4 Tier Formulary
Select Drug ListSubject to Regulatory Approval
40627CAMENABC
1332531 40627CAMENABC Select Drig List Update BO 07 15
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Anthem Blue Cross Select Drug List
Your prescription drug benefit includes coverage for
medicines that you’ll find on the Select Drug List. You can
often find more savings when your doctor prescribes
medicine that is on our Select Drug List. Here are some
commonly asked questions and answers about how the
Select Drug List works with your prescription drug plan.
Q. What is a Select Drug List?
A. The Select Drug List, also called a formulary is a list of
U.S. Food and Drug Administration (FDA)-approved
brand-name and generic drugs that have been reviewed
and recommended for their quality and how well they
work. The review is done by the National Pharmacy and
Therapeutics (P&T) Process. The P&T Process is
performed by an independent group of practicing
doctors and pharmacists in charge of the research and
decisions surrounding our Select Drug List. This group
meets regularly to review new and existing drugs and
they choose the top drugs for our list—based on their
safety, how they work and their value.
Because the drugs on our list are reviewed from time to
time, it’s a good idea to check the list to find out if any
drugs have been added or removed. You can do this by
going to anthem.com/ca.
Q. What are Tiers?
A. Drugs on the Select Drug List are grouped into tiers.
There are several factors that are used to determine
under which tier a drug will be put in. This can include
(but it’s not limited to):
Cost of the drug
Cost of the drug in comparison to other drugs used for the same type of treatment
Availability of over-the-counter options
Other clinical and cost factors.
Q. What is a brand-name drug?
A. These are drugs that are developed by a company
who holds the rights to sell them. When the rights
expire, other drug companies can make their own
version of the drugs (see generic drugs below). You
may be more familiar with brand-name drugs through
advertising or because you know people who take
them. When you see a drug in all caps in this piece,
it is a brand-name drug.
Q. What is a generic drug?
A. Generics are simply copies of brand-name drugs.
Brand-name and generic drugs have the same active
ingredients, strength and dose. And the FDA requires
that generic drugs meet the same high standards for
purity, quality, safety and strength. When you see a
drug in all lowercase in this piece, it is a generic drug.
Q. What do I do if I am prescribed or currently taking a
prescription drug that is not on the Anthem Select
Drug List?
A. If you are prescribed or currently taking a non
formulary drug, you should discuss formulary
alternatives your physician. If your physician feels that
the medication is medically necessary, it will be
necessary to obtain Prior Authorization of Benefits in
order for the prescription to be a covered benefit.
Information is available to you and your physician
through the Certificate or Evidence of Coverage, health
plan web site and newsletters. You may also call
customer service for more information.
Q. Can I request that a drug be added to the
Select Drug List?
A. You or your doctor can put in a request to add a drug to
the Select Drug List. You can do this either in writing or
on our website. Requests are reviewed by the P&T
Process team during the Select Drug List review. Please
note that if a drug request is approved, it does not
guarantee coverage. Some drugs, such as those used
for cosmetic purposes, may be excluded from your
benefits. Please refer to your insurance Certificate or
Evidence of Coverage to know for sure.
Q. What if my medication is not covered?
A. You may want to first check with your doctor about
prescribing a drug that is covered. If your doctor
prescribes a drug that’s not covered, you will need to
pay the out-of-pocket cost that applies to drugs not on
the formulary.
Preventive Care Drugs: We cover preventive care drugs
with zero cost share in compliance with the Affordable
Care Act (ACA).
Please note: In selecting medications for the prescription
drug list, the therapeutic efficacy and cost effectiveness
are addressed for each category. All therapeutic
categories are represented on the drug list by at least one
medication. When a closed drug list is in effect, only
medications that are included on the drug list are a
covered service. In certain clinical situations, a member
may require use of a non-covered product. Anthem has
criteria that permits a member to obtain a non-covered
medication in a closed drug list plan. If specific criteria are
met, a member can receive a non-covered drug for a drug
list co-pay. The criteria preserves the clinical integrity of
the drug list and provides a process by which deviations
from the drug list may be allowed. An appeals process is in
place for any medications that do not meet the criteria.
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For more information about your drug plan, you can do the following:
Go to anthem.com/ca.
Call Customer Service at the number on your ID card.
Speech and hearing impaired users (TDD/TTY) should call 1-800-221-6915, Monday – Friday, 8:30 a.m. – 5 p.m., ET.
California Select Drug List
Table of Contents
Table of Contents
ANALGESICS ........................................................................................................................................................................................................................................................................................... 8ANESTHETICS ........................................................................................................................................................................................................................................................................................ 9ANTIARTHRITICS ................................................................................................................................................................................................................................................................................ 9ANTIASTHMATICS ......................................................................................................................................................................................................................................................................... 10ANTIBIOTICS ........................................................................................................................................................................................................................................................................................ 11ANTICOAGULANTS ...................................................................................................................................................................................................................................................................... 15ANTIDOTES ............................................................................................................................................................................................................................................................................................ 15ANTIFUNGALS .................................................................................................................................................................................................................................................................................... 15ANTIHISTAMINE AND DECONGESTANT COMBINATION ................................................................................................................................................................. 16ANTIHISTAMINES ............................................................................................................................................................................................................................................................................ 16ANTIHYPERGLYCEMICS ........................................................................................................................................................................................................................................................ 16ANTIINFECTIVES ............................................................................................................................................................................................................................................................................. 17ANTIINFECTIVES/MISCELLANEOUS ........................................................................................................................................................................................................................ 17ANTINEOPLASTICS ...................................................................................................................................................................................................................................................................... 17ANTIPARKINSON DRUGS ..................................................................................................................................................................................................................................................... 19ANTIPLATELET DRUGS .......................................................................................................................................................................................................................................................... 19ANTIVIRALS ........................................................................................................................................................................................................................................................................................... 20AUTONOMIC DRUGS .................................................................................................................................................................................................................................................................. 21BIOLOGICALS ..................................................................................................................................................................................................................................................................................... 21BLOOD ......................................................................................................................................................................................................................................................................................................... 24CARDIAC DRUGS ............................................................................................................................................................................................................................................................................ 24CARDIOVASCULAR ...................................................................................................................................................................................................................................................................... 26CNS DRUGS ........................................................................................................................................................................................................................................................................................... 27COLONY STIMULATING FACTORS ............................................................................................................................................................................................................................ 28CONTRACEPTIVES ....................................................................................................................................................................................................................................................................... 