A nonprofit independent licensee of the Blue Cross Blue Shield Association
3-TIER FORMULARY GUIDEIncludes generic and brand-name medications
ExcellusBCBS.comB-1354 Y18 / 12291-18FLRX
January 2019
Dear Member,
The prescription drug benefit is one of the most important and frequently
utilized elements of health plan coverage. To help you identify which
medications are covered under your plan, we are pleased to provide the
3-Tier Formulary Guide. This booklet provides you with easy to understand
information about your prescription drug coverage including descriptions of
prescription drug safety and cost-saving programs.
The 3-Tier Formulary Guide lists commonly prescribed medications and their
tier classifications. The medications listed have been approved by the Food
and Drug Administration (FDA) as safe and effective and were selected in
consultation with a team of health care professionals because they meet our
criteria for safety, quality and value. We continually review and update
our formulary.
The drugs listed in the formulary and program descriptions may not apply to all plans.
This booklet includes the Formulary Guide and prescription drug benefit information. Please refer to this booklet when you see your healthcare practioner or are prescribed a medication.
The drugs listed in the formulary and program descriptions may not apply to all plans. Please see your plan documents for a complete description of your pharmacy benefit.
If you have questions or need additional information, please visit our website, ExcellusBCBS.com or contact the Pharmacy Help Desk at 1-800-499-1275.
What is a Formulary?A formulary is a list of brand-name and generic drugs that are covered under your prescription drug benefit.
How is the Formulary Developed?Drugs listed on the formulary were selected by our independent Pharmacy and Therapeutics (P&T) Committee, which is made up of practicing health care providers and clinical pharmacists. The P&T Committee reviews each drug based upon scientific evidence, findings by federal government agencies, professional medical associations and journals to help ensure that the medications covered meet criteria for safety, effectiveness and value.
How do I use the Formulary?There are two ways to find your drug within the formulary:
Medical ConditionDrugs are listed in alphabetical order according to drug categories. For example, drugs used to treat heart conditions are listed under the category “Cardiovascular.” Drugs are listed in alphabetical order by condition.
Alphabetical ListingIf you are not sure what category to look under, look for your drug in the Index that follows the formulary. The Index provides an alphabetical listing of all of the drugs included in the formulary and the page where they can be found in the formulary.
3-Tier Drug BenefitYour 3-tier prescription drug benefit allows you to make informed choices and encourages value when choosing your prescription medications. Your copayment will vary depending on the tier in which your prescription drug is placed.
• Tier One drugs are typically generics and have the lowest copayment amount.
• Tier Two drugs are brand drugs that have unique, significant clinical advantages and offer overall greater value over the other products in the same drug class.
• Tier Three drugs are all other brand drugs, including new brand drugs and drugs that have generic equivalents. Tier Three drugs have the highest copayment amount.
The 3-Tier Formulary Guide lists commonly used medications and their tier designations. Because there are thousands of medications included in your pharmacy benefit, we list only the most commonly prescribed.
Your plan may not cover all medications listed in this booklet. Please see your plan documents for a complete description of your pharmacy benefit, or call the Pharmacy Help Desk at 1-800-499-1275.
Can the Formulary Change?Our P&T Committee regularly reviews the drugs on our formulary to be sure they meet the criteria for safety, effectiveness and value. The list is subject to change. Drugs may be added, removed, or change tier designation at any time.
Generics Are Real MedicineGeneric drugs: safe, effective, affordable!
To help keep your prescription drug costs down, choose a generic drug over a brand. Generics are as safe and effective as their brand-name counterparts – they just cost a lot less.
In fact, you’ll save money when you choose a generic because generics have the lowest copay. That means you’ll always pay the lowest out-of-pocket amount for a generic.
Generic drugs treat your illness or condition with the same effectiveness and safety as their brand-name equivalents because they have to meet the same rigorous FDA requirements as brand-name drugs.
Experience has shown that more than 90 percent of members who start on a generic will stay on a generic. So the next time you need your brand prescription filled, ask your doctor or pharmacist if a generic is right for you.
Where Can I Purchase My Prescription Medications?You have access to more than 65,000 participating pharmacies in our nationwide Pharmacy Network, including national chains and most independents. Just show your Member Card at any participating pharmacy; it identifies you as having prescription drug coverage. A list of participating pharmacies in your area is available on our website, ExcellusBCBS.com
Mail Service PharmacyGet your prescriptions delivered right to your door!
When you use Express Scripts Home Delivery PharmacySM or Wegmans® Home Delivery Pharmacy, you get the convenience of home delivery and the ease of ordering new prescriptions and refills either by phone or via our website, ExcellusBCBS.com. Some benefits offer
opay savings for ordering prescriptions cthrough Express Scripts Home Delivery PharmacySM
or Wegmans® Home Delivery Pharmacy.
Using a home delivery pharmacy is ideal for those who take prescription medication on a continuing basis. For more information on how to use Express Scripts Home Delivery PharmacySM or Wegmans® Home Delivery Pharmacy, please visit our website at ExcellusBCBS.com or contact the Pharmacy Help Desk at 1-800-499-1275.
Specialty PharmacySpecialty pharmacies focus on you and your individual health care needs. Because they work exclusively with specialty medications, they are experts in handling and administering these complex medications. Nationally recognized specialty pharmacy Accredo Health participates in our network. Accredo Health offers outstanding customer service and is dedicated to providing quality care to our members. With a single, toll-free phone call they take care of all the details – they will contact your doctor for your prescription and arrange delivery to your home. There are several local/regional specialty pharmacies also participating in our specialty pharmacy network. A complete listing of participating specialty pharmacies is available on our website, ExcellusBCBS.com
Are There Any Restrictions On Coverage?Some covered drugs may have additional requirements or limits for coverage. If a drug has requirements or limits, it will be noted in the formulary.
If your health-care practitioner determines that you need a medication that has a requirement or limit, we have an exception process in place. Your health-care practitioner must submit a request to the Health Plan supporting your need.
Coverage requirements or limits may include:
Prior Authorization Prior authorization helps ensure that a prescribed drug is safe and appropriate for your medical condition. Certain medications require that your doctor gets approval before the medication is covered. Our clinical pharmacists and physicians review medication requests to make sure that the choice of drug or dose is appropriately prescribed based
on FDA and manufacturer guidelines, medical literature, safety, use and benefit design.
Step Therapy In some cases you may be required to first try one or more drugs to treat your medical condition before another drug for that condition will be covered. The medication treatment moves along a series of “steps.” For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work, we will then cover Drug B.
Specialty Drug Benefit Specialty medications are designed for conditions like multiple sclerosis, rheumatoid arthritis, hepatitis C, and others that are difficult to treat with traditional medications. These medications are self-administered, either taken orally or by injection.
Your prescription drug benefit may require that you purchase certain specialty medications at a specialty pharmacy that participates in the Specialty Pharmacy Network in order to receive coverage. If a participating specialty pharmacy is not used, you may be responsible for the full cost of the prescription. A complete listing of participating specialty pharmacies can be found on our website, ExcellusBCBS.com
Quantity Limits For certain drugs, we limit the amount of the drug that we will cover. The amount of drug we cover is based on FDA approved dosing and usage guidelines.
Generic Advantage Program The Generic Advantage program promotes the use of generic medications. If you fill your prescription with a brand-name medication when there is a generic equivalent available, you will pay the difference between the pharmacy’s charge for the more costly brand-name medication and our price for the less expensive generic. Check your benefits summary to find out if the Generic Advantage program applies to your plan.
Key:
UPPERCASE – Brand name medicationlowercase – generic medication
PA = Prior Authorization required
QL = Quantity Limit applies
ST = Step Therapy required
S = Specialty Drugs
MS = Drug must be purchased at a participating network specialty pharmacy for coverage
LIST OF COVERED PRESCRIPTION MEDICATIONS
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANALGESICS
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS
ANAPROX 3
ANAPROX DS 3
ARTHROTEC 50 3 QL
ARTHROTEC 75 3 QL
butalbital/aspirin/caffeine 50-325-40 capsule 1 QL
butalbital/aspirin/caffeine 50-325-40 tablet 1
CAMBIA 3
QL
ST
CELEBREX (50 MG CAPSULE, 100 MG CAPSULE, 200 MG CAPSULE, 400MG CAPSULE)
3 QL
celecoxib (50 mg capsule, 100 mg capsule, 200 mg capsule, 400 mg capsule) 1 QL
choline salicylate/magnesium salicylate 1
DAYPRO 3 QL
diclofenac potassium 1
diclofenac sodium (1.5 % drops, 25 mg tablet dr, 50 mg tablet dr, 75 mg tabletdr, 100 mg tab er 24h)
1
diclofenac sodium/misoprostol 1 QL
DICLOPR 3
QL
PA
diflunisal 1
DISALCID 3
DITHOL 3
QL
PA
DUEXIS 3
QL
PA
EC-NAPROSYN 3
etodolac 1
FELDENE 3
FENOPROFEN CALCIUM (200 MG CAPSULE, 400 MG CAPSULE) 3 PA
PAGE 5 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
fenoprofen calcium 600 mg tablet 1 PA
FENORTHO 3 PA
FIORINAL 3 QL
FLECTOR 3
QL
PA
flurbiprofen 1
IBU 1
ibuprofen (100 mg/5ml oral susp, 400 mg tablet, 600 mg tablet, 800 mg tablet) 1
INDOCIN (25 MG/5 ML SUSPENSION, 50 MG SUPPOSITORY) 3
indomethacin 1
ketoprofen 1
ketorolac tromethamine 10 mg tablet 1 QL
LODINE 3
MECLOFENAMATE SODIUM 3
mefenamic acid 1
meloxicam (7.5 mg tablet, 15 mg tablet) 1
MELOXICAM 7.5 MG/5 ML ORAL SUSP 3
MOBIC (7.5 MG TABLET, 7.5 MG/5 ML SUSPENSION, 15 MG TABLET) 3
nabumetone (500 mg tablet, 750 mg tablet) 1 QL
NALFON 3 PA
NAPRELAN 3
NAPROSYN (125 MG/5 ML SUSPEN, 250 MG TABLET, 375 MG TABLET, 500MG TABLET)
3
naproxen (250 mg tablet, 375 mg tablet, 375 mg tablet dr, 500 mg tablet, 500mg tablet dr)
1
NAPROXEN 125 MG/5 ML ORAL SUSP 3
naproxen sodium (275 mg tablet, 375 mg tbmp 24hr, 500 mg tbmp 24hr, 550mg tablet)
1
NUDROXIPAK 3
QL
PA
oxaprozin 600 mg tablet 1 QL
PENNSAID 2% PUMP 3
QL
PA
PAGE 6 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
piroxicam 1
PONSTEL 3
PROFENO 1 PA
salsalate 1
SPRIX 3
QL
PA
S
sulindac 1
TIVORBEX 3
QL
PA
tolmetin sodium 1
VIMOVO 3
QL
PA
VIVLODEX 3 PA
VOLTAREN-XR 3
ZIPSOR 3
QL
PA
ZORVOLEX 3
QL
PA
OPIOID ANALGESICS, LONG-ACTING
ARYMO ER 3 PA
AVINZA 3 PA
BELBUCA 3 PA
BUPRENORPHINE PATCH 3 PA
BUTRANS 3 PA
CONZIP 3 PA
DOLOPHINE HCL 3
DURAGESIC 3 PA
EMBEDA 3 PA
EXALGO 3 PA
PAGE 7 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
fentanyl (12 mcg/hr patch td72, 25 mcg/hr patch td72, 50mcg/hr patch td72,75mcg/hr patch td72, 100 mcg/hr patch td72)
1 PA
FENTANYL (37.5MCG/HR PATCH TD72, 62.5MCG/HR PATCH TD72,87.5MCG/HR PATCH TD72)
1 PA
hydromorphone hcl (8 mg tab er 24h, 12 mg tab er 24h, 16 mg tab er 24h, 32mg tab er 24h)
1 PA
HYSINGLA ER 3 PA
KADIAN (ER 10 MG CAPSULE, ER 20 MG CAPSULE, ER 30 MG CAPSULE,ER 50 MG CAPSULE, ER 60 MG CAPSULE, ER 80 MG CAPSULE, ER 100MG CAPSULE)
3 PA
KADIAN (ER 40 MG CAPSULE, ER 200 MG CAPSULE) 3
PA
ST
levorphanol tartrate 1 PA
methadone hcl (5 mg tablet, 5 mg/5 ml solution, 10 mg tablet, 10 mg/5 mlsolution, 10 mg/ml oral conc, 40 mg tablet sol)
1 PA
METHADONE INTENSOL 1 PA
METHADOSE 10 MG/ML ORAL CONC 3 PA
METHADOSE 40 MG TABLET DISPR 1 PA
MORPHABOND ER 3 PA
morphine sulfate (10 mg cap er pel, 15 mg tablet er, 20 mg cap er pel, 30 mgcap er pel, 30 mg cpmp 24hr, 30 mg tablet er, 40 mg cap er pel, 45 mg cpmp24hr, 50 mg cap er pel, 60 mg cap er pel, 60 mg cpmp 24hr, 60 mg tablet er, 75mg cpmp 24hr, 80 mg cap er pel, 90 mg cpmp 24hr, 100 mg cap er pel, 100 mgtablet er, 120 mg cpmp 24hr, 200 mg tablet er)
1 PA
MS CONTIN 3 PA
NUCYNTA ER 2 PA
OXYCODONE HCL ER 3 PA
OXYCONTIN 3 PA
oxymorphone hcl (5 mg tab er 12h, 7.5 mg tab er 12h, 10 mg tab er 12h, 15 mgtab er 12h, 20 mg tab er 12h, 30 mg tab er 12h, 40 mg tab er 12h)
1 PA
TRAMADOL ER CAPS 3 PA
tramadol hcl (100 mg tab er 24h, 100 mg tbmp 24hr, 200 mg tab er 24h, 200mg tbmp 24hr, 300 mg tab er 24h, 300 mg tbmp 24hr)
1 PA
ULTRAM ER 3 PA
XTAMPZA ER 2 PA
ZOHYDRO ER 3 PA
OPIOID ANALGESICS, SHORT-ACTING
ABSTRAL 3
QL
PA
PAGE 8 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
acetaminophen with codeine phosphate (120-12mg/5 solution, 300mg-15mgtablet, 300mg-30mg tablet, 300mg-60mg tablet, 300mg/12.5 solution)
1
acetaminophen/caff/dihydrocod 320.5-30mg capsule 1
ACETAMINOPHEN/CAFF/DIHYDROCOD 325-30-16 TABLET 3
ACTIQ 3
QL
PA
ASCOMP WITH CODEINE 1
aspirin/caffeine/dihydrocodeine bitartrate 1
butalbital/acetaminophen/caffeine/codeine phosphate 1 QL
butorphanol tartrate 10 mg/ml spray 1 QL
CAPITAL W-CODEINE 3
carisoprodol/aspirin/codeine 200-325-16 tablet 1
codeine phosphate/butalbital/aspirin/caffeine 1
codeine sulfate 1
DEMEROL (50 MG TABLET, 100 MG TABLET) 3
DILAUDID (2 MG TABLET, 4 MG TABLET, 5 MG/5 ML ORAL LIQUID, 8 MGTABLET)
3
ENDOCET 1
fentanyl citrate 1
QL
PA
FENTORA 3
QL
PA
FIORICET WITH CODEINE 3 QL
FIORINAL WITH CODEINE #3 3
HYCET 3
PAGE 9 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
hydrocodone bitartrate/acetaminophen (hydrocodone/acetaminophen 2.5-108/5solution, hydrocodone/acetaminophen 2.5-325 mg tablet,hydrocodone/acetaminophen 5 mg-300mg tablet, hydrocodone/acetaminophen5 mg-325mg tablet, hydrocodone/acetaminophen 5-163/7.5 solution,hydrocodone/acetaminophen 5-217mg/10 solution,hydrocodone/acetaminophen 7.5-300 mg tablet, hydrocodone/acetaminophen7.5-325 mg tablet, hydrocodone/acetaminophen 7.5-325/15 solution,hydrocodone/acetaminophen 10-325/15 solution, hydrocodone/acetaminophen10mg-300mg tablet, hydrocodone/acetaminophen 10mg-325mg tablet)
1
hydrocodone/ibuprofen 1
hydromorphone hcl (1 mg/ml liquid, 2 mg tablet, 3 mg supp.rect, 4 mg tablet, 8mg tablet)
1
IBUDONE 3
ibuprofen/oxycodone hcl 1
LAZANDA 3
QL
PA
LORCET 1
LORCET HD 1
LORCET PLUS 1
LORTAB (5-325 MG TABLET, 7.5-325 MG TABLET, 10-325 MG TABLET) 1
LORTAB 10 MG-300 MG/15 ML ELXR 3
meperidine hcl (50 mg tablet, 50 mg/5 ml solution, 100 mg tablet) 1
MORPHINE SULFATE (15 MG TABLET, 30 MG TABLET) 2
morphine sulfate (5 mg supp.rect, 10 mg supp.rect, 10 mg/5 ml solution, 20 mgsupp.rect, 20 mg/5 ml solution, 30 mg supp.rect, 100 mg/5ml solution)
1
NALOCET 3
NORCO 3
NUCYNTA 2
OPANA (5 MG TABLET, 10 MG TABLET) 3
opium/belladonna alkaloids 1
OXAYDO 3
OXECTA 3
OXYCODONE 10MG/0.5ML ORAL SYRINGE 3
oxycodone hcl (5 mg capsule, 5 mg tablet, 5 mg/5 ml solution, 10 mg tablet, 15mg tablet, 20 mg tablet, 20 mg/ml oral conc, 30 mg tablet)
1
PAGE 10 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
oxycodone hcl/acetaminophen (hcl/acetaminophen 2.5-325 mg tablet,hcl/acetaminophen 5 mg-325mg tablet, hcl/acetaminophen 5-325/5 ml solution,hcl/acetaminophen 7.5-325 mg tablet, hcl/acetaminophen 10mg-325mg tablet)
1
oxycodone hcl/aspirin 1
oxymorphone hcl (5 mg tablet, 10 mg tablet) 1
PANLOR 3 QL
pentazocine hcl/naloxone hcl 1
PERCOCET 3
PRIMLEV 3
REPREXAIN 1
ROXICODONE 3
ROXYBOND 3
SUBSYS (100 MCG SPRAY, 200 MCG SPRAY, 400 MCG SPRAY, 600 MCGSPRAY, 800 MCG SPRAY, 1,200 MCG SPRAY, 1,600 MCG SPRAY)
3
QL
PA
SYNALGOS-DC 3
tramadol hcl 50 mg tablet 1
tramadol hcl/acetaminophen 1
TREZIX 3
TYLENOL-CODEINE NO.3 3
TYLENOL-CODEINE NO.4 3
ULTRACET 3
ULTRAM 3
VERDROCET 1
VICODIN 1
VICODIN ES 1
VICODIN HP 1
XARTEMIS XR 3 PA
XODOL 10-300 3
XODOL 5-300 3
XODOL 7.5-300 3
XYLON 10 1
ZAMICET 3
PAGE 11 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANESTHETICS
LOCAL ANESTHETICS
ANACAINE 3
ANASTIA 3
ANODYNE LPT 3
QL
PA
BUCALSEP 3
DERMACINRX EMPRICAINE 3 PA
DERMACINRX PRIZOPAK 1
QL
PA
DOLOTRANZ 3
QL
PA
EMLA 3
GLYDO 1
LIDO-K 1
LIDO-PRILO CAINE PACK 3
QL
PA
lidocaine (5 % adh. patch, 5 % oint. (g)) 1
lidocaine hcl (2 % jel/pf app, 2 % jelly(ml), 2 % solution, 3 % cream (g), 3 %lotion, 4 % solution, 40 mg/ml solution)
1
lidocaine/prilocaine (lidocaine/prilocaine 2.5 cream (g), lidocaine/prilocaine 2.5kit)
1
LIDODERM 3
LIDOPAC 3
QL
PA
LIDOPIN 3% CREAM 1
LIDOPIN 3.25% CREAM 3
LIDOPRIL 3
QL
PA
LIDOPRIL XR 3
QL
PA
LIDOTRANS 5 PAK 3
QL
PA
PAGE 12 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
LIPROZONEPAK 3 PA
MEDOLOR PAK 3 PA
NEURCAINE 3
QL
PA
NUMBONEX 3
PAINGO KFT 3
QL
PA
PRILOLID 3 PA
RELADOR PAK 3
QL
PA
SOLUPAK 3
QL
PA
ZTLIDO 3 QL
ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS
ALCOHOL DETERRENTS/ANTI-CRAVING
acamprosate calcium 1 QL
ANTABUSE 3
disulfiram 1
naltrexone hcl 1
REVIA 3
OPIOID DEPENDENCE TREATMENTS
BUNAVAIL 3
buprenorphine hcl (2 mg tab subl, 8 mg tab subl) 1
buprenorphine hcl/naloxone hcl 1
LUCEMYRA 3 QL
SUBOXONE 2
ZUBSOLV 2
OPIOID REVERSAL AGENTS
naloxone hcl (0.4 mg/ml cartridge, 0.4 mg/ml vial, 1 mg/ml syringe) 1
NARCAN 4 MG NASAL SPRAY 2
PAGE 13 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SMOKING CESSATION AGENTS
BUPROBAN 1
bupropion hcl 150 mg tab er 12h 1
CHANTIX 3 QL
NICOTROL 3 QL
NICOTROL NS 3 QL
ZYBAN 3
ANTIBACTERIALS
AMINOGLYCOSIDES
ARIKAYCE 3
QL
PA
S
GENTAK 1
gentamicin sulfate (0.1 % cream (g), 0.1 % oint. (g), 0.3 % drops, 0.3 % oint.(g))
1
neomycin sulfate 1
paromomycin sulfate 1
tobramycin 1
TOBREX (DROP, OINTMENT) 3
ANTIBACTERIALS, OTHER
AKTIPAK 3
QL
ST
ALTABAX 3
bacitracin 500 unit/g oint. (g) 1
BACTROBAN (CREAM, OINTMENT) 3
BACTROBAN NASAL 3
BENZAMYCIN 3
CENTANY 3
CENTANY AT 3
QL
PA
CLEOCIN (2% CREAM, 100 MG OVULE) 3
CLEOCIN HCL 3
CLEOCIN PALMITATE 3
PAGE 14 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
CLEOCIN T (T GEL, T LOTION, T PLEDGETS, T SOLUTION) 3 ST
CLINDACIN ETZ 1% PLEDGET 1
CLINDACIN ETZ KIT 3
QL
PA
CLINDACIN P 1
CLINDACIN PAC 3
QL
PA
CLINDAGEL 3 ST
clindamycin hcl 1
clindamycin palmitate hcl 75 mg/5 ml soln recon 1
clindamycin phosphate (1 % foam, 1 % gel (gram), 1 % lotion, 1 % med. swab,1 % solution, 2 % cream/appl)
1
clindamycin phosphate 1 % gel daily 3 ST
CLINDESSE 3
erythromycin base/benzoyl peroxide 1
EVOCLIN 3 ST
FIRVANQ 2
FLAGYL 3
FLAGYL ER 3
FURADANTIN 3
HIPREX 3
HYOPHEN 1
linezolid 100 mg/5ml susp recon 1
linezolid 600 mg tablet 1 QL
MACROBID 3
MACRODANTIN 3
methenamine hippurate 1
methenamine mandelate 1
methenamine/sod phosph,monobasic/methylene blue/hyoscyamine 1
METROGEL-VAGINAL 3
metronidazole (0.75 % gel w/appl, 250 mg tablet, 375 mg capsule, 500 mgtablet)
1
MONUROL 3
PAGE 15 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
mupirocin 1
mupirocin calcium 1
nitrofurantoin 1
nitrofurantoin macrocrystal 1
nitrofurantoin monohydrate/macrocrystals 1
NUVESSA 3 QL
PHOSPHASAL 1
PRIMSOL 3
SIVEXTRO 200 MG TABLET 3 PA
SOLOSEC 3
SULFAMYLON (8.5% CREAM, POWDER PACKET) 3
TINDAMAX 3
tinidazole 1
trimethoprim 1
TRIMPEX 3
UR N-C 1
URAMIT MB 1
URELLE 3
URETRON D-S 1
URIBEL 3
URIMAR-T 1
URIN D.S. 1
URO-458 1
URO-MP 1
UROGESIC-BLUE 1
URYL 1
UTIRA-C 1
VANCOCIN HCL 3
vancomycin hcl (125 mg capsule, 250 mg capsule) 1
VANDAZOLE 1
ZYVOX 100 MG/5 ML SUSPENSION 3
ZYVOX 600 MG TABLET 3 QL
PAGE 16 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
BETA-LACTAM, CEPHALOSPORINS
CEDAX (180 MG/5 ML SUSPENSION, 400 MG CAPSULE) 3
cefaclor (125 mg/5ml susp recon, 250 mg capsule, 250 mg/5ml susp recon, 375mg/5ml susp recon, 500 mg capsule, 500 mg tab er 12h)
1
cefadroxil (1 g tablet, 250 mg/5ml susp recon, 500 mg capsule, 500 mg/5mlsusp recon)
1
cefdinir (125 mg/5ml susp recon, 250 mg/5ml susp recon, 300 mg capsule) 1
cefditoren pivoxil 1
cefixime 1
cefpodoxime proxetil (50 mg/5 ml susp recon, 100 mg tablet, 100 mg/5ml susprecon, 200 mg tablet)
1
cefprozil (125 mg/5ml susp recon, 250 mg tablet, 250 mg/5ml susp recon, 500mg tablet)
1
CEFTIBUTEN 3
CEFTIN (250 MG TABLET, 500 MG TABLET) 3
cefuroxime axetil 1
