2015 Drug Formulary - HealthPlus of Michigan

Transcription

2015 Drug Formulary
For VenturePlus (Small Group) and Signature (Individual)
ACA-Compliant HMO & PPO
Effective 1/1/2015
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VenturePlus (Small Group) & Signature (Individual)
2015 DRUG FORMULARY
TABLE OF CONTENTS
PREFACE TO THE CURRENT EDITION ..................................................................................................3
HOW TO USE THIS FORMULARY ...........................................................................................................4
DEFINITIONS ...............................................................................................................................................6
MEMBER PRESCRIPTION BENEFIT ........................................................................................................7
GENERIC SUBSTITUTION GUIDELINES ................................................................................................7
PREFERRED MEDICATION PROGRAM ..................................................................................................7
PRIOR AUTHORIZATION PROGRAM .....................................................................................................7
PHARMACY AUDIT PROGRAM ...............................................................................................................8
DRUG RECALL SURVEILLANCE PROGRAM ........................................................................................8
DOSE OPTIMIZATION PROGRAM ...........................................................................................................9
DRUG UTILIZATION REVIEW (DUR) .....................................................................................................9
CONTROLLED SUBSTANCES PHARMACY PROGRAM (CSPP) .........................................................9
MANDATORY 90-DAY MEDICATION PROGRAM................................................................................9
MANDATORY SPECIALTY PHARMACY PROGRAM .........................................................................10
HEALTHPLUS DENTAL FORMULARY .................................................................................................10
PHARMACY & THERAPEUTICS COMMITTEE....................................................................................12
FORMULARY UPDATES AND REVISIONS ..........................................................................................12
SMOKING CESSATION PHARMACOTHERAPY ..................................................................................12
HEALTHPLUS REQUEST FOR ADDITION TO THE FORMULARY ..................................................13
PHARMACY PRIOR AUTHORIZATION FORM ....................................................................................14
PRESCRIPTION BENEFIT LIMITATIONS..............................................................................................15
FORMULARY LIST .................................................................................................................................18
PREFACE TO THE CURRENT EDITION
Recommendations in the Formulary are intended to promote the most cost-effective therapy
while maintaining a high quality drug benefit. The Drug Formulary is not meant to take the place
of the product package insert, and users are encouraged to refer to the full prescribing
information provided with the product.
Input and suggestions for inclusion in the 2016 edition are encouraged.
Please direct your comments and suggestions to:
HealthPlus of Michigan
Pharmacy Department
2050 S Linden Road
P.O. Box 1700
Flint, MI 48501-1700
Or e-mail:
[email protected]
Formulary information is also available at www.healthplus.org.
Formulary information is also available through various e-prescribing applications
(along with eligibility verification and prescription history).
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HOW TO USE THIS FORMULARY
ORGANIZATION
The HealthPlus Drug Formulary contains information about medication coverage, generic and
preferred brand prescriptions, and information about HealthPlus Pharmacy policies and
procedures that reflect best practices in the pharmacy industry and current treatment standards.
There are two ways to find your drug within the formulary:
Category of Drug/Medical Condition
The drugs in this formulary are grouped into categories depending on the type of drug or
medical conditions they are used to treat. For example, drugs used to treat infections are listed
under the category “ANTI-INFECTIVE AGENTS.” If you know what your drug is used for, look
for the drug category name in the list that begins on page 17. 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 224. 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.
CONTENT
A formulary is a list of covered drugs selected by HealthPlus 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. Recommendations for the HealthPlus formulary are
developed through the Pharmacy & Therapeutics Committee and are based on a review of
current drug information and medical literature. HealthPlus recognizes that it is the sole
responsibility of the physician to determine the best course of care for a particular patient. The
HealthPlus Drug Formulary is VOLUNTARY or OPEN, with some restrictions for drugs included
in special programs such as the Prior Authorization program (including Step Therapy).
Procedures for requesting consideration of non-preferred drugs for addition to “preferred” status
are discussed under the heading “Formulary Updates and Revisions” on page 12.
DRUG LISTING
For each drug category, there is an alphabetic listing of medications that includes both brand
and generic drugs. Generic drugs (Tier 1) are listed in lower case italic letters. Brand name
drugs are listed in UPPER CASE bolded letters. The copay level/drug tier is included for each
medication, along with any type of restrictions such as prior authorization (PA), quantity limits,
etc.
For VenturePlus (Small Group) and Signature (Individual), the following copay tiers apply:
 Generic Drugs=Tier 1, lowest copay
 Preferred Brand Drugs=Tier 2, medium copay
 Non-Preferred Brand Drugs=Tier 3, higher copay
 Specialty Drugs=Tier 4, highest copay OR percent copay
 Zero Copay Drugs=Tier 5, required by health care reform
Members have access to up-to-date information about prescription drugs, the formulary and
information specific to their benefit at the website at www.healthplus.org.
HealthPlus encourages the consideration of OTC products. In general, OTC products are not
covered, with the exception of insulin and insulin syringes. Specific OTC medications
(preventative medications for health care reform) are covered at a zero copay with a
prescription, including OTC folic acid, iron supplements, oral fluoride, aspirin, and FDAapproved smoking cessation products. These products may have restrictions as specified by
health care reform (i.e., restrictions by age or sex). These OTC products are a covered benefit
with a written prescription.
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DEFINITIONS
1. FORMULARY: A list of medications and medical devices recommended for use under
the HealthPlus prescription drug benefit.
2. OPEN FORMULARY: A Drug Formulary that is voluntary. The HealthPlus Drug
Formulary is currently an “open” or “voluntary” Formulary, with some restrictions for drugs
included in special programs, such as the Prior Authorization program. Prescriptions for
drugs listed as Non-Preferred, or not listed in the HealthPlus Drug Formulary, are still a
covered benefit to the patient as stipulated in the individual group subscriber contract,
with exceptions as noted.
3. CLOSED FORMULARY: A Drug Formulary that is mandatory. In a “mandatory”
Formulary, prescriptions for products that are Non-Preferred, or not listed in the
Formulary, are not a covered benefit for the patient. Patients are still at liberty to use outof-pocket expenses for non-formulary drug products.
4. PHARMACY & THERAPEUTICS COMMITTEE: An interdisciplinary committee
comprised of HealthPlus staff and community physicians and pharmacists who are
primarily responsible for the maintenance of the HealthPlus Drug Formulary, including the
evaluation and selection of drug products. The Pharmacy & Therapeutics Committee
meets at least five times annually.
5. PREFERRED DRUGS: Drugs included in copay tier 1 or 2 in the HealthPlus Drug
Formulary or updates to the Formulary. Tier 4, specialty drugs, may contain both
preferred and non-preferred drugs.
6. NON-PREFERRED DRUGS: Drug products not recommended by the Pharmacy &
Therapeutics Committee and included in copay tier 3. Non-preferred drugs are still a
covered benefit in an Open Formulary, and are assigned to a higher copay tier. There
may also be some limitations (see Prescription Benefit Limitations, Appendix E, page on
page 15). Tier 4, specialty drugs, may contain both preferred and non-preferred drugs.
7. MAXIMUM ALLOWABLE COST (MAC): The maximum allowable cost that HealthPlus
reimburses to a pharmacy for generic medications.
8. EXCLUDED DRUGS: Drugs that are excluded from the drug benefit. Excluded drugs
that are not reimbursable to the pharmacy include (but are not limited to): products for
cosmetic use, experimental drugs, medical foods, bulk chemicals, surgical
supplies/medical devices/ostomy supplies/diagnostic agents (when billed by a
pharmacy), compounding kits, dermatological kits, prescription homeopathic products,
wound dressings, pharmaceutical aids, impotence/erectile dysfunction agents. See
Prescription Benefit Limitations (Appendix E, page 15) for specific limitations.
9. PRIOR AUTHORIZATION DRUGS: Drugs for which specific established criteria must be
met for coverage. Criteria are usually based on appropriate selection of recommended
first-line alternatives prior to selection of the prior authorization drug. A sample prior
authorization request form is included as Appendix C, page on page 14.
10. STEP THERAPY: Drugs for which a “first step” medication is required before coverage of
the second step drug. Step therapy is a process that may be used for administering
established Prior Authorization criteria.
11. COPAYMENT: A fee charged to the member for each prescription filled. Copayments
vary depending on the member’s benefit level.
MEMBER PRESCRIPTION BENEFIT
For VenturePlus (Small Group) and Signature (Individual) ACA-Compliant HMO, prescriptions
must be written by a participating physician, or a non-participating physician with the required
referral (this does not apply to PPO members). If the medication is a covered benefit, members
may fill their prescription at a participating HealthPlus pharmacy by presenting their identification
card. A list of participating pharmacies may be found in the Provider Directory, on-line at
www.healthplus.org or by contacting the Customer Service Department.
Based on the member’s benefit level, a copayment may be required. Copayments vary. If you
or the member has questions about copayments or deductibles (if applicable), please contact
the HealthPlus Customer Service Department at 1-800-332-9161. For specific information
about PPO members, please contact HealthPlus PPO Customer Service at 1-888-212-1512.
GENERIC SUBSTITUTION GUIDELINES
Drugs that have generic equivalents MUST BE DISPENSED GENERICALLY. The drugs
appear in lower case italics in the formulary. Maximum Allowable Cost (MAC) limits have been
established for the majority of these agents. 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. When a drug is generically available, the generic product is covered under
Copay Tier 1.
In cases of medical necessity, generic substitution may be overridden by the use of the
“Dispense as Written (DAW)” notation by the physician, with Prior Authorization required in
these instances. If the physician obtains prior authorization, the member may receive the brand
name drug instead of the generic equivalent. Brand drugs with a generic equivalent are NonPreferred and are covered under Copay Tier 3. If DAW is not medically necessary but the
member chooses the brand product in the absence of a DAW, he or she may do so by paying
the difference in cost and/or any applicable copayment.
PREFERRED MEDICATION PROGRAM
HealthPlus administers a Preferred Medication Program to promote the use of specific cobranded products or specific multi-source brand products. HealthPlus uses system messaging
in the pharmacy claims system to provide information to the dispensing pharmacist.
PRIOR AUTHORIZATION PROGRAM
HealthPlus requires prior authorization for selected drug products based on clinical, safety, or
cost reasons. A copy of the Pharmacy Prior Authorization Form is included as Appendix C on
page 14. The Prior Authorization Criteria for medications that require prior authorization at the
time of publication is available on the HealthPlus website.
In some cases, HealthPlus uses Step Therapy for some medications that require prior
authorization. This means that there are established “first step” drugs that must be used before
the “second step” drug is covered.
To prescribe a medication that requires prior authorization:

The physician or office staff may complete the Pharmacy Prior Authorization form.
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
Fax the form to the HealthPlus Pharmacy Department:
FAX (810) 720-2757 (FLINT)

If the patient presents a prescription to the pharmacy and prior authorization or an
exception has not been obtained, the pharmacy should contact the prescribing physician
and suggest preferred alternatives or instruct the physician to complete the Pharmacy
Prior Authorization Form. For medications included in the specialty injectable program,
the physician may initiate the request for medication through the specialty vendor. The
specialty vendor will then contact HealthPlus.
7-Day Starter Dose:
To ensure that members are never in a situation where they are unable to obtain their
medication, a 7-day starter dose may be dispensed by the pharmacy when an on-line edit is
received for a medication or quantity that requires prior authorization. This override is a onetime override and is subject to audit.


If the prescribing physician is unavailable for consult, the pharmacy may dispense up to a
7-day starter dose to initiate care for the member.
Place a “06” in the denial clarification field (field 420) and enter up to a “7” for the days
supply.
Emergency Override:
Pharmacies may also override non-participating physician edits that may apply when a
prescription is written for an emergency situation. Entering “03” in the level of service field (field
418) will allow an override for emergency prescriptions only. This override is intended to be a
one-time override and is subject to audit.
If you would like an updated list of medications that require prior authorization, or if you have
questions about this program, please call the Prior Authorization line at:
Flint local phone (810) 720-2758
Toll-free phone (877) 710-0993
PHARMACY AUDIT PROGRAM
HealthPlus (or its designee) performs pharmacy audits to help ensure consistent and accurate
electronic submission of prescription claims by the pharmacy network. Prescription claim audit
activities may include a review of utilization by pharmacies, physicians, and members. The
pharmacy audit program includes desk (paper) audits, on-site audits, and an appeals process.
DRUG RECALL SURVEILLANCE PROGRAM
When a particular drug product is recalled or withdrawn from the market due to safety reasons,
HealthPlus reviews prescription utilization to identify members receiving that drug. HealthPlus
notifies members and physicians affected by the recall, as appropriate.
DOSE OPTIMIZATION PROGRAM
HealthPlus administers a Dose Optimization Program to target medications that are
recommended for once daily dosing and/or support maximum dose recommendations through
quantity limits. By optimizing the dose and decreasing the frequency, patient compliance
increases and prescription costs decrease.
System edits apply for the targeted medications when prescribed more often than once daily or
above the quantity limits. Physicians may submit the standard HealthPlus Pharmacy Prior
Authorization form, with information that includes a current diagnosis and medical necessity for
the dosage regimen.
Some of the categories included in the Dose Optimization Program are: proton pump inhibitors,
HMG CoA reductase inhibitors, COX-II inhibitors, angiotensin II receptor antagonists, selected
narcotic analgesics, selected antipsychotics, selected urinary incontinence drugs and selected
sleeping medications. For more information regarding the Dose Optimization Program, please
contact the HealthPlus Pharmacy Department at 1-810-720-2758 or toll-free at 1-877-710-0993.
DRUG UTILIZATION REVIEW (DUR)
HealthPlus administers a comprehensive DUR program to help ensure the quality and safety of
prescribing and dispensing medications to members. The program includes point-of-service
quality and safety edits to the pharmacist when a prescription is being filled, and retrospective
analysis of claims data (with integration of medical and pharmacy data) to identify opportunities
for educational intervention and improve quality and outcomes. For more information regarding
the DUR program, please contact the HealthPlus Pharmacy Department at 1-810-720-2758 or
toll-free at 1-877-710-0993.
CONTROLLED SUBSTANCES PHARMACY PROGRAM (CSPP)
HealthPlus offers services through a Controlled Substances Pharmacy Program to support the
appropriate management of pain, ensure patient safety of narcotic use, and monitor for and
prevent potential fraud and abuse of narcotics. For more information about the CSPP program,
please contact the HealthPlus Pharmacy Department at 1-810-720-2758 or toll-free at 1-877710-0993.
MANDATORY 90-DAY MEDICATION PROGRAM
For most chronic medications (medications that are taken every day), members are required to
receive a 90-day supply each time they fill their prescription. Members have two options for
obtaining a 90-day supply of medications:
1. LOCAL PHARMACIES-Members may receive up to a 90-day supply of medication from
participating local retail pharmacies. Copay savings may apply. For more information, go
to www.healthplus.org for a Frequently Asked Questions flyer and a list of retail
pharmacies that participate in the Ask for 90 Rx program. Or, you may contact the
HealthPlus Customer Service Department.
2. MAIL SERVICE PROGRAM-Members may receive up to a 90-day of medication by mail
order through Express Scripts and have prescriptions delivered to their home with no
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shipping costs. Copay savings may apply. For more information about mail service, go to
www.healthplus.org, or contact the HealthPlus Customer Service Department.
Covered compounded medications and injectable medications (with the exception of injectable
diabetes medications, glucagon, Epi-Pen and Imitrex) are limited to a 30-day supply.
To receive a 90-day supply of medication, HealthPlus requires that the member has already
received a 30-day supply of the same drug and same strength within the last year (to help
assure the member is stabilized on the drug and dose before receiving a 90-day supply). The
prescription claims processing system looks for previous pharmacy claims billed to HealthPlus
for the member.
MANDATORY SPECIALTY PHARMACY PROGRAM
HealthPlus administers a MANDATORY specialty pharmacy program for oral and injectable
specialty medications; including medications administered in the physician’s office and selfadministered medications. For specific self-injected medications, the member is required to
receive the medication from a HealthPlus-contracted specialty pharmacy (the specialty
pharmacy will mail the medication to the physician’s office or the member’s home). This
program applies to self-injected medications for Rheumatoid Arthritis, Hepatitis C, Multiple
Sclerosis, Infertility, Endometriosis, and other targeted categories.
For more information about the specialty pharmacy program or specialty drugs, please contact
the HealthPlus Customer Service Department at 1-800-332-9161. For PPO, please contact
HealthPlus PPO Customer Service at 1-888-212-1512.
HEALTHPLUS DENTAL FORMULARY
The HealthPlus Dental Formulary is a restricted list of pharmaceutical agents covered when
prescribed by dentists. This list was established by the Medical Affairs Committee and Board of
Directors with recommendations by the Pharmacy & Therapeutics Committee. In the opinion of
the Medical Affairs Committee, these medications are of established value in the treatment or
prophylaxis of dental conditions, and present a broad range of choices to meet the usual clinical
problems. These products are covered when written by a dental provider treating a patient with
a HealthPlus drug benefit. Products that are not listed on the Dental Formulary are not a
covered benefit when prescribed by a dentist. Medications listed in the Dental Formulary are
available as either oral solids or oral liquids, whichever fits the clinical situation as determined by
the prescriber. Products on the Dental Formulary must be filled with a generic equivalent; for
these generic medications, a Tier 1 copay applies. In cases of medical necessity, generic
substitution may be overridden by the use of the “Dispense as Written” (DAW) notation, with
prior authorization required for these instances. A copy of the HEALTHPLUS DENTAL
FORMULARY is printed on the next page.
HEALTHPLUS DENTAL FORMULARY
Antifungals
nystatin
MYCOSTATIN*
Antivirals
acyclovir
valacyclovir
ZOVIRAX*
VALTREX*
Antibiotics
Cephalosporins
cephalexin HCL
cefadroxil
cefuroxime
KEFLEX* (NOT 750MG)
DURICEF*
CEFTIN*
Erythromycins
erythromycin
ERYTHROMYCIN*
Penicillins
amoxicillin
amoxicillin-clavulanate potassium
penicillin V potassium
AMOXIL*
AUGMENTIN*
PENVEEK*
Tetracyclines
doxycycline hyclate
tetracycline HCL
VIBRAMYCIN*, VIBRATABS*
(NOT DORYX, ORACEA)
Miscellaneous Antibiotics
clindamycin HCL
CLEOCIN 150mg*
Miscellaneous Anti-Infectives
metronidazole
FLAGYL*
Skeletal Muscle Relaxants
diazepam
ibuprofen
indomethacin
naproxen
VALIUM*
Nonsteroidal Anti-Inflammatory Agents
RX MOTRIN*
INDOCIN CAPSULES*
NAPROSYN*
Narcotic Analgesics
acetaminophen/codeine
acetaminophen 325/oxycodone 5
aspirin/caffeine/dihydrocodeine
aspirin/codeine
aspirin 325/oxycodone 5
butalbital/aspirin/caffeine/codeine
acetaminophen 325/hydrocodone 10
acetaminophen 325/hydrocodone 7.5
acetaminophen 325/hydrocodone 5
ibuprofen 200/hydrocodone 7.5
TYLENOL W/CODEINE*
PERCOCET*
SYNALGOS-DC*
EMPIRIN W/CODEINE*
PERCODAN*
FIORINAL W/CODEINE*
NORCO*
NORCO*
NORCO*
VICOPROFEN*
Systemic Corticosteroids
methylprednisolone
MEDROL DOSE PAK*
Miscellaneous Rinses
chlorhexidine gluconate
PERIDEX*
Miscellaneous
lidocaine viscous solution/ointment
LIDOCAINE*
*generic available
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PHARMACY & THERAPEUTICS COMMITTEE
The Pharmacy & Therapeutics Committee is an interdisciplinary body made up of practicing
physicians and pharmacists from the community, in addition to staff. The committee may invite
persons within or outside the organization who can contribute specialized or unique knowledge,
skills, and judgments. The function of the committee is to serve in an evaluative, educational,
and advisory capacity to the physician providers in all matters pertaining to drug use. The
committee also provides strategic guidance for pharmacy programs. The committee is involved
in the development and updating of pharmaceutical management procedures. In addition, the
committee meets at least five times annually to evaluate drugs for inclusion in the formulary.
The recommendations of the Pharmacy & Therapeutics Committee are communicated to the
Medical Affairs Committee and finally sent to the Board of Directors for approval.
FORMULARY UPDATES AND REVISIONS
The Formulary is revised regularly through recommendations from the Pharmacy &
Therapeutics Committee. HealthPlus reviews medications and medication categories on an
ongoing basis to help ensure that the Drug Formulary provides an ample, up-to-date selection of
quality, cost-effective medication choices. The Formulary is revised and republished annually
with notification to providers, with periodic updates on the website at www.healthplus.org;
providers and members may also receive a printed copy of the formulary upon request.
HealthPlus routinely provides updated information to physicians, pharmacies and members with
updates at the website, articles in the newsletters, etc. The Formulary is also available for
providers through various e-prescribing software applications. Specifically for negative changes
to the formulary (addition of prior authorization requirements, step therapy, or a change in status
from preferred to non-preferred when a generic equivalent is not available), HealthPlus notifies
affected members and their prescribers of the change.
Members may also obtain up-to-date formulary and cost information specific to their benefit and
copays at www.healthplus.org. For more information, please contact the HealthPlus Pharmacy
Department at 1-810-230-2118.
Physician requests for additions to the Formulary (or changes from Non-Preferred to Preferred
status) must be made on a Request for Addition to the Formulary form, which includes the
reason for the request and any clinical data supporting that request. Please refer to APPENDIX
A (page 13) for a copy of the HEALTHPLUS REQUEST FOR ADDITION TO THE FORMULARY
form. Member requests for additions to the formulary are forwarded to the Pharmacy
Department for appropriate review and consideration.
SMOKING CESSATION PHARMACOTHERAPY
All OTC and prescription FDA-approved smoking cessation products are covered. These
products are covered with no copay and prior authorization is not required. Duration limits may
apply for specific products.
APPENDIX A
HEALTHPLUS REQUEST FOR ADDITION TO THE FORMULARY
(including requests for changes from Non-Preferred to Preferred Status)
Completed forms will be reviewed by the Pharmacy & Therapeutics Committee. The need for
the drug, alternative therapy available, efficacy, safety and cost-effectiveness will be considered.
It is essential that this form be completed for proper evaluation.
1. Generic Names: ___________________________________________________________
2. Brand Name & Manufacturer: _________________________________________________
3. Dosage Form(s) & Strength(s): ________________________________________________
4. Specific pharmacologic action and indications for use:
___________________________________________________________________
___________________________________________________________________
5. Comparable drugs currently on the Formulary with a Preferred Status:
________________
___________________________________________________________________
6. If the requested drug is changed to a Preferred Status, which of the brand drugs above may
be changed to Non-Preferred Status?
___________________________________________________________________
7. List the therapeutic advantages of the requested drugs over those already listed as Preferred
on the Formulary. Supply references to support these advantages:
___________________________________________________________________
___________________________________________________________________
8. Estimate the anticipated cost impact if the requested drug is given Preferred Status on the
Formulary:
________________________________________________________________________
________________________________
DATE
___________________________________
PRINT NAME
_________________________________________________________________________
SIGNATURE
Send to: HealthPlus
ATTN: Pharmacy Department
2050 S Linden Road; PO Box 1700
Flint, MI 48501-1700
FAX: 810-720-2757
E-MAIL: [email protected]
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STATUS
APPENDIX C
PHARMACY PRIOR AUTHORIZATION FORM
Forward form to the HealthPlus Pharmacy Department via facsimile:
Flint facsimile: 810-720-2757
For questions or to request via telephone:
Flint local phone: 810-720-2758
Toll free phone: 877-710-0993
FOR A TIMELY RESPONSE, PLEASE PROVIDE COMPLETE INFORMATION.
HealthPlus ID#:
Date of Birth:
Patient Name:
Height:
Weight:
BMI:
Thi
Prescribed Drug and Dosing Regimen:
Reason for Use (Diagnosis):
Previous Medications:
Please attach pertinent laboratory test(s) or procedure(s): (if applicable)
Reason why an alternative drug (or dosing regimen) cannot be used:
DEA#:
Office Phone: (_____)
Pharmacy Name (optional):
HealthPlus Provider ID#:
Office Facsimile: (_____)
Pharmacy Phone:
Infusions/Injections (if applicable)
Place of Infusion/injection: ________________________
Provider ID: ____________________________________
Lab Results (if applicable)
CrCL: _________________
TG: ____________________
I represent to the best of my knowledge and belief that the information provided is true, complete, and
fully disclosed. A person may be committing insurance fraud if false or deceptive information with the
intent to defraud is provided.
Physician’s Name (please print) ____________________ Physician’s Signature
Office Contact Person:
Request Date:
For HealthPlus Use Only
LOB:
L
E
N
Non-Urgent Request:
Urgent Request:
CPhT Review Time
RPh Review Time
Med Dir Review Time
Comments:
Approv
Approved by:
Reason for Denial:
Effective Date:
Faxed to Indigent Program:
If you would like to discuss this case with a physician reviewer, please call 800 332-9161.
**THIS DOCUMENT MAY BE PHOTOCOPIED, or you may request additional copies by calling the HealthPlus
Pharmacy Department at the telephone number(s) listed above.
Rev August 2014
PRESCRIPTION BENEFIT LIMITATIONS
APPENDIX E
HealthPlus Administrative Limitations:
 Prescription drugs are limited to the reasonable cost of generically-available products, unless
no generically-available product exists or a member-specific review for medical necessity
determines the need for the brand name medication.
 Prescription drugs are limited to FDA-approved indications when reviewed, unless a
member-specific review for medical necessity determines the need for a particular
medication for an off-label use.
 Prescriptions written by a Dentist are limited to those medications on the HealthPlus Dental
Formulary.
 Prescriptions for testosterone products are limited to male members only, unless a memberspecific review for a female member determines medical necessity or if the medication is
being used for an FDA-approved indication.
 Prescriptions for products that contain estrogen are limited to female members only.
 Prior Authorization based on specific criteria is required for medications included in the
Pharmacy Prior Authorization Program including the Dose Optimization Program.
 Coverage for medications included in the Dose Optimization Program is limited to once daily
dosing, or maximum dose recommendations with quantity limits, unless a member specific
review determines medical necessity for the specified dosing regimen.
 Coverage for specific migraine medications is limited to 9 tablets per month, unless a
member specific review determines that the member is also currently taking medication for
the prophylaxis of migraine and still requires more than 9 tablets per month.
 Prescription medications for weight loss require Prior Authorization, initiated through the
Pharmacy Department.
 Prescriptions for compounded medications require Prior Authorization based on established
criteria for safety and appropriateness.
 There is no coverage for replacement of lost, stolen or destroyed medication.
 Selected antipsychotic medications are limited to maximum daily dosage recommendations
from the manufacturer.
 Selected sleeping medications are limited to a quantity of 30 in 30 days..
 Covered medications are limited to a 30-day supply at participating “30-day supply” retail
pharmacies and specialty pharmacies, and up to a 90-day supply through participating
HealthPlus Ask for 90 Rx retail pharmacies and the designated mail service provider. Refills
may be obtained when 80% of the day supply received has passed. Specifically for the
Mandatory 90-Day Medication programs (mail service and retail pharmacies), injectable
medications are not covered with the exception of injectable diabetes medications, Epipen,
glucagon, and Imitrex. Specialty medications and fertility drugs are limited to a 30-day
supply.
 To receive a 3-month supply, HealthPlus requires that the member has already received a
30-day supply of the same drug and strength within the last year.
 All prescription and non-prescription products for smoking cessation are covered.
 Coverage for prescription drugs for primary oral drug therapy for Hepatitis C shall be subject
to quantity limits and other restrictions that may include step therapy, prior authorization or
duration limits. Authorization of primary oral Hepatitis C agents is limited to one treatment
course per lifetime. There shall be no coverage for replacement of lost, stolen or destroyed
medication.
 Coverage for prescription drugs with potential for abuse and/or dependency shall be subject
to quantity limits and other restrictions that may include step therapy, prior authorization or
duration limits. Prescription drugs with potential for abuse and/or dependency shall be limited
to established quantities approved by HealthPlus Pharmacy and Therapeutics Committee
and only for FDA approved indications. There shall be no coverage for replacement of lost,
stolen or destroyed medication.
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HealthPlus Contractual Exclusions (non-covered services):
 Erectile dysfunction medications, cosmetic alteration drugs, bulk chemicals, compounding
kits, dermatological kits, prescription homeopathic products, pharmaceutical aids, diagnostic
agents, wound dressings, surgical supplies, medical devices or ostomy supplies
 Specialty prescription drugs included on the Mandatory Specialty Drug List when filled at a
non-affiliated specialty pharmacy provider
 Prescription drugs for chronic health conditions included on the Mandatory 90-Day
Medication List when filled for less than the mandatory ninety day supply
 Non-prescription drugs (or their prescription drug equivalents), dietary and other
supplements (such as vitamins, minerals, protein or caloric boosting supplements, food
supplements, medical foods and infant formula)
16
Table of Contents
Analgesic, Anti-Inflammatory Or Antipyretic ................................................................................................... 18
Anesthetics ......................................................................................................................................................... 30
Anorectal Preparations ....................................................................................................................................... 30
Antidotes And Other Reversal Agents ............................................................................................................... 31
Anti-Infective Agents ......................................................................................................................................... 32
Antineoplastics ................................................................................................................................................... 49
Antiseptics & Disinfectants................................................................................................................................ 60
Biologicals .......................................................................................................................................................... 60
Cardiovascular Therapy Agents ......................................................................................................................... 66
Central Nervous System Agents ........................................................................................................................ 85
Chemical Dependency, Agents To Treat ......................................................................................................... 113
Chemicals-Pharmaceutical Adjuvants.............................................................................................................. 115
Cognitive Disorder Therapy ............................................................................................................................. 115
Contraceptives .................................................................................................................................................. 116
Dermatological ................................................................................................................................................. 125
Diagnostic Agents ............................................................................................................................................ 146
Drugs To Treat Erectile Dysfunction ............................................................................................................... 146
Eating Disorder Therapy .................................................................................................................................. 146
Electrolyte Balance-Nutritional Products......................................................................................................... 148
Endocrine ......................................................................................................................................................... 153
Gastrointestinal Therapy Agents ...................................................................................................................... 172
Genitourinary Therapy ..................................................................................................................................... 184
Gout And Hyperuricemia Therapy ................................................................................................................... 188
Hematological Agents ...................................................................................................................................... 189
Immunosuppressive Agents ............................................................................................................................. 194
Locomotor System ........................................................................................................................................... 195
Medical Supplies And Durable Medical Equipment (Dme) ............................................................................ 198
Medical Supply, Fdb Superset ......................................................................................................................... 198
Metabolic Disease Enzyme Replacement Agents ............................................................................................ 198
Metabolic Modifiers ......................................................................................................................................... 199
Mouth-Throat-Dental - Preparations ................................................................................................................ 200
Multiple Sclerosis Agents ................................................................................................................................ 202
Ophthalmic Agents ........................................................................................................................................... 203
Otic ................................................................................................................................................................... 211
Respiratory Therapy Agents............................................................................................................................. 212
Vaginal Products .............................................................................................................................................. 221
Index ................................................................................................................................................................. 224
17
FORMULARY LIST
CURRENT AS OF 1/1/2015
UPPERCASE BOLD= Brand
name drugs
italics= Generic drugs
Drug Tier
Tier 1= Generic
Tier 2= Preferred Brand
Tier 3 = Non-preferred Brand
Tier 4= Specialty
Tier 5= Zero Copay (ACA
Required)
Tier 6 = Medical
Drug Name
Drug Tier
Notes
PA= Prior Authorization
QL= Quantity Limit
30D= 30 Day Supply
AR= Age Restriction
Notes
Analgesic, Anti-Inflammatory Or Antipyretic
Analgesic - Neuronal (N)-Type Calcium Channel Blockers (Nccbs)
Tier 6
30D
ABSTRAL SUBLINGUAL TABLET,
SUBLINGUAL 100 MCG, 200 MCG, 300
MCG, 400 MCG, 600 MCG, 800 MCG
Tier 3
PA; QL (4 tablets per 1 day)
ACTIQ BUCCAL LOZENGE ON A HANDLE
1,200 MCG, 1,600 MCG, 200 MCG, 400 MCG,
600 MCG, 800 MCG
Tier 3
PA; QL (4 lozenges per 1 day)
AVINZA ORAL CAPSULE, ER
MULTIPHASE 24 HR 120 MG, 30 MG, 45
MG, 60 MG, 75 MG, 90 MG
Tier 3
PA; QL (1 capsule per 1 day)
codeine sulfate Oral Solution 30 mg/5 mL
Tier 3
codeine sulfate Oral tablet 15 mg, 30 mg, 60 mg
Tier 1
CONZIP ORAL CAPSULE,ER BIPHASE 24
HR 17-83 300 MG
Tier 3
QL (1 capsule per 1 day)
CONZIP ORAL CAPSULE,ER BIPHASE 24
HR 25-75 100 MG, 200 MG
Tier 3
DEMEROL ORAL TABLET 100 MG, 50 MG
Tier 3
DILAUDID ORAL LIQUID 1 MG/ML
Tier 3
PRIALT INTRATHECAL SOLUTION 100
MCG/ML, 25 MCG/ML
Analgesic Narcotic Agonists
18
Drug Name
Drug Tier
Notes
DILAUDID ORAL TABLET 2 MG, 4 MG, 8
MG
Tier 3
DOLOPHINE ORAL TABLET 10 MG, 5 MG
Tier 3
DURAGESIC TRANSDERMAL PATCH 72
HOUR 100 MCG/HR, 12 MCG/HR, 25
MCG/HR, 50 MCG/HR, 75 MCG/HR
Tier 3
QL (15 patches per 30 days)
EXALGO ER ORAL TABLET EXTENDED
RELEASE 24 HR 12 MG, 16 MG, 8 MG
Tier 3
PA; QL (1 tablet per 1 day)
EXALGO ER ORAL TABLET EXTENDED
RELEASE 24 HR 32 MG
Tier 3
QL (2 tablets per 1 day)
fentanyl transdermal patch 72 hour 100 mcg/hr,
12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr
Tier 1
QL (15 patches per 30 days)
fentanyl citrate buccal lozenge on a handle 1,200
mcg, 1,600 mcg, 200 mcg, 400 mcg, 600 mcg, 800
mcg
Tier 1
PA; QL (4 lozenges per 1 day)
FENTORA BUCCAL TABLET,
EFFERVESCENT 100 MCG, 200 MCG, 400
MCG, 600 MCG, 800 MCG
Tier 3
hydromorphone Oral Liquid 1 mg/mL
Tier 1
hydromorphone Oral tablet 2 mg, 4 mg, 8 mg
Tier 1
hydromorphone oral tablet extended release 24 hr
12 mg, 16 mg, 8 mg
Tier 1
hydromorphone oral tablet extended release 24 hr
32 mg
Tier 1
hydromorphone rectal suppository 3 mg
Tier 1
KADIAN ORAL
CAPSULE,EXTEND.RELEASE PELLETS 10
MG, 100 MG, 20 MG, 30 MG, 50 MG, 60 MG,
80 MG
Tier 3
QL (2 capsules per 1 day)
LAZANDA NASAL SPRAY,NON-AEROSOL
100 MCG/SPRAY, 400 MCG/SPRAY
Tier 3
PA; QL (1 bottle {5ml} per day)
levorphanol tartrate Oral tablet 2 mg
Tier 1
meperidine oral solution 50 mg/5 mL
Tier 1
meperidine Oral tablet 100 mg, 50 mg
Tier 1
methadone oral solution 10 mg/5 mL, 5 mg/5 mL
Tier 1
methadone Oral tablet 10 mg, 5 mg
Tier 1
methadone Oral tablet,soluble 40 mg
Tier 1
19
Drug Name
Drug Tier
Notes
METHADONE INTENSOL ORAL
CONCENTRATE 10 MG/ML
Tier 1
METHADOSE ORAL CONCENTRATE 10
MG/ML
Tier 3
METHADOSE ORAL TABLET,SOLUBLE 40
MG
Tier 1
morphine oral capsule, ER multiphase 24 hr 30
mg, 60 mg
Tier 1
morphine Oral capsule,extend.release pellets 10
mg, 100 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg
Tier 1
morphine oral capsule, er multiphase 24 hr 120
mg, 30 mg, 45 mg, 60 mg, 75 mg, 90 mg
Tier 1
morphine oral solution 10 mg/5 mL, 20 mg/5 mL
Tier 1
morphine Oral tablet 15 mg
Tier 2
morphine Oral tablet 30 mg
Tier 1
morphine Oral tablet extended release 100 mg, 15
mg, 200 mg, 30 mg, 60 mg
Tier 1
morphine rectal suppository 10 mg, 20 mg, 30 mg,
5 mg
Tier 1
morphine concentrate oral solution 100 mg/5 mL
(20 mg/mL)
Tier 1
morphine concentrate oral syringe 20 mg/mL
Tier 1
MS CONTIN ORAL TABLET EXTENDED
RELEASE 100 MG, 15 MG, 200 MG, 30 MG,
60 MG
Tier 3
NUCYNTA ORAL TABLET 100 MG, 50 MG,
75 MG
Tier 3
NUCYNTA ER ORAL TABLET EXTENDED
RELEASE 12 HR 100 MG, 150 MG, 200 MG,
250 MG, 50 MG
Tier 3
OPANA ORAL TABLET 10 MG, 5 MG
Tier 3
OPANA ER ORAL TABLET,ORAL
ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20
MG, 30 MG, 40 MG, 5 MG, 7.5 MG
Tier 3
OXECTA ORAL TABLET, ORAL ONLY 5
MG, 7.5 MG
Tier 3
PA
oxycodone Oral capsule 5 mg
Tier 1
oxycodone oral concentrate 20 mg/mL
Tier 1
20
Drug Name
Drug Tier
Notes
oxycodone oral solution 5 mg/5 mL
Tier 1
oxycodone Oral tablet 10 mg, 15 mg, 20 mg, 30
mg, 5 mg
Tier 1
OXYCONTIN ORAL TABLET EXTENDED
RELEASE 12 HR 10 MG, 15 MG, 20 MG, 30
MG, 40 MG, 60 MG, 80 MG
Tier 2
oxymorphone Oral tablet 10 mg, 5 mg
Tier 1
oxymorphone oral tablet extended release 12 hr 10
mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg, 7.5 mg
Tier 1
ROXICODONE ORAL TABLET 15 MG, 30
MG, 5 MG
Tier 3
SUBSYS SUBLINGUAL SPRAY,NONAEROSOL 1,200 MCG (600 MCG/SPRAY X
2), 1,600 MCG (800 MCG/SPRAY X 2), 100
MCG/SPRAY, 200 MCG/SPRAY, 400
MCG/SPRAY, 600 MCG/SPRAY, 800
MCG/SPRAY
Tier 4
PA; QL (4 sprays per 1 day)
tramadol oral tablet 50 mg
Tier 1
tramadol Oral tablet extended release 24 hr 100
mg, 200 mg, 300 mg
Tier 1
QL (1 tablet per 1 day)
ULTRAM ORAL TABLET 50 MG
Tier 3
ULTRAM ER ORAL TABLET EXTENDED
Tier 3
ZOHYDRO ER ORAL
CAPSULE,EXTENDED RELEASE 12 HR 10
MG, 15 MG, 20 MG, 30 MG, 40 MG, 50 MG
Tier 3
PA; QL (2 capsules per 1 day)
Analgesic Narcotic Codeine Combinations
acetaminophen-codeine oral solution 120-12 mg/5
mL
Tier 1
acetaminophen-codeine oral tablet 300-15 mg,
300-30 mg, 300-60 mg
Tier 1
ASCOMP WITH CODEINE ORAL CAPSULE
30-50-325-40 MG
Tier 1
QL (12 caps per 1 day)
BUTALBITAL COMPOUND W/CODEINE
ORAL CAPSULE 30-50-325-40 MG
Tier 1
butalbital-acetaminop-caf-cod oral capsule 50300-40-30 mg, 50-325-40-30 mg
Tier 1
CAPITAL WITH CODEINE ORAL
SUSPENSION 120-12 MG/5 ML
Tier 3
21
Drug Name
Drug Tier
Notes
FIORICET WITH CODEINE ORAL
CAPSULE 50-300-40-30 MG
Tier 3
FIORINAL-CODEINE #3 ORAL CAPSULE
30-50-325-40 MG
Tier 3
TYLENOL-CODEINE #3 ORAL TABLET
300-30 MG
Tier 3
TYLENOL-CODEINE #4 ORAL TABLET
300-60 MG
Tier 3
Analgesic Narcotic Dihydrocodeine Combinations
dihydrocodeine-aspirin-caff oral capsule 16356.4-30 mg
Tier 1
SYNALGOS-DC ORAL CAPSULE 16-356.430 MG
Tier 3
Analgesic Narcotic Hydrocodone Combinations
HYCET ORAL SOLUTION 7.5-325 MG/15
ML
Tier 3
hydrocodone-acetaminophen oral solution 2.5-167
mg/5 mL, 7.5-325 mg/15 mL
Tier 1
hydrocodone-acetaminophen Oral tablet 10-300
mg, 5-300 mg, 7.5-300 mg
Tier 1
hydrocodone-acetaminophen oral tablet 10-325
mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg
Tier 1
hydrocodone-ibuprofen Oral tablet 10-200 mg,
2.5-200 mg, 5-200 mg, 7.5-200 mg
Tier 1
IBUDONE ORAL TABLET 10-200 MG, 5-200
MG
Tier 3
LORCET PLUS ORAL TABLET 7.5-325 MG
Tier 1
LORTAB 10-325 ORAL TABLET 10-325 MG
Tier 3
LORTAB 5-325 ORAL TABLET 5-325 MG
Tier 3
LORTAB 7.5-325 ORAL TABLET 7.5-325 MG
Tier 3
LORTAB ELIXIR ORAL SOLUTION 10-300
MG/15 ML
Tier 3
NORCO ORAL TABLET 10-325 MG, 5-325
MG, 7.5-325 MG
Tier 3
REPREXAIN ORAL TABLET 10-200 MG
Tier 1
REPREXAIN ORAL TABLET 2.5-200 MG, 5200 MG
Tier 3
PA
VERDROCET ORAL TABLET 2.5-325 MG
Tier 3
22
Drug Name
Drug Tier
Notes
VICODIN ORAL TABLET 5-300 MG
Tier 1
VICODIN ES ORAL TABLET 7.5-300 MG
Tier 1
VICODIN HP ORAL TABLET 10-300 MG
Tier 1
VICOPROFEN ORAL TABLET 7.5-200 MG
Tier 3
XODOL 10/300 ORAL TABLET 10-300 MG
Tier 3
XODOL 5/300 ORAL TABLET 5-300 MG
Tier 3
XODOL 7.5/300 ORAL TABLET 7.5-300 MG
Tier 3
ZAMICET ORAL SOLUTION 10-325 MG/15
ML
Tier 3
Analgesic Narcotic Oxycodone Combinations
ENDOCET ORAL TABLET 10-325 MG, 2.5325 MG, 5-325 MG, 7.5-325 MG
Tier 1
ENDODAN ORAL TABLET 4.8355-325 MG
Tier 1
ibuprofen-oxycodone Oral tablet 400-5 mg
Tier 1
QL (28 tablets per 30 days)
oxycodone-acetaminophen oral tablet 10-325 mg,
2.5-325 mg, 5-325 mg, 7.5-325 mg
Tier 1
oxycodone-aspirin Oral tablet 4.8355-325 mg
Tier 1
PERCOCET ORAL TABLET 10-325 MG, 2.5325 MG, 5-325 MG, 7.5-325 MG
Tier 3
PERCODAN ORAL TABLET 4.8355-325 MG
Tier 3
PRIMLEV ORAL TABLET 10-300 MG, 5-300
MG, 7.5-300 MG
Tier 3
ROXICET ORAL SOLUTION 5-325 MG/5
ML
Tier 2
ROXICET ORAL TABLET 5-325 MG
Tier 1
XARTEMIS XR ORAL TAB,ORAL ONLY,IR
& ER, BIPHASE 7.5-325 MG
Tier 3
butorphanol tartrate nasal spray,non-aerosol 10
mg/mL
Tier 1
QL (2 bottles {5ml} per 30 days)
BUTRANS TRANSDERMAL PATCH
WEEKLY 10 MCG/HOUR, 15 MCG/HOUR,
20 MCG/HOUR, 5 MCG/HOUR
Tier 3
PA; QL (4 patches per 28 days)
pentazocine-naloxone Oral tablet 50-0.5 mg
Tier 1
Analgesic Narcotic Partial-Mixed Agonists
Analgesic Narcotic Tramadol Combinations
23
Drug Name
Drug Tier
Notes
tramadol-acetaminophen oral tablet 37.5-325 mg
Tier 1
ULTRACET ORAL TABLET 37.5-325 MG
Tier 3
Analgesic Or Antipyretic Non-Narcotic/Sedative Combinations
ALAGESIC LQ ORAL SOLUTION 50-325-40
MG/15 ML
Tier 3
BUPAP ORAL TABLET 50-300 MG
Tier 3
butalbital-acetaminophen oral tablet 50-325 mg
Tier 1
butalbital-acetaminophen-caff oral capsule 50300-40 mg, 50-325-40 mg
Tier 1
butalbital-acetaminophen-caff oral tablet 50-32540 mg
Tier 1
CAPACET ORAL CAPSULE 50-325-40 MG
Tier 1
ESGIC ORAL CAPSULE 50-325-40 MG
Tier 3
ESGIC ORAL TABLET 50-325-40 MG
Tier 3
FIORICET ORAL CAPSULE 50-300-40 MG
Tier 3
MARGESIC ORAL CAPSULE 50-325-40 MG
Tier 1
MARTEN-TAB ORAL TABLET 50-325 MG
Tier 1
TENCON ORAL TABLET 50-325 MG
Tier 1
PA
Anti-Inflammatory - Interleukin-1 Beta Blockers
ILARIS (PF) SUBCUTANEOUS RECON
SOLN 180 MG/1.2 ML (150 MG/ML)
Tier 6
PA; 30D
Anti-Inflammatory - Interleukin-1 Receptor Antagonist
ARCALYST SUBCUTANEOUS RECON
SOLN 220 MG
Tier 6
PA; 30D
Anti-Inflammatory Tumor Necrosis Factor Inhibiting Agnts,Non-Seiective
ENBREL SUBCUTANEOUS KIT 25 MG (1
ML)
Tier 4
PA
ENBREL SUBCUTANEOUS SYRINGE 25
MG/0.5ML (0.51), 50 MG/ML (0.98 ML)
Tier 4
PA
ENBREL SURECLICK SUBCUTANEOUS
PEN INJECTOR 50 MG/ML (0.98 ML)
Tier 4
PA
Anti-Inflammatory Tumor Necrosis Factor Inhibiting Agnts,Tnf-Alpha Sel
CIMZIA SUBCUTANEOUS SYRINGE KIT
400 MG/2 ML (200 MG/ML X 2)
24
Tier 4
PA
Drug Name
Drug Tier
Notes
CIMZIA STARTER KIT SUBCUTANEOUS
SYRINGE KIT 400 MG/2 ML (200 MG/ML X
2)
Tier 4
PA
HUMIRA SUBCUTANEOUS KIT 20 MG/0.4
ML, 40 MG/0.8 ML
Tier 4
PA
HUMIRA CROHN'S DIS START PCK
SUBCUTANEOUS PEN INJECTOR KIT 40
MG/0.8 ML
Tier 4
PA
HUMIRA PEN SUBCUTANEOUS PEN
INJECTOR KIT 40 MG/0.8 ML
Tier 4
PA
HUMIRA PSORIASIS STARTER PACK
SUBCUTANEOUS PEN INJECTOR KIT 40
MG/0.8 ML
Tier 4
PA
SIMPONI SUBCUTANEOUS PEN
INJECTOR 100 MG/ML, 50 MG/0.5 ML
Tier 4
PA
SIMPONI SUBCUTANEOUS SYRINGE 100
MG/ML, 50 MG/0.5 ML
Tier 4
PA
SIMPONI ARIA INTRAVENOUS SOLUTION
12.5 MG/ML
Tier 4
PA
Dmard - Antimetabolites
RHEUMATREX ORAL TABLETS,DOSE
PACK 2.5 MG
Tier 3
Dmard - Antinflammatory, Select. Costimulation Modulator,T-Cell Inhib.
