BlueCross BlueShield Medicaid/Family Health Plus Formulary Guide

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BlueCross BlueShield Medicaid/Family Health Plus Formulary Guide
BlueCross BlueShield
Medicaid/Family
Health Plus
Formulary Guide
Please bring this guide
with you the next time
you visit your doctor.
If you have questions about your prescription drug benefit,
visit the Pharmacy Services section of the BlueCross BlueShield web site at
www.bcbswny.com.
MG45831E
(Revise Date 3/2015)
A Division of HealthNow New York Inc. An independent licensee of the BlueCross BlueShield Association. The Cross and Shield
are registered trademarks of the BlueCross BlueShield Association.
TABLE OF CONTENTS
INTRODUCTION
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii
Formularies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii
UNDERSTANDING THE
SYMBOLS USED
THROUGHOUT THIS BOOK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii
USING THIS
FORMULARY BOOK TO HELP CONTAIN COSTS . . iv
Save Money on Your Prescription Drugs . . . . . . . . . . . . . . . . . iv
Finding Medications in the Guide
. . . . . . . . . . . . . . . . . . . . . . iv
SECTION 1 — THERAPEUTIC DRUG CATEGORIES . . . . . . . . . . .1
SECTION II — MEDICAID OVER-THE-COUNTER (OTC)
MEDICATION LIST . . . . . . . . . . . . . . . . . . . . . . . . .5
SECTION III — INDEX
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6
ii
The BlueCross BlueShield Medicaid/Family Health Plus Formulary Guide is a list of drugs to help guide
physicians and pharmacists to select the medication that provides the appropriate treatment for the best
price.
INTRODUCTION
BlueCross Blue Shield of Western New York has established an independent committee of practicing physicians
and a pharmacist to help ensure that our formularies are medically sound and that they support your patients’
health. This committee—called the Pharmacy and Therapeutics Committee—reviews and evaluates medications
on the formulary based on safety and efficacy to help maintain clinical integrity in all therapeutic categories.
Formularies
In order to serve the diverse needs of patients and their plan sponsors, BlueCross BlueShield of Western
New York makes available this formulary design:
Closed Formulary — Features the requirement that prescribed drugs must be on the formulary in
order for the member to receive coverage. If a prescription is written for a medication that is
not on the formulary, the patient will be responsible for the full cost. If special circumstances
necessitate that the patient take the nonpreferred drug, prescribers may request a coverage review.
If coverage is approved, the medication will be covered. If coverage is not approved, the patient
will be responsible for the full cost of the medication.
UNDERSTANDING THE
SYMBOLS USED THROUGHOUT THIS BOOK
Throughout this book, you will see certain symbols that indicate a management program is in place for selected
medications. The symbols are as follows:
Key
❚ =
! =
◆ =
+ =
Specific quantity limits apply. Quantity limits are in place to ensure members receive the
appropriate amount of medication not to exceed the maximum allowable daily dosage of
medication.
Prior authorization required. Prior authorization (also referred to as coverage review)
means that a healthcare professional must submit clinical documentation to obtain
approval for a member to receive the medication. Prior authorizations ensure medications
are being used appropriately.
Included in tablet-splitting program. The medication can be cut in half to obtain the daily
dose of medication (i.e., 20mg daily of simvastatin can be obtained by 1/2 tablet of
simvastatin 40mg). A member will receive a 1-month supply for half their regular 1-month
copay.
Access restricted to network specialty pharmacies. Medications must be obtained through a
network specialty pharmacy.
iii
USING THIS
FORMULARY BOOK TO HELP CONTAIN COSTS
We realize that the formulary may not include every drug from every manufacturer. However, using a
generic or preferred drug can help you stay healthy at a more affordable cost.
Save Money on Your Prescription Drugs
Here’s what you can do to save money:
1. Bring this member guide to your doctor and review the cost-saving information below.
2. Ask your doctor whether a generic or formulary brand-name drug listed in this guide is
right for you.
Formulary
generic drugs
Formulary
brand-name drugs
Lowest cost to you
Non-formulary
drugs
Highest cost to you
The amount you pay for a drug is determined by which medication you purchase and where it appears
on the guide. Some drug plans also exclude certain drugs or classes of drugs from coverage. Please check
your contract or other plan documents if you have a question about your specific drug coverage.
Finding Medications in the Guide
This guide lists medications two different ways:
Section 1: Alphabetically by drug category (such as Diabetes, Heart or Pain/Arthritis)
Locate a category on the guide to see what drugs are on the formulary. Generic drugs are
listed as G and brand drugs are listed with a B.
Section 2: Alphabetically by drug name. Use this list to find your drug.
Questions? Please call Member Services at 1-866-544-7948 if you have any questions about the
BlueCross BlueShield Medicaid/Family Health Plus Formulary Guide. For the most up-to-date version of
the Guide, visit the Pharmacy Services section of our web site at www.bcbswny.com/NYSdrug.
Disclaimer: The BlueCross BlueShield Medicaid/Family Health Plus Formulary Guide is subject to change, as we regularly
review medications and existing therapies for inclusion in the BlueCross BlueShield Medicaid/Family Health Plus Formulary
Guide. The tier that a medication is currently in may change during the effective dates of the guides due to generic
availability.
iv
SECTION I — THERAPEUTIC DRUG CATEGORIES
TIER
TIER
Allergy/Cough & Cold
Antihistamines & Decongestants
❚
!❚
!❚
!❚
brompheniramine/
phenylephrine
brompheniramine/
pseudoephedrine
cetirizine
chlorpheniramine/
pseudoephedrine
clemastine
cyproheptadine
dexchlorpheniramine
diphenhydramine
hydroxyzine HCL
hydroxyzine pamoate
loratadine
loratadine-D
promethazine
pseudoephedrine
Grastek
Histex IE
Oralair
Ragwitek
Semprex-D
Expectorant & Cough Products
benzonatate
cardec/DM
guaifenesin 1200/DM
guaifenesin/codeine
hydrocodone/chlorpheniramine
hydrocodone/homatropine
promethazine/codeine
pseudoephedrine/codeine
Mucolytic Agents
acetylcysteine inh soln.
Nasal Medications
❚
❚
❚
azelastine 0.1% nasal spray
fluticasone nasal spray
ipratropium nasal spray
Nasacort OTC
G
+
❚
G
!❚
G
G
Other Blood Modifiers
G
G
G
G
G
G
G
G
G
G
B
B
B
B
B
+!
+
+
+
+!
G
G
G
G
G
G
G
G
❚
❚
❚
❚
donepezil
ergoloid mesylates
galantamine
rivastigamine
Exelon Patch
Namenda
G
G
G
B
G
G
G
G
B
B
Bladder/Kidney
Alkalinizers
citric acid/sod citrate
potassium citrate
Analgesics
phenazopyridine
Anticholinergics
❚
❚
❚
❚
❚
BPH
!❚
G
G
G
oxybutynin
oxybutynin ER
tolterodine
tolterodine ER
trospium
G
G
G
G
G
finasteride
tamsulosin
G
G
Cholinergic Agents
bethanecol
!
+!
+!
+!❚
+
+!❚
G
Alkylating Agents
cyclophosphamide
melphalan
CeeNu
Emcyt
Hexalen
Leukeran
Myleran
Antimetabolites
capecitabine
mercaptopurine
methotrexate
Purixan
Hormones
!
+!
+!❚
anagrelide
clopidogrel
dipyridamole
enoxaparin
fondaparinux
heparin
jantoven
ticlopidine
warfarin
Aggrenox
Brilinta
Effient
KEY: ❚
!
◆
+
=
=
=
=
G
G
G
G
G
G
G
G
G
B
B
B
bicalutamide
exemestane
flutamide
letrozole
leuprolide
megestrol
tamoxifen
anastrozole
Fareston
Xtandi
Zytiga
Miscellaneous
+!
+!❚
+!
+!
+!❚
+!❚
+!❚
+!❚
+!❚
+
+!❚
!❚
+!❚
+!
!
+!❚
Blood
Anticoagulants/antithrombotics
cilostazol
pentoxifylline
Actimmune
Aranesp
Epogen
Exjade
Leukine
Miacalcin inj.
Neulasta
Neumega
Neupogen
Promacta
Procrit
Revlimid
TIER
B
B
B
B
B
B
+!❚
+!❚
+!❚
+!❚
+!❚
+!
+!❚
+!❚
+!❚
+!
+!❚
+
etoposide
hydroxyurea
mesna
temozolomide
topotecan
Afinitor
Arcalyst
Bosulif
Caprelsa
Cometriq
Erivedge
Gilotrif
Gleevec
Hycamptin
Iclusig
Imbruvica
Inlyta
Intron A
Iressa
Jakafi
Lysodren
Matulane
Mekinist
Nexavar
Nilandron
Pomalyst
Signifor
Sprycel
Stivarga
Sutent
Sylatron
Tafinlar
Tarceva
Tasigna
Thalomid
Tykerb
Valchlor
Votrient
Xalkori
Zelboraf
Zolinza
Zydelig
Zykadia
+!
+!❚
!
+!❚
+!❚
!
