE 1
aspirin/caffeine/dihydrocodeine bitartrate 1
butalbital/acetaminophen/caffeine/codeine phosphate 1 QL
butorphanol tartrate 10 mg/ml spray 1 QL
carisoprodol/aspirin/codeine 200-325-16 tablet 1
codeine phosphate/butalbital/aspirin/caffeine 1
codeine sulfate 1
ENDOCET 1
fentanyl citrate 1
QL
PA
FENTORA 3
QL
PA
PAGE 8 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
hydrocodone bitartrate/acetaminophen (hydrocodone/acetaminophen 2.5-108/5solution, hydrocodone/acetaminophen 2.5-325 mg tablet,hydrocodone/acetaminophen 5 mg-300mg tablet, hydrocodone/acetaminophen5 mg-325mg tablet, hydrocodone/acetaminophen 5-163/7.5 solution,hydrocodone/acetaminophen 5-217mg/10 solution,hydrocodone/acetaminophen 7.5-300 mg tablet, hydrocodone/acetaminophen7.5-325 mg tablet, hydrocodone/acetaminophen 7.5-325/15 solution,hydrocodone/acetaminophen 10-325/15 solution, hydrocodone/acetaminophen10mg-300mg tablet, hydrocodone/acetaminophen 10mg-325mg tablet)
1
hydrocodone/ibuprofen 1
hydromorphone hcl (1 mg/ml liquid, 2 mg tablet, 3 mg supp.rect, 4 mg tablet, 8mg tablet)
1
ibuprofen/oxycodone hcl 1
LAZANDA 3
QL
PA
LORCET 1
LORCET HD 1
LORCET PLUS 1
LORTAB (5-325 MG TABLET, 7.5-325 MG TABLET, 10-325 MG TABLET) 1
meperidine hcl (50 mg tablet, 50 mg/5 ml solution, 100 mg tablet) 1
MORPHINE SULFATE (15 MG TABLET, 30 MG TABLET) 2
morphine sulfate (5 mg supp.rect, 10 mg supp.rect, 10 mg/5 ml solution, 20 mgsupp.rect, 20 mg/5 ml solution, 30 mg supp.rect, 100 mg/5ml solution)
1
NUCYNTA 2 QL
opium/belladonna alkaloids 1
oxycodone hcl (5 mg capsule, 5 mg tablet, 5 mg/5 ml solution, 10 mg tablet, 15mg tablet, 20 mg tablet, 20 mg/ml oral conc, 30 mg tablet)
1
oxycodone hcl/acetaminophen (hcl/acetaminophen 2.5-325 mg tablet,hcl/acetaminophen 5 mg-325mg tablet, hcl/acetaminophen 5-325/5 ml solution,hcl/acetaminophen 7.5-325 mg tablet, hcl/acetaminophen 10mg-325mg tablet)
1
oxycodone hcl/aspirin 1
oxymorphone hcl (5 mg tablet, 10 mg tablet) 1
pentazocine hcl/naloxone hcl 1
REPREXAIN 1
SUBSYS (100 MCG SPRAY, 200 MCG SPRAY, 400 MCG SPRAY, 600 MCGSPRAY, 800 MCG SPRAY, 1,200 MCG SPRAY, 1,600 MCG SPRAY)
3
QL
PA
tramadol hcl 50 mg tablet 1
tramadol hcl/acetaminophen 1
VERDROCET 1
VICODIN 1
VICODIN ES 1
PAGE 9 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
VICODIN HP 1
XARTEMIS XR 3 PA
XYLON 10 1
ANESTHETICS
LOCAL ANESTHETICS
ANODYNE LPT 3
QL
PA
DERMACINRX EMPRICAINE 3 PA
DERMACINRX PRIZOPAK 1
QL
PA
DOLOTRANZ 3
QL
PA
GLYDO 1
LIDO-K 1
LIDO-PRILO CAINE PACK 3
QL
PA
lidocaine (5 % adh. patch, 5 % oint. (g)) 1
lidocaine hcl (2 % jel/pf app, 2 % jelly(ml), 2 % solution, 3 % cream (g), 3 %lotion, 4 % solution, 40 mg/ml solution)
1
lidocaine/prilocaine (lidocaine/prilocaine 2.5 cream (g), lidocaine/prilocaine 2.5kit)
1
LIDOPAC 3
QL
PA
LIDOPIN 3% CREAM 1
LIDOPRIL 3
QL
PA
LIDOPRIL XR 3
QL
PA
LIDOTRANS 5 PAK 3
QL
PA
LIPROZONEPAK 3 PA
MEDOLOR PAK 3 PA
NEURCAINE 3
QL
PA
PAGE 10 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PAINGO KFT 3
QL
PA
PRILOLID 3 PA
RELADOR PAK 3
QL
PA
SOLUPAK 3
QL
PA
ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS
ALCOHOL DETERRENTS/ANTI-CRAVING
acamprosate calcium 1 QL
disulfiram 1
naltrexone hcl 1
OPIOID DEPENDENCE TREATMENTS
buprenorphine hcl (2 mg tab subl, 8 mg tab subl) 1
buprenorphine hcl/naloxone hcl 1
SUBOXONE 2
ZUBSOLV 2
OPIOID REVERSAL AGENTS
naloxone hcl (0.4 mg/ml syringe, 0.4 mg/ml vial, 1 mg/ml syringe) 1
NARCAN 4 MG NASAL SPRAY 2
SMOKING CESSATION AGENTS
BUPROBAN 1
bupropion hcl 150 mg tab er 12h 1
CHANTIX 3 QL
NICOTROL 3 QL
NICOTROL NS 3 QL
ZYBAN 3
ANTIBACTERIALS
AMINOGLYCOSIDES
GENTAK 1
gentamicin sulfate (0.1 % cream (g), 0.1 % oint. (g), 0.3 % drops, 0.3 % oint.(g))
1
PAGE 11 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
neomycin sulfate 1
paromomycin sulfate 1
tobramycin 1
ANTIBACTERIALS, OTHER
ALTABAX 3
bacitracin 500 unit/g oint. (g) 1
CENTANY AT 3
QL
PA
CLINDACIN ETZ 1% PLEDGET 1
CLINDACIN ETZ KIT 3
QL
PA
CLINDACIN P 1
CLINDACIN PAC 3
QL
PA
clindamycin hcl 1
clindamycin palmitate hcl 75 mg/5 ml soln recon 1
clindamycin phosphate (1 % gel (gram), 1 % lotion, 1 % med. swab, 1 %solution, 2 % cream/appl)
1
erythromycin base/benzoyl peroxide 1
FIRVANQ 2
HYOLEV MB 1
HYOPHEN 1
linezolid 100 mg/5ml susp recon 1
linezolid 600 mg tablet 1 QL
methenamine hippurate 1
methenamine mandelate 1
methenamine/sod phosph,monobasic/methylene blue/hyoscyamine 1
metronidazole (0.75 % gel w/appl, 250 mg tablet, 375 mg capsule, 500 mgtablet)
1
MONUROL 3
mupirocin 1
mupirocin calcium 1
nitrofurantoin 1
nitrofurantoin macrocrystal 1
PAGE 12 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
nitrofurantoin monohydrate/macrocrystals 1
PHOSPHASAL 1
SIVEXTRO 200 MG TABLET 3 PA
SULFAMYLON 8.5% CREAM 3
tinidazole 1
trimethoprim 1
UR N-C 1
URAMIT MB 1
URETRON D-S 1
URIMAR-T 1
URIN D.S. 1
URO-458 1
URO-MP 1
UROGESIC-BLUE 1
UROLET MB 1
UROPHEN MB 1
URYL 1
UTIRA-C 1
vancomycin hcl (125 mg capsule, 250 mg capsule) 1
VANDAZOLE 1
ZYVOX 100 MG/5 ML SUSPENSION 3
ZYVOX 600 MG TABLET 3 QL
BETA-LACTAM, CEPHALOSPORINS
cefaclor (125 mg/5ml susp recon, 250 mg capsule, 250 mg/5ml susp recon, 375mg/5ml susp recon, 500 mg capsule, 500 mg tab er 12h)
1
cefadroxil (1 g tablet, 250 mg/5ml susp recon, 500 mg capsule, 500 mg/5mlsusp recon)
1
cefdinir (125 mg/5ml susp recon, 250 mg/5ml susp recon, 300 mg capsule) 1
cefditoren pivoxil 1
cefixime 1
cefpodoxime proxetil (50 mg/5 ml susp recon, 100 mg tablet, 100 mg/5ml susprecon, 200 mg tablet)
1
cefprozil (125 mg/5ml susp recon, 250 mg tablet, 250 mg/5ml susp recon, 500mg tablet)
1
CEFTIBUTEN 3
cefuroxime axetil 1
PAGE 13 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
cephalexin (125 mg/5ml susp recon, 250 mg capsule, 250 mg tablet, 250mg/5ml susp recon, 500 mg capsule, 500 mg tablet, 750 mg capsule)
1
BETA-LACTAM, PENICILLINS
amoxicillin (125 mg tab chew, 125 mg/5ml susp recon, 200 mg/5ml susp recon,250 mg capsule, 250 mg tab chew, 250 mg/5ml susp recon, 400 mg/5ml susprecon, 500 mg capsule, 500 mg tablet, 875 mg tablet)
1
AMOXICILLIN ER 775 MG 3
amoxicillin/potassium clavulanate (amoxicillin/potassium 200-28.5/5 susp recon,amoxicillin/potassium 200-28.5mg tab chew, amoxicillin/potassium 250-125 mgtablet, amoxicillin/potassium 250-62.5/5 susp recon, amoxicillin/potassium 400-57mg tab chew, amoxicillin/potassium 400-57mg/5 susp recon,amoxicillin/potassium 500-125 mg tablet, amoxicillin/potassium 600-42.9/5 susprecon, amoxicillin/potassium 875-125 mg tablet, amoxicillin/potassium 1000-62.5 tab er 12h)
1
ampicillin trihydrate (125 mg/5ml susp recon, 250 mg capsule, 250 mg/5ml susprecon, 500 mg capsule)
1
dicloxacillin sodium 1
MOXATAG 3 PA
penicillin v potassium (125 mg/5ml soln recon, 250 mg tablet, 250 mg/5ml solnrecon, 500 mg tablet)
1
MACROLIDES
AZASITE 3
azithromycin (1 g packet, 100 mg/5ml susp recon, 200 mg/5ml susp recon, 250mg tablet, 500 mg tablet, 600 mg tablet)
1
clarithromycin (125 mg/5ml susp recon, 250 mg tablet, 250 mg/5ml susp recon,500 mg tab er 24h, 500 mg tablet)
1
DIFICID 3 ST
E.E.S. 200 3
E.E.S. 400 3
ERY 1
ERY-TAB 1
ERYPED 200 3
ERYPED 400 3
ERYTHROCIN STEARATE 1
erythromycin base (5 mg/gram oint. (g), 250 mg capsule dr, 250 mg tablet, 500mg tablet)
1
erythromycin base in ethanol (erythromyc2 % gel (gram), erythromyc2 % med.swab, erythromyc2 % solution)
1
erythromycin ethylsuccinate (200 mg/5ml susp recon, 400 mg tablet) 1
QUINOLONES
BAXDELA 450 MG TABLET 3 QL
BESIVANCE 3
CILOXAN 0.3% OINTMENT 3
PAGE 14 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ciprofloxacin 1
ciprofloxacin hcl (0.3 % drops, 100 mg tablet, 250 mg tablet, 500 mg tablet, 750mg tablet)
1
ciprofloxacin hcl 0.2 % droperette 1 QL
ciprofloxacin/ciprofloxacin hcl 1
FACTIVE 3
gatifloxacin 1
levofloxacin (0.5 % drops, 250 mg tablet, 250mg/10ml solution, 500 mg tablet,500mg/20ml solution, 750 mg tablet)
1
MOXEZA 2
moxifloxacin hcl (0.5 % drops, 400 mg tablet) 1
ofloxacin (0.3 % drops, 300 mg tablet, 400 mg tablet) 1
VIGAMOX 3
ZYMAXID 3
SULFONAMIDES
silver sulfadiazine 1
SSD 1
sulfacetamide sodium (10 % drops, 10 % oint. (g), 10 % suspension) 1
sulfadiazine 1
sulfamethoxazole/trimethoprim (sulfamethoxazole/trimethoprim 200-40mg/5 oralsusp, sulfamethoxazole/trimethoprim 400mg-80mg tablet,sulfamethoxazole/trimethoprim 800-160 mg tablet,sulfamethoxazole/trimethoprim 800-160/20 oral susp)
1
SULFATRIM 1
THERMAZENE 1
TETRACYCLINES
ACTICLATE 3 PA
AVIDOXY 1
demeclocycline hcl 1
DORYX 3 ST
doxycycline hyclate (20 mg tablet, 50 mg capsule, 50 mg tablet dr, 75 mg tabletdr, 100 mg capsule, 100 mg tablet, 100 mg tablet dr, 150 mg tablet dr, 200 mgtablet dr)
1
doxycycline hyclate (75 mg tablet, 150 mg tablet) 1
QL
PA
PAGE 15 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
doxycycline monohydrate (25 mg/5 ml susp recon, 50 mg capsule, 50 mgtablet, 75 mg capsule, 75 mg tablet, 100 mg capsule, 100 mg tablet, 150 mgcapsule, 150 mg tablet)
1
DOXYCYCLINE MONOHYDRATE 40 MG CAP IR DR 3
QL
ST
minocycline hcl (45 mg tab er 24h, 65 mg tab er 24h, 90 mg tab er 24h, 115mgtab er 24h, 135 mg tab er 24h)
1
QL
PA
minocycline hcl (50 mg capsule, 50 mg tablet, 75 mg capsule, 75 mg tablet, 100mg capsule, 100 mg tablet)
1
MONDOXYNE NL 1
MORGIDOX (1X100 MG KIT, 1X50 MG KIT, 2X100 MG KIT) 3
QL
PA
MORGIDOX (50 MG CAPSULE, 100 MG CAPSULE) 1
ORACEA 3
QL
ST
SOLODYN 3
QL
PA
tetracycline hcl 1
ANTICONVULSANTS
ANTICONVULSANTS, OTHER
BRIVIACT (10 MG TABLET, 10 MG/ML ORAL SOLN, 25 MG TABLET, 50 MGTABLET, 75 MG TABLET, 100 MG TABLET)
3
QL
PA
levetiracetam (100 mg/ml solution, 250 mg tablet, 500 mg tablet, 500 mg/5mlsolution, 750 mg tablet, 1000 mg tablet)
1
levetiracetam (500 mg tab er 24h, 750 mg tab er 24h) 1 QL
ROWEEPRA 1
ROWEEPRA XR 500 MG TABLET 1
ROWEEPRA XR 750 MG TABLET 1 QL
SPRITAM (250 MG TABLET, 500 MG TABLET, 750 MG TABLET, 1,000 MGTABLET)
3
QL
PA
CALCIUM CHANNEL MODIFYING AGENTS
CELONTIN 3
ethosuximide (250 mg capsule, 250 mg/5ml solution) 1
zonisamide 1
PAGE 16 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS
diazepam (2.5 mg kit, 5-7.5-10mg kit, 12.5-15-20 kit) 1
divalproex sodium 1
gabapentin (100 mg capsule, 250 mg/5ml solution, 300 mg capsule, 300mg/6ml solution, 400 mg capsule, 600 mg tablet, 800 mg tablet)
1
GRALISE (ER 300 MG TABLET, ER 600 MG TABLET) 3
QL
PA
GRALISE 30-DAY STARTER PACK 3 PA
ONFI (10 MG TABLET, 20 MG TABLET) 3 QL
ONFI 2.5 MG/ML SUSPENSION 3
phenobarbital (15 mg tablet, 16.2 mg tablet, 20 mg/5 ml elixir, 30 mg tablet,32.4 mg tablet, 60 mg tablet, 64.8 mg tablet, 97.2mg tablet, 100 mg tablet)
1
primidone 1
SABRIL 3
QL
PA
MS
tiagabine hcl 1
valproic acid 1
valproic acid (as sodium salt) (valproate sodium) (250 mg/5ml solution,500mg/10ml solution)
1
vigabatrin 1
QL
PA
MS
GLUTAMATE REDUCING AGENTS
felbamate (400 mg tablet, 600 mg tablet, 600 mg/5ml oral susp) 1
lamotrigine (25 mg tab rapdis, 25(42)-100 tab ds pk, 25(84)-100 tab ds pk, 50mg tab rapdis, 100 mg tab rapdis, 200 mg tab rapdis)
1 QL
lamotrigine (5 mg tb chw dsp, 25 mg tab er 24, 25 mg tablet, 25 mg tb chw dsp,25(21)-50 tb rd dspk, 25-50-100 tb rd dspk, 25mg (35) tab ds pk, 50 mg tab er24, 50(42)-100 tb rd dspk, 100 mg tab er 24, 100 mg tablet, 150 mg tablet, 200mg tab er 24, 200 mg tablet, 250 mg tab er 24, 300 mg tab er 24)
1
QUDEXY XR (25 MG CAPSULE, 50 MG CAPSULE, 100 MG CAPSULE, 150MG CAPSULE, 200 MG CAPSULE)
3
QL
PA
topiramate (15 mg cap sprink, 25 mg cap sprink, 25 mg tablet, 50 mg tablet,100 mg tablet, 200 mg tablet)
1
topiramate (25 mg cap spr 24, 50 mg cap spr 24, 100 mg cap spr 24, 150 mgcap spr 24, 200 mg cap spr 24)
3
QL
PA
PAGE 17 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
TROKENDI XR 3
QL
PA
SODIUM CHANNEL AGENTS
APTIOM (200 MG TABLET, 400 MG TABLET, 600 MG TABLET, 800 MGTABLET)
3
QL
PA
BANZEL (40 MG/ML SUSPENSION, 200 MG TABLET, 400 MG TABLET) 3
carbamazepine (100 mg cpmp 12hr, 100 mg tab chew, 100 mg tab er 12h, 100mg/5ml oral susp, 200 mg cpmp 12hr, 200 mg tab er 12h, 200 mg tablet, 300mg cpmp 12hr, 400 mg tab er 12h)
1
EPITOL 1
oxcarbazepine (150 mg tablet, 300 mg tablet, 300 mg/5ml oral susp, 600 mgtablet)
1
OXTELLAR XR (150 MG TABLET, 300 MG TABLET, 600 MG TABLET) 3
QL
PA
PEGANONE 3
phenytoin (50 mg tab chew, 100 mg/4ml oral susp, 125 mg/5ml oral susp) 1
phenytoin sodium extended 1
VIMPAT (10 MG/ML SOLUTION, 50 MG TABLET, 100 MG TABLET, 150 MGTABLET, 200 MG TABLET)
2
ANTIDEMENTIA AGENTS
ANTIDEMENTIA AGENTS, OTHER
ergoloid mesylates 1
CHOLINESTERASE INHIBITORS
donepezil hcl 1
galantamine hbr (4 mg tablet, 4 mg/ml solution, 8 mg cap24h pel, 8 mg tablet,12 mg tablet, 16 mg cap24h pel, 24 mg cap24h pel)
1
NAMZARIC 3
QL
PA
rivastigmine 1
rivastigmine tartrate 1
N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST
memantine hcl (2 mg/ml solution, 5 mg tablet, 5 mg-10 mg tab ds pk, 10 mgtablet)
1
memantine hcl (7 mg cap spr 24, 14 mg cap spr 24, 21 mg cap spr 24, 28 mgcap spr 24)
1 QL
NAMENDA (2 MG/ML SOLUTION, 5-10 MG TITRATION PK) 3
NAMENDA XR 3
QL
ST
PAGE 18 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANTIDEPRESSANTS
ANTIDEPRESSANTS, OTHER
amitriptyline hcl/chlordiazepoxide 1
bupropion hcl (150 mg tab er 24h, 300 mg tab er 24h) 1 QL
bupropion hcl (75 mg tablet, 100 mg tab sr 12h, 100 mg tablet, 150 mg tab sr12h, 200 mg tab sr 12h)
1
mirtazapine 1
perphenazine/amitriptyline hcl 1
MONOAMINE OXIDASE INHIBITORS
EMSAM 3
QL
ST
MARPLAN 3
phenelzine sulfate 1
tranylcypromine sulfate 1
SSRIS/SNRIS (SELECTIVE SEROTONIN REUPTAKE INHIBITORS/SEROTONIN AND NOREPINEPHRINE REUPTAKE INHIBITORS)
BRISDELLE 3
QL
PA
citalopram hydrobromide (10 mg tablet, 20 mg tablet, 40 mg tablet) 1 QL
citalopram hydrobromide 10 mg/5 ml solution 1
DESVENLAFAXINE ER 3
QL
ST
DESVENLAFAXINE FUMARATE 3
QL
ST
desvenlafaxine succinate 1 QL
escitalopram oxalate (5 mg tablet, 5 mg/5 ml solution, 10 mg tablet, 20 mgtablet)
1
FETZIMA 3 QL
fluoxetine hcl (10 mg capsule, 10 mg tablet, 20 mg capsule, 20 mg tablet, 20mg/5 ml solution, 40 mg capsule, 60 mg tablet)
1
fluoxetine hcl 90 mg capsule dr 1 QL
fluvoxamine maleate (100 mg cap er 24h, 150 mg cap er 24h) 1 QL
fluvoxamine maleate (25 mg tablet, 50 mg tablet, 100 mg tablet) 1
KHEDEZLA 3
QL
ST
PAGE 19 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
maprotiline hcl 1
nefazodone hcl (150 mg tablet, 200 mg tablet, 250 mg tablet) 1
nefazodone hcl (50 mg tablet, 100 mg tablet) 1 QL
OLEPTRO ER (ER 150 MG TABLET, ER 300 MG TABLET) 3
QL
ST
paroxetine hcl (10 mg tablet, 20 mg tablet, 30 mg tablet, 40 mg tablet) 1
paroxetine hcl (12.5 mg tab er 24h, 25 mg tab er 24h, 37.5 mg tab er 24h) 1 QL
paroxetine mesylate 1
QL
PA
sertraline hcl (20 mg/ml oral conc, 25 mg tablet, 50 mg tablet, 100 mg tablet) 1
trazodone hcl 1
TRINTELLIX 3 QL
VENLAFAXINE ER TAB (TIER DEPENDENT ON MANUFACTURER. UCB T3,OTHERS T1)
3
QL
ST
venlafaxine hcl (25 mg tablet, 37.5 mg tablet, 50 mg tablet, 75 mg tablet, 100mg tablet)
1
venlafaxine hcl (37.5 mg cap er 24h, 75 mg cap er 24h, 150 mg cap er 24h) 1 QL
VIIBRYD (10 MG TABLET, 10-20-40 MG STARTER PK, 20 MG TABLET, 40MG TABLET)
3 QL
VIIBRYD 10-20 MG STARTER PACK 3
TRICYCLICS
amitriptyline hcl 1
amoxapine 1
clomipramine hcl 1
desipramine hcl 1
doxepin hcl (10 mg capsule, 10 mg/ml oral conc, 25 mg capsule, 50 mgcapsule, 75 mg capsule, 100 mg capsule, 150 mg capsule)
1
imipramine hcl 1
imipramine pamoate 1
nortriptyline hcl (10 mg capsule, 25 mg capsule, 50 mg capsule, 75 mg capsule) 1
nortriptyline hcl (10 mg/5 ml solution, 20 mg/10ml solution) 3
QL
PA
protriptyline hcl 1
trimipramine maleate 1
PAGE 20 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANTIEMETICS
ANTIEMETICS, OTHER
BONJESTA 3
QL
PA
COMPAZINE 25 MG SUPPOSITORY 1
COMPRO 1
DICLEGIS 3
QL
PA
metoclopramide hcl (5 mg tablet, 5 mg/5 ml solution, 10 mg tablet, 10 mg/10mlsolution)
1
perphenazine 1
PHENADOZ 1
PHENERGAN (12.5 MG, 25 MG, 50 MG) 1
prochlorperazine 1
prochlorperazine maleate 1
promethazine hcl (12.5 mg supp.rect, 25 mg supp.rect, 50 mg supp.rect, 50 mgtablet)
1
PROMETHEGAN 1
scopolamine 1
TRANSDERM-SCOP 3
trimethobenzamide hcl 1
EMETOGENIC THERAPY ADJUNCTS
AKYNZEO 300-0.5 MG CAPSULE 3 QL
aprepitant (40 mg capsule, 80 mg capsule, 125 mg capsule, 125mg-80mg capds pk)
1 QL
CESAMET 3
dronabinol 1
granisetron hcl 1 mg tablet 1 QL
ondansetron 1
ondansetron hcl (4 mg tablet, 4 mg/5 ml solution, 8 mg tablet, 24 mg tablet) 1
SANCUSO 3
QL
ST
SYNDROS 3 PA
VARUBI 90 MG TABLET 3
PAGE 21 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANTIFUNGALS
CICLODAN 0.77% CREAM 1
CICLODAN 8% SOLUTION 1 QL
ciclopirox (0.77 % gel (gram), 1 % shampoo) 1
ciclopirox 8 % solution 1 QL
ciclopirox olamine (0.77 % cream (g), 0.77 % suspension) 1
clotrimazole 10 mg troche 1
CRESEMBA 186 MG CAPSULE 3
econazole nitrate 1
ERTACZO 3 ST
EXELDERM (CREAM, SOLUTION) 3
EXTINA 3 ST
fluconazole (10 mg/ml susp recon, 40 mg/ml susp recon, 50 mg tablet, 100 mgtablet, 150 mg tablet, 200 mg tablet)
1
flucytosine 1
griseofulvin ultramicrosize 1
griseofulvin, microsize (125 mg/5ml oral susp, 500 mg tablet) 1
itraconazole (10 mg/ml solution, 100 mg capsule) 1
JUBLIA 3
QL
PA
KERYDIN 3 PA
ketoconazole (2 % cream (g), 2 % foam, 2 % shampoo, 200 mg tablet) 1
KETODAN 2% FOAM 1
LAMISIL (125 MG GRANULES PACKET, 187.5 MG GRANULES PACK) 3