ORENCIA SUBCUTANEOUS SYRINGE 125
MG/ML
Tier 4
PA
Dmard - Gold Compounds
RIDAURA ORAL CAPSULE 3 MG
Tier 2
Dmard - Interleukin-1 Receptor Antagonist (Il-1Ra)
KINERET SUBCUTANEOUS SYRINGE 100
MG/0.67 ML
Tier 4
PA
Dmard - Interleukin-6 (Il-6) Receptor Inhibitors, Monoclonal Antibody
ACTEMRA INTRAVENOUS SOLUTION 200
MG/10 ML (20 MG/ML)
Tier 4
PA; 30D
ACTEMRA INTRAVENOUS SOLUTION 400
MG/20 ML (20 MG/ML), 80 MG/4 ML (20
MG/ML)
Tier 4
PA
ACTEMRA SUBCUTANEOUS SYRINGE 162
MG/0.9 ML
Tier 4
PA
25
Drug Name
Drug Tier
Notes
Dmard - Janus Kinase (Jak) Inhibitors
XELJANZ ORAL TABLET 5 MG
Tier 4
PA
Dmard - Other
CUPRIMINE ORAL CAPSULE 250 MG
Tier 3
DEPEN TITRATABS ORAL TABLET 250
MG
Tier 3
Dmard - Phosphodiesterase-4 (Pde4) Inhibitors
OTEZLA ORAL TABLET 30 MG
Tier 4
PA
OTEZLA STARTER ORAL TABLETS,DOSE
PACK 10 MG (4)-20 MG (4)-30 MG(19)
Tier 4
PA
Dmard - Pyrimidine Synthesis Inhibitors
ARAVA ORAL TABLET 10 MG, 20 MG
Tier 3
leflunomide Oral tablet 10 mg, 20 mg
Tier 1
Immunomodulator B-Lymphocyte Stimulator (Blys)-Specific Inhibitor Mcab
BENLYSTA INTRAVENOUS RECON SOLN
120 MG
Tier 6
30D
Nsaid Analgesic & Histamine H2 Receptor Antagonist Combinations
DUEXIS ORAL TABLET 800-26.6 MG
Tier 3
PA
Nsaid Analgesic & Prostaglandin Analog Combinations
ARTHROTEC 50 ORAL TABLET,IR &
DELAY REL,BIPHASIC 50-200 MG-MCG
Tier 3
PA
ARTHROTEC 75 ORAL TABLET,IR &
DELAY REL,BIPHASIC 75-200 MG-MCG
Tier 3
PA
diclofenac-misoprostol oral tablet,IR & delay
rel,biphasic 50-200 mg-mcg, 75-200 mg-mcg
Tier 1
PA
Nsaid Analgesic & Proton Pump Inhibitor Combinations
VIMOVO ORAL TABLET,IR & DELAY
REL,BIPHASIC 375-20 MG, 500-20 MG
Tier 3
PA
Nsaid Analgesic, Cyclooxygenase-2 (Cox-2) Selective Inhibitors
CELEBREX ORAL CAPSULE 100 MG, 200
MG, 400 MG, 50 MG
Tier 2
Nsaid Analgesics (Cox Non-Specific) - Anthranilic Acid Derivatives
meclofenamate Oral capsule 100 mg, 50 mg
Tier 1
mefenamic acid Oral capsule 250 mg
Tier 1
26
Drug Name
PONSTEL ORAL CAPSULE 250 MG
Drug Tier
Notes
Tier 3
Nsaid Analgesics (Cox Non-Specific) - Other
ketorolac oral tablet 10 mg
Tier 1
nabumetone oral tablet 500 mg, 750 mg
Tier 1
SPRIX NASAL SPRAY,NON-AEROSOL 15.75
MG/SPRAY
Tier 3
sulindac oral tablet 150 mg, 200 mg
Tier 1
tolmetin Oral capsule 400 mg
Tier 1
tolmetin Oral tablet 200 mg, 600 mg
Tier 1
PA (PA required for age 66 and
older); AR
Nsaid Analgesics (Cox Non-Specific) - Oxicam Derivatives
FELDENE ORAL CAPSULE 10 MG, 20 MG
Tier 3
meloxicam oral suspension 7.5 mg/5 mL
Tier 1
QL (34 ML per 34 days)
meloxicam oral tablet 15 mg, 7.5 mg
Tier 1
MOBIC ORAL SUSPENSION 7.5 MG/5 ML
Tier 3
MOBIC ORAL TABLET 15 MG, 7.5 MG
Tier 3
piroxicam oral capsule 10 mg, 20 mg
Tier 1
Nsaid Analgesics (Cox Non-Specific) - Phenylacetic Acid Derivatives
CAMBIA ORAL POWDER IN PACKET 50
MG
Tier 3
PA
CATAFLAM ORAL TABLET 50 MG
Tier 3
diclofenac potassium oral tablet 50 mg
Tier 1
diclofenac sodium oral tablet extended release 24
hr 100 mg
Tier 1
diclofenac sodium oral tablet,delayed release
(DR/EC) 25 mg, 50 mg, 75 mg
Tier 1
VOLTAREN-XR ORAL TABLET
EXTENDED RELEASE 24 HR 100 MG
Tier 3
ZIPSOR ORAL CAPSULE 25 MG
Tier 3
PA
ZORVOLEX ORAL CAPSULE 18 MG, 35 MG
Tier 3
PA
Nsaid Analgesics (Cox Non-Specific) - Propionic Acid Derivatives
ANAPROX ORAL TABLET 275 MG
Tier 3
ANAPROX DS ORAL TABLET 550 MG
Tier 3
ANSAID ORAL TABLET 100 MG
Tier 3
27
Drug Name
Drug Tier
DAYPRO ORAL TABLET 600 MG
Tier 3
EC-NAPROSYN ORAL TABLET,DELAYED
RELEASE (DR/EC) 375 MG, 500 MG
Tier 3
fenoprofen Oral tablet 600 mg
Tier 1
flurbiprofen Oral tablet 100 mg, 50 mg
Tier 1
ibuprofen oral suspension 100 mg/5 mL
Tier 1
ibuprofen oral tablet 400 mg, 600 mg, 800 mg
Tier 1
ketoprofen Oral capsule 50 mg, 75 mg
Tier 1
ketoprofen Oral capsule,ext rel. pellets 24 hr 200
mg
Tier 1
NALFON ORAL CAPSULE 400 MG
Tier 3
NAPRELAN CR ORAL TABLET, ER
MG
Tier 3
NAPROSYN ORAL SUSPENSION 125 MG/5
ML
Tier 3
NAPROSYN ORAL TABLET 250 MG, 375
MG, 500 MG
Tier 3
naproxen oral suspension 125 mg/5 mL
Tier 1
naproxen oral tablet 250 mg, 375 mg, 500 mg
Tier 1
naproxen oral tablet,delayed release (DR/EC) 375
mg, 500 mg
Tier 1
naproxen sodium oral tablet 275 mg, 550 mg
Tier 1
oxaprozin oral tablet 600 mg
Tier 1
Notes
PA
Nsaid Analgesics (Cyclooxygenase Inhibitors-Non-Selective)
MG
Tier 3
PA
Nsaid Analgesics, (Cox Non-Specific) - Indole Acetic Acid Derivatives
etodolac Oral capsule 200 mg, 300 mg
Tier 1
etodolac oral tablet 400 mg, 500 mg
Tier 1
etodolac oral tablet extended release 24 hr 400
mg, 500 mg, 600 mg
Tier 1
INDOCIN ORAL SUSPENSION 25 MG/5 ML
Tier 2
older); AR
indomethacin Oral capsule 25 mg, 50 mg
Tier 1
older); AR
28
Drug Name
indomethacin oral capsule, extended release 75
mg
Drug Tier
Tier 1
Notes
older); AR
Salicylate Analgesic And Sedative Combinations
butalbital-aspirin-caffeine Oral capsule 50-325-40
mg
Tier 1
FIORINAL ORAL CAPSULE 50-325-40 MG
Tier 3
Salicylate Analgesic Combinations
choline & magnesium salicylate Oral Liquid 500
mg/5 mL
Tier 1
LEVACET ORAL TABLET 500-250-150 MG
Tier 3
Salicylate Analgesics
ASPIR-LOW ORAL TABLET,DELAYED
RELEASE (DR/EC) 81 MG
Tier 5
PA (covered for age 45 and older);
AR
aspirin Oral tablet 325 mg
Tier 5
AR
aspirin oral tablet,chewable 81 mg
Tier 5
AR
aspirin Oral tablet,delayed release (DR/EC) 325
mg, 500 mg, 81 mg
Tier 5
AR
BAYER CHEWABLE ASPIRIN ORAL
TABLET,CHEWABLE 81 MG
Tier 5
AR
diflunisal Oral tablet 500 mg
Tier 1
ECOTRIN ORAL TABLET,DELAYED
Tier 5
AR
ECOTRIN LOW STRENGTH ORAL
TABLET,DELAYED RELEASE (DR/EC) 81
MG
Tier 5
AR
salsalate oral tablet 500 mg, 750 mg
Tier 1
ST JOSEPH ASPIRIN ORAL
Tier 5
AR
ST. JOSEPH ASPIRIN ORAL
MG
Tier 5
AR
BAYER PLUS EXTRA STRENGTH ORAL
TABLET 500 MG
Tier 5
AR
BUFFERIN ORAL TABLET 325 MG
Tier 5
Salicylate Analgesics, Buffered
29
Drug Name
Drug Tier
TRI-BUFFERED ASPIRIN ORAL TABLET
325 MG
Tier 5
Anesthetics
Local Anesthetic - Amides
bupivacaine injection solution 0.25 % (2.5
mg/mL), 0.5 % (5 mg/mL)
Tier 6
bupivacaine (PF) injection solution 0.25 % (2.5
mg/mL), 0.5 % (5 mg/mL), 0.75 % (7.5 mg/mL)
Tier 6
bupivacaine-dextrose-water(PF) injection solution
0.75 % (7.5 mg/mL)
Tier 6
lidocaine topical ointment 5 %
Tier 1
lidocaine HCl laryngotracheal solution 4 %
Tier 1
LTA PRE-ATTACHED
LARYNGOTRACHEAL SOLUTION 4 %
Tier 3
MARCAINE INJECTION SOLUTION 0.25 %
(2.5 MG/ML), 0.5 % (5 MG/ML)
Tier 6
MARCAINE (PF) INJECTION SOLUTION
0.25 % (2.5 MG/ML), 0.5 % (5 MG/ML), 0.75
% (7.5 MG/ML)
Tier 6
MARCAINE SPINAL (PF) INJECTION
SOLUTION 0.75 % (7.5 MG/ML)
Tier 6
Anorectal Preparations
Anal Fissure Pain/Treatment Agents - Nitrates
RECTIV RECTAL OINTMENT 0.4 % (W/W)
Tier 3
Anorectal - Glucocorticoids
ANUCORT-HC RECTAL SUPPOSITORY 25
MG
Tier 1
ANUSOL-HC RECTAL CREAM 2.5 %
Tier 3
ANUSOL-HC RECTAL SUPPOSITORY 25
MG
Tier 3
GRX HICORT 25 RECTAL SUPPOSITORY
25 MG
Tier 1
hydrocortisone acetate rectal suppository 25 mg,
30 mg
Tier 1
PROCTO-PAK RECTAL CREAM 1 %
Tier 1
PROCTOCORT RECTAL CREAM 1 %
Tier 3
30
Notes
Drug Name
Drug Tier
PROCTOCORT RECTAL SUPPOSITORY 30
MG
Tier 3
PROCTOSOL HC RECTAL CREAM 2.5 %
Tier 1
PROCTOZONE-HC RECTAL CREAM 2.5 %
Tier 1
RECTACORT-HC RECTAL SUPPOSITORY
25 MG
Tier 3
Notes
Anorectal - Hemorrhoidal Rectal Glucocorticoid-Local Anesthetic Comb
ANALPRAM E RECTAL KIT,CREAM &
TOWELETTE 2.5-1-1 %-(4 GRAM)-%
Tier 3
ANALPRAM-HC RECTAL CREAM 1-1 %,
2.5-1 %
Tier 3
ANALPRAM-HC RECTAL LOTION 2.5-1 %
Tier 3
hydrocortisone-pramoxine rectal cream 1-1 %,
2.5-1 %
Tier 1
lidocaine-hydrocortisone-aloe rectal gel 2.8-0.55
%
Tier 1
PRAMCORT RECTAL CREAM 1-1 %
Tier 3
PROCORT RECTAL CREAM 1.85-1.15 %
Tier 3
PROCTOFOAM HC RECTAL FOAM 1-1 %
Tier 2
PA
Antidotes And Other Reversal Agents
Antidote - Acetaminophen Poisoning
ACETADOTE INTRAVENOUS SOLUTION
200 MG/ML (20 %)
Tier 3
acetylcysteine solution 100 mg/mL (10 %), 200
mg/mL (20 %)
Tier 1
Antidote - Alcohol Dehydrogenase Enzyme Inhibitor
fomepizole intravenous solution 1 gram/mL
Tier 6
30D
Antidote - Radioactive Agents
RADIOGARDASE ORAL CAPSULE 0.5
GRAM
Tier 3
Antidote Others
GALZIN ORAL CAPSULE 25 MG (ZINC), 50
MG (ZINC)
Tier 3
RADIOGARDASE ORAL CAPSULE 0.5
GRAM
Tier 3
31
Drug Name
Drug Tier
Notes
Chelating Agents - Copper
CUPRIMINE ORAL CAPSULE 250 MG
Tier 3
DEPEN TITRATABS ORAL TABLET 250
MG
Tier 3
SYPRINE ORAL CAPSULE 250 MG
Tier 3
Chelating Agents - Iron
deferoxamine injection recon soln 2 gram
Tier 6
30D
DESFERAL INJECTION RECON SOLN 2
GRAM
Tier 6
30D
EXJADE ORAL TABLET, DISPERSIBLE 125
MG, 250 MG, 500 MG
Tier 4
FERRIPROX ORAL TABLET 500 MG
Tier 3
Chelating Agents - Lead Poisoning
CHEMET ORAL CAPSULE 100 MG
Tier 3
Chelating Agents - Others
CA-DTPA INTRAVENOUS SOLUTION 200
MG/ML
Tier 2
ZN-DTPA INTRAVENOUS SOLUTION 200
MG/ML
Tier 2
Mu-Opioid Receptor Antagonists, Peripherally-Acting
ENTEREG ORAL CAPSULE 12 MG
Tier 3
RELISTOR SUBCUTANEOUS KIT 12 MG/0.6
ML
Tier 3
RELISTOR SUBCUTANEOUS SYRINGE 8
MG/0.4 ML
Tier 3
Narcotic Antagonists
EVZIO INJECTION AUTO-INJECTOR 0.4
MG/0.4 ML
Tier 6
naltrexone Oral tablet 50 mg
Tier 1
Anti-Infective Agents
Amebicides
paromomycin Oral capsule 250 mg
Tier 1
YODOXIN ORAL TABLET 210 MG, 650 MG
Tier 3
Aminoglycoside Antibiotic
32
Drug Name
Drug Tier
Notes
BETHKIS INHALATION SOLUTION FOR
NEBULIZATION 300 MG/4 ML
Tier 3
neomycin Oral tablet 500 mg
Tier 1
TOBI INHALATION SOLUTION FOR
NEBULIZATION 300 MG/5 ML
Tier 4
PA
TOBI PODHALER INHALATION CAPSULE
28 MG
Tier 4
PA
TOBI PODHALER INHALATION CAPSULE,
W/INHALATION DEVICE 28 MG
Tier 4
PA
tobramycin in 0.225 % NaCl inhalation solution
for nebulization 300 mg/5 mL
Tier 4
PA
Aminopenicillin Antibiotic
amoxicillin oral capsule 250 mg, 500 mg
Tier 1
amoxicillin oral suspension for reconstitution 125
mg/5 mL, 200 mg/5 mL, 250 mg/5 mL, 400 mg/5
mL
Tier 1
amoxicillin oral tablet 500 mg, 875 mg
Tier 1
amoxicillin oral tablet,chewable 125 mg, 250 mg
Tier 1
ampicillin Oral capsule 250 mg, 500 mg
Tier 1
ampicillin oral suspension for reconstitution 250
mg/5 mL
Tier 1
MOXATAG ORAL TABLET, ER
MULTIPHASE 24 HR 775 MG
Tier 3
PA
Aminopenicillin Antibiotic - Beta-Lactamase Inhibitor Combinations
amoxicillin-pot clavulanate oral suspension for
reconstitution 200-28.5 mg/5 mL, 250-62.5 mg/5
mL, 400-57 mg/5 mL, 600-42.9 mg/5 mL
Tier 1
amoxicillin-pot clavulanate oral tablet 250-125
mg, 500-125 mg, 875-125 mg
Tier 1
amoxicillin-pot clavulanate oral tablet extended
release 12 hr 1,000-62.5 mg
Tier 1
amoxicillin-pot clavulanate oral tablet,chewable
200-28.5 mg, 400-57 mg
Tier 1
AUGMENTIN ORAL SUSPENSION FOR
RECONSTITUTION 125-31.25 MG/5 ML
Tier 2
AUGMENTIN ORAL SUSPENSION FOR
RECONSTITUTION 250-62.5 MG/5 ML
Tier 3
33
Drug Name
Drug Tier
AUGMENTIN ORAL TABLET 500-125 MG,
875-125 MG
Tier 3
AUGMENTIN ES-600 ORAL SUSPENSION
FOR RECONSTITUTION 600-42.9 MG/5 ML
Tier 3
AUGMENTIN XR ORAL TABLET
EXTENDED RELEASE 12 HR 1,000-62.5 MG
Tier 3
Notes
Anthelmintic Agents Other
BILTRICIDE ORAL TABLET 600 MG
Tier 2
STROMECTOL ORAL TABLET 3 MG
Tier 3
Anthelmintic Benzimidazole Derivatives
ALBENZA ORAL TABLET 200 MG
Tier 3
Antibacterial Folate Antagonist - Other Combinations
BACTRIM ORAL TABLET 400-80 MG
Tier 3
BACTRIM DS ORAL TABLET 800-160 MG
Tier 3
sulfamethoxazole-trimethoprim oral suspension
200-40 mg/5 mL
Tier 1
sulfamethoxazole-trimethoprim oral tablet 400-80
mg, 800-160 mg
Tier 1
Antibacterial Folate Antagonist Others
PRIMSOL ORAL SOLUTION 50 MG/5 ML
Tier 3
trimethoprim Oral tablet 100 mg
Tier 1
Antifungal - Allylamines
LAMISIL ORAL GRANULES IN PACKET
125 MG, 187.5 MG
Tier 3
LAMISIL ORAL TABLET 250 MG
Tier 3
terbinafine oral tablet 250 mg
Tier 1
Antifungal - Amphoteric Polyene Macrolides
AMBISOME INTRAVENOUS SUSPENSION
FOR RECONSTITUTION 50 MG
Tier 6
nystatin Oral tablet 500,000 unit
Tier 1
Antifungal - Imidazoles
ketoconazole oral tablet 200 mg
Tier 1
Antifungal - Triazoles
DIFLUCAN ORAL SUSPENSION FOR
RECONSTITUTION 10 MG/ML, 40 MG/ML
34
Tier 3
30D
Drug Name
Drug Tier
DIFLUCAN ORAL TABLET 100 MG, 150
MG, 200 MG, 50 MG
Tier 3
fluconazole oral suspension for reconstitution 10
mg/mL, 40 mg/mL
Tier 1
fluconazole oral tablet 100 mg, 150 mg, 200 mg,
50 mg
Tier 1
fluconazole in NaCl (iso-osm) intravenous
piggyback 400 mg/200 mL
Tier 6
itraconazole Oral capsule 100 mg
Tier 1
NOXAFIL ORAL SUSPENSION 200 MG/5
ML (40 MG/ML)
Tier 3
NOXAFIL ORAL TABLET,DELAYED
Tier 3
ONMEL ORAL TABLET 200 MG
Tier 3
SPORANOX ORAL CAPSULE 100 MG
Tier 3
SPORANOX ORAL SOLUTION 10 MG/ML
Tier 3
SPORANOX PULSEPAK ORAL CAPSULE
100 MG
Tier 3
VFEND ORAL SUSPENSION FOR
RECONSTITUTION 200 MG/5 ML (40
MG/ML)
Tier 3
VFEND ORAL TABLET 200 MG, 50 MG
Tier 3
voriconazole oral suspension for reconstitution
200 mg/5 mL (40 mg/mL)
Tier 1
voriconazole Oral tablet 200 mg, 50 mg
Tier 1
Notes
30D
Antifungal Other
ANCOBON ORAL CAPSULE 250 MG, 500
MG
Tier 3
flucytosine oral capsule 250 mg, 500 mg
Tier 1
GRIFULVIN V ORAL TABLET 500 MG
Tier 3
GRIS-PEG (ULTRAMICROSIZE) ORAL
TABLET 125 MG, 250 MG
Tier 3
griseofulvin microsize oral suspension 125 mg/5
mL
Tier 1
griseofulvin microsize oral tablet 500 mg
Tier 1
griseofulvin ultramicrosize oral tablet 125 mg, 250
mg
Tier 1
35
Drug Name
Drug Tier
Notes
Anti-Infective Immunologic Adjuvants - Interferons
ACTIMMUNE SUBCUTANEOUS
SOLUTION 100 MCG/0.5 ML
Tier 4
Antileprotic - Immunomodulators
THALOMID ORAL CAPSULE 100 MG, 150
MG, 200 MG, 50 MG
Tier 4
Antileprotic - Sulfone Agents
dapsone Oral tablet 100 mg, 25 mg
Tier 1
Antimalarial Combinations
atovaquone-proguanil oral tablet 250-100 mg,
62.5-25 mg
Tier 1
COARTEM ORAL TABLET 20-120 MG
Tier 3
MALARONE ORAL TABLET 250-100 MG
Tier 3
MALARONE PEDIATRIC ORAL TABLET
62.5-25 MG
Tier 3
Antimalarials
chloroquine phosphate oral tablet 250 mg, 500 mg
Tier 1
DARAPRIM ORAL TABLET 25 MG
Tier 2
hydroxychloroquine oral tablet 200 mg
Tier 1
mefloquine oral tablet 250 mg
Tier 1
PLAQUENIL ORAL TABLET 200 MG
Tier 3
primaquine Oral tablet 26.3 mg
Tier 2
QUALAQUIN ORAL CAPSULE 324 MG
Tier 3
quinine sulfate oral capsule 324 mg
Tier 1
Antiprotozoal Other
ALINIA ORAL SUSPENSION FOR
RECONSTITUTION 100 MG/5 ML
Tier 3
ALINIA ORAL TABLET 500 MG
Tier 3
atovaquone oral suspension 750 mg/5 mL
Tier 1
MEPRON ORAL SUSPENSION 750 MG/5 ML
Tier 3
Antiprotozoal-Antibacterial 1St Generation 2-Methyl-5-Nitroimidazole
FLAGYL ORAL CAPSULE 375 MG
Tier 3
FLAGYL ORAL TABLET 250 MG, 500 MG
Tier 3
36
Drug Name
Drug Tier
FLAGYL ER ORAL TABLET EXTENDED
RELEASE 750 MG
Tier 3
metronidazole oral tablet 250 mg, 500 mg
Tier 1
Notes
PA
Antiprotozoal-Antibacterial 2Nd Generation 2-Methyl-5-Nitroimidazole
TINDAMAX ORAL TABLET 250 MG, 500
MG
Tier 3
tinidazole oral tablet 250 mg, 500 mg
Tier 1
Antiretroviral - Ccr5 Co-Receptor Antagonist
SELZENTRY ORAL TABLET 150 MG, 300
MG
Tier 4
PA
Tier 4
PA
Antiretroviral - Hiv-1 Fusion Inhibitors
FUZEON SUBCUTANEOUS RECON SOLN
90 MG
Antiretroviral - Hiv-1 Integrase Strand Transfer Inhibitors
ISENTRESS ORAL POWDER IN PACKET
100 MG
Tier 2
ISENTRESS ORAL TABLET 400 MG
Tier 4
ISENTRESS ORAL TABLET,CHEWABLE
100 MG, 25 MG
Tier 2
TIVICAY ORAL TABLET 50 MG
Tier 4
Antiretroviral - Non-Nucleoside Reverse Transcriptase Inhib (Nnrti)
EDURANT ORAL TABLET 25 MG
Tier 4
INTELENCE ORAL TABLET 100 MG, 200
MG, 25 MG
Tier 4
nevirapine oral suspension 50 mg/5 mL
Tier 1
nevirapine oral tablet 200 mg
Tier 1
nevirapine oral tablet extended release 24 hr 400
mg
Tier 1
RESCRIPTOR ORAL TABLET 200 MG
Tier 3
RESCRIPTOR ORAL TABLET,
DISPERSIBLE 100 MG
Tier 3
SUSTIVA ORAL CAPSULE 200 MG, 50 MG
Tier 2
SUSTIVA ORAL TABLET 600 MG
Tier 2
VIRAMUNE ORAL SUSPENSION 50 MG/5
ML
Tier 3
PA
37
Drug Name
Drug Tier
VIRAMUNE ORAL TABLET 200 MG
Tier 3
VIRAMUNE XR ORAL TABLET
Tier 2
VIRAMUNE XR ORAL TABLET
Tier 3
Notes
Antiretroviral - Nucleoside & Nucleotide Analogs, Integrase Inhibitors
STRIBILD ORAL TABLET 150-150-200-300
MG
Tier 4
Antiretroviral - Nucleoside Reverse Transcriptase Inhibitors (Nrti)
abacavir oral tablet 300 mg
Tier 1
didanosine Oral capsule,delayed release(DR/EC)
125 mg, 200 mg, 250 mg, 400 mg
Tier 1
EMTRIVA ORAL CAPSULE 200 MG
Tier 2
EMTRIVA ORAL SOLUTION 10 MG/ML
Tier 2
EPIVIR ORAL SOLUTION 10 MG/ML
Tier 2
EPIVIR ORAL TABLET 150 MG, 300 MG
Tier 3
lamivudine oral tablet 150 mg, 300 mg
Tier 1
RETROVIR INTRAVENOUS SOLUTION 10
MG/ML
Tier 6
RETROVIR ORAL CAPSULE 100 MG
Tier 3
RETROVIR ORAL SYRUP 10 MG/ML
Tier 3
stavudine Oral capsule 15 mg, 20 mg, 30 mg, 40
mg
Tier 1
stavudine Oral Recon Soln 1 mg/mL
Tier 1
VIDEX 2 GRAM PEDIATRIC ORAL RECON
SOLN 10 MG/ML (FINAL)
Tier 2
VIDEX 4 GRAM PEDIATRIC ORAL RECON
SOLN 10 MG/ML (FINAL)
Tier 2
VIDEX EC ORAL CAPSULE,DELAYED
RELEASE(DR/EC) 125 MG, 200 MG, 250 MG,
400 MG
Tier 3
ZERIT ORAL CAPSULE 15 MG, 20 MG, 30
MG, 40 MG
Tier 3
ZERIT ORAL RECON SOLN 1 MG/ML
Tier 3
ZIAGEN ORAL SOLUTION 20 MG/ML
Tier 2
PA
ZIAGEN ORAL TABLET 300 MG
Tier 3
PA
38
PA
Drug Name
Drug Tier
zidovudine Oral capsule 100 mg
Tier 1
zidovudine Oral Syrup 10 mg/mL
Tier 1
zidovudine oral tablet 300 mg
Tier 1
Notes
Antiretroviral - Nucleotide Analog Reverse Transcriptase Inhibitors
VIREAD ORAL POWDER 40 MG/SCOOP (40
MG/GRAM)
Tier 2
VIREAD ORAL TABLET 150 MG, 200 MG,
250 MG, 300 MG
Tier 2
Antiretroviral Combinations - Nrti's
abacavir-lamivudine-zidovudine oral tablet 300150-300 mg
Tier 1
COMBIVIR ORAL TABLET 150-300 MG
Tier 4
EPZICOM ORAL TABLET 600-300 MG
Tier 4
lamivudine-zidovudine oral tablet 150-300 mg
Tier 1
TRIZIVIR ORAL TABLET 300-150-300 MG
Tier 4
PA
PA
PA
Antiretroviral Combinations - Nucleoside & Nucleotide Analog Rtis
TRUVADA ORAL TABLET 200-300 MG
Tier 2
Antiretroviral Combinations - Protease Inhibitors
KALETRA ORAL SOLUTION 400-100 MG/5
ML
Tier 2
KALETRA ORAL TABLET 100-25 MG, 20050 MG
Tier 2
Antiretroviral-Nucleoside& Nucleotide Analogs& Non-Nucleoside Rti Comb
ATRIPLA ORAL TABLET 600-200-300 MG
Tier 4
COMPLERA ORAL TABLET 200-25-300 MG
Tier 4
PA
Antitubercular - Aminobenzoic Acid Analogs
PASER ORAL PACKET 4 GRAM
Tier 3
Antitubercular - D-Alanine Analogs
cycloserine Oral capsule 250 mg
Tier 1
Antitubercular - Diarylquinoline Antibiotics
SIRTURO ORAL TABLET 100 MG
Tier 4
Antitubercular - Isonicotinic Acid Derivatives
isoniazid oral solution 50 mg/5 mL
Tier 1
39
Drug Name
isoniazid oral tablet 100 mg, 300 mg
Drug Tier
Tier 1
Antitubercular - Niacinamide Derivatives
pyrazinamide Oral tablet 500 mg
Tier 1
Antitubercular - Rifamycin And Derivatives
MYCOBUTIN ORAL CAPSULE 150 MG
Tier 3
PRIFTIN ORAL TABLET 150 MG
Tier 3
rifabutin oral capsule 150 mg
Tier 1
RIFADIN ORAL CAPSULE 150 MG, 300 MG
Tier 3
rifampin oral capsule 150 mg, 300 mg
Tier 1
Antitubercular Agents Other
ethambutol Oral tablet 100 mg, 400 mg
Tier 1
MYAMBUTOL ORAL TABLET 400 MG
Tier 3
TRECATOR ORAL TABLET 250 MG
Tier 3
Antitubercular Combinations
RIFAMATE ORAL CAPSULE 300-150 MG
Tier 3
RIFATER ORAL TABLET 50-120-300 MG
Tier 3
Cephalosporin Antibiotics - 1St Generation
cefadroxil Oral capsule 500 mg
Tier 1
cefadroxil oral suspension for reconstitution 250
mg/5 mL, 500 mg/5 mL
Tier 1
cefadroxil Oral tablet 1 gram
Tier 1
cephalexin Oral capsule 250 mg, 500 mg, 750 mg
Tier 1
cephalexin oral suspension for reconstitution 125
Tier 1
cephalexin Oral tablet 250 mg, 500 mg
Tier 1
KEFLEX ORAL CAPSULE 250 MG, 500 MG,
750 MG
Tier 3
Cephalosporin Antibiotics - 2Nd Generation
cefaclor Oral capsule 250 mg, 500 mg
Tier 1
cefaclor oral suspension for reconstitution 125
mg/5 mL, 250 mg/5 mL, 375 mg/5 mL
Tier 1
cefaclor Oral tablet extended release 12 hr 500 mg
Tier 1
cefprozil oral suspension for reconstitution 125
Tier 1
40
Notes
Drug Name
Drug Tier
cefprozil oral tablet 250 mg, 500 mg
Tier 1
CEFTIN ORAL SUSPENSION FOR
Tier 3
CEFTIN ORAL SUSPENSION FOR
Tier 3
CEFTIN ORAL TABLET 250 MG, 500 MG
Tier 3
cefuroxime axetil oral suspension for
reconstitution 125 mg/5 mL
Tier 3
cefuroxime axetil oral tablet 250 mg, 500 mg
Tier 1
Notes
PA
Cephalosporin Antibiotics - 3Rd Generation
CEDAX ORAL CAPSULE 400 MG
Tier 3
CEDAX ORAL SUSPENSION FOR
RECONSTITUTION 180 MG/5 ML, 90 MG/5
ML
Tier 3
cefdinir oral capsule 300 mg
Tier 1
cefdinir oral suspension for reconstitution 125
Tier 1
cefditoren pivoxil oral tablet 400 mg
Tier 1
cefpodoxime oral suspension for reconstitution
100 mg/5 mL, 50 mg/5 mL
Tier 1
cefpodoxime Oral tablet 100 mg, 200 mg
Tier 1
ceftibuten oral capsule 400 mg
Tier 1
ceftibuten oral suspension for reconstitution 180
mg/5 mL
Tier 1
SPECTRACEF ORAL TABLET 400 MG
Tier 3
SUPRAX ORAL CAPSULE 400 MG
Tier 3
SUPRAX ORAL SUSPENSION FOR
ML, 500 MG/5 ML
Tier 3
SUPRAX ORAL TABLET,CHEWABLE 100
MG, 200 MG
Tier 3
Cephalosporin Antibiotics - 5Th Generation
TEFLARO INTRAVENOUS RECON SOLN
400 MG, 600 MG
Tier 6
30D
Cmv Antiviral Agent - Inorganic Pyrophosphate Analogs
41
Drug Name
FOSCAVIR INTRAVENOUS SOLUTION 24
MG/ML
Drug Tier
Notes
Tier 6
Cmv Antiviral Agent - Nucleoside Analogs
CYTOVENE INTRAVENOUS RECON SOLN
500 MG
Tier 6
30D
ganciclovir sodium intravenous recon soln 500 mg
Tier 6
30D
VALCYTE ORAL RECON SOLN 50 MG/ML
Tier 4
VALCYTE ORAL TABLET 450 MG
Tier 4
Cmv Antiviral Agent - Nucleotide Analogs
VISTIDE INTRAVENOUS SOLUTION 75
MG/ML
Tier 3
Fluoroquinolone Antibiotics
AVELOX ORAL TABLET 400 MG
Tier 3
AVELOX ABC PACK ORAL TABLET 400
MG
Tier 3
CIPRO ORAL
SUSPENSION,MICROCAPSULE RECON 250
MG/5 ML, 500 MG/5 ML
Tier 2
CIPRO ORAL TABLET 250 MG, 500 MG
Tier 3
ciprofloxacin oral suspension,microcapsule recon
250 mg/5 mL, 500 mg/5 mL
Tier 1
ciprofloxacin Oral tablet 100 mg, 250 mg, 500 mg,
750 mg
Tier 1
FACTIVE ORAL TABLET 320 MG
Tier 3
LEVAQUIN ORAL SOLUTION 250 MG/10
ML
Tier 3
LEVAQUIN ORAL TABLET 250 MG, 500
MG, 750 MG
Tier 3
levofloxacin oral solution 250 mg/10 mL
Tier 1
levofloxacin oral tablet 250 mg, 500 mg, 750 mg
Tier 1
moxifloxacin oral tablet 400 mg
Tier 1
NOROXIN ORAL TABLET 400 MG
Tier 3
ofloxacin Oral tablet 300 mg, 400 mg
Tier 1
Glycopeptide Antibiotics
VANCOCIN ORAL CAPSULE 125 MG, 250
MG
42
Tier 3
PA
Drug Name
Drug Tier
vancomycin oral capsule 125 mg, 250 mg
Notes
Tier 1
Hepatitis B Treatment- Nucleoside Analogs (Antiviral)
BARACLUDE ORAL SOLUTION 0.05
MG/ML
Tier 2
BARACLUDE ORAL TABLET 0.5 MG, 1 MG
Tier 2
EPIVIR HBV ORAL SOLUTION 25 MG/5 ML
(5 MG/ML)
Tier 3
EPIVIR HBV ORAL TABLET 100 MG
Tier 3
TYZEKA ORAL TABLET 600 MG
Tier 4
Hepatitis B Treatment- Nucleotide Analogs (Antiviral)
adefovir Oral tablet 10 mg
Tier 2
HEPSERA ORAL TABLET 10 MG
Tier 4
Hepatitis C - Interferons
PEGASYS SUBCUTANEOUS SOLUTION 180
MCG/ML
Tier 4
PA
PEGASYS SUBCUTANEOUS SYRINGE 180
MCG/0.5 ML
Tier 4
PA
PEGASYS CONVENIENCE PACK
SUBCUTANEOUS KIT 180 MCG/0.5 ML
Tier 4
PA
PEGASYS PROCLICK SUBCUTANEOUS
PEN INJECTOR 135 MCG/0.5 ML, 180
MCG/0.5 ML
Tier 4
PA
PEGINTRON SUBCUTANEOUS KIT 120
MCG/0.5 ML, 150 MCG/0.5 ML, 50 MCG/0.5
ML, 80 MCG/0.5 ML
Tier 4
PA
PEGINTRON REDIPEN SUBCUTANEOUS
PEN INJECTOR KIT 120 MCG/0.5 ML, 150
MCG/0.5 ML, 50 MCG/0.5 ML, 80 MCG/0.5
ML
Tier 4
PA
OLYSIO ORAL CAPSULE 150 MG
Tier 4
PA; QL (limited to 14 day supply
per prescription)
VICTRELIS ORAL CAPSULE 200 MG
Tier 4
per prescription)
Hepatitis C - Ns3/4A Serine Protease Inhibitors
Hepatitis C - Nucleos(T)Ide Analog Ns5b Polymerase Inhibitors
SOVALDI ORAL TABLET 400 MG
Tier 4
per prescription)
43
Drug Name
Drug Tier
Notes
Hepatitis C - Nucleoside Analogs
COPEGUS ORAL TABLET 200 MG
Tier 4
MODERIBA ORAL TABLET 200 MG
Tier 3
MODERIBA DOSE PACK ORAL
TABLETS,DOSE PACK 200 MG (7)- 400 MG
(7), 400 MG (7)- 400 MG (7), 600 MG (7)- 400
MG (7), 600 MG (7)- 600 MG (7)
Tier 3
REBETOL ORAL CAPSULE 200 MG
Tier 4
REBETOL ORAL SOLUTION 40 MG/ML
Tier 3
RIBAPAK DOSE PACK ORAL
(28), 200 MG (7)- 400 MG (7)
Tier 3
PA
RIBAPAK DOSE PACK ORAL
(7), 400-400 MG (28)-MG (28), 600 MG (7)- 400
MG (7), 600 MG (7)- 600 MG (7), 600-400 MG
(28)-MG (28), 600-600 MG (28)-MG (28)
Tier 4
PA
RIBASPHERE ORAL CAPSULE 200 MG
Tier 1
RIBASPHERE ORAL TABLET 200 MG, 400
MG, 600 MG
Tier 1
RIBATAB DOSE PACK ORAL
TABLETS,DOSE PACK 400-400 MG (28)-MG
(28), 600-400 MG (28)-MG (28), 600-600 MG
(28)-MG (28)
Tier 3
ribavirin oral capsule 200 mg
Tier 1
ribavirin oral tablet 200 mg
Tier 1
PA
Hepatitis C – NS5B Polymerase and NS5A Inhibitor Combinations
HARVONI 90MG-400MG TABLET
Tier 4
Herpes Antiviral Agent - Purine Analogs
acyclovir oral capsule 200 mg
Tier 1
acyclovir oral suspension 200 mg/5 mL
Tier 1
acyclovir oral tablet 400 mg, 800 mg
Tier 1
acyclovir sodium intravenous recon soln 1,000 mg,
500 mg
Tier 6
acyclovir sodium intravenous solution 50 mg/mL
Tier 6
SITAVIG BUCCAL MUCO-ADHESIVE
BUCCAL TABLET 50 MG
Tier 3
44
per prescription)
Drug Name
Drug Tier
valacyclovir oral tablet 1 gram, 500 mg
Tier 1
VALTREX ORAL TABLET 1 GRAM, 500 MG
Tier 3
ZOVIRAX ORAL CAPSULE 200 MG
Tier 3
ZOVIRAX ORAL SUSPENSION 200 MG/5
ML
Tier 3
ZOVIRAX ORAL TABLET 400 MG, 800 MG
Tier 3
Notes
Herpes Antiviral Agent - Thymidine Analogs
famciclovir Oral tablet 125 mg, 250 mg, 500 mg
Tier 1
FAMVIR ORAL TABLET 125 MG, 250 MG,
500 MG
Tier 3
Influenza Antiviral Agents - Neuraminidase Inhibitors
RELENZA DISKHALER INHALATION
BLISTER WITH DEVICE 5
MG/ACTUATION
Tier 2
TAMIFLU ORAL CAPSULE 30 MG, 45 MG,
75 MG
Tier 2
TAMIFLU ORAL SUSPENSION FOR
RECONSTITUTION 6 MG/ML
Tier 2
Influenza-A Antiviral Agents
FLUMADINE ORAL TABLET 100 MG
Tier 3
rimantadine Oral tablet 100 mg
Tier 1
Ketolide Antibiotics
KETEK ORAL TABLET 300 MG, 400 MG
Tier 3
Lincosamide Antibiotics
CLEOCIN ORAL CAPSULE 150 MG, 300
MG, 75 MG
Tier 3
CLEOCIN ORAL RECON SOLN 75 MG/5
ML
Tier 3
clindamycin HCl Oral capsule 150 mg, 300 mg, 75
mg
Tier 1
clindamycin palmitate HCl Oral Recon Soln 75
mg/5 mL
Tier 1
Macrolides
Azithromycin Oral Packet 1 gram
Tier 1
45
Drug Name
Drug Tier
azithromycin oral suspension for reconstitution
100 mg/5 mL, 200 mg/5 mL
Tier 1
azithromycin oral tablet 250 mg, 500 mg, 600 mg
Tier 1
BIAXIN ORAL SUSPENSION FOR
Tier 3
BIAXIN ORAL TABLET 250 MG, 500 MG
Tier 3
BIAXIN XL ORAL TABLET EXTENDED
RELEASE 24 HR 500 MG
Tier 3
BIAXIN XL PAK ORAL TABLET
Tier 3
clarithromycin oral suspension for reconstitution
125 mg/5 mL, 250 mg/5 mL
Tier 1
clarithromycin oral tablet 250 mg, 500 mg
Tier 1
clarithromycin Oral tablet extended release 24 hr
500 mg
Tier 1
DIFICID ORAL TABLET 200 MG
Tier 3
E.E.S. 400 ORAL TABLET 400 MG
Tier 1
E.E.S. GRANULES ORAL SUSPENSION FOR
Tier 3
ERY-TAB ORAL TABLET,DELAYED
Tier 1
ERY-TAB ORAL TABLET,DELAYED
Tier 2
ERYPED 200 ORAL SUSPENSION FOR
Tier 3
ERYPED 400 ORAL SUSPENSION FOR
Tier 3
ERYTHROCIN (AS STEARATE) ORAL
TABLET 250 MG
Tier 1
erythromycin Oral capsule,delayed
release(DR/EC) 250 mg
Tier 1
erythromycin Oral tablet 250 mg, 500 mg
Tier 1
erythromycin ethylsuccinate Oral tablet 400 mg
Tier 2
PCE ORAL TABLET,
PARTICLES/CRYSTALS 333 MG, 500 MG
Tier 3
ZITHROMAX ORAL PACKET 1 GRAM
Tier 3
46
Notes
PA
Drug Name
Drug Tier
ZITHROMAX ORAL SUSPENSION FOR
ML
Tier 3
ZITHROMAX ORAL TABLET 250 MG, 500
MG, 600 MG
Tier 3
ZITHROMAX TRI-PAK ORAL TABLET 500
MG
Tier 3
ZITHROMAX Z-PAK ORAL TABLET 250
MG
Tier 3
ZMAX ORAL SUSPENSION,EXTENDED
REL RECON 2 GRAM/60 ML
Tier 3
Notes
Misc Anti-Infective
NEBUPENT INHALATION RECON SOLN
300 MG
Tier 3
PENTAM INJECTION RECON SOLN 300
MG
Tier 6
30D
pentamidine injection recon soln 300 mg
Tier 6
30D
Tier 4
PA
Monobactam Antibiotics
CAYSTON INHALATION SOLUTION FOR
NEBULIZATION 75 MG/ML
Oxazolidinone Antibiotics
ZYVOX ORAL SUSPENSION FOR
Tier 2
ZYVOX ORAL TABLET 600 MG
Tier 2
Penicillin Antibiotic - Natural (I.E. Pen G, Pen V)
penicillin V potassium Oral Recon Soln 125 mg/5
mL, 250 mg/5 mL
Tier 1
penicillin V potassium oral tablet 250 mg, 500 mg
Tier 1
Penicillin Antibiotic - Penicillinase-Resistant
dicloxacillin Oral capsule 250 mg, 500 mg
Tier 1
Protease Inhibitors (Non-Peptidic) Antiretroviral
APTIVUS ORAL CAPSULE 250 MG
Tier 4
PA
APTIVUS ORAL SOLUTION 100 MG/ML
Tier 4
PA
PREZISTA ORAL SUSPENSION 100 MG/ML
Tier 2
PA
PREZISTA ORAL TABLET 150 MG, 400 MG,
600 MG, 75 MG, 800 MG
Tier 2
PA
47
Drug Name
Drug Tier
Notes
Protease Inhibitors (Peptidic) Antiretroviral
CRIXIVAN ORAL CAPSULE 200 MG, 400
MG
Tier 2
INVIRASE ORAL CAPSULE 200 MG
Tier 2
PA
INVIRASE ORAL TABLET 500 MG
Tier 4
PA
LEXIVA ORAL SUSPENSION 50 MG/ML
Tier 2
LEXIVA ORAL TABLET 700 MG
Tier 4
NORVIR ORAL CAPSULE 100 MG
Tier 2
NORVIR ORAL SOLUTION 80 MG/ML
Tier 2
NORVIR ORAL TABLET 100 MG
Tier 2
REYATAZ ORAL CAPSULE 150 MG, 200
MG, 300 MG
Tier 4
VIRACEPT ORAL TABLET 250 MG, 625 MG
Tier 4
Respiratory Syncytial Virus (Rsv) Antiviral Agents
VIRAZOLE INHALATION RECON SOLN 6
GRAM
Tier 3
Rifamycins And Related Derivative Antibiotics
MYCOBUTIN ORAL CAPSULE 150 MG
Tier 3
PRIFTIN ORAL TABLET 150 MG
Tier 3
rifabutin oral capsule 150 mg
Tier 1
RIFADIN ORAL CAPSULE 150 MG, 300 MG
Tier 3
rifampin oral capsule 150 mg, 300 mg
Tier 1
XIFAXAN ORAL TABLET 200 MG, 550 MG
Tier 3
Sulfonamide Antibiotic
sulfadiazine oral tablet 500 mg
Tier 1
Tetracycline Antibiotics
ADOXA ORAL CAPSULE 150 MG
Tier 3
AVIDOXY ORAL TABLET 100 MG
Tier 3
demeclocycline Oral tablet 150 mg, 300 mg
Tier 1
DORYX ORAL TABLET,DELAYED
Tier 3
doxycycline hyclate oral capsule 100 mg, 50 mg
Tier 1
doxycycline hyclate oral tablet 100 mg
Tier 1
48
Drug Name
Drug Tier
Notes
doxycycline hyclate oral tablet,delayed release
(DR/EC) 100 mg, 150 mg, 75 mg
Tier 1
doxycycline monohydrate Oral capsule 100 mg,
150 mg, 50 mg, 75 mg
Tier 1
doxycycline monohydrate oral suspension for
reconstitution 25 mg/5 mL
Tier 1
doxycycline monohydrate Oral tablet 100 mg, 150
mg, 50 mg, 75 mg
Tier 1
MINOCIN ORAL CAPSULE 100 MG, 50 MG,
75 MG
Tier 3
minocycline Oral capsule 100 mg, 50 mg, 75 mg
Tier 1
minocycline Oral tablet 100 mg, 50 mg, 75 mg
Tier 1
minocycline oral tablet extended release 24 hr 135
mg, 45 mg, 90 mg
Tier 1
MONODOX ORAL CAPSULE 100 MG, 50
MG, 75 MG
Tier 3
MORGIDOX ORAL CAPSULE 100 MG
Tier 3
MORGIDOX 1X100 KIT 100 MG
Tier 3
ORACEA ORAL CAPSULE, ER
Tier 3
PA
SOLODYN ORAL TABLET EXTENDED
MG, 80 MG
Tier 3
PA
tetracycline oral capsule 250 mg, 500 mg
Tier 1
VIBRAMYCIN ORAL CAPSULE 100 MG
Tier 3
VIBRAMYCIN ORAL SUSPENSION FOR
Tier 3
VIBRAMYCIN ORAL SYRUP 50 MG/5 ML
Tier 3
Antineoplastics
Anp - Human Vascular Endothelial Growth Factor Inhib Rec-Mc Antibody
AVASTIN INTRAVENOUS SOLUTION 25
MG/ML
Tier 6
30D
Antineoplasic-Epiderm.Growth Factor-Egfr (Erbb1)&Her-2 (Erbb2)R.Inhib
TYKERB ORAL TABLET 250 MG
Tier 4
Antineoplastic - Cyp17 (17 Alpha-Hydroxylase/C17,20-Lyase) Inhibitor
ZYTIGA ORAL TABLET 250 MG
Tier 2
49
Drug Name
Drug Tier
Notes
Antineoplastic - 2Nd Generation Egfr Tyrosine Kinase Inhibitor
GILOTRIF ORAL TABLET 20 MG, 30 MG,
40 MG
Tier 4
Antineoplastic - Alkylating Agent - Alkyl Sulfonates
BUSULFEX INTRAVENOUS SOLUTION 60
MG/10 ML
Tier 6
MYLERAN ORAL TABLET 2 MG
Tier 2
30D
Antineoplastic - Alkylating Agent - Ethylenimines And Methylmelamines
HEXALEN ORAL CAPSULE 50 MG
Tier 4
thiotepa injection recon soln 15 mg
Tier 6
30D
Antineoplastic - Alkylating Agent - Methylhydrazines
MATULANE ORAL CAPSULE 50 MG
Tier 4
Antineoplastic - Alkylating Agent - Nitrogen Mustard With Rescue Agent
ifosfamide-mesna intravenous kit 1-1 gram, 3,0001,000 mg
Tier 6
30D
Antineoplastic - Alkylating Agent - Nitrogen Mustards
ALKERAN INTRAVENOUS RECON SOLN
50 MG
Tier 6
30D
ALKERAN ORAL TABLET 2 MG
Tier 2
cyclophosphamide oral capsule 25 mg, 50 mg
Tier 2
cyclophosphamide Oral tablet 25 mg, 50 mg
Tier 1
IFEX INTRAVENOUS RECON SOLN 1
GRAM
Tier 6
30D
ifosfamide intravenous solution 1 gram/20 mL
Tier 6
30D
LEUKERAN ORAL TABLET 2 MG
Tier 2
melphalan intravenous recon soln 50 mg
Tier 6
30D
MUSTARGEN INJECTION RECON SOLN 10
MG
Tier 6
30D
Antineoplastic - Alkylating Agent - Nitrosoureas
BICNU INTRAVENOUS RECON SOLN 100
MG
Tier 6
30D
GLIADEL WAFER IMPLANT WAFER 7.7
MG
Tier 6
30D
lomustine Oral capsule 10 mg, 40 mg
Tier 1
Antineoplastic - Alkylating Agent - Other
50
Drug Name
Drug Tier
Notes
Tier 6
30D
dacarbazine intravenous recon soln 200 mg
Tier 6
30D
TEMODAR ORAL CAPSULE 100 MG, 140
MG, 180 MG, 20 MG, 250 MG, 5 MG
Tier 4
temozolomide oral capsule 100 mg, 140 mg, 180
mg, 20 mg, 250 mg
Tier 2
temozolomide oral capsule 5 mg
Tier 1
TREANDA INTRAVENOUS RECON SOLN
100 MG
Antineoplastic - Alkylating Agent - Triazenes
Antineoplastic - Antiadrenals
LYSODREN ORAL TABLET 500 MG
Tier 2
Antineoplastic - Antiandrogens
bicalutamide Oral tablet 50 mg
Tier 1
CASODEX ORAL TABLET 50 MG
Tier 3
flutamide Oral capsule 125 mg
Tier 1
NILANDRON ORAL TABLET 150 MG
Tier 2
XTANDI ORAL CAPSULE 40 MG
Tier 4
ZYTIGA ORAL TABLET 250 MG
Tier 4
Antineoplastic - Antibody-Drug Complexes
ADCETRIS INTRAVENOUS RECON SOLN
50 MG
Tier 6
30D
KADCYLA INTRAVENOUS RECON SOLN
160 MG
Tier 6
30D
Antineoplastic - Antimetabolite - Folic Acid Analogs
ALIMTA INTRAVENOUS RECON SOLN 500
MG
Tier 6
30D
FOLOTYN INTRAVENOUS SOLUTION 20
MG/ML (1 ML)
Tier 6
30D
methotrexate sodium injection solution 25 mg/mL
Tier 6
30D
methotrexate sodium Oral tablet 2.5 mg
Tier 1
methotrexate sodium (PF) injection recon soln 1
gram
Tier 6
TREXALL ORAL TABLET 10 MG, 15 MG, 5
MG, 7.5 MG
Tier 3
30D
Antineoplastic - Antimetabolite - Purine Analogs
51
Drug Name
Drug Tier
Notes
cladribine intravenous solution 10 mg/10 mL
Tier 6
30D
fludarabine intravenous solution 50 mg/2 mL
Tier 6
30D
mercaptopurine Oral tablet 50 mg
Tier 1
NIPENT INTRAVENOUS RECON SOLN 10
MG
Tier 6
30D
pentostatin intravenous recon soln 10 mg
Tier 6
30D
PURINETHOL ORAL TABLET 50 MG
Tier 3
PURIXAN ORAL SUSPENSION 20 MG/ML
Tier 2
TABLOID ORAL TABLET 40 MG
Tier 2
Antineoplastic - Antimetabolite - Pyrimidine Analogs
ADRUCIL INTRAVENOUS SOLUTION 500
MG/10 ML
Tier 6
30D
azacitidine injection recon soln 100 mg
Tier 6
30D
capecitabine oral tablet 150 mg, 500 mg
Tier 1
cytarabine (PF) injection recon soln 1 gram, 100
mg, 500 mg
Tier 6
DACOGEN INTRAVENOUS RECON SOLN
50 MG
Tier 3
DEPOCYT (PF) INTRATHECAL
SUSPENSION 50 MG/5 ML (10 MG/ML)
Tier 6
30D
floxuridine injection recon soln 0.5 gram
Tier 6
30D
fluorouracil intravenous solution 500 mg/10 mL
Tier 6
30D
gemcitabine intravenous recon soln 1 gram
Tier 6
30D
GEMZAR INTRAVENOUS RECON SOLN
200 MG
Tier 6
30D
VIDAZA INJECTION RECON SOLN 100 MG
Tier 6
30D
XELODA ORAL TABLET 150 MG, 500 MG
Tier 4
Antineoplastic - Antimetabolite - Urea Derivatives
HYDREA ORAL CAPSULE 500 MG
Tier 3
hydroxyurea Oral capsule 500 mg
Tier 1
Antineoplastic - Aromatase Inhibitors
anastrozole oral tablet 1 mg
Tier 5
ARIMIDEX ORAL TABLET 1 MG
Tier 5
AROMASIN ORAL TABLET 25 MG
Tier 5
exemestane Oral tablet 25 mg
Tier 5
52
30D
Drug Name
Drug Tier
FEMARA ORAL TABLET 2.5 MG
Tier 5
letrozole Oral tablet 2.5 mg
Tier 5
Notes
Antineoplastic - Asparaginase Enzyme Therapy Agents
ELSPAR INJECTION RECON SOLN 10,000
UNIT
Tier 6
30D
ONCASPAR INJECTION SOLUTION 750
UNIT/ML
Tier 6
30D
Antineoplastic - Bruton's Tyrosine Kinase (Btk) Inhibitor
IMBRUVICA ORAL CAPSULE 140 MG
Tier 2
Antineoplastic - Cd20 Specific Recombinant Monoclonal Antibody Agents
ARZERRA INTRAVENOUS SOLUTION
1,000 MG/50 ML
Tier 6
30D
RITUXAN INTRAVENOUS CONCENTRATE
10 MG/ML
Tier 6
PA; 30D
Antineoplastic - Cytotoxic T-Lymphocyte Antigen (Ctla-4),R-Mc Antibody
YERVOY INTRAVENOUS SOLUTION 50
MG/10 ML (5 MG/ML)
Tier 6
30D
Antineoplastic - Epidermal Growth Factor Receptor (Egfr) - Specific
TARCEVA ORAL TABLET 100 MG, 150 MG,
25 MG
Tier 4
Antineoplastic - Epipodophyllotoxins
ETOPOPHOS INTRAVENOUS RECON
SOLN 100 MG
Tier 6
30D
etoposide intravenous solution 20 mg/mL
Tier 6
30D
etoposide Oral capsule 50 mg
Tier 1
TOPOSAR INTRAVENOUS SOLUTION 20
MG/ML
Tier 6
30D
Tier 6
30D
Antineoplastic - Estrogen Receptor Antagonist
FASLODEX INTRAMUSCULAR SYRINGE
250 MG/5 ML
Antineoplastic - Estrogens
EMCYT ORAL CAPSULE 140 MG
Tier 2
Antineoplastic - Halichondrin B Analogs, Microtubule Inhibitors
HALAVEN INTRAVENOUS SOLUTION 1
MG/2 ML (0.5 MG/ML)
Tier 6
30D
53
Drug Name
Drug Tier
Notes
Antineoplastic - Hedgehog Pathway Inhibitor
ERIVEDGE ORAL CAPSULE 150 MG
Tier 4
Antineoplastic - Histone Deacetylase (Hdac) Inhibitors
ISTODAX INTRAVENOUS RECON SOLN 10
MG/2 ML
Tier 6
ZOLINZA ORAL CAPSULE 100 MG
Tier 4
30D
Antineoplastic - Immunotherapy, Therapeutic Vaccines
Tier 6
30D
INTRON A INJECTION RECON SOLN 10
MILLION UNIT (1 ML), 18 MILLION UNIT
(1 ML), 50 MILLION UNIT (1 ML)
Tier 4
PA
INTRON A INJECTION SOLUTION 10
MILLION UNIT/ML, 6 MILLION UNIT/ML
Tier 4
PA
SYLATRON SUBCUTANEOUS KIT 296
MCG, 444 MCG, 888 MCG
Tier 4
SYLATRON 4-PACK SUBCUTANEOUS KIT
296 MCG, 444 MCG
Tier 4
PROVENGE INTRAVENOUS SUSPENSION
50 MILLION CELL/250 ML
Antineoplastic - Interferons
Antineoplastic - Interleukins
PROLEUKIN INTRAVENOUS RECON
SOLN 22 MILLION UNIT
Tier 6
30D
Tier 4
PA
Antineoplastic - Janus Kinase (Jak) Inhibitors
JAKAFI ORAL TABLET 10 MG, 15 MG, 20
MG, 25 MG, 5 MG
Antineoplastic - Lhrh (Gnrh) Agonist Analog Pituitary Suppressants
ELIGARD SUBCUTANEOUS SYRINGE 22.5
MG, 30 MG, 45 MG, 7.5 MG
Tier 6
30D
leuprolide subcutaneous kit 1 mg/0.2 mL
Tier 6
30D
TRELSTAR INTRAMUSCULAR SYRINGE
11.25 MG/2 ML, 22.5 MG/2 ML, 3.75 MG/2
ML
Tier 6
30D
ZOLADEX SUBCUTANEOUS IMPLANT 10.8
MG, 3.6 MG
Tier 6
30D
Antineoplastic - Lhrh (Gnrh) Antagonist Pituitary Suppressants
FIRMAGON SUBCUTANEOUS RECON
SOLN 120 MG, 80 MG
54
Tier 6
30D
Drug Name
Drug Tier
Notes
Antineoplastic - Mast Cell Stabilizers
cromolyn oral solution 100 mg/5 mL
Tier 1
GASTROCROM ORAL SOLUTION 100
MG/5 ML
Tier 3
Antineoplastic - Monoclonal Antibodies For Radiopharmaceutical Therapy
ZEVALIN (Y-90) INTRAVENOUS KIT 3.2
MG/2 ML
Tier 6
30D
Antineoplastic - Mtor Kinase Inhibitors
AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5
MG, 7.5 MG
Tier 4
AFINITOR DISPERZ ORAL TABLET FOR
SUSPENSION 2 MG, 3 MG, 5 MG
Tier 4
Antineoplastic - Multikinase Inhibitors
COMETRIQ ORAL CAPSULE 100
MG/DAY(80 MG[1]-20 MG[1]), 140
MG/DAY(80 MG[1]-20 MG[3]), 60 MG/DAY
(20 MG [3]/DAY)
Tier 4
ICLUSIG ORAL TABLET 15 MG, 45 MG
Tier 4
MEKINIST ORAL TABLET 0.5 MG, 2 MG
Tier 4
NEXAVAR ORAL TABLET 200 MG
Tier 4
STIVARGA ORAL TABLET 40 MG
Tier 2
TAFINLAR ORAL CAPSULE 50 MG, 75 MG
Tier 4
ZELBORAF ORAL TABLET 240 MG
Tier 4
Antineoplastic - Other
THERACYS INTRAVESICAL SUSPENSION
Tier 6
30D
TICE BCG INTRAVESICAL SUSPENSION
Tier 6
30D
carboplatin intravenous solution 10 mg/mL
Tier 6
30D
cisplatin intravenous solution 1 mg/mL
Tier 6
30D
ELOXATIN INTRAVENOUS SOLUTION 50
MG/10 ML (5 MG/ML)
Tier 6
30D
oxaliplatin intravenous recon soln 50 mg
Tier 6
30D
Antineoplastic - Platinum Complexes
Antineoplastic - Progestins
55
Drug Name
Drug Tier
DEPO-PROVERA INTRAMUSCULAR
SOLUTION 400 MG/ML
Tier 6
megestrol Oral tablet 20 mg, 40 mg
Tier 1
Notes
30D
Antineoplastic - Proteasome Enzyme Inhibitors
VELCADE INJECTION RECON SOLN 3.5
MG
Tier 6
30D
Antineoplastic - Protein-Tyrosine Kinase Inhibitors
BOSULIF ORAL TABLET 100 MG, 500 MG
Tier 4
CAPRELSA ORAL TABLET 100 MG, 300
MG
Tier 4
GLEEVEC ORAL TABLET 100 MG, 400 MG
Tier 4
IMBRUVICA ORAL CAPSULE 140 MG
Tier 4
INLYTA ORAL TABLET 1 MG, 5 MG
Tier 4
SPRYCEL ORAL TABLET 100 MG, 140 MG,
20 MG, 50 MG, 70 MG, 80 MG
Tier 4
SUTENT ORAL CAPSULE 12.5 MG, 25 MG,
37.5 MG, 50 MG
Tier 4
TASIGNA ORAL CAPSULE 150 MG, 200 MG
Tier 4
VOTRIENT ORAL TABLET 200 MG
Tier 4
XALKORI ORAL CAPSULE 200 MG, 250
MG
Tier 4
ZYKADIA ORAL CAPSULE 150 MG
Tier 2
Antineoplastic - Retinoids
tretinoin (chemotherapy) Oral capsule 10 mg
Tier 2
Antineoplastic - Selective Estrogen Receptor Modulators (Serms)
FARESTON ORAL TABLET 60 MG
Tier 5
SOLTAMOX ORAL SOLUTION 10 MG/5 ML
Tier 5
tamoxifen Oral tablet 10 mg, 20 mg
Tier 5
Antineoplastic - Selective Retinoid X Receptor Agonists
TARGRETIN ORAL CAPSULE 75 MG
Tier 2
Antineoplastic - Taxanes
ABRAXANE INTRAVENOUS RECON SOLN
100 MG
Tier 6
30D
DOCEFREZ INTRAVENOUS RECON SOLN
20 MG, 80 MG
Tier 6
30D
56
Drug Name
Drug Tier
Notes
docetaxel intravenous solution 20 mg/2 mL (10
mg/mL), 20 mg/2 mL (Final), 20 mg/mL (1 mL)
Tier 6
30D
JEVTANA INTRAVENOUS SOLUTION 10
MG/ML (FINAL CONC.)
