Select Drug List

Select Drug List Drug list — Four Tier Drug Plan

Your prescription benefit comes with a drug list, which is also called a formulary. This list is made up of brand-name and generic prescription drugs approved by the U.S. Food & Drug Administration (FDA).

Here are a few things to remember about the list:

o You and your doctor can use it as a guide to choose drugs that are best for you. Drugs that aren’t on this listmay not be covered by your plan and may cost you more out of pocket.

o Your coverage has limitations and exclusions, which means there are certain rules about what’s covered byyour plan and what isn’t. To find out more, read your Certificate or Evidence of Coverage or your SummaryPlan Description. If you’re not sure where to find it, ask your employer for a copy.

o To help you see how the drug list works with your drug benefit, we've included some frequently askedquestions (FAQ) about how the list is set up and what to do if a drug you take isn't on it.

o The most up-to-date drug list for your plan - including drugs that have been added, generic drugs and more- is available at anthem.com/pharmacyinformation. Select the Select Drug List.

If you have questions about your pharmacy benefits, we're here to help. Just call us at the Member Services number on your ID card.

40627MEMENABS SG

What is a drug list? The drug list, also called a formulary, is a list of prescription medicines your plan covers. It includes hundreds of brand-name and generic drugs approved by the U.S. Food & Drug Administration (FDA).

Is this a complete listing of all covered drugs? Yes, this is a complete listing of all the drugs on the drug list. But, it’s possible a drug(s) on this list may not be covered, depending on your plan’s design. Your coverage has limitations and exclusions, which means there are certain conditions that determine what’s covered by your plan and what isn’t. To find out more, read your Certificate/Evidence of Coverage or your Summary Plan Description, which you got when you signed up for your plan.

How can I find a drug on the list? The drugs are listed in alphabetical order based on the name of their drug class, also called therapeutic class. You can search the PDF drug list by:

o Drug name, using Ctrl + F on your keyboard, then type in the name of the drug you’re looking for.o Drug class, using the categories listed in alphabetical order.

The Notes column will tell you if you need preapproval before you can take the drug (called prior authorization or PA), or if you need to try other drugs first for your treatment (called step therapy or ST).

When I search the list, I see that each drug is on a tier. What are the tiers for? The drug list is set up in tiers or levels. We place drugs on different tiers based on how well they work to improve health, whether there are over-the-counter (OTC) options and their costs compared to other drugs used for the same type of treatment. Your share of the drug cost will depend on what tier a drug is on. The lower the tier, the lower your share of the cost. Here’s a breakdown of the tiers in your plan:

o Tier 1 drugs have the lowest cost share for you. These are usually generic drugs that offer the best value compared to other drugs that treat the same conditions. Some plans split Tier 1 into Tier 1a and Tier 1b:

oTier 2 drugs have a higher cost share than Tier 1. They may be preferred brand drugs, based on how well they workand their cost compared to other drugs used for the same type of treatment. Some are generic drugs that may costmore because they’re newer to the market.

o Tier 3 drugs have a higher cost share. They often include non-preferred brand and generic drugs. They may cost more than drugs on lower tiers that are used to treat the same condition. Tier 3 may also include drugs that were recently approved by the FDA.

o Tier 4 drugs have the highest cost share and usually include specialty brand and generic drugs. They may cost more than drugs on lower tiers that are used to treat the same condition. Tier 4 may also include drugs recently approved by the FDA or specialty drugs used to treat serious, long-term health conditions and that may need special handling.

How will I know how much my drug will cost? You can go online to estimate your share of a drug’s cost and compare prices at different pharmacies. Here’s how:

o At the top right of the anthem.com home page, select Manage Prescriptions from the Popular Tasks icon, then log in using your user name and password. If you haven’t signed up on the site, you’ll need to do that first.

o On your personal Pharmacy Overview page, select Price a Medication, then select one or more pharmacies and enter the name of the drug you’d like to price.

Select Drug List

Please note: This tool will provide you with an estimate of your cost, but may not reflect the actual amount you pay at the pharmacy. Actual prices are based on your plan design and also include sales tax where applicable.

If my medicine isn’t on the drug list, what are my options? Here are a few things to think about:

o If you want to take a drug that’s not on the drug list, you may have to pay the full cost for it.

o You can also talk to your doctor or pharmacist to see if there’s another drug covered by your plan that will work just aswell, or if generic or OTC drugs are an option. Only you and your doctor can decide what drugs are right for you.

o You can search for generic drugs at anthem.com. OTC drugs aren’t shown on the list.

o If a drug you’re taking isn’t covered, your doctor can ask us to review the coverage. This process is called preapprovalor prior authorization. Your doctor can get the process started by calling the Member Services number on the back ofyour member ID card or by downloading a prior authorization form from our website and submitting it. If your request isapproved, the amount you pay for the drug will depend on your plan’s benefit.

Who decides what drugs are on the list? The drugs on the list are reviewed through our Pharmacy and Therapeutics (P&T) process. In this process, a group of independent doctors, pharmacists and other health care professionals decides which drugs we include on our lists. This group meets regularly to look at new and existing drugs and recommends drugs based on how safe they are, how well they work and the value they offer our members.

What’s the difference between brand-name and generic drugs? A brand-name drug is FDA-approved and usually available from only one manufacturer. It may be protected by a patent, which means it can only be made or sold by the company that has the patent.

A generic drug is also FDA-approved and has the same active ingredients as the brand-name drug. But a generic drug is usually available only after the patent on the brand-name drug ends. It may look different, but a generic drug works the same as the brand-name drug.

Does the drug list change, and how will I know if it does? Drugs on our list are reviewed on a regular basis. Sometimes, drugs are added, removed or moved to a different tier. We’ll let you know if a drug you take is taken off the list and, in some cases, if a drug you take is moved to a higher tier.

You can always check the drug list to make sure medicines you take are still on it. You’ll find the most up-to-date drug list when you log in at anthem.com.

Does my plan cover preventive drugs? We cover preventive care drugs with zero cost share in compliance with the Affordable Care Act (ACA).

A note about opioid analgesics. The member cost share for certain abuse-deterrent opioid analgesics may be lower in some states because of laws in those states. Opioid analgesics are a type of painkiller. In response to the global opioid epidemic, the U.S. Food and Drug Administration (FDA) has encouraged drug manufacturers to develop opioids with properties that help deter their misuse and abuse.

Drug(s) may be excluded from the list based on your plan's benefit design.

Search for a drug online

The most up-to-date drug list — including drugs that have been added, generic drugs and more — is always

available online when you log in at anthem.com. At the top right of the home page, choose Manage Prescriptions

from the Popular Tasks icon, then log in. On your personal Pharmacy Overview page, choose Search Your Drug

List and you can easily look up drugs by name, class or brand versus generic.

KEY Here are some terms and notes you’ll find on the drug list.

Brand name drugs are in UPPER CASE, bold type.

Generic drugs are in lower case, plain type.

$0 = preventive drugs. For some members, this product may be covered at 100% with $0 cost share with a prescription

from your provider if specified criteria are met.

DO = dose optimization. Usually, this means you may have to switch from taking a drug twice a day to taking it once

a day at a higher strength.

LD = limited distribution. These drugs are available only through certain pharmacies or wholesalers, depending on

what the manufacturer decides.

PA = prior authorization. You may need to get benefits approved before certain prescriptions can be filled.

QL = quantity limits. There are limits on the amount of medicine covered within a certain amount of time.

SP = specialty drugs. Specialty drugs are used to treat difficult, long -term conditions. You may need to get this drug

through a specialty pharmacy.

ST = step therapy. You may need to use another recommended drug first before a prescribed drug is covered.

2018 Maine Select Drug List

Table of Contents

ANALGESICS ...........................................................................................................................................................................7ANESTHETICS .........................................................................................................................................................................8ANTIARTHRITICS .................................................................................................................................................................... 9ANTIASTHMATICS .................................................................................................................................................................. 9ANTIBIOTICS ......................................................................................................................................................................... 11ANTICOAGULANTS .............................................................................................................................................................. 14ANTIDOTES ........................................................................................................................................................................... 15ANTIFUNGALS ...................................................................................................................................................................... 15ANTIHISTAMINE AND DECONGESTANT COMBINATION ................................................................................................. 16ANTIHISTAMINES ..................................................................................................................................................................16ANTIHYPERGLYCEMICS ...................................................................................................................................................... 17ANTIINFECTIVES/MISCELLANEOUS ...................................................................................................................................19ANTIINFLAM.TUMOR NECROSIS FACTOR INHIBITING AGENTS ....................................................................................19ANTINEOPLASTICS .............................................................................................................................................................. 20ANTI-OBESITY DRUGS .........................................................................................................................................................21ANTIPARKINSON DRUGS .................................................................................................................................................... 21ANTIPLATELET DRUGS ....................................................................................................................................................... 22ANTIVIRALS ...........................................................................................................................................................................22AUTONOMIC DRUGS ............................................................................................................................................................ 24BIOLOGICALS ....................................................................................................................................................................... 24BLOOD ................................................................................................................................................................................... 27CARDIAC DRUGS ..................................................................................................................................................................27CARDIOVASCULAR .............................................................................................................................................................. 29CNS DRUGS ...........................................................................................................................................................................31COLONY STIMULATING FACTORS .....................................................................................................................................33CONTRACEPTIVES ............................................................................................................................................................... 33COUGH/COLD PREPARATIONS .......................................................................................................................................... 36DIAGNOSTIC ..........................................................................................................................................................................37DIURETICS .............................................................................................................................................................................37EENT PREPS ......................................................................................................................................................................... 37ELECT/CALORIC/H2O ...........................................................................................................................................................39GASTROINTESTINAL ............................................................................................................................................................40HORMONES ........................................................................................................................................................................... 42IMMUNOSUPPRESSANTS ....................................................................................................................................................44MISCELLANEOUS MEDICAL SUPPLIES, DEVICES, NON-DRUG ..................................................................................... 44MUSCLE RELAXANTS .......................................................................................................................................................... 45PRE-NATAL VITAMINS ......................................................................................................................................................... 45PSYCHOTHERAPEUTIC DRUGS ..........................................................................................................................................46SEDATIVE/HYPNOTICS ........................................................................................................................................................ 49SKIN PREPS .......................................................................................................................................................................... 49SMOKING DETERRENTS ......................................................................................................................................................52THYROID PREPS ...................................................................................................................................................................52UNCLASSIFIED DRUG PRODUCTS .....................................................................................................................................53VITAMINS ............................................................................................................................................................................... 54

5

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2018 Maine Select Drug List

CURRENT AS OF 10/1/2018

Drug Name Tier Notes

ANALGESICS

acetaminophen-codeine oral solution 120 mg-12 mg /5 ml (5 ml), 120-12 mg/5 ml, 240 mg-24 mg /10 ml (10 ml), 300 mg-30 mg /12.5 ml

Tier 1a QL

acetaminophen-codeine oral tablet

Tier 1a QL

almotriptan malate oral tablet

Tier 1b QL

ascomp with codeine oral capsule

Tier 1b QL

buprenorphine hcl injection solution

Tier 2 QL

buprenorphine hcl injection syringe

Tier 2 QL

butalbital compound w/codeine oral capsule

Tier 1b QL

butalbital compound-codeine oral capsule

Tier 1b QL

butalbital-acetaminop-caf-cod oral capsule

Tier 1b QL

butalbital-acetaminophen oral tablet

Tier 1b

butalbital-acetaminophen-caff oral capsule

Tier 1b

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

Tier 1b

butalbital-aspirin-caffeine oral capsule

Tier 1b

butalbital-aspirin-caffeine oral tablet

Tier 1b

butorphanol tartrate nasal spray,non-aerosol

Tier 1b PA; QL

capacet oral capsule Tier 1b

codeine sulfate oral tablet Tier 2 QL

codeine-butalbital-asa-caff oral capsule

Tier 1b QL

diclofenac potassium oral tablet

Tier 1b

diflunisal oral tablet Tier 1b


dihydroergotamine nasal spray,non-aerosol

Tier 2 QL

diskets oral tablet,soluble Tier 1b PA; QL

eletriptan oral tablet Tier 2 QL

ELMIRON ORAL CAPSULE

Tier 3

EMBEDA ORAL CAPSULE,ORAL ONLY,EXT.REL PELL

Tier 1b PA; QL

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

Tier 2 QL

ergotamine-caffeine oral tablet

Tier 1b

fentanyl transdermal patch 72 hour

Tier 2 PA; QL

frovatriptan oral tablet Tier 2 QL

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

Tier 1b QL

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

Tier 1b QL

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

Tier 1b QL

hydromorphone oral liquid Tier 1b QL

hydromorphone oral tablet Tier 1b QL

hydromorphone oral tablet extended release 24 hr

Tier 2 PA; QL

hydromorphone rectal suppository

Tier 2 QL

ibuprofen-oxycodone oral tablet

Tier 1a QL

ketorolac oral tablet Tier 1a QL

levorphanol tartrate oral tablet

Tier 2 PA; QL

mefenamic acid oral capsule

Tier 1b QL

meperidine oral solution Tier 1b QL

meperidine oral tablet Tier 1b QL

methadone intensol oral concentrate

Tier 1b PA; QL

Effective 10/1/2018

7


methadone oral concentrate

Tier 1b PA; QL

methadone oral solution Tier 1b PA; QL

methadone oral tablet Tier 1b PA; QL

methadone oral tablet,soluble

Tier 1b PA; QL

methadose oral concentrate

Tier 1b PA; QL

methadose oral tablet,soluble

Tier 1b PA; QL

migergot rectal suppository

Tier 1b

morphine concentrate oral solution

Tier 1b QL

morphine oral capsule,extend.release pellets

Tier 2 PA; QL

morphine oral solution Tier 1b QL

morphine oral tablet Tier 1b QL

morphine oral tablet extended release

Tier 2 PA; QL

morphine rectal suppository

Tier 1b QL

naratriptan oral tablet Tier 1b QL

NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR

Tier 3 PA; QL

NUCYNTA ORAL TABLET

Tier 3 QL

oxycodone oral capsule Tier 2 QL

oxycodone oral concentrate

Tier 2 QL

oxycodone oral solution Tier 2 QL

oxycodone oral syringe Tier 2 QL

oxycodone oral tablet Tier 2 QL

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

Tier 1b QL

oxycodone-aspirin oral tablet

Tier 1b QL

OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR

Tier 1b PA; QL

oxymorphone oral tablet Tier 2 QL


oxymorphone oral tablet extended release 12 hr

Tier 2 PA; QL

pentazocine-naloxone oral tablet

Tier 1b QL

rizatriptan oral tablet Tier 1b QL

rizatriptan oral tablet,disintegrating

Tier 1b QL

sumatriptan nasal spray,non-aerosol

Tier 1b QL

sumatriptan succinate oral tablet

Tier 1b QL

sumatriptan succinate subcutaneous cartridge

Tier 2 QL

sumatriptan succinate subcutaneous pen injector

Tier 2 QL

sumatriptan succinate subcutaneous solution

Tier 2 QL

tencon oral tablet 50-325 mg

Tier 1b

tramadol oral tablet Tier 1b QL

tramadol oral tablet extended release 24 hr

Tier 2 PA; QL

tramadol oral tablet, er multiphase 24 hr

Tier 2 PA; QL

vicodin es oral tablet Tier 2 QL

vicodin hp oral tablet Tier 2 QL

vicodin oral tablet Tier 2 QL

zebutal oral capsule 50-325-40 mg

Tier 2

ZIPSOR ORAL CAPSULE Tier 3 QL

ZOHYDRO ER ORAL CAPSULE, ORAL ONLY, ER 12HR

Tier 3 PA; QL

zolmitriptan oral tablet Tier 1b QL

zolmitriptan oral tablet,disintegrating

Tier 1b QL

ANESTHETICS

lidocaine viscous mucous membrane solution

Tier 1a QL

lidocaine-prilocaine topical cream

Tier 1b QL

lidocaine-prilocaine topical kit

Tier 1b

phenazopyridine oral tablet 100 mg, 200 mg

Tier 1a

Effective 10/1/2018

8


SYNERA TOPICAL PATCH, MEDICATED SELF-HEATING

Tier 3

ANTIARTHRITICS

allopurinol oral tablet Tier 1a

celecoxib oral capsule Tier 2 ST; QL

COLCRYS ORAL TABLET

Tier 3 PA; QL

CUPRIMINE ORAL CAPSULE

Tier 3

diclofenac sodium oral tablet extended release 24 hr

Tier 1b

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

Tier 1b

etodolac oral capsule Tier 1b

etodolac oral tablet Tier 1b

etodolac oral tablet extended release 24 hr

Tier 1b

fenoprofen oral tablet Tier 1b QL

flurbiprofen oral tablet Tier 1b

ibu oral tablet Tier 1a

ibuprofen oral suspension Tier 1a QL

ibuprofen oral tablet 400 mg, 600 mg, 800 mg

Tier 1a

indomethacin oral capsule Tier 1b QL

indomethacin oral capsule, extended release

Tier 1b QL

ketoprofen oral capsule Tier 1b

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

Tier 1b QL

meclofenamate oral capsule

Tier 1b

meloxicam oral suspension

Tier 1b QL

meloxicam oral tablet Tier 1b QL

nabumetone oral tablet Tier 1b

naproxen oral suspension Tier 1b

naproxen oral tablet Tier 1b

naproxen oral tablet,delayed release (dr/ec)

Tier 1b


naproxen sodium oral tablet 275 mg, 550 mg

Tier 1b

ORENCIA (WITH MALTOSE) INTRAVENOUS RECON SOLN

Tier 4 PA; SP; QL

ORENCIA CLICKJECT SUBCUTANEOUS AUTO-INJECTOR

Tier 4 PA; SP; QL

ORENCIA SUBCUTANEOUS SYRINGE

Tier 4 PA; SP; QL

oxaprozin oral tablet Tier 1b

piroxicam oral capsule Tier 1b

probenecid oral tablet Tier 1b

probenecid-colchicine oral tablet

Tier 1b

RIDAURA ORAL CAPSULE

Tier 3

sulindac oral tablet Tier 1b

tolmetin oral capsule Tier 2

tolmetin oral tablet Tier 2

ULORIC ORAL TABLET Tier 3 ST

XELJANZ ORAL TABLET10 MG

Tier 4 PA; SP

XELJANZ ORAL TABLET5 MG

Tier 4 PA; SP; QL

ANTIASTHMATICS

acetylcysteine solution Tier 2

ADVAIR DISKUS INHALATION BLISTER WITH DEVICE

Tier 2 QL

ADVAIR HFA INHALATION HFA AEROSOL INHALER

Tier 2 QL

albuterol sulfate inhalation solution for nebulization

Tier 1b

albuterol sulfate oral syrup Tier 1b

ANORO ELLIPTA INHALATION BLISTER WITH DEVICE

Tier 3 QL

ARCAPTA NEOHALER INHALATION CAPSULE, W/INHALATION DEVICE

Tier 3 QL

Effective 10/1/2018

9


ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (30 DOSES), 220 MCG (120 DOSES), 220 MCG (30 DOSES), 220 MCG (60 DOSES)

