2020 formularylist of covered drugs
CitrusElite by Ultimate (HMO) 013-4 Premier Plus by Ultimate(HMO) 014-2
HernandoPremier by Ultimate (HMO) 001 Premier Plus by Ultimate (HMO)014-1
MarionAscent Plus by Ultimate (HMO) 016
PascoElite by Ultimate (HMO) 013-3 Premier Plus by Ultimate (HMO)014-1
PinellasAcclaim by Ultimate (HMO) 011 Acclaim Plus by Ultimate (HMO) 012
SumterAscend Plus by Ultimate (HMO) 018
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN. This formulary was updated on 11/01/2020. For more recent information or other questions, please contact Ultimate Health Plans Member Services at 1-888-657-4170 or, for TTY users, 711, Monday through Sunday from 8 a.m. to 8 p.m. (during certain times of the year we may use alternative technologies to answer your call on weekends and Federal holidays), or visit www.chooseultimate.com.
H2962_2020 Formulary _v120_C 00020471, Version 25
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Note to existing members: This formulary has changed since last year. Please review this document to make
sure that it still contains the drugs you take.
When this drug list (formulary) refers to “we,” “us”, or “our,” it means Ultimate Health Plans. When it refers to
“plan” or “our plan,” it means Acclaim by Ultimate (HMO), Acclaim Plus by Ultimate (HMO), Ascend Plus by
Ultimate (HMO), Elite by Ultimate (HMO), Premier by Ultimate (HMO) and Premier Plus by Ultimate (HMO).
This document includes a list of the drugs (formulary) for our plan which is current as of 11/01/2020. For an
updated formulary, please contact us. Our contact information, along with the date we last updated the
formulary, appears on the front and back cover pages.
You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary,
pharmacy network, and/or copayments/coinsurance may change on January 1, 2021, and from time to time
during the year.
What is the Acclaim by Ultimate, Acclaim Plus by Ultimate, Ascend Plus by Ultimate,
Elite by Ultimate, Premier by Ultimate and Premier Plus by Ultimate Formulary?
A formulary is a list of covered drugs selected by our plan in consultation with a team of health care providers,
which represents the prescription therapies believed to be a necessary part of a quality treatment program. We
will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription
is filled at a plan network pharmacy, and other plan rules are followed. For more information on how to fill
your prescriptions, please review your Evidence of Coverage.
Can the Formulary (drug list) change?
Most changes in drug coverage happen on January 1, but we may add or remove drugs on the Drug List during
the year, move them to different cost-sharing tiers, or add new restrictions. We must follow Medicare rules in
making these changes.
Changes that can affect you this year: In the below cases, you will be affected by coverage changes during
the year:
• New generic drugs. We may immediately remove a brand name drug on our Drug List if we are replacing it with a new generic drug that will appear on the same or lower cost sharing tier and with the
same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand
name drug on our Drug List, but immediately move it to a different cost-sharing tier or add new
restrictions. If you are currently taking that brand name drug, we may not tell you in advance before we
make that change, but we will later provide you with information about the specific change(s) we have
made.
o If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on how to request an exception, and you can also find information in the section below entitled “How do I request an exception to the Acclaim by Ultimate, Acclaim Plus by Ultimate, Ascend Plus by Ultimate, Elite by Ultimate, Premier by Ultimate and Premier Plus by Ultimate Formulary?”
• Drugs removed from the market. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove
the drug from our formulary and provide notice to members who take the drug.
• Other changes. We may make other changes that affect members currently taking a drug. For instance, we may add a generic drug that is not new to market to replace a brand name drug currently on the
formulary or add new restrictions to the brand name drug or move it to a different cost-sharing tier. Or
we may make changes based on new clinical guidelines. If we remove drugs from our formulary, add
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prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher
cost-sharing tier, we must notify affected members of the change at least 30 days before the change
becomes effective, or at the time the member requests a refill of the drug, at which time the member will
receive a 30-day supply of the drug.
o If we make these other changes, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include
information on how to request an exception, and you can also find information in the section below entitled “How do I request an exception to the Acclaim by Ultimate, Acclaim Plus by Ultimate, Ascend Plus by Ultimate, Elite by Ultimate, Premier by Ultimate and Premier Plus by Ultimate Formulary?”
Changes that will not affect you if you are currently taking the drug. Generally, if you are taking a drug on
our 2020 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of
the drug during the 2020 coverage year except as described above. This means these drugs will remain
available at the same cost-sharing and with no new restrictions for those members taking them for the remainder
of the coverage year.
The enclosed formulary is current as of 11/01/2020. To get updated information about the drugs covered by our
plan, please contact us. Our contact information appears on the front and back cover pages. In the event of mid-
year non-maintenance formulary changes, we update our printed formularies at the next printing and we also
publish a monthly summary of all drug list changes, which is available for download from our website or in
printed format upon request.
How do I use the Formulary?
There are two ways to find your drug within the formulary:
Medical Condition
The formulary begins on page 7. The drugs in this formulary are grouped into categories depending on the
type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are
listed under the category, Cardiovascular Agents. If you know what your drug is used for, look for the
category name in the list that begins below. Then look under the category name for your drug.
Alphabetical Listing
If you are not sure what category to look under, you should look for your drug in the Index that begins on
page 116. The Index provides an alphabetical list of all of the drugs included in this document. Both
brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next
to your drug, you will see the page number where you can find coverage information. Turn to the page
listed in the Index and find the name of your drug in the first column of the list.
What are generic drugs?
Our plan covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as
having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand
name drugs.
Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These requirements and limits
may include:
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• Prior Authorization: Our plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from us before you fill your prescriptions. If you
don’t get approval, we may not cover the drug.
• Quantity Limits: For certain drugs, our plan limits the amount of the drug that we will cover. For example, our plan provides 30 tablets per prescription for alprazolam ER 1 mg tablets. This may be in
addition to a standard one-month or three-month supply.
• Step Therapy: In some cases, our plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both
treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not
work for you, we will then cover Drug B.
You can find out if your drug has any additional requirements or limits by looking in the formulary that begins
on page 7. You can also get more information about the restrictions applied to specific covered drugs by
visiting our Web site. We have posted online documents that explain our prior authorization and step therapy
restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last
updated the formulary, appears on the front and back cover pages.
You can ask us to make an exception to these restrictions or limits or for a list of other, similar drugs that may
treat your health condition. See the section, “How do I request an exception to the Acclaim by Ultimate,
Acclaim Plus by Ultimate, Ascend Plus by Ultimate, Elite by Ultimate, Premier by Ultimate and Premier Plus
by Ultimate formulary?” on page iii for information about how to request an exception.
What if my drug is not on the Formulary?
If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services
and ask if your drug is covered.
If you learn that our plan does not cover your drug, you have two options:
• You can ask Member Services for a list of similar drugs that are covered by our plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by our plan.
• You can ask us to make an exception and cover your drug. See below for information about how to request an exception.
How do I request an exception to the Acclaim by Ultimate, Acclaim Plus by Ultimate,
Ascend Plus by Ultimate, Elite by Ultimate, Premier by Ultimate and Premier Plus by
Ultimate Formulary?
You can ask us to make an exception to our coverage rules. There are several types of exceptions that you can
ask us to make.
• You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a
lower cost-sharing level.
• You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug.
• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, our plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask
us to waive the limit and cover a greater amount.
Generally, we will only approve your request for an exception if the alternative drugs included on the plan’s
formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating
your condition and/or would cause you to have adverse medical effects.
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You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction
exception. When you request a formulary, tiering or utilization restriction exception you should submit a
statement from your prescriber or physician supporting your request. Generally, we must make our
decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast)
exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for
a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we
get a supporting statement from your doctor or other prescriber.
What do I do before I can talk to my doctor about changing my drugs or requesting an
exception?
As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may
be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior
authorization from us before you can fill your prescription. You should talk to your doctor to decide if you
should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the
drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your
drug in certain cases during the first 90 days you are a member of our plan.
For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a
temporary 30-day supply. If your prescription is written for fewer days, we’ll allow refills to provide up to a
maximum 30-day supply of medication. After your first 30-day supply, we will not pay for these drugs, even if
you have been a member of the plan less than 90 days.
If you are a resident of a long-term care facility and you need a drug that is not on our formulary or if your
ability to get your drugs is limited, but you are past the first 98 days of membership in our plan, we will cover a
31-day emergency supply of that drug while you pursue a formulary exception.
We will cover a Transition Supply for enrollees who have a level of care change, which is defined as when
enrollees:
• Enter a Long-Term-Care (LTC) facility from a hospital or other setting
• Leave a Long-Term-Care (LTC) facility and return to the community
• Are discharged from a hospital to a home
• End a skilled nursing facility (SNF) stay covered under Medicare Part A (where all pharmacy charges are covered), and must revert to coverage under their Part D plan Formulary
• Revert from hospice status to standard Medicare Part A and Part B benefits; or
• Are discharged from a psychiatric hospital with a medication regimen that is highly individualized
We will provide you with a written notice after we cover the Transition Supply. This notice will explain the
steps you can take to request an exception and how to work with your doctor to decide if you should switch to
an appropriate drug that Ultimate Health Plans covers.
For more information
For more detailed information about your plan’s prescription drug coverage, please review your Evidence of
Coverage and other plan materials.
If you have questions about our plan, please contact us. Our contact information, along with the date we last
updated the formulary, appears on the front and back cover pages.
If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-
MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or,
visit http://www.medicare.gov.
http://www.medicare.gov/
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Our Plan’s Formulary
The formulary that begins on the next page provides coverage information about the drugs covered by our plan.
If you have trouble finding your drug in the list, turn to the Index that begins on page 116.
The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., ADVAIR) and generic
drugs are listed in lower-case italics (e.g., lisinopril).
The information in the Requirements/Limits column tells you if our plan has any special requirements for
coverage of your drug. Below is a list of abbreviations that may appear in the Requirements/Limits column.
B/D: This prescription drug may be covered under our medical benefit. For more information, call Member
Services at 1-888-657-4170, Monday through Sunday from 8 a.m. to 8 p.m. TTY users should call 711.
E: Excluded Drug. This prescription drug is not normally covered in a Medicare Prescription Drug Plan. The
amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is,
the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra
help to pay for your prescriptions, you will not get any extra help to pay for this drug.
CG: Coverage in the Gap. We provide additional coverage of this prescription drug in the coverage gap. Please
refer to our Evidence of Coverage for more information about this coverage.
HI: Home Infusion. This prescription drug may be covered under our medical benefit. For more information,
call Member Services at 1-888-657-4170, Monday through Sunday from 8 a.m. to 8 p.m. TTY users should call
711.
MO: Mail Order Drug. This prescription drug is available through our mail order service, as well as through our
retail network pharmacies. Generally, the drugs provided through mail order are drugs that you take on a regular
basis, for a chronic or long-term medical condition. Our plan’s mail-order service requires you to order a 90-day
supply. Usually a mail-order pharmacy order will get to you in no more than 14 days. However, if your order is
delayed, immediately contact us) so we can make arrangements for you to pick up your prescription at your
local pharmacy. You may contact us 24 hours a day, 7 days a week at 1-800-311-7517 (TTY users dial 711).
PA: Prior Authorization. We require you or your physician to get prior authorization for certain drugs. This
means that you will need to get approval before you fill your prescriptions. If you don’t get approval, we may
not cover the drug.
QL: Quantity Limit. For certain drugs we limit the amount of the drug that we will cover.
ST: Step Therapy. In some cases, we require you to first try certain drugs to treat your medical condition before
we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical
condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then
cover Drug B.
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The Formulary is Divided into Five (5) Tiers
Every drug on the plan’s Drug List is in one of 5 cost-sharing tiers with a corresponding cost sharing amount
depending on the plan as shown below. In general, the higher the cost-sharing tier, the higher your cost for the
drug:
• Cost-Sharing Tier 1 includes preferred generic drugs. This is the lowest tier. • Cost-Sharing Tier 2 includes generic drugs. • Cost-Sharing Tier 3 includes preferred brand drugs. • Cost-Sharing Tier 4 includes non-preferred drugs. • Cost-Sharing Tier 5 includes specialty drugs. This is the highest tier.
For Premier by Ultimate, Elite by Ultimate and Acclaim by Ultimate: Cost
Sharing
Tier
Copay or coinsurance
for a 30-day supply at
a Retail Pharmacy
Copay or coinsurance
for a 60-day supply at
a Retail Pharmacy
Copay or coinsurance
for a 90-day supply at
a Retail Pharmacy
Copay or coinsurance
for a 90-day supply
through the Mail
Order Pharmacy Tier 1 $0 $0 $0 $0
Tier 2 $12 $24 $36 $24
Tier 3 $35 $70 $105 $70
Tier 4 $60 $120 $180 $120
Tier 5 33% coinsurance 33% coinsurance 33% coinsurance 33% coinsurance
For Premier Plus by Ultimate and Acclaim Plus by Ultimate: Cost
Sharing
Tier
Copay or coinsurance
for a 30-day supply at
a Retail Pharmacy
Copay or coinsurance
for a 60-day supply at
a Retail Pharmacy
Copay or coinsurance
for a 90-day supply at
a Retail Pharmacy
Copay or coinsurance
for a 90-day supply
through the Mail
Order Pharmacy Tier 1 $0 $0 $0 $0
Tier 2 $8 $16 $24 $16
Tier 3 $25 $50 $75 $50
Tier 4 $50 $100 $150 $100
Tier 5 33% coinsurance 33% coinsurance 33% coinsurance 33% coinsurance
For Ascend Plus by Ultimate: Cost
Sharing
Tier
Copay or coinsurance
for a 30-day supply at
a Retail Pharmacy
Copay or coinsurance
for a 60-day supply at
a Retail Pharmacy
Copay or coinsurance
for a 90-day supply at
a Retail Pharmacy
Copay or coinsurance
for a 90-day supply
through the Mail
Order Pharmacy
Tier 1 $0 $0 $0 $0
Tier 2 $8 $16 $24 $16
Tier 3 $30 $60 $90 $60
Tier 4 $70 $140 $210 $140
Tier 5 33% coinsurance 33% coinsurance 33% coinsurance 33% coinsurance
Please consult your Evidence of Coverage or Summary of Benefits for additional information on the applicable
co-pays or co-insurance amounts in each formulary tier.