QL
PA
LOPROX (CREAM KIT, SUSPENSION KIT) 3
QL
PA
luliconazole 3 QL
miconazole nitrate 200 mg supp.vag 1
naftifine hcl 1 % cream (g) 1
naftifine hcl 2 % cream (g) 1 QL
NAFTIN (1% GEL, 2% GEL) 3 ST
PAGE 22 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
NAFTIN 2% CREAM 3 QL
NATACYN 3
NOXAFIL 40 MG/ML SUSPENSION 3
NYAMYC 1
NYATA 100,000 UNIT/GM POWDER 3
nystatin (50mm unit powder(ea), 150mm unit powder(ea), 500k unit tablet,500mm unit powder(ea), 100000/g cream (g), 100000/g oint. (g), 100000/gpowder, 100000/ml oral susp)
1
nystatin/triamcinolone acetonide 1
NYSTOP 1
ORAVIG 3 PA
oxiconazole nitrate 1
OXISTAT 1% CREAM 3
OXISTAT 1% LOTION 3 ST
terbinafine hcl 250 mg tablet 1
terconazole (0.4 % cream/appl, 0.8 % cream/appl, 80 mg supp.vag) 1
voriconazole (50 mg tablet, 200 mg/5ml susp recon) 1
voriconazole 200 mg tablet 1 QL
ANTIGOUT AGENTS
allopurinol 1
COLCHICINE 3 QL
COLCRYS 2 QL
DUZALLO 3
QL
PA
probenecid 1
probenecid/colchicine 1
ULORIC 2
QL
ST
ZURAMPIC 3
QL
PA
PAGE 23 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANTIMIGRAINE AGENTS
ANTIMIGRAINE AGENTS, OTHER
AIMOVIG AUTOINJECTOR 2
QL
PA
AIMOVIG AUTOINJECTOR (2 PACK) 2
QL
PA
ERGOT ALKALOIDS
D.H.E.45 3
dihydroergotamine mesylate (1 mg/ml ampul, 1 mg/ml vial) 1
DIHYDROERGOTAMINE MESYLATE 0.5MG/SPRY SPRAY/PUMP 3 QL
ERGOMAR 3
ergotamine tartrate/caffeine 1
MIGRANAL 3 QL
SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS
almotriptan malate 1 QL
eletriptan hydrobromide 1 QL
frovatriptan succinate 1 QL
naratriptan hcl (1 mg tablet, 2.5 mg tablet) 1 QL
rizatriptan benzoate 1 QL
sumatriptan (5 mg spray, 20 mg spray) 1 QL
sumatriptan succinate (4 mg/0.5ml cartridge, 4 mg/0.5ml pen injctr, 6 mg/0.5mlcartridge, 6 mg/0.5ml pen injctr, 6 mg/0.5ml syringe, 6 mg/0.5ml vial, 25 mgtablet, 50 mg tablet, 100 mg tablet)
1 QL
sumatriptan succinate/naproxen sodium 1 QL
SUMAVEL DOSEPRO (4 MG/0.5 ML, 6 MG/0.5 ML) 3
QL
ST
TREXIMET 3 QL
zolmitriptan 1 QL
ZOMIG (2.5 MG NASAL SPRAY, 5 MG NASAL SPRAY) 3
QL
ST
PAGE 24 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANTIMYASTHENIC AGENTS
PARASYMPATHOMIMETICS
GUANIDINE HCL 3
MESTINON 60 MG/5 ML SYRUP 3
pyridostigmine bromide 1
ANTIMYCOBACTERIALS
ANTIMYCOBACTERIALS, OTHER
dapsone (25 mg tablet, 100 mg tablet) 1
MYCOBUTIN 3
rifabutin 1
ANTITUBERCULARS
cycloserine 1
ethambutol hcl 1
isoniazid (50 mg/5 ml solution, 100 mg tablet, 300 mg tablet) 1
PASER 3
PRIFTIN 3
pyrazinamide 1
rifampin (150 mg capsule, 300 mg capsule) 1
RIFATER 3
SIRTURO 3
TRECATOR 3
ANTINEOPLASTICS
ALKYLATING AGENTS
ALKERAN 2 MG TABLET 2
CYCLOPHOSPHAMIDE (25 MG CAPSULE, 50 MG CAPSULE) 1
GLEOSTINE 3
HEXALEN 3
LEUKERAN 2
lomustine 1
MATULANE 2
melphalan 1
MYLERAN 2
PAGE 25 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
TEMODAR (5 MG CAPSULE, 20 MG CAPSULE, 100 MG CAPSULE, 140 MGCAPSULE, 180 MG CAPSULE, 250 MG CAPSULE)
3 MS
temozolomide 1 MS
VALCHLOR 3
QL
PA
MS
ANTIANDROGENS
bicalutamide 1
ERLEADA 3
QL
PA
MS
flutamide 1
NILANDRON 3
nilutamide 1
XTANDI 2
QL
PA
MS
YONSA 3
QL
PA
MS
ZYTIGA (250 MG TABLET, 500 MG TABLET) 2
QL
PA
MS
ANTIANGIOGENIC AGENTS
POMALYST 3
QL
PA
MS
REVLIMID 2
QL
PA
MS
THALOMID 3
QL
MS
PAGE 26 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANTIESTROGENS/MODIFIERS
EMCYT 3
FARESTON 2
SOLTAMOX 3
QL
PA
tamoxifen citrate 1
ANTIMETABOLITES
capecitabine 1 MS
DROXIA 3
fluorouracil (2 % solution, 5 % cream (g), 5 % solution) 1
hydroxyurea 1
mercaptopurine 1
PURIXAN 3
QL
PA
TABLOID 2
ANTINEOPLASTICS, OTHER
ALUNBRIG (30 MG TABLET, 90 MG TABLET, 90 MG-180 MG TAB PACK, 180MG TABLET)
3
QL
PA
MS
IDHIFA (50 MG TABLET, 100 MG TABLET) 3
QL
PA
MS
leucovorin calcium (5 mg tablet, 10 mg tablet, 15 mg tablet, 25 mg tablet) 1
LONSURF 3
PA
MS
LYSODREN 2
NINLARO 3
PA
MS
RUBRACA 250 MG TABLET 3
QL
PA
RYDAPT 3
QL
PA
MS
PAGE 27 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SYLATRON 3
PA
MS
ZOLINZA 3
QL
PA
MS
AROMATASE INHIBITORS, 3RD GENERATION
anastrozole 1
exemestane 1
letrozole 1
ENZYME INHIBITORS
etoposide 50 mg capsule 1
HYCAMTIN (0.25 MG CAPSULE, 1 MG CAPSULE) 2
QL
PA
MS
MOLECULAR TARGET INHIBITORS
AFINITOR 2
QL
PA
MS
ALECENSA 3
PA
MS
BOSULIF (100 MG TABLET, 400 MG TABLET, 500 MG TABLET) 3
QL
PA
MS
BRAFTOVI (50 MG CAPSULE, 75 MG CAPSULE) 3
QL
PA
CABOMETYX 3
QL
PA
MS
CALQUENCE 3
QL
PA
CAPRELSA (100 MG TABLET, 300 MG TABLET) 2
QL
PA
PAGE 28 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
COMETRIQ (60 MG PACK, 100 MG PK, 140 MG PK) 2
QL
PA
COTELLIC 3
PA
MS
ERIVEDGE 3
QL
PA
MS
FARYDAK 3
QL
PA
MS
GILOTRIF 3
QL
PA
MS
IBRANCE 2
QL
PA
MS
ICLUSIG (15 MG TABLET, 45 MG TABLET) 3
QL
PA
imatinib mesylate (100 mg tablet, 400 mg tablet) 1
QL
MS
IMBRUVICA (70 MG CAPSULE, 140 MG CAPSULE, 140 MG TABLET, 280MG TABLET, 420 MG TABLET, 560 MG TABLET)
3
QL
PA
INLYTA (1 MG TABLET, 5 MG TABLET) 3
QL
PA
MS
IRESSA 3
QL
PA
MS
JAKAFI 2
QL
PA
MS
PAGE 29 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
KISQALI (200 MG DAILY, 400 MG DAILY, 600 MG DAILY) 3
QL
PA
MS
KISQALI FEMARA CO-PACK (200 MG, 400 MG, 600 MG) 3
QL
PA
MS
LENVIMA (4 MG CAPSULE, 8 MG DAILY DOSE, 10 MG DAILY DOSE, 12 MGDAILY DOSE, 14 MG DAILY DOSE, 18 MG DAILY DOSE, 20 MG DAILYDOSE, 24 MG DAILY DOSE)
3
QL
PA
MS
LYNPARZA (100 MG TABLET, 150 MG TABLET) 3
QL
PA
MS
LYNPARZA 50 MG CAPSULE 3
PA
MS
MEKINIST (0.5 MG TABLET, 2 MG TABLET) 3
QL
PA
MS
MEKTOVI 3
QL
PA
MS
NERLYNX 3
QL
PA
MS
NEXAVAR 2
QL
PA
MS
ODOMZO 3
PA
MS
SPRYCEL (20 MG TABLET, 50 MG TABLET, 70 MG TABLET, 80 MGTABLET, 100 MG TABLET, 140 MG TABLET)
2
QL
PA
MS
PAGE 30 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
STIVARGA 2
QL
PA
MS
SUTENT (12.5 MG CAPSULE, 25 MG CAPSULE, 37.5 MG CAPSULE, 50 MGCAPSULE)
2
QL
PA
MS
TAFINLAR (50 MG CAPSULE, 75 MG CAPSULE) 3
QL
PA
MS
TAGRISSO 3
PA
MS
TARCEVA 3
QL
PA
MS
TASIGNA (150 MG CAPSULE, 200 MG CAPSULE) 3
QL
PA
MS
TYKERB 2
QL
PA
MS
VENCLEXTA 3
QL
PA
VERZENIO 2
QL
PA
MS
VOTRIENT 2
QL
PA
MS
XALKORI 3
QL
PA
MS
ZEJULA 3
QL
PA
PAGE 31 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ZELBORAF 2
QL
PA
MS
ZYDELIG 3
QL
PA
MS
ZYKADIA 3
QL
PA
MS
RETINOIDS
bexarotene 1
QL
PA
MS
PANRETIN 3
TARGRETIN 1% GEL 3
PA
MS
TARGRETIN 75 MG CAPSULE 2
QL
PA
MS
tretinoin 10 mg capsule 1
TREATMENT ADJUNCTS
MESNEX 400 MG TABLET 3
ANTIPARASITICS
ANTIHELMINTHICS
ALBENZA 3
benznidazole (12.5 mg tablet, 100 mg tablet) 3 QL
BILTRICIDE 3
ivermectin 1
praziquantel 1
STROMECTOL 3
ANTIPROTOZOALS
ALINIA (100 MG/5 ML SUSPENSION, 500 MG TABLET) 3
PAGE 32 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
atovaquone 1
atovaquone/proguanil hcl 1
chloroquine phosphate 1
COARTEM 3
DARAPRIM 3
hydroxychloroquine sulfate 1
IMPAVIDO 3
QL
PA
mefloquine hcl 1
MEPRON 3
NEBUPENT 3
quinine sulfate 1 PA
PEDICULICIDES/SCABICIDES
EURAX 3 QL
lindane 1 QL
malathion 1
permethrin 5 % cream (g) 1
ANTIPARKINSON AGENTS
ANTICHOLINERGICS
benztropine mesylate (0.5 mg tablet, 1 mg tablet, 2 mg tablet) 1
trihexyphenidyl hcl (2 mg tablet, 2 mg/5 ml elixir, 5 mg tablet) 1
ANTIPARKINSON AGENTS, OTHER
amantadine hcl (50 mg/5 ml solution, 100 mg capsule, 100 mg tablet) 1
carbidopa/levodopa/entacapone 1
entacapone 1
GOCOVRI 3
QL
PA
OSMOLEX ER (ER 129 MG TABLET, ER 193 MG TABLET, ER 258 MGTABLET)
3
QL
PA
TASMAR 3
tolcapone 1
PAGE 33 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
DOPAMINE AGONISTS
APOKYN 3 MS
bromocriptine mesylate 1
NEUPRO 3
QL
PA
pramipexole di-hcl 1
ropinirole hcl (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet, 2 mg tablet, 3 mgtablet, 4 mg tablet, 5 mg tablet)
1
ropinirole hcl (2 mg tab er 24h, 4 mg tab er 24h, 6 mg tab er 24h, 8 mg tab er24h, 12 mg tab er 24h)
1 QL
DOPAMINE PRECURSORS/L-AMINO ACID DECARBOXYLASE INHIBITORS
carbidopa 1
carbidopa/levodopa 1
LODOSYN 3
RYTARY (ER 23.75 MG-95 MG CAP, ER 36.25 MG-145 MG CAP, ER 48.75MG-195 MG CAP, ER 61.25 MG-245 MG CAP)
3
QL
PA
MONOAMINE OXIDASE B (MAO-B) INHIBITORS
rasagiline mesylate 1 QL
selegiline hcl 1
ZELAPAR 3
QL
PA
ANTIPSYCHOTICS
1ST GENERATION/TYPICAL
chlorpromazine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 100 mg tablet,200 mg tablet)
1
fluphenazine decanoate 1
fluphenazine hcl (1 mg tablet, 2.5 mg tablet, 2.5 mg/5ml elixir, 5 mg tablet, 5mg/ml oral conc, 10 mg tablet)
1
haloperidol 1
haloperidol lactate (2 mg/ml oral conc, 5 mg/ml vial) 1
loxapine succinate 1
molindone hcl 1
ORAP 3
pimozide 1
thioridazine hcl 1
PAGE 34 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
thiothixene 1
trifluoperazine hcl 1
2ND GENERATION/ATYPICAL
aripiprazole (1 mg/ml solution, 2 mg tablet, 5 mg tablet, 10 mg tab rapdis, 10mg tablet, 15 mg tab rapdis, 15 mg tablet, 20 mg tablet, 30 mg tablet)
1 QL
FANAPT (1 MG TABLET, 2 MG TABLET, 4 MG TABLET, 6 MG TABLET, 8 MGTABLET, 10 MG TABLET, 12 MG TABLET)
3
QL
ST
FANAPT TITRATION PACK 3 ST
LATUDA (20 MG TABLET, 40 MG TABLET, 60 MG TABLET, 80 MG TABLET,120 MG TABLET)
3
QL
ST
NUPLAZID 17 MG TABLET 3
QL
PA
MS
olanzapine (2.5 mg tablet, 5 mg tab rapdis, 5 mg tablet, 7.5 mg tablet, 10 mgtab rapdis, 10 mg tablet, 15 mg tab rapdis, 15 mg tablet, 20 mg tab rapdis, 20mg tablet)
1
paliperidone 1 QL
quetiapine fumarate (25 mg tablet, 50 mg tablet, 100 mg tablet, 200 mg tablet,300 mg tablet)
1
quetiapine fumarate (50 mg tab er 24h, 150 mg tab er 24h, 200 mg tab er 24h,300 mg tab er 24h, 400 mg tab er 24h, 400 mg tablet)
1 QL
REXULTI 3
QL
ST
risperidone (0.25 mg tab rapdis, 0.25 mg tablet, 0.5 mg tab rapdis, 0.5 mgtablet, 1 mg tab rapdis, 1 mg tablet, 1 mg/ml solution, 2 mg tab rapdis, 2 mgtablet, 3 mg tab rapdis, 3 mg tablet, 4 mg tab rapdis, 4 mg tablet)
1
SAPHRIS 3
QL
ST
VRAYLAR 3
QL
ST
ziprasidone hcl 1
TREATMENT-RESISTANT
clozapine 1
ANTISPASTICITY AGENTS
baclofen (10 mg tablet, 20 mg tablet) 1
baclofen 5 mg tablet 1
dantrolene sodium 1
PAGE 35 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
tizanidine hcl 1
ANTIVIRALS
ANTI-CYTOMEGALOVIRUS (CMV) AGENTS
PREVYMIS (240 MG TABLET, 480 MG TABLET) 3
VALCYTE 450 MG TABLET 3
valganciclovir hcl (50 mg/ml soln recon, 450 mg tablet) 1
ZIRGAN 3
ANTI-HEPATITIS B (HBV) AGENTS
adefovir dipivoxil 1
BARACLUDE (0.05 MG/ML SOLUTION, 0.5 MG TABLET, 1 MG TABLET) 3 QL
entecavir 1 QL
EPIVIR HBV (25 MG/5 ML SOLN, 100 MG TABLET) 3
HEPSERA 3
lamivudine 100 mg tablet 1
TYZEKA 3 QL
ANTI-HEPATITIS C (HCV) AGENTS, DIRECT ACTING AGENTS
DAKLINZA (30 MG TABLET, 60 MG TABLET, 90 MG TABLET) 3
QL
PA
ST
MS
EPCLUSA 3
QL
PA
MS
HARVONI 3
QL
PA
MS
MAVYRET 3
QL
PA
MS
OLYSIO 3
QL
PA
ST
MS
PAGE 36 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SOVALDI 3
QL
PA
MS
TECHNIVIE 3
QL
PA
ST
MS
VIEKIRA PAK 3
QL
PA
ST
MS
VIEKIRA XR 3
QL
PA
ST
MS
VOSEVI 3
QL
PA
MS
ZEPATIER 3
QL
PA
ST
MS
ANTI-HEPATITIS C (HCV) AGENTS, OTHER
COPEGUS 3
PA
MS
INTRON A (10 MILLION UNITS VIL, 18 MILLION UNIT/3 ML, 18 MILLIONUNITS VIL, 25 MILLION UNIT/2.5ML, 50 MILLION UNITS VIL)
3 MS
MODERIBA 1
PA
MS
PEGASYS 3
QL
PA
MS
PEGASYS PROCLICK 3
QL
PA
MS
PAGE 37 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PEGINTRON 3
QL
PA
MS
PEGINTRON REDIPEN 3
QL
PA
MS
REBETOL (40 MG/ML SOLUTION, 200 MG CAPSULE) 3
PA
MS
RIBASPHERE (200 MG CAPSULE, 200 MG TABLET) 1
PA
MS
RIBASPHERE (400 MG TABLET, 600 MG TABLET) 3
PA
MS
RIBASPHERE RIBAPAK 3
PA
MS
RIBATAB 3
PA
MS
ribavirin (200 mg capsule, 200 mg tablet) 1
PA
MS
ANTI-HIV AGENTS, INTEGRASE INHIBITORS (INSTI)
BIKTARVY 2
GENVOYA 2
ISENTRESS (25 MG TABLET CHEW, 100 MG TABLET CHEW, 400 MGTABLET)
2 QL
ISENTRESS 100 MG POWDER PACKET 2
ISENTRESS HD 2 QL
STRIBILD 3 QL
TIVICAY (10 MG TABLET, 25 MG TABLET, 50 MG TABLET) 3 QL
ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI)
ATRIPLA 3 QL
COMPLERA 3
DELSTRIGO 3 QL
EDURANT 3
PAGE 38 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
efavirenz 1
INTELENCE 2
nevirapine (100 mg tab er 24h, 200 mg tablet, 400 mg tab er 24h) 1
NEVIRAPINE 50 MG/5 ML ORAL SUSP 1
ODEFSEY 3
PIFELTRO 3 QL
RESCRIPTOR 2
SUSTIVA 3
SYMFI LO 2 QL
VIRAMUNE (50 MG/5 ML SUSP, 200 MG TABLET) 3
VIRAMUNE XR 3
ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTI)
abacavir sulfate (20 mg/ml solution, 300 mg tablet) 1
abacavir sulfate/lamivudine 1
abacavir sulfate/lamivudine/zidovudine 1
didanosine 1
EMTRIVA (10 MG/ML SOLUTION, 200 MG CAPSULE) 3
EPIVIR (10 MG/ML ORAL SOLN, 150 MG TABLET, 300 MG TABLET) 3
lamivudine (10 mg/ml solution, 150 mg tablet, 300 mg tablet) 1
lamivudine/zidovudine 1
stavudine (1 mg/ml soln recon, 15 mg capsule, 20 mg capsule, 30 mg capsule,40 mg capsule)
1
tenofovir disoproxil fumarate 1
TRIZIVIR 3
TRUVADA 2
VIDEX 2
VIREAD (150 MG TABLET, 200 MG TABLET, 250 MG TABLET, 300 MGTABLET, POWDER)
3
ZIAGEN 20 MG/ML SOLUTION 3
zidovudine (10 mg/ml syrup, 100 mg capsule, 300 mg tablet) 1
ANTI-HIV AGENTS, OTHER
DESCOVY 2
JULUCA 3 QL
SELZENTRY (25 MG TABLET, 75 MG TABLET, 150 MG TABLET, 300 MGTABLET)
2 QL
PAGE 39 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SELZENTRY 20 MG/ML ORAL SOLN 2
TRIUMEQ 3
TYBOST 2 QL
ANTI-HIV AGENTS, PROTEASE INHIBITORS
APTIVUS (100 MG/ML SOLUTION, 250 MG CAPSULE) 3
atazanavir sulfate 1
CRIXIVAN 3
INVIRASE 3
KALETRA (80 MG-20 MG/ML SOLN, 100-25 MG TABLET, 200-50 MGTABLET)
3
LEXIVA 50 MG/ML SUSPENSION 3
lopinavir/ritonavir 1
NORVIR (80 MG/ML SOLUTION, 100 MG POWDER PACKET, 100 MGSOFTGEL CAP, 100 MG TABLET)
3
PREZISTA (75 MG TABLET, 100 MG/ML SUSPENSION, 150 MG TABLET,400 MG TABLET, 600 MG TABLET, 800 MG TABLET)
3
REYATAZ 3
ritonavir 1
VIRACEPT 3
ANTI-INFLUENZA AGENTS
oseltamivir phosphate (6 mg/ml susp recon, 30 mg capsule, 45 mg capsule, 75mg capsule)
1 QL
RELENZA 3 QL
rimantadine hcl 1
ANTIHERPETIC AGENTS
acyclovir (200 mg capsule, 200 mg/5ml oral susp, 400 mg tablet, 800 mg tablet) 1
acyclovir 5 % oint. (g) 1 QL
ALFERON N 3
DENAVIR 3 QL
famciclovir (125 mg tablet, 250 mg tablet) 1
famciclovir 500 mg tablet 1 QL
SITAVIG 3 PA
trifluridine 1
valacyclovir hcl 1
XERESE 3 PA
PAGE 40 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANXIOLYTICS
ANXIOLYTICS, OTHER
buspirone hcl 1
meprobamate 1
midazolam hcl 2 mg/ml syrup 1
BENZODIAZEPINES
alprazolam (0.25 mg tab rapdis, 0.25 mg tablet, 0.5 mg tab er 24h, 0.5 mg tabrapdis, 0.5 mg tablet, 1 mg tab er 24h, 1 mg tab rapdis, 1 mg tablet, 2 mg tab er24h, 2 mg tab rapdis, 2 mg tablet, 3 mg tab er 24h)
1
ALPRAZOLAM INTENSOL 1
chlordiazepoxide hcl 1
clonazepam (0.125 mg tab rapdis, 0.25 mg tab rapdis, 0.5 mg tab rapdis, 0.5mg tablet, 1 mg tab rapdis, 1 mg tablet, 2 mg tab rapdis, 2 mg tablet)
1
clorazepate dipotassium 1
diazepam (2 mg tablet, 5 mg tablet, 5 mg/5 ml solution, 5 mg/ml oral conc, 10mg tablet)
1
lorazepam (0.5 mg tablet, 1 mg tablet, 2 mg tablet, 2 mg/ml oral conc) 1
LORAZEPAM INTENSOL 1
oxazepam 1
BIPOLAR AGENTS
MOOD STABILIZERS
lithium carbonate 1
lithium citrate 1
BLOOD GLUCOSE REGULATORS
DIABETIC BENEFIT and/or DME BENEFIT APPLIES. Please refer to member contract for copayment amount. If Diabetic BenefitDOES NOT apply please refer to the following tier classifications:
ANTIDIABETIC AGENTS
acarbose 1
ACTOPLUS MET 3
ACTOPLUS MET XR (15-1,000 MG TB, 30-1,000 MG TB) 3 QL
ACTOS 3
ADLYXIN 3 QL
ALOGLIPTIN BENZOATE 3
QL
ST
ALOGLIPTIN BENZOATE/METFORMIN HCL 3
QL
ST
PAGE 41 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ALOGLIPTIN BENZOATE/PIOGLITAZONE HCL 3
QL
ST
AVANDIA 3
BYDUREON 2 QL
BYDUREON BCISE 2 QL
BYDUREON PEN 2 QL
BYETTA (5 MCG PEN INJ, 10 MCG PEN INJ) 2 QL
CYCLOSET 3 QL
DUETACT 3 QL
FARXIGA 2
glimepiride 1
glipizide (2.5 mg tab er 24, 5 mg tab er 24, 5 mg tablet, 10 mg tab er 24, 10 mgtablet)
1
glipizide/metformin hcl 1
GLUMETZA 3 ST
glyburide 1
glyburide,micronized 1
glyburide/metformin hcl 1
GLYXAMBI 3 QL
INVOKAMET (50-1,000 MG TABLET, 150-1,000 MG TABLET, 150-500 MGTABLET)
2
INVOKAMET 50-500 MG TABLET 2 QL
INVOKAMET XR 2
INVOKANA (100 MG TABLET, 300 MG TABLET) 2 QL
JANUMET 2 QL
JANUMET XR (50-1,000 MG TABLET, 50-500 MG TABLET, 100-1,000 MGTABLET)
2 QL
JANUVIA 2 QL
JARDIANCE 10 MG TABLET 3 QL
JARDIANCE 25 MG TABLET 3
JENTADUETO 2 QL
JENTADUETO XR (2.5 MG, 5 MG TB) 2 QL
PAGE 42 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
KAZANO 3
QL
ST
KOMBIGLYZE XR (2.5-1,000 MG TAB, 5-1,000 MG TAB, 5-500 MG TABLET) 3
QL
ST
metformin er 500mg & 1000mg tab (generic version of glumetza and fortamet) 1 ST
metformin hcl (500 mg tab er 24, 500 mg tab er 24h, 500 mg tablet, 750 mg taber 24h, 850 mg tablet, 1000 mg tablet)
1
metformin hcl 1000 mg tab er 24 1 ST
miglitol 1
nateglinide 1
NESINA 3
QL
ST
ONGLYZA 3
QL
ST
OSENI 3
QL
ST
OZEMPIC (0.25-0.5 MG PEN, 1 MG PEN) 2 QL
pioglitazone hcl 1
pioglitazone hcl/glimepiride 1 QL
pioglitazone hcl/metformin hcl 1
PRANDIN 3
QTERN 3 QL
repaglinide 1
REPAGLINIDE/METFORMIN 3
SEGLUROMET 2 QL
STEGLATRO 2 QL
STEGLUJAN 3 QL
SYMLINPEN 120 3
SYMLINPEN 60 3
SYNJARDY 3
PAGE 43 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SYNJARDY XR (5-1,000 MG TABLET, 10-1,000 MG TABLET, 12.5-1,000 MGTAB, 25-1,000 MG TABLET)
3 QL
TANZEUM 30 MG PEN INJECT 3 QL
TANZEUM 50 MG PEN INJECT 3
tolazamide 1
tolbutamide 1
TRADJENTA 2 QL
TRULICITY 2 QL
VICTOZA 2-PAK 2 QL
VICTOZA 3-PAK 2 QL
XIGDUO XR (2.5 MG-1,000 MG TAB, 5 MG-1,000 MG TABLET, 5 MG-500 MGTABLET, 10 MG-1,000 MG TAB, 10 MG-500 MG TABLET)
2 QL
BLOOD GLUCOSE SUPPLIES
Lifescan and Abbott are preferred test meters/strips and Step Therapy applies prior to all other meters and strips.