cephalexin (125 mg/5ml susp recon, 250 mg capsule, 250 mg tablet, 250mg/5ml susp recon, 500 mg capsule, 500 mg tablet, 750 mg capsule)
1
DAXBIA 3
KEFLEX 3
SPECTRACEF 3
SUPRAX (100 MG TABLET CHEWABLE, 100 MG/5 ML SUSPENSION, 200MG TABLET CHEWABLE, 200 MG/5 ML SUSPENSION, 400 MG CAPSULE,500 MG/5 ML SUSPENSION)
3
BETA-LACTAM, PENICILLINS
amoxicillin (125 mg tab chew, 125 mg/5ml susp recon, 200 mg/5ml susp recon,250 mg capsule, 250 mg tab chew, 250 mg/5ml susp recon, 400 mg/5ml susprecon, 500 mg capsule, 500 mg tablet, 875 mg tablet)
1
AMOXICILLIN ER 775 MG 3
PAGE 17 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
amoxicillin/potassium clavulanate (amoxicillin/potassium 200-28.5/5 susp recon,amoxicillin/potassium 200-28.5mg tab chew, amoxicillin/potassium 250-125 mgtablet, amoxicillin/potassium 250-62.5/5 susp recon, amoxicillin/potassium 400-57mg tab chew, amoxicillin/potassium 400-57mg/5 susp recon,amoxicillin/potassium 500-125 mg tablet, amoxicillin/potassium 600-42.9/5 susprecon, amoxicillin/potassium 875-125 mg tablet, amoxicillin/potassium 1000-62.5 tab er 12h)
1
ampicillin trihydrate (125 mg/5ml susp recon, 250 mg capsule, 250 mg/5ml susprecon, 500 mg capsule)
1
AUGMENTIN (125-31.25 MG/5 ML, 250-62.5 MG/5 ML, 500-125 TABLET, 875-125 TABLET)
3
AUGMENTIN ES-600 3
AUGMENTIN XR 3
dicloxacillin sodium 1
MOXATAG 3 PA
penicillin v potassium (125 mg/5ml soln recon, 250 mg tablet, 250 mg/5ml solnrecon, 500 mg tablet)
1
MACROLIDES
AZASITE 3
azithromycin (1 g packet, 100 mg/5ml susp recon, 200 mg/5ml susp recon, 250mg tablet, 500 mg tablet, 600 mg tablet)
1
BIAXIN (250 MG TABLET, 250 MG/5 ML SUSPENSION, 500 MG TABLET) 3
clarithromycin (125 mg/5ml susp recon, 250 mg tablet, 250 mg/5ml susp recon,500 mg tab er 24h, 500 mg tablet)
1
DIFICID 3 ST
E.E.S. 200 3
E.E.S. 400 3
ERY 1
ERY-TAB 1
ERYGEL 3
ERYPED 200 3
ERYPED 400 3
ERYTHROCIN STEARATE 1
erythromycin base (5 mg/gram oint. (g), 250 mg capsule dr, 250 mg tablet, 500mg tablet)
1
erythromycin base in ethanol (in 2 % gel (gram), in 2 % med. swab, in 2 %solution)
1
erythromycin ethylsuccinate (200 mg/5ml susp recon, 400 mg tablet) 1
ILOTYCIN 3
PCE 3
PAGE 18 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ZITHROMAX (1 GM POWDER PACKET, 100 MG/5 ML SUSP, 200 MG/5 MLSUSP, 250 MG TABLET, 250 MG Z-PAK TABLET, 500 MG TABLET, 600 MGTABLET)
3
ZITHROMAX TRI-PAK 3
ZMAX 3
QUINOLONES
AVELOX 3
AVELOX ABC PACK 3
BAXDELA 450 MG TABLET 3 QL
BESIVANCE 3
CETRAXAL 3 QL
CILOXAN (EYE DROPS, OINTMENT) 3
CIPRO (5% SUSPENSION, 10% SUSPENSION, 250 MG TABLET, 500 MGTABLET)
3
CIPRO XR 3
ciprofloxacin 1
ciprofloxacin hcl (0.3 % drops, 100 mg tablet, 250 mg tablet, 500 mg tablet, 750mg tablet)
1
ciprofloxacin hcl 0.2 % droperette 1 QL
ciprofloxacin/ciprofloxacin hcl 1
FACTIVE 3
FLOXIN 3
gatifloxacin 1
LEVAQUIN (25 MG/ML SOLUTION, 250 MG TABLET, 500 MG TABLET, 750MG TABLET)
3
levofloxacin (0.5 % drops, 250 mg tablet, 250mg/10ml solution, 500 mg tablet,500mg/20ml solution, 750 mg tablet)
1
MOXEZA 2
moxifloxacin hcl (0.5 % drops, 400 mg tablet) 1
OCUFLOX 3
ofloxacin (0.3 % drops, 300 mg tablet, 400 mg tablet) 1
OTIPRIO 3
VIGAMOX 3
ZYMAXID 3
SULFONAMIDES
AVC 3
BACTRIM 3
PAGE 19 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
BACTRIM DS 3
BLEPH-10 3
KLARON 3
SILVADENE 3
silver sulfadiazine 1
SSD 1
sulfacetamide sodium (10 % drops, 10 % oint. (g), 10 % suspension) 1
sulfadiazine 1
sulfamethoxazole/trimethoprim (sulfamethoxazole/trimethoprim 200-40mg/5 oralsusp, sulfamethoxazole/trimethoprim 400mg-80mg tablet,sulfamethoxazole/trimethoprim 800-160 mg tablet,sulfamethoxazole/trimethoprim 800-160/20 oral susp)
1
SULFATRIM 1
THERMAZENE 1
TETRACYCLINES
ACTICLATE 3 PA
ADOXA 3
AVIDOXY 1
demeclocycline hcl 1
DORYX 3 ST
DORYX MPC 3 ST
doxycycline hyclate (20 mg tablet, 50 mg capsule, 50 mg tablet, 50 mg tablet dr,75 mg tablet dr, 100 mg capsule, 100 mg tablet, 100 mg tablet dr, 150 mg tabletdr, 200 mg tablet dr)
1
doxycycline hyclate (75 mg tablet, 150 mg tablet) 1
QL
PA
doxycycline monohydrate (25 mg/5 ml susp recon, 50 mg capsule, 50 mgtablet, 75 mg capsule, 75 mg tablet, 100 mg capsule, 100 mg tablet, 150 mgcapsule, 150 mg tablet)
1
DOXYCYCLINE MONOHYDRATE 40 MG CAP IR DR 3
QL
ST
MINOCIN (50 MG CAP, 75 MG CAP, 100 MG CAP) 3
minocycline hcl (45 mg tab er 24h, 65 mg tab er 24h, 90 mg tab er 24h, 115mgtab er 24h, 135 mg tab er 24h)
1
QL
PA
minocycline hcl (50 mg capsule, 50 mg tablet, 75 mg capsule, 75 mg tablet, 100mg capsule, 100 mg tablet)
1
MINOLIRA ER 3
QL
PA
PAGE 20 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
MONDOXYNE NL 1
MONODOX 3
MORGIDOX (1X100 MG KIT, 1X50 MG KIT, 2X100 MG KIT) 3
QL
PA
MORGIDOX (50 MG CAPSULE, 100 MG CAPSULE) 1
ORACEA 3
QL
ST
SOLODYN 3
QL
PA
TARGADOX 3
tetracycline hcl 1
VIBRAMYCIN (25 MG/5 ML SUSP, 50 MG/5 ML SYRUP, 100 MG CAPSULE) 3
XIMINO 3
QL
PA
ANTICONVULSANTS
ANTICONVULSANTS, OTHER
BRIVIACT (10 MG TABLET, 10 MG/ML ORAL SOLN, 25 MG TABLET, 50 MGTABLET, 75 MG TABLET, 100 MG TABLET)
3
QL
PA
EPIDIOLEX 3
QL
PA
S
MS
KEPPRA (100 MG/ML ORAL SOLN, 250 MG TABLET, 500 MG TABLET, 750MG TABLET, 1,000 MG TABLET)
3
KEPPRA XR (500 MG TABLET, 750 MG TABLET) 3 QL
levetiracetam (100 mg/ml solution, 250 mg tablet, 500 mg tablet, 500 mg/5mlsolution, 750 mg tablet, 1000 mg tablet)
1
levetiracetam (500 mg tab er 24h, 750 mg tab er 24h) 1 QL
POTIGA 3
ROWEEPRA 1
ROWEEPRA XR 500 MG TABLET 1
ROWEEPRA XR 750 MG TABLET 1 QL
PAGE 21 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SPRITAM (250 MG TABLET, 500 MG TABLET, 750 MG TABLET, 1,000 MGTABLET)
3
QL
PA
CALCIUM CHANNEL MODIFYING AGENTS
CELONTIN 3
ethosuximide (250 mg capsule, 250 mg/5ml solution) 1
ZARONTIN (250 MG CAPSULE, 250 MG/5 ML SOLUTION) 3
ZONEGRAN 3
zonisamide 1
GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS
clobazam (10 mg tablet, 20 mg tablet) 1 QL
clobazam 2.5 mg/ml oral susp 1
DEPAKENE (250 MG CAPSULE, 250 MG/5 ML SOLUTION) 3
DEPAKOTE 3
DEPAKOTE ER 3
DEPAKOTE SPRINKLE 3
DIASTAT 3 QL
DIASTAT ACUDIAL 3 QL
diazepam (2.5 mg kit, 5-7.5-10mg kit, 12.5-15-20 kit) 1
divalproex sodium 1
gabapentin (100 mg capsule, 250 mg/5ml solution, 300 mg capsule, 300mg/6ml solution, 400 mg capsule, 600 mg tablet, 800 mg tablet)
1
GABITRIL 3
GRALISE (ER 300 MG TABLET, ER 600 MG TABLET) 3
QL
PA
GRALISE 30-DAY STARTER PACK 3 PA
MYSOLINE 3
NEURONTIN (100 MG CAPSULE, 250 MG/5 ML SOLN, 300 MG CAPSULE,400 MG CAPSULE, 600 MG TABLET, 800 MG TABLET)
3
ONFI (10 MG TABLET, 20 MG TABLET) 3 QL
ONFI 2.5 MG/ML SUSPENSION 3
PAGE 22 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
phenobarbital (15 mg tablet, 16.2 mg tablet, 20 mg/5 ml elixir, 30 mg tablet,32.4 mg tablet, 60 mg tablet, 64.8 mg tablet, 97.2mg tablet, 100 mg tablet)
1
primidone 1
SABRIL 3
QL
PA
S
MS
tiagabine hcl 1
valproic acid 1
valproic acid (as sodium salt) (valproate sodium) (250 mg/5ml solution,500mg/10ml solution)
1
vigabatrin 1
QL
PA
S
MS
GLUTAMATE REDUCING AGENTS
felbamate (400 mg tablet, 600 mg tablet, 600 mg/5ml oral susp) 1
FELBATOL (400 MG TABLET, 600 MG TABLET, 600 MG/5 ML SUSP) 3
FYCOMPA (0.5 MG/ML ORAL SUSP, 2 MG TABLET, 4 MG TABLET, 6 MGTABLET, 8 MG TABLET, 10 MG TABLET, 12 MG TABLET)
3 QL
LAMICTAL (5 MG DISPER TABLET, 25 MG DISPER TABLET, 25 MGTABLET, 100 MG TABLET, 150 MG TABLET, 200 MG TABLET)
3
LAMICTAL (BLUE) 3
LAMICTAL (GREEN) 3
LAMICTAL (ORANGE) 3
LAMICTAL ODT 3 QL
LAMICTAL XR 3
lamotrigine (25 mg tab rapdis, 25(42)-100 tab ds pk, 25(84)-100 tab ds pk, 50mg tab rapdis, 100 mg tab rapdis, 200 mg tab rapdis)
1 QL
lamotrigine (5 mg tb chw dsp, 25 mg tab er 24, 25 mg tablet, 25 mg tb chw dsp,25(21)-50 tb rd dspk, 25-50-100 tb rd dspk, 25mg (35) tab ds pk, 50 mg tab er24, 50(42)-100 tb rd dspk, 100 mg tab er 24, 100 mg tablet, 150 mg tablet, 200mg tab er 24, 200 mg tablet, 250 mg tab er 24, 300 mg tab er 24)
1
QUDEXY XR (25 MG CAPSULE, 50 MG CAPSULE, 100 MG CAPSULE, 150MG CAPSULE, 200 MG CAPSULE)
3
QL
PA
TOPAMAX 3
topiramate (15 mg cap sprink, 25 mg cap sprink, 25 mg tablet, 50 mg tablet,100 mg tablet, 200 mg tablet)
1
TOPIRAMATE ER CAPS 3
QL
PA
PAGE 23 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
TROKENDI XR 3
QL
PA
SODIUM CHANNEL AGENTS
APTIOM (200 MG TABLET, 400 MG TABLET, 600 MG TABLET, 800 MGTABLET)
3
QL
PA
BANZEL (40 MG/ML SUSPENSION, 200 MG TABLET, 400 MG TABLET) 3
carbamazepine (100 mg cpmp 12hr, 100 mg tab chew, 100 mg tab er 12h, 100mg/5ml oral susp, 200 mg cpmp 12hr, 200 mg tab er 12h, 200 mg tablet, 300mg cpmp 12hr, 400 mg tab er 12h)
1
CARBATROL 3
DILANTIN (30 MG CAPSULE, 50 MG INFATAB, 100 MG CAPSULE) 2
DILANTIN-125 2
EPITOL 1
oxcarbazepine (150 mg tablet, 300 mg tablet, 300 mg/5ml oral susp, 600 mgtablet)
1
OXTELLAR XR (150 MG TABLET, 300 MG TABLET, 600 MG TABLET) 3
QL
PA
PEGANONE 3
PHENYTEK 2
phenytoin (50 mg tab chew, 100 mg/4ml oral susp, 125 mg/5ml oral susp) 1
phenytoin sodium extended 1
TEGRETOL (100 MG/5 ML SUSP, 200 MG TABLET) 3
TEGRETOL XR 3
TRILEPTAL (150 MG TABLET, 300 MG TABLET, 300 MG/5 ML SUSP, 600MG TABLET)
3
VIMPAT (10 MG/ML SOLUTION, 50 MG TABLET, 100 MG TABLET, 150 MGTABLET, 200 MG TABLET)
2
ANTIDEMENTIA AGENTS
ANTIDEMENTIA AGENTS, OTHER
ergoloid mesylates 1
CHOLINESTERASE INHIBITORS
ARICEPT 3
donepezil hcl 1
EXELON (1.5 MG CAPSULE, 3 MG CAPSULE, 4.5 MG CAPSULE, 4.6MG/24HR PATCH, 6 MG CAPSULE, 9.5 MG/24HR PATCH, 13.3 MG/24HRPATCH)
3
PAGE 24 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
galantamine hbr (4 mg tablet, 4 mg/ml solution, 8 mg cap24h pel, 8 mg tablet,12 mg tablet, 16 mg cap24h pel, 24 mg cap24h pel)
1
NAMZARIC 3
QL
PA
RAZADYNE 3
RAZADYNE ER 3
rivastigmine 1
rivastigmine tartrate 1
N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST
memantine hcl (2 mg/ml solution, 5 mg tablet, 5 mg-10 mg tab ds pk, 10 mgtablet)
1
memantine hcl (7 mg cap spr 24, 14 mg cap spr 24, 21 mg cap spr 24, 28 mgcap spr 24)
1 QL
NAMENDA (2 MG/ML SOLUTION, 5 MG TABLET, 5-10 MG TITRATION PK,10 MG TABLET)
3
NAMENDA XR 3
QL
ST
ANTIDEPRESSANTS
ANTIDEPRESSANTS, OTHER
amitriptyline hcl/chlordiazepoxide 1
APLENZIN 3
QL
ST
bupropion hcl (150 mg tab er 24h, 300 mg tab er 24h) 1 QL
bupropion hcl (75 mg tablet, 100 mg tab sr 12h, 100 mg tablet, 150 mg tab sr12h, 200 mg tab sr 12h)
1
bupropion hcl 450 mg tab er 24h 3
QL
ST
FORFIVO XL 3
QL
ST
mirtazapine 1
olanzapine/fluoxetine hcl 1
perphenazine/amitriptyline hcl 1
REMERON 3
SYMBYAX 3
WELLBUTRIN 3
WELLBUTRIN SR 3
PAGE 25 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
WELLBUTRIN XL (150 MG TABLET, 300 MG TABLET) 3 QL
MONOAMINE OXIDASE INHIBITORS
EMSAM 3
QL
ST
MARPLAN 3
NARDIL 3
PARNATE 3
phenelzine sulfate 1
tranylcypromine sulfate 1
SSRIS/SNRIS (SELECTIVE SEROTONIN REUPTAKE INHIBITORS/SEROTONIN AND NOREPINEPHRINE REUPTAKE INHIBITORS)
BRISDELLE 3
QL
PA
CELEXA (10 MG TABLET, 20 MG TABLET, 40 MG TABLET) 3 QL
citalopram hydrobromide (10 mg tablet, 20 mg tablet, 40 mg tablet) 1 QL
citalopram hydrobromide 10 mg/5 ml solution 1
DESVENLAFAXINE ER 3
QL
ST
DESVENLAFAXINE FUMARATE 3
QL
ST
desvenlafaxine succinate 1 QL
EFFEXOR XR (37.5 MG CAPSULE, 75 MG CAPSULE, 150 MG CAPSULE) 3 QL
escitalopram oxalate (5 mg tablet, 5 mg/5 ml solution, 10 mg tablet, 20 mgtablet)
1
FETZIMA 3 QL
fluoxetine hcl (10 mg capsule, 10 mg tablet, 20 mg capsule, 20 mg tablet, 20mg/5 ml solution, 40 mg capsule, 60 mg tablet)
1
fluoxetine hcl 90 mg capsule dr 1 QL
fluvoxamine maleate (100 mg cap er 24h, 150 mg cap er 24h) 1 QL
fluvoxamine maleate (25 mg tablet, 50 mg tablet, 100 mg tablet) 1
KHEDEZLA 3
QL
ST
LEXAPRO (5 MG TABLET, 5 MG/5 ML SOLUTION, 10 MG TABLET, 20 MGTABLET)
3
PAGE 26 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
maprotiline hcl 1
nefazodone hcl (150 mg tablet, 200 mg tablet, 250 mg tablet) 1
nefazodone hcl (50 mg tablet, 100 mg tablet) 1 QL
OLEPTRO ER (ER 150 MG TABLET, ER 300 MG TABLET) 3
QL
ST
paroxetine hcl (10 mg tablet, 20 mg tablet, 30 mg tablet, 40 mg tablet) 1
paroxetine hcl (12.5 mg tab er 24h, 25 mg tab er 24h, 37.5 mg tab er 24h) 1 QL
paroxetine mesylate 1
QL
PA
PAXIL (10 MG TABLET, 10 MG/5 ML SUSPENSION, 20 MG TABLET, 30 MGTABLET, 40 MG TABLET)
3
PAXIL CR 3 QL
PEXEVA 3
QL
ST
PRISTIQ (ER 25 MG TABLET, ER 50 MG TABLET, ER 100 MG TABLET) 3 QL
PROZAC (10 MG, 40 MG) 3 QL
PROZAC 20 MG PULVULE 3
PROZAC WEEKLY 3 QL
SARAFEM 3
sertraline hcl (20 mg/ml oral conc, 25 mg tablet, 50 mg tablet, 100 mg tablet) 1
trazodone hcl 1
TRINTELLIX 3 QL
VENLAFAXINE ER TAB (TIER DEPENDENT ON MANUFACTURER. UCB T3,OTHERS T1)
3
QL
ST
venlafaxine hcl (25 mg tablet, 37.5 mg tablet, 50 mg tablet, 75 mg tablet, 100mg tablet)
1
venlafaxine hcl (37.5 mg cap er 24h, 75 mg cap er 24h, 150 mg cap er 24h) 1 QL
VIIBRYD (10 MG TABLET, 10-20-40 MG STARTER PK, 20 MG TABLET, 40MG TABLET)
3 QL
VIIBRYD 10-20 MG STARTER PACK 3
ZOLOFT (20 MG/ML ORAL CONC, 25 MG TABLET, 50 MG TABLET, 100 MGTABLET)
3
ZOLOFT 20 MG/ML ORAL SOLN 3
PAGE 27 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
TRICYCLICS
amitriptyline hcl 1
amoxapine 1
ANAFRANIL 3
clomipramine hcl 1
desipramine hcl 1
doxepin hcl (10 mg capsule, 10 mg/ml oral conc, 25 mg capsule, 50 mgcapsule, 75 mg capsule, 100 mg capsule, 150 mg capsule)
1
imipramine hcl 1
imipramine pamoate 1
NORPRAMIN 3
nortriptyline hcl (10 mg capsule, 25 mg capsule, 50 mg capsule, 75 mg capsule) 1
nortriptyline hcl (10 mg/5 ml solution, 20 mg/10ml solution) 3
QL
PA
PAMELOR 3
protriptyline hcl 1
SURMONTIL 3
TOFRANIL 3
TOFRANIL-PM 3
trimipramine maleate 1
ANTIEMETICS
ANTIEMETICS, OTHER
BONJESTA 3
QL
PA
COMPAZINE (5 MG TABLET, 10 MG TABLET) 3
COMPAZINE 25 MG SUPPOSITORY 1
COMPRO 1
DICLEGIS 3
QL
PA
meclizine hcl (12.5 mg tablet, 25 mg tablet) 1
metoclopramide hcl (5 mg tab rapdis, 10 mg tab rapdis) 1 QL
metoclopramide hcl (5 mg tablet, 5 mg/5 ml solution, 10 mg tablet, 10 mg/10mlsolution)
1
METOZOLV ODT 3 QL
PAGE 28 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
perphenazine 1
PHENADOZ 1
PHENERGAN (12.5 MG, 25 MG, 50 MG) 1
prochlorperazine 1
prochlorperazine maleate 1
promethazine hcl (12.5 mg supp.rect, 25 mg supp.rect, 50 mg supp.rect, 50 mgtablet)
1
PROMETHEGAN 1
REGLAN 3
scopolamine 1
TIGAN 300 MG CAPSULE 3
TRANSDERM-SCOP 3
trimethobenzamide hcl 1
EMETOGENIC THERAPY ADJUNCTS
AKYNZEO 300-0.5 MG CAPSULE 3 QL
ANZEMET (50 MG TABLET, 100 MG TABLET) 3
QL
ST
aprepitant (40 mg capsule, 80 mg capsule, 125 mg capsule, 125mg-80mg capds pk)
1 QL
CESAMET 3
dronabinol 1
EMEND (40 MG CAPSULE, 80 MG CAPSULE, 125 MG CAPSULE, 125 MGPOWDER PACKET, TRIPACK)
3 QL
granisetron hcl 1 mg tablet 1 QL
MARINOL 3
ondansetron 1
ondansetron hcl (4 mg tablet, 4 mg/5 ml solution, 8 mg tablet, 24 mg tablet) 1
SANCUSO 3
QL
ST
SUSTOL 3
SYNDROS 3 PA
VARUBI 90 MG TABLET 3
ZOFRAN (4 MG TABLET, 4 MG/5 ML ORAL SOLN, 8 MG TABLET) 3
ZOFRAN ODT 3
PAGE 29 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ZUPLENZ 3
QL
ST
ANTIFUNGALS
ANCOBON 3
CICLODAN 0.77% CREAM 1
CICLODAN 8% SOLUTION 1 QL
ciclopirox (0.77 % gel (gram), 1 % shampoo) 1
ciclopirox 8 % solution 1 QL
ciclopirox olamine (0.77 % cream (g), 0.77 % suspension) 1
clotrimazole (1 % cream (g), 10 mg troche) 1
CRESEMBA 186 MG CAPSULE 3
DIFLUCAN (10 MG/ML SUSPENSION, 40 MG/ML SUSPENSION, 50 MGTABLET, 100 MG TABLET, 150 MG TABLET, 200 MG TABLET)
3
econazole nitrate 1
ECOZA 3
QL
ST
ERTACZO 3 ST
EXELDERM (CREAM, SOLUTION) 3
EXTINA 3 ST
fluconazole (10 mg/ml susp recon, 40 mg/ml susp recon, 50 mg tablet, 100 mgtablet, 150 mg tablet, 200 mg tablet)
1
flucytosine 1
GRIFULVIN V 3
GRIS-PEG 3
griseofulvin ultramicrosize 1
griseofulvin, microsize (125 mg/5ml oral susp, 500 mg tablet) 1
GYNAZOLE 1 3
itraconazole (10 mg/ml solution, 100 mg capsule) 1
JUBLIA 3
QL
PA
KERYDIN 3 PA
ketoconazole (2 % cream (g), 2 % foam, 2 % shampoo, 200 mg tablet) 1
KETODAN (FOAM, FOAM KIT) 1
PAGE 30 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
LAMISIL (125 MG GRANULES PACKET, 187.5 MG GRANULES PACK) 3
QL
PA
LAMISIL 250 MG TABLET 3
LOPROX (0.77% CREAM, 0.77% TOPICAL SUSP, 1% SHAMPOO) 3
LOPROX (CREAM KIT, SUSPENSION KIT) 3
QL
PA
luliconazole 3 QL
LUZU 3
QL
ST
MENTAX 3 ST
miconazole nitrate 200 mg supp.vag 1
naftifine hcl 1 % cream (g) 1
naftifine hcl 2 % cream (g) 1 QL
NAFTIN (1% GEL, 2% GEL) 3 ST
NAFTIN 2% CREAM 3 QL
NATACYN 3
NIZORAL 3
NOXAFIL (40 MG/ML SUSPENSION, DR 100 MG TABLET) 3
NYAMYC 1
NYATA 3
nystatin (50mm unit powder(ea), 150mm unit powder(ea), 500k unit tablet,500mm unit powder(ea), 100000/g cream (g), 100000/g oint. (g), 100000/gpowder, 100000/ml oral susp)
1
nystatin/triamcinolone acetonide 1
NYSTOP 1
ONMEL 3
QL
PA
ORAVIG 3 PA
oxiconazole nitrate 1
OXISTAT 1% CREAM 3
OXISTAT 1% LOTION 3 ST
PENLAC 3 QL
PAGE 31 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SPORANOX (10 MG/ML SOLUTION, 100 MG CAPSULE) 3
TERAZOL 3 3
TERAZOL 7 3
terbinafine hcl 250 mg tablet 1
terconazole (0.4 % cream/appl, 0.8 % cream/appl, 80 mg supp.vag) 1
VFEND (40 MG/ML SUSPENSION, 50 MG TABLET) 3
VFEND 200 MG TABLET 3 QL
voriconazole (50 mg tablet, 200 mg/5ml susp recon) 1
voriconazole 200 mg tablet 1 QL
VUSION 3
XOLEGEL 3 ST
ANTIGOUT AGENTS
allopurinol 1
COLCHICINE 3 QL
COLCRYS 2 QL
DUZALLO 3
QL
PA
MITIGARE 3 QL
probenecid 1
probenecid/colchicine 1
ULORIC 2
QL
ST
ZURAMPIC 3
QL
PA
ZYLOPRIM 3
ANTIMIGRAINE AGENTS
ANTIMIGRAINE AGENTS, OTHER
AIMOVIG AUTOINJECTOR 2
QL
PA
AIMOVIG AUTOINJECTOR (2 PACK) 2
QL
PA
PAGE 32 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
AJOVY 2
QL
PA
EMGALITY 2
QL
PA
ERGOT ALKALOIDS
CAFERGOT 3
D.H.E.45 3
dihydroergotamine mesylate (1 mg/ml ampul, 1 mg/ml vial) 1
DIHYDROERGOTAMINE MESYLATE 0.5MG/SPRY SPRAY/PUMP 3 QL
ERGOMAR 3
ergotamine tartrate/caffeine 1
MIGERGOT 3
MIGRANAL 3 QL
SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS
almotriptan malate 1 QL
AMERGE 3 QL
AXERT 3 QL
eletriptan hydrobromide 1 QL
FROVA 3 QL
frovatriptan succinate 1 QL
IMITREX (4 MG/0.5 ML CARTRIDGES, 4 MG/0.5 ML PEN INJECT, 5 MGNASAL SPRAY, 6 MG/0.5 ML CARTRIDGES, 6 MG/0.5 ML PEN INJECT, 6MG/0.5 ML VIAL, 20 MG NASAL SPRAY, 25 MG TABLET, 50 MG TABLET,100 MG TABLET)
3 QL
MAXALT 3 QL
MAXALT MLT 3 QL
naratriptan hcl (1 mg tablet, 2.5 mg tablet) 1 QL
ONZETRA XSAIL 3
QL
ST
RELPAX 3 QL
rizatriptan benzoate 1 QL
sumatriptan (5 mg spray, 20 mg spray) 1 QL
PAGE 33 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
sumatriptan succinate (4 mg/0.5ml cartridge, 4 mg/0.5ml pen injctr, 6 mg/0.5mlcartridge, 6 mg/0.5ml pen injctr, 6 mg/0.5ml syringe, 6 mg/0.5ml vial, 25 mgtablet, 50 mg tablet, 100 mg tablet)
1 QL
sumatriptan succinate/naproxen sodium 1 QL
SUMAVEL DOSEPRO (4 MG/0.5 ML, 6 MG/0.5 ML) 3
QL
ST
TREXIMET 3 QL
ZEMBRACE SYMTOUCH 3
QL
ST
zolmitriptan 1 QL
ZOMIG (2.5 MG NASAL SPRAY, 5 MG NASAL SPRAY) 3
QL
ST
ZOMIG (2.5 MG TABLET, 5 MG TABLET) 3 QL
ZOMIG ZMT 3 QL
ANTIMYASTHENIC AGENTS
PARASYMPATHOMIMETICS
GUANIDINE HCL 3
MESTINON (60 MG TABLET, 60 MG/5 ML SYRUP, 180 MG TIMESPAN) 3
pyridostigmine bromide 1
ANTIMYCOBACTERIALS
ANTIMYCOBACTERIALS, OTHER
dapsone (25 mg tablet, 100 mg tablet) 1
MYCOBUTIN 3
rifabutin 1
ANTITUBERCULARS
cycloserine 1
ethambutol hcl 1
isoniazid (50 mg/5 ml solution, 100 mg tablet, 300 mg tablet) 1
MYAMBUTOL 3
PASER 3
PRIFTIN 3
pyrazinamide 1
RIFADIN (150 MG CAPSULE, 300 MG CAPSULE) 3
PAGE 34 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
RIFAMATE 3
rifampin (150 mg capsule, 300 mg capsule) 1
RIFATER 3
SIRTURO 3
TRECATOR 3
ANTINEOPLASTICS
ALKYLATING AGENTS
ALKERAN 2 MG TABLET 3
CYCLOPHOSPHAMIDE (25 MG CAPSULE, 50 MG CAPSULE) 1
GLEOSTINE 3
HEXALEN 3
LEUKERAN 2
lomustine 1
MATULANE 2 S
melphalan 1
MYLERAN 2
TEMODAR (5 MG CAPSULE, 20 MG CAPSULE, 100 MG CAPSULE, 140 MGCAPSULE, 180 MG CAPSULE, 250 MG CAPSULE)
3
S
MS
temozolomide 1
S
MS
VALCHLOR 3
QL
PA
S
MS
ANTIANDROGENS
bicalutamide 1
CASODEX 3
ERLEADA 3
QL
PA
S
MS
flutamide 1
PAGE 35 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
NILANDRON 3
nilutamide 1
XTANDI 2
QL
PA
S
MS
YONSA 3
QL
PA
S
MS
ZYTIGA (250 MG TABLET, 500 MG TABLET) 2
QL
PA
S
MS
ANTIANGIOGENIC AGENTS
POMALYST 3
QL
PA
S
MS
REVLIMID 2
QL
PA
S
MS
THALOMID 3
QL
S
MS
ANTIESTROGENS/MODIFIERS
EMCYT 3
FARESTON 2
SOLTAMOX 3
QL
PA
tamoxifen citrate 1
PAGE 36 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANTIMETABOLITES
capecitabine 1
S
MS
DROXIA 3
EFUDEX 3
fluorouracil (2 % solution, 5 % cream (g), 5 % solution) 1
HYDREA 3
hydroxyurea 1
mercaptopurine 1
PURIXAN 3
QL
PA
S
SIKLOS 100 MG TABLET 3
TABLOID 2
XELODA 3
S
MS
ANTINEOPLASTICS, OTHER
ALUNBRIG (30 MG TABLET, 90 MG TABLET, 90 MG-180 MG TAB PACK, 180MG TABLET)
3
QL
PA
S
MS
COPIKTRA 15 MG CAPSULE 3
QL
PA
S
COPIKTRA 25 MG CAPSULE 3
QL
PA
HEMANGEOL 3 S
IDHIFA 3
QL
PA
S
MS
leucovorin calcium (5 mg tablet, 10 mg tablet, 15 mg tablet, 25 mg tablet) 1
PAGE 37 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
LONSURF 3
PA
S
MS
LYSODREN 2
NINLARO 3
PA
S
MS
RUBRACA (200 MG TABLET, 250 MG TABLET, 300 MG TABLET) 3
QL
PA
S
RYDAPT 3
QL
PA
S
MS
SYLATRON 3
PA
S
MS
TIBSOVO 3
QL
PA
VIZIMPRO 3
QL
PA
S
MS
ZOLINZA 3
QL
PA
S
MS
AROMATASE INHIBITORS, 3RD GENERATION
anastrozole 1
ARIMIDEX 3
AROMASIN 3
exemestane 1
FEMARA 3
PAGE 38 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
letrozole 1
ENZYME INHIBITORS
etoposide 50 mg capsule 1
HYCAMTIN (0.25 MG CAPSULE, 1 MG CAPSULE) 2
QL
PA
S
MS
MOLECULAR TARGET INHIBITORS
AFINITOR 2
QL
PA
S
MS
ALECENSA 3
PA
S
MS
BOSULIF (100 MG TABLET, 400 MG TABLET, 500 MG TABLET) 3
QL
PA
S
MS
BRAFTOVI (50 MG CAPSULE, 75 MG CAPSULE) 3
QL
PA
S
CABOMETYX 3
QL
PA
S
MS
CALQUENCE 3