!❚
+!❚
G
G
B
B
B
B
B
B
B
B
B
B
B
B
Rexinoids
Targretin
TIER
B
B
B
B
B
B
B
B
Eye
Antiallergy Agents (Eye)
azelastine ophth
cromolyn ophth
ketotifen opthalmic solution
Patanol
Anti-infective Agents
bacitracin ophth
bacitracin/polymyxin
ciprofloxacin ophth
erythromycin ophth
gentamicin ophth
neomycin/bacitracin/poly B
ofloxacin ophth
polymyxin B/TMP
sulfacetamide 10%
tobramycin soln
B
Diabetes
Antidiabetic Agents, Injectable
Apidra
Bydureon
Byetta
Humalog insulin
Humulin (all types)
Lantus
Levemir
Novolin
Novolog
Symlin
Tanzeum
Trulicity
Victoza
!
!
Cancer Drugs
G
Alzheimer Agents
❚
Eliquis
Fragmin
Innohep
Pradaxa
Xarelto
Zontivity
!❚
!❚
!❚
!❚
G
G
B
B
B
B
B
Antidiabetic Agents, Oral & Glucose
Elevating agents
acarbose
chlorpropamide
glimepiride
glipizide
glipizide ER
glipizide/metformin
glyburide
glyburide micronized
metformin
metformin ER
metformin/glyburide
nateglinide
pioglitazone
repaglanide
tolazamide
tolbutamide
Avandamet
Avandaryl
Avandia
Farxiga
Glucagon
Invokamet
Invokana
Janumet
Januvia
Jardiance
Jentadueto
Juvisync
Kazano
Kombiglyze
Nesina
Onglyza
Oseni
Tradjenta
Xigduo XR
❚
G
G
G
B
❚
❚
G
G
G
G
G
G
G
G
B
B
B
❚
❚
❚
❚
❚
G
G
G
G
G
B
B
B
B
B
B
B
B
B
B
B
B
B
B
B
B
B
B
B
B
B
B
B
B
B
B
B
B
B
B
❚
❚
❚
❚
❚
❚
❚
❚
❚
❚
Diabetic Test Strips
!
!
!
!
Accu-Chek
Ascensia Breeze
Contour
FreeStyle
OneTouch
Precision
TRUEtest
TRUEtrack
!
!
!
B
B
B
B
B
B
B
B
B
B
B
B
B
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
B
B
B
B
B
B
B
B
B
B
B
B
B
B
B
B
B
B
B
B
B
B
B
B
B
B
B
Anti-inflammatory
dexamethasone ophth
fluorometholone ophth
prednisolone acetate
prednisolone sod acetate
FML Forte
FML S.O.P.
Lotemax
Pred Mild
Anti-inflammatory/Anti-infective
combinations
dexameth/neomycin/poly B
neomycin/bacitracin/poly B/HC
sulfacetamide/prednisolone
ophth
tobramycin/dexameth
Antiviral
❚
famciclovir
trifluridine
Beta-Blockers (Eye)
betaxolol HCl
carteolol
levobunolol
metipranolol
timolol
Betoptic-S
Carbonic Anhydrase Inhibitors
Miotics
Anti-infective Agents
acetic acid otic
acetic acid/aluminum acetate
ofloxacin otic
Anti-infective/Anti-inflammatory
combinations
acetic acid HC otic
neomycin/polymyxin/HC otic
Ciprodex
G
G
G
G
G
B
G
G
G
G
G
G
G
G
B
G
B
B
Cystaran
Mydriatics
B
atropine sulfate ophth
homatropine
tropicamide
G
G
G
bromfenac
flurbiprofen ophth
ketorolac tromethamine
Nevanac
G
G
G
B
Prostaglandin Analogues/Prostamines
latanoprost
travoprost
Lumigan
Sympathomimetics
brimonidine
G
G
B
G
naphazoline
phenylephrine ophth
G
G
allopurinol
colchicine
colchicine/probenecid
indomethacin
probenecid
Colcrys
G
G
G
G
G
B
Gout
1. * All branded self-injectables are subject to prior authorization.
2. * Some drugs are limited to 1 unit of use package per dispensing.
1
G
G
G
pilocarpine
Isopto Carbachol 1.5%
Phospholine Iodide
Note:
Specific Quantity Limits Apply.
Prior Authorization Required.
Included in Tablet-Splitting Program
Access restricted to network specialty phamacies.
G
G
G
G
B
B
B
B
G
G
B
Vasoconstrictors
Ear
G
G
G
G
G
G
G
G
G
G
dorzolamide 2% eye drops
dorzolamide/timolol eye drops
Azopt
Miscellaneous
NSAIDs
G
G
G
B
SECTION I — THERAPEUTIC DRUG CATEGORIES (CONT’D)
TIER
TIER
Heart
Combination Anti-Hypertensive
Angiotensin Converting Enzyme Inhibitors
benazepril
captopril
enalapril
fosinopril
lisinopril
quinapril
ramipril
Angiotensin II Antagonists
❚
❚
❚
❚
❚
❚
candesartan
eprosartan
irbesartan
losartan
telmisartan
valsartan
G
G
G
G
G
G
G
G
G
G
G
G
G
Anti-Adrenergic Blockers Centrally acting
+!❚
clonidine, oral, patch
guanabenz
guanfacine
methyldopa
midodrine
Dibenzyline
Northera
Anti-Adrenergic Blockers Peripheral
doxazosin
prazosin
terazosin
Antiarrhythmics
amiodarone
digoxin
disopyramide
disopyramide CR
flecainide
mexiletine
propafenone
quinidine gluconate
quinidine sulfate SR
sotalol
Antilipidemics
❚◆
❚◆
❚◆
+!
❚
atorvastatin calcium
cholestyramine
colestipol
fenofibrate
fenofibric acid, tab
fluvastatin
gemfibrozil
lovastatin
niacin ER
pravastatin
simvastatin
Kynamro
Zetia
Beta Blockers
acebutolol
atenolol
betaxolol
bisoprolol
carvedilol
labetalol
metoprolol
metoprolol ER
nadolol
pindolol
propranolol
timolol
Calcium Channel Blockers
amlodipine
cartia XT
diltia XT
diltiazem
diltiazem CD/SR/ER/XR
felodipine ER
isradipine
nicardipine
nifediac CC
nifedical XL
nifedipine
nifedipine SR
nimodipine
nisoldipine
verapamil
verapamil SR
KEY: ❚
!
◆
+
=
=
=
=
G
G
G
G
G
B
B
❚
❚
❚
❚
❚
Diuretics
acetazolamide
acetazolamide ER
amiloride
amiloride/HCTZ
bumetanide
chlorothiazide
chlorthalidone
furosemide
hydrochlorothiazide
indapamide
methazolamide
metolazone
spironolactone
spironolactone/HCTZ
torsemide
triamterene/HCTZ
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
B
B
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
amlodipine/benazepril
atenolol/chlorthalidone
benazepril/HCTZ
bisoprolol/HCTZ
candesartan/HCTZ
captopril/HCTZ
enalapril/HCTZ
irbesartan/HCTZ
lisinopril/HCTZ
losartan HCT
methyldopa/HCTZ
metoprolol/HCTZ
propranolol/HCTZ
quinapril/HCTZ
telmisartan/HCTZ
valsartan/HCTZ
Miscellaneous Cardiovascular Agents
+!❚
!❚
!❚
!❚
eplerenone
midodrine
Berinert
Cinryze
Firazyr
Ranexa
Ruconest
Samsca
Tekturna
Tekturna HCT
+!❚
+!❚
+!
+!❚
+!❚
+!❚
+!❚
+!
Adcirca
Adempas
Flolan
Letairis
Opsumit
Orenitram
Tracleer
Veletri
+!
!
+!
Pulmonary Arterial Hypertension
Vasodilators
hydralazine
isosorbide dinitrate
isosorbide mononitrate
isosorbide mononitrate SA
isoxsuprine
minoxidil oral
nitroglycerin oint
nitroglycerin pumpspray
nitroglycerin SR
nitroglycerin transdermal
patch
Dilatrate SR
Nitrostat
TIER
Stribild
Triumeq
Truvada
Viread
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
Nucleoside Reverse Transcriptase
Inhibitors
Other
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
+
nevirapine
Atripla
Intelence
Rescriptor
Sustiva
Viramune XR
Complera
Edurant
Fuzeon
Isentress
Selzentry
Tivicay
Tybost
Vitekta
B
B
B
B
B
B
B
B
Protease Inhibitors Combinations
Kaletra
B
B
B
B
B
B
B
B
B
B
B
Xenazine
+!❚
azathioprine
cyclosporine
gengraf
mycophenolate mofetil
sirolimus
tacrolimus
Astagraf XL
Sandimmune
Antifungals
!
❚
❚
!❚
G
G
G
G
G
G
B
B
chloroquine phosphate
hydroxychloroquine
mefloquine
Daraprim
Malarone
Primaquine
Antituberculosis
ethambutol
isoniazid
pyrazinamide
rifabutin
rifampin
Coartem
Rifater
Antivirals
❚
❚
+!
+!
+!
+!❚
❚
+!❚
+!