29COUGH/COLD PREPARATIONS .................................................................................................................................................................................................................................... 31DIAGNOSTIC ......................................................................................................................................................................................................................................................................................... 31DIURETICS .............................................................................................................................................................................................................................................................................................. 32EENT PREPS ......................................................................................................................................................................................................................................................................................... 32ELECT/CALORIC/H2O ................................................................................................................................................................................................................................................................ 33GASTROINTESTINAL .................................................................................................................................................................................................................................................................. 34HORMONES ........................................................................................................................................................................................................................................................................................... 35IMMUNOSUPPRESANT ............................................................................................................................................................................................................................................................. 36MISCELLANEOUS MEDICAL SUPPLIES, DEVICES, NON-DRUG ............................................................................................................................................ 37MUSCLE RELAXANTS ............................................................................................................................................................................................................................................................... 37PRE-NATAL VITAMINS .............................................................................................................................................................................................................................................................. 37PSYCHOTHERAPEUTIC DRUGS ................................................................................................................................................................................................................................... 39SEDATIVE/HYPNOTICS ............................................................................................................................................................................................................................................................ 41SKIN PREPS .......................................................................................................................................................................................................................................................................................... 41SMOKING DETERRENTS ........................................................................................................................................................................................................................................................ 43THYROID PREPS .............................................................................................................................................................................................................................................................................. 43UNCLASSIFIED DRUG PRODUCTS ............................................................................................................................................................................................................................ 43VITAMINS .................................................................................................................................................................................................................................................................................................. 44
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NOTE: Not all medications and not all plans are subject to prior authorization and quantity limits. For more information regarding prior authorization or quantity limits, contact Member Services at the telephone number listed on your identification card.
List of Abbreviations
Tier 1: Tier 1 drugs have the lowest cost share. these drugs offer the greatest value compared to others that treat the same conditions.
Tier 2: Tier 2 drugs have a medium cost share. They may be preferred drugs, based on their effectiveness and value. Some are newer, more expensive generic drugs.
Tier 3: Tier 3 drugs have a higher cost share. They may cost more than others used to treat the same condition. Tier 3 may also include drugs that were recently approved by the FDA.
Tier 4: Tier 4 specialty drugs have the highest cost share. They may cost more than others used to treat the same condition. Specialty drugs are used to treat complex, chronic conditions and may need special handling.
$0: PREVENTATIVE DRUGS: For some members, this product may be covered at 100% with $0 cost share with a prescription from your provider if specified criteria are met.
DO: DOSE OPTIMIZATION REQUIRED. Normally involves the conversion from twice-daily dosing to a once-daily dosing schedule.
PA: PRIOR AUTHORIZATION REQUIRED. Prior authorization is the process of obtaining approval of benefits before certain prescriptions may be filled.
QL: QUANTITY LIMITS. Certain prescription drugs have specific quantity limits per prescription or per month.
ST: STEP THERAPY REQUIRED. You may need to use one medication before benefits for the use of another medication can be authorized. Please note: Foradil and Serevent are safety edits that prevent duplication of therapy.
Below is a list of drug name formatting patterns that may appear in the following pages.
List of Patterns
lowercase: Generic drugs
UPPERCASE BOLD: Brand name drugs
California Select Drug List
Drug Name Tier Notes
ANALGESICS
acetaminophen-codeine oral solution 120 mg-12 mg /5 ml (5 ml), 120-12 mg/5 ml
Tier 1 QL
acetaminophen-codeine oral solution 240 mg-24 mg /10 ml (10 ml), 300 mg-30 mg /12.5 ml
Tier 1
acetaminophen-codeine oral tablet 300-15 mg, 300-30 mg, 300-60 mg
Tier 1 QL
ascomp with codeine oral capsule
Tier 1
buprenorphine hcl injection solution
Tier 2
buprenorphine hcl injection syringe
Tier 2
butalbital compound w/codeine oral capsule
Tier 1
butalbital-acetaminop-caf-cod oral capsule
Tier 1 QL
butalbital-acetaminophen-caff oral capsule
Tier 1
butalbital-acetaminophen-caff oral tablet
Tier 1
butalbital-aspirin-caffeine oral capsule
Tier 1
butorphanol tartrate nasal spray,non-aerosol
Tier 1 PA; QL
capacet oral capsule Tier 1
codeine sulfate oral tablet 15 mg, 30 mg, 60 mg
Tier 1 QL
codeine-butalbital-asa-caff oral capsule
Tier 1
diclofenac potassium oral tablet
Tier 1
diflunisal oral tablet Tier 1
Drug Name Tier Notes
dihydroergotamine nasal spray,non-aerosol
Tier 2 QL
diskets oral tablet,soluble Tier 1
ELMIRON ORAL CAPSULE
Tier 3
endocet oral tablet Tier 1 QL
endodan oral tablet Tier 1
ERGOMAR SUBLINGUAL TABLET
Tier 3
fentanyl transdermal patch 72 hour
Tier 2 ST; QL
hydrocodone-acetaminophen oral solution 10-325 mg/15 ml(15 ml), 2.5-167 mg/5 ml, 5-163 mg/7.5ml(7.5ml)
Tier 1 QL
hydrocodone-acetaminophen oral tablet 10-300 mg, 10-325 mg, 2.5-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg
Tier 1 QL
hydromorphone oral liquid Tier 1 QL
hydromorphone oral tablet 2 mg, 4 mg, 8 mg
Tier 1 QL
hydromorphone rectal suppository
Tier 1
ibuprofen-oxycodone oral tablet
Tier 1 QL
isometh-dichloral-acetaminophn oral capsule
Tier 1
ketorolac oral tablet Tier 1 QL
margesic oral capsule Tier 1
marten-tab oral tablet Tier 1
meperidine oral solution Tier 1 QL
meperidine oral tablet 100 mg, 50 mg
Tier 1 QL
meperitab oral tablet Tier 1 QL
methadone intensol oral concentrate
Tier 1 QL
methadone oral concentrate
Tier 1 QL
methadone oral solution 10 mg/5 ml, 5 mg/5 ml
Tier 1 QL
methadone oral tablet 10 mg, 5 mg
Tier 1 QL
methadone oral tablet,soluble
Tier 1 QL
Revised 4/1/2016
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Drug Name Tier Notes
methadose oral concentrate
Tier 1 QL
methadose oral tablet,soluble
Tier 1
migergot rectal suppository
Tier 1
morphine concentrate oral solution
Tier 1 QL
morphine oral capsule,extend.release pellets
Tier 2 QL
morphine oral solution 10 mg/5 ml, 20 mg/5 ml
Tier 1 QL
morphine oral tablet 15 mg, 30 mg
Tier 1 QL
morphine oral tablet extended release 100 mg, 15 mg, 200 mg, 30 mg, 60 mg
Tier 2 QL
morphine rectal suppository
Tier 1
nalbuphine injection solution
Tier 2
naratriptan oral tablet Tier 1 QL
nodolor oral capsule Tier 1
oxycodone oral capsule Tier 1 QL
oxycodone oral concentrate
Tier 1 QL
oxycodone oral solution Tier 1 QL
oxycodone oral tablet 10 mg, 15 mg, 20 mg, 30 mg, 5 mg
Tier 1 QL
oxycodone-acetaminophen oral tablet
Tier 1 QL
oxycodone-aspirin oral tablet
Tier 1 QL
oxymorphone oral tablet 10 mg, 5 mg
Tier 1 QL
sumatriptan succinate oral tablet
Tier 1 QL
sumatriptan succinate subcutaneous cartridge
Tier 2 QL
sumatriptan succinate subcutaneous pen injector
Tier 2 QL
sumatriptan succinate subcutaneous solution
Tier 2 QL
sumatriptan succinate subcutaneous syringe
Tier 2 QL
Drug Name Tier Notes
tencon oral tablet Tier 1
tramadol oral tablet Tier 1 QL
vicodin es oral tablet Tier 1 QL
vicodin hp oral tablet Tier 1 QL
vicodin oral tablet Tier 1 QL
zamicet oral solution Tier 1 QL
zebutal oral capsule Tier 2
ANESTHETICS
lidocaine hcl mucous membrane solution
Tier 1
lidocaine viscous mucous membrane solution
Tier 1
lidocaine-prilocaine topical cream
Tier 1
lidocaine-prilocaine topical kit
Tier 1
phenazopyridine oral tablet
Tier 1
ANTIARTHRITICS
allopurinol oral tablet Tier 1
colchicine-probenecid oral tablet
Tier 1
COLCRYS ORAL TABLET
Tier 3 PA; QL
CUPRIMINE ORAL CAPSULE
Tier 3
diclofenac sodium oral tablet extended release 24 hr
Tier 1
diclofenac sodium oral tablet,delayed release (dr/ec)
Tier 1
ENBREL SUBCUTANEOUS RECON SOLN
Tier 4 PA; QL
ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5ML (0.51), 50 MG/ML (0.98 ML)
Tier 4 PA; QL
ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR
Tier 4 PA; QL
HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT
Tier 4 PA; QL
Revised 4/1/2016
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Drug Name Tier Notes
HUMIRA PEN CROHN'S-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT
Tier 4 PA; QL
HUMIRA PEN PSORIASIS STARTER SUBCUTANEOUS PEN INJECTOR KIT
Tier 4 PA; QL
HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT
Tier 4 PA; QL
HUMIRA SUBCUTANEOUS SYRINGE KIT
Tier 4 PA; QL
ibuprofen oral suspension Tier 1
ibuprofen oral tablet Tier 1
indomethacin oral capsule Tier 1
indomethacin oral capsule, extended release
Tier 1
KINERET SUBCUTANEOUS SYRINGE
Tier 4 PA
leflunomide oral tablet Tier 2
meclofenamate oral capsule
Tier 1
meloxicam oral suspension
Tier 1 QL
meloxicam oral tablet Tier 1 QL
nabumetone oral tablet Tier 1
naproxen oral suspension Tier 1
naproxen oral tablet Tier 1
naproxen oral tablet,delayed release (dr/ec)
Tier 1
naproxen sodium oral tablet
Tier 1
