Health Net 2-Tier Recommended Drug List

California

2 Tier Drug List The 2 Tier Drug List (formulary) includes a list of drugs covered by Health Net The drug list is updated

at least monthly and is subject to change All previous versions are no longer in effect You can view the

most current drug list by going to our website at wwwhealthnetcom

California Large Group members

Go to httpswwwhealthnetcomstaticgeneralunprotectedpdfscapharmacyrdl_alpha_listpdf

Use the ldquo2 Tierrdquo List (pdf)

NOTE To search the drug list online open the (pdf) document Hold down the ldquoControlrdquo (Ctrl)

and ldquoFrdquo keys When the search box appears type the name of your drug and press the ldquoEnterrdquo key

If you have questions or need more information call us toll free

If you have questions about your pharmacy coverage call Customer Service at 1-800-522-0088

Hours of Operation

800am ndash 600pm Monday through Friday

Updated April 1 2019

Table of Contents

What If I Have Questions Regarding My Pharmacy Benefit helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellipii

What is the Drug List ii

How do I find a drug on the Drug Listii

How are the drugs listed in the categorical listii

How much will I pay for my drugs iii Tier description table

Are there any limits on my drug coverage iii Abbreviations table

How often does the Drug List changeiv

How can I get prior authorization or an exception to the rules for drug coverageiv

Are all contraceptives coveredv

What blood glucose supplies coveredvi

What drugs are under my medical benefitvi

Can I go to any pharmacyvi

Can I use a mail order pharmacyvi

How can I save money on my prescription drugs vi

Definitions vii

Categorical list of prescription drugs1

Alphabetical index of prescription drugsIndex 1

i

Welcome to Health Net

What If I Have Questions Regarding My Pharmacy Benefit If you have questions about your pharmacy coverage contact Customer Service at the phone number

listed on your Health Net ID card or on the cover of this book Customer Service can help you with

questions about your prescription drug benefits including but not limited to

information about drugs covered under the medical benefit

the processes for submitting an exception request requesting prior authorization and step therapy

exceptions

actual dollar amounts of cost sharing for drugs including drugs subject to coinsurance

What is the Drug List The drug list is a list of covered drugs used to treat common diseases or health problems The drug list

is selected by a committee of doctors and pharmacists who meet regularly to decide which drugs

should be included The committee reviews new drugs and new information about existing drugs and

chooses drugs based on

Safety

Effectiveness

Side effects

Value (if two drugs are equally effective the less costly drug will be preferred)

How do I find a drug in the Drug List You can search for a drug by using the search tool alphabetical index or by medical condition There

are three ways to find out if your drug is covered

Search Tool Open the List of Drugs (PDF) Hold down the ldquoControlrdquo (Ctrl) and ldquoFrdquo keys When the

search box appears type the name of your drug Press the ldquoEnterrdquo key

Alphabetical Index The index at the end of the PDF lists the names of generic and brand name drugs

from A to Z Once you find a drug name go to the page number listed to see if the drug is covered

Therapeutic category The drugs are grouped into therapeutic categories The categories may be

grouped the class to which the drug belongs If you know what therapeutic category your drug is in

look through the list to find the category Then look under the category for your drug

If a generic equivalent for a brand name drug is not available in the market or not covered the generic

drug will not be listed separately The presence of a drug on the drug list does not guarantee that your

doctor will prescribe the drug for a particular medical condition

How are the drugs listed in the categorical list A drug is listed alphabetically by its brand and generic names in its therapeutic category and class

Example

ii

The generic drug name for a brand drug is included after the brand name in parentheses and all

lowercase italicized letters

Brand Drug Example MAVYRET (glecaprevir-pibrentasvir) TABS

If a generic equivalent for a brand name drug is both available and covered the generic drug will be

listed separately from the brand name drug in all lowercase italicized letters

Generic Drug Example terbutaline sulfate tabs

If a generic drug is marketed under a proprietary trademark-protected brand name the brand drug will

be listed after the generic name in parentheses and regular typeface with the first letter of each word

capitalized

Generic Drug Marketed Under A Brand Name Example levothyroxine sodium (Levoxyl) TABS

How much will I pay for my drugs To see how much you will pay for a drug check the abbreviations in the Drug Tier column on the

formulary The copayment or coinsurance for each tier is defined in your Summary of Benefits or other

plan documents

Drug ClassPlan Benefit Phase Maximum Cost Share Days Supply

Oral Cancer Drugs Only Deductible met $200 30 days

All Other (non-oral cancer)

Drugs

Deductible met $250 30 days

Bronze Plan Members Deductible met $500 30 days

Below is a description for each tier

Tier Description

1 Drugs in this tier include preferred generic drugs

2 Drugs in this tier include preferred brand drugs

GP Generic drugs are preferred To get a brand drug that has a generic available your

doctor must request prior authorization to show medical necessity If we approve

the request the drug may be covered at the highest copayment Refer to your plan

documents for coverage details

NF The NF next to a drug (including brands with a generic available) means the drug is

not covered on Health Netrsquos Formulary Your doctor must request authorization

from Health Net and show medical necessity for the drug to be covered

PV Includes preventive benefit drugs including contraceptives covered at no cost to

members under the Affordable Care Act A deductible does not apply

SP Coverage for drugs at the SP Tier may differ based on your benefits Please refer to

your plan documents for coverage

Are there any limits on my drug coverage Some drugs have limits on coverage The table below provides a description of abbreviations that may

appear in the Limits column on the drug list

iii

limited access drugs once the drug has been approved

Abbreviation Definition Description

AL Age Limit These drugs may require prior authorization if your age does

not fall within manufacturer FDA or clinical

recommendations

AC Anti-cancer These oral cancer drugs are subject to a maximum $200

copayment for a one-month supply after any deductible

has been met per state law (or $600 maximum for a

three-month supply through mail order)

LA Limited Access Some drugs may be subject to limited access or restricted

access This means that a drug may only be available at

select pharmacies Limited access may be due to the

following reasons

bull The FDA or the manufacturer has restricted distribution of

a drug to certain facilities pharmacies or prescribers or

bull Certain drugs require special handling coordination of care

or patient education that cannot be provided at a retail

pharmacy

If the drug is approved we will let you know how to get limited

access drugs PA Prior Authorization This drug requires prior authorization This means that you

or your prescriber must get approval from us before you fill

your prescription If you donrsquot get approval we may not

cover the drug QL Quantity Limit These drugs have a limit on the amount that will be covered

Your doctor must request approval for a higher quantity of

the drug from Health Net Health Net covers a 12-month

supply when dispensed at one time of all self-administered

hormonal contraceptives on the Formulary

RXOTC Prescription amp

Over-the-

Counter (OTC)

Certain drugs are available both in a prescription form and in

an OTC form Only prescription drugs are covered by your

plan with the exception of some insulins insulin supplies and

some covered preventive drugs OTC drugs on the drug list

including OTC preventive drugs and contraceptives require a

prescription to be covered

SP Specialty Drug Specialty drugs are required to be provided through a Health

Net contracted Specialty Pharmacy Once Health Net approves

the medication our contracted Specialty pharmacy will contact

you to arrange for delivery

ST Step Therapy Step therapy is when you are required to use one drug before

another in a stepwise fashion Unless an exception is made

one or more preferred drugs must be tried first before

progressing to a drug that is subject to step therapy

iv

How often does the Drug List change Changes such as removing a drug or dosage form from the drug list may occur monthly The types of

changes may include the following

Removal of a drug or dosage form of a drug from the formulary

Any change in tier placement of a drug that results in an increase in cost sharing

Adding or changing utilization management procedures applicable to a drug

If these changes occur you will be notified at least 60 days in advance of the change unless the drug is

removed for safety reasons

How can I get prior authorization or an exception to the rules for drug coverage Requests for prior authorization may be submitted electronically or by phone at 1-800-548-5524 or by fax

at 1-800-314-6223 Once your doctorrsquos request is received we will notify your doctor of our decision

within 72 hours If Health Net fails to respond to a completed prior authorization or step therapy

exception request within 72 hours of receiving a non-urgent request and 24 hours of receiving a request

based on exigent circumstances the request is deemed approved and the health insurer may not deny the

request thereafter

If your doctor believes that waiting 72 hours for a standard decision could seriously harm your health

your doctor can ask for a fast (expedited) decision This applies only to requests for drugs that you have

not already received We must make expedited decisions within 24 hours after we get your doctorrsquos

supporting statement

If we approve your drugrsquos exception the approval continues until the end of the plan year To keep the

exception in place for the plan year you must remain enrolled in our plan your doctor must continue to

prescribe your drug and your drug must be safe for treating your condition

In some cases our plan requires you to first try certain drugs to treat your medical condition before we

will cover another drug for that condition This is called step therapy Step therapy is when you are

required to use one drug before another in a stepwise fashion The required first step drug or preferred

drug is a proven cost-effective medication Unless an exception is made one or more preferred drugs

must be tried before progressing to a drug that is subject to step therapy You or your doctor can request

an exception if your health may be harmed by waiting Your doctor must submit a supporting statement to

us explaining why you need the drug You or your doctor may appeal the denial of an exception request

The denial documents provide more information on appeal rights and procedures If there is a medical

need to use a second step drug without trying a first step drug an exception to coverage may be requested

by the prescriber A request for an exception to a step therapy requirement may be submitted in the same

manner as a request for prior authorization The request shall be treated in the same manner and shall be

responded to in the same manner as a request for prior authorization for prescription drugs If you have

already tried and failed the preferred drug(s) or if you are already taking a drug that is subject to step

therapy when you switch toenrolled in a Health Net plan you will not have to undergo step therapy and

the drug will be approved for coverage when medically necessary

If a drug is not on the drug list and is not specifically excluded from coverage your doctor can ask for an

exception To request an exception your doctor can submit a prior authorization request along with a

supporting statement explaining why you need the drug Requests for prior authorization may be

submitted electronically or by telephone or fax If we approve an exception for a drug that is not on the

drug list the highest drug tier (Tier 2) copayment applies

v

Health Net will cover all medically necessary drugs If Health Net fails to respond to a completed prior

authorization or step therapy exception request within 72 hours of receiving a non-urgent request and 24

hours of receiving an expedited request the request will be approved and Health Net may not deny the

request thereafter

Are all contraceptives covered Contraceptive benefits include coverage for a variety of US Food and Drug Administration (FDA)-

approved prescription contraceptive methods If your doctor determines that none of the covered methods

on the drug list or if a covered therapeutic equivalent of a drug device or product is not available and is

medically necessary for you Health Net will provide coverage Coverage is subject to limitations and

restrictions Prior authorization or step therapy may be required for some other FDA-approved

prescription contraceptive drugs devices or products prescribed by your doctor

What blood glucose supplies covered Specific brands of blood glucose monitors blood glucose testing strips lancets ketone testing strips pen

delivery systems for injecting insulin and insulin needles and syringes are covered on the drug list A

prescription from your doctor is required to obtain these from a pharmacy Insulin pumps and all related

necessary supplies podiatric devices to prevent or treat diabetes-related complications and visual aids

excluding eyewear to assist the visually impaired with proper dosing of insulin are covered under the

medical benefit

What drugs are under my medical benefit Drugs that are self-injected or are administered by your doctor will be covered under you medical

benefit If your doctor does not have the drug your doctor will give you instructions on where you can

receive the drug Certain drugs that are self-administered are covered under your pharmacy benefit

Refer to your Evidence of Coverage or Certificate of Insurance for coverage information and

exceptions

Can I go to any pharmacy Except in emergency and urgent situations Health Net does not cover drugs dispensed by non-network

pharmacies Health Net contracts with most US chain pharmacies and many independent pharmacies

These pharmacies are called in-network pharmacies To find an in-network pharmacy near you visit our

website at wwwhealthnetcaliforniacom or call us at the telephone number on your Health Net ID card

or listed on the front cover of this book

Some high cost drugs are considered specialty drugs These drugs must be filled at an in-network

specialty pharmacy Specialty drugs are noted on the drug list in the RequirementsLimits column with

the abbreviation ldquoLArdquo or a statement indicating the drug must be dispensed from a network specialty

pharmacy After your drug has been approved we will arrange for the specialty pharmacy to contact

you to set up delivery

Can I use a mail order pharmacy For certain kinds of prescription drugs you can use the our contracted Mail Order Pharmacy Generally

the drugs available through mail order are drugs that you take on a regular basis for a chronic or long-

term medical condition Specialty drugs are not available through mail order

To use the mail order pharmacy your doctor must provide a new prescription that allows up to a 90-day

supply of each drug Mail order forms are available on our website at

vi

httpswwwhealthnetcomportalmembercontentiwcmemberunprotectedhealth_plancontentmail_or

der_groupaction or you may call us at the telephone number on your Health Net ID card or on the front

cover of this book to request a form

How can I save money on my prescription drugs You can save time and money with these simple steps

Ask your doctor about generic drugs that may work for you

Fill prescriptions at in-network pharmacies

Be sure your doctor prescribes drugs on the drug list

Fill your maintenance drugs through our mail order pharmacy program

Definitions

Brand drug Is a drug that is marketed under a proprietary trademark-protected name A brand drug is

listed in this formulary in all CAPITAL letters

Coinsurance Is a percentage of the cost of a covered health care benefit that you pay after you have

paid the deductible if a deductible applies to the health care benefit

Copayment Is a fixed dollar amount that you pay for a covered health care benefit after you have paid

the deductible if a deductible applies to the health care benefit

Deductible Is the amount you pay for covered health care benefits that are subject to the deductible

before your health insurer begins to pay If the plan has a deductible it may have either one deductible

or separate deductibles for medical benefits and prescription drug benefits After you pay your

deductible you usually pay only a copayment or coinsurance for covered health care benefits The plan

pays the rest

Drug Tier Is a group of prescription drugs that correspond to a specified cost sharing tier The drug tier

in which a prescription drug is placed determines your portion of the cost for the drug

Exception request Is a request for coverage of a non-formulary drug If you your designee or your

doctor submits a request for coverage of a non-formulary drug the plan must cover the non-formulary

drug when it is medically necessary for you to take the drug

Exigent circumstances Is when you are suffering from a medical condition that may seriously

jeopardize your life health or ability to regain maximum function or when you are undergoing a

current course of treatment using a non-formulary drug

Formulary or prescription drug list Is the list of drugs that is covered by the plan under the

prescription drug benefit of the policy

Generic drug Is a drug that is the same as its brand name drug equivalent in dosage strength effect

how it is taken quality safety and intended use A generic drug is listed in the drug list in italicized

lowercase letters

Medically Necessary Is health care benefits needed to diagnose treat or prevent a medical condition

or its symptoms and that meet accepted standards of medicine Plans usually do not cover health care

benefits that are not medically necessary

Non-formulary drug Is a prescription drug that is not listed on the drug list

vii

Out-of-pocket costs Are your expenses for health care benefits that arent reimbursed by the plan Out-

of-pocket costs include deductibles copayments and coinsurance for covered health care benefits plus

all costs for health care benefits that are not covered paid by the Member

Prescribing provider This is a health care provider who can write a prescription for a drug to

diagnose treat or prevent a medical condition

Prescription Is an oral written or electronic order from a prescribing provider authorizing a

prescription drug to be provided to a specific individual

Prescription drug Is a drug that by law requires a prescription

Prior Authorization Is a decision by the plan that a health care benefit is medically necessary for you

If a prescription drug is subject to prior authorization in the drug list your doctor must request approval

from the plan to cover the drug before you fill your prescription The plan must grant a prior

authorization request when it is medically necessary for you to take the drug

Specialty drugs Specialty Drugs include drugs that are made using biotechnology drugs that must be

distributed through a specialty pharmacy drugs that require special training for self-administration or

drugs that require regular monitoring of care by a pharmacy and drugs that cost more than six hundred

dollars for a one-month supply

Step therapy Is a specific sequence in which prescription drugs for a particular medical condition

must be tried If a drug is subject to step therapy in the drug list you may have to try one or more other

drugs before the plan will cover that drug for your medical condition If your doctor submits a request

for an exception to the step therapy requirement the plan must grant the request when it is medically

necessary for you to take the drug

viii

Drug Name DrugTier

RequirementsLimits

ADHDANTI-NARCOLEPSYANTI-OBESITYANOREXIANTS - Drugs to TreatADHD Sleep and Eating Disorders Amphetamines ADDERALL TABS (Use Amphetamine-Dextroamphetamine)

GP

ADDERALL XR CP24 (Use Amphetamine-Dextroamphetamine)

GP

QL(2 eadaily90 day(s)limit180 ea perfill retail)

amphetamine-dextroamphetamine cp245mg-5mg-5mg-5mg25mg-25mg-25mg-25mg 75mg-75mg-75mg-75mg 125mg-125mg-125mg-125mg375mg-375mg-375mg-375mg 625mg-625mg-625mg-625mg

1

amphetamine-dextroamphetamine tabs5mg-5mg-5mg-5mg25mg-25mg-25mg-25mg 75mg-75mg-75mg-75mg 125mg-125mg-125mg-125mg375mg-375mg-375mg-375mg 1875mg-1875mg-1875mg-1875mg 3125mg-3125mg-3125mg-3125mg

1

DEXEDRINE CP24 (Use DextroamphetamineSulfate)

GP

dextroamphetamine sulfatecp24 5 mg 10 mg 15 mg 1

dextroamphetamine sulfatetabs 5 mg 10 mg 1

VYVANSE CAPS 10 MG 20 MG 30 MG 40 MG 50 MG 60 MG 70 MG

2 QL(1 ea daily)

VYVANSE CHEW 10 MG 20 MG 30 MG 40 MG 50 MG 60 MG

2 Limited to 1 perdayQL(1 eadaily)

Analeptics

Drug Name DrugTier

RequirementsLimits

caffeine citrate soln 1

Anorexiants Non-Amphetamine ADIPEX-P CAPS (Use Phentermine HCl) SP PA

BENZPHETAMINE HCL TABS SP PA

LOMAIRA TABS 2 PA

phentermine hcl caps SP PA

QSYMIA CP24 23MG-375MG SP PA QL(1 eadaily) QSYMIA CP24 92MG-15MG 46MG-75MG 69MG-1125MG

SP PA

REGIMEX TABS (Use Benzphetamine HCl) SP PA

Anti-Obesity Agents BELVIQ TABS SP PA

CONTRAVE TB12 SP PA

XENICAL CAPS SP PA

Attention-DeficitHyperactivity Disorder (ADHD) atomoxetine hcl caps 10mg 18 mg 25 mg 40 mg 1 QL(2 ea daily)

atomoxetine hcl caps 60mg 80 mg 100 mg 1

guanfacine hcl (adhd) tb24 1 QL(1 ea daily)

INTUNIV TB24 (Use Guanfacine HCl (ADHD)) GP QL(1 ea daily)

STRATTERA CAPS 10 MG 18 MG 25 MG 40 MG (Use Atomoxetine HCl)

GP QL(2 ea daily)

STRATTERA CAPS 60 MG 80 MG 100 MG (Use Atomoxetine HCl)

GP

Stimulants - Misc armodafinil tabs 1 PA

CONCERTA TBCR 18 MG 27 MG 36 MG (Use Methylphenidate HCl)

GP QL(1 ea daily)

1=Preferred Generics 2=Preferred BrandsHigh Cost Generics GP=Generic Preferred SP(Tier)=Specialty Tier NF=Non-Formulary PV=Preventive Drugs AL=Age LimitPA=Prior Authorization QL=Quantity Limit SP(Limits)=Specialty Drug ST=Step TherapyAC=Anti-Cancer LA=Limited Access RXOTC=Prescription amp Over-the-Counter

1

Drug Name DrugTier

RequirementsLimits

CONCERTA TBCR 54 MG (Use Methylphenidate HCl) GP QL(2 ea daily)

dexmethylphenidate hcltabs 5 mg 10 mg 25 mg 1 QL(2 ea daily)

FOCALIN TABS (Use Dexmethylphenidate HCl) GP QL(2 ea daily)

METHYLIN SOLN 5 MG5ML (Use Methylphenidate HCl)

GP

methylphenidate hcl soln 5mg5ml 1

methylphenidate hcl tabs20 mg 1 QL(3 ea daily)

methylphenidate hcl tabs 5mg 10 mg 1

methylphenidate hcl tb2418 mg 27 mg 54 mg 1

QL(1 eadaily90 day(s)limit)

methylphenidate hcl tb2436 mg 1

QL(1 eadaily90 ea perfill retail)

methylphenidate hcl tbcr 10 mg 1

methylphenidate hcl tbcr 18mg 27 mg 36 mg 1 QL(1 ea daily)

methylphenidate hcl tbcr 20 mg 1 QL(90 day(s)

limit) methylphenidate hcl tbcr 54 mg 1 QL(2 ea daily)

NUVIGIL TABS (Use Armodafinil) GP PA

RITALIN TABS 20 MG (Use Methylphenidate HCl) GP QL(3 ea daily)

RITALIN TABS 5 MG 10 MG (Use MethylphenidateHCl)

GP

AMINOGLYCOSIDES - Drugs to Treat BacterialInfections Aminoglycosides BETHKIS NEBU 2

Drug Name DrugTier

RequirementsLimits

KITABIS PAK NEBU 2

PA Must use AcariaHlth SpRx 1-844-538-4661

neomycin sulfate tabs 1

paromomycin sulfate caps 1

TOBI NEBU (Use Tobramycin) GP

TOBI PODHALER CAPS 2

tobramycin nebu 1

TOBRAMYCIN NEBU 2

ANALGESICS - ANTI-INFLAMMATORY - Drugsto Treat Pain Swelling Muscle and JointConditions Anti-TNF-alpha - Monoclonal Antibodies HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK PSKT 40 MG08ML

SP

PA Check plandocuments for coverage

HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK PSKT 80 MG08ML

SP

PA

HUMIRA PEN PNKT 40 MG04ML SP PA

HUMIRA PEN PNKT 40 MG08ML SP

HUMIRA PEN-CDUCHSSTARTER PNKT SP

HUMIRA PEN-PSUVSTARTER PNKT SP

2

Drug Name DrugTier

RequirementsLimits

HUMIRA PSKT 10 MG01ML 20 MG02ML40 MG04ML

SP PA

SP PA Check plandocuments for coverage

Antirheumatic - Enzyme Inhibitors XELJANZ TABS 10 MG SP PA

XELJANZ TABS 5 MG SP PA QL(2 eadaily) SP

XELJANZ XR TB24 SP PA QL(1 eadaily) SP Antirheumatic Antimetabolites METHOTREXATE TABS 2

Gold Compounds RIDAURA CAPS 2

Interleukin-6 Receptor Inhibitors

KEVZARA SOAJ SP

PA Not covered by allplans under thepharmacybenefitSP

KEVZARA SOSY SP

Nonsteroidal Anti-inflammatory Agents (NSAIDs) ANAPROX DS TABS (Use Naproxen Sodium) GP

DAYPRO TABS (Use Oxaprozin) GP

diclofenac sodium tbec 1

etodolac caps 200 mg 300 mg 1

etodolac tabs 400 mg 500 mg 1

etodolac tb24 400 mg 500mg 600 mg 1 QL(2 ea daily)

FELDENE CAPS 10 MG (Use Piroxicam) GP

Drug Name DrugTier

RequirementsLimits

FELDENE CAPS 20 MG (Use Piroxicam) GP QL(1 ea daily)

FENOPROFEN CALCIUM CAPS 2

FENORTHO CAPS 2

flurbiprofen tabs 50 mg 1

ibuprofen tabs 1

INDOCIN SUSP OR 25 MG5ML 2

indomethacin caps 1

indomethacin cpcr 1

ketoprofen caps 50 mg 75 mg 1

KETOPROFEN CAPS 50 MG 75 MG 2

ketorolac tromethamine tabs 1

QL(20 ea perfill retail20 ea per 30 daysretail)

LODINE TABS (Use Etodolac) GP

meclofenamate sodium caps 1

meloxicam tabs 15 mg 1 QL(1 ea daily)

MOBIC TABS 15 MG (Use Meloxicam) GP QL(1 ea daily)

nabumetone tabs 500 mg 1 QL(4 ea daily)

NAPROSYN SUSP (Use Naproxen) GP

NAPROSYN TABS (Use Naproxen) GP

naproxen sodium tabs 275mg 550 mg 1

naproxen susp 125 mg5ml 1

3

Drug Name DrugTier

RequirementsLimits

naproxen tabs 250 mg 375mg 500 mg 1

oxaprozin tabs 1

piroxicam caps 10 mg 1

piroxicam caps 20 mg 1 QL(1 ea daily)

sulindac tabs 150 mg 1 QL(2 ea daily)

sulindac tabs 200 mg 1

TOLMETIN SODIUM CAPS 400 MG 2

tolmetin sodium tabs 200 mg 600 mg 1

Phosphodiesterase 4 (PDE4) Inhibitors

OTEZLA TABS SP

OTEZLA TBPK SP

Pyrimidine Synthesis Inhibitors ARAVA TABS 10 MG (Use Leflunomide) GP QL(2 ea daily)

ARAVA TABS 20 MG (Use Leflunomide) GP QL(1 ea daily)

leflunomide tabs 10 mg 1 QL(2 ea daily)

Soluble Tumor Necrosis Factor Receptor Agents ENBREL MINI SOCT SP PA

ENBREL SOLR SP PA Check plandocuments for coverage

ENBREL SOSY SP PA Check plandocuments for coverage

ENBREL SURECLICK SOAJ SP

Drug Name DrugTier

RequirementsLimits

ANALGESICS - NonNarcotic - Drugs to TreatPain Muscle and Joint Conditions Analgesic Combinations butalbital-acetaminophen-caffeine caps 325mg-50mg-40mg

1

butalbital-acetaminophen-caffeine tabs 325mg-50mg-40mg

1

butalbital-aspirin-caffeine caps 1

butalbital-aspirin-caffeinetabs 1

ESGIC TABS (Use Butalbital-Acetaminophen-Caffeine)

GP

FIORINAL CAPS (Use Butalbital-Aspirin-Caffeine) GP

Salicylates choline amp mag salicylateliqd 1

salsalate tabs 1

ANALGESICS - OPIOID - Drugs to Treat PainMuscle and Joint Conditions Opioid Agonists codeine sulfate tabs 15 mg30 mg 60 mg 1

CODEINE SULFATE TABS 60 MG 2

DEMEROL TABS (Use Meperidine HCl) GP

DILAUDID LIQD (Use Hydromorphone HCl) GP

DILAUDID TABS (Use Hydromorphone HCl) GP

DOLOPHINE TABS (Use Methadone HCl) GP QL(12 ea daily)

DURAGESIC PT72 (Use Fentanyl) GP

Limit 15 permonthQL(05ea daily)

EXALGO T24A 8 MG 12 MG 16 MG (Use Hydromorphone HCl)

GP QL(4 ea daily)

4

Drug Name DrugTier

RequirementsLimits

fentanyl pt72 12 mcghr 25mcghr 50 mcghr 75mcghr 100 mcghr

1 Limit 15 permonthQL(05ea daily)

hydromorphone hcl liqd 1mgml 1

hydromorphone hcl t24a8mg 8 mg 12 mg 16 mg 1 QL(4 ea daily)

hydromorphone hcl tabs 2mg 4 mg 8 mg 1

KADIAN CP24 10 MG (Use Morphine Sulfate) GP

KADIAN CP24 20 MG 30 MG 50 MG 60 MG 80 MG 100 MG (Use Morphine Sulfate)

GP

QL(2 ea daily)

meperidine hcl soln 1

meperidine hcl tabs 1

methadone hcl tabs 5 mg10 mg 1 QL(12 ea daily)

methadone hcl tbso 40 mg 1

morphine sulfate cp24 or10 mg 1

morphine sulfate cp24 or20 mg 30 mg 50 mg 60mg 80 mg 100 mg

1 QL(2 ea daily)

MORPHINE SULFATE ER CP24 2 QL(1 ea daily)

morphine sulfate soln or 20mgml 10 mg5ml 20mg5ml 100 mg5ml

1

morphine sulfate supp re20 mg 1

MORPHINE SULFATE SUPP RE 30 MG 2

morphine sulfate tabs or 15mg 30 mg 1

morphine sulfate tbcr or 15mg 30 mg 60 mg 100 mg200 mg

1 QL(3 ea daily)

MS CONTIN TBCR (Use Morphine Sulfate) GP QL(3 ea daily)

NUCYNTA ER TB12 2 QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

NUCYNTA TABS 2 QL(6 ea daily)

OPANA ER (CRUSH RESISTANT) T12A 2 QL(2 ea daily)

oxycodone hcl caps 5 mg 1

oxycodone hcl conc 100mg5ml 1

oxycodone hcl soln 5mg5ml 1

oxycodone hcl tabs 30 mg 1 QL(4 ea daily)

oxycodone hcl tabs 5 mg10 mg 15 mg 20 mg 1

OXYMORPHONE HYDROCHLORIDE ER TB12

2 QL(2 ea daily)

ROXICODONE TABS 30 MG (Use Oxycodone HCl) GP QL(4 ea daily)

ROXICODONE TABS 5 MG 15 MG (Use Oxycodone HCl)

GP

tramadol hcl tabs 50 mg 1 QL(8 ea daily)

ULTRAM TABS (Use Tramadol HCl) GP QL(8 ea daily)

Opioid Combinations acetaminophen w codeinesoln 120mg5ml-12mg5ml 1

acetaminophen w codeinetabs 300mg-15mg 300mg-30mg

1

acetaminophen w codeinetabs 300mg-60mg 1 QL(6 ea daily)

hydrocodone-acetaminophen soln25mg5ml-108mg5ml5mg10ml-217mg10ml75mg15ml-325mg15ml

1

hydrocodone-acetaminophen tabs 5mg-300mg 10mg-300mg

1

hydrocodone-acetaminophen tabs 5mg-325mg 10mg-325mg75mg-325mg

1

QL(240 ea perfill retail)

5

Drug Name DrugTier

RequirementsLimits

hydrocodone-acetaminophen tabs75mg-300mg

1 QL(6 ea daily)

hydrocodone-ibuprofentabs 200mg-10mg 1

Not available through mailorder

hydrocodone-ibuprofentabs 200mg-5mg 200mg-10mg 200mg-75mg

1

NORCO TABS (Use Hydrocodone-Acetaminophen)

GP QL(240 ea perfill retail)

oxycodone wacetaminophen tabs 5mg-325mg

1 QL(6 ea daily)

OXYCODONEACETAMINOPHEN SOLN 2

PERCOCET TABS 5MG-325MG (Use Oxycodonew Acetaminophen)

GP QL(6 ea daily)

REPREXAIN TABS (Use Hydrocodone-Ibuprofen) GP

TYLENOLCODEINE 3TABS (Use Acetaminophenw Codeine)

GP

GP QL(6 ea daily)

XODOL TABS 5MG-300MG 10MG-300MG (Use Hydrocodone-Acetaminophen)

GP

XODOL TABS 75MG-300MG (Use Hydrocodone-Acetaminophen)

GP QL(6 ea daily)

Opioid Partial Agonists buprenorphine hcl subl 2 mg 1 QL(3 ea daily)

buprenorphine hcl subl 8 mg 1 QL(4 ea daily)

buprenorphine hcl-naloxone hcl dihydrate subl8mg-2mg 2mg-05mg

1 QL(3 ea daily)

ANDROGENS-ANABOLIC - Drugs to RegulateHormones Anabolic Steroids

Drug Name DrugTier

RequirementsLimits

OXANDRIN TABS 10 MG (Use Oxandrolone) GP QL(2 ea daily)

OXANDRIN TABS 25 MG (Use Oxandrolone) GP

oxandrolone tabs 10 mg 1 QL(2 ea daily)

oxandrolone tabs 25 mg 1

Androgens ANDROGEL GEL 25 MG25GM (Use Testosterone)

GP QL(10 gmdaily)

ANDROGEL GEL 405 MG25GM 2025MG125GM (Use Testosterone)

GP

Limited to 300 gms permonthQL(10gm daily)

ANDROGEL GEL 50 MG5GM (Use Testosterone)

NF QL(10 gmdaily)

ANDROGEL PUMP GEL (Use Testosterone) GP

ANDROXY TABS 2 AC

danazol caps 1

FORTESTA GEL (Use Testosterone) GP QL(35 gmdaily)

METHITEST TABS 2

METHYLTESTOSTERONE CAPS 1

methyltestosterone caps 1

TESTIM GEL (Use Testosterone) NF QL(10 gmdaily)

testosterone gel 1 1

Limit 300gms permonthQL(10gm daily)

testosterone gel 1 162 50 mg5gm 25mg25gm 405 mg25gm2025 mg125gm

1

testosterone gel 1 50mg5gm 25 mg25gm 1 QL(10 gm

daily)

6

Drug Name DrugTier

RequirementsLimits

testosterone gel 10 mgact 1 QL(35 gmdaily)

TESTRED CAPS (Use Methyltestosterone) GP

ANORECTAL AGENTS - Rectal Drugs to TreatPain Swelling and Itching Intrarectal Steroids CORTENEMA ENEM (Use Hydrocortisone(Intrarectal))

GP QL(60 ml daily)

CORTIFOAM FOAM 2

hydrocortisone (intrarectal) enem 1 QL(60 ml daily)

Rectal Combinations PROCTOFOAM HC FOAM 2

Rectal Steroids ANUSOL-HC CREA (Use Hydrocortisone (Rectal)) GP

hydrocortisone (rectal) crea 1

Vasodilating Agents RECTIV OINT 2

ANTHELMINTICS - Drugs to Treat WormInfections Anthelmintics

BENZNIDAZOLE TABS 2 AL(At least 2yrs old - Up to12 yrs old)

BILTRICIDE TABS (Use Praziquantel) GP

praziquantel tabs 1

ANTI-INFECTIVE AGENTS - MISC - Drugs toTreat Bacterial Infections Anti-infective Agents - Misc FLAGYL CAPS (Use Metronidazole) GP

FLAGYL TABS (Use Metronidazole) GP

IMPAVIDO CAPS 2

Drug Name DrugTier

RequirementsLimits

metronidazole caps 1

metronidazole tabs 1

NEBUPENT SOLR 2

trimethoprim tabs 1

Anti-infective Misc - Combinations BACTRIM DS TABS (Use Sulfamethoxazole-Trimethoprim)

GP

BACTRIM TABS (Use Sulfamethoxazole-Trimethoprim)

GP

sulfamethoxazole-trimethoprim susp 1

sulfamethoxazole-trimethoprim tabs 1

Antiprotozoal Agents atovaquone susp 1

MEPRON SUSP (Use Atovaquone) GP

Glycopeptides VANCOCIN HCL CAPS (Use Vancomycin HCl) GP PA

vancomycin hcl caps 1 PA

Leprostatics dapsone tabs 100 mg 1 QL(4 ea daily)

dapsone tabs 25 mg 1

Lincosamides CLEOCIN CAPS OR 75 MG 150 MG 300 MG (Use Clindamycin HCl)

GP

clindamycin hcl caps 1

Oxazolidinones

linezolid susr 100 mg5ml 1 QL(210 ml per90 days retail)

linezolid tabs 600 mg 1 QL(20 ea per90 days retail)

7

Drug Name DrugTier

RequirementsLimits

SIVEXTRO TABS 2 QL(6 ea per 90days retail)

ZYVOX SUSR 100 MG5ML (Use Linezolid) GP QL(210 ml per90 days retail) ZYVOX TABS 600 MG (Use Linezolid) GP QL(20 ea per90 days retail) ANTIANGINAL AGENTS - Drugs to Treat ChestPain Nitrates ISORDIL TITRADOSE TABS 40 MG 2

ISORDIL TITRADOSE TABS 5 MG (Use Isosorbide Dinitrate)

GP

ISOSORBIDE DINITRATE ER TBCR 2

ISOSORBIDE DINITRATE TABS 30 MG 2

isosorbide dinitrate tabs 5 mg 10 mg 20 mg 1

isosorbide mononitrate tabs 1

isosorbide mononitrate tb24 1

NITRO-BID OINT 2

NITRO-DUR PT24 01 MGHR 02 MGHR 04MGHR 06 MGHR (Use Nitroglycerin)

GP

QL(1 ea daily)

NITRO-DUR PT24 03 MGHR 08 MGHR 2 QL(1 ea daily)

nitroglycerin pt24 td 01mghr 02 mghr 04mghr 06 mghr

1 QL(1 ea daily)

nitroglycerin soln tl 04mgspray 1

nitroglycerin subl sl 03 mg04 mg 06 mg 1

NITROLINGUAL PUMPSPRAY SOLN (Use Nitroglycerin)

GP

NITROSTAT SUBL (Use Nitroglycerin) GP

ANTIANXIETY AGENTS - Drugs to Treat Anxiety

Drug Name DrugTier

RequirementsLimits

Antianxiety Agents - Misc buspirone hcl tabs 1

hydroxyzine hcl syrp 1

hydroxyzine hcl tabs 1

hydroxyzine pamoate caps 1

VISTARIL CAPS (Use Hydroxyzine Pamoate) GP

Benzodiazepines alprazolam tabs 025 mg05 mg 1 mg 2 mg 1

ATIVAN TABS (Use Lorazepam) NF

chlordiazepoxide hcl caps 1

clorazepate dipotassiumtabs 1

diazepam conc or 5 mgml 1

diazepam soln or 5 mg5ml 1

diazepam tabs or 10 mg 1 QL(4 ea daily)

diazepam tabs or 2 mg 5 mg 1

lorazepam conc 1

lorazepam tabs 1

oxazepam caps 10 mg 15 mg 1

oxazepam caps 30 mg 1 QL(2 ea daily)

OXAZEPAM CAPS 30 MG 2 QL(2 ea daily)

TRANXENE T TABS (Use Clorazepate Dipotassium) GP

VALIUM TABS 10 MG (Use Diazepam) GP QL(4 ea daily)

VALIUM TABS 2 MG 5 MG (Use Diazepam) GP

XANAX TABS (Use Alprazolam) GP

8

Drug Name DrugTier

RequirementsLimits

ANTIARRHYTHMICS - Drugs to treat abnormalheart rhythms Antiarrhythmics Type I-A disopyramide phosphate caps 1

NORPACE CAPS (Use Disopyramide Phosphate) GP

NORPACE CR CP12 2

quinidine gluconate tbcr 1

QUINIDINE SULFATE TABS 2

Antiarrhythmics Type I-B MEXILETINE HCL CAPS 2

Antiarrhythmics Type I-C flecainide acetate tabs 1

propafenone hcl cp12 225mg 325 mg 425 mg 1

propafenone hcl tabs 150 mg 1 QL(6 ea daily)

propafenone hcl tabs 225mg 300 mg 1 QL(3 ea daily)

RYTHMOL SR CP12 (Use Propafenone HCl) GP

Antiarrhythmics Type III amiodarone hcl tabs 1

dofetilide caps 1

MULTAQ TABS 2

TIKOSYN CAPS (Use Dofetilide) GP

ANTIASTHMATIC AND BRONCHODILATOR AGENTS - Drugs to Treat Lung Conditions Anti-Inflammatory Agents cromolyn sodium nebu 1

Bronchodilators - Anticholinergics

Drug Name DrugTier

RequirementsLimits

ATROVENT HFA AERS 2

Limit 2 inhalers permonthQL(086gm daily)

INCRUSE ELLIPTA AEPB 2 QL(1 ea daily)

ipratropium bromide soln 1

SPIRIVA HANDIHALER CAPS 2 QL(1 ea daily)

SPIRIVA RESPIMAT AERS 125 MCGACT 2

Limit 1 Inhaler permonthQL(0143 gm daily)

Limit 1 permonthQL(014gm daily)

Leukotriene Modulators montelukast sodium chew 1 QL(1 ea daily)

montelukast sodium pack 1 QL(1 ea daily)

montelukast sodium tabs 1 QL(1 ea daily)

SINGULAIR CHEW (Use Montelukast Sodium) GP QL(1 ea daily)

SINGULAIR PACK (Use Montelukast Sodium) GP QL(1 ea daily)

SINGULAIR TABS (Use Montelukast Sodium) GP QL(1 ea daily)

Steroid Inhalants

AEROSPAN AERS 2

ARNUITY ELLIPTA AEPB 2 QL(1 ea daily)

ASMANEX HFA AERO 2

Limit 1 Inhaler permonthQL(044gm daily)

ASMANEX TWISTHALER 120 METERED DOSES AEPB

2

Limit 1 inhaler permonthQL(004ea daily)

9

Drug Name DrugTier

RequirementsLimits

2

budesonide (inhalation)susp 025 mg2ml 1 QL(8 ml daily)

FLOVENT DISKUS AEPB 100 MCGBLIST 2 QL(20 ea daily)

FLOVENT HFA AERO 110 MCGACT 220 MCGACT 2

FLOVENT HFA AERO 44 MCGACT 2

PULMICORT FLEXHALER AEPB 180 MCGACT 2

Limit 2 inhalers permonthQL(007ea daily)

Limit 8 Inhalers permonthQL(027ea daily)

PULMICORT SUSP 025 MG2ML (Use Budesonide (Inhalation))

GP QL(8 ml daily)

Drug Name DrugTier

RequirementsLimits

GP QL(4 ml daily)

GP QL(2 ml daily)

QVAR AERS 40 MCGACT 2

Limit 3 Inhalers per Month-73gpkg Limit 2Inhalers perMonth-87gpkgQL(058gm daily)

QVAR REDIHALER AERB 2 QL(072 gmdaily)

Sympathomimetics ADVAIR DISKUS AEPB (Use Fluticasone-Salmeterol)

GP QL(2 ea daily)

ADVAIR HFA AERO 21MCGACT-230MCGACT

2

ADVAIR HFA AERO 21MCGACT-45MCGACT21MCGACT-115MCGACT

2

Limit 1 inhaler permonthQL(04gm daily)

albuterol sulfate aers in 108 mcgact 1 QL(12 gm

daily) ALBUTEROL SULFATE ER TB12 2 QL(2 ea daily)

albuterol sulfate nebu in 063 mg3ml 0083 05 125 mg3ml

1

albuterol sulfate syrp or 2mg5ml 1

albuterol sulfate tabs or 2 mg 4 mg 1

albuterol sulfate tb12 or 4 mg 8 mg 1 QL(2 ea daily)

ANORO ELLIPTA AEPB 2 QL(2 ea daily)

BREO ELLIPTA AEPB 2 QL(2 ea daily)

10

Drug Name DrugTier

RequirementsLimits

DULERA AERO 2

FLUTICASONE PROPIONATESALMETEROL AEPB

2 QL(004 eadaily)

fluticasone-salmeterol aepb 1 QL(2 ea daily)

ipratropium-albuterol soln 1

levalbuterol hcl nebu 1

levalbuterol tartrate aero 1 QL(05 gmdaily)

metaproterenol sulfate syrp 1

metaproterenol sulfate tabs 1

PROAIR HFA AERS (Use Albuterol Sulfate) NF QL(028 gmdaily) SEREVENT DISKUS AEPB 2 QL(2 ea daily)

STIOLTO RESPIMAT AERS 2

STRIVERDI RESPIMAT AERS 2

SYMBICORT AERO 2

terbutaline sulfate tabs 1

TRELEGY ELLIPTA AEPB 2 QL(2 ea daily)

VENTOLIN HFA AERS (Use Albuterol Sulfate) NF QL(054 gmdaily) VENTOLIN HFA AERS (Use Albuterol Sulfate) NF QL(12 gmdaily) VOSPIRE ER TB12 (Use Albuterol Sulfate) GP QL(2 ea daily)

XOPENEX CONCENTRATE NEBU (Use Levalbuterol HCl)

GP

Drug Name DrugTier

RequirementsLimits

XOPENEX NEBU (Use Levalbuterol HCl) GP

Xanthines theophylline tb12 100 mg200 mg 1

theophylline tb12 300 mg450 mg 1 QL(1 ea daily)

ANTICOAGULANTS - Blood Thinners

Coumarin Anticoagulants COUMADIN TABS (Use Warfarin Sodium) GP

warfarin sodium tabs 1

Direct Factor Xa Inhibitors

BEVYXXA CAPS 2 QL(42 ea per42 days retail)

ELIQUIS STARTER PACK TABS 2

ELIQUIS TABS 25 MG 2 QL(2 ea daily)

ELIQUIS TABS 5 MG 2

XARELTO STARTER PACK TBPK 2

XARELTO TABS 10 MG 15 MG 25 MG 2

XARELTO TABS 20 MG 2 QL(1 ea daily)

Thrombin Inhibitors PRADAXA CAPS 2

ANTICONVULSANTS - Drugs to Treat Seizures

Anticonvulsants - Benzodiazepines clonazepam tabs 1

clonazepam tbdp 1

KLONOPIN TABS (Use Clonazepam) GP

Anticonvulsants - Misc

11

Drug Name DrugTier

RequirementsLimits

BANZEL SUSP 40 MGML 2

BANZEL TABS 200 MG 2

BANZEL TABS 400 MG 2 QL(8 ea daily)

carbamazepine chew 100 mg 1

carbamazepine cp12 100mg 200 mg 300 mg 1

carbamazepine susp 100mg5ml 1

carbamazepine tabs 200 mg 1

carbamazepine tb12 100 mg 1

carbamazepine tb12 200 mg 1 QL(8 ea daily)

CARBATROL CP12 (Use Carbamazepine) GP

gabapentin caps 1

gabapentin soln 1

gabapentin tabs 1

KEPPRA SOLN 100 MGML (Use Levetiracetam)

GP

KEPPRA TABS 250 MG 500 MG 750 MG 1000 MG (Use Levetiracetam)

GP QL(6 ea daily)

KEPPRA XR TB24 (Use Levetiracetam) GP QL(4 ea daily)

LAMICTAL CHEWABLE DISPERSIBLE CHEW (Use Lamotrigine)

GP

LAMICTAL ODT TBDP 25 MG 50 MG 100 MG 200 MG (Use Lamotrigine)

GP PA

LAMICTAL STARTERNOTTAKING CARBAMAZEPINE KIT (Use Lamotrigine)

GP

Drug Name DrugTier

RequirementsLimits

LAMICTAL STARTERTAKINGCARBAMAZEPINENOTTAKING VALPROATE KIT (Use Lamotrigine)

GP

LAMICTAL STARTERTAKINGVALPROATE KIT (Use Lamotrigine)

GP

LAMICTAL TABS (Use Lamotrigine) GP

lamotrigine chew 5 mg 25 mg 1

lamotrigine kit 25 mg 1

lamotrigine tabs 25 mg100 mg 150 mg 200 mg 1

lamotrigine tbdp 25 mg 50mg 100 mg 200 mg 1 PA

levetiracetam soln or 100 mgml 500 mg5ml 1

levetiracetam tabs or 250 mg 500 mg 750 mg 1000 mg

1 QL(6 ea daily)

levetiracetam tb24 or 500 mg 750 mg 1 QL(4 ea daily)

MYSOLINE TABS (Use Primidone) GP

NEURONTIN CAPS (Use Gabapentin) GP

NEURONTIN SOLN (Use Gabapentin) GP

NEURONTIN TABS (Use Gabapentin) GP

oxcarbazepine susp 60mgml 300 mg5ml 1 QL(40 ml daily)

oxcarbazepine tabs 150 mg 1

oxcarbazepine tabs 300 mg 1 QL(8 ea daily)

POTIGA TABS 2

primidone tabs 1

12

Drug Name DrugTier

RequirementsLimits

TEGRETOL SUSP (Use Carbamazepine) GP

TEGRETOL TABS (Use Carbamazepine) GP

TEGRETOL-XR TB12 100 MG (Use Carbamazepine) GP

TEGRETOL-XR TB12 200 MG (Use Carbamazepine) GP QL(8 ea daily)

TOPAMAX SPRINKLE CPSP (Use Topiramate) GP

TOPAMAX TABS 100 MG (Use Topiramate) GP QL(4 ea daily)

TOPAMAX TABS 25 MG (Use Topiramate) GP

topiramate cpsp 15 mg 25 mg 1

topiramate tabs 100 mg 1 QL(4 ea daily)

topiramate tabs 25 mg 1

TRILEPTAL TABS 150 MG (Use Oxcarbazepine) GP

TRILEPTAL TABS 300 MG (Use Oxcarbazepine) GP QL(8 ea daily)

VIMPAT SOLN 10 MGML 2 QL(40 ml daily)

VIMPAT TABS 50 MG 100 MG 150 MG 200 MG 2

ZONEGRAN CAPS 100 MG (Use Zonisamide) GP QL(6 ea daily)

ZONEGRAN CAPS 25 MG (Use Zonisamide) GP

zonisamide caps 100 mg 1 QL(6 ea daily)

Drug Name DrugTier

RequirementsLimits

zonisamide caps 25 mg 50 mg 1

Carbamates felbamate susp 1

felbamate tabs 1

FELBATOL SUSP (Use Felbamate) GP

FELBATOL TABS (Use Felbamate) GP

GABA Modulators SABRIL PACK (Use Vigabatrin) GP QL(6 ea daily)

SABRIL TABS (Use Vigabatrin) GP

vigabatrin pack 1 QL(6 ea daily)

vigabatrin tabs 1

Hydantoins DILANTIN CAPS 100 MG (Use Phenytoin SodiumExtended)

GP

DILANTIN CAPS 30 MG 2

DILANTIN INFATABS CHEW (Use Phenytoin) GP

DILANTIN-125 SUSP (Use Phenytoin) GP

PHENYTEK CAPS (Use Phenytoin SodiumExtended)

GP

phenytoin chew 1

phenytoin sodium extended caps 1

phenytoin susp 1

Succinimides CELONTIN CAPS 2

ethosuximide caps 1

ethosuximide soln 1

13

Drug Name DrugTier

RequirementsLimits

ZARONTIN CAPS (Use Ethosuximide) GP

ZARONTIN SOLN (Use Ethosuximide) GP

Valproic Acid DEPAKENE CAPS (Use Valproic Acid) GP

DEPAKENE SOLN (Use Valproate Sodium) GP

DEPAKOTE ER TB24 (Use Divalproex Sodium) GP

DEPAKOTE SPRINKLES CSDR (Use DivalproexSodium)

GP

DEPAKOTE TBEC (Use Divalproex Sodium) GP

divalproex sodium csdr 1

divalproex sodium tb24 1

divalproex sodium tbec 1

valproate sodium soln 1

valproic acid caps or 1

ANTIDEPRESSANTS - Drugs to TreatDepression Alpha-2 Receptor Antagonists (Tetracyclics) mirtazapine tabs 1

mirtazapine tbdp 1

REMERON SOLTAB TBDP (Use Mirtazapine) GP

REMERON TABS (Use Mirtazapine) GP

Antidepressants - Misc bupropion hcl tabs 75 mg100 mg 1

bupropion hcl tb12 100 mg150 mg 200 mg 1

bupropion hcl tb24 150 mg300 mg 1 QL(1 ea daily)

maprotiline hcl tabs 1

Drug Name DrugTier

RequirementsLimits

WELLBUTRIN SR TB12 (Use Bupropion HCl) GP

WELLBUTRIN XL TB24 (Use Bupropion HCl) GP QL(1 ea daily)

Monoamine Oxidase Inhibitors (MAOIs) NARDIL TABS (Use Phenelzine Sulfate) GP

PARNATE TABS (Use Tranylcypromine Sulfate) GP

phenelzine sulfate tabs 1

tranylcypromine sulfatetabs 1

Selective Serotonin Reuptake Inhibitors (SSRIs) CELEXA TABS (Use Citalopram Hydrobromide) GP QL(1 ea daily)

citalopram hydrobromidesoln 10 mg5ml 1 QL(20 ml daily)

citalopram hydrobromidetabs 10 mg 20 mg 40 mg 1 QL(1 ea daily)

escitalopram oxalate soln 5mg5ml 1

escitalopram oxalate tabs10 mg 20 mg 1 QL(1 ea daily)

escitalopram oxalate tabs 5 mg 1 QL(2 ea daily)

fluoxetine hcl caps 10 mg20 mg 1

fluoxetine hcl caps 40 mg 1 QL(1 ea daily)

fluoxetine hcl soln 20 mg5ml 1 QL(15 ml daily)

fluoxetine hcl tabs 10 mg 1

fluoxetine hcl tabs 20 mg 1 QL(1 ea daily)

fluvoxamine maleate cp24100 mg 1 QL(3 ea daily)

fluvoxamine maleate cp24150 mg 1

fluvoxamine maleate tabs 100 mg 1 QL(3 ea daily)

fluvoxamine maleate tabs 25 mg 50 mg 1

14

Drug Name DrugTier

RequirementsLimits

LEXAPRO SOLN 5 MG5ML (Use Escitalopram Oxalate)

GP

LEXAPRO TABS 10 MG 20 MG (Use EscitalopramOxalate)

GP QL(1 ea daily)

LEXAPRO TABS 5 MG (Use Escitalopram Oxalate) GP QL(2 ea daily)

paroxetine hcl tabs 1

paroxetine hcl tb24 1

PAXIL CR TB24 (Use Paroxetine HCl) GP

PAXIL SUSP 10 MG5ML 2

PAXIL TABS 10 MG 20 MG 30 MG 40 MG (Use Paroxetine HCl)

GP

PROZAC CAPS 10 MG 20 MG (Use Fluoxetine HCl) GP

PROZAC CAPS 40 MG (Use Fluoxetine HCl) GP QL(1 ea daily)

sertraline hcl conc 20 mgml 1

sertraline hcl tabs 25 mg50 mg 100 mg 1 QL(2 ea daily)

ZOLOFT CONC 20 MGML(Use Sertraline HCl) GP

ZOLOFT TABS 25 MG 50 MG 100 MG (Use Sertraline HCl)

GP QL(2 ea daily)

Serotonin Modulators NEFAZODONE HCL TABS 100 MG 150 MG 2

nefazodone hcl tabs 50 mg 250 mg 1

NEFAZODONE HYDROCHLORIDE TABS 2

trazodone hcl tabs 1

Serotonin-Norepinephrine Reuptake Inhibitors CYMBALTA CPEP (Use Duloxetine HCl) GP QL(2 ea daily)

desvenlafaxine succinate tb24 1 QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

duloxetine hcl cpep 20 mg30 mg 60 mg 1 QL(2 ea daily)

EFFEXOR XR CP24 150 MG (Use Venlafaxine HCl) GP QL(2 ea daily)

EFFEXOR XR CP24 75 MG 375 MG (Use Venlafaxine HCl)

GP QL(1 ea daily)

PRISTIQ TB24 (Use Desvenlafaxine Succinate) GP QL(1 ea daily)

venlafaxine hcl cp24 150 mg 1 QL(2 ea daily)

venlafaxine hcl cp24 75mg 375 mg 1 QL(1 ea daily)

venlafaxine hcl tabs 25 mg50 mg 75 mg 100 mg375 mg

1

venlafaxine hcl tb24 75 mg150 mg 225 mg 375 mg 1

venlafaxine hcl tb24 75 mg375 mg 1 QL(1 ea daily)

Tricyclic Agents amitriptyline hcl tabs 1

AMOXAPINE TABS 2

ANAFRANIL CAPS (Use Clomipramine HCl) GP

clomipramine hcl caps 1

desipramine hcl tabs 1

doxepin hcl caps 10 mg 25mg 50 mg 75 mg 100 mg 1

DOXEPIN HCL CAPS 150 MG 2

doxepin hcl conc 10 mgml 1

ELAVIL TABS (Use Amitriptyline HCl) GP

imipramine hcl tabs 10 mg25 mg 1

imipramine hcl tabs 50 mg 1 QL(4 ea daily)

NORPRAMIN TABS (Use Desipramine HCl) GP

nortriptyline hcl caps 10mg 25 mg 50 mg 75 mg 1

15

Drug Name DrugTier

RequirementsLimits

nortriptyline hcl soln 10mg5ml 1

NORTRIPTYLINE HCL SOLN 10 MG5ML 2

PAMELOR CAPS (Use Nortriptyline HCl) GP

TOFRANIL TABS 10 MG 25 MG (Use ImipramineHCl)

GP

TOFRANIL TABS 50 MG (Use Imipramine HCl) GP QL(4 ea daily)

ANTIDIABETICS - Drugs to Regulate BloodSugar Alpha-Glucosidase Inhibitors acarbose tabs 1

PRECOSE TABS (Use Acarbose) GP

Antidiabetic Combinations ACTOPLUS MET TABS (Use Pioglitazone HCl-Metformin HCl)

GP

DUETACT TABS (Use Pioglitazone HCl-Glimepiride)

GP

glipizide-metformin hcl tabs 1

GLUCOVANCE TABS (Use Glyburide-Metformin) GP

glyburide-metformin tabs 1

GLYXAMBI TABS 2

INVOKAMET TABS 2

INVOKAMET XR TB24 2

JANUMET TABS 50MG-1000MG 2

JANUMET TABS 50MG-500MG 2 QL(2 ea daily)

JANUMET XR TB24 100MG-1000MG 2 QL(1 ea daily)