You can find information on what the symbols and abbreviations on this table mean by going to page V.
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DRUG NAME TIER REQUIREMENTS/LIMITS
ANALGESICS
Analgesics
butalbital-acetaminophen tab 50-325 mg 1 CG; MO
butalbital-acetaminophen-caffeine cap 50-300-40 mg 2 CG; MO
butalbital-acetaminophen-caffeine cap 50-325-40 mg 2 CG; MO
butalbital-acetaminophen-caffeine tab 50-325-40 mg 1 CG; MO
butalbital-aspirin-caffeine cap 50-325-40 mg 2 CG; MO
esgic tab 50-325-40 mg 1 CG; MO
tencon tab 50-325 mg 1 CG; MO
VANATOL LQ SOL 4 MO
zebutal cap 50-325-40 mg 1 CG; MO
Opioid Analgesics, Long-acting
fentanyl td patch 72hr 100 mcg/hr 3 MO
fentanyl td patch 72hr 12 mcg/hr 3 MO
fentanyl td patch 72hr 25 mcg/hr 3 MO
fentanyl td patch 72hr 37.5 mcg/hr 4 MO
fentanyl td patch 72hr 50 mcg/hr 3 MO
fentanyl td patch 72hr 62.5 mcg/hr 4 MO
fentanyl td patch 72hr 75 mcg/hr 3 MO
fentanyl td patch 72hr 87.5 mcg/hr 5 MO
hydromorphone hcl tab er 12 mg 4 MO
hydromorphone hcl tab er 16 mg 4 MO
hydromorphone hcl tab er 32 mg 5 MO
hydromorphone hcl tab er 8 mg 4 MO
levorphanol tartrate tab 2 mg 4 MO
methadone hcl soln 10 mg/5ml 2 CG; MO
methadone hcl soln 5 mg/5ml 2 CG; MO
methadone hcl tab 10 mg 1 CG; MO
methadone hcl tab 5 mg 1 CG; MO
morphine sulfate beads cap er 120 mg 4 MO
morphine sulfate beads cap er 30 mg 4 MO
morphine sulfate beads cap er 45 mg 4 MO
morphine sulfate beads cap er 60 mg 4 MO
morphine sulfate beads cap er 75 mg 4 MO
morphine sulfate beads cap er 90 mg 4 MO
morphine sulfate cap er 10 mg 4 MO
morphine sulfate cap er 100 mg 5 MO
morphine sulfate cap er 20 mg 4 MO
morphine sulfate cap er 30 mg 4 MO
morphine sulfate cap er 40 mg 4 MO
You can find information on what the symbols and abbreviations on this table mean by going to page V.
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DRUG NAME TIER REQUIREMENTS/LIMITS
morphine sulfate cap er 50 mg 4 MO
morphine sulfate cap er 60 mg 4 MO
morphine sulfate cap er 80 mg 4 MO
morphine sulfate oral soln 20 mg/5ml 2 CG; MO
morphine sulfate tab er 100 mg 2 CG; MO
morphine sulfate tab er 15 mg 2 CG; MO
morphine sulfate tab er 200 mg 2 CG; MO
morphine sulfate tab er 30 mg 2 CG; MO
morphine sulfate tab er 60 mg 2 CG; MO
oxymorphone hcl tab er 10 mg 4 MO
oxymorphone hcl tab er 15 mg 4 MO
oxymorphone hcl tab er 20 mg 4 MO
oxymorphone hcl tab er 30 mg 4 MO
oxymorphone hcl tab er 40 mg 4 MO
oxymorphone hcl tab er 5 mg 4 MO
oxymorphone hcl tab er 7.5 mg 4 MO
tramadol hcl tab er 100 mg 2 CG; MO
tramadol hcl tab er 200 mg 2 CG; MO
tramadol hcl tab er 300 mg 2 CG; MO
Opioid Analgesics, Short-acting
acetaminophen w/ codeine soln 120-12 mg/5ml 1 CG; MO
acetaminophen w/ codeine tab 300-15 mg 2 CG; MO
acetaminophen w/ codeine tab 300-30 mg 2 CG; MO
acetaminophen w/ codeine tab 300-60 mg 2 CG; MO
ascomp/codeine cap 50-325-40-30 mg 2 CG; MO
butalbital-acetaminophen-caff w/ cod cap 50-300-40-30 mg 2 CG; MO
butalbital-acetaminophen-caff w/ cod cap 50-325-40-30 mg 2 CG; MO
butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg 2 CG; MO
butorphanol tartrate nasal soln 10 mg/ml 2 CG; MO
CODEINE SULF TAB 30MG 2 CG; MO
CODEINE SULF TAB 60MG 3 MO
endocet tab 10-325 mg 2 CG; MO
endocet tab 5-325 mg 2 CG; MO
endocet tab 7.5-325 mg 2 CG; MO
fentanyl citrate lozenge 1200 mcg 5 MO; PA
fentanyl citrate lozenge 1600 mcg 5 MO; PA
fentanyl citrate lozenge 200 mcg 4 MO; PA
fentanyl citrate lozenge 400 mcg 4 MO; PA
fentanyl citrate lozenge 600 mcg 5 MO; PA
fentanyl citrate lozenge 800 mcg 5 MO; PA
You can find information on what the symbols and abbreviations on this table mean by going to page V.
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DRUG NAME TIER REQUIREMENTS/LIMITS
hydrocodone-acetaminophen soln 7.5-325 mg/15ml 2 CG; MO
hydrocodone-acetaminophen tab 10-300 mg 2 CG; MO
hydrocodone-acetaminophen tab 10-325 mg 1 CG; MO
hydrocodone-acetaminophen tab 5-300 mg 2 CG; MO
hydrocodone-acetaminophen tab 5-325 mg 1 CG; MO
hydrocodone-acetaminophen tab 7.5-300 mg 2 CG; MO
hydrocodone-acetaminophen tab 7.5-325 mg 1 CG; MO
hydrocodone-ibuprofen tab 10-200 mg 2 CG; MO
hydrocodone-ibuprofen tab 5-200 mg 2 CG; MO
hydrocodone-ibuprofen tab 7.5-200 mg 2 CG; MO
hydromorphone hcl liqd 1 mg/ml 2 CG; MO
hydromorphone hcl preservative free (pf) inj 10 mg/ml 2 CG; MO
hydromorphone hcl tab 2 mg 2 CG; MO
hydromorphone hcl tab 4 mg 2 CG; MO
hydromorphone hcl tab 8 mg 2 CG; MO
morphine sulfate inj pf 0.5 mg/ml 2 CG; MO
morphine sulfate inj pf 1 mg/ml 2 CG; MO
morphine sulfate oral soln 10 mg/5ml 2 CG; MO
morphine sulfate oral soln 100 mg/5ml 2 CG; MO
morphine sulfate tab 15 mg 2 CG; MO
morphine sulfate tab 30 mg 2 CG; MO
norco tab 10-325 mg 1 CG; MO
norco tab 5-325 mg 1 CG; MO
norco tab 7.5-325 mg 1 CG; MO
oxycodone hcl cap 5 mg 2 CG; MO
oxycodone hcl conc 100 mg/5ml 4 MO
oxycodone hcl soln 5 mg/5ml 2 CG; MO
oxycodone hcl tab 10 mg 2 CG; MO
oxycodone hcl tab 15 mg 2 CG; MO
oxycodone hcl tab 20 mg 2 CG; MO
oxycodone hcl tab 30 mg 2 CG; MO
oxycodone hcl tab 5 mg 2 CG; MO
oxycodone w/ acetaminophen tab 10-325 mg 2 CG; MO
oxycodone w/ acetaminophen tab 2.5-325 mg 2 CG; MO
oxycodone w/ acetaminophen tab 5-325 mg 2 CG; MO
oxycodone w/ acetaminophen tab 7.5-325 mg 2 CG; MO
oxycodone-aspirin tab 4.8355-325 mg 2 CG; MO
oxymorphone hcl tab 10 mg 2 CG; MO
oxymorphone hcl tab 5 mg 2 CG; MO
pentazocine w/ naloxone tab 50-0.5 mg 4 MO
You can find information on what the symbols and abbreviations on this table mean by going to page V.
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DRUG NAME TIER REQUIREMENTS/LIMITS
primlev tab 10-300 mg 4 MO
primlev tab 5-300 mg 4 MO
primlev tab 7.5-300 mg 4 MO
prolate tab 10-300 mg 4 MO
prolate tab 5-300 mg 4 MO
prolate tab 7.5-300 mg 4 MO
tramadol hcl tab 50 mg 1 CG; MO
tramadol hcl tab 100 mg 1 CG; MO
tramadol-acetaminophen tab 37.5-325 mg 2 CG; MO
ANESTHETICS
Local Anesthetics
lidocaine hcl soln 4% 2 CG; MO
lidocaine hcl urethral/mucosal gel 2% 2 CG; MO
lidocaine hcl viscous soln 2% 1 CG; MO
lidocaine oint 5% 3 MO; QL 120 PER 30 DAYS; PA
lidocaine patch 5% 3 MO; PA
lidocaine-prilocaine cream 2.5-2.5% 2 CG; MO; QL 30 PER 30 DAYS
ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS
Alcohol Deterrents/Anti-craving
acamprosate calcium tab dr 333 mg 2 CG; MO
disulfiram tab 250 mg 2 CG; MO
disulfiram tab 500 mg 2 CG; MO
LUCEMYRA TAB 0.18MG 4 MO; QL 480 PER 30 DAYS
naltrexone hcl tab 50 mg 2 CG; MO
Opioid Dependence Treatments
buprenorphine hcl sl tab 2 mg 1 CG; MO
buprenorphine hcl sl tab 8 mg 1 CG; MO
buprenorphine hcl-naloxone hcl sl film 12-3 mg 1 CG; MO; QL 60 PER 30 DAYS
buprenorphine hcl-naloxone hcl sl film 2-0.5 mg 1 CG; MO; QL 360 PER 30 DAYS
buprenorphine hcl-naloxone hcl sl film 4-1 mg 1 CG; MO; QL 180 PER 30 DAYS
buprenorphine hcl-naloxone hcl sl film 8-2 mg 1 CG; MO; QL 90 PER 30 DAYS
buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg 1 CG; MO; QL 360 PER 30 DAYS
buprenorphine hcl-naloxone hcl sl tab 8-2 mg 1 CG; MO; QL 90 PER 30 DAYS
VIVITROL INJ 380MG 5 MO; PA
ZUBSOLV SUB 1.4-0.36 4 MO; QL 360 PER 30 DAYS
ZUBSOLV SUB 11.4-2.9 4 MO; QL 30 PER 30 DAYS
ZUBSOLV SUB 2.9-0.71 4 MO; QL 180 PER 30 DAYS
ZUBSOLV SUB 5.7-1.4 4 MO; QL 90 PER 30 DAYS
You can find information on what the symbols and abbreviations on this table mean by going to page V.
11
DRUG NAME TIER REQUIREMENTS/LIMITS
ZUBSOLV SUB 8.6-2.1 4 MO; QL 60 PER 30 DAYS
Opioid Reversal Agents
naloxone hcl inj 0.4 mg/ml 1 CG; MO
naloxone hcl soln cartridge 0.4 mg/ml 1 CG; MO
naloxone hcl soln prefilled syringe 2 mg/2ml 2 CG; MO
NARCAN SPR 3 MO
Smoking Cessation Agents
bupropion hcl (smoking deterrent) tab er 150 mg 1 CG; MO; QL 60 PER 30 DAYS
CHANTIX PAK 0.5& 1MG 4 MO; QL 504 PER 365 DAYS
CHANTIX PAK 1MG 4 MO; QL 504 PER 365 DAYS
CHANTIX TAB 0.5MG 4 MO; QL 504 PER 365 DAYS
CHANTIX TAB 1MG 4 MO; QL 504 PER 365 DAYS
NICOTROL INH 4 MO; QL 2688 PER 365 DAYS
NICOTROL NS SPR 10MG/ML 3 MO; QL 360 PER 365 DAYS
ANTIBACTERIALS
Aminoglycosides
amikacin sulfate inj 500 mg/2ml 2 CG; HI; MO
gentak oint 0.3% 2 CG; MO
gentamicin in saline inj 0.8 mg/ml 2 CG; HI; MO
gentamicin in saline inj 1 mg/ml 2 CG; HI; MO
gentamicin in saline inj 1.2 mg/ml 2 CG; HI; MO
gentamicin in saline inj 1.6 mg/ml 2 CG; HI; MO
gentamicin sulfate cream 0.1% 2 CG; MO
gentamicin sulfate inj 40 mg/ml 2 CG; HI; MO
gentamicin sulfate oint 0.1% 2 CG; MO
gentamicin sulfate ophth soln 0.3% 1 CG; MO
neomycin sulfate tab 500 mg 2 CG; MO
paromomycin sulfate cap 250 mg 2 CG; MO
streptomycin sulfate for inj 1 gm 4 MO
TOBRADEX OIN 0.3-0.1% 3 MO
tobramycin ophth soln 0.3% 1 CG; MO
tobramycin sulfate inj 10 mg/ml 2 CG; HI; MO
tobramycin sulfate inj 40 mg/ml 2 CG; HI; MO
TOBREX OIN 0.3% OP 4 MO
Antibacterials, Other
acetic acid otic soln 2% 2 CG; MO
bacitracin ophth oint 500 unit/gm 2 CG; MO
CLEOCIN SUP 100MG 4 MO
clindacin-p pad 1% 2 CG; MO
clindamycin hcl cap 150 mg 2 CG; MO
You can find information on what the symbols and abbreviations on this table mean by going to page V.