QL
PA
S
CAPRELSA (100 MG TABLET, 300 MG TABLET) 2
QL
PA
S
PAGE 39 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
COMETRIQ (60 MG PACK, 100 MG PK, 140 MG PK) 2
QL
PA
S
COTELLIC 3
PA
S
MS
ERIVEDGE 3
QL
PA
S
MS
FARYDAK 3
QL
PA
S
MS
GILOTRIF 3
QL
PA
S
MS
GLEEVEC (100 MG TABLET, 400 MG TABLET) 3
QL
ST
S
MS
IBRANCE 2
QL
PA
S
MS
ICLUSIG (15 MG TABLET, 45 MG TABLET) 3
QL
PA
S
imatinib mesylate (100 mg tablet, 400 mg tablet) 1
QL
S
MS
PAGE 40 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
IMBRUVICA (70 MG CAPSULE, 140 MG CAPSULE, 140 MG TABLET, 280MG TABLET, 420 MG TABLET, 560 MG TABLET)
3
QL
PA
S
INLYTA (1 MG TABLET, 5 MG TABLET) 3
QL
PA
S
MS
IRESSA 3
QL
PA
S
MS
JAKAFI 2
QL
PA
S
MS
KISQALI 3
QL
PA
S
MS
KISQALI FEMARA CO-PACK (200 MG, 400 MG, 600 MG) 3
QL
PA
S
MS
LENVIMA (4 MG CAPSULE, 8 MG DAILY DOSE, 10 MG DAILY DOSE, 12 MGDAILY DOSE, 14 MG DAILY DOSE, 18 MG DAILY DOSE, 20 MG DAILYDOSE, 24 MG DAILY DOSE)
3
QL
PA
S
MS
LYNPARZA (100 MG TABLET, 150 MG TABLET) 3
QL
PA
S
MS
LYNPARZA 50 MG CAPSULE 3
PA
S
MS
PAGE 41 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
MEKINIST (0.5 MG TABLET, 2 MG TABLET) 3
QL
PA
S
MS
MEKTOVI 3
QL
PA
S
MS
NERLYNX 3
QL
PA
S
MS
NEXAVAR 2
QL
PA
S
MS
ODOMZO 3
PA
S
MS
SPRYCEL (20 MG TABLET, 50 MG TABLET, 70 MG TABLET, 80 MGTABLET, 100 MG TABLET, 140 MG TABLET)
2
QL
PA
S
MS
STIVARGA 2
QL
PA
S
MS
SUTENT (12.5 MG CAPSULE, 25 MG CAPSULE, 37.5 MG CAPSULE, 50 MGCAPSULE)
2
QL
PA
S
MS
PAGE 42 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
TAFINLAR (50 MG CAPSULE, 75 MG CAPSULE) 3
QL
PA
S
MS
TAGRISSO 3
PA
S
MS
TALZENNA (0.25 MG CAPSULE, 1 MG CAPSULE) 3
QL
PA
S
MS
TARCEVA 3
QL
PA
S
MS
TASIGNA (50 MG CAPSULE, 150 MG CAPSULE, 200 MG CAPSULE) 3
QL
PA
S
MS
TYKERB 2
QL
PA
S
MS
VENCLEXTA 3
QL
PA
S
VERZENIO 2
QL
PA
MS
VOTRIENT 2
QL
PA
S
MS
PAGE 43 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
XALKORI 3
QL
PA
S
MS
ZEJULA 3
QL
PA
ZELBORAF 2
QL
PA
S
MS
ZYDELIG 3
QL
PA
S
MS
ZYKADIA 3
QL
PA
S
MS
RETINOIDS
bexarotene 1
QL
PA
S
MS
PANRETIN 3
TARGRETIN 1% GEL 3
PA
S
MS
TARGRETIN 75 MG CAPSULE 3
QL
PA
S
MS
tretinoin 10 mg capsule 1
PAGE 44 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
TREATMENT ADJUNCTS
MESNEX 400 MG TABLET 3
ANTIPARASITICS
ANTIHELMINTHICS
albendazole 1
ALBENZA 3
benznidazole (12.5 mg tablet, 100 mg tablet) 3 QL
BILTRICIDE 3
EMVERM 3
QL
PA
ivermectin 1
praziquantel 1
SKLICE 3 QL
STROMECTOL 3
ANTIPROTOZOALS
ALINIA (100 MG/5 ML SUSPENSION, 500 MG TABLET) 3
atovaquone 1
atovaquone/proguanil hcl 1
chloroquine phosphate 1
COARTEM 3
DARAPRIM 3 S
hydroxychloroquine sulfate 1
IMPAVIDO 3
QL
PA
MALARONE 3
mefloquine hcl 1
MEPRON 3
NEBUPENT 3
PLAQUENIL 3
PRIMAQUINE PHOSPHATE 3
QUALAQUIN 3 PA
quinine sulfate 1 PA
PAGE 45 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PEDICULICIDES/SCABICIDES
CROTAN 1 QL
ELIMITE 3
EURAX 3 QL
lindane 1 QL
malathion 1
OVIDE 3
permethrin 5 % cream (g) 1
ANTIPARKINSON AGENTS
ANTICHOLINERGICS
benztropine mesylate (0.5 mg tablet, 1 mg tablet, 2 mg tablet) 1
trihexyphenidyl hcl (2 mg tablet, 2 mg/5 ml elixir, 5 mg tablet) 1
ANTIPARKINSON AGENTS, OTHER
amantadine hcl (50 mg/5 ml solution, 100 mg capsule, 100 mg tablet) 1
carbidopa/levodopa/entacapone 1
COMTAN 3
entacapone 1
GOCOVRI 3
QL
PA
OSMOLEX ER 3
QL
PA
STALEVO 3
TASMAR 3
tolcapone 1
DOPAMINE AGONISTS
APOKYN 3
S
MS
bromocriptine mesylate 1
MIRAPEX 3
MIRAPEX ER 3
NEUPRO 3
QL
PA
PAGE 46 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PARLODEL 3
pramipexole di-hcl 1
REQUIP 3
REQUIP XL 3 QL
ropinirole hcl (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet, 2 mg tablet, 3 mgtablet, 4 mg tablet, 5 mg tablet)
1
ropinirole hcl (2 mg tab er 24h, 4 mg tab er 24h, 6 mg tab er 24h, 8 mg tab er24h, 12 mg tab er 24h)
1 QL
DOPAMINE PRECURSORS/L-AMINO ACID DECARBOXYLASE INHIBITORS
carbidopa 1
carbidopa/levodopa 1
LODOSYN 3
RYTARY (ER 23.75 MG-95 MG CAP, ER 36.25 MG-145 MG CAP, ER 48.75MG-195 MG CAP, ER 61.25 MG-245 MG CAP)
3
QL
PA
SINEMET 10-100 3
SINEMET 25-100 3
SINEMET 25-250 3
SINEMET CR 3
MONOAMINE OXIDASE B (MAO-B) INHIBITORS
AZILECT 3 QL
ELDEPRYL 3
rasagiline mesylate 1 QL
selegiline hcl 1
XADAGO (50 MG TABLET, 100 MG TABLET) 3
QL
ST
ZELAPAR 3
QL
PA
ANTIPSYCHOTICS
1ST GENERATION/TYPICAL
ADASUVE 3
chlorpromazine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 100 mg tablet,200 mg tablet)
1
fluphenazine decanoate 1
PAGE 47 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
fluphenazine hcl (1 mg tablet, 2.5 mg tablet, 2.5 mg/5ml elixir, 5 mg tablet, 5mg/ml oral conc, 10 mg tablet)
1
haloperidol 1
haloperidol lactate (2 mg/ml oral conc, 5 mg/ml vial) 1
loxapine succinate 1
molindone hcl 1
ORAP 3
pimozide 1
thioridazine hcl 1
thiothixene 1
trifluoperazine hcl 1
2ND GENERATION/ATYPICAL
ABILIFY (2 MG TABLET, 5 MG TABLET, 10 MG TABLET, 15 MG TABLET, 20MG TABLET, 30 MG TABLET)
3 QL
ABILIFY DISCMELT 3 QL
aripiprazole (1 mg/ml solution, 2 mg tablet, 5 mg tablet, 10 mg tab rapdis, 10mg tablet, 15 mg tab rapdis, 15 mg tablet, 20 mg tablet, 30 mg tablet)
1 QL
FANAPT (1 MG TABLET, 2 MG TABLET, 4 MG TABLET, 6 MG TABLET, 8 MGTABLET, 10 MG TABLET, 12 MG TABLET)
3
QL
ST
FANAPT TITRATION PACK 3 ST
GEODON (20 MG CAPSULE, 40 MG CAPSULE, 60 MG CAPSULE, 80 MGCAPSULE)
3
INVEGA 3 QL
LATUDA (20 MG TABLET, 40 MG TABLET, 60 MG TABLET, 80 MG TABLET,120 MG TABLET)
3
QL
ST
NUPLAZID (10 MG TABLET, 17 MG TABLET, 34 MG CAPSULE) 3
QL
PA
S
MS
olanzapine (2.5 mg tablet, 5 mg tab rapdis, 5 mg tablet, 7.5 mg tablet, 10 mgtab rapdis, 10 mg tablet, 15 mg tab rapdis, 15 mg tablet, 20 mg tab rapdis, 20mg tablet)
1
paliperidone 1 QL
quetiapine fumarate (25 mg tablet, 50 mg tablet, 100 mg tablet, 200 mg tablet,300 mg tablet)
1
PAGE 48 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
quetiapine fumarate (50 mg tab er 24h, 150 mg tab er 24h, 200 mg tab er 24h,300 mg tab er 24h, 400 mg tab er 24h, 400 mg tablet)
1 QL
REXULTI 3
QL
ST
RISPERDAL (0.25 MG TABLET, 0.5 MG TABLET, 1 MG TABLET, 1 MG/MLSOLUTION, 2 MG TABLET, 3 MG TABLET, 4 MG TABLET)
3
RISPERDAL M-TAB 3
risperidone (0.25 mg tab rapdis, 0.25 mg tablet, 0.5 mg tab rapdis, 0.5 mgtablet, 1 mg tab rapdis, 1 mg tablet, 1 mg/ml solution, 2 mg tab rapdis, 2 mgtablet, 3 mg tab rapdis, 3 mg tablet, 4 mg tab rapdis, 4 mg tablet)
1
SAPHRIS 3
QL
ST
SEROQUEL (25 MG TABLET, 50 MG TABLET, 100 MG TABLET, 200 MGTABLET, 300 MG TABLET)
3
SEROQUEL 400 MG TABLET 3 QL
SEROQUEL XR (50 MG TABLET, 150 MG TABLET, 200 MG TABLET, 300 MGTABLET, 400 MG TABLET)
3 QL
VRAYLAR 3
QL
ST
ziprasidone hcl 1
ZYPREXA (2.5 MG TABLET, 5 MG TABLET, 7.5 MG TABLET, 10 MGTABLET, 15 MG TABLET, 20 MG TABLET)
3
ZYPREXA ZYDIS 3
TREATMENT-RESISTANT
clozapine 1
CLOZARIL 3
FAZACLO 3
VERSACLOZ 3
ANTISPASTICITY AGENTS
baclofen (10 mg tablet, 20 mg tablet) 1
baclofen 5 mg tablet 1
DANTRIUM (25 MG CAPSULE, 50 MG CAPSULE) 3
dantrolene sodium 1
tizanidine hcl 1
ZANAFLEX 3
PAGE 49 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANTIVIRALS
ANTI-CYTOMEGALOVIRUS (CMV) AGENTS
PREVYMIS (240 MG TABLET, 480 MG TABLET) 3
VALCYTE (50 MG/ML SOLUTION, 450 MG TABLET) 3
valganciclovir hcl (50 mg/ml soln recon, 450 mg tablet) 1
ZIRGAN 3
ANTI-HEPATITIS B (HBV) AGENTS
adefovir dipivoxil 1
BARACLUDE (0.05 MG/ML SOLUTION, 0.5 MG TABLET, 1 MG TABLET) 3 QL
entecavir 1 QL
EPIVIR HBV (25 MG/5 ML SOLN, 100 MG TABLET) 3
HEPSERA 3
lamivudine 100 mg tablet 1
TYZEKA 3 QL
VEMLIDY 3
ANTI-HEPATITIS C (HCV) AGENTS, DIRECT ACTING AGENTS
DAKLINZA (30 MG TABLET, 60 MG TABLET, 90 MG TABLET) 3
QL
PA
ST
S
MS
EPCLUSA 3
QL
PA
S
MS
HARVONI 3
QL
PA
S
MS
MAVYRET 3
QL
PA
S
MS
PAGE 50 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
OLYSIO 3
QL
PA
ST
S
MS
SOVALDI 3
QL
PA
S
MS
TECHNIVIE 3
QL
PA
ST
S
MS
VIEKIRA PAK 3
QL
PA
ST
S
MS
VIEKIRA XR 3
QL
PA
ST
S
MS
VOSEVI 3
QL
PA
S
MS
ZEPATIER 3
QL
PA
ST
S
MS
PAGE 51 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANTI-HEPATITIS C (HCV) AGENTS, OTHER
COPEGUS 3
PA
S
MS
INTRON A (10 MILLION UNITS VIL, 18 MILLION UNIT/3 ML, 18 MILLIONUNITS VIL, 25 MILLION UNIT/2.5ML, 50 MILLION UNITS VIL)
3
S
MS
MODERIBA 1
PA
S
MS
PEGASYS 3
QL
PA
S
MS
PEGASYS PROCLICK 3
QL
PA
S
MS
PEGINTRON 3
QL
PA
S
MS
PEGINTRON REDIPEN 3
QL
PA
S
MS
REBETOL (40 MG/ML SOLUTION, 200 MG CAPSULE) 3
PA
S
MS
RIBASPHERE (200 MG CAPSULE, 200 MG TABLET) 1
PA
S
MS
RIBASPHERE (400 MG TABLET, 600 MG TABLET) 3
PA
S
MS
PAGE 52 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
RIBASPHERE RIBAPAK 3
PA
S
MS
RIBATAB 3
PA
MS
ribavirin (200 mg capsule, 200 mg tablet) 1
PA
S
MS
ANTI-HIV AGENTS, INTEGRASE INHIBITORS (INSTI)
BIKTARVY 2 S
GENVOYA 2 S
ISENTRESS (25 MG TABLET CHEW, 100 MG TABLET CHEW, 400 MGTABLET)
2
QL
S
ISENTRESS 100 MG POWDER PACKET 2 S
ISENTRESS HD 2
QL
S
STRIBILD 3
QL
S
TIVICAY (10 MG TABLET, 25 MG TABLET, 50 MG TABLET) 3
QL
S
VITEKTA 150 MG TABLET 3
QL
S
VITEKTA 85 MG TABLET 3 S
ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI)
ATRIPLA 3
QL
ST
S
COMPLERA 3 S
DELSTRIGO 3
QL
S
EDURANT 3 S
PAGE 53 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
efavirenz 1 S
INTELENCE 2 S
nevirapine (100 mg tab er 24h, 200 mg tablet, 400 mg tab er 24h) 1 S
NEVIRAPINE 50 MG/5 ML ORAL SUSP 2 S
ODEFSEY 3 S
PIFELTRO 3
QL
S
RESCRIPTOR 2 S
SUSTIVA 3 S
SYMFI 2
QL
S
SYMFI LO 2
QL
S
VIRAMUNE (50 MG/5 ML SUSP, 200 MG TABLET) 3 S
VIRAMUNE XR 3 S
ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTI)
abacavir sulfate 20 mg/ml solution 1
abacavir sulfate 300 mg tablet 1 S
abacavir sulfate/lamivudine 1 S
abacavir sulfate/lamivudine/zidovudine 1 S
CIMDUO 2
QL
S
COMBIVIR 3 S
didanosine 1 S
EMTRIVA (10 MG/ML SOLUTION, 200 MG CAPSULE) 3 S
EPIVIR (10 MG/ML ORAL SOLN, 150 MG TABLET, 300 MG TABLET) 3 S
EPZICOM 3 S
lamivudine (10 mg/ml solution, 150 mg tablet, 300 mg tablet) 1 S
lamivudine/zidovudine 1 S
PAGE 54 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
RETROVIR (10 MG/ML SYRUP, 100 MG CAPSULE) 3 S
stavudine (1 mg/ml soln recon, 15 mg capsule, 20 mg capsule, 30 mg capsule,40 mg capsule)
1 S
tenofovir disoproxil fumarate 1 S
TRIZIVIR 3 S
TRUVADA 2 S
VIDEX 2 S
VIDEX EC 3 S
VIREAD (150 MG TABLET, 200 MG TABLET, 250 MG TABLET, 300 MGTABLET, POWDER)
3 S
ZERIT (1 MG/ML SOLUTION, 15 MG CAPSULE, 20 MG CAPSULE, 30 MGCAPSULE, 40 MG CAPSULE)
3 S
ZIAGEN (20 MG/ML SOLUTION, 300 MG TABLET) 3 S
zidovudine (10 mg/ml syrup, 100 mg capsule, 300 mg tablet) 1 S
ANTI-HIV AGENTS, OTHER
DESCOVY 2 S
JULUCA 3
QL
S
SELZENTRY (25 MG TABLET, 75 MG TABLET, 150 MG TABLET, 300 MGTABLET)
2
QL
S
SELZENTRY 20 MG/ML ORAL SOLN 2 S
TRIUMEQ 3 S
TYBOST 2
QL
S
ANTI-HIV AGENTS, PROTEASE INHIBITORS
APTIVUS (100 MG/ML SOLUTION, 250 MG CAPSULE) 3 S
atazanavir sulfate 1 S
CRIXIVAN 3 S
EVOTAZ 3
QL
S
INVIRASE 3 S
KALETRA (80 MG-20 MG/ML SOLN, 100-25 MG TABLET, 200-50 MGTABLET)
3 S
PAGE 55 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
LEXIVA (50 MG/ML SUSPENSION, 700 MG TABLET) 3 S
lopinavir/ritonavir 1 S
NORVIR (80 MG/ML SOLUTION, 100 MG POWDER PACKET, 100 MGSOFTGEL CAP, 100 MG TABLET)
3 S
PREZCOBIX 3 S
PREZISTA (75 MG TABLET, 100 MG/ML SUSPENSION, 150 MG TABLET,400 MG TABLET, 600 MG TABLET, 800 MG TABLET)
3 S
REYATAZ 3 S
ritonavir 1 S
SYMTUZA 3 QL
VIRACEPT 3 S
ANTI-INFLUENZA AGENTS
FLUMADINE 3
oseltamivir phosphate (6 mg/ml susp recon, 30 mg capsule, 45 mg capsule, 75mg capsule)
1 QL
RELENZA 3 QL
rimantadine hcl 1
TAMIFLU (6 MG/ML SUSPENSION, 30 MG CAPSULE, 45 MG CAPSULE, 75MG CAPSULE)
3 QL
ANTIHERPETIC AGENTS
acyclovir (200 mg capsule, 200 mg/5ml oral susp, 400 mg tablet, 800 mg tablet) 1
acyclovir 5 % oint. (g) 1 QL
ALFERON N 3
DENAVIR 3 QL
famciclovir (125 mg tablet, 250 mg tablet) 1
famciclovir 500 mg tablet 1 QL
FAMVIR (125 MG TABLET, 250 MG TABLET) 3
FAMVIR 500 MG TABLET 3 QL
SITAVIG 3 PA
trifluridine 1
valacyclovir hcl 1
VALTREX 3
VIROPTIC 3
PAGE 56 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
XERESE 3 PA
ZOVIRAX (200 MG CAPSULE, 200 MG/5 ML SUSP, 400 MG TABLET, 800MG TABLET)
3
ZOVIRAX (CREAM, OINTMENT) 3 QL
ANXIOLYTICS
ANXIOLYTICS, OTHER
buspirone hcl 1
meprobamate 1
midazolam hcl 2 mg/ml syrup 1
BENZODIAZEPINES
alprazolam (0.25 mg tab rapdis, 0.25 mg tablet, 0.5 mg tab er 24h, 0.5 mg tabrapdis, 0.5 mg tablet, 1 mg tab er 24h, 1 mg tab rapdis, 1 mg tablet, 2 mg tab er24h, 2 mg tab rapdis, 2 mg tablet, 3 mg tab er 24h)
1
ALPRAZOLAM INTENSOL 1
ATIVAN (0.5 MG TABLET, 1 MG TABLET, 2 MG TABLET) 3
chlordiazepoxide hcl 1
clonazepam (0.125 mg tab rapdis, 0.25 mg tab rapdis, 0.5 mg tab rapdis, 0.5mg tablet, 1 mg tab rapdis, 1 mg tablet, 2 mg tab rapdis, 2 mg tablet)
1
clorazepate dipotassium 1
diazepam (2 mg tablet, 5 mg tablet, 5 mg/5 ml solution, 5 mg/ml oral conc, 10mg tablet)
1
KLONOPIN 3
lorazepam (0.5 mg tablet, 1 mg tablet, 2 mg tablet, 2 mg/ml oral conc) 1
LORAZEPAM INTENSOL 1
oxazepam 1
TRANXENE T-TAB 3
VALIUM 3
XANAX 3
XANAX XR 3
BIPOLAR AGENTS
MOOD STABILIZERS
EQUETRO 3
lithium carbonate 1
lithium citrate 1
LITHOBID 3
PAGE 57 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
BLOOD GLUCOSE REGULATORS
DIABETIC BENEFIT and/or DME BENEFIT APPLIES. Please refer to member contract for copayment amount. If Diabetic BenefitDOES NOT apply please refer to the following tier classifications:
ANTIDIABETIC AGENTS
acarbose 1
ACTOPLUS MET 3
ACTOPLUS MET XR (15-1,000 MG TB, 30-1,000 MG TB) 3 QL
ACTOS 3
ADLYXIN 3 QL
ALOGLIPTIN BENZOATE 3
QL
ST
ALOGLIPTIN BENZOATE/METFORMIN HCL 3
QL
ST
ALOGLIPTIN BENZOATE/PIOGLITAZONE HCL 3
QL
ST
AMARYL 3
AVANDIA 3
BYDUREON 2 QL
BYDUREON BCISE 2 QL
BYDUREON PEN 2 QL
BYETTA (5 MCG PEN INJ, 10 MCG PEN INJ) 2 QL
CHLORPROPAMIDE 3
CYCLOSET 3 QL
DIABETA 3
DUETACT 3 QL
FARXIGA 2
FORTAMET 3 ST
glimepiride 1
glipizide (2.5 mg tab er 24, 5 mg tab er 24, 5 mg tablet, 10 mg tab er 24, 10 mgtablet)
1
glipizide/metformin hcl 1
GLUCOPHAGE 3
PAGE 58 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
GLUCOPHAGE XR 3
GLUCOTROL 3
GLUCOTROL XL 3
GLUCOVANCE 3
GLUMETZA 3 ST
glyburide 1
glyburide,micronized 1
glyburide/metformin hcl 1
GLYNASE 3
GLYSET 3
GLYXAMBI 3 QL
INVOKAMET (50-1,000 MG TABLET, 150-1,000 MG TABLET, 150-500 MGTABLET)
2
INVOKAMET 50-500 MG TABLET 2 QL
INVOKAMET XR 2
INVOKANA (100 MG TABLET, 300 MG TABLET) 2 QL
JANUMET 2 QL
JANUMET XR (50-1,000 MG TABLET, 50-500 MG TABLET, 100-1,000 MGTABLET)
2 QL
JANUVIA 2 QL
JARDIANCE 10 MG TABLET 3 QL
JARDIANCE 25 MG TABLET 3
JENTADUETO 2 QL
JENTADUETO XR (2.5 MG, 5 MG TB) 2 QL
KAZANO 3
QL
ST
KOMBIGLYZE XR (2.5-1,000 MG TAB, 5-1,000 MG TAB, 5-500 MG TABLET) 3
QL
ST
metformin er 500mg & 1000mg tab (generic version of glumetza) 1 ST
metformin hcl (500 mg tab er 24h, 500 mg tablet, 750 mg tab er 24h, 850 mgtablet, 1000 mg tablet)
1
metformin hcl 1000 mg tab er 24 1 ST
metformin hcl 500 mg tab er 24 1
PAGE 59 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
metformin hcl 500 mg/5ml solution 3
miglitol 1
nateglinide 1
NESINA 3
QL
ST
ONGLYZA 3
QL
ST
OSENI 3
QL
ST
OZEMPIC (0.25-0.5 MG PEN, 1 MG PEN) 2 QL
pioglitazone hcl 1
pioglitazone hcl/glimepiride 1 QL
pioglitazone hcl/metformin hcl 1
PRANDIN 3
PRECOSE 3
QTERN 3 QL
repaglinide 1
REPAGLINIDE/METFORMIN 3
RIOMET 3
SEGLUROMET 2 QL
STARLIX 3
STEGLATRO 2 QL
STEGLUJAN 3 QL
SYMLINPEN 120 3
SYMLINPEN 60 3
SYNJARDY 3
SYNJARDY XR (5-1,000 MG TABLET, 10-1,000 MG TABLET, 12.5-1,000 MGTAB, 25-1,000 MG TABLET)
3 QL
TANZEUM 30 MG PEN INJECT 3 QL
TANZEUM 50 MG PEN INJECT 3
tolazamide 1
tolbutamide 1
PAGE 60 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
TRADJENTA 2 QL
TRULICITY 2 QL
VICTOZA 2-PAK 2 QL
VICTOZA 3-PAK 2 QL
XIGDUO XR (2.5 MG-1,000 MG TAB, 5 MG-1,000 MG TABLET, 5 MG-500 MGTABLET, 10 MG-1,000 MG TAB, 10 MG-500 MG TABLET)
2 QL
BLOOD GLUCOSE SUPPLIES
Lifescan and Abbott are preferred test meters/strips and Step Therapy applies prior to all other meters and strips.
FREESTYLE FREEDOM LITE METER 2
FREESTYLE INSULINX GLUCOSE SYS 2
FREESTYLE INSULINX TEST STRIPS 2 QL
FREESTYLE LITE METER 2
FREESTYLE LITE TEST STRIPS 2 QL
FREESTYLE PREC NEO TEST STRIPS 2 QL
FREESTYLE PRECISION NEO METER 2
FREESTYLE TEST STRIPS 2 QL
ONETOUCH ULTRA TEST STRIP 2 QL
ONETOUCH ULTRA2 GLUCOSE SYST 2
ONETOUCH ULTRAMINI METER 2
ONETOUCH VERIO FLEX SYSTEM KIT 2
ONETOUCH VERIO IQ SYSTEM KIT 2
ONETOUCH VERIO METER SYSTEM 2
ONETOUCH VERIO SYNC SYST KIT 2
ONETOUCH VERIO TEST STRIP 2 QL
PRECISION XTRA MONITOR 2
PRECISION XTRA TEST STRIPS 2 QL
GLYCEMIC AGENTS
GLUCAGEN 1 MG HYPOKIT 2
GLUCAGON EMERGENCY KIT 2 QL
PROGLYCEM 3
PAGE 61 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
INSULINS
ADMELOG 3
ADMELOG SOLOSTAR 3
AFREZZA 3
APIDRA 3
APIDRA SOLOSTAR 3
BASAGLAR KWIKPEN U-100 3
FIASP 3
FIASP FLEXTOUCH 3
HUMALOG 2
HUMALOG JUNIOR KWIKPEN 2
HUMALOG KWIKPEN U-100 2
HUMALOG KWIKPEN U-200 2
HUMALOG MIX 50-50 2
HUMALOG MIX 50-50 KWIKPEN 2
HUMALOG MIX 75-25 2
HUMALOG MIX 75-25 KWIKPEN 2
HUMULIN 70-30 2
HUMULIN 70/30 KWIKPEN 2
HUMULIN N 2
HUMULIN N KWIKPEN 2
HUMULIN R 2
HUMULIN R U-500 2
HUMULIN R U-500 KWIKPEN 2
LANTUS 2
LANTUS SOLOSTAR 2
LEVEMIR 2
LEVEMIR FLEXTOUCH 2
NOVOLIN 70-30 2
NOVOLIN 70-30 FLEXPEN 2
NOVOLIN N 2
NOVOLIN R 2
NOVOLOG 2
PAGE 62 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
NOVOLOG FLEXPEN 2
NOVOLOG MIX 70-30 2
NOVOLOG MIX 70-30 FLEXPEN 2
SOLIQUA 100-33 3 QL
TOUJEO MAX SOLOSTAR 2
TOUJEO SOLOSTAR 2
TRESIBA FLEXTOUCH U-100 2
TRESIBA FLEXTOUCH U-200 2
XULTOPHY 100-3.6 3 QL
BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS
ANTICOAGULANTS
ARIXTRA 3 S
BEVYXXA 3 QL
COUMADIN 2
ELIQUIS (2.5 MG TABLET, 5 MG TABLET) 2 QL
ELIQUIS 5 MG STARTER PACK 2 QL
enoxaparin sodium 1 S
fondaparinux sodium 1 S
FRAGMIN 3 S
IPRIVASK 3 S
JANTOVEN 1
LOVENOX 3 S
PRADAXA (75 MG CAPSULE, 150 MG CAPSULE) 3
QL
ST
PRADAXA 110 MG CAPSULE 3 ST
SAVAYSA 3
QL
ST
warfarin sodium 1
XARELTO (2.5 MG TABLET, 10 MG TABLET, 15 MG TABLET, 20 MGTABLET)
2 QL
XARELTO STARTER PACK 2
PAGE 63 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ZONTIVITY 3
QL
PA
BLOOD FORMATION MODIFIERS
AGRYLIN 3
anagrelide hcl 1
ARANESP 2
S
MS
DOPTELET 3
QL
PA
S
MS
EPOGEN 2
S
MS
FULPHILA 3
QL
S
MS
GRANIX (300 MCG/0.5 ML SAFE SYR, 300 MCG/0.5 ML SYRINGE, 480MCG/0.8 ML SAFE SYR, 480 MCG/0.8 ML SYRINGE)
3
QL
PA
S
MS
LEUKINE 3
QL
S
MS
MOZOBIL 3
QL
PA
S
MS
MULPLETA 3
QL
PA
S
MS
NEULASTA 3
QL
S
MS
PAGE 64 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
NEUPOGEN (300 MCG/0.5 ML SYR, 300 MCG/ML VIAL, 480 MCG/0.8 MLSYR, 480 MCG/1.6 ML VIAL)
3
QL
PA
S
MS
NIVESTYM 3
PA
S
MS
PROCRIT 2
S
MS
PROMACTA 3
QL
PA
S
MS
RETACRIT 3
S
MS
TAVALISSE 3
QL
PA
S
ZARXIO 2
S
MS
HEMOSTASIS AGENTS
AMICAR (0.25 GRAM/ML ORAL SOLN, 500 MG TABLET, 1,000 MG TABLET) 3
aminocaproic acid (250 mg/ml solution, 500 mg tablet) 1
aminocaproic acid 1000 mg tablet 3
LYSTEDA 3 QL
MEPHYTON 3
phytonadione (vit k1) 5 mg tablet 1
tranexamic acid 650 mg tablet 1 QL
PLATELET MODIFYING AGENTS
ASPIRIN/DIPYRIDAMOLE 3
BRILINTA 60 MG TABLET 2
BRILINTA 90 MG TABLET 2 QL
PAGE 65 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
cilostazol 1
clopidogrel bisulfate 300 mg tablet 1
clopidogrel bisulfate 75 mg tablet 1 QL
dipyridamole (25 mg tablet, 50 mg tablet, 75 mg tablet) 1
EFFIENT (5 MG TABLET, 10 MG TABLET) 3 QL
PERSANTINE 3
PLAVIX 300 MG TABLET 3
PLAVIX 75 MG TABLET 3 QL
PLETAL 3
prasugrel hcl (5 mg tablet, 10 mg tablet) 1 QL
ticlopidine hcl 1
CARDIOVASCULAR AGENTS
ALPHA-ADRENERGIC AGONISTS
CATAPRES 3
CATAPRES-TTS 3 QL
clonidine (0.1mg/24hr patch tdwk, 0.2mg/24hr patch tdwk, 0.3mg/24hr patchtdwk)
1 QL
clonidine hcl (0.1 mg tablet, 0.2 mg tablet, 0.3 mg tablet) 1
guanfacine hcl (1 mg tablet, 2 mg tablet) 1
methyldopa 1
midodrine hcl 1
NORTHERA 3
QL
PA
S
MS
TENEX 3
ALPHA-ADRENERGIC BLOCKING AGENTS
CARDURA 3
DIBENZYLINE 3
doxazosin mesylate 1
MINIPRESS 3
phenoxybenzamine hcl 1
PAGE 66 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
prazosin hcl 1
terazosin hcl 1
ANGIOTENSIN II RECEPTOR ANTAGONISTS
ATACAND 3
AVAPRO 3
BENICAR 3
candesartan cilexetil 1
COZAAR 3
DIOVAN 3
EDARBI 3 ST
eprosartan mesylate 1
irbesartan 1
losartan potassium 1
MICARDIS 3
olmesartan medoxomil 1
telmisartan 1
valsartan 1
ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS
ACCUPRIL 3
ACEON 3
ALTACE 3
benazepril hcl 1
captopril 1
enalapril maleate 1
EPANDED SOLUTION 3 PA
fosinopril sodium 1
lisinopril 1
LOTENSIN 3
MAVIK 3
moexipril hcl 1
perindopril erbumine 1
PRINIVIL 3
PAGE 67 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
QBRELIS 3
QL
PA
quinapril hcl 1
ramipril 1
trandolapril 1
VASOTEC 3
ZESTRIL 3
ANTIARRHYTHMICS
amiodarone hcl (100 mg tablet, 200 mg tablet, 400 mg tablet) 1
BETAPACE 3
BETAPACE AF 3
CORDARONE 3
disopyramide phosphate 1
dofetilide 1
flecainide acetate 1
mexiletine hcl 1
MULTAQ 2 QL
NORPACE 3
NORPACE CR 3
PACERONE 1
propafenone hcl 1
quinidine gluconate 324 mg tablet er 1
quinidine sulfate 1
RYTHMOL 3
RYTHMOL SR 3
SORINE 1
sotalol hcl (80 mg tablet, 120 mg tablet, 160 mg tablet, 240 mg tablet) 1
SOTYLIZE 3 PA
TIKOSYN 3
BETA-ADRENERGIC BLOCKING AGENTS
acebutolol hcl 1
atenolol 1
PAGE 68 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
betaxolol hcl (10 mg tablet, 20 mg tablet) 1
bisoprolol fumarate 1
BYSTOLIC 3
carvedilol 1
carvedilol phosphate 1 QL
COREG 3
COREG CR 3 QL
CORGARD 3
INDERAL LA 3
INDERAL XL 3
INNOPRAN XL 3
KAPSPARGO SPRINKLE 3
labetalol hcl (100 mg tablet, 200 mg tablet, 300 mg tablet) 1
LEVATOL 3
LOPRESSOR (50 MG TABLET, 100 MG TABLET) 3
metoprolol succinate 1