JANUMET XR TB24 50MG-500MG 50MG-1000MG

2 QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

JENTADUETO TABS 2

JENTADUETO XR TB24 25MG-1000MG 2

JENTADUETO XR TB24 5MG-1000MG 2 QL(1 ea daily)

pioglitazone hcl-glimepiridetabs 1

pioglitazone hcl-metforminhcl tabs 1

SYNJARDY TABS 2

SYNJARDY XR TB24 2

Biguanides GLUCOPHAGE TABS (Use Metformin HCl) GP

GLUCOPHAGE XR TB24 (Use Metformin HCl) GP

metformin hcl tabs 1

metformin hcl tb24 1

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors JANUVIA TABS 25 MG 2

JANUVIA TABS 50 MG 100 MG 2 QL(1 ea daily)

TRADJENTA TABS 2 QL(1 ea daily)

Insulin Sensitizing Agents ACTOS TABS 15 MG (Use Pioglitazone HCl) GP

ACTOS TABS 30 MG 45 MG (Use Pioglitazone HCl) GP QL(1 ea daily)

AVANDIA TABS 2

pioglitazone hcl tabs 15 mg 1

pioglitazone hcl tabs 30mg 45 mg 1 QL(1 ea daily)

Insulin

HUMALOG JUNIOR KWIKPEN SOPN 2

Limit 45mls permonthQL(15ml daily)

16

Drug Name DrugTier

RequirementsLimits

HUMALOG KWIKPEN SOPN 100 UNITML 2

HUMALOG MIX 5050KWIKPEN SUPN 2

HUMALOG MIX 5050SUSP 2

HUMALOG SOCT 2 Limit 45mls permonthQL(15ml daily)

HUMALOG SOLN 2 Limit 45mls permonthQL(15ml daily)

HUMULIN 7030 KWIKPENSUPN 2

HUMULIN 7030 SUSP 2 Limit 4 vials permonthQL(134ml daily)

HUMULIN 7030 SUSP 2 Limit 40mls permonthQL(134ml daily)

HUMULIN N KWIKPEN SUPN 2

HUMULIN N SUSP 2 QL(134 mldaily)

HUMULIN R SOLN 2 Limit 40mls permonthQL(134ml daily)

HUMULIN R U-500 (CONCENTRATED) SOLN 2 QL(134 ml

daily)

Drug Name DrugTier

RequirementsLimits

HUMULIN R U-500 KWIKPEN SOPN 2

QL(40 ml perfill retail40 ml per 30 daysretail)

LANTUS SOLN 2 Limit 45mls permonthQL(15ml daily)

LANTUS SOLOSTAR SOPN 2

LEVEMIR FLEXTOUCH SOPN 2

Limit 45mls permonthQL(15ml daily135 mlper fill mail)

LEVEMIR SOLN 2

TOUJEO MAX SOLOSTAR SOPN 2

Limit 3 pens permonthQL(05ml daily)

TOUJEO SOLOSTAR SOPN 2

TRESIBA FLEXTOUCH SOPN 100 UNITML 2

TRESIBA SOLN 2

Meglitinide Analogues nateglinide tabs 1

PRANDIN TABS (Use Repaglinide) GP

repaglinide tabs 1

STARLIX TABS (Use Nateglinide) GP

Sodium-Glucose Co-Transporter 2 (SGLT2) INVOKANA TABS 100 MG 2

INVOKANA TABS 300 MG 2 QL(1 ea daily)

17

Drug Name DrugTier

RequirementsLimits

JARDIANCE TABS 10 MG 2

JARDIANCE TABS 25 MG 2 QL(1 ea daily)

Sulfonylureas AMARYL TABS (Use Glimepiride) GP

chlorpropamide tabs 1

glimepiride tabs 1

glipizide tabs 1

glipizide tb24 1

GLUCOTROL TABS (Use Glipizide) GP

GLUCOTROL XL TB24 (Use Glipizide) GP

glyburide micronized tabs 1

glyburide tabs 1

GLYNASE TABS (Use Glyburide Micronized) GP

TOLAZAMIDE TABS 250 MG 2

tolazamide tabs 500 mg 1

tolbutamide tabs 1

ANTIDIARRHEALPROBIOTIC AGENTS - Drugsto Treat Diarrhea Antiperistaltic Agents diphenoxylate w atropineliqd 1

diphenoxylate w atropinetabs 1

LOMOTIL TABS (Use Diphenoxylate w Atropine) GP

ANTIDOTES AND SPECIFIC ANTAGONISTS

Antidotes - Chelating Agents JADENU TABS 2 PA

Opioid Antagonists

Drug Name DrugTier

RequirementsLimits

naltrexone hcl tabs 1

ANTIEMETICS - Drugs to Treat Nausea andVomiting 5-HT3 Receptor Antagonists

ondansetron hcl soln 4 mg5ml 1

Limit 50mls permonthQL(167ml daily50 mlper fill retail)

ondansetron hcl tabs 4 mg8 mg 1 QL(20 ea per

fill retail)

ondansetron tbdp 1 QL(20 ea perfill retail)

ZOFRAN ODT TBDP (Use Ondansetron) GP QL(20 ea perfill retail)

ZOFRAN SOLN 4 MG5ML(Use Ondansetron HCl) GP

ZOFRAN TABS 4 MG 8 MG (Use Ondansetron HCl)

Antiemetics - Anticholinergic TIGAN CAPS (Use Trimethobenzamide HCl) GP

trimethobenzamide hcl caps 1

ANTIFUNGALS - Drugs to Treat Fungal Infections

Antifungals GRIS-PEG TABS (Use Griseofulvin Ultramicrosize) GP

griseofulvin microsize susp 1

griseofulvin microsize tabs 1

griseofulvin ultramicrosizetabs 1

LAMISIL TABS (Use Terbinafine HCl) GP

QL(1 eadaily90 ea per365 days retail)

nystatin tabs 1

terbinafine hcl tabs 1 QL(1 eadaily90 ea per365 days retail)

18

Drug Name DrugTier

RequirementsLimits

Imidazole-Related Antifungals DIFLUCAN SUSR (Use Fluconazole) GP

DIFLUCAN TABS (Use Fluconazole) GP

fluconazole susr 1

fluconazole tabs 1

itraconazole caps 1 PA

itraconazole soln 1 PA

ketoconazole tabs 1

SPORANOX CAPS (Use Itraconazole) GP PA

SPORANOX PULSEPAK CAPS (Use Itraconazole) GP PA

SPORANOX SOLN (Use Itraconazole) GP PA

VFEND SUSR 40 MGML(Use Voriconazole) GP

VFEND TABS 50 MG 200 MG (Use Voriconazole) GP QL(2 ea daily)

voriconazole susr or 40 mgml 1

voriconazole tabs or 50 mg 200 mg 1 QL(2 ea daily)

ANTIHISTAMINES - Drugs to Treat Allergies

Antihistamines - Ethanolamines carbinoxamine maleate soln 4 mg5ml 1

CLEMASTINE FUMARATE TABS 2

Antihistamines - Phenothiazines promethazine hcl soln or625 mg5ml 1

promethazine hcl supp re25 mg 125 mg 1

promethazine hcl supp re50 mg 1 QL(3 ea daily)

promethazine hcl syrp or625 mg5ml 1

Drug Name DrugTier

RequirementsLimits

promethazine hcl tabs or125 mg 1

promethazine hcl tabs or25 mg 1 QL(6 ea daily)

Antihistamines - Piperidines cyproheptadine hcl syrp 1

cyproheptadine hcl tabs 1

ANTIHYPERLIPIDEMICS - Drugs to Treat HighCholesterol Antihyperlipidemics - Combinations ezetimibe-simvastatin tabs 1 QL(1 ea daily)

VYTORIN TABS (Use Ezetimibe-Simvastatin) GP QL(1 ea daily)

Antihyperlipidemics - Misc LOVAZA CAPS (Use Omega-3-acid Ethyl Esters) GP QL(4 ea daily)

omega-3-acid ethyl esters caps 1 QL(4 ea daily)

Bile Acid Sequestrants cholestyramine light powd4 gmdose 1

cholestyramine powd or 4gmdose 1

COLESTID FLAVORED GRAN 5 GM (Use Colestipol HCl)

GP

COLESTID GRAN 5 GM (Use Colestipol HCl) GP

COLESTID TABS 1 GM (Use Colestipol HCl) GP

colestipol hcl gran 5 gm 1

colestipol hcl tabs 1 gm 1

QUESTRAN LIGHT POWD (Use Cholestyramine Light) GP

QUESTRAN POWD 4 GMDOSE (Use Cholestyramine)

GP

Fibric Acid Derivatives

19

Drug Name DrugTier

RequirementsLimits

choline fenofibrate cpdr135 mg 1 QL(1 ea daily)

choline fenofibrate cpdr 45 mg 1

fenofibrate micronized caps130 mg 200 mg 1 QL(1 ea daily)

fenofibrate micronized caps43 mg 67 mg 134 mg 1

fenofibrate tabs 145 mg160 mg 1 QL(1 ea daily)

FENOFIBRATE TABS 160 MG 2 QL(1 ea daily)

fenofibrate tabs 48 mg 1

fenofibrate tabs 54 mg 1 QL(2 ea daily)

gemfibrozil tabs 1

LOFIBRA CAPS (Use Fenofibrate Micronized) GP QL(1 ea daily)

LOPID TABS (Use Gemfibrozil) GP

TRICOR TABS 145 MG (Use Fenofibrate) GP QL(1 ea daily)

TRICOR TABS 48 MG (Use Fenofibrate) GP

TRIGLIDE TABS 2 QL(1 ea daily)

TRILIPIX CPDR 135 MG (Use Choline Fenofibrate) GP QL(1 ea daily)

TRILIPIX CPDR 45 MG (Use Choline Fenofibrate) GP

HMG CoA Reductase Inhibitors atorvastatin calcium tabs 1 QL(1 ea daily)

CRESTOR TABS (Use Rosuvastatin Calcium) GP QL(1 ea daily)

fluvastatin sodium caps 1 QL(1 ea daily)

fluvastatin sodium tb24 1 QL(1 ea daily)

LESCOL XL TB24 (Use Fluvastatin Sodium) GP QL(1 ea daily)

LIPITOR TABS (Use Atorvastatin Calcium) GP QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

lovastatin tabs 10 mg 20 mg 1

$0 copay forGeneric onlyage 40 to 75QL(1 ea daily)AL(At least 40yrs old - Up to75 yrs old) PV

lovastatin tabs 40 mg 1

$0 copay forGeneric onlyage 40 to75SL(2 eadaily) AL(Atleast 40 yrs old- Up to 75 yrsold) PV

MEVACOR TABS (Use Lovastatin) GP

PRAVACHOL TABS 20 MG 80 MG (Use Pravastatin Sodium)

GP QL(1 ea daily)

PRAVACHOL TABS 40 MG (Use Pravastatin Sodium)

GP QL(2 ea daily)

pravastatin sodium tabs 10mg 20 mg 80 mg 1 QL(1 ea daily)

pravastatin sodium tabs 40 mg 1 QL(2 ea daily)

rosuvastatin calcium tabs 1 QL(1 ea daily)

simvastatin tabs 1 QL(1 ea daily)

ZOCOR TABS (Use Simvastatin) GP QL(1 ea daily)

Intestinal Cholesterol Absorption Inhibitors ezetimibe tabs 1

ZETIA TABS (Use Ezetimibe) GP

Nicotinic Acid Derivatives niacin (antihyperlipidemic)tbcr 1

20

Drug Name DrugTier

RequirementsLimits

NIASPAN TBCR (Use Niacin (Antihyperlipidemic)) GP

ANTIHYPERTENSIVES - Drugs to Treat HighBlood Pressure ACE Inhibitors ACCUPRIL TABS (Use Quinapril HCl) GP

ACEON TABS (Use Perindopril Erbumine) GP

ALTACE CAPS (Use Ramipril) GP QL(2 ea daily)

benazepril hcl tabs 1

captopril tabs 1

enalapril maleate tabs 1 QL(2 ea daily)

fosinopril sodium tabs 1

lisinopril tabs 40 mg 1 QL(2 ea daily)

lisinopril tabs 5 mg 10 mg20 mg 30 mg 25 mg 1

LOTENSIN TABS (Use Benazepril HCl) GP

moexipril hcl tabs 1

perindopril erbumine tabs 1

PRINIVIL TABS (Use Lisinopril) GP

quinapril hcl tabs 1

ramipril caps 1 QL(2 ea daily)

trandolapril tabs 1

VASOTEC TABS (Use Enalapril Maleate) GP QL(2 ea daily)

ZESTRIL TABS 40 MG (Use Lisinopril) GP QL(2 ea daily)

ZESTRIL TABS 5 MG 10 MG 20 MG 30 MG 25 MG (Use Lisinopril)

GP

Agents for Pheochromocytoma DIBENZYLINE CAPS (Use Phenoxybenzamine HCl) GP Not available through mail

Drug Name DrugTier

RequirementsLimits

phenoxybenzamine hcl caps 1 Not available

through mail Angiotensin II Receptor Antagonists ATACAND TABS 32 MG (Use Candesartan Cilexetil) GP QL(1 ea daily)

ATACAND TABS 4 MG 8 MG 16 MG (Use Candesartan Cilexetil)

GP

AVAPRO TABS (Use Irbesartan) GP

BENICAR TABS 40 MG (Use Olmesartan Medoxomil)

GP QL(1 ea daily)

BENICAR TABS 5 MG 20 MG (Use Olmesartan Medoxomil)

GP

candesartan cilexetil tabs 32 mg 1 QL(1 ea daily)

candesartan cilexetil tabs 4 mg 8 mg 16 mg 1

COZAAR TABS (Use Losartan Potassium) GP

DIOVAN TABS 160 MG (Use Valsartan) GP QL(2 ea daily)

DIOVAN TABS 40 MG 80 MG 320 MG (Use Valsartan)

GP

EPROSARTAN MESYLATE TABS 2

irbesartan tabs 1

losartan potassium tabs 1

MICARDIS TABS 20 MG 40 MG (Use Telmisartan) GP

MICARDIS TABS 80 MG (Use Telmisartan) GP QL(1 ea daily)

olmesartan medoxomil tabs 40 mg 1 QL(1 ea daily)

olmesartan medoxomil tabs 5 mg 20 mg 1

telmisartan tabs 20 mg 40 mg 1

telmisartan tabs 80 mg 1 QL(1 ea daily)

valsartan tabs 160 mg 1 QL(2 ea daily)

21

Drug Name DrugTier

RequirementsLimits

valsartan tabs 40 mg 80mg 320 mg 1

Antiadrenergic Antihypertensives CARDURA TABS (Use Doxazosin Mesylate) GP

CATAPRES TABS (Use Clonidine HCl) GP

clonidine hcl tabs 1

doxazosin mesylate tabs 1

guanfacine hcl tabs 1

methyldopa tabs 1

MINIPRESS CAPS (Use Prazosin HCl) GP

prazosin hcl caps 1

terazosin hcl caps 1 mg 2mg 5 mg 1

terazosin hcl caps 10 mg 1 QL(2 ea daily)

Antihypertensive Combinations ACCURETIC TABS 10MG-125MG 20MG-125MG (Use Quinapril-Hydrochlorothiazide)

GP

ACCURETIC TABS 20MG-25MG (Use Quinapril-Hydrochlorothiazide)

GP QL(1 ea daily)

amlodipine besylate-benazepril hcl caps 25mg-10mg

1

amlodipine besylate-benazepril hcl caps 5mg-10mg 5mg-20mg 5mg-40mg 10mg-20mg 10mg-40mg

1

QL(1 ea daily)

amlodipine besylate-valsartan tabs 160mg-10mg

1 QL(1 ea daily)

amlodipine besylate-valsartan tabs 160mg-5mg320mg-5mg 320mg-10mg

1

amlodipine-valsartan-hydrochlorothiazide tabs 1

Drug Name DrugTier

RequirementsLimits

ATACAND HCT TABS (Use Candesartan Cilexetil-Hydrochlorothiazide)

GP

atenolol amp chlorthalidone tabs 1

AVALIDE TABS (Use Irbesartan-Hydrochlorothiazide)

GP

benazepril amphydrochlorothiazide tabs 1

BENICAR HCT TABS 20MG-125MG (Use Olmesartan Medoxomil-Hydrochlorothiazide)

GP

BENICAR HCT TABS 40MG-25MG 40MG-125MG (Use Olmesartan Medoxomil-Hydrochlorothiazide)

GP

QL(1 ea daily)

bisoprolol amphydrochlorothiazide tabs 1

candesartan cilexetil-hydrochlorothiazide tabs 1

captopril amphydrochlorothiazide tabs 1

DIOVAN HCT TABS 160MG-25MG (Use Valsartan-Hydrochlorothiazide)

GP

QL(1 ea daily)

DIOVAN HCT TABS 320MG-25MG 80MG-125MG 160MG-125MG 320MG-125MG (Use Valsartan-Hydrochlorothiazide)

GP

enalapril maleate amphydrochlorothiazide tabs 1

EXFORGE HCT TABS (Use Amlodipine-Valsartan-Hydrochlorothiazide)

GP

EXFORGE TABS 160MG-10MG (Use AmlodipineBesylate-Valsartan)

GP QL(1 ea daily)

EXFORGE TABS 160MG-5MG 320MG-5MG 320MG-10MG (Use Amlodipine Besylate-Valsartan)

GP

22

Drug Name DrugTier

RequirementsLimits

fosinopril sodium amphydrochlorothiazide tabs 1

HYZAAR TABS (Use Losartan Potassium amp Hydrochlorothiazide)

GP

irbesartan-hydrochlorothiazide tabs 1

lisinopril amphydrochlorothiazide tabs10mg-125mg 20mg-125mg

1

lisinopril amphydrochlorothiazide tabs20mg-25mg

1 QL(2 ea daily)

LOPRESSOR HCT TABS (Use Metoprolol ampHydrochlorothiazide)

GP

losartan potassium amphydrochlorothiazide tabs 1

LOTENSIN HCT TABS (Use Benazepril ampHydrochlorothiazide)

GP

LOTREL CAPS (Use Amlodipine Besylate-Benazepril HCl)

GP QL(1 ea daily)

methyldopa amphydrochlorothiazide tabs 1

metoprolol amphydrochlorothiazide tabs 1

METOPROLOLHYDROCHLOROTHIAZIDE TABS 2

MICARDIS HCT TABS (Use Telmisartan-Hydrochlorothiazide)

GP

moexipril-hydrochlorothiazide tabs 1

olmesartan medoxomil-amlodipine-hydrochlorothiazide tabs

1 ST

olmesartan medoxomil-hydrochlorothiazide tabs20mg-125mg

1

olmesartan medoxomil-hydrochlorothiazide tabs40mg-25mg 40mg-125mg

1 QL(1 ea daily)

propranolol amphydrochlorothiazide tabs 1

Drug Name DrugTier

RequirementsLimits

quinapril-hydrochlorothiazide tabs10mg-125mg 20mg-125mg

1

quinapril-hydrochlorothiazide tabs20mg-25mg

1 QL(1 ea daily)

telmisartan-amlodipine tabs 1

telmisartan-hydrochlorothiazide tabs 1

TENORETIC 100 TABS (Use Atenolol amp Chlorthalidone)

GP

TRIBENZOR TABS (Use Olmesartan Medoxomil-Amlodipine-Hydrochlorothiazide)

GP

ST

TWYNSTA TABS (Use Telmisartan-Amlodipine) GP

valsartan-hydrochlorothiazide tabs160mg-25mg

1 QL(1 ea daily)

valsartan-hydrochlorothiazide tabs320mg-25mg 80mg-125mg 160mg-125mg320mg-125mg

1

VASERETIC TABS (Use Enalapril Maleate ampHydrochlorothiazide)

GP

ZESTORETIC TABS 10MG-125MG 20MG-125MG (Use Lisinopril ampHydrochlorothiazide)

GP

ZESTORETIC TABS 20MG-25MG (Use Lisinopril ampHydrochlorothiazide)

GP

QL(2 ea daily)

ZIAC TABS (Use Bisoprololamp Hydrochlorothiazide) GP

Vasodilators hydralazine hcl tabs 1

23

Drug Name DrugTier

RequirementsLimits

minoxidil tabs 1

ANTIMALARIALS - Drugs to Treat Malaria(Parasitic Infections) Antimalarial Combinations atovaquone-proguanil hcltabs 625mg-25mg 1

COARTEM TABS 2 QL(08 eadaily)

MALARONE TABS 625MG-25MG (Use Atovaquone-Proguanil HCl)

GP

Antimalarials CHLOROQUINE PHOSPHATE TABS 250 MG

2

chloroquine phosphatetabs 500 mg 1

hydroxychloroquine sulfatetabs 1

MEFLOQUINE HCL TABS 2 QL(6 ea per fillretail)

mefloquine hcl tabs 1 QL(6 ea per fillretail)

PLAQUENIL TABS (Use HydroxychloroquineSulfate)

GP

primaquine phosphate tabs 1

PRIMAQUINE PHOSPHATE TABS (Use Primaquine Phosphate)

GP

QUALAQUIN CAPS (Use Quinine Sulfate) GP PA QL(2 eadaily)

quinine sulfate caps 1 PA QL(2 eadaily)

ANTIMYASTHENICCHOLINERGIC AGENTS

AntimyasthenicCholinergic Agents MESTINON TABS 60 MG (Use PyridostigmineBromide)

GP

MESTINON TIMESPAN TBCR (Use PyridostigmineBromide)

GP

Drug Name DrugTier

RequirementsLimits

pyridostigmine bromidetabs 60 mg 1

pyridostigmine bromide tbcr180 mg 1

ANTIMYCOBACTERIAL AGENTS - Drugs toTreat Tuberculosis (Bacterial Infections) Anti TB Combinations RIFAMATE CAPS 2

Antimycobacterial Agents ethambutol hcl tabs 1

isoniazid syrp 1

isoniazid tabs 1

MYAMBUTOL TABS (Use Ethambutol HCl) GP

MYCOBUTIN CAPS (Use Rifabutin) GP

PRIFTIN TABS 2

pyrazinamide tabs 1

rifabutin caps 1

RIFADIN CAPS (Use Rifampin) GP

rifampin caps 1

TRECATOR TABS 2

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES - Drugs to Treat Cancer Alkylating Agents ALKERAN TABS (Use Melphalan) GP AC

cyclophosphamide caps 50 mg 1 AC

CYCLOPHOSPHAMIDE CAPS 50 MG (Use Cyclophosphamide)

GP AC

24

Drug Name DrugTier

RequirementsLimits

GLEOSTINE CAPS 2

New commercial members to be referred to AcariaHealthS P AC

HEXALEN CAPS 2 AC

LEUKERAN TABS 2 AC

melphalan tabs 1 AC

MYLERAN TABS 2 AC

TEMODAR CAPS (Use Temozolomide) GP AC

temozolomide caps 1 AC

Antimetabolites capecitabine tabs 1 AC

mercaptopurine tabs 1 AC

methotrexate sodium tabs 1 AC

TABLOID TABS 2 AC

XATMEP SOLN 2 PA SP AC

XELODA TABS (Use Capecitabine) GP AC

Antineoplastic - BCL-2 Inhibitors VENCLEXTA STARTING PACK TBPK 2 PA AC

VENCLEXTA TABS 10 MG 2 PA QL(2 eadaily) AC

VENCLEXTA TABS 100 MG 2 PA QL(4 ea

daily) AC

VENCLEXTA TABS 50 MG 2 PA AC

Antineoplastic - Hedgehog Pathway Inhibitors ERIVEDGE CAPS 2 AC

ODOMZO CAPS 2 AC

Antineoplastic - Hormonal and Related Agents

Drug Name DrugTier

RequirementsLimits

abiraterone acetate tabs 1

PA New commercial members to be referred to AcariaHealthS P AC

anastrozole tabs 1 QL(1 ea daily)AC

ARIMIDEX TABS (Use Anastrozole) GP QL(1 ea daily)AC AROMASIN TABS (Use Exemestane) GP AC

bicalutamide tabs 1 QL(1 ea daily)AC

CASODEX TABS (Use Bicalutamide) GP QL(1 ea daily)AC

EMCYT CAPS 2 AC

exemestane tabs 1 AC

FARESTON TABS (Use Toremifene Citrate) GP AC

FEMARA TABS (Use Letrozole) GP AC

flutamide caps 1 AC

letrozole tabs 1 AC

LYSODREN TABS 2 AC

megestrol acetate susp 1 AC

megestrol acetate tabs 1 AC

NILANDRON TABS (Use Nilutamide) GP AC

nilutamide tabs 1 AC

tamoxifen citrate tabs 1 PV AC

toremifene citrate tabs 1 AC

ZYTIGA TABS 250 MG (Use Abiraterone Acetate) GP

25

Drug Name DrugTier

RequirementsLimits

ZYTIGA TABS 500 MG 2 PA SP AC

Antineoplastic - Immunomodulators POMALYST CAPS 2 SP AC

Antineoplastic Combinations LONSURF TABS 2 PA SP AC

Antineoplastic Enzyme Inhibitors AFINITOR TABS 25 MG 2 PA AC

ALECENSA CAPS 2 PA AC

ALUNBRIG TABS 2 PA AC

ALUNBRIG TBPK 2 PA AC

BRAFTOVI CAPS 2 PA

CABOMETYX TABS 2 PA AC

CAPRELSA TABS 2 AC

COMETRIQ KIT 2 SP AC

COTELLIC TABS 2 PA AC

FARYDAK CAPS 2 PA AC

GILOTRIF TABS 2 PA AC

GLEEVEC TABS (Use Imatinib Mesylate) GP AC

IBRANCE CAPS 2

PA Must use AcariaHlth SpRx 1-844-538-4661LA AC

IDHIFA TABS 2 PA LA AC

imatinib mesylate tabs 1 AC

IMBRUVICA CAPS 140 MG 2 PA SP AC

IMBRUVICA CAPS 70 MG 2 PA AC

IMBRUVICA TABS 140 MG 280 MG 420 MG 560 MG

2 PA QL(1 eadaily) AC

Drug Name DrugTier

RequirementsLimits

IRESSA TABS 2 AC

JAKAFI TABS 2 AC

LENVIMA 10 MG DAILY DOSE CPPK 2 PA AC

LENVIMA 18 MG DAILY DOSE CPPK 2 PA LA AC

LYNPARZA CAPS 50 MG 2 PA AC

LYNPARZA TABS 100 MG 150 MG 2

PA Refer to Accredo SP RxAC

MEKINIST TABS 2 PA SP AC

MEKTOVI TABS 2 PA

NERLYNX TABS 2 PA AC

NEXAVAR TABS 2

PA Must use AcariaHlth SpRx 1-844-538-4661SP AC

NINLARO CAPS 2 PA AC

RUBRACA TABS 2 PA SP AC

RYDAPT CAPS 2 PA AC

SPRYCEL TABS 2

SUTENT CAPS 2

TAFINLAR CAPS 2 PA AC

26

Drug Name DrugTier

RequirementsLimits

TAGRISSO TABS 2 PA AC

TARCEVA TABS 2

TASIGNA CAPS 2 PA AC

TYKERB TABS 2

VERZENIO TABS 2 PA AC

VOTRIENT TABS 2

XALKORI CAPS 2 PA AC

ZEJULA CAPS 2

PA Specialtydrug-HealthNet will refer to SP PharmacyLAAC

ZELBORAF TABS 2 PA AC

ZOLINZA CAPS 2 PA AC

ZYDELIG TABS 2 PA AC

Antineoplastics Misc bexarotene caps 1 AC

HYDREA CAPS (Use Hydroxyurea) GP AC

hydroxyurea caps 1 AC

MATULANE CAPS 2 AC

TARGRETIN CAPS OR 75 MG (Use Bexarotene) GP AC

tretinoin (chemotherapy) caps 1 AC

Chemotherapy RescueAntidote Agents

Drug Name DrugTier

RequirementsLimits

leucovorin calcium tabs 1 AC

Mitotic Inhibitors etoposide caps 1 AC

Topoisomerase I Inhibitors HYCAMTIN CAPS 2 PA AC

ANTIPARKINSON AND RELATED THERAPY AGENTS - Drugs to Treat Parkinsons Disease Antiparkinson Anticholinergics benztropine mesylate tabs 1

trihexyphenidyl hcl elix 1

trihexyphenidyl hcl tabs 1

Antiparkinson Dopaminergics amantadine hcl caps 100 mg 1

amantadine hcl syrp 50mg5ml 1

bromocriptine mesylate caps 1

bromocriptine mesylatetabs 1

carbidopa-levodopa tabs10mg-100mg 25mg-100mg 25mg-250mg

1

carbidopa-levodopa tbcr25mg-100mg 1 QL(8 ea daily)

carbidopa-levodopa tbcr50mg-200mg 1

carbidopa-levodopa-entacapone tabs 1

CARBIDOPALEVODOPAENTACAPONE TABS 2

MIRAPEX TABS 0125 MG 025 MG 075 MG 05 MG (Use PramipexoleDihydrochloride)

GP

MIRAPEX TABS 1 MG (Use PramipexoleDihydrochloride)

GP QL(4 ea daily)

27

Drug Name DrugTier

RequirementsLimits

GP QL(3 ea daily)

PARLODEL CAPS (Use Bromocriptine Mesylate) GP

PARLODEL TABS (Use Bromocriptine Mesylate) GP

pramipexoledihydrochloride tabs 0125mg 025 mg 075 mg 05 mg

1

pramipexoledihydrochloride tabs 1 mg 1 QL(4 ea daily)

pramipexoledihydrochloride tabs 15 mg

1 QL(3 ea daily)

REQUIP TABS (Use Ropinirole Hydrochloride) GP

REQUIP XL TB24 12 MG (Use RopiniroleHydrochloride)

GP QL(2 ea daily)

REQUIP XL TB24 2 MG 4 MG 6 MG 8 MG (Use Ropinirole Hydrochloride)

GP

ropinirole hydrochloridetabs 025 mg 05 mg 1mg 2 mg 3 mg 4 mg 5 mg

1

ropinirole hydrochloridetb24 12 mg 1 QL(2 ea daily)

ropinirole hydrochloridetb24 2 mg 4 mg 6 mg 8 mg

1

SINEMET CR TBCR 25MG-100MG (Use Carbidopa-Levodopa)

GP QL(8 ea daily)

GP

SINEMET TABS (Use Carbidopa-Levodopa) GP

STALEVO 100 TABS 2

STALEVO 125 TABS 2

STALEVO 150 TABS 2

Drug Name DrugTier

RequirementsLimits

STALEVO 50 TABS 2

STALEVO 75 TABS 2

Antiparkinson Monoamine Oxidase Inhibitors AZILECT TABS (Use Rasagiline Mesylate) GP

ELDEPRYL CAPS (Use Selegiline HCl) GP QL(2 ea daily)

rasagiline mesylate tabs 1

selegiline hcl caps 1 QL(2 ea daily)

selegiline hcl tabs 1 QL(2 ea daily)

ANTIPSYCHOTICSANTIMANIC AGENTS -Drugs to Treat Mood Disorders Antimanic Agents lithium carbonate caps 150mg 600 mg 1

lithium carbonate caps 300 mg 1 QL(6 ea daily)

lithium carbonate tabs 300 mg 1

lithium carbonate tbcr 300 mg 450 mg 1

LITHIUM SOLN 2

LITHOBID TBCR (Use Lithium Carbonate) GP

Antipsychotics - Misc GEODON CAPS 20 MG 40 MG (Use ZiprasidoneHCl)

GP

GEODON CAPS 60 MG 80 MG (Use ZiprasidoneHCl)

GP QL(2 ea daily)

ziprasidone hcl caps 20mg 40 mg 1

ziprasidone hcl caps 60mg 80 mg 1 QL(2 ea daily)

Benzisoxazoles RISPERDAL M-TAB TBDP (Use Risperidone) GP

28

Drug Name DrugTier

RequirementsLimits

RISPERDAL SOLN 1 MGML (Use Risperidone) GP

RISPERDAL TABS 025 MG 05 MG 1 MG 2 MG 4 MG (Use Risperidone)

GP

RISPERDAL TABS 3 MG (Use Risperidone) GP QL(2 ea daily)

risperidone soln 1 mgml 1

risperidone tabs 025 mg05 mg 1 mg 2 mg 4 mg 1

risperidone tabs 3 mg 1 QL(2 ea daily)

risperidone tbdp 05 mg 1mg 2 mg 3 mg 4 mg 1

Butyrophenones haloperidol lactate conc 1

haloperidol tabs 1

Dibenzapines clozapine tabs 25 mg 50mg 100 mg 200 mg 1

CLOZARIL TABS (Use Clozapine) GP

loxapine succinate caps 1

olanzapine tabs 15 mg 20 mg 1 QL(1 ea daily)

olanzapine tabs 5 mg 10mg 25 mg 75 mg 1

quetiapine fumarate tabs200 mg 1 QL(4 ea daily)

quetiapine fumarate tabs25 mg 50 mg 100 mg 1

quetiapine fumarate tabs300 mg 400 mg 1 QL(2 ea daily)

SEROQUEL TABS 200 MG (Use Quetiapine Fumarate) GP QL(4 ea daily)

SEROQUEL TABS 25 MG 50 MG 100 MG (Use Quetiapine Fumarate)

GP

SEROQUEL TABS 300 MG 400 MG (Use Quetiapine Fumarate)

GP QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

ZYPREXA TABS 15 MG 20 MG (Use Olanzapine) GP QL(1 ea daily)

ZYPREXA TABS 5 MG 10 MG 25 MG 75 MG (Use Olanzapine)

GP

Phenothiazines chlorpromazine hcl tabs 1

fluphenazine hcl elix 25mg5ml 1

fluphenazine hcl tabs 1 mg5 mg 10 mg 25 mg 1

perphenazine tabs 1

prochlorperazine maleatetabs 1

prochlorperazine supp 1 QL(2 ea daily)

thioridazine hcl tabs 10 mg25 mg 100 mg 1

thioridazine hcl tabs 50 mg 1 QL(4 ea daily)

trifluoperazine hcl tabs 1

Quinolinone Derivatives ABILIFY TABS 15 MG (Use Aripiprazole) GP QL(2 ea daily)

ABILIFY TABS 2 MG 5 MG 10 MG 30 MG (Use Aripiprazole)

GP

ABILIFY TABS 20 MG (Use Aripiprazole) GP QL(1 ea daily)

aripiprazole soln 1 mgml 1

aripiprazole tabs 15 mg 1 QL(2 ea daily)

aripiprazole tabs 2 mg 5mg 10 mg 30 mg 1

Thioxanthenes THIOTHIXENE CAPS 1 MG 2

thiothixene caps 1 mg 2mg 5 mg 10 mg 1

29

Drug Name DrugTier

RequirementsLimits

ANTIVIRALS - Drugs to Treat Viral Infections

Antiretrovirals abacavir sulfate soln 1

abacavir sulfate tabs 1

abacavir sulfate-lamivudine tabs 1

abacavir sulfate-lamivudine-zidovudine tabs 1

APTIVUS CAPS 2

APTIVUS SOLN 2

atazanavir sulfate caps 1

ATRIPLA TABS 2 ST QL(1 eadaily)

BIKTARVY TABS 2

CIMDUO TABS 2

COMBIVIR TABS (Use Lamivudine-Zidovudine) GP

COMPLERA TABS 2 ST

CRIXIVAN CAPS 2

DELSTRIGO TABS 2 ST

DESCOVY TABS 2

didanosine cpdr 1

EDURANT TABS 2

efavirenz caps 1

efavirenz tabs 1

EMTRIVA CAPS 2

EMTRIVA SOLN 2

EPIVIR SOLN (Use Lamivudine) GP

Drug Name DrugTier

RequirementsLimits

EPIVIR TABS (Use Lamivudine) GP

EPZICOM TABS (Use Abacavir Sulfate-Lamivudine)

GP

EVOTAZ TABS 2

fosamprenavir calcium tabs 1

GENVOYA TABS 2

INTELENCE TABS 2

INVIRASE CAPS 2

INVIRASE TABS 2

ISENTRESS CHEW 2

ISENTRESS HD TABS 2

ISENTRESS PACK 2

ISENTRESS TABS 2

JULUCA TABS 2

KALETRA SOLN 400MG5ML-100MG5ML(Use Lopinavir-Ritonavir)

GP

KALETRA TABS 100MG-25MG 200MG-50MG 2

lamivudine soln 1

lamivudine tabs 1

lamivudine-zidovudine tabs 1

LEXIVA SUSP 50 MGML 2

LEXIVA TABS 700 MG (Use FosamprenavirCalcium)

GP

lopinavir-ritonavir soln 1

nevirapine susp 1

nevirapine tabs 1

30

Drug Name DrugTier

RequirementsLimits

nevirapine tb24 1

NORVIR CAPS 100 MG 2

NORVIR PACK 100 MG 2

NORVIR SOLN 80 MGML 2

NORVIR TABS 100 MG (Use Ritonavir) GP

PIFELTRO TABS 2

PREZCOBIX TABS 2 QL(1 ea daily)

PREZISTA SUSP 2

PREZISTA TABS 2

RESCRIPTOR TABS 2

RETROVIR CAPS (Use Zidovudine) GP

RETROVIR SYRP (Use Zidovudine) GP

REYATAZ CAPS 150 MG 200 MG 300 MG (Use Atazanavir Sulfate)

GP

REYATAZ PACK 50 MG 2

ritonavir tabs 1

SELZENTRY SOLN 2

SELZENTRY TABS 2

stavudine caps 1

STRIBILD TABS 2

SUSTIVA CAPS (Use Efavirenz) GP

SUSTIVA TABS (Use Efavirenz) GP

SYMTUZA TABS 2 ST

tenofovir disoproxilfumarate tabs 1

TIVICAY TABS 2

Drug Name DrugTier

RequirementsLimits

TRIUMEQ TABS 2

TRIZIVIR TABS (Use Abacavir Sulfate-Lamivudine-Zidovudine)

GP

TRUVADA TABS 2

TYBOST TABS 2

VIDEX EC CPDR 125 MG 2

VIDEX EC CPDR 200 MG 250 MG 400 MG (Use Didanosine)

GP

VIDEXPEDIATRIC SOLR 2

VIRACEPT TABS 2

VIRAMUNE SUSP (Use Nevirapine) GP

VIRAMUNE TABS (Use Nevirapine) GP

VIRAMUNE XR TB24 (Use Nevirapine) GP

VIREAD POWD 40 MGGM 2

VIREAD TABS 150 MG 200 MG 250 MG 2

VIREAD TABS 300 MG (Use Tenofovir DisoproxilFumarate)

GP

ZERIT CAPS 15 MG 20 MG 30 MG 40 MG (Use Stavudine)

GP

ZERIT SOLR 1 MGML 2

ZIAGEN SOLN (Use Abacavir Sulfate) GP

ZIAGEN TABS (Use Abacavir Sulfate) GP

zidovudine caps 1

zidovudine syrp 1

zidovudine tabs 1

CMV Agents

31

Drug Name DrugTier

RequirementsLimits

VALCYTE SOLR 50 MGML (Use ValganciclovirHCl)

GP QL(21 ml daily)

VALCYTE TABS 450 MG (Use Valganciclovir HCl) GP

valganciclovir hcl solr 50mgml 1 QL(21 ml daily)

valganciclovir hcl tabs 450 mg 1

Hepatitis Agents adefovir dipivoxil tabs 1

BARACLUDE SOLN 005 MGML 2

BARACLUDE TABS 05 MG 1 MG (Use Entecavir) GP

COPEGUS TABS (Use Ribavirin (Hepatitis C)) GP PA

DAKLINZA TABS 30 MG 60 MG 2 PA

DAKLINZA TABS 90 MG 2 PA LA

entecavir tabs 1

EPCLUSA TABS 2 PA LA

HARVONI TABS 2 PA SP

HEPSERA TABS (Use Adefovir Dipivoxil) GP

LEDIPASVIRSOFOSBUVIR TABS 2 PA SP

MAVYRET TABS 2

PA Must use AcariaHealth Specialty Rx at1-844-538-4661LA

MODERIBA 1200 DOSE PACK TABS 2 PA

MODERIBA TBPK 2 PA

OLYSIO CAPS 2

Drug Name DrugTier

RequirementsLimits

REBETOL CAPS 200 MG (Use Ribavirin (HepatitisC))

GP PA

REBETOL SOLN 40 MGML 2 PA

RIBASPHERE RIBAPAK TBPK 2 PA

ribavirin (hepatitis c) caps 1 PA

ribavirin (hepatitis c) tabs 1 PA

SOFOSBUVIRVELPATASVIR TABS 2 PA LA

SOVALDI TABS 2 PA SP

TECHNIVIE TABS 2 PA

VIEKIRA PAK TBPK 2 PA SP

VIEKIRA XR TB24 2 PA SP

VOSEVI TABS 2

PA Must use AcariaHealth Specialty Rx at1-844-538-4661 SP

ZEPATIER TABS 2 PA SP

Herpes Agents acyclovir caps 200 mg 1

acyclovir susp 200 mg5ml 1

acyclovir tabs 400 mg 1

acyclovir tabs 800 mg 1 QL(5 ea daily)

famciclovir tabs 1

valacyclovir hcl tabs 1 gm1000 mg 1 QL(4 ea daily)

valacyclovir hcl tabs 500 mg 1 QL(8 ea daily)

VALTREX TABS 1 GM (Use Valacyclovir HCl) GP QL(4 ea daily)

VALTREX TABS 500 MG (Use Valacyclovir HCl) GP QL(8 ea daily)

32

Drug Name DrugTier

RequirementsLimits

ZOVIRAX CAPS OR 200 MG (Use Acyclovir) GP

ZOVIRAX SUSP OR 200 MG5ML (Use Acyclovir) GP

ZOVIRAX TABS OR 400 MG (Use Acyclovir) GP

ZOVIRAX TABS OR 800 MG (Use Acyclovir) GP QL(5 ea daily)

Influenza Agents

FLUMADINE TABS (Use Rimantadine Hydrochloride)

GP

oseltamivir phosphate capsor 30 mg 45 mg 1 QL(10 ea per

fill retail) oseltamivir phosphate capsor 75 mg 1

oseltamivir phosphate susror 6 mgml 1

QL(75 mldaily5 day(s)limit) AL(Atleast 1 yrs old)

rimantadine hydrochloridetabs 1

TAMIFLU CAPS 30 MG 45 MG (Use Oseltamivir Phosphate)

TAMIFLU CAPS 75 MG (Use Oseltamivir Phosphate)

GP

TAMIFLU SUSR 6 MGML(Use Oseltamivir Phosphate)

GP

BETA BLOCKERS - Drugs to Treat High BloodPressure Alpha-Beta Blockers carvedilol tabs 1

COREG TABS (Use Carvedilol) GP

labetalol hcl tabs 1

Beta Blockers Cardio-Selective

Drug Name DrugTier

RequirementsLimits

acebutolol hcl caps 1

atenolol tabs 1

betaxolol hcl tabs 1

bisoprolol fumarate tabs 1 QL(1 ea daily)

LOPRESSOR TABS (Use Metoprolol Tartrate) GP

metoprolol succinate tb24 1

metoprolol tartrate tabs 25mg 50 mg 100 mg 1

METOPROLOL TARTRATE TABS 75 MG 375 MG

2

TENORMIN TABS (Use Atenolol) GP

TOPROL XL TB24 (Use Metoprolol Succinate) GP

ZEBETA TABS (Use Bisoprolol Fumarate) GP QL(1 ea daily)

Beta Blockers Non-Selective BETAPACE AF TABS (Use Sotalol HCl (AFIBAFL)) GP

BETAPACE TABS (Use Sotalol HCl) GP

CORGARD TABS (Use Nadolol) GP

HEMANGEOL SOLN 2 AL(Up to 1 yrsold )

INDERAL LA CP24 (Use Propranolol HCl) GP

nadolol tabs 1

pindolol tabs 1

propranolol hcl cp24 1

propranolol hcl soln 1

propranolol hcl tabs 1

sotalol hcl (afibafl) tabs 1

33

Drug Name DrugTier

RequirementsLimits

sotalol hcl tabs 1

SOTYLIZE SOLN 2

timolol maleate tabs 10 mg 1 QL(6 eadaily60 ea perfill retail)

timolol maleate tabs 5 mg20 mg 1 QL(60 ea per

fill retail) CALCIUM CHANNEL BLOCKERS - Drugs toTreat High Blood Pressure Calcium Channel Blockers ADALAT CC TB24 30 MG 60 MG (Use Nifedipine) GP

ADALAT CC TB24 90 MG (Use Nifedipine) GP QL(1 ea daily)

amlodipine besylate tabs25 mg 1 QL(2 ea daily)

amlodipine besylate tabs 5mg 10 mg 1 QL(1 ea daily)

CALAN SR TBCR 120 MG (Use Verapamil HCl) GP

CALAN SR TBCR 180 MG 240 MG (Use VerapamilHCl)

GP QL(2 ea daily)

CALAN TABS (Use Verapamil HCl) GP

CARDIZEM CD CP24 (Use Diltiazem HCl Coated Beads)

GP QL(1 ea daily)

CARDIZEM LA TB24 120 MG 2

CARDIZEM LA TB24 180 MG 240 MG 300 MG 360 MG 420 MG (Use Diltiazem HCl Coated Beads)

GP

CARDIZEM TABS (Use Diltiazem HCl) GP

diltiazem hcl coated beads cp24 120 mg 180 mg 240mg 300 mg 360 mg

1 QL(1 ea daily)

diltiazem hcl coated beads tb24 180 mg 240 mg 300mg 360 mg 420 mg

1

diltiazem hcl cp12 1

Drug Name DrugTier

RequirementsLimits

diltiazem hcl extended release beads cp24 1

diltiazem hcl tabs 1

felodipine tb24 10 mg 1 QL(1 ea daily)

felodipine tb24 5 mg 25 mg 1

nifedipine caps 10 mg 20 mg 1

nifedipine tb24 30 mg 60 mg 1

nifedipine tb24 30 mg 60mg 90 mg 1 QL(1 ea daily)

nimodipine caps 1

NISOLDIPINE ER TB24 2

nisoldipine tb24 1

NORVASC TABS 25 MG (Use Amlodipine Besylate) GP QL(2 ea daily)

NORVASC TABS 5 MG 10 MG (Use AmlodipineBesylate)

GP QL(1 ea daily)

NYMALIZE SOLN 2

PROCARDIA CAPS (Use Nifedipine) GP

PROCARDIA XL TB24 (Use Nifedipine) GP QL(1 ea daily)

SULAR TB24 (Use Nisoldipine) GP

TIAZAC CP24 (Use Diltiazem HCl Extended Release Beads)

GP

verapamil hcl cp24 100 mg120 mg 200 mg 240 mg300 mg

1

verapamil hcl cp24 180 mg 1 QL(2 ea daily)

VERAPAMIL HCL SR CP24 2 QL(1 ea daily)

verapamil hcl tabs 40 mg80 mg 120 mg 1

34

Drug Name DrugTier

RequirementsLimits

verapamil hcl tbcr 120 mg 1

verapamil hcl tbcr 180 mg240 mg 1 QL(2 ea daily)

VERELAN CP24 120 MG 240 MG (Use VerapamilHCl)

GP

VERELAN CP24 180 MG (Use Verapamil HCl) GP QL(2 ea daily)

VERELAN CP24 360 MG 2 QL(1 ea daily)

VERELAN PM CP24 (Use Verapamil HCl) GP

CARDIOTONICS - Drugs to Treat Heart Failureand Abnormal Heart Rhythm Cardiac Glycosides digoxin soln 1

digoxin tabs 1

LANOXIN TABS 125 MCG 250 MCG (Use Digoxin) GP

LANOXIN TABS 625 MCG 1875 MCG 2

CARDIOVASCULAR AGENTS - MISC - Drugs toTreat Heart and Circulation Conditions Impotence Agents

CIALIS TABS (Use Tadalafil) SP

PA QL(027 eadaily) AL(Atleast 21 yrsold)

LEVITRA TABS (Use Vardenafil HCl) SP

MUSE PLLT SP

PA Limit 6 permonth Check your plandocuments for coveragebenefits and copaymentcoinsuranceQL(02 ea daily)

Drug Name DrugTier

RequirementsLimits

sildenafil citrate tabs SP

tadalafil tabs SP

vardenafil hcl tabs SP

VIAGRA TABS (Use Sildenafil Citrate) SP

Prostaglandin Vasodilators VENTAVIS SOLN 2 PA SP

Pulmonary Hypertension - Endothelin Receptor LETAIRIS TABS 2 SP

TRACLEER TABS 125 MG 625 MG 2

TRACLEER TBSO 32 MG 2 PA SP

Pulmonary Hypertension - Phosphodiesterase

ADCIRCA TABS (Use Tadalafil (PulmonaryHypertension))

GP

PA New commercial members to be referred to AcariaHealthQ L(2 ea daily)

tadalafil (pulmonaryhypertension) tabs 1

CEPHALOSPORINS - Drugs to Treat BacterialInfections Cephalosporins - 1st Generation cefadroxil caps 1

cefadroxil susr 1

35

Drug Name DrugTier

RequirementsLimits

cefadroxil tabs 1

cephalexin caps 250 mg500 mg 1

cephalexin susr 125mg5ml 250 mg5ml 1

KEFLEX CAPS 250 MG 500 MG (Use Cephalexin) GP

Cephalosporins - 2nd Generation cefaclor caps 250 mg 500 mg 1

CEFACLOR SUSR 125 MG5ML 250 MG5ML375 MG5ML

2

cefaclor susr 125 mg5ml375 mg5ml 1

cefprozil susr 1

cefprozil tabs 1

CEFTIN SUSR 2

cefuroxime axetil tabs 1

Cephalosporins - 3rd Generation cefdinir caps 1

cefdinir susr 1

cefixime susr 1

cefpodoxime proxetil susr 1

cefpodoxime proxetil tabs 1

SUPRAX SUSR 100 MG5ML 200 MG5ML(Use Cefixime)

GP

CONTRACEPTIVES - Drugs to PreventPregnancy Combination Contraceptives - Oral BEYAZ TABS (Use Drospirenone-EthinylEstradiol-Levomefolate Calcium)

GP

QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

BREVICON-28 TABS (Use Norethindrone amp Eth Estradiol)

GP

CYCLESSA TABS (Use Desogestrel-EthinylEstradiol (Triphasic))

GP

DESOGEN TABS (Use Desogestrel amp EthinylEstradiol)

GP

desogestrel amp ethinylestradiol tabs 1

desogestrel-ethinylestradiol (biphasic) tabs 1

desogestrel-ethinylestradiol (triphasic) tabs 1

drospirenone-ethinylestradiol tabs 3mg-002mg 1 QL(1 ea daily)

PV drospirenone-ethinylestradiol tabs 3mg-003mg 1 QL(1 ea daily)

drospirenone-ethinylestradiol-levomefolate calcium tabs

1 QL(1 ea daily)

ethynodiol diacet amp ethestrad tabs 1mg-35mcg1mg-50mcg

1

ethynodiol diacet amp ethestrad tabs 1mg-50mcg 1 PV

GENERESS FE CHEW (Use Norethindrone amp Ethinyl Estradiol-Fe)

GP QL(1 ea daily)PV

levonorgestrel amp ethestradiol tabs 1

levonorgestrel-eth estradiol(triphasic) tabs 1

levonorgestrel-ethinylestradiol (91-day) tabs 1

levonorgestrel-ethinylestradiol (continuous) tabs 1 PV

LOESTRIN 1530-21TABS (Use Norethindrone Acet amp Eth Estra)

GP

LOESTRIN 120-21 TABS(Use Norethindrone Acet amp Eth Estra)

GP

36

Drug Name DrugTier

RequirementsLimits

LOESTRIN FE 1530TABS (Use Norethin Acet amp Estrad-Fe)

GP

LOESTRIN FE 120 TABS(Use Norethin Acet amp Estrad-Fe)

GP

LOSEASONIQUE TABS (Use Levonorgestrel-Ethinyl Estradiol (91-Day))

GP QL(1 eadaily91 day(s)limit)

MINASTRIN 24 FE CHEW (Use Norethin Acet amp Estrad-Fe)

GP QL(365 ea perfill retail) PV

MIRCETTE TABS (Use Desogestrel-EthinylEstradiol (Biphasic))

GP

NATAZIA TABS 2 QL(1 ea daily)

NECON 1011-28 TABS 2

norethin acet amp estrad-fe chew 75mg-20mcg-1mg 1 QL(365 ea per

fill retail) PV norethin acet amp estrad-fe tabs 75mg-20mcg-1mg 1 QL(1 ea daily)

PV norethin acet amp estrad-fe tabs 75mg-20mcg-1mg75mg-30mcg-15mg

1

norethindrone amp eth estradiol tabs 1

norethindrone amp ethinylestradiol-fe chew 75mg-08mg-25mcg

1 QL(1 ea daily)PV

norethindrone amp mestranol tabs 1

norethindrone acet amp eth estra tabs 1

norethindrone-eth estradiol (triphasic) tabs 1

norethindrone-eth estradiol (triphasic) tabs 1 QL(1 ea daily)

PV norgestimate-ethinylestradiol (triphasic) tabs 1 PV

norgestimate-ethinylestradiol (triphasic) tabs 1 QL(1 ea daily)

norgestimate-ethinylestradiol tabs 1 QL(1 ea daily)

norgestrel amp ethinylestradiol tabs 1

Drug Name DrugTier

RequirementsLimits

NORINYL 1+35 TABS (Use Norethindrone amp Eth Estradiol)

GP

ORTHO TRI-CYCLEN LO TABS (Use Norgestimate-Ethinyl Estradiol(Triphasic))

GP

PV

ORTHO TRI-CYCLEN TABS (Use Norgestimate-Ethinyl Estradiol(Triphasic))

GP

QL(1 ea daily)

ORTHO-CYCLEN TABS (Use Norgestimate-EthinylEstradiol)

GP QL(1 ea daily)

ORTHO-NOVUM 135TABS (Use Norethindrone amp Eth Estradiol)

GP

ORTHO-NOVUM 777TABS (Use Norethindrone-Eth Estradiol (Triphasic))

GP QL(1 ea daily)PV

OVCON-35 TABS (Use Norethindrone amp Eth Estradiol)

GP

SAFYRAL TABS (Use Drospirenone-EthinylEstradiol-Levomefolate Calcium)

GP

QL(1 ea daily)

SEASONIQUE TABS (Use Levonorgestrel-EthinylEstradiol (91-Day))

TRI-NORINYL 28 TABS (Use Norethindrone-Eth Estradiol (Triphasic))

GP

YASMIN 28 TABS (Use Drospirenone-EthinylEstradiol)

GP QL(1 ea daily)

YAZ TABS (Use Drospirenone-EthinylEstradiol)

GP QL(1 ea daily)PV

Combination Contraceptives - Transdermal

XULANE PTWK 2 Limit 3 permonthQL(0143 ea daily) PV

Combination Contraceptives - Vaginal NUVARING RING 2 PV

Emergency Contraceptives

37

Drug Name DrugTier

RequirementsLimits

ELLA TABS 2 PV

levonorgestrel (emergencyoc) tabs 1 PV

PLAN B ONE-STEP TABS (Use Levonorgestrel(Emergency OC))

GP PV

Progestin Contraceptives - Oral norethindrone (contraceptive) tabs 1 QL(1 ea daily)

ORTHO MICRONOR TABS (Use Norethindrone (Contraceptive))

GP QL(1 ea daily)

CORTICOSTEROIDS - Steroid Hormone Drugs toTreat Systemic Swelling Conditions Glucocorticosteroids budesonide cpep 3 mg 1 QL(3 ea daily)

CORTEF TABS (Use Hydrocortisone) GP

cortisone acetate tabs 1

dexamethasone elix 05 mg5ml 1

DEXAMETHASONE INTENSOL CONC 2

dexamethasone soln 05 mg5ml 1

dexamethasone tabs 075 mg 05 mg 1 mg 2 mg 4mg 6 mg 15 mg

1

ENTOCORT EC CPEP (Use Budesonide) GP QL(3 ea daily)

hydrocortisone tabs 1

MEDROL DOSEPAK TBPK (Use Methylprednisolone) GP

MEDROL TABS 2 MG 2

MEDROL TABS 4 MG 8 MG 16 MG 32 MG (Use Methylprednisolone)

GP

methylprednisolone tabs 1

methylprednisolone tbpk 1

Drug Name DrugTier

RequirementsLimits

MILLIPRED TABS 5 MG 2

PEDIAPRED SOLN (Use Prednisolone Sodium Phosphate)