❚
+!❚
❚
+!❚
Antibacterial agents/Antibiotics
amoxicillin
amoxicillin-clavulanate ER
ampicillin
azithromycin suspension
azithromycin tablets
cefaclor
cefadroxil
cefdinir
cefpodoxime
cefprozil
cefuroxime
cephalexin
ciprofloxacin
clarithromycin susp
clarithromycin tabs
clindamycin HCL
dicloxacillin
doxycycline
erythromycin base
erythromycin ethylsuccinate
(E.E.S.)
erythromycin stearate
erythromycin/sulfisoxazole
minocycline
ofloxacin
penicillin VK
sulfamethoxazole/trimethoprim
tetracycline
B
B
G
B
B
B
B
B
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
acyclovir oral
amantadine
famciclovir
ganciclovir
lamivudine tabs
ribapak
ribasphere
ribavirin
rimantadine
valacyclovir
valganciclovir tablets
Epivir-HBV solution
Harvoni
Hepsera
Olysio
Pegasys
Relenza
Sovaldi
Tamiflu
Viekira Pak
Other Anti-Infectives
Infection
G
G
G
G
G
G
G
G
G
G
ciclodan
clotrimazole lozenge
fluconazole
flucytosine
griseofulvin
itraconazole
ketoconazole
nystatin
terbinafine
voriconazole
Antimalarials
B
Immunosuppressants
B
B
B
B
B
B
B
B
Ery-Tab
Ketek
Zmax
❚
Huntington’s Disease
Nucleoside Analog Reverse Transcriptase
Inhibitor Combination
abacavir/lamivudine/
zidovudine
lamivudine/zidovudine
G
G
G
G
G
B
B
B
B
B
B
Aptivus
Crixivan
Evotaz
Invirase
Lexiva
Norvir
Prezcobix
Prezista
Reyataz
Viracept
HIV - Antivirals
Non-Nucleoside Reverse Transcriptase
Inhibitor
abacavir sulfate
didanosine
lamivudine
stavudine
zidovudine
Emtriva
Epivir solution
Epzicom
Retrovir IV infusion vial
Videx
Videx pediatric solution
Protease Inhibitors
G
G
B
B
B
B
B
B
B
B
TIER
B
B
B
B
!❚
+
!❚
atovaquone
methenamine combination
metronidazole
neomycin
nitrofurantoin
paromomycin
trimethoprim
vancomycin
Dapsone
Nebupent
Sivextro
Tobi
Zyvox
G
G
G
B
B
B
G
G
G
G
G
B
B
G
G
G
G
G
G
G
G
G
G
G
B
B
B
B
B
B
B
B
B
G
G
G
G
G
G
G
G
B
B
B
B
B
Impotence - possible contract exclusion;
refer to individual contract
yohimbine
G
Male Hormones
❚
❚
❚
❚
❚
❚
Androderm patch
Androgel
Axiron
Fortesta
Testim
Testosterone gel
Vogelxo
Prostate Health
❚
!❚
alfuzosin HCl
finasteride
tamsulosin
1. * All branded self-injectables are subject to prior authorization.
2. * Some drugs are limited to 1 unit of use package per dispensing.
2
G
G
G
G
G
G
G
G
G
G
Men’s Health
Note:
Specific Quantity Limits Apply.
Prior Authorization Required.
Included in Tablet-Splitting Program
Access restricted to network specialty phamacies.
B
B
B
B
B
B
B
B
B
B
G
G
G
SECTION I — THERAPEUTIC DRUG CATEGORIES (CONT’D)
TIER
TIER
Mental Health
Antidepressants
❚
❚
❚
◆
◆
◆
◆
◆
◆
◆
◆
amitriptyline
amitriptyline/
chlordiazepoxide
amitriptyline/perphenazine
amoxapine
bupropion
bupropion ER
bupropion XL
citalopram
clomipramine
desipramine
doxepin
duloxetine
escitalopram
fluoxetine 10, 20mg tablet
fluoxetine capsule
fluvoxamine tab
imipramine
maprotiline
mirtazapine
nefazodone
nortriptyline
paroxetine HCl
phenelzine
sertraline
tranylcypromine
trazodone
venlafaxine
venlafaxine ER
Brintellix
Desvenlafaxine ER
Desvenlafaxine fumarate
Fetzima
Khedezla
Pexeva
Pristiq
Viibryd
Antimanic Agents
lithium carbonate
Antipsychotic Agents
❚
❚
❚
❚
❚
❚
❚
❚
❚
❚
❚
❚
chlorpromazine
clozapine
fluphenazine decanoate
fluphenazine, oral
haloperidol decanoate
haloperidol, oral
loxapine
olanzapine
olanzapine/fluoxetine
perphenazine
quetiapine
risperidone
risperidone m-tab
thioridazine
thiothixene
trifluoperazine
ziprasidone caps
Abilify
Fanapt
Invega
Latuda
Saphris
Seroquel XR
Versacloz
Anxiolytics, Sedatives, and Hypnotics
❚
❚
❚
!❚
alprazolam/ER
buspirone
chloral hydrate
chlordiazepoxide
clorazepate
diazepam
estazolam
flurazepam
lorazepam
meprobamate
oxazepam
temazepam
triazolam
zaleplon
zolpidem
zolpidem CR
Hetlioz
KEY: ❚
!
◆
+
=
=
=
=
Cerebral Stimulants
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
B
B
B
B
B
B
B
B
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
B
B
B
B
B
B
B
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
B
!❚
!❚
dexmethylphenidate
dexmethylphenidate ER
dextroamphetamine tabs
generic Adderall
generic Adderall XR
generic Concerta
generic Dexedrine spansules
metadate ER
methylphenidate/SR/CD
modafinil
procentra
Daytrana
Intuniv
Nuvigil
Strattera
TIER
Osteoporosis
G
G
G
G
G
G
G
G
G
G
G
B
B
B
B
alendronate
calcitonin-salmon
fortical NS
ibandronate
raloxifene
risedronate 150mg
Actonel 5mg, 30mg
Actonel with Calcium
Atelvia
Binosto
Fosamax Plus D
Forteo
❚
❚
❚
❚
❚
❚
❚
❚
❚
❚
❚
+!
+
desmopressin solution
desmopressin tabs
desmopressin vial 4mcg/ml
Stimate
Other CNS
❚
acamprosate calcium tablet
EC
buprenorphine HCl
disulfiram
naltrexone
Campral dosepack
Evzio
Rilutek
Savella
Suboxone Film
Other Endocrine
+
+!❚
!❚
!
+!
+!
+!❚
+!
+!
+!
+!
+
+!
+!
+
+!
danazol
fludrocortisone
octreotide
Acthar H.P. gel
Cerdelga
Egrifta
Genotropin
Humatrope
Myalept
Norditropin
Nutropin
Omnitrope
Saizen
Sensipar
Somavert
Synarel
Tev-Tropin
Zavesca
Zorbtive
Other Miscellaneous
+!
+!
+!
!
Gamunex C
Hizentra
Procysbi
Ravicti
Analgesics, Narcotic
acetaminophen w/codeine
belladonna & opium supp
butorphanol NS
codeine sulfate
endocet
fentanyl lozenge
fentanyl patch
hydrocodone/ibuprofen
hydromorphone
meperidine
meperidine/promethazine
methadone
morphine SR
morphine tab, soln, supp
MSIR tabs, sol
oxycodone
oxycodone/acetaminophen
oxycodone/aspirin
oxymorphone ER
pentazocine/naloxone
Opana ER
G
G
G
B
!❚
G
G
G
G
B
B
B
B
B
G
G
G
B
B
B
B
B
B
B
B
B
B
B
B
B
B
B
B
Analgesics, Salicylates
aspirin SR
choline mag. trisalicylate
diflunisal
salsalate
Anti-Rheumatic
+!❚
+!❚
+!❚
+!
+!❚
+!❚
+!❚
+!❚
B
B
B
B
Cox-2s
!❚
Ampyra
Aubagio
Avonex
Betaseron
Copaxone
Extavia
Gilenya
Plegridy
Rebif
Tecfidera
B
B
B
B
B
B
B
B
B
B
baclofen
carisoprodol
carisoprodol/ASA
chlorzoxazone
cyclobenzaprine
dantrolene sodium
diazepam
methocarbamol
orphenadrine
tizanidine
Celebrex
B
Nonsteroidal Anti-Inflammatory/
Combination Products
diclofenac potassium
diclofenac sodium
etodolac
etodolac SA
fenoprofen
flurbiprofen
ibuprofen
indomethacin
ketoprofen
ketorolac inj.
ketorolac tab
meclofenamate
meloxicam
Muscle Relaxants
G
G
G
G
G
G
G
G
G
G
❚
G
G
G
G
G
G
G
B
B
B
B
B
B
B
B
B
B
butalbital/APAP
butalbital/APAP/caffeine
butalbital/aspirin/caffeine
dihydroergotamine mesylate
ergotamine/caffeine
isometh/dichloralphen/APAP
naratriptan
sumatriptan
tramadol
Ergomar
❚
❚
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
B
hydroxychloroquine
leflunomide
methotrexate
Actemra SC
Cuprimine
Enbrel
Humira
Kineret
Orencia
Otezla
Ridaura
Simponi
Xeljanz
Migraine (Analgesics, Non-narcotic)
Multiple Sclerosis Agents
+!
+!❚
+!
+!
+!
+!
+!❚
+!❚
+!
+!❚
G
G
G
G
G
G
B
B
B
B
B
B
G
G
G
G
G
G
G
G
G
B
G
G
G
G
G
G
G
G
G
G
G
G
G
❚
+
amantadine
benztropine
bromocriptine
carbidopa/levodopa
carbidopa/levodopa SA
carbidopa/levodopa/
entacapone
entacapone
pramipexole
ropinirole
selegiline
trihexyphenidyl
Apokyn
Potassium agents
potassium bicarbonate
potassium chloride
Potassium Removing agent
sod. polystyrene sulfonate
G
G
G
G
G
B
G
G
G
Respiratory/Asthma
Adrenergic
epinephrine inj.
