formulario completo para 2020 - elderplan

2020

Formulario Completo para 2020 (Lista de medicamentos cubiertos)

Elderplan For Medicaid Beneficiaries (HMO D-SNP) Elderplan Advantage For Nursing Home Residents (HMO I-SNP)

Elderplan Plus Long Term Care (HMO D-SNP)

Lea lo siguiente: Este documento contiene información acerca de los medicamentos que cubrimos en este plan.

No hemos realizado cambios en el formulario completo desde 08/27/2019. Para obtener la información más reciente o si tiene otras preguntas, póngase en contacto con el Departamento de Servicios para los miembros de Elderplan al 1-800-353-3765 (los usuarios de TTY/TDD deben llamar al 711) de 8:00 a.m. a 8:00 p.m., los 7 días de la semana, o visítenos en www.elderplan.org.

HPMS Approved Formulary File Submission ID 00020357, Version Number 5

H3347_EPS16686_C

http://www.elderplan.org

Elderplan For Medicaid Beneficiaries (HMO D-SNP)

Elderplan Advantage For Nursing Home Residents (HMO I-SNP)

Elderplan Plus Long Term Care (HMO D-SNP)

Formulario para 2020 (Lista de medicamentos cubiertos)

LEA LO SIGUIENTE: ESTE DOCUMENTO CONTIENE INFORMACIÓN

ACERCA DE LOS MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN

HPMS Approved Formulary File Submission ID 00020357, Version Number 5

No hemos realizado cambios en este formulario desde 08/27/2019. Para obtener información más reciente o si tiene otras preguntas, comuníquese con Servicios para los Miembros de Elderplan al 1-800-353-3765 (los usuarios de TTY deben llamar al 711) de 8:00 a.m. a 8:00 p.m., los 7 días de la semana, o visite www.elderplan.org.

Nota para los miembros actuales: este formulario ha cambiado con respecto al año pasado. Revise este documento para asegurarse de que aún contiene los medicamentos que toma.

Cuando esta lista de medicamentos (formulario) menciona “nosotros”, “nos” o “nuestro”, hace referencia a Elderplan. Cuando menciona “el plan” o “nuestro plan” hace referencia a Elderplan For Medicaid Beneficiaries, Elderplan Advantage For Nursing Home Residents y Elderplan Plus Long Term Care.

Este documento incluye una lista de los medicamentos (formulario) de nuestro plan, la cual estará en vigencia a partir del 08/27/2019. Para obtener un formulario actualizado, comuníquese con nosotros. Nuestra información de contacto, junto con la fecha de la última actualización del formulario, aparece en las páginas de la portada y la contratapa.

Generalmente, debe ir a las farmacias de la red para usar el beneficio de medicamentos con receta. Los beneficios, el formulario, la red de farmacias o los copagos/coseguros pueden cambiar el 1 de enero de 2020 y periódicamente durante el año.

H3347_EPS16686_C


Formulario para 2020

¿Qué es el Formulario de Elderplan For Medicaid Beneficiaries, Elderplan Advantage For Nursing Home Residents y Elderplan Plus Long Term Care? Un formulario es una lista de medicamentos cubiertos seleccionados por nuestro plan con la colaboración de un equipo de proveedores de atención médica, que representa los tratamientos con receta considerados parte necesaria de un programa de tratamiento de calidad. Normalmente, nuestro plan cubrirá los medicamentos incluidos en el formulario siempre que el medicamento sea médicamente necesario, la receta se obtenga en una farmacia de la red del plan y se cumplan otras normas del plan. Para obtener más información sobre cómo obtener sus medicamentos con receta, consulte la Evidencia de cobertura.

¿Puede cambiar el Formulario (lista de medicamentos)? La mayoría de los cambios en la cobertura de medicamentos ocurren el 1 de enero, pero durante el año, podemos agregar o quitar medicamentos de la Lista de medicamentos, moverlos a niveles de costo compartido diferentes o agregar nuevas restricciones. Debemos seguir las reglas de Medicare al hacer estos cambios.

Cambios que pueden afectarlo este año: en los siguientes casos, usted se verá afectado por cambios de cobertura durante el año:

• Medicamentos genéricos nuevos. Podemos eliminar de inmediato un medicamento de marca de la Lista de medicamentos si lo vamos a reemplazar con un medicamento genérico nuevo que aparecerá en el mismo nivel de costo compartido o en uno inferior, y con las mismas restricciones o menos. Además, cuando agreguemos un medicamento genérico nuevo, podemos decidir conservar el medicamento de marca en la Lista de medicamentos,

pero pasarlo de inmediato a un nivel de costo compartido diferente o agregar restricciones nuevas. Si actualmente toma un medicamento de marca, podríamos no informarle antes de realizar el cambio, pero posteriormente le proporcionaremos información sobre los cambios específicos que realizamos.

—S i introducimos un cambio, usted o la persona autorizada a dar recetas pueden solicitarnos que hagamos una excepción y sigamos cubriendo el medicamento de marca. El aviso que le enviemos también incluirá información sobre cómo solicitar una excepción; puede encontrar información en la siguiente sección titulada “¿Cómo solicito una excepción al Formulario de Elderplan For Medicaid Beneficiaries, Elderplan Advantage For Nursing Home Residents y Elderplan Plus Long Term Care?”.

• Medicamentos retirados del mercado. Si la Administración de Alimentos y Medicamentos (Food and Drug Administration, FDA) considera que un medicamento de nuestro formulario es inseguro o si el fabricante del medicamento lo retira del mercado, eliminaremos de inmediato dicho medicamento de nuestro formulario y notificaremos a los miembros que toman el medicamento en cuestión.

• Otros cambios. Podríamos introducir otros cambios que afecten a los miembros que actualmente toman un medicamento. Por ejemplo, podemos agregar un medicamento genérico que no sea nuevo en el mercado para reemplazar un medicamento de marca que actualmente esté en el formulario, agregar nuevas restricciones al medicamento de marca o pasarlo a un nivel de costo compartido diferente. O bien, podríamos introducir cambios a partir de pautas clínicas nuevas. Si retiramos medicamentos de nuestro formulario, o agregamos autorizaciones previas, límites de cantidad o restricciones de tratamiento escalonado en relación con un

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medicamento, debemos notificar sobre el cambio a los miembros afectados al menos 30 días antes de que entre en vigencia dicho cambio, o cuando el miembro solicite un resurtido del medicamento, momento en el cual el miembro recibirá un suministro del medicamento para 30 días.

—Si introducimos estos otros cambios, usted o la persona autorizada a dar recetas pueden solicitarnos que hagamos una excepción y sigamos cubriendo el medicamento de marca para usted. El aviso que le enviemos también incluirá información sobre cómo solicitar una excepción; puede encontrar información en la siguiente sección titulada “¿Cómo solicito una excepción al Formulario de Elderplan For Medicaid Beneficiaries, Elderplan Advantage For Nursing Home Residents y Elderplan Plus Long Term Care?”.

Cambios que no lo afectarán si toma actualmente el medicamento. Por lo general, si usted toma un medicamento de nuestro Formulario para 2019 que estaba cubierto al comienzo del año, no suspenderemos ni reduciremos la cobertura del medicamento durante el año de cobertura 2020, excepto por lo descrito anteriormente. Esto significa que estos medicamentos seguirán estando disponibles durante el resto del año de cobertura por el mismo costo compartido y sin restricciones nuevas para aquellos miembros que los tomen.

El formulario adjunto está vigente a partir del 08/27/2019. Para recibir información actualizada sobre los medicamentos cubiertos por nuestro plan, comuníquese con nosotros. Nuestra información de contacto aparece en las páginas de la portada y la contratapa.

En caso de que el plan realice a mitad de año un cambio en el formulario no relacionado con el mantenimiento, le avisaremos sobre el cambio por correo electrónico para que pueda actualizar el formulario impreso que tiene en la actualidad. El correo incluirá información específica sobre el cambio en el formulario no relacionado con el mantenimiento y se lo enviaremos a más tardar 60 días antes de la fecha de entrada en vigencia del cambio.

¿Cómo utilizo el Formulario? Hay dos formas para encontrar su medicamento dentro del formulario:

Por afección médica

El formulario empieza en la página 7. Los medicamentos de este formulario están agrupados en categorías según el tipo de afección médica para cuyo tratamiento se los emplea. Por ejemplo, los medicamentos utilizados para tratar una afección cardíaca se incluyen en la categoría “Cardiovascular”. Si sabe para qué se utiliza su medicamento, busque el nombre de la categoría en la lista que empieza en la página 7. Luego busque su medicamento debajo del nombre de la categoría.

Por orden alfabético

Si no está seguro de qué categoría consultar, debe buscar su medicamento en el índice que comienza en la página 63. El índice proporciona una lista alfabética de todos los medicamentos incluidos en este documento. Se incluyen tanto los medicamentos de marca como los genéricos. Busque en el índice y encuentre su medicamento. Junto a su medicamento, verá el número de página en la que encontrará información acerca de la cobertura. Vaya a la página que figura en el índice y encuentre el nombre de su medicamento en la primera columna de la lista.

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¿Qué son los medicamentos genéricos? Nuestro plan cubre tanto los medicamentos de marca como los genéricos. Un medicamento genérico está aprobado por la FDA dado que se considera que tiene el mismo ingrediente activo que el medicamento de marca. Normalmente, los medicamentos genéricos cuestan menos que los de marca.

¿Hay alguna restricción en mi cobertura? Algunos medicamentos cubiertos pueden tener requisitos o límites adicionales de cobertura. Estos requisitos y límites pueden incluir:

• Autorización previa: nuestro plan exige que usted o su médico obtengan una autorización previa para determinados medicamentos. Esto significa que necesitará contar con la aprobación de nuestro plan antes de obtener sus medicamentos con receta. Si no consigue la autorización, es posible que nuestro plan no cubra el medicamento.

• Límites de cantidad: para ciertos medicamentos, nuestro plan limita la cantidad del medicamento que cubrirá. Por ejemplo, nuestro plan provee 30 comprimidos por receta de Januvia. Esto puede ser complementario a un suministro estándar para un mes o tres meses.

• T ratamiento escalonado: en algunos casos, nuestro plan requiere que usted primero pruebe ciertos medicamentos para tratar su afección médica antes de que cubramos otro medicamento para esa enfermedad. Por ejemplo, si el medicamento A y el medicamento B tratan su afección médica, es posible que nuestro plan no cubra el medicamento B a menos que usted pruebe primero el medicamento A. Si el medicamento A no funciona para usted, entonces nuestro plan cubrirá el medicamento B.

Para averiguar si su medicamento tiene requisitos o límites adicionales, consulte el formulario que empieza en la página 7. También puede obtener más información sobre las restricciones que se aplican a

medicamentos cubiertos específicos en nuestro sitio web. Hemos publicado documentos en Internet que explican nuestra autorización previa y las restricciones de tratamiento escalonado. También puede pedirnos que le enviemos una copia. Nuestra información de contacto, junto con la fecha de la última actualización del formulario, aparece en las páginas de la portada y la contratapa.

Puede pedirle a nuestro plan que haga una excepción a estas restricciones o límites, o puede solicitarle una lista de otros medicamentos similares que puedan tratar su afección médica. Consulte la sección “¿Cómo solicito una excepción al formulario de Elderplan For Medicaid Beneficiaries, Elderplan Advantage For Nursing Home Residents y Elderplan Plus Long-Term Care?” en la página IV para obtener información acerca de cómo solicitar una excepción.

¿Qué pasa si mi medicamento no está en el Formulario? Si el medicamento que toma no está incluido en este formulario (lista de medicamentos cubiertos), primero debe ponerse en contacto con el Departamento de Servicios para los Miembros y preguntar si su medicamento está cubierto.

Si resulta que nuestro plan no cubre el medicamento que toma, tiene dos alternativas:

• Puede pedir al Departamento de Servicios para los Miembros una lista de medicamentos similares que estén cubiertos por nuestro plan. Cuando reciba la lista, muéstresela a su médico y pídale que le recete un medicamento similar que esté cubierto por nuestro plan.

• Puede solicitarle a nuestro plan que haga una excepción y cubra el medicamento. Consulte más abajo para obtener información sobre cómo solicitar una excepción.

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¿Cómo solicito una excepción al Formulario de Elderplan For Medicaid Beneficiaries, Elderplan Advantage For Nursing Home Residents y Elderplan Plus Long Term Care? Puede solicitarle a nuestro plan que haga una excepción a nuestras normas de cobertura. Hay varios tipos de excepciones que puede solicitarnos.

• Puede pedirnos que cubramos un medicamento, incluso si no está en nuestro formulario. Si se aprueba, este medicamento estará cubierto a un nivel de costo compartido predeterminado, y usted no podrá pedirnos que proporcionemos el medicamento a un nivel de costo compartido menor.

• Puede pedirnos que no apliquemos restricciones o límites de cobertura para su medicamento. Por ejemplo, para ciertos medicamentos, nuestro plan limita la cantidad del medicamento que cubriremos. Si su medicamento tiene un límite de cantidad, puede pedirnos que hagamos una excepción al límite y cubramos una cantidad mayor.

Por lo general, nuestro plan solo aprobará su solicitud de excepción si los medicamentos alternativos incluidos en el formulario del plan o las restricciones de uso adicionales no fueran tan efectivos para tratar su afección o le causaran efectos médicos adversos.

Debe comunicarse con nosotros para solicitarnos una decisión de cobertura inicial para una excepción al formulario o a las restricciones de utilización. Cuando solicita una excepción al formulario o a las restricciones de utilización, usted debe presentar una declaración de su médico o de la persona autorizada a dar recetas que respalde su solicitud. Por lo general, debemos tomar una decisión dentro de las 72 horas a partir de la fecha de haber recibido la declaración que respalda su solicitud por parte de la persona autorizada a dar recetas. Puede solicitar una excepción acelerada (rápida) si usted o su médico

consideran que esperar 72 horas para que se tome una decisión podría perjudicar gravemente su salud. Si se le concede el trámite acelerado de la excepción, debemos comunicarle nuestra decisión a más tardar dentro de las 24 horas después de haber recibido la declaración de respaldo de su médico o de otra persona autorizada a dar recetas.

¿Qué debo hacer antes de hablar con mi médico sobre el cambio de los medicamentos que tomo o la solicitud de una excepción? Como miembro nuevo o permanente de nuestro plan, es posible que esté tomando medicamentos que no están incluidos en nuestro formulario. También es posible que esté tomando un medicamento incluido en el formulario, pero su capacidad de conseguirlo sea limitada. Por ejemplo, puede necesitar nuestra autorización previa antes de poder obtener su medicamento con receta. Debe consultar con su médico para decidir si debe cambiar su medicamento por uno apropiado que nosotros cubramos o solicitar una excepción al formulario para que cubramos el medicamento que toma. Mientras evalúa con su médico el procedimiento adecuado para seguir en su caso, podemos cubrir su medicamento en ciertos casos durante los primeros 90 días en que usted sea miembro de nuestro plan.

Para cada uno de los medicamentos que no está incluido en el formulario, o si su capacidad para conseguir los medicamentos es limitada, cubriremos un suministro temporal para 30 días. Si su receta está indicada para menos días, permitiremos resurtidos hasta llegar a un suministro máximo del medicamento para 30 días. Después del primer suministro para 30 días, no seguiremos pagando estos medicamentos, incluso si ha sido miembro del plan durante menos de 90 días.

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Si reside en un centro de atención a largo plazo y necesita un medicamento que no está en nuestro formulario o si su capacidad para conseguir los medicamentos es limitada, pero ya pasaron los primeros 90 días de membresía en nuestro plan, cubriremos un suministro de emergencia del medicamento para 31 días mientras solicita la excepción al formulario.

Miembro existente de un plan con cambios en el nivel de atención Si ingresa en un centro de atención a largo plazo (Long-Term Care, LTC) y provenía de un entorno (hogar) como paciente externo, un hospital u otro centro de atención a largo plazo, cubriremos un suministro de transición temporal para 31 días (a menos que tenga una receta para menos días) para cada uno de los medicamentos que no estén incluidos en nuestro formulario o que tengan restricciones o límites de cobertura.

Si deja el centro de atención a largo plazo o un hospital y regresa a su hogar como paciente externo, cubriremos un suministro temporal para 30 días (a menos que tenga una receta para menos días) al alta para cada uno de los medicamentos que no estén incluidos en nuestro formulario o que tengan restricciones o límites de cobertura.

Tenga en cuenta que nuestra política de transición se aplica únicamente a aquellos medicamentos que se incluyen como “medicamentos de la Parte D” y que se surten en una farmacia de la red.

Para obtener más información Para obtener información más detallada sobre la cobertura para medicamentos con receta de nuestro plan, consulte la Evidencia de cobertura y otra documentación del plan.

Si tiene alguna pregunta sobre nuestro plan, comuníquese con nosotros. Nuestra información de contacto, junto con la fecha de la última actualización del formulario, aparece en las páginas de la portada y la contratapa.

Si tiene preguntas generales sobre su cobertura para medicamentos con receta de Medicare, llame a Medicare al 1-800-MEDICARE (1-800-633-4227), durante las 24 horas, los 7 días de la semana. Los usuarios de TTY deben llamar al 1-877-486-2048. O bien, visite http://www.medicare.gov.

El Formulario de nuestro plan El formulario que empieza en la siguiente página proporciona información acerca de la cobertura para los medicamentos cubiertos por nuestro plan. Si tiene alguna dificultad para encontrar el medicamento que toma en la lista, consulte el índice que comienza en la página 63.

La primera columna de la tabla menciona el nombre del medicamento. Los medicamentos de marca están en letra mayúscula (p. ej., LANOXIN), y los medicamentos genéricos están en letra minúscula y cursiva (p. ej., digoxin).

La información incluida en la columna Requisitos/ límites indica si nuestro plan tiene algún requisito especial para la cobertura del medicamento.

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http://www.medicare.gov

B/D (autorización previa de B frente a D): es posible que determinados medicamentos estén cubiertos por la Parte B o D de Medicare, según las circunstancias. Para tomar la determinación, se deberá enviar información que incluya la descripción del uso y la situación en que se administra el medicamento.

PA (autorización previa): usted o su médico deben obtener la autorización previa de nuestro plan para determinados medicamentos. Esto significa que necesitará contar con la aprobación de nuestro plan antes de obtener su medicamento con receta. Si no consigue la autorización, es posible que nuestro plan no cubra el medicamento.

QL (límites de cantidad): para ciertos medicamentos, nuestro plan limita la cantidad del medicamento que cubrirá. Por ejemplo, nuestro plan provee 30 comprimidos por receta de Januvia. El límite de cantidad se indica en la cantidad entregada para días de suministro.

LA (medicamentos de acceso limitado): son los medicamentos que pueden obtenerse solo en determinadas farmacias. Para obtener más información, consulte el directorio de farmacias o llame a Servicios para los Miembros al 1-800-353-3765, de 8:00 a.m. a 8:00 p.m., los siete días de la semana (los usuarios de TTY/TDD deben llamar al 711).

ST (tratamiento escalonado): nuestro plan requiere que usted primero pruebe ciertos medicamentos para tratar su afección médica antes de que cubramos otro medicamento para esa afección. Por ejemplo, si el medicamento A y el medicamento B tratan su afección médica, es posible que nuestro plan no cubra el medicamento B a menos que usted pruebe primero el medicamento A. Si el medicamento A no funciona para usted, nuestro plan cubrirá el medicamento B.

NM: estos medicamentos NO se encuentran disponibles a través de pedido por correo.

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Elderplan, Inc.

Notice of Nondiscrimination – Discrimination is Against the Law

Elderplan is an HMO plan with Medicare and Medicaid contracts. Enrollment in Elderplan depends on contract renewal. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. This is not a complete list of drugs covered by our plan. For a complete listing, please call 1-800-353-3765 (TTY/TDD 711) or visit www.elderplan.org.

Elderplan/HomeFirst complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Elderplan, Inc. does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Elderplan/HomeFirst.:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as: —Qualified sign language interpreters —Written information in other formats (large print, audio, accessible electronic formats, other formats)

• Provides free language services to people whose primary language is not English, such as: —Qualified interpreters —Information written in other languages

If you need these services, contact Civil Rights Coordinator. If you believe that Elderplan/HomeFirst has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you may file a grievance with:

Civil Rights Coordinator 6323 7th Ave

Brooklyn, NY, 11220 Phone: 1-877-326-9978, TTY: 711

Fax: 1-718-759-3643

You may file a grievance in person or by mail, phone, or fax. If you need help filing a grievance, Civil Rights Coordinator, is available to help you.

You may also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue, SW, Room 509F, HHH Building

Washington, D.C. 20201 1-800-368-1019, 1-800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

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http://www.hhs.gov/ocr/office/file/index.html

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf


Multi-language Interpreter Services ATTENTION: If you speak a non-English language or require assistance in ASL, language assistance services, free of charge, are available to you. Call 1-800-353-3765 (TTY: 711). (Spanish) ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-353-3765 (TTY: 711).

(Chinese) 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-800-353-3765 (TTY: 711). (Russian) ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-353-3765 (телетайп: 711). (French Creole) ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-800-353-3765 (TTY: 711). (Korean) 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-800-353-3765 (TTY: 711)번으로 전화해 주십시오. (Italian) ATTENZIONE: In caso la lingua parlata sia l’italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-800-353-3765 (TTY: 711).

(Yiddish) ןופ יירפ סעסיוורעס ףליה ךארפש ךייא ראפ ןאהראפ ןענעז ,שידיא טדער ריא ביוא :םאזקרעמפיוא .(TTY: 711) 1-800-353-3765 טפור .לאצפא

(Polish) UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-800-353-3765 (TTY: 711).

(French) ATTENTION : Si vous parlez français, des services d’aide linguistique vous sont proposés gratuitement. Appelez le 1-800-353-3765 (ATS: 711).

(Tagalog) PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-800-353-3765 (TTY: 711). (Greek) ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε 1-800-353-3765 (TTY: 711). (Albanian) KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në 1-800-353-3765 (TTY: 711).