12
DRUG NAME TIER REQUIREMENTS/LIMITS
clindamycin hcl cap 300 mg 2 CG; MO
clindamycin hcl cap 75 mg 2 CG; MO
clindamycin palmitate hcl for soln 75 mg/5ml 2 CG; MO
clindamycin phosphate foam 1% 4 MO
clindamycin phosphate gel 1% 4 MO
clindamycin phosphate in d5w iv soln 300 mg/50ml 2 CG; HI; MO
clindamycin phosphate in d5w iv soln 600 mg/50ml 2 CG; HI; MO
clindamycin phosphate in d5w iv soln 900 mg/50ml 2 CG; HI; MO
clindamycin phosphate inj 300 mg/2ml 2 CG; HI; MO
clindamycin phosphate inj 600 mg/4ml 2 CG; HI; MO
clindamycin phosphate inj 900 mg/6ml 2 CG; HI; MO
clindamycin phosphate lotion 1% 2 CG; MO
clindamycin phosphate soln 1% 2 CG; MO
clindamycin phosphate swab 1% 2 CG; MO
clindamycin phosphate vaginal cream 2% 2 CG; MO
clindamycin phosphate-tretinoin gel 1.2-0.025% 4 MO; PA
clindamycin phosph-benzoyl peroxide (refrig) gel 1.2 (1)-5% 4 MO
CLINDESSE CRE2% 4 MO
colistimethate sod for inj 150 mg 4 HI; MO
DALVANCE SOL 500MG 5 HI; MO
daptomycin for iv soln 500 mg 5 MO
linezolid for susp 100 mg/5ml 4 MO; QL 1800 PER 30 DAYS
linezolid inj 2 mg/ml 4 HI; MO
linezolid tab 600 mg 1 CG; MO; QL 56 PER 28 DAYS
methenamine hippurate tab 1 gm 2 CG; MO
metronidazole cap 375 mg 2 CG; MO
metronidazole cream 0.75% 2 CG; MO
metronidazole gel 0.75% 2 CG; MO
metronidazole gel 1% 2 CG; MO
metronidazole in nacl 0.79% iv soln 500 mg/100ml 2 CG; HI; MO
metronidazole lotion 0.75% 2 CG; MO
metronidazole tab 250 mg 2 CG; MO
metronidazole tab 500 mg 1 CG; MO
metronidazole vaginal gel 0.75% 2 CG; MO
MONUROL PAK GRANULES 3 MO
mupirocin cream 2% 3 MO
mupirocin oint 2% 2 CG; MO
nitrofurantoin macrocrystalline cap 100 mg 1
CG; MO; QL 360 PER
365 DAYS nitrofurantoin macrocrystalline cap 25 mg
1 CG; MO; QL 1440 PER
365 DAYS
You can find information on what the symbols and abbreviations on this table mean by going to page V.
13
DRUG NAME TIER REQUIREMENTS/LIMITS
nitrofurantoin macrocrystalline cap 50 mg 1
CG; MO; QL 720 PER
365 DAYS nitrofurantoin monohydrate macrocrystalline cap 100 mg
1 CG; MO; QL 180 PER
365 DAYS
nitrofurantoin susp 25 mg/5ml 4 MO; QL 7200 PER 365 DAYS
NORITATE CRE 1% 5 MO
polymyxin b sulfate for inj 500000 unit 2 CG; MO
SIVEXTRO INJ 200MG 5 HI; MO; QL 6 PER 30 DAYS
SIVEXTRO TAB 200MG 5 MO; QL 6 PER 30 DAYS
SULFAMYLON CRE 85MG/GM 4 MO
tigecycline for iv soln 50 mg 5 MO
tinidazole tab 250 mg 2 CG; MO
tinidazole tab 500 mg 2 CG; MO
trimethoprim tab 100 mg 1 CG; MO
vancomycin hcl cap 125 mg 4 MO
vancomycin hcl cap 250 mg 5 MO
vancomycin hcl for iv soln 1 gm 2 CG; HI; MO
vancomycin hcl for iv soln 10 gm 2 CG; HI; MO
vancomycin hcl for iv soln 500 mg 2 CG; HI; MO
Beta-lactam, Cephalosporins
AVYCAZ INJ 2-0.5GM 5 HI; MO
CEFACLOR SUS 125/5ML 3 MO
CEFACLOR SUS 250/5ML 3 MO
CEFACLOR SUS 375/5ML 3 MO
cefaclor cap 250 mg 1 CG; MO
cefaclor cap 500 mg 1 CG; MO
cefaclor monohydrate tab er 500 mg 1 CG; MO
cefadroxil cap 500 mg 2 CG; MO
cefadroxil for susp 250 mg/5ml 2 CG; MO
cefadroxil for susp 500 mg/5ml 2 CG; MO
cefadroxil tab 1 gm 2 CG; MO
cefazolin sodium for inj 1 gm 2 CG; HI; MO
cefazolin sodium for inj 10 gm 2 CG; HI; MO
cefazolin sodium for inj 500 mg 2 CG; HI; MO
cefdinir cap 300 mg 1 CG; MO
cefdinir for susp 125 mg/5ml 2 CG; MO
cefdinir for susp 250 mg/5ml 2 CG; MO
cefepime hcl for inj 1 gm 2 CG; HI; MO
cefepime hcl for inj 2 gm 2 CG; HI; MO
cefixime cap 400mg 3 MO
cefixime chew tab 100 mg 3 MO
You can find information on what the symbols and abbreviations on this table mean by going to page V.
14
DRUG NAME TIER REQUIREMENTS/LIMITS
cefixime chew tab 200 mg 3 MO
cefixime for susp 100 mg/5ml 4 MO
cefixime for susp 200 mg/5ml 4 MO
cefotetan disodium for inj 1 gm 2 CG; HI; MO
cefotetan disodium for inj 2 gm 2 CG; HI; MO
cefoxitin sodium for inj 10 gm 2 CG; HI; MO
cefoxitin sodium for iv soln 1 gm 2 CG; HI; MO
cefoxitin sodium for iv soln 2 gm 2 CG; HI; MO
cefpodoxime proxetil for susp 100 mg/5ml 2 CG; MO
cefpodoxime proxetil for susp 50 mg/5ml 2 CG; MO
cefpodoxime proxetil tab 100 mg 2 CG; MO
cefpodoxime proxetil tab 200 mg 2 CG; MO
cefprozil for susp 125 mg/5ml 2 CG; MO
cefprozil for susp 250 mg/5ml 2 CG; MO
cefprozil tab 250 mg 2 CG; MO
cefprozil tab 500 mg 2 CG; MO
ceftazidime for inj 1 gm 2 CG; HI; MO
ceftazidime for inj 2 gm 2 CG; HI; MO
ceftazidime for inj 6 gm 2 CG; HI; MO
ceftriaxone sodium for inj 1 gm 2 CG; HI; MO
ceftriaxone sodium for inj 10 gm 2 CG; HI; MO
ceftriaxone sodium for inj 2 gm 2 CG; HI; MO
ceftriaxone sodium for inj 250 mg 2 CG; HI; MO
ceftriaxone sodium for inj 500 mg 2 CG; HI; MO
cefuroxime axetil tab 250 mg 1 CG; MO
cefuroxime axetil tab 500 mg 1 CG; MO
cefuroxime sodium for inj 7.5 gm 2 CG; HI; MO
cefuroxime sodium for inj 750 mg 2 CG; HI; MO
cefuroxime sodium for iv soln 1.5 gm 2 CG; HI; MO
cephalexin cap 250 mg 1 CG; MO
cephalexin cap 500 mg 1 CG; MO
cephalexin cap 750 mg 1 CG; MO
cephalexin for susp 125 mg/5ml 2 CG; MO
cephalexin for susp 250 mg/5ml 2 CG; MO
cephalexin tab 250 mg 2 CG; MO
cephalexin tab 500 mg 2 CG; MO
SUPRAX CAP 400MG 3 MO
SUPRAX SUS 500/5ML 3 MO
tazicef inj 1 gm 2 HI; CG; MO
tazicef inj 2 gm 2 HI; CG; MO
You can find information on what the symbols and abbreviations on this table mean by going to page V.
15
DRUG NAME TIER REQUIREMENTS/LIMITS
tazicef inj 6 gm 2 HI; CG; MO
TEFLARO INJ 400MG 5 HI; MO
TEFLARO INJ 600MG 5 HI; MO
Beta-lactam, Other
aztreonam for inj 1 gm 4 HI; MO
CAYSTON INH 75MG 5 MO; PA
ertapenem sodium for inj 1 gm 3 MO
imipenem-cilastatin intravenous for soln 250 mg 4 HI; MO
imipenem-cilastatin intravenous for soln 500 mg 4 HI; MO
meropenem iv for soln 500 mg 2 CG; HI; MO
Beta-lactam, Penicillins
amoxicillin & k clavulanate chew tab 200-28.5 mg 1 CG; MO
amoxicillin & k clavulanate chew tab 400-57 mg 1 CG; MO
amoxicillin & k clavulanate for susp 200-28.5 mg/5ml 1 CG; MO
amoxicillin & k clavulanate for susp 250-62.5 mg/5ml 1 CG; MO
amoxicillin & k clavulanate for susp 400-57 mg/5ml 1 CG; MO
amoxicillin & k clavulanate for susp 600-42.9 mg/5ml 1 CG; MO
amoxicillin & k clavulanate tab 250-125 mg 1 CG; MO
amoxicillin & k clavulanate tab 500-125 mg 1 CG; MO
amoxicillin & k clavulanate tab 875-125 mg 1 CG; MO
amoxicillin (trihydrate) cap 250 mg 1 CG; MO
amoxicillin (trihydrate) cap 500 mg 1 CG; MO
amoxicillin (trihydrate) chew tab 125 mg 1 CG; MO
amoxicillin (trihydrate) chew tab 250 mg 1 CG; MO
amoxicillin (trihydrate) for susp 125 mg/5ml 1 CG; MO
amoxicillin (trihydrate) for susp 200 mg/5ml 1 CG; MO
amoxicillin (trihydrate) for susp 250 mg/5ml 1 CG; MO
amoxicillin (trihydrate) for susp 400 mg/5ml 1 CG; MO
amoxicillin (trihydrate) tab 500 mg 1 CG; MO
amoxicillin (trihydrate) tab 875 mg 1 CG; MO
AMOX-POT CLA TAB ER 3 MO
ampicillin & sulbactam sodium for inj 1-0.5 gm 2 CG; HI; MO
ampicillin & sulbactam sodium for inj 15 gm 2 CG; HI; MO
ampicillin & sulbactam sodium for inj 2-1 gm 2 CG; HI; MO
ampicillin cap 500 mg 1 CG; MO
ampicillin sodium for inj 1 gm 2 CG; HI; MO
ampicillin sodium for inj 125 mg 2 CG; HI; MO
ampicillin sodium for iv soln 10 gm 2 CG; HI; MO
BACTOCILL INJ DEX 1GM 4 HI; MO
BACTOCILL INJ DEX 2GM 4 HI; MO
You can find information on what the symbols and abbreviations on this table mean by going to page V.