NF

prednisolone sodiumphosphate soln or 5mg5ml 15 mg5ml 67mg5ml

1

PREDNISOLONE SOLN 2

prednisolone soln 1

prednisolone syrp 1

PREDNISONE INTENSOL CONC 2

prednisone soln 5 mg5ml 1

prednisone tabs 1 mg 5mg 10 mg 20 mg 50 mg25 mg

1

PREDNISONE TBPK 10 MG 2

Mineralocorticoids fludrocortisone acetate tabs 1

COUGHCOLDALLERGY - Drugs to TreatCough Cold and Allergy Symptoms Antitussives benzonatate caps 100 mg200 mg 1

hydrocodone whomatropine syrp 1

hydrocodone whomatropine tabs 1

TESSALON PERLES CAPS (Use Benzonatate) GP

CoughColdAllergy Combinations guaifenesin-codeine soln100mg5ml-10mg5ml 1

guaifenesin-codeine syrp100mg5ml-10mg5ml 1

38

Drug Name DrugTier

RequirementsLimits

hydrocodone polistirex-chlorpheniramine polistirex suer

1

Limit 10mls perdayQL(10 mldaily) AL(Atleast 6 yrs old)

MUCINEX D TB12 (Use Pseudoephedrine-Guaifenesin)

GP

PHENYLHISTINE DH LIQD 2

promethazine ampphenylephrine soln 1 QL(30 ml daily)

promethazine ampphenylephrine syrp 1 QL(30 ml daily)

promethazine wcodeinesoln 1 QL(30 ml daily)

promethazine wcodeine syrp 1 QL(30 ml daily)

promethazine-dm syrp 1 QL(30 ml daily)

promethazine-phenylephrine-codeine syrp

1

PROMETHAZINEPHENYLEPHRINE SYRP 1 QL(30 ml daily)

PROMETHAZINEPHENYLEPHRINECODEINE SYRP 2

pseudoephedrine wcodeine-gg soln 1

pseudoephedrine-guaifenesin tb12 60mg-600mg

1

TUSSIONEX PENNKINETIC EXTENDED RELEASE SUER (Use HydrocodonePolistirex-ChlorpheniraminePolistirex)

GP

Mucolytics acetylcysteine soln 1

DERMATOLOGICALS - Drugs to Treat SkinConditions Acne Products ABSORICA CAPS 10 MG 2 PA

Drug Name DrugTier

RequirementsLimits

ABSORICA CAPS 20 MG 2

PA Use genericisotretinoin Caps

ABSORICA CAPS 30 MG 2 PA QL(3 eadaily)

PA Use genericisotretinoin CapsQL(2 eadaily)

adapalene crea 01 1 QL(45 gm perfill retail)

adapalene gel 01 1 QL(45 gm perfill retail)RXOTC

adapalene gel 03 1 QL(45 gm perfill retail135 gmper fill mail)

BENZAMYCIN GEL (Use Benzoyl Peroxide-Erythromycin)

GP QL(2 gm daily)

benzoyl peroxide-erythromycin gel 1 QL(2 gm daily)

BP CLEANSING WASH EMUL 2

CLEOCIN-T GEL (Use Clindamycin Phosphate(Topical))

GP

CLEOCIN-T LOTN (Use Clindamycin Phosphate(Topical))

GP

CLEOCIN-T SOLN (Use Clindamycin Phosphate(Topical))

GP

CLINDAGEL GEL 2

clindamycin phosphate(topical) gel 1

clindamycin phosphate(topical) lotn 1

clindamycin phosphate(topical) soln 1

CLINDAMYCIN PHOSPHATE GEL 2

39

Drug Name DrugTier

RequirementsLimits

clindamycin phosphate-benzoyl peroxide(refrigerate) gel

1

DIFFERIN CREA 01 (Use Adapalene) GP QL(45 gm perfill retail)

DIFFERIN GEL 01 (Use Adapalene) GP

QL(45 gm perfill retail)RXOTC

QL(45 gm perfill retail135 gmper fill mail)

DUAC GEL (Use Clindamycin Phosphate-Benzoyl Peroxide(Refrigerate))

GP

ERYGEL GEL (Use Erythromycin (Acne Aid)) GP

erythromycin (acne aid) gel 1

erythromycin (acne aid)soln 1

isotretinoin caps 10 mg 1 QL(4 eadaily150day(s) limit)

isotretinoin caps 20 mg 1

QL(5 eadaily)150 rtlMAX day(s)supply750 rtllmt day(s)

KLARON LOTN (Use Sulfacetamide Sodium (Acne))

GP

Drug Name DrugTier

RequirementsLimits

RETIN-A CREA (Use Tretinoin) GP

RETIN-A GEL (Use Tretinoin) GP

RETIN-A MICRO GEL 004 01 (Use Tretinoin Microsphere)

GP

RETIN-A MICRO PUMP GEL 004 01 (Use Tretinoin Microsphere)

GP

SODIUM SULFACETAMIDESULFUR LOTN

2 QL(30 gm perfill retail)

SSS 10-5 FOAM 2

sulfacetamide sodium (acne) lotn 1

tretinoin crea 0025 005 01 1

tretinoin gel 0025 001 1

tretinoin microsphere gel 1

Anti-inflammatory Agents - Topical diclofenac sodium (topical)gel 1 1

diclofenac sodium (topical)soln 15 1 QL(5 ml daily)

VOLTAREN GEL (Use Diclofenac Sodium (Topical))

GP

Antibiotics - Topical BACTROBAN CREA (Use Mupirocin Calcium(Topical))

GP

CENTANY OINT 2

gentamicin sulfate (topical) crea 1

gentamicin sulfate (topical)oint 1

40

Drug Name DrugTier

RequirementsLimits

mupirocin calcium (topical) crea 1

MUPIROCIN CREA 2

mupirocin oint 1

Antifungals - Topical ciclopirox gel 077 1

ciclopirox olamine crea 1

ciclopirox olamine susp 1

ciclopirox sham 1 1

clotrimazole (topical) soln 1 RXOTC

clotrimazole wbetamethasone crea 1

QL(45 gm perfill retail45 gmper 30 daysretail)

clotrimazole wbetamethasone lotn 1

econazole nitrate crea 1

ketoconazole (topical) crea 1 QL(2 gm daily)

LAMISIL AT SPRAY SOLN 2 PA

LOPROX CREA (Use Ciclopirox Olamine) GP

LOPROX SHAMPOO SHAM (Use Ciclopirox) GP

LOPROX SUSP (Use Ciclopirox Olamine) GP

LOTRISONE CREA (Use Clotrimazole wBetamethasone)

GP

nystatin (topical) crea 1

nystatin (topical) oint 1

nystatin (topical) powd 1

Drug Name DrugTier

RequirementsLimits

nystatin-triamcinolone crea 1 Limit 30gmsper monthQL(1gm daily)

nystatin-triamcinolone oint 1 Limit 30gmsper monthQL(1gm daily)

Antineoplastic or Premalignant Lesion Agents -CARAC CREA 2 QL(1 gm daily)

EFUDEX CREA (Use Fluorouracil (Topical)) GP

FLUOROPLEX CREA 2

fluorouracil (topical) crea 1

FLUOROURACIL CREA 05 2 QL(1 gm daily)

FLUOROURACIL SOLN 2 5 2

PICATO GEL 2

TARGRETIN GEL EX 1 2

Antipsoriatics calcipotriene crea 1 QL(5 gm daily)

calcipotriene oint 1 QL(5 gm daily)

calcipotriene soln 1

calcitriol (topical) oint 1

Limited 100 gms permonthQL(34gm daily)

DOVONEX CREA (Use Calcipotriene) GP QL(5 gm daily)

methoxsalen rapid caps 1

OXSORALEN ULTRA CAPS (Use Methoxsalen Rapid)

GP

tazarotene crea 1 QL(1 gm daily)

TAZORAC CREA 005 2 QL(1 gm daily)

TAZORAC CREA 01 (Use Tazarotene) GP QL(1 gm daily)

41

Drug Name DrugTier

RequirementsLimits

TAZORAC GEL 005 01 2 QL(1 gm daily)

Antiseborrheic Products OVACE PLUS WASH LIQD (Use Sulfacetamide Sodium)

GP

OVACE WASH LIQD (Use Sulfacetamide Sodium) GP

selenium sulfide lotn 1

sulfacetamide sodium liqd ex 1

Antivirals - Topical acyclovir topical oint 1 QL(1 gm daily)

ZOVIRAX OINT EX 5 (Use Acyclovir Topical) GP QL(1 gm daily)

Burn Products SILVADENE CREA (Use Silver Sulfadiazine) GP

silver sulfadiazine crea 1

Corticosteroids - Topical ACLOVATE CREA (Use Alclometasone Dipropionate)

GP

alclometasone dipropionate crea 1

alclometasone dipropionateoint 1

AMCINONIDE CREA 2

APEXICON E CREA 2

AUGMENTED BETAMETHASONE DIPROPIONATE GEL

2

betamethasone dipropionate (topical) crea 1

betamethasone dipropionate (topical) lotn 1

betamethasone dipropionate (topical) oint 1

betamethasone dipropionate augmented crea

1

Drug Name DrugTier

RequirementsLimits

betamethasone dipropionate augmentedgel

1

betamethasone dipropionate augmentedlotn

1

betamethasone dipropionate augmentedoint

1

betamethasone valerate crea 01 1

betamethasone valerate lotn 01 1

betamethasone valerate oint 01 1

CAPEX SHAM 2

clobetasol propionate crea 1

clobetasol propionateemollient base crea 1

clobetasol propionate gel 1

clobetasol propionate oint 1

clobetasol propionate sham 1

clobetasol propionate soln 1

CLOBEX SHAM (Use Clobetasol Propionate) GP

DERMA-SMOOTHEFSBODY OIL (Use Fluocinolone Acetonide)

GP

DERMA-SMOOTHEFSSCALP OIL (Use Fluocinolone Acetonide)

GP

DERMATOP CREA (Use Prednicarbate) GP

desonide crea 1

desonide lotn 1

desonide oint 1

DESOWEN CREA (Use Desonide) GP

42

Drug Name DrugTier

RequirementsLimits

DESOWEN LOTN (Use Desonide) GP

desoximetasone crea 005 025 1

desoximetasone gel 005 1

desoximetasone oint 025 1

diflorasone diacetate crea 1

diflorasone diacetate oint 1

DIPROLENE AF CREA (Use Betamethasone Dipropionate Augmented)

GP

DIPROLENE OINT (Use Betamethasone Dipropionate Augmented)

GP

ELOCON CREA (Use Mometasone Furoate) GP

ELOCON OINT (Use Mometasone Furoate) GP

fluocinolone acetonide crea 1

fluocinolone acetonide oil 1

fluocinolone acetonide oint 1

fluocinolone acetonide soln 1

fluocinonide crea 005 1

fluocinonide emulsified base crea 1

fluocinonide gel 005 1

fluocinonide oint 005 1

fluocinonide soln 005 1

fluticasone propionate crea005 1

fluticasone propionate oint0005 1

halobetasol propionate crea 1

halobetasol propionate oint 1

Drug Name DrugTier

RequirementsLimits

hydrocortisone (topical) crea 1

hydrocortisone (topical) lotn 1

hydrocortisone (topical) oint 1

hydrocortisone butyrate crea 1

hydrocortisone butyrateoint 1

KENALOG AERS (Use Triamcinolone Acetonide (Topical))

GP

LOCOID CREA (Use Hydrocortisone Butyrate) GP

LOCOID OINT (Use Hydrocortisone Butyrate) GP

mometasone furoate crea 1

mometasone furoate oint 1

mometasone furoate soln 1

PREDNICARBATE CREA 2

prednicarbate crea 1

SYNALAR CREA (Use Fluocinolone Acetonide) GP

SYNALAR OINT (Use Fluocinolone Acetonide) GP

SYNALAR SOLN (Use Fluocinolone Acetonide) GP

TEMOVATE CREA (Use Clobetasol Propionate) GP

TEMOVATE E CREA (Use Clobetasol PropionateEmollient Base)

GP

TEMOVATE OINT (Use Clobetasol Propionate) GP

TOPICORT CREA 005 025 (Use Desoximetasone)

GP

TOPICORT GEL 005 (Use Desoximetasone) GP

TOPICORT OINT 025 (Use Desoximetasone) GP

43

Drug Name DrugTier

RequirementsLimits

triamcinolone acetonide (topical) aers 1

triamcinolone acetonide (topical) crea 1

triamcinolone acetonide (topical) lotn 1

triamcinolone acetonide (topical) oint 1

TRIDESILON CREA (Use Desonide) GP

ULTRAVATE CREA (Use Halobetasol Propionate) GP

ULTRAVATE OINT (Use Halobetasol Propionate) GP

Immunomodulating Agents - Topical ALDARA CREA (Use Imiquimod) GP

imiquimod crea 1

Immunosuppressive Agents - Topical

PROTOPIC OINT 003 (Use Tacrolimus (Topical)) GP

QL(2 gm daily)AL(At least 2yrs old)

tacrolimus (topical) oint003 1

tacrolimus (topical) oint 01 1

KeratolyticAntimitotic Agents CONDYLOX GEL 2

CONDYLOX SOLN (Use Podofilox) GP

podofilox soln 1

SALEX SHAM (Use Salicylic Acid) GP

salicylic acid sham 6 1

Local Anesthetics - Topical lidocaine hcl soln ex 1

Drug Name DrugTier

RequirementsLimits

lidocaine ptch 1 QL(3 ea daily)

LIDODERM PTCH (Use Lidocaine) GP QL(3 ea daily)

Misc Topical DRYSOL SOLN 2

Rosacea Agents azelaic acid gel 1

FINACEA GEL (Use Azelaic Acid) GP

METROCREAM CREA (Use Metronidazole (Topical))

GP

METROGEL GEL (Use Metronidazole (Topical)) GP

METROLOTION LOTN (Use Metronidazole (Topical))

GP QL(60 ml perfill retail)

metronidazole (topical)crea 075 1

metronidazole (topical) gel075 1 QL(45 gm per

fill retail) metronidazole (topical) gel1 1

metronidazole (topical) lotn075 1 QL(60 ml per

fill retail) Scabicides amp Pediculicides ELIMITE CREA (Use Permethrin) GP QL(60 gm perfill retail)

permethrin crea 1 QL(60 gm perfill retail)

DIAGNOSTIC PRODUCTS

Diagnostic Tests

FREESTYLE INSULINX BLOODGLUCOSE TEST STRIPS STRP

2

Limit 200 permonth without authorizationQ L(67 ea daily)RXOTC

FREESTYLE INSULINX BLOODGLUCOSE TEST STRP

2

44

Drug Name DrugTier

RequirementsLimits

FREESTYLE LITE TEST STRIPS STRP 2

FREESTYLE TEST STRIPS STRP 2

KETOCARE STRP 2 QL(50 ea perfill retail)

KETOSTIX STRP 2 QL(50 ea perfill retail)

ONETOUCH ULTRA BLUE STRP 2

ONETOUCH VERIO TEST STRIPS STRP 2

PRECISION XTRA BLOOD GLUCOSE TEST STRIPS STRP

2

RELION KETONE STRP 2 QL(50 ea perfill retail)

DIGESTIVE AIDS - Drugs to Treat Low DigestiveEnzymes Digestive Enzymes CREON CPEP 2

ZENPEP CPEP 2

DIURETICS - Drugs to Treat Heart CirculationConditions and Blood Pressure Carbonic Anhydrase Inhibitors acetazolamide cp12 500 mg 1 QL(2 ea daily)

acetazolamide tabs 125 mg 1

acetazolamide tabs 250 mg 1 QL(4 ea daily)

Drug Name DrugTier

RequirementsLimits

DIAMOX CP12 (Use Acetazolamide) GP QL(2 ea daily)

methazolamide tabs 1

NEPTAZANE TABS (Use Methazolamide) GP

Diuretic Combinations ALDACTAZIDE TABS 25MG-25MG (Use Spironolactone ampHydrochlorothiazide)

GP

ALDACTAZIDE TABS 50MG-50MG 2

amiloride amp hydrochlorothiazide tabs 1

DYAZIDE CAPS (Use Triamterene amp Hydrochlorothiazide)

GP

MAXZIDE TABS (Use Triamterene amp Hydrochlorothiazide)

GP QL(1 ea daily)

MAXZIDE-25 TABS (Use Triamterene amp Hydrochlorothiazide)

GP QL(2 ea daily)

spironolactone amphydrochlorothiazide tabs 1

triamterene amp hydrochlorothiazide caps375mg-25mg

1

triamterene amp hydrochlorothiazide tabs375mg-25mg

1 QL(2 ea daily)

1 QL(1 ea daily)

Loop Diuretics bumetanide tabs 05 mg 1 mg 1

bumetanide tabs 2 mg 1 QL(5 ea daily)

BUMEX TABS 05 MG 1 MG (Use Bumetanide) GP

BUMEX TABS 2 MG (Use Bumetanide) GP QL(5 ea daily)

DEMADEX TABS (Use Torsemide) GP

45

Drug Name DrugTier

RequirementsLimits

furosemide soln 10 mgml 1

furosemide tabs 20 mg 40mg 80 mg 1

LASIX TABS (Use Furosemide) GP

torsemide tabs 100 mg 1 QL(2 ea daily)

torsemide tabs 5 mg 10mg 20 mg 1

Potassium Sparing Diuretics ALDACTONE TABS (Use Spironolactone) GP

amiloride hcl tabs 1

spironolactone tabs 1

Thiazides and Thiazide-Like Diuretics chlorthalidone tabs 1

hydrochlorothiazide caps125 mg 1 QL(1 ea daily)

hydrochlorothiazide tabs 25mg 50 mg 1

indapamide tabs 1

metolazone tabs 1

MICROZIDE CAPS (Use Hydrochlorothiazide) GP QL(1 ea daily)

ENDOCRINE AND METABOLIC AGENTS -MISC - Drugs to Treat Bone Disease andRegulate Hormones Bone Density Regulators alendronate sodium tabs 35 mg 70 mg 1 QL(015 ea

daily) ALENDRONATE SODIUM TABS 40 MG 2

alendronate sodium tabs 5 mg 10 mg 1 QL(1 ea daily)

ATELVIA TBEC (Use Risedronate Sodium) GP

BONIVA TABS (Use Ibandronate Sodium) GP QL(004 eadaily)

Drug Name DrugTier

RequirementsLimits

calcitonin (salmon) soln 1

FOSAMAX TABS (Use Alendronate Sodium) GP QL(015 eadaily)

ibandronate sodium tabs 1 QL(004 eadaily)

MIACALCIN SOLN (Use Calcitonin (Salmon)) GP

risedronate sodium tbec 35 mg 1

Fertility Regulators

CLOMIPHENE CITRATE TABS 2

Check plandocuments for coverageQL(15 ea per fillretail00 ea perfill mail15 ea per 30 daysretail)

clomiphene citrate tabs 1

Hormone Receptor Modulators EVISTA TABS (Use Raloxifene HCl) GP PV

raloxifene hcl tabs 1 PV

LHRHGnRH Agonist Analog Pituitary SYNAREL SOLN 2

Metabolic Modifiers calcitriol caps or 025 mcg 1

calcitriol caps or 05 mcg 1 QL(4 ea daily)

calcitriol soln or 1 mcgml 1

CARBAGLU TABS 2

46

Drug Name DrugTier

RequirementsLimits

KUVAN PACK 2

Specialty Drugrefer to Caremark SP RX

KUVAN TBSO 2

paricalcitol caps 1

ROCALTROL CAPS 025 MCG (Use Calcitriol) GP

ROCALTROL CAPS 05 MCG (Use Calcitriol) GP QL(4 ea daily)

ROCALTROL SOLN 1 MCGML (Use Calcitriol) GP

ZEMPLAR CAPS (Use Paricalcitol) GP

Posterior Pituitary Hormones DDAVP SOLN NA 001 2

DDAVP SOLN NA 001 (Use DesmopressinAcetate Spray)

GP

DDAVP TABS OR 01 MG (Use DesmopressinAcetate)

GP

GP QL(6 ea daily)

desmopressin acetatespray refrigerated soln 1

desmopressin acetatespray soln 1

desmopressin acetate tabs01 mg 1

desmopressin acetate tabs02 mg 1 QL(6 ea daily)

Prolactin Inhibitors cabergoline tabs 1

ESTROGENS - Hormone ReplacementModifyingDrugs Estrogen Combinations

Drug Name DrugTier

RequirementsLimits

ACTIVELLA TABS (Use Estradiol amp Norethindrone Acetate)

GP

CLIMARA PRO PTWK 2 QL(4 ea per 30days retail)

estradiol amp norethindrone acetate tabs 1

FEMHRT LOW DOSE TABS (Use Norethindrone Acetate-Ethinyl Estradiol)

GP

norethindrone acetate-ethinyl estradiol tabs 1

PREMPHASE TABS 2

PREMPRO TABS 03MG-15MG 2 QL(1 ea daily)

PREMPRO TABS 0625MG-25MG 045MG-15MG 0625MG-5MG

2

Estrogens

ALORA PTTW 0075 MG24HR 005 MG24HR01 MG24HR

2

Limit 8 patches permonthQL(029ea daily)

CLIMARA PTWK (Use Estradiol) GP

QL(4 ea per fillretail4 ea per30 days retail)

ESTRACE TABS (Use Estradiol) GP

estradiol pttw td 00375mg24hr 0075 mg24hr005 mg24hr 01 mg24hr

1

estradiol ptwk td 0025mg24hr 0075 mg24hr005 mg24hr 006mg24hr 01 mg24hr 375mcg24hr

1

estradiol tabs or 05 mg 1mg 2 mg 1

ESTROPIPATE TABS 075 MG 15 MG 2

estropipate tabs 3 mg 1

MENEST TABS 2

47

Drug Name DrugTier

RequirementsLimits

MINIVELLE PTTW 00375 MG24HR 0075MG24HR 005 MG24HR01 MG24HR (Use Estradiol)

GP

PREMARIN TABS OR 0625 MG 045 MG 03 MG 125 MG

2 QL(1 ea daily)

PREMARIN TABS OR 09 MG 2

VIVELLE-DOT PTTW 00375 MG24HR 0075MG24HR 005 MG24HR01 MG24HR (Use Estradiol)

GP

FLUOROQUINOLONES - Drugs to Treat BacterialInfections Fluoroquinolones AVELOX ABC PACK TABS (Use Moxifloxacin HCl) GP

AVELOX TABS (Use Moxifloxacin HCl) GP

CIPRO SUSR 5 GM100ML 2

CIPRO SUSR 500 MG5ML (Use Ciprofloxacin)

GP

CIPRO TABS 250 MG 500 MG (Use CiprofloxacinHCl)

GP

CIPROFLOXACIN ER TB24 1000MG 2 QL(14 ea per

fill retail) CIPROFLOXACIN ER TB24 500MG 2 QL(3 ea per fill

retail) CIPROFLOXACIN HCL TABS 100 MG 2

ciprofloxacin hcl tabs 250mg 500 mg 750 mg 1

ciprofloxacin susr 1

LEVAQUIN TABS (Use Levofloxacin) GP QL(14 ea perfill retail)

levofloxacin soln 25 mgml 1

levofloxacin tabs 250 mg500 mg 750 mg 1 QL(14 ea per

fill retail)

Drug Name DrugTier

RequirementsLimits

moxifloxacin hcl tabs 1

OFLOXACIN TABS 300 MG 2

GASTROINTESTINAL AGENTS - MISC -Miscellaneous Gastrointestinal Drugs Gallstone Solubilizing Agents ACTIGALL CAPS (Use Ursodiol) GP

URSO 250 TABS (Use Ursodiol) GP

URSO FORTE TABS (Use Ursodiol) GP

ursodiol caps 1

ursodiol tabs 1

Gastrointestinal Chloride Channel Activators AMITIZA CAPS 2

Gastrointestinal Stimulants metoclopramide hcl tabs 5mg 10 mg 1

REGLAN TABS (Use Metoclopramide HCl) GP

Inflammatory Bowel Agents ASACOL HD TBEC 2

ASACOL HD TBEC (Use Mesalamine) GP

AZULFIDINE EN-TABS TBEC (Use Sulfasalazine) GP QL(8 ea daily)

AZULFIDINE TABS (Use Sulfasalazine) GP QL(8 ea daily)

balsalazide disodium caps 1 QL(9 eadaily280 eaper fill retail)

CANASA SUPP (Use Mesalamine) GP QL(1 ea daily)

COLAZAL CAPS (Use Balsalazide Disodium) GP

QL(9 eadaily280 eaper fill retail)

LIALDA TBEC (Use Mesalamine) GP QL(4 ea daily)

48

Drug Name DrugTier

RequirementsLimits

mesalamine enem re 4 gm 1 QL(60 ml daily)

mesalamine supp re 1000 mg 1 QL(1 ea daily)

mesalamine tbec or 12 gm 1 QL(4 ea daily)

mesalamine tbec or 800 mg 1

SFROWASA ENEM 2

sulfasalazine tabs 1 QL(8 ea daily)

sulfasalazine tbec 1 QL(8 ea daily)

Intestinal Acidifiers lactulose (encephalopathy)soln 1

Irritable Bowel Syndrome (IBS) Agents LINZESS CAPS 2 QL(1 ea daily)

Phosphate Binder Agents calcium acetate (phosphatebinder) caps 1

calcium acetate (phosphatebinder) tabs 1 RXOTC

ELIPHOS TABS (Use Calcium Acetate (Phosphate Binder))

GP RXOTC

FOSRENOL CHEW 1000 MG (Use Lanthanum Carbonate)

GP QL(3 ea daily)

GP

GP QL(4 ea daily)

FOSRENOL PACK 750 MG 1000 MG 2

lanthanum carbonate chew 1000 mg 1 QL(3 ea daily)

lanthanum carbonate chew 500 mg 1

Drug Name DrugTier

RequirementsLimits

RENVELA PACK 08 GM (Use Sevelamer Carbonate)

GP

GP QL(5 ea daily)

RENVELA TABS 800 MG (Use Sevelamer Carbonate)

GP

sevelamer carbonate pack08 gm 1

sevelamer carbonate pack24 gm 1 QL(5 ea daily)

sevelamer carbonate tabs 800 mg 1

GENITOURINARY AGENTS - MISCELLANEOUS - Miscellaneous Drugs to Treat ReproductiveOrgans and Urinary System Acidifiers K-PHOS NO 2 TABS 2

Alkalinizers pot amp sod citrates wcitricac syrp 550mg5ml-550mg5ml-334mg5ml-334mg5ml-500mg5ml-500mg5ml

1

potassium citrate(alkalinizer) tbcr 1

potassium citrate-citric acidpack 3300mg-1002mg 1

potassium citrate-citric acidsoln 1100mg5ml-334mg5ml 1100mg5ml-1100mg5ml-334mg5ml-334mg5ml

1

RXOTC

sodium citrate amp citric acid soln 1 RXOTC

UROCIT-K 10 TBCR (Use Potassium Citrate (Alkalinizer))

GP

49

Drug Name DrugTier

RequirementsLimits

Cystinosis Agents CYSTAGON CAPS 2

PROCYSBI CPDR 2 SP

Prostatic Hypertrophy Agents alfuzosin hcl tb24 1 QL(1 ea daily)

AVODART CAPS (Use Dutasteride) GP AL(At least 40yrs old)

dutasteride caps 1 AL(At least 40yrs old)

dutasteride-tamsulosin hcl caps 1

finasteride tabs 1 QL(1 ea daily)AL(At least 40yrs old)

FLOMAX CAPS (Use Tamsulosin HCl) GP QL(2 ea daily)

JALYN CAPS (Use Dutasteride-Tamsulosin HCl)

GP

PROSCAR TABS (Use Finasteride) GP

QL(1 ea daily)AL(At least 40yrs old)

tamsulosin hcl caps 1 QL(2 ea daily)

UROXATRAL TB24 (Use Alfuzosin HCl) GP QL(1 ea daily)

GOUT AGENTS - Drugs to Treat Gout

Gout Agent Combinations colchicine w probenecidtabs 1

Gout Agents allopurinol tabs 100 mg 1 QL(3 ea daily)

allopurinol tabs 300 mg 1 QL(2 ea daily)

colchicine tabs 1

COLCRYS TABS 2

ULORIC TABS 40 MG 2 QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

ZYLOPRIM TABS 100 MG (Use Allopurinol) GP QL(3 ea daily)

Uricosurics probenecid tabs 1

HEMATOLOGICAL AGENTS - MISC - Drugs toTreat Blood Disorders Antihemophilic Products IXINITY SOLR SP PA

RIXUBIS SOLR SP PA

Hematorheologic Agents pentoxifylline tbcr 1 QL(3 ea daily)

Platelet Aggregation Inhibitors AGRYLIN CAPS (Use Anagrelide HCl) GP

anagrelide hcl caps 1

BRILINTA TABS 60 MG 2 QL(2 ea daily)

BRILINTA TABS 90 MG 2

cilostazol tabs 1 QL(2 ea daily)

clopidogrel bisulfate tabs 1 QL(2 ea daily)

dipyridamole tabs 1

EFFIENT TABS (Use Prasugrel HCl) GP

PLAVIX TABS (Use Clopidogrel Bisulfate) GP QL(2 ea daily)

prasugrel hcl tabs 1

HEMATOPOIETIC AGENTS - Drugs to TreatBlood Disorders Agents for Sickle Cell Anemia DROXIA CAPS 2

Folic AcidFolates

50

Drug Name DrugTier

RequirementsLimits

folic acid tabs 1 mg 1 RXOTC

folic acid tabs 400 mcg800 mcg 1 PV

Hematopoietic Mixtures FOLIVANE-F CAPS 2

INTEGRA F CAPS 2

HEMOSTATICS - Drugs to Stop BleedingTreatBlood Disorders Hemostatics - Systemic LYSTEDA TABS (Use Tranexamic Acid) GP QL(6 ea daily5day(s) limit)

tranexamic acid tabs 1 QL(6 ea daily5day(s) limit)

HYPNOTICSSEDATIVESSLEEP DISORDERAGENTS Barbiturate Hypnotics phenobarbital elix 1

phenobarbital soln 1

phenobarbital tabs 1

Non-Barbiturate Hypnotics

AMBIEN TABS 10 MG (Use Zolpidem Tartrate) GP

QL(1 eadaily30 ea perfill retail30 ea per 30 daysretail)

estazolam tabs 1

flurazepam hcl caps 15 mg 1 QL(2 ea daily)

HALCION TABS (Use Triazolam) GP QL(1 ea daily)

RESTORIL CAPS 15 MG (Use Temazepam) GP QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

RESTORIL CAPS 75 MG (Use Temazepam) GP

SONATA CAPS (Use Zaleplon) GP QL(1 ea daily)

temazepam caps 15 mg 1 QL(2 ea daily)

temazepam caps 75 mg 1

triazolam tabs 0125 mg 1

triazolam tabs 025 mg 1 QL(1 ea daily)

zaleplon caps 1 QL(1 ea daily)

zolpidem tartrate tabs or 10 mg 1

Orexin Receptor Antagonists

BELSOMRA TABS 2 ST QL(1 eadaily)

LAXATIVES - Bowel Treatment Drugs

Laxative Combinations bisacodyl-peg 3350-potchloride-sod bicarb-sod chloride kit

1 QL(1 ea per fillretail) PV

CLENPIQ SOLN 2 PV

COLYTE-FLAVOR PACKS SOLR (Use PEG 3350-KCl-Sod Bicarb-Sod Chloride-Sod Sulfate)

GP

QL(4000 ml perfill retail) PV

GOLYTELY SOLR 2271GM-215GM-553GM-282GM-636GM

2 PA QL(4000ea per fillretail) PV

GOLYTELY SOLR 236GM-2274GM-586GM-297GM-674GM (Use PEG 3350-KCl-Sod Bicarb-Sod Chloride-Sod Sulfate)

GP

51

Drug Name DrugTier

RequirementsLimits

MOVIPREP SOLR 2 PA PV

NULYTELYFLAVORPACKS SOLR (Use PEG 3350-Potassium Chloride-Sod Bicarbonate-Sod Chloride)

GP

PV

peg 3350-kcl-sod bicarb-sod chloride-sod sulfate solr

1 QL(4000 ml perfill retail) PV

peg 3350-potassiumchloride-sod bicarbonate-sod chloride solr

1 PV

PREPOPIK PACK 2 PA PV

SUPREP BOWEL PREP KIT SOLN 2 PV

Laxatives - Miscellaneous lactulose soln 1

MIRALAX POWD (Use Polyethylene Glycol 3350) GP

Limit 528gms permonthQL(176gm daily)RXOTC

polyethylene glycol 3350powd 1

Saline Laxatives

ORAL SALINE LAXATIVE SOLN 2

Available for members in non-grandfatheredplans ages 50-74AL(At least50 yrs old - Upto 74 yrs old)PV

sodium phosphates soln 1

Drug Name DrugTier

RequirementsLimits

Stimulant Laxatives

bisacodyl supp 1

bisacodyl tbec 1

DULCOLAX SUPP (Use Bisacodyl) GP

DULCOLAX TBEC (Use Bisacodyl) GP

MACROLIDES - Drugs to Treat BacterialInfections Azithromycin AZITHROMYCIN PACK 1 GM 2

azithromycin susr 100mg5ml 200 mg5ml 1

azithromycin tabs 250 mg 1 QL(6 ea per fillretail)

azithromycin tabs 500 mg 1 QL(3 ea daily)

52

Drug Name DrugTier

RequirementsLimits

azithromycin tabs 600 mg 1 QL(10 ea perfill retail)

ZITHROMAX PACK 1 GM 2

ZITHROMAX SUSR 100 MG5ML 200 MG5ML(Use Azithromycin)

GP

ZITHROMAX TABS 250 MG (Use Azithromycin) GP QL(6 ea per fillretail) ZITHROMAX TABS 500 MG (Use Azithromycin) GP QL(3 ea daily)

ZITHROMAX TABS 600 MG (Use Azithromycin) GP QL(10 ea perfill retail) ZITHROMAX TRI-PAK TABS (Use Azithromycin) GP QL(3 ea daily)

ZITHROMAX Z-PAK TABS (Use Azithromycin) GP QL(6 ea per fillretail)

ZMAX SUSR 2 QL(2 ea per fillretail)

Clarithromycin BIAXIN TABS (Use Clarithromycin) GP

CLARITHROMYCIN SUSR 125 MG5ML 250 MG5ML 2

clarithromycin susr 125mg5ml 250 mg5ml 1

clarithromycin tabs 250 mg500 mg 1

clarithromycin tb24 500 mg 1 QL(14 ea perfill retail)

Erythromycins EES GRANULES SUSR (Use ErythromycinEthylsuccinate)

GP

ERY-TAB TBEC 2

ERYPED 200 SUSR (Use ErythromycinEthylsuccinate)

GP

erythromycin base cpep 1

erythromycin base tabs 1

Drug Name DrugTier

RequirementsLimits

erythromycinethylsuccinate susr 1

erythromycinethylsuccinate tabs 1

erythromycin stearate tabs 1

MEDICAL DEVICES AND SUPPLIES

Contraceptives

CAYA DPRH 2 QL(1 ea per365 daysretail) PV

OMNIFLEX DIAPHRAGM DPRH 2

Diabetic Supplies 1ST TIER UNILET COMFORTOUCH LANCETS 28G MISC

2 QL(200 ea perfill retail600 ea per fill mail)

1ST TIER UNILET COMFORTOUCH LANCETS 30G MISC

ACCU-CHEK FASTCLIX LANCETS MISC 2

QL(200 ea perfill retail600 ea per fill mail)

ACCU-CHEK MULTICLIX LANCETS MISC 2

ACCU-CHEK SAFE-T-PRO LANCETS MISC 2

ACCU-CHEK SAFE-T-PRO PLUSLANCETS MISC 2

ACCU-CHEK SOFT TOUCH LANCETS MISC 2

ACCU-CHEK SOFTCLIX LANCETS MISC 2

ACTI-LANCE LANCETS 28G MISC 2

ACTI-LANCE LITE SAFETY LANCETS 28G MISC

53

Drug Name DrugTier

RequirementsLimits

ACTI-LANCE SPECIAL SAFETY LANCETS 17G MISC

ACTI-LANCE SPECIAL SAFETYLANCETS 17G MISC

ACTI-LANCE UNIVERSAL SAFETY LANCETS 23G MISC

ACTIVE 1ST BLOOD LANCETS30GEASYTWIST CAP MISC

ADVANCED MOBILE LANCET 30G MISC 2

ADVOCATE LANCETS 30G MISC 2

ADVOCATE LANCETS MISC 2

ADVOCATE SAFETY LANCETS 26G MISC 2

ADVOCATE SAFETY LANCETS MISC 2

AGAMATRIX ULTRA-THIN LANCETS 33G MISC 2

AQUALANCE LANCETS ULTRA THIN 30G MISC 2

ASSURE COMFORT LANCETS ULTRA THIN 28G MISC

ASSURE HAEMOLANCE PLUS HIGH FLOW 18G MISC

ASSURE HAEMOLANCE PLUS LOW FLOW 25G MISC

ASSURE HAEMOLANCE PLUS MICRO FLOW 28G MISC

ASSURE HAEMOLANCE PLUS NORMAL FLOW 21G MISC

Drug Name DrugTier

RequirementsLimits

ASSURE HAEMOLANCE PLUS PEDIATRIC BLADE MISC

ASSURE LANCE LANCETS 21G MISC 2

ASSURE LANCE LANCETS MISC 2

ASSURE LANCE PLUS SAFETYLANCETS 25G MISC

ASSURE LANCETS MISC 2 QL(200 ea perfill retail600 ea per fill mail)

AT LAST LANCETS MISC 2 QL(200 ea perfill retail600 ea per fill mail)

AURORA LANCET SUPER THIN30G MISC 2

AURORA LANCET THIN 23G MISC 2

BAYER MICROLET LANCETS MISC 2

BD LANCET ULTRAFINE 30G MISC 2

BD MICROTAINER LANCETS MISC 2

BULLSEYE MINI SAFETY LANCETS MISC 2

BULLSEYE SAFETY LANCETS MISC 2

CAREONE LANCET THIN MISC 2

54

Drug Name DrugTier

RequirementsLimits

CAREONE LANCET ULTRA THIN MISC 2

CARETOUCH TWIST LANCETS 28G MISC 2

CLEANLET LANCETS 28G MISC 2

CLEVER CHEK LANCETS ULTRATHIN 30G MISC 2

CLEVER CHEK LANCETS ULTRATHIN MISC 2

CLEVER CHOICE COMFORT EZLANCETS 21G MISC

COAGUCHEK LANCETS MISC 2

COMFORT ASSURED LANCETS MICRO THIN 33G MISC

COMFORT ASSURED LANCETS SUPER THIN 28G MISC

COMFORT LANCETS MISC 2

CVS LANCETS 21G MISC 2 QL(200 ea perfill retail600 ea per fill mail)

CVS LANCETS MICRO THIN 33G MISC 2

Drug Name DrugTier

RequirementsLimits

CVS LANCETS MICRO-THIN 33G MISC 2

CVS LANCETS ORIGINAL MISC 2

CVS LANCETS THIN 26G MISC 2

CVS LANCETS ULTRA THIN 30G MISC 2

CVS LANCETS ULTRA-THIN 30G MISC 2

CVS ULTRA THIN LANCETS MISC 2

DIATHRIVE LANCETS MISC 2

DIATHRIVE LANCETS ULTRA THIN 30G MISC 2

DROPLET LANCETS ULTRA THIN 30G MISC 2

DRUG MART LANCETS THIN MISC 2

DRUG MART ON-THE-GO LANCETS GENTLE 30G MISC

DRUG MART UNILET LANCETSSUPER THIN 30G MISC

DRUG MART UNILET LANCETSULTRA THIN 28G MISC

DRUG MART UNILET MICRO THIN LANCETS 33G MISC

E-Z JECT LANCETS 21G MISC 2

E-Z JECT LANCETS COLOR MISC 2

55

Drug Name DrugTier

RequirementsLimits

E-Z JECT LANCETS MISC 2 QL(200 ea perfill retail600 ea per fill mail)

E-Z JECT LANCETS SUPER THIN 30G MISC 2

E-Z JECT LANCETS THIN 26G MISC 2

E-ZJECT LANCETS MICRO-THIN 33G MISC 2

EASY COMFORT LANCETS 30GPULL TOPMISC

EASY COMFORT LANCETS 30GTHIN TOPMISC

EASY COMFORT LANCETS MISC 2

EASY COMFORT LANCETS TWIST TOP MISC

EASY TOUCH LANCETS 21GPRESSUREACTIVATED MISC

EASY TOUCH LANCETS 26GPULL-TOP MISC 2

EASY TOUCH LANCETS 26GTWIST MISC 2

Drug Name DrugTier

RequirementsLimits

EASY TOUCH LANCETS 30GBUTTON-ACTIVATEDMISC

EASY TOUCH SAFETY LANCETS21GPRESSUREACTIVATED MISC

EASY TOUCH SAFETY LANCETS26GBUTTONACTIVATED MISC

EASY TWIST amp CAP LANCETS MISC 2

EASYTEST II LANCETS MISC 2

56

Drug Name DrugTier

RequirementsLimits

EASYTEST LANCETS MISC 2

EMBRACE LANCETS ULTRA THIN 30G MISC 2

EQL COLOR LANCETS 21G MISC 2

EQL COLOR LANCETS MICRO THIN 33G MISC 2

EQL SUPER THIN LANCETS 30G MISC 2

EQL THIN LANCETS 26G MISC 2

EZ SMART BLOOD GLUCOSE LANCETS MISC

EZ-LETS LANCETS 21G MISC 2

EZ-LETS LANCETS 26G SUPER-SOFT MISC 2

EZ-LETS LANCETS 28G ULTRA-SOFT MISC 2

FIFTY50 SAFETY SEAL LANCETS 30G MISC 2

FIFTY50 UNILET LANCETS 33G MISC 2

FINE 30 MISC 2 QL(200 ea perfill retail600 ea per fill mail)

Drug Name DrugTier

RequirementsLimits

FINGERSTIX LANCETS MISC 2

FORA LANCETS MISC 2 QL(200 ea perfill retail600 ea per fill mail)

FREDS PHARMACY UNILET LANCETS SUPER THIN 30G MISC

FREDS PHARMACY UNILET LANCETS ULTRA THIN 28G MISC

FREESTYLE LANCETS MISC 2

FREESTYLE UNISTICK II LANCETS MISC 2

GENTEEL BUTTERFLY TOUCH LANCETS MISC 2

GENTLE-LET GP LANCETS MISC 2

GENTLE-LET LANCETS GENERAL PURPOSE STYLEFINE POINT MISC

GENTLE-LET LANCETS GENERAL PURPOSE STYLEMEDIUM POINTMISC

2

GENTLE-LET LANCETS SAFETY STYLEFINEPOINT MISC

GENTLE-LET LANCETS SAFETY STYLEMEDIUMPOINT MISC

GLOBAL INJECT EASE LANCETS 28G MISC 2

GLUCOCOM LANCETS 28G MISC 2

57

Drug Name DrugTier

RequirementsLimits

GLUCOSOURCE LANCETS MISC 2

GNP LANCETS 21G MISC 2 QL(200 ea perfill retail600 ea per fill mail)

GNP LANCETS MICRO THIN 33G MISC 2

GNP LANCETS MISC 2 QL(200 ea perfill retail600 ea per fill mail)

GNP LANCETS SUPER THIN 30G MISC 2

GNP LANCETS THIN 26G MISC 2

GNP LANCETS THIN MISC 2

GNP MICRO THIN LANCETS 33G MISC 2

GNP SUPER THIN LANCETS30G MISC 2

GOODSENSE COLOR LANCETS MICRO-THIN 33G UNIVERSAL MISC

GOODSENSE LANCETS MICRO-THIN 33G MISC 2

GOODSENSE LANCETS MICRO-THIN 33G UNIVERSAL MISC

GOODSENSE LANCETS ULTRA-THIN 26G UNIVERSAL MISC

GOODSENSE LANCETS ULTRA-THIN 30G MISC 2

Drug Name DrugTier

RequirementsLimits

H-E-B INCONTROL LANCETS MICRO THIN 33G MISC

H-E-B INCONTROL LANCETS SUPER THIN 30G MISC

H-E-B INCONTROL LANCETS ULTRA THIN 28G MISC

HAEMOLANCE LOW FLOW LANCETS MISC 2

HAEMOLANCE MISC 2 QL(200 ea perfill retail600 ea per fill mail)

HAEMOLANCE PLUS HIGH FLOW MISC 2

HAEMOLANCE PLUS LOW FLOW MISC 2

HAEMOLANCE PLUS MAX FLOW MISC 2

HAEMOLANCE PLUS MISC 2

HAEMOLANCE PLUS PEDIATRIC FLOW MISC 2

HEALTHWISE LANCETS 30G MISC 2

HEALTHY ACCENTS UNILET LANCETS SUPER THIN 30G MISC

HY-VEE LANCETS MISC 2 QL(200 ea perfill retail600 ea per fill mail)

HY-VEE THIN LANCETS MISC 2

IN TOUCH STERILE LANCETS30G MISC 2

58

Drug Name DrugTier

RequirementsLimits

KINNEY LANCETS MISC 2 QL(200 ea perfill retail600 ea per fill mail)

KINNEY THIN LANCETS MISC 2

KROGER LANCETS 21G MISC 2

KROGER LANCETS MICRO THIN33G MISC 2

KROGER LANCETS MISC 2 QL(200 ea perfill retail600 ea per fill mail)

KROGER LANCETS SUPER THIN MISC 2

KROGER LANCETS THIN 26G MISC 2

KROGER LANCETS THIN MISC 2

KROGER LANCETS ULTRATHIN30G MISC 2

LANCETS 26G TWIST TOP MISC 2

LANCETS 28G MISC 2 QL(200 ea perfill retail600 ea per fill mail)

LANCETS 30GTWISTTOP MISC 2

LANCETS 33G UNIVERSAL DESIGN MISC

Drug Name DrugTier

RequirementsLimits

LANCETS MICRO THIN 33G MISC 2

LANCETS MISC 2 QL(200 ea perfill retail600 ea per fill mail)

LANCETS SAFETY SEAL 21G MISC 2

LANCETS SUPER THIN 28G MISC 2

LANCETS THIN MISC 2 QL(200 ea perfill retail600 ea per fill mail)

LANCETS TWIST TOP MISC 2

LANCETS ULTRA FINE MISC 2

LANCETS ULTRA THIN 30G MISC 2

LANCETS ULTRA THIN MISC 2

LANCETSBULLSEYE SAFETY MISC 2

LIBERTY MEDICAL LANCETS 30G MISC 2

LIFESCAN UNISTIK 2 DEEP PENETRATION MISC

LIFESCAN UNISTIK II LANCETS MISC 2

59

Drug Name DrugTier

RequirementsLimits

LITE TOUCH LANCETS MISC 2

LITETOUCH LANCETS MICRO THIN 33G MISC 2

LIVE BETTER LANCET SUPERTHIN 30G MISC 2

LIVE BETTER LANCET ULTRATHIN 28G MISC 2

LONGS LANCETS STANDARD MISC 2

LONGS LANCETS THIN MISC 2

LONGS LANCETS ULTRA THIN MISC 2

MEDICHOICE PRE-SET SAFETY LANCET DUAL USE MISC

MEDICHOICE PRE-SET SAFETY LANCET LOW FLOW MISC

MEDICHOICE PRE-SET SAFETY LANCET MEDIUM FLOW MISC

MEDICHOICE PRE-SET SAFETY LANCET MODERATE FLOW MISC

MEDICHOICE SAFETY LANCETEXTRA MISC 2

MEDICHOICE SAFETY LANCETNORMAL MISC 2

MEDISENSE THIN LANCETS MISC 2

MEDLANCE PLUS EXTRA LANCETS 21G MISC 2

MEDLANCE PLUS LANCETS LITE 25G MISC 2

Drug Name DrugTier

RequirementsLimits

MEDLANCE PLUS LANCETS MISC 2

MEDLANCE PLUS LITE LANCETS 25G MISC 2

MEDLANCE PLUS SPECIAL LANCETS 08MM MISC

MEDLANCE PLUS SUPERLITE 30G MISC 2

MEDLANCE PLUS SUPERLITE 30GCOMFORT MAXMISC

2

MEDLANCE PLUS UNIVERSAL LANCETS 21G MISC

MEDLANCE PLUSLITE25G MISC 2

MEDLANCEEXTRA MISC 2 QL(200 ea perfill retail600 ea per fill mail)

MEDLANCELITE MISC 2 QL(200 ea perfill retail600 ea per fill mail)

MEDLANCEUNIVERSALMISC 2

MEIJER COLOR LANCETS UNIVERSAL 33G MISC

MEIJER LANCETS MISC 2 QL(200 ea perfill retail600 ea per fill mail)

MEIJER LANCETS THIN MISC 2

MEIJER LANCETS UNIVERSAL21G MISC 2

60

Drug Name DrugTier

RequirementsLimits

MEIJER SUPER THIN LANCETS MISC 2

MICROLET LANCETS MISC 2

MICROTAINER SAFETY FLOW LANCETSTERILESINGLE-USE MISC

2

MM TWIST LANCETS MISC 2

MONOLET LANCETS MISC 2

MONOLET OPD LANCETS MISC 2

MONOLETTOR SAFETY LANCETS MISC 2

MPD SAFETY LANCET 21G18MM MISC 2

MPD SAFETY LANCETS 23G18MM MISC 2

MYGLUCOHEALTH MGH SOFTLANCE LANCETS 30G MISC

NETGROUP LANCETS MISC 2

NOVA SAFETY LANCETS 23G MISC 2

Drug Name DrugTier

RequirementsLimits

NOVA SUREFLEX LANCETS MISC 2

ON CALL LANCETS MISC 2 QL(200 ea perfill retail600 ea per fill mail)

ON CALL PLUS LANCETS MISC 2

ONETOUCH CLUB LANCETS FINE POINT MISC

ONETOUCH COMBO PACK MISC 2

ONETOUCH DELICA LANCETS EXTRA FINE 33G MISC

ONETOUCH DELICA LANCETS FINE 30G MISC 2

ONETOUCH FINEPOINT LANCETS MISC 2

ONETOUCH ULTRASOFT LANCETS MISC 2

PC LANCETS SUPER THIN 30G MISC 2

PERFECT LANCETS 30G MISC 2

PERFECT PRESSURE ACTIVATED SAFETY LANCETS 28G MISC

PHARMACIST CHOICE ULTRA THIN LANCETS 28G MISC

61

Drug Name DrugTier

RequirementsLimits

PHARMACIST CHOICE ULTRA THIN LANCETS MISC

PHARMACY COUNTER LANCETS MISC 2

PRECISION THIN LANCETS MISC 2

PRECISION THINS GP LANCET MISC 2

PRECISION ULTRA LANCET MISC 2

PREFERRED PLUS LANCETS COLORED 21G MISC

PREFERRED PLUS LANCETS SUPER THIN 30G MISC

PREFERRED PLUS LANCETS THIN 26G MISC 2

PRESSURE ACTIVATED SAFETYLANCET 21G MISC

PRO COMFORT LANCETS 30G MISC 2

PRODIGY PRESSURE ACTIVATED SAFETY LANCETS MISC

PRODIGY SAFETY LANCETS MISC 2

PRODIGY TWIST TOP LANCETS MISC 2

PSS SELECT GP LANCETS MISC 2

Drug Name DrugTier

RequirementsLimits

PSS SELECT SAFETY LANCETS MISC 2

PUSH BUTTON SAFETY LANCETS 21G MISC 2

PX LANCETS ULTRA THIN 28G MISC 2

PX LANCETS ULTRA THIN MISC 2

QC LANCETS SUPER THIN MISC 2

QC LANCETS ULTRA THIN MISC 2

QC UNILET LANCETS 28GULTRA THIN MISC 2

QC UNILET LANCETS 33GMICRO THIN MISC 2

RA E-ZJECT COLOR LANCETSMICRO-THIN 33G MISC

RA E-ZJECT LANCETS 28G MISC 2

RA E-ZJECT LANCETS THIN 26G MISC 2

RA E-ZJECT LANCETS ULTRATHIN 30G MISC 2

READYLANCE SAFETY LANCETS21G22MMMISC

62

Drug Name DrugTier

RequirementsLimits

REALITY LANCETS MISC 2 QL(200 ea perfill retail600 ea per fill mail)

REALITY TRIGGER LANCETS MISC 2

RELION LANCETS MICRO-THIN33G MISC 2

RELION LANCETS STANDARD 21G MISC 2

RELION LANCETS THIN 26G MISC 2

RELION LANCETS ULTRA-THIN30G MISC 2

RELION ULTRA THIN LANCETS30G MISC 2

RELION ULTRA THIN PLUS LANCETS 32G MISC

REXALL LANCETS ULTRA THIN MISC 2

RIGHTEST GL300 LANCETS MISC 2

SAFE-T-LANCE LOW FLOW 25G MISC 2

SAFE-T-LANCE NORMAL FLOW21G MISC 2

Drug Name DrugTier

RequirementsLimits

SAFE-T-LANCE PLUS SAFETYLANCET HIGH FLOW MISC

SAFE-T-LANCE PLUS SAFETYLANCET LOW FLOW MISC

SAFE-T-LANCE PLUS SAFETYLANCET NORMAL FLOW MISC

SAFETY LANCET 21GPRESSUREACTIVATED MISC

SAFETY LANCETS 21G MISC 2

SAFETY LANCETS MISC 2 QL(200 ea perfill retail600 ea per fill mail)

SAFETY LET LANCETS MISC 2

SAFETY SEAL LANCETS 28G MISC 2

SAPS HEALTH CARE TWIST TOP LANCETS MISC

SAPS HEALTH TWIST TOP LANCETS 30G MISC 2

SAPSCARE TWIST TOP LANCETS 30G MISC 2

SB LANCETS THIN MISC 2 QL(200 ea perfill retail600 ea per fill mail)

SB LANCETS ULTRA THIN MISC 2

63

Drug Name DrugTier

RequirementsLimits

SHOPKO ON-THE-GO COMFORTLANCETS 30G MISC

SHOPKO UNILET LANCETS SUPER THIN 30G MISC

SHOPKO UNILET LANCETS ULTRA THIN 28G MISC

SIDE BUTTON SAFETY LANCET21G MISC 2

SINGLE-LET MISC 2 QL(200 ea perfill retail600 ea per fill mail)

SM MICRO THIN LANCETS 33G MISC 2

SMART SENSE COLOR LANCETS UNIVERSAL 33G MISC

SMART SENSE STANDARD LANCETS UNIVERSAL 21G MISC

SMART SENSE SUPER THIN LANCETS UNIVERSAL 30G MISC

SMART SENSE THIN LANCETSUNIVERSAL 26G MISC

SMARTEST LANCETS 28G MISC 2

SOLUS V2 PRESSURE ACTIVATED SAFETY LANCETS 28G MISC

SOLUS V2 TWIST LANCETS 30G MISC 2

STERILANCE TL MISC 2 QL(200 ea perfill retail600 ea per fill mail)

SUPER THIN LANCETS MISC 2

SURE COMFORT LANCETS 18G MISC 2

Drug Name DrugTier

RequirementsLimits

SURE-LANCE FLAT LANCETS MISC 2

SURE-LANCE LANCETS 26G MISC 2

SURE-LANCE THIN LANCETS 28G MISC 2

SURE-LANCE ULTRA THIN LANCETS MISC 2

SURE-TOUCH LANCETS UNIVERSAL MISC 2

SURELITE LANCETS MISC 2

TECHLITE AST LANCETS MISC 2

TECHLITE LANCETS 30G MISC 2

TECHLITE LANCETS MISC 2

TGT LANCET MICRO THIN 33G MISC 2

TGT LANCET THIN 26G MISC 2

TGT LANCET ULTRA THIN 30G MISC 2

64

Drug Name DrugTier

RequirementsLimits

THINLETS GP LANCETS MISC 2

THINLETS LANCET MISC 2 QL(200 ea perfill retail600 ea per fill mail)

TODAYS HEALTH SUPER THINLANCETS 30G MISC 2

TODAYS HEALTH ULTRA THINLANCETS 28G MISC 2

TOPCARE LANCETS MICRO-THIN 33G MISC 2

TRAVEL LANCETS 30G MISC 2

TRAVEL LANCETS ADVANCED 28G MISC 2

TRUE COMFORT TWIST TOP LANCETS 30G MISC 2

TRUEPLUS LANCETS 26G MISC 2

TRUEPLUS LANCETS 28G SUPER THIN MISC 2

TRUEPLUS LANCETS 30G ULTRA THIN MISC 2

TRUEPLUS LANCETS 33G MICRO THIN MISC 2

TRUEPLUS SAFETY LANCETS 28G MISC 2

Drug Name DrugTier

RequirementsLimits

ULTICARE THIN LANCETS 30G MISC 2

ULTILET CLASSIC LANCETS MISC 2

ULTILET LANCETS 33G MISC 2

ULTILET LANCETS MISC 2 QL(200 ea perfill retail600 ea per fill mail)

ULTILET SAFETY LANCETS 21G X 22MM MISC

ULTILET SAFETY LANCETS 23G MISC 2

ULTRA THIN LANCETS 31G MISC 2

ULTRA-CARE LANCETS 30G MISC 2

ULTRA-THIN II AUTO LANCET MISC 2

ULTRA-THIN II LANCETS 28G MISC 2

ULTRA-THIN II SAFETY AUTOLANCETS 26G MISC

UNILET COMFORTOUCH LANCET MISC 2

UNILET EXCELITE II MISC 2 QL(200 ea perfill retail600 ea per fill mail)