Epipen/Jr.
Corticosteroids
❚
❚
❚
❚
❚
❚
budesonide inh. (0.25mg/2ml,
0.5mg/2ml)
Alvesco
Flovent Diskus
Flovent HFA
Pulmicort Flexhaler
Qvar
Symbicort
Leukotrienes
❚
❚
montelukast
zafirlukast
Other Agents
❚
❚
❚
❚
+!❚
+!
+!❚
+
❚
❚
cromolyn inh. soln.
ipratropium inh. soln.
Advair diskus
Atrovent/HFA
Combivent Respimat
Dulera
Esbriet
Kaldydeco
Ofev
Pulmozyme
Spiriva
Spiriva Respimat
Sympathomimetics
❚
❚
❚
❚
❚
❚
albuterol sulfate ER
albuterol tab, syr
metaproterenol syr
terbutaline tab
Maxair Autohaler
ProAir HFA
Serevent Diskus
Ventolin HFA
Xanthine Derivatives
aminophylline
theochron
theophylline/SR tabs, liquid
G
B
G
B
B
B
B
B
B
G
G
G
G
B
B
B
B
B
B
B
B
B
B
G
G
G
G
B
B
B
B
G
G
G
Seizures
Barbiturates
phenobarbital
Hydantoins
phenytoin
Miscellaneous
carbamazepine
carbamazepine XR 200mg,
400mg
clonazepam
divalproex sodium/ER
1. * All branded self-injectables are subject to prior authorization.
2. * Some drugs are limited to 1 unit of use package per dispensing.
3
G
G
G
G
G
G
Potassium
Note:
Specific Quantity Limits Apply.
Prior Authorization Required.
Included in Tablet-Splitting Program
Access restricted to network specialty phamacies.
G
G
G
G
G
B
Parkinson’s Disease
Pain/Arthritis
Miscellaneous
Antidiuretic Agents
TIER
nabumetone
naproxen
naproxen EC
piroxicam
sulindac
Voltaren gel
G
G
G
G
G
G
SECTION I — THERAPEUTIC DRUG CATEGORIES (CONT’D)
TIER
felbamate
gabapentin
lamotrigine
levetiracetam
oxcarbazepine
primidone
tiagabine
topiramate
valproic acid
zonisamide
Aptiom
Banzel
Fycompa
Gabitril
Lyrica
Onfi
Potiga
Qudexy XR
Sabril
Trokendi XR
Succinimides
ethosuximide
Celontin
TIER
G
G
G
G
G
G
G
G
G
G
B
B
B
B
B
B
B
B
B
B
!
!
Topical Anti-Inflammatory Agents
❚
adapalene
amnesteem
avita cream
benzoyl peroxide
claravis
erythromycin/benz peroxide
prascion RA
sod.sulfacetamide/sulfur
emulsion cleanser
sod. sulfacetamide/sulfur lot
sotret
sulfacetamide
tretinoin cr/gel
Tazorac
Antibiotics (Topical)
acitretin
clindamycin sol/swabs/gel/
lotion
erythromycin sol/swabs/gel
gentamicin cr/oint
metronidazole cream/lotion/gel
mupirocin
Centany
Antipsoriatics
+!❚
acticin
Lindane
Ulesfia
G
B
Skin
Acne
Scabicides & Pediculicides
calcipotriene ointment
calcipotriene solution
tacrolimus ointment
Elidel
Stelara
Burn preparation
silver sulfadiazine
Fungicides
betamethasone/clotrimazole
ciclopirox cream/gel
ciclopirox soln
econazole
ketoconazole
nystatin
nystatin/triamcinolone
nystop
Exelderm
Oxistat
Other Topicals
aluminum chloride 20%
fluorouracil
imiquimod 5% cream
podofilox
sodium chloride irrigating soln
Carac
Phisohex
Regranex
Psoralens
8-MOP
Oxsoralen Ultra
KEY: ❚
!
◆
+
=
=
=
=
G
G
G
G
G
G
G
G
G
G
G
G
B
G
G
G
G
G
G
B
G
G
G
B
B
Topical Antipruritics/Anesthetics
!❚
G
G
G
G
G
B
B
B
B
B
lidocaine
lidocaine patch
selenium sulf 2.25% shampoo
Topical Antivirals
acyclovir
G
B
B
peg 3350/electrolyte
Digestants
G
G
G
G
Creon
Pancreaze
Pertzye
Ultresa
Viokace
Zenpep
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
B
Gallstone Solubilizing Agents
ursodiol
H2 Antagonists
cimetidine
famotidine
nizatidine
ranitidine (all)
Other Antiulcer
misoprostol
sucralfate
Other GI Products
G
!❚
+!
+!
!❚
Proton Pump Inhibitors
G
G
G
G
G
G
Antithyroid
Thyroid
G
G
G
G
B
B
Anticholinergics/Antispasmodic/GI Motility
belladonna/phenobarbital
chlordiazepoxide/clindinium
dicyclomine
glycopyrrolate
hyoscyamine/CR
metoclopramide
Antidiarrheal
❚
diphenoxylate/atropine
paregoric
Alinia
Fulyzaq
Antiemetic/Antivertigo
!❚
❚
granisetron
meclizine
ondansetron
prochlorperazine
promethazine
trimethobenzamide
TIER
B
B
G
B
B
B
B
B
B
G
G
G
G
G
G
G
G
G
G
G
G
G
B
B
B
B
B
B
B
B
B
B
B
B
+
Contraceptives - Other
❚
G
G
levothroid
levothyroxine
levoxyl
liothyronine
thyroid
unithroid
Synthroid
Thyrolar
G
G
G
G
G
G
B
B
Vitamins
G
G
G
G
G
G
calcitriol
calcium acetate
cyanocobalamin inj.
etidronate disodium
folic acid
leucovorin
levocarnitine
multivitamin + fluoride
phytonadione
potassium aminobenzoate
pre-natal vitamins
sevelamer tablets
sodium fluoride chewable tab
& drops
vit A,D,C + fluoride
vit A,D,C + fluoride and iron
Galzin
Mephyton
G
G
B
B
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
B
B
xulane
Mirena
NuvaRing
Hormones
❚
❚
❚
❚
❚
❚
❚
❚
❚
❚
❚
❚
❚
❚
❚
estradiol/noreth ac
estradiol oral
estradiol patches
estropipate
estrogen/methyltesterone
medroxyprogesterone
norethindrone
progesterone, micronized
Cenestin
Climara Pro
Combipatch
Enjuvia
Estring
Evamist
Menest
Premarin
Premarin vag cream
Premphase
Prempro
Vagifem
Miscellaneous
Brisdelle
Oral Contraceptives
G
G
G
G
methimazole
propylthiouracil
Nascobal
Orfadin
Renvela
❚
❚
❚
amethia
apri
aranelle
aviane
balziva
camila
camrese
cesia
cryselle
enpresse
errin
jolessa
jolivette
junel/FE
kariva
lessina
levonorgestrel
levora
low-ogestrel
lutera
microgestin/FE
mononessa
necon
next choice
next choice one dose
nora-BE
norethindrone a-e estradiol/
ferrous fumarate
nortrel
ocella
ogestrel
portia
previfem
quasense
solia
sprintec
tri-sprintec
trinessa
trivora
velivet
zarah
zenchent
zovia
Vaginal Preparations
miconazole vag supp
nystatin vag tab
terconazole
vandazole vag
Note:
Specific Quantity Limits Apply.
Prior Authorization Required.
Included in Tablet-Splitting Program
Access restricted to network specialty phamacies.
1. * All branded self-injectables are subject to prior authorization.
2. * Some drugs are limited to 1 unit of use package per dispensing.
4
B
B
B
Women’s Health
Thyroid
Stomach/Ulcer
hydrocortisone/pramoxine
hydrocortisone rectal cr. & supp.
hydrocortisone rectal enema
pramoxine/HC acetate 2.5%
Cortifoam
Proctofoam-HC
lansoprazole
omeprazole
pantoprazole
Prilosec-OTC
❚
❚
❚
❚
Steroids
Anorectal
cromolyn sodium
enulose
lactulose
mesalamine enema
sulfasalazine
sulfasalazine EC
Asacol
Asacol HD
Canasa supp.
Cimzia
Delzicol
Dipentum
Gattex
Kuvan
Linzess
Pentasa
Relistor
Uceris ER tablet
G
G
G
Members coverage varies by plan. Patient
should be in a smoking cessation program.