FREESTYLE FREEDOM LITE METER 2
FREESTYLE INSULINX GLUCOSE SYS 2
FREESTYLE INSULINX TEST STRIPS 2 QL
FREESTYLE LITE METER 2
FREESTYLE LITE TEST STRIPS 2 QL
FREESTYLE PREC NEO TEST STRIPS 2 QL
FREESTYLE PRECISION NEO METER 2
FREESTYLE TEST STRIPS 2 QL
ONETOUCH ULTRA TEST STRIP 2 QL
ONETOUCH ULTRA2 GLUCOSE SYST 2
ONETOUCH ULTRAMINI METER 2
ONETOUCH VERIO FLEX SYSTEM KIT 2
ONETOUCH VERIO IQ SYSTEM KIT 2
ONETOUCH VERIO METER SYSTEM 2
ONETOUCH VERIO SYNC SYST KIT 2
ONETOUCH VERIO TEST STRIP 2 QL
PRECISION XTRA MONITOR 2
PRECISION XTRA TEST STRIPS 2 QL
PAGE 44 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
GLYCEMIC AGENTS
GLUCAGEN 1 MG HYPOKIT 2
GLUCAGON EMERGENCY KIT 2 QL
PROGLYCEM 3
INSULINS
ADMELOG 3 ST
ADMELOG SOLOSTAR 3 ST
AFREZZA 3
APIDRA 3 ST
APIDRA SOLOSTAR 3 ST
BASAGLAR KWIKPEN U-100 3
FIASP 3 ST
FIASP FLEXTOUCH 3 ST
HUMALOG 2
HUMALOG JUNIOR KWIKPEN 2
HUMALOG KWIKPEN U-100 2
HUMALOG KWIKPEN U-200 2
HUMALOG MIX 50-50 2
HUMALOG MIX 50-50 KWIKPEN 2
HUMALOG MIX 75-25 2
HUMALOG MIX 75-25 KWIKPEN 2
HUMULIN 70-30 2
HUMULIN 70/30 KWIKPEN 2
HUMULIN N 2
HUMULIN N KWIKPEN 2
HUMULIN R 2
HUMULIN R U-500 2
HUMULIN R U-500 KWIKPEN 2
LANTUS 2
LANTUS SOLOSTAR 2
LEVEMIR 2
PAGE 45 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
LEVEMIR FLEXTOUCH 2
NOVOLIN 70-30 2
NOVOLIN N 2
NOVOLIN R 2
NOVOLOG 3 ST
NOVOLOG FLEXPEN 3 ST
NOVOLOG MIX 70-30 3 ST
NOVOLOG MIX 70-30 FLEXPEN 3 ST
SOLIQUA 100-33 3 QL
TOUJEO SOLOSTAR 2
TRESIBA FLEXTOUCH U-100 2
TRESIBA FLEXTOUCH U-200 2
XULTOPHY 100-3.6 3 QL
BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS
ANTICOAGULANTS
COUMADIN 2
ELIQUIS (2.5 MG TABLET, 5 MG TABLET) 2 QL
ELIQUIS 5 MG STARTER PACK 2 QL
enoxaparin sodium 1
fondaparinux sodium 1
FRAGMIN 3
JANTOVEN 1
PRADAXA (75 MG CAPSULE, 150 MG CAPSULE) 2 QL
PRADAXA 110 MG CAPSULE 2
SAVAYSA 3 QL
warfarin sodium 1
XARELTO (10 MG TABLET, 15 MG TABLET, 20 MG TABLET) 2 QL
XARELTO STARTER PACK 2
ZONTIVITY 3
QL
PA
PAGE 46 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
BLOOD FORMATION MODIFIERS
anagrelide hcl 1
ARANESP 2 MS
DOPTELET 3
QL
PA
MS
EPOGEN 2 MS
FULPHILA 3
QL
MS
GRANIX 3
QL
PA
MS
LEUKINE 3
QL
MS
MOZOBIL 3
QL
PA
MS
MULPLETA 3
QL
PA
MS
NEUPOGEN (300 MCG/0.5 ML SYR, 300 MCG/ML VIAL, 480 MCG/0.8 MLSYR, 480 MCG/1.6 ML VIAL)
3
QL
PA
MS
NIVESTYM 3
PA
MS
PROCRIT 2 MS
PROMACTA 3
QL
PA
MS
TAVALISSE (100 MG TABLET, 150 MG TABLET) 3
QL
PA
ZARXIO 2 MS
PAGE 47 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
HEMOSTASIS AGENTS
AMICAR (0.25 GRAM/ML ORAL SOLN, 500 MG TABLET, 1,000 MG TABLET) 3
aminocaproic acid (250 mg/ml solution, 500 mg tablet) 1
aminocaproic acid 1000 mg tablet 3
phytonadione (vit k1) 5 mg tablet 1
tranexamic acid 650 mg tablet 1 QL
PLATELET MODIFYING AGENTS
ASPIRIN/DIPYRIDAMOLE 1
BRILINTA 60 MG TABLET 2
BRILINTA 90 MG TABLET 2 QL
cilostazol 1
clopidogrel bisulfate 300 mg tablet 1
clopidogrel bisulfate 75 mg tablet 1 QL
dipyridamole (25 mg tablet, 50 mg tablet, 75 mg tablet) 1
EFFIENT (5 MG TABLET, 10 MG TABLET) 3 QL
prasugrel hcl (5 mg tablet, 10 mg tablet) 1 QL
ticlopidine hcl 1
CARDIOVASCULAR AGENTS
ALPHA-ADRENERGIC AGONISTS
clonidine (0.1mg/24hr patch tdwk, 0.2mg/24hr patch tdwk, 0.3mg/24hr patchtdwk)
1 QL
clonidine hcl (0.1 mg tablet, 0.2 mg tablet, 0.3 mg tablet) 1
guanfacine hcl (1 mg tablet, 2 mg tablet) 1
methyldopa 1
midodrine hcl 1
NORTHERA 3
QL
PA
MS
ALPHA-ADRENERGIC BLOCKING AGENTS
DIBENZYLINE 3
doxazosin mesylate 1
phenoxybenzamine hcl 1
PAGE 48 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
prazosin hcl 1
terazosin hcl 1
ANGIOTENSIN II RECEPTOR ANTAGONISTS
candesartan cilexetil 1
EDARBI 3 ST
eprosartan mesylate 1
irbesartan 1
losartan potassium 1
olmesartan medoxomil 1
telmisartan 1
valsartan 1
ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS
benazepril hcl 1
captopril 1
enalapril maleate 1
EPANDED SOLUTION 3 PA
fosinopril sodium 1
lisinopril 1
moexipril hcl 1
perindopril erbumine 1
QBRELIS 3
QL
PA
quinapril hcl 1
ramipril 1
trandolapril 1
ANTIARRHYTHMICS
amiodarone hcl (100 mg tablet, 200 mg tablet, 400 mg tablet) 1
disopyramide phosphate 1
dofetilide 1
flecainide acetate 1
mexiletine hcl 1
MULTAQ 2 QL
PAGE 49 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PACERONE 1
propafenone hcl 1
quinidine gluconate 324 mg tablet er 1
quinidine sulfate 1
SORINE 1
sotalol hcl (80 mg tablet, 120 mg tablet, 160 mg tablet, 240 mg tablet) 1
SOTYLIZE 3 PA
TIKOSYN 3
BETA-ADRENERGIC BLOCKING AGENTS
acebutolol hcl 1
atenolol 1
betaxolol hcl (10 mg tablet, 20 mg tablet) 1
bisoprolol fumarate 1
BYSTOLIC 3
carvedilol 1
carvedilol phosphate 1 QL
labetalol hcl (100 mg tablet, 200 mg tablet, 300 mg tablet) 1
metoprolol succinate 1
metoprolol tartrate (25 mg tablet, 37.5 mg tablet, 50 mg tablet, 75 mg tablet,100 mg tablet)
1
nadolol 1
pindolol 1
propranolol hcl (10 mg tablet, 20 mg tablet, 20 mg/5 ml solution, 40 mg tablet,40mg/5ml solution, 60 mg cap sa 24h, 60 mg tablet, 80 mg cap sa 24h, 80 mgtablet, 120 mg cap sa 24h, 160 mg cap sa 24h)
1
timolol maleate (5 mg tablet, 10 mg tablet, 20 mg tablet) 1
CALCIUM CHANNEL BLOCKING AGENTS
AFEDITAB CR 1
amlodipine besylate 1
CARTIA XT 1
DILT-XR 1
PAGE 50 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
diltiazem hcl (30 mg tablet, 60 mg cap er 12h, 60 mg tablet, 90 mg cap er 12h,90 mg tablet, 120 mg cap er 12h, 120 mg cap er 24h, 120 mg cap er deg, 120mg cap sa 24h, 120 mg tablet, 180 mg cap er 24h, 180 mg cap er deg, 180 mgcap sa 24h, 180 mg tab er 24h, 240 mg cap er 24h, 240 mg cap er deg, 240 mgcap sa 24h, 240 mg tab er 24h, 300 mg cap er 24h, 300 mg cap sa 24h, 300mg tab er 24h, 360 mg cap er 24h, 360 mg cap sa 24h, 360 mg tab er 24h, 420mg cap sa 24h, 420 mg tab er 24h)
1
felodipine 1
isradipine 1
MATZIM LA 1
nicardipine hcl (20 mg capsule, 30 mg capsule) 1
NIFEDICAL XL 1
nifedipine 1
nimodipine 1
nisoldipine 1 QL
TAZTIA XT 1
verapamil hcl 1
CARDIOVASCULAR AGENTS, OTHER
amiloride hcl/hydrochlorothiazide 1
amlodipine besylate/atorvastatin calcium 1 QL
amlodipine besylate/benazepril hcl 1
amlodipine besylate/olmesartan medoxomil 1 QL
amlodipine besylate/valsartan 1
QL
PA
amlodipine besylate/valsartan/hydrochlorothiazide 1
QL
PA
atenolol/chlorthalidone 1
benazepril hcl/hydrochlorothiazide 1
bisoprolol fumarate/hydrochlorothiazide 1
BYVALSON 3 QL
candesartan cilexetil/hydrochlorothiazide 1
captopril/hydrochlorothiazide 1
CLORPRES (0.1-15 TABLET, 0.2-15 TABLET) 1
CORLANOR 3 QL
DIGITEK 1
PAGE 51 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
DIGOX 1
digoxin (50 mcg/ml solution, 125 mcg tablet, 250 mcg tablet) 1
enalapril maleate/hydrochlorothiazide 1
ENTRESTO 3
QL
ST
EXFORGE 3 QL
EXFORGE HCT 3 QL
fosinopril sodium/hydrochlorothiazide 1
irbesartan/hydrochlorothiazide 1
isoxsuprine hcl 1
lisinopril/hydrochlorothiazide 1
losartan potassium/hydrochlorothiazide 1
methyldopa/hydrochlorothiazide 1
metoprolol tartrate/hydrochlorothiazide 1
moexipril hcl/hydrochlorothiazide 1
nadolol/bendroflumethiazide 1
olmesartan medoxomil/amlodipine besylate/hydrochlorothiazide 1 QL
olmesartan medoxomil/hydrochlorothiazide 1
pentoxifylline 1
propranolol hcl/hydrochlorothiazide 1
quinapril hcl/hydrochlorothiazide 1
RANEXA (ER 500 MG TABLET, ER 1,000 MG TABLET) 3 QL
RESERPINE 3
spironolactone/hydrochlorothiazide 1
TEKTURNA 3 QL
telmisartan/hydrochlorothiazide 1
trandolapril/verapamil hcl 1 QL
triamterene/hydrochlorothiazide 1
valsartan/hydrochlorothiazide 1
DIURETICS, CARBONIC ANHYDRASE INHIBITORS
acetazolamide 1
PAGE 52 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
KEVEYIS 3 PA
DIURETICS, LOOP
bumetanide (0.5 mg tablet, 1 mg tablet, 2 mg tablet) 1
EDECRIN 3
ethacrynic acid 1
furosemide (10 mg/ml solution, 20 mg tablet, 40 mg tablet, 40mg/5ml solution,80 mg tablet)
1
torsemide 1
DIURETICS, POTASSIUM-SPARING
amiloride hcl 1
DYRENIUM 3
eplerenone 1
spironolactone 1
DIURETICS, THIAZIDE
chlorothiazide 1
chlorthalidone 1
hydrochlorothiazide 1
indapamide 1
methyclothiazide 1
metolazone 1
DYSLIPIDEMICS, FIBRIC ACID DERIVATIVES
fenofibrate (40 mg tablet, 120 mg tablet, 160 mg tablet) 1 QL
fenofibrate (50 mg capsule, 54 mg tablet, 150 mg capsule) 1
fenofibrate nanocrystallized (48 mg tablet, 145mg tablet) 1 QL
fenofibrate,micronized 1
fenofibric acid 1
fenofibric acid (choline) 1 QL
gemfibrozil 1
TRILIPIX 3 QL
DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS
atorvastatin calcium 1
fluvastatin sodium (20 mg capsule, 40 mg capsule) 1 QL
PAGE 53 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
LIVALO 3
QL
ST
lovastatin (10 mg tablet, 20 mg tablet) 1
lovastatin 40 mg tablet 1 QL
pravastatin sodium 1
rosuvastatin calcium (5 mg tablet, 10 mg tablet, 20 mg tablet, 40 mg tablet) 1 QL
simvastatin (5 mg tablet, 10 mg tablet, 20 mg tablet, 40 mg tablet, 80 mg tablet) 1 QL
DYSLIPIDEMICS, OTHER
cholestyramine (with sugar) (4 g powd pack, 4 g powder) 1
cholestyramine/aspartame (cholestyramine/aspartame 4 g powd pack,cholestyramine/aspartame 4 g powder)
1
colesevelam hcl 1
colestipol hcl 1
ezetimibe 1
ezetimibe/simvastatin 1
JUXTAPID 3
QL
PA
KYNAMRO 3
PA
MS
niacin (500 mg tab er 24h, 750 mg tab er 24h, 1000 mg tab er 24h) 1 QL
omega-3 acid ethyl esters 1 QL
PRALUENT 2
QL
PA
MS
PREVALITE (PACKET, POWDER) 1
REPATHA 2
QL
PA
MS
VYTORIN 3
WELCHOL 3
ZETIA 3
PAGE 54 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
VASODILATORS, DIRECT-ACTING ARTERIAL
hydralazine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 100 mg tablet) 1
minoxidil (2.5 mg tablet, 10 mg tablet) 1
VASODILATORS, DIRECT-ACTING ARTERIAL/VENOUS
GONITRO 3 PA
isosorbide dinitrate 1
isosorbide mononitrate (10 mg tablet, 20 mg tablet) 1
isosorbide mononitrate (30 mg tab er 24h, 60 mg tab er 24h, 120 mg tab er24h)
1
MINITRAN 1
NITRO-TIME 1
nitroglycerin (0.1mg/hr patch td24, 0.2mg/hr patch td24, 0.4mg/hr patch td24,0.6mg/hr patch td24, 2.5 mg capsule er, 6.5 mg capsule er, 9 mg capsule er)
1
nitroglycerin (0.3 mg tab subl, 0.4 mg tab subl, 0.6 mg tab subl) 1
nitroglycerin 400mcg/spr spray 1
QL
PA
NITROLINGUAL 3 QL
NITROMIST 3
QL
PA
NITROSTAT 3
CENTRAL NERVOUS SYSTEM AGENTS
ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, AMPHETAMINES
ADZENYS ER 3
QL
PA
ADZENYS XR-ODT (3.1 MG TABLET, 6.3 MG TABLET, 9.4 MG TABLET, 12.5MG TABLET, 15.7 MG TABLET, 18.8 MG TABLET)
3
QL
PA
DEXEDRINE 10 MG TABLET 1
PAGE 55 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
dextroamphetamine sulf-saccharate/amphetamine sulf-aspartate(dextroamphetamine/amphetamine 5 mg cap er 24h,dextroamphetamine/amphetamine 10 mg cap er 24h,dextroamphetamine/amphetamine 15 mg cap er 24h,dextroamphetamine/amphetamine 20 mg cap er 24h,dextroamphetamine/amphetamine 25 mg cap er 24h,dextroamphetamine/amphetamine 30 mg cap er 24h)
1 QL
dextroamphetamine sulf-saccharate/amphetamine sulf-aspartate(dextroamphetamine/amphetamine 5 mg tablet,dextroamphetamine/amphetamine 7.5 mg tablet,dextroamphetamine/amphetamine 10 mg tablet,dextroamphetamine/amphetamine 12.5 mg tablet,dextroamphetamine/amphetamine 15 mg tablet,dextroamphetamine/amphetamine 20 mg tablet,dextroamphetamine/amphetamine 30 mg tablet)
1
dextroamphetamine sulfate (5 mg capsule er, 5 mg tablet, 5 mg/5 ml solution,10 mg capsule er, 10 mg tablet, 15 mg capsule er)
1
DYANAVEL XR 3
QL
PA
VYVANSE 2 QL
ZENZEDI (5 MG TABLET, 10 MG TABLET) 1
ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON-AMPHETAMINES
atomoxetine hcl 1
clonidine hcl 0.1 mg tab er 12h 1 QL
CONCERTA 3 QL
COTEMPLA XR-ODT 3
QL
PA
dexmethylphenidate hcl (2.5 mg tablet, 5 mg tablet, 10 mg tablet) 1
dexmethylphenidate hcl (5 mg cpbp 50-50, 10 mg cpbp 50-50, 15 mg cpbp 50-50, 20 mg cpbp 50-50, 25 mg cpbp 50-50, 30 mg cpbp 50-50, 35 mg cpbp 50-50, 40 mg cpbp 50-50)
1 QL
guanfacine hcl (1 mg tab er 24h, 2 mg tab er 24h, 3 mg tab er 24h, 4 mg tab er24h)
1 QL
METADATE ER 1
methylphenidate hcl (10 mg cpbp 30-70, 10 mg cpbp 50-50, 20 mg cpbp 30-70,20 mg cpbp 50-50, 30 mg cpbp 30-70, 30 mg cpbp 50-50, 40 mg cpbp 30-70,40 mg cpbp 50-50)
1 QL
methylphenidate hcl (18 mg tab er 24, 27 mg tab er 24, 36 mg tab er 24, 50 mgcpbp 30-70, 54 mg tab er 24, 60 mg cpbp 30-70, 60 mg cpbp 50-50)
1 QL
methylphenidate hcl (2.5 mg tab chew, 5 mg tab chew, 5 mg tablet, 5 mg/5 mlsolution, 10 mg tab chew, 10 mg tablet, 10 mg tablet er, 10 mg/5 ml solution, 20mg tablet, 20 mg tablet er)
1
methylphenidate hcl 72 mg tab er 24 3 QL
QUILLICHEW ER (ER 20 MG CHEW TAB, ER 30 MG CHEW TAB, ER 40 MGCHEW TAB)
3
QL
PA
QUILLIVANT XR 3
QL
PA
PAGE 56 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
RELEXXII 3 QL
CENTRAL NERVOUS SYSTEM, OTHER
AUSTEDO (6 MG TABLET, 9 MG TABLET, 12 MG TABLET) 3
QL
PA
MS
BELVIQ 3
QL
PA
BELVIQ XR 3
QL
PA
benzphetamine hcl 1
butalbital/acetaminophen 50mg-325mg tablet 1
butalbital/acetaminophen/caffeine 1
CAPACET 1
CONTRAVE 3
QL
PA
diethylpropion hcl 1
ESGIC CAPSULE 1
HORIZANT (ER 300 MG TABLET, ER 600 MG TABLET) 3
QL
PA
INGREZZA 3
QL
PA
MARGESIC 1
MARTEN-TAB 1
NUEDEXTA 3
QL
PA
phendimetrazine tartrate 1
phentermine hcl 1
QSYMIA (3.75 MG-23 MG CAPSULE, 7.5 MG-46 MG CAPSULE, 11.25 MG-69MG CAPSULE, 15 MG-92 MG CAPSULE)
3
QL
PA
riluzole 1
SUPRENZA ODT 3
QL
PA
PAGE 57 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
tetrabenazine (12.5 mg tablet, 25 mg tablet) 1
QL
PA
MS
ZEBUTAL 1
FIBROMYALGIA AGENTS
duloxetine hcl (20 mg capsule dr, 30 mg capsule dr, 60 mg capsule dr) 1 QL
duloxetine hcl 40 mg capsule dr 1
LYRICA (25 MG CAPSULE, 50 MG CAPSULE, 75 MG CAPSULE, 100 MGCAPSULE, 150 MG CAPSULE, 200 MG CAPSULE, 225 MG CAPSULE, 300MG CAPSULE)
2
LYRICA 20 MG/ML ORAL SOLUTION 2 QL
LYRICA CR (CR 82.5 MG TABLET, CR 165 MG TABLET, CR 330 MGTABLET)
3
QL
PA
SAVELLA (12.5 MG TABLET, 25 MG TABLET, 50 MG TABLET, 100 MGTABLET, TITRATION PACK)
3
QL
ST
MULTIPLE SCLEROSIS AGENTS
AMPYRA 3
QL
PA
MS
AUBAGIO 3
QL
ST
MS
AVONEX 2
QL
MS
BETASERON 3
QL
ST
MS
COPAXONE (20 MG/ML SYRINGE, 40 MG/ML SYRINGE) 2
QL
MS
dalfampridine 1
QL
PA
MS
EXTAVIA 3
PA
MS
PAGE 58 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
GILENYA 0.5 MG CAPSULE 2
QL
MS
glatiramer acetate 20 mg/ml syringe 1
QL
ST
MS
glatiramer acetate 40 mg/ml syringe 1
QL
MS
GLATOPA 20 MG/ML SYRINGE 1
QL
ST
MS
GLATOPA 40 MG/ML SYRINGE 1
QL
MS
PLEGRIDY 2
QL
MS
PLEGRIDY PEN 2
QL
MS
REBIF 2
QL
MS
TECFIDERA 2
QL
MS
ZINBRYTA 3
QL
ST
DENTAL AND ORAL AGENTS
cevimeline hcl 1
chlorhexidine gluconate 0.12 % mouthwash 1
EVOXAC 3
ORALONE 1
PAROEX 1
PERIOGARD 1
pilocarpine hcl (5 mg tablet, 7.5 mg tablet) 1
triamcinolone acetonide 0.1 % paste (g) 1
PAGE 59 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
DERMATOLOGICAL AGENTS
ABSORICA 3 PA
acitretin 1 QL
ACZONE 5% GEL 3
QL
ST
adapalene 0.3 % gel w/pump 1
adapalene/benzoyl peroxide 1 QL
AMNESTEEM 1
AVAR CLEANSER 1
AVITA 1
AZELEX 3
BENZEPRO 6% FOAMING CLOTHS 1 QL
BENZEPRO 7% CREAMY WASH 1
benzoyl peroxide 7 % cleanser 1
BPO (4% GEL, 8% GEL) 1
calcipotriene (0.005 % cream (g), 0.005 % oint. (g), 0.005 % solution) 1
calcipotriene/betamethasone dipropionate 1
CALCITRENE 1
CALCITRIOL 3 MCG/G OINTMENT 3
CARAC 3 PA
CLARAVIS 1
clindamycin phos/benzoyl perox 1.2(1)%-5% gel (gram) 1
QL
PA
clindamycin phosphate/benzoyl peroxide (phos/benzoyl 1 % gel (gram),phos/benzoyl 1 % gel w/pump)
1 QL
clindamycin phosphate/tretinoin 1 PA
clotrimazole/betamethasone dipropionate (clotrimazole/betamethasone 1 %cream (g), clotrimazole/betamethasone 1 % lotion)
1
CORTISPORIN OINTMENT 3
COSENTYX 2
QL
PA
ST
MS
PAGE 60 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
dapsone 5 % gel (gram) 1 QL
DERMACINRX CLORHEXACIN 3
QL
PA
DERMACINRX SURGICAL PHARMAPAK 3
QL
PA
DERMACINRX THERAZOLE PAK 3
QL
PA
DICLO GEL 3