ORENCIA (WITH MALTOSE) INTRAVENOUS RECON SOLN
Tier 4 PA; QL
ORENCIA SUBCUTANEOUS SYRINGE
Tier 4 PA; QL
probenecid oral tablet Tier 1
RIDAURA ORAL CAPSULE
Tier 3
Drug Name Tier Notes
SIMPONI ARIA INTRAVENOUS SOLUTION
Tier 4 PA
SIMPONI SUBCUTANEOUS PEN INJECTOR
Tier 4 PA; QL
SIMPONI SUBCUTANEOUS SYRINGE
Tier 4 PA; QL
ANTIASTHMATICS
acetylcysteine solution Tier 2
ADVAIR DISKUS INHALATION BLISTER WITH DEVICE
Tier 2 QL
ADVAIR HFA INHALATION HFA AEROSOL INHALER
Tier 2 QL
albuterol sulfate inhalation solution for nebulization
Tier 1
albuterol sulfate oral syrup Tier 1
ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED
Tier 2 QL
budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml, 1 mg/2 ml
Tier 1 QL
cromolyn inhalation solution for nebulization
Tier 1
DALIRESP ORAL TABLET
Tier 3 QL
DULERA INHALATION HFA AEROSOL INHALER
Tier 2 QL
FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 250 MCG/ACTUATION, 50 MCG/ACTUATION
Tier 2 QL
FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION, 220 MCG/ACTUATION, 44 MCG/ACTUATION
Tier 2 QL
ipratropium bromide inhalation solution
Tier 1 QL
metaproterenol oral syrup Tier 1
Revised 4/1/2016
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Drug Name Tier Notes
metaproterenol oral tablet Tier 1
montelukast oral granules in packet
Tier 1 QL
montelukast oral tablet Tier 1 QL
montelukast oral tablet,chewable
Tier 1 QL
PROAIR HFA INHALATION HFA AEROSOL INHALER
Tier 2 QL
PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED
Tier 2 QL
PROVENTIL HFA INHALATION HFA AEROSOL INHALER
Tier 3 QL
PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED
Tier 2 QL
QVAR INHALATION AEROSOL 40 MCG/ACTUATION, 80 MCG/ACTUATION
Tier 2 QL
SEREVENT DISKUS INHALATION BLISTER WITH DEVICE
Tier 2 QL
SPIRIVA RESPIMAT INHALATION MIST
Tier 3 QL
SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE
Tier 3 QL
SYMBICORT INHALATION HFA AEROSOL INHALER
Tier 2 QL
theochron oral tablet extended release 12 hr
Tier 1
theophylline oral elixir Tier 1
theophylline oral solution Tier 1
theophylline oral tablet extended release
Tier 1
theophylline oral tablet extended release 12 hr
Tier 1
VENTOLIN HFA INHALATION HFA AEROSOL INHALER
Tier 3 QL
Drug Name Tier Notes
XOPENEX HFA INHALATION HFA AEROSOL INHALER
Tier 3 QL
ANTIBIOTICS
ak-poly-bac ophthalmic ointment
Tier 1
amikacin injection solution Tier 2
amoxicillin oral capsule Tier 1
amoxicillin oral suspension for reconstitution
Tier 1
amoxicillin oral tablet Tier 1
amoxicillin oral tablet,chewable
Tier 1
amoxicillin-pot clavulanate oral suspension for reconstitution
Tier 1
amoxicillin-pot clavulanate oral tablet
Tier 1
amoxicillin-pot clavulanate oral tablet extended release 12 hr
Tier 1
amoxicillin-pot clavulanate oral tablet,chewable
Tier 1
ampicillin oral capsule Tier 1
ampicillin oral suspension for reconstitution
Tier 1
ampicillin sodium injection recon soln
Tier 2
ampicillin sodium intravenous recon soln
Tier 2
ampicillin-sulbactam injection recon soln
Tier 2
ampicillin-sulbactam intravenous recon soln
Tier 2
avar topical cleanser Tier 1
avidoxy oral tablet Tier 1
azithromycin oral packet Tier 1 QL
azithromycin oral suspension for reconstitution 100 mg/5 ml, 200 mg/5 ml
Tier 1 QL
azithromycin oral tablet 250 mg, 500 mg, 600 mg
Tier 1 QL
aztreonam injection recon soln
Tier 2
bacitracin ophthalmic ointment
Tier 1
Revised 4/1/2016
11
Drug Name Tier Notes
bacitracin-polymyxin b ophthalmic ointment
Tier 1
BESIVANCE OPHTHALMIC DROPS,SUSPENSION
Tier 3
bp 10-1 topical cleanser Tier 1
cefaclor oral capsule Tier 1
cefaclor oral suspension for reconstitution
Tier 1
cefaclor oral tablet extended release 12 hr
Tier 1
cefadroxil oral capsule Tier 1
cefadroxil oral suspension for reconstitution
Tier 1
cefadroxil oral tablet Tier 1
cefazolin in dextrose (iso-os) intravenous piggyback
Tier 2
cefazolin injection recon soln
Tier 2
cefazolin intravenous recon soln
Tier 2
cefdinir oral capsule Tier 1
cefdinir oral suspension for reconstitution
Tier 1
cefditoren pivoxil oral tablet
Tier 1
cefotaxime injection recon soln
Tier 2
CEFOTETAN IN DEXTROSE, ISO-OSM INTRAVENOUS PIGGYBACK
Tier 2
cefotetan injection recon soln
Tier 2
cefotetan intravenous recon soln
Tier 2
cefpodoxime oral suspension for reconstitution
Tier 2
cefpodoxime oral tablet Tier 2
cefprozil oral suspension for reconstitution
Tier 1
cefprozil oral tablet Tier 1
ceftibuten oral capsule Tier 2
ceftibuten oral suspension for reconstitution
Tier 2
Drug Name Tier Notes
ceftriaxone in dextrose,iso-os intravenous piggyback
Tier 2
ceftriaxone injection recon soln
Tier 2
ceftriaxone intravenous recon soln
Tier 2
cefuroxime axetil oral tablet
Tier 1
cephalexin oral capsule Tier 1
cephalexin oral suspension for reconstitution
Tier 1
cephalexin oral tablet Tier 1
chloramphenicol sod succinate intravenous recon soln
Tier 2
CIPRODEX OTIC DROPS,SUSPENSION
Tier 3 PA
ciprofloxacin (mixture) oral tablet, er multiphase 24 hr 1,000 mg, 500 mg
Tier 1 QL
ciprofloxacin hcl ophthalmic drops
Tier 1
ciprofloxacin hcl oral tablet Tier 1 QL
ciprofloxacin hcl otic dropperette
Tier 1
clarithromycin oral suspension for reconstitution
Tier 1
clarithromycin oral tablet Tier 1
clarithromycin oral tablet extended release 24 hr
Tier 1
cleansing wash topical cleanser
Tier 1
CLINDACIN ETZ TOPICAL KIT
Tier 3
clindacin etz topical swab Tier 1
clindacin p topical swab Tier 1
CLINDACIN PAC TOPICAL KIT
Tier 3
clindamycin hcl oral capsule
Tier 1
clindamycin palmitate hcl oral recon soln
Tier 1
clindamycin pediatric oral recon soln
Tier 1
Revised 4/1/2016
12
Drug Name Tier Notes
clindamycin phosphate topical foam
Tier 1
clindamycin phosphate topical gel
Tier 1
clindamycin phosphate topical lotion
Tier 1
clindamycin phosphate topical solution
Tier 1
clindamycin phosphate topical swab
Tier 1
clindamycin phosphate vaginal cream
Tier 1
DAPSONE ORAL TABLET
Tier 3
demeclocycline oral tablet Tier 2
dicloxacillin oral capsule Tier 1
doxycycline hyclate oral capsule
Tier 1
doxycycline hyclate oral tablet
Tier 1
doxycycline hyclate oral tablet,delayed release (dr/ec)
Tier 1 PA
doxycycline monohydrate oral capsule
Tier 1
doxycycline monohydrate oral suspension for reconstitution
Tier 1
doxycycline monohydrate oral tablet
Tier 1
e.e.s. 400 oral tablet Tier 1
ery pads topical swab Tier 1
erygel topical gel Tier 1
ery-tab oral tablet,delayed release (dr/ec)
Tier 1
erythrocin (as stearate) oral tablet
Tier 1
erythromycin ethylsuccinate oral tablet
Tier 1
erythromycin ophthalmic ointment
Tier 1
erythromycin oral capsule,delayed release(dr/ec)
Tier 1
erythromycin oral tablet Tier 1
erythromycin with ethanol topical gel
Tier 1
Drug Name Tier Notes
erythromycin with ethanol topical solution
Tier 1
erythromycin with ethanol topical swab
Tier 1
erythromycin-benzoyl peroxide topical gel
Tier 1
ethambutol oral tablet Tier 1
garamycin ophthalmic drops
Tier 1
gentak ophthalmic ointment
Tier 1
gentamicin ophthalmic drops
Tier 1
gentamicin ophthalmic ointment
Tier 1
imipenem-cilastatin intravenous recon soln
Tier 2
INVANZ INJECTION RECON SOLN
Tier 3
INVANZ INTRAVENOUS RECON SOLN
Tier 3
isoniazid oral solution Tier 1
isoniazid oral tablet Tier 1
levofloxacin oral tablet Tier 1 QL
LINCOCIN INJECTION SOLUTION
Tier 3
lincomycin injection solution
Tier 2
linezolid oral tablet Tier 2 PA; QL
meropenem intravenous recon soln
Tier 2
metronidazole oral capsule
Tier 1
metronidazole oral tablet Tier 1
metronidazole vaginal gel Tier 1
minocycline oral capsule Tier 1
minocycline oral tablet Tier 1
minocycline oral tablet extended release 24 hr
Tier 1 PA
MORGIDOX 1X100 KIT Tier 3
MORGIDOX 2X100 KIT Tier 3
morgidox oral capsule Tier 1
mupirocin topical ointment Tier 1
nafcillin in dextrose iso-osm intravenous piggyback
Tier 2
Revised 4/1/2016
13
Drug Name Tier Notes
nafcillin injection recon soln
Tier 2
nafcillin intravenous recon soln
Tier 2
neomycin oral tablet Tier 1
neomycin-bacitracin-poly-hc ophthalmic ointment
Tier 1
neomycin-bacitracin-polymyxin ophthalmic ointment
Tier 1
neomycin-polymyxin b-dexameth ophthalmic drops,suspension
Tier 1
neomycin-polymyxin b-dexameth ophthalmic ointment
Tier 1
neomycin-polymyxin-gramicidin ophthalmic drops
Tier 1
neomycin-polymyxin-hc ophthalmic drops,suspension
Tier 1
neomycin-polymyxin-hc otic drops,suspension
Tier 1
neomycin-polymyxin-hc otic solution
Tier 1
neo-polycin hc ophthalmic ointment
Tier 1
neo-polycin ophthalmic ointment
Tier 1
nitrofurantoin macrocrystal oral capsule
Tier 1
nitrofurantoin monohyd/m-cryst oral capsule
Tier 1
nitrofurantoin oral suspension
Tier 1
ofloxacin ophthalmic drops Tier 1
ofloxacin oral tablet Tier 1 QL
ofloxacin otic drops Tier 1
ORACEA ORAL CAPSULE,IR - DELAY REL,BIPHASE
Tier 3
oxacillin injection recon soln
Tier 2
oxacillin intravenous recon soln
Tier 2
penicillin g potassium injection recon soln
Tier 2
Drug Name Tier Notes
penicillin v potassium oral recon soln
Tier 1
penicillin v potassium oral tablet
Tier 1
pfizerpen-g injection recon soln
Tier 2
piperacillin-tazobactam intravenous recon soln
Tier 1
polycin ophthalmic ointment
Tier 1
polymyxin b sulf-trimethoprim ophthalmic drops
Tier 1
PRED-G OPHTHALMIC DROPS,SUSPENSION
Tier 3
PRED-G S.O.P. OPHTHALMIC OINTMENT
Tier 3
pyrazinamide oral tablet Tier 1
rifabutin oral capsule Tier 2
rifampin oral capsule Tier 1
RIFATER ORAL TABLET Tier 3
silver sulfadiazine topical cream
Tier 1
ssd topical cream Tier 1
sss 10-5 topical cream Tier 1
sss 10-5 topical foam Tier 1
STREPTOMYCIN INTRAMUSCULAR RECON SOLN
Tier 3
sulfacetamide sodium ophthalmic drops
Tier 1
sulfacetamide sodium ophthalmic ointment
Tier 1
sulfacetamide sodium-sulfur topical cleanser
Tier 1
sulfacetamide sodium-sulfur topical cream
Tier 1
sulfacetamide sodium-sulfur topical foam
Tier 1
sulfacetamide sodium-sulfur topical lotion
Tier 1
sulfacetamide sodium-sulfur topical pads, medicated
Tier 1
Revised 4/1/2016
14
Drug Name Tier Notes
sulfacetamide sodium-sulfur topical suspension
Tier 1
sulfacetamide sod-sulfur-urea topical cleanser
Tier 1
sulfacetamide-prednisolone ophthalmic drops
Tier 1
sulfacetamide-sulfur-cleansr23 topical kit
Tier 1
sulfacleanse 8-4 topical suspension
Tier 1
sulfadiazine oral tablet Tier 2
sulfamethoxazole-trimethoprim oral suspension
Tier 1
sulfamethoxazole-trimethoprim oral tablet
Tier 1
sulfatrim oral suspension Tier 1
SUPRAX ORAL CAPSULE
Tier 3
SUPRAX ORAL SUSPENSION FOR RECONSTITUTION
Tier 3
tetracycline oral capsule Tier 1
THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG
Tier 3 PA; QL
thermazene topical cream Tier 1
tobramycin in 0.225 % nacl inhalation solution for nebulization
Tier 4
tobramycin ophthalmic drops
Tier 1
tobramycin-dexamethasone ophthalmic drops,suspension
Tier 1
trimethoprim oral tablet Tier 1
vancomycin oral capsule Tier 2 PA
vandazole vaginal gel Tier 1
VIBATIV INTRAVENOUS RECON SOLN
Tier 3
VIGAMOX OPHTHALMIC DROPS
Tier 3
zencia topical cleanser Tier 1
ANTICOAGULANTS
enoxaparin subcutaneous solution
Tier 4
Drug Name Tier Notes
enoxaparin subcutaneous syringe
Tier 4
fondaparinux subcutaneous syringe
Tier 4 PA
jantoven oral tablet Tier 1
PRADAXA ORAL CAPSULE
Tier 3 QL
warfarin oral tablet Tier 1
ANTIDOTES
naltrexone oral tablet Tier 1
ANTIFUNGALS
CICLODAN KIT TOPICAL COMBO PACK
Tier 3
CICLODAN KIT TOPICAL SOLUTION
Tier 3
ciclodan topical cream Tier 1
ciclodan topical solution Tier 1
ciclopirox topical cream Tier 1
ciclopirox topical gel Tier 1
ciclopirox topical shampoo Tier 1
ciclopirox topical solution Tier 1
ciclopirox topical suspension
Tier 1
clotrimazole mucous membrane troche
Tier 1
clotrimazole topical cream Tier 1
clotrimazole topical solution
Tier 1
clotrimazole-betamethasone topical cream
Tier 1
clotrimazole-betamethasone topical lotion
Tier 1
econazole topical cream Tier 1
fluconazole oral suspension for reconstitution
Tier 1
fluconazole oral tablet Tier 1
flucytosine oral capsule Tier 1
griseofulvin microsize oral suspension
Tier 1
griseofulvin microsize oral tablet
Tier 1
griseofulvin ultramicrosize oral tablet
Tier 1
itraconazole oral capsule Tier 2 PA
Revised 4/1/2016
15
Drug Name Tier Notes
ketoconazole oral tablet Tier 1
ketoconazole topical cream
Tier 1
ketoconazole topical foam Tier 1
ketoconazole topical shampoo
Tier 1
naftifine topical cream Tier 2
nyamyc topical powder Tier 1
nystatin oral powder Tier 1
nystatin oral suspension Tier 1