❚
bupropion
G
❚
Nicotine Gum
G
❚
Nicotine lozenges
G
❚
Nicotine patches various
G
❚
Chantix
B
❚
Commit
B
❚
Nicotrol Inhaler/NS
B
cortisone acetate
dexamethasone oral
hydrocortisone oral
methylprednisolone
prednisolone oral
prednisone oral
Emend
Transderm Scop
Bowel Evacuants
Smoking Cessation
G
G
G
G
G
G
G
G
G
B
B
alclometasone
amcinonide
betamethasone dipropionate
betamethasone dipropionate
augmented oint
betamethasone valerate
clobetasol propionate
desonide
desoximetasone
diflorasone
fluocinolone acetonide
fluocinonide
fluticasone propionate
halobetasol
hydrocortisone 2.5%
hydrocortisone valerate
hydrocortisone/iodoquinol
hydrocortisone/urea
mometasone cr/oint
triamcinolone acetonide
Cordran tape
TIER
!❚
G
B
B
G
G
G
G
G
G
G
G
B
B
B
B
B
B
B
B
B
B
B
B
B
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
SECTION II — MEDICAID OVER-THE-COUNTER (OTC) MEDICATION LIST
This OTC Medication List does not apply to Family Health Plus
acetaminophen
hydrocortisone
permethrin
AFRIN
hydrocortisone acetate
PINX
ALAVERT
ibuprofen
polyethylene glycol
alum/mag hydroxide w/simethicone
iron
prenatal
aluminum acetate
lice treatment
PRILOSEC OTC
aluminum hydroxide
loperamide HCl
pyridoxine HCl
artificial tears
loratadine
ranitidine HCl
aspirin
loratadine-D
reese’s pinworm
aspirin buffered
lubricant eye drops
ROBITUSSIN
B complex w/ vitamin C
MAALOX
ROBITUSSIN-DM
bacitracin
MAALOX PLUS EXTRA STRENGTH
saline nasal spray
BENADRYL
magnesium
senna
BENEFIBER
magnesium gluconate
sennosides
benzoyl peroxide
mag-oxide
SENOKOT
beta-carotene
meclizine HCl
sinus congestion & pain
bisacodyl
METAMUCIL
sochlor
bismuth subsalicylate
MICONAZOLE 3
SPECTRAVITE
calcium + vitamin D
MICONAZOLE 7
SPECTRAVITE SENIOR
calcium carbonate
miconazole nitrate
SUDAFED PE
calcium lactate
MILK OF MAGNESIA
SUDAFED SINUS NIGHTTIME
CENTRA-VITE
mineral oil
suphedrine PE
CENTRUM SILVER
MONISTAT 1
SYSTANE
cetirizine HCl
MUCINEX
THERAFLU
children’s vitamin with minerals
MUCINEX DM
THERA-M
children’s acetaminophen
multivitamin
tolnaftate
children’s cold & cough
multivitamin w/iron
tussin
CHILDREN’S MUCINEX
multivitamin w/iron
tussin DM
CHILDREN’S PEPTO
multivitamin w/minerals
TYLENOL SINUS
chlorpheniramine maleate
multivitamin with calcium-iron
VISINE
cimetidine
MYLANTA
vitamin A
clotrimazole vaginal
NASACORT OTC
vitamin B-1
cold multi-symptom nighttime
nasal moisturizer
vitamin C
daytime cold & flu
niacin
vitamin D
diabetic tussin DM
NICODERM CQ
vitamin D3
DIMAPHEN
NICOTINE GUM
vitamins A-D-E
dimenhydrinate
nighttime cold & flu relief
ZANTAC OTC
DIMETAPP
NIX
DIMETAPP DM
OCUTABS
diphenhydramine HCl
OCUVITE
docusate sodium
OCUVITE PRESERVISION
DRAMAMINE
omeprazole
famotidine
oxymetazoline HCl
fexofenadine
oyster shell calcium
fiber tabs
oyster shell calcium w/vit D
fiber therapy
pedia relief cough & cold
GAVISCON
pediatric electrolyte
guaifenesin
PEPCID COMPLETE
guaifenesin DM
PEPTO-BISMOL
KEY: ❚
!
◆
+
=
=
=
=
Note:
Specific Quantity Limits Apply.
Prior Authorization Required.
Included in Tablet-Splitting Program
Access restricted to network specialty phamacies.
1. * All branded self-injectables are subject to prior authorization.
2. * Some drugs are limited to 1 unit of use package per dispensing.
5
SECTION III — INDEX
DRUG NAME
TIER PAGE DRUG NAME
A
abacavir sulfate
abacavir/lamivudine/
zidovudine
❚Abilify
acamprosate calcium
tablet EC
acarbose
!Accu-Chek
acebutolol
acetaminophen w/
codeine
acetazolamide
acetazolamide ER
acetic acid HC otic
acetic acid otic
acetic acid/aluminum
acetate
acetylcysteine inh soln.
acitretin
+!❚Actemra SC
+!❚Acthar H.P. gel
acticin
+!Actimmune
❚Actonel 5mg, 30mg
❚Actonel with Calcium
acyclovir
❚acyclovir oral
adapalene
+!❚Adcirca
+!❚Adempas
❚Advair diskus
+!❚Afinitor
Aggrenox
❚albuterol sulfate ER
❚albuterol tab, syr
alclometasone
❚alendronate
❚alfuzosin HCl
❚Alinia
allopurinol
alprazolam/ER
aluminum chloride 20%
❚Alvesco
amantadine
amcinonide
amethia
amiloride
amiloride/HCTZ
aminophylline
amiodarone
amitriptyline
amitriptyline/
chlordiazepoxide
amitriptyline/perphenazine
amlodipine
amlodipine/benazepril
amnesteem
amoxapine
amoxicillin
amoxicillin-clavulanate ER
ampicillin
+!Ampyra
anagrelide
anastrozole
Androderm patch
❚Androgel
Apidra
+Apokyn
apri
Aptiom
Aptivus
aranelle
+Aranesp
+!Arcalyst
Asacol
Asacol HD
!Ascensia Breeze
aspirin SR
Astagraf XL
❚Atelvia
atenolol
atenolol/chlorthalidone
atorvastatin calcium
atovaquone
Atripla
atropine sulfate ophth
❚Atrovent/HFA
+!❚Aubagio
❚Avandamet
❚Avandaryl
❚Avandia
aviane
avita cream
+!Avonex
❚Axiron
azathioprine
❚azelastine 0.1%
nasal spray
azelastine ophth
KEY: ❚
!
◆
+
=
=
=
=
G
G
B
G
G
B
G
G
G
G
G
G
G
G
G
B
B
G
B
B
B
G
G
G
B
B
B
B
B
G
G
G
G
G
B
G
G
G
B
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
B
G
G
B
B
B
B
G
B
B
G
B
B
B
B
B
G
B
B
G
G
G
G
B
G
B
B
B
B
B
G
G
B
B
G
G
G
TIER PAGE DRUG NAME
azithromycin suspension G
G
2 azithromycin tablets
B
2 Azopt
B
3 bacitracin ophth
3 bacitracin/polymyxin
baclofen
1 balziva
1 Banzel
2 belladonna & opium
3 supp
belladonna/phenobarbital
2 benazepril
2 benazepril/HCTZ
1 benzonatate
1 benzoyl peroxide
1 benztropine
+!Berinert
1 betamethasone
4 dipropionate
3 betamethasone
3 dipropionate
4 augmented oint
1 betamethasone valerate
3 betamethasone/
3 clotrimazole
4 +!Betaseron
2 betaxolol
4 betaxolol HCl
2 bethanecol
2 Betoptic-S
3 bicalutamide
1 ❚Binosto
1 bisoprolol
3 bisoprolol/HCTZ
3 +!Bosulif
4 Brilinta
3 brimonidine
2 Brintellix
4 Brisdelle
1 bromfenac
3 bromocriptine
4 brompheniramine/
3 phenylephrine
2,3 brompheniramine/
4 pseudoephedrine
4 budesonide inh.
2 (0.25mg/2ml, 0.5mg/
2 2ml)
3 bumetanide
2 buprenorphine HCl
3 ❚bupropion
3 ❚bupropion ER
❚bupropion XL
3 buspirone
2 butalbital/APAP
2 butalbital/APAP/caffeine
4 butalbital/aspirin/caffeine
3 butorphanol NS
2 !Bydureon
2 !Byetta
2
C
3
1 calcipotriene ointment
1 calcipotriene solution
2 ❚calcitonin-salmon
2 calcitriol
1 calcium acetate
3 camila
4 Campral dosepack
4 camrese
2 Canasa supp.
4 ❚candesartan
1 ❚candesartan/HCTZ
1 capecitabine
4 +!❚Caprelsa
4 captopril
1 captopril/HCTZ
3 Carac
2 carbamazepine
3 carbamazepine XR
2 200mg, 400mg
2 carbidopa/levodopa
2 carbidopa/levodopa SA
2 carbidopa/levodopa/
2 entacapone
1 cardec/DM
3 carisoprodol
3 carisoprodol/ASA
1 carteolol
1 cartia XT
1 carvedilol
4 CeeNu
4 cefaclor
3 cefadroxil
2 cefdinir
2 cefpodoxime
1 cefprozil
cefuroxime
1 !❚Celebrex
G
G
G
G
B
G
G
G
G
G
G
G
B
G
G
G
G
B
G
G
G
B
G
B
G
G
B
B
G
B
B
G
G
G
G
G
G
G
G
G
G
G
G
G
G
G
B
B
G
G
G
G
G
G
B
G
B
G
G
G
B
G
G
B
G
G
G
G
G
G
G
G
G
G
G
B
G
G
G
G
G
G
B
2 Celontin
2 ❚Cenestin
1 Centany
cephalexin
1 !❚Cerdelga
1 cesia
3 ❚cetirizine
4 ❚Chantix
4 chloral hydrate
3 chlordiazepoxide
chlordiazepoxide/
4 clindinium
2 chloroquine phosphate
2 chlorothiazide
1 chlorpheniramine/
4 pseudoephedrine
3 chlorpromazine
2 chlorpropamide
4 chlorthalidone
chlorzoxazone
4 cholestyramine
choline mag. trisalicylate
!ciclodan
4 ciclopirox cream/gel
4 ciclopirox soln
cilostazol
cimetidine
3
!❚Cimzia
2
!Cinryze
1
Ciprodex
1
ciprofloxacin
1
ciprofloxacin ophth
1
◆citalopram
3
citric acid/sod citrate
2
claravis
2
clarithromycin susp
1
clarithromycin tabs
1
clemastine
1
❚Climara Pro
3
clindamycin HCL
4
clindamycin sol/
1
swabs/gel/lotion
3
clobetasol propionate
1
clomipramine
clonazepam
1
clonidine, oral, patch
clopidogrel
3
clorazepate
clotrimazole lozenge
clozapine
2
Coartem
3
codeine sulfate
3,4
colchicine
3 colchicine/probenecid
3 Colcrys
3 colestipol
3 ❚Combipatch
3 ❚Combivent Respimat
3 +!❚Cometriq
3 ❚Commit
1 Complera
1 !Contour
+!Copaxone
4 Cordran tape
4 Cortifoam
3 cortisone acetate
4 Creon
4 Crixivan
4 cromolyn inh. soln.