UNILET EXCELITE MISC 2 QL(200 ea perfill retail600 ea per fill mail)

UNILET GP LANCET MISC 2

65

Drug Name DrugTier

RequirementsLimits

UNILET GP SUPERLITE LANCET MISC 2

UNILET GP 28 ULTRA THIN MISC 2

UNILET LANCET MISC 2 QL(200 ea perfill retail600 ea per fill mail)

UNILET LANCETS MICRO-THIN33G MISC 2

UNILET LANCETS SUPER-THIN30G MISC 2

UNILET LANCETS ULTRA-THIN 28G MISC 2

UNILET SUPERLITE LANCET MISC 2

UNISTIK 3 GENTLE MISC 2 QL(200 ea perfill retail600 ea per fill mail)

UNISTIK PRO SAFETY LANCET 21G MISC 2

UNISTIK SAFETY LANCETS 28G MISC 2

UNISTIK TOUCH SAFETY LANCETS 21G MISC 2

Drug Name DrugTier

RequirementsLimits

UNIVERSAL 1 LANCETS THIN26G MISC 2

UNIVERSAL 1 LANCETS ULTRA THIN 30G MISC 2

UNIVERSAL 1 LANCETS33GMICRO-THIN MISC

VALUE PLUS LANCETS STANDARD 21G MISC 2

VALUE PLUS LANCETS SUPERTHIN 30G MISC 2

VALUE PLUS LANCETS THIN 26G MISC 2

VALUMARK LANCET SUPER THIN 30G MISC 2

VALUMARK LANCET ULTRA THIN 28G MISC 2

VIDA MIA UNILET LANCETS SUPER THIN 30G MISC

VIDA MIA UNILET LANCETS ULTRA THIN 28G MISC

VITALET PRO LANCETS MISC 2

VITALET PRO PLUS LANCETS MISC 2

WampF LANCETS 26G MISC 2 QL(200 ea perfill retail600 ea per fill mail)

WampF LANCETS COLORED 21G MISC 2

WALGREENS ADVANCED TRAVELLANCETS 28G MISC

66

Drug Name DrugTier

RequirementsLimits

WALGREENS COMFORT ASSUREDLANCETS MICRO THIN33G MISC

WALGREENS COMFORT ASSUREDLANCETS SUPER THIN28G MISC

WALGREENS LANCETS MISC 2

WALGREENS THIN LANCETS MISC 2

WALGREENS ULTRA THIN LANCETS MISC 2

Parenteral Therapy Supplies BD ECLIPSE NEEDLE 30G X12 MISC 2

BD NEEDLE30G X 12MISC 2

BD SAFETYGLIDE INSULIN SYRINGE1ML31G X1564 MISC

2

Limit 200QL(667 eadaily)

BD VEO INSULIN SYRINGE ULTRA-FINE1ML31G X 6MMMISC

2

DROPLET INSULIN SYRINGE U-1001ML31GX 1564 MISC

2 Limit 200QL(667 eadaily)

DROPLET INSULIN SYRINGEU-1001ML31GX 1564 MISC

EASY TOUCH FLIPLOCK NEEDLES 30GX12 MISC 2

EASY TOUCH HYPODERMIC NEEDLES 30GX12 MISC

2

HYPODERMIC NEEDLE 30GX12 MISC 2

INSULIN SYRINGES AND PEN NEEDLES 2 MO

POLY HUB NEEDLE30GX 12 MISC 2

Drug Name DrugTier

RequirementsLimits

RELION INSULIN SYRINGE 1ML31GX1564 MISC

RELION INSULIN SYRINGEU-1001ML31GX 1564 MISC

TECHLITE INSULIN SYRINGEU-1001ML31GX 1564 MISC

MIGRAINE PRODUCTS - Drugs to Treat MigraineHeadaches Migraine Combinations CAFERGOT TABS (Use Ergotamine w Caffeine) GP

ergotamine w caffeine tabs 1

MIGERGOT SUPP 2

Migraine Products ERGOMAR SUBL 2

Serotonin Agonists

almotriptan malate tabs 1 QL(02 eadaily)

AMERGE TABS (Use Naratriptan HCl) GP

AXERT TABS (Use Almotriptan Malate) GP QL(02 eadaily)

IMITREX SOLN NA 20 MGACT (Use Sumatriptan) GP

Limit 6 sprayers permonthQL(2 eadaily)

IMITREX TABS OR 25 MG 50 MG 100 MG (Use Sumatriptan Succinate)

GP QL(2 ea daily)

MAXALT TABS (Use Rizatriptan Benzoate) GP QL(06 eadaily)

MAXALT-MLT TBDP (Use Rizatriptan Benzoate) GP

67

Drug Name DrugTier

RequirementsLimits

naratriptan hcl tabs 1 QL(9 ea per fillretail9 ea per30 days retail)

rizatriptan benzoate tabs 5mg 10 mg 1 QL(06 ea

daily)

rizatriptan benzoate tbdp 5mg 10 mg 1

sumatriptan soln 20 mgact 1

sumatriptan soln 5 mgact 1 QL(6 ea per fillretail6 ea per30 days retail)

sumatriptan succinate tabs 1 QL(2 ea daily)

MINERALS amp ELECTROLYTES

Fluoride

FLUORABON SOLN 2 AL(Up to 6 yrsold ) PV

FLURA-DROPS SOLN 2 AL(Up to 6 yrsold ) PV

LOZI-FLUR LOZG 2

LURIDE SOLN (Use Sodium Fluoride) GP AL(Up to 6 yrsold ) PV

sodium fluoride chew 1 AL(Up to 6 yrsold ) PV

sodium fluoride soln 1 AL(Up to 6 yrsold ) PV

sodium fluoride tabs 1 AL(Up to 6 yrsold ) PV

Phosphate K-PHOS NEUTRAL TABS (Use Pot PhosphateMonobasic w SodPhosphate Dibasic ampMonobasic)

GP

K-PHOS TABS 2

pot phosphate monobasicw sod phosphate dibasic ampmonobasic tabs

1

Potassium

Drug Name DrugTier

RequirementsLimits

EFFERVESCENT POTASSIUMCHLORIDETBEF

2

K-TAB TBCR 10 MEQ (Use Potassium Chloride) GP

K-TAB TBCR 8 MEQ 2

KLOR-CON M15 TBCR 2

KLOR-CON25 PACK 2

potassium bicarb amp chloridetbef 1

potassium bicarbonate tbef 1

potassium chloride cpcr or8 meq 10 meq 1

POTASSIUM CHLORIDE ER TBCR 8 MEQ 2

potassium chloridemicroencapsulated crystalser tbcr

1

potassium chloride pack or20 meq 1

potassium chloride soln or10 20 1

potassium chloride tbcr or 8meq 10 meq 1

MISCELLANEOUS THERAPEUTIC CLASSES

Chelating Agents D-PENAMINE TABS 2

DEPEN TITRATABS TABS 2

Immunomodulators REVLIMID CAPS 2 PA AC

Immunosuppressive Agents azathioprine tabs 1

CELLCEPT CAPS (Use Mycophenolate Mofetil) GP

CELLCEPT SUSR (Use Mycophenolate Mofetil) GP

68

Drug Name DrugTier

RequirementsLimits

CELLCEPT TABS (Use Mycophenolate Mofetil) GP

cyclosporine caps 1

cyclosporine modified (formicroemulsion) caps 1

cyclosporine modified (formicroemulsion) soln 1

CYCLOSPORINE MODIFIED CAPS 2

CYCLOSPORINE MODIFIED CAPS (Use Cyclosporine Modified (ForMicroemulsion))

GP

IMURAN TABS (Use Azathioprine) GP

mycophenolate mofetil caps 1

mycophenolate mofetil susr 1

mycophenolate mofetil tabs 1

NEORAL CAPS (Use Cyclosporine Modified (ForMicroemulsion))

GP

NEORAL SOLN (Use Cyclosporine Modified (ForMicroemulsion))

GP

PROGRAF CAPS 05 MG 1 MG 5 MG (Use Tacrolimus)

GP

SANDIMMUNE CAPS 25 MG 100 MG (Use Cyclosporine)

GP

SANDIMMUNE SOLN 100 MGML 2

tacrolimus caps 1

ZORTRESS TABS 2

Potassium Removing Agents KAYEXALATE POWD (Use Sodium PolystyreneSulfonate)

GP

sodium polystyrenesulfonate powd or 1

Drug Name DrugTier

RequirementsLimits

sodium polystyrenesulfonate susp or 15gm60ml

1

MOUTHTHROATDENTAL AGENTS

Anesthetics Topical Oral lidocaine hcl (mouth-throat)soln 1

Anti-infectives - Throat clotrimazole lozg 1

clotrimazole troc 1

nystatin (mouth-throat) susp 1

Antiseptics - MouthThroat chlorhexidine gluconate(mouth-throat) soln 1

PERIDEX SOLN (Use Chlorhexidine Gluconate (Mouth-Throat))

GP

Steroids - MouthThroatDental triamcinolone acetonide (mouth) pste 1

Throat Products - Misc pilocarpine hcl (oral) tabs 5 mg 1 QL(6 ea daily)

pilocarpine hcl (oral) tabs75 mg 1 QL(4 ea daily)

SALAGEN TABS 5 MG (Use Pilocarpine HCl(Oral))

GP QL(6 ea daily)

GP QL(4 ea daily)

MULTIVITAMINS

Ped MV w Fluoride

FLORIVA PLUS SOLN 2 AL(Up to 6 yrsold )

MULTIVITAMINFLUORIDE CHEW 2 AL(Up to 6 yrs

old ) pediatric multivitamins wflchew 1 AL(Up to 6 yrs

old )

69

Drug Name DrugTier

RequirementsLimits

pediatric multivitamins wflsoln 1 AL(Up to 6 yrs

old ) pediatric vitamins acd wfluoride soln 1 AL(Up to 6 yrs

old ) QUFLORA GUMMIES CHEW 2 AL(Up to 6 yrs

old ) QUFLORA PEDIATRIC CHEW 2 AL(Up to 6 yrs

old ) QUFLORA PEDIATRIC SOLN 2 AL(Up to 6 yrs

old ) Ped Multi Vitamins wFl amp FE ped multivitamins wfl ampiron soln 1 AL(Up to 6 yrs

old ) pediatric vitamins acdfluoride amp iron soln 1 AL(Up to 6 yrs

old ) QUFLORA FE PEDIATRIC LIQD 2 AL(Up to 6 yrs

old ) Prenatal Vitamins ATABEX EC TBEC 2

BAL-CARE DHA MISC 2

CITRANATAL 90 DHA MISC 2

CITRANATAL ASSURE MISC 2

CITRANATAL BLOOM DHA MISC 2

CITRANATAL DHA MISC 2

CITRANATAL RX TABS 2

COMPLETENATE CHEW 2

CONCEPT DHA CAPS 2

CONCEPT OB CAPS 2

DOTHELLE DHA CAPS 2

FOCALGIN 90 DHA MISC 2

FOCALGIN CA MISC 2

FOLIVANE-OB CAPS 2

Drug Name DrugTier

RequirementsLimits

HEMENATAL OB + DHA MISC 2

M-NATAL PLUS TABS 2 RXOTC

M-VIT TABS 2 RXOTC

MARNATAL-F CAPS 2

MYNATAL ADVANCE TABS 2

MYNATAL ULTRACAPLET TABS 2

MYNATE 90 PLUS TBCR 2

NEONATAL PLUS TABS 2 RXOTC

NESTABS DHA MISC 2

NIVA-PLUS TABS 2 RXOTC

O-CAL FA TABS 2 RXOTC

OBSTETRIX DHA MISC 2 RXOTC

OBTREX DHA MISC 2 RXOTC

PNV FOLIC ACID + IRON MULTIVITAMIN TABS 2 RXOTC

PNV OB+DHA MISC 2

PNV PRENATAL PLUS MULTIVITAMIN TABS 2 RXOTC

PNV-VP-U CAPS 2

PR NATAL 400 EC MISC 2

PR NATAL 400 MISC 2

PR NATAL 430 MISC 2

PREFERAOB +DHA MISC 2

PRENA 1 TRUE MISC 2

PRENATA CHEW 2

70

Drug Name DrugTier

RequirementsLimits

PRENATAL 19 CHEW 30UNIT-1000UNIT-20MG-3MG-200MG-29MG-7MG-15MG-3MG-12MCG-400UNIT-1MG-20MG-100MG 1000UNIT-400UNIT-20MG-25MG-3MG-200MG-29MG-7MG-6MG-3MG-12MCG-1MG-30UNIT-20MG-100MG

2

PRENATAL PLUS TABS 2 RXOTC

PRENATAL TABS 2 RXOTC

prenatal vit w docusate-iron carbonyl-folic acid tabs 1

PRENATAL VITAMINS PLUS LOW IRON TABS 2 RXOTC

prenatal without a vit w fefumarate-folic acid tabs 1

PRENATAL-U CAPS 2

PRENATE DHA CAPS 600MCG-10UNIT-300MG-50MG-145MG-28MG-13MCG-220UNIT-400MCG-26MG-90MG

2

QL(1 ea daily)

PRENATE ELITE TABS 600MCG-10UNIT-150MCG-2600UNIT-15MG-15MG-25MG-3MG-100MG-26MG-6MG-21MG-35MG-13MCG-450UNIT-400MCG-330MCG-21MG-75MG 600MCG-10UNIT-150MCG-2600UNIT-15MG-15MG-15MG-25MG-3MG-100MG-26MG-6MG-21MG-35MG-13MCG-450UNIT-400MCG-330MCG-21MG-75MG

2

PREPLUS TABS 2 RXOTC

PROVIDA DHA CAPS 2

PROVIDA OB CAPS 2

Drug Name DrugTier

RequirementsLimits

SE-NATAL 19 CHEW 30UNIT-1000UNIT-100MG-20MG-3MG-200MG-29MG-7MG-15MG-3MG-12MCG-400UNIT-1MG-20MG

2

SELECT-OB CHEW 06MG-29MG-30UNIT-15MG-25MG-1700UNIT-15MG-18MG-5MCG-400UNIT-16MG-04MG-25MG-60MG

2

TARON-C DHA CAPS 2

THERANATAL CORE NUTRITION TABS 2 RXOTC

TRI-TABS DHA MISC 2

TRICARE PRENATAL CHEW 2

TRICARE PRENATAL DHA ONEFOLATE CAPS 2

TRICARE PRENATAL THPK 2

TRICARE TABS 2 RXOTC

TRINATAL GT TABS 2

TRIVEEN-DUO DHA MISC 2

VENA-BAL DHA MISC 2

VIRT-ADVANCE TABS 2

VIRT-C DHA CAPS 2

VIRT-VITE GT TABS 2

VITATRUE MISC 2

VOL-PLUS TABS 2 RXOTC

VP-HEME OB + DHA MISC 2

MUSCULOSKELETAL THERAPY AGENTS -Drugs to Treat Spasms Central Muscle Relaxants baclofen tabs 10 mg 1 QL(6 ea daily)

71

Drug Name DrugTier

RequirementsLimits

baclofen tabs 20 mg 1 QL(4 ea daily)

BACLOFEN TABS 5 MG 2

carisoprodol tabs 350 mg 1

cyclobenzaprine hcl tabs 5mg 10 mg 1

methocarbamol tabs 1

orphenadrine citrate tb12 1

ROBAXIN TABS (Use Methocarbamol) GP

ROBAXIN-750 TABS (Use Methocarbamol) GP

SOMA TABS 350 MG (Use Carisoprodol) GP

tizanidine hcl tabs 2 mg 1

tizanidine hcl tabs 4 mg 1 QL(9 ea daily)

ZANAFLEX TABS 4 MG (Use Tizanidine HCl) GP QL(9 ea daily)

Direct Muscle Relaxants DANTRIUM CAPS (Use Dantrolene Sodium) GP

dantrolene sodium caps 1

Muscle Relaxant Combinations carisoprodol w aspirin tabs 1

NASAL AGENTS - SYSTEMIC AND TOPICAL -Drugs to treat the Nose or Sinus Nasal Anti-infectives BACTROBAN NASAL OINT 2

Nasal Antiallergy

ASTEPRO SOLN (Use Azelastine HCl) GP

Limit 1 bottle permonthQL(12ml daily)

azelastine hcl soln 01 137 mcgspray 1

Limit 1 inhaler permonthQL(12ml daily)

Drug Name DrugTier

RequirementsLimits

azelastine hcl soln 015 1

Nasal Anticholinergics ipratropium bromide (nasal)soln 1

Nasal Steroids FLONASE ALLERGY RELIEF CHILDRENS SUSP (Use Fluticasone Propionate (Nasal))

GP

QL(32 ml perfill retail32 ml per 30 daysretail) RXOTC

FLONASE ALLERGY RELIEF SUSP (Use Fluticasone Propionate(Nasal))

GP

fluticasone propionate(nasal) susp 1

mometasone furoate (nasal) susp 1

NASACORT ALLERGY 24HR AERO 2

Limit 1 sprayer permonthQL(12ml daily)RXOTC

NASACORT ALLERGY 24HR AERO (Use Triamcinolone Acetonide (Nasal))

GP

NASACORT ALLERGY 24HR CHILDRENS AERO (Use Triamcinolone Acetonide (Nasal))

GP

NASONEX SUSP (Use Mometasone Furoate (Nasal))

GP

triamcinolone acetonide (nasal) aero 1

72

Drug Name DrugTier

RequirementsLimits

OPHTHALMIC AGENTS - Drugs to Treat the Eye

Beta-blockers - Ophthalmic BETAGAN SOLN (Use Levobunolol HCl) GP

betaxolol hcl (ophth) soln 1

BETIMOL SOLN 2

BETOPTIC-S SUSP 2

COSOPT SOLN (Use Dorzolamide HCl-Timolol Maleate)

GP

dorzolamide hcl-timolol maleate soln 2-05223mgml-68mgml

1

DORZOLAMIDE HCLTIMOLOL MALEATESOLN

2

ISTALOL SOLN 2

ISTALOL SOLN (Use Timolol Maleate (Ophth)) GP

levobunolol hcl soln 1

timolol maleate (ophth)solg 1

timolol maleate (ophth)soln 1

TIMOLOL MALEATE OPHTHALMIC GEL FORMING SOLG

2

TIMOPTIC SOLN (Use Timolol Maleate (Ophth)) GP

TIMOPTIC-XE SOLG 025 (Use Timolol Maleate (Ophth))

GP

TIMOPTIC-XE SOLG 025 05 2

Cycloplegic Mydriatics ATROPINE SULFATE OINT OP 1 2

ATROPINE SULFATE SOLN OP 1 2

CYCLOGYL SOLN (Use Cyclopentolate HCl) GP

Drug Name DrugTier

RequirementsLimits

cyclopentolate hcl soln 1

homatropine hbr soln 1

ISOPTO ATROPINE SOLN 2

Miotics ISOPTO CARPINE SOLN (Use Pilocarpine HCl) GP QL(05 mldaily) PHOSPHOLINE IODIDE SOLR 2

pilocarpine hcl soln 1 QL(05 mldaily)

Ophthalmic Adrenergic Agents ALPHAGAN P SOLN 01 2

ALPHAGAN P SOLN 015 (Use Brimonidine Tartrate)

GP

brimonidine tartrate soln 1

Ophthalmic Anti-infectives BACITRACIN OINT 2

bacitracin-polymyxin b(ophth) oint 1

BLEPH-10 SOLN (Use Sulfacetamide Sodium (Ophth))

GP

CILOXAN OINT 2

CILOXAN SOLN (Use Ciprofloxacin HCl (Ophth)) GP

ciprofloxacin hcl (ophth)soln 1

erythromycin (ophth) oint 1

gatifloxacin (ophth) soln 1

GENTAK OINT 2

gentamicin sulfate (ophth)oint 1

gentamicin sulfate (ophth)soln 1

MOXEZA SOLN 2

73

Drug Name DrugTier

RequirementsLimits

moxifloxacin hcl (ophth)soln 1 QL(3 ml per fill

retail)

NATACYN SUSP 2

neomycin-bacitracin zn-polymyxin oint 1

NEOMYCINPOLYMYXINGRAMICIDIN SOLN 2

NEOSPORIN SOLN (Use Neomycin-Polymyxin-Gramicidin)

GP

OCUFLOX SOLN (Use Ofloxacin (Ophth)) GP QL(5 ml per fillretail)

ofloxacin (ophth) soln 1 QL(5 ml per fillretail)

polymyxin b-trimethoprimsoln 1

POLYTRIM SOLN (Use Polymyxin B-Trimethoprim) GP

sulfacetamide sodium (ophth) soln 1

SULFACETAMIDE SODIUM OINT OP 2

tobramycin (ophth) soln 1

TOBREX OINT 2

TOBREX SOLN (Use Tobramycin (Ophth)) GP

trifluridine soln 1

VIGAMOX SOLN (Use Moxifloxacin HCl (Ophth)) GP QL(3 ml per fillretail) VIROPTIC SOLN (Use Trifluridine) GP

ZYMAXID SOLN (Use Gatifloxacin (Ophth)) GP

Ophthalmic Decongestants phenylephrine hcl (ophth)soln 25 1

Ophthalmic Steroids bacitracin-poly-neomycin-hc oint 1 QL(4 gm per fill

retail) BLEPHAMIDE SOP OINT 2

Drug Name DrugTier

RequirementsLimits

BLEPHAMIDE SUSP 2

DEXAMETHASONE SODIUM PHOSPHATE SOLN

2

FLAREX SUSP 2

fluorometholone (ophth) susp 1

FML FORTE SUSP 2

FML LIQUIFILM SUSP (Use Fluorometholone (Ophth))

GP

FML OINT 2

MAXIDEX SUSP 2

MAXITROL OINT (Use Neomycin-Polymy-Dexameth)

GP

MAXITROL SUSP (Use Neomycin-Polymy-Dexameth)

GP

neomycin-polymy-dexameth oint 1

neomycin-polymy-dexameth susp 1

neomycin-polymyxin-hc(ophth) susp 1

OMNIPRED SUSP (Use Prednisolone Acetate (Ophth))

GP

PRED FORTE SUSP (Use Prednisolone Acetate (Ophth))

GP

PRED MILD SUSP 2

prednisolone acetate(ophth) susp 1

PREDNISOLONE ACETATE P-F SUSP 2

PREDNISOLONE SODIUM PHOSPHATE SOLN OP 1

2

sulfacetamide sod-prednisolone soln 1

74

Drug Name DrugTier

RequirementsLimits

SULFACETAMIDE SODIUMPREDNISOLONESODIUM PHOSPHATE SOLN

2

TOBRADEX SUSP (Use Tobramycin-Dexamethasone)

GP QL(5 ml per fillretail)

tobramycin-dexamethasone susp 1 QL(5 ml per fill

retail) Ophthalmics - Misc ACULAR LS SOLN (Use Ketorolac Tromethamine (Ophth))

GP

ACULAR SOLN (Use Ketorolac Tromethamine (Ophth))

GP

ALOCRIL SOLN 2

ALOMIDE SOLN 2

azelastine hcl (ophth) soln 1

AZOPT SUSP 2 Limit 10mls permonthQL(04ml daily)

bromfenac sodium (ophth)soln 1

BROMFENAC SOLN 2

cromolyn sodium (ophth)soln 1

CYSTARAN SOLN 2

Limit 4 bottles permonthQL(215ml daily)

diclofenac sodium (ophth)soln 1

dorzolamide hcl soln 1

DORZOLAMIDE HCL SOLN 2

ELESTAT SOLN (Use Epinastine HCl (Ophth)) GP

epinastine hcl (ophth) soln 1

flurbiprofen sodium soln 1

Drug Name DrugTier

RequirementsLimits

ketorolac tromethamine (ophth) soln 1

olopatadine hcl soln 01 1

Limit 10mls permonth without priorauthorizationQ L(034 ml daily)

Limit 25mls permonthQL(0084 ml daily)

PATADAY SOLN (Use Olopatadine HCl) GP

PATANOL SOLN (Use Olopatadine HCl) GP

TRUSOPT SOLN (Use Dorzolamide HCl) GP

Prostaglandins - Ophthalmic

bimatoprost soln 1

latanoprost soln op 1

LATANOPROST SOLN OP 2

LUMIGAN SOLN 2

TRAVATAN Z SOLN 2

XALATAN SOLN (Use Latanoprost) GP

75

Drug Name DrugTier

RequirementsLimits

OTIC AGENTS - Drugs to Treat the Ear

Otic Agents - Miscellaneous acetic acid (otic) soln 1

acetic acid-aluminum acetate soln 1

Otic Anti-infectives CETRAXAL SOLN (Use Ciprofloxacin HCl (Otic)) GP

ciprofloxacin hcl (otic) soln 1

FLOXIN OTIC SOLN (Use Ofloxacin (Otic)) GP

ofloxacin (otic) soln 1

Otic Combinations

CIPRODEX SUSP 2 QL(8 ml per fillretail)

CORTANE-B-OTIC SOLN (Use Pramoxine-HC-Chloroxylenol)

GP

neomycin-polymyxin-hc(otic) soln 1

neomycin-polymyxin-hc(otic) susp 1

OTICIN HC NR SOLN (Use Pramoxine-HC-Chloroxylenol)

GP

pramoxine-hc-chloroxylenolsoln 1

OXYTOCICS - Drugs to PreventControl UterineBleeding Oxytocics methylergonovine maleatetabs 1

PENICILLINS - Drugs to Treat Bacterial Infections

Aminopenicillins amoxicillin caps 1

amoxicillin chew 1

amoxicillin susr 1

Drug Name DrugTier

RequirementsLimits

amoxicillin tabs 1

ampicillin caps 1

ampicillin susr 1

Natural Penicillins PENICILLIN V POTASSIUM SOLR 125 MG5ML 250 MG5ML

2

penicillin v potassium solr125 mg5ml 250 mg5ml 1

penicillin v potassium tabs250 mg 500 mg 1

Penicillin Combinations amoxicillin amp potclavulanate susr 1

amoxicillin amp potclavulanate tabs 1

amoxicillin amp potclavulanate tb12 1

AMOXICILLINCLAVULANATE POTASSIUM CHEW 2

AUGMENTIN ES-600 SUSR (Use Amoxicillin amp Pot Clavulanate)

GP

AUGMENTIN SUSR 125MG5ML-3125MG5ML 2

AUGMENTIN SUSR 250MG5ML-625MG5ML(Use Amoxicillin amp Pot Clavulanate)

GP

AUGMENTIN TABS 500MG-125MG 875MG-125MG (Use Amoxicillin amp Pot Clavulanate)

GP

AUGMENTIN XR TB12 (Use Amoxicillin amp Pot Clavulanate)

GP

Penicillinase-Resistant Penicillins dicloxacillin sodium caps 1

PROGESTINS - Hormone ReplacementModifyingDrugs Progestins

76

Drug Name DrugTier

RequirementsLimits

AYGESTIN TABS (Use Norethindrone Acetate) GP

medroxyprogesteroneacetate tabs 10 mg 1 QL(1 ea daily)

medroxyprogesteroneacetate tabs 5 mg 25 mg 1

norethindrone acetate tabs 1

PROVERA TABS 10 MG (Use MedroxyprogesteroneAcetate)

GP QL(1 ea daily)

PROVERA TABS 5 MG 25 MG (Use MedroxyprogesteroneAcetate)

GP

PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC - Drugs to Treat Mental andEmotional Conditions Agents for Chemical Dependency acamprosate calcium tbec 1

ANTABUSE TABS (Use Disulfiram) GP

disulfiram tabs 1

Antidementia Agents ARICEPT TABS 23 MG (Use DonepezilHydrochloride)

GP QL(1 ea daily)

ARICEPT TABS 5 MG 10 MG (Use DonepezilHydrochloride)

GP

donepezil hydrochloridetabs 23 mg 1 QL(1 ea daily)

donepezil hydrochloridetabs 5 mg 10 mg 1

donepezil hydrochloridetbdp 5 mg 10 mg 1 QL(1 ea daily)

EXELON PT24 (Use Rivastigmine) GP

galantamine hydrobromidecp24 8 mg 16 mg 24 mg 1 QL(1 ea daily)

GALANTAMINE HYDROBROMIDE SOLN 4 MGML

2

Drug Name DrugTier

RequirementsLimits

galantamine hydrobromidetabs 4 mg 8 mg 12 mg 1

memantine hcl soln 2 mgml 1

memantine hcl tabs 1

memantine hcl tabs 10 mg 1 QL(2 ea daily)

NAMENDA TABS 10 MG (Use Memantine HCl) GP QL(2 ea daily)

NAMENDA TITRATION PAK TABS (Use Memantine HCl)

GP

RAZADYNE ER CP24 (Use Galantamine Hydrobromide)

GP QL(1 ea daily)

RAZADYNE TABS (Use Galantamine Hydrobromide)

GP

rivastigmine pt24 1

rivastigmine tartrate caps 1

Multiple Sclerosis Agents AMPYRA TB12 (Use Dalfampridine) GP PA

AUBAGIO TABS 2 PA SP

dalfampridine tb12 1 PA

GILENYA CAPS 2

PA Must use AcariaHlth SpRx 1-844-538-4661SP

TECFIDERA CPDR 120 MG 2

PA Must use AcariaHlth SpRx 1-844-538-4661LA

77

Drug Name DrugTier

RequirementsLimits

TECFIDERA STARTER PACK MISC 2

Premenstrual Dysphoric Disorder (PMDD) Agents FLUOXETINE CAPS 10 MG 2

FLUOXETINE CAPS 20 MG 2 QL(1 ea daily)

Smoking Deterrents bupropion hcl (smokingdeterrent) tb12 1 PV

CHANTIX CONTINUING MONTHPAK TABS 2 QL(2 ea daily)

PV CHANTIX STARTING MONTH PAK TABS 2 PV

CHANTIX TABS 05 MG 2 PV

CHANTIX TABS 1 MG 2 QL(2 ea daily)PV

NICODERM CQ PT24 (Use Nicotine) GP PV

NICORETTE GUM (Use Nicotine Polacrilex) GP PV

NICORETTE LOZG (Use Nicotine Polacrilex) GP PV

NICORETTE MINI LOZG (Use Nicotine Polacrilex) GP PV

NICORETTE STARTER KIT GUM (Use Nicotine Polacrilex)

GP PV

nicotine polacrilex gum 1 PV

nicotine polacrilex lozg 1 PV

nicotine pt24 1 PV

NICOTINE TRANSDERMAL SYSTEM KIT

2 PV

NICOTROL INHALER INHA 2 PV

NICOTROL NS SOLN 2 PV

Drug Name DrugTier

RequirementsLimits

ZYBAN TB12 (Use Bupropion HCl (SmokingDeterrent))

GP PV

RESPIRATORY AGENTS - MISC - Drugs toTreat Lung Conditions Cystic Fibrosis Agents

PULMOZYME SOLN 2 PA QL(5 mldaily)

SYMDEKO TBPK 2 PA LA

TETRACYCLINES - Drugs to Treat BacterialInfections Tetracyclines demeclocycline hcl tabs 1

doxycycline (monohydrate)caps 50 mg 100 mg 1

doxycycline (monohydrate)susr 25 mg5ml 1

doxycycline hyclate caps50 mg 100 mg 1

doxycycline hyclate tabs100 mg 1

MINOCIN CAPS (Use Minocycline HCl) NF

minocycline hcl caps 50mg 75 mg 100 mg 1

minocycline hcl tabs 50 mg100 mg 1

MONODOX CAPS 100 MG (Use Doxycycline(Monohydrate))

GP

tetracycline hcl caps 250mg 500 mg 1

VIBRAMYCIN CAPS 100 MG (Use DoxycyclineHyclate)

GP

VIBRAMYCIN SUSR 25 MG5ML (Use Doxycycline(Monohydrate))

GP

VIBRAMYCIN SYRP 50 MG5ML 2

THYROID AGENTS - Drugs to Regulate ThyroidHormones Antithyroid Agents

78

Drug Name DrugTier

RequirementsLimits

methimazole tabs 1

propylthiouracil tabs 1 QL(3 ea daily)

TAPAZOLE TABS (Use Methimazole) GP

Thyroid Hormones ARMOUR THYROID TABS 2

CYTOMEL TABS 25 MCG 50 MCG (Use LiothyronineSodium)

GP QL(2 ea daily)

CYTOMEL TABS 5 MCG (Use Liothyronine Sodium) GP

levothyroxine sodium tabs112 mcg 125 mcg 175mcg 200 mcg

1 QL(1 ea daily)

levothyroxine sodium tabs25 mcg 50 mcg 75 mcg88 mcg 100 mcg 137mcg 150 mcg 300 mcg

1

liothyronine sodium tabs 25mcg 50 mcg 1 QL(2 ea daily)

liothyronine sodium tabs 5 mcg 1

NATURE-THROID TABS 65 MG 130 MG 195 MG 260 MG 325 MG 325 MG 975 MG 1625 MG 8125 MG 11375 MG 14625 MG

2

SYNTHROID TABS 112 MCG 125 MCG 175 MCG 200 MCG (Use Levothyroxine Sodium)

GP

QL(1 ea daily)

SYNTHROID TABS 25 MCG 50 MCG 75 MCG 88 MCG 100 MCG 137 MCG 150 MCG 300 MCG (Use LevothyroxineSodium)

GP

thyroid tabs 1

WESTHROID TABS 2

Drug Name DrugTier

RequirementsLimits

WP THYROID TABS 65 MG 130 MG 325 MG 975 MG 1625 MG 8125 MG 11375 MG

2

ULCER DRUGS - Drugs to Treat Bowel Intestineand Stomach Conditions Antispasmodics BENTYL CAPS (Use Dicyclomine HCl) GP

chlordiazepoxide hcl-clidinium bromide caps 1

CUVPOSA SOLN 2

dicyclomine hcl caps 1

dicyclomine hcl soln 1

dicyclomine hcl tabs 1

glycopyrrolate tabs or 1mg 2 mg 1

LIBRAX CAPS (Use Chlordiazepoxide HCl-Clidinium Bromide)

GP

methscopolamine bromidetabs 1

propantheline bromide tabs 1

ROBINUL FORTE TABS (Use Glycopyrrolate) GP

ROBINUL TABS (Use Glycopyrrolate) GP

H-2 Antagonists CIMETIDINE HCL SOLN 2

cimetidine tabs 300 mg800 mg 1

cimetidine tabs 400 mg 1 QL(4 ea daily)

famotidine tabs 20 mg 1 QL(4 ea daily)RXOTC

famotidine tabs 40 mg 1 QL(2 ea daily)

nizatidine caps 150 mg300 mg 1

NIZATIDINE SOLN 15 MGML 2

79

Drug Name DrugTier

RequirementsLimits

PEPCID AC MAXIMUM STRENGTH TABS (Use Famotidine)

GP QL(4 ea daily)RXOTC

PEPCID TABS 20 MG (Use Famotidine) GP QL(4 ea daily)RXOTC PEPCID TABS 40 MG (Use Famotidine) GP QL(2 ea daily)

ranitidine hcl caps 150 mg 1

ranitidine hcl syrp 15mgml 75 mg5ml 150mg10ml

1

ranitidine hcl tabs 150 mg 1 QL(4 ea daily)RXOTC

ranitidine hcl tabs 300 mg 1 QL(2 ea daily)

ZANTAC 150 MAXIMUM STRENGTH TABS (Use Ranitidine HCl)

ZANTAC TABS 150 MG (Use Ranitidine HCl) GP QL(4 ea daily)RXOTC ZANTAC TABS 300 MG (Use Ranitidine HCl) GP QL(2 ea daily)

Misc Anti-Ulcer CARAFATE SUSP 1 GM10ML 2

CARAFATE TABS 1 GM (Use Sucralfate) GP QL(4 ea daily)

sucralfate tabs 1 QL(4 ea daily)

Proton Pump Inhibitors

lansoprazole cpdr 15 mg 1 QL(1 ea daily)RXOTC

lansoprazole cpdr 30 mg 1 QL(1 ea daily)

omeprazole cpdr 10 mg 1

omeprazole cpdr 20 mg 1 QL(1 ea daily)RXOTC

omeprazole cpdr 40 mg 1 QL(1 ea daily)

pantoprazole sodium tbec 1 QL(1 ea daily)

PREVACID 24HR CPDR (Use Lansoprazole) GP QL(1 ea daily)RXOTC PREVACID CPDR 15 MG (Use Lansoprazole) GP QL(1 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

PREVACID CPDR 30 MG (Use Lansoprazole) GP QL(1 ea daily)

PROTONIX TBEC 20 MG 40 MG (Use PantoprazoleSodium)

GP QL(1 ea daily)

Ulcer Drugs - Prostaglandins CYTOTEC TABS (Use Misoprostol) GP

misoprostol tabs 1

Ulcer Therapy Combinations amoxicillin-clarithromycinw lansoprazole misc 1

PREVPAC MISC (Use Amoxicillin-Clarithromycinw Lansoprazole)

GP

URINARY ANTI-INFECTIVES - Drugs to TreatBladderKidney Infections Urinary Anti-infectives FURADANTIN SUSP (Use Nitrofurantoin) GP

MACROBID CAPS (Use Nitrofurantoin MonohydMacro)

GP

MACRODANTIN CAPS (Use Nitrofurantoin Macrocrystal)

GP

methenamine mandelate tabs 1

nitrofurantoin macrocrystal caps 1

nitrofurantoin monohyd macro caps 1

nitrofurantoin susp 1

URINARY ANTISPASMODICS - Drugs to TreatMiscellaneous Bladder Spasms Urinary Antispasmodic - Antimuscarinics DETROL LA CP24 (Use Tolterodine Tartrate) GP QL(1 ea daily)

DETROL TABS (Use Tolterodine Tartrate) GP QL(2 ea daily)

DITROPAN XL TB24 (Use Oxybutynin Chloride) GP

80

Drug Name DrugTier

RequirementsLimits

oxybutynin chloride syrp 5mg5ml 1 QL(15 ml daily)

oxybutynin chloride tabs 5 mg 1 QL(4 ea daily)

oxybutynin chloride tb24 5mg 10 mg 15 mg 1

tolterodine tartrate cp24 2mg 4 mg 1 QL(1 ea daily)

tolterodine tartrate tabs 1 mg 2 mg 1 QL(2 ea daily)

TOVIAZ TB24 2 QL(1 ea daily)

trospium chloride cp24 60 mg 1

trospium chloride tabs 20 mg 1 QL(2 ea daily)

Urinary Antispasmodics - Cholinergic Agonists bethanechol chloride tabs 1

URECHOLINE TABS (Use Bethanechol Chloride) GP

Urinary Antispasmodics - Direct Muscle Relaxants flavoxate hcl tabs 1

VAGINAL PRODUCTS - Drugs to Treat VaginalInfections and Low Hormones Miscellaneous Vaginal Products FEM PH GEL (Use Acetic Acid-Oxyquinoline Vaginal) NF

Spermicides TODAY SPONGE MISC 2

Vaginal Anti-infectives CLEOCIN CREA VA 2 (Use ClindamycinPhosphate Vaginal)

GP

clindamycin phosphatevaginal crea 1

METROGEL-VAGINAL GEL (Use Metronidazole Vaginal)

GP

metronidazole vaginal gel 1

TERAZOL 7 CREA (Use Terconazole Vaginal) GP

Drug Name DrugTier

RequirementsLimits

TERCONAZOLE CREA 2

terconazole vaginal crea 1

Vaginal Estrogens ESTRACE CREA (Use Estradiol Vaginal) GP

estradiol vaginal crea 1

estradiol vaginal tabs 1

PREMARIN CREA VA 0625 MGGM 2 QL(2 gm daily)

VAGIFEM TABS (Use Estradiol Vaginal) GP

Vaginal Progestins

CRINONE GEL 2 PA QL(168 gmper 180 daysretail)

VASOPRESSORS - Drugs to Treat Heart andCirculation Conditions Anaphylaxis Therapy Agents

epinephrine (anaphylaxis)soaj SP

PA Limited to 2 pens per fill4 pens permonthQL(2 eaper fill retail4ea per 30 daysretail)

VITAMINS

Oil Soluble Vitamins DRISDOL CAPS (Use Ergocalciferol) GP PV

ergocalciferol caps 1 PV

MEPHYTON TABS (Use Phytonadione) GP

phytonadione tabs 1

81

Index 1ST TIER UNILET ACTOS 16 ALTACE 21 COMFORTOUCH LANCETS 28G 53 1ST TIER UNILET

ACULAR ACULAR LS

75 75

ALUNBRIG amantadine hcl

26 27

COMFORTOUCH LANCETS 30G 53 abacavir sulfate 30

acyclovir acyclovir topical ADALAT CC

32 42 34

AMARYL AMBIEN AMCINONIDE

18 51 42

abacavir sulfate-lamivudine 30 abacavir sulfate-lamivudine-zidovudine 30 ABILIFY 29 abiraterone acetate 25 ABSORICA 39 acamprosate calcium 77 acarbose 16 ACCU-CHEK FASTCLIX LANCETS 53 ACCU-CHEK MULTICLIX LANCETS 53 ACCU-CHEK SAFE-T-PRO LANCETS 53 ACCU-CHEK SAFE-T-PRO PLUSLANCETS 53 ACCU-CHEK SOFT TOUCH LANCETS 53 ACCU-CHEK SOFTCLIX LANCETS 53 ACCUPRIL 21 ACCURETIC 22 acebutolol hcl 33 ACEON 21 acetaminophen w codeine 5 acetazolamide 45 acetic acid (otic) 76 acetic acid-aluminum acetate 76 acetylcysteine 39 ACLOVATE 42

adapalene 39 ADCIRCA 35 ADDERALL 1 ADDERALL XR 1 adefovir dipivoxil 32 ADIPEX-P 1 ADVAIR DISKUS 10 ADVAIR HFA 10 ADVANCED MOBILE LANCET 30G 54 ADVOCATE LANCETS 54 ADVOCATE LANCETS 30G 54 ADVOCATE SAFETY LANCETS 54 ADVOCATE SAFETY LANCETS 26G 54 AEROSPAN 9 AFINITOR 26 AGAMATRIX ULTRA-THIN LANCETS 33G 54 AGRYLIN 50 albuterol sulfate 10 ALBUTEROL SULFATE ER 10 alclometasone dipropionate 42 ALDACTAZIDE 45 ALDACTONE 46 ALDARA 44

AMERGE 67 amiloride amp hydrochlorothiazide 45 amiloride hcl 46 amiodarone hcl 9 AMITIZA 48 amitriptyline hcl 15 amlodipine besylate 34 amlodipine besylate-benazeprilhcl 22 amlodipine besylate-valsartan 22 amlodipine-valsartan-hydrochlorothiazide 22 AMOXAPINE 15 amoxicillin 76 amoxicillin amp pot clavulanate 76 amoxicillin-clarithromycin wlansoprazole 80 AMOXICILLINCLAVULANATEPOTASSIUM 76 amphetamine-dextroamphetamine 1 ampicillin 76 AMPYRA 77 ANAFRANIL 15 anagrelide hcl 50 ANAPROX DS 3 anastrozole 25 ANDROGEL 6

ACTI-LANCE LANCETS ALECENSA 26 ANDROGEL PUMP 6 28G 53 alendronate sodium 46 ANDROXY 6 ACTI-LANCE LITE SAFETY LANCETS 28G 53 ACTI-LANCE SPECIAL SAFETY

ALENDRONATE SODIUM 46 alendronate sodium 46

ANORO ELLIPTA ANTABUSE

10 77

LANCETS 17G 54 alfuzosin hcl 50 ANUSOL-HC 7 ACTI-LANCE SPECIAL SAFETYLANCETS 17G 54 ACTI-LANCE UNIVERSAL SAFETY LANCETS 23G 54 ACTIGALL 48 ACTIVE 1ST BLOOD LANCETS30GEASY TWISTCAP 54 ACTIVELLA 47 ACTOPLUS MET 16

ALKERAN allopurinol almotriptan malate ALOCRIL ALOMIDE ALORA ALPHAGAN P alprazolam

24 50 67 75 75 47 73 8

APEXICON E 42 APTIVUS 30 AQUALANCE LANCETS ULTRA THIN 30G 54 ARAVA 4 ARICEPT 77 ARIMIDEX 25 aripiprazole 29 armodafinil 1

Index 1

ARMOUR THYROID 79 AUBAGIO 77 BD LANCET ULTRAFINE ARNUITY ELLIPTA 9 AROMASIN 25 ASACOL HD 48 ASMANEX HFA 9 ASMANEX TWISTHALER 120 METERED DOSES 9 ASMANEX TWISTHALER 14 METERED DOSES 10 ASMANEX TWISTHALER 30 METERED DOSES 10

AUGMENTED BETAMETHASONE DIPROPIONATE 42 AUGMENTIN 76 AUGMENTIN ES-600 76 AUGMENTIN XR 76 AURORA LANCET SUPER THIN30G 54 AURORA LANCET THIN 23G 54

33G 54 BD MICROTAINER LANCETS 54 BD NEEDLE30G X 12 67 BD SAFETYGLIDE INSULIN SYRINGE1ML31G X1564 67 BD VEO INSULIN SYRINGE ULTRA-FINE1ML31G X6MM 67 BELSOMRA 51

ASMANEX TWISTHALER 60 METERED DOSES 10 ASMANEX TWISTHALER 7 METERED DOSES 10 ASSURE COMFORT LANCETS

AVALIDE AVANDIA AVAPRO AVELOX

22 16 21 48

BELVIQ benazepril amphydrochlorothiazide benazepril hcl

1

22 21

ULTRA THIN 28G 54 AVELOX ABC PACK 48 BENICAR 21 ASSURE HAEMOLANCE PLUS HIGH FLOW 18G 54 ASSURE HAEMOLANCE PLUS LOW FLOW 25G 54

AVODART AXERT AYGESTIN

50 67 77

BENICAR HCT BENTYL BENZAMYCIN

22 79 39

ASSURE HAEMOLANCE PLUS MICRO FLOW 28G 54 ASSURE HAEMOLANCE PLUS NORMAL FLOW 21G 54 ASSURE HAEMOLANCE PLUS PEDIATRIC BLADE 54 ASSURE LANCE LANCETS 54 ASSURE LANCE LANCETS 21G 54 ASSURE LANCE PLUS SAFETYLANCETS 25G 54 ASSURE LANCE PLUS SAFETYLANCETS 30G 54 ASSURE LANCETS 54 ASTEPRO 72 AT LAST LANCETS 54 ATABEX EC 70 ATACAND 21 ATACAND HCT 22 atazanavir sulfate 30 ATELVIA 46 atenolol 33 atenolol amp chlorthalidone 22 ATIVAN 8 atomoxetine hcl 1 atorvastatin calcium 20 atovaquone 7 atovaquone-proguanil hcl 24 ATRIPLA 30 ATROPINE SULFATE 73 ATROVENT HFA 9

azathioprine 68 azelaic acid 44 azelastine hcl 72 azelastine hcl (ophth) 75 AZILECT 28 AZITHROMYCIN 52 azithromycin 5253 AZOPT 75 AZULFIDINE 48 AZULFIDINE EN-TABS 48 BACITRACIN 73 bacitracin-poly-neomycin-hc

74 bacitracin-polymyxin b(ophth) 73 baclofen 7172 BACLOFEN 72 BACTRIM 7 BACTRIM DS 7 BACTROBAN 40 BACTROBAN NASAL 72 BAL-CARE DHA 70 balsalazide disodium 48 BANZEL 12 BARACLUDE 32 BAYER MICROLET LANCETS 54 BD ECLIPSE NEEDLE 30G X12 67 BD LANCET ULTRAFINE 30G 54

BENZNIDAZOLE 7 benzonatate 38 benzoyl peroxide-erythromycin 39 BENZPHETAMINE HCL 1 benztropine mesylate 27 BETAGAN 73 betamethasone dipropionate(topical) 42 betamethasone dipropionateaugmented 42 betamethasone valerate 42 BETAPACE 33 BETAPACE AF 33 betaxolol hcl 33 betaxolol hcl (ophth) 73 bethanechol chloride 81 BETHKIS 2 BETIMOL 73 BETOPTIC-S 73 BEVYXXA 11 bexarotene 27 BEYAZ 36 BIAXIN 53 bicalutamide 25 BIKTARVY 30 BILTRICIDE 7 bimatoprost 75 bisacodyl 52

Index 2

bisacodyl-peg 3350-pot chloride- candesartan cilexetil- CELONTIN 13 sod bicarb-sod chloride 51 hydrochlorothiazide 22 CENTANY 40bisoprolol amp capecitabine 25 cephalexin 36hydrochlorothiazide 22 CAPEX 42bisoprolol fumarate 33 CETRAXAL 76

CAPRELSA 26BLEPH-10 73 CHANTIX 78

captopril 21 CHANTIX CONTINUINGBLEPHAMIDE 74 captopril amp MONTHPAK 78BLEPHAMIDE SOP 74 hydrochlorothiazide 22 CHANTIX STARTING MONTH BONIVA 46 CARAC 41 PAK 78 BP CLEANSING WASH 39 CARAFATE 80 chlordiazepoxide hcl 8 BRAFTOVI 26 CARBAGLU 46 chlordiazepoxide hcl-clidinium

bromide 79BREO ELLIPTA 10 carbamazepine 12 chlorhexidine gluconate (mouth-BREVICON-28 36 CARBATROL 12 throat) 69 BRILINTA 50 carbidopa-levodopa 27 CHLOROQUINE brimonidine tartrate 73 carbidopa-levodopa- PHOSPHATE 24

entacapone 27 chloroquine phosphate 24BROMFENAC 75 CARBIDOPALEVODOPAENT chlorpromazine hcl 29bromfenac sodium (ophth) 75 ACAPONE 27 chlorpropamide 18bromocriptine mesylate 27 carbinoxamine maleate 19 chlorthalidone 46budesonide 38 CARDIZEM 34 cholestyramine 19budesonide (inhalation) 10 CARDIZEM CD 34 cholestyramine light 19BULLSEYE MINI SAFETY CARDIZEM LA 34

LANCETS 54 choline amp mag salicylate 4CARDURA 22BULLSEYE SAFETY choline fenofibrate 20LANCETS 54 CAREONE LANCET THIN 54

CIALIS 35bumetanide 45 CAREONE LANCET ULTRA THIN 55 ciclopirox 41BUMEX 45 CARETOUCH TWIST ciclopirox olamine 41buprenorphine hcl 6 LANCETS 28G 55 cilostazol 50buprenorphine hcl-naloxone hcl CARETOUCH TWIST

dihydrate 6 LANCETS 30G 55 CILOXAN 73 bupropion hcl 14 CARETOUCH TWIST CIMDUO 30 bupropion hcl (smoking LANCETS 33G 55 cimetidine 79 deterrent) 78 carisoprodol 72 CIMETIDINE HCL 79buspirone hcl 8 carisoprodol w aspirin 72 CIPRO 48butalbital-acetaminophen- carvedilol 33 CIPRODEX 76caffeine 4 CASODEX 25butalbital-aspirin-caffeine 4 ciprofloxacin 48

CATAPRES 22cabergoline 47 CIPROFLOXACIN ER 48 CAYA 53CABOMETYX 26 CIPROFLOXACIN HCL 48 cefaclor 36CAFERGOT 67 ciprofloxacin hcl 48 CEFACLOR 36caffeine citrate 1 ciprofloxacin hcl (ophth) 73 cefaclor 36CALAN 34 ciprofloxacin hcl (otic) 76 cefadroxil 35CALAN SR 34 citalopram hydrobromide 14 cefdinir 36calcipotriene 41 CITRANATAL 90 DHA 70 cefixime 36calcitonin (salmon) 46 CITRANATAL ASSURE 70 cefpodoxime proxetil 36calcitriol 46 CITRANATAL BLOOM DHA 70 cefprozil 36calcitriol (topical) 41 CITRANATAL DHA 70 CEFTINcalcium acetate (phosphate 36 CITRANATAL RX 70

binder) 49 cefuroxime axetil 36 CLARITHROMYCIN 53 CANASA 48 CELEXA 14 clarithromycincandesartan cilexetil 21 CELLCEPT 68

Index 3

53

CLEANLET LANCETS 28G 55 COLCRYS 50 CVS LANCETS ULTRA-THIN30G 55CLEMASTINE FUMARATE 19 COLESTID 19 CVS ULTRA THIN

CLENPIQ 51 COLESTID FLAVORED 19 LANCETS 55 CLEOCIN 781 colestipol hcl 19 CYCLESSA 36 CLEOCIN-T 39 COLYTE-FLAVOR PACKS51 cyclobenzaprine hcl 72 CLEVER CHEK LANCETS COMBIVIR 30 CYCLOGYL 73ULTRATHIN 55 COMETRIQ 26 cyclopentolate hcl 73CLEVER CHEK LANCETS COMFORT ASSUREDULTRATHIN 30G 55 cyclophosphamide 24

LANCETS MICRO THINCLEVER CHOICE COMFORT CYCLOPHOSPHAMIDE 2433G 55EZLANCETS 21G 55 COMFORT ASSURED cyclosporine 69CLEVER CHOICE COMFORT LANCETS SUPER THIN CYCLOSPORINEEZLANCETS 23G 55 28G 55 MODIFIED 69CLEVER CHOICE COMFORT COMFORT LANCETS 55 cyclosporine modified (forEZLANCETS 28G 55 microemulsion) 69CLIMARA 47 COMPLERA 30 CYMBALTA 15

CLIMARA PRO 47 COMPLETENATE 70 cyproheptadine hcl 19CLINDAGEL 39 CONCEPT DHA 70 CYSTAGON 50clindamycin hcl 7 CONCEPT OB 70 CYSTARAN 75CLINDAMYCIN CONCERTA 12 CYTOMEL 79PHOSPHATE 39 CONDYLOX 44clindamycin phosphate CYTOTEC 80CONTRAVE 1(topical) 39 D-PENAMINE 68clindamycin phosphate COPEGUS 32 DAKLINZA 32vaginal 81 COREG 33clindamycin phosphate-benzoyl dalfampridine 77CORGARD 33peroxide (refrigerate) 40 danazol 6CORTANE-B-OTIC 76clobetasol propionate 42 DANTRIUM 72 clobetasol propionate emollient CORTEF 38 dantrolene sodium 72base 42 CORTENEMA 7 dapsone 7CLOBEX 42 CORTIFOAM 7 DAYPRO 3CLOMIPHENE CITRATE 46 cortisone acetate 38 DDAVP 47clomiphene citrate 46 COSOPT 73 DELSTRIGO 30clomipramine hcl 15 COTELLIC 26 DEMADEX 45clonazepam 11 COUMADIN 11 demeclocycline hcl 78clonidine hcl 22 COZAAR 21 DEMEROL 4clopidogrel bisulfate 50 CREON 45 DEPAKENE 14clorazepate dipotassium 8 CRESTOR 20 DEPAKOTE 14clotrimazole 69 CRINONE 81 DEPAKOTE ER 14clotrimazole (topical) 41 CRIXIVAN 30 clotrimazole w DEPAKOTE SPRINKLES 14cromolyn sodium 9betamethasone 41 DEPEN TITRATABS 68cromolyn sodium (ophth) 75clozapine 29 DERMA-SMOOTHEFS

CUVPOSA 79 BODY 42CLOZARIL 29 CVS LANCETS 21G 55 DERMA-SMOOTHEFSCOAGUCHEK LANCETS 55 CVS LANCETS MICRO THIN SCALP 42

COARTEM 24 33G 55 DERMATOP 42 codeine sulfate 4 CVS LANCETS MICRO-THIN DESCOVY 30 CODEINE SULFATE 4 33G 55 desipramine hcl 15CVS LANCETS ORIGINAL55COLAZAL 48 desmopressin acetate 47CVS LANCETS THIN 26G 55colchicine 50 desmopressin acetate spray 47CVS LANCETS ULTRA THINcolchicine w probenecid 50 30G 55

Index 4

desmopressin acetate sprayrefrigerated 47 DESOGEN 36 desogestrel amp ethinylestradiol 36