nystatin oral tablet Tier 1
nystatin topical cream Tier 1
nystatin topical ointment Tier 1
nystatin topical powder Tier 1
nystatin-triamcinolone topical cream
Tier 1
nystatin-triamcinolone topical ointment
Tier 1
nystop topical powder Tier 1
terbinafine hcl oral tablet Tier 1 PA
terconazole vaginal cream Tier 1
terconazole vaginal suppository
Tier 1
ANTIHISTAMINE AND DECONGESTANT COMBINATION
promethazine vc oral syrup
Tier 1
ANTIHISTAMINES
azelastine ophthalmic drops
Tier 1 QL
diphenhydramine hcl injection solution
Tier 2
diphenhydramine hcl injection syringe
Tier 2
diphenhydramine hcl oral capsule
Tier 1
epinastine ophthalmic drops
Tier 1 QL
fexofenadine oral tablet Tier 1 QL
hydroxyzine hcl oral tablet Tier 1
hydroxyzine pamoate oral capsule
Tier 1
olopatadine ophthalmic drops
Tier 2 PA; QL
Drug Name Tier Notes
PATADAY OPHTHALMIC DROPS
Tier 3 PA; QL
promethazine oral syrup Tier 1
promethazine oral tablet Tier 1
ANTIHYPERGLYCEMICS
acarbose oral tablet Tier 1
glimepiride oral tablet Tier 1
glipizide oral tablet Tier 1
glipizide oral tablet extended release 24hr
Tier 1
glipizide-metformin oral tablet
Tier 1
glyburide oral tablet Tier 1
glyburide-metformin oral tablet
Tier 1
HUMALOG KWIKPEN SUBCUTANEOUS INSULIN PEN
Tier 2
HUMALOG MIX 50-50 KWIKPEN SUBCUTANEOUS INSULIN PEN
Tier 2
HUMALOG MIX 50-50 SUBCUTANEOUS SUSPENSION
Tier 2
HUMALOG MIX 75-25 KWIKPEN SUBCUTANEOUS INSULIN PEN
Tier 2
HUMALOG MIX 75-25 SUBCUTANEOUS SUSPENSION
Tier 2
HUMALOG SUBCUTANEOUS CARTRIDGE
Tier 2
HUMALOG SUBCUTANEOUS SOLUTION
Tier 2
HUMULIN 70/30 KWIKPEN SUBCUTANEOUS INSULIN PEN
Tier 2
HUMULIN 70/30 SUBCUTANEOUS SUSPENSION
Tier 2
HUMULIN N KWIKPEN SUBCUTANEOUS INSULIN PEN
Tier 2
Revised 4/1/2016
16
Drug Name Tier Notes
HUMULIN N SUBCUTANEOUS SUSPENSION
Tier 2
HUMULIN R INJECTION SOLUTION
Tier 2
HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN
Tier 2
HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION
Tier 2
JANUVIA ORAL TABLET Tier 3 ST; QL
JARDIANCE ORAL TABLET
Tier 3 ST; QL
LANTUS SOLOSTAR SUBCUTANEOUS INSULIN PEN
Tier 2
LANTUS SUBCUTANEOUS SOLUTION
Tier 2
LEVEMIR FLEXTOUCH SUBCUTANEOUS INSULIN PEN
Tier 2
LEVEMIR SUBCUTANEOUS SOLUTION
Tier 2
metformin oral tablet Tier 1
metformin oral tablet extended release 24 hr
Tier 1
metformin oral tablet extended release 24hr
Tier 1
NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION
Tier 2
NOVOLIN N SUBCUTANEOUS SUSPENSION
Tier 2
NOVOLIN R INJECTION SOLUTION
Tier 2
NOVOLOG MIX 70-30 FLEXPEN SUBCUTANEOUS INSULIN PEN
Tier 2
NOVOLOG MIX 70-30 SUBCUTANEOUS SOLUTION
Tier 2
pioglitazone oral tablet Tier 1 QL
Drug Name Tier Notes
tolbutamide oral tablet Tier 1
ANTIINFECTIVES/MISCELLANEOUS
ALBENZA ORAL TABLET
Tier 3
ALINIA ORAL SUSPENSION FOR RECONSTITUTION
Tier 3
ALINIA ORAL TABLET Tier 3
atovaquone-proguanil oral tablet
Tier 1
BILTRICIDE ORAL TABLET
Tier 3
chloroquine phosphate oral tablet
Tier 1
COARTEM ORAL TABLET
Tier 3
DARAPRIM ORAL TABLET
Tier 3
hydroxychloroquine oral tablet
Tier 1
ivermectin oral tablet Tier 1
mefloquine oral tablet Tier 1
paromomycin oral capsule Tier 1
PRIMAQUINE ORAL TABLET
Tier 3
quinine sulfate oral capsule
Tier 1 PA; QL
ANTIINFECTIVES
ARESTIN DENTAL CARTRIDGE
Tier 3
ANTINEOPLASTICS
AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG, 3 MG, 5 MG
Tier 4 PA; QL
AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG
Tier 4 PA; QL
ALFERON N INJECTION SOLUTION
Tier 4
ALKERAN ORAL TABLET
Tier 4
anastrozole oral tablet Tier 2 PA; QL
BOSULIF ORAL TABLET100 MG, 500 MG
Tier 4 PA; QL
Revised 4/1/2016
17
Drug Name Tier Notes
BUSULFEX INTRAVENOUS SOLUTION
Tier 4
capecitabine oral tablet 150 mg, 500 mg
Tier 4 PA; QL
CAPRELSA ORAL TABLET 100 MG, 300 MG
Tier 4 PA; QL
COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG[1]-20 MG[1]), 140 MG/DAY(80 MG[1]-20 MG[3]), 60 MG/DAY (20 MG [3]/DAY)
Tier 4 PA; QL
CYCLOPHOSPHAMIDE ORAL CAPSULE
Tier 4
EMCYT ORAL CAPSULE Tier 4 PA
ERIVEDGE ORAL CAPSULE
Tier 4 PA; QL
ETOPOPHOS INTRAVENOUS RECON SOLN
Tier 4
etoposide oral capsule Tier 4
exemestane oral tablet Tier 4 PA; QL
FARESTON ORAL TABLET
Tier 4 QL
FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN
Tier 4 PA
fludarabine intravenous recon soln
Tier 4
fludarabine intravenous solution
Tier 4
fluorouracil topical cream Tier 1
fluorouracil topical solution Tier 1
flutamide oral capsule Tier 2
GILOTRIF ORAL TABLET
Tier 3 QL
GLEEVEC ORAL TABLET 100 MG, 400 MG
Tier 4 PA; QL
HEXALEN ORAL CAPSULE
Tier 4
HYCAMTIN ORAL CAPSULE
Tier 4
hydroxyurea oral capsule Tier 2
ICLUSIG ORAL TABLET15 MG, 45 MG
Tier 4 PA; QL
Drug Name Tier Notes
imatinib oral tablet 100 mg, 400 mg
Tier 4 PA; QL
INLYTA ORAL TABLET 1 MG, 5 MG
Tier 4 PA; QL
INTRON A INJECTION RECON SOLN
Tier 4 PA
INTRON A INJECTION SOLUTION
Tier 4 PA
JAKAFI ORAL TABLET10 MG, 15 MG, 20 MG, 25 MG, 5 MG
Tier 4 PA; QL
letrozole oral tablet Tier 2 QL
LEUKERAN ORAL TABLET
Tier 4
leuprolide subcutaneous kit
Tier 4 PA
LYSODREN ORAL TABLET
Tier 4 QL
MATULANE ORAL CAPSULE
Tier 4
MEKINIST ORAL TABLET 0.5 MG, 2 MG
Tier 4 PA; QL
melphalan hcl intravenous recon soln
Tier 4
mercaptopurine oral tablet Tier 4
methotrexate sodium oral tablet
Tier 2
mitoxantrone intravenous concentrate
Tier 4
MYLERAN ORAL TABLET
Tier 4
NEXAVAR ORAL TABLET
Tier 4 PA; QL
NILANDRON ORAL TABLET
Tier 4 QL
PANRETIN TOPICAL GEL
Tier 3
POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG
Tier 4 QL
REVLIMID ORAL CAPSULE
Tier 4 PA; QL
RITUXAN INTRAVENOUS CONCENTRATE
Tier 3 PA
SPRYCEL ORAL TABLET
Tier 4 PA; QL
Revised 4/1/2016
18
Drug Name Tier Notes
STIVARGA ORAL TABLET
Tier 4 PA; QL
SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG
Tier 4 PA; QL
TABLOID ORAL TABLET Tier 4
TAFINLAR ORAL CAPSULE
Tier 4 QL
tamoxifen oral tablet Tier 1 $0
TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG
Tier 4 PA; QL
TASIGNA ORAL CAPSULE
Tier 4 PA; QL
temozolomide oral capsule 100 mg, 140 mg, 180 mg, 20 mg, 250 mg, 5 mg
Tier 4 PA; QL
topotecan intravenous recon soln
Tier 4
topotecan intravenous solution
Tier 4
TRELSTAR DEPOT INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION
Tier 4 PA; QL
TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION
Tier 4 PA; QL
TRELSTAR INTRAMUSCULAR SYRINGE 11.25 MG/2 ML, 22.5 MG/2 ML, 3.75 MG/2 ML
Tier 4 PA; QL
TRELSTAR LA INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION
Tier 4 PA; QL
tretinoin (chemotherapy) oral capsule
Tier 4
TYKERB ORAL TABLET Tier 3 PA; QL
VOTRIENT ORAL TABLET
Tier 4 PA; QL
XTANDI ORAL CAPSULE Tier 4 PA; QL
ZELBORAF ORAL TABLET
Tier 4 PA; QL
ZOLINZA ORAL CAPSULE
Tier 4 PA; QL
Drug Name Tier Notes
ZYTIGA ORAL TABLET250 MG
Tier 4 PA; QL
ANTIPARKINSON DRUGS
amantadine hcl oral capsule
Tier 1
amantadine hcl oral solution
Tier 1
amantadine hcl oral tablet Tier 1
APOKYN SUBCUTANEOUS CARTRIDGE
Tier 4
AZILECT ORAL TABLET Tier 3
benztropine oral tablet Tier 1
bromocriptine oral capsule Tier 1
bromocriptine oral tablet Tier 1
carbidopa oral tablet Tier 2
carbidopa-levodopa oral tablet
Tier 1
carbidopa-levodopa oral tablet extended release
Tier 1
carbidopa-levodopa oral tablet,disintegrating
Tier 1
entacapone oral tablet Tier 2
pramipexole oral tablet Tier 1
ropinirole oral tablet Tier 1
ropinirole oral tablet extended release 24 hr
Tier 1
selegiline hcl oral capsule Tier 1
selegiline hcl oral tablet Tier 1
trihexyphenidyl oral elixir Tier 1
trihexyphenidyl oral tablet Tier 1
ANTIPLATELET DRUGS
anagrelide oral capsule Tier 2
aspirin-dipyridamole oral capsule, er multiphase 12 hr
Tier 2 QL
cilostazol oral tablet Tier 2
clopidogrel oral tablet 300 mg
Tier 1
clopidogrel oral tablet 75 mg
Tier 1 QL
dipyridamole oral tablet Tier 1
ticlopidine oral tablet Tier 1
Revised 4/1/2016
19
Drug Name Tier Notes
ANTIVIRALS
abacavir oral tablet Tier 1
abacavir-lamivudine-zidovudine oral tablet
Tier 2
acyclovir oral capsule Tier 1
acyclovir oral suspension Tier 1
acyclovir oral tablet Tier 1
adefovir oral tablet Tier 4
APTIVUS ORAL CAPSULE
Tier 2
APTIVUS ORAL SOLUTION
Tier 2
ATRIPLA ORAL TABLET Tier 2
BARACLUDE ORAL SOLUTION
Tier 4 PA
cidofovir intravenous solution
Tier 2
CRIXIVAN ORAL CAPSULE
Tier 2
didanosine oral capsule,delayed release(dr/ec)
Tier 1
EDURANT ORAL TABLET
Tier 2
EMTRIVA ORAL CAPSULE
Tier 2
EMTRIVA ORAL SOLUTION
Tier 2
entecavir oral tablet Tier 4
EPIVIR HBV ORAL SOLUTION
Tier 2
EPZICOM ORAL TABLET Tier 2
famciclovir oral tablet Tier 1
foscarnet intravenous solution
Tier 2
FUZEON SUBCUTANEOUS RECON SOLN
Tier 2
ganciclovir sodium intravenous recon soln
Tier 4
HARVONI ORAL TABLET
Tier 4 PA; QL
INTELENCE ORAL TABLET
Tier 2
INVIRASE ORAL CAPSULE
Tier 2
Drug Name Tier Notes
INVIRASE ORAL TABLET
Tier 2
ISENTRESS ORAL TABLET
Tier 2
ISENTRESS ORAL TABLET,CHEWABLE
Tier 2
KALETRA ORAL SOLUTION
Tier 2
KALETRA ORAL TABLET
Tier 2
lamivudine oral tablet Tier 1
lamivudine-zidovudine oral tablet
Tier 1
LEXIVA ORAL SUSPENSION
Tier 2
LEXIVA ORAL TABLET Tier 2
moderiba dose pack oral tablets,dose pack
Tier 3
moderiba oral tablet Tier 3
nevirapine oral suspension Tier 1
nevirapine oral tablet Tier 1
NORVIR ORAL CAPSULE
Tier 2
NORVIR ORAL SOLUTION
Tier 2
NORVIR ORAL TABLET Tier 2
PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR
Tier 4 PA; QL
PEGASYS SUBCUTANEOUS SOLUTION
Tier 4 PA; QL
PEGASYS SUBCUTANEOUS SYRINGE
Tier 4 PA; QL
PEGINTRON REDIPEN SUBCUTANEOUS PEN INJECTOR KIT
Tier 4 PA
PEGINTRON SUBCUTANEOUS KIT
Tier 4 PA
PREZISTA ORAL SUSPENSION
Tier 2
PREZISTA ORAL TABLET
Tier 2
RELENZA DISKHALER INHALATION BLISTER WITH DEVICE
Tier 2 QL
Revised 4/1/2016
20
Drug Name Tier Notes
RESCRIPTOR ORAL TABLET
Tier 2
RESCRIPTOR ORAL TABLET, DISPERSIBLE
Tier 2
REYATAZ ORAL CAPSULE
Tier 2
ribasphere oral capsule Tier 3
ribasphere oral tablet Tier 3
ribasphere ribapak oral tablets,dose pack
Tier 3
ribavirin oral capsule Tier 3
ribavirin oral tablet Tier 3
rimantadine oral tablet Tier 1
SELZENTRY ORAL TABLET
Tier 2
stavudine oral capsule Tier 1
stavudine oral recon soln Tier 1
SUSTIVA ORAL CAPSULE
Tier 2
SUSTIVA ORAL TABLET Tier 2
TAMIFLU ORAL CAPSULE 30 MG, 45 MG, 75 MG
Tier 2 QL
TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION
Tier 2 QL
TRUVADA ORAL TABLET
Tier 2
TYZEKA ORAL TABLET Tier 4 PA
valacyclovir oral tablet Tier 1
VEREGEN TOPICAL OINTMENT
Tier 3
VIRACEPT ORAL TABLET
Tier 2
VIREAD ORAL TABLET Tier 2
zidovudine oral capsule Tier 1
zidovudine oral syrup Tier 1
zidovudine oral tablet Tier 1
ZIRGAN OPHTHALMIC GEL
Tier 3
AUTONOMIC DRUGS
amphetamine salt combo oral tablet
Tier 1 PA
bethanechol chloride oral tablet
Tier 2
cevimeline oral capsule Tier 2
Drug Name Tier Notes
dextroamphetamine oral capsule, extended release
Tier 1 PA
dextroamphetamine oral solution
Tier 1 PA
dextroamphetamine oral tablet
Tier 1 PA
dextroamphetamine-amphetamine oral capsule,extended release 24hr
Tier 1 PA
epinephrine injection auto-injector
Tier 2
EPIPEN 2-PAK INJECTION AUTO-INJECTOR
Tier 2
EPIPEN JR 2-PAK INJECTION AUTO-INJECTOR
Tier 2
galantamine oral capsule,ext rel. pellets 24 hr 16 mg, 24 mg
Tier 2 QL
galantamine oral capsule,ext rel. pellets 24 hr 8 mg
Tier 2 DO
galantamine oral solution Tier 2 QL
galantamine oral tablet 12 mg, 4 mg
Tier 2 DO
galantamine oral tablet 8 mg
Tier 2 QL
guanidine oral tablet Tier 1
midodrine oral tablet Tier 1
phenoxybenzamine oral capsule
Tier 2
procentra oral solution Tier 1 PA
pyridostigmine bromide oral tablet
Tier 1
rivastigmine tartrate oral capsule 1.5 mg, 3 mg
Tier 2 DO
rivastigmine tartrate oral capsule 4.5 mg, 6 mg
Tier 2 QL
zenzedi oral tablet Tier 1 PA
BIOLOGICALS
ACTHIB (PF) INTRAMUSCULAR RECON SOLN
Tier 3 $0
Revised 4/1/2016
21
Drug Name Tier Notes
ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
AFLURIA 2015-2016 (PF) INTRAMUSCULAR SYRINGE
Tier 1 $0; QL
AFLURIA 2015-2016 INTRAMUSCULAR SUSPENSION
Tier 1 $0; QL
BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION
Tier 3 $0
BOOSTRIX TDAP INTRAMUSCULAR SYRINGE
Tier 3 $0
CERVARIX VACCINE (PF) INTRAMUSCULAR SYRINGE
Tier 2 $0
DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
ENGERIX-B (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
EZ FLU 2015-16 (FLUVIRIN) (PF) INTRAMUSCULAR SYRINGE KIT
Tier 1 QL
EZ FLU 2015-16(FLUCELVAX)(PF) INTRAMUSCULAR SYRINGE KIT
Tier 1 $0; QL
FLUARIX QUAD 2015-2016 (PF) INTRAMUSCULAR SYRINGE
Tier 1 $0; QL
Drug Name Tier Notes
FLUBLOK 2015-2016 (PF) INTRAMUSCULAR SOLUTION
Tier 1 $0; QL