Tier 2 QL

ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (7 DOSES), 220 MCG (14 DOSES)

Tier 2

BREO ELLIPTA INHALATION BLISTER WITH DEVICE

Tier 3 QL

BROVANA INHALATION SOLUTION FOR NEBULIZATION

Tier 3 QL

budesonide inhalation suspension for nebulization

Tier 1b QL

cromolyn inhalation solution for nebulization

Tier 2

DALIRESP ORAL TABLET

Tier 3 QL

DULERA INHALATION HFA AEROSOL INHALER

Tier 2 QL

FLOVENT DISKUS INHALATION BLISTER WITH DEVICE

Tier 2 QL

FLOVENT HFA INHALATION HFA AEROSOL INHALER

Tier 2 QL

ipratropium bromide inhalation solution

Tier 1b QL

ipratropium-albuterol inhalation solution for nebulization

Tier 2

levalbuterol hcl inhalation solution for nebulization

Tier 2

metaproterenol oral syrup Tier 1a

metaproterenol oral tablet Tier 1a

montelukast oral granules in packet

Tier 1b QL

montelukast oral tablet Tier 1b QL


montelukast oral tablet,chewable

Tier 1b QL

PERFOROMIST INHALATION SOLUTION FOR NEBULIZATION

Tier 3 QL

PROAIR HFA INHALATION HFA AEROSOL INHALER

Tier 2 QL

PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED

Tier 2 QL

PROVENTIL HFA INHALATION HFA AEROSOL INHALER

Tier 3 QL

PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED

Tier 2 QL

SEREVENT DISKUS INHALATION BLISTER WITH DEVICE

Tier 2 QL

SPIRIVA RESPIMAT INHALATION MIST

Tier 3 QL

SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE

Tier 3 QL

STRIVERDI RESPIMAT INHALATION MIST

Tier 3 QL

SYMBICORT INHALATION HFA AEROSOL INHALER

Tier 2 QL

terbutaline oral tablet Tier 2

theochron oral tablet extended release 12 hr

Tier 1b

theophylline oral elixir Tier 1b

theophylline oral solution Tier 1b

theophylline oral tablet extended release 12 hr

Tier 1b

theophylline oral tablet extended release 24 hr

Tier 1b

TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED

Tier 3 QL

Effective 10/1/2018

10


VENTOLIN HFA INHALATION HFA AEROSOL INHALER

Tier 3 QL

XOPENEX HFA INHALATION HFA AEROSOL INHALER

Tier 3 QL

zafirlukast oral tablet Tier 1b

zileuton oral tablet, er multiphase 12 hr

Tier 2 PA

ANTIBIOTICS

ak-poly-bac ophthalmic (eye) ointment

Tier 1a

amoxicillin oral capsule Tier 1a

amoxicillin oral suspension for reconstitution

Tier 1a

amoxicillin oral tablet Tier 1a

amoxicillin oral tablet,chewable 125 mg, 250 mg

Tier 1a

amoxicillin-pot clavulanate oral suspension for reconstitution

Tier 1b

amoxicillin-pot clavulanate oral tablet

Tier 1b

amoxicillin-pot clavulanate oral tablet extended release 12 hr

Tier 1b

amoxicillin-pot clavulanate oral tablet,chewable

Tier 1b

ampicillin oral capsule Tier 1a

avidoxy oral tablet Tier 1b

AZASITE OPHTHALMIC (EYE) DROPS

Tier 3

azithromycin oral packet Tier 1b QL

azithromycin oral suspension for reconstitution

Tier 1b QL

azithromycin oral tablet Tier 1b QL

bacitracin ophthalmic (eye) ointment

Tier 1b

bacitracin-polymyxin b ophthalmic (eye) ointment

Tier 1a

BESIVANCE OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 3

bp 10-1 topical cleanser Tier 1b


CAYSTON INHALATION SOLUTION FOR NEBULIZATION

Tier 4 SP; LD

cefaclor oral capsule Tier 1b

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

Tier 1b

cefaclor oral tablet extended release 12 hr

Tier 2

cefadroxil oral capsule Tier 1b

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

Tier 1b

cefadroxil oral tablet Tier 1b

cefdinir oral capsule Tier 1b

cefdinir oral suspension for reconstitution

Tier 1b

cefditoren pivoxil oral tablet

Tier 2

cefpodoxime oral suspension for reconstitution

Tier 2

cefpodoxime oral tablet Tier 2

cefprozil oral suspension for reconstitution

Tier 1b

cefprozil oral tablet Tier 1b

cefuroxime axetil oral tablet

Tier 1b

cephalexin oral capsule Tier 1a

cephalexin oral suspension for reconstitution

Tier 1a

cephalexin oral tablet Tier 1a

CIPRO HC OTIC (EAR) DROPS,SUSPENSION

Tier 3

CIPRODEX OTIC (EAR) DROPS,SUSPENSION

Tier 3 PA

ciprofloxacin (mixture) oral tablet, er multiphase 24 hr

Tier 1b QL

ciprofloxacin hcl ophthalmic (eye) drops

Tier 1a

ciprofloxacin hcl oral tablet Tier 1b QL

ciprofloxacin hcl otic (ear) dropperette

Tier 1b

Effective 10/1/2018

11


clarithromycin oral suspension for reconstitution

Tier 1b

clarithromycin oral tablet Tier 1b

clarithromycin oral tablet extended release 24 hr

Tier 1b

cleansing wash topical cleanser

Tier 1b

clindamycin hcl oral capsule

Tier 1b

clindamycin palmitate hcl oral recon soln

Tier 1b

clindamycin pediatric oral recon soln

Tier 1b

clindamycin phosphate topical foam

Tier 1b

clindamycin phosphate topical gel

Tier 1b

clindamycin phosphate topical lotion

Tier 1b

clindamycin phosphate topical solution

Tier 1b

clindamycin phosphate topical swab

Tier 1b

clindamycin phosphate vaginal cream

Tier 1b

COLY-MYCIN S OTIC (EAR) DROPS,SUSPENSION

Tier 3

CORTISPORIN TOPICAL CREAM

Tier 3

CORTISPORIN TOPICAL OINTMENT

Tier 3

CYCLOSERINE ORAL CAPSULE

Tier 3

DAPSONE ORAL TABLET

Tier 2

demeclocycline oral tablet Tier 2

dicloxacillin oral capsule Tier 1b

DIFICID ORAL TABLET Tier 3 PA

doxycycline hyclate oral capsule

Tier 1b

doxycycline hyclate oral tablet 100 mg, 50 mg

Tier 1b


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

Tier 1b PA

doxycycline monohydrate oral capsule

Tier 1b

doxycycline monohydrate oral suspension for reconstitution

Tier 1b

doxycycline monohydrate oral tablet

Tier 1b

e.e.s. 400 oral tablet Tier 2

ertapenem injection recon soln

Tier 2

ery pads topical swab Tier 1b

erygel topical gel Tier 1b

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

Tier 1b

erythrocin (as stearate) oral tablet 250 mg

Tier 1b

erythromycin ethylsuccinate oral tablet

Tier 2

erythromycin ophthalmic (eye) ointment

Tier 1a

erythromycin oral capsule,delayed release(dr/ec)

Tier 2

erythromycin oral tablet Tier 2

erythromycin with ethanol topical gel

Tier 1b

erythromycin with ethanol topical solution

Tier 1b

erythromycin with ethanol topical swab

Tier 1b

erythromycin-benzoyl peroxide topical gel

Tier 1b

ethambutol oral tablet Tier 2

FACTIVE ORAL TABLET Tier 3 QL

gatifloxacin ophthalmic (eye) drops

Tier 1b

gentak ophthalmic (eye) ointment

Tier 1a

gentamicin ophthalmic (eye) drops

Tier 1a

gentamicin ophthalmic (eye) ointment

Tier 1a

Effective 10/1/2018

12


gentamicin topical cream Tier 1b

gentamicin topical ointment

Tier 1b

INVANZ INTRAVENOUS RECON SOLN

Tier 3

isoniazid oral solution Tier 1a

isoniazid oral tablet Tier 1a

levofloxacin ophthalmic (eye) drops

Tier 1b

levofloxacin oral tablet Tier 2 QL

linezolid oral suspension for reconstitution

Tier 2 PA; QL

linezolid oral tablet Tier 2 PA; QL

mafenide acetate topical packet

Tier 2

methenamine hippurate oral tablet

Tier 2

methenamine mandelate oral tablet

Tier 2

metronidazole oral capsule

Tier 1a

metronidazole oral tablet Tier 1a

metronidazole vaginal gel Tier 1b

minocycline oral capsule Tier 1b

minocycline oral tablet Tier 1b

minocycline oral tablet extended release 24 hr

Tier 1b PA

MONUROL ORAL PACKET

Tier 3

morgidox oral capsule 100 mg

Tier 1b

MOXATAG ORAL TABLET, ER MULTIPHASE 24 HR

Tier 3

moxifloxacin ophthalmic (eye) drops

Tier 1b

mupirocin topical ointment Tier 1b

neomycin oral tablet Tier 1a

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

Tier 1b

neomycin-bacitracin-polymyxin ophthalmic (eye) ointment

Tier 1b


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

Tier 1a

neomycin-polymyxin b-dexameth ophthalmic (eye) ointment

Tier 1a

neomycin-polymyxin-gramicidin ophthalmic (eye) drops

Tier 1b

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

Tier 1b

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

Tier 1b

neomycin-polymyxin-hc otic (ear) solution

Tier 1b

neo-polycin hc ophthalmic (eye) ointment

Tier 1b

neo-polycin ophthalmic (eye) ointment

Tier 1b

nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg

Tier 1b

nitrofurantoin monohyd/m-cryst oral capsule

Tier 1b

nitrofurantoin oral suspension

Tier 1b

ofloxacin ophthalmic (eye) drops

Tier 1a

ofloxacin oral tablet 300 mg, 400 mg

Tier 1b QL

ofloxacin otic (ear) drops Tier 1b

ORACEA ORAL CAPSULE,IR - DELAY REL,BIPHASE

Tier 3

penicillin v potassium oral recon soln

Tier 1b

penicillin v potassium oral tablet

Tier 1b

polycin ophthalmic (eye) ointment

Tier 1a

polymyxin b sulf-trimethoprim ophthalmic (eye) drops

Tier 1a

PRIFTIN ORAL TABLET Tier 3

PRIMSOL ORAL SOLUTION

Tier 3

Effective 10/1/2018

13


pyrazinamide oral tablet Tier 2

rifabutin oral capsule Tier 2

rifampin oral capsule Tier 2

RIFATER ORAL TABLET Tier 3

silver sulfadiazine topical cream

Tier 1a

SIRTURO ORAL TABLET Tier 3

SIVEXTRO ORAL TABLET

Tier 3 PA; QL

ssd topical cream Tier 1a

sss 10-5 topical cream Tier 1b

sss 10-5 topical foam Tier 1b

sulfacetamide sodium ophthalmic (eye) drops

Tier 1b

sulfacetamide sodium ophthalmic (eye) ointment

Tier 1b

sulfacetamide sodium-sulfur topical cleanser 10-5 % (w/w), 9-4 %, 9-4.5 %

Tier 1b

sulfacetamide sodium-sulfur topical cream 10-2 %, 10-5 % (w/w)

Tier 1b

sulfacetamide sodium-sulfur topical lotion 10-5 % (w/v), 10-5 % (w/w)

Tier 1b

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

Tier 1b

sulfacetamide sodium-sulfur topical suspension

Tier 1b

sulfacetamide sod-sulfur-urea topical cleanser

Tier 1b

sulfacetamide-prednisolone ophthalmic (eye) drops

Tier 1a

sulfacetamide-sulfur-cleansr23 topical kit

Tier 1b

sulfact na-sul-avobnz-otn-ocsa topical combo pack,cleanser and cream

Tier 1b

sulfadiazine oral tablet Tier 2

sulfamethoxazole-trimethoprim oral suspension

Tier 1a

sulfamethoxazole-trimethoprim oral tablet

Tier 1a


SULFAMYLON TOPICAL CREAM

Tier 3

sulfatrim oral suspension Tier 1a

SUPRAX ORAL CAPSULE

Tier 3

SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 500 MG/5 ML

Tier 3

tetracycline oral capsule Tier 1b

THALOMID ORAL CAPSULE

Tier 4 PA; SP; QL

tigecycline intravenous recon soln

Tier 2

TOBRADEX OPHTHALMIC (EYE) OINTMENT

Tier 3

tobramycin in 0.225 % nacl inhalation solution for nebulization

Tier 4 SP

tobramycin ophthalmic (eye) drops

Tier 1a

tobramycin-dexamethasone ophthalmic (eye) drops,suspension

Tier 1b

TRECATOR ORAL TABLET

Tier 3

trimethoprim oral tablet Tier 1a

vancomycin oral capsule Tier 2 PA

vandazole vaginal gel Tier 1b

XIFAXAN ORAL TABLET Tier 3 PA; QL

ANTICOAGULANTS

ELIQUIS ORAL TABLET Tier 3 QL

ELIQUIS ORAL TABLETS,DOSE PACK

Tier 3 QL

enoxaparin subcutaneous solution

Tier 4 QL

enoxaparin subcutaneous syringe

Tier 4 QL

fondaparinux subcutaneous syringe

Tier 4 PA; QL

FRAGMIN SUBCUTANEOUS SOLUTION

Tier 4 QL

Effective 10/1/2018

14


FRAGMIN SUBCUTANEOUS SYRINGE

Tier 4 QL

hep flush-10 (pf) intravenous solution

Tier 1b

heparin (porcine) in 5 % dex intravenous parenteral solution 20,000 unit/500 ml (40 unit/ml), 25,000 unit/250 ml(100 unit/ml), 25,000 unit/500 ml (50 unit/ml)

Tier 1b

heparin (porcine) in nacl (pf) intravenous parenteral solution

Tier 1b

heparin (porcine) injection cartridge

Tier 1b

heparin (porcine) injection solution

Tier 1b

heparin flush(porcine)-0.9nacl intravenous kit

Tier 1b

heparin lock flush (porcine) intravenous solution

Tier 1b

heparin lock flush (porcine) intravenous syringe

Tier 1b

heparin lock flush intravenous solution

Tier 1b

heparin lock flush intravenous syringe

Tier 1b

heparin lock intravenous solution

Tier 1b

heparin lockflush(porcine)(pf) intravenous syringe

Tier 1b

heparin(porcine) in 0.45% nacl intravenous parenteral solution 25,000 unit/250 ml, 25,000 unit/500 ml