Tier 6
30D
ONXOL INTRAVENOUS CONCENTRATE 6
MG/ML
Tier 6
30D
paclitaxel intravenous concentrate 6 mg/mL
Tier 6
30D
TAXOTERE INTRAVENOUS SOLUTION 20
MG/ML (1 ML)
Tier 6
30D
Antineoplastic - Thalidomide Analogs
POMALYST ORAL CAPSULE 1 MG, 2 MG, 3
MG, 4 MG
Tier 4
REVLIMID ORAL CAPSULE 10 MG, 15 MG,
2.5 MG, 20 MG, 25 MG, 5 MG
Tier 4
THALOMID ORAL CAPSULE 100 MG, 150
MG, 200 MG, 50 MG
Tier 3
Antineoplastic - Topoisomerase I Inhibitors
CAMPTOSAR INTRAVENOUS SOLUTION
40 MG/2 ML
Tier 6
30D
HYCAMTIN ORAL CAPSULE 0.25 MG, 1
MG
Tier 4
irinotecan intravenous solution 100 mg/5 mL
Tier 6
30D
topotecan intravenous solution 4 mg/4 mL (1
mg/mL)
Tier 6
30D
Antineoplastic - Vasc Endothelial Growth Factor Receptor (Vegfr) Antag
Tier 6
30D
NAVELBINE INTRAVENOUS SOLUTION 10
MG/ML
Tier 6
30D
vinblastine intravenous recon soln 10 mg
Tier 6
30D
vinorelbine intravenous solution 10 mg/mL
Tier 6
30D
COSMEGEN INTRAVENOUS RECON SOLN
0.5 MG
Tier 6
30D
dactinomycin intravenous recon soln 0.5 mg
Tier 6
30D
CYRAMZA INTRAVENOUS SOLUTION 10
MG/ML
Antineoplastic - Vinca Alkaloids And Analogs
Antineoplastic Antibiotic - Actinomycins
57
Drug Name
Drug Tier
Notes
Antineoplastic Antibiotic - Anthracyclines
ADRIAMYCIN INTRAVENOUS RECON
SOLN 10 MG
Tier 6
30D
CERUBIDINE INTRAVENOUS RECON
SOLN 20 MG
Tier 6
30D
daunorubicin intravenous solution 5 mg/mL
Tier 6
30D
DAUNOXOME INTRAVENOUS SOLUTION
2 MG/ML
Tier 6
30D
DOXIL INTRAVENOUS SOLUTION 2
MG/ML
Tier 6
30D
doxorubicin HCl peg-liposomal intravenous
solution 2 mg/mL
Tier 6
30D
ELLENCE INTRAVENOUS SOLUTION 50
MG/25 ML
Tier 6
30D
epirubicin intravenous solution 50 mg/25 mL
Tier 6
30D
IDAMYCIN PFS INTRAVENOUS
SOLUTION 1 MG/ML
Tier 6
30D
idarubicin intravenous solution 1 mg/mL
Tier 6
30D
LIPODOX INTRAVENOUS SOLUTION 2
MG/ML
Tier 6
30D
mitoxantrone intravenous concentrate 2 mg/mL
Tier 6
30D
bleomycin injection recon soln 15 unit
Tier 6
30D
mitomycin intravenous recon soln 20 mg
Tier 6
30D
ZANOSAR INTRAVENOUS RECON SOLN 1
GRAM
Tier 6
30D
Tier 6
30D
Antineoplastic Antibiotic - Others
Antineoplastic -Cephalotaxines
SYNRIBO SUBCUTANEOUS RECON SOLN
3.5 MG
Antineoplastic-Cd30 Directed Antibody-Microtubule Disrupting Conjugate
ADCETRIS INTRAVENOUS RECON SOLN
50 MG
Tier 6
30D
Antineoplastic-Her2 Targeted Antibody-Microtubule Inhibitor Conjugate
KADCYLA INTRAVENOUS RECON SOLN
160 MG
Tier 6
30D
Cardiac Protective Agents Used In Conjunction With Chemotherapy
58
Drug Name
Drug Tier
Notes
dexrazoxane intravenous recon soln 250 mg
Tier 6
30D
ZINECARD INTRAVENOUS RECON SOLN
250 MG
Tier 6
30D
Epidermal Growth Factor Recept Blocker (Her-1 Type), Rec-Mc Antibody
ERBITUX INTRAVENOUS SOLUTION 100
MG/50 ML
Tier 6
30D
VECTIBIX INTRAVENOUS SOLUTION 100
MG/5 ML (20 MG/ML)
Tier 6
30D
Epidermal Growth Factor Recept Blocker (Her-2 Type), Rec-Mc Antibody
Tier 6
30D
CALCIUM FOLINATE (LEUCOVORIN)
INJECTION SOLUTION 10 MG/ML
Tier 6
30D
FUSILEV INTRAVENOUS RECON SOLN 50
MG
Tier 6
30D
leucovorin calcium injection recon soln 350 mg
Tier 6
30D
leucovorin calcium Oral tablet 10 mg, 25 mg, 5
mg
Tier 1
HERCEPTIN INTRAVENOUS RECON SOLN
440 MG
Methotrexate Rescue Agents
Methotrexate Rescue Agents - Folic Acid Antagonist Type
CALCIUM FOLINATE (LEUCOVORIN)
INJECTION SOLUTION 10 MG/ML
Tier 6
30D
FUSILEV INTRAVENOUS RECON SOLN 50
MG
Tier 6
30D
leucovorin calcium injection recon soln 350 mg
Tier 6
30D
leucovorin calcium Oral tablet 10 mg, 25 mg, 5
mg
Tier 1
Tissue Protective Agents For Tx Of Cancer Chemotherapy Extravasation
TOTECT INTRAVENOUS RECON SOLN 500
MG (X 10)
Tier 6
30D
Urinary Tract Protective Agents Used In Conjunction With Chemotherapy
amifostine crystalline intravenous recon soln 500
mg
Tier 6
30D
mesna intravenous solution 100 mg/mL
Tier 6
30D
MESNEX INTRAVENOUS SOLUTION 100
MG/ML
Tier 6
30D
59
Drug Name
MESNEX ORAL TABLET 400 MG
Drug Tier
Notes
Tier 2
Antiseptics & Disinfectants
Antiseptic - Iodine/Iodophores
IODOFLEX TOPICAL PADS, MEDICATED
0.9 %
Tier 3
IODOSORB TOPICAL GEL 0.9 %
Tier 3
Antiseptic - Others
FORMA-RAY SOLUTION 20 %
Tier 2
FORMADON TOPICAL SOLUTION 10 %
Tier 1
formaldehyde topical solution with applicator 10
%
Tier 1
formaldehyde (bulk) solution 10 %
Tier 1
Disinfectants - Aldehydes
FORMADON TOPICAL SOLUTION 10 %
Tier 1
Biologicals
Allergenic Extract Others
RAGWITEK SUBLINGUAL TABLET,
SUBLINGUAL 12 AMB A 1 UNIT
Tier 3
Allergenic Extracts - Grass Pollen
GRASTEK SUBLINGUAL TABLET,
SUBLINGUAL 2,800 BAU
Tier 3
ORALAIR SUBLINGUAL TABLET,
SUBLINGUAL 300 IR
Tier 3
RAGWITEK SUBLINGUAL TABLET,
SUBLINGUAL 12 UNIT
Tier 3
SYNAGIS INTRAMUSCULAR SOLUTION
100 MG/ML
Tier 6
PA; 30D
SYNAGIS INTRAMUSCULAR SOLUTION 50
MG/0.5 ML
Tier 6
PA; 30D
HAVRIX (PF) INTRAMUSCULAR
SUSPENSION 1,440 ELISA UNIT/ML
Tier 6
30D
HAVRIX (PF) INTRAMUSCULAR SYRINGE
1,440 ELISA UNIT/ML, 720 ELISA UNIT/0.5
ML
60
Tier 6
30D
Antiviral Monoclonal Antibodies
Hepatitis A Vaccine - Single Agents
Drug Name
Drug Tier
Notes
Hepatitis B Vaccines - Single Agents
ENGERIX-B (PF) INTRAMUSCULAR
SYRINGE 20 MCG/ML
Tier 6
30D
ENGERIX-B PEDIATRIC (PF)
INTRAMUSCULAR SUSPENSION 10
MCG/0.5 ML
Tier 6
30D
Tier 6
30D
Immune Globulin - Cytomegalovirus (Cmv)
CYTOGAM INTRAVENOUS SOLUTION 50
MG/ML
Immune Globulin - Gamma Globulin (Igg), Human
BIVIGAM INTRAVENOUS SOLUTION 10 %
Tier 6
PA; 30D
CARIMUNE NF NANOFILTERED
INTRAVENOUS RECON SOLN 12 GRAM, 6
GRAM
Tier 6
PA
CARIMUNE NF NANOFILTERED
INTRAVENOUS RECON SOLN 3 GRAM
Tier 6
PA; 30D
FLEBOGAMMA DIF INTRAVENOUS
SOLUTION 10 %
Tier 6
PA; 30D
FLEBOGAMMA DIF INTRAVENOUS
SOLUTION 5 %
Tier 6
PA
GAMASTAN S/D INTRAMUSCULAR
SOLUTION 15-18 % RANGE
Tier 6
PA; 30D
GAMMAGARD LIQUID INTRAVENOUS
SOLUTION 10 %
Tier 6
PA; 30D
GAMMAGARD S-D (IGA &LT; 1 MCG/ML)
INTRAVENOUS RECON SOLN 10 GRAM, 5
GRAM
Tier 6
PA
GAMMAGARD S/D INTRAVENOUS RECON
SOLN 10 GRAM, 2.5 GRAM, 5 GRAM
Tier 6
PA
GAMMAKED INJECTION SOLUTION 1
GRAM/10 ML (10 %)
Tier 6
PA; 30D
GAMMAKED INJECTION SOLUTION 10
GRAM/100 ML (10 %), 2.5 GRAM/25 ML (10
%), 20 GRAM/200 ML (10 %), 5 GRAM/50
ML (10 %)
Tier 6
PA
GAMMAPLEX INTRAVENOUS SOLUTION
5%
Tier 6
PA; 30D
61
Drug Name
Drug Tier
Notes
GAMUNEX-C INJECTION SOLUTION 1
GRAM/10 ML (10 %), 2.5 GRAM/25 ML (10
%), 20 GRAM/200 ML (10 %), 5 GRAM/50
ML (10 %)
Tier 6
PA
GAMUNEX-C INJECTION SOLUTION 10
GRAM/100 ML (10 %)
Tier 6
PA; 30D
HIZENTRA SUBCUTANEOUS SOLUTION 1
GRAM/5 ML (20 %)
Tier 6
PA; 30D
HIZENTRA SUBCUTANEOUS SOLUTION
10 GRAM/50 ML (20 %), 2 GRAM/10 ML (20
%), 4 GRAM/20 ML (20 %)
Tier 6
PA
OCTAGAM INTRAVENOUS SOLUTION 5
%
Tier 6
PA; 30D
PRIVIGEN INTRAVENOUS SOLUTION 10
%
Tier 6
PA; 30D
HYPERHEP B S-D NEONATAL
INTRAMUSCULAR SYRINGE 110 UNIT/0.5
ML
Tier 6
30D
HYPERHEP B S/D INTRAMUSCULAR
SOLUTION 220 UNIT/ML
Tier 6
30D
HYPERHEP B S/D INTRAMUSCULAR
SYRINGE 220 UNIT/ML
Tier 6
30D
NABI-HB INTRAMUSCULAR SOLUTION
&GT;312 UNIT/ML
Tier 6
30D
HYPERRHO S/D INTRAMUSCULAR
SYRINGE 1,500 UNIT (300 MCG), 250 UNIT
(50 MCG)
Tier 6
30D
MICRHOGAM ULTRA-FILTERED PLUS
INTRAMUSCULAR SYRINGE 250 UNIT (50
MCG)
Tier 6
30D
RHOGAM ULTRA-FILTERED PLUS
INTRAMUSCULAR SYRINGE 1,500 UNIT
(300 MCG)
Tier 6
30D
Tier 6
30D
Immune Globulin - Hepatitis B
Immune Globulin - Rho(D)
Immune Globulin - Varicella-Zoster
VARIZIG INTRAMUSCULAR RECON SOLN
125 UNIT
Immune Serums
62
Drug Name
Drug Tier
Notes
Tier 6
30D
ROTARIX ORAL SUSPENSION FOR
RECONSTITUTION 10EXP6 CCID50/ML
Tier 6
30D
THERACYS INTRAVESICAL SUSPENSION
Tier 6
30D
TICE BCG INTRAVESICAL SUSPENSION
Tier 6
30D
VARIVAX (PF) SUBCUTANEOUS
SUSPENSION FOR RECONSTITUTION
1,350 UNIT/0.5 ML
Tier 6
30D
ZOSTAVAX (PF) SUBCUTANEOUS
19,400 UNIT/0.65 ML
Tier 6
30D
ADACEL(TDAP ADOLESN/ADULT)(PF)
INTRAMUSCULAR SYRINGE 2-5-3-5-5 LFMCG-LF/0.5ML
Tier 6
30D
INFANRIX (DTAP) (PF) INTRAMUSCULAR
SUSPENSION 25-58-10 LF-MCG-LF/0.5ML
Tier 6
30D
KINRIX (PF) INTRAMUSCULAR
SUSPENSION 25 LF-58 MCG-10 LF/0.5 ML
Tier 6
30D
KINRIX (PF) INTRAMUSCULAR SYRINGE
25 LF-58 MCG-10 LF/0.5 ML
Tier 6
30D
TENIVAC (PF) INTRAMUSCULAR
SUSPENSION 5 LF UNIT- 2 LF UNIT/0.5ML
Tier 6
30D
MENACTRA (PF) INTRAMUSCULAR
SOLUTION 4 MCG/0.5 ML
Tier 6
30D
MENOMUNE - A/C/Y/W-135
SUBCUTANEOUS RECON SOLN 50 MCG
Tier 6
30D
MENVEO A-C-Y-W-135-DIP (PF)
INTRAMUSCULAR KIT 10-5 MCG/0.5 ML
Tier 6
30D
Tier 6
30D
ATGAM INTRAVENOUS INJECTABLE 50
MG/ML
Live Vaccines
Toxoid Vaccine Combinations
Vaccine Bacterial - Gram Negative Cocci
Vaccine Bacterial - Gram Positive Cocci
PNEUMOVAX 23 INJECTION INJECTABLE
25 MCG/0.5 ML
63
Drug Name
PREVNAR 13 (PF) INTRAMUSCULAR
SYRINGE 0.5 ML
Drug Tier
Notes
Tier 6
30D
Tier 6
30D
Vaccine Bacterial - Toxin-Producing Bacilli
BIOTHRAX INTRAMUSCULAR
SUSPENSION 0.5 ML/DOSE
Vaccine Mixed Combinations (Bacterial & Viral)
PENTACEL (PF) INTRAMUSCULAR KIT 15
LF UNIT-20 MCG-5 LF/0.5 ML
Tier 6
30D
Vaccine Viral - Human Papillomavirus (Hpv) Vaccines
CERVARIX VACCINE (PF)
INTRAMUSCULAR SYRINGE 20-20
MCG/0.5 ML
Tier 6
30D
GARDASIL (PF) INTRAMUSCULAR
SUSPENSION 20-40-40-20 MCG/0.5 ML
Tier 6
30D
GARDASIL (PF) INTRAMUSCULAR
SYRINGE 20-40-40-20 MCG/0.5 ML
Tier 6
30D
Vaccine Viral - Influenza A & B
FLUARIX 2014-2015 (PF)
INTRAMUSCULAR SYRINGE 45 MCG (15
MCG X 3)/0.5 ML
Tier 5
FLUARIX QUAD 2014-2015 (PF)
MCG X 4)/0.5 ML
Tier 5
FLUBLOK 2014-2015 (PF)
INTRAMUSCULAR SOLUTION 135 MCG
(45 MCG X 3)/0.5 ML
Tier 5
FLUCELVAX 2014-2015 (PF)
MCG X 3)0.5 ML
Tier 5
FLULAVAL 2014-2015 INTRAMUSCULAR
SUSPENSION 45 MCG (15 MCG X 3)/0.5 ML
Tier 5
FLULAVAL 2014-2015 (PF)
MCG X 3)/0.5 ML
Tier 5
FLULAVAL QUAD 2014-2015
INTRAMUSCULAR SUSPENSION 60 MCG
(15 MCG X 4)/0.5 ML
Tier 5
FLULAVAL QUAD 2014-2015 (PF)
MCG X 4)/0.5 ML
Tier 5
64
Drug Name
Drug Tier
FLUVIRIN 2014-2015 INTRAMUSCULAR
Tier 5
FLUVIRIN 2014-2015 (PF)
MCG X 3)/0.5 ML
Tier 5
FLUZONE 2013-2014 (PF)
(15 MCG X 3)/0.5 ML
Tier 5
FLUZONE 2014-2015 INTRAMUSCULAR
Tier 5
FLUZONE 2014-2015 (PF)
MCG X 3)/0.5 ML
Tier 5
FLUZONE HIGH-DOSE 2014-15 (PF)
INTRAMUSCULAR SYRINGE 180 MCG/0.5
ML
Tier 5
FLUZONE INTRADERM 2014-15 (PF)
INTRADERMAL SYRINGE 27 MCG/0.1 ML
Tier 5
FLUZONE PEDI 2013-2014 (PF)
INTRAMUSCULAR SYRINGE 22.5
MCG/0.25 ML
Tier 5
FLUZONE QUAD 2014-2015
(15 MCG X 4)/0.5 ML
Tier 5
FLUZONE QUAD 2014-2015 (PF)
(15 MCG X 4)/0.5 ML
Tier 5
FLUZONE QUAD 2014-2015 (PF)
MCG X 4)/0.5 ML
Tier 5
FLUZONE QUAD PEDI 2014-15 (PF)
INTRAMUSCULAR SYRINGE 30 MCG (7.5
MCG X 4)/0.25 ML
Tier 5
PHYSICIANS EZ USE FLU 2012-13
INTRAMUSCULAR KIT 45 MCG (15 MCG X
3)/0.5 ML
Tier 5
SINGLE USE EZ FLU 2012-13 (PF)
INTRAMUSCULAR SYRINGE KIT 45 MCG
(15 MCG X 3)/0.5 ML
Tier 5
Notes
65
Drug Name
Drug Tier
INTRAMUSCULAR KIT 60 MCG (15 MCG X
4)/0.5 ML
Tier 5
INTRAMUSCULAR SYRINGE KIT 45 MCG
(15 MCG X 3)/0.5 ML, 60 MCG (15 MCG X
4)/0.5 ML
Tier 5
Notes
Vaccine Viral - Japanese Encephalitis
Tier 6
30D
Tier 6
30D
VARIVAX (PF) SUBCUTANEOUS
1,350 UNIT/0.5 ML
Tier 6
30D
ZOSTAVAX (PF) SUBCUTANEOUS
19,400 UNIT/0.65 ML
Tier 6
30D
IXIARO (PF) INTRAMUSCULAR SYRINGE
6 MCG/0.5 ML
Vaccine Viral - Rotavirus
ROTARIX ORAL SUSPENSION FOR
RECONSTITUTION 10EXP6 CCID50/ML
Vaccine Viral - Varicella
Cardiovascular Therapy Agents
Ace Inhibitor And Calcium Channel Blocker Combinations
amlodipine-benazepril oral capsule 10-20 mg, 1040 mg, 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg
Tier 1
LOTREL ORAL CAPSULE 10-20 MG, 10-40
MG, 2.5-10 MG, 5-10 MG, 5-20 MG, 5-40 MG
Tier 3
TARKA ORAL TABLET, ER MULTIPHASE
24 HR 1-240 MG, 2-180 MG, 2-240 MG, 4-240
MG
Tier 2
Ace Inhibitors
ACCUPRIL ORAL TABLET 10 MG, 20 MG,
40 MG, 5 MG
Tier 3
ACEON ORAL TABLET 4 MG, 8 MG
Tier 3
ALTACE ORAL CAPSULE 1.25 MG, 10 MG,
2.5 MG, 5 MG
Tier 3
benazepril oral tablet 10 mg, 20 mg, 5 mg
Tier 1
captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50
mg
Tier 1
66
Drug Name
Drug Tier
enalapril maleate oral tablet 10 mg, 2.5 mg, 20
mg, 5 mg
Tier 1
EPANED ORAL RECON SOLN 1 MG/ML
Tier 3
fosinopril oral tablet 10 mg, 20 mg, 40 mg
Tier 1
lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg,
40 mg, 5 mg
Tier 1
LOTENSIN ORAL TABLET 20 MG, 40 MG
Tier 3
MAVIK ORAL TABLET 1 MG, 2 MG, 4 MG
Tier 3
moexipril oral tablet 15 mg, 7.5 mg
Tier 1
perindopril erbumine Oral tablet 2 mg, 4 mg, 8 mg
Tier 1
PRINIVIL ORAL TABLET 10 MG, 20 MG, 5
MG
Tier 3
quinapril oral tablet 10 mg, 20 mg, 40 mg, 5 mg
Tier 1
ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5
mg
Tier 1
trandolapril Oral tablet 1 mg, 2 mg, 4 mg
Tier 1
UNIVASC ORAL TABLET 15 MG, 7.5 MG
Tier 3
VASOTEC ORAL TABLET 10 MG, 2.5 MG,
20 MG, 5 MG
Tier 3
ZESTRIL ORAL TABLET 10 MG, 2.5 MG, 20
MG, 30 MG, 40 MG, 5 MG
Tier 3
Notes
Ace Inhibitors-Diuretic Combinations
ACCURETIC ORAL TABLET 10-12.5 MG,
20-12.5 MG, 20-25 MG
Tier 3
benazepril-hydrochlorothiazide oral tablet 10-12.5
mg, 20-12.5 mg, 20-25 mg, 5-6.25 mg
Tier 1
captopril-hydrochlorothiazide oral tablet 25-15
mg, 25-25 mg, 50-15 mg, 50-25 mg
Tier 1
enalapril-hydrochlorothiazide Oral tablet 10-25
mg, 5-12.5 mg
Tier 1
fosinopril-hydrochlorothiazide oral tablet 10-12.5
mg, 20-12.5 mg
Tier 1
lisinopril-hydrochlorothiazide Oral tablet 10-12.5
mg, 20-12.5 mg, 20-25 mg
Tier 1
LOTENSIN HCT ORAL TABLET 10-12.5
MG, 20-12.5 MG, 20-25 MG
Tier 3
67
Drug Name
Drug Tier
moexipril-hydrochlorothiazide Oral tablet 15-12.5
mg, 15-25 mg, 7.5-12.5 mg
Tier 1
quinapril-hydrochlorothiazide oral tablet 10-12.5
mg, 20-12.5 mg, 20-25 mg
Tier 1
UNIRETIC ORAL TABLET 15-12.5 MG
Tier 3
VASERETIC ORAL TABLET 10-25 MG
Tier 3
ZESTORETIC ORAL TABLET 10-12.5 MG,
20-12.5 MG, 20-25 MG
Tier 3
Notes
Aldosterone Receptor Antagonists
ALDACTONE ORAL TABLET 100 MG, 25
MG, 50 MG
Tier 3
eplerenone oral tablet 25 mg, 50 mg
Tier 1
INSPRA ORAL TABLET 25 MG, 50 MG
Tier 3
spironolactone oral tablet 100 mg, 25 mg, 50 mg
Tier 1
Alpha-Beta Blockers
carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg,
6.25 mg
Tier 1
COREG ORAL TABLET 12.5 MG, 25 MG,
3.125 MG, 6.25 MG
Tier 3
COREG CR ORAL CAPSULE, ER
MULTIPHASE 24 HR 10 MG, 20 MG, 40 MG,
80 MG
Tier 3
labetalol oral tablet 100 mg, 200 mg, 300 mg
Tier 1
TRANDATE ORAL TABLET 100 MG, 200
MG, 300 MG
Tier 3
PA
Angiotensin Ii Receptor Blocker (Arb)-Calcium Channel Blocker Comb.
AZOR ORAL TABLET 10-20 MG, 10-40 MG,
5-20 MG, 5-40 MG
Tier 2
EXFORGE ORAL TABLET 10-160 MG, 10320 MG, 5-160 MG, 5-320 MG
Tier 2
TWYNSTA ORAL TABLET 40-10 MG, 40-5
MG, 80-10 MG, 80-5 MG
Tier 3
Angiotensin Ii Receptor Blocker (Arb)-Calcium Channel Blocker-Diuretic
EXFORGE HCT ORAL TABLET 10-160-12.5
MG, 10-160-25 MG, 10-320-25 MG, 5-160-12.5
MG, 5-160-25 MG
68
Tier 2
Drug Name
TRIBENZOR ORAL TABLET 20-5-12.5 MG,
40-10-12.5 MG, 40-10-25 MG, 40-5-12.5 MG,
40-5-25 MG
Drug Tier
Notes
Tier 2
Angiotensin Ii Receptor Blocker (Arb)-Diuretic Combinations
ATACAND HCT ORAL TABLET 16-12.5 MG,
32-12.5 MG, 32-25 MG
Tier 3
AVALIDE ORAL TABLET 150-12.5 MG, 30012.5 MG
Tier 3
BENICAR HCT ORAL TABLET 20-12.5 MG,
40-12.5 MG, 40-25 MG
Tier 2
candesartan-hydrochlorothiazid oral tablet 1612.5 mg, 32-12.5 mg, 32-25 mg
Tier 1
DIOVAN HCT ORAL TABLET 160-12.5 MG,
160-25 MG, 320-12.5 MG, 320-25 MG, 80-12.5
MG
Tier 3
EDARBYCLOR ORAL TABLET 40-12.5 MG,
40-25 MG
Tier 3
HYZAAR ORAL TABLET 100-12.5 MG, 10025 MG, 50-12.5 MG
Tier 3
irbesartan-hydrochlorothiazide oral tablet 15012.5 mg, 300-12.5 mg
Tier 1
losartan-hydrochlorothiazide oral tablet 100-12.5
mg, 100-25 mg, 50-12.5 mg
Tier 1
MICARDIS HCT ORAL TABLET 40-12.5
MG, 80-12.5 MG, 80-25 MG
Tier 3
telmisartan-hydrochlorothiazid oral tablet 40-12.5
mg, 80-25 mg
Tier 1
TEVETEN HCT ORAL TABLET 600-12.5
MG, 600-25 MG
Tier 3
valsartan-hydrochlorothiazide oral tablet 160-12.5
mg, 160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5
mg
Tier 1
PA
Angiotensin Ii Receptor Blockers (Arbs)
ATACAND ORAL TABLET 16 MG, 32 MG, 4
MG, 8 MG
Tier 3
AVAPRO ORAL TABLET 150 MG, 300 MG,
75 MG
Tier 3
BENICAR ORAL TABLET 20 MG, 40 MG, 5
MG
Tier 2
69
Drug Name
Drug Tier
Notes
candesartan oral tablet 16 mg, 32 mg, 4 mg, 8 mg
Tier 1
COZAAR ORAL TABLET 100 MG, 25 MG, 50
MG
Tier 3
DIOVAN ORAL TABLET 160 MG, 320 MG,
40 MG, 80 MG
Tier 2
EDARBI ORAL TABLET 40 MG, 80 MG
Tier 3
eprosartan Oral tablet 600 mg
Tier 1
irbesartan oral tablet 150 mg, 300 mg, 75 mg
Tier 1
losartan oral tablet 100 mg, 25 mg, 50 mg
Tier 1
MICARDIS ORAL TABLET 20 MG, 40 MG,
80 MG
Tier 3
telmisartan oral tablet 20 mg, 40 mg, 80 mg
Tier 1
TEVETEN ORAL TABLET 600 MG
Tier 3
valsartan oral tablet 160 mg, 320 mg, 40 mg, 80
mg
Tier 1
Antianginal - Coronary Vasodilators (Nitrates)
DILATRATE-SR ORAL CAPSULE,
EXTENDED RELEASE 40 MG
Tier 2
IMDUR ORAL TABLET EXTENDED
Tier 3
ISOCHRON ORAL TABLET EXTENDED
RELEASE 40 MG
Tier 3
ISORDIL ORAL TABLET 40 MG
Tier 3
ISORDIL TITRADOSE ORAL TABLET 5
MG
Tier 3
isosorbide dinitrate oral tablet 10 mg, 20 mg, 30
mg, 5 mg
Tier 1
isosorbide dinitrate oral tablet extended release 40
mg
Tier 1
isosorbide mononitrate Oral tablet 10 mg, 20 mg
Tier 1
isosorbide mononitrate Oral tablet extended
release 24 hr 120 mg, 30 mg, 60 mg
Tier 1
MINITRAN TRANSDERMAL PATCH 24
HOUR 0.1 MG/HR, 0.2 MG/HR, 0.4 MG/HR,
0.6 MG/HR
Tier 1
NITRO-BID TRANSDERMAL OINTMENT 2
%
Tier 2
70
Drug Name
Drug Tier
NITRO-DUR TRANSDERMAL PATCH 24
HOUR 0.1 MG/HR, 0.2 MG/HR, 0.4 MG/HR,
0.6 MG/HR
Tier 3
NITRO-DUR TRANSDERMAL PATCH 24
HOUR 0.3 MG/HR, 0.8 MG/HR
Tier 2
nitroglycerin Oral capsule, extended release 2.5
mg, 6.5 mg, 9 mg
Tier 1
nitroglycerin transdermal patch 24 hour 0.1
mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr
Tier 1
nitroglycerin translingual spray,non-aerosol 400
mcg/spray
Tier 2
NITROLINGUAL TRANSLINGUAL
SPRAY,NON-AEROSOL 400 MCG/SPRAY
Tier 3
NITROMIST TRANSLINGUAL
AEROSOL,SPRAY 400 MCG/SPRAY
Tier 3
NITROSTAT SUBLINGUAL TABLET,
SUBLINGUAL 0.3 MG, 0.4 MG, 0.6 MG
Tier 2
Notes
Antianginal And Anti-Ischemic Agents, Non-Hemodynamic
RANEXA ORAL TABLET EXTENDED
RELEASE 12 HR 1,000 MG, 500 MG
Tier 2
Antiarrhythmic - Class Ia
disopyramide Oral capsule 100 mg, 150 mg
Tier 1
NORPACE ORAL CAPSULE 100 MG, 150
MG
Tier 3
NORPACE CR ORAL CAPSULE,
EXTENDED RELEASE 100 MG, 150 MG
Tier 3
quinidine gluconate oral tablet extended release
324 mg
Tier 1
quinidine sulfate oral tablet 200 mg, 300 mg
Tier 1
quinidine sulfate Oral tablet extended release 300
mg
Tier 1
Antiarrhythmic - Class Ib
mexiletine Oral capsule 150 mg, 200 mg, 250 mg
Tier 1
Antiarrhythmic - Class Ic
flecainide Oral tablet 100 mg, 150 mg, 50 mg
Tier 1
propafenone Oral capsule,extended release 12 hr
225 mg, 325 mg, 425 mg
Tier 1
71
Drug Name
Drug Tier
propafenone Oral tablet 150 mg, 225 mg, 300 mg
Tier 1
RYTHMOL ORAL TABLET 150 MG, 225 MG
Tier 3
RYTHMOL SR ORAL
CAPSULE,EXTENDED RELEASE 12 HR 225
MG, 325 MG, 425 MG
Tier 3
Notes
Antiarrhythmic - Class Ii
BETAPACE ORAL TABLET 120 MG, 160
MG, 240 MG, 80 MG
Tier 3
BETAPACE AF ORAL TABLET 120 MG, 160
MG, 80 MG
Tier 3
SORINE ORAL TABLET 120 MG, 160 MG,
240 MG, 80 MG
Tier 1
sotalol Oral tablet 120 mg, 160 mg, 240 mg, 80
mg
Tier 1
SOTALOL AF ORAL TABLET 120 MG, 160
MG, 80 MG
Tier 1
Antiarrhythmic - Class Iii
amiodarone Oral tablet 100 mg, 200 mg, 400 mg
Tier 1
CORDARONE ORAL TABLET 200 MG
Tier 3
MULTAQ ORAL TABLET 400 MG
Tier 2
PACERONE ORAL TABLET 100 MG, 200
MG, 400 MG
Tier 1
TIKOSYN ORAL CAPSULE 125 MCG, 250
MCG, 500 MCG
Tier 3
Antiarrhythmic - Class Iv
CALAN ORAL TABLET 120 MG, 80 MG
Tier 3
verapamil Oral tablet 120 mg, 40 mg, 80 mg
Tier 1
Antihyperlipidemic - Apolipoprotein B-100 Synthesis Inhibitor
KYNAMRO SUBCUTANEOUS SYRINGE 200
MG/ML
Tier 4
Antihyperlipidemic - Bile Acid Sequestrants
cholestyramine (with sugar) oral powder in packet
4 gram
Tier 1
COLESTID ORAL PACKET 5 GRAM
Tier 3
COLESTID ORAL TABLET 1 GRAM
Tier 3
Colestipol Oral Packet 5 gram
Tier 1
72
PA
Drug Name
Drug Tier
colestipol Oral tablet 1 gram
Tier 1
PREVALITE ORAL POWDER IN PACKET 4
GRAM
Tier 1
QUESTRAN ORAL POWDER IN PACKET 4
GRAM
Tier 3
WELCHOL ORAL POWDER IN PACKET
3.75 GRAM
Tier 2
WELCHOL ORAL TABLET 625 MG
Tier 2
Notes
Antihyperlipidemic - Fibric Acid Derivatives
ANTARA ORAL CAPSULE 30 MG, 90 MG
Tier 3
fenofibrate oral capsule 150 mg, 50 mg
Tier 1
fenofibrate Oral tablet 160 mg, 54 mg
Tier 1
fenofibrate micronized Oral capsule 130 mg, 134
mg, 200 mg, 43 mg, 67 mg
Tier 1
fenofibrate nanocrystallized oral tablet 145 mg, 48
mg
Tier 1
fenofibric acid Oral tablet 105 mg, 35 mg
Tier 1
fenofibric acid (choline) oral capsule,delayed
release(DR/EC) 135 mg, 45 mg
Tier 1
FENOGLIDE ORAL TABLET 120 MG, 40
MG
Tier 3
FIBRICOR ORAL TABLET 105 MG, 35 MG
Tier 3
gemfibrozil oral tablet 600 mg
Tier 1
LIPOFEN ORAL CAPSULE 150 MG, 50 MG
Tier 3
LOFIBRA ORAL CAPSULE 134 MG, 200
MG, 67 MG
Tier 3
LOFIBRA ORAL TABLET 160 MG, 54 MG
Tier 3
LOPID ORAL TABLET 600 MG
Tier 3
TRICOR ORAL TABLET 145 MG, 48 MG
Tier 3
TRIGLIDE ORAL TABLET 160 MG
Tier 3
TRILIPIX ORAL CAPSULE,DELAYED
RELEASE(DR/EC) 135 MG, 45 MG
Tier 3
PA
PA
PA
PA
Antihyperlipidemic - Hmg Coa Reductase Inhibitor & Niacin Combinations
ADVICOR ORAL TABLET, ER
MULTIPHASE 24 HR 1,000-20 MG, 1,000-40
MG, 500-20 MG, 750-20 MG
Tier 3
73
Drug Name
Drug Tier
SIMCOR ORAL TABLET, ER MULTIPHASE
24 HR 1,000-20 MG, 1,000-40 MG, 500-20 MG,
500-40 MG, 750-20 MG
Tier 2
Notes
Antihyperlipidemic - Hmg Coa Reductase Inhibitors (Statins)
ALTOPREV ORAL TABLET EXTENDED
Tier 3
atorvastatin oral tablet 10 mg, 20 mg, 40 mg, 80
mg
Tier 1
CRESTOR ORAL TABLET 10 MG, 20 MG, 40
MG, 5 MG
Tier 2
fluvastatin Oral capsule 20 mg, 40 mg
Tier 1
LESCOL ORAL CAPSULE 20 MG, 40 MG
Tier 3
LESCOL XL ORAL TABLET EXTENDED
RELEASE 24 HR 80 MG
Tier 3
LIPITOR ORAL TABLET 10 MG, 20 MG, 40
MG, 80 MG
Tier 3
LIVALO ORAL TABLET 1 MG, 2 MG, 4 MG
Tier 3
lovastatin oral tablet 10 mg, 20 mg, 40 mg
Tier 1
MEVACOR ORAL TABLET 20 MG
Tier 3
PRAVACHOL ORAL TABLET 20 MG, 40
MG, 80 MG
Tier 3
pravastatin oral tablet 10 mg, 20 mg, 40 mg, 80
mg
Tier 1
simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg
Tier 1
simvastatin oral tablet 80 mg
Tier 1
ZOCOR ORAL TABLET 10 MG, 20 MG, 40
MG, 5 MG, 80 MG
Tier 3
Antihyperlipidemic - Nicotinic Acid Derivatives
niacin oral tablet extended release 24 hr 1,000 mg,
500 mg, 750 mg
Tier 1
NIACOR ORAL TABLET 500 MG
Tier 1
NIASPAN EXTENDED-RELEASE ORAL
TABLET EXTENDED RELEASE 24 HR 1,000
MG, 500 MG, 750 MG
Tier 3
Antihyperlipidemic - Selective Cholesterol Absorption Inhibitor
ZETIA ORAL TABLET 10 MG
Antihyperlipidemic Agents - Dietary Source
74
Tier 2
PA
Drug Name
Drug Tier
Notes
LOVAZA ORAL CAPSULE 1 GRAM
Tier 3
PA
omega-3 acid ethyl esters oral capsule 1 gram
Tier 1
PA
VASCEPA ORAL CAPSULE 1 GRAM
Tier 3
PA
Antihyperlipidemic Hmg Coa Reduct Inhib & Calcium Channel Blocker Comb
amlodipine-atorvastatin oral tablet 10-10 mg, 1020 mg, 10-40 mg, 10-80 mg, 2.5-10 mg, 2.5-20 mg,
2.5-40 mg, 5-10 mg, 5-20 mg, 5-40 mg, 5-80 mg
Tier 1
CADUET ORAL TABLET 10-10 MG, 10-20
MG, 10-40 MG, 10-80 MG, 2.5-10 MG, 2.5-20
MG, 2.5-40 MG, 5-10 MG, 5-20 MG, 5-40 MG,
5-80 MG
Tier 3
Antihyperlipidemic Hmg Coa Reduct Inhib & Cholesterol Absorption Inhib
LIPTRUZET ORAL TABLET 10-10 MG, 1020 MG, 10-40 MG, 10-80 MG
Tier 2
VYTORIN 10-10 ORAL TABLET 10-10 MG
Tier 2
Tier 2
Tier 2
Tier 2
Antihyperlipidemic-Microsomal Triglyceride Transfer Protein (Mtp)Inhib
JUXTAPID ORAL CAPSULE 10 MG, 20 MG,
5 MG
Tier 4
PA
Beta Blockers Cardiac Selective
atenolol oral tablet 100 mg, 25 mg, 50 mg
Tier 1
betaxolol Oral tablet 10 mg, 20 mg
Tier 1
bisoprolol fumarate Oral tablet 10 mg, 5 mg
Tier 1
BYSTOLIC ORAL TABLET 10 MG, 2.5 MG,
20 MG, 5 MG
Tier 2
LOPRESSOR INTRAVENOUS SOLUTION 5
MG/5 ML
Tier 6
metoprolol succinate oral tablet extended release
24 hr 100 mg, 200 mg, 25 mg, 50 mg
Tier 1
metoprolol tartrate oral tablet 100 mg, 25 mg, 50
mg
Tier 1
TENORMIN ORAL TABLET 100 MG, 25
MG, 50 MG
Tier 3
75
Drug Name
Drug Tier
TOPROL XL ORAL TABLET EXTENDED
MG
Tier 3
ZEBETA ORAL TABLET 10 MG, 5 MG
Tier 3
Notes
Beta Blockers Cardiac Selective, Intrinsic Sympathomimetic Activity
acebutolol Oral capsule 200 mg, 400 mg
Tier 1
SECTRAL ORAL CAPSULE 200 MG, 400 MG
Tier 3
Beta Blockers Non-Cardiac Select., Intrinsic Sympathomimetic Activity
LEVATOL ORAL TABLET 20 MG
Tier 3
pindolol oral tablet 10 mg, 5 mg
Tier 1
Beta Blockers Non-Cardiac Selective
BETAPACE ORAL TABLET 160 MG, 240
MG, 80 MG
Tier 3
BETAPACE AF ORAL TABLET 120 MG
Tier 3
CORGARD ORAL TABLET 20 MG, 40 MG,
80 MG
Tier 3
HEMANGEOL ORAL SOLUTION 4.28
MG/ML
Tier 3
INDERAL LA ORAL CAPSULE,EXTENDED
MG
Tier 3
INDERAL XL ORAL CAPSULE,EXTENDED
RELEASE 24HR 120 MG, 80 MG
Tier 3
INNOPRAN XL ORAL
CAPSULE,EXTENDED RELEASE 24HR 120
MG, 80 MG
Tier 3
nadolol oral tablet 20 mg, 40 mg, 80 mg
Tier 1
propranolol intravenous solution 1 mg/mL
Tier 3
propranolol Oral capsule,extended release 24 hr
120 mg, 160 mg, 60 mg, 80 mg
Tier 1
propranolol oral solution 20 mg/5 mL, 40 mg/5
mL
Tier 1
propranolol oral tablet 10 mg, 20 mg, 40 mg, 60
mg, 80 mg
Tier 1
SORINE ORAL TABLET 120 MG, 160 MG,
240 MG, 80 MG
Tier 1
76
Drug Name
Drug Tier
sotalol Oral tablet 120 mg, 160 mg, 240 mg, 80
mg
Tier 1
timolol maleate oral tablet 10 mg, 20 mg, 5 mg
Tier 1
Notes
Bradykinin B2 Receptor Antagonists
FIRAZYR SUBCUTANEOUS SYRINGE 30
MG/3 ML
Tier 4
PA
Calcium Channel Blockers - Benzothiazepines
CARDIZEM ORAL TABLET 120 MG, 30 MG,
60 MG
Tier 3
CARDIZEM CD ORAL
MG, 180 MG, 240 MG, 300 MG, 360 MG
Tier 3
CARDIZEM LA ORAL TABLET EXTENDED
Tier 3
CARDIZEM LA ORAL TABLET EXTENDED
360 MG, 420 MG
Tier 3
CARTIA XT ORAL CAPSULE,EXTENDED
RELEASE 24HR 120 MG, 180 MG, 240 MG,
300 MG
Tier 1
DILT-XR ORAL CAPSULE,EXT RELEASE
DEGRADABLE 120 MG, 180 MG, 240 MG
Tier 1
diltiazem HCl oral capsule, extended release 360
mg, 420 mg
Tier 1
diltiazem HCl oral capsule,ext release degradable
240 mg
Tier 1
diltiazem HCl oral capsule,extended release 12 hr
120 mg, 60 mg, 90 mg
Tier 1
diltiazem HCl oral capsule,extended release 24hr
120 mg, 180 mg, 300 mg
Tier 1
diltiazem HCl oral tablet 120 mg, 30 mg, 60 mg,
90 mg
Tier 1
diltiazem HCl oral tablet extended release 24 hr
180 mg, 240 mg, 300 mg, 360 mg, 420 mg
Tier 1
MATZIM LA ORAL TABLET EXTENDED
360 MG, 420 MG
Tier 1
PA
77
Drug Name
Drug Tier
TAZTIA XT ORAL CAPSULE, EXTENDED
RELEASE 120 MG, 180 MG, 240 MG, 300
MG, 360 MG
Tier 1
TIAZAC ORAL CAPSULE, EXTENDED
RELEASE 120 MG, 180 MG, 240 MG, 300
MG, 360 MG, 420 MG
Tier 3
Notes
Calcium Channel Blockers - Dihydropyridines
ADALAT CC ORAL TABLET EXTENDED
RELEASE 30 MG, 60 MG, 90 MG
Tier 3
AFEDITAB CR ORAL TABLET EXTENDED
RELEASE 30 MG, 60 MG
Tier 1
amlodipine oral tablet 10 mg, 2.5 mg, 5 mg
Tier 1
CARDENE IV INTRAVENOUS SOLUTION
25 MG/10 ML
Tier 6
CARDENE SR ORAL CAPSULE,
EXTENDED RELEASE 30 MG, 60 MG
Tier 3
CLEVIPREX INTRAVENOUS EMULSION 50
MG/100 ML
Tier 6
felodipine oral tablet extended release 24 hr 10
mg, 2.5 mg, 5 mg
Tier 1
isradipine Oral capsule 2.5 mg, 5 mg
Tier 1
nicardipine Oral capsule 20 mg, 30 mg
Tier 1
NIFEDICAL XL ORAL TABLET
EXTENDED RELEASE 24HR 30 MG, 60 MG
Tier 1
nifedipine Oral capsule 10 mg, 20 mg
Tier 1
nifedipine Oral tablet extended release 24hr 30
mg, 60 mg, 90 mg
Tier 1
nisoldipine Oral tablet extended release 24 hr 17
mg, 20 mg, 25.5 mg, 30 mg, 34 mg, 40 mg, 8.5 mg
Tier 1
NORVASC ORAL TABLET 10 MG, 2.5 MG, 5
MG
Tier 3
PROCARDIA ORAL CAPSULE 10 MG
Tier 3
PROCARDIA XL ORAL TABLET
EXTENDED RELEASE 24HR 30 MG, 60 MG,
90 MG
Tier 3
SULAR ORAL TABLET EXTENDED
RELEASE 24 HR 17 MG, 34 MG, 8.5 MG
Tier 3
30D
Calcium Channel Blockers - Dihydropyridines - Cerebrovascular Specific
78
Drug Name
Drug Tier
nimodipine Oral capsule 30 mg
Tier 1
NYMALIZE ORAL SOLUTION 60 MG/20
ML
Tier 3
Notes
Calcium Channel Blockers - Phenylakylamines
CALAN ORAL TABLET 120 MG, 80 MG
Tier 3
CALAN SR ORAL TABLET EXTENDED
RELEASE 120 MG, 180 MG, 240 MG
Tier 3
verapamil Oral capsule, 24 hr ER pellet CT 100
mg, 200 mg, 300 mg
Tier 1
verapamil Oral capsule,ext rel. pellets 24 hr 120
mg, 180 mg, 240 mg, 360 mg
Tier 1
verapamil Oral tablet 120 mg, 40 mg, 80 mg
Tier 1
verapamil oral tablet extended release 120 mg,
180 mg, 240 mg
Tier 1
VERELAN ORAL CAPSULE,EXT REL.
PELLETS 24 HR 120 MG, 180 MG, 240 MG,
360 MG
Tier 3
VERELAN PM ORAL CAPSULE, 24 HR ER
PELLET CT 100 MG, 200 MG, 300 MG
Tier 3
Cardiac Selective Beta Blocker-Thiazide Diuretic & Related Comb.
atenolol-chlorthalidone Oral tablet 100-25 mg,
50-25 mg
Tier 1
bisoprolol-hydrochlorothiazide Oral tablet 106.25 mg, 2.5-6.25 mg, 5-6.25 mg
Tier 1
DUTOPROL ORAL TABLET EXTENDED
RELEASE 24 HR 100-12.5 MG, 25-12.5 MG,
50-12.5 MG
Tier 3
LOPRESSOR HCT ORAL TABLET 50-25 MG
Tier 3
metoprolol ta-hydrochlorothiaz oral tablet 100-25
mg, 100-50 mg, 50-25 mg
Tier 1
TENORETIC 100 ORAL TABLET 100-25 MG
Tier 3
TENORETIC 50 ORAL TABLET 50-25 MG
Tier 3
ZIAC ORAL TABLET 10-6.25 MG, 2.5-6.25
MG, 5-6.25 MG
Tier 3
Cardiac Sympathomimetic - Anaphylaxis Therapy Single Agents
79
Drug Name
Drug Tier
ADRENACLICK INJECTION AUTOINJECTOR 0.15 MG/0.15 ML (1:1,000), 0.3
MG/0.3 ML (1:1,000)
Tier 3
AUVI-Q INJECTION AUTO-INJECTOR 0.15
MG/0.15 ML (1:1,000), 0.3 MG/0.3 ML
(1:1,000)
Tier 3
epinephrine injection auto-injector 0.15 mg/0.15
mL (1:1,000), 0.3 mg/0.3 mL (1:1,000)
Tier 1
epinephrine injection solution 1 mg/mL (1:1,000)
(1mL)
Tier 3
EPIPEN 2-PAK INJECTION AUTOINJECTOR 0.3 MG/0.3 ML (1:1,000)
Tier 2
EPIPEN JR 2-PAK INJECTION AUTOINJECTOR 0.15 MG/0.3 ML (1:2,000)
Tier 2
Notes
Cardiac Sympathomimetics
LEVOPHED (BITARTRATE)
INTRAVENOUS SOLUTION 1 MG/ML
Tier 6
midodrine oral tablet 10 mg, 2.5 mg, 5 mg
Tier 1
Central Alpha-2 Agonists-Thiazide Diuretic & Related Comb.
CLORPRES ORAL TABLET 0.1-15 MG, 0.215 MG, 0.3-15 MG
Tier 3
methyldopa-hydrochlorothiazide Oral tablet 25015 mg, 250-25 mg
Tier 1
Central Alpha-2 Receptor Agonists
CATAPRES ORAL TABLET 0.1 MG, 0.2 MG,
0.3 MG
Tier 3
CATAPRES-TTS-1 TRANSDERMAL PATCH
WEEKLY 0.1 MG/24 HR
Tier 3
WEEKLY 0.2 MG/24 HR
Tier 3
WEEKLY 0.3 MG/24 HR
Tier 3
clonidine transdermal patch weekly 0.1 mg/24 hr,
0.2 mg/24 hr, 0.3 mg/24 hr
Tier 1
clonidine HCl oral tablet 0.1 mg, 0.2 mg, 0.3 mg
Tier 1
guanfacine oral tablet 1 mg, 2 mg
Tier 1
methyldopa Oral tablet 250 mg, 500 mg
Tier 1
TENEX ORAL TABLET 1 MG, 2 MG
Tier 3
80
Drug Name
Drug Tier
Notes
Digitalis Glycosides
DIGOX ORAL TABLET 125 MCG, 250 MCG
Tier 1
digoxin oral solution 50 mcg/mL
Tier 1
LANOXIN INJECTION SOLUTION 250
MCG/ML
Tier 3
LANOXIN ORAL TABLET 125 MCG, 250
MCG
Tier 2
Direct Acting Vasodilators
hydralazine injection solution 20 mg/mL
Tier 6
hydralazine Oral tablet 10 mg, 100 mg, 25 mg, 50
mg
Tier 1
minoxidil Oral tablet 10 mg, 2.5 mg
Tier 1
NITROPRESS INTRAVENOUS SOLUTION
25 MG/ML
Tier 6
Diuretic - Aldosterone Receptor Antagonist, Non-Selective
ALDACTONE ORAL TABLET 100 MG, 25
MG, 50 MG
Tier 3
spironolactone oral tablet 100 mg, 25 mg, 50 mg
Tier 1
Diuretic - Aldosterone Receptor Antagonist, Selective
eplerenone oral tablet 25 mg, 50 mg
Tier 1
INSPRA ORAL TABLET 25 MG, 50 MG
Tier 3
Diuretic - Carbonic Anhydrase Inhibitors
acetazolamide Oral capsule, extended release 500
mg
Tier 1
acetazolamide Oral tablet 125 mg, 250 mg
Tier 1
DIAMOX SEQUELS ORAL CAPSULE,
Tier 3
methazolamide Oral tablet 25 mg, 50 mg
Tier 1
NEPTAZANE ORAL TABLET 25 MG, 50 MG
Tier 3
Diuretic - Loop
bumetanide oral tablet 0.5 mg, 1 mg, 2 mg
Tier 1
DEMADEX ORAL TABLET 10 MG, 100 MG,
20 MG, 5 MG
Tier 3
EDECRIN ORAL TABLET 25 MG
Tier 3
81
Drug Name
Drug Tier
furosemide oral solution 10 mg/mL, 40 mg/5 mL
Tier 1
furosemide oral tablet 20 mg, 40 mg, 80 mg
Tier 1
LASIX ORAL TABLET 20 MG, 40 MG, 80
MG
Tier 3
torsemide Oral tablet 10 mg, 100 mg, 20 mg, 5 mg
Tier 1
Notes
Diuretic - Potassium Sparing
amiloride Oral tablet 5 mg
Tier 1
DYRENIUM ORAL CAPSULE 100 MG, 50
MG
Tier 3
Diuretic - Potassium Sparing-Thiazide & Related Combinations
ALDACTAZIDE ORAL TABLET 25-25 MG,
50-50 MG
Tier 3
amiloride-hydrochlorothiazide Oral tablet 5-50
mg
Tier 1
DYAZIDE ORAL CAPSULE 37.5-25 MG
Tier 3
MAXZIDE ORAL TABLET 75-50 MG
Tier 3
MAXZIDE-25MG ORAL TABLET 37.5-25
MG
Tier 3
spironolacton-hydrochlorothiaz oral tablet 25-25
mg
Tier 1
triamterene-hydrochlorothiazid oral capsule 37.525 mg, 50-25 mg
Tier 1
triamterene-hydrochlorothiazid oral tablet 37.5-25
mg, 75-50 mg
Tier 1
Diuretic - Selective Arginine Vasopressin V2 Receptor Antagonists
SAMSCA ORAL TABLET 15 MG
Tier 4
SAMSCA ORAL TABLET 30 MG
Tier 4
Diuretic - Thiazides And Related
chlorothiazide Oral tablet 250 mg, 500 mg
Tier 1
chlorthalidone Oral tablet 25 mg, 50 mg
Tier 1
DIURIL ORAL SUSPENSION 250 MG/5 ML
Tier 3
hydrochlorothiazide oral capsule 12.5 mg
Tier 1
hydrochlorothiazide Oral tablet 12.5 mg, 25 mg,
50 mg
Tier 1
indapamide Oral tablet 1.25 mg, 2.5 mg
Tier 1
82
Drug Name
Drug Tier
methyclothiazide Oral tablet 5 mg
Tier 1
metolazone Oral tablet 10 mg, 2.5 mg, 5 mg
Tier 1
MICROZIDE ORAL CAPSULE 12.5 MG
Tier 3
ZAROXOLYN ORAL TABLET 2.5 MG, 5 MG
Tier 3
Notes
Ganglionic Blocking, Non-Depolarizing
VECAMYL ORAL TABLET 2.5 MG
Tier 3
Non-Cardiac Selective Beta Blocker-Thiazide Diuretic & Related Comb.
CORZIDE ORAL TABLET 40-5 MG, 80-5 MG
Tier 3
nadolol-bendroflumethiazide Oral tablet 40-5 mg,
80-5 mg
Tier 1
propranolol-hydrochlorothiazid oral tablet 40-25
mg, 80-25 mg
Tier 1
Patent Ductus Arteriosus (Pda) Treatment Agents, Prostaglandin-Type
PROSTIN VR PEDIATRIC INJECTION
SOLUTION 500 MCG/ML
Tier 3
Peripheral Alpha-1 Receptor Blockers
CARDURA ORAL TABLET 1 MG, 2 MG, 4
MG, 8 MG
Tier 3
CARDURA XL ORAL TABLET EXTENDED
Tier 3
DIBENZYLINE ORAL CAPSULE 10 MG
Tier 3
doxazosin oral tablet 1 mg, 2 mg, 4 mg, 8 mg
Tier 1
MINIPRESS ORAL CAPSULE 1 MG, 2 MG, 5
MG
Tier 3
prazosin Oral capsule 1 mg, 2 mg, 5 mg
Tier 1
terazosin Oral capsule 1 mg, 10 mg, 2 mg, 5 mg
Tier 1
PA
Peripheral Vasodilators, Single Agents
isoxsuprine Oral tablet 10 mg, 20 mg
Tier 1
Pheochromocytoma, Agents To Treat
DEMSER ORAL CAPSULE 250 MG
Tier 3
Plasma Kallikrein Inhibitor Agents
KALBITOR SUBCUTANEOUS SOLUTION
10 MG/ML (1 ML)
Tier 6
30D
Pulmonary Antihypertensive Agents - Endothelin Receptor Antagonists
83
Drug Name
Drug Tier
LETAIRIS ORAL TABLET 10 MG, 5 MG
Tier 4
OPSUMIT ORAL TABLET 10 MG
Tier 4
TRACLEER ORAL TABLET 125 MG, 62.5
MG
Tier 4
Notes
Pulmonary Antihypertensive Agents - Prostacyclin-Type
epoprostenol (glycine) intravenous recon soln 0.5
mg, 1.5 mg
Tier 6
30D
FLOLAN INTRAVENOUS RECON SOLN 0.5
MG, 1.5 MG
Tier 6
30D
ORENITRAM ORAL TABLET EXTENDED
RELEASE 0.125 MG, 0.25 MG, 1 MG, 2.5 MG
Tier 3
REMODULIN INJECTION SOLUTION 1
MG/ML, 10 MG/ML, 2.5 MG/ML, 5 MG/ML
Tier 6
TYVASO INHALATION SOLUTION FOR
NEBULIZATION 1.74 MG/2.9 ML (0.6
MG/ML)
Tier 3
TYVASO REFILL KIT INHALATION
SOLUTION FOR NEBULIZATION 1.74
MG/2.9 ML (0.6 MG/ML)
Tier 3
TYVASO STARTER KIT INHALATION
SOLUTION FOR NEBULIZATION 1.74
MG/2.9 ML
Tier 3
VELETRI INTRAVENOUS RECON SOLN 0.5
MG, 1.5 MG
Tier 6
VENTAVIS INHALATION SOLUTION FOR
NEBULIZATION 10 MCG/ML, 20 MCG/ML
Tier 4
30D
30D
Pulmonary Antihypertensive Agents - Selective C-Gmp Pde Type 5 Inhib.