metoprolol tartrate (25 mg tablet, 37.5 mg tablet, 50 mg tablet, 75 mg tablet,100 mg tablet)
1
nadolol 1
pindolol 1
propranolol hcl (10 mg tablet, 20 mg tablet, 20 mg/5 ml solution, 40 mg tablet,40mg/5ml solution, 60 mg cap sa 24h, 60 mg tablet, 80 mg cap sa 24h, 80 mgtablet, 120 mg cap sa 24h, 160 mg cap sa 24h)
1
SECTRAL 3
TENORMIN 3
timolol maleate (5 mg tablet, 10 mg tablet, 20 mg tablet) 1
TOPROL XL 3
ZEBETA 3
CALCIUM CHANNEL BLOCKING AGENTS
ADALAT CC 3
AFEDITAB CR 1
amlodipine besylate 1
CALAN 3
CALAN SR 3
PAGE 69 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
CARDIZEM 3
CARDIZEM CD 3
CARDIZEM LA 3
CARTIA XT 1
DILT-XR 1
diltiazem hcl (30 mg tablet, 60 mg cap er 12h, 60 mg tablet, 90 mg cap er 12h,90 mg tablet, 120 mg cap er 12h, 120 mg cap er 24h, 120 mg cap er deg, 120mg cap sa 24h, 120 mg tablet, 180 mg cap er 24h, 180 mg cap er deg, 180 mgcap sa 24h, 180 mg tab er 24h, 240 mg cap er 24h, 240 mg cap er deg, 240 mgcap sa 24h, 240 mg tab er 24h, 300 mg cap er 24h, 300 mg cap sa 24h, 300mg tab er 24h, 360 mg cap er 24h, 360 mg cap sa 24h, 360 mg tab er 24h, 420mg cap sa 24h, 420 mg tab er 24h)
1
felodipine 1
isradipine 1
MATZIM LA 1
nicardipine hcl (20 mg capsule, 30 mg capsule) 1
NIFEDICAL XL 1
nifedipine 1
nimodipine 1
nisoldipine 1 QL
NORVASC 3
NYMALIZE (30 MG/10 ML SOLUTION, 60 MG/20 ML SOLUTION) 3 QL
PROCARDIA 3
PROCARDIA XL 3
SULAR 3 QL
TAZTIA XT 1
TIAZAC 3
verapamil hcl 1
VERELAN 3
VERELAN PM 3
CARDIOVASCULAR AGENTS, OTHER
ACCURETIC 3
ALDACTAZIDE 3
amiloride hcl/hydrochlorothiazide 1
amlodipine besylate/atorvastatin calcium 1 QL
PAGE 70 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
amlodipine besylate/benazepril hcl 1
amlodipine besylate/olmesartan medoxomil 1 QL
amlodipine besylate/valsartan 1
QL
PA
amlodipine besylate/valsartan/hydrochlorothiazide 1
QL
PA
ATACAND HCT 3
atenolol/chlorthalidone 1
AVALIDE 3
AZOR 3 QL
benazepril hcl/hydrochlorothiazide 1
BENICAR HCT 3
BIDIL 3 QL
bisoprolol fumarate/hydrochlorothiazide 1
BYVALSON 3 QL
CADUET 3 QL
candesartan cilexetil/hydrochlorothiazide 1
captopril/hydrochlorothiazide 1
CLORPRES (0.1-15 TABLET, 0.2-15 TABLET) 1
CLORPRES 0.3-15 TABLET 3
CORLANOR 3 QL
CORZIDE 3
DEMSER 3
DIGITEK 1
DIGOX 1
digoxin (50 mcg/ml solution, 125 mcg tablet, 250 mcg tablet) 1
DIOVAN HCT 3
DUTOPROL 3 QL
DYAZIDE 3
EDARBYCLOR 3 ST
enalapril maleate/hydrochlorothiazide 1
PAGE 71 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ENTRESTO 3
QL
ST
EXFORGE 3 QL
EXFORGE HCT 3 QL
fosinopril sodium/hydrochlorothiazide 1
HYZAAR 3
irbesartan/hydrochlorothiazide 1
isoxsuprine hcl 1
LANOXIN (62.5 MCG TABLET, 125 MCG TABLET, 187.5 MCG TABLET, 250MCG TABLET)
2
lisinopril/hydrochlorothiazide 1
LOPRESSOR HCT 3
losartan potassium/hydrochlorothiazide 1
LOTENSIN HCT 3
LOTREL 3
MAXZIDE 3
MAXZIDE-25 MG 3
methyldopa/hydrochlorothiazide 1
METOPROLOL SUCCINATE/HYDROCHLOROTHIAZIDE 3 QL
metoprolol tartrate/hydrochlorothiazide 1
MICARDIS HCT 3
moexipril hcl/hydrochlorothiazide 1
nadolol/bendroflumethiazide 1
olmesartan medoxomil/amlodipine besylate/hydrochlorothiazide 1 QL
olmesartan medoxomil/hydrochlorothiazide 1
pentoxifylline 1
PRESTALIA (7 MG-5 MG TABLET, 14 MG-10 MG TABLET) 3 QL
PRESTALIA 3.5 MG-2.5 MG TABLET 3
propranolol hcl/hydrochlorothiazide 1
quinapril hcl/hydrochlorothiazide 1
RANEXA (ER 500 MG TABLET, ER 1,000 MG TABLET) 3 QL
RESERPINE 3
PAGE 72 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
spironolactone/hydrochlorothiazide 1
TARKA 3 QL
TEKTURNA 3 QL
TEKTURNA HCT 3 QL
telmisartan/amlodipine besylate 1 QL
telmisartan/hydrochlorothiazide 1
TENORETIC 100 3
TENORETIC 50 3
trandolapril/verapamil hcl 1 QL
triamterene/hydrochlorothiazide 1
TRIBENZOR 3 QL
TWYNSTA 3 QL
valsartan/hydrochlorothiazide 1
VASERETIC 3
VECAMYL 3
ZESTORETIC 3
ZIAC 3
DIURETICS, CARBONIC ANHYDRASE INHIBITORS
acetazolamide 1
DIAMOX SEQUELS 3
KEVEYIS 3
PA
S
DIURETICS, LOOP
bumetanide (0.5 mg tablet, 1 mg tablet, 2 mg tablet) 1
DEMADEX 3
EDECRIN 3
ethacrynic acid 1
furosemide (10 mg/ml solution, 20 mg tablet, 40 mg tablet, 40mg/5ml solution,80 mg tablet)
1
LASIX 3
torsemide 1
PAGE 73 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
DIURETICS, POTASSIUM-SPARING
ALDACTONE 3
amiloride hcl 1
CAROSPIR 3 QL
DYRENIUM 3
eplerenone 1
INSPRA 3
spironolactone 1
DIURETICS, THIAZIDE
chlorothiazide 1
chlorthalidone 1
DIURIL 3
hydrochlorothiazide 1
indapamide 1
methyclothiazide 1
metolazone 1
MICROZIDE 3
DYSLIPIDEMICS, FIBRIC ACID DERIVATIVES
ANTARA 3
fenofibrate (40 mg tablet, 120 mg tablet, 160 mg tablet) 1 QL
fenofibrate (50 mg capsule, 54 mg tablet, 150 mg capsule) 1
fenofibrate nanocrystallized (48 mg tablet, 145mg tablet) 1 QL
fenofibrate,micronized 1
fenofibric acid 1
fenofibric acid (choline) 1 QL
FENOGLIDE 3 QL
FIBRICOR 3
gemfibrozil 1
LIPOCHOL PLUS 3
LIPOFEN 3
LOFIBRA (67 MG CAPSULE, 134 MG CAPSULE, 200 MG CAPSULE) 3
LOFIBRA 160 MG TABLET 3 QL
PAGE 74 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
LOFIBRA 54 MG TABLET 3
LOPID 3
TRICOR (48 MG TABLET, 145 MG TABLET) 3 QL
TRIGLIDE 3 QL
TRILIPIX 3 QL
DYSLIPIDEMICS, HMG COA REDUCTASE INHIBITORS
ALTOPREV 3 QL
atorvastatin calcium 1
CRESTOR (5 MG TABLET, 10 MG TABLET, 20 MG TABLET, 40 MG TABLET) 3 QL
FLOLIPID 3
fluvastatin sodium 1 QL
LESCOL 3 QL
LESCOL XL 3 QL
LIPITOR 3
LIVALO 3
QL
ST
lovastatin (10 mg tablet, 20 mg tablet) 1
lovastatin 40 mg tablet 1 QL
PRAVACHOL 3
pravastatin sodium 1
rosuvastatin calcium (5 mg tablet, 10 mg tablet, 20 mg tablet, 40 mg tablet) 1 QL
simvastatin (5 mg tablet, 10 mg tablet, 20 mg tablet, 40 mg tablet, 80 mg tablet) 1 QL
ZOCOR (5 MG TABLET, 10 MG TABLET, 20 MG TABLET, 40 MG TABLET, 80MG TABLET)
3 QL
ZYPITAMAG 3 ST
DYSLIPIDEMICS, OTHER
cholestyramine (with sugar) (4 g powd pack, 4 g powder) 1
cholestyramine/aspartame (cholestyramine/aspartame 4 g powd pack,cholestyramine/aspartame 4 g powder)
1
colesevelam hcl 1
COLESTID (1 GM TABLET, FLAVORED GRANULES, GRANULES,GRANULES PACKET)
3
colestipol hcl 1
PAGE 75 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ezetimibe 1
ezetimibe/simvastatin 1
JUXTAPID 3
QL
PA
S
KYNAMRO 3
PA
S
MS
LOVAZA 3 QL
niacin (500 mg tab er 24h, 750 mg tab er 24h, 1000 mg tab er 24h) 1 QL
NIACOR 3
NIASPAN (ER 500 MG TABLET, ER 750 MG TABLET, ER 1,000 MG TABLET) 3 QL
omega-3 acid ethyl esters 1 QL
PRALUENT 2
QL
PA
S
MS
PREVALITE (PACKET, POWDER) 1
QUESTRAN (PACKET, POWDER) 3
QUESTRAN LIGHT 3
REPATHA 2
QL
PA
S
MS
VASCEPA 0.5 GM CAPSULE 3
VASCEPA 1 GM CAPSULE 3 QL
VYTORIN 3
WELCHOL 3
ZETIA 3
VASODILATORS, DIRECT-ACTING ARTERIAL
hydralazine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet, 100 mg tablet) 1
minoxidil (2.5 mg tablet, 10 mg tablet) 1
PAGE 76 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
VASODILATORS, DIRECT-ACTING ARTERIAL/VENOUS
DILATRATE-SR 3
GONITRO 3 PA
ISORDIL 3
ISORDIL TITRADOSE 3
isosorbide dinitrate 1
isosorbide mononitrate (10 mg tablet, 20 mg tablet) 1
isosorbide mononitrate (30 mg tab er 24h, 60 mg tab er 24h, 120 mg tab er24h)
1
MINITRAN 1
NITRO-BID 3
NITRO-DUR 3
NITRO-TIME 1
nitroglycerin (0.1mg/hr patch td24, 0.2mg/hr patch td24, 0.4mg/hr patch td24,0.6mg/hr patch td24, 2.5 mg capsule er, 6.5 mg capsule er, 9 mg capsule er)
1
nitroglycerin (0.3 mg tab subl, 0.4 mg tab subl, 0.6 mg tab subl) 1
nitroglycerin 400mcg/spr spray 1
QL
PA
NITROLINGUAL 3 QL
NITROMIST 3
QL
PA
NITROSTAT 3
CENTRAL NERVOUS SYSTEM AGENTS
ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, AMPHETAMINES
ADDERALL 3
ADDERALL XR (5 MG CAPSULE, 10 MG CAPSULE, 15 MG CAPSULE, 20MG CAPSULE, 25 MG CAPSULE, 30 MG CAPSULE)
3 QL
ADZENYS ER 3
QL
PA
ADZENYS XR-ODT 3
QL
PA
amphetamine sulfate 1
DESOXYN 3
DEXEDRINE (SPANSULE 5 MG, SPANSULE 10 MG, SPANSULE 15 MG) 3
PAGE 77 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
DEXEDRINE 10 MG TABLET 1
dextroamphetamine sulf-saccharate/amphetamine sulf-aspartate(dextroamphetamine/amphetamine 5 mg cap er 24h,dextroamphetamine/amphetamine 10 mg cap er 24h,dextroamphetamine/amphetamine 15 mg cap er 24h,dextroamphetamine/amphetamine 20 mg cap er 24h,dextroamphetamine/amphetamine 25 mg cap er 24h,dextroamphetamine/amphetamine 30 mg cap er 24h)
1 QL
dextroamphetamine sulf-saccharate/amphetamine sulf-aspartate(dextroamphetamine/amphetamine 5 mg tablet,dextroamphetamine/amphetamine 7.5 mg tablet,dextroamphetamine/amphetamine 10 mg tablet,dextroamphetamine/amphetamine 12.5 mg tablet,dextroamphetamine/amphetamine 15 mg tablet,dextroamphetamine/amphetamine 20 mg tablet,dextroamphetamine/amphetamine 30 mg tablet)
1
dextroamphetamine sulfate (5 mg capsule er, 5 mg tablet, 5 mg/5 ml solution,10 mg capsule er, 10 mg tablet, 15 mg capsule er)
1
DYANAVEL XR 3
QL
PA
EVEKEO 3
methamphetamine hcl 1
MYDAYIS 3
QL
ST
PROCENTRA 3
VYVANSE 2 QL
ZENZEDI (2.5 MG TABLET, 7.5 MG TABLET, 15 MG TABLET, 20 MGTABLET, 30 MG TABLET)
3
ZENZEDI (5 MG TABLET, 10 MG TABLET) 1
ATTENTION DEFICIT HYPERACTIVITY DISORDER AGENTS, NON-AMPHETAMINES
APTENSIO XR (10 MG CAPSULE, 15 MG CAPSULE, 20 MG CAPSULE, 30MG CAPSULE, 40 MG CAPSULE, 50 MG CAPSULE, 60 MG CAPSULE)
3
QL
ST
atomoxetine hcl 1
clonidine hcl 0.1 mg tab er 12h 1 QL
CONCERTA 3 QL
COTEMPLA XR-ODT 3
QL
PA
DAYTRANA 3
QL
ST
dexmethylphenidate hcl (2.5 mg tablet, 5 mg tablet, 10 mg tablet) 1
PAGE 78 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
dexmethylphenidate hcl (5 mg cpbp 50-50, 10 mg cpbp 50-50, 15 mg cpbp 50-50, 20 mg cpbp 50-50, 25 mg cpbp 50-50, 30 mg cpbp 50-50, 35 mg cpbp 50-50, 40 mg cpbp 50-50)
1 QL
FOCALIN 3
FOCALIN XR (5 MG CAPSULE, 10 MG CAPSULE, 15 MG CAPSULE, 20 MGCAPSULE, 25 MG CAPSULE, 30 MG CAPSULE, 35 MG CAPSULE, 40 MGCAPSULE)
3 QL
guanfacine hcl (1 mg tab er 24h, 2 mg tab er 24h, 3 mg tab er 24h, 4 mg tab er24h)
1 QL
INTUNIV (ER 1 MG TABLET, ER 2 MG TABLET, ER 3 MG TABLET, ER 4 MGTABLET)
3 QL
KAPVAY 3 QL
METADATE CD (10 MG CAPSULE, 20 MG CAPSULE, 30 MG CAPSULE, 40MG CAPSULE, 50 MG CAPSULE, 60 MG CAPSULE)
3 QL
METADATE ER 1
METHYLIN (2.5 MG CHEWABLE TAB, 5 MG CHEWABLE TABLET, 5 MG/5ML SOLUTION, 10 MG CHEWABLE TABLET, 10 MG/5 ML SOLUTION)
3
methylphenidate hcl (10 mg cpbp 30-70, 10 mg cpbp 50-50, 20 mg cpbp 30-70,20 mg cpbp 50-50, 30 mg cpbp 30-70, 30 mg cpbp 50-50, 40 mg cpbp 30-70,40 mg cpbp 50-50)
1 QL
methylphenidate hcl (18 mg tab er 24, 27 mg tab er 24, 36 mg tab er 24, 50 mgcpbp 30-70, 54 mg tab er 24, 60 mg cpbp 30-70, 60 mg cpbp 50-50)
1 QL
methylphenidate hcl (2.5 mg tab chew, 5 mg tab chew, 5 mg tablet, 5 mg/5 mlsolution, 10 mg tab chew, 10 mg tablet, 10 mg tablet er, 10 mg/5 ml solution, 20mg tablet, 20 mg tablet er)
1
methylphenidate hcl 72 mg tab er 24 3 QL
QUILLICHEW ER (ER 20 MG CHEW TAB, ER 30 MG CHEW TAB, ER 40 MGCHEW TAB)
3
QL
PA
QUILLIVANT XR 3
QL
PA
RELEXXII 3 QL
RITALIN 3
RITALIN LA (10 MG CAPSULE, 20 MG CAPSULE, 30 MG CAPSULE, 40 MGCAPSULE, 60 MG CAPSULE)
3 QL
STRATTERA 3
CENTRAL NERVOUS SYSTEM, OTHER
ADIPEX-P 3
ALLZITAL 3
AUSTEDO (6 MG TABLET, 9 MG TABLET, 12 MG TABLET) 3
QL
PA
S
MS
PAGE 79 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
BELVIQ 3
QL
PA
BELVIQ XR 3
QL
PA
benzphetamine hcl 1
BONTRIL PDM 3
BUPAP 3 QL
butalbital/acetaminophen (butalbital/acetaminophen capsule,butalbital/acetaminophen tablet)
1 QL
butalbital/acetaminophen 50mg-325mg tablet 1
butalbital/acetaminophen/caffeine 1
CAPACET 1
CONTRAVE 3
QL
PA
diethylpropion hcl 1
ESGIC 50-325-40 MG TABLET 3
ESGIC CAPSULE 1
FIORICET 3
HORIZANT (ER 300 MG TABLET, ER 600 MG TABLET) 3
QL
PA
INGREZZA 3
QL
PA
S
LOMAIRA 3
MARTEN-TAB 1
NUEDEXTA 3
QL
PA
phendimetrazine tartrate 1
phentermine hcl 1
QSYMIA (3.75 MG-23 MG CAPSULE, 7.5 MG-46 MG CAPSULE, 11.25 MG-69MG CAPSULE, 15 MG-92 MG CAPSULE)
3
QL
PA
REGIMEX 3
RILUTEK 3
PAGE 80 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
riluzole 1
SUPRENZA ODT 3
QL
PA
TEGSEDI 3
QL
PA
S
MS
TENCON 3
tetrabenazine (12.5 mg tablet, 25 mg tablet) 1
QL
PA
S
MS
TIGLUTIK 3 QL
VANATOL LQ 3
XENAZINE (12.5 MG TABLET, 25 MG TABLET) 3
QL
S
MS
ZEBUTAL 1
FIBROMYALGIA AGENTS
CYMBALTA (20 MG CAPSULE, 30 MG CAPSULE, 60 MG CAPSULE) 3 QL
duloxetine hcl (20 mg capsule dr, 30 mg capsule dr, 60 mg capsule dr) 1 QL
duloxetine hcl 40 mg capsule dr 1
IRENKA 3
LYRICA (25 MG CAPSULE, 50 MG CAPSULE, 75 MG CAPSULE, 100 MGCAPSULE, 150 MG CAPSULE, 200 MG CAPSULE, 225 MG CAPSULE, 300MG CAPSULE)
2
LYRICA 20 MG/ML ORAL SOLUTION 2 QL
LYRICA CR (CR 82.5 MG TABLET, CR 165 MG TABLET, CR 330 MGTABLET)
3
QL
PA
SAVELLA (12.5 MG TABLET, 25 MG TABLET, 50 MG TABLET, 100 MGTABLET, TITRATION PACK)
3
QL
ST
PAGE 81 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
MULTIPLE SCLEROSIS AGENTS
AMPYRA 3
QL
PA
S
MS
AUBAGIO 3
QL
ST
S
MS
AVONEX 2
QL
S
MS
BETASERON 3
QL
ST
S
MS
COPAXONE (20 MG/ML SYRINGE, 40 MG/ML SYRINGE) 2
QL
S
MS
dalfampridine 1
QL
PA
S
MS
EXTAVIA 3
PA
S
MS
GILENYA 0.5 MG CAPSULE 2
QL
S
MS
glatiramer acetate (20 mg/ml syringe, 40 mg/ml syringe) 1
QL
S
MS
PAGE 82 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
GLATOPA 20 MG/ML SYRINGE 1
QL
ST
S
MS
GLATOPA 40 MG/ML SYRINGE 1
QL
S
MS
PLEGRIDY 2
QL
S
MS
PLEGRIDY PEN 2
QL
S
MS
REBIF 2
QL
S
MS
TECFIDERA 2
QL
S
MS
ZINBRYTA 3
QL
ST
S
DENTAL AND ORAL AGENTS
cevimeline hcl 1
chlorhexidine gluconate 0.12 % mouthwash 1
EVOXAC 3
ORALONE 1
PAROEX 1
PERIDEX 3
PERIOGARD 1
pilocarpine hcl (5 mg tablet, 7.5 mg tablet) 1
SALAGEN 3
triamcinolone acetonide 0.1 % paste (g) 1
PAGE 83 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
DERMATOLOGICAL AGENTS
8-MOP 3
ABSORICA 3 PA
ACANYA 3
QL
PA
acitretin 1 QL
ACZONE 3
QL
ST
adapalene (0.1 % cream (g), 0.1 % gel (gram), 0.3 % gel (gram), 0.3 % gelw/pump)
1
adapalene 0.1 % solution 1
QL
ST
ADAPALENE 0.1% LOTION 3 ST
adapalene/benzoyl peroxide 1 QL
ALDARA 3
ALEVICYN PLUS 3
ALTRENO 3 QL
AMELUZ 3
ammonium lactate 1
AMNESTEEM 1
ANA-LEX 3
ANALPRAM E 3
ANALPRAM HC (1% CREAM, 2.5%-1% CREAM, 2.5%-1% CRM SINGLE,2.5%-1% LOTION)
3
ATRALIN 3
ATRAPRO DERMAL SPRAY 3
AVAR CLEANSER 1
AVAR-E 3
AVAR-E GREEN 3
AVITA 1
AZELEX 3
BENZACLIN (GEL, GEL 35G PUMP, GEL 50G PUMP) 3 QL
BENZEPRO 6% FOAMING CLOTHS 1 QL
PAGE 84 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
BENZEPRO 7% CREAMY WASH 1
benzoyl peroxide 7 % cleanser 1
BPO (4% GEL, 8% GEL) 1
BPO 6% FOAMING CLOTHS 1 QL
calcipotriene (0.005 % cream (g), 0.005 % oint. (g), 0.005 % solution) 1
calcipotriene/betamethasone dipropionate 1
CALCITRENE 1
CALCITRIOL 3 MCG/G OINTMENT 3
CARAC 3 PA
CLARAVIS 1
clindamycin phos/benzoyl perox 1.2(1)%-5% gel (gram) 1
QL
PA
clindamycin phosphate/benzoyl peroxide (phos/benzoyl 1 % gel (gram),phos/benzoyl 1 % gel w/pump)
1 QL
clindamycin phosphate/tretinoin 1 PA
clotrimazole/betamethasone dipropionate (clotrimazole/betamethasone 1 %cream (g), clotrimazole/betamethasone 1 % lotion)
1
CONDYLOX (GEL, TOPICAL SOLN) 3
CORTISPORIN (CREAM, OINTMENT) 3
COSENTYX 2
QL
PA
ST
S
MS
dapsone 5 % gel (gram) 1 QL
DERMACINRX CLORHEXACIN 3
QL
PA
DERMACINRX LEXITRAL 3
QL
PA
DERMACINRX SURGICAL PHARMAPAK 3
QL
PA
DERMACINRX THERAZOLE PAK 3
QL
PA
PAGE 85 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
DICLO GEL 3
QL
PA
DICLO GEL-XRYLIX SHEET 3
QL
PA
diclofenac sodium 1 % gel (gram) 1 QL
diclofenac sodium 3 % gel (gram) 1 PA
DICLOZOR 3
QL
PA
DIFFERIN (0.1% CREAM, 0.1% GEL, 0.3% GEL, 0.3% GEL PUMP) 3
DIFFERIN 0.1% LOTION 3 ST
DOVONEX 3
DOXEPIN HCL 5 % CREAM (G) 3
DRITHOCREME HP 3
DRYSOL 3
DUAC 3
DUPIXENT 200 MG/1.14 ML SYRING 3
QL
PA
S
MS
ELIDEL 3 QL
ENSTILAR 3
QL
PA
EPIDUO 3 QL
EPIDUO FORTE 3 QL
EPIFOAM 3
EUCRISA 3 ST
FABIOR 3
QL
PA
FINACEA 3
FLUOROPLEX 3
FLUOROURACIL 0.5% CREAM 3 PA
PAGE 86 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
GORDON'S UREA 3
hydrocortisone acetate/iodoquinol/aloe vera 1
hydrocortisone acetate/lidocaine hcl/aloe vera (hydrocortisone/lidocaine/aloe0.55%-2.8% gel w/appl, hydrocortisone/lidocaine/aloe 2 %-2 % kit,hydrocortisone/lidocaine/aloe 2.5-3%(7g) kit)
1
hydrocortisone acetate/pramoxine hcl 1
hydroquinone microspheres 1
imiquimod 3.75 % crm md pmp 3
imiquimod 5 % cream pack 1
lactic acid 10 % lotion 1
LEVULAN 3
LEXIXRYL 3
QL
PA
lidocaine hcl/hydrocortisone acetate (lidocaine/hydrocortisone 3 %-0.5 % cream(g), lidocaine/hydrocortisone 3 %-0.5 % cream/appl, lidocaine/hydrocortisone 3%-0.5 % kit, lidocaine/hydrocortisone 3%-1%(7 g) cream/appl,lidocaine/hydrocortisone 3%-1%(7 g) kit, lidocaine/hydrocortisone 3-2.5%(7g)gel w/appl)
1
LOTRISONE 3
methoxsalen 10 mg cap lq rap 1
METROCREAM 3
METROGEL 3
METROLOTION 3
metronidazole (0.75 % cream (g), 0.75 % gel (gram), 0.75 % lotion, 1 % gel(gram), 1 % gel w/pump)
1
MICORT HC 2.5% CREAM 3
MICROCYN 3
MICROCYN HYDROGEL 3
MYORISAN 1
NATROBA 3
NEO-SYNALAR 0.5%-0.025% CREAM 3
NEUAC GEL 1
NORITATE 3 ST
NOVACORT 3
NUDICLO SOLUPAK 3
QL
PA
NUOX 3
PAGE 87 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ONEXTON GEL PUMP 3
QL
PA
OVACE 3
OVACE PLUS (9.8% FOAM, 10% CREAM, 10% SHAMPOO, 10% WASH) 3
OVACE PLUS WASH 3
OXSORALEN-ULTRA 3
PACNEX 3
PACNEX HP 3
PACNEX LP 3
PICATO (0.015% GEL, 0.05% GEL) 2 QL
PLEXION (CLNSING CLOTH, CREAM, LOTION) 3
PLIXDA 3
QL
ST
podofilox 1
PR BENZOYL PEROXIDE 1
PRAMCORT 1
PRAMOSONE (1% LOTION, 1%-1% CREAM, 1%-1% OINTMENT, 2.5%-1%CREAM, 2.5%-1% LOTION, 2.5%-1% OINTMENT)
3
PRAMOSONE E 3
PROCORT 3
PROCTOFOAM-HC 3
PROTOPIC 3 QL
PRUDOXIN 3
QBREXZA 3
QL
ST
REA LO 39 1
REA LO 40 (40 CM, 40 TION) 1
RECTIV 3 QL
REGRANEX 3 QL
RETIN-A 3
RETIN-A MICRO 3
RETIN-A MICRO PUMP 3
PAGE 88 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ROSADAN (CREAM KIT, GEL KIT) 3
QL
PA
ROSADAN (CREAM, GEL) 1
ROSANIL 3
ROSULA 10%-5% CLOTHS 3
SANTYL 3
SEB-PREV 1
selenium sulfide 1
SELRX 3
SILIQ 3
QL
PA
ST
S
MS
silver nitrate/potassium nitrate 1
SOLARAZE 3 PA
SOOLANTRA 3
QL
ST
SORIATANE 3 QL
SORILUX 3
QL
PA
SPINOSAD 3
SSS 10-5 CREAM 1
STELARA (45 MG/0.5 ML SYRINGE, 90 MG/ML SYRINGE) 2
QL
PA
S
MS
STELARA 45 MG/0.5 ML VIAL 2
PA
S
MS
sulfacetamide sodium (10 % cleanser, 10 % clnsr gel, 10 % shampoo) 1
PAGE 89 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
sulfacetamide sodium/sulfur (sodium/sulfur 9.8%-4.8% cream (g), sodium/sulfur9.8%-4.8% lotion, sodium/sulfur 10-5%(w/v) lotion, sodium/sulfur 10-5%(w/w)cleanser, sodium/sulfur 10-5%(w/w) cream (g), sodium/sulfur 10-5%(w/w) lotion,sodium/sulfur 10-5%(w/w) suspension)
1
TACLONEX 0.005%-0.064% SUSPENS 3
QL
PA
TACLONEX OINTMENT 3
tacrolimus (0.03 % oint. (g), 0.1 % oint. (g)) 1 QL
TALTZ 3
QL
PA
ST
S
MS
tazarotene 1
TAZORAC 3
TOLAK 2
TREMFYA 3
QL
PA
ST
S
MS
TRETIN-X (0.025% CREAM COMB PCK, 0.05% COMBO PACK, 0.1%COMBO PACK)
3
TRETIN-X (0.0375% CREAM, 0.075% CREAM) 3
QL
PA
tretinoin (0.01 % gel (gram), 0.025 % cream (g), 0.025 % gel (gram), 0.05 %cream (g), 0.05 % gel (gram), 0.1 % cream (g))
1
tretinoin microspheres 1
tretinoin/emollient base 1 PA
TRI-CHLOR 1
ULESFIA 3
VECTICAL 3
VELTIN 3 PA
VEREGEN 3
VOLTAREN 3 QL
VYTONE 3
PAGE 90 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
XELITRAL 3
QL
PA
XEPI 3 QL
XRYLIX 3
QL
PA
ZENATANE 1
ZEYOCAINE 3
QL
PA
ZIANA 3 PA
ZITHRANOL-RR 3
ZONALON 3
ZYCLARA (2.5% CREAM PUMP, 3.75% CREAM, 3.75% CREAM PUMP) 3
ZYPRAM 3
ELECTROLYTES/MINERALS/METALS/VITAMINS
ELECTROLYTE/MINERAL REPLACEMENT
CARBAGLU 3
PA
S
MS
CARNITOR (100 MG/ML ORAL SOLN, 330 MG TABLET) 3
CARNITOR SF 3
CLINPRO 5000 1
CYTRA-K CRYSTALS PACKET 1
DENTA 5000 PLUS 1
DENTAGEL 1
EFFER-K (10 TABLET EFF, 20 TABLET EFF) 3
EFFER-K 25 MEQ TABLET EFF 1
ENDARI 3
QL
PA
ICAR-C PLUS 3
K EFFERVESCENT 1
K-SOL 1
K-TAB ER 3
PAGE 91 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
KLOR-CON 10 1
KLOR-CON 20 MEQ PACKET 1
KLOR-CON 25 MEQ PACKET 3
KLOR-CON 8 1
KLOR-CON M10 1
KLOR-CON M15 1
KLOR-CON M20 1
KLOR-CON SPRINKLE 1
KLOR-CON-EF 1
levocarnitine (with sugar) 1
levocarnitine 330 mg tablet 1
NESTABS ONE 3
NUTRESTORE 3 PA
ORACIT 3
potassium bicarbonate/citric acid 1
potassium chloride (8 meq capsule er, 8 meq tablet er, 10 meq capsule er, 10meq tab er prt, 10 meq tablet er, 20 meq packet, 20 meq tab er prt, 20 meqtablet er, 20meq/15ml liquid, 40meq/15ml liquid)
1
potassium chloride/potassium bicarbonate/citric acid 1
potassium citrate 1
potassium citrate/citric acid 3300-1002 packet 1
PREVIDENT (0.2%, DENTAL) 1
PREVIDENT (1.1% GEL, 5000 BOOSTER PLUS) 3
PREVIDENT 5000 3
PREVIDENT 5000 ENAMEL PROTECT 3
PREVIDENT 5000 PLUS 3
PREVIDENT 5000 SENSITIVE 3
SF 1
SF 5000 PLUS 1
TL G-FOL OS 1
UROCIT-K 3
ELECTROLYTE/MINERAL/METAL MODIFIERS
CHEMET 3
CUPRIMINE 3 PA
PAGE 92 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
EXJADE 3
S
MS
FERRIPROX (100 MG/ML SOLUTION, 500 MG TABLET) 3 S
GALZIN 3
JADENU 3
S
MS
JYNARQUE 3
QL
PA
S
KAYEXALATE 3
KIONEX (15 GM/60 ML SUSPENSION, POWDER) 1
RADIOGARDASE 3
SAMSCA 3
QL
S
MS
sodium polystyrene sulfonate 1
SPS 1
SYPRINE 3 PA
trientine hcl 1 PA
DEPEN 2
PHOSPHATE BINDERS
AURYXIA 3 QL
calcium acetate 1
ELIPHOS 1
FOSRENOL (500 MG TABLET CHEW, 750 MG TABLET CHEW, 1,000 MGTABLET CHEW)
3 QL
FOSRENOL (750 MG POWDER PACKET, 1,000 MG POWDER PACK) 3
lanthanum carbonate (500 mg tab chew, 750 mg tab chew, 1000 mg tab chew) 1 QL
PHOSLO 3
PHOSLYRA 3
RENAGEL 3
RENVELA 3
PAGE 93 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
sevelamer carbonate (2.4 g powd pack, 800 mg tablet) 1
sevelamer carbonate 0.8 g powd pack 1 QL
VELPHORO 3 QL
VELTASSA 3 ST
VITAMINS
BRAND RX PRENATAL VITAMINS ARE T3 AND GENERIC RX PRENATALVITAMINS ARE T1
3
cyanocobalamin (vitamin b-12) 1000mcg/ml vial 1
ENTERAL FORMULA REQUIRES PRIOR AUTHORIZATION. BRANDS ARETIER 3 & GENERICS ARE TIER 1.