QL
PA
DICLO GEL-XRYLIX SHEET 3
QL
PA
diclofenac sodium 1 % gel (gram) 1 QL
diclofenac sodium 3 % gel (gram) 1 PA
DICLOZOR 3
QL
PA
DRYSOL 3
ELIDEL 3 QL
ENSTILAR 3
QL
PA
EPIDUO FORTE 3 QL
FABIOR 3
QL
PA
FLUOROURACIL 0.5% CREAM 3 PA
hydrocortisone acetate/iodoquinol/aloe vera 1
hydrocortisone acetate/lidocaine hcl/aloe vera (hydrocortisone/lidocaine/aloe0.55%-2.8% gel w/appl, hydrocortisone/lidocaine/aloe 2 %-2 % kit,hydrocortisone/lidocaine/aloe 2.5-3%(7g) kit)
1
hydrocortisone acetate/pramoxine hcl 1
hydroquinone microspheres 1
imiquimod 5 % cream pack 1
lactic acid 10 % lotion 1
PAGE 61 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
LEXIXRYL 3
QL
PA
lidocaine hcl/hydrocortisone acetate (lidocaine/hydrocortisone 3 %-0.5 % cream(g), lidocaine/hydrocortisone 3 %-0.5 % cream/appl, lidocaine/hydrocortisone 3%-0.5 % kit, lidocaine/hydrocortisone 3%-1%(7 g) cream/appl,lidocaine/hydrocortisone 3%-1%(7 g) kit, lidocaine/hydrocortisone 3-2.5%(7g)gel w/appl)
1
methoxsalen 10 mg cap lq rap 1
metronidazole (0.75 % cream (g), 0.75 % gel (gram), 0.75 % lotion, 1 % gel(gram), 1 % gel w/pump)
1
MYORISAN 1
NEUAC GEL 1
NUDICLO SOLUPAK 3
QL
PA
ONEXTON GEL PUMP 3
QL
PA
PICATO (0.015% GEL, 0.05% GEL) 2 QL
podofilox 1
PR BENZOYL PEROXIDE 1
PRAMCORT 1
PROTOPIC 3 QL
REA LO 39 1
REA LO 40 (40 CM, 40 TION) 1
RECTIV 3 QL
REGRANEX 3 QL
ROSADAN (CREAM KIT, GEL KIT) 3
QL
PA
ROSADAN (CREAM, GEL) 1
SANTYL 3
SEB-PREV 1
selenium sulfide (2.25 % shampoo, 2.5 % lotion) 1
SOLARAZE 3 PA
SORIATANE 3 QL
PAGE 62 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SORILUX 3
QL
PA
spinosad 3
STELARA (45 MG/0.5 ML SYRINGE, 90 MG/ML SYRINGE) 2
QL
PA
MS
STELARA 45 MG/0.5 ML VIAL 2
PA
MS
sulfacetamide sodium (10 % cleanser, 10 % clnsr gel, 10 % shampoo) 1
sulfacetamide sodium/sulfur (sodium/sulfur 9.8%-4.8% cream (g), sodium/sulfur9.8%-4.8% lotion, sodium/sulfur 10-5%(w/v) lotion, sodium/sulfur 10-5%(w/w)cleanser, sodium/sulfur 10-5%(w/w) cream (g), sodium/sulfur 10-5%(w/w) lotion,sodium/sulfur 10-5%(w/w) suspension)
1
TACLONEX 0.005%-0.064% SUSPENS 3
QL
PA
tacrolimus (0.03 % oint. (g), 0.1 % oint. (g)) 1 QL
tazarotene 1
TAZORAC 3
TOLAK 2
TREMFYA 3
QL
PA
ST
MS
TRETIN-X (0.0375% CREAM, 0.075% CREAM) 3
QL
PA
tretinoin (0.01 % gel (gram), 0.025 % cream (g), 0.025 % gel (gram), 0.05 %cream (g), 0.05 % gel (gram), 0.1 % cream (g))
1
tretinoin microspheres 1
tretinoin/emollient base 1 PA
TRI-CHLOR 1
ULESFIA 3
VELTIN 3 PA
VEREGEN 3
XELITRAL 3
QL
PA
PAGE 63 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
XRYLIX 3
QL
PA
ZENATANE 1
ZEYOCAINE 3
QL
PA
ZIANA 3 PA
ELECTROLYTES/MINERALS/METALS/VITAMINS
ELECTROLYTE/MINERAL REPLACEMENT
CARBAGLU 3
PA
MS
CYTRA-K CRYSTALS PACKET 1
DENTA 5000 PLUS 1
DENTAGEL 1
EFFER-K 25 MEQ TABLET EFF 1
ENDARI 3
QL
PA
FLUORIDEX DAILY DEFENSE 1
FLUORIDEX SENSITIVITY RELIEF 1
K EFFERVESCENT 1
K-SOL 1
K-TAB ER 3
KLOR-CON 10 1
KLOR-CON 20 MEQ PACKET 1
KLOR-CON 8 1
KLOR-CON M10 1
KLOR-CON M15 1
KLOR-CON M20 1
KLOR-CON SPRINKLE 1
KLOR-CON-EF 1
levocarnitine (with sugar) 1
levocarnitine 330 mg tablet 1
NUTRESTORE 3
PAGE 64 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
potassium bicarbonate/citric acid 1
potassium chloride (8 meq capsule er, 8 meq tablet er, 10 meq capsule er, 10meq tab er prt, 10 meq tablet er, 20 meq packet, 20 meq tab er prt, 20 meqtablet er, 20meq/15ml liquid, 40meq/15ml liquid)
1
potassium chloride/potassium bicarbonate/citric acid 1
potassium citrate 1
potassium citrate/citric acid 3300-1002 packet 1
PREVIDENT (0.2%, DENTAL) 1
SF 1
SF 5000 PLUS 1
TL G-FOL OS 1
UROCIT-K 3
ELECTROLYTE/MINERAL/METAL MODIFIERS
CHEMET 3
CUPRIMINE 3 PA
EXJADE 3 MS
FERRIPROX (100 MG/ML SOLUTION, 500 MG TABLET) 3
JADENU 3 MS
KIONEX (15 GM/60 ML SUSPENSION, POWDER) 1
SAMSCA 3
QL
MS
sodium polystyrene sulfonate 1
SPS 1
SYPRINE 3 PA
trientine hcl 1 PA
DEPEN 2
PHOSPHATE BINDERS
calcium acetate 1
ELIPHOS 1
FOSRENOL (500 MG TABLET CHEW, 750 MG TABLET CHEW, 1,000 MGTABLET CHEW)
3 QL
lanthanum carbonate (500 mg tab chew, 750 mg tab chew, 1000 mg tab chew) 1 QL
PHOSLO 3
PAGE 65 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PHOSLYRA 3
RENAGEL 3
sevelamer carbonate (2.4 g powd pack, 800 mg tablet) 1
sevelamer carbonate 0.8 g powd pack 1 QL
VELPHORO 3 QL
VELTASSA 3
VITAMINS
cyanocobalamin (vitamin b-12) 1000mcg/ml vial 1
ENTERAL FORMULA REQUIRES PRIOR AUTHORIZATION. BRANDS ARETIER 3 & GENERICS ARE TIER 1.
3 PA
XURIDEN 3
QL
PA
GASTROINTESTINAL AGENTS
ANTISPASMODICS, GASTROINTESTINAL
chlordiazepoxide/clidinium bromide 1
CUVPOSA 3
QL
PA
dicyclomine hcl (10 mg capsule, 10 mg/5 ml solution, 20 mg tablet) 1
ED-SPAZ 1
GLYCATE 3
QL
PA
glycopyrrolate (1 mg tablet, 2 mg tablet) 1
glycopyrrolate 1.5 mg tablet 1
QL
PA
hyoscyamine sulfate (0.125 mg tab rapdis, 0.125 mg tab subl, 0.125 mg tablet,0.125mg/ml drops, 0.375 mg tab er 12h, 125mcg/5ml elixir)
1
HYOSYNE 1
methscopolamine bromide 1
NULEV 1
OSCIMIN 1
OSCIMIN SL 1
OSCIMIN SR 1
propantheline bromide 1
PAGE 66 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SYMAX 1
SYMAX-SL 1
SYMAX-SR 1
GASTROINTESTINAL AGENTS, OTHER
cromolyn sodium 20 mg/ml oral conc 1
diphenoxylate hcl/atropine sulfate (hcl/atropine 2.5-.025/5 liquid, hcl/atropine2.5-.025mg tablet)
1
GATTEX 3
QL
PA
MS
lansoprazole/amoxicillin trihydrate/clarithromycin 1
MOTOFEN 3
MOVANTIK 2 QL
MYALEPT 3
PA
MS
MYTESI 3
QL
PA
OMECLAMOX-PAK 3
QL
PA
opium tincture 1
paregoric 1
ursodiol 1
XENICAL 3 PA
HISTAMINE2 (H2) RECEPTOR ANTAGONISTS
cimetidine 1
cimetidine hcl 1
famotidine (40 mg tablet, 40mg/5ml oral susp) 1
nizatidine (150 mg capsule, 150mg/10ml solution, 300 mg capsule) 1
ranitidine hcl (15 mg/ml syrup, 150 mg capsule, 300 mg capsule, 300 mg tablet) 1
IRRITABLE BOWEL SYNDROME AGENTS
alosetron hcl 1 QL
AMITIZA 3
QL
ST
PAGE 67 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
LINZESS 2 QL
LOTRONEX 3 QL
LAXATIVES
CLENPIQ 3
CONSTULOSE 1
ENULOSE 1
GAVILYTE-C 1
GAVILYTE-G 1
GAVILYTE-H AND BISACODYL 1
GAVILYTE-N 1
GENERLAC 1
GOLYTELY PACKET 3
lactulose (10 g/15 ml solution, 20 g/30 ml solution) 1
MOVIPREP 3 QL
peg 3350/sod sulf/sod bicarb/sod chloride/potassium chloride 1
PEG-PREP 1
polyethylene glycol 3350 (3350 17g powd pack, 3350 17g/dose powder) 1
PREPOPIK 2
sodium chloride/sodium bicarbonate/potassium chloride/peg 1
SUPREP 2
TRILYTE WITH FLAVOR PACKETS 1
PROTECTANTS
CARAFATE (1 GM TABLET, 1 GM/10 ML SUSP) 3
misoprostol 1
sucralfate 1
PROTON PUMP INHIBITORS
ACIPHEX SPRINKLE 3
QL
PA
DEXILANT 3
QL
ST
esomeprazole magnesium 1 QL
ESOMEPRAZOLE STRONTIUM 3 PA
PAGE 68 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
lansoprazole (15 mg tab rap dr, 30 mg tab rap dr) 1
QL
ST
lansoprazole 30 mg capsule dr 1 QL
NEXIUM 3
QL
ST
omeprazole (10 mg capsule dr, 20 mg capsule dr, 40 mg capsule dr) 1 QL
pantoprazole sodium (20 mg tablet dr, 40 mg tablet dr) 1 QL
rabeprazole sodium 1 QL
GENETIC OR ENZYME DISORDER: REPLACEMENT, MODIFIERS, TREATMENT
BUPHENYL (500 MG TABLET, POWDER) 3
CERDELGA 3
PA
MS
CHOLBAM 3 PA
CREON 2
CYSTADANE 3
CYSTAGON 2
GALAFOLD 3
QL
PA
MS
KUVAN 3
PA
MS
miglustat 1
QL
PA
MS
NITYR (2 MG TABLET, 5 MG TABLET, 10 MG TABLET) 3 PA
OCALIVA 3
QL
PA
MS
ORFADIN (2 MG CAPSULE, 5 MG CAPSULE, 10 MG CAPSULE, 20 MGCAPSULE)
3 PA
PALYNZIQ (2.5 MG/0.5 ML SYRINGE, 10 MG/0.5 ML SYRINGE, 20 MG/MLSYRINGE)
3
PA
MS
PAGE 69 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PANCREAZE 3
PANCRELIPASE 5,000 1
PROCYSBI (DR 25 MG CAPSULE, DR 75 MG CAPSULE) 3
QL
PA
MS
RAVICTI 3
QL
PA
MS
sodium phenylbutyrate (0.94 g/g powder, 500 mg tablet) 1
STRENSIQ (18 MG/0.45 ML VIAL, 28 MG/0.7 ML VIAL, 40 MG/ML VIAL, 80MG/0.8 ML VIAL)
3
QL
PA
ZAVESCA 3
QL
PA
MS
ZENPEP 2
GENITOURINARY AGENTS
ANTISPASMODICS, URINARY
darifenacin hydrobromide 1 QL
flavoxate hcl 1
GELNIQUE (3% GEL, 10% GEL PUMP, 10% GEL SACHET, 10% GELSACHETS)
3
QL
ST
MYRBETRIQ 2 QL
oxybutynin chloride (5 mg tab er 24, 5 mg tablet, 5 mg/5 ml syrup, 10 mg tab er24, 15 mg tab er 24)
1
OXYTROL 3 ST
tolterodine tartrate (1 mg tablet, 2 mg cap er 24h, 2 mg tablet, 4 mg cap er 24h) 1 QL
TOVIAZ 2 QL
trospium chloride (20 mg tablet, 60 mg cap er 24h) 1 QL
VESICARE 2 QL
BENIGN PROSTATIC HYPERTROPHY AGENTS
alfuzosin hcl 1 QL
CIALIS (2.5 MG TABLET, 5 MG TABLET) 3
QL
ST
PAGE 70 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
dutasteride 1 QL
finasteride 5 mg tablet 1
RAPAFLO 3
QL
ST
tamsulosin hcl 1 QL
GENITOURINARY AGENTS, OTHER
ADDYI 3 PA
bethanechol chloride 1
CIALIS (10 MG TABLET, 20 MG TABLET) 3
QL
ST
CONCEPTROL 3 C zero copay
ELMIRON 3
GYNOL II 3 C zero copay
LEVITRA 3
QL
ST
phenazopyridine hcl 1
sildenafil citrate (25 mg tablet, 50 mg tablet, 100 mg tablet) 1 QL
STAXYN 3
QL
ST
STENDRA 3
QL
ST
TODAY CONTRACEPTIVE SPONGE 3 C zero copay
VCF (FILM, FOAM, GEL) 3 C zero copay
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL)
ALA-CORT 1
alclometasone dipropionate 1
amcinonide (0.1 % cream (g), 0.1 % lotion, 0.1 % oint. (g)) 1
ANUCORT-HC 1
betamethasone dipropionate (0.05 % cream (g), 0.05 % gel (gram), 0.05 %lotion, 0.05 % oint. (g))
1
PAGE 71 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
betamethasone dipropionate/propylene glycol (betamethasone/propylene 0.05% cream (g), betamethasone/propylene 0.05 % lotion,betamethasone/propylene 0.05 % oint. (g))
1
betamethasone valerate (0.1 % cream (g), 0.1 % lotion, 0.1 % oint. (g), 0.12 %foam)
1
clobetasol propionate (0.05 % cream (g), 0.05 % gel (gram), 0.05 % lotion, 0.05% oint. (g), 0.05 % shampoo, 0.05 % solution, 0.05 % spray)
1
CLOCORTOLONE PIVALATE 0.1 % CREAM(G) 3 ST
CLODAN 0.05% KIT 3
QL
PA
CLODAN 0.05% SHAMPOO 1
CLODERM 3 ST
CORDRAN (4 MCG/SQ CM TAPE LARGE, 4 MCG/SQ CM TAPE SMALL) 3 QL
CORMAX 1
cortisone acetate 1
DECADRON 0.5 MG/5 ML ELIXIR 1
DELTASONE 1
DERMACINRX CINLONE-I CPI 3
QL
PA
DERMACINRX SILAPAK 3
QL
PA
DERMACINRX SILAZONE 3
QL
PA
DERMAZONE 3
QL
PA
DESONATE 3 ST
desonide (0.05 % cream (g), 0.05 % lotion, 0.05 % oint. (g)) 1
desoximetasone (0.05 % cream (g), 0.05 % gel (gram), 0.05 % oint. (g), 0.25 %cream (g), 0.25 % oint. (g))
1
dexamethasone ((21) tab ds pk, (35) tab ds pk, (51) tab ds pk) 1
QL
PA
dexamethasone (0.5 mg tablet, 0.5 mg/5ml elixir, 0.5 mg/5ml solution, 0.75 mgtablet, 1 mg tablet, 1.5 mg tablet, 2 mg tablet, 4 mg tablet, 6 mg tablet)
1
DIFLORASONE DIACETATE 3
ELLZIA PAK 3
QL
PA
PAGE 72 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
EMFLAZA (6 MG TABLET, 18 MG TABLET, 22.75 MG/ML ORAL SUSP, 36MG TABLET)
3
QL
PA
EMFLAZA 30 MG TABLET 3 QL
fludrocortisone acetate 1
fluocinolone acetonide (0.01 % cream (g), 0.01 % oil, 0.01 % solution, 0.025 %cream (g), 0.025 % oint. (g))
1
fluocinolone acetonide/shower cap 1
fluocinonide (0.05 % cream (g), 0.05 % gel (gram), 0.05 % oint. (g), 0.05 %solution, 0.1 % cream (g))
1
fluocinonide/emollient base 1
flurandrenolide (0.05 % cream (g), 0.05 % lotion, 0.05 % oint. (g)) 1
fluticasone propionate (0.005 % oint. (g), 0.05 % cream (g), 0.05 % lotion) 1
H.P. ACTHAR 3
QL
PA
MS
halobetasol propionate 1
HALOG 3 ST
HEMMOREX-HC 1
hydrocortisone (1 % cream (g), 1 % crm/pe app, 1 % oint. (g), 2.5 % cream (g),2.5 % crm/pe app, 2.5 % lotion, 2.5 % oint. (g), 5 mg tablet, 10 mg tablet, 20 mgtablet)
1
hydrocortisone acetate (25 mg supp.rect, 30 mg supp.rect) 1
hydrocortisone butyrate (0.1 % cream (g), 0.1 % oint. (g), 0.1 % solution) 1
hydrocortisone butyrate/emoll 0.1 % cream (g) 1
hydrocortisone valerate 1
hydrocortisone/mineral oil/petrolatum,white 1
methylprednisolone 1
mometasone furoate (0.1 % cream (g), 0.1 % oint. (g), 0.1 % solution) 1
NOLIX 0.05% CREAM 1
NUTRIARX 3
QL
PA
PEDIADERM HC 3
QL
PA
prednicarbate 1
prednisolone 15 mg/5 ml solution 1
PAGE 73 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
prednisolone sod phosphate (5 mg/5 ml solution, 10 mg tab rapdis, 10 mg/5 mlsolution, 15 mg tab rapdis, 15 mg/5 ml solution, 20 mg/5 ml solution, 25 mg/5ml solution, 30 mg tab rapdis)
1
prednisone (1 mg tablet, 2.5 mg tablet, 5 mg tab ds pk, 5 mg tablet, 5 mg/5 mlsolution, 10 mg tab ds pk, 10 mg tablet, 20 mg tablet, 50 mg tablet)
1
PREDNISONE INTENSOL 1
PROCTO-MED HC 1
PROCTO-PAK 1
PROCTOSOL-HC 1
PROCTOZONE-HC 1
RAYOS 3 PA
SANADERMRX 3
QL
PA
SCALACORT 1
SILALITE PAK 3
QL
PA
SILAZONE-II 3
QL
PA
SYNALAR TS 3
QL
PA
TAPERDEX 3
QL
PA
TRI-SILA 3
QL
PA
triamcinolone acetonide (0.025 % cream (g), 0.025 % lotion, 0.025 % oint. (g),0.1 % cream (g), 0.1 % lotion, 0.1 % oint. (g), 0.147mg/g aerosol, 0.5 % cream(g), 0.5 % oint. (g))
1
TRIANEX 3 ST
TRIDERM 1
ULTRAVATE X 3
QL
PA
WHYTEDERM TRILASIL PAK 3
QL
PA
ZODEX 12 DAY 1.5 MG TABLET 3 QL
ZODEX 6 DAY 1.5 MG TABLET 3
QL
PA
PAGE 74 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)
BRAVELLE 3
QL
PA
MS
chorionic gonadotropin, human 1
QL
PA
MS
desmopressin acetate (0.1 mg tablet, 0.1 mg/ml solution, 0.2 mg tablet,10/spray spray/pump)
1
desmopressin acetate (4 mcg/ml ampul, 4 mcg/ml vial) 1 MS
desmopressin acetate (non-refrigerated) 1
EGRIFTA (1 MG VIAL, 2 MG VIAL) 3
QL
PA
FOLLISTIM AQ (75 VIAL, 300 CARTRIDG, 600 CARTRIDG, 900 CARTRIDG) 3
QL
PA
ST
MS
GENOTROPIN 3
PA
ST
MS
GONAL-F 2
QL
PA
MS
HUMATROPE 3
PA
ST
MS
INCRELEX 3
PA
MS
MENOPUR 3
PA
MS
NORDITROPIN FLEXPRO 3
PA
ST
MS
PAGE 75 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
NOVAREL 10,000 UNITS VIAL 1
QL
PA
MS
NUTROPIN AQ 3
PA
ST
MS
OMNITROPE (5 MG/1.5 ML CRTG, 5.8 MG VIAL, 10 MG/1.5 ML CRTG) 2
PA
MS
OVIDREL 3
PA
MS
PREGNYL 1
QL
PA
MS
SAIZEN 3
QL
PA
ST
MS
SEROSTIM 3
QL
PA
MS
ZOMACTON 3
QL
PA
MS
ZORBTIVE 3
QL
PA
MS
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS)
ANABOLIC STEROIDS
ANADROL-50 3
oxandrolone 1
ANDROGENS
ANDRODERM 2 PA
PAGE 76 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANDROGEL 2 PA
ANDROID 3 PA
ANDROXY 1 PA
AXIRON 3 PA
danazol 1
DEPO-TESTOSTERONE 3
FORTESTA 3 PA
METHITEST 1 PA
methyltestosterone 1 PA
NATESTO 3
QL
PA
STRIANT 3 PA
TESTIM 3 PA
TESTOSTERONE (10 MG (2%) GEL MD PMP, 12.5/1.25G GEL MD PMP, 50MG (1%) GEL (GRAM)
3 PA
testosterone (25mg(1%) gel packet, 30mg/1.5ml sol md pmp) 1 PA
TESTOSTERONE (50 MG (1%) GEL PACKET). SOME MANUFACTURERSARE T3 AND OTHERS T1
3 PA
testosterone cypionate (100 mg/ml vial, 200 mg/ml vial) 1
testosterone enanthate 200 mg/ml vial 1
TESTRED 3 PA
VOGELXO 3 PA
ESTROGENS
ALORA 3 QL
ALTAVERA 1 C zero copay
ALYACEN 1 C zero copay
AMABELZ 1
AMETHIA 1 C zero copay
AMETHIA LO 1 C zero copay
AMETHYST 1 C zero copay
PAGE 77 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
APRI 1 C zero copay
ARANELLE 1 C zero copay
ASHLYNA 1 C zero copay
AUBRA 1 C zero copay
AVIANE 1 C zero copay
AZURETTE 1 C zero copay
BALZIVA 1 C zero copay
BEKYREE 1 C zero copay
BLISOVI 24 FE 1 C zero copay
BLISOVI FE 1 C zero copay
BRIELLYN 1 C zero copay
CAMRESE 1 C zero copay
CAMRESE LO 1 C zero copay
CAZIANT 1 C zero copay
CHATEAL 1 C zero copay
CLIMARA PRO 2
COMBIPATCH 3
COVARYX 1
COVARYX H.S. 1
CRYSELLE 1 C zero copay
CYCLAFEM 1 C zero copay
CYRED 1 C zero copay
DASETTA 1 C zero copay
DAYSEE 1 C zero copay
DELYLA 1 C zero copay
desogestrel-ethinyl estradiol 1 C zero copay
desogestrel-ethinyl estradiol/ethinyl estradiol 1 C zero copay
drospirenone/ethinyl estradiol/levomefolate calcium 1 C zero copay
PAGE 78 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ECONTRA ONE-STEP 3 C zero copay
EEMT 1
EEMT H.S. 1
ELINEST 1 C zero copay
EMOQUETTE 1 C zero copay
ENJUVIA (0.3 MG TABLET, 0.45 MG TABLET, 0.625 MG TABLET, 0.9 MGTABLET, 1.25 MG TABLET)
3 QL
ENPRESSE 1 C zero copay
ENSKYCE 1 C zero copay
ESTARYLLA 1 C zero copay
ESTRACE 0.01% CREAM 2