ADCIRCA ORAL TABLET 20 MG
Tier 4
PA
REVATIO ORAL TABLET 20 MG
Tier 4
PA
sildenafil oral tablet 20 mg
Tier 1
PA
Pulmonary Antihypertensive Agents-Soluble Guanylate Cyclase Stimulator
ADEMPAS ORAL TABLET 0.5 MG, 1 MG,
1.5 MG, 2 MG, 2.5 MG
Tier 4
Renin Inhib, Direct - Calcium Channel Blocker & Thiazide Combinations
AMTURNIDE ORAL TABLET 150-5-12.5
MG, 300-10-12.5 MG, 300-10-25 MG, 300-512.5 MG, 300-5-25 MG
Renin Inhibitor, Direct
84
Tier 2
Drug Name
TEKTURNA ORAL TABLET 150 MG, 300
MG
Drug Tier
Notes
Tier 2
Renin Inhibitor, Direct And Calcium Channel Blocker Combinations
TEKAMLO ORAL TABLET 150-10 MG, 1505 MG, 300-10 MG, 300-5 MG
Tier 2
Renin Inhibitor, Direct And Diuretic Combinations
TEKTURNA HCT ORAL TABLET 150-12.5
MG, 150-25 MG, 300-12.5 MG, 300-25 MG
Tier 2
Reserpine And Derivatives
reserpine Oral tablet 0.1 mg, 0.25 mg
Tier 1
Vasodilator Combinations
BIDIL ORAL TABLET 20-37.5 MG
Tier 3
Central Nervous System Agents
Antianxiety Agent - Antihistamine Type
hydroxyzine HCl oral syrup 10 mg/5 mL
Tier 1
older); AR
hydroxyzine HCl oral tablet 10 mg, 25 mg, 50 mg
Tier 1
older); AR
hydroxyzine pamoate Oral capsule 100 mg, 25 mg,
50 mg
Tier 1
older); AR
VISTARIL ORAL CAPSULE 25 MG, 50 MG
Tier 3
older); AR
Antianxiety Agent - Benzodiazepines
alprazolam Oral tablet 0.25 mg, 0.5 mg, 1 mg, 2
mg
Tier 1
alprazolam oral tablet extended release 24 hr 0.5
mg, 1 mg, 2 mg, 3 mg
Tier 1
alprazolam Oral tablet,disintegrating 0.25 mg, 0.5
mg, 1 mg, 2 mg
Tier 1
ALPRAZOLAM INTENSOL ORAL
CONCENTRATE 1 MG/ML
Tier 2
ATIVAN ORAL TABLET 1 MG, 2 MG
Tier 3
chlordiazepoxide HCl Oral capsule 10 mg, 25 mg,
5 mg
Tier 1
clonazepam oral tablet 0.5 mg, 1 mg, 2 mg
Tier 1
85
Drug Name
Drug Tier
clonazepam Oral tablet,disintegrating 0.125 mg,
0.25 mg, 0.5 mg, 1 mg, 2 mg
Tier 1
clorazepate dipotassium Oral tablet 15 mg, 3.75
mg, 7.5 mg
Tier 1
diazepam oral solution 5 mg/5 mL
Tier 1
diazepam Oral tablet 10 mg, 2 mg, 5 mg
Tier 1
DIAZEPAM INTENSOL ORAL
CONCENTRATE 5 MG/ML
Tier 2
KLONOPIN ORAL TABLET 0.5 MG, 1 MG, 2
MG
Tier 3
lorazepam oral tablet 0.5 mg, 1 mg, 2 mg
Tier 1
LORAZEPAM INTENSOL ORAL
CONCENTRATE 2 MG/ML
Tier 1
oxazepam Oral capsule 10 mg, 15 mg, 30 mg
Tier 1
TRANXENE T-TAB ORAL TABLET 15 MG,
3.75 MG, 7.5 MG
Tier 3
VALIUM ORAL TABLET 10 MG, 2 MG, 5
MG
Tier 3
XANAX ORAL TABLET 0.25 MG, 0.5 MG, 1
MG, 2 MG
Tier 3
XANAX XR ORAL TABLET EXTENDED
RELEASE 24 HR 0.5 MG, 1 MG, 2 MG, 3 MG
Tier 3
Notes
Antianxiety Agent - Dicarbamate Type
meprobamate Oral tablet 200 mg, 400 mg
Tier 1
Antianxiety Agent - Non-Benzodiazepine
buspirone Oral tablet 10 mg, 15 mg, 30 mg, 5 mg,
7.5 mg
Tier 1
Anticonvulsant - Ampa-Type Glutamate Receptor Antagonists
FYCOMPA ORAL TABLET 2 MG, 4 MG, 6
MG, 8 MG
Tier 3
Anticonvulsant - Barbiturates And Derivatives
MYSOLINE ORAL TABLET 250 MG, 50 MG
Tier 3
phenobarbital oral elixir 20 mg/5 mL
Tier 1
phenobarbital Oral tablet 100 mg, 15 mg, 16.2 mg,
30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg
Tier 1
primidone oral tablet 250 mg, 50 mg
Tier 1
86
Drug Name
Drug Tier
Notes
Anticonvulsant - Benzodiazepines
clonazepam oral tablet 0.5 mg, 1 mg, 2 mg
Tier 1
clonazepam Oral tablet,disintegrating 0.125 mg,
0.25 mg, 0.5 mg, 1 mg, 2 mg
Tier 1
DIASTAT RECTAL KIT 2.5 MG
Tier 3
DIASTAT ACUDIAL RECTAL KIT 12.5-1517.5-20 MG
Tier 2
DIASTAT ACUDIAL RECTAL KIT 5-7.5-10
MG
Tier 3
diazepam rectal kit 12.5-15-17.5-20 mg, 2.5 mg, 57.5-10 mg
Tier 1
KLONOPIN ORAL TABLET 0.5 MG, 1 MG, 2
MG
Tier 3
ONFI ORAL SUSPENSION 2.5 MG/ML
Tier 2
ONFI ORAL TABLET 10 MG, 20 MG
Tier 2
Anticonvulsant - Carbamates
felbamate oral suspension 600 mg/5 mL
Tier 1
felbamate Oral tablet 400 mg, 600 mg
Tier 1
FELBATOL ORAL SUSPENSION 600 MG/5
ML
Tier 3
FELBATOL ORAL TABLET 400 MG, 600
MG
Tier 3
Anticonvulsant - Carboxylic Acid Derivatives
DEPACON INTRAVENOUS SOLUTION 500
MG/5 ML (100 MG/ML)
Tier 6
DEPAKENE ORAL CAPSULE 250 MG
Tier 2
DEPAKENE ORAL SOLUTION 250 MG/5
ML
Tier 2
DEPAKOTE ORAL TABLET,DELAYED
RELEASE (DR/EC) 125 MG, 250 MG, 500 MG
Tier 2
DEPAKOTE ER ORAL TABLET
EXTENDED RELEASE 24 HR 250 MG, 500
MG
Tier 2
DEPAKOTE SPRINKLES ORAL CAPSULE,
SPRINKLE 125 MG
Tier 2
divalproex Oral capsule, sprinkle 125 mg
Tier 1
87
Drug Name
Drug Tier
divalproex oral tablet extended release 24 hr 250
mg, 500 mg
Tier 1
divalproex oral tablet,delayed release (DR/EC)
125 mg, 250 mg, 500 mg
Tier 1
STAVZOR ORAL CAPSULE,DELAYED
RELEASE(DR/EC) 125 MG, 250 MG, 500 MG
Tier 3
valproic acid oral capsule 250 mg
Tier 1
valproic acid (as sodium salt) oral solution 250
mg/5 mL
Tier 1
Notes
Anticonvulsant - Functionalized Amino Acid
VIMPAT ORAL SOLUTION 10 MG/ML
Tier 2
VIMPAT ORAL TABLET 100 MG, 150 MG,
200 MG, 50 MG
Tier 2
Anticonvulsant - Gaba Analogs
gabapentin oral capsule 100 mg, 300 mg, 400 mg
Tier 1
gabapentin oral solution 250 mg/5 mL
Tier 1
gabapentin oral tablet 600 mg, 800 mg
Tier 1
LYRICA ORAL CAPSULE 100 MG, 150 MG,
200 MG, 25 MG, 50 MG, 75 MG
Tier 2
LYRICA ORAL CAPSULE 225 MG, 300 MG
Tier 2
LYRICA ORAL SOLUTION 20 MG/ML
Tier 2
NEURONTIN ORAL CAPSULE 100 MG, 300
MG, 400 MG
Tier 3
NEURONTIN ORAL SOLUTION 250 MG/5
ML
Tier 3
NEURONTIN ORAL TABLET 600 MG, 800
MG
Tier 3
Anticonvulsant - Gaba Re-Uptake Inhibitor, Nipecotic Acid Derivatives
GABITRIL ORAL TABLET 12 MG, 16 MG
Tier 2
GABITRIL ORAL TABLET 2 MG, 4 MG
Tier 3
tiagabine Oral tablet 2 mg, 4 mg
Tier 1
Anticonvulsant - Gaba Transaminase (Gaba-T) Inhibitor
SABRIL ORAL POWDER IN PACKET 500
MG
Tier 3
SABRIL ORAL TABLET 500 MG
Tier 2
Anticonvulsant - Hydantoins
88
Drug Name
Drug Tier
CEREBYX INJECTION SOLUTION 100 MG
PE/2 ML
Tier 3
DILANTIN ORAL CAPSULE 30 MG
Tier 2
DILANTIN EXTENDED ORAL CAPSULE
100 MG
Tier 2
DILANTIN INFATABS ORAL
Tier 2
DILANTIN-125 ORAL SUSPENSION 125
MG/5 ML
Tier 2
PEGANONE ORAL TABLET 250 MG
Tier 2
PHENYTEK ORAL CAPSULE 200 MG, 300
MG
Tier 3
phenytoin oral suspension 125 mg/5 mL
Tier 1
phenytoin oral tablet,chewable 50 mg
Tier 1
phenytoin sodium extended Oral capsule 100 mg,
200 mg, 300 mg
Tier 1
Notes
Anticonvulsant - Iminostilbene Derivatives
APTIOM ORAL TABLET 200 MG
Tier 3
PA
APTIOM ORAL TABLET 400 MG, 600 MG,
800 MG
Tier 4
PA
carbamazepine Oral capsule, ER multiphase 12 hr
100 mg, 200 mg, 300 mg
Tier 1
carbamazepine oral suspension 100 mg/5 mL
Tier 1
carbamazepine oral tablet 200 mg
Tier 1
carbamazepine Oral tablet extended release 12 hr
200 mg, 400 mg
Tier 1
carbamazepine oral tablet,chewable 100 mg
Tier 1
CARBATROL ORAL CAPSULE, ER
MG
Tier 3
EPITOL ORAL TABLET 200 MG
Tier 1
oxcarbazepine oral suspension 300 mg/5 mL
Tier 1
oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg
Tier 1
OXTELLAR XR ORAL TABLET
MG, 600 MG
Tier 3
89
Drug Name
Drug Tier
TEGRETOL ORAL SUSPENSION 100 MG/5
ML
Tier 2
TEGRETOL ORAL TABLET 200 MG
Tier 2
TEGRETOL XR ORAL TABLET
MG, 400 MG
Tier 2
TRILEPTAL ORAL SUSPENSION 300 MG/5
ML
Tier 3
TRILEPTAL ORAL TABLET 150 MG, 300
MG, 600 MG
Tier 3
Anticonvulsant - Monosaccharide Derivatives
QUDEXY XR ORAL
CAPSULE,SPRINKLE,ER 24HR 100 MG, 150
MG, 200 MG, 25 MG, 50 MG
Tier 3
TOPAMAX ORAL CAPSULE, SPRINKLE 15
MG, 25 MG
Tier 3
TOPAMAX ORAL TABLET 100 MG, 200
MG, 25 MG, 50 MG
Tier 3
TOPIRAGEN ORAL TABLET 100 MG, 200
MG, 25 MG, 50 MG
Tier 1
topiramate oral capsule, sprinkle 15 mg, 25 mg
Tier 1
topiramate oral capsule,sprinkle,ER 24hr 100 mg,
150 mg, 200 mg, 25 mg, 50 mg
Tier 1
topiramate oral tablet 100 mg, 200 mg, 25 mg, 50
mg
Tier 1
TROKENDI XR ORAL
MG, 200 MG, 25 MG, 50 MG
Tier 3
Anticonvulsant - Phenyltriazine Derivatives
LAMICTAL ORAL TABLET 100 MG, 150
MG, 200 MG, 25 MG
Tier 3
LAMICTAL ORAL TABLET, CHEWABLE
DISPERSIBLE 2 MG
Tier 2
LAMICTAL ORAL TABLET, CHEWABLE
DISPERSIBLE 25 MG, 5 MG
Tier 3
LAMICTAL ODT ORAL
TABLET,DISINTEGRATING 100 MG, 200
MG, 25 MG, 50 MG
Tier 2
90
Notes
PA
Drug Name
Drug Tier
LAMICTAL ODT STARTER (BLUE) ORAL
TABLET DISINTEGRATING, DOSE PK 25
MG (21) -50 MG (7)
Tier 2
LAMICTAL ODT STARTER (GREEN)
ORAL TABLET DISINTEGRATING, DOSE
PK 50 MG (42) -100 MG (14)
Tier 2
LAMICTAL ODT STARTER (ORANGE)
PK 25 MG(14)-50 MG (14)-100 MG (7)
Tier 2
LAMICTAL STARTER (BLUE) KIT ORAL
TABLETS,DOSE PACK 25 MG (35)
Tier 3
LAMICTAL STARTER (GREEN) KIT ORAL
TABLETS,DOSE PACK 25 MG (84) -100 MG
(14)
Tier 2
LAMICTAL STARTER (ORANGE) KIT
ORAL TABLETS,DOSE PACK 25 MG (42) 100 MG (7)
Tier 2
LAMICTAL XR ORAL TABLET EXTENDED
250 MG, 300 MG, 50 MG
Tier 3
LAMICTAL XR STARTER (BLUE) ORAL
TABLET EXTENDED REL,DOSE PACK 25
MG (21) -50 MG (7)
Tier 2
LAMICTAL XR STARTER (GREEN) ORAL
TABLET EXTENDED REL,DOSE PACK 50
MG(14)-100MG (14)-200 MG (7)
Tier 2
LAMICTAL XR STARTER (ORANGE)
ORAL TABLET EXTENDED REL,DOSE
PACK 25MG (14)-50 MG (14)-100MG (7)
Tier 2
lamotrigine oral tablet 100 mg, 150 mg, 200 mg,
25 mg
Tier 1
lamotrigine Oral tablet extended release 24hr 100
mg, 200 mg, 25 mg, 250 mg, 300 mg, 50 mg
Tier 1
lamotrigine Oral tablet, chewable dispersible 25
mg, 5 mg
Tier 1
Notes
Anticonvulsant - Potassium Channel Opener
POTIGA ORAL TABLET 200 MG, 300 MG,
400 MG, 50 MG
Tier 3
Anticonvulsant - Pyrrolidine Derivatives
91
Drug Name
Drug Tier
KEPPRA INTRAVENOUS SOLUTION 500
MG/5 ML
Tier 6
KEPPRA ORAL SOLUTION 100 MG/ML
Tier 3
KEPPRA ORAL TABLET 1,000 MG, 250 MG,
500 MG, 750 MG
Tier 3
KEPPRA XR ORAL TABLET EXTENDED
RELEASE 24 HR 500 MG, 750 MG
Tier 3
levetiracetam oral solution 100 mg/mL
Tier 1
levetiracetam oral tablet 1,000 mg, 250 mg, 500
mg, 750 mg
Tier 1
levetiracetam oral tablet extended release 24 hr
500 mg, 750 mg
Tier 1
Notes
Anticonvulsant - Succinimides
CELONTIN ORAL CAPSULE 300 MG
Tier 2
ethosuximide Oral capsule 250 mg
Tier 1
ethosuximide oral solution 250 mg/5 mL
Tier 1
ZARONTIN ORAL CAPSULE 250 MG
Tier 3
ZARONTIN ORAL SOLUTION 250 MG/5 ML
Tier 3
Anticonvulsant - Sulfonamide Derivatives
ZONEGRAN ORAL CAPSULE 100 MG, 25
MG
Tier 3
zonisamide oral capsule 100 mg, 25 mg, 50 mg
Tier 1
Anticonvulsant - Triazole Derivatives
BANZEL ORAL SUSPENSION 40 MG/ML
Tier 2
BANZEL ORAL TABLET 200 MG, 400 MG
Tier 2
Antidepressant - Alpha-2 Receptor Antagonists (Nassa)
mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5
mg
Tier 1
mirtazapine oral tablet,disintegrating 15 mg, 30
mg, 45 mg
Tier 1
REMERON ORAL TABLET 15 MG, 30 MG,
45 MG
Tier 3
REMERON SOLTAB ORAL
TABLET,DISINTEGRATING 15 MG, 30 MG,
45 MG
Tier 3
Antidepressant - Mao Inhibitor Nonselective & Irreversible -Types A,B
92
Drug Name
Drug Tier
EMSAM TRANSDERMAL PATCH 24 HOUR
12 MG/24 HR, 6 MG/24 HR, 9 MG/24 HR
Tier 3
MARPLAN ORAL TABLET 10 MG
Tier 3
NARDIL ORAL TABLET 15 MG
Tier 3
PARNATE ORAL TABLET 10 MG
Tier 3
phenelzine Oral tablet 15 mg
Tier 1
tranylcypromine Oral tablet 10 mg
Tier 1
Notes
Antidepressant - Norepinephrine & Dopamine Reuptake Inhibitors (Ndris)
APLENZIN ORAL TABLET EXTENDED
Tier 3
bupropion HCl oral tablet 100 mg, 75 mg
Tier 1
bupropion HCl oral tablet extended release 100
mg, 150 mg, 200 mg
Tier 1
bupropion HCl oral tablet extended release 24 hr
150 mg, 300 mg
Tier 1
FORFIVO XL ORAL TABLET EXTENDED
Tier 3
WELLBUTRIN ORAL TABLET 100 MG, 75
MG
Tier 3
WELLBUTRIN SR ORAL TABLET
EXTENDED RELEASE 100 MG, 150 MG, 200
MG
Tier 3
WELLBUTRIN XL ORAL TABLET
MG
Tier 3
PA
Antidepressant - Selective Serotonin Reuptake Inhibitors (Ssris)
CELEXA ORAL TABLET 10 MG, 20 MG, 40
MG
Tier 3
citalopram oral solution 10 mg/5 mL
Tier 1
citalopram oral tablet 10 mg, 20 mg, 40 mg
Tier 1
escitalopram oxalate oral solution 5 mg/5 mL
Tier 1
escitalopram oxalate oral tablet 10 mg, 20 mg, 5
mg
Tier 1
fluoxetine Oral capsule 10 mg, 20 mg, 40 mg
Tier 1
fluoxetine Oral capsule,delayed release(DR/EC)
90 mg
Tier 1
fluoxetine oral solution 20 mg/5 mL
Tier 1
QL (12 EA per 90 days)
93
Drug Name
Drug Tier
Notes
fluoxetine Oral tablet 10 mg, 20 mg, 60 mg
Tier 1
fluvoxamine Oral capsule,extended release 24hr
100 mg, 150 mg
Tier 1
fluvoxamine oral tablet 100 mg, 25 mg, 50 mg
Tier 1
LEXAPRO ORAL SOLUTION 5 MG/5 ML
Tier 3
LEXAPRO ORAL TABLET 10 MG, 20 MG, 5
MG
Tier 3
LUVOX CR ORAL CAPSULE,EXTENDED
Tier 3
paroxetine HCl oral tablet 10 mg, 20 mg, 30 mg,
40 mg
Tier 1
paroxetine HCl oral tablet extended release 24 hr
12.5 mg, 25 mg, 37.5 mg
Tier 1
PAXIL ORAL SUSPENSION 10 MG/5 ML
Tier 2
PAXIL ORAL TABLET 10 MG, 20 MG, 30
MG, 40 MG
Tier 3
PAXIL CR ORAL TABLET EXTENDED
RELEASE 24 HR 12.5 MG, 25 MG, 37.5 MG
Tier 3
PEXEVA ORAL TABLET 10 MG, 20 MG, 30
MG, 40 MG
Tier 3
PROZAC ORAL CAPSULE 10 MG, 20 MG, 40
MG
Tier 3
PROZAC WEEKLY ORAL
CAPSULE,DELAYED RELEASE(DR/EC) 90
MG
Tier 3
PA
SARAFEM ORAL TABLET 10 MG, 20 MG
Tier 3
PA
sertraline Oral Concentrate 20 mg/mL
Tier 1
sertraline oral tablet 100 mg, 25 mg, 50 mg
Tier 1
ZOLOFT ORAL CONCENTRATE 20 MG/ML
Tier 3
ZOLOFT ORAL TABLET 100 MG, 25 MG, 50
MG
Tier 3
PA
Antidepressant - Serotonin-2 Antagonist-Reuptake Inhibitors (Saris)
nefazodone Oral tablet 100 mg, 150 mg, 200 mg,
250 mg, 50 mg
Tier 1
OLEPTRO ER TABLET 15 MG, 300 MG
Tier 3
trazodone oral tablet 100 mg, 150 mg, 300 mg, 50
mg
Tier 1
94
PA
Drug Name
Drug Tier
Notes
Antidepressant - Serotonin-Norepinephrine Reuptake Inhibitors (Snris)
CYMBALTA ORAL CAPSULE,DELAYED
Tier 3
desvenlafaxine oral tablet extended release 24 hr
100 mg, 50 mg
Tier 3
desvenlafaxine oral tablet extended release 24hr
100 mg, 50 mg
Tier 3
EFFEXOR XR ORAL CAPSULE,EXTENDED
RELEASE 24HR 150 MG, 37.5 MG, 75 MG
Tier 3
FETZIMA ORAL CAPSULE,EXT REL 24HR
DOSE PACK 20 MG (2)- 40 MG (26)
Tier 3
FETZIMA ORAL CAPSULE,EXTENDED
MG
Tier 3
KHEDEZLA ORAL TABLET EXTENDED
Tier 3
PRISTIQ ORAL TABLET EXTENDED
Tier 2
SAVELLA ORAL TABLET 100 MG, 12.5 MG,
25 MG, 50 MG
Tier 3
PA
SAVELLA ORAL TABLETS,DOSE PACK
12.5 MG (5)-25 MG(8)-50 MG(42)
Tier 3
PA
venlafaxine Oral capsule,extended release 24hr
150 mg, 37.5 mg, 75 mg
Tier 1
venlafaxine oral tablet 100 mg, 25 mg, 37.5 mg, 50
mg, 75 mg
Tier 1
venlafaxine Oral tablet extended release 24hr 150
mg
Tier 1
venlafaxine Oral tablet extended release 24hr 225
mg, 75 mg
Tier 1
venlafaxine Oral tablet extended release 24hr 37.5
mg
Tier 1
Antidepressant - Ssri & 5Ht1a Partial Agonist
VIIBRYD ORAL TABLET 10 MG, 20 MG, 40
MG
Tier 3
PA; QL (1 tablet per day)
VIIBRYD ORAL TABLETS,DOSE PACK 10
MG (7)-20 MG (7)-40 MG (16)
Tier 3
Antidepressant - Ssri & Serotonin (5-Ht) Receptor Modulator
95
Drug Name
BRINTELLIX ORAL TABLET 10 MG, 20
MG, 5 MG
Drug Tier
Tier 3
Notes
PA
Antidepressant - Tricyclic & Antipsychotic, Phenothiazine Comb
perphenazine-amitriptyline Oral tablet 2-10 mg, 225 mg, 4-10 mg, 4-25 mg, 4-50 mg
Tier 1
Antidepressant - Tricyclic-Benzodiazepine Combinations
amitriptyline-chlordiazepoxide Oral tablet 12.5-5
mg, 25-10 mg
Tier 1
Antidepressant - Tricyclics & Related (Non-Select Reuptake Inhibitors)
amitriptyline Oral tablet 10 mg, 100 mg, 150 mg,
25 mg, 50 mg, 75 mg
Tier 1
amoxapine Oral tablet 100 mg, 150 mg, 25 mg, 50
mg
Tier 1
ANAFRANIL ORAL CAPSULE 25 MG, 50
MG, 75 MG
Tier 3
clomipramine Oral capsule 25 mg, 50 mg, 75 mg
Tier 1
desipramine oral tablet 10 mg, 100 mg, 150 mg,
25 mg, 50 mg, 75 mg
Tier 1
doxepin Oral capsule 10 mg, 100 mg, 150 mg, 25
mg, 50 mg, 75 mg
Tier 1
Doxepin Oral Concentrate 10 mg/mL
Tier 1
imipramine HCl oral tablet 10 mg, 25 mg, 50 mg
Tier 1
older); AR
imipramine pamoate Oral capsule 100 mg, 125
mg, 150 mg, 75 mg
Tier 1
older); AR
maprotiline Oral tablet 25 mg, 50 mg, 75 mg
Tier 1
NORPRAMIN ORAL TABLET 10 MG, 100
MG, 150 MG, 25 MG, 50 MG, 75 MG
Tier 3
nortriptyline oral capsule 10 mg, 25 mg, 50 mg, 75
mg
Tier 1
PAMELOR ORAL CAPSULE 10 MG, 25 MG,
50 MG, 75 MG
Tier 3
protriptyline oral tablet 10 mg, 5 mg
Tier 1
SURMONTIL ORAL CAPSULE 100 MG, 25
MG, 50 MG
Tier 3
PA
TOFRANIL ORAL TABLET 10 MG, 25 MG,
50 MG
Tier 3
older); AR
96
older); AR
Drug Name
Drug Tier
TOFRANIL-PM ORAL CAPSULE 100 MG,
125 MG, 150 MG, 75 MG
Tier 3
VIVACTIL ORAL TABLET 10 MG, 5 MG
Tier 3
Notes
older); AR
Antidepressant-Ssri & Atypical Antipsych,Dopamine&Serotonin Antag Comb
olanzapine-fluoxetine Oral capsule 12-25 mg, 1250 mg, 3-25 mg, 6-25 mg, 6-50 mg
Tier 1
SYMBYAX ORAL CAPSULE 12-25 MG, 12-50
MG, 3-25 MG, 6-25 MG, 6-50 MG
Tier 3
Antiparkinson - Dopaminergic-Periph Comt-Dopa-Decarboxylase Inhib Comb
carbidopa-levodopa-entacapone oral tablet 12.550-200 mg, 18.75-75-200 mg, 25-100-200 mg,
31.25-125-200 mg, 37.5-150-200 mg, 50-200-200
mg
Tier 1
STALEVO 100 ORAL TABLET 25-100-200
MG
Tier 3
STALEVO 125 ORAL TABLET 31.25-125-200
MG
Tier 3
MG
Tier 3
STALEVO 200 ORAL TABLET 50-200-200
MG
Tier 3
MG
Tier 3
MG
Tier 3
Antiparkinson - Dopaminerg-Peripheral Dopa-Decarboxylase Inhibit Comb
carbidopa-levodopa oral tablet 10-100 mg, 25-100
mg, 25-250 mg
Tier 1
carbidopa-levodopa oral tablet extended release
25-100 mg, 50-200 mg
Tier 1
carbidopa-levodopa Oral tablet,disintegrating 10100 mg, 25-100 mg, 25-250 mg
Tier 1
SINEMET ORAL TABLET 10-100 MG, 25-100
MG, 25-250 MG
Tier 3
SINEMET CR ORAL TABLET EXTENDED
RELEASE 25-100 MG, 50-200 MG
Tier 3
Antiparkinson Adjuvant - Central/Peripheral Comt Inhibitors
TASMAR ORAL TABLET 100 MG
Tier 3
97
Drug Name
Drug Tier
Notes
Antiparkinson Adjuvant - Peripheral Comt Inhibitors
COMTAN ORAL TABLET 200 MG
Tier 3
entacapone oral tablet 200 mg
Tier 1
Antiparkinson Adjuvant - Peripheral Dopa-Decarboxylase Inhibitors
carbidopa oral tablet 25 mg
Tier 1
LODOSYN ORAL TABLET 25 MG
Tier 3
Antiparkinson Therapy - Anticholinergic Agents
benztropine oral tablet 0.5 mg, 1 mg, 2 mg
Tier 1
COGENTIN INJECTION SOLUTION 2 MG/2
ML
Tier 3
trihexyphenidyl oral elixir 0.4 mg/mL
Tier 1
trihexyphenidyl Oral tablet 2 mg, 5 mg
Tier 1
Antiparkinson Therapy - Ergot Alkaloids And Derivatives
bromocriptine Oral capsule 5 mg
Tier 1
bromocriptine Oral tablet 2.5 mg
Tier 1
PARLODEL ORAL CAPSULE 5 MG
Tier 3
PARLODEL ORAL TABLET 2.5 MG
Tier 3
Antiparkinson Therapy - Monoamine Oxidase Inhibitor(Mao-B)
AZILECT ORAL TABLET 0.5 MG, 1 MG
Tier 2
ELDEPRYL ORAL CAPSULE 5 MG
Tier 3
selegiline HCl oral capsule 5 mg
Tier 1
selegiline HCl oral tablet 5 mg
Tier 1
ZELAPAR ORAL
TABLET,DISINTEGRATING 1.25 MG
Tier 3
Antiparkinson Therapy - Non-Ergot Dopamine Agonist Agents
amantadine HCl oral capsule 100 mg
Tier 1
amantadine HCl Oral Syrup 50 mg/5 mL
Tier 1
amantadine HCl Oral tablet 100 mg
Tier 1
APOKYN SUBCUTANEOUS CARTRIDGE 10
MG/ML
Tier 3
MIRAPEX ORAL TABLET 0.125 MG, 0.25
MG, 0.5 MG, 0.75 MG, 1 MG, 1.5 MG
Tier 3
98
PA
Drug Name
Drug Tier
MIRAPEX ER ORAL TABLET EXTENDED
RELEASE 24 HR 0.375 MG, 0.75 MG, 1.5 MG,
2.25 MG, 3 MG, 3.75 MG, 4.5 MG
Tier 3
NEUPRO TRANSDERMAL PATCH 24
HOUR 1 MG/24 HOUR, 2 MG/24 HOUR, 3
MG/24 HOUR, 4 MG/24 HOUR, 6 MG/24
HOUR, 8 MG/24 HOUR
Tier 3
pramipexole Oral tablet 0.125 mg, 0.25 mg, 0.5
mg, 0.75 mg, 1 mg, 1.5 mg
Tier 1
REQUIP ORAL TABLET 0.25 MG, 0.5 MG, 1
MG, 2 MG, 3 MG, 4 MG, 5 MG
Tier 3
REQUIP XL ORAL TABLET EXTENDED
RELEASE 24 HR 12 MG, 2 MG, 4 MG, 6 MG,
8 MG
Tier 3
ropinirole oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg,
3 mg, 4 mg, 5 mg
Tier 1
ropinirole Oral tablet extended release 24 hr 12
mg, 2 mg, 4 mg, 6 mg, 8 mg
Tier 1
Notes
Antipsychotic - Atyp Dopamine-Serotonin Antag Dibenzo-Oxepino Pyrroles
SAPHRIS SUBLINGUAL TABLET,
SUBLINGUAL 10 MG, 5 MG
Tier 2
SAPHRIS (BLACK CHERRY) SUBLINGUAL
TABLET, SUBLINGUAL 10 MG, 5 MG
Tier 2
Antipsychotic - Atypical Dopamine Partial Agonist-Serotonin Mixed
ABILIFY ORAL SOLUTION 1 MG/ML
Tier 2
ABILIFY ORAL TABLET 10 MG, 15 MG, 2
MG, 20 MG, 30 MG, 5 MG
Tier 2
ABILIFY DISCMELT ORAL
TABLET,DISINTEGRATING 10 MG, 15 MG
Tier 2
Antipsychotic - Atypical Dopamine-Serotonin Antag- Benzisothiazolones
GEODON INTRAMUSCULAR RECON
SOLN 20 MG/ML (FINAL CONC.)
Tier 6
GEODON ORAL CAPSULE 20 MG, 40 MG,
60 MG, 80 MG
Tier 3
LATUDA ORAL TABLET 120 MG, 20 MG, 40
MG, 60 MG, 80 MG
Tier 3
ziprasidone HCl oral capsule 20 mg, 40 mg, 60
mg, 80 mg
Tier 1
PA
99
Drug Name
Drug Tier
Notes
Antipsychotic - Atypical Dopamine-Serotonin Antag- Benzisoxazole Deriv
FANAPT ORAL TABLET 1 MG, 10 MG, 12
MG, 2 MG, 4 MG, 6 MG, 8 MG
Tier 3
FANAPT ORAL TABLETS,DOSE PACK
1MG(2)-2MG(2)- 4MG(2)-6MG(2)
Tier 3
INVEGA ORAL TABLET EXTENDED
RELEASE 24HR 1.5 MG, 3 MG, 6 MG, 9 MG
Tier 2
INVEGA SUSTENNA INTRAMUSCULAR
SYRINGE 117 MG/0.75 ML, 156 MG/ML, 234
MG/1.5 ML, 39 MG/0.25 ML, 78 MG/0.5 ML
Tier 6
RISPERDAL ORAL SOLUTION 1 MG/ML
Tier 3
RISPERDAL ORAL TABLET 0.25 MG, 0.5
MG, 1 MG, 2 MG, 3 MG, 4 MG
Tier 3
RISPERDAL CONSTA INTRAMUSCULAR
SYRINGE 12.5 MG/2 ML, 25 MG/2 ML, 37.5
MG/2 ML, 50 MG/2 ML
Tier 6
RISPERDAL M-TAB ORAL
TABLET,DISINTEGRATING 0.5 MG, 1 MG,
2 MG, 3 MG, 4 MG
Tier 3
risperidone oral solution 1 mg/mL
Tier 1
risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2
mg, 3 mg, 4 mg
Tier 1
risperidone Oral tablet,disintegrating 0.25 mg, 0.5
mg, 1 mg, 2 mg, 3 mg, 4 mg
Tier 1
30D
30D
Antipsychotic - Atypical Dopamine-Serotonin Antag-Dibenzodiazepine Der
clozapine Oral tablet 100 mg, 200 mg, 25 mg, 50
mg
Tier 1
clozapine Oral tablet,disintegrating 100 mg, 12.5
mg, 25 mg
Tier 1
CLOZARIL ORAL TABLET 100 MG, 25 MG
Tier 3
FAZACLO ORAL
TABLET,DISINTEGRATING 100 MG, 12.5
MG, 25 MG
Tier 3
FAZACLO ORAL
MG
Tier 2
VERSACLOZ ORAL SUSPENSION 50
MG/ML
Tier 3
Antipsychotic - Butyrophenone Derivatives
100
Drug Name
Drug Tier
HALDOL INJECTION SOLUTION 5 MG/ML
Tier 3
HALDOL DECANOATE INTRAMUSCULAR
SOLUTION 100 MG/ML, 50 MG/ML
Tier 3
haloperidol Oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg,
20 mg, 5 mg
Tier 1
haloperidol decanoate intramuscular solution 100
mg/mL, 50 mg/mL
Tier 6
haloperidol lactate injection solution 5 mg/mL
Tier 6
haloperidol lactate Oral Concentrate 2 mg/mL
Tier 1
Notes
Antipsychotic - Dibenzoxazepine Derivatives
loxapine succinate Oral capsule 10 mg, 25 mg, 5
mg, 50 mg
Tier 1
LOXITANE ORAL CAPSULE 5 MG
Tier 3
Antipsychotic - Diphenylbutylpiperidine Derivatives
ORAP ORAL TABLET 1 MG, 2 MG
Tier 2
Antipsychotic - Phenothiazines, Aliphatic
chlorpromazine Oral tablet 10 mg, 100 mg, 200
mg, 25 mg, 50 mg
Tier 1
Antipsychotic - Phenothiazines, Piperazine
fluphenazine decanoate injection solution 25
mg/mL
Tier 6
fluphenazine HCl oral concentrate 5 mg/mL
Tier 1
fluphenazine HCl oral elixir 2.5 mg/5 mL
Tier 1
fluphenazine HCl oral tablet 1 mg, 10 mg, 2.5 mg,
5 mg
Tier 1
perphenazine Oral tablet 16 mg, 2 mg, 4 mg, 8 mg
Tier 1
trifluoperazine Oral tablet 1 mg, 10 mg, 2 mg, 5
mg
Tier 1
Antipsychotic - Phenothiazines, Piperidine
thioridazine Oral tablet 10 mg, 100 mg, 25 mg, 50
mg
Tier 1
Antipsychotic - Thioxanthenes
thiothixene Oral capsule 1 mg, 10 mg, 2 mg, 5 mg
Tier 1
Antipsychotic -Atypical Dopamine-Serotonin Antag-Dibenzothiazepine Der
101
Drug Name
Drug Tier
quetiapine oral tablet 100 mg, 200 mg, 25 mg, 300
mg, 400 mg, 50 mg
Tier 1
SEROQUEL ORAL TABLET 100 MG, 200
MG, 25 MG, 300 MG, 400 MG, 50 MG
Tier 3
SEROQUEL XR ORAL TABLET
MG, 300 MG, 400 MG, 50 MG
Tier 2
Notes
Antipsychotic -Atypical Dopamine-Serotonin Antag-Thienobenzodiazepines
olanzapine intramuscular recon soln 10 mg
Tier 6
olanzapine oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg,
7.5 mg
Tier 1
olanzapine oral tablet 15 mg
Tier 1
olanzapine oral tablet,disintegrating 10 mg, 15
mg, 20 mg, 5 mg
Tier 1
ZYPREXA INTRAMUSCULAR RECON
SOLN 10 MG
Tier 6
30D
ZYPREXA ORAL TABLET 10 MG, 2.5 MG,
20 MG, 5 MG, 7.5 MG
Tier 3
ZYPREXA ORAL TABLET 15 MG
Tier 3
ZYPREXA RELPREVV INTRAMUSCULAR
SUSPENSION FOR RECONSTITUTION 210
MG, 405 MG
Tier 6
ZYPREXA RELPREVV INTRAMUSCULAR
SUSPENSION FOR RECONSTITUTION 300
MG
Tier 6
30D
ZYPREXA ZYDIS ORAL
20 MG, 5 MG
Tier 3
Attention Deficit-Hyperact. Disorder (Adhd)- Alpha-2 Receptor Agonist
INTUNIV ER ORAL TABLET EXTENDED
RELEASE 24 HR 1 MG, 2 MG, 3 MG, 4 MG
Tier 3
KAPVAY ORAL TABLET EXTENDED
RELEASE 12 HR 0.1 MG
Tier 3
Attention Deficit-Hyperactivity (Adhd) Therapy, Stimulant-Type
ADDERALL ORAL TABLET 10 MG, 12.5
MG, 15 MG, 20 MG, 30 MG, 5 MG, 7.5 MG
Tier 3
ADDERALL XR ORAL
MG, 15 MG, 20 MG, 25 MG, 30 MG, 5 MG
Tier 1
102
Drug Name
Drug Tier
AMPHETAMINE SALT COMBO ORAL
TABLET 10 MG, 12.5 MG, 15 MG, 20 MG, 30
MG, 5 MG, 7.5 MG
Tier 1
CONCERTA ORAL TABLET EXTENDED
RELEASE 24HR 18 MG, 27 MG, 36 MG, 54
MG
Tier 3
DAYTRANA TRANSDERMAL PATCH 24
HOUR 10 MG/9 HR, 15 MG/9 HR, 20 MG/9
HR, 30 MG/9 HR
Tier 3
DESOXYN ORAL TABLET 5 MG
Tier 3
DEXEDRINE SPANSULE ORAL CAPSULE,
EXTENDED RELEASE 10 MG, 15 MG, 5 MG
Tier 3
dexmethylphenidate oral capsule,ER biphasic 5050 15 mg, 30 mg, 40 mg
Tier 1
dexmethylphenidate Oral tablet 10 mg, 2.5 mg, 5
mg
Tier 1
dextroamphetamine oral capsule, extended release
10 mg, 15 mg, 5 mg
Tier 1
dextroamphetamine oral tablet 10 mg, 5 mg
Tier 1
dextroamphetamine-amphetamine Oral
capsule,extended release 24hr 10 mg, 15 mg, 20
mg, 25 mg, 30 mg, 5 mg
NC
FOCALIN ORAL TABLET 10 MG, 2.5 MG, 5
MG
Tier 3
FOCALIN XR ORAL CAPSULE,ER
BIPHASIC 50-50 15 MG, 30 MG, 40 MG
Tier 3
FOCALIN XR ORAL CAPSULE,ER
BIPHASIC 50-50 10 MG, 20 MG, 25 MG, 35
MG, 5 MG
Tier 3
METADATE CD ORAL CAPSULE, ER
BIPHASIC 30-70 10 MG, 20 MG, 30 MG, 40
MG, 50 MG, 60 MG
Tier 3
METADATE ER ORAL TABLET
Tier 3
methamphetamine Oral tablet 5 mg
Tier 1
METHYLIN ORAL SOLUTION 10 MG/5 ML,
5 MG/5 ML
Tier 3
METHYLIN ORAL TABLET,CHEWABLE 10
MG, 2.5 MG, 5 MG
Tier 3
Notes
PA
Not covered (brand Adderall XR
covered as Tier 1)
PA
103
Drug Name
Drug Tier
methylphenidate oral capsule, ER biphasic 30-70
10 mg, 20 mg, 40 mg, 50 mg, 60 mg
Tier 1
methylphenidate oral capsule,ER biphasic 50-50
30 mg
Tier 1
methylphenidate oral solution 10 mg/5 mL, 5 mg/5
mL
Tier 1
methylphenidate oral tablet 10 mg, 20 mg, 5 mg
Tier 1
methylphenidate Oral tablet extended release 10
mg, 20 mg
Tier 1
methylphenidate Oral tablet extended release 24hr
18 mg, 27 mg, 36 mg, 54 mg
Tier 1
QUILLIVANT XR ORAL SUSPENSION,EXT
REL 24HR,RECON 5 MG/ML (25 MG/5 ML)
Tier 3
RITALIN ORAL TABLET 10 MG, 20 MG, 5
MG
Tier 3
RITALIN LA ORAL CAPSULE,ER
BIPHASIC 50-50 10 MG, 20 MG, 30 MG, 40
MG
Tier 3
RITALIN SR ORAL TABLET EXTENDED
RELEASE 20 MG
Tier 3
VYVANSE ORAL CAPSULE 20 MG, 30 MG,
40 MG, 50 MG, 60 MG, 70 MG
Tier 3
ZENZEDI ORAL TABLET 10 MG, 5 MG
Tier 1
ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20
MG, 30 MG, 7.5 MG
Tier 3
Notes
PA
PA
Attention Deficit-Hyperactivity Disorder (Adhd) Therapy, Nri-Type
STRATTERA ORAL CAPSULE 10 MG, 18
MG, 25 MG, 40 MG
Tier 2
PA; QL (2 capsules per 1 day)
STRATTERA ORAL CAPSULE 100 MG, 60
MG, 80 MG
Tier 2
Bipolar Therapy Agents - Anticonvulsant Type
carbamazepine Oral capsule, ER multiphase 12 hr
100 mg, 200 mg, 300 mg
Tier 1
carbamazepine oral suspension 100 mg/5 mL, 200
mg/10 mL
Tier 1
carbamazepine oral tablet 200 mg
Tier 1
carbamazepine Oral tablet extended release 12 hr
200 mg, 400 mg
Tier 1
104
Drug Name
Drug Tier
carbamazepine oral tablet,chewable 100 mg
Tier 1
CARBATROL ORAL CAPSULE, ER
MG
Tier 3
DEPAKENE ORAL CAPSULE 250 MG
Tier 2
DEPAKENE ORAL SOLUTION 250 MG/5
ML
Tier 2
DEPAKOTE ORAL TABLET,DELAYED
Tier 2
MG
Tier 2
DEPAKOTE SPRINKLES ORAL CAPSULE,
SPRINKLE 125 MG
Tier 2
divalproex Oral capsule, sprinkle 125 mg
Tier 1
mg, 500 mg
Tier 1
divalproex oral tablet,delayed release (DR/EC)
125 mg, 250 mg, 500 mg
Tier 1
EPITOL ORAL TABLET 200 MG
Tier 1
EQUETRO ORAL CAPSULE, ER
MG
Tier 3
LAMICTAL ODT ORAL
MG, 25 MG, 50 MG
Tier 2
LAMICTAL ODT STARTER (BLUE) ORAL
TABLET DISINTEGRATING, DOSE PK 25
MG (21) -50 MG (7)
Tier 2
LAMICTAL ODT STARTER (GREEN)
PK 50 MG (42) -100 MG (14)
Tier 2
LAMICTAL ODT STARTER (ORANGE)
PK 25 MG(14)-50 MG (14)-100 MG (7)
Tier 2
LAMICTAL STARTER (BLUE) KIT ORAL
TABLETS,DOSE PACK 25 MG (35)
Tier 3
LAMICTAL STARTER (GREEN) KIT ORAL
TABLETS,DOSE PACK 25 MG (84) -100 MG
(14)
Tier 2
Notes
105
Drug Name
Drug Tier
LAMICTAL STARTER (ORANGE) KIT
ORAL TABLETS,DOSE PACK 25 MG (42) 100 MG (7)
Tier 2
lamotrigine Oral tablets,dose pack 25 mg (35), 25
mg (42) -100 mg (7), 25 mg (84) -100 mg (14)
Tier 1
STAVZOR ORAL CAPSULE,DELAYED
Tier 3
TEGRETOL ORAL SUSPENSION 100 MG/5
ML
Tier 2
TEGRETOL ORAL TABLET 200 MG
Tier 2
TEGRETOL XR ORAL TABLET
MG
Tier 2
valproic acid oral capsule 250 mg
Tier 1
valproic acid (as sodium salt) oral solution 250
mg/5 mL, 250 mg/5 mL (5 mL), 500 mg/10 mL (10
mL)
Tier 1
Notes
Bipolar Therapy Agents - Atypical Antipsychotics
ABILIFY INTRAMUSCULAR SOLUTION
9.75 MG/1.3 ML
Tier 6
ABILIFY ORAL SOLUTION 1 MG/ML
Tier 2
ABILIFY ORAL TABLET 10 MG, 15 MG, 2
MG, 20 MG, 30 MG, 5 MG
Tier 2
QL (1 tablet per day)
ABILIFY DISCMELT ORAL
Tier 2
GEODON INTRAMUSCULAR RECON
SOLN 20 MG/ML (FINAL CONC.)
Tier 6
GEODON ORAL CAPSULE 20 MG, 40 MG,
60 MG, 80 MG
Tier 3
olanzapine intramuscular recon soln 10 mg
Tier 6
olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20
mg, 5 mg, 7.5 mg
Tier 1
olanzapine oral tablet,disintegrating 10 mg, 15
mg, 20 mg, 5 mg
Tier 1
quetiapine oral tablet 100 mg, 200 mg, 25 mg, 300
mg, 400 mg, 50 mg
Tier 1
RISPERDAL ORAL SOLUTION 1 MG/ML
Tier 3
RISPERDAL ORAL TABLET 0.25 MG, 0.5
MG, 1 MG, 2 MG, 3 MG, 4 MG
Tier 3
106
30D
Drug Name
Drug Tier
RISPERDAL M-TAB ORAL
TABLET,DISINTEGRATING 0.5 MG, 1 MG,
2 MG, 3 MG, 4 MG
Tier 3
risperidone oral solution 1 mg/mL
Tier 1
risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2
mg, 3 mg, 4 mg
Tier 1
risperidone Oral tablet,disintegrating 0.25 mg, 0.5
mg, 1 mg, 2 mg, 3 mg, 4 mg
Tier 1
SAPHRIS SUBLINGUAL TABLET,
Tier 2
SAPHRIS (BLACK CHERRY) SUBLINGUAL
TABLET, SUBLINGUAL 10 MG, 5 MG
Tier 2
SEROQUEL ORAL TABLET 100 MG, 200
MG, 25 MG, 300 MG, 400 MG, 50 MG
Tier 3
SEROQUEL XR ORAL TABLET
MG, 300 MG, 400 MG, 50 MG
Tier 2
ziprasidone HCl oral capsule 20 mg, 40 mg, 60
mg, 80 mg
Tier 1
ZYPREXA INTRAMUSCULAR RECON
SOLN 10 MG
Tier 6
ZYPREXA ORAL TABLET 10 MG, 15 MG,
2.5 MG, 20 MG, 5 MG, 7.5 MG
Tier 3
ZYPREXA ZYDIS ORAL
20 MG, 5 MG
Tier 3
Notes
30D
Bipolar Therapy Agents - Lithium
lithium carbonate Oral capsule 150 mg, 300 mg,
600 mg
Tier 1
lithium carbonate Oral tablet 300 mg
Tier 1
lithium carbonate Oral tablet extended release 300
mg, 450 mg
Tier 1
lithium citrate oral solution 8 mEq/5 mL, 8 mEq/5
mL (5 mL)
Tier 1
LITHOBID ORAL TABLET EXTENDED
RELEASE 300 MG
Tier 3
Cns Stimulant - Amphetamine Combinations
107
Drug Name
Drug Tier
MG, 15 MG, 20 MG, 30 MG, 5 MG, 7.5 MG
Tier 3
ADDERALL XR ORAL
MG, 15 MG, 20 MG, 25 MG, 30 MG, 5 MG
Tier 1
TABLET 10 MG, 12.5 MG, 15 MG, 20 MG, 30
MG, 5 MG, 7.5 MG
Tier 1
dextroamphetamine-amphetamine Oral
capsule,extended release 24hr 10 mg, 15 mg, 20
mg, 25 mg, 30 mg, 5 mg
NC
Notes
Not covered (brand Adderall XR
covered as Tier 1)
Cns Stimulant - Amphetamines
DESOXYN ORAL TABLET 5 MG
Tier 3
Tier 3
10 mg, 15 mg, 5 mg
Tier 1
dextroamphetamine oral solution 5 mg/5 mL
Tier 1
Tier 1
methamphetamine Oral tablet 5 mg
Tier 1
PROCENTRA ORAL SOLUTION 5 MG/5 ML
Tier 3
Tier 1
MG, 30 MG, 7.5 MG
Tier 3
Cns Stimulant - Analeptics
CAFCIT ORAL SOLUTION 60 MG/3 ML (20
MG/ML)
Tier 3
caffeine citrated oral solution 60 mg/3 mL (20
mg/mL)
Tier 1
Fibromyalgia Agents - Serotonin-Norepinephrine Reuptake-Inhib (Snris)
SAVELLA ORAL TABLET 100 MG, 12.5 MG,
25 MG, 50 MG
Tier 3
PA
SAVELLA ORAL TABLETS,DOSE PACK
12.5 MG (5)-25 MG(8)-50 MG(42)
Tier 3
PA
Hypnotics - Melatonin M1/M2 Receptor Agonists
HETLIOZ ORAL CAPSULE 20 MG
Tier 3
ROZEREM ORAL TABLET 8 MG
Tier 3
108
Drug Name
Drug Tier
Notes
Migraine Therapy - Analgesic-Vasoconstrictor-Sedative Combinations
MIGRAGESIC IDA ORAL CAPSULE 65-100325 MG
Tier 1
NODOLOR ORAL CAPSULE 65-100-325 MG
Tier 3
Migraine Therapy - Carboxylic Acid Derivatives
MG
Tier 2
mg, 500 mg
Tier 1
Migraine Therapy - Ergot Alkaloids And Derivatives
D.H.E.45 INJECTION SOLUTION 1 MG/ML
Tier 3
dihydroergotamine injection solution 1 mg/mL
Tier 1
dihydroergotamine nasal spray,non-aerosol 0.5
mg/pump act. (4 mg/mL)
Tier 1
ERGOMAR SUBLINGUAL TABLET,
SUBLINGUAL 2 MG
Tier 3
MIGRANAL NASAL SPRAY,NONAEROSOL 0.5 MG/PUMP ACT. (4 MG/ML)
Tier 3
PA; QL (8 units (ml) per 30 days)
CAFERGOT ORAL TABLET 1-100 MG
Tier 3
PA; QL (40 tablets per 30 days)
MIGERGOT RECTAL SUPPOSITORY 2-100
MG
Tier 3
PA; QL (20 suppositories per 30
days)
PA
Migraine Therapy - Ergot Combinations
Migraine Therapy - Nsaid Analgesics(Cyclooxygenase Inhib-Non-Selectiv)
MG
Tier 3
PA
Migraine Therapy - Selective Serotonin Agonists 5-Ht(1)
ALSUMA SUBCUTANEOUS PEN INJECTOR
6 MG/0.5 ML
Tier 3
AMERGE ORAL TABLET 1 MG, 2.5 MG
Tier 3
AXERT ORAL TABLET 12.5 MG, 6.25 MG
Tier 3
FROVA ORAL TABLET 2.5 MG
Tier 3
IMITREX NASAL SPRAY,NON-AEROSOL
20 MG/ACTUATION, 5 MG/ACTUATION
Tier 3
IMITREX ORAL TABLET 100 MG, 25 MG,
50 MG
Tier 3
109
Drug Name
Drug Tier
Notes
IMITREX SUBCUTANEOUS SOLUTION 6
MG/0.5 ML
Tier 3
QL (6 injections per 30 days)
IMITREX STATDOSE KIT REFILL
SUBCUTANEOUS CARTRIDGE 4 MG/0.5
ML, 6 MG/0.5 ML
Tier 3
IMITREX STATDOSE PEN
SUBCUTANEOUS PEN INJECTOR 4 MG/0.5
ML, 6 MG/0.5 ML
Tier 3
MAXALT ORAL TABLET 10 MG, 5 MG
Tier 3
MAXALT-MLT ORAL
Tier 3
naratriptan Oral tablet 1 mg, 2.5 mg
Tier 1
RELPAX ORAL TABLET 20 MG, 40 MG
Tier 2
rizatriptan oral tablet 10 mg, 5 mg
Tier 1
rizatriptan oral tablet,disintegrating 10 mg, 5 mg
Tier 1
sumatriptan nasal spray,non-aerosol 20
mg/actuation, 5 mg/actuation
Tier 1
sumatriptan succinate oral tablet 100 mg, 25 mg,
50 mg
Tier 1
sumatriptan succinate subcutaneous cartridge 4
mg/0.5 mL, 6 mg/0.5 mL
Tier 1
sumatriptan succinate subcutaneous solution 6
mg/0.5 mL
Tier 1
SUMAVEL DOSEPRO SUBCUTANEOUS
NEEDLE-FREE INJECTOR 6 MG/0.5 ML
Tier 3
PA; QL (6 injections per 30 days)
zolmitriptan oral tablet 2.5 mg, 5 mg
Tier 1
zolmitriptan Oral tablet,disintegrating 2.5 mg, 5
mg
Tier 1
ZOMIG NASAL SPRAY,NON-AEROSOL 2.5
MG, 5 MG
Tier 3
ZOMIG ORAL TABLET 2.5 MG, 5 MG
Tier 3
ZOMIG ZMT ORAL
TABLET,DISINTEGRATING 2.5 MG, 5 MG
Tier 3
Migraine Therapy - Serotonin Agonist 5-Ht(1) And Nsaid Comb.
