your guide to prescription drug coverage · check often for updates, as this list is subject to...

Your Guide to Prescription Drug Coverage 2019 PREFERRED FORMULARY DRUG LIST

This document contains information about the drugs covered in your prescription drug benefit plan.

Important Contacts For more information about your prescription drug coverage, call the phone number listed on your BlueCross BlueShield of Tennessee Member ID card. For information about your home delivery prescription, call 1-877-673-9165.

Visit bcbst.com • Find a pharmacy in your network • Look up lower-cost prescription alternatives • Compare your pricing and options

If You Want Us to Rethink Your Request You or your doctor may ask to reconsider any of these things:

• A denial of a drug benefit • Limits on a drug quantity • The details needed for prior authorization • Getting a non-covered drug approved

You’ll need written reasons from your doctor about why we should rethink your situation.

We look at all reconsiderations on a case-by-case basis. Your Evidence of Coverage or member handbook has details on your rights to file reconsiderations.

Fax all information to 1-888-343-4232. Or send a written request to:

Pharmacy Management Reconsiderations BlueCross BlueShield of Tennessee 1 Cameron Hill Circle Chattanooga, TN 37402-2555

Please provide the following information with your request:

• Patient name and cardholder ID number • Physician name and phone number • Drug and diagnosis information

2019 Preferred FormularyCheck often for updates, as this list is subject to change.

2019 Preferred Formulary

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Understanding the Formulary Drug List This formulary drug list will help you understand the drugs your plan covers. The drugs in this formulary are listed by common categories, then alphabetically. They’re placed into cost levels known as tiers. The tiers include generic, preferred brand and non-preferred brand drugs reviewed by a panel of physicians and pharmacists regularly and revised to reflect availability of new drugs and other changes in the market.

Some drugs have notes with letters next to them. The letters refer to certain pharmacy benefit programs. To make sure that prescriptions are used safely, some drugs have additional requirements you’ll need to meet before we can cover your prescription. Those drugs will have an abbreviation next to the drug name to let you and your doctor know there are additional requirements.

For more information on how to fill your prescriptions, please refer to your Evidence of Coverage or member handbook on bcbst.com or call the phone number listed on your BlueCross Member ID card.

Abbreviation Description

Affordable Care Act means drugs with the ACA indicator may be available to you at no ACA out-of-pocket cost depending on your plan. Check your Evidence of Coverage or member

handbook for plan details.

Age Requirement means a person who is within a specific age group will require prior authorization for the drug to be covered. Prior authorization is required for members 17 years of AGE-A age and younger. Your doctor must call Express Scripts at 1-877-916-2271 to request approval for coverage.

Limited Distribution means drugs may only be available at certain pharmacies. For more LD information, please call us at the phone number listed on your Member ID card.

Morphine Milligram Equivalent: Your plan measures how strong each medicine is compared to morphine and limits the combined total, or MME. Prior authorization is required for members MME who take greater than 120 mg equivalents of morphine a day. Your doctor must call Express Scripts at 1-877-916-2271 to request approval for coverage.

Prior Authorization may be required for certain drugs. Your doctor must call Express Scripts at PA 1-877-916-2271 to get approval before you may fill your prescription.

Quantity Limit means you may have coverage for a limited amount of a specific drug. QL

Specialty Drug includes drugs for chronic, serious diseases such as hepatitis C, multiple SPRx sclerosis, arthritis, hemophilia and other conditions. Some plans may cover specialty drugs at

different benefit levels or may require the use of a network specialty pharmacy.

Step Therapy is a prior authorization program that requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. Your doctor must ST call Express Scripts at 1-877-916-2271 to request approval for coverage. Please refer to the list included on pages iv-v for drugs that require step therapy.

Some plans do not cover these drugs. Check your Evidence of Coverage guide or Member # Handbook for plan details.

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What’s a Drug Tier? Tiers are the different cost levels you pay for a prescription drug. Each tier is assigned a cost (copay, deductible or coinsurance), which your employer or health plan determines. This is how much you will pay when you fill a prescription. If you have a high deductible plan, the tier cost levels may apply once you hit your deductible. Check your Evidence of Coverage or member handbook for plan details.

Generic Drugs

Generic Drugs have the same strength and active ingredients as the brand name – but typically are the most affordable and offer you the lowest available copayment or coinsurance. The active ingredient in a generic drug is chemically identical to the active ingredient of the corresponding brand drug. To help lower your out-of-pocket costs, we encourage you to choose a generic medication whenever possible. Look for these drugs under “Tier 1” in this formulary.

Preferred Brand Drugs

Preferred Brand Drugs will usually have a slightly higher copay or coinsurance than generic drugs, but less than a non-preferred brand drug under your plan. These drugs are designated preferred brand because they have been proven to be safe, effective, and more affordable compared to other brand or over-the-counter drugs that treat the same condition. Look for these drugs under “Tier 2” in this formulary.

Non-Preferred Brand Drugs

Non-Preferred Brand Drugs are those that generally have generic alternatives and/ or one or more preferred options within the same drug class. You will usually pay the highest copay or coinsurance for a non-preferred drug under your plan. These drugs are listed as non-preferred because they have not been found to be any more effective than available generics, preferred brands, or over-the-counter drugs. Look for these drugs under “Tier 3” in this formulary.

Tier

1 Tier

2 Tier

3



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Step Therapy Requirements Step Therapy requires you to first try certain drugs to treat your medical condition before we cover another drug for that condition. This chart lists the drugs that require step therapy before your plan will cover the medication.

Step Therapy Drugs Step Therapy Requirements

Edarbi Edarbyclor

Non-preferred diabetic test strips (e.g., Accu-Chek, Freestyle)QL

Xalatan Zioptan

Admelog Admelog SoloStar Apidra Apidra SoloStar Humalog Humalog KwikPen Humalog Junior KwikPen

Humulin

Proventil HFAQL

Ventolin HFAQL

Xopenex HFAQL

Trial and failure of a generic Angiotensin II Receptor Blocker (ARB), including candesartan, candesartan-hydrochlorothiazide, eprosartan, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, olmesartan, olmesartan-hydrochlorothiazide, telmisartan, telmisartanhydrochlorothiazide, valsartan and valsartan-hydrochlorothiazide

Trial and failure of preferred products made by Lifescan (OneTouch)QL or Ascensia (Contour)QL

Trial and failure of latanoprost, Lumigan, or Travatan Z

Trial and failure of Fiasp, Fiasp FlexTouch or Novolog

Trial and failure of Novolin

Trial and failure of ProAir HFAQL or ProAir RespiClickQL

For certain medical conditions, it is best practice to try a Tier 2 Preferred Drug before your plan will cover a Tier 3 Non-Preferred Drug.

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You’ll need to try one or two Preferred Drugs before we’ll cover a Non-Preferred Drug. Below is a table of Preferred and Non-Preferred Drugs for various medical conditions. Find your condition in the first column of the chart. If there are drugs listed in the second column, your doctor must prescribe one of those to determine effectiveness prior to prescribing a drug listed in the third or fourth columns.

Tier

2 Tier

3 Tier

3

Medical Condition

Preferred Drug

Non Preferred Drug (directed to ONE Preferred Drug)

Non Preferred Drug (directed to TWO Preferred Drugs)

Rheumatoid arthritis

Ankylosing spondylitis

Juvenile idiopathic arthritis

Psoriatic arthritis

Psoriasis

Crohn’s disease

Ulcerative colitis

ActemraSC

Enbrel Humira

Xeljanz/XR

Cosentyx Enbrel Humira

Enbrel Humira

Cosentyx Enbrel Humira

StelaraSC

Cosentyx Humira Otezla

StelaraSC

Humira StelaraSC

Humira

ActemraSC

Otezla

Enbrel* Tremfya*

Cimzia

SimponiSC

Xeljanz

Cimzia Kevzara Kineret

Olumiant OrenciaSC

SimponiSC

Cimzia SimponiSC

OrenciaSC

Cimzia OrenciaSC

SimponiSC

Taltz Xeljanz/XR

Cimzia Siliq Taltz

SC – subcutaneous

*For the treatment of Psoriasis, you must try Humira first before Enbrel or Tremfya is approved. Cosentyx, Otezla or StelaraSC don’t meet the requirement for coverage of Enbrel or Tremfya for Psoriasis.

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Where to Get Your Prescriptions Filled You’ll need to show your Member ID card when you have a prescription filled. You may have to pay part of the cost for prescription medicines and supplies. Check your Evidence of Coverage or member handbook for specifics.

Network Pharmacies Our pharmacy networks include many retail drug store chains and independent pharmacies across the country. If your medication isn’t for managing a long-term condition, the prescription is typically written for less than a 30-day supply. (See the Retail 90 and Home Delivery Network sections for information on 90-day supplies).

It’s important that you always use an in-network pharmacy. If you don’t, you’ll have to pay all of the costs for your prescription. If you’re outside Tennessee, you can find a pharmacy in our nationwide network. Check your Evidence of Coverage or member handbook for your pharmacy network details.

How to find a network pharmacy:

• Go to bcbst.com.

Sign up for BlueAccessSM , our secure member portal.

Click on Find a Doctor.

Click on Pharmacy and select your Pharmacy Network.

Or • Call Member Service at the

number on the back of your Member ID card.

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Retail 90 Networks Through Retail 90 Networks you can get up to a 90-day (three-month) supply of your prescriptions.*

• With a three-month supply, you're less likely to miss a dose, and you don't have to refill as often, which can save you time and money.

• If you use a pharmacy that’s not part of your Retail 90 Network, you’re limited to a 30-day (one-month) supply.

• These networks are made up of some local pharmacies and drug store chains. Ask your pharmacy if they’re part of your Retail 90 Network.

Home Delivery You can sign up for home delivery and have your prescription delivered right to your door. Home Delivery is for prescriptions with a 30-day (one-month) or a 90-day (three-month) supply.* Call 1-877-673-9165 to get started.

With home delivery you get:

• FREE standard shipping**

• Access to a pharmacist 24/7 • Automatic refill reminders so you’re

less likely to miss a dose • Extended payment plan available

Specialty Pharmacies Some serious medical conditions need specialty drugs. They may be given at the doctor’s office or at home. Our specialty pharmacies are a special network of vendors, experienced in managing these specialty drugs and supporting you and your doctor. You and your doctor can find a list of specialty pharmacies at bcbst.com.

Specialty drugs:

• Usually require a prior authorization • Usually are limited to a 30-day supply • Are usually only available from specialty

pharmacies in our network. Check your Evidence of Coverage or member handbook for your pharmacy network details.

*Your doctor will need to write your prescription for a 90-day supply.

**Standard shipping costs are included.



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Talk with your doctor. Doctors are your partners, so discuss every aspect of your treatment, including the selection of drugs. The more you know, the better choices you can make.

Ask your doctor to check the list of drugs your plan covers

before prescribing a medicine.

Give your doctor a list of all the medicines you take.

Include medicines that don’t need a prescription. This helps them choose medicines that

work well together.

Advertising, social media or the internet may not be your best source of information. Discuss all your concerns

with your doctor.

Ask for generic drugs. The U.S. Food and Drug Administration (FDA) requires generic drugs to have the same quality, strength and purity as brand-name drugs.

• Generic drugs work the same as brand name drugs, but cost less.

• Talk to your doctor about the different kinds of generic drugs.

• The formulary drug list has different tiers (levels) of drugs that you can use (see “What’s a Drug Tier?” on page iii).

• You pay less for generic drugs almost every time.

• Under most BlueCross plans, if you request a brand name drug that has a generic equivalent, you pay the cost difference between the generic and brand name drug. Check your Evidence of Coverage or member handbook to see if this applies to your plan.

Tips for Using Your Prescription Drug Benefits



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Talk to your pharmacist. Your pharmacist can answer questions about the drugs you take, help you avoid harmful drug interactions, and help you select appropriate, lower-cost generics and preferred brands whenever available.

• Have all of your family’s prescriptions filled at the same pharmacy. • By knowing all your prescriptions, your pharmacist can make sure all of your drugs work

well together. This can help keep you and your family safe.

Use over-the-counter (OTC) medicines to save money. • OTC medicines are sold without

a prescription. • Some prescription drugs may not be

covered under your plan because there is an OTC available that works just as well.

• Don’t switch from a prescription drug to an OTC without talking with your doctor.

Be safe with your prescriptions. • Never share prescription drugs–even if

it’s for a member of the family. • Keep all medicines safe from children,

out of sight and out of reach. Lock them away, if possible.

• Don’t stop using a prescription without talking to the doctor.

• Follow up with the doctor about any side effects.

Some prescriptions need an approval for coverage. • Some prescriptions require prior

authorization or step therapy. • Some drugs have limits on the amount of

them that your plan will pay for. • Network doctors usually know this and

know how to get authorizations. However, you may want to show this formulary drug list to your doctor - especially if you use an out-of-network doctor or a doctor outside Tennessee.



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Table of Contents

Anti - Infectives.....................................................................................................................................................2 Antineoplastic & Immunosuppressant Drugs ....................................................................................................14 Autonomic & CNS Drugs, Neurology & Psych ....................................................................................................19 Cardiovascular, Hypertension & Lipids ..............................................................................................................43 Dermatologicals/Topical Therapy ......................................................................................................................56 Diagnostics & Miscellaneous Agents..................................................................................................................70 Ear, Nose & Throat Medications ........................................................................................................................75 Endocrine/Diabetes............................................................................................................................................77 Gastroenterology ...............................................................................................................................................95 Immunology, Vaccines & Biotechnology..........................................................................................................102 Musculoskeletal & Rheumatology ...................................................................................................................108 Obstetrics & Gynecology..................................................................................................................................110 Ophthalmology.................................................................................................................................................120 Respiratory, Allergy, Cough & Cold ..................................................................................................................126 Urologicals........................................................................................................................................................133 Vitamins, Hematinics & Electrolytes ................................................................................................................135 Index of Drugs ..................................................................................................................................................142

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Drug Name Drug Tier Requirements/Limits

Anti - Infectives

Antifungal Agents ANCOBON ORAL CAPSULE Tier 3

clotrimazole mucous membrane troche Tier 1

CRESEMBA ORAL CAPSULE Tier 3

DIFLUCAN ORAL SUSPENSION FOR RECONSTITUTION

Tier 3

DIFLUCAN ORAL TABLET Tier 3

fluconazole oral suspension for reconstitution Tier 1

fluconazole oral tablet Tier 1

flucytosine oral capsule Tier 1

griseofulvin microsize oral suspension Tier 1

griseofulvin microsize oral tablet Tier 1

griseofulvin ultramicrosize oral tablet Tier 1

GRIS-PEG (ULTRAMICROSIZE) ORAL TABLET Tier 3

itraconazole oral capsule Tier 1

itraconazole oral solution Tier 1

ketoconazole oral tablet Tier 1

NOXAFIL ORAL SUSPENSION Tier 3

NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC)

Tier 3

nystatin oral powder 150 million unit, 500 million unit

Tier 1

nystatin oral suspension Tier 1

nystatin oral tablet Tier 1

ONMEL ORAL TABLET Tier 3

ORAVIG BUCCAL MUCO-ADHESIVE BUCCAL TABLET

Tier 3

SPORANOX ORAL SOLUTION Tier 3

SPORANOX PULSEPAK ORAL CAPSULE Tier 3

terbinafine hcl oral tablet Tier 1

VFEND ORAL SUSPENSION FOR RECONSTITUTION Tier 3

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VFEND ORAL TABLET Tier 3

voriconazole oral suspension for reconstitution Tier 1

voriconazole oral tablet Tier 1

Antivirals abacavir oral solution Tier 1

abacavir oral tablet Tier 1

abacavir-lamivudine oral tablet Tier 1 SPRx

abacavir-lamivudine-zidovudine oral tablet Tier 1

acyclovir oral capsule Tier 1

acyclovir oral suspension 200 mg/5 ml Tier 1

acyclovir oral tablet Tier 1

adefovir oral tablet Tier 1

amantadine hcl oral capsule Tier 1

amantadine hcl oral solution Tier 1

amantadine hcl oral tablet Tier 1

APTIVUS ORAL CAPSULE Tier 3

APTIVUS ORAL SOLUTION Tier 3

atazanavir oral capsule Tier 1 SPRx

ATRIPLA ORAL TABLET Tier 3 SPRx

BARACLUDE ORAL SOLUTION Tier 3

BARACLUDE ORAL TABLET Tier 3

BIKTARVY ORAL TABLET Tier 3 SPRx

CIMDUO ORAL TABLET Tier 3 SPRx

COMBIVIR ORAL TABLET Tier 3

COMPLERA ORAL TABLET Tier 3 SPRx

CRIXIVAN ORAL CAPSULE 200 MG, 400 MG Tier 3

DESCOVY ORAL TABLET Tier 3 SPRx

didanosine oral capsule,delayed release(dr/ec) Tier 1

EDURANT ORAL TABLET Tier 3

efavirenz oral capsule Tier 1

efavirenz oral tablet Tier 1


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EMTRIVA ORAL CAPSULE Tier 3

EMTRIVA ORAL SOLUTION Tier 3

entecavir oral tablet Tier 1

EPCLUSA ORAL TABLET Tier 2 PA; SPRx

EPIVIR HBV ORAL SOLUTION Tier 3

EPIVIR HBV ORAL TABLET Tier 3

EPIVIR ORAL SOLUTION Tier 3

EPIVIR ORAL TABLET Tier 3

EPZICOM ORAL TABLET Tier 3 SPRx

EVOTAZ ORAL TABLET Tier 3 SPRx

famciclovir oral tablet Tier 1

FLUMADINE ORAL TABLET Tier 3

fosamprenavir oral tablet Tier 1

FUZEON SUBCUTANEOUS RECON SOLN Tier 3 SPRx

GENVOYA ORAL TABLET Tier 3 SPRx

HARVONI ORAL TABLET Tier 2 PA; SPRx

HEPSERA ORAL TABLET Tier 3

INTELENCE ORAL TABLET Tier 3

INVIRASE ORAL CAPSULE Tier 3

INVIRASE ORAL TABLET Tier 3

ISENTRESS HD ORAL TABLET Tier 3 SPRx

ISENTRESS ORAL POWDER IN PACKET Tier 3 SPRx

ISENTRESS ORAL TABLET Tier 3 SPRx

ISENTRESS ORAL TABLET,CHEWABLE Tier 3 SPRx

JULUCA ORAL TABLET Tier 3 SPRx

KALETRA ORAL SOLUTION Tier 3

KALETRA ORAL TABLET Tier 3

lamivudine oral solution Tier 1

lamivudine oral tablet Tier 1

lamivudine-zidovudine oral tablet Tier 1

LEXIVA ORAL SUSPENSION Tier 3


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LEXIVA ORAL TABLET Tier 3

lopinavir-ritonavir oral solution Tier 1

MAVYRET ORAL TABLET Tier 2 PA; SPRx

nevirapine oral suspension Tier 1

nevirapine oral tablet Tier 1

nevirapine oral tablet extended release 24 hr Tier 1

NORVIR ORAL CAPSULE Tier 3

NORVIR ORAL POWDER IN PACKET Tier 3

NORVIR ORAL SOLUTION Tier 3

NORVIR ORAL TABLET Tier 3

ODEFSEY ORAL TABLET Tier 3 SPRx

oseltamivir oral capsule 30 mg Tier 1 QL (20 EA per 180 days)

oseltamivir oral capsule 45 mg, 75 mg Tier 1 QL (10 EA per 180 days)

oseltamivir oral suspension for reconstitution Tier 1 QL (180 ML per 180 days)

PREZCOBIX ORAL TABLET Tier 3 SPRx

PREZISTA ORAL SUSPENSION Tier 3 SPRx

PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG

Tier 3 SPRx

RELENZA DISKHALER INHALATION BLISTER WITH DEVICE

Tier 3 QL (20 EA per 180 days)

RESCRIPTOR ORAL TABLET Tier 3

RESCRIPTOR ORAL TABLET, DISPERSIBLE Tier 3

RETROVIR ORAL CAPSULE Tier 3

REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG

Tier 3 SPRx

REYATAZ ORAL POWDER IN PACKET Tier 3 SPRx

rimantadine oral tablet Tier 1

ritonavir oral tablet Tier 1

SELZENTRY ORAL SOLUTION Tier 3

SELZENTRY ORAL TABLET Tier 3

SOVALDI ORAL TABLET Tier 2 PA; SPRx

stavudine oral capsule Tier 1


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stavudine oral recon soln Tier 1

STRIBILD ORAL TABLET Tier 3 SPRx

SUSTIVA ORAL CAPSULE Tier 3

SUSTIVA ORAL TABLET Tier 3

SYMFI LO ORAL TABLET Tier 3 SPRx

SYMFI ORAL TABLET Tier 3 SPRx

SYMTUZA ORAL TABLET Tier 3 SPRx

TAMIFLU ORAL CAPSULE 30 MG Tier 3 QL (20 EA per 180 days)

TAMIFLU ORAL CAPSULE 45 MG, 75 MG Tier 3 QL (10 EA per 180 days)

TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION

Tier 3 QL (180 ML per 180 days)

tenofovir disoproxil fumarate oral tablet Tier 1

TIVICAY ORAL TABLET Tier 3 SPRx

TRIUMEQ ORAL TABLET Tier 3 SPRx

TRIZIVIR ORAL TABLET Tier 3

TRUVADA ORAL TABLET Tier 3 SPRx

TYBOST ORAL TABLET Tier 3

valacyclovir oral tablet Tier 1

VALCYTE ORAL RECON SOLN Tier 3

VALCYTE ORAL TABLET Tier 3

valganciclovir oral recon soln Tier 1

valganciclovir oral tablet Tier 1

VALTREX ORAL TABLET Tier 3

VEMLIDY ORAL TABLET Tier 3 SPRx

VIDEX 2 GRAM PEDIATRIC ORAL RECON SOLN Tier 3

VIDEX 4 GRAM PEDIATRIC ORAL RECON SOLN Tier 3

VIDEX EC ORAL CAPSULE,DELAYED RELEASE(DR/EC)

Tier 3

VIRACEPT ORAL TABLET Tier 3

VIRAMUNE ORAL SUSPENSION Tier 3

VIRAMUNE ORAL TABLET Tier 3


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VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR

Tier 3

VIRAZOLE INHALATION RECON SOLN Tier 3

VIREAD ORAL POWDER Tier 3

VIREAD ORAL TABLET Tier 3

VOSEVI ORAL TABLET Tier 2 PA; SPRx

ZERIT ORAL CAPSULE Tier 3

ZERIT ORAL RECON SOLN Tier 3

ZIAGEN ORAL SOLUTION Tier 3

ZIAGEN ORAL TABLET Tier 3

zidovudine oral capsule Tier 1

zidovudine oral syrup Tier 1

zidovudine oral tablet Tier 1

ZOVIRAX ORAL CAPSULE Tier 3

ZOVIRAX ORAL SUSPENSION Tier 3

ZOVIRAX ORAL TABLET Tier 3

Cephalosporins CEDAX ORAL CAPSULE Tier 3

CEDAX ORAL SUSPENSION FOR RECONSTITUTION Tier 3

cefaclor oral capsule Tier 1

cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml

Tier 1

cefaclor oral tablet extended release 12 hr Tier 1

cefadroxil oral capsule Tier 1

cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml

Tier 1

cefadroxil oral tablet Tier 1

cefdinir oral capsule Tier 1

cefdinir oral suspension for reconstitution Tier 1

cefditoren pivoxil oral tablet Tier 1

cefixime oral suspension for reconstitution Tier 1

cefpodoxime oral suspension for reconstitution Tier 1


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cefpodoxime oral tablet Tier 1

cefprozil oral suspension for reconstitution Tier 1

cefprozil oral tablet Tier 1

ceftibuten oral capsule Tier 1

ceftibuten oral suspension for reconstitution Tier 1

CEFTIN ORAL SUSPENSION FOR RECONSTITUTION

Tier 3

cefuroxime axetil oral tablet Tier 1

cephalexin oral capsule Tier 1

cephalexin oral suspension for reconstitution Tier 1

cephalexin oral tablet Tier 1

SUPRAX ORAL CAPSULE Tier 3

SUPRAX ORAL SUSPENSION FOR RECONSTITUTION

Tier 3

SUPRAX ORAL TABLET,CHEWABLE Tier 3

Erythromycins & Other Macrolides azithromycin oral packet Tier 1

azithromycin oral suspension for reconstitution Tier 1

azithromycin oral tablet Tier 1

clarithromycin oral suspension for reconstitution Tier 1

clarithromycin oral tablet Tier 1

clarithromycin oral tablet extended release 24 hr Tier 1

DIFICID ORAL TABLET Tier 3

e.e.s. 400 oral tablet Tier 1

E.E.S. GRANULES ORAL SUSPENSION FOR RECONSTITUTION

Tier 3

ERYPED 200 ORAL SUSPENSION FOR RECONSTITUTION

Tier 3

ERYPED 400 ORAL SUSPENSION FOR RECONSTITUTION

Tier 3

ery-tab oral tablet,delayed release (dr/ec) 250 mg, 333 mg

Tier 1


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ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 500 MG

Tier 3

erythrocin (as stearate) oral tablet 250 mg Tier 1

erythromycin ethylsuccinate oral tablet Tier 1

erythromycin oral capsule,delayed release(dr/ec) Tier 1

erythromycin oral tablet Tier 1

PCE ORAL TABLET, PARTICLES/CRYSTALS Tier 3

ZITHROMAX ORAL PACKET Tier 3

ZITHROMAX ORAL SUSPENSION FOR RECONSTITUTION

Tier 3

ZITHROMAX ORAL TABLET Tier 3

ZMAX ORAL SUSPENSION,EXTENDED REL RECON Tier 3

Miscellaneous Antiinfectives ALBENZA ORAL TABLET Tier 3

ALINIA ORAL SUSPENSION FOR RECONSTITUTION Tier 3

ALINIA ORAL TABLET Tier 3

atovaquone oral suspension Tier 1

atovaquone-proguanil oral tablet Tier 1

BILTRICIDE ORAL TABLET Tier 3

CAYSTON INHALATION SOLUTION FOR NEBULIZATION

Tier 3 PA; LD; SPRx

chloroquine phosphate oral tablet Tier 1

CLEOCIN HCL ORAL CAPSULE Tier 3

CLEOCIN PEDIATRIC ORAL RECON SOLN Tier 3

clindamycin hcl oral capsule Tier 1

clindamycin palmitate hcl oral recon soln Tier 1

clindamycin pediatric oral recon soln Tier 1

COARTEM ORAL TABLET Tier 3

CYCLOSERINE ORAL CAPSULE Tier 3

dapsone oral tablet Tier 1

DARAPRIM ORAL TABLET Tier 3 PA; LD; SPRx

ethambutol oral tablet Tier 1


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Effective 1/2019

FLAGYL ORAL CAPSULE Tier 3

FLAGYL ORAL TABLET Tier 3

hydroxychloroquine oral tablet Tier 1

isoniazid oral solution Tier 1

isoniazid oral tablet Tier 1

ivermectin oral tablet Tier 1

KITABIS PAK INHALATION SOLUTION FOR NEBULIZATION

Tier 2 LD; SPRx; QL (56 ML per 30 days)

linezolid oral suspension for reconstitution Tier 1 QL (14 day supply per 30 days)

linezolid oral tablet Tier 1 QL (14 day supply per 30 days)

MALARONE ORAL TABLET Tier 3

MALARONE PEDIATRIC ORAL TABLET Tier 3

mefloquine oral tablet Tier 1

MEPRON ORAL SUSPENSION Tier 3

metronidazole oral capsule Tier 1

metronidazole oral tablet Tier 1

MYAMBUTOL ORAL TABLET 400 MG Tier 3

MYCOBUTIN ORAL CAPSULE Tier 3

NEBUPENT INHALATION RECON SOLN Tier 3

neomycin oral tablet Tier 1

paromomycin oral capsule Tier 1

PASER ORAL GRANULES DR FOR SUSP IN PACKET Tier 3

PLAQUENIL ORAL TABLET Tier 3

praziquantel oral tablet Tier 1

PRIFTIN ORAL TABLET Tier 3

PRIMAQUINE ORAL TABLET Tier 3

pyrazinamide oral tablet Tier 1

QUALAQUIN ORAL CAPSULE Tier 3

quinine sulfate oral capsule Tier 1

rifabutin oral capsule Tier 1

RIFADIN ORAL CAPSULE Tier 3

RIFAMATE ORAL CAPSULE Tier 3


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rifampin oral capsule Tier 1

RIFATER ORAL TABLET Tier 3

SIRTURO ORAL TABLET Tier 3 LD; SPRx

STROMECTOL ORAL TABLET Tier 3

TINDAMAX ORAL TABLET 500 MG Tier 3

tinidazole oral tablet Tier 1

TOBI INHALATION SOLUTION FOR NEBULIZATION Tier 3 SPRx; QL (56 ML per 30 days)

tobramycin in 0.225 % nacl inhalation solution for nebulization

Tier 1 SPRx; QL (56 ML per 30 days)

TRECATOR ORAL TABLET Tier 3

XIFAXAN ORAL TABLET 200 MG Tier 3

XIFAXAN ORAL TABLET 550 MG Tier 2

ZYVOX ORAL SUSPENSION FOR RECONSTITUTION Tier 3 QL (14 day supply per 30 days)

ZYVOX ORAL TABLET Tier 3 QL (14 day supply per 30 days)

Penicillins amoxicillin oral capsule Tier 1

amoxicillin oral suspension for reconstitution Tier 1

amoxicillin oral tablet Tier 1

amoxicillin oral tablet,chewable 125 mg, 250 mg Tier 1

amoxicillin-pot clavulanate oral suspension for reconstitution

Tier 1

amoxicillin-pot clavulanate oral tablet Tier 1

amoxicillin-pot clavulanate oral tablet extended release 12 hr

Tier 1

amoxicillin-pot clavulanate oral tablet,chewable Tier 1

ampicillin oral capsule Tier 1

AUGMENTIN ES-600 ORAL SUSPENSION FOR RECONSTITUTION

Tier 3

AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION 125-31.25 MG/5 ML, 250-62.5 MG/5 ML

Tier 3

AUGMENTIN ORAL TABLET 500-125 MG, 875-125 MG

Tier 3


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AUGMENTIN XR ORAL TABLET EXTENDED RELEASE 12 HR

Tier 3

dicloxacillin oral capsule Tier 1

penicillin v potassium oral recon soln Tier 1

penicillin v potassium oral tablet Tier 1

Quinolones AVELOX ORAL TABLET Tier 3

CIPRO ORAL SUSPENSION,MICROCAPSULE RECON

Tier 3

CIPRO ORAL TABLET 250 MG, 500 MG Tier 3

CIPRO XR ORAL TABLET, ER MULTIPHASE 24 HR Tier 3

ciprofloxacin (mixture) oral tablet, er multiphase 24 hr

Tier 1

ciprofloxacin hcl oral tablet Tier 1

ciprofloxacin oral suspension,microcapsule recon Tier 1

FACTIVE ORAL TABLET Tier 3

LEVAQUIN ORAL TABLET Tier 3

levofloxacin oral solution Tier 1

levofloxacin oral tablet Tier 1

moxifloxacin oral tablet Tier 1

ofloxacin oral tablet 300 mg, 400 mg Tier 1

Sulfa's & Related Agents BACTRIM DS ORAL TABLET Tier 3

BACTRIM ORAL TABLET Tier 3

sulfadiazine oral tablet Tier 1

sulfamethoxazole-trimethoprim oral suspension Tier 1

sulfamethoxazole-trimethoprim oral tablet Tier 1

sulfatrim oral suspension Tier 1

Tetracyclines avidoxy oral tablet Tier 1

demeclocycline oral tablet Tier 1

doxycycline hyclate oral capsule Tier 1


13

Effective 1/2019

doxycycline hyclate oral tablet 100 mg, 20 mg Tier 1

doxycycline hyclate oral tablet,delayed release (dr/ec) 100 mg, 150 mg, 75 mg

Tier 1

doxycycline monohydrate oral capsule Tier 1

doxycycline monohydrate oral suspension for reconstitution

Tier 1

doxycycline monohydrate oral tablet Tier 1

minocycline oral capsule Tier 1

minocycline oral tablet Tier 1

soloxide oral tablet,delayed release (dr/ec) Tier 1

tetracycline oral capsule Tier 1

VIBRAMYCIN ORAL CAPSULE 100 MG Tier 3

VIBRAMYCIN ORAL SUSPENSION FOR RECONSTITUTION

Tier 3

VIBRAMYCIN ORAL SYRUP Tier 3

Urinary Tract Agents FURADANTIN ORAL SUSPENSION Tier 3

HIPREX ORAL TABLET Tier 3

MACROBID ORAL CAPSULE Tier 3

MACRODANTIN ORAL CAPSULE Tier 3

methenamine hippurate oral tablet Tier 1

methenamine mandelate oral tablet Tier 1

MONUROL ORAL PACKET Tier 3

nitrofurantoin macrocrystal oral capsule Tier 1

nitrofurantoin monohyd/m-cryst oral capsule Tier 1

nitrofurantoin oral suspension Tier 1

PRIMSOL ORAL SOLUTION Tier 3

trimethoprim oral tablet Tier 1

Vancomycin FIRVANQ ORAL RECON SOLN Tier 3

VANCOCIN ORAL CAPSULE Tier 3

vancomycin oral capsule Tier 1


14

Effective 1/2019Drug Name Drug Tier Requirements/Limits

Antineoplastic & Immunosuppressant Drugs

Adjunctive Agents leucovorin calcium oral tablet Tier 1

MESNEX ORAL TABLET Tier 3

Antineoplastic & Immunosuppressant Drugs AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION

Tier 3 PA; SPRx

AFINITOR ORAL TABLET Tier 3 PA; SPRx

ALECENSA ORAL CAPSULE Tier 3 PA; LD; SPRx

ALKERAN ORAL TABLET Tier 3

ALUNBRIG ORAL TABLET Tier 3 PA; SPRx

ALUNBRIG ORAL TABLETS,DOSE PACK Tier 3 PA; SPRx

anastrozole oral tablet Tier 1

ARIMIDEX ORAL TABLET Tier 3

AROMASIN ORAL TABLET Tier 3

ASTAGRAF XL ORAL CAPSULE,EXTENDED RELEASE 24HR

Tier 3 SPRx

AZASAN ORAL TABLET Tier 3

azathioprine oral tablet Tier 1

bexarotene oral capsule Tier 1 SPRx

bicalutamide oral tablet Tier 1

BOSULIF ORAL TABLET Tier 3 PA; LD; SPRx

BRAFTOVI ORAL CAPSULE Tier 3 PA; SPRx

CABOMETYX ORAL TABLET Tier 3 PA; LD; SPRx

CALQUENCE ORAL CAPSULE Tier 3 PA; SPRx

capecitabine oral tablet Tier 1 SPRx

CAPRELSA ORAL TABLET Tier 3 PA; LD; SPRx

CASODEX ORAL TABLET Tier 3

CELLCEPT ORAL CAPSULE Tier 3

CELLCEPT ORAL SUSPENSION FOR RECONSTITUTION

Tier 3

COMETRIQ ORAL CAPSULE Tier 3 LD; SPRx

15

Effective 1/2019

COTELLIC ORAL TABLET Tier 3 PA; LD; SPRx

cyclophosphamide oral capsule Tier 1

cyclosporine modified oral capsule Tier 1

cyclosporine modified oral solution Tier 1

cyclosporine oral capsule Tier 1

DROXIA ORAL CAPSULE Tier 3

EMCYT ORAL CAPSULE Tier 3

ERIVEDGE ORAL CAPSULE Tier 3 PA; LD; SPRx

ERLEADA ORAL TABLET Tier 3 PA; SPRx

etoposide oral capsule Tier 1

exemestane oral tablet Tier 1

FARESTON ORAL TABLET Tier 3

FARYDAK ORAL CAPSULE Tier 3 PA; LD; SPRx

FEMARA ORAL TABLET Tier 3

flutamide oral capsule Tier 1

gengraf oral capsule Tier 1

gengraf oral solution Tier 1

GILOTRIF ORAL TABLET Tier 3 PA; LD; SPRx

GLEEVEC ORAL TABLET Tier 3 SPRx

GLEOSTINE ORAL CAPSULE Tier 3

HEXALEN ORAL CAPSULE Tier 3

HYCAMTIN ORAL CAPSULE Tier 3 SPRx

HYDREA ORAL CAPSULE Tier 3

hydroxyurea oral capsule Tier 1

IBRANCE ORAL CAPSULE Tier 3 PA; LD; SPRx

ICLUSIG ORAL TABLET Tier 3 PA; LD; SPRx

IDHIFA ORAL TABLET Tier 3 PA; SPRx

imatinib oral tablet Tier 1 SPRx

IMBRUVICA ORAL CAPSULE Tier 3 PA; LD; SPRx

IMBRUVICA ORAL TABLET Tier 3 PA; LD; SPRx

IMURAN ORAL TABLET Tier 3


16

Effective 1/2019

INLYTA ORAL TABLET Tier 3 PA; LD; SPRx

IRESSA ORAL TABLET Tier 3 PA; LD; SPRx

JAKAFI ORAL TABLET Tier 3 PA; LD; SPRx

KISQALI FEMARA CO-PACK ORAL TABLET Tier 3 PA; SPRx

KISQALI ORAL TABLET Tier 3 PA; SPRx

LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1), 14 MG/DAY(10 MG X 1-4 MG X 1), 18 MG/DAY (10 MG X 1-4 MG X2), 20 MG/DAY (10 MG X 2), 24 MG/DAY(10 MG X 2-4 MG X 1), 8 MG/DAY (4 MG X 2)

Tier 3 PA; LD; SPRx

LENVIMA ORAL CAPSULE 12 MG/DAY (4 MG X 3), 4 MG

Tier 3 PA; SPRx

letrozole oral tablet Tier 1

LEUKERAN ORAL TABLET Tier 2

leuprolide subcutaneous kit Tier 1 PA; SPRx

LONSURF ORAL TABLET Tier 3 PA; LD; SPRx

LYNPARZA ORAL CAPSULE Tier 3 PA; LD; SPRx

LYNPARZA ORAL TABLET Tier 3 PA; SPRx

LYSODREN ORAL TABLET Tier 3

MATULANE ORAL CAPSULE Tier 3 SPRx

MEGACE ES ORAL SUSPENSION Tier 3

megestrol oral suspension 400 mg/10 ml (40 mg/ml), 625 mg/5 ml

Tier 1

megestrol oral tablet Tier 1

MEKINIST ORAL TABLET Tier 3 PA; SPRx

MEKTOVI ORAL TABLET Tier 3 PA; SPRx

melphalan oral tablet Tier 1

mercaptopurine oral tablet Tier 1

methotrexate sodium (pf) injection recon soln Tier 1

methotrexate sodium (pf) injection solution Tier 1

methotrexate sodium injection solution Tier 1

methotrexate sodium oral tablet Tier 1

mycophenolate mofetil oral capsule Tier 1


17

Effective 1/2019

mycophenolate mofetil oral suspension for reconstitution

Tier 1

mycophenolate mofetil oral tablet Tier 1

mycophenolate sodium oral tablet,delayed release (dr/ec)

Tier 1

MYFORTIC ORAL TABLET,DELAYED RELEASE (DR/EC)

Tier 3

MYLERAN ORAL TABLET Tier 3

NEORAL ORAL CAPSULE Tier 3

NEORAL ORAL SOLUTION Tier 3

NERLYNX ORAL TABLET Tier 3 PA; SPRx

NEXAVAR ORAL TABLET Tier 3 PA; LD; SPRx

NILANDRON ORAL TABLET Tier 3 SPRx

nilutamide oral tablet Tier 1 SPRx

NINLARO ORAL CAPSULE Tier 3 PA; LD; SPRx

octreotide acetate injection solution Tier 1 SPRx

octreotide acetate injection syringe Tier 1 SPRx

ODOMZO ORAL CAPSULE Tier 3 PA; SPRx

PROGRAF ORAL CAPSULE Tier 3

PURIXAN ORAL SUSPENSION Tier 3 SPRx

RAPAMUNE ORAL SOLUTION Tier 3

RAPAMUNE ORAL TABLET Tier 3

RUBRACA ORAL TABLET Tier 3 PA; LD; SPRx

RYDAPT ORAL CAPSULE Tier 3 PA; SPRx

SANDIMMUNE ORAL CAPSULE Tier 3

SANDIMMUNE ORAL SOLUTION Tier 3

SANDOSTATIN INJECTION SOLUTION Tier 3 SPRx

SIGNIFOR SUBCUTANEOUS SOLUTION Tier 3 PA; LD; SPRx

SIKLOS ORAL TABLET 100 MG Tier 3

sirolimus oral tablet Tier 1

SOLTAMOX ORAL SOLUTION Tier 3 ACA

SPRYCEL ORAL TABLET Tier 3 SPRx


18

Effective 1/2019

STIVARGA ORAL TABLET Tier 3 PA; LD; SPRx

SUTENT ORAL CAPSULE Tier 3 PA; LD; SPRx

TABLOID ORAL TABLET Tier 3

tacrolimus oral capsule Tier 1

TAFINLAR ORAL CAPSULE Tier 3 PA; LD; SPRx

TAGRISSO ORAL TABLET Tier 3 PA; LD; SPRx

tamoxifen oral tablet Tier 1 ACA

TARCEVA ORAL TABLET Tier 3 PA; LD; SPRx

TARGRETIN ORAL CAPSULE Tier 3 SPRx

TARGRETIN TOPICAL GEL Tier 3 SPRx

TASIGNA ORAL CAPSULE Tier 3 SPRx

TEMODAR ORAL CAPSULE Tier 3 PA; SPRx

temozolomide oral capsule Tier 1 PA; SPRx

THALOMID ORAL CAPSULE Tier 3 PA; LD; SPRx

TIBSOVO ORAL TABLET Tier 3 PA; SPRx

tretinoin (chemotherapy) oral capsule Tier 1

TREXALL ORAL TABLET Tier 3

TYKERB ORAL TABLET Tier 3 PA; LD; SPRx

VENCLEXTA ORAL TABLET Tier 3 PA; LD; SPRx

VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK

Tier 3 PA; LD; SPRx

VERZENIO ORAL TABLET Tier 3 PA; SPRx

VOTRIENT ORAL TABLET Tier 3 PA; LD; SPRx

XALKORI ORAL CAPSULE Tier 3 PA; LD; SPRx

XELODA ORAL TABLET Tier 3 SPRx

XERMELO ORAL TABLET Tier 3 PA; SPRx

XTANDI ORAL CAPSULE Tier 3 LD; SPRx

YONSA ORAL TABLET Tier 3 PA; SPRx

ZEJULA ORAL CAPSULE Tier 3 PA; LD; SPRx

ZELBORAF ORAL TABLET Tier 3 PA; LD; SPRx

ZOLINZA ORAL CAPSULE Tier 3 SPRx


19

Effective 1/2019

ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG, 0.75 MG

Tier 3 SPRx

ZYDELIG ORAL TABLET Tier 3 PA; SPRx

ZYKADIA ORAL CAPSULE Tier 3 PA; SPRx

ZYTIGA ORAL TABLET Tier 3 SPRx


Autonomic & CNS Drugs, Neurology & Psych

Agents for Narcotic Withdrawal BUNAVAIL BUCCAL FILM Tier 2 QL (90 EA per 30 days)

buprenorphine-naloxone sublingual tablet Tier 1 QL (90 EA per 30 days)

SUBOXONE SUBLINGUAL FILM Tier 2 QL (90 EA per 30 days)

ZUBSOLV SUBLINGUAL TABLET Tier 2 QL (90 EA per 30 days)

Anticonvulsants APTIOM ORAL TABLET Tier 3

BANZEL ORAL SUSPENSION Tier 3

BANZEL ORAL TABLET Tier 3

carbamazepine oral capsule, er multiphase 12 hr Tier 1

carbamazepine oral suspension Tier 1

carbamazepine oral tablet Tier 1

carbamazepine oral tablet extended release 12 hr Tier 1

carbamazepine oral tablet,chewable Tier 1

CARBATROL ORAL CAPSULE, ER MULTIPHASE 12 HR

Tier 3

CELONTIN ORAL CAPSULE 300 MG Tier 3

clobazam oral suspension Tier 1

clobazam oral tablet Tier 1

clonazepam oral tablet Tier 1

clonazepam oral tablet,disintegrating Tier 1

DEPAKENE ORAL CAPSULE Tier 3

DEPAKENE ORAL SOLUTION Tier 3

DEPAKOTE ER ORAL TABLET EXTENDED RELEASE 24 HR

Tier 3

20

Effective 1/2019

DEPAKOTE ORAL TABLET,DELAYED RELEASE (DR/EC)

Tier 3

DEPAKOTE SPRINKLES ORAL CAPSULE, DELAYED REL SPRINKLE

Tier 3

DIASTAT ACUDIAL RECTAL KIT Tier 3

DIASTAT RECTAL KIT Tier 3

diazepam rectal kit Tier 1

DILANTIN EXTENDED ORAL CAPSULE Tier 2

DILANTIN INFATABS ORAL TABLET,CHEWABLE Tier 2

DILANTIN KAPSEAL ORAL CAPSULE Tier 2

DILANTIN ORAL CAPSULE Tier 2

DILANTIN-125 ORAL SUSPENSION Tier 2

divalproex oral capsule, delayed rel sprinkle Tier 1

divalproex oral tablet extended release 24 hr Tier 1

divalproex oral tablet,delayed release (dr/ec) Tier 1

epitol oral tablet Tier 1

EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR Tier 3

ethosuximide oral capsule Tier 1

ethosuximide oral solution Tier 1

felbamate oral suspension Tier 1

felbamate oral tablet Tier 1

FELBATOL ORAL SUSPENSION Tier 3

FELBATOL ORAL TABLET Tier 3

FYCOMPA ORAL TABLET Tier 3

gabapentin oral capsule Tier 1 PA; QL (180 EA per 30 days)

gabapentin oral solution Tier 1 PA; QL (2160 ML per 30 days)

gabapentin oral tablet 600 mg Tier 1 PA; QL (180 EA per 30 days)

gabapentin oral tablet 800 mg Tier 1 PA; QL (120 EA per 30 days)