16
DRUG NAME TIER REQUIREMENTS/LIMITS
BICILLIN C-R INJ 1200000 4 MO
BICILLIN C-R INJ 900/300 4 MO
BICILLIN L-A INJ 1200000 4 MO
BICILLIN L-A INJ 2400000 4 MO
BICILLIN L-A INJ 600000 4 MO
dicloxacillin sodium cap 250 mg 2 CG; MO
dicloxacillin sodium cap 500 mg 2 CG; MO
nafcillin sodium for inj 1 gm 4 HI; MO
nafcillin sodium for inj 2 gm 1 HI; MO
nafcillin sodium for iv soln 10 gm 4 HI; MO
oxacillin sodium for inj 10 gm 5 HI; MO
oxacillin sodium for inj 2 gm 4 HI; MO
PENICILL GK/INJ DEX 2MU 3 HI; MO
PENICILL GK/INJ DEX 3MU 3 HI; MO
penicillin g potassium for inj 20000000 unit 2 CG; HI; MO
penicillin g sodium for inj 5000000 unit 2 CG; HI; MO
penicillin v potassium for soln 125 mg/5ml 1 CG; MO
penicillin v potassium for soln 250 mg/5ml 1 CG; MO
penicillin v potassium tab 250 mg 1 CG; MO
penicillin v potassium tab 500 mg 1 CG; MO
piperacillin sod-tazobactam na for inj 3-0.375 gm 2 CG; HI; MO
piperacillin sod-tazobactam sod for inj 2-0.25 gm 1 CG; HI; MO
piperacillin sod-tazobactam sod for inj 36-4.5 gm 2 CG; HI; MO
piperacillin sod-tazobactam sod for inj 4-0.5 gm 2 CG; HI; MO
ZOSYN SOL 2-0.25GM 4 HI; MO
ZOSYN SOL 3-0.375G 4 HI; MO
Macrolides
AZASITE SOL 1% 4 MO
azithromycin iv for soln 500 mg 2 CG; HI; MO
azithromycin powd pack for susp 1 gm 2 CG; MO
azithromycin susp 100 mg/5ml 2 CG; MO
azithromycin susp 200 mg/5ml 2 CG; MO
azithromycin tab 250 mg 1 CG; MO
azithromycin tab 500 mg 1 CG; MO
azithromycin tab 600 mg 1 CG; MO
clarithromycin for susp 125 mg/5ml 2 CG; MO
clarithromycin for susp 250 mg/5ml 2 CG; MO
clarithromycin tab 250 mg 2 CG; MO
clarithromycin tab 500 mg 2 CG; MO
clarithromycin tab er 500 mg 2 CG; MO
You can find information on what the symbols and abbreviations on this table mean by going to page V.
17
DRUG NAME TIER REQUIREMENTS/LIMITS
DIFICID TAB 200MG 5 MO
ERYTHROCIN INJ 500MG 4 HI; MO
erythromycin ethylsuccinate for susp 200 mg/5ml 2 CG; MO
erythromycin ethylsuccinate for susp 400 mg/5ml 3 MO
erythromycin ethylsuccinate tab 400 mg 2 CG; MO
erythromycin gel 2% 2 CG; MO
erythromycin ophth oint 5 mg/gm 1 CG; MO
erythromycin pads 2% 2 CG; MO
erythromycin soln 2% 2 CG; MO
erythromycin stearate tab 250 mg 2 CG; MO
erythromycin tab 250 mg bs 2 CG; MO
erythromycin tab 500 mg bs 2 CG; MO
erythromycin tab dr 250 mg 2 CG; MO
erythromycin tab dr 333 mg 2 CG; MO
erythromycin tab dr 500 mg 2 CG; MO
erythromycin w/ delayed release particles cap 250 mg 2 CG; MO
Quinolones
BESIVANCE SUS 0.6% 3 MO
CILOXAN OIN 0.3% OP 4 MO
ciprofloxacin 200 mg/100ml in d5w 2 CG; HI; MO
ciprofloxacin hcl ophth soln 0.3% 1 CG; MO
ciprofloxacin hcl tab 100 mg 1 CG; MO
ciprofloxacin hcl tab 250 mg 1 CG; MO
ciprofloxacin hcl tab 500 mg 1 CG; MO
ciprofloxacin hcl tab 750 mg 1 CG; MO
gatifloxacin ophth soln 0.5% 2 CG; MO
levofloxacin in d5w iv soln 500 mg/100ml 2 CG; HI; MO
levofloxacin in d5w iv soln 750 mg/150ml 2 CG; HI; MO
levofloxacin iv soln 25 mg/ml 4 HI; MO
levofloxacin ophth soln 0.5% 2 CG; MO
levofloxacin oral soln 25 mg/ml 4 MO
levofloxacin tab 250 mg 1 CG; MO
levofloxacin tab 500 mg 1 CG; MO
levofloxacin tab 750 mg 1 CG; MO
MOXEZA SOL 0.5% 3 MO
moxifloxacin hcl 400 mg/250ml in sodium chloride 0.8% inj 4 HI; MO
moxifloxacin hcl ophth soln 0.5% 2 CG; MO
moxifloxacin hcl tab 400 mg 2 CG; MO
ofloxacin ophth soln 0.3% 1 CG; MO
ofloxacin otic soln 0.3% 2 CG; MO
You can find information on what the symbols and abbreviations on this table mean by going to page V.
18
DRUG NAME TIER REQUIREMENTS/LIMITS
ofloxacin tab 300 mg 2 CG; MO
ofloxacin tab 400 mg 2 CG; MO
Sulfonamides
silver sulfadiazine cream 1% 1 CG; MO
sulfacetamide sodium lotion 10% (acne) 4 MO
sulfacetamide sodium ophth soln 10% 2 CG; MO
sulfadiazine tab 500 mg 4 MO
sulfamethoxazole-trimethoprim susp 200-40 mg/5ml 2 CG; MO
sulfamethoxazole-trimethoprim tab 400-80 mg 1 CG; MO
sulfamethoxazole-trimethoprim tab 800-160 mg 1 CG; MO
Tetracyclines
demeclocycline hcl tab 150 mg 2 CG; MO
demeclocycline hcl tab 300 mg 2 CG; MO
DORYX MPC TAB 120MG 4 MO
doxycycline hyclate cap 100 mg 1 CG; MO
doxycycline hyclate cap 50 mg 1 CG; MO
doxycycline hyclate for inj 100 mg 2 CG; HI; MO
doxycycline hyclate tab 100 mg 1 CG; MO
doxycycline hyclate tab delayed release 150 mg 2 CG; MO
doxycycline hyclate tab dr 100 mg 2 CG; MO
doxycycline hyclate tab dr 150 mg 2 CG; MO
doxycycline hyclate tab dr 50 mg 4 MO
doxycycline hyclate tab dr 75 mg 2 CG; MO
doxycycline monohydrate cap 100 mg 2 CG; MO
doxycycline monohydrate cap 50 mg 2 CG; MO
doxycycline monohydrate cap 75 mg 2 CG; MO
doxycycline monohydrate for susp 25 mg/5ml 2 CG; MO
doxycycline monohydrate tab 100 mg 2 CG; MO
doxycycline monohydrate tab 150 mg 2 CG; MO
doxycycline monohydrate tab 50 mg 2 CG; MO
doxycycline monohydrate tab 75 mg 2 CG; MO
minocycline hcl cap 100 mg 1 CG; MO
minocycline hcl cap 50 mg 1 CG; MO
minocycline hcl cap 75 mg 1 CG; MO
minocycline hcl tab 100 mg 1 CG; MO
minocycline hcl tab 50 mg 1 CG; MO
minocycline hcl tab 75 mg 1 CG; MO
tetracycline hcl cap 250 mg 4 MO
tetracycline hcl cap 500 mg 4 MO
VIBRAMYCIN SYP 50MG/5ML 4 MO
You can find information on what the symbols and abbreviations on this table mean by going to page V.
19
DRUG NAME TIER REQUIREMENTS/LIMITS
ANTICONVULSANTS
Anticonvulsants, Other
BRIVIACT SOL 10MG/ML 5 MO
BRIVIACT TAB 100MG 5 MO
BRIVIACT TAB 10MG 5 MO
BRIVIACT TAB 25MG 5 MO
BRIVIACT TAB 50MG 5 MO
BRIVIACT TAB 75MG 5 MO
EPIDIOLEX SOL 100MG/ML 5 MO
levetiracetam oral soln 100 mg/ml 2 CG; MO
levetiracetam tab 1000 mg 1 CG; MO
levetiracetam tab 250 mg 1 CG; MO
levetiracetam tab 500 mg 1 CG; MO
levetiracetam tab 750 mg 1 CG; MO
levetiracetam tab er 500 mg 2 CG; MO
levetiracetam tab er 750 mg 2 CG; MO
SPRITAM TAB 1000MG 4 MO
SPRITAM TAB 250MG 4 MO
SPRITAM TAB 500MG 4 MO
SPRITAM TAB 750MG 4 MO
Calcium Channel Modifying Agents
CELONTIN CAP 300MG 4 MO
ethosuximide cap 250 mg 2 CG; MO
ethosuximide soln 250 mg/5ml 2 CG; MO
zonisamide cap 100 mg 2 CG; MO
zonisamide cap 25 mg 2 CG; MO
zonisamide cap 50 mg 2 CG; MO
Gamma-aminobutyric Acid (GABA) Augmenting Agents
clobazam suspension 2.5 mg/ml 5 MO
clobazam tab 10 mg 4 MO
clobazam tab 20 mg 5 MO
DIASTAT ACDL GEL 12.5-20 4 MO
DIASTAT ACDL GEL 5-10MG 4 MO
DIASTAT PED GEL 2.5M GEL 4 MO
diazepam conc 5 mg/ml 2 CG; MO
DIAZEPAM GEL 10MG 4 MO
DIAZEPAM GEL 2.5MG 4 MO
DIAZEPAM GEL 20MG 4 MO
diazepam oral soln 1 mg/ml 2 CG; MO
diazepam tab 10 mg 1 CG; MO
You can find information on what the symbols and abbreviations on this table mean by going to page V.
20
DRUG NAME TIER REQUIREMENTS/LIMITS
diazepam tab 2 mg 1 CG; MO
diazepam tab 5 mg 1 CG; MO
gabapentin cap 100 mg 1 CG; MO
gabapentin cap 300 mg 1 CG; MO
gabapentin cap 400 mg 1 CG; MO
gabapentin oral soln 250 mg/5ml 2 CG; MO
gabapentin tab 600 mg 1 CG; MO
gabapentin tab 800 mg 1 CG; MO
NAYZILAM SPRAY 5 MG 4 MO; QL 10 PER 30 DAYS
phenobarbital elixir 20 mg/5ml 2 CG; MO
phenobarbital tab 100 mg 2 CG; MO
phenobarbital tab 15 mg 2 CG; MO
phenobarbital tab 16.2 mg 2 CG; MO
phenobarbital tab 30 mg 2 CG; MO
phenobarbital tab 32.4 mg 2 CG; MO
phenobarbital tab 60 mg 2 CG; MO
phenobarbital tab 64.8 mg 2 CG; MO
phenobarbital tab 97.2 mg 2 CG; MO
primidone tab 250 mg 1 CG; MO
primidone tab 50 mg 1 CG; MO
SYMPAZAN MIS 10MG 4 MO; QL 120 PER 30 DAYS
SYMPAZAN MIS 20MG 4 MO; QL 60 PER 30 DAYS
SYMPAZAN MIS 5MG 4 MO; QL 240 PER 30 DAYS
tiagabine hcl tab 12 mg 4 MO
tiagabine hcl tab 16 mg 4 MO
tiagabine hcl tab 2 mg 4 MO
tiagabine hcl tab 4 mg 4 MO
VALTOCO LIQ 15MG 4 MO; QL 10 PER 30 DAYS
VALTOCO LIQ 20MG 4 MO; QL 10 PER 30 DAYS
VALTOCO SPR 10MG 4 MO; QL 10 PER 30 DAYS
VALTOCO SPR 5MG 4 MO; QL 10 PER 30 DAYS
vigabatrin powd pack 500 mg 5 MO
vigabatrin tab 500 mg 5 MO; QL 180 PER 30 DAYS
vigadrone powd pack 500 mg 5 MO; QL 180 PER 30 DAYS
Glutamate Reducing Agents
felbamate susp 600 mg/5ml 5 MO
felbamate tab 400 mg 4 MO
felbamate tab 600 mg 4 MO
FYCOMPA SUS 0.5MG/ML 4 MO
FYCOMPA TAB 10MG 4 MO
You can find information on what the symbols and abbreviations on this table mean by going to page V.
21
DRUG NAME TIER REQUIREMENTS/LIMITS
FYCOMPA TAB 12MG 4 MO
FYCOMPA TAB 2MG 4 MO
FYCOMPA TAB 4MG 4 MO
FYCOMPA TAB 6MG 4 MO
FYCOMPA TAB 8MG 4 MO
TOPIRAMATE CAP ER 100MG 4 MO
TOPIRAMATE CAP ER 150MG 4 MO
TOPIRAMATE CAP ER 200MG 4 MO
TOPIRAMATE CAP ER 25MG 4 MO
TOPIRAMATE CAP ER 50MG 4 MO
topiramate sprinkle cap 15 mg 2 CG; MO
topiramate sprinkle cap 25 mg 2 CG; MO
XCOPRI PAK 12.5MG-25MG 4 MO
XCOPRI PAK 150MG-200MG 5 MO
XCOPRI PAK 50MG-100MG 5 MO
XCOPRI TAB 100MG 4 MO
XCOPRI TAB 150MG 4 MO
XCOPRI TAB 200MG 5 MO
XCOPRI TAB 50MG-200MG 5 MO
XCOPRI TAB 50MG 4 MO
Sodium Channel Agents
APTIOM TAB 200MG 4 MO
APTIOM TAB 400MG 5 MO
APTIOM TAB 600MG 5 MO
APTIOM TAB 800MG 5 MO
BANZEL SUS 40MG/ML 5 MO
BANZEL TAB 200MG 5 MO
BANZEL TAB 400MG 5 MO
carbamazepine cap er 100 mg 2 CG; MO
carbamazepine cap er 200 mg 2 CG; MO
carbamazepine cap er 300 mg 2 CG; MO
carbamazepine chew tab 100 mg 2 CG; MO
carbamazepine susp 100 mg/5ml 2 CG; MO
carbamazepine tab 200 mg 1 CG; MO
carbamazepine tab er 100 mg 2 CG; MO
carbamazepine tab er 200 mg 2 CG; MO
carbamazepine tab er 400 mg 2 CG; MO
dilantin cap 30 mg 4 MO
You can find information on what the symbols and abbreviations on this table mean by going to page V.