FLUCELVAX 2015-2016 (PF) INTRAMUSCULAR SYRINGE
Tier 1 $0; QL
FLULAVAL QUAD 2015-2016 INTRAMUSCULAR SUSPENSION
Tier 1 $0; QL
FLUMIST QUAD 2015-2016 NASAL NASAL SPRAY SYRINGE
Tier 1 $0; QL
FLUVIRIN 2015-2016 (PF) INTRAMUSCULAR SYRINGE
Tier 1 $0; QL
FLUVIRIN 2015-2016 INTRAMUSCULAR SUSPENSION
Tier 1 $0; QL
FLUZONE 2015-2016 INTRAMUSCULAR SUSPENSION
Tier 1 $0; QL
FLUZONE HIGH-DOSE 2015-16 (PF) INTRAMUSCULAR SYRINGE
Tier 1 $0; QL
FLUZONE INTRADERM QUAD 2015-16 INTRADERMAL SYRINGE
Tier 1 $0; QL
FLUZONE QUAD 2015-2016 (PF) INTRAMUSCULAR SUSPENSION
Tier 1 $0; QL
FLUZONE QUAD 2015-2016 (PF) INTRAMUSCULAR SYRINGE
Tier 1 $0; QL
FLUZONE QUAD 2015-2016 INTRAMUSCULAR SUSPENSION
Tier 1 $0; QL
FLUZONE QUAD PEDI 2015-16 (PF) INTRAMUSCULAR SYRINGE
Tier 1 $0; QL
GAMASTAN S/D INTRAMUSCULAR SOLUTION
Tier 3
Revised 4/1/2016
22
Drug Name Tier Notes
GARDASIL (PF) INTRAMUSCULAR SUSPENSION
Tier 2 $0
GARDASIL (PF) INTRAMUSCULAR SYRINGE
Tier 2 $0
GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION
Tier 2 $0
GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE
Tier 2 $0
HAVRIX (PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
HAVRIX (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN
Tier 3
INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
IPOL INJECTION SUSPENSION
Tier 3 $0
IXIARO (PF) INTRAMUSCULAR SYRINGE
Tier 3
KINRIX (PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
KINRIX (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
MENACTRA (PF) INTRAMUSCULAR SOLUTION
Tier 3 $0
MENHIBRIX (PF) INTRAMUSCULAR RECON SOLN
Tier 3 $0
MENOMUNE - A/C/Y/W-135 (PF) SUBCUTANEOUS RECON SOLN
Tier 3 $0
Drug Name Tier Notes
MENOMUNE - A/C/Y/W-135 SUBCUTANEOUS RECON SOLN
Tier 3 $0
MENVEO A-C-Y-W-135-DIP (PF) INTRAMUSCULAR KIT
Tier 3 $0
M-M-R II (PF) SUBCUTANEOUS RECON SOLN
Tier 3 $0
OCTAGAM INTRAVENOUS SOLUTION
Tier 3
PEDIARIX (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION
Tier 3 $0
PENTACEL (PF) INTRAMUSCULAR KIT
Tier 3 $0
PNEUMOVAX 23 INJECTION SOLUTION
Tier 2 $0
PNEUMOVAX 23 INJECTION SYRINGE
Tier 2 $0
PREVNAR 13 (PF) INTRAMUSCULAR SYRINGE
Tier 2 $0
PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION
Tier 3 $0
RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION
Tier 3
RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
ROTARIX ORAL SUSPENSION FOR RECONSTITUTION
Tier 3 $0
ROTATEQ VACCINE ORAL SUSPENSION
Tier 3 $0
TENIVAC (PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
Revised 4/1/2016
23
Drug Name Tier Notes
TENIVAC (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
TETANUS,DIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
TETANUS-DIPHTHERIA TOXOIDS-TD INTRAMUSCULAR SUSPENSION
Tier 3 $0
TRUMENBA INTRAMUSCULAR SYRINGE
Tier 2 $0
TWINRIX (PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
TWINRIX (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
TYPHIM VI INTRAMUSCULAR SOLUTION
Tier 3
TYPHIM VI INTRAMUSCULAR SYRINGE
Tier 3
VAQTA (PF) INTRAMUSCULAR SUSPENSION
Tier 3 $0
VAQTA (PF) INTRAMUSCULAR SYRINGE
Tier 3 $0
VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION
Tier 3 $0
VIVOTIF BERNA VACCINE ORAL CAPSULE,DELAYED RELEASE(DR/EC)
Tier 2
YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION
Tier 3
ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION
Tier 2 $0
BLOOD
DROXIA ORAL CAPSULE
Tier 4
Drug Name Tier Notes
pentoxifylline oral tablet extended release
Tier 1
tranexamic acid intravenous solution
Tier 2
tranexamic acid oral tablet Tier 1
CARDIAC DRUGS
afeditab cr oral tablet extended release 30 mg
Tier 1 DO
afeditab cr oral tablet extended release 60 mg
Tier 1 QL
amlodipine oral tablet 10 mg
Tier 1 QL
amlodipine oral tablet 2.5 mg, 5 mg
Tier 1 DO
cartia xt oral capsule,extended release 24hr 120 mg, 180 mg
Tier 1 DO
cartia xt oral capsule,extended release 24hr 240 mg, 300 mg
Tier 1 QL
digox oral tablet Tier 1
digoxin oral solution Tier 1
digoxin oral tablet Tier 1
diltiazem hcl oral capsule, extended release 120 mg, 180 mg
Tier 1 DO
diltiazem hcl oral capsule, extended release 240 mg, 300 mg, 360 mg, 420 mg
Tier 1 QL
diltiazem hcl oral capsule,ext release degradable 120 mg, 180 mg
Tier 1 DO
diltiazem hcl oral capsule,ext release degradable 240 mg
Tier 1 QL
diltiazem hcl oral capsule,extended release 12 hr 120 mg, 90 mg
Tier 1 QL
diltiazem hcl oral capsule,extended release 12 hr 60 mg
Tier 1 DO; QL
diltiazem hcl oral capsule,extended release 24hr 120 mg, 180 mg
Tier 1 DO
diltiazem hcl oral capsule,extended release 24hr 240 mg, 300 mg, 360 mg
Tier 1 QL
Revised 4/1/2016
24
Drug Name Tier Notes
diltiazem hcl oral tablet Tier 1 QL
diltiazem hcl oral tablet extended release 24 hr 180 mg
Tier 1 DO
diltiazem hcl oral tablet extended release 24 hr 240 mg, 300 mg, 360 mg, 420 mg
Tier 1 QL
dilt-xr oral capsule,ext release degradable 120 mg, 180 mg
Tier 1 DO
dilt-xr oral capsule,ext release degradable 240 mg
Tier 1 QL
disopyramide phosphate oral capsule
Tier 1
felodipine oral tablet extended release 24 hr 10 mg
Tier 1 QL
felodipine oral tablet extended release 24 hr 2.5 mg, 5 mg
Tier 1 DO
flecainide oral tablet Tier 2
isosorbide dinitrate oral tablet
Tier 1
isosorbide dinitrate oral tablet extended release
Tier 1
isosorbide mononitrate oral tablet
Tier 1
isosorbide mononitrate oral tablet extended release 24 hr
Tier 1
LANOXIN ORAL TABLET Tier 3
matzim la oral tablet extended release 24 hr 180 mg
Tier 1 DO
matzim la oral tablet extended release 24 hr 240 mg, 300 mg, 360 mg, 420 mg
Tier 1 QL
mexiletine oral capsule Tier 2
MULTAQ ORAL TABLET Tier 3
nifedical xl oral tablet extended release 24hr 30 mg
Tier 1 DO
nifedical xl oral tablet extended release 24hr 60 mg
Tier 1 QL
nifedipine oral capsule Tier 1 QL
Drug Name Tier Notes
nifedipine oral tablet extended release 24hr 30 mg
Tier 1 DO
nifedipine oral tablet extended release 24hr 60 mg, 90 mg
Tier 1 QL
nifedipine oral tablet extended release 30 mg
Tier 1 DO
nifedipine oral tablet extended release 60 mg, 90 mg
Tier 1 QL
nisoldipine oral tablet extended release 24 hr 17 mg, 20 mg, 8.5 mg
Tier 1 DO
nisoldipine oral tablet extended release 24 hr 25.5 mg, 30 mg, 34 mg, 40 mg
Tier 1 QL
nitro-bid transdermal ointment
Tier 1
nitroglycerin oral capsule, extended release
Tier 1
nitroglycerin translingual aerosol,spray
Tier 2
nitroglycerin translingual spray,non-aerosol
Tier 2
NITROSTAT SUBLINGUAL TABLET
Tier 2
nitro-time oral capsule, extended release
Tier 1
procainamide injection solution
Tier 2
propafenone oral capsule,extended release 12 hr
Tier 2
propafenone oral tablet Tier 2
quinidine sulfate oral tablet Tier 1
quinidine sulfate oral tablet extended release
Tier 1
taztia xt oral capsule, extended release 120 mg, 180 mg
Tier 1 DO
taztia xt oral capsule, extended release 240 mg, 300 mg, 360 mg
Tier 1 QL
TIKOSYN ORAL CAPSULE
Tier 3
verapamil oral capsule, 24 hr er pellet ct 100 mg
Tier 1 DO
Revised 4/1/2016
25
Drug Name Tier Notes
verapamil oral capsule, 24 hr er pellet ct 200 mg, 300 mg
Tier 1 QL
verapamil oral capsule,ext rel. pellets 24 hr 120 mg, 180 mg
Tier 1
verapamil oral capsule,ext rel. pellets 24 hr 240 mg, 360 mg
Tier 1 QL
verapamil oral tablet 120 mg, 40 mg, 80 mg
Tier 1 QL
verapamil oral tablet extended release
Tier 1 QL
CARDIOVASCULAR
acebutolol oral capsule Tier 1
ADCIRCA ORAL TABLET
Tier 3 PA
amlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg, 5-80 mg
Tier 1 QL
amlodipine-atorvastatin oral tablet 2.5-10 mg, 2.5-20 mg, 2.5-40 mg, 5-10 mg, 5-20 mg, 5-40 mg
Tier 1 DO
amlodipine-benazepril oral capsule
Tier 1
amlodipine-valsartan oral tablet 10-160 mg, 10-320 mg, 5-320 mg
Tier 1 QL
amlodipine-valsartan oral tablet 5-160 mg
Tier 1 DO
amlodipine-valsartan-hcthiazid oral tablet 10-160-12.5 mg, 10-160-25 mg, 10-320-25 mg, 5-160-25 mg
Tier 1 QL
amlodipine-valsartan-hcthiazid oral tablet 5-160-12.5 mg
Tier 1 DO
atenolol oral tablet Tier 1
atenolol-chlorthalidone oral tablet
Tier 1
atorvastatin oral tablet 10 mg, 20 mg, 40 mg
Tier 1 DO
atorvastatin oral tablet 80 mg
Tier 1 QL
benazepril oral tablet Tier 1
Drug Name Tier Notes
benazepril-hydrochlorothiazide oral tablet
Tier 1
BENICAR HCT ORAL TABLET 20-12.5 MG
Tier 3 DO
BENICAR HCT ORAL TABLET 40-12.5 MG, 40-25 MG
Tier 3 QL
BENICAR ORAL TABLET20 MG
Tier 3 DO
BENICAR ORAL TABLET40 MG, 5 MG
Tier 3 QL
betaxolol oral tablet Tier 1
bisoprolol fumarate oral tablet
Tier 1
bisoprolol-hydrochlorothiazide oral tablet
Tier 1
candesartan-hydrochlorothiazid oral tablet 16-12.5 mg
Tier 1 DO; QL
candesartan-hydrochlorothiazid oral tablet 32-12.5 mg
Tier 1 QL
candesartan-hydrochlorothiazid oral tablet 32-25 mg
Tier 1
clonidine hcl oral tablet Tier 1
doxazosin oral tablet Tier 1
enalapril maleate oral tablet
Tier 1
enalapril-hydrochlorothiazide oral tablet
Tier 1
ergoloid oral tablet Tier 2
fenofibrate micronized oral capsule
Tier 1
fenofibrate nanocrystallized oral tablet
Tier 1
fenofibrate oral tablet Tier 1
fenofibric acid (choline) oral capsule,delayed release(dr/ec)
Tier 1
fenofibric acid oral tablet Tier 1
fosinopril oral tablet Tier 1
fosinopril-hydrochlorothiazide oral tablet
Tier 1
gemfibrozil oral tablet Tier 1
guanfacine oral tablet Tier 1
hydralazine oral tablet Tier 1
Revised 4/1/2016
26
Drug Name Tier Notes
irbesartan oral tablet 150 mg, 75 mg
Tier 1 DO
irbesartan oral tablet 300 mg
Tier 1 QL
irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg, 300-12.5 mg
Tier 1 QL
LETAIRIS ORAL TABLET Tier 4 PA
lisinopril oral tablet Tier 1
lisinopril-hydrochlorothiazide oral tablet
Tier 1
losartan oral tablet 100 mg Tier 1 QL
losartan oral tablet 25 mg, 50 mg
Tier 1 DO; QL
losartan-hydrochlorothiazide oral tablet 100-12.5 mg, 100-25 mg
Tier 1 QL
losartan-hydrochlorothiazide oral tablet 50-12.5 mg
Tier 1 DO
lovastatin oral tablet 10 mg, 20 mg
Tier 1 DO
lovastatin oral tablet 40 mg
Tier 1 QL
methyldopa oral tablet Tier 1
methyldopa-hydrochlorothiazide oral tablet
Tier 1
metoprolol succinate oral tablet extended release 24 hr
Tier 1
metoprolol ta-hydrochlorothiaz oral tablet
Tier 1
metoprolol tartrate oral tablet
Tier 1
minoxidil oral tablet Tier 1
nadolol-bendroflumethiazide oral tablet
Tier 1
niacin oral tablet extended release 24 hr 1,000 mg, 500 mg, 750 mg
Tier 1 QL
pravastatin oral tablet 10 mg, 20 mg, 40 mg
Tier 1 DO
pravastatin oral tablet 80 mg
Tier 1 QL
prazosin oral capsule Tier 1
propranolol oral capsule,extended release 24 hr
Tier 1
Drug Name Tier Notes
propranolol oral solution Tier 1
propranolol oral tablet Tier 1
propranolol-hydrochlorothiazid oral tablet
Tier 1
quinapril oral tablet Tier 1
quinapril-hydrochlorothiazide oral tablet
Tier 1
ramipril oral capsule Tier 1
REMODULIN INJECTION SOLUTION
Tier 4 PA
simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg
Tier 1 DO
simvastatin oral tablet 80 mg
Tier 1 PA; QL
sorine oral tablet Tier 2
sotalol af oral tablet Tier 2
sotalol oral tablet Tier 2
terazosin oral capsule Tier 1
timolol maleate oral tablet Tier 1
trandolapril oral tablet Tier 1
trandolapril-verapamil oral tablet, ir - er, biphasic 24hr
Tier 1
valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg
Tier 1 QL
valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 80-12.5 mg
Tier 1 DO
valsartan-hydrochlorothiazide oral tablet 160-25 mg, 320-12.5 mg, 320-25 mg
Tier 1 QL
VENTAVIS INHALATION SOLUTION FOR NEBULIZATION
Tier 4 PA
WELCHOL ORAL POWDER IN PACKET
Tier 3
WELCHOL ORAL TABLET
Tier 3
CNS DRUGS
AVONEX (WITH ALBUMIN) INTRAMUSCULAR KIT
Tier 3
AVONEX INTRAMUSCULAR PEN INJECTOR
Tier 3
Revised 4/1/2016
27
Drug Name Tier Notes
AVONEX INTRAMUSCULAR PEN INJECTOR KIT
Tier 3
AVONEX INTRAMUSCULAR SYRINGE
Tier 3
AVONEX INTRAMUSCULAR SYRINGE KIT
Tier 3
carbamazepine oral capsule, er multiphase 12 hr
Tier 1
carbamazepine oral suspension
Tier 1
carbamazepine oral tablet Tier 1
carbamazepine oral tablet extended release 12 hr
Tier 1
carbamazepine oral tablet,chewable
Tier 1
clonazepam oral tablet Tier 1
clonazepam oral tablet,disintegrating
Tier 1
divalproex oral capsule, sprinkle
Tier 1
divalproex oral tablet extended release 24 hr
Tier 1
divalproex oral tablet,delayed release (dr/ec)
Tier 1
epitol oral tablet Tier 1
ethosuximide oral capsule Tier 1
ethosuximide oral solution Tier 1
EXTAVIA SUBCUTANEOUS KIT
Tier 4 PA
EXTAVIA SUBCUTANEOUS RECON SOLN
Tier 4 PA
felbamate oral suspension Tier 1
felbamate oral tablet Tier 1
fosphenytoin injection solution