GABITRIL ORAL TABLET Tier 3

KEPPRA ORAL SOLUTION Tier 3

KEPPRA ORAL TABLET Tier 3


21

Effective 1/2019

KEPPRA XR ORAL TABLET EXTENDED RELEASE 24 HR

Tier 3

KLONOPIN ORAL TABLET Tier 3

LAMICTAL ODT ORAL TABLET,DISINTEGRATING Tier 3

LAMICTAL ODT STARTER (BLUE) ORAL TABLET DISINTEGRATING, DOSE PK

Tier 3

LAMICTAL ODT STARTER (GREEN) ORAL TABLET DISINTEGRATING, DOSE PK

Tier 3

LAMICTAL ODT STARTER (ORANGE) ORAL TABLET DISINTEGRATING, DOSE PK

Tier 3

LAMICTAL ORAL TABLET Tier 3

LAMICTAL ORAL TABLET, CHEWABLE DISPERSIBLE 25 MG, 5 MG

Tier 3

LAMICTAL STARTER (BLUE) KIT ORAL TABLETS,DOSE PACK

Tier 3

LAMICTAL STARTER (GREEN) KIT ORAL TABLETS,DOSE PACK

Tier 3

LAMICTAL STARTER (ORANGE) KIT ORAL TABLETS,DOSE PACK

Tier 3

LAMICTAL XR ORAL TABLET EXTENDED RELEASE 24HR

Tier 3

LAMICTAL XR STARTER (BLUE) ORAL TABLET EXTENDED REL,DOSE PACK

Tier 3

LAMICTAL XR STARTER (GREEN) ORAL TABLET EXTENDED REL,DOSE PACK

Tier 3

LAMICTAL XR STARTER (ORANGE) ORAL TABLET EXTENDED REL,DOSE PACK

Tier 3

lamotrigine oral tablet Tier 1

lamotrigine oral tablet disintegrating, dose pk Tier 1

lamotrigine oral tablet extended release 24hr Tier 1

lamotrigine oral tablet, chewable dispersible Tier 1

lamotrigine oral tablet,disintegrating Tier 1

lamotrigine oral tablets,dose pack Tier 1

levetiracetam oral solution Tier 1

levetiracetam oral tablet Tier 1


22

Effective 1/2019

levetiracetam oral tablet extended release 24 hr Tier 1

LYRICA CR ORAL TABLET EXTENDED RELEASE 24 HR

Tier 2

LYRICA ORAL CAPSULE Tier 2

LYRICA ORAL SOLUTION Tier 2

MYSOLINE ORAL TABLET Tier 3

NEURONTIN ORAL CAPSULE Tier 3 PA; QL (180 EA per 30 days)

NEURONTIN ORAL SOLUTION Tier 3 PA; QL (2160 ML per 30 days)

NEURONTIN ORAL TABLET 600 MG Tier 3 PA; QL (180 EA per 30 days)

NEURONTIN ORAL TABLET 800 MG Tier 3 PA; QL (120 EA per 30 days)

ONFI ORAL SUSPENSION Tier 3

ONFI ORAL TABLET 10 MG, 20 MG Tier 3

oxcarbazepine oral suspension Tier 1

oxcarbazepine oral tablet Tier 1

OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR

Tier 2

PEGANONE ORAL TABLET Tier 3

phenobarbital oral elixir Tier 1

phenobarbital oral tablet Tier 1

PHENYTEK ORAL CAPSULE Tier 3

phenytoin oral suspension Tier 1

phenytoin oral tablet,chewable Tier 1

phenytoin sodium extended oral capsule Tier 1

primidone oral tablet Tier 1

QUDEXY XR ORAL CAPSULE,SPRINKLE,ER 24HR Tier 2

roweepra oral tablet Tier 1

roweepra xr oral tablet extended release 24 hr Tier 1

SABRIL ORAL POWDER IN PACKET Tier 3 LD

SABRIL ORAL TABLET Tier 3 LD

SPRITAM ORAL TABLET FOR SUSPENSION Tier 3

subvenite oral tablet Tier 1

subvenite starter (blue) kit oral tablets,dose pack Tier 1


23

Effective 1/2019

subvenite starter (green) kit oral tablets,dose pack Tier 1

subvenite starter (orange) kit oral tablets,dose pack

Tier 1

TEGRETOL ORAL SUSPENSION Tier 3

TEGRETOL ORAL TABLET Tier 3

TEGRETOL XR ORAL TABLET EXTENDED RELEASE 12 HR

Tier 3

tiagabine oral tablet Tier 1

TOPAMAX ORAL CAPSULE, SPRINKLE Tier 3

TOPAMAX ORAL TABLET Tier 3

topiramate oral capsule, sprinkle Tier 1

TOPIRAMATE ORAL CAPSULE,SPRINKLE,ER 24HR Tier 3

topiramate oral tablet Tier 1

TRILEPTAL ORAL SUSPENSION Tier 3

TRILEPTAL ORAL TABLET Tier 3

TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 24HR

Tier 2

valproic acid (as sodium salt) oral solution Tier 1

valproic acid oral capsule Tier 1

vigabatrin oral powder in packet Tier 1

vigadrone oral powder in packet Tier 1

VIMPAT ORAL SOLUTION Tier 2

VIMPAT ORAL TABLET Tier 2

ZARONTIN ORAL CAPSULE Tier 3

ZARONTIN ORAL SOLUTION Tier 3

ZONEGRAN ORAL CAPSULE 100 MG, 25 MG Tier 3

zonisamide oral capsule Tier 1

Antiparkinsonism Agents APOKYN SUBCUTANEOUS CARTRIDGE Tier 3 SPRx

AZILECT ORAL TABLET Tier 3

benztropine oral tablet Tier 1

bromocriptine oral capsule Tier 1


24

Effective 1/2019

bromocriptine oral tablet Tier 1

carbidopa oral tablet Tier 1

carbidopa-levodopa oral tablet Tier 1

carbidopa-levodopa oral tablet extended release Tier 1

carbidopa-levodopa oral tablet,disintegrating Tier 1

carbidopa-levodopa-entacapone oral tablet Tier 1

COMTAN ORAL TABLET Tier 3

DUOPA J-TUBE INTESTINAL PUMP SUSPENSION Tier 3 LD; SPRx

ELDEPRYL ORAL CAPSULE Tier 3

entacapone oral tablet Tier 1

LODOSYN ORAL TABLET Tier 3

MIRAPEX ER ORAL TABLET EXTENDED RELEASE 24 HR

Tier 3

MIRAPEX ORAL TABLET Tier 3

NEUPRO TRANSDERMAL PATCH 24 HOUR Tier 3

PARLODEL ORAL CAPSULE Tier 3

PARLODEL ORAL TABLET Tier 3

pramipexole oral tablet Tier 1

pramipexole oral tablet extended release 24 hr Tier 1

rasagiline oral tablet Tier 1

REQUIP ORAL TABLET Tier 3

REQUIP XL ORAL TABLET EXTENDED RELEASE 24 HR

Tier 3

ropinirole oral tablet Tier 1

ropinirole oral tablet extended release 24 hr Tier 1

selegiline hcl oral capsule Tier 1

selegiline hcl oral tablet Tier 1

SINEMET CR ORAL TABLET EXTENDED RELEASE Tier 3

SINEMET ORAL TABLET Tier 3

STALEVO 100 ORAL TABLET Tier 3




25

Effective 1/2019




TASMAR ORAL TABLET 100 MG Tier 3

tolcapone oral tablet Tier 1

trihexyphenidyl oral elixir Tier 1

trihexyphenidyl oral tablet Tier 1

ZELAPAR ORAL TABLET,DISINTEGRATING Tier 3

Migraine & Cluster Headache Therapy almotriptan malate oral tablet Tier 1 QL (18 EA per 30 days)

ALSUMA SUBCUTANEOUS PEN INJECTOR Tier 3 QL (8 ML per 30 days)

AMERGE ORAL TABLET Tier 3 QL (18 EA per 30 days)

ascomp with codeine oral capsule Tier 1 MME

BUPAP ORAL TABLET 50-300 MG Tier 3 QL (120 EA per 30 days)

butalbital compound w/codeine oral capsule Tier 1 MME

butalbital-acetaminop-caf-cod oral capsule Tier 1 MME

butalbital-acetaminophen oral tablet Tier 1 QL (120 EA per 30 days)

butalbital-acetaminophen-caff oral capsule Tier 1 QL (120 EA per 30 days)

butalbital-acetaminophen-caff oral tablet 50-325-40 mg


butalbital-aspirin-caffeine oral capsule Tier 1 QL (120 EA per 30 days)

butalbital-aspirin-caffeine oral tablet Tier 1 QL (120 EA per 30 days)

CAFERGOT ORAL TABLET Tier 3

capacet oral capsule Tier 1 QL (120 EA per 30 days)

codeine-butalbital-asa-caff oral capsule Tier 1 MME

D.H.E.45 INJECTION SOLUTION Tier 3

dihydroergotamine injection solution Tier 1

dihydroergotamine nasal spray,non-aerosol Tier 1 QL (8 ML per 30 days)

eletriptan oral tablet Tier 1 QL (18 EA per 30 days)

ERGOMAR SUBLINGUAL TABLET Tier 3

ergotamine-caffeine oral tablet Tier 1

ESGIC ORAL CAPSULE Tier 3 QL (120 EA per 30 days)


26

Effective 1/2019

ESGIC ORAL TABLET Tier 3 QL (120 EA per 30 days)

FIORICET ORAL CAPSULE Tier 3 QL (120 EA per 30 days)

FIORINAL ORAL CAPSULE Tier 3 QL (120 EA per 30 days)

FIORINAL-CODEINE #3 ORAL CAPSULE Tier 3 MME

frovatriptan oral tablet Tier 1 QL (18 EA per 30 days)

IMITREX NASAL SPRAY,NON-AEROSOL Tier 3 QL (12 EA per 30 days)

IMITREX ORAL TABLET Tier 3 QL (18 EA per 30 days)

IMITREX STATDOSE PEN SUBCUTANEOUS PEN INJECTOR 4 MG/0.5 ML


IMITREX STATDOSE PEN SUBCUTANEOUS PEN INJECTOR 6 MG/0.5 ML


IMITREX STATDOSE REFILL SUBCUTANEOUS CARTRIDGE 4 MG/0.5 ML


IMITREX STATDOSE REFILL SUBCUTANEOUS CARTRIDGE 6 MG/0.5 ML


IMITREX SUBCUTANEOUS SOLUTION Tier 3 QL (8 ML per 30 days)

isometh-dichloral-acetaminophn oral capsule Tier 1

isomethepten-caf-acetaminophen oral tablet 65-20-325 mg

Tier 1

marten-tab oral tablet Tier 1 QL (120 EA per 30 days)

migergot rectal suppository Tier 1

MIGRANAL NASAL SPRAY,NON-AEROSOL Tier 3 QL (8 ML per 30 days)

naratriptan oral tablet Tier 1 QL (18 EA per 30 days)

nodolor oral capsule Tier 1

phrenilin forte(with caffeine) oral capsule Tier 1 QL (120 EA per 30 days)

RELPAX ORAL TABLET Tier 3 QL (18 EA per 30 days)

rizatriptan oral tablet Tier 1 QL (18 EA per 30 days)

rizatriptan oral tablet,disintegrating Tier 1 QL (18 EA per 30 days)

sumatriptan nasal spray,non-aerosol Tier 1 QL (12 EA per 30 days)

sumatriptan succinate oral tablet Tier 1 QL (18 EA per 30 days)

sumatriptan succinate subcutaneous cartridge 4 mg/0.5 ml


sumatriptan succinate subcutaneous cartridge 6 mg/0.5 ml



27

Effective 1/2019

sumatriptan succinate subcutaneous pen injector 4 mg/0.5 ml


sumatriptan succinate subcutaneous pen injector 6 mg/0.5 ml


sumatriptan succinate subcutaneous solution Tier 1 QL (8 ML per 30 days)

sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml


SUMAVEL DOSEPRO SUBCUTANEOUS NEEDLE-FREE INJECTOR 4 MG/0.5 ML


SUMAVEL DOSEPRO SUBCUTANEOUS NEEDLE-FREE INJECTOR 6 MG/0.5 ML


tencon oral tablet 50-325 mg Tier 1 QL (120 EA per 30 days)

zebutal oral capsule 50-325-40 mg Tier 1 QL (120 EA per 30 days)

zolmitriptan oral tablet Tier 1 QL (18 EA per 30 days)

zolmitriptan oral tablet,disintegrating Tier 1 QL (18 EA per 30 days)

Miscellaneous Neurological Therapy AMPYRA ORAL TABLET EXTENDED RELEASE 12 HR

Tier 2 PA; SPRx

ARICEPT ORAL TABLET Tier 3

AUSTEDO ORAL TABLET Tier 3 PA; LD; SPRx

dalfampridine oral tablet extended release 12 hr Tier 1 PA; SPRx

donepezil oral tablet Tier 1

donepezil oral tablet,disintegrating Tier 1

galantamine oral capsule,ext rel. pellets 24 hr Tier 1

galantamine oral solution Tier 1

galantamine oral tablet Tier 1

HORIZANT ORAL TABLET EXTENDED RELEASE Tier 3

KEVEYIS ORAL TABLET Tier 3 PA; LD; SPRx

memantine oral capsule,sprinkle,er 24hr Tier 1

memantine oral solution Tier 1

memantine oral tablet Tier 1

MEMANTINE ORAL TABLETS,DOSE PACK Tier 3

NAMENDA ORAL TABLET Tier 3


28

Effective 1/2019

NAMENDA TITRATION PAK ORAL TABLETS,DOSE PACK

Tier 3

NAMENDA XR ORAL CAP,SPRINKLE,ER 24HR DOSE PACK

Tier 2

NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 24HR Tier 2

NAMZARIC ORAL CAP,SPRINKLE,ER 24HR DOSE PACK

Tier 2

NAMZARIC ORAL CAPSULE,SPRINKLE,ER 24HR Tier 2

NUEDEXTA ORAL CAPSULE Tier 3

RAZADYNE ER ORAL CAPSULE,EXT REL. PELLETS 24 HR

Tier 3

RAZADYNE ORAL TABLET Tier 3

rivastigmine tartrate oral capsule Tier 1

rivastigmine transdermal patch 24 hour Tier 1

tetrabenazine oral tablet Tier 1 PA; SPRx

XENAZINE ORAL TABLET Tier 3 PA; SPRx

Muscle Relaxants & Antispasmodic Therapy baclofen oral tablet 10 mg, 20 mg Tier 1

carisoprodol oral tablet Tier 1 QL (120 EA per 30 days)

carisoprodol-asa-codeine oral tablet Tier 1 PA; MME

carisoprodol-aspirin oral tablet Tier 1 QL (240 EA per 30 days)

chlorzoxazone oral tablet 250 mg Tier 1 QL (360 EA per 30 days)

chlorzoxazone oral tablet 500 mg Tier 1 QL (180 EA per 30 days)

cyclobenzaprine oral tablet Tier 1 QL (90 EA per 30 days)

DANTRIUM ORAL CAPSULE 25 MG, 50 MG Tier 3

dantrolene oral capsule Tier 1

FEXMID ORAL TABLET Tier 3 QL (90 EA per 30 days)

meprobamate oral tablet 200 mg Tier 1 QL (360 EA per 30 days)

meprobamate oral tablet 400 mg Tier 1 QL (180 EA per 30 days)

MESTINON ORAL SYRUP Tier 3

MESTINON ORAL TABLET Tier 3

MESTINON TIMESPAN ORAL TABLET EXTENDED RELEASE

Tier 3


29

Effective 1/2019

metaxalone oral tablet 800 mg Tier 1 QL (90 EA per 30 days)

methocarbamol oral tablet 500 mg Tier 1 QL (240 EA per 30 days)

methocarbamol oral tablet 750 mg Tier 1 QL (160 EA per 30 days)

orphenadrine citrate oral tablet extended release Tier 1 QL (60 EA per 30 days)

PARAFON FORTE DSC ORAL TABLET Tier 3

pyridostigmine bromide oral tablet Tier 1

pyridostigmine bromide oral tablet extended release

Tier 1

ROBAXIN ORAL TABLET Tier 3 QL (240 EA per 30 days)

ROBAXIN-750 ORAL TABLET Tier 3 QL (160 EA per 30 days)

SKELAXIN ORAL TABLET Tier 3 QL (90 EA per 30 days)

SOMA ORAL TABLET Tier 3 QL (120 EA per 30 days)

tizanidine oral capsule Tier 1

tizanidine oral tablet Tier 1

ZANAFLEX ORAL CAPSULE Tier 3

ZANAFLEX ORAL TABLET Tier 3

Narcotic Analgesics ABSTRAL SUBLINGUAL TABLET Tier 3 PA; MME

acetaminophen-caff-dihydrocod oral capsule Tier 1 PA; MME

acetaminophen-codeine oral solution 120-12 mg/5 ml, 300 mg-30 mg /12.5 ml

Tier 1 PA; MME

acetaminophen-codeine oral tablet Tier 1 PA; MME

ACTIQ BUCCAL LOZENGE ON A HANDLE Tier 3 PA; MME

aspirin-caffeine-dihydrocodein oral capsule Tier 1 PA; MME

butorphanol tartrate nasal spray,non-aerosol Tier 1 PA; MME

BUTRANS TRANSDERMAL PATCH WEEKLY Tier 2 PA; QL (4 EA per 28 days)

CAPITAL WITH CODEINE ORAL SUSPENSION Tier 3 PA; MME

codeine sulfate oral tablet Tier 1 PA; MME

DEMEROL ORAL TABLET 100 MG Tier 3 PA; MME

DILAUDID ORAL LIQUID Tier 3 PA; MME

DILAUDID ORAL TABLET Tier 3 PA; MME

diskets oral tablet,soluble Tier 1 PA; MME


30

Effective 1/2019

DOLOPHINE ORAL TABLET Tier 3 PA; MME

DURAGESIC TRANSDERMAL PATCH 72 HOUR Tier 3 PA; MME

endocet oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg

Tier 1 PA; MME

fentanyl citrate buccal lozenge on a handle Tier 1 PA; MME

fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr

Tier 1 PA; MME

FENTORA BUCCAL TABLET, EFFERVESCENT Tier 3 PA; MME

HYCET ORAL SOLUTION Tier 3 PA; MME

hydrocodone-acetaminophen oral solution 7.5-325 mg/15 ml

Tier 1 PA; MME

hydrocodone-acetaminophen oral tablet 10-300 mg, 10-325 mg, 2.5-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg

Tier 1 PA; MME

hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 mg

Tier 1 PA; MME

hydromorphone oral liquid Tier 1 PA; MME

hydromorphone oral tablet Tier 1 PA; MME

hydromorphone rectal suppository Tier 1 PA; MME

IBUDONE ORAL TABLET Tier 3 PA; MME

ibuprofen-oxycodone oral tablet Tier 1 PA; MME

KADIAN ORAL CAPSULE,EXTEND.RELEASE PELLETS 10 MG, 100 MG, 20 MG, 200 MG, 30 MG, 40 MG, 50 MG, 60 MG, 80 MG

Tier 3 PA; MME

levorphanol tartrate oral tablet Tier 1 PA; MME

lorcet (hydrocodone) oral tablet Tier 1 PA; MME

lorcet hd oral tablet Tier 1 PA; MME

lorcet plus oral tablet 7.5-325 mg Tier 1 PA; MME

LORTAB ELIXIR ORAL SOLUTION 10-300 MG/15 ML

Tier 3 PA; MME

meperidine oral solution Tier 1 PA; MME

meperidine oral tablet Tier 1 PA; MME

methadone oral concentrate Tier 1 PA; MME

methadone oral solution Tier 1 PA; MME


31

Effective 1/2019

methadone oral tablet Tier 1 PA; MME

methadone oral tablet,soluble Tier 1 PA; MME

methadose oral concentrate Tier 1 PA; MME

methadose oral tablet,soluble Tier 1 PA; MME

MORPHABOND ER ORAL TABLET,ORAL ONLY,EXT.REL.12 HR

Tier 2 PA; MME

morphine concentrate oral solution Tier 1 PA; MME

morphine oral capsule, er multiphase 24 hr Tier 1 PA; MME

morphine oral capsule,extend.release pellets Tier 1 PA; MME

morphine oral solution Tier 1 PA; MME

morphine oral tablet Tier 1 PA; MME

morphine oral tablet extended release Tier 1 PA; MME

morphine rectal suppository Tier 1 PA; MME

MS CONTIN ORAL TABLET EXTENDED RELEASE Tier 3 PA; MME

NORCO ORAL TABLET Tier 3 PA; MME

NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR

Tier 3 PA; MME

NUCYNTA ORAL TABLET Tier 3 PA; MME

OPANA ORAL TABLET Tier 3 PA; MME

oxycodone oral capsule Tier 1 PA; MME

oxycodone oral concentrate Tier 1 PA; MME

oxycodone oral solution Tier 1 PA; MME

oxycodone oral tablet Tier 1 PA; MME

oxycodone-acetaminophen oral solution Tier 1 PA; MME

oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg

Tier 1 PA; MME

oxycodone-aspirin oral tablet Tier 1 PA; MME

oxymorphone oral tablet Tier 1 PA; MME

oxymorphone oral tablet extended release 12 hr Tier 1 PA; MME

pentazocine-naloxone oral tablet Tier 1 PA; MME

PERCOCET ORAL TABLET 10-325 MG, 2.5-325 MG, 5-325 MG, 7.5-325 MG

Tier 3 PA; MME

PRIMLEV ORAL TABLET Tier 3 PA; MME


32

Effective 1/2019

reprexain oral tablet 2.5-200 mg Tier 1 PA; MME

ROXICODONE ORAL TABLET Tier 3 PA; MME

SYNALGOS-DC ORAL CAPSULE Tier 3 PA; MME

tramadol oral tablet Tier 1 PA; MME

tramadol oral tablet extended release 24 hr Tier 1 PA; MME

tramadol oral tablet, er multiphase 24 hr Tier 1 PA; MME

tramadol-acetaminophen oral tablet Tier 1 PA; MME

TREZIX ORAL CAPSULE 320.5-30-16 MG Tier 3 PA; MME

TYLENOL-CODEINE #3 ORAL TABLET Tier 3 PA; MME

TYLENOL-CODEINE #4 ORAL TABLET Tier 3 PA; MME

ULTRACET ORAL TABLET Tier 3 PA; MME

ULTRAM ER ORAL TABLET EXTENDED RELEASE 24 HR 300 MG

Tier 3 PA; MME

ULTRAM ORAL TABLET Tier 3 PA; MME

verdrocet oral tablet Tier 1 PA; MME

vicodin es oral tablet Tier 1 PA; MME

vicodin hp oral tablet Tier 1 PA; MME

vicodin oral tablet Tier 1 PA; MME

XODOL 10/300 ORAL TABLET Tier 3 PA; MME

XODOL 5/300 ORAL TABLET Tier 3 PA; MME

XODOL 7.5/300 ORAL TABLET Tier 3 PA; MME

XTAMPZA ER ORAL CAPSULE,SPRINKLE,ER 12HR TMPRR

Tier 2 PA; MME

xylon 10 oral tablet Tier 1 PA; MME

zamicet oral solution Tier 1 PA; MME

Non-Narcotic Analgesics ANAPROX DS ORAL TABLET Tier 3

ARTHROTEC 50 ORAL TABLET,IR,DELAYED REL,BIPHASIC

Tier 3

ARTHROTEC 75 ORAL TABLET,IR,DELAYED REL,BIPHASIC

Tier 3

aspirin oral tablet,delayed release (dr/ec) 81 mg Tier 1 ACA


33

Effective 1/2019

buprenorphine-naloxone sublingual film Tier 1 QL (90 EA per 30 days)

CELEBREX ORAL CAPSULE Tier 3

celecoxib oral capsule Tier 1

choline,magnesium salicylate oral liquid Tier 1

DAYPRO ORAL TABLET Tier 3

diclofenac potassium oral tablet Tier 1

diclofenac sodium oral tablet extended release 24 hr

Tier 1

diclofenac sodium oral tablet,delayed release (dr/ec)

Tier 1

diclofenac sodium topical gel 1 % Tier 1 QL (500 GM per 30 days)

diclofenac-misoprostol oral tablet,ir,delayed rel,biphasic

Tier 1

diflunisal oral tablet Tier 1

DISALCID ORAL TABLET Tier 3

EC-NAPROSYN ORAL TABLET,DELAYED RELEASE (DR/EC)

Tier 3

etodolac oral capsule Tier 1

etodolac oral tablet Tier 1

etodolac oral tablet extended release 24 hr Tier 1

FELDENE ORAL CAPSULE Tier 3

fenoprofen oral tablet Tier 1

flurbiprofen oral tablet Tier 1

ibu oral tablet Tier 1

ibuprofen oral suspension Tier 1

ibuprofen oral tablet 400 mg, 600 mg, 800 mg Tier 1

INDOCIN ORAL SUSPENSION Tier 3

INDOCIN RECTAL SUPPOSITORY Tier 3

indomethacin oral capsule Tier 1

indomethacin oral capsule, extended release Tier 1

ketoprofen oral capsule Tier 1

ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg

Tier 1


34

Effective 1/2019

ketorolac oral tablet Tier 1

LODINE ORAL TABLET Tier 3

LUCEMYRA ORAL TABLET Tier 3

meclofenamate oral capsule Tier 1

mefenamic acid oral capsule Tier 1

meloxicam oral suspension Tier 1

meloxicam oral tablet Tier 1

MOBIC ORAL TABLET Tier 3

nabumetone oral tablet Tier 1

NALFON ORAL CAPSULE 400 MG Tier 3

NAPRELAN CR ORAL TABLET, ER MULTIPHASE 24 HR

Tier 3

NAPROSYN ORAL SUSPENSION Tier 3

NAPROSYN ORAL TABLET 500 MG Tier 3

naproxen oral suspension Tier 1

naproxen oral tablet Tier 1

naproxen oral tablet,delayed release (dr/ec) Tier 1

naproxen sodium oral tablet 275 mg, 550 mg Tier 1

oxaprozin oral tablet Tier 1

piroxicam oral capsule Tier 1

PONSTEL ORAL CAPSULE Tier 3

REVIA ORAL TABLET Tier 3

salsalate oral tablet Tier 1

SPRIX NASAL SPRAY,NON-AEROSOL Tier 3 LD; SPRx

sulindac oral tablet Tier 1

tolmetin oral capsule Tier 1

tolmetin oral tablet Tier 1

VOLTAREN-XR ORAL TABLET EXTENDED RELEASE 24 HR

Tier 3

Opiate/Narcotic Reversal Agents - Opiate Antagonists naloxone injection solution Tier 1 QL (2 units per 1 claim)

naloxone injection syringe Tier 1 QL (2 units per 1 claim)


35

Effective 1/2019

naltrexone oral tablet Tier 1

NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION

Tier 3 QL (2 units per 1 claim)

Psychotherapeutic Drugs ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON

Tier 3 SPRx

ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING

Tier 3 SPRx

ABILIFY ORAL TABLET Tier 3 AGE-A

ADDERALL ORAL TABLET Tier 3

alprazolam intensol oral concentrate Tier 1

alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg Tier 1 QL (90 EA per 30 days)

alprazolam oral tablet 2 mg Tier 1 QL (150 EA per 30 days)

alprazolam oral tablet extended release 24 hr Tier 1 QL (60 EA per 30 days)

alprazolam oral tablet,disintegrating 0.25 mg, 0.5 mg, 1 mg


alprazolam oral tablet,disintegrating 2 mg Tier 1 QL (150 EA per 30 days)

AMBIEN CR ORAL TABLET,EXT RELEASE MULTIPHASE

Tier 3

AMBIEN ORAL TABLET Tier 3

amitriptyline oral tablet Tier 1

amitriptyline-chlordiazepoxide oral tablet Tier 1

amoxapine oral tablet Tier 1

ANAFRANIL ORAL CAPSULE Tier 3

aripiprazole oral solution Tier 1 AGE-A

aripiprazole oral tablet Tier 1 AGE-A

aripiprazole oral tablet,disintegrating Tier 1 AGE-A

ARISTADA INITIO INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING

Tier 3 SPRx

ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING

Tier 3 SPRx

armodafinil oral tablet Tier 1 PA

ATIVAN ORAL TABLET 0.5 MG, 1 MG Tier 3 QL (90 EA per 30 days)


36

Effective 1/2019

ATIVAN ORAL TABLET 2 MG Tier 3 QL (150 EA per 30 days)

atomoxetine oral capsule Tier 1

bupropion hcl oral tablet Tier 1

bupropion hcl oral tablet extended release 24 hr 150 mg, 300 mg

Tier 1

bupropion hcl oral tablet sustained-release 12 hr Tier 1

buspirone oral tablet Tier 1

BUTISOL ORAL TABLET 30 MG Tier 3

CELEXA ORAL TABLET Tier 3

chlordiazepoxide hcl oral capsule Tier 1

chlorpromazine oral tablet Tier 1

citalopram oral solution Tier 1

citalopram oral tablet Tier 1

clomipramine oral capsule Tier 1

clonidine hcl oral tablet extended release 12 hr Tier 1

clorazepate dipotassium oral tablet Tier 1

clozapine oral tablet Tier 1 AGE-A

clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 25 mg

Tier 1 AGE-A

CLOZAPINE ORAL TABLET,DISINTEGRATING 150 MG, 200 MG

Tier 3 AGE-A

CLOZARIL ORAL TABLET Tier 3 AGE-A

CYMBALTA ORAL CAPSULE,DELAYED RELEASE(DR/EC)

Tier 3

DAYTRANA TRANSDERMAL PATCH 24 HOUR Tier 2

desipramine oral tablet Tier 1

desvenlafaxine succinate oral tablet extended release 24 hr

Tier 1

DEXEDRINE SPANSULE ORAL CAPSULE, EXTENDED RELEASE 15 MG

Tier 3

dexmethylphenidate oral capsule,er biphasic 50-50

Tier 1

dexmethylphenidate oral tablet Tier 1


37

Effective 1/2019

dextroamphetamine oral capsule, extended release

Tier 1

dextroamphetamine oral solution Tier 1

dextroamphetamine oral tablet Tier 1

dextroamphetamine-amphetamine oral capsule,extended release 24hr

Tier 1

dextroamphetamine-amphetamine oral tablet Tier 1

diazepam intensol oral concentrate Tier 1

diazepam oral concentrate Tier 1

diazepam oral solution Tier 1

diazepam oral tablet Tier 1 QL (120 EA per 30 days)

DORAL ORAL TABLET Tier 3

doxepin oral capsule Tier 1

doxepin oral concentrate Tier 1

duloxetine oral capsule,delayed release(dr/ec) Tier 1

EFFEXOR XR ORAL CAPSULE,EXTENDED RELEASE 24HR

Tier 3

EMSAM TRANSDERMAL PATCH 24 HOUR Tier 3

ergoloid oral tablet Tier 1

escitalopram oxalate oral solution Tier 1

escitalopram oxalate oral tablet Tier 1

estazolam oral tablet Tier 1

eszopiclone oral tablet Tier 1

FANAPT ORAL TABLET Tier 3 AGE-A

FANAPT ORAL TABLETS,DOSE PACK Tier 3 AGE-A

FAZACLO ORAL TABLET,DISINTEGRATING Tier 3 AGE-A

fluoxetine oral capsule Tier 1

fluoxetine oral capsule,delayed release(dr/ec) Tier 1

fluoxetine oral solution Tier 1

fluoxetine oral tablet Tier 1

fluphenazine hcl oral concentrate Tier 1

fluphenazine hcl oral elixir Tier 1


38

Effective 1/2019

fluphenazine hcl oral tablet Tier 1

flurazepam oral capsule Tier 1

fluvoxamine oral capsule,extended release 24hr Tier 1

fluvoxamine oral tablet Tier 1

GEODON ORAL CAPSULE Tier 3 AGE-A

guanfacine oral tablet extended release 24 hr Tier 1

guanidine oral tablet Tier 1

HALCION ORAL TABLET 0.25 MG Tier 3 QL (60 EA per 30 days)

haloperidol lactate oral concentrate Tier 1

haloperidol oral tablet Tier 1

imipramine hcl oral tablet Tier 1

imipramine pamoate oral capsule Tier 1

INTUNIV ER ORAL TABLET EXTENDED RELEASE 24 HR

Tier 3

INVEGA ORAL TABLET EXTENDED RELEASE 24HR Tier 3 AGE-A

INVEGA SUSTENNA INTRAMUSCULAR SYRINGE Tier 3 SPRx

INVEGA TRINZA INTRAMUSCULAR SYRINGE Tier 3 SPRx

KAPVAY ORAL TABLET EXTENDED RELEASE 12 HR Tier 3

LATUDA ORAL TABLET Tier 2 AGE-A

LEXAPRO ORAL TABLET Tier 3

lithium carbonate oral capsule Tier 1

lithium carbonate oral tablet Tier 1

lithium carbonate oral tablet extended release Tier 1

lithium citrate oral solution 8 meq/5 ml Tier 1

LITHOBID ORAL TABLET EXTENDED RELEASE Tier 3

lorazepam intensol oral concentrate Tier 1

lorazepam oral concentrate Tier 1

lorazepam oral tablet 0.5 mg, 1 mg Tier 1 QL (90 EA per 30 days)

lorazepam oral tablet 2 mg Tier 1 QL (150 EA per 30 days)

loxapine succinate oral capsule Tier 1

LUNESTA ORAL TABLET Tier 3

maprotiline oral tablet Tier 1


39

Effective 1/2019

MARPLAN ORAL TABLET Tier 3

metadate er oral tablet extended release Tier 1

methamphetamine oral tablet Tier 1

METHYLIN ORAL SOLUTION Tier 3

methylphenidate hcl oral capsule, er biphasic 30-70

Tier 1

methylphenidate hcl oral capsule,er biphasic 50-50

Tier 1

methylphenidate hcl oral solution Tier 1

methylphenidate hcl oral tablet Tier 1

methylphenidate hcl oral tablet extended release Tier 1

methylphenidate hcl oral tablet extended release 24hr 18 mg, 27 mg, 36 mg, 54 mg

Tier 1

methylphenidate hcl oral tablet,chewable Tier 1

midazolam oral syrup 2 mg/ml Tier 1

mirtazapine oral tablet Tier 1

mirtazapine oral tablet,disintegrating Tier 1

modafinil oral tablet Tier 1 PA

MYDAYIS ORAL CAPSULE, ER TRIPHASIC 24 HR Tier 2

NARDIL ORAL TABLET Tier 3

nefazodone oral tablet Tier 1

NORPRAMIN ORAL TABLET 10 MG, 25 MG Tier 3

nortriptyline oral capsule Tier 1

nortriptyline oral solution Tier 1

NUPLAZID ORAL CAPSULE Tier 3 PA; SPRx

NUPLAZID ORAL TABLET Tier 3 PA; SPRx

NUVIGIL ORAL TABLET Tier 3 PA

olanzapine oral tablet Tier 1 AGE-A

olanzapine oral tablet,disintegrating Tier 1 AGE-A

olanzapine-fluoxetine oral capsule Tier 1 AGE-A

ORAP ORAL TABLET Tier 3

oxazepam oral capsule Tier 1 QL (120 EA per 30 days)


40

Effective 1/2019

paliperidone oral tablet extended release 24hr Tier 1 AGE-A

PAMELOR ORAL CAPSULE Tier 3

PARNATE ORAL TABLET Tier 3

paroxetine hcl oral tablet Tier 1

paroxetine hcl oral tablet extended release 24 hr Tier 1

PAXIL CR ORAL TABLET EXTENDED RELEASE 24 HR

Tier 3

PAXIL ORAL SUSPENSION Tier 3

PAXIL ORAL TABLET Tier 3

perphenazine oral tablet Tier 1

perphenazine-amitriptyline oral tablet Tier 1

PERSERIS ABDOMINAL SUBCUTANEOUS SUSPENSION,EXTEND REL SYR KIT

Tier 3 SPRx

PEXEVA ORAL TABLET Tier 3

phenelzine oral tablet Tier 1

pimozide oral tablet Tier 1

PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR Tier 3

procentra oral solution Tier 1

protriptyline oral tablet Tier 1

PROZAC ORAL CAPSULE Tier 3

quazepam oral tablet Tier 1

quetiapine oral tablet Tier 1 AGE-A

quetiapine oral tablet extended release 24 hr Tier 1 AGE-A

QUILLICHEW ER ORAL TABLET,CHEW,IR-ER.BIPHASIC24HR

Tier 2

QUILLIVANT XR ORAL SUSPENSION,EXT REL 24HR,RECON

Tier 2

REMERON ORAL TABLET Tier 3

REMERON SOLTAB ORAL TABLET,DISINTEGRATING

Tier 3

RESTORIL ORAL CAPSULE Tier 3

REXULTI ORAL TABLET Tier 3 AGE-A

RISPERDAL CONSTA INTRAMUSCULAR SYRINGE Tier 3 SPRx


41

Effective 1/2019

RISPERDAL M-TAB ORAL TABLET,DISINTEGRATING

Tier 3 AGE-A

RISPERDAL ORAL SOLUTION Tier 3 AGE-A

RISPERDAL ORAL TABLET Tier 3 AGE-A

risperidone oral solution Tier 1 AGE-A

risperidone oral tablet Tier 1 AGE-A

risperidone oral tablet,disintegrating Tier 1 AGE-A

RITALIN ORAL TABLET Tier 3

ROZEREM ORAL TABLET Tier 3

SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET Tier 3 AGE-A

SAPHRIS SUBLINGUAL TABLET 2.5 MG Tier 3 AGE-A

SARAFEM ORAL TABLET 10 MG, 20 MG Tier 3

seconal sodium oral capsule Tier 1

SEROQUEL ORAL TABLET Tier 3 AGE-A

SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR

Tier 3 AGE-A

sertraline oral concentrate Tier 1

sertraline oral tablet Tier 1

SONATA ORAL CAPSULE Tier 3

STRATTERA ORAL CAPSULE Tier 3

SURMONTIL ORAL CAPSULE Tier 3

SYMBYAX ORAL CAPSULE Tier 3 AGE-A

temazepam oral capsule Tier 1

thioridazine oral tablet Tier 1

thiothixene oral capsule Tier 1

TOFRANIL ORAL TABLET Tier 3

TRANXENE T-TAB ORAL TABLET 7.5 MG Tier 3

tranylcypromine oral tablet Tier 1

trazodone oral tablet Tier 1

triazolam oral tablet 0.125 mg Tier 1 QL (120 EA per 30 days)

triazolam oral tablet 0.25 mg Tier 1 QL (60 EA per 30 days)

trifluoperazine oral tablet Tier 1


42

Effective 1/2019

trimipramine oral capsule Tier 1

TRINTELLIX ORAL TABLET Tier 3

VALIUM ORAL TABLET Tier 3 QL (120 EA per 30 days)

venlafaxine oral capsule,extended release 24hr Tier 1

venlafaxine oral tablet Tier 1

venlafaxine oral tablet extended release 24hr Tier 1

VIIBRYD ORAL TABLET Tier 2

VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)-20 MG (23)

Tier 2

VRAYLAR ORAL CAPSULE Tier 3 AGE-A

VRAYLAR ORAL CAPSULE,DOSE PACK Tier 3 AGE-A

VYVANSE ORAL CAPSULE Tier 2

VYVANSE ORAL TABLET,CHEWABLE Tier 2

WELLBUTRIN SR ORAL TABLET SUSTAINED-RELEASE 12 HR

Tier 3

WELLBUTRIN XL ORAL TABLET EXTENDED RELEASE 24 HR

Tier 3

XANAX ORAL TABLET 0.25 MG, 0.5 MG, 1 MG Tier 3 QL (90 EA per 30 days)

XANAX ORAL TABLET 2 MG Tier 3 QL (150 EA per 30 days)

XANAX XR ORAL TABLET EXTENDED RELEASE 24 HR


XYREM ORAL SOLUTION Tier 3 PA; LD; SPRx

zaleplon oral capsule Tier 1

zenzedi oral tablet 10 mg, 5 mg Tier 1

ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20 MG, 30 MG, 7.5 MG

Tier 3

ziprasidone hcl oral capsule Tier 1 AGE-A

ZOLOFT ORAL CONCENTRATE Tier 3

ZOLOFT ORAL TABLET Tier 3

zolpidem oral tablet Tier 1

zolpidem oral tablet,ext release multiphase Tier 1

ZYPREXA ORAL TABLET Tier 3 AGE-A


43

Effective 1/2019

ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION

Tier 3 SPRx

ZYPREXA ZYDIS ORAL TABLET,DISINTEGRATING Tier 3 AGE-A


Cardiovascular, Hypertension & Lipids

Antiarrhythmic Agents amiodarone oral tablet Tier 1

BETAPACE AF ORAL TABLET Tier 3

BETAPACE ORAL TABLET Tier 3

disopyramide phosphate oral capsule Tier 1

dofetilide oral capsule Tier 1

flecainide oral tablet Tier 1

mexiletine oral capsule Tier 1

MULTAQ ORAL TABLET Tier 3

NORPACE CR ORAL CAPSULE, EXTENDED RELEASE Tier 3

NORPACE ORAL CAPSULE Tier 3

pacerone oral tablet 100 mg, 200 mg, 400 mg Tier 1

propafenone oral capsule,extended release 12 hr Tier 1

propafenone oral tablet Tier 1

quinidine gluconate oral tablet extended release Tier 1

quinidine sulfate oral tablet Tier 1

RYTHMOL SR ORAL CAPSULE,EXTENDED RELEASE 12 HR

Tier 3

sorine oral tablet Tier 1

sotalol af oral tablet Tier 1

sotalol oral tablet Tier 1

SOTYLIZE ORAL SOLUTION Tier 3

TIKOSYN ORAL CAPSULE Tier 3

Antihypertensive Therapy ACCUPRIL ORAL TABLET Tier 3

ACCURETIC ORAL TABLET Tier 3

acebutolol oral capsule Tier 1

ADALAT CC ORAL TABLET EXTENDED RELEASE Tier 3

44

Effective 1/2019

afeditab cr oral tablet extended release Tier 1

ALDACTAZIDE ORAL TABLET Tier 3

ALDACTONE ORAL TABLET Tier 3

ALTACE ORAL CAPSULE Tier 3

amiloride oral tablet Tier 1

amiloride-hydrochlorothiazide oral tablet Tier 1

amlodipine oral tablet Tier 1

amlodipine-benazepril oral capsule Tier 1

amlodipine-olmesartan oral tablet Tier 1

amlodipine-valsartan oral tablet Tier 1

amlodipine-valsartan-hcthiazid oral tablet Tier 1

ATACAND HCT ORAL TABLET Tier 3

ATACAND ORAL TABLET Tier 3

atenolol oral tablet Tier 1

atenolol-chlorthalidone oral tablet Tier 1

AVALIDE ORAL TABLET Tier 3

AVAPRO ORAL TABLET Tier 3

AZOR ORAL TABLET Tier 3

benazepril oral tablet Tier 1

benazepril-hydrochlorothiazide oral tablet Tier 1

BENICAR HCT ORAL TABLET Tier 3

BENICAR ORAL TABLET Tier 3

betaxolol oral tablet Tier 1

BIDIL ORAL TABLET Tier 3

bisoprolol fumarate oral tablet Tier 1

bisoprolol-hydrochlorothiazide oral tablet Tier 1

bumetanide oral tablet Tier 1

BYSTOLIC ORAL TABLET Tier 2

CALAN ORAL TABLET Tier 3

CALAN SR ORAL TABLET EXTENDED RELEASE Tier 3

candesartan oral tablet Tier 1


45

Effective 1/2019

candesartan-hydrochlorothiazid oral tablet Tier 1

captopril oral tablet Tier 1

captopril-hydrochlorothiazide oral tablet Tier 1

CARDIZEM CD ORAL CAPSULE,EXTENDED RELEASE 24HR

Tier 3

CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HR

Tier 3

CARDIZEM ORAL TABLET 120 MG, 30 MG, 60 MG Tier 3

CARDURA ORAL TABLET Tier 3

CARDURA XL ORAL TABLET EXTENDED RELEASE 24HR

Tier 3

cartia xt oral capsule,extended release 24hr Tier 1

carvedilol oral tablet Tier 1

carvedilol phosphate oral capsule, er multiphase 24 hr

Tier 1

CATAPRES ORAL TABLET Tier 3

CATAPRES-TTS-1 TRANSDERMAL PATCH WEEKLY Tier 3



chlorothiazide oral tablet Tier 1

chlorthalidone oral tablet 25 mg, 50 mg Tier 1

clonidine hcl oral tablet Tier 1

clonidine transdermal patch weekly Tier 1

clorpres oral tablet 0.1-15 mg, 0.2-15 mg Tier 1

CLORPRES ORAL TABLET 0.3-15 MG Tier 3

COREG CR ORAL CAPSULE, ER MULTIPHASE 24 HR Tier 2

COREG ORAL TABLET Tier 3

CORGARD ORAL TABLET Tier 3

CORZIDE ORAL TABLET Tier 3

COZAAR ORAL TABLET Tier 3

DEMADEX ORAL TABLET 10 MG, 20 MG Tier 3

DIBENZYLINE ORAL CAPSULE Tier 3

diltiazem hcl oral capsule,ext.rel 24h degradable Tier 1


46

Effective 1/2019

diltiazem hcl oral capsule,extended release 12 hr Tier 1

diltiazem hcl oral capsule,extended release 24 hr Tier 1

diltiazem hcl oral capsule,extended release 24hr Tier 1

diltiazem hcl oral tablet Tier 1

diltiazem hcl oral tablet extended release 24 hr Tier 1

dilt-xr oral capsule,ext.rel 24h degradable Tier 1

DIOVAN HCT ORAL TABLET Tier 3

DIOVAN ORAL TABLET Tier 3

DIURIL ORAL SUSPENSION Tier 3

doxazosin oral tablet Tier 1

DUTOPROL ORAL TABLET EXTENDED RELEASE 24 HR

Tier 3

DYAZIDE ORAL CAPSULE Tier 3

DYRENIUM ORAL CAPSULE Tier 3

EDARBI ORAL TABLET Tier 3 ST

EDARBYCLOR ORAL TABLET Tier 3 ST

EDECRIN ORAL TABLET Tier 3

enalapril maleate oral tablet Tier 1

enalapril-hydrochlorothiazide oral tablet Tier 1

EPANED ORAL SOLUTION Tier 3

eplerenone oral tablet Tier 1

epoprostenol (glycine) intravenous recon soln Tier 1 PA; SPRx

eprosartan oral tablet Tier 1

ethacrynic acid oral tablet Tier 1

EXFORGE HCT ORAL TABLET Tier 3

EXFORGE ORAL TABLET Tier 3

felodipine oral tablet extended release 24 hr Tier 1

FLOLAN INTRAVENOUS RECON SOLN Tier 3 PA; LD; SPRx

fosinopril oral tablet Tier 1

fosinopril-hydrochlorothiazide oral tablet Tier 1

furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml)