TREXIMET ORAL TABLET 85-500 MG
Tier 3
Tier 3
PA
Migraine Therapy Other
MG
110
Drug Name
Drug Tier
Notes
Movement Disorder Drug Therapy
HORIZANT ORAL TABLET EXTENDED
Tier 3
XENAZINE ORAL TABLET 12.5 MG, 25 MG
Tier 4
PA
Movement Disorder Therapy - Huntington's Disease
XENAZINE ORAL TABLET 12.5 MG, 25 MG
Tier 4
PA
Movement Disorder Therapy - Restless Legs Syndrome
HORIZANT ORAL TABLET EXTENDED
Tier 3
Narcolepsy & Cataplexy Therapy Agents - Sedative-Type
XYREM ORAL SOLUTION 500 MG/ML
Tier 4
PA; QL (540 mls per 30 days)
Narcolepsy Therapy Agents - Non-Sympathomimetic
modafinil oral tablet 100 mg, 200 mg
Tier 1
NUVIGIL ORAL TABLET 150 MG, 200 MG,
250 MG, 50 MG
Tier 2
PROVIGIL ORAL TABLET 100 MG, 200 MG
Tier 3
Narcolepsy Therapy Agents - Stimulant-Type, Piperadine Derivative
METHYLIN ORAL SOLUTION 10 MG/5 ML,
5 MG/5 ML
Tier 3
METHYLIN ORAL TABLET,CHEWABLE 10
MG, 2.5 MG, 5 MG
Tier 3
methylphenidate oral solution 10 mg/5 mL, 5 mg/5
mL
Tier 1
methylphenidate oral tablet 10 mg, 20 mg, 5 mg
Tier 1
RITALIN ORAL TABLET 10 MG, 20 MG, 5
MG
Tier 3
Narcolepsy Therapy Agents- Stimulant-Type,Sympathomimetic,Amphetamines
MG, 15 MG, 20 MG, 30 MG, 5 MG, 7.5 MG
Tier 3
TABLET 10 MG, 12.5 MG, 15 MG, 20 MG, 30
MG, 5 MG, 7.5 MG
Tier 1
Tier 3
10 mg, 15 mg, 5 mg
Tier 1
111
Drug Name
Drug Tier
Tier 1
Tier 1
MG, 30 MG, 7.5 MG
Tier 3
Notes
Postherpetic Neuralgia Agents
GRALISE ORAL TABLET EXTENDED
Tier 3
PA
GRALISE 30-DAY STARTER PACK ORAL
TABLET EXTENDED RELEASE 24 HR 300
MG (9)- 600 MG (69)
Tier 3
PA
Pseudobulbar Affect (Pba) Agents, Nmda Antagonists Type
NUEDEXTA ORAL CAPSULE 20-10 MG
Tier 3
PA
Sedative-Hypnotic - Antihistamines
diphenhydramine HCl oral capsule 50 mg
Tier 1
Sedative-Hypnotic - Barbiturates
BUTISOL ORAL ELIXIR 30 MG/5 ML
Tier 3
BUTISOL ORAL TABLET 30 MG, 50 MG
Tier 3
phenobarbital oral elixir 20 mg/5 mL
Tier 1
phenobarbital Oral tablet 100 mg, 15 mg, 16.2 mg,
30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg
Tier 1
SECONAL SODIUM ORAL CAPSULE 100
MG
Tier 3
Sedative-Hypnotic - Benzodiazepines
DORAL ORAL TABLET 15 MG
Tier 3
estazolam Oral tablet 1 mg, 2 mg
Tier 1
flurazepam Oral capsule 15 mg, 30 mg
Tier 1
HALCION ORAL TABLET 0.25 MG
Tier 3
Midazolam Oral Syrup 2 mg/mL
Tier 1
quazepam Oral tablet 15 mg
Tier 1
RESTORIL ORAL CAPSULE 15 MG, 22.5
MG, 30 MG, 7.5 MG
Tier 3
temazepam Oral capsule 15 mg, 22.5 mg, 30 mg,
7.5 mg
Tier 1
triazolam Oral tablet 0.125 mg, 0.25 mg
Tier 1
Sedative-Hypnotic - Gaba-Receptor Modulators
112
Drug Name
Drug Tier
Notes
AMBIEN ORAL TABLET 10 MG, 5 MG
Tier 3
AMBIEN CR ORAL TABLET,EXT RELEASE
MULTIPHASE 12.5 MG, 6.25 MG
Tier 3
EDLUAR SUBLINGUAL TABLET,
Tier 3
eszopiclone oral tablet 1 mg, 2 mg, 3 mg
Tier 1
INTERMEZZO SUBLINGUAL TABLET,
SUBLINGUAL 1.75 MG, 3.5 MG
Tier 3
LUNESTA ORAL TABLET 1 MG, 2 MG, 3
MG
Tier 3
SONATA ORAL CAPSULE 10 MG, 5 MG
Tier 3
zaleplon Oral capsule 10 mg, 5 mg
Tier 1
zolpidem oral tablet 10 mg, 5 mg
Tier 1
zolpidem oral tablet,ext release multiphase 12.5
mg, 6.25 mg
Tier 1
ZOLPIMIST ORAL SPRAY,NON-AEROSOL
5 MG/SPRAY (0.1 ML)
Tier 3
PA; QL (1 spray per 1 day)
Sedative-Hypnotic - Tricyclic Antidepressant Type
Tier 3
BUNAVAIL BUCCAL FILM 2.1 MG-0.3 MG,
4.2 MG-0.7MG, 6.3 MG-1 MG
Tier 3
QL (2 films per 1 day)
buprenorphine sublingual tablet, sublingual 2 mg,
8 mg
Tier 1
buprenorphine-naloxone sublingual tablet,
sublingual 2-0.5 mg, 8-2 mg
Tier 1
SUBOXONE SUBLINGUAL FILM 2-0.5 MG,
8-2 MG
Tier 2
SUBOXONE SUBLINGUAL FILM 12-3 MG,
4-1 MG
Tier 2
ZUBSOLV SUBLINGUAL TABLET,
SUBLINGUAL 1.4-0.36 MG, 5.7-1.4 MG
Tier 3
SILENOR ORAL TABLET 3 MG, 6 MG
Chemical Dependency, Agents To Treat
Agents For Narcotic Withdrawal
Alcohol Abstinence Therapy - Glutamate And Gaba System Type
acamprosate Oral tablet,delayed release (DR/EC)
333 mg
Tier 1
113
Drug Name
CAMPRAL ORAL TABLET,DELAYED
Drug Tier
Notes
Tier 3
Alcohol Abstinence Therapy - Opioid Receptor Antagonist-Type
VIVITROL INTRAMUSCULAR
SUSPENSION,EXTENDED REL RECON 380
MG
Tier 6
30D
Alcohol Deterrents
ANTABUSE ORAL TABLET 250 MG, 500
MG
Tier 3
disulfiram oral tablet 250 mg, 500 mg
Tier 1
Smoking Deterrents - Ne & Dopamine Reuptake Inhibitor (Ndri)-Type
BUPROBAN ORAL TABLET EXTENDED
RELEASE 150 MG
Tier 5
bupropion HCl oral tablet extended release 150
mg
Tier 5
ZYBAN ORAL TABLET EXTENDED
RELEASE 150 MG
Tier 5
Smoking Deterrents - Nicotine-Type
NICODERM CQ TRANSDERMAL PATCH
24 HOUR 14 MG/24 HR, 21 MG/24 HR, 7
MG/24 HR
Tier 5
NICORELIEF BUCCAL GUM 2 MG, 4 MG
Tier 5
NICORETTE BUCCAL GUM 2 MG, 4 MG
Tier 5
NICORETTE BUCCAL LOZENGE 2 MG, 4
MG
Tier 5
nicotine transdermal patch 24 hour 14 mg/24 hr,
21 mg/24 hr, 7 mg/24 hr
Tier 5
nicotine transdermal patch, TD daily, sequential
21-14-7 mg/24 hr
Tier 5
nicotine (polacrilex) buccal gum 2 mg, 4 mg
Tier 5
nicotine (polacrilex) buccal lozenge 2 mg, 4 mg
Tier 5
NICOTROL INHALATION CARTRIDGE 10
MG
Tier 5
NICOTROL NS NASAL SPRAY,NONAEROSOL 10 MG/ML
Tier 5
Smoking Deterrents - Nicotinic Receptor Partial Agonist, Alpha4beta2
CHANTIX ORAL TABLET 0.5 MG, 1 MG
114
Tier 5
Drug Name
Drug Tier
CHANTIX CONTINUING MONTH BOX
ORAL TABLET 1 MG
Tier 5
CHANTIX CONTINUING MONTH PAK
ORAL TABLET 1 MG
Tier 5
CHANTIX STARTING MONTH BOX ORAL
TABLETS,DOSE PACK 0.5 MG (11)- 1 MG
(42)
Tier 5
CHANTIX STARTING MONTH PAK ORAL
TABLETS,DOSE PACK 0.5 MG (11)- 1 MG
(42)
Tier 5
Notes
Chemicals-Pharmaceutical Adjuvants
Bulk Chemicals
benzalkonium chloride solution 50 %
Tier 1
chlorhexidine gluconate solution 20 %
Tier 3
NAPRO CREAM 15 %
Tier 3
PEG 3350-GRX POWDER
Tier 1
Pharmaceutical Adjuvant - Cream/Ointment Vehicles
PEG 3350-GRX POWDER
Tier 1
Pharmaceutical Adjuvant - Inhalation Vehicles
HYPER-SAL INHALATION SOLUTION FOR
NEBULIZATION 3.5 %
Tier 2
HYPER-SAL INHALATION SOLUTION FOR
NEBULIZATION 7 %
Tier 3
NEBUSAL INHALATION SOLUTION FOR
NEBULIZATION 6 %
Tier 3
PULMOSAL INHALATION SOLUTION FOR
NEBULIZATION 7 %
Tier 3
sodium chloride inhalation solution for
nebulization 10 %, 3 %, 7 %
Tier 1
Cognitive Disorder Therapy
Alzheimer's Disease Therapy - Cholinesterase Inhibitors
ARICEPT ORAL TABLET 10 MG, 23 MG, 5
MG
Tier 3
ARICEPT ODT ORAL
TABLET,DISINTEGRATING 10 MG
Tier 3
donepezil oral tablet 10 mg, 23 mg, 5 mg
Tier 1
115
Drug Name
Drug Tier
donepezil oral tablet,disintegrating 10 mg, 5 mg
Tier 1
EXELON ORAL CAPSULE 1.5 MG, 3 MG, 4.5
MG, 6 MG
Tier 3
EXELON TRANSDERMAL PATCH 24
HOUR 13.3 MG/24 HOUR, 4.6 MG/24 HR, 9.5
MG/24 HR
Tier 2
galantamine Oral capsule,ext rel. pellets 24 hr 16
mg, 24 mg, 8 mg
Tier 1
galantamine oral solution 4 mg/mL
Tier 1
galantamine oral tablet 12 mg, 4 mg, 8 mg
Tier 1
RAZADYNE ORAL SOLUTION 4 MG/ML
Tier 3
RAZADYNE ORAL TABLET 12 MG, 4 MG, 8
MG
Tier 3
RAZADYNE ER ORAL CAPSULE,EXT REL.
PELLETS 24 HR 16 MG, 24 MG, 8 MG
Tier 3
rivastigmine tartrate oral capsule 1.5 mg, 3 mg,
4.5 mg, 6 mg
Tier 1
Notes
Alzheimer's Disease Therapy - Nmda Receptor Antagonists
NAMENDA ORAL SOLUTION 10 MG/5 ML
Tier 2
NAMENDA ORAL TABLET 10 MG, 5 MG
Tier 2
NAMENDA TITRATION PAK ORAL
TABLETS,DOSE PACK 5-10 MG
Tier 2
NAMENDA XR ORAL CAP,SPRINKLE,ER
24HR DOSE PACK 7-14-21-28 MG
Tier 3
NAMENDA XR ORAL
CAPSULE,SPRINKLE,ER 24HR 14 MG, 21
MG, 28 MG, 7 MG
Tier 3
Cognitive Disorder Therapy - Cerebral Vasodilators
ergoloid Oral tablet 1 mg
Tier 1
Contraceptives
Contraceptive Implant - Progestin
NEXPLANON SUBDERMAL IMPLANT 68
MG
Tier 6
30D
Tier 6
30D
Contraceptive Injectable - Progestin
SUSPENSION 150 MG/ML
116
Drug Name
Drug Tier
Notes
SYRINGE 150 MG/ML
Tier 6
30D
DEPO-SUBQ PROVERA 104
SUBCUTANEOUS SYRINGE 104 MG/0.65
ML
Tier 5
medroxyprogesterone intramuscular suspension
150 mg/mL
Tier 6
30D
medroxyprogesterone intramuscular syringe 150
mg/mL
Tier 6
30D
Contraceptive Intrauterine - Copper Iud
PARAGARD T 380A INTRAUTERINE
INTRAUTERINE DEVICE 380 SQUARE MM
Tier 5
Contraceptive Intrauterine - Progesterone Iud
MIRENA INTRAUTERINE INTRAUTERINE
DEVICE 20 MCG/24 HR (5 YEARS)
Tier 5
SKYLA INTRAUTERINE INTRAUTERINE
DEVICE 14 MCG/24 HOUR (3 YEARS)
Tier 5
PA
Contraceptive Oral - Biphasic
AMETHIA ORAL TABLETS,DOSE PACK,3
MONTH 0.15 MG-30 MCG (84)/10 MCG (7)
Tier 5
AMETHIA LO ORAL TABLETS,DOSE
PACK,3 MONTH 0.10 MG-20 MCG (84)/10
MCG (7)
Tier 5
AZURETTE (28) ORAL TABLET 0.15-0.02
MGX21 /0.01 MG X 5
Tier 5
CAMRESE ORAL TABLETS,DOSE PACK,3
MONTH 0.15 MG-30 MCG (84)/10 MCG (7)
Tier 5
CAMRESE LO ORAL TABLETS,DOSE
MCG (7)
Tier 5
DAYSEE ORAL TABLETS,DOSE PACK,3
MONTH 0.15 MG-30 MCG (84)/10 MCG (7)
Tier 5
KARIVA (28) ORAL TABLET 0.15-0.02
MGX21 /0.01 MG X 5
Tier 5
L norgest&E estradiol-E estrad oral tablets,dose
pack,3 month 0.10 mg-20 mcg (84)/10 mcg (7)
Tier 5
LO LOESTRIN FE ORAL TABLET 1 MG-10
MCG(24) /10 MCG (2)
Tier 5
PA
117
Drug Name
Drug Tier
LOSEASONIQUE ORAL TABLETS,DOSE
MCG (7)
Tier 5
MIRCETTE (28) ORAL TABLET 0.15-0.02
MGX21 /0.01 MG X 5
Tier 5
NECON 10/11 (28) ORAL TABLET 0.5-35/1-35
MG-MCG/MG-MCG
Tier 5
PIMTREA (28) ORAL TABLET 0.15-0.02
MGX21 /0.01 MG X 5
Tier 5
SEASONIQUE ORAL TABLETS,DOSE
MCG (7)
Tier 5
VIORELE (28) ORAL TABLET 0.15-0.02
MGX21 /0.01 MG X 5
Tier 5
Notes
Contraceptive Oral - Monophasic
ALTAVERA (28) ORAL TABLET 0.15-30
MG-MCG
Tier 5
ALYACEN 1/35 (28) ORAL TABLET 1-35
MG-MCG
Tier 5
AMETHYST ORAL TABLET 90-20 MCG
Tier 5
APRI ORAL TABLET 0.15-30 MG-MCG
Tier 5
AUBRA ORAL TABLET 0.1-20 MG-MCG
Tier 5
AVIANE ORAL TABLET 0.1-20 MG-MCG
Tier 5
BALZIVA (28) ORAL TABLET 0.4-35 MGMCG
Tier 5
BEYAZ ORAL TABLET 3-0.02-0.451 MG (24)
Tier 5
PA
BREVICON (28) ORAL TABLET 0.5-35 MGMCG
Tier 5
PA
BRIELLYN ORAL TABLET 0.4-35 MG-MCG
Tier 5
CHATEAL ORAL TABLET 0.15-30 MG-MCG
Tier 5
CRYSELLE (28) ORAL TABLET 0.3-30 MGMCG
Tier 5
CYCLAFEM 1/35 (28) ORAL TABLET 1-35
MG-MCG
Tier 5
DASETTA 1/35 (28) ORAL TABLET 1-35
MG-MCG
Tier 5
DESOGEN ORAL TABLET 0.15-30 MG-MCG
Tier 5
118
PA
Drug Name
Drug Tier
desogestrel-ethinyl estradiol oral tablet 0.15-30
mg-mcg
Tier 5
drospirenone-ethinyl estradiol oral tablet 3-0.03
mg
Tier 5
ELINEST ORAL TABLET 0.3-30 MG-MCG
Tier 5
EMOQUETTE ORAL TABLET 0.15-30 MGMCG
Tier 5
ENSKYCE ORAL TABLET 0.15-30 MG-MCG
Tier 5
ESTARYLLA ORAL TABLET 0.25-35 MGMCG
Tier 5
FALMINA (28) ORAL TABLET 0.1-20 MGMCG
Tier 5
FEMCON FE ORAL TABLET,CHEWABLE
0.4MG-35MCG(21) & 75 MG (7)
Tier 5
GENERESS FE ORAL TABLET,CHEWABLE
0.8MG-25MCG(24) & 75 MG (4)
Tier 5
GIANVI (28) ORAL TABLET 3-0.02 MG
Tier 5
GILDAGIA ORAL TABLET 0.4-35 MG-MCG
Tier 5
GILDESS ORAL TABLET 1-20 MG-MCG,
1.5-30 MG-MCG
Tier 5
GILDESS FE ORAL TABLET 1-20 MG-MCG,
1.5-30 MG-MCG
Tier 5
INTROVALE ORAL TABLETS,DOSE
PACK,3 MONTH 0.15-30 MG-MCG
Tier 5
JOLESSA ORAL TABLETS,DOSE PACK,3
MONTH 0.15-30 MG-MCG
Tier 5
JUNEL 1.5/30 (21) ORAL TABLET 1.5-30
MG-MCG
Tier 5
JUNEL 1/20 (21) ORAL TABLET 1-20 MGMCG
Tier 5
JUNEL FE 1.5/30 (28) ORAL TABLET 1.5-30
MG-MCG
Tier 5
JUNEL FE 1/20 (28) ORAL TABLET 1-20
MG-MCG
Tier 5
KELNOR 1/35 (28) ORAL TABLET 1-35 MGMCG
Tier 5
KURVELO ORAL TABLET 0.15-30 MGMCG
Tier 5
Notes
PA
119
Drug Name
Drug Tier
LARIN 1.5/30 (21) ORAL TABLET 1.5-30
MG-MCG
Tier 5
LARIN 1/20 (21) ORAL TABLET 1-20 MGMCG
Tier 5
LARIN FE ORAL TABLET 1-20 MG-MCG,
1.5-30 MG-MCG
Tier 5
LESSINA ORAL TABLET 0.1-20 MG-MCG
Tier 5
levonorgestrel-ethinyl estrad oral tablet 0.1-20
mg-mcg, 0.15-30 mg-mcg
Tier 5
LEVORA-28 ORAL TABLET 0.15-30 MGMCG
Tier 5
LO LOESTRIN FE ORAL TABLET 1 MG-10
MCG(24) /10 MCG (2)
Tier 5
LOESTRIN 1.5/30 (21) ORAL TABLET 1.5-30
MG-MCG
Tier 5
LOESTRIN 1/20 (21) ORAL TABLET 1-20
MG-MCG
Tier 5
LOESTRIN FE 1.5/30 (28) ORAL TABLET
1.5-30 MG-MCG
Tier 5
LOESTRIN FE 1/20 (28) ORAL TABLET 1-20
MG-MCG
Tier 5
LOMEDIA 24 FE ORAL TABLET 1-20 (24)75(4) MG-MCG-MG
Tier 5
LORYNA (28) ORAL TABLET 3-0.02 MG
Tier 5
LOW-OGESTREL (28) ORAL TABLET 0.3-30
MG-MCG
Tier 5
LUTERA (28) ORAL TABLET 0.1-20 MGMCG
Tier 5
MARLISSA ORAL TABLET 0.15-30 MGMCG
Tier 5
MICROGESTIN 1.5/30 (21) ORAL TABLET
1.5-30 MG-MCG
Tier 5
MICROGESTIN 1/20 (21) ORAL TABLET 120 MG-MCG
Tier 5
MICROGESTIN FE 1.5/30 (28) ORAL
TABLET 1.5-30 MG-MCG
Tier 5
MICROGESTIN FE 1/20 (28) ORAL TABLET
1-20 MG-MCG
Tier 5
120
Notes
PA
Drug Name
Drug Tier
MINASTRIN 24 FE ORAL
TABLET,CHEWABLE 1 MG-20 MCG(24) /75
MG (4)
Tier 5
MODICON (28) ORAL TABLET 0.5-35 MGMCG
Tier 5
MONO-LINYAH ORAL TABLET 0.25-35
MG-MCG
Tier 5
MONONESSA (28) ORAL TABLET 0.25-35
MG-MCG
Tier 5
NECON 0.5/35 (28) ORAL TABLET 0.5-35
MG-MCG
Tier 5
NECON 1/35 (28) ORAL TABLET 1-35 MGMCG
Tier 5
NECON 1/50 (28) ORAL TABLET 1-50 MGMCG
Tier 5
NORINYL 1+35 (28) ORAL TABLET 1-35
MG-MCG
Tier 5
NORINYL 1+50 (28) ORAL TABLET 1-50
MG-MCG
Tier 5
NORTREL 0.5/35 (28) ORAL TABLET 0.5-35
MG-MCG
Tier 5
NORTREL 1/35 (21) ORAL TABLET 1-35
MG-MCG
Tier 5
NORTREL 1/35 (28) ORAL TABLET 1-35
MG-MCG
Tier 5
OCELLA ORAL TABLET 3-0.03 MG
Tier 5
OGESTREL (28) ORAL TABLET 0.5-50 MGMCG
Tier 5
ORSYTHIA ORAL TABLET 0.1-20 MG-MCG
Tier 5
ORTHO-NOVUM 1/35 (28) ORAL TABLET 135 MG-MCG
Tier 5
OVCON-35 (28) ORAL TABLET 0.4-35 MGMCG
Tier 5
PHILITH ORAL TABLET 0.4-35 MG-MCG
Tier 5
PIRMELLA ORAL TABLET 1-35 MG-MCG
Tier 5
PORTIA ORAL TABLET 0.15-30 MG-MCG
Tier 5
PREVIFEM ORAL TABLET 0.25-35 MGMCG
Tier 5
Notes
PA
PA
121
Drug Name
Drug Tier
QUASENSE ORAL TABLETS,DOSE PACK,3
MONTH 0.15-30 MG-MCG
Tier 5
RECLIPSEN (28) ORAL TABLET 0.15-30
MG-MCG
Tier 5
SAFYRAL ORAL TABLET 3-0.03-0.451 MG
(21/7)
Tier 5
SPRINTEC (28) ORAL TABLET 0.25-35 MGMCG
Tier 5
SRONYX ORAL TABLET 0.1-20 MG-MCG
Tier 5
SYEDA ORAL TABLET 3-0.03 MG
Tier 5
VESTURA (28) ORAL TABLET 3-0.02 MG
Tier 5
VYFEMLA (28) ORAL TABLET 0.4-35 MGMCG
Tier 5
WERA (28) ORAL TABLET 0.5-35 MG-MCG
Tier 5
WYMZYA FE ORAL TABLET,CHEWABLE
0.4MG-35MCG(21) & 75 MG (7)
Tier 5
YASMIN (28) ORAL TABLET 3-0.03 MG
Tier 5
YAZ (28) ORAL TABLET 3-0.02 MG
Tier 5
ZARAH ORAL TABLET 3-0.03 MG
Tier 5
ZENCHENT (28) ORAL TABLET 0.4-35 MGMCG
Tier 5
ZENCHENT FE ORAL
TABLET,CHEWABLE 0.4MG-35MCG(21) &
75 MG (7)
Tier 5
ZEOSA ORAL TABLET,CHEWABLE
0.4MG-35MCG(21) & 75 MG (7)
Tier 5
ZOVIA 1/35E (28) ORAL TABLET 1-35 MGMCG
Tier 5
ZOVIA 1/50E (28) ORAL TABLET 1-50 MGMCG
Tier 5
Contraceptive Oral - Progestin
CAMILA ORAL TABLET 0.35 MG
Tier 5
ERRIN ORAL TABLET 0.35 MG
Tier 5
HEATHER ORAL TABLET 0.35 MG
Tier 5
JENCYCLA ORAL TABLET 0.35 MG
Tier 5
JOLIVETTE ORAL TABLET 0.35 MG
Tier 5
LYZA ORAL TABLET 0.35 MG
Tier 5
122
Notes
PA
Drug Name
Drug Tier
NOR-QD ORAL TABLET 0.35 MG
Tier 5
NORA-BE ORAL TABLET 0.35 MG
Tier 5
norethindrone (contraceptive) oral tablet 0.35 mg
Tier 5
ORTHO MICRONOR ORAL TABLET 0.35
MG
Tier 5
Notes
Contraceptive Oral - Quadraphasic
NATAZIA ORAL TABLET 3 MG/2 MG-2
MG/ 2 MG-3 MG/1 MG
Tier 5
PA
QUARTETTE ORAL TABLETS,DOSE
PACK,3 MONTH 0.15 MG-20 MCG/ 0.15 MG25 MCG
Tier 5
PA
Contraceptive Oral - Triphasic
ALYACEN 7/7/7 (28) ORAL TABLET
0.5/0.75/1 MG- 35 MCG
Tier 5
ARANELLE (28) ORAL TABLET 0.5/1/0.5-35
MG-MCG
Tier 5
CAZIANT (28) ORAL TABLET 0.1/.125/.15-25
MG-MCG
Tier 5
CYCLAFEM 7/7/7 (28) ORAL TABLET
0.5/0.75/1 MG- 35 MCG
Tier 5
CYCLESSA (28) ORAL TABLET 0.1/.125/.1525 MG-MCG
Tier 5
DASETTA 7/7/7 (28) ORAL TABLET
0.5/0.75/1 MG- 35 MCG
Tier 5
ENPRESSE ORAL TABLET 50-30 (6)/75-40
(5)/125-30(10)
Tier 5
ESTROSTEP FE-28 ORAL TABLET 120(5)/1-30(7) /1MG-35MCG (9)
Tier 5
LEENA 28 ORAL TABLET 0.5/1/0.5-35 MGMCG
Tier 5
LEVONEST (28) ORAL TABLET 50-30 (6)/7540 (5)/125-30(10)
Tier 5
MYZILRA ORAL TABLET 50-30 (6)/75-40
(5)/125-30(10)
Tier 5
NECON 7/7/7 (28) ORAL TABLET 0.5/0.75/1
MG- 35 MCG
Tier 5
norgestimate-ethinyl estradiol oral tablet
0.18/0.215/0.25 mg-35 mcg (28)
Tier 5
123
Drug Name
Drug Tier
NORTREL 7/7/7 (28) ORAL TABLET
0.5/0.75/1 MG- 35 MCG
Tier 5
ORTHO TRI-CYCLEN (28) ORAL TABLET
0.18/0.215/0.25 MG-35 MCG (28)
Tier 5
ORTHO TRI-CYCLEN LO (28) ORAL
TABLET 0.18/0.215/0.25 MG-25 MCG (28)
Tier 5
ORTHO-NOVUM 7/7/7 (28) ORAL TABLET
0.5/0.75/1 MG- 35 MCG
Tier 5
PIRMELLA ORAL TABLET 0.5/0.75/1 MG35 MCG
Tier 5
TILIA FE ORAL TABLET 1-20(5)/1-30(7)
/1MG-35MCG (9)
Tier 5
TRI-ESTARYLLA ORAL TABLET
0.18/0.215/0.25 MG-35 MCG (28)
Tier 5
TRI-LEGEST FE ORAL TABLET 1-20(5)/130(7) /1MG-35MCG (9)
Tier 5
TRI-LINYAH ORAL TABLET 0.18/0.215/0.25
MG-35 MCG (28)
Tier 5
TRI-NORINYL (28) ORAL TABLET 0.5/1/0.535 MG-MCG
Tier 5
TRI-PREVIFEM (28) ORAL TABLET
0.18/0.215/0.25 MG-35 MCG (28)
Tier 5
TRI-SPRINTEC (28) ORAL TABLET
0.18/0.215/0.25 MG-35 MCG (28)
Tier 5
TRINESSA (28) ORAL TABLET
0.18/0.215/0.25 MG-35 MCG (28)
Tier 5
TRIVORA (28) ORAL TABLET 50-30 (6)/7540 (5)/125-30(10)
Tier 5
VELIVET TRIPHASIC REGIMEN (28)
ORAL TABLET 0.1/.125/.15-25 MG-MCG
Tier 5
Notes
PA
Contraceptive Transdermal Combinations
ORTHO EVRA TRANSDERMAL PATCH
WEEKLY 150-35 MCG/24 HR
Tier 5
PA
XULANE TRANSDERMAL PATCH
WEEKLY 150-35 MCG/24 HR
Tier 5
PA
Tier 5
PA
Contraceptives - Intravaginal, Systemic
NUVARING VAGINAL RING 0.12-0.015
MG/24 HR
124
Drug Name
Drug Tier
Notes
Emergency Contraceptives
ELLA ORAL TABLET 30 MG
Tier 5
levonorgestrel Oral tablet 0.75 mg, 1.5 mg
Tier 5
MY WAY ORAL TABLET 1.5 MG
Tier 5
NEXT CHOICE ONE DOSE ORAL TABLET
1.5 MG
Tier 5
PLAN B ONE-STEP ORAL TABLET 1.5 MG
Tier 5
PA
Emergency Contraceptives - Progesterone Agonist/Antagonist Type
ELLA ORAL TABLET 30 MG
Tier 5
PA
Emergency Contraceptives - Progestin Type
levonorgestrel Oral tablet 0.75 mg, 1.5 mg
Tier 5
MY WAY ORAL TABLET 1.5 MG
Tier 5
NEXT CHOICE ONE DOSE ORAL TABLET
1.5 MG
Tier 5
PLAN B ONE-STEP ORAL TABLET 1.5 MG
Tier 5
Dermatological
Acne Therapy Systemic - Retinoids & Derivatives
ABSORICA ORAL CAPSULE 10 MG, 20 MG,
30 MG, 40 MG
Tier 3
AMNESTEEM ORAL CAPSULE 10 MG, 20
MG, 40 MG
Tier 1
CLARAVIS ORAL CAPSULE 10 MG, 20 MG,
30 MG, 40 MG
Tier 1
MYORISAN ORAL CAPSULE 10 MG, 20
MG, 40 MG
Tier 1
ZENATANE ORAL CAPSULE 10 MG, 20
MG, 40 MG
Tier 1
Acne Therapy Systemic - Tetracyclines
minocycline oral tablet extended release 24 hr 135
mg, 45 mg, 90 mg
Tier 1
SOLODYN ORAL TABLET EXTENDED
MG, 80 MG
Tier 3
PA
Tier 3
PA
Acne Therapy Topical - Anti-Infective
ACZONE TOPICAL GEL 5 %
125
Drug Name
Drug Tier
AZELEX TOPICAL CREAM 20 %
Tier 3
CLEOCIN T TOPICAL GEL 1 %
Tier 3
CLEOCIN T TOPICAL LOTION 1 %
Tier 3
CLEOCIN T TOPICAL SOLUTION 1 %
Tier 3
CLEOCIN T TOPICAL SWAB 1 %
Tier 3
CLINDACIN P TOPICAL SWAB 1 %
Tier 3
CLINDAGEL TOPICAL GEL 1 %
Tier 3
clindamycin phosphate topical foam 1 %
Tier 1
clindamycin phosphate topical gel 1 %
Tier 1
clindamycin phosphate topical lotion 1 %
Tier 1
clindamycin phosphate topical solution 1 %
Tier 1
clindamycin phosphate topical swab 1 %
Tier 1
ERY PADS TOPICAL SWAB 2 %
Tier 1
erythromycin with ethanol topical gel 2 %
Tier 1
erythromycin with ethanol topical solution 2 %
Tier 1
erythromycin with ethanol topical swab 2 %
Tier 1
EVOCLIN TOPICAL FOAM 1 %
Tier 3
FINACEA TOPICAL GEL 15 %
Tier 3
KLARON TOPICAL SUSPENSION 10 %
Tier 3
METROCREAM TOPICAL CREAM 0.75 %
Tier 3
METROGEL TOPICAL GEL 1 %
Tier 3
METROLOTION TOPICAL LOTION 0.75 %
Tier 3
metronidazole topical cream 0.75 %
Tier 1
metronidazole topical gel 0.75 %, 1 %
Tier 1
metronidazole topical lotion 0.75 %
Tier 1
NORITATE TOPICAL CREAM 1 %
Tier 3
ROSADAN TOPICAL CREAM 0.75 %
Tier 1
ROSADAN TOPICAL GEL 0.75 %
Tier 3
sulfacetamide sodium (acne) topical suspension 10
%
Tier 1
Notes
PA
Acne Therapy Topical - Anti-Infective-Keratolytic Combinations
ACANYA TOPICAL GEL 1.2-2.5 %
Tier 3
PA
AVAR TOPICAL CLEANSER 10-5 % (W/W)
Tier 3
PA
126
Drug Name
Drug Tier
Notes
AVAR TOPICAL PADS, MEDICATED 9.5-5
%
Tier 3
PA
AVAR LS TOPICAL CLEANSER 10-2 %
Tier 3
PA
AVAR LS TOPICAL PADS, MEDICATED 102%
Tier 3
PA
AVAR-E LS TOPICAL CREAM 10-2 %
Tier 3
PA
BENZACLIN TOPICAL GEL 1-5 %
Tier 3
BENZACLIN PUMP TOPICAL GEL 1-5 %
Tier 3
BENZAMYCIN TOPICAL GEL 3-5 %
Tier 1
BENZAMYCINPAK TOPICAL GEL 3-5 %
Tier 3
BP 10-1 TOPICAL CLEANSER 10-1 %
Tier 1
CLARIFOAM EF TOPICAL FOAM 10-5 %
Tier 3
CLARIS CLARIFYING WASH TOPICAL
CLEANSER 10-4-10 %
Tier 3
CLEANSING WASH TOPICAL CLEANSER
10-4-10 %
Tier 1
clindamycin-benzoyl peroxide topical gel 1-5 %
Tier 1
clindamycin-benzoyl peroxide topical gel,extended
release 1.2 %(1 % base) -5 %
Tier 1
DUAC TOPICAL GEL,EXTENDED
RELEASE 1.2 %(1 % BASE) -5 %
Tier 3
erythromycin-benzoyl peroxide topical gel 3-5 %
Tier 1
NEUAC TOPICAL GEL,EXTENDED
RELEASE 1.2 %(1 % BASE) -5 %
Tier 1
PLEXION TOPICAL CLEANSER 9.8-4.8 %
Tier 3
PA
PLEXION TOPICAL CREAM 9.8-4.8 %
Tier 3
PA
PLEXION TOPICAL LOTION 9.8-4.8 %
Tier 3
PA
PLEXION CLEANSING CLOTHS TOPICAL
PADS, MEDICATED 9.8-4.8 %
Tier 3
PA
ROSANIL TOPICAL CLEANSER 10-5 %
(W/W)
Tier 3
PA
SSS 10-4 TOPICAL FOAM 10-4 %
Tier 1
SSS 10-5 TOPICAL FOAM 10-5 %
Tier 1
sulfacetamide sod-sulfur-urea topical gel 10-5-10
%
Tier 1
PA
PA
127
Drug Name
Drug Tier
sulfacetamide sodium-sulfur topical cleanser 10-2
%, 10-5 % (w/w), 9-4 %, 9-4.5 %
Tier 1
sulfacetamide sodium-sulfur topical cream 10-2 %
Tier 1
sulfacetamide sodium-sulfur topical lotion 10-5 %
(w/v)
Tier 1
sulfacetamide sodium-sulfur topical pads,
medicated 10-4 %, 10-5 %
Tier 1
sulfacetamide sodium-sulfur topical suspension 84%
Tier 1
SUMADAN TOPICAL CLEANSER 9-4.5 %
Tier 3
SUMAXIN TOPICAL CLEANSER 9-4 %
Tier 3
SUMAXIN TOPICAL PADS, MEDICATED
10-4 %
Tier 3
SUMAXIN TS TOPICAL SUSPENSION 8-4 %
Tier 3
ZENCIA TOPICAL CLEANSER 9-4 %
Tier 3
Notes
PA
Acne Therapy Topical - Anti-Infective-Retinoid Combinations
VELTIN TOPICAL GEL 1.2-0.025 %
Tier 3
PA
ZIANA TOPICAL GEL 1.2-0.025 %
Tier 3
PA
Acne Therapy Topical - Keratolytic
BENZAC AC WASH TOPICAL CLEANSER
10 %
Tier 3
BENZEFOAM TOPICAL FOAM 5.3 %
Tier 3
BENZEFOAM ULTRA TOPICAL FOAM 9.8
%
Tier 3
BENZEPRO TOPICAL FOAM 5.3 %, 9.8 %
Tier 1
benzoyl peroxide topical cleanser 6 %, 7 %
Tier 1
benzoyl peroxide topical foam 5.3 %
Tier 1
benzoyl peroxide topical gel 10 %, 5 %
Tier 1
BP FOAM TOPICAL FOAM 5.3 %, 9.8 %
Tier 1
BP WASH TOPICAL CLEANSER 10 %, 2.5
%, 5 %
Tier 3
BPO TOPICAL GEL 4 %, 8 %
Tier 1
BPO TOPICAL TOWELETTE 3 %, 6 %, 9 %
Tier 1
PACNEX TOPICAL CLEANSER 7 %
Tier 3
PACNEX MX TOPICAL CLEANSER 4.25 %
Tier 3
128
Drug Name
RIAX TOPICAL FOAM 5.5 %, 9.5 %
Drug Tier
Notes
Tier 3
PA
Tier 3
PA
Acne Therapy Topical - Keratolytic Mixtures
NUOX TOPICAL GEL 6-3 %
Acne Therapy Topical - Keratolytic-Glucocorticoid Combinations
VANOXIDE-HC TOPICAL SUSPENSION 50.5 %
Tier 3
PA
Acne Therapy Topical - Retinoid Combinations Other
EPIDUO TOPICAL GEL 0.1-2.5 %
Tier 3
PA
EPIDUO TOPICAL GEL WITH PUMP 0.1-2.5
%
Tier 3
PA
Acne Therapy Topical - Retinoids & Derivatives
adapalene topical cream 0.1 %
Tier 1
adapalene topical gel 0.1 %, 0.3 %
Tier 1
ATRALIN TOPICAL GEL 0.05 %
Tier 3
PA; AR
AVITA TOPICAL CREAM 0.025 %
Tier 1
PA (PA required for 25 years and
older); AR
AVITA TOPICAL GEL 0.025 %
Tier 1
older); AR
DIFFERIN TOPICAL CREAM 0.1 %
Tier 3
DIFFERIN TOPICAL GEL 0.1 %, 0.3 %
Tier 3
DIFFERIN TOPICAL LOTION 0.1 %
Tier 3
FABIOR TOPICAL FOAM 0.1 %
Tier 3
RETIN-A TOPICAL CREAM 0.025 %, 0.05
%, 0.1 %
Tier 3
older); AR
RETIN-A TOPICAL GEL 0.01 %, 0.025 %
Tier 3
older); AR
RETIN-A MICRO TOPICAL GEL 0.04 %, 0.1
%
Tier 3
older); AR
RETIN-A MICRO PUMP TOPICAL GEL 0.04
%, 0.1 %
Tier 3
older); AR
RETIN-A MICRO PUMP TOPICAL GEL 0.08
%
Tier 3
older); AR
TRETIN-X TOPICAL CREAM 0.0375 %,
0.075 %
Tier 3
PA; AR
tretinoin topical cream 0.025 %, 0.05 %, 0.1 %
Tier 1
older); AR
PA
129
Drug Name
Drug Tier
Notes
tretinoin topical gel 0.01 %, 0.025 %
Tier 1
older); AR
tretinoin microsphere topical gel 0.04 %, 0.1 %
Tier 1
older); AR
Antipsoriatic - Vitamin D Analog - Glucocorticoid Combinations
calcipotriene-betamethasone topical ointment
0.005-0.064 %
Tier 1
QL (100 GM per 7 days)
TACLONEX TOPICAL OINTMENT 0.0050.064 %
Tier 3
TACLONEX TOPICAL SUSPENSION 0.0050.064 %
Tier 3
Antipsoriatic Agents - Mc Antibody, Human Interleukin 12/23 Inhibitors
STELARA SUBCUTANEOUS SYRINGE 45
MG/0.5 ML, 90 MG/ML
Tier 6
PA; 30D
Dermatological - Antibacterial & Antifungal Agents
ALOQUIN TOPICAL GEL 1.25-1 %
Tier 3
Dermatological - Antibacterial Aminoglycosides
gentamicin topical cream 0.1 %
Tier 1
gentamicin topical ointment 0.1 %
Tier 1
Dermatological - Antibacterial Erythromycins
AKNE-MYCIN TOPICAL OINTMENT 2 %
Tier 3
Dermatological - Antibacterial Other
BACTROBAN TOPICAL CREAM 2 %
Tier 3
BACTROBAN TOPICAL OINTMENT 2 %
Tier 3
CENTANY TOPICAL OINTMENT 2 %
Tier 3
mupirocin topical ointment 2 %
Tier 1
mupirocin calcium topical cream 2 %
Tier 1
silver nitrate topical ointment 10 %
Tier 1
silver nitrate topical solution 0.5 %, 10 %, 25 %,
50 %
Tier 1
Dermatological - Antibacterial Pleuromutilin Derivatives
ALTABAX TOPICAL OINTMENT 1 %
Tier 3
PA
Tier 3
PA
Dermatological - Antibacterial Sulfonamides
AVAR-E TOPICAL CREAM 10-5 % (W/W)
130
Drug Name
AVAR-E GREEN TOPICAL CREAM 10-5 %
(W/W)
Drug Tier
Tier 3
Notes
PA
Dermatological - Antibacterial,Antifungal Agent With Glucocorticoid
ALA-QUIN TOPICAL CREAM 3-0.5 %
Tier 3
ALCORTIN A TOPICAL GEL IN PACKET 21-1 %
Tier 3
VYTONE TOPICAL CREAM IN PACKET
1.9-1 %
Tier 1
Dermatological - Antibacterial-Glucocorticoid Combinations
CORTISPORIN TOPICAL CREAM 3.510,000-0.5 MG/G-UNIT/G-%
Tier 2
CORTISPORIN TOPICAL OINTMENT 1 %
Tier 2
NEO-SYNALAR TOPICAL CREAM 0.5-0.025
%
Tier 3
Dermatological - Antifungal Allylamines
NAFTIN TOPICAL CREAM 1 %, 2 %
Tier 3
PA
NAFTIN TOPICAL GEL 1 %
Tier 3
PA
NAFTIN TOPICAL GEL 2 %
Tier 3
Dermatological - Antifungal Amphoteric Polyene Macrolides
NYAMYC TOPICAL POWDER 100,000
UNIT/GRAM
Tier 1
nystatin topical cream 100,000 unit/gram
Tier 1
nystatin topical ointment 100,000 unit/gram
Tier 1
nystatin topical powder 100,000 unit/gram
Tier 1
NYSTOP TOPICAL POWDER 100,000
UNIT/GRAM
Tier 1
PEDI-DRI TOPICAL POWDER 100,000
UNIT/GRAM
Tier 1
Dermatological - Antifungal Benzylamines
MENTAX TOPICAL CREAM 1 %
Tier 3
PA
Dermatological - Antifungal Combinations Other
EXODERM TOPICAL LOTION 25-1 %
Tier 1
Dermatological - Antifungal Hydroxypyridinone
CICLODAN TOPICAL CREAM 0.77 %
Tier 3
131
Drug Name
Drug Tier
CICLODAN TOPICAL SOLUTION 8 %
Tier 3
ciclopirox topical cream 0.77 %
Tier 1
ciclopirox topical gel 0.77 %
Tier 1
ciclopirox topical shampoo 1 %
Tier 1
ciclopirox topical solution 8 %
Tier 1
ciclopirox topical suspension 0.77 %
Tier 1
ciclopirox-ure-camph-menth-euc topical solution 8
%
Tier 1
LOPROX TOPICAL GEL 0.77 %
Tier 3
LOPROX TOPICAL SHAMPOO 1 %
Tier 3
PENLAC TOPICAL SOLUTION 8 %
Tier 3
Notes
Dermatological - Antifungal Imidazole & Related Agents
clotrimazole topical cream 1 %
Tier 1
clotrimazole topical solution 1 %
Tier 1
econazole topical cream 1 %
Tier 1
ECOZA TOPICAL FOAM 1%
Tier 3
PA
ERTACZO TOPICAL CREAM 2 %
Tier 3
PA
EXELDERM TOPICAL CREAM 1 %
Tier 3
PA
EXELDERM TOPICAL SOLUTION 1 %
Tier 3
PA
EXTINA TOPICAL FOAM 2 %
Tier 3
ketoconazole topical cream 2 %
Tier 1
ketoconazole topical shampoo 2 %
Tier 1
KETODAN TOPICAL FOAM 2 %
Tier 3
LUZU TOPICAL CREAM 1%
Tier 3
NIZORAL TOPICAL SHAMPOO 2 %
Tier 3
OXISTAT TOPICAL CREAM 1 %
Tier 3
PA
OXISTAT TOPICAL LOTION 1 %
Tier 3
PA
VUSION TOPICAL OINTMENT 0.25-15-81.35
%
Tier 3
PA
XOLEGEL TOPICAL GEL 2 %
Tier 3
PA
Tier 3
PA
PA
Dermatological - Antifungal Oxaborole
KERYDIN TOPICAL SOLUTION WITH
APPLICATOR 5 %
Dermatological - Antifungal Triazole
132
Drug Name
Drug Tier
JUBLIA TOPICAL SOLUTION WITH
APPLICATOR 10 %
Tier 3
Notes
PA
Dermatological - Antifungal-Glucocorticoid Combinations
clotrimazole-betamethasone topical cream 1-0.05
%
Tier 1
clotrimazole-betamethasone topical lotion 1-0.05
%
Tier 1
DERMAZENE TOPICAL CREAM 1-1 %
Tier 1
iodoquinol-HC topical cream 1-1 %
Tier 1
LOTRISONE TOPICAL CREAM 1-0.05 %
Tier 3
nystatin-triamcinolone topical cream 100,000-0.1
unit/g-%
Tier 1
nystatin-triamcinolone topical ointment 100,0000.1 unit/gram-%
Tier 1
Dermatological - Antineoplastic Alkylating Agents
VALCHLOR TOPICAL GEL 0.016 %
Tier 4
Dermatological - Antineoplastic Antimetabolites
CARAC TOPICAL CREAM 0.5 %
Tier 3
EFUDEX TOPICAL CREAM 5 %
Tier 3
FLUOROPLEX TOPICAL CREAM 1 %
Tier 2
fluorouracil topical cream 5 %
Tier 1
fluorouracil topical solution 2 %, 5 %
Tier 1
Dermatological - Antineoplastic Or Premalig. Lesions -Diterpene Esters
PICATO TOPICAL GEL 0.015 %, 0.05 %
Tier 3
Dermatological - Antineoplastic Or Premalignant Lesions - Nsaid's
diclofenac sodium topical gel 3 %
Tier 1
PA
SOLARAZE TOPICAL GEL 3 %
Tier 3
PA
Dermatological - Antineoplastic Retinoids
PANRETIN TOPICAL GEL 0.1 %
Tier 2
Dermatological - Antineoplastic Selective Retinoid X Receptor Agonist
TARGRETIN TOPICAL GEL 1 %
Tier 2
Dermatological - Antiperspirants
DRYSOL DAB-O-MATIC TOPICAL
SOLUTION 20 %
Tier 3
133
Drug Name
Drug Tier
HYPERCARE TOPICAL SOLUTION 20 %
Tier 1
XERAC AC TOPICAL SOLUTION 6.25 %
Tier 3
Notes
Dermatological - Antipsoriatic Agents Systemic, Photosensitizing
8-MOP ORAL CAPSULE 10 MG
Tier 3
OXSORALEN ULTRA ORAL CAPSULE 10
MG
Tier 4
Dermatological - Antipsoriatic Agents Systemic, Vitamin A Derivatives
acitretin Oral capsule 10 mg, 17.5 mg, 25 mg
Tier 1
SORIATANE ORAL CAPSULE 10 MG, 17.5
MG, 25 MG
Tier 3
Dermatological - Antipsoriatic Agents Topical
calcipotriene topical cream 0.005 %
Tier 1
calcipotriene topical ointment 0.005 %
Tier 1
calcipotriene topical solution 0.005 %
Tier 1
CALCITRENE TOPICAL OINTMENT 0.005
%
Tier 1
calcitriol topical ointment 3 mcg/gram
Tier 3
DOVONEX TOPICAL CREAM 0.005 %
Tier 3
DRITHOCREME HP TOPICAL CREAM 1 %
Tier 3
SORILUX TOPICAL FOAM 0.005 %
Tier 3
TAZORAC TOPICAL CREAM 0.05 %, 0.1 %
Tier 3
TAZORAC TOPICAL GEL 0.05 %, 0.1 %
Tier 3
VECTICAL TOPICAL OINTMENT 3
MCG/GRAM
Tier 3
ZITHRANOL TOPICAL SHAMPOO 1 %
Tier 3
ZITHRANOL-RR TOPICAL CREAM, RAPID
RELEASE 1.2 %
Tier 3
Dermatological - Antiseborrheic
LOUTREX TOPICAL CREAM
Tier 1
OVACE PLUS TOPICAL CREAM 10 %
Tier 3
PA
OVACE PLUS SHAMPOO TOPICAL
SHAMPOO 10 %
Tier 3
PA
OVACE PLUS WASH TOPICAL
CLEANSER,GEL EXTENDED RELEASE 10
%
Tier 3
134
Drug Name
Drug Tier
PROMISEB TOPICAL CREAM
Tier 3
SEB-PREV TOPICAL CLEANSER 10 %
Tier 1
selenium sulfide topical shampoo 2.25 %
Tier 1
selenium sulfide topical suspension 2.5 %
Tier 1
SELRX TOPICAL SHAMPOO 2.3 %
Tier 2
sulfacetamide sodium topical cleanser 10 %
Tier 1
sulfacetamide sodium topical shampoo 10 %
Tier 1
TERSI FOAM TOPICAL FOAM 2.25 %
Tier 3
TL TRISEB (WITH TELMESTEINE)
TOPICAL CREAM
Tier 3
Notes
PA
Dermatological - Antiseborrheic Combinations
sulfacetamide sodium-urea topical pads,
medicated 10-10 %
Tier 1
Dermatological - Antiviral, Herpes
acyclovir topical ointment 5 %
Tier 1
DENAVIR TOPICAL CREAM 1 %
Tier 3
ZOVIRAX TOPICAL CREAM 5 %
Tier 2
ZOVIRAX TOPICAL OINTMENT 5 %
Tier 3
Dermatological - Antiviral-Glucocorticoid Combinations
XERESE TOPICAL CREAM 5-1 %
Tier 3
Dermatological - Burn Products Anti-Infective
mafenide acetate topical packet 50 gram
Tier 1
SILVADENE TOPICAL CREAM 1 %
Tier 3
SSD TOPICAL CREAM 1 %
Tier 1
SULFAMYLON TOPICAL CREAM 85 MG/G
Tier 3
SULFAMYLON TOPICAL PACKET 50
GRAM
Tier 3
THERMAZENE TOPICAL CREAM 1 %
Tier 3
Dermatological - Calcineurin Inhibitors
ELIDEL TOPICAL CREAM 1 %
Tier 2
PROTOPIC TOPICAL OINTMENT 0.03 %,
0.1 %
Tier 3
PA
Dermatological - Depigmenting Agents
135
Drug Name
LUSTRA TOPICAL CREAM 4 %
Drug Tier
Tier 3
Dermatological - Emollient Mixtures
ATOPICLAIR TOPICAL CREAM
Tier 3
ELETONE TOPICAL CREAM
Tier 3
HPR TOPICAL FOAM
Tier 3
HPR PLUS TOPICAL CREAM
Tier 3
HPR PLUS TOPICAL FOAM
Tier 3
HYLATOPIC TOPICAL FOAM
Tier 3
HYLATOPIC PLUS TOPICAL CREAM
Tier 3
HYLATOPIC PLUS TOPICAL FOAM
Tier 3
LOUTREX TOPICAL CREAM
Tier 1
NEOSALUS TOPICAL CREAM
Tier 3
NEOSALUS TOPICAL FOAM
Tier 3
NEOSALUS TOPICAL LOTION
Tier 3
NIVATOPIC PLUS TOPICAL CREAM
Tier 1
PRESERA TOPICAL FOAM
Tier 3
PROMISEB TOPICAL CREAM
Tier 3
PRUCLAIR TOPICAL CREAM
Tier 3
PRUMYX TOPICAL CREAM
Tier 3
TL TRISEB (WITH TELMESTEINE)
TOPICAL CREAM
Tier 3
Dermatological - Emollients
ALUVEA TOPICAL CREAM 39 %
Tier 3
ammonium lactate topical cream 12 %
Tier 1
ammonium lactate topical lotion 12 %
Tier 1
GORDONS UREA TOPICAL OINTMENT 40
%
Tier 3
LAC-HYDRIN TOPICAL CREAM 12 %
Tier 3
LAC-HYDRIN TOPICAL LOTION 12 %
Tier 3
lactic acid topical lotion 10 %
Tier 1
LACTIC ACID E TOPICAL CREAM 10 %
Tier 1
urea topical cream 39 %
Tier 1
urea topical gel 40 %
Tier 1
136
Notes
Drug Name
Drug Tier
X-VIATE TOPICAL GEL 40 %
Notes
Tier 3
Dermatological - Enzyme Combinations Other
GRANULEX TOPICAL AEROSOL,SPRAY
0.12-87 MG/GRAM
Tier 3
VASOLEX TOPICAL OINTMENT 90-87-788
UNIT-MG-MG/GRAM
Tier 1
PA
Dermatological - Enzymes
SANTYL TOPICAL OINTMENT 250
UNIT/GRAM
Tier 3
Dermatological - Glucocorticoid
ALA-CORT TOPICAL CREAM 1 %
Tier 1
ALA-SCALP TOPICAL LOTION 2 %
Tier 3
alclometasone topical cream 0.05 %
Tier 1
alclometasone topical ointment 0.05 %
Tier 1
amcinonide topical cream 0.1 %
Tier 1
amcinonide topical lotion 0.1 %
Tier 1
amcinonide topical ointment 0.1 %
Tier 1
APEXICON E TOPICAL CREAM 0.05 %
Tier 2
betamethasone dipropionate topical cream 0.05 %
Tier 1
betamethasone dipropionate topical lotion 0.05 %
Tier 1
betamethasone dipropionate topical ointment 0.05
%
Tier 1
betamethasone valerate topical cream 0.1 %
Tier 1
betamethasone valerate topical foam 0.12 %
Tier 1
betamethasone valerate topical lotion 0.1 %
Tier 1
betamethasone valerate topical ointment 0.1 %
Tier 1
betamethasone, augmented topical cream 0.05 %
Tier 1
betamethasone, augmented topical gel 0.05 %
Tier 1
betamethasone, augmented topical lotion 0.05 %
Tier 1
betamethasone, augmented topical ointment 0.05
%
Tier 1
CAPEX TOPICAL SHAMPOO 0.01 %
Tier 3
clobetasol topical cream 0.05 %
Tier 1
clobetasol topical foam 0.05 %
Tier 1
PA
PA
137
Drug Name
Drug Tier
Notes
clobetasol topical gel 0.05 %
Tier 1
clobetasol topical lotion 0.05 %
Tier 1
clobetasol topical ointment 0.05 %
Tier 1
clobetasol topical shampoo 0.05 %
Tier 1
clobetasol topical solution 0.05 %
Tier 1
clobetasol-emollient topical cream 0.05 %
Tier 1
clobetasol-emollient topical foam 0.05 %
Tier 1
CLOBEX TOPICAL LOTION 0.05 %
Tier 3
CLOBEX TOPICAL SHAMPOO 0.05 %
Tier 3
CLOBEX TOPICAL SPRAY,NON-AEROSOL
0.05 %
Tier 3
clocortolone pivalate topical cream 0.1 %
Tier 1
CLODAN TOPICAL SHAMPOO 0.05 %
Tier 3
CLODERM TOPICAL CREAM 0.1 %
Tier 3
CORDRAN TOPICAL CREAM 0.05 %
Tier 3
PA
CORDRAN TOPICAL LOTION 0.05 %
Tier 3
PA
CORDRAN TAPE LARGE ROLL TOPICAL
TAPE 4 MCG/CM2
Tier 2
CORDRAN TAPE SMALL ROLL TOPICAL
TAPE 4 MCG/CM2
Tier 2
CORMAX TOPICAL SOLUTION 0.05 %
Tier 1
CUTIVATE TOPICAL CREAM 0.05 %
Tier 3
CUTIVATE TOPICAL LOTION 0.05 %
Tier 3
DERMA-SMOOTHE/FS BODY OIL
TOPICAL OIL 0.01 %
Tier 3