estradiol (.025mg/24h patch tdsw, .025mg/24h patch tdwk, .0375mg/24 patchtdsw, .0375mg/24 patch tdwk, 0.05mg/24h patch tdsw, 0.05mg/24h patch tdwk,0.06mg/24h patch tdwk, .075mg/24h patch tdsw, .075mg/24h patch tdwk,0.1mg/24hr patch tdsw, 0.1mg/24hr patch tdwk)
1 QL
estradiol (0.01 % cream/appl, 0.5 mg tablet, 1 mg tablet, 2 mg tablet, 10 mcgtablet)
1
estradiol valerate 1
estradiol/norethindrone acetate 1
ESTRING 3
estrogens,esterified/methyltestosterone 1
estropipate 1
ethinyl estradiol/drospirenone 1 C zero copay
ethynodiol d-ethinyl estradiol 1 mg-35mcg tablet 1 C zero copay
ethynodiol d-ethinyl estradiol 1 mg-50mcg tablet 1 C zero copay
FALMINA 1 C zero copay
FAYOSIM 1 C zero copay
FEMYNOR 1 C zero copay
FYAVOLV 1
GENERESS FE 3
GIANVI 1 C zero copay
GILDAGIA 1 C zero copay
GILDESS 24 FE 1 C zero copay
PAGE 79 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
INTROVALE 1 C zero copay
JEVANTIQUE LO 1
JINTELI 1
JOLESSA 1 C zero copay
JULEBER 1 C zero copay
JUNEL 1 C zero copay
JUNEL FE 1 C zero copay
JUNEL FE 24 1 C zero copay
KAITLIB FE 1 C zero copay
KARIVA 1 C zero copay
KELNOR 1-35 1 C zero copay
KIMIDESS 1 C zero copay
KURVELO 1 C zero copay
l-norgest/e.estradiol-e.estrad 0.15mg(84) tbdspk 3mo 1 C zero copay
LARIN 1 C zero copay
LARIN 24 FE 1 C zero copay
LARIN FE 1 C zero copay
LARISSIA 1 C zero copay
LAYOLIS FE 1 C zero copay
LEENA 1 C zero copay
LESSINA 1 C zero copay
LEVONEST 1 C zero copay
levonorgestrel-ethinyl estradiol 1 C zero copay
levonorgestrel/ethinyl estradiol and ethinyl estradiol (l-norgest/e.estradiol-e.estrad 100-20(84) tbdspk 3mo, l-norgest/e.estradiol-e.estrad 150-30(84)tbdspk 3mo)
1 C zero copay
LEVORA-28 1 C zero copay
LO LOESTRIN FE 2 C zero copay
LOMEDIA 24 FE 1 C zero copay
PAGE 80 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
LOPREEZA 1
LORYNA 1 C zero copay
LOW-OGESTREL 1 C zero copay
LUTERA 1 C zero copay
MARLISSA 1 C zero copay
MENEST 3
MIBELAS 24 FE 1 C zero copay
MICROGESTIN 1 C zero copay
MICROGESTIN 24 FE 1 C zero copay
MICROGESTIN FE 1 C zero copay
MIMVEY 1
MIMVEY LO 1
MONO-LINYAH 1 C zero copay
MONONESSA 1 C zero copay
MY CHOICE 3 C zero copay
MY WAY 3 C zero copay
MYZILRA 1 C zero copay
NATAZIA 3 C zero copay
NECON (0.5-35-28 TABLET, 1-35-28 TABLET, 1-50-28 TABLET, 7-7-7-28TABLET, 10-11-28 TABLET)
1 C zero copay
NEW DAY 3 C zero copay
NIKKI 1 C zero copay
norethindrone ac-eth estradiol 1mg-20mcg tablet 1 C zero copay
norethindrone acetate-ethinyl estradiol (0.5mg-2.5 tablet, 1mg-5mcg tablet) 1
norethindrone acetate-ethinyl estradiol/ferrous fumarate 1 C zero copay
norethindrone-ethinyl estradiol/ferrous fumarate 1 C zero copay
norgestimate-ethinyl estradiol 1 C zero copay
NORTREL 1 C zero copay
OCELLA 1 C zero copay
PAGE 81 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
OGESTREL 1 C zero copay
ORSYTHIA 1 C zero copay
ORTHO TRI-CYCLEN LO 3
PHILITH 1 C zero copay
PIMTREA 1 C zero copay
PIRMELLA 1 C zero copay
PORTIA 1 C zero copay
PREMARIN (0.3 MG TABLET, 0.45 MG TABLET, 0.625 MG TABLET, 0.9 MGTABLET, 1.25 MG TABLET, VAGINAL CREAM-APPL)
2
PREMPHASE 2
PREMPRO 2
PREVIFEM 1 C zero copay
QUASENSE 1 C zero copay
RAJANI 1 C zero copay
RECLIPSEN 1 C zero copay
SETLAKIN 1 C zero copay
SPRINTEC 1 C zero copay
SRONYX 1 C zero copay
SYEDA 1 C zero copay
TARINA FE 1 C zero copay
TILIA FE 1 C zero copay
TRI-ESTARYLLA 1 C zero copay
TRI-LEGEST FE 1 C zero copay
TRI-LINYAH 1 C zero copay
TRI-LO-ESTARYLLA 1 C zero copay
TRI-LO-MARZIA 1 C zero copay
TRI-LO-SPRINTEC 1 C zero copay
TRI-PREVIFEM 1 C zero copay
TRI-SPRINTEC 1 C zero copay
PAGE 82 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
TRINESSA 1 C zero copay
TRINESSA LO 1 C zero copay
TRIVORA-28 1 C zero copay
TYDEMY 1 C zero copay
VAGIFEM 3
VELIVET 1 C zero copay
VESTURA 1 C zero copay
VIENVA 1 C zero copay
VIORELE 1 C zero copay
VIVELLE-DOT 3 QL
VYFEMLA 1 C zero copay
WERA 1 C zero copay
WYMZYA FE 1 C zero copay
XULANE 3 C zero copay
YUVAFEM 1
ZARAH 1 C zero copay
ZENCHENT 1 C zero copay
ZENCHENT FE 1 C zero copay
ZOVIA 1-35E 1 C zero copay
ZOVIA 1-50E 1 C zero copay
PROGESTERONE AGONISTS/ANTAGONISTS
ELLA 3 C zero copay
PROGESTINS
AFTERA 3 C zero copay
CAMILA 1 C zero copay
CRINONE 3
DEBLITANE 1 C zero copay
DEPO-SUBQ PROVERA 104 3 C zero copay
PAGE 83 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ECONTRA EZ 3 C zero copay
ENDOMETRIN 3 PA
ERRIN 1 C zero copay
FALLBACK SOLO 3 C zero copay
HEATHER 1 C zero copay
JENCYCLA 1 C zero copay
JOLIVETTE 1 C zero copay
levonorgestrel 3 C zero copay
LYZA 1 C zero copay
medroxyprogesterone acetate (150 mg/ml syringe, 150 mg/ml vial) 1 C zero copay
medroxyprogesterone acetate (2.5 mg tablet, 5 mg tablet, 10 mg tablet) 1
megestrol acetate (20 mg tablet, 40 mg tablet) 1
megestrol acetate (400mg/10ml oral susp, 625mg/5ml oral susp) 1
NEXT CHOICE ONE DOSE 3 C zero copay
NORA-BE 1 C zero copay
norethindrone 1 C zero copay
norethindrone acetate 5 mg tablet 1
NORLYROC 1 C zero copay
OPCICON ONE-STEP 3 C zero copay
OPTION 2 3 C zero copay
PLAN B ONE-STEP 3 C zero copay
progesterone 1 MS
progesterone, micronized 1
SHAROBEL 1 C zero copay
TAKE ACTION 3 C zero copay
SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTS
clomiphene citrate 1
DUAVEE 2
raloxifene hcl 1
PAGE 84 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SEROPHENE 1
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID)
ARMOUR THYROID 3
LEVO-T 1
levothyroxine sodium (25 mcg tablet, 50 mcg tablet, 75 mcg tablet, 88 mcgtablet, 100 mcg tablet, 112 mcg tablet, 125 mcg tablet, 137 mcg tablet, 150 mcgtablet, 175mcg tablet, 200 mcg tablet, 300 mcg tablet)
1
LEVOXYL 1
liothyronine sodium (5 mcg tablet, 25 mcg tablet, 50 mcg tablet) 1
NATURE-THROID 3
NP THYROID 1
SYNTHROID 3
THYROLAR-1 3
THYROLAR-1/2 3
THYROLAR-1/4 3
THYROLAR-2 3
THYROLAR-3 3
TIROSINT 3
UNITHROID 1
WESTHROID 3
WP THYROID 3
HORMONAL AGENTS, SUPPRESSANT (PITUITARY)
cabergoline 1
CETROTIDE 3
PA
MS
GANIRELIX ACETATE 3
PA
MS
leuprolide acetate 1 PA
octreotide acetate (50 mcg/ml ampul, 50 mcg/ml syringe, 50 mcg/ml vial, 100mcg/ml ampul, 100 mcg/ml syringe, 100 mcg/ml vial, 200 mcg/ml vial, 500mcg/ml ampul, 500 mcg/ml syringe, 500 mcg/ml vial, 1000mcg/ml vial)
1 MS
SIGNIFOR 3
PA
MS
SOMAVERT 3
PA
MS
PAGE 85 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
HORMONAL AGENTS, SUPPRESSANT (THYROID)
ANTITHYROID AGENTS
methimazole 1
propylthiouracil 1
SSKI 3
IMMUNOLOGICAL AGENTS
ANGIOEDEMA AGENTS
BERINERT 500 UNIT KIT 3
QL
PA
MS
CINRYZE 3
QL
PA
MS
FIRAZYR 3
QL
PA
MS
HAEGARDA (2,000 VIAL, 3,000 VIAL) 3
QL
PA
MS
RUCONEST 3
QL
PA
MS
TAKHZYRO 3
QL
PA
MS
IMMUNE SUPPRESSANTS
ASTAGRAF XL (0.5 MG CAPSULE, 1 MG CAPSULE, 5 MG CAPSULE) 3
QL
PA
azathioprine 1
CELLCEPT 200 MG/ML ORAL SUSP 3
cyclosporine (25 mg capsule, 100 mg capsule) 1
cyclosporine, modified (25 mg capsule, 50 mg capsule, 100 mg capsule, 100mg/ml solution)
1
PAGE 86 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ENBREL (25 MG KIT, 25 MG/0.5 ML SYRINGE, 50 MG/ML SYRINGE) 2
QL
PA
MS
ENBREL MINI 2
QL
PA
MS
ENBREL SURECLICK 2
QL
PA
MS
ENVARSUS XR (0.75 MG TABLET, 1 MG TABLET, 4 MG TABLET) 3
QL
PA
GENGRAF (25 MG CAPSULE, 50 MG CAPSULE, 100 MG CAPSULE, 100MG/ML SOLUTION)
1
HUMIRA 2
QL
PA
MS
KINERET 3
QL
PA
ST
methotrexate sodium (2.5 mg tablet, 25 mg/ml vial) 1
methotrexate sodium/pf (sodium/pf 1 g vial, sodium/pf 25 mg/ml vial) 1
mycophenolate mofetil (200 mg/ml susp recon, 250 mg capsule, 500 mg tablet) 1
mycophenolate sodium 1
OLUMIANT 3
QL
PA
MS
ORENCIA 3
QL
PA
ST
MS
OTREXUP 3 PA
RAPAMUNE (0.5 MG TABLET, 1 MG TABLET, 1 MG/ML ORAL SOLN, 2 MGTABLET)
3
RASUVO 3 PA
PAGE 87 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
sirolimus 1
tacrolimus (0.5 mg capsule, 1 mg capsule, 5 mg capsule) 1
TREXALL 3
XATMEP 3 PA
XELJANZ 10 MG TABLET 2
QL
PA
MS
XELJANZ 5 MG TABLET 2
PA
MS
XELJANZ XR 2
QL
PA
MS
ZORTRESS 3
IMMUNOMODULATORS
ACTEMRA 162 MG/0.9 ML SYRINGE 2
QL
PA
MS
ACTIMMUNE 3
PA
MS
ARCALYST 3
PA
MS
BENLYSTA (200 MG/ML AUTOINJECT, 200 MG/ML SYRINGE) 3
QL
PA
MS
DUPIXENT 3
QL
PA
GRASTEK 3 QL
leflunomide 1
ORALAIR 3 QL
OTEZLA 2
QL
PA
MS
PAGE 88 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
RAGWITEK 3 QL
INFLAMMATORY BOWEL DISEASE AGENTS
AMINOSALICYLATES
APRISO 3 QL
ASACOL HD 3
balsalazide disodium 1
CANASA 3
DELZICOL 2
DIPENTUM 3
GIAZO 3
QL
PA
mesalamine (1.2 g tablet dr, 4 g/60 ml enema) 1
MESALAMINE 800 MG TABLET DR 1
mesalamine with cleansing wipes 1
QL
PA
PENTASA 2
ROWASA 4 GM/60 ML ENEMA KIT 3
QL
PA
GLUCOCORTICOIDS
budesonide 3 mg capdr - er 1
budesonide 9 mg tabdr - er 1
QL
PA
COLOCORT 1
hydrocortisone 100mg/60ml enema 1
UCERIS (2 MG RECTAL FOAM, 9 MG ER TABLET) 3
QL
PA
SULFONAMIDES
sulfasalazine 1
METABOLIC BONE DISEASE AGENTS
alendronate sodium (5 mg tablet, 10 mg tablet, 35 mg tablet, 40 mg tablet, 70mg tablet)
1 QL
alendronate sodium 70 mg/75ml solution 1
PAGE 89 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
calcitonin,salmon,synthetic 1
calcitriol (0.25 mcg capsule, 0.5 mcg capsule, 1 mcg/ml solution) 1
doxercalciferol (0.5 mcg capsule, 1 mcg capsule, 2.5 mcg capsule) 1
ergocalciferol (vitamin d2) 50000 unit capsule 1
etidronate disodium 1
FORTEO 3
PA
MS
ibandronate sodium 150 mg tablet 1 QL
NATPARA 3
QL
PA
MS
paricalcitol (1 mcg capsule, 2 mcg capsule, 4 mcg capsule) 1
risedronate sodium (5 mg tablet, 30 mg tablet, 35 mg tablet, 35 mg tablet dr,150 mg tablet)
1 QL
SENSIPAR 3
TRIXYLITRAL 3
QL
PA
TYMLOS 3
QL
PA
MS
MISCELLANEOUS THERAPEUTIC AGENTS
BD PEN NEEDLES T2. ALL OTHER MANUFACTURERS T3. 2
cervical cap 3 C zero copay
COMFORT PAC-MELOXICAM 3
QL
PA
COMFORT PAC-NAPROXEN 3
QL
PA
condoms, female 3 C zero copay
diaphragms, contoured 3 C zero copay
diaphragms, wide seal 3 C zero copay
PAGE 90 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
FLEXIPAK 3
QL
PA
foam/gauze bandage/lidocaine/chlorhexidine/isopropyl alcohol 3
QL
PA
INFLAMMACIN 3
QL
PA
isometheptene mucate/dichloralphenazone/acetaminophen 1
MD-GASTROVIEW 1
METHERGINE 1 QL
methylergonovine maleate 0.2 mg tablet 1 QL
NODOLOR 1
NUDICLO TABPAK 3
QL
PA
ODACTRA 3 QL
potassium iodide/iodine 1
PREVIDOLRX PLUS ANALGESIC PAK 3
QL
PA
SAXENDA 3
QL
PA
silver/bandage/foam/gauze/lidocaine/chlorhexidin/isopropanol 3
QL
PA
XENAFLAMM 3
QL
PA
XERMELO 3
QL
PA
MODIFIED SOLID FOODS
All modified solid foods are covered as brands with Prior Authorization
OPHTHALMIC AGENTS
OPHTHALMIC AGENTS, OTHER
atropine sulfate (1 % drops, 1 % oint. (g)) 1
bacitracin/polymyxin b sulfate 500-10k/g oint. (g) 1
PAGE 91 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
BLEPHAMIDE S.O.P. 3
cyclopentolate hcl (0.5 % drops, 1 % drops, 2 % drops) 1
CYSTARAN 3 PA
NAPHAZOLINE 0.1% 3
NEO-POLYCIN 1
NEO-POLYCIN HC 1
neomycin sulfate/bacitracin zinc/polymyxin b/hydrocortisone 1
neomycin sulfate/bacitracin/polymyxin b 1
neomycin sulfate/polymyxin b sulfate/gramicidin d 1
neomycin/polymyxin b sulfate/dexamethasone (neomycin/polymyxinb/dexametha 0.1 % drops susp, neomycin/polymyxin b/dexametha 3.5-10k-.1oint. (g))
1
neomycin/polymyxin b/hydrocort 3.5-10k-10 drops susp 1
phenylephrine hcl (2.5 % drops, 10 % drops) 1
POLYCIN 1
polymyxin b sulfate/trimethoprim 1
proparacaine hcl 1
RESTASIS 2 QL
RESTASIS MULTIDOSE 2 QL
sulfacetamide sodium/prednisolone sodium phosphate 1
TOBRADEX EYE OINTMENT 3
tobramycin/dexamethasone 1
tropicamide (0.5 % drops, 1 % drops) 1
XIIDRA 2 QL
OPHTHALMIC ANTI-ALLERGY AGENTS
ALOCRIL 3
ALOMIDE 3
azelastine hcl 0.05 % drops 1
BEPREVE 3
cromolyn sodium 4 % drops 1
ELESTAT 3
EMADINE 3
epinastine hcl 1
PAGE 92 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
LASTACAFT 3
olopatadine hcl 0.1 % drops 1
OPHTHALMIC ANTI-INFLAMMATORIES
bromfenac sodium 1
dexamethasone sodium phosphate 0.1 % drops 1
diclofenac sodium 0.1 % drops 1
DUREZOL 3
fluorometholone 1
flurbiprofen sodium 1
ILEVRO 3
ketorolac tromethamine (0.4 % drops, 0.5 % drops) 1
LOTEMAX (EYE DROPS, EYE OINTMENT, OPHTHALMIC GEL) 2
MAXIDEX 3
NEVANAC 3
prednisolone acetate 1
prednisolone sod phosphate 1 % drops 1
VEXOL 3
OPHTHALMIC ANTIGLAUCOMA AGENTS
ALPHAGAN P 2
apraclonidine hcl 1
AZOPT 3
betaxolol hcl 0.5 % drops 1
brimonidine tartrate 1
carteolol hcl 1
COMBIGAN 2 QL
dorzolamide hcl 1
dorzolamide hcl/timolol maleate 1
dorzolamide/timolol/pf 2 %-0.5 % droperette 1 QL
levobunolol hcl 1
methazolamide 1
metipranolol 1
PHOSPHOLINE IODIDE 3
PAGE 93 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
pilocarpine hcl (1 % drops, 2 % drops, 4 % drops) 1
SIMBRINZA 3 QL
timolol maleate (0.25 % drops, 0.25 % sol-gel, 0.5 % drops, 0.5 % sol-gel) 1
OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS
BIMATOPROST 0.03 % DROPS (INTO THE EYE FOR GLAUCOMA) 2
latanoprost 1 QL
LUMIGAN 2
TRAVATAN Z 2
ZIOPTAN 3
QL
ST
OTIC AGENTS
ACETASOL HC 1
acetic acid 2 % solution 1
acetic acid/aluminum acetate 1
CIPRO HC 3
CIPRODEX 2
COLY-MYCIN S 3
CORTISPORIN-TC 3
fluocinolone acetonide oil 1
hydrocortisone/acetic acid 1
neomycin sulfate/polymyxin b sulfate/hydrocortisone (neomycin/polymyxinb/hydrocort drops susp, neomycin/polymyxin b/hydrocort solution)
1
RESPIRATORY TRACT/PULMONARY AGENTS
ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS
ARMONAIR RESPICLICK 2 QL
ARNUITY ELLIPTA 2 QL
ASMANEX 2 QL
ASMANEX HFA 2 QL
BECONASE AQ 3 QL
budesonide (0.25mg/2ml ampul-neb, 0.5 mg/2ml ampul-neb, 1 mg/2 ml ampul-neb)
1 QL
FLOVENT DISKUS 2 QL
PAGE 94 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
FLOVENT HFA (HFA 44 MCG INHALER, HFA 110 MCG INHALER, HFA 220MCG INHALER)
2 QL
flunisolide 1 QL
mometasone furoate 50 mcg spray/pump 1
NASONEX 3
OMNARIS 3 QL
PULMICORT 3 QL
PULMICORT FLEXHALER (90 MCG, 180 MCG) 3
QL
ST
QNASL 2 QL
QNASL CHILDREN 2 QL
QVAR 2 QL
QVAR REDIHALER 2 QL
TICANASE 3
QL
PA
TICASPRAY 3
QL
PA
triamcinolone acetonide 55 mcg spray 1
VERAMYST 3 QL
XHANCE 3
QL
PA
ZETONNA 3 QL
ANTIHISTAMINES
ARBINOXA (4 MG TABLET, 4 MG/5 ML LIQUID) 1
azelastine hcl 137 mcg spray/pump 1
azelastine hcl 205.5 mcg spray/pump 1 QL
carbinoxamine maleate (4 mg tablet, 4 mg/5 ml liquid) 1
clemastine fumarate (0.67mg/5ml syrup, 2.68 mg tablet) 1
cyproheptadine hcl (2 mg/5 ml syrup, 4 mg/10 ml syrup) 1
QL
PA
cyproheptadine hcl 4 mg tablet 1
PAGE 95 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
desloratadine 5 mg tablet 1
diphenhydramine hcl 12.5mg/5ml elixir 1
hydroxyzine hcl (10 mg tablet, 10 mg/5 ml solution, 25 mg tablet, 50 mg tablet,50 mg/25ml solution)
1
hydroxyzine pamoate 1
levocetirizine dihydrochloride (2.5 mg/5ml solution, 5 mg tablet) 1 QL
olopatadine hcl 0.6 % spray/pump 1 QL
promethazine hcl (6.25mg/5ml syrup, 12.5 mg tablet, 25 mg tablet) 1
ANTILEUKOTRIENES
montelukast sodium (4 mg gran pack, 4 mg tab chew, 5 mg tab chew, 10 mgtablet)
1 QL
zafirlukast 1
zileuton 1 QL
ZYFLO CR 3 QL
BRONCHODILATORS, ANTICHOLINERGIC
ATROVENT HFA 2
INCRUSE ELLIPTA 3 QL
ipratropium bromide 1
SPIRIVA 2
SPIRIVA RESPIMAT 2
TUDORZA PRESSAIR 3 QL
BRONCHODILATORS, SYMPATHOMIMETIC
albuterol sulfate (0.63mg/3ml vial-neb, 1.25mg/3ml vial-neb, 2 mg tablet, 2 mg/5ml syrup, 2.5 mg/0.5 vial-neb, 2.5 mg/3ml vial-neb, 4 mg tab er 12h, 4 mgtablet, 5 mg/ml solution, 8 mg tab er 12h)
1
AUVI-Q (0.15 MG, 0.3 MG) 3
QL
PA
BROVANA 3
epinephrine (0.1 mg/ml syringe, 1 mg/ml vial, 1 mg/ml(1) ampul) 1
epinephrine (0.15/0.15 auto injct, 0.15mg/0.3 auto injct, 0.3mg/0.3 auto injct) 1 QL
EPIPEN 2 QL
EPIPEN 2-PAK 2 QL
EPIPEN JR 2-PAK 2 QL
FORADIL 2 QL
PAGE 96 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
levalbuterol hcl (0.31mg/3ml vial-neb, 0.63mg/3ml vial-neb, 1.25mg/0.5 vial-neb, 1.25mg/3ml vial-neb)
1
levalbuterol tartrate 1
metaproterenol sulfate (10 mg tablet, 10 mg/5 ml syrup, 20 mg tablet) 1
PERFOROMIST 3 QL
PROAIR HFA 2 QL
PROAIR RESPICLICK 2 QL
PROVENTIL HFA 3 QL