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PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access

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ELDERPLAN_CY20_1T_SNP eff 01/01/2020

Drug Name Drug Tier Requirements/LimitsANALGESICS

GOUTallopurinol tab 1colchicine w/ probenecid 1COLCRYS 1 QL (120 tabs / 30 days) MITIGARE 1 QL (60 caps / 30 days) probenecid 1

NSAIDS celecoxib CAPS 50mg 1 QL (240 caps / 30 days) celecoxib CAPS 100mg 1 QL (120 caps / 30 days) celecoxib CAPS 200mg 1 QL (60 caps / 30 days) celecoxib CAPS 400mg 1 QL (30 caps / 30 days) diclofenac potassium 1 QL (120 tabs / 30 days) diclofenac sodium TB24; TBEC 1 diflunisal TABS 1 etodolac 1 flurbiprofen TABS 1 ibu tab 600mg 1 ibu tab 800mg 1 ibuprofen SUSP 1 ibuprofen TABS 400mg, 600mg, 800mg 1 meloxicam TABS 1 nabumetone TABS 1 naproxen TABS 1 naproxen dr 1 naproxen sodium TABS 275mg, 550mg 1 piroxicam CAPS 1 sulindac TABS 1

OPIOID ANALGESICS acetaminophen w/ codeine 300-15mg 1 QL (400 tabs / 30 days) acetaminophen w/ codeine 300-30mg 1 QL (360 tabs / 30 days) acetaminophen w/ codeine 300-60mg 1 QL (180 tabs / 30 days) acetaminophen w/ codeine soln 1 QL (2700 mL / 30 days) butorphanol tartrate SOLN 1mg/ml, 2mg/ml

1

nalbuphine hcl SOLN 1 tramadol hcl tab 50 mg 1 QL (240 tabs / 30 days) tramadol-acetaminophen 1 QL (240 tabs / 30 days)

OPIOID ANALGESICS, CII endocet 2.5-325mg 1 QL (360 tabs / 30 days) endocet 5-325mg 1 QL (360 tabs / 30 days) endocet 7.5-325mg 1 QL (240 tabs / 30 days) endocet 10-325mg 1 QL (180 tabs / 30 days)


8

Drug Name Drug Tier Requirements/Limits fentanyl citrate LPOP 1 QL (120 lozenges / 30

days), PA fentanyl patch 12 mcg/hr 1 QL (10 patches / 30





days), PA hydroco/apap tab 5-325mg 1 QL (240 tabs / 30 days) hydroco/apap tab 7.5-325 1 QL (180 tabs / 30 days) hydroco/apap tab 10-325mg 1 QL (180 tabs / 30 days) hydrocodone-acetaminophen 7.5-325 mg/15ml

1 QL (2700 mL / 30 days)

hydrocodone-ibuprofen tab 7.5-200 mg 1 QL (150 tabs / 30 days) hydromorphone hcl LIQD 1 QL (600 mL / 30 days) hydromorphone hcl SOLN 10mg/ml, 50mg/5ml, 500mg/50ml

1 B/D

hydromorphone hcl TABS 1 QL (180 tabs / 30 days) HYSINGLA ER 1 QL (30 tabs / 30 days),

PA

lorcet hd tab 10-325mg 1 QL (180 tabs / 30 days) lorcet plus tab 7.5-325 1 QL (180 tabs / 30 days) lorcet tab 5-325mg 1 QL (240 tabs / 30 days) methadone hcl SOLN 5mg/5ml, 10mg/5ml

1 QL (450 mL / 30 days),PA

methadone hcl 5mg 1 QL (90 tabs / 30 days), PA

methadone hcl 10mg 1 QL (90 tabs / 30 days),PA

methadone hcl intensol 1 QL (90 mL / 30 days),PA

morphine ext-rel tab 1 QL (90 tabs / 30 days), PA

morphine sul inj 1mg/ml 1 B/D MORPHINE SUL INJ 4MG/ML 1 B/D morphine sul inj 10mg/ml 1 B/D MORPHINE SULFATE SOLN 2mg/ml, 4mg/ml, 5mg/ml, 8mg/ml, 10mg/ml, 150mg/30ml

1 B/D

morphine sulfate SOLN 4mg/ml, 8mg/ml, 10mg/ml

1 B/D

morphine sulfate TABS 1 QL (180 tabs / 30 days) morphine sulfate oral soln 10mg/5ml 1 QL (900 mL / 30 days)


9

Drug Name Drug Tier Requirements/Limitsmorphine sulfate oral soln 20mg/5ml 1 QL (900 mL / 30 days)morphine sulfate oral soln 100mg/5ml 1 QL (180 mL / 30 days) NUCYNTA ER 1 QL (60 tabs / 30 days),

PA oxycodone hcl CAPS 1 QL (180 caps / 30 days)oxycodone hcl CONC 1 QL (180 mL / 30 days) oxycodone hcl SOLN 1 QL (900 mL / 30 days) oxycodone hcl TABS 1 QL (180 tabs / 30 days)oxycodone w/ acetaminophen 2.5-325mg 1 QL (360 tabs / 30 days)oxycodone w/ acetaminophen 5-325mg 1 QL (360 tabs / 30 days)oxycodone w/ acetaminophen 7.5-325mg 1 QL (240 tabs / 30 days)oxycodone w/ acetaminophen 10-325mg 1 QL (180 tabs / 30 days)

ANESTHETICSLOCAL ANESTHETICS

lidocaine hcl (local anesth.) 1 B/D lidocaine inj 0.5% 1 B/D lidocaine inj 1% 1 B/D lidocaine inj 1.5% preservative free (pf) 1 B/D

ANTI-INFECTIVES ANTI-BACTERIALS - MISCELLANEOUS

amikacin sulfate SOLN 1gentamicin in saline 1gentamicin sulfate SOLN 1neomycin sulfate TABS 1paromomycin sulfate CAPS 1streptomycin sulfate SOLR 1SULFADIAZINE TABS 1tobramycin NEBU 1 NM, PA tobramycin inj 1.2 gm/30ml 1tobramycin inj 1.2gm 1tobramycin inj 10mg/ml 1tobramycin inj 80mg/2ml 1tobramycin sulfate SOLN 1

ANTI-INFECTIVES - MISCELLANEOUS albendazole TABS 1ALINIA 1atovaquone SUSP 1aztreonam 1CAYSTON 1 NM, LA, PA clindamycin cap 75mg 1clindamycin cap 300 mg 1clindamycin hcl cap 150 mg 1clindamycin phosphate in d5w 1CLINDAMYCIN PHOSPHATE IN NACL 1clindamycin phosphate inj 1


10

Drug Name Drug Tier Requirements/Limits clindamycin soln 75mg/5ml 1 colistimethate sodium SOLR 1 dapsone TABS 1 DAPTOMYCIN 350mg 1 daptomycin 500mg 1 EMVERM 1 QL (12 tabs / 365 days) ertapenem sodium 1 imipenem-cilastatin 1 ivermectin TABS 1 linezolid in sodium chloride 1 linezolid inj 1 linezolid susp 1 linezolid tab 600mg 1 meropenem 1 methenamine hippurate 1 metronidazole TABS 1 metronidazole in nacl 1 NEBUPENT 1 B/D nitrofurantoin macrocrystal 50mg, 100mg 1 nitrofurantoin monohyd macro 1 PENTAM 300 1 pentamidine isethionate 1 praziquantel TABS 1 SIVEXTRO 1 sulfamethoxazole-trimethop ds 1 sulfamethoxazole-trimethoprim inj 1 sulfamethoxazole-trimethoprim susp 1 sulfamethoxazole-trimethoprim tab 400-80mg

1

SYNERCID 1 tigecycline 1 trimethoprim TABS 1 vancomycin hcl CAPS 125mg 1 QL (120 caps / 30 days) vancomycin hcl CAPS 250mg 1 QL (240 caps / 30 days) vancomycin hcl SOLR 1gm, 5gm, 10gm, 500mg, 750mg

1

VANCOMYCIN IN NACL 1 ANTIFUNGALS

ABELCET 1 B/D AMBISOME 1 B/D amphotericin b SOLR 1 B/D caspofungin acetate 1 fluconazole SUSR; TABS 1 fluconazole inj nacl 200 1 fluconazole inj nacl 400 1 flucytosine CAPS 1


11

Drug Name Drug Tier Requirements/Limits griseofulvin microsize 1 griseofulvin ultramicrosize 1 itraconazole CAPS 1 PA ketoconazole TABS 1 PA MYCAMINE 1 NOXAFIL SUSP 1 QL (630 mL / 30 days) NOXAFIL TBEC 1 QL (93 tabs / 30 days) nystatin TABS 1 terbinafine hcl TABS 1 QL (90 tabs / year) voriconazole SOLR; SUSR 1 PA voriconazole TABS 1

ANTIMALARIALS atovaquone-proguanil hcl 1 chloroquine phosphate TABS 1 COARTEM 1 mefloquine hcl 1 primaquine phosphate 26.3mg 1 PRIMAQUINE PHOSPHATE 26.3mg 1 quinine sulfate CAPS 1 PA

ANTIRETROVIRAL AGENTS abacavir sulfate 1 NM APTIVUS 1 NM atazanavir sulfate 1 NM CRIXIVAN 1 NM didanosine 1 NM EDURANT 1 NM efavirenz 1 NM EMTRIVA 1 NM fosamprenavir tab 700 mg 1 NM FUZEON 1 NM INTELENCE 1 NM INVIRASE 1 NM ISENTRESS 1 NM ISENTRESS HD 1 NM lamivudine 1 NM LEXIVA SUSP 1 NM nevirapine susp 50 mg/5ml 1 NM nevirapine tab 100mg er 1 NM nevirapine tab 200mg 1 NM nevirapine tab 400mg er 1 NM NORVIR PACK 1 NM NORVIR SOLN 1 NM PIFELTRO 1 NM PREZISTA SUSP 1 QL (400 mL / 30 days),

NM


12

Drug Name Drug Tier Requirements/Limits PREZISTA TABS 75mg 1 QL (480 tabs / 30 days),

NM PREZISTA TABS 150mg 1 QL (240 tabs / 30 days),



NM RESCRIPTOR 1 NM REYATAZ PACK 1 NM ritonavir 1 NM SELZENTRY 1 NM stavudine 1 NM tenofovir disoproxil fumarate 1 NM TIVICAY 1 NM TROGARZO 1 NM, LA TYBOST 1 NM VIDEX EC 125mg 1 NM VIDEX PEDIATRIC 1 NM VIRACEPT 1 NM VIREAD POWD 1 NM VIREAD TABS 150mg, 200mg, 250mg 1 NM zidovudine cap 100mg 1 NM zidovudine syp 50mg/5ml 1 NM zidovudine tab 300mg 1 NM

ANTIRETROVIRAL COMBINATION AGENTS

abacavir sulfate-lamivudine 1 NM abacavir sulfate-lamivudine-zidovudine 1 NM ATRIPLA 1 NM BIKTARVY 1 NM CIMDUO 1 NM COMPLERA 1 NM DELSTRIGO 1 NM DESCOVY 1 NM DOVATO 1 NM EVOTAZ 1 NM GENVOYA 1 NM JULUCA 1 NM KALETRA TAB 100-25MG 1 NM KALETRA TAB 200-50MG 1 NM lamivudine-zidovudine 1 NM lopinavir-ritonavir 1 NM ODEFSEY 1 NM PREZCOBIX 1 NM STRIBILD 1 NM SYMFI 1 NM


13

Drug Name Drug Tier Requirements/Limits SYMFI LO 1 NM SYMTUZA 1 NM TRIUMEQ 1 NM TRUVADA TAB 100-150 1 QL (30 tabs / 30 days),

NM TRUVADA TAB 133-200 1 QL (30 tabs / 30 days),



NM ANTITUBERCULAR AGENTS

cycloserine CAPS 1ethambutol hcl TABS 1isoniazid TABS 1isoniazid syp 50mg/5ml 1PASER D/R 1PRIFTIN 1pyrazinamide TABS 1rifabutin 1rifampin CAPS; SOLR 1RIFATER 1SIRTURO 1 LA, PA TRECATOR 1

ANTIVIRALS acyclovir CAPS; SUSP; TABS 1acyclovir sodium 1 B/D adefovir dipivoxil 1 NM BARACLUDE SOLN 1 NM entecavir 1 NM EPCLUSA 1 NM, PA EPIVIR HBV SOLN 1 NM famciclovir 1ganciclovir sodium 1 B/D HARVONI 1 NM, PA lamivudine (hbv) 1 NM MAVYRET 1 NM, PA oseltamivir phospha te CAPS 30mg 1 QL (168 caps / ye ar) oseltamivir phospha te CAPS 45mg, 75 mg 1 QL (84 caps / ye ar) oseltamivir phosphate SUSR 1 QL (108 0 mL / ye ar) PEGASYS 1 NM, PA PEGASYS PROC LICK 1 NM, PA REBETOL SOLN 1 NM RELENZA DISKHALER 1 QL (6 inhaler s / ye ar) ribasphere CAPS 1 NM ribasphere TABS 20 0mg, 60 0mg 1 NM


14

Drug Name Drug Tier Requirements/Limits ribavirin cap 200mg 1 NM ribavirin tab 200mg 1 NM rimantadine hydrochloride 1valacyclovir hcl TABS 1valganciclovir hcl 1VEMLIDY 1 NM VOSEVI 1 NM, PA

CEPHALOSPORINS cefaclor 1CEFACLOR ER TAB 500MG 1cefadroxil 1CEFAZOLIN IN DEXTROSE 2GM/100ML-4% 1cefazolin inj 1cefazolin sodium SOLR 1gm, 20gm 1CEFAZOLIN SODIUM 1 GM/50ML 1cefdinir 1cefepime for inj 1cefixime SUSR 1cefoxitin for inj 1cefpodoxime proxetil 1cefprozil 1ceftazidime SOLR 1CEFTAZIDIME/DEXTROSE 1ceftriaxone sodium SOLR 1gm, 2gm, 10gm, 250mg, 500mg

1

cefuroxime axetil 1cefuroxime sodium 1cephalexin CAPS 250mg, 500mg 1cephalexin SUSR 1tazicef SOLR 1TEFLARO 1

ERYTHROMYCINS/MACROLIDES azithromycin PACK; SOLR; SUSR; TABS 1clarithromycin TABS 1clarithromycin er 1clarithromycin for susp 1DIFICID 1e.e.s. 400 1ery-tab 1ERYTHROCIN LACTOBIONATE 1erythrocin stearate 1erythromycin base 1erythromycin cap 250mg ec 1erythromycin ethylsuccinate TABS 1

Drug Name Drug Tier Requirements/Limits FLUOROQUINOLONES

ciprofloxacin SUSR 1ciprofloxacin hcl tab 1ciprofloxacin in d5w 1levofloxacin TABS 1levofloxacin in d5w 1levofloxacin inj 25mg/ml 1levofloxacin oral soln 25 mg/ml 1moxifloxacin hcl TABS 1

PENICILLINS amoxicillin 1amoxicillin & pot clavulanate 200-28.5 chw tabs

1

amoxicillin & pot clavulanate 200/5ml susr 1amoxicillin & pot clavulanate 250-125 tabs 1amoxicillin & pot clavulanate 250/5ml susr 1amoxicillin & pot clavulanate 400-57 chw tabs

1

amoxicillin & pot clavulanate 400/5ml susr 1amoxicillin & pot clavulanate 500-125 tabs 1amoxicillin & pot clavulanate 600/5ml susr 1amoxicillin & pot clavulanate 875-125 tabs 1amoxicillin & pot clavulanate er 12hr 1000-62.5 tabs

1

ampicillin & sulbactam sodium 1ampicillin cap 500mg 1ampicillin inj 1ampicillin sodium 1BICILLIN L-A 1dicloxacillin sodium 1nafcillin sodium for inj 1NAFCILLIN SODIUM FOR INJ 10GM 1oxacillin sodium 1PENICILLIN G POT IN DEXTROSE 2MU 1PENICILLIN G POT IN DEXTROSE 3MU 1PENICILLIN G PROCAINE 1penicillin g sodium 1penicillin v potassium 1penicilln gk inj 5mu 1penicilln gk inj 20mu 1pfizerpen-g inj 5mu 1pfizerpen-g inj 20mu 1piper/tazoba inj 2-0.25gm 1piper/tazoba inj 3-0.375gm 1piper/tazoba inj 4-0.5gm 1PIPER/TAZOBA INJ 12-1.5GM 1


15


16

Drug Name Drug Tier Requirements/Limits piper/tazoba inj 36-4.5gm 1

TETRACYCLINES doxy 100 1doxycycline (monohydrate) CAPS 50mg, 100mg

1

doxycycline (monohydrate) TABS 50mg, 75mg, 100mg

1

doxycycline hyclate CAPS; SOLR 1doxycycline hyclate 20 mg 1doxycycline hyclate 100 mg 1minocycline hcl CAPS 1mondoxyne nl cap 100mg 1morgidox cap 1x50mg 1tetracycline hcl CAPS 1

ANTINEOPLASTIC AGENTS ALKYLATING AGENTS

BENDEKA 1 B/D, NM cyclophosphamide CAPS 25mg, 50mg 1 B/D CYCLOPHOSPHAMIDE CAPS 25mg, 50mg 1 B/D cyclophosphamide SOLR 1 B/D EMCYT 1GLEOSTINE 1LEUKERAN 1

ANTHRACYCLINES adriamycin SOLN 1 B/D doxorubicin hcl 1 B/D doxorubicin hcl liposomal 1 B/D epirubicin hcl 1 B/D

ANTIMETABOLITES adrucil inj 1 B/D ALIMTA 1 B/D azacitidine 1 B/D, NM cytarabine 20mg/ml 1 B/D fluorouracil SOLN 1 B/D gemcitabine inj soln 1 B/D gemcitabine inj solr 1 B/D mercaptopurine TABS 1methotrexate sodium inj soln 1 B/D methotrexate sodium inj solr 1 B/D PURIXAN 1 NM TABLOID 1

ANTIMITOTIC, TAXOIDS ABRAXANE 1 B/D docetaxel CONC 20mg/ml, 80mg/4ml 1 B/D


17

Drug Name Drug Ti er Requirements/Limits DOCETAXEL CONC 80mg/4ml, 160mg/8ml, 200mg/10ml

1 B/D

docetaxel SOLN 20mg/2ml, 80mg/8ml, 160mg/16ml

1 B/D

DOCETAXEL SOLN 20mg/2ml, 80mg/8ml, 160mg/16ml

1 B/D

paclitaxel 1 B/DTAXOTERE 80mg/4ml 1 B/D

ANTIMITOTIC, VINCA ALKALOIDS vincristine sulfate 1 B/Dvinorelbine tartrate 1 B/D

BIOLOGIC RESPONSE MODIFIERS AVASTIN 1 NM, LA, PA BORTEZOMIB 1 NM, PA DAURISMO 1 NM, LA, PA ERIVEDGE 1 NM, LA, PA FARYDAK 1 NM, LA, PA HERCEPTIN 1 NM, PA HERCEPTIN HYLECTA 1 NM, PA IBRANCE 1 QL (21 caps / 28 days),

NM, LA, PA IDHIFA 1 QL (30 tabs / 30 days),

NM, LA, PA KADCYLA 1 B/D, NM KEYTRUDA 1 NM, PA KISQALI 1 NM, PA KISQALI FEMARA 200 DOSE 1 NM, PA KISQALI FEMARA 400 DOSE 1 NM, PA KISQALI FEMARA 600 DOSE 1 NM, PA LYNPARZA 1 NM, LA, PANINLARO 1 NM, PA ODOMZO 1 NM, LA, PARITUXAN 1 NM, LA, PARITUXAN HYCELA 1 NM, LA, PARUBRACA 1 NM, LA, PATALZENNA 1 NM, LA, PATECENTRIQ 1 NM, LA, PATIBSOVO 1 NM, LA, PAVELCADE 1 NM, PA VENCLEXTA 1 NM, LA, PAVENCLEXTA STARTING PACK 1 NM, LA, PAVERZENIO 1 NM, LA, PAZEJULA 1 NM, LA, PAZOLINZA 1 NM, PA

HORMONAL ANTINEOPLASTIC AGENTS abiraterone acetate 1 NM, PA


18

Drug Name Drug Tier Requirements/Limits anastrozole TABS 1bicalutamide 1DEPO-PROVERA INJ 400/ML 1 B/D ERLEADA 1 NM, LA, PA exemestane 1FASLODEX 1 B/D flutamide 1letrozole TABS 1leuprolide inj 1mg/0.2 1 NM, PA LUPRON DEPOT (1-MONTH) 3.75mg 1 NM, PA LUPRON DEPOT INJ 11.25MG (3-MONTH) 1 NM, PA LYSODREN 1megestrol ac sus 40mg/ml 1megestrol ac tab 20mg 1megestrol ac tab 40mg 1megestrol sus 625mg/5ml 1 PA nilutamide 1SOLTAMOX 1tamoxifen citrate TABS 1toremifene citrate 1TRELSTAR DEP INJ 3.75MG 1 NM, PA TRELSTAR LA INJ 11.25MG 1 NM, PA XTANDI 1 NM, LA, PA ZYTIGA 500mg 1 NM, LA, PA

IMMUNOMODULATORS POMALYST 1mg, 2mg 1 QL (21 caps / 21 days),

NM, LA, PA POMALYST 3mg, 4mg 1 QL (21 caps / 28 days),

NM, LA, PA REVLIMID 1 QL (28 caps / 28 days),

NM, LA, PA THALOMID 50mg, 100mg 1 QL (28 caps / 28 days),

NM, PA THALOMID 150mg, 200mg 1 QL (56 caps / 28 days),

NM, PA KINASE INHIBITORS

AFINITOR 1 QL (30 tabs / 30 days), NM, PA

AFINITOR DISPERZ 2mg 1 QL (150 tabs / 30 days), NM, PA



ALECENSA 1 NM, LA, PA ALUNBRIG 1 NM, LA, PA


19

Drug Name Drug Tier Requirements/Limits BALVERSA 1 NM, LA, PA BOSULIF 1 NM, PA BRAFTOVI 1 NM, LA, PA CABOMETYX 1 QL (30 tabs / 30 days),

NM, LA, PA CALQUENCE 1 NM, LA, PA CAPRELSA 1 NM, LA, PA COMETRIQ 1 NM, LA, PA COPIKTRA 1 NM, LA, PA COTELLIC 1 NM, LA, PA erlotinib hcl 25mg 1 QL (90 tabs / 30 days),

NM, PA erlotinib hcl 100mg, 150mg 1 QL (30 tabs / 30 days),

NM, PA GILOTRIF TAB 20MG 1 NM, LA, PA GILOTRIF TAB 30MG 1 NM, LA, PA GILOTRIF TAB 40MG 1 NM, LA, PA ICLUSIG 1 NM, LA, PA imatinib mesylate 100mg 1 QL (90 tabs / 30 days),

NM, PA imatinib mesylate 400mg 1 QL (60 tabs / 30 days),

NM, PA IMBRUVICA 1 NM, LA, PA INLYTA 1mg 1 QL (180 tabs / 30 days),

NM, LA, PA INLYTA 5mg 1 QL (120 tabs / 30 days),

NM, LA, PA IRESSA 1 NM, LA, PA JAKAFI 1 QL (60 tabs / 30 days),

NM, LA, PA LENVIMA 4 MG DAILY DOSE 1 NM, LA, PA LENVIMA 8 MG DAILY DOSE 1 NM, LA, PA LENVIMA 10 MG DAILY DOSE 1 NM, LA, PA LENVIMA 12MG DAILY DOSE 1 NM, LA, PA LENVIMA 14 MG DAILY DOSE 1 NM, LA, PA LENVIMA 18 MG DAILY DOSE 1 NM, LA, PA LENVIMA 20 MG DAILY DOSE 1 NM, LA, PA LENVIMA 24 MG DAILY DOSE 1 NM, LA, PA LORBRENA 1 NM, LA, PA MEKINIST 1 NM, LA, PA MEKTOVI 1 NM, LA, PA NERLYNX 1 NM, LA, PA NEXAVAR 1 NM, LA, PA PIQRAY 200MG DAILY DOSE 1 NM, PA PIQRAY 250MG DAILY DOSE 1 NM, PA PIQRAY 300MG DAILY DOSE 1 NM, PA