Tier 1b

heparin, porcine (pf) injection solution

Tier 1b

heparin, porcine (pf) injection syringe

Tier 1b

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

Tier 1b


heparin, porcine (pf) intravenous syringe

Tier 1b

jantoven oral tablet Tier 1a

PRADAXA ORAL CAPSULE

Tier 3 QL

warfarin oral tablet Tier 1a

XARELTO ORAL TABLET

Tier 3 QL

XARELTO ORAL TABLETS,DOSE PACK

Tier 3 QL

ANTIDOTES

naloxone injection solution Tier 2 QL

naloxone injection syringe Tier 2 QL

naltrexone oral tablet Tier 1b

ANTIFUNGALS

ciclopirox topical cream Tier 1b

ciclopirox topical gel Tier 1b

ciclopirox topical shampoo Tier 1b

ciclopirox topical solution Tier 1b

ciclopirox topical suspension

Tier 1b

clotrimazole mucous membrane troche

Tier 2 QL

clotrimazole topical cream Tier 1b

clotrimazole topical solution

Tier 1b

clotrimazole-betamethasone topical cream

Tier 1b

clotrimazole-betamethasone topical lotion

Tier 1b

econazole topical cream Tier 1b

ERTACZO TOPICAL CREAM

Tier 3

EXELDERM TOPICAL CREAM

Tier 3

EXELDERM TOPICAL SOLUTION

Tier 3

fluconazole oral suspension for reconstitution

Tier 1b QL

fluconazole oral tablet Tier 1b QL

flucytosine oral capsule Tier 2

Effective 10/1/2018

15


griseofulvin microsize oral suspension

Tier 1b

griseofulvin microsize oral tablet

Tier 1b

griseofulvin ultramicrosize oral tablet

Tier 1b

GYNAZOLE-1 VAGINAL CREAM

Tier 3

itraconazole oral capsule Tier 2 PA; QL

JUBLIA TOPICAL SOLUTION WITH APPLICATOR

Tier 3

KERYDIN TOPICAL SOLUTION WITH APPLICATOR

Tier 3

ketoconazole oral tablet Tier 1b QL

ketoconazole topical cream

Tier 1b

ketoconazole topical foam Tier 1b

ketoconazole topical shampoo

Tier 1b

LUZU TOPICAL CREAM Tier 3

MENTAX TOPICAL CREAM

Tier 3

miconazole-3 vaginal suppository

Tier 1b

NAFTIFINE TOPICAL CREAM 1 %

Tier 2

naftifine topical cream 2 % Tier 2

NATACYN OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 3

NOXAFIL ORAL SUSPENSION

Tier 3 QL

nyamyc topical powder Tier 1b

nystatin oral powder 150 million unit, 500 million unit

Tier 1b

nystatin oral suspension Tier 1b

nystatin oral tablet Tier 1b

nystatin topical cream Tier 1b

nystatin topical ointment Tier 1b

nystatin topical powder Tier 1b

nystatin-triamcinolone topical cream

Tier 1b


nystatin-triamcinolone topical ointment

Tier 1b

nystop topical powder Tier 1b

ORAVIG BUCCAL MUCO-ADHESIVE BUCCAL TABLET

Tier 3

oxiconazole topical cream Tier 2

OXISTAT TOPICAL LOTION

Tier 3

terbinafine hcl oral tablet Tier 1b PA; QL

terconazole vaginal cream Tier 1b

terconazole vaginal suppository

Tier 1b

voriconazole oral suspension for reconstitution

Tier 2 PA; QL

voriconazole oral tablet Tier 2 PA; QL

ANTIHISTAMINE AND DECONGESTANT COMBINATION

promethazine vc oral syrup

Tier 1b

promethazine-phenylephrine syr

Tier 1b

ANTIHISTAMINES

azelastine ophthalmic (eye) drops

Tier 1b QL

BEPREVE OPHTHALMIC (EYE) DROPS

Tier 3 PA; QL

carbinoxamine maleate oral liquid

Tier 1b

carbinoxamine maleate oral tablet

Tier 1b

cetirizine oral solution 1 mg/ml

Tier 1b

clemastine oral tablet 2.68 mg

Tier 1b

cyproheptadine oral syrup Tier 1b

cyproheptadine oral tablet Tier 1b

desloratadine oral tablet Tier 1b

desloratadine oral tablet,disintegrating

Tier 1b

diphenhydramine hcl injection solution 50 mg/ml

Tier 2

diphenhydramine hcl injection syringe

Tier 2

Effective 10/1/2018

16


diphenhydramine hcl oral capsule 50 mg

Tier 1a

EMADINE OPHTHALMIC (EYE) DROPS

Tier 3 PA; QL

epinastine ophthalmic (eye) drops

Tier 1b QL

fexofenadine oral tablet 180 mg

Tier 1b

hydroxyzine hcl oral solution 10 mg/5 ml

Tier 1b

hydroxyzine hcl oral tablet Tier 1b

hydroxyzine pamoate oral capsule

Tier 1a

LASTACAFT OPHTHALMIC (EYE) DROPS

Tier 3 PA; QL

levocetirizine oral solution Tier 1b

levocetirizine oral tablet Tier 1b

olopatadine ophthalmic (eye) drops

Tier 2 PA; QL

promethazine oral syrup Tier 1a

promethazine oral tablet Tier 1a

ANTIHYPERGLYCEMICS

acarbose oral tablet Tier 1b

APIDRA SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN

Tier 3 ST

APIDRA U-100 INSULIN SUBCUTANEOUS SOLUTION

Tier 3 ST

AVANDIA ORAL TABLET2 MG, 4 MG

Tier 3 ST; QL

BYDUREON BCISE SUBCUTANEOUS AUTO-INJECTOR

Tier 3 ST; QL

BYDUREON SUBCUTANEOUS PEN INJECTOR

Tier 3 ST; QL

BYDUREON SUBCUTANEOUS SUSPENSION,EXTENDED REL RECON

Tier 3 ST; QL

chlorpropamide oral tablet Tier 1b

CYCLOSET ORAL TABLET

Tier 3

FARXIGA ORAL TABLET Tier 3 ST; QL


glimepiride oral tablet Tier 1b

glipizide oral tablet Tier 1a

glipizide oral tablet extended release 24hr

Tier 1a

glipizide-metformin oral tablet

Tier 1b

glyburide micronized oral tablet

Tier 1b

glyburide oral tablet Tier 1b

glyburide-metformin oral tablet

Tier 1b

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

Tier 2

HUMALOG KWIKPEN INSULIN SUBCUTANEOUS INSULIN PEN

Tier 2

HUMALOG MIX 50-50 INSULN U-100 SUBCUTANEOUS SUSPENSION

Tier 2

HUMALOG MIX 50-50 KWIKPEN SUBCUTANEOUS INSULIN PEN

Tier 2

HUMALOG MIX 75-25 KWIKPEN SUBCUTANEOUS INSULIN PEN

Tier 2

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

Tier 2

HUMALOG U-100 INSULIN SUBCUTANEOUS CARTRIDGE

Tier 2

HUMALOG U-100 INSULIN SUBCUTANEOUS SOLUTION

Tier 2

HUMULIN 70/30 U-100 INSULIN SUBCUTANEOUS SUSPENSION

Tier 2

Effective 10/1/2018

17


HUMULIN 70/30 U-100 KWIKPEN SUBCUTANEOUS INSULIN PEN

Tier 2

HUMULIN N NPH INSULIN KWIKPEN SUBCUTANEOUS INSULIN PEN

Tier 2

HUMULIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION

Tier 2

HUMULIN R REGULAR U-100 INSULN INJECTION SOLUTION

Tier 2

HUMULIN R U-500 (CONC) INSULIN SUBCUTANEOUS SOLUTION

Tier 2

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

Tier 2

INVOKAMET ORAL TABLET

Tier 3 ST; QL

INVOKANA ORAL TABLET

Tier 3 ST; QL

JANUMET ORAL TABLET

Tier 2 ST; QL

JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR

Tier 2 ST; QL

JANUVIA ORAL TABLET Tier 2 ST; QL

JARDIANCE ORAL TABLET

Tier 2 ST; QL

JENTADUETO ORAL TABLET

Tier 2 ST; QL

LANTUS SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN

Tier 2

LANTUS U-100 INSULIN SUBCUTANEOUS SOLUTION

Tier 2

LEVEMIR FLEXTOUCH U-100 INSULN SUBCUTANEOUS INSULIN PEN

Tier 2


LEVEMIR U-100 INSULIN SUBCUTANEOUS SOLUTION

Tier 2

metformin oral tablet Tier 1b

metformin oral tablet extended release 24 hr

Tier 1b

metformin oral tablet extended release 24hr

Tier 1b

miglitol oral tablet Tier 2

nateglinide oral tablet Tier 2

NESINA ORAL TABLET Tier 3 ST; QL

NOVOLIN 70/30 U-100 INSULIN SUBCUTANEOUS SUSPENSION

Tier 2

NOVOLIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION

Tier 2

NOVOLIN R REGULAR U-100 INSULN INJECTION SOLUTION

Tier 2

NOVOLOG FLEXPEN U-100 INSULIN SUBCUTANEOUS INSULIN PEN

Tier 2

NOVOLOG MIX 70-30 U-100 INSULN SUBCUTANEOUS SOLUTION

Tier 2

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

Tier 2

NOVOLOG PENFILL U-100 INSULIN SUBCUTANEOUS CARTRIDGE

Tier 2

NOVOLOG U-100 INSULIN ASPART SUBCUTANEOUS SOLUTION

Tier 2

ONGLYZA ORAL TABLET 2.5 MG

Tier 3 ST; DO

ONGLYZA ORAL TABLET 5 MG

Tier 3 ST; QL

pioglitazone oral tablet Tier 1b QL

repaglinide oral tablet Tier 2

Effective 10/1/2018

18


repaglinide-metformin oral tablet

Tier 2

SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR

Tier 3 PA

SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR

Tier 3 PA

SYNJARDY ORAL TABLET

Tier 2 ST; QL

TANZEUM SUBCUTANEOUS PEN INJECTOR

Tier 3 ST; QL

tolazamide oral tablet Tier 1b

tolbutamide oral tablet Tier 2

TRADJENTA ORAL TABLET

Tier 2 ST; DO

TRULICITY SUBCUTANEOUS PEN INJECTOR

Tier 3 ST; QL

VICTOZA 2-PAK SUBCUTANEOUS PEN INJECTOR

Tier 2 ST; QL

VICTOZA 3-PAK SUBCUTANEOUS PEN INJECTOR

Tier 2 ST; QL

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

Tier 3 ST; QL

ANTIINFECTIVES/MISCELLANEOUS

ALINIA ORAL SUSPENSION FOR RECONSTITUTION

Tier 3

ALINIA ORAL TABLET Tier 3

atovaquone oral suspension

Tier 2

atovaquone-proguanil oral tablet

Tier 1b

chloroquine phosphate oral tablet

Tier 1a

COARTEM ORAL TABLET

Tier 3

DARAPRIM ORAL TABLET

Tier 3 PA; LD; QL

hydroxychloroquine oral tablet

Tier 1b


ivermectin oral tablet Tier 1b

mefloquine oral tablet Tier 1b

NEBUPENT INHALATION RECON SOLN

Tier 4

paromomycin oral capsule Tier 1b

praziquantel oral tablet Tier 2

PRIMAQUINE ORAL TABLET

Tier 3

quinine sulfate oral capsule

Tier 2 PA; QL

ANTIINFLAM.TUMOR NECROSIS FACTOR INHIBITING AGENTS

CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT

Tier 4 PA; SP; LD; QL

CIMZIA STARTER KIT SUBCUTANEOUS SYRINGE KIT


CIMZIA SUBCUTANEOUS SYRINGE KIT


ENBREL MINI SUBCUTANEOUS CARTRIDGE

Tier 4 PA; SP; QL

ENBREL SUBCUTANEOUS RECON SOLN

Tier 4 PA; SP; QL

ENBREL SUBCUTANEOUS SYRINGE

Tier 4 PA; SP; QL

ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR

Tier 4 PA; SP; QL

HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT

Tier 4 PA; SP; QL

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

Tier 4 PA; SP; QL

HUMIRA PEN PSORIASIS-UVEITIS SUBCUTANEOUS PEN INJECTOR KIT

Tier 4 PA; SP; QL

Effective 10/1/2018

19


HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT

Tier 4 PA; SP; QL

HUMIRA SUBCUTANEOUS SYRINGE KIT

Tier 4 PA; SP; QL

SIMPONI ARIA INTRAVENOUS SOLUTION

Tier 4 PA; SP

SIMPONI SUBCUTANEOUS PEN INJECTOR

Tier 4 PA; SP; QL

SIMPONI SUBCUTANEOUS SYRINGE

Tier 4 PA; SP; QL

ANTINEOPLASTICS

ACTIMMUNE SUBCUTANEOUS SOLUTION

Tier 4 PA; SP; LD

AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION

Tier 4 PA; SP

AFINITOR ORAL TABLET

Tier 4 PA; SP

anastrozole oral tablet Tier 2 QL

bexarotene oral capsule Tier 4 PA; SP; QL

bicalutamide oral tablet Tier 2

BOSULIF ORAL TABLET Tier 4 PA; SP; QL

capecitabine oral tablet Tier 4 PA; SP

CAPRELSA ORAL TABLET

Tier 4 PA; QL

CARAC TOPICAL CREAM

Tier 2 QL

COMETRIQ ORAL CAPSULE

Tier 4 PA; LD; QL

CYCLOPHOSPHAMIDE ORAL CAPSULE

Tier 4 SP

diclofenac sodium topical gel 3 %

Tier 2 QL

EMCYT ORAL CAPSULE Tier 4 PA

ERIVEDGE ORAL CAPSULE

Tier 4 PA; SP; QL

etoposide oral capsule Tier 4 SP

exemestane oral tablet Tier 2 PA; QL

FARESTON ORAL TABLET

Tier 4 QL


FARYDAK ORAL CAPSULE

Tier 4 PA; SP; QL

FIRMAGON SUBCUTANEOUS RECON SOLN 120 MG

Tier 4 PA; SP; QL

fluorouracil topical cream 5 %

Tier 1b QL

fluorouracil topical solution Tier 1b QL

flutamide oral capsule Tier 2

GILOTRIF ORAL TABLET


GLEOSTINE ORAL CAPSULE

Tier 4 PA

HEXALEN ORAL CAPSULE

Tier 4

HYCAMTIN ORAL CAPSULE

Tier 4 SP

hydroxyurea oral capsule Tier 2

IBRANCE ORAL CAPSULE

Tier 4 PA; SP; QL

ICLUSIG ORAL TABLET Tier 4 PA; QL

imatinib oral tablet Tier 4 PA; SP; QL

IMBRUVICA ORAL CAPSULE

Tier 4 PA; LD; QL

IMBRUVICA ORAL TABLET

Tier 4 PA; LD; QL

INLYTA ORAL TABLET Tier 4 PA; SP; QL

INTRON A INJECTION RECON SOLN

Tier 4 SP

INTRON A INJECTION SOLUTION

Tier 4 SP

JAKAFI ORAL TABLET Tier 4 PA; SP; LD; QL

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


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

Tier 4 PA; SP

letrozole oral tablet Tier 2 QL

Effective 10/1/2018

20


LEUKERAN ORAL TABLET

Tier 4

leuprolide subcutaneous kit

Tier 4 PA; SP

LYNPARZA ORAL TABLET


LYSODREN ORAL TABLET

Tier 4 QL

MATULANE ORAL CAPSULE

Tier 4 LD

MEKINIST ORAL TABLET

Tier 4 PA; SP; QL

melphalan oral tablet Tier 4 SP

mercaptopurine oral tablet Tier 2

methotrexate sodium oral tablet

Tier 2

MYLERAN ORAL TABLET

Tier 4

NEXAVAR ORAL TABLET

Tier 4 PA; SP; QL

nilutamide oral tablet Tier 4 QL

ODOMZO ORAL CAPSULE

Tier 4 PA; SP; QL

PICATO TOPICAL GEL Tier 3 PA; QL

POMALYST ORAL CAPSULE

Tier 4 PA; SP; QL

REVLIMID ORAL CAPSULE

Tier 4 PA; SP; QL

SPRYCEL ORAL TABLET

Tier 4 PA; SP; QL

STIVARGA ORAL TABLET

Tier 4 PA; SP; QL

SUTENT ORAL CAPSULE

Tier 4 PA; SP; QL

TABLOID ORAL TABLET Tier 4

TAFINLAR ORAL CAPSULE

Tier 4 PA; SP; QL

tamoxifen oral tablet Tier 2 $0

TARCEVA ORAL TABLET

Tier 4 PA; SP; QL

TARGRETIN TOPICAL GEL

Tier 4 PA; SP

TASIGNA ORAL CAPSULE

Tier 4 PA; SP; QL

temozolomide oral capsule Tier 4 PA; SP; QL


tretinoin (chemotherapy) oral capsule

Tier 2

TYKERB ORAL TABLET Tier 4 PA; SP; QL

VOTRIENT ORAL TABLET

Tier 4 PA; SP; QL

XALKORI ORAL CAPSULE

Tier 4 PA; SP; QL

XTANDI ORAL CAPSULE Tier 4 PA; SP; QL

ZELBORAF ORAL TABLET

Tier 4 PA; SP; QL

ZOLINZA ORAL CAPSULE

Tier 4 PA; SP; QL

ZYDELIG ORAL TABLET Tier 4 PA; SP; LD; QL

ZYKADIA ORAL CAPSULE

Tier 4 PA; SP; QL

ZYTIGA ORAL TABLET Tier 4 PA; SP; QL

ANTI-OBESITY DRUGS

BELVIQ ORAL TABLET Tier 3 PA

phendimetrazine tartrate oral capsule, extended release

Tier 1b PA

phendimetrazine tartrate oral tablet

Tier 1b PA

phentermine oral capsule Tier 1b PA

phentermine oral tablet Tier 1b PA

ANTIPARKINSON DRUGS

amantadine hcl oral capsule

Tier 2 QL

amantadine hcl oral solution

Tier 2

amantadine hcl oral tablet Tier 2 QL

APOKYN SUBCUTANEOUS CARTRIDGE

Tier 4 SP; LD; QL

benztropine oral tablet Tier 1a

bromocriptine oral capsule Tier 1b

bromocriptine oral tablet Tier 1b

carbidopa oral tablet Tier 2

carbidopa-levodopa oral tablet

Tier 1b

carbidopa-levodopa oral tablet extended release

Tier 2

carbidopa-levodopa oral tablet,disintegrating

Tier 2

Effective 10/1/2018

21


entacapone oral tablet Tier 2 QL

pramipexole oral tablet Tier 2 QL

rasagiline oral tablet Tier 2

ropinirole oral tablet Tier 1b

ropinirole oral tablet extended release 24 hr

Tier 2

selegiline hcl oral capsule Tier 2

selegiline hcl oral tablet Tier 2

tolcapone oral tablet Tier 2 QL

trihexyphenidyl oral elixir Tier 1a

trihexyphenidyl oral tablet Tier 1a

ANTIPLATELET DRUGS

anagrelide oral capsule Tier 2

aspirin-dipyridamole oral capsule, er multiphase 12 hr

Tier 2 QL

BRILINTA ORAL TABLET

Tier 3 QL

cilostazol oral tablet Tier 2

clopidogrel oral tablet 300 mg

Tier 2

clopidogrel oral tablet 75 mg

Tier 2 QL

dipyridamole oral tablet Tier 2

prasugrel oral tablet 10 mg Tier 2 QL

prasugrel oral tablet 5 mg Tier 2 DO

ZONTIVITY ORAL TABLET

Tier 3 QL

ANTIVIRALS

abacavir oral solution Tier 4

abacavir oral tablet Tier 4

abacavir-lamivudine oral tablet

Tier 4

abacavir-lamivudine-zidovudine oral tablet

Tier 4

acyclovir oral capsule Tier 1b

acyclovir oral suspension 200 mg/5 ml

Tier 1b

acyclovir oral tablet Tier 1b

acyclovir topical ointment Tier 3 QL

adefovir oral tablet Tier 4 SP

APTIVUS ORAL CAPSULE

Tier 4


APTIVUS ORAL SOLUTION

Tier 4

atazanavir oral capsule Tier 4

BARACLUDE ORAL SOLUTION

Tier 4 SP

CRIXIVAN ORAL CAPSULE 200 MG, 400 MG

Tier 4

DENAVIR TOPICAL CREAM

Tier 3 QL

didanosine oral capsule,delayed release(dr/ec)

Tier 4

EDURANT ORAL TABLET

Tier 4

efavirenz oral capsule Tier 4

efavirenz oral tablet Tier 4

EMTRIVA ORAL CAPSULE

Tier 4

EMTRIVA ORAL SOLUTION

Tier 4

entecavir oral tablet Tier 4 SP

EPCLUSA ORAL TABLET

Tier 4 PA; SP; QL

EPIVIR HBV ORAL SOLUTION

Tier 4 SP

EVOTAZ ORAL TABLET Tier 4

famciclovir oral tablet Tier 1b

FUZEON SUBCUTANEOUS RECON SOLN

Tier 4

GENVOYA ORAL TABLET

Tier 4

HARVONI ORAL TABLET

Tier 4 PA; SP; QL

INTELENCE ORAL TABLET

Tier 4

INVIRASE ORAL CAPSULE

Tier 4

INVIRASE ORAL TABLET

Tier 4

ISENTRESS ORAL TABLET

Tier 4

ISENTRESS ORAL TABLET,CHEWABLE

Tier 4

Effective 10/1/2018

22


KALETRA ORAL TABLET

Tier 4

lamivudine oral tablet 150 mg, 300 mg

Tier 4

lamivudine-zidovudine oral tablet

Tier 4

lopinavir-ritonavir oral solution

Tier 4

MAVYRET ORAL TABLET

Tier 4 PA; SP; QL

MODERIBA DOSE PACK ORAL TABLETS,DOSE PACK 200 MG (28)- 400 MG (28), 400-400 MG (28)-MG (28), 600-400 MG (28)-MG (28), 600-600 MG (28)-MG (28)