Tier 2
gabapentin oral capsule Tier 2
gabapentin oral solution Tier 2
gabapentin oral tablet Tier 2
GILENYA ORAL CAPSULE
Tier 4 PA; QL
lamotrigine oral tablet Tier 1
Drug Name Tier Notes
lamotrigine oral tablet, chewable dispersible
Tier 1
levetiracetam oral solution Tier 2
levetiracetam oral tablet Tier 2
levetiracetam oral tablet extended release 24 hr 500 mg, 750 mg
Tier 2 PA; QL
memantine oral solution Tier 2
memantine oral tablet Tier 2
memantine oral tablets,dose pack
Tier 2
NUEDEXTA ORAL CAPSULE
Tier 3
oxcarbazepine oral suspension
Tier 1
oxcarbazepine oral tablet Tier 1
PEGANONE ORAL TABLET
Tier 3
phenytoin sodium extended oral capsule
Tier 1
primidone oral tablet Tier 1
REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE
Tier 3 PA
REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR
Tier 3 PA
REBIF TITRATION PACK SUBCUTANEOUS SYRINGE
Tier 3 PA
tiagabine oral tablet Tier 2
topiramate oral capsule, sprinkle
Tier 1
topiramate oral tablet Tier 1
valproic acid (as sodium salt) oral solution
Tier 1
valproic acid oral capsule Tier 1
zonisamide oral capsule Tier 2
COLONY STIMULATING FACTORS
ARANESP (IN POLYSORBATE) INJECTION SOLUTION
Tier 4 PA
ARANESP (IN POLYSORBATE) INJECTION SYRINGE
Tier 4 PA
Revised 4/1/2016
28
Drug Name Tier Notes
MOZOBIL SUBCUTANEOUS SOLUTION
Tier 4 PA
NEULASTA SUBCUTANEOUS SYRINGE
Tier 4 PA; QL
PROMACTA ORAL TABLET
Tier 4 PA
CONTRACEPTIVES
altavera (28) oral tablet Tier 1 $0
alyacen 1/35 (28) oral tablet
Tier 1 $0
alyacen 7/7/7 (28) oral tablet
Tier 1 $0
amethia lo oral tablets,dose pack,3 month
Tier 1 $0
amethia oral tablets,dose pack,3 month
Tier 1 $0
amethyst oral tablet Tier 1 $0
apri oral tablet Tier 1 $0
aranelle (28) oral tablet Tier 1 $0
ashlyna oral tablets,dose pack,3 month
Tier 1 $0
aubra oral tablet Tier 1 $0
aviane oral tablet Tier 1 $0
azurette (28) oral tablet Tier 1 $0
balziva (28) oral tablet Tier 1 $0
BEKYREE (28) ORAL TABLET
Tier 1 $0
BEYAZ ORAL TABLET Tier 3 $0
BLISOVI 24 FE ORAL TABLET
Tier 1 $0
BLISOVI FE 1.5/30 (28) ORAL TABLET
Tier 1 $0
BLISOVI FE 1/20 (28) ORAL TABLET
Tier 1 $0
briellyn oral tablet Tier 1 $0
camila oral tablet Tier 1 $0
camrese lo oral tablets,dose pack,3 month
Tier 1 $0
camrese oral tablets,dose pack,3 month
Tier 1 $0
caziant (28) oral tablet Tier 1 $0
chateal oral tablet Tier 1 $0
cryselle (28) oral tablet Tier 1 $0
Drug Name Tier Notes
cyclafem 1/35 (28) oral tablet
Tier 1 $0
cyclafem 7/7/7 (28) oral tablet
Tier 1 $0
cyred oral tablet Tier 1 $0
dasetta 1/35 (28) oral tablet
Tier 1 $0
dasetta 7/7/7 (28) oral tablet
Tier 1 $0
daysee oral tablets,dose pack,3 month
Tier 1 $0
deblitane oral tablet Tier 1 $0
delyla (28) oral tablet Tier 1 $0
desog-e.estradiol/e.estradiol oral tablet
Tier 1 $0
desogestrel-ethinyl estradiol oral tablet
Tier 1 $0
drospirenone-ethinyl estradiol oral tablet
Tier 1 $0
elinest oral tablet Tier 1 $0
ELLA ORAL TABLET Tier 3 $0
emoquette oral tablet Tier 1 $0
enpresse oral tablet Tier 1 $0
enskyce oral tablet Tier 1 $0
errin oral tablet Tier 1 $0
estarylla oral tablet Tier 1 $0
falmina (28) oral tablet Tier 1 $0
gianvi (28) oral tablet Tier 1 $0
gildagia oral tablet Tier 1 $0
gildess 1.5/30 (21) oral tablet
Tier 1 $0
gildess 1/20 (21) oral tablet
Tier 1 $0
gildess 24 fe oral tablet Tier 1 $0
gildess fe 1.5/30 (28) oral tablet
Tier 1 $0
gildess fe 1/20 (28) oral tablet
Tier 1 $0
heather oral tablet Tier 1 $0
introvale oral tablets,dose pack,3 month
Tier 1 $0
jencycla oral tablet Tier 1 $0
jolessa oral tablets,dose pack,3 month
Tier 1 $0
jolivette oral tablet Tier 1 $0
Revised 4/1/2016
29
Drug Name Tier Notes
JULEBER ORAL TABLET
Tier 1 $0
junel 1.5/30 (21) oral tablet Tier 1 $0
junel 1/20 (21) oral tablet Tier 1 $0
junel fe 1.5/30 (28) oral tablet
Tier 1 $0
junel fe 1/20 (28) oral tablet
Tier 1 $0
junel fe 24 oral tablet Tier 1 $0
kariva (28) oral tablet Tier 1 $0
kelnor 1/35 (28) oral tablet Tier 1 $0
kurvelo oral tablet Tier 1 $0
l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month
Tier 1 $0
larin 1.5/30 (21) oral tablet Tier 1 $0
larin 1/20 (21) oral tablet Tier 1 $0
larin fe 1.5/30 (28) oral tablet
Tier 1 $0
larin fe 1/20 (28) oral tablet
Tier 1 $0
layolis fe oral tablet,chewable
Tier 1 $0
leena 28 oral tablet Tier 1 $0
lessina oral tablet Tier 1 $0
levonest (28) oral tablet Tier 1 $0
levonorgestrel-ethinyl estrad oral tablet
Tier 1 $0
levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month
Tier 1 $0
levora-28 oral tablet Tier 1 $0
LO LOESTRIN FE ORAL TABLET
Tier 3 $0
lomedia 24 fe oral tablet Tier 1 $0
loryna (28) oral tablet Tier 1 $0
low-ogestrel (28) oral tablet
Tier 1 $0
lutera (28) oral tablet Tier 1 $0
lyza oral tablet Tier 1 $0
marlissa oral tablet Tier 1 $0
medroxyprogesterone intramuscular suspension
Tier 1 $0
medroxyprogesterone intramuscular syringe
Tier 1 $0
Drug Name Tier Notes
microgestin 1.5/30 (21) oral tablet
Tier 1 $0
microgestin 1/20 (21) oral tablet
Tier 1 $0
microgestin fe 1.5/30 (28) oral tablet
Tier 1 $0
microgestin fe 1/20 (28) oral tablet
Tier 1 $0
MINASTRIN 24 FE ORAL TABLET,CHEWABLE
Tier 3 $0
mono-linyah oral tablet Tier 1 $0
mononessa (28) oral tablet Tier 1 $0
my way oral tablet 1.5 mg Tier 1 $0; QL
myzilra oral tablet Tier 1 $0
NATAZIA ORAL TABLET Tier 3 $0
necon 0.5/35 (28) oral tablet
Tier 1 $0
necon 1/35 (28) oral tablet Tier 1 $0
necon 1/50 (28) oral tablet Tier 1 $0
necon 10/11 (28) oral tablet
Tier 1 $0
necon 7/7/7 (28) oral tablet
Tier 1 $0
next choice one dose oral tablet
Tier 1 $0; QL
nikki (28) oral tablet Tier 1 $0
nora-be oral tablet Tier 1 $0
noreth-ethinyl estradiol-iron oral tablet,chewable
Tier 1 $0
norethindrone (contraceptive) oral tablet
Tier 1 $0
norethindrone ac-eth estradiol oral tablet
Tier 1 $0
norethindrone-e.estradiol-iron oral tablet
Tier 1 $0
norgestimate-ethinyl estradiol oral tablet
Tier 1 $0
norlyroc oral tablet Tier 1 $0
nortrel 0.5/35 (28) oral tablet
Tier 1 $0
nortrel 1/35 (21) oral tablet Tier 1 $0
nortrel 1/35 (28) oral tablet Tier 1 $0
nortrel 7/7/7 (28) oral tablet
Tier 1 $0
Revised 4/1/2016
30
Drug Name Tier Notes
NUVARING VAGINAL RING
Tier 3 $0
ocella oral tablet Tier 1 $0
ogestrel (28) oral tablet Tier 1 $0
orsythia oral tablet Tier 1 $0
philith oral tablet Tier 1 $0
pimtrea (28) oral tablet Tier 1 $0
pirmella oral tablet Tier 1 $0
portia oral tablet Tier 1 $0
previfem oral tablet Tier 1 $0
QUARTETTE ORAL TABLETS,DOSE PACK,3 MONTH
Tier 3 $0
quasense oral tablets,dose pack,3 month
Tier 1 $0
reclipsen (28) oral tablet Tier 1 $0
SAFYRAL ORAL TABLET
Tier 3 $0
setlakin oral tablets,dose pack,3 month
Tier 1 $0
sharobel oral tablet Tier 1 $0
sprintec (28) oral tablet Tier 1 $0
sronyx oral tablet Tier 1 $0
syeda oral tablet Tier 1 $0
tarina fe 1/20 (28) oral tablet
Tier 1 $0
tilia fe oral tablet Tier 1 $0
tri-estarylla oral tablet Tier 1 $0
tri-legest fe oral tablet Tier 1 $0
tri-linyah oral tablet Tier 1 $0
TRI-LO-ESTARYLLA ORAL TABLET
Tier 1 $0
TRI-LO-SPRINTEC ORAL TABLET
Tier 1 $0
trinessa (28) oral tablet Tier 1 $0
TRINESSA LO ORAL TABLET
Tier 1 $0
tri-previfem (28) oral tablet Tier 1 $0
tri-sprintec (28) oral tablet Tier 1 $0
trivora (28) oral tablet Tier 1 $0
velivet triphasic regimen (28) oral tablet
Tier 1 $0
vestura (28) oral tablet Tier 1 $0
viorele (28) oral tablet Tier 1 $0
Drug Name Tier Notes
vyfemla (28) oral tablet Tier 1 $0
wera (28) oral tablet Tier 1 $0
wymzya fe oral tablet,chewable
Tier 1 $0
xulane transdermal patch weekly
Tier 1 $0
zarah oral tablet Tier 1 $0
zenchent (28) oral tablet Tier 1 $0
zenchent fe oral tablet,chewable
Tier 1 $0
zovia 1/35e (28) oral tablet Tier 1 $0
zovia 1/50e (28) oral tablet Tier 1 $0
COUGH/COLD PREPARATIONS
benzonatate oral capsule Tier 1
cheratussin ac oral liquid Tier 1
guaifenesin ac oral liquid Tier 1
iophen c-nr oral liquid Tier 1
promethazine vc-codeine oral syrup
Tier 1
promethazine-codeine oral syrup
Tier 1
promethazine-dm oral syrup
Tier 1
promethazine-phenyleph-codeine oral syrup
Tier 1
DIAGNOSTIC
ACCU-CHEK AVIVA PLUS TEST STRP STRIP
Tier 2 QL
ACCU-CHEK AVIVA STRIP
Tier 2 QL
ACCU-CHEK COMPACT PLUS TEST STRIP
Tier 2 QL
ACCU-CHEK COMPACT TEST STRIP
Tier 2 QL
ACCU-CHEK SMARTVIEW TEST STRIP STRIP
Tier 2 QL
ACCUTREND GLUCOSE STRIP
Tier 2 QL
dipyridamole intravenous solution
Tier 2
GLUCAGEN DIAGNOSTIC KIT INJECTION RECON SOLN
Tier 2
Revised 4/1/2016
31
Drug Name Tier Notes
ONETOUCH ULTRA TEST STRIP
Tier 2 QL
ONETOUCH VERIO STRIP
Tier 2 QL
DIURETICS
acetazolamide oral capsule, extended release
Tier 1
acetazolamide oral tablet Tier 1
AMMONIUM CHLORIDE INTRAVENOUS SOLUTION
Tier 3
chlorthalidone oral tablet Tier 1
EDECRIN ORAL TABLET Tier 3
furosemide oral solution Tier 1
furosemide oral tablet Tier 1
hydrochlorothiazide oral capsule
Tier 1
hydrochlorothiazide oral tablet
Tier 1
indapamide oral tablet Tier 1
methazolamide oral tablet Tier 1
methyclothiazide oral tablet
Tier 1
spironolactone oral tablet Tier 1
torsemide oral tablet Tier 1
triamterene-hydrochlorothiazid oral capsule
Tier 1
triamterene-hydrochlorothiazid oral tablet
Tier 1
EENT PREPS
acetasol hc otic drops Tier 1
acetic acid otic solution Tier 1
acetic acid-aluminum acetate otic drops
Tier 1
ALOCRIL OPHTHALMIC DROPS
Tier 3 PA; QL
ALOMIDE OPHTHALMIC DROPS
Tier 3 PA; QL
apraclonidine ophthalmic drops
Tier 1
azelastine nasal aerosol,spray
Tier 1 QL
betaxolol ophthalmic drops Tier 1
bimatoprost ophthalmic drops
Tier 2
Drug Name Tier Notes
brimonidine ophthalmic drops
Tier 1
carteolol ophthalmic drops Tier 1
cromolyn ophthalmic drops
Tier 1 QL
CYSTARAN OPHTHALMIC DROPS
Tier 3
dexamethasone sodium phosphate ophthalmic drops
Tier 1
diclofenac sodium ophthalmic drops
Tier 1
dorzolamide ophthalmic drops
Tier 1
dorzolamide-timolol ophthalmic drops
Tier 1
fluocinolone acetonide oil otic drops
Tier 1
fluorometholone ophthalmic drops,suspension
Tier 1
fluticasone nasal spray,suspension
Tier 1 QL
hydrocortisone-acetic acid otic drops
Tier 1
ketorolac ophthalmic drops
Tier 1
LACRISERT OPHTHALMIC INSERT
Tier 3
latanoprost ophthalmic drops
Tier 1
LOTEMAX OPHTHALMIC DROPS,GEL
Tier 3
LOTEMAX OPHTHALMIC DROPS,SUSPENSION
Tier 3
LOTEMAX OPHTHALMIC OINTMENT
Tier 3
LUMIGAN OPHTHALMIC DROPS
Tier 3
metipranolol ophthalmic drops
Tier 1
naphazoline ophthalmic drops
Tier 1
PHOSPHOLINE IODIDE OPHTHALMIC DROPS
Tier 3
prednisolone acetate ophthalmic drops,suspension
Tier 1
Revised 4/1/2016
32
Drug Name Tier Notes
prednisolone sodium phosphate ophthalmic drops
Tier 1
RESTASIS OPHTHALMIC DROPPERETTE
Tier 3
timolol maleate ophthalmic drops
Tier 1
timolol maleate ophthalmic gel forming solution
Tier 1
TRAVATAN Z OPHTHALMIC DROPS
Tier 3
triamcinolone acetonide nasal aerosol,spray
Tier 1 QL
TYZINE NASAL DROPS Tier 3
TYZINE NASAL SPRAY,NON-AEROSOL
Tier 3
ELECT/CALORIC/H2O
calcium acetate oral tablet Tier 2
cytra k crystals oral packet Tier 1
cytra-k oral solution Tier 1
denta 5000 plus dental cream
Tier 1
dentagel dental gel Tier 1
EFFER-K ORAL TABLET, EFFERVESCENT 10 MEQ, 20 MEQ
Tier 3
effer-k oral tablet, effervescent 25 meq
Tier 1
eliphos oral tablet Tier 2 PA
fe c plus oral tablet Tier 1
fluoridex daily defense dental gel
Tier 1
FLUORIDEX SENSITIVITY RELIEF DENTAL GEL
Tier 3
fluoritab oral tablet,chewable
Tier 1
GLUCAGEN HYPOKIT INJECTION RECON SOLN
Tier 2
k-effervescent oral tablet, effervescent
Tier 1
kionex oral powder Tier 1
kionex oral suspension Tier 1
Drug Name Tier Notes
klor-con 10 oral tablet extended release
Tier 1
klor-con 8 oral tablet extended release
Tier 1
klor-con m10 oral tablet,er particles/crystals
Tier 1
klor-con m15 oral tablet,er particles/crystals
Tier 1
klor-con m20 oral tablet,er particles/crystals
Tier 1
klor-con/ef oral tablet, effervescent
Tier 1
ludent fluoride oral tablet,chewable
Tier 1
magnesium sulfate injection syringe
Tier 2
NUTRAMINE ORAL POWDER
Tier 3
potassium bicarb-citric acid oral tablet, effervescent
Tier 1
potassium chloride oral capsule, extended release
Tier 1
potassium chloride oral tablet extended release
Tier 1
potassium chloride oral tablet,er particles/crystals
Tier 1
potassium citrate oral tablet extended release
Tier 1
potassium citrate-citric acid oral solution
Tier 1
PREVIDENT 5000 BOOSTER PLUS DENTAL PASTE
Tier 3
RENVELA ORAL POWDER IN PACKET
Tier 3
RENVELA ORAL TABLET
Tier 3
sf 5000 plus dental cream Tier 1
sodium chloride 0.45 % intravenous parenteral solution
Tier 2