3 PA
folic acid 1 mg tablet 1
NASCOBAL 3
OB COMPLETE PETITE 3
POTABA 3
XURIDEN 3
QL
PA
S
GASTROINTESTINAL AGENTS
ANTISPASMODICS, GASTROINTESTINAL
ANASPAZ 3
BENTYL (10 MG CAPSULE, 20 MG TABLET) 3
chlordiazepoxide/clidinium bromide 1
CUVPOSA 3
QL
PA
dicyclomine hcl (10 mg capsule, 10 mg/5 ml solution, 20 mg tablet) 1
ED-SPAZ 1
GLYCATE 3
QL
PA
glycopyrrolate (1 mg tablet, 2 mg tablet) 1
glycopyrrolate 1.5 mg tablet 1
QL
PA
PAGE 94 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
hyoscyamine sulfate (0.125 mg tab rapdis, 0.125 mg tab subl, 0.125 mg tablet,0.125mg/ml drops, 0.375 mg tab er 12h, 125mcg/5ml elixir)
1
HYOSYNE 1
LEVBID 3
LEVSIN 0.125 MG TABLET 3
LEVSIN-SL 3
LIBRAX 3
methscopolamine bromide 1
NULEV 1
OSCIMIN 1
OSCIMIN SL 1
OSCIMIN SR 1
propantheline bromide 1
ROBINUL 1 MG TABLET 3
ROBINUL FORTE 3
SYMAX 1
SYMAX DUOTAB 3
SYMAX-SL 1
SYMAX-SR 1
GASTROINTESTINAL AGENTS, OTHER
ACTIGALL 3
CHENODAL 3 S
cromolyn sodium 20 mg/ml oral conc 1
diphenoxylate hcl/atropine sulfate (hcl/atropine 2.5-.025/5 liquid, hcl/atropine2.5-.025mg tablet)
1
ENTEREG 3
FULYZAQ 3
QL
PA
GASTROCROM 3
GATTEX 3
QL
PA
S
MS
lansoprazole/amoxicillin trihydrate/clarithromycin 1
PAGE 95 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
LOMOTIL 3
MOTOFEN 3
MOVANTIK 2 QL
MYALEPT 3
PA
S
MS
MYTESI 3
QL
PA
OMECLAMOX-PAK 3
QL
PA
opium tincture 1
paregoric 1
PREVPAC 3
PYLERA 3
RELISTOR (8 MG/0.4 ML SYRINGE, 12 MG/0.6 ML SYRINGE, 12 MG/0.6 MLVIAL, 150 MG TABLET)
3
SYMPROIC 3
QL
ST
URSO 3
URSO FORTE 3
ursodiol 1
XENICAL 3 PA
XIFAXAN 200 MG TABLET 3
XIFAXAN 550 MG TABLET 3 QL
HISTAMINE2 (H2) RECEPTOR ANTAGONISTS
cimetidine 1
cimetidine hcl 1
famotidine (20 mg tablet, 40 mg tablet, 40mg/5ml oral susp) 1
nizatidine (150 mg capsule, 150mg/10ml solution, 300 mg capsule) 1
PEPCID (40 MG TABLET, 40 MG/5 ML ORAL SUSP) 3
ranitidine hcl (15 mg/ml syrup, 150 mg capsule, 150 mg tablet, 300 mg capsule,300 mg tablet)
1
ZANTAC 300 MG TABLET 3
PAGE 96 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
IRRITABLE BOWEL SYNDROME AGENTS
alosetron hcl 1 QL
AMITIZA 3
QL
ST
LINZESS 2 QL
LOTRONEX 3 QL
TRULANCE 3
QL
ST
VIBERZI 3
LAXATIVES
CLENPIQ 3
COLYTE WITH FLAVOR PACKETS 3
CONSTULOSE 1
ENULOSE 1
GAVILYTE-C 1
GAVILYTE-G 1
GAVILYTE-H AND BISACODYL 1
GAVILYTE-N 1
GENERLAC 1
GIALAX 3
GOLYTELY (PACKET, SOLUTION) 3
KRISTALOSE 3 PA
lactulose (10 g/15 ml solution, 20 g/30 ml solution) 1
lactulose 10 g packet 1
QL
PA
MOVIPREP 3 QL
NULYTELY WITH FLAVOR PACKS 3
OSMOPREP 3
peg 3350/sod sulf/sod bicarb/sod chloride/potassium chloride 1
PEG-PREP 1
PLENVU 3
PAGE 97 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
polyethylene glycol 3350 (3350 17g powd pack, 3350 17g/dose powder) 1
PREPOPIK 2
sodium chloride/sodium bicarbonate/potassium chloride/peg 1
SUPREP 2
TRILYTE WITH FLAVOR PACKETS 1
PROTECTANTS
CARAFATE (1 GM TABLET, 1 GM/10 ML SUSP) 3
CYTOTEC 3
misoprostol 1
sucralfate 1
PROTON PUMP INHIBITORS
ACIPHEX 3 QL
ACIPHEX SPRINKLE 3
QL
PA
DEXILANT 3
QL
ST
ESOMEP-EZS 3
QL
PA
esomeprazole magnesium 1 QL
ESOMEPRAZOLE STRONTIUM 3 PA
lansoprazole (15 mg capsule dr, 30 mg capsule dr) 1 QL
lansoprazole (15 mg tab rap dr, 30 mg tab rap dr) 1
QL
ST
NEXIUM 3
QL
ST
omeprazole (10 mg capsule dr, 20 mg capsule dr, 40 mg capsule dr) 1 QL
omeprazole/sodium bicarbonate 1
QL
ST
pantoprazole sodium (20 mg tablet dr, 40 mg tablet dr) 1 QL
PREVACID (30 MG SOLUTAB, DR 30 MG CAPSULE) 3 QL
PRILOSEC 3 QL
PAGE 98 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PROTONIX 3 QL
rabeprazole sodium 1 QL
ZEGERID (20 MG PACKET, 40 MG CAPSULE, 40 MG PACKET) 3
QL
ST
GENETIC OR ENZYME DISORDER: REPLACEMENT, MODIFIERS, TREATMENT
BUPHENYL (500 MG TABLET, POWDER) 3
CERDELGA 3
PA
S
MS
CHOLBAM 3
PA
S
CREON 2
CYSTADANE 3 S
CYSTAGON 2 S
GALAFOLD 3
QL
PA
S
MS
KUVAN 3
PA
S
MS
miglustat 1
QL
PA
S
MS
NITYR 3
PA
S
OCALIVA 3
QL
PA
S
MS
ORFADIN (2 MG CAPSULE, 4 MG/ML SUSPENSION, 5 MG CAPSULE, 10MG CAPSULE, 20 MG CAPSULE)
3
PA
S
PAGE 99 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PALYNZIQ 3
PA
S
MS
PANCREAZE 3
PANCRELIPASE 5,000 1
PERTZYE 3
PROCYSBI (DR 25 MG CAPSULE, DR 75 MG CAPSULE) 3
QL
PA
S
MS
RAVICTI 3
QL
PA
S
MS
sodium phenylbutyrate (0.94 g/g powder, 500 mg tablet) 1
STRENSIQ (18 MG/0.45 ML VIAL, 28 MG/0.7 ML VIAL, 40 MG/ML VIAL, 80MG/0.8 ML VIAL)
3
QL
PA
S
SUCRAID 3
PA
S
MS
ULTRESA 3
VIOKACE 3
ZAVESCA 3
QL
PA
S
MS
ZENPEP 2
GENITOURINARY AGENTS
ANTISPASMODICS, URINARY
darifenacin hydrobromide 1 QL
DETROL 3 QL
PAGE 100 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
DETROL LA 3 QL
DITROPAN XL 3
ENABLEX 3 QL
flavoxate hcl 1
GELNIQUE (3% GEL, 10% GEL PUMP, 10% GEL SACHET, 10% GELSACHETS)
3
QL
ST
MYRBETRIQ 2 QL
oxybutynin chloride (5 mg tab er 24, 5 mg tablet, 5 mg/5 ml syrup, 10 mg tab er24, 15 mg tab er 24)
1
OXYTROL 3 ST
tolterodine tartrate (1 mg tablet, 2 mg cap er 24h, 2 mg tablet, 4 mg cap er 24h) 1 QL
TOVIAZ 2 QL
trospium chloride (20 mg tablet, 60 mg cap er 24h) 1 QL
VESICARE 2 QL
BENIGN PROSTATIC HYPERTROPHY AGENTS
alfuzosin hcl 1 QL
AVODART 3 QL
CARDURA XL 3
CIALIS (2.5 MG TABLET, 5 MG TABLET) 3
QL
ST
dutasteride 1 QL
dutasteride/tamsulosin hcl 1 QL
finasteride 5 mg tablet 1
FLOMAX 3 QL
JALYN 3 QL
PROSCAR 3
RAPAFLO 3
QL
ST
tadalafil (2.5 mg tablet, 5 mg tablet) 1 QL
tamsulosin hcl 1 QL
PAGE 101 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
UROXATRAL 3 QL
GENITOURINARY AGENTS, OTHER
ADDYI 3 PA
bethanechol chloride 1
CAVERJECT 3 QL
CIALIS (10 MG TABLET, 20 MG TABLET) 3
QL
ST
CONCEPTROL 0 C Covered in full
EDEX 3 QL
ELMIRON 3
FEM PH 3
GYNOL II 0 C Covered in full
K-PHOS NO.2 3
K-PHOS ORIGINAL 3
LEVITRA 3
QL
ST
LITHOSTAT 3
MUSE 3 QL
phenazopyridine hcl 1
PYRIDIUM 3
RELAGARD 3
RIMSO-50 3
sildenafil citrate (25 mg tablet, 50 mg tablet, 100 mg tablet) 1 QL
STAXYN 3
QL
ST
STENDRA 3
QL
ST
tadalafil 10 mg tablet 1 QL
tadalafil 20 mg tablet 1
QL
PA
S
MS
PAGE 102 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
THIOLA 3
QL
S
TODAY CONTRACEPTIVE SPONGE 0 C Covered in full
URECHOLINE 3
UROQID-ACID NO.2 3
VCF (FILM, FOAM, GEL) 0 C Covered in full
VIAGRA 3 QL
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL)
ALA-CORT 1
ALA-SCALP 3
alclometasone dipropionate 1
amcinonide (0.1 % cream (g), 0.1 % lotion, 0.1 % oint. (g)) 1
ANUCORT-HC 1
ANUSOL-HC 25 MG SUPPOSITORY 3
APEXICON E 3
betamethasone dipropionate (0.05 % cream (g), 0.05 % gel (gram), 0.05 %lotion, 0.05 % oint. (g))
1
betamethasone dipropionate/propylene glycol (betamethasone/propylene 0.05% cream (g), betamethasone/propylene 0.05 % lotion,betamethasone/propylene 0.05 % oint. (g))
1
betamethasone valerate (0.1 % cream (g), 0.1 % lotion, 0.1 % oint. (g), 0.12 %foam)
1
CAPEX SHAMPOO 3
clobetasol propionate (0.05 % cream (g), 0.05 % foam, 0.05 % gel (gram), 0.05% lotion, 0.05 % oint. (g), 0.05 % shampoo, 0.05 % solution, 0.05 % spray)
1
clobetasol propionate/emollient base (propionate/emoll 0.05 % cream (g),propionate/emoll 0.05 % foam)
1
CLOBEX 3
CLOCORTOLONE PIVALATE 0.1 % CREAM(G) 3 ST
CLODAN 0.05% KIT 3
QL
PA
CLODAN 0.05% SHAMPOO 1
CLODERM 3 ST
CORDRAN (0.025% CREAM, 0.05% CREAM, 0.05% LOTION, 0.05%OINTMENT)
3 ST
CORDRAN (4 MCG/SQ CM TAPE LARGE, 4 MCG/SQ CM TAPE SMALL) 3 QL
CORMAX 1
PAGE 103 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
CORTEF 3
cortisone acetate 1
CUTIVATE (CREAM, LOTION) 3
DECADRON 0.5 MG/5 ML ELIXIR 1
DELTASONE 1
DERMA-SMOOTHE-FS (BODY OIL, SCALP OIL) 3
DERMACINRX CINLONE-I CPI 3
QL
PA
DERMACINRX SILAPAK 3
QL
PA
DERMACINRX SILAZONE 3
QL
PA
DERMATOP 3
DERMAZONE 3
QL
PA
DESONATE 3 ST
desonide (0.05 % cream (g), 0.05 % lotion, 0.05 % oint. (g)) 1
DESOWEN (CREAM, LOTION) 3
desoximetasone (0.05 % cream (g), 0.05 % gel (gram), 0.05 % oint. (g), 0.25 %cream (g), 0.25 % oint. (g), 0.25 % spray)
1
dexamethasone ((21) tab ds pk, (35) tab ds pk, (51) tab ds pk) 1
QL
PA
dexamethasone (0.5 mg tablet, 0.5 mg/5ml elixir, 0.5 mg/5ml solution, 0.75 mgtablet, 1 mg tablet, 1.5 mg tablet, 2 mg tablet, 4 mg tablet, 6 mg tablet)
1
DEXAMETHASONE INTENSOL 3
DIFLORASONE DIACETATE 3
DIPROLENE (LOTION, OINTMENT) 3
DIPROLENE AF 3
ELLZIA PAK 3
QL
PA
ELOCON (CREAM, LOTION, OINTMENT) 3
EMFLAZA (6 MG TABLET, 18 MG TABLET, 22.75 MG/ML ORAL SUSP, 30MG TABLET, 36 MG TABLET)
3
QL
PA
S
PAGE 104 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
fludrocortisone acetate 1
fluocinolone acetonide (0.01 % cream (g), 0.01 % oil, 0.01 % solution, 0.025 %cream (g), 0.025 % oint. (g))
1
fluocinolone acetonide/shower cap 1
fluocinonide (0.05 % cream (g), 0.05 % gel (gram), 0.05 % oint. (g), 0.05 %solution, 0.1 % cream (g))
1
fluocinonide/emollient base 1
flurandrenolide (0.05 % cream (g), 0.05 % lotion, 0.05 % oint. (g)) 1
fluticasone propionate (0.005 % oint. (g), 0.05 % cream (g), 0.05 % lotion) 1
H.P. ACTHAR 3
QL
PA
S
MS
halobetasol propionate 1
HALOG 3 ST
HEMMOREX-HC 1
hydrocortisone (1 % cream (g), 1 % crm/pe app, 1 % oint. (g), 2.5 % cream (g),2.5 % crm/pe app, 2.5 % lotion, 2.5 % oint. (g), 5 mg tablet, 10 mg tablet, 20 mgtablet)
1
hydrocortisone acetate (25 mg supp.rect, 30 mg supp.rect) 1
hydrocortisone butyrate (0.1 % cream (g), 0.1 % oint. (g), 0.1 % solution) 1
hydrocortisone butyrate 0.1 % lotion 1 ST
hydrocortisone butyrate/emoll 0.1 % cream (g) 1
hydrocortisone valerate 1
hydrocortisone/mineral oil/petrolatum,white 1
IMPOYZ 3 ST
KENALOG 3 ST
KORLYM 3
QL
PA
S
LOCOID (CREAM, LOTION, OINTMENT, SOLUTION) 3 ST
LOCOID LIPOCREAM 3 ST
LUXIQ 3
MEDROL 3
methylprednisolone 1
PAGE 105 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
MICORT-HC 2.5% CREAM 3
MIFEPREX 3
MILLIPRED (5 MG TABLET, 10 MG/5 ML SOLUTION) 3
MILLIPRED DP 3
mometasone furoate (0.1 % cream (g), 0.1 % oint. (g), 0.1 % solution) 1
NOLIX 0.05% CREAM 1
NUCORT 3
NUTRIARX 3
QL
PA
OLUX 3
OLUX-E 3
ORAPRED ODT 3
PANDEL 3 ST
PEDIADERM HC 3
QL
PA
PEDIAPRED 3
prednicarbate 1
prednisolone 15 mg/5 ml solution 1
prednisolone sod phosphate (5 mg/5 ml solution, 10 mg tab rapdis, 10 mg/5 mlsolution, 15 mg tab rapdis, 15 mg/5 ml solution, 20 mg/5 ml solution, 25 mg/5ml solution, 30 mg tab rapdis)
1
prednisone (1 mg tablet, 2.5 mg tablet, 5 mg tab ds pk, 5 mg tablet, 5 mg/5 mlsolution, 10 mg tab ds pk, 10 mg tablet, 20 mg tablet, 50 mg tablet)
1
PREDNISONE INTENSOL 1
PROCTO-MED HC 1
PROCTO-PAK 1
PROCTOCORT (1% CREAM, 30 MG SUPPOSITORY) 3
PROCTOSOL-HC 1
PROCTOZONE-HC 1
PSORCON 3
RAYOS 3 PA
SANADERMRX 3
QL
PA
SCALACORT 1
PAGE 106 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SERNIVO 3
QL
ST
SILALITE PAK 3
QL
PA
SILAZONE-II 3
QL
PA
SYNALAR (0.01% SOLUTION, 0.025% CREAM, 0.025% OINTMENT) 3
SYNALAR TS 3
QL
PA
TAPERDEX 3
QL
PA
TEMOVATE 3
TEXACORT 3
TOPICORT (0.05% CREAM, 0.05% GEL, 0.05% OINTMENT, 0.25% CREAM,0.25% OINTMENT, 0.25% SPRAY)
3
TRI-SILA 3
QL
PA
triamcinolone acetonide (0.025 % cream (g), 0.025 % lotion, 0.025 % oint. (g),0.1 % cream (g), 0.1 % lotion, 0.1 % oint. (g), 0.147mg/g aerosol, 0.5 % cream(g), 0.5 % oint. (g))
1
TRIANEX 3
TRIDERM 1
TRIDESILON 3
ULTRAVATE (CREAM, OINTMENT) 3
ULTRAVATE 0.05% LOTION 3
QL
ST
ULTRAVATE X 3
QL
PA
VANOS 3 ST
VERDESO 3 ST
VERIPRED 20 3
WHYTEDERM TRILASIL PAK 3
QL
PA
ZODEX (6 1.5 MG TABLET, 12 1.5 MG TABLET) 3
QL
PA
PAGE 107 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY)
BRAVELLE 3
QL
PA
S
MS
chorionic gonadotropin, human 1
QL
PA
S
MS
DDAVP (0.1 MG TABLET, 0.2 MG TABLET, 10 MCG/0.1 ML SOLUTION) 3
DDAVP (4 MCG/ML AMPUL, 4 MCG/ML VIAL) 3
S
MS
DDAVP 0.01% NASAL SPRAY 3
desmopressin acetate (0.1 mg tablet, 0.1 mg/ml solution, 0.2 mg tablet,10/spray spray/pump)
1
desmopressin acetate (4 mcg/ml ampul, 4 mcg/ml vial) 1
S
MS
desmopressin acetate (non-refrigerated) 1
EGRIFTA (1 MG VIAL, 2 MG VIAL) 3
QL
PA
S
FOLLISTIM AQ (75 VIAL, 300 CARTRIDG, 600 CARTRIDG, 900 CARTRIDG) 3
QL
PA
ST
S
MS
GENOTROPIN (MINIQUICK 0.2 MG, MINIQUICK 0.4 MG, MINIQUICK 0.6 MG,MINIQUICK 0.8 MG, MINIQUICK 1 MG, MINIQUICK 1.2 MG, MINIQUICK 1.4MG, MINIQUICK 1.6 MG, MINIQUICK 1.8 MG, MINIQUICK 2 MG, 5 MGCARTRIDGE, 12 MG CARTRIDGE)
3
PA
ST
S
MS
GONAL-F 2
QL
PA
S
MS
PAGE 108 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
HUMATROPE 3
PA
ST
S
MS
INCRELEX 3
PA
S
MS
MENOPUR 3
PA
S
MS
NOCDURNA 3 QL
NOCTIVA 3
QL
S
NORDITROPIN FLEXPRO (5 MG/1.5, 10 MG/1.5, 15 MG/1.5, 30 MG/3 ML) 3
PA
ST
S
MS
NOVAREL 10,000 UNITS VIAL 1
QL
PA
S
MS
NUTROPIN AQ 3
PA
ST
S
MS
OMNITROPE (5 MG/1.5 ML CRTG, 5.8 MG VIAL, 10 MG/1.5 ML CRTG) 2
PA
S
MS
OVIDREL 3
PA
S
MS
PAGE 109 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PREGNYL 1
QL
PA
S
MS
SAIZEN 3
QL
PA
ST
S
MS
SEROSTIM 3
QL
PA
S
MS
STIMATE 3 S
ZOMACTON 3
QL
PA
S
MS
ZORBTIVE 3
QL
PA
S
MS
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX HORMONES/MODIFIERS)
ANABOLIC STEROIDS
ANADROL-50 3
OXANDRIN 3
oxandrolone 1
ANDROGENS
ANDRODERM 2 PA
ANDROGEL 2 PA
ANDROID 3 PA
ANDROXY 1 PA
PAGE 110 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
AXIRON 3 PA
danazol 1
DEPO-TESTOSTERONE 3
FORTESTA 3 PA
METHITEST 1 PA
methyltestosterone 1 PA
NATESTO 3
QL
PA
STRIANT 3 PA
TESTIM 3 PA
testosterone (1.25g-1.62 gel packet, 2.5g-1.62% gel packet, 20.25/1.25 gel mdpmp, 25mg(1%) gel packet, 30mg/1.5ml sol md pmp)
1 PA
TESTOSTERONE (10 MG (2%) GEL MD PMP, 12.5/1.25G GEL MD PMP, 50MG (1%) GEL (GRAM)
3 PA
TESTOSTERONE (50 MG (1%) GEL PACKET). SOME MANUFACTURERSARE T3 AND OTHERS T1
3 PA
testosterone cypionate (100 mg/ml vial, 200 mg/ml vial) 1
testosterone enanthate 200 mg/ml vial 1
TESTRED 3 PA
VOGELXO 3 PA
ESTROGENS
ACTIVELLA 3
AFTERA 0 C Covered in full
ALORA 3 QL
ALTAVERA 0 C Covered in full
ALYACEN 0 C Covered in full
AMABELZ 1
AMETHIA 0 C Covered in full
AMETHIA LO 0 C Covered in full
AMETHYST 0 C Covered in full
ANGELIQ 3
APRI 0 C Covered in full
PAGE 111 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ARANELLE 0 C Covered in full
ASHLYNA 0 C Covered in full
AUBRA 0 C Covered in full
AUBRA EQ 0 C Covered in full
AVIANE 0 C Covered in full
AZURETTE 0 C Covered in full
BALCOLTRA 0 C Covered in full
BALZIVA 0 C Covered in full
BEKYREE 0 C Covered in full
BEYAZ 3
BLISOVI 24 FE 0 C Covered in full
BLISOVI FE 0 C Covered in full
BREVICON 3
BRIELLYN 0 C Covered in full
CAMRESE 0 C Covered in full
CAMRESE LO 0 C Covered in full
CAZIANT 0 C Covered in full
CHATEAL 0 C Covered in full
CHATEAL EQ 0 C Covered in full
CLIMARA 3 QL
CLIMARA PRO 2
COMBIPATCH 3
COVARYX 1
COVARYX H.S. 1
CRYSELLE 0 C Covered in full
CYCLAFEM 0 C Covered in full
CYCLESSA 3
CYRED 0 C Covered in full
PAGE 112 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
DASETTA 0 C Covered in full
DAYSEE 0 C Covered in full
DELESTROGEN 3
DELYLA 0 C Covered in full
DEPO-ESTRADIOL 3
DESOGEN 3
desogestrel-ethinyl estradiol 0 C Covered in full
desogestrel-ethinyl estradiol/ethinyl estradiol 0 C Covered in full
DIVIGEL (0.25 MG GEL PACKET, 0.5 MG GEL PACKET, 1 MG GEL PACKET) 3
drospirenone/ethinyl estradiol/levomefolate calcium 0 C Covered in full
ECONTRA ONE-STEP 0 C Covered in full
EEMT 1
EEMT H.S. 1
ELESTRIN 3
ELINEST 0 C Covered in full
EMOQUETTE 0 C Covered in full
ENJUVIA (0.3 MG TABLET, 0.45 MG TABLET, 0.625 MG TABLET, 0.9 MGTABLET, 1.25 MG TABLET)
3 QL
ENPRESSE 0 C Covered in full
ENSKYCE 0 C Covered in full
ESTARYLLA 0 C Covered in full
ESTRACE (0.5 MG TABLET, 1 MG TABLET, 2 MG TABLET) 3
ESTRACE 0.01% CREAM 2
estradiol (.025mg/24h patch tdsw, .025mg/24h patch tdwk, .0375mg/24 patchtdsw, .0375mg/24 patch tdwk, 0.05mg/24h patch tdsw, 0.05mg/24h patch tdwk,0.06mg/24h patch tdwk, .075mg/24h patch tdsw, .075mg/24h patch tdwk,0.1mg/24hr patch tdsw, 0.1mg/24hr patch tdwk)
1 QL
estradiol (0.01 % cream/appl, 0.5 mg tablet, 1 mg tablet, 2 mg tablet, 10 mcgtablet)
1
estradiol valerate 1
estradiol/norethindrone acetate 1
ESTRING 3
ESTROGEL 3
estrogens,esterified/methyltestosterone 1
PAGE 113 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
estropipate 1
ESTROSTEP FE 3
ethinyl estradiol/drospirenone 0 C Covered in full
ethynodiol d-ethinyl estradiol 1 mg-35mcg tablet 0 C Covered in full
ethynodiol d-ethinyl estradiol 1 mg-50mcg tablet 0 C Covered in full
EVAMIST 3
FALMINA 0 C Covered in full
FAYOSIM 0 C Covered in full
FEMCON FE 3
FEMHRT 3
FEMRING 3
FEMYNOR 0 C Covered in full
FYAVOLV 1
GENERESS FE 3
GIANVI 0 C Covered in full
GILDAGIA 0 C Covered in full
GILDESS 24 FE 0 C Covered in full
IMVEXXY 3
INTROVALE 0 C Covered in full
ISIBLOOM 0 C Covered in full
JEVANTIQUE LO 1
JINTELI 1
JOLESSA 0 C Covered in full
JULEBER 0 C Covered in full
JUNEL 0 C Covered in full
JUNEL FE 0 C Covered in full
JUNEL FE 24 0 C Covered in full
KAITLIB FE 0 C Covered in full
KARIVA 0 C Covered in full
PAGE 114 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
KELNOR 1-35 0 C Covered in full
KELNOR 1-50 0 C Covered in full
KIMIDESS 0 C Covered in full
KURVELO 0 C Covered in full
l-norgest/e.estradiol-e.estrad 0.15mg(84) tbdspk 3mo 0 C Covered in full
LARIN 0 C Covered in full
LARIN 24 FE 0 C Covered in full
LARIN FE 0 C Covered in full
LARISSIA 0 C Covered in full
LAYOLIS FE 0 C Covered in full
LEENA 0 C Covered in full
LESSINA 0 C Covered in full
LEVONEST 0 C Covered in full
levonorgestrel 0 C Covered in full
levonorgestrel-ethinyl estradiol 0 C Covered in full
levonorgestrel/ethinyl estradiol and ethinyl estradiol (l-norgest/e.estradiol-e.estrad 100-20(84) tbdspk 3mo, l-norgest/e.estradiol-e.estrad 150-30(84)tbdspk 3mo)
0 C Covered in full
LEVORA-28 0 C Covered in full
LILLOW 0 C Covered in full
LO LOESTRIN FE 0 C Covered in full
LOESTRIN 3
LOESTRIN FE 3
LOMEDIA 24 FE 0 C Covered in full
LOPREEZA 1
LORYNA 0 C Covered in full
LOSEASONIQUE 3
LOW-OGESTREL 0 C Covered in full
LUTERA 0 C Covered in full
MARLISSA 0 C Covered in full
PAGE 115 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
MELODETTA 24 FE 0 C Covered in full
MENEST 3
MENOSTAR 3 QL
MIBELAS 24 FE 0 C Covered in full
MICROGESTIN 0 C Covered in full
MICROGESTIN 24 FE 0 C Covered in full
MICROGESTIN FE 0 C Covered in full
MILI 0 C Covered in full
MIMVEY 1
MIMVEY LO 1
MINASTRIN 24 FE 3
MINIVELLE 3 QL
MIRCETTE 3
MONO-LINYAH 0 C Covered in full
MONONESSA 0 C Covered in full
MY CHOICE 0 C Covered in full
MY WAY 0 C Covered in full
MYZILRA 0 C Covered in full
NATAZIA 0 C Covered in full
NECON (0.5-35-28 TABLET, 1-35-28 TABLET, 1-50-28 TABLET, 7-7-7-28TABLET, 10-11-28 TABLET)
0 C Covered in full
NEW DAY 0 C Covered in full
NIKKI 0 C Covered in full
norethindrone ac-eth estradiol 1mg-20mcg tablet 0 C Covered in full
norethindrone acetate-ethinyl estradiol (0.5mg-2.5 tablet, 1mg-5mcg tablet) 1
norethindrone acetate-ethinyl estradiol/ferrous fumarate 0 C Covered in full
norethindrone-ethinyl estradiol/ferrous fumarate 0 C Covered in full
norgestimate-ethinyl estradiol 0 C Covered in full
NORINYL 1-35 3
PAGE 116 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
NORTREL 0 C Covered in full
NUVARING 0 C Covered in full
OCELLA 0 C Covered in full
OGESTREL 0 C Covered in full
ORSYTHIA 0 C Covered in full
ORTHO TRI-CYCLEN 3
ORTHO TRI-CYCLEN LO 3
ORTHO-CYCLEN 3
ORTHO-NOVUM 3
OVCON-35 3
PHILITH 0 C Covered in full
PIMTREA 0 C Covered in full
PIRMELLA 0 C Covered in full
PLAN B ONE-STEP 0 C Covered in full
PORTIA 0 C Covered in full
PREFEST 3
PREMARIN (0.3 MG TABLET, 0.45 MG TABLET, 0.625 MG TABLET, 0.9 MGTABLET, 1.25 MG TABLET, VAGINAL CREAM-APPL)
2
PREMPHASE 2
PREMPRO 2
PREVIFEM 0 C Covered in full
QUARTETTE 3
QUASENSE 0 C Covered in full
RAJANI 0 C Covered in full
RECLIPSEN 0 C Covered in full
RIVELSA 0 C Covered in full
SAFYRAL 3
SEASONIQUE 3
SETLAKIN 0 C Covered in full
SPRINTEC 0 C Covered in full
PAGE 117 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SRONYX 0 C Covered in full
SYEDA 0 C Covered in full
TAKE ACTION 0 C Covered in full
TARINA FE 0 C Covered in full
TAYTULLA 0 C Covered in full
TILIA FE 0 C Covered in full
TRI FEMYNOR 0 C Covered in full
TRI-ESTARYLLA 0 C Covered in full
TRI-LEGEST FE 0 C Covered in full
TRI-LINYAH 0 C Covered in full
TRI-LO-ESTARYLLA 0 C Covered in full
TRI-LO-MARZIA 0 C Covered in full
TRI-LO-SPRINTEC 0 C Covered in full
TRI-MILI 0 C Covered in full
TRI-NORINYL 3
TRI-PREVIFEM 0 C Covered in full
TRI-SPRINTEC 0 C Covered in full
TRI-VYLIBRA 0 C Covered in full
TRINESSA 0 C Covered in full
TRINESSA LO 0 C Covered in full
TRIVORA-28 0 C Covered in full
TYDEMY 0 C Covered in full
VAGIFEM 3
VELIVET 0 C Covered in full
VESTURA 0 C Covered in full
VIENVA 0 C Covered in full
VIORELE 0 C Covered in full
VIVELLE-DOT 3 QL
PAGE 118 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
VYFEMLA 0 C Covered in full
VYLIBRA 0 C Covered in full
WERA 0 C Covered in full
WYMZYA FE 0 C Covered in full
XULANE 0 C Covered in full
YASMIN 28 3
YAZ 3
YUVAFEM 1
ZARAH 0 C Covered in full
ZENCHENT 0 C Covered in full
ZENCHENT FE 0 C Covered in full
ZOVIA 1-35E 0 C Covered in full
ZOVIA 1-50E 0 C Covered in full
PROGESTERONE AGONISTS/ANTAGONISTS
ELLA 0 C Covered in full
PROGESTINS
AYGESTIN 3
CAMILA 0 C Covered in full
CRINONE 4% GEL 3
CRINONE 8% GEL 3 S
DEBLITANE 0 C Covered in full
DEPO-SUBQ PROVERA 104 0 C Covered in full
ECONTRA EZ 0 C Covered in full
ENDOMETRIN 3
PA
S
ERRIN 0 C Covered in full
FALLBACK SOLO 0 C Covered in full
HEATHER 0 C Covered in full
INCASSIA 0 C Covered in full
PAGE 119 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
JENCYCLA 0 C Covered in full
JOLIVETTE 0 C Covered in full
KYLEENA 0 C Covered in full as medicalbenefit
LILETTA 0 C Covered in full as medicalbenefit
LYZA 0 C Covered in full
medroxyprogesterone acetate (150 mg/ml syringe, 150 mg/ml vial) 0 C Covered in full
medroxyprogesterone acetate (2.5 mg tablet, 5 mg tablet, 10 mg tablet) 1
MEGACE 3
MEGACE ES 3
megestrol acetate (20 mg tablet, 40 mg tablet) 1
megestrol acetate (400mg/10ml oral susp, 625mg/5ml oral susp) 1
MIRENA 0 C Covered in full as medicalbenefit
NEXPLANON 0 C Covered in full as medicalbenefit
NEXT CHOICE ONE DOSE 0 C Covered in full
NOR-Q-D 3
NORA-BE 0 C Covered in full
norethindrone 0 C Covered in full
norethindrone acetate 5 mg tablet 1
NORLYDA 0 C Covered in full
NORLYROC 0 C Covered in full
OPCICON ONE-STEP 0 C Covered in full
OPTION 2 0 C Covered in full
ORTHO MICRONOR 3
progesterone 1
S
MS
progesterone, micronized 1
PROMETRIUM 3
PROVERA 3
SHAROBEL 0 C Covered in full
PAGE 120 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SKYLA 0 C Covered in full as medicalbenefit
TULANA 0 C Covered in full
SELECTIVE ESTROGEN RECEPTOR MODIFYING AGENTS
clomiphene citrate 1
DUAVEE 2
EVISTA 3
OSPHENA 3 ST
raloxifene hcl 1
SEROPHENE 1
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (THYROID)
ARMOUR THYROID 3
CYTOMEL 3
LEVO-T 1
levothyroxine sodium (25 mcg tablet, 50 mcg tablet, 75 mcg tablet, 88 mcgtablet, 100 mcg tablet, 112 mcg tablet, 125 mcg tablet, 137 mcg tablet, 150 mcgtablet, 175mcg tablet, 200 mcg tablet, 300 mcg tablet)
1
LEVOXYL 1
liothyronine sodium (5 mcg tablet, 25 mcg tablet, 50 mcg tablet) 1
NATURE-THROID 3
NP THYROID 1
SYNTHROID 3
THYROLAR-1 3
THYROLAR-1/2 3
THYROLAR-1/4 3
THYROLAR-2 3
THYROLAR-3 3
TIROSINT 3
UNITHROID 1
WESTHROID 3
WP THYROID 3
HORMONAL AGENTS, SUPPRESSANT (PITUITARY)
cabergoline 1
PAGE 121 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
CETROTIDE 3
PA
S
MS
GANIRELIX ACETATE 3
PA
S
MS
leuprolide acetate 1
PA
S
LUPANETA PACK 3
S
MS
octreotide acetate (50 mcg/ml ampul, 50 mcg/ml syringe, 50 mcg/ml vial, 100mcg/ml ampul, 100 mcg/ml syringe, 100 mcg/ml vial, 200 mcg/ml vial, 500mcg/ml ampul, 500 mcg/ml syringe, 500 mcg/ml vial, 1000mcg/ml vial)
1
S
MS
ORILISSA (150 MG TABLET, 200 MG TABLET) 3
QL
PA
SANDOSTATIN 3
S
MS
SANDOSTATIN LAR 3
S
MS
SANDOSTATIN LAR DEPOT 3
S
MS
SIGNIFOR 3
PA
S
MS
SOMATULINE DEPOT 3