20

Drug Name Drug Tier Requirements/Limits RYDAPT 1 NM, PA SPRYCEL 1 NM, PA STIVARGA 1 NM, LA, PA SUTENT 1 QL (30 caps / 30 days),

NM, PA TAFINLAR 1 NM, LA, PA TAGRISSO 1 QL (30 tabs / 30 days),

NM, LA, PA TASIGNA 1 NM, PA TYKERB 1 NM, LA, PA VITRAKVI 1 NM, LA, PA VIZIMPRO 1 NM, LA, PA VOTRIENT 1 NM, LA, PA XALKORI 1 NM, LA, PA XOSPATA 1 NM, LA, PA ZELBORAF 1 NM, LA, PA ZYDELIG 1 NM, LA, PA ZYKADIA 1 NM, LA, PA

MISCELLANEOUS bexarotene 1 NM, PAhydroxyurea CAPS 1LONSURF 1 NM, PAMATULANE 1 LA SYLATRON 1 NM, PASYNRIBO 1 NM, PAtretinoin (chemotherapy) 1

PLATINUM-BASED AGENTS carboplatin 1 B/Dcisplatin SOLN 1 B/Doxaliplatin inj 50mg 1 B/Doxaliplatin inj 50mg/10ml 1 B/Doxaliplatin inj 100mg 1 B/Doxaliplatin inj 100mg/20ml 1 B/D

PROTECTIVE AGENTS leucovorin calcium SOLN 500mg/50ml 1 B/D leucovorin calcium SOLR 1 B/D leucovorin calcium TABS 1MESNEX TABS 1

TOPOISOMERASE INHIBITORS etoposide SOLN 1 B/D irinotecan hcl 1 B/D toposar 1 B/D


21

Drug Name Drug Ti er Requirements/Limits CARDIOVASCULAR

ACE INHIBITOR COMBINATIONS amlodipine besylate-benazepril hcl cap 2.5-10 mg

1

amlodipine besylate-benazepril hcl cap 5-10 mg

1


1


1


1


1

benazepril & hydrochlorothiazide 1captopril & hydrochlorothiazide 1 enalapril maleate & hydrochlorothiazide 1fosinopril sodium & hydrochlorothiazide 1 lisinopril & hydrochlorothiazide 1quinapril-hydrochlorothiazide 1

ACE INHIBITORS benazepril hcl TABS 1captopril TABS 1 enalapril maleate TABS 1fosinopril sodium 1lisinopril TABS 1 moexipril hcl 1perindopril erbumine 1 quinapril hcl 1ramipril 1trandolapril 1

ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone 1 spironolactone TABS 1

ALPHA BLOCKERS doxazosin mesylate TABS 1 prazosin hcl 1 terazosin hcl 1

ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS amlodipine besylate-olmesartan medoxomil 1

amlodipine besylate-valsartan tab 1amlodipine-valsartan-hydrochlorothiazide tab

1

candesartan cilexetil-hydrochlorothiazide 1ENTRESTO 1


22

Drug Name Drug Ti er Requirements/Limits irbesartan-hydrochlorothiazide 1losartan-hydrochlorothiazide 1

olmesartan medoxomil-amlodipine-hydrochlorothiazide

1

olmesartan medoxomil-hydrochlorothiazide 1telmisartan-amlodipine 1telmisartan-hydrochlorothiazide 1valsartan-hydrochlorothiazide 1

ANGIOTENSIN II RECEPTOR ANTAGONISTS candesartan cilexetil 1eprosartan mesylate 1irbesartan 1losartan potassium 1olmesartan medoxomil TABS 1telmisartan 1valsartan 1

ANTIARRHYTHMICS amiodarone hcl soln 1amiodarone tab 100mg 1amiodarone tab 200mg 1amiodarone tab 400mg 1disopyramide phosphate 1dofetilide 1 NMflecainide acetate 1MULTAQ 1NORPACE CR 1pacerone 1propafenone hcl 1propafenone hcl 12hr 1quinidine sulfate 1sorine 1sotalol hcl 1sotalol hcl (afib/afl) 1

ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS atorvastatin calcium TABS 1lovastatin 1

pravastatin sodium 1rosuvastatin calcium 1 QL (30 tabs / 30 days) simvastatin TABS 5mg, 10mg, 20mg, 40mg

1

simvastatin TABS 80mg 1 QL (30 tabs / 30 days)

ANTILIPEMICS, MISCELLANEOUS cholestyramine 1cholestyramine light pack 1cholestyramine light powd 1


23

Drug Name Drug Tier Requirements/Limits colesevelam hcl 1colestipol hcl gran 1colestipol hcl pack 1colestipol hcl tabs 1ezetimibe 1ezetimibe-simvastatin 1fenofibrate TABS 48mg, 54mg, 145mg, 160mg

1

fenofibrate micronized 67mg, 134mg, 200mg

1

gemfibrozil TABS 1JUXTAPID 1 NM, LA, PA niacin er (antihyperlipidemic) 500mg 1 QL (60 tabs / 30 days) niacin er (antihyperlipidemic) 750mg, 1000mg

1

niacor 1PRALUENT 1 PA prevalite 1VASCEPA 1

BETA-BLOCKER/DIURETIC COMBINATIONSatenolol & chlorthalidone 1bisoprolol & hydrochlorothiazide 1metoprolol & hydrochlorothiazide 1propranolol & hydrochlorothiazide 1

BETA-BLOCKERS acebutolol hcl CAPS 1atenolol TABS 1betaxolol hcl 1bisoprolol fumarate 1BYSTOLIC 2.5mg, 5mg, 10mg 1 QL (30 tabs / 30 days) BYSTOLIC 20mg 1 QL (60 tabs / 30 days) carvedilol 1labetalol hcl TABS 1metoprolol succinate 1metoprolol tartrate SOCT 1metoprolol tartrate SOLN 1metoprolol tartrate TABS 25mg, 50mg, 100mg

1

nadolol TABS 1pindolol 1propranolol cap er 1propranolol hcl TABS 1propranolol oral sol 1timolol maleate TABS 1

CALCIUM CHANNEL BLOCKERS amlodipine besylate TABS 1


24

Drug Name Drug Tier Requirements/Limits cartia xt 1dilt-xr cap 1diltiazem cap 240mg cd 1diltiazem cap 360mg cd 1diltiazem cap er/12hr 1diltiazem hcl TABS 1diltiazem hcl coated beads CP24 1diltiazem hcl coated beads cap sr 24hr 1diltiazem hcl extended release beads cap sr

1

diltiazem inj 1felodipine 1isradipine 1nicardipine hcl CAPS 1nifedipine TB24 1nifedipine er 1nimodipine CAPS 1NYMALIZE 1taztia xt 1verapamil cap er 1verapamil hcl SOLN; TABS; TBCR 1verapamil tab er 1

DIGITALIS GLYCOSIDES digitek .25mg 1 PA; PA if 70 years and

older digitek .125mg 1 QL (30 tabs / 30 days) digox 125mcg 1 QL (30 tabs / 30 days) digox 250mcg 1 PA; PA if 70 years and

older digoxin TABS 125mcg 1 QL (30 tabs / 30 days) digoxin TABS 250mcg 1 PA; PA if 70 years and

older digoxin inj 1digoxin sol 50mcg/ml 1 PA; PA if 70 years and

older DIURETICS

acetazolamide CP12; TABS 1amiloride & hydrochlorothiazide 1amiloride hcl TABS 1bumetanide inj 0.25/ml 1bumetanide tab 1chlorothiazide tabs 1chlorthalidone 1furosemide SOLN; TABS 1furosemide inj 1hydrochlorothiazide CAPS; TABS 1


25

Drug Name Drug Ti er Requirements/Limits indapamide 1methazolamide TABS 1

metolazone 1spironolactone & hydrochlorothiazide 1torsemide tabs 1triamterene & hydrochlorothiazide cap 37.5-25 mg

1

triamterene & hydrochlorothiazide tabs 1MISCELLANEOUS

aliskiren fumarate 1clonidine hcl TABS 1clonidine hcl ptwk 1CORLANOR TABS 1DEMSER 1 PA hydralazine hcl SOLN; TABS 1midodrine hcl 1minoxidil TABS 1NORTHERA 100mg 1 QL (90 caps / 30 days),

NM, LA, PA NORTHERA 200mg, 300mg 1 QL (180 caps / 30

days), NM, LA, PA ranolazine 1

NITRATES isosorb mononitrate tab 1isosorbide dinitrate 1isosorbide dinitrate er 1isosorbide mononitrate er 1minitran 1NITRO-BID 1NITRO-DUR DIS 0.3MG/HR 1NITRO-DUR DIS 0.8MG/HR 1nitroglycerin SOLN .4mg/spray 1nitroglycerin SUBL 1nitroglycerin td patch 1

PULMONARY ARTERIAL HYPERTENSION ADEMPAS 1 QL (90 tabs / 30 days),

NM, LA, PA ambrisentan 1 QL (30 tabs / 30 days),

NM, LA, PA bosentan 62.5mg 1 QL (120 tabs / 30 days),

NM, LA, PA bosentan 125mg 1 QL (60 tabs / 30 days),

NM, LA, PA OPSUMIT 1 QL (30 tabs / 30 days),

NM, LA, PA


26

Drug Name Drug Tier Requirements/Limits sildenafil citrate tab 20 mg (pulmonary hypertension)

1 QL (90 tabs / 30 days), NM, PA

treprostinil 1 NM, LA, PA VENTAVIS 1 NM, PA

CENTRAL NERVOUS SYSTEM ANTIANXIETY

alprazolam tab 0.5mg 1 QL (150 tabs / 30 days) alprazolam tab 0.25mg 1 QL (150 tabs / 30 days) alprazolam tab 1mg 1 QL (150 tabs / 30 days) alprazolam tab 2 mg 1 QL (150 tabs / 30 days) buspirone hcl TABS 1fluvoxamine maleate TABS 1lorazepam SOLN 1lorazepam TABS 1 QL (150 tabs / 30 days) lorazepam intensol 1 QL (150 mL / 30 days)

ANTICONVULSANTS APTIOM 1 QL (60 tabs / 30 days) BANZEL SUS 40MG/ML 1 PA BANZEL TAB 200MG 1 PA BANZEL TAB 400MG 1 PABRIVIACT INJ 50MG/5ML 1 PABRIVIACT SOL 10MG/ML 1 PABRIVIACT TAB 10MG 1 PABRIVIACT TAB 25MG 1 PABRIVIACT TAB 50MG 1 PABRIVIACT TAB 75MG 1 PABRIVIACT TAB 100MG 1 PAcarbamazepine CHEW; CP12; SUSP; TABS; TB12

1

CELONTIN 1clobazam 1 PA clonazepam TABS 2mg 1 QL (300 tabs / 30 days) clonazepam TABS .5mg, 1mg 1 QL (90 tabs / 30 days) clonazepam TBDP 2mg 1 QL (300 tabs / 30 days) clonazepam TBDP .125mg, .25mg, .5mg, 1mg

1 QL (90 tabs / 30 days)

clorazepate dipotassium 1 QL (180 tabs / 30 days), PA; PA if 65 years and older

DIASTAT ACUDIAL 1DIASTAT PEDIATRIC 1diazepam TABS 1 QL (120 tabs / 30 days),

PA; PA if 65 years and older

diazepam gel 1diazepam inj 1


27

Drug Name Drug Tier Requirements/Limits diazepam intensol 1 QL (240 mL / 30 days),


diazepam oral soln 1 mg/ml 1 QL (1200 mL / 30 days), PA; PA if 65 years and older

DILANTIN CAP 30MG 1DILANTIN CAP 100MG 1DILANTIN CHEW TAB 50MG 1DILANTIN-125 SUSP 1divalproex sodium CSDR; TB24; TBEC 1EPIDIOLEX 1 QL (600 mL / 30 days),

NM, LA, PA epitol 1ethosuximide CAPS; SOLN 1felbamate 1FYCOMPA SUSP 1 QL (720 mL / 30 days),

PA FYCOMPA TABS 2mg, 4mg, 6mg 1 QL (60 tabs / 30 days),

PA FYCOMPA TABS 8mg, 10mg, 12mg 1 QL (30 tabs / 30 days),

PA gabapentin CAPS 100mg 1 QL (1080 caps / 30

days) gabapentin CAPS 300mg 1 QL (360 caps / 30 days) gabapentin CAPS 400mg 1 QL (270 caps / 30 days) gabapentin SOLN 1 QL (2160 mL / 30 days) gabapentin TABS 600mg 1 QL (180 tabs / 30 days) gabapentin TABS 800mg 1 QL (120 tabs / 30 days) lamotrigine CHEW; TABS; TB24 1levetiracetam SOLN; TABS; TB24 1levetiracetam in sodium chloride 1levetiracetam oral soln 100 mg/ml 1LYRICA CAPS 25mg, 50mg, 75mg, 100mg, 150mg

1 QL (120 caps / 30 days), PA

LYRICA CAPS 200mg 1 QL (90 caps / 30 days), PA

LYRICA CAPS 225mg, 300mg 1 QL (60 caps / 30 days), PA

LYRICA SOLN 1 QL (900 mL / 30 days), PA

oxcarbazepine 1PEGANONE 1phenobarbital ELIX; TABS 1 PA; PA if 70 years and

older PHENOBARBITAL SODIUM SOLN 65mg/ml 1 PA; PA if 70 years and

older


28

Drug Name Drug Tier Requirements/Limits phenobarbital sodium SOLN 130mg/ml 1 PA; PA if 70 years and

older PHENYTEK 1 phenytoin CHEW; SUSP 1 phenytoin sodium extended 1 phenytoin sodium inj 50mg/ml 1 primidone TABS 1 roweepra 1 roweepra xr 1 SPRITAM 1 subvenite tab 1 SYMPAZAN 1 PA tiagabine hcl 1 topiramate CPSP; TABS 1 valproate sodium SOLN 1 valproate sodium oral soln 1 valproic acid CAPS 1 vigabatrin powd pack 500mg 1 QL (180 packets / 30

days), NM, LA, PA vigabatrin tab 500mg 1 QL (180 tabs / 30 days),

NM, LA, PA vigadrone 1 QL (180 packets / 30

days), NM, LA, PA VIMPAT 50mg 1 QL (120 tabs / 30 days) VIMPAT 100mg, 150mg, 200mg 1 QL (60 tabs / 30 days) VIMPAT INJ 200MG/20ML 1 VIMPAT SOL 10MG/ML 1 QL (1200 mL / 30 days) zonisamide CAPS 1

ANTIDEMENTIA donepezil hydrochloride TABS 5mg 1 QL (30 tabs / 30 days) donepezil hydrochloride TABS 10mg 1 donepezil hydrochloride TBDP 5mg 1 QL (30 tabs / 30 days) donepezil hydrochloride TBDP 10mg 1 galantamine hydrobromide SOLN 1 galantamine hydrobromide TABS 1 QL (60 tabs / 30 days) galantamine hydrobromide er 1 QL (30 caps / 30 days) memantine hcl cp24 1 PA; PA if < 30 yrs memantine soln 1 PA; PA if < 30 yrs memantine tabs 1 PA; PA if < 30 yrs memantine titration pak 1 PA; PA if < 30 yrs NAMZARIC 1 rivastigmine tartrate 1.5mg, 3mg 1 QL (90 caps / 30 days) rivastigmine tartrate 4.5mg, 6mg 1 QL (60 caps / 30 days) rivastigmine td patch 24hr 4.6 mg/24hr 1 QL (30 patches / 30

days)


29

Drug Name Drug Tier Requirements/Limits rivastigmine td patch 24hr 9.5 mg/24hr 1 QL (30 patches / 30

days) rivastigmine td patch 24hr 13.3 mg/24hr 1 QL (30 patches / 30

days) ANTIDEPRESSANTS

amitriptyline hcl TABS 1

amoxapine 1 bupropion hcl TABS 1 bupropion hcl TB12 1 bupropion hcl TB24 150mg, 300mg 1 citalopram hydrobromide 1 clomipramine hcl CAPS 1 PA desipramine hcl TABS 1 desvenlafaxine succinate 1 QL (30 tabs / 30 days),

PA doxepin hcl CAPS; CONC 1 duloxetine hcl CPEP 20mg, 30mg, 60mg 1 QL (60 caps / 30 days) EMSAM 1 QL (30 patches / 30

days), PA escitalopram oxalate 1 FETZIMA 20mg, 40mg 1 QL (60 caps / 30 days),

PA FETZIMA 80mg, 120mg 1 QL (30 caps / 30 days),

PA FETZIMA TITRATION PACK 1 PA fluoxetine cap 10mg 1

fluoxetine cap 20mg 1 fluoxetine cap 40mg 1 fluoxetine hcl SOLN 1 imipramine hcl TABS 1 maprotiline hcl 1 MARPLAN TAB 10MG 1 QL (180 tabs / 30 days) mirtazapine TABS; TBDP 1

nefazodone hcl 1 nortriptyline hcl CAPS; SOLN 1 paroxetine hcl tabs 1 PAXIL SUSP 1 QL (900 mL / 30 days) phenelzine sulfate TABS 1

protriptyline hcl 1 sertraline hcl CONC; TABS 1 tranylcypromine sulfate 1 trazodone hcl TABS 50mg, 100mg, 150mg

1

trimipramine maleate CAPS 25mg 1 QL (240 caps / 30 days) trimipramine maleate CAPS 50mg 1 QL (120 caps / 30 days) trimipramine maleate CAPS 100mg 1 QL (60 caps / 30 days)


30

Drug Name Drug Tier Requirements/Limits TRINTELLIX 5mg 1 QL (120 tabs / 30 days),

PA TRINTELLIX 10mg 1 QL (60 tabs / 30 days),

PA TRINTELLIX 20mg 1 QL (30 tabs / 30 days),

PA venlafaxine hcl CP24; TABS 1 VIIBRYD STARTER PACK 1 PA VIIBRYD TAB 1 QL (30 tabs / 30 days),

PA ANTIPARKINSONIAN AGENTS

amantadine hcl CAPS 1 QL (120 caps / 30 days) amantadine hcl SYRP; TABS 1 APOKYN 1 QL (20 cartridges / 30

days), NM, LA, PA benztropine mesylate inj 1 benztropine mesylate tab 0.5mg 1 PA; PA if 70 years and

older benztropine mesylate tab 1mg 1 PA; PA if 70 years and

older benztropine mesylate tab 2mg 1 PA; PA if 70 years and

older bromocriptine mesylate CAPS; TABS 1

carbidopa-levodopa 1

carbidopa/levodopa/entacapone 1 entacapone 1NEUPRO 1pramipexole tab 0.5mg 1pramipexole tab 0.25mg 1pramipexole tab 0.75mg 1pramipexole tab 0.125mg 1pramipexole tab 1.5mg 1pramipexole tab 1mg 1rasagiline mesylate TABS 1ropinirole tab 0.5mg 1ropinirole tab 0.25mg 1ropinirole tab 1mg 1ropinirole tab 2mg 1ropinirole tab 3mg 1ropinirole tab 4mg 1ropinirole tab 5mg 1selegiline hcl CAPS; TABS 1 trihexyphenidyl hcl 1 PA; PA if 70 years and

older


31

Drug Name Drug Tier Requirements/Limits ANTIPSYCHOTICS

ABILIFY MAINTENA 1 QL (1 injection / 28 days)

aripiprazole odt 1 QL (60 tabs / 30 days) aripiprazole oral solution 1 mg/ml 1 QL (900 mL / 30 days) aripiprazole tab 1 QL (30 tabs / 30 days) ARISTADA 441mg/1.6ml, 662mg/2.4ml, 882mg/3.2ml

1 QL (1 injection / 28 days)

ARISTADA 1064mg/3.9ml 1 QL (1 injection / 56 days)

ARISTADA INITIO 1 chlorpromazine hcl TABS 1 CHLORPROMAZINE INJ 1 clozapine odt 12.5mg, 25mg 1 PA clozapine odt 100mg 1 QL (270 tabs / 30 days),

PA clozapine odt 150mg 1 QL (180 tabs / 30 days),

PA clozapine odt 200mg 1 QL (135 tabs / 30 days),

PA clozapine tab 25mg 1 clozapine tab 50mg 1 clozapine tab 100mg 1 QL (270 tabs / 30 days) clozapine tab 200mg 1 QL (135 tabs / 30 days) FANAPT 1 QL (60 tabs / 30 days),

PA FANAPT TITRATION PACK 1 PA fluphenazine decanoate SOLN 1 fluphenazine hcl 1 GEODON SOLR 1 QL (6 mL / 3 days) haloperidol TABS 1 haloperidol conc 2mg/ml 1 haloperidol decanoate SOLN 1 haloperidol lactate inj 5mg/ml 1 INVEGA SUST INJ 39 MG/0.25 ML 1 QL (1 injection / 28

days) INVEGA SUST INJ 78 MG/0.5 ML 1 QL (1 injection / 28


days) INVEGA SUST INJ 156MG/ML 1 QL (1 injection / 28


days) INVEGA TRINZA 1 QL (1 injection / 90

days) LATUDA 20mg, 40mg, 60mg, 120mg 1 QL (30 tabs / 30 days)


32

Drug Name Drug Tier Requirements/Limits LATUDA 80mg 1 QL (60 tabs / 30 days) loxapine succinate 1 molindone hcl 1 NUPLAZID CAPS 1 QL (30 caps / 30 days),

NM, LA, PA NUPLAZID TABS 10MG 1 QL (30 tabs / 30 days),

NM, LA, PA olanzapine SOLR 1 QL (3 vials / 1 day) olanzapine TABS 2.5mg, 5mg, 10mg 1 QL (60 tabs / 30 days) olanzapine TABS 7.5mg, 15mg, 20mg 1 QL (30 tabs / 30 days) olanzapine TBDP 5mg, 15mg, 20mg 1 QL (30 tabs / 30 days) olanzapine TBDP 10mg 1 QL (60 tabs / 30 days) paliperidone 1.5mg, 3mg, 9mg 1 QL (30 tabs / 30 days) paliperidone 6mg 1 QL (60 tabs / 30 days) perphenazine TABS 1 PERSERIS 1 QL (1 injection / 30

days) pimozide 1 quetiapine fumarate TABS 1 quetiapine fumarate TB24 50mg, 300mg, 400mg