Tier 1


47

Effective 1/2019

furosemide oral tablet Tier 1

guanfacine oral tablet Tier 1

hydralazine oral tablet Tier 1

hydrochlorothiazide oral capsule Tier 1

hydrochlorothiazide oral tablet Tier 1

HYZAAR ORAL TABLET Tier 3

indapamide oral tablet Tier 1

INDERAL LA ORAL CAPSULE,EXTENDED RELEASE 24 HR

Tier 3

INDERAL XL ORAL CAPSULE,EXTENDED RELEASE 24HR

Tier 3

INNOPRAN XL ORAL CAPSULE,EXTENDED RELEASE 24HR

Tier 3

INSPRA ORAL TABLET Tier 3

irbesartan oral tablet Tier 1

irbesartan-hydrochlorothiazide oral tablet Tier 1

isradipine oral capsule Tier 1

labetalol oral tablet Tier 1

LASIX ORAL TABLET Tier 3

LEVATOL ORAL TABLET Tier 3

lisinopril oral tablet Tier 1

lisinopril-hydrochlorothiazide oral tablet Tier 1

LOPRESSOR HCT ORAL TABLET Tier 3

LOPRESSOR ORAL TABLET Tier 3

losartan oral tablet Tier 1

losartan-hydrochlorothiazide oral tablet Tier 1

LOTENSIN HCT ORAL TABLET Tier 3

LOTENSIN ORAL TABLET 10 MG, 20 MG, 40 MG Tier 3

LOTREL ORAL CAPSULE 10-20 MG, 10-40 MG, 5-10 MG, 5-20 MG, 5-40 MG

Tier 3

matzim la oral tablet extended release 24 hr Tier 1

MAXZIDE ORAL TABLET Tier 3

MAXZIDE-25MG ORAL TABLET Tier 3


48

Effective 1/2019

methyclothiazide oral tablet Tier 1

methyldopa oral tablet Tier 1

methyldopa-hydrochlorothiazide oral tablet Tier 1

metolazone oral tablet Tier 1

metoprolol succinate oral tablet extended release 24 hr

Tier 1

metoprolol ta-hydrochlorothiaz oral tablet Tier 1

metoprolol tartrate oral tablet Tier 1

MICARDIS HCT ORAL TABLET Tier 3

MICARDIS ORAL TABLET Tier 3

MICROZIDE ORAL CAPSULE Tier 3

MINIPRESS ORAL CAPSULE Tier 3

minoxidil oral tablet Tier 1

moexipril oral tablet Tier 1

moexipril-hydrochlorothiazide oral tablet Tier 1

nadolol oral tablet Tier 1

nadolol-bendroflumethiazide oral tablet Tier 1

nicardipine oral capsule Tier 1

nifedipine oral capsule Tier 1

nifedipine oral tablet extended release Tier 1

nifedipine oral tablet extended release 24hr Tier 1

nimodipine oral capsule Tier 1

nisoldipine oral tablet extended release 24 hr Tier 1

NORVASC ORAL TABLET Tier 3

olmesartan oral tablet Tier 1

olmesartan-amlodipin-hcthiazid oral tablet Tier 1

olmesartan-hydrochlorothiazide oral tablet Tier 1

ORENITRAM ORAL TABLET EXTENDED RELEASE Tier 3 PA; SPRx

perindopril erbumine oral tablet Tier 1

phenoxybenzamine oral capsule Tier 1

pindolol oral tablet Tier 1

prazosin oral capsule Tier 1


49

Effective 1/2019

PRINIVIL ORAL TABLET 10 MG, 20 MG, 5 MG Tier 3

PROCARDIA ORAL CAPSULE Tier 3

PROCARDIA XL ORAL TABLET EXTENDED RELEASE 24HR

Tier 3

propranolol oral capsule,extended release 24 hr Tier 1

propranolol oral solution Tier 1

propranolol oral tablet Tier 1

propranolol-hydrochlorothiazid oral tablet Tier 1

quinapril oral tablet Tier 1

quinapril-hydrochlorothiazide oral tablet Tier 1

ramipril oral capsule Tier 1

REMODULIN INJECTION SOLUTION Tier 3 PA; LD; SPRx

spironolactone oral tablet Tier 1

spironolacton-hydrochlorothiaz oral tablet Tier 1

SULAR ORAL TABLET EXTENDED RELEASE 24 HR 17 MG, 34 MG, 8.5 MG

Tier 3

TARKA ORAL TABLET, IR - ER, BIPHASIC 24HR Tier 3

taztia xt oral capsule,extended release 24 hr Tier 1

TEKTURNA HCT ORAL TABLET Tier 3

TEKTURNA ORAL TABLET Tier 3

telmisartan oral tablet Tier 1

telmisartan-amlodipine oral tablet Tier 1

telmisartan-hydrochlorothiazid oral tablet Tier 1

TENORETIC 100 ORAL TABLET Tier 3

TENORETIC 50 ORAL TABLET Tier 3

TENORMIN ORAL TABLET Tier 3

terazosin oral capsule Tier 1

TIAZAC ORAL CAPSULE,EXTENDED RELEASE 24 HR

Tier 3

timolol maleate oral tablet Tier 1

TOPROL XL ORAL TABLET EXTENDED RELEASE 24 HR

Tier 3

torsemide oral tablet Tier 1


50

Effective 1/2019

trandolapril oral tablet Tier 1

trandolapril-verapamil oral tablet, ir - er, biphasic 24hr

Tier 1

triamterene-hydrochlorothiazid oral capsule Tier 1

triamterene-hydrochlorothiazid oral tablet Tier 1

TRIBENZOR ORAL TABLET Tier 3

TWYNSTA ORAL TABLET Tier 3

valsartan oral tablet Tier 1

valsartan-hydrochlorothiazide oral tablet Tier 1

VASERETIC ORAL TABLET Tier 3

VASOTEC ORAL TABLET Tier 3

veletri intravenous recon soln Tier 1 PA; LD; SPRx

verapamil oral capsule, 24 hr er pellet ct Tier 1

verapamil oral capsule,ext rel. pellets 24 hr Tier 1

verapamil oral tablet Tier 1

verapamil oral tablet extended release Tier 1

VERELAN ORAL CAPSULE,EXT REL. PELLETS 24 HR Tier 3

VERELAN PM ORAL CAPSULE, 24 HR ER PELLET CT Tier 3

ZESTORETIC ORAL TABLET Tier 3

ZESTRIL ORAL TABLET Tier 3

ZIAC ORAL TABLET Tier 3

Cardiac Glycosides digitek oral tablet Tier 1

digox oral tablet Tier 1

digoxin oral solution 50 mcg/ml Tier 1

digoxin oral tablet Tier 1

LANOXIN ORAL TABLET Tier 2

Coagulation Therapy ADVATE INTRAVENOUS RECON SOLN Tier 3 SPRx

AGGRENOX ORAL CAPSULE, ER MULTIPHASE 12 HR

Tier 3

ALPHANATE INTRAVENOUS RECON SOLN Tier 3 SPRx


51

Effective 1/2019

ALPHANINE SD INTRAVENOUS RECON SOLN Tier 3 SPRx

ALPROLIX INTRAVENOUS RECON SOLN Tier 3 SPRx

AMICAR ORAL SOLUTION Tier 3

AMICAR ORAL TABLET Tier 3

ARIXTRA SUBCUTANEOUS SYRINGE Tier 3 QL (42 Day Supply per 365 days)

aspirin-dipyridamole oral capsule, er multiphase 12 hr

Tier 1

BEBULIN INTRAVENOUS RECON SOLN Tier 3 LD; SPRx

BENEFIX INTRAVENOUS RECON SOLN Tier 3 LD; SPRx

BRILINTA ORAL TABLET Tier 2

cilostazol oral tablet Tier 1

clopidogrel oral tablet Tier 1

COAGADEX INTRAVENOUS RECON SOLN Tier 3 LD; SPRx

CORIFACT INTRAVENOUS RECON SOLN Tier 3 SPRx

COUMADIN ORAL TABLET Tier 3

dipyridamole oral tablet Tier 1

DOPTELET ORAL TABLET Tier 3 PA; LD; SPRx

EFFIENT ORAL TABLET Tier 3

ELIQUIS ORAL TABLET Tier 2

ELIQUIS ORAL TABLETS,DOSE PACK Tier 2

enoxaparin subcutaneous solution Tier 1 QL (42 Day Supply per 365 days)

enoxaparin subcutaneous syringe Tier 1 QL (42 Day Supply per 365 days)

FEIBA NF INTRAVENOUS RECON SOLN Tier 3 LD; SPRx

fondaparinux subcutaneous syringe Tier 1 QL (42 Day Supply per 365 days)

FRAGMIN SUBCUTANEOUS SOLUTION Tier 3 QL (42 Day Supply per 365 days)

FRAGMIN SUBCUTANEOUS SYRINGE Tier 3 QL (42 Day Supply per 365 days)

HELIXATE FS INTRAVENOUS RECON SOLN Tier 3 LD; SPRx

HEMOFIL M HIGH INTRAVENOUS RECON SOLN Tier 3 LD; SPRx

HEMOFIL M LOW INTRAVENOUS RECON SOLN Tier 3 LD; SPRx

HEMOFIL M MID INTRAVENOUS RECON SOLN Tier 3 LD; SPRx

HEMOFIL M SUPER HIGH INTRAVENOUS RECON SOLN

Tier 3 LD; SPRx


52

Effective 1/2019

hep flush-10 (pf) intravenous solution Tier 1

heparin (porcine) injection solution Tier 1

heparin (porcine) injection syringe 5,000 unit/ml Tier 1

heparin lock flush (porcine) intravenous solution 100 unit/ml

Tier 1

heparin lock flush (porcine) intravenous syringe Tier 1

heparin lock flush intravenous solution Tier 1

heparin lockflush(porcine)(pf) intravenous syringe Tier 1

heparin, porcine (pf) injection solution Tier 1

heparin, porcine (pf) injection syringe Tier 1

heparin, porcine (pf) intravenous solution 100 unit/ml (1 ml)

Tier 1

heparin, porcine (pf) intravenous syringe Tier 1

HUMATE-P INTRAVENOUS RECON SOLN Tier 3 LD; SPRx

jantoven oral tablet Tier 1

KOATE INTRAVENOUS RECON SOLN Tier 3 LD; SPRx

KOGENATE FS INTRAVENOUS RECON SOLN Tier 3 LD; SPRx

LOVENOX SUBCUTANEOUS SOLUTION Tier 3 QL (42 Day Supply per 365 days)

LOVENOX SUBCUTANEOUS SYRINGE Tier 3 QL (42 Day Supply per 365 days)

MEPHYTON ORAL TABLET Tier 3

MONOCLATE-P INTRAVENOUS RECON SOLN Tier 3 LD; SPRx

MULPLETA ORAL TABLET Tier 3 PA; SPRx

NOVOEIGHT INTRAVENOUS RECON SOLN Tier 3 SPRx

NOVOSEVEN RT INTRAVENOUS RECON SOLN Tier 3 LD; SPRx

pentoxifylline oral tablet extended release Tier 1

phytonadione (vitamin k1) oral tablet 5 mg Tier 1

PLAVIX ORAL TABLET Tier 3

PRADAXA ORAL CAPSULE Tier 3

prasugrel oral tablet Tier 1

PROFILNINE INTRAVENOUS RECON SOLN Tier 3 SPRx

PROMACTA ORAL TABLET Tier 3 LD; SPRx

RECOMBINATE INTRAVENOUS RECON SOLN Tier 3 LD; SPRx


53

Effective 1/2019

RIXUBIS INTRAVENOUS RECON SOLN Tier 3 LD; SPRx

TAVALISSE ORAL TABLET Tier 3 PA; LD; SPRx

ticlopidine oral tablet Tier 1

warfarin oral tablet Tier 1

WILATE INTRAVENOUS RECON SOLN Tier 3 SPRx

XARELTO ORAL TABLET Tier 2

XARELTO ORAL TABLETS,DOSE PACK Tier 2

XYNTHA INTRAVENOUS SOLUTION Tier 3 LD; SPRx

XYNTHA SOLOFUSE INTRAVENOUS SYRINGE Tier 3 LD; SPRx

ZONTIVITY ORAL TABLET Tier 3

Lipid/Cholesterol Lowering Agents amlodipine-atorvastatin oral tablet Tier 1

ANTARA ORAL CAPSULE 30 MG, 90 MG Tier 3

atorvastatin oral tablet 10 mg, 20 mg Tier 1 ACA

atorvastatin oral tablet 40 mg, 80 mg Tier 1

CADUET ORAL TABLET 10-10 MG, 10-20 MG, 10-40 MG, 10-80 MG, 5-10 MG, 5-20 MG, 5-40 MG, 5-80 MG

Tier 3

cholestyramine (with sugar) oral powder Tier 1

cholestyramine (with sugar) oral powder in packet Tier 1

cholestyramine light oral powder Tier 1

cholestyramine light oral powder in packet Tier 1

colesevelam oral powder in packet Tier 1

colesevelam oral tablet Tier 1

COLESTID FLAVORED ORAL PACKET Tier 3

COLESTID ORAL GRANULES Tier 3

COLESTID ORAL TABLET Tier 3

colestipol oral granules Tier 1

colestipol oral packet Tier 1

colestipol oral tablet Tier 1

CRESTOR ORAL TABLET Tier 3

ezetimibe oral tablet Tier 1


54

Effective 1/2019

ezetimibe-simvastatin oral tablet Tier 1

fenofibrate micronized oral capsule Tier 1

fenofibrate nanocrystallized oral tablet 145 mg, 48 mg

Tier 1

fenofibrate oral tablet Tier 1

fenofibric acid (choline) oral capsule,delayed release(dr/ec)

Tier 1

fenofibric acid oral tablet Tier 1

FENOGLIDE ORAL TABLET Tier 3

FIBRICOR ORAL TABLET Tier 3

fluvastatin oral capsule Tier 1 ACA

fluvastatin oral tablet extended release 24 hr Tier 1 ACA

gemfibrozil oral tablet Tier 1

JUXTAPID ORAL CAPSULE Tier 3 PA; LD; SPRx

KYNAMRO SUBCUTANEOUS SYRINGE Tier 3 PA; LD; SPRx

LESCOL ORAL CAPSULE Tier 3

LESCOL XL ORAL TABLET EXTENDED RELEASE 24 HR

Tier 3

LIPITOR ORAL TABLET Tier 3

LIPOFEN ORAL CAPSULE Tier 3

LIVALO ORAL TABLET Tier 3

LOPID ORAL TABLET Tier 3

lovastatin oral tablet Tier 1 ACA

niacin oral tablet extended release 24 hr Tier 1

NIACOR ORAL TABLET Tier 3

NIASPAN EXTENDED-RELEASE ORAL TABLET EXTENDED RELEASE 24 HR

Tier 3

PRALUENT PEN SUBCUTANEOUS PEN INJECTOR Tier 2 PA; LD; SPRx

PRAVACHOL ORAL TABLET 20 MG, 40 MG, 80 MG Tier 3

pravastatin oral tablet Tier 1 ACA

prevalite oral powder Tier 1

prevalite oral powder in packet Tier 1

QUESTRAN LIGHT ORAL POWDER Tier 3


55

Effective 1/2019

QUESTRAN ORAL POWDER Tier 3

QUESTRAN ORAL POWDER IN PACKET Tier 3

REPATHA PUSHTRONEX SUBCUTANEOUS WEARABLE INJECTOR

Tier 2 PA; SPRx

REPATHA SURECLICK SUBCUTANEOUS PEN INJECTOR

Tier 2 PA; SPRx

REPATHA SYRINGE SUBCUTANEOUS SYRINGE Tier 2 PA; SPRx

rosuvastatin oral tablet 10 mg, 5 mg Tier 1 ACA

rosuvastatin oral tablet 20 mg, 40 mg Tier 1

simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg Tier 1 ACA

simvastatin oral tablet 80 mg Tier 1

TRICOR ORAL TABLET Tier 3

TRIGLIDE ORAL TABLET 160 MG Tier 3

TRILIPIX ORAL CAPSULE,DELAYED RELEASE(DR/EC)

Tier 3

VYTORIN 10-10 ORAL TABLET Tier 3




WELCHOL ORAL POWDER IN PACKET Tier 3

WELCHOL ORAL TABLET Tier 3

ZETIA ORAL TABLET Tier 3

ZOCOR ORAL TABLET Tier 3

Miscellaneous Cardiovascular Agents CORLANOR ORAL TABLET Tier 3

ENTRESTO ORAL TABLET Tier 3

RANEXA ORAL TABLET EXTENDED RELEASE 12 HR Tier 3

Nitrates DILATRATE-SR ORAL CAPSULE, EXTENDED RELEASE

Tier 3

ISOCHRON ORAL TABLET EXTENDED RELEASE Tier 3

ISORDIL ORAL TABLET Tier 3


56

Effective 1/2019

ISORDIL TITRADOSE ORAL TABLET 5 MG Tier 3

isosorbide dinitrate oral tablet Tier 1

isosorbide dinitrate oral tablet extended release Tier 1

isosorbide mononitrate oral tablet Tier 1

isosorbide mononitrate oral tablet extended release 24 hr

Tier 1

MINITRAN TRANSDERMAL PATCH 24 HOUR Tier 3

nitro-bid transdermal ointment Tier 1

NITRO-DUR TRANSDERMAL PATCH 24 HOUR Tier 3

nitroglycerin oral capsule, extended release Tier 1

nitroglycerin sublingual tablet Tier 1

nitroglycerin transdermal patch 24 hour Tier 1

nitroglycerin translingual aerosol,spray Tier 1

nitroglycerin translingual spray,non-aerosol Tier 1

NITROLINGUAL TRANSLINGUAL SPRAY,NON-AEROSOL

Tier 3

NITROMIST TRANSLINGUAL AEROSOL,SPRAY Tier 3

NITROSTAT SUBLINGUAL TABLET Tier 3

nitro-time oral capsule, extended release Tier 1


Dermatologicals/Topical Therapy

Antipsoriatic / Antiseborrheic acitretin oral capsule Tier 1

calcipotriene scalp solution Tier 1

calcipotriene topical cream Tier 1

calcipotriene topical ointment Tier 1

calcipotriene-betamethasone topical ointment Tier 1

calcitrene topical ointment Tier 1

calcitriol topical ointment Tier 1

COAL TAR TOPICAL SOLUTION Tier 3

COSENTYX (2 SYRINGES) SUBCUTANEOUS SYRINGE

Tier 2 PA; LD; SPRx

57

Effective 1/2019

COSENTYX PEN (2 PENS) SUBCUTANEOUS PEN INJECTOR

Tier 2 PA; LD; SPRx

COSENTYX PEN SUBCUTANEOUS PEN INJECTOR Tier 2 PA; LD; SPRx

COSENTYX SUBCUTANEOUS SYRINGE Tier 2 PA; LD; SPRx

drithocreme hp topical cream Tier 1

ENSTILAR TOPICAL FOAM Tier 2

hydrocortisone-pramoxine topical cream Tier 1

OVACE PLUS SHAMPOO TOPICAL SHAMPOO Tier 3

OVACE PLUS TOPICAL CLEANSER,EXTENDED RELEASE

Tier 3

OVACE PLUS TOPICAL CREAM Tier 3

OVACE PLUS TOPICAL LOTION Tier 3

OVACE PLUS WASH TOPICAL CLEANSER,GEL EXTENDED RELEASE

Tier 3

OVACE TOPICAL CLEANSER Tier 3

seb-prev topical cleanser Tier 1

selenium sulfide topical lotion Tier 1

selenium sulfide topical shampoo 2.25 % Tier 1

SILIQ SUBCUTANEOUS SYRINGE Tier 3 PA; SPRx

SORIATANE ORAL CAPSULE 10 MG, 17.5 MG, 25 MG

Tier 3

STELARA SUBCUTANEOUS SYRINGE Tier 2 PA; SPRx

sulfacetamide sodium topical cleanser Tier 1

sulfacetamide sodium topical shampoo Tier 1

TACLONEX TOPICAL OINTMENT Tier 3

TACLONEX TOPICAL SUSPENSION Tier 2

TALTZ AUTOINJECTOR (2 PACK) SUBCUTANEOUS AUTO-INJECTOR

Tier 3 PA; SPRx

TALTZ AUTOINJECTOR (3 PACK) SUBCUTANEOUS AUTO-INJECTOR

Tier 3 PA; SPRx

TALTZ AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR

Tier 3 PA; SPRx

TALTZ SYRINGE (2 PACK) SUBCUTANEOUS SYRINGE

Tier 3 PA; SPRx


58

Effective 1/2019

TALTZ SYRINGE (3 PACK) SUBCUTANEOUS SYRINGE

Tier 3 PA; SPRx

TALTZ SYRINGE SUBCUTANEOUS SYRINGE Tier 3 PA; SPRx

TREMFYA SUBCUTANEOUS SYRINGE Tier 3 PA; SPRx

Burn Therapy SILVADENE TOPICAL CREAM Tier 3

silver sulfadiazine topical cream Tier 1

ssd topical cream Tier 1

thermazene topical cream Tier 1

Keratolytics PODOCON TOPICAL LIQUID Tier 3

POTASSIUM HYDROXIDE TOPICAL SOLUTION Tier 3

SALEX TOPICAL COMBO PACK Tier 3

SALEX TOPICAL KIT,CLEANSER AND CREAM ER Tier 3

SALEX TOPICAL SHAMPOO Tier 3

salicylic acid er-ceramides topical combo pack Tier 1

salicylic acid er-ceramides topical kit,cleanser and cream er

Tier 1

salicylic acid topical cream Tier 1

salicylic acid topical cream,extended release Tier 1

salicylic acid topical film forming liquid w/appl Tier 1

salicylic acid topical foam Tier 1

salicylic acid topical liquid 26 % Tier 1

salicylic acid topical lotion Tier 1

salicylic acid topical lotion,extended release Tier 1

salicylic acid topical shampoo Tier 1

Miscellaneous Dermatologicals BIAFINE EMULSION TOPICAL EMULSION Tier 3

CONDYLOX TOPICAL GEL Tier 3

diclofenac sodium topical gel 3 % Tier 1 QL (100 GM per 30 days)

doxepin topical cream Tier 1


59

Effective 1/2019

DUPIXENT SUBCUTANEOUS SYRINGE 300 MG/2 ML

Tier 3 PA; SPRx; QL (2 ML per 30 days)

EFUDEX TOPICAL CREAM Tier 3

eletone topical cream Tier 1

ELIDEL TOPICAL CREAM Tier 2

emulsion sb topical emulsion Tier 1

EPICERAM TOPICAL EMULSION, EXTENDED RELEASE

Tier 3

EUCRISA TOPICAL OINTMENT Tier 3

fluorouracil topical cream 5 % Tier 1

fluorouracil topical solution Tier 1

HYDRO 40 TOPICAL FOAM Tier 3

KERALAC TOPICAL CREAM Tier 3

LEVULAN TOPICAL SOLUTION Tier 3

LOUTREX TOPICAL CREAM Tier 3

methoxsalen oral capsule,liqd-filled,rapid rel Tier 1

NEOSALUS TOPICAL CREAM Tier 3

NEOSALUS TOPICAL FOAM Tier 3

NEOSALUS TOPICAL LOTION Tier 3

OXSORALEN ULTRA ORAL CAPSULE,LIQD-FILLED,RAPID REL

Tier 3

PANRETIN TOPICAL GEL Tier 3

PICATO TOPICAL GEL Tier 3

podofilox topical solution Tier 1

PROMISEB TOPICAL CREAM Tier 3

pruclair topical cream Tier 1

prudoxin topical cream Tier 1

prutect topical emulsion Tier 1

REGRANEX TOPICAL GEL Tier 3

silver nitrate applicators topical stick Tier 1

silver nitrate topical solution 10 % Tier 1

tacrolimus topical ointment Tier 1


60

Effective 1/2019

URAMAXIN TOPICAL GEL Tier 3

VALCHLOR TOPICAL GEL Tier 3 PA; LD; SPRx

VEREGEN TOPICAL OINTMENT Tier 3

ZONALON TOPICAL CREAM Tier 3

Therapy For Acne ACANYA TOPICAL GEL WITH PUMP Tier 2

adapalene topical cream Tier 1

adapalene topical gel Tier 1

adapalene topical gel with pump Tier 1

adapalene-benzoyl peroxide topical gel with pump Tier 1

amnesteem oral capsule Tier 1

avita topical cream Tier 1 PA

AZELEX TOPICAL CREAM Tier 3

BENZAMYCIN TOPICAL GEL Tier 3

BENZEFOAM TOPICAL FOAM Tier 3

BENZEFOAM ULTRA TOPICAL FOAM Tier 3

BENZEPRO (MICROSPHERES) TOPICAL CLEANSER Tier 3

benzepro topical towelette Tier 1

benzoyl peroxide topical cleanser 7 % Tier 1

benzoyl peroxide topical foam 9.8 % Tier 1

bpo topical gel Tier 1

claravis oral capsule Tier 1

CLEOCIN T TOPICAL GEL Tier 3

CLEOCIN T TOPICAL LOTION Tier 3

CLEOCIN T TOPICAL SOLUTION Tier 3

CLEOCIN T TOPICAL SWAB Tier 3

clindacin p topical swab Tier 1

CLINDAGEL TOPICAL GEL, ONCE DAILY Tier 3

clindamycin phosphate topical foam Tier 1

clindamycin phosphate topical gel Tier 1

clindamycin phosphate topical lotion Tier 1


61

Effective 1/2019

clindamycin phosphate topical solution Tier 1

clindamycin phosphate topical swab Tier 1

clindamycin-benzoyl peroxide topical gel Tier 1

clindamycin-benzoyl peroxide topical gel with pump

Tier 1

EPIDUO FORTE TOPICAL GEL WITH PUMP Tier 2

EPIDUO TOPICAL GEL WITH PUMP Tier 2

ery pads topical swab Tier 1

erygel topical gel Tier 1

erythromycin with ethanol topical gel Tier 1

erythromycin with ethanol topical solution Tier 1

erythromycin with ethanol topical swab Tier 1

erythromycin-benzoyl peroxide topical gel Tier 1

EVOCLIN TOPICAL FOAM Tier 3

FABIOR TOPICAL FOAM Tier 3 PA

FINACEA TOPICAL FOAM Tier 2

FINACEA TOPICAL GEL Tier 2

isotretinoin oral capsule Tier 1

METROCREAM TOPICAL CREAM Tier 3

METROLOTION TOPICAL LOTION Tier 3

metronidazole topical cream Tier 1

metronidazole topical gel Tier 1

metronidazole topical gel with pump Tier 1

metronidazole topical lotion Tier 1

myorisan oral capsule Tier 1

neuac topical gel Tier 1

NUOX TOPICAL GEL Tier 3

PACNEX TOPICAL CLEANSER Tier 3

PLEXION CLEANSING CLOTHS TOPICAL PADS, MEDICATED

Tier 3

PLEXION TOPICAL CLEANSER Tier 3

PLEXION TOPICAL CREAM Tier 3


62

Effective 1/2019

PLEXION TOPICAL LOTION Tier 3

RETIN-A TOPICAL CREAM Tier 3 PA

RETIN-A TOPICAL GEL Tier 3 PA

rosadan topical cream Tier 1

rosadan topical gel Tier 1

ROSANIL TOPICAL CLEANSER Tier 3

rosula cleansing cloths topical pads, medicated Tier 1

ROSULA TOPICAL CLEANSER Tier 3

sss 10-5 topical cream Tier 1

sss 10-5 topical foam Tier 1

sulfacetamide sodium-sulfur topical cleanser Tier 1

sulfacetamide sodium-sulfur topical cream Tier 1

sulfacetamide sodium-sulfur topical lotion Tier 1

sulfacetamide sodium-sulfur topical pads, medicated 10-4 %

Tier 1

sulfacetamide sodium-sulfur topical suspension Tier 1

sulfacetamide sod-sulfur-urea topical cleanser Tier 1

SUMAXIN TOPICAL PADS, MEDICATED Tier 3

tazarotene topical cream Tier 1 PA

TAZORAC TOPICAL CREAM Tier 3 PA

TAZORAC TOPICAL GEL Tier 3 PA

tretinoin (emollient) topical cream Tier 1 PA

tretinoin microspheres topical gel Tier 1 PA

tretinoin microspheres topical gel with pump Tier 1 PA

tretinoin topical cream Tier 1 PA

tretinoin topical gel Tier 1 PA

TRETIN-X CREAM KIT TOPICAL COMBO PACK Tier 3 PA

TRETIN-X TOPICAL CREAM 0.075 % Tier 3 PA

VANOXIDE-HC TOPICAL SUSPENSION Tier 3

zenatane oral capsule Tier 1

Topical Anesthetics ethyl chloride topical aerosol,spray Tier 1


63

Effective 1/2019

glydo mucous membrane jelly in applicator Tier 1

lidocaine hcl mucous membrane jelly Tier 1

lidocaine hcl mucous membrane jelly in applicator Tier 1

lidocaine hcl mucous membrane solution 4 % (40 mg/ml)

Tier 1

lidocaine hcl-hydrocortison ac topical cream Tier 1

lidocaine topical adhesive patch,medicated Tier 1 QL (90 EA per 30 days)

lidocaine topical ointment Tier 1 QL (100 GM per 30 days)

lidocaine viscous mucous membrane solution Tier 1

lidocaine-prilocaine topical cream Tier 1 QL (60 GM per 30 days)

LIDODERM TOPICAL ADHESIVE PATCH,MEDICATED


SYNERA TOPICAL PATCH, MEDICATED SELF-HEATING

Tier 3

Topical Antibacterials ALTABAX TOPICAL OINTMENT Tier 3

CENTANY AT TOPICAL OINTMENT KIT Tier 3

CENTANY TOPICAL OINTMENT Tier 3

CORTISPORIN TOPICAL CREAM Tier 3

CORTISPORIN TOPICAL OINTMENT Tier 3

gentamicin topical cream Tier 1

gentamicin topical ointment Tier 1

KLARON TOPICAL SUSPENSION Tier 3

mafenide acetate topical packet Tier 1

mupirocin calcium topical cream Tier 1

mupirocin topical ointment Tier 1

NEO-SYNALAR KIT TOPICAL CREAM Tier 3

NEO-SYNALAR TOPICAL CREAM Tier 3

sulfacetamide sodium (acne) topical suspension Tier 1

SULFAMYLON TOPICAL CREAM Tier 3

SULFAMYLON TOPICAL PACKET Tier 3

Topical Antifungals


64

Effective 1/2019

ciclodan topical cream Tier 1

ciclodan topical solution Tier 1

ciclopirox topical cream Tier 1

ciclopirox topical gel Tier 1

ciclopirox topical shampoo Tier 1

ciclopirox topical solution Tier 1

ciclopirox topical suspension Tier 1

ciclopirox-ure-camph-menth-euc topical solution Tier 1

clotrimazole-betamethasone topical cream Tier 1

clotrimazole-betamethasone topical lotion Tier 1

econazole topical cream Tier 1

ERTACZO TOPICAL CREAM Tier 3

EXELDERM TOPICAL CREAM Tier 3

EXELDERM TOPICAL SOLUTION Tier 3

EXODERM TOPICAL LOTION Tier 3

EXTINA TOPICAL FOAM Tier 3

ketoconazole topical cream Tier 1

ketoconazole topical foam Tier 1

ketoconazole topical shampoo Tier 1

LOPROX TOPICAL SHAMPOO Tier 3

LOTRISONE TOPICAL CREAM Tier 3

naftifine topical cream Tier 1

NAFTIN TOPICAL GEL Tier 3

NIZORAL TOPICAL SHAMPOO Tier 3

nyamyc topical powder Tier 1

nystatin topical cream Tier 1

nystatin topical ointment Tier 1

nystatin topical powder Tier 1

nystatin-triamcinolone topical cream Tier 1

nystatin-triamcinolone topical ointment Tier 1

nystop topical powder Tier 1


65

Effective 1/2019

oxiconazole topical cream Tier 1

OXISTAT TOPICAL LOTION Tier 3

PENLAC TOPICAL SOLUTION Tier 3

VUSION TOPICAL OINTMENT Tier 3

XOLEGEL TOPICAL GEL Tier 3

Topical Antivirals acyclovir topical ointment Tier 1

DENAVIR TOPICAL CREAM Tier 3

ZOVIRAX TOPICAL CREAM Tier 2

ZOVIRAX TOPICAL OINTMENT Tier 3

Topical Corticosteroids ala-cort topical cream 2.5 % Tier 1

ALA-SCALP TOPICAL LOTION Tier 3

alclometasone topical cream Tier 1

alclometasone topical ointment Tier 1

amcinonide topical cream Tier 1

amcinonide topical lotion Tier 1

amcinonide topical ointment Tier 1

apexicon e topical cream Tier 1

AQUA GLYCOLIC HC TOPICAL COMBO PACK Tier 3

betamethasone dipropionate topical cream Tier 1

betamethasone dipropionate topical lotion Tier 1

betamethasone dipropionate topical ointment Tier 1

betamethasone valerate topical cream Tier 1

betamethasone valerate topical foam Tier 1

betamethasone valerate topical lotion Tier 1

betamethasone valerate topical ointment Tier 1

betamethasone, augmented topical cream Tier 1

betamethasone, augmented topical gel Tier 1

betamethasone, augmented topical lotion Tier 1

betamethasone, augmented topical ointment Tier 1


66

Effective 1/2019

CAPEX TOPICAL SHAMPOO Tier 3

clobetasol scalp solution Tier 1

clobetasol topical cream Tier 1

clobetasol topical foam Tier 1

clobetasol topical gel Tier 1

clobetasol topical lotion Tier 1

clobetasol topical ointment Tier 1

clobetasol topical shampoo Tier 1

clobetasol topical spray,non-aerosol Tier 1

clobetasol-emollient topical cream Tier 1

clobetasol-emollient topical foam Tier 1

CLOBEX TOPICAL LOTION Tier 3

CLOBEX TOPICAL SHAMPOO Tier 3

CLOBEX TOPICAL SPRAY,NON-AEROSOL Tier 3

CLOCORTOLONE PIVALATE TOPICAL CREAM Tier 3

clodan topical shampoo Tier 1

CLODERM TOPICAL CREAM Tier 3

CORDRAN TOPICAL CREAM Tier 3

CORDRAN TOPICAL LOTION Tier 3

CORDRAN TOPICAL OINTMENT Tier 3

cormax scalp solution Tier 1

CUTIVATE TOPICAL CREAM Tier 3

CUTIVATE TOPICAL LOTION Tier 3

DERMA-SMOOTHE/FS BODY OIL TOPICAL OIL Tier 3

DERMA-SMOOTHE/FS SCALP OIL SCALP OIL Tier 3

DERMASORB HC COMPLETE KIT TOPICAL COMBO PACK,CLEANSER AND LOTION

Tier 3

DERMASORB TA COMPLETE KIT TOPICAL CREAM Tier 3

DERMATOP TOPICAL CREAM Tier 3

DERMATOP TOPICAL OINTMENT Tier 3

DESONATE TOPICAL GEL Tier 3

desonide topical cream Tier 1


67

Effective 1/2019

desonide topical lotion Tier 1

desonide topical ointment Tier 1

DESOWEN TOPICAL CREAM Tier 3

DESOWEN TOPICAL LOTION Tier 3

desoximetasone topical cream Tier 1

desoximetasone topical gel Tier 1

desoximetasone topical ointment Tier 1

desoximetasone topical spray,non-aerosol Tier 1

diflorasone topical cream Tier 1

diflorasone topical ointment Tier 1

DIPROLENE TOPICAL OINTMENT Tier 3

ELOCON TOPICAL CREAM Tier 3

ELOCON TOPICAL OINTMENT Tier 3

fluocinolone and shower cap scalp oil Tier 1

fluocinolone topical cream Tier 1

fluocinolone topical oil Tier 1

fluocinolone topical ointment Tier 1

fluocinolone topical solution Tier 1

fluocinonide topical cream Tier 1

fluocinonide topical gel Tier 1

fluocinonide topical ointment Tier 1

fluocinonide topical solution Tier 1

fluocinonide-e topical cream Tier 1

fluocinonide-emollient topical cream Tier 1

flurandrenolide topical cream Tier 1

flurandrenolide topical lotion Tier 1

flurandrenolide topical ointment Tier 1

fluticasone topical cream Tier 1

fluticasone topical lotion Tier 1

fluticasone topical ointment Tier 1

halobetasol propionate topical cream Tier 1


68

Effective 1/2019

halobetasol propionate topical ointment Tier 1

HALOG TOPICAL CREAM Tier 3

HALOG TOPICAL OINTMENT Tier 3

hydrocortisone butyrate topical cream Tier 1

hydrocortisone butyrate topical lotion Tier 1

hydrocortisone butyrate topical ointment Tier 1

hydrocortisone butyrate topical solution Tier 1

hydrocortisone butyr-emollient topical cream Tier 1

hydrocortisone topical cream 2.5 % Tier 1

hydrocortisone topical lotion 2.5 % Tier 1

hydrocortisone topical ointment 2.5 % Tier 1

hydrocortisone valerate topical cream Tier 1

hydrocortisone valerate topical ointment Tier 1

hydrocortisone-min oil-wht pet topical ointment Tier 1

KENALOG TOPICAL AEROSOL Tier 3

LOCOID LIPOCREAM TOPICAL CREAM Tier 3

LOCOID TOPICAL LOTION Tier 3

LUXIQ TOPICAL FOAM Tier 3

mometasone topical cream Tier 1

mometasone topical ointment Tier 1

mometasone topical solution Tier 1

OLUX TOPICAL FOAM Tier 3

OLUX-E TOPICAL FOAM Tier 3

PANDEL TOPICAL CREAM Tier 3

prednicarbate topical cream Tier 1

prednicarbate topical ointment Tier 1

PSORCON TOPICAL CREAM Tier 3

SYNALAR CREAM KIT TOPICAL CREAM Tier 3

SYNALAR OINTMENT KIT TOPICAL COMBO PACK,OINTMENT AND CREAM

Tier 3

SYNALAR TOPICAL CREAM Tier 3

SYNALAR TOPICAL SOLUTION Tier 3


69

Effective 1/2019

SYNALAR TS TOPICAL KIT Tier 3

TEMOVATE TOPICAL CREAM Tier 3

TEMOVATE TOPICAL OINTMENT Tier 3

TEXACORT TOPICAL SOLUTION Tier 3

TOPICORT TOPICAL CREAM 0.05 % Tier 3

TOPICORT TOPICAL GEL Tier 3

TOPICORT TOPICAL OINTMENT 0.05 % Tier 3

TOPICORT TOPICAL SPRAY,NON-AEROSOL Tier 3

triamcinolone acetonide topical aerosol Tier 1

triamcinolone acetonide topical cream Tier 1

triamcinolone acetonide topical lotion Tier 1

triamcinolone acetonide topical ointment 0.025 %, 0.1 %, 0.5 %

Tier 1

trianex topical ointment Tier 1

triderm topical cream 0.1 % Tier 1

ULTRAVATE X TOPICAL COMBO PACK Tier 3

ULTRAVATE X TOPICAL COMBO PACK,OINTMENT AND CREAM

Tier 3

VANOS TOPICAL CREAM Tier 3

VERDESO TOPICAL FOAM Tier 3

Topical Enzymes SANTYL TOPICAL OINTMENT Tier 3

Topical Scabicides / Pediculicides ELIMITE TOPICAL CREAM Tier 3

EURAX TOPICAL CREAM Tier 3

lindane topical shampoo Tier 1

malathion topical lotion Tier 1

NATROBA TOPICAL SUSPENSION Tier 3

OVIDE TOPICAL LOTION Tier 3

permethrin topical cream Tier 1

spinosad topical suspension Tier 1

ULESFIA TOPICAL LOTION Tier 3


70

Effective 1/2019Drug Name Drug Tier Requirements/Limits

Diagnostics & Miscellaneous Agents

Anorexiants ADIPEX-P ORAL CAPSULE Tier 3 #

ADIPEX-P ORAL TABLET Tier 3 #

BELVIQ ORAL TABLET Tier 3 #

benzphetamine oral tablet Tier 1 #

CONTRAVE ORAL TABLET EXTENDED RELEASE Tier 3 #

diethylpropion oral tablet Tier 1 #

diethylpropion oral tablet extended release Tier 1 #

LOMAIRA ORAL TABLET Tier 3 #

phendimetrazine tartrate oral capsule, extended release

Tier 1 #

phendimetrazine tartrate oral tablet Tier 1 #

phentermine oral capsule Tier 1 #

phentermine oral tablet Tier 1 #

QSYMIA ORAL CAPSULE, ER MULTIPHASE 24 HR Tier 3 #

REGIMEX ORAL TABLET Tier 3 #

SAXENDA SUBCUTANEOUS PEN INJECTOR Tier 3 #

XENICAL ORAL CAPSULE Tier 3 #

Irrigating Solutions aqua care sodium chloride irrigation solution Tier 1

aqua care sterile water irrigation solution Tier 1

lactated ringers irrigation solution Tier 1

neomycin-polymyxin b gu irrigation solution Tier 1

NEOSPORIN GU IRRIGANT IRRIGATION SOLUTION

Tier 3

PHYSIOLYTE IRRIGATION SOLUTION Tier 3

PHYSIOSOL IRRIGATION IRRIGATION SOLUTION Tier 3

ringer's irrigation solution Tier 1

SORBITOL IRRIGATION SOLUTION Tier 3

SORBITOL-MANNITOL URETHRAL SOLUTION Tier 3

tis-u-sol pentalyte irrigation solution Tier 1

71

Effective 1/2019

Miscellaneous Agents acamprosate oral tablet,delayed release (dr/ec) Tier 1

acetic acid irrigation solution Tier 1

ACTONEL ORAL TABLET 30 MG Tier 3

AGRYLIN ORAL CAPSULE Tier 3

alendronate oral tablet 40 mg Tier 1

anagrelide oral capsule Tier 1

ANTABUSE ORAL TABLET Tier 3

bd pre-filled normal saline injection syringe Tier 1

BUPHENYL ORAL POWDER Tier 3

BUPHENYL ORAL TABLET Tier 3

caffeine citrate oral solution Tier 1

CARBAGLU ORAL TABLET, DISPERSIBLE Tier 3 LD

CARNITOR (SUGAR-FREE) ORAL SOLUTION Tier 3

CARNITOR ORAL SOLUTION Tier 3

CARNITOR ORAL TABLET Tier 3

cevimeline oral capsule Tier 1

CHEMET ORAL CAPSULE Tier 3

disulfiram oral tablet Tier 1

etidronate disodium oral tablet Tier 1

EVOXAC ORAL CAPSULE Tier 3

EXJADE ORAL TABLET, DISPERSIBLE Tier 3 LD; SPRx

FERRIPROX ORAL TABLET Tier 3 LD; SPRx

JADENU ORAL TABLET Tier 3 LD; SPRx

levocarnitine (with sugar) oral solution Tier 1

levocarnitine oral tablet Tier 1

LITHOSTAT ORAL TABLET Tier 3

METOPIRONE ORAL CAPSULE Tier 3

midodrine oral tablet Tier 1

monoject 0.9% sodium chloride injection syringe Tier 1

monoject prefill advanced ns injection syringe Tier 1


72

Effective 1/2019

monoject prefill saline flush injection syringe Tier 1

NITYR ORAL TABLET Tier 3 SPRx

normal saline flush injection syringe Tier 1

NORTHERA ORAL CAPSULE Tier 3 PA; LD; SPRx

ORFADIN ORAL CAPSULE Tier 3 LD; SPRx

pilocarpine hcl oral tablet 5 mg Tier 1

RADIOGARDASE ORAL CAPSULE Tier 3

RAVICTI ORAL LIQUID Tier 3 LD; SPRx

RILUTEK ORAL TABLET Tier 3

riluzole oral tablet Tier 1

risedronate oral tablet 30 mg Tier 1

SALAGEN (PILOCARPINE) ORAL TABLET 5 MG Tier 3

sodium chlor 0.9% bacteriostat injection solution Tier 1

sodium chloride 0.9 % injection syringe Tier 1

sodium chloride irrigation solution Tier 1

sodium phenylbutyrate oral powder Tier 1

syrex sodium chloride 0.9 % injection syringe Tier 1

THIOLA ORAL TABLET Tier 3 SPRx

tiglutik oral suspension Tier 3 SPRx

water for irrigation, sterile irrigation solution Tier 1

Phenylketonuria (Pku) Nutritional Products CAMINO PRO 15 PE PKU ORAL LIQUID IN PACKET Tier 3