QL
S
MS
SOMAVERT 3
PA
S
MS
SYNAREL 3
PAGE 122 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
HORMONAL AGENTS, SUPPRESSANT (THYROID)
ANTITHYROID AGENTS
methimazole 1
propylthiouracil 1
SSKI 3
TAPAZOLE 3
IMMUNOLOGICAL AGENTS
ANGIOEDEMA AGENTS
BERINERT 500 UNIT KIT 3
QL
PA
S
MS
CINRYZE 3
QL
PA
S
MS
FIRAZYR 3
QL
PA
S
MS
HAEGARDA 3
QL
PA
S
MS
RUCONEST 3
QL
PA
S
MS
TAKHZYRO 3
QL
PA
S
MS
PAGE 123 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
IMMUNE SUPPRESSANTS
ASTAGRAF XL (0.5 MG CAPSULE, 1 MG CAPSULE, 5 MG CAPSULE) 3
QL
PA
S
AZASAN 3
ST
S
azathioprine 1 S
CELLCEPT (200 MG/ML ORAL SUSP, 250 MG CAPSULE, 500 MG TABLET) 3 S
CIMZIA (200 MG/ML STARTER KIT, 200 MG/ML SYRINGE KIT) 3
QL
PA
ST
S
MS
cyclosporine (25 mg capsule, 100 mg capsule) 1 S
cyclosporine, modified (25 mg capsule, 50 mg capsule, 100 mg capsule, 100mg/ml solution)
1 S
ENBREL (25 MG KIT, 25 MG/0.5 ML SYRINGE, 50 MG/ML SYRINGE) 2
QL
PA
S
MS
ENBREL MINI 2
QL
PA
S
MS
ENBREL SURECLICK 2
QL
PA
S
MS
ENVARSUS XR (0.75 MG TABLET, 1 MG TABLET, 4 MG TABLET) 3
QL
PA
S
GENGRAF (25 MG CAPSULE, 50 MG CAPSULE, 100 MG CAPSULE, 100MG/ML SOLUTION)
1 S
PAGE 124 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
HUMIRA 2
QL
PA
S
MS
IMURAN 3 S
KINERET 3
QL
PA
ST
S
methotrexate sodium (2.5 mg tablet, 25 mg/ml vial) 1
methotrexate sodium/pf (sodium/pf 1 g vial, sodium/pf 25 mg/ml vial) 1
mycophenolate mofetil (200 mg/ml susp recon, 250 mg capsule, 500 mg tablet) 1 S
mycophenolate sodium 1 S
MYFORTIC 3 S
NEORAL (25 MG GELATIN CAPSULE, 100 MG GELATIN CAPSULE, 100MG/ML SOLUTION)
3 S
OLUMIANT 3
QL
PA
S
MS
ORENCIA 3
QL
PA
ST
S
MS
OTREXUP 3 PA
PROGRAF (0.5 MG CAPSULE, 1 MG CAPSULE, 5 MG CAPSULE) 3 S
RAPAMUNE (0.5 MG TABLET, 1 MG TABLET, 1 MG/ML ORAL SOLN, 2 MGTABLET)
3 S
RASUVO 3 PA
RHEUMATREX 3
SANDIMMUNE (25 MG CAPSULE, 100 MG CAPSULE, 100 MG/ML SOLN) 3 S
PAGE 125 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SIMPONI (50 MG/0.5 ML PEN INJEC, 50 MG/0.5 ML SYRINGE, 100 MG/MLPEN INJECTOR, 100 MG/ML SYRINGE)
3
QL
PA
ST
S
MS
sirolimus 1 S
tacrolimus (0.5 mg capsule, 1 mg capsule, 5 mg capsule) 1 S
TREXALL 3
XATMEP 3 PA
XELJANZ 10 MG TABLET 2
QL
PA
S
MS
XELJANZ 5 MG TABLET 2
PA
S
MS
XELJANZ XR 2
QL
PA
S
MS
ZORTRESS 3 S
IMMUNOMODULATORS
ACTEMRA 162 MG/0.9 ML SYRINGE 2
QL
PA
S
MS
ACTIMMUNE 3
PA
S
MS
ARAVA 3
ARCALYST 3
PA
S
MS
PAGE 126 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
BENLYSTA (200 MG/ML AUTOINJECT, 200 MG/ML SYRINGE) 3
QL
PA
S
MS
DUPIXENT 300 MG/2 ML SAFE SYRG 3
QL
PA
S
MS
GRASTEK 3 QL
KEVZARA (150 MG/1.14 ML PEN INJ, 150 MG/1.14 ML SYRINGE, 200MG/1.14 ML PEN INJ, 200 MG/1.14 ML SYRINGE)
3
QL
PA
ST
S
MS
leflunomide 1
ORALAIR 3
QL
S
OTEZLA 2
QL
PA
S
MS
RAGWITEK 3 QL
RIDAURA 3
VACCINES
XOFLUZA 3 QL
INFLAMMATORY BOWEL DISEASE AGENTS
AMINOSALICYLATES
APRISO 3 QL
ASACOL HD 3
balsalazide disodium 1
CANASA 3
COLAZAL 3
PAGE 127 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
DELZICOL 2
DIPENTUM 3
GIAZO 3
QL
PA
LIALDA 3
mesalamine (1.2 g tablet dr, 4 g/60 ml enema) 1
MESALAMINE 800 MG TABLET DR 1
mesalamine with cleansing wipes 1
QL
PA
PENTASA 2
ROWASA 4 GM/60 ML ENEMA KIT 3
QL
PA
SFROWASA 3
GLUCOCORTICOIDS
budesonide 3 mg capdr - er 1
budesonide 9 mg tabdr - er 1
QL
PA
COLOCORT 1
CORTENEMA 3
CORTIFOAM 3
ENTOCORT EC 3
hydrocortisone 100mg/60ml enema 1
UCERIS (2 MG RECTAL FOAM, 9 MG ER TABLET) 3
QL
PA
SULFONAMIDES
AZULFIDINE 3
sulfasalazine 1
METABOLIC BONE DISEASE AGENTS
ACTONEL (5 MG TABLET, 30 MG TABLET, 35 MG TABLET, 150 MGTABLET)
3 QL
alendronate sodium (5 mg tablet, 10 mg tablet, 35 mg tablet, 40 mg tablet, 70mg tablet)
1 QL
alendronate sodium 70 mg/75ml solution 1
ATELVIA 3 QL
PAGE 128 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
BINOSTO 3 QL
BONIVA 150 MG TABLET 3 QL
calcitonin,salmon,synthetic 1
calcitriol (0.25 mcg capsule, 0.5 mcg capsule, 1 mcg/ml solution) 1
doxercalciferol (0.5 mcg capsule, 1 mcg capsule, 2.5 mcg capsule) 1
DRISDOL 3
ergocalciferol (vitamin d2) 50000 unit capsule 1
etidronate disodium 1
FORTEO 3
PA
S
MS
FORTICAL 3
FOSAMAX 3 QL
FOSAMAX PLUS D 3 QL
HECTOROL (0.5 MCG CAPSULE, 1 MCG CAPSULE, 2.5 MCG CAPSULE) 3
ibandronate sodium 150 mg tablet 1 QL
MIACALCIN 200 UNIT NASAL SPRAY 3
NATPARA 3
QL
PA
S
MS
paricalcitol (1 mcg capsule, 2 mcg capsule, 4 mcg capsule) 1
RAYALDEE 3
risedronate sodium (5 mg tablet, 30 mg tablet, 35 mg tablet, 35 mg tablet dr,150 mg tablet)
1 QL
ROCALTROL (0.25 MCG CAPSULE, 0.5 MCG CAPSULE, 1 MCG/ML ORALSOLN)
3
SENSIPAR 3
TRIXYLITRAL 3
QL
PA
TYMLOS 3
QL
PA
S
MS
PAGE 129 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ZEMPLAR (1 MCG CAPSULE, 2 MCG CAPSULE) 3
MISCELLANEOUS THERAPEUTIC AGENTS
BD PEN NEEDLES T2. ALL OTHER MANUFACTURERS T3. 2
cervical cap 0 C Covered in full
CETYLEV 3
COMFORT PAC-MELOXICAM 3
QL
PA
COMFORT PAC-NAPROXEN 3
QL
PA
condoms, female 0 C Covered in full
diaphragms, contoured 0 C Covered in full
diaphragms, wide seal 0 C Covered in full
FLEXIPAK 3
QL
PA
foam/gauze bandage/lidocaine/chlorhexidine/isopropyl alcohol 3
QL
PA
INFLAMMACIN 3
QL
PA
INTRAROSA 3 QL
isometheptene mucate/dichloralphenazone/acetaminophen 1
LOKELMA (5 POWDER PACKET, 10 POWDER PACKET) 2 QL
METHERGINE 1 QL
methylergonovine maleate 0.2 mg tablet 1 QL
NODOLOR 1
NUDICLO TABPAK 3
QL
PA
NUDROXIPAK DSDR-50 3
QL
PA
PAGE 130 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
NUDROXIPAK DSDR-75 3
QL
PA
NUDROXIPAK E-400 3
QL
PA
NUDROXIPAK I-800 3
QL
PA
NUDROXIPAK N-500 3
QL
PA
ODACTRA 3 QL
PARAGARD T 380-A 0 C Covered in full as medicalbenefit
PREVIDOLRX PLUS ANALGESIC PAK 3
QL
PA
SAXENDA 3
QL
PA
silver/bandage/foam/gauze/lidocaine/chlorhexidin/isopropanol 3
QL
PA
syringe, insulin u-500 with needle, disposable, 0.5 ml 3
XENAFLAMM 3
QL
PA
XERMELO 3
QL
PA
MODIFIED SOLID FOODS
All modified solid foods are covered as brands with Prior Authorization
OPHTHALMIC AGENTS
OPHTHALMIC AGENTS, OTHER
AKTEN 3
ALCAINE 3
atropine sulfate (1 % drops, 1 % oint. (g)) 1
bacitracin/polymyxin b sulfate 500-10k/g oint. (g) 1
BLEPHAMIDE 3
BLEPHAMIDE S.O.P. 3
PAGE 131 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
cyclopentolate hcl (0.5 % drops, 1 % drops, 2 % drops) 1
CYSTARAN 3
PA
S
ISOPTO ATROPINE 1% EYE DROP 3
ISOPTO ATROPINE 1% EYE DROPS 3
LACRISERT 3
MAXITROL (DROPS, OINTMENT) 3
MITOSOL 3
NAPHAZOLINE 0.1% 3
NEO-POLYCIN 1
NEO-POLYCIN HC 1
neomycin sulfate/bacitracin zinc/polymyxin b/hydrocortisone 1
neomycin sulfate/bacitracin/polymyxin b 1
neomycin sulfate/polymyxin b sulfate/gramicidin d 1
neomycin/polymyxin b sulfate/dexamethasone (neomycin/polymyxinb/dexametha 0.1 % drops susp, neomycin/polymyxin b/dexametha 3.5-10k-.1oint. (g))
1
neomycin/polymyxin b/hydrocort 3.5-10k-10 drops susp 1
NEOSPORIN EYE DROPS 3
PAREMYD 3
phenylephrine hcl (2.5 % drops, 10 % drops) 1
POLYCIN 1
polymyxin b sulfate/trimethoprim 1
POLYTRIM 3
PRED-G (1% DROPS, S.O.P. OINTMENT) 3
proparacaine hcl 1
RESTASIS 2 QL
RESTASIS MULTIDOSE 2 QL
sulfacetamide sodium/prednisolone sodium phosphate 1
TETRAVISC 3
TETRAVISC FORTE 3
TOBRADEX (DROPS, OINTMENT) 3
TOBRADEX ST 3
PAGE 132 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
tobramycin/dexamethasone 1
tropicamide (0.5 % drops, 1 % drops) 1
XIIDRA 2 QL
ZYLET 3
OPHTHALMIC ANTI-ALLERGY AGENTS
ALOCRIL 3
ALOMIDE 3
azelastine hcl 0.05 % drops 1
BEPREVE 3
cromolyn sodium 4 % drops 1
ELESTAT 3
EMADINE 3
epinastine hcl 1
LASTACAFT 3
olopatadine hcl (0.1 % drops, 0.2 % drops) 1
PATADAY 3
PATANOL 3
PAZEO 3
OPHTHALMIC ANTI-INFLAMMATORIES
ACULAR 3
ACULAR LS 3
ACUVAIL 3
ALREX 3
bromfenac sodium 1
BROMSITE 3 QL
dexamethasone sodium phosphate 0.1 % drops 1
diclofenac sodium 0.1 % drops 1
DUREZOL 3
FLAREX 3
fluorometholone 1
flurbiprofen sodium 1
FML 3
PAGE 133 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
FML FORTE 3
FML S.O.P. 3
ILEVRO 3
ketorolac tromethamine (0.4 % drops, 0.5 % drops) 1
LOTEMAX (EYE DROPS, EYE OINTMENT, OPHTHALMIC GEL) 2
MAXIDEX 3
NEVANAC 3
OCUFEN 3
OMNIPRED 3
PRED FORTE 3
PRED MILD 3
prednisolone acetate 1
prednisolone sod phosphate 1 % drops 1
PROLENSA 3 QL
VEXOL 3
OPHTHALMIC ANTIGLAUCOMA AGENTS
ALPHAGAN P 2
apraclonidine hcl 1
AZOPT 3
BETAGAN 3
betaxolol hcl 0.5 % drops 1
BETIMOL 3
BETOPTIC S 3
brimonidine tartrate 1
carteolol hcl 1
COMBIGAN 2 QL
COSOPT 3
COSOPT PF 3 QL
dorzolamide hcl 1
dorzolamide hcl/timolol maleate 1
dorzolamide/timolol/pf 2 %-0.5 % droperette 1 QL
IOPIDINE (0.5% DROPS, 1% DROPS) 3
PAGE 134 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ISOPTO CARPINE 3
ISTALOL 3
levobunolol hcl 1
methazolamide 1
metipranolol 1
NEPTAZANE 3
PHOSPHOLINE IODIDE 3
pilocarpine hcl (1 % drops, 2 % drops, 4 % drops) 1
RESCULA 3
RHOPRESSA 3
QL
ST
SIMBRINZA 3 QL
timolol maleate (0.25 % drops, 0.25 % sol-gel, 0.5 % drop daily, 0.5 % drops,0.5 % sol-gel)
1
TIMOPTIC (0.25% DROP, 0.5% DROP) 3
TIMOPTIC (0.25% DROPS, 0.5% DROPS) 3
TIMOPTIC OCUDOSE 3
TIMOPTIC-XE (0.25% EYE GEL-SOLN, 0.5% GEL-SOLUTION) 3
TIMOPTIC-XE (0.25% SOLN, 0.5% SOLN) 3
TRUSOPT 3
VYZULTA 3 ST
OPHTHALMIC PROSTAGLANDIN AND PROSTAMIDE ANALOGS
BIMATOPROST 0.03 % DROPS (INTO THE EYE FOR GLAUCOMA) 2
latanoprost 1 QL
LUMIGAN 2
TRAVATAN Z 2
XALATAN 3 QL
ZIOPTAN 3
QL
ST
OTIC AGENTS
ACETASOL HC 1
acetic acid 2 % solution 1
PAGE 135 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
acetic acid/aluminum acetate 1
CIPRO HC 3
CIPRODEX 2
COLY-MYCIN S 3
CORTISPORIN-TC 3
DERMOTIC 3
fluocinolone acetonide oil 1
hydrocortisone/acetic acid 1
neomycin sulfate/polymyxin b sulfate/hydrocortisone (neomycin/polymyxinb/hydrocort drops susp, neomycin/polymyxin b/hydrocort solution)
1
OTOVEL 3 QL
RESPIRATORY TRACT/PULMONARY AGENTS
ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS
AEROSPAN 3
QL
ST
ALVESCO (80 MCG INHALER, 160 MCG INHALER) 3
QL
ST
ARMONAIR RESPICLICK 2 QL
ARNUITY ELLIPTA 2 QL
ASMANEX 2 QL
ASMANEX HFA 2 QL
BECONASE AQ 3 QL
budesonide (0.25mg/2ml ampul-neb, 0.5 mg/2ml ampul-neb, 1 mg/2 ml ampul-neb)
1 QL
FLOVENT DISKUS 2 QL
FLOVENT HFA (HFA 44 MCG INHALER, HFA 110 MCG INHALER, HFA 220MCG INHALER)
2 QL
flunisolide 1 QL
fluticasone propionate 50 mcg spray susp 1
mometasone furoate 50 mcg spray/pump 1
NASONEX 3
OMNARIS 3 QL
PULMICORT 3 QL
PAGE 136 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PULMICORT FLEXHALER (90 MCG, 180 MCG) 3
QL
ST
QNASL 2 QL
QNASL CHILDREN 2 QL
QVAR 2 QL
QVAR REDIHALER 2 QL
RHINOCORT AQUA 3
TICANASE 3
QL
PA
TICASPRAY 3
QL
PA
triamcinolone acetonide 55 mcg spray 1
VERAMYST 3 QL
XHANCE 3
QL
PA
ZETONNA 3 QL
ANTIHISTAMINES
ARBINOXA (4 MG TABLET, 4 MG/5 ML LIQUID) 1
ASTEPRO 3 QL
azelastine hcl 137 mcg spray/pump 1
azelastine hcl 205.5 mcg spray/pump 1 QL
carbinoxamine maleate (4 mg tablet, 4 mg/5 ml liquid) 1
carbinoxamine maleate 6 mg tablet 1
QL
PA
cetirizine hcl 1 mg/ml solution 1
CLARINEX (0.5 MG/ML (2.5 MG/5), 5 MG TABLET) 3
clemastine fumarate (0.67mg/5ml syrup, 2.68 mg tablet) 1
cyproheptadine hcl (2 mg/5 ml syrup, 4 mg/10 ml syrup) 1
QL
PA
cyproheptadine hcl 4 mg tablet 1
PAGE 137 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
desloratadine 1
diphenhydramine hcl 12.5mg/5ml elixir 1
hydroxyzine hcl (10 mg tablet, 10 mg/5 ml solution, 25 mg tablet, 50 mg tablet,50 mg/25ml solution)
1
hydroxyzine pamoate 1
KARBINAL ER 3 QL
levocetirizine dihydrochloride 2.5 mg/5ml solution 1 QL
levocetirizine dihydrochloride 5 mg tablet 1
olopatadine hcl 0.6 % spray/pump 1 QL
PATANASE 3 QL
promethazine hcl (6.25mg/5ml syrup, 12.5 mg tablet, 25 mg tablet) 1
RYCLORA 3 QL
RYVENT 3
QL
PA
VISTARIL 3
XYZAL (2.5 MG/5 ML SOLUTION, 5 MG TABLET) 3
ANTILEUKOTRIENES
ACCOLATE 3
montelukast sodium (4 mg gran pack, 4 mg tab chew, 5 mg tab chew, 10 mgtablet)
1 QL
SINGULAIR (4 MG GRANULES, 4 MG TABLET CHEW, 5 MG TABLET CHEW,10 MG TABLET)
3 QL
zafirlukast 1
zileuton 1 QL
ZYFLO 3 QL
ZYFLO CR 3 QL
BRONCHODILATORS, ANTICHOLINERGIC
ATROVENT 3
ATROVENT HFA 2
INCRUSE ELLIPTA 3 QL
ipratropium bromide 1
LONHALA MAGNAIR REFILL 3
QL
ST
PAGE 138 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
LONHALA MAGNAIR STARTER 3
QL
ST
SEEBRI NEOHALER 3
SPIRIVA 2
SPIRIVA RESPIMAT 2
TUDORZA PRESSAIR 3 QL
BRONCHODILATORS, SYMPATHOMIMETIC
ADRENACLICK 3 QL
albuterol sulfate (0.63mg/3ml vial-neb, 1.25mg/3ml vial-neb, 2 mg tablet, 2 mg/5ml syrup, 2.5 mg/0.5 vial-neb, 2.5 mg/3ml vial-neb, 4 mg tab er 12h, 4 mgtablet, 5 mg/ml solution, 8 mg tab er 12h)
1
ARCAPTA NEOHALER 3 QL
AUVI-Q (0.15 MG, 0.3 MG) 3
QL
PA
BROVANA 3
epinephrine (0.1 mg/ml syringe, 1 mg/ml vial, 1 mg/ml(1) ampul) 1
epinephrine (0.15/0.15 auto injct, 0.15mg/0.3 auto injct, 0.3mg/0.3 auto injct) 1 QL
EPIPEN 2 QL
EPIPEN 2-PAK 2 QL
EPIPEN JR 2-PAK 2 QL
FORADIL 2 QL
levalbuterol hcl (0.31mg/3ml vial-neb, 0.63mg/3ml vial-neb, 1.25mg/0.5 vial-neb, 1.25mg/3ml vial-neb)
1
levalbuterol tartrate 1
metaproterenol sulfate (10 mg tablet, 10 mg/5 ml syrup, 20 mg tablet) 1
PERFOROMIST 3 QL
PROAIR HFA 2 QL
PROAIR RESPICLICK 2 QL
PROVENTIL HFA 3 QL
SEREVENT DISKUS 2
STRIVERDI RESPIMAT 2 QL
terbutaline sulfate (2.5 mg tablet, 5 mg tablet) 1
PAGE 139 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
VENTOLIN HFA 2 QL
VOSPIRE ER 3
XOPENEX 3
XOPENEX CONCENTRATE 3
XOPENEX HFA 3
CYSTIC FIBROSIS AGENTS
BETHKIS 3
QL
S
MS
CAYSTON 3
S
MS
KALYDECO 3
QL
PA
S
MS
KITABIS PAK 3
S
MS
ORKAMBI (100 MG-125 MG TABLET, 100-125 MG GRANULE PKT, 150-188MG GRANULE PKT, 200 MG-125 MG TABLET)
3
QL
PA
S
MS
PULMOZYME 3
S
MS
SYMDEKO 3
QL
PA
S
MS
TOBI PODHALER 3
QL
S
tobramycin/nebulizer 1
S
MS
PAGE 140 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
MAST CELL STABILIZERS
cromolyn sodium 20 mg/2 ml ampul-neb 1
PHOSPHODIESTERASE INHIBITORS, AIRWAYS DISEASE
caffeine citrate 60 mg/3 ml solution 1
DALIRESP (250 MCG TABLET, 500 MCG TABLET) 3
QL
ST
ELIXOPHYLLIN 3
THEO-24 3
THEOCHRON 1
theophylline anhydrous (80 mg/15ml elixir, 80 mg/15ml solution, 100 mg tab er12h, 200 mg tab er 12h, 300 mg tab er 12h, 400 mg tab er 24h, 450 mg tab er12h, 600 mg tab er 24h)
1
PULMONARY ANTIHYPERTENSIVES
ADCIRCA 3
QL
PA
S
MS
ADEMPAS 3
QL
PA
S
MS
LETAIRIS 3
QL
PA
S
MS
OPSUMIT 3
QL
PA
S
MS
ORENITRAM ER 3
PA
S
MS
PAGE 141 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
REVATIO (10 MG/ML ORAL SUSP, 20 MG TABLET) 3
QL
PA
S
MS
sildenafil citrate 20 mg tablet 1
QL
PA
S
MS
TRACLEER (62.5 MG TABLET, 125 MG TABLET) 3
PA
S
MS
TRACLEER 32 MG TABLET FOR SUSP 3
QL
PA
S
MS
TYVASO 3
QL
PA
S
MS
UPTRAVI (200 MCG TABLET, 200-800 TITRATION PACK, 400 MCG TABLET,600 MCG TABLET, 800 MCG TABLET, 1,000 MCG TABLET, 1,200 MCGTABLET, 1,400 MCG TABLET, 1,600 MCG TABLET)
3
QL
PA
S
PULMONARY FIBROSIS AGENTS
ESBRIET (267 MG CAPSULE, 267 MG TABLET, 801 MG TABLET) 2
QL
PA
S
MS
OFEV 2
QL
PA
S
MS
RESPIRATORY TRACT AGENTS, OTHER
acetylcysteine (100 mg/ml vial, 200 mg/ml vial) 1
PAGE 142 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ADVAIR DISKUS 2 QL
ADVAIR HFA 2 QL
AIRDUO RESPICLICK 3
QL
ST
ANORO ELLIPTA 2 QL
benzonatate 1
BEVESPI AEROSPHERE 2 QL
BREO ELLIPTA 100-25 MCG INH 2 QL
BREO ELLIPTA 200-25 MCG INH 2
BROMFED DM 1
brompheniramine/pseudoephed/dm 2-30-10/5 syrup 1
CENTERGY DM 1
CLARINEX-D 12 HOUR 3
COMBIVENT RESPIMAT 2 QL
CUROSURF 3
DULERA 3 QL
DYMISTA 3
QL
PA
FLOWTUSS 3 QL
FLUTICASONE PROPIONATE/SALMETEROL XINAFOATE 2 QL
guaifenesin/hydrocodone bitartrate 3
QL
PA
HYCOFENIX 3
hydrocodone bitart/chlorpheniramine maleate/pseudoephedrine 1
hydrocodone bitartrate/homatropine methylbromide (bit/homatrop 5 mg-1.5mgtablet, bit/homatrop 5-1.5 mg/5 syrup)
1
hydrocodone polistirex/chlorpheniramine polistirex 1 QL
HYDROMET 1
ipratropium bromide/albuterol sulfate 1
NEBUSAL 3% VIAL 1
OBREDON 3 QL
PAGE 143 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
phenylephrine hcl/prometh hcl 5-6.25mg/5 syrup 1
promethazine hcl/codeine 1
promethazine/dextromethorphan 6.25-15/5 syrup 1
promethazine/phenyleph/codeine 6.25-5-10 syrup 1
REZIRA 3
ribavirin 6 g vial-neb 1 MS
SEMPREX-D 3
sodium chloride for inhalation 1
STIOLTO RESPIMAT 2 QL
SYMBICORT 2 QL
TESSALON PERLE 3
TICALAST 3
QL
PA
TOBI 3 S
tobramycin in 0.225 % sodium chloride 1 S
TRELEGY ELLIPTA 3
QL
ST
TUSSICAPS 3
TUSSIGON 1
TUSSIONEX 3
QL
ST
TUZISTRA XR 3 ST
TYZINE 3
UTIBRON NEOHALER 2
VIRAZOLE 3
VITUZ 3 QL
ZUTRIPRO 3
SKELETAL MUSCLE RELAXANTS
AMRIX 3
QL
PA
carisoprodol 250 mg tablet 1
QL
PA
PAGE 144 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
carisoprodol 350 mg tablet 1
carisoprodol/aspirin 200-325 mg tablet 1
chlorzoxazone 250 mg tablet 1
QL
PA
chlorzoxazone 500 mg tablet 1 QL
COMFORT PAC-CYCLOBENZAPRINE 3
QL
PA
COMFORT PAC-TIZANIDINE 3
QL
PA
cyclobenzaprine hcl (5 mg tablet, 10 mg tablet) 1
cyclobenzaprine hcl 7.5 mg tablet 1
QL
PA
FEXMID 3
QL
PA
LORZONE 3
QL
PA
METAXALL 1 QL
metaxalone 400 mg tablet 1
metaxalone 800 mg tablet 1 QL
methocarbamol (500 mg tablet, 750 mg tablet) 1
orphenadrine citrate 100 mg tablet er 1
PARAFON FORTE DSC 3 QL
ROBAXIN 500 MG TABLET 3
ROBAXIN-750 3
SKELAXIN 3 QL
SOMA 250 MG TABLET 3
QL
PA
SOMA 350 MG TABLET 3
PAGE 145 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SLEEP DISORDER AGENTS
GABA RECEPTOR MODULATORS
AMBIEN (5 MG TABLET, 10 MG TABLET) 3 QL
AMBIEN CR 3 QL
DORAL 3
EDLUAR 3
QL
ST
estazolam 1
eszopiclone 1 QL
flurazepam hcl 1
HALCION 3
INTERMEZZO 3
QL
ST
LUNESTA 3 QL
quazepam 1
RESTORIL 3
SONATA (5 MG CAPSULE, 10 MG CAPSULE) 3 QL
temazepam 1
triazolam 1
zaleplon (5 mg capsule, 10 mg capsule) 1 QL
zolpidem tartrate (1.75 mg tab subl, 3.5 mg tab subl, 5 mg tablet, 6.25 mg tabmphase, 10 mg tablet, 12.5 mg tab mphase)
1 QL
ZOLPIMIST 3
QL
ST
SLEEP DISORDERS, OTHER
armodafinil (50 mg tablet, 150 mg tablet, 200 mg tablet, 250 mg tablet) 1 QL
BELSOMRA 3
QL
ST
BUTISOL SODIUM 3
HETLIOZ 3
QL
PA
S
MS
PAGE 146 LAST UPDATED 01/2019
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
modafinil 1 QL
NUVIGIL (50 MG TABLET, 150 MG TABLET, 200 MG TABLET, 250 MGTABLET)
3 QL
PROVIGIL 3 QL
ROZEREM 3
QL
ST
SECONAL SODIUM 3
SILENOR 3
QL
ST
XYREM 3
QL
PA
S
PAGE 147 LAST UPDATED 01/2019
Index of covered drugs
88-MOP 84
Aabacavir sulfate 54
abacavir sulfate/lamivudine 54
abacavir sulfate/lamivudine/zidovudine 54
ABILIFY 48
ABILIFY DISCMELT 48
ABSORICA 84
ABSTRAL 8
acamprosate calcium 13
ACANYA 84
acarbose 58
ACCOLATE 138
ACCUPRIL 67
ACCURETIC 70
acebutolol hcl 68
ACEON 67
acetaminophen with codeine phosphate 9
ACETAMINOPHEN/CAFF/DIHYDROCOD 325-
30-16 TABLET 9
acetaminophen/caffeine/dihydrocodeine
bitartrate 9
ACETASOL HC 135
acetazolamide 73
acetic acid 135
acetic acid/aluminum acetate 136
acetylcysteine 142
ACIPHEX 98
ACIPHEX SPRINKLE 98
acitretin 84
ACTEMRA 126
ACTICLATE 20
ACTIGALL 95
ACTIMMUNE 126
ACTIQ 9
ACTIVELLA 111
ACTONEL 128
ACTOPLUS MET 58
ACTOPLUS MET XR 58
ACTOS 58
ACULAR 133
ACULAR LS 133
ACUVAIL 133
acyclovir 56
ACZONE 84
ADALAT CC 69
adapalene 84
ADAPALENE 0.1% LOTION 84
adapalene/benzoyl peroxide 84
ADASUVE 47
ADCIRCA 141
ADDERALL 77
ADDERALL XR 77
ADDYI 102
adefovir dipivoxil 50
ADEMPAS 141
ADIPEX-P 79
ADLYXIN 58
ADMELOG 62
ADMELOG SOLOSTAR 62
ADOXA 20
ADRENACLICK 139
ADVAIR DISKUS 143
ADVAIR HFA 143
ADZENYS ER 77
ADZENYS XR-ODT 77
AEROSPAN 136
AFEDITAB CR 69
AFINITOR 39
AFREZZA 62
AFTERA 111
AGRYLIN 64
AIMOVIG AUTOINJECTOR 32
AIMOVIG AUTOINJECTOR (2 PACK) 32
AIRDUO RESPICLICK 143
AJOVY 33
AKTEN 131
AKTIPAK 14
AKYNZEO 29
ALA-CORT 103
ALA-SCALP 103
albendazole 45
ALBENZA 45
albuterol sulfate 139
ALCAINE 131
alclometasone dipropionate 103
ALDACTAZIDE 70
ALDACTONE 74
ALDARA 84
ALECENSA 39
alendronate sodium 128
ALEVICYN PLUS 84
ALFERON N 56
alfuzosin hcl 101
ALINIA 45
ALKERAN 35
allopurinol 32
ALLZITAL 79
almotriptan malate 33
ALOCRIL 133
ALOGLIPTIN BENZOATE 58
alogliptin benzoate/metformin hcl 58
alogliptin benzoate/pioglitazone hcl 58
ALOMIDE 133
ALORA 111
alosetron hcl 97
ALPHAGAN P 134
alprazolam 57
ALPRAZOLAM INTENSOL 57
ALREX 133
ALTABAX 14
ALTACE 67
ALTAVERA 111
ALTOPREV 75
ALTRENO 84
ALUNBRIG 37
ALVESCO 136
ALYACEN 111
AMABELZ 111
amantadine hcl 46
PAGE 148 LAST UPDATED 01/2019
AMARYL 58
AMBIEN 146
AMBIEN CR 146
amcinonide 103
AMELUZ 84
AMERGE 33
AMETHIA 111
AMETHIA LO 111
AMETHYST 111
AMICAR 65
amiloride hcl 74
amiloride hcl/hydrochlorothiazide 70
aminocaproic acid 65
amiodarone hcl 68
AMITIZA 97
amitriptyline hcl 28
amitriptyline hcl/chlordiazepoxide 25
amlodipine besylate 69
amlodipine besylate/atorvastatin calcium 70
amlodipine besylate/benazepril hcl 71
amlodipine besylate/olmesartan medoxomil 71
amlodipine besylate/valsartan 71
amlodipine
besylate/valsartan/hydrochlorothiazide 71
ammonium lactate 84
AMNESTEEM 84
amoxapine 28
amoxicillin 17
AMOXICILLIN ER 775 MG 17
amoxicillin/potassium clavulanate 18
amphetamine sulfate 77
ampicillin trihydrate 18
AMPYRA 82
AMRIX 144
ANA-LEX 84
ANACAINE 12
ANADROL-50 110
ANAFRANIL 28
anagrelide hcl 64
ANALPRAM E 84
ANALPRAM HC 84
ANAPROX 5
ANAPROX DS 5
ANASPAZ 94
ANASTIA 12
anastrozole 38
ANCOBON 30
ANDRODERM 110
ANDROGEL 110
ANDROID 110
ANDROXY 110
ANGELIQ 111
ANODYNE LPT 12
ANORO ELLIPTA 143
ANTABUSE 13
ANTARA 74
ANUCORT-HC 103
ANUSOL-HC 103
ANZEMET 29
APEXICON E 103
APIDRA 62
APIDRA SOLOSTAR 62
APLENZIN 25
APOKYN 46
apraclonidine hcl 134
aprepitant 29
APRI 111
APRISO 127
APTENSIO XR 78
APTIOM 24
APTIVUS 55
ARANELLE 112
ARANESP 64
ARAVA 126
ARBINOXA 137
ARCALYST 126
ARCAPTA NEOHALER 139
ARICEPT 24
ARIKAYCE 14
ARIMIDEX 38
aripiprazole 48
ARIXTRA 63
armodafinil 146
ARMONAIR RESPICLICK 136
ARMOUR THYROID 121
ARNUITY ELLIPTA 136
AROMASIN 38
ARTHROTEC 50 5
ARTHROTEC 75 5
ARYMO ER 7
ASACOL HD 127
ASCOMP WITH CODEINE 9
ASHLYNA 112
ASMANEX 136
ASMANEX HFA 136
aspirin/caffeine/dihydrocodeine bitartrate 9
ASPIRIN/DIPYRIDAMOLE 65
ASTAGRAF XL 124
ASTEPRO 137
ATACAND 67
ATACAND HCT 71
atazanavir sulfate 55
ATELVIA 128
atenolol 68
atenolol/chlorthalidone 71
ATIVAN 57
atomoxetine hcl 78
atorvastatin calcium 75
atovaquone 45
atovaquone/proguanil hcl 45
ATRALIN 84
ATRAPRO DERMAL SPRAY 84
ATRIPLA 53
atropine sulfate 131
ATROVENT 138
ATROVENT HFA 138
AUBAGIO 82
AUBRA 112
AUBRA EQ 112
AUGMENTIN 18
AUGMENTIN ES-600 18
AUGMENTIN XR 18
AURYXIA 93
PAGE 149 LAST UPDATED 01/2019
AUSTEDO 79
AUVI-Q 139
AVALIDE 71
AVANDIA 58
AVAPRO 67
AVAR 84
AVAR-E 84
AVAR-E GREEN 84
AVC 19
AVELOX 19
AVELOX ABC PACK 19
AVIANE 112
AVIDOXY 20
AVINZA 7
AVITA 84
AVODART 101
Avonex 82
AXERT 33
AXIRON 111
AYGESTIN 119
AZASAN 124
AZASITE 18
azathioprine 124
azelastine hcl 133,137
AZELEX 84
AZILECT 47
azithromycin 18
AZOPT 134
AZOR 71
AZULFIDINE 128
AZURETTE 112
Bbacitracin 14
bacitracin/polymyxin b sulfate 131
baclofen 49
BACTRIM 19
BACTRIM DS 20
BACTROBAN 14
BACTROBAN NASAL 14
BALCOLTRA 112
balsalazide disodium 127
BALZIVA 112
BANZEL 24
BARACLUDE 50
BASAGLAR KWIKPEN U-100 62
BAXDELA 19
BD Pen Needles T2. All other manufacturers
T3. 130
BECONASE AQ 136
BEKYREE 112
BELBUCA 7
BELSOMRA 146
BELVIQ 80
BELVIQ XR 80
benazepril hcl 67
benazepril hcl/hydrochlorothiazide 71
BENICAR 67
BENICAR HCT 71
BENLYSTA 127
BENTYL 94
BENZACLIN 84
BENZAMYCIN 14
BENZEPRO 84,85
benznidazole 45
benzonatate 143
benzoyl peroxide 85
benzphetamine hcl 80
benztropine mesylate 46
BEPREVE 133
BERINERT 123
BESIVANCE 19
BETAGAN 134
betamethasone dipropionate 103
betamethasone dipropionate/propylene
glycol 103
betamethasone valerate 103
BETAPACE 68
BETAPACE AF 68
BETASERON 82
betaxolol hcl 69,134
bethanechol chloride 102
140
134
134
143
63
44
112
18
35
71
53
45
135
129
69
71
20
131
131
112
112
129
28
80
39
85
39
94
108
143
112
112
65
BETHKIS
BETIMOL
BETOPTIC S
BEVESPI AEROSPHERE
BEVYXXA
bexarotene
BEYAZ
BIAXIN
bicalutamide
BIDIL
BIKTARVY
BILTRICIDE
bimatoprost 0.03 % drops (into the eye for
glaucoma)
BINOSTO
bisoprolol fumarate
bisoprolol fumarate/hydrochlorothiazide
BLEPH-10
BLEPHAMIDE
BLEPHAMIDE S.O.P.