22
DRUG NAME TIER REQUIREMENTS/LIMITS
epitol tab 200 mg 1 CG; MO
FINTEPLA SOL 2.2MG/ML 5 MO
oxcarbazepine susp 300 mg/5ml 4 MO
oxcarbazepine tab 150 mg 1 CG; MO
oxcarbazepine tab 300 mg 1 CG; MO
oxcarbazepine tab 600 mg 1 CG; MO
PEGANONE TAB 250MG 4 MO
phenytoin chew tab 50 mg 2 CG; MO
phenytoin sodium extended cap 100 mg 1 CG; MO
phenytoin sodium extended cap 200 mg 2 CG; MO
phenytoin sodium extended cap 300 mg 2 CG; MO
phenytoin susp 125 mg/5ml 2 CG; MO
VIMPAT SOL 10MG/ML 4 MO
VIMPAT TAB 100MG 4 MO
VIMPAT TAB 150MG 4 MO
VIMPAT TAB 200MG 4 MO
VIMPAT TAB 50MG 4 MO
ANTIDEMENTIA AGENTS
Antidementia Agents, Other
ergoloid mesylates tab 1 mg 3 MO
Cholinesterase Inhibitors
donepezil hydrochloride odt tab 10 mg 1 CG; MO
donepezil hydrochloride odt tab 5 mg 1 CG; MO
donepezil hydrochloride tab 10 mg 1 CG; MO
donepezil hydrochloride tab 23 mg 2 CG; MO
donepezil hydrochloride tab 5 mg 1 CG; MO
galantamine hydrobromide cap er 16 mg 2 CG; MO
galantamine hydrobromide cap er 24 mg 2 CG; MO
galantamine hydrobromide cap er 8 mg 2 CG; MO
galantamine hydrobromide oral soln 4 mg/ml 4 MO
galantamine hydrobromide tab 12 mg 2 CG; MO
galantamine hydrobromide tab 4 mg 2 CG; MO
galantamine hydrobromide tab 8 mg 2 CG; MO
rivastigmine tartrate cap 1.5 mg 2 CG; MO
rivastigmine tartrate cap 3 mg 2 CG; MO
rivastigmine tartrate cap 4.5 mg 2 CG; MO
rivastigmine tartrate cap 6 mg 2 CG; MO
rivastigmine td patch 24hr 13.3 mg/24hr 3 MO
rivastigmine td patch 24hr 4.6 mg/24hr 3 MO
rivastigmine td patch 24hr 9.5 mg/24hr 3 MO
You can find information on what the symbols and abbreviations on this table mean by going to page V.
23
DRUG NAME TIER REQUIREMENTS/LIMITS
N-methyl-D-aspartate (NMDA) Receptor Antagonist
memantine hcl cap er 14 mg 3 MO; QL 30 PER 30 DAYS
memantine hcl cap er 21 mg 3 MO; QL 30 PER 30 DAYS
memantine hcl cap er 28 mg 3 MO; QL 30 PER 30 DAYS
memantine hcl cap er 7 mg 3 MO; QL 30 PER 30 DAYS
memantine hcl oral solution 2 mg/ml 2 CG; MO
memantine hcl tab 10 mg 1 CG; MO
memantine hcl tab 5 mg 1 CG; MO
memantine hcl tab 5 mg (28) & 10 mg (21) titration pak 2 CG; MO
NAMENDA XR CAP TITRATION 3 MO; QL 56 PER 365 DAYS
ANTIDEPRESSANTS
Antidepressants, Other
APLENZIN TAB 174MG 5 MO; QL 30 PER 30 DAYS
APLENZIN TAB 348MG 5 MO; QL 30 PER 30 DAYS
APLENZIN TAB 522MG 5 MO; QL 30 PER 30 DAYS
BUPROPION TAB 450MG XL 3 MO; QL 30 PER 30 DAYS
bupropion hcl tab 100 mg 1 CG; MO
bupropion hcl tab 75 mg 1 CG; MO
bupropion hcl tab er 100 mg 1 CG; MO; QL 90 PER 30 DAYS
bupropion hcl tab er 12hr 200 mg 1 CG; MO; QL 90 PER 30 DAYS
bupropion hcl tab er 150 mg 1 CG; MO; QL 90 PER 30 DAYS
bupropion hcl tab er 150 mg xl 2 CG; MO; QL 90 PER 30 DAYS
bupropion hcl tab er 300 mg 1 CG; MO; QL 30 PER 30 DAYS
chlordiazepoxide-amitriptyline tab 10-25 mg 2 CG; MO
chlordiazepoxide-amitriptyline tab 5-12.5 mg 2 CG; MO
FORFIVO XL TAB 450MG 3 MO; QL 30 PER 30 DAYS
mirtazapine odt tab 15 mg 2 CG; MO
mirtazapine odt tab 30 mg 2 CG; MO
mirtazapine odt tab 45 mg 2 CG; MO
mirtazapine tab 15 mg 1 CG; MO
mirtazapine tab 30 mg 1 CG; MO
mirtazapine tab 45 mg 1 CG; MO
mirtazapine tab 7.5 mg 2 CG; MO
olanzapine-fluoxetine hcl cap 12-25 mg 4 MO; QL 30 PER 30 DAYS
olanzapine-fluoxetine hcl cap 12-50 mg 4 MO; QL 30 PER 30 DAYS
olanzapine-fluoxetine hcl cap 3-25 mg 4 MO; QL 90 PER 30 DAYS
olanzapine-fluoxetine hcl cap 6-25 mg 4 MO; QL 90 PER 30 DAYS
olanzapine-fluoxetine hcl cap 6-50 mg 4 MO; QL 30 PER 30 DAYS
perphenazine-amitriptyline tab 2-10 mg 4 MO
perphenazine-amitriptyline tab 2-25 mg 2 CG; MO
You can find information on what the symbols and abbreviations on this table mean by going to page V.
24
DRUG NAME TIER REQUIREMENTS/LIMITS
perphenazine-amitriptyline tab 4-10 mg 2 CG; MO
perphenazine-amitriptyline tab 4-25 mg 2 CG; MO
perphenazine-amitriptyline tab 4-50 mg 2 CG; MO
Monoamine Oxidase Inhibitors
EMSAM DIS 12MG/24H 5 MO; QL 30 PER 30 DAYS
EMSAM DIS 6MG/24HR 5 MO; QL 30 PER 30 DAYS
EMSAM DIS 9MG/24HR 5 MO; QL 30 PER 30 DAYS
MARPLAN TAB 10MG 4 MO
phenelzine sulfate tab 15 mg 2 CG; MO
tranylcypromine sulfate tab 10 mg 4 MO
SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin Norepinephrine Reuptake Inhibitors)
citalopram hydrobromide oral soln 10 mg/5ml 2 CG; MO
citalopram hydrobromide tab 10 mg 1 CG; MO
citalopram hydrobromide tab 20 mg 1 CG; MO
citalopram hydrobromide tab 40 mg 1 CG; MO
DRIZALMA CAP 20 MG DR 4 MO; QL 180 PER 30 DAYS
DRIZALMA CAP 30 MG DR 4 MO; QL 120 PER 30 DAYS
DRIZALMA CAP 40 MG DR 4 MO; QL 90 PER 30 DAYS
DRIZALMA CAP 60 MG DR 4 MO; QL 60 PER 30 DAYS
DESVENLAFAX TAB 100MG ER 4 MO; QL 120 PER 30 DAYS
DESVENLAFAX TAB 50MG ER 2 CG; MO; QL 30 PER 30 DAYS
desvenlafaxine succinate tab er 100 mg 2 CG; MO; QL 120 PER 30 DAYS
desvenlafaxine succinate tab er 25 mg 2 CG; MO; QL 30 PER 30 DAYS
desvenlafaxine succinate tab er 50 mg 2 CG; MO; QL 30 PER 30 DAYS
FETZIMA CAP 120MG 4 MO; QL 30 PER 30 DAYS
FETZIMA CAP 20MG 4 MO; QL 30 PER 30 DAYS
FETZIMA CAP 40MG 4 MO; QL 30 PER 30 DAYS
FETZIMA CAP 80MG 4 MO; QL 30 PER 30 DAYS
FETZIMA CAP TITRATION 4 MO; QL 56 PER 365 DAYS
fluoxetine hcl cap 10 mg 1 CG; MO
fluoxetine hcl cap 20 mg 1 CG; MO
fluoxetine hcl cap 40 mg 1 CG; MO
fluoxetine hcl cap dr 90 mg 2 CG; MO; QL 4 PER 28 DAYS
fluoxetine hcl solution 20 mg/5ml 2 CG; MO
fluoxetine hcl tab 10 mg 2 CG; MO
fluoxetine hcl tab 20 mg 2 CG; MO
fluvoxamine maleate cap er 100 mg 2 CG; MO; QL 60 PER 30 DAYS
fluvoxamine maleate cap er 150 mg 2 CG; MO; QL 60 PER 30 DAYS
fluvoxamine maleate tab 100 mg 2 CG; MO
You can find information on what the symbols and abbreviations on this table mean by going to page V.
25
DRUG NAME TIER REQUIREMENTS/LIMITS
fluvoxamine maleate tab 25 mg 2 CG; MO
fluvoxamine maleate tab 50 mg 2 CG; MO
maprotiline hcl tab 25 mg 2 CG; MO
maprotiline hcl tab 50 mg 2 CG; MO
maprotiline hcl tab 75 mg 2 CG; MO
nefazodone hcl tab 100 mg 1 CG; MO
nefazodone hcl tab 150 mg 4 MO
nefazodone hcl tab 200 mg 1 CG; MO
nefazodone hcl tab 250 mg 1 CG; MO
nefazodone hcl tab 50 mg 1 CG; MO
trazodone hcl tab 100 mg 1 CG; MO
trazodone hcl tab 150 mg 1 CG; MO
trazodone hcl tab 300 mg 2 CG; MO
trazodone hcl tab 50 mg 1 CG; MO
TRINTELLIX TAB 10MG 4 MO; QL 30 PER 30 DAYS
TRINTELLIX TAB 20MG 4 MO; QL 30 PER 30 DAYS
TRINTELLIX TAB 5MG 4 MO; QL 30 PER 30 DAYS
VIIBRYD KIT STARTER 4 MO; QL 60 PER 365 DAYS
VIIBRYD TAB 10MG 4 MO; QL 30 PER 30 DAYS
VIIBRYD TAB 20MG 4 MO; QL 30 PER 30 DAYS
VIIBRYD TAB 40MG 4 MO; QL 30 PER 30 DAYS
Tricyclics
amitriptyline hcl tab 10 mg 1 CG; MO
amitriptyline hcl tab 100 mg 1 CG; MO
amitriptyline hcl tab 150 mg 1 CG; MO
amitriptyline hcl tab 25 mg 1 CG; MO
amitriptyline hcl tab 50 mg 1 CG; MO
amitriptyline hcl tab 75 mg 1 CG; MO
amoxapine tab 100 mg 2 CG; MO
amoxapine tab 150 mg 2 CG; MO
amoxapine tab 25 mg 2 CG; MO
amoxapine tab 50 mg 2 CG; MO
clomipramine hcl cap 25 mg 4 MO
clomipramine hcl cap 50 mg 4 MO
clomipramine hcl cap 75 mg 4 MO
desipramine hcl tab 10 mg 2 CG; MO
desipramine hcl tab 100 mg 2 CG; MO
desipramine hcl tab 150 mg 2 CG; MO
desipramine hcl tab 25 mg 2 CG; MO
desipramine hcl tab 50 mg 2 CG; MO
You can find information on what the symbols and abbreviations on this table mean by going to page V.
26
DRUG NAME TIER REQUIREMENTS/LIMITS
desipramine hcl tab 75 mg 2 CG; MO
imipramine hcl tab 10 mg 1 CG; MO
imipramine hcl tab 25 mg 1 CG; MO
imipramine hcl tab 50 mg 1 CG; MO
imipramine pamoate cap 100 mg 1 CG; MO
imipramine pamoate cap 125 mg 1 CG; MO
imipramine pamoate cap 150 mg 1 CG; MO
imipramine pamoate cap 75 mg 1 CG; MO
nortriptyline hcl cap 10 mg 1 CG; MO
nortriptyline hcl cap 25 mg 1 CG; MO
nortriptyline hcl cap 50 mg 1 CG; MO
nortriptyline hcl cap 75 mg 1 CG; MO
nortriptyline hcl soln 10 mg/5ml 2
CG; MO
protriptyline hcl tab 10 mg 2 CG; MO
protriptyline hcl tab 5 mg 2 CG; MO
trimipramine maleate cap 100 mg 4
MO
trimipramine maleate cap 25 mg 4 MO
trimipramine maleate cap 50 mg 4 MO
ANTIEMETICS
Antiemetics, Other
compro suppos 25 mg 2 CG; MO
meclizine hcl tab 12.5 mg 1 CG; MO
meclizine hcl tab 25 mg 1 CG; MO
metoclopramide hcl odt tab 10 mg 4 MO
prochlorperazine suppos 25 mg 2 CG; MO
promethazine hcl suppos 50 mg 2 CG; MO
scopolamine td patch 72hr 1 mg/3days 1 CG; MO; QL 10 PER 30 DAYS
trimethobenzamide hcl cap 300 mg 2 CG; MO; B/D PA
Emetogenic Therapy Adjuncts
aprepitant capsule 125 mg 2
CG; MO; QL 2 PER 30
DAYS; B/D PA aprepitant capsule 40 mg
2 CG; MO; QL 1 PER 30
DAYS; B/D PA aprepitant capsule 80 mg
2 CG; MO; QL 8 PER 30
DAYS; B/D PA aprepitant capsule therapy pack 80 & 125 mg
2 CG; MO; QL 6 PER 30
DAYS; B/D PA
You can find information on what the symbols and abbreviations on this table mean by going to page V.