EAA SUPPLEMENT ORAL POWDER IN PACKET Tier 3

GLYTACTIN 10 PE COMPLETE ORAL BAR Tier 3

GLYTACTIN 15 PE BETTERMILK ORAL POWDER IN PACKET

Tier 3

GLYTACTIN 15 PE COMPLETE ORAL BAR Tier 3

GLYTACTIN 20PE BETTERMILK LITE ORAL POWDER IN PACKET

Tier 3

GLYTACTIN BUILD 10 PE ORAL POWDER IN PACKET

Tier 3

GLYTACTIN RESTORE 10 PE LITE ORAL LIQUID Tier 3


73

Effective 1/2019

GLYTACTIN RESTORE 10 PE LITE ORAL POWDER IN PACKET

Tier 3

GLYTACTIN RESTORE 10 PE ORAL LIQUID Tier 3

GLYTACTIN RESTORE 5 PE ORAL POWDER IN PACKET

Tier 3

GLYTACTIN RTD 10 PE ORAL LIQUID Tier 3

GLYTACTIN RTD 15 PE ORAL LIQUID Tier 3

GLYTACTIN SWIRL 15 PE ORAL POWDER IN PACKET

Tier 3

LANAFLEX ORAL POWDER IN PACKET Tier 3

LOPHLEX ORAL POWDER IN PACKET Tier 3

PERIFLEX ADVANCE ORAL POWDER Tier 3

PERIFLEX INFANT ORAL POWDER Tier 3

PERIFLEX JUNIOR ORAL POWDER Tier 3

PERIFLEX LQ PKU ORAL LIQUID Tier 3

PHENACTIN AA PLUS 20 PE ORAL LIQUID Tier 3

PHENEX-1 ORAL POWDER Tier 3

PHENEX-2 ORAL POWDER Tier 3

PHENYLADE 40 ORAL POWDER IN PACKET Tier 3

PHENYLADE 60 ORAL POWDER Tier 3

PHENYLADE 60 ORAL POWDER IN PACKET Tier 3

PHENYLADE AMINO ACID ORAL BAR Tier 3

PHENYLADE AMINO ACIDS ORAL POWDER Tier 3

PHENYLADE AMINO ACIDS ORAL POWDER IN PACKET

Tier 3

PHENYLADE DRINK MIX ORAL POWDER Tier 3

PHENYLADE ESSENTIAL ORAL POWDER Tier 3

PHENYLADE ESSENTIAL ORAL POWDER IN PACKET

Tier 3

PHENYLADE GMP MIX-IN ORAL POWDER Tier 3

PHENYLADE GMP MIX-IN ORAL POWDER IN PACKET

Tier 3

PHENYLADE GMP ORAL POWDER Tier 3


74

Effective 1/2019

PHENYLADE GMP ORAL POWDER IN PACKET Tier 3

PHENYLADE MTE AMINO ACIDS ORAL POWDER Tier 3

PHENYLADE MTE AMINO ACIDS ORAL POWDER IN PACKET

Tier 3

PHENYLADE PHEBLOC ORAL POWDER IN PACKET Tier 3

phenylade phebloc oral tablet Tier 1

PHENYLADE RTD PKU 10 ORAL LIQUID Tier 3

PHENYL-FREE 1 ORAL POWDER Tier 3

PHENYL-FREE 2 PKU ORAL POWDER Tier 3

PHENYL-FREE 2HP PKU ORAL POWDER Tier 3

PHLEXY-10 DRINK MIX POWDER ORAL POWDER IN PACKET

Tier 3

PHLEXY-10 ORAL TABLET 8.33 GRAM-35 KCAL/10 Tier 3

PKU 2 ORAL POWDER Tier 3

PKU 3 ORAL POWDER Tier 3

PKU AIR15 ORAL LIQUID IN PACKET Tier 3

PKU AIR20 ORAL LIQUID IN PACKET Tier 3

PKU COOLER 10 ORAL SUSPENSION Tier 3



PKU EASY MICROTABS ORAL GRANULES DELAYED RELEASE

Tier 3

PKU EXPRESS15 ORAL POWDER IN PACKET Tier 3

PKU EXPRESS20 ORAL POWDER IN PACKET Tier 3

PKU GEL POWDER ORAL POWDER IN PACKET Tier 3

PKU LOPHLEX ORAL LIQUID IN PACKET Tier 3

PKU PERIFLEX EARLY YEARS ORAL POWDER Tier 3

PKU PERIFLEX JUNIOR PLUS ORAL POWDER Tier 3

PKU SPHERE20 ORAL POWDER IN PACKET Tier 3

PKU TRIO ORAL POWDER Tier 3

XPHE MAXAMAID ORAL POWDER Tier 3

xphe maxamum oral powder Tier 1


75

Effective 1/2019

XPHE MAXAMUM ORAL POWDER IN PACKET Tier 3

Smoking Deterrents bupropion hcl (smoking deter) oral tablet extended release 12 hr

Tier 1 ACA

CHANTIX CONTINUING MONTH BOX ORAL TABLET

Tier 3 ACA

CHANTIX ORAL TABLET Tier 3 ACA

CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK

Tier 3 ACA

NICODERM CQ TRANSDERMAL PATCH 24 HOUR Tier 3 ACA

NICORETTE BUCCAL GUM Tier 3 ACA

NICORETTE BUCCAL LOZENGE Tier 3 ACA

NICORETTE BUCCAL MINI LOZENGE Tier 3 ACA

nicotine (polacrilex) buccal gum Tier 1 ACA

nicotine (polacrilex) buccal lozenge Tier 1 ACA

nicotine (polacrilex) buccal mini lozenge Tier 1 ACA

nicotine transdermal patch 24 hour 14 mg/24 hr, 21 mg/24 hr, 7 mg/24 hr

Tier 1 ACA

nicotine transdermal patch, td daily, sequential Tier 1 ACA

NICOTROL INHALATION CARTRIDGE Tier 3 ACA

NICOTROL NS NASAL SPRAY,NON-AEROSOL Tier 3 ACA

ZYBAN ORAL TABLET EXTENDED RELEASE 12 HR Tier 3 ACA


Ear, Nose & Throat Medications

Miscellaneous Agents ARESTIN DENTAL CARTRIDGE Tier 3

ASTEPRO NASAL SPRAY,NON-AEROSOL Tier 3

azelastine nasal aerosol,spray Tier 1

azelastine nasal spray,non-aerosol Tier 1

BACTROBAN NASAL NASAL OINTMENT Tier 3

chlorhexidine gluconate mucous membrane mouthwash

Tier 1

CLINPRO 5000 DENTAL PASTE Tier 3

denta 5000 plus dental cream Tier 1

76

Effective 1/2019

dentagel dental gel Tier 1

fluoride (sodium) dental solution Tier 1

FLUORIDEX DAILY DEFENSE DENTAL PASTE Tier 3

ipratropium bromide nasal spray,non-aerosol Tier 1

olopatadine nasal spray,non-aerosol Tier 1

oralone dental paste Tier 1

ORAMAGICRX MUCOUS MEMBRANE MOUTHWASH

Tier 3

PATANASE NASAL SPRAY,NON-AEROSOL Tier 3

PERIDEX MUCOUS MEMBRANE MOUTHWASH Tier 3

periogard mucous membrane mouthwash Tier 1

pilocarpine hcl oral tablet 7.5 mg Tier 1

PREVIDENT 5000 BOOSTER PLUS DENTAL PASTE Tier 3

PREVIDENT 5000 DRY MOUTH DENTAL GEL Tier 3

PREVIDENT 5000 ENAMEL PROTECT DENTAL PASTE

Tier 3

PREVIDENT 5000 SENSITIVE DENTAL PASTE Tier 3

PREVIDENT DENTAL SOLUTION Tier 3

SALAGEN (PILOCARPINE) ORAL TABLET 7.5 MG Tier 3

sf 5000 plus dental cream Tier 1

sf dental gel Tier 1

triamcinolone acetonide dental paste Tier 1

Miscellaneous Otic Preparations acetic acid otic (ear) solution Tier 1

ciprofloxacin hcl otic (ear) dropperette Tier 1

DERMOTIC OIL OTIC (EAR) DROPS Tier 3

flac otic oil otic (ear) drops Tier 1

floxin otic (ear) drops Tier 1

fluocinolone acetonide oil otic (ear) drops Tier 1

hydrocortisone-acetic acid otic (ear) drops Tier 1

ofloxacin otic (ear) drops Tier 1

Otic Steroid / Antibiotic


77

Effective 1/2019

CIPRO HC OTIC (EAR) DROPS,SUSPENSION Tier 3

CIPRODEX OTIC (EAR) DROPS,SUSPENSION Tier 2

COLY-MYCIN S OTIC (EAR) DROPS,SUSPENSION Tier 3

neomycin-polymyxin-hc otic (ear) drops,suspension

Tier 1

neomycin-polymyxin-hc otic (ear) solution Tier 1

OTOVEL OTIC (EAR) SOLUTION Tier 2


Endocrine/Diabetes

Adrenal Hormones ACTHAR H.P. INJECTION GEL Tier 3 PA; SPRx

CORTEF ORAL TABLET Tier 3

cortisone oral tablet Tier 1

decadron oral tablet Tier 1

deltasone oral tablet 20 mg Tier 1

dexamethasone intensol oral drops Tier 1

dexamethasone oral elixir Tier 1

dexamethasone oral solution Tier 1

dexamethasone oral tablet Tier 1

EMFLAZA ORAL SUSPENSION Tier 3 PA; LD; SPRx

EMFLAZA ORAL TABLET Tier 3 PA; LD; SPRx

fludrocortisone oral tablet Tier 1

hydrocortisone oral tablet Tier 1

MEDROL (PAK) ORAL TABLETS,DOSE PACK Tier 3

MEDROL ORAL TABLET Tier 3

methylprednisolone oral tablet Tier 1

methylprednisolone oral tablets,dose pack Tier 1

millipred dp oral tablets,dose pack Tier 1

MILLIPRED ORAL SOLUTION Tier 3

millipred oral tablet Tier 1

ORAPRED ODT ORAL TABLET,DISINTEGRATING Tier 3

PEDIAPRED ORAL SOLUTION Tier 3

78

Effective 1/2019

prednisolone oral solution 15 mg/5 ml Tier 1

prednisolone sodium phosphate oral solution 10 mg/5 ml, 15 mg/5 ml (3 mg/ml), 20 mg/5 ml (4 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)

Tier 1

prednisolone sodium phosphate oral tablet,disintegrating

Tier 1

prednisone intensol oral concentrate Tier 1

prednisone oral solution Tier 1

prednisone oral tablet Tier 1

prednisone oral tablets,dose pack Tier 1

veripred 20 oral solution Tier 1

Antithyroid Agents methimazole oral tablet 10 mg, 5 mg Tier 1

propylthiouracil oral tablet Tier 1

SSKI ORAL SOLUTION Tier 3

TAPAZOLE ORAL TABLET Tier 3

Blood Glucose Monitoring Devices & Supplies ACCU-CHEK AVIVA PLUS TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

ACCU-CHEK COMPACT PLUS TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

ACCU-CHEK GUIDE STRIP Tier 3 ST; QL (102 EA per 30 days)

ACCU-CHEK SMARTVIEW TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

ACCUTREND GLUCOSE STRIP Tier 3 ST; QL (102 EA per 30 days)

ADVANCED GLUC METER TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

ADVOCATE REDI-CODE STRIP Tier 3 ST; QL (102 EA per 30 days)

ADVOCATE TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

AGAMATRIX AMP TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

ASSURE 4 STRIP Tier 3 ST; QL (102 EA per 30 days)

ASSURE PLATINUM STRIP Tier 3 ST; QL (102 EA per 30 days)

ASSURE PRISM MULTI STRIP Tier 3 ST; QL (102 EA per 30 days)

BIONIME RIGHTEST TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

BLOOD GLUCOSE TEST STRIP Tier 3 ST; QL (102 EA per 30 days)


79

Effective 1/2019

BREEZE 2 TEST STRIP Tier 2 QL (102 EA per 30 days)

CARESENS N TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

CARETOUCH TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

CLEVER CHOICE MICRO TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

CLEVER CHOICE PRO STRIP Tier 3 ST; QL (102 EA per 30 days)

CLEVER CHOICE TALK TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

CLEVER CHOICE TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

CLEVER CHOICE VOICE+ TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

CONTOUR NEXT TEST STRIP Tier 2 QL (102 EA per 30 days)

CONTOUR TEST STRIP Tier 2 QL (102 EA per 30 days)

COOL GLUCOSE TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

DIATRUE PLUS TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

EASY PLUS II TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

EASY STEP STRIP Tier 3 ST; QL (102 EA per 30 days)

EASY TALK GLUCOSE TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

EASY TOUCH TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

EASY TRAK GLUCOSE TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

EASYGLUCO PLUS STRIP Tier 3 ST; QL (102 EA per 30 days)

EASYGLUCO TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

EASYMAX STRIP Tier 3 ST; QL (102 EA per 30 days)

ELEMENT COMPACT TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

ELEMENT TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

EMBRACE BLOOD GLUCOSE SYSTEM STRIP Tier 3 ST; QL (102 EA per 30 days)

EMBRACE EVO TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

EMBRACE PRO TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

EVENCARE G2 STRIP Tier 3 ST; QL (102 EA per 30 days)

EVENCARE G3 TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

EVENCARE MINI GLUCOSE TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

EVOLUTION TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

EZ SMART PLUS TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

EZ SMART TEST STRIP Tier 3 ST; QL (102 EA per 30 days)


80

Effective 1/2019

FIFTY50 TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

FORA D15G STRIP Tier 3 ST; QL (102 EA per 30 days)

FORA D20 STRIP Tier 3 ST; QL (102 EA per 30 days)

FORA D40-G31 TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

FORA G20 STRIP Tier 3 ST; QL (102 EA per 30 days)

FORA G30-PREMIUM V10 TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

FORA GD50 TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

FORA TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

FORA TN'G VOICE TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

FORA V10 STRIP Tier 3 ST; QL (102 EA per 30 days)

FORA V12 GLUCOSE STRIP Tier 3 ST; QL (102 EA per 30 days)

FORA V20 STRIP Tier 3 ST; QL (102 EA per 30 days)

FORACARE GD20 STRIP Tier 3 ST; QL (102 EA per 30 days)

FORACARE GD40 STRIP Tier 3 ST; QL (102 EA per 30 days)

FORTISCARE GLUCOSE TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

FREESTYLE INSULINX STRIP Tier 3 ST; QL (102 EA per 30 days)

FREESTYLE INSULINX TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

FREESTYLE LITE STRIP Tier 3 ST; QL (102 EA per 30 days)

FREESTYLE PRECISION NEO STRIP Tier 3 ST; QL (102 EA per 30 days)

FREESTYLE TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

GE100 BLOOD GLUCOSE TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

GENSTRIP TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

GLUCO NAVII TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

GLUCOCARD 01 SENSOR PLUS STRIP Tier 3 ST; QL (102 EA per 30 days)

GLUCOCARD EXPRESSION STRIP Tier 3 ST; QL (102 EA per 30 days)

GLUCOCARD SHINE TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

GLUCOCARD VITAL SENSOR STRIP Tier 3 ST; QL (102 EA per 30 days)

GLUCOCARD VITAL TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

GLUCOCOM GLUCOSE STRIP Tier 3 ST; QL (102 EA per 30 days)

GM100 STRIP Tier 3 ST; QL (102 EA per 30 days)

HEALTHPRO TEST STRIP Tier 3 ST; QL (102 EA per 30 days)


81

Effective 1/2019

IGLUCOSE TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

INFINITY TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

INFINITY VOICE TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

MICRO BLOOD GLUCOSE STRIP Tier 3 ST; QL (102 EA per 30 days)

MICRODOT BLOOD GLUCOSE SYSTEM STRIP Tier 3 ST; QL (102 EA per 30 days)

MYGLUCOHEALTH STRIP Tier 3 ST; QL (102 EA per 30 days)

NEUTEK 2TEK TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

NOVA MAX GLUCOSE TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

ON CALL EXPRESS TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

ON CALL PLUS TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

ON CALL VIVID TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

ONETOUCH ULTRA BLUE TEST STRIP Tier 2 QL (102 EA per 30 days)

ONETOUCH ULTRA TEST STRIP Tier 2 QL (102 EA per 30 days)

ONETOUCH VERIO STRIP Tier 2 QL (102 EA per 30 days)

OPTIUM EZ STRIP Tier 3 ST; QL (102 EA per 30 days)

OPTIUM TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

OPTUMRX STRIP Tier 3 ST; QL (102 EA per 30 days)

PHARMACIST CHOICE STRIP Tier 3 ST; QL (102 EA per 30 days)

PRECISION PCX PLUS TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

PRECISION PCX TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

PRECISION POINT OF CARE TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

PRECISION Q-I-D TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

PRECISION XTRA TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

PREMIER TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

PREMIUM V10 STRIP Tier 3 ST; QL (102 EA per 30 days)

PRO VOICE V8-V9 TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

PRODIGY NO CODING STRIP Tier 3 ST; QL (102 EA per 30 days)

QUINTET AC STRIP Tier 3 ST; QL (102 EA per 30 days)

REFUAH PLUS STRIP Tier 3 ST; QL (102 EA per 30 days)

RELION CONFIRM-MICRO STRIP Tier 3 ST; QL (102 EA per 30 days)

RELION PRIME TEST STRIP Tier 3 ST; QL (102 EA per 30 days)


82

Effective 1/2019

REVEAL TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

RIGHTEST GS550 TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

SMART SENSE TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

SMARTEST TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

SURE-TEST EASYPLUS MINI STRIP Tier 3 ST; QL (102 EA per 30 days)

TELCARE TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

TEST N'GO TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

TRUE METRIX GLUCOSE TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

TRUETEST TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

TRUETRACK TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

ULTIMA TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

ULTRATRAK STRIP Tier 3 ST; QL (102 EA per 30 days)

ULTRATRAK ULTIMATE STRIP Tier 3 ST; QL (102 EA per 30 days)

UNISTRIP1 TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

VERASENS TEST STRIP Tier 3 ST; QL (102 EA per 30 days)

WAVESENSE JAZZ STRIP Tier 3 ST; QL (102 EA per 30 days)

WAVESENSE PRESTO STRIP Tier 3 ST; QL (102 EA per 30 days)

Diabetes, Supplies, & Durable Medical Equipment GLUCAGEN DIAGNOSTIC KIT INJECTION RECON SOLN

Tier 2

Glucose Elevating Agents GLUCAGEN HYPOKIT INJECTION RECON SOLN Tier 2

GLUCAGON EMERGENCY KIT (HUMAN) INJECTION RECON SOLN

Tier 2

PROGLYCEM ORAL SUSPENSION Tier 3

TRUEPLUS GLUCOSE ORAL GEL IN PACKET Tier 3

Insulin Syringes/Miscellaneous Durable Medical Equipment 1ST TIER UNIFINE PENTIPS NEEDLE 29 GAUGE X 1/2"


1ST TIER UNILET COMFORTOUCH 28 GAUGE Tier 2

ACCU-CHEK SAFE-T-PRO Tier 2

ACCU-CHEK SOFTCLIX LANCETS Tier 2


83

Effective 1/2019

ACTI-LANCE LANCETS 23 GAUGE Tier 2

ADVANCED TRAVEL LANCETS 30 GAUGE Tier 2

ADVOCATE LANCET 30 GAUGE Tier 2

ADVOCATE PEN NEEDLE 29 GAUGE X 1/2" Tier 2 QL (1000 EA per 30 days)

ALCOHOL SWABS TOPICAL PADS, MEDICATED Tier 2 QL (300 EA per 30 days)

ALTERNATE SITE LANCET Tier 2

ASSURE HAEMOLANCE PLUS 1.2 MM Tier 3

ASSURE LANCE 25 GAUGE Tier 2

ASSURE LANCE PLUS 21 GAUGE Tier 2

BD ECLIPSE NEEDLE 25 GAUGE X 1" Tier 2 QL (1000 EA per 30 days)

BD FILTER NEEDLE-5 MICRON NEEDLE Tier 2 QL (1000 EA per 30 days)

BD INTEGRA NEEDLE Tier 2 QL (1000 EA per 30 days)

BD MICROTAINER LANCET 30 GAUGE Tier 2

BD NOKOR ADMIX NEEDLE Tier 2 QL (1000 EA per 30 days)

BD PRECISIONGLIDE NEEDLE 27 GAUGE X 1 1/2" Tier 2 QL (1000 EA per 30 days)

BD PRECISIONGLIDE NON-STERILE NEEDLE 18 GAUGE X 1 1/2"


BD SAFETYGLIDE NEEDLE 22 GAUGE X 1 1/2" Tier 2 QL (1000 EA per 30 days)

BD SPECIALTY USE NEEDLE 30 GAUGE X 1/2" Tier 2 QL (1000 EA per 30 days)

BD ULTRA FINE LANCETS Tier 2

BD ULTRA-FINE NANO PEN NEEDLE Tier 2 QL (1000 EA per 30 days)

BD ULTRA-FINE SHORT PEN NEEDLE Tier 2 QL (1000 EA per 30 days)

BLUNT NEEDLE, DISPOSABLE NEEDLE 18 X 1 1/2 " Tier 2 QL (1000 EA per 30 days)

BULLSEYE MINI SAFETY LANCETS 21 GAUGE Tier 2

CAREFINE PEN NEEDLE 31 GAUGE X 1/4" Tier 2 QL (1000 EA per 30 days)

CAREONE THIN LANCET Tier 2

CLEVER CHEK LANCETS Tier 2

CLICKFINE NEEDLE 31 GAUGE X 1/4" Tier 2 QL (1000 EA per 30 days)

COAGUCHEK LANCETS Tier 2

COLOR LANCETS Tier 2

COMFORT EZ PEN NEEDLE 31 GAUGE X 5/16" Tier 2 QL (1000 EA per 30 days)

COMFORT LANCETS Tier 2


84

Effective 1/2019

DROPLET LANCETS Tier 2

DROPLET PEN NEEDLE 32 GAUGE X 5/32" Tier 2 QL (1000 EA per 30 days)

EASY COMFORT LANCETS Tier 2

EASY COMFORT PEN NEEDLE 31 GAUGE X 3/16" Tier 3 QL (1000 EA per 30 days)

EASY TOUCH FLIPLOCK NEEDLE 22 GAUGE X 3/4", 25 GAUGE X 1 1/2"


EASY TOUCH HYPODERMIC NEEDLE 32 GAUGE X 5/16"


EXEL HYPODERMIC NEEDLE 27 GAUGE X 1/2" Tier 2 QL (1000 EA per 30 days)

e-z ject lancets 26 gauge Tier 1

EZ SMART LANCETS Tier 2

FIFTY50 SAFETY SEAL LANCETS 30 GAUGE Tier 2

FINE 30 UNIVERSAL LANCETS Tier 2

FINGERSTIX LANCETS Tier 2

FLOW-EZE VENTED NEEDLE Tier 2 QL (1000 EA per 30 days)

FORA V10-V12-D10-D20 STRP-LNCT COMBO PACK

Tier 3

FORACARE LANCETS Tier 2

FREESTYLE LANCETS Tier 2

FREESTYLE UNISTIK 2 Tier 2

GLUCOCOM LANCETS 28 GAUGE, 33 GAUGE Tier 2

HEALTHY ACCENTS UNIFINE PENTIP NEEDLE 29 GAUGE X 1/2"


HEALTHY ACCENTS UNILET LANCET Tier 2

huber safety needles (disp.) needle Tier 1 QL (1000 EA per 30 days)

INCONTROL PEN NEEDLE 29 GAUGE X 1/2" Tier 2 QL (1000 EA per 30 days)

INCONTROL SUPER THIN LANCETS Tier 2

INCONTROL ULTRA THIN LANCETS Tier 2

INJECT EASE LANCETS 28 GAUGE Tier 2

INSUPEN NEEDLE 29 GAUGE X 1/2" Tier 2 QL (1000 EA per 30 days)

INVACARE LANCETS Tier 2

lancets Tier 2

LANCETS 30 GAUGE Tier 2


85

Effective 1/2019

LANCETS,THIN, 28 GAUGE Tier 2

LIFESHIELD BLUNT CANNULA NEEDLE Tier 2 QL (1000 EA per 30 days)

LITE TOUCH LANCETS 33 GAUGE Tier 2

MEDISENSE THIN LANCETS Tier 2

MEDLANCE PLUS LANCETS 25 GAUGE Tier 2

MEDLANCE PLUS SPECIAL BLADE Tier 3

MICRO THIN LANCETS Tier 2

MICROLET LANCET Tier 2

MINI ULTRA-THIN II NEEDLE Tier 2 QL (1000 EA per 30 days)

MONOJECT BLOOD COLLECTION NEEDLE 20 GAUGE X 1"


MONOJECT HYPODERMIC NEEDLE 18 GAUGE X 1"


MONOJECT MEDICATION TRANSF NEEDLE Tier 2 QL (1000 EA per 30 days)

MONOLET THIN LANCETS Tier 2

MULTI-DRAW NEEDLE 20 GAUGE X 1" Tier 2 QL (1000 EA per 30 days)

MYGLUCOHEALTH LANCETS Tier 2

NEEDLES, HUBER DISPOSABLE NEEDLE Tier 2 QL (1000 EA per 30 days)

NOKOR NEEDLE 16 GAUGE X 1" Tier 2 QL (1000 EA per 30 days)

NOVA SAFETY LANCETS 28 GAUGE Tier 2

NOVA SUREFLEX LANCETS Tier 2

NOVOFINE 32 NEEDLE Tier 2 QL (1000 EA per 30 days)

NOVOFINE AUTOCOVER NEEDLE Tier 2 QL (1000 EA per 30 days)

NOVOFINE PLUS NEEDLE Tier 2 QL (1000 EA per 30 days)

NOVOPEN ECHO SUBCUTANEOUS INSULIN PEN Tier 3

ON CALL LANCET Tier 2

ON CALL PLUS LANCET Tier 2

ONETOUCH ULTRASOFT LANCETS Tier 2

ON-THE-GO LANCETS Tier 2

PEN NEEDLE 29 GAUGE X 1/2" Tier 2 QL (1000 EA per 30 days)

PEN NEEDLE, DIABETIC NEEDLE 29 GAUGE X 1/2" Tier 2 QL (1000 EA per 30 days)


86

Effective 1/2019

PENTIPS NEEDLE 31 GAUGE X 1/4", 31 GAUGE X 5/16"


PHASEAL PROTECTOR DEVICE 20 MM Tier 2 QL (1000 EA per 30 days)

POLY HUB NEEDLE 18 GAUGE X 1" Tier 2 QL (1000 EA per 30 days)

PRESSURE ACTIVATED LANCETS 21 GAUGE Tier 2

PRO COMFORT LANCET 30 GAUGE Tier 3

PRODIGY LANCETS 28 GAUGE Tier 2

PRODIGY TWIST TOP LANCET Tier 2

RELIAMED LANCET 28 GAUGE Tier 2

RELIAMED SAFETY SEAL LANCETS 28 GAUGE Tier 2

RELION NEEDLE Tier 2 QL (1000 EA per 30 days)

RELION PEN NEEDLE Tier 2 QL (1000 EA per 30 days)

RELION THIN LANCETS Tier 2

RELION ULTRA THIN PLUS LANCETS Tier 2

RIGHTEST GL300 LANCETS Tier 2

SAFETY LANCETS 21 GAUGE Tier 2

SAFETY SEAL LANCETS 28 GAUGE Tier 2

SAFETY-LET LANCETS Tier 2

SINGLE-LET Tier 2

SMART SENSE LANCETS 26 GAUGE, 33 GAUGE Tier 2

SMARTEST LANCET Tier 2

SOFT TOUCH LANCETS Tier 2

SOLUS V2 LANCETS 30 GAUGE Tier 2

STERILANCE TL 30 GAUGE Tier 2

SUPER THIN LANCETS 30 GAUGE Tier 2

SURE COMFORT LANCETS 28 GAUGE Tier 2

SURE COMFORT PEN NEEDLE 29 GAUGE X 1/2" Tier 2 QL (1000 EA per 30 days)

SURE-FINE PEN NEEDLE 29 GAUGE X 1/2" Tier 2 QL (1000 EA per 30 days)

SURE-LANCE 28 GAUGE Tier 2

SURE-TOUCH LANCET Tier 2

SURGUARD2 SAFETY NEEDLE 18 GAUGE X 1" Tier 2 QL (1000 EA per 30 days)

TECHLITE LANCETS 25 GAUGE Tier 2


87

Effective 1/2019

TECHLITE PEN NEEDLE 31 GAUGE X 5/16" Tier 2 QL (1000 EA per 30 days)

TOPCARE UNIVERSAL1 LANCET Tier 2

TRUEPLUS LANCETS 28 GAUGE Tier 2

ULTICARE PEN NEEDLE 29 GAUGE X 1/2" Tier 2 QL (1000 EA per 30 days)

ULTILET BASIC LANCETS Tier 2

ULTILET CLASSIC LANCETS Tier 2

ULTILET LANCETS 28 GAUGE Tier 2

ULTILET PEN NEEDLE 29 GAUGE Tier 2 QL (1000 EA per 30 days)

ULTILET SAFETY LANCETS Tier 2

ULTRA THIN LANCETS 28 GAUGE Tier 2

ULTRA THIN PLUS LANCETS Tier 2

ULTRA TLC LANCETS Tier 2

ULTRALANCE LANCETS 26 GAUGE Tier 2

ULTRA-THIN II INS PEN NEEDLE Tier 2 QL (1000 EA per 30 days)

UNIFINE PENTIPS NEEDLE 29 GAUGE X 1/2" Tier 2 QL (1000 EA per 30 days)

UNIFINE PENTIPS PLUS NEEDLE 31 GAUGE X 5/16"


UNILET COMFORTOUCH LANCET 26 GAUGE Tier 2

UNILET EXCELITE II LANCET Tier 2

UNILET EXCELITE LANCET Tier 2

UNILET GP LANCET Tier 2

UNILET LANCET 28 GAUGE Tier 2

UNISTIK 3 EXTRA LANCET Tier 2

UNISTIK CZT LANCET 23 GAUGE Tier 2

UNISTIK SAFETY 30 GAUGE Tier 2

UNISTIK TOUCH LANCETS 28 GAUGE Tier 2

UNIVERSAL 1 LANCETS 26 GAUGE Tier 2

VGO 20 DEVICE Tier 2



Insulin Therapy


88

Effective 1/2019

ADMELOG SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN

Tier 3 ST

ADMELOG U-100 INSULIN LISPRO SUBCUTANEOUS SOLUTION

Tier 3 ST

AFREZZA INHALATION CARTRIDGE WITH INHALER

Tier 3

APIDRA SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN

Tier 3 ST

APIDRA U-100 INSULIN SUBCUTANEOUS SOLUTION

Tier 3 ST

FIASP FLEXTOUCH U-100 INSULIN SUBCUTANEOUS INSULIN PEN

Tier 2

FIASP U-100 INSULIN SUBCUTANEOUS SOLUTION Tier 2

HUMALOG JUNIOR KWIKPEN U-100 SUBCUTANEOUS INSULIN PEN, HALF-UNIT

Tier 3 ST

HUMALOG KWIKPEN INSULIN SUBCUTANEOUS INSULIN PEN

Tier 3 ST

HUMALOG MIX 50-50 INSULN U-100 SUBCUTANEOUS SUSPENSION

Tier 3

HUMALOG MIX 50-50 KWIKPEN SUBCUTANEOUS INSULIN PEN

Tier 3

HUMALOG MIX 75-25 KWIKPEN SUBCUTANEOUS INSULIN PEN

Tier 3 ST

HUMALOG MIX 75-25(U-100)INSULN SUBCUTANEOUS SUSPENSION

Tier 3 ST

HUMALOG U-100 INSULIN SUBCUTANEOUS CARTRIDGE

Tier 3 ST

HUMALOG U-100 INSULIN SUBCUTANEOUS SOLUTION

Tier 3 ST

HUMULIN 70/30 U-100 INSULIN SUBCUTANEOUS SUSPENSION

Tier 3 ST

HUMULIN 70/30 U-100 KWIKPEN SUBCUTANEOUS INSULIN PEN

Tier 3 ST

HUMULIN N NPH INSULIN KWIKPEN SUBCUTANEOUS INSULIN PEN

Tier 3 ST

HUMULIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION

Tier 3 ST


89

Effective 1/2019

HUMULIN R REGULAR U-100 INSULN INJECTION SOLUTION

Tier 3 ST

HUMULIN R U-500 (CONC) INSULIN SUBCUTANEOUS SOLUTION

Tier 2

HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN

Tier 2

LANTUS SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN

Tier 2

LANTUS U-100 INSULIN SUBCUTANEOUS SOLUTION

Tier 2

LEVEMIR FLEXTOUCH U-100 INSULN SUBCUTANEOUS INSULIN PEN

Tier 2

LEVEMIR U-100 INSULIN SUBCUTANEOUS SOLUTION

Tier 2

NOVOLIN 70/30 U-100 INSULIN SUBCUTANEOUS SUSPENSION

Tier 2

NOVOLIN 70-30 FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN

Tier 2

NOVOLIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION

Tier 2

NOVOLIN R REGULAR U-100 INSULN INJECTION SOLUTION

Tier 2

NOVOLOG FLEXPEN U-100 INSULIN SUBCUTANEOUS INSULIN PEN

Tier 2

NOVOLOG MIX 70-30 U-100 INSULN SUBCUTANEOUS SOLUTION

Tier 2

NOVOLOG MIX 70-30FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN

Tier 2

NOVOLOG PENFILL U-100 INSULIN SUBCUTANEOUS CARTRIDGE

Tier 2

NOVOLOG U-100 INSULIN ASPART SUBCUTANEOUS SOLUTION

Tier 2

SOLIQUA 100/33 SUBCUTANEOUS INSULIN PEN Tier 2

TOUJEO MAX U-300 SOLOSTAR SUBCUTANEOUS INSULIN PEN

Tier 2

TOUJEO SOLOSTAR U-300 INSULIN SUBCUTANEOUS INSULIN PEN

Tier 2


90

Effective 1/2019

TRESIBA FLEXTOUCH U-100 SUBCUTANEOUS INSULIN PEN

Tier 2

TRESIBA FLEXTOUCH U-200 SUBCUTANEOUS INSULIN PEN

Tier 2

Miscellaneous Hormones ANADROL-50 ORAL TABLET Tier 3 PA

ANDRODERM TRANSDERMAL PATCH 24 HOUR Tier 3 PA

ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 20.25 MG/1.25 GRAM (1.62 %)

Tier 2 PA

ANDROGEL TRANSDERMAL GEL IN PACKET 1 % (25 MG/2.5GRAM), 1 % (50 MG/5 GRAM)

Tier 3 PA

ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM), 1.62 % (40.5 MG/2.5 GRAM)

Tier 2 PA

ANDROID ORAL CAPSULE Tier 3 PA

BRAVELLE INJECTION RECON SOLN Tier 3 #

cabergoline oral tablet Tier 1

calcitonin (salmon) nasal spray,non-aerosol Tier 1

calcitriol oral capsule Tier 1

calcitriol oral solution Tier 1

CERDELGA ORAL CAPSULE Tier 3 PA; SPRx

CETROTIDE SUBCUTANEOUS KIT 0.25 MG Tier 3 #

danazol oral capsule Tier 1

DDAVP NASAL SOLUTION Tier 3

DDAVP NASAL SPRAY WITH PUMP Tier 3

DDAVP ORAL TABLET Tier 3

DEPO-TESTOSTERONE INTRAMUSCULAR OIL Tier 3 PA

desmopressin nasal solution Tier 1

desmopressin nasal spray,non-aerosol Tier 1

desmopressin oral tablet Tier 1

doxercalciferol oral capsule Tier 1

FOLLISTIM AQ SUBCUTANEOUS CARTRIDGE Tier 3 #

GALAFOLD ORAL CAPSULE Tier 3 PA; SPRx


91

Effective 1/2019

GANIRELIX SUBCUTANEOUS SYRINGE Tier 3 #

GONAL-F RFF REDI-JECT SUBCUTANEOUS PEN INJECTOR

Tier 3 #

GONAL-F RFF SUBCUTANEOUS RECON SOLN Tier 3 #

GONAL-F SUBCUTANEOUS RECON SOLN Tier 3 #

HECTOROL ORAL CAPSULE Tier 3

JYNARQUE ORAL TABLETS, SEQUENTIAL Tier 3 LD; SPRx

KORLYM ORAL TABLET Tier 3 PA; LD; SPRx

KUVAN ORAL POWDER IN PACKET Tier 3 SPRx

KUVAN ORAL TABLET,SOLUBLE Tier 3 SPRx

MENOPUR SUBCUTANEOUS RECON SOLN Tier 3 #

METHITEST ORAL TABLET Tier 3 PA

methyltestosterone oral capsule Tier 1 PA

MIACALCIN INJECTION SOLUTION Tier 2

miglustat oral capsule Tier 1 SPRx

MYALEPT SUBCUTANEOUS RECON SOLN Tier 3 PA; LD; SPRx

NATPARA SUBCUTANEOUS CARTRIDGE Tier 3 PA; SPRx

ORILISSA ORAL TABLET Tier 3 PA

OVIDREL SUBCUTANEOUS SYRINGE Tier 3 #

OXANDRIN ORAL TABLET Tier 3 PA

oxandrolone oral tablet Tier 1 PA

PALYNZIQ SUBCUTANEOUS SYRINGE Tier 3 PA; LD; SPRx

paricalcitol oral capsule Tier 1

PREGNYL INTRAMUSCULAR RECON SOLN Tier 3 #

ROCALTROL ORAL CAPSULE Tier 3

ROCALTROL ORAL SOLUTION Tier 3

SAMSCA ORAL TABLET Tier 3 LD; SPRx

SENSIPAR ORAL TABLET Tier 3 SPRx

SOMAVERT SUBCUTANEOUS RECON SOLN 15 MG, 20 MG, 25 MG, 30 MG

Tier 3 LD; SPRx

STIMATE NASAL SPRAY,NON-AEROSOL Tier 3 SPRx

STRENSIQ SUBCUTANEOUS SOLUTION Tier 2 PA; LD; SPRx


92

Effective 1/2019

STRIANT BUCCAL MUCOADHESIVE SYSTEM ER 12 HR

Tier 3 PA

SYNAREL NASAL SPRAY,NON-AEROSOL Tier 3

testosterone cypionate intramuscular oil Tier 1 PA

testosterone enanthate intramuscular oil Tier 1 PA

testosterone transdermal gel Tier 1 PA

testosterone transdermal gel in metered-dose pump 12.5 mg/ 1.25 gram (1 %)

Tier 1 PA

testosterone transdermal gel in packet 1 % (25 mg/2.5gram), 1 % (50 mg/5 gram)

Tier 1 PA

TESTRED ORAL CAPSULE Tier 3 PA

ZAVESCA ORAL CAPSULE Tier 3 LD; SPRx

ZEMPLAR ORAL CAPSULE 1 MCG, 2 MCG Tier 3

Non-Insulin Hypoglycemic Agents acarbose oral tablet Tier 1

ACTOPLUS MET ORAL TABLET Tier 3

ACTOPLUS MET XR ORAL TABLET, ER MULTIPHASE 24 HR

Tier 3

ACTOS ORAL TABLET Tier 3

AMARYL ORAL TABLET Tier 3

AVANDIA ORAL TABLET 2 MG, 4 MG Tier 3

BYDUREON BCISE SUBCUTANEOUS AUTO-INJECTOR

Tier 2

BYDUREON SUBCUTANEOUS PEN INJECTOR Tier 2

BYDUREON SUBCUTANEOUS SUSPENSION,EXTENDED REL RECON

Tier 2

BYETTA SUBCUTANEOUS PEN INJECTOR Tier 2

chlorpropamide oral tablet Tier 1

CYCLOSET ORAL TABLET Tier 3

DUETACT ORAL TABLET Tier 3

FARXIGA ORAL TABLET Tier 2

glimepiride oral tablet Tier 1

glipizide oral tablet Tier 1


93

Effective 1/2019

glipizide oral tablet extended release 24hr Tier 1

glipizide-metformin oral tablet Tier 1

GLUCOPHAGE ORAL TABLET Tier 3

GLUCOPHAGE XR ORAL TABLET EXTENDED RELEASE 24 HR

Tier 3

GLUCOTROL ORAL TABLET Tier 3

GLUCOTROL XL ORAL TABLET EXTENDED RELEASE 24HR

Tier 3

GLUCOVANCE ORAL TABLET Tier 3

glyburide micronized oral tablet Tier 1

glyburide oral tablet Tier 1

glyburide-metformin oral tablet Tier 1

GLYNASE ORAL TABLET Tier 3

GLYSET ORAL TABLET Tier 3

GLYXAMBI ORAL TABLET Tier 2

INVOKAMET ORAL TABLET Tier 2

INVOKAMET XR ORAL TABLET, IR - ER, BIPHASIC 24HR

Tier 2

INVOKANA ORAL TABLET Tier 2

JANUMET ORAL TABLET Tier 2

JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR

Tier 2

JANUVIA ORAL TABLET Tier 2

JARDIANCE ORAL TABLET Tier 2

JENTADUETO ORAL TABLET Tier 2

JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR

Tier 2

metformin oral tablet Tier 1

metformin oral tablet extended release 24 hr Tier 1 Generic for Glucophage XR

miglitol oral tablet Tier 1

nateglinide oral tablet Tier 1

OZEMPIC SUBCUTANEOUS PEN INJECTOR Tier 2

pioglitazone oral tablet Tier 1


94

Effective 1/2019

pioglitazone-glimepiride oral tablet Tier 1

pioglitazone-metformin oral tablet Tier 1

PRANDIN ORAL TABLET 1 MG, 2 MG Tier 3

PRECOSE ORAL TABLET Tier 3

repaglinide oral tablet Tier 1

repaglinide-metformin oral tablet Tier 1

RIOMET ORAL SOLUTION Tier 3

STARLIX ORAL TABLET Tier 3

SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR Tier 3

SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR Tier 3

SYNJARDY ORAL TABLET Tier 2

SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR

Tier 2

tolazamide oral tablet Tier 1

tolbutamide oral tablet Tier 1

TRADJENTA ORAL TABLET Tier 2

TRULICITY SUBCUTANEOUS PEN INJECTOR Tier 2

XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR Tier 2

Thyroid Hormones ARMOUR THYROID ORAL TABLET Tier 3

CYTOMEL ORAL TABLET Tier 3

LEVO-T ORAL TABLET Tier 3

levothyroxine oral tablet Tier 1

levoxyl oral tablet Tier 1

liothyronine oral tablet Tier 1

nature-throid oral tablet Tier 1

np thyroid oral tablet Tier 1

SYNTHROID ORAL TABLET Tier 3

thyroid (pork) oral tablet Tier 1

THYROLAR-1 ORAL TABLET Tier 3

THYROLAR-1/2 ORAL TABLET Tier 3

THYROLAR-1/4 ORAL TABLET Tier 3


95

Effective 1/2019



unithroid oral tablet Tier 1

westhroid oral tablet Tier 1

WP THYROID ORAL TABLET Tier 3


Gastroenterology

Antidiarrheals & Antispasmodics BENTYL ORAL CAPSULE Tier 3

chlordiazepoxide-clidinium oral capsule Tier 1

CUVPOSA ORAL SOLUTION Tier 3

dicyclomine oral capsule Tier 1

dicyclomine oral solution Tier 1

dicyclomine oral tablet Tier 1

diphenoxylate-atropine oral liquid Tier 1

diphenoxylate-atropine oral tablet Tier 1

DONNATAL ORAL ELIXIR 16.2 MG-0.1037 MG/5 ML (5 ML), 16.2-0.1037 -0.0194 MG/5 ML

Tier 3

DONNATAL ORAL TABLET Tier 3

glycopyrrolate oral tablet 1 mg, 2 mg Tier 1

hyoscyamine sulfate oral drops Tier 1

hyoscyamine sulfate oral elixir Tier 1

hyoscyamine sulfate oral tablet Tier 1

hyoscyamine sulfate oral tablet extended release 12 hr

Tier 1

hyoscyamine sulfate oral tablet,disintegrating Tier 1

hyoscyamine sulfate sublingual tablet Tier 1

LEVBID ORAL TABLET EXTENDED RELEASE 12 HR Tier 3

LEVSIN ORAL TABLET Tier 3

LEVSIN/SL SUBLINGUAL TABLET Tier 3

LIBRAX (WITH CLIDINIUM) ORAL CAPSULE Tier 3

LOMOTIL ORAL TABLET Tier 3

methscopolamine oral tablet Tier 1

96

Effective 1/2019

MOTOFEN ORAL TABLET Tier 3

MYTESI ORAL TABLET,DELAYED RELEASE (DR/EC) Tier 3

NULEV ORAL TABLET,DISINTEGRATING Tier 3

paregoric oral liquid Tier 1

propantheline oral tablet Tier 1

ROBINUL FORTE ORAL TABLET Tier 3

ROBINUL ORAL TABLET Tier 3

Miscellaneous Gastrointestinal Agents ACTIGALL ORAL CAPSULE Tier 3

alosetron oral tablet Tier 1

AMITIZA ORAL CAPSULE Tier 2

anucort-hc rectal suppository Tier 1

ANUSOL-HC RECTAL SUPPOSITORY Tier 3

ANZEMET ORAL TABLET Tier 3

aprepitant oral capsule Tier 1

aprepitant oral capsule,dose pack Tier 1

APRISO ORAL CAPSULE,EXTENDED RELEASE 24HR Tier 2

AURYXIA ORAL TABLET Tier 3

AZULFIDINE EN-TABS ORAL TABLET,DELAYED RELEASE (DR/EC)