sodium chloride 0.45 % intravenous piggyback
Tier 2
sodium chloride 0.9 % intravenous parenteral solution
Tier 2
Revised 4/1/2016
33
Drug Name Tier Notes
sodium chloride 0.9 % intravenous piggyback
Tier 2
sodium chloride 3 % intravenous parenteral solution
Tier 2
sodium chloride 5 % intravenous parenteral solution
Tier 2
sodium chloride intravenous parenteral solution
Tier 2
sodium fluoride dental solution
Tier 1
sodium fluoride oral drops Tier 1
sodium fluoride oral tablet,chewable
Tier 1
sodium polystyrene (sorb free) oral suspension
Tier 1
sodium polystyrene sulfonate oral powder
Tier 1
sodium polystyrene sulfonate oral suspension
Tier 1
sodium polystyrene sulfonate rectal enema
Tier 1
sps oral suspension Tier 1
sps rectal enema Tier 1
GASTROINTESTINAL
ALOXI INTRAVENOUS SOLUTION
Tier 3
AMITIZA ORAL CAPSULE
Tier 3
anaspaz oral tablet,disintegrating
Tier 2
anucort-hc rectal suppository
Tier 1
APRISO ORAL CAPSULE,EXTENDED RELEASE 24HR
Tier 3
balsalazide oral capsule Tier 1
BUPHENYL ORAL TABLET
Tier 3 PA
CANTIL ORAL TABLET Tier 3
carafate oral suspension Tier 1
CESAMET ORAL CAPSULE
Tier 3 ST
cimetidine hcl oral solution Tier 1
cimetidine oral tablet Tier 1
Drug Name Tier Notes
CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT
Tier 4 PA; QL
CIMZIA STARTER KIT SUBCUTANEOUS SYRINGE KIT
Tier 4 PA; QL
CIMZIA SUBCUTANEOUS SYRINGE KIT
Tier 4 PA; QL
COMPAZINE ORAL TABLET
Tier 1
constulose oral solution Tier 1
dicyclomine oral capsule Tier 1
dicyclomine oral solution Tier 1
dicyclomine oral tablet Tier 1
diphenoxylate-atropine oral liquid
Tier 1
diphenoxylate-atropine oral tablet
Tier 1
enulose oral solution Tier 1
famotidine oral suspension Tier 1
famotidine oral tablet Tier 1
gavilyte-c oral recon soln Tier 1
gavilyte-g oral recon soln Tier 1
gavilyte-n oral recon soln Tier 1
generlac oral solution Tier 1
glycopyrrolate oral tablet Tier 1
hydrocortisone acetate rectal suppository
Tier 1
hydrocortisone-pramox-e-pram#1 rectal kit,cream and towelette
Tier 1
hydrocortisone-pramoxine rectal cream
Tier 1
lactulose oral solution Tier 1
lansoprazole oral capsule,delayed release(dr/ec)
Tier 1 QL
lidocaine hcl-hydrocortison ac rectal cream
Tier 1
lidocaine hcl-hydrocortison ac rectal kit
Tier 1
lidocaine-hydrocortisone-aloe rectal gel
Tier 1
lidocaine-hydrocortisone-aloe rectal kit
Tier 1
Revised 4/1/2016
34
Drug Name Tier Notes
LOVAZA ORAL CAPSULE
Tier 3 QL
meclizine oral tablet Tier 1
methscopolamine oral tablet
Tier 1
metoclopramide hcl oral solution
Tier 1
metoclopramide hcl oral tablet
Tier 1
misoprostol oral tablet Tier 1
MOTOFEN ORAL TABLET
Tier 3
MOVIPREP ORAL POWDER IN PACKET
Tier 3
omega-3 acid ethyl esters oral capsule
Tier 1 QL
omeprazole oral capsule,delayed release(dr/ec)
Tier 1 QL
ondansetron hcl oral solution
Tier 2 QL
ondansetron hcl oral tablet 24 mg, 4 mg, 8 mg
Tier 2 QL
ondansetron oral tablet,disintegrating 4 mg, 8 mg
Tier 2 QL
OSMOPREP ORAL TABLET
Tier 3
peg 3350-electrolytes oral recon soln
Tier 1
peg-3350 with flavor packs oral recon soln
Tier 1
phenadoz rectal suppository
Tier 1
pramcort rectal cream Tier 1
prochlorperazine maleate oral tablet
Tier 1
proctosol hc rectal cream Tier 1
proctozone-hc rectal cream
Tier 1
promethazine rectal suppository
Tier 1
promethegan rectal suppository
Tier 1
ranitidine hcl oral capsule Tier 1
ranitidine hcl oral syrup Tier 1
ranitidine hcl oral tablet Tier 1
Drug Name Tier Notes
REMICADE INTRAVENOUS RECON SOLN
Tier 4 PA
sucralfate oral tablet Tier 1
sulfasalazine oral tablet Tier 1
sulfasalazine oral tablet,delayed release (dr/ec)
Tier 1
sulfazine ec oral tablet,delayed release (dr/ec)
Tier 1
sulfazine oral tablet Tier 1
TRANSDERM-SCOP TRANSDERMAL PATCH 3 DAY
Tier 3
trilyte with flavor packets oral recon soln
Tier 1
trimethobenzamide oral capsule
Tier 1
ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC)
Tier 2
HORMONES
ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP
Tier 3 PA; QL
ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM), 1.62 % (40.5 MG/2.5 GRAM)
Tier 3 PA; QL
androxy oral tablet Tier 1
budesonide oral capsule,delayed,extend.release
Tier 2
cabergoline oral tablet Tier 1
calcitonin (salmon) nasal spray,non-aerosol
Tier 2 QL
chorionic gonadotropin, human intramuscular recon soln
Tier 4
covaryx h.s. oral tablet Tier 1
covaryx oral tablet Tier 1
danazol oral capsule Tier 2
desmopressin injection solution
Tier 1
desmopressin nasal aerosol,spray
Tier 1
Revised 4/1/2016
35
Drug Name Tier Notes
desmopressin nasal solution
Tier 1
desmopressin nasal spray,non-aerosol
Tier 1
desmopressin oral tablet Tier 1
dexamethasone intensol oral drops
Tier 1
dexamethasone oral elixir Tier 1
dexamethasone oral solution
Tier 1
dexamethasone oral tablet Tier 1
eemt hs oral tablet Tier 1
eemt oral tablet Tier 1
estradiol oral tablet Tier 1
estradiol transdermal patch semiweekly
Tier 1 QL
estradiol transdermal patch weekly
Tier 1 QL
estradiol-norethindrone acet oral tablet
Tier 1 $0
ESTRING VAGINAL RING
Tier 3
estrogens-methyltestosterone oral tablet
Tier 1
estropipate oral tablet Tier 1
fortical nasal spray,non-aerosol
Tier 2 QL
hydrocortisone oral tablet Tier 1
hydrocortisone rectal enema
Tier 1
jinteli oral tablet Tier 1
medroxyprogesterone oral tablet
Tier 1
METHITEST ORAL TABLET
Tier 3
methylergonovine oral tablet
Tier 1
methylprednisolone oral tablet
Tier 1
methylprednisolone oral tablets,dose pack
Tier 1
millipred dp oral tablets,dose pack
Tier 1
millipred oral tablet Tier 1
mimvey oral tablet Tier 1
Drug Name Tier Notes
norethindrone acetate oral tablet
Tier 1
OMNITROPE SUBCUTANEOUS CARTRIDGE
Tier 4 PA
OMNITROPE SUBCUTANEOUS RECON SOLN
Tier 4 PA
oxandrolone oral tablet Tier 2 PA
prednisolone oral solution Tier 1
prednisolone sodium phosphate oral solution
Tier 1
prednisone intensol oral concentrate
Tier 1
prednisone oral solution Tier 1
prednisone oral tablet Tier 1
prednisone oral tablets,dose pack
Tier 1
PREMARIN ORAL TABLET
Tier 3
PREMARIN VAGINAL CREAM
Tier 3
PREMPHASE ORAL TABLET
Tier 3
PREMPRO ORAL TABLET
Tier 3
progesterone micronized oral capsule
Tier 1
testosterone cypionate intramuscular oil
Tier 1
testosterone transdermal gel in metered-dose pump
Tier 2 PA; QL
testosterone transdermal gel in packet 1 % (25 mg/2.5gram), 1 % (50 mg/5 gram)
Tier 2 PA; QL
VAGIFEM VAGINAL TABLET
Tier 3
veripred 20 oral solution Tier 1
IMMUNOSUPPRESANT
azathioprine oral tablet Tier 4
cyclosporine modified oral capsule
Tier 2
cyclosporine modified oral solution
Tier 2
cyclosporine oral capsule Tier 2
Revised 4/1/2016
36
Drug Name Tier Notes
ELIDEL TOPICAL CREAM
Tier 3 PA
gengraf oral capsule Tier 4
gengraf oral solution Tier 4
mycophenolate mofetil oral capsule
Tier 4
mycophenolate mofetil oral tablet
Tier 4
mycophenolate sodium oral tablet,delayed release (dr/ec)
Tier 4
RAPAMUNE ORAL SOLUTION
Tier 4
sirolimus oral tablet Tier 4
tacrolimus topical ointment Tier 1 PA
MISCELLANEOUS MEDICAL SUPPLIES, DEVICES, NON-DRUG
ACCU-CHEK AVIVA CONNECT METER
Tier 2
ACCU-CHEK AVIVA CONTROL SOLN SOLUTION
Tier 2
ACCU-CHEK AVIVA PLUS METER
Tier 2
ACCU-CHEK COMP BLUE CONT, M-H SOLUTION
Tier 2
ACCU-CHEK COMPACT PLUS CARE KIT
Tier 2
ACCU-CHEK COMPACT PLUS CONTROL SOLUTION
Tier 2
ACCU-CHEK FASTCLIX Tier 2
ACCU-CHEK FASTCLIX KIT
Tier 2
ACCU-CHEK MULTICLIX LANCET
Tier 2
ACCU-CHEK MULTICLIX LANCET KIT
Tier 2
ACCU-CHEK NANO Tier 2
ACCU-CHEK SAFE-T-PRO PLUS
Tier 2
ACCU-CHEK SMARTVIEW CONTRL SOL SOLUTION
Tier 2
ACCU-CHEK SOFT DEV LANCETS KIT
Tier 2
Drug Name Tier Notes
ACCU-CHEK SOFTCLIX LANCET DEV
Tier 2
ACCU-CHEK SOFTCLIX LANCETS
Tier 2
ACCU-CHEK VOICEMATE KIT
Tier 2
acti-lance lancets Tier 1
e-z ject lancets Tier 1
ONETOUCH DELICA LANC DEVICE KIT
Tier 2
ONETOUCH DELICA LANCETS
Tier 2
ONETOUCH SURESOFT LANCING DEV
Tier 2
ONETOUCH ULTRA CONTROL SOLUTION
Tier 2
ONETOUCH ULTRA2 KIT Tier 2
ONETOUCH ULTRAMINI KIT
Tier 2
ONETOUCH ULTRASOFT LANCETS
Tier 2
ONETOUCH VERIO HIGH CONTROL SOLUTION
Tier 2
ONETOUCH VERIO IQ METER
Tier 2
ONETOUCH VERIO SYNC KIT
Tier 2
ONETOUCH VERIO SYSTEM
Tier 2
MUSCLE RELAXANTS
baclofen oral tablet Tier 1
chlorzoxazone oral tablet Tier 1
cyclobenzaprine oral tablet Tier 1
dantrolene oral capsule Tier 2
tizanidine oral capsule Tier 1
tizanidine oral tablet Tier 1
PRE-NATAL VITAMINS
bal-care dha oral combo pack,tablet and cap,dr
Tier 1
c-nate dha oral capsule Tier 1
complete natal dha oral combo pack
Tier 1
completenate oral tablet,chewable
Tier 1
elite-ob 400 oral capsule Tier 1
elite-ob oral capsule Tier 1
Revised 4/1/2016
37
Drug Name Tier Notes
folbecal oral tablet, er multiphase 24 hr
Tier 1
folivane-ob oral capsule Tier 1
hemenatal ob + dha oral combo pack
Tier 1
hemenatal ob oral tablet Tier 1
inatal advance oral tablet Tier 1
inatal ultra oral tablet Tier 1
levomefolate dha oral capsule
Tier 1
macnatal cn dha oral capsule
Tier 1
mynatal advance oral tablet
Tier 1
mynatal oral capsule Tier 1
mynatal oral tablet Tier 1
mynatal plus oral tablet Tier 1
mynatal-z oral tablet Tier 1
mynate 90 plus oral tablet extended release
Tier 1
obstetrix dha oral combo pack,tablet and cap,dr
Tier 1
pnv ob+dha oral combo pack
Tier 1
pnv-dha + docusate oral capsule
Tier 1
pnv-dha oral capsule Tier 1
pnv-ferrous fumarate-docu-fa oral tablet
Tier 1
pnv-omega oral capsule Tier 1
pnv-select oral tablet Tier 1
pr natal 400 ec oral combo pack,tablet and cap,dr
Tier 1
pr natal 400 oral combo pack
Tier 1
pr natal 430 ec oral combo pack,tablet and cap,dr
Tier 1
pr natal 430 oral combo pack
Tier 1
prenaissance next oral tablet
Tier 1
prenaissance oral capsule Tier 1
prenaissance plus oral capsule
Tier 1
prenatabs fa oral tablet Tier 1
Drug Name Tier Notes
prenatabs rx oral tablet Tier 1
PRENATAL 19 (WITH DOCUSATE) ORAL TABLET
Tier 1
PRENATAL 19 ORAL TABLET,CHEWABLE
Tier 1
prenatal low iron oral tablet
Tier 1
prenatal plus (calcium carb) oral tablet
Tier 1
prenatal plus oral tablet Tier 1
prenatal-u oral capsule Tier 1
preplus oral tablet Tier 1
relnate dha oral capsule Tier 1
se-natal 19 (with docusate) oral tablet
Tier 1
se-natal 19 oral tablet,chewable
Tier 1
se-tan dha oral capsule Tier 1
taron-c dha oral capsule Tier 1
taron-prex prenatal-dha oral capsule
Tier 1
tl-select oral capsule Tier 1
triadvance oral tablet Tier 1
trinatal gt oral tablet Tier 1
trinatal rx 1 oral tablet Tier 1
trinate oral tablet Tier 1
tri-tabs dha oral combo pack
Tier 1
triveen-duo dha oral combo pack
Tier 1
triveen-one oral capsule Tier 1
triveen-prx rnf oral capsule Tier 1
trust natal dha oral combo pack
Tier 1
ultimatecare one nf oral capsule
Tier 1
ultimatecare one oral capsule
Tier 1
vemavite-prx-2 oral capsule
Tier 1
vena-bal dha oral combo pack,tablet and cap,dr
Tier 1
vinacal oral tablet Tier 1
vinate care oral tablet,chewable
Tier 1
Revised 4/1/2016
38
Drug Name Tier Notes
vinate dha oral capsule Tier 1
vinate gt oral tablet Tier 1
vinate ii oral tablet Tier 1
vinate m oral tablet Tier 1
vinate one oral tablet Tier 1
vinate pn care oral tablet Tier 1
vinate ultra oral tablet Tier 1
virt-pn dha oral capsule Tier 1
virt-pn oral tablet Tier 1
virt-pn plus oral capsule Tier 1
virt-select oral capsule Tier 1
vitafol-ob oral tablet Tier 1
vol-nate oral tablet Tier 1
vol-plus oral tablet Tier 1
vol-tab rx oral tablet Tier 1
vp-ch plus oral capsule Tier 1
vp-ch-pnv oral capsule Tier 1
vp-ggr-b6 oral tablet Tier 1
vp-heme ob + dha oral combo pack
Tier 1
vp-heme ob oral tablet Tier 1
vp-heme one oral capsule Tier 1
zatean-ch oral capsule Tier 1
zatean-pn dha oral capsule
Tier 1
zatean-pn plus oral capsule
Tier 1
zingiber oral tablet Tier 1
PSYCHOTHERAPEUTIC DRUGS
alprazolam oral tablet Tier 1
amitriptyline oral tablet Tier 1
amoxapine oral tablet Tier 1
aripiprazole oral solution Tier 2
aripiprazole oral tablet Tier 2
bupropion hcl oral tablet 100 mg
Tier 1 QL
bupropion hcl oral tablet 75 mg
Tier 1
bupropion hcl oral tablet extended release 100 mg
Tier 1 DO
bupropion hcl oral tablet extended release 150 mg
Tier 1 $0; QL
Drug Name Tier Notes
bupropion hcl oral tablet extended release 200 mg
Tier 1 QL
bupropion hcl oral tablet extended release 24 hr 150 mg
Tier 1 DO
bupropion hcl oral tablet extended release 24 hr 300 mg
Tier 1 QL
buspirone oral tablet Tier 1
chlorpromazine oral tablet Tier 1
citalopram oral solution Tier 1 QL
citalopram oral tablet 10 mg, 20 mg
Tier 1 DO
citalopram oral tablet 40 mg