27
DRUG NAME TIER REQUIREMENTS/LIMITS
dronabinol cap 10 mg 4
MO; QL 60 PER 30 DAYS;
B/D PA dronabinol cap 2.5 mg
4 MO; QL 60 PER 30 DAYS;
B/D PA dronabinol cap 5 mg
4 MO; QL 60 PER 30 DAYS;
B/D PA EMEND SUS 125MG
4 MO; QL 6 PER 30 DAYS;
B/D PA granisetron hcl tab 1 mg
2 CG; MO; QL 30 PER 30
DAYS; B/D PA ondansetron hcl oral soln 4 mg/5ml
2 CG; MO; QL 450 PER 30 DAYS; B/D PA
ondansetron hcl tab 24 mg 2 QL 14 PER 28 DAYS; B/D PA
ondansetron hcl tab 4 mg 2 CG; MO; B/D PA
ondansetron hcl tab 8 mg 2 CG; MO; B/D PA
ondansetron odt tab 4 mg 1 CG; MO; B/D PA
ondansetron odt tab 8 mg 1 CG; MO; B/D PA
SANCUSO DIS 3.1MG 5 MO; QL 2 PER 30 DAYS
ANTIFUNGALS
Antifungals
ABELCET INJ 5MG/ML 5 HI; MO; B/D PA
AMBISOME INJ 50MG 5 MO; B/D PA
amphotericin b for iv soln 50 mg 4 MO; B/D PA
caspofungin acetate for iv soln 50 mg 3 HI; MO
caspofungin acetate for iv soln 70 mg 3 HI; MO
ciclopirox gel 0.77% 2 CG; MO
ciclopirox olamine cream 0.77% 2 CG; MO
ciclopirox olamine susp 0.77% 2 CG; MO
ciclopirox shampoo 1% 2 CG; MO
ciclopirox solution 8% 2 CG; MO; PA
clotrimazole cream 1% 1 CG; MO
clotrimazole soln 1% 2 CG; MO
clotrimazole troche 10 mg 2 CG; MO
CRESEMBA CAP 186 MG 5 MO
econazole nitrate cream 1% 2 CG; MO
ERAXIS INJ 100MG 5 HI; MO
ERAXIS INJ 50MG 4 HI; MO
fluconazole for susp 10 mg/ml 2 CG; MO
fluconazole for susp 40 mg/ml 2 CG; MO
fluconazole in nacl 0.9% inj 200 mg/100ml 2 CG; HI; MO
fluconazole in nacl 0.9% inj 400 mg/200ml 2 CG; HI; MO
You can find information on what the symbols and abbreviations on this table mean by going to page V.
28
DRUG NAME TIER REQUIREMENTS/LIMITS
fluconazole tab 100 mg 1 CG; MO
fluconazole tab 150 mg 1 CG; MO
fluconazole tab 200 mg 1 CG; MO
fluconazole tab 50 mg 1 CG; MO
flucytosine cap 250 mg 5 MO
flucytosine cap 500 mg 5 MO
griseofulvin microsize susp 125 mg/5ml 2 CG; MO
griseofulvin microsize tab 500 mg 4 MO
griseofulvin ultramicrosize tab 125 mg 4 MO
griseofulvin ultramicrosize tab 250 mg 4 MO
itraconazole cap 100 mg 4 MO; PA
itraconazole oral soln 10 mg/ml 3 MO; PA
ketoconazole cream 2% 2 CG; MO
ketoconazole foam 2% 4 MO
ketoconazole shampoo 2% 1 CG; MO
ketoconazole tab 200 mg 2 CG; MO
MENTAX CRE 1% 4 MO
micafungin inj 100mg 5 HI; MO
miconazole nitrate vaginal suppos 200 mg 2 CG; MO
MYCAMINE INJ 50MG 4 HI; MO
naftifine hcl cream 1% 4 MO
naftifine hcl cream 2% 4 MO
NAFTIN GEL 1% 4 MO
NAFTIN GEL 2% 4 MO
NATACYN SUS 5% OP 4 MO
NOXAFIL SUS 40MG/ML 5 MO
NOXAFIL TAB 100MG 5 MO
nyamyc powder 100000 unit/gm 2 CG; MO
nystatin cream 100000 unit/gm 2 CG; MO
nystatin oint 100000 unit/gm 2 CG; MO
nystatin susp 100000 unit/ml 1 CG; MO
nystatin tab 500000 unit 2 CG; MO
nystatin topical powder 100000 unit/gm 2 CG; MO
nystatin-triamcinolone cream 100000-0.1 unit/gm-% 2 CG; MO
nystatin-triamcinolone oint 100000-0.1 unit/gm-% 2 CG; MO
nystop powder 100000 unit/gm 2 CG; MO
oxiconazole nitrate cream 1% 2 CG; MO
OXISTAT LOT 1% 4 MO
posaconazole tab 100 mg dr 5 MO
terbinafine hcl tab 250 mg 1 CG; MO; QL 84 PER 180
You can find information on what the symbols and abbreviations on this table mean by going to page V.
29
DRUG NAME TIER REQUIREMENTS/LIMITS
DAYS
terconazole vaginal cream 0.4% 2 CG; MO
terconazole vaginal cream 0.8% 2 CG; MO
terconazole vaginal suppos 80 mg 2 CG; MO
voriconazole for inj 200 mg 4 HI; MO
voriconazole for susp 40 mg/ml 5 MO
voriconazole tab 200 mg 4 MO
voriconazole tab 50 mg 4 MO
ANTIGOUT AGENTS
Antigout Agents
allopurinol tab 300 mg 1 CG; MO
COLCHICINE TAB0.6MG 3 MO
COLCRYS TAB 0.6MG 3 MO
febuxostat tab 40 mg 3 MO
febuxostat tab 80 mg 3 MO
probenecid tab 500 mg 2 CG; MO
probenecid/colchicine tab 0.5-500 mg 2 CG; MO
ULORIC TAB 40MG 3 MO; ST
ULORIC TAB 80MG 3 MO; ST
ANTI-INFLAMMATORY AGENTS
Nonsteroidal Anti-inflammatory Drugs
celecoxib cap 100 mg 2 CG; MO; QL 60 PER 30 DAYS
celecoxib cap 200 mg 2 CG; MO; QL 60 PER 30 DAYS
celecoxib cap 400 mg 2 CG; MO; QL 60 PER 30 DAYS
celecoxib cap 50 mg 2 CG; MO; QL 60 PER 30 DAYS
diclofenac potassium tab 50 mg 2 CG; MO
diclofenac sodium tab dr 25 mg 2 CG; MO
diclofenac sodium tab dr 50 mg 1 CG; MO
diclofenac sodium tab dr 75 mg 1 CG; MO
diclofenac sodium tab er 100 mg 2 CG; MO
diclofenac w/ misoprostol tab delayed release 50-0.2 mg 4 MO
diclofenac w/ misoprostol tab delayed release 75-0.2 mg 4 MO
diflunisal tab 500 mg 2 CG; MO
etodolac cap 200 mg 2 CG; MO
etodolac cap 300 mg 2 CG; MO
etodolac tab 400 mg 2 CG; MO
etodolac tab 500 mg 2 CG; MO
etodolac tab er 400 mg 2 CG; MO
etodolac tab er 500 mg 2 CG; MO
etodolac tab er 600 mg 2 CG; MO
You can find information on what the symbols and abbreviations on this table mean by going to page V.
30
DRUG NAME TIER REQUIREMENTS/LIMITS
FENOPROFEN CAP 400MG 4 MO
fenoprofen calcium tab 600 mg 4 MO
flurbiprofen tab 100 mg 1 CG; MO
ibuprofen susp 100 mg/5ml 2 CG; MO
ibuprofen tab 400 mg 1 CG; MO
ibuprofen tab 600 mg 1 CG; MO
ibuprofen tab 800 mg 1 CG; MO
indomethacin cap 25 mg 1 CG; MO
indomethacin cap 50 mg 1 CG; MO
indomethacin cap er 75 mg 1 CG; MO
ketoprofen cap er 200 mg 4 MO
ketorolac tromethamine tab 10 mg 1 CG; MO; QL 20 PER 30 DAYS
lodine tab 400 mg 2 CG; MO
meclofenamate sodium cap 100 mg 4 MO
meclofenamate sodium cap 50 mg 4 MO
mefenamic acid cap 250 mg 4 MO
meloxicam tab 15 mg 1 CG; MO
meloxicam tab 7.5 mg 1 CG; MO
nabumetone tab 500 mg 1 CG; MO
nabumetone tab 750 mg 1 CG; MO
naproxen sodium tab 275 mg 2 CG; MO
naproxen sodium tab 550 mg 2 CG; MO
naproxen susp 125 mg/5ml 2 CG; MO
naproxen tab 250 mg 1 CG; MO
naproxen tab 375 mg 1 CG; MO
naproxen tab 500 mg 1 CG; MO
naproxen tab ec 375 mg 1 CG; MO
naproxen tab ec 500 mg 1 CG; MO
oxaprozin tab 600 mg 2 CG; MO
piroxicam cap 10 mg 2 CG; MO
piroxicam cap 20 mg 2 CG; MO
sulindac tab 150 mg 1 CG; MO
sulindac tab 200 mg 1 CG; MO
tolmetin sodium cap 400 mg 2 CG; MO
tolmetin sodium tab 600 mg 2 CG; MO
ZIPSOR CAP 25MG 4 MO
ANTIMIGRAINE AGENTS
Antimigraine Agents
AIMOVIG INJ 140MG/ML 4 MO; PA
AIMOVIG INJ 70MG/ML 4 MO; PA
You can find information on what the symbols and abbreviations on this table mean by going to page V.
31
DRUG NAME TIER REQUIREMENTS/LIMITS
AJOVY INJ 225/1.5 4 MO; QL 4.5 PER 90 DAYS; PA
EMGALITY INJ 100MG/ML 4 MO; PA
EMGALITY INJ 120MG/ML 4 MO; PA
NURTEC TAB 75MG ODT 5 MO; QL 8 PER 30 DAYS; ST
UBRELVY TAB 100MG 4 MO; QL 16 PER 30 DAYS; ST
UBRELVY TAB 50MG 4 MO; QL 16 PER 30 DAYS; ST
Ergot Alkaloids
cafergot tab 1-100 mg 2 CG; MO
DIHYDROERGOT SPR 4MG/ML 5 MO; QL 8 PER 30 DAYS
ergotamine w/ caffeine tab 1-100 mg 2 CG; MO
migergot suppos 2-100 mg 4 MO
Prophylactic
timolol maleate tab 10 mg 2 CG; MO
timolol maleate tab 20 mg 2 CG; MO
timolol maleate tab 5 mg 2 CG; MO
topiramate tab 100 mg 1 CG; MO
topiramate tab 200 mg 1 CG; MO
topiramate tab 25 mg 1 CG; MO
topiramate tab 50 mg 1 CG; MO
Serotonin (5-HT) 1b/1d Receptor Agonists
almotriptan malate tab 12.5 mg 4 MO; QL 12 PER 30 DAYS
almotriptan malate tab 6.25 mg 4 MO; QL 12 PER 30 DAYS
frovatriptan succinate tab 2.5 mg 4 MO; QL 12 PER 30 DAYS
naratriptan hcl tab 1 mg 2 CG; MO; QL 9 PER 30 DAYS
naratriptan hcl tab 2.5 mg 2 CG; MO; QL 9 PER 30 DAYS
REYVOW TAB 100MG 4 MO; QL 8 PER 30 DAYS
REYVOW TAB 50MG 4 MO; QL 4 PER 30 DAYS
rizatriptan benzoate odt tab 10 mg 2 CG; MO; QL 18 PER 30 DAYS
rizatriptan benzoate odt tab 5 mg 2 CG; MO; QL 18 PER 30 DAYS
rizatriptan benzoate tab 10 mg 2 CG; MO; QL 18 PER 30 DAYS
rizatriptan benzoate tab 5 mg 2 CG; MO; QL 18 PER 30 DAYS
sumatriptan nasal spray 20 mg/act 4 MO; QL 12 PER 30 DAYS
sumatriptan nasal spray 5 mg/act 4 MO; QL 12 PER 30 DAYS
sumatriptan succinate inj 6 mg/0.5ml 4 MO; QL 5 PER 30 DAYS
sumatriptan succinate solution auto-injector 4 mg/0.5ml 4 MO; QL 8 PER 30 DAYS
sumatriptan succinate solution auto-injector 6 mg/0.5ml 4 MO; QL 5 PER 30 DAYS
sumatriptan succinate solution cartridge 4 mg/0.5ml 4 MO; QL 8 PER 30 DAYS
sumatriptan succinate tab 100 mg 1 CG; MO; QL 9 PER 30 DAYS
sumatriptan succinate tab 25 mg 1 CG; MO; QL 9 PER 30 DAYS
sumatriptan succinate tab 50 mg 1 CG; MO; QL 9 PER 30 DAYS
You can find information on what the symbols and abbreviations on this table mean by going to page V.