Tier 3

AZULFIDINE ORAL TABLET Tier 3

balsalazide oral capsule Tier 1

bisacodyl oral tablet,delayed release (dr/ec) Tier 1 ACA

budesonide oral capsule,delayed,extend.release Tier 1

budesonide oral tablet,delayed and ext.release Tier 1

calcium acetate oral capsule Tier 1

calcium acetate oral tablet 667 mg Tier 1

CANASA RECTAL SUPPOSITORY Tier 2

CESAMET ORAL CAPSULE Tier 3

CHENODAL ORAL TABLET Tier 3 LD

CHOLBAM ORAL CAPSULE Tier 3 PA; LD; SPRx


97

Effective 1/2019

CIMZIA STARTER KIT SUBCUTANEOUS SYRINGE KIT

Tier 3 PA; SPRx

CIMZIA SUBCUTANEOUS SYRINGE KIT Tier 3 PA; SPRx

citrate of magnesia oral solution Tier 1 ACA

clearlax oral powder in packet Tier 1 ACA

CLENPIQ ORAL SOLUTION Tier 2 ACA

COLAZAL ORAL CAPSULE Tier 3

colocort rectal enema Tier 1

COLYTE WITH FLAVOR PACKS ORAL RECON SOLN 240-22.72-6.72 -5.84 GRAM

Tier 3

COMPAZINE ORAL TABLET Tier 3

COMPAZINE RECTAL SUPPOSITORY Tier 3

compro rectal suppository Tier 1

constulose oral solution Tier 1

CORTENEMA RECTAL ENEMA Tier 3

CORTIFOAM RECTAL FOAM Tier 3

CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC) Tier 2

cromolyn oral concentrate Tier 1

CYSTADANE ORAL POWDER Tier 3 LD; SPRx

dronabinol oral capsule Tier 1

eliphos oral tablet Tier 1

EMEND ORAL CAPSULE Tier 3

EMEND ORAL CAPSULE,DOSE PACK Tier 3

ENTOCORT EC ORAL CAPSULE,DELAYED,EXTEND.RELEASE

Tier 3

enulose oral solution Tier 1

FOSRENOL ORAL POWDER IN PACKET Tier 3

FOSRENOL ORAL TABLET,CHEWABLE Tier 3

GASTROCROM ORAL CONCENTRATE Tier 3

GATTEX 30-VIAL SUBCUTANEOUS KIT Tier 3 PA; LD; SPRx

GATTEX ONE-VIAL SUBCUTANEOUS KIT Tier 3 PA; SPRx

gavilyte-c oral recon soln Tier 1 ACA


98

Effective 1/2019

gavilyte-g oral recon soln Tier 1 ACA

gavilyte-n oral recon soln Tier 1 ACA

generlac oral solution Tier 1

GIAZO ORAL TABLET Tier 3

GOLYTELY ORAL POWDER IN PACKET Tier 3 ACA

GOLYTELY ORAL RECON SOLN Tier 3

granisetron hcl oral tablet Tier 1

hemmorex-hc rectal suppository Tier 1

hydrocortisone acetate rectal suppository Tier 1

hydrocortisone rectal enema Tier 1

hydrocortisone topical cream with perineal applicator

Tier 1

hydrocortisone-pramoxine rectal cream Tier 1

kionex (with sorbitol) oral suspension Tier 1

kionex oral powder Tier 1

KRISTALOSE ORAL PACKET Tier 2

lactulose oral solution Tier 1

lanthanum oral tablet,chewable Tier 1

laxaclear oral powder Tier 1 ACA

laxative peg 3350 oral powder Tier 1 ACA

lidocaine hcl-hydrocortison ac rectal cream 3-0.5 %

Tier 1

lidocaine hcl-hydrocortison ac rectal kit Tier 1

lidocaine-hydrocortisone-aloe rectal gel Tier 1

lidocaine-hydrocortisone-aloe rectal kit Tier 1

LINZESS ORAL CAPSULE Tier 2

LOTRONEX ORAL TABLET Tier 3

MARINOL ORAL CAPSULE Tier 3

mesalamine oral tablet,delayed release (dr/ec) Tier 1

mesalamine rectal enema Tier 1

mesalamine with cleansing wipe rectal enema kit Tier 1

metoclopramide hcl oral solution Tier 1


99

Effective 1/2019

metoclopramide hcl oral tablet Tier 1

MOVANTIK ORAL TABLET Tier 2

NULYTELY WITH FLAVOR PACKS ORAL RECON SOLN

Tier 3

OCALIVA ORAL TABLET Tier 3 PA; SPRx

ondansetron hcl oral solution Tier 1

ondansetron hcl oral tablet Tier 1

ondansetron oral tablet,disintegrating Tier 1

OSMOPREP ORAL TABLET Tier 3 ACA

peg 3350-electrolytes oral recon soln Tier 1 ACA

peg-3350 with flavor packs oral recon soln Tier 1 ACA

peg-electrolyte soln oral recon soln Tier 1 ACA

peg-prep oral kit Tier 1 ACA

PENTASA ORAL CAPSULE, EXTENDED RELEASE Tier 2

PHOSLYRA ORAL SOLUTION Tier 2

phosphate laxative oral liquid Tier 1 ACA

polyethylene glycol 3350 oral powder Tier 1 ACA

polyethylene glycol 3350 oral powder in packet Tier 1 ACA

pramcort rectal cream Tier 1

prochlorperazine maleate oral tablet Tier 1

prochlorperazine rectal suppository Tier 1

PROCTOCORT RECTAL SUPPOSITORY Tier 3

procto-med hc topical cream with perineal applicator

Tier 1

procto-pak topical cream with perineal applicator Tier 1

proctosol hc topical cream with perineal applicator

Tier 1

proctozone-hc topical cream with perineal applicator

Tier 1

REGLAN ORAL TABLET Tier 3

RELISTOR SUBCUTANEOUS SOLUTION Tier 3

RELISTOR SUBCUTANEOUS SYRINGE Tier 3

RENAGEL ORAL TABLET Tier 3


100

Effective 1/2019

RENVELA ORAL POWDER IN PACKET Tier 3

RENVELA ORAL TABLET Tier 3

ROWASA RECTAL ENEMA KIT Tier 3

scopolamine base transdermal patch 3 day Tier 1

sevelamer carbonate oral powder in packet Tier 1

sevelamer carbonate oral tablet Tier 1

sodium polystyrene sulfonate oral powder Tier 1

sodium polystyrene sulfonate oral suspension Tier 1

sodium polystyrene sulfonate rectal enema 30 gram/120 ml

Tier 1

SODIUM POLYSTYRENE SULFONATE RECTAL ENEMA 50 GRAM/200 ML

Tier 3

SOLESTA IMPLANT GEL FOR IMPLANT IN SYRINGE Tier 3

sps (with sorbitol) oral suspension Tier 1

sps (with sorbitol) rectal enema Tier 1

SUCRAID ORAL SOLUTION Tier 3

sulfasalazine oral tablet Tier 1

sulfasalazine oral tablet,delayed release (dr/ec) Tier 1

SUPREP BOWEL PREP KIT ORAL RECON SOLN Tier 2 ACA

SYNDROS ORAL SOLUTION Tier 3

TIGAN ORAL CAPSULE 300 MG Tier 3

TRANSDERM-SCOP TRANSDERMAL PATCH 3 DAY Tier 3

trilyte with flavor packets oral recon soln Tier 1 ACA

trimethobenzamide oral capsule Tier 1

UCERIS ORAL TABLET,DELAYED AND EXT.RELEASE Tier 3

URSO 250 ORAL TABLET Tier 3

URSO FORTE ORAL TABLET Tier 3

ursodiol oral capsule Tier 1

ursodiol oral tablet Tier 1

VELPHORO ORAL TABLET,CHEWABLE Tier 2

VIBERZI ORAL TABLET Tier 3

VIOKACE ORAL TABLET Tier 3


101

Effective 1/2019

ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC)

Tier 2

ZOFRAN ODT ORAL TABLET,DISINTEGRATING Tier 3

ZOFRAN ORAL SOLUTION Tier 3

ZOFRAN ORAL TABLET Tier 3

Ulcer Therapy amoxicil-clarithromy-lansopraz oral combo pack Tier 1

CARAFATE ORAL SUSPENSION Tier 3

CARAFATE ORAL TABLET Tier 3

cimetidine hcl oral solution Tier 1

cimetidine oral tablet 300 mg, 400 mg, 800 mg Tier 1

CYTOTEC ORAL TABLET Tier 3

DEXILANT ORAL CAPSULE,BIPHASE DELAYED RELEAS

Tier 3

esomeprazole magnesium oral capsule,delayed release(dr/ec)

Tier 1

famotidine oral suspension Tier 1

famotidine oral tablet 40 mg Tier 1

lansoprazole oral capsule,delayed release(dr/ec) 30 mg

Tier 1

lansoprazole oral tablet,disintegrat, delay rel Tier 1

misoprostol oral tablet Tier 1

NEXIUM ORAL CAPSULE,DELAYED RELEASE(DR/EC)

Tier 3

NEXIUM PACKET ORAL GRANULES DR FOR SUSP IN PACKET

Tier 3

nizatidine oral capsule Tier 1

nizatidine oral solution Tier 1

OMECLAMOX-PAK ORAL COMBO PACK Tier 2

omeprazole oral capsule,delayed release(dr/ec) Tier 1

pantoprazole oral tablet,delayed release (dr/ec) Tier 1

PEPCID ORAL SUSPENSION Tier 3

PEPCID ORAL TABLET 40 MG Tier 3


102

Effective 1/2019

PREVACID SOLUTAB ORAL TABLET,DISINTEGRAT, DELAY REL

Tier 3

PREVPAC ORAL COMBO PACK Tier 3

PRILOSEC ORAL SUSP,DELAYED RELEASE FOR RECON

Tier 3

PROTONIX ORAL GRANULES DR FOR SUSP IN PACKET

Tier 3

PROTONIX ORAL TABLET,DELAYED RELEASE (DR/EC) 20 MG

Tier 3

PYLERA ORAL CAPSULE Tier 2

rabeprazole oral tablet,delayed release (dr/ec) Tier 1

ranitidine hcl oral capsule Tier 1

ranitidine hcl oral syrup Tier 1

ranitidine hcl oral tablet 300 mg Tier 1

sucralfate oral suspension Tier 1

sucralfate oral tablet Tier 1

ZANTAC ORAL TABLET 300 MG Tier 3


Immunology, Vaccines & Biotechnology

Biotechnology Drugs ARANESP (IN POLYSORBATE) INJECTION SOLUTION

Tier 3 PA; SPRx

ARANESP (IN POLYSORBATE) INJECTION SYRINGE Tier 3 PA; SPRx

EPOGEN INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML

Tier 3 PA; SPRx

FULPHILA SUBCUTANEOUS SYRINGE Tier 3 PA; SPRx

MIRCERA INJECTION SYRINGE Tier 3 PA; LD; SPRx

MOZOBIL SUBCUTANEOUS SOLUTION Tier 3 LD; SPRx

NEULASTA SUBCUTANEOUS SYRINGE Tier 3 PA; SPRx

NEULASTA SUBCUTANEOUS SYRINGE, W/ WEARABLE INJECTOR

Tier 3 PA; SPRx

NEUPOGEN INJECTION SOLUTION Tier 3 SPRx

NEUPOGEN INJECTION SYRINGE Tier 3 SPRx

NIVESTYM SUBCUTANEOUS SYRINGE Tier 3 SPRx

103

Effective 1/2019

PROCRIT INJECTION SOLUTION Tier 3 PA; SPRx

ZARXIO INJECTION SYRINGE Tier 3 SPRx

Growth Hormones NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR

Tier 3 PA; SPRx

Interferons AUBAGIO ORAL TABLET Tier 3 PA; LD; SPRx

AVONEX (WITH ALBUMIN) INTRAMUSCULAR KIT Tier 2 SPRx

AVONEX INTRAMUSCULAR PEN INJECTOR KIT Tier 2 SPRx

AVONEX INTRAMUSCULAR SYRINGE KIT Tier 2 SPRx

BETASERON SUBCUTANEOUS KIT Tier 3 SPRx

BETASERON SUBCUTANEOUS RECON SOLN Tier 3 SPRx

COPAXONE SUBCUTANEOUS SYRINGE Tier 2 SPRx

COPEGUS ORAL TABLET Tier 3 PA; SPRx

EXTAVIA SUBCUTANEOUS KIT Tier 3 SPRx

EXTAVIA SUBCUTANEOUS RECON SOLN Tier 3 SPRx

GILENYA ORAL CAPSULE 0.5 MG Tier 2 SPRx

glatiramer subcutaneous syringe Tier 1 SPRx

glatopa subcutaneous syringe Tier 1 SPRx

moderiba dose pack oral tablets,dose pack Tier 1 PA; SPRx

moderiba oral tablet Tier 1 PA; SPRx

PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR

Tier 2 SPRx

PEGASYS SUBCUTANEOUS SOLUTION Tier 2 SPRx

PEGASYS SUBCUTANEOUS SYRINGE Tier 2 SPRx

PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5 ML Tier 3 SPRx

PLEGRIDY SUBCUTANEOUS PEN INJECTOR Tier 2 SPRx

PLEGRIDY SUBCUTANEOUS SYRINGE Tier 2 SPRx

POMALYST ORAL CAPSULE Tier 3 PA; LD; SPRx

REBETOL ORAL SOLUTION Tier 3 PA; SPRx

REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE

Tier 2 SPRx


104

Effective 1/2019

REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR Tier 2 SPRx

REBIF TITRATION PACK SUBCUTANEOUS SYRINGE

Tier 2 SPRx

REVLIMID ORAL CAPSULE Tier 3 PA; LD; SPRx

ribasphere oral capsule Tier 1 PA; SPRx

ribasphere oral tablet Tier 1 PA; SPRx

ribavirin oral capsule Tier 1 PA; SPRx

ribavirin oral tablet 200 mg Tier 1 PA; SPRx

SYLATRON SUBCUTANEOUS KIT Tier 3 LD; SPRx

TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC)

Tier 2 LD; SPRx

ZINBRYTA SUBCUTANEOUS SYRINGE Tier 3 PA; SPRx

Interleukins ACTIMMUNE SUBCUTANEOUS SOLUTION Tier 3 SPRx

ALDARA TOPICAL CREAM IN PACKET Tier 3

ARCALYST SUBCUTANEOUS RECON SOLN Tier 3 PA; SPRx

ILARIS (PF) SUBCUTANEOUS SOLUTION Tier 3 PA; SPRx

imiquimod topical cream in packet Tier 1

INTRON A INJECTION RECON SOLN Tier 3 LD; SPRx

INTRON A INJECTION SOLUTION Tier 3 LD; SPRx

KINERET SUBCUTANEOUS SYRINGE Tier 3 PA; LD; SPRx

Vaccines & Miscellaneous Immunologicals ACTHIB (PF) INTRAMUSCULAR RECON SOLN Tier 3 ACA

ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION

Tier 3 ACA

ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE

Tier 3 ACA

AFLURIA 2018-2019 (PF) INTRAMUSCULAR SYRINGE

Tier 2 ACA

AFLURIA 2018-2019 INTRAMUSCULAR SUSPENSION

Tier 2 ACA

AFLURIA QUAD 2018-2019 (PF) INTRAMUSCULAR SYRINGE

Tier 2 ACA


105

Effective 1/2019

AFLURIA QUAD 2018-2019 INTRAMUSCULAR SUSPENSION

Tier 2 ACA

BCG VACCINE, LIVE (PF) PERCUTANEOUS SUSPENSION FOR RECONSTITUTION

Tier 3 ACA

BEXSERO INTRAMUSCULAR SYRINGE Tier 3 ACA

BIOTHRAX INTRAMUSCULAR SUSPENSION Tier 3 ACA

BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION Tier 3 ACA

BOOSTRIX TDAP INTRAMUSCULAR SYRINGE Tier 3 ACA

CUVITRU SUBCUTANEOUS SOLUTION Tier 3 PA; SPRx

DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION

Tier 3 ACA

ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION Tier 3 ACA

ENGERIX-B (PF) INTRAMUSCULAR SYRINGE Tier 3 ACA

ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE

Tier 3 ACA

FLUAD 2018-2019 (65 YR UP)(PF) INTRAMUSCULAR SYRINGE

Tier 2 ACA

FLUARIX QUAD 2018-2019 (PF) INTRAMUSCULAR SYRINGE

Tier 2 ACA

FLUBLOK QUAD 2018-2019 (PF) INTRAMUSCULAR SYRINGE

Tier 2 ACA

FLUCELVAX QUAD 2018-2019 (PF) INTRAMUSCULAR SYRINGE

Tier 2 ACA

FLUCELVAX QUAD 2018-2019 INTRAMUSCULAR SUSPENSION

Tier 2 ACA

FLULAVAL QUAD 2018-2019 (PF) INTRAMUSCULAR SYRINGE

Tier 2 ACA

FLULAVAL QUAD 2018-2019 INTRAMUSCULAR SUSPENSION

Tier 2 ACA

FLUMIST QUAD 2018-2019 NASAL NASAL SPRAY SYRINGE

Tier 2 ACA

FLUZONE HIGH-DOSE 2018-19 (PF) INTRAMUSCULAR SYRINGE

Tier 2 ACA

FLUZONE QUAD 2018-2019 (PF) INTRAMUSCULAR SUSPENSION

Tier 2 ACA


106

Effective 1/2019

FLUZONE QUAD 2018-2019 (PF) INTRAMUSCULAR SYRINGE

Tier 2 ACA

FLUZONE QUAD 2018-2019 INTRAMUSCULAR SUSPENSION

Tier 2 ACA

FLUZONE QUAD PEDI 2018-19 (PF) INTRAMUSCULAR SYRINGE

Tier 2 ACA

GAMMAGARD LIQUID INJECTION SOLUTION Tier 3 PA; LD; SPRx

GAMUNEX-C INJECTION SOLUTION Tier 3 PA; LD; SPRx

GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION Tier 3 ACA

GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE Tier 3 ACA

GRASTEK SUBLINGUAL TABLET Tier 2 PA

HAVRIX (PF) INTRAMUSCULAR SUSPENSION Tier 3 ACA

HAVRIX (PF) INTRAMUSCULAR SYRINGE Tier 3 ACA

HEPLISAV-B (PF) INTRAMUSCULAR SOLUTION Tier 3 ACA

HEPLISAV-B (PF) INTRAMUSCULAR SYRINGE Tier 3 ACA

HIBERIX (PF) INTRAMUSCULAR RECON SOLN Tier 3 ACA

HIZENTRA SUBCUTANEOUS SOLUTION Tier 3 PA; LD; SPRx

HYQVIA SUBCUTANEOUS SOLUTION Tier 3 PA; LD; SPRx

IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN

Tier 3 ACA

INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION

Tier 3 ACA

INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE Tier 3 ACA

IPOL INJECTION SUSPENSION Tier 3 ACA

IXIARO (PF) INTRAMUSCULAR SYRINGE Tier 3 ACA

KINRIX (PF) INTRAMUSCULAR SUSPENSION Tier 3 ACA

KINRIX (PF) INTRAMUSCULAR SYRINGE Tier 3 ACA

MENACTRA (PF) INTRAMUSCULAR SOLUTION Tier 3 ACA

MENHIBRIX (PF) INTRAMUSCULAR RECON SOLN Tier 3 ACA

MENOMUNE - A/C/Y/W-135 (PF) SUBCUTANEOUS RECON SOLN

Tier 3 ACA

MENOMUNE - A/C/Y/W-135 SUBCUTANEOUS RECON SOLN

Tier 3 ACA


107

Effective 1/2019

MENVEO A-C-Y-W-135-DIP (PF) INTRAMUSCULAR KIT

Tier 3 ACA

M-M-R II (PF) SUBCUTANEOUS RECON SOLN Tier 3 ACA

ODACTRA SUBLINGUAL TABLET Tier 3 PA

ORALAIR SUBLINGUAL TABLET 300 INDX REACTIVITY

Tier 3 PA; LD; SPRx

PEDIARIX (PF) INTRAMUSCULAR SYRINGE Tier 3 ACA

PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION Tier 3 ACA

PENTACEL (PF) INTRAMUSCULAR KIT Tier 3 ACA

PENTACEL ACTHIB COMPONENT (PF) INTRAMUSCULAR RECON SOLN

Tier 3 ACA

PNEUMOVAX 23 INJECTION SOLUTION Tier 3 ACA

PNEUMOVAX 23 INJECTION SYRINGE Tier 3 ACA

PREVNAR 13 (PF) INTRAMUSCULAR SYRINGE Tier 3 ACA

PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

Tier 3 ACA

QUADRACEL (PF) INTRAMUSCULAR SUSPENSION Tier 3 ACA

RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION

Tier 3 ACA

RAGWITEK SUBLINGUAL TABLET Tier 3 PA

RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION

Tier 3 ACA

RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE Tier 3 ACA

ROTARIX ORAL SUSPENSION FOR RECONSTITUTION

Tier 3 ACA

ROTATEQ VACCINE ORAL SOLUTION Tier 3 ACA

SHINGRIX (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION

Tier 3 ACA

SHINGRIX GE ANTIGEN COMPONENT INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION

Tier 3 ACA

STAMARIL (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

Tier 3 ACA

TENIVAC (PF) INTRAMUSCULAR SUSPENSION Tier 3 ACA

TENIVAC (PF) INTRAMUSCULAR SYRINGE Tier 3 ACA


108

Effective 1/2019

TETANUS,DIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION

Tier 3 ACA

TETANUS-DIPHTHERIA TOXOIDS-TD INTRAMUSCULAR SUSPENSION

Tier 3 ACA

TICE BCG INTRAVESICAL SUSPENSION FOR RECONSTITUTION

Tier 3 ACA

TRUMENBA INTRAMUSCULAR SYRINGE Tier 3 ACA

TWINRIX (PF) INTRAMUSCULAR SYRINGE Tier 3 ACA

TYPHIM VI INTRAMUSCULAR SOLUTION Tier 3 ACA

TYPHIM VI INTRAMUSCULAR SYRINGE Tier 3 ACA

VAQTA (PF) INTRAMUSCULAR SUSPENSION Tier 3 ACA

VAQTA (PF) INTRAMUSCULAR SYRINGE Tier 3 ACA

VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

Tier 3 ACA

VAXCHORA VACCINE ORAL SUSPENSION FOR RECONSTITUTION

Tier 3 ACA

VIVOTIF BERNA VACCINE ORAL CAPSULE,DELAYED RELEASE(DR/EC)

Tier 3 ACA

VIVOTIF ORAL CAPSULE,DELAYED RELEASE(DR/EC)

Tier 3 ACA

YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

Tier 3 ACA

ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

Tier 3 ACA


Musculoskeletal & Rheumatology

Gout Therapy allopurinol oral tablet Tier 1

COLCRYS ORAL TABLET Tier 2

probenecid oral tablet Tier 1

probenecid-colchicine oral tablet Tier 1

ULORIC ORAL TABLET Tier 2

ZYLOPRIM ORAL TABLET Tier 3

Osteoporosis Therapy ACTONEL ORAL TABLET 150 MG, 35 MG, 5 MG Tier 3

109

Effective 1/2019

alendronate oral solution Tier 1

alendronate oral tablet 10 mg, 35 mg, 5 mg, 70 mg

Tier 1

ATELVIA ORAL TABLET,DELAYED RELEASE (DR/EC)

Tier 3

BINOSTO ORAL TABLET, EFFERVESCENT Tier 3

BONIVA ORAL TABLET Tier 3

EVISTA ORAL TABLET Tier 3

FORTEO SUBCUTANEOUS PEN INJECTOR Tier 3 SPRx

FOSAMAX ORAL TABLET 70 MG Tier 3

FOSAMAX PLUS D ORAL TABLET Tier 3

ibandronate oral tablet Tier 1

raloxifene oral tablet Tier 1 ACA

risedronate oral tablet 150 mg, 35 mg, 5 mg Tier 1

risedronate oral tablet,delayed release (dr/ec) Tier 1

TYMLOS SUBCUTANEOUS PEN INJECTOR Tier 3

Other Rheumatologicals ACTEMRA SUBCUTANEOUS SYRINGE Tier 2 PA; SPRx

ARAVA ORAL TABLET Tier 3

BENLYSTA SUBCUTANEOUS AUTO-INJECTOR Tier 3 PA; SPRx

BENLYSTA SUBCUTANEOUS SYRINGE Tier 3 PA; SPRx

DEPEN TITRATABS ORAL TABLET Tier 3

ENBREL MINI SUBCUTANEOUS CARTRIDGE Tier 2 PA; SPRx

ENBREL SUBCUTANEOUS RECON SOLN Tier 2 PA; SPRx

ENBREL SUBCUTANEOUS SYRINGE Tier 2 PA; SPRx

ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR

Tier 2 PA; SPRx

HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT

Tier 2 PA; SPRx; QL (2 EA per 30 days)

HUMIRA PEN CROHN'S-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT


HUMIRA PEN PSORIASIS-UVEITIS SUBCUTANEOUS PEN INJECTOR KIT



110

Effective 1/2019

HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT Tier 2 PA; SPRx; QL (2 EA per 30 days)

HUMIRA SUBCUTANEOUS SYRINGE KIT Tier 2 PA; SPRx; QL (2 EA per 30 days)

KEVZARA SUBCUTANEOUS PEN INJECTOR Tier 3 PA; SPRx

KEVZARA SUBCUTANEOUS SYRINGE Tier 3 PA; SPRx

leflunomide oral tablet Tier 1

ORENCIA CLICKJECT SUBCUTANEOUS AUTO-INJECTOR

Tier 3 PA; SPRx; QL (4 ML per 30 days)

ORENCIA SUBCUTANEOUS SYRINGE Tier 3 PA; SPRx; QL (4 ML per 30 days)

OTEZLA ORAL TABLET Tier 2 PA; LD; SPRx

OTEZLA STARTER ORAL TABLETS,DOSE PACK Tier 2 PA; LD; SPRx

RIDAURA ORAL CAPSULE Tier 3

SAVELLA ORAL TABLET Tier 2

SAVELLA ORAL TABLETS,DOSE PACK Tier 2

SIMPONI SUBCUTANEOUS PEN INJECTOR Tier 3 PA; SPRx

SIMPONI SUBCUTANEOUS SYRINGE Tier 3 PA; SPRx

XELJANZ ORAL TABLET Tier 2 PA; SPRx

XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR

Tier 2 PA; SPRx


Obstetrics & Gynecology

Estrogens & Progestins ACTIVELLA ORAL TABLET Tier 3

ALORA TRANSDERMAL PATCH SEMIWEEKLY Tier 3

amabelz oral tablet Tier 1

ANGELIQ ORAL TABLET Tier 3

AYGESTIN ORAL TABLET Tier 3

camila oral tablet Tier 1 ACA

CLIMARA PRO TRANSDERMAL PATCH WEEKLY Tier 3

CLIMARA TRANSDERMAL PATCH WEEKLY Tier 3

COMBIPATCH TRANSDERMAL PATCH SEMIWEEKLY

Tier 2

covaryx h.s. oral tablet Tier 1

covaryx oral tablet Tier 1

111

Effective 1/2019

CRINONE VAGINAL GEL 4 % Tier 3

deblitane oral tablet Tier 1 ACA

DELESTROGEN INTRAMUSCULAR OIL Tier 3

DEPO-ESTRADIOL INTRAMUSCULAR OIL Tier 3

DEPO-PROVERA INTRAMUSCULAR SUSPENSION Tier 3

DEPO-PROVERA INTRAMUSCULAR SYRINGE Tier 3

DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SYRINGE

Tier 3 ACA

DIVIGEL TRANSDERMAL GEL IN PACKET Tier 2

DUAVEE ORAL TABLET Tier 3

eemt hs oral tablet Tier 1

eemt oral tablet Tier 1

ELESTRIN TRANSDERMAL GEL IN METERED-DOSE PUMP

Tier 3

errin oral tablet Tier 1 ACA

ESTRACE ORAL TABLET Tier 3

ESTRACE VAGINAL CREAM Tier 2

estradiol oral tablet Tier 1

estradiol transdermal patch semiweekly Tier 1

estradiol transdermal patch weekly Tier 1

estradiol vaginal cream Tier 1

estradiol vaginal tablet Tier 1

estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml

Tier 1

estradiol-norethindrone acet oral tablet Tier 1

ESTRING VAGINAL RING Tier 3

ESTROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP

Tier 3

estrogens-methyltestosterone oral tablet Tier 1

estropipate oral tablet Tier 1

EVAMIST TRANSDERMAL SPRAY,NON-AEROSOL Tier 2

FEMHRT LOW DOSE ORAL TABLET Tier 3

FEMRING VAGINAL RING Tier 3


112

Effective 1/2019

fyavolv oral tablet Tier 1 ACA

heather oral tablet Tier 1 ACA

incassia oral tablet Tier 1 ACA

jencycla oral tablet Tier 1 ACA

jevantique lo oral tablet Tier 1 ACA

jinteli oral tablet Tier 1 ACA

jolivette oral tablet Tier 1 ACA

lopreeza oral tablet Tier 1

lyza oral tablet Tier 1 ACA

medroxyprogesterone intramuscular suspension Tier 1 ACA

medroxyprogesterone intramuscular syringe Tier 1 ACA

medroxyprogesterone oral tablet Tier 1

MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG

Tier 3

MENOSTAR TRANSDERMAL PATCH WEEKLY Tier 3

mimvey lo oral tablet Tier 1

mimvey oral tablet Tier 1

MINIVELLE TRANSDERMAL PATCH SEMIWEEKLY Tier 2

nora-be oral tablet Tier 1 ACA

norethindrone (contraceptive) oral tablet Tier 1 ACA

norethindrone acetate oral tablet Tier 1

norethindrone ac-eth estradiol oral tablet 0.5-2.5 mg-mcg, 1-5 mg-mcg

Tier 1 ACA

norlyda oral tablet Tier 1 ACA

norlyroc oral tablet Tier 1 ACA

ORTHO MICRONOR ORAL TABLET Tier 3

PREFEST ORAL TABLET Tier 3

PREMARIN ORAL TABLET Tier 2

PREMARIN VAGINAL CREAM Tier 3

PREMPHASE ORAL TABLET Tier 2

PREMPRO ORAL TABLET Tier 2

progesterone micronized oral capsule Tier 1


113

Effective 1/2019

PROMETRIUM ORAL CAPSULE Tier 3

PROVERA ORAL TABLET Tier 3

sharobel oral tablet Tier 1 ACA

VAGIFEM VAGINAL TABLET Tier 3

VIVELLE-DOT TRANSDERMAL PATCH SEMIWEEKLY

Tier 3

yuvafem vaginal tablet Tier 1

Miscellaneous Ob/Gyn AVC VAGINAL VAGINAL CREAM Tier 3

CLEOCIN VAGINAL CREAM Tier 3

CLEOCIN VAGINAL SUPPOSITORY Tier 2

clindamycin phosphate vaginal cream Tier 1

CLINDESSE VAGINAL CREAM,EXTENDED RELEASE Tier 3

fem ph vaginal gel Tier 1

GYNAZOLE-1 VAGINAL CREAM Tier 3

INTRAROSA VAGINAL INSERT Tier 2

LUPANETA PACK (1 MONTH) KIT. SYRINGE AND TABLET

Tier 3 PA; SPRx

LUPANETA PACK (3 MONTH) KIT. SYRINGE AND TABLET

Tier 3 PA; SPRx

LYSTEDA ORAL TABLET Tier 3

METROGEL VAGINAL VAGINAL GEL Tier 3

metronidazole vaginal gel Tier 1

miconazole-3 vaginal suppository Tier 1

NUVARING VAGINAL RING Tier 2 ACA

NUVESSA VAGINAL GEL Tier 3

OSPHENA ORAL TABLET Tier 2

RELAGARD VAGINAL GEL Tier 3

TERAZOL 7 VAGINAL CREAM Tier 3

terconazole vaginal cream Tier 1

terconazole vaginal suppository Tier 1

tranexamic acid oral tablet Tier 1


114

Effective 1/2019

vandazole vaginal gel Tier 1

xulane transdermal patch weekly Tier 1 ACA

Oral Contraceptives & Related Agents altavera (28) oral tablet Tier 1 ACA

alyacen 1/35 (28) oral tablet Tier 1 ACA

alyacen 7/7/7 (28) oral tablet Tier 1 ACA

amethia lo oral tablets,dose pack,3 month Tier 1 ACA

amethia oral tablets,dose pack,3 month Tier 1 ACA

amethyst oral tablet Tier 1 ACA

apri oral tablet Tier 1 ACA

aranelle (28) oral tablet Tier 1 ACA

ashlyna oral tablets,dose pack,3 month Tier 1 ACA

aubra eq oral tablet Tier 1 ACA

aubra oral tablet Tier 1 ACA

aviane oral tablet Tier 1 ACA

azurette (28) oral tablet Tier 1 ACA

BALCOLTRA ORAL TABLET Tier 3 ACA

balziva (28) oral tablet Tier 1 ACA

bekyree (28) oral tablet Tier 1 ACA

BEYAZ ORAL TABLET Tier 3

blisovi 24 fe oral tablet Tier 1 ACA

blisovi fe 1.5/30 (28) oral tablet Tier 1 ACA

blisovi fe 1/20 (28) oral tablet Tier 1 ACA

BREVICON (28) ORAL TABLET Tier 3

briellyn oral tablet Tier 1 ACA

camrese lo oral tablets,dose pack,3 month Tier 1 ACA

camrese oral tablets,dose pack,3 month Tier 1 ACA

caziant (28) oral tablet Tier 1 ACA

chateal eq oral tablet Tier 1 ACA

chateal oral tablet Tier 1 ACA

cryselle (28) oral tablet Tier 1 ACA


115

Effective 1/2019

cyclafem 1/35 (28) oral tablet Tier 1 ACA

cyclafem 7/7/7 (28) oral tablet Tier 1 ACA

CYCLESSA (28) ORAL TABLET Tier 3

cyred eq oral tablet Tier 1 ACA

cyred oral tablet Tier 1 ACA

dasetta 1/35 (28) oral tablet Tier 1 ACA

dasetta 7/7/7 (28) oral tablet Tier 1 ACA

daysee oral tablets,dose pack,3 month Tier 1 ACA

delyla (28) oral tablet Tier 1 ACA

desog-e.estradiol/e.estradiol oral tablet Tier 1 ACA

desogestrel-ethinyl estradiol oral tablet Tier 1 ACA

drospirenone-e.estradiol-lm.fa oral tablet Tier 1 ACA

drospirenone-ethinyl estradiol oral tablet Tier 1 ACA

econtra ez oral tablet Tier 1 ACA; QL (2 EA per 365 days)

econtra one-step oral tablet Tier 1 ACA; QL (2 EA per 365 days)

elinest oral tablet Tier 1 ACA

ELLA ORAL TABLET Tier 3 ACA; QL (2 EA per 365 days)

emoquette oral tablet Tier 1 ACA

enpresse oral tablet Tier 1 ACA

enskyce oral tablet Tier 1 ACA

estarylla oral tablet Tier 1 ACA

ESTROSTEP FE-28 ORAL TABLET Tier 3

ethynodiol diac-eth estradiol oral tablet Tier 1 ACA

falmina (28) oral tablet Tier 1 ACA

fayosim oral tablets,dose pack,3 month Tier 1 ACA

femynor oral tablet Tier 1 ACA

GENERESS FE ORAL TABLET,CHEWABLE Tier 3

gianvi (28) oral tablet Tier 1 ACA

gildagia oral tablet Tier 1 ACA

introvale oral tablets,dose pack,3 month Tier 1 ACA

isibloom oral tablet Tier 1 ACA


116

Effective 1/2019

jolessa oral tablets,dose pack,3 month Tier 1 ACA

juleber oral tablet Tier 1 ACA

junel 1.5/30 (21) oral tablet Tier 1 ACA

junel 1/20 (21) oral tablet Tier 1 ACA

junel fe 1.5/30 (28) oral tablet Tier 1 ACA

junel fe 1/20 (28) oral tablet Tier 1 ACA

junel fe 24 oral tablet Tier 1 ACA

kaitlib fe oral tablet,chewable Tier 1 ACA

kariva (28) oral tablet Tier 1 ACA

kelnor 1/35 (28) oral tablet Tier 1 ACA

kelnor 1-50 oral tablet Tier 1 ACA

kimidess (28) oral tablet Tier 1 ACA

kurvelo oral tablet Tier 1 ACA

l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month

Tier 1 ACA

larin 1.5/30 (21) oral tablet Tier 1 ACA

larin 1/20 (21) oral tablet Tier 1 ACA

larin 24 fe oral tablet Tier 1 ACA

larin fe 1.5/30 (28) oral tablet Tier 1 ACA

larin fe 1/20 (28) oral tablet Tier 1 ACA

larissia oral tablet Tier 1 ACA

layolis fe oral tablet,chewable Tier 1 ACA

leena 28 oral tablet Tier 1 ACA

lessina oral tablet Tier 1 ACA

levonest (28) oral tablet Tier 1 ACA

levonorgestrel oral tablet 1.5 mg Tier 1 ACA; QL (2 EA per 365 days)

levonorgestrel-ethinyl estrad oral tablet Tier 1 ACA

levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month

Tier 1 ACA

levonorg-eth estrad triphasic oral tablet Tier 1 ACA

levora 0.15/30 (28) oral tablet Tier 1 ACA

levora-28 oral tablet Tier 1 ACA


117

Effective 1/2019

lillow oral tablet Tier 1 ACA

LO LOESTRIN FE ORAL TABLET Tier 2 ACA

LOESTRIN 1.5/30 (21) ORAL TABLET Tier 3

LOESTRIN 1/20 (21) ORAL TABLET Tier 3

LOESTRIN FE 1.5/30 (28-DAY) ORAL TABLET Tier 3

LOESTRIN FE 1/20 (28-DAY) ORAL TABLET Tier 3

lomedia 24 fe oral tablet Tier 1 ACA

loryna (28) oral tablet Tier 1 ACA

LOSEASONIQUE ORAL TABLETS,DOSE PACK,3 MONTH

Tier 3

low-ogestrel (28) oral tablet Tier 1 ACA

lutera (28) oral tablet Tier 1 ACA

marlissa oral tablet Tier 1 ACA

melodetta 24 fe oral tablet,chewable Tier 1 ACA

mibelas 24 fe oral tablet,chewable Tier 1 ACA

microgestin 1.5/30 (21) oral tablet Tier 1 ACA

microgestin 1/20 (21) oral tablet Tier 1 ACA

MICROGESTIN 24 FE ORAL TABLET Tier 3

microgestin fe 1.5/30 (28) oral tablet Tier 1 ACA

microgestin fe 1/20 (28) oral tablet Tier 1 ACA

mili oral tablet Tier 1 ACA

MINASTRIN 24 FE ORAL TABLET,CHEWABLE Tier 3

MIRCETTE (28) ORAL TABLET Tier 3

mono-linyah oral tablet Tier 1 ACA

mononessa (28) oral tablet Tier 1 ACA

my choice oral tablet Tier 1 ACA; QL (2 EA per 365 days)

my way oral tablet Tier 1 ACA; QL (2 EA per 365 days)

myzilra oral tablet Tier 1 ACA

NATAZIA ORAL TABLET Tier 3 ACA

necon 0.5/35 (28) oral tablet Tier 1 ACA

necon 1/50 (28) oral tablet Tier 1 ACA

necon 7/7/7 (28) oral tablet Tier 1 ACA


118

Effective 1/2019

new day oral tablet Tier 1 ACA; QL (2 EA per 365 days)

next choice one dose oral tablet Tier 1 ACA; QL (2 EA per 365 days)

nikki (28) oral tablet Tier 1 ACA

noreth-ethinyl estradiol-iron oral tablet,chewable Tier 1 ACA

norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg

Tier 1 ACA

norethindrone-e.estradiol-iron oral tablet Tier 1 ACA

norethindrone-e.estradiol-iron oral tablet,chewable

Tier 1 ACA

norgestimate-ethinyl estradiol oral tablet Tier 1 ACA

norgestrel-ethinyl estradiol oral tablet Tier 1 ACA

nortrel 0.5/35 (28) oral tablet Tier 1 ACA

nortrel 1/35 (21) oral tablet Tier 1 ACA

nortrel 1/35 (28) oral tablet Tier 1 ACA

nortrel 7/7/7 (28) oral tablet Tier 1 ACA

ocella oral tablet Tier 1 ACA

ogestrel (28) oral tablet Tier 1 ACA

opcicon one-step oral tablet Tier 1 ACA; QL (2 EA per 365 days)

option-2 oral tablet Tier 1 ACA; QL (2 EA per 365 days)

orsythia oral tablet Tier 1 ACA

ORTHO TRI-CYCLEN (28) ORAL TABLET Tier 3

ORTHO TRI-CYCLEN LO (28) ORAL TABLET Tier 3

ORTHO-CYCLEN (28) ORAL TABLET Tier 3

ORTHO-NOVUM 1/35 (28) ORAL TABLET Tier 3

ORTHO-NOVUM 7/7/7 (28) ORAL TABLET Tier 3

philith oral tablet Tier 1 ACA

pimtrea (28) oral tablet Tier 1 ACA

pirmella oral tablet Tier 1 ACA

portia oral tablet Tier 1 ACA

previfem oral tablet Tier 1 ACA

QUARTETTE ORAL TABLETS,DOSE PACK,3 MONTH

Tier 3


119

Effective 1/2019

quasense oral tablets,dose pack,3 month Tier 1 ACA

rajani oral tablet Tier 1 ACA

reclipsen (28) oral tablet Tier 1 ACA

rivelsa oral tablets,dose pack,3 month Tier 1 ACA

SAFYRAL ORAL TABLET Tier 3

SEASONIQUE ORAL TABLETS,DOSE PACK,3 MONTH

Tier 3

setlakin oral tablets,dose pack,3 month Tier 1 ACA

sprintec (28) oral tablet Tier 1 ACA

sronyx oral tablet Tier 1 ACA

syeda oral tablet Tier 1 ACA

tarina fe 1/20 (28) oral tablet Tier 1 ACA

tilia fe oral tablet Tier 1 ACA

tri femynor oral tablet Tier 1 ACA

tri-estarylla oral tablet Tier 1 ACA

tri-legest fe oral tablet Tier 1 ACA

tri-linyah oral tablet Tier 1 ACA

tri-lo-estarylla oral tablet Tier 1 ACA

tri-lo-marzia oral tablet Tier 1 ACA

tri-lo-sprintec oral tablet Tier 1 ACA

tri-mili oral tablet Tier 1 ACA

trinessa (28) oral tablet Tier 1 ACA

trinessa lo oral tablet Tier 1 ACA

TRI-NORINYL (28) ORAL TABLET Tier 3

tri-previfem (28) oral tablet Tier 1 ACA

tri-sprintec (28) oral tablet Tier 1 ACA

trivora (28) oral tablet Tier 1 ACA

tri-vylibra oral tablet Tier 1 ACA

tulana oral tablet Tier 1 ACA

tydemy oral tablet Tier 1 ACA

velivet triphasic regimen (28) oral tablet Tier 1 ACA

vestura (28) oral tablet Tier 1 ACA


120

Effective 1/2019

vienva oral tablet Tier 1 ACA

viorele (28) oral tablet Tier 1 ACA

vyfemla (28) oral tablet Tier 1 ACA

vylibra oral tablet Tier 1 ACA

wera (28) oral tablet Tier 1 ACA

wymzya fe oral tablet,chewable Tier 1 ACA

YASMIN (28) ORAL TABLET Tier 3

YAZ (28) ORAL TABLET Tier 3

zarah oral tablet Tier 1 ACA

zenchent (28) oral tablet Tier 1 ACA

zovia 1/35e (28) oral tablet Tier 1 ACA

zovia 1/50e (28) oral tablet Tier 1 ACA


Ophthalmology

Antibiotics AZASITE OPHTHALMIC (EYE) DROPS Tier 3

bacitracin ophthalmic (eye) ointment Tier 1

bacitracin-polymyxin b ophthalmic (eye) ointment Tier 1

BESIVANCE OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 2

BETADINE OPHTHALMIC PREP OPHTHALMIC (EYE) SOLUTION

Tier 3

CILOXAN OPHTHALMIC (EYE) OINTMENT Tier 3

ciprofloxacin hcl ophthalmic (eye) drops Tier 1

erythromycin ophthalmic (eye) ointment Tier 1

gatifloxacin ophthalmic (eye) drops Tier 1

gentak ophthalmic (eye) ointment Tier 1

gentamicin ophthalmic (eye) drops Tier 1

gentamicin ophthalmic (eye) ointment Tier 1

levofloxacin ophthalmic (eye) drops Tier 1

MOXEZA OPHTHALMIC (EYE) DROPS, VISCOUS Tier 3

moxifloxacin ophthalmic (eye) drops Tier 1

121

Effective 1/2019

NATACYN OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 3

neomycin-bacitracin-polymyxin ophthalmic (eye) ointment

Tier 1

neomycin-polymyxin-gramicidin ophthalmic (eye) drops

Tier 1

neo-polycin ophthalmic (eye) ointment Tier 1

OCUFLOX OPHTHALMIC (EYE) DROPS Tier 3

ofloxacin ophthalmic (eye) drops Tier 1

polycin ophthalmic (eye) ointment Tier 1

polymyxin b sulf-trimethoprim ophthalmic (eye) drops

Tier 1

POLYTRIM OPHTHALMIC (EYE) DROPS Tier 3

tobramycin ophthalmic (eye) drops Tier 1

TOBREX OPHTHALMIC (EYE) OINTMENT Tier 3

VIGAMOX OPHTHALMIC (EYE) DROPS Tier 3

Antivirals trifluridine ophthalmic (eye) drops Tier 1

VIROPTIC OPHTHALMIC (EYE) DROPS Tier 3

ZIRGAN OPHTHALMIC (EYE) GEL Tier 3

Beta-Blockers BETAGAN OPHTHALMIC (EYE) DROPS 0.5 % Tier 3

betaxolol ophthalmic (eye) drops Tier 1

carteolol ophthalmic (eye) drops Tier 1

levobunolol ophthalmic (eye) drops 0.5 % Tier 1

metipranolol ophthalmic (eye) drops Tier 1

timolol maleate ophthalmic (eye) drops 0.25 % Tier 1

timolol maleate ophthalmic (eye) drops 0.5 % Tier 1 Generic for Timoptic

timolol maleate ophthalmic (eye) gel forming solution

Tier 1

TIMOPTIC OCUDOSE (PF) OPHTHALMIC (EYE) DROPPERETTE

Tier 3

TIMOPTIC OPHTHALMIC (EYE) DROPS 0.25 % Tier 3


122

Effective 1/2019

TIMOPTIC-XE OPHTHALMIC (EYE) GEL FORMING SOLUTION

Tier 3

Cholinesterase Inhibitor Miotics PHOSPHOLINE IODIDE OPHTHALMIC (EYE) DROPS

Tier 3

Cycloplegic Mydriatics atropine ophthalmic (eye) drops Tier 1

atropine ophthalmic (eye) ointment Tier 1

CYCLOGYL OPHTHALMIC (EYE) DROPS Tier 3

cyclopentolate ophthalmic (eye) drops Tier 1

homatropaire ophthalmic (eye) drops Tier 1

homatropine hbr ophthalmic (eye) drops Tier 1

MYDRIACYL OPHTHALMIC (EYE) DROPS Tier 3

PAREMYD OPHTHALMIC (EYE) DROPS Tier 3

tropicamide ophthalmic (eye) drops Tier 1

Direct Acting Miotics ISOPTO CARPINE OPHTHALMIC (EYE) DROPS Tier 3

MIOCHOL-E INTRAOCULAR KIT Tier 3

pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %, 4 %

Tier 1

Miscellaneous Ophthalmologics AKTEN (PF) OPHTHALMIC (EYE) GEL Tier 3

azelastine ophthalmic (eye) drops Tier 1

cromolyn ophthalmic (eye) drops Tier 1

CYSTARAN OPHTHALMIC (EYE) DROPS Tier 3 LD; SPRx

epinastine ophthalmic (eye) drops Tier 1

flucaine ophthalmic (eye) drops Tier 1

fluorescein-proparacaine ophthalmic (eye) drops Tier 1

LACRISERT OPHTHALMIC (EYE) INSERT Tier 3

olopatadine ophthalmic (eye) drops Tier 1

PATADAY OPHTHALMIC (EYE) DROPS Tier 3

PATANOL OPHTHALMIC (EYE) DROPS Tier 3


123

Effective 1/2019

PAZEO OPHTHALMIC (EYE) DROPS Tier 2

proparacaine ophthalmic (eye) drops Tier 1

tetracaine hcl (pf) ophthalmic (eye) drops Tier 1

tetracaine hcl ophthalmic (eye) drops Tier 1

TETRAVISC FORTE OPHTHALMIC (EYE) DROPPERETTE,HYPERVISCOUS

Tier 3

TETRAVISC OPHTHALMIC (EYE) DROPS, VISCOUS Tier 3

XIIDRA OPHTHALMIC (EYE) DROPPERETTE Tier 2

Non-Steroidal Anti-Inflammatory Agents bromfenac ophthalmic (eye) drops Tier 1

diclofenac sodium ophthalmic (eye) drops Tier 1

flurbiprofen sodium ophthalmic (eye) drops Tier 1

ketorolac ophthalmic (eye) drops Tier 1

PROLENSA OPHTHALMIC (EYE) DROPS Tier 2

Oral Drugs For Glaucoma acetazolamide oral capsule, extended release Tier 1

acetazolamide oral tablet Tier 1

DIAMOX SEQUELS ORAL CAPSULE, EXTENDED RELEASE

Tier 3

methazolamide oral tablet Tier 1

NEPTAZANE ORAL TABLET Tier 3

Other Glaucoma Drugs bimatoprost ophthalmic (eye) drops Tier 1

COMBIGAN OPHTHALMIC (EYE) DROPS Tier 2

COSOPT OPHTHALMIC (EYE) DROPS Tier 3

dorzolamide ophthalmic (eye) drops Tier 1

dorzolamide-timolol ophthalmic (eye) drops Tier 1

latanoprost ophthalmic (eye) drops Tier 1

LUMIGAN OPHTHALMIC (EYE) DROPS 0.01 % Tier 2

miostat intraocular solution Tier 1

MITOSOL OPHTHALMIC (EYE) KIT Tier 3

RHOPRESSA OPHTHALMIC (EYE) DROPS Tier 2


124

Effective 1/2019

TRAVATAN Z OPHTHALMIC (EYE) DROPS Tier 2

TRUSOPT OPHTHALMIC (EYE) DROPS Tier 3

XALATAN OPHTHALMIC (EYE) DROPS Tier 3 ST

ZIOPTAN (PF) OPHTHALMIC (EYE) DROPPERETTE Tier 3 ST

Steroid-Antibiotic Combinations MAXITROL OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 3