DIPROLENE DIPROLENE AF dipyridamole disopyramide phosphate

43 43 50 9

DULCOLAX DULERA duloxetine hcl DURAGESIC

52 11 15 4

desogestrel-ethinyl estradiol(biphasic) 36 desogestrel-ethinyl estradiol(triphasic) 36 desonide 42

disulfiram DITROPAN XL divalproex sodium dofetilide

77 80 14 9

dutasteride dutasteride-tamsulosin hcl DYAZIDE E-Z JECT LANCETS

50 50 45 56

DESOWEN 42 DOLOPHINE 4 E-Z JECT LANCETS 21G 55

desoximetasone 43 desvenlafaxine succinate 15 DETROL 80 DETROL LA 80 dexamethasone 38 DEXAMETHASONE INTENSOL 38 DEXAMETHASONE SODIUM PHOSPHATE 74 DEXEDRINE 1 dexmethylphenidate hcl 2 dextroamphetamine sulfate 1 DIAMOX 45 DIATHRIVE LANCETS 55 DIATHRIVE LANCETS ULTRA THIN 30G 55 diazepam 8 DIBENZYLINE 21 diclofenac sodium 3 diclofenac sodium (ophth) 75 diclofenac sodium (topical) 40 dicloxacillin sodium 76 dicyclomine hcl 79 didanosine 30 DIFFERIN 40

donepezil hydrochloride 77 dorzolamide hcl 75 DORZOLAMIDE HCL 75 dorzolamide hcl-timolol maleate 73 DORZOLAMIDE HCLTIMOLOL MALEATE 73 DOTHELLE DHA 70 DOVONEX 41 doxazosin mesylate 22 doxepin hcl 15 DOXEPIN HCL 15 doxepin hcl 15 doxycycline (monohydrate)78 doxycycline hyclate 78 DRISDOL 81 DROPLET INSULIN SYRINGE U-1001ML31G X 1564 67 DROPLET INSULIN SYRINGEU-1001ML31G X1564 67 DROPLET LANCETS ULTRA THIN 30G 55 drospirenone-ethinylestradiol 36 drospirenone-ethinyl estradiol-levomefolate calcium 36

E-Z JECT LANCETS COLOR 55 E-Z JECT LANCETS SUPER THIN 30G 56 E-Z JECT LANCETS THIN 26G 56 E-ZJECT LANCETS MICRO-THIN 33G 56 EES GRANULES 53 EASY COMFORT LANCETS56 EASY COMFORT LANCETS 30GPULL TOP 56 EASY COMFORT LANCETS 30GTHIN TOP 56 EASY COMFORT LANCETS TWIST TOP 56 EASY TOUCH FLIPLOCK NEEDLES 30GX12 67 EASY TOUCH HYPODERMIC NEEDLES 30GX12 67 EASY TOUCH LANCETS 21GPRESSUREACTIVATED 56 EASY TOUCH LANCETS 23GPRESSUREACTIVATED 56 EASY TOUCH LANCETS 26GPRESSUREACTIVATED 56 EASY TOUCH LANCETS

diflorasone diacetate DIFLUCAN digoxin

43 19 35

DROXIA 50 DRUG MART LANCETS THIN 55 DRUG MART ON-THE-GO

26GPULL-TOPEASY TOUCH LANCETS 26GTWISTEASY TOUCH LANCETS

56

DILANTIN DILANTIN INFATABS DILANTIN-125 DILAUDID

13 13 13 4

LANCETS GENTLE 30G DRUG MART UNILET LANCETSSUPER THIN 30G DRUG MART UNILET

55

28GPRESSUREACTIVATED EASY TOUCH LANCETS 28GPULL-TOPEASY TOUCH LANCETS

56

diltiazem hcl 34 diltiazem hcl coated beads 34 diltiazem hcl extended release beads 34 DIOVAN 21 DIOVAN HCT 22 diphenoxylate w atropine 18

LANCETSULTRA THIN 28G 55 DRUG MART UNILET MICRO THIN LANCETS 33G 55 DRYSOL 44 DUAC 40 DUETACT 16

28GTWISTEASY TOUCH LANCETS 30GBUTTON-ACTIVATEDEASY TOUCH LANCETS 30GPRESSUREACTIVATED EASY TOUCH LANCETS 30GPULL-TOP

56

Index 5

EASY TOUCH LANCETS 30GTWISTEASY TOUCH LANCETS 32GPRESSUREACTIVATED EASY TOUCH LANCETS 32GPULL-TOPEASY TOUCH LANCETS 32GTWISTEASY TOUCH LANCETS 33GTWISTEASY TOUCH SAFETY LANCETS21GPRESSUREACTIVATED EASY TOUCH SAFETY LANCETS23GPRESSUREACTIVATED

56

enalapril maleate 21 enalapril maleate amphydrochlorothiazide 22 ENBREL 4 ENBREL MINI 4 ENBREL SURECLICK 4 entecavir 32 ENTOCORT EC 38 EPCLUSA 32 epinastine hcl (ophth) 75 epinephrine (anaphylaxis) 81 EPIVIR 30 EPROSARTAN MESYLATE 21

etodolac 3 etoposide 27 EVISTA 46 EVOTAZ 30 EXALGO 4 EXELON 77 exemestane 25 EXFORGE 22 EXFORGE HCT 22 EZ SMART BLOOD GLUCOSE LANCETS 57 EZ-LETS LANCETS 21G 57 EZ-LETS LANCETS 23G 57 EZ-LETS LANCETS 26G

EASY TOUCH SAFETY EPZICOM 30 SUPER-SOFT 57 LANCETS26GBUTTONACTIVATED 56

EQL COLOR LANCETS 21G 57

EZ-LETS LANCETS 28G ULTRA-SOFT 57

EASY TOUCH SAFETY LANCETS26GPRESSUREACTIVATED EASY TOUCH SAFETY

56

EQL COLOR LANCETS MICRO THIN 33G 57 EQL SUPER THIN LANCETS 30G 57

EZ-LETS LANCETS 30G ezetimibe ezetimibe-simvastatin

57 20 19

LANCETS28GBUTTONACTIVATED 56 EASY TOUCH SAFETY LANCETS28GPRESSUREACTIVATED 56 EASY TWIST amp CAP LANCETS 56 EASYTEST II LANCETS 56 EASYTEST LANCETS 57 econazole nitrate 41 EDURANT 30 efavirenz 30 EFFERVESCENT POTASSIUMCHLORIDE 68 EFFEXOR XR 15 EFFIENT 50 EFUDEX 41 ELAVIL 15 ELDEPRYL 28 ELESTAT 75 ELIMITE 44 ELIPHOS 49 ELIQUIS 11 ELIQUIS STARTER PACK 11 ELLA 38 ELOCON 43 EMBRACE LANCETS ULTRA THIN 30G 57 EMCYT 25 EMTRIVA 30

EQL THIN LANCETS 26G 57 ergocalciferol 81 ERGOMAR 67 ergotamine w caffeine 67 ERIVEDGE 25 ERY-TAB 53 ERYGEL 40 ERYPED 200 53 ERYPED 400 53 erythromycin (acne aid) 40 erythromycin (ophth) 73 erythromycin base 53 erythromycinethylsuccinate 53 erythromycin stearate 53 escitalopram oxalate 14 ESGIC 4 estazolam 51 ESTRACE 47 estradiol 47 estradiol amp norethindrone acetate 47 estradiol vaginal 81 ESTROPIPATE 47 estropipate 47 ethambutol hcl 24 ethosuximide 13 ethynodiol diacet amp ethestrad 36

famciclovir 32 famotidine 79 FARESTON 25 FARYDAK 26 felbamate 13 FELBATOL 13 FELDENE 3 felodipine 34 FEM PH 81 FEMARA 25 FEMHRT LOW DOSE 47 fenofibrate 20 FENOFIBRATE 20 fenofibrate 20 fenofibrate micronized 20 FENOPROFEN CALCIUM 3 FENORTHO 3 fentanyl 5 FIFTY50 SAFETY SEAL LANCETS 30G 57 FIFTY50 SAFETY SEAL LANCETS 32G 57 FIFTY50 UNILET LANCETS 33G 57 FINACEA 44 finasteride 50 FINE 30 57 FINGERSTIX LANCETS 57 FIORINAL 4

Index 6

FLAGYL 7 FOLIVANE-F 51 GENTLE-LET LANCETS FLAREX flavoxate hcl

74 81

FOLIVANE-OB FORA LANCETS

70 57

SAFETY STYLEFINEPOINT GENTLE-LET LANCETS

57

flecainide acetate FLOMAX

9 50

FORTESTA FOSAMAX

6 46

SAFETY STYLEMEDIUMPOINT 57

FLONASE ALLERGY RELIEF 72 FLONASE ALLERGY RELIEF CHILDRENS 72 FLORIVA PLUS 69 FLOVENT DISKUS 10 FLOVENT HFA 10 FLOXIN OTIC 76 fluconazole 19 fludrocortisone acetate 38 FLUMADINE 33 fluocinolone acetonide 43 fluocinonide 43 fluocinonide emulsified base 43 FLUORABON 68

fosamprenavir calcium 30 fosinopril sodium 21 fosinopril sodium amphydrochlorothiazide 23 FOSRENOL 49 FREDS PHARMACY UNILET LANCETS SUPER THIN 30G 57 FREDS PHARMACY UNILET LANCETS ULTRA THIN 28G 57 FREESTYLE INSULINX BLOODGLUCOSE TEST 44 FREESTYLE INSULINX BLOODGLUCOSE TEST STRIPS 44 FREESTYLE LANCETS 57

GENVOYA GEODON GILENYA GILOTRIF GLEEVEC GLEOSTINE glimepiride glipizide glipizide-metformin hcl GLOBAL INJECT EASE LANCETS 28G GLOBAL INJECT EASE LANCETS 30G GLUCOCOM LANCETS 28G GLUCOCOM LANCETS

30 28 77 26 26 25 18 18 16

57

fluorometholone (ophth) FLUOROPLEX FLUOROURACIL fluorouracil (topical) FLUOXETINE fluoxetine hcl fluphenazine hcl FLURA-DROPS flurazepam hcl flurbiprofen flurbiprofen sodium flutamide fluticasone propionate fluticasone propionate(nasal)FLUTICASONE

74 41 41 41 78 14 29 68 51 3

75 25 43

72

FREESTYLE LITE TEST STRIPS 45 FREESTYLE TEST STRIPS 45 FREESTYLE UNISTICK II LANCETS 57 FURADANTIN 80 furosemide 46 gabapentin 12 galantamine hydrobromide 77 GALANTAMINE HYDROBROMIDE 77 galantamine hydrobromide 77 gatifloxacin (ophth) 73 gemfibrozil 20 GENERESS FE 36 GENTAK 73

30G 58 GLUCOCOM LANCETS 33G 58 GLUCOPHAGE 16 GLUCOPHAGE XR 16 GLUCOSOURCE LANCETS 58 GLUCOTROL 18 GLUCOTROL XL 18 GLUCOVANCE 16 glyburide 18 glyburide micronized 18 glyburide-metformin 16 glycopyrrolate 79 GLYNASE 18 GLYXAMBI 16 GNP LANCETS 58

PROPIONATESALMETEROL11

fluticasone-salmeterol 11 fluvastatin sodium 20 fluvoxamine maleate 14 FML 74 FML FORTE 74 FML LIQUIFILM 74 FOCALGIN 90 DHA 70 FOCALGIN CA 70 FOCALIN 2

gentamicin sulfate (ophth) 73 gentamicin sulfate (topical) 40 GENTEEL BUTTERFLY TOUCH LANCETS 57 GENTLE-LET GP LANCETS 57 GENTLE-LET LANCETS GENERAL PURPOSE STYLEFINE POINT 57 GENTLE-LET LANCETS GENERAL PURPOSE STYLEMEDIUM POINT 57

GNP LANCETS 21G 58 GNP LANCETS MICRO THIN 33G 58 GNP LANCETS SUPER THIN 30G 58 GNP LANCETS THIN 58 GNP LANCETS THIN 26G 58 GNP MICRO THIN LANCETS 33G 58 GNP SUPER THIN LANCETS30G 58 GOLYTELY 51

folic acid 51

Index 7

GOODSENSE COLOR homatropine hbr 73 hydroxyzine pamoate 8 LANCETS MICRO-THIN 33G HUMALOG 17 HYPODERMIC NEEDLEUNIVERSAL 58 30GX12 67HUMALOG JUNIORGOODSENSE LANCETS KWIKPEN 16 HYZAAR 23MICRO-THIN 33G 58 HUMALOG KWIKPEN 17 ibandronate sodium 46GOODSENSE LANCETS MICRO-THIN 33G HUMALOG MIX 5050 17 IBRANCE 26 UNIVERSAL 58 HUMALOG MIX 5050 ibuprofen 3GOODSENSE LANCETS KWIKPEN 17 IDHIFA 26ULTRA-THIN 26G HUMALOG MIX 7525 17 UNIVERSAL 58 imatinib mesylate 26HUMALOG MIX 7525GOODSENSE LANCETS IMBRUVICA 26KWIKPEN 17ULTRA-THIN 30G 58 HUMIRA 3 imipramine hcl 15GOODSENSE LANCETS HUMIRA PEDIATRIC CROHNS imiquimod 44ULTRA-THIN 30G DISEASE STARTER PACK 2UNIVERSAL 58 IMITREX 67

HUMIRA PEN 2GRIS-PEG 18 IMPAVIDO 7HUMIRA PEN-CDUCHSgriseofulvin microsize 18 IMURAN 69STARTER 2 griseofulvin ultramicrosize 18 HUMIRA PEN-PSUV IN TOUCH STERILE

LANCETS30G 58guaifenesin-codeine 38 STARTER 2 HUMULIN 7030 17 INCRUSE ELLIPTA 9guanfacine hcl 22 HUMULIN 7030 indapamide 46guanfacine hcl (adhd) 1 KWIKPEN 17 INDERAL LA 33H-E-B INCONTROL LANCETS HUMULIN N 17MICRO THIN 33G 58 INDOCIN 3

H-E-B INCONTROL LANCETS HUMULIN N KWIKPEN 17 indomethacin 3 SUPER THIN 30G 58 HUMULIN R 17 INSULIN SYRINGES AND PENH-E-B INCONTROL LANCETS HUMULIN R U-500 NEEDLES 67ULTRA THIN 28G 58 (CONCENTRATED) 17 INTEGRA F 51HAEMOLANCE 58 HUMULIN R U-500 INTELENCE 30HAEMOLANCE LOW FLOW KWIKPEN 17

INTUNIV 1LANCETS 58 HY-VEE LANCETS 58 HAEMOLANCE PLUS 58 INVIRASE 30HY-VEE THIN LANCETS 58 HAEMOLANCE PLUS HIGH INVOKAMET 16HYCAMTIN 27FLOW 58 INVOKAMET XR 16HAEMOLANCE PLUS LOW hydralazine hcl 23

INVOKANA 17FLOW 58 HYDREA 27 HAEMOLANCE PLUS MAX ipratropium bromide 9hydrochlorothiazide 46FLOW 58 hydrocodone polistirex- ipratropium bromide (nasal) 72HAEMOLANCE PLUS chlorpheniramine polistirex 39 ipratropium-albuterol 11PEDIATRIC FLOW 58 hydrocodone w irbesartan 21HALCION 51 homatropine 38 irbesartan-hydrochlorothiazidehalobetasol propionate 43 hydrocodone-haloperidol 29 acetaminophen 56 23

IRESSA 26hydrocodone-ibuprofen 6haloperidol lactate 29 ISENTRESS 30hydrocortisone 38HARVONI 32 ISENTRESS HD 30HEALTHWISE LANCETS hydrocortisone (intrarectal) 7

isoniazid 2430G 58 hydrocortisone (rectal) 7 HEALTHY ACCENTS UNILET ISOPTO ATROPINE 73hydrocortisone (topical) 43LANCETS SUPER THIN ISOPTO CARPINE 73hydrocortisone butyrate 4330G 58 ISORDIL TITRADOSE 8HEMANGEOL 33 hydromorphone hcl 5

ISOSORBIDE DINITRATE 8HEMENATAL OB + DHA 70 hydroxychloroquine sulfate 24

isosorbide dinitrate 8HEPSERA 32 hydroxyurea 27

ISOSORBIDE DINITRATE ER8HEXALEN 25 hydroxyzine hcl 8

isosorbide mononitrate 8

Index 8

isotretinoin 40 KROGER LANCETS SUPER LANCETS TWIST TOP 59 ISTALOL itraconazole IXINITY JADENU JAKAFI JALYN JANUMET JANUMET XR JANUVIA JARDIANCE JENTADUETO

73 19 50 18 26 50 16 16 16 18 16

THIN 59 KROGER LANCETS THIN 59 KROGER LANCETS THIN 26G 59 KROGER LANCETS ULTRATHIN30G 59 KUVAN 47 labetalol hcl 33 lactulose 52 lactulose (encephalopathy)49 LAMICTAL 12 LAMICTAL CHEWABLE DISPERSIBLE 12

LANCETS ULTRA FINE LANCETS ULTRA THIN LANCETS ULTRA THIN 30G LANCETSBULLSEYE SAFETY LANOXIN lansoprazole lanthanum carbonate LANTUS LANTUS SOLOSTAR LASIX

59 59

59

59 35 80 49 17 17 46

JENTADUETO XR JULUCA K-PHOS K-PHOS NEUTRAL K-PHOS NO 2 K-TAB KADIAN KALETRA KAYEXALATE KEFLEX KENALOG KEPPRA KEPPRA XR KETOCARE ketoconazole

16 30 68 68 49 68 5

30 69 36 43 12 12 45 19

LAMICTAL ODT 12 LAMICTAL STARTERNOTTAKING CARBAMAZEPINE 12 LAMICTAL STARTERTAKINGCARBAMAZEPINENOTTAKING VALPROATE 12 LAMICTAL STARTERTAKINGVALPROATE 12 LAMISIL 18 LAMISIL AT SPRAY 41 lamivudine 30 lamivudine-zidovudine 30 lamotrigine 12 LANCETS 59 LANCETS 26G TWIST TOP 59

latanoprost 75 LATANOPROST 75 LEDIPASVIRSOFOSBUVIR

32 leflunomide 4 LENVIMA 10 MG DAILY DOSE 26 LENVIMA 14 MG DAILY DOSE 26 LENVIMA 18 MG DAILY DOSE 26 LENVIMA 20 MG DAILY DOSE 26 LENVIMA 24 MG DAILY DOSE 26 LENVIMA 8 MG DAILY DOSE 26 LESCOL XL 20

ketoconazole (topical) 41 LANCETS 28G 59 LETAIRIS 35 ketoprofen KETOPROFEN

3 3

LANCETS 30G LANCETS 30G TWIST

59 letrozole leucovorin calcium

25 27

ketorolac tromethamine 3 ketorolac tromethamine (ophth) 75 KETOSTIX 45 KEVZARA 3 KINNEY LANCETS 59 KINNEY THIN LANCETS 59 KITABIS PAK 2 KLARON 40 KLONOPIN 11 KLOR-CON M15 68 KLOR-CON25 68 KROGER LANCETS 59 KROGER LANCETS 21G 59 KROGER LANCETS MICRO THIN33G 59

TOP 59 LANCETS 30GTWISTTOP 59 LANCETS 31G TWIST TOP 59 LANCETS 33G UNIVERSAL DESIGN 59 LANCETS MICRO THIN 33G 59 LANCETS SAFETY SEAL 21G 59 LANCETS SAFETY SEAL 26G 59 LANCETS SAFETY SEAL 28G 59 LANCETS SAFETY SEAL 30G 59 LANCETS SUPER THIN 28G 59 LANCETS THIN 59

LEUKERAN 25 levalbuterol hcl 11 levalbuterol tartrate 11 LEVAQUIN 48 LEVEMIR 17 LEVEMIR FLEXTOUCH 17 levetiracetam 12 LEVITRA 35 levobunolol hcl 73 levofloxacin 48 levonorgestrel amp ethestradiol 36 levonorgestrel (emergencyoc) 38 levonorgestrel-eth estradiol(triphasic) 36 levonorgestrel-ethinyl estradiol(91-day) 36

Index 9

levonorgestrel-ethinyl estradiol(continuous) 36 levothyroxine sodium 79 LEXAPRO 15 LEXIVA 30 LIALDA 48 LIBERTY MEDICAL LANCETS 30G 59 LIBRAX 79 lidocaine 44 lidocaine hcl 44 lidocaine hcl (mouth-throat) 69 LIDODERM 44 LIFESCAN UNISTIK 2 DEEP PENETRATION 59 LIFESCAN UNISTIK II LANCETS 59 linezolid 7 LINZESS 49 liothyronine sodium 79 LIPITOR 20 lisinopril 21 lisinopril amphydrochlorothiazide 23 LITE TOUCH LANCETS 60 LITETOUCH LANCETS MICRO THIN 33G 60 LITHIUM 28 lithium carbonate 28 LITHOBID 28 LIVE BETTER LANCET SUPERTHIN 30G 60 LIVE BETTER LANCET

lopinavir-ritonavir LOPRESSOR LOPRESSOR HCT LOPROX LOPROX SHAMPOO lorazepam losartan potassium losartan potassium amphydrochlorothiazide LOSEASONIQUE LOTENSIN LOTENSIN HCT LOTREL LOTRISONE lovastatin LOVAZA loxapine succinate LOZI-FLUR LUMIGAN LURIDE LYNPARZA LYSODREN LYSTEDA M-NATAL PLUS M-VIT MACROBID MACRODANTIN MALARONE maprotiline hcl MARNATAL-F

30 33 23 41 41 8

21

23 37 21 23 23 41 20 19 29 68 75 68 26 25 51 70 70 80 80 24 14 70

MEDICHOICE PRE-SET SAFETY LANCET MODERATE FLOW 60 MEDICHOICE SAFETY LANCETEXTRA 60 MEDICHOICE SAFETY LANCETNORMAL 60 MEDISENSE THIN LANCETS 60 MEDLANCE PLUS EXTRA LANCETS 21G 60 MEDLANCE PLUS LANCETS 60 MEDLANCE PLUS LANCETS LITE 25G 60 MEDLANCE PLUS LITE LANCETS 25G 60 MEDLANCE PLUS SPECIAL LANCETS 08MM 60 MEDLANCE PLUS SUPERLITE 30G 60 MEDLANCE PLUS SUPERLITE 30GCOMFORT MAX 60 MEDLANCE PLUS UNIVERSAL LANCETS 21G 60 MEDLANCE PLUSLITE25G 60 MEDLANCEEXTRA 60 MEDLANCELITE 60 MEDLANCEUNIVERSAL 60 MEDROL 38 MEDROL DOSEPAK 38 medroxyprogesterone acetate 77 MEFLOQUINE HCL 24 mefloquine hcl 24

ULTRATHIN 28G LOCOID LODINE LOESTRIN 1530-21 LOESTRIN 120-21 LOESTRIN FE 1530

60 43 3

36 36 37

MATULANE MAVYRET MAXALT MAXALT-MLT MAXIDEX MAXITROL

27 32 67 67 74 74

megestrol acetate MEIJER COLOR LANCETS UNIVERSAL 33G MEIJER LANCETS MEIJER LANCETS THIN MEIJER LANCETS UNIVERSAL21G

25

60 60 60

60 LOESTRIN FE 120 LOFIBRA LOMAIRA LOMOTIL LONGS LANCETS STANDARD LONGS LANCETS THIN LONGS LANCETS ULTRA THIN LONSURF LOPID

37 20 1

18

60 60

60 26 20

MAXZIDE 45 MAXZIDE-25 45 meclofenamate sodium 3 MEDICHOICE PRE-SET SAFETY LANCET DUAL USE 60 MEDICHOICE PRE-SET SAFETY LANCET LOW FLOW 60 MEDICHOICE PRE-SET SAFETY LANCET MEDIUM FLOW 60

MEIJER LANCETS UNIVERSAL30G MEIJER LANCETS UNIVERSAL33G MEIJER SUPER THIN LANCETS MEKINIST MEKTOVI meloxicam melphalan memantine hcl MENEST

60

61

61 26 26 3

25 77 47

Index 10

meperidine hcl MEPHYTON MEPRON mercaptopurine mesalamine MESTINON MESTINON TIMESPAN metaproterenol sulfate metformin hcl methadone hcl methazolamide methenamine mandelate methimazole METHITEST methocarbamol METHOTREXATE methotrexate sodium

5 81 7

25 49 24 24 11 16 5

45 80 79 6

72 3

25

MICARDIS 21 MICARDIS HCT 23 MICROLET LANCETS 61 MICROTAINER SAFETY FLOW LANCETSTERILESINGLE-USE 61 MICROZIDE 46 MIGERGOT 67 MILLIPRED 38 MINASTRIN 24 FE 37 MINIPRESS 22 MINIVELLE 48 MINOCIN 78 minocycline hcl 78 minoxidil 24 MIRALAX 52 MIRAPEX 2728

MPD SAFETY LANCET 28G18MM 61 MPD SAFETY LANCET 30G18MM 61 MPD SAFETY LANCETS 23G18MM 61 MS CONTIN 5 MUCINEX D 39 MULTAQ 9 MULTIVITAMINFLUORIDE 69 MUPIROCIN 41 mupirocin 41 mupirocin calcium (topical) 41 MUSE 35 MYAMBUTOL 24 MYCOBUTIN 24 mycophenolate mofetil 69 MYGLUCOHEALTH MGH SOFTLANCE LANCETS

methoxsalen rapid 41 MIRCETTE 37 30G 61 methscopolamine bromide 79 methyldopa 22 methyldopa amphydrochlorothiazide 23 methylergonovine maleate 76 METHYLIN 2 methylphenidate hcl 2 methylprednisolone 38 METHYLTESTOSTERONE 6 methyltestosterone 6 metoclopramide hcl 48 metolazone 46 metoprolol amphydrochlorothiazide 23 metoprolol succinate 33 metoprolol tartrate 33 METOPROLOL TARTRATE 33 METOPROLOLHYDROCHLOROTHIAZIDE 23 METROCREAM 44 METROGEL 44 METROGEL-VAGINAL 81 METROLOTION 44 metronidazole 7 metronidazole (topical) 44 metronidazole vaginal 81 MEVACOR 20 MEXILETINE HCL 9 MIACALCIN 46

mirtazapine 14 misoprostol 80 MM TWIST LANCETS 61 MOBIC 3 MODERIBA 32 MODERIBA 1200 DOSE PACK 32 moexipril hcl 21 moexipril-hydrochlorothiazide

23 mometasone furoate 43 mometasone furoate (nasal) 72 MONODOX 78 MONOLET LANCETS 61 MONOLET OPD LANCETS 61 MONOLETTOR SAFETY LANCETS 61 montelukast sodium 9 morphine sulfate 5 MORPHINE SULFATE 5 morphine sulfate 5 MORPHINE SULFATE ER 5 MOVIPREP 52 MOXEZA 73 moxifloxacin hcl 48 moxifloxacin hcl (ophth) 74 MPD SAFETY LANCET 21G18MM 61

MYLERAN 25 MYNATAL ADVANCE 70 MYNATAL ULTRACAPLET 70 MYNATE 90 PLUS 70 MYSOLINE 12 nabumetone 3 nadolol 33 naltrexone hcl 18 NAMENDA 77 NAMENDA TITRATION PAK77 NAPROSYN 3 naproxen 34 naproxen sodium 3 naratriptan hcl 68 NARDIL 14 NASACORT ALLERGY 24HR 72 NASACORT ALLERGY 24HR CHILDRENS 72 NASONEX 72 NATACYN 74 NATAZIA 37 nateglinide 17 NATURE-THROID 79 NEBUPENT 7 NECON 1011-28 37 NEFAZODONE HCL 15 nefazodone hcl 15

Index 11

NEFAZODONE NITROSTAT 8 OBSTETRIX DHA 70 HYDROCHLORIDE 15 neomycin sulfate 2 neomycin-bacitracin zn-polymyxin 74 neomycin-polymy-dexameth 74 neomycin-polymyxin-hc(ophth) 74 neomycin-polymyxin-hc(otic) 76 NEOMYCINPOLYMYXINGRAMICIDIN 74 NEONATAL PLUS 70 NEORAL 69 NEOSPORIN 74 NEPTAZANE 45 NERLYNX 26 NESTABS DHA 70 NETGROUP LANCETS 61 NEURONTIN 12 nevirapine 30

NIVA-PLUS 70 nizatidine 79 NIZATIDINE 79 NORCO 6 norethin acet amp estrad-fe 37 norethindrone amp eth estradiol 37 norethindrone amp ethinylestradiol-fe 37 norethindrone amp mestranol 37 norethindrone (contraceptive) 38 norethindrone acet amp eth estra 37 norethindrone acetate 77 norethindrone acetate-ethinylestradiol 47 norethindrone-eth estradiol (triphasic) 37 norgestimate-ethinylestradiol 37

OBTREX DHA 70 OCUFLOX 74 ODOMZO 25 OFLOXACIN 48 ofloxacin (ophth) 74 ofloxacin (otic) 76 olanzapine 29 olmesartan medoxomil 21 olmesartan medoxomil-amlodipine-hydrochlorothiazide

23 olmesartan medoxomil-hydrochlorothiazide 23 olopatadine hcl 75 OLYSIO 32 omega-3-acid ethyl esters 19 omeprazole 80 OMNIFLEX DIAPHRAGM 53 OMNIPRED 74

NEXAVAR niacin (antihyperlipidemic) NIASPAN

26 20 21

norgestimate-ethinyl estradiol(triphasic) 37 norgestrel amp ethinylestradiol 37

ON CALL LANCETS ON CALL PLUS LANCETS ondansetron

61 61 18

NICODERM CQ 78 NORINYL 1+35 37 ondansetron hcl 18 NICORETTE 78 NICORETTE MINI 78 NICORETTE STARTER KIT 78 nicotine 78 nicotine polacrilex 78 NICOTINE TRANSDERMAL SYSTEM 78 NICOTROL INHALER 78 NICOTROL NS 78 nifedipine 34 NILANDRON 25 nilutamide 25 nimodipine 34 NINLARO 26 nisoldipine 34 NISOLDIPINE ER 34 NITRO-BID 8 NITRO-DUR 8 nitrofurantoin 80 nitrofurantoin macrocrystal 80 nitrofurantoin monohyd macro 80 nitroglycerin 8 NITROLINGUAL PUMPSPRAY 8

NORPACE 9 NORPACE CR 9 NORPRAMIN 15 nortriptyline hcl 1516 NORTRIPTYLINE HCL 16 NORVASC 34 NORVIR 31 NOVA SAFETY LANCETS 23G 61 NOVA SAFETY LANCETS 28G 61 NOVA SUREFLEX LANCETS 61 NUCYNTA 5 NUCYNTA ER 5 NULYTELYFLAVORPACKS 52 NUVARING 37 NUVIGIL 2 NYMALIZE 34 nystatin 18 nystatin (mouth-throat) 69 nystatin (topical) 41 nystatin-triamcinolone 41 O-CAL FA 70

ONETOUCH CLUB LANCETS FINE POINT 61 ONETOUCH COMBO PACK61 ONETOUCH DELICA LANCETS EXTRA FINE 33G 61 ONETOUCH DELICA LANCETS FINE 30G 61 ONETOUCH FINEPOINT LANCETS 61 ONETOUCH ULTRA BLUE 45 ONETOUCH ULTRASOFT LANCETS 61 ONETOUCH VERIO TEST STRIPS 45 OPANA ER (CRUSHRESISTANT) 5 ORAL SALINE LAXATIVE 52 orphenadrine citrate 72 ORTHO MICRONOR 38 ORTHO TRI-CYCLEN 37 ORTHO TRI-CYCLEN LO 37 ORTHO-CYCLEN 37 ORTHO-NOVUM 135 37 ORTHO-NOVUM 777 37 oseltamivir phosphate 33 OTEZLA 4

Index 12

OTICIN HC NR 76 PERFECT PRESSURE PNV PRENATAL PLUS OVACE PLUS WASH OVACE WASH OVCON-35 OXANDRIN oxandrolone oxaprozin

42 42 37 6 6 4

ACTIVATED SAFETY LANCETS 28G PERIDEX perindopril erbumine permethrin perphenazine PHARMACIST CHOICE

61 69 21 44 29

MULTIVITAMIN 70 PNV-VP-U 70 podofilox 44 POLY HUB NEEDLE30G X12 67 polyethylene glycol 3350 52 polymyxin b-trimethoprim 74

oxazepam 8 OXAZEPAM 8 oxcarbazepine 12 OXSORALEN ULTRA 41 oxybutynin chloride 81 oxycodone hcl 5 oxycodone w acetaminophen 6 OXYCODONEACETAMINOPHEN 6 OXYMORPHONE HYDROCHLORIDE ER 5 PAMELOR 16 pantoprazole sodium 80 paricalcitol 47 PARLODEL 28 PARNATE 14

ULTRA THIN LANCETS PHARMACIST CHOICE ULTRA THIN LANCETS 28G PHARMACIST CHOICE ULTRA THIN LANCETS 30G PHARMACIST CHOICE ULTRA THIN LANCETS 31G PHARMACIST CHOICE ULTRA THIN LANCETS 33G PHARMACY COUNTER LANCETS phenelzine sulfate phenobarbital phenoxybenzamine hcl

62

61

62

62 14 51 21

POLYTRIM 74 POMALYST 26 pot amp sod citrates wcitric ac 49 pot phosphate monobasic w sodphosphate dibasic ampmonobasic 68 potassium bicarb amp chloride 68 potassium bicarbonate 68 potassium chloride 68 POTASSIUM CHLORIDE ER 68 potassium chloridemicroencapsulated crystals er 68 potassium citrate(alkalinizer) 49 potassium citrate-citric acid 49

paromomycin sulfate paroxetine hcl PATADAY

2 15 75

phentermine hcl phenylephrine hcl (ophth) PHENYLHISTINE DH

1 74 39

POTIGA PR NATAL 400 PR NATAL 400 EC

12 70 70

PATANOL 75 PHENYTEK 13 PR NATAL 430 70

PAXIL 15 PAXIL CR 15 PC LANCETS SUPER THIN 30G 61 ped multivitamins wfl amp iron 70 PEDIAPRED 38 pediatric multivitamins wfl 69 pediatric vitamins acd fluoride ampiron 70 pediatric vitamins acd wfluoride 70 peg 3350-kcl-sod bicarb-sodchloride-sod sulfate 52 peg 3350-potassium chloride-sodbicarbonate-sod chloride 52 PENICILLIN V POTASSIUM 76 penicillin v potassium 76 pentoxifylline 50 PEPCID 80 PEPCID AC MAXIMUM STRENGTH 80 PERCOCET 6 PERFECT LANCETS 30G 61

phenytoin 13 phenytoin sodiumextended 13 PHOSPHOLINE IODIDE 73 phytonadione 81 PICATO 41 PIFELTRO 31 pilocarpine hcl 73 pilocarpine hcl (oral) 69 pindolol 33 pioglitazone hcl 16 pioglitazone hcl-glimepiride 16 pioglitazone hcl-metforminhcl 16 piroxicam 4 PLAN B ONE-STEP 38 PLAQUENIL 24 PLAVIX 50 PNV FOLIC ACID + IRON MULTIVITAMIN 70 PNV OB+DHA 70

PR NATAL 430 EC 70 PRADAXA 11 pramipexole dihydrochloride 28 pramoxine-hc-chloroxylenol 76 PRANDIN 17 prasugrel hcl 50 PRAVACHOL 20 pravastatin sodium 20 praziquantel 7 prazosin hcl 22 PRECISION THIN LANCETS 62 PRECISION THINS GP LANCET 62 PRECISION ULTRA LANCET 62 PRECISION XTRA BLOOD GLUCOSE TEST STRIPS 45 PRECOSE 16 PRED FORTE 74 PRED MILD 74 PREDNICARBATE 43

Index 13

prednicarbate 43 PRINIVIL 21 PSS SELECT SAFETY LANCETS 62PREDNISOLONE 38 PRISTIQ 15 PULMICORT 10prednisolone 38 PRO COMFORT LANCETS

30G 62 PULMICORT FLEXHALER 10prednisolone acetate (ophth) 74 PRO COMFORT LANCETS PULMOZYME 78PREDNISOLONE ACETATE P- 31G 62 PUSH BUTTON SAFETYF 74 prednisolone sodium PROAIR HFA 11 LANCETS 21G 62 phosphate 38 probenecid 50 PUSH BUTTON SAFETY

LANCETS 28G 62PREDNISOLONE SODIUM PROCARDIA 34 PHOSPHATE 74 PX LANCETS ULTRA THIN 62PROCARDIA XL 34prednisone 38 PX LANCETS ULTRA THIN

prochlorperazine 29 28G 62PREDNISONE 38 prochlorperazine maleate 29 pyrazinamide 24PREDNISONE INTENSOL 38 PROCTOFOAM HC 7 pyridostigmine bromide 24PREFERAOB +DHA 70 PROCYSBI 50 QC LANCETS SUPER THIN 62PREFERRED PLUS LANCETS PRODIGY PRESSURECOLORED 21G 62 QC LANCETS ULTRA THIN 62ACTIVATED SAFETYPREFERRED PLUS LANCETS QC UNILET LANCETSLANCETS 62SUPER THIN 30G 62 28GULTRA THIN 62PRODIGY SAFETYPREFERRED PLUS LANCETS QC UNILET LANCETSLANCETS 62THIN 26G 62 33GMICRO THIN 62PRODIGY TWIST TOPPREMARIN 4881 QSYMIA 1LANCETS 62

PREMPHASE 47 QUALAQUIN 24PROGRAF 69 PREMPRO 47 promethazine amp QUESTRAN 19 PRENA 1 TRUE 70 phenylephrine 39 QUESTRAN LIGHT 19 PRENATA 70 promethazine hcl 19 quetiapine fumarate 29 PRENATAL 71 promethazine wcodeine 39 QUFLORA FE PEDIATRIC 70 PRENATAL 19 71 promethazine-dm 39 QUFLORA GUMMIES 70

promethazine-phenylephrine-PRENATAL PLUS 71 QUFLORA PEDIATRIC 70codeine 39prenatal vit w docusate-iron quinapril hcl 21PROMETHAZINEPHENYLEPcarbonyl-folic acid 71 HRINE 39 quinapril-hydrochlorothiazidePRENATAL VITAMINS PLUS PROMETHAZINEPHENYLEP 23LOW IRON 71 HRINECODEINE 39 quinidine gluconate 9prenatal without a vit w fe propafenone hcl 9 QUINIDINE SULFATE 9fumarate-folic acid 71 PRENATAL-U 71 propantheline bromide 79 quinine sulfate 24

propranolol ampPRENATE DHA 71 QVAR 10hydrochlorothiazide 23PRENATE ELITE 71 QVAR REDIHALER 10propranolol hcl 33 RA E-ZJECT COLORPREPLUS 71 propylthiouracil 79 LANCETSMICRO-THIN 33G62PREPOPIK 52 PROSCAR 50 RA E-ZJECT LANCETS 28G62PRESSURE ACTIVATED PROTONIX 80 RA E-ZJECT LANCETS THINSAFETYLANCET 21G 62 26G 62PROTOPIC 44PREVACID 80 RA E-ZJECT LANCETS THINPROVERA 77PREVACID 24HR 80 28G 62

PREVPAC 80 PROVIDA DHA 71 RA E-ZJECT LANCETS PROVIDA OB 71 ULTRATHIN 30G 62PREZCOBIX 31

raloxifene hcl 46PROZAC 15PREZISTA 31 pseudoephedrine w codeine- ramipril 21PRIFTIN 24 gg 39 ranitidine hcl 80primaquine phosphate 24 pseudoephedrine-guaifenesin rasagiline mesylate 28PRIMAQUINE PHOSPHATE24 39 RAZADYNE 77primidone 12 PSS SELECT GP LANCETS 62 RAZADYNE ER 77

Index 14

READYLANCE SAFETY RIBASPHERE RIBAPAK 32 SAFETY LANCETS 63 LANCETS21G22MM 62 ribavirin (hepatitis c) 32 SAFETY LANCETS 21G 63READYLANCE SAFETY

RIDAURA 3 SAFETY LANCETS 28G 63LANCETS23G18MM 62 READYLANCE SAFETY rifabutin 24 SAFETY LET LANCETS 63 LANCETS26G18MM 63 RIFADIN 24 SAFETY SEAL LANCETS READYLANCE SAFETY 28G 63RIFAMATE 24LANCETS28G18MM 63 SAFETY SEAL LANCETS READYLANCE SAFETY rifampin 24 30G 63 LANCETS30G16MM 63 RIGHTEST GL300 SAFYRAL 37 REALITY LANCETS 63 LANCETS 63 SALAGEN 69REALITY TRIGGER rimantadine hydrochloride 33

SALEX 44LANCETS 63 risedronate sodium 46 REBETOL 32 salicylic acid 44RISPERDAL 29

salsalate 4RECTIV 7 RISPERDAL M-TAB 28 SANDIMMUNE 69REGIMEX 1 risperidone 29 SAPS HEALTH CARE TWISTREGLAN 48 RITALIN 2 TOP LANCETS 63RELION INSULIN SYRINGE ritonavir 31 SAPS HEALTH TWIST TOP1ML31GX1564 67 LANCETS 30G 63RELION INSULIN SYRINGEU- rivastigmine 77 SAPSCARE TWIST TOP1001ML31G X 1564 67 rivastigmine tartrate 77 LANCETS 30G 63RELION KETONE 45 RIXUBIS 50 SB LANCETS THIN 63RELION LANCETS MICRO- rizatriptan benzoate 68 SB LANCETS ULTRA THIN 63THIN33G 63 ROBAXIN 72RELION LANCETS STANDARD SE-NATAL 19 71

21G 63 ROBAXIN-750 72 SEASONIQUE 37 RELION LANCETS THIN ROBINUL 79 SELECT-OB 7126G 63 ROBINUL FORTE 79RELION LANCETS ULTRA- selegiline hcl 28

ROCALTROL 47THIN30G 63 selenium sulfide 42 RELION ULTRA THIN ropinirole hydrochloride 28 SELZENTRY 31LANCETS30G 63 rosuvastatin calcium 20 SEREVENT DISKUS 11RELION ULTRA THIN PLUS ROXICODONE 5LANCETS 32G 63 SEROQUEL 29 RELION ULTRA THIN PLUS RUBRACA 26 sertraline hcl 15 LANCETS 33G 63 RYDAPT 26 sevelamer carbonate 49REMERON 14 RYTHMOL SR 9 SFROWASA 49REMERON SOLTAB 14 SABRIL 13 SHOPKO ON-THE-GO RENVELA 49 SAFE-T-LANCE LOW FLOW COMFORTLANCETS 30G 64 repaglinide 17 25G 63 SHOPKO UNILET LANCETS

SAFE-T-LANCE NORMAL SUPER THIN 30G 64REPREXAIN 6 FLOW21G 63 SHOPKO UNILET LANCETSREQUIP 28 SAFE-T-LANCE PLUS ULTRA THIN 28G 64 REQUIP XL 28 SAFETYLANCET HIGH SIDE BUTTON SAFETY

FLOW 63 LANCET21G 64RESCRIPTOR 31 SAFE-T-LANCE PLUS sildenafil citrate 35RESTORIL 51 SAFETYLANCET LOW SILVADENE 42RETIN-A 40 FLOW 63 silver sulfadiazine 42RETIN-A MICRO 40 SAFE-T-LANCE PLUS SAFETYLANCET NORMAL simvastatin 20RETIN-A MICRO PUMP 40 FLOW 63 SINEMET 28RETROVIR 31 SAFETY LANCET SINEMET CR 28REVLIMID 68 21GPRESSURE

SINGLE-LET 64REXALL LANCETS ULTRA ACTIVATED 63 THIN 63 SAFETY LANCET SINGULAIR 9 REYATAZ 31 28GPRESSURE SIVEXTRO 8

ACTIVATED 63

Index 15

SM MICRO THIN LANCETS STRIBILD 31 SYNJARDY 16 33G 64 STRIVERDI RESPIMAT 11 SYNJARDY XR 16SMART SENSE COLOR

sucralfate 80 SYNTHROID 79LANCETS UNIVERSAL 33G 64 SMART SENSE STANDARD SULAR 34 TABLOID 25 LANCETS UNIVERSAL 21G 64 sulfacetamide sod- tacrolimus 69SMART SENSE SUPER THIN prednisolone 74 tacrolimus (topical) 44LANCETS UNIVERSAL 30G 64 sulfacetamide sodium 42SMART SENSE THIN tadalafil 35SULFACETAMIDELANCETSUNIVERSAL 26G 64 tadalafil (pulmonarySODIUM 74SMARTEST LANCETS 28G 64 hypertension) 35sulfacetamide sodium sodium citrate amp citric acid 49 (acne) 40 TAFINLAR 26

sulfacetamide sodium TAGRISSO 27sodium fluoride 68 (ophth) 74sodium phosphates 52 TAMIFLU 33SULFACETAMIDE

sodium polystyrene tamoxifen citrate 25SODIUMPREDNISOLONEsulfonate 69 SODIUM PHOSPHATE 75 tamsulosin hcl 50 SODIUM sulfamethoxazole- TAPAZOLE 79SULFACETAMIDESULFUR trimethoprim 7 TARCEVA 2740 sulfasalazine 49SOFOSBUVIRVELPATASVIR TARGRETIN 2741

sulindac 432 TARON-C DHA 71SOLUS V2 PRESSURE sumatriptan 68 TASIGNA 27ACTIVATED SAFETY LANCETS sumatriptan succinate 6828G 64 tazarotene 41

SUPER THIN LANCETS 64SOLUS V2 TWIST LANCETS TAZORAC 414230G 64 SUPRAX 36 TECFIDERA 77SOMA 72 SUPREP BOWEL PREP TECFIDERA STARTERKIT 52SONATA 51 PACK 78SURE COMFORT LANCETSsotalol hcl 34 TECHLITE AST LANCETS 6418G 64 sotalol hcl (afibafl) 33 SURE COMFORT LANCETS TECHLITE INSULIN SYRINGEU-

21G 64 1001ML31G X 1564 67SOTYLIZE 34 SURE COMFORT LANCETS TECHLITE LANCETS 64SOVALDI 32 23G 64 TECHLITE LANCETS 30G 64SPIRIVA HANDIHALER 9 SURE COMFORT LANCETS TECHNIVIE 32SPIRIVA RESPIMAT 9 28G 64 SURE COMFORT LANCETS TEGRETOL 13spironolactone 46 30G 64 TEGRETOL-XR 13spironolactone amp SURE-LANCE FLAThydrochlorothiazide 45 telmisartan 21LANCETS 64

SPORANOX 19 SURE-LANCE LANCETS telmisartan-amlodipine 23 SPORANOX PULSEPAK 19 26G 64 telmisartan-hydrochlorothiazide

SURE-LANCE THIN LANCETS 23SPRYCEL 26 28G 64 temazepam 51SSS 10-5 40 SURE-LANCE ULTRA THIN TEMODAR 25STALEVO 100 28 LANCETS 64 TEMOVATE 43SURE-TOUCH LANCETSSTALEVO 125 28 UNIVERSAL 64 TEMOVATE E 43STALEVO 150 28 SURELITE LANCETS 64 temozolomide 25STALEVO 50 28 SUSTIVA 31 tenofovir disoproxil fumarate 31STALEVO 75 28 SUTENT 26 TENORETIC 100 23STARLIX 17 SYMBICORT 11 TENORETIC 50 23stavudine 31 SYMDEKO 78 TENORMIN 33STERILANCE TL 64 SYMTUZA 31 TERAZOL 7 81STIOLTO RESPIMAT 11 SYNALAR 43 terazosin hcl 22STRATTERA 1 SYNAREL 46 terbinafine hcl 18

Index 16

terbutaline sulfate 11 tolazamide 18 TRICARE 71 TERCONAZOLE 81 tolbutamide 18 TRICARE PRENATAL 71 terconazole vaginal 81 TESSALON PERLES 38 TESTIM 6 testosterone 67 TESTRED 7 tetracycline hcl 78 TGT LANCET MICRO THIN

TOLMETIN SODIUM 4 tolmetin sodium 4 tolterodine tartrate 81 TOPAMAX 13 TOPAMAX SPRINKLE 13 TOPCARE LANCETS MICRO-THIN 33G 65

TRICARE PRENATAL DHA ONEFOLATE TRICOR TRIDESILON trifluoperazine hcl trifluridine TRIGLIDE

71 20 44 29 74 20

33G 64 TOPICORT 43 trihexyphenidyl hcl 27 TGT LANCET THIN 26G TGT LANCET ULTRA THIN

64 topiramate TOPROL XL

13 33

TRILEPTAL TRILIPIX

13 20

30G theophylline THERANATAL CORE NUTRITION THINLETS GP LANCETS THINLETS LANCET thioridazine hcl THIOTHIXENE thiothixene thyroid TIAZAC TIGAN TIKOSYN timolol maleate timolol maleate (ophth) TIMOLOL MALEATE OPHTHALMIC GEL FORMING TIMOPTIC TIMOPTIC-XE TIVICAY tizanidine hcl TOBI TOBI PODHALER

64 11

71 65 65 29 29 29 79 34 18 9

34 73

73 73 73 31 72 2 2

toremifene citrate torsemide TOUJEO MAX SOLOSTAR TOUJEO SOLOSTAR TOVIAZ TRACLEER TRADJENTA tramadol hcl trandolapril tranexamic acid TRANXENE T tranylcypromine sulfate TRAVATAN Z TRAVEL LANCETS 30G TRAVEL LANCETS ADVANCED 28G trazodone hcl TRECATOR TRELEGY ELLIPTA TRESIBA TRESIBA FLEXTOUCH tretinoin

25 46

17 17 81 35 16 5

21 51 8

14 75 65

65 15 24 11 17 17 40

trimethobenzamide hcl 18 trimethoprim 7 TRINATAL GT 71 TRIUMEQ 31 TRIVEEN-DUO DHA 71 TRIZIVIR 31 trospium chloride 81 TRUE COMFORT TWIST TOP LANCETS 30G 65 TRUEPLUS LANCETS 26G 65 TRUEPLUS LANCETS 28G 65 TRUEPLUS LANCETS 28G SUPER THIN 65 TRUEPLUS LANCETS 30G 65 TRUEPLUS LANCETS 30G ULTRA THIN 65 TRUEPLUS LANCETS 33G 65 TRUEPLUS LANCETS 33G MICRO THIN 65 TRUEPLUS SAFETY LANCETS 28G 65 TRUSOPT 75 TRUVADA 31 TUSSIONEX PENNKINETIC EXTENDED RELEASE 39

TOBRADEX 75 tretinoin (chemotherapy) 27 TWYNSTA 23 tobramycin TOBRAMYCIN

2 2

tretinoin microsphere TRI-NORINYL 28

40 37

TYBOST TYKERB

31 27

tobramycin (ophth) 74 tobramycin-dexamethasone 75 TOBREX 74 TODAY SPONGE 81 TODAYS HEALTH SUPER THINLANCETS 30G 65 TODAYS HEALTH ULTRA THINLANCETS 28G 65 TOFRANIL 16

TRI-TABS DHA triamcinolone acetonide (mouth)triamcinolone acetonide (nasal)triamcinolone acetonide (topical)triamterene amp hydrochlorothiazide triazolam

71

69

72

44

45 51

TYLENOLCODEINE 3 6 TYLENOLCODEINE 4 6 ULORIC 50 ULTICARE THIN LANCETS 30G 65 ULTILET CLASSIC LANCETS 65 ULTILET LANCETS 65 ULTILET LANCETS 33G 65

TOLAZAMIDE 18 TRIBENZOR 23

Index 17

ULTILET SAFETY LANCETS UNIVERSAL 1 LANCETS VERZENIO 27 21G X 22MM 65 ULTILET SAFETY LANCETS 23G 65 ULTRA THIN LANCETS

ULTRA THIN 30G 66 UNIVERSAL 1 LANCETS33GMICRO-THIN

66

VFEND VIAGRA VIBRAMYCIN

19 35 78

31G ULTRA-CARE LANCETS 30G ULTRA-THIN II AUTO

65

URECHOLINE UROCIT-K 10 UROCIT-K 15

81 49 49

VIDA MIA UNILET LANCETS SUPER THIN 30G 66 VIDA MIA UNILET LANCETS ULTRA THIN 28G 66

LANCET ULTRA-THIN II LANCETS 28G ULTRA-THIN II LANCETS

65

UROCIT-K 5 UROXATRAL URSO 250

49 50 48

VIDEX EC VIDEXPEDIATRIC VIEKIRA PAK

31 31 32

30G ULTRA-THIN II SAFETY AUTOLANCETS 26G ULTRAM ULTRAVATE UNILET COMFORTOUCH LANCET

65

65 5

44

65

URSO FORTE ursodiol VAGIFEM valacyclovir hcl VALCYTE valganciclovir hcl

48 48 81 32 32 32

VIEKIRA XR vigabatrin VIGAMOX VIMPAT VIRACEPT VIRAMUNE

32 13 74 13 31 31

UNILET EXCELITE 65 VALIUM 8 VIRAMUNE XR 31 UNILET EXCELITE II 65 valproate sodium 14 VIREAD 31 UNILET GP LANCET 65 valproic acid 14 VIROPTIC 74 UNILET GP SUPERLITE LANCET 66 UNILET GP 28 ULTRA THIN66 UNILET LANCET 66 UNILET LANCETS MICRO-

valsartan 2122 valsartan-hydrochlorothiazide

23 VALTREX 32 VALUE PLUS LANCETS

VIRT-ADVANCE VIRT-C DHA VIRT-VITE GT VISTARIL

71 71 71 8

THIN33G 66 STANDARD 21G 66 VITALET PRO LANCETS 66 UNILET LANCETS SUPER- VALUE PLUS LANCETS VITALET PRO PLUS THIN30G 66 SUPERTHIN 30G 66 LANCETS 66 UNILET LANCETS ULTRA-THIN 28G 66 UNILET SUPERLITE LANCET 66

VALUE PLUS LANCETS THIN 26G 66 VALUMARK LANCET SUPER THIN 30G 66

VITATRUE VIVELLE-DOT VOL-PLUS

71 48 71

UNISTIK 3 GENTLE 66 UNISTIK PRO SAFETY LANCET 21G 66 UNISTIK PRO SAFETY LANCET 25G 66 UNISTIK PRO SAFETY LANCET 28G 66 UNISTIK SAFETY LANCETS 28G 66 UNISTIK SAFETY LANCETS 30G 66 UNISTIK TOUCH SAFETY LANCETS 21G 66 UNISTIK TOUCH SAFETY LANCETS 23G 66 UNISTIK TOUCH SAFETY LANCETS 28G 66 UNISTIK TOUCH SAFETY LANCETS 30G 66 UNIVERSAL 1 LANCETS THIN26G 66

VALUMARK LANCET ULTRA THIN 28G 66 VANCOCIN HCL 7 vancomycin hcl 7 vardenafil hcl 35 VASERETIC 23 VASOTEC 21 VENA-BAL DHA 71 VENCLEXTA 25 VENCLEXTA STARTING PACK 25 venlafaxine hcl 15 VENTAVIS 35 VENTOLIN HFA 11 verapamil hcl 3435 VERAPAMIL HCL SR 34 VERELAN 35 VERELAN PM 35

VOLTAREN 40 voriconazole 19 VOSEVI 32 VOSPIRE ER 11 VOTRIENT 27 VP-HEME OB + DHA 71 VYTORIN 19 VYVANSE 1 WampF LANCETS 26G 66 WampF LANCETS COLORED 21G 66 WALGREENS ADVANCED TRAVELLANCETS 28G 66 WALGREENS COMFORT ASSUREDLANCETS MICRO THIN33G 67 WALGREENS COMFORT ASSUREDLANCETS SUPER THIN28G 67 WALGREENS LANCETS 67

Index 18

WALGREENS THIN LANCETS 67 WALGREENS ULTRA THIN LANCETS 67 warfarin sodium 11 WELLBUTRIN SR 14 WELLBUTRIN XL 14 WESTHROID 79 WP THYROID 79 XALATAN 75 XALKORI 27 XANAX 8 XARELTO 11 XARELTO STARTER PACK 11 XATMEP 25 XELJANZ 3 XELJANZ XR 3 XELODA 25 XENICAL 1 XODOL 6 XOPENEX 11 XOPENEX CONCENTRATE 11 XULANE 37 YASMIN 28 37 YAZ 37 zaleplon 51 ZANAFLEX 72 ZANTAC 80 ZANTAC 150 MAXIMUM STRENGTH 80 ZARONTIN 14 ZEBETA 33 ZEJULA 27 ZELBORAF 27 ZEMPLAR 47 ZENPEP 45 ZEPATIER 32 ZERIT 31 ZESTORETIC 23 ZESTRIL 21 ZETIA 20 ZIAC 23 ZIAGEN 31 zidovudine 31 ziprasidone hcl 28 ZITHROMAX 53 ZITHROMAX TRI-PAK 53

ZITHROMAX Z-PAK 53 ZMAX 53 ZOCOR 20 ZOFRAN 18 ZOFRAN ODT 18 ZOLINZA 27 ZOLOFT 15 zolpidem tartrate 51 ZONEGRAN 13 zonisamide 13 ZORTRESS 69 ZOVIRAX 3342 ZYBAN 78 ZYDELIG 27 ZYLOPRIM 50 ZYMAXID 74 ZYPREXA 29 ZYTIGA 2526 ZYVOX 8