32
DRUG NAME TIER REQUIREMENTS/LIMITS
zolmitriptan odt tab 2.5 mg 2 CG; MO; QL 12 PER 30 DAYS
zolmitriptan odt tab 5 mg 2 CG; MO; QL 9 PER 30 DAYS
zolmitriptan tab 2.5 mg 2 CG; MO; QL 12 PER 30 DAYS
zolmitriptan tab 5 mg 2 CG; MO; QL 12 PER 30 DAYS
ANTIMYASTHENIC AGENTS
Parasympathomimetics
FIRDAPSE TAB 10 MG 5 MO; QL 240 PER 30 DAYS; PA
GUANIDINE TAB 125MG 4 MO
MESTINON SYP 60MG/5ML 5 MO
pyridostigmine bromide tab 60 mg 2 CG; MO
pyridostigmine bromide tab er 180 mg 4 MO
RUZURGI TAB 10 MG 5 MO; QL 300 PER 30 DAYS; PA
ANTIMYCOBACTERIALS
Antimycobacterials, Other
dapsone tab 100 mg 2 CG; MO
dapsone tab 25 mg 2 CG; MO
paser granules packet 4 gm 4 MO
rifabutin cap 150 mg 2 CG; MO
Antituberculars
ethambutol hcl tab 100 mg 2 CG; MO
ethambutol hcl tab 400 mg 2 CG; MO
isoniazid syrup 50 mg/5ml 4 MO
isoniazid tab 100 mg 1 CG; MO
isoniazid tab 300 mg 1 CG; MO
PRETOMANID TAB 200MG 4 MO; QL 26 PER 26 DAYS; PA
PRIFTIN TAB 150MG 4 MO
pyrazinamide tab 500 mg 2 CG; MO
rifampin cap 150 mg 2 CG; MO
rifampin cap 300 mg 2 CG; MO
rifampin inj 600 mg 4 HI; MO
SIRTURO TAB 100MG 5 MO
TRECATOR TAB 250MG 4 MO
ANTINEOPLASTICS
Alkylating Agents
CYCLOPHOSPH CAP 25MG 3 MO; B/D PA
CYCLOPHOSPH CAP 50MG 3 MO; B/D PA
GLEOSTINE CAP 100MG 4 MO
GLEOSTINE CAP 10MG 4 MO
GLEOSTINE CAP 40MG 4 MO
LEUKERAN TAB 2MG 4 MO
You can find information on what the symbols and abbreviations on this table mean by going to page V.
33
DRUG NAME TIER REQUIREMENTS/LIMITS
MATULANE CAP 50MG 5 MO
VALCHLOR GEL 0.016% 5 MO
Antiandrogens
abiraterone acetate tab 250 mg 5 MO
bicalutamide tab 50 mg 1 CG; MO
ERLEADA TAB 60MG 5 MO; QL 120 PER 30 DAYS
flutamide cap 125 mg 2 CG; MO
NUBEQA TAB 300MG 5 MO; QL 120 PER 30 DAYS
nilutamide tab 150 mg 5 MO
XTANDI CAP 40MG 5 MO
YONSA TAB 125MG 5 MO; QL 120 PER 30 DAYS
ZYTIGA TAB 500MG 5 MO
Antiangiogenic Agents
POMALYST CAP 1MG 5 MO
POMALYST CAP 2MG 5 MO
POMALYST CAP 3MG 5 MO
POMALYST CAP 4MG 5 MO
REVLIMID CAP 10MG 5 MO
REVLIMID CAP 15MG 5 MO
REVLIMID CAP 2.5MG 5 MO
REVLIMID CAP 20MG 5 MO
REVLIMID CAP 25MG 5 MO
REVLIMID CAP 5MG 5 MO
THALOMID CAP 100MG 5 MO
THALOMID CAP 150MG 5 MO
THALOMID CAP 200MG 5 MO
THALOMID CAP 50MG 5 MO
Antiestrogens/Modifiers
EMCYT CAP 140MG 5 MO
SOLTAMOX SOL 10MG/5ML 4 MO
tamoxifen citrate tab 10 mg 1 CG; MO
tamoxifen citrate tab 20 mg 1 CG; MO
toremifene citrate tab 60 mg 5 MO; QL 30 PER 30 DAYS
Antimetabolites
DROXIA CAP 200MG 4 MO
DROXIA CAP 300MG 4 MO
DROXIA CAP 400MG 4 MO
hydroxyurea cap 500 mg 1 CG; MO
PURIXAN SUS 20MG/ML 5 MO
SIKLOS TAB 1000MG 4 MO
You can find information on what the symbols and abbreviations on this table mean by going to page V.
34
DRUG NAME TIER REQUIREMENTS/LIMITS
SIKLOS TAB 100MG 4 MO
TABLOID TAB 40MG 4 MO
Antineoplastics, Other
INQOVI TAB 35-100MG 5 MO
KISQALI 200 PAK FEMARA 5 MO; QL 49 PER 28 DAYS
KISQALI 400 PAK FEMARA 5 MO; QL 70 PER 28 DAYS
KISQALI 600 PAK FEMARA 5 MO; QL 91 PER 28 DAYS
leucovorin calcium tab 10 mg 2 CG; MO
leucovorin calcium tab 15 mg 2 CG; MO
leucovorin calcium tab 25 mg 2 CG; MO
leucovorin calcium tab 5 mg 1 CG; MO
LONSURF TAB 15-6.14 5 MO; QL 100 PER 28 DAYS
LONSURF TAB 20-8.19 5 MO; QL 80 PER 28 DAYS
NINLARO CAP 2.3MG 5 MO
NINLARO CAP 3MG 5 MO
NINLARO CAP 4MG 5 MO
RUBRACA TAB 200MG 5 MO; QL 120 PER 30 DAYS
RUBRACA TAB 250MG 5 MO; QL 120 PER 30 DAYS
RUBRACA TAB 300MG 5 MO; QL 120 PER 30 DAYS
SYNRIBO INJ 3.5MG 5 MO
TALZENNA CAP 0.25MG 5 MO; QL 120 PER 30 DAYS
TALZENNA CAP 1MG 5 MO; QL 30 PER 30 DAYS
VERZENIO TAB 100MG 5 MO; QL 112 PER 28 DAYS
VERZENIO TAB 150MG 5 MO; QL 56 PER 28 DAYS
VERZENIO TAB 200MG 5 MO; QL 56 PER 28 DAYS
VERZENIO TAB 50MG 5 MO; QL 224 PER 28 DAYS
XPOVIO PAK 40MG (TWICE WEEKLY) 5 MO; QL 16 PER 28 DAYS
XPOVIO PAK 40MG (ONCE WEEKLY) 5 MO; QL 8 PER 28 DAYS
XPOVIO PAK 100MG 5 MO; QL 20 PER 28 DAYS
XPOVIO PAK 60MG (ONCE WEEKLY) 5 MO; QL 12 PER 28 DAYS
XPOVIO PAK 60MG (TWICE WEEKLY) 5 MO; QL 24 PER 28 DAYS
XPOVIO PAK 80MG 5 MO; QL 32 PER 28 DAYS
ZOLINZA CAP 100MG 5 MO
Aromatase Inhibitors, 3rd Generation
anastrozole tab 1 mg 1 CG; MO
exemestane tab 25 mg 4 MO
letrozole tab 2.5 mg 1 CG; MO
Molecular Target Inhibitors
AFINITOR TAB 10MG 5 MO; QL 30 PER 30 DAYS
AFINITOR TAB 2.5MG 5 MO; QL 30 PER 30 DAYS
You can find information on what the symbols and abbreviations on this table mean by going to page V.
35
DRUG NAME TIER REQUIREMENTS/LIMITS
AFINITOR TAB 5MG 5 MO; QL 30 PER 30 DAYS
AFINITOR TAB 7.5MG 5 MO; QL 30 PER 30 DAYS
AFINITOR DIS TAB 2MG 5 MO
AFINITOR DIS TAB 3MG 5 MO
AFINITOR DIS TAB 5MG 5 MO
ALECENSA CAP 150MG 5 MO; QL 240 PER 30 DAYS
ALUNBRIG PAK 5 MO; QL 30 PER 30 DAYS
ALUNBRIG TAB 180MG 5 MO; QL 30 PER 30 DAYS
ALUNBRIG TAB 30MG 5 MO; QL 180 PER 30 DAYS
ALUNBRIG TAB 90MG 5 MO; QL 60 PER 30 DAYS
AYVAKIT TAB 100MG 5 MO
AYVAKIT TAB 200MG 5 MO
AYVAKIT TAB 300MG 5 MO
BALVERSA TAB 3MG 5 MO; QL 84 PER 28 DAYS
BALVERSA TAB 4MG 5 MO; QL 56 PER 28 DAYS
BALVERSA TAB 5MG 5 MO; QL 28 PER 28 DAYS
BOSULIF TAB 100MG 5 MO
BOSULIF TAB 400MG 5 MO
BOSULIF TAB 500MG 5 MO
BRAFTOVI CAP 75MG 5 MO; QL 180 PER 30 DAYS
BRUKINSA CAP 80MG 5 MO; QL 120 PER 30 DAYS
CABOMETYX TAB 20MG 5 MO
CABOMETYX TAB 40MG 5 MO
CABOMETYX TAB 60MG 5 MO
CALQUENCE CAP 100MG 5 MO; QL 60 PER 30 DAYS
CAPRELSA TAB 100MG 5 MO; QL 60 PER 30 DAYS
CAPRELSA TAB 300MG 5 MO
COMETRIQ KIT 100MG 5 MO
COMETRIQ KIT 140MG 5 MO
COMETRIQ KIT 60MG 5 MO
COPIKTRA CAP 15MG 5 MO; QL 56 PER 28 DAYS
COPIKTRA CAP 25MG 5 MO; QL 56 PER 28 DAYS
COTELLIC TAB 20MG 5 MO; QL 90 PER 30 DAYS
DAURISMO TAB 100MG 5 MO; QL 30 PER 30 DAYS
DAURISMO TAB 25MG 5 MO; QL 120 PER 30 DAYS
ERIVEDGE CAP 150MG 5 MO
erlotinib hcl tab 100 mg 5 MO; QL 30 PER 30 DAYS
erlotinib hcl tab 150 mg 5 MO; QL 30 PER 30 DAYS
erlotinib hcl tab 25 mg 5 MO; QL 90 PER 30 DAYS
everolimus tab 2.5mg 5 MO; QL 30 PER 30 DAYS
You can find information on what the symbols and abbreviations on this table mean by going to page V.
36
DRUG NAME TIER REQUIREMENTS/LIMITS
everolimus tab 5mg 5 MO; QL 30 PER 30 DAYS
everolimus tab 7.5mg 5 MO; QL 30 PER 30 DAYS
FARYDAK CAP 10MG 5 MO; QL 6 PER 21 DAYS
FARYDAK CAP 20MG 5 MO; QL 6 PER 21 DAYS
GILOTRIF TAB 20MG 5 MO; QL 30 PER 30 DAYS
GILOTRIF TAB 30MG 5 MO; QL 30 PER 30 DAYS
GILOTRIF TAB 40MG 5 MO; QL 30 PER 30 DAYS
IBRANCE CAP 100MG 5 MO
IBRANCE CAP 125MG 5 MO
IBRANCE CAP 75MG 5 MO
IBRANCE TAB 100MG 5 MO
IBRANCE TAB 125MG 5 MO
IBRANCE TAB 75MG 5 MO
ICLUSIG TAB 15MG 5 MO; QL 60 PER 30 DAYS
ICLUSIG TAB 45MG 5 MO
IDHIFA TAB 100MG 5 MO; QL 30 PER 30 DAYS
IDHIFA TAB 50MG 5 MO; QL 60 PER 30 DAYS
imatinib mesylate tab 100 mg 5 MO
imatinib mesylate tab 400 mg 5 MO
IMBRUVICA CAP 140MG 5 MO
IMBRUVICA CAP 70MG 5 MO; QL 240 PER 30 DAYS
IMBRUVICA TAB 140MG 5 MO; QL 120 PER 30 DAYS
IMBRUVICA TAB 280MG 5 MO; QL 60 PER 30 DAYS
IMBRUVICA TAB 420MG 5 MO; QL 30 PER 30 DAYS
IMBRUVICA TAB 560MG 5 MO; QL 30 PER 30 DAYS
INLYTA TAB 1MG 5 MO
INLYTA TAB 5MG 5 MO
INREBIC CAP 100MG 5 MO; QL 120 PER 30 DAYS
IRESSA TAB 250MG 5 MO
JAKAFI TAB 10MG 5 MO; QL 60 PER 30 DAYS
JAKAFI TAB 15MG 5 MO; QL 60 PER 30 DAYS
JAKAFI TAB 20MG 5 MO; QL 60 PER 30 DAYS
JAKAFI TAB 25MG 5 MO; QL 60 PER 30 DAYS
JAKAFI TAB 5MG 5 MO; QL 60 PER 30 DAYS
KISQALI TAB 200DOSE 5 MO; QL 63 PER 28 DAYS
KISQALI TAB 400DOSE 5 MO; QL 63 PER 28 DAYS
KISQALI TAB 600DOSE 5 MO; QL 63 PER 28 DAYS
KOSELUGO CAP 10MG 5 MO
KOSELUGO CAP 25MG 5 MO
LENVIMA CAP 10 MG 5 MO
You can find information on what the symbols and abbreviations on this table mean by going to page V.