DERMA-SMOOTHE/FS SCALP OIL
TOPICAL OIL 0.01 %
Tier 3
DERMATOP TOPICAL CREAM 0.1 %
Tier 3
DERMATOP TOPICAL OINTMENT 0.1 %
Tier 3
DESONATE TOPICAL GEL 0.05 %
Tier 3
desonide topical cream 0.05 %
Tier 1
desonide topical lotion 0.05 %
Tier 1
desonide topical ointment 0.05 %
Tier 1
DESOWEN TOPICAL CREAM 0.05 %
Tier 3
DESOWEN TOPICAL LOTION 0.05 %
Tier 3
138
PA
PA
PA
PA
Drug Name
Drug Tier
desoximetasone topical cream 0.05 %, 0.25 %
Tier 1
desoximetasone topical gel 0.05 %
Tier 1
desoximetasone topical ointment 0.05 %, 0.25 %
Tier 1
diflorasone topical cream 0.05 %
Tier 1
diflorasone topical ointment 0.05 %
Tier 1
DIPROLENE TOPICAL LOTION 0.05 %
Tier 3
DIPROLENE TOPICAL OINTMENT 0.05 %
Tier 3
DIPROLENE AF TOPICAL CREAM 0.05 %
Tier 3
ELOCON TOPICAL CREAM 0.1 %
Tier 3
ELOCON TOPICAL OINTMENT 0.1 %
Tier 3
ELOCON TOPICAL SOLUTION 0.1 %
Tier 3
FIRST-HYDROCORTISONE TOPICAL GEL
10 %
Tier 3
fluocinolone topical cream 0.01 %, 0.025 %
Tier 1
fluocinolone topical oil 0.01 %
Tier 1
fluocinolone topical ointment 0.025 %
Tier 1
fluocinolone topical solution 0.01 %
Tier 1
fluocinolone-shower cap topical oil 0.01 %
Tier 1
fluocinonide topical cream 0.05 %, 0.1 %
Tier 1
fluocinonide topical gel 0.05 %
Tier 1
fluocinonide topical ointment 0.05 %
Tier 1
fluocinonide topical solution 0.05 %
Tier 1
fluticasone topical cream 0.05 %
Tier 1
fluticasone topical lotion 0.05 %
Tier 1
fluticasone topical ointment 0.005 %
Tier 1
halobetasol propionate topical cream 0.05 %
Tier 1
halobetasol propionate topical ointment 0.05 %
Tier 1
HALOG TOPICAL CREAM 0.1 %
Tier 2
HALOG TOPICAL OINTMENT 0.1 %
Tier 2
hydrocortisone topical cream 1 %, 2.5 %
Tier 1
hydrocortisone topical lotion 1 %, 2.5 %
Tier 1
hydrocortisone topical ointment 1 %, 2.5 %
Tier 1
hydrocortisone butyrate topical cream 0.1 %
Tier 1
Notes
PA
139
Drug Name
Drug Tier
Notes
hydrocortisone butyrate topical ointment 0.1 %
Tier 1
hydrocortisone butyrate topical solution 0.1 %
Tier 1
hydrocortisone valerate topical cream 0.2 %
Tier 1
hydrocortisone valerate topical ointment 0.2 %
Tier 1
hydrocortisone-pramoxine topical cream 2.5-1 %
Tier 1
KENALOG TOPICAL AEROSOL 0.147
MG/GRAM
Tier 3
PA
LOCOID TOPICAL LOTION 0.1 %
Tier 3
PA
LOCOID TOPICAL OINTMENT 0.1 %
Tier 3
LOCOID TOPICAL SOLUTION 0.1 %
Tier 3
LOCOID LIPOCREAM TOPICAL CREAM
0.1 %
Tier 3
LUXIQ TOPICAL FOAM 0.12 %
Tier 3
mometasone topical cream 0.1 %
Tier 1
mometasone topical ointment 0.1 %
Tier 1
mometasone topical solution 0.1 %
Tier 1
OLUX-E TOPICAL FOAM 0.05 %
Tier 3
PANDEL TOPICAL CREAM 0.1 %
Tier 3
prednicarbate topical cream 0.1 %
Tier 1
prednicarbate topical ointment 0.1 %
Tier 1
SCALACORT TOPICAL LOTION 2 %
Tier 3
SYNALAR TOPICAL CREAM 0.025 %
Tier 3
SYNALAR TOPICAL OINTMENT 0.025 %
Tier 3
SYNALAR TOPICAL SOLUTION 0.01 %
Tier 3
TEMOVATE TOPICAL CREAM 0.05 %
Tier 3
TEMOVATE TOPICAL OINTMENT 0.05 %
Tier 3
TEXACORT TOPICAL SOLUTION 2.5 %
Tier 3
TOPICORT TOPICAL CREAM 0.05 %, 0.25
%
Tier 3
TOPICORT TOPICAL GEL 0.05 %
Tier 3
TOPICORT TOPICAL OINTMENT 0.05 %,
0.25 %
Tier 3
TOPICORT TOPICAL SPRAY,NONAEROSOL 0.25 %
Tier 3
140
PA
PA
PA
Drug Name
Drug Tier
triamcinolone acetonide topical cream 0.025 %,
0.1 %, 0.5 %
Tier 1
triamcinolone acetonide topical lotion 0.025 %,
0.1 %
Tier 1
triamcinolone acetonide topical ointment 0.025 %,
0.1 %, 0.5 %
Tier 1
TRIANEX TOPICAL OINTMENT 0.05 %
Tier 3
TRIDERM TOPICAL CREAM 0.1 %
Tier 1
ULTRAVATE TOPICAL CREAM 0.05 %
Tier 3
ULTRAVATE TOPICAL OINTMENT 0.05 %
Tier 3
VANOS TOPICAL CREAM 0.1 %
Tier 3
VERDESO TOPICAL FOAM 0.05 %
Tier 3
Notes
PA
Dermatological - Glucocorticoid-Emollient Combinations
fluocinolone topical cream 0.025 %
Tier 1
hydrocortisone acet-aloe vera topical gel 2 %
Tier 1
NUCORT TOPICAL LOTION 2 %
Tier 3
U-CORT TOPICAL CREAM 1-10 %
Tier 1
Dermatological - Glucocorticoid-Local Anesthetic Combinations
EPIFOAM TOPICAL FOAM 1-1 %
Tier 3
hydrocortisone-pramoxine topical cream 2.5-1 %
Tier 1
NOVACORT TOPICAL GEL 2-1-1 %
Tier 3
PRAMOSONE TOPICAL CREAM 1-1 %
Tier 3
PRAMOSONE TOPICAL CREAM 2.5-1 %
Tier 3
PA
PRAMOSONE TOPICAL LOTION 1-1 %, 2.51%
Tier 3
PA
PRAMOSONE TOPICAL OINTMENT 1-1 %,
2.5-1 %
Tier 3
PA
PRAMOSONE E TOPICAL CREAM 2.5-1 %
Tier 3
PA
Dermatological - Immunomodulator - Catechins - Genital Wart/Hpv Tx
VEREGEN TOPICAL OINTMENT 15 %
Tier 3
Dermatological - Immunomodulator - Imidazoquinolinamines
ALDARA TOPICAL CREAM IN PACKET 5
%
Tier 3
imiquimod topical cream in packet 5 %
Tier 1
141
Drug Name
Drug Tier
Notes
ZYCLARA TOPICAL CREAM IN
METERED-DOSE PUMP 2.5 %
Tier 3
PA
ZYCLARA TOPICAL CREAM IN PACKET
3.75 %
Tier 3
PA
Dermatological - Immunomodulator - Interferons
ALFERON N INJECTION SOLUTION 5
MILLION UNIT/ML
Tier 6
30D
Dermatological - Keratolytic-Antimitotic Combinations
salicylic acid-ammon lact-aloe topical foam 6 %
Tier 3
SALKERA TOPICAL FOAM 6 %
Tier 3
SALVAX DUO PLUS TOPICAL FOAM 6-35
%
Tier 3
silver nitrate applicators topical stick 75-25 %
Tier 3
PA
Dermatological - Keratolytic-Antimitotic Single Agents
BENSAL HP TOPICAL OINTMENT 3 %
Tier 3
BP-50% UREA TOPICAL EMULSION 50 %
Tier 1
CEM-UREA TOPICAL GEL 45 %
Tier 1
CONDYLOX TOPICAL GEL 0.5 %
Tier 3
CONDYLOX TOPICAL SOLUTION 0.5 %
Tier 3
HYDRO 35 TOPICAL FOAM 35 %
Tier 3
HYDRO 40 TOPICAL FOAM 40 %
Tier 3
KERAFOAM TOPICAL FOAM 30 %, 42 %
Tier 3
KERALAC TOPICAL CREAM 47 %
Tier 3
KERALYT RX TOPICAL GEL 6 %
Tier 3
LATRIX XM TOPICAL EMULSION IN
METERED-DOSE PUMP 45 %
Tier 3
PODOCON TOPICAL LIQUID 25 %
Tier 1
podofilox topical solution 0.5 %
Tier 1
REMEVEN TOPICAL CREAM 50 %
Tier 1
SALACYN TOPICAL CREAM 6 %
Tier 3
SALACYN TOPICAL LOTION 6 %
Tier 1
SALEX TOPICAL SHAMPOO 6 %
Tier 3
salicylic acid topical cream 6 %
Tier 1
salicylic acid topical foam 6 %
Tier 1
142
PA
Drug Name
Drug Tier
salicylic acid topical gel 6 %
Tier 1
salicylic acid topical shampoo 6 %
Tier 1
SALVAX TOPICAL FOAM 6 %
Tier 1
TRI-CHLOR TOPICAL SOLUTION 80 %
Tier 3
UMECTA TOPICAL EMULSION 40 %
Tier 3
UMECTA TOPICAL FOAM 40 %
Tier 3
UMECTA PD TOPICAL EMULSION,
ADHESIVE 40 %
Tier 3
URAMAXIN TOPICAL CREAM 45 %
Tier 3
URAMAXIN TOPICAL FOAM 20 %
Tier 3
URAMAXIN TOPICAL GEL 45 %
Tier 3
URAMAXIN TOPICAL LOTION 45 %
Tier 3
URAMAXIN GT TOPICAL GEL 45 %
Tier 3
urea topical cream 40 %, 45 %, 50 %
Tier 1
urea topical foam 35 %
Tier 1
urea topical gel 45 %
Tier 1
urea topical lotion 40 %, 45 %
Tier 1
UREA NAIL STICK TOPICAL SOLUTION
50 %
Tier 3
UTOPIC TOPICAL CREAM 41 %
Tier 3
VIRASAL TOPICAL FILM FORMING
LIQUID W/APPL 27.5 %
Tier 3
X-VIATE TOPICAL CREAM 40 %
Tier 1
X-VIATE TOPICAL LOTION 40 %
Tier 1
Notes
PA
PA
Dermatological - Local Anesthetic Combinations
ELENZAPATCH TOPICAL ADHESIVE
PATCH,MEDICATED 4-1 %
Tier 3
EMLA TOPICAL CREAM 2.5-2.5 %
Tier 3
lidocaine-prilocaine topical cream 2.5-2.5 %
Tier 1
lidocaine-prilocaine topical kit 2.5-2.5 %
Tier 1
Dermatological - Local Anesthetic Gas Combinations
PAIN EASE TOPICAL AEROSOL,SPRAY
Tier 3
SPRAY AND STRETCH TOPICAL
AEROSOL,SPRAY
Tier 3
143
Drug Name
Drug Tier
Notes
Dermatological - Local Anesthetic Gas Single Agents
ethyl chloride topical aerosol,spray 100 %
Tier 1
Dermatological - Miscellaneous Single Agents
PYROGALLIC ACID TOPICAL OINTMENT
25-2 %
Tier 3
Dermatological - Nsaid Single Agents
diclofenac sodium topical drops 1.5 %
Tier 1
FLECTOR TRANSDERMAL PATCH 12
HOUR 1.3 %
Tier 3
NAPRO CREAM 15 %
Tier 3
PENNSAID TOPICAL DROPS 1.5 %
Tier 3
VOLTAREN TOPICAL GEL 1 %
Tier 3
PA
PA
Dermatological - Photodynamic Therapy Agents Topical
LEVULAN TOPICAL SOLUTION 20 %
Tier 3
Dermatological - Pigmenting Agents
OXSORALEN TOPICAL LOTION 1 %
Tier 3
Dermatological - Pigmenting, Photosensitizing Agents
OXSORALEN TOPICAL LOTION 1 %
Tier 3
Dermatological - Protectants
sodium hyaluronate topical gel 0.2 %
Tier 3
PA
Dermatological - Retinoids (Vitamin A Derivatives) - Topical Cosmetic
tretinoin (emollient) topical cream 0.05 %
Tier 1
older); AR
Tier 3
PA
Dermatological - Rosacea Therapy, Systemic
ORACEA ORAL CAPSULE, ER
Dermatological - Rosacea Therapy, Topical
AZELEX TOPICAL CREAM 20 %
Tier 3
CLARIS CLARIFYING WASH TOPICAL
CLEANSER 10-4-10 %
Tier 3
CLEANSING WASH TOPICAL CLEANSER
10-4-10 %
Tier 1
FINACEA TOPICAL GEL 15 %
Tier 3
MIRVASO TOPICAL GEL 0.33 %
Tier 3
144
Drug Name
sulfacetamide sod-sulfur-urea topical gel 10-5-10
%
Drug Tier
Notes
Tier 1
Dermatological - Tissue/Wound Adhesives - Fibrin Sealants
ARTISS TOPICAL SYRINGE 2.5-6.5
UNIT/ML (2 ML)
Tier 3
Dermatological - Topical Local Anesthetic Amides
lidocaine topical adhesive patch,medicated 5
%(700 mg/patch)
Tier 1
lidocaine topical ointment 5 %
Tier 1
lidocaine HCl mucous membrane gel 2 %
Tier 1
lidocaine HCl mucous membrane jelly in
applicator 2 %
Tier 1
lidocaine HCl topical cream 3 %
Tier 1
lidocaine HCl topical lotion 3 %
Tier 1
LIDODERM TOPICAL ADHESIVE
PATCH,MEDICATED 5 %(700 MG/PATCH)
Tier 3
LIDORX TOPICAL GEL WITH PUMP 3 %
Tier 3
PLIAGLIS TOPICAL CREAM 7-7 %
Tier 3
REGENECARE WITH ALOE TOPICAL GEL
2%
Tier 3
SYNERA TOPICAL PATCH, MEDICATED
SELF-HEATING 70-70 MG
Tier 3
Dermatological - Topical Local Anesthetic Esters
ANACAINE TOPICAL OINTMENT 10 %
Tier 3
PONTOCAINE TOPICAL SOLUTION 2 %
Tier 3
Dermatological Antipruritics - Antihistamines
PRUDOXIN TOPICAL CREAM 5 %
Tier 3
ZONALON TOPICAL CREAM 5 %
Tier 3
Dermatological Antipruritics Other
PRUDOXIN TOPICAL CREAM 5 %
Tier 3
ZONALON TOPICAL CREAM 5 %
Tier 3
PA
Hair Growth Agents - Type Ii 5-Alpha Reductase Inhibitors
PROPECIA ORAL TABLET 1 MG
Tier 3
Scabicide & Pediculicide Single Agents
145
Drug Name
Drug Tier
ELIMITE TOPICAL CREAM 5 %
Tier 3
EURAX TOPICAL CREAM 10 %
Tier 3
EURAX TOPICAL LOTION 10 %
Tier 3
lindane topical lotion 1 %
Tier 1
lindane topical shampoo 1 %
Tier 1
malathion topical lotion 0.5 %
Tier 1
NATROBA TOPICAL SUSPENSION 0.9 %
Tier 3
OVIDE TOPICAL LOTION 0.5 %
Tier 3
permethrin topical cream 5 %
Tier 1
SKLICE TOPICAL LOTION 0.5 %
Tier 3
spinosad topical suspension 0.9 %
Tier 3
ULESFIA TOPICAL LOTION 5 %
Tier 3
Notes
Wound Care - Growth Factor Agents
REGRANEX TOPICAL GEL 0.01 %
Tier 3
Wound Care Combinations Other
VENELEX TOPICAL OINTMENT 87-788
MG/GRAM
Tier 3
Diagnostic Agents
Diagnostic Drugs - Biliary
IC GREEN INJECTION INJECTABLE 25
MG
Tier 6
30D
indocyanine green injection injectable 25 mg
Tier 6
30D
Tier 6
30D
Diagnostic Drugs - Thyroid Function
THYROGEN INTRAMUSCULAR RECON
SOLN 1.1 MG
Drugs To Treat Erectile Dysfunction
Erectile Dysfunction (Ed) Drugs-Sel.Cgmp Phosphodiesterase Type5 Inhib
CIALIS ORAL TABLET 2.5 MG, 5 MG
Tier 2
PA
Tier 3
PA
Eating Disorder Therapy
Anorexiant Combinations
QSYMIA ORAL CAPSULE, ER
MULTIPHASE 24 HR 11.25-69 MG, 15-92
MG, 3.75-23 MG, 7.5-46 MG
146
Drug Name
Drug Tier
Notes
Anorexiants
ADIPEX-P ORAL CAPSULE 37.5 MG
Tier 3
PA
ADIPEX-P ORAL TABLET 37.5 MG
Tier 3
PA
benzphetamine Oral tablet 50 mg
Tier 1
PA
BONTRIL PDM ORAL TABLET 35 MG
Tier 3
PA
DIDREX ORAL TABLET 50 MG
Tier 3
diethylpropion Oral tablet 25 mg
Tier 1
PA
diethylpropion Oral tablet extended release 75 mg
Tier 1
PA
phendimetrazine tartrate Oral capsule, extended
release 105 mg
Tier 1
PA
phendimetrazine tartrate oral tablet 35 mg
Tier 1
PA
phentermine Oral capsule 15 mg, 30 mg, 37.5 mg
Tier 1
PA
phentermine oral tablet 37.5 mg
Tier 1
PA
REGIMEX ORAL TABLET 25 MG
Tier 3
PA
SUPRENZA ORAL
37.5 MG
Tier 3
PA
Anti-Obesity - Fat Absorption Decreasing Agents
XENICAL ORAL CAPSULE 120 MG
Tier 3
PA
Tier 3
PA
Anti-Obesity - Serotonin 2C Receptor Agonists
BELVIQ ORAL TABLET 10 MG
Appetite Stimulants
MEGACE ORAL SUSPENSION 400 MG/10
ML (40 MG/ML)
Tier 3
MEGACE ES ORAL SUSPENSION 625 MG/5
ML
Tier 3
megestrol oral suspension 400 mg/10 mL (40
mg/mL)
Tier 1
Appetite Stimulants - Progestin Hormone Type
MEGACE ORAL SUSPENSION 400 MG/10
ML (40 MG/ML)
Tier 3
MEGACE ES ORAL SUSPENSION 625 MG/5
ML
Tier 3
megestrol oral suspension 400 mg/10 mL (40
mg/mL)
Tier 1
147
Drug Name
Drug Tier
Notes
Electrolyte Balance-Nutritional Products
Amino Acids, Single Ingredient, Oral (Non-Injectable)
NUTRESTORE ORAL POWDER IN
PACKET 5 GRAM
Tier 3
B-Complex Vitamin Combinations
DIALYVITE ORAL TABLET 100-1 MG
Tier 3
FOLBEE PLUS ORAL TABLET 5 MG
Tier 1
LYSIPLEX PLUS ORAL TABLET
Tier 3
NEPHROCAPS ORAL CAPSULE 1 MG
Tier 3
NEPHROCAPS QT ORAL
TABLET,DISINTEGRATING 1-1,750 MGUNIT
Tier 3
RENO CAPS ORAL CAPSULE 1 MG
Tier 1
VIRT-VITE PLUS ORAL TABLET 5 MG
Tier 1
B-Complex Vitamins And Combinations
NEPHRO-VITE RX ORAL TABLET 1-60-300
MG-MG-MCG
Tier 3
RENA-VITE RX ORAL TABLET 1-60-300
MG-MG-MCG
Tier 1
VOL-CARE RX ORAL TABLET 1-60-300
MG-MG-MCG
Tier 1
Dietary Product - Dietary Supplements
NICAZEL ORAL TABLET 600-5-10-5-1.5 MG
Tier 3
NICAZEL FORTE ORAL TABLET 700-500-812 MG-MCG-MG-MG
Tier 3
VP-ZEL ORAL TABLET 600-5-10-5-1.5 MG
Tier 1
Electrolyte Depleters - Ion Exchange Resin
KAYEXALATE ORAL POWDER
Tier 3
KIONEX ORAL POWDER
Tier 1
KIONEX ORAL SUSPENSION 15 GRAM/60
ML
Tier 1
sodium polystyrene sulfonate oral powder
Tier 1
sodium polystyrene sulfonate oral suspension 15
gram/60 mL
Tier 1
sodium polystyrene sulfonate rectal enema 30
gram/120 mL
Tier 1
148
PA
Drug Name
Drug Tier
SPS ORAL SUSPENSION 15 GRAM/60 ML
Notes
Tier 1
Geriatric Vitamins
REQ49+ ORAL TABLET 200-1.5-1.5 MCGMG-MG
Tier 3
Irrigation Solutions
PHYSIOLYTE IRRIGATION SOLUTION
140-5-3-98 MEQ/L
Tier 3
PHYSIOSOL IRRIGATION IRRIGATION
SOLUTION 140-5-3-98 MEQ/L
Tier 3
Minerals & Electrolytes - Calcium Replacement
calcium acetate Oral tablet 667 mg
Tier 1
Minerals & Electrolytes - Calcium Replacement Combinations
FOLGARD OS ORAL TABLET 500-1.1 MG
Tier 3
Minerals & Electrolytes - Electrolytes & Dextrose
NORMOSOL-R IN 5 % DEXTROSE
INTRAVENOUS PARENTERAL SOLUTION
5%
Tier 6
Minerals & Electrolytes - Iron
DEXFERRUM INTRAVENOUS SOLUTION
50 MG/ML (1 ML)
Tier 6
30D
FERAHEME INTRAVENOUS SOLUTION
510 MG/17 ML (30 MG/ML)
Tier 6
30D
FERRLECIT INTRAVENOUS SOLUTION
62.5 MG/5 ML
Tier 6
30D
INFED INJECTION SOLUTION 100 MG/2
ML (50 MG/ML)
Tier 6
30D
Minerals & Electrolytes - Iron Combinations
BIFERA RX ORAL TABLET 22-6-1-25 MGMG-MG-MCG
Tier 3
FERIVA ORAL CAPSULE,EXT RELEASE
MULTIPHASE 75 MG IRON- 1 MG-175 MG
Tier 6
FEROTRINSIC ORAL CAPSULE 110-0.5 MG
Tier 1
FERRALET 90 DUAL-IRON DELIVERY
ORAL TABLET 90-1-12-50 MG-MG-MCGMG
Tier 3
30D
149
Drug Name
Drug Tier
FERRAPLUS 90 ORAL TABLET 90-1-12-12050 MG-MG-MCG-MG-MG
Tier 1
FERROGELS FORTE ORAL CAPSULE 46060-0.01-1 MG
Tier 1
FOLIVANE-F ORAL CAPSULE 125-1-40-3
MG
Tier 3
HEMATINIC/FOLIC ACID ORAL TABLET
324 MG (106 MG IRON)-1 MG
Tier 1
HEMATOGEN FA ORAL CAPSULE 200-2500.01-1 MG
Tier 1
HEMATOGEN FORTE ORAL CAPSULE
460-60-0.01-1 MG
Tier 1
HEMATRON-AF ORAL TABLET
EXTENDED RELEASE 24 HR 150-1-50 MG
Tier 3
HEMAX ORAL TABLET EXTENDED
RELEASE 24 HR 150-1-50 MG
Tier 3
HEMOCYTE-F ORAL TABLET 324 MG (106
MG IRON)-1 MG
Tier 3
HEMOCYTE-PLUS ORAL CAPSULE 106
MG IRON- 1 MG
Tier 3
IFEREX 150 FORTE ORAL CAPSULE 15025-1 MG-MCG-MG
Tier 1
INTEGRA F ORAL CAPSULE 125-1-40-3 MG
Tier 3
INTEGRA PLUS ORAL CAPSULE 125-1 MG
Tier 3
IROSPAN 24/6 ORAL TABLET 65 MG-65
MG -1,000 MCG (24)
Tier 3
NOVAFERRUM ORAL RECON SOLN 100-160 MG/5 ML
Tier 3
POLY-IRON 150 FORTE ORAL CAPSULE
150-25-1 MG-MCG-MG
Tier 1
SIDEROL ORAL TABLET
Tier 3
Minerals & Electrolytes - Phosphate
K-PHOS-NEUTRAL ORAL TABLET 250 MG
Tier 3
PHOSPHA 250 NEUTRAL ORAL TABLET
250 MG
Tier 1
Minerals & Electrolytes - Potassium Combinations
potassium bicarb & chloride Oral tablet,
effervescent 25 mEq
150
Tier 1
Notes
PA
Drug Name
Drug Tier
Notes
Minerals & Electrolytes - Potassium, Oral
EFFER-K ORAL TABLET, EFFERVESCENT
10 MEQ, 20 MEQ
Tier 3
EFFER-K ORAL TABLET, EFFERVESCENT
25 MEQ
Tier 1
K-EFFERVESCENT ORAL TABLET,
EFFERVESCENT 25 MEQ
Tier 1
K-TAB ORAL TABLET EXTENDED
RELEASE 10 MEQ, 20 MEQ
Tier 3
KLOR-CON ORAL PACKET 20 MEQ
Tier 2
KLOR-CON ORAL TABLET EXTENDED
RELEASE 8 MEQ
Tier 1
KLOR-CON 10 ORAL TABLET EXTENDED
RELEASE 10 MEQ
Tier 1
KLOR-CON M15 ORAL TABLET,ER
PARTICLES/CRYSTALS 15 MEQ
Tier 2
KLOR-CON M20 ORAL TABLET,ER
PARTICLES/CRYSTALS 20 MEQ
Tier 1
KLOR-CON/EF ORAL TABLET,
EFFERVESCENT 25 MEQ
Tier 1
potassium bicarb-citric acid oral tablet,
effervescent 25 mEq
Tier 1
potassium chloride oral capsule, extended release
10 mEq, 8 mEq
Tier 1
potassium chloride oral liquid 10 %, 20 %
Tier 1
potassium chloride oral packet 20 mEq
Tier 1
potassium chloride Oral tablet extended release 10
mEq, 8 mEq
Tier 1
potassium chloride oral tablet,ER
particles/crystals 20 mEq
Tier 1
Minerals & Electrolytes - Zinc
zinc sulfate oral capsule 220 (50) mg
Tier 1
Multiple Vitamins And Mineral Combinations
B-PLEX PLUS ORAL TABLET 27-0.8 MG
Tier 1
BACMIN ORAL TABLET 27-1 MG
Tier 3
CORVITE FREE ORAL TABLET 1.25-400125-35 MG-MCG-MCG-MG
Tier 3
151
Drug Name
Drug Tier
ELDERCAPS ORAL CAPSULE 1 MG
Tier 3
NICOMIDE ORAL TABLET 500-750-1.5-25
MCG-MG-MG-MG
Tier 3
NUTRICAP ORAL TABLET 1 MG
Tier 3
PROTECT PLUS ORAL LIQUID
Tier 3
REQ49+ ORAL TABLET 200-1.5-1.5 MCGMG-MG
Tier 3
STROVITE FORTE ORAL TABLET 10-1 MG
Tier 3
STROVITE ONE ORAL TABLET 1-1,000-155 MG-UNIT-MG-MG
Tier 3
V-C FORTE ORAL CAPSULE 1 MG
Tier 1
VIC-FORTE ORAL CAPSULE 1 MG
Tier 3
Notes
PA
Multivitamins
ANIMI-3 WITH VITAMIN D ORAL
CAPSULE 500-1,000-500 MG-UNIT-MCG
Tier 3
FORTAVIT ORAL CAPSULE
Tier 3
PUREVIT DUALFE PLUS ORAL CAPSULE
162-115.2-1 MG
Tier 3
TANDEM PLUS ORAL CAPSULE 162-115.2-1
MG
Tier 3
Nutritional Product - Medical Condition Specific Formulation
PACKET 5 GRAM
Tier 3
Parenteral Nutrition - Intravenous Fat Emulsions
LIPOSYN III INTRAVENOUS EMULSION 30
%
Tier 5
Prenatal Vitamins And Minerals
PRENAPLUS ORAL TABLET 27-1 MG
Tier 3
VINATE DHA ORAL CAPSULE 27-400-1.13250 MG-MCG-MG-MG
Tier 3
Ringer's And Lactated Ringer's Solutions
lactated ringers intravenous parenteral solution
Tier 6
Vitamins - B Preparation Combinations
FOLGARD RX ORAL TABLET 2.2-25-1 MG
Tier 3
NEURIN-SL SUBLINGUAL TABLET,
SUBLINGUAL 600-600 MCG
152
Tier 3
Drug Name
Drug Tier
Notes
Vitamins - B-12 And Folic Acid Combinations
FOLTRATE ORAL TABLET 0.5-1 MG
Tier 3
Vitamins - B-12, Cyanocobalamin And Derivatives
cyanocobalamin (vitamin B-12) injection solution
1,000 mcg/mL
Tier 6
NASCOBAL NASAL SPRAY,NON-AEROSOL
500 MCG/SPRAY
Tier 3
NEURIN-SL SUBLINGUAL TABLET,
SUBLINGUAL 600-600 MCG
Tier 3
30D
Vitamins - D Derivatives
calcitriol Oral capsule 0.25 mcg, 0.5 mcg
Tier 1
calcitriol oral solution 1 mcg/mL
Tier 1
DRISDOL ORAL CAPSULE 50,000 UNIT
Tier 5
PA (covered for age 66 and older)
ergocalciferol (vitamin D2) oral capsule 50,000
unit
Tier 5
ROCALTROL ORAL CAPSULE 0.25 MCG,
0.5 MCG
Tier 3
ROCALTROL ORAL SOLUTION 1 MCG/ML
Tier 3
VITAMIN D2 ORAL CAPSULE 50,000 UNIT
Tier 5
Vitamins - Folic Acid And Derivatives
folic acid oral tablet 1 mg
Tier 5
Vitamins - Folic Acid Combinations
FOLGARD RX ORAL TABLET 2.2-25-1 MG
Tier 3
Vitamins - K, Phytonadione And Derivatives
MEPHYTON ORAL TABLET 5 MG
Tier 2
phytonadione (bulk) liquid 100 %
Tier 1
Vitamins - Paba
POTABA ORAL CAPSULE 500 MG
Tier 3
Endocrine
Abortifacients Or Cervical Ripening Agents - Prostaglandin Analogs
CERVIDIL VAGINAL INSERT, EXTENDED
RELEASE 10 MG
Tier 3
PREPIDIL VAGINAL GEL 0.5 MG/3 G
Tier 3
153
Drug Name
PROSTIN E2 VAGINAL SUPPOSITORY 20
MG
Drug Tier
Notes
Tier 3
Abortifacients- Progesterone Receptor Antagonist
MIFEPREX ORAL TABLET 200 MG
Tier 3
Adrenocorticotrophic Hormones
ACTHAR H.P. INJECTION GEL 80
UNIT/ML
Tier 4
Agents To Treat Hypoglycemia (Hyperglycemics)
GLUCAGEN HYPOKIT INJECTION RECON
SOLN 1 MG
Tier 2
GLUCAGON EMERGENCY INJECTION
KIT 1 MG
Tier 2
glucose oral tablet,chewable 4 gram
Tier 1
PROGLYCEM ORAL SUSPENSION 50
MG/ML
Tier 3
Anabolic Steroid - Single Agents
ANADROL-50 ORAL TABLET 50 MG
Tier 3
OXANDRIN ORAL TABLET 10 MG, 2.5 MG
Tier 3
oxandrolone Oral tablet 10 mg, 2.5 mg
Tier 1
Androgen - Single Agents
ANDRODERM TRANSDERMAL PATCH 24
HOUR 2 MG/24 HOUR, 4 MG/24 HR
Tier 3
ANDROGEL TRANSDERMAL GEL IN
METERED-DOSE PUMP 20.25 MG/1.25
GRAM (1.62 %)
Tier 2
ANDROGEL TRANSDERMAL GEL IN
PACKET 1 % (50 MG/5 GRAM)
Tier 2
ANDROID ORAL CAPSULE 10 MG
Tier 2
ANDROXY ORAL TABLET 10 MG
Tier 1
AXIRON TRANSDERMAL SOLUTION IN
METERED PUMP W/APP 30
MG/ACTUATION (1.5 ML)
Tier 3
DELATESTRYL INTRAMUSCULAR OIL
200 MG/ML
Tier 3
DEPO-TESTOSTERONE INTRAMUSCULAR
OIL 100 MG/ML, 200 MG/ML
Tier 3
154
PA
PA
Drug Name
Drug Tier
Notes
FORTESTA TRANSDERMAL GEL IN
METERED-DOSE PUMP 10 MG/0.5 GRAM
/ACTUATION
Tier 3
PA
METHITEST ORAL TABLET 10 MG
Tier 3
PA
methyltestosterone Oral tablet 10 mg
Tier 1
STRIANT BUCCAL MUCOADHESIVE
SYSTEM ER 12 HR 30 MG
Tier 3
TESTIM TRANSDERMAL GEL 50 MG/5
GRAM (1 %)
Tier 3
TESTOPEL IMPLANT PELLET 75 MG
Tier 6
PA
testosterone transdermal gel 50 mg/5 gram (1 %)
Tier 1
PA
testosterone transdermal gel in metered-dose
pump 1.25 gram/ actuation (1 %)
Tier 1
testosterone transdermal gel in packet 1 % (50
mg/5 gram)
Tier 1
testosterone cypionate intramuscular oil 100
mg/mL, 200 mg/mL
Tier 4
testosterone enanthate intramuscular oil 200
mg/mL
Tier 4
TESTRED ORAL CAPSULE 10 MG
Tier 3
VOGELXO TRANSDERMAL GEL 50 MG/5
GRAM (1 %)
Tier 3
VOGELXO TRANSDERMAL GEL IN
METERED-DOSE PUMP 1.25 GRAM/
ACTUATION (1 %)
Tier 3
VOGELXO TRANSDERMAL GEL IN
PACKET 1 % (50 MG/5 GRAM)
Tier 3
PA
PA
Antidiuretic And Vasopressor Hormones
DDAVP INJECTION SOLUTION 4 MCG/ML
Tier 3
DDAVP NASAL AEROSOL,SPRAY 10
MCG/SPRAY
Tier 3
DDAVP NASAL SOLUTION 0.1 MG/ML
(REFRIG)
Tier 3
DDAVP ORAL TABLET 0.1 MG, 0.2 MG
Tier 3
desmopressin nasal solution 0.1 mg/mL (Refrig)
Tier 1
desmopressin nasal spray,non-aerosol 10
mcg/spray (0.1 mL)
Tier 1
155
Drug Name
Drug Tier
desmopressin oral tablet 0.1 mg, 0.2 mg
Tier 1
PITRESSIN INJECTION SOLUTION 20
UNIT/ML
Tier 3
STIMATE NASAL SPRAY,NON-AEROSOL
150 MCG/SPRAY
Tier 3
Notes
Antihyperglycemic - Alpha-Glucosidase Inhibitors
acarbose oral tablet 100 mg, 25 mg, 50 mg
Tier 1
GLYSET ORAL TABLET 100 MG, 25 MG, 50
MG
Tier 3
PRECOSE ORAL TABLET 100 MG, 25 MG,
50 MG
Tier 3
Antihyperglycemic - Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors
JANUVIA ORAL TABLET 100 MG, 25 MG,
50 MG
Tier 3
NESINA ORAL TABLET 12.5 MG, 25 MG,
6.25 MG
Tier 3
ONGLYZA ORAL TABLET 2.5 MG, 5 MG
Tier 3
TRADJENTA ORAL TABLET 5 MG
Tier 2
Antihyperglycemic - Dopamine Receptor Agonists
CYCLOSET ORAL TABLET 0.8 MG
Tier 3
Antihyperglycemic - Glucocorticoid (Cortisol) Receptor Blocker (Gr-Ii)
KORLYM ORAL TABLET 300 MG
Tier 4
Antihyperglycemic - Meglitinide Analog And Biguanide Combinations
PRANDIMET ORAL TABLET 1-500 MG, 2500 MG
Tier 3
Antihyperglycemic - Meglitinide Analogs
nateglinide Oral tablet 120 mg, 60 mg
Tier 1
PRANDIN ORAL TABLET 0.5 MG, 1 MG, 2
MG
Tier 3
repaglinide oral tablet 0.5 mg, 1 mg, 2 mg
Tier 1
STARLIX ORAL TABLET 120 MG, 60 MG
Tier 3
Antihyperglycemic - Sodium Glucose Cotransporter-2 (Sglt2) Inhibitors
INVOKANA ORAL TABLET 100 MG, 300
MG
Tier 3
Antihyperglycemic - Sulfonylurea And Biguanide Combinations
156
Drug Name
Drug Tier
Notes
glipizide-metformin oral tablet 2.5-250 mg, 2.5500 mg, 5-500 mg
Tier 1
GLUCOVANCE ORAL TABLET 2.5-500 MG,
5-500 MG
Tier 3
older); AR
glyburide-metformin oral tablet 1.25-250 mg, 2.5500 mg, 5-500 mg
Tier 1
older); AR
Antihyperglycemic - Sulfonylurea Derivatives
AMARYL ORAL TABLET 1 MG, 2 MG, 4
MG
Tier 3
chlorpropamide Oral tablet 100 mg, 250 mg
Tier 1
older); AR
DIABETA ORAL TABLET 1.25 MG, 2.5 MG,
5 MG
Tier 3
older); AR
glimepiride oral tablet 1 mg, 2 mg, 4 mg
Tier 1
glipizide oral tablet 10 mg, 5 mg
Tier 1
glipizide Oral tablet extended release 24hr 10 mg,
2.5 mg, 5 mg
Tier 1
GLUCOTROL ORAL TABLET 10 MG, 5 MG
Tier 3
GLUCOTROL XL ORAL TABLET
EXTENDED RELEASE 24HR 10 MG, 2.5 MG,
5 MG
Tier 3
glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg
Tier 1
older); AR
glyburide micronized Oral tablet 1.5 mg, 3 mg, 6
mg
Tier 1
older); AR
GLYNASE ORAL TABLET 1.5 MG, 3 MG, 6
MG
Tier 3
older); AR
tolazamide Oral tablet 250 mg, 500 mg
Tier 1
tolbutamide Oral tablet 500 mg
Tier 1
Antihyperglycemic - Thiazolidinedione And Biguanide Combinations
ACTOPLUS MET ORAL TABLET 15-500
MG, 15-850 MG
Tier 3
ACTOPLUS MET XR ORAL TABLET, ER
MULTIPHASE 24 HR 15-1,000 MG, 30-1,000
MG
Tier 3
AVANDAMET ORAL TABLET 2-1,000 MG,
2-500 MG, 4-500 MG
Tier 3
157
Drug Name
pioglitazone-metformin Oral tablet 15-500 mg, 15850 mg
Drug Tier
Notes
Tier 1
Antihyperglycemic - Thiazolidinedione And Sulfonylurea Combinations
AVANDARYL ORAL TABLET 4-1 MG, 4-2
MG, 4-4 MG, 8-4 MG
Tier 3
DUETACT ORAL TABLET 30-2 MG, 30-4
MG
Tier 3
pioglitazone-glimepiride Oral tablet 30-2 mg, 30-4
mg
Tier 1
Antihyperglycemic, Amylin Analog-Type
SYMLINPEN 120 SUBCUTANEOUS PEN
INJECTOR 2,700 MCG/2.7 ML
Tier 2
SYMLINPEN 60 SUBCUTANEOUS PEN
INJECTOR 1,500 MCG/1.5 ML
Tier 2
Antihyperglycemic, Incretin Mimetic,Glp-1 Receptor Agonist Analog-Type
BYDUREON SUBCUTANEOUS
MG
Tier 2
BYETTA SUBCUTANEOUS PEN INJECTOR
10 MCG/0.04 ML, 5 MCG/0.02 ML
Tier 2
TANZEUM SUBCUTANEOUS PEN
INJECTOR 30 MG/0.5 ML, 50 MG/0.5 ML
Tier 3
VICTOZA 3-PAK SUBCUTANEOUS PEN
INJECTOR 0.6 MG/0.1 ML (18 MG/3 ML)
Tier 2
Antihyperglycemic-Dipeptidyl Peptidase-4 (Dpp-4) Inhibitor & Biguanide
JANUMET ORAL TABLET 50-1,000 MG, 50500 MG
Tier 3
PA
JANUMET XR ORAL TABLET, ER
MULTIPHASE 24 HR 100-1,000 MG, 50-1,000
MG, 50-500 MG
Tier 3
PA
JENTADUETO ORAL TABLET 2.5-1,000
MG, 2.5-500 MG, 2.5-850 MG
Tier 2
KAZANO ORAL TABLET 12.5-1,000 MG,
12.5-500 MG
Tier 3
PA
KOMBIGLYZE XR ORAL TABLET, ER
MULTIPHASE 24 HR 2.5-1,000 MG, 5-1,000
MG, 5-500 MG
Tier 3
PA
Antihyperglycemic-Dipeptidyl Peptidase-4 Inhibitor & Thiazolidinedione
158
Drug Name
OSENI ORAL TABLET 12.5-15 MG, 12.5-30
MG, 12.5-45 MG, 25-15 MG, 25-30 MG, 25-45
MG
Drug Tier
Tier 3
Notes
PA
Antithyroid Agents, Thionamides - Imidazole Derivatives
methimazole Oral tablet 10 mg, 5 mg
Tier 1
TAPAZOLE ORAL TABLET 10 MG, 5 MG
Tier 3
Antithyroid Agents, Thionamides - Thiouracil Derivatives
propylthiouracil oral tablet 50 mg
Tier 1
Bone Formation Stimulating Agents - Parathyroid Hormone-Type
FORTEO SUBCUTANEOUS PEN INJECTOR
20 MCG/DOSE - 600 MCG/2.4 ML
Tier 4
Bone Resorption Inhibitors - Bisphosphonate And Vitamin D Combinations
FOSAMAX PLUS D ORAL TABLET 70-2,800
MG-UNIT, 70-5,600 MG-UNIT
Tier 3
Bone Resorption Inhibitors - Bisphosphonates
ACTONEL ORAL TABLET 150 MG
Tier 3
ACTONEL ORAL TABLET 30 MG, 35 MG, 5
MG
Tier 2
alendronate oral solution 70 mg/75 mL
Tier 1
alendronate Oral tablet 10 mg, 35 mg, 40 mg, 5
mg, 70 mg
Tier 1
ATELVIA ORAL TABLET,DELAYED
Tier 3
BINOSTO ORAL TABLET,
EFFERVESCENT 70 MG
Tier 3
BONIVA INTRAVENOUS SYRINGE 3 MG/3
ML
Tier 4
BONIVA ORAL TABLET 150 MG
Tier 3
etidronate disodium Oral tablet 200 mg, 400 mg
Tier 1
FOSAMAX ORAL TABLET 70 MG
Tier 3
ibandronate intravenous solution 3 mg/3 mL
Tier 3
ibandronate oral tablet 150 mg
Tier 1
pamidronate intravenous recon soln 90 mg
Tier 6
30D
pamidronate intravenous solution 30 mg/10 mL (3
mg/mL), 60 mg/10 mL (6 mg/mL)
Tier 6
30D
159
Drug Name
Drug Tier
Notes
RECLAST INTRAVENOUS SOLUTION 5
MG/100 ML
Tier 6
PA; 30D
risedronate oral tablet 150 mg
Tier 1
zoledronic acid intravenous solution 4 mg/5 mL
Tier 6
30D
zoledronic acid-mannitol-water intravenous
solution 5 mg/100 mL
Tier 6
30D
ZOMETA INTRAVENOUS SOLUTION 4
MG/5 ML
Tier 6
30D
Calcimimetic, Parathyroid Calcium Receptor Sensitivity Enhancer
SENSIPAR ORAL TABLET 30 MG
Tier 3
SENSIPAR ORAL TABLET 60 MG, 90 MG
Tier 4
Calcitonins
calcitonin (salmon) nasal spray,non-aerosol 200
unit/actuation
Tier 1
FORTICAL NASAL SPRAY,NON-AEROSOL
200 UNIT/ACTUATION
Tier 3
MIACALCIN NASAL SPRAY,NONAEROSOL 200 UNIT/ACTUATION
Tier 3
Estrogen & Progestin With Antimineralocorticoid Activity, Combinations
Tier 5
PA
COVARYX ORAL TABLET 1.25-2.5 MG
Tier 1
older); AR
COVARYX H.S. ORAL TABLET 0.625-1.25
MG
Tier 1
older); AR
EEMT ORAL TABLET 1.25-2.5 MG
Tier 1
older); AR
EEMT HS ORAL TABLET 0.625-1.25 MG
Tier 1
older); AR
estrogens-methyltestosterone oral tablet 0.6251.25 mg, 1.25-2.5 mg
Tier 1
older); AR
ACTIVELLA ORAL TABLET 0.5-0.1 MG, 10.5 MG
Tier 3
older)
CLIMARA PRO TRANSDERMAL PATCH
WEEKLY 0.045-0.015 MG/24 HR
Tier 3
older); AR
ANGELIQ ORAL TABLET 0.25-0.5 MG, 0.5-1
MG
Estrogen-Androgen
Estrogen-Progestin
160
Drug Name
Drug Tier
Notes
COMBIPATCH TRANSDERMAL PATCH
SEMIWEEKLY 0.05-0.14 MG/24 HR, 0.05-0.25
MG/24 HR
Tier 2
older); AR
estradiol-norethindrone acet oral tablet 0.5-0.1
mg, 1-0.5 mg
Tier 1
older)
FEMHRT LOW DOSE ORAL TABLET 0.52.5 MG-MCG
Tier 3
JINTELI ORAL TABLET 1-5 MG-MCG
Tier 1
MIMVEY ORAL TABLET 1-0.5 MG
Tier 1
older)
MIMVEY LO ORAL TABLET 0.5-0.1 MG
Tier 1
older)
PREFEST ORAL TABLET 1/1-0.09 MG
(15/15)
Tier 3
PREMPHASE ORAL TABLET 0.625 MG (14)/
0.625MG-5MG(14)
Tier 2
older); AR
PREMPRO ORAL TABLET 0.3-1.5 MG, 0.451.5 MG, 0.625-2.5 MG, 0.625-5 MG
Tier 2
older); AR
ALORA TRANSDERMAL PATCH
SEMIWEEKLY 0.025 MG/24 HR, 0.05 MG/24
HR, 0.075 MG/24 HR, 0.1 MG/24 HR
Tier 2
older); AR
CENESTIN ORAL TABLET 0.3 MG, 0.45
MG, 0.625 MG, 0.9 MG
Tier 3
older); AR
CENESTIN ORAL TABLET 1.25 MG
Tier 3
older)
CLIMARA TRANSDERMAL PATCH
WEEKLY 0.025 MG/24 HR, 0.0375 MG/24 HR,
0.05 MG/24 HR, 0.06 MG/24 HR, 0.075 MG/24
HR, 0.1 MG/24 HR
Tier 3
older); AR
DELESTROGEN INTRAMUSCULAR OIL 10
MG/ML, 20 MG/ML, 40 MG/ML
Tier 6
30D
DEPO-ESTRADIOL INTRAMUSCULAR OIL
5 MG/ML
Tier 6
30D
DIVIGEL TRANSDERMAL GEL IN
PACKET 0.5 (0.1) MG (%)
Tier 3
ELESTRIN TRANSDERMAL GEL IN
METERED-DOSE PUMP 0.87
GRAM/ACTUATION
Tier 3
Estrogens
161
Drug Name
Drug Tier
Notes
ENJUVIA ORAL TABLET 0.3 MG, 0.45 MG,
0.625 MG, 0.9 MG, 1.25 MG
Tier 3
older); AR
ESTRACE ORAL TABLET 0.5 MG, 1 MG, 2
MG
Tier 3
older); AR
estradiol Oral tablet 0.5 mg, 1 mg, 2 mg
Tier 1
older); AR
estradiol transdermal patch weekly 0.025 mg/24
hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.06 mg/24
hr, 0.075 mg/24 hr, 0.1 mg/24 hr
Tier 1
older); AR
estradiol valerate intramuscular oil 10 mg/mL, 20
mg/mL, 40 mg/mL
Tier 6
30D
ESTROGEL TRANSDERMAL GEL IN
METERED-DOSE PUMP 1.25
GRAM/ACTUATION
Tier 3
estropipate Oral tablet 0.75 mg, 1.5 mg, 3 mg
Tier 1
EVAMIST TRANSDERMAL SPRAY,NONAEROSOL 1.53 MG/SPRAY (1.7%)
Tier 3
MENEST ORAL TABLET 0.3 MG, 0.625 MG,
1.25 MG, 2.5 MG
Tier 3
older); AR
MENOSTAR TRANSDERMAL PATCH
WEEKLY 14 MCG/24 HR
Tier 3
older); AR
MINIVELLE TRANSDERMAL PATCH
SEMIWEEKLY 0.0375 MG/24 HR, 0.05
MG/24 HR, 0.075 MG/24 HR, 0.1 MG/24 HR
Tier 3
older); AR
OGEN 2.5 ORAL TABLET 3 MG
Tier 3
older); AR
PREMARIN ORAL TABLET 0.3 MG, 0.45
MG, 0.625 MG, 0.9 MG, 1.25 MG
Tier 2
older); AR
VIVELLE-DOT TRANSDERMAL PATCH
SEMIWEEKLY 0.025 MG/24 HR, 0.0375
MG/24 HR, 0.05 MG/24 HR, 0.075 MG/24 HR,
0.1 MG/24 HR
Tier 2
older); AR
MENOPUR SUBCUTANEOUS RECON SOLN
75 UNIT
Tier 4
PA
REPRONEX INJECTION RECON SOLN 75
UNIT
Tier 4
PA
older); AR
Follicle-Stimulating & Luteinizing Hormones
Follicle-Stimulating Hormone (Fsh)
162
Drug Name
Drug Tier
Notes
BRAVELLE INJECTION RECON SOLN 75
UNIT
Tier 4
PA
FOLLISTIM AQ INJECTION SOLUTION
150 UNIT/0.5 ML, 75 UNIT/0.5 ML
Tier 4
PA
FOLLISTIM AQ SUBCUTANEOUS
CARTRIDGE 300 UNIT/0.36 ML, 600
UNIT/0.72 ML, 900 UNIT/1.08 ML
Tier 4
PA
GONAL-F SUBCUTANEOUS RECON SOLN
1,050 UNIT
Tier 4
PA; 30D
GONAL-F SUBCUTANEOUS RECON SOLN
450 UNIT
Tier 4
PA
GONAL-F RFF SUBCUTANEOUS RECON
SOLN 75 UNIT
Tier 4
PA
GONAL-F RFF REDI-JECT
SUBCUTANEOUS PEN INJECTOR 300/0.5
UNIT/ML, 450/0.75 UNIT/ML, 900/1.5
UNIT/ML
Tier 4
PA
Glucocorticoids
CORTEF ORAL TABLET 10 MG, 20 MG, 5
MG
Tier 3
cortisone Oral tablet 25 mg
Tier 1
DEPO-MEDROL INJECTION SUSPENSION
20 MG/ML, 40 MG/ML, 80 MG/ML
Tier 6
dexamethasone oral elixir 0.5 mg/5 mL
Tier 1
dexamethasone oral solution 0.5 mg/5 mL
Tier 1
dexamethasone Oral tablet 0.5 mg, 0.75 mg, 1 mg,
1.5 mg, 2 mg, 4 mg, 6 mg
Tier 1
DEXAMETHASONE INTENSOL ORAL
DROPS 1 MG/ML
Tier 3
dexamethasone sodium phos (PF) injection
solution 10 mg/mL
Tier 6
dexamethasone sodium phosphate injection
solution 10 mg/mL, 4 mg/mL
Tier 6
DEXPAK 10 DAY ORAL TABLETS,DOSE
PACK 1.5 MG (35 TABS)
Tier 3
Tier 3
Tier 3
30D
163
Drug Name
Drug Tier
FLO-PRED ORAL SUSPENSION 15 MG/5
ML
Tier 3
hydrocortisone Oral tablet 10 mg, 20 mg, 5 mg
Tier 1
KENALOG INJECTION SUSPENSION 10
MG/ML, 40 MG/ML
Tier 6
MEDROL ORAL TABLET 16 MG, 32 MG, 4
MG, 8 MG
Tier 3
MEDROL ORAL TABLET 2 MG
Tier 2
MEDROL (PAK) ORAL TABLETS,DOSE
PACK 4 MG
Tier 3
methylprednisolone Oral tablet 16 mg, 32 mg, 4
mg, 8 mg
Tier 1
methylprednisolone oral tablets,dose pack 4 mg
Tier 1
methylprednisolone acetate injection suspension
40 mg/mL, 80 mg/mL
Tier 6
methylprednisolone sodium succ injection recon
soln 125 mg, 125 mg/2 mL, 40 mg, 40 mg/mL
Tier 6
MILLIPRED ORAL SOLUTION 10 MG/5 ML
Tier 3
MILLIPRED ORAL TABLET 5 MG
Tier 3
MILLIPRED DP ORAL TABLETS,DOSE
PACK 5 MG (21 TABS), 5 MG (48 TABS)
Tier 3
ORAPRED ODT ORAL
30 MG
Tier 3
PEDIAPRED ORAL SOLUTION 5 MG
BASE/5 ML (6.7 MG/5 ML)
Tier 3
prednisolone oral solution 15 mg/5 mL
Tier 1
prednisolone Oral tablet 5 mg
Tier 1
prednisolone sodium phosphate oral solution 15
mg/5 mL, 25 mg/5 mL (5 mg/mL), 5 mg base/5 mL
(6.7 mg/5 mL)
Tier 1
prednisone oral solution 5 mg/5 mL
Tier 1
prednisone Oral tablet 1 mg, 10 mg, 2.5 mg, 20
mg, 5 mg, 50 mg
Tier 1
prednisone Oral tablets,dose pack 10 mg, 5 mg
Tier 1
PREDNISONE INTENSOL ORAL
CONCENTRATE 5 MG/ML
Tier 2
164
Notes
30D
Drug Name
Drug Tier
RAYOS ORAL TABLET,DELAYED
Tier 3
SOLU-CORTEF INJECTION RECON SOLN
100 MG
Tier 6
SOLU-CORTEF (PF) INJECTION RECON
SOLN 1,000 MG/8 ML, 100 MG/2 ML, 250
MG/2 ML, 500 MG/4 ML
Tier 6
SOLU-MEDROL INJECTION RECON SOLN
125 MG/2 ML
Tier 6
SOLU-MEDROL (PF) INJECTION RECON
SOLN 125 MG/2 ML, 40 MG/ML
Tier 6
triamcinolone acetonide injection suspension 10
mg/mL, 40 mg/mL
Tier 6
VERIPRED 20 ORAL SOLUTION 20 MG/5
ML
Tier 3
Notes
PA
Gonadotropin Inhibitor Pituitary Suppressants
danazol Oral capsule 100 mg, 200 mg, 50 mg
Tier 1
Growth Hormone Receptor Antagonists
Tier 4
PA
Tier 4
PA
GENOTROPIN SUBCUTANEOUS
CARTRIDGE 12 MG/ML (36 UNIT/ML), 5
MG/ML (15 UNIT/ML)
Tier 4
PA
GENOTROPIN MINIQUICK
SUBCUTANEOUS SYRINGE 0.2 MG/0.25
ML, 0.4 MG/0.25 ML, 0.6 MG/0.25 ML, 0.8
MG/0.25 ML, 1 MG/0.25 ML, 1.2 MG/0.25 ML,
1.4 MG/0.25 ML, 1.6 MG/0.25 ML, 1.8 MG/0.25
ML, 2 MG/0.25 ML
Tier 4
PA
HUMATROPE INJECTION CARTRIDGE 12
(36 UNIT) MG, 24 (72 UNIT) MG, 6 (18 UNIT)
MG
Tier 4
PA
HUMATROPE INJECTION RECON SOLN 5
(15 UNIT) MG
Tier 4
PA
SOMAVERT SUBCUTANEOUS RECON
SOLN 10 MG, 15 MG, 20 MG