Tier 4 SP

moderiba dose pack oral tablets,dose pack 200 mg (7)- 400 mg (7), 400 mg (7)- 400 mg (7), 600 mg (7)- 400 mg (7), 600 mg (7)- 600 mg (7)

Tier 4 SP

moderiba oral tablet Tier 4 SP

nevirapine oral suspension Tier 4

nevirapine oral tablet Tier 4

NORVIR ORAL CAPSULE

Tier 4

NORVIR ORAL SOLUTION

Tier 4

oseltamivir oral capsule Tier 2 QL

oseltamivir oral suspension for reconstitution

Tier 2 QL

PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR

Tier 4 SP; QL

PEGASYS SUBCUTANEOUS SOLUTION

Tier 4 SP; QL

PEGASYS SUBCUTANEOUS SYRINGE

Tier 4 SP; QL

PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5 ML

Tier 4 SP

PREZISTA ORAL SUSPENSION

Tier 4


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

Tier 4

RELENZA DISKHALER INHALATION BLISTER WITH DEVICE

Tier 2 QL

RESCRIPTOR ORAL TABLET

Tier 4

RESCRIPTOR ORAL TABLET, DISPERSIBLE

Tier 4

ribasphere oral capsule Tier 4 SP

ribasphere oral tablet Tier 4 SP

ribasphere ribapak oral tablets,dose pack

Tier 4 SP

ribavirin oral capsule Tier 4 SP

ribavirin oral tablet 200 mg Tier 4 SP

rimantadine oral tablet Tier 1b

ritonavir oral tablet Tier 4

SELZENTRY ORAL TABLET

Tier 4

SOVALDI ORAL TABLET Tier 4 PA; SP; QL

stavudine oral capsule Tier 4

STRIBILD ORAL TABLET

Tier 4

TECHNIVIE ORAL TABLET

Tier 4 PA; SP; QL

tenofovir disoproxil fumarate oral tablet

Tier 4

TIVICAY ORAL TABLET Tier 4

trifluridine ophthalmic (eye) drops

Tier 1b

TRIUMEQ ORAL TABLET

Tier 4

TRUVADA ORAL TABLET

Tier 4

valacyclovir oral tablet Tier 1b

valganciclovir oral recon soln

Tier 2 SP

valganciclovir oral tablet Tier 2 SP

VEREGEN TOPICAL OINTMENT

Tier 3

VIEKIRA PAK ORAL TABLETS,DOSE PACK

Tier 4 PA; SP; QL

VIRACEPT ORAL TABLET

Tier 4

Effective 10/1/2018

23


VIREAD ORAL TABLET150 MG, 200 MG, 250 MG

Tier 4

ZEPATIER ORAL TABLET

Tier 4 PA; SP; QL

zidovudine oral capsule Tier 4

zidovudine oral syrup Tier 4

zidovudine oral tablet Tier 4

ZIRGAN OPHTHALMIC (EYE) GEL

Tier 3

AUTONOMIC DRUGS

bethanechol chloride oral tablet

Tier 2

cevimeline oral capsule Tier 2

dextroamphetamine oral capsule, extended release

Tier 1b PA

dextroamphetamine oral solution

Tier 1b PA

dextroamphetamine oral tablet

Tier 1b PA

dextroamphetamine-amphetamine oral capsule,extended release 24hr

Tier 1b PA

dextroamphetamine-amphetamine oral tablet

Tier 1b PA

donepezil oral tablet Tier 2

donepezil oral tablet,disintegrating

Tier 2

epinephrine 0.3 mg auto-inject

Tier 1b QL

epinephrine 0.3 mg auto-inject inner, suv

Tier 1b QL

epinephrine 0.3 mg auto-inject latex-free, sdv

Tier 1b QL

epinephrine 0.3 mg auto-inject latex-free, suv

Tier 1b QL

epinephrine 0.3 mg auto-inject no latex, auto-injct

Tier 1b QL

epinephrine 0.3 mg auto-inject no latex, two-pack

Tier 1b QL

epinephrine injection auto-injector 0.15 mg/0.15 ml, 0.15 mg/0.3 ml

Tier 1b QL

EPIPEN 2-PAK INJECTION AUTO-INJECTOR

Tier 2 QL


EPIPEN INJECTION AUTO-INJECTOR

Tier 2 QL

EPIPEN JR 2-PAK INJECTION AUTO-INJECTOR

Tier 2 QL

EPIPEN JR INJECTION AUTO-INJECTOR

Tier 2 QL

galantamine oral capsule,ext rel. pellets 24 hr

Tier 2

galantamine oral solution Tier 2

galantamine oral tablet Tier 2

guanidine oral tablet Tier 1b

methamphetamine oral tablet

Tier 2 PA

midodrine oral tablet Tier 2

NORTHERA ORAL CAPSULE

Tier 3 SP; LD

phenoxybenzamine oral capsule

Tier 2

pilocarpine hcl oral tablet Tier 2

procentra oral solution Tier 1b PA

pyridostigmine bromide oral tablet

Tier 2

rivastigmine tartrate oral capsule

Tier 2

zenzedi oral tablet 10 mg, 5 mg

Tier 1b PA

BIOLOGICALS

ACTHIB (PF) INTRAMUSCULAR RECON SOLN

Tier 3 $0

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

Tier 3 $0

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

Tier 3 $0

AFLURIA 2018-2019 (PF) INTRAMUSCULAR SYRINGE

Tier 1b $0; QL

AFLURIA 2018-2019 INTRAMUSCULAR SUSPENSION

Tier 1b $0; QL

Effective 10/1/2018

24


AFLURIA QUAD 2018-2019 (PF) INTRAMUSCULAR SYRINGE

Tier 1b $0; QL

AFLURIA QUAD 2018-2019 INTRAMUSCULAR SUSPENSION

Tier 1b $0; QL

BEXSERO INTRAMUSCULAR SYRINGE

Tier 2 $0

BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION

Tier 3 $0

BOOSTRIX TDAP INTRAMUSCULAR SYRINGE

Tier 3 $0

DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION

Tier 3 $0

ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION

Tier 3 $0

ENGERIX-B (PF) INTRAMUSCULAR SYRINGE

Tier 3 $0

ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE

Tier 3 $0

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

Tier 1b $0; QL

FLUARIX QUAD 2018-2019 (PF) INTRAMUSCULAR SYRINGE

Tier 1b $0; QL

FLUBLOK QUAD 2018-2019 (PF) INTRAMUSCULAR SYRINGE

Tier 1b $0; QL

FLUCELVAX QUAD 2018-2019 (PF) INTRAMUSCULAR SYRINGE

Tier 1b $0; QL

FLUCELVAX QUAD 2018-2019 INTRAMUSCULAR SUSPENSION

Tier 1b $0; QL


FLULAVAL QUAD 2018-2019 (PF) INTRAMUSCULAR SYRINGE

Tier 1b $0; QL

FLULAVAL QUAD 2018-2019 INTRAMUSCULAR SUSPENSION

Tier 1b $0; QL

FLUMIST QUAD 2018-2019 NASAL NASAL SPRAY SYRINGE

Tier 1b QL

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

Tier 1b $0; QL

FLUZONE QUAD 2018-2019 (PF) INTRAMUSCULAR SUSPENSION

Tier 1b $0; QL

FLUZONE QUAD 2018-2019 (PF) INTRAMUSCULAR SYRINGE

Tier 1b $0; QL

FLUZONE QUAD 2018-2019 INTRAMUSCULAR SUSPENSION

Tier 1b $0; QL

FLUZONE QUAD PEDI 2018-19 (PF) INTRAMUSCULAR SYRINGE

Tier 1b $0; QL

GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION

Tier 2 $0

GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE

Tier 2 $0

GRASTEK SUBLINGUAL TABLET

Tier 3 PA; QL

HAVRIX (PF) INTRAMUSCULAR SUSPENSION

Tier 3 $0

HAVRIX (PF) INTRAMUSCULAR SYRINGE

Tier 3 $0

HEPLISAV-B (PF) INTRAMUSCULAR SOLUTION

Tier 3 $0

HEPLISAV-B (PF) INTRAMUSCULAR SYRINGE

Tier 3 $0

Effective 10/1/2018

25


HIBERIX (PF) INTRAMUSCULAR RECON SOLN

Tier 3 $0

HYQVIA SUBCUTANEOUS SOLUTION

Tier 4 PA; SP

IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN

Tier 3

INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION

Tier 3 $0

INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE

Tier 3 $0

IPOL INJECTION SUSPENSION

Tier 3 $0

IXIARO (PF) INTRAMUSCULAR SYRINGE

Tier 3

KINRIX (PF) INTRAMUSCULAR SUSPENSION

Tier 3 $0

KINRIX (PF) INTRAMUSCULAR SYRINGE

Tier 3 $0

MENACTRA (PF) INTRAMUSCULAR SOLUTION

Tier 3 $0

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

Tier 3 $0

M-M-R II (PF) SUBCUTANEOUS RECON SOLN

Tier 3 $0

PEDIARIX (PF) INTRAMUSCULAR SYRINGE

Tier 3 $0

PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION

Tier 3 $0

PENTACEL (PF) INTRAMUSCULAR KIT

Tier 3 $0

PENTACEL ACTHIB COMPONENT (PF) INTRAMUSCULAR RECON SOLN

Tier 3 $0


PNEUMOVAX 23 INJECTION SOLUTION

Tier 2 $0

PNEUMOVAX 23 INJECTION SYRINGE

Tier 2 $0

PREVNAR 13 (PF) INTRAMUSCULAR SYRINGE

Tier 2 $0

PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

Tier 3 $0

QUADRACEL (PF) INTRAMUSCULAR SUSPENSION

Tier 3 $0

RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION

Tier 3

RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION

Tier 3 $0

RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE

Tier 3 $0

ROTARIX ORAL SUSPENSION FOR RECONSTITUTION

Tier 3 $0

ROTATEQ VACCINE ORAL SOLUTION

Tier 3 $0

SHINGRIX (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION

Tier 2 $0

SHINGRIX GE ANTIGEN COMPONENT INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION

Tier 2 $0

TENIVAC (PF) INTRAMUSCULAR SUSPENSION

Tier 3 $0

TENIVAC (PF) INTRAMUSCULAR SYRINGE

Tier 3 $0

TETANUS,DIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION

Tier 3 $0

Effective 10/1/2018

26


TETANUS-DIPHTHERIA TOXOIDS-TD INTRAMUSCULAR SUSPENSION

Tier 3 $0

TRUMENBA INTRAMUSCULAR SYRINGE

Tier 2 $0

TWINRIX (PF) INTRAMUSCULAR SYRINGE

Tier 3 $0

TYPHIM VI INTRAMUSCULAR SOLUTION

Tier 3

TYPHIM VI INTRAMUSCULAR SYRINGE

Tier 3

VAQTA (PF) INTRAMUSCULAR SUSPENSION

Tier 3 $0

VAQTA (PF) INTRAMUSCULAR SYRINGE

Tier 3 $0

VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

Tier 3 $0

VIVOTIF ORAL CAPSULE,DELAYED RELEASE(DR/EC)

Tier 2

YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

Tier 3

ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

Tier 2 $0

BLOOD

DROXIA ORAL CAPSULE

Tier 4

pentoxifylline oral tablet extended release

Tier 1b

tranexamic acid oral tablet Tier 1b

CARDIAC DRUGS

afeditab cr oral tablet extended release 30 mg

Tier 2 DO

afeditab cr oral tablet extended release 60 mg

Tier 2 QL

amiodarone oral tablet Tier 1b


amlodipine oral tablet 10 mg

Tier 1b QL

amlodipine oral tablet 2.5 mg, 5 mg

Tier 1b DO

cartia xt oral capsule,extended release 24hr 120 mg, 180 mg

Tier 1b DO

cartia xt oral capsule,extended release 24hr 240 mg, 300 mg

Tier 1b QL

digox oral tablet Tier 1b

digoxin oral solution 50 mcg/ml

Tier 1b

digoxin oral tablet Tier 1b

diltiazem hcl oral capsule,ext.rel 24h degradable 120 mg, 180 mg

Tier 1b DO

diltiazem hcl oral capsule,ext.rel 24h degradable 240 mg

Tier 1b QL

diltiazem hcl oral capsule,extended release 12 hr

Tier 2 QL

diltiazem hcl oral capsule,extended release 24 hr 120 mg, 180 mg

Tier 1b DO

diltiazem hcl oral capsule,extended release 24 hr 240 mg, 300 mg, 360 mg, 420 mg

Tier 1b QL

diltiazem hcl oral capsule,extended release 24hr 120 mg, 180 mg

Tier 1b DO

diltiazem hcl oral capsule,extended release 24hr 240 mg, 300 mg, 360 mg

Tier 1b QL

diltiazem hcl oral tablet Tier 1b QL

diltiazem hcl oral tablet extended release 24 hr 180 mg

Tier 1b DO

diltiazem hcl oral tablet extended release 24 hr 240 mg, 300 mg, 360 mg, 420 mg

Tier 1b QL

dilt-xr oral capsule,ext.rel 24h degradable 120 mg, 180 mg

Tier 1b DO

Effective 10/1/2018

27


dilt-xr oral capsule,ext.rel 24h degradable 240 mg

Tier 1b QL

disopyramide phosphate oral capsule

Tier 2

dofetilide oral capsule Tier 2

felodipine oral tablet extended release 24 hr 10 mg

Tier 1b QL

felodipine oral tablet extended release 24 hr 2.5 mg, 5 mg

Tier 1b DO

flecainide oral tablet Tier 2

isosorbide dinitrate oral tablet

Tier 1b

isosorbide dinitrate oral tablet extended release

Tier 1b

isosorbide mononitrate oral tablet

Tier 1b

isosorbide mononitrate oral tablet extended release 24 hr

Tier 1b

isradipine oral capsule Tier 1b QL

LANOXIN ORAL TABLET Tier 3

matzim la oral tablet extended release 24 hr 180 mg

Tier 1b DO

matzim la oral tablet extended release 24 hr 240 mg, 300 mg, 360 mg, 420 mg

Tier 1b QL

mexiletine oral capsule Tier 2

MULTAQ ORAL TABLET Tier 3

nicardipine oral capsule Tier 2 QL

nifedipine oral capsule Tier 2 QL

nifedipine oral tablet extended release 24hr 30 mg

Tier 2 DO

nifedipine oral tablet extended release 24hr 60 mg, 90 mg

Tier 2 QL

nifedipine oral tablet extended release 30 mg

Tier 2 DO

nifedipine oral tablet extended release 60 mg, 90 mg

Tier 2 QL

nimodipine oral capsule Tier 2 QL


nisoldipine oral tablet extended release 24 hr 17 mg, 20 mg, 8.5 mg

Tier 1b DO

nisoldipine oral tablet extended release 24 hr 25.5 mg, 30 mg, 34 mg, 40 mg

Tier 1b QL

nitro-bid transdermal ointment

Tier 1b

nitroglycerin oral capsule, extended release

Tier 2

nitroglycerin sublingual tablet

Tier 1b

nitroglycerin translingual spray,non-aerosol

Tier 2

nitro-time oral capsule, extended release

Tier 1b

pacerone oral tablet 100 mg, 200 mg, 400 mg

Tier 2

propafenone oral capsule,extended release 12 hr

Tier 2

propafenone oral tablet Tier 2

quinidine sulfate oral tablet Tier 1a

RANEXA ORAL TABLET EXTENDED RELEASE 12 HR

Tier 3

taztia xt oral capsule,extended release 24 hr 120 mg, 180 mg

Tier 1b DO

taztia xt oral capsule,extended release 24 hr 240 mg, 300 mg, 360 mg

Tier 1b QL

verapamil oral capsule, 24 hr er pellet ct 100 mg

Tier 1b DO

verapamil oral capsule, 24 hr er pellet ct 200 mg, 300 mg

Tier 1b QL

verapamil oral capsule,ext rel. pellets 24 hr 120 mg, 180 mg

Tier 1b DO

verapamil oral capsule,ext rel. pellets 24 hr 240 mg, 360 mg

Tier 1b QL

verapamil oral tablet Tier 1b QL

verapamil oral tablet extended release

Tier 1b QL

Effective 10/1/2018

28


CARDIOVASCULAR

acebutolol oral capsule Tier 1b

ADCIRCA ORAL TABLET

Tier 4 PA; SP; QL

ADEMPAS ORAL TABLET


amlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg, 5-80 mg

Tier 1b QL

amlodipine-atorvastatin oral tablet 2.5-10 mg, 2.5-20 mg, 2.5-40 mg, 5-10 mg, 5-20 mg, 5-40 mg