Tier 1 QL
clomipramine oral capsule Tier 1
clozapine oral tablet Tier 2
clozapine oral tablet,disintegrating
Tier 2
desipramine oral tablet Tier 2
dexmethylphenidate oral capsule,er biphasic 50-50
Tier 1 PA
dexmethylphenidate oral tablet
Tier 1 PA
diazepam intensol oral concentrate
Tier 1
diazepam oral concentrate Tier 1
diazepam oral solution Tier 1
diazepam oral tablet Tier 1
doxepin oral capsule Tier 1
doxepin oral concentrate Tier 1
escitalopram oxalate oral solution
Tier 1 QL
escitalopram oxalate oral tablet 10 mg, 5 mg
Tier 1 DO
escitalopram oxalate oral tablet 20 mg
Tier 1 QL
fluoxetine oral capsule 10 mg, 20 mg
Tier 1 DO
fluoxetine oral capsule 40 mg
Tier 1 QL
fluoxetine oral capsule,delayed release(dr/ec)
Tier 1 QL
fluoxetine oral solution Tier 1 QL
fluoxetine oral tablet Tier 1 DO
Revised 4/1/2016
39
Drug Name Tier Notes
fluphenazine hcl oral concentrate
Tier 1
fluphenazine hcl oral elixir Tier 1
fluphenazine hcl oral tablet Tier 1
FOCALIN XR ORAL CAPSULE,ER BIPHASIC 50-50
Tier 3 PA
haloperidol oral tablet Tier 1
imipramine hcl oral tablet Tier 1
lithium carbonate oral capsule
Tier 1
lithium carbonate oral tablet
Tier 1
lithium carbonate oral tablet extended release
Tier 1
lithium citrate oral solution Tier 1
loxapine succinate oral capsule
Tier 1
maprotiline oral tablet Tier 1
metadate er oral tablet extended release
Tier 1 PA
methylphenidate oral capsule, er biphasic 30-70
Tier 1 PA
methylphenidate oral capsule,er biphasic 50-50
Tier 1 PA
methylphenidate oral solution
Tier 1 PA
methylphenidate oral tablet
Tier 1 PA
methylphenidate oral tablet extended release
Tier 1 PA
methylphenidate oral tablet extended release 24hr
Tier 1 PA
mirtazapine oral tablet Tier 1
mirtazapine oral tablet,disintegrating
Tier 1
nefazodone oral tablet Tier 1
nortriptyline oral capsule Tier 1
nortriptyline oral solution Tier 1
olanzapine oral tablet Tier 2
olanzapine oral tablet,disintegrating
Tier 2
paliperidone oral tablet extended release 24hr
Tier 2
Drug Name Tier Notes
paroxetine hcl oral tablet 10 mg, 20 mg
Tier 1 DO
paroxetine hcl oral tablet 30 mg, 40 mg
Tier 1 QL
paroxetine hcl oral tablet extended release 24 hr 12.5 mg
Tier 1 DO
paroxetine hcl oral tablet extended release 24 hr 25 mg, 37.5 mg
Tier 1 QL
perphenazine oral tablet Tier 1
phenelzine oral tablet Tier 1
pimozide oral tablet Tier 2
protriptyline oral tablet Tier 1
quetiapine oral tablet Tier 1
risperidone oral solution Tier 1
risperidone oral tablet Tier 1
risperidone oral tablet,disintegrating
Tier 1
sertraline oral concentrate Tier 1 QL
sertraline oral tablet 100 mg
Tier 1 QL
sertraline oral tablet 25 mg, 50 mg
Tier 1 DO
STRATTERA ORAL CAPSULE
Tier 3 PA
thioridazine oral tablet Tier 1
thiothixene oral capsule Tier 1
tranylcypromine oral tablet Tier 1
trazodone oral tablet Tier 1
trifluoperazine oral tablet Tier 1
venlafaxine oral capsule,extended release 24hr 150 mg
Tier 1 QL
venlafaxine oral capsule,extended release 24hr 37.5 mg, 75 mg
Tier 1 DO
venlafaxine oral tablet Tier 1 QL
venlafaxine oral tablet extended release 24hr 150 mg, 225 mg
Tier 1 QL
venlafaxine oral tablet extended release 24hr 37.5 mg, 75 mg
Tier 1 DO
VYVANSE ORAL CAPSULE
Tier 3 PA
Revised 4/1/2016
40
Drug Name Tier Notes
ziprasidone hcl oral capsule
Tier 1
SEDATIVE/HYPNOTICS
phenobarbital oral elixir Tier 1
phenobarbital oral tablet Tier 1
SILENOR ORAL TABLET Tier 3 QL
zaleplon oral capsule Tier 1 QL
SKIN PREPS
acitretin oral capsule Tier 2
ACZONE TOPICAL GEL Tier 3
adapalene topical cream Tier 1
adapalene topical gel Tier 1
alclometasone topical cream
Tier 1
alclometasone topical ointment
Tier 1
ALTABAX TOPICAL OINTMENT
Tier 3
amcinonide topical cream Tier 1
amcinonide topical lotion Tier 1
amcinonide topical ointment
Tier 1
ammonium lactate topical cream
Tier 1
ammonium lactate topical lotion
Tier 1
amnesteem oral capsule Tier 1 PA
avita topical cream Tier 1 PA
benzoyl peroxide topical cleanser
Tier 1
benzoyl peroxide topical foam
Tier 1
betamethasone dipropionate topical cream
Tier 1
betamethasone dipropionate topical lotion
Tier 1
betamethasone dipropionate topical ointment
Tier 1
betamethasone valerate topical cream
Tier 1
betamethasone valerate topical foam
Tier 1
betamethasone valerate topical lotion
Tier 1
Drug Name Tier Notes
betamethasone valerate topical ointment
Tier 1
betamethasone, augmented topical cream
Tier 1
betamethasone, augmented topical gel
Tier 1
betamethasone, augmented topical lotion
Tier 1
betamethasone, augmented topical ointment
Tier 1
bpo topical gel Tier 1
bpo topical towelette Tier 1
calcipotriene scalp solution
Tier 1
calcipotriene topical cream Tier 1
calcipotriene topical ointment
Tier 1
calcitrene topical ointment Tier 1
claravis oral capsule Tier 1 PA
clindamycin-benzoyl peroxide topical gel
Tier 1
clobetasol scalp solution Tier 1
clobetasol topical cream Tier 1
clobetasol topical foam Tier 1
clobetasol topical gel Tier 1
clobetasol topical lotion Tier 1
clobetasol topical ointment Tier 1
clobetasol topical shampoo
Tier 1
clobetasol-emollient topical cream
Tier 1
cormax scalp solution Tier 1
dermazene topical cream Tier 1
desonide topical cream Tier 1
desonide topical lotion Tier 1
desonide topical ointment Tier 1
desoximetasone topical cream
Tier 1
desoximetasone topical gel
Tier 1
desoximetasone topical ointment
Tier 1
diflorasone topical cream Tier 1
Revised 4/1/2016
41
Drug Name Tier Notes
diflorasone topical ointment
Tier 1
EPIDUO TOPICAL GEL Tier 3
EPIDUO TOPICAL GEL WITH PUMP
Tier 3
FINACEA TOPICAL GEL Tier 3
fluocinolone and shower cap scalp oil
Tier 1
fluocinolone topical cream Tier 1
fluocinolone topical oil Tier 1
fluocinolone topical ointment
Tier 1
fluocinolone topical solution
Tier 1
fluocinonide topical cream Tier 1
fluocinonide topical gel Tier 1
fluocinonide topical ointment
Tier 1
fluocinonide topical solution
Tier 1
fluocinonide-e topical cream
Tier 1
fluticasone topical cream Tier 1
fluticasone topical lotion Tier 1
fluticasone topical ointment
Tier 1
halobetasol propionate topical cream
Tier 1
halobetasol propionate topical ointment
Tier 1
hydrocortisone butyrate topical cream
Tier 1
hydrocortisone butyrate topical ointment
Tier 1
hydrocortisone butyrate topical solution
Tier 1
hydrocortisone topical cream
Tier 1
hydrocortisone topical lotion
Tier 1
hydrocortisone topical ointment
Tier 1
hydrocortisone valerate topical cream
Tier 1
hydrocortisone valerate topical ointment
Tier 1
Drug Name Tier Notes
hydrocortisone-pramoxine topical cream
Tier 1
imiquimod topical cream in packet
Tier 1 PA; QL
iodoquinol-hc topical cream
Tier 1
lidocaine hcl-hydrocortison ac topical cream
Tier 1
lindane topical lotion Tier 1
lindane topical shampoo Tier 1
malathion topical lotion Tier 1
methoxsalen rapid oral capsule
Tier 2 PA
metronidazole topical cream
Tier 1
metronidazole topical lotion
Tier 1
mometasone topical cream
Tier 1
mometasone topical ointment
Tier 1
mometasone topical solution
Tier 1
OVACE PLUS TOPICAL CLEANSER,EXTENDED RELEASE
Tier 3
OVACE PLUS TOPICAL CREAM
Tier 3
OVACE PLUS WASH TOPICAL CLEANSER,GEL EXTENDED RELEASE
Tier 3
OXSORALEN TOPICAL LOTION
Tier 3
permethrin topical cream Tier 1
podofilox topical solution Tier 1
prednicarbate topical cream
Tier 1
prednicarbate topical ointment
Tier 1
prudoxin topical cream Tier 2
rosadan topical cream Tier 1
ROSADAN TOPICAL KIT, CLEANSER AND GEL
Tier 3
ROSADAN TOPICAL KIT,CLEANSER AND CREAM
Tier 3
Revised 4/1/2016
42
Drug Name Tier Notes
salacyn topical cream Tier 1
salacyn topical lotion Tier 1
salicylic acid er-ceramides topical combo pack
Tier 1
salicylic acid er-ceramides topical kit,cleanser and cream er
Tier 1
salicylic acid topical cream Tier 1
salicylic acid topical cream,extended release
Tier 1
salicylic acid topical film forming liquid w/appl
Tier 1
salicylic acid topical foam Tier 1
salicylic acid topical gel Tier 1
salicylic acid topical liquid Tier 1
salicylic acid topical lotion Tier 1
salicylic acid topical lotion,extended release
Tier 1
salicylic acid topical shampoo
Tier 1
salvax topical foam Tier 1
seb-prev topical cleanser Tier 1
selenium sulfide topical shampoo
Tier 1
spinosad topical suspension
Tier 1
sulfacetamide sodium (acne) topical suspension
Tier 1
sulfacetamide sodium topical cleanser
Tier 1
sulfacetamide sodium topical shampoo
Tier 1
tretinoin (emollient) topical cream
Tier 1
tretinoin topical cream Tier 1 PA
tretinoin topical gel Tier 1 PA
triamcinolone acetonide topical cream
Tier 1
triamcinolone acetonide topical lotion
Tier 1
triamcinolone acetonide topical ointment
Tier 1
trianex topical ointment Tier 1
triderm topical cream Tier 1
VOLTAREN TOPICAL GEL
Tier 3
Drug Name Tier Notes
zenatane oral capsule Tier 1 PA
SMOKING DETERRENTS
buproban oral tablet extended release
Tier 1 $0; QL
CHANTIX CONTINUING MONTH BOX ORAL TABLET
Tier 3 $0; QL
CHANTIX CONTINUING MONTH PAK ORAL TABLET
Tier 3 $0; QL
CHANTIX ORAL TABLET Tier 3 $0; QL
CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK
Tier 3 $0; QL
CHANTIX STARTING MONTH PAK ORAL TABLETS,DOSE PACK
Tier 3 $0; QL
THYROID PREPS
levothyroxine oral tablet Tier 1
levoxyl oral tablet Tier 1
liothyronine oral tablet Tier 1
methimazole oral tablet Tier 1
nature-throid oral tablet Tier 1
np thyroid oral tablet Tier 1
propylthiouracil oral tablet Tier 1
unithroid oral tablet Tier 1
westhroid oral tablet Tier 1
UNCLASSIFIED DRUG PRODUCTS
acamprosate oral tablet,delayed release (dr/ec)
Tier 2
alendronate oral solution Tier 1 QL
alendronate oral tablet 10 mg, 35 mg, 40 mg, 5 mg, 70 mg
Tier 1 QL
alfuzosin oral tablet extended release 24 hr
Tier 1
amifostine crystalline intravenous recon soln
Tier 4 PA
buprenorphine hcl sublingual tablet 2 mg, 8 mg
Tier 1 PA; QL
CARBAGLU ORAL TABLET, DISPERSIBLE
Tier 4 PA
CHEMET ORAL CAPSULE
Tier 3
Revised 4/1/2016
43
Drug Name Tier Notes
chlorhexidine gluconate mucous membrane mouthwash
Tier 1
CIALIS ORAL TABLET10 MG, 2.5 MG, 20 MG, 5 MG
Tier 3 PA; QL
CYSTADANE ORAL POWDER
Tier 3
disulfiram oral tablet Tier 1
doxycycline hyclate oral tablet
Tier 1
FABRAZYME INTRAVENOUS RECON SOLN
Tier 4 PA
finasteride oral tablet Tier 1 PA
FORTEO SUBCUTANEOUS PEN INJECTOR
Tier 4 PA; QL
FOSAMAX PLUS D ORAL TABLET
Tier 3 ST; QL
ibandronate oral tablet Tier 1 QL
KALYDECO ORAL TABLET
Tier 4 PA; QL
KUVAN ORAL TABLET,SOLUBLE
Tier 4 PA
leucovorin calcium oral tablet
Tier 2
levocarnitine (with sugar) oral solution
Tier 2
levocarnitine oral tablet Tier 2
MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR
Tier 3 ST
NAGLAZYME INTRAVENOUS SOLUTION
Tier 4 PA
NYSTATIN (BULK) POWDER
Tier 1
oralone dental paste Tier 1
ORFADIN ORAL CAPSULE
Tier 4
oxybutynin chloride oral syrup
Tier 1
oxybutynin chloride oral tablet
Tier 1
oxybutynin chloride oral tablet extended release 24hr
Tier 1
Drug Name Tier Notes
paroex oral rinse mucous membrane mouthwash
Tier 1
periogard mucous membrane mouthwash
Tier 1
PROLIA SUBCUTANEOUS SYRINGE
Tier 3 PA; QL
PULMOZYME INHALATION SOLUTION
Tier 4 PA
raloxifene oral tablet Tier 1 $0
risedronate oral tablet 150 mg, 30 mg, 35 mg, 5 mg
Tier 1 QL
risedronate oral tablet,delayed release (dr/ec)
Tier 1 QL
SAVELLA ORAL TABLET
Tier 3 QL
SAVELLA ORAL TABLETS,DOSE PACK
Tier 3 QL
SENSIPAR ORAL TABLET
Tier 3
sodium chlor 0.9% bacteriostat injection solution
Tier 2
SYPRINE ORAL CAPSULE
Tier 3
triamcinolone acetonide dental paste
Tier 1
TYSABRI INTRAVENOUS SOLUTION
Tier 4 PA
XIAFLEX INJECTION RECON SOLN
Tier 4 PA
zoledronic acid intravenous recon soln
Tier 4
zoledronic acid-mannitol-water intravenous solution
Tier 4 PA
VITAMINS
cyanocobalamin (vitamin b-12) injection solution
Tier 1
ergocalciferol (vitamin d2) oral capsule
Tier 1
folic acid oral tablet Tier 1
vitamin d2 oral capsule Tier 1
Revised 4/1/2016
44
Revised 4/1/2016
45
40627CAMENABC
For more information, please visit anthem.com/ca.
If you have additional questions about your prescription benefits,
please call the Member Services number on your ID card.
Speech and hearing impaired (TDD/TTY users) should call
800-221-6915, Monday – Friday, 8:30 a.m. – 5 p.m., ET.
For the most current version of this Selected Drug List,
please visit anthem.com/ca.
Subject to Regulatory Approval
Anthem Blue Cross is the trade name of Blue Cross of California. Independent licensee of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association.