1 QL (60 tabs / 30 days), PA

quetiapine fumarate TB24 150mg, 200mg 1 QL (30 tabs / 30 days), PA

REXULTI 3mg, 4mg 1 QL (30 tabs / 30 days) REXULTI .25mg, .5mg, 1mg, 2mg 1 QL (60 tabs / 30 days) RISPERDAL INJ 12.5MG 1 QL (2 injections / 28

days) RISPERDAL INJ 25MG 1 QL (2 injections / 28

days) RISPERDAL INJ 37.5MG 1 QL (2 injections / 28

days) RISPERDAL INJ 50MG 1 QL (2 injections / 28

days) risperidone SOLN 1 QL (240 mL / 30 days) risperidone TABS 1 risperidone TBDP 1mg, 2mg, 3mg, 4mg 1 QL (60 tabs / 30 days) risperidone TBDP .25mg, .5mg 1 QL (90 tabs / 30 days) SAPHRIS 1 QL (60 tabs / 30 days) thioridazine hcl TABS 1 thiothixene 1 trifluoperazine hcl 1 VERSACLOZ 1 QL (600 mL / 30 days),

PA VRAYLAR 1.5mg 1 QL (60 caps / 30 days),

PA VRAYLAR 3mg, 4.5mg, 6mg 1 QL (30 caps / 30 days),

PA


33

Drug Name Drug Tier Requirements/Limits VRAYLAR THERAPY PACK 1 PA ziprasidone hcl 1 QL (60 caps / 30 days) ZYPREXA RELPREVV 300mg 1 QL (2 vials / 28 days),

PA ZYPREXA RELPREVV 405mg 1 QL (1 vial / 28 days), PA ZYPREXA RELPREVV INJ 210MG 1 QL (2 vials / 28 days),

PA ATTENTION DEFICIT HYPERACTIVITY DISORDER

amphetamine-dextroamphetamine cap sr 24hr 5 mg

1 QL (90 caps / 30 days)











amphetamine-dextroamphetamine tab 5 mg


amphetamine-dextroamphetamine tab 7.5 mg




amphetamine-dextroamphetamine tab 12.5 mg








atomoxetine hcl 10mg, 18mg, 25mg 1 QL (120 caps / 30 days) atomoxetine hcl 40mg 1 QL (60 caps / 30 days) atomoxetine hcl 60mg, 80mg, 100mg 1 QL (30 caps / 30 days) dexmethylphenidate hcl TABS 2.5mg, 5mg


dexmethylphenidate hcl TABS 10mg 1 QL (60 tabs / 30 days) guanfacine er (adhd) 1 PA; PA if 70 years and

older metadate er tab 20mg 1 QL (90 tabs / 30 days) methylphenidate hcl TABS 5mg, 10mg 1 QL (180 tabs / 30 days) methylphenidate hcl TABS 20mg 1 QL (90 tabs / 30 days) methylphenidate hcl oral soln 5mg/5ml 1 QL (1800 mL / 30 days) methylphenidate hcl oral soln 10mg/5ml 1 QL (900 mL / 30 days)


34

Drug Name Drug Tier Requirements/Limits methylphenidate hcl tbcr 10 mg 1 QL (90 tabs / 30 days) methylphenidate hcl tbcr 20mg 1 QL (90 tabs / 30 days)

HYPNOTICS eszopiclone 1 QL (30 tabs / 30 days),

PA; PA applies if 70 years and older after a 90 day supply in a calendar year

HETLIOZ 1 NM, LA, PA SILENOR 1 QL (30 tabs / 30 days) temazepam 7.5mg 1 QL (30 caps / 30 days),

PA; PA applies if 65 years and older after a 90 day supply in a calendar year

temazepam 15mg 1 QL (60 caps / 30 days), PA; PA applies if 65 years and older after a 90 day supply in a calendar year

zaleplon 1 QL (60 caps / 30 days), PA; PA applies if 70 years and older after a 90 day supply in a calendar year

zolpidem tartrate TABS 1 QL (30 tabs / 30 days), PA; PA applies if 70 years and older after a 90 day supply in a calendar year

MIGRAINE AIMOVIG 1 QL (1 pen / 30 days), PA dihydroergotamine mesylate inj 1 mg/ml 1 dihydroergotamine mesylate nasal spr 4 mg/ml

1 QL (8 mL / 30 days), PA

eletriptan hydrobromide 1 QL (12 tabs / 30 days) EMGALITY SOAJ 1 QL (2 pens / 30 days),

PA EMGALITY SOSY 120mg/ml 1 QL (2 syringes / 30

days), PA ergotamine w/ caffeine TABS 1 naratriptan hcl 1 QL (12 tabs / 30 days) rizatriptan benzoate 1 QL (18 tabs / 30 days) rizatriptan benzoate odt 1 QL (18 tabs / 30 days) sumatriptan SOLN 5mg/act 1 QL (24 inhalers / 30

days) sumatriptan SOLN 20mg/act 1 QL (12 inhalers / 30

days)


35

Drug Name Drug Tier Requirements/Limits sumatriptan inj 4mg/0.5ml 1 QL (18 injections / 30

days) sumatriptan inj 6mg/0.5ml 1 QL (12 injections / 30

days) sumatriptan succinate TABS 1 QL (12 tabs / 30 days) zolmitriptan TABS 1 QL (12 tabs / 30 days) zolmitriptan odt 1 QL (12 tabs / 30 days)

MISCELLANEOUS AUSTEDO 6mg 1 QL (60 tabs / 30 days),

NM, LA, PA AUSTEDO 9mg, 12mg 1 QL (120 tabs / 30 days),

NM, LA, PA lithium carbonate CAPS; TABS 1 lithium carbonate er 1 LITHIUM SOLN 8MEQ/5ML 1 LYRICA CR 1 QL (60 tabs / 30 days),

PA NUEDEXTA 1 QL (60 caps / 30 days),

PA pyridostigmine tab 60mg 1 riluzole 1 tetrabenazine 12.5mg 1 QL (240 tabs / 30 days),

NM, PA tetrabenazine 25mg 1 QL (120 tabs / 30 days),

NM, PA MULTIPLE SCLEROSIS AGENTS

BETASERON 1 QL (14 syringes / 28 days), NM, PA

dalfampridine 1 NM, PA GILENYA 1 QL (28 caps / 28 days),

NM, PA glatiramer acetate 20mg/ml 1 QL (30 syringes / 30

days), NM, PA glatiramer acetate 40mg/ml 1 QL (12 syringes / 28

days), NM, PA glatopa 20mg/ml 1 QL (30 syringes / 30

days), NM, PA glatopa 40mg/ml 1 QL (12 syringes / 28

days), NM, PA MUSCULOSKELETAL THERAPY AGENTS

baclofen TABS 10mg, 20mg 1 carisoprodol TABS 350mg 1 QL (120 tabs / 30 days),


cyclobenzaprine hcl TABS 5mg, 10mg 1 PA; PA if 70 years and older

dantrolene sodium CAPS 1

PA - Prior Authorization QL - Quantity Limits ST - Step Theravailable at mail-order B/D - Covered under Medicare B or D

apy NM - Not 36 LA - Limited Access

Drug Name Drug Tier Requirements/Limits methocarbamol TABS 1 PA; PA if 70 years and

older tizanidine hcl TABS 1

NARCOLEPSY/CATAPLEXY armodafinil 50mg 1 QL (90 tabs / 30 days),

PA armodafinil 150mg, 200mg, 250mg 1 QL (30 tabs / 30 days),

PA XYREM 1 QL (540 mL / 30 days),

NM, LA, PA PSYCHOTHERAPEUTIC-MISC

acamprosate calcium 1 buprenorphine hcl SUBL 1 QL (90 tabs / 30 days),

PA buprenorphine hcl-naloxone hcl dihydrate 2-0.5mg

1 QL (90 films / 30 days)

buprenorphine hcl-naloxone hcl dihydrate 4-1mg






buprenorphine hcl-naloxone hcl sl 1 QL (90 tabs / 30 days) bupropion hcl (smoking deterrent) 1 CHANTIX 1 PA CHANTIX CONTINUING MONTH 1 PA CHANTIX STARTER PACK 1 PA disulfiram TABS 1 naloxone inj 0.4mg/ml 1 naloxone inj 1mg/ml 1 naltrexone hcl TABS 1

NARCAN 1 NICOTROL INHALER 1 NICOTROL NS 1 VIVITROL 1

ENDOCRINE AND METABOLIC ANDROGENS

ANADROL-50 1 PA ANDRODERM 1 QL (30 patches / 30

days), PA oxandrolone tab 2.5mg 1 PA oxandrolone tab 10mg 1 PA testosterone GEL 1%, 25mg/2.5gm, 50mg/5gm

1 QL (300 grams / 30 days), PA

testosterone cypionate SOLN 100mg/ml, 200mg/ml

1 PA


37

Drug Name Drug Tier Requirements/Limits testosterone enanthate SOLN 1 PA

ANTIDIABETICS, INJECTABLE BASAGLAR KWIKPEN 1 BD ALCOHOL SWABS 1 BD ULTRAFINE INSULIN SYRINGE 1 BD ULTRAFINE/NANO PEN NEEDLES 1 BYDUREON BCISE 1 QL (4 pens / 28 days) BYDUREON PEN 1 QL (4 pens / 28 days) BYETTA 1 QL (1 pen / 30 days) FIASP 1 FIASP FLEXTOUCH 1 GAUZE PADS 2" X 2" 1 HUMULIN R INJ U-500 1 B/DHUMULIN R U-500 KWIKPEN 1 INSULIN PEN NEEDLE 1 INSULIN SAFETY NEEDLES 1 INSULIN SYRINGE 1 LEVEMIR 1 LEVEMIR FLEXTOUCH 1 NOVOLIN 70/30 1 (brand RELION not

covered) NOVOLIN 70/30 FLEXPEN 1 (brand RELION not

covered) NOVOLIN N 1 (brand RELION not

covered) NOVOLIN R 1 (brand RELION not

covered) NOVOLOG 1 NOVOLOG 70/30 FLEXPEN 1 NOVOLOG FLEXPEN 1 NOVOLOG MIX 70/30 1 NOVOLOG PENFILL 1 OZEMPIC INJ 0.25 OR 0.5MG/DOSE 1 QL (1 pen / 28 days) OZEMPIC INJ 1MG/DOSE 1 QL (2 pens / 28 days) SOLIQUA 100/33 1 QL (10 pens / 30 days) TRESIBA FLEXTOUCH 1 TRESIBA INJ 1 TRULICITY 1 QL (4 pens / 28 days) VICTOZA 1 QL (3 pens / 30 days) XULTOPHY 100/3.6 1 QL (5 pens / 30 days)

ANTIDIABETICS, ORAL acarbose TABS 1 FARXIGA 1 QL (30 tabs / 30 days) glimepiride 1mg, 2mg 1 QL (90 tabs / 30 days) glimepiride 4mg 1 QL (60 tabs / 30 days) glip/metform tab 2.5-250mg 1 QL (240 tabs / 30 days)


38

Drug Name Drug Tier Requirements/Limits glip/metform tab 2.5-500mg 1 QL (120 tabs / 30 days) glip/metform tab 5-500mg 1 QL (120 tabs / 30 days) glipizide TABS 5mg 1 QL (240 tabs / 30 days) glipizide TABS 10mg 1 QL (120 tabs / 30 days) glipizide TB24 2.5mg, 5mg 1 QL (90 tabs / 30 days) glipizide TB24 10mg 1 QL (60 tabs / 30 days) glipizide xl 2.5mg, 5mg 1 QL (90 tabs / 30 days) glipizide xl 10mg 1 QL (60 tabs / 30 days) glyburide TABS 1.25mg 1 QL (480 tabs / 30 days),


glyburide TABS 2.5mg 1 QL (240 tabs / 30 days), PA; PA if 70 years and older

glyburide TABS 5mg 1 QL (120 tabs / 30 days), PA; PA if 70 years and older

glyburide micronized 1.5mg 1 QL (240 tabs / 30 days), PA; PA if 70 years and older

glyburide micronized 3mg 1 QL (120 tabs / 30 days), PA; PA if 70 years and older

glyburide micronized 6mg 1 QL (60 tabs / 30 days), PA; PA if 70 years and older

glyburide-metformin tab 1.25-250 mg 1 QL (240 tabs / 30 days), PA; PA if 70 years and older

glyburide-metformin tab 2.5-500 mg 1 QL (120 tabs / 30 days), PA; PA if 70 years and older

glyburide-metformin tab 5-500mg 1 QL (120 tabs / 30 days), PA; PA if 70 years and older

JANUMET 1 QL (60 tabs / 30 days) JANUMET XR TAB 50-500MG 1 QL (60 tabs / 30 days) JANUMET XR TAB 50-1000 1 QL (60 tabs / 30 days) JANUMET XR TAB 100-1000 1 QL (30 tabs / 30 days) JANUVIA 1 QL (30 tabs / 30 days) JARDIANCE 10mg 1 QL (60 tabs / 30 days) JARDIANCE 25mg 1 QL (30 tabs / 30 days) JENTADUETO 1 QL (60 tabs / 30 days) JENTADUETO TAB XR 2.5-1000 MG 1 QL (60 tabs / 30 days) JENTADUETO TAB XR 5-1000 MG 1 QL (30 tabs / 30 days)


39

Drug Name Drug Tier Requirements/Limits metformin er 500mg 1 QL (120 tabs / 30 days);

(generic of GLUCOPHAGE XR)

metformin er 750mg 1 QL (60 tabs / 30 days); (generic of GLUCOPHAGE XR)

metformin hcl TABS 500mg 1 QL (150 tabs / 30 days) metformin hcl TABS 850mg 1 QL (90 tabs / 30 days) metformin hcl TABS 1000mg 1 QL (75 tabs / 30 days) nateglinide 1 QL (90 tabs / 30 days) pioglitazone hcl 1 QL (30 tabs / 30 days) repaglinide 2mg 1 QL (240 tabs / 30 days) repaglinide .5mg, 1mg 1 QL (120 tabs / 30 days) SYNJARDY TAB 5-500MG 1 QL (120 tabs / 30 days) SYNJARDY TAB 5-1000MG 1 QL (60 tabs / 30 days) SYNJARDY TAB 12.5-500MG 1 QL (60 tabs / 30 days) SYNJARDY TAB 12.5-1000MG 1 QL (60 tabs / 30 days) SYNJARDY XR TAB 5-1000MG 1 QL (60 tabs / 30 days) SYNJARDY XR TAB 10-1000MG 1 QL (60 tabs / 30 days) SYNJARDY XR TAB 12.5-1000MG 1 QL (60 tabs / 30 days) SYNJARDY XR TAB 25-1000MG 1 QL (30 tabs / 30 days) TRADJENTA 1 QL (30 tabs / 30 days) XIGDUO XR TAB 2.5-1000MG 1 QL (60 tabs / 30 days) XIGDUO XR TAB 5-500MG 1 QL (60 tabs / 30 days) XIGDUO XR TAB 5-1000MG 1 QL (60 tabs / 30 days) XIGDUO XR TAB 10-500MG 1 QL (30 tabs / 30 days) XIGDUO XR TAB 10-1000MG 1 QL (30 tabs / 30 days)

BISPHOSPHONATES alendronate sodium 1 ibandronate sodium tabs 1 B/D PAMIDRONATE DISODIUM 6mg/ml 1 B/D pamidronate disodium 30mg/10ml, 90mg/10ml

1 B/D

pamidronate inj 30mg 1 B/D pamidronate inj 90mg 1 B/D risedronate sodium TABS 5mg, 35mg, 150mg

1

risedronate sodium TBEC 1 zoledronic acid inj 5mg/100ml 1 B/D, NM zoledronic inj 4mg/5ml 1 B/D, NM

CHELATING AGENTS CHEMET 1 DEPEN TITRATABS 1 JADENU 1 NM, LA, PA JADENU SPRINKLE 1 NM, LA, PA kionex sus 15gm/60ml 1


40

Drug Name Drug Tier Requirements/Limits sodium polystyrene sulfonate powder 1 sodium polystyrene sulfonate susp 1 sps susp 15gm/60ml 1 trientine hcl 1 PA

CONTRACEPTIVES altavera tab 1 alyacen 1/35 1 amethia 1 amethia lo 1 apri 1 aranelle 1 ashlyna 1 aubra 1 aviane 1 balziva 1 bekyree 1 blisovi 24 fe 1 blisovi fe 1.5/30 1 briellyn 1 camila 1 camrese lo 1 caziant pak 1 cryselle-28 1 cyclafem 1/35 1 cyclafem 7/7/7 1 cyred tab 1 dasetta 1/35 1 dasetta 7/7/7 1 deblitane 1 delyla 1 desogestrel & ethinyl estradiol 1 desogestrel-ethinyl estradiol (biphasic) 1 drospirenone-ethinyl estradiol 1 drospirenone-ethinyl estradiol-levomefolate calcium

1

ELLA 1 emoquette 1 enpresse-28 1 enskyce 1 errin 1 estarylla tab 0.25-35 1 ethynodiol diacet & eth estrad 1 ethynodiol tab 1-50 1 falmina 1 fayosim 1


41

Drug Name Drug Tier Requirements/Limits femynor 1 gianvi tab 3-0.02mg 1 hailey 24 fe 1 heather 1 incassia 1 introvale 1 isibloom 1 jasmiel 1 jolessa tab 0.15-0.03 mg 1 jolivette 1 juleber 1 junel 1.5/30 1 junel 1/20 1 junel fe 1.5/30 1 junel fe 1/20 1 junel fe 24 1 kaitlib fe 1 kariva 1 kelnor 1/35 1 kelnor 1/50 1 kurvelo 1 larin 1.5/30 1 larin 1/20 1 larin fe 1.5/30 1 larin fe 1/20 1 larissia tab 1 layolis fe 1 leena tab 1 lessina 1 levonest 1 levonor-eth est tab 0.15-0.02/0.025/0.03mg & eth est 0.01mg

1

levonor/ethi tab 1 levonorg-eth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7)

1

levonorg-eth est tab 0.15-0.03mg (84) & eth est tab 0.01mg(7)

1

levonorgestrel & eth estradiol 1 levonorgestrel-ethinyl estradiol 0.15-0.03mg (91-day)

1

levora 0.15/30-28 1 loryna 1 low-ogestrel 1 lutera 1 lyza 1 marlissa 1


42

Drug Name Drug Tier Requirements/Limits medroxyprogesterone acetate (contraceptive)

1

melodetta 24 fe 1 mibelas 24 fe 1 microgestin 1.5/30 1 microgestin 1/20 1 microgestin fe 1.5/30 1 microgestin fe 1/20 1 mili 1 mono-linyah tab 0.25-35 1 necon 0.5/35-28 1 nikki 1 nora-be tab 0.35mg 1 nore/eth/fer chw 0.4mg-35 1 noreth/ethin chw fe 1 norethin acet & estrad-fe 1 norethindrone (contraceptive) 1 norethindrone acet & eth estra 1 norgest/ethi tab 0.25/35 1 norgestimate-ethinyl estradiol (triphasic) 0.18-25/0.215-25/0.25-25 mg-mcg

1

norgestimate-ethinyl estradiol (triphasic) 0.18-35/0.215-35/0.25-35 mg-mcg

1

norlyroc 1 nortrel 0.5/35 (28) 1 nortrel 1/35 1 nortrel 7/7/7 1 NUVARING 1 ocella tab 3-0.03mg 1 orsythia 1 philith 1 pimtrea 1 pirmella 1/35 1 portia-28 1 previfem 1 reclipsen 1 rivelsa 1 setlakin tab 1 sharobel 1 sprintec 28 1 sronyx 1 syeda 1 tarina 24 fe 1 tarina fe 1/20 1 tilia fe 1 tri-estarylla 1


43

Drug Name Drug Tier Requirements/Limits tri-legest fe 1

tri-linyah 1tri-lo marzia 1tri-lo-estarylla 1tri-lo-sprintec 1tri-mili 1tri-previfem 1tri-sprintec 1tri-vylibra 1tri-vylibra lo 1trivora-28 1tulana 1tydemy 1velivet 1vienva 1viorele 1vyfemla 1vylibra 1wymzya fe 1xulane dis 150-35 1zarah 1zovia 1/35e 1

ENDOMETRIOSIS danazol CAPS 1SYNAREL 1

ENZYME REPLACEMENTS ALDURAZYME 1 NM, LA, PA CARBAGLU 1 NM, LA, PA CERDELGA 1 NM, PA CEREZYME 1 NM, LA, PA CYSTADANE 1 NM, LA CYSTAGON 1 NM, LA, PA FABRAZYME 1 NM, LA, PA KUVAN 1 NM, LA, PA levocarnitine (metabolic modifiers) 1 B/D LUMIZYME 1 NM, LA, PA miglustat 1 NM, PA NAGLAZYME 1 NM, LA, PA NITYR 1 NM, LA, PA ORFADIN 1 NM, LA, PA sodium phenylbutyrate 1 NM, PA

ESTROGENS DELESTROGEN 10mg/ml 1estradiol PTWK; TABS 1estradiol vaginal cream 1


44

Drug Name Drug Tier Requirements/Limits estradiol vaginal tab 1 estradiol valerate inj 1 fyavolv 1 jinteli 1 norethindrone acetate-ethinyl estradiol 1 yuvafem vaginal tablet 10 mcg 1

GLUCOCORTICOIDS cortisone acetate TABS 1 DEXAMETHASONE CONC 1 dexamethasone ELIX; SOLN; TABS 1 dexamethasone sodium phosphate 1 fludrocortisone acetate TABS 1 hydrocortisone TABS 1 methylpr ss inj 1 B/D methylpred pak 4mg 1 methylpred tab 4mg 1 B/D methylpred tab 8mg 1 B/D methylpred tab 16mg 1 B/D methylpred tab 32mg 1 B/D methylprednisolone acetate 1 B/D pred sod pho sol 5mg/5ml 1 B/D prednisolone sodium phosphate SOLN 15mg/5ml

1 B/D

prednisolone sol 15mg/5ml 1 B/D prednisolone sol 25mg/5ml 1 B/D PREDNISONE CON 5MG/ML 1 B/D prednisone pak 5mg 1 prednisone pak 10mg 1 prednisone sol 5mg/5ml 1 B/D prednisone tab 1mg 1 B/D prednisone tab 2.5mg 1 B/D prednisone tab 5mg 1 B/D prednisone tab 10mg 1 B/D prednisone tab 20mg 1 B/D prednisone tab 50mg 1 B/D SOLU-CORTEF 1

GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT 1 GLUCAGON EMERGENCY KIT 1 PROGLYCEM SUS 50MG/ML 1

MISCELLANEOUS cabergoline 1 calcitonin (salmon) 1 B/D cinacalcet hcl 30mg, 90mg 1 B/D, QL (120 tabs / 30

days), NM


45

Drug Name Drug Tier Requirements/Limits cinacalcet hcl 60mg 1 B/D, QL (60 tabs / 30

days), NM FORTEO 1 NM, PA GENOTROPIN 1 NM, PA GENOTROPIN MINIQUICK 1 NM, PA INCRELEX 1 NM, LA, PA KORLYM 1 NM, LA, PA LUPRON DEP-PED INJ 7.5MG 1 NM, PA LUPRON DEP-PED INJ 11.25MG (3-MONTH) 1 NM, PA LUPRON DEPOT-PED (1-MONTH 1 NM, PA LUPRON DEPOT-PED (3-MONTH 1 NM, PA NATPARA 1 NM, PA octreotide acetate 1 NM, PA PROLIA 1 QL (1 injection / 180

days), NM raloxifene tab 60mg 1 SIGNIFOR 1 NM, LA, PA SOMATULINE DEPOT 1 NM, PA SOMAVERT 1 NM, LA, PA TYMLOS 1 NM, PA XGEVA 1 NM, PA