BLISOVI 24 FE
BLISOVI FE
BONIVA
BONJESTA
BONTRIL PDM
BOSULIF
BPO
BRAFTOVI
BRAND RX PRENATAL VITAMINS ARE T3
AND GENERIC RX PRENATAL VITAMINS
ARE T1
BRAVELLE
BREO ELLIPTA
BREVICON
BRIELLYN
BRILINTA
brimonidine tartrate 134
PAGE 150 LAST UPDATED 01/2019
BRISDELLE 26
BRIVIACT 21
BROMFED DM 143
bromfenac sodium 133
bromocriptine mesylate 46
brompheniramine maleate/pseudoephedrine
hcl/dextromethorphan 143
BROMSITE 133
BROVANA 139
BUCALSEP 12
budesonide 128,136
bumetanide 73
BUNAVAIL 13
BUPAP 80
BUPHENYL 99
buprenorphine hcl 13
buprenorphine hcl/naloxone hcl 13
BUPRENORPHINE PATCH 7
BUPROBAN 14
bupropion hcl 14,25
buspirone hcl 57
butalbital/acetaminophen 80
butalbital/acetaminophen/caffeine 80
butalbital/acetaminophen/caffeine/codeine
phosphate 9
butalbital/aspirin/caffeine 5
BUTISOL SODIUM 146
butorphanol tartrate 9
BUTRANS 7
BYDUREON 58
BYDUREON BCISE 58
BYDUREON PEN 58
BYETTA 58
BYSTOLIC 69
BYVALSON 71
Ccabergoline 121
CABOMETYX 39
CADUET 71
CAFERGOT 33
caffeine citrate 141
CALAN 69
CALAN SR 69
calcipotriene 85
calcipotriene/betamethasone dipropionate 85
calcitonin,salmon,synthetic 129
CALCITRENE 85
calcitriol 129
CALCITRIOL 3 MCG/G OINTMENT 85
calcium acetate 93
CALQUENCE 39
CAMBIA 5
CAMILA 119
CAMRESE 112
CAMRESE LO 112
CANASA 127
candesartan cilexetil 67
candesartan cilexetil/hydrochlorothiazide 71
CAPACET 80
capecitabine 37
CAPEX SHAMPOO 103
CAPITAL W-CODEINE 9
CAPRELSA 39
captopril 67
captopril/hydrochlorothiazide 71
CARAC 85
CARAFATE 98
CARBAGLU 91
carbamazepine 24
CARBATROL 24
carbidopa 47
carbidopa/levodopa 47
carbidopa/levodopa/entacapone 46
carbinoxamine maleate 137
CARDIZEM 70
CARDIZEM CD 70
CARDIZEM LA 70
CARDURA 66
CARDURA XL 101
carisoprodol 144,145
carisoprodol/aspirin 145
carisoprodol/aspirin/codeine phosphate 9
CARNITOR 91
CARNITOR SF 91
CAROSPIR 74
carteolol hcl 134
CARTIA XT 70
carvedilol 69
carvedilol phosphate 69
CASODEX 35
CATAPRES 66
CATAPRES-TTS 66
CAVERJECT 102
CAYSTON 140
CAZIANT 112
CEDAX 17
cefaclor 17
cefadroxil 17
cefdinir 17
cefditoren pivoxil 17
cefixime 17
cefpodoxime proxetil 17
cefprozil 17
CEFTIBUTEN 17
CEFTIN 17
cefuroxime axetil 17
CELEBREX 5
celecoxib 5
CELEXA 26
CELLCEPT 124
CELONTIN 22
CENTANY 14
CENTANY AT 14
CENTERGY DM 143
cephalexin 17
CERDELGA 99
cervical cap 130
CESAMET 29
cetirizine hcl 137
CETRAXAL 19
CETROTIDE 122
CETYLEV 130
PAGE 151 LAST UPDATED 01/2019
cevimeline hcl 83
CHANTIX 14
CHATEAL 112
CHATEAL EQ 112
CHEMET 92
CHENODAL 95
chlordiazepoxide hcl 57
chlordiazepoxide/clidinium bromide 94
chlorhexidine gluconate 83
chloroquine phosphate 45
chlorothiazide 74
chlorpromazine hcl 47
CHLORPROPAMIDE 58
chlorthalidone 74
chlorzoxazone 145
CHOLBAM 99
cholestyramine (with sugar) 75
cholestyramine/aspartame 75
choline salicylate/magnesium salicylate 5
chorionic gonadotropin, human 108
CIALIS 101,102
CICLODAN 30
ciclopirox 30
ciclopirox olamine 30
cilostazol 66
CILOXAN 19
CIMDUO 54
cimetidine 96
cimetidine hcl 96
CIMZIA 124
CINRYZE 123
CIPRO 19
CIPRO HC 136
CIPRO XR 19
CIPRODEX 136
ciprofloxacin 19
ciprofloxacin hcl 19
ciprofloxacin/ciprofloxacin hcl 19
citalopram hydrobromide 26
CLARAVIS 85
CLARINEX 137
CLARINEX-D 12 HOUR 143
clarithromycin 18
clemastine fumarate 137
CLENPIQ 97
CLEOCIN 14
CLEOCIN HCL 14
CLEOCIN PALMITATE 14
CLEOCIN T 15
CLIMARA 112
CLIMARA PRO 112
CLINDACIN ETZ 15
CLINDACIN P 15
CLINDACIN PAC 15
CLINDAGEL 15
clindamycin hcl 15
clindamycin palmitate hcl 15
clindamycin phosphate 15
clindamycin phosphate/benzoyl peroxide 85
clindamycin phosphate/tretinoin 85
CLINDESSE 15
CLINPRO 5000 91
clobazam 22
clobetasol propionate 103
clobetasol propionate/emollient base 103
CLOBEX 103
CLOCORTOLONE PIVALATE 0.1 %
CREAM(G) 103
CLODAN 103
CLODERM 103
clomiphene citrate 121
clomipramine hcl 28
clonazepam 57
clonidine 66
clonidine hcl 66,78
clopidogrel bisulfate 66
clorazepate dipotassium 57
CLORPRES 71
clotrimazole 30
clotrimazole/betamethasone dipropionate 85
clozapine 49
CLOZARIL 49
COARTEM 45
codeine phosphate/butalbital/aspirin/caffeine 9
codeine sulfate 9
COLAZAL 127
COLCHICINE 32
COLCRYS 32
colesevelam hcl 75
COLESTID 75
colestipol hcl 75
COLOCORT 128
COLY-MYCIN S 136
COLYTE WITH FLAVOR PACKETS 97
COMBIGAN 134
COMBIPATCH 112
COMBIVENT RESPIMAT 143
COMBIVIR 54
COMETRIQ 40
COMFORT PAC-CYCLOBENZAPRINE 145
COMFORT PAC-MELOXICAM 130
COMFORT PAC-NAPROXEN 130
COMFORT PAC-TIZANIDINE 145
COMPAZINE 28
COMPLERA 53
COMPRO 28
COMTAN 46
CONCEPTROL 102
CONCERTA 78
condoms, female 130
CONDYLOX 85
CONSTULOSE 97
CONTRAVE 80
CONZIP 7
COPAXONE 82
COPEGUS 52
COPIKTRA 37
CORDARONE 68
CORDRAN 103
COREG 69
COREG CR 69
CORGARD 69
CORLANOR 71
PAGE 152 LAST UPDATED 01/2019
CORMAX 103
CORTEF 104
CORTENEMA 128
CORTIFOAM 128
cortisone acetate 104
CORTISPORIN 85
CORTISPORIN-TC 136
CORZIDE 71
COSENTYX 85
COSOPT 134
COSOPT PF 134
COTELLIC 40
COTEMPLA XR-ODT 78
COUMADIN 63
COVARYX 112
COVARYX H.S. 112
COZAAR 67
CREON 99
CRESEMBA 30
CRESTOR 75
CRINONE 119
CRIXIVAN 55
cromolyn sodium 95,133,141
CROTAN 46
CRYSELLE 112
CUPRIMINE 92
CUROSURF 143
CUTIVATE 104
CUVPOSA 94
cyanocobalamin (vitamin b-12) 94
CYCLAFEM 112
CYCLESSA 112
cyclobenzaprine hcl 145
cyclopentolate hcl 132
CYCLOPHOSPHAMIDE (25 mg CAPSULE, 50
mg CAPSULE) 35
cycloserine 34
CYCLOSET 58
cyclosporine 124
cyclosporine, modified 124
CYMBALTA 81
cyproheptadine hcl 137
CYRED 112
CYSTADANE 99
CYSTAGON 99
CYSTARAN 132
CYTOMEL 121
CYTOTEC 98
CYTRA-K 91
DD.H.E.45 33
DAKLINZA 50
dalfampridine 82
DALIRESP 141
danazol 111
DANTRIUM 49
dantrolene sodium 49
dapsone 34,85
DARAPRIM 45
darifenacin hydrobromide 100
DASETTA 113
DAXBIA 17
DAYPRO 5
DAYSEE 113
DAYTRANA 78
DDAVP 108
DEBLITANE 119
DECADRON 104
DELESTROGEN 113
DELSTRIGO 53
DELTASONE 104
DELYLA 113
DELZICOL 128
DEMADEX 73
demeclocycline hcl 20
DEMEROL 9
DEMSER 71
DENAVIR 56
DENTA 5000 PLUS 91
DENTAGEL 91
DEPAKENE 22
DEPAKOTE 22
DEPAKOTE ER 22
DEPAKOTE SPRINKLE 22
DEPEN 93
DEPO-ESTRADIOL 113
DEPO-SUBQ PROVERA 104 119
DEPO-TESTOSTERONE 111
DERMA-SMOOTHE-FS 104
DERMACINRX CINLONE-I CPI 104
DERMACINRX CLORHEXACIN 85
DERMACINRX EMPRICAINE 12
DERMACINRX LEXITRAL 85
DERMACINRX PRIZOPAK 12
DERMACINRX SILAPAK 104
DERMACINRX SILAZONE 104
DERMACINRX SURGICAL PHARMAPAK 85
DERMACINRX THERAZOLE PAK 85
DERMATOP 104
DERMAZONE 104
DERMOTIC 136
DESCOVY 55
desipramine hcl 28
desloratadine 138
desmopressin acetate 108
desmopressin acetate (non-refrigerated) 108
DESOGEN 113
desogestrel-ethinyl estradiol 113
desogestrel-ethinyl estradiol/ethinyl
estradiol 113
DESONATE 104
desonide 104
DESOWEN 104
desoximetasone 104
DESOXYN 77
DESVENLAFAXINE ER 26
DESVENLAFAXINE FUMARATE 26
desvenlafaxine succinate 26
DETROL 100
DETROL LA 101
dexamethasone 104
DEXAMETHASONE INTENSOL 104
PAGE 153 LAST UPDATED 01/2019
dexamethasone sodium phosphate 133
DEXEDRINE 77,78
DEXILANT 98
dexmethylphenidate hcl 78,79
dextroamphetamine sulf-
saccharate/amphetamine sulf-aspartate 78
dextroamphetamine sulfate 78
DIABETA 58
DIAMOX SEQUELS 73
diaphragms, contoured 130
diaphragms, wide seal 130
DIASTAT 22
DIASTAT ACUDIAL 22
diazepam 22,57
DIBENZYLINE 66
DICLEGIS 28
DICLO GEL 86
DICLO GEL-XRYLIX SHEET 86
diclofenac potassium 5
diclofenac sodium 5,86,133
diclofenac sodium/misoprostol 5
DICLOPR 5
dicloxacillin sodium 18
DICLOZOR 86
dicyclomine hcl 94
didanosine 54
diethylpropion hcl 80
DIFFERIN 86
DIFICID 18
diflorasone diacetate 104
DIFLUCAN 30
diflunisal 5
DIGITEK 71
DIGOX 71
digoxin 71
dihydroergotamine mesylate 33
dihydroergotamine mesylate 0.5mg/spry
spray/pump 33
DILANTIN 24
DILANTIN-125 24
DILATRATE-SR 77
DILAUDID 9
DILT-XR 70
diltiazem hcl 70
DIOVAN 67
DIOVAN HCT 71
DIPENTUM 128
diphenhydramine hcl 138
diphenoxylate hcl/atropine sulfate 95
DIPROLENE 104
DIPROLENE AF 104
dipyridamole 66
DISALCID 5
disopyramide phosphate 68
disulfiram 13
DITHOL 5
DITROPAN XL 101
DIURIL 74
divalproex sodium 22
DIVIGEL 113
dofetilide 68
DOLOPHINE HCL 7
DOLOTRANZ 12
donepezil hcl 24
DOPTELET 64
DORAL 146
DORYX 20
DORYX MPC 20
dorzolamide hcl 134
dorzolamide hcl/timolol maleate 134
dorzolamide hcl/timolol maleate/pf 134
DOVONEX 86
doxazosin mesylate 66
doxepin hcl 28
doxepin hcl 5 % cream (g) 86
doxercalciferol 129
doxycycline hyclate 20
doxycycline monohydrate 20
DOXYCYCLINE MONOHYDRATE 40 mg CAP
IR DR 20
DRISDOL 129
DRITHOCREME HP 86
dronabinol 29
drospirenone/ethinyl estradiol/levomefolate
calcium 113
DROXIA 37
DRYSOL 86
DUAC 86
DUAVEE 121
DUETACT 58
DUEXIS 5
DULERA 143
duloxetine hcl 81
DUPIXENT 86,127
DURAGESIC 7
DUREZOL 133
dutasteride 101
dutasteride/tamsulosin hcl 101
DUTOPROL 71
DUZALLO 32
DYANAVEL XR 78
DYAZIDE 71
DYMISTA 143
DYRENIUM 74
EE.E.S. 200 18
E.E.S. 400 18
EC-NAPROSYN 5
econazole nitrate 30
ECONTRA EZ 119
ECONTRA ONE-STEP 113
ECOZA 30
ED-SPAZ 94
EDARBI 67
EDARBYCLOR 71
EDECRIN 73
EDEX 102
EDLUAR 146
EDURANT 53
EEMT 113
EEMT H.S. 113
efavirenz 54
PAGE 154 LAST UPDATED 01/2019
EFFER-K 91
EFFEXOR XR 26
EFFIENT 66
EFUDEX 37
EGRIFTA 108
ELDEPRYL 47
ELESTAT 133
ELESTRIN 113
eletriptan hydrobromide 33
ELIDEL 86
ELIMITE 46
ELINEST 113
ELIPHOS 93
ELIQUIS 63
ELIXOPHYLLIN 141
ELLA 119
ELLZIA PAK 104
ELMIRON 102
ELOCON 104
EMADINE 133
EMBEDA 7
EMCYT 36
EMEND 29
EMFLAZA 104
EMGALITY 33
EMLA 12
EMOQUETTE 113
EMSAM 26
EMTRIVA 54
EMVERM 45
ENABLEX 101
enalapril maleate 67
enalapril maleate/hydrochlorothiazide 71
ENBREL 124
ENBREL MINI 124
ENBREL SURECLICK 124
ENDARI 91
ENDOCET 9
ENDOMETRIN 119
ENJUVIA 113
enoxaparin sodium 63
ENPRESSE 113
ENSKYCE 113
ENSTILAR 86
entacapone 46
entecavir 50
Enteral Formula Requires Prior Authorization.
Brands are Tier 3 & generics are Tier 1. 94
ENTEREG 95
ENTOCORT EC 128
ENTRESTO 72
ENULOSE 97
ENVARSUS XR 124
EPANDED SOLUTION 67
EPCLUSA 50
EPIDIOLEX 21
EPIDUO 86
EPIDUO FORTE 86
EPIFOAM 86
epinastine hcl 133
epinephrine 139
EPIPEN 139
EPIPEN 2-PAK 139
EPIPEN JR 2-PAK 139
EPITOL 24
EPIVIR 54
EPIVIR HBV 50
eplerenone 74
EPOGEN 64
eprosartan mesylate 67
EPZICOM 54
EQUETRO 57
ergocalciferol (vitamin d2) 129
ergoloid mesylates 24
ERGOMAR 33
ergotamine tartrate/caffeine 33
ERIVEDGE 40
ERLEADA 35
ERRIN 119
ERTACZO 30
ERY 18
ERY-TAB 18
ERYGEL 18
ERYPED 200 18
ERYPED 400 18
ERYTHROCIN STEARATE 18
erythromycin base 18
erythromycin base in ethanol 18
erythromycin base/benzoyl peroxide 15
erythromycin ethylsuccinate 18
ESBRIET 142
escitalopram oxalate 26
ESGIC 80
ESOMEP-EZS 98
esomeprazole magnesium 98
esomeprazole strontium 98
ESTARYLLA 113
estazolam 146
ESTRACE 113
estradiol 113
estradiol valerate 113
estradiol/norethindrone acetate 113
ESTRING 113
ESTROGEL 113
estrogens,esterified/methyltestosterone 113
estropipate 114
ESTROSTEP FE 114
eszopiclone 146
ethacrynic acid 73
ethambutol hcl 34
ethinyl estradiol/drospirenone 114
ethosuximide 22
ethynodiol diacetate-ethinyl estradiol 114
etidronate disodium 129
etodolac 5
etoposide 39
EUCRISA 86
EURAX 46
EVAMIST 114
EVEKEO 78
EVISTA 121
EVOCLIN 15
EVOTAZ 55
PAGE 155 LAST UPDATED 01/2019
EVOXAC 83
EXALGO 7
EXELDERM 30
EXELON 24
exemestane 38
EXFORGE 72
EXFORGE HCT 72
EXJADE 93
EXTAVIA 82
EXTINA 30
ezetimibe 76
ezetimibe/simvastatin 76
FFABIOR 86
FACTIVE 19
FALLBACK SOLO 119
FALMINA 114
famciclovir 56
famotidine 96
FAMVIR 56
FANAPT 48
FARESTON 36
FARXIGA 58
FARYDAK 40
FAYOSIM 114
FAZACLO 49
felbamate 23
FELBATOL 23
FELDENE 5
felodipine 70
FEM PH 102
FEMARA 38
FEMCON FE 114
FEMHRT 114
FEMRING 114
FEMYNOR 114
fenofibrate 74
fenofibrate nanocrystallized 74
fenofibrate,micronized 74
fenofibric acid 74
fenofibric acid (choline) 74
FENOGLIDE 74
fenoprofen calcium 6
FENOPROFEN CALCIUM (200 mg CAPSULE,
400 mg CAPSULE) 5
FENORTHO 6
fentanyl 8
FENTANYL (37.5mcg/hr patch td72,
62.5mcg/hr patch td72, 87.5mcg/hr patch
td72) 8
fentanyl citrate 9
FENTORA 9
FERRIPROX 93
FETZIMA 26
FEXMID 145
FIASP 62
FIASP FLEXTOUCH 62
FIBRICOR 74
FINACEA 86
finasteride 101
FIORICET 80
FIORICET WITH CODEINE 9
FIORINAL 6
FIORINAL WITH CODEINE #3 9
FIRAZYR 123
FIRVANQ 15
FLAGYL 15
FLAGYL ER 15
FLAREX 133
flavoxate hcl 101
flecainide acetate 68
FLECTOR 6
FLEXIPAK 130
FLOLIPID 75
FLOMAX 101
FLOVENT DISKUS 136
FLOVENT HFA 136
FLOWTUSS 143
FLOXIN 19
fluconazole 30
flucytosine 30
fludrocortisone acetate 105
FLUMADINE 56
flunisolide 136
fluocinolone acetonide 105
fluocinolone acetonide oil 136
fluocinolone acetonide/shower cap 105
fluocinonide 105
fluocinonide/emollient base 105
fluorometholone 133
FLUOROPLEX 86
fluorouracil 37
FLUOROURACIL 0.5% CREAM 86
fluoxetine hcl 26
fluphenazine decanoate 47
fluphenazine hcl 48
flurandrenolide 105
flurazepam hcl 146
flurbiprofen 6
flurbiprofen sodium 133
flutamide 35
fluticasone propionate 105,136
fluticasone propionate/salmeterol xinafoate 143
fluvastatin sodium 75
fluvoxamine maleate 26
FML 133
FML FORTE 134
FML S.O.P. 134
foam/gauze
bandage/lidocaine/chlorhexidine/isopropyl
alcohol 130
FOCALIN 79
FOCALIN XR 79
folic acid 94
FOLLISTIM AQ 108
fondaparinux sodium 63
FORADIL 139
FORFIVO XL 25
FORTAMET 58
FORTEO 129
FORTESTA 111
FORTICAL 129
PAGE 156 LAST UPDATED 01/2019
FOSAMAX 129
FOSAMAX PLUS D 129
fosinopril sodium 67
fosinopril sodium/hydrochlorothiazide 72
FOSRENOL 93
FRAGMIN 63
FREESTYLE FREEDOM LITE METER 61
FREESTYLE INSULINX GLUCOSE SYS 61
FREESTYLE INSULINX TEST STRIPS 61
FREESTYLE LITE METER 61
FREESTYLE LITE TEST STRIPS 61
FREESTYLE PREC NEO TEST STRIPS 61
FREESTYLE PRECISION NEO METER 61
FREESTYLE TEST STRIPS 61
FROVA 33
frovatriptan succinate 33
FULPHILA 64
FULYZAQ 95
FURADANTIN 15
furosemide 73
FYAVOLV 114
FYCOMPA 23
Ggabapentin 22
GABITRIL 22
GALAFOLD 99
galantamine hbr 25
GALZIN 93
GANIRELIX ACETATE 122
GASTROCROM 95
gatifloxacin 19
GATTEX 95
GAVILYTE-C 97
GAVILYTE-G 97
GAVILYTE-H AND BISACODYL 97
GAVILYTE-N 97
GELNIQUE 101
gemfibrozil 74
GENERESS FE 114
GENERLAC 97
GENGRAF 124
GENOTROPIN 108
GENTAK 14
gentamicin sulfate 14
GENVOYA 53
GEODON 48
GIALAX 97
GIANVI 114
GIAZO 128
GILDAGIA 114
GILDESS 24 FE 114
GILENYA 82
GILOTRIF 40
glatiramer acetate 82
GLATOPA 83
GLEEVEC 40
GLEOSTINE 35
glimepiride 58
glipizide 58
glipizide/metformin hcl 58
GLUCAGEN 61
GLUCAGON EMERGENCY KIT 61
GLUCOPHAGE 58
GLUCOPHAGE XR 59
GLUCOTROL 59
GLUCOTROL XL 59
GLUCOVANCE 59
GLUMETZA 59
glyburide 59
glyburide,micronized 59
glyburide/metformin hcl 59
GLYCATE 94
glycopyrrolate 94
GLYDO 12
GLYNASE 59
GLYSET 59
GLYXAMBI 59
GOCOVRI 46
GOLYTELY 97
Gonal-f 108
GONITRO 77
GORDON'S UREA 87
GRALISE 22
granisetron hcl 29
GRANIX 64
GRASTEK 127
GRIFULVIN V 30
GRIS-PEG 30
griseofulvin ultramicrosize 30
griseofulvin, microsize 30
guaifenesin/hydrocodone bitartrate 143
guanfacine hcl 66,79
GUANIDINE HCL 34
GYNAZOLE 1 30
GYNOL II 102
HH.P. ACTHAR 105
HAEGARDA 123
HALCION 146
halobetasol propionate 105
HALOG 105
haloperidol 48
haloperidol lactate 48
HARVONI 50
HEATHER 119
HECTOROL 129
HEMANGEOL 37
HEMMOREX-HC 105
HEPSERA 50
HETLIOZ 146
HEXALEN 35
HIPREX 15
HORIZANT 80
HUMALOG 62
HUMALOG JUNIOR KWIKPEN 62
HUMALOG KWIKPEN U-100 62
HUMALOG KWIKPEN U-200 62
HUMALOG MIX 50-50 62
HUMALOG MIX 50-50 KWIKPEN 62
HUMALOG MIX 75-25 62
HUMALOG MIX 75-25 KWIKPEN 62
PAGE 157 LAST UPDATED 01/2019
HUMATROPE 109
Humira 125
HUMULIN 70-30 62
HUMULIN 70/30 KWIKPEN 62
HUMULIN N 62
HUMULIN N KWIKPEN 62
HUMULIN R 62
HUMULIN R U-500 62
HUMULIN R U-500 KWIKPEN 62
HYCAMTIN 39
HYCET 9
HYCOFENIX 143
hydralazine hcl 76
HYDREA 37
hydrochlorothiazide 74
hydrocodone bitart/chlorpheniramine
maleate/pseudoephedrine 143
hydrocodone bitartrate/acetaminophen 10
hydrocodone bitartrate/homatropine
methylbromide 143
hydrocodone polistirex/chlorpheniramine
polistirex 143
hydrocodone/ibuprofen 10
hydrocortisone 105,128
hydrocortisone acetate 105
hydrocortisone acetate/iodoquinol/aloe vera 87
hydrocortisone acetate/lidocaine hcl/aloe
vera 87
hydrocortisone acetate/pramoxine hcl 87
hydrocortisone butyrate 105
hydrocortisone butyrate/emollient base 105
hydrocortisone valerate 105
hydrocortisone/acetic acid 136
hydrocortisone/mineral oil/petrolatum,white 105
HYDROMET 143
hydromorphone hcl 8,10
hydroquinone microspheres 87
hydroxychloroquine sulfate 45
hydroxyurea 37
hydroxyzine hcl 138
hydroxyzine pamoate 138
HYOPHEN 15
hyoscyamine sulfate 95
HYOSYNE 95
HYSINGLA ER 8
HYZAAR 72
Iibandronate sodium 129
IBRANCE 40
IBU 6
IBUDONE 10
ibuprofen 6
ibuprofen/oxycodone hcl 10
ICAR-C PLUS 91
ICLUSIG 40
IDHIFA 37
ILEVRO 134
ILOTYCIN 18
imatinib mesylate 40
IMBRUVICA 41
imipramine hcl 28
imipramine pamoate 28
imiquimod 87
IMITREX 33
IMPAVIDO 45
IMPOYZ 105
IMURAN 125
IMVEXXY 114
INCASSIA 119
INCRELEX 109
INCRUSE ELLIPTA 138
indapamide 74
INDERAL LA 69
INDERAL XL 69
INDOCIN 6
indomethacin 6
INFLAMMACIN 130
INGREZZA 80
INLYTA 41
INNOPRAN XL 69
INSPRA 74
INTELENCE 54
INTERMEZZO 146
INTRAROSA 130
INTRON A 52
INTROVALE 114
INTUNIV 79
INVEGA 48
INVIRASE 55
INVOKAMET 59
INVOKAMET XR 59
INVOKANA 59
IOPIDINE 134
ipratropium bromide 138
ipratropium bromide/albuterol sulfate 143
IPRIVASK 63
irbesartan 67
irbesartan/hydrochlorothiazide 72
IRENKA 81
IRESSA 41
ISENTRESS 53
ISENTRESS HD 53
ISIBLOOM 114
isometheptene
mucate/dichloralphenazone/acetaminophen 13
0
isoniazid 34
ISOPTO ATROPINE 132
ISOPTO CARPINE 135
ISORDIL 77
ISORDIL TITRADOSE 77
isosorbide dinitrate 77
isosorbide mononitrate 77
isoxsuprine hcl 72
isradipine 70
ISTALOL 135
itraconazole 30
ivermectin 45
JJadenu 93
JAKAFI 41
PAGE 158 LAST UPDATED 01/2019
JALYN 101
JANTOVEN 63
JANUMET 59
JANUMET XR 59
JANUVIA 59
JARDIANCE 59
JENCYCLA 120
JENTADUETO 59
JENTADUETO XR 59
JEVANTIQUE LO 114
JINTELI 114
JOLESSA 114
JOLIVETTE 120
JUBLIA 30
JULEBER 114
JULUCA 55
JUNEL 114
JUNEL FE 114
JUNEL FE 24 114
JUXTAPID 76
JYNARQUE 93
KK EFFERVESCENT 91
K-PHOS NO.2 102
K-PHOS ORIGINAL 102
K-SOL 91
K-TAB ER 91
KADIAN 8
KAITLIB FE 114
KALETRA 55
KALYDECO 140
KAPSPARGO SPRINKLE 69
KAPVAY 79
KARBINAL ER 138
KARIVA 114
KAYEXALATE 93
KAZANO 59
KEFLEX 17
KELNOR 1-35 115
KELNOR 1-50 115
KENALOG 105
KEPPRA 21
KEPPRA XR 21
KERYDIN 30
ketoconazole 30
KETODAN 30
ketoprofen 6
ketorolac tromethamine 6,134
KEVEYIS 73
KEVZARA 127
KHEDEZLA 26
KIMIDESS 115
KINERET 125
KIONEX 93
KISQALI 41
KISQALI FEMARA CO-PACK 41
KITABIS PAK 140
KLARON 20
KLONOPIN 57
KLOR-CON 92
KLOR-CON 10 92
KLOR-CON 8 92
KLOR-CON M10 92
KLOR-CON M15 92
KLOR-CON M20 92
KLOR-CON SPRINKLE 92
KLOR-CON-EF 92
KOMBIGLYZE XR 59
KORLYM 105
KRISTALOSE 97
KURVELO 115
KUVAN 99
KYLEENA 120
KYNAMRO 76
Llabetalol hcl 69
LACRISERT 132
lactic acid 87
lactulose 97
LAMICTAL 23
LAMICTAL (BLUE) 23
LAMICTAL (GREEN) 23
LAMICTAL (ORANGE) 23
LAMICTAL ODT 23
LAMICTAL XR 23
LAMISIL 31
lamivudine 50,54
lamivudine/zidovudine 54
lamotrigine 23
LANOXIN 72
lansoprazole 98
lansoprazole/amoxicillin
trihydrate/clarithromycin 95
lanthanum carbonate 93
LANTUS 62
LANTUS SOLOSTAR 62
LARIN 115
LARIN 24 FE 115
LARIN FE 115
LARISSIA 115
LASIX 73
LASTACAFT 133
latanoprost 135
LATUDA 48
LAYOLIS FE 115
LAZANDA 10
LEENA 115
leflunomide 127
LENVIMA 41
LESCOL 75
LESCOL XL 75
LESSINA 115
LETAIRIS 141
letrozole 39
leucovorin calcium 37
LEUKERAN 35
LEUKINE 64
leuprolide acetate 122
levalbuterol hcl 139
levalbuterol tartrate 139
LEVAQUIN 19
PAGE 159 LAST UPDATED 01/2019
LEVATOL 69
LEVBID 95
LEVEMIR 62
LEVEMIR FLEXTOUCH 62
levetiracetam 21
LEVITRA 102
LEVO-T 121
levobunolol hcl 135
levocarnitine 92
levocarnitine (with sugar) 92
levocetirizine dihydrochloride 138
levofloxacin 19
LEVONEST 115
levonorgestrel 115
levonorgestrel-ethinyl estradiol 115
levonorgestrel/ethinyl estradiol and ethinyl
estradiol 115
LEVORA-28 115
levorphanol tartrate 8
levothyroxine sodium 121
LEVOXYL 121
LEVSIN 95
LEVSIN-SL 95
LEVULAN 87
LEXAPRO 26
LEXIVA 56
LEXIXRYL 87
LIALDA 128
LIBRAX 95
LIDO-K 12
LIDO-PRILO CAINE PACK 12
lidocaine 12
lidocaine hcl 12
lidocaine hcl/hydrocortisone acetate 87
lidocaine/prilocaine 12
LIDODERM 12
LIDOPAC 12
LIDOPIN 12
LIDOPRIL 12
LIDOPRIL XR 12
LIDOTRANS 5 PAK 12
LILETTA 120
LILLOW 115
lindane 46
linezolid 15
LINZESS 97
liothyronine sodium 121
LIPITOR 75
LIPOCHOL PLUS 74
LIPOFEN 74
LIPROZONEPAK 13
lisinopril 67
lisinopril/hydrochlorothiazide 72
lithium carbonate 57
lithium citrate 57
LITHOBID 57
LITHOSTAT 102
LIVALO 75
LO LOESTRIN FE 115
LOCOID 105
LOCOID LIPOCREAM 105
LODINE 6
LODOSYN 47
LOESTRIN 115
LOESTRIN FE 115
LOFIBRA 74,75
LOKELMA 130
LOMAIRA 80
LOMEDIA 24 FE 115
LOMOTIL 96
lomustine 35
LONHALA MAGNAIR REFILL 138
LONHALA MAGNAIR STARTER 139
LONSURF 38
LOPID 75
lopinavir/ritonavir 56
LOPREEZA 115
LOPRESSOR 69
LOPRESSOR HCT 72
LOPROX 31
lorazepam 57
LORAZEPAM INTENSOL 57
LORCET 10
LORCET HD 10
LORCET PLUS 10
LORTAB 10
LORYNA 115
LORZONE 145
losartan potassium 67
losartan potassium/hydrochlorothiazide 72
LOSEASONIQUE 115
LOTEMAX 134
LOTENSIN 67
LOTENSIN HCT 72
LOTREL 72
LOTRISONE 87
LOTRONEX 97
lovastatin 75
LOVAZA 76
LOVENOX 63
LOW-OGESTREL 115
loxapine succinate 48
LUCEMYRA 13
luliconazole 31
LUMIGAN 135
LUNESTA 146
LUPANETA PACK 122
LUTERA 115
LUXIQ 105
LUZU 31
LYNPARZA 41
LYRICA 81
LYRICA CR 81
LYSODREN 38
LYSTEDA 65
LYZA 120
MMACROBID 15
MACRODANTIN 15
MALARONE 45
malathion 46
maprotiline hcl 27
PAGE 160 LAST UPDATED 01/2019
MARINOL 29
MARLISSA 115
MARPLAN 26
MARTEN-TAB 80
MATULANE 35
MATZIM LA 70
MAVIK 67
MAVYRET 50
MAXALT 33
MAXALT MLT 33
MAXIDEX 134
MAXITROL 132
MAXZIDE 72
MAXZIDE-25 MG 72
meclizine hcl 28
MECLOFENAMATE SODIUM 6
MEDOLOR PAK 13
MEDROL 105
medroxyprogesterone acetate 120
mefenamic acid 6
mefloquine hcl 45
MEGACE 120
MEGACE ES 120
megestrol acetate 120
MEKINIST 42
MEKTOVI 42
MELODETTA 24 FE 116
meloxicam 6
MELOXICAM 7.5 MG/5 ML ORAL SUSP 6
melphalan 35
memantine hcl 25
MENEST 116
MENOPUR 109
MENOSTAR 116
MENTAX 31
meperidine hcl 10
MEPHYTON 65
meprobamate 57
MEPRON 45
mercaptopurine 37
mesalamine 128
MESALAMINE 800 MG TABLET DR 128
mesalamine with cleansing wipes 128
MESNEX 45
MESTINON 34
METADATE CD 79
METADATE ER 79
metaproterenol sulfate 139
METAXALL 145
metaxalone 145
metformin er 500mg & 1000mg tab (generic
version of glumetza) 59
metformin hcl 59,60
methadone hcl 8
METHADONE INTENSOL 8
METHADOSE 8
methamphetamine hcl 78
methazolamide 135
methenamine hippurate 15
methenamine mandelate 15
methenamine/sod
phosph,monobasic/methylene
blue/hyoscyamine 15
METHERGINE 130
methimazole 123
METHITEST 111
methocarbamol 145
methotrexate sodium 125
methotrexate sodium/pf 125
methoxsalen 87
methscopolamine bromide 95
methyclothiazide 74
methyldopa 66
methyldopa/hydrochlorothiazide 72
methylergonovine maleate 130
METHYLIN 79
methylphenidate hcl 79
methylprednisolone 105
methyltestosterone 111
metipranolol 135