Index 19

Classes
- ADHDANTI-NARCOLEPSYANTI-OBESITYANOREXIANTS - Drugs to Treat ADHD Sleep and Eating Disorders
- AMINOGLYCOSIDES - Drugs to Treat Bacterial Infections
- ANALGESICS - ANTI-INFLAMMATORY - Drugs to Treat Pain Swelling Muscle and Joint Conditions
- ANALGESICS - NonNarcotic - Drugs to Treat Pain Muscle and Joint Conditions
- ANALGESICS - OPIOID - Drugs to Treat Pain Muscle and Joint Conditions
- ANDROGENS-ANABOLIC - Drugs to Regulate Hormones
- ANORECTAL AGENTS - Rectal Drugs to Treat Pain Swelling and Itching
- ANTHELMINTICS - Drugs to Treat Worm Infections
- ANTI-INFECTIVE AGENTS - MISC - Drugs to Treat Bacterial Infections
- ANTIANGINAL AGENTS - Drugs to Treat Chest Pain
- ANTIANXIETY AGENTS - Drugs to Treat Anxiety
- ANTIARRHYTHMICS - Drugs to treat abnormal heart rhythms
- ANTIASTHMATIC AND BRONCHODILATOR AGENTS - Drugs to Treat Lung Conditions
- ANTICOAGULANTS - Blood Thinners
- ANTICONVULSANTS - Drugs to Treat Seizures
- ANTIDEPRESSANTS - Drugs to Treat Depression
- ANTIDIABETICS - Drugs to Regulate Blood Sugar
- ANTIDIARRHEALPROBIOTIC AGENTS - Drugs to Treat Diarrhea
- ANTIDOTES AND SPECIFIC ANTAGONISTS
- ANTIEMETICS - Drugs to Treat Nausea and Vomiting
- ANTIFUNGALS - Drugs to Treat Fungal Infections
- ANTIHISTAMINES - Drugs to Treat Allergies
- ANTIHYPERLIPIDEMICS - Drugs to Treat High Cholesterol
- ANTIHYPERTENSIVES - Drugs to Treat High Blood Pressure
- ANTIMALARIALS - Drugs to Treat Malaria (Parasitic Infections)
- ANTIMYASTHENICCHOLINERGIC AGENTS
- ANTIMYCOBACTERIAL AGENTS - Drugs to Treat Tuberculosis (Bacterial Infections)
- ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES - Drugs to Treat Cancer
- ANTIPARKINSON AND RELATED THERAPY AGENTS - Drugs to Treat Parkinsons Disease
- ANTIPSYCHOTICSANTIMANIC AGENTS - Drugs to Treat Mood Disorders
- ANTIVIRALS - Drugs to Treat Viral Infections
- BETA BLOCKERS - Drugs to Treat High Blood Pressure
- CALCIUM CHANNEL BLOCKERS - Drugs to Treat High Blood Pressure
- CARDIOTONICS - Drugs to Treat Heart Failure and Abnormal Heart Rhythm
- CARDIOVASCULAR AGENTS - MISC - Drugs to Treat Heart and Circulation Conditions
- CEPHALOSPORINS - Drugs to Treat Bacterial Infections
- CONTRACEPTIVES - Drugs to Prevent Pregnancy
- CORTICOSTEROIDS - Steroid Hormone Drugs to Treat Systemic Swelling Conditions
- COUGHCOLDALLERGY - Drugs to Treat Cough Cold and Allergy Symptoms
- DERMATOLOGICALS - Drugs to Treat Skin Conditions
- DIAGNOSTIC PRODUCTS
- DIGESTIVE AIDS - Drugs to Treat Low Digestive Enzymes
- DIURETICS - Drugs to Treat Heart Circulation Conditions and Blood Pressure
- ENDOCRINE AND METABOLIC AGENTS - MISC - Drugs to Treat Bone Disease and Regulate Hormones
- ESTROGENS - Hormone ReplacementModifying Drugs
- FLUOROQUINOLONES - Drugs to Treat Bacterial Infections
- GASTROINTESTINAL AGENTS - MISC - Miscellaneous Gastrointestinal Drugs
- GENITOURINARY AGENTS - MISCELLANEOUS - Miscellaneous Drugs to Treat Reproductive Organs and Urinary System
- GOUT AGENTS - Drugs to Treat Gout
- HEMATOLOGICAL AGENTS - MISC - Drugs to Treat Blood Disorders
- HEMATOPOIETIC AGENTS - Drugs to Treat Blood Disorders
- HEMOSTATICS - Drugs to Stop BleedingTreat Blood Disorders
- HYPNOTICSSEDATIVESSLEEP DISORDER AGENTS
- LAXATIVES - Bowel Treatment Drugs
- MACROLIDES - Drugs to Treat Bacterial Infections
- MEDICAL DEVICES AND SUPPLIES
- MIGRAINE PRODUCTS - Drugs to Treat Migraine Headaches
- MINERALS amp ELECTROLYTES
- MISCELLANEOUS THERAPEUTIC CLASSES
- MOUTHTHROATDENTAL AGENTS
- MULTIVITAMINS
- MUSCULOSKELETAL THERAPY AGENTS - Drugs to Treat Spasms
- NASAL AGENTS - SYSTEMIC AND TOPICAL - Drugs to treat the Nose or Sinus
- OPHTHALMIC AGENTS - Drugs to Treat the Eye
- OTIC AGENTS - Drugs to Treat the Ear
- OXYTOCICS - Drugs to PreventControl Uterine Bleeding
- PENICILLINS - Drugs to Treat Bacterial Infections
- PROGESTINS - Hormone ReplacementModifying Drugs
- PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC - Drugs to Treat Mental and Emotional Conditions
- RESPIRATORY AGENTS - MISC - Drugs to Treat Lung Conditions
- TETRACYCLINES - Drugs to Treat Bacterial Infections
- THYROID AGENTS - Drugs to Regulate Thyroid Hormones
- ULCER DRUGS - Drugs to Treat Bowel Intestine and Stomach Conditions
- URINARY ANTI-INFECTIVES - Drugs to Treat BladderKidney Infections
- URINARY ANTISPASMODICS - Drugs to Treat Miscellaneous Bladder Spasms
- VAGINAL PRODUCTS - Drugs to Treat Vaginal Infections and Low Hormones
- VASOPRESSORS - Drugs to Treat Heart and Circulation Conditions
- VITAMINS

Page 2: Health Net 2-Tier Recommended Drug List

Table of Contents

What If I Have Questions Regarding My Pharmacy Benefit helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellipii

What is the Drug List ii

How do I find a drug on the Drug Listii

How are the drugs listed in the categorical listii

How much will I pay for my drugs iii Tier description table

Are there any limits on my drug coverage iii Abbreviations table

How often does the Drug List changeiv

How can I get prior authorization or an exception to the rules for drug coverageiv

Are all contraceptives coveredv

What blood glucose supplies coveredvi

What drugs are under my medical benefitvi

Can I go to any pharmacyvi

Can I use a mail order pharmacyvi

How can I save money on my prescription drugs vi

Definitions vii

Categorical list of prescription drugs1

Alphabetical index of prescription drugsIndex 1

i

exceptions

Safety

Effectiveness

Side effects

Example

ii

capitalized

plan documents

Drugs

Tier Description

iii

recommendations

following reasons

pharmacy

Over-the-

Counter (OTC)

iv

request thereafter

v

request thereafter

medical benefit

exceptions

vi

Definitions

pays the rest

lowercase letters

vii

viii

Drug Name DrugTier

RequirementsLimits

GP

1

GP

2 QL(1 ea daily)

Analeptics

Drug Name DrugTier

RequirementsLimits

LOMAIRA TABS 2 PA

SP PA

CONTRAVE TB12 SP PA

XENICAL CAPS SP PA

GP QL(2 ea daily)

GP

GP QL(1 ea daily)

1

Drug Name DrugTier

RequirementsLimits

GP

Drug Name DrugTier

RequirementsLimits

KITABIS PAK NEBU 2

tobramycin nebu 1

TOBRAMYCIN NEBU 2

SP

PA

2

Drug Name DrugTier

RequirementsLimits

SP PA

KEVZARA SOAJ SP

KEVZARA SOSY SP

Drug Name DrugTier

RequirementsLimits

FENORTHO CAPS 2

ibuprofen tabs 1

indomethacin caps 1

indomethacin cpcr 1

3

Drug Name DrugTier

RequirementsLimits

oxaprozin tabs 1

OTEZLA TABS SP

OTEZLA TBPK SP

Drug Name DrugTier

RequirementsLimits

1

GP

salsalate tabs 1

GP QL(4 ea daily)

4

Drug Name DrugTier

RequirementsLimits

GP

QL(2 ea daily)

1 QL(2 ea daily)

1

1 QL(3 ea daily)

Drug Name DrugTier

RequirementsLimits

2 QL(2 ea daily)

GP

1

5

Drug Name DrugTier

RequirementsLimits

1 QL(6 ea daily)

1

1 QL(6 ea daily)

GP QL(6 ea daily)

GP

GP QL(6 ea daily)

GP

GP QL(6 ea daily)

1 QL(3 ea daily)

Drug Name DrugTier

RequirementsLimits

GP QL(10 gmdaily)

GP

NF QL(10 gmdaily)

ANDROXY TABS 2 AC

danazol caps 1

METHITEST TABS 2

1

daily)

6

Drug Name DrugTier

RequirementsLimits

GP QL(60 ml daily)

CORTIFOAM FOAM 2

praziquantel tabs 1

IMPAVIDO CAPS 2

Drug Name DrugTier

RequirementsLimits

NEBUPENT SOLR 2

trimethoprim tabs 1

GP

Oxazolidinones

7

Drug Name DrugTier

RequirementsLimits

GP

NITRO-BID OINT 2

GP

QL(1 ea daily)

1 QL(1 ea daily)

GP

Drug Name DrugTier

RequirementsLimits

lorazepam conc 1

lorazepam tabs 1

8

Drug Name DrugTier

RequirementsLimits

NORPACE CR CP12 2

dofetilide caps 1

MULTAQ TABS 2

Drug Name DrugTier

RequirementsLimits

ATROVENT HFA AERS 2

Steroid Inhalants

AEROSPAN AERS 2

ASMANEX HFA AERO 2

2

9

Drug Name DrugTier

RequirementsLimits

2

GP QL(8 ml daily)

Drug Name DrugTier

RequirementsLimits

GP QL(4 ml daily)

GP QL(2 ml daily)

GP QL(2 ea daily)

2

1

10

Drug Name DrugTier

RequirementsLimits

DULERA AERO 2

2 QL(004 eadaily)

SYMBICORT AERO 2

GP

Drug Name DrugTier

RequirementsLimits

ELIQUIS TABS 5 MG 2

clonazepam tbdp 1

11

Drug Name DrugTier

RequirementsLimits

gabapentin caps 1

gabapentin soln 1

gabapentin tabs 1

GP

GP QL(6 ea daily)

GP

GP PA

GP

Drug Name DrugTier

RequirementsLimits

GP

1 QL(6 ea daily)

POTIGA TABS 2

primidone tabs 1

12

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

felbamate tabs 1

vigabatrin tabs 1

GP

phenytoin chew 1

phenytoin susp 1

ethosuximide caps 1

ethosuximide soln 1

13

Drug Name DrugTier

RequirementsLimits

GP

mirtazapine tbdp 1

Drug Name DrugTier

RequirementsLimits

14

Drug Name DrugTier

RequirementsLimits

GP

GP QL(1 ea daily)

GP

GP QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

GP QL(1 ea daily)

1

AMOXAPINE TABS 2

15

Drug Name DrugTier

RequirementsLimits

GP

GLYXAMBI TABS 2

INVOKAMET TABS 2

INVOKAMET XR TB24 2

2 QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

JENTADUETO TABS 2

SYNJARDY TABS 2

SYNJARDY XR TB24 2

AVANDIA TABS 2

Insulin

16

Drug Name DrugTier

RequirementsLimits

daily)

Drug Name DrugTier

RequirementsLimits

LEVEMIR SOLN 2

TRESIBA SOLN 2

repaglinide tabs 1

17

Drug Name DrugTier

RequirementsLimits

glimepiride tabs 1

glipizide tabs 1

glipizide tb24 1

glyburide tabs 1

tolbutamide tabs 1

Opioid Antagonists

Drug Name DrugTier

RequirementsLimits

fill retail)

nystatin tabs 1

18

Drug Name DrugTier

RequirementsLimits

fluconazole susr 1

fluconazole tabs 1

ketoconazole tabs 1

Drug Name DrugTier

RequirementsLimits

GP

19

Drug Name DrugTier

RequirementsLimits

gemfibrozil tabs 1

Drug Name DrugTier

RequirementsLimits

GP QL(1 ea daily)

GP QL(2 ea daily)

20

Drug Name DrugTier

RequirementsLimits

captopril tabs 1

trandolapril tabs 1

GP

Drug Name DrugTier

RequirementsLimits

GP

GP QL(1 ea daily)

GP

irbesartan tabs 1

21

Drug Name DrugTier

RequirementsLimits

methyldopa tabs 1

prazosin hcl caps 1

GP

GP QL(1 ea daily)

1

QL(1 ea daily)

1 QL(1 ea daily)

1

Drug Name DrugTier

RequirementsLimits

GP

QL(1 ea daily)

GP

QL(1 ea daily)

GP

GP QL(1 ea daily)

GP

22

Drug Name DrugTier

RequirementsLimits

GP

1

1 QL(2 ea daily)

GP

GP QL(1 ea daily)

GP

1 ST

1

1 QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

1

1 QL(1 ea daily)

GP

ST

1 QL(1 ea daily)

1

GP

QL(2 ea daily)

23

Drug Name DrugTier

RequirementsLimits

minoxidil tabs 1

GP

2

GP

Drug Name DrugTier

RequirementsLimits

isoniazid syrp 1

isoniazid tabs 1

PRIFTIN TABS 2

pyrazinamide tabs 1

rifabutin caps 1

rifampin caps 1

TRECATOR TABS 2

GP AC

24

Drug Name DrugTier

RequirementsLimits

GLEOSTINE CAPS 2

HEXALEN CAPS 2 AC

LEUKERAN TABS 2 AC

melphalan tabs 1 AC

MYLERAN TABS 2 AC

TABLOID TABS 2 AC

daily) AC

ODOMZO CAPS 2 AC

Drug Name DrugTier

RequirementsLimits

EMCYT CAPS 2 AC

flutamide caps 1 AC

letrozole tabs 1 AC

LYSODREN TABS 2 AC

25

Drug Name DrugTier

RequirementsLimits

BRAFTOVI CAPS 2 PA

CAPRELSA TABS 2 AC

IBRANCE CAPS 2

Drug Name DrugTier

RequirementsLimits

IRESSA TABS 2 AC

JAKAFI TABS 2 AC

MEKTOVI TABS 2 PA

NEXAVAR TABS 2

RYDAPT CAPS 2 PA AC

SPRYCEL TABS 2

SUTENT CAPS 2

26

Drug Name DrugTier

RequirementsLimits

TARCEVA TABS 2

TYKERB TABS 2

VOTRIENT TABS 2

ZEJULA CAPS 2

MATULANE CAPS 2 AC

Drug Name DrugTier

RequirementsLimits

1

GP

GP QL(4 ea daily)

27

Drug Name DrugTier

RequirementsLimits

GP QL(3 ea daily)

1

1 QL(3 ea daily)

GP QL(2 ea daily)

GP

1

GP QL(8 ea daily)

GP

STALEVO 100 TABS 2

STALEVO 125 TABS 2

STALEVO 150 TABS 2

Drug Name DrugTier

RequirementsLimits

STALEVO 50 TABS 2

STALEVO 75 TABS 2

LITHIUM SOLN 2

GP

GP QL(2 ea daily)

28

Drug Name DrugTier

RequirementsLimits

GP

haloperidol tabs 1

GP

GP QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

GP

perphenazine tabs 1

GP

29

Drug Name DrugTier

RequirementsLimits

APTIVUS CAPS 2

APTIVUS SOLN 2

BIKTARVY TABS 2

CIMDUO TABS 2

COMPLERA TABS 2 ST

CRIXIVAN CAPS 2

DELSTRIGO TABS 2 ST

DESCOVY TABS 2

didanosine cpdr 1

EDURANT TABS 2

efavirenz caps 1

efavirenz tabs 1

EMTRIVA CAPS 2

EMTRIVA SOLN 2

Drug Name DrugTier

RequirementsLimits

GP

EVOTAZ TABS 2

GENVOYA TABS 2

INTELENCE TABS 2

INVIRASE CAPS 2

INVIRASE TABS 2

ISENTRESS CHEW 2

ISENTRESS HD TABS 2

ISENTRESS PACK 2

ISENTRESS TABS 2

JULUCA TABS 2

GP

lamivudine soln 1

lamivudine tabs 1

GP

nevirapine susp 1

nevirapine tabs 1

30

Drug Name DrugTier

RequirementsLimits

nevirapine tb24 1

PIFELTRO TABS 2

PREZISTA SUSP 2

PREZISTA TABS 2

RESCRIPTOR TABS 2

GP

ritonavir tabs 1

SELZENTRY SOLN 2

SELZENTRY TABS 2

stavudine caps 1

STRIBILD TABS 2

SYMTUZA TABS 2 ST

TIVICAY TABS 2

Drug Name DrugTier

RequirementsLimits

TRIUMEQ TABS 2

GP

TRUVADA TABS 2

TYBOST TABS 2

GP

VIRACEPT TABS 2

GP

ZERIT SOLR 1 MGML 2

zidovudine caps 1

zidovudine syrp 1

zidovudine tabs 1

CMV Agents

31

Drug Name DrugTier

RequirementsLimits

GP QL(21 ml daily)

entecavir tabs 1

MAVYRET TABS 2

MODERIBA TBPK 2 PA

OLYSIO CAPS 2

Drug Name DrugTier

RequirementsLimits

GP PA

TECHNIVIE TABS 2 PA

VOSEVI TABS 2

famciclovir tabs 1

32

Drug Name DrugTier

RequirementsLimits

Influenza Agents

GP

Drug Name DrugTier

RequirementsLimits

atenolol tabs 1

2

nadolol tabs 1

pindolol tabs 1

33

Drug Name DrugTier

RequirementsLimits

sotalol hcl tabs 1

SOTYLIZE SOLN 2

GP QL(2 ea daily)

GP QL(1 ea daily)

GP

1 QL(1 ea daily)

1

Drug Name DrugTier

RequirementsLimits

nimodipine caps 1

nisoldipine tb24 1

GP QL(1 ea daily)

NYMALIZE SOLN 2

GP

1

34

Drug Name DrugTier

RequirementsLimits

GP

digoxin tabs 1

MUSE PLLT SP

Drug Name DrugTier

RequirementsLimits

tadalafil tabs SP

GP

cefadroxil susr 1

35

Drug Name DrugTier

RequirementsLimits

cefadroxil tabs 1

2

cefprozil susr 1

cefprozil tabs 1

CEFTIN SUSR 2

cefdinir susr 1

cefixime susr 1

GP

QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

GP

1 QL(1 ea daily)

1

GP QL(1 ea daily)PV

GP

36

Drug Name DrugTier

RequirementsLimits

GP

1

1 QL(1 ea daily)PV

Drug Name DrugTier

RequirementsLimits

GP

PV

GP

QL(1 ea daily)

GP QL(1 ea daily)

GP

GP QL(1 ea daily)PV

GP

QL(1 ea daily)

GP

GP QL(1 ea daily)

GP QL(1 ea daily)PV

37

Drug Name DrugTier

RequirementsLimits

ELLA TABS 2 PV

GP PV

GP QL(1 ea daily)

1

MEDROL TABS 2 MG 2

GP

Drug Name DrugTier

RequirementsLimits

NF

1

PREDNISOLONE SOLN 2

prednisolone soln 1

prednisolone syrp 1

1

38

Drug Name DrugTier

RequirementsLimits

1

GP

1

GP

Drug Name DrugTier

RequirementsLimits

GP QL(2 gm daily)

GP

CLINDAGEL GEL 2

39

Drug Name DrugTier

RequirementsLimits

1

GP

Drug Name DrugTier

RequirementsLimits

GP

SSS 10-5 FOAM 2

GP

CENTANY OINT 2

40

Drug Name DrugTier

RequirementsLimits

MUPIROCIN CREA 2

mupirocin oint 1

ciclopirox sham 1 1

GP

Drug Name DrugTier

RequirementsLimits

FLUOROPLEX CREA 2

PICATO GEL 2

GP

41

Drug Name DrugTier

RequirementsLimits

GP

AMCINONIDE CREA 2

APEXICON E CREA 2

2

1

Drug Name DrugTier

RequirementsLimits

1

CAPEX SHAM 2

GP

desonide crea 1

desonide lotn 1

desonide oint 1

42

Drug Name DrugTier

RequirementsLimits

GP

Drug Name DrugTier

RequirementsLimits

GP

43

Drug Name DrugTier

RequirementsLimits

imiquimod crea 1

podofilox soln 1

Drug Name DrugTier

RequirementsLimits

GP

DIAGNOSTIC PRODUCTS

Diagnostic Tests

2

44

Drug Name DrugTier

RequirementsLimits

2

ZENPEP CPEP 2

Drug Name DrugTier

RequirementsLimits

GP

GP QL(1 ea daily)

GP QL(2 ea daily)

1

1 QL(2 ea daily)

1 QL(1 ea daily)

45

Drug Name DrugTier

RequirementsLimits

indapamide tabs 1

metolazone tabs 1

Drug Name DrugTier

RequirementsLimits

CARBAGLU TABS 2

46

Drug Name DrugTier

RequirementsLimits

KUVAN PACK 2

KUVAN TBSO 2

paricalcitol caps 1

GP

GP QL(6 ea daily)

Drug Name DrugTier

RequirementsLimits

GP

PREMPHASE TABS 2

2

Estrogens

2

1

MENEST TABS 2

47

Drug Name DrugTier

RequirementsLimits

GP

2 QL(1 ea daily)

GP

fill retail)

Drug Name DrugTier

RequirementsLimits

ursodiol caps 1

ursodiol tabs 1

48

Drug Name DrugTier

RequirementsLimits

SFROWASA ENEM 2

GP RXOTC

GP QL(3 ea daily)

GP

GP QL(4 ea daily)

Drug Name DrugTier

RequirementsLimits

GP

GP QL(5 ea daily)

GP

1

RXOTC

GP

49

Drug Name DrugTier

RequirementsLimits

PROCYSBI CPDR 2 SP

GP

colchicine tabs 1

COLCRYS TABS 2

Drug Name DrugTier

RequirementsLimits

RIXUBIS SOLR SP PA

dipyridamole tabs 1

Folic AcidFolates

50

Drug Name DrugTier

RequirementsLimits

INTEGRA F CAPS 2

estazolam tabs 1

Drug Name DrugTier

RequirementsLimits

CLENPIQ SOLN 2 PV

GP

51

Drug Name DrugTier

RequirementsLimits

GP

PV

1 PV

Saline Laxatives

Drug Name DrugTier

RequirementsLimits

Stimulant Laxatives

bisacodyl supp 1

bisacodyl tbec 1

52

Drug Name DrugTier

RequirementsLimits

GP

ERY-TAB TBEC 2

GP

Drug Name DrugTier

RequirementsLimits

Contraceptives

53

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

54

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

55

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

56

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

2

57

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

58

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

59

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

2

60

Drug Name DrugTier

RequirementsLimits

2

Drug Name DrugTier

RequirementsLimits

61

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

62

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

63

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

64

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

65

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

66

Drug Name DrugTier

RequirementsLimits

2

Drug Name DrugTier

RequirementsLimits

MIGERGOT SUPP 2

Serotonin Agonists

GP QL(2 ea daily)

67

Drug Name DrugTier

RequirementsLimits

daily)

Fluoride

LOZI-FLUR LOZG 2

GP

K-PHOS TABS 2

1

Potassium

Drug Name DrugTier

RequirementsLimits

2

K-TAB TBCR 8 MEQ 2

KLOR-CON M15 TBCR 2

KLOR-CON25 PACK 2

1

68

Drug Name DrugTier

RequirementsLimits

cyclosporine caps 1

GP

tacrolimus caps 1

ZORTRESS TABS 2

GP

Drug Name DrugTier

RequirementsLimits

1

clotrimazole troc 1

GP

GP QL(6 ea daily)

GP QL(4 ea daily)

MULTIVITAMINS

Ped MV w Fluoride

old )

69

Drug Name DrugTier

RequirementsLimits

BAL-CARE DHA MISC 2

COMPLETENATE CHEW 2

CONCEPT DHA CAPS 2

CONCEPT OB CAPS 2

DOTHELLE DHA CAPS 2

FOCALGIN CA MISC 2

FOLIVANE-OB CAPS 2

Drug Name DrugTier

RequirementsLimits

M-VIT TABS 2 RXOTC

MARNATAL-F CAPS 2

NESTABS DHA MISC 2

PNV OB+DHA MISC 2

PNV-VP-U CAPS 2

PR NATAL 400 MISC 2

PR NATAL 430 MISC 2

PRENA 1 TRUE MISC 2

PRENATA CHEW 2

70

Drug Name DrugTier

RequirementsLimits

2

PRENATAL-U CAPS 2

2

QL(1 ea daily)

2

PROVIDA DHA CAPS 2

PROVIDA OB CAPS 2

Drug Name DrugTier

RequirementsLimits

2

TARON-C DHA CAPS 2

TRI-TABS DHA MISC 2

TRINATAL GT TABS 2

VENA-BAL DHA MISC 2

VIRT-ADVANCE TABS 2

VIRT-C DHA CAPS 2

VIRT-VITE GT TABS 2

VITATRUE MISC 2

71

Drug Name DrugTier

RequirementsLimits

Nasal Antiallergy

Drug Name DrugTier

RequirementsLimits

GP

72

Drug Name DrugTier

RequirementsLimits

BETIMOL SOLN 2

BETOPTIC-S SUSP 2

GP

1

2

ISTALOL SOLN 2

2

GP

Drug Name DrugTier

RequirementsLimits

GP

CILOXAN OINT 2

GENTAK OINT 2

MOXEZA SOLN 2

73

Drug Name DrugTier

RequirementsLimits

retail)

NATACYN SUSP 2

GP

TOBREX OINT 2

trifluridine soln 1

Drug Name DrugTier

RequirementsLimits

BLEPHAMIDE SUSP 2

2

FLAREX SUSP 2

FML FORTE SUSP 2

GP

FML OINT 2

MAXIDEX SUSP 2

GP

PRED MILD SUSP 2

2

74

Drug Name DrugTier

RequirementsLimits

2

GP

ALOCRIL SOLN 2

ALOMIDE SOLN 2

BROMFENAC SOLN 2

CYSTARAN SOLN 2

Drug Name DrugTier

RequirementsLimits

bimatoprost soln 1

LUMIGAN SOLN 2

TRAVATAN Z SOLN 2

75

Drug Name DrugTier

RequirementsLimits

Otic Combinations

GP

amoxicillin chew 1

amoxicillin susr 1

Drug Name DrugTier

RequirementsLimits

amoxicillin tabs 1

ampicillin caps 1

ampicillin susr 1

2

GP

76

Drug Name DrugTier

RequirementsLimits

GP QL(1 ea daily)

GP

disulfiram tabs 1

GP QL(1 ea daily)

GP

2

Drug Name DrugTier

RequirementsLimits

GP

GP QL(1 ea daily)

GP

rivastigmine pt24 1

GILENYA CAPS 2

77

Drug Name DrugTier

RequirementsLimits

GP PV

nicotine pt24 1 PV

2 PV

Drug Name DrugTier

RequirementsLimits

GP PV

GP

78

Drug Name DrugTier

RequirementsLimits

methimazole tabs 1

GP QL(2 ea daily)

1 QL(1 ea daily)

1

2

GP

QL(1 ea daily)

GP

thyroid tabs 1

WESTHROID TABS 2

Drug Name DrugTier

RequirementsLimits

2

CUVPOSA SOLN 2

GP

79

Drug Name DrugTier

RequirementsLimits

1

Drug Name DrugTier

RequirementsLimits

GP QL(1 ea daily)

misoprostol tabs 1

GP

80

Drug Name DrugTier

RequirementsLimits

GP

Drug Name DrugTier

RequirementsLimits

TERCONAZOLE CREA 2

Vaginal Progestins

VITAMINS

phytonadione tabs 1

81

ACULAR ACULAR LS

75 75

26 27

32 42 34

18 51 42

10 77

24 50 67 75 75 47 73 8

Index 1

22 16 21 48

1

22 21

50 67 77

22 79 39

Index 2

Index 3

53

Index 4

43 43 50 9

52 11 15 4

77 80 14 9

50 50 45 56

43 19 35

56

13 13 13 4

55

56

Index 5

56

57 20 19

Index 6

74 81

70 57

57

9 50

FORTESTA FOSAMAX

6 46

30 28 77 26 26 25 18 18 16

57

74 41 41 41 78 14 29 68 51 3

75 25 43

72

folic acid 51

Index 7

Index 8

73 19 50 18 26 50 16 16 16 18 16

59 59

59

59 35 80 49 17 17 46

16 30 68 68 49 68 5

30 69 36 43 12 12 45 19

3 3

25 27

Index 9

30 33 23 41 41 8

21

23 37 21 23 23 41 20 19 29 68 75 68 26 25 51 70 70 80 80 24 14 70

60 43 3

36 36 37

27 32 67 67 74 74

25

60 60 60

37 20 1

18

60 60

60 26 20

60

61

61 26 26 3

25 77 47

Index 10

5 81 7

25 49 24 24 11 16 5

45 80 79 6

72 3

25

Index 11

26 20 21

61 61 18

Index 12

42 42 37 6 6 4

61 69 21 44 29

62

61

62

62 14 51 21

2 15 75

1 74 39

12 70 70

Index 13

Index 14

ACTIVATED 63

Index 15

Index 16

71 20 44 29 74 20

13 33

TRILEPTAL TRILIPIX

13 20

64 11

71 65 65 29 29 29 79 34 18 9

34 73

73 73 73 31 72 2 2

25 46

17 17 81 35 16 5

21 51 8

14 75 65

65 15 24 11 17 17 40

2 2

40 37

TYBOST TYKERB

31 27

71

69

72

44

45 51

Index 17

66

19 35 78

65

81 49 49

65

49 50 48

31 31 32

65

65 5

44

65

48 48 81 32 32 32

32 13 74 13 31 31

71 71 71 8

71 48 71

Index 18

Index 19

Classes
- MULTIVITAMINS
- VITAMINS

Page 3: Health Net 2-Tier Recommended Drug List

exceptions

Safety

Effectiveness

Side effects

Example

ii

capitalized

plan documents

Drugs

Tier Description

iii

recommendations

following reasons

pharmacy

Over-the-

Counter (OTC)

iv

request thereafter

v

request thereafter

medical benefit

exceptions

vi

Definitions

pays the rest

lowercase letters

vii

viii

Drug Name DrugTier

RequirementsLimits

GP

1

GP

2 QL(1 ea daily)

Analeptics

Drug Name DrugTier

RequirementsLimits

LOMAIRA TABS 2 PA

SP PA

CONTRAVE TB12 SP PA

XENICAL CAPS SP PA

GP QL(2 ea daily)

GP

GP QL(1 ea daily)

1

Drug Name DrugTier

RequirementsLimits

GP

Drug Name DrugTier

RequirementsLimits

KITABIS PAK NEBU 2

tobramycin nebu 1

TOBRAMYCIN NEBU 2

SP

PA

2

Drug Name DrugTier

RequirementsLimits

SP PA

KEVZARA SOAJ SP

KEVZARA SOSY SP

Drug Name DrugTier

RequirementsLimits

FENORTHO CAPS 2

ibuprofen tabs 1

indomethacin caps 1

indomethacin cpcr 1

3

Drug Name DrugTier

RequirementsLimits

oxaprozin tabs 1

OTEZLA TABS SP

OTEZLA TBPK SP

Drug Name DrugTier

RequirementsLimits

1

GP

salsalate tabs 1

GP QL(4 ea daily)

4

Drug Name DrugTier

RequirementsLimits

GP

QL(2 ea daily)

1 QL(2 ea daily)

1

1 QL(3 ea daily)

Drug Name DrugTier

RequirementsLimits

2 QL(2 ea daily)

GP

1

5

Drug Name DrugTier

RequirementsLimits

1 QL(6 ea daily)

1

1 QL(6 ea daily)

GP QL(6 ea daily)

GP

GP QL(6 ea daily)

GP

GP QL(6 ea daily)

1 QL(3 ea daily)

Drug Name DrugTier

RequirementsLimits

GP QL(10 gmdaily)

GP

NF QL(10 gmdaily)

ANDROXY TABS 2 AC

danazol caps 1

METHITEST TABS 2

1

daily)

6

Drug Name DrugTier

RequirementsLimits

GP QL(60 ml daily)

CORTIFOAM FOAM 2

praziquantel tabs 1

IMPAVIDO CAPS 2

Drug Name DrugTier

RequirementsLimits

NEBUPENT SOLR 2

trimethoprim tabs 1

GP

Oxazolidinones

7

Drug Name DrugTier

RequirementsLimits

GP

NITRO-BID OINT 2

GP

QL(1 ea daily)

1 QL(1 ea daily)

GP

Drug Name DrugTier

RequirementsLimits

lorazepam conc 1

lorazepam tabs 1

8

Drug Name DrugTier

RequirementsLimits

NORPACE CR CP12 2

dofetilide caps 1

MULTAQ TABS 2

Drug Name DrugTier

RequirementsLimits

ATROVENT HFA AERS 2

Steroid Inhalants

AEROSPAN AERS 2

ASMANEX HFA AERO 2

2

9

Drug Name DrugTier

RequirementsLimits

2

GP QL(8 ml daily)

Drug Name DrugTier

RequirementsLimits

GP QL(4 ml daily)

GP QL(2 ml daily)

GP QL(2 ea daily)

2

1

10

Drug Name DrugTier

RequirementsLimits

DULERA AERO 2

2 QL(004 eadaily)

SYMBICORT AERO 2

GP

Drug Name DrugTier

RequirementsLimits

ELIQUIS TABS 5 MG 2

clonazepam tbdp 1

11

Drug Name DrugTier

RequirementsLimits

gabapentin caps 1

gabapentin soln 1

gabapentin tabs 1

GP

GP QL(6 ea daily)

GP

GP PA

GP

Drug Name DrugTier

RequirementsLimits

GP

1 QL(6 ea daily)

POTIGA TABS 2

primidone tabs 1

12

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

felbamate tabs 1

vigabatrin tabs 1

GP

phenytoin chew 1

phenytoin susp 1

ethosuximide caps 1

ethosuximide soln 1

13

Drug Name DrugTier

RequirementsLimits

GP

mirtazapine tbdp 1

Drug Name DrugTier

RequirementsLimits

14

Drug Name DrugTier

RequirementsLimits

GP

GP QL(1 ea daily)

GP

GP QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

GP QL(1 ea daily)

1

AMOXAPINE TABS 2

15

Drug Name DrugTier

RequirementsLimits

GP

GLYXAMBI TABS 2

INVOKAMET TABS 2

INVOKAMET XR TB24 2

2 QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

JENTADUETO TABS 2

SYNJARDY TABS 2

SYNJARDY XR TB24 2

AVANDIA TABS 2

Insulin

16

Drug Name DrugTier

RequirementsLimits

daily)

Drug Name DrugTier

RequirementsLimits

LEVEMIR SOLN 2

TRESIBA SOLN 2

repaglinide tabs 1

17

Drug Name DrugTier

RequirementsLimits

glimepiride tabs 1

glipizide tabs 1

glipizide tb24 1

glyburide tabs 1

tolbutamide tabs 1

Opioid Antagonists

Drug Name DrugTier

RequirementsLimits

fill retail)

nystatin tabs 1

18

Drug Name DrugTier

RequirementsLimits

fluconazole susr 1

fluconazole tabs 1

ketoconazole tabs 1

Drug Name DrugTier

RequirementsLimits

GP

19

Drug Name DrugTier

RequirementsLimits

gemfibrozil tabs 1

Drug Name DrugTier

RequirementsLimits

GP QL(1 ea daily)

GP QL(2 ea daily)

20

Drug Name DrugTier

RequirementsLimits

captopril tabs 1

trandolapril tabs 1

GP

Drug Name DrugTier

RequirementsLimits

GP

GP QL(1 ea daily)

GP

irbesartan tabs 1

21

Drug Name DrugTier

RequirementsLimits

methyldopa tabs 1

prazosin hcl caps 1

GP

GP QL(1 ea daily)

1

QL(1 ea daily)

1 QL(1 ea daily)

1

Drug Name DrugTier

RequirementsLimits

GP

QL(1 ea daily)

GP

QL(1 ea daily)

GP

GP QL(1 ea daily)

GP

22

Drug Name DrugTier

RequirementsLimits

GP

1

1 QL(2 ea daily)

GP

GP QL(1 ea daily)

GP

1 ST

1

1 QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

1

1 QL(1 ea daily)

GP

ST

1 QL(1 ea daily)

1

GP

QL(2 ea daily)

23

Drug Name DrugTier

RequirementsLimits

minoxidil tabs 1

GP

2

GP

Drug Name DrugTier

RequirementsLimits

isoniazid syrp 1

isoniazid tabs 1

PRIFTIN TABS 2

pyrazinamide tabs 1

rifabutin caps 1

rifampin caps 1

TRECATOR TABS 2

GP AC

24

Drug Name DrugTier

RequirementsLimits

GLEOSTINE CAPS 2

HEXALEN CAPS 2 AC

LEUKERAN TABS 2 AC

melphalan tabs 1 AC

MYLERAN TABS 2 AC

TABLOID TABS 2 AC

daily) AC

ODOMZO CAPS 2 AC

Drug Name DrugTier

RequirementsLimits

EMCYT CAPS 2 AC

flutamide caps 1 AC

letrozole tabs 1 AC

LYSODREN TABS 2 AC

25

Drug Name DrugTier

RequirementsLimits

BRAFTOVI CAPS 2 PA

CAPRELSA TABS 2 AC

IBRANCE CAPS 2

Drug Name DrugTier

RequirementsLimits

IRESSA TABS 2 AC

JAKAFI TABS 2 AC

MEKTOVI TABS 2 PA

NEXAVAR TABS 2

RYDAPT CAPS 2 PA AC

SPRYCEL TABS 2

SUTENT CAPS 2

26

Drug Name DrugTier

RequirementsLimits

TARCEVA TABS 2

TYKERB TABS 2

VOTRIENT TABS 2

ZEJULA CAPS 2

MATULANE CAPS 2 AC

Drug Name DrugTier

RequirementsLimits

1

GP

GP QL(4 ea daily)

27

Drug Name DrugTier

RequirementsLimits

GP QL(3 ea daily)

1

1 QL(3 ea daily)

GP QL(2 ea daily)

GP

1

GP QL(8 ea daily)

GP

STALEVO 100 TABS 2

STALEVO 125 TABS 2

STALEVO 150 TABS 2

Drug Name DrugTier

RequirementsLimits

STALEVO 50 TABS 2

STALEVO 75 TABS 2

LITHIUM SOLN 2

GP

GP QL(2 ea daily)

28

Drug Name DrugTier

RequirementsLimits

GP

haloperidol tabs 1

GP

GP QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

GP

perphenazine tabs 1

GP

29

Drug Name DrugTier

RequirementsLimits

APTIVUS CAPS 2

APTIVUS SOLN 2

BIKTARVY TABS 2

CIMDUO TABS 2

COMPLERA TABS 2 ST

CRIXIVAN CAPS 2

DELSTRIGO TABS 2 ST

DESCOVY TABS 2

didanosine cpdr 1

EDURANT TABS 2

efavirenz caps 1

efavirenz tabs 1

EMTRIVA CAPS 2

EMTRIVA SOLN 2

Drug Name DrugTier

RequirementsLimits

GP

EVOTAZ TABS 2

GENVOYA TABS 2

INTELENCE TABS 2

INVIRASE CAPS 2

INVIRASE TABS 2

ISENTRESS CHEW 2

ISENTRESS HD TABS 2

ISENTRESS PACK 2

ISENTRESS TABS 2

JULUCA TABS 2

GP

lamivudine soln 1

lamivudine tabs 1

GP

nevirapine susp 1

nevirapine tabs 1

30

Drug Name DrugTier

RequirementsLimits

nevirapine tb24 1

PIFELTRO TABS 2

PREZISTA SUSP 2

PREZISTA TABS 2

RESCRIPTOR TABS 2

GP

ritonavir tabs 1

SELZENTRY SOLN 2

SELZENTRY TABS 2

stavudine caps 1

STRIBILD TABS 2

SYMTUZA TABS 2 ST

TIVICAY TABS 2

Drug Name DrugTier

RequirementsLimits

TRIUMEQ TABS 2

GP

TRUVADA TABS 2

TYBOST TABS 2

GP

VIRACEPT TABS 2

GP

ZERIT SOLR 1 MGML 2

zidovudine caps 1

zidovudine syrp 1

zidovudine tabs 1

CMV Agents

31

Drug Name DrugTier

RequirementsLimits

GP QL(21 ml daily)

entecavir tabs 1

MAVYRET TABS 2

MODERIBA TBPK 2 PA

OLYSIO CAPS 2

Drug Name DrugTier

RequirementsLimits

GP PA

TECHNIVIE TABS 2 PA

VOSEVI TABS 2

famciclovir tabs 1

32

Drug Name DrugTier

RequirementsLimits

Influenza Agents

GP

Drug Name DrugTier

RequirementsLimits

atenolol tabs 1

2

nadolol tabs 1

pindolol tabs 1

33

Drug Name DrugTier

RequirementsLimits

sotalol hcl tabs 1

SOTYLIZE SOLN 2

GP QL(2 ea daily)

GP QL(1 ea daily)

GP

1 QL(1 ea daily)

1

Drug Name DrugTier

RequirementsLimits

nimodipine caps 1

nisoldipine tb24 1

GP QL(1 ea daily)

NYMALIZE SOLN 2

GP

1

34

Drug Name DrugTier

RequirementsLimits

GP

digoxin tabs 1

MUSE PLLT SP

Drug Name DrugTier

RequirementsLimits

tadalafil tabs SP

GP

cefadroxil susr 1

35

Drug Name DrugTier

RequirementsLimits

cefadroxil tabs 1

2

cefprozil susr 1

cefprozil tabs 1

CEFTIN SUSR 2

cefdinir susr 1

cefixime susr 1

GP

QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

GP

1 QL(1 ea daily)

1

GP QL(1 ea daily)PV

GP

36

Drug Name DrugTier

RequirementsLimits

GP

1

1 QL(1 ea daily)PV

Drug Name DrugTier

RequirementsLimits

GP

PV

GP

QL(1 ea daily)

GP QL(1 ea daily)

GP

GP QL(1 ea daily)PV

GP

QL(1 ea daily)

GP

GP QL(1 ea daily)

GP QL(1 ea daily)PV

37

Drug Name DrugTier

RequirementsLimits

ELLA TABS 2 PV

GP PV

GP QL(1 ea daily)

1

MEDROL TABS 2 MG 2

GP

Drug Name DrugTier

RequirementsLimits

NF

1

PREDNISOLONE SOLN 2

prednisolone soln 1

prednisolone syrp 1

1

38

Drug Name DrugTier

RequirementsLimits

1

GP

1

GP

Drug Name DrugTier

RequirementsLimits

GP QL(2 gm daily)

GP

CLINDAGEL GEL 2

39

Drug Name DrugTier

RequirementsLimits

1

GP

Drug Name DrugTier

RequirementsLimits

GP

SSS 10-5 FOAM 2

GP

CENTANY OINT 2

40

Drug Name DrugTier

RequirementsLimits

MUPIROCIN CREA 2

mupirocin oint 1

ciclopirox sham 1 1

GP

Drug Name DrugTier

RequirementsLimits

FLUOROPLEX CREA 2

PICATO GEL 2

GP

41

Drug Name DrugTier

RequirementsLimits

GP

AMCINONIDE CREA 2

APEXICON E CREA 2

2

1

Drug Name DrugTier

RequirementsLimits

1

CAPEX SHAM 2

GP

desonide crea 1

desonide lotn 1

desonide oint 1

42

Drug Name DrugTier

RequirementsLimits

GP

Drug Name DrugTier

RequirementsLimits

GP

43

Drug Name DrugTier

RequirementsLimits

imiquimod crea 1

podofilox soln 1

Drug Name DrugTier

RequirementsLimits

GP

DIAGNOSTIC PRODUCTS

Diagnostic Tests

2

44

Drug Name DrugTier

RequirementsLimits

2

ZENPEP CPEP 2

Drug Name DrugTier

RequirementsLimits

GP

GP QL(1 ea daily)

GP QL(2 ea daily)

1

1 QL(2 ea daily)

1 QL(1 ea daily)

45

Drug Name DrugTier

RequirementsLimits

indapamide tabs 1

metolazone tabs 1

Drug Name DrugTier

RequirementsLimits

CARBAGLU TABS 2

46

Drug Name DrugTier

RequirementsLimits

KUVAN PACK 2

KUVAN TBSO 2

paricalcitol caps 1

GP

GP QL(6 ea daily)

Drug Name DrugTier

RequirementsLimits

GP

PREMPHASE TABS 2

2

Estrogens

2

1

MENEST TABS 2

47

Drug Name DrugTier

RequirementsLimits

GP

2 QL(1 ea daily)

GP

fill retail)

Drug Name DrugTier

RequirementsLimits

ursodiol caps 1

ursodiol tabs 1

48

Drug Name DrugTier

RequirementsLimits

SFROWASA ENEM 2

GP RXOTC

GP QL(3 ea daily)

GP

GP QL(4 ea daily)

Drug Name DrugTier

RequirementsLimits

GP

GP QL(5 ea daily)

GP

1

RXOTC

GP

49

Drug Name DrugTier

RequirementsLimits

PROCYSBI CPDR 2 SP

GP

colchicine tabs 1

COLCRYS TABS 2

Drug Name DrugTier

RequirementsLimits

RIXUBIS SOLR SP PA

dipyridamole tabs 1

Folic AcidFolates

50

Drug Name DrugTier

RequirementsLimits

INTEGRA F CAPS 2

estazolam tabs 1

Drug Name DrugTier

RequirementsLimits

CLENPIQ SOLN 2 PV

GP

51

Drug Name DrugTier

RequirementsLimits

GP

PV

1 PV

Saline Laxatives

Drug Name DrugTier

RequirementsLimits

Stimulant Laxatives

bisacodyl supp 1

bisacodyl tbec 1

52

Drug Name DrugTier

RequirementsLimits

GP

ERY-TAB TBEC 2

GP

Drug Name DrugTier

RequirementsLimits

Contraceptives

53

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

54

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

55

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

56

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

2

57

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

58

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

59

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

2

60

Drug Name DrugTier

RequirementsLimits

2

Drug Name DrugTier

RequirementsLimits

61

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

62

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

63

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

64

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

65

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

66

Drug Name DrugTier

RequirementsLimits

2

Drug Name DrugTier

RequirementsLimits

MIGERGOT SUPP 2

Serotonin Agonists

GP QL(2 ea daily)

67

Drug Name DrugTier

RequirementsLimits

daily)

Fluoride

LOZI-FLUR LOZG 2

GP

K-PHOS TABS 2

1

Potassium

Drug Name DrugTier

RequirementsLimits

2

K-TAB TBCR 8 MEQ 2

KLOR-CON M15 TBCR 2

KLOR-CON25 PACK 2

1

68

Drug Name DrugTier

RequirementsLimits

cyclosporine caps 1

GP

tacrolimus caps 1

ZORTRESS TABS 2

GP

Drug Name DrugTier

RequirementsLimits

1

clotrimazole troc 1

GP

GP QL(6 ea daily)

GP QL(4 ea daily)

MULTIVITAMINS

Ped MV w Fluoride

old )

69

Drug Name DrugTier

RequirementsLimits

BAL-CARE DHA MISC 2

COMPLETENATE CHEW 2

CONCEPT DHA CAPS 2

CONCEPT OB CAPS 2

DOTHELLE DHA CAPS 2

FOCALGIN CA MISC 2

FOLIVANE-OB CAPS 2

Drug Name DrugTier

RequirementsLimits

M-VIT TABS 2 RXOTC

MARNATAL-F CAPS 2

NESTABS DHA MISC 2

PNV OB+DHA MISC 2

PNV-VP-U CAPS 2

PR NATAL 400 MISC 2

PR NATAL 430 MISC 2

PRENA 1 TRUE MISC 2

PRENATA CHEW 2

70

Drug Name DrugTier

RequirementsLimits

2

PRENATAL-U CAPS 2

2

QL(1 ea daily)

2

PROVIDA DHA CAPS 2

PROVIDA OB CAPS 2

Drug Name DrugTier

RequirementsLimits

2

TARON-C DHA CAPS 2

TRI-TABS DHA MISC 2

TRINATAL GT TABS 2

VENA-BAL DHA MISC 2

VIRT-ADVANCE TABS 2

VIRT-C DHA CAPS 2

VIRT-VITE GT TABS 2

VITATRUE MISC 2

71

Drug Name DrugTier

RequirementsLimits

Nasal Antiallergy

Drug Name DrugTier

RequirementsLimits

GP

72

Drug Name DrugTier

RequirementsLimits

BETIMOL SOLN 2

BETOPTIC-S SUSP 2

GP

1

2

ISTALOL SOLN 2

2

GP

Drug Name DrugTier

RequirementsLimits

GP

CILOXAN OINT 2

GENTAK OINT 2

MOXEZA SOLN 2

73

Drug Name DrugTier

RequirementsLimits

retail)

NATACYN SUSP 2

GP

TOBREX OINT 2

trifluridine soln 1

Drug Name DrugTier

RequirementsLimits

BLEPHAMIDE SUSP 2

2

FLAREX SUSP 2

FML FORTE SUSP 2

GP

FML OINT 2

MAXIDEX SUSP 2

GP

PRED MILD SUSP 2

2

74

Drug Name DrugTier

RequirementsLimits

2

GP

ALOCRIL SOLN 2

ALOMIDE SOLN 2

BROMFENAC SOLN 2

CYSTARAN SOLN 2

Drug Name DrugTier

RequirementsLimits

bimatoprost soln 1

LUMIGAN SOLN 2

TRAVATAN Z SOLN 2

75

Drug Name DrugTier

RequirementsLimits

Otic Combinations

GP

amoxicillin chew 1

amoxicillin susr 1

Drug Name DrugTier

RequirementsLimits

amoxicillin tabs 1

ampicillin caps 1

ampicillin susr 1

2

GP

76

Drug Name DrugTier

RequirementsLimits

GP QL(1 ea daily)

GP

disulfiram tabs 1

GP QL(1 ea daily)

GP

2

Drug Name DrugTier

RequirementsLimits

GP

GP QL(1 ea daily)

GP

rivastigmine pt24 1

GILENYA CAPS 2

77

Drug Name DrugTier

RequirementsLimits

GP PV

nicotine pt24 1 PV

2 PV

Drug Name DrugTier

RequirementsLimits

GP PV

GP

78

Drug Name DrugTier

RequirementsLimits

methimazole tabs 1

GP QL(2 ea daily)

1 QL(1 ea daily)

1

2

GP

QL(1 ea daily)

GP

thyroid tabs 1

WESTHROID TABS 2

Drug Name DrugTier

RequirementsLimits

2

CUVPOSA SOLN 2

GP

79

Drug Name DrugTier

RequirementsLimits

1

Drug Name DrugTier

RequirementsLimits

GP QL(1 ea daily)

misoprostol tabs 1

GP

80

Drug Name DrugTier

RequirementsLimits

GP

Drug Name DrugTier

RequirementsLimits

TERCONAZOLE CREA 2

Vaginal Progestins

VITAMINS

phytonadione tabs 1

81

ACULAR ACULAR LS

75 75

26 27

32 42 34

18 51 42

10 77

24 50 67 75 75 47 73 8

Index 1

22 16 21 48

1

22 21

50 67 77

22 79 39

Index 2

Index 3

53

Index 4

43 43 50 9

52 11 15 4

77 80 14 9

50 50 45 56

43 19 35

56

13 13 13 4

55

56

Index 5

56

57 20 19

Index 6

74 81

70 57

57

9 50

FORTESTA FOSAMAX

6 46

30 28 77 26 26 25 18 18 16

57

74 41 41 41 78 14 29 68 51 3

75 25 43

72

folic acid 51

Index 7

Index 8

73 19 50 18 26 50 16 16 16 18 16

59 59

59

59 35 80 49 17 17 46

16 30 68 68 49 68 5

30 69 36 43 12 12 45 19

3 3

25 27

Index 9

30 33 23 41 41 8

21

23 37 21 23 23 41 20 19 29 68 75 68 26 25 51 70 70 80 80 24 14 70

60 43 3

36 36 37

27 32 67 67 74 74

25

60 60 60

37 20 1

18

60 60

60 26 20

60

61

61 26 26 3

25 77 47

Index 10

5 81 7

25 49 24 24 11 16 5

45 80 79 6

72 3

25

Index 11

26 20 21

61 61 18

Index 12

42 42 37 6 6 4

61 69 21 44 29

62

61

62

62 14 51 21

2 15 75

1 74 39

12 70 70

Index 13

Index 14

ACTIVATED 63

Index 15

Index 16

71 20 44 29 74 20

13 33

TRILEPTAL TRILIPIX

13 20

64 11

71 65 65 29 29 29 79 34 18 9

34 73

73 73 73 31 72 2 2

25 46

17 17 81 35 16 5

21 51 8

14 75 65

65 15 24 11 17 17 40

2 2

40 37

TYBOST TYKERB

31 27

71

69

72

44

45 51

Index 17

66

19 35 78

65

81 49 49

65

49 50 48

31 31 32

65

65 5

44

65

48 48 81 32 32 32

32 13 74 13 31 31

71 71 71 8

71 48 71

Index 18

Index 19

Classes
- MULTIVITAMINS
- VITAMINS

Page 4: Health Net 2-Tier Recommended Drug List

capitalized

plan documents

Drugs

Tier Description

iii

recommendations

following reasons

pharmacy

Over-the-

Counter (OTC)

iv

request thereafter

v

request thereafter

medical benefit

exceptions

vi

Definitions

pays the rest

lowercase letters

vii

viii

Drug Name DrugTier

RequirementsLimits

GP

1

GP

2 QL(1 ea daily)

Analeptics

Drug Name DrugTier

RequirementsLimits

LOMAIRA TABS 2 PA

SP PA

CONTRAVE TB12 SP PA

XENICAL CAPS SP PA

GP QL(2 ea daily)

GP

GP QL(1 ea daily)

1

Drug Name DrugTier

RequirementsLimits

GP

Drug Name DrugTier

RequirementsLimits

KITABIS PAK NEBU 2

tobramycin nebu 1

TOBRAMYCIN NEBU 2

SP

PA

2

Drug Name DrugTier

RequirementsLimits

SP PA

KEVZARA SOAJ SP

KEVZARA SOSY SP

Drug Name DrugTier

RequirementsLimits

FENORTHO CAPS 2

ibuprofen tabs 1

indomethacin caps 1

indomethacin cpcr 1

3

Drug Name DrugTier

RequirementsLimits

oxaprozin tabs 1

OTEZLA TABS SP

OTEZLA TBPK SP

Drug Name DrugTier

RequirementsLimits

1

GP

salsalate tabs 1

GP QL(4 ea daily)

4

Drug Name DrugTier

RequirementsLimits

GP

QL(2 ea daily)

1 QL(2 ea daily)

1

1 QL(3 ea daily)

Drug Name DrugTier

RequirementsLimits

2 QL(2 ea daily)

GP

1

5

Drug Name DrugTier

RequirementsLimits

1 QL(6 ea daily)

1

1 QL(6 ea daily)

GP QL(6 ea daily)

GP

GP QL(6 ea daily)

GP

GP QL(6 ea daily)

1 QL(3 ea daily)

Drug Name DrugTier

RequirementsLimits

GP QL(10 gmdaily)

GP

NF QL(10 gmdaily)

ANDROXY TABS 2 AC

danazol caps 1

METHITEST TABS 2

1

daily)

6

Drug Name DrugTier

RequirementsLimits

GP QL(60 ml daily)

CORTIFOAM FOAM 2

praziquantel tabs 1

IMPAVIDO CAPS 2

Drug Name DrugTier

RequirementsLimits

NEBUPENT SOLR 2

trimethoprim tabs 1

GP

Oxazolidinones

7

Drug Name DrugTier

RequirementsLimits

GP

NITRO-BID OINT 2

GP

QL(1 ea daily)

1 QL(1 ea daily)

GP

Drug Name DrugTier

RequirementsLimits

lorazepam conc 1

lorazepam tabs 1

8

Drug Name DrugTier

RequirementsLimits

NORPACE CR CP12 2

dofetilide caps 1

MULTAQ TABS 2

Drug Name DrugTier

RequirementsLimits

ATROVENT HFA AERS 2

Steroid Inhalants

AEROSPAN AERS 2

ASMANEX HFA AERO 2

2

9

Drug Name DrugTier

RequirementsLimits

2

GP QL(8 ml daily)