3 cromolyn ophth
4 cromolyn sodium
4 cryselle
2 Cuprimine
2 cyanocobalamin inj.
1 cyclobenzaprine
1 cyclophosphamide
2 cyclosporine
2 cyproheptadine
4 Cystaran
3
D
3 danazol
dantrolene sodium
3 Dapsone
3 Daraprim
3 Daytrana
Delzicol
1 desipramine
3 desmopressin solution
3 desmopressin tabs
1 desmopressin vial
2 4mcg/ml
2 desonide
1 desoximetasone
2 Desvenlafaxine ER
2 Desvenlafaxine fumarate
2 dexameth/neomycin/
2 poly B
2 dexamethasone ophth
2 dexamethasone oral
3 dexchlorpheniramine
TIER PAGE DRUG NAME
dexmethylphenidate
dexmethylphenidate ER
dextroamphetamine tabs
diazepam
Dibenzyline
diclofenac potassium
diclofenac sodium
dicloxacillin
dicyclomine
didanosine
diflorasone
diflunisal
digoxin
dihydroergotamine
mesylate
Dilatrate SR
diltia XT
diltiazem
diltiazem CD/SR/ER/XR
Dipentum
diphenhydramine
diphenoxylate/atropine
dipyridamole
disopyramide
disopyramide CR
disulfiram
divalproex sodium/ER
❚donepezil
dorzolamide 2% eye
drops
dorzolamide/timolol
eye drops
doxazosin
doxepin
doxycycline
❚Dulera
duloxetine
B
B
B
G
B
G
G
B
G
G
G
4
4
4
2
3
4
1
4
3
3
4
G
G
G
2
2
1
G
G
G
G
G
G
G
G
G
G
G
B
B
B
G
G
G
G
G
G
G
G
B
G
G
3
1
2
3
2
3
2
4
4
1
4
4
2
1
2
1
3
1
4
2
2
1
E
4 econazole
2 Edurant
4 Effient
!Egrifta
4 8-MOP
3 Elidel
3 Eliquis
2 Emcyt
1 !❚Emend
3 Emtriva
2 enalapril
3 enalapril/HCTZ
2 +!❚Enbrel
3 endocet
1 ❚Enjuvia
1 enoxaparin
1 enpresse
2 entacapone
4 enulose
3 epinephrine inj.
1 Epipen/Jr.
4 Epivir solution
2 Epivir-HBV solution
1 eplerenone
3 +Epogen
4 ❚eprosartan
4 Epzicom
4 ergoloid mesylates
4 Ergomar
2 ergotamine/caffeine
3 +!❚Erivedge
1 errin
4 Ery-Tab
4 erythromycin base
3 erythromycin
4 ethylsuccinate (E.E.S.)
3 erythromycin ophth
1 erythromycin sol/
2 swabs/gel
1 erythromycin stearate
1 erythromycin/benz
peroxide
3 erythromycin/
3 sulfisoxazole
2 +!❚Esbriet
2 ◆escitalopram
3 estazolam
4 ❚estradiol oral
3 ❚estradiol patches
3 ❚estradiol/noreth ac
3 ❚Estring
3 ❚estrogen/
methyltesterone
4 ❚estropipate
4 ethambutol
3 ethosuximide
3 etidronate disodium
1 etodolac
etodolac SA
1 etoposide
4 ❚Evamist
1 Evotaz
G
G
G
G
G
G
G
G
B
G
G
G
B
G
B
B
B
B
B
B
B
B
B
G
B
B
G
G
G
G
B
G
G
G
G
G
B
G
G
B
B
B
B
G
G
G
G
G
G
B
B
G
G
G
G
TIER PAGE DRUG NAME
G
G
G
G
B
G
G
G
G
G
G
G
G
G
3
3
3
3
2
3
3
2
4
2
4
3
2
3
B
G
G
G
B
G
G
G
G
G
G
G
G
G
2
2
2
2
4
1
4
1
2
2
3
3
1
1
G
1
G
G
G
B
G
2
3
2
3
3
G
B
B
B
B
B
B
B
B
B
G
G
B
G
B
G
G
G
G
G
B
B
B
G
B
G
B
G
B
G
B
G
B
G
G
4
2
1
3
4
4
1
1
4
2
2
2
3
3
4
1
4
3
4
3
3
2
2
2
1
2
2
1
3
3
1
4
2
2
2
G
G
1
4
G
G
2
4
G
2
B
G
G
G
G
G
B
G
3
3
3
4
4
4
4
4
G
G
G
G
G
G
G
B
B
4
2
4
4
3
3
1
4
2
❚Evzio
Exelderm
❚Exelon Patch
exemestane
+Exjade
+!Extavia
TIER PAGE DRUG NAME
F
❚famciclovir
famotidine
❚Fanapt
Fareston
❚Farxiga
felbamate
felodipine ER
fenofibrate
fenofibric acid, tab
fenoprofen
!❚fentanyl lozenge
fentanyl patch
Fetzima
!❚finasteride
+!Firazyr
flecainide
+!Flolan
❚Flovent Diskus
❚Flovent HFA
fluconazole
flucytosine
fludrocortisone
fluocinolone
acetonide
fluocinonide
fluorometholone
ophth
fluorouracil
◆fluoxetine 10, 20mg
tablet
fluoxetine capsule
fluphenazine
decanoate
fluphenazine, oral
flurazepam
flurbiprofen
flurbiprofen ophth
flutamide
❚fluticasone nasal spray
fluticasone propionate
fluvastatin
◆fluvoxamine tab
FML Forte
FML S.O.P.
folic acid
fondaparinux
+!Forteo
❚Fortesta
❚fortical NS
❚Fosamax Plus D
fosinopril
Fragmin
!FreeStyle
Fulyzaq
furosemide
+Fuzeon
Fycompa
G
gabapentin
Gabitril
❚galantamine
Galzin
+!Gamunex C
ganciclovir
+!Gattex
gemfibrozil
generic Adderall
generic Adderall XR
generic Concerta
generic Dexedrine
spansules
gengraf
+!Genotropin
gentamicin cr/oint
gentamicin ophth
+!❚Gilenya
+!❚Gilotrif
+!❚Gleevec
❚glimepiride
glipizide
❚glipizide ER
❚glipizide/metformin
Glucagon
glyburide
glyburide micronized
glycopyrrolate
!❚granisetron
!❚Grastek
griseofulvin
guaifenesin 1200/DM
guaifenesin/codeine
guanabenz
B
B
B
G
B
B
3
4
1
1
1
3
G
G
B
B
B
G
G
G
G
G
G
G
B
G
B
G
B
B
B
G
G
G
G
1,2
4
3
1
1
4
2
2
2
3
3
3
3
1,2
2
2
2
3
3
2
2
3
4
G
G
4
1
G
G
4
3
G
G
3
3
G
G
G
G
G
G
G
G
G
B
B
G
G
B
B
G
B
G
B
B
B
G
B
B
3
3
3
1
1
1
4
2
3
1
1
4
1
3
2
3
3
2
1
1
4
2
2
4
G
B
G
B
B
G
B
G
G
G
G
G
4
4
1
4
3
2
4
2
3
3
3
3
G
B
G
G
B
B
B
G
G
G
G
B
G
G
G
G
B
G
G
G
G
2
3
4
1
3
1
1
1
1
1
1
1
1
1
4
4
1
2
1
1
2
guanfacine
TIER PAGE
H
halobetasol
haloperidol decanoate
haloperidol, oral
+!❚Harvoni
heparin
❚Hepsera
!❚Hetlioz
Hexalen
Histex IE
+!Hizentra
homatropine
Humalog insulin
+!Humatrope
+!❚Humira
Humulin (all types)
+Hycamptin
hydralazine
hydrochlorothiazide
hydrocodone/
chlorpheniramine
hydrocodone/
homatropine
hydrocodone/ibuprofen
hydrocortisone 2.5%
hydrocortisone oral
hydrocortisone
rectal cr. & supp.
hydrocortisone
rectal enema
hydrocortisone valerate
hydrocortisone/
iodoquinol
hydrocortisone/
pramoxine
hydrocortisone/urea
hydromorphone
hydroxychloroquine
hydroxyurea
hydroxyzine HCL
hydroxyzine pamoate
hyoscyamine/CR
G
1
G
G
G
G
3
4
4
4
G
4
G
G
4
4
G
4
4
3
2,3
1
1
1
4
❚ibandronate
ibuprofen
+!❚Iclusig
!❚Imbruvica
imipramine
imiquimod 5% cream
indapamide
indomethacin
+!❚Inlyta
+Innohep
Intelence
+!Intron A
Intuniv
❚Invega
Invirase
❚Invokamet
❚Invokana
ipratropium inh. soln.