Growth Hormone Releasing Hormones (Ghrh)
EGRIFTA SUBCUTANEOUS RECON SOLN
2 MG
Growth Hormones
165
Drug Name
Drug Tier
Notes
NORDITROPIN FLEXPRO
SUBCUTANEOUS PEN INJECTOR 10
MG/1.5 ML (6.7 MG/ML), 15 MG/1.5 ML (10
MG/ML), 5 MG/1.5 ML (3.3 MG/ML)
Tier 4
PA
NORDITROPIN NORDIFLEX
SUBCUTANEOUS PEN INJECTOR 30 MG/3
ML (10 MG/ML)
Tier 4
PA
NUTROPIN AQ SUBCUTANEOUS
CARTRIDGE 10 MG/2 ML (5 MG/ML), 20
MG/2 ML (10 MG/ML)
Tier 4
PA
NUTROPIN AQ NUSPIN SUBCUTANEOUS
MG/2 ML (10 MG/ML), 5 MG/2 ML (2.5
MG/ML)
Tier 4
PA
OMNITROPE SUBCUTANEOUS
CARTRIDGE 10 MG/1.5 ML (6.7 MG/ML), 5
MG/1.5 ML (3.3 MG/ML)
Tier 4
PA
OMNITROPE SUBCUTANEOUS RECON
SOLN 5.8 MG
Tier 4
PA
SAIZEN SUBCUTANEOUS RECON SOLN 5
MG, 8.8 MG
Tier 4
PA
SAIZEN CLICK.EASY SUBCUTANEOUS
CARTRIDGE 8.8 MG/1.5 ML (FNL)
Tier 4
PA
SEROSTIM SUBCUTANEOUS RECON
Tier 4
PA
TEV-TROPIN SUBCUTANEOUS RECON
SOLN 5 MG
Tier 4
PA
ZORBTIVE SUBCUTANEOUS RECON
SOLN 8.8 MG
Tier 4
PA
NOVAREL INTRAMUSCULAR RECON
SOLN 10,000 UNIT
Tier 4
PA
OVIDREL SUBCUTANEOUS SYRINGE 250
MCG/0.5 ML
Tier 4
PA
PREGNYL INTRAMUSCULAR RECON
SOLN 10,000 UNIT
Tier 4
PA
Human Chorionic Gonadotropin (Hcg)
Human Insulins - Fixed Combinations
HUMULIN 70/30 SUBCUTANEOUS
SUSPENSION 100 UNIT/ML (70-30)
166
Tier 2
Drug Name
Drug Tier
HUMULIN 70/30 KWIKPEN
SUBCUTANEOUS INSULIN PEN 100
UNIT/ML (70-30)
Tier 2
NOVOLIN 70/30 SUBCUTANEOUS
Tier 3
Notes
PA
Human Insulins - Intermediate Acting
HUMULIN N SUBCUTANEOUS
SUSPENSION 100 UNIT/ML
Tier 2
HUMULIN N KWIKPEN SUBCUTANEOUS
INSULIN PEN 100 UNIT/ML (3 ML)
Tier 2
NOVOLIN N SUBCUTANEOUS
SUSPENSION 100 UNIT/ML
Tier 3
PA
Human Insulins - Short Acting
HUMULIN R INJECTION SOLUTION 100
UNIT/ML
Tier 2
HUMULIN R U-500 "CONCENTRATED"
SUBCUTANEOUS SOLUTION 500 UNIT/ML
Tier 2
NOVOLIN R INJECTION SOLUTION 100
UNIT/ML
Tier 3
PA
Insulin Analogs - Fixed Combinations
HUMALOG MIX 50-50 SUBCUTANEOUS
Tier 2
HUMALOG MIX 50-50 KWIKPEN
UNIT/ML (50-50)
Tier 2
HUMALOG MIX 75-25 SUBCUTANEOUS
Tier 2
HUMALOG MIX 75-25 KWIKPEN
UNIT/ML (75-25)
Tier 2
NOVOLOG MIX 70-30 SUBCUTANEOUS
SOLUTION 100 UNIT/ML (70-30)
Tier 3
PA
NOVOLOG MIX 70-30 FLEXPEN
UNIT/ML (70-30)
Tier 3
PA
Insulin Analogs - Long Acting
LANTUS SUBCUTANEOUS SOLUTION 100
UNIT/ML
Tier 2
167
Drug Name
Drug Tier
LANTUS SOLOSTAR SUBCUTANEOUS
Tier 2
LEVEMIR SUBCUTANEOUS SOLUTION
100 UNIT/ML
Tier 2
LEVEMIR FLEXPEN SUBCUTANEOUS
Tier 2
LEVEMIR FLEXTOUCH SUBCUTANEOUS
Tier 2
Notes
Insulin Analogs - Rapid Acting
APIDRA SUBCUTANEOUS SOLUTION 100
UNIT/ML
Tier 3
PA
APIDRA SOLOSTAR SUBCUTANEOUS
INSULIN PEN 100 UNIT/ML
Tier 3
PA
HUMALOG SUBCUTANEOUS CARTRIDGE
100 UNIT/ML
Tier 2
HUMALOG SUBCUTANEOUS SOLUTION
100 UNIT/ML
Tier 2
HUMALOG KWIKPEN SUBCUTANEOUS
Tier 2
NOVOLOG SUBCUTANEOUS SOLUTION
100 UNIT/ML
Tier 3
PA
NOVOLOG FLEXPEN SUBCUTANEOUS
Tier 3
PA
NOVOLOG PENFILL SUBCUTANEOUS
CARTRIDGE 100 UNIT/ML
Tier 3
PA
Insulin Response Enhancers - Biguanides
FORTAMET ORAL TABLET EXTENDED
RELEASE 24HR 1,000 MG, 500 MG
Tier 3
GLUCOPHAGE ORAL TABLET 1,000 MG,
500 MG, 850 MG
Tier 3
GLUCOPHAGE XR ORAL TABLET
MG
Tier 3
GLUMETZA ORAL TABLET,ER
GAST.RETENTION 24 HR 1,000 MG, 500 MG
Tier 3
metformin oral tablet 1,000 mg, 500 mg, 850 mg
Tier 1
metformin Oral tablet extended release 24 hr 500
mg, 750 mg
Tier 1
168
PA
Drug Name
Drug Tier
metformin Oral tablet extended release 24hr 1,000
mg
Tier 1
RIOMET ORAL SOLUTION 500 MG/5 ML
Tier 3
Notes
Insulin Response Enhancers - Thiazolidinediones (Ppar-Gamma Agonists)
ACTOS ORAL TABLET 15 MG, 30 MG, 45
MG
Tier 3
AVANDIA ORAL TABLET 2 MG, 4 MG, 8
MG
Tier 3
pioglitazone oral tablet 15 mg, 30 mg, 45 mg
Tier 1
Insulin-Like Growth Factor-1 (Igf-1)
INCRELEX SUBCUTANEOUS SOLUTION
10 MG/ML
Tier 4
PA
Lhrh (Gnrh) Agonist Analog Pit Suppres - Central Precocious Puberty
LUPRON DEPOT-PED INTRAMUSCULAR
KIT 11.25 MG, 15 MG
Tier 6
LUPRON DEPOT-PED INTRAMUSCULAR
KIT 7.5 MG (PED)
Tier 6
LUPRON DEPOT-PED (3 MONTH)
INTRAMUSCULAR SYRINGE KIT 11.25
MG, 30 MG
Tier 6
30D
Lhrh (Gnrh) Agonist Analog Pituitary Suppressants
LUPRON DEPOT INTRAMUSCULAR
SYRINGE KIT 3.75 MG
Tier 2
PA
LUPRON DEPOT (3 MONTH)
INTRAMUSCULAR SYRINGE KIT 11.25 MG
Tier 6
30D
SUPPRELIN LA IMPLANT KIT 50 MG
Tier 6
30D
SYNAREL NASAL SPRAY,NON-AEROSOL 2
MG/ML
Tier 3
VANTAS IMPLANT KIT 50 MG
Tier 6
30D
CETROTIDE SUBCUTANEOUS KIT 0.25
MG
Tier 4
PA
ganirelix subcutaneous syringe 250 mcg/0.5 mL
Tier 4
PA
Lhrh (Gnrh) Antagonists
Luteal Phase Supporting, Progesterone-Type
CRINONE VAGINAL GEL 8 %
Tier 3
ENDOMETRIN VAGINAL INSERT 100 MG
Tier 4
169
Drug Name
Drug Tier
Notes
Menopausal Symptoms Suppressant-Selective Estrogen Receptor Modulators
OSPHENA ORAL TABLET 60 MG
Tier 3
Menopausal Symptoms Suppressant-Ssri Antidepressant Type
BRISDELLE ORAL CAPSULE 7.5 MG
Tier 3
PA
Mineralocorticoids
fludrocortisone Oral tablet 0.1 mg
Tier 1
Ovulation Stimulant - Synthetic (Non-Fsh)
clomiphene citrate oral tablet 50 mg
Tier 1
SEROPHENE ORAL TABLET 50 MG
Tier 3
Oxytocic - Ergot Alkaloids
methylergonovine Oral tablet 0.2 mg
Tier 1
Progestins
AYGESTIN ORAL TABLET 5 MG
Tier 3
MAKENA INTRAMUSCULAR OIL 250
MG/ML
Tier 6
medroxyprogesterone Oral tablet 10 mg, 2.5 mg, 5
mg
Tier 1
norethindrone acetate Oral tablet 5 mg
Tier 1
PROGESTERONE IN OIL
INTRAMUSCULAR OIL 50 MG/ML
Tier 3
progesterone micronized oral capsule 100 mg, 200
mg
Tier 1
PROMETRIUM ORAL CAPSULE 100 MG,
200 MG
Tier 3
PROVERA ORAL TABLET 10 MG, 2.5 MG, 5
MG
Tier 3
30D
Prolactin Inhibitor - Ergot Derivative Dopamine Receptor Agonists
cabergoline oral tablet 0.5 mg
Tier 1
Rank Ligand (Rankl) Inhibitor, Mc Antibody
PROLIA SUBCUTANEOUS SYRINGE 60
MG/ML
Tier 6
30D
XGEVA SUBCUTANEOUS SOLUTION 120
MG/1.7 ML (70 MG/ML)
Tier 6
PA; 30D
Selective Estrogen Receptor Modulators (Serms)
EVISTA ORAL TABLET 60 MG
170
Tier 5
Drug Name
raloxifene oral tablet 60 mg
Drug Tier
Notes
Tier 5
Somatostatic Agents
octreotide acetate injection solution 1,000
mcg/mL, 100 mcg/mL, 200 mcg/mL, 50 mcg/mL,
500 mcg/mL
Tier 1
SANDOSTATIN INJECTION SOLUTION
1,000 MCG/ML, 100 MCG/ML, 200 MCG/ML,
50 MCG/ML, 500 MCG/ML
Tier 3
SANDOSTATIN LAR DEPOT
INTRAMUSCULAR KIT 10 MG, 20 MG, 30
MG
Tier 6
SIGNIFOR SUBCUTANEOUS SOLUTION 0.3
MG/ML (1 ML), 0.6 MG/ML (1 ML), 0.9
MG/ML (1 ML)
Tier 4
SOMATULINE DEPOT SUBCUTANEOUS
SYRINGE 120 MG/0.5 ML, 60 MG/0.2 ML, 90
MG/0.3 ML
Tier 4
30D
PA
Thyroid Hormone Combinations - Synthetic T3 And T4
THYROLAR-1 ORAL TABLET 12.5-50 MCG
Tier 2
THYROLAR-1/2 ORAL TABLET 6.25-25
MCG
Tier 2
THYROLAR-1/4 ORAL TABLET 3.1-12.5
MCG
Tier 2
THYROLAR-2 ORAL TABLET 25-100 MCG
Tier 2
THYROLAR-3 ORAL TABLET 37.5-150
MCG
Tier 2
Thyroid Hormones - Animal Source (Porcine)
ARMOUR THYROID ORAL TABLET 120
MG, 15 MG, 180 MG, 240 MG, 30 MG, 300
MG, 60 MG, 90 MG
Tier 2
older); AR
NATURE-THROID ORAL TABLET 113.75
MG, 130 MG, 146.25 MG, 16.25 MG, 162.5
MG, 195 MG, 260 MG, 32.5 MG, 325 MG,
48.75 MG, 65 MG, 81.25 MG, 97.5 MG
Tier 1
older); AR
NP THYROID ORAL TABLET 30 MG, 60
MG, 90 MG
Tier 1
older); AR
WESTHROID ORAL TABLET 130 MG, 195
MG, 32.5 MG, 65 MG, 97.5 MG
Tier 1
171
Drug Name
Drug Tier
WP THYROID ORAL TABLET 113.75 MG,
130 MG, 16.25 MG, 32.5 MG, 48.75 MG, 65
MG, 81.25 MG, 97.5 MG
Notes
Tier 1
Thyroid Hormones - Synthetic T3 (Triiodothyronine)
CYTOMEL ORAL TABLET 25 MCG, 5
MCG, 50 MCG
Tier 3
liothyronine Oral tablet 25 mcg, 5 mcg, 50 mcg
Tier 1
Thyroid Hormones - Synthetic T4 (Thyroxine)
levothyroxine Oral tablet 100 mcg, 112 mcg, 125
mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25
mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg
Tier 1
LEVOXYL ORAL TABLET 100 MCG, 112
MCG, 125 MCG, 137 MCG, 150 MCG, 175
MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG,
88 MCG
Tier 1
SYNTHROID ORAL TABLET 100 MCG, 112
MCG, 125 MCG, 137 MCG, 150 MCG, 175
75 MCG, 88 MCG
Tier 2
TIROSINT ORAL CAPSULE 100 MCG, 112
MCG, 125 MCG, 13 MCG, 137 MCG, 150
MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG
Tier 3
UNITHROID ORAL TABLET 100 MCG, 112
MCG, 125 MCG, 137 MCG, 150 MCG, 175
75 MCG, 88 MCG
Tier 1
Gastrointestinal Therapy Agents
Antidiarrheal - Antiperistaltic Agents
loperamide Oral capsule 2 mg
Tier 1
opium tincture Oral Tincture 10 mg/mL
(morphine)
Tier 1
paregoric Oral Liquid 2 mg/5 mL
Tier 1
Antidiarrheal - Gastrointestinal Chloride Channel Inhibitors
FULYZAQ ORAL TABLET,DELAYED
Tier 3
Antidiarrheal Antiperistaltic-Anticholinergic Combinations
Diphenoxylate-Atropine Oral Liquid 2.5-0.025
mg/5 mL
172
Tier 1
Drug Name
Drug Tier
diphenoxylate-atropine Oral tablet 2.5-0.025 mg
Tier 1
LOMOTIL ORAL TABLET 2.5-0.025 MG
Tier 3
MOTOFEN ORAL TABLET 1-0.025 MG
Tier 3
Notes
Antiemetic - Anticholinergics
TRANSDERM-SCOP TRANSDERMAL
PATCH 72 HOUR 1.5 MG
Tier 2
Antiemetic - Antihistamines
ANTIVERT ORAL TABLET 12.5 MG, 25 MG
Tier 3
meclizine oral tablet 12.5 mg, 25 mg
Tier 1
Antiemetic - Antihistamine-Vitamin Combinations
DICLEGIS ORAL TABLET,DELAYED
RELEASE (DR/EC) 10-10 MG
Tier 3
PA; QL (4 tabs per 1 day)
Antiemetic - Cannabinoids
CESAMET ORAL CAPSULE 1 MG
Tier 3
dronabinol Oral capsule 10 mg, 2.5 mg, 5 mg
Tier 1
MARINOL ORAL CAPSULE 10 MG, 2.5 MG,
5 MG
Tier 3
Antiemetic - Dopamine (D2)/5-Ht3 Antagonists
TIGAN ORAL CAPSULE 300 MG
Tier 3
older); AR
trimethobenzamide Oral capsule 300 mg
Tier 1
older); AR
Antiemetic - Phenothiazines
COMPAZINE ORAL TABLET 10 MG, 5 MG
Tier 3
COMPAZINE RECTAL SUPPOSITORY 25
MG
Tier 3
COMPRO RECTAL SUPPOSITORY 25 MG
Tier 1
PHENADOZ RECTAL SUPPOSITORY 12.5
MG, 25 MG
Tier 1
prochlorperazine rectal suppository 25 mg
Tier 1
prochlorperazine maleate Oral tablet 10 mg, 5 mg
Tier 1
promethazine rectal suppository 12.5 mg, 25 mg
Tier 1
older); AR
PROMETHEGAN RECTAL SUPPOSITORY
12.5 MG, 25 MG, 50 MG
Tier 1
older); AR
older); AR
173
Drug Name
Drug Tier
Notes
Antiemetic - Selective Serotonin 5-Ht3 Antagonists
ALOXI INTRAVENOUS SOLUTION 0.25
MG/5 ML
Tier 6
ANZEMET INTRAVENOUS SOLUTION 100
MG/5 ML
Tier 3
ANZEMET ORAL TABLET 100 MG, 50 MG
Tier 3
granisetron Oral tablet 1 mg
Tier 1
GRANISOL ORAL SOLUTION 1 MG/5 ML
Tier 3
ondansetron oral tablet,disintegrating 4 mg, 8 mg
Tier 1
ondansetron HCl oral solution 4 mg/5 mL
Tier 1
ondansetron HCl Oral tablet 24 mg, 4 mg, 8 mg
Tier 1
ondansetron HCl (PF) injection solution 4 mg/2
mL
Tier 6
SANCUSO TRANSDERMAL PATCH
WEEKLY 3.1 MG/24 HOUR
Tier 3
ZOFRAN (AS HYDROCHLORIDE)
INTRAVENOUS SOLUTION 2 MG/ML
Tier 6
ZOFRAN (AS HYDROCHLORIDE) ORAL
SOLUTION 4 MG/5 ML
Tier 3
ZOFRAN (AS HYDROCHLORIDE) ORAL
TABLET 4 MG, 8 MG
Tier 3
ZOFRAN ODT ORAL
Tier 3
ZUPLENZ ORAL FILM 4 MG, 8 MG
Tier 3
30D
30D
30D
PA
Antiemetic - Substance P-Neurokinin 1 (Nk1) Receptor Antagonists
EMEND ORAL CAPSULE 125 MG, 40 MG, 80
MG
Tier 3
EMEND ORAL CAPSULE,DOSE PACK 125
MG (1)- 80 MG (2)
Tier 3
Colonic Acidifier (Ammonia Inhibitor)
ENULOSE ORAL SOLUTION 10 GRAM/15
ML
Tier 1
GENERLAC ORAL SOLUTION 10 GRAM/15
ML
Tier 1
lactulose oral solution 10 gram/15 mL
Tier 1
Digestive Enzyme Mixtures
174
Drug Name
Drug Tier
CREON ORAL CAPSULE,DELAYED
RELEASE(DR/EC) 12,000-38,000 -60,000
UNIT, 24,000-76,000 -120,000 UNIT, 3,0009,500- 15,000 UNIT, 36,000-114,000- 180,000
UNIT, 6,000-19,000 -30,000 UNIT
Tier 2
PANCREAZE ORAL CAPSULE,DELAYED
RELEASE(DR/EC) 10,500-25,000 -43,750
UNIT, 16,800-40,000 -70,000 UNIT, 21,00037,000 -61,000 UNIT, 4,200-10,000 -17,500
UNIT
Tier 3
PANCRELIPASE 5000 ORAL
CAPSULE,DELAYED RELEASE(DR/EC)
5,000-17,000 -27,000 UNIT
Tier 1
PERTZYE ORAL CAPSULE,DELAYED
RELEASE(DR/EC) 16,000-57,500- 60,500
UNIT, 8,000-28,750- 30,250 UNIT
Tier 3
ULTRESA ORAL CAPSULE,DELAYED
RELEASE(DR/EC) 13,800-27,600 UNIT,
20,700-41,400 UNIT, 23,000-46,000 UNIT
Tier 3
VIOKACE ORAL TABLET 10,440-39,15039,150 UNIT, 20,880-78,300- 78,300 UNIT
Tier 3
ZENPEP ORAL CAPSULE,DELAYED
RELEASE(DR/EC) 10,000-34,000 -55,000
UNIT, 15,000-51,000 -82,000 UNIT, 20,00068,000 -109,000 UNIT, 25,000-85,000- 136,000
UNIT, 3,000-10,000- 16,000 UNIT, 5,000-17,000
-27,000 UNIT
Tier 3
Notes
Digestive Enzymes
SUCRAID ORAL SOLUTION 8,500 UNIT/ML
Tier 4
Gallstone Solubilizing (Litholysis) Agents
ACTIGALL ORAL CAPSULE 300 MG
Tier 3
CHENODAL ORAL TABLET 250 MG
Tier 4
URSO 250 ORAL TABLET 250 MG
Tier 3
URSO FORTE ORAL TABLET 500 MG
Tier 3
ursodiol Oral capsule 300 mg
Tier 1
ursodiol oral tablet 250 mg, 500 mg
Tier 1
Gastric Acid Secretion Reducers - Histamine H2-Receptor Antagonists
cimetidine oral solution 300 mg/5 mL
Tier 1
175
Drug Name
Drug Tier
cimetidine Oral tablet 200 mg, 300 mg, 400 mg,
800 mg
Tier 1
famotidine oral suspension 40 mg/5 mL
Tier 1
famotidine oral tablet 20 mg, 40 mg
Tier 1
nizatidine oral capsule 150 mg, 300 mg
Tier 1
nizatidine oral solution 150 mg/10 mL
Tier 1
PEPCID ORAL SUSPENSION 40 MG/5 ML
Tier 3
ranitidine HCl oral capsule 150 mg, 300 mg
Tier 1
ranitidine HCl oral syrup 15 mg/mL
Tier 1
ranitidine HCl oral tablet 150 mg, 300 mg
Tier 1
ZANTAC ORAL TABLET 150 MG, 300 MG
Tier 3
Notes
Gastric Acid Secretion Reducing Agents - Proton Pump Inhibitors (Ppis)
ACIPHEX ORAL TABLET,DELAYED
Tier 3
ACIPHEX SPRINKLE ORAL CAPSULE,
DELAYED REL SPRINKLE 10 MG, 5 MG
Tier 3
DEXILANT ORAL CAPSULE,BIPHASE
DELAYED RELEAS 30 MG, 60 MG
Tier 3
esomeprazole strontium oral capsule,delayed
release(DR/EC) 49.3 mg
Tier 3
lansoprazole oral capsule,delayed release(DR/EC)
15 mg, 30 mg
Tier 1
NEXIUM ORAL CAPSULE,DELAYED
RELEASE(DR/EC) 20 MG, 40 MG
Tier 3
NEXIUM PACKET ORAL GRANULES DR
FOR SUSP IN PACKET 10 MG, 2.5 MG, 20
MG, 40 MG, 5 MG
Tier 3
PA
omeprazole Oral capsule,delayed release(DR/EC)
10 mg, 20 mg, 40 mg
Tier 1
pantoprazole oral tablet,delayed release (DR/EC)
20 mg, 40 mg
Tier 1
PREVACID ORAL CAPSULE,DELAYED
RELEASE(DR/EC) 30 MG
Tier 3
PREVACID SOLUTAB ORAL
TABLET,DISINTEGRAT, DELAY REL 15
MG, 30 MG
Tier 3
PRILOSEC ORAL CAPSULE,DELAYED
Tier 3
176
Drug Name
Drug Tier
PRILOSEC ORAL SUSP,DELAYED
RELEASE FOR RECON 10 MG, 2.5 MG
Tier 3
PROTONIX ORAL GRANULES DR FOR
SUSP IN PACKET 40 MG
Tier 3
PROTONIX ORAL TABLET,DELAYED
Tier 3
rabeprazole oral tablet,delayed release (DR/EC)
20 mg
Tier 1
Notes
Gastric Acid Secretion Reducing- Proton Pump Inhibitor & Antacid Comb.
omeprazole-sodium bicarbonate Oral capsule 201.1 mg-gram, 40-1.1 mg-gram
Tier 1
ZEGERID ORAL CAPSULE 20-1.1 MGGRAM, 40-1.1 MG-GRAM
Tier 3
ZEGERID ORAL PACKET 20-1,680 MG, 401,680 MG
Tier 3
PA
Gastric Mucosa - Cytoprotective Prostaglandin Analogs
CYTOTEC ORAL TABLET 100 MCG, 200
MCG
Tier 3
misoprostol Oral tablet 100 mcg, 200 mcg
Tier 1
Gastrointestinal Prokinetic Agents - D2 Antagonist/5-Ht4 Agonists
metoclopramide HCl oral solution 5 mg/5 mL
Tier 1
metoclopramide HCl oral tablet 10 mg, 5 mg
Tier 1
METOZOLV ODT ORAL
TABLET,DISINTEGRATING 5 MG
Tier 3
REGLAN ORAL TABLET 10 MG, 5 MG
Tier 3
Gi Antispasmodic - Belladonna Alkaloids
ANASPAZ ORAL
Tier 3
ED-SPAZ ORAL
Tier 1
hyoscyamine sulfate Oral Drops 0.125 mg/mL
Tier 1
hyoscyamine sulfate oral elixir 0.125 mg/5 mL
Tier 1
hyoscyamine sulfate oral tablet 0.125 mg
Tier 1
hyoscyamine sulfate oral tablet extended release
12 hr 0.375 mg
Tier 1
177
Drug Name
Drug Tier
hyoscyamine sulfate oral tablet,disintegrating
0.125 mg
Tier 1
hyoscyamine sulfate sublingual tablet, sublingual
0.125 mg
Tier 1
HYOSYNE ORAL ELIXIR 0.125 MG/5 ML
Tier 1
LEVBID ORAL TABLET EXTENDED
Tier 3
LEVSIN ORAL TABLET 0.125 MG
Tier 3
LEVSIN/SL SUBLINGUAL TABLET,
SUBLINGUAL 0.125 MG
Tier 3
methscopolamine oral tablet 2.5 mg, 5 mg
Tier 1
NULEV ORAL TABLET,DISINTEGRATING
0.125 MG
Tier 3
OSCIMIN ORAL TABLET 0.125 MG
Tier 1
OSCIMIN SL SUBLINGUAL TABLET,
SUBLINGUAL 0.125 MG
Tier 1
OSCIMIN SR ORAL TABLET EXTENDED
Tier 1
PAMINE ORAL TABLET 2.5 MG
Tier 3
PAMINE FORTE ORAL TABLET 5 MG
Tier 3
SYMAX FASTABS ORAL
Tier 1
SYMAX-SL SUBLINGUAL TABLET,
SUBLINGUAL 0.125 MG
Tier 3
SYMAX-SR ORAL TABLET EXTENDED
Tier 3
Gi Antispasmodic - Quaternary Ammonium Compounds
CANTIL ORAL TABLET 25 MG
Tier 3
GLYCATE ORAL TABLET 1.5 MG
Tier 3
glycopyrrolate Oral tablet 1 mg, 2 mg
Tier 1
propantheline Oral tablet 15 mg
Tier 1
ROBINUL ORAL TABLET 1 MG
Tier 3
ROBINUL FORTE ORAL TABLET 2 MG
Tier 3
Gi Antispasmodic - Synthetic Tertiary Amines
BENTYL ORAL CAPSULE 10 MG
Tier 3
BENTYL ORAL TABLET 20 MG
Tier 3
178
Notes
Drug Name
Drug Tier
dicyclomine Oral capsule 10 mg
Tier 1
dicyclomine oral solution 10 mg/5 mL
Tier 1
dicyclomine oral tablet 20 mg
Tier 1
Notes
Gi Antispasmodic Combinations Other
belladonna alkaloids-opium rectal suppository
16.2-60 mg
Tier 1
BELLADONNA-OPIUM RECTAL
SUPPOSITORY 16.2-30 MG
Tier 1
chlordiazepoxide-clidinium Oral capsule 5-2.5 mg
Tier 1
DONNATAL ORAL ELIXIR 16.2-0.1037 0.0194 MG/5 ML
Tier 3
DONNATAL ORAL TABLET 16.2-0.1037 0.0194 MG
Tier 3
LIBRAX (WITH CLIDINIUM) ORAL
CAPSULE 5-2.5 MG
Tier 3
Ibs Agent - Gastrointestinal Chloride Channel Activator Agents
AMITIZA ORAL CAPSULE 24 MCG, 8 MCG
Tier 2
Ibs Agent - Guanylate Cyclase-C (Gc-C) Agonists
LINZESS ORAL CAPSULE 145 MCG, 290
MCG
Tier 3
Ibs Agent - Selective 5-Ht3 Receptor Antagonists
LOTRONEX ORAL TABLET 0.5 MG, 1 MG
Tier 2
Inflammatory Bowel Agent - Aminosalicylates And Related Agents
APRISO ORAL CAPSULE,EXTENDED
RELEASE 24HR 0.375 GRAM
Tier 2
ASACOL HD ORAL TABLET,DELAYED
Tier 2
AZULFIDINE ORAL TABLET 500 MG
Tier 3
AZULFIDINE EN-TABS ORAL
MG
Tier 3
balsalazide Oral capsule 750 mg
Tier 1
CANASA RECTAL SUPPOSITORY 1,000 MG
Tier 2
COLAZAL ORAL CAPSULE 750 MG
Tier 3
DELZICOL ORAL CAPSULE,DELAYED
RELEASE(DR/EC) 400 MG
Tier 2
QL (1 suppository per 1 day)
179
Drug Name
Drug Tier
Notes
DIPENTUM ORAL CAPSULE 250 MG
Tier 3
PA
GIAZO ORAL TABLET 1.1 GRAM
Tier 3
PA
LIALDA ORAL TABLET,DELAYED
RELEASE (DR/EC) 1.2 GRAM
Tier 3
PA
mesalamine rectal enema 4 gram/60 mL
Tier 1
PENTASA ORAL CAPSULE, EXTENDED
Tier 2
ROWASA RECTAL ENEMA KIT 4 GRAM/60
ML
Tier 3
sulfasalazine Oral tablet 500 mg
Tier 1
sulfasalazine Oral tablet,delayed release (DR/EC)
500 mg
Tier 1
SULFAZINE ORAL TABLET 500 MG
Tier 1
Inflammatory Bowel Agent - Glucocorticoids
budesonide Oral capsule, delayed & ext.release 3
mg
Tier 1
COLOCORT RECTAL ENEMA 100 MG/60
ML
Tier 1
CORTENEMA RECTAL ENEMA 100 MG/60
ML
Tier 3
CORTIFOAM RECTAL FOAM 10 % (80 MG)
Tier 3
ENTOCORT EC ORAL CAPSULE,
DELAYED & EXT.RELEASE 3 MG
Tier 3
hydrocortisone rectal enema 100 mg/60 mL
Tier 1
UCERIS ORAL TABLET, DELAYED &
EXT.RELEASE 9 MG
Tier 4
PA
Inflammatory Bowel Agent - Integrin Receptor Antagonist, Mc Antibody
ENTYVIO INTRAVENOUS RECON SOLN
300 MG
Tier 6
PA; 30D
Inflammatory Bowel Agent - Tumor Necrosis Factor Alpha Blockers
CIMZIA SUBCUTANEOUS SYRINGE KIT
400 MG/2 ML (200 MG/ML X 2)
Tier 4
PA
CIMZIA POWDER FOR RECONST
SUBCUTANEOUS KIT 400 MG (200 MG X 2
VIALS)
Tier 4
PA
180
Drug Name
Drug Tier
Notes
CIMZIA STARTER KIT SUBCUTANEOUS
SYRINGE KIT 400 MG/2 ML (200 MG/ML X
2)
Tier 4
PA
REMICADE INTRAVENOUS RECON SOLN
100 MG
Tier 6
PA; 30D
Irritable Bowel Syndrome (Ibs) Agents
LINZESS ORAL CAPSULE 145 MCG, 290
MCG
Tier 3
LOTRONEX ORAL TABLET 0.5 MG, 1 MG
Tier 2
Laxative - Saline And Osmotic
CONSTULOSE ORAL SOLUTION 10
GRAM/15 ML
Tier 1
KRISTALOSE ORAL PACKET 10 GRAM, 20
GRAM
Tier 3
lactulose oral solution 10 gram/15 mL
Tier 1
Polyethylene Glycol 3350 Oral Powder in Packet
17 gram
Tier 1
Laxative - Saline/Osmotic Mixtures
COLYTE WITH FLAVOR PACKS ORAL
RECON SOLN 240-22.72-6.72 GRAM
Tier 3
GAVILYTE-C ORAL RECON SOLN 24022.72-6.72 GRAM
Tier 1
GAVILYTE-G ORAL RECON SOLN 23622.74-6.74 GRAM
Tier 1
GAVILYTE-N ORAL RECON SOLN 420
GRAM
Tier 1
GOLYTELY ORAL POWDER IN PACKET
227.1-21.5-6.36 GRAM
Tier 2
GOLYTELY ORAL RECON SOLN 236-22.746.74 GRAM
Tier 3
MOVIPREP ORAL POWDER IN PACKET
100-7.5-2.691 GRAM
Tier 3
NULYTELY WITH FLAVOR PACKS ORAL
RECON SOLN 420 GRAM
Tier 3
OSMOPREP ORAL TABLET 1.5 GRAM
Tier 3
PEG 3350-Electrolytes Oral Recon Soln 23622.74-6.74 gram, 240-22.72-6.72 gram
Tier 1
181
Drug Name
Drug Tier
PEG-3350 WITH FLAVOR PACKS ORAL
RECON SOLN 420 GRAM
Tier 1
SUPREP ORAL RECON SOLN 17.5-3.13-1.6
GRAM
Tier 3
TRILYTE WITH FLAVOR PACKETS ORAL
RECON SOLN 420 GRAM
Tier 1
Notes
Laxative - Stimulant & Saline/Osmotic Combinations
PREPOPIK ORAL POWDER IN PACKET 10
MG-3.5 GRAM /16.1 GRAM
Tier 3
Peptic Ulcer - Gastric Lumen Adherent Cytoprotectives
CARAFATE ORAL SUSPENSION 100
MG/ML
Tier 2
CARAFATE ORAL TABLET 1 GRAM
Tier 3
sucralfate oral suspension 100 mg/mL
Tier 1
sucralfate oral tablet 1 gram
Tier 1
Peptic Ulcer - Treatment Of H. Pylori: Antibiotic-Bismuth Combinations
PYLERA ORAL CAPSULE 140-125-125 MG
Tier 3
Peptic Ulcer-Treatment H. Pylori - Proton Pump Inhibitor & Antibiotics
amoxicil-clarithromy-lansopraz oral combo pack
500-500-30 mg
Tier 1
OMECLAMOX-PAK ORAL COMBO PACK
20 MG (20)- 500 MG (20)
Tier 3
PREVPAC ORAL COMBO PACK 500-500-30
MG
Tier 3
Phosphate Binders
calcium acetate oral capsule 667 mg
Tier 1
calcium acetate Oral tablet 667 mg
Tier 1
ELIPHOS ORAL TABLET 667 MG
Tier 3
FOSRENOL ORAL TABLET,CHEWABLE
1,000 MG, 500 MG, 750 MG
Tier 2
MAGNEBIND 400 ORAL TABLET 400-200-1
MG
Tier 3
PHOSLO ORAL CAPSULE 667 MG
Tier 3
PHOSLYRA ORAL SOLUTION 667 MG (169
MG CALCIUM)/5 ML
Tier 3
RENAGEL ORAL TABLET 400 MG, 800 MG
Tier 2
182
PA
Drug Name
Drug Tier
RENVELA ORAL POWDER IN PACKET 0.8
GRAM, 2.4 GRAM
Tier 2
RENVELA ORAL TABLET 800 MG
Tier 3
Notes
Short Bowel Syndrome (Sbs) - Glucagon-Like Peptide-2 (Glp-2) Analog
GATTEX 30-VIAL SUBCUTANEOUS KIT 5
MG
Tier 4
GATTEX ONE-VIAL SUBCUTANEOUS KIT
5 MG
Tier 4
Short Bowel Syndrome (Sbs) Agents
GENOTROPIN SUBCUTANEOUS
CARTRIDGE 12 MG/ML (36 UNIT/ML), 5
MG/ML (15 UNIT/ML)
Tier 4
PA
SUBCUTANEOUS SYRINGE 0.2 MG/0.25
ML, 0.4 MG/0.25 ML, 0.6 MG/0.25 ML, 0.8
MG/0.25 ML, 1 MG/0.25 ML, 1.2 MG/0.25 ML,
1.4 MG/0.25 ML, 1.6 MG/0.25 ML, 1.8 MG/0.25
ML, 2 MG/0.25 ML
Tier 4
PA
HUMATROPE INJECTION CARTRIDGE 12
(36 UNIT) MG, 24 (72 UNIT) MG, 6 (18 UNIT)
MG
Tier 4
PA
HUMATROPE INJECTION RECON SOLN 5
(15 UNIT) MG
Tier 4
PA
NORDITROPIN FLEXPRO
SUBCUTANEOUS PEN INJECTOR 10
MG/1.5 ML (6.7 MG/ML), 15 MG/1.5 ML (10
MG/ML), 5 MG/1.5 ML (3.3 MG/ML)
Tier 4
PA
SUBCUTANEOUS PEN INJECTOR 30 MG/3
ML (10 MG/ML)
Tier 4
PA
PACKET 5 GRAM
Tier 3
NUTROPIN AQ SUBCUTANEOUS
CARTRIDGE 20 MG/2 ML (10 MG/ML)
Tier 4
PA
NUTROPIN AQ NUSPIN SUBCUTANEOUS
MG/2 ML (2.5 MG/ML)
Tier 4
PA
octreotide acetate injection solution 1,000
mcg/mL, 100 mcg/mL, 200 mcg/mL, 50 mcg/mL,
500 mcg/mL
Tier 1
183
Drug Name
Drug Tier
Notes
OMNITROPE SUBCUTANEOUS
CARTRIDGE 10 MG/1.5 ML (6.7 MG/ML), 5
MG/1.5 ML (3.3 MG/ML)
Tier 4
PA
OMNITROPE SUBCUTANEOUS RECON
SOLN 5.8 MG
Tier 4
PA
SAIZEN SUBCUTANEOUS RECON SOLN 5
MG, 8.8 MG
Tier 4
PA
SAIZEN CLICK.EASY SUBCUTANEOUS
CARTRIDGE 8.8 MG/1.5 ML (FNL)
Tier 4
PA
SANDOSTATIN INJECTION SOLUTION
1,000 MCG/ML, 100 MCG/ML, 200 MCG/ML,
50 MCG/ML, 500 MCG/ML
Tier 3
SANDOSTATIN LAR DEPOT
INTRAMUSCULAR KIT 10 MG, 20 MG, 30
MG
Tier 6
30D
SEROSTIM SUBCUTANEOUS RECON
Tier 4
PA
TEV-TROPIN SUBCUTANEOUS RECON
SOLN 5 MG
Tier 4
PA
ZORBTIVE SUBCUTANEOUS RECON
SOLN 8.8 MG
Tier 4
PA
Genitourinary Therapy
Bph Agent - 5-Alpha Reductase Inhib. & Alpha-1 Adrenoceptor Antag Comb
JALYN ORAL CAPSULE, ER MULTIPHASE
24 HR 0.5-0.4 MG
Tier 2
Cystinosis Therapy (Cystine Depleting Agents)
CYSTAGON ORAL CAPSULE 150 MG, 50
MG
Tier 3
PROCYSBI ORAL CAPSULE, DELAYED
REL SPRINKLE 25 MG, 75 MG
Tier 4
G.U. Irrigants - Anti-Infective
NEOSPORIN GU IRRIGANT IRRIGATION
SOLUTION 40-200,000 MG-UNIT/ML
Tier 3
Interstitial Cystitis Agents
ELMIRON ORAL CAPSULE 100 MG
Tier 2
Kidney Stone Agents
THIOLA ORAL TABLET 100 MG
184
Tier 3
Drug Name
Drug Tier
Notes
Kidney Stone Therapy - Adjunctive Agents
LITHOSTAT ORAL TABLET 250 MG
Tier 3
Overactive Bladder Agents - Beta -3 Adrenergic Receptor Agonist
MYRBETRIQ ORAL TABLET EXTENDED
Tier 3
Prostatic Hypertrophy Agent - Alpha-1-Adrenoceptor Antagonists
alfuzosin oral tablet extended release 24 hr 10 mg
Tier 1
FLOMAX ORAL CAPSULE,EXTENDED
RELEASE 24HR 0.4 MG
Tier 3
RAPAFLO ORAL CAPSULE 4 MG, 8 MG
Tier 3
tamsulosin oral capsule,extended release 24hr 0.4
mg
Tier 1
UROXATRAL ORAL TABLET EXTENDED
RELEASE 24 HR 10 MG
Tier 3
PA
Prostatic Hypertrophy Agent - Type I & Ii 5-Alpha Reductase Inhibitors
AVODART ORAL CAPSULE 0.5 MG
Tier 2
Prostatic Hypertrophy Agent - Type Ii 5-Alpha Reductase Inhibitors
finasteride oral tablet 5 mg
Tier 1
PROSCAR ORAL TABLET 5 MG
Tier 3
Urinary Acidifier - Bacterial Urease Inhibitor
LITHOSTAT ORAL TABLET 250 MG
Tier 3
Urinary Acidifier - Phosphates
K-PHOS NO 2 ORAL TABLET 305-700 MG
Tier 2
K-PHOS ORIGINAL ORAL
TABLET,SOLUBLE 500 MG
Tier 2
K-PHOS-NEUTRAL ORAL TABLET 250 MG
Tier 3
PHOSPHA 250 NEUTRAL ORAL TABLET
250 MG
Tier 1
Urinary Alkalinizer - Citrates
CYTRA K CRYSTALS ORAL PACKET
3,300-1,002 MG
Tier 1
CYTRA-2 ORAL SOLUTION 500-334 MG/5
ML
Tier 1
CYTRA-3 ORAL SOLUTION 550-500-334
MG/5 ML
Tier 3
185
Drug Name
Drug Tier
ORACIT ORAL SOLUTION 490-640 MG/5
ML
Tier 3
potassium citrate oral tablet extended release 10
mEq, 5 mEq
Tier 1
potassium citrate-citric acid oral solution 1,100334 mg/5 mL
Tier 1
TARON-CRYSTALS ORAL PACKET 3,3001,002 MG
Tier 3
TRICITRATES ORAL SOLUTION 550-500334 MG/5 ML
Tier 1
UROCIT-K 10 ORAL TABLET EXTENDED
RELEASE 10 MEQ
Tier 3
RELEASE 15 MEQ
Tier 3
RELEASE 5 MEQ
Tier 3
Notes
PA
Urinary Analgesics
phenazopyridine oral tablet 100 mg, 200 mg
Tier 1
PYRIDIUM ORAL TABLET 100 MG, 200 MG
Tier 3
Urinary Antibacterial - Methenamine & Salts
HIPREX ORAL TABLET 1 GRAM
Tier 3
methenamine hippurate Oral tablet 1 gram
Tier 1
methenamine mandelate Oral tablet 0.5 g, 1 gram
Tier 1
UROQID-ACID NO.2 ORAL TABLET 500500 MG
Tier 3
Urinary Antibacterial - Nitrofuran Derivatives
FURADANTIN ORAL SUSPENSION 25 MG/5
ML
Tier 3
MACROBID ORAL CAPSULE 100 MG
Tier 3
older); AR
MACRODANTIN ORAL CAPSULE 100 MG,
50 MG
Tier 3
older); AR
MACRODANTIN ORAL CAPSULE 25 MG
Tier 2
older); AR
nitrofurantoin oral suspension 25 mg/5 mL
Tier 1
older); AR
186
Drug Name
Drug Tier
Notes
nitrofurantoin macrocrystal Oral capsule 100 mg,
25 mg, 50 mg
Tier 1
older); AR
nitrofurantoin monohyd/m-cryst oral capsule 100
mg
Tier 1
older); AR
Urinary Antibacterial - Quinolones
CIPRO XR ORAL TABLET, ER
MULTIPHASE 24 HR 1,000 MG, 500 MG
Tier 3
ciprofloxacin (mixture) Oral tablet, ER multiphase
24 hr 1,000 mg, 500 mg
Tier 1
Urinary Antibacterials Other
MONUROL ORAL PACKET 3 GRAM
Tier 3
Urinary Anti-Infective Methenamine-Antispas-Analg Combinations
HYOPHEN ORAL TABLET 81.6-0.12-10.8
MG
Tier 1
PHOSPHASAL ORAL TABLET 81.6-10.8-40.8
MG
Tier 2
PROSED/DS (ATROPINE FREE) ORAL
TABLET 81.6-0.12-10.8 MG
Tier 3
UR N-C ORAL TABLET 81.6-10.8-40.8 MG
Tier 1
URELLE ORAL TABLET 81-0.12 MG
Tier 3
URETRON D-S ORAL TABLET 120-0.12-10.8
MG
Tier 1
URETRON D-S ORAL TABLET 81.6-10.8-40.8
MG
Tier 2
URIBEL ORAL CAPSULE 118-10-40.8-36 MG
Tier 3
URIMAR-T ORAL TABLET 120-0.12-10.8
MG
Tier 3
URIN DS ORAL TABLET 81.6-10.8-40.8 MG
Tier 2
USTELL ORAL CAPSULE 120-0.12 MG
Tier 1
UTA ORAL CAPSULE 120-0.12 MG
Tier 3
PA
Urinary Anti-Infective Methenamine-Antispasmodic Combinations
UROGESIC-BLUE ORAL TABLET 81.6-40.80.12 MG
Tier 3
URYL ORAL TABLET 81.6-40.8-0.12 MG
Tier 3
PA
Urinary Antispasmodic - Antichol., M(3) Muscarinic Selective (Bladder)
187
Drug Name
Drug Tier
Notes
ENABLEX ORAL TABLET EXTENDED
RELEASE 24 HR 15 MG, 7.5 MG
Tier 3
VESICARE ORAL TABLET 10 MG, 5 MG
Tier 2
Urinary Antispasmodic - Smooth Muscle Relaxants
DETROL ORAL TABLET 1 MG, 2 MG
Tier 3
DETROL LA ORAL CAPSULE,EXTENDED
Tier 3
DITROPAN XL ORAL TABLET EXTENDED
RELEASE 24HR 10 MG, 15 MG, 5 MG
Tier 3
flavoxate Oral tablet 100 mg
Tier 1
GELNIQUE TRANSDERMAL GEL IN
METERED-DOSE PUMP 28 MG/0.92 GRAM
(3 %)
Tier 3
GELNIQUE TRANSDERMAL GEL IN
PACKET 10 % (100 MG/GRAM)
Tier 3
oxybutynin chloride oral syrup 5 mg/5 mL
Tier 1
oxybutynin chloride Oral tablet 5 mg
Tier 1
oxybutynin chloride Oral tablet extended release
24hr 10 mg, 15 mg, 5 mg
Tier 1
OXYTROL TRANSDERMAL PATCH
SEMIWEEKLY 3.9 MG/24 HR
Tier 3
SANCTURA ORAL TABLET 20 MG
Tier 3
tolterodine oral capsule,extended release 24hr 2
mg, 4 mg
Tier 1
tolterodine oral tablet 1 mg, 2 mg
Tier 1
TOVIAZ ORAL TABLET EXTENDED
Tier 2
trospium oral capsule,extended release 24hr 60
mg
Tier 1
trospium Oral tablet 20 mg
Tier 1
Urinary Retention Therapy - Parasympathomimetic Agents
bethanechol chloride Oral tablet 10 mg, 25 mg, 5
mg, 50 mg
Tier 1
URECHOLINE ORAL TABLET 10 MG, 25
MG, 5 MG, 50 MG
Tier 3
Gout And Hyperuricemia Therapy
Gout Acute Therapy - Antimitotics
188
Drug Name
COLCRYS ORAL TABLET 0.6 MG
Drug Tier
Notes
Tier 2
Gout And Hyperuricemia - Antimitotic-Uricosuric Combinations
colchicine-probenecid Oral tablet 0.5-500 mg
Tier 1
Hyperuricemia Therapy - Urate-Oxidase Enzyme-Type
ELITEK INTRAVENOUS RECON SOLN 1.5
MG
Tier 6
30D
KRYSTEXXA INTRAVENOUS SOLUTION 8
MG/ML
Tier 6
30D
Hyperuricemia Therapy - Uricosurics
probenecid oral tablet 500 mg
Tier 1
Hyperuricemia Therapy - Xanthine Oxidase Inhibitors
allopurinol oral tablet 100 mg, 300 mg
Tier 1
ALOPRIM INTRAVENOUS RECON SOLN
500 MG
Tier 3
ULORIC ORAL TABLET 40 MG, 80 MG
Tier 2
ZYLOPRIM ORAL TABLET 100 MG, 300
MG
Tier 3
Hematological Agents
Anticoagulants - Citrate-Based
ACD-A SOLUTION
Tier 3
Anticoagulants - Coumarin
COUMADIN ORAL TABLET 1 MG, 10 MG, 2
MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5
MG
Tier 2
JANTOVEN ORAL TABLET 1 MG, 10 MG, 2
MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5
MG
Tier 1
warfarin Oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3
mg, 4 mg, 5 mg, 6 mg
Tier 1
C1 Esterase Inhibitor Agents
BERINERT INTRAVENOUS KIT 500 UNIT
(10 ML)
Tier 6
PA; 30D
BERINERT INTRAVENOUS RECON SOLN
500 UNIT (10 ML)
Tier 6
PA
CINRYZE INTRAVENOUS RECON SOLN
500 UNIT (5 ML)
Tier 6
PA; 30D
189
Drug Name
Drug Tier
Notes
Cxcr4 Chemokine Receptor Antagonists
Tier 6
30D
ELIQUIS ORAL TABLET 2.5 MG, 5 MG
Tier 3
XARELTO ORAL TABLET 10 MG, 20 MG
Tier 2
XARELTO ORAL TABLET 15 MG
Tier 2
MOZOBIL SUBCUTANEOUS SOLUTION 24
MG/1.2 ML (20 MG/ML)
Direct Factor Xa Inhibitors
Erythropoietins
ARANESP (IN POLYSORBATE) INJECTION
SOLUTION 100 MCG/ML, 150 MCG/0.75 ML,
200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40
MCG/ML, 60 MCG/ML
Tier 3
PA
ARANESP (IN POLYSORBATE) INJECTION
SYRINGE 100 MCG/0.5 ML, 150 MCG/0.3
ML, 200 MCG/0.4 ML, 25 MCG/0.42 ML, 300
MCG/0.6 ML, 40 MCG/0.4 ML, 500 MCG/ML,
60 MCG/0.3 ML
Tier 3
PA
EPOGEN INJECTION SOLUTION 10,000
UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/ML,
3,000 UNIT/ML, 4,000 UNIT/ML
Tier 2
PA
EPOGEN INJECTION SOLUTION 20,000
UNIT/2 ML
Tier 4
PA
PROCRIT INJECTION SOLUTION 10,000
UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2
ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000
UNIT/ML, 40,000 UNIT/ML
Tier 2
PA
Tier 6
30D
Factor Ix Preparations
ALPHANINE SD INTRAVENOUS RECON
SOLN 1,500 (+/-) UNIT
Granulocyte Colony-Stimulating Factor (G-Csf)
GRANIX SUBCUTANEOUS SYRINGE 300
MCG/0.5 ML, 480 MCG/0.8 ML
Tier 4
NEULASTA SUBCUTANEOUS SYRINGE 6
MG/0.6ML
Tier 3
NEUPOGEN INJECTION SOLUTION 300
MCG/ML, 480 MCG/1.6 ML
Tier 4
NEUPOGEN INJECTION SYRINGE 300
MCG/0.5 ML, 480 MCG/0.8 ML
Tier 4
190
Drug Name
Drug Tier
Notes
Granulocyte-Macrophage Colony-Stimulating Factor (Gm-Csf)
LEUKINE INJECTION RECON SOLN 250
MCG
Tier 4
Hematorheologic Agents
pentoxifylline Oral tablet extended release 400 mg
Tier 1
Hemostatic Systemic - Antifibrinolytic Agents
aminocaproic acid oral solution 25 %
Tier 1
aminocaproic acid Oral tablet 1,000 mg, 500 mg
Tier 1
CYKLOKAPRON INTRAVENOUS
SOLUTION 1,000 MG/10 ML (100 MG/ML)
Tier 6
LYSTEDA ORAL TABLET 650 MG
Tier 3
tranexamic acid oral tablet 650 mg
Tier 1
Hemostatic Topical Agents
ASTRINGYN TOPICAL SOLUTION 259
MG/G
Tier 3
MONSEL'S TOPICAL SOLUTION 0.2 TO
0.22 GRAM/ML IRON
Tier 3
THROMBI-GEL TOPICAL PADS,
MEDICATED 10 CM2, 100 CM2, 40 CM2
Tier 3
THROMBI-PAD TOPICAL PADS,
MEDICATED 3 X 3 "
Tier 3
Hemostatic Topical Combinations
TISSEEL VHSD TOPICAL SYRINGE 2 ML
Tier 3
Human Monoclonal Antibody Complement (C5) Inhibitors
SOLIRIS INTRAVENOUS SOLUTION 300
MG/30 ML
Tier 6
30D
Indirect Factor Xa Inhibitors
ARIXTRA SUBCUTANEOUS SYRINGE 10
MG/0.8 ML, 2.5 MG/0.5 ML, 5 MG/0.4 ML, 7.5
MG/0.6 ML
Tier 3
fondaparinux subcutaneous syringe 10 mg/0.8 mL,
2.5 mg/0.5 mL, 5 mg/0.4 mL, 7.5 mg/0.6 mL
Tier 1
Low Molecular Weight Heparins
enoxaparin subcutaneous solution 300 mg/3 mL
Tier 1
191
Drug Name
Drug Tier
enoxaparin subcutaneous syringe 100 mg/mL, 120
mg/0.8 mL, 150 mg/mL, 30 mg/0.3 mL, 40 mg/0.4
mL, 60 mg/0.6 mL, 80 mg/0.8 mL
Tier 1
FRAGMIN SUBCUTANEOUS SOLUTION
25,000 UNIT/ML
Tier 3
FRAGMIN SUBCUTANEOUS SYRINGE
10,000 UNIT/ML, 12,500 UNIT/0.5 ML, 15,000
UNIT/0.6 ML, 18,000 UNIT/0.72 ML, 2,500
UNIT/0.2 ML, 5,000 UNIT/0.2 ML, 7,500
UNIT/0.3 ML
Tier 3
LOVENOX SUBCUTANEOUS SOLUTION
300 MG/3 ML
Tier 3
LOVENOX SUBCUTANEOUS SYRINGE 100
MG/ML, 120 MG/0.8 ML, 150 MG/ML, 30
MG/0.3 ML, 40 MG/0.4 ML, 60 MG/0.6 ML, 80
MG/0.8 ML
Tier 3
Notes
Platelet Aggregation Inhib - Cyclopentyl-Triazolo-Pyrimidines (Cptps)
BRILINTA ORAL TABLET 90 MG
Tier 3
Platelet Aggregation Inhib - Pdesterase &Adenosine Deaminase Inhibitor
dipyridamole Oral tablet 25 mg, 50 mg, 75 mg
Tier 1
older); AR
PERSANTINE ORAL TABLET 25 MG, 50
MG, 75 MG
Tier 3
older); AR
Platelet Aggregation Inhibitor Combinations
AGGRENOX ORAL CAPSULE, ER
MULTIPHASE 12 HR 200-25 MG
Tier 3
Platelet Aggregation Inhibitors - Phosphodiesterase Iii Inhibitors
cilostazol Oral tablet 100 mg, 50 mg
Tier 1
PLETAL ORAL TABLET 100 MG, 50 MG
Tier 3
Platelet Aggregation Inhibitors - Quinazoline Agents
AGRYLIN ORAL CAPSULE 0.5 MG
Tier 3
anagrelide Oral capsule 0.5 mg, 1 mg
Tier 1
Platelet Aggregation Inhibitors - Salicylates
ADULT LOW DOSE ASPIRIN ORAL
MG
Tier 5
ASPIR-LOW ORAL TABLET,DELAYED
Tier 5
AR
192
Drug Name
Drug Tier
Notes
aspirin Oral tablet 325 mg
Tier 5
AR
aspirin oral tablet,chewable 81 mg
Tier 5
AR
aspirin oral tablet,delayed release (DR/EC) 325
mg, 81 mg
Tier 5
AR
BAYER CHEWABLE ASPIRIN ORAL
Tier 5
AR
ECOTRIN ORAL TABLET,DELAYED
Tier 5
AR
ECOTRIN LOW STRENGTH ORAL
MG
Tier 5
AR
ST JOSEPH ASPIRIN ORAL
Tier 5
AR
ST. JOSEPH ASPIRIN ORAL
MG
Tier 5
AR
Platelet Aggregation Inhibitors - Thienopyridine Agents
clopidogrel oral tablet 300 mg, 75 mg
Tier 1
EFFIENT ORAL TABLET 10 MG, 5 MG
Tier 2
PLAVIX ORAL TABLET 300 MG, 75 MG
Tier 3
ticlopidine oral tablet 250 mg
Tier 1
Platelet Aggregation Inhib-Protease-Activ.Receptor-1(Par-1) Antagonist
ZONTIVITY ORAL TABLET 2.08 MG
Tier 3
Platelet Proliferation Stimulants (Interleukins)