PHOSPHATE BINDER AGENTS AURYXIA 1 QL (360 tabs / 30 days),

PA calcium acetate (phosphate binder) CAPS 1 QL (360 caps / 30 days) calcium acetate (phosphate binder) TABS 1 QL (360 tabs / 30 days) sevelamer carbonate PACK 2.4gm 1 QL (180 packets / 30

days) sevelamer carbonate PACK .8gm 1 QL (540 packets / 30

days) sevelamer carbonate TABS 1 QL (540 tabs / 30 days)

PROGESTINS medroxyprogesterone acetate tab 1 norethindrone acetate TABS 1

THYROID AGENTS levo-t 1 levothyroxine sodium TABS 1 levoxyl 1 liothyronine sodium TABS 1 methimazole TABS 1 propylthiouracil TABS 1 SYNTHROID 1 unithroid 1

VASOPRESSINS desmopressin acetate spray 1


46

Drug Name Drug Tier Requirements/Limits desmopressin acetate spray refrigerated 1 desmopressin acetate tabs 1 desmopressin inj 4mcg/ml 1 STIMATE 1 NM

GASTROINTESTINAL ANTIEMETICS

aprepitant 1 B/D aprepitant pak 80mg & 125mg 1 B/D compro supp 1 dronabinol 1 B/D, QL (60 caps / 30

days) EMEND SUSR 1 B/D granisetron hcl SOLN 1 granisetron hcl TABS 1 B/D meclizine hcl TABS 1 metoclopramide hcl SOLN; TABS 1 metoclopramide hcl inj 1 ondansetron hcl TABS 1 B/D ondansetron hcl inj 1 ondansetron hcl oral soln 1 B/D ondansetron odt 1 B/D prochlorperazine inj 1 prochlorperazine maleate TABS 1 prochlorperazine supp 1 promethazine hcl SYRP; TABS 1 PA; PA if 70 years and

older promethazine hcl inj 1 PA; PA if 70 years and

older scopolamine 1 QL (10 patches / 30

days), PA; PA if 70 years and older

ANTISPASMODICS dicyclomine hcl cap 10mg 1 dicyclomine hcl soln 10mg/5ml 1 dicyclomine hcl tab 20mg 1 glycopyrrolate tab 1mg 1 glycopyrrolate tab 2mg 1

H2-RECEPTOR ANTAGONISTS famotidine SUSR 1 famotidine TABS 20mg, 40mg 1 famotidine in nacl 1 famotidine inj 1 ranitidine hcl TABS 150mg, 300mg 1 ranitidine hcl inj 1 ranitidine syrup 1


47

Drug Name Drug Tier Requirements/Limits INFLAMMATORY BOWEL DISEASE

balsalazide disodium 1

budesonide ec 1colocort 1hydrocortisone (enema) 1mesalamine CPDR 1mesalamine ENEM 1mesalamine SUPP 1mesalamine TBEC 1.2gm 1mesalamine w/ cleanser 1sulfasalazine TABS 1sulfasalazine ec 1

LAXATIVES constulose 1enulose 1gavilyte-c 1gavilyte-g 1gavilyte-n/flavor pack 1generlac 1GOLYTELY 1lactulose SOLN 1lactulose (encephalopathy) 1NULYTELY/FLAVOR PACKS 1peg 3350-kcl-sod bicarb-sod chloride-sod sulfate

1

peg 3350-potassium chloride-sod bicarbonate-sod chloride

1

peg 3350/electrolytes 1PLENVU 1SUPREP BOWEL PREP KIT 1trilyte 1

MISCELLANEOUS alosetron hcl 1 PA AMITIZA CAP 8MCG 1 QL (180 caps / 30 days) AMITIZA CAP 24MCG 1 QL (60 caps / 30 days) cromolyn sodium (mastocytosis) 1diphenoxylate w/ atropine 1GATTEX 1 NM, LA, PA LINZESS 1 QL (30 caps / 30 days) loperamide hcl CAPS 1misoprostol TABS 1MOVANTIK 12.5mg 1 QL (60 tabs / 30 days) MOVANTIK 25mg 1 QL (30 tabs / 30 days) RELISTOR SOLN 1 PA sucralfate TABS 1


48

Drug Name Drug Tier Requirements/Limits ursodiol CAPS; TABS 1 XIFAXAN 550mg 1

PA PANCREATIC ENZYMES

CREON 1ZENPEP 1

PROTON PUMP INHIBITORS DEXILANT 1 QL (30 caps / 30 days) esomeprazole magnesium 1 QL (30 caps / 30 days),

ST lansoprazole CPDR 1 QL (30 caps / 30 days) omeprazole cap 10mg 1omeprazole cap 20mg 1omeprazole cap 40mg 1pantoprazole sodium SOLR 1pantoprazole sodium tbec 1rabeprazole sodium 1 QL (30 tabs / 30 days)

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA

alfuzosin hcl 1 QL (30 tabs / 30 days) dutasteride CAPS 1 QL (30 caps / 30 days) dutasteride-tamsulosin hcl 1 QL (30 caps / 30 days) finasteride TABS 5mg 1tamsulosin hcl 1

MISCELLANEOUS bethanechol chloride TABS 1potassium citrate (alkalinizer) er tabs 1

URINARY ANTISPASMODICS MYRBETRIQ 1 QL (30 tabs / 30 days) oxybutynin chloride SYRP 1oxybutynin chloride TABS 1oxybutynin chloride TB24 5mg 1 QL (30 tabs / 30 days) oxybutynin chloride TB24 10mg, 15mg 1 QL (60 tabs / 30 days) tolterodine tartrate CP24 1 QL (30 caps / 30 days),

ST tolterodine tartrate TABS 1 ST TOVIAZ 1 QL (30 tabs / 30 days) trospium chloride TABS 1 QL (60 tabs / 30 days)

VAGINAL ANTI-INFECTIVES clindamycin phosphate vaginal 1metronidazole vaginal 1terconazole vaginal 1vandazole 1

PA - availa

Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not ble at mail-order B/D - Covered under Medicare B or D LA - Limited Access

49

Drug Name Drug Tier Requirements/Limits HEMATOLOGIC

ANTICOAGULANTS COUMADIN 1

ELIQUIS 2.5mg 1 QL (60 tabs / 30 days) ELIQUIS 5mg 1 QL (74 tabs / 30 days) ELIQUIS STARTER PACK 1 QL (74 tabs / 30 days) enoxaparin sodium 1fondaparinux sodium 1heparin sod (porcine) in d5w 1heparin sod inj 1000/ml 1 B/D heparin sod inj 5000/ml 1 B/D heparin sod inj 10000/ml 1 B/D heparin sod inj 20000/ml 1 B/D HEPARIN SODIUM/NACL 0.45% 1jantoven 1PRADAXA 1 QL (60 caps / 30 days) warfarin sodium 1XARELTO 2.5mg 1 QL (60 tabs / 30 days) XARELTO 10mg, 15mg, 20mg 1 QL (30 tabs / 30 days) XARELTO STARTER PACK 1 QL (51 tabs / 30 days)

HEMATOPOIETIC GROWTH FACTORS PROCRIT 1 NM, PA ZARXIO 1 NM, PA

MISCELLANEOUS anagrelide hcl 1BERINERT 1 QL (24 boxes / 30

days), NM, LA, PA cilostazol 1DROXIA 1ENDARI 1 NM, LA, PA FIRAZYR 1 QL (9 syringes / 30

days), NM, PA HAEGARDA 2000unit 1 QL (30 vials / 30 days),

NM, LA, PA HAEGARDA 3000unit 1 QL (20 vials / 30 days),

NM, LA, PA pentoxifylline TBCR 1PROMACTA PACK 1 QL (360 packets / 30

days), NM, LA, PA PROMACTA TABS 12.5mg, 25mg 1 QL (30 tabs / 30 days),

NM, LA, PA PROMACTA TABS 50mg, 75mg 1 QL (60 tabs / 30 days),

NM, LA, PA tranexamic acid SOLN; TABS 1

PLATELET AGGREGATION INHIBITORS aspirin-dipyridamole 1


50

Drug Name Drug Tier Requirements/Limits BRILINTA 1clopidogrel tab 75mg 1prasugrel hcl 1

IMMUNOLOGIC AGENTS DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS)

HUMIRA 10mg/0.1ml, 20mg/0.2ml 1

QL (2 injections / 28 days), NM, PA

HUMIRA 40mg/0.4ml 1 QL (6 injections / 28 days), NM, PA

HUMIRA INJ 10MG/0.2ML 1 QL (2 syringes / 28 days), NM, PA

HUMIRA KIT 20MG/0.4ML 1 QL (2 syringes / 28 days), NM, PA

HUMIRA KIT 40MG/0.8ML 1 QL (6 syringes / 28 days), NM, PA

HUMIRA PEDIATRIC CROHNS DISEASE 1 NM, PA HUMIRA PEN 1 QL (6 pens / 28 days),

NM, PA HUMIRA PEN CD/UC/HS STARTER 1 NM, PA HUMIRA PEN INJ CD/UC/HS STARTER 1 NM, PA HUMIRA PEN INJ PS/UV STARTER 1 NM, PA HUMIRA PEN-PS/UV STARTER 1 NM, PA hydroxychloroquine sulfate 1leflunomide TABS 1 QL (30 tabs / 30 days) methotrexate sodium tabs 1REMICADE 1 NM, PA RENFLEXIS 1 NM, LA, PA STELARA SOLN 45mg/0.5ml 1 QL (1 vial / 28 days),

NM, LA, PA STELARA SOSY 1 QL (1 syringe / 28

days), NM, PA XATMEP 1 B/D XELJANZ 1 QL (60 tabs / 30 days),

NM, PA XELJANZ XR 1 QL (30 tabs / 30 days),

NM, PA IMMUNOGLOBULINS

BIVIGAM 1 NM, PA GAMASTAN S/D 1 B/D, NM GAMMAGARD LIQUID 1 NM, PA GAMMAGARD S/D 1 NM, PA GAMMAKED 1 NM, PA GAMMAPLEX 1 NM, PA GAMMAPLEX 10GM/100ML 1 NM, PA GAMUNEX-C 1 NM, PA OCTAGAM 1 NM, PA


51

Drug Name Drug Tier Requirements/Limits PANZYGA 1

NM, PA PRIVIGEN 1 NM, PA

IMMUNOMODULATORS ACTIMMUNE 1 NM, LA, PA ARCALYST 1 NM, PA INTRON-A INJ 10MU 1 B/D, NM INTRON-A INJ 18MU 1 B/D, NM INTRON-A INJ 25MU 1 B/D, NM INTRON-A INJ 50MU 1 B/D, NM

IMMUNOSUPPRESSANTS azathioprine TABS 1 B/D BENLYSTA 1 NM, PA cyclosporine CAPS; SOLN 1 B/D, NM cyclosporine modified (for microemulsion) 1 B/D, NM gengraf 1 B/D, NM mycophenolate mofetil CAPS; SUSR; TABS

1 B/D, NM

mycophenolate sodium tbec 1 B/D, NM NULOJIX 1 B/D, NM PROGRAF PACK 1 B/D, NM SANDIMMUNE SOLN 100mg/ml 1 B/D, NM sirolimus SOLN; TABS 1 B/D, NM tacrolimus CAPS 1 B/D, NM ZORTRESS TAB 0.5MG 1 B/D, NM ZORTRESS TAB 0.25MG 1 B/D, NM ZORTRESS TAB 0.75MG 1 B/D, NM ZORTRESS TAB 1MG 1 B/D, NM

VACCINES ACTHIB 1ADACEL 1BCG VACCINE 1BEXSERO 1BOOSTRIX 1DAPTACEL 1DIPHTHERIA/TETANUS TOXOID 1 B/D ENGERIX-B SUSP 1 B/D GARDASIL 9 1HAVRIX 1HIBERIX 1IMOVAX RABIES (H.D.C.V.) 1 B/D INFANRIX 1IPOL INACTIVATED IPV 1IXIARO 1KINRIX 1M-M-R II 1


52

Drug Name Drug Tier Requirements/Limits MENACTRA 1

MENVEO 1PEDIARIX 1PEDVAX HIB 1PENTACEL 1PROQUAD 1QUADRACEL 1RABAVERT 1 B/D RECOMBIVAX HB 1 B/D ROTARIX 1ROTATEQ 1SHINGRIX 1 QL (2 vials per lifetime) TDVAX 1 B/D TENIVAC 1 B/D TRUMENBA 1TWINRIX INJ 1TYPHIM VI 1VAQTA 1VARIVAX 1YF-VAX 1ZOSTAVAX 1 QL (1 vial per lifetime)

NUTRITIONAL/SUPPLEMENTS ELECTROLYTES

klor-con 8 1klor-con 10 1klor-con m10 1klor-con m15 1klor-con m20 1klor-con pak 20meq 1klor-con spr cap 8meq 1klor-con spr cap 10meq 1MAGNESIUM SULFATE SOLN 2gm/50ml, 4gm/100ml, 4gm/50ml, 20gm/500ml, 40gm/1000ml

1

magnesium sulfate SOLN 2gm/50ml, 4gm/100ml, 4gm/50ml, 20gm/500ml, 40gm/1000ml, 50%

1

MAGNESIUM SULFATE IN D5W 1magnesium sulfate in dextrose 1magnesium sulfate inj 50% 1potassium chloride CPCR 1potassium chloride PACK 1potassium chloride SOLN 10%, 20% 1potassium chloride TBCR 1potassium chloride microencapsulated crystals er

1

Drug Name Drug Tier Requirements/Limits sodium chloride SOLN 2.5meq/ml 1sodium fluoride chew; tab; 1.1 (0.5 f) mg/ml soln

1

TPN ELEC TROLYTES 1 B/DIV NUT RITION

AMINOSYN II INJ 10 % 1 B/DAMINOSYN-PF 7% 1 B/DAMINOSYN-PF INJ 10 % 1 B/DCLINIMIX 4.2 5%/DEXTROSE 5% 1 B/DCLINIMIX 5%/DEXTRO SE 15 % 1 B/DCLINIMIX 5%/DEXTRO SE 20 % 1 B/DCLINIMIX INJ 4.2 5/D10 1 B/DFREAMINE HBC 6.9 % 1 B/DFREAMINE III 1 B/Dhepatamine 1 B/DINTRALIPID 30% 1 B/DINTRALIPID INJ 20 % 1 B/DNEPHRAMINE 1 B/DNUTRILIPID INJ 20 % 1 B/DPREMASOL 10% 1 B/DPROCALAMINE 1 B/DPROSOL 1 B/DTRAVASOL 1 B/DTROPHAMINE INJ 10 % 1 B/D

IV REPLA CEMENT SO LUTIONS dextrose 2.5 %/nacl 0.4 5% 1dextrose 5% 1DEXTROSE 5% /ELEC TROLYTE 1dextrose 5%/na cl 0.2 % 1DEXTROSE 5%/NACL 0.3 % 1dextrose 5%/na cl 0.9 % 1dextrose 5%/na cl 0.3 3% 1dextrose 5%/na cl 0.4 5% 1dextrose 5%/na cl 0.2 25% 1dextrose 5%/potassium chl 1dextrose 10 % flex contain 1DEXTROSE 10 % W/ SOD IUM CH LORIDE 0.2%

1

dextrose 10 %/nacl 0.4 5% 1dextrose 50 % 1dextrose in lactate d ringe rs 1dextrose inj 70 % 1IONOSOL-MB/DEXTROSE 5% 1ISOLYTE P 1ISOLYTE S 1


53

Drug Name Drug Ti er Requirements/Limits kcl0.15%/d5w/nacl0.2% 1KCL 0.3 %/D5W/NACL 0.9% 1kcl 0.3 %/d5w/nacl 0.4 5% 1kcl 0.1 5%/d5w/nacl 0.9 % 1KCL 0.1 5%/D5W/NACL 0.2 25% 1kcl 0.0 75%/d5w/nacl 0.4 5% 1kcl/d5w inj 0.3 % 1kcl/d5w/nacl inj 0.2 2%/0.45% 1kcl/d5w/nacl inj .15 /.33% 1kcl/d5w/nacl inj .15 /.45% 1kcl/nacl inj 0.3 -0.9 1kcl/nacl inj 0.1 5%-0.9% 1lactated ringe r's 1NORMOSOL-M IN D5 W 1NORMOSOL-R 1NORMOSOL-R IN D5 W 1PLASMA-LYTE A 1PLASMA-LYTE-148 1pot chloride inj 2meq/ml 1potassium chloride SOLN .4m eq/ml, 2meq/ml, 10 meq/100ml, 10 meq/50ml, 20meq/100ml, 40 meq/100ml

1

potassium chloride in na cl 1sodium chloride SOLN 3%, 5% 1sodium chloride 0.4 5% 1sodium chloride inj 0.9 % 1

VITAMINS calcitriol CAPS 1 B/D calcitriol inj 1 B/D calcitriol ora l soln 1 mcg/ml 1 B/D M-NATAL PLUS 1paricalcitol CAPS 1 B/D PNV FOL IC ACID + IRON MUL 1PRENATAL 1PRENATAL PLUS 1PRENATAL PLUS LOW IRON 1RAYALDEE 1TRICARE 1

OPHTHALMIC ANTI-INFECTIVE/ANTI-INFLAMMATORY

bacitracin-poly-neomycin-hc 1BLEPHAMIDE OINT 1neomycin-polymy-dexameth 1neomycin-polymyxin-hc (ophth) 1sulfacetamide sod-predn isolone 1


54

Drug Name Drug Ti er Requirements/Limits TOBRADEX OINT 1TOBRADEX ST 1tobramycin-dexamethasone 1ZYLET 1

ANTI-INFECTIVES AZASITE 1bacitracin (ophtha lmic) 1bacitracin-polymyxin b (ophth) 1BESIVANCE 1CILOXAN OINT 1ciprofloxacin hcl (ophth) 1erythromycin (ophth) 1gatifloxacin (ophth) 1gentak 1gentamicin sulfa te soln (ophth) 1MOXEZA 1moxifloxacin hcl (ophth) 1NATACYN 1neomycin-bacitracin zn-polymyxin 1neomycin-polymyxin-gramicidin 1ofloxacin (ophth) 1polymyxin b-trim ethoprim 1sulfacetamide sodium (ophth) 1tobramycin (ophth) 1trifluridine 1ZIRGAN 1

ANTI-INFLAMMATORIES ALREX 1bromfenac sodium (ophth) 1BROMSITE 1dexamethasone sodium phospha te (ophth) 1diclofenac sodium (ophth) 1DUREZOL 1fluorometholone 1flurbiprofen sodium 1ILEVRO 1ketorolac trometh amine (ophth) 1LOTEMAX GEL; OINT 1loteprednol etabonate 1prednisolone ace tate (ophth) 1PREDNISOLONE SOD IUM PHO SPHATE (OPHTH)

1

PROLENSA 1ANTIALLERGICS

azelastine drop 0.05% 1


55

Drug Name Drug Ti er Requirements/Limits BEPREVE 1cromolyn sodium (ophth) 1LASTACAFT 1 olopatadine hcl 0.2 % 1PAZEO 1

ANTIGLAUCOMA ALPHAGAN P SOL 0.1% 1AZOPT 1betaxolol hcl (ophth) 1BETOPTIC-S 1 brimonidine sol 0.2 % 1brimonidine sol 0.1 5% 1carteolol hcl (ophth) 1COMBIGAN 1 dorzolamide hcl 1dorzolamide hcl-timolol malea te 1latanoprost SOLN 1levobunolol hcl 1 LUMIGAN 1PHOSPHOLINE IODIDE 1pilocarpine hcl SOLN 1RHOPRESSA 1 SIMBRINZA 1timolol malea te (ophth) soln 1timolol malea te ge l 1 timolol malea te ophth soln 0.5 % (once-daily)

1

TRAVATAN Z 1MISCELLANEOUS

CYSTARAN 1 NM, LA , PA proparacaine hcl SOLN 1RESTASIS 1 QL (60 singl e use vials /

30 days) RESTASIS MULTIDOSE 1 QL (1 bottle / 30 days)

RESPIRATORY ANTICHOLINERGIC/BETA AGONIST COMBINATIONS

ANORO ELLIPTA 1 QL (60 bli sters / 30 days)

BEVESPI AEROSPHE RE 1 QL (1 inhaler / 30 days)COMBIVENT RE SPIMAT 1 QL (2 inhaler s / 30

days) ipratropium-albuterol nebu 1 B/D TRELEGY ELLIPTA 1 QL (60 bli sters / 30

days)


56

Drug Name Drug Ti er Requirements/Limits ANTICHOLINERGICS

ATROVENT HFA 1 QL (2 inhaler s / 30 days)

INCRUSE ELLIPTA 1 QL (30 bli sters / 30 days)

ipratropium bromide SOLN 1 B/D ipratropium bromide (nas al) 1

ANTIHISTAMINES azelastine spr 0.1 % 1azelastine spr 0.1 5% 1cetirizine syru p 1cyproheptadine hcl SYRP; TAB S 1 PA; PA if 70 years an d

older diphenhydramine hcl inj 50 mg/ml 1hydroxyzine hcl SYRP; TAB S 1 PA; PA if 70 years an d

older hydroxyzine hcl inj 1 PA; PA if 70 years an d

older hydroxyzine pamoate CAPS 25mg, 50mg 1 PA; PA if 70 years an d

older levocetirizine dihydrochloride 1

BETA AGONISTS albuterol sulfate AERS 10 8mcg/act 1 QL (2 inhaler s / 30

days); (gene ric of Proair HFA)

albuterol sulfate AERS 10 8mcg/act 1 QL (2 inhaler s / 30 days); (gene ric of Ventolin HFA)

albuterol sulfate NEBU 1 B/D albuterol sulfate SYRP 1albuterol sulfate TABS 1albuterol sulfate TB12 1levalbuterol hcl NEBU 1 B/D levalbuterol hcl soln nebu conc 1.2 5 mg/0.5ml

1 B/D

levalbuterol tartrate hf a 1 QL (2 inhaler s / 30 days)

SEREVENT DI SKUS 1 QL (60 inhalations / 30 days)

terbutaline sulfate TABS 1 VENTOLIN HFA 1 QL (2 inhaler s / 30

days) LEUKOTRIENE MODULA TORS

montelukast sodium CHEW; PACK; TAB S 1zafirlukast 1


57

Drug Name Drug Ti er Requirements/Limits MAST CELL STABILIZERS

cromolyn sod neb 20 mg/2ml 1 B/D MISCELLANEOUS

acetylcysteine SOLN 10 %, 20% 1 B/D ARALAST NP 1 NM, LA , PA DALIRESP 1 epinephrine (anaphylaxis) .15mg/0.3ml, .3mg/0.3ml