37
DRUG NAME TIER REQUIREMENTS/LIMITS
LENVIMA CAP 12MG 5 MO
LENVIMA CAP 14 MG 5 MO
LENVIMA CAP 18 MG 5 MO
LENVIMA CAP 20 MG 5 MO
LENVIMA CAP 24 MG 5 MO
LENVIMA CAP 4MG 5 MO
LENVIMA CAP 8MG 5 MO
LORBRENA TAB 100MG 5 MO; QL 30 PER 30 DAYS
LORBRENA TAB 25MG 5 MO; QL 120 PER 30 DAYS
LYNPARZA TAB 100MG 5 MO; QL 180 PER 30 DAYS
LYNPARZA TAB 150MG 5 MO; QL 120 PER 30 DAYS
MEKINIST TAB 0.5MG 5 MO
MEKINIST TAB 2MG 5 MO
MEKTOVI TAB 15MG 5 MO; QL 180 PER 30 DAYS
NERLYNX TAB 40MG 5 MO; QL 180 PER 30 DAYS
NEXAVAR TAB 200MG 5 MO
ODOMZO CAP 200MG 5 MO
PEMAZYRE TAB 13.5MG 5 MO; QL 30 PER 30 DAYS
PEMAZYRE TAB 4.5MG 5 MO; QL 30 PER 30 DAYS
PEMAZYRE TAB 9MG 5 MO; QL 30 PER 30 DAYS
PIQRAY 200MG TAB DOSE 5 MO; QL 28 PER 28 DAYS
PIQRAY 250MG TAB DOSE 5 MO; QL 56 PER 28 DAYS
PIQRAY 300MG TAB DOSE 5 MO; QL 56 PER 28 DAYS
QINLOCK TAB 50MG 5 MO
RETEVMO CAP 40MG 5 MO
RETEVMO CAP 80MG 5 MO
ROZLYTREK CAP 100 MG 5 MO; QL 180 PER 30 DAYS
ROZLYTREK CAP 200 MG 5 MO; QL 90 PER 30 DAYS
RYDAPT CAP 25MG 5 MO; QL 224 PER 28 DAYS
SPRYCEL TAB 100MG 5 MO
SPRYCEL TAB 140MG 5 MO
SPRYCEL TAB 20MG 5 MO
SPRYCEL TAB 50MG 5 MO
SPRYCEL TAB 70MG 5 MO
SPRYCEL TAB 80MG 5 MO
STIVARGA TAB 40MG 5 MO
SUTENT CAP 12.5MG 5 MO
SUTENT CAP 25MG 5 MO
SUTENT CAP 37.5MG 5 MO
SUTENT CAP 50MG 5 MO
You can find information on what the symbols and abbreviations on this table mean by going to page V.
38
DRUG NAME TIER REQUIREMENTS/LIMITS
TABRECTA TAB 150MG 5 MO
TABRECTA TAB 200MG 5 MO; QL 120 PER 30 DAYS
TAFINLAR CAP 50MG 5 MO
TAFINLAR CAP 75MG 5 MO
TAGRISSO TAB 40MG 5 MO; QL 30 PER 30 DAYS
TAGRISSO TAB 80MG 5 MO; QL 30 PER 30 DAYS
TARCEVA TAB 100MG 5 MO; QL 30 PER 30 DAYS
TARCEVA TAB 150MG 5 MO; QL 30 PER 30 DAYS
TARCEVA TAB 25MG 5 MO; QL 90 PER 30 DAYS
TASIGNA CAP 150MG 5 MO
TASIGNA CAP 200MG 5 MO
TASIGNA CAP 50MG 5 MO; QL 360 PER 30 DAYS
TAZVERIK TAB 200MG 5 MO; QL 240 PER 30 DAYS
TIBSOVO TAB 250MG 5 MO; QL 60 PER 30 DAYS
TUKYSA TAB 150MG 5 MO
TUKYSA TAB 50MG 5 MO
TURALIO CAP 200MG 5 MO; QL 120 PER 30 DAYS
TYKERB TAB 250MG 5 MO
VENCLEXTA TAB 100MG 5 MO
VENCLEXTA TAB 10MG 3 MO
VENCLEXTA TAB 50MG 3 MO
VENCLEXTA TAB START PK 5 MO
VITRAKVI CAP 100MG 5 MO; QL 60 PER 30 DAYS
VITRAKVI CAP 25MG 5 MO; QL 240 PER 30 DAYS
VITRAKVI SOL 20MG/ML 5 MO; QL 300 PER 30 DAYS
VIZIMPRO TAB 15MG 5 MO
VIZIMPRO TAB 30MG 5 MO
VIZIMPRO TAB 45MG 5 MO
VOTRIENT TAB 200MG 5 MO
XALKORI CAP 200MG 5 MO
XALKORI CAP 250MG 5 MO
XOSPATA TAB 40MG 5 MO; QL 90 PER 30 DAYS
ZEJULA CAP 100MG 5 MO; QL 90 PER 30 DAYS
ZELBORAF TAB 240MG 5 MO
ZYDELIG TAB 100MG 5 MO
ZYDELIG TAB 150MG 5 MO
ZYKADIA TAB 150MG 5 MO
Retinoids
bexarotene cap 75 mg 5 MO
PANRETIN GEL 0.1% 5 MO
You can find information on what the symbols and abbreviations on this table mean by going to page V.
39
DRUG NAME TIER REQUIREMENTS/LIMITS
TARGRETIN GEL 1% 5 MO
tretinoin cap 10 mg 5 MO
Treatment Adjuncts
allopurinol tab 100 mg 1 CG; MO
MESNEX TAB 400MG 5 MO
ANTIPARASITICS
Antihelminthics
albendazole tab 200 mg 5 MO
benznidazole tab 100mg 2 CG; MO
benznidazole tab 12.5mg 2 CG; MO
ivermectin tab 3 mg 2 CG; MO
praziquantel tab 600 mg 3 MO
SKLICE LOT 0.5% 4 MO
Antiprotozoals
ALINIA SUS 100/5ML 4 MO
ALINIA TAB 500MG 4 MO
atovaquone susp 750 mg/5ml 5 MO
atovaquone-proguanil hcl tab 250-100 mg 2 CG; MO
atovaquone-proguanil hcl tab 62.5-25 mg 2 CG; MO
chloroquine phosphate tab 250 mg 2 CG; MO
chloroquine phosphate tab 500 mg 2 CG; MO
COARTEM TAB 20-120MG 4 MO
hydroxychloroquine sulfate tab 200 mg 2 CG; MO
mefloquine hcl tab 250 mg 2 CG; MO
PENTAM 300 INJ 300MG 4 HI; MO
pentamidine inh 300 mg 2 CG; MO; B/D PA
PRIMAQUINE TAB 26.3MG 2 CG; MO
pyrimethamin tab 25mg 5 MO; PA
quinine sulfate cap 324 mg 2 CG; MO; PA
Pediculicides/Scabicides
lindane shampoo 1% 4 MO
malathion lotion 0.5% 4 MO
permethrin cream 5% 2 CG; MO
ANTIPARKINSON AGENTS
Anticholinergics
benztropine mesylate tab 0.5 mg 1 CG; MO
benztropine mesylate tab 1 mg 1 CG; MO
benztropine mesylate tab 2 mg 1 CG; MO
trihexyphenidyl hcl elixir 0.4 mg/ml 4 MO
trihexyphenidyl hcl tab 2 mg 1 CG; MO
You can find information on what the symbols and abbreviations on this table mean by going to page V.
40
DRUG NAME TIER REQUIREMENTS/LIMITS
trihexyphenidyl hcl tab 5 mg 1 CG; MO
Antiparkinson Agents, Other
amantadine hcl syrup 50 mg/5ml 1 CG; MO
CARB/LEVO 50TAB/ENTACAP 3 MO
CARB/LEVO 75TAB/ENTACAP 3 MO
CARB/LEVO100TAB/ENTACAP 4 MO
CARB/LEVO125TAB/ENTACAP 4 MO
CARB/LEVO150TAB/ENTACAP 4 MO
CARB/LEVO200TAB/ENTACAP 4 MO
entacapone tab 200 mg 2 CG; MO
STALEVO 100 TAB 4 MO
STALEVO 125 TAB 4 MO
STALEVO 150 TAB 4 MO
STALEVO 200 TAB 4 MO
STALEVO 50 TAB 4 MO
STALEVO 75 TAB 4 MO
tolcapone tab 100 mg 5 MO
Dopamine Agonists
APOKYN INJ 10MG/ML 5 MO; QL 60 PER 30 DAYS; PA
NEUPRO DIS 1MG/24HR 4 MO; ST
NEUPRO DIS 2MG/24HR 4 MO; ST
NEUPRO DIS 3MG/24HR 4 MO; ST
NEUPRO DIS 4MG/24HR 4 MO; ST
NEUPRO DIS 6MG/24HR 4 MO; ST
NEUPRO DIS 8MG/24HR 4 MO; ST
pramipexole tab 0.125 mg 1 CG; MO
pramipexole tab 0.25 mg 1 CG; MO
pramipexole tab 0.5 mg 1 CG; MO
pramipexole tab 0.75 mg 1 CG; MO
pramipexole tab 1 mg 1 CG; MO
pramipexole tab 1.5 mg 1 CG; MO
pramipexole tab er 0.375 mg 4 MO
pramipexole tab er 0.75 mg 4 MO
pramipexole tab er 1.5 mg 4 MO
pramipexole tab er 2.25 mg 4 MO
pramipexole tab er 3 mg 4 MO
pramipexole tab er 3.75 mg 2 CG; MO
pramipexole tab er 4.5 mg 4 MO
ropinirole hydrochloride tab 0.25 mg 1 CG; MO
ropinirole hydrochloride tab 0.5 mg 1 CG; MO
You can find information on what the symbols and abbreviations on this table mean by going to page V.
41
DRUG NAME TIER REQUIREMENTS/LIMITS
ropinirole hydrochloride tab 1 mg 1 CG; MO
ropinirole hydrochloride tab 2 mg 1 CG; MO
ropinirole hydrochloride tab 3 mg 1 CG; MO
ropinirole hydrochloride tab 4 mg 1 CG; MO
ropinirole hydrochloride tab 5 mg 1 CG; MO
ropinirole hydrochloride tab er 12 mg 2 CG; MO
ropinirole hydrochloride tab er 2 mg 2 CG; MO
ropinirole hydrochloride tab er 4 mg 2 CG; MO
ropinirole hydrochloride tab er 6 mg 2 CG; MO
ropinirole hydrochloride tab er 8 mg 2 CG; MO
Dopamine Precursors/ L-Amino Acid Decarboxylase Inhibitors
carbidopa & levodopa odt tab 10-100 mg 1 CG; MO
carbidopa & levodopa odt tab 25-100 mg 1 CG; MO
carbidopa & levodopa odt tab 25-250 mg 1 CG; MO
carbidopa & levodopa tab 10-100 mg 1 CG; MO
carbidopa & levodopa tab 25-100 mg 1 CG; MO
carbidopa & levodopa tab 25-250 mg 1 CG; MO
carbidopa & levodopa tab er 25-100 mg 1 CG; MO
carbidopa & levodopa tab er 50-200 mg 1 CG; MO
carbidopa tab 25 mg 4 MO
NOURIANZ TAB 20 MG 5 MO; QL 30 PER 30 DAYS; PA
NOURIANZ TAB 40 MG 5 MO; QL 30 PER 30 DAYS; PA
RYTARY CAP 145MG 4 MO; ST
RYTARY CAP 195MG 4 MO; ST
RYTARY CAP 245MG 4 MO; ST
RYTARY CAP 95MG 4 MO; ST
Monoamine Oxidase B (MAO-B) Inhibitors
rasagiline mesylate tab 0.5 mg 2 CG; MO
rasagiline mesylate tab 1 mg 2 CG; MO
selegiline hcl cap 5 mg 2 CG; MO
selegiline hcl tab 5 mg 2 CG; MO
ZELAPAR TAB 1.25MG 5 MO
ANTIPSYCHOTICS
1st Generation/Typical
chlorpromazine hcl tab 10 mg 4 MO
chlorpromazine hcl tab 100 mg 4 MO
chlorpromazine hcl tab 200 mg 4 MO
chlorpromazine hcl tab 25 mg 4 MO
chlorpromazine hcl tab 50 mg 4 MO
fluphenazine decanoate inj 25 mg/ml 2 CG; MO
You can find information on what the symbols and abbreviations on this table mean by going to page V.
42
DRUG NAME TIER REQUIREMENTS/LIMITS
fluphenazine hcl elixir 2.5 mg/5ml 2 CG; MO
fluphenazine hcl inj 2.5 mg/ml 2 CG; MO
fluphenazine hcl oral conc 5 mg/ml 2 CG; MO
fluphenazine hcl tab 1 mg 1 CG; MO
fluphenazine hcl tab 10 mg 1 CG; MO
fluphenazine hcl tab 2.5 mg 1 CG; MO
fluphenazine hcl tab 5 mg 1 CG; MO