MAXITROL OPHTHALMIC (EYE) OINTMENT Tier 3

neomycin-bacitracin-poly-hc ophthalmic (eye) ointment

Tier 1

neomycin-polymyxin b-dexameth ophthalmic (eye) drops,suspension

Tier 1

neomycin-polymyxin b-dexameth ophthalmic (eye) ointment

Tier 1

neomycin-polymyxin-hc ophthalmic (eye) drops,suspension

Tier 1

neo-polycin hc ophthalmic (eye) ointment Tier 1

PRED-G OPHTHALMIC (EYE) DROPS,SUSPENSION Tier 3

PRED-G S.O.P. OPHTHALMIC (EYE) OINTMENT Tier 3

tobramycin-dexamethasone ophthalmic (eye) drops,suspension

Tier 1

Steroids dexamethasone sodium phosphate ophthalmic (eye) drops

Tier 1

DUREZOL OPHTHALMIC (EYE) DROPS Tier 2

FLAREX OPHTHALMIC (EYE) DROPS,SUSPENSION Tier 3

fluorometholone ophthalmic (eye) drops,suspension

Tier 1

FML FORTE OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 3

FML LIQUIFILM OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 3

FML S.O.P. OPHTHALMIC (EYE) OINTMENT Tier 3

LOTEMAX OPHTHALMIC (EYE) DROPS,GEL Tier 2


125

Effective 1/2019

LOTEMAX OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 2

LOTEMAX OPHTHALMIC (EYE) OINTMENT Tier 2

MAXIDEX OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 3

OMNIPRED OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 3

PRED FORTE OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 3

PRED MILD OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 3

prednisolone acetate ophthalmic (eye) drops,suspension

Tier 1

prednisolone sodium phosphate ophthalmic (eye) drops

Tier 1

Steroid-Sulfonamide Combinations BLEPHAMIDE OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 3

BLEPHAMIDE S.O.P. OPHTHALMIC (EYE) OINTMENT

Tier 3

sulfacetamide-prednisolone ophthalmic (eye) drops

Tier 1

Sulfonamides BLEPH-10 OPHTHALMIC (EYE) DROPS Tier 3

sulfacetamide sodium ophthalmic (eye) drops Tier 1

sulfacetamide sodium ophthalmic (eye) ointment Tier 1

Sympathomimetics ALPHAGAN P OPHTHALMIC (EYE) DROPS 0.1 % Tier 2

ALPHAGAN P OPHTHALMIC (EYE) DROPS 0.15 % Tier 3

apraclonidine ophthalmic (eye) drops Tier 1

brimonidine ophthalmic (eye) drops Tier 1

IOPIDINE OPHTHALMIC (EYE) DROPPERETTE Tier 3

IOPIDINE OPHTHALMIC (EYE) DROPS Tier 3

Vasoconstrictor Decongestants


126

Effective 1/2019

CYCLOMYDRIL OPHTHALMIC (EYE) DROPS Tier 3

phenylephrine hcl ophthalmic (eye) drops Tier 1


Respiratory, Allergy, Cough & Cold

Antihistamine & Antiallergenic Agents adrenalin injection solution Tier 1

carbinoxamine maleate oral liquid Tier 1

carbinoxamine maleate oral tablet 4 mg Tier 1

CLARINEX ORAL SYRUP Tier 3

CLARINEX ORAL TABLET Tier 3

clemastine oral tablet 2.68 mg Tier 1

cyproheptadine oral syrup Tier 1

cyproheptadine oral tablet Tier 1

desloratadine oral tablet Tier 1

desloratadine oral tablet,disintegrating Tier 1

diphenhydramine hcl injection solution 50 mg/ml Tier 1

diphenhydramine hcl injection syringe Tier 1

EPINEPHRINE INJECTION AUTO-INJECTOR Tier 1 QL (4 EA per 30 days)

epinephrine injection solution Tier 1

epinephrine injection syringe 0.1 mg/ml Tier 1

EPIPEN 2-PAK INJECTION AUTO-INJECTOR Tier 2 QL (4 EA per 30 days)

EPIPEN INJECTION AUTO-INJECTOR Tier 2 QL (4 EA per 30 days)

EPIPEN JR 2-PAK INJECTION AUTO-INJECTOR Tier 2 QL (4 EA per 30 days)

EPIPEN JR INJECTION AUTO-INJECTOR Tier 2 QL (4 EA per 30 days)

hydroxyzine hcl oral solution 10 mg/5 ml Tier 1

hydroxyzine hcl oral tablet Tier 1

hydroxyzine pamoate oral capsule Tier 1

phenadoz rectal suppository Tier 1

phenergan rectal suppository Tier 1

promethazine oral syrup Tier 1

promethazine oral tablet Tier 1

promethazine rectal suppository Tier 1

127

Effective 1/2019

promethegan rectal suppository Tier 1

VISTARIL ORAL CAPSULE Tier 3

Cough & Cold Therapy benzonatate oral capsule Tier 1

BROMFED DM ORAL SYRUP Tier 3

brompheniramine-pseudoeph-dm oral syrup Tier 1

CAPCOF ORAL LIQUID Tier 3

cheratussin ac oral liquid Tier 1

CLARINEX-D 12 HOUR ORAL TABLET, ER MULTIPHASE 12 HR

Tier 3

codeine-guaifenesin oral liquid Tier 1

guaiatussin ac oral liquid Tier 1

guaifenesin ac oral liquid Tier 1

guaifenesin dac oral syrup Tier 1

hydrocodone-chlorpheniramine oral suspension,extended rel 12 hr

Tier 1

hydrocodone-cpm-pseudoephed oral solution Tier 1

hydrocodone-homatropine oral syrup 5-1.5 mg/5 ml

Tier 1

hydrocodone-homatropine oral tablet Tier 1

hydromet oral syrup Tier 1

lortuss ex oral syrup Tier 1

MAR-COF BP ORAL LIQUID Tier 3

MAR-COF CG ORAL LIQUID Tier 3

m-clear wc oral liquid Tier 1

M-END PE ORAL LIQUID Tier 3

promethazine vc oral syrup Tier 1

promethazine vc-codeine oral syrup Tier 1

promethazine-codeine oral syrup Tier 1

promethazine-dm oral syrup Tier 1

promethazine-phenyleph-codeine oral syrup Tier 1


128

Effective 1/2019

PRO-RED AC (W/ DEXCHLORPHENIR) ORAL LIQUID

Tier 3

relcof c oral liquid Tier 1

RESPA-AR ORAL TABLET EXTENDED RELEASE 12 HR

Tier 3

robafen ac oral liquid Tier 1

rydex oral liquid Tier 1

SEMPREX-D ORAL CAPSULE Tier 3

TESSALON PERLES ORAL CAPSULE Tier 3

tusnel c oral syrup Tier 1

TUSSICAPS ORAL CAPSULE,EXTENDED RELEASE 12 HR

Tier 3

tussigon oral tablet Tier 1

TUSSIONEX PENNKINETIC ER ORAL SUSPENSION,EXTENDED REL 12 HR

Tier 3

virtussin ac oral liquid Tier 1

ZODRYL AC 25 ORAL SUSPENSION Tier 3







ZODRYL DAC 25 ORAL SUSPENSION Tier 3







ZODRYL DEC 25 ORAL SUSPENSION Tier 3




129

Effective 1/2019





ZONATUSS ORAL CAPSULE Tier 3

Z-TUSS AC ORAL LIQUID Tier 3

ZUTRIPRO ORAL SOLUTION Tier 3

Pulmonary Agents ACCOLATE ORAL TABLET Tier 3

acetylcysteine solution Tier 1

ADCIRCA ORAL TABLET Tier 2 PA; SPRx

ADEMPAS ORAL TABLET Tier 3 PA; SPRx

ADVAIR DISKUS INHALATION BLISTER WITH DEVICE

Tier 2

ADVAIR HFA INHALATION HFA AEROSOL INHALER

Tier 2

AEROSPAN INHALATION HFA AEROSOL INHALER Tier 3

albuterol sulfate inhalation solution for nebulization

Tier 1

albuterol sulfate oral syrup Tier 1

albuterol sulfate oral tablet Tier 1

albuterol sulfate oral tablet extended release 12 hr

Tier 1

ANORO ELLIPTA INHALATION BLISTER WITH DEVICE

Tier 2

ARCAPTA NEOHALER INHALATION CAPSULE, W/INHALATION DEVICE

Tier 2

ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE

Tier 2

ASMANEX HFA INHALATION HFA AEROSOL INHALER

Tier 2

ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED

Tier 2


130

Effective 1/2019

ATROVENT HFA INHALATION HFA AEROSOL INHALER

Tier 3

BERINERT INTRAVENOUS KIT Tier 3 PA; LD; SPRx

BEVESPI AEROSPHERE INHALATION HFA AEROSOL INHALER

Tier 2

BREO ELLIPTA INHALATION BLISTER WITH DEVICE Tier 2

BROVANA INHALATION SOLUTION FOR NEBULIZATION

Tier 2

budesonide inhalation suspension for nebulization Tier 1

budesonide nasal spray,non-aerosol Tier 1

CINRYZE INTRAVENOUS RECON SOLN Tier 3 PA; LD; SPRx

COMBIVENT RESPIMAT INHALATION MIST Tier 2

cromolyn inhalation solution for nebulization Tier 1

DALIRESP ORAL TABLET Tier 2

DULERA INHALATION HFA AEROSOL INHALER Tier 2

ELIXOPHYLLIN ORAL ELIXIR 80 MG/15 ML Tier 3

ESBRIET ORAL CAPSULE Tier 3 PA; LD; SPRx

ESBRIET ORAL TABLET Tier 3 PA; SPRx

FIRAZYR SUBCUTANEOUS SYRINGE Tier 3 PA; LD; SPRx

FLOVENT DISKUS INHALATION BLISTER WITH DEVICE

Tier 2

FLOVENT HFA INHALATION HFA AEROSOL INHALER

Tier 2

flunisolide nasal spray,non-aerosol 25 mcg (0.025 %)

Tier 1

fluticasone nasal spray,suspension Tier 1

HAEGARDA SUBCUTANEOUS RECON SOLN Tier 3 PA; SPRx

ipratropium bromide inhalation solution Tier 1

ipratropium-albuterol inhalation solution for nebulization

Tier 1

KALYDECO ORAL GRANULES IN PACKET Tier 3 PA; LD; SPRx

KALYDECO ORAL TABLET Tier 3 PA; LD; SPRx

levalbuterol hcl inhalation solution for nebulization

Tier 1


131

Effective 1/2019

LONHALA MAGNAIR REFILL INHALATION SOLUTION FOR NEBULIZATION

Tier 2

LONHALA MAGNAIR STARTER INHALATION SOLUTION FOR NEBULIZATION

Tier 2

metaproterenol oral syrup Tier 1

metaproterenol oral tablet Tier 1

mometasone nasal spray,non-aerosol Tier 1

montelukast oral granules in packet Tier 1

montelukast oral tablet Tier 1

montelukast oral tablet,chewable Tier 1

OFEV ORAL CAPSULE Tier 3 PA; LD; SPRx

OPSUMIT ORAL TABLET Tier 3 PA; LD; SPRx

ORKAMBI ORAL GRANULES IN PACKET Tier 3 PA; SPRx

ORKAMBI ORAL TABLET Tier 3 PA; SPRx

PERFOROMIST INHALATION SOLUTION FOR NEBULIZATION

Tier 2

PROAIR HFA INHALATION HFA AEROSOL INHALER


PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED


PROVENTIL HFA INHALATION HFA AEROSOL INHALER

Tier 3 ST; QL (2 EA per 30 days)

PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED

Tier 3

PULMICORT INHALATION SUSPENSION FOR NEBULIZATION

Tier 3

pulmosal inhalation solution for nebulization Tier 1

PULMOZYME INHALATION SOLUTION Tier 3 SPRx

QVAR INHALATION AEROSOL Tier 2

QVAR REDIHALER INHALATION HFA AEROSOL BREATH ACTIVATED

Tier 2

REVATIO INTRAVENOUS SOLUTION Tier 3 PA; SPRx

REVATIO ORAL SUSPENSION FOR RECONSTITUTION

Tier 3 PA; SPRx


132

Effective 1/2019

REVATIO ORAL TABLET Tier 3 PA; SPRx

RUCONEST INTRAVENOUS RECON SOLN Tier 3 PA; SPRx

SEREVENT DISKUS INHALATION BLISTER WITH DEVICE

Tier 2

sildenafil (antihypertensive) intravenous solution Tier 1 PA; SPRx

sildenafil (antihypertensive) oral tablet Tier 1 PA; SPRx

SINGULAIR ORAL GRANULES IN PACKET Tier 3

SINGULAIR ORAL TABLET Tier 3

SINGULAIR ORAL TABLET,CHEWABLE Tier 3

sodium chloride inhalation solution for nebulization

Tier 1

SPIRIVA RESPIMAT INHALATION MIST Tier 2

SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE

Tier 2

STIOLTO RESPIMAT INHALATION MIST Tier 2

STRIVERDI RESPIMAT INHALATION MIST Tier 2

SYMBICORT INHALATION HFA AEROSOL INHALER Tier 2

SYMDEKO ORAL TABLETS, SEQUENTIAL Tier 3 PA; SPRx

tadalafil (antihypertensive) oral tablet Tier 1 PA; SPRx

TAKHZYRO SUBCUTANEOUS SOLUTION Tier 3 PA; SPRx

terbutaline oral tablet Tier 1

terbutaline subcutaneous solution Tier 1

THEO-24 ORAL CAPSULE,EXTENDED RELEASE 24HR

Tier 3

theochron oral tablet extended release 12 hr Tier 1

theophylline oral elixir Tier 1

theophylline oral solution Tier 1

theophylline oral tablet extended release 12 hr Tier 1

theophylline oral tablet extended release 24 hr Tier 1

TRACLEER ORAL TABLET Tier 3 PA; LD; SPRx

TRACLEER ORAL TABLET FOR SUSPENSION Tier 3 PA; LD; SPRx

TRELEGY ELLIPTA INHALATION BLISTER WITH DEVICE

Tier 2


133

Effective 1/2019

TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED

Tier 2

TYVASO INHALATION SOLUTION FOR NEBULIZATION

Tier 3 PA; LD; SPRx

TYVASO INSTITUTIONAL START KIT INHALATION SOLUTION FOR NEBULIZATION

Tier 3 PA; LD; SPRx

TYVASO REFILL KIT INHALATION SOLUTION FOR NEBULIZATION

Tier 3 PA; LD; SPRx

TYVASO STARTER KIT INHALATION SOLUTION FOR NEBULIZATION

Tier 3 PA; LD; SPRx

UTIBRON NEOHALER INHALATION CAPSULE, W/INHALATION DEVICE

Tier 3

VENTAVIS INHALATION SOLUTION FOR NEBULIZATION

Tier 3 PA; LD; SPRx

VENTOLIN HFA INHALATION HFA AEROSOL INHALER


XOPENEX CONCENTRATE INHALATION SOLUTION FOR NEBULIZATION

Tier 3

XOPENEX HFA INHALATION HFA AEROSOL INHALER


XOPENEX INHALATION SOLUTION FOR NEBULIZATION

Tier 3

zafirlukast oral tablet Tier 1


Urologicals

Anticholinergics & Antispasmodics darifenacin oral tablet extended release 24 hr Tier 1

DITROPAN XL ORAL TABLET EXTENDED RELEASE 24HR

Tier 3

flavoxate oral tablet Tier 1

GELNIQUE TRANSDERMAL GEL IN METERED-DOSE PUMP 100 MG/GRAM (10 %)

Tier 2

GELNIQUE TRANSDERMAL GEL IN PACKET Tier 2

MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR

Tier 2

oxybutynin chloride oral syrup Tier 1

134

Effective 1/2019

oxybutynin chloride oral tablet Tier 1

oxybutynin chloride oral tablet extended release 24hr

Tier 1

OXYTROL TRANSDERMAL PATCH SEMIWEEKLY Tier 3

tolterodine oral capsule,extended release 24hr Tier 1

tolterodine oral tablet Tier 1

trospium oral capsule,extended release 24hr Tier 1

trospium oral tablet Tier 1

VESICARE ORAL TABLET Tier 2

Benign Prostatic Hyperplasia (Bph) Therapy alfuzosin oral tablet extended release 24 hr Tier 1

AVODART ORAL CAPSULE Tier 3

CIALIS ORAL TABLET 2.5 MG Tier 3 PA; #

CIALIS ORAL TABLET 5 MG Tier 3 PA; #; QL (15 EA per 60 days)

dutasteride oral capsule Tier 1

dutasteride-tamsulosin oral capsule, er multiphase 24 hr

Tier 1

finasteride oral tablet 5 mg Tier 1

FLOMAX ORAL CAPSULE Tier 3

JALYN ORAL CAPSULE, ER MULTIPHASE 24 HR Tier 3

PROSCAR ORAL TABLET Tier 3

RAPAFLO ORAL CAPSULE Tier 3

tadalafil oral tablet 2.5 mg Tier 1 PA; #

tadalafil oral tablet 5 mg Tier 1 PA; #; QL (15 EA per 60 days)

tamsulosin oral capsule Tier 1

UROXATRAL ORAL TABLET EXTENDED RELEASE 24 HR

Tier 3

Cholinergic Stimulants bethanechol chloride oral tablet Tier 1

URECHOLINE ORAL TABLET Tier 3

Miscellaneous Urologicals alprostadil injection solution Tier 1


135

Effective 1/2019

CAVERJECT IMPULSE INTRACAVERNOSAL KIT Tier 3 #; QL (8 EA per 30 days)

CAVERJECT INTRACAVERNOSAL RECON SOLN Tier 3 #; QL (8 EA per 30 days)

CIALIS ORAL TABLET 10 MG, 20 MG Tier 3 #; QL (8 EA per 30 days)

CYSTAGON ORAL CAPSULE Tier 3 SPRx

EDEX INTRACAVERNOSAL KIT Tier 3 #; QL (8 EA per 30 days)

ELMIRON ORAL CAPSULE Tier 3

K-PHOS NO 2 ORAL TABLET Tier 3

K-PHOS ORIGINAL ORAL TABLET,SOLUBLE Tier 3

LEVITRA ORAL TABLET Tier 3 #; QL (8 EA per 30 days)

methen-sod phos-meth blue-hyos oral tablet Tier 1

MUSE URETHRAL SUPPOSITORY Tier 3 #; QL (8 EA per 30 days)

potassium citrate oral tablet extended release Tier 1

potassium citrate-citric acid oral packet Tier 1

PROCYSBI ORAL CAPSULE, DELAYED REL SPRINKLE

Tier 3 PA; LD; SPRx

PROSTIN VR PEDIATRIC INJECTION SOLUTION Tier 3

sildenafil oral tablet Tier 1 #; QL (8 EA per 30 days)

STAXYN ORAL TABLET,DISINTEGRATING Tier 3 #; QL (8 EA per 30 days)

STENDRA ORAL TABLET Tier 3 #; QL (8 EA per 30 days)

tadalafil oral tablet 10 mg, 20 mg Tier 1 #; QL (8 EA per 30 days)

uro-458 oral tablet Tier 1

UROCIT-K 10 ORAL TABLET EXTENDED RELEASE Tier 3



VIAGRA ORAL TABLET Tier 3 #; QL (8 EA per 30 days)

Urinary Anesthetics phenazopyridine oral tablet 100 mg, 200 mg Tier 1

PYRIDIUM ORAL TABLET Tier 3


Vitamins, Hematinics & Electrolytes

Electrolytes calcium 500 with d oral tablet Tier 1 ACA

136

Effective 1/2019

calcium carbonate-vitamin d3 oral tablet 500mg (1,250mg) -600 unit, 600 mg(1,500mg) -400 unit

Tier 1 ACA

calcium citrate + d oral tablet Tier 1 ACA

calcium citrate-vitamin d3 oral tablet 200 mg calcium -250 unit

Tier 1 ACA

EFFER-K ORAL TABLET, EFFERVESCENT 10 MEQ, 20 MEQ

Tier 3

effer-k oral tablet, effervescent 25 meq Tier 1

GALZIN ORAL CAPSULE Tier 3

k-effervescent oral tablet, effervescent Tier 1

klor-con 10 oral tablet extended release Tier 1

klor-con 8 oral tablet extended release Tier 1

klor-con m10 oral tablet,er particles/crystals Tier 1



klor-con oral packet Tier 1

klor-con sprinkle oral capsule, extended release Tier 1

KLOR-CON/25 ORAL PACKET Tier 3

klor-con/ef oral tablet, effervescent Tier 1

K-TAB ORAL TABLET EXTENDED RELEASE 10 MEQ, 20 MEQ

Tier 3

k-tab oral tablet extended release 8 meq Tier 1

lugols oral solution Tier 1

POTABA ORAL CAPSULE Tier 3

potassium bicarb and chloride oral tablet, effervescent

Tier 1

potassium bicarb-citric acid oral tablet, effervescent

Tier 1

potassium chloride oral capsule, extended release Tier 1

potassium chloride oral liquid Tier 1

potassium chloride oral packet Tier 1

potassium chloride oral tablet extended release Tier 1

potassium chloride oral tablet,er particles/crystals Tier 1


137

Effective 1/2019

strong iodine oral solution Tier 1

Vitamins & Hematinics b complex-vitamin b12 oral tablet Tier 1 ACA

b complex-vitamin c-folic acid oral tablet Tier 1 ACA

bal-care dha oral combo pack,tablet and cap,dr Tier 1

b-complex with vitamin c oral tablet Tier 1 ACA

calcium 500 + d oral tablet 500 mg(1,250mg) -200 unit

Tier 1 ACA

calcium 600 + d(3) oral capsule Tier 1 ACA

calcium 600 + d(3) oral tablet 600 mg(1,500mg) -200 unit

Tier 1 ACA

calcium citrate-vitamin d3 oral tablet 200-125 mg-unit, 250 mg calcium- 200 unit

Tier 1 ACA

calcium pnv oral capsule Tier 1

cholecalciferol (vitamin d3) oral drops 400 unit/ml Tier 1 ACA

c-nate dha oral capsule Tier 1

complete natal dha oral combo pack Tier 1

completenate oral tablet,chewable Tier 1

cyanocobalamin (vitamin b-12) injection solution Tier 1

dothelle dha oral capsule Tier 1

elite-ob oral tablet Tier 1

ergocalciferol (vitamin d2) oral capsule Tier 1

ergocalciferol (vitamin d2) oral tablet 400 unit Tier 1 ACA

fluor-a-day (with xylitol) oral tablet,chewable 0.25 mg f (0.55 mg)-236.79mg, 0.5 mg f (1.1 mg)-236.79 mg

Tier 1 ACA

fluor-a-day (with xylitol) oral tablet,chewable 1 mg f (2.2 mg)-236.79 mg

Tier 1

FLUOR-A-DAY ORAL DROPS Tier 3

fluoride (sodium) oral drops Tier 1 ACA

fluoride (sodium) oral tablet,chewable 0.25 mg(0.55 mg sod. fluoride), 0.5 mg (1.1 mg sodium fluorid)

Tier 1 ACA


138

Effective 1/2019

fluoritab oral tablet,chewable 0.5 mg (1.1 mg sodium fluorid)

Tier 1 ACA

focalgin 90 dha oral combo pack Tier 1

focalgin ca oral combo pack Tier 1

focalgin dss oral tablet Tier 1

folic acid oral tablet 400 mcg, 800 mcg Tier 1 ACA

folivane-ob oral capsule Tier 1

hemenatal ob + dha oral combo pack Tier 1

hemenatal ob oral tablet Tier 1

levomefolate dha oral capsule Tier 1

ludent fluoride oral tablet,chewable 0.25 mg(0.55 mg sod. fluoride), 0.5 mg (1.1 mg sodium fluorid)

Tier 1 ACA

multi-vitamin with fluoride oral drops Tier 1 ACA

multivitamin with fluoride oral tablet,chewable Tier 1 ACA

multi-vitamin with fluoride oral tablet,chewable 0.25 mg, 0.5 mg

Tier 1 ACA

multivitamins with fluoride oral tablet,chewable 0.25 mg, 0.5 mg

Tier 1 ACA

multivit-fluor (vit e acetate) oral drops Tier 1 ACA

mvc-fluoride oral tablet,chewable 0.25 mg, 0.5 mg Tier 1 ACA

mynatal advance oral tablet Tier 1

mynatal oral capsule Tier 1

mynatal oral tablet Tier 1

mynatal plus oral tablet Tier 1

mynatal-z oral tablet Tier 1

mynate 90 plus oral tablet extended release Tier 1

newgen oral tablet Tier 1

obstetrix dha oral combo pack,tablet and cap,dr Tier 1

pnv 29-1 oral tablet Tier 1

pnv ob+dha oral combo pack 27-1-50-250 mg Tier 1

pnv-dha + docusate oral capsule Tier 1

pnv-dha oral capsule Tier 1

pnv-ferrous fumarate-docu-fa oral tablet Tier 1


139

Effective 1/2019

pnv-omega oral capsule Tier 1

pnv-select oral tablet Tier 1

pnv-vp-u oral capsule Tier 1

pr natal 400 ec oral combo pack,tablet and cap,dr Tier 1

pr natal 400 oral combo pack Tier 1

pr natal 430 ec oral combo pack,tablet and cap,dr Tier 1

pr natal 430 oral combo pack Tier 1

prena1 chew oral tablet,chew,ir - dr,biphase Tier 1

prena1 pearl oral capsule,ir - delay rel,biphase Tier 1

prena1 true oral combo pack Tier 1

prenaissance oral capsule Tier 1

prenaissance plus oral capsule Tier 1

prenatabs fa oral tablet Tier 1

prenatabs rx oral tablet Tier 1

prenatal formula oral tablet 28 mg iron- 800 mcg Tier 1 ACA

prenatal multi-dha (algal oil) oral capsule Tier 1 ACA

prenatal one daily oral tablet Tier 1 ACA

prenatal oral tablet 28 mg iron- 800 mcg Tier 1 ACA

prenatal plus (calcium carb) oral tablet Tier 1

prenatal plus oral tablet Tier 1

prenatal vitamin oral tablet , 27 mg iron- 0.8 mg Tier 1 ACA

prenatal vitamin plus low iron oral tablet Tier 1

prenatal-u oral capsule Tier 1

preplus oral tablet Tier 1

pretab oral tablet Tier 1

relnate dha oral capsule Tier 1

risacal-d oral tablet Tier 1 ACA

se-natal 19 (with docusate) oral tablet Tier 1

se-natal 19 oral tablet,chewable Tier 1

sodium fluoride 0.25 (0.55) mg s/f, chewable tablet

Tier 1 ACA

taron-c dha oral capsule Tier 1


140

Effective 1/2019

taron-prex prenatal-dha oral capsule Tier 1

tl g-fol os oral tablet Tier 1

trinatal gt oral tablet Tier 1

trinatal rx 1 oral tablet Tier 1

trinate oral tablet Tier 1

triple vitamin with fluoride oral drops Tier 1 ACA

tri-tabs dha oral combo pack Tier 1

triveen-duo dha oral combo pack Tier 1

tri-vit with fluoride and iron oral drops Tier 1 ACA

tri-vitamin with fluoride oral drops Tier 1 ACA

tri-vite with fluoride oral drops Tier 1 ACA

trust natal dha oral combo pack Tier 1

ultimatecare one nf oral capsule Tier 1

ultimatecare one oral capsule Tier 1

vemavite-prx-2 oral capsule Tier 1

vinate care oral tablet,chewable Tier 1

vinate ii oral tablet Tier 1

vinate m oral tablet Tier 1

vinate one oral tablet Tier 1

vinate ultra oral tablet Tier 1

virt-advance oral tablet Tier 1

virt-c dha oral capsule Tier 1

virt-nate dha oral capsule Tier 1

virt-nate oral tablet Tier 1

virt-pn dha oral capsule Tier 1

virt-pn oral tablet Tier 1

virt-pn plus oral capsule Tier 1

virt-select oral capsule Tier 1

virt-vite gt oral tablet Tier 1

vitamin b complex-folic acid oral tablet Tier 1 ACA

vitamin d3 oral capsule 1,000 unit, 400 unit Tier 1 ACA


141

Effective 1/2019

vitamin d3 oral tablet 1,000 unit, 400 unit Tier 1 ACA

vitamin d3 oral tablet,chewable Tier 1 ACA

vitamins a,c,d and fluoride oral drops 0.25 mg fluor. (0.55 mg)/ml

Tier 1 ACA

vol-care rx oral tablet Tier 1

vp-ch plus oral capsule Tier 1

vp-ch-pnv oral capsule Tier 1

vp-ggr-b6 oral tablet Tier 1

vp-heme ob oral tablet Tier 1

vp-heme one oral capsule Tier 1

zatean-ch oral capsule Tier 1

zatean-pn dha oral capsule Tier 1

zatean-pn plus oral capsule Tier 1

zingiber oral tablet Tier 1


Effective 1/2019

142

Index of Drugs

1 1ST TIER UNIFINE PENTIPS ...82 1ST TIER UNILET

COMFORTOUCH ...............82 A abacavir ..................................3 abacavir-lamivudine ...............3 abacavir-lamivudine-

zidovudine ..........................3 ABILIFY..................................35 ABILIFY MAINTENA...............35 ABSTRAL ...............................29 acamprosate.........................71 ACANYA ................................60 acarbose ...............................92 ACCOLATE...........................129 ACCU-CHEK AVIVA PLUS TEST

STRP..................................78 ACCU-CHEK COMPACT PLUS

TEST ..................................78 ACCU-CHEK GUIDE ...............78 ACCU-CHEK SAFE-T-PRO.......82 ACCU-CHEK SMARTVIEW TEST

STRIP.................................78 ACCU-CHEK SOFTCLIX LANCETS

..........................................82 ACCUPRIL..............................43 ACCURETIC ...........................43 ACCUTREND GLUCOSE .........78 acebutolol.............................43 acetaminophen-caff-

dihydrocod .......................29 acetaminophen-codeine ......29 acetazolamide ....................123 acetic acid.......................71, 76 acetylcysteine.....................129 acitretin ................................56 ACTEMRA............................109 ACTHAR H.P. .........................77 ACTHIB (PF).........................104 ACTIGALL ..............................96 ACTI-LANCE LANCETS ...........83 ACTIMMUNE ......................104 ACTIQ....................................29

ACTIVELLA...........................110 ACTONEL.......................71, 108 ACTOPLUS MET.....................92 ACTOPLUS MET XR ...............92 ACTOS ...................................92 acyclovir............................3, 65 ADACEL(TDAP

ADOLESN/ADULT)(PF) ....104 ADALAT CC............................43 adapalene .............................60 adapalene-benzoyl peroxide 60 ADCIRCA .............................129 ADDERALL.............................35 adefovir...................................3 ADEMPAS............................129 ADIPEX-P...............................70 ADMELOG SOLOSTAR U-100

INSULIN.............................88 ADMELOG U-100 INSULIN

LISPRO...............................88 adrenalin.............................126 ADVAIR DISKUS...................129 ADVAIR HFA........................129 ADVANCED GLUC METER TEST

STRIP.................................78 ADVANCED TRAVEL LANCETS

..........................................83 ADVATE.................................50 ADVOCATE LANCET ..............83 ADVOCATE PEN NEEDLE.......83 ADVOCATE REDI-CODE.........78 ADVOCATE TEST STRIPS........78 AEROSPAN ..........................129 afeditab cr ............................44 AFINITOR ..............................14 AFINITOR DISPERZ ................14 AFLURIA 2018-2019............104 AFLURIA 2018-2019 (PF) ....104 AFLURIA QUAD 2018-2019.105 AFLURIA QUAD 2018-2019 (PF)

........................................104 AFREZZA................................88 AGAMATRIX AMP TEST STRIPS

..........................................78

AGGRENOX ...........................50 AGRYLIN................................71 AKTEN (PF) ..........................122 ala-cort..................................65 ALA-SCALP.............................65 ALBENZA .................................9 albuterol sulfate .................129 alclometasone ......................65 ALCOHOL SWABS..................83 ALDACTAZIDE........................44 ALDACTONE ..........................44 ALDARA...............................104 ALECENSA .............................14 alendronate ..................71, 109 alfuzosin..............................134 ALINIA .....................................9 ALKERAN ...............................14 allopurinol...........................108 almotriptan malate...............25 ALORA .................................110 alosetron...............................96 ALPHAGAN P.......................125 ALPHANATE ..........................50 ALPHANINE SD......................51 alprazolam ............................35 alprazolam intensol ..............35 ALPROLIX ..............................51 alprostadil ...........................134 ALSUMA................................25 ALTABAX ...............................63 ALTACE..................................44 altavera (28)........................114 ALTERNATE SITE LANCET ......83 ALUNBRIG .............................14 alyacen 1/35 (28)................114 alyacen 7/7/7 (28) ..............114 amabelz...............................110 amantadine hcl .......................3 AMARYL ................................92 AMBIEN.................................35 AMBIEN CR ...........................35 amcinonide ...........................65 AMERGE................................25 amethia...............................114

Effective 1/2019

143

amethia lo...........................114 amethyst.............................114 AMICAR ................................51 amiloride ..............................44 amiloride-hydrochlorothiazide

..........................................44 amiodarone ..........................43 AMITIZA................................96 amitriptyline.........................35 amitriptyline-chlordiazepoxide

..........................................35 amlodipine............................44 amlodipine-atorvastatin.......53 amlodipine-benazepril .........44 amlodipine-olmesartan........44 amlodipine-valsartan ...........44 amlodipine-valsartan-hcthiazid

..........................................44 amnesteem...........................60 amoxapine............................35 amoxicil-clarithromy-lansopraz

........................................101 amoxicillin.............................11 amoxicillin-pot clavulanate ..11 ampicillin ..............................11 AMPYRA................................27 ANADROL-50 ........................90 ANAFRANIL ...........................35 anagrelide.............................71 ANAPROX DS ........................32 anastrozole...........................14 ANCOBON...............................2 ANDRODERM........................90 ANDROGEL............................90 ANDROID ..............................90 ANGELIQ .............................110 ANORO ELLIPTA..................129 ANTABUSE ............................71 ANTARA ................................53 anucort-hc ............................96 ANUSOL-HC ..........................96 ANZEMET..............................96 apexicon e ............................65 APIDRA SOLOSTAR U-100

INSULIN.............................88 APIDRA U-100 INSULIN.........88

APOKYN ................................23 apraclonidine......................125 aprepitant.............................96 apri......................................114 APRISO..................................96 APTIOM.................................19 APTIVUS..................................3 aqua care sodium chloride ...70 aqua care sterile water.........70 AQUA GLYCOLIC HC..............65 aranelle (28) .......................114 ARANESP (IN POLYSORBATE)

........................................102 ARAVA.................................109 ARCALYST............................104 ARCAPTA NEOHALER..........129 ARESTIN ................................75 ARICEPT ................................27 ARIMIDEX..............................14 aripiprazole...........................35 ARISTADA..............................35 ARISTADA INITIO ..................35 ARIXTRA................................51 armodafinil ...........................35 ARMOUR THYROID ...............94 ARNUITY ELLIPTA................129 AROMASIN............................14 ARTHROTEC 50 .....................32 ARTHROTEC 75 .....................32 ascomp with codeine ...........25 ashlyna................................114 ASMANEX HFA....................129 ASMANEX TWISTHALER......129 aspirin ...................................32 aspirin-caffeine-dihydrocodein

..........................................29 aspirin-dipyridamole ............51 ASSURE 4 STRIPS...................78 ASSURE HAEMOLANCE PLUS 83 ASSURE LANCE......................83 ASSURE LANCE PLUS.............83 ASSURE PLATINUM...............78 ASSURE PRISM MULTI STRIP 78 ASTAGRAF XL ........................14 ASTEPRO ...............................75 ATACAND..............................44

ATACAND HCT.......................44 atazanavir ...............................3 ATELVIA...............................109 atenolol.................................44 atenolol-chlorthalidone........44 ATIVAN............................35, 36 atomoxetine .........................36 atorvastatin ..........................53 atovaquone.............................9 atovaquone-proguanil ............9 ATRIPLA...................................3 atropine ..............................122 ATROVENT HFA...................130 AUBAGIO.............................103 aubra...................................114 aubra eq..............................114 AUGMENTIN .........................11 AUGMENTIN ES-600 .............11 AUGMENTIN XR ....................12 AURYXIA................................96 AUSTEDO ..............................27 AVALIDE ................................44 AVANDIA...............................92 AVAPRO ................................44 AVC VAGINAL......................113 AVELOX .................................12 aviane .................................114 avidoxy..................................12 avita ......................................60 AVODART ............................134 AVONEX ..............................103 AVONEX (WITH ALBUMIN) .103 AYGESTIN ............................110 AZASAN.................................14 AZASITE...............................120 azathioprine..........................14 azelastine......................75, 122 AZELEX ..................................60 AZILECT .................................23 azithromycin ...........................8 AZOR .....................................44 AZULFIDINE...........................96 AZULFIDINE EN-TABS............96 azurette (28) .......................114 B b complex-vitamin b12.......137

Effective 1/2019

144

b complex-vitamin c-folic acid ........................................137

bacitracin............................120 bacitracin-polymyxin b.......120 baclofen................................28 BACTRIM...............................12 BACTRIM DS .........................12 BACTROBAN NASAL..............75 bal-care dha........................137 BALCOLTRA.........................114 balsalazide ............................96 balziva (28) .........................114 BANZEL .................................19 BARACLUDE ............................3 BCG VACCINE, LIVE (PF)......105 b-complex with vitamin c ...137 BD ECLIPSE............................83 BD FILTER NEEDLE-5 MICRON

..........................................83 BD INTEGRA NEEDLE ............83 BD MICROTAINER LANCET ...83 BD NOKOR ADMIX NEEDLE ..83 BD PRECISIONGLIDE .............83 BD PRECISIONGLIDE NON-

STERILE .............................83 bd pre-filled normal saline ...71 BD SAFETYGLIDE NEEDLE .....83 BD SPECIALTY USE NEEDLES.83 BD ULTRA FINE LANCETS......83 BD ULTRA-FINE NANO PEN

NEEDLE .............................83 BD ULTRA-FINE SHORT PEN

NEEDLE .............................83 BEBULIN................................51 bekyree (28) .......................114 BELVIQ ..................................70 benazepril.............................44 benazepril-

hydrochlorothiazide .........44 BENEFIX ................................51 BENICAR................................44 BENICAR HCT ........................44 BENLYSTA ...........................109 BENTYL..................................95 BENZAMYCIN........................60 BENZEFOAM .........................60

BENZEFOAM ULTRA..............60 benzepro...............................60 BENZEPRO (MICROSPHERES)60 benzonatate .......................127 benzoyl peroxide ..................60 benzphetamine.....................70 benztropine ..........................23 BERINERT ............................130 BESIVANCE..........................120 BETADINE OPHTHALMIC PREP

........................................120 BETAGAN ............................121 betamethasone dipropionate

..........................................65 betamethasone valerate ......65 betamethasone, augmented 65 BETAPACE .............................43 BETAPACE AF ........................43 BETASERON ........................103 betaxolol.......................44, 121 bethanechol chloride .........134 BEVESPI AEROSPHERE ........130 bexarotene ...........................14 BEXSERO .............................105 BEYAZ..................................114 BIAFINE EMULSION ..............58 bicalutamide.........................14 BIDIL......................................44 BIKTARVY ................................3 BILTRICIDE ..............................9 bimatoprost........................123 BINOSTO .............................109 BIONIME RIGHTEST TEST

STRIPS ...............................78 BIOTHRAX ...........................105 bisacodyl...............................96 bisoprolol fumarate..............44 bisoprolol-hydrochlorothiazide

..........................................44 BLEPH-10 ............................125 BLEPHAMIDE ......................125 BLEPHAMIDE S.O.P. ............125 blisovi 24 fe.........................114 blisovi fe 1.5/30 (28)...........114 blisovi fe 1/20 (28)..............114 BLOOD GLUCOSE TEST..........78

BLUNT NEEDLE, DISPOSABLE83 BONIVA ...............................109 BOOSTRIX TDAP..................105 BOSULIF ................................14 bpo........................................60 BRAFTOVI..............................14 BRAVELLE..............................90 BREEZE 2 TEST STRIPS...........79 BREO ELLIPTA......................130 BREVICON (28)....................114 briellyn ................................114 BRILINTA ...............................51 brimonidine ........................125 BROMFED DM.....................127 bromfenac ..........................123 bromocriptine.................23, 24 brompheniramine-pseudoeph-

dm...................................127 BROVANA............................130 budesonide ...................96, 130 BULLSEYE MINI SAFETY

LANCETS............................83 bumetanide ..........................44 BUNAVAIL .............................19 BUPAP...................................25 BUPHENYL.............................71 buprenorphine-naloxone19, 33 bupropion hcl .......................36 bupropion hcl (smoking deter)

..........................................75 buspirone..............................36 butalbital compound

w/codeine.........................25 butalbital-acetaminop-caf-cod

..........................................25 butalbital-acetaminophen....25 butalbital-acetaminophen-caff

..........................................25 butalbital-aspirin-caffeine ....25 BUTISOL ................................36 butorphanol tartrate ............29 BUTRANS...............................29 BYDUREON............................92 BYDUREON BCISE..................92 BYETTA..................................92 BYSTOLIC...............................44

Effective 1/2019

145

C cabergoline...........................90 CABOMETYX .........................14 CADUET ................................53 CAFERGOT ............................25 caffeine citrate .....................71 CALAN...................................44 CALAN SR..............................44 calcipotriene.........................56 calcipotriene-betamethasone

..........................................56 calcitonin (salmon) ...............90 calcitrene..............................56 calcitriol ..........................56, 90 calcium 500 + d...................137 calcium 500 with d .............135 calcium 600 + d(3) ..............137 calcium acetate ....................96 calcium carbonate-vitamin d3

........................................136 calcium citrate + d ..............136 calcium citrate-vitamin d3 136,

137 calcium pnv ........................137 CALQUENCE..........................14 camila .................................110 CAMINO PRO 15 PE PKU ......72 camrese ..............................114 camrese lo ..........................114 CANASA ................................96 candesartan..........................44 candesartan-

hydrochlorothiazid ...........45 capacet .................................25 CAPCOF...............................127 capecitabine .........................14 CAPEX ...................................66 CAPITAL WITH CODEINE.......29 CAPRELSA .............................14 captopril ...............................45 captopril-hydrochlorothiazide

..........................................45 CARAFATE...........................101 CARBAGLU ............................71 carbamazepine .....................19 CARBATROL ..........................19

carbidopa..............................24 carbidopa-levodopa .............24 carbidopa-levodopa-

entacapone.......................24 carbinoxamine maleate......126 CARDIZEM.............................45 CARDIZEM CD .......................45 CARDIZEM LA........................45 CARDURA..............................45 CARDURA XL .........................45 CAREFINE PEN NEEDLE .........83 CAREONE THIN LANCET........83 CARESENS N TEST STRIPS .....79 CARETOUCH TEST STRIP .......79 carisoprodol..........................28 carisoprodol-asa-codeine.....28 carisoprodol-aspirin .............28 CARNITOR .............................71 CARNITOR (SUGAR-FREE) .....71 carteolol..............................121 cartia xt.................................45 carvedilol ..............................45 carvedilol phosphate............45 CASODEX...............................14 CATAPRES .............................45 CATAPRES-TTS-1 ...................45 CATAPRES-TTS-2 ...................45 CATAPRES-TTS-3 ...................45 CAVERJECT..........................135 CAVERJECT IMPULSE ..........135 CAYSTON.................................9 caziant (28) .........................114 CEDAX .....................................7 cefaclor ...................................7 cefadroxil ................................7 cefdinir....................................7 cefditoren pivoxil....................7 cefixime ..................................7 cefpodoxime.......................7, 8 cefprozil ..................................8 ceftibuten ...............................8 CEFTIN ....................................8 cefuroxime axetil ....................8 CELEBREX..............................33 celecoxib...............................33 CELEXA..................................36

CELLCEPT...............................14 CELONTIN..............................19 CENTANY...............................63 CENTANY AT .........................63 cephalexin...............................8 CERDELGA.............................90 CESAMET...............................96 CETROTIDE............................90 cevimeline.............................71 CHANTIX................................75 CHANTIX CONTINUING

MONTH BOX .....................75 CHANTIX STARTING MONTH

BOX ...................................75 chateal ................................114 chateal eq ...........................114 CHEMET ................................71 CHENODAL............................96 cheratussin ac.....................127 chlordiazepoxide hcl.............36 chlordiazepoxide-clidinium ..95 chlorhexidine gluconate .......75 chloroquine phosphate ..........9 chlorothiazide.......................45 chlorpromazine.....................36 chlorpropamide ....................92 chlorthalidone ......................45 chlorzoxazone.......................28 CHOLBAM .............................96 cholecalciferol (vitamin d3) 137 cholestyramine (with sugar).53 cholestyramine light .............53 choline,magnesium salicylate

..........................................33 CIALIS ..........................134, 135 ciclodan.................................64 ciclopirox...............................64 ciclopirox-ure-camph-menth-

euc ....................................64 cilostazol ...............................51 CILOXAN..............................120 CIMDUO..................................3 cimetidine...........................101 cimetidine hcl .....................101 CIMZIA ..................................97 CIMZIA STARTER KIT .............97

Effective 1/2019

146

CINRYZE ..............................130 CIPRO....................................12 CIPRO HC ..............................77 CIPRO XR...............................12 CIPRODEX .............................77 ciprofloxacin .........................12 ciprofloxacin (mixture) .........12 ciprofloxacin hcl .....12, 76, 120 citalopram ............................36 citrate of magnesia...............97 claravis..................................60 CLARINEX............................126 CLARINEX-D 12 HOUR ........127 clarithromycin ........................8 clearlax .................................97 clemastine ..........................126 CLENPIQ................................97 CLEOCIN..............................113 CLEOCIN HCL ..........................9 CLEOCIN PEDIATRIC................9 CLEOCIN T.............................60 CLEVER CHEK LANCETS.........83 CLEVER CHOICE MICRO TEST

STRIP.................................79 CLEVER CHOICE PRO.............79 CLEVER CHOICE TALK TEST...79 CLEVER CHOICE TEST STRIPS 79 CLEVER CHOICE VOICE+ TEST

..........................................79 CLICKFINE .............................83 CLIMARA.............................110 CLIMARA PRO .....................110 clindacin p ............................60 CLINDAGEL............................60 clindamycin hcl.......................9 clindamycin palmitate hcl ......9 clindamycin pediatric .............9 clindamycin phosphate .60, 61,

113 clindamycin-benzoyl peroxide

..........................................61 CLINDESSE ..........................113 CLINPRO 5000.......................75 clobazam ..............................19 clobetasol .............................66 clobetasol-emollient ............66

CLOBEX .................................66 CLOCORTOLONE PIVALATE...66 clodan ...................................66 CLODERM .............................66 clomipramine........................36 clonazepam ..........................19 clonidine ...............................45 clonidine hcl ...................36, 45 clopidogrel............................51 clorazepate dipotassium ......36 clorpres.................................45 CLORPRES .............................45 clotrimazole............................2 clotrimazole-betamethasone

..........................................64 clozapine...............................36 CLOZAPINE............................36 CLOZARIL ..............................36 c-nate dha...........................137 COAGADEX............................51 COAGUCHEK LANCETS..........83 COAL TAR..............................56 COARTEM ...............................9 codeine sulfate .....................29 codeine-butalbital-asa-caff ..25 codeine-guaifenesin ...........127 COLAZAL ...............................97 COLCRYS .............................108 colesevelam..........................53 COLESTID ..............................53 COLESTID FLAVORED ............53 colestipol ..............................53 colocort.................................97 COLOR LANCETS ...................83 COLY-MYCIN S ......................77 COLYTE WITH FLAVOR PACKS

..........................................97 COMBIGAN .........................123 COMBIPATCH......................110 COMBIVENT RESPIMAT ......130 COMBIVIR ...............................3 COMETRIQ ............................14 COMFORT EZ PEN NEEDLES..83 COMFORT LANCETS..............83 COMPAZINE..........................97 COMPLERA..............................3

complete natal dha.............137 completenate .....................137 compro..................................97 COMTAN ...............................24 CONDYLOX............................58 constulose.............................97 CONTOUR NEXT TEST STRIPS79 CONTOUR TEST STRIPS .........79 CONTRAVE ............................70 COOL GLUCOSE TEST STRIP ..79 COPAXONE..........................103 COPEGUS ............................103 CORDRAN..............................66 COREG...................................45 COREG CR .............................45 CORGARD..............................45 CORIFACT ..............................51 CORLANOR............................55 cormax ..................................66 CORTEF .................................77 CORTENEMA.........................97 CORTIFOAM ..........................97 cortisone...............................77 CORTISPORIN........................63 CORZIDE................................45 COSENTYX.............................57 COSENTYX (2 SYRINGES).......56 COSENTYX PEN .....................57 COSENTYX PEN (2 PENS).......57 COSOPT...............................123 COTELLIC ...............................15 COUMADIN ...........................51 covaryx................................110 covaryx h.s. .........................110 COZAAR.................................45 CREON...................................97 CRESEMBA ..............................2 CRESTOR ...............................53 CRINONE .............................111 CRIXIVAN.................................3 cromolyn...............97, 122, 130 cryselle (28) ........................114 CUTIVATE..............................66 CUVITRU .............................105 CUVPOSA ..............................95

Effective 1/2019

147

cyanocobalamin (vitamin b-12) ........................................137

cyclafem 1/35 (28) .............115 cyclafem 7/7/7 (28) ............115 CYCLESSA (28).....................115 cyclobenzaprine ...................28 CYCLOGYL ...........................122 CYCLOMYDRIL.....................126 cyclopentolate....................122 cyclophosphamide ...............15 CYCLOSERINE..........................9 CYCLOSET..............................92 cyclosporine .........................15 cyclosporine modified..........15 CYMBALTA............................36 cyproheptadine ..................126 cyred...................................115 cyred eq..............................115 CYSTADANE ..........................97 CYSTAGON..........................135 CYSTARAN...........................122 CYTOMEL ..............................94 CYTOTEC .............................101 D D.H.E.45................................25 dalfampridine .......................27 DALIRESP ............................130 danazol .................................90 DANTRIUM ...........................28 dantrolene............................28 dapsone..................................9 DAPTACEL (DTAP PEDIATRIC)

(PF)..................................105 DARAPRIM..............................9 darifenacin..........................133 dasetta 1/35 (28)................115 dasetta 7/7/7 (28) ..............115 DAYPRO ................................33 daysee ................................115 DAYTRANA............................36 DDAVP ..................................90 deblitane ............................111 decadron ..............................77 DELESTROGEN ....................111 deltasone..............................77 delyla (28)...........................115

DEMADEX .............................45 demeclocycline.....................12 DEMEROL..............................29 DENAVIR ...............................65 denta 5000 plus....................75 dentagel................................76 DEPAKENE.............................19 DEPAKOTE.............................20 DEPAKOTE ER........................19 DEPAKOTE SPRINKLES ..........20 DEPEN TITRATABS ..............109 DEPO-ESTRADIOL................111 DEPO-PROVERA..................111 DEPO-SUBQ PROVERA 104.111 DEPO-TESTOSTERONE ..........90 DERMA-SMOOTHE/FS BODY

OIL.....................................66 DERMA-SMOOTHE/FS SCALP

OIL.....................................66 DERMASORB HC COMPLETE

KIT.....................................66 DERMASORB TA COMPLETE

KIT.....................................66 DERMATOP...........................66 DERMOTIC OIL ......................76 DESCOVY.................................3 desipramine..........................36 desloratadine......................126 desmopressin .......................90 desog-e.estradiol/e.estradiol

........................................115 desogestrel-ethinyl estradiol

........................................115 DESONATE ............................66 desonide .........................66, 67 DESOWEN.............................67 desoximetasone ...................67 desvenlafaxine succinate .....36 dexamethasone....................77 dexamethasone intensol ......77 dexamethasone sodium

phosphate.......................124 DEXEDRINE SPANSULE..........36 DEXILANT............................101 dexmethylphenidate ............36 dextroamphetamine.............37

dextroamphetamine-amphetamine ...................37

DIAMOX SEQUELS...............123 DIASTAT ................................20 DIASTAT ACUDIAL.................20 DIATRUE PLUS TEST STRIP ....79 diazepam ........................20, 37 diazepam intensol ................37 DIBENZYLINE.........................45 diclofenac potassium............33 diclofenac sodium...33, 58, 123 diclofenac-misoprostol .........33 dicloxacillin ...........................12 dicyclomine...........................95 didanosine ..............................3 diethylpropion ......................70 DIFICID ....................................8 diflorasone............................67 DIFLUCAN................................2 diflunisal ...............................33 digitek ...................................50 digox .....................................50 digoxin ..................................50 dihydroergotamine...............25 DILANTIN...............................20 DILANTIN EXTENDED ............20 DILANTIN INFATABS..............20 DILANTIN KAPSEAL ...............20 DILANTIN-125 .......................20 DILATRATE-SR .......................55 DILAUDID ..............................29 diltiazem hcl....................45, 46 dilt-xr ....................................46 DIOVAN.................................46 DIOVAN HCT .........................46 diphenhydramine hcl..........126 diphenoxylate-atropine........95 DIPROLENE............................67 dipyridamole.........................51 DISALCID ...............................33 diskets...................................29 disopyramide phosphate......43 disulfiram..............................71 DITROPAN XL ......................133 DIURIL ...................................46 divalproex .............................20

Effective 1/2019

148

DIVIGEL...............................111 dofetilide ..............................43 DOLOPHINE ..........................30 donepezil ..............................27 DONNATAL ...........................95 DOPTELET .............................51 DORAL...................................37 dorzolamide........................123 dorzolamide-timolol...........123 dothelle dha .......................137 doxazosin..............................46 doxepin...........................37, 58 doxercalciferol......................90 doxycycline hyclate ........12, 13 doxycycline monohydrate....13 drithocreme hp.....................57 dronabinol ............................97 DROPLET LANCETS................84 DROPLET PEN NEEDLE..........84 drospirenone-e.estradiol-lm.fa

........................................115 drospirenone-ethinyl estradiol

........................................115 DROXIA .................................15 DUAVEE ..............................111 DUETACT...............................92 DULERA...............................130 duloxetine.............................37 DUOPA..................................24 DUPIXENT .............................59 DURAGESIC...........................30 DUREZOL ............................124 dutasteride .........................134 dutasteride-tamsulosin ......134 DUTOPROL............................46 DYAZIDE................................46 DYRENIUM............................46 E e.e.s. 400 ................................8 E.E.S. GRANULES.....................8 EAA SUPPLEMENT ................72 EASY COMFORT LANCETS.....84 EASY COMFORT PEN NEEDLES

..........................................84 EASY PLUS II TEST .................79 EASY STEP .............................79

EASY TALK GLUCOSE TEST ....79 EASY TOUCH FLIPLOCK NEEDLE

..........................................84 EASY TOUCH HYPODERMIC

NEEDLE .............................84 EASY TOUCH TEST STRIP.......79 EASY TRAK GLUCOSE TEST....79 EASYGLUCO PLUS .................79 EASYGLUCO TEST..................79 EASYMAX ..............................79 EC-NAPROSYN ......................33 econazole..............................64 econtra ez ...........................115 econtra one-step ................115 EDARBI..................................46 EDARBYCLOR ........................46 EDECRIN................................46 EDEX....................................135 EDURANT................................3 eemt ...................................111 eemt hs...............................111 efavirenz .................................3 effer-k .................................136 EFFER-K...............................136 EFFEXOR XR ..........................37 EFFIENT.................................51 EFUDEX .................................59 ELDEPRYL ..............................24 ELEMENT COMPACT TEST

STRIPS ...............................79 ELEMENT TEST STRIPS ..........79 ELESTRIN.............................111 eletone..................................59 eletriptan..............................25 ELIDEL ...................................59 ELIMITE .................................69 elinest .................................115 eliphos ..................................97 ELIQUIS .................................51 elite-ob ...............................137 ELIXOPHYLLIN .....................130 ELLA ....................................115 ELMIRON ............................135 ELOCON ................................67 EMBRACE BLOOD GLUCOSE

SYSTEM .............................79

EMBRACE EVO TEST STRIPS..79 EMBRACE PRO TEST STRIPS..79 EMCYT...................................15 EMEND..................................97 EMFLAZA...............................77 emoquette..........................115 EMSAM .................................37 EMTRIVA .................................4 emulsion sb...........................59 enalapril maleate..................46 enalapril-hydrochlorothiazide

..........................................46 ENBREL................................109 ENBREL MINI.......................109 ENBREL SURECLICK .............109 endocet.................................30 ENGERIX-B (PF) ...................105 ENGERIX-B PEDIATRIC (PF) .105 enoxaparin............................51 enpresse .............................115 enskyce ...............................115 ENSTILAR...............................57 entacapone...........................24 entecavir .................................4 ENTOCORT EC .......................97 ENTRESTO .............................55 enulose .................................97 EPANED.................................46 EPCLUSA..................................4 EPICERAM .............................59 EPIDUO .................................61 EPIDUO FORTE......................61 epinastine ...........................122 epinephrine ........................126 EPINEPHRINE ......................126 EPIPEN ................................126 EPIPEN 2-PAK......................126 EPIPEN JR ............................126 EPIPEN JR 2-PAK..................126 epitol.....................................20 EPIVIR......................................4 EPIVIR HBV..............................4 eplerenone ...........................46 EPOGEN ..............................102 epoprostenol (glycine)..........46 eprosartan ............................46

Effective 1/2019

149

EPZICOM.................................4 EQUETRO..............................20 ergocalciferol (vitamin d2) .137 ergoloid ................................37 ERGOMAR.............................25 ergotamine-caffeine.............25 ERIVEDGE..............................15 ERLEADA...............................15 errin ....................................111 ERTACZO...............................64 ery pads ................................61 erygel....................................61 ERYPED 200 ............................8 ERYPED 400 ............................8 ery-tab ....................................8 ERY-TAB ..................................9 erythrocin (as stearate)..........9 erythromycin ..................9, 120 erythromycin ethylsuccinate..9 erythromycin with ethanol ..61 erythromycin-benzoyl

peroxide............................61 ESBRIET...............................130 escitalopram oxalate............37 ESGIC ..............................25, 26 esomeprazole magnesium .101 estarylla ..............................115 estazolam .............................37 ESTRACE..............................111 estradiol..............................111 estradiol valerate ...............111 estradiol-norethindrone acet

........................................111 ESTRING..............................111 ESTROGEL ...........................111 estrogens-methyltestosterone

........................................111 estropipate .........................111 ESTROSTEP FE-28 ...............115 eszopiclone...........................37 ethacrynic acid .....................46 ethambutol.............................9 ethosuximide........................20 ethyl chloride........................62 ethynodiol diac-eth estradiol

........................................115

etidronate disodium.............71 etodolac................................33 etoposide..............................15 EUCRISA ................................59 EURAX...................................69 EVAMIST .............................111 EVENCARE G2 .......................79 EVENCARE G3 TEST...............79 EVENCARE MINI GLUCOSE

TEST STR ...........................79 EVISTA.................................109 EVOCLIN................................61 EVOLUTION TEST STRIPS ......79 EVOTAZ...................................4 EVOXAC.................................71 EXEL HYPODERMIC NEEDLES 84 EXELDERM ............................64 exemestane ..........................15 EXFORGE...............................46 EXFORGE HCT .......................46 EXJADE..................................71 EXODERM .............................64 EXTAVIA ..............................103 EXTINA ..................................64 e-z ject lancets......................84 EZ SMART LANCETS ..............84 EZ SMART PLUS TEST............79 EZ SMART TEST.....................79 ezetimibe..............................53 ezetimibe-simvastatin ..........54 F FABIOR..................................61 FACTIVE ................................12 falmina (28) ........................115 famciclovir ..............................4 famotidine ..........................101 FANAPT.................................37 FARESTON.............................15 FARXIGA................................92 FARYDAK...............................15 fayosim ...............................115 FAZACLO ...............................37 FEIBA NF ...............................51 felbamate .............................20 FELBATOL..............................20 FELDENE................................33

felodipine..............................46 fem ph.................................113 FEMARA ................................15 FEMHRT LOW DOSE............111 FEMRING.............................111 femynor ..............................115 fenofibrate............................54 fenofibrate micronized.........54 fenofibrate nanocrystallized.54 fenofibric acid.......................54 fenofibric acid (choline)........54 FENOGLIDE ...........................54 fenoprofen............................33 fentanyl.................................30 fentanyl citrate .....................30 FENTORA...............................30 FERRIPROX ............................71 FEXMID .................................28 FIASP FLEXTOUCH U-100

INSULIN.............................88 FIASP U-100 INSULIN ............88 FIBRICOR ...............................54 FIFTY50 SAFETY SEAL LANCETS

..........................................84 FIFTY50 TEST STRIP...............80 FINACEA................................61 finasteride...........................134 FINE 30 UNIVERSAL LANCETS

..........................................84 FINGERSTIX LANCETS............84 FIORICET ...............................26 FIORINAL...............................26 FIORINAL-CODEINE #3..........26 FIRAZYR...............................130 FIRVANQ ...............................13 flac otic oil.............................76 FLAGYL ..................................10 FLAREX ................................124 flavoxate .............................133 flecainide ..............................43 FLOLAN .................................46 FLOMAX ..............................134 FLOVENT DISKUS.................130 FLOVENT HFA......................130 FLOW-EZE VENTED NEEDLE..84 floxin .....................................76

Effective 1/2019

150

FLUAD 2018-2019 (65 YR UP)(PF)............................105

FLUARIX QUAD 2018-2019 (PF) ........................................105

FLUBLOK QUAD 2018-2019 (PF)..................................105

flucaine ...............................122 FLUCELVAX QUAD 2018-2019

........................................105 FLUCELVAX QUAD 2018-2019

(PF)..................................105 fluconazole .............................2 flucytosine ..............................2 fludrocortisone.....................77 FLULAVAL QUAD 2018-2019

........................................105 FLULAVAL QUAD 2018-2019

(PF)..................................105 FLUMADINE ............................4 FLUMIST QUAD 2018-2019 105 flunisolide...........................130 fluocinolone..........................67 fluocinolone acetonide oil....76 fluocinolone and shower cap

..........................................67 fluocinonide..........................67 fluocinonide-e ......................67 fluocinonide-emollient.........67 FLUOR-A-DAY .....................137 fluor-a-day (with xylitol).....137 fluorescein-proparacaine ...122 fluoride (sodium)..76, 137, 139 FLUORIDEX DAILY DEFENSE..76 fluoritab..............................138 fluorometholone ................124 fluorouracil ...........................59 fluoxetine .............................37 fluphenazine hcl .............37, 38 flurandrenolide.....................67 flurazepam............................38 flurbiprofen ..........................33 flurbiprofen sodium ...........123 flutamide ..............................15 fluticasone....................67, 130 fluvastatin.............................54 fluvoxamine..........................38

FLUZONE HIGH-DOSE 2018-19 (PF)..................................105

FLUZONE QUAD 2018-2019106 FLUZONE QUAD 2018-2019

(PF)..........................105, 106 FLUZONE QUAD PEDI 2018-19

(PF)..................................106 FML FORTE..........................124 FML LIQUIFILM ...................124 FML S.O.P............................124 focalgin 90 dha ...................138 focalgin ca...........................138 focalgin dss .........................138 folic acid..............................138 folivane-ob..........................138 FOLLISTIM AQ.......................90 fondaparinux ........................51 FORA D15G ...........................80 FORA D20..............................80 FORA D40-G31 TEST STRIPS .80 FORA G20..............................80 FORA G30-PREMIUM V10 TEST

STRP..................................80 FORA GD50 TEST STRIPS.......80 FORA TEST STRIP ..................80 FORA TN'G VOICE TEST STRIPS

..........................................80 FORA V10..............................80 FORA V10-V12-D10-D20 STRP-

LNCT..................................84 FORA V12 GLUCOSE..............80 FORA V20..............................80 FORACARE GD20 ..................80 FORACARE GD40 ..................80 FORACARE LANCETS .............84 FORTEO...............................109 FORTISCARE GLUCOSE TEST

STRIPS ...............................80 FOSAMAX............................109 FOSAMAX PLUS D ...............109 fosamprenavir ........................4 fosinopril...............................46 fosinopril-hydrochlorothiazide

..........................................46 FOSRENOL.............................97 FRAGMIN ..............................51

FREESTYLE INSULINX.............80 FREESTYLE INSULINX TEST

STRIPS ...............................80 FREESTYLE LANCETS .............84 FREESTYLE LITE STRIPS..........80 FREESTYLE PRECISION NEO

STRIPS ...............................80 FREESTYLE TEST ....................80 FREESTYLE UNISTIK 2 ............84 frovatriptan...........................26 FULPHILA ............................102 FURADANTIN ........................13 furosemide......................46, 47 FUZEON...................................4 fyavolv.................................112 FYCOMPA..............................20 G gabapentin............................20 GABITRIL ...............................20 GALAFOLD.............................90 galantamine..........................27 GALZIN ................................136 GAMMAGARD LIQUID ........106 GAMUNEX-C .......................106 GANIRELIX.............................91 GARDASIL 9 (PF)..................106 GASTROCROM ......................97 gatifloxacin .........................120 GATTEX 30-VIAL....................97 GATTEX ONE-VIAL.................97 gavilyte-c...............................97 gavilyte-g ..............................98 gavilyte-n ..............................98 GE100 BLOOD GLUCOSE TEST

STRIP .................................80 GELNIQUE ...........................133 gemfibrozil ............................54 GENERESS FE.......................115 generlac ................................98 gengraf..................................15 GENSTRIP TEST STRIP ...........80 gentak .................................120 gentamicin ....................63, 120 GENVOYA................................4 GEODON ...............................38 gianvi (28) ...........................115

Effective 1/2019

151

GIAZO ...................................98 gildagia ...............................115 GILENYA..............................103 GILOTRIF ...............................15 glatiramer...........................103 glatopa................................103 GLEEVEC ...............................15 GLEOSTINE............................15 glimepiride............................92 glipizide...........................92, 93 glipizide-metformin..............93 GLUCAGEN DIAGNOSTIC KIT 82 GLUCAGEN HYPOKIT ............82 GLUCAGON EMERGENCY KIT

(HUMAN) ..........................82 GLUCO NAVII TEST STRIP......80 GLUCOCARD 01 SENSOR PLUS

..........................................80 GLUCOCARD EXPRESSION ....80 GLUCOCARD SHINE TEST

STRIPS ...............................80 GLUCOCARD VITAL SENSOR .80 GLUCOCARD VITAL TEST

STRIPS ...............................80 GLUCOCOM GLUCOSE..........80 GLUCOCOM LANCETS...........84 GLUCOPHAGE.......................93 GLUCOPHAGE XR..................93 GLUCOTROL..........................93 GLUCOTROL XL .....................93 GLUCOVANCE .......................93 glyburide...............................93 glyburide micronized............93 glyburide-metformin............93 glycopyrrolate ......................95 glydo .....................................63 GLYNASE...............................93 GLYSET..................................93 GLYTACTIN 10 PE COMPLETE72 GLYTACTIN 15 PE BETTERMILK

..........................................72 GLYTACTIN 15 PE COMPLETE72 GLYTACTIN 20PE BETTERMILK

LITE ...................................72 GLYTACTIN BUILD 10 PE .......72 GLYTACTIN RESTORE 10 PE ..73

GLYTACTIN RESTORE 10 PE LITE .............................72, 73

GLYTACTIN RESTORE 5 PE ....73 GLYTACTIN RTD 10 PE ..........73 GLYTACTIN RTD 15 PE ..........73 GLYTACTIN SWIRL 15 PE.......73 GLYXAMBI.............................93 GM100..................................80 GOLYTELY..............................98 GONAL-F ...............................91 GONAL-F RFF ........................91 GONAL-F RFF REDI-JECT .......91 granisetron hcl......................98 GRASTEK .............................106 griseofulvin microsize.............2 griseofulvin ultramicrosize .....2 GRIS-PEG (ULTRAMICROSIZE).2 guaiatussin ac .....................127 guaifenesin ac.....................127 guaifenesin dac...................127 guanfacine ......................38, 47 guanidine..............................38 GYNAZOLE-1 .......................113 H HAEGARDA .........................130 HALCION ...............................38 halobetasol propionate ..67, 68 HALOG ..................................68 haloperidol ...........................38 haloperidol lactate ...............38 HARVONI ................................4 HAVRIX (PF) ........................106 HEALTHPRO TEST STRIPS......80 HEALTHY ACCENTS UNIFINE

PENTIP ..............................84 HEALTHY ACCENTS UNILET

LANCET .............................84 heather ...............................112 HECTOROL ............................91 HELIXATE FS..........................51 hemenatal ob .....................138 hemenatal ob + dha ...........138 hemmorex-hc .......................98 HEMOFIL M HIGH .................51 HEMOFIL M LOW..................51 HEMOFIL M MID...................51

HEMOFIL M SUPER HIGH......51 hep flush-10 (pf) ...................52 heparin (porcine) ..................52 heparin lock flush .................52 heparin lock flush (porcine)..52 heparin lockflush(porcine)(pf)

..........................................52 heparin, porcine (pf).............52 HEPLISAV-B (PF)..................106 HEPSERA .................................4 HEXALEN ...............................15 HIBERIX (PF) ........................106 HIPREX ..................................13 HIZENTRA............................106 homatropaire......................122 homatropine hbr ................122 HORIZANT .............................27 huber safety needles (disp.) .84 HUMALOG JUNIOR KWIKPEN

U-100 ................................88 HUMALOG KWIKPEN INSULIN

..........................................88 HUMALOG MIX 50-50 INSULN

U-100 ................................88 HUMALOG MIX 50-50

KWIKPEN...........................88 HUMALOG MIX 75-25

KWIKPEN...........................88 HUMALOG MIX 75-25(U-

100)INSULN.......................88 HUMALOG U-100 INSULIN....88 HUMATE-P ............................52 HUMIRA ..............................110 HUMIRA PEDIATRIC CROHN'S

START..............................109 HUMIRA PEN.......................110 HUMIRA PEN CROHN'S-UC-HS

START..............................109 HUMIRA PEN PSORIASIS-

UVEITIS............................109 HUMULIN 70/30 U-100

INSULIN.............................88 HUMULIN 70/30 U-100

KWIKPEN...........................88 HUMULIN N NPH INSULIN

KWIKPEN...........................88

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152

HUMULIN N NPH U-100 INSULIN.............................88

HUMULIN R REGULAR U-100 INSULN..............................89

HUMULIN R U-500 (CONC) INSULIN.............................89

HUMULIN R U-500 (CONC) KWIKPEN...........................89

HYCAMTIN ............................15 HYCET ...................................30 hydralazine ...........................47 HYDREA ................................15 HYDRO 40 .............................59 hydrochlorothiazide .............47 hydrocodone-acetaminophen

..........................................30 hydrocodone-

chlorpheniramine...........127 hydrocodone-cpm-

pseudoephed..................127 hydrocodone-homatropine 127 hydrocodone-ibuprofen.......30 hydrocortisone .........68, 77, 98 hydrocortisone acetate ........98 hydrocortisone butyrate ......68 hydrocortisone butyr-

emollient ..........................68 hydrocortisone valerate.......68 hydrocortisone-acetic acid...76 hydrocortisone-min oil-wht

pet ....................................68 hydrocortisone-pramoxine .57,

98 hydromet............................127 hydromorphone ...................30 hydroxychloroquine .............10 hydroxyurea .........................15 hydroxyzine hcl...................126 hydroxyzine pamoate.........126 hyoscyamine sulfate.............95 HYQVIA ...............................106 HYZAAR.................................47 I ibandronate........................109 IBRANCE................................15 ibu.........................................33

IBUDONE...............................30 ibuprofen..............................33 ibuprofen-oxycodone...........30 ICLUSIG .................................15 IDHIFA...................................15 IGLUCOSE TEST STRIP ...........81 ILARIS (PF)...........................104 imatinib.................................15 IMBRUVICA...........................15 imipramine hcl......................38 imipramine pamoate............38 imiquimod ..........................104 IMITREX ................................26 IMITREX STATDOSE PEN .......26 IMITREX STATDOSE REFILL ...26 IMOVAX RABIES VACCINE (PF)

........................................106 IMURAN................................15 incassia ...............................112 INCONTROL PEN NEEDLE......84 INCONTROL SUPER THIN

LANCETS............................84 INCONTROL ULTRA THIN

LANCETS............................84 indapamide...........................47 INDERAL LA...........................47 INDERAL XL ...........................47 INDOCIN................................33 indomethacin .......................33 INFANRIX (DTAP) (PF) .........106 INFINITY TEST STRIPS............81 INFINITY VOICE TEST STRIP...81 INJECT EASE LANCETS...........84 INLYTA ..................................16 INNOPRAN XL .......................47 INSPRA..................................47 INSUPEN ...............................84 INTELENCE ..............................4 INTRAROSA.........................113 INTRON A............................104 introvale .............................115 INTUNIV ER...........................38 INVACARE LANCETS..............84 INVEGA .................................38 INVEGA SUSTENNA...............38 INVEGA TRINZA.....................38

INVIRASE .................................4 INVOKAMET..........................93 INVOKAMET XR.....................93 INVOKANA ............................93 IOPIDINE .............................125 IPOL.....................................106 ipratropium bromide....76, 130 ipratropium-albuterol.........130 irbesartan .............................47 irbesartan-hydrochlorothiazide

..........................................47 IRESSA ...................................16 ISENTRESS ...............................4 ISENTRESS HD .........................4 isibloom ..............................115 ISOCHRON.............................55 isometh-dichloral-

acetaminophn...................26 isomethepten-caf-

acetaminophen.................26 isoniazid ................................10 ISOPTO CARPINE.................122 ISORDIL .................................55 ISORDIL TITRADOSE ..............56 isosorbide dinitrate ..............56 isosorbide mononitrate........56 isotretinoin ...........................61 isradipine ..............................47 itraconazole ............................2 ivermectin.............................10 IXIARO (PF)..........................106 J JADENU.................................71 JAKAFI ...................................16 JALYN ..................................134 jantoven................................52 JANUMET ..............................93 JANUMET XR.........................93 JANUVIA................................93 JARDIANCE............................93 jencycla ...............................112 JENTADUETO ........................93 JENTADUETO XR ...................93 jevantique lo .......................112 jinteli ...................................112 jolessa .................................116

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153

jolivette ..............................112 juleber ................................116 JULUCA ...................................4 junel 1.5/30 (21).................116 junel 1/20 (21)....................116 junel fe 1.5/30 (28).............116 junel fe 1/20 (28)................116 junel fe 24...........................116 JUXTAPID ..............................54 JYNARQUE ............................91 K KADIAN .................................30 kaitlib fe..............................116 KALETRA .................................4 KALYDECO...........................130 KAPVAY.................................38 kariva (28)...........................116 k-effervescent ....................136 kelnor 1/35 (28)..................116 kelnor 1-50 .........................116 KENALOG ..............................68 KEPPRA .................................20 KEPPRA XR ............................21 KERALAC ...............................59 ketoconazole ....................2, 64 ketoprofen............................33 ketorolac.......................34, 123 KEVEYIS.................................27 KEVZARA.............................110 kimidess (28) ......................116 KINERET ..............................104 KINRIX (PF)..........................106 kionex ...................................98 kionex (with sorbitol) ...........98 KISQALI .................................16 KISQALI FEMARA CO-PACK...16 KITABIS PAK ..........................10 KLARON ................................63 KLONOPIN.............................21 klor-con ..............................136 klor-con 10..........................136 klor-con 8............................136 klor-con m10 ......................136 klor-con m15 ......................136 klor-con m20 ......................136 klor-con sprinkle.................136

KLOR-CON/25 .....................136 klor-con/ef..........................136 KOATE ...................................52 KOGENATE FS .......................52 KORLYM ................................91 K-PHOS NO 2.......................135 K-PHOS ORIGINAL...............135 KRISTALOSE ..........................98 k-tab....................................136 K-TAB ..................................136 kurvelo................................116 KUVAN ..................................91 KYNAMRO.............................54 L l norgest/e.estradiol-e.estrad

........................................116 labetalol................................47 LACRISERT...........................122 lactated ringers.....................70 lactulose ...............................98 LAMICTAL .............................21 LAMICTAL ODT .....................21 LAMICTAL ODT STARTER

(BLUE) ...............................21 LAMICTAL ODT STARTER

(GREEN) ............................21 LAMICTAL ODT STARTER

(ORANGE) .........................21 LAMICTAL STARTER (BLUE) KIT

..........................................21 LAMICTAL STARTER (GREEN)

KIT.....................................21 LAMICTAL STARTER (ORANGE)

KIT.....................................21 LAMICTAL XR ........................21 LAMICTAL XR STARTER (BLUE)

..........................................21 LAMICTAL XR STARTER

(GREEN) ............................21 LAMICTAL XR STARTER

(ORANGE) .........................21 lamivudine ..............................4 lamivudine-zidovudine ...........4 lamotrigine ...........................21 LANAFLEX..............................73 lancets ..................................84

LANCETS................................84 LANCETS,THIN.......................85 LANOXIN ...............................50 lansoprazole .......................101 lanthanum ............................98 LANTUS SOLOSTAR U-100

INSULIN.............................89 LANTUS U-100 INSULIN ........89 larin 1.5/30 (21)..................116 larin 1/20 (21) .....................116 larin 24 fe............................116 larin fe 1.5/30 (28)..............116 larin fe 1/20 (28).................116 larissia .................................116 LASIX .....................................47 latanoprost .........................123 LATUDA.................................38 laxaclear................................98 laxative peg 3350..................98 layolis fe..............................116 leena 28 ..............................116 leflunomide.........................110 LENVIMA...............................16 LESCOL ..................................54 LESCOL XL..............................54 lessina .................................116 letrozole................................16 leucovorin calcium................14 LEUKERAN.............................16 leuprolide..............................16 levalbuterol hcl ...................130 LEVAQUIN .............................12 LEVATOL................................47 LEVBID...................................95 LEVEMIR FLEXTOUCH U-100

INSULN..............................89 LEVEMIR U-100 INSULIN.......89 levetiracetam..................21, 22 LEVITRA...............................135 levobunolol .........................121 levocarnitine.........................71 levocarnitine (with sugar).....71 levofloxacin...................12, 120 levomefolate dha................138 levonest (28).......................116 levonorgestrel.....................116

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154

levonorgestrel-ethinyl estrad ........................................116

levonorg-eth estrad triphasic ........................................116

levora 0.15/30 (28).............116 levora-28 ............................116 levorphanol tartrate.............30 LEVO-T ..................................94 levothyroxine........................94 levoxyl...................................94 LEVSIN...................................95 LEVSIN/SL .............................95 LEVULAN...............................59 LEXAPRO...............................38 LEXIVA.................................4, 5 LIBRAX (WITH CLIDINIUM) ...95 lidocaine ...............................63 lidocaine hcl..........................63 lidocaine hcl-hydrocortison ac

....................................63, 98 lidocaine viscous...................63 lidocaine-hydrocortisone-aloe

..........................................98 lidocaine-prilocaine..............63 LIDODERM ............................63 LIFESHIELD BLUNT CANNULA

..........................................85 lillow ...................................117 lindane..................................69 linezolid ................................10 LINZESS .................................98 liothyronine ..........................94 LIPITOR .................................54 LIPOFEN ................................54 lisinopril ................................47 lisinopril-hydrochlorothiazide

..........................................47 LITE TOUCH LANCETS ...........85 lithium carbonate.................38 lithium citrate.......................38 LITHOBID ..............................38 LITHOSTAT ............................71 LIVALO ..................................54 LO LOESTRIN FE ..................117 LOCOID .................................68 LOCOID LIPOCREAM .............68

LODINE..................................34 LODOSYN ..............................24 LOESTRIN 1.5/30 (21) .........117 LOESTRIN 1/20 (21) ............117 LOESTRIN FE 1.5/30 (28-DAY)

........................................117 LOESTRIN FE 1/20 (28-DAY)117 LOMAIRA ..............................70 lomedia 24 fe......................117 LOMOTIL...............................95 LONHALA MAGNAIR REFILL131 LONHALA MAGNAIR STARTER

........................................131 LONSURF...............................16 LOPHLEX ...............................73 LOPID ....................................54 lopinavir-ritonavir...................5 lopreeza..............................112 LOPRESSOR...........................47 LOPRESSOR HCT ...................47 LOPROX.................................64 lorazepam.............................38 lorazepam intensol...............38 lorcet (hydrocodone)............30 lorcet hd ...............................30 lorcet plus.............................30 LORTAB ELIXIR ......................30 lortuss ex ............................127 loryna (28) ..........................117 losartan.................................47 losartan-hydrochlorothiazide

..........................................47 LOSEASONIQUE ..................117 LOTEMAX....................124, 125 LOTENSIN..............................47 LOTENSIN HCT ......................47 LOTREL..................................47 LOTRISONE ...........................64 LOTRONEX ............................98 LOUTREX...............................59 lovastatin ..............................54 LOVENOX ..............................52 low-ogestrel (28) ................117 loxapine succinate................38 LUCEMYRA............................34 ludent fluoride....................138

lugols...................................136 LUMIGAN ............................123 LUNESTA ...............................38 LUPANETA PACK (1 MONTH)

........................................113 LUPANETA PACK (3 MONTH)

........................................113 lutera (28) ...........................117 LUXIQ ....................................68 LYNPARZA .............................16 LYRICA...................................22 LYRICA CR..............................22 LYSODREN.............................16 LYSTEDA..............................113 lyza......................................112 M MACROBID............................13 MACRODANTIN.....................13 mafenide acetate..................63 MALARONE ...........................10 MALARONE PEDIATRIC .........10 malathion..............................69 maprotiline ...........................38 MAR-COF BP .......................127 MAR-COF CG.......................127 MARINOL ..............................98 marlissa...............................117 MARPLAN..............................39 marten-tab............................26 MATULANE ...........................16 matzim la ..............................47 MAVYRET ................................5 MAXIDEX.............................125 MAXITROL...........................124 MAXZIDE...............................47 MAXZIDE-25MG....................47 m-clear wc ..........................127 meclofenamate.....................34 MEDISENSE THIN LANCETS...85 MEDLANCE PLUS LANCETS ...85 MEDLANCE PLUS SPECIAL

BLADE................................85 MEDROL................................77 MEDROL (PAK) ......................77 medroxyprogesterone........112 mefenamic acid ....................34

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155

mefloquine ...........................10 MEGACE ES...........................16 megestrol .............................16 MEKINIST ..............................16 MEKTOVI...............................16 melodetta 24 fe..................117 meloxicam ............................34 melphalan.............................16 memantine ...........................27 MEMANTINE.........................27 MENACTRA (PF)..................106 M-END PE ...........................127 MENEST ..............................112 MENHIBRIX (PF)..................106 MENOMUNE - A/C/Y/W-135

........................................106 MENOMUNE - A/C/Y/W-135

(PF)..................................106 MENOPUR ............................91 MENOSTAR.........................112 MENVEO A-C-Y-W-135-DIP (PF)

........................................107 meperidine ...........................30 MEPHYTON...........................52 meprobamate.......................28 MEPRON ...............................10 mercaptopurine ...................16 mesalamine ..........................98 mesalamine with cleansing

wipe ..................................98 MESNEX................................14 MESTINON............................28 MESTINON TIMESPAN..........28 metadate er..........................39 metaproterenol ..................131 metaxalone...........................29 metformin ............................93 methadone.....................30, 31 methadose............................31 methamphetamine ..............39 methazolamide...................123 methenamine hippurate ......13 methenamine mandelate.....13 methen-sod phos-meth blue-

hyos ................................135 methimazole.........................78

METHITEST ...........................91 methocarbamol ....................29 methotrexate sodium...........16 methotrexate sodium (pf) ....16 methoxsalen .........................59 methscopolamine.................95 methyclothiazide..................48 methyldopa ..........................48 methyldopa-

hydrochlorothiazide .........48 METHYLIN.............................39 methylphenidate hcl ............39 methylprednisolone .............77 methyltestosterone..............91 metipranolol .......................121 metoclopramide hcl .......98, 99 metolazone...........................48 METOPIRONE........................71 metoprolol succinate............48 metoprolol ta-

hydrochlorothiaz ..............48 metoprolol tartrate ..............48 METROCREAM......................61 METROGEL VAGINAL ..........113 METROLOTION .....................61 metronidazole ........10, 61, 113 mexiletine.............................43 MIACALCIN ...........................91 mibelas 24 fe ......................117 MICARDIS..............................48 MICARDIS HCT ......................48 miconazole-3 ......................113 MICRO BLOOD GLUCOSE......81 MICRO THIN LANCETS ..........85 MICRODOT BLOOD GLUCOSE

SYSTEM .............................81 microgestin 1.5/30 (21)......117 microgestin 1/20 (21) .........117 MICROGESTIN 24 FE ...........117 microgestin fe 1.5/30 (28)..117 microgestin fe 1/20 (28).....117 MICROLET LANCET ...............85 MICROZIDE ...........................48 midazolam ............................39 midodrine .............................71 migergot ...............................26

miglitol ..................................93 miglustat ...............................91 MIGRANAL ............................26 mili ......................................117 millipred................................77 MILLIPRED.............................77 millipred dp...........................77 mimvey ...............................112 mimvey lo ...........................112 MINASTRIN 24 FE................117 MINI ULTRA-THIN II ..............85 MINIPRESS ............................48 MINITRAN .............................56 MINIVELLE...........................112 minocycline...........................13 minoxidil ...............................48 MIOCHOL-E.........................122 miostat................................123 MIRAPEX ...............................24 MIRAPEX ER ..........................24 MIRCERA.............................102 MIRCETTE (28) ....................117 mirtazapine...........................39 misoprostol.........................101 MITOSOL.............................123 M-M-R II (PF).......................107 MOBIC...................................34 modafinil...............................39 moderiba ............................103 moderiba dose pack ...........103 moexipril...............................48 moexipril-hydrochlorothiazide

..........................................48 mometasone.................68, 131 MONOCLATE-P .....................52 monoject 0.9% sodium

chloride.............................71 MONOJECT BLOOD

COLLECTION......................85 MONOJECT HYPODERMIC

NEEDLES............................85 MONOJECT MEDICATION

TRANSF NDL......................85 monoject prefill advanced ns

..........................................71 monoject prefill saline flush .72

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156

MONOLET THIN LANCETS.....85 mono-linyah .......................117 mononessa (28)..................117 montelukast .......................131 MONUROL ............................13 MORPHABOND ER................31 morphine..............................31 morphine concentrate .........31 MOTOFEN.............................96 MOVANTIK............................99 MOXEZA..............................120 moxifloxacin .................12, 120 MOZOBIL ............................102 MS CONTIN...........................31 MULPLETA ............................52 MULTAQ ...............................43 MULTI-DRAW NEEDLE ..........85 multivitamin with fluoride .138 multi-vitamin with fluoride 138 multi-vitamin with fluoride 138 multivitamins with fluoride 138 multivit-fluor (vit e acetate)

........................................138 mupirocin .............................63 mupirocin calcium................63 MUSE ..................................135 mvc-fluoride .......................138 my choice ...........................117 my way ...............................117 MYALEPT...............................91 MYAMBUTOL........................10 MYCOBUTIN .........................10 mycophenolate mofetil ..16, 17 mycophenolate sodium........17 MYDAYIS...............................39 MYDRIACYL.........................122 MYFORTIC.............................17 MYGLUCOHEALTH ................81 MYGLUCOHEALTH LANCETS.85 MYLERAN..............................17 mynatal...............................138 mynatal advance ................138 mynatal plus .......................138 mynatal-z............................138 mynate 90 plus...................138 myorisan...............................61

MYRBETRIQ ........................133 MYSOLINE.............................22 MYTESI..................................96 myzilra ................................117 N nabumetone .........................34 nadolol..................................48 nadolol-bendroflumethiazide

..........................................48 naftifine ................................64 NAFTIN..................................64 NALFON ................................34 naloxone...............................34 naltrexone ............................35 NAMENDA ............................27 NAMENDA TITRATION PAK ..28 NAMENDA XR .......................28 NAMZARIC ............................28 NAPRELAN CR .......................34 NAPROSYN............................34 naproxen...............................34 naproxen sodium..................34 naratriptan............................26 NARCAN................................35 NARDIL..................................39 NATACYN ............................121 NATAZIA..............................117 nateglinide............................93 NATPARA ..............................91 NATROBA..............................69 nature-throid........................94 NEBUPENT ............................10 necon 0.5/35 (28) ...............117 necon 1/50 (28) ..................117 necon 7/7/7 (28).................117 NEEDLES, HUBER DISPOSABLE

..........................................85 nefazodone...........................39 neomycin ..............................10 neomycin-bacitracin-poly-hc

........................................124 neomycin-bacitracin-

polymyxin .......................121 neomycin-polymyxin b gu ....70 neomycin-polymyxin b-

dexameth........................124

neomycin-polymyxin-gramicidin .......................121

neomycin-polymyxin-hc ......77, 124

neo-polycin .........................121 neo-polycin hc ....................124 NEORAL.................................17 NEOSALUS.............................59 NEOSPORIN GU IRRIGANT ....70 NEO-SYNALAR.......................63 NEO-SYNALAR KIT.................63 NEPTAZANE.........................123 NERLYNX ...............................17 neuac ....................................61 NEULASTA...........................102 NEUPOGEN .........................102 NEUPRO ................................24 NEURONTIN ..........................22 NEUTEK 2TEK TEST STRIPS....81 nevirapine...............................5 new day ..............................118 newgen ...............................138 NEXAVAR ..............................17 NEXIUM...............................101 NEXIUM PACKET .................101 next choice one dose..........118 niacin ....................................54 NIACOR .................................54 NIASPAN EXTENDED-RELEASE

..........................................54 nicardipine............................48 NICODERM CQ ......................75 NICORETTE............................75 nicotine.................................75 nicotine (polacrilex) ..............75 NICOTROL .............................75 NICOTROL NS ........................75 nifedipine..............................48 nikki (28) .............................118 NILANDRON ..........................17 nilutamide.............................17 nimodipine............................48 NINLARO ...............................17 nisoldipine ............................48 nitro-bid................................56 NITRO-DUR ...........................56

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157

nitrofurantoin.......................13 nitrofurantoin macrocrystal .13 nitrofurantoin monohyd/m-

cryst ..................................13 nitroglycerin .........................56 NITROLINGUAL .....................56 NITROMIST ...........................56 NITROSTAT ...........................56 nitro-time .............................56 NITYR ....................................72 NIVESTYM...........................102 nizatidine............................101 NIZORAL................................64 nodolor .................................26 NOKOR NEEDLE ....................85 nora-be ...............................112 NORCO..................................31 NORDITROPIN FLEXPRO .....103 noreth-ethinyl estradiol-iron

........................................118 norethindrone (contraceptive)

........................................112 norethindrone acetate .......112 norethindrone ac-eth estradiol