metoclopramide hcl 28
metolazone 74
metoprolol succinate 69
metoprolol succinate/hydrochlorothiazide 72
metoprolol tartrate 69
metoprolol tartrate/hydrochlorothiazide 72
METOZOLV ODT 28
METROCREAM 87
METROGEL 87
METROGEL-VAGINAL 15
METROLOTION 87
metronidazole 15,87
mexiletine hcl 68
MIACALCIN 129
MIBELAS 24 FE 116
MICARDIS 67
MICARDIS HCT 72
miconazole nitrate 31
MICORT-HC 87,106
MICROCYN 87
MICROCYN HYDROGEL 87
MICROGESTIN 116
MICROGESTIN 24 FE 116
MICROGESTIN FE 116
MICROZIDE 74
midazolam hcl 57
midodrine hcl 66
MIFEPREX 106
MIGERGOT 33
miglitol 60
miglustat 99
MIGRANAL 33
MILI 116
MILLIPRED 106
MILLIPRED DP 106
MIMVEY 116
MIMVEY LO 116
MINASTRIN 24 FE 116
MINIPRESS 66
MINITRAN 77
MINIVELLE 116
MINOCIN 20
minocycline hcl 20
PAGE 161 LAST UPDATED 01/2019
MINOLIRA ER 20
minoxidil 76
MIRAPEX 46
MIRAPEX ER 46
MIRCETTE 116
MIRENA 120
mirtazapine 25
misoprostol 98
MITIGARE 32
MITOSOL 132
MOBIC 6
modafinil 147
MODERIBA 52
moexipril hcl 67
moexipril hcl/hydrochlorothiazide 72
molindone hcl 48
mometasone furoate 106,136
MONDOXYNE NL 21
MONO-LINYAH 116
MONODOX 21
MONONESSA 116
montelukast sodium 138
MONUROL 15
MORGIDOX 21
MORPHABOND ER 8
morphine sulfate 8,10
morphine sulfate (15 mg tablet, 30 mg tablet)
10
MOTOFEN 96
MOVANTIK 96
MOVIPREP 97
MOXATAG 18
MOXEZA 19
moxifloxacin hcl 19
MOZOBIL 64
MS CONTIN 8
MULPLETA 64
MULTAQ 68
mupirocin 16
mupirocin calcium 16
MUSE 102
MY CHOICE 116
MY WAY 116
MYALEPT 96
MYAMBUTOL 34
MYCOBUTIN 34
mycophenolate mofetil 125
mycophenolate sodium 125
MYDAYIS 78
MYFORTIC 125
MYLERAN 35
MYORISAN 87
MYRBETRIQ 101
MYSOLINE 22
MYTESI 96
MYZILRA 116
Nnabumetone 6
nadolol 69
nadolol/bendroflumethiazide 72
naftifine hcl 31
NAFTIN 31
NALFON 6
NALOCET 10
naloxone hcl 13
naltrexone hcl 13
NAMENDA 25
NAMENDA XR 25
NAMZARIC 25
NAPHAZOLINE 0.1% 132
NAPRELAN 6
NAPROSYN 6
naproxen 6
NAPROXEN 125 MG/5 ML ORAL SUSP 6
naproxen sodium 6
naratriptan hcl 33
NARCAN 13
NARDIL 26
NASCOBAL 94
NASONEX 136
NATACYN 31
NATAZIA 116
nateglinide 60
NATESTO 111
NATPARA 129
NATROBA 87
NATURE-THROID 121
NEBUPENT 45
NEBUSAL 143
NECON 116
nefazodone hcl 27
NEO-POLYCIN 132
NEO-POLYCIN HC 132
NEO-SYNALAR 87
neomycin sulfate 14
neomycin sulfate/bacitracin zinc/polymyxin
b/hydrocortisone 132
neomycin sulfate/bacitracin/polymyxin b 132
neomycin sulfate/polymyxin b
sulfate/gramicidin d 132
neomycin sulfate/polymyxin b
sulfate/hydrocortisone 132,136
neomycin/polymyxin b
sulfate/dexamethasone 132
NEORAL 125
NEOSPORIN 132
NEPTAZANE 135
NERLYNX 42
NESINA 60
NESTABS ONE 92
NEUAC 87
NEULASTA 64
NEUPOGEN 65
NEUPRO 46
NEURCAINE 13
NEURONTIN 22
NEVANAC 134
nevirapine 54
NEVIRAPINE 50 MG/5 ML ORAL SUSP 54
NEW DAY 116
NEXAVAR 42
NEXIUM 98
PAGE 162 LAST UPDATED 01/2019
NEXPLANON 120
NEXT CHOICE ONE DOSE 120
niacin 76
NIACOR 76
NIASPAN 76
nicardipine hcl 70
NICOTROL 14
NICOTROL NS 14
NIFEDICAL XL 70
nifedipine 70
NIKKI 116
NILANDRON 36
nilutamide 36
nimodipine 70
NINLARO 38
nisoldipine 70
NITRO-BID 77
NITRO-DUR 77
NITRO-TIME 77
nitrofurantoin 16
nitrofurantoin macrocrystal 16
nitrofurantoin monohydrate/macrocrystals 16
nitroglycerin 77
NITROLINGUAL 77
NITROMIST 77
NITROSTAT 77
NITYR 99
NIVESTYM 65
nizatidine 96
NIZORAL 31
NOCDURNA 109
NOCTIVA 109
NODOLOR 130
NOLIX 106
NOR-Q-D 120
NORA-BE 120
NORCO 10
NORDITROPIN FLEXPRO 109
norethindrone 120
norethindrone acetate 120
norethindrone acetate-ethinyl estradiol 116
norethindrone acetate-ethinyl estradiol/ferrous
fumarate 116
norethindrone-ethinyl estradiol/ferrous
fumarate 116
norgestimate-ethinyl estradiol 116
NORINYL 1-35 116
NORITATE 87
NORLYDA 120
NORLYROC 120
NORPACE 68
NORPACE CR 68
NORPRAMIN 28
NORTHERA 66
NORTREL 117
nortriptyline hcl 28
NORVASC 70
NORVIR 56
NOVACORT 87
NOVAREL 109
NOVOLIN 70-30 62
NOVOLIN 70-30 FLEXPEN 62
NOVOLIN N 62
NOVOLIN R 62
NOVOLOG 62
NOVOLOG FLEXPEN 63
NOVOLOG MIX 70-30 63
NOVOLOG MIX 70-30 FLEXPEN 63
NOXAFIL 31
NP THYROID 121
NUCORT 106
NUCYNTA 10
NUCYNTA ER 8
NUDICLO 87,130
NUDROXIPAK 6
NUDROXIPAK DSDR-50 130
NUDROXIPAK DSDR-75 131
NUDROXIPAK E-400 131
NUDROXIPAK I-800 131
NUDROXIPAK N-500 131
NUEDEXTA 80
NULEV 95
NULYTELY WITH FLAVOR PACKS 97
NUMBONEX 13
NUOX 87
NUPLAZID 48
NUTRESTORE 92
NUTRIARX 106
NUTROPIN AQ 109
NUVARING 117
NUVESSA 16
NUVIGIL 147
NYAMYC 31
NYATA 31
NYMALIZE 70
nystatin 31
nystatin/triamcinolone acetonide 31
NYSTOP 31
OOB COMPLETE PETITE 94
OBREDON 143
OCALIVA 99
OCELLA 117
octreotide acetate 122
OCUFEN 134
OCUFLOX 19
ODACTRA 131
ODEFSEY 54
ODOMZO 42
OFEV 142
ofloxacin 19
OGESTREL 117
olanzapine 48
olanzapine/fluoxetine hcl 25
OLEPTRO ER 27
olmesartan medoxomil 67
olmesartan medoxomil/amlodipine
besylate/hydrochlorothiazide 72
olmesartan medoxomil/hydrochlorothiazide 72
olopatadine hcl 133,138
OLUMIANT 125
OLUX 106
PAGE 163 LAST UPDATED 01/2019
OLUX-E 106
OLYSIO 51
OMECLAMOX-PAK 96
omega-3 acid ethyl esters 76
omeprazole 98
omeprazole/sodium bicarbonate 98
OMNARIS 136
OMNIPRED 134
OMNITROPE 109
ondansetron 29
ondansetron hcl 29
ONETOUCH ULTRA TEST STRIP 61
ONETOUCH ULTRA2 GLUCOSE SYST 61
ONETOUCH ULTRAMINI METER 61
ONETOUCH VERIO FLEX SYSTEM KIT 61
ONETOUCH VERIO IQ SYSTEM KIT 61
ONETOUCH VERIO METER SYSTEM 61
ONETOUCH VERIO SYNC SYST KIT 61
ONETOUCH VERIO TEST STRIP 61
ONEXTON 88
ONFI 22
ONGLYZA 60
ONMEL 31
ONZETRA XSAIL 33
OPANA 10
OPCICON ONE-STEP 120
opium tincture 96
opium/belladonna alkaloids 10
OPSUMIT 141
OPTION 2 120
ORACEA 21
ORACIT 92
Oralair 127
ORALONE 83
ORAP 48
ORAPRED ODT 106
ORAVIG 31
ORENCIA 125
ORENITRAM ER 141
ORFADIN 99
ORILISSA 122
ORKAMBI 140
orphenadrine citrate 145
ORSYTHIA 117
ORTHO MICRONOR 120
ORTHO TRI-CYCLEN 117
ORTHO TRI-CYCLEN LO 117
ORTHO-CYCLEN 117
ORTHO-NOVUM 117
OSCIMIN 95
OSCIMIN SL 95
OSCIMIN SR 95
oseltamivir phosphate 56
OSENI 60
OSMOLEX ER 46
OSMOPREP 97
OSPHENA 121
OTEZLA 127
OTIPRIO 19
OTOVEL 136
OTREXUP 125
OVACE 88
OVACE PLUS 88
OVACE PLUS WASH 88
OVCON-35 117
OVIDE 46
OVIDREL 109
OXANDRIN 110
oxandrolone 110
oxaprozin 6
OXAYDO 10
oxazepam 57
oxcarbazepine 24
OXECTA 10
oxiconazole nitrate 31
OXISTAT 31
OXSORALEN-ULTRA 88
OXTELLAR XR 24
oxybutynin chloride 101
OXYCODONE 10MG/0.5ML ORAL
SYRINGE 10
oxycodone hcl 10
OXYCODONE HCL ER 8
oxycodone hcl/acetaminophen 11
oxycodone hcl/aspirin 11
OXYCONTIN 8
oxymorphone hcl 8,11
OXYTROL 101
OZEMPIC 60
PPACERONE 68
PACNEX 88
PACNEX HP 88
PACNEX LP 88
PAINGO KFT 13
paliperidone 48
PALYNZIQ 100
PAMELOR 28
PANCREAZE 100
PANCRELIPASE 5,000 100
PANDEL 106
PANLOR 11
PANRETIN 44
pantoprazole sodium 98
PARAFON FORTE DSC 145
PARAGARD T 380-A 131
paregoric 96
PAREMYD 132
paricalcitol 129
PARLODEL 47
PARNATE 26
PAROEX 83
paromomycin sulfate 14
paroxetine hcl 27
paroxetine mesylate 27
PASER 34
PATADAY 133
PATANASE 138
PATANOL 133
PAXIL 27
PAXIL CR 27
PAZEO 133
PAGE 164 LAST UPDATED 01/2019
PCE 18
PEDIADERM HC 106
PEDIAPRED 106
peg 3350/sod sulf/sod bicarb/sod
chloride/potassium chloride 97
PEG-PREP 97
PEGANONE 24
PEGASYS 52
PEGASYS PROCLICK 52
PEGINTRON 52
PEGINTRON REDIPEN 52
penicillin v potassium 18
PENLAC 31
PENNSAID 6
PENTASA 128
pentazocine hcl/naloxone hcl 11
pentoxifylline 72
PEPCID 96
PERCOCET 11
PERFOROMIST 139
PERIDEX 83
perindopril erbumine 67
PERIOGARD 83
permethrin 46
perphenazine 29
perphenazine/amitriptyline hcl 25
PERSANTINE 66
PERTZYE 100
PEXEVA 27
PHENADOZ 29
phenazopyridine hcl 102
phendimetrazine tartrate 80
phenelzine sulfate 26
PHENERGAN 29
phenobarbital 23
phenoxybenzamine hcl 66
phentermine hcl 80
phenylephrine hcl 132
phenylephrine hcl/promethazine hcl 144
PHENYTEK 24
phenytoin 24
phenytoin sodium extended 24
PHILITH 117
PHOSLO 93
PHOSLYRA 93
PHOSPHASAL 16
PHOSPHOLINE IODIDE 135
phytonadione (vit k1) 65
PICATO 88
PIFELTRO 54
pilocarpine hcl 83,135
pimozide 48
PIMTREA 117
pindolol 69
pioglitazone hcl 60
pioglitazone hcl/glimepiride 60
pioglitazone hcl/metformin hcl 60
PIRMELLA 117
piroxicam 7
PLAN B ONE-STEP 117
PLAQUENIL 45
PLAVIX 66
PLEGRIDY 83
PLEGRIDY PEN 83
PLENVU 97
PLETAL 66
PLEXION 88
PLIXDA 88
podofilox 88
POLYCIN 132
polyethylene glycol 3350 98
polymyxin b sulfate/trimethoprim 132
POLYTRIM 132
POMALYST 36
PONSTEL 7
PORTIA 117
POTABA 94
potassium bicarbonate/citric acid 92
potassium chloride 92
potassium chloride/potassium bicarbonate/citric
acid 92
potassium citrate 92
potassium citrate/citric acid 92
POTIGA 21
PR BENZOYL PEROXIDE 88
PRADAXA 63
PRALUENT 76
PRAMCORT 88
pramipexole di-hcl 47
PRAMOSONE 88
PRAMOSONE E 88
PRANDIN 60
prasugrel hcl 66
PRAVACHOL 75
pravastatin sodium 75
praziquantel 45
prazosin hcl 67
PRECISION XTRA MONITOR 61
PRECISION XTRA TEST STRIPS 61
PRECOSE 60
PRED FORTE 134
PRED MILD 134
PRED-G 132
prednicarbate 106
prednisolone 106
prednisolone acetate 134
prednisolone sod phosphate 106,134
prednisone 106
PREDNISONE INTENSOL 106
PREFEST 117
PREGNYL 110
PREMARIN 117
PREMPHASE 117
PREMPRO 117
PREPOPIK 98
PRESTALIA 72
PREVACID 98
PREVALITE 76
PREVIDENT 92
PREVIDENT 5000 92
PREVIDENT 5000 ENAMEL PROTECT 92
PREVIDENT 5000 PLUS 92
PREVIDENT 5000 SENSITIVE 92
PAGE 165 LAST UPDATED 01/2019
PREVIDOLRX PLUS ANALGESIC PAK 131
PREVIFEM 117
PREVPAC 96
PREVYMIS 50
PREZCOBIX 56
PREZISTA 56
PRIFTIN 34
PRILOLID 13
PRILOSEC 98
PRIMAQUINE PHOSPHATE 45
primidone 23
PRIMLEV 11
PRIMSOL 16
PRINIVIL 67
PRISTIQ 27
PROAIR HFA 139
PROAIR RESPICLICK 139
probenecid 32
probenecid/colchicine 32
PROCARDIA 70
PROCARDIA XL 70
PROCENTRA 78
prochlorperazine 29
prochlorperazine maleate 29
PROCORT 88
PROCRIT 65
PROCTO-MED HC 106
PROCTO-PAK 106
PROCTOCORT 106
PROCTOFOAM-HC 88
PROCTOSOL-HC 106
PROCTOZONE-HC 106
PROCYSBI 100
PROFENO 7
progesterone 120
progesterone, micronized 120
PROGLYCEM 61
PROGRAF 125
PROLENSA 134
PROMACTA 65
promethazine hcl 29,138
promethazine hcl/codeine 144
promethazine hcl/dextromethorphan hbr 144
promethazine/phenylephrine hcl/codeine 144
PROMETHEGAN 29
PROMETRIUM 120
propafenone hcl 68
propantheline bromide 95
proparacaine hcl 132
propranolol hcl 69
propranolol hcl/hydrochlorothiazide 72
propylthiouracil 123
PROSCAR 101
PROTONIX 99
PROTOPIC 88
protriptyline hcl 28
PROVENTIL HFA 139
PROVERA 120
PROVIGIL 147
PROZAC 27
PROZAC WEEKLY 27
PRUDOXIN 88
PSORCON 106
PULMICORT 136
PULMICORT FLEXHALER 137
PULMOZYME 140
PURIXAN 37
PYLERA 96
pyrazinamide 34
PYRIDIUM 102
pyridostigmine bromide 34
QQBRELIS 68
QBREXZA 88
QNASL 137
QNASL CHILDREN 137
QSYMIA 80
QTERN 60
QUALAQUIN 45
QUARTETTE 117
QUASENSE 117
quazepam 146
QUDEXY XR 23
QUESTRAN 76
QUESTRAN LIGHT 76
quetiapine fumarate 48,49
QUILLICHEW ER 79
QUILLIVANT XR 79
quinapril hcl 68
quinapril hcl/hydrochlorothiazide 72
quinidine gluconate 68
quinidine sulfate 68
quinine sulfate 45
QVAR 137
QVAR REDIHALER 137
Rrabeprazole sodium 99
RADIOGARDASE 93
RAGWITEK 127
RAJANI 117
raloxifene hcl 121
ramipril 68
RANEXA 72
ranitidine hcl 96
RAPAFLO 101
RAPAMUNE 125
rasagiline mesylate 47
RASUVO 125
RAVICTI 100
RAYALDEE 129
RAYOS 106
RAZADYNE 25
RAZADYNE ER 25
REA LO 39 88
REA LO 40 88
REBETOL 52
Rebif 83
RECLIPSEN 117
RECTIV 88
REGIMEX 80
REGLAN 29
PAGE 166 LAST UPDATED 01/2019
REGRANEX 88
RELADOR PAK 13
RELAGARD 102
RELENZA 56
RELEXXII 79
RELISTOR 96
RELPAX 33
REMERON 25
RENAGEL 93
RENVELA 93
repaglinide 60
REPAGLINIDE/METFORMIN 60
REPATHA 76
REPREXAIN 11
REQUIP 47
REQUIP XL 47
RESCRIPTOR 54
RESCULA 135
RESERPINE 72
RESTASIS 132
RESTASIS MULTIDOSE 132
RESTORIL 146
RETACRIT 65
RETIN-A 88
RETIN-A MICRO 88
RETIN-A MICRO PUMP 88
RETROVIR 55
REVATIO 142
REVIA 13
REVLIMID 36
REXULTI 49
REYATAZ 56
REZIRA 144
RHEUMATREX 125
RHINOCORT AQUA 137
RHOPRESSA 135
RIBASPHERE 52
RIBASPHERE RIBAPAK 53
RIBATAB 53
ribavirin 53,144
RIDAURA 127
rifabutin 34
RIFADIN 34
RIFAMATE 35
rifampin 35
RIFATER 35
RILUTEK 80
riluzole 81
rimantadine hcl 56
RIMSO-50 102
RIOMET 60
risedronate sodium 129
RISPERDAL 49
RISPERDAL M-TAB 49
risperidone 49
RITALIN 79
RITALIN LA 79
ritonavir 56
rivastigmine 25
rivastigmine tartrate 25
RIVELSA 117
rizatriptan benzoate 33
ROBAXIN 145
ROBAXIN-750 145
ROBINUL 95
ROBINUL FORTE 95
ROCALTROL 129
ropinirole hcl 47
ROSADAN 89
ROSANIL 89
ROSULA 89
rosuvastatin calcium 75
ROWASA 128
ROWEEPRA 21
ROWEEPRA XR 21
ROXICODONE 11
ROXYBOND 11
ROZEREM 147
RUBRACA 38
RUCONEST 123
RYCLORA 138
RYDAPT 38
RYTARY 47
RYTHMOL 68
RYTHMOL SR 68
RYVENT 138
SSABRIL 23
SAFYRAL 117
SAIZEN 110
SALAGEN 83
salsalate 7
SAMSCA 93
SANADERMRX 106
SANCUSO 29
SANDIMMUNE 125
SANDOSTATIN 122
SANDOSTATIN LAR 122
SANDOSTATIN LAR DEPOT 122
SANTYL 89
SAPHRIS 49
SARAFEM 27
SAVAYSA 63
SAVELLA 81
SAXENDA 131
SCALACORT 106
scopolamine 29
SEASONIQUE 117
SEB-PREV 89
SECONAL SODIUM 147
SECTRAL 69
SEEBRI NEOHALER 139
SEGLUROMET 60
selegiline hcl 47
selenium sulfide 89
SELRX 89
SELZENTRY 55
SEMPREX-D 144
SENSIPAR 129
SEREVENT DISKUS 139
SERNIVO 107
SEROPHENE 121
PAGE 167 LAST UPDATED 01/2019
SEROQUEL 49
SEROQUEL XR 49
SEROSTIM 110
sertraline hcl 27
SETLAKIN 117
sevelamer carbonate 94
SF 92
SF 5000 PLUS 92
SFROWASA 128
SHAROBEL 120
SIGNIFOR 122
SIKLOS 37
SILALITE PAK 107
SILAZONE-II 107
sildenafil citrate 102,142
SILENOR 147
SILIQ 89
SILVADENE 20
silver nitrate/potassium nitrate 89
silver sulfadiazine 20
silver/bandage/foam/gauze/lidocaine/chlorhexid
in/isopropanol 131
SIMBRINZA 135
SIMPONI 126
simvastatin 75
SINEMET 10-100 47
SINEMET 25-100 47
SINEMET 25-250 47
SINEMET CR 47
SINGULAIR 138
sirolimus 126
SIRTURO 35
SITAVIG 56
SIVEXTRO 16
SKELAXIN 145
SKLICE 45
SKYLA 121
sodium chloride for inhalation 144
sodium chloride/sodium bicarbonate/potassium
chloride/peg 98
sodium phenylbutyrate 100
sodium polystyrene sulfonate 93
SOLARAZE 89
SOLIQUA 100-33 63
SOLODYN 21
SOLOSEC 16
SOLTAMOX 36
SOLUPAK 13
SOMA 145
SOMATULINE DEPOT 122
SOMAVERT 122
SONATA 146
SOOLANTRA 89
SORIATANE 89
SORILUX 89
SORINE 68
sotalol hcl 68
SOTYLIZE 68
SOVALDI 51
SPECTRACEF 17
SPINOSAD 89
SPIRIVA 139
SPIRIVA RESPIMAT 139
spironolactone 74
spironolactone/hydrochlorothiazide 73
SPORANOX 32
SPRINTEC 117
SPRITAM 22
SPRIX 7
SPRYCEL 42
SPS 93
SRONYX 118
SSD 20
SSKI 123
SSS 10-5 89
STALEVO 46
STARLIX 60
stavudine 55
STAXYN 102
STEGLATRO 60
STEGLUJAN 60
STELARA 89
STENDRA 102
STIMATE 110
STIOLTO RESPIMAT 144
STIVARGA 42
STRATTERA 79
STRENSIQ 100
STRIANT 111
STRIBILD 53
STRIVERDI RESPIMAT 139
STROMECTOL 45
SUBOXONE 13
SUBSYS 11
SUCRAID 100
sucralfate 98
SULAR 70
sulfacetamide sodium 20,89
sulfacetamide sodium/prednisolone sodium
phosphate 132
sulfacetamide sodium/sulfur 90
sulfadiazine 20
sulfamethoxazole/trimethoprim 20
SULFAMYLON 16
sulfasalazine 128
SULFATRIM 20
sulindac 7
sumatriptan 33
sumatriptan succinate 34
sumatriptan succinate/naproxen sodium 34
SUMAVEL DOSEPRO 34
SUPRAX 17
SUPRENZA ODT 81
SUPREP 98
SURMONTIL 28
SUSTIVA 54
SUSTOL 29
SUTENT 42
SYEDA 118
SYLATRON 38
SYMAX 95
SYMAX DUOTAB 95
SYMAX-SL 95
PAGE 168 LAST UPDATED 01/2019
SYMAX-SR 95
SYMBICORT 144
SYMBYAX 25
SYMDEKO 140
SYMFI 54
SYMFI LO 54
SYMLINPEN 120 60
SYMLINPEN 60 60
SYMPROIC 96
SYMTUZA 56
SYNALAR 107
SYNALAR TS 107
SYNALGOS-DC 11
SYNAREL 122
SYNDROS 29
SYNJARDY 60
SYNJARDY XR 60
SYNTHROID 121
SYPRINE 93
syringe, insulin u-500 with needle, disposable,
0.5 ml 131
TTABLOID 37
TACLONEX 90
tacrolimus 90,126
tadalafil 101,102
TAFINLAR 43
TAGRISSO 43
TAKE ACTION 118
TAKHZYRO 123
Taltz 90
TALZENNA 43
TAMIFLU 56
tamoxifen citrate 36
tamsulosin hcl 101
TANZEUM 60
TAPAZOLE 123
TAPERDEX 107
TARCEVA 43
TARGADOX 21
TARGRETIN 44
TARINA FE 118
TARKA 73
TASIGNA 43
TASMAR 46
TAVALISSE 65
TAYTULLA 118
tazarotene 90
TAZORAC 90
TAZTIA XT 70
TECFIDERA 83
TECHNIVIE 51
TEGRETOL 24
TEGRETOL XR 24
TEGSEDI 81
TEKTURNA 73
TEKTURNA HCT 73
telmisartan 67
telmisartan/amlodipine besylate 73
telmisartan/hydrochlorothiazide 73
temazepam 146
TEMODAR 35
TEMOVATE 107
temozolomide 35
TENCON 81
TENEX 66
tenofovir disoproxil fumarate 55
TENORETIC 100 73
TENORETIC 50 73
TENORMIN 69
TERAZOL 3 32
TERAZOL 7 32
terazosin hcl 67
terbinafine hcl 32
terbutaline sulfate 139
terconazole 32
TESSALON PERLE 144
TESTIM 111
testosterone 111
TESTOSTERONE (10 mg (2%) gel md pmp,
12.5/1.25g gel md pmp, 50 mg (1%) gel
(gram) 111
TESTOSTERONE (50 mg (1%) gel packet).
SOME MANUFACTURERS ARE T3 AND
OTHERS T1 111
testosterone cypionate 111
testosterone enanthate 111
TESTRED 111
tetrabenazine 81
tetracycline hcl 21
TETRAVISC 132
TETRAVISC FORTE 132
TEXACORT 107
THALOMID 36
THEO-24 141
THEOCHRON 141
theophylline anhydrous 141
THERMAZENE 20
THIOLA 103
thioridazine hcl 48
thiothixene 48
THYROLAR-1 121
THYROLAR-1/2 121
THYROLAR-1/4 121
THYROLAR-2 121
THYROLAR-3 121
tiagabine hcl 23
TIAZAC 70
TIBSOVO 38
TICALAST 144
TICANASE 137
TICASPRAY 137
ticlopidine hcl 66
TIGAN 29
TIGLUTIK 81
TIKOSYN 68
TILIA FE 118
timolol maleate 69,135
TIMOPTIC 135
TIMOPTIC OCUDOSE 135
PAGE 169 LAST UPDATED 01/2019
TIMOPTIC-XE 135
TINDAMAX 16
tinidazole 16
TIROSINT 121
TIVICAY 53
TIVORBEX 7
tizanidine hcl 49
TL G-FOL OS 92
TOBI 144
TOBI PODHALER 140
TOBRADEX 132
TOBRADEX ST 132
tobramycin 14
tobramycin in 0.225 % sodium chloride 144
tobramycin/dexamethasone 133
tobramycin/nebulizer 140
TOBREX 14
TODAY CONTRACEPTIVE SPONGE 103
TOFRANIL 28
TOFRANIL-PM 28
TOLAK 90
tolazamide 60
tolbutamide 60
tolcapone 46
tolmetin sodium 7
tolterodine tartrate 101
TOPAMAX 23
TOPICORT 107
topiramate 23
TOPIRAMATE ER CAPS 23
TOPROL XL 69
torsemide 73
TOUJEO MAX SOLOSTAR 63
TOUJEO SOLOSTAR 63
TOVIAZ 101
TRACLEER 142
TRADJENTA 61
TRAMADOL ER CAPS 8
tramadol hcl 8,11
tramadol hcl/acetaminophen 11
trandolapril 68
trandolapril/verapamil hcl 73
tranexamic acid 65
TRANSDERM-SCOP 29
TRANXENE T-TAB 57
tranylcypromine sulfate 26
TRAVATAN Z 135
trazodone hcl 27
TRECATOR 35
TRELEGY ELLIPTA 144
TREMFYA 90
TRESIBA FLEXTOUCH U-100 63
TRESIBA FLEXTOUCH U-200 63
TRETIN-X 90
tretinoin 44,90
tretinoin microspheres 90
tretinoin/emollient base 90
TREXALL 126
TREXIMET 34
TREZIX 11
TRI FEMYNOR 118
TRI-CHLOR 90
TRI-ESTARYLLA 118
TRI-LEGEST FE 118
TRI-LINYAH 118
TRI-LO-ESTARYLLA 118
TRI-LO-MARZIA 118
TRI-LO-SPRINTEC 118
TRI-MILI 118
TRI-NORINYL 118
TRI-PREVIFEM 118
TRI-SILA 107
TRI-SPRINTEC 118
TRI-VYLIBRA 118
triamcinolone acetonide 83,107,137
triamterene/hydrochlorothiazide 73
TRIANEX 107
triazolam 146
TRIBENZOR 73
TRICOR 75
TRIDERM 107
TRIDESILON 107
trientine hcl 93
trifluoperazine hcl 48
trifluridine 56
TRIGLIDE 75
trihexyphenidyl hcl 46
TRILEPTAL 24
TRILIPIX 75
TRILYTE WITH FLAVOR PACKETS 98
trimethobenzamide hcl 29
trimethoprim 16
trimipramine maleate 28
TRIMPEX 16
TRINESSA 118
TRINESSA LO 118
TRINTELLIX 27
TRIUMEQ 55
TRIVORA-28 118
TRIXYLITRAL 129
TRIZIVIR 55
TROKENDI XR 24
tropicamide 133
trospium chloride 101
TRULANCE 97
TRULICITY 61
TRUSOPT 135
TRUVADA 55
TUDORZA PRESSAIR 139
TULANA 121
TUSSICAPS 144
TUSSIGON 144
TUSSIONEX 144
TUZISTRA XR 144
TWYNSTA 73
TYBOST 55
TYDEMY 118
TYKERB 43
TYLENOL-CODEINE NO.3 11
TYLENOL-CODEINE NO.4 11
TYMLOS 129
Tyvaso 142
TYZEKA 50
PAGE 170 LAST UPDATED 01/2019
TYZINE 144
UUCERIS 128
ULESFIA 90
ULORIC 32
ULTRACET 11
ULTRAM 11
ULTRAM ER 8
ULTRAVATE 107
ULTRAVATE X 107
ULTRESA 100
UNITHROID 121
UPTRAVI 142
UR N-C 16
URAMIT MB 16
URECHOLINE 103
URELLE 16
URETRON D-S 16
URIBEL 16
URIMAR-T 16
URIN D.S. 16
URO-458 16
URO-MP 16
UROCIT-K 92
UROGESIC-BLUE 16
UROQID-ACID NO.2 103
UROXATRAL 102
URSO 96
URSO FORTE 96
ursodiol 96
URYL 16
UTIBRON NEOHALER 144
UTIRA-C 16
VVAGIFEM 118
valacyclovir hcl 56
VALCHLOR 35
VALCYTE 50
valganciclovir hcl 50
VALIUM 57
valproic acid 23
valproic acid (as sodium salt) (valproate
sodium) 23
valsartan 67
valsartan/hydrochlorothiazide 73
VALTREX 56
VANATOL LQ 81
VANCOCIN HCL 16
vancomycin hcl 16
VANDAZOLE 16
VANOS 107
VARUBI 29
VASCEPA 76
VASERETIC 73
VASOTEC 68
VCF 103
VECAMYL 73
VECTICAL 90
VELIVET 118
VELPHORO 94
VELTASSA 94
VELTIN 90
VEMLIDY 50
VENCLEXTA 43
VENLAFAXINE ER TAB (TIER DEPENDENT
ON MANUFACTURER. UCB T3, OTHERS
T1) 27
venlafaxine hcl 27
VENTOLIN HFA 140
VERAMYST 137
verapamil hcl 70
VERDESO 107
VERDROCET 11
VEREGEN 90
VERELAN 70
VERELAN PM 70
VERIPRED 20 107
VERSACLOZ 49
VERZENIO 43
VESICARE 101
VESTURA 118
VEXOL 134
VFEND 32
VIAGRA 103
VIBERZI 97
VIBRAMYCIN 21
VICODIN 11
VICODIN ES 11
VICODIN HP 11
VICTOZA 2-PAK 61
VICTOZA 3-PAK 61
VIDEX 55
VIDEX EC 55
VIEKIRA PAK 51
VIEKIRA XR 51
VIENVA 118
vigabatrin 23
VIGAMOX 19
VIIBRYD 27
VIMOVO 7
VIMPAT 24
VIOKACE 100
VIORELE 118
VIRACEPT 56
VIRAMUNE 54
VIRAMUNE XR 54
VIRAZOLE 144
VIREAD 55
VIROPTIC 56
VISTARIL 138
VITEKTA 53
VITUZ 144
VIVELLE-DOT 118
VIVLODEX 7
VIZIMPRO 38
VOGELXO 111
VOLTAREN 90
VOLTAREN-XR 7
voriconazole 32
VOSEVI 51
VOSPIRE ER 140
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VOTRIENT 43
VRAYLAR 49
VUSION 32
VYFEMLA 119
VYLIBRA 119
VYTONE 90
VYTORIN 76
VYVANSE 78
VYZULTA 135
Wwarfarin sodium 63
WELCHOL 76
WELLBUTRIN 25
WELLBUTRIN SR 25
WELLBUTRIN XL 26
WERA 119
WESTHROID 121
WHYTEDERM TRILASIL PAK 107
WP THYROID 121
WYMZYA FE 119
XXADAGO 47
XALATAN 135
XALKORI 44
XANAX 57
XANAX XR 57
XARELTO 63
XARTEMIS XR 11
XATMEP 126
XELITRAL 91
XELJANZ 126
XELJANZ XR 126
XELODA 37
XENAFLAMM 131
XENAZINE 81
XENICAL 96
XEPI 91
XERESE 57
XERMELO 131
XHANCE 137
XIFAXAN 96
XIGDUO XR 61
XIIDRA 133
XIMINO 21
XODOL 10-300 11
XODOL 5-300 11
XODOL 7.5-300 11
XOFLUZA 127
XOLEGEL 32
XOPENEX 140
XOPENEX CONCENTRATE 140
XOPENEX HFA 140
XRYLIX 91
XTAMPZA ER 8
XTANDI 36
XULANE 119
XULTOPHY 100-3.6 63
XURIDEN 94
XYLON 10 11
XYREM 147
XYZAL 138
YYASMIN 28 119
YAZ 119
YONSA 36
YUVAFEM 119
Zzafirlukast 138
zaleplon 146
ZAMICET 11
ZANAFLEX 49
ZANTAC 96
ZARAH 119
ZARONTIN 22
ZARXIO 65
ZAVESCA 100
ZEBETA 69
ZEBUTAL 81
ZEGERID 99
ZEJULA 44
ZELAPAR 47
ZELBORAF 44
ZEMBRACE SYMTOUCH 34
ZEMPLAR 130
ZENATANE 91
ZENCHENT 119
ZENCHENT FE 119
ZENPEP 100
ZENZEDI 78
ZEPATIER 51
ZERIT 55
ZESTORETIC 73
ZESTRIL 68
ZETIA 76
ZETONNA 137
ZEYOCAINE 91
ZIAC 73
ZIAGEN 55
ZIANA 91
zidovudine 55
zileuton 138
ZINBRYTA 83
ZIOPTAN 135
ziprasidone hcl 49
ZIPSOR 7
ZIRGAN 50
ZITHRANOL-RR 91
ZITHROMAX 19
ZITHROMAX TRI-PAK 19
ZMAX 19
ZOCOR 75
ZODEX 107
ZOFRAN 29
ZOFRAN ODT 29
ZOHYDRO ER 8
ZOLINZA 38
zolmitriptan 34
ZOLOFT 27
zolpidem tartrate 146
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ZOLPIMIST 146
ZOMACTON 110
ZOMIG 34
ZOMIG ZMT 34
ZONALON 91
ZONEGRAN 22
zonisamide 22
ZONTIVITY 64
ZORBTIVE 110
ZORTRESS 126
ZORVOLEX 7
ZOVIA 1-35E 119
ZOVIA 1-50E 119
ZOVIRAX 57
ZTLIDO 13
ZUBSOLV 13
ZUPLENZ 30
ZURAMPIC 32
ZUTRIPRO 144
ZYBAN 14
ZYCLARA 91
ZYDELIG 44
ZYFLO 138
ZYFLO CR 138
ZYKADIA 44
ZYLET 133
ZYLOPRIM 32
ZYMAXID 19
ZYPITAMAG 75
ZYPRAM 91
ZYPREXA 49
ZYPREXA ZYDIS 49
ZYTIGA 36
ZYVOX 16
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