Revised 8/12/16 Level 4 Medication List The medications listed

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Revised 8/12/16 Level 4 Medication List The medications listed
Revised 10/3/16
Level 4 Medication List
The medications listed below have the highest copayment level
Abilify Discmelt
Abilify Oral solution
Abilify Tablets
Absorica
Abstral
Aciphex
Aciphex Sprinkle
Acticlate
Actiq
Actonel 5mg, 30mg, 35mg
Adoxa
Adoxa Pak
Adempas
Adrenaclick
Afrezza
Akynzeo
Alocril
Alomide
Alphagan P 0.15%
Alrex
Alsuma
Ambien
Ambien CR
Amlodipine-Atorvastatin
Amnesteem
Androderm
Androgel
Androderm
Aplenzin
Aptensio XR
Aptiom
Amrix
Arestin
Aripiprazole ODT
Armodafinil
Atelvia
Ativan
Atralin
Auvi-Q
Avar LS Cleanser
Avar-E LS Cream
Avinza
Axiron
Bactroban Cream
Baraclude tablets
Belbuca
Belsomra
Benzaclin Gel 1-5%
Benzefoamultra
Bepreve
Betapace AF
Betimol
Biaxin XL
Binosto
Brisdelle
Briviact
Butrans
Caduet
Calcitriol ointment
Cambia
Carbaglu
Cardura XL
Carisoprodol 250mg
Celexa
Cerdelga
Ciprofloxacin ER/SR
Claravis
Clarinex
Clarinex D
Clarinex ODT
Cleocin-T Solution 1%
Cleocin-T Gel 1%
Cleocin-T Lotion 1%
Cleocin-T Swab 1%
Clindamax Gel 1%
Clindamycin PhosphateTretinoin Gel 1.2-0.025%
Clonidine ER
Clozapine ODT
Concerta
Conzip
Cordran cream
Cordran lotion
Cordran ointment
Coreg CR
Cyclogyl 0.5%
Daraprim
Daytrana
Desloratadine 5mg tab
Desloratadine ODT
Detrol
Detrol LA
Dexmethylphenidate ER/SR
Diabeta
Differin cream
Differin gel
Differin lotion
Dificid
Diflorasone ointment
Diovan
Diovan HCT
Ditropan XL
Doryx
Doryx MPC
Doxycycline (Rosacea) cap
Doxycycline Hyclate DR tablet
Doxycycline Monohydrate
150mg capsule
Drospirenone-Ethinyl-Estradiol
Duac gel
Duavee
Duexis
Dulera
Duragesic Disc
DuoNeb
Dymista Nasal Spray
Elimite
Edluar
Elestat
Emadine
Enablex
Envarsus XR
Epinephrine Pen
Equetro
Erygel
Esbriet
Esomeprazole strontium
Eszopiclone
Eurax cream
Eurax lotion
Evoclin
Exalgo
Exforge
Exforge HCT
Extina
Fanapt
Fazaclo
Fentanyl lollipop
Fentora
Ferriprox
Flector patch
1
Revised 10/3/16
Level 4 Medication List
The medications listed below have the highest copayment level
Fluoxteine capsules (PMDD)
Fluoxetine 60mg Tab
Fluoxetine 90mg DR
Flurandrenolide Cream
Focalin XR
Fortamet
Fortesta
Fosamax Plus D
Gelnique
Generess FE
Gianvi
Glucophage XR
Glumetza
Glyxambi
Gralise
Gralise Starter Kit
Grastek
Guanfacine ER/SR
HC Butyrate cream
Hemangeol
Hetlioz
Horizant
Hydroc/APAP sol 10-325mg
Hydroc/IBU 2.5-200mg
Hydroc/IBU 5-200mg
Hydroc/IBU 10-200mg
Hydromorphone HCL ER
Hysingla ER
Ibudone
Imitrex cartridge
Imitrex syringe
Intermezzo
Intuniv
Invega
Istalol
Jadenu
Jublia
Kadian
Kalydeco Tab
Kalydeco Pak
Kapvay
Karbinal ER
Keppra
Keppra XR
Kerafoam
Kerydin
Keveyis
Klaron
Kuvan
Lansoprazole/Amox/Clarithr