ipratropium nasal spray
❚irbesartan
❚irbesartan/HCTZ
!Iressa
Isentress
isometh/
dichloralphen/APAP
isoniazid
Isopto Carbachol 1.5%
isosorbide dinitrate
isosorbide mononitrate
isosorbide
mononitrate SA
isoxsuprine
isradipine
❚itraconazole
G
G
B
B
G
G
G
G
B
B
B
B
B
B
B
B
B
G
G
G
G
B
B
G
3
3
1
1
3
4
2
1,3
1
1
2
1
3
3
2
1
1
3
1
2
2
1
2
3
G
B
G
G
G
2
1
2
2
2
G
G
G
2
2
2
+!❚Jakafi
jantoven
❚Janumet
❚Januvia
❚Jardiance
Jentadueto
jolessa
jolivette
junel/FE
Juvisync
B
G
B
B
B
B
G
G
G
B
1
1
1
1
1
1
4
4
4
1
B
B
G
B
B
G
G
G
3
2
4
1
2
2,4
3
3
I
J
K
+!Kaldydeco
Kaletra
kariva
Kazano
Ketek
ketoconazole
ketoprofen
ketorolac inj.
1. * All branded self-injectables are subject to prior authorization.
2. * Some drugs are limited to 1 unit of use package per dispensing.
6
2
4
3
3
2
1
2
3
1
1
3
1
1
3
3
1
1
2
2
1
G
G
G
G
G
G
G
Note:
Specific Quantity Limits Apply.
Prior Authorization Required.
Included in Tablet-Splitting Program
Access restricted to network specialty phamacies.
G
G
G
G
B
G
B
B
B
B
B
G
B
B
B
B
B
G
G
G
SECTION III — INDEX (CONT’D)
DRUG NAME
TIER PAGE DRUG NAME
❚ketorolac tab
ketorolac tromethamine
ketotifen opthalmic
solution
Khedezla
+!Kineret
Kombiglyze
+!Kuvan
+!Kynamro
G
G
G
labetalol
lactulose
lamivudine
lamivudine tabs
lamivudine/zidovudine
lamotrigine
❚lansoprazole
Lantus
latanoprost
❚Latuda
leflunomide
lessina
+!❚Letairis
letrozole
leucovorin
Leukeran
+!Leukine
!leuprolide
Levemir
levetiracetam
levobunolol
levocarnitine
❚levonorgestrel
levora
levothroid
levothyroxine
levoxyl
Lexiva
lidocaine
!❚lidocaine patch
Lindane
Linzess
liothyronine
lisinopril
lisinopril/HCTZ
lithium carbonate
loratadine
loratadine-D
lorazepam
❚losartan
❚losartan HCT
Lotemax
❚◆lovastatin
low-ogestrel
loxapine
Lumigan
lutera
Lyrica
Lysodren
G
G
G
G
G
G
G
B
G
B
G
G
B
G
G
B
B
G
B
G
G
G
G
G
G
G
G
B
G
G
B
B
G
G
G
G
G
G
G
G
G
B
G
G
G
B
G
B
B
Malarone
maprotiline
Matulane
❚Maxair Autohaler
meclizine
meclofenamate
medroxyprogesterone
mefloquine
megestrol
+!❚Mekinist
meloxicam
melphalan
❚Menest
meperidine
meperidine/promethazine
Mephyton
meprobamate
mercaptopurine
mesalamine enema
mesna
metadate ER
metaproterenol syr
metformin
❚metformin ER
❚metformin/glyburide
methadone
methazolamide
methenamine
combination
methimazole
methocarbamol
methotrexate
methyldopa
methyldopa/HCTZ
methylphenidate/SR/CD
methylprednisolone
metipranolol
metoclopramide
metolazone
B
G
B
B
G
G
G
G
G
B
G
G
B
G
G
B
G
G
G
G
G
G
G
G
G
G
G
G
L
M
KEY: ❚
!
◆
+
=
=
=
=
B
B
B
B
B
G
G
G
G
G
G
G
G
G
G
3 metoprolol
1 metoprolol ER
1 metoprolol/HCTZ
metronidazole
3 metronidazole cream/
3 lotion/gel
1 mexiletine
4 Miacalcin inj.
2 miconazole vag supp
microgestin/FE
2 midodrine
4 minocycline
2 minoxidil oral
2 Mirena
2 ◆mirtazapine
4 misoprostol
4 !❚modafinil
1 mometasone cr/oint
1 mononessa
3 ❚montelukast
3 morphine SR
4 morphine tab, soln, supp
2 MSIR tabs, sol
1 multivitamin + fluoride
4 mupirocin
1 +!❚Myalept
1 mycophenolate
1 mofetil
1 Myleran
N
4
1 nabumetone
4 nadolol
4 naltrexone
4 ❚Namenda
4 naphazoline
4 naproxen
4 naproxen EC
2 ❚naratriptan
4 ❚Nasacort OTC
4 Nascobal
4 ❚nateglinide
4 Nebupent
4 necon
2 nefazodone
2 neomycin
3 neomycin/bacitracin/
1 poly B
1 neomycin/bacitracin/
3 poly B/HC
2 neomycin/polymyxin/
2 HC otic
1 Nesina
2 !Neulasta
4 +!Neumega
3 +!Neupogen
1 Nevanac
4 nevirapine
4 +!❚Nexavar
1 ❚next choice
❚next choice one dose
2 niacin ER
3 nicardipine
1 ❚Nicotine Gum
3 ❚Nicotine lozenges
4 ❚Nicotine patches
3 various
4 ❚Nicotrol Inhaler/NS
2 nifediac CC
1 nifedical XL
1 nifedipine
3 nifedipine SR
1 Nilandron
4 nimodipine
3 nisoldipine
3 nitrofurantoin
4 nitroglycerin oint
3 nitroglycerin pumpspray
1 nitroglycerin SR
4 nitroglycerin
1 transdermal patch
3 Nitrostat
3 nizatidine
1 nora-BE
1 +!Norditropin
1 norethindrone
3 norethindrone a-e
2 estradiol/ferrous
2 fumarate
+!❚Northera
4 nortrel
3 nortriptyline
1,3 Norvir
2 Novolin
2 Novolog
3 +!Nutropin
4 NuvaRing
1 !❚Nuvigil
4 nystatin
2 nystatin vag tab
TIER PAGE DRUG NAME
G
G
G
G
G
2
2
2
2
4
G
B
G
G
G
G
G
B
G
G
G
G
G
G
G
G
G
G
G
B
G
2
1
4
4
2
2
2
4
3
4
3
4
4
3
3
3
3
4
4
3
2
B
1
G
G
G
B
G
G
G
G
B
B
G
B
G
G
G
G
3
2
3
1
1
3
3
3
1
4
1
2
4
3
2
1
G
1
G
1
B
B
B
B
B
G
B
G
G
G
G
G
G
G
1
1
1
1
1
2
1
4
4
2
2
4
4
4
B
G
G
G
G
B
G
G
G
G
G
G
G
4
2
2
2
2
1
2
2
2
2
2
2
2
B
G
G
B
G
G
2
4
4
3
4
4
B
G
G
B
B
B
B
B
B
G
G
2
4
3
2
1
1
3
4
3
2,4
4
TIER PAGE DRUG NAME
nystatin/triamcinolone
nystop
G
G
ocella
+octreotide
+!❚Ofev
ofloxacin
ofloxacin ophth
ofloxacin otic
ogestrel
❚olanzapine
❚olanzapine/
fluoxetine
+!❚Olysio
❚omeprazole
+!Omnitrope
❚ondansetron
OneTouch
Onfi
Onglyza
Opana ER
+!❚Opsumit
!❚Oralair
+!❚Orencia
+!❚Orenitram
+Orfadin
orphenadrine
Oseni
+!❚Otezla
oxazepam
oxcarbazepine
Oxistat
Oxsoralen Ultra
❚oxybutynin
❚oxybutynin ER
oxycodone
oxycodone/
acetaminophen
oxycodone/aspirin
oxymorphone ER
G
G
B
G
G
G
G
G
G
O
P
B
G
B
G
B
B
B
B
B
B
B
B
B
G
B
B
G
G
B
B
G
G
G
G
G
G
Pancreaze
B
❚pantoprazole
G
paregoric
G
paromomycin
G
◆paroxetine HCl
G
Patanol
B
peg 3350/electrolyte
G
+!Pegasys
B
penicillin VK
G
Pentasa
B
pentazocine/naloxone
G
pentoxifylline
G
perphenazine
G
Pertzye
B
Pexeva
B
phenazopyridine
G
phenelzine
G
phenobarbital
G
phenylephrine ophth
G
phenytoin
G
Phisohex
B
Phospholine Iodide
B
phytonadione
G
pilocarpine
G
pindolol
G
❚pioglitazone
G
piroxicam
G
+!❚Plegridy
B
podofilox
G
polymyxin B/TMP
G
+!❚Pomalyst
B
portia
G
potassium aminobenzoate G
potassium bicarbonate
G
potassium chloride
G
potassium citrate
G
Potiga
B
❚Pradaxa
B