SEREVENT DISKUS 2
STRIVERDI RESPIMAT 2 QL
terbutaline sulfate (2.5 mg tablet, 5 mg tablet) 1
VENTOLIN HFA 2 QL
CYSTIC FIBROSIS AGENTS
BETHKIS 3
QL
MS
CAYSTON 3 MS
KALYDECO 3
QL
PA
MS
KITABIS PAK 3 MS
ORKAMBI (100 MG-125 MG TABLET, 100-125 MG GRANULE PKT, 150-188MG GRANULE PKT, 200 MG-125 MG TABLET)
3
QL
PA
MS
SYMDEKO 3
QL
PA
MS
TOBI PODHALER 3 QL
tobramycin/nebulizer 1 MS
MAST CELL STABILIZERS
cromolyn sodium 20 mg/2 ml ampul-neb 1
PAGE 97 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PHOSPHODIESTERASE INHIBITORS, AIRWAYS DISEASE
caffeine citrate 60 mg/3 ml solution 1
THEOCHRON 1
theophylline anhydrous (80 mg/15ml elixir, 80 mg/15ml solution, 100 mg tab er12h, 200 mg tab er 12h, 300 mg tab er 12h, 400 mg tab er 24h, 450 mg tab er12h, 600 mg tab er 24h)
1
PULMONARY ANTIHYPERTENSIVES
ADCIRCA 3
QL
PA
MS
ADEMPAS 3
QL
PA
MS
LETAIRIS 3
QL
PA
MS
OPSUMIT 3
QL
PA
MS
ORENITRAM ER 3
PA
MS
REVATIO (10 MG/ML ORAL SUSP, 20 MG TABLET) 3
QL
PA
MS
sildenafil citrate 20 mg tablet 1
QL
PA
MS
tadalafil 20 mg tablet 1
QL
PA
MS
TRACLEER (62.5 MG TABLET, 125 MG TABLET) 3
PA
MS
TRACLEER 32 MG TABLET FOR SUSP 3
QL
PA
MS
PAGE 98 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
TYVASO 3
QL
PA
MS
UPTRAVI (200 MCG TABLET, 200-800 TITRATION PACK, 400 MCG TABLET,600 MCG TABLET, 800 MCG TABLET, 1,000 MCG TABLET, 1,200 MCGTABLET, 1,400 MCG TABLET, 1,600 MCG TABLET)
3
QL
PA
PULMONARY FIBROSIS AGENTS
ESBRIET (267 MG CAPSULE, 267 MG TABLET, 801 MG TABLET) 2
QL
PA
MS
OFEV 2
QL
PA
MS
RESPIRATORY TRACT AGENTS, OTHER
acetylcysteine (100 mg/ml vial, 200 mg/ml vial) 1
ADVAIR DISKUS 2 QL
ADVAIR HFA 2 QL
ANORO ELLIPTA 2 QL
benzonatate 1
BEVESPI AEROSPHERE 2 QL
BREO ELLIPTA 100-25 MCG INH 2 QL
BREO ELLIPTA 200-25 MCG INH 2
BROMFED DM 1
brompheniramine/pseudoephed/dm 2-30-10/5 syrup 1
CENTERGY DM 1
COMBIVENT RESPIMAT 2 QL
DYMISTA 3
QL
PA
FLUTICASONE PROPIONATE/SALMETEROL XINAFOATE 2 QL
hydrocodone bitart/chlorpheniramine maleate/pseudoephedrine 1
hydrocodone bitartrate/homatropine methylbromide (bit/homatrop 5 mg-1.5mgtablet, bit/homatrop 5-1.5 mg/5 syrup)
1
hydrocodone polistirex/chlorpheniramine polistirex 1 QL
PAGE 99 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
HYDROMET 1
ipratropium bromide/albuterol sulfate 1
phenylephrine hcl/prometh hcl 5-6.25mg/5 syrup 1
promethazine hcl/codeine 1
promethazine/dextromethorphan 6.25-15/5 syrup 1
promethazine/phenyleph/codeine 6.25-5-10 syrup 1
ribavirin 6 g vial-neb 1 MS
sodium chloride for inhalation 1
STIOLTO RESPIMAT 2 QL
SYMBICORT 2 QL
TICALAST 3
QL
PA
TOBI 3
tobramycin in 0.225 % sodium chloride 1
TUSSIGON 1
TYZINE 3
UTIBRON NEOHALER 2
SKELETAL MUSCLE RELAXANTS
AMRIX 3
QL
PA
carisoprodol 250 mg tablet 1
QL
PA
carisoprodol 350 mg tablet 1
carisoprodol/aspirin 200-325 mg tablet 1
chlorzoxazone 250 mg tablet 1
QL
PA
chlorzoxazone 500 mg tablet 1 QL
COMFORT PAC-CYCLOBENZAPRINE 3
QL
PA
COMFORT PAC-TIZANIDINE 3
QL
PA
PAGE 100 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
cyclobenzaprine hcl (5 mg tablet, 10 mg tablet) 1
cyclobenzaprine hcl 7.5 mg tablet 1
QL
PA
FEXMID 3
QL
PA
LORZONE 3
QL
PA
METAXALL 1 QL
metaxalone 400 mg tablet 1
metaxalone 800 mg tablet 1 QL
methocarbamol (500 mg tablet, 750 mg tablet) 1
orphenadrine citrate 100 mg tablet er 1
SOMA 250 MG TABLET 3
QL
PA
SOMA 350 MG TABLET 3
SLEEP DISORDER AGENTS
GABA RECEPTOR MODULATORS
EDLUAR 3
QL
ST
estazolam 1
eszopiclone 1 QL
flurazepam hcl 1
INTERMEZZO 3
QL
ST
quazepam 1
temazepam 1
triazolam 1
zaleplon (5 mg capsule, 10 mg capsule) 1 QL
zolpidem tartrate (1.75 mg tab subl, 3.5 mg tab subl, 5 mg tablet, 6.25 mg tabmphase, 10 mg tablet, 12.5 mg tab mphase)
1 QL
ZOLPIMIST 3
QL
ST
PAGE 101 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SLEEP DISORDERS, OTHER
armodafinil (50 mg tablet, 150 mg tablet, 200 mg tablet, 250 mg tablet) 1 QL
HETLIOZ 3
QL
PA
MS
modafinil 1 QL
ROZEREM 3
QL
ST
SILENOR 3
QL
ST
XYREM 3
QL
PA
Uncategorized
Unclassified
CIMDUO 2 QL
ESOMEP-EZS 3
QL
PA
JYNARQUE 3
QL
PA
KAPSPARGO SPRINKLE 3
NUDROXIPAK 3
QL
PA
NUDROXIPAK DSDR-50 3
QL
PA
NUDROXIPAK DSDR-75 3
QL
PA
NUDROXIPAK E-400 3
QL
PA
NUDROXIPAK I-800 3
QL
PA
NUDROXIPAK N-500 3
QL
PA
PAGE 102 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
NUPLAZID (10 MG TABLET, 34 MG CAPSULE) 3
QL
PA
MS
ORILISSA (150 MG TABLET, 200 MG TABLET) 3
QL
PA
SYMFI 2 QL
SYMTUZA 3 QL
TASIGNA 50 MG CAPSULE 3
QL
PA
MS
TIBSOVO 3
QL
PA
TOUJEO MAX SOLOSTAR 2
XIMINO 3
QL
PA
PAGE 103 LAST UPDATED 01/2019
Index of covered drugs
Aabacavir sulfate 39
abacavir sulfate/lamivudine 39
abacavir sulfate/lamivudine/zidovudine 39
ABSORICA 60
ABSTRAL 8
acamprosate calcium 11
acarbose 41
acebutolol hcl 50
acetaminophen with codeine phosphate 8
acetaminophen/caffeine/dihydrocodeine
bitartrate 8
ACETASOL HC 94
acetazolamide 52
acetic acid 94
acetic acid/aluminum acetate 94
acetylcysteine 99
ACIPHEX SPRINKLE 68
acitretin 60
ACTEMRA 88
ACTICLATE 15
ACTIMMUNE 88
ACTIQ 8
ACTOPLUS MET 41
ACTOPLUS MET XR 41
ACTOS 41
acyclovir 40
ACZONE 60
adapalene 60
adapalene/benzoyl peroxide 60
ADCIRCA 98
ADDYI 71
adefovir dipivoxil 36
ADEMPAS 98
ADLYXIN 41
ADMELOG 45
ADMELOG SOLOSTAR 45
ADVAIR DISKUS 99
ADVAIR HFA 99
ADZENYS ER 55
ADZENYS XR-ODT 55
AFEDITAB CR 50
AFINITOR 28
AFREZZA 45
AFTERA 83
AIMOVIG AUTOINJECTOR 24
AIMOVIG AUTOINJECTOR (2 PACK) 24
AKYNZEO 21
ALA-CORT 71
ALBENZA 32
albuterol sulfate 96
alclometasone dipropionate 71
ALECENSA 28
alendronate sodium 89
ALFERON N 40
alfuzosin hcl 70
ALINIA 32
ALKERAN 25
allopurinol 23
almotriptan malate 24
ALOCRIL 92
ALOGLIPTIN BENZOATE 41
alogliptin benzoate/metformin hcl 41
alogliptin benzoate/pioglitazone hcl 42
ALOMIDE 92
ALORA 77
alosetron hcl 67
ALPHAGAN P 93
alprazolam 41
ALPRAZOLAM INTENSOL 41
ALTABAX 12
ALTAVERA 77
ALUNBRIG 27
ALYACEN 77
AMABELZ 77
amantadine hcl 33
amcinonide 71
AMETHIA 77
AMETHIA LO 77
AMETHYST 77
AMICAR 48
amiloride hcl 53
amiloride hcl/hydrochlorothiazide 51
aminocaproic acid 48
amiodarone hcl 49
AMITIZA 67
amitriptyline hcl 20
amitriptyline hcl/chlordiazepoxide 19
amlodipine besylate 50
amlodipine besylate/atorvastatin calcium 51
amlodipine besylate/benazepril hcl 51
amlodipine besylate/olmesartan medoxomil 51
amlodipine besylate/valsartan 51
amlodipine
besylate/valsartan/hydrochlorothiazide 51
AMNESTEEM 60
amoxapine 20
amoxicillin 14
AMOXICILLIN ER 775 MG 14
amoxicillin/potassium clavulanate 14
ampicillin trihydrate 14
AMPYRA 58
AMRIX 100
ANADROL-50 76
anagrelide hcl 47
anastrozole 28
ANDRODERM 76
ANDROGEL 77
ANDROID 77
ANDROXY 77
ANODYNE LPT 10
ANORO ELLIPTA 99
ANUCORT-HC 71
APIDRA 45
APIDRA SOLOSTAR 45
APOKYN 34
apraclonidine hcl 93
aprepitant 21
APRI 78
APRISO 89
APTIOM 18
APTIVUS 40
PAGE 104 LAST UPDATED 01/2019
ARANELLE 78
ARANESP 47
ARBINOXA 95
ARCALYST 88
aripiprazole 35
102
94
85
94
6
89
8
78
94
94
8
48
86
40
50
51
56
53
33
33
38
91
96
58
78
57
96
42
60
78
15
60
58
77
armodafinil
ARMONAIR RESPICLICK
ARMOUR THYROID
ARNUITY ELLIPTA
ARYMO ER
ASACOL HD
ASCOMP WITH CODEINE
ASHLYNA
ASMANEX
ASMANEX HFA
aspirin/caffeine/dihydrocodeine bitartrate
ASPIRIN/DIPYRIDAMOLE
ASTAGRAF XL
atazanavir sulfate
atenolol
atenolol/chlorthalidone
atomoxetine hcl
atorvastatin calcium
atovaquone
atovaquone/proguanil hcl
ATRIPLA
atropine sulfate
ATROVENT HFA
AUBAGIO
AUBRA
AUSTEDO
AUVI-Q
AVANDIA
AVAR
AVIANE
AVIDOXY
AVITA
Avonex
AXIRON
AZASITE 14
azathioprine 86
azelastine hcl 92,95
AZELEX 60
azithromycin 14
AZOPT 93
AZURETTE 78
Bbacitracin 12
bacitracin/polymyxin b sulfate 91
baclofen 35
balsalazide disodium 89
BALZIVA 78
BANZEL 18
BARACLUDE 36
BASAGLAR KWIKPEN U-100 45
BAXDELA 14
BD Pen Needles T2. All other manufacturers
T3. 90
BECONASE AQ 94
BEKYREE 78
BELBUCA 7
BELVIQ 57
BELVIQ XR 57
benazepril hcl 49
benazepril hcl/hydrochlorothiazide 51
BENLYSTA 88
BENZEPRO 60
benznidazole 32
benzonatate 99
benzoyl peroxide 60
benzphetamine hcl 57
benztropine mesylate 33
BEPREVE 92
BERINERT 86
BESIVANCE 14
betamethasone dipropionate 71
betamethasone dipropionate/propylene
glycol 72
betamethasone valerate 72
BETASERON 58
betaxolol hcl 50,93
bethanechol chloride 71
BETHKIS 97
BEVESPI AEROSPHERE 99
bexarotene 32
bicalutamide 26
BIKTARVY 38
BILTRICIDE 32
bimatoprost 0.03 % drops (into the eye for
glaucoma) 94
bisoprolol fumarate 50
bisoprolol fumarate/hydrochlorothiazide 51
BLEPHAMIDE S.O.P. 92
BLISOVI 24 FE 78
BLISOVI FE 78
BONJESTA 21
BOSULIF 28
BPO 60
BRAFTOVI 28
BRAVELLE 75
BREO ELLIPTA 99
BRIELLYN 78
BRILINTA 48
brimonidine tartrate 93
BRISDELLE 19
BRIVIACT 16
BROMFED DM 99
bromfenac sodium 93
bromocriptine mesylate 34
brompheniramine maleate/pseudoephedrine
hcl/dextromethorphan 99
BROVANA 96
budesonide 89,94
bumetanide 53
BUPHENYL 69
buprenorphine hcl 11
buprenorphine hcl/naloxone hcl 11
BUPRENORPHINE PATCH 7
BUPROBAN 11
bupropion hcl 11,19
buspirone hcl 41
PAGE 105 LAST UPDATED 01/2019
butalbital/acetaminophen 57
butalbital/acetaminophen/caffeine 57
butalbital/acetaminophen/caffeine/codeine
phosphate 8
butalbital/aspirin/caffeine 5
butorphanol tartrate 8
BUTRANS 7
BYDUREON 42
BYDUREON BCISE 42
BYDUREON PEN 42
BYETTA 42
BYSTOLIC 50
BYVALSON 51
Ccabergoline 85
CABOMETYX 28
caffeine citrate 98
calcipotriene 60
calcipotriene/betamethasone dipropionate 60
calcitonin,salmon,synthetic 90
CALCITRENE 60
calcitriol 90
CALCITRIOL 3 MCG/G OINTMENT 60
calcium acetate 65
CALQUENCE 28
CAMBIA 5
CAMILA 83
CAMRESE 78
CAMRESE LO 78
CANASA 89
candesartan cilexetil 49
candesartan cilexetil/hydrochlorothiazide 51
CAPACET 57
capecitabine 27
CAPRELSA 28
captopril 49
captopril/hydrochlorothiazide 51
CARAC 60
CARAFATE 68
CARBAGLU 64
carbamazepine 18
carbidopa 34
carbidopa/levodopa 34
carbidopa/levodopa/entacapone 33
carbinoxamine maleate 95
carisoprodol 100
carisoprodol/aspirin 100
carisoprodol/aspirin/codeine phosphate 8
carteolol hcl 93
CARTIA XT 50
carvedilol 50
carvedilol phosphate 50
CAYSTON 97
CAZIANT 78
cefaclor 13
cefadroxil 13
cefdinir 13
cefditoren pivoxil 13
cefixime 13
cefpodoxime proxetil 13
cefprozil 13
CEFTIBUTEN 13
cefuroxime axetil 13
celecoxib 5
CELLCEPT 86
CELONTIN 16
CENTANY AT 12
CENTERGY DM 99
cephalexin 14
CERDELGA 69
cervical cap 90
CESAMET 21
CETROTIDE 85
cevimeline hcl 59
CHANTIX 11
CHATEAL 78
CHEMET 65
chlordiazepoxide hcl 41
chlordiazepoxide/clidinium bromide 66
chlorhexidine gluconate 59
chloroquine phosphate 33
chlorothiazide 53
chlorpromazine hcl 34
chlorthalidone 53
chlorzoxazone 100
CHOLBAM 69
cholestyramine (with sugar) 54
cholestyramine/aspartame 54
choline salicylate/magnesium salicylate 5
chorionic gonadotropin, human 75
CIALIS 70,71
CICLODAN 22
ciclopirox 22
ciclopirox olamine 22
cilostazol 48
CILOXAN 14
CIMDUO 102
cimetidine 67
cimetidine hcl 67
CINRYZE 86
CIPRO HC 94
CIPRODEX 94
ciprofloxacin 15
ciprofloxacin hcl 15
ciprofloxacin/ciprofloxacin hcl 15
citalopram hydrobromide 19
CLARAVIS 60
clarithromycin 14
clemastine fumarate 95
CLENPIQ 68
CLIMARA PRO 78
CLINDACIN ETZ 12
CLINDACIN P 12
CLINDACIN PAC 12
clindamycin hcl 12
clindamycin palmitate hcl 12
clindamycin phosphate 12
clindamycin phosphate/benzoyl peroxide 60
clindamycin phosphate/tretinoin 60
clobetasol propionate 72
CLOCORTOLONE PIVALATE 0.1 %
CREAM(G) 72
PAGE 106 LAST UPDATED 01/2019
CLODAN 72
CLODERM 72
clomiphene citrate 84
clomipramine hcl 20
clonazepam 41
clonidine 48
clonidine hcl 48,56
clopidogrel bisulfate 48
clorazepate dipotassium 41
CLORPRES 51
clotrimazole 22
clotrimazole/betamethasone dipropionate 60
clozapine 35
COARTEM 33
codeine phosphate/butalbital/aspirin/caffeine 8
codeine sulfate 8
COLCHICINE 23
COLCRYS 23
colesevelam hcl 54
colestipol hcl 54
COLOCORT 89
COLY-MYCIN S 94
COMBIGAN 93
COMBIPATCH 78
COMBIVENT RESPIMAT 99
COMETRIQ 29
COMFORT PAC-CYCLOBENZAPRINE 100
COMFORT PAC-MELOXICAM 90
COMFORT PAC-NAPROXEN 90
COMFORT PAC-TIZANIDINE 100
COMPAZINE 21
COMPLERA 38
COMPRO 21
CONCEPTROL 71
CONCERTA 56
condoms, female 90
CONSTULOSE 68
CONTRAVE 57
COPAXONE 58
COPEGUS 37
CORDRAN 72
CORLANOR 51
CORMAX 72
cortisone acetate 72
CORTISPORIN 60
CORTISPORIN-TC 94
COSENTYX 60
COTELLIC 29
COTEMPLA XR-ODT 56
COUMADIN 46
COVARYX 78
COVARYX H.S. 78
CREON 69
CRESEMBA 22
CRINONE 83
CRIXIVAN 40
cromolyn sodium 67,92,97
CRYSELLE 78
CUPRIMINE 65
CUVPOSA 66
cyanocobalamin (vitamin b-12) 66
CYCLAFEM 78
cyclobenzaprine hcl 101
cyclopentolate hcl 92
CYCLOPHOSPHAMIDE (25 mg CAPSULE, 50
mg CAPSULE) 25
cycloserine 25
CYCLOSET 42
cyclosporine 86
cyclosporine, modified 86
cyproheptadine hcl 95
CYRED 78
CYSTADANE 69
CYSTAGON 69
CYSTARAN 92
CYTRA-K 64
DD.H.E.45 24
DAKLINZA 36
dalfampridine 58
danazol 77
dantrolene sodium 35
dapsone 25,61
DARAPRIM 33
darifenacin hydrobromide 70
DASETTA 78
DAYSEE 78
DEBLITANE 83
DECADRON 72
DELSTRIGO 38
DELTASONE 72
DELYLA 78
DELZICOL 89
demeclocycline hcl 15
DENAVIR 40
DENTA 5000 PLUS 64
DENTAGEL 64
DEPEN 65
DEPO-SUBQ PROVERA 104 83
DEPO-TESTOSTERONE 77
DERMACINRX CINLONE-I CPI 72
DERMACINRX CLORHEXACIN 61
DERMACINRX EMPRICAINE 10
DERMACINRX PRIZOPAK 10
DERMACINRX SILAPAK 72
DERMACINRX SILAZONE 72
DERMACINRX SURGICAL PHARMAPAK 61
DERMACINRX THERAZOLE PAK 61
DERMAZONE 72
DESCOVY 39
desipramine hcl 20
desloratadine 96
desmopressin acetate 75
desmopressin acetate (non-refrigerated) 75
desogestrel-ethinyl estradiol 78
desogestrel-ethinyl estradiol/ethinyl estradiol 78
DESONATE 72
desonide 72
desoximetasone 72
DESVENLAFAXINE ER 19
DESVENLAFAXINE FUMARATE 19
desvenlafaxine succinate 19
PAGE 107 LAST UPDATED 01/2019
dexamethasone 72
dexamethasone sodium phosphate 93
DEXEDRINE 55
DEXILANT 68
dexmethylphenidate hcl 56
dextroamphetamine sulf-
saccharate/amphetamine sulf-aspartate 56
dextroamphetamine sulfate 56
diaphragms, contoured 90
diaphragms, wide seal 90
diazepam 17,41
DIBENZYLINE 48
DICLEGIS 21
DICLO GEL 61
DICLO GEL-XRYLIX SHEET 61
diclofenac potassium 5
diclofenac sodium 5,61,93
diclofenac sodium/misoprostol 5
DICLOPR 5
dicloxacillin sodium 14
DICLOZOR 61
dicyclomine hcl 66
didanosine 39
diethylpropion hcl 57
DIFICID 14
diflorasone diacetate 72
diflunisal 5
DIGITEK 51
DIGOX 52
digoxin 52
dihydroergotamine mesylate 24
dihydroergotamine mesylate 0.5mg/spry
spray/pump 24
DILT-XR 50
diltiazem hcl 51
DIPENTUM 89
diphenhydramine hcl 96
diphenoxylate hcl/atropine sulfate 67
dipyridamole 48
disopyramide phosphate 49
disulfiram 11
DITHOL 5
divalproex sodium 17
dofetilide 49
DOLOTRANZ 10
donepezil hcl 18
DOPTELET 47
DORYX 15
dorzolamide hcl 93
dorzolamide hcl/timolol maleate 93
dorzolamide hcl/timolol maleate/pf 93
doxazosin mesylate 48
doxepin hcl 20
doxercalciferol 90
doxycycline hyclate 15
doxycycline monohydrate 16
DOXYCYCLINE MONOHYDRATE 40 mg CAP
IR DR 16
dronabinol 21
drospirenone/ethinyl estradiol/levomefolate
calcium 78
DROXIA 27
DRYSOL 61
DUAVEE 84
DUETACT 42
DUEXIS 5
duloxetine hcl 58
DUPIXENT 88
DUREZOL 93
dutasteride 71
DUZALLO 23
DYANAVEL XR 56
DYMISTA 99
DYRENIUM 53
EE.E.S. 200 14
E.E.S. 400 14
econazole nitrate 22
ECONTRA EZ 84
ECONTRA ONE-STEP 79
ED-SPAZ 66
EDARBI 49
EDECRIN 53
EDLUAR 101
EDURANT 38
EEMT 79
EEMT H.S. 79
efavirenz 39
EFFER-K 64
EFFIENT 48
EGRIFTA 75
ELESTAT 92
eletriptan hydrobromide 24
ELIDEL 61
ELINEST 79
ELIPHOS 65
ELIQUIS 46
ELLA 83
ELLZIA PAK 72
ELMIRON 71
EMADINE 92
EMBEDA 7
EMCYT 27
EMFLAZA 73
EMOQUETTE 79
EMSAM 19
EMTRIVA 39
enalapril maleate 49
enalapril maleate/hydrochlorothiazide 52
ENBREL 87
ENBREL MINI 87
ENBREL SURECLICK 87
ENDARI 64
ENDOCET 8
ENDOMETRIN 84
ENJUVIA 79
enoxaparin sodium 46
ENPRESSE 79
ENSKYCE 79
ENSTILAR 61
entacapone 33
entecavir 36
PAGE 108 LAST UPDATED 01/2019
66
52
68
87
49
36
61
92
96
96
96
96
18
39
36
53
47
49
90
18
24
24
29
26
84
22
14
14
14
14
14
14
14
12
14
99
19
57
Enteral Formula Requires Prior Authorization.