1 (generic of EpiPen)

epinephrine (anaphylaxis) .15mg/0.15ml, .3mg/0.3ml

1 (generic of Adrenaclick)

ESBRIET 1 NM, PA KALYDECO 1 NM, PA NUCALA 1 NM, LA , PA OFEV 1 NM, PA ORKAMBI 1 NM, PA PROLASTIN-C 1 NM, LA , PA PULMOZYME 1 NM, PA SYMDEKO 1 NM, LA , PA THEO-24 1 theophylline 1 XOLAIR 1 NM, LA , PA ZEMAIRA 1 NM, LA , PA

NASAL STERO IDS flunisolide (na sal) 1 QL (3 bottles / 30 days) fluticasone propionate (nasal) 1 QL (1 bottle / 30 days)

STEROID INHAL ANTS ARNUITY ELLIPTA 1 QL (30 inhalations / 30

days) budesonide (inhalation) .25mg/2ml, .5mg/2ml

1 B/D

FLOVENT DISKUS 50mcg/blist, 100mcg/blist

1 QL (120 inhalations / 30 days)

FLOVENT DISKUS 250mcg/blist 1 QL (240 inhalations / 30 days)

FLOVENT HFA 1 QL (2 inhaler s / 30 days)

PULMICORT FL EXHALER 1 QL (2 inhaler s / 30 days)

STEROID/BETA-AGONIST COM BINATIONS ADVAIR DI SKUS 1 QL (60 inhalations / 30

days) ADVAIR HFA 1 QL (1 inhaler / 30 days) BREO ELLIPTA 1 QL (60 bli sters / 30

days) SYMBICORT 1 QL (1 inhaler / 30 days)


58

Drug Name Drug Ti er Requirements/Limits TOPICAL

DERMATOLOGY, ACNE amnesteem 1 PA avita 1 QL (45 gra ms / 30

days), PA benzoyl pero xide-erythromycin 1claravis 1 PA clindamycin phosphate (topical) GEL 1 QL (75 gra ms / 30 days) clindamycin phosphate (topical) LOTN 1clindamycin phosphate (topical) SOLN 1 QL (60 mL / 30 days) ery pad 2% 1erythromycin (acn e aid) 1isotretinoin CAPS 1 PA myorisan 1 PA sulfacetamide sodium (acn e) 1tretinoin CREA 1 QL (45 gra ms / 30

days), PA tretinoin GEL .01%, .02 5% 1 QL (45 gra ms / 30

days), PA zenatane 1 PA

DERMATOLOGY, ANTIBIOTICS gentamicin sulfa te (topi cal) 1mupirocin OINT 1 QL (220 grams / 30

days) silver sulfa diazine CREA 1ssd 1SULFAMYLON CREA 1

DERMATOLOGY, ANTIFUNGALS ciclopirox CREA 1 QL (90 gra ms / 30 days) ciclopirox SUSP 1 QL (60 mL / 30 days) clotrimazole (topi cal) CREA 1clotrimazole (topi cal) SOLN 1 QL (30 mL / 30 days) clotrimazole w/ beta methasone CREA 1ketoconazole cream 1 QL (60 gra ms / 30 days) nyamyc 1 QL (60 gra ms / 30 days) nystatin (topi cal) CREA; OINT 1nystatin (topi cal) POWD 1 QL (60 gra ms / 30 days) nystop 1 QL (60 gra ms / 30 days)

DERMATOLOGY, ANTIPSORIATICS acitretin 1 PA calcipotriene CREA; OINT 1 QL (120 grams / 30

days), PA calcipotriene SOLN 1 QL (120 mL / 30 days),

PA calcitrene 1 QL (120 grams / 30

days), PA


59

Drug Name Drug Ti er Requirements/Limits tazarotene CREA 1 QL (60 gra ms / 30

days), PA TAZORAC CREA .05% 1 QL (60 gra ms / 30

days), PA DERMATOLOGY, ANTISEBORRHEICS

ketoconazole shampoo 1selenium sulfide LOTN 1

DERMATOLOGY, CORTICOSTEROIDS ala-cort 1alclometasone dipropionate 1betamethasone dip ropionate (topi cal) 1betamethasone dip ropionate au gmented 1betamethasone va lerate CREA; LOTN; OINT

1

ENSTILAR 1 QL (120 grams / 30 days), PA

fluocinolone ace tonide CREA; OIL; OINT 1fluocinolone ace tonide SOLN 1 QL (90 mL / 30 days) fluocinolone ace tonide oil body 1fluocinonide CREA .05% 1 QL (120 grams / 30

days) fluocinonide GEL 1 QL (60 gra ms / 30 days) fluocinonide OINT 1 QL (60 gra ms / 30 days) fluocinonide SOLN 1 QL (60 mL / 30 days) fluocinonide emulsified base 1 QL (120 grams / 30

days) fluticasone propionate CREA; OINT 1halobetasol propionate CREA; OINT 1 QL (50 gra ms / 30 days) hydrocortisone (topi cal) cre am 1% 1hydrocortisone (topi cal) cre am 2.5 % 1hydrocortisone (topi cal) loti on 2.5 % 1hydrocortisone (topi cal) oint 2.5 % 1hydrocortisone butyr ate cre am 0.1 % 1 QL (45 gra ms / 30 days) hydrocortisone butyr ate oint 0.1 % 1 QL (45 gra ms / 30 days) mometasone fu roate CREA; OINT; SOL N 1TEXACORT SOL N 2.5 % 1triamcinolone ace tonide (topical) CREA .1%

1 QL (454 grams / 30 days)

triamcinolone ace tonide (topical) CREA .025%, .5%

1

triamcinolone ace tonide (topical) LOTN 1triamcinolone ace tonide (topical) OINT 1

DERMATOLOGY, LOCAL ANES THETICS glydo 1 QL (30 mL / 30 days),

PA


60

Drug Name Drug Ti er Requirements/Limits lidocaine PTCH 1 QL (3 patch es / 1 day ),

PA lidocaine hcl GEL 1 QL (30 mL / 30 days),

PA lidocaine hcl SOLN 4% 1 QL (50 mL / 30 days),

PA lidocaine oint 5% 1 QL (50 gra ms / 30

days), PA lidocaine-prilocaine 1 QL (30 gra ms / 30

days), PA DERMATOLOGY, MISCELLANEOUS SKIN AND MUC OUS MEMB RANE

ammonium lactate CREA; LOTN 1diclofenac sodium (topi cal) 1% ge l 1 QL (100 0 gra ms / 30

days), PA doxepin hcl (an tipruritic) 1 QL (45 gra ms / 30

days), PA fluorouracil (topi cal) CREA 5% 1 QL (40 gra ms / 30 days) fluorouracil (topi cal) SOLN 1 QL (10 mL / 30 days) imiquimod CREA 5% 1 QL (24 pack ets / 30

days) metronidazole (topi cal) CREA; LOTN 1metronidazole ge l 0.7 5% 1PANRETIN 1 QL (60 gra ms / 30 days) PENNSAID 1 QL (224 grams / 28

days), PA PICATO .05% 1 QL (2 tubes / 30 days) PICATO .015% 1 QL (3 tubes / 30 days) podofilox SOLN 1procto-med hc 1procto-pak 1proctosol hc cre 2.5% 1proctozone-hc 1RECTIV 1 QL (3 0 gra ms / 30 days) rosadan cre 0.75% 1tacrolimus (topi cal) 1 QL (100 grams / 30

days) TARGRETIN GEL 1 QL (60 gra ms / 30

days), NM, PA VALCHLOR 1 QL (60 gra ms / 30

days), NM, LA , PA DERMATOLOGY, SCABICIDES AND PEDIC ULIDES

malathion 1permethrin cre 5% 1

DERMATOLOGY, WOUND CARE AGE NTS acetic acid .25% 1REGRANEX 1 QL (30 gra ms / 30

days), PA


61

62

Drug Name Drug Ti er Requirements/Limits SANTYL 1 sodium chlor sol 0.9 % irr 1 water for irrigation, sterile 1

MOUTH/THROAT/DENTAL AGE NTS cevimeline hcl 1chlorhexidine glucona te (mouth-thro at) 1 clotrimazole LOZG 1lidocaine hcl (mouth-thro at) 1 nystatin (mouth-thro at) 1 paroex sol 0.1 2% 1periogard 1 pilocarpine hcl (ora l) 1 triamcinolone ace tonide (mouth) 1

OTIC acetic acid (otic) 1 CIPRODEX 1flac 1fluocinolone ace tonide (otic) 1 neomycin-polymyxin-hc (otic) 1 ofloxacin (otic) 1

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered u nder Medicare B or D LA - Limited Access

63

Index A abacavir sulfate ................................

...............

.................................................................... ...........................

....................................... ........................

......................................... ...................................

... ... ...

............ ..................................

....................................... ...............................

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..................................................................................

............................... ................

................................... .......................................

.......................... .....................................

........................................... ..............................................

............................. ....................................

....................................

11abacavir sulfate-lamivudine 12abacavir sulfate-lamivudine-zidovudine12 ABELCET 10ABILIFY MAINTENA 31abiraterone acetate 17ABRAXANE 16acamprosate calcium 36acarbose 37acebutolol hcl 23acetaminophen w/ codeine 300-15mg 7acetaminophen w/ codeine 300-30mg 7acetaminophen w/ codeine 300-60mg 7acetaminophen w/ codeine soln 7acetazolamide 24acetic acid 61acetic acid (otic) 62acetylcysteine 58acitretin 59ACTHIB 51ACTIMMUNE 51acyclovir 13acyclovir sodium 13ADACEL 51adefovir dipivoxil 13ADEMPAS 25adriamycin 16adrucil inj 16ADVAIR DISKUS 58ADVAIR HFA 58AFINITOR 18AFINITOR DISPERZ 18AIMOVIG 34ala-cort 60albendazole 9albuterol sulfate 57alclometasone dipropionate 60ALDURAZYME 43ALECENSA 18alendronate sodium 39alfuzosin hcl 48ALIMTA 16ALINIA 9aliskiren fumarate 25allopurinol tab 7alosetron hcl 47

ALPHAGAN P SOL 0.1% ..........................................

....................... .......................... .........................

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........................................

........................................

.......................................

..........................................

..........................................

..........................................

...................................... .......

................................................. ............................

.....................................

56 alprazolam tab 0.25mg 26 alprazolam tab 0.5mg 26 alprazolam tab 1mg 26 alprazolam tab 2 mg 26 ALREX 55 altavera tab 40 ALUNBRIG 18 alyacen 1/35 40 amantadine hcl 30 AMBISOME 10 ambrisentan 25 amethia 40 amethia lo 40 amikacin sulfate 9 amiloride & hydrochlorothiazide 24 amiloride hcl 24 AMINOSYN II INJ 10% 53 AMINOSYN-PF 7% 53 AMINOSYN-PF INJ 10% 53 amiodarone hcl soln 22 amiodarone tab 100mg 22 amiodarone tab 200mg 22 amiodarone tab 400mg 22 AMITIZA CAP 24MCG 47 AMITIZA CAP 8MCG 47 amitriptyline hcl 29 amlodipine besylate 23 amlodipine besylate-benazepril hcl cap 10-20 mg 21 amlodipine besylate-benazepril hcl cap 10-40 mg 21 amlodipine besylate-benazepril hcl cap 2.5-10 mg 21 amlodipine besylate-benazepril hcl cap 5-10 mg 21 amlodipine besylate-benazepril hcl cap 5-20 mg 21 amlodipine besylate-benazepril hcl cap 5-40 mg 21 amlodipine besylate-olmesartan medoxomil 21 amlodipine besylate-valsartan tab 21 amlodipine-valsartan-hydrochlorothiazide tab 21 ammonium lactate 61 amnesteem 59

64

amoxapine ....................................... .......................................

................................................

.........................................

................................................

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................................................

................................................

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.............................................

.............................................

.............................................

.................................................

............................................

29 amoxicillin 15 amoxicillin & pot clavulanate 200/5ml susr 15 amoxicillin & pot clavulanate 200-28.5 chw tabs 15 amoxicillin & pot clavulanate 250/5ml susr 15 amoxicillin & pot clavulanate 250-125 tabs 15 amoxicillin & pot clavulanate 400/5ml susr 15 amoxicillin & pot clavulanate 400-57 chw tabs 15 amoxicillin & pot clavulanate 500-125 tabs 15 amoxicillin & pot clavulanate 600/5ml susr 15 amoxicillin & pot clavulanate 875-125 tabs 15 amoxicillin & pot clavulanate er 12hr 1000-62.5 tabs 15 amphetamine-dextroamphetamine cap sr 24hr 10 mg 33 amphetamine-dextroamphetamine cap sr 24hr 15 mg 33 amphetamine-dextroamphetamine cap sr 24hr 20 mg 33 amphetamine-dextroamphetamine cap sr 24hr 25 mg 33 amphetamine-dextroamphetamine cap sr 24hr 30 mg 33 amphetamine-dextroamphetamine cap sr 24hr 5 mg 33 amphetamine-dextroamphetamine tab 10 mg 33 amphetamine-dextroamphetamine tab 12.5 mg 33 amphetamine-dextroamphetamine tab 15 mg 33 amphetamine-dextroamphetamine tab 20 mg 33 amphetamine-dextroamphetamine tab 30 mg 33 amphetamine-dextroamphetamine tab 5 mg 33 amphetamine-dextroamphetamine tab 7.5 mg 33

amphotericin b ................................. ............

........................ ....................................

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............................................. ...............................................

....................................... ..........................................

...........................................................

..........................

10 ampicillin & sulbactam sodium 15 ampicillin cap 500mg 15 ampicillin inj 15 ampicillin sodium 15 ANADROL-50 36 anagrelide hcl 49 anastrozole 18 ANDRODERM 36 ANORO ELLIPTA 56 APOKYN 30 aprepitant 46 aprepitant pak 80mg & 125mg 46 apri 40 APTIOM 26 APTIVUS 11 ARALAST NP 58 aranelle 40 ARCALYST 51 aripiprazole odt 31 aripiprazole oral solution 1 mg/ml . 31 aripiprazole tab 31 ARISTADA 31 ARISTADA INITIO 31 armodafinil 36 ARNUITY ELLIPTA 58 ashlyna 40 aspirin-dipyridamole 49 atazanavir sulfate 11 atenolol 23 atenolol & chlorthalidone 23 atomoxetine hcl 33 atorvastatin calcium 22 atovaquone 9 atovaquone-proguanil hcl 11 ATRIPLA 12 ATROVENT HFA 57 aubra 40 AURYXIA 45 AUSTEDO 35 AVASTIN 17 aviane 40 avita 59 azacitidine 16 AZASITE 55 azathioprine 51 azelastine drop 0.05% 55 azelastine spr 0.1% 57

65

azelastine spr 0.15% ............................................................

.....................................................................................

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57 azithromycin 14 AZOPT 56 aztreonam 9 B bacitracin (ophthalmic) 55 bacitracin-polymyxin b (ophth) 55 bacitracin-poly-neomycin-hc 54 baclofen 35 balsalazide disodium 47 BALVERSA 19 balziva 40 BANZEL SUS 40MG/ML 26 BANZEL TAB 200MG 26 BANZEL TAB 400MG 26 BARACLUDE 13 BASAGLAR KWIKPEN 37 BCG VACCINE 51 BD ALCOHOL SWABS 37 BD ULTRAFINE/NANO PEN NEEDLES 37 BD ULTRAFINE INSULIN SYRINGE 37 bekyree 40 benazepril & hydrochlorothiazide 21 benazepril hcl 21 BENDEKA 16 BENLYSTA 51 benzoyl peroxide-erythromycin 59 benztropine mesylate inj 30 benztropine mesylate tab 0.5mg 30 benztropine mesylate tab 1mg 30 benztropine mesylate tab 2mg 30 BEPREVE 56 BERINERT 49 BESIVANCE 55 betamethasone dipropionate (topical) 60 betamethasone dipropionate augmented

60 betamethasone valerate 60 BETASERON 35 betaxolol hcl 23 betaxolol hcl (ophth) 56 bethanechol chloride 48 BETOPTIC-S 56 BEVESPI AEROSPHERE 56 bexarotene 20 BEXSERO 51 bicalutamide 18 BICILLIN L-A 15

BIKTARVY .................................................

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12 bisoprolol & hydrochlorothiazide 23 bisoprolol fumarate 23 BIVIGAM 50 BLEPHAMIDE 54 blisovi 24 fe 40 blisovi fe 1.5/30 40 BOOSTRIX 51 BORTEZOMIB 17 bosentan 25 BOSULIF 19 BRAFTOVI 19 BREO ELLIPTA 58 briellyn 40 BRILINTA 50 brimonidine sol 0.15% 56 brimonidine sol 0.2% 56 BRIVIACT INJ 50MG/5ML 26 BRIVIACT SOL 10MG/ML 26 BRIVIACT TAB 100MG 26 BRIVIACT TAB 10MG 26 BRIVIACT TAB 25MG 26 BRIVIACT TAB 50MG 26 BRIVIACT TAB 75MG 26 bromfenac sodium (ophth) 55 bromocriptine mesylate 30 BROMSITE 55 budesonide (inhalation) 58 budesonide ec 47 bumetanide inj 0.25/ml 24 bumetanide tab 24 buprenorphine hcl 36 buprenorphine hcl-naloxone hcl dihydrate 12-3mg 36 buprenorphine hcl-naloxone hcl dihydrate 2-0.5mg 36 buprenorphine hcl-naloxone hcl dihydrate 4-1mg 36 buprenorphine hcl-naloxone hcl dihydrate 8-2mg 36 buprenorphine hcl-naloxone hcl sl 36 bupropion hcl 29 bupropion hcl (smoking deterrent) 36 buspirone hcl 26 butorphanol tartrate 7 BYDUREON BCISE 37 BYDUREON PEN 37 BYETTA 37

66

BYSTOLIC ........................................

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23 C cabergoline 44 CABOMETYX 19 calcipotriene 59 calcitonin (salmon) 44 calcitrene 59 calcitriol 54 calcitriol inj 54 calcitriol oral soln 1 mcg/ml 54 calcium acetate (phosphate binder) 45 CALQUENCE 19 camila 40 camrese lo 40 candesartan cilexetil 22 candesartan cilexetil-hydrochlorothiazide

21 CAPRELSA 19 captopril 21 captopril & hydrochlorothiazide 21 CARBAGLU 43 carbamazepine 26 carbidopa/levodopa/entacapone 30 carbidopa-levodopa 30 carboplatin 20 carisoprodol 35 carteolol hcl (ophth) 56 cartia xt 24 carvedilol 23 caspofungin acetate 10 CAYSTON 9 caziant pak 40 cefaclor 14 CEFACLOR ER TAB 500MG 14 cefadroxil 14 CEFAZOLIN IN DEXTROSE 2GM/100ML-4% 14 cefazolin inj 14 cefazolin sodium 14 CEFAZOLIN SODIUM 1 GM/50ML 14 cefdinir 14 cefepime for inj 14 cefixime 14 cefoxitin for inj 14 cefpodoxime proxetil 14 cefprozil 14 ceftazidime 14 CEFTAZIDIME/DEXTROSE 14

ceftriaxone sodium ........................... ..............................

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14 cefuroxime axetil 14 cefuroxime sodium 14 celecoxib 7 CELONTIN 26 cephalexin 14 CERDELGA 43 CEREZYME 43 cetirizine syrup 57 cevimeline hcl 62 CHANTIX 36 CHANTIX CONTINUING MONTH 36 CHANTIX STARTER PACK 36 CHEMET 39 chlorhexidine gluconate (mouth-throat)

62 chloroquine phosphate 11 chlorothiazide tabs 24 chlorpromazine hcl 31 CHLORPROMAZINE INJ 31 chlorthalidone 24 cholestyramine 22 cholestyramine light pack 22 cholestyramine light powd 22 ciclopirox 59 cilostazol 49 CILOXAN 55 CIMDUO 12 cinacalcet hcl 44, 45 CIPRODEX 62 ciprofloxacin 15 ciprofloxacin hcl (ophth) 55 ciprofloxacin hcl tab 15 ciprofloxacin in d5w 15 cisplatin 20 citalopram hydrobromide 29 claravis 59 clarithromycin 14 clarithromycin er 14 clarithromycin for susp 14 clindamycin cap 300 mg 9 clindamycin cap 75mg 9 clindamycin hcl cap 150 mg 9 clindamycin phosphate (topical) 59 clindamycin phosphate in d5w 9 clindamycin phosphate inj 9 CLINDAMYCIN PHOSPHATE IN NACL 9 clindamycin phosphate vaginal 48

67

clindamycin soln 75mg/5ml ........................

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10 CLINIMIX 4.25%/DEXTROSE 5% 53 CLINIMIX 5%/DEXTROSE 15% 53 CLINIMIX 5%/DEXTROSE 20% 53 CLINIMIX INJ 4.25/D10 53 clobazam 26 clomipramine hcl 29 clonazepam 26 clonidine hcl 25 clonidine hcl ptwk 25 clopidogrel tab 75mg 50 clorazepate dipotassium 26 clotrimazole 62 clotrimazole (topical) 59 clotrimazole w/ betamethasone 59 clozapine odt 31 clozapine tab 100mg 31 clozapine tab 200mg 31 clozapine tab 25mg 31 clozapine tab 50mg 31 COARTEM 11 colchicine w/ probenecid 7 COLCRYS 7 colesevelam hcl 23 colestipol hcl gran 23 colestipol hcl pack 23 colestipol hcl tabs 23 colistimethate sodium 10 colocort 47 COMBIGAN 56 COMBIVENT RESPIMAT 56 COMETRIQ 19 COMPLERA 12 compro supp 46 constulose 47 COPIKTRA 19 CORLANOR 25 cortisone acetate 44 COTELLIC 19 COUMADIN 49 CREON 48 CRIXIVAN 11 cromolyn sodium (mastocytosis) 47 cromolyn sodium (ophth) 56 cromolyn sod neb 20mg/2ml 58 cryselle-28 40 cyclafem 1/35 40 cyclafem 7/7/7 40

cyclobenzaprine hcl .......................................................