NEUMEGA SUBCUTANEOUS RECON
SOLN 5 MG
Tier 4
Sickle Cell Anemia Agents
DROXIA ORAL CAPSULE 200 MG, 300 MG,
400 MG
Tier 2
Thrombin Inhibitor - Selective Direct & Reversible
PRADAXA ORAL CAPSULE 150 MG, 75 MG
Tier 2
Thrombin Inhibitor - Selective Direct & Reversible - Hirudin Type
IPRIVASK SUBCUTANEOUS RECON SOLN
15 MG
Tier 3
193
Drug Name
Drug Tier
Notes
Thrombopoietin Receptor Agonists
NPLATE SUBCUTANEOUS RECON SOLN
250 MCG
Tier 6
PROMACTA ORAL TABLET 12.5 MG, 25
MG, 50 MG, 75 MG
Tier 4
30D
Immunosuppressive Agents
Immunosuppressive - Calcineurin Inhibitors
ASTAGRAF XL ORAL
CAPSULE,EXTENDED RELEASE 24HR 0.5
MG, 1 MG
Tier 3
ASTAGRAF XL ORAL
MG
Tier 4
cyclosporine Oral capsule 100 mg, 25 mg
Tier 1
cyclosporine modified Oral capsule 100 mg, 25
mg, 50 mg
Tier 1
cyclosporine modified oral solution 100 mg/mL
Tier 1
GENGRAF ORAL CAPSULE 100 MG, 25 MG
Tier 1
GENGRAF ORAL SOLUTION 100 MG/ML
Tier 1
HECORIA ORAL CAPSULE 0.5 MG, 1 MG, 5
MG
Tier 3
NEORAL ORAL CAPSULE 100 MG, 25 MG
Tier 3
NEORAL ORAL SOLUTION 100 MG/ML
Tier 3
PROGRAF INTRAVENOUS SOLUTION 5
MG/ML
Tier 6
PROGRAF ORAL CAPSULE 0.5 MG, 1 MG, 5
MG
Tier 3
SANDIMMUNE INTRAVENOUS SOLUTION
250 MG/5 ML
Tier 3
SANDIMMUNE ORAL CAPSULE 100 MG, 25
MG
Tier 3
SANDIMMUNE ORAL SOLUTION 100
MG/ML
Tier 2
tacrolimus Oral capsule 0.5 mg, 1 mg, 5 mg
Tier 1
30D
Immunosuppressive - Inosine Monophosphate Dehydrogenase Inhibitors
CELLCEPT ORAL CAPSULE 250 MG
194
Tier 3
Drug Name
Drug Tier
CELLCEPT ORAL SUSPENSION FOR
RECONSTITUTION 200 MG/ML
Tier 2
CELLCEPT ORAL TABLET 500 MG
Tier 3
mycophenolate mofetil oral capsule 250 mg
Tier 1
mycophenolate mofetil oral tablet 500 mg
Tier 1
mycophenolate sodium oral tablet,delayed release
(DR/EC) 180 mg, 360 mg
Tier 1
MYFORTIC ORAL TABLET,DELAYED
Tier 3
Notes
Immunosuppressive - Mammalian Target Of Rapamycin (Mtor) Inhibitors
RAPAMUNE ORAL SOLUTION 1 MG/ML
Tier 3
RAPAMUNE ORAL TABLET 0.5 MG, 1 MG,
2 MG
Tier 3
ZORTRESS ORAL TABLET 0.25 MG
Tier 2
ZORTRESS ORAL TABLET 0.5 MG, 0.75 MG
Tier 4
Immunosuppressive - Purine Analogs
AZASAN ORAL TABLET 100 MG, 75 MG
Tier 2
azathioprine oral tablet 50 mg
Tier 1
IMURAN ORAL TABLET 50 MG
Tier 3
Immunosuppressive - Selective T-Cell Costimulation Blocker
NULOJIX INTRAVENOUS RECON SOLN
250 MG
Tier 6
30D
Locomotor System
Als Agent - Benzathiazoles
RILUTEK ORAL TABLET 50 MG
Tier 4
riluzole oral tablet 50 mg
Tier 2
Antimyasthenic Agent - Reversible Cholinesterase Inhibitors
MESTINON ORAL SYRUP 60 MG/5 ML
Tier 3
MESTINON ORAL TABLET 60 MG
Tier 3
MESTINON TIMESPAN ORAL TABLET
Tier 3
pyridostigmine bromide Oral tablet 60 mg
Tier 1
Antimyasthenic Agents Other
guanidine Oral tablet 125 mg
Tier 1
195
Drug Name
Drug Tier
Notes
Musculoskeletal Therapy Agent - Viscosupplements
EUFLEXXA INTRA-ARTICULAR SYRINGE
10 MG/ML
Tier 6
30D
GEL-ONE INTRA-ARTICULAR SYRINGE
30 MG/3 ML
Tier 6
30D
HYALGAN INTRA-ARTICULAR
SOLUTION 10 MG/ML
Tier 6
30D
ORTHOVISC INTRA-ARTICULAR
SYRINGE 30 MG/2 ML
Tier 6
30D
SUPARTZ INTRA-ARTICULAR SYRINGE
10 MG/ML
Tier 6
30D
SYNVISC INTRA-ARTICULAR SYRINGE 16
MG/2 ML
Tier 6
30D
SYNVISC-ONE INTRA-ARTICULAR
SYRINGE 48 MG/6 ML
Tier 6
30D
Musculoskeletal Tx Agent-Joint Contracture Therapy, Collagenase Enzyme
Tier 6
30D
BOTOX INJECTION RECON SOLN 100
UNIT, 200 UNIT
Tier 6
PA; 30D
DYSPORT INTRAMUSCULAR RECON
SOLN 300 UNIT
Tier 6
PA
DYSPORT INTRAMUSCULAR RECON
SOLN 500 UNIT
Tier 6
PA; 30D
MYOBLOC INTRAMUSCULAR SOLUTION
2,500 UNIT/0.5 ML
Tier 6
30D
XEOMIN INTRAMUSCULAR RECON SOLN
100 UNIT
Tier 6
PA
XEOMIN INTRAMUSCULAR RECON SOLN
50 UNIT
Tier 6
PA; 30D
XIAFLEX INJECTION RECON SOLN 0.9
MG
Neuromuscular Blocker - Neurotoxins
Neuromuscular Blocker - Nondepolarizing Agents
rocuronium intravenous solution 10 mg/mL
Tier 6
30D
ZEMURON INTRAVENOUS SOLUTION 10
MG/ML
Tier 6
30D
Skeletal Muscle Relaxant - Analgesic Salicylate Combinations
carisoprodol-aspirin Oral tablet 200-325 mg
196
Tier 1
Drug Name
Drug Tier
Notes
Skeletal Muscle Relaxant - Central Muscle Relaxants
AMRIX ORAL CAPSULE,EXTENDED
Tier 3
older); AR
baclofen oral tablet 10 mg, 20 mg
Tier 1
carisoprodol Oral tablet 250 mg, 350 mg
Tier 1
older); AR
chlorzoxazone Oral tablet 500 mg
Tier 1
older); AR
cyclobenzaprine Oral tablet 10 mg, 5 mg, 7.5 mg
Tier 1
older); AR
FEXMID ORAL TABLET 7.5 MG
Tier 3
LORZONE ORAL TABLET 375 MG, 750 MG
Tier 3
older); AR
metaxalone oral tablet 800 mg
Tier 1
older); AR
methocarbamol oral tablet 500 mg, 750 mg
Tier 1
older); AR
orphenadrine citrate Oral tablet extended release
100 mg
Tier 1
older); AR
PARAFON FORTE DSC ORAL TABLET 500
MG
Tier 3
older); AR
ROBAXIN ORAL TABLET 500 MG
Tier 3
older); AR
ROBAXIN-750 ORAL TABLET 750 MG
Tier 3
older); AR
SKELAXIN ORAL TABLET 800 MG
Tier 3
older); AR
SOMA ORAL TABLET 250 MG, 350 MG
Tier 3
older); AR
tizanidine Oral capsule 2 mg, 4 mg, 6 mg
Tier 1
tizanidine oral tablet 2 mg, 4 mg
Tier 1
ZANAFLEX ORAL CAPSULE 2 MG, 4 MG, 6
MG
Tier 3
ZANAFLEX ORAL TABLET 4 MG
Tier 3
Skeletal Muscle Relaxant - Direct Muscle Relaxants
DANTRIUM INTRAVENOUS RECON SOLN
20 MG
Tier 6
197
Drug Name
Drug Tier
DANTRIUM ORAL CAPSULE 100 MG, 25
MG, 50 MG
Tier 3
dantrolene Oral capsule 100 mg, 25 mg, 50 mg
Tier 1
Notes
Skeletal Muscle Relaxant - Narcotic Analgesic Combinations
carisoprodol-ASA-codeine Oral tablet 200-325-16
mg
Tier 1
Medical Supplies And Durable Medical Equipment (Dme)
Medical Supplies & Dme - Insulin Needles-Syringes & Admin. Supplies
BD AUTOSHIELD PEN NEEDLE NEEDLE
29 X 5/16 "
Tier 1
BD INSULIN PEN NEEDLE UF SHORT
NEEDLE 31 X 5/16 "
Tier 1
BD INSULIN SYRINGE ULTRA-FINE
SYRINGE 0.3 ML 31 X 5/16", 1 ML 31 X
5/16", 1/2 ML 31 X 5/16"
Tier 1
Medical Supplies & Dme - Iud's
PARAGARD T 380A INTRAUTERINE
INTRAUTERINE DEVICE 380 SQUARE MM
Tier 5
Medical Supplies & Dme - Needles & Syringes
BD ECLIPSE LUER-LOK SYRINGE 1 ML 27
X 1/2"
Tier 1
Medical Supply, Fdb Superset
Medical Supply, Fdb Superset
BD AUTOSHIELD PEN NEEDLE NEEDLE
29 X 5/16 "
Tier 1
BD ECLIPSE LUER-LOK SYRINGE 1 ML 27
X 1/2"
Tier 1
BD INSULIN PEN NEEDLE UF SHORT
NEEDLE 31 X 5/16 "
Tier 1
BD INSULIN SYRINGE ULTRA-FINE
SYRINGE 0.3 ML 31 X 5/16", 1 ML 31 X
5/16", 1/2 ML 31 X 5/16"
Tier 1
Metabolic Disease Enzyme Replacement Agents
Metabolic Disease Enzyme Replacement, Fabry's Disease
FABRAZYME INTRAVENOUS RECON
SOLN 35 MG, 5 MG
198
Tier 6
PA
Drug Name
Drug Tier
Notes
Metabolic Disease Enzyme Replacement, Gaucher's Disease
CEREZYME INTRAVENOUS RECON SOLN
400 UNIT
Tier 6
PA; 30D
VPRIV INTRAVENOUS RECON SOLN 400
UNIT
Tier 6
PA; 30D
Metabolic Disease Enzyme Replacement, Mucopolysaccharidosis
ALDURAZYME INTRAVENOUS SOLUTION
2.9 MG/5 ML
Tier 6
30D
ELAPRASE INTRAVENOUS SOLUTION 6
MG/3 ML
Tier 6
PA; 30D
NAGLAZYME INTRAVENOUS SOLUTION
5 MG/5 ML
Tier 6
30D
Metabolic Disease Enzyme Replacement, Pompe Disease
LUMIZYME INTRAVENOUS RECON SOLN
50 MG
Tier 6
30D
MYOZYME INTRAVENOUS RECON SOLN
50 MG
Tier 6
PA; 30D
Metabolic Dx Enzyme Replacement, Severe Combined Immune Deficiency
ADAGEN INTRAMUSCULAR SOLUTION
250 UNIT/ML
Tier 3
Metabolic Modifiers
Hyperparathyroid Treatment Agents - Vitamin D Analog-Type
doxercalciferol intravenous solution 4 mcg/2 mL
Tier 6
doxercalciferol oral capsule 0.5 mcg, 1 mcg, 2.5
mcg
Tier 1
HECTOROL INTRAVENOUS SOLUTION 4
MCG/2 ML
Tier 6
HECTOROL ORAL CAPSULE 0.5 MCG, 1
MCG, 2.5 MCG
Tier 3
paricalcitol oral capsule 1 mcg, 2 mcg, 4 mcg
Tier 1
ZEMPLAR ORAL CAPSULE 1 MCG, 2 MCG,
4 MCG
Tier 3
30D
30D
Metabolic Modifier - Carnitine Replenisher Agents
CARNITOR INTRAVENOUS SOLUTION 200
MG/ML
Tier 6
CARNITOR ORAL SOLUTION 100 MG/ML
Tier 3
199
Drug Name
Drug Tier
CARNITOR ORAL TABLET 330 MG
Tier 3
levocarnitine Oral tablet 330 mg
Tier 1
levocarnitine (with sugar) oral solution 100
mg/mL
Tier 1
Notes
Metabolic Modifier - Gaucher's Disease, Type-1, Substrate Reduction Tx
ZAVESCA ORAL CAPSULE 100 MG
Tier 4
Metabolic Modifier - Hereditary Tyrosinemia Treatment Agents
ORFADIN ORAL CAPSULE 10 MG, 2 MG, 5
MG
Tier 4
Metabolic Modifier - Homocystinuria Treatment Agents
CYSTADANE ORAL POWDER 1 GRAM/ 1.7
ML
Tier 3
Metabolic Modifier - Urea Cycle Disorder Agents-Conjugating Agents
BUPHENYL ORAL POWDER 0.94
GRAM/GRAM
Tier 3
BUPHENYL ORAL TABLET 500 MG
Tier 3
RAVICTI ORAL LIQUID 1.1 GRAM/ML
Tier 4
sodium phenylbutyrate oral powder 0.94
gram/gram
Tier 1
Metabolic Modifier-Carbamoyl Phosphate Synthetase 1 (Cps 1) Activator
CARBAGLU ORAL TABLET, DISPERSIBLE
200 MG
Tier 3
Phenylketonuria(Pku) Tx Agents - Cofactor Of Phenylalanine Hydroxylase
KUVAN ORAL TABLET,SOLUBLE 100 MG
Tier 4
Mouth-Throat-Dental - Preparations
Dental Product - Fluoride Preparations
CLINPRO 5000 DENTAL PASTE 1.1 %
Tier 3
DENTA 5000 PLUS DENTAL CREAM 1.1 %
Tier 1
DENTAGEL DENTAL GEL 1.1 %
Tier 1
FLUORIDEX DAILY DEFENSE DENTAL
GEL 1.1 %
Tier 3
FLUORIDEX SENSITIVITY RELIEF
DENTAL GEL 1.1-5 %
Tier 3
PREVIDENT DENTAL SOLUTION 0.2 %
Tier 3
200
Drug Name
Drug Tier
PREVIDENT 5000 PLUS DENTAL CREAM
1.1 %
Tier 3
PREVIDENT 5000 SENSITIVE DENTAL
PASTE 1.1-5 %
Tier 3
SF 5000 PLUS DENTAL CREAM 1.1 %
Tier 1
sodium fluoride dental solution 0.2 %
Tier 1
sodium fluoride Oral Drops 0.5 mg fluoride (1.1
mg)/mL
Tier 5
sodium fluoride oral tablet,chewable 0.25 mg
fluorid (0.55 mg)
Tier 5
stannous fluoride dental solution 0.63 %
Tier 1
Notes
PA
Mouth And Throat - Antifungals
clotrimazole mucous membrane troche 10 mg
Tier 1
nystatin oral suspension 100,000 unit/mL
Tier 1
Mouth And Throat - Anti-Infective Mixtures
DEBACTEROL MUCOUS MEMBRANE
SWAB 30-50 %
Tier 3
Mouth And Throat - Anti-Infective-Local Anesthetic Combinations
BUCALSEP MUCOUS MEMBRANE
SOLUTION
Tier 3
Mouth And Throat - Antiseptics
chlorhexidine gluconate mucous membrane
mouthwash 0.12 %
Tier 1
PERIDEX MUCOUS MEMBRANE
MOUTHWASH 0.12 %
Tier 3
PERIOGARD MUCOUS MEMBRANE
MOUTHWASH 0.12 %
Tier 1
Mouth And Throat - Glucocorticoids
ORALONE DENTAL PASTE 0.1 %
Tier 1
triamcinolone acetonide dental paste 0.1 %
Tier 1
Mouth And Throat - Local Anesthetic Amides
lidocaine HCl mucous membrane gel 2 %
Tier 1
lidocaine HCl mucous membrane solution 2 %, 4
%
Tier 1
201
Drug Name
Drug Tier
LIDOCAINE VISCOUS MUCOUS
MEMBRANE SOLUTION 2 %
Tier 1
XYLOCAINE MUCOUS MEMBRANE
SOLUTION 4 %
Tier 3
Notes
Mouth And Throat - Saliva Stimulants
cevimeline oral capsule 30 mg
Tier 1
EVOXAC ORAL CAPSULE 30 MG
Tier 3
pilocarpine HCl oral tablet 5 mg, 7.5 mg
Tier 1
SALAGEN ORAL TABLET 5 MG, 7.5 MG
Tier 3
Periodontal Product - Tetracycline Antiinfective, Local
ARESTIN DENTAL CARTRIDGE 1 MG
Tier 3
Periodontal Product - Tetracycline-Type, Collagenase Inhibitors
doxycycline hyclate Oral tablet 20 mg
Tier 1
Therapy For Drooling- Primary Or Secondary Sialorrhea-Anticholinergic
CUVPOSA ORAL SOLUTION 1 MG/5 ML
(0.2 MG/ML)
Tier 3
Multiple Sclerosis Agents
Leukocyte Adhesion Inhibitors, Alpha4-Mediated, Igg4k Mc Antibody
Tier 6
PA; 30D
AVONEX INTRAMUSCULAR KIT 30 MCG
Tier 4
PA
AVONEX INTRAMUSCULAR PEN
INJECTOR 30 MCG/0.5 ML
Tier 4
PA
AVONEX INTRAMUSCULAR PEN
INJECTOR KIT 30 MCG/0.5 ML
Tier 4
PA
AVONEX INTRAMUSCULAR SYRINGE 30
MCG/0.5 ML
Tier 4
PA
AVONEX ADMINISTRATION PACK
INTRAMUSCULAR KIT 30 MCG/0.5 ML
Tier 4
PA
BETASERON SUBCUTANEOUS KIT 0.3 MG
Tier 4
PA
BETASERON SUBCUTANEOUS RECON
SOLN 0.3 MG
Tier 4
PA
EXTAVIA SUBCUTANEOUS KIT 0.3 MG
Tier 4
PA
TYSABRI INTRAVENOUS SOLUTION 300
MG/15 ML
Multiple Sclerosis Agent - Interferons
202
Drug Name
Drug Tier
Notes
EXTAVIA SUBCUTANEOUS RECON SOLN
0.3 MG
Tier 4
PA; 30D
PLEGRIDY SUBCUTANEOUS SYRINGE 63
MCG/0.5 ML, 125 MCG/0.5 ML
Tier 4
PA
PLEGRIDY SUBCUTANEOUS PEN
INJECTOR 63 MCG/0.5 ML, 125 MCG/0.5
ML
Tier 4
PA
REBIF (WITH ALBUMIN) SUBCUTANEOUS
SYRINGE 22 MCG/0.5 ML, 44 MCG/0.5 ML
Tier 4
PA
REBIF REBIDOSE SUBCUTANEOUS PEN
INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML,
8.8MCG/0.2ML-22 MCG/0.5ML (6)
Tier 4
PA
REBIF TITRATION PACK
SUBCUTANEOUS SYRINGE 8.8MCG/0.2ML22 MCG/0.5ML (6)
Tier 4
PA
COPAXONE SUBCUTANEOUS SYRINGE 40
MG/ML
Tier 4
PA
COPAXONE SUBCUTANEOUS SYRINGE
KIT 20 MG/ML
Tier 4
PA
TECFIDERA ORAL CAPSULE,DELAYED
RELEASE(DR/EC) 120 MG, 120 MG (14)- 240
MG (46), 240 MG
Tier 4
PA
Multiple Sclerosis Agent - Others
Multiple Sclerosis Agent - Potassium Channel Blocker
AMPYRA ORAL TABLET EXTENDED
RELEASE 12 HR 10 MG
Tier 4
PA
Multiple Sclerosis Agent - Pyrimidine Synthesis Inhibitors
AUBAGIO ORAL TABLET 14 MG, 7 MG
Tier 4
PA
Multiple Sclerosis Agent - Sphingosine 1-Phosphate Receptor Modulator
GILENYA ORAL CAPSULE 0.5 MG
Tier 4
PA; QL (1 capsule per day)
Ophthalmic Agents
Artificial Tears And Lubricant Single Agents
LACRISERT OPHTHALMIC INSERT 5 MG
Tier 3
Miotics - Cholinesterase Inhibitors
PHOSPHOLINE IODIDE OPHTHALMIC
DROPS 0.125 %
Tier 2
203
Drug Name
Drug Tier
Notes
Miotics - Direct Acting
ISOPTO CARBACHOL OPHTHALMIC
DROPS 1.5 %
Tier 2
ISOPTO CARPINE OPHTHALMIC DROPS 1
%, 2 %, 4 %
Tier 3
pilocarpine HCl ophthalmic drops 1 %, 2 %, 4 %
Tier 1
Mydriatic And Cycloplegic Combinations
CYCLOMYDRIL OPHTHALMIC DROPS
0.2-1 %
Tier 3
Ophthalmic - Adrenergic-Carbonic Anhydrase Inhibitor Combinations
SIMBRINZA OPHTHALMIC
DROPS,SUSPENSION 1-0.2 %
Tier 3
Ophthalmic - Antibacterial-Glucocorticoid Combinations
BLEPHAMIDE OPHTHALMIC
DROPS,SUSPENSION 10-0.2 %
Tier 2
BLEPHAMIDE S.O.P. OPHTHALMIC
OINTMENT 10-0.2 %
Tier 2
MAXITROL OPHTHALMIC
DROPS,SUSPENSION 3.5-10,000-0.1 MG/MLUNIT/ML-%
Tier 3
MAXITROL OPHTHALMIC OINTMENT
3.5-10,000-0.1 MG-UNIT/G-%
Tier 3
neomycin-bacitracin-poly-HC ophthalmic
ointment 3.5-400-10,000 mg-unit/g-1%
Tier 1
neomycin-polymyxin-dexameth ophthalmic
drops,suspension 3.5-10,000-0.1 mg/mL-unit/mL%
Tier 1
neomycin-polymyxin-dexameth ophthalmic
ointment 3.5-10,000-0.1 mg-unit/g-%
Tier 1
neomycin-polymyxin-HC ophthalmic
drops,suspension 3.5-10,000-10 mg-unit-mg/mL
Tier 1
PRED-G OPHTHALMIC
DROPS,SUSPENSION 0.3-1 %
Tier 3
PRED-G S.O.P. OPHTHALMIC OINTMENT
0.3-0.6 %
Tier 3
sulfacetamide-prednisolone ophthalmic drops 10
%-0.23 % (0.25 %)
Tier 1
204
Drug Name
Drug Tier
TOBRADEX OPHTHALMIC
DROPS,SUSPENSION 0.3-0.1 %
Tier 3
TOBRADEX OPHTHALMIC OINTMENT
0.3-0.1 %
Tier 2
TOBRADEX ST OPHTHALMIC
Tier 3
tobramycin-dexamethasone ophthalmic
drops,suspension 0.3-0.1 %
Tier 1
ZYLET OPHTHALMIC
Tier 3
Notes
Ophthalmic - Anticholinergics
atropine ophthalmic drops 1 %
Tier 1
atropine ophthalmic ointment 1 %
Tier 1
CYCLOGYL OPHTHALMIC DROPS 0.5 %, 1
%, 2 %
Tier 3
cyclopentolate ophthalmic drops 1 %, 2 %
Tier 1
HOMATROPAIRE OPHTHALMIC DROPS 5
%
Tier 1
homatropine HBr ophthalmic drops 5 %
Tier 1
ISOPTO ATROPINE OPHTHALMIC DROPS
1%
Tier 3
ISOPTO HOMATROPINE OPHTHALMIC
DROPS 5 %
Tier 3
ISOPTO HYOSCINE OPHTHALMIC DROPS
0.25 %
Tier 3
MYDRIACYL OPHTHALMIC DROPS 1 %
Tier 3
tropicamide ophthalmic drops 0.5 %, 1 %
Tier 1
Ophthalmic - Antihistamines
ALAWAY OPHTHALMIC DROPS 0.025 %
Tier 1
azelastine ophthalmic drops 0.05 %
Tier 1
BEPREVE OPHTHALMIC DROPS 1.5 %
Tier 3
ELESTAT OPHTHALMIC DROPS 0.05 %
Tier 3
EMADINE OPHTHALMIC DROPS 0.05 %
Tier 3
epinastine ophthalmic drops 0.05 %
Tier 1
ketotifen fumarate ophthalmic drops 0.025 %
Tier 1
LASTACAFT OPHTHALMIC DROPS 0.25 %
Tier 3
PA
PA
PA
205
Drug Name
Drug Tier
Notes
OPTIVAR OPHTHALMIC DROPS 0.05 %
Tier 3
PATADAY OPHTHALMIC DROPS 0.2 %
Tier 3
PA
PATANOL OPHTHALMIC DROPS 0.1 %
Tier 2
PA
ZADITOR OPHTHALMIC DROPS 0.025 %
Tier 3
Ophthalmic - Anti-Inflammatory, Glucocorticoids
ALREX OPHTHALMIC
DROPS,SUSPENSION 0.2 %
Tier 3
dexamethasone sodium phosphate ophthalmic
drops 0.1 %
Tier 1
DUREZOL OPHTHALMIC DROPS 0.05 %
Tier 3
FLAREX OPHTHALMIC
Tier 3
fluorometholone ophthalmic drops,suspension 0.1
%
Tier 1
FML FORTE OPHTHALMIC
Tier 3
FML LIQUIFILM OPHTHALMIC
Tier 3
FML S.O.P. OPHTHALMIC OINTMENT 0.1
%
Tier 3
LOTEMAX OPHTHALMIC DROPS,GEL 0.5
%
Tier 3
LOTEMAX OPHTHALMIC
Tier 3
LOTEMAX OPHTHALMIC OINTMENT 0.5
%
Tier 3
MAXIDEX OPHTHALMIC
Tier 2
OMNIPRED OPHTHALMIC
DROPS,SUSPENSION 1 %
Tier 3
PRED FORTE OPHTHALMIC
Tier 3
PRED MILD OPHTHALMIC
Tier 2
prednisolone acetate ophthalmic drops,suspension
1%
Tier 1
prednisolone sodium phosphate ophthalmic drops
1%
Tier 1
206
Drug Name
VEXOL OPHTHALMIC
Drug Tier
Notes
Tier 3
Ophthalmic - Anti-Inflammatory, Immunomodulators
RESTASIS OPHTHALMIC DROPPERETTE
0.05 %
Tier 2
QL (2 drops per 1 day)
Ophthalmic - Anti-Inflammatory, Nsaids
ACULAR OPHTHALMIC DROPS 0.5 %
Tier 3
ACULAR LS OPHTHALMIC DROPS 0.4 %
Tier 3
ACUVAIL (PF) OPHTHALMIC
DROPPERETTE 0.45 %
Tier 3
bromfenac ophthalmic drops 0.09 %
Tier 1
diclofenac sodium ophthalmic drops 0.1 %
Tier 1
flurbiprofen sodium ophthalmic drops 0.03 %
Tier 1
ILEVRO OPHTHALMIC
Tier 3
ketorolac ophthalmic drops 0.4 %, 0.5 %
Tier 1
NEVANAC OPHTHALMIC
Tier 2
OCUFEN OPHTHALMIC DROPS 0.03 %
Tier 3
PROLENSA OPHTHALMIC DROPS 0.07 %
Tier 3
Ophthalmic - Beta Blockers-Adrenergic Combinations
COMBIGAN OPHTHALMIC DROPS 0.2-0.5
%
Tier 3
Ophthalmic - Beta Blockers-Carbonic Anhydrase Inhibitor Combinations
COSOPT OPHTHALMIC DROPS 2-0.5 %
Tier 3
COSOPT (PF) OPHTHALMIC
DROPPERETTE 2-0.5 %
Tier 3
dorzolamide-timolol ophthalmic drops 2-0.5 %
Tier 1
Ophthalmic - Carbonic Anhydrase Inhibitors
AZOPT OPHTHALMIC
Tier 2
dorzolamide ophthalmic drops 2 %
Tier 1
TRUSOPT OPHTHALMIC DROPS 2 %
Tier 3
Ophthalmic - Cystine Depleting Agents
207
Drug Name
CYSTARAN OPHTHALMIC DROPS 0.44 %
Drug Tier
Notes
Tier 4
Ophthalmic - Decongestants
phenylephrine HCl ophthalmic drops 10 %, 2.5 %
Tier 1
Ophthalmic - Intraocular Pressure Reducing Agents, Beta-Blockers
BETAGAN OPHTHALMIC DROPS 0.5 %
Tier 3
betaxolol ophthalmic drops 0.5 %
Tier 1
BETIMOL OPHTHALMIC DROPS 0.25 %,
0.5 %
Tier 3
BETOPTIC S OPHTHALMIC
Tier 3
carteolol ophthalmic drops 1 %
Tier 1
ISTALOL OPHTHALMIC DROPS, ONCE
DAILY 0.5 %
Tier 3
levobunolol ophthalmic drops 0.25 %, 0.5 %
Tier 1
metipranolol ophthalmic drops 0.3 %
Tier 1
timolol maleate ophthalmic drops 0.25 %, 0.5 %
Tier 1
timolol maleate ophthalmic gel forming solution
0.25 %, 0.5 %
Tier 1
TIMOPTIC OPHTHALMIC DROPS 0.25 %,
0.5 %
Tier 3
TIMOPTIC OCUDOSE (PF) OPHTHALMIC
DROPPERETTE 0.25 %, 0.5 %
Tier 3
TIMOPTIC-XE OPHTHALMIC GEL
FORMING SOLUTION 0.25 %, 0.5 %
Tier 3
PA
PA
PA
Ophthalmic - Local Anesthetic Esters
ALCAINE OPHTHALMIC DROPS 0.5 %
Tier 3
proparacaine ophthalmic drops 0.5 %
Tier 1
TETCAINE OPHTHALMIC DROPS 0.5 %
Tier 3
tetracaine HCl (PF) ophthalmic drops 0.5 %
Tier 1
TETRAVISC FORTE OPHTHALMIC
DROPPERETTE,HYPERVISCOUS 0.5 %
Tier 3
PA
Ophthalmic - Local Anesthetic, Amides
AKTEN (PF) OPHTHALMIC GEL 3.5 %
Tier 3
Ophthalmic - Mast Cell Stabilizers
ALOCRIL OPHTHALMIC DROPS 2 %
208
Tier 3
PA
Drug Name
Drug Tier
ALOMIDE OPHTHALMIC DROPS 0.1 %
Tier 3
cromolyn ophthalmic drops 4 %
Tier 1
Notes
PA
Ophthalmic - Photodynamic Therapy Agents
VISUDYNE INTRAVENOUS RECON SOLN
15 MG
Tier 6
30D
Ophthalmic Antibacterial Mixtures
bacitracin-polymyxin B ophthalmic ointment 50010,000 unit/gram
Tier 1
NEO-POLYCIN OPHTHALMIC OINTMENT
3.5-400-10,000 MG-UNIT-UNIT/G
Tier 3
neomycin-bacitracin-polymyxin ophthalmic
ointment 3.5-400-10,000 mg-unit-unit/g
Tier 1
neomycin-polymyxin-gramicidin ophthalmic drops
1.75-10K-0.025 mg-unit-mg/mL
Tier 1
NEOSPORIN (NEO-POLYM-GRAMICID)
OPHTHALMIC DROPS 1.75-10K-0.025 MGUNIT-MG/ML
Tier 3
polymyxin B sulf-trimethoprim ophthalmic drops
10,000 unit- 1 mg/mL
Tier 1
POLYTRIM OPHTHALMIC DROPS 10,000
UNIT- 1 MG/ML
Tier 3
Ophthalmic Antibiotic - Aminoglycosides
GARAMYCIN OPHTHALMIC DROPS 0.3 %
Tier 3
GARAMYCIN OPHTHALMIC OINTMENT
0.3 % (3 MG/GRAM)
Tier 3
GENTAK OPHTHALMIC OINTMENT 0.3 %
(3 MG/GRAM)
Tier 1
gentamicin ophthalmic drops 0.3 %
Tier 1
gentamicin ophthalmic ointment 0.3 % (3
mg/gram)
Tier 1
tobramycin ophthalmic drops 0.3 %
Tier 1
TOBREX OPHTHALMIC DROPS 0.3 %
Tier 3
TOBREX OPHTHALMIC OINTMENT 0.3 %
Tier 2
Ophthalmic Antibiotic - Dehydropeptidase Inhibitors
bacitracin ophthalmic ointment 500 unit/gram
Tier 1
Ophthalmic Antibiotic - Fluoroquinolones
209
Drug Name
Drug Tier
BESIVANCE OPHTHALMIC
Tier 3
CILOXAN OPHTHALMIC DROPS 0.3 %
Tier 3
CILOXAN OPHTHALMIC OINTMENT 0.3
%
Tier 3
ciprofloxacin ophthalmic drops 0.3 %
Tier 1
gatifloxacin ophthalmic drops 0.5 %
Tier 1
levofloxacin ophthalmic drops 0.5 %
Tier 1
MOXEZA OPHTHALMIC DROPS, VISCOUS
0.5 %
Tier 3
OCUFLOX OPHTHALMIC DROPS 0.3 %
Tier 3
ofloxacin ophthalmic drops 0.3 %
Tier 1
VIGAMOX OPHTHALMIC DROPS 0.5 %
Tier 2
ZYMAXID OPHTHALMIC DROPS 0.5 %
Tier 3
Notes
Ophthalmic Antibiotic - Macrolides
AZASITE OPHTHALMIC DROPS 1 %
Tier 3
erythromycin ophthalmic ointment 5 mg/gram (0.5
%)
Tier 1
ILOTYCIN OPHTHALMIC OINTMENT 5
MG/GRAM (0.5 %)
Tier 3
Ophthalmic Antibiotic - Sulfonamides
BLEPH-10 OPHTHALMIC DROPS 10 %
Tier 3
sulfacetamide sodium ophthalmic drops 10 %
Tier 1
PA
Ophthalmic Antifungals
NATACYN OPHTHALMIC
Tier 3
Ophthalmic Antiseptics
BETADINE OPHTHALMIC PREP
OPHTHALMIC SOLUTION 5 %
Tier 3
Ophthalmic Antivirals
trifluridine ophthalmic drops 1 %
Tier 1
VIROPTIC OPHTHALMIC DROPS 1 %
Tier 3
ZIRGAN OPHTHALMIC GEL 0.15 %
Tier 3
Ophthalmic-Intraocular Press. Reducing, Sel. Alpha Adrenergic Agonists
210
Drug Name
Drug Tier
ALPHAGAN P OPHTHALMIC DROPS 0.1
%, 0.15 %
Tier 3
apraclonidine ophthalmic drops 0.5 %
Tier 1
brimonidine ophthalmic drops 0.15 %, 0.2 %
Tier 1
IOPIDINE OPHTHALMIC DROPPERETTE 1
%
Tier 3
IOPIDINE OPHTHALMIC DROPS 0.5 %
Tier 3
Notes
Ophthalmic-Intraocular Pressure Reducing Agents, Prostaglandin Analogs
latanoprost ophthalmic drops 0.005 %
Tier 1
LUMIGAN OPHTHALMIC DROPS 0.01 %
Tier 2
RESCULA OPHTHALMIC DROPS 0.15 %
Tier 3
TRAVATAN Z OPHTHALMIC DROPS 0.004
%
Tier 3
travoprost (benzalkonium) ophthalmic drops 0.004
%
Tier 1
XALATAN OPHTHALMIC DROPS 0.005 %
Tier 3
ZIOPTAN (PF) OPHTHALMIC
DROPPERETTE 0.0015 %
Tier 3
PA
PA
PA; QL (1 unit per day)
Otic
Otic - Anti-Infective-Glucocorticoid Combinations
CIPRO HC OTIC DROPS,SUSPENSION 0.2-1
%
Tier 3
CIPRODEX OTIC DROPS,SUSPENSION 0.30.1 %
Tier 2
COLY-MYCIN S OTIC
DROPS,SUSPENSION 3.3-3-10-0.5 MG/ML
Tier 2
CORTISPORIN OTIC SOLUTION 3.5-10,0001 MG-UNIT/ML-%
Tier 3
CORTISPORIN-TC OTIC
DROPS,SUSPENSION 3.3-3-10-0.5 MG/ML
Tier 3
neomycin-polymyxin-HC otic drops,suspension
3.5-10,000-1 mg-unit/mL-%
Tier 1
neomycin-polymyxin-HC otic solution 3.5-10,0001 mg-unit/mL-%
Tier 1
Otic - Anti-Infective-Glucocorticoid-Local Anesthetic Combinations
CORTANE-B OTIC DROPS 10-10-1 MG/ML
Tier 3
PA
211
Drug Name
Drug Tier
EXOTIC-HC OTIC DROPS 10-10-1 MG/ML
Tier 1
OTICIN HC (BAK FREE) OTIC DROPS 1010-1 MG/ML
Tier 3
OTOMAX-HC OTIC DROPS 10-10-1 MG/ML
Tier 1
Notes
Otic - Anti-Infective-Local Anesthetic Combinations
chloroxylenol-pramoxine Otic Drops 0.1-1 %
Tier 1
OTICIN OTIC DROPS 0.1-1 %
Tier 3
Otic - Anti-Infectives Other
acetic acid otic solution 2 %
Tier 1
CRESYLATE OTIC DROPS 25 %
Tier 3
Otic - Fluoroquinolones
CETRAXAL OTIC DROPPERETTE 0.2 %
Tier 3
ciprofloxacin otic dropperette 0.2 %
Tier 1
ofloxacin Otic Drops 0.3 %
Tier 1
Otic - Glucocorticoids
ACETASOL HC OTIC DROPS 1-2 %
Tier 1
DERMOTIC OIL OTIC DROPS 0.01 %
Tier 3
fluocinolone acetonide oil Otic Drops 0.01 %
Tier 1
hydrocortisone-acetic acid Otic Drops 1-2 %
Tier 1
VOSOL-HC OTIC DROPS 1-2 %
Tier 3
Otic - Local Anesthetic Esters
PINNACAINE OTIC DROPS 20 %
Tier 1
Otic - Local Anesthetic-Analgesic Combinations
antipyrine-benzocaine Otic Drops 5.4-1.4 %, 5.51.4 %
Tier 1
AURODEX OTIC DROPS 5.4-1.4 %
Tier 1
OTIC CARE (ANTIPYRINE) OTIC DROPS
5.4-1.4 %
Tier 3
OTOZIN OTIC DROPS 5.4-1-2-1 %
Tier 1
TREAGAN OTIC OTIC DROPS 5.4-1.4 %
Tier 3
Otic - Pinna Combinations
CORTANE-B TOPICAL LOTION 1-1-0.1 %
Respiratory Therapy Agents
212
Tier 3
PA
Drug Name
Drug Tier
Notes
1St Generation Antihistamine-Decongestant Combinations
PEDIATEX TD ORAL LIQUID 0.938-10
MG/ML
Tier 3
PA
PROMETHAZINE VC ORAL SYRUP 6.25-5
MG/5 ML
Tier 1
older); AR
2Nd Generation Antihistamine-Decongestant Combinations
CLARINEX-D 12 HOUR ORAL TABLET, ER
MULTIPHASE 12 HR 2.5-120 MG
Tier 3
SEMPREX-D ORAL CAPSULE 8-60 MG
Tier 3
PA
Antihistamine - 1St Generation - Ethanolamines
ARBINOXA ORAL LIQUID 4 MG/5 ML
Tier 1
ARBINOXA ORAL TABLET 4 MG
Tier 1
carbinoxamine maleate oral liquid 4 mg/5 mL
Tier 1
carbinoxamine maleate oral tablet 4 mg
Tier 1
clemastine Oral Syrup 0.67 mg/5 mL
Tier 1
clemastine Oral tablet 2.68 mg
Tier 1
Tier 1
diphenhydramine HCl oral elixir 12.5 mg/5 mL
Tier 1
KARBINAL ER ORAL
SUSPENSION,EXTENDED REL 12 HR 4
MG/5 ML
Tier 3
Antihistamine - 1St Generation - Phenothiazines
Promethazine Oral Syrup 6.25 mg/5 mL
Tier 1
older); AR
promethazine oral tablet 12.5 mg, 25 mg, 50 mg
Tier 1
older); AR
Antihistamine - 1St Generation - Piperidines
cyproheptadine oral syrup 2 mg/5 mL
Tier 1
cyproheptadine oral tablet 4 mg
Tier 1
Antihistamines - 1St Generation
ARBINOXA ORAL LIQUID 4 MG/5 ML
Tier 1
ARBINOXA ORAL TABLET 4 MG
Tier 1
carbinoxamine maleate oral liquid 4 mg/5 mL
Tier 1
carbinoxamine maleate oral tablet 4 mg
Tier 1
213
Drug Name
Drug Tier
Notes
clemastine Oral Syrup 0.67 mg/5 mL
Tier 1
clemastine Oral tablet 2.68 mg
Tier 1
cyproheptadine oral syrup 2 mg/5 mL
Tier 1
cyproheptadine oral tablet 4 mg
Tier 1
Tier 1
diphenhydramine HCl oral elixir 12.5 mg/5 mL
Tier 1
KARBINAL ER ORAL
SUSPENSION,EXTENDED REL 12 HR 4
MG/5 ML
Tier 3
Promethazine Oral Syrup 6.25 mg/5 mL
Tier 1
older); AR
promethazine oral tablet 12.5 mg, 25 mg, 50 mg
Tier 1
older); AR
CLARINEX ORAL TABLET 5 MG
Tier 3
XYZAL ORAL SOLUTION 2.5 MG/5 ML
Tier 3
XYZAL ORAL TABLET 5 MG
Tier 3
Antihistamines - 2Nd Generation
Antihistamines - 2Nd Generation - Piperazines
XYZAL ORAL SOLUTION 2.5 MG/5 ML
Tier 3
XYZAL ORAL TABLET 5 MG
Tier 3
Antihistamines - 2Nd Generation - Piperidines
CLARINEX ORAL TABLET 5 MG
Tier 3
Antitussives - Nonnarcotic
benzonatate oral capsule 100 mg, 200 mg
Tier 1
TESSALON PERLES ORAL CAPSULE 100
MG
Tier 3
ZONATUSS ORAL CAPSULE 150 MG
Tier 3
Asthma Therapy - 5-Lipoxygenase Inhibitors
ZYFLO ORAL TABLET 600 MG
Tier 3
PA
ZYFLO CR ORAL TABLET, ER
Tier 3
PA
Asthma Therapy - Glucocorticoids
AEROSPAN INHALATION HFA AEROSOL
INHALER 80 MCG/ACTUATION
214
Tier 3
Drug Name
Drug Tier
ALVESCO INHALATION HFA AEROSOL
INHALER 160 MCG/ACTUATION, 80
MCG/ACTUATION
Tier 3
ASMANEX TWISTHALER INHALATION
AEROSOL POWDR BREATH ACTIVATED
110 MCG (30 DOSES), 110 MCG (7 DOSES),
220 MCG (120 DOSES), 220 MCG (14
DOSES), 220 MCG (30 DOSES), 220 MCG (60
DOSES)
Tier 2
budesonide inhalation suspension for nebulization
0.25 mg/2 mL, 0.5 mg/2 mL
Tier 1
FLOVENT DISKUS INHALATION BLISTER
WITH DEVICE 100 MCG/ACTUATION, 250
MCG/ACTUATION, 50 MCG/ACTUATION
Tier 2
FLOVENT HFA INHALATION AEROSOL
110 MCG/ACTUATION, 220
Tier 2
PULMICORT INHALATION SUSPENSION
FOR NEBULIZATION 0.25 MG/2 ML, 0.5
MG/2 ML
Tier 3
PULMICORT INHALATION SUSPENSION
FOR NEBULIZATION 1 MG/2 ML
Tier 2
PULMICORT FLEXHALER INHALATION
180 MCG/ACTUATION, 90
MCG/ACTUATION
Tier 2
QVAR INHALATION AEROSOL 40
Tier 2
Notes
Asthma Therapy - Leukotriene Receptor Antagonists
ACCOLATE ORAL TABLET 10 MG, 20 MG
Tier 3
montelukast oral granules in packet 4 mg
Tier 1
montelukast oral tablet 10 mg
Tier 1
montelukast oral tablet,chewable 4 mg, 5 mg
Tier 1
SINGULAIR ORAL GRANULES IN PACKET
4 MG
Tier 3
SINGULAIR ORAL TABLET 10 MG
Tier 3
SINGULAIR ORAL TABLET,CHEWABLE 4
MG, 5 MG
Tier 3
zafirlukast Oral tablet 10 mg, 20 mg
Tier 1
215
Drug Name
Drug Tier
Notes
Asthma Therapy - Mast Cell Stabilizers
cromolyn inhalation solution for nebulization 20
mg/2 mL
Tier 1
Asthma Therapy - Monoclonal Antibodies To Immunoglobulin E (Ige)
XOLAIR SUBCUTANEOUS RECON SOLN
150 MG
Tier 6
PA; 30D
Asthma Therapy - Xanthines
ELIXOPHYLLIN ORAL ELIXIR 80 MG/15
ML
Tier 2
LUFYLLIN ORAL TABLET 200 MG, 400 MG
Tier 3
THEO-24 ORAL CAPSULE,EXTENDED
400 MG
Tier 2
THEOCHRON ORAL TABLET EXTENDED
Tier 1
theophylline oral elixir 80 mg/15 mL
Tier 1
theophylline Oral tablet extended release 400 mg,
600 mg
Tier 1
theophylline Oral tablet extended release 12 hr
100 mg, 200 mg, 300 mg, 450 mg
Tier 1
Asthma/Copd - Phosphodiesterase-4 (Pde4) Inhibitors
DALIRESP ORAL TABLET 500 MCG
Tier 2
Asthma/Copd - Anticholinergic Agents, Inhaled Long Acting
SPIRIVA WITH HANDIHALER
INHALATION CAPSULE, W/INHALATION
DEVICE 18 MCG
Tier 2
TUDORZA PRESSAIR INHALATION
400 MCG/ACTUATION
Tier 2
Asthma/Copd - Anticholinergic Agents, Inhaled Short Acting
ATROVENT HFA INHALATION HFA
AEROSOL INHALER 17 MCG/ACTUATION
Tier 2
ipratropium bromide inhalation solution 0.02 %
Tier 1
Asthma/Copd - Beta 2-Adrenergic Agents, Inhaled, Ultra-Long Acting
ARCAPTA NEOHALER INHALATION
CAPSULE, W/INHALATION DEVICE 75
MCG
216
Tier 2
Drug Name
Drug Tier
Notes
Asthma/Copd Therapy - Anticholinergic Agents
ATROVENT HFA INHALATION HFA
Tier 2
ipratropium bromide inhalation solution 0.02 %
Tier 1
SPIRIVA WITH HANDIHALER
INHALATION CAPSULE, W/INHALATION
DEVICE 18 MCG
Tier 2
TUDORZA PRESSAIR INHALATION
400 MCG/ACTUATION
Tier 2
Asthma/Copd Therapy - Beta 2-Adrenergic Agents, Inhaled, Long Acting
ARCAPTA NEOHALER INHALATION
MCG
Tier 2
BROVANA INHALATION SOLUTION FOR
NEBULIZATION 15 MCG/2 ML
Tier 2
FORADIL AEROLIZER INHALATION
MCG
Tier 2
PERFOROMIST INHALATION SOLUTION
FOR NEBULIZATION 20 MCG/2 ML
Tier 3
SEREVENT DISKUS INHALATION
BLISTER WITH DEVICE 50 MCG/DOSE
Tier 2
Asthma/Copd Therapy - Beta 2-Adrenergic Agents, Inhaled, Short Acting
albuterol sulfate inhalation solution for
nebulization 0.63 mg/3 mL, 1.25 mg/3 mL, 2.5 mg
/3 mL (0.083 %), 5 mg/mL
Tier 1
levalbuterol HCl inhalation solution for
nebulization 0.31 mg/3 mL, 0.63 mg/3 mL, 1.25
mg/0.5 mL
Tier 1
PROAIR HFA INHALATION HFA
Tier 3
PA
PROVENTIL HFA INHALATION HFA
Tier 3
PA
VENTOLIN HFA INHALATION HFA
Tier 2
XOPENEX INHALATION SOLUTION FOR
NEBULIZATION 0.31 MG/3 ML, 0.63 MG/3
ML, 1.25 MG/3 ML
Tier 3
217
Drug Name
XOPENEX HFA INHALATION HFA
Drug Tier
Tier 3
Notes
PA
Asthma/Copd Therapy - Beta Adrenergic Agents
albuterol sulfate Oral Syrup 2 mg/5 mL
Tier 1
albuterol sulfate Oral tablet 2 mg, 4 mg
Tier 1
albuterol sulfate Oral tablet extended release 12
hr 4 mg, 8 mg
Tier 1
metaproterenol Oral Syrup 10 mg/5 mL
Tier 1
metaproterenol Oral tablet 10 mg, 20 mg
Tier 1
terbutaline Oral tablet 2.5 mg, 5 mg
Tier 1
VOSPIRE ER ORAL TABLET EXTENDED
Tier 3
Asthma/Copd Therapy - Beta Adrenergic-Anticholinergic Combinations
COMBIVENT RESPIMAT INHALATION
AEROSOL 20-100 MCG/ACTUATION
Tier 2
ipratropium-albuterol inhalation solution for
nebulization 0.5 mg-3 mg(2.5 mg base)/3 mL
Tier 1
QL (6 doses per 1 day)
Asthma/Copd Therapy - Beta Adrenergic-Glucocorticoid Combinations
ADVAIR DISKUS INHALATION BLISTER
WITH DEVICE 100-50 MCG/DOSE, 250-50
MCG/DOSE, 500-50 MCG/DOSE
Tier 2
ADVAIR HFA INHALATION HFA
AEROSOL INHALER 115-21
MCG/ACTUATION, 230-21
MCG/ACTUATION, 45-21
MCG/ACTUATION
Tier 2
BREO ELLIPTA INHALATION BLISTER
WITH DEVICE 100-25 MCG/DOSE
Tier 2
DULERA INHALATION HFA AEROSOL
INHALER 100-5 MCG/ACTUATION, 200-5
MCG/ACTUATION
Tier 2
SYMBICORT INHALATION HFA AEROSOL
INHALER 160-4.5 MCG/ACTUATION, 80-4.5
MCG/ACTUATION
Tier 2
Cystic Fibrosis-Transmembrane Conductance Regulator (Cftr) Potentiator
KALYDECO ORAL TABLET 150 MG
Elastase Inhibitors
218
Tier 4
PA
Drug Name
Drug Tier
GLASSIA INTRAVENOUS SOLUTION 1
GRAM/50 ML (2 %)
Tier 6
Notes
30D
Mucolytics
acetylcysteine solution 100 mg/mL (10 %), 200
mg/mL (20 %)
Tier 1
PULMOZYME INHALATION SOLUTION 1
MG/ML
Tier 2
Narcotic Antitussive-1St Gen. Antihistamine-Decongestant Combinations
cpm-pseudoephed-hydrocodone oral solution 460-5 mg/5 mL
Tier 3
PROMETHAZINE VC-CODEINE ORAL
SYRUP 6.25-5-10 MG/5 ML
Tier 3
ZUTRIPRO ORAL SOLUTION 4-60-5 MG/5
ML
Tier 3
older); AR
Narcotic Antitussive-1St Generation Antihistamine Combinations
chlorpheniramine-hydrocodone oral
suspension,extended rel 12 hr 8-10 mg/5 mL
Tier 1
promethazine-codeine oral syrup 6.25-10 mg/5 mL
Tier 1
TUSSICAPS ORAL CAPSULE,EXTENDED
RELEASE 12 HR 4-5 MG, 8-10 MG
Tier 3
TUSSIONEX PENNKINETIC ER ORAL
SUSPENSION,EXTENDED REL 12 HR 8-10
MG/5 ML
Tier 3
VITUZ ORAL SOLUTION 4-5 MG/5 ML
Tier 3
older); AR
PA
Narcotic Antitussive-Anticholinergic Combinations
hydrocodone-homatropine Oral Syrup 5-1.5 mg/5
mL
Tier 1
hydrocodone-homatropine Oral tablet 5-1.5 mg
Tier 1
HYDROMET ORAL SYRUP 5-1.5 MG/5 ML
Tier 1
TUSSIGON ORAL TABLET 5-1.5 MG
Tier 3
Narcotic Antitussive-Decongestant Combinations
REZIRA ORAL SOLUTION 60-5 MG/5 ML
Tier 3
Narcotic Antitussive-Expectorant Combinations
codeine-guaifenesin oral liquid 10-100 mg/5 mL
Tier 1
Nasal Antibiotics
219
Drug Name
BACTROBAN NASAL NASAL OINTMENT 2
%
Drug Tier
Tier 2
Notes
PA; QL 10 GMs per month
Nasal Anticholinergics
ATROVENT NASAL SPRAY,NONAEROSOL 0.03 %, 0.06 %
Tier 3
ipratropium bromide nasal spray,non-aerosol 0.03
%, 0.06 %
Tier 1
Nasal Antihistamine And Anti-Inflammatory Steroid Combinations
DYMISTA NASAL SPRAY,NON-AEROSOL
137-50 MCG/SPRAY
Tier 3
PA
Nasal Antihistamines
ASTEPRO NASAL SPRAY,NON-AEROSOL
0.15 % (205.5 MCG)
Tier 3
azelastine nasal aerosol,spray 137 mcg
Tier 1
azelastine nasal spray,non-aerosol 0.15 % (205.5
mcg)
Tier 1
PATANASE NASAL SPRAY,NON-AEROSOL
0.6 %
Tier 3
Nasal Corticosteroids
BECONASE AQ NASAL SPRAY,NONAEROSOL 42 MCG (0.042 %)
Tier 3
budesonide nasal spray,non-aerosol 32
mcg/actuation
Tier 1
FLONASE NASAL SPRAY,SUSPENSION 50
MCG/ACTUATION
Tier 3
flunisolide nasal spray,non-aerosol 25 mcg (0.025
%)
Tier 1
fluticasone nasal spray,suspension 50
mcg/actuation
Tier 1
NASONEX NASAL SPRAY,NON-AEROSOL
50 MCG/ACTUATION
Tier 3
PA
OMNARIS NASAL SPRAY,NON-AEROSOL
50 MCG
Tier 3
PA
QNASL NASAL HFA AEROSOL INHALER
80 MCG/ACTUATION
Tier 3
PA
RHINOCORT AQUA NASAL SPRAY,NONAEROSOL 32 MCG/ACTUATION
Tier 3
220
PA
Drug Name
Drug Tier
Notes
triamcinolone acetonide nasal aerosol,spray 55
mcg
Tier 1
VERAMYST NASAL SPRAY,SUSPENSION
27.5 MCG/ACTUATION
Tier 3
PA
ZETONNA NASAL HFA AEROSOL
INHALER 37 MCG/ACTUATION
Tier 3
PA
Nasal Sympathomimetic Decongestants (Intranasal)
TYZINE NASAL DROPS 0.05 %, 0.1 %
Tier 3
TYZINE NASAL SPRAY,NON-AEROSOL 0.1
%
Tier 3
Non-Narc Antitussive-1St Gen. Antihistamine-Decongestant Combinations
BROMFED DM ORAL SYRUP 2-30-10 MG/5
ML
Tier 1
Non-Narcotic Antitus-Decongestant-Analgesic,Non-Salicylate-Expectorant
DURAFLU ORAL TABLET 60-20-200-500
MG
Tier 3
Non-Narcotic Antitussive-Antihistamine Combinations
promethazine-DM Oral Syrup 6.25-15 mg/5 mL
Tier 1
older); AR
Vaginal Products
Vaginal Antibacterial - Lincosamides
CLEOCIN VAGINAL CREAM 2 %
Tier 3
CLEOCIN VAGINAL SUