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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
i
2019 Preferred FormularyCheck often for updates, as this list is subject to change.
2019 Preferred Formulary
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
2019 Preferred FormularyCheck often for updates, as this list is subject to change.
2019 Preferred Formulary
iii
2019 Preferred FormularyCheck often for updates, as this list is subject to change.
2019 Preferred Formulary
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.
iv
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2019 Preferred FormularyCheck often for updates, as this list is subject to change.
2019 Preferred Formulary
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.
Rheumatoid arthritis
Ankylosing spondylitis
Juvenile idiopathic arthritis
Psoriatic arthritis
Psoriasis
Crohn’s disease
Ulcerative colitis
SC – subcutaneous
Medical Condition
Preferred Drug
Non Preferred Drug (directed to ONE Preferred Drug)
Non Preferred Drug (directed to TWO Preferred Drugs)
Tier
2 Tier
3
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
Tier
3
Cimzia Kevzara Kineret
Olumiant OrenciaSC
SimponiSC
Cimzia SimponiSC
OrenciaSC
Cimzia OrenciaSC
SimponiSC
Taltz Xeljanz/XR
Cimzia Siliq Taltz
*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.
v
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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.
RX04
2019 Preferred FormularyCheck often for updates, as this list is subject to change.
2019 Preferred Formulary
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vi
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.
2019 Preferred FormularyCheck often for updates, as this list is subject to change.
2019 Preferred Formulary
vii
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
2019 Preferred FormularyCheck often for updates, as this list is subject to change.
2019 Preferred Formulary
viii
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.
2019 Preferred FormularyCheck often for updates, as this list is subject to change.
2019 Preferred Formulary
ix
2019 Preferred Formulary
Table of Contents
Anti - Infectives.................................................................................................................................................... 2 Antineoplastic & Immunosuppressant Drugs ....................................................................................................13 Autonomic & Cns Drugs, Neurology & Psych ..................................................................................................18 Cardiovascular, Hypertension & Lipids.............................................................................................................41 Dermatologicals/Topical Therapy......................................................................................................................54 Diagnostics & Miscellaneous Agents ................................................................................................................67 Ear, Nose & Throat Medications........................................................................................................................73 Endocrine/Diabetes ............................................................................................................................................ 75 Gastroenterology ................................................................................................................................................ 93 Immunology, Vaccines & Biotechnology........................................................................................................100 Musculoskeletal & Rheumatology...................................................................................................................107 Obstetrics & Gynecology................................................................................................................................. 109 Ophthalmology................................................................................................................................................. 118 Respiratory, Allergy, Cough & Cold ...............................................................................................................124 Urologicals ....................................................................................................................................................... 131 Vitamins, Hematinics & Electrolytes...............................................................................................................133 Index of Drugs.................................................................................................................................................. 142
1
2
Effective 1/2019
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
itraconazole oral capsule 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
VFEND ORAL TABLET Tier 3
voriconazole oral suspension for reconstitution Tier 1
3
Effective 1/2019
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
EMTRIVA ORAL CAPSULE Tier 3
EMTRIVA ORAL SOLUTION Tier 3
entecavir oral tablet Tier 1
Drug Name Drug Tier Requirements/Limits
4
Effective 1/2019
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
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
Drug Name Drug Tier Requirements/Limits
5
Effective 1/2019
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
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
TAMIFLU ORAL CAPSULE 30 MG Tier 3 QL (20 EA per 180 days)
Drug Name Drug Tier Requirements/Limits
6
Effective 1/2019
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
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
Drug Name Drug Tier Requirements/Limits
7
Effective 1/2019
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 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
cefpodoxime oral tablet Tier 1
cefprozil oral suspension for reconstitution Tier 1
cefprozil oral tablet Tier 1
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
Drug Name Drug Tier Requirements/Limits
8
Effective 1/2019
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
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
ZITHROMAX ORAL PACKET Tier 3
ZITHROMAX ORAL SUSPENSION FOR RECONSTITUTION
Tier 3
ZITHROMAX ORAL TABLET 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
Drug Name Drug Tier Requirements/Limits
9
Effective 1/2019
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
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
Drug Name Drug Tier Requirements/Limits
10
Effective 1/2019
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
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
Drug Name Drug Tier Requirements/Limits
11
Effective 1/2019
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, 25062.5 MG/5 ML
Tier 3
AUGMENTIN ORAL TABLET 500-125 MG, 875-125 MG
Tier 3
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 500 MG, 750 MG
Tier 3
levofloxacin oral solution Tier 1
levofloxacin oral tablet Tier 1
moxifloxacin oral tablet Tier 1
Drug Name Drug Tier Requirements/Limits
12
Effective 1/2019
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
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
Drug Name Drug Tier Requirements/Limits
13
Effective 1/2019
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
Drug 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
14
Effective 1/2019
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
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 100 mg, 25 mg 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
Drug Name Drug Tier Requirements/Limits
15
Effective 1/2019
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
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
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 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
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
Drug Name Drug Tier Requirements/Limits
16
Effective 1/2019
methotrexate sodium oral tablet Tier 1
mycophenolate mofetil oral capsule Tier 1
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 100 MCG/ML, 50 MCG/ML, 500 MCG/ML
Tier 3 SPRx
SIGNIFOR SUBCUTANEOUS SOLUTION Tier 3 PA; LD; SPRx
SIKLOS ORAL TABLET Tier 3
sirolimus oral tablet Tier 1
SOLTAMOX ORAL SOLUTION Tier 3 ACA
Drug Name Drug Tier Requirements/Limits
17
Effective 1/2019
SPRYCEL ORAL TABLET Tier 3 SPRx
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
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
ZORTRESS ORAL TABLET Tier 3 SPRx
ZYDELIG ORAL TABLET Tier 3 PA; SPRx
Drug Name Drug Tier Requirements/Limits
18
Effective 1/2019
ZYKADIA ORAL CAPSULE Tier 3 PA; SPRx
ZYTIGA ORAL TABLET Tier 3 SPRx
Drug Name Drug Tier Requirements/Limits
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
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
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
19
Effective 1/2019
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
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
Drug Name Drug Tier Requirements/Limits
20
Effective 1/2019
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
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)
Drug Name Drug Tier Requirements/Limits
21
Effective 1/2019
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
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
Drug Name Drug Tier Requirements/Limits
22
Effective 1/2019
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
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
Drug Name Drug Tier Requirements/Limits
23
Effective 1/2019
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
STALEVO 125 ORAL TABLET Tier 3
STALEVO 150 ORAL TABLET Tier 3
STALEVO 200 ORAL TABLET Tier 3
STALEVO 50 ORAL TABLET Tier 3
STALEVO 75 ORAL TABLET Tier 3
TASMAR ORAL TABLET 100 MG Tier 3
tolcapone oral tablet Tier 1
trihexyphenidyl oral elixir Tier 1
Drug Name Drug Tier Requirements/Limits
24
Effective 1/2019
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 50-300 mg Tier 1 QL (120 EA per 30 days)
butalbital-acetaminophen-caff oral capsule 50300-40 mg
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 TABLET Tier 3 QL (120 EA per 30 days)
FIORICET 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 KIT REFILL SUBCUTANEOUS CARTRIDGE 4 MG/0.5 ML
Tier 3 QL (12 ML per 30 days)
IMITREX STATDOSE KIT REFILL SUBCUTANEOUS CARTRIDGE 6 MG/0.5 ML
Tier 3 QL (8 ML per 30 days)
Drug Name Drug Tier Requirements/Limits
25
Effective 1/2019
IMITREX STATDOSE PEN SUBCUTANEOUS PEN INJECTOR 4 MG/0.5 ML
Tier 3 QL (12 ML per 30 days)
IMITREX STATDOSE PEN SUBCUTANEOUS PEN INJECTOR 6 MG/0.5 ML
Tier 3 QL (8 ML per 30 days)
IMITREX SUBCUTANEOUS SOLUTION Tier 3 QL (8 ML per 30 days)
isometh-dichloral-acetaminophn oral capsule Tier 1
isomethepten-caf-acetaminophen oral tablet 6520-325 mg
Tier 1
migergot rectal suppository Tier 1
MIGRANAL NASAL SPRAY,NONAEROSOL
Tier 3 QL (8 ML per 30 days)
naratriptan oral tablet Tier 1 QL (18 EA per 30 days)
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
Tier 1 QL (12 ML per 30 days)
sumatriptan succinate subcutaneous cartridge 6 mg/0.5 ml
Tier 1 QL (8 ML per 30 days)
sumatriptan succinate subcutaneous pen injector 4 mg/0.5 ml
Tier 1 QL (12 ML per 30 days)
sumatriptan succinate subcutaneous pen injector 6 mg/0.5 ml
Tier 1 QL (8 ML per 30 days)
sumatriptan succinate subcutaneous solution Tier 1 QL (8 ML per 30 days)
SUMAVEL DOSEPRO SUBCUTANEOUS NEEDLE-FREE INJECTOR 4 MG/0.5 ML
Tier 3 QL (12 ML per 30 days)
SUMAVEL DOSEPRO SUBCUTANEOUS NEEDLE-FREE INJECTOR 6 MG/0.5 ML
Tier 3 QL (8 ML per 30 days)
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)
Drug Name Drug Tier Requirements/Limits
26
Effective 1/2019
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
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
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
Drug Name Drug Tier Requirements/Limits
27
Effective 1/2019
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
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)
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
Drug Name Drug Tier Requirements/Limits
28
Effective 1/2019
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
butalbital-acetaminophen oral tablet 50-325 mg Tier 1 QL (120 EA per 30 days)
butalbital-acetaminophen-caff oral capsule 50325-40 mg
Tier 1 QL (120 EA per 30 days)
butalbital-acetaminophen-caff oral tablet 50-32540 mg
Tier 1 QL (120 EA per 30 days)
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)
butorphanol tartrate nasal spray,non-aerosol Tier 1 PA; MME
BUTRANS TRANSDERMAL PATCH WEEKLY
Tier 2 PA; QL (4 EA per 28 days)
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
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
ESGIC ORAL CAPSULE Tier 3 QL (120 EA per 30 days)
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
FIORINAL ORAL CAPSULE Tier 3 QL (120 EA per 30 days)
HYCET ORAL SOLUTION Tier 3 PA; MME
Drug Name Drug Tier Requirements/Limits
29
Effective 1/2019
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, 5200 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
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
Drug Name Drug Tier Requirements/Limits
30
Effective 1/2019
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 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, 2.5325 MG, 5-325 MG, 7.5-325 MG
Tier 3 PA; MME
PRIMLEV ORAL TABLET Tier 3 PA; MME
reprexain oral tablet 2.5-200 mg Tier 1 PA; MME
ROXICODONE ORAL TABLET 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
Drug Name Drug Tier Requirements/Limits
31
Effective 1/2019
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
XTAMPZA ER ORAL CAPSULE,SPRINKLE,ER 12HR TMPRR
Tier 2 PA; MME
xylon 10 oral tablet 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
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
Drug Name Drug Tier Requirements/Limits
32
Effective 1/2019
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
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
Drug Name Drug Tier Requirements/Limits
33
Effective 1/2019
piroxicam oral capsule Tier 1
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)
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
Tier 1 QL (90 EA per 30 days)
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
Drug Name Drug Tier Requirements/Limits
34
Effective 1/2019
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)
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 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
Drug Name Drug Tier Requirements/Limits
35
Effective 1/2019
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 5050
Tier 1
dexmethylphenidate oral tablet Tier 1
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
Drug Name Drug Tier Requirements/Limits
36
Effective 1/2019
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
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 117 MG/0.75 ML, 156 MG/ML
Tier 3 SPRx; AGE-A
INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 234 MG/1.5 ML, 39 MG/0.25 ML, 78 MG/0.5 ML
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
Drug Name Drug Tier Requirements/Limits
37
Effective 1/2019
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
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 3070
Tier 1
methylphenidate hcl oral capsule,er biphasic 5050
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
Drug Name Drug Tier Requirements/Limits
38
Effective 1/2019
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)
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
Drug Name Drug Tier Requirements/Limits
39
Effective 1/2019
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 15 MG, 30 MG 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
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 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
Drug Name Drug Tier Requirements/Limits
40
Effective 1/2019
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
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
Tier 3 QL (60 EA per 30 days)
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
Drug Name Drug Tier Requirements/Limits
41
Effective 1/2019
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
ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION
Tier 3 SPRx
ZYPREXA ZYDIS ORAL TABLET,DISINTEGRATING
Tier 3 AGE-A
Drug Name Drug Tier Requirements/Limits
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
42
Effective 1/2019
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
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
Drug Name Drug Tier Requirements/Limits
43
Effective 1/2019
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
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
CATAPRES-TTS-2 TRANSDERMAL PATCH WEEKLY
Tier 3
CATAPRES-TTS-3 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
Drug Name Drug Tier Requirements/Limits
44
Effective 1/2019
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
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
Drug Name Drug Tier Requirements/Limits
45
Effective 1/2019
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
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
Drug Name Drug Tier Requirements/Limits
46
Effective 1/2019
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
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
Drug Name Drug Tier Requirements/Limits
47
Effective 1/2019
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
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 2-180 MG, 2-240 MG, 4-240 MG
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
Drug Name Drug Tier Requirements/Limits
48
Effective 1/2019
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
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
Drug Name Drug Tier Requirements/Limits
49
Effective 1/2019
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
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)
Drug Name Drug Tier Requirements/Limits
50
Effective 1/2019
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
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
Drug Name Drug Tier Requirements/Limits
51
Effective 1/2019
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
RIXUBIS INTRAVENOUS RECON SOLN Tier 3 LD; SPRx
TAVALISSE ORAL TABLET Tier 3 PA; LD; SPRx
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
Drug Name Drug Tier Requirements/Limits
52
Effective 1/2019
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
ezetimibe-simvastatin oral tablet Tier 1
fenofibrate micronized oral capsule Tier 1
fenofibrate nanocrystallized oral tablet Tier 1
fenofibrate oral tablet Tier 1
fenofibric acid (choline) oral capsule,delayed release(dr/ec)
Tier 1
fenofibric acid oral tablet Tier 1
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
Drug Name Drug Tier Requirements/Limits
53
Effective 1/2019
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
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
VYTORIN 10-20 ORAL TABLET Tier 3
VYTORIN 10-40 ORAL TABLET Tier 3
VYTORIN 10-80 ORAL TABLET Tier 3
WELCHOL ORAL POWDER IN PACKET Tier 3
WELCHOL ORAL TABLET Tier 3
ZETIA ORAL TABLET Tier 3
Drug Name Drug Tier Requirements/Limits
54
Effective 1/2019
ZOCOR ORAL TABLET 10 MG, 20 MG, 40 MG, 80 MG
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
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 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
Drug Name Drug Tier Requirements/Limits
Dermatologicals/Topical Therapy
55
Effective 1/2019
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
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 CREAM Tier 3
OVACE PLUS TOPICAL LOTION 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
Drug Name Drug Tier Requirements/Limits
56
Effective 1/2019
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 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
Keratolytics PODOCON TOPICAL LIQUID 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 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)
Drug Name Drug Tier Requirements/Limits
57
Effective 1/2019
doxepin topical cream Tier 1
DUPIXENT SUBCUTANEOUS SYRINGE 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
URAMAXIN TOPICAL GEL Tier 3
Drug Name Drug Tier Requirements/Limits
58
Effective 1/2019
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
clindamycin phosphate topical solution Tier 1
clindamycin phosphate topical swab Tier 1
Drug Name Drug Tier Requirements/Limits
59
Effective 1/2019
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
PLEXION TOPICAL LOTION Tier 3
RETIN-A TOPICAL CREAM Tier 3 PA
RETIN-A TOPICAL GEL Tier 3 PA
Drug Name Drug Tier Requirements/Limits
60
Effective 1/2019
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
glydo mucous membrane jelly in applicator Tier 1
lidocaine hcl mucous membrane jelly Tier 1
lidocaine hcl mucous membrane jelly in applicator Tier 1
Drug Name Drug Tier Requirements/Limits
61
Effective 1/2019
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
Tier 3 QL (90 EA per 30 days)
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 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
Drug Name Drug Tier Requirements/Limits
62
Effective 1/2019
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
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
Drug Name Drug Tier Requirements/Limits
63
Effective 1/2019
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
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
Drug Name Drug Tier Requirements/Limits
64
Effective 1/2019
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 OINTMENT Tier 3
DESONATE TOPICAL GEL Tier 3
desonide topical cream Tier 1
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
Drug Name Drug Tier Requirements/Limits
65
Effective 1/2019
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
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
Drug Name Drug Tier Requirements/Limits
66
Effective 1/2019
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
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,NONAEROSOL
Tier 3
triamcinolone acetonide topical aerosol Tier 1
Drug Name Drug Tier Requirements/Limits
67
Effective 1/2019
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
Drug 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 #
68
Effective 1/2019
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
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
Miscellaneous Agents acamprosate oral tablet,delayed release (dr/ec) Tier 1
acetic acid irrigation solution Tier 1
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
Drug Name Drug Tier Requirements/Limits
69
Effective 1/2019
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
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
Drug Name Drug Tier Requirements/Limits
70
Effective 1/2019
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
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
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
Drug Name Drug Tier Requirements/Limits
71
Effective 1/2019
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 ACIDS ORAL POWDER
Tier 3
PHENYLADE AMINO ACIDS ORAL POWDER IN PACKET
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
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
PHENYL-FREE 1 ORAL POWDER Tier 3
PHENYL-FREE 2 PKU ORAL POWDER Tier 3
PHENYL-FREE 2HP PKU ORAL POWDER Tier 3
Drug Name Drug Tier Requirements/Limits
72
Effective 1/2019
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 AIR20 ORAL LIQUID IN PACKET Tier 3
PKU COOLER 10 ORAL SUSPENSION Tier 3
PKU COOLER 15 ORAL SUSPENSION Tier 3
PKU COOLER 20 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
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
Drug Name Drug Tier Requirements/Limits
73
Effective 1/2019
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,NONAEROSOL
Tier 3 ACA
ZYBAN ORAL TABLET EXTENDED RELEASE 12 HR
Tier 3 ACA
Drug Name Drug Tier Requirements/Limits
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
dentagel dental gel 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
74
Effective 1/2019
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
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 CIPRO HC OTIC (EAR) DROPS,SUSPENSION
Tier 3
CIPRODEX OTIC (EAR) DROPS,SUSPENSION
Tier 2
COLY-MYCIN S OTIC (EAR) DROPS,SUSPENSION
Tier 3
Drug Name Drug Tier Requirements/Limits
75
Effective 1/2019
neomycin-polymyxin-hc otic (ear) drops,suspension
Tier 1
neomycin-polymyxin-hc otic (ear) solution Tier 1
OTOVEL OTIC (EAR) SOLUTION Tier 2
Drug Name Drug Tier Requirements/Limits
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 tablet Tier 1
ORAPRED ODT ORAL TABLET,DISINTEGRATING
Tier 3
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
76
Effective 1/2019
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 STRP 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 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 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 STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)
AGAMATRIX AMP TEST STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)
ASSURE 4 STRIPS 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 STRIP Tier 3 ST; QL (102 EA per 30 days)
BIONIME RIGHTEST TEST STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)
BLOOD GLUCOSE TEST STRIP Tier 3 ST; QL (102 EA per 30 days)
BREEZE 2 TEST STRIPS STRIP Tier 2 QL (102 EA per 30 days)
CARESENS N TEST STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)
CARETOUCH TEST STRIP STRIP Tier 3 ST; QL (102 EA per 30 days)
CLEVER CHOICE MICRO TEST STRIP STRIP
Tier 3 ST; QL (102 EA per 30 days)
CLEVER CHOICE PRO STRIP Tier 3 ST; QL (102 EA per 30 days)
Drug Name Drug Tier Requirements/Limits
77
Effective 1/2019
CLEVER CHOICE TALK TEST STRIP Tier 3 ST; QL (102 EA per 30 days)
CLEVER CHOICE TEST STRIPS 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 STRIPS STRIP Tier 2 QL (102 EA per 30 days)
CONTOUR TEST STRIPS STRIP Tier 2 QL (102 EA per 30 days)
COOL GLUCOSE TEST STRIP STRIP Tier 3 ST; QL (102 EA per 30 days)
DIATRUE PLUS TEST STRIP 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 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 STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)
ELEMENT TEST STRIPS 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 STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)
EMBRACE PRO TEST STRIPS 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 STR STRIP
Tier 3 ST; QL (102 EA per 30 days)
EVOLUTION TEST STRIPS 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)
FIFTY50 TEST STRIP 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 STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)
FORA G20 STRIP Tier 3 ST; QL (102 EA per 30 days)
Drug Name Drug Tier Requirements/Limits
78
Effective 1/2019
FORA G30-PREMIUM V10 TEST STRP STRIP
Tier 3 ST; QL (102 EA per 30 days)
FORA GD50 TEST STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)
FORA TEST STRIP STRIP Tier 3 ST; QL (102 EA per 30 days)
FORA TN'G VOICE TEST STRIPS 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 STRIPS 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 STRIPS STRIP
Tier 3 ST; QL (102 EA per 30 days)
FREESTYLE LITE STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)
FREESTYLE PRECISION NEO STRIPS 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 STRIP
Tier 3 ST; QL (102 EA per 30 days)
GENSTRIP TEST STRIP STRIP Tier 3 ST; QL (102 EA per 30 days)
GLUCO NAVII TEST STRIP 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 STRIPS 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 STRIPS 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 STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)
IGLUCOSE TEST STRIP STRIP Tier 3 ST; QL (102 EA per 30 days)
INFINITY TEST STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)
INFINITY VOICE TEST STRIP STRIP Tier 3 ST; QL (102 EA per 30 days)
Drug Name Drug Tier Requirements/Limits
79
Effective 1/2019
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 STRIPS 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 STRIP Tier 3 ST; QL (102 EA per 30 days)
ON CALL PLUS TEST STRIP STRIP Tier 3 ST; QL (102 EA per 30 days)
ON CALL VIVID TEST STRIP STRIP Tier 3 ST; 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 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 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 STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)
REVEAL TEST STRIP STRIP Tier 3 ST; QL (102 EA per 30 days)
RIGHTEST GS550 TEST STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)
SMART SENSE TEST STRIPS 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 STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)
Drug Name Drug Tier Requirements/Limits
80
Effective 1/2019
TEST N'GO TEST STRIP Tier 3 ST; QL (102 EA per 30 days)
TRUE METRIX GLUCOSE TEST STRIP STRIP
Tier 3 ST; QL (102 EA per 30 days)
TRUETEST TEST STRIPS STRIP Tier 3 ST; QL (102 EA per 30 days)
TRUETRACK TEST STRIP Tier 3 ST; QL (102 EA per 30 days)
ULTIMA TEST STRIPS 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 STRIP Tier 3 ST; QL (102 EA per 30 days)
VERASENS TEST STRIP 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 KIT
Tier 2
PROGLYCEM ORAL SUSPENSION Tier 3
TRUEPLUS GLUCOSE ORAL GEL IN PACKET
Tier 3
Insulin Syringes/Miscellaneous Durable Medical Equ 1ST TIER UNIFINE PENTIPS NEEDLE 29 GAUGE X 1/2"
Tier 2 QL (1000 EA per 30 days)
1ST TIER UNILET COMFORTOUCH 28 GAUGE
Tier 2
ACCU-CHEK SAFE-T-PRO Tier 2
ACCU-CHEK SOFTCLIX LANCETS Tier 2
ACTI-LANCE LANCETS 23 GAUGE Tier 2
ADVANCED TRAVEL LANCETS 30 GAUGE Tier 2
ADVOCATE LANCET 30 GAUGE Tier 2
ADVOCATE PEN NEEDLE NEEDLE 29 GAUGE X 1/2"
Tier 2 QL (1000 EA per 30 days)
Drug Name Drug Tier Requirements/Limits
81
Effective 1/2019
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 NEEDLE Tier 2 QL (1000 EA per 30 days)
BD MICROTAINER LANCET 30 GAUGE Tier 2
BD NOKOR ADMIX NEEDLE 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"
Tier 2 QL (1000 EA per 30 days)
BD SAFETYGLIDE NEEDLE NEEDLE 22 GAUGE X 1 1/2"
Tier 2 QL (1000 EA per 30 days)
BD SPECIALTY USE NEEDLES 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 NEEDLE
Tier 2 QL (1000 EA per 30 days)
BD ULTRA-FINE SHORT PEN NEEDLE 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 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
Drug Name Drug Tier Requirements/Limits
82
Effective 1/2019
COMFORT EZ PEN NEEDLES NEEDLE 31 GAUGE X 5/16"
Tier 2 QL (1000 EA per 30 days)
COMFORT LANCETS Tier 2
DROPLET LANCETS Tier 2
DROPLET PEN NEEDLE NEEDLE 32 GAUGE X 5/32"
Tier 2 QL (1000 EA per 30 days)
EASY COMFORT LANCETS Tier 2
EASY COMFORT PEN NEEDLES NEEDLE 31 GAUGE X 3/16"
Tier 3 QL (1000 EA per 30 days)
EASY TOUCH FLIPLOCK NEEDLE NEEDLE 22 GAUGE X 3/4", 25 GAUGE X 1 1/2"
Tier 2 QL (1000 EA per 30 days)
EASY TOUCH HYPODERMIC NEEDLE NEEDLE 32 GAUGE X 5/16"
Tier 2 QL (1000 EA per 30 days)
EXEL HYPODERMIC NEEDLES 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 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"
Tier 2 QL (1000 EA per 30 days)
HEALTHY ACCENTS UNILET LANCET Tier 2
huber safety needles (disp.) needle Tier 1 QL (1000 EA per 30 days)
INCONTROL PEN NEEDLE NEEDLE 29 GAUGE X 1/2"
Tier 2 QL (1000 EA per 30 days)
INCONTROL SUPER THIN LANCETS Tier 2
Drug Name Drug Tier Requirements/Limits
83
Effective 1/2019
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
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"
Tier 2 QL (1000 EA per 30 days)
MONOJECT HYPODERMIC NEEDLES NEEDLE 18 GAUGE X 1"
Tier 2 QL (1000 EA per 30 days)
MONOJECT MEDICATION TRANSF NDL NEEDLE
Tier 2 QL (1000 EA per 30 days)
MONOLET THIN LANCETS Tier 2
MULTI-DRAW NEEDLE 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 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
Drug Name Drug Tier Requirements/Limits
84
Effective 1/2019
ON CALL LANCET Tier 2
ON CALL PLUS LANCET Tier 2
ONETOUCH ULTRASOFT LANCETS Tier 2
ON-THE-GO LANCETS Tier 2
PEN NEEDLE 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)
PENTIPS NEEDLE 31 GAUGE X 1/4", 31 GAUGE X 5/16"
Tier 2 QL (1000 EA per 30 days)
PHASEAL PROTECTOR DEVICE 20 MM Tier 2 QL (1000 EA per 30 days)
POLY HUB NEEDLE 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 NEEDLES NEEDLE Tier 2 QL (1000 EA per 30 days)
RELION PEN NEEDLES 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
Drug Name Drug Tier Requirements/Limits
85
Effective 1/2019
SUPER THIN LANCETS 30 GAUGE Tier 2
SURE COMFORT LANCETS 28 GAUGE Tier 2
SURE COMFORT PEN NEEDLE NEEDLE 29 GAUGE X 1/2"
Tier 2 QL (1000 EA per 30 days)
SURE-FINE PEN NEEDLES 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
TECHLITE PEN NEEDLE 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 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 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 NEEDLES 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"
Tier 2 QL (1000 EA per 30 days)
UNILET COMFORTOUCH LANCET 26 GAUGE
Tier 2
UNILET EXCELITE II LANCET Tier 2
Drug Name Drug Tier Requirements/Limits
86
Effective 1/2019
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
VGO 30 DEVICE Tier 2
VGO 40 DEVICE Tier 2
Insulin Therapy 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 12 UNIT, 4 UNIT, 4 UNIT (60)/ 8 UNIT (30), 4 UNIT (90)/ 8 UNIT (90), 4 UNIT/8 UNIT/ 12 UNIT (60), 8 UNIT
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, HALFUNIT
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
Drug Name Drug Tier Requirements/Limits
87
Effective 1/2019
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
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 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
Drug Name Drug Tier Requirements/Limits
88
Effective 1/2019
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
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
Drug Name Drug Tier Requirements/Limits
89
Effective 1/2019
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 spray,non-aerosol Tier 1
desmopressin oral tablet Tier 1
doxercalciferol oral capsule Tier 1
FOLLISTIM AQ SUBCUTANEOUS CARTRIDGE
Tier 3 #
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 #
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
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
Drug Name Drug Tier Requirements/Limits
90
Effective 1/2019
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
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 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
Drug Name Drug Tier Requirements/Limits
91
Effective 1/2019
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
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
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
Drug Name Drug Tier Requirements/Limits
92
Effective 1/2019
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
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
Drug Name Drug Tier Requirements/Limits
93
Effective 1/2019
levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg
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
THYROLAR-2 ORAL TABLET Tier 3
THYROLAR-3 ORAL TABLET Tier 3
unithroid oral tablet Tier 1
westhroid oral tablet 130 mg, 195 mg, 32.5 mg, 65 mg, 97.5 mg
Tier 1
WP THYROID ORAL TABLET Tier 3
Drug Name Drug Tier Requirements/Limits
Gastroenterology Antidiarrheals & Antispasmodics 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
94
Effective 1/2019
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
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
Drug Name Drug Tier Requirements/Limits
95
Effective 1/2019
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
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
Drug Name Drug Tier Requirements/Limits
96
Effective 1/2019
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
gavilyte-g oral recon soln Tier 1 ACA
gavilyte-n oral recon soln Tier 1 ACA
generlac oral solution Tier 1
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
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
Drug Name Drug Tier Requirements/Limits
97
Effective 1/2019
MAGNEBIND 400 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
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
Drug Name Drug Tier Requirements/Limits
98
Effective 1/2019
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 800 MG Tier 3
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
Drug Name Drug Tier Requirements/Limits
99
Effective 1/2019
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
ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,000-32,000 -42,000 UNIT, 15,000-47,000 -63,000 UNIT, 20,00063,000- 84,000 UNIT, 25,000-79,000- 105,000 UNIT, 3,000-10,000 -14,000-UNIT, 40,000126,000- 168,000 UNIT, 5,000-17,000- 24,000 UNIT
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
Drug Name Drug Tier Requirements/Limits
100
Effective 1/2019
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
PREVACID SOLUTAB ORAL TABLET,DISINTEGRAT, DELAY REL
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
Drug Name Drug Tier Requirements/Limits
Immunology, Vaccines & Biotechnology Biotechnology Drugs ARANESP (IN POLYSORBATE) INJECTION SOLUTION
Tier 3 PA; SPRx
ARANESP (IN POLYSORBATE) INJECTION SYRINGE
Tier 3 PA; SPRx
101
Effective 1/2019
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
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
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
Drug Name Drug Tier Requirements/Limits
102
Effective 1/2019
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
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
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
Drug Name Drug Tier Requirements/Limits
103
Effective 1/2019
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
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
Drug Name Drug Tier Requirements/Limits
104
Effective 1/2019
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
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
Drug Name Drug Tier Requirements/Limits
105
Effective 1/2019
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
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
Drug Name Drug Tier Requirements/Limits
106
Effective 1/2019
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
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
Drug Name Drug Tier Requirements/Limits
107
Effective 1/2019
VAXCHORA VACCINE ORAL SUSPENSION FOR RECONSTITUTION
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
Drug Name Drug Tier Requirements/Limits
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
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
108
Effective 1/2019
Other Rheumatologicals ACTEMRA SUBCUTANEOUS SYRINGE Tier 2 PA; SPRx
ARAVA ORAL TABLET Tier 3
BENLYSTA SUBCUTANEOUS AUTOINJECTOR
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
Tier 2 PA; SPRx; QL (2 EA per 30 days)
HUMIRA PEN PSORIASIS-UVEITIS SUBCUTANEOUS PEN INJECTOR KIT
Tier 2 PA; SPRx; QL (2 EA per 30 days)
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
Drug Name Drug Tier Requirements/Limits
109
Effective 1/2019
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
Drug Name Drug Tier Requirements/Limits
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
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
110
Effective 1/2019
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 0.75 mg Tier 1
EVAMIST TRANSDERMAL SPRAY,NONAEROSOL
Tier 2
FEMHRT LOW DOSE ORAL TABLET Tier 3
FEMRING VAGINAL RING Tier 3
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
Drug Name Drug Tier Requirements/Limits
111
Effective 1/2019
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
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
Drug Name Drug Tier Requirements/Limits
112
Effective 1/2019
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
terconazole vaginal cream Tier 1
terconazole vaginal suppository Tier 1
tranexamic acid oral tablet Tier 1
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
Drug Name Drug Tier Requirements/Limits
113
Effective 1/2019
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
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 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)
Drug Name Drug Tier Requirements/Limits
114
Effective 1/2019
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
introvale oral tablets,dose pack,3 month Tier 1 ACA
isibloom oral tablet Tier 1 ACA
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
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
Drug Name Drug Tier Requirements/Limits
115
Effective 1/2019
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-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
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
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
Drug Name Drug Tier Requirements/Limits
116
Effective 1/2019
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
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
Drug Name Drug Tier Requirements/Limits
117
Effective 1/2019
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
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
Drug Name Drug Tier Requirements/Limits
118
Effective 1/2019
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
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
Drug Name Drug Tier Requirements/Limits
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
119
Effective 1/2019
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
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 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
Drug Name Drug Tier Requirements/Limits
120
Effective 1/2019
TIMOPTIC OCUDOSE (PF) OPHTHALMIC (EYE) DROPPERETTE
Tier 3
TIMOPTIC OPHTHALMIC (EYE) DROPS 0.25 %
Tier 3
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
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
Drug Name Drug Tier Requirements/Limits
121
Effective 1/2019
PATANOL OPHTHALMIC (EYE) DROPS Tier 3
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
methazolamide oral tablet Tier 1
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
Drug Name Drug Tier Requirements/Limits
122
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
Drug Name Drug Tier Requirements/Limits
123
Effective 1/2019
FML S.O.P. OPHTHALMIC (EYE) OINTMENT
Tier 3
LOTEMAX OPHTHALMIC (EYE) DROPS,GEL
Tier 2
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
Drug Name Drug Tier Requirements/Limits
124
Effective 1/2019
brimonidine ophthalmic (eye) drops Tier 1
IOPIDINE OPHTHALMIC (EYE) DROPPERETTE
Tier 3
IOPIDINE OPHTHALMIC (EYE) DROPS Tier 3
Vasoconstrictor Decongestants CYCLOMYDRIL OPHTHALMIC (EYE) DROPS
Tier 3
phenylephrine hcl ophthalmic (eye) drops Tier 1
Drug Name Drug Tier Requirements/Limits
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 AUTOINJECTOR
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 AUTOINJECTOR
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 AUTOINJECTOR
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
125
Effective 1/2019
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
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
Drug Name Drug Tier Requirements/Limits
126
Effective 1/2019
promethazine-codeine oral syrup Tier 1
promethazine-dm oral syrup Tier 1
promethazine-phenyleph-codeine oral syrup Tier 1
PRO-RED AC (W/ DEXCHLORPHENIR) ORAL LIQUID
Tier 3
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 AC 30 ORAL SUSPENSION Tier 3
ZODRYL AC 35 ORAL SUSPENSION Tier 3
ZODRYL AC 40 ORAL SUSPENSION Tier 3
ZODRYL AC 50 ORAL SUSPENSION Tier 3
ZODRYL AC 60 ORAL SUSPENSION Tier 3
ZODRYL AC 80 ORAL SUSPENSION Tier 3
ZODRYL DAC 25 ORAL SUSPENSION Tier 3
ZODRYL DAC 30 ORAL SUSPENSION Tier 3
ZODRYL DAC 35 ORAL SUSPENSION Tier 3
ZODRYL DAC 40 ORAL SUSPENSION Tier 3
ZODRYL DAC 50 ORAL SUSPENSION Tier 3
ZODRYL DAC 60 ORAL SUSPENSION Tier 3
ZODRYL DAC 80 ORAL SUSPENSION Tier 3
ZODRYL DEC 25 ORAL SUSPENSION Tier 3
ZODRYL DEC 30 ORAL SUSPENSION Tier 3
Drug Name Drug Tier Requirements/Limits
127
Effective 1/2019
ZODRYL DEC 35 ORAL SUSPENSION Tier 3
ZODRYL DEC 40 ORAL SUSPENSION Tier 3
ZODRYL DEC 50 ORAL SUSPENSION Tier 3
ZODRYL DEC 60 ORAL SUSPENSION Tier 3
ZODRYL DEC 80 ORAL SUSPENSION Tier 3
Z-TUSS AC ORAL LIQUID 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
ATROVENT HFA INHALATION HFA AEROSOL INHALER
Tier 3
BERINERT INTRAVENOUS KIT Tier 3 PA; LD; SPRx
Drug Name Drug Tier Requirements/Limits
128
Effective 1/2019
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
Drug Name Drug Tier Requirements/Limits
129
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
Tier 2 QL (2 EA per 30 days)
PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED
Tier 2 QL (2 EA per 30 days)
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 REDIHALER INHALATION HFA AEROSOL BREATH ACTIVATED
Tier 2
REVATIO INTRAVENOUS SOLUTION Tier 3 PA; SPRx
REVATIO ORAL SUSPENSION FOR RECONSTITUTION
Tier 3 PA; SPRx
REVATIO ORAL TABLET Tier 3 PA; SPRx
RUCONEST INTRAVENOUS RECON SOLN Tier 3 PA; SPRx
Drug Name Drug Tier Requirements/Limits
130
Effective 1/2019
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
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
TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED
Tier 2
Drug Name Drug Tier Requirements/Limits
131
Effective 1/2019
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
Tier 3 ST; QL (2 EA per 30 days)
XOPENEX CONCENTRATE INHALATION SOLUTION FOR NEBULIZATION
Tier 3
XOPENEX HFA INHALATION HFA AEROSOL INHALER
Tier 3 ST; QL (2 EA per 30 days)
XOPENEX INHALATION SOLUTION FOR NEBULIZATION
Tier 3
zafirlukast oral tablet Tier 1
Drug Name Drug Tier Requirements/Limits
Urologicals Anticholinergics & Antispasmodics darifenacin oral tablet extended release 24 hr Tier 1
DITROPAN XL ORAL TABLET EXTENDED RELEASE 24HR 10 MG, 5 MG
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
oxybutynin chloride oral tablet Tier 1
132
Effective 1/2019
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, 5 MG Tier 3 PA; #; QL (8 EA per 30 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
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
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)
Drug Name Drug Tier Requirements/Limits
133
Effective 1/2019
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)
pot,sodium citrate-citric acid oral solution Tier 1
potassium citrate oral tablet extended release 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)
uro-458 oral tablet Tier 1
UROCIT-K 10 ORAL TABLET EXTENDED RELEASE
Tier 3
UROCIT-K 15 ORAL TABLET EXTENDED RELEASE
Tier 3
UROCIT-K 5 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
Drug Name Drug Tier Requirements/Limits
Vitamins, Hematinics & Electrolytes Electrolytes calcium 500 with d oral tablet Tier 1 ACA
calcium carbonate-vitamin d3 oral tablet 500mg (1,250mg) -600 unit, 600 mg(1,500mg) -400 unit
Tier 1 ACA
134
Effective 1/2019
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 m15 oral tablet,er particles/crystals Tier 1
klor-con m20 oral tablet,er particles/crystals Tier 1
klor-con oral packet Tier 1
klor-con sprinkle oral capsule, extended release 8 meq
Tier 1
klor-con/ef oral tablet, effervescent Tier 1
k-phos-neutral oral tablet 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
phospha 250 neutral oral tablet Tier 1
phosphorous oral tablet 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
strong iodine oral solution Tier 1
Drug Name Drug Tier Requirements/Limits
135
Effective 1/2019
virt-phos 250 neutral oral tablet Tier 1
Miscellaneous Vitamins, Hematinics, & Electrolytes FORTAVIT ORAL CAPSULE Tier 3
Vitamins & Hematinics ACTIVE FE ORAL TABLET Tier 3
ANIMI-3 WITH VITAMIN D ORAL CAPSULE
Tier 3
b complex-vitamin b12 oral tablet Tier 1 ACA
b complex-vitamin c-folic acid oral tablet Tier 1 ACA
BACMIN ORAL TABLET Tier 3
bal-care dha oral combo pack,tablet and cap,dr Tier 1
b-complex with vitamin c oral tablet Tier 1 ACA
calcium pnv oral capsule Tier 1
calcium-folic acid-vitamin d oral wafer Tier 1
centratex oral capsule Tier 1
c-nate dha oral capsule Tier 1
complete natal dha oral combo pack Tier 1
completenate oral tablet,chewable Tier 1
corvita 150 oral tablet Tier 1
corvita oral tablet Tier 1
CORVITE 150 ORAL TABLET 150 MG IRON- 1 MG
Tier 3
CORVITE FE ORAL TABLET 150 MG IRON- 1 MG
Tier 3
CORVITE FREE ORAL TABLET Tier 3
CORVITE ORAL TABLET Tier 3
cyanocobalamin (vitamin b-12) injection solution Tier 1
DIALYVITE 800 WITH IRON ORAL TABLET
Tier 3
dialyvite oral tablet Tier 1
DIALYVITE SUPREME D ORAL TABLET Tier 3
dothelle dha oral capsule Tier 1
elite-ob oral tablet Tier 1
ergocalciferol (vitamin d2) oral capsule Tier 1
Drug Name Drug Tier Requirements/Limits
136
Effective 1/2019
ESCAVITE ORAL TABLET,CHEWABLE Tier 3
fabb oral tablet Tier 1
fe c plus oral tablet Tier 1
ferocon oral capsule Tier 1
FERRALET 90 DUAL-IRON DELIVERY ORAL TABLET
Tier 3
ferraplus 90 oral tablet Tier 1
ferrocite plus oral tablet Tier 1
FLUORABON 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
fluoride (sodium) oral tablet,chewable 1 mg (2.2 mg sod. fluoride)
Tier 1
fluoritab oral tablet,chewable 0.5 mg (1.1 mg sodium fluorid)
Tier 1 ACA
fluoritab oral tablet,chewable 1 mg (2.2 mg sod. fluoride)
Tier 1
FLURA-DROPS ORAL DROPS Tier 3
folbee oral tablet Tier 1
folbee plus oral tablet 5 mg Tier 1
FOLGARD OS ORAL TABLET Tier 3
FOLGARD RX ORAL TABLET Tier 3
folic acid oral tablet 1 mg Tier 1
folic acid oral tablet 400 mcg, 800 mcg Tier 1 ACA
folic acid-vit b6-vit b12 oral tablet 2.2-25-0.5 mg Tier 1
folivane-f oral capsule Tier 1
folivane-ob oral capsule Tier 1
folivane-plus oral capsule Tier 1
folplex 2.2 oral tablet Tier 1
FOLTRATE ORAL TABLET Tier 3
hematinic plus vit/minerals oral tablet Tier 1
hematinic/folic acid oral tablet Tier 1
hematogen fa oral capsule Tier 1
Drug Name Drug Tier Requirements/Limits
137
Effective 1/2019
hematogen forte oral capsule Tier 1
hematogen oral capsule Tier 1
hemenatal ob + dha oral combo pack Tier 1
hemenatal ob oral tablet Tier 1
HEMOCYTE-F ORAL TABLET Tier 3
HEMOCYTE-PLUS ORAL CAPSULE Tier 3
ICAR-C PLUS ORAL TABLET Tier 3
INTEGRA F ORAL CAPSULE Tier 3
INTEGRA PLUS ORAL CAPSULE Tier 3
IROSPAN 24/6 ORAL TABLET Tier 3
ludent fluoride oral tablet,chewable Tier 1 ACA
multi-vit with fluoride-iron oral drops Tier 1 ACA
multi-vitamin with fluoride oral drops Tier 1 ACA
multi-vitamin with fluoride oral tablet,chewable 0.25 mg, 0.5 mg
Tier 1 ACA
multi-vitamin with fluoride oral tablet,chewable 1 mg
Tier 1
multivitamins with fluoride oral tablet,chewable 0.25 mg, 0.5 mg
Tier 1 ACA
multivitamins with fluoride oral tablet,chewable 1 mg
Tier 1
mvc-fluoride oral tablet,chewable 0.25 mg, 0.5 mg Tier 1 ACA
mvc-fluoride oral tablet,chewable 1 mg Tier 1
mynatal advance oral tablet Tier 1
mynatal oral capsule Tier 1
mynatal oral tablet Tier 1
mynatal plus oral tablet Tier 1
mynatal-z oral tablet Tier 1
mynate 90 plus oral tablet extended release Tier 1
mynephrocaps oral capsule Tier 1
mynephron oral capsule Tier 1
nephplex rx oral tablet Tier 1
NEPHRON FA ORAL TABLET Tier 3
nephro-vite rx oral tablet Tier 1
Drug Name Drug Tier Requirements/Limits
138
Effective 1/2019
NEURIN-SL SUBLINGUAL TABLET Tier 3
newgen oral tablet Tier 1
NUTRICAP ORAL TABLET Tier 3
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
pnv-omega oral capsule Tier 1
pnv-select oral tablet Tier 1
pnv-vp-u oral capsule Tier 1
POLY-VI-FLOR ORAL DROPS,SUSPENSION BIPHASIC
Tier 3
POLY-VI-FLOR ORAL TABLET,CHEWABLE
Tier 3
POLY-VI-FLOR WITH IRON ORAL DROPS,SUSPENSION BIPHASIC
Tier 3
POLY-VI-FLOR WITH IRON ORAL TABLET,CHEWABLE
Tier 3
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
Drug Name Drug Tier Requirements/Limits
139
Effective 1/2019
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
PROFERRIN-FORTE ORAL TABLET Tier 3
PROTECT IRON ORAL TABLET Tier 3
purevit dualfe plus oral capsule Tier 1
renal caps oral capsule Tier 1
rena-vite rx oral tablet Tier 1
reno caps 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
se-tan plus oral capsule Tier 1
STROVITE FORTE ORAL TABLET Tier 3
STROVITE ONE ORAL TABLET Tier 3
TANDEM PLUS ORAL CAPSULE Tier 3
taron forte oral capsule Tier 1
taron-c dha oral capsule Tier 1
taron-prex prenatal-dha oral capsule Tier 1
thrivite-19 oral tablet Tier 1
tl gard rx oral tablet Tier 1
tl g-fol os oral tablet Tier 1
tl icon oral capsule Tier 1
tricon oral capsule Tier 1
trigels-f forte oral capsule Tier 1
trinatal rx 1 oral tablet Tier 1
trinate oral tablet Tier 1
triphrocaps oral capsule Tier 1
Drug Name Drug Tier Requirements/Limits
140
Effective 1/2019
triveen-duo dha oral combo pack Tier 1
TRI-VI-FLOR ORAL DROPS,SUSPENSION BIPHASIC
Tier 3
tri-vitamin with fluoride oral drops Tier 1 ACA
trust natal dha oral combo pack Tier 1
UDAMIN SP ORAL TABLET Tier 3
v-c forte 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-CAPS ORAL CAPSULE Tier 3
virt-gard oral tablet Tier 1
virt-nate dha oral capsule 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
virt-vite oral tablet Tier 1
VIRT-VITE PLUS ORAL TABLET Tier 3
vit 3 oral capsule Tier 1
VITAFOL ORAL TABLET Tier 3
VITAL-D RX ORAL TABLET Tier 3
vitamin b complex-folic acid oral tablet Tier 1 ACA
vitamin d3 oral tablet 400 unit Tier 1 ACA
vitamins a,c,d and fluoride oral drops Tier 1 ACA
VITA-RESPA ORAL TABLET Tier 3
vol-nate oral tablet Tier 1
vol-plus oral tablet Tier 1
Drug Name Drug Tier Requirements/Limits
141
Effective 1/2019
vol-tab rx oral tablet Tier 1
vp-ch plus oral capsule Tier 1
vp-ch-pnv oral capsule Tier 1
vp-vite rx oral tablet Tier 1
zatean-pn dha oral capsule Tier 1
zatean-pn plus oral capsule Tier 1
zingiber oral tablet Tier 1
Drug Name Drug Tier Requirements/Limits
Effective 1/2019
142
Index of Drugs
1 1ST TIER UNIFINE PENTIPS
..........................................80 1ST TIER UNILET
COMFORTOUCH ...........80 A abacavir ..................................3 abacavir-lamivudine ...............3 abacavir-lamivudine
zidovudine ..........................3 ABILIFY ..............................33 ABILIFY MAINTENA........33 ABSTRAL............................28 acamprosate..........................68 ACANYA.............................58 acarbose................................90 ACCOLATE.......................127 ACCU-CHEK AVIVA PLUS
TEST STRP......................76 ACCU-CHEK COMPACT
PLUS TEST......................76 ACCU-CHEK GUIDE .........76 ACCU-CHEK SAFE-T-PRO
..........................................80 ACCU-CHEK SMARTVIEW
TEST STRIP ....................76 ACCU-CHEK SOFTCLIX
LANCETS........................80 ACCUPRIL ..........................42 ACCURETIC .......................42 ACCUTREND GLUCOSE..76 acebutolol .............................42 acetaminophen-caff
dihydrocod........................28 acetaminophen-codeine........28 acetazolamide .....................121 acetic acid....................... 68, 74acetylcysteine .....................127 acitretin.................................55 ACTEMRA ........................108 ACTHAR H.P. .....................75 ACTHIB (PF).....................103 ACTIGALL..........................94 ACTI-LANCE LANCETS...80 ACTIMMUNE ...................102 ACTIQ..................................28 ACTIVE FE........................135
ACTIVELLA......................109 ACTONEL .........................107 ACTOPLUS MET................90 ACTOPLUS MET XR .........90 ACTOS.................................90 acyclovir ........................... 3, 62 ADACEL(TDAP
ADOLESN/ADULT)(PF) ........................................103
ADALAT CC .......................42 adapalene ..............................58 adapalene-benzoyl peroxide . 58 ADCIRCA..........................127 ADDERALL ........................33 adefovir...................................3 ADEMPAS.........................127 ADIPEX-P............................67 ADMELOG SOLOSTAR U
100 INSULIN...................86 ADMELOG U-100 INSULIN
LISPRO ............................86 adrenalin .............................124 ADVAIR DISKUS.............127 ADVAIR HFA ...................127 ADVANCED GLUC METER
TEST STRIP.....................76 ADVANCED TRAVEL
LANCETS........................80 ADVATE..............................49 ADVOCATE LANCET .......80 ADVOCATE PEN NEEDLE
..........................................80 ADVOCATE REDI-CODE . 76 ADVOCATE TEST STRIPS76 AEROSPAN.......................127 afeditab cr .............................42 AFINITOR ...........................13 AFINITOR DISPERZ ..........13 AFLURIA 2018-2019 ........103 AFLURIA 2018-2019 (PF) 103 AFLURIA QUAD 2018-2019
........................................103 AFLURIA QUAD 2018-2019
(PF).................................103 AFREZZA ............................86 AGAMATRIX AMP TEST
STRIPS.............................76
AGGRENOX........................49 AGRYLIN ............................68 AKTEN (PF) ......................120 ala-cort ..................................63 ALA-SCALP ........................63 ALBENZA .............................8 albuterol sulfate ..................127 alclometasone .......................63 ALCOHOL SWABS ............81 ALDACTAZIDE..................42 ALDACTONE......................42 ALDARA ...........................102 ALECENSA .........................13 alendronate ................... 68, 107alfuzosin .............................132 ALINIA ..................................8 ALKERAN ...........................13 allopurinol...........................107 almotriptan malate ................24 ALORA ..............................109 alosetron ...............................94 ALPHAGAN P...................123 ALPHANATE ......................49 ALPHANINE SD .................49 alprazolam ............................33 alprazolam intensol...............33 ALPROLIX ..........................49 alprostadil ...........................132 ALSUMA .............................24 ALTABAX ...........................61 ALTACE ..............................42 altavera (28)........................112 ALTERNATE SITE LANCET
..........................................81 ALUNBRIG .........................13 alyacen 1/35 (28) ................112 alyacen 7/7/7 (28) ...............112 amabelz...............................109 amantadine hcl........................3 AMARYL.............................90 AMBIEN ..............................33 AMBIEN CR ........................33 amcinonide ...........................63 AMERGE .............................24 amethia ...............................112 amethia lo ...........................112 amethyst..............................112
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143
AMICAR..............................49 amiloride...............................42 amiloride-hydrochlorothiazide
..........................................42 amiodarone ...........................41 AMITIZA .............................94 amitriptyline .........................33 amitriptyline-chlordiazepoxide
..........................................33 amlodipine............................42 amlodipine-atorvastatin........51 amlodipine-benazepril ..........42 amlodipine-olmesartan .........42 amlodipine-valsartan ............42 amlodipine-valsartan-hcthiazid
..........................................42 amnesteem............................58 amoxapine ............................33 amoxicil-clarithromy-lansopraz
..........................................99 amoxicillin............................10 amoxicillin-pot clavulanate ..11 ampicillin..............................11 AMPYRA.............................26 ANADROL-50 .....................88 ANAFRANIL.......................34 anagrelide .............................68 ANAPROX DS ....................31 anastrozole............................13 ANCOBON ............................2 ANDRODERM ....................88 ANDROGEL........................88 ANDROID ...........................88 ANGELIQ ..........................109 ANIMI-3 WITH VITAMIN D
........................................135 ANORO ELLIPTA ............127 ANTABUSE.........................68 ANTARA .............................51 anucort-hc.............................94 ANUSOL-HC.......................94 ANZEMET...........................94 apexicon e.............................63 APIDRA SOLOSTAR U-100
INSULIN..........................86 APIDRA U-100 INSULIN...86 APOKYN .............................22 apraclonidine ......................123 aprepitant ..............................94 apri...................................... 112
APRISO................................94 APTIOM...............................18 APTIVUS ...............................3 aqua care sodium chloride....68 aqua care sterile water ..........68 AQUA GLYCOLIC HC.......63 aranelle (28)........................112 ARANESP (IN
POLYSORBATE) ..........100 ARAVA..............................108 ARCALYST.......................102 ARCAPTA NEOHALER...127 ARESTIN .............................73 ARICEPT .............................26 ARIMIDEX ..........................13 aripiprazole...........................34 ARISTADA..........................34 ARISTADA INITIO.............34 ARIXTRA ............................49 armodafinil ...........................34 ARMOUR THYROID .........92 ARNUITY ELLIPTA.........127 AROMASIN.........................13 ARTHROTEC 50.................31 ARTHROTEC 75.................31 ascomp with codeine ............24 ashlyna................................112 ASMANEX HFA ...............127 ASMANEX TWISTHALER
........................................127 aspirin ...................................31 aspirin-dipyridamole ............49 ASSURE 4 STRIPS..............76 ASSURE HAEMOLANCE
PLUS ................................81 ASSURE LANCE ................81 ASSURE LANCE PLUS......81 ASSURE PLATINUM.........76 ASSURE PRISM MULTI
STRIP ...............................76 ASTAGRAF XL...................13 ASTEPRO ............................73 ATACAND ..........................42 ATACAND HCT .................42 atazanavir................................3 ATELVIA...........................107 atenolol .................................42 atenolol-chlorthalidone.........42 ATIVAN...............................34 atomoxetine ..........................34
atorvastatin ...........................51 atovaquone..............................8 atovaquone-proguanil .............8 ATRIPLA ...............................3 atropine ...............................120 ATROVENT HFA..............127 AUBAGIO..........................101 aubra ...................................113 aubra eq ..............................113 AUGMENTIN......................11 AUGMENTIN ES-600.........11 AUGMENTIN XR ...............11 AURYXIA............................94 AUSTEDO ...........................26 AVALIDE ............................42 AVANDIA ...........................90 AVAPRO..............................42 AVC VAGINAL ................111 AVELOX..............................11 aviane..................................113 avidoxy .................................12 avita ......................................58 AVODART.........................132 AVONEX ...........................101 AVONEX (WITH ALBUMIN)
........................................101 AYGESTIN ........................109 AZASAN..............................13 AZASITE ...........................118 azathioprine ..........................13 azelastine ...................... 73, 120AZELEX...............................58 AZILECT .............................22 azithromycin ....................... 7, 8 AZOR ...................................42 AZULFIDINE ......................94 AZULFIDINE EN-TABS ....94 azurette (28)........................113 B b complex-vitamin b12.......135 b complex-vitamin c-folic acid
........................................135 bacitracin ............................118 bacitracin-polymyxin b.......118 baclofen ................................27 BACMIN ............................135 BACTRIM............................12 BACTRIM DS......................12 BACTROBAN NASAL .......73 bal-care dha ........................135
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BALCOLTRA....................113 balsalazide ............................95 balziva (28).........................113 BANZEL ..............................18 BARACLUDE .......................3 BCG VACCINE, LIVE (PF)
........................................103 b-complex with vitamin c...135 BD ECLIPSE........................81 BD FILTER NEEDLE-5
MICRON..........................81 BD INTEGRA NEEDLE .....81 BD MICROTAINER
LANCET ..........................81 BD NOKOR ADMIX
NEEDLE ..........................81 BD PRECISIONGLIDE.......81 BD PRECISIONGLIDE NON
STERILE..........................81 bd pre-filled normal saline ...68 BD SAFETYGLIDE NEEDLE
..........................................81 BD SPECIALTY USE
NEEDLES ........................81 BD ULTRA FINE LANCETS
..........................................81 BD ULTRA-FINE NANO
PEN NEEDLE..................81 BD ULTRA-FINE SHORT
PEN NEEDLE..................81 BEBULIN.............................49 bekyree (28)........................113 BELVIQ ...............................67 benazepril .............................42 benazepril-hydrochlorothiazide
..........................................42 BENEFIX .............................49 BENICAR ............................42 BENICAR HCT ...................42 BENLYSTA.......................108 BENZAMYCIN ...................58 BENZEFOAM .....................58 BENZEFOAM ULTRA .......58 benzepro ...............................58 BENZEPRO
(MICROSPHERES) .........58 benzonatate.........................125 benzoyl peroxide ..................58 benzphetamine......................67 benztropine ...........................22
BERINERT ........................127 BESIVANCE......................118 BETADINE OPHTHALMIC
PREP ..............................118 betamethasone dipropionate . 63 betamethasone valerate.........63 betamethasone, augmented...63 BETAPACE .........................41 BETAPACE AF ...................41 BETASERON ....................101 betaxolol ....................... 42, 119bethanechol chloride...........132 BEVESPI AEROSPHERE. 128 bexarotene ............................13 BEXSERO..........................103 BEYAZ...............................113 BIAFINE EMULSION.........56 bicalutamide .........................13 BIDIL ...................................42 BIKTARVY ...........................3 BILTRICIDE..........................8 bimatoprost.........................121 BINOSTO...........................107 BIONIME RIGHTEST TEST
STRIPS.............................76 BIOTHRAX .......................103 bisacodyl...............................95 bisoprolol fumarate...............42 bisoprolol-hydrochlorothiazide
..........................................42 BLEPH-10 ..........................123 BLEPHAMIDE ..................123 BLEPHAMIDE S.O.P........ 123 blisovi 24 fe ........................113 blisovi fe 1.5/30 (28) ..........113 blisovi fe 1/20 (28) .............113 BLOOD GLUCOSE TEST ..76 BLUNT NEEDLE,
DISPOSABLE..................81 BONIVA ............................107 BOOSTRIX TDAP.............103 BOSULIF .............................13 bpo........................................58 BRAVELLE .........................88 BREEZE 2 TEST STRIPS ...76 BREO ELLIPTA ................128 BREVICON (28)................113 briellyn................................113 BRILINTA ...........................49 brimonidine ........................124
BROMFED DM .................125 bromfenac ...........................121 bromocriptine .......................22 brompheniramine-pseudoeph
dm...................................125 BROVANA ........................128 budesonide.................... 95, 128 BULLSEYE MINI SAFETY
LANCETS ........................81 bumetanide ...........................43 BUNAVAIL .........................18 BUPAP .................................24 BUPHENYL................... 68, 69buprenorphine-naloxone.......18 bupropion hcl........................34 bupropion hcl (smoking deter)
..........................................72 buspirone ..............................34 butalbital compound w/codeine
..........................................24 butalbital-acetaminop-caf-cod
..........................................24 butalbital-acetaminophen24, 28 butalbital-acetaminophen-caff
.................................... 24, 28 butalbital-aspirin-caffeine.....28 BUTISOL .............................34 butorphanol tartrate ..............28 BUTRANS ...........................28 BYDUREON.................. 90, 91BYDUREON BCISE............90 BYETTA ..............................91 BYSTOLIC...........................43 C cabergoline ...........................88 CABOMETYX.....................14 CADUET..............................51 CAFERGOT .........................24 caffeine citrate ......................69 CALAN ................................43 CALAN SR ..........................43 calcipotriene .........................55 calcipotriene-betamethasone 55 calcitonin (salmon) ...............88 calcitrene...............................55 calcitriol .......................... 55, 88calcium 500 with d .............133 calcium acetate .....................95 calcium carbonate-vitamin d3
........................................133
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145
calcium citrate + d ..............134 calcium citrate-vitamin d3..134 calcium pnv ........................135 calcium-folic acid-vitamin d
........................................135 CALQUENCE......................14 camila .................................109 CAMINO PRO 15 PE PKU . 70 camrese...............................113 camrese lo...........................113 CANASA .............................95 candesartan ...........................43 candesartan-hydrochlorothiazid
..........................................43 capacet ..................................24 CAPCOF ............................125 capecitabine..........................14 CAPEX.................................63 CAPRELSA .........................14 captopril................................43 captopril-hydrochlorothiazide
..........................................43 CARAFATE.........................99 CARBAGLU........................69 carbamazepine......................18 CARBATROL......................18 carbidopa ..............................22 carbidopa-levodopa ..............22 carbidopa-levodopa
entacapone........................22 carbinoxamine maleate.......124 CARDIZEM.........................43 CARDIZEM CD ..................43 CARDIZEM LA...................43 CARDURA ..........................43 CARDURA XL....................43 CAREFINE PEN NEEDLE . 81 CAREONE THIN LANCET81 CARESENS N TEST STRIPS
..........................................76 CARETOUCH TEST STRIP
..........................................76 carisoprodol..........................27 carisoprodol-asa-codeine......27 carisoprodol-aspirin..............27 CARNITOR .........................69 CARNITOR (SUGAR-FREE)
..........................................69 carteolol ..............................119 cartia xt.................................43
carvedilol ..............................43 carvedilol phosphate.............43 CASODEX ...........................14 CATAPRES..........................43 CATAPRES-TTS-1 ..............43 CATAPRES-TTS-2 ..............43 CATAPRES-TTS-3 ..............43 CAVERJECT .....................132 CAVERJECT IMPULSE ...132 CAYSTON .............................8 caziant (28) .........................113 cefaclor ...................................7 cefadroxil................................7 cefdinir....................................7 cefditoren pivoxil ...................7 cefixime..................................7 cefpodoxime ...........................7 cefprozil..................................7 cefuroxime axetil....................7 CELEBREX .........................31 celecoxib...............................31 CELEXA ..............................34 CELLCEPT ..........................14 CELONTIN..........................18 CENTANY...........................61 CENTANY AT.....................61 centratex .............................135 cephalexin...............................7 CERDELGA.........................88 CESAMET ...........................95 CETROTIDE........................89 cevimeline ............................69 CHANTIX............................72 CHANTIX CONTINUING
MONTH BOX..................72 CHANTIX STARTING
MONTH BOX..................73 chateal.................................113 chateal eq............................113 CHEMET..............................69 CHENODAL........................95 cheratussin ac .....................125 chlordiazepoxide hcl.............34 chlordiazepoxide-clidinium..93 chlorhexidine gluconate .......73 chloroquine phosphate............9 chlorothiazide .......................43 chlorpromazine.....................34 chlorpropamide.....................91 chlorthalidone.......................43
chlorzoxazone.......................27 CHOLBAM ..........................95 cholestyramine (with sugar) . 51 cholestyramine light ....... 51, 52 choline,magnesium salicylate
..........................................31 CIALIS ...............................132 ciclodan.................................61 ciclopirox ........................ 61, 62 ciclopirox-ure-camph-menth
euc.....................................62 cilostazol...............................49 CILOXAN ..........................118 CIMDUO................................3 cimetidine .............................99 cimetidine hcl .......................99 CIMZIA................................95 CIMZIA STARTER KIT .....95 CINRYZE...........................128 CIPRO ..................................11 CIPRO HC............................74 CIPRO XR............................11 CIPRODEX ..........................74 ciprofloxacin.........................11 ciprofloxacin (mixture).........11 ciprofloxacin hcl ..... 11, 74, 118 citalopram .............................34 citrate of magnesia................95 claravis..................................58 CLARINEX........................124 CLARINEX-D 12 HOUR ..125 clarithromycin.........................8 clearlax .................................95 clemastine ...........................124 CLENPIQ .............................95 CLEOCIN................... 111, 112CLEOCIN HCL......................9 CLEOCIN PEDIATRIC.........9 CLEOCIN T .........................58 CLEVER CHEK LANCETS81 CLEVER CHOICE MICRO
TEST STRIP.....................76 CLEVER CHOICE PRO......76 CLEVER CHOICE TALK
TEST.................................77 CLEVER CHOICE TEST
STRIPS .............................77 CLEVER CHOICE VOICE+
TEST.................................77 CLICKFINE .........................81
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146
CLIMARA .........................109 CLIMARA PRO.................109 clindacin p ............................58 CLINDAGEL.......................58 clindamycin hcl ......................9 clindamycin palmitate hcl ......9 clindamycin pediatric .............9 clindamycin phosphate. 58, 112 clindamycin-benzoyl peroxide
..........................................59 CLINDESSE ......................112 CLINPRO 5000....................73 clobetasol........................ 63, 64clobetasol-emollient .............64 CLOBEX..............................64 CLOCORTOLONE
PIVALATE ......................64 clodan ...................................64 CLODERM ..........................64 clomipramine........................34 clonazepam...........................18 clonidine ...............................43 clonidine hcl ................... 34, 43clopidogrel............................49 clorazepate dipotassium .......34 clorpres .................................43 CLORPRES..........................43 clotrimazole............................2 clotrimazole-betamethasone. 62 clozapine...............................34 CLOZAPINE........................34 CLOZARIL ..........................34 c-nate dha ...........................135 COAGADEX .......................49 COAGUCHEK LANCETS..81 COAL TAR..........................55 COARTEM ............................9 codeine sulfate......................28 codeine-butalbital-asa-caff ...24 codeine-guaifenesin............125 COLAZAL ...........................95 COLCRYS .........................107 colesevelam ..........................52 COLESTID...........................52 COLESTID FLAVORED ....52 colestipol ..............................52 colocort.................................95 COLOR LANCETS .............81 COLY-MYCIN S .................74
COLYTE WITH FLAVOR
PACKS .............................95 COMBIGAN ......................121 COMBIPATCH..................109 COMBIVENT RESPIMAT128 COMBIVIR ............................3 COMETRIQ .........................14 COMFORT EZ PEN
NEEDLES ........................82 COMFORT LANCETS........82 COMPAZINE.......................95 COMPLERA ..........................3 complete natal dha..............135 completenate.......................135 compro ..................................95 COMTAN.............................22 CONDYLOX........................56 constulose .............................95 CONTOUR NEXT TEST
STRIPS.............................77 CONTOUR TEST STRIPS..77 CONTRAVE ........................67 COOL GLUCOSE TEST
STRIP ...............................77 COPAXONE ......................101 CORDRAN ..........................64 COREG ................................44 COREG CR ..........................44 CORGARD ..........................44 CORIFACT ..........................49 CORLANOR........................54 cormax ..................................64 CORTEF...............................75 CORTENEMA .....................95 CORTIFOAM ......................95 cortisone ...............................75 CORTISPORIN....................61 corvita.................................135 corvita 150..........................135 CORVITE...........................135 CORVITE 150....................135 CORVITE FE.....................135 CORVITE FREE................135 CORZIDE.............................44 COSENTYX.........................55 COSENTYX (2 SYRINGES)
..........................................55 COSENTYX PEN ................55 COSENTYX PEN (2 PENS)55 COSOPT.............................121
COTELLIC...........................14 COUMADIN ........................49 covaryx ...............................109 covaryx h.s.......................... 109 COZAAR..............................44 CREON.................................95 CRESEMBA...........................2 CRESTOR ............................52 CRINONE ..........................109 CRIXIVAN.............................3 cromolyn............... 95, 120, 128 cryselle (28) ........................113 CUTIVATE ..........................64 CUVITRU ..........................103 CUVPOSA ...........................93 cyanocobalamin (vitamin b-12)
........................................135 cyclafem 1/35 (28)..............113 cyclafem 7/7/7 (28).............113 CYCLESSA (28) ................113 cyclobenzaprine ....................27 CYCLOGYL ......................120 CYCLOMYDRIL...............124 cyclopentolate.....................120 cyclophosphamide ................14 CYCLOSERINE.....................9 CYCLOSET .........................91 cyclosporine..........................14 cyclosporine modified ..........14 CYMBALTA........................34 cyproheptadine ...................124 cyred ...................................113 CYSTADANE......................95 CYSTAGON ......................133 CYSTARAN.......................120 CYTOMEL...........................92 CYTOTEC............................99 D D.H.E.45...............................24 DALIRESP .........................128 danazol..................................89 DANTRIUM.........................27 dantrolene .............................27 dapsone ...................................9 DAPTACEL (DTAP
PEDIATRIC) (PF)..........103 DARAPRIM ...........................9 darifenacin ..........................131 dasetta 1/35 (28) .................113 dasetta 7/7/7 (28) ................113
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DAYPRO .............................31 daysee .................................113 DAYTRANA .......................35 DDAVP ................................89 deblitane .............................109 decadron ...............................75 DELESTROGEN ...............109 deltasone...............................75 delyla (28) ..........................113 DEMADEX..........................44 demeclocycline.....................12 DEMEROL...........................28 DENAVIR............................63 denta 5000 plus.....................73 dentagel ................................73 DEPAKENE.........................18 DEPAKOTE.........................18 DEPAKOTE ER...................18 DEPAKOTE SPRINKLES ..18 DEPEN TITRATABS........108 DEPO-ESTRADIOL..........109 DEPO-PROVERA .............109 DEPO-SUBQ PROVERA 104
........................................109 DEPO-TESTOSTERONE....89 DERMA-SMOOTHE/FS
BODY OIL.......................64 DERMA-SMOOTHE/FS
SCALP OIL......................64 DERMASORB HC
COMPLETE KIT .............64 DERMASORB TA
COMPLETE KIT .............64 DERMATOP........................64 DERMOTIC OIL .................74 DESCOVY.............................3 desipramine ..........................35 desloratadine.......................124 desmopressin ........................89 desog-e.estradiol/e.estradiol
........................................113 desogestrel-ethinyl estradiol
........................................113 DESONATE.........................64 desonide................................64 DESOWEN ..........................64 desoximetasone .............. 64, 65desvenlafaxine succinate ......35 dexamethasone .....................75 dexamethasone intensol........75
dexamethasone sodium
phosphate........................122 DEXEDRINE SPANSULE..35 DEXILANT..........................99 dexmethylphenidate..............35 dextroamphetamine ..............35 dextroamphetamine
amphetamine ....................35 dialyvite ..............................135 DIALYVITE 800 WITH IRON
........................................135 DIALYVITE SUPREME D
........................................135 DIASTAT.............................18 DIASTAT ACUDIAL..........18 DIATRUE PLUS TEST STRIP
..........................................77 diazepam......................... 18, 35 diazepam intensol .................35 DIBENZYLINE ...................44 diclofenac potassium ............31 diclofenac sodium... 31, 56, 121diclofenac-misoprostol .........31 dicloxacillin ..........................11 dicyclomine ..........................93 didanosine...............................3 diethylpropion ......................67 DIFICID .................................8 diflorasone ............................65 DIFLUCAN............................2 diflunisal...............................31 digitek...................................48 digox.....................................48 digoxin ..................................49 dihydroergotamine................24 DILANTIN...........................19 DILANTIN EXTENDED.....18 DILANTIN INFATABS ......19 DILANTIN KAPSEAL........19 DILANTIN-125....................19 DILATRATE-SR .................54 DILAUDID ..........................28 diltiazem hcl .........................44 dilt-xr ....................................44 DIOVAN ..............................44 DIOVAN HCT .....................44 diphenhydramine hcl ..........124 diphenoxylate-atropine.........93 DIPROLENE........................65 dipyridamole.........................49
DISALCID ...........................31 diskets ...................................28 disopyramide phosphate .......41 disulfiram..............................69 DITROPAN XL..................131 DIURIL.................................44 divalproex .............................19 DIVIGEL............................109 dofetilide...............................41 DOLOPHINE .......................28 donepezil...............................26 DONNATAL........................93 DOPTELET..........................49 DORAL ................................35 dorzolamide ........................121 dorzolamide-timolol ...........121 dothelle dha ........................135 doxazosin ..............................44 doxepin ........................... 35, 57 doxercalciferol ......................89 doxycycline hyclate ..............12 doxycycline monohydrate ....12 drithocreme hp......................55 dronabinol.............................95 DROPLET LANCETS .........82 DROPLET PEN NEEDLE...82 drospirenone-e.estradiol-lm.fa
........................................113 drospirenone-ethinyl estradiol
........................................113 DROXIA...............................14 DUAVEE............................109 DUETACT ...........................91 DULERA............................128 duloxetine .............................35 DUOPA ................................23 DUPIXENT ..........................57 DURAGESIC .......................28 DUREZOL .........................122 dutasteride...........................132 dutasteride-tamsulosin........132 DUTOPROL.........................44 DYAZIDE ............................44 DYRENIUM.........................44 E e.e.s. 400 .................................8 E.E.S. GRANULES................8 EAA SUPPLEMENT ...........70 EASY COMFORT LANCETS
..........................................82
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148
EASY COMFORT PEN NEEDLES ........................82
EASY PLUS II TEST ..........77 EASY STEP .........................77 EASY TALK GLUCOSE
TEST ................................77 EASY TOUCH FLIPLOCK
NEEDLE ..........................82 EASY TOUCH
HYPODERMIC NEEDLE ..........................................82
EASY TOUCH TEST STRIP ..........................................77
EASY TRAK GLUCOSE TEST ................................77
EASYGLUCO PLUS...........77 EASYGLUCO TEST ...........77 EASYMAX ..........................77 EC-NAPROSYN..................31 econazole..............................62 econtra ez............................113 econtra one-step..................113 EDARBI...............................44 EDARBYCLOR...................44 EDECRIN.............................44 EDEX .................................133 EDURANT.............................3 eemt ....................................110 eemt hs................................110 efavirenz .................................3 effer-k .................................134 EFFER-K............................134 EFFEXOR XR......................35 EFFIENT..............................49 EFUDEX ..............................57 ELDEPRYL .........................23 ELEMENT COMPACT TEST
STRIPS.............................77 ELEMENT TEST STRIPS...77 ELESTRIN.........................110 eletone ..................................57 eletriptan...............................24 ELIDEL................................57 ELIMITE..............................67 elinest .................................114 eliphos ..................................95 ELIQUIS ..............................49 elite-ob ................................135 ELIXOPHYLLIN...............128 ELLA..................................114
ELMIRON..........................133 ELOCON..............................65 EMBRACE BLOOD
GLUCOSE SYSTEM.......77 EMBRACE EVO TEST
STRIPS.............................77 EMBRACE PRO TEST
STRIPS.............................77 EMCYT................................14 EMEND................................95 EMFLAZA ...........................75 emoquette ...........................114 EMSAM ...............................35 EMTRIVA..............................3 emulsion sb ...........................57 enalapril maleate...................44 enalapril-hydrochlorothiazide
..........................................44 ENBREL ............................108 ENBREL MINI ..................108 ENBREL SURECLICK .....108 endocet..................................28 ENGERIX-B (PF) ..............103 ENGERIX-B PEDIATRIC
(PF).................................103 enoxaparin ............................49 enpresse ..............................114 enskyce ...............................114 ENSTILAR...........................55 entacapone ............................23 entecavir .................................3 ENTOCORT EC...................96 ENTRESTO..........................54 enulose..................................96 EPANED ..............................44 EPCLUSA ..............................4 EPICERAM..........................57 EPIDUO ...............................59 EPIDUO FORTE..................59 epinastine............................120 epinephrine .........................124 EPINEPHRINE ..................124 EPIPEN ..............................124 EPIPEN 2-PAK ..................124 EPIPEN JR .........................124 EPIPEN JR 2-PAK.............124 epitol.....................................19 EPIVIR ...................................4 EPIVIR HBV..........................4 eplerenone ............................44
EPOGEN ............................101 epoprostenol (glycine) ..........44 eprosartan .............................44 EPZICOM...............................4 EQUETRO ...........................19 ergocalciferol (vitamin d2) . 135 ergoloid .................................35 ERGOMAR ..........................24 ergotamine-caffeine ..............24 ERIVEDGE ..........................14 ERLEADA ...........................14 errin.....................................110 ERTACZO............................62 ery pads.................................59 erygel ....................................59 ERYPED 200..........................8 ERYPED 400..........................8 ery-tab.....................................8 ERY-TAB...............................8 erythrocin (as stearate) ...........8 erythromycin................... 8, 118 erythromycin ethylsuccinate...8 erythromycin with ethanol....59 erythromycin-benzoyl peroxide
..........................................59 ESBRIET............................128 ESCAVITE.........................136 escitalopram oxalate .............35 ESGIC............................. 24, 28esomeprazole magnesium.....99 estarylla...............................114 estazolam ..............................35 ESTRACE ..........................110 estradiol ..............................110 estradiol valerate.................110 estradiol-norethindrone acet
........................................110 ESTRING ...........................110 ESTROGEL........................110 estrogens-methyltestosterone
........................................110 estropipate...........................110 ESTROSTEP FE-28 ...........114 eszopiclone ...........................35 ethacrynic acid......................44 ethambutol ..............................9 ethosuximide.........................19 ethyl chloride ........................60 ethynodiol diac-eth estradiol
........................................114
Effective 1/2019
149
etidronate disodium..............69 etodolac .......................... 31, 32etoposide...............................14 EUCRISA.............................57 EURAX ................................67 EVAMIST ..........................110 EVENCARE G2...................77 EVENCARE G3 TEST ........77 EVENCARE MINI
GLUCOSE TEST STR.....77 EVISTA..............................107 EVOCLIN ............................59 EVOLUTION TEST STRIPS
..........................................77 EVOTAZ................................4 EVOXAC .............................69 EXEL HYPODERMIC
NEEDLES ........................82 EXELDERM ........................62 exemestane ...........................14 EXFORGE ...........................45 EXFORGE HCT ..................45 EXJADE...............................69 EXODERM ..........................62 EXTAVIA ..........................101 EXTINA...............................62 e-z ject lancets ......................82 EZ SMART LANCETS .......82 EZ SMART PLUS TEST.....77 EZ SMART TEST................77 ezetimibe ..............................52 ezetimibe-simvastatin...........52 F fabb.....................................136 FABIOR ...............................59 FACTIVE.............................11 falmina (28) ........................114 famciclovir .............................4 famotidine.............................99 FANAPT ..............................35 FARESTON .........................14 FARXIGA ............................91 FARYDAK...........................14 fayosim...............................114 FAZACLO ...........................36 fe c plus ..............................136 FEIBA NF ............................49 felbamate ..............................19 FELBATOL .........................19 FELDENE ............................32
felodipine..............................45 fem ph.................................112 FEMARA .............................14 FEMHRT LOW DOSE ......110 FEMRING ..........................110 femynor ..............................114 fenofibrate ............................52 fenofibrate micronized .........52 fenofibrate nanocrystallized . 52 fenofibric acid.......................52 fenofibric acid (choline) .......52 FENOGLIDE........................52 fenoprofen ............................32 fentanyl.................................28 fentanyl citrate ......................28 FENTORA............................28 ferocon................................136 FERRALET 90 DUAL-IRON
DELIVERY....................136 ferraplus 90 .........................136 FERRIPROX........................69 ferrocite plus.......................136 FEXMID...............................27 FIASP FLEXTOUCH U-100
INSULIN ..........................86 FIASP U-100 INSULIN.......86 FIBRICOR............................52 FIFTY50 SAFETY SEAL
LANCETS........................82 FIFTY50 TEST STRIP ........77 FINACEA.............................59 finasteride ...........................132 FINE 30 UNIVERSAL
LANCETS........................82 FINGERSTIX LANCETS....82 FIORICET ............................24 FIORINAL ...........................28 FIORINAL-CODEINE #3 ...24 FIRAZYR...........................128 FIRVANQ ............................13 FLAGYL ................................9 FLAREX ............................122 flavoxate .............................131 flecainide ..............................41 FLOLAN ..............................45 FLOMAX ...........................132 FLOVENT DISKUS ..........128 FLOVENT HFA.................128 FLOW-EZE VENTED
NEEDLE ..........................82
FLUAD 2018-2019 (65 YR UP)(PF)...........................103
FLUARIX QUAD 2018-2019 (PF) .................................103
FLUBLOK QUAD 2018-2019 (PF) .................................104
flucaine ...............................120 FLUCELVAX QUAD 2018
2019 ................................104 FLUCELVAX QUAD 2018
2019 (PF) ........................104 fluconazole .............................2 flucytosine ..............................2 fludrocortisone......................75 FLULAVAL QUAD 2018
2019 ................................104 FLULAVAL QUAD 2018
2019 (PF) ........................104 FLUMADINE.........................4 FLUMIST QUAD 2018-2019
........................................104 flunisolide ...........................128 fluocinolone..........................65 fluocinolone acetonide oil ....74 fluocinolone and shower cap 65 fluocinonide..........................65 fluocinonide-e.......................65 fluocinonide-emollient .........65 FLUORABON....................136 fluorescein-proparacaine ....120 fluoride (sodium) ................136 FLUORIDEX DAILY
DEFENSE.........................73 fluoritab ..............................136 fluorometholone .................122 fluorouracil ...........................57 fluoxetine..............................36 fluphenazine hcl....................36 FLURA-DROPS.................136 flurandrenolide .....................65 flurazepam ............................36 flurbiprofen...........................32 flurbiprofen sodium ............121 flutamide...............................14 fluticasone..................... 65, 128fluvastatin .............................52 fluvoxamine..........................36 FLUZONE HIGH-DOSE
2018-19 (PF)...................104
Effective 1/2019
150
FLUZONE QUAD 2018-2019 ........................................104
FLUZONE QUAD 2018-2019 (PF).................................104
FLUZONE QUAD PEDI 2018-19 (PF) ..................104
FML FORTE......................122 FML LIQUIFILM ..............122 FML S.O.P. ........................123 folbee..................................136 folbee plus ..........................136 FOLGARD OS...................136 FOLGARD RX ..................136 folic acid.............................136 folic acid-vit b6-vit b12......136 folivane-f ............................136 folivane-ob .........................136 folivane-plus.......................136 FOLLISTIM AQ ..................89 folplex 2.2...........................136 FOLTRATE .......................136 fondaparinux.........................49 FORA D15G ........................77 FORA D20 ...........................77 FORA D40-G31 TEST
STRIPS.............................77 FORA G20 ...........................77 FORA G30-PREMIUM V10
TEST STRP......................78 FORA GD50 TEST STRIPS 78 FORA TEST STRIP.............78 FORA TN'G VOICE TEST
STRIPS.............................78 FORA V10 ...........................78 FORA V10-V12-D10-D20
STRP-LNCT.....................82 FORA V12 GLUCOSE........78 FORA V20 ...........................78 FORACARE GD20..............78 FORACARE GD40..............78 FORACARE LANCETS .....82 FORTAVIT ........................135 FORTEO ............................107 FORTISCARE GLUCOSE
TEST STRIPS ..................78 FOSAMAX ........................107 FOSAMAX PLUS D..........107 fosamprenavir.........................4 fosinopril ..............................45
fosinopril-hydrochlorothiazide
..........................................45 FOSRENOL .........................96 FRAGMIN............................50 FREESTYLE INSULINX....78 FREESTYLE INSULINX
TEST STRIPS ..................78 FREESTYLE LANCETS.....82 FREESTYLE LITE STRIPS 78 FREESTYLE PRECISION
NEO STRIPS....................78 FREESTYLE TEST .............78 FREESTYLE UNISTIK 2....82 frovatriptan ...........................24 FULPHILA.........................101 FURADANTIN....................12 furosemide ............................45 FUZEON ................................4 fyavolv ................................110 FYCOMPA...........................19 G gabapentin ............................19 GABITRIL ...........................19 galantamine ..........................26 GALZIN .............................134 GAMMAGARD LIQUID ..104 GAMUNEX-C....................104 GANIRELIX ........................89 GARDASIL 9 (PF).............104 GASTROCROM ..................96 gatifloxacin.........................118 GATTEX 30-VIAL ..............96 GATTEX ONE-VIAL..........96 gavilyte-c ..............................96 gavilyte-g ..............................96 gavilyte-n..............................96 GE100 BLOOD GLUCOSE
TEST STRIP.....................78 GELNIQUE........................131 gemfibrozil ...........................52 GENERESS FE ..................114 generlac ................................96 gengraf..................................14 GENSTRIP TEST STRIP ....78 gentak .................................118 gentamicin ............ 61, 118, 119 GENVOYA ............................4 GEODON .............................36 gianvi (28) ..........................114 GILENYA ..........................101
GILOTRIF............................14 glatiramer............................101 glatopa ................................101 GLEEVEC............................14 GLEOSTINE ........................14 glimepiride............................91 glipizide ................................91 glipizide-metformin..............91 GLUCAGEN DIAGNOSTIC
KIT ...................................80 GLUCAGEN HYPOKIT......80 GLUCAGON EMERGENCY
KIT (HUMAN).................80 GLUCO NAVII TEST STRIP
..........................................78 GLUCOCARD 01 SENSOR
PLUS ................................78 GLUCOCARD EXPRESSION
..........................................78 GLUCOCARD SHINE TEST
STRIPS .............................78 GLUCOCARD VITAL
SENSOR...........................78 GLUCOCARD VITAL TEST
STRIPS .............................78 GLUCOCOM GLUCOSE....78 GLUCOCOM LANCETS ....82 GLUCOPHAGE ...................91 GLUCOPHAGE XR ............91 GLUCOTROL......................91 GLUCOTROL XL................91 glyburide...............................91 glyburide micronized ............91 glyburide-metformin.............91 glycopyrrolate.......................93 glydo .....................................60 GLYNASE ...........................91 GLYSET...............................91 GLYTACTIN 10 PE
COMPLETE .....................70 GLYTACTIN 15 PE
BETTERMILK.................70 GLYTACTIN 15 PE
COMPLETE .....................70 GLYTACTIN 20PE
BETTERMILK LITE .......70 GLYTACTIN BUILD 10 PE70 GLYTACTIN RESTORE 10
PE .....................................70
Effective 1/2019
151
GLYTACTIN RESTORE 10 PE LITE............................70
GLYTACTIN RESTORE 5 PE ..........................................70
GLYTACTIN RTD 10 PE ...70 GLYTACTIN RTD 15 PE ...70 GLYTACTIN SWIRL 15 PE
..........................................70 GLYXAMBI ........................91 GM100 .................................78 GOLYTELY.........................96 GONAL-F ............................89 GONAL-F RFF ....................89 GONAL-F RFF REDI-JECT89 granisetron hcl ......................96 GRASTEK .........................104 griseofulvin microsize ............2 griseofulvin ultramicrosize.....2 guaiatussin ac .....................125 guaifenesin ac.....................125 guaifenesin dac...................125 guanfacine ...................... 36, 45 guanidine ..............................36 GYNAZOLE-1...................112 H HAEGARDA .....................128 HALCION............................36 halobetasol propionate..........65 HALOG................................65 haloperidol............................36 haloperidol lactate ................36 HARVONI .............................4 HAVRIX (PF) ....................104 HEALTHPRO TEST STRIPS
..........................................78 HEALTHY ACCENTS
UNIFINE PENTIP ...........82 HEALTHY ACCENTS
UNILET LANCET...........82 heather ................................110 HELIXATE FS.....................50 hematinic plus vit/minerals 136 hematinic/folic acid ............136 hematogen ..........................137 hematogen fa ......................136 hematogen forte..................137 hemenatal ob ......................137 hemenatal ob + dha ............137 hemmorex-hc........................96 HEMOCYTE-F ..................137
HEMOCYTE-PLUS...........137 HEMOFIL M HIGH.............50 HEMOFIL M LOW..............50 HEMOFIL M MID...............50 HEMOFIL M SUPER HIGH50 hep flush-10 (pf)...................50 heparin (porcine) ..................50 heparin lock flush .................50 heparin lock flush (porcine) . 50 heparin lockflush(porcine)(pf)
..........................................50 heparin, porcine (pf) .............50 HEPLISAV-B (PF).............104 HEPSERA ..............................4 HEXALEN ...........................14 HIBERIX (PF)....................104 HIPREX................................12 HIZENTRA........................105 HORIZANT..........................26 huber safety needles (disp.) ..82 HUMALOG JUNIOR
KWIKPEN U-100 ............86 HUMALOG KWIKPEN
INSULIN ..........................86 HUMALOG MIX 50-50
INSULN U-100 ................86 HUMALOG MIX 50-50
KWIKPEN........................86 HUMALOG MIX 75-25
KWIKPEN........................87 HUMALOG MIX 75-25(U
100)INSULN....................87 HUMALOG U-100 INSULIN
..........................................87 HUMATE-P .........................50 HUMIRA............................108 HUMIRA PEDIATRIC
CROHN'S START .........108 HUMIRA PEN ...................108 HUMIRA PEN CROHN'S
UC-HS START ..............108 HUMIRA PEN PSORIASIS
UVEITIS ........................108 HUMULIN 70/30 U-100
INSULIN ..........................87 HUMULIN 70/30 U-100
KWIKPEN........................87 HUMULIN N NPH INSULIN
KWIKPEN........................87
HUMULIN N NPH U-100 INSULIN ..........................87
HUMULIN R REGULAR U100 INSULN ....................87
HUMULIN R U-500 (CONC) INSULIN ..........................87
HUMULIN R U-500 (CONC) KWIKPEN........................87
HYCAMTIN.........................14 HYCET.................................28 hydralazine ...........................45 HYDREA .............................14 HYDRO 40...........................57 hydrochlorothiazide..............45 hydrocodone-acetaminophen29 hydrocodone-chlorpheniramine
........................................125 hydrocodone-cpm
pseudoephed ...................125 hydrocodone-homatropine..125 hydrocodone-ibuprofen ........29 hydrocortisone .... 65, 66, 75, 96 hydrocortisone acetate ..........96 hydrocortisone butyrate ........65 hydrocortisone butyr-emollient
..........................................65 hydrocortisone valerate ........66 hydrocortisone-acetic acid....74 hydrocortisone-min oil-wht pet
..........................................66 hydrocortisone-pramoxine...55,
96 hydromet.............................125 hydromorphone.....................29 hydroxychloroquine................9 hydroxyurea ..........................14 hydroxyzine hcl ..................124 hydroxyzine pamoate..........125 hyoscyamine sulfate ....... 93, 94 HYQVIA ............................105 HYZAAR .............................45 I ibandronate .........................107 IBRANCE.............................15 ibu .........................................32 IBUDONE ............................29 ibuprofen...............................32 ibuprofen-oxycodone............29 ICAR-C PLUS....................137 ICLUSIG ..............................15
Effective 1/2019
152
IDHIFA ................................15 IGLUCOSE TEST STRIP....78 ILARIS (PF).......................102 imatinib.................................15 IMBRUVICA .......................15 imipramine hcl......................36 imipramine pamoate.............36 imiquimod ..........................102 IMITREX ....................... 24, 25 IMITREX STATDOSE KIT
REFILL ............................24 IMITREX STATDOSE PEN25 IMOVAX RABIES VACCINE
(PF).................................105 IMURAN..............................15 incassia ...............................110 INCONTROL PEN NEEDLE
..........................................82 INCONTROL SUPER THIN
LANCETS........................82 INCONTROL ULTRA THIN
LANCETS........................83 indapamide ...........................45 INDERAL LA......................45 INDERAL XL......................45 INDOCIN .............................32 indomethacin ........................32 INFANRIX (DTAP) (PF)...105 INFINITY TEST STRIPS....78 INFINITY VOICE TEST
STRIP ...............................78 INJECT EASE LANCETS ..83 INLYTA ...............................15 INNOPRAN XL...................45 INSPRA................................45 INSUPEN.............................83 INTEGRA F .......................137 INTEGRA PLUS................137 INTELENCE..........................4 INTRAROSA.....................112 INTRON A.........................102 introvale..............................114 INTUNIV ER .......................36 INVACARE LANCETS ......83 INVEGA...............................36 INVEGA SUSTENNA.........36 INVEGA TRINZA...............36 INVIRASE .............................4 INVOKAMET......................91 INVOKAMET XR ...............91
INVOKANA ........................91 IOPIDINE...........................124 IPOL ...................................105 ipratropium bromide..... 73, 128 ipratropium-albuterol..........128 irbesartan ..............................45 irbesartan-hydrochlorothiazide
..........................................45 IRESSA ................................15 IROSPAN 24/6...................137 ISENTRESS ...........................4 ISENTRESS HD ....................4 isibloom..............................114 ISOCHRON..........................54 isometh-dichloral
acetaminophn....................25 isomethepten-caf
acetaminophen..................25 isoniazid..................................9 ISOPTO CARPINE............120 ISORDIL ..............................54 ISORDIL TITRADOSE.......54 isosorbide dinitrate ...............54 isosorbide mononitrate .........54 isotretinoin............................59 isradipine ..............................45 itraconazole ............................2 ivermectin...............................9 IXIARO (PF)......................105 J JADENU ..............................69 JAKAFI ................................15 JALYN ...............................132 jantoven ................................50 JANUMET ...........................91 JANUMET XR.....................91 JANUVIA.............................91 JARDIANCE........................91 jencycla...............................110 JENTADUETO ....................91 JENTADUETO XR..............91 jevantique lo .......................110 jinteli...................................110 jolessa .................................114 jolivette...............................110 juleber.................................114 JULUCA.................................4 junel 1.5/30 (21) .................114 junel 1/20 (21) ....................114 junel fe 1.5/30 (28) .............114
junel fe 1/20 (28) ................114 junel fe 24 ...........................114 JUXTAPID ...........................52 JYNARQUE.........................89 K KADIAN ..............................29 kaitlib fe..............................114 KALETRA .............................4 KALYDECO ......................128 KAPVAY .............................36 kariva (28) ..........................114 k-effervescent .....................134 kelnor 1/35 (28) ..................114 kelnor 1-50..........................114 KENALOG...........................66 KEPPRA...............................19 KEPPRA XR ........................19 KERALAC ...........................57 ketoconazole ..................... 2, 62ketoprofen.............................32 ketorolac ....................... 32, 121KEVEYIS .............................26 KEVZARA .........................108 KINERET ...........................102 KINRIX (PF) ......................105 kionex (with sorbitol) ...........96 KISQALI ..............................15 KISQALI FEMARA CO
PACK ...............................15 KITABIS PAK .......................9 KLARON .............................61 KLONOPIN..........................19 klor-con...............................134 klor-con 10..........................134 klor-con 8............................134 klor-con m10 ......................134 klor-con m15 ......................134 klor-con m20 ......................134 klor-con sprinkle.................134 klor-con/ef ..........................134 KOATE.................................50 KOGENATE FS...................50 KORLYM.............................89 K-PHOS NO 2....................133 K-PHOS ORIGINAL .........133 k-phos-neutral.....................134 KRISTALOSE......................96 k-tab....................................134 K-TAB................................134 kurvelo ................................114
Effective 1/2019
153
KUVAN ...............................89 KYNAMRO .........................52 L l norgest/e.estradiol-e.estrad
........................................114 labetalol ................................45 LACRISERT ......................120 lactated ringers .....................68 lactulose................................96 LAMICTAL .........................20 LAMICTAL ODT................19 LAMICTAL ODT STARTER
(BLUE).............................19 LAMICTAL ODT STARTER
(GREEN)..........................19 LAMICTAL ODT STARTER
(ORANGE).......................20 LAMICTAL STARTER
(BLUE) KIT .....................20 LAMICTAL STARTER
(GREEN) KIT ..................20 LAMICTAL STARTER
(ORANGE) KIT...............20 LAMICTAL XR...................20 LAMICTAL XR STARTER
(BLUE).............................20 LAMICTAL XR STARTER
(GREEN)..........................20 LAMICTAL XR STARTER
(ORANGE).......................20 lamivudine..............................4 lamivudine-zidovudine...........4 lamotrigine ...........................20 LANAFLEX.........................70 lancets...................................83 LANCETS............................83 LANCETS,THIN .................83 LANOXIN............................49 lansoprazole..........................99 lanthanum.............................96 LANTUS SOLOSTAR U-100
INSULIN..........................87 LANTUS U-100 INSULIN..87 larin 1.5/30 (21)..................114 larin 1/20 (21).....................114 larin 24 fe ...........................114 larin fe 1.5/30 (28)..............114 larin fe 1/20 (28).................115 larissia.................................115 LASIX ..................................45
latanoprost ..........................121 LATUDA..............................36 laxaclear................................96 laxative peg 3350..................96 layolis fe .............................115 leena 28...............................115 leflunomide.........................108 LENVIMA............................15 LESCOL...............................52 LESCOL XL.........................52 lessina .................................115 letrozole ................................15 leucovorin calcium ...............13 LEUKERAN ........................15 leuprolide..............................15 levalbuterol hcl ...................128 LEVAQUIN .........................11 LEVATOL............................45 LEVBID ...............................94 LEVEMIR FLEXTOUCH U
100 INSULN ....................87 LEVEMIR U-100 INSULIN 87 levetiracetam ........................20 LEVITRA...........................133 levobunolol.........................119 levocarnitine .........................69 levocarnitine (with sugar).....69 levofloxacin .................. 11, 119levonest (28) .......................115 levonorgestrel-ethinyl estrad
........................................115 levonorg-eth estrad triphasic
........................................115 levora 0.15/30 (28) .............115 levora-28.............................115 levorphanol tartrate...............29 LEVO-T................................92 levothyroxine........................92 levoxyl ..................................93 LEVSIN................................94 LEVSIN/SL..........................94 LEVULAN ...........................57 LEXAPRO............................36 LEXIVA .................................4 LIBRAX (WITH
CLIDINIUM) ...................94 lidocaine ...............................61 lidocaine hcl ................... 60, 61lidocaine hcl-hydrocortison ac
.................................... 61, 96
lidocaine viscous ..................61 lidocaine-hydrocortisone-aloe
..........................................96 lidocaine-prilocaine ..............61 LIDODERM .........................61 LIFESHIELD BLUNT
CANNULA.......................83 lillow...................................115 lindane ..................................67 linezolid ..................................9 LINZESS ..............................96 liothyronine...........................93 LIPITOR...............................52 LIPOFEN..............................52 lisinopril................................45 lisinopril-hydrochlorothiazide
..........................................45 LITE TOUCH LANCETS....83 lithium carbonate ..................37 lithium citrate........................37 LITHOBID ...........................37 LITHOSTAT ........................69 LIVALO ...............................52 LO LOESTRIN FE.............115 LOCOID ...............................66 LOCOID LIPOCREAM.......66 LODINE ...............................32 LODOSYN ...........................23 LOESTRIN 1.5/30 (21) ......115 LOESTRIN 1/20 (21) .........115 LOESTRIN FE 1.5/30 (28
DAY) ..............................115 LOESTRIN FE 1/20 (28-DAY)
........................................115 LOMAIRA ...........................68 LOMOTIL ............................94 LONHALA MAGNAIR
REFILL...........................129 LONHALA MAGNAIR
STARTER ......................129 LONSURF............................15 LOPHLEX............................70 LOPID ..................................52 lopinavir-ritonavir...................4 lopreeza...............................110 LOPRESSOR .......................45 LOPRESSOR HCT ..............45 LOPROX ..............................62 lorazepam .............................37 lorazepam intensol................37
Effective 1/2019
154
lorcet (hydrocodone) ............ 29 lorcet hd................................ 29 lorcet plus ............................. 29 LORTAB ELIXIR................ 29 lortuss ex ............................ 125 loryna (28) .......................... 115 losartan ................................. 45 losartan-hydrochlorothiazide45 LOSEASONIQUE ............. 115 LOTEMAX ........................ 123 LOTENSIN .......................... 46 LOTENSIN HCT ................. 46 LOTREL............................... 46 LOTRISONE........................ 62 LOTRONEX ........................ 96 LOUTREX ........................... 57 lovastatin .............................. 52 LOVENOX........................... 50 low-ogestrel (28) ................ 115 loxapine succinate ................ 37 LUCEMYRA ....................... 32 ludent fluoride .................... 137 lugols .................................. 134 LUMIGAN......................... 121 LUNESTA............................ 37 LUPANETA PACK (1
MONTH)........................ 112 LUPANETA PACK (3
MONTH)........................ 112 lutera (28) ........................... 115 LUXIQ ................................. 66 LYNPARZA......................... 15 LYRICA ............................... 20 LYRICA CR......................... 20 LYSODREN......................... 15 LYSTEDA.......................... 112 lyza ..................................... 110 M MACROBID ........................ 12 MACRODANTIN................ 12 mafenide acetate................... 61 MAGNEBIND 400 .............. 97 MALARONE ......................... 9 MALARONE PEDIATRIC ... 9 malathion.............................. 67 maprotiline ........................... 37 MAR-COF BP.................... 125 MAR-COF CG ................... 125 MARINOL ........................... 97 marlissa............................... 115
MARPLAN .......................... 37 MATULANE........................ 15 matzim la .............................. 46 MAVYRET ............................ 4 MAXIDEX ......................... 123 MAXITROL....................... 122 MAXZIDE............................ 46 MAXZIDE-25MG................ 46 m-clear wc .......................... 125 meclofenamate...................... 32 MEDISENSE THIN
LANCETS........................ 83 MEDLANCE PLUS
LANCETS........................ 83 MEDLANCE PLUS SPECIAL
BLADE............................. 83 MEDROL ............................. 75 MEDROL (PAK) ................. 75 medroxyprogesterone . 110, 111 mefenamic acid..................... 32 mefloquine.............................. 9 MEGACE ES ....................... 15 megestrol .............................. 15 MEKINIST........................... 15 melodetta 24 fe ................... 115 meloxicam ............................ 32 melphalan ............................. 15 memantine ............................ 26 MEMANTINE...................... 26 MENACTRA (PF) ............. 105 M-END PE ......................... 125 MENEST............................ 111 MENOPUR .......................... 89 MENOSTAR...................... 111 MENVEO A-C-Y-W-135-DIP
(PF)................................. 105 meperidine ............................ 29 MEPHYTON........................ 50 meprobamate ........................ 27 MEPRON ............................... 9 mercaptopurine..................... 15 mesalamine........................... 97 mesalamine with cleansing
wipe .................................. 97 MESNEX.............................. 13 MESTINON ......................... 27 MESTINON TIMESPAN .... 27 metadate er ........................... 37 metaproterenol.................... 129 metaxalone............................ 27
metformin ............................. 92 methadone............................. 29 methadose ............................. 29 methamphetamine................. 37 methazolamide.................... 121 methenamine hippurate ........ 12 methenamine mandelate ....... 13 methen-sod phos-meth blue
hyos................................. 133 methimazole ......................... 76 METHITEST........................ 89 methocarbamol ..................... 27 methotrexate sodium ...... 15, 16 methotrexate sodium (pf) ..... 15 methoxsalen.......................... 57 methscopolamine.................. 94 methyclothiazide................... 46 methyldopa ........................... 46 methyldopa
hydrochlorothiazide.......... 46 METHYLIN ......................... 37 methylphenidate hcl.............. 37 methylprednisolone .............. 75 methyltestosterone ................ 89 metipranolol........................ 119 metoclopramide hcl .............. 97 metolazone............................ 46 METOPIRONE .................... 69 metoprolol succinate............. 46 metoprolol ta-hydrochlorothiaz
.......................................... 46 metoprolol tartrate ................ 46 METROCREAM.................. 59 METROGEL VAGINAL ... 112 METROLOTION ................. 59 metronidazole ........... 9, 59, 112 mexiletine ............................. 41 MIACALCIN ....................... 89 mibelas 24 fe....................... 115 MICARDIS........................... 46 MICARDIS HCT.................. 46 miconazole-3 ...................... 112 MICRO BLOOD GLUCOSE
.......................................... 79 MICRO THIN LANCETS ... 83 MICRODOT BLOOD
GLUCOSE SYSTEM....... 79 microgestin 1.5/30 (21) ...... 115 microgestin 1/20 (21) ......... 115 MICROGESTIN 24 FE ...... 115
Effective 1/2019
155
microgestin fe 1.5/30 (28) ..115 microgestin fe 1/20 (28) .....115 MICROLET LANCET.........83 MICROZIDE........................46 midazolam ............................37 midodrine .............................69 migergot ...............................25 miglitol .................................92 miglustat ...............................89 MIGRANAL ........................25 mili .....................................115 millipred ...............................75 millipred dp ..........................75 mimvey...............................111 mimvey lo...........................111 MINASTRIN 24 FE ...........116 MINI ULTRA-THIN II........83 MINIPRESS.........................46 MINITRAN..........................54 MINIVELLE ......................111 minocycline ..........................12 minoxidil ..............................46 MIOCHOL-E .....................120 miostat ................................121 MIRAPEX............................23 MIRAPEX ER......................23 MIRCERA..........................101 MIRCETTE (28) ................116 mirtazapine ...........................37 misoprostol ...........................99 MITOSOL ..........................121 M-M-R II (PF)....................105 MOBIC.................................32 modafinil ..............................37 moderiba.............................101 moderiba dose pack............101 moexipril ..............................46 moexipril-hydrochlorothiazide
..........................................46 mometasone.................. 66, 129MONOCLATE-P .................50 monoject 0.9% sodium
chloride.............................69 MONOJECT BLOOD
COLLECTION.................83 MONOJECT HYPODERMIC
NEEDLES ........................83 MONOJECT MEDICATION
TRANSF NDL .................83 monoject prefill advanced ns69
monoject prefill saline flush . 69 MONOLET THIN LANCETS
..........................................83 mono-linyah........................116 mononessa (28)...................116 montelukast ........................129 MONUROL..........................13 MORPHABOND ER ...........29 morphine......................... 29, 30 morphine concentrate ...........29 MOTOFEN...........................94 MOVANTIK ........................97 MOXEZA...........................119 moxifloxacin................. 11, 119MOZOBIL..........................101 MS CONTIN ........................30 MULTAQ.............................41 MULTI-DRAW NEEDLE ...83 multi-vit with fluoride-iron 137 multi-vitamin with fluoride 137 multivitamins with fluoride 137 mupirocin..............................61 mupirocin calcium................61 MUSE.................................133 mvc-fluoride .......................137 my choice ...........................116 my way ...............................116 MYALEPT ...........................89 MYAMBUTOL......................9 MYCOBUTIN........................9 mycophenolate mofetil .........16 mycophenolate sodium.........16 MYDAYIS ...........................37 MYDRIACYL....................120 MYFORTIC .........................16 MYGLUCOHEALTH..........79 MYGLUCOHEALTH
LANCETS........................83 MYLERAN ..........................16 mynatal ...............................137 mynatal advance .................137 mynatal plus .......................137 mynatal-z ............................137 mynate 90 plus....................137 mynephrocaps.....................137 mynephron..........................137 myorisan ...............................59 MYRBETRIQ ....................131 MYSOLINE .........................20 MYTESI ...............................94
myzilra ................................116 N nabumetone...........................32 nadolol ..................................46 nadolol-bendroflumethiazide46 naftifine.................................62 NAFTIN ...............................62 NALFON..............................32 naloxone ...............................33 naltrexone .............................33 NAMENDA..........................26 NAMENDA TITRATION
PAK ..................................26 NAMENDA XR ...................26 NAMZARIC.........................26 NAPRELAN CR ..................32 NAPROSYN.........................32 naproxen ...............................32 naproxen sodium ..................32 naratriptan.............................25 NARCAN .............................33 NARDIL...............................37 NATACYN.........................119 NATAZIA ..........................116 nateglinide ............................92 NATPARA ...........................89 NATROBA...........................67 nature-throid .........................93 NEBUPENT ...........................9 necon 0.5/35 (28)................116 NEEDLES, HUBER
DISPOSABLE..................83 nefazodone............................38 neomycin ................................9 neomycin-bacitracin-poly-hc
........................................122 neomycin-bacitracin
polymyxin .......................119 neomycin-polymyxin b gu ....68 neomycin-polymyxin b
dexameth.........................122 neomycin-polymyxin
gramicidin.......................119 neomycin-polymyxin-hc......75,
122 neo-polycin .........................119 neo-polycin hc ....................122 NEORAL..............................16 NEOSALUS .........................57 NEO-SYNALAR..................61
Effective 1/2019
156
NEO-SYNALAR KIT..........61 nephplex rx .........................137 NEPHRON FA...................137 nephro-vite rx .....................137 NERLYNX...........................16 neuac.....................................59 NEULASTA.......................101 NEUPOGEN ......................101 NEUPRO..............................23 NEURIN-SL.......................138 NEURONTIN................. 20, 21 NEUTEK 2TEK TEST
STRIPS.............................79 nevirapine ........................... 4, 5 new day ..............................116 newgen ...............................138 NEXAVAR ..........................16 NEXIUM............................100 NEXIUM PACKET ...........100 next choice one dose ..........116 niacin ....................................53 NIACOR...............................53 NIASPAN EXTENDED
RELEASE ........................53 nicardipine............................46 NICODERM CQ..................73 NICORETTE........................73 nicotine .................................73 nicotine (polacrilex) .............73 NICOTROL..........................73 NICOTROL NS....................73 nifedipine..............................46 nikki (28) ............................116 NILANDRON ......................16 nilutamide.............................16 nimodipine............................46 NINLARO............................16 nisoldipine ............................46 nitro-bid................................54 NITRO-DUR........................54 nitrofurantoin ........................13 nitrofurantoin macrocrystal ..13 nitrofurantoin monohyd/m
cryst ..................................13 nitroglycerin .........................54 NITROLINGUAL................54 NITROMIST ........................54 NITROSTAT........................54 nitro-time..............................54 NITYR..................................69
nizatidine ............................100 NIZORAL ............................62 NOKOR NEEDLE ...............83 nora-be................................111 NORCO................................30 NORDITROPIN FLEXPRO
........................................101 noreth-ethinyl estradiol-iron
........................................116 norethindrone (contraceptive)
........................................111 norethindrone acetate .........111 norethindrone ac-eth estradiol
................................ 111, 116 norethindrone-e.estradiol-iron
........................................116 norgestimate-ethinyl estradiol
........................................116 norgestrel-ethinyl estradiol. 116 norlyda................................111 norlyroc ..............................111 normal saline flush ...............69 NORPACE ...........................41 NORPACE CR.....................41 NORPRAMIN......................38 NORTHERA ........................69 nortrel 0.5/35 (28)...............116 nortrel 1/35 (21)..................116 nortrel 1/35 (28)..................116 nortrel 7/7/7 (28) ................116 nortriptyline ..........................38 NORVASC...........................46 NORVIR.................................5 NOVA MAX GLUCOSE
TEST ................................79 NOVA SAFETY LANCETS83 NOVA SUREFLEX
LANCETS........................83 NOVOEIGHT ......................51 NOVOFINE 32.....................83 NOVOFINE AUTOCOVER 83 NOVOFINE PLUS...............83 NOVOLIN 70/30 U-100
INSULIN ..........................87 NOVOLIN N NPH U-100
INSULIN ..........................87 NOVOLIN R REGULAR U
100 INSULN ....................87 NOVOLOG FLEXPEN U-100
INSULIN ..........................87
NOVOLOG MIX 70-30 U-100 INSULN ...........................88
NOVOLOG MIX 7030FLEXPEN U-100 .........88
NOVOLOG PENFILL U-100 INSULIN ..........................88
NOVOLOG U-100 INSULIN ASPART...........................88
NOVOPEN ECHO ...............83 NOVOSEVEN RT................51 NOXAFIL...............................2 np thyroid..............................93 NUCYNTA...........................30 NUCYNTA ER ....................30 NUEDEXTA ........................26 NULEV.................................94 NULYTELY WITH FLAVOR
PACKS .............................97 NUOX...................................59 NUPLAZID ..........................38 NUTRICAP ........................138 NUVARING.......................112 NUVESSA..........................112 NUVIGIL .............................38 nyamyc .................................62 nystatin ............................. 2, 62 nystatin-triamcinolone ..........62 nystop ...................................62 O obstetrix dha .......................138 OCALIVA ............................97 ocella...................................116 octreotide acetate ..................16 OCUFLOX .........................119 ODACTRA.........................105 ODEFSEY ..............................5 ODOMZO.............................16 OFEV..................................129 ofloxacin ................. 12, 74, 119ogestrel (28)........................116 olanzapine.............................38 olanzapine-fluoxetine ...........38 olmesartan.............................46 olmesartan-amlodipin
hcthiazid ...........................46 olmesartan
hydrochlorothiazide..........47 olopatadine ................... 73, 120 OLUX ...................................66 OLUX-E ...............................66
Effective 1/2019
157
OMECLAMOX-PAK ........ 100 omeprazole ......................... 100 OMNIPRED ....................... 123 ON CALL EXPRESS TEST
STRIP ............................... 79 ON CALL LANCET............ 84 ON CALL PLUS LANCET . 84 ON CALL PLUS TEST STRIP
.......................................... 79 ON CALL VIVID TEST
STRIP ............................... 79 ondansetron .......................... 97 ondansetron hcl .................... 97 ONETOUCH ULTRASOFT
LANCETS........................ 84 ONETOUCH VERIO........... 79 ONFI..................................... 21 ONMEL.................................. 2 ON-THE-GO LANCETS..... 84 OPANA ................................ 30 opcicon one-step................. 116 OPSUMIT .......................... 129 option-2 .............................. 116 OPTIUM EZ......................... 79 OPTIUM TEST.................... 79 OPTUMRX .......................... 79 ORALAIR .......................... 105 oralone.................................. 73 ORAMAGICRX................... 74 ORAP ................................... 38 ORAPRED ODT.................. 75 ORAVIG ................................ 2 ORENCIA .......................... 108 ORENCIA CLICKJECT.... 108 ORENITRAM ...................... 47 ORFADIN ............................ 69 ORKAMBI......................... 129 orphenadrine citrate.............. 27 orsythia ............................... 116 ORTHO MICRONOR........ 111 ORTHO TRI-CYCLEN (28)
........................................ 116 ORTHO TRI-CYCLEN LO
(28) ................................. 116 ORTHO-CYCLEN (28) ..... 116 ORTHO-NOVUM 1/35 (28)
........................................ 117 ORTHO-NOVUM 7/7/7 (28)
........................................ 117 oseltamivir.............................. 5
OSMOPREP......................... 97 OSPHENA.......................... 112 OTEZLA ............................ 108 OTEZLA STARTER.......... 108 OTOVEL.............................. 75 OVACE ................................ 55 OVACE PLUS ..................... 55 OVACE PLUS SHAMPOO. 55 OVIDE.................................. 67 OVIDREL ............................ 89 OXANDRIN......................... 89 oxandrolone .......................... 89 oxaprozin.............................. 32 oxazepam.............................. 38 oxcarbazepine....................... 21 oxiconazole........................... 62 OXISTAT............................. 62 OXSORALEN ULTRA ....... 57 OXTELLAR XR .................. 21 oxybutynin chloride.... 131, 132 oxycodone ............................ 30 oxycodone-acetaminophen... 30 oxycodone-aspirin ................ 30 oxymorphone........................ 30 OXYTROL......................... 132 OZEMPIC ............................ 92 P pacerone................................ 41 PACNEX.............................. 59 paliperidone .......................... 38 PALYNZIQ.......................... 89 PAMELOR........................... 38 PANDEL .............................. 66 PANRETIN .......................... 57 pantoprazole ....................... 100 paregoric............................... 94 PAREMYD ........................ 120 paricalcitol ............................ 90 PARLODEL ......................... 23 PARNATE............................ 38 paromomycin.......................... 9 paroxetine hcl ....................... 38 PASER.................................. 10 PATADAY......................... 120 PATANASE ......................... 74 PATANOL ......................... 121 PAXIL .................................. 38 PAXIL CR............................ 38 PAZEO ............................... 121 PEDIARIX (PF) ................. 105
PEDVAX HIB (PF)............ 105 peg 3350-electrolytes............ 97 peg-3350 with flavor packs .. 97 PEGANONE......................... 21 PEGASYS .......................... 102 PEGASYS PROCLICK...... 102 peg-electrolyte soln .............. 97 PEGINTRON ..................... 102 peg-prep ................................ 97 PEN NEEDLE ...................... 84 PEN NEEDLE, DIABETIC . 84 penicillin v potassium........... 11 PENLAC............................... 62 PENTACEL (PF)................ 105 PENTACEL ACTHIB
COMPONENT (PF) ....... 105 PENTASA ............................ 97 pentazocine-naloxone ........... 30 PENTIPS .............................. 84 pentoxifylline........................ 51 PEPCID .............................. 100 PERCOCET.......................... 30 PERFOROMIST................. 129 PERIDEX ............................. 74 PERIFLEX ADVANCE....... 71 PERIFLEX INFANT............ 71 PERIFLEX JUNIOR ............ 71 PERIFLEX LQ PKU ............ 71 perindopril erbumine ............ 47 periogard............................... 74 permethrin............................. 67 perphenazine......................... 38 perphenazine-amitriptyline... 38 PERSERIS............................ 38 PEXEVA .............................. 38 PHARMACIST CHOICE .... 79 PHASEAL PROTECTOR.... 84 PHENACTIN AA PLUS 20
PE ..................................... 71 phenadoz............................. 125 phenazopyridine ................. 133 phendimetrazine tartrate ....... 68 phenelzine............................. 38 phenergan ........................... 125 PHENEX-1 ........................... 71 PHENEX-2 ........................... 71 phenobarbital ........................ 21 phenoxybenzamine ............... 47 phentermine .......................... 68 PHENYLADE 40 ................. 71
Effective 1/2019
158
PHENYLADE 60.................71 PHENYLADE AMINO
ACIDS..............................71 PHENYLADE ESSENTIAL71 PHENYLADE GMP ............71 PHENYLADE GMP MIX-IN
..........................................71 PHENYLADE MTE AMINO
ACIDS..............................71 phenylade phebloc................71 PHENYLADE PHEBLOC...71 phenylephrine hcl ...............124 PHENYL-FREE 1 ................71 PHENYL-FREE 2 PKU.......71 PHENYL-FREE 2HP PKU..71 PHENYTEK.........................21 phenytoin..............................21 phenytoin sodium extended ..21 philith .................................117 PHLEXY-10.........................72 PHLEXY-10 DRINK MIX
POWDER.........................72 PHOSLYRA.........................97 phospha 250 neutral ...........134 phosphate laxative ................97 PHOSPHOLINE IODIDE..120 phosphorous .......................134 phrenilin forte(with caffeine)25 PHYSIOLYTE .....................68 PHYSIOSOL IRRIGATION68 phytonadione (vitamin k1) ...51 PICATO ...............................57 pilocarpine hcl ........ 69, 74, 120 pimozide...............................38 pimtrea (28) ........................117 pindolol.................................47 pioglitazone ..........................92 pioglitazone-glimepiride ......92 pioglitazone-metformin........92 pirmella...............................117 piroxicam..............................33 PKU 2...................................72 PKU 3...................................72 PKU AIR20 ..........................72 PKU COOLER 10................72 PKU COOLER 15................72 PKU COOLER 20................72 PKU EASY MICROTABS ..72 PKU EXPRESS15................72 PKU EXPRESS20................72
PKU GEL POWDER ...........72 PKU LOPHLEX...................72 PKU PERIFLEX EARLY
YEARS.............................72 PKU PERIFLEX JUNIOR
PLUS ................................72 PKU SPHERE20 ..................72 PKU TRIO............................72 PLAQUENIL........................10 PLAVIX ...............................51 PLEGRIDY ........................102 PLEXION.............................59 PLEXION CLEANSING
CLOTHS ..........................59 PNEUMOVAX 23 .............105 pnv 29-1 ..............................138 pnv ob+dha.........................138 pnv-dha...............................138 pnv-dha + docusate.............138 pnv-ferrous fumarate-docu-fa
........................................138 pnv-omega ..........................138 pnv-select............................138 pnv-vp-u .............................138 PODOCON...........................56 podofilox ..............................57 POLY HUB NEEDLE..........84 polycin ................................119 polyethylene glycol 3350 .....97 polymyxin b sulf-trimethoprim
........................................119 POLYTRIM........................119 POLY-VI-FLOR ................138 POLY-VI-FLOR WITH IRON
........................................138 POMALYST ......................102 portia...................................117 pot,sodium citrate-citric acid
........................................133 POTABA............................134 potassium bicarb and chloride
........................................134 potassium bicarb-citric acid134 potassium chloride..............134 potassium citrate.................133 pr natal 400.........................138 pr natal 400 ec ....................138 pr natal 430.........................138 pr natal 430 ec ....................138 PRADAXA...........................51
PRALUENT PEN.................53 pramcort................................97 pramipexole ..........................23 PRANDIN ............................92 prasugrel ...............................51 PRAVACHOL......................53 pravastatin.............................53 praziquantel ..........................10 prazosin .................................47 PRECISION PCX PLUS TEST
..........................................79 PRECISION PCX TEST ......79 PRECISION POINT OF
CARE TEST.....................79 PRECISION Q-I-D TEST ....79 PRECISION XTRA TEST...79 PRECOSE.............................92 PRED FORTE ....................123 PRED MILD.......................123 PRED-G..............................122 PRED-G S.O.P. ..................122 prednicarbate ........................66 prednisolone .........................75 prednisolone acetate ...........123 prednisolone sodium phosphate
.................................. 75, 123 prednisone.............................76 prednisone intensol ...............76 PREFEST ...........................111 PREGNYL............................90 PREMARIN .......................111 PREMIER TEST STRIP ......79 PREMIUM V10....................79 PREMPHASE.....................111 PREMPRO .........................111 prena1 chew........................138 prena1 pearl ........................138 prena1 true ..........................138 prenaissance........................138 prenaissance plus ................138 prenatabs fa.........................138 prenatabs rx ........................138 prenatal ...............................139 prenatal formula..................138 prenatal multi-dha (algal oil)
........................................138 prenatal one daily ...............138 prenatal plus........................139 prenatal plus (calcium carb)139 prenatal vitamin ..................139
Effective 1/2019
159
prenatal vitamin plus low iron ........................................ 139
prenatal-u............................ 139 preplus ................................ 139 PRESSURE ACTIVATED
LANCETS........................ 84 pretab.................................. 139 PREVACID SOLUTAB .... 100 prevalite................................ 53 PREVIDENT........................ 74 PREVIDENT 5000 BOOSTER
PLUS ................................ 74 PREVIDENT 5000 DRY
MOUTH ........................... 74 PREVIDENT 5000 ENAMEL
PROTECT ........................ 74 PREVIDENT 5000
SENSITIVE...................... 74 previfem ............................. 117 PREVNAR 13 (PF) ............ 105 PREZCOBIX.......................... 5 PREZISTA ............................. 5 PRIFTIN............................... 10 PRILOSEC......................... 100 PRIMAQUINE..................... 10 primidone ............................. 21 PRIMLEV ............................ 30 PRIMSOL............................. 13 PRINIVIL............................. 47 PRISTIQ............................... 38 PRO COMFORT LANCET. 84 PRO VOICE V8-V9 TEST
STRIP ............................... 79 PROAIR HFA .................... 129 PROAIR RESPICLICK ..... 129 probenecid .......................... 107 probenecid-colchicine ........ 107 PROCARDIA....................... 47 PROCARDIA XL ................ 47 procentra............................... 38 prochlorperazine................... 97 prochlorperazine maleate ..... 97 PROCRIT........................... 101 PROCTOCORT ................... 97 procto-med hc....................... 97 procto-pak............................. 97 proctosol hc .......................... 97 proctozone-hc ....................... 98 PROCYSBI ........................ 133 PRODIGY LANCETS ......... 84
PRODIGY NO CODING..... 79 PRODIGY TWIST TOP
LANCET .......................... 84 PROFERRIN-FORTE ........ 139 PROFILNINE....................... 51 progesterone micronized .... 111 PROGLYCEM ..................... 80 PROGRAF............................ 16 PROLENSA ....................... 121 PROMACTA........................ 51 promethazine ...................... 125 promethazine vc ................. 125 promethazine vc-codeine.... 125 promethazine-codeine ........ 126 promethazine-dm................ 126 promethazine-phenyleph
codeine............................ 126 promethegan ....................... 125 PROMETRIUM ................. 111 PROMISEB.......................... 57 propafenone .......................... 41 propantheline ........................ 94 proparacaine ....................... 121 propranolol ........................... 47 propranolol-hydrochlorothiazid
.......................................... 47 propylthiouracil .................... 76 PROQUAD (PF)................. 105 PRO-RED AC (W/
DEXCHLORPHENIR) .. 126 PROSCAR.......................... 132 PROSTIN VR PEDIATRIC
........................................ 133 PROTECT IRON ............... 139 PROTONIX........................ 100 protriptyline .......................... 38 PROVENTIL HFA............. 129 PROVERA ......................... 111 PROZAC .............................. 38 pruclair.................................. 57 prudoxin................................ 57 prutect ................................... 57 PSORCON............................ 66 PULMICORT..................... 129 PULMICORT FLEXHALER
........................................ 129 pulmosal ............................. 129 PULMOZYME................... 129 purevit dualfe plus .............. 139 PURIXAN ............................ 16
PYLERA............................. 100 pyrazinamide ........................ 10 PYRIDIUM ........................ 133 pyridostigmine bromide........ 27 Q QSYMIA .............................. 68 QUADRACEL (PF) ........... 105 QUALAQUIN ...................... 10 QUARTETTE..................... 117 quasense.............................. 117 quazepam.............................. 38 QUDEXY XR....................... 21 QUESTRAN......................... 53 QUESTRAN LIGHT............ 53 quetiapine ............................. 39 QUILLICHEW ER............... 39 QUILLIVANT XR ............... 39 quinapril................................ 47 quinapril-hydrochlorothiazide
.......................................... 47 quinidine gluconate .............. 41 quinidine sulfate ................... 41 quinine sulfate ...................... 10 QUINTET AC ...................... 79 QVAR REDIHALER ......... 129 R RABAVERT (PF) .............. 106 rabeprazole ......................... 100 RADIOGARDASE............... 69 RAGWITEK....................... 106 rajani ................................... 117 raloxifene............................ 107 ramipril ................................. 47 RANEXA ............................. 54 ranitidine hcl ....................... 100 RAPAFLO.......................... 132 RAPAMUNE........................ 16 rasagiline............................... 23 RAVICTI.............................. 69 RAZADYNE ........................ 26 RAZADYNE ER .................. 26 REBETOL .......................... 102 REBIF (WITH ALBUMIN)
........................................ 102 REBIF REBIDOSE ............ 102 REBIF TITRATION PACK
........................................ 102 reclipsen (28) ...................... 117 RECOMBINATE ................. 51 RECOMBIVAX HB (PF)... 106
Effective 1/2019
160
REFUAH PLUS ................... 79 REGIMEX............................ 68 REGLAN.............................. 98 REGRANEX ........................ 57 RELAGARD ...................... 112 RELENZA DISKHALER...... 5 RELIAMED LANCET ........ 84 RELIAMED SAFETY SEAL
LANCETS........................ 84 RELION CONFIRM-MICRO
.......................................... 79 RELION NEEDLES ............ 84 RELION PEN NEEDLES.... 84 RELION PRIME TEST
STRIPS............................. 79 RELION THIN LANCETS.. 84 RELION ULTRA THIN PLUS
LANCETS........................ 84 RELISTOR........................... 98 RELPAX .............................. 25 REMERON .......................... 39 REMERON SOLTAB.......... 39 REMODULIN...................... 47 RENAGEL ........................... 98 renal caps............................ 139 rena-vite rx ......................... 139 reno caps............................. 139 RENVELA ........................... 98 repaglinide............................ 92 repaglinide-metformin.......... 92 REPATHA PUSHTRONEX 53 REPATHA SURECLICK .... 53 REPATHA SYRINGE ......... 53 reprexain............................... 30 REQUIP ............................... 23 REQUIP XL ......................... 23 RESCRIPTOR........................ 5 RESPA-AR......................... 126 RESTORIL........................... 39 RETIN-A.............................. 59 RETROVIR............................ 5 REVATIO .......................... 129 REVEAL TEST STRIP........ 79 REVIA.................................. 33 REVLIMID ........................ 102 REXULTI............................. 39 REYATAZ ............................. 5 RHOPRESSA..................... 121 ribasphere ........................... 102 ribavirin .............................. 102
RIDAURA.......................... 108 rifabutin ................................ 10 RIFADIN.............................. 10 RIFAMATE.......................... 10 rifampin ................................ 10 RIFATER ............................. 10 RIGHTEST GL300 LANCETS
.......................................... 84 RIGHTEST GS550 TEST
STRIPS............................. 79 RILUTEK............................. 69 riluzole.................................. 69 rimantadine............................. 5 ringer's .................................. 68 RIOMET............................... 92 risacal-d .............................. 139 risedronate .................... 69, 107 RISPERDAL ........................ 39 RISPERDAL CONSTA ....... 39 risperidone ............................ 39 RITALIN .............................. 39 ritonavir .................................. 5 rivastigmine .......................... 26 rivastigmine tartrate.............. 26 rivelsa ................................. 117 RIXUBIS .............................. 51 rizatriptan.............................. 25 robafen ac ........................... 126 ROBAXIN............................ 27 ROBAXIN-750 .................... 27 ROBINUL ............................ 94 ROBINUL FORTE............... 94 ROCALTROL...................... 90 ropinirole .............................. 23 rosadan.................................. 60 ROSANIL............................. 60 ROSULA .............................. 60 rosula cleansing cloths.......... 60 rosuvastatin ........................... 53 ROTARIX .......................... 106 ROTATEQ VACCINE....... 106 ROWASA............................. 98 roweepra ............................... 21 roweepra xr........................... 21 ROXICODONE.................... 30 ROZEREM........................... 39 RUBRACA........................... 16 RUCONEST....................... 129 RYDAPT.............................. 16 rydex................................... 126
RYTHMOL SR .................... 41 S SABRIL................................ 21 SAFETY LANCETS ............ 84 SAFETY SEAL LANCETS . 84 SAFETY-LET LANCETS ... 84 SAFYRAL.......................... 117 SALAGEN (PILOCARPINE)
.................................... 70, 74 SALEX ................................. 56 salicylic acid ......................... 56 salicylic acid er-ceramides ... 56 salsalate................................. 33 SAMSCA.............................. 90 SANDIMMUNE................... 16 SANDOSTATIN .................. 16 SANTYL .............................. 67 SAPHRIS.............................. 39 SARAFEM ........................... 39 SAVELLA.......................... 108 SAXENDA ........................... 68 scopolamine base.................. 98 SEASONIQUE ................... 117 seb-prev ................................ 55 seconal sodium ..................... 39 selegiline hcl ......................... 23 selenium sulfide.................... 55 SELZENTRY ......................... 5 SEMPREX-D ..................... 126 se-natal 19........................... 139 se-natal 19 (with docusate) . 139 SENSIPAR ........................... 90 SEREVENT DISKUS ........ 130 SEROQUEL ......................... 39 SEROQUEL XR................... 39 sertraline ............................... 39 se-tan plus ........................... 139 setlakin................................ 117 sevelamer carbonate ............. 98 sf 74 sf 5000 plus........................... 74 sharobel............................... 111 SHINGRIX (PF)................. 106 SHINGRIX GE ANTIGEN
COMPONENT ............... 106 SIGNIFOR............................ 16 SIKLOS ................................ 16 sildenafil ............................. 133 sildenafil (antihypertensive)
........................................ 130
Effective 1/2019
161
SILIQ.................................... 55 SILVADENE ....................... 56 silver nitrate.......................... 57 silver nitrate applicators ....... 57 silver sulfadiazine................. 56 SIMPONI ........................... 109 simvastatin............................ 53 SINEMET............................. 23 SINEMET CR ...................... 23 SINGLE-LET ....................... 84 SINGULAIR ...................... 130 sirolimus............................... 16 SIRTURO............................. 10 SKELAXIN.......................... 27 SMART SENSE LANCETS 84 SMART SENSE TEST
STRIPS............................. 79 SMARTEST LANCET ........ 84 SMARTEST TEST .............. 79 sodium chlor 0.9% bacteriostat
.......................................... 70 sodium chloride ............ 70, 130 sodium chloride 0.9 %.......... 70 sodium phenylbutyrate ......... 70 sodium polystyrene sulfonate
.......................................... 98 SODIUM POLYSTYRENE
SULFONATE................... 98 SOFT TOUCH LANCETS .. 84 SOLESTA ............................ 98 SOLIQUA 100/33 ................ 88 soloxide ................................ 12 SOLTAMOX........................ 16 SOLUS V2 LANCETS ........ 84 SOMA .................................. 27 SOMAVERT........................ 90 SONATA.............................. 39 SORBITOL .......................... 68 SORBITOL-MANNITOL.... 68 SORIATANE ....................... 55 sorine .................................... 41 sotalol ................................... 41 sotalol af ............................... 41 SOTYLIZE........................... 41 SOVALDI .............................. 5 spinosad ................................ 67 SPIRIVA RESPIMAT ....... 130 SPIRIVA WITH
HANDIHALER.............. 130 spironolactone ...................... 47
spironolacton-hydrochlorothiaz
.......................................... 47 SPORANOX .......................... 2 SPORANOX PULSEPAK ..... 2 sprintec (28)........................ 117 SPRITAM............................. 21 SPRIX................................... 33 SPRYCEL ............................ 17 sps (with sorbitol)................. 98 sronyx ................................. 117 ssd......................................... 56 SSKI ..................................... 76 sss 10-5 ................................. 60 STALEVO 100..................... 23 STALEVO 125..................... 23 STALEVO 150..................... 23 STALEVO 200..................... 23 STALEVO 50....................... 23 STALEVO 75....................... 23 STAMARIL (PF) ............... 106 STARLIX ............................. 92 stavudine................................. 5 STAXYN............................ 133 STELARA ............................ 55 STENDRA.......................... 133 STERILANCE TL................ 84 STIMATE............................. 90 STIOLTO RESPIMAT....... 130 STIVARGA.......................... 17 STRATTERA....................... 39 STRENSIQ........................... 90 STRIANT ............................. 90 STRIBILD.............................. 5 STRIVERDI RESPIMAT .. 130 STROMECTOL ................... 10 strong iodine ....................... 134 STROVITE FORTE........... 139 STROVITE ONE ............... 139 SUBOXONE ........................ 18 subvenite............................... 21 subvenite starter (blue) kit.... 21 subvenite starter (green) kit.. 21 subvenite starter (orange) kit 21 SUCRAID ............................ 98 sucralfate ............................ 100 SULAR................................. 47 sulfacetamide sodium... 55, 123 sulfacetamide sodium (acne) 61 sulfacetamide sodium-sulfur 60
sulfacetamide sod-sulfur-urea .......................................... 60
sulfacetamide-prednisolone 123 sulfadiazine........................... 12 sulfamethoxazole-trimethoprim
.......................................... 12 SULFAMYLON................... 61 sulfasalazine ......................... 98 sulfatrim................................ 12 sulindac................................. 33 sumatriptan ........................... 25 sumatriptan succinate ........... 25 SUMAVEL DOSEPRO........ 25 SUMAXIN ........................... 60 SUPER THIN LANCETS .... 85 SUPRAX ................................ 7 SUPREP BOWEL PREP KIT
.......................................... 98 SURE COMFORT LANCETS
.......................................... 85 SURE COMFORT PEN
NEEDLE........................... 85 SURE-FINE PEN NEEDLES
.......................................... 85 SURE-LANCE ..................... 85 SURE-TEST EASYPLUS
MINI ................................. 79 SURE-TOUCH LANCET.... 85 SURGUARD2 SAFETY ...... 85 SURMONTIL....................... 39 SUSTIVA ............................... 5 SUTENT............................... 17 syeda ................................... 117 SYLATRON....................... 102 SYMBICORT..................... 130 SYMBYAX .......................... 39 SYMDEKO ........................ 130 SYMFI.................................... 5 SYMFI LO.............................. 5 SYMLINPEN 120 ................ 92 SYMLINPEN 60 .................. 92 SYNALAR ........................... 66 SYNALAR CREAM KIT .... 66 SYNALAR OINTMENT KIT
.......................................... 66 SYNALAR TS...................... 66 SYNAREL............................ 90 SYNDROS ........................... 98 SYNERA .............................. 61 SYNJARDY ......................... 92
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SYNJARDY XR .................. 92 SYNTHROID....................... 93 syrex sodium chloride 0.9 % 70 T TABLOID ............................ 17 TACLONEX .................. 55, 56 tacrolimus ....................... 17, 57 tadalafil (antihypertensive). 130 TAFINLAR .......................... 17 TAGRISSO .......................... 17 TALTZ AUTOINJECTOR .. 56 TALTZ AUTOINJECTOR (2
PACK).............................. 56 TALTZ AUTOINJECTOR (3
PACK).............................. 56 TALTZ SYRINGE............... 56 TAMIFLU .......................... 5, 6 tamoxifen.............................. 17 tamsulosin........................... 132 TANDEM PLUS................ 139 TAPAZOLE ......................... 76 TARCEVA........................... 17 TARGRETIN ....................... 17 tarina fe 1/20 (28)............... 117 TARKA ................................ 47 taron forte ........................... 139 taron-c dha.......................... 139 taron-prex prenatal-dha ...... 139 TASIGNA ............................ 17 TASMAR ............................. 23 TAVALISSE ........................ 51 tazarotene ............................. 60 TAZORAC........................... 60 taztia xt ................................. 47 TECFIDERA...................... 102 TECHLITE LANCETS........ 85 TECHLITE PEN NEEDLE.. 85 TEGRETOL ......................... 21 TEGRETOL XR................... 21 TEKTURNA ........................ 47 TEKTURNA HCT ............... 47 TELCARE TEST STRIPS ... 79 telmisartan ............................ 47 telmisartan-amlodipine......... 47 telmisartan-hydrochlorothiazid
.......................................... 47 temazepam............................ 39 TEMODAR .......................... 17 TEMOVATE........................ 66 temozolomide....................... 17
tencon ................................... 25 TENIVAC (PF) .................. 106 tenofovir disoproxil fumarate. 6 TENORETIC 100................. 47 TENORETIC 50................... 47 TENORMIN......................... 48 terazosin................................ 48 terbinafine hcl......................... 2 terbutaline........................... 130 terconazole.......................... 112 TESSALON PERLES ........ 126 TEST N'GO TEST ............... 80 testosterone........................... 90 testosterone cypionate .......... 90 testosterone enanthate........... 90 TESTRED ............................ 90 TETANUS,DIPHTHERIA
TOX PED(PF) ................ 106 TETANUS-DIPHTHERIA
TOXOIDS-TD................ 106 tetrabenazine......................... 26 tetracaine hcl....................... 121 tetracaine hcl (pf)................ 121 tetracycline ........................... 12 TETRAVISC...................... 121 TETRAVISC FORTE ........ 121 TEXACORT......................... 66 THALOMID......................... 17 THEO-24 ............................ 130 theochron ............................ 130 theophylline ........................ 130 THIOLA ............................... 70 thioridazine........................... 39 thiothixene ............................ 40 thrivite-19 ........................... 139 thyroid (pork) ....................... 93 THYROLAR-1..................... 93 THYROLAR-1/2.................. 93 THYROLAR-1/4.................. 93 THYROLAR-2..................... 93 THYROLAR-3..................... 93 tiagabine ............................... 21 TIAZAC ............................... 48 TICE BCG.......................... 106 TIGAN.................................. 98 TIKOSYN ............................ 42 tilia fe.................................. 117 timolol maleate ............. 48, 119 TIMOPTIC ......................... 120
TIMOPTIC OCUDOSE (PF) ........................................ 120
TIMOPTIC-XE................... 120 TINDAMAX ........................ 10 tinidazole .............................. 10 tis-u-sol pentalyte ................. 68 TIVICAY................................ 6 tizanidine .............................. 27 tl gard rx ............................. 139 tl g-fol os............................. 139 tl icon .................................. 139 TOBI..................................... 10 tobramycin .......................... 119 tobramycin in 0.225 % nacl.. 10 tobramycin-dexamethasone 122 TOBREX ............................ 119 TOFRANIL .......................... 40 tolazamide............................. 92 tolbutamide ........................... 92 tolcapone............................... 23 tolmetin................................. 33 tolterodine........................... 132 TOPAMAX .......................... 22 TOPCARE UNIVERSAL1
LANCET .......................... 85 TOPICORT........................... 66 topiramate ............................. 22 TOPIRAMATE .................... 22 TOPROL XL ........................ 48 torsemide .............................. 48 TOUJEO MAX U-300
SOLOSTAR ..................... 88 TOUJEO SOLOSTAR U-300
INSULIN .......................... 88 TRACLEER ....................... 130 TRADJENTA....................... 92 tramadol ................................ 30 tramadol-acetaminophen ...... 30 trandolapril ........................... 48 trandolapril-verapamil .......... 48 tranexamic acid................... 112 TRANSDERM-SCOP .......... 98 TRANXENE T-TAB............ 40 tranylcypromine.................... 40 TRAVATAN Z................... 122 trazodone .............................. 40 TRECATOR......................... 10 TRELEGY ELLIPTA......... 130 TREMFYA ........................... 56
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TRESIBA FLEXTOUCH U100 .................................... 88
TRESIBA FLEXTOUCH U200 .................................... 88
tretinoin ................................ 60 tretinoin (chemotherapy) ...... 17 tretinoin (emollient).............. 60 tretinoin microspheres .......... 60 TRETIN-X ........................... 60 TRETIN-X CREAM KIT..... 60 TREXALL............................ 17 TREZIX................................ 30 tri femynor.......................... 117 triamcinolone acetonide 66, 67,
74 triamterene-hydrochlorothiazid
.......................................... 48 trianex................................... 67 triazolam............................... 40 TRIBENZOR ....................... 48 tricon................................... 139 TRICOR ............................... 53 triderm .................................. 67 tri-estarylla ......................... 117 trifluoperazine ...................... 40 trifluridine........................... 119 trigels-f forte....................... 139 TRIGLIDE ........................... 53 trihexyphenidyl............... 23, 24 tri-legest fe.......................... 117 TRILEPTAL......................... 22 tri-linyah ............................. 117 TRILIPIX ............................. 53 tri-lo-estarylla ..................... 117 tri-lo-marzia........................ 117 tri-lo-sprintec...................... 117 trilyte with flavor packets..... 98 trimethobenzamide............... 98 trimethoprim......................... 13 tri-mili................................. 117 trimipramine ......................... 40 trinatal rx 1 ......................... 139 trinate.................................. 139 trinessa (28) ........................ 117 trinessa lo............................ 117 TRI-NORINYL (28) .......... 117 TRINTELLIX....................... 40 triphrocaps.......................... 139 tri-previfem (28)................. 118 tri-sprintec (28)................... 118
TRIUMEQ.............................. 6 triveen-duo dha................... 140 TRI-VI-FLOR .................... 140 tri-vitamin with fluoride ..... 140 trivora (28).......................... 118 tri-vylibra............................ 118 TRIZIVIR............................... 6 TROKENDI XR................... 22 tropicamide......................... 120 trospium.............................. 132 TRUE METRIX GLUCOSE
TEST STRIP..................... 80 TRUEPLUS GLUCOSE ...... 80 TRUEPLUS LANCETS....... 85 TRUETEST TEST STRIPS . 80 TRUETRACK TEST ........... 80 TRULICITY......................... 92 TRUMENBA...................... 106 TRUSOPT .......................... 122 trust natal dha ..................... 140 TRUVADA ............................ 6 TUDORZA PRESSAIR ..... 130 tulana .................................. 118 tusnel c................................ 126 TUSSICAPS....................... 126 tussigon ............................... 126 TUSSIONEX PENNKINETIC
ER................................... 126 TWINRIX (PF)................... 106 TWYNSTA .......................... 48 TYBOST ................................ 6 tydemy................................ 118 TYKERB.............................. 17 TYLENOL-CODEINE #3.... 30 TYLENOL-CODEINE #4.... 30 TYMLOS............................ 107 TYPHIM VI ....................... 106 TYVASO............................ 131 TYVASO INSTITUTIONAL
START KIT.................... 131 TYVASO REFILL KIT...... 131 TYVASO STARTER KIT . 131 U UCERIS................................ 98 UDAMIN SP ...................... 140 ULESFIA.............................. 67 ULORIC ............................. 107 ULTICARE PEN NEEDLE . 85 ULTILET BASIC LANCETS
.......................................... 85
ULTILET CLASSIC LANCETS ........................ 85
ULTILET LANCETS........... 85 ULTILET PEN NEEDLE..... 85 ULTILET SAFETY
LANCETS ........................ 85 ULTIMA TEST STRIPS...... 80 ULTRA THIN LANCETS ... 85 ULTRA THIN PLUS
LANCETS ........................ 85 ULTRA TLC LANCETS ..... 85 ULTRACET ......................... 30 ULTRALANCE LANCETS 85 ULTRAM ............................. 31 ULTRAM ER ....................... 31 ULTRA-THIN II INS PEN
NEEDLES ........................ 85 ULTRATRAK...................... 80 ULTRATRAK ULTIMATE 80 ULTRAVATE X .................. 67 UNIFINE PENTIPS ............. 85 UNIFINE PENTIPS PLUS... 85 UNILET COMFORTOUCH
LANCET .......................... 85 UNILET EXCELITE II
LANCET .......................... 85 UNILET EXCELITE
LANCET .......................... 86 UNILET GP LANCET......... 86 UNILET LANCET............... 86 UNISTIK 3 EXTRA LANCET
.......................................... 86 UNISTIK CZT LANCET..... 86 UNISTIK SAFETY .............. 86 UNISTIK TOUCH LANCETS
.......................................... 86 UNISTRIP1 TEST STRIP.... 80 unithroid ............................... 93 UNIVERSAL 1 LANCETS . 86 URAMAXIN ........................ 57 URECHOLINE................... 132 uro-458 ............................... 133 UROCIT-K 10 .................... 133 UROCIT-K 15 .................... 133 UROCIT-K 5 ...................... 133 UROXATRAL ................... 132 URSO 250 ............................ 99 URSO FORTE...................... 99 ursodiol ................................. 99 UTIBRON NEOHALER.... 131
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V VAGIFEM.......................... 111 valacyclovir ............................ 6 VALCHLOR ........................ 58 VALCYTE ............................. 6 valganciclovir ......................... 6 VALIUM.............................. 40 valproic acid ......................... 22 valproic acid (as sodium salt)
.......................................... 22 valsartan ............................... 48 valsartan-hydrochlorothiazide
.......................................... 48 VALTREX ............................. 6 VANCOCIN......................... 13 vancomycin .......................... 13 vandazole............................ 112 VANOS ................................ 67 VANOXIDE-HC.................. 60 VAQTA (PF)...................... 106 VARIVAX (PF) ................. 106 VASERETIC........................ 48 VASOTEC ........................... 48 VAXCHORA VACCINE .. 107 v-c forte .............................. 140 veletri.................................... 48 velivet triphasic regimen (28)
........................................ 118 VELPHORO......................... 99 VEMLIDY ............................. 6 VENCLEXTA...................... 17 VENCLEXTA STARTING
PACK ............................... 17 venlafaxine ........................... 40 VENTAVIS........................ 131 VENTOLIN HFA............... 131 verapamil .............................. 48 VERASENS TEST STRIP... 80 VERDESO ........................... 67 verdrocet............................... 31 VEREGEN ........................... 58 VERELAN ........................... 48 VERELAN PM .................... 48 veripred 20............................ 76 VERZENIO.......................... 17 VESICARE ........................ 132 VFEND................................... 2 VGO 20 ................................ 86 VGO 30 ................................ 86 VGO 40 ................................ 86
VIAGRA ............................ 133 VIBERZI .............................. 99 VIBRAMYCIN .................... 12 vicodin .................................. 31 vicodin es.............................. 31 vicodin hp ............................. 31 VIDEX 2 GRAM PEDIATRIC
............................................ 6 VIDEX 4 GRAM PEDIATRIC
............................................ 6 VIDEX EC ............................. 6 vienva ................................. 118 vigabatrin.............................. 22 vigadrone .............................. 22 VIGAMOX......................... 119 VIIBRYD ............................. 40 VIMPAT............................... 22 vinate care........................... 140 vinate ii ............................... 140 vinate m .............................. 140 vinate one ........................... 140 vinate ultra.......................... 140 VIOKACE............................ 99 viorele (28) ......................... 118 VIRACEPT ............................ 6 VIRAMUNE .......................... 6 VIRAMUNE XR.................... 6 VIRAZOLE............................ 6 VIREAD................................. 6 VIROPTIC.......................... 119 virt-advance ........................ 140 virt-c dha............................. 140 VIRT-CAPS ....................... 140 virt-gard .............................. 140 virt-nate dha........................ 140 virt-phos 250 neutral .......... 135 virt-pn ................................. 140 virt-pn dha .......................... 140 virt-pn plus ......................... 140 virt-select ............................ 140 virtussin ac.......................... 126 virt-vite ............................... 140 virt-vite gt ........................... 140 VIRT-VITE PLUS ............. 140 VISTARIL.......................... 125 vit 3..................................... 140 VITAFOL........................... 140 VITAL-D RX ..................... 140 vitamin b complex-folic acid
........................................ 140
vitamin d3........................... 140 vitamins a,c,d and fluoride . 140 VITA-RESPA..................... 140 VIVELLE-DOT.................. 111 VIVOTIF ............................ 107 vol-nate ............................... 140 vol-plus ............................... 140 vol-tab rx ............................ 141 VOLTAREN-XR.................. 33 voriconazole ....................... 2, 3 VOSEVI ................................. 6 VOTRIENT .......................... 17 vp-ch plus ........................... 141 vp-ch-pnv............................ 141 vp-vite rx ............................ 141 VRAYLAR........................... 40 VUSION ............................... 62 vyfemla (28) ....................... 118 vylibra................................. 118 VYTORIN 10-10.................. 53 VYTORIN 10-20.................. 53 VYTORIN 10-40.................. 53 VYTORIN 10-80.................. 53 VYVANSE ........................... 40 W warfarin................................. 51 water for irrigation, sterile .... 70 WAVESENSE JAZZ............ 80 WAVESENSE PRESTO...... 80 WELCHOL........................... 53 WELLBUTRIN SR .............. 40 WELLBUTRIN XL.............. 40 wera (28)............................. 118 westhroid .............................. 93 WILATE............................... 51 WP THYROID ..................... 93 wymzya fe .......................... 118 X XALATAN......................... 122 XALKORI ............................ 17 XANAX................................ 40 XANAX XR ......................... 40 XARELTO ........................... 51 XELJANZ........................... 109 XELJANZ XR .................... 109 XELODA.............................. 17 XENAZINE.......................... 27 XENICAL............................. 68 XERMELO........................... 17 XIFAXAN ............................ 10
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XIGDUO XR........................ 92 XIIDRA.............................. 121 XOLEGEL ........................... 62 XOPENEX ......................... 131 XOPENEX CONCENTRATE
........................................ 131 XOPENEX HFA ................ 131 XPHE MAXAMAID............ 72 xphe maxamum .................... 72 XPHE MAXAMUM ............ 72 XTAMPZA ER .................... 31 XTANDI............................... 17 xulane ................................. 112 xylon 10................................ 31 XYNTHA............................. 51 XYNTHA SOLOFUSE........ 51 XYREM ............................... 40 Y YASMIN (28) .................... 118 YAZ (28) ............................ 118 YF-VAX (PF)..................... 107 YONSA ................................ 17 yuvafem.............................. 111 Z zafirlukast ........................... 131 zaleplon ................................ 40 ZANAFLEX......................... 27 ZANTAC............................ 100 zarah ................................... 118 ZARONTIN ......................... 22 ZARXIO............................. 101 zatean-pn dha...................... 141 zatean-pn plus..................... 141 ZAVESCA ........................... 90 zebutal .................................. 25
ZEJULA ............................... 17 ZELAPAR ............................ 24 ZELBORAF ......................... 17 ZEMPLAR ........................... 90 zenatane ................................ 60 zenchent (28) ...................... 118 ZENPEP ............................... 99 zenzedi.................................. 40 ZENZEDI ............................. 40 ZERIT..................................... 6 ZESTORETIC...................... 48 ZESTRIL.............................. 48 ZETIA .................................. 53 ZIAC..................................... 48 ZIAGEN ............................. 6, 7 zidovudine .............................. 7 zingiber............................... 141 ZIOPTAN (PF)................... 122 ziprasidone hcl...................... 41 ZIRGAN............................. 119 ZITHROMAX........................ 8 ZOCOR ................................ 54 ZODRYL AC 25 ................ 126 ZODRYL AC 30 ................ 126 ZODRYL AC 35 ................ 126 ZODRYL AC 40 ................ 126 ZODRYL AC 50 ................ 126 ZODRYL AC 60 ................ 126 ZODRYL AC 80 ................ 126 ZODRYL DAC 25 ............. 126 ZODRYL DAC 30 ............. 126 ZODRYL DAC 35 ............. 126 ZODRYL DAC 40 ............. 126 ZODRYL DAC 50 ............. 126 ZODRYL DAC 60 ............. 126
ZODRYL DAC 80 ............. 126 ZODRYL DEC 25.............. 126 ZODRYL DEC 30.............. 126 ZODRYL DEC 35.............. 127 ZODRYL DEC 40.............. 127 ZODRYL DEC 50.............. 127 ZODRYL DEC 60.............. 127 ZODRYL DEC 80.............. 127 ZOFRAN .............................. 99 ZOFRAN ODT..................... 99 ZOLINZA............................. 17 zolmitriptan........................... 25 ZOLOFT............................... 41 zolpidem ............................... 41 ZONALON........................... 58 ZONEGRAN ........................ 22 zonisamide............................ 22 ZONTIVITY......................... 51 ZORTRESS .......................... 17 ZOSTAVAX (PF) .............. 107 zovia 1/35e (28).................. 118 ZOVIRAX ........................ 7, 63 Z-TUSS AC ........................ 127 ZUBSOLV............................ 18 ZYBAN ................................ 73 ZYDELIG............................. 17 ZYKADIA............................ 18 ZYLOPRIM........................ 107 ZYPREXA............................ 41 ZYPREXA RELPREVV ...... 41 ZYPREXA ZYDIS............... 41 ZYTIGA ............................... 18 ZYVOX ................................ 10
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BlueCross: • Provides free aids and services to people withdisabilities to communicate effectively with us, such as: (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.
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).
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RX-11 (10/18) 2019 Preferred Formulary Guidebook and
Prescription Drug List