Brands are Tier 3 & generics are Tier 1.
ENTRESTO
ENULOSE
ENVARSUS XR
EPANDED SOLUTION
EPCLUSA
EPIDUO FORTE
epinastine hcl
epinephrine
EPIPEN
EPIPEN 2-PAK
EPIPEN JR 2-PAK
EPITOL
EPIVIR
EPIVIR HBV
eplerenone
EPOGEN
eprosartan mesylate
ergocalciferol (vitamin d2)
ergoloid mesylates
ERGOMAR
ergotamine tartrate/caffeine
ERIVEDGE
ERLEADA
ERRIN
ERTACZO
ERY
ERY-TAB
ERYPED 200
ERYPED 400
ERYTHROCIN STEARATE
erythromycin base
erythromycin base in ethanol
erythromycin base/benzoyl peroxide
erythromycin ethylsuccinate
ESBRIET
escitalopram oxalate
ESGIC
ESOMEP-EZS 102
esomeprazole magnesium 68
esomeprazole strontium 68
ESTARYLLA 79
estazolam 101
ESTRACE 79
estradiol 79
estradiol valerate 79
estradiol/norethindrone acetate 79
ESTRING 79
estrogens,esterified/methyltestosterone 79
estropipate 79
eszopiclone 101
ethacrynic acid 53
ethambutol hcl 25
ethinyl estradiol/drospirenone 79
ethosuximide 16
ethynodiol diacetate-ethinyl estradiol 79
etidronate disodium 90
etodolac 5
etoposide 28
EURAX 33
EVOXAC 59
EXALGO 7
EXELDERM 22
exemestane 28
EXFORGE 52
EXFORGE HCT 52
EXJADE 65
EXTAVIA 58
EXTINA 22
ezetimibe 54
ezetimibe/simvastatin 54
FFABIOR 61
FACTIVE 15
FALLBACK SOLO 84
FALMINA 79
famciclovir 40
famotidine 67
FANAPT 35
FARESTON 27
FARXIGA 42
FARYDAK 29
FAYOSIM 79
felbamate 17
felodipine 51
FEMYNOR 79
fenofibrate 53
fenofibrate nanocrystallized 53
fenofibrate,micronized 53
fenofibric acid 53
fenofibric acid (choline) 53
fenoprofen calcium 5
FENORTHO 5
fentanyl 7
FENTANYL (37.5mcg/hr patch td72,
62.5mcg/hr patch td72, 87.5mcg/hr patch
td72) 7
fentanyl citrate 8
FENTORA 8
FERRIPROX 65
FETZIMA 19
FEXMID 101
FIASP 45
FIASP FLEXTOUCH 45
finasteride 71
FIRAZYR 86
FIRVANQ 12
flavoxate hcl 70
flecainide acetate 49
FLECTOR 5
FLEXIPAK 91
FLOVENT DISKUS 94
FLOVENT HFA 95
fluconazole 22
flucytosine 22
fludrocortisone acetate 73
flunisolide 95
fluocinolone acetonide 73
fluocinolone acetonide oil 94
fluocinolone acetonide/shower cap 73
PAGE 109 LAST UPDATED 01/2019
fluocinonide 73
fluocinonide/emollient base 73
FLUORIDEX DAILY DEFENSE 64
FLUORIDEX SENSITIVITY RELIEF 64
fluorometholone 93
fluorouracil 27
FLUOROURACIL 0.5% CREAM 61
fluoxetine hcl 19
fluphenazine decanoate 34
fluphenazine hcl 34
flurandrenolide 73
flurazepam hcl 101
flurbiprofen 5
flurbiprofen sodium 93
flutamide 26
fluticasone propionate 73
fluticasone propionate/salmeterol xinafoate 99
fluvastatin sodium 53
fluvoxamine maleate 19
foam/gauze
bandage/lidocaine/chlorhexidine/isopropyl
alcohol 91
FOLLISTIM AQ 75
fondaparinux sodium 46
FORADIL 96
FORTEO 90
FORTESTA 77
FOSAMAX PLUS D 90
fosinopril sodium 49
fosinopril sodium/hydrochlorothiazide 52
FOSRENOL 65
FRAGMIN 46
FREESTYLE FREEDOM LITE METER 44
FREESTYLE INSULINX GLUCOSE SYS 44
FREESTYLE INSULINX TEST STRIPS 44
FREESTYLE LITE METER 44
FREESTYLE LITE TEST STRIPS 44
FREESTYLE PREC NEO TEST STRIPS 44
FREESTYLE PRECISION NEO METER 44
FREESTYLE TEST STRIPS 44
frovatriptan succinate 24
FULPHILA 47
furosemide 53
FYAVOLV 79
Ggabapentin 17
GALAFOLD 69
galantamine hbr 18
GANIRELIX ACETATE 85
gatifloxacin 15
GATTEX 67
GAVILYTE-C 68
GAVILYTE-G 68
GAVILYTE-H AND BISACODYL 68
GAVILYTE-N 68
GELNIQUE 70
gemfibrozil 53
GENERESS FE 79
GENERLAC 68
GENGRAF 87
GENOTROPIN 75
GENTAK 11
gentamicin sulfate 11
GENVOYA 38
GIANVI 79
GIAZO 89
GILDAGIA 79
GILDESS 24 FE 79
GILENYA 59
GILOTRIF 29
glatiramer acetate 59
GLATOPA 59
GLEOSTINE 25
glimepiride 42
glipizide 42
glipizide/metformin hcl 42
GLUCAGEN 45
GLUCAGON EMERGENCY KIT 45
GLUMETZA 42
glyburide 42
glyburide,micronized 42
glyburide/metformin hcl 42
GLYCATE 66
glycopyrrolate 66
GLYDO 10
GLYXAMBI 42
GOCOVRI 33
GOLYTELY 68
Gonal-f 75
GONITRO 55
GRALISE 17
granisetron hcl 21
GRANIX 47
GRASTEK 88
griseofulvin ultramicrosize 22
griseofulvin, microsize 22
guanfacine hcl 48,56
GUANIDINE HCL 25
GYNOL II 71
HH.P. ACTHAR 73
HAEGARDA 86
halobetasol propionate 73
HALOG 73
haloperidol 34
haloperidol lactate 34
HARVONI 36
HEATHER 84
HEMMOREX-HC 73
HEPSERA 36
HETLIOZ 102
HEXALEN 25
HORIZANT 57
HUMALOG 45
HUMALOG JUNIOR KWIKPEN 45
HUMALOG KWIKPEN U-100 45
HUMALOG KWIKPEN U-200 45
HUMALOG MIX 50-50 45
HUMALOG MIX 50-50 KWIKPEN 45
HUMALOG MIX 75-25 45
HUMALOG MIX 75-25 KWIKPEN 45
PAGE 110 LAST UPDATED 01/2019
HUMATROPE 75
Humira 87
HUMULIN 70-30 45
HUMULIN 70/30 KWIKPEN 45
HUMULIN N 45
HUMULIN N KWIKPEN 45
HUMULIN R 45
HUMULIN R U-500 45
HUMULIN R U-500 KWIKPEN 45
HYCAMTIN 28
hydralazine hcl 55
hydrochlorothiazide 53
hydrocodone bitart/chlorpheniramine
maleate/pseudoephedrine 99
hydrocodone bitartrate/acetaminophen 9
hydrocodone bitartrate/homatropine
methylbromide 99
hydrocodone polistirex/chlorpheniramine
polistirex 99
hydrocodone/ibuprofen 9
hydrocortisone 73,89
hydrocortisone acetate 73
hydrocortisone acetate/iodoquinol/aloe vera 61
hydrocortisone acetate/lidocaine hcl/aloe
vera 61
hydrocortisone acetate/pramoxine hcl 61
hydrocortisone butyrate 73
hydrocortisone butyrate/emollient base 73
hydrocortisone valerate 73
hydrocortisone/acetic acid 94
hydrocortisone/mineral oil/petrolatum,white 73
HYDROMET 100
hydromorphone hcl 7,9
hydroquinone microspheres 61
hydroxychloroquine sulfate 33
hydroxyurea 27
hydroxyzine hcl 96
hydroxyzine pamoate 96
HYOLEV MB 12
HYOPHEN 12
hyoscyamine sulfate 66
HYOSYNE 66
HYSINGLA ER 7
Iibandronate sodium 90
IBRANCE 29
IBU 5
ibuprofen 5
ibuprofen/oxycodone hcl 9
ICLUSIG 29
IDHIFA 27
ILEVRO 93
imatinib mesylate 29
IMBRUVICA 29
imipramine hcl 20
imipramine pamoate 20
imiquimod 61
IMPAVIDO 33
INCRELEX 75
INCRUSE ELLIPTA 96
indapamide 53
indomethacin 5
INFLAMMACIN 91
INGREZZA 57
INLYTA 29
INTELENCE 39
INTERMEZZO 101
INTRON A 37
INTROVALE 80
INVIRASE 40
INVOKAMET 42
INVOKAMET XR 42
INVOKANA 42
ipratropium bromide 96
ipratropium bromide/albuterol sulfate 100
irbesartan 49
irbesartan/hydrochlorothiazide 52
IRESSA 29
ISENTRESS 38
ISENTRESS HD 38
isometheptene
mucate/dichloralphenazone/acetaminophen 91
isoniazid 25
isosorbide dinitrate 55
isosorbide mononitrate 55
isoxsuprine hcl 52
isradipine 51
itraconazole 22
ivermectin 32
JJadenu 65
JAKAFI 29
JANTOVEN 46
JANUMET 42
JANUMET XR 42
JANUVIA 42
JARDIANCE 42
JENCYCLA 84
JENTADUETO 42
JENTADUETO XR 42
JEVANTIQUE LO 80
JINTELI 80
JOLESSA 80
JOLIVETTE 84
JUBLIA 22
JULEBER 80
JULUCA 39
JUNEL 80
JUNEL FE 80
JUNEL FE 24 80
JUXTAPID 54
JYNARQUE 102
KK EFFERVESCENT 64
K-SOL 64
K-TAB ER 64
KAITLIB FE 80
KALETRA 40
KALYDECO 97
PAGE 111 LAST UPDATED 01/2019
KAPSPARGO SPRINKLE 102
KARIVA 80
KAZANO 43
KELNOR 1-35 80
KERYDIN 22
ketoconazole 22
KETODAN 22
ketoprofen 5
ketorolac tromethamine 6,93
KEVEYIS 53
KHEDEZLA 19
KIMIDESS 80
KINERET 87
KIONEX 65
KISQALI 30
KISQALI FEMARA CO-PACK 30
KITABIS PAK 97
KLOR-CON 64
KLOR-CON 10 64
KLOR-CON 8 64
KLOR-CON M10 64
KLOR-CON M15 64
KLOR-CON M20 64
KLOR-CON SPRINKLE 64
KLOR-CON-EF 64
KOMBIGLYZE XR 43
KURVELO 80
KUVAN 69
KYNAMRO 54
Llabetalol hcl 50
lactic acid 61
lactulose 68
LAMISIL 22
lamivudine 36,39
lamivudine/zidovudine 39
lamotrigine 17
lansoprazole 69
lansoprazole/amoxicillin
trihydrate/clarithromycin 67
lanthanum carbonate 65
LANTUS 45
LANTUS SOLOSTAR 45
LARIN 80
LARIN 24 FE 80
LARIN FE 80
LARISSIA 80
LASTACAFT 93
latanoprost 94
LATUDA 35
LAYOLIS FE 80
LAZANDA 9
LEENA 80
leflunomide 88
LENVIMA 30
LESSINA 80
LETAIRIS 98
letrozole 28
leucovorin calcium 27
LEUKERAN 25
LEUKINE 47
leuprolide acetate 85
levalbuterol hcl 97
levalbuterol tartrate 97
LEVEMIR 45
LEVEMIR FLEXTOUCH 46
levetiracetam 16
LEVITRA 71
LEVO-T 85
levobunolol hcl 93
levocarnitine 64
levocarnitine (with sugar) 64
levocetirizine dihydrochloride 96
levofloxacin 15
LEVONEST 80
levonorgestrel 84
levonorgestrel-ethinyl estradiol 80
levonorgestrel/ethinyl estradiol and ethinyl
estradiol 80
LEVORA-28 80
levorphanol tartrate 7
levothyroxine sodium 85
LEVOXYL 85
LEXIVA 40
LEXIXRYL 62
LIDO-K 10
LIDO-PRILO CAINE PACK 10
lidocaine 10
lidocaine hcl 10
lidocaine hcl/hydrocortisone acetate 62
lidocaine/prilocaine 10
LIDOPAC 10
LIDOPIN 10
LIDOPRIL 10
LIDOPRIL XR 10
LIDOTRANS 5 PAK 10
lindane 33
linezolid 12
LINZESS 68
liothyronine sodium 85
LIPROZONEPAK 10
lisinopril 49
lisinopril/hydrochlorothiazide 52
lithium carbonate 41
lithium citrate 41
LIVALO 54
LO LOESTRIN FE 80
LODOSYN 34
LOMEDIA 24 FE 80
lomustine 25
LONSURF 27
lopinavir/ritonavir 40
LOPREEZA 81
LOPROX 22
lorazepam 41
LORAZEPAM INTENSOL 41
LORCET 9
LORCET HD 9
LORCET PLUS 9
LORTAB 9
LORYNA 81
LORZONE 101
PAGE 112 LAST UPDATED 01/2019
losartan potassium 49
losartan potassium/hydrochlorothiazide 52
LOTEMAX 93
LOTRONEX 68
lovastatin 54
LOW-OGESTREL 81
loxapine succinate 34
luliconazole 22
LUMIGAN 94
LUTERA 81
LYNPARZA 30
LYRICA 58
LYRICA CR 58
LYSODREN 27
LYZA 84
Mmalathion 33
maprotiline hcl 20
MARGESIC 57
MARLISSA 81
MARPLAN 19
MARTEN-TAB 57
MATULANE 25
MATZIM LA 51
MAVYRET 36
MAXIDEX 93
MD-GASTROVIEW 91
MECLOFENAMATE SODIUM 6
MEDOLOR PAK 10
medroxyprogesterone acetate 84
mefenamic acid 6
mefloquine hcl 33
megestrol acetate 84
MEKINIST 30
MEKTOVI 30
meloxicam 6
MELOXICAM 7.5 MG/5 ML ORAL SUSP 6
melphalan 25
memantine hcl 18
MENEST 81
75
9
41
33
27
89
89
89
32
25
56
97
101
101
43
43
7
7
7
93
12
12
12
91
86
77
101
87
87
62
66
53
48
52
91
56
73
MENOPUR
meperidine hcl
meprobamate
MEPRON
mercaptopurine
mesalamine
MESALAMINE 800 MG TABLET DR
mesalamine with cleansing wipes
MESNEX
MESTINON
METADATE ER
metaproterenol sulfate
METAXALL
metaxalone
metformin er 500mg & 1000mg tab (generic
version of glumetza and fortamet)
metformin hcl
methadone hcl
METHADONE INTENSOL
METHADOSE
methazolamide
methenamine hippurate
methenamine mandelate
methenamine/sod
phosph,monobasic/methylene
blue/hyoscyamine
METHERGINE
methimazole
METHITEST
methocarbamol
methotrexate sodium
methotrexate sodium/pf
methoxsalen
methscopolamine bromide
methyclothiazide
methyldopa
methyldopa/hydrochlorothiazide
methylergonovine maleate
methylphenidate hcl
methylprednisolone
methyltestosterone 77
metipranolol 93
metoclopramide hcl 21
metolazone 53
metoprolol succinate 50
metoprolol tartrate 50
metoprolol tartrate/hydrochlorothiazide 52
metronidazole 12,62
mexiletine hcl 49
MIBELAS 24 FE 81
miconazole nitrate 22
MICROGESTIN 81
MICROGESTIN 24 FE 81
MICROGESTIN FE 81
midazolam hcl 41
midodrine hcl 48
miglitol 43
miglustat 69
MIGRANAL 24
MIMVEY 81
MIMVEY LO 81
MINITRAN 55
minocycline hcl 16
minoxidil 55
mirtazapine 19
misoprostol 68
modafinil 102
MODERIBA 37
moexipril hcl 49
moexipril hcl/hydrochlorothiazide 52
molindone hcl 34
mometasone furoate 73,95
MONDOXYNE NL 16
MONO-LINYAH 81
MONONESSA 81
montelukast sodium 96
MONUROL 12
MORGIDOX 16
MORPHABOND ER 7
morphine sulfate 7,9
morphine sulfate (15 mg tablet, 30 mg tablet) 9
MOTOFEN 67
PAGE 113 LAST UPDATED 01/2019
MOVANTIK 67
MOVIPREP 68
MOXATAG 14
MOXEZA 15
moxifloxacin hcl 15
MOZOBIL 47
MULPLETA 47
MULTAQ 49
mupirocin 12
mupirocin calcium 12
MY CHOICE 81
MY WAY 81
MYALEPT 67
MYCOBUTIN 25
mycophenolate mofetil 87
mycophenolate sodium 87
MYLERAN 25
MYORISAN 62
MYRBETRIQ 70
MYTESI 67
MYZILRA 81
Nnabumetone 6
nadolol 50
nadolol/bendroflumethiazide 52
naftifine hcl 22
NAFTIN 22,23
naloxone hcl 11
naltrexone hcl 11
NAMENDA 18
NAMENDA XR 18
NAMZARIC 18
NAPHAZOLINE 0.1% 92
naproxen 6
NAPROXEN 125 MG/5 ML ORAL SUSP 6
naproxen sodium 6
naratriptan hcl 24
NARCAN 11
NASONEX 95
NATACYN 23
NATAZIA 81
nateglinide 43
NATESTO 77
NATPARA 90
NATURE-THROID 85
NEBUPENT 33
NECON 81
nefazodone hcl 20
NEO-POLYCIN 92
NEO-POLYCIN HC 92
neomycin sulfate 12
neomycin sulfate/bacitracin zinc/polymyxin
b/hydrocortisone 92
neomycin sulfate/bacitracin/polymyxin b 92
neomycin sulfate/polymyxin b sulfate/gramicidin
d 92
neomycin sulfate/polymyxin b
sulfate/hydrocortisone 92,94
neomycin/polymyxin b
sulfate/dexamethasone 92
NERLYNX 30
NESINA 43
NEUAC 62
NEUPOGEN 47
NEUPRO 34
NEURCAINE 10
NEVANAC 93
nevirapine 39
NEVIRAPINE 50 MG/5 ML ORAL SUSP 39
NEW DAY 81
NEXAVAR 30
NEXIUM 69
NEXT CHOICE ONE DOSE 84
niacin 54
nicardipine hcl 51
NICOTROL 11
NICOTROL NS 11
NIFEDICAL XL 51
nifedipine 51
NIKKI 81
NILANDRON 26
nilutamide 26
nimodipine 51
NINLARO 27
nisoldipine 51
NITRO-TIME 55
nitrofurantoin 12
nitrofurantoin macrocrystal 12
nitrofurantoin monohydrate/macrocrystals 13
nitroglycerin 55
NITROLINGUAL 55
NITROMIST 55
NITROSTAT 55
NITYR 69
NIVESTYM 47
nizatidine 67
NODOLOR 91
NOLIX 73
NORA-BE 84
NORDITROPIN FLEXPRO 75
norethindrone 84
norethindrone acetate 84
norethindrone acetate-ethinyl estradiol 81
norethindrone acetate-ethinyl estradiol/ferrous
fumarate 81
norethindrone-ethinyl estradiol/ferrous
fumarate 81
norgestimate-ethinyl estradiol 81
NORLYROC 84
NORTHERA 48
NORTREL 81
nortriptyline hcl 20
NORVIR 40
NOVAREL 76
NOVOLIN 70-30 46
NOVOLIN N 46
NOVOLIN R 46
NOVOLOG 46
NOVOLOG FLEXPEN 46
NOVOLOG MIX 70-30 46
NOVOLOG MIX 70-30 FLEXPEN 46
NOXAFIL 23
PAGE 114 LAST UPDATED 01/2019
NP THYROID 85
NUCYNTA 9