Tier 1b DO

amlodipine-benazepril oral capsule

Tier 1b

atenolol oral tablet Tier 1a

atenolol-chlorthalidone oral tablet

Tier 1b

atorvastatin oral tablet 10 mg, 20 mg

Tier 1b DO; $0

atorvastatin oral tablet 40 mg

Tier 1b DO

atorvastatin oral tablet 80 mg

Tier 1b QL

benazepril oral tablet Tier 1a

benazepril-hydrochlorothiazide oral tablet

Tier 1b

betaxolol oral tablet Tier 1b

bisoprolol fumarate oral tablet

Tier 1b

bisoprolol-hydrochlorothiazide oral tablet

Tier 1b

BYSTOLIC ORAL TABLET

Tier 3

candesartan oral tablet Tier 1b QL

candesartan-hydrochlorothiazid oral tablet 16-12.5 mg, 32-12.5 mg

Tier 1b QL

candesartan-hydrochlorothiazid oral tablet 32-25 mg

Tier 1b

captopril oral tablet Tier 2


captopril-hydrochlorothiazide oral tablet

Tier 2

carvedilol oral tablet Tier 1b

cholestyramine (with sugar) oral powder

Tier 2 QL

cholestyramine (with sugar) oral powder in packet

Tier 2 QL

cholestyramine light oral powder

Tier 2 QL

cholestyramine light oral powder in packet

Tier 2

clonidine hcl oral tablet Tier 1a

colesevelam oral powder in packet

Tier 2

colesevelam oral tablet Tier 2

colestipol oral granules Tier 1b

colestipol oral packet Tier 1b

colestipol oral tablet Tier 1b

doxazosin oral tablet Tier 1b

EDARBI ORAL TABLET40 MG

Tier 3 DO

EDARBI ORAL TABLET80 MG

Tier 3 QL

enalapril maleate oral tablet

Tier 1b

enalapril-hydrochlorothiazide oral tablet

Tier 1b

eprosartan oral tablet Tier 1b QL

ergoloid oral tablet Tier 2

ezetimibe oral tablet Tier 2 PA; QL

fenofibrate micronized oral capsule 130 mg, 43 mg

Tier 1b

fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg

Tier 1b QL

fenofibrate nanocrystallized oral tablet

Tier 1b QL

fenofibrate oral tablet 160 mg, 54 mg

Tier 1b QL

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

Tier 1b QL

fenofibric acid oral tablet Tier 1b QL

Effective 10/1/2018

29


fluvastatin oral capsule Tier 1b DO; $0

fluvastatin oral tablet extended release 24 hr

Tier 1b $0

fosinopril oral tablet Tier 1b

fosinopril-hydrochlorothiazide oral tablet

Tier 1b

gemfibrozil oral tablet Tier 1b

guanfacine oral tablet Tier 1b

hydralazine oral tablet Tier 1b

irbesartan oral tablet 150 mg, 75 mg

Tier 1b DO

irbesartan oral tablet 300 mg

Tier 1b QL

irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg

Tier 1b QL

irbesartan-hydrochlorothiazide oral tablet 300-12.5 mg

Tier 1b

labetalol oral tablet Tier 1b

LETAIRIS ORAL TABLET Tier 4 PA; SP; LD; QL

LEVATOL ORAL TABLET

Tier 3

lisinopril oral tablet Tier 1a

lisinopril-hydrochlorothiazide oral tablet

Tier 1b

LIVALO ORAL TABLET 1 MG, 2 MG

Tier 3 ST; DO

LIVALO ORAL TABLET 4 MG

Tier 3 ST; QL

losartan oral tablet Tier 1b QL

losartan-hydrochlorothiazide oral tablet 100-12.5 mg, 100-25 mg

Tier 1b QL

losartan-hydrochlorothiazide oral tablet 50-12.5 mg

Tier 1b DO

lovastatin oral tablet 10 mg, 20 mg

Tier 1b DO; $0

lovastatin oral tablet 40 mg

Tier 1b $0; QL

methyldopa oral tablet Tier 1b


methyldopa-hydrochlorothiazide oral tablet

Tier 1b

metoprolol succinate oral tablet extended release 24 hr

Tier 1b

metoprolol ta-hydrochlorothiaz oral tablet

Tier 1b

metoprolol tartrate oral tablet

Tier 1a

minoxidil oral tablet Tier 1b

moexipril oral tablet Tier 1b

moexipril-hydrochlorothiazide oral tablet

Tier 1b

nadolol oral tablet Tier 2

nadolol-bendroflumethiazide oral tablet

Tier 1b

niacin oral tablet extended release 24 hr

Tier 1b QL

olmesartan oral tablet 20 mg

Tier 2 DO

olmesartan oral tablet 40 mg, 5 mg

Tier 2 QL

OPSUMIT ORAL TABLET Tier 4 PA; SP; LD; QL

ORENITRAM ORAL TABLET EXTENDED RELEASE

Tier 4 PA; SP; LD

perindopril erbumine oral tablet

Tier 1b

pindolol oral tablet Tier 2

pravastatin oral tablet 10 mg, 20 mg

Tier 1b DO; $0

pravastatin oral tablet 40 mg

Tier 1b $0

pravastatin oral tablet 80 mg

Tier 1b $0; QL

prazosin oral capsule Tier 1b

prevalite oral powder Tier 2 QL

prevalite oral powder in packet

Tier 2

propranolol oral capsule,extended release 24 hr

Tier 1b

propranolol oral solution Tier 1b

Effective 10/1/2018

30


propranolol oral tablet Tier 1b

propranolol-hydrochlorothiazid oral tablet

Tier 1b

quinapril oral tablet Tier 1b

quinapril-hydrochlorothiazide oral tablet

Tier 1b

ramipril oral capsule Tier 1b

REMODULIN INJECTION SOLUTION

Tier 4 PA; SP; LD

rosuvastatin oral tablet 10 mg, 5 mg

Tier 2 DO; $0

rosuvastatin oral tablet 20 mg

Tier 2 DO

rosuvastatin oral tablet 40 mg

Tier 2 QL

sildenafil (antihypertensive) oral tablet

Tier 4 PA; SP; QL

simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg

Tier 1b DO; $0

simvastatin oral tablet 80 mg

Tier 1b PA; QL

sorine oral tablet Tier 2

sotalol af oral tablet Tier 2

sotalol oral tablet Tier 2

tadalafil (antihypertensive) oral tablet

Tier 4 PA; SP; QL

TEKTURNA ORAL TABLET 150 MG

Tier 3 DO

TEKTURNA ORAL TABLET 300 MG

Tier 3 QL

telmisartan oral tablet 20 mg, 40 mg

Tier 1b DO

telmisartan oral tablet 80 mg

Tier 1b QL

terazosin oral capsule Tier 1b

timolol maleate oral tablet Tier 1b

TRACLEER ORAL TABLET

Tier 4 PA; SP; QL

trandolapril oral tablet Tier 1b

trandolapril-verapamil oral tablet, ir - er, biphasic 24hr 1-240 mg

Tier 1b DO


trandolapril-verapamil oral tablet, ir - er, biphasic 24hr 2-180 mg, 2-240 mg, 4-240 mg

Tier 1b QL

valsartan oral tablet Tier 1b QL

valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 80-12.5 mg

Tier 1b DO

valsartan-hydrochlorothiazide oral tablet 160-25 mg, 320-12.5 mg, 320-25 mg

Tier 1b QL

VECAMYL ORAL TABLET

Tier 3

VENTAVIS INHALATION SOLUTION FOR NEBULIZATION


CNS DRUGS

APTIOM ORAL TABLET Tier 3

AUBAGIO ORAL TABLET

Tier 4 PA; SP; QL

BANZEL ORAL SUSPENSION

Tier 3

BANZEL ORAL TABLET Tier 3

carbamazepine oral capsule, er multiphase 12 hr

Tier 1b

carbamazepine oral suspension 100 mg/5 ml

Tier 1b

carbamazepine oral tablet Tier 1b

carbamazepine oral tablet extended release 12 hr

Tier 1b

carbamazepine oral tablet,chewable

Tier 1b

CELONTIN ORAL CAPSULE 300 MG

Tier 3

clonazepam oral tablet Tier 1b

clonazepam oral tablet,disintegrating

Tier 1b

DIASTAT ACUDIAL RECTAL KIT

Tier 2 QL

DIASTAT RECTAL KIT Tier 2 QL

diazepam rectal kit Tier 2 QL

divalproex oral capsule, delayed rel sprinkle

Tier 2

Effective 10/1/2018

31


divalproex oral tablet extended release 24 hr

Tier 2

divalproex oral tablet,delayed release (dr/ec)

Tier 2

epitol oral tablet Tier 1b

ethosuximide oral capsule Tier 1b

ethosuximide oral solution Tier 1b

EXTAVIA SUBCUTANEOUS KIT

Tier 4 PA; SP

EXTAVIA SUBCUTANEOUS RECON SOLN

Tier 4 PA; SP

felbamate oral suspension Tier 2

felbamate oral tablet Tier 2

FYCOMPA ORAL TABLET

Tier 3

gabapentin oral capsule Tier 2

gabapentin oral solution Tier 2

gabapentin oral tablet 600 mg, 800 mg

Tier 2

GILENYA ORAL CAPSULE 0.5 MG

Tier 4 PA; SP; QL

glatiramer subcutaneous syringe 20 mg/ml

Tier 4 PA; SP

glatopa subcutaneous syringe 20 mg/ml

Tier 4 PA; SP

HORIZANT ORAL TABLET EXTENDED RELEASE

Tier 3 PA; QL

lamotrigine oral tablet Tier 1b

lamotrigine oral tablet, chewable dispersible

Tier 1b

levetiracetam oral solution Tier 2

levetiracetam oral tablet Tier 2

levetiracetam oral tablet extended release 24 hr

Tier 2 PA

LYRICA ORAL CAPSULE Tier 3 PA; QL

LYRICA ORAL SOLUTION

Tier 3 PA; QL

memantine oral solution Tier 2

memantine oral tablet Tier 2

memantine oral tablets,dose pack

Tier 3


NAMENDA TITRATION PAK ORAL TABLETS,DOSE PACK

Tier 3

ONFI ORAL SUSPENSION

Tier 3

ONFI ORAL TABLET 10 MG, 20 MG

Tier 3

oxcarbazepine oral suspension

Tier 2

oxcarbazepine oral tablet Tier 2

PEGANONE ORAL TABLET

Tier 3

phenytoin sodium extended oral capsule

Tier 1b

PLEGRIDY SUBCUTANEOUS PEN INJECTOR

Tier 4 PA; SP

PLEGRIDY SUBCUTANEOUS SYRINGE

Tier 4 PA; SP

primidone oral tablet Tier 1b

REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE

Tier 4 PA; SP

REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR

Tier 4 PA; SP

REBIF TITRATION PACK SUBCUTANEOUS SYRINGE

Tier 4 PA; SP

riluzole oral tablet Tier 4 SP

SABRIL ORAL TABLET Tier 3 SP; LD

TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC)

Tier 4 PA; SP; QL

tetrabenazine oral tablet Tier 2 PA; SP; LD

tiagabine oral tablet Tier 2

topiramate oral capsule, sprinkle

Tier 1b

topiramate oral tablet Tier 1b

valproic acid (as sodium salt) oral solution

Tier 1b

valproic acid oral capsule Tier 1b

vigabatrin oral powder in packet

Tier 2 SP; LD

VIMPAT ORAL SOLUTION

Tier 3

Effective 10/1/2018

32


VIMPAT ORAL TABLET Tier 3

zonisamide oral capsule Tier 2

COLONY STIMULATING FACTORS

ARANESP (IN POLYSORBATE) INJECTION SOLUTION

Tier 4 PA; SP

ARANESP (IN POLYSORBATE) INJECTION SYRINGE

Tier 4 PA; SP

NEULASTA SUBCUTANEOUS SYRINGE

Tier 4 PA; SP; QL

NEULASTA SUBCUTANEOUS SYRINGE, W/ WEARABLE INJECTOR

Tier 4 PA; SP; QL

NEUPOGEN INJECTION SOLUTION

Tier 4 PA; SP

NEUPOGEN INJECTION SYRINGE

Tier 4 PA; SP

PROCRIT INJECTION SOLUTION

Tier 4 PA; SP

PROMACTA ORAL TABLET

Tier 4 PA; SP

CONTRACEPTIVES

AFTERA ORAL TABLET Tier 1b $0; QL

altavera (28) oral tablet Tier 1a $0

alyacen 1/35 (28) oral tablet

Tier 1a $0

alyacen 7/7/7 (28) oral tablet

Tier 1a $0

amethia lo oral tablets,dose pack,3 month

Tier 1b $0

amethia oral tablets,dose pack,3 month

Tier 1b $0

amethyst oral tablet Tier 1b $0

apri oral tablet Tier 1a $0

aranelle (28) oral tablet Tier 1a $0

ashlyna oral tablets,dose pack,3 month

Tier 1b $0

aubra eq oral tablet Tier 1a

aubra oral tablet Tier 1a $0

aviane oral tablet Tier 1a $0

azurette (28) oral tablet Tier 1b $0


BALCOLTRA ORAL TABLET

Tier 3 $0

balziva (28) oral tablet Tier 1a $0

BEKYREE (28) ORAL TABLET

Tier 1b $0

BLISOVI 24 FE ORAL TABLET

Tier 1a $0

BLISOVI FE 1.5/30 (28) ORAL TABLET

Tier 1a $0

BLISOVI FE 1/20 (28) ORAL TABLET

Tier 1a $0

briellyn oral tablet Tier 1a $0

camila oral tablet Tier 1b $0

camrese lo oral tablets,dose pack,3 month

Tier 1b $0

camrese oral tablets,dose pack,3 month

Tier 1b $0

CAYA CONTOURED VAGINAL DIAPHRAGM

Tier 3 $0

caziant (28) oral tablet Tier 1a $0

chateal eq oral tablet Tier 1a $0

chateal oral tablet Tier 1a $0

cryselle (28) oral tablet Tier 1a $0

cyclafem 1/35 (28) oral tablet

Tier 1a $0

cyclafem 7/7/7 (28) oral tablet

Tier 1a $0

cyred oral tablet Tier 1a $0

dasetta 1/35 (28) oral tablet

Tier 1a $0

dasetta 7/7/7 (28) oral tablet

Tier 1a $0

daysee oral tablets,dose pack,3 month

Tier 1b $0

deblitane oral tablet Tier 1b $0

delyla (28) oral tablet Tier 1a $0

desog-e.estradiol/e.estradiol oral tablet

Tier 1b $0

desogestrel-ethinyl estradiol oral tablet

Tier 1a $0

drospirenone-e.estradiol-lm.fa oral tablet

Tier 1b $0

drospirenone-ethinyl estradiol oral tablet

Tier 1b $0

Effective 10/1/2018

33


econtra ez oral tablet Tier 1b $0; QL

econtra one-step oral tablet

Tier 1b $0; QL

elinest oral tablet Tier 1a $0

ELLA ORAL TABLET Tier 3 $0

emoquette oral tablet Tier 1a $0

enpresse oral tablet Tier 1a $0

enskyce oral tablet Tier 1a $0

errin oral tablet Tier 1b $0

estarylla oral tablet Tier 1a $0

ethynodiol diac-eth estradiol oral tablet

Tier 1a $0

falmina (28) oral tablet Tier 1a $0

FAYOSIM ORAL TABLETS,DOSE PACK,3 MONTH

Tier 1b $0

FEMCAP VAGINAL DEVICE

Tier 3 $0

femynor oral tablet Tier 1a $0

gianvi (28) oral tablet Tier 1b $0

heather oral tablet Tier 1b $0

incassia oral tablet Tier 1b $0

introvale oral tablets,dose pack,3 month

Tier 1b $0

isibloom oral tablet Tier 1a $0

jencycla oral tablet Tier 1b $0

jolessa oral tablets,dose pack,3 month

Tier 1b $0

jolivette oral tablet Tier 1b $0

JULEBER ORAL TABLET

Tier 1a $0

junel 1.5/30 (21) oral tablet Tier 1a $0

junel 1/20 (21) oral tablet Tier 1a $0

junel fe 1.5/30 (28) oral tablet

Tier 1a $0

junel fe 1/20 (28) oral tablet

Tier 1a $0

junel fe 24 oral tablet Tier 1a $0

KAITLIB FE ORAL TABLET,CHEWABLE

Tier 1b $0

kariva (28) oral tablet Tier 1b $0

kelnor 1/35 (28) oral tablet Tier 1a $0

kelnor 1-50 oral tablet Tier 1a $0


kurvelo oral tablet Tier 1a $0

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

Tier 1b $0

larin 1.5/30 (21) oral tablet Tier 1a $0

larin 1/20 (21) oral tablet Tier 1a $0

larin 24 fe oral tablet Tier 1a $0

larin fe 1.5/30 (28) oral tablet

Tier 1a $0

larin fe 1/20 (28) oral tablet

Tier 1a $0

larissia oral tablet Tier 1a $0

layolis fe oral tablet,chewable

Tier 1b $0

leena 28 oral tablet Tier 1a $0

lessina oral tablet Tier 1a $0

levonest (28) oral tablet Tier 1a $0

levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-0.03 mg

Tier 1a $0

levonorgestrel-ethinyl estrad oral tablet 90-20 mcg

Tier 1b $0

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

Tier 1b $0

levonorg-eth estrad triphasic oral tablet

Tier 1a $0

levora-28 oral tablet Tier 1a $0

lillow oral tablet Tier 1a $0

LO LOESTRIN FE ORAL TABLET

Tier 3 $0

loryna (28) oral tablet Tier 1b $0

low-ogestrel (28) oral tablet

Tier 1a $0

lutera (28) oral tablet Tier 1a $0

lyza oral tablet Tier 1b $0

marlissa oral tablet Tier 1a $0

medroxyprogesterone intramuscular suspension

Tier 1b $0

medroxyprogesterone intramuscular syringe

Tier 1b $0

MELODETTA 24 FE ORAL TABLET,CHEWABLE

Tier 1a $0

Effective 10/1/2018

34


MIBELAS 24 FE ORAL TABLET,CHEWABLE

Tier 1a $0

microgestin 1.5/30 (21) oral tablet

Tier 1a $0

microgestin 1/20 (21) oral tablet

Tier 1a $0

microgestin fe 1.5/30 (28) oral tablet

Tier 1a $0

microgestin fe 1/20 (28) oral tablet

Tier 1a $0

mili oral tablet Tier 1a $0

mono-linyah oral tablet Tier 1a $0

mononessa (28) oral tablet Tier 1a $0

my way oral tablet Tier 1b $0; QL

myzilra oral tablet Tier 1a $0

NATAZIA ORAL TABLET Tier 3 $0

necon 0.5/35 (28) oral tablet

Tier 1a $0

next choice one dose oral tablet

Tier 1b $0; QL

nikki (28) oral tablet Tier 1b $0

nora-be oral tablet Tier 1b $0

noreth-ethinyl estradiol-iron oral tablet,chewable

Tier 1b $0

norethindrone (contraceptive) oral tablet

Tier 1b $0

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

Tier 1a $0

norethindrone-e.estradiol-iron oral tablet

Tier 1a $0

norethindrone-e.estradiol-iron oral tablet,chewable

Tier 1a $0

norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25 mg-25 mcg, 0.18/0.215/0.25 mg-35 mcg (28)