pramipexole
G
pramoxine/HC acetate
G
2.5%
prascion RA
G
❚◆pravastatin
G
prazosin
G
pre-natal vitamins
G
!Precision
B
Pred Mild
B
prednisolone acetate
G
prednisolone oral
G
prednisolone sod acetate G
prednisone oral
G
❚Premarin
B
Premarin vag cream
B
❚Premphase
B
❚Prempro
B
previfem
G
Prezcobix
B
Prezista
B
4 ❚Prilosec-OTC
4 Primaquine
primidone
4 Pristiq
3 ❚ProAir HFA
3 probenecid
2 procentra
1 prochlorperazine
1 +Procrit
4 Proctofoam-HC
3 +!Procysbi
3 progesterone, micronized
+!❚Promacta
promethazine
2
promethazine/codeine
4
propafenone
3
propranolol
4
propranolol/HCTZ
1
propylthiouracil
4
pseudoephedrine
1
pseudoephedrine/
3
codeine
2
❚Pulmicort Flexhaler
1
+Pulmozyme
3
Purixan
2 pyrazinamide
4
Q
3
1 quasense
Qudexy
XR
3
3 ❚quetiapine
4 quinapril
4 quinapril/HCTZ
4 quinidine gluconate
1 quinidine sulfate SR
1 ❚Qvar
R
3
3 !❚Ragwitek
❚raloxifene
3 ramipril
3 Ranexa
ranitidine (all)
4 !Ravicti
4 +!Rebif
4 Regranex
2 ❚Relenza
3 !❚Relistor
1 Renvela
4 ❚repaglanide
2 Rescriptor
2 Retrovir IV infusion vial
4 +!❚Revlimid
3 Reyataz
1 +!ribapak
3 +!ribasphere
4 +!ribavirin
3 Ridaura
1 rifabutin
3 rifampin
3 Rifater
1 Rilutek
3 rimantadine
4 ❚risedronate 150mg
1 ❚risperidone
4 ❚risperidone m-tab
1 ❚rivastigamine
2 ropinirole
1 +!❚Ruconest
S
3
3 Sabril
4 +!Saizen
1 salsalate
1 !❚Samsca
4 Sandimmune
4 ❚Saphris
3 Savella
3 ❚selegiline
1 selenium sulf 2.25%
4 shampoo
1 Selzentry
3 Semprex-D
4 +Sensipar
❚Serevent Diskus
4 ❚Seroquel XR
2 ◆sertraline
2 sevelamer tablets
4 +!❚Signifor
1 silver sulfadiazine
1 +!❚Simponi
1 ❚◆simvastatin
4 sirolimus
1 !❚Sivextro
4 sod. polystyrene
4 sulfonate
4 sod. sulfacetamide/
4 sulfur lot
4 sod.sulfacetamide/sulfur
4 emulsion cleanser
2 sodium chloride
2 irrigating soln
TIER PAGE DRUG NAME
G
B
G
B
B
G
G
G
B
B
B
G
B
G
G
G
G
G
G
G
G
4
2
4
3
3
1
3
4
1
4
3
4
1
1,4
1
2
2
2
4
1
1
B
B
B
G
3
3
1
2
G
B
G
G
G
G
G
B
4
4
3
2
2
2
2
3
B
G
G
B
G
B
B
B
B
B
B
G
B
B
B
B
G
G
G
B
G
G
B
B
G
G
G
G
G
G
B
1
3
2
2
4
3
3
4
2
4
4
1
2
2
1
2
2
2
2
3
2
2
2
3
2
3
3
3
1
3
2
B
B
G
B
B
B
B
G
G
4
3
3
2
2
3
3
3
4
B
B
B
B
B
G
G
B
G
B
G
G
B
G
2
1
3
3
3
3
4
1
4
3
2
2
2
3
G
4
G
4
G
4
TIER PAGE DRUG NAME
sodium fluoride
chewable tab & drops
solia
+!Somavert
sotalol
sotret
+!❚Sovaldi
❚Spiriva
❚Spiriva Respimat
spironolactone
spironolactone/HCTZ
sprintec
+!❚Sprycel
stavudine
+!❚Stelara
+Stimate
+!Stivarga
Strattera
Stribild
Suboxone Film
sucralfate
sulfacetamide
sulfacetamide 10%
sulfacetamide/
prednisolone ophth
sulfamethoxazole/
trimethoprim
sulfasalazine
sulfasalazine EC
sulindac
❚sumatriptan
Sustiva
+!❚Sutent
+!❚Sylatron
❚Symbicort
!❚Symlin
Synarel
Synthroid
G
tacrolimus
tacrolimus ointment
+!❚Tafinlar
❚Tamiflu
tamoxifen
tamsulosin
!❚Tanzeum
+!Tarceva
Targretin
+!❚Tasigna
!Tazorac
+!❚Tecfidera
!❚Tekturna
!❚Tekturna HCT
❚telmisartan
❚telmisartan/HCTZ
temazepam
+!temozolomide
terazosin
❚terbinafine
terbutaline tab
terconazole
❚Testim
❚Testosterone gel
tetracycline
+!Tev-Tropin
+Thalomid
theochron
theophylline/SR tabs,
liquid
thioridazine
thiothixene
thyroid
Thyrolar
tiagabine
ticlopidine
timolol
Tivicay
tizanidine
+Tobi
tobramycin soln
tobramycin/dexameth
tolazamide
tolbutamide
❚tolterodine
❚tolterodine ER
topiramate
topotecan
torsemide
+!❚Tracleer
Tradjenta
tramadol
Transderm Scop
tranylcypromine
travoprost
trazodone
!tretinoin cr/gel
tri-sprintec
❚triamcinolone acetonide
triamterene/HCTZ
triazolam
T
G
B
G
G
B
B
B
G
G
G
B
G
B
B
B
B
B
B
G
G
G
G
TIER PAGE
4 trifluoperazine
trifluridine
4 trihexyphenidyl
3 trimethobenzamide
2 trimethoprim
4 trinessa
2 Triumeq
3 trivora
3 Trokendi XR
2 tropicamide
2
❚trospium
4
1 !TRUEtest
2 !TRUEtrack
4 !❚Trulicity
3 Truvada
1 Tybost
3 +!Tykerb
U
2
3 Uceris ER tablet
4 Ulesfia
4 Ultresa
1 unithroid
1
ursodiol
G
2
G
G
G
G
B
B
B
B
B
B
B
4
4
3
3
2
1
1
3
1
3
4
G
G
B
B
G
G
B
B
B
B
B
B
B
B
G
G
G
G
G
G
G
G
B
B
G
B
B
G
G
2
4
1
2
1
1,2
1
1
1
1
4
3
2
2
2
2
3
1
2
2
3
4
2
2
2
3
1
3
3
G
G
G
B
G
G
G
B
G
B
G
G
G
G
G
G
G
G
G
B
B
G
B
G
G
G
G
G
G
G
G
3
3
4
4
4
1
1,2
2
3
2
1
1
1
1
1
1
4
1
2
2
1
3
4
3
1
3
4
4
4
2
3
V
B
B
B
G
G
4
4
4
4
4
B
G
B
G
G
G
G
G
G
B
G
G
G
B
G
G
B
B
B
B
B
B
B
B
B
B
G
G
4
2
1
2
4
2
2
2
4
2
4
3
3
3
2
2
3
1
2
2
2
3
4
2
2
2
4
4
B
B
B
G
B
2
2
3
2
1
warfarin
G
1
B
B
B
B
B
B
G
1
1
3
2
1
1
4
G
2
G
G
G
B
B
G
B
B
G
G
B
B
G
G
G
B
B
G
B
B
B
B
3
3
4
3
1
4
4
2
2
3
2
1
3
3
4
1
3
4
1
1
1
2
W
+!❚Xalkori
Xarelto
+!❚Xeljanz
+!❚Xenazine
❚Xigduo XR
+!Xtandi
❚xulane
yohimbine
X
Y
Z
❚zafirlukast
❚zaleplon
zarah
+Zavesca
+!❚Zelboraf
zenchent
Zenpep
❚Zetia
zidovudine
❚ziprasidone caps
Zmax
!Zolinza
❚zolpidem
❚zolpidem CR
zonisamide
!❚Zontivity
+!Zorbtive
zovia
!❚Zydelig
+!❚Zykadia
+!❚Zytiga
!❚Zyvox
1. * All branded self-injectables are subject to prior authorization.
2. * Some drugs are limited to 1 unit of use package per dispensing.
7
3
1
3
4
2
4
2
4
4
1
1
1
1
1
2
2
1
Vagifem
❚valacyclovir
+!❚Valchlor
valganciclovir tablets
valproic acid
❚valsartan
❚valsartan/HCTZ
vancomycin
vandazole vag
+!Veletri
velivet
◆venlafaxine
venlafaxine ER
❚Ventolin HFA
verapamil
verapamil SR
Versacloz
!❚Victoza
Videx
Videx pediatric solution
+!❚Viekira Pak
Viibryd
Viokace
Viracept
Viramune XR
Viread
vit A,D,C + fluoride
vit A,D,C + fluoride
and iron
Vitekta
❚Vogelxo
Voltaren gel
!❚voriconazole
!Votrient
Note:
Specific Quantity Limits Apply.
Prior Authorization Required.
Included in Tablet-Splitting Program
Access restricted to network specialty phamacies.
G
G
G
G
G
G
B
G
B
G
G
B
B
B
B
B
B

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