NUCYNTA ER 7
NUDICLO 62,91
NUDROXIPAK 102
NUDROXIPAK DSDR-50 102
NUDROXIPAK DSDR-75 102
NUDROXIPAK E-400 102
NUDROXIPAK I-800 102
NUDROXIPAK N-500 102
NUEDEXTA 57
NULEV 66
NUPLAZID 35,103
NUTRESTORE 64
NUTRIARX 73
NUTROPIN AQ 76
NYAMYC 23
NYATA 23
nystatin 23
nystatin/triamcinolone acetonide 23
NYSTOP 23
OOCALIVA 69
OCELLA 81
octreotide acetate 85
ODACTRA 91
ODEFSEY 39
ODOMZO 30
OFEV 99
ofloxacin 15
OGESTREL 82
olanzapine 35
OLEPTRO ER 20
olmesartan medoxomil 49
olmesartan medoxomil/amlodipine
besylate/hydrochlorothiazide 52
olmesartan medoxomil/hydrochlorothiazide 52
olopatadine hcl 93,96
OLUMIANT 87
OLYSIO 36
OMECLAMOX-PAK 67
omega-3 acid ethyl esters 54
omeprazole 69
OMNARIS 95
OMNITROPE 76
ondansetron 21
ondansetron hcl 21
ONETOUCH ULTRA TEST STRIP 44
ONETOUCH ULTRA2 GLUCOSE SYST 44
ONETOUCH ULTRAMINI METER 44
ONETOUCH VERIO FLEX SYSTEM KIT 44
ONETOUCH VERIO IQ SYSTEM KIT 44
ONETOUCH VERIO METER SYSTEM 44
ONETOUCH VERIO SYNC SYST KIT 44
ONETOUCH VERIO TEST STRIP 44
ONEXTON 62
ONFI 17
ONGLYZA 43
OPCICON ONE-STEP 84
opium tincture 67
opium/belladonna alkaloids 9
OPSUMIT 98
OPTION 2 84
ORACEA 16
Oralair 88
ORALONE 59
ORAP 34
ORAVIG 23
ORENCIA 87
ORENITRAM ER 98
ORFADIN 69
ORILISSA 103
ORKAMBI 97
orphenadrine citrate 101
ORSYTHIA 82
ORTHO TRI-CYCLEN LO 82
OSCIMIN 66
OSCIMIN SL 66
OSCIMIN SR 66
oseltamivir phosphate 40
OSENI 43
OSMOLEX ER 33
OTEZLA 88
OTREXUP 87
OVIDREL 76
oxandrolone 76
oxaprozin 6
oxazepam 41
oxcarbazepine 18
oxiconazole nitrate 23
OXISTAT 23
OXTELLAR XR 18
oxybutynin chloride 70
oxycodone hcl 9
OXYCODONE HCL ER 7
oxycodone hcl/acetaminophen 9
oxycodone hcl/aspirin 9
OXYCONTIN 7
oxymorphone hcl 7,9
OXYTROL 70
OZEMPIC 43
PPACERONE 50
PAINGO KFT 11
paliperidone 35
PALYNZIQ 69
PANCREAZE 70
PANCRELIPASE 5,000 70
PANRETIN 32
pantoprazole sodium 69
paregoric 67
paricalcitol 90
PAROEX 59
paromomycin sulfate 12
paroxetine hcl 20
paroxetine mesylate 20
PASER 25
PEDIADERM HC 73
peg 3350/sod sulf/sod bicarb/sod
chloride/potassium chloride 68
PEG-PREP 68
PAGE 115 LAST UPDATED 01/2019
PEGANONE 18
PEGASYS 37
PEGASYS PROCLICK 37
PEGINTRON 38
PEGINTRON REDIPEN 38
penicillin v potassium 14
PENNSAID 6
PENTASA 89
pentazocine hcl/naloxone hcl 9
pentoxifylline 52
PERFOROMIST 97
perindopril erbumine 49
PERIOGARD 59
permethrin 33
perphenazine 21
perphenazine/amitriptyline hcl 19
PHENADOZ 21
phenazopyridine hcl 71
phendimetrazine tartrate 57
phenelzine sulfate 19
PHENERGAN 21
phenobarbital 17
phenoxybenzamine hcl 48
phentermine hcl 57
phenylephrine hcl 92
phenylephrine hcl/promethazine hcl 100
phenytoin 18
phenytoin sodium extended 18
PHILITH 82
PHOSLO 65
PHOSLYRA 66
PHOSPHASAL 13
PHOSPHOLINE IODIDE 93
phytonadione (vit k1) 48
PICATO 62
PIFELTRO 39
pilocarpine hcl 59,94
pimozide 34
PIMTREA 82
pindolol 50
pioglitazone hcl 43
pioglitazone hcl/glimepiride 43
pioglitazone hcl/metformin hcl 43
PIRMELLA 82
piroxicam 6
PLAN B ONE-STEP 84
PLEGRIDY 59
PLEGRIDY PEN 59
podofilox 62
POLYCIN 92
polyethylene glycol 3350 68
polymyxin b sulfate/trimethoprim 92
POMALYST 26
PORTIA 82
potassium bicarbonate/citric acid 65
potassium chloride 65
potassium chloride/potassium bicarbonate/citric
acid 65
potassium citrate 65
potassium citrate/citric acid 65
potassium iodide/iodine 91
PR BENZOYL PEROXIDE 62
PRADAXA 46
PRALUENT 54
PRAMCORT 62
pramipexole di-hcl 34
PRANDIN 43
prasugrel hcl 48
pravastatin sodium 54
praziquantel 32
prazosin hcl 49
PRECISION XTRA MONITOR 44
PRECISION XTRA TEST STRIPS 44
prednicarbate 73
prednisolone 73
prednisolone acetate 93
prednisolone sod phosphate 74,93
prednisone 74
PREDNISONE INTENSOL 74
PREGNYL 76
PREMARIN 82
PREMPHASE 82
PREMPRO 82
PREPOPIK 68
PREVALITE 54
PREVIDENT 65
PREVIDOLRX PLUS ANALGESIC PAK 91
PREVIFEM 82
PREVYMIS 36
PREZISTA 40
PRIFTIN 25
PRILOLID 11
primidone 17
PROAIR HFA 97
PROAIR RESPICLICK 97
probenecid 23
probenecid/colchicine 23
prochlorperazine 21
prochlorperazine maleate 21
PROCRIT 47
PROCTO-MED HC 74
PROCTO-PAK 74
PROCTOSOL-HC 74
PROCTOZONE-HC 74
PROCYSBI 70
PROFENO 6
progesterone 84
progesterone, micronized 84
PROGLYCEM 45
PROMACTA 47
promethazine hcl 21,96
promethazine hcl/codeine 100
promethazine hcl/dextromethorphan hbr 100
promethazine/phenylephrine hcl/codeine 100
PROMETHEGAN 21
propafenone hcl 50
propantheline bromide 66
proparacaine hcl 92
propranolol hcl 50
propranolol hcl/hydrochlorothiazide 52
propylthiouracil 86
PROTOPIC 62
protriptyline hcl 20
PAGE 116 LAST UPDATED 01/2019
PROVENTIL HFA 97
PULMICORT 95
PULMICORT FLEXHALER 95
PURIXAN 27
pyrazinamide 25
pyridostigmine bromide 25
QQBRELIS 49
QNASL 95
QNASL CHILDREN 95
QSYMIA 57
QTERN 43
QUASENSE 82
quazepam 101
QUDEXY XR 17
quetiapine fumarate 35
QUILLICHEW ER 56
QUILLIVANT XR 56
quinapril hcl 49
quinapril hcl/hydrochlorothiazide 52
quinidine gluconate 50
quinidine sulfate 50
quinine sulfate 33
QVAR 95
QVAR REDIHALER 95
Rrabeprazole sodium 69
RAGWITEK 89
RAJANI 82
raloxifene hcl 84
ramipril 49
RANEXA 52
ranitidine hcl 67
RAPAFLO 71
RAPAMUNE 87
rasagiline mesylate 34
RASUVO 87
RAVICTI 70
RAYOS 74
REA LO 39 62
REA LO 40 62
REBETOL 38
Rebif 59
RECLIPSEN 82
RECTIV 62
REGRANEX 62
RELADOR PAK 11
RELENZA 40
RELEXXII 57
RENAGEL 66
repaglinide 43
REPAGLINIDE/METFORMIN 43
REPATHA 54
REPREXAIN 9
RESCRIPTOR 39
RESERPINE 52
RESTASIS 92
RESTASIS MULTIDOSE 92
REVATIO 98
REVLIMID 26
REXULTI 35
REYATAZ 40
RIBASPHERE 38
RIBASPHERE RIBAPAK 38
RIBATAB 38
ribavirin 38,100
rifabutin 25
rifampin 25
RIFATER 25
riluzole 57
rimantadine hcl 40
risedronate sodium 90
risperidone 35
ritonavir 40
rivastigmine 18
rivastigmine tartrate 18
rizatriptan benzoate 24
ropinirole hcl 34
ROSADAN 62
rosuvastatin calcium 54
ROWASA 89
ROWEEPRA 16
ROWEEPRA XR 16
ROZEREM 102
RUBRACA 27
RUCONEST 86
RYDAPT 27
RYTARY 34
SSABRIL 17
SAIZEN 76
salsalate 6
SAMSCA 65
SANADERMRX 74
SANCUSO 21
SANTYL 62
SAPHRIS 35
SAVAYSA 46
SAVELLA 58
SAXENDA 91
SCALACORT 74
scopolamine 21
SEB-PREV 62
SEGLUROMET 43
selegiline hcl 34
selenium sulfide 62
SELZENTRY 39,40
SENSIPAR 90
SEREVENT DISKUS 97
SEROPHENE 85
SEROSTIM 76
sertraline hcl 20
SETLAKIN 82
sevelamer carbonate 66
SF 65
SF 5000 PLUS 65
SHAROBEL 84
SIGNIFOR 85
SILALITE PAK 74
SILAZONE-II 74
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sildenafil citrate 71,98
SILENOR 102
silver sulfadiazine 15
silver/bandage/foam/gauze/lidocaine/chlorhexid
in/isopropanol 91
SIMBRINZA 94
simvastatin 54
sirolimus 88
SIRTURO 25
SITAVIG 40
SIVEXTRO 13
sodium chloride for inhalation 100
sodium chloride/sodium bicarbonate/potassium
chloride/peg 68
sodium phenylbutyrate 70
sodium polystyrene sulfonate 65
SOLARAZE 62
SOLIQUA 100-33 46
SOLODYN 16
SOLTAMOX 27
SOLUPAK 11
SOMA 101
SOMAVERT 85
SORIATANE 62
SORILUX 63
SORINE 50
sotalol hcl 50
SOTYLIZE 50
SOVALDI 37
spinosad 63
SPIRIVA 96
SPIRIVA RESPIMAT 96
spironolactone 53
spironolactone/hydrochlorothiazide 52
SPRINTEC 82
SPRITAM 16
SPRIX 6
SPRYCEL 30
SPS 65
SRONYX 82
SSD 15
SSKI 86
stavudine 39
STAXYN 71
STEGLATRO 43
STEGLUJAN 43
STELARA 63
STENDRA 71
STIOLTO RESPIMAT 100
STIVARGA 31
STRENSIQ 70
STRIANT 77
STRIBILD 38
STRIVERDI RESPIMAT 97
STROMECTOL 32
SUBOXONE 11
SUBSYS 9
sucralfate 68
sulfacetamide sodium 15,63
sulfacetamide sodium/prednisolone sodium
phosphate 92
sulfacetamide sodium/sulfur 63
sulfadiazine 15
sulfamethoxazole/trimethoprim 15
SULFAMYLON 13
sulfasalazine 89
SULFATRIM 15
sulindac 6
sumatriptan 24
sumatriptan succinate 24
sumatriptan succinate/naproxen sodium 24
SUMAVEL DOSEPRO 24
SUPRENZA ODT 57
SUPREP 68
SUSTIVA 39
SUTENT 31
SYEDA 82
SYLATRON 28
SYMAX 67
SYMAX-SL 67
SYMAX-SR 67
SYMBICORT 100
SYMDEKO 97
SYMFI 103
SYMFI LO 39
SYMLINPEN 120 43
SYMLINPEN 60 43
SYMTUZA 103
SYNALAR TS 74
SYNDROS 21
SYNJARDY 43
SYNJARDY XR 44
SYNTHROID 85
SYPRINE 65
TTABLOID 27
TACLONEX 63
tacrolimus 63,88
tadalafil 98
TAFINLAR 31
TAGRISSO 31
TAKE ACTION 84
TAKHZYRO 86
tamoxifen citrate 27
tamsulosin hcl 71
TANZEUM 44
TAPERDEX 74
TARCEVA 31
TARGRETIN 32
TARINA FE 82
TASIGNA 31,103
TASMAR 33
TAVALISSE 47
tazarotene 63
TAZORAC 63
TAZTIA XT 51
TECFIDERA 59
TECHNIVIE 37
TEKTURNA 52
telmisartan 49
telmisartan/hydrochlorothiazide 52
temazepam 101
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TEMODAR 26
temozolomide 26
tenofovir disoproxil fumarate 39
terazosin hcl 49
terbinafine hcl 23
terbutaline sulfate 97
terconazole 23
TESTIM 77
testosterone 77
TESTOSTERONE (10 mg (2%) gel md pmp,
12.5/1.25g gel md pmp, 50 mg (1%) gel
(gram) 77
TESTOSTERONE (50 mg (1%) gel packet).
SOME MANUFACTURERS ARE T3 AND
OTHERS T1 77
testosterone cypionate 77
testosterone enanthate 77
TESTRED 77
tetrabenazine 58
tetracycline hcl 16
THALOMID 26
THEOCHRON 98
theophylline anhydrous 98
THERMAZENE 15
thioridazine hcl 34
thiothixene 35
THYROLAR-1 85
THYROLAR-1/2 85
THYROLAR-1/4 85
THYROLAR-2 85
THYROLAR-3 85
tiagabine hcl 17
TIBSOVO 103
TICALAST 100
TICANASE 95
TICASPRAY 95
ticlopidine hcl 48
TIKOSYN 50
TILIA FE 82
timolol maleate 50,94
tinidazole 13
TIROSINT 85
TIVICAY 38
TIVORBEX 6
tizanidine hcl 36
TL G-FOL OS 65
TOBI 100
TOBI PODHALER 97
TOBRADEX 92
tobramycin 12
tobramycin in 0.225 % sodium chloride 100
tobramycin/dexamethasone 92
tobramycin/nebulizer 97
TODAY CONTRACEPTIVE SPONGE 71
TOLAK 63
tolazamide 44
tolbutamide 44
tolcapone 33
tolmetin sodium 6
tolterodine tartrate 70
topiramate 17
torsemide 53
TOUJEO MAX SOLOSTAR 103
TOUJEO SOLOSTAR 46
TOVIAZ 70
TRACLEER 98
TRADJENTA 44
TRAMADOL ER CAPS 7
tramadol hcl 7,9
tramadol hcl/acetaminophen 9
trandolapril 49
trandolapril/verapamil hcl 52
tranexamic acid 48
TRANSDERM-SCOP 21
tranylcypromine sulfate 19
TRAVATAN Z 94
trazodone hcl 20
TRECATOR 25
TREMFYA 63
TRESIBA FLEXTOUCH U-100 46
TRESIBA FLEXTOUCH U-200 46
TRETIN-X 63
tretinoin 32,63
tretinoin microspheres 63
tretinoin/emollient base 63
TREXALL 88
TREXIMET 24
TRI-CHLOR 63
TRI-ESTARYLLA 82
TRI-LEGEST FE 82
TRI-LINYAH 82
TRI-LO-ESTARYLLA 82
TRI-LO-MARZIA 82
TRI-LO-SPRINTEC 82
TRI-PREVIFEM 82
TRI-SILA 74
TRI-SPRINTEC 82
triamcinolone acetonide 59,74,95
triamterene/hydrochlorothiazide 52
TRIANEX 74
triazolam 101
TRIDERM 74
trientine hcl 65
trifluoperazine hcl 35
trifluridine 40
trihexyphenidyl hcl 33
TRILIPIX 53
TRILYTE WITH FLAVOR PACKETS 68
trimethobenzamide hcl 21
trimethoprim 13
trimipramine maleate 20
TRINESSA 83
TRINESSA LO 83
TRINTELLIX 20
TRIUMEQ 40
TRIVORA-28 83
TRIXYLITRAL 90
TRIZIVIR 39
TROKENDI XR 18
tropicamide 92
trospium chloride 70
TRULICITY 44
TRUVADA 39
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TUDORZA PRESSAIR 96
TUSSIGON 100
TYBOST 40
TYDEMY 83
TYKERB 31
TYMLOS 90
Tyvaso 99
TYZEKA 36
TYZINE 100
UUCERIS 89
ULESFIA 63
ULORIC 23
ULTRAVATE X 74
UNITHROID 85
UPTRAVI 99
UR N-C 13
URAMIT MB 13
URETRON D-S 13
URIMAR-T 13
URIN D.S. 13
URO-458 13
URO-MP 13
UROCIT-K 65
UROGESIC-BLUE 13
UROLET MB 13
UROPHEN MB 13
ursodiol 67
URYL 13
UTIBRON NEOHALER 100
UTIRA-C 13
VVAGIFEM 83
valacyclovir hcl 40
VALCHLOR 26
VALCYTE 36
valganciclovir hcl 36
valproic acid 17
valproic acid (as sodium salt) (valproate
sodium) 17
valsartan 49
valsartan/hydrochlorothiazide 52
vancomycin hcl 13
VANDAZOLE 13
VARUBI 21
VCF 71
VELIVET 83
VELPHORO 66
VELTASSA 66
VELTIN 63
VENCLEXTA 31
VENLAFAXINE ER TAB (TIER DEPENDENT
ON MANUFACTURER. UCB T3, OTHERS
T1) 20
venlafaxine hcl 20
VENTOLIN HFA 97
VERAMYST 95
verapamil hcl 51
VERDROCET 9
VEREGEN 63
VERZENIO 31
VESICARE 70
VESTURA 83
VEXOL 93
VICODIN 9
VICODIN ES 9
VICODIN HP 10
VICTOZA 2-PAK 44
VICTOZA 3-PAK 44
VIDEX 39
VIEKIRA PAK 37
VIEKIRA XR 37
VIENVA 83
vigabatrin 17
VIGAMOX 15
VIIBRYD 20
VIMOVO 6
VIMPAT 18
VIORELE 83
VIRACEPT 40
VIRAMUNE 39
VIRAMUNE XR 39
VIREAD 39
VIVELLE-DOT 83
VIVLODEX 6
VOGELXO 77
voriconazole 23
VOSEVI 37
VOTRIENT 31
VRAYLAR 35
VYFEMLA 83
VYTORIN 54
VYVANSE 56
Wwarfarin sodium 46
WELCHOL 54
WERA 83
WESTHROID 85
WHYTEDERM TRILASIL PAK 74
WP THYROID 85
WYMZYA FE 83
XXALKORI 31
XARELTO 46
XARTEMIS XR 10
XATMEP 88
XELITRAL 63
XELJANZ 88
XELJANZ XR 88
XENAFLAMM 91
XENICAL 67
XERESE 40
XERMELO 91
XHANCE 95
XIGDUO XR 44
XIIDRA 92
XIMINO 103
XRYLIX 64
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XTAMPZA ER 8
XTANDI 26
XULANE 83
XULTOPHY 100-3.6 46
XURIDEN 66
XYLON 10 10
XYREM 102
YYONSA 26
YUVAFEM 83
Zzafirlukast 96
zaleplon 101
ZARAH 83
ZARXIO 47
ZAVESCA 70
ZEBUTAL 58
ZEJULA 31
ZELAPAR 34
ZELBORAF 32
ZENATANE 64
ZENCHENT 83
ZENCHENT FE 83
ZENPEP 70
ZENZEDI 56
ZEPATIER 37
ZETIA 54
ZETONNA 95
ZEYOCAINE 64
ZIAGEN 39
ZIANA 64
zidovudine 39
zileuton 96
ZINBRYTA 59
ZIOPTAN 94
ziprasidone hcl 35
ZIPSOR 6
ZIRGAN 36
ZODEX 74
ZOHYDRO ER 8
ZOLINZA 28
zolmitriptan 24
zolpidem tartrate 101
ZOLPIMIST 101
ZOMACTON 76
ZOMIG 24
zonisamide 16
ZONTIVITY 46
ZORBTIVE 76
ZORTRESS 88
ZORVOLEX 6
ZOVIA 1-35E 83
ZOVIA 1-50E 83
ZUBSOLV 11
ZURAMPIC 23
ZYBAN 11
ZYDELIG 32
ZYFLO CR 96
ZYKADIA 32
ZYMAXID 15
ZYTIGA 26
ZYVOX 13
PAGE 121 LAST UPDATED 01/2019