Latuda
Lastacaft
Letairis
Levocetirizine dihydrochlor
Lexapro
Linezolid
Lipitor
Liptruzet
Locoid Lipocream
Lortab
Loryna
Lotemax
Lovaza
Lunesta
Luzu cream
Magnacet
Metformin HCL SR
Metrocream 0.75%
Metrogel 1%
Metrolotion 0.75%
Minocycline ER/SR
Mometasone Furoate
Morphine sulfate ER/SR beads
Morphine sulfate ER/SR
capsules
Myfortic
Myorisan
Naprelan
Nasonex
Natazia
Natesto
Natroba
Neuac gel
Nexium
Nexium granules
Nikki
Niravam
Neurontin
Non-Lifescan Glucose Test
Strips
Non-Lifescan Glucose Test
Disks
Northera
Nucynta
Nucynta ER
Nuedexta
Nuvigil
Ofev
Oleptro
Olopatadine NS
Olysio
Omeprazole/Bicarbonate
Omeprazole-Sodium
Bicarbonate Powd Pack
Omnaris
Onfi
Opana ER
Opsumit
Optivar
Oracea
Oralair
Orenitram
Otezla
Otrexup
Ovide
Oxaydo
Oxistat
Oxtellar XR
Oxycontin
Oxycodone HCL ER
Oxymorphone ER/SR
Oxytrol
Paliperidone ER/SR
Pataday
Patanase
Patanol
Paxil
Paxil CR
Paroxetine SR/ER
Pazeo
Percocet
Pexeva
Plavix
Plexion Cream 9.8-4.8%
Plexion Lotion 9.8-4.8%
Plexion Cleanser 9.8-4.8%
Prandimet
Prestalia
Prevacid
Prevacid Solu-tab
PrevPac
2
Revised 10/3/16
Level 4 Medication List
The medications listed below have the highest copayment level
Prilosec
ProAir HFA
ProAir Respiclick
Prolensa
Protonix
Protonix Pak
Proventil HFA
Prozac
Prozac Weekly
Pylera
Qnasl
Qnasl Childrens
Qudexy XR
Radiogardase
Ragwitek
Ravicti
Rasuvo
Rayos
Relenza
Reprexain
Retin-A cream
Retin-A gel
Retin-A Micro
Rexulti
Rilutek
Risperdal M-ODT
Risperidone M-ODT
Rosula
Rybix ODT
Safryl
Sanctura
Sanctura XR
Saphris
Silenor
Sitavig
Sivextro
Sklice
Sod sul/sulf cream 9.8-4.8%
Solodyn
Soma
Sonata
Soolantra
Sorilux
Spinosad
Spirtam
Sprix
Striant
Stromectol
Subsys
Sulfacetamide sodium sulfur
cleansing pad 10-4%
Sumadan Wash
Sumatriptan cartridge
Sumatriptan syringe
Sumavel
Sumaxin
Sumaxin TS
Symbicort
Synera Topical Patch
Synjardy
Tamiflu
Tecfidera
Technivie
Temodar
Testosterone gel 1%, 2%
Testosterone gel pump 1%
Timoptic
Timoptic Ocudose
Timoptic-XE
Tizanidine capsules
Tolterodine capsules ER/SR
Toviaz
Tracleer
Tramadol Biphasic Cap ER/SR
Tramadol Biphasic Tab ER/SR
Tretin-X
Treximet
Trokendi XR
Trospium Chloride ER/SR
Tussicaps
Tuzistra XR
Ulesfia
Ultram ER
Uptravi
Vanatol LQ
Valium
Varubi
Vascepa
Vectical
Veltassa
Veltin
Veramyst
Vestura
Viberzi
Vicodin
Vicoprofen
Viekira Pak
Viekira XR
Viibryd
Vimovo
Vivlodex
Vogelxo
Vusion
Wellbutrin XL
Xanax
Xanax XR
Xartemis XR
Xeljanz
Xeljanz XR
Xifaxan
Xtampza ER
Xyrem
Xyzal
Zamicet
Zanaflex capsules
Zavesca
Zegerid
Zembrace Symtouch
Zemplar
Zenatane
Zepatier
Ziagen tablets
Ziana
Zipsor
Zithranol shampoo
Zocor
Zofran
Zofran ODT
Zofran oral solution
Zohydro ER
Zoloft
Zolpidem Tartrate SL
Zolpimist
Zorvolex
Zutripro
Zyprexa
Zyvox
3
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