Drug Name DrugTier

RequirementsLimits

GP QL(4 ml daily)

GP QL(2 ml daily)

GP QL(2 ea daily)

2

1

10

Drug Name DrugTier

RequirementsLimits

DULERA AERO 2

2 QL(004 eadaily)

SYMBICORT AERO 2

GP

Drug Name DrugTier

RequirementsLimits

ELIQUIS TABS 5 MG 2

clonazepam tbdp 1

11

Drug Name DrugTier

RequirementsLimits

gabapentin caps 1

gabapentin soln 1

gabapentin tabs 1

GP

GP QL(6 ea daily)

GP

GP PA

GP

Drug Name DrugTier

RequirementsLimits

GP

1 QL(6 ea daily)

POTIGA TABS 2

primidone tabs 1

12

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

felbamate tabs 1

vigabatrin tabs 1

GP

phenytoin chew 1

phenytoin susp 1

ethosuximide caps 1

ethosuximide soln 1

13

Drug Name DrugTier

RequirementsLimits

GP

mirtazapine tbdp 1

Drug Name DrugTier

RequirementsLimits

14

Drug Name DrugTier

RequirementsLimits

GP

GP QL(1 ea daily)

GP

GP QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

GP QL(1 ea daily)

1

AMOXAPINE TABS 2

15

Drug Name DrugTier

RequirementsLimits

GP

GLYXAMBI TABS 2

INVOKAMET TABS 2

INVOKAMET XR TB24 2

2 QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

JENTADUETO TABS 2

SYNJARDY TABS 2

SYNJARDY XR TB24 2

AVANDIA TABS 2

Insulin

16

Drug Name DrugTier

RequirementsLimits

daily)

Drug Name DrugTier

RequirementsLimits

LEVEMIR SOLN 2

TRESIBA SOLN 2

repaglinide tabs 1

17

Drug Name DrugTier

RequirementsLimits

glimepiride tabs 1

glipizide tabs 1

glipizide tb24 1

glyburide tabs 1

tolbutamide tabs 1

Opioid Antagonists

Drug Name DrugTier

RequirementsLimits

fill retail)

nystatin tabs 1

18

Drug Name DrugTier

RequirementsLimits

fluconazole susr 1

fluconazole tabs 1

ketoconazole tabs 1

Drug Name DrugTier

RequirementsLimits

GP

19

Drug Name DrugTier

RequirementsLimits

gemfibrozil tabs 1

Drug Name DrugTier

RequirementsLimits

GP QL(1 ea daily)

GP QL(2 ea daily)

20

Drug Name DrugTier

RequirementsLimits

captopril tabs 1

trandolapril tabs 1

GP

Drug Name DrugTier

RequirementsLimits

GP

GP QL(1 ea daily)

GP

irbesartan tabs 1

21

Drug Name DrugTier

RequirementsLimits

methyldopa tabs 1

prazosin hcl caps 1

GP

GP QL(1 ea daily)

1

QL(1 ea daily)

1 QL(1 ea daily)

1

Drug Name DrugTier

RequirementsLimits

GP

QL(1 ea daily)

GP

QL(1 ea daily)

GP

GP QL(1 ea daily)

GP

22

Drug Name DrugTier

RequirementsLimits

GP

1

1 QL(2 ea daily)

GP

GP QL(1 ea daily)

GP

1 ST

1

1 QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

1

1 QL(1 ea daily)

GP

ST

1 QL(1 ea daily)

1

GP

QL(2 ea daily)

23

Drug Name DrugTier

RequirementsLimits

minoxidil tabs 1

GP

2

GP

Drug Name DrugTier

RequirementsLimits

isoniazid syrp 1

isoniazid tabs 1

PRIFTIN TABS 2

pyrazinamide tabs 1

rifabutin caps 1

rifampin caps 1

TRECATOR TABS 2

GP AC

24

Drug Name DrugTier

RequirementsLimits

GLEOSTINE CAPS 2

HEXALEN CAPS 2 AC

LEUKERAN TABS 2 AC

melphalan tabs 1 AC

MYLERAN TABS 2 AC

TABLOID TABS 2 AC

daily) AC

ODOMZO CAPS 2 AC

Drug Name DrugTier

RequirementsLimits

EMCYT CAPS 2 AC

flutamide caps 1 AC

letrozole tabs 1 AC

LYSODREN TABS 2 AC

25

Drug Name DrugTier

RequirementsLimits

BRAFTOVI CAPS 2 PA

CAPRELSA TABS 2 AC

IBRANCE CAPS 2

Drug Name DrugTier

RequirementsLimits

IRESSA TABS 2 AC

JAKAFI TABS 2 AC

MEKTOVI TABS 2 PA

NEXAVAR TABS 2

RYDAPT CAPS 2 PA AC

SPRYCEL TABS 2

SUTENT CAPS 2

26

Drug Name DrugTier

RequirementsLimits

TARCEVA TABS 2

TYKERB TABS 2

VOTRIENT TABS 2

ZEJULA CAPS 2

MATULANE CAPS 2 AC

Drug Name DrugTier

RequirementsLimits

1

GP

GP QL(4 ea daily)

27

Drug Name DrugTier

RequirementsLimits

GP QL(3 ea daily)

1

1 QL(3 ea daily)

GP QL(2 ea daily)

GP

1

GP QL(8 ea daily)

GP

STALEVO 100 TABS 2

STALEVO 125 TABS 2

STALEVO 150 TABS 2

Drug Name DrugTier

RequirementsLimits

STALEVO 50 TABS 2

STALEVO 75 TABS 2

LITHIUM SOLN 2

GP

GP QL(2 ea daily)

28

Drug Name DrugTier

RequirementsLimits

GP

haloperidol tabs 1

GP

GP QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

GP

perphenazine tabs 1

GP

29

Drug Name DrugTier

RequirementsLimits

APTIVUS CAPS 2

APTIVUS SOLN 2

BIKTARVY TABS 2

CIMDUO TABS 2

COMPLERA TABS 2 ST

CRIXIVAN CAPS 2

DELSTRIGO TABS 2 ST

DESCOVY TABS 2

didanosine cpdr 1

EDURANT TABS 2

efavirenz caps 1

efavirenz tabs 1

EMTRIVA CAPS 2

EMTRIVA SOLN 2

Drug Name DrugTier

RequirementsLimits

GP

EVOTAZ TABS 2

GENVOYA TABS 2

INTELENCE TABS 2

INVIRASE CAPS 2

INVIRASE TABS 2

ISENTRESS CHEW 2

ISENTRESS HD TABS 2

ISENTRESS PACK 2

ISENTRESS TABS 2

JULUCA TABS 2

GP

lamivudine soln 1

lamivudine tabs 1

GP

nevirapine susp 1

nevirapine tabs 1

30

Drug Name DrugTier

RequirementsLimits

nevirapine tb24 1

PIFELTRO TABS 2

PREZISTA SUSP 2

PREZISTA TABS 2

RESCRIPTOR TABS 2

GP

ritonavir tabs 1

SELZENTRY SOLN 2

SELZENTRY TABS 2

stavudine caps 1

STRIBILD TABS 2

SYMTUZA TABS 2 ST

TIVICAY TABS 2

Drug Name DrugTier

RequirementsLimits

TRIUMEQ TABS 2

GP

TRUVADA TABS 2

TYBOST TABS 2

GP

VIRACEPT TABS 2

GP

ZERIT SOLR 1 MGML 2

zidovudine caps 1

zidovudine syrp 1

zidovudine tabs 1

CMV Agents

31

Drug Name DrugTier

RequirementsLimits

GP QL(21 ml daily)

entecavir tabs 1

MAVYRET TABS 2

MODERIBA TBPK 2 PA

OLYSIO CAPS 2

Drug Name DrugTier

RequirementsLimits

GP PA

TECHNIVIE TABS 2 PA

VOSEVI TABS 2

famciclovir tabs 1

32

Drug Name DrugTier

RequirementsLimits

Influenza Agents

GP

Drug Name DrugTier

RequirementsLimits

atenolol tabs 1

2

nadolol tabs 1

pindolol tabs 1

33

Drug Name DrugTier

RequirementsLimits

sotalol hcl tabs 1

SOTYLIZE SOLN 2

GP QL(2 ea daily)

GP QL(1 ea daily)

GP

1 QL(1 ea daily)

1

Drug Name DrugTier

RequirementsLimits

nimodipine caps 1

nisoldipine tb24 1

GP QL(1 ea daily)

NYMALIZE SOLN 2

GP

1

34

Drug Name DrugTier

RequirementsLimits

GP

digoxin tabs 1

MUSE PLLT SP

Drug Name DrugTier

RequirementsLimits

tadalafil tabs SP

GP

cefadroxil susr 1

35

Drug Name DrugTier

RequirementsLimits

cefadroxil tabs 1

2

cefprozil susr 1

cefprozil tabs 1

CEFTIN SUSR 2

cefdinir susr 1

cefixime susr 1

GP

QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

GP

1 QL(1 ea daily)

1

GP QL(1 ea daily)PV

GP

36

Drug Name DrugTier

RequirementsLimits

GP

1

1 QL(1 ea daily)PV

Drug Name DrugTier

RequirementsLimits

GP

PV

GP

QL(1 ea daily)

GP QL(1 ea daily)

GP

GP QL(1 ea daily)PV

GP

QL(1 ea daily)

GP

GP QL(1 ea daily)

GP QL(1 ea daily)PV

37

Drug Name DrugTier

RequirementsLimits

ELLA TABS 2 PV

GP PV

GP QL(1 ea daily)

1

MEDROL TABS 2 MG 2

GP

Drug Name DrugTier

RequirementsLimits

NF

1

PREDNISOLONE SOLN 2

prednisolone soln 1

prednisolone syrp 1

1

38

Drug Name DrugTier

RequirementsLimits

1

GP

1

GP

Drug Name DrugTier

RequirementsLimits

GP QL(2 gm daily)

GP

CLINDAGEL GEL 2

39

Drug Name DrugTier

RequirementsLimits

1

GP

Drug Name DrugTier

RequirementsLimits

GP

SSS 10-5 FOAM 2

GP

CENTANY OINT 2

40

Drug Name DrugTier

RequirementsLimits

MUPIROCIN CREA 2

mupirocin oint 1

ciclopirox sham 1 1

GP

Drug Name DrugTier

RequirementsLimits

FLUOROPLEX CREA 2

PICATO GEL 2

GP

41

Drug Name DrugTier

RequirementsLimits

GP

AMCINONIDE CREA 2

APEXICON E CREA 2

2

1

Drug Name DrugTier

RequirementsLimits

1

CAPEX SHAM 2

GP

desonide crea 1

desonide lotn 1

desonide oint 1

42

Drug Name DrugTier

RequirementsLimits

GP

Drug Name DrugTier

RequirementsLimits

GP

43

Drug Name DrugTier

RequirementsLimits

imiquimod crea 1

podofilox soln 1

Drug Name DrugTier

RequirementsLimits

GP

DIAGNOSTIC PRODUCTS

Diagnostic Tests

2

44

Drug Name DrugTier

RequirementsLimits

2

ZENPEP CPEP 2

Drug Name DrugTier

RequirementsLimits

GP

GP QL(1 ea daily)

GP QL(2 ea daily)

1

1 QL(2 ea daily)

1 QL(1 ea daily)

45

Drug Name DrugTier

RequirementsLimits

indapamide tabs 1

metolazone tabs 1

Drug Name DrugTier

RequirementsLimits

CARBAGLU TABS 2

46

Drug Name DrugTier

RequirementsLimits

KUVAN PACK 2

KUVAN TBSO 2

paricalcitol caps 1

GP

GP QL(6 ea daily)

Drug Name DrugTier

RequirementsLimits

GP

PREMPHASE TABS 2

2

Estrogens

2

1

MENEST TABS 2

47

Drug Name DrugTier

RequirementsLimits

GP

2 QL(1 ea daily)

GP

fill retail)

Drug Name DrugTier

RequirementsLimits

ursodiol caps 1

ursodiol tabs 1

48

Drug Name DrugTier

RequirementsLimits

SFROWASA ENEM 2

GP RXOTC

GP QL(3 ea daily)

GP

GP QL(4 ea daily)

Drug Name DrugTier

RequirementsLimits

GP

GP QL(5 ea daily)

GP

1

RXOTC

GP

49

Drug Name DrugTier

RequirementsLimits

PROCYSBI CPDR 2 SP

GP

colchicine tabs 1

COLCRYS TABS 2

Drug Name DrugTier

RequirementsLimits

RIXUBIS SOLR SP PA

dipyridamole tabs 1

Folic AcidFolates

50

Drug Name DrugTier

RequirementsLimits

INTEGRA F CAPS 2

estazolam tabs 1

Drug Name DrugTier

RequirementsLimits

CLENPIQ SOLN 2 PV

GP

51

Drug Name DrugTier

RequirementsLimits

GP

PV

1 PV

Saline Laxatives

Drug Name DrugTier

RequirementsLimits

Stimulant Laxatives

bisacodyl supp 1

bisacodyl tbec 1

52

Drug Name DrugTier

RequirementsLimits

GP

ERY-TAB TBEC 2

GP

Drug Name DrugTier

RequirementsLimits

Contraceptives

53

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

54

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

55

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

56

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

2

57

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

58

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

59

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

2

60

Drug Name DrugTier

RequirementsLimits

2

Drug Name DrugTier

RequirementsLimits

61

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

62

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

63

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

64

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

65

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

66

Drug Name DrugTier

RequirementsLimits

2

Drug Name DrugTier

RequirementsLimits

MIGERGOT SUPP 2

Serotonin Agonists

GP QL(2 ea daily)

67

Drug Name DrugTier

RequirementsLimits

daily)

Fluoride

LOZI-FLUR LOZG 2

GP

K-PHOS TABS 2

1

Potassium

Drug Name DrugTier

RequirementsLimits

2

K-TAB TBCR 8 MEQ 2

KLOR-CON M15 TBCR 2

KLOR-CON25 PACK 2

1

68

Drug Name DrugTier

RequirementsLimits

cyclosporine caps 1

GP

tacrolimus caps 1

ZORTRESS TABS 2

GP

Drug Name DrugTier

RequirementsLimits

1

clotrimazole troc 1

GP

GP QL(6 ea daily)

GP QL(4 ea daily)

MULTIVITAMINS

Ped MV w Fluoride

old )

69

Drug Name DrugTier

RequirementsLimits

BAL-CARE DHA MISC 2

COMPLETENATE CHEW 2

CONCEPT DHA CAPS 2

CONCEPT OB CAPS 2

DOTHELLE DHA CAPS 2

FOCALGIN CA MISC 2

FOLIVANE-OB CAPS 2

Drug Name DrugTier

RequirementsLimits

M-VIT TABS 2 RXOTC

MARNATAL-F CAPS 2

NESTABS DHA MISC 2

PNV OB+DHA MISC 2

PNV-VP-U CAPS 2

PR NATAL 400 MISC 2

PR NATAL 430 MISC 2

PRENA 1 TRUE MISC 2

PRENATA CHEW 2

70

Drug Name DrugTier

RequirementsLimits

2

PRENATAL-U CAPS 2

2

QL(1 ea daily)

2

PROVIDA DHA CAPS 2

PROVIDA OB CAPS 2

Drug Name DrugTier

RequirementsLimits

2

TARON-C DHA CAPS 2

TRI-TABS DHA MISC 2

TRINATAL GT TABS 2

VENA-BAL DHA MISC 2

VIRT-ADVANCE TABS 2

VIRT-C DHA CAPS 2

VIRT-VITE GT TABS 2

VITATRUE MISC 2

71

Drug Name DrugTier

RequirementsLimits

Nasal Antiallergy

Drug Name DrugTier

RequirementsLimits

GP

72

Drug Name DrugTier

RequirementsLimits

BETIMOL SOLN 2

BETOPTIC-S SUSP 2

GP

1

2

ISTALOL SOLN 2

2

GP

Drug Name DrugTier

RequirementsLimits

GP

CILOXAN OINT 2

GENTAK OINT 2

MOXEZA SOLN 2

73

Drug Name DrugTier

RequirementsLimits

retail)

NATACYN SUSP 2

GP

TOBREX OINT 2

trifluridine soln 1

Drug Name DrugTier

RequirementsLimits

BLEPHAMIDE SUSP 2

2

FLAREX SUSP 2

FML FORTE SUSP 2

GP

FML OINT 2

MAXIDEX SUSP 2

GP

PRED MILD SUSP 2

2

74

Drug Name DrugTier

RequirementsLimits

2

GP

ALOCRIL SOLN 2

ALOMIDE SOLN 2

BROMFENAC SOLN 2

CYSTARAN SOLN 2

Drug Name DrugTier

RequirementsLimits

bimatoprost soln 1

LUMIGAN SOLN 2

TRAVATAN Z SOLN 2

75

Drug Name DrugTier

RequirementsLimits

Otic Combinations

GP

amoxicillin chew 1

amoxicillin susr 1

Drug Name DrugTier

RequirementsLimits

amoxicillin tabs 1

ampicillin caps 1

ampicillin susr 1

2

GP

76

Drug Name DrugTier

RequirementsLimits

GP QL(1 ea daily)

GP

disulfiram tabs 1

GP QL(1 ea daily)

GP

2

Drug Name DrugTier

RequirementsLimits

GP

GP QL(1 ea daily)

GP

rivastigmine pt24 1

GILENYA CAPS 2

77

Drug Name DrugTier

RequirementsLimits

GP PV

nicotine pt24 1 PV

2 PV

Drug Name DrugTier

RequirementsLimits

GP PV

GP

78

Drug Name DrugTier

RequirementsLimits

methimazole tabs 1

GP QL(2 ea daily)

1 QL(1 ea daily)

1

2

GP

QL(1 ea daily)

GP

thyroid tabs 1

WESTHROID TABS 2

Drug Name DrugTier

RequirementsLimits

2

CUVPOSA SOLN 2

GP

79

Drug Name DrugTier

RequirementsLimits

1

Drug Name DrugTier

RequirementsLimits

GP QL(1 ea daily)

misoprostol tabs 1

GP

80

Drug Name DrugTier

RequirementsLimits

GP

Drug Name DrugTier

RequirementsLimits

TERCONAZOLE CREA 2

Vaginal Progestins

VITAMINS

phytonadione tabs 1

81

ACULAR ACULAR LS

75 75

26 27

32 42 34

18 51 42

10 77

24 50 67 75 75 47 73 8

Index 1

22 16 21 48

1

22 21

50 67 77

22 79 39

Index 2

Index 3

53

Index 4

43 43 50 9

52 11 15 4

77 80 14 9

50 50 45 56

43 19 35

56

13 13 13 4

55

56

Index 5

56

57 20 19

Index 6

74 81

70 57

57

9 50

FORTESTA FOSAMAX

6 46

30 28 77 26 26 25 18 18 16

57

74 41 41 41 78 14 29 68 51 3

75 25 43

72

folic acid 51

Index 7

Index 8

73 19 50 18 26 50 16 16 16 18 16

59 59

59

59 35 80 49 17 17 46

16 30 68 68 49 68 5

30 69 36 43 12 12 45 19

3 3

25 27

Index 9

30 33 23 41 41 8

21

23 37 21 23 23 41 20 19 29 68 75 68 26 25 51 70 70 80 80 24 14 70

60 43 3

36 36 37

27 32 67 67 74 74

25

60 60 60

37 20 1

18

60 60

60 26 20

60

61

61 26 26 3

25 77 47

Index 10

5 81 7

25 49 24 24 11 16 5

45 80 79 6

72 3

25

Index 11

26 20 21

61 61 18

Index 12

42 42 37 6 6 4

61 69 21 44 29

62

61

62

62 14 51 21

2 15 75

1 74 39

12 70 70

Index 13

Index 14

ACTIVATED 63

Index 15

Index 16

71 20 44 29 74 20

13 33

TRILEPTAL TRILIPIX

13 20

64 11

71 65 65 29 29 29 79 34 18 9

34 73

73 73 73 31 72 2 2

25 46

17 17 81 35 16 5

21 51 8

14 75 65

65 15 24 11 17 17 40

2 2

40 37

TYBOST TYKERB

31 27

71

69

72

44

45 51

Index 17

66

19 35 78

65

81 49 49

65

49 50 48

31 31 32

65

65 5

44

65

48 48 81 32 32 32

32 13 74 13 31 31

71 71 71 8

71 48 71

Index 18

Index 19

Classes
- MULTIVITAMINS
- VITAMINS

Page 5: Health Net 2-Tier Recommended Drug List

recommendations

following reasons

pharmacy

Over-the-

Counter (OTC)

iv

request thereafter

v

request thereafter

medical benefit

exceptions

vi

Definitions

pays the rest

lowercase letters

vii

viii

Drug Name DrugTier

RequirementsLimits

GP

1

GP

2 QL(1 ea daily)

Analeptics

Drug Name DrugTier

RequirementsLimits

LOMAIRA TABS 2 PA

SP PA

CONTRAVE TB12 SP PA

XENICAL CAPS SP PA

GP QL(2 ea daily)

GP

GP QL(1 ea daily)

1

Drug Name DrugTier

RequirementsLimits

GP

Drug Name DrugTier

RequirementsLimits

KITABIS PAK NEBU 2

tobramycin nebu 1

TOBRAMYCIN NEBU 2

SP

PA

2

Drug Name DrugTier

RequirementsLimits

SP PA

KEVZARA SOAJ SP

KEVZARA SOSY SP

Drug Name DrugTier

RequirementsLimits

FENORTHO CAPS 2

ibuprofen tabs 1

indomethacin caps 1

indomethacin cpcr 1

3

Drug Name DrugTier

RequirementsLimits

oxaprozin tabs 1

OTEZLA TABS SP

OTEZLA TBPK SP

Drug Name DrugTier

RequirementsLimits

1

GP

salsalate tabs 1

GP QL(4 ea daily)

4

Drug Name DrugTier

RequirementsLimits

GP

QL(2 ea daily)

1 QL(2 ea daily)

1

1 QL(3 ea daily)

Drug Name DrugTier

RequirementsLimits

2 QL(2 ea daily)

GP

1

5

Drug Name DrugTier

RequirementsLimits

1 QL(6 ea daily)

1

1 QL(6 ea daily)

GP QL(6 ea daily)

GP

GP QL(6 ea daily)

GP

GP QL(6 ea daily)

1 QL(3 ea daily)

Drug Name DrugTier

RequirementsLimits

GP QL(10 gmdaily)

GP

NF QL(10 gmdaily)

ANDROXY TABS 2 AC

danazol caps 1

METHITEST TABS 2

1

daily)

6

Drug Name DrugTier

RequirementsLimits

GP QL(60 ml daily)

CORTIFOAM FOAM 2

praziquantel tabs 1

IMPAVIDO CAPS 2

Drug Name DrugTier

RequirementsLimits

NEBUPENT SOLR 2

trimethoprim tabs 1

GP

Oxazolidinones

7

Drug Name DrugTier

RequirementsLimits

GP

NITRO-BID OINT 2

GP

QL(1 ea daily)

1 QL(1 ea daily)

GP

Drug Name DrugTier

RequirementsLimits

lorazepam conc 1

lorazepam tabs 1

8

Drug Name DrugTier

RequirementsLimits

NORPACE CR CP12 2

dofetilide caps 1

MULTAQ TABS 2

Drug Name DrugTier

RequirementsLimits

ATROVENT HFA AERS 2

Steroid Inhalants

AEROSPAN AERS 2

ASMANEX HFA AERO 2

2

9

Drug Name DrugTier

RequirementsLimits

2

GP QL(8 ml daily)

Drug Name DrugTier

RequirementsLimits

GP QL(4 ml daily)

GP QL(2 ml daily)

GP QL(2 ea daily)

2

1

10

Drug Name DrugTier

RequirementsLimits

DULERA AERO 2

2 QL(004 eadaily)

SYMBICORT AERO 2

GP

Drug Name DrugTier

RequirementsLimits

ELIQUIS TABS 5 MG 2

clonazepam tbdp 1

11

Drug Name DrugTier

RequirementsLimits

gabapentin caps 1

gabapentin soln 1

gabapentin tabs 1

GP

GP QL(6 ea daily)

GP

GP PA

GP

Drug Name DrugTier

RequirementsLimits

GP

1 QL(6 ea daily)

POTIGA TABS 2

primidone tabs 1

12

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

felbamate tabs 1

vigabatrin tabs 1

GP

phenytoin chew 1

phenytoin susp 1

ethosuximide caps 1

ethosuximide soln 1

13

Drug Name DrugTier

RequirementsLimits

GP

mirtazapine tbdp 1

Drug Name DrugTier

RequirementsLimits

14

Drug Name DrugTier

RequirementsLimits

GP

GP QL(1 ea daily)

GP

GP QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

GP QL(1 ea daily)

1

AMOXAPINE TABS 2

15

Drug Name DrugTier

RequirementsLimits

GP

GLYXAMBI TABS 2

INVOKAMET TABS 2

INVOKAMET XR TB24 2

2 QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

JENTADUETO TABS 2

SYNJARDY TABS 2

SYNJARDY XR TB24 2

AVANDIA TABS 2

Insulin

16

Drug Name DrugTier

RequirementsLimits

daily)

Drug Name DrugTier

RequirementsLimits

LEVEMIR SOLN 2

TRESIBA SOLN 2

repaglinide tabs 1

17

Drug Name DrugTier

RequirementsLimits

glimepiride tabs 1

glipizide tabs 1

glipizide tb24 1

glyburide tabs 1

tolbutamide tabs 1

Opioid Antagonists

Drug Name DrugTier

RequirementsLimits

fill retail)

nystatin tabs 1

18

Drug Name DrugTier

RequirementsLimits

fluconazole susr 1

fluconazole tabs 1

ketoconazole tabs 1

Drug Name DrugTier

RequirementsLimits

GP

19

Drug Name DrugTier

RequirementsLimits

gemfibrozil tabs 1

Drug Name DrugTier

RequirementsLimits

GP QL(1 ea daily)

GP QL(2 ea daily)

20

Drug Name DrugTier

RequirementsLimits

captopril tabs 1

trandolapril tabs 1

GP

Drug Name DrugTier

RequirementsLimits

GP

GP QL(1 ea daily)

GP

irbesartan tabs 1

21

Drug Name DrugTier

RequirementsLimits

methyldopa tabs 1

prazosin hcl caps 1

GP

GP QL(1 ea daily)

1

QL(1 ea daily)

1 QL(1 ea daily)

1

Drug Name DrugTier

RequirementsLimits

GP

QL(1 ea daily)

GP

QL(1 ea daily)

GP

GP QL(1 ea daily)

GP

22

Drug Name DrugTier

RequirementsLimits

GP

1

1 QL(2 ea daily)

GP

GP QL(1 ea daily)

GP

1 ST

1

1 QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

1

1 QL(1 ea daily)

GP

ST

1 QL(1 ea daily)

1

GP

QL(2 ea daily)

23

Drug Name DrugTier

RequirementsLimits

minoxidil tabs 1

GP

2

GP

Drug Name DrugTier

RequirementsLimits

isoniazid syrp 1

isoniazid tabs 1

PRIFTIN TABS 2

pyrazinamide tabs 1

rifabutin caps 1

rifampin caps 1

TRECATOR TABS 2

GP AC

24

Drug Name DrugTier

RequirementsLimits

GLEOSTINE CAPS 2

HEXALEN CAPS 2 AC

LEUKERAN TABS 2 AC

melphalan tabs 1 AC

MYLERAN TABS 2 AC

TABLOID TABS 2 AC

daily) AC

ODOMZO CAPS 2 AC

Drug Name DrugTier

RequirementsLimits

EMCYT CAPS 2 AC

flutamide caps 1 AC

letrozole tabs 1 AC

LYSODREN TABS 2 AC

25

Drug Name DrugTier

RequirementsLimits

BRAFTOVI CAPS 2 PA

CAPRELSA TABS 2 AC

IBRANCE CAPS 2

Drug Name DrugTier

RequirementsLimits

IRESSA TABS 2 AC

JAKAFI TABS 2 AC

MEKTOVI TABS 2 PA

NEXAVAR TABS 2

RYDAPT CAPS 2 PA AC

SPRYCEL TABS 2

SUTENT CAPS 2

26

Drug Name DrugTier

RequirementsLimits

TARCEVA TABS 2

TYKERB TABS 2

VOTRIENT TABS 2

ZEJULA CAPS 2

MATULANE CAPS 2 AC

Drug Name DrugTier

RequirementsLimits

1

GP

GP QL(4 ea daily)

27

Drug Name DrugTier

RequirementsLimits

GP QL(3 ea daily)

1

1 QL(3 ea daily)

GP QL(2 ea daily)

GP

1

GP QL(8 ea daily)

GP

STALEVO 100 TABS 2

STALEVO 125 TABS 2

STALEVO 150 TABS 2

Drug Name DrugTier

RequirementsLimits

STALEVO 50 TABS 2

STALEVO 75 TABS 2

LITHIUM SOLN 2

GP

GP QL(2 ea daily)

28

Drug Name DrugTier

RequirementsLimits

GP

haloperidol tabs 1

GP

GP QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

GP

perphenazine tabs 1

GP

29

Drug Name DrugTier

RequirementsLimits

APTIVUS CAPS 2

APTIVUS SOLN 2

BIKTARVY TABS 2

CIMDUO TABS 2

COMPLERA TABS 2 ST

CRIXIVAN CAPS 2

DELSTRIGO TABS 2 ST

DESCOVY TABS 2

didanosine cpdr 1

EDURANT TABS 2

efavirenz caps 1

efavirenz tabs 1

EMTRIVA CAPS 2

EMTRIVA SOLN 2

Drug Name DrugTier

RequirementsLimits

GP

EVOTAZ TABS 2

GENVOYA TABS 2

INTELENCE TABS 2

INVIRASE CAPS 2

INVIRASE TABS 2

ISENTRESS CHEW 2

ISENTRESS HD TABS 2

ISENTRESS PACK 2

ISENTRESS TABS 2

JULUCA TABS 2

GP

lamivudine soln 1

lamivudine tabs 1

GP

nevirapine susp 1

nevirapine tabs 1

30

Drug Name DrugTier

RequirementsLimits

nevirapine tb24 1

PIFELTRO TABS 2

PREZISTA SUSP 2

PREZISTA TABS 2

RESCRIPTOR TABS 2

GP

ritonavir tabs 1

SELZENTRY SOLN 2

SELZENTRY TABS 2

stavudine caps 1

STRIBILD TABS 2

SYMTUZA TABS 2 ST

TIVICAY TABS 2

Drug Name DrugTier

RequirementsLimits

TRIUMEQ TABS 2

GP

TRUVADA TABS 2

TYBOST TABS 2

GP

VIRACEPT TABS 2

GP

ZERIT SOLR 1 MGML 2

zidovudine caps 1

zidovudine syrp 1

zidovudine tabs 1

CMV Agents

31

Drug Name DrugTier

RequirementsLimits

GP QL(21 ml daily)

entecavir tabs 1

MAVYRET TABS 2

MODERIBA TBPK 2 PA

OLYSIO CAPS 2

Drug Name DrugTier

RequirementsLimits

GP PA

TECHNIVIE TABS 2 PA

VOSEVI TABS 2

famciclovir tabs 1

32

Drug Name DrugTier

RequirementsLimits

Influenza Agents

GP

Drug Name DrugTier

RequirementsLimits

atenolol tabs 1

2

nadolol tabs 1

pindolol tabs 1

33

Drug Name DrugTier

RequirementsLimits

sotalol hcl tabs 1

SOTYLIZE SOLN 2

GP QL(2 ea daily)

GP QL(1 ea daily)

GP

1 QL(1 ea daily)

1

Drug Name DrugTier

RequirementsLimits

nimodipine caps 1

nisoldipine tb24 1

GP QL(1 ea daily)

NYMALIZE SOLN 2

GP

1

34

Drug Name DrugTier

RequirementsLimits

GP

digoxin tabs 1

MUSE PLLT SP

Drug Name DrugTier

RequirementsLimits

tadalafil tabs SP

GP

cefadroxil susr 1

35

Drug Name DrugTier

RequirementsLimits

cefadroxil tabs 1

2

cefprozil susr 1

cefprozil tabs 1

CEFTIN SUSR 2

cefdinir susr 1

cefixime susr 1

GP

QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

GP

1 QL(1 ea daily)

1

GP QL(1 ea daily)PV

GP

36

Drug Name DrugTier

RequirementsLimits

GP

1

1 QL(1 ea daily)PV

Drug Name DrugTier

RequirementsLimits

GP

PV

GP

QL(1 ea daily)

GP QL(1 ea daily)

GP

GP QL(1 ea daily)PV

GP

QL(1 ea daily)

GP

GP QL(1 ea daily)

GP QL(1 ea daily)PV

37

Drug Name DrugTier

RequirementsLimits

ELLA TABS 2 PV

GP PV

GP QL(1 ea daily)

1

MEDROL TABS 2 MG 2

GP

Drug Name DrugTier

RequirementsLimits

NF

1

PREDNISOLONE SOLN 2

prednisolone soln 1

prednisolone syrp 1

1

38

Drug Name DrugTier

RequirementsLimits

1

GP

1

GP

Drug Name DrugTier

RequirementsLimits

GP QL(2 gm daily)

GP

CLINDAGEL GEL 2

39

Drug Name DrugTier

RequirementsLimits

1

GP

Drug Name DrugTier

RequirementsLimits

GP

SSS 10-5 FOAM 2

GP

CENTANY OINT 2

40

Drug Name DrugTier

RequirementsLimits

MUPIROCIN CREA 2

mupirocin oint 1

ciclopirox sham 1 1

GP

Drug Name DrugTier

RequirementsLimits

FLUOROPLEX CREA 2

PICATO GEL 2

GP

41

Drug Name DrugTier

RequirementsLimits

GP

AMCINONIDE CREA 2

APEXICON E CREA 2

2

1

Drug Name DrugTier

RequirementsLimits

1

CAPEX SHAM 2

GP

desonide crea 1

desonide lotn 1

desonide oint 1

42

Drug Name DrugTier

RequirementsLimits

GP

Drug Name DrugTier

RequirementsLimits

GP

43

Drug Name DrugTier

RequirementsLimits

imiquimod crea 1

podofilox soln 1

Drug Name DrugTier

RequirementsLimits

GP

DIAGNOSTIC PRODUCTS

Diagnostic Tests

2

44

Drug Name DrugTier

RequirementsLimits

2

ZENPEP CPEP 2

Drug Name DrugTier

RequirementsLimits

GP

GP QL(1 ea daily)

GP QL(2 ea daily)

1

1 QL(2 ea daily)

1 QL(1 ea daily)

45

Drug Name DrugTier

RequirementsLimits

indapamide tabs 1

metolazone tabs 1

Drug Name DrugTier

RequirementsLimits

CARBAGLU TABS 2

46

Drug Name DrugTier

RequirementsLimits

KUVAN PACK 2

KUVAN TBSO 2

paricalcitol caps 1

GP

GP QL(6 ea daily)

Drug Name DrugTier

RequirementsLimits

GP

PREMPHASE TABS 2

2

Estrogens

2

1

MENEST TABS 2

47

Drug Name DrugTier

RequirementsLimits

GP

2 QL(1 ea daily)

GP

fill retail)

Drug Name DrugTier

RequirementsLimits

ursodiol caps 1

ursodiol tabs 1

48

Drug Name DrugTier

RequirementsLimits

SFROWASA ENEM 2

GP RXOTC

GP QL(3 ea daily)

GP

GP QL(4 ea daily)

Drug Name DrugTier

RequirementsLimits

GP

GP QL(5 ea daily)

GP

1

RXOTC

GP

49

Drug Name DrugTier

RequirementsLimits

PROCYSBI CPDR 2 SP

GP

colchicine tabs 1

COLCRYS TABS 2

Drug Name DrugTier

RequirementsLimits

RIXUBIS SOLR SP PA

dipyridamole tabs 1

Folic AcidFolates

50

Drug Name DrugTier

RequirementsLimits

INTEGRA F CAPS 2

estazolam tabs 1

Drug Name DrugTier

RequirementsLimits

CLENPIQ SOLN 2 PV

GP

51

Drug Name DrugTier

RequirementsLimits

GP

PV

1 PV

Saline Laxatives

Drug Name DrugTier

RequirementsLimits

Stimulant Laxatives

bisacodyl supp 1

bisacodyl tbec 1

52

Drug Name DrugTier

RequirementsLimits

GP

ERY-TAB TBEC 2

GP

Drug Name DrugTier

RequirementsLimits

Contraceptives

53

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

54

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

55

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

56

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

2

57

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

58

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

59

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

2

60

Drug Name DrugTier

RequirementsLimits

2

Drug Name DrugTier

RequirementsLimits

61

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

62

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

63

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

64

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

65

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

66

Drug Name DrugTier

RequirementsLimits

2

Drug Name DrugTier

RequirementsLimits

MIGERGOT SUPP 2

Serotonin Agonists

GP QL(2 ea daily)

67

Drug Name DrugTier

RequirementsLimits

daily)

Fluoride

LOZI-FLUR LOZG 2

GP

K-PHOS TABS 2

1

Potassium

Drug Name DrugTier

RequirementsLimits

2

K-TAB TBCR 8 MEQ 2

KLOR-CON M15 TBCR 2

KLOR-CON25 PACK 2

1

68

Drug Name DrugTier

RequirementsLimits

cyclosporine caps 1

GP

tacrolimus caps 1

ZORTRESS TABS 2

GP

Drug Name DrugTier

RequirementsLimits

1

clotrimazole troc 1

GP

GP QL(6 ea daily)

GP QL(4 ea daily)

MULTIVITAMINS

Ped MV w Fluoride

old )

69

Drug Name DrugTier

RequirementsLimits

BAL-CARE DHA MISC 2

COMPLETENATE CHEW 2

CONCEPT DHA CAPS 2

CONCEPT OB CAPS 2

DOTHELLE DHA CAPS 2

FOCALGIN CA MISC 2

FOLIVANE-OB CAPS 2

Drug Name DrugTier

RequirementsLimits

M-VIT TABS 2 RXOTC

MARNATAL-F CAPS 2

NESTABS DHA MISC 2

PNV OB+DHA MISC 2

PNV-VP-U CAPS 2

PR NATAL 400 MISC 2

PR NATAL 430 MISC 2

PRENA 1 TRUE MISC 2

PRENATA CHEW 2

70

Drug Name DrugTier

RequirementsLimits

2

PRENATAL-U CAPS 2

2

QL(1 ea daily)

2

PROVIDA DHA CAPS 2

PROVIDA OB CAPS 2

Drug Name DrugTier

RequirementsLimits

2

TARON-C DHA CAPS 2

TRI-TABS DHA MISC 2

TRINATAL GT TABS 2

VENA-BAL DHA MISC 2

VIRT-ADVANCE TABS 2

VIRT-C DHA CAPS 2

VIRT-VITE GT TABS 2

VITATRUE MISC 2

71

Drug Name DrugTier

RequirementsLimits

Nasal Antiallergy

Drug Name DrugTier

RequirementsLimits

GP

72

Drug Name DrugTier

RequirementsLimits

BETIMOL SOLN 2

BETOPTIC-S SUSP 2

GP

1

2

ISTALOL SOLN 2

2

GP

Drug Name DrugTier

RequirementsLimits

GP

CILOXAN OINT 2

GENTAK OINT 2

MOXEZA SOLN 2

73

Drug Name DrugTier

RequirementsLimits

retail)

NATACYN SUSP 2

GP

TOBREX OINT 2

trifluridine soln 1

Drug Name DrugTier

RequirementsLimits

BLEPHAMIDE SUSP 2

2

FLAREX SUSP 2

FML FORTE SUSP 2

GP

FML OINT 2

MAXIDEX SUSP 2

GP

PRED MILD SUSP 2

2

74

Drug Name DrugTier

RequirementsLimits

2

GP

ALOCRIL SOLN 2

ALOMIDE SOLN 2

BROMFENAC SOLN 2

CYSTARAN SOLN 2

Drug Name DrugTier

RequirementsLimits

bimatoprost soln 1

LUMIGAN SOLN 2

TRAVATAN Z SOLN 2

75

Drug Name DrugTier

RequirementsLimits

Otic Combinations

GP

amoxicillin chew 1

amoxicillin susr 1

Drug Name DrugTier

RequirementsLimits

amoxicillin tabs 1

ampicillin caps 1

ampicillin susr 1

2

GP

76

Drug Name DrugTier

RequirementsLimits

GP QL(1 ea daily)

GP

disulfiram tabs 1

GP QL(1 ea daily)

GP

2

Drug Name DrugTier

RequirementsLimits

GP

GP QL(1 ea daily)

GP

rivastigmine pt24 1

GILENYA CAPS 2

77

Drug Name DrugTier

RequirementsLimits

GP PV

nicotine pt24 1 PV

2 PV

Drug Name DrugTier

RequirementsLimits

GP PV

GP

78

Drug Name DrugTier

RequirementsLimits

methimazole tabs 1

GP QL(2 ea daily)

1 QL(1 ea daily)

1

2

GP

QL(1 ea daily)

GP

thyroid tabs 1

WESTHROID TABS 2

Drug Name DrugTier

RequirementsLimits

2

CUVPOSA SOLN 2

GP

79

Drug Name DrugTier

RequirementsLimits

1

Drug Name DrugTier

RequirementsLimits

GP QL(1 ea daily)

misoprostol tabs 1

GP

80

Drug Name DrugTier

RequirementsLimits

GP

Drug Name DrugTier

RequirementsLimits

TERCONAZOLE CREA 2

Vaginal Progestins

VITAMINS

phytonadione tabs 1

81

ACULAR ACULAR LS

75 75

26 27

32 42 34

18 51 42

10 77

24 50 67 75 75 47 73 8

Index 1

22 16 21 48

1

22 21

50 67 77

22 79 39

Index 2

Index 3

53

Index 4

43 43 50 9

52 11 15 4

77 80 14 9

50 50 45 56

43 19 35

56

13 13 13 4

55

56

Index 5

56

57 20 19

Index 6

74 81

70 57

57

9 50

FORTESTA FOSAMAX

6 46

30 28 77 26 26 25 18 18 16

57

74 41 41 41 78 14 29 68 51 3

75 25 43

72

folic acid 51

Index 7

Index 8

73 19 50 18 26 50 16 16 16 18 16

59 59

59

59 35 80 49 17 17 46

16 30 68 68 49 68 5

30 69 36 43 12 12 45 19

3 3

25 27

Index 9

30 33 23 41 41 8

21

23 37 21 23 23 41 20 19 29 68 75 68 26 25 51 70 70 80 80 24 14 70

60 43 3

36 36 37

27 32 67 67 74 74

25

60 60 60

37 20 1

18

60 60

60 26 20

60

61

61 26 26 3

25 77 47

Index 10

5 81 7

25 49 24 24 11 16 5

45 80 79 6

72 3

25

Index 11

26 20 21

61 61 18

Index 12

42 42 37 6 6 4

61 69 21 44 29

62

61

62

62 14 51 21

2 15 75

1 74 39

12 70 70

Index 13

Index 14

ACTIVATED 63

Index 15

Index 16

71 20 44 29 74 20

13 33

TRILEPTAL TRILIPIX

13 20

64 11

71 65 65 29 29 29 79 34 18 9

34 73

73 73 73 31 72 2 2

25 46

17 17 81 35 16 5

21 51 8

14 75 65

65 15 24 11 17 17 40

2 2

40 37

TYBOST TYKERB

31 27

71

69

72

44

45 51

Index 17

66

19 35 78

65

81 49 49

65

49 50 48

31 31 32

65

65 5

44

65

48 48 81 32 32 32

32 13 74 13 31 31

71 71 71 8

71 48 71

Index 18

Index 19

Classes
- MULTIVITAMINS
- VITAMINS

Page 6: Health Net 2-Tier Recommended Drug List

request thereafter

v

request thereafter

medical benefit

exceptions

vi

Definitions

pays the rest

lowercase letters

vii

viii

Drug Name DrugTier

RequirementsLimits

GP

1

GP

2 QL(1 ea daily)

Analeptics

Drug Name DrugTier

RequirementsLimits

LOMAIRA TABS 2 PA

SP PA

CONTRAVE TB12 SP PA

XENICAL CAPS SP PA

GP QL(2 ea daily)

GP

GP QL(1 ea daily)

1

Drug Name DrugTier

RequirementsLimits

GP

Drug Name DrugTier

RequirementsLimits

KITABIS PAK NEBU 2

tobramycin nebu 1

TOBRAMYCIN NEBU 2

SP

PA

2

Drug Name DrugTier

RequirementsLimits

SP PA

KEVZARA SOAJ SP

KEVZARA SOSY SP

Drug Name DrugTier

RequirementsLimits

FENORTHO CAPS 2

ibuprofen tabs 1

indomethacin caps 1

indomethacin cpcr 1

3

Drug Name DrugTier

RequirementsLimits

oxaprozin tabs 1

OTEZLA TABS SP

OTEZLA TBPK SP

Drug Name DrugTier

RequirementsLimits

1

GP

salsalate tabs 1

GP QL(4 ea daily)

4

Drug Name DrugTier

RequirementsLimits

GP

QL(2 ea daily)

1 QL(2 ea daily)

1

1 QL(3 ea daily)

Drug Name DrugTier

RequirementsLimits

2 QL(2 ea daily)

GP

1

5

Drug Name DrugTier

RequirementsLimits

1 QL(6 ea daily)

1

1 QL(6 ea daily)

GP QL(6 ea daily)

GP

GP QL(6 ea daily)

GP

GP QL(6 ea daily)

1 QL(3 ea daily)

Drug Name DrugTier

RequirementsLimits

GP QL(10 gmdaily)

GP

NF QL(10 gmdaily)

ANDROXY TABS 2 AC

danazol caps 1

METHITEST TABS 2

1

daily)

6

Drug Name DrugTier

RequirementsLimits

GP QL(60 ml daily)

CORTIFOAM FOAM 2

praziquantel tabs 1

IMPAVIDO CAPS 2

Drug Name DrugTier

RequirementsLimits

NEBUPENT SOLR 2

trimethoprim tabs 1

GP

Oxazolidinones

7

Drug Name DrugTier

RequirementsLimits

GP

NITRO-BID OINT 2

GP

QL(1 ea daily)

1 QL(1 ea daily)

GP

Drug Name DrugTier

RequirementsLimits

lorazepam conc 1

lorazepam tabs 1

8

Drug Name DrugTier

RequirementsLimits

NORPACE CR CP12 2

dofetilide caps 1

MULTAQ TABS 2

Drug Name DrugTier

RequirementsLimits

ATROVENT HFA AERS 2

Steroid Inhalants

AEROSPAN AERS 2

ASMANEX HFA AERO 2

2

9

Drug Name DrugTier

RequirementsLimits

2

GP QL(8 ml daily)

Drug Name DrugTier

RequirementsLimits

GP QL(4 ml daily)

GP QL(2 ml daily)

GP QL(2 ea daily)

2

1

10

Drug Name DrugTier

RequirementsLimits

DULERA AERO 2

2 QL(004 eadaily)

SYMBICORT AERO 2

GP

Drug Name DrugTier

RequirementsLimits

ELIQUIS TABS 5 MG 2

clonazepam tbdp 1

11

Drug Name DrugTier

RequirementsLimits

gabapentin caps 1

gabapentin soln 1

gabapentin tabs 1

GP

GP QL(6 ea daily)

GP

GP PA

GP

Drug Name DrugTier

RequirementsLimits

GP

1 QL(6 ea daily)

POTIGA TABS 2

primidone tabs 1

12

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

felbamate tabs 1

vigabatrin tabs 1

GP

phenytoin chew 1

phenytoin susp 1

ethosuximide caps 1

ethosuximide soln 1

13

Drug Name DrugTier

RequirementsLimits

GP

mirtazapine tbdp 1

Drug Name DrugTier

RequirementsLimits

14

Drug Name DrugTier

RequirementsLimits

GP

GP QL(1 ea daily)

GP

GP QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

GP QL(1 ea daily)

1

AMOXAPINE TABS 2

15

Drug Name DrugTier

RequirementsLimits

GP

GLYXAMBI TABS 2

INVOKAMET TABS 2

INVOKAMET XR TB24 2

2 QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

JENTADUETO TABS 2

SYNJARDY TABS 2

SYNJARDY XR TB24 2

AVANDIA TABS 2

Insulin

16

Drug Name DrugTier

RequirementsLimits

daily)

Drug Name DrugTier

RequirementsLimits

LEVEMIR SOLN 2

TRESIBA SOLN 2

repaglinide tabs 1

17

Drug Name DrugTier

RequirementsLimits

glimepiride tabs 1

glipizide tabs 1

glipizide tb24 1

glyburide tabs 1

tolbutamide tabs 1

Opioid Antagonists

Drug Name DrugTier

RequirementsLimits

fill retail)

nystatin tabs 1

18

Drug Name DrugTier

RequirementsLimits

fluconazole susr 1

fluconazole tabs 1

ketoconazole tabs 1

Drug Name DrugTier

RequirementsLimits

GP

19

Drug Name DrugTier

RequirementsLimits

gemfibrozil tabs 1

Drug Name DrugTier

RequirementsLimits

GP QL(1 ea daily)

GP QL(2 ea daily)

20

Drug Name DrugTier

RequirementsLimits

captopril tabs 1

trandolapril tabs 1

GP

Drug Name DrugTier

RequirementsLimits

GP

GP QL(1 ea daily)

GP

irbesartan tabs 1

21

Drug Name DrugTier

RequirementsLimits

methyldopa tabs 1

prazosin hcl caps 1

GP

GP QL(1 ea daily)

1

QL(1 ea daily)

1 QL(1 ea daily)

1

Drug Name DrugTier

RequirementsLimits

GP

QL(1 ea daily)

GP

QL(1 ea daily)

GP

GP QL(1 ea daily)

GP

22

Drug Name DrugTier

RequirementsLimits

GP

1

1 QL(2 ea daily)

GP

GP QL(1 ea daily)

GP

1 ST

1

1 QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

1

1 QL(1 ea daily)

GP

ST

1 QL(1 ea daily)

1

GP

QL(2 ea daily)

23

Drug Name DrugTier

RequirementsLimits

minoxidil tabs 1

GP

2

GP

Drug Name DrugTier

RequirementsLimits

isoniazid syrp 1

isoniazid tabs 1

PRIFTIN TABS 2

pyrazinamide tabs 1

rifabutin caps 1

rifampin caps 1

TRECATOR TABS 2

GP AC

24

Drug Name DrugTier

RequirementsLimits

GLEOSTINE CAPS 2

HEXALEN CAPS 2 AC

LEUKERAN TABS 2 AC

melphalan tabs 1 AC

MYLERAN TABS 2 AC

TABLOID TABS 2 AC

daily) AC

ODOMZO CAPS 2 AC

Drug Name DrugTier

RequirementsLimits

EMCYT CAPS 2 AC

flutamide caps 1 AC

letrozole tabs 1 AC

LYSODREN TABS 2 AC

25

Drug Name DrugTier

RequirementsLimits

BRAFTOVI CAPS 2 PA

CAPRELSA TABS 2 AC

IBRANCE CAPS 2

Drug Name DrugTier

RequirementsLimits

IRESSA TABS 2 AC

JAKAFI TABS 2 AC

MEKTOVI TABS 2 PA

NEXAVAR TABS 2

RYDAPT CAPS 2 PA AC

SPRYCEL TABS 2

SUTENT CAPS 2

26

Drug Name DrugTier

RequirementsLimits

TARCEVA TABS 2

TYKERB TABS 2

VOTRIENT TABS 2

ZEJULA CAPS 2

MATULANE CAPS 2 AC

Drug Name DrugTier

RequirementsLimits

1

GP

GP QL(4 ea daily)

27

Drug Name DrugTier

RequirementsLimits

GP QL(3 ea daily)

1

1 QL(3 ea daily)

GP QL(2 ea daily)

GP

1

GP QL(8 ea daily)

GP

STALEVO 100 TABS 2

STALEVO 125 TABS 2

STALEVO 150 TABS 2

Drug Name DrugTier

RequirementsLimits

STALEVO 50 TABS 2

STALEVO 75 TABS 2

LITHIUM SOLN 2

GP

GP QL(2 ea daily)

28

Drug Name DrugTier

RequirementsLimits

GP

haloperidol tabs 1

GP

GP QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

GP

perphenazine tabs 1

GP

29

Drug Name DrugTier

RequirementsLimits

APTIVUS CAPS 2

APTIVUS SOLN 2

BIKTARVY TABS 2

CIMDUO TABS 2

COMPLERA TABS 2 ST

CRIXIVAN CAPS 2

DELSTRIGO TABS 2 ST

DESCOVY TABS 2

didanosine cpdr 1

EDURANT TABS 2

efavirenz caps 1

efavirenz tabs 1

EMTRIVA CAPS 2

EMTRIVA SOLN 2

Drug Name DrugTier

RequirementsLimits

GP

EVOTAZ TABS 2

GENVOYA TABS 2

INTELENCE TABS 2

INVIRASE CAPS 2

INVIRASE TABS 2

ISENTRESS CHEW 2

ISENTRESS HD TABS 2

ISENTRESS PACK 2

ISENTRESS TABS 2

JULUCA TABS 2

GP

lamivudine soln 1

lamivudine tabs 1

GP

nevirapine susp 1

nevirapine tabs 1

30

Drug Name DrugTier

RequirementsLimits

nevirapine tb24 1

PIFELTRO TABS 2

PREZISTA SUSP 2

PREZISTA TABS 2

RESCRIPTOR TABS 2

GP

ritonavir tabs 1

SELZENTRY SOLN 2

SELZENTRY TABS 2

stavudine caps 1

STRIBILD TABS 2

SYMTUZA TABS 2 ST

TIVICAY TABS 2

Drug Name DrugTier

RequirementsLimits

TRIUMEQ TABS 2

GP

TRUVADA TABS 2

TYBOST TABS 2

GP

VIRACEPT TABS 2

GP

ZERIT SOLR 1 MGML 2

zidovudine caps 1

zidovudine syrp 1

zidovudine tabs 1

CMV Agents

31

Drug Name DrugTier

RequirementsLimits

GP QL(21 ml daily)

entecavir tabs 1

MAVYRET TABS 2

MODERIBA TBPK 2 PA

OLYSIO CAPS 2

Drug Name DrugTier

RequirementsLimits

GP PA

TECHNIVIE TABS 2 PA

VOSEVI TABS 2

famciclovir tabs 1

32

Drug Name DrugTier

RequirementsLimits

Influenza Agents

GP

Drug Name DrugTier

RequirementsLimits

atenolol tabs 1

2

nadolol tabs 1

pindolol tabs 1

33

Drug Name DrugTier

RequirementsLimits

sotalol hcl tabs 1

SOTYLIZE SOLN 2

GP QL(2 ea daily)

GP QL(1 ea daily)

GP

1 QL(1 ea daily)

1

Drug Name DrugTier

RequirementsLimits

nimodipine caps 1

nisoldipine tb24 1

GP QL(1 ea daily)

NYMALIZE SOLN 2

GP

1

34

Drug Name DrugTier

RequirementsLimits

GP

digoxin tabs 1

MUSE PLLT SP

Drug Name DrugTier

RequirementsLimits

tadalafil tabs SP

GP

cefadroxil susr 1

35

Drug Name DrugTier

RequirementsLimits

cefadroxil tabs 1

2

cefprozil susr 1

cefprozil tabs 1

CEFTIN SUSR 2

cefdinir susr 1

cefixime susr 1

GP

QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

GP

1 QL(1 ea daily)

1

GP QL(1 ea daily)PV

GP

36

Drug Name DrugTier

RequirementsLimits

GP

1

1 QL(1 ea daily)PV

Drug Name DrugTier

RequirementsLimits

GP

PV

GP

QL(1 ea daily)

GP QL(1 ea daily)

GP

GP QL(1 ea daily)PV

GP

QL(1 ea daily)

GP

GP QL(1 ea daily)

GP QL(1 ea daily)PV

37

Drug Name DrugTier

RequirementsLimits

ELLA TABS 2 PV

GP PV

GP QL(1 ea daily)

1

MEDROL TABS 2 MG 2

GP

Drug Name DrugTier

RequirementsLimits

NF

1

PREDNISOLONE SOLN 2

prednisolone soln 1

prednisolone syrp 1

1

38

Drug Name DrugTier

RequirementsLimits

1

GP

1

GP

Drug Name DrugTier

RequirementsLimits

GP QL(2 gm daily)