Tier 1b $0

norgestimate-ethinyl estradiol oral tablet 0.25-35 mg-mcg

Tier 1a $0

NORLYDA ORAL TABLET

Tier 1b $0

norlyroc oral tablet Tier 1b $0

nortrel 0.5/35 (28) oral tablet

Tier 1a $0


nortrel 1/35 (21) oral tablet Tier 1a $0

nortrel 1/35 (28) oral tablet Tier 1a $0

nortrel 7/7/7 (28) oral tablet

Tier 1a $0

NUVARING VAGINAL RING

Tier 3 $0

ocella oral tablet Tier 1b $0

ogestrel (28) oral tablet Tier 1a $0

opcicon one-step oral tablet

Tier 1b $0; QL

option-2 oral tablet Tier 3 $0; QL

orsythia oral tablet Tier 1a $0

philith oral tablet Tier 1a $0

pimtrea (28) oral tablet Tier 1b $0

pirmella oral tablet Tier 1a $0

PLAN B ONE-STEP ORAL TABLET

Tier 1b $0; QL

portia oral tablet Tier 1a $0

previfem oral tablet Tier 1a $0

quasense oral tablets,dose pack,3 month

Tier 1b $0

RAJANI ORAL TABLET Tier 1b $0

reclipsen (28) oral tablet Tier 1a $0

RIVELSA ORAL TABLETS,DOSE PACK,3 MONTH

Tier 1b $0

setlakin oral tablets,dose pack,3 month

Tier 1b $0

sharobel oral tablet Tier 1b $0

sprintec (28) oral tablet Tier 1a $0

sronyx oral tablet Tier 1a $0

syeda oral tablet Tier 1b $0

TAKE ACTION ORAL TABLET

Tier 1b $0; QL

tarina fe 1/20 (28) oral tablet

Tier 1a $0

TAYTULLA ORAL CAPSULE

Tier 3 $0

tilia fe oral tablet Tier 1b $0

TRI FEMYNOR ORAL TABLET

Tier 1b $0

tri-estarylla oral tablet Tier 1b $0

tri-legest fe oral tablet Tier 1b $0

tri-linyah oral tablet Tier 1b $0

Effective 10/1/2018

35


TRI-LO-ESTARYLLA ORAL TABLET

Tier 1b $0

tri-lo-marzia oral tablet Tier 1b $0

TRI-LO-SPRINTEC ORAL TABLET

Tier 1b $0

tri-mili oral tablet Tier 1b $0

trinessa (28) oral tablet Tier 1b $0

TRINESSA LO ORAL TABLET

Tier 1b $0

tri-previfem (28) oral tablet Tier 1b $0

tri-sprintec (28) oral tablet Tier 1b $0

trivora (28) oral tablet Tier 1a $0

tri-vylibra oral tablet Tier 1b $0

tulana oral tablet Tier 1b $0

tydemy oral tablet Tier 1b $0

velivet triphasic regimen (28) oral tablet

Tier 1a $0

VIENVA ORAL TABLET Tier 1a $0

viorele (28) oral tablet Tier 1b $0

vyfemla (28) oral tablet Tier 1a $0

vylibra oral tablet Tier 1a $0

wera (28) oral tablet Tier 1a $0

WIDE-SEAL DIAPHRAGM 60 VAGINAL DIAPHRAGM

Tier 3 $0


Tier 3 $0


Tier 3 $0


Tier 3 $0


Tier 3 $0


Tier 3 $0


Tier 3 $0


Tier 3 $0


wymzya fe oral tablet,chewable

Tier 1b $0

xulane transdermal patch weekly

Tier 1b $0

zarah oral tablet Tier 1b $0

zenchent (28) oral tablet Tier 1a $0

zovia 1/35e (28) oral tablet Tier 1a $0

COUGH/COLD PREPARATIONS

benzonatate oral capsule 100 mg, 200 mg

Tier 1b

cheratussin ac oral liquid Tier 1a

codeine-guaifen 10-100 mg/5 ml (otc)

Tier 1a

codeine-guaifen 10-100 mg/5 ml a/f,d/f,s/f (otc)

Tier 1a

g tussin ac oral liquid Tier 1a

guaiatussin ac oral liquid Tier 1a

guaifen-codeine 100-10 mg/5 ml (otc)

Tier 1a

guaifen-codeine 100-10 mg/5 ml inner (otc)

Tier 1b

guaifen-codeine 100-10 mg/5 ml outer (otc)

Tier 1b

guaifen-codeine 200-20 mg/10 ml inner (otc)

Tier 1b

guaifen-codeine 200-20 mg/10 ml outer (otc)

Tier 1b

guaifenesin ac oral liquid Tier 1a

guaifenesin-codeine syrup (otc)

Tier 1a

guaifenesin-codeine syrup (otc)

Tier 1b

hydrocodone-chlorpheniramine oral suspension,extended rel 12 hr

Tier 1b

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

Tier 1a

promethazine vc-codeine oral syrup

Tier 1b

promethazine-codeine oral syrup

Tier 1a

promethazine-dm oral syrup

Tier 1a

Effective 10/1/2018

36


promethazine-phenyleph-codeine oral syrup

Tier 1b

TUZISTRA XR ORAL SUSPENSION,EXTENDED REL 12 HR

Tier 3

virtussin ac oral liquid Tier 1a

VITUZ ORAL SOLUTION Tier 3

DIAGNOSTIC

ACCU-CHEK AVIVA PLUS TEST STRP STRIP

Tier 2 QL

ACCU-CHEK COMPACT PLUS TEST STRIP

Tier 2 QL

ACCU-CHEK GUIDE STRIP

Tier 2 QL

ACCU-CHEK SMARTVIEW TEST STRIP STRIP

Tier 2 QL

ACCUTREND GLUCOSE STRIP

Tier 2 QL

GLUCAGEN DIAGNOSTIC KIT INJECTION RECON SOLN

Tier 2

GLUCAGON HCL INJECTION RECON SOLN

Tier 2

ONETOUCH VERIO STRIP

Tier 2 QL

DIURETICS

acetazolamide oral capsule, extended release

Tier 1b

acetazolamide oral tablet Tier 1b

amiloride oral tablet Tier 2

AMMONIUM CHLORIDE INTRAVENOUS SOLUTION

Tier 3

bumetanide oral tablet Tier 1b

chlorothiazide oral tablet Tier 1b

chlorthalidone oral tablet 25 mg, 50 mg

Tier 1a

DYRENIUM ORAL CAPSULE

Tier 3

eplerenone oral tablet Tier 2

ethacrynic acid oral tablet Tier 2


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

Tier 1a

furosemide oral tablet Tier 1a

hydrochlorothiazide oral capsule

Tier 1a

hydrochlorothiazide oral tablet

Tier 1a

indapamide oral tablet Tier 1b

methazolamide oral tablet Tier 2

methyclothiazide oral tablet

Tier 1b

metolazone oral tablet Tier 1b

SAMSCA ORAL TABLET Tier 3 SP; LD

spironolactone oral tablet Tier 1a

torsemide oral tablet Tier 1b

triamterene-hydrochlorothiazid oral capsule

Tier 1a

triamterene-hydrochlorothiazid oral tablet

Tier 1a

EENT PREPS

acetic acid otic (ear) solution

Tier 1b

ALOCRIL OPHTHALMIC (EYE) DROPS

Tier 3 PA; QL

ALOMIDE OPHTHALMIC (EYE) DROPS

Tier 3 PA; QL

apraclonidine ophthalmic (eye) drops

Tier 1b

azelastine nasal aerosol,spray

Tier 1b QL

AZOPT OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 3

betaxolol ophthalmic (eye) drops

Tier 1b

bimatoprost ophthalmic (eye) drops

Tier 2

brimonidine ophthalmic (eye) drops

Tier 1b

bromfenac ophthalmic (eye) drops

Tier 2

carteolol ophthalmic (eye) drops

Tier 1a

Effective 10/1/2018

37


COMBIGAN OPHTHALMIC (EYE) DROPS

Tier 3

cromolyn ophthalmic (eye) drops

Tier 1a QL

dexamethasone sodium phosphate ophthalmic (eye) drops

Tier 1b

diclofenac sodium ophthalmic (eye) drops

Tier 1b

dorzolamide ophthalmic (eye) drops

Tier 1b

dorzolamide-timolol ophthalmic (eye) drops

Tier 1b

DUREZOL OPHTHALMIC (EYE) DROPS

Tier 3 QL

DYMISTA NASAL SPRAY,NON-AEROSOL

Tier 3 QL

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

Tier 1b ST; QL

fluocinolone acetonide oil otic (ear) drops

Tier 1b

fluorometholone ophthalmic (eye) drops,suspension

Tier 1b

flurbiprofen sodium ophthalmic (eye) drops

Tier 1b

fluticasone nasal spray,suspension

Tier 1b QL

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

Tier 3

hydrocortisone-acetic acid otic (ear) drops

Tier 1b

ketorolac ophthalmic (eye) drops

Tier 1b

LACRISERT OPHTHALMIC (EYE) INSERT

Tier 3

latanoprost ophthalmic (eye) drops

Tier 1b

levobunolol ophthalmic (eye) drops 0.5 %

Tier 1b

LOTEMAX OPHTHALMIC (EYE) DROPS,GEL

Tier 3


LOTEMAX OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 3

LOTEMAX OPHTHALMIC (EYE) OINTMENT

Tier 3

LUMIGAN OPHTHALMIC (EYE) DROPS 0.01 %

Tier 3

metipranolol ophthalmic (eye) drops

Tier 1b

NEVANAC OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 3

olopatadine nasal spray,non-aerosol

Tier 1b QL

OMNARIS NASAL SPRAY,NON-AEROSOL

Tier 3 ST; QL

PHOSPHOLINE IODIDE OPHTHALMIC (EYE) DROPS

Tier 3

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

Tier 1b

prednisolone acetate ophthalmic (eye) drops,suspension

Tier 1b

prednisolone sodium phosphate ophthalmic (eye) drops

Tier 1b

RESTASIS OPHTHALMIC (EYE) DROPPERETTE

Tier 3

SIMBRINZA OPHTHALMIC (EYE) DROPS,SUSPENSION

Tier 3

timolol maleate ophthalmic (eye) drops

Tier 1b

timolol maleate ophthalmic (eye) gel forming solution

Tier 1b

TRAVATAN Z OPHTHALMIC (EYE) DROPS

Tier 3

tropicamide ophthalmic (eye) drops

Tier 1b

TYZINE NASAL DROPS0.05 %

Tier 3

ZIOPTAN (PF) OPHTHALMIC (EYE) DROPPERETTE

Tier 3

Effective 10/1/2018

38


ELECT/CALORIC/H2O

calcium acetate oral tablet 667 mg

Tier 2

dentagel dental gel Tier 1a

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

Tier 3

effer-k oral tablet, effervescent 25 meq

Tier 1b

eliphos oral tablet Tier 2 PA

enfagrow toddler next step oral powder

Tier 3

fe c plus oral tablet Tier 1a

fluoride (sodium) oral drops

Tier 1a $0

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

Tier 1a $0

fluoride (sodium) oral tablet,chewable 1 mg (2.2 mg sod. fluoride)

Tier 1a

fluoridex daily defense dental paste

Tier 1b

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

Tier 1a $0

fluoritab oral tablet,chewable 1 mg (2.2 mg sod. fluoride)

Tier 1a

FOSRENOL ORAL POWDER IN PACKET

Tier 3 PA

GLUCAGEN HYPOKIT INJECTION RECON SOLN

Tier 2

GLUCAGON EMERGENCY KIT (HUMAN) INJECTION KIT

Tier 2

k-effervescent oral tablet, effervescent

Tier 1b

kionex (with sorbitol) oral suspension

Tier 2

klor-con 10 oral tablet extended release

Tier 1b

klor-con 8 oral tablet extended release

Tier 1b


klor-con m10 oral tablet,er particles/crystals

Tier 1a


Tier 1a


Tier 1a

klor-con/ef oral tablet, effervescent

Tier 1b

lanthanum oral tablet,chewable

Tier 2 PA

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

Tier 1a $0

ludent fluoride oral tablet,chewable 1 mg (2.2 mg sod. fluoride)

Tier 1a

magnesium sulfate in 0.9 %nacl intravenous solution 40 gram/1,000ml (40 mg/ml)

Tier 2

NUTRAMINE ORAL POWDER

Tier 3

potassium bicarb and chloride oral tablet, effervescent

Tier 1b

potassium bicarb-citric acid oral tablet, effervescent

Tier 1b

potassium chloride oral capsule, extended release

Tier 1b

potassium chloride oral tablet extended release

Tier 1b

potassium chloride oral tablet,er particles/crystals

Tier 1a

potassium citrate oral tablet extended release

Tier 2

potassium citrate-citric acid oral solution

Tier 1b

PREVIDENT 5000 BOOSTER PLUS DENTAL PASTE

Tier 3

PREVIDENT 5000 ENAMEL PROTECT DENTAL PASTE

Tier 3

PREVIDENT DENTAL GEL

Tier 3

Effective 10/1/2018

39


sevelamer carbonate oral powder in packet

Tier 1b

sevelamer carbonate oral tablet

Tier 1b

sf dental gel Tier 1a

SHOHL'S MODIFIED ORAL SOLUTION

Tier 3

sodium chloride 0.45 % intravenous parenteral solution

Tier 1b

sodium chloride 0.45 % intravenous piggyback

Tier 1b

sodium chloride 0.9 % injection solution

Tier 1b

sodium chloride 0.9 % intravenous parenteral solution

Tier 1b

sodium chloride 0.9 % intravenous piggyback

Tier 1b

sodium chloride 3 % intravenous parenteral solution

Tier 1b

sodium chloride 5 % intravenous parenteral solution

Tier 1b

sodium chloride intravenous parenteral solution 2.5 meq/ml

Tier 1b

sodium polystyrene (sorb free) oral suspension

Tier 2

sodium polystyrene sulfonate oral powder

Tier 2

sodium polystyrene sulfonate oral suspension

Tier 2

sodium polystyrene sulfonate rectal enema 30 gram/120 ml

Tier 1b

sps (with sorbitol) oral suspension

Tier 2

sps (with sorbitol) rectal enema

Tier 1b

SSKI ORAL SOLUTION Tier 3

VELPHORO ORAL TABLET,CHEWABLE

Tier 3 PA


GASTROINTESTINAL

AKYNZEO (NETUPITANT) ORAL CAPSULE

Tier 3 QL

alosetron oral tablet Tier 2 QL

AMITIZA ORAL CAPSULE

Tier 3

anaspaz oral tablet,disintegrating

Tier 2

ANZEMET ORAL TABLET

Tier 3 QL

aprepitant oral capsule Tier 2 QL

aprepitant oral capsule,dose pack

Tier 2 QL

APRISO ORAL CAPSULE,EXTENDED RELEASE 24HR

Tier 3 QL

balsalazide oral capsule Tier 1b QL

carafate oral suspension Tier 1b

CESAMET ORAL CAPSULE

Tier 3

CHOLBAM ORAL CAPSULE

Tier 3 PA; LD; QL

cimetidine hcl oral solution Tier 1b

cimetidine oral tablet Tier 1b

COMPAZINE ORAL TABLET

Tier 1b

constulose oral solution Tier 1b

DEXILANT ORAL CAPSULE,BIPHASE DELAYED RELEAS

Tier 3 PA; QL

dicyclomine oral capsule Tier 1a

dicyclomine oral solution Tier 1a

dicyclomine oral tablet Tier 1a

DIPENTUM ORAL CAPSULE

Tier 3 QL

diphenoxylate-atropine oral liquid

Tier 1b

diphenoxylate-atropine oral tablet

Tier 1b

dronabinol oral capsule Tier 2

enulose oral solution Tier 1b

famotidine oral suspension Tier 1b

famotidine oral tablet 20 mg, 40 mg

Tier 1b

Effective 10/1/2018

40


fish oil ec 1,000 mg softgel Tier 1b

gavilyte-c oral recon soln Tier 1a $0

gavilyte-g oral recon soln Tier 1a $0

gavilyte-n oral recon soln Tier 1a $0

generlac oral solution Tier 1b

glycopyrrolate oral tablet 1 mg, 2 mg

Tier 1b

granisetron hcl oral tablet Tier 2 QL

hydrocortisone ac 25 mg supp outer

Tier 1b

hydrocortisone-pramoxine rectal cream 1-1 %

Tier 1b

hyoscyamine 0.125 mg odt

Tier 1b

hyoscyamine 0.125 mg tab sl

Tier 1b

hyoscyamine sulf 0.125 mg tab

Tier 1b

hyoscyamine sulfate oral tablet extended release 12 hr

Tier 1b

lactulose oral solution Tier 1b

lansoprazole oral capsule,delayed release(dr/ec)

Tier 1b QL

laxaclear powder Tier 1b $0

LINZESS ORAL CAPSULE

Tier 2

meclizine oral tablet 12.5 mg, 25 mg

Tier 1a

methscopolamine oral tablet

Tier 1b

metoclopramide hcl oral solution

Tier 1a

metoclopramide hcl oral tablet

Tier 1a

metoclopramide hcl oral tablet,disintegrating

Tier 1a

misoprostol oral tablet Tier 1a

MOTOFEN ORAL TABLET

Tier 3

MOVIPREP ORAL POWDER IN PACKET

Tier 3

nizatidine oral capsule Tier 1b

nizatidine oral solution Tier 1b


omega-3 acid ethyl esters oral capsule

Tier 1b QL

omeprazole oral capsule,delayed release(dr/ec)

Tier 1b QL

ondansetron hcl oral solution

Tier 2 QL

ondansetron hcl oral tablet Tier 2 QL

ondansetron oral tablet,disintegrating

Tier 2 QL

OSMOPREP ORAL TABLET

Tier 3

pantoprazole oral tablet,delayed release (dr/ec)

Tier 2 QL

peg 3350-electrolytes oral recon soln

Tier 1a $0

peg-3350 with flavor packs oral recon soln

Tier 1a $0

peg-electrolyte soln oral recon soln

Tier 1a $0

peg-prep oral kit Tier 3 $0

phenadoz rectal suppository

Tier 2

phenobarb-hyoscy-atropine-scop oral elixir

Tier 1b

polyethylene glycol 3350 oral powder in packet

Tier 1b $0

pramcort rectal cream Tier 1b

PREPOPIK ORAL POWDER IN PACKET

Tier 3

prochlorperazine maleate oral tablet

Tier 1a

promethazine rectal suppository

Tier 2

promethegan rectal suppository

Tier 2

rabeprazole oral tablet,delayed release (dr/ec)

Tier 2 QL

ranitidine hcl oral capsule Tier 1b

ranitidine hcl oral syrup Tier 1b

ranitidine hcl oral tablet 150 mg, 300 mg

Tier 1b

RECTIV RECTAL OINTMENT

Tier 3

Effective 10/1/2018

41


SANCUSO TRANSDERMAL PATCH WEEKLY

Tier 3 QL

scopolamine base transdermal patch 3 day

Tier 2

sodium phenylbutyrate oral tablet

Tier 2 PA; QL

sucralfate oral tablet Tier 1b

sulfasalazine oral tablet Tier 1b QL

sulfasalazine oral tablet,delayed release (dr/ec)

Tier 1b QL

SUPREP BOWEL PREP KIT ORAL RECON SOLN

Tier 3

trilyte with flavor packets oral recon soln

Tier 1a $0

trimethobenzamide oral capsule

Tier 1b

ursodiol oral capsule Tier 2

ursodiol oral tablet Tier 2

VARUBI ORAL TABLET Tier 3 QL

VASCEPA ORAL CAPSULE

Tier 3 QL

VIBERZI ORAL TABLET Tier 3 PA; QL

ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC)10,000-32,000 -42,000 UNIT, 15,000-47,000 -63,000 UNIT, 20,000-63,000- 84,000 UNIT, 25,000-79,000- 105,000 UNIT, 3,000-10,000 -14,000-UNIT, 40,000-126,000- 168,000 UNIT, 5,000-17,000- 24,000 UNIT