................................112, 118 norethindrone-e.estradiol-iron

........................................118 norgestimate-ethinyl estradiol

........................................118 norgestrel-ethinyl estradiol118 norlyda ...............................112 norlyroc ..............................112 normal saline flush ...............72 NORPACE ..............................43 NORPACE CR.........................43 NORPRAMIN.........................39 NORTHERA............................72 nortrel 0.5/35 (28)..............118 nortrel 1/35 (21).................118 nortrel 1/35 (28).................118 nortrel 7/7/7 (28) ...............118 nortriptyline .........................39 NORVASC..............................48 NORVIR ...................................5 NOVA MAX GLUCOSE TEST ..81 NOVA SAFETY LANCETS........85

NOVA SUREFLEX LANCETS....85 NOVOEIGHT..........................52 NOVOFINE 32 .......................85 NOVOFINE AUTOCOVER.......85 NOVOFINE PLUS ...................85 NOVOLIN 70/30 U-100

INSULIN.............................89 NOVOLIN 70-30 FLEXPEN U-

100....................................89 NOVOLIN N NPH U-100

INSULIN.............................89 NOVOLIN R REGULAR U-100

INSULN..............................89 NOVOLOG FLEXPEN U-100

INSULIN.............................89 NOVOLOG MIX 70-30 U-100

INSULN..............................89 NOVOLOG MIX 70-30FLEXPEN

U-100 ................................89 NOVOLOG PENFILL U-100

INSULIN.............................89 NOVOLOG U-100 INSULIN

ASPART .............................89 NOVOPEN ECHO ...................85 NOVOSEVEN RT ....................52 NOXAFIL..................................2 np thyroid .............................94 NUCYNTA..............................31 NUCYNTA ER.........................31 NUEDEXTA ............................28 NULEV...................................96 NULYTELY WITH FLAVOR

PACKS................................99 NUOX ....................................61 NUPLAZID .............................39 NUVARING..........................113 NUVESSA.............................113 NUVIGIL ................................39 nyamyc .................................64 nystatin.............................2, 64 nystatin-triamcinolone.........64 nystop...................................64 O obstetrix dha ......................138 OCALIVA................................99 ocella ..................................118

octreotide acetate ................17 OCUFLOX.............................121 ODACTRA ............................107 ODEFSEY .................................5 ODOMZO ..............................17 OFEV ...................................131 ofloxacin .................12, 76, 121 ogestrel (28)........................118 olanzapine ............................39 olanzapine-fluoxetine...........39 olmesartan............................48 olmesartan-amlodipin-

hcthiazid ...........................48 olmesartan-

hydrochlorothiazide .........48 olopatadine...................76, 122 OLUX .....................................68 OLUX-E ..................................68 OMECLAMOX-PAK ..............101 omeprazole.........................101 OMNIPRED..........................125 ON CALL EXPRESS TEST STRIP

..........................................81 ON CALL LANCET...................85 ON CALL PLUS LANCET..........85 ON CALL PLUS TEST STRIP.....81 ON CALL VIVID TEST STRIP....81 ondansetron .........................99 ondansetron hcl....................99 ONETOUCH ULTRA BLUE TEST

STRIP .................................81 ONETOUCH ULTRA TEST.......81 ONETOUCH ULTRASOFT

LANCETS............................85 ONETOUCH VERIO ................81 ONFI ......................................22 ONMEL....................................2 ON-THE-GO LANCETS............85 OPANA ..................................31 opcicon one-step ................118 OPSUMIT.............................131 option-2 ..............................118 OPTIUM EZ............................81 OPTIUM TEST........................81 OPTUMRX .............................81 ORALAIR..............................107

Effective 1/2019

158

oralone .................................76 ORAMAGICRX .......................76 ORAP.....................................39 ORAPRED ODT ......................77 ORAVIG...................................2 ORENCIA .............................110 ORENCIA CLICKJECT............110 ORENITRAM..........................48 ORFADIN...............................72 ORILISSA ...............................91 ORKAMBI ............................131 orphenadrine citrate ............29 orsythia...............................118 ORTHO MICRONOR ............112 ORTHO TRI-CYCLEN (28).....118 ORTHO TRI-CYCLEN LO (28)118 ORTHO-CYCLEN (28)...........118 ORTHO-NOVUM 1/35 (28) .118 ORTHO-NOVUM 7/7/7 (28) 118 oseltamivir..............................5 OSMOPREP ...........................99 OSPHENA............................113 OTEZLA ...............................110 OTEZLA STARTER ................110 OTOVEL.................................77 OVACE...................................57 OVACE PLUS .........................57 OVACE PLUS SHAMPOO .......57 OVACE PLUS WASH ..............57 OVIDE ...................................69 OVIDREL................................91 OXANDRIN ............................91 oxandrolone .........................91 oxaprozin..............................34 oxazepam .............................39 oxcarbazepine ......................22 oxiconazole...........................65 OXISTAT ................................65 OXSORALEN ULTRA ..............59 OXTELLAR XR ........................22 oxybutynin chloride....133, 134 oxycodone ............................31 oxycodone-acetaminophen .31oxycodone-aspirin ................31 oxymorphone .......................31 OXYTROL.............................134

OZEMPIC...............................93 P pacerone...............................43 PACNEX.................................61 paliperidone .........................40 PALYNZIQ..............................91 PAMELOR..............................40 PANDEL.................................68 PANRETIN .............................59 pantoprazole ......................101 PARAFON FORTE DSC ...........29 paregoric...............................96 PAREMYD............................122 paricalcitol ............................91 PARLODEL .............................24 PARNATE...............................40 paromomycin .......................10 paroxetine hcl.......................40 PASER....................................10 PATADAY.............................122 PATANASE.............................76 PATANOL ............................122 PAXIL.....................................40 PAXIL CR................................40 PAZEO .................................123 PCE..........................................9 PEDIAPRED............................77 PEDIARIX (PF)......................107 PEDVAX HIB (PF) .................107 peg 3350-electrolytes...........99 peg-3350 with flavor packs ..99 PEGANONE ...........................22 PEGASYS .............................103 PEGASYS PROCLICK.............103 peg-electrolyte soln..............99 PEGINTRON ........................103 peg-prep ...............................99 PEN NEEDLE..........................85 PEN NEEDLE, DIABETIC .........85 penicillin v potassium...........12 PENLAC .................................65 PENTACEL (PF) ....................107 PENTACEL ACTHIB

COMPONENT (PF)...........107 PENTASA...............................99 pentazocine-naloxone..........31

PENTIPS.................................86 pentoxifylline........................52 PEPCID ................................101 PERCOCET .............................31 PERFOROMIST ....................131 PERIDEX ................................76 PERIFLEX ADVANCE ..............73 PERIFLEX INFANT ..................73 PERIFLEX JUNIOR ..................73 PERIFLEX LQ PKU ..................73 perindopril erbumine ...........48 periogard ..............................76 permethrin............................69 perphenazine........................40 perphenazine-amitriptyline..40 PERSERIS ...............................40 PEXEVA .................................40 PHARMACIST CHOICE ...........81 PHASEAL PROTECTOR...........86 PHENACTIN AA PLUS 20 PE...73 phenadoz ............................126 phenazopyridine.................135 phendimetrazine tartrate.....70 phenelzine ............................40 phenergan...........................126 PHENEX-1..............................73 PHENEX-2..............................73 phenobarbital .......................22 phenoxybenzamine ..............48 phentermine.........................70 PHENYLADE 40......................73 PHENYLADE 60......................73 PHENYLADE AMINO ACID .....73 PHENYLADE AMINO ACIDS ...73 PHENYLADE DRINK MIX ........73 PHENYLADE ESSENTIAL.........73 PHENYLADE GMP............73, 74 PHENYLADE GMP MIX-IN......73 PHENYLADE MTE AMINO

ACIDS ................................74 phenylade phebloc ...............74 PHENYLADE PHEBLOC...........74 PHENYLADE RTD PKU 10.......74 phenylephrine hcl...............126 PHENYL-FREE 1 .....................74 PHENYL-FREE 2 PKU..............74

Effective 1/2019

159

PHENYL-FREE 2HP PKU.........74 PHENYTEK.............................22 phenytoin .............................22 phenytoin sodium extended 22 philith .................................118 PHLEXY-10 ............................74 PHLEXY-10 DRINK MIX

POWDER...........................74 PHOSLYRA.............................99 phosphate laxative ...............99 PHOSPHOLINE IODIDE........122 phrenilin forte(with caffeine)

..........................................26 PHYSIOLYTE ..........................70 PHYSIOSOL IRRIGATION .......70 phytonadione (vitamin k1)...52 PICATO..................................59 pilocarpine hcl ........72, 76, 122 pimozide...............................40 pimtrea (28)........................118 pindolol.................................48 pioglitazone..........................93 pioglitazone-glimepiride ......94 pioglitazone-metformin .......94 pirmella ..............................118 piroxicam..............................34 PKU 2 ....................................74 PKU 3 ....................................74 PKU AIR15.............................74 PKU AIR20.............................74 PKU COOLER 10 ....................74 PKU COOLER 15 ....................74 PKU COOLER 20 ....................74 PKU EASY MICROTABS..........74 PKU EXPRESS15 ....................74 PKU EXPRESS20 ....................74 PKU GEL POWDER ................74 PKU LOPHLEX........................74 PKU PERIFLEX EARLY YEARS .74 PKU PERIFLEX JUNIOR PLUS .74 PKU SPHERE20......................74 PKU TRIO ..............................74 PLAQUENIL ...........................10 PLAVIX ..................................52 PLEGRIDY ............................103 PLEXION..........................61, 62

PLEXION CLEANSING CLOTHS ..........................................61

PNEUMOVAX 23 .................107 pnv 29-1..............................138 pnv ob+dha.........................138 pnv-dha...............................138 pnv-dha + docusate ............138 pnv-ferrous fumarate-docu-fa

........................................138 pnv-omega..........................139 pnv-select ...........................139 pnv-vp-u .............................139 PODOCON.............................58 podofilox...............................59 POLY HUB NEEDLE ................86 polycin ................................121 polyethylene glycol 3350......99 polymyxin b sulf-trimethoprim

........................................121 POLYTRIM ...........................121 POMALYST ..........................103 PONSTEL ...............................34 portia ..................................118 POTABA ..............................136 potassium bicarb and chloride

........................................136 potassium bicarb-citric acid136 potassium chloride .............136 potassium citrate................135 potassium citrate-citric acid

........................................135 POTASSIUM HYDROXIDE ......58 pr natal 400 ........................139 pr natal 400 ec....................139 pr natal 430 ........................139 pr natal 430 ec....................139 PRADAXA ..............................52 PRALUENT PEN .....................54 pramcort...............................99 pramipexole..........................24 PRANDIN...............................94 prasugrel...............................52 PRAVACHOL..........................54 pravastatin............................54 praziquantel..........................10 prazosin ................................48

PRECISION PCX PLUS TEST....81 PRECISION PCX TEST.............81 PRECISION POINT OF CARE

TEST ..................................81 PRECISION Q-I-D TEST...........81 PRECISION XTRA TEST...........81 PRECOSE ...............................94 PRED FORTE........................125 PRED MILD ..........................125 PRED-G................................124 PRED-G S.O.P. .....................124 prednicarbate .......................68 prednisolone.........................78 prednisolone acetate..........125 prednisolone sodium

phosphate.................78, 125 prednisone............................78 prednisone intensol..............78 PREFEST ..............................112 PREGNYL ...............................91 PREMARIN ..........................112 PREMIER TEST STRIP.............81 PREMIUM V10 ......................81 PREMPHASE........................112 PREMPRO............................112 prena1 chew .......................139 prena1 pearl .......................139 prena1 true.........................139 prenaissance.......................139 prenaissance plus ...............139 prenatabs fa........................139 prenatabs rx........................139 prenatal ..............................139 prenatal formula.................139 prenatal multi-dha (algal oil)

........................................139 prenatal one daily...............139 prenatal plus.......................139 prenatal plus (calcium carb)

........................................139 prenatal vitamin .................139 prenatal vitamin plus low iron

........................................139 prenatal-u ...........................139 preplus................................139

Effective 1/2019

160

PRESSURE ACTIVATED LANCETS ...........................86

pretab .................................139 PREVACID SOLUTAB ...........102 prevalite ...............................54 PREVIDENT ...........................76 PREVIDENT 5000 BOOSTER

PLUS..................................76 PREVIDENT 5000 DRY MOUTH

..........................................76 PREVIDENT 5000 ENAMEL

PROTECT ...........................76 PREVIDENT 5000 SENSITIVE .76 previfem .............................118 PREVNAR 13 (PF) ................107 PREVPAC.............................102 PREZCOBIX..............................5 PREZISTA.................................5 PRIFTIN .................................10 PRILOSEC ............................102 PRIMAQUINE ........................10 primidone.............................22 PRIMLEV ...............................31 PRIMSOL ...............................13 PRINIVIL ................................49 PRISTIQ .................................40 PRO COMFORT LANCET........86 PRO VOICE V8-V9 TEST STRIP

..........................................81 PROAIR HFA........................131 PROAIR RESPICLICK ............131 probenecid .........................108 probenecid-colchicine ........108 PROCARDIA...........................49 PROCARDIA XL......................49 procentra..............................40 prochlorperazine ..................99 prochlorperazine maleate....99 PROCRIT..............................103 PROCTOCORT .......................99 procto-med hc......................99 procto-pak ............................99 proctosol hc..........................99 proctozone-hc ......................99 PROCYSBI............................135 PRODIGY LANCETS................86

PRODIGY NO CODING...........81 PRODIGY TWIST TOP LANCET

..........................................86 PROFILNINE ..........................52 progesterone micronized ...112 PROGLYCEM .........................82 PROGRAF ..............................17 PROLENSA...........................123 PROMACTA...........................52 promethazine .....................126 promethazine vc.................127 promethazine vc-codeine...127 promethazine-codeine .......127 promethazine-dm...............127 promethazine-phenyleph-

codeine ...........................127 promethegan......................127 PROMETRIUM.....................113 PROMISEB.............................59 propafenone.........................43 propantheline.......................96 proparacaine ......................123 propranolol...........................49 propranolol-

hydrochlorothiazid ...........49 propylthiouracil ....................78 PROQUAD (PF)....................107 PRO-RED AC (W/

DEXCHLORPHENIR).........128 PROSCAR.............................134 PROSTIN VR PEDIATRIC ......135 PROTONIX...........................102 protriptyline..........................40 PROVENTIL HFA ..................131 PROVERA ............................113 PROZAC.................................40 pruclair..................................59 prudoxin ...............................59 prutect ..................................59 PSORCON..............................68 PULMICORT ........................131 PULMICORT FLEXHALER .....131 pulmosal .............................131 PULMOZYME ......................131 PURIXAN ...............................17 PYLERA................................102

pyrazinamide ........................10 PYRIDIUM ...........................135 pyridostigmine bromide .......29 Q QSYMIA.................................70 QUADRACEL (PF).................107 QUALAQUIN..........................10 QUARTETTE.........................118 quasense.............................119 quazepam .............................40 QUDEXY XR ...........................22 QUESTRAN ............................55 QUESTRAN LIGHT .................54 quetiapine.............................40 QUILLICHEW ER ....................40 QUILLIVANT XR .....................40 quinapril................................49 quinapril-hydrochlorothiazide

..........................................49 quinidine gluconate..............43 quinidine sulfate...................43 quinine sulfate......................10 QUINTET AC ..........................81 QVAR...................................131 QVAR REDIHALER................131 R RABAVERT (PF)....................107 rabeprazole.........................102 RADIOGARDASE....................72 RAGWITEK...........................107 rajani ...................................119 raloxifene............................109 ramipril .................................49 RANEXA.................................55 ranitidine hcl.......................102 RAPAFLO .............................134 RAPAMUNE...........................17 rasagiline...............................24 RAVICTI .................................72 RAZADYNE ............................28 RAZADYNE ER .......................28 REBETOL..............................103 REBIF (WITH ALBUMIN) ......103 REBIF REBIDOSE..................104 REBIF TITRATION PACK.......104 reclipsen (28) ......................119

Effective 1/2019

161

RECOMBINATE......................52 RECOMBIVAX HB (PF).........107 REFUAH PLUS .......................81 REGIMEX...............................70 REGLAN.................................99 REGRANEX ............................59 RELAGARD ..........................113 relcof c................................128 RELENZA DISKHALER ..............5 RELIAMED LANCET ...............86 RELIAMED SAFETY SEAL

LANCETS ...........................86 RELION CONFIRM-MICRO ....81 RELION NEEDLES ..................86 RELION PEN NEEDLES...........86 RELION PRIME TEST STRIPS..81 RELION THIN LANCETS..........86 RELION ULTRA THIN PLUS

LANCETS ...........................86 RELISTOR ..............................99 relnate dha .........................139 RELPAX..................................26 REMERON.............................40 REMERON SOLTAB ...............40 REMODULIN .........................49 RENAGEL...............................99 RENVELA.............................100 repaglinide............................94 repaglinide-metformin.........94 REPATHA PUSHTRONEX .......55 REPATHA SURECLICK ............55 REPATHA SYRINGE................55 reprexain ..............................32 REQUIP .................................24 REQUIP XL.............................24 RESCRIPTOR............................5 RESPA-AR............................128 RESTORIL ..............................40 RETIN-A.................................62 RETROVIR ...............................5 REVATIO......................131, 132 REVEAL TEST STRIP...............82 REVIA ....................................34 REVLIMID............................104 REXULTI ................................40 REYATAZ .................................5

RHOPRESSA ........................123 ribasphere ..........................104 ribavirin ..............................104 RIDAURA.............................110 rifabutin ................................10 RIFADIN.................................10 RIFAMATE.............................10 rifampin ................................11 RIFATER.................................11 RIGHTEST GL300 LANCETS....86 RIGHTEST GS550 TEST STRIPS

..........................................82 RILUTEK.................................72 riluzole ..................................72 rimantadine ............................5 ringer's..................................70 RIOMET.................................94 risacal-d ..............................139 risedronate ...................72, 109 RISPERDAL ............................41 RISPERDAL CONSTA..............40 RISPERDAL M-TAB ................41 risperidone ...........................41 RITALIN .................................41 ritonavir ..................................5 rivastigmine ..........................28 rivastigmine tartrate ............28 rivelsa .................................119 RIXUBIS .................................53 rizatriptan .............................26 robafen ac...........................128 ROBAXIN ...............................29 ROBAXIN-750........................29 ROBINUL ...............................96 ROBINUL FORTE....................96 ROCALTROL...........................91 ropinirole ..............................24 rosadan.................................62 ROSANIL................................62 ROSULA.................................62 rosula cleansing cloths .........62 rosuvastatin..........................55 ROTARIX..............................107 ROTATEQ VACCINE.............107 ROWASA .............................100 roweepra ..............................22

roweepra xr ..........................22 ROXICODONE........................32 ROZEREM..............................41 RUBRACA ..............................17 RUCONEST ..........................132 RYDAPT .................................17 rydex ...................................128 RYTHMOL SR.........................43 S SABRIL ...................................22 SAFETY LANCETS...................86 SAFETY SEAL LANCETS ..........86 SAFETY-LET LANCETS ............86 SAFYRAL ..............................119 SALAGEN (PILOCARPINE) 72, 76 SALEX ....................................58 salicylic acid ..........................58 salicylic acid er-ceramides ....58 salsalate ................................34 SAMSCA ................................91 SANDIMMUNE......................17 SANDOSTATIN.......................17 SANTYL..................................69 SAPHRIS ................................41 SAPHRIS (BLACK CHERRY).....41 SARAFEM ..............................41 SAVELLA ..............................110 SAXENDA...............................70 scopolamine base ...............100 SEASONIQUE.......................119 seb-prev................................57 seconal sodium.....................41 selegiline hcl .........................24 selenium sulfide....................57 SELZENTRY ..............................5 SEMPREX-D.........................128 se-natal 19 ..........................139 se-natal 19 (with docusate)139 SENSIPAR ..............................91 SEREVENT DISKUS...............132 SEROQUEL.............................41 SEROQUEL XR .......................41 sertraline...............................41 setlakin................................119 sevelamer carbonate..........100 sf 76

Effective 1/2019

162

sf 5000 plus ..........................76 sharobel..............................113 SHINGRIX (PF) .....................107 SHINGRIX GE ANTIGEN

COMPONENT..................107 SIGNIFOR ..............................17 SIKLOS...................................17 sildenafil .............................135 sildenafil (antihypertensive)

........................................132 SILIQ......................................57 SILVADENE............................58 silver nitrate .........................59 silver nitrate applicators ......59 silver sulfadiazine .................58 SIMPONI .............................110 simvastatin ...........................55 SINEMET ...............................24 SINEMET CR..........................24 SINGLE-LET ...........................86 SINGULAIR ..........................132 sirolimus ...............................17 SIRTURO ...............................11 SKELAXIN ..............................29 SMART SENSE LANCETS........86 SMART SENSE TEST STRIPS...82 SMARTEST LANCET...............86 SMARTEST TEST....................82 sodium chlor 0.9% bacteriostat

..........................................72 sodium chloride............72, 132 sodium chloride 0.9 %..........72 sodium phenylbutyrate........72 sodium polystyrene sulfonate

........................................100 SODIUM POLYSTYRENE

SULFONATE ....................100 SOFT TOUCH LANCETS..........86 SOLESTA..............................100 SOLIQUA 100/33...................89 soloxide ................................13 SOLTAMOX ...........................17 SOLUS V2 LANCETS...............86 SOMA....................................29 SOMAVERT ...........................91 SONATA ................................41

SORBITOL..............................70 SORBITOL-MANNITOL ..........70 SORIATANE ...........................57 sorine....................................43 sotalol ...................................43 sotalol af ...............................43 SOTYLIZE ...............................43 SOVALDI..................................5 spinosad................................69 SPIRIVA RESPIMAT..............132 SPIRIVA WITH HANDIHALER

........................................132 spironolactone......................49 spironolacton-

hydrochlorothiaz ..............49 SPORANOX..............................2 SPORANOX PULSEPAK ............2 sprintec (28) .......................119 SPRITAM ...............................22 SPRIX.....................................34 SPRYCEL ................................17 sps (with sorbitol)...............100 sronyx .................................119 ssd.........................................58 SSKI .......................................78 sss 10-5 .................................62 STALEVO 100 ........................24 STALEVO 125 ........................24 STALEVO 150 ........................24 STALEVO 200 ........................25 STALEVO 50 ..........................25 STALEVO 75 ..........................25 STAMARIL (PF) ....................107 STARLIX.................................94 stavudine ............................5, 6 STAXYN ...............................135 STELARA................................57 STENDRA.............................135 STERILANCE TL......................86 STIMATE................................91 STIOLTO RESPIMAT.............132 STIVARGA..............................18 STRATTERA ...........................41 STRENSIQ..............................91 STRIANT ................................92 STRIBILD..................................6

STRIVERDI RESPIMAT..........132 STROMECTOL........................11 strong iodine.......................137 SUBOXONE............................19 subvenite ..............................22 subvenite starter (blue) kit ...22 subvenite starter (green) kit.23 subvenite starter (orange) kit

..........................................23 SUCRAID..............................100 sucralfate ............................102 SULAR....................................49 sulfacetamide sodium ..57, 125 sulfacetamide sodium (acne)63 sulfacetamide sodium-sulfur62 sulfacetamide sod-sulfur-urea

..........................................62 sulfacetamide-prednisolone

........................................125 sulfadiazine...........................12 sulfamethoxazole-

trimethoprim ....................12 SULFAMYLON........................63 sulfasalazine .......................100 sulfatrim................................12 sulindac.................................34 sumatriptan ..........................26 sumatriptan succinate ....26, 27 SUMAVEL DOSEPRO .............27 SUMAXIN ..............................62 SUPER THIN LANCETS ...........86 SUPRAX ...................................8 SUPREP BOWEL PREP KIT ...100 SURE COMFORT LANCETS.....86 SURE COMFORT PEN NEEDLE

..........................................86 SURE-FINE PEN NEEDLES ......86 SURE-LANCE..........................86 SURE-TEST EASYPLUS MINI...82 SURE-TOUCH LANCET ...........86 SURGUARD2 SAFETY.............86 SURMONTIL ..........................41 SUSTIVA ..................................6 SUTENT .................................18 syeda...................................119 SYLATRON ...........................104

Effective 1/2019

163

SYMBICORT.........................132 SYMBYAX ..............................41 SYMDEKO ...........................132 SYMFI......................................6 SYMFI LO.................................6 SYMLINPEN 120....................94 SYMLINPEN 60......................94 SYMTUZA................................6 SYNALAR...............................68 SYNALAR CREAM KIT ............68 SYNALAR OINTMENT KIT ......68 SYNALAR TS ..........................69 SYNALGOS-DC.......................32 SYNAREL ...............................92 SYNDROS ............................100 SYNERA .................................63 SYNJARDY .............................94 SYNJARDY XR ........................94 SYNTHROID...........................94 syrex sodium chloride 0.9 %.72 T TABLOID................................18 TACLONEX.............................57 tacrolimus.......................18, 59 tadalafil.......................134, 135 tadalafil (antihypertensive) 132 TAFINLAR..............................18 TAGRISSO..............................18 TAKHZYRO ..........................132 TALTZ AUTOINJECTOR..........57 TALTZ AUTOINJECTOR (2 PACK)

..........................................57 TALTZ AUTOINJECTOR (3 PACK)

..........................................57 TALTZ SYRINGE .....................58 TALTZ SYRINGE (2 PACK) ......57 TALTZ SYRINGE (3 PACK) ......58 TAMIFLU .................................6 tamoxifen .............................18 tamsulosin ..........................134 TAPAZOLE .............................78 TARCEVA...............................18 TARGRETIN ...........................18 tarina fe 1/20 (28) ..............119 TARKA ...................................49 taron-c dha .........................139

taron-prex prenatal-dha.....140 TASIGNA ...............................18 TASMAR................................25 TAVALISSE.............................53 tazarotene ............................62 TAZORAC...............................62 taztia xt .................................49 TECFIDERA ..........................104 TECHLITE LANCETS ...............86 TECHLITE PEN NEEDLE..........87 TEGRETOL .............................23 TEGRETOL XR........................23 TEKTURNA ............................49 TEKTURNA HCT.....................49 TELCARE TEST STRIPS ...........82 telmisartan ...........................49 telmisartan-amlodipine........49 telmisartan-hydrochlorothiazid

..........................................49 temazepam...........................41 TEMODAR .............................18 TEMOVATE............................69 temozolomide ......................18 tencon...................................27 TENIVAC (PF).......................107 tenofovir disoproxil fumarate 6 TENORETIC 100.....................49 TENORETIC 50.......................49 TENORMIN............................49 TERAZOL 7 ..........................113 terazosin ...............................49 terbinafine hcl ........................2 terbutaline..........................132 terconazole.........................113 TESSALON PERLES...............128 TEST N'GO TEST ....................82 testosterone .........................92 testosterone cypionate ........92 testosterone enanthate .......92 TESTRED................................92 TETANUS,DIPHTHERIA TOX

PED(PF) ...........................108 TETANUS-DIPHTHERIA

TOXOIDS-TD....................108 tetrabenazine .......................28 tetracaine hcl......................123

tetracaine hcl (pf) ...............123 tetracycline ...........................13 TETRAVISC...........................123 TETRAVISC FORTE ...............123 TEXACORT.............................69 THALOMID ............................18 THEO-24..............................132 theochron ...........................132 theophylline........................132 thermazene...........................58 THIOLA ..................................72 thioridazine...........................41 thiothixene ...........................41 thyroid (pork)........................94 THYROLAR-1 .........................94 THYROLAR-1/2......................94 THYROLAR-1/4......................94 THYROLAR-2 .........................95 THYROLAR-3 .........................95 tiagabine ...............................23 TIAZAC...................................49 TIBSOVO................................18 TICE BCG .............................108 ticlopidine .............................53 TIGAN..................................100 tiglutik...................................72 TIKOSYN ................................43 tilia fe ..................................119 timolol maleate ............49, 121 TIMOPTIC............................121 TIMOPTIC OCUDOSE (PF)....121 TIMOPTIC-XE.......................122 TINDAMAX ............................11 tinidazole ..............................11 tis-u-sol pentalyte.................70 TIVICAY ...................................6 tizanidine ..............................29 tl g-fol os .............................140 TOBI ......................................11 tobramycin..........................121 tobramycin in 0.225 % nacl ..11 tobramycin-dexamethasone

........................................124 TOBREX ...............................121 TOFRANIL..............................41 tolazamide ............................94

Effective 1/2019

164

tolbutamide..........................94 tolcapone..............................25 tolmetin................................34 tolterodine..........................134 TOPAMAX .............................23 TOPCARE UNIVERSAL1 LANCET

..........................................87 TOPICORT .............................69 topiramate............................23 TOPIRAMATE ........................23 TOPROL XL ............................49 torsemide .............................49 TOUJEO MAX U-300 SOLOSTAR

..........................................89 TOUJEO SOLOSTAR U-300

INSULIN.............................89 TRACLEER............................132 TRADJENTA...........................94 tramadol ...............................32 tramadol-acetaminophen ....32 trandolapril...........................50 trandolapril-verapamil .........50 tranexamic acid ..................113 TRANSDERM-SCOP .............100 TRANXENE T-TAB..................41 tranylcypromine ...................41 TRAVATAN Z .......................124 trazodone .............................41 TRECATOR.............................11 TRELEGY ELLIPTA ................132 TREMFYA ..............................58 TRESIBA FLEXTOUCH U-100 .90 TRESIBA FLEXTOUCH U-200 .90 tretinoin................................62 tretinoin (chemotherapy).....18 tretinoin (emollient).............62 tretinoin microspheres.........62 TRETIN-X...............................62 TRETIN-X CREAM KIT ............62 TREXALL ................................18 TREZIX...................................32 tri femynor .........................119 triamcinolone acetonide 69, 76 triamterene-

hydrochlorothiazid ...........50 trianex ..................................69

triazolam...............................41 TRIBENZOR ...........................50 TRICOR..................................55 triderm..................................69 tri-estarylla .........................119 trifluoperazine......................41 trifluridine...........................121 TRIGLIDE ...............................55 trihexyphenidyl.....................25 tri-legest fe .........................119 TRILEPTAL .............................23 tri-linyah .............................119 TRILIPIX .................................55 tri-lo-estarylla .....................119 tri-lo-marzia........................119 tri-lo-sprintec......................119 trilyte with flavor packets...100 trimethobenzamide............100 trimethoprim........................13 tri-mili .................................119 trimipramine.........................42 trinatal gt ............................140 trinatal rx 1 .........................140 trinate.................................140 trinessa (28)........................119 trinessa lo ...........................119 TRI-NORINYL (28)................119 TRINTELLIX............................42 triple vitamin with fluoride 140 tri-previfem (28) .................119 tri-sprintec (28)...................119 tri-tabs dha .........................140 TRIUMEQ ................................6 triveen-duo dha..................140 tri-vit with fluoride and iron

........................................140 tri-vitamin with fluoride .....140 tri-vite with fluoride ...........140 trivora (28)..........................119 tri-vylibra ............................119 TRIZIVIR ..................................6 TROKENDI XR........................23 tropicamide ........................122 trospium .............................134 TRUE METRIX GLUCOSE TEST

STRIP.................................82

TRUEPLUS GLUCOSE .............82 TRUEPLUS LANCETS..............87 TRUETEST TEST STRIPS .........82 TRUETRACK TEST ..................82 TRULICITY..............................94 TRUMENBA .........................108 TRUSOPT.............................124 trust natal dha ....................140 TRUVADA ................................6 TUDORZA PRESSAIR............133 tulana..................................119 tusnel c................................128 TUSSICAPS...........................128 tussigon...............................128 TUSSIONEX PENNKINETIC ER

........................................128 TWINRIX (PF).......................108 TWYNSTA..............................50 TYBOST....................................6 tydemy................................119 TYKERB..................................18 TYLENOL-CODEINE #3...........32 TYLENOL-CODEINE #4...........32 TYMLOS...............................109 TYPHIM VI ...........................108 TYVASO ...............................133 TYVASO INSTITUTIONAL START

KIT ...................................133 TYVASO REFILL KIT ..............133 TYVASO STARTER KIT ..........133 U UCERIS ................................100 ULESFIA.................................69 ULORIC................................108 ULTICARE PEN NEEDLE .........87 ULTILET BASIC LANCETS........87 ULTILET CLASSIC LANCETS ....87 ULTILET LANCETS..................87 ULTILET PEN NEEDLE ............87 ULTILET SAFETY LANCETS .....87 ULTIMA TEST STRIPS.............82 ultimatecare one ................140 ultimatecare one nf ............140 ULTRA THIN LANCETS ...........87 ULTRA THIN PLUS LANCETS ..87 ULTRA TLC LANCETS .............87

Effective 1/2019

165

ULTRACET .............................32 ULTRALANCE LANCETS .........87 ULTRAM................................32 ULTRAM ER...........................32 ULTRA-THIN II INS PEN

NEEDLES ...........................87 ULTRATRAK...........................82 ULTRATRAK ULTIMATE.........82 ULTRAVATE X........................69 UNIFINE PENTIPS..................87 UNIFINE PENTIPS PLUS.........87 UNILET COMFORTOUCH

LANCET .............................87 UNILET EXCELITE II LANCET ..87 UNILET EXCELITE LANCET.....87 UNILET GP LANCET ...............87 UNILET LANCET.....................87 UNISTIK 3 EXTRA LANCET .....87 UNISTIK CZT LANCET ............87 UNISTIK SAFETY ....................87 UNISTIK TOUCH LANCETS.....87 UNISTRIP1 TEST STRIP ..........82 unithroid...............................95 UNIVERSAL 1 LANCETS .........87 URAMAXIN ...........................60 URECHOLINE.......................134 uro-458...............................135 UROCIT-K 10 .......................135 UROCIT-K 15 .......................135 UROCIT-K 5 .........................135 UROXATRAL........................134 URSO 250............................100 URSO FORTE .......................100 ursodiol...............................100 UTIBRON NEOHALER ..........133 V VAGIFEM.............................113 valacyclovir .............................6 VALCHLOR ............................60 VALCYTE..................................6 valganciclovir..........................6 VALIUM.................................42 valproic acid .........................23 valproic acid (as sodium salt)23 valsartan...............................50

valsartan-hydrochlorothiazide ..........................................50

VALTREX..................................6 VANCOCIN ............................13 vancomycin...........................13 vandazole............................114 VANOS ..................................69 VANOXIDE-HC.......................62 VAQTA (PF) .........................108 VARIVAX (PF) ......................108 VASERETIC ............................50 VASOTEC...............................50 VAXCHORA VACCINE ..........108 veletri....................................50 velivet triphasic regimen (28)

........................................119 VELPHORO ..........................100 vemavite-prx-2 ...................140 VEMLIDY .................................6 VENCLEXTA ...........................18 VENCLEXTA STARTING PACK 18 venlafaxine ...........................42 VENTAVIS............................133 VENTOLIN HFA....................133 verapamil..............................50 VERASENS TEST STRIP...........82 VERDESO...............................69 verdrocet ..............................32 VEREGEN...............................60 VERELAN ...............................50 VERELAN PM.........................50 veripred 20 ...........................78 VERZENIO .............................18 VESICARE ............................134 vestura (28) ........................119 VFEND.................................2, 3 VGO 20..................................87 VGO 30..................................87 VGO 40..................................87 VIAGRA ...............................135 VIBERZI................................100 VIBRAMYCIN.........................13 vicodin ..................................32 vicodin es..............................32 vicodin hp .............................32 VIDEX 2 GRAM PEDIATRIC ......6

VIDEX 4 GRAM PEDIATRIC ......6 VIDEX EC .................................6 vienva..................................120 vigabatrin..............................23 vigadrone..............................23 VIGAMOX............................121 VIIBRYD .................................42 VIMPAT .................................23 vinate care ..........................140 vinate ii ...............................140 vinate m..............................140 vinate one...........................140 vinate ultra .........................140 VIOKACE..............................100 viorele (28)..........................120 VIRACEPT ................................6 VIRAMUNE..............................6 VIRAMUNE XR.........................7 VIRAZOLE ................................7 VIREAD....................................7 VIROPTIC.............................121 virt-advance........................140 virt-c dha.............................140 virt-nate ..............................140 virt-nate dha .......................140 virt-pn .................................140 virt-pn dha ..........................140 virt-pn plus..........................140 virt-select ............................140 virtussin ac..........................128 virt-vite gt ...........................140 VISTARIL..............................127 vitamin b complex-folic acid

........................................140 vitamin d3...................140, 141 vitamins a,c,d and fluoride .141 VIVELLE-DOT .......................113 VIVOTIF ...............................108 VIVOTIF BERNA VACCINE....108 vol-care rx ...........................141 VOLTAREN-XR .......................34 voriconazole ...........................3 VOSEVI ....................................7 VOTRIENT..............................18 vp-ch plus............................141 vp-ch-pnv............................141

Effective 1/2019

166

vp-ggr-b6 ............................141 vp-heme ob ........................141 vp-heme one ......................141 VRAYLAR...............................42 VUSION.................................65 vyfemla (28)........................120 vylibra .................................120 VYTORIN 10-10 .....................55 VYTORIN 10-20 .....................55 VYTORIN 10-40 .....................55 VYTORIN 10-80 .....................55 VYVANSE...............................42 W warfarin ................................53 water for irrigation, sterile...72 WAVESENSE JAZZ .................82 WAVESENSE PRESTO ............82 WELCHOL..............................55 WELLBUTRIN SR....................42 WELLBUTRIN XL....................42 wera (28) ............................120 westhroid .............................95 WILATE .................................53 WP THYROID.........................95 wymzya fe...........................120 X XALATAN.............................124 XALKORI................................18 XANAX ..................................42 XANAX XR .............................42 XARELTO ...............................53 XELJANZ ..............................110 XELJANZ XR.........................110 XELODA.................................18 XENAZINE .............................28 XENICAL ................................70 XERMELO..............................18 XIFAXAN................................11 XIGDUO XR ...........................94 XIIDRA.................................123 XODOL 10/300......................32 XODOL 5/300........................32 XODOL 7.5/300.....................32 XOLEGEL ...............................65 XOPENEX ............................133 XOPENEX CONCENTRATE ...133

XOPENEX HFA .....................133 XPHE MAXAMAID .................74 xphe maxamum....................74 XPHE MAXAMUM.................75 XTAMPZA ER.........................32 XTANDI..................................18 xulane .................................114 xylon 10 ................................32 XYNTHA.................................53 XYNTHA SOLOFUSE...............53 XYREM ..................................42 Y YASMIN (28) .......................120 YAZ (28) ..............................120 YF-VAX (PF) .........................108 YONSA...................................18 yuvafem..............................113 Z zafirlukast ...........................133 zaleplon ................................42 zamicet .................................32 ZANAFLEX .............................29 ZANTAC...............................102 zarah ...................................120 ZARONTIN.............................23 ZARXIO................................103 zatean-ch ............................141 zatean-pn dha.....................141 zatean-pn plus ....................141 ZAVESCA ...............................92 zebutal ..................................27 ZEJULA ..................................18 ZELAPAR................................25 ZELBORAF .............................18 ZEMPLAR ..............................92 zenatane ...............................62 zenchent (28)......................120 ZENPEP ...............................101 zenzedi..................................42 ZENZEDI ................................42 ZERIT .......................................7 ZESTORETIC ..........................50 ZESTRIL .................................50 ZETIA.....................................55 ZIAC.......................................50 ZIAGEN....................................7

zidovudine ..............................7 ZINBRYTA ............................104 zingiber ...............................141 ZIOPTAN (PF) ......................124 ziprasidone hcl......................42 ZIRGAN................................121 ZITHROMAX ............................9 ZMAX ......................................9 ZOCOR...................................55 ZODRYL AC 25 .....................128 ZODRYL AC 30 .....................128 ZODRYL AC 35 .....................128 ZODRYL AC 40 .....................128 ZODRYL AC 50 .....................128 ZODRYL AC 60 .....................128 ZODRYL AC 80 .....................128 ZODRYL DAC 25...................128 ZODRYL DAC 30...................128 ZODRYL DAC 35...................128 ZODRYL DAC 40...................128 ZODRYL DAC 50...................128 ZODRYL DAC 60...................128 ZODRYL DAC 80...................128 ZODRYL DEC 25...................128 ZODRYL DEC 30...................128 ZODRYL DEC 35...................128 ZODRYL DEC 40...................129 ZODRYL DEC 50...................129 ZODRYL DEC 60...................129 ZODRYL DEC 80...................129 ZOFRAN...............................101 ZOFRAN ODT.......................101 ZOLINZA ................................18 zolmitriptan ..........................27 ZOLOFT .................................42 zolpidem ...............................42 ZONALON..............................60 ZONATUSS...........................129 ZONEGRAN ...........................23 zonisamide............................23 ZONTIVITY.............................53 ZORTRESS..............................19 ZOSTAVAX (PF)....................108 zovia 1/35e (28)..................120 zovia 1/50e (28)..................120 ZOVIRAX............................7, 65

Effective 1/2019

167

Z-TUSS AC ...........................129 ZUBSOLV...............................19 ZUTRIPRO ...........................129 ZYBAN ...................................75

ZYDELIG.................................19 ZYKADIA................................19 ZYLOPRIM ...........................108 ZYPREXA................................42

ZYPREXA RELPREVV ..............43 ZYPREXA ZYDIS......................43 ZYTIGA...................................19 ZYVOX ...................................11

BlueCross BlueShield of Tennessee 1 Cameron Hill Circle | Chattanooga, TN 37402 | bcbst.com

BlueCross BlueShield of Tennessee (BlueCross) complies with applicable Federal civil rights laws anddoes not discriminate on the basis of race, color, nationalorigin, age, disability or sex. BlueCross does not excludepeople or treat them differently because of race, color, national origin, age, disability or sex. BlueCross: • Provides free aids and services to people withdisabilities to communicate effectively with us, suchas: (1) qualified interpreters and (2) written informationin other formats, such as large print, audio and accessible electronic formats.

• Provides free language services to people whoseprimary language is not English, such as: (1) qualifiedinterpreters and (2) written information in otherlanguages.

If you need these services, contact a consumer advisorat the number on the back of your Member ID card orcall 1-800-565-9140 (TTY: 1-800-848-0298 or 711). If you believe that BlueCross has failed to providethese services or discriminated in another way onthe basis of race, color, national origin, age, disabilityor sex, you can file a grievance (“NondiscriminationGrievance”). For help with preparing and submittingyour Nondiscrimination Grievance, contact a consumer advisor at the number on the back of your Member ID cardor call 1-800-565-9140 (TTY: 1-800-848-0298 or 711). They can provide you with the appropriate form to usein submitting a Nondiscrimination Grievance. You can file a Nondiscrimination Grievance in person or by mail, fax or email. Address your Nondiscrimination Grievanceto: Nondiscrimination Compliance Coordinator; c/oManager, Operations, Member Benefits Administration;1 Cameron Hill Circle, Suite 0019, Chattanooga, TN37402-0019; (423) 591-9208 (fax); [email protected] (email). You can 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, HHHBuilding, Washington, DC 20201, 1–800–368–1019,800–537–7697 (TDD). Complaint forms are available athttp://www.hhs.gov/ocr/office/file/index.html. BlueCross BlueShield of Tennessee, Inc., anIndependent Licensee of the BlueCross BlueShieldAssociation. Express Scripts, Inc. is an independent company that manages your pharmacy benefits on behalf of BlueCross Blueshield of Tennessee.

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-565-9140 (TTY: 1-800-848-0298).

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 1-800-565-9140 (TTY:1-800-848-0298) 。

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-565-9140 (TTY:1-800-848-0298).

주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다.1-800-565-9140 (TTY: 1-800-848-0298) 번으로 전화해 주십시오.

ATTENTION : Si vous parlez français, des services d’aide linguistique vous sont proposés gratuitement. Appelez le 1-800-565-9140 (ATS : 1-800-848-0298).

ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວົ້າພາສາ ລາວ,ການບໍລິການຊ່ວຍເຫຼືອດ້ານພາສາ, ໂດຍບໍ່ເສັຽຄ່າ, ແມ່ນມີພ້ອມໃຫ້ທ່ານ. ໂທຣ 1-800-565-9140(TTY: 1-800-848-0298).

ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡ ወደ ሚከተለው ቁጥር ይደውሉ 1-800-565-9140 (መስማት ለተሳናቸው: 1-800-848-0298).

ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-800-565-9140(TTY: 1-800-848-0298).

સુચના: જો તમે ગુજરાતી બોલતા હો, તો નિ:શુલ્ક ભાષા સહાય સેવાઓ તમારા માટે ઉપલબ્ધ છે. ફોન કરો 1-800-565-9140 (TTY:1-800-848-0298)

注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-800-565-9140 (TTY:1-800-848-0298) まで、お電話にてご連絡ください。

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-800-565-9140(TTY:1-800-848-0298).

ध्यान दें: यिद आप िहंदी बोलते हैं तो आपके िलए मुफ्त में भाषा सहायता सेवाएं उपलब्ध हैं। 1-800-565-9140 (TTY:1-800-848-0298) पर कॉल करें।

ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-565-9140 (телетайп: 1-800-848-0298).

انی بصورت رایگان برای شما فراهم می باشد. با توجه: اگر به زبان فارسی گفتگو می کنید، تسهیالت زب-1-800-565-9140 (TTY:1-800-848-0298) . تماس بگیرید.

ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-800-565-9140 (TTY: 1-800-848-0298).

UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-800-565-9140 (TTY: 1-800-848-0298).

ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-800-565-9140 (TTY: 1-800-848-0298).

ATTENZIONE: In caso la lingua parlata sia l’italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-800-565-9140 (TTY: 1-800-848-0298).

D77 baa ak0 n7n7zin: D77 saad bee y1n7[ti’go Diné Bizaad, saad bee 1k1’1n7da’1wo’d66’, t’11 jiik’eh, 47 n1 h0l=, koj8’ h0d77lnih 1-800-565-9140 (TTY: 1-800-848-0298).

(رقم 1-9140-565-800 اتصل برقملمجان. لك باللغویة تتوافر لمساعدة اخدمات اللغة، فإن ملحوظة: إذا كنت تتحدث اذكر ا 1-0298-848-800).م: لبكلصم واھاتف ا

RX-11 (12/18) 2019 Preferred Formulary Guidebook and

Prescription Drug List

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

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

mailto:[email protected]

http://bcbst.com

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

mailto:[email protected]

your guide to prescription drug coverage · check often for updates, as this list is subject to...

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