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35 cyclophosphamide 16 CYCLOPHOSPHAMIDE 16 cycloserine 13 cyclosporine 51 cyclosporine modified (for microemulsion) 51 cyproheptadine hcl 57 cyred tab 40 CYSTADANE 43 CYSTAGON 43 CYSTARAN 56 cytarabine 16 D dalfampridine . 35 DALIRESP 58 danazol 43 dantrolene sodium 35 dapsone 10 DAPTACEL 51 daptomycin 10 DAPTOMYCIN 10 dasetta 1/35 40 dasetta 7/7/7 40 DAURISMO 17 deblitane 40 DELESTROGEN 43 DELSTRIGO 12 delyla 40 DEMSER 25 DEPEN TITRATABS 39 DEPO-PROVERA INJ 400/ML 18 DESCOVY 12 desipramine hcl 29 desmopressin acetate spray 45 desmopressin acetate spray refrigerated

46 desmopressin acetate tabs 46 desmopressin inj 4mcg/ml 46 desogestrel & ethinyl estradiol 40 desogestrel-ethinyl estradiol (biphasic) 40 desvenlafaxine succinate 29 dexamethasone 44 DEXAMETHASONE 44 dexamethasone sodium phosphate 44 dexamethasone sodium phosphate (ophth) 55 DEXILANT 48

68

dexmethylphenidate hcl .......................................................

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33 dextrose 10%/nacl 0.45% 53 dextrose 10% flex contain 53 DEXTROSE 10% W/ SODIUM CHLORIDE 0.2% 53 dextrose 2.5%/nacl 0.45% 53 dextrose 5% 53 DEXTROSE 5% /ELECTROLYTE 53 dextrose 5%/nacl 0.2% 53 dextrose 5%/nacl 0.225% 53 DEXTROSE 5%/NACL 0.3% 53 dextrose 5%/nacl 0.33% 53 dextrose 5%/nacl 0.45% 53 dextrose 5%/nacl 0.9% 53 dextrose 5%/potassium chl 53 dextrose 50% 53 dextrose inj 70% 53 dextrose in lactated ringers 53 DIASTAT ACUDIAL 26 DIASTAT PEDIATRIC 26 diazepam 26 diazepam gel 26 diazepam inj 26 diazepam intensol 27 diazepam oral soln 1 mg/ml 27 diclofenac potassium 7 diclofenac sodium 7 diclofenac sodium (ophth) 55 diclofenac sodium (topical) 1% gel 61 dicloxacillin sodium 15 dicyclomine hcl cap 10mg 46 dicyclomine hcl soln 10mg/5ml 46 dicyclomine hcl tab 20mg 46 didanosine 11 DIFICID 14 diflunisal 7 digitek 24 digox 24 digoxin 24 digoxin inj 24 digoxin sol 50mcg/ml 24 dihydroergotamine mesylate inj 1 mg/ml

34 dihydroergotamine mesylate nasal spr 4 mg/ml 34 DILANTIN-125 SUSP 27 DILANTIN CAP 100MG 27 DILANTIN CAP 30MG 27

DILANTIN CHEW TAB 50MG .........................................................

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27 diltiazem cap 240mg cd 24 diltiazem cap 360mg cd 24 diltiazem cap er/12hr 24 diltiazem hcl 24 diltiazem hcl coated beads 24 diltiazem hcl coated beads cap sr 24hr 24 diltiazem hcl extended release beads cap sr 24 diltiazem inj 24 dilt-xr cap 24 diphenhydramine hcl inj 50mg/ml 57 diphenoxylate w/ atropine 47 DIPHTHERIA/TETANUS TOXOID 51 disopyramide phosphate 22 disulfiram 36 divalproex sodium 27 docetaxel 16, 17 DOCETAXEL 17 dofetilide 22 donepezil hydrochloride 28 dorzolamide hcl 56 dorzolamide hcl-timolol maleate 56 DOVATO 12 doxazosin mesylate 21 doxepin hcl 29 doxepin hcl (antipruritic) 61 doxorubicin hcl 16 doxorubicin hcl liposomal 16 doxy 100 16 doxycycline (monohydrate) 16 doxycycline hyclate 16 doxycycline hyclate 100 mg 16 doxycycline hyclate 20 mg 16 dronabinol 46 drospirenone-ethinyl estradiol 40 drospirenone-ethinyl estradiol-levomefolate calcium 40 DROXIA 49 duloxetine hcl 29 DUREZOL 55 dutasteride 48 dutasteride-tamsulosin hcl 48 E e.e.s. 400 14 EDURANT 11 efavirenz 11 eletriptan hydrobromide 34

69

ELIQUIS .......................................... ....................

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49 ELIQUIS STARTER PACK 49 ELLA 40 EMCYT 16 EMEND 46 EMGALITY 34 emoquette 40 EMSAM 29 EMTRIVA 11 EMVERM 10 enalapril maleate 21 enalapril maleate & hydrochlorothiazide

21 ENDARI 49 endocet 10-325mg 7 endocet 2.5-325mg 7 endocet 5-325mg 7 endocet 7.5-325mg 7 ENGERIX-B 51 enoxaparin sodium 49 enpresse-28 40 enskyce 40 ENSTILAR 60 entacapone 30 entecavir 13 ENTRESTO 21 enulose 47 EPCLUSA 13 EPIDIOLEX 27 epinephrine (anaphylaxis) 58 epirubicin hcl 16 epitol 27 EPIVIR HBV 13 eplerenone 21 eprosartan mesylate 22 ergotamine w/ caffeine 34 ERIVEDGE 17 ERLEADA 18 erlotinib hcl 19 errin 40 ertapenem sodium 10 ery pad 2% 59 ery-tab 14 ERYTHROCIN LACTOBIONATE 14 erythrocin stearate 14 erythromycin (acne aid) 59 erythromycin (ophth) 55 erythromycin base 14

erythromycin cap 250mg ec ............... ...............

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14 erythromycin ethylsuccinate 14 ESBRIET 58 escitalopram oxalate 29 esomeprazole magnesium 48 estarylla tab 0.25-35 40 estradiol 43 estradiol vaginal cream 43 estradiol vaginal tab 44 estradiol valerate inj 44 eszopiclone 34 ethambutol hcl 13 ethosuximide 27 ethynodiol diacet & eth estrad 40 ethynodiol tab 1-50 40 etodolac 7 etoposide 20 EVOTAZ 12 exemestane 18 ezetimibe 23 ezetimibe-simvastatin 23 F FABRAZYME 43 falmina 40 famciclovir 13 famotidine 46 famotidine inj 46 famotidine in nacl 46 FANAPT 31 FANAPT TITRATION PACK 31 FARXIGA 37 FARYDAK 17 FASLODEX 18 fayosim 40 felbamate 27 felodipine 24 femynor 41 fenofibrate 23 fenofibrate micronized 23 fentanyl citrate 8 fentanyl patch 100 mcg/hr 8 fentanyl patch 12 mcg/hr 8 fentanyl patch 25 mcg/hr 8 fentanyl patch 50 mcg/hr 8 fentanyl patch 75 mcg/hr 8 FETZIMA 29 FETZIMA TITRATION PACK 29 FIASP 37

70

FIASP FLEXTOUCH ............................ .......................................

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37 finasteride 48 FIRAZYR 49 flac 62 flecainide acetate 22 FLOVENT DISKUS 58 FLOVENT HFA 58 fluconazole 10 fluconazole inj nacl 200 10 fluconazole inj nacl 400 10 flucytosine 10 fludrocortisone acetate 44 flunisolide (nasal) 58 fluocinolone acetonide 60 fluocinolone acetonide (otic) 62 fluocinolone acetonide oil body 60 fluocinonide 60 fluocinonide emulsified base 60 fluorometholone 55 fluorouracil 16 fluorouracil (topical) 61 fluoxetine cap 10mg 29 fluoxetine cap 20mg 29 fluoxetine cap 40mg 29 fluoxetine hcl 29 fluphenazine decanoate 31 fluphenazine hcl 31 flurbiprofen 7 flurbiprofen sodium 55 flutamide 18 fluticasone propionate 60 fluticasone propionate (nasal) 58 fluvoxamine maleate 26 fondaparinux sodium 49 FORTEO 45 fosamprenavir tab 700 mg 11 fosinopril sodium 21 fosinopril sodium & hydrochlorothiazide

21 FREAMINE HBC 6.9% 53 FREAMINE III 53 furosemide 24 furosemide inj 24 FUZEON 11 fyavolv 44 FYCOMPA 27 G gabapentin 27

galantamine hydrobromide ................ .............

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28 galantamine hydrobromide er 28 GAMASTAN S/D 50 GAMMAGARD LIQUID 50 GAMMAGARD S/D 50 GAMMAKED 50 GAMMAPLEX 50 GAMMAPLEX 10GM/100ML 50 GAMUNEX-C 50 ganciclovir sodium 13 GARDASIL 9 51 gatifloxacin (ophth) 55 GATTEX 47 GAUZE PADS 2 37 gavilyte-c 47 gavilyte-g 47 gavilyte-n/flavor pack 47 gemcitabine inj soln 16 gemcitabine inj solr 16 gemfibrozil 23 generlac 47 gengraf 51 GENOTROPIN 45 GENOTROPIN MINIQUICK 45 gentak 55 gentamicin in saline 9 gentamicin sulfate 9 gentamicin sulfate (topical) 59 gentamicin sulfate soln (ophth) 55 GENVOYA 12 GEODON 31 gianvi tab 3-0.02mg 41 GILENYA 35 GILOTRIF TAB 20MG 19 GILOTRIF TAB 30MG 19 GILOTRIF TAB 40MG 19 glatiramer acetate 20mg/ml 35 glatiramer acetate 40mg/ml 35 glatopa 35 GLEOSTINE 16 glimepiride 37 glip/metform tab 2.5-250mg 37 glip/metform tab 2.5-500mg 38 glip/metform tab 5-500mg 38 glipizide 38 glipizide xl 38 GLUCAGEN HYPOKIT 44 GLUCAGON EMERGENCY KIT 44

71

glyburide ......................................... .

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38 glyburide-metformin tab 1.25-250 mg 38 glyburide-metformin tab 2.5-500 mg 38 glyburide-metformin tab 5-500mg 38 glyburide micronized 38 glycopyrrolate tab 1mg 46 glycopyrrolate tab 2mg 46 glydo 60 GOLYTELY 47 granisetron hcl 46 griseofulvin microsize 11 griseofulvin ultramicrosize 11 guanfacine er (adhd) 33 H HAEGARDA 49 hailey 24 fe 41 halobetasol propionate 60 haloperidol 31 haloperidol conc 2mg/ml 31 haloperidol decanoate 31 haloperidol lactate inj 5mg/ml 31 HARVONI 13 HAVRIX 51 heather 41 heparin sod (porcine) in d5w 49 heparin sod inj 1000/ml 49 heparin sod inj 10000/ml 49 heparin sod inj 20000/ml 49 heparin sod inj 5000/ml 49 HEPARIN SODIUM/NACL 0.45% 49 hepatamine 53 HERCEPTIN 17 HERCEPTIN HYLECTA 17 HETLIOZ 34 HIBERIX 51 HUMIRA 50 HUMIRA INJ 10MG/0.2ML 50 HUMIRA KIT 20MG/0.4ML 50 HUMIRA KIT 40MG/0.8ML 50 HUMIRA PEDIATRIC CROHNS DISEASE 50 HUMIRA PEN 50 HUMIRA PEN CD/UC/HS STARTER 50 HUMIRA PEN INJ CD/UC/HS STARTER 50 HUMIRA PEN INJ PS/UV STARTER 50 HUMIRA PEN-PS/UV STARTER 50 HUMULIN R INJ U-500 37 HUMULIN R U-500 KWIKPEN 37 hydralazine hcl 25

hydrochlorothiazide ........................... .................................

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24 hydroco/apap tab 10-325mg 8 hydroco/apap tab 5-325mg 8 hydroco/apap tab 7.5-325 8 hydrocodone-acetaminophen 7.5-325 mg/15ml 8 hydrocodone-ibuprofen tab 7.5-200 mg 8 hydrocortisone 44 hydrocortisone (enema) 47 hydrocortisone (topical) cream 1% 60 hydrocortisone (topical) cream 2.5% 60 hydrocortisone (topical) lotion 2.5% 60 hydrocortisone (topical) oint 2.5% 60 hydrocortisone butyrate cream 0.1% 60 hydrocortisone butyrate oint 0.1% 60 hydromorphone hcl 8 hydroxychloroquine sulfate 50 hydroxyurea 20 hydroxyzine hcl 57 hydroxyzine hcl inj 57 hydroxyzine pamoate 57 HYSINGLA ER 8 I ibandronate sodium tabs 39 IBRANCE 17 ibuprofen 7 ibu tab 600mg 7 ibu tab 800mg 7 ICLUSIG 19 IDHIFA 17 ILEVRO 55 imatinib mesylate 19 IMBRUVICA 19 imipenem-cilastatin 10 imipramine hcl 29 imiquimod 61 IMOVAX RABIES (H.D.C.V.) 51 incassia 41 INCRELEX 45 INCRUSE ELLIPTA 57 indapamide 25 INFANRIX 51 INLYTA 19 INSULIN PEN NEEDLE 37 INSULIN SAFETY NEEDLES 37 INSULIN SYRINGE 37 INTELENCE 11 INTRALIPID 30% 53

72

INTRALIPID INJ 20% ........................ ......................... ......................... ......................... .........................

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53 INTRON-A INJ 10MU 51 INTRON-A INJ 18MU 51 INTRON-A INJ 25MU 51 INTRON-A INJ 50MU 51 introvale 41 INVEGA SUST INJ 117 MG/0.75 ML 31 INVEGA SUST INJ 156MG/ML 31 INVEGA SUST INJ 234 MG/1.5 ML 31 INVEGA SUST INJ 39 MG/0.25 ML 31 INVEGA SUST INJ 78 MG/0.5 ML 31 INVEGA TRINZA 31 INVIRASE 11 IONOSOL-MB/DEXTROSE 5% 53 IPOL INACTIVATED IPV 51 ipratropium-albuterol nebu 56 ipratropium bromide 57 ipratropium bromide (nasal) 57 irbesartan 22 irbesartan-hydrochlorothiazide 22 IRESSA 19 irinotecan hcl 20 ISENTRESS 11 ISENTRESS HD 11 isibloom 41 ISOLYTE P 53 ISOLYTE S 53 isoniazid 13 isoniazid syp 50mg/5ml 13 isosorbide dinitrate 25 isosorbide dinitrate er 25 isosorbide mononitrate er 25 isosorb mononitrate tab 25 isotretinoin 59 isradipine 24 itraconazole 11 ivermectin 10 IXIARO 51 J JADENU 39 JADENU SPRINKLE 39 JAKAFI 19 jantoven 49 JANUMET 38 JANUMET XR TAB 100-1000 38 JANUMET XR TAB 50-1000 38 JANUMET XR TAB 50-500MG 38 JANUVIA 38

JARDIANCE ..................................................................................

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38 jasmiel 41 JENTADUETO 38 JENTADUETO TAB XR 2.5-1000 MG 38 JENTADUETO TAB XR 5-1000 MG 38 jinteli 44 jolessa tab 0.15-0.03 mg 41 jolivette 41 juleber 41 JULUCA 12 junel 1/20 41 junel 1.5/30 41 junel fe 1/20 41 junel fe 1.5/30 41 junel fe 24 41 JUXTAPID 23 K KADCYLA 17 kaitlib fe 41 KALETRA TAB 100-25MG 12 KALETRA TAB 200-50MG 12 KALYDECO 58 kariva 41 kcl/d5w/nacl inj .15/.33% 54 kcl/d5w/nacl inj .15/.45% 54 kcl/d5w/nacl inj 0.22%/0.45% 54 kcl/d5w inj 0.3% 54 kcl/nacl inj 0.15%-0.9% 54 kcl/nacl inj 0.3-0.9 54 kcl 0.075%/d5w/nacl 0.45% 54 kcl0.15%/d5w/nacl0.2% 54 KCL 0.15%/D5W/NACL 0.225% 54 kcl 0.15%/d5w/nacl 0.9% 54 kcl 0.3%/d5w/nacl 0.45% 54 KCL 0.3%/D5W/NACL 0.9% 54 kelnor 1/35 41 kelnor 1/50 41 ketoconazole 11 ketoconazole cream 59 ketoconazole shampoo 60 ketorolac tromethamine (ophth) 55 KEYTRUDA 17 KINRIX 51 kionex sus 15gm/60ml 39 KISQALI 17 KISQALI FEMARA 200 DOSE 17 KISQALI FEMARA 400 DOSE 17 KISQALI FEMARA 600 DOSE 17

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klor-con 10 ...................................... ........................................

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52 klor-con 8 52 klor-con m10 52 klor-con m15 52 klor-con m20 52 klor-con pak 20meq 52 klor-con spr cap 10meq 52 klor-con spr cap 8meq 52 KORLYM 45 kurvelo 41 KUVAN 43 L labetalol hcl 23 lactated ringer's 54 lactulose 47 lactulose (encephalopathy) 47 lamivudine 11 lamivudine (hbv) 13 lamivudine-zidovudine . 12 lamotrigine 27 lansoprazole 48 larin 1/20 41 larin 1.5/30 41 larin fe 1/20 41 larin fe 1.5/30 41 larissia tab 41 LASTACAFT 56 latanoprost 56 LATUDA 31, 32 layolis fe 41 leena tab 41 leflunomide 50 LENVIMA 10 MG DAILY DOSE 19 LENVIMA 12MG DAILY DOSE 19 LENVIMA 14 MG DAILY DOSE 19 LENVIMA 18 MG DAILY DOSE 19 LENVIMA 20 MG DAILY DOSE 19 LENVIMA 24 MG DAILY DOSE 19 LENVIMA 4 MG DAILY DOSE 19 LENVIMA 8 MG DAILY DOSE 19 lessina 41 letrozole 18 leucovorin calcium 20 LEUKERAN 16 leuprolide inj 1mg/0.2 18 levalbuterol hcl 57 levalbuterol hcl soln nebu conc 1.25 mg/0.5ml 57

levalbuterol tartrate hfa ..................... .........................................

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57 LEVEMIR 37 LEVEMIR FLEXTOUCH 37 levetiracetam 27 levetiracetam in sodium chloride 27 levetiracetam oral soln 100 mg/ml 27 levobunolol hcl 56 levocarnitine (metabolic modifiers) 43 levocetirizine dihydrochloride 57 levofloxacin 15 levofloxacin in d5w 15 levofloxacin inj 25mg/ml 15 levofloxacin oral soln 25 mg/ml 15 levonest 41 levonor/ethi tab 41 levonor-eth est tab 0.15-0.02/0.025/0.03mg & eth est 0.01mg 41 levonorgestrel & eth estradiol 41 levonorgestrel-ethinyl estradiol 0.15-0.03mg (91-day) 41 levonorg-eth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7) 41 levonorg-eth est tab 0.15-0.03mg (84) & eth est tab 0.01mg(7) 41 levora 0.15/30-28 41 levo-t 45 levothyroxine sodium 45 levoxyl 45 LEXIVA 11 lidocaine 61 lidocaine hcl 61 lidocaine hcl (local anesth.) 9 lidocaine hcl (mouth-throat) 62 lidocaine inj 0.5% 9 lidocaine inj 1.5% preservative free (pf) 9 lidocaine inj 1% 9 lidocaine oint 5% 61 lidocaine-prilocaine 61 linezolid inj 10 linezolid in sodium chloride 10 linezolid susp 10 linezolid tab 600mg 10 LINZESS 47 liothyronine sodium 45 lisinopril 21 lisinopril & hydrochlorothiazide 21 lithium carbonate 35

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lithium carbonate er ...........................................

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35 LITHIUM SOLN 8MEQ/5ML 35 LONSURF 20 loperamide hcl 47 lopinavir-ritonavir 12 lorazepam 26 lorazepam intensol 26 LORBRENA 19 lorcet hd tab 10-325mg 8 lorcet plus tab 7.5-325 8 lorcet tab 5-325mg 8 loryna 41 losartan-hydrochlorothiazide 22 losartan potassium 22 LOTEMAX 55 loteprednol etabonate 55 lovastatin 22 low-ogestrel 41 loxapine succinate 32 LUMIGAN 56 LUMIZYME 43 LUPRON DEPOT (1-MONTH) 18 LUPRON DEPOT INJ 11.25MG (3-MONTH)

18 LUPRON DEPOT-PED (1-MONTH 45 LUPRON DEPOT-PED (3-MONTH 45 LUPRON DEP-PED INJ 11.25MG (3-MONTH) 45 LUPRON DEP-PED INJ 7.5MG 45 lutera 41 LYNPARZA 17 LYRICA 27 LYRICA CR 35 LYSODREN 18 lyza 41 M magnesium sulfate 52 MAGNESIUM SULFATE 52 MAGNESIUM SULFATE IN D5W 52 magnesium sulfate in dextrose 52 magnesium sulfate inj 50% 52 malathion 61 maprotiline hcl 29 marlissa 41 MARPLAN TAB 10MG 29 MATULANE 20 MAVYRET 13 meclizine hcl 46

medroxyprogesterone acetate (contraceptive) .................................

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42 medroxyprogesterone acetate tab 45 mefloquine hcl 11 megestrol ac sus 40mg/ml 18 megestrol ac tab 20mg 18 megestrol ac tab 40mg 18 megestrol sus 625mg/5ml 18 MEKINIST 19 MEKTOVI 19 melodetta 24 fe 42 meloxicam 7 memantine hcl cp24 28 memantine soln 28 memantine tabs 28 memantine titration pak 28 MENACTRA 52 MENVEO 52 mercaptopurine 16 meropenem 10 mesalamine 47 mesalamine w/ cleanser 47 MESNEX 20 metadate er tab 20mg 33 metformin er 39 metformin hcl 39 methadone hcl 8 methadone hcl 10mg 8 methadone hcl 5mg 8 methadone hcl intensol 8 methazolamide 25 methenamine hippurate 10 methimazole 45 methocarbamol 36 methotrexate sodium inj soln 16 methotrexate sodium inj solr 16 methotrexate sodium tabs 50 methylphenidate hcl 33 methylphenidate hcl oral soln 33 methylphenidate hcl tbcr 10 mg 34 methylphenidate hcl tbcr 20mg 34 methylprednisolone acetate 44 methylpred pak 4mg 44 methylpred tab 16mg 44 methylpred tab 32mg 44 methylpred tab 4mg 44 methylpred tab 8mg 44 methylpr ss inj 44

75

metoclopramide hcl ........................... ......................

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46 metoclopramide hcl inj 46 metolazone 25 metoprolol & hydrochlorothiazide 23 metoprolol succinate 23 metoprolol tartrate 23 metronidazole 10 metronidazole (topical) 61 metronidazole gel 0.75% 61 metronidazole in nacl 10 metronidazole vaginal 48 mibelas 24 fe 42 microgestin 1/20 42 microgestin 1.5/30 42 microgestin fe 1/20 42 microgestin fe 1.5/30 42 midodrine hcl 25 miglustat 43 mili 42 minitran 25 minocycline hcl 16 minoxidil 25 mirtazapine 29 misoprostol 47 MITIGARE 7 M-M-R II 51 M-NATAL PLUS 54 moexipril hcl 21 molindone hcl 32 mometasone furoate 60 mondoxyne nl cap 100mg 16 mono-linyah tab 0.25-35 42 montelukast sodium 57 morgidox cap 1x50mg 16 morphine ext-rel tab 8 morphine sulfate 8 MORPHINE SULFATE 8 morphine sulfate oral soln 100mg/5ml 9 morphine sulfate oral soln 10mg/5ml 8 morphine sulfate oral soln 20mg/5ml 9 morphine sul inj 10mg/ml 8 morphine sul inj 1mg/ml 8 MORPHINE SUL INJ 4MG/ML 8 MOVANTIK 47 MOXEZA 55 moxifloxacin hcl 15 moxifloxacin hcl (ophth) 55 MULTAQ 22

mupirocin ........................................ .......................................