Tier 2

HORMONES

AMABELZ ORAL TABLET

Tier 1b

ANADROL-50 ORAL TABLET

Tier 3

ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP20.25 MG/1.25 GRAM (1.62 %)

Tier 3 PA; QL


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

Tier 3 PA; QL

budesonide oral capsule,delayed,extend.release

Tier 2 QL

cabergoline oral tablet Tier 1b

calcitonin (salmon) nasal spray,non-aerosol

Tier 2 QL

chorionic gonadotropin, human intramuscular recon soln

Tier 4 PA; SP

cortisone oral tablet Tier 1b

danazol oral capsule Tier 2

decadron oral elixir Tier 1a

DELTASONE ORAL TABLET 20 MG

Tier 1a

desmopressin nasal spray with pump

Tier 2

desmopressin nasal spray,non-aerosol

Tier 2

desmopressin oral tablet Tier 1b

dexamethasone intensol oral drops

Tier 1a

dexamethasone oral elixir Tier 1a

dexamethasone oral solution

Tier 1a

dexamethasone oral tablet Tier 1a

DUAVEE ORAL TABLET Tier 3 QL

estradiol oral tablet Tier 1b

estradiol transdermal patch semiweekly

Tier 1b QL

estradiol transdermal patch weekly

Tier 1b

estradiol vaginal cream Tier 2

estradiol vaginal tablet Tier 2 QL

estradiol-norethindrone acet oral tablet

Tier 1b

ESTRING VAGINAL RING

Tier 3 QL

estropipate oral tablet 0.75 mg

Tier 1a

fludrocortisone oral tablet Tier 1b

Effective 10/1/2018

42


GONAL-F RFF REDI-JECT SUBCUTANEOUS PEN INJECTOR

Tier 4 PA; SP

GONAL-F RFF SUBCUTANEOUS RECON SOLN

Tier 4 PA; SP

GONAL-F SUBCUTANEOUS RECON SOLN

Tier 4 PA; SP

hydrocortisone oral tablet Tier 1b

hydrocortisone rectal enema

Tier 2

INCRELEX SUBCUTANEOUS SOLUTION

Tier 4 PA; SP; LD

jinteli oral tablet Tier 1b

LOPREEZA ORAL TABLET

Tier 1b

LUPANETA PACK (1 MONTH) KIT. SYRINGE AND TABLET

Tier 4 PA; SP; QL

LUPANETA PACK (3 MONTH) KIT. SYRINGE AND TABLET

Tier 4 PA; SP; QL

medroxyprogesterone oral tablet

Tier 1a QL

MENEST ORAL TABLET Tier 3

METHITEST ORAL TABLET

Tier 3

methylergonovine oral tablet

Tier 1b

methylprednisolone oral tablet

Tier 1a

methylprednisolone oral tablets,dose pack

Tier 1a

millipred dp oral tablets,dose pack

Tier 1a

millipred oral tablet Tier 1a

mimvey lo oral tablet Tier 1b

mimvey oral tablet Tier 1b

MYALEPT SUBCUTANEOUS RECON SOLN

Tier 4 SP; LD

norethindrone acetate oral tablet

Tier 1b


NUTROPIN AQ NUSPIN SUBCUTANEOUS PEN INJECTOR

Tier 4 PA; SP

oxandrolone oral tablet Tier 2 PA

prednisolone oral solution 15 mg/5 ml

Tier 1a

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

Tier 1a

prednisone intensol oral concentrate

Tier 1a

prednisone oral solution Tier 1a

prednisone oral tablet Tier 1a

prednisone oral tablets,dose pack

Tier 1a

PREMARIN ORAL TABLET

Tier 3 QL

PREMARIN VAGINAL CREAM

Tier 3 QL

PREMPHASE ORAL TABLET

Tier 3

PREMPRO ORAL TABLET

Tier 3

progesterone micronized oral capsule

Tier 1b QL

SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON

Tier 4 PA; SP; QL

SIGNIFOR LAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 10 MG, 30 MG

Tier 4 PA; SP; QL

SIGNIFOR LAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 20 MG, 40 MG, 60 MG


SIGNIFOR SUBCUTANEOUS SOLUTION


Effective 10/1/2018

43


SOMATULINE DEPOT SUBCUTANEOUS SYRINGE

Tier 4 PA; SP; QL

SYNAREL NASAL SPRAY,NON-AEROSOL

Tier 4 PA; SP; QL

testosterone 12.5 mg/1.25 gram

Tier 2 PA; QL

testosterone 12.5 mg/1.25 gram outer

Tier 2 PA; QL

testosterone 50 mg/5 gram pkt

Tier 2 PA; QL

testosterone 50 mg/5 gram pkt inner

Tier 2 PA; QL

testosterone 50 mg/5 gram pkt outer

Tier 2 PA; QL

testosterone cypionate intramuscular oil

Tier 1b

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

Tier 2 PA; QL

veripred 20 oral solution Tier 1a

YUVAFEM VAGINAL TABLET

Tier 2 QL

IMMUNOSUPPRESSANTS

ACTEMRA INTRAVENOUS SOLUTION

Tier 4 PA; SP

ACTEMRA SUBCUTANEOUS SYRINGE

Tier 4 PA; SP; QL

azathioprine oral tablet Tier 2

cyclosporine modified oral capsule

Tier 4 SP

cyclosporine modified oral solution

Tier 4 SP

cyclosporine oral capsule Tier 4 SP

ELIDEL TOPICAL CREAM

Tier 3 PA

gengraf oral capsule 100 mg, 25 mg

Tier 4 SP

gengraf oral solution Tier 4 SP

mycophenolate mofetil oral capsule

Tier 4 SP

mycophenolate mofetil oral tablet

Tier 4 SP


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

Tier 4 SP

RAPAMUNE ORAL SOLUTION

Tier 4 SP

STELARA INTRAVENOUS SOLUTION

Tier 4 PA; SP; QL

STELARA SUBCUTANEOUS SOLUTION

Tier 4 PA; SP; QL

STELARA SUBCUTANEOUS SYRINGE

Tier 4 PA; SP; QL

tacrolimus oral capsule Tier 4 SP

tacrolimus topical ointment Tier 1b PA

ZORTRESS ORAL TABLET

Tier 4 PA; SP

MISCELLANEOUS MEDICAL SUPPLIES, DEVICES, NON-DRUG

ACCU-CHEK AVIVA CONTROL SOLN SOLUTION

Tier 2

ACCU-CHEK AVIVA PLUS METER

Tier 2

ACCU-CHEK COMP BLUE CONT, M-H SOLUTION

Tier 2

ACCU-CHEK COMPACT PLUS CARE KIT

Tier 2

ACCU-CHEK COMPACT PLUS CONTROL SOLUTION

Tier 2

ACCU-CHEK FASTCLIX LANCING DEV KIT

Tier 2

ACCU-CHEK GUIDE GLUCOSE METER

Tier 2

ACCU-CHEK GUIDE L1-L2 CTRL SOL SOLUTION

Tier 2

ACCU-CHEK MULTICLIX LANCET

Tier 2

ACCU-CHEK MULTICLIX LANCET KIT

Tier 2

ACCU-CHEK NANO Tier 2

ACCU-CHEK SAFE-T-PRO PLUS

Tier 2

Effective 10/1/2018

44


ACCU-CHEK SMARTVIEW CONTRL SOL SOLUTION

Tier 2

ACCU-CHEK SOFT DEV LANCETS KIT

Tier 2

ACCU-CHEK SOFTCLIX LANCET DEV

Tier 2

ACCU-CHEK SOFTCLIX LANCETS

Tier 2

ACCU-CHEK VOICEMATE KIT

Tier 2

ACCUTREND GLUCOSE CONTROL SOLUTION

Tier 2

acti-lance lancets 17 gauge, 28 gauge

Tier 1b

CHEMSTRIP BG LOG BOOK

Tier 2

e-z ject lancets Tier 1b

E-Z JECT THIN LANCETS

Tier 1b

insulin syringe-needle u-100 syringe 1 ml 30 gauge x 3/8"

Tier 1b

ONETOUCH DELICA LANC DEVICE KIT

Tier 2

ONETOUCH DELICA LANCETS

Tier 2

ONETOUCH ULTRA CONTROL SOLUTION

Tier 2

ONETOUCH ULTRA2 KIT Tier 2

ONETOUCH ULTRAMINI KIT

Tier 2

ONETOUCH ULTRASOFT LANCETS

Tier 2

ONETOUCH VERIO FLEX

Tier 2

ONETOUCH VERIO HIGH CONTROL SOLUTION

Tier 2

ONETOUCH VERIO IQ METER

Tier 2

ONETOUCH VERIO MID CONTROL SOLUTION

Tier 2

ONETOUCH VERIO SYSTEM

Tier 2


thinpro insulin syringe syringe 0.3 ml 29 gauge x 1/2", 0.5 ml 29 gauge x 1/2", 1 ml 29 gauge x 1/2"

Tier 1b

MUSCLE RELAXANTS

baclofen oral tablet 10 mg, 20 mg

Tier 2

carisoprodol oral tablet Tier 1b

chlorzoxazone oral tablet Tier 1b

cyclobenzaprine oral tablet Tier 1b

dantrolene oral capsule Tier 2

metaxalone oral tablet Tier 1b

methocarbamol oral tablet Tier 1b

orphenadrine citrate oral tablet extended release

Tier 1b

tizanidine oral capsule Tier 1b

tizanidine oral tablet Tier 1b

PRE-NATAL VITAMINS

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

Tier 1b

c-nate dha oral capsule Tier 1b

complete natal dha oral combo pack

Tier 1b

completenate oral tablet,chewable

Tier 1a

elite ob with dha oral capsule

Tier 1b

elite-ob 400 oral capsule Tier 1b

ELITE-OB ORAL TABLET

Tier 1b

folivane-ob oral capsule Tier 1a

hemenatal ob + dha oral combo pack

Tier 1b

hemenatal ob oral tablet Tier 1b

mynatal advance oral tablet

Tier 1b

mynatal oral capsule Tier 1b

mynatal oral tablet Tier 1b

mynatal plus oral tablet Tier 1a

mynatal-z oral tablet Tier 1a

mynate 90 plus oral tablet extended release

Tier 1a

obstetrix dha oral combo pack,tablet and cap,dr

Tier 1b

Effective 10/1/2018

45


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

Tier 1b

pnv-dha + docusate oral capsule

Tier 1b

pnv-ferrous fumarate-docu-fa oral tablet

Tier 1a

pnv-omega oral capsule Tier 1b

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

Tier 1a

pr natal 400 oral combo pack

Tier 1a

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

Tier 1a

pr natal 430 oral combo pack

Tier 1a

prenaissance oral capsule Tier 1b

prenaissance plus oral capsule

Tier 1b

prenatabs fa oral tablet Tier 1a

prenatabs rx oral tablet Tier 1a

prenatal 19 (with docusate) oral tablet

Tier 1a

prenatal low iron oral tablet

Tier 1a

prenatal multivitamin tablet Tier 1a $0

PRENATAL ONE DAILY ORAL TABLET

Tier 1a $0

prenatal plus (calcium carb) oral tablet

Tier 1a

prenatal plus oral tablet Tier 1a

prenatal vitamin plus low iron

Tier 1a

prenatal-u oral capsule Tier 1a

preplus oral tablet Tier 1a

se-natal 19 (with docusate) oral tablet

Tier 1a

se-natal 19 oral tablet,chewable

Tier 1a

taron-c dha oral capsule Tier 1b

taron-prex prenatal-dha oral capsule

Tier 1b

tl-select oral capsule Tier 1b

triadvance oral tablet Tier 1b

trinatal rx 1 oral tablet Tier 1a

trinate oral tablet Tier 1a


triveen-duo dha oral combo pack

Tier 1b

triveen-one oral capsule Tier 1b

triveen-prx rnf oral capsule Tier 1b

trust natal dha oral combo pack

Tier 1b

vena-bal dha oral combo pack,tablet and cap,dr

Tier 1b

vinacal oral tablet Tier 1b

vinate care oral tablet,chewable

Tier 1a

vinate gt oral tablet Tier 1b

vinate ii oral tablet Tier 1a

vinate one oral tablet Tier 1a

vinate pn care oral tablet Tier 1b

vinate ultra oral tablet Tier 1b

VIRT-NATE DHA ORAL CAPSULE

Tier 1b

virt-pn dha oral capsule Tier 1b

virt-pn oral tablet Tier 1b

virt-pn plus oral capsule Tier 1b

virt-select oral capsule Tier 1b

vitafol-ob oral tablet Tier 1b

vp-ch plus oral capsule Tier 1b

vp-ch-pnv oral capsule Tier 1b

zatean-pn dha oral capsule

Tier 1b

zatean-pn plus oral capsule

Tier 1b

zingiber oral tablet Tier 1a

PSYCHOTHERAPEUTIC DRUGS

ADDYI ORAL TABLET Tier 3 PA; QL

alprazolam oral tablet Tier 1b

amitriptyline oral tablet Tier 1a

amoxapine oral tablet Tier 1b

aripiprazole oral solution Tier 2

aripiprazole oral tablet Tier 2

armodafinil oral tablet 150 mg, 250 mg, 50 mg

Tier 2 PA; QL

armodafinil oral tablet 200 mg

Tier 2 PA

atomoxetine oral capsule Tier 2 PA

Effective 10/1/2018

46


bupropion hcl oral tablet 100 mg

Tier 1b QL

bupropion hcl oral tablet 75 mg

Tier 1b DO

bupropion hcl oral tablet extended release 24 hr 150 mg

Tier 1b DO

bupropion hcl oral tablet extended release 24 hr 300 mg

Tier 1b QL

bupropion hcl oral tablet sustained-release 12 hr 100 mg

Tier 1b DO


Tier 1b $0


Tier 1b

buspirone oral tablet Tier 1b

chlorpromazine oral tablet Tier 2

citalopram oral solution Tier 1b QL

citalopram oral tablet 10 mg, 20 mg

Tier 1b DO

citalopram oral tablet 40 mg

Tier 1b QL

clomipramine oral capsule Tier 2

clonidine hcl oral tablet extended release 12 hr

Tier 1b PA

clozapine oral tablet Tier 2

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

Tier 2

desipramine oral tablet Tier 2

desvenlafaxine succinate oral tablet extended release 24 hr 100 mg

Tier 1b QL

desvenlafaxine succinate oral tablet extended release 24 hr 25 mg, 50 mg

Tier 1b DO

dexmethylphenidate oral capsule,er biphasic 50-50

Tier 1b PA

dexmethylphenidate oral tablet

Tier 1b PA

diazepam intensol oral concentrate

Tier 1a


diazepam oral concentrate Tier 1a

diazepam oral solution Tier 1a

diazepam oral tablet Tier 1a

doxepin oral capsule Tier 1b

doxepin oral concentrate Tier 1b

duloxetine oral capsule,delayed release(dr/ec) 20 mg, 40 mg, 60 mg

Tier 2 PA; QL

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

Tier 2 PA; DO

EMSAM TRANSDERMAL PATCH 24 HOUR

Tier 3

escitalopram oxalate oral solution

Tier 1b QL

escitalopram oxalate oral tablet 10 mg, 5 mg

Tier 1b DO

escitalopram oxalate oral tablet 20 mg

Tier 1b QL

FANAPT ORAL TABLET Tier 3

FANAPT ORAL TABLETS,DOSE PACK

Tier 3

FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK

Tier 3 ST; QL

FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR

Tier 3 ST; QL

fluoxetine oral capsule 10 mg, 20 mg

Tier 1b DO

fluoxetine oral capsule 40 mg

Tier 1b QL

fluoxetine oral capsule,delayed release(dr/ec)

Tier 1b QL

fluoxetine oral solution Tier 1b QL

fluoxetine oral tablet 10 mg

Tier 1b DO

fluoxetine oral tablet 20 mg

Tier 1b

fluphenazine hcl oral concentrate

Tier 1b

fluphenazine hcl oral elixir Tier 1b

fluphenazine hcl oral tablet Tier 1b

Effective 10/1/2018

47


fluvoxamine oral tablet 100 mg

Tier 1b QL

fluvoxamine oral tablet 25 mg, 50 mg

Tier 1b DO

guanfacine oral tablet extended release 24 hr

Tier 1b PA

haloperidol oral tablet Tier 1b

imipramine hcl oral tablet Tier 1b

LATUDA ORAL TABLET Tier 3

lithium carbonate oral capsule

Tier 1a

lithium carbonate oral tablet

Tier 1a

lithium carbonate oral tablet extended release

Tier 1a

lithium citrate oral solution Tier 1b

loxapine succinate oral capsule

Tier 1b

maprotiline oral tablet Tier 1b

MARPLAN ORAL TABLET

Tier 3

meprobamate oral tablet Tier 1b

metadate er oral tablet extended release

Tier 1b PA

methylphenidate hcl oral capsule, er biphasic 30-70

Tier 1b PA

methylphenidate hcl oral capsule,er biphasic 50-50

Tier 1b PA

methylphenidate hcl oral solution

Tier 1b PA

methylphenidate hcl oral tablet

Tier 1b PA

methylphenidate hcl oral tablet extended release

Tier 1b PA

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

Tier 1b PA

mirtazapine oral tablet Tier 1b

mirtazapine oral tablet,disintegrating

Tier 1b

modafinil oral tablet 100 mg

Tier 2 PA; DO

modafinil oral tablet 200 mg

Tier 2 PA; QL

nefazodone oral tablet Tier 1b


nortriptyline oral capsule Tier 1b

nortriptyline oral solution Tier 1b

olanzapine oral tablet Tier 2

olanzapine oral tablet,disintegrating

Tier 2

paliperidone oral tablet extended release 24hr

Tier 2

paroxetine hcl oral tablet 10 mg, 20 mg

Tier 1b DO

paroxetine hcl oral tablet 30 mg, 40 mg

Tier 1b QL

paroxetine hcl oral tablet extended release 24 hr 12.5 mg

Tier 1b DO

paroxetine hcl oral tablet extended release 24 hr 25 mg, 37.5 mg

Tier 1b QL

perphenazine oral tablet Tier 1b

phenelzine oral tablet Tier 1b

pimozide oral tablet Tier 2

protriptyline oral tablet Tier 2

quetiapine oral tablet Tier 2

quetiapine oral tablet extended release 24 hr

Tier 2

risperidone oral solution Tier 1b

risperidone oral tablet Tier 1b

risperidone oral tablet,disintegrating

Tier 2

SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET

Tier 3

sertraline oral concentrate Tier 1b QL

sertraline oral tablet 100 mg

Tier 1b QL

sertraline oral tablet 25 mg, 50 mg

Tier 1b DO

thioridazine oral tablet Tier 1b

thiothixene oral capsule Tier 1b

tranylcypromine oral tablet Tier 1b

trazodone oral tablet Tier 1a

trifluoperazine oral tablet Tier 1b

trimipramine oral capsule Tier 1b

TRINTELLIX ORAL TABLET 10 MG, 5 MG

Tier 3 ST; DO

Effective 10/1/2018

48


TRINTELLIX ORAL TABLET 20 MG

Tier 3 ST; QL

venlafaxine oral capsule,extended release 24hr 150 mg

Tier 1b QL

venlafaxine oral capsule,extended release 24hr 37.5 mg, 75 mg

Tier 1b DO

venlafaxine oral tablet Tier 1b QL

venlafaxine oral tablet extended release 24hr 150 mg, 225 mg

Tier 1b QL

venlafaxine oral tablet extended release 24hr 37.5 mg, 75 mg

Tier 1b DO

VIIBRYD ORAL TABLET10 MG, 20 MG

Tier 3 ST; DO

VIIBRYD ORAL TABLET40 MG

Tier 3 ST; QL

VIIBRYD ORAL TABLETS,DOSE PACK10 MG (7)- 20 MG (23)