GP

CLINDAGEL GEL 2

39

Drug Name DrugTier

RequirementsLimits

1

GP

Drug Name DrugTier

RequirementsLimits

GP

SSS 10-5 FOAM 2

GP

CENTANY OINT 2

40

Drug Name DrugTier

RequirementsLimits

MUPIROCIN CREA 2

mupirocin oint 1

ciclopirox sham 1 1

GP

Drug Name DrugTier

RequirementsLimits

FLUOROPLEX CREA 2

PICATO GEL 2

GP

41

Drug Name DrugTier

RequirementsLimits

GP

AMCINONIDE CREA 2

APEXICON E CREA 2

2

1

Drug Name DrugTier

RequirementsLimits

1

CAPEX SHAM 2

GP

desonide crea 1

desonide lotn 1

desonide oint 1

42

Drug Name DrugTier

RequirementsLimits

GP

Drug Name DrugTier

RequirementsLimits

GP

43

Drug Name DrugTier

RequirementsLimits

imiquimod crea 1

podofilox soln 1

Drug Name DrugTier

RequirementsLimits

GP

DIAGNOSTIC PRODUCTS

Diagnostic Tests

2

44

Drug Name DrugTier

RequirementsLimits

2

ZENPEP CPEP 2

Drug Name DrugTier

RequirementsLimits

GP

GP QL(1 ea daily)

GP QL(2 ea daily)

1

1 QL(2 ea daily)

1 QL(1 ea daily)

45

Drug Name DrugTier

RequirementsLimits

indapamide tabs 1

metolazone tabs 1

Drug Name DrugTier

RequirementsLimits

CARBAGLU TABS 2

46

Drug Name DrugTier

RequirementsLimits

KUVAN PACK 2

KUVAN TBSO 2

paricalcitol caps 1

GP

GP QL(6 ea daily)

Drug Name DrugTier

RequirementsLimits

GP

PREMPHASE TABS 2

2

Estrogens

2

1

MENEST TABS 2

47

Drug Name DrugTier

RequirementsLimits

GP

2 QL(1 ea daily)

GP

fill retail)

Drug Name DrugTier

RequirementsLimits

ursodiol caps 1

ursodiol tabs 1

48

Drug Name DrugTier

RequirementsLimits

SFROWASA ENEM 2

GP RXOTC

GP QL(3 ea daily)

GP

GP QL(4 ea daily)

Drug Name DrugTier

RequirementsLimits

GP

GP QL(5 ea daily)

GP

1

RXOTC

GP

49

Drug Name DrugTier

RequirementsLimits

PROCYSBI CPDR 2 SP

GP

colchicine tabs 1

COLCRYS TABS 2

Drug Name DrugTier

RequirementsLimits

RIXUBIS SOLR SP PA

dipyridamole tabs 1

Folic AcidFolates

50

Drug Name DrugTier

RequirementsLimits

INTEGRA F CAPS 2

estazolam tabs 1

Drug Name DrugTier

RequirementsLimits

CLENPIQ SOLN 2 PV

GP

51

Drug Name DrugTier

RequirementsLimits

GP

PV

1 PV

Saline Laxatives

Drug Name DrugTier

RequirementsLimits

Stimulant Laxatives

bisacodyl supp 1

bisacodyl tbec 1

52

Drug Name DrugTier

RequirementsLimits

GP

ERY-TAB TBEC 2

GP

Drug Name DrugTier

RequirementsLimits

Contraceptives

53

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

54

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

55

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

56

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

2

57

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

58

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

59

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

2

60

Drug Name DrugTier

RequirementsLimits

2

Drug Name DrugTier

RequirementsLimits

61

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

62

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

63

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

64

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

65

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

66

Drug Name DrugTier

RequirementsLimits

2

Drug Name DrugTier

RequirementsLimits

MIGERGOT SUPP 2

Serotonin Agonists

GP QL(2 ea daily)

67

Drug Name DrugTier

RequirementsLimits

daily)

Fluoride

LOZI-FLUR LOZG 2

GP

K-PHOS TABS 2

1

Potassium

Drug Name DrugTier

RequirementsLimits

2

K-TAB TBCR 8 MEQ 2

KLOR-CON M15 TBCR 2

KLOR-CON25 PACK 2

1

68

Drug Name DrugTier

RequirementsLimits

cyclosporine caps 1

GP

tacrolimus caps 1

ZORTRESS TABS 2

GP

Drug Name DrugTier

RequirementsLimits

1

clotrimazole troc 1

GP

GP QL(6 ea daily)

GP QL(4 ea daily)

MULTIVITAMINS

Ped MV w Fluoride

old )

69

Drug Name DrugTier

RequirementsLimits

BAL-CARE DHA MISC 2

COMPLETENATE CHEW 2

CONCEPT DHA CAPS 2

CONCEPT OB CAPS 2

DOTHELLE DHA CAPS 2

FOCALGIN CA MISC 2

FOLIVANE-OB CAPS 2

Drug Name DrugTier

RequirementsLimits

M-VIT TABS 2 RXOTC

MARNATAL-F CAPS 2

NESTABS DHA MISC 2

PNV OB+DHA MISC 2

PNV-VP-U CAPS 2

PR NATAL 400 MISC 2

PR NATAL 430 MISC 2

PRENA 1 TRUE MISC 2

PRENATA CHEW 2

70

Drug Name DrugTier

RequirementsLimits

2

PRENATAL-U CAPS 2

2

QL(1 ea daily)

2

PROVIDA DHA CAPS 2

PROVIDA OB CAPS 2

Drug Name DrugTier

RequirementsLimits

2

TARON-C DHA CAPS 2

TRI-TABS DHA MISC 2

TRINATAL GT TABS 2

VENA-BAL DHA MISC 2

VIRT-ADVANCE TABS 2

VIRT-C DHA CAPS 2

VIRT-VITE GT TABS 2

VITATRUE MISC 2

71

Drug Name DrugTier

RequirementsLimits

Nasal Antiallergy

Drug Name DrugTier

RequirementsLimits

GP

72

Drug Name DrugTier

RequirementsLimits

BETIMOL SOLN 2

BETOPTIC-S SUSP 2

GP

1

2

ISTALOL SOLN 2

2

GP

Drug Name DrugTier

RequirementsLimits

GP

CILOXAN OINT 2

GENTAK OINT 2

MOXEZA SOLN 2

73

Drug Name DrugTier

RequirementsLimits

retail)

NATACYN SUSP 2

GP

TOBREX OINT 2

trifluridine soln 1

Drug Name DrugTier

RequirementsLimits

BLEPHAMIDE SUSP 2

2

FLAREX SUSP 2

FML FORTE SUSP 2

GP

FML OINT 2

MAXIDEX SUSP 2

GP

PRED MILD SUSP 2

2

74

Drug Name DrugTier

RequirementsLimits

2

GP

ALOCRIL SOLN 2

ALOMIDE SOLN 2

BROMFENAC SOLN 2

CYSTARAN SOLN 2

Drug Name DrugTier

RequirementsLimits

bimatoprost soln 1

LUMIGAN SOLN 2

TRAVATAN Z SOLN 2

75

Drug Name DrugTier

RequirementsLimits

Otic Combinations

GP

amoxicillin chew 1

amoxicillin susr 1

Drug Name DrugTier

RequirementsLimits

amoxicillin tabs 1

ampicillin caps 1

ampicillin susr 1

2

GP

76

Drug Name DrugTier

RequirementsLimits

GP QL(1 ea daily)

GP

disulfiram tabs 1

GP QL(1 ea daily)

GP

2

Drug Name DrugTier

RequirementsLimits

GP

GP QL(1 ea daily)

GP

rivastigmine pt24 1

GILENYA CAPS 2

77

Drug Name DrugTier

RequirementsLimits

GP PV

nicotine pt24 1 PV

2 PV

Drug Name DrugTier

RequirementsLimits

GP PV

GP

78

Drug Name DrugTier

RequirementsLimits

methimazole tabs 1

GP QL(2 ea daily)

1 QL(1 ea daily)

1

2

GP

QL(1 ea daily)

GP

thyroid tabs 1

WESTHROID TABS 2

Drug Name DrugTier

RequirementsLimits

2

CUVPOSA SOLN 2

GP

79

Drug Name DrugTier

RequirementsLimits

1

Drug Name DrugTier

RequirementsLimits

GP QL(1 ea daily)

misoprostol tabs 1

GP

80

Drug Name DrugTier

RequirementsLimits

GP

Drug Name DrugTier

RequirementsLimits

TERCONAZOLE CREA 2

Vaginal Progestins

VITAMINS

phytonadione tabs 1

81

ACULAR ACULAR LS

75 75

26 27

32 42 34

18 51 42

10 77

24 50 67 75 75 47 73 8

Index 1

22 16 21 48

1

22 21

50 67 77

22 79 39

Index 2

Index 3

53

Index 4

43 43 50 9

52 11 15 4

77 80 14 9

50 50 45 56

43 19 35

56

13 13 13 4

55

56

Index 5

56

57 20 19

Index 6

74 81

70 57

57

9 50

FORTESTA FOSAMAX

6 46

30 28 77 26 26 25 18 18 16

57

74 41 41 41 78 14 29 68 51 3

75 25 43

72

folic acid 51

Index 7

Index 8

73 19 50 18 26 50 16 16 16 18 16

59 59

59

59 35 80 49 17 17 46

16 30 68 68 49 68 5

30 69 36 43 12 12 45 19

3 3

25 27

Index 9

30 33 23 41 41 8

21

23 37 21 23 23 41 20 19 29 68 75 68 26 25 51 70 70 80 80 24 14 70

60 43 3

36 36 37

27 32 67 67 74 74

25

60 60 60

37 20 1

18

60 60

60 26 20

60

61

61 26 26 3

25 77 47

Index 10

5 81 7

25 49 24 24 11 16 5

45 80 79 6

72 3

25

Index 11

26 20 21

61 61 18

Index 12

42 42 37 6 6 4

61 69 21 44 29

62

61

62

62 14 51 21

2 15 75

1 74 39

12 70 70

Index 13

Index 14

ACTIVATED 63

Index 15

Index 16

71 20 44 29 74 20

13 33

TRILEPTAL TRILIPIX

13 20

64 11

71 65 65 29 29 29 79 34 18 9

34 73

73 73 73 31 72 2 2

25 46

17 17 81 35 16 5

21 51 8

14 75 65

65 15 24 11 17 17 40

2 2

40 37

TYBOST TYKERB

31 27

71

69

72

44

45 51

Index 17

66

19 35 78

65

81 49 49

65

49 50 48

31 31 32

65

65 5

44

65

48 48 81 32 32 32

32 13 74 13 31 31

71 71 71 8

71 48 71

Index 18

Index 19

Classes
- MULTIVITAMINS
- VITAMINS

Page 7: Health Net 2-Tier Recommended Drug List

request thereafter

medical benefit

exceptions

vi

Definitions

pays the rest

lowercase letters

vii

viii

Drug Name DrugTier

RequirementsLimits

GP

1

GP

2 QL(1 ea daily)

Analeptics

Drug Name DrugTier

RequirementsLimits

LOMAIRA TABS 2 PA

SP PA

CONTRAVE TB12 SP PA

XENICAL CAPS SP PA

GP QL(2 ea daily)

GP

GP QL(1 ea daily)

1

Drug Name DrugTier

RequirementsLimits

GP

Drug Name DrugTier

RequirementsLimits

KITABIS PAK NEBU 2

tobramycin nebu 1

TOBRAMYCIN NEBU 2

SP

PA

2

Drug Name DrugTier

RequirementsLimits

SP PA

KEVZARA SOAJ SP

KEVZARA SOSY SP

Drug Name DrugTier

RequirementsLimits

FENORTHO CAPS 2

ibuprofen tabs 1

indomethacin caps 1

indomethacin cpcr 1

3

Drug Name DrugTier

RequirementsLimits

oxaprozin tabs 1

OTEZLA TABS SP

OTEZLA TBPK SP

Drug Name DrugTier

RequirementsLimits

1

GP

salsalate tabs 1

GP QL(4 ea daily)

4

Drug Name DrugTier

RequirementsLimits

GP

QL(2 ea daily)

1 QL(2 ea daily)

1

1 QL(3 ea daily)

Drug Name DrugTier

RequirementsLimits

2 QL(2 ea daily)

GP

1

5

Drug Name DrugTier

RequirementsLimits

1 QL(6 ea daily)

1

1 QL(6 ea daily)

GP QL(6 ea daily)

GP

GP QL(6 ea daily)

GP

GP QL(6 ea daily)

1 QL(3 ea daily)

Drug Name DrugTier

RequirementsLimits

GP QL(10 gmdaily)

GP

NF QL(10 gmdaily)

ANDROXY TABS 2 AC

danazol caps 1

METHITEST TABS 2

1

daily)

6

Drug Name DrugTier

RequirementsLimits

GP QL(60 ml daily)

CORTIFOAM FOAM 2

praziquantel tabs 1

IMPAVIDO CAPS 2

Drug Name DrugTier

RequirementsLimits

NEBUPENT SOLR 2

trimethoprim tabs 1

GP

Oxazolidinones

7

Drug Name DrugTier

RequirementsLimits

GP

NITRO-BID OINT 2

GP

QL(1 ea daily)

1 QL(1 ea daily)

GP

Drug Name DrugTier

RequirementsLimits

lorazepam conc 1

lorazepam tabs 1

8

Drug Name DrugTier

RequirementsLimits

NORPACE CR CP12 2

dofetilide caps 1

MULTAQ TABS 2

Drug Name DrugTier

RequirementsLimits

ATROVENT HFA AERS 2

Steroid Inhalants

AEROSPAN AERS 2

ASMANEX HFA AERO 2

2

9

Drug Name DrugTier

RequirementsLimits

2

GP QL(8 ml daily)

Drug Name DrugTier

RequirementsLimits

GP QL(4 ml daily)

GP QL(2 ml daily)

GP QL(2 ea daily)

2

1

10

Drug Name DrugTier

RequirementsLimits

DULERA AERO 2

2 QL(004 eadaily)

SYMBICORT AERO 2

GP

Drug Name DrugTier

RequirementsLimits

ELIQUIS TABS 5 MG 2

clonazepam tbdp 1

11

Drug Name DrugTier

RequirementsLimits

gabapentin caps 1

gabapentin soln 1

gabapentin tabs 1

GP

GP QL(6 ea daily)

GP

GP PA

GP

Drug Name DrugTier

RequirementsLimits

GP

1 QL(6 ea daily)

POTIGA TABS 2

primidone tabs 1

12

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

felbamate tabs 1

vigabatrin tabs 1

GP

phenytoin chew 1

phenytoin susp 1

ethosuximide caps 1

ethosuximide soln 1

13

Drug Name DrugTier

RequirementsLimits

GP

mirtazapine tbdp 1

Drug Name DrugTier

RequirementsLimits

14

Drug Name DrugTier

RequirementsLimits

GP

GP QL(1 ea daily)

GP

GP QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

GP QL(1 ea daily)

1

AMOXAPINE TABS 2

15

Drug Name DrugTier

RequirementsLimits

GP

GLYXAMBI TABS 2

INVOKAMET TABS 2

INVOKAMET XR TB24 2

2 QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

JENTADUETO TABS 2

SYNJARDY TABS 2

SYNJARDY XR TB24 2

AVANDIA TABS 2

Insulin

16

Drug Name DrugTier

RequirementsLimits

daily)

Drug Name DrugTier

RequirementsLimits

LEVEMIR SOLN 2

TRESIBA SOLN 2

repaglinide tabs 1

17

Drug Name DrugTier

RequirementsLimits

glimepiride tabs 1

glipizide tabs 1

glipizide tb24 1

glyburide tabs 1

tolbutamide tabs 1

Opioid Antagonists

Drug Name DrugTier

RequirementsLimits

fill retail)

nystatin tabs 1

18

Drug Name DrugTier

RequirementsLimits

fluconazole susr 1

fluconazole tabs 1

ketoconazole tabs 1

Drug Name DrugTier

RequirementsLimits

GP

19

Drug Name DrugTier

RequirementsLimits

gemfibrozil tabs 1

Drug Name DrugTier

RequirementsLimits

GP QL(1 ea daily)

GP QL(2 ea daily)

20

Drug Name DrugTier

RequirementsLimits

captopril tabs 1

trandolapril tabs 1

GP

Drug Name DrugTier

RequirementsLimits

GP

GP QL(1 ea daily)

GP

irbesartan tabs 1

21

Drug Name DrugTier

RequirementsLimits

methyldopa tabs 1

prazosin hcl caps 1

GP

GP QL(1 ea daily)

1

QL(1 ea daily)

1 QL(1 ea daily)

1

Drug Name DrugTier

RequirementsLimits

GP

QL(1 ea daily)

GP

QL(1 ea daily)

GP

GP QL(1 ea daily)

GP

22

Drug Name DrugTier

RequirementsLimits

GP

1

1 QL(2 ea daily)

GP

GP QL(1 ea daily)

GP

1 ST

1

1 QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

1

1 QL(1 ea daily)

GP

ST

1 QL(1 ea daily)

1

GP

QL(2 ea daily)

23

Drug Name DrugTier

RequirementsLimits

minoxidil tabs 1

GP

2

GP

Drug Name DrugTier

RequirementsLimits

isoniazid syrp 1

isoniazid tabs 1

PRIFTIN TABS 2

pyrazinamide tabs 1

rifabutin caps 1

rifampin caps 1

TRECATOR TABS 2

GP AC

24

Drug Name DrugTier

RequirementsLimits

GLEOSTINE CAPS 2

HEXALEN CAPS 2 AC

LEUKERAN TABS 2 AC

melphalan tabs 1 AC

MYLERAN TABS 2 AC

TABLOID TABS 2 AC

daily) AC

ODOMZO CAPS 2 AC

Drug Name DrugTier

RequirementsLimits

EMCYT CAPS 2 AC

flutamide caps 1 AC

letrozole tabs 1 AC

LYSODREN TABS 2 AC

25

Drug Name DrugTier

RequirementsLimits

BRAFTOVI CAPS 2 PA

CAPRELSA TABS 2 AC

IBRANCE CAPS 2

Drug Name DrugTier

RequirementsLimits

IRESSA TABS 2 AC

JAKAFI TABS 2 AC

MEKTOVI TABS 2 PA

NEXAVAR TABS 2

RYDAPT CAPS 2 PA AC

SPRYCEL TABS 2

SUTENT CAPS 2

26

Drug Name DrugTier

RequirementsLimits

TARCEVA TABS 2

TYKERB TABS 2

VOTRIENT TABS 2

ZEJULA CAPS 2

MATULANE CAPS 2 AC

Drug Name DrugTier

RequirementsLimits

1

GP

GP QL(4 ea daily)

27

Drug Name DrugTier

RequirementsLimits

GP QL(3 ea daily)

1

1 QL(3 ea daily)

GP QL(2 ea daily)

GP

1

GP QL(8 ea daily)

GP

STALEVO 100 TABS 2

STALEVO 125 TABS 2

STALEVO 150 TABS 2

Drug Name DrugTier

RequirementsLimits

STALEVO 50 TABS 2

STALEVO 75 TABS 2

LITHIUM SOLN 2

GP

GP QL(2 ea daily)

28

Drug Name DrugTier

RequirementsLimits

GP

haloperidol tabs 1

GP

GP QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

GP

perphenazine tabs 1

GP

29

Drug Name DrugTier

RequirementsLimits

APTIVUS CAPS 2

APTIVUS SOLN 2

BIKTARVY TABS 2

CIMDUO TABS 2

COMPLERA TABS 2 ST

CRIXIVAN CAPS 2

DELSTRIGO TABS 2 ST

DESCOVY TABS 2

didanosine cpdr 1

EDURANT TABS 2

efavirenz caps 1

efavirenz tabs 1

EMTRIVA CAPS 2

EMTRIVA SOLN 2

Drug Name DrugTier

RequirementsLimits

GP

EVOTAZ TABS 2

GENVOYA TABS 2

INTELENCE TABS 2

INVIRASE CAPS 2

INVIRASE TABS 2

ISENTRESS CHEW 2

ISENTRESS HD TABS 2

ISENTRESS PACK 2

ISENTRESS TABS 2

JULUCA TABS 2

GP

lamivudine soln 1

lamivudine tabs 1

GP

nevirapine susp 1

nevirapine tabs 1

30

Drug Name DrugTier

RequirementsLimits

nevirapine tb24 1

PIFELTRO TABS 2

PREZISTA SUSP 2

PREZISTA TABS 2

RESCRIPTOR TABS 2

GP

ritonavir tabs 1

SELZENTRY SOLN 2

SELZENTRY TABS 2

stavudine caps 1

STRIBILD TABS 2

SYMTUZA TABS 2 ST

TIVICAY TABS 2

Drug Name DrugTier

RequirementsLimits

TRIUMEQ TABS 2

GP

TRUVADA TABS 2

TYBOST TABS 2

GP

VIRACEPT TABS 2

GP

ZERIT SOLR 1 MGML 2

zidovudine caps 1

zidovudine syrp 1

zidovudine tabs 1

CMV Agents

31

Drug Name DrugTier

RequirementsLimits

GP QL(21 ml daily)

entecavir tabs 1

MAVYRET TABS 2

MODERIBA TBPK 2 PA

OLYSIO CAPS 2

Drug Name DrugTier

RequirementsLimits

GP PA

TECHNIVIE TABS 2 PA

VOSEVI TABS 2

famciclovir tabs 1

32

Drug Name DrugTier

RequirementsLimits

Influenza Agents

GP

Drug Name DrugTier

RequirementsLimits

atenolol tabs 1

2

nadolol tabs 1

pindolol tabs 1

33

Drug Name DrugTier

RequirementsLimits

sotalol hcl tabs 1

SOTYLIZE SOLN 2

GP QL(2 ea daily)

GP QL(1 ea daily)

GP

1 QL(1 ea daily)

1

Drug Name DrugTier

RequirementsLimits

nimodipine caps 1

nisoldipine tb24 1

GP QL(1 ea daily)

NYMALIZE SOLN 2

GP

1

34

Drug Name DrugTier

RequirementsLimits

GP

digoxin tabs 1

MUSE PLLT SP

Drug Name DrugTier

RequirementsLimits

tadalafil tabs SP

GP

cefadroxil susr 1

35

Drug Name DrugTier

RequirementsLimits

cefadroxil tabs 1

2

cefprozil susr 1

cefprozil tabs 1

CEFTIN SUSR 2

cefdinir susr 1

cefixime susr 1

GP

QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

GP

1 QL(1 ea daily)

1

GP QL(1 ea daily)PV

GP

36

Drug Name DrugTier

RequirementsLimits

GP

1

1 QL(1 ea daily)PV

Drug Name DrugTier

RequirementsLimits

GP

PV

GP

QL(1 ea daily)

GP QL(1 ea daily)

GP

GP QL(1 ea daily)PV

GP

QL(1 ea daily)

GP

GP QL(1 ea daily)

GP QL(1 ea daily)PV

37

Drug Name DrugTier

RequirementsLimits

ELLA TABS 2 PV

GP PV

GP QL(1 ea daily)

1

MEDROL TABS 2 MG 2

GP

Drug Name DrugTier

RequirementsLimits

NF

1

PREDNISOLONE SOLN 2

prednisolone soln 1

prednisolone syrp 1

1

38

Drug Name DrugTier

RequirementsLimits

1

GP

1

GP

Drug Name DrugTier

RequirementsLimits

GP QL(2 gm daily)

GP

CLINDAGEL GEL 2

39

Drug Name DrugTier

RequirementsLimits

1

GP

Drug Name DrugTier

RequirementsLimits

GP

SSS 10-5 FOAM 2

GP

CENTANY OINT 2

40

Drug Name DrugTier

RequirementsLimits

MUPIROCIN CREA 2

mupirocin oint 1

ciclopirox sham 1 1

GP

Drug Name DrugTier

RequirementsLimits

FLUOROPLEX CREA 2

PICATO GEL 2

GP

41

Drug Name DrugTier

RequirementsLimits

GP

AMCINONIDE CREA 2

APEXICON E CREA 2

2

1

Drug Name DrugTier

RequirementsLimits

1

CAPEX SHAM 2

GP

desonide crea 1

desonide lotn 1

desonide oint 1

42

Drug Name DrugTier

RequirementsLimits

GP

Drug Name DrugTier

RequirementsLimits

GP

43

Drug Name DrugTier

RequirementsLimits

imiquimod crea 1

podofilox soln 1

Drug Name DrugTier

RequirementsLimits

GP

DIAGNOSTIC PRODUCTS

Diagnostic Tests

2

44

Drug Name DrugTier

RequirementsLimits

2

ZENPEP CPEP 2

Drug Name DrugTier

RequirementsLimits

GP

GP QL(1 ea daily)

GP QL(2 ea daily)

1

1 QL(2 ea daily)

1 QL(1 ea daily)

45

Drug Name DrugTier

RequirementsLimits

indapamide tabs 1

metolazone tabs 1

Drug Name DrugTier

RequirementsLimits

CARBAGLU TABS 2

46

Drug Name DrugTier

RequirementsLimits

KUVAN PACK 2

KUVAN TBSO 2

paricalcitol caps 1

GP

GP QL(6 ea daily)

Drug Name DrugTier

RequirementsLimits

GP

PREMPHASE TABS 2

2

Estrogens

2

1

MENEST TABS 2

47

Drug Name DrugTier

RequirementsLimits

GP

2 QL(1 ea daily)

GP

fill retail)

Drug Name DrugTier

RequirementsLimits

ursodiol caps 1

ursodiol tabs 1

48

Drug Name DrugTier

RequirementsLimits

SFROWASA ENEM 2

GP RXOTC

GP QL(3 ea daily)

GP

GP QL(4 ea daily)

Drug Name DrugTier

RequirementsLimits

GP

GP QL(5 ea daily)

GP

1

RXOTC

GP

49

Drug Name DrugTier

RequirementsLimits

PROCYSBI CPDR 2 SP

GP

colchicine tabs 1

COLCRYS TABS 2

Drug Name DrugTier

RequirementsLimits

RIXUBIS SOLR SP PA

dipyridamole tabs 1

Folic AcidFolates

50

Drug Name DrugTier

RequirementsLimits

INTEGRA F CAPS 2

estazolam tabs 1

Drug Name DrugTier

RequirementsLimits

CLENPIQ SOLN 2 PV

GP

51

Drug Name DrugTier

RequirementsLimits

GP

PV

1 PV

Saline Laxatives

Drug Name DrugTier

RequirementsLimits

Stimulant Laxatives

bisacodyl supp 1

bisacodyl tbec 1

52

Drug Name DrugTier

RequirementsLimits

GP

ERY-TAB TBEC 2

GP

Drug Name DrugTier

RequirementsLimits

Contraceptives

53

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

54

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

55

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

56

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

2

57

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

58

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

59

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

2

60

Drug Name DrugTier

RequirementsLimits

2

Drug Name DrugTier

RequirementsLimits

61

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

62

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

63

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

64

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

65

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

66

Drug Name DrugTier

RequirementsLimits

2

Drug Name DrugTier

RequirementsLimits

MIGERGOT SUPP 2

Serotonin Agonists

GP QL(2 ea daily)

67

Drug Name DrugTier

RequirementsLimits

daily)

Fluoride

LOZI-FLUR LOZG 2

GP

K-PHOS TABS 2

1

Potassium

Drug Name DrugTier

RequirementsLimits

2

K-TAB TBCR 8 MEQ 2

KLOR-CON M15 TBCR 2

KLOR-CON25 PACK 2

1

68

Drug Name DrugTier

RequirementsLimits

cyclosporine caps 1

GP

tacrolimus caps 1

ZORTRESS TABS 2

GP

Drug Name DrugTier

RequirementsLimits

1

clotrimazole troc 1

GP

GP QL(6 ea daily)

GP QL(4 ea daily)

MULTIVITAMINS

Ped MV w Fluoride

old )

69

Drug Name DrugTier

RequirementsLimits

BAL-CARE DHA MISC 2

COMPLETENATE CHEW 2

CONCEPT DHA CAPS 2

CONCEPT OB CAPS 2

DOTHELLE DHA CAPS 2

FOCALGIN CA MISC 2

FOLIVANE-OB CAPS 2

Drug Name DrugTier

RequirementsLimits

M-VIT TABS 2 RXOTC

MARNATAL-F CAPS 2

NESTABS DHA MISC 2

PNV OB+DHA MISC 2

PNV-VP-U CAPS 2

PR NATAL 400 MISC 2

PR NATAL 430 MISC 2

PRENA 1 TRUE MISC 2

PRENATA CHEW 2

70

Drug Name DrugTier

RequirementsLimits

2

PRENATAL-U CAPS 2

2

QL(1 ea daily)

2

PROVIDA DHA CAPS 2

PROVIDA OB CAPS 2

Drug Name DrugTier

RequirementsLimits

2

TARON-C DHA CAPS 2

TRI-TABS DHA MISC 2

TRINATAL GT TABS 2

VENA-BAL DHA MISC 2

VIRT-ADVANCE TABS 2

VIRT-C DHA CAPS 2

VIRT-VITE GT TABS 2

VITATRUE MISC 2

71

Drug Name DrugTier

RequirementsLimits

Nasal Antiallergy

Drug Name DrugTier

RequirementsLimits

GP

72

Drug Name DrugTier

RequirementsLimits

BETIMOL SOLN 2

BETOPTIC-S SUSP 2

GP

1

2

ISTALOL SOLN 2

2

GP

Drug Name DrugTier

RequirementsLimits

GP

CILOXAN OINT 2

GENTAK OINT 2

MOXEZA SOLN 2

73

Drug Name DrugTier

RequirementsLimits

retail)

NATACYN SUSP 2

GP

TOBREX OINT 2

trifluridine soln 1

Drug Name DrugTier

RequirementsLimits

BLEPHAMIDE SUSP 2

2

FLAREX SUSP 2

FML FORTE SUSP 2

GP

FML OINT 2

MAXIDEX SUSP 2

GP

PRED MILD SUSP 2

2

74

Drug Name DrugTier

RequirementsLimits

2

GP

ALOCRIL SOLN 2

ALOMIDE SOLN 2

BROMFENAC SOLN 2

CYSTARAN SOLN 2

Drug Name DrugTier

RequirementsLimits

bimatoprost soln 1

LUMIGAN SOLN 2

TRAVATAN Z SOLN 2

75

Drug Name DrugTier

RequirementsLimits

Otic Combinations

GP

amoxicillin chew 1

amoxicillin susr 1

Drug Name DrugTier

RequirementsLimits

amoxicillin tabs 1

ampicillin caps 1

ampicillin susr 1

2

GP

76

Drug Name DrugTier

RequirementsLimits

GP QL(1 ea daily)

GP

disulfiram tabs 1

GP QL(1 ea daily)

GP

2

Drug Name DrugTier

RequirementsLimits

GP

GP QL(1 ea daily)

GP

rivastigmine pt24 1

GILENYA CAPS 2

77

Drug Name DrugTier

RequirementsLimits

GP PV

nicotine pt24 1 PV

2 PV

Drug Name DrugTier

RequirementsLimits

GP PV

GP

78

Drug Name DrugTier

RequirementsLimits

methimazole tabs 1

GP QL(2 ea daily)

1 QL(1 ea daily)

1

2

GP

QL(1 ea daily)

GP

thyroid tabs 1

WESTHROID TABS 2

Drug Name DrugTier

RequirementsLimits

2

CUVPOSA SOLN 2

GP

79

Drug Name DrugTier

RequirementsLimits

1

Drug Name DrugTier

RequirementsLimits

GP QL(1 ea daily)

misoprostol tabs 1

GP

80

Drug Name DrugTier

RequirementsLimits

GP

Drug Name DrugTier

RequirementsLimits

TERCONAZOLE CREA 2

Vaginal Progestins

VITAMINS

phytonadione tabs 1

81

ACULAR ACULAR LS

75 75

26 27

32 42 34

18 51 42

10 77

24 50 67 75 75 47 73 8

Index 1

22 16 21 48

1

22 21

50 67 77

22 79 39

Index 2

Index 3

53

Index 4

43 43 50 9

52 11 15 4

77 80 14 9

50 50 45 56

43 19 35

56

13 13 13 4

55

56

Index 5

56

57 20 19

Index 6

74 81

70 57

57

9 50

FORTESTA FOSAMAX

6 46

30 28 77 26 26 25 18 18 16

57

74 41 41 41 78 14 29 68 51 3

75 25 43

72

folic acid 51

Index 7

Index 8

73 19 50 18 26 50 16 16 16 18 16

59 59

59

59 35 80 49 17 17 46

16 30 68 68 49 68 5

30 69 36 43 12 12 45 19

3 3

25 27

Index 9

30 33 23 41 41 8

21

23 37 21 23 23 41 20 19 29 68 75 68 26 25 51 70 70 80 80 24 14 70

60 43 3

36 36 37

27 32 67 67 74 74

25

60 60 60

37 20 1

18

60 60

60 26 20

60

61

61 26 26 3

25 77 47

Index 10

5 81 7

25 49 24 24 11 16 5

45 80 79 6

72 3

25

Index 11

26 20 21

61 61 18

Index 12

42 42 37 6 6 4

61 69 21 44 29

62

61

62

62 14 51 21

2 15 75

1 74 39

12 70 70

Index 13

Index 14

ACTIVATED 63

Index 15

Index 16

71 20 44 29 74 20

13 33

TRILEPTAL TRILIPIX

13 20

64 11

71 65 65 29 29 29 79 34 18 9

34 73

73 73 73 31 72 2 2

25 46

17 17 81 35 16 5

21 51 8

14 75 65

65 15 24 11 17 17 40

2 2

40 37

TYBOST TYKERB

31 27

71

69

72

44

45 51

Index 17

66

19 35 78

65

81 49 49

65

49 50 48

31 31 32

65

65 5

44

65

48 48 81 32 32 32

32 13 74 13 31 31

71 71 71 8

71 48 71

Index 18

Index 19

Classes
- MULTIVITAMINS
- VITAMINS

Page 8: Health Net 2-Tier Recommended Drug List

Definitions

pays the rest

lowercase letters

vii

viii

Drug Name DrugTier

RequirementsLimits

GP

1

GP

2 QL(1 ea daily)

Analeptics

Drug Name DrugTier

RequirementsLimits

LOMAIRA TABS 2 PA

SP PA

CONTRAVE TB12 SP PA

XENICAL CAPS SP PA

GP QL(2 ea daily)

GP

GP QL(1 ea daily)

1

Drug Name DrugTier

RequirementsLimits

GP

Drug Name DrugTier

RequirementsLimits

KITABIS PAK NEBU 2

tobramycin nebu 1

TOBRAMYCIN NEBU 2

SP

PA

2

Drug Name DrugTier

RequirementsLimits

SP PA

KEVZARA SOAJ SP

KEVZARA SOSY SP

Drug Name DrugTier

RequirementsLimits

FENORTHO CAPS 2

ibuprofen tabs 1

indomethacin caps 1

indomethacin cpcr 1

3

Drug Name DrugTier

RequirementsLimits

oxaprozin tabs 1

OTEZLA TABS SP

OTEZLA TBPK SP

Drug Name DrugTier

RequirementsLimits

1

GP

salsalate tabs 1

GP QL(4 ea daily)

4

Drug Name DrugTier

RequirementsLimits

GP

QL(2 ea daily)

1 QL(2 ea daily)

1

1 QL(3 ea daily)

Drug Name DrugTier

RequirementsLimits

2 QL(2 ea daily)

GP

1

5

Drug Name DrugTier

RequirementsLimits

1 QL(6 ea daily)

1

1 QL(6 ea daily)

GP QL(6 ea daily)

GP

GP QL(6 ea daily)

GP

GP QL(6 ea daily)

1 QL(3 ea daily)

Drug Name DrugTier

RequirementsLimits

GP QL(10 gmdaily)

GP

NF QL(10 gmdaily)

ANDROXY TABS 2 AC

danazol caps 1

METHITEST TABS 2

1

daily)

6

Drug Name DrugTier

RequirementsLimits

GP QL(60 ml daily)

CORTIFOAM FOAM 2

praziquantel tabs 1

IMPAVIDO CAPS 2

Drug Name DrugTier

RequirementsLimits

NEBUPENT SOLR 2

trimethoprim tabs 1

GP

Oxazolidinones

7

Drug Name DrugTier

RequirementsLimits

GP

NITRO-BID OINT 2

GP

QL(1 ea daily)

1 QL(1 ea daily)

GP

Drug Name DrugTier

RequirementsLimits

lorazepam conc 1

lorazepam tabs 1

8

Drug Name DrugTier

RequirementsLimits

NORPACE CR CP12 2

dofetilide caps 1

MULTAQ TABS 2

Drug Name DrugTier

RequirementsLimits

ATROVENT HFA AERS 2

Steroid Inhalants

AEROSPAN AERS 2

ASMANEX HFA AERO 2

2

9

Drug Name DrugTier

RequirementsLimits

2

GP QL(8 ml daily)

Drug Name DrugTier

RequirementsLimits

GP QL(4 ml daily)

GP QL(2 ml daily)

GP QL(2 ea daily)

2

1

10

Drug Name DrugTier

RequirementsLimits

DULERA AERO 2

2 QL(004 eadaily)

SYMBICORT AERO 2

GP

Drug Name DrugTier

RequirementsLimits

ELIQUIS TABS 5 MG 2

clonazepam tbdp 1

11

Drug Name DrugTier

RequirementsLimits

gabapentin caps 1

gabapentin soln 1

gabapentin tabs 1

GP

GP QL(6 ea daily)

GP

GP PA

GP

Drug Name DrugTier

RequirementsLimits

GP

1 QL(6 ea daily)

POTIGA TABS 2

primidone tabs 1

12

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

felbamate tabs 1

vigabatrin tabs 1

GP

phenytoin chew 1

phenytoin susp 1

ethosuximide caps 1

ethosuximide soln 1

13

Drug Name DrugTier

RequirementsLimits

GP

mirtazapine tbdp 1

Drug Name DrugTier

RequirementsLimits

14

Drug Name DrugTier

RequirementsLimits

GP

GP QL(1 ea daily)

GP

GP QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

GP QL(1 ea daily)

1

AMOXAPINE TABS 2

15

Drug Name DrugTier

RequirementsLimits

GP

GLYXAMBI TABS 2

INVOKAMET TABS 2

INVOKAMET XR TB24 2

2 QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

JENTADUETO TABS 2

SYNJARDY TABS 2

SYNJARDY XR TB24 2

AVANDIA TABS 2

Insulin

16

Drug Name DrugTier

RequirementsLimits

daily)

Drug Name DrugTier

RequirementsLimits

LEVEMIR SOLN 2

TRESIBA SOLN 2

repaglinide tabs 1

17

Drug Name DrugTier

RequirementsLimits

glimepiride tabs 1

glipizide tabs 1

glipizide tb24 1

glyburide tabs 1

tolbutamide tabs 1

Opioid Antagonists

Drug Name DrugTier

RequirementsLimits

fill retail)

nystatin tabs 1

18

Drug Name DrugTier

RequirementsLimits

fluconazole susr 1

fluconazole tabs 1

ketoconazole tabs 1

Drug Name DrugTier

RequirementsLimits

GP

19

Drug Name DrugTier

RequirementsLimits

gemfibrozil tabs 1

Drug Name DrugTier

RequirementsLimits

GP QL(1 ea daily)

GP QL(2 ea daily)

20

Drug Name DrugTier

RequirementsLimits

captopril tabs 1

trandolapril tabs 1

GP

Drug Name DrugTier

RequirementsLimits

GP

GP QL(1 ea daily)

GP

irbesartan tabs 1

21

Drug Name DrugTier

RequirementsLimits

methyldopa tabs 1

prazosin hcl caps 1

GP

GP QL(1 ea daily)

1

QL(1 ea daily)

1 QL(1 ea daily)

1

Drug Name DrugTier

RequirementsLimits

GP

QL(1 ea daily)

GP

QL(1 ea daily)

GP

GP QL(1 ea daily)

GP

22

Drug Name DrugTier

RequirementsLimits

GP

1

1 QL(2 ea daily)

GP

GP QL(1 ea daily)

GP

1 ST

1

1 QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

1

1 QL(1 ea daily)

GP

ST

1 QL(1 ea daily)

1

GP

QL(2 ea daily)

23

Drug Name DrugTier

RequirementsLimits

minoxidil tabs 1

GP

2

GP

Drug Name DrugTier

RequirementsLimits

isoniazid syrp 1

isoniazid tabs 1

PRIFTIN TABS 2

pyrazinamide tabs 1

rifabutin caps 1

rifampin caps 1

TRECATOR TABS 2

GP AC

24

Drug Name DrugTier

RequirementsLimits

GLEOSTINE CAPS 2

HEXALEN CAPS 2 AC

LEUKERAN TABS 2 AC

melphalan tabs 1 AC

MYLERAN TABS 2 AC

TABLOID TABS 2 AC

daily) AC

ODOMZO CAPS 2 AC

Drug Name DrugTier

RequirementsLimits

EMCYT CAPS 2 AC

flutamide caps 1 AC

letrozole tabs 1 AC

LYSODREN TABS 2 AC

25

Drug Name DrugTier

RequirementsLimits

BRAFTOVI CAPS 2 PA

CAPRELSA TABS 2 AC

IBRANCE CAPS 2

Drug Name DrugTier

RequirementsLimits

IRESSA TABS 2 AC

JAKAFI TABS 2 AC

MEKTOVI TABS 2 PA

NEXAVAR TABS 2

RYDAPT CAPS 2 PA AC

SPRYCEL TABS 2

SUTENT CAPS 2

26

Drug Name DrugTier

RequirementsLimits

TARCEVA TABS 2

TYKERB TABS 2

VOTRIENT TABS 2

ZEJULA CAPS 2

MATULANE CAPS 2 AC

Drug Name DrugTier

RequirementsLimits

1

GP

GP QL(4 ea daily)

27

Drug Name DrugTier

RequirementsLimits

GP QL(3 ea daily)

1

1 QL(3 ea daily)

GP QL(2 ea daily)

GP

1

GP QL(8 ea daily)

GP

STALEVO 100 TABS 2

STALEVO 125 TABS 2

STALEVO 150 TABS 2

Drug Name DrugTier

RequirementsLimits

STALEVO 50 TABS 2

STALEVO 75 TABS 2

LITHIUM SOLN 2

GP

GP QL(2 ea daily)

28

Drug Name DrugTier

RequirementsLimits

GP

haloperidol tabs 1

GP

GP QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

GP

perphenazine tabs 1

GP

29

Drug Name DrugTier

RequirementsLimits

APTIVUS CAPS 2

APTIVUS SOLN 2

BIKTARVY TABS 2

CIMDUO TABS 2

COMPLERA TABS 2 ST

CRIXIVAN CAPS 2

DELSTRIGO TABS 2 ST

DESCOVY TABS 2

didanosine cpdr 1

EDURANT TABS 2

efavirenz caps 1

efavirenz tabs 1

EMTRIVA CAPS 2

EMTRIVA SOLN 2

Drug Name DrugTier

RequirementsLimits

GP

EVOTAZ TABS 2

GENVOYA TABS 2

INTELENCE TABS 2

INVIRASE CAPS 2

INVIRASE TABS 2

ISENTRESS CHEW 2

ISENTRESS HD TABS 2

ISENTRESS PACK 2

ISENTRESS TABS 2

JULUCA TABS 2

GP

lamivudine soln 1

lamivudine tabs 1

GP

nevirapine susp 1

nevirapine tabs 1

30

Drug Name DrugTier

RequirementsLimits

nevirapine tb24 1

PIFELTRO TABS 2

PREZISTA SUSP 2

PREZISTA TABS 2

RESCRIPTOR TABS 2

GP

ritonavir tabs 1

SELZENTRY SOLN 2

SELZENTRY TABS 2

stavudine caps 1

STRIBILD TABS 2

SYMTUZA TABS 2 ST

TIVICAY TABS 2

Drug Name DrugTier

RequirementsLimits

TRIUMEQ TABS 2

GP

TRUVADA TABS 2

TYBOST TABS 2

GP

VIRACEPT TABS 2

GP

ZERIT SOLR 1 MGML 2

zidovudine caps 1

zidovudine syrp 1

zidovudine tabs 1

CMV Agents

31

Drug Name DrugTier

RequirementsLimits

GP QL(21 ml daily)

entecavir tabs 1

MAVYRET TABS 2

MODERIBA TBPK 2 PA

OLYSIO CAPS 2

Drug Name DrugTier

RequirementsLimits

GP PA

TECHNIVIE TABS 2 PA

VOSEVI TABS 2

famciclovir tabs 1

32

Drug Name DrugTier

RequirementsLimits

Influenza Agents

GP

Drug Name DrugTier

RequirementsLimits

atenolol tabs 1

2

nadolol tabs 1

pindolol tabs 1

33

Drug Name DrugTier

RequirementsLimits

sotalol hcl tabs 1

SOTYLIZE SOLN 2

GP QL(2 ea daily)

GP QL(1 ea daily)

GP

1 QL(1 ea daily)

1

Drug Name DrugTier

RequirementsLimits

nimodipine caps 1

nisoldipine tb24 1

GP QL(1 ea daily)

NYMALIZE SOLN 2

GP

1

34

Drug Name DrugTier

RequirementsLimits

GP

digoxin tabs 1

MUSE PLLT SP

Drug Name DrugTier

RequirementsLimits

tadalafil tabs SP

GP

cefadroxil susr 1

35

Drug Name DrugTier

RequirementsLimits

cefadroxil tabs 1

2

cefprozil susr 1

cefprozil tabs 1

CEFTIN SUSR 2

cefdinir susr 1

cefixime susr 1

GP

QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

GP

1 QL(1 ea daily)

1

GP QL(1 ea daily)PV

GP

36

Drug Name DrugTier

RequirementsLimits

GP

1

1 QL(1 ea daily)PV

Drug Name DrugTier

RequirementsLimits

GP

PV

GP

QL(1 ea daily)

GP QL(1 ea daily)

GP

GP QL(1 ea daily)PV

GP

QL(1 ea daily)

GP

GP QL(1 ea daily)

GP QL(1 ea daily)PV

37

Drug Name DrugTier

RequirementsLimits

ELLA TABS 2 PV

GP PV

GP QL(1 ea daily)

1

MEDROL TABS 2 MG 2

GP

Drug Name DrugTier

RequirementsLimits

NF

1

PREDNISOLONE SOLN 2

prednisolone soln 1

prednisolone syrp 1

1

38

Drug Name DrugTier

RequirementsLimits

1

GP

1

GP

Drug Name DrugTier

RequirementsLimits

GP QL(2 gm daily)

GP

CLINDAGEL GEL 2

39

Drug Name DrugTier

RequirementsLimits

1

GP

Drug Name DrugTier

RequirementsLimits

GP

SSS 10-5 FOAM 2

GP

CENTANY OINT 2

40

Drug Name DrugTier

RequirementsLimits

MUPIROCIN CREA 2

mupirocin oint 1

ciclopirox sham 1 1

GP

Drug Name DrugTier

RequirementsLimits

FLUOROPLEX CREA 2

PICATO GEL 2

GP

41

Drug Name DrugTier

RequirementsLimits

GP

AMCINONIDE CREA 2

APEXICON E CREA 2

2

1

Drug Name DrugTier

RequirementsLimits

1

CAPEX SHAM 2

GP

desonide crea 1

desonide lotn 1

desonide oint 1

42

Drug Name DrugTier

RequirementsLimits

GP

Drug Name DrugTier

RequirementsLimits

GP

43

Drug Name DrugTier

RequirementsLimits

imiquimod crea 1

podofilox soln 1

Drug Name DrugTier

RequirementsLimits

GP

DIAGNOSTIC PRODUCTS

Diagnostic Tests

2

44

Drug Name DrugTier

RequirementsLimits

2

ZENPEP CPEP 2

Drug Name DrugTier

RequirementsLimits

GP

GP QL(1 ea daily)

GP QL(2 ea daily)

1

1 QL(2 ea daily)

1 QL(1 ea daily)

45

Drug Name DrugTier

RequirementsLimits

indapamide tabs 1

metolazone tabs 1

Drug Name DrugTier

RequirementsLimits

CARBAGLU TABS 2

46

Drug Name DrugTier

RequirementsLimits

KUVAN PACK 2

KUVAN TBSO 2

paricalcitol caps 1

GP

GP QL(6 ea daily)

Drug Name DrugTier

RequirementsLimits

GP

PREMPHASE TABS 2

2

Estrogens

2

1

MENEST TABS 2

47

Drug Name DrugTier

RequirementsLimits

GP

2 QL(1 ea daily)

GP

fill retail)

Drug Name DrugTier

RequirementsLimits

ursodiol caps 1

ursodiol tabs 1

48

Drug Name DrugTier

RequirementsLimits

SFROWASA ENEM 2

GP RXOTC

GP QL(3 ea daily)

GP

GP QL(4 ea daily)

Drug Name DrugTier

RequirementsLimits

GP

GP QL(5 ea daily)

GP

1

RXOTC

GP

49

Drug Name DrugTier

RequirementsLimits

PROCYSBI CPDR 2 SP

GP

colchicine tabs 1

COLCRYS TABS 2

Drug Name DrugTier

RequirementsLimits

RIXUBIS SOLR SP PA

dipyridamole tabs 1

Folic AcidFolates

50

Drug Name DrugTier

RequirementsLimits

INTEGRA F CAPS 2

estazolam tabs 1

Drug Name DrugTier

RequirementsLimits

CLENPIQ SOLN 2 PV

GP

51

Drug Name DrugTier

RequirementsLimits

GP

PV

1 PV

Saline Laxatives

Drug Name DrugTier

RequirementsLimits

Stimulant Laxatives

bisacodyl supp 1

bisacodyl tbec 1

52

Drug Name DrugTier

RequirementsLimits

GP

ERY-TAB TBEC 2

GP

Drug Name DrugTier

RequirementsLimits

Contraceptives

53

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

54

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

55

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

56

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

2

57

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

58

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

59

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

2

60

Drug Name DrugTier

RequirementsLimits

2

Drug Name DrugTier

RequirementsLimits

61

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

62

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

63

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

64

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

65

Drug Name DrugTier

RequirementsLimits

Drug Name DrugTier

RequirementsLimits

66

Drug Name DrugTier

RequirementsLimits

2

Drug Name DrugTier

RequirementsLimits

MIGERGOT SUPP 2

Serotonin Agonists

GP QL(2 ea daily)

67

Drug Name DrugTier

RequirementsLimits

daily)

Fluoride

LOZI-FLUR LOZG 2

GP

K-PHOS TABS 2

1

Potassium

Drug Name DrugTier

RequirementsLimits

2

K-TAB TBCR 8 MEQ 2

KLOR-CON M15 TBCR 2

KLOR-CON25 PACK 2

1

68

Drug Name DrugTier

RequirementsLimits

cyclosporine caps 1

GP

tacrolimus caps 1

ZORTRESS TABS 2

GP

Drug Name DrugTier

RequirementsLimits

1

clotrimazole troc 1

GP

GP QL(6 ea daily)

GP QL(4 ea daily)

MULTIVITAMINS

Ped MV w Fluoride

old )

69

Drug Name DrugTier

RequirementsLimits

BAL-CARE DHA MISC 2

COMPLETENATE CHEW 2

CONCEPT DHA CAPS 2

CONCEPT OB CAPS 2

DOTHELLE DHA CAPS 2

FOCALGIN CA MISC 2

FOLIVANE-OB CAPS 2

Drug Name DrugTier

RequirementsLimits

M-VIT TABS 2 RXOTC

MARNATAL-F CAPS 2

NESTABS DHA MISC 2

PNV OB+DHA MISC 2

PNV-VP-U CAPS 2

PR NATAL 400 MISC 2

PR NATAL 430 MISC 2

PRENA 1 TRUE MISC 2

PRENATA CHEW 2

70

Drug Name DrugTier

RequirementsLimits

2

PRENATAL-U CAPS 2

2

QL(1 ea daily)

2

PROVIDA DHA CAPS 2

PROVIDA OB CAPS 2

Drug Name DrugTier

RequirementsLimits

2

TARON-C DHA CAPS 2

TRI-TABS DHA MISC 2

TRINATAL GT TABS 2

VENA-BAL DHA MISC 2

VIRT-ADVANCE TABS 2

VIRT-C DHA CAPS 2

VIRT-VITE GT TABS 2

VITATRUE MISC 2

71

Drug Name DrugTier

RequirementsLimits

Nasal Antiallergy

Drug Name DrugTier

RequirementsLimits

GP

72

Drug Name DrugTier

RequirementsLimits

BETIMOL SOLN 2

BETOPTIC-S SUSP 2

GP

1

2

ISTALOL SOLN 2

2

GP

Drug Name DrugTier

RequirementsLimits

GP

CILOXAN OINT 2

GENTAK OINT 2

MOXEZA SOLN 2

73

Drug Name DrugTier

RequirementsLimits

retail)

NATACYN SUSP 2

GP

TOBREX OINT 2

trifluridine soln 1

Drug Name DrugTier

RequirementsLimits

BLEPHAMIDE SUSP 2

2

FLAREX SUSP 2

FML FORTE SUSP 2

GP

FML OINT 2

MAXIDEX SUSP 2

GP

PRED MILD SUSP 2

2

74

Drug Name DrugTier

RequirementsLimits

2

GP

ALOCRIL SOLN 2

ALOMIDE SOLN 2

BROMFENAC SOLN 2

CYSTARAN SOLN 2

Drug Name DrugTier

RequirementsLimits

bimatoprost soln 1

LUMIGAN SOLN 2

TRAVATAN Z SOLN 2

75

Drug Name DrugTier

RequirementsLimits

Otic Combinations

GP

amoxicillin chew 1

amoxicillin susr 1

Drug Name DrugTier

RequirementsLimits

amoxicillin tabs 1

ampicillin caps 1

ampicillin susr 1

2

GP

76

Drug Name DrugTier

RequirementsLimits

GP QL(1 ea daily)

GP

disulfiram tabs 1

GP QL(1 ea daily)

GP

2

Drug Name DrugTier

RequirementsLimits

GP

GP QL(1 ea daily)

GP

rivastigmine pt24 1

GILENYA CAPS 2

77

Drug Name DrugTier

RequirementsLimits

GP PV

nicotine pt24 1 PV

2 PV

Drug Name DrugTier

RequirementsLimits

GP PV

GP

78

Drug Name DrugTier

RequirementsLimits

methimazole tabs 1

GP QL(2 ea daily)

1 QL(1 ea daily)

1

2

GP

QL(1 ea daily)

GP

thyroid tabs 1

WESTHROID TABS 2

Drug Name DrugTier

RequirementsLimits

2

CUVPOSA SOLN 2

GP

79

Drug Name DrugTier

RequirementsLimits

1

Drug Name DrugTier

RequirementsLimits

GP QL(1 ea daily)

misoprostol tabs 1

GP

80

Drug Name DrugTier

RequirementsLimits

GP

Drug Name DrugTier

RequirementsLimits

TERCONAZOLE CREA 2

Vaginal Progestins

VITAMINS

phytonadione tabs 1

81

ACULAR ACULAR LS

75 75

26 27

32 42 34

18 51 42

10 77

24 50 67 75 75 47 73 8

Index 1

22 16 21 48

1

22 21

50 67 77

22 79 39

Index 2

Index 3

53

Index 4

43 43 50 9

52 11 15 4

77 80 14 9

50 50 45 56

43 19 35

56

13 13 13 4

55

56

Index 5

56

57 20 19

Index 6

74 81

70 57

57

9 50

FORTESTA FOSAMAX

6 46

30 28 77 26 26 25 18 18 16

57

74 41 41 41 78 14 29 68 51 3

75 25 43

72

folic acid 51

Index 7

Index 8

73 19 50 18 26 50 16 16 16 18 16

59 59

59

59 35 80 49 17 17 46

16 30 68 68 49 68 5

30 69 36 43 12 12 45 19

3 3

25 27

Index 9

30 33 23 41 41 8

21

23 37 21 23 23 41 20 19 29 68 75 68 26 25 51 70 70 80 80 24 14 70

60 43 3

36 36 37

27 32 67 67 74 74

25

60 60 60

37 20 1

18

60 60

60 26 20

60

61

61 26 26 3

25 77 47

Index 10

5 81 7

25 49 24 24 11 16 5

45 80 79 6

72 3

25

Index 11

26 20 21

61 61 18

Index 12

42 42 37 6 6 4

61 69 21 44 29

62

61

62

62 14 51 21

2 15 75

1 74 39

12 70 70

Index 13

Index 14

ACTIVATED 63

Index 15

Index 16

71 20 44 29 74 20

13 33

TRILEPTAL TRILIPIX

13 20

64 11

71 65 65 29 29 29 79 34 18 9

34 73

73 73 73 31 72 2 2

25 46

17 17 81 35 16 5

21 51 8

14 75 65

65 15 24 11 17 17 40

2 2

40 37

TYBOST TYKERB

31 27

71

69

72

44

45 51

Index 17

66

19 35 78

65

81 49 49

65

49 50 48

31 31 32

65

65 5

44

65

48 48 81 32 32 32

32 13 74 13 31 31

71 71 71 8

71 48 71

Index 18

Index 19

Classes
- MULTIVITAMINS
- VITAMINS

Date post:	09-Feb-2022
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Health Net 2-Tier Recommended Drug List

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