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59 MYCAMINE 11 mycophenolate mofetil 51 mycophenolate sodium tbec 51 myorisan 59 MYRBETRIQ 48 N nabumetone 7 nadolol 23 nafcillin sodium for inj 15 NAFCILLIN SODIUM FOR INJ 10GM 15 NAGLAZYME 43 nalbuphine hcl 7 naloxone inj 0.4mg/ml 36 naloxone inj 1mg/ml . 36 naltrexone hcl 36 NAMZARIC 28 naproxen 7 naproxen dr 7 naproxen sodium 7 naratriptan hcl 34 NARCAN 36 NATACYN 55 nateglinide 39 NATPARA 45 NEBUPENT 10 necon 0.5/35-28 42 nefazodone hcl 29 neomycin-bacitracin zn-polymyxin 55 neomycin-polymy-dexameth 54 neomycin-polymyxin-gramicidin 55 neomycin-polymyxin-hc (ophth) 54 neomycin-polymyxin-hc (otic) 62 neomycin sulfate 9 NEPHRAMINE 53 NERLYNX 19 NEUPRO 30 nevirapine susp 50 mg/5ml 11 nevirapine tab 100mg er 11 nevirapine tab 200mg 11 nevirapine tab 400mg er 11 NEXAVAR 19 niacin er (antihyperlipidemic) 23 niacor 23 nicardipine hcl 24 NICOTROL INHALER 36 NICOTROL NS 36 nifedipine 24

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nifedipine er ...................................................................................

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24 nikki 42 nilutamide 18 nimodipine 24 NINLARO 17 NITRO-BID 25 NITRO-DUR DIS 0.3MG/HR 25 NITRO-DUR DIS 0.8MG/HR 25 nitrofurantoin macrocrystal 10 nitrofurantoin monohyd macro 10 nitroglycerin 25 nitroglycerin td patch 25 NITYR 43 nora-be tab 0.35mg 42 nore/eth/fer chw 0.4mg-35 42 noreth/ethin chw fe 42 norethin acet & estrad-fe 42 norethindrone (contraceptive) 42 norethindrone acet & eth estra 42 norethindrone acetate 45 norethindrone acetate-ethinyl estradiol 44 norgest/ethi tab 0.25/35 42 norgestimate-ethinyl estradiol (triphasic) 0.18-25/0.215-25/0.25-25 mg-mcg 42 norgestimate-ethinyl estradiol (triphasic) 0.18-35/0.215-35/0.25-35 mg-mcg 42 norlyroc 42 NORMOSOL-M IN D5W 54 NORMOSOL-R 54 NORMOSOL-R IN D5W 54 NORPACE CR 22 NORTHERA 25 nortrel 0.5/35 (28) 42 nortrel 1/35 42 nortrel 7/7/7 42 nortriptyline hcl 29 NORVIR PACK 11 NORVIR SOLN 11 NOVOLIN 70/30 37 NOVOLIN 70/30 FLEXPEN 37 NOVOLIN N 37 NOVOLIN R 37 NOVOLOG 37 NOVOLOG 70/30 FLEXPEN 37 NOVOLOG FLEXPEN 37 NOVOLOG MIX 70/30 37 NOVOLOG PENFILL 37 NOXAFIL 11

NUCALA .......................................... .....................................

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58 NUCYNTA ER 9 NUEDEXTA 35 NULOJIX 51 NULYTELY/FLAVOR PACKS 47 NUPLAZID CAPS 32 NUPLAZID TABS 10MG 32 NUTRILIPID INJ 20% 53 NUVARING 42 nyamyc 59 NYMALIZE 24 nystatin 11 nystatin (mouth-throat) 62 nystatin (topical) 59 nystop 59 O ocella tab 3-0.03mg 42 OCTAGAM 50 octreotide acetate 45 ODEFSEY 12 ODOMZO 17 OFEV 58 ofloxacin (ophth) 55 ofloxacin (otic) 62 olanzapine 32 olmesartan medoxomil 22 olmesartan medoxomil-amlodipine-hydrochlorothiazide 22 olmesartan medoxomil-hydrochlorothiazide 22 olopatadine hcl 0.2% 56 omeprazole cap 10mg 48 omeprazole cap 20mg 48 omeprazole cap 40mg 48 ondansetron hcl 46 ondansetron hcl inj 46 ondansetron hcl oral soln 46 ondansetron odt 46 OPSUMIT 25 ORFADIN 43 ORKAMBI 58 orsythia 42 oseltamivir phosphate 13 oxacillin sodium 15 oxaliplatin inj 100mg 20 oxaliplatin inj 100mg/20ml 20 oxaliplatin inj 50mg 20

77

oxaliplatin inj 50mg/10ml ........................................ .....................

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20 oxandrolone tab 10mg 36 oxandrolone tab 2.5mg 36 oxcarbazepine 27 oxybutynin chloride 48 oxycodone hcl 9 oxycodone w/ acetaminophen 10-325mg

9 oxycodone w/ acetaminophen 2.5-325mg

9 oxycodone w/ acetaminophen 5-325mg 9 oxycodone w/ acetaminophen 7.5-325mg

9 OZEMPIC INJ 0.25 OR 0.5MG/DOSE 37 OZEMPIC INJ 1MG/DOSE 37 P pacerone 22 paclitaxel 17 paliperidone 32 pamidronate disodium 39 PAMIDRONATE DISODIUM 39 pamidronate inj 30mg 39 pamidronate inj 90mg 39 PANRETIN 61 pantoprazole sodium 48 pantoprazole sodium tbec 48 PANZYGA 51 paricalcitol 54 paroex sol 0.12% 62 paromomycin sulfate 9 paroxetine hcl tabs 29 PASER D/R 13 PAXIL 29 PAZEO 56 PEDIARIX 52 PEDVAX HIB 52 peg 3350/electrolytes 47 peg 3350-kcl-sod bicarb-sod chloride-sod sulfate 47 peg 3350-potassium chloride-sod bicarbonate-sod chloride 47 PEGANONE 27 PEGASYS 13 PEGASYS PROCLICK 13 PENICILLIN G POT IN DEXTROSE 2MU 15 PENICILLIN G POT IN DEXTROSE 3MU 15 PENICILLIN G PROCAINE 15 penicillin g sodium 15

penicillin v potassium ........................ .........................

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15 penicilln gk inj 20mu 15 penicilln gk inj 5mu 15 PENNSAID 61 PENTACEL 52 PENTAM 300 10 pentamidine isethionate 10 pentoxifylline 49 perindopril erbumine 21 periogard 62 permethrin cre 5% 61 perphenazine 32 PERSERIS 32 pfizerpen-g inj 20mu 15 pfizerpen-g inj 5mu 15 phenelzine sulfate 29 phenobarbital 27 phenobarbital sodium 28 PHENOBARBITAL SODIUM 27 PHENYTEK 28 phenytoin 28 phenytoin sodium extended 28 phenytoin sodium inj 50mg/ml 28 philith 42 PHOSPHOLINE IODIDE 56 PICATO 61 PIFELTRO 11 pilocarpine hcl 56 pilocarpine hcl (oral) 62 pimozide 32 pimtrea 42 pindolol 23 pioglitazone hcl 39 PIPER/TAZOBA INJ 12-1.5GM 15 piper/tazoba inj 2-0.25gm 15 piper/tazoba inj 3-0.375gm 15 piper/tazoba inj 36-4.5gm 16 piper/tazoba inj 4-0.5gm 15 PIQRAY 200MG DAILY DOSE 19 PIQRAY 250MG DAILY DOSE 19 PIQRAY 300MG DAILY DOSE 19 pirmella 1/35 42 piroxicam 7 PLASMA-LYTE-148 54 PLASMA-LYTE A 54 PLENVU 47 PNV FOLIC ACID + IRON MUL 54 podofilox 61

78

polymyxin b-trimethoprim ................. .......................................

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55POMALYST 18portia-28 42potassium chloride 52, 54potassium chloride in nacl 54potassium chloride microencapsulated crystals er 52potassium citrate (alkalinizer) er tabs 48pot chloride inj 2meq/ml 54PRADAXA 49PRALUENT 23pramipexole tab 0.125mg 30pramipexole tab 0.25mg 30pramipexole tab 0.5mg 30pramipexole tab 0.75mg 30pramipexole tab 1.5mg 30pramipexole tab 1mg 30prasugrel hcl 50pravastatin sodium 22praziquantel 10prazosin hcl 21prednisolone acetate (ophth) 55prednisolone sodium phosphate 44PREDNISOLONE SODIUM PHOSPHATE (OPHTH) 55prednisolone sol 15mg/5ml 44prednisolone sol 25mg/5ml 44PREDNISONE CON 5MG/ML 44prednisone pak 10mg 44prednisone pak 5mg 44prednisone sol 5mg/5ml 44prednisone tab 10mg 44prednisone tab 1mg 44prednisone tab 2.5mg 44prednisone tab 20mg 44prednisone tab 50mg 44prednisone tab 5mg 44pred sod pho sol 5mg/5ml 44PREMASOL 10% 53PRENATAL 54PRENATAL PLUS 54PRENATAL PLUS LOW IRON 54prevalite 23previfem 42PREZCOBIX 12PREZISTA 11, 12PRIFTIN 13primaquine phosphate 11

PRIMAQUINE PHOSPHATE .................. ........................................ ........................................

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11 primidone 28 PRIVIGEN 51 probenecid 7 PROCALAMINE 53 prochlorperazine inj 46 prochlorperazine maleate 46 prochlorperazine supp 46 PROCRIT 49 procto-med hc 61 procto-pak 61 proctosol hc cre 2.5% 61 proctozone-hc 61 PROGLYCEM SUS 50MG/ML 44 PROGRAF 51 PROLASTIN-C 58 PROLENSA 55 PROLIA 45 PROMACTA 49 promethazine hcl 46 promethazine hcl inj 46 propafenone hcl 22 propafenone hcl 12hr 22 proparacaine hcl 56 propranolol & hydrochlorothiazide 23 propranolol cap er 23 propranolol hcl 23 propranolol oral sol 23 propylthiouracil 45 PROQUAD 52 PROSOL 53 protriptyline hcl 29 PULMICORT FLEXHALER 58 PULMOZYME 58 PURIXAN 16 pyrazinamide 13 pyridostigmine tab 60mg 35 Q QUADRACEL 52 quetiapine fumarate 32 quinapril hcl 21 quinapril-hydrochlorothiazide 21 quinidine sulfate 22 quinine sulfate 11 R RABAVERT 52 rabeprazole sodium 48 raloxifene tab 60mg 45

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ramipril ........................................... ....................................

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21 ranitidine hcl 46 ranitidine hcl inj 46 ranitidine syrup 46 ranolazine 25 rasagiline mesylate 30 RAYALDEE 54 REBETOL SOLN 13 reclipsen 42 RECOMBIVAX HB 52 RECTIV 61 REGRANEX 61 RELENZA DISKHALER 13 RELISTOR 47 REMICADE 50 RENFLEXIS 50 repaglinide 39 RESCRIPTOR 12 RESTASIS 56 RESTASIS MULTIDOSE 56 REVLIMID 18 REXULTI 32 REYATAZ 12 RHOPRESSA 56 ribasphere 13 ribavirin cap 200mg 14 ribavirin tab 200mg 14 rifabutin 13 rifampin 13 RIFATER 13 riluzole 35 rimantadine hydrochloride 14 risedronate sodium 39 RISPERDAL INJ 12.5MG 32 RISPERDAL INJ 25MG 32 RISPERDAL INJ 37.5MG 32 RISPERDAL INJ 50MG 32 risperidone 32 ritonavir 12 RITUXAN 17 RITUXAN HYCELA 17 rivastigmine tartrate 28 rivastigmine td patch 24hr 13.3 mg/24hr

29 rivastigmine td patch 24hr 4.6 mg/24hr

28 rivastigmine td patch 24hr 9.5 mg/24hr

29

rivelsa .......................................................................

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42 rizatriptan benzoate 34 rizatriptan benzoate odt 34 ropinirole tab 0.25mg 30 ropinirole tab 0.5mg 30 ropinirole tab 1mg 30 ropinirole tab 2mg 30 ropinirole tab 3mg 30 ropinirole tab 4mg 30 ropinirole tab 5mg 30 rosadan cre 0.75% 61 rosuvastatin calcium 22 ROTARIX 52 ROTATEQ 52 roweepra 28 roweepra xr 28 RUBRACA 17 RYDAPT 20 S SANDIMMUNE 51 SANTYL 62 SAPHRIS 32 scopolamine 46 selegiline hcl 30 selenium sulfide 60 SELZENTRY 12 SEREVENT DISKUS 57 sertraline hcl 29 setlakin tab 42 sevelamer carbonate 45 sharobel 42 SHINGRIX 52 SIGNIFOR 45 sildenafil citrate tab 20 mg (pulmonary hypertension) 26 SILENOR 34 silver sulfadiazine 59 SIMBRINZA 56 simvastatin 22 sirolimus 51 SIRTURO 13 SIVEXTRO 10 sodium chloride 53, 54 sodium chloride 0.45% 54 sodium chloride inj 0.9% 54 sodium chlor sol 0.9% irr 62 sodium fluoride chew; tab; 1.1 (0.5 f) mg/ml soln 53

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sodium phenylbutyrate ...................... ..

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43 sodium polystyrene sulfonate powder 40 sodium polystyrene sulfonate susp 40 SOLIQUA 100/33 37 SOLTAMOX 18 SOLU-CORTEF 44 SOMATULINE DEPOT 45 SOMAVERT 45 sorine 22 sotalol hcl 22 sotalol hcl (afib/afl) 22 spironolactone 21 spironolactone & hydrochlorothiazide 25 sprintec 28 42 SPRITAM 28 SPRYCEL 20 sps susp 15gm/60ml 40 sronyx 42 ssd 59 stavudine 12 STELARA 50 STIMATE 46 STIVARGA 20 streptomycin sulfate 9 STRIBILD 12 subvenite tab 28 sucralfate 47 sulfacetamide sodium (acne) 59 sulfacetamide sodium (ophth) 55 sulfacetamide sod-prednisolone 54 SULFADIAZINE 9 sulfamethoxazole-trimethop ds 10 sulfamethoxazole-trimethoprim inj 10 sulfamethoxazole-trimethoprim susp 10 sulfamethoxazole-trimethoprim tab 400-80mg 10 SULFAMYLON 59 sulfasalazine 47 sulfasalazine ec 47 sulindac 7 sumatriptan 34 sumatriptan inj 4mg/0.5ml 35 sumatriptan inj 6mg/0.5ml 35 sumatriptan succinate 35 SUPREP BOWEL PREP KIT 47 SUTENT 20 syeda 42 SYLATRON 20

SYMBICORT .............................................................................

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58 SYMDEKO 58 SYMFI 12 SYMFI LO 13 SYMPAZAN 28 SYMTUZA 13 SYNAREL 43 SYNERCID 10 SYNJARDY TAB 12.5-1000MG 39 SYNJARDY TAB 12.5-500MG 39 SYNJARDY TAB 5-1000MG 39 SYNJARDY TAB 5-500MG 39 SYNJARDY XR TAB 10-1000MG 39 SYNJARDY XR TAB 12.5-1000MG 39 SYNJARDY XR TAB 25-1000MG 39 SYNJARDY XR TAB 5-1000MG 39 SYNRIBO 20 SYNTHROID 45 T TABLOID 16 tacrolimus 51 tacrolimus (topical) 61 TAFINLAR 20 TAGRISSO 20 TALZENNA 17 tamoxifen citrate 18 tamsulosin hcl 48 TARGRETIN 61 tarina 24 fe 42 tarina fe 1/20 42 TASIGNA 20 TAXOTERE 17 tazarotene 60 tazicef 14 TAZORAC 60 taztia xt 24 TDVAX 52 TECENTRIQ 17 TEFLARO 14 telmisartan 22 telmisartan-amlodipine 22 telmisartan-hydrochlorothiazide 22 temazepam 34 TENIVAC 52 tenofovir disoproxil fumarate 12 terazosin hcl 21 terbinafine hcl 11 terbutaline sulfate 57

81

terconazole vaginal ...............................................................

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48 testosterone 36 testosterone cypionate 36 testosterone enanthate 37 tetrabenazine 35 tetracycline hcl 16 TEXACORT SOLN 2.5% 60 THALOMID 18 THEO-24 58 theophylline 58 thioridazine hcl 32 thiothixene 32 tiagabine hcl 28 TIBSOVO 17 tigecycline 10 tilia fe 42 timolol maleate 23 timolol maleate (ophth) soln 56 timolol maleate gel 56 timolol maleate ophth soln 0.5% (once-daily) 56 TIVICAY 12 tizanidine hcl 36 TOBRADEX 55 TOBRADEX ST 55 tobramycin 9 tobramycin (ophth) 55 tobramycin-dexamethasone 55 tobramycin inj 1.2gm 9 tobramycin inj 1.2 gm/30ml 9 tobramycin inj 10mg/ml 9 tobramycin inj 80mg/2ml 9 tobramycin sulfate 9 tolterodine tartrate 48 topiramate 28 toposar 20 toremifene citrate 18 torsemide tabs 25 TOVIAZ 48 TPN ELECTROLYTES 53 TRADJENTA 39 tramadol-acetaminophen 7 tramadol hcl tab 50 mg 7 trandolapril 21 tranexamic acid 49 tranylcypromine sulfate 29 TRAVASOL 53 TRAVATAN Z 56

trazodone hcl ................................... .......................................

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29 TRECATOR 13 TRELEGY ELLIPTA 56 TRELSTAR DEP INJ 3.75MG 18 TRELSTAR LA INJ 11.25MG 18 treprostinil 26 TRESIBA FLEXTOUCH 37 TRESIBA INJ 37 tretinoin 59 tretinoin (chemotherapy) 20 triamcinolone acetonide (mouth) 62 triamcinolone acetonide (topical) 60 triamterene & hydrochlorothiazide cap 37.5-25 mg 25 triamterene & hydrochlorothiazide tabs 25 TRICARE 54 trientine hcl 40 tri-estarylla 42 trifluoperazine hcl 32 trifluridine 55 trihexyphenidyl hcl 30 tri-legest fe 43 tri-linyah 43 tri-lo-estarylla 43 tri-lo marzia 43 tri-lo-sprintec 43 trilyte 47 trimethoprim 10 tri-mili 43 trimipramine maleate 29 TRINTELLIX 30 tri-previfem 43 tri-sprintec 43 TRIUMEQ 13 trivora-28 43 tri-vylibra 43 tri-vylibra lo 43 TROGARZO 12 TROPHAMINE INJ 10% 53 trospium chloride 48 TRULICITY 37 TRUMENBA 52 TRUVADA TAB 100-150 13 TRUVADA TAB 133-200 13 TRUVADA TAB 167-250 13 TRUVADA TAB 200-300 13 tulana 43 TWINRIX INJ 52

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12 tydemy 43 TYKERB 20 TYMLOS 45 TYPHIM VI 52 U unithroid 45 ursodiol 48 V valacyclovir hcl 14 VALCHLOR 61 valganciclovir hcl 14 valproate sodium 28 valproate sodium oral soln 28 valproic acid 28 valsartan 22 valsartan-hydrochlorothiazide 22 vancomycin hcl 10 VANCOMYCIN IN NACL 10 vandazole 48 VAQTA 52 VARIVAX 52 VASCEPA 23 VELCADE 17 velivet 43 VEMLIDY 14 VENCLEXTA 17 VENCLEXTA STARTING PACK 17 venlafaxine hcl 30 VENTAVIS 26 VENTOLIN HFA 57 verapamil cap er 24 verapamil hcl 24 verapamil tab er 24 VERSACLOZ 32 VERZENIO 17 VICTOZA 37 VIDEX EC 12 VIDEX PEDIATRIC 12 vienva 43 vigabatrin powd pack 500mg 28 vigabatrin tab 500mg 28 vigadrone 28 VIIBRYD STARTER PACK 30 VIIBRYD TAB 30 VIMPAT 28 VIMPAT INJ 200MG/20ML 28 VIMPAT SOL 10MG/ML 28

vincristine sulfate ............................. ...........................

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17 vinorelbine tartrate 17 viorele 43 VIRACEPT 12 VIREAD 12 VITRAKVI 20 VIVITROL 36 VIZIMPRO 20 voriconazole 11 VOSEVI 14 VOTRIENT 20 VRAYLAR 32 VRAYLAR THERAPY PACK 33 vyfemla 43 vylibra 43 W warfarin sodium 49 water for irrigation, sterile 62 wymzya fe 43 X XALKORI 20 XARELTO 49 XARELTO STARTER PACK 49 XATMEP 50 XELJANZ 50 XELJANZ XR 50 XGEVA 45 XIFAXAN 48 XIGDUO XR TAB 10-1000MG 39 XIGDUO XR TAB 10-500MG 39 XIGDUO XR TAB 2.5-1000MG 39 XIGDUO XR TAB 5-1000MG 39 XIGDUO XR TAB 5-500MG 39 XOLAIR 58 XOSPATA 20 XTANDI 18 xulane dis 150-35 43 XULTOPHY 100/3.6 37 XYREM 36 Y YF-VAX 52 yuvafem vaginal tablet 10 mcg 44 Z zafirlukast 57 zaleplon 34 zarah 43 ZARXIO 49 ZEJULA 17

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20 ZEMAIRA 58 zenatane 59 ZENPEP 48 zidovudine cap 100mg 12 zidovudine syp 50mg/5ml 12 zidovudine tab 300mg 12 ziprasidone hcl 33 ZIRGAN 55 zoledronic acid inj 5mg/100ml 39 zoledronic inj 4mg/5ml 39 ZOLINZA 17 zolmitriptan 35 zolmitriptan odt 35 zolpidem tartrate 34 zonisamide 28 ZORTRESS TAB 0.25MG 51 ZORTRESS TAB 0.5MG 51 ZORTRESS TAB 0.75MG 51 ZORTRESS TAB 1MG 51 ZOSTAVAX 52 zovia 1/35e 43 ZYDELIG 20 ZYKADIA 20 ZYLET 55 ZYPREXA RELPREVV 33 ZYPREXA RELPREVV INJ 210MG 33 ZYTIGA 18

Elderplan For Medicaid Beneficiaries (HMO D-SNP) Elderplan Advantage For Nursing Home Residents (HMO I-SNP) Elderplan Plus Long Term Care (HMO D-SNP)

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formulario completo para 2020 - elderplan

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