Tier 3 ST; QL

VYVANSE ORAL CAPSULE

Tier 3 PA

ziprasidone hcl oral capsule

Tier 2

SEDATIVE/HYPNOTICS

estazolam oral tablet Tier 1b

eszopiclone oral tablet 1 mg, 2 mg

Tier 1b QL

eszopiclone oral tablet 3 mg

Tier 1b PA; QL

HETLIOZ ORAL CAPSULE


hm nighttime sleep aid 50 mg softgel,max strength

Tier 1a

phenobarbital oral elixir Tier 1b

phenobarbital oral tablet Tier 1b

ROZEREM ORAL TABLET

Tier 3 ST; QL

SILENOR ORAL TABLET Tier 3 QL

XYREM ORAL SOLUTION


zaleplon oral capsule Tier 1b QL

zolpidem oral tablet Tier 1b QL


SKIN PREPS

acitretin oral capsule Tier 2

adapalene topical cream Tier 1b

adapalene topical gel Tier 1b

adapalene topical gel with pump

Tier 1b

adapalene-benzoyl peroxide topical gel with pump

Tier 2

alclometasone topical cream

Tier 1b

alclometasone topical ointment

Tier 1b

ALTABAX TOPICAL OINTMENT

Tier 3

amcinonide topical cream Tier 1b

amcinonide topical lotion Tier 1b

amcinonide topical ointment

Tier 1b

ammonium lactate topical cream

Tier 1b

ammonium lactate topical lotion

Tier 1b

AMNESTEEM ORAL CAPSULE

Tier 2 PA

avita topical cream Tier 1b PA

AZELEX TOPICAL CREAM

Tier 3 PA

benzoyl peroxide 9.8% foam emollient foam (otc)

Tier 1b

benzoyl peroxide topical cleanser 3 %, 6 %, 9 %

Tier 1b

benzoyl peroxide topical foam 5.3 %

Tier 1b

betamethasone dipropionate topical cream

Tier 1b

betamethasone dipropionate topical lotion

Tier 1b

betamethasone dipropionate topical ointment

Tier 1b

betamethasone valerate topical cream

Tier 1b

betamethasone valerate topical foam

Tier 1b

Effective 10/1/2018

49


betamethasone valerate topical lotion

Tier 1b

betamethasone valerate topical ointment

Tier 1b

betamethasone, augmented topical cream

Tier 1b

betamethasone, augmented topical gel

Tier 1b

betamethasone, augmented topical lotion

Tier 1b

betamethasone, augmented topical ointment

Tier 1b

bpo topical gel Tier 1b

bpo topical towelette 6 % Tier 1b

calcipotriene scalp solution

Tier 1b

calcipotriene topical cream Tier 1b

calcipotriene topical ointment

Tier 1b

calcipotriene-betamethasone topical ointment

Tier 1b

calcitrene topical ointment Tier 1b

calcitriol topical ointment Tier 1b

claravis oral capsule Tier 2 PA

clindamycin-benzoyl peroxide topical gel

Tier 1b

clindamycin-benzoyl peroxide topical gel with pump 1-5 %

Tier 1b

clindamycin-tretinoin topical gel

Tier 2

clobetasol scalp solution Tier 1b

clobetasol topical cream Tier 1b

clobetasol topical foam Tier 1b

clobetasol topical gel Tier 1b

clobetasol topical lotion Tier 1b

clobetasol topical ointment Tier 1b

clobetasol topical shampoo

Tier 1b

clobetasol-emollient topical cream

Tier 1b

clobetasol-emollient topical foam

Tier 1b


CLODERM TOPICAL CREAM

Tier 3

CORDRAN TAPE LARGE ROLL TOPICAL TAPE

Tier 3

cormax scalp solution Tier 1b

COSENTYX (2 SYRINGES) SUBCUTANEOUS SYRINGE

Tier 4 PA; SP; QL

COSENTYX PEN (2 PENS) SUBCUTANEOUS PEN INJECTOR

Tier 4 PA; SP; QL

COSENTYX PEN SUBCUTANEOUS PEN INJECTOR

Tier 4 PA; SP; QL

COSENTYX SUBCUTANEOUS SYRINGE

Tier 4 PA; SP; QL

crotan topical lotion Tier 2

dapsone topical gel Tier 2

desonide topical cream Tier 1b

desonide topical lotion Tier 1b

desonide topical ointment Tier 1b

desoximetasone topical cream

Tier 1b

desoximetasone topical gel

Tier 1b

desoximetasone topical ointment

Tier 1b

diclofenac sodium topical gel 1 %

Tier 2 QL

diflorasone topical cream Tier 1b

diflorasone topical ointment

Tier 1b

EURAX TOPICAL CREAM

Tier 3

EURAX TOPICAL LOTION

Tier 3

FINACEA TOPICAL GEL Tier 3

FLECTOR TRANSDERMAL PATCH 12 HOUR

Tier 3 QL

fluocinolone and shower cap scalp oil

Tier 1b

fluocinolone topical cream Tier 1b

fluocinolone topical oil Tier 1b

Effective 10/1/2018

50


fluocinolone topical ointment

Tier 1b

fluocinolone topical solution

Tier 1b

fluocinonide topical cream Tier 1b

fluocinonide topical gel Tier 1b

fluocinonide topical ointment

Tier 1b

fluocinonide topical solution

Tier 1b

fluocinonide-e topical cream

Tier 1b

fluocinonide-emollient topical cream

Tier 1b

flurandrenolide topical cream

Tier 2

flurandrenolide topical lotion

Tier 2

fluticasone topical cream Tier 1b

fluticasone topical lotion Tier 1b

fluticasone topical ointment

Tier 1b

halobetasol propionate topical cream

Tier 1b

halobetasol propionate topical ointment

Tier 1b

HALOG TOPICAL CREAM

Tier 3

HALOG TOPICAL OINTMENT

Tier 3

hydrocortisone butyrate topical cream

Tier 1b

hydrocortisone butyrate topical lotion

Tier 1b

hydrocortisone butyrate topical ointment

Tier 1b

hydrocortisone butyrate topical solution

Tier 1b

hydrocortisone butyr-emollient topical cream

Tier 1b

hydrocortisone topical cream 2.5 %

Tier 1a

hydrocortisone topical cream with perineal applicator

Tier 1b


hydrocortisone topical lotion 2.5 %

Tier 1a

hydrocortisone topical ointment 2.5 %

Tier 1a

hydrocortisone valerate topical cream

Tier 1b

hydrocortisone valerate topical ointment

Tier 1b

imiquimod topical cream in packet

Tier 1b PA; QL

lindane topical shampoo Tier 1b

malathion topical lotion Tier 1b

methoxsalen oral capsule,liqd-filled,rapid rel

Tier 2 PA; SP

metronidazole topical 0.75% gl

Tier 1b

metronidazole topical cream

Tier 1b

metronidazole topical gel 1 %

Tier 1b

metronidazole topical gel with pump

Tier 1b

metronidazole topical lotion

Tier 1b

MIRVASO TOPICAL GEL Tier 3

MIRVASO TOPICAL GEL WITH PUMP

Tier 3

mometasone topical cream

Tier 1b

mometasone topical ointment

Tier 1b

mometasone topical solution

Tier 1b

OVACE TOPICAL CLEANSER

Tier 3

permethrin topical cream Tier 1b

PHYSIOLYTE IRRIGATION SOLUTION

Tier 3

podofilox topical solution Tier 1b

prednicarbate topical cream

Tier 1b

prednicarbate topical ointment

Tier 1b

PROCTOSOL-HC 2.5% CREAM

Tier 1b

Effective 10/1/2018

51


proctozone-hc topical cream with perineal applicator

Tier 1b

prudoxin topical cream Tier 2

REGRANEX TOPICAL GEL

Tier 3

rosadan topical cream Tier 1b

ROSADAN TOPICAL GEL

Tier 1b

salicylic acid 26% liquid Tier 1b

salicylic acid 27.5% liquid Tier 1b

salicylic acid topical cream Tier 1b

salicylic acid topical cream,extended release

Tier 1b

salicylic acid topical foam Tier 1b

salicylic acid topical gel Tier 1b

salicylic acid topical lotion Tier 1b

salicylic acid topical lotion,extended release

Tier 1b

salicylic acid topical shampoo

Tier 1b

salvax topical foam Tier 1b

SANTYL TOPICAL OINTMENT

Tier 3

seb-prev topical cleanser Tier 1b

selenium sulfide topical lotion

Tier 1a

selenium sulfide topical shampoo 2.25 %

Tier 1a

SKLICE TOPICAL LOTION

Tier 3

sodium chloride irrigation solution

Tier 1b

spinosad topical suspension

Tier 1b

sulfacetamide sodium (acne) topical suspension

Tier 1b

sulfacetamide sodium topical cleanser

Tier 1b

sulfacetamide sodium topical cleanser, gel

Tier 1b

sulfacetamide sodium topical shampoo

Tier 1b

tazarotene topical cream Tier 2


TAZORAC TOPICAL CREAM 0.05 %

Tier 3

TAZORAC TOPICAL GEL Tier 3

tretinoin (emollient) topical cream

Tier 1b PA

tretinoin topical cream Tier 1b PA

tretinoin topical gel 0.01 %, 0.025 %

Tier 1b PA

triamcinolone acetonide topical cream

Tier 1a

triamcinolone acetonide topical lotion

Tier 1a

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

Tier 1a

trianex topical ointment Tier 1a

triderm topical cream 0.1 %

Tier 1a

TRIDERM TOPICAL CREAM 0.5 %

Tier 1a

ULESFIA TOPICAL LOTION

Tier 3

zenatane oral capsule Tier 2 PA

SMOKING DETERRENTS

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

Tier 1b $0; QL

CHANTIX CONTINUING MONTH BOX ORAL TABLET

Tier 3 $0; QL

CHANTIX ORAL TABLET Tier 3 $0; QL

CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK

Tier 3 $0; QL

NICOTROL INHALATION CARTRIDGE

Tier 3 $0

NICOTROL NS NASAL SPRAY,NON-AEROSOL

Tier 3 $0

ZYBAN ORAL TABLET EXTENDED RELEASE 12 HR

Tier 3 $0; QL

THYROID PREPS

ARMOUR THYROID ORAL TABLET

Tier 1b

levothyroxine oral tablet Tier 1a

Effective 10/1/2018

52


levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg

Tier 1a

liothyronine oral tablet Tier 1b

methimazole oral tablet 10 mg, 5 mg

Tier 1a

nature-throid oral tablet Tier 1a

NP THYROID ORAL TABLET 120 MG, 15 MG

Tier 1a

np thyroid oral tablet 30 mg, 60 mg, 90 mg

Tier 1a

propylthiouracil oral tablet Tier 1b

SYNTHROID ORAL TABLET

Tier 1b

THYROLAR-1 ORAL TABLET

Tier 3

THYROLAR-1/2 ORAL TABLET

Tier 3

THYROLAR-1/4 ORAL TABLET

Tier 3


Tier 3


Tier 3

unithroid oral tablet Tier 1a

westhroid oral tablet 130 mg, 195 mg, 32.5 mg, 65 mg, 97.5 mg

Tier 1a

WP THYROID ORAL TABLET

Tier 1b

UNCLASSIFIED DRUG PRODUCTS

acamprosate oral tablet,delayed release (dr/ec)

Tier 2 QL

alendronate oral solution Tier 1b

alendronate oral tablet Tier 1b QL

alfuzosin oral tablet extended release 24 hr

Tier 1b

ARCALYST SUBCUTANEOUS RECON SOLN


BERINERT INTRAVENOUS KIT

Tier 4 PA; LD


BERINERT INTRAVENOUS RECON SOLN

Tier 4 PA; LD

buprenorphine hcl sublingual tablet

Tier 2 QL

buprenorphine-naloxone sublingual tablet

Tier 1b QL

CARBAGLU ORAL TABLET, DISPERSIBLE

Tier 4 LD

CERDELGA ORAL CAPSULE

Tier 4 PA; SP

CHEMET ORAL CAPSULE

Tier 3

chlorhexidine gluconate mucous membrane mouthwash

Tier 1a

CIALIS ORAL TABLET2.5 MG, 5 MG

Tier 3 PA; QL

CYSTADANE ORAL POWDER

Tier 3 LD

darifenacin oral tablet extended release 24 hr

Tier 2 ST

DEBACTEROL MUCOUS MEMBRANE SOLUTION

Tier 3

DEBACTEROL MUCOUS MEMBRANE SWAB

Tier 3

disulfiram oral tablet Tier 1b

doxercalciferol oral capsule

Tier 2

doxycycline hyclate oral tablet 20 mg

Tier 1b

dutasteride oral capsule Tier 2

etidronate disodium oral tablet

Tier 2

FERRIPROX ORAL TABLET

Tier 4 PA; LD

finasteride oral tablet Tier 1b

flavoxate oral tablet Tier 1b

FORTEO SUBCUTANEOUS PEN INJECTOR

Tier 4 PA; SP; QL

FOSAMAX PLUS D ORAL TABLET 70 MG- 2,800 UNIT

Tier 3 ST; QL

FOSAMAX PLUS D ORAL TABLET 70 MG- 5,600 UNIT

Tier 3 ST

Effective 10/1/2018

53


ibandronate oral tablet Tier 1b QL

KALYDECO ORAL GRANULES IN PACKET


KALYDECO ORAL TABLET


KEVEYIS ORAL TABLET Tier 4 PA; LD; QL

KUVAN ORAL TABLET,SOLUBLE

Tier 4 PA; SP; LD

leucovorin calcium oral tablet

Tier 2

levocarnitine (with sugar) oral solution

Tier 1b

levocarnitine oral tablet Tier 2

miglustat oral capsule Tier 4 PA; SP

MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR

Tier 3

OFEV ORAL CAPSULE Tier 4 PA; SP; LD; QL

oralone dental paste Tier 1b

ORFADIN ORAL CAPSULE

Tier 4 LD

OSPHENA ORAL TABLET

Tier 3 QL

oxybutynin chloride oral syrup

Tier 1b

oxybutynin chloride oral tablet

Tier 1b

oxybutynin chloride oral tablet extended release 24hr

Tier 1b

paricalcitol oral capsule Tier 2

paroex oral rinse mucous membrane mouthwash

Tier 1a

periogard mucous membrane mouthwash

Tier 1a

raloxifene oral tablet Tier 1b $0

RAPAFLO ORAL CAPSULE

Tier 3

risedronate oral tablet Tier 1b QL

SAVELLA ORAL TABLET

Tier 3 QL

SAVELLA ORAL TABLETS,DOSE PACK

Tier 3 QL

SENSIPAR ORAL TABLET 30 MG, 60 MG

Tier 4 QL


SENSIPAR ORAL TABLET 90 MG

Tier 4

SHINGRIX ADJUVANT COMPONENT-PF INTRAMUSCULAR SUSPENSION

Tier 2 $0

sildenafil oral tablet Tier 1b PA; QL

tamsulosin oral capsule Tier 1b

tolterodine oral tablet Tier 1b

TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HR

Tier 3

triamcinolone acetonide dental paste

Tier 1b

trientine oral capsule Tier 2 SP

trospium oral capsule,extended release 24hr

Tier 2

VESICARE ORAL TABLET

Tier 3

VITAMINS

calcitriol oral capsule Tier 1b

calcitriol oral solution Tier 2

cyanocobalamin (vitamin b-12) injection solution

Tier 1a

ergocalciferol (vitamin d2) oral capsule

Tier 1a

folic acid oral tablet 1 mg Tier 1a

multi-vitamin with fluoride oral drops

Tier 3 $0

multivitamin with fluoride oral tablet,chewable

Tier 3 $0

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

Tier 3 $0

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

Tier 3 $0

mvc-fluoride oral tablet,chewable 0.25 mg, 0.5 mg

Tier 3 $0

tl gard rx oral tablet Tier 1b

triple vitamin with fluoride oral drops

Tier 3 $0

tri-vitamin with fluoride oral drops

Tier 3 $0

Effective 10/1/2018

54


tri-vite with fluoride oral drops

Tier 3

vinate m oral tablet Tier 1a

vitamin d2 oral capsule Tier 1a

vitamins a,c,d and fluoride oral drops

Tier 3 $0

vol-nate oral tablet Tier 1a

vol-plus oral tablet Tier 1a

vol-tab rx oral tablet Tier 1a

Effective 10/1/2018

55

Effective 10/1/2018

56

Most plans include our convenient home delivery program at no extra cost to you. Find out more

at anthem.com or call 866-217-2328.

Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Maine, Inc. Independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc.

Express Scripts, Inc. is a separate company that manages the pharmacy benefit services for members of our health plans. Rev. 3/18

For information about your pharmacy benefit, log in at anthem.com. You’ll find the most up-to-date drug list and details about your benefits. If you still have questions, we’re here. Just call the Member Services number on your ID card.

Speech and hearing impaired (TDD/TTY) users Call 1-800-221-6915, Monday through Friday, 8:30 a.m. to 5 p.m.ET.

Date post:	18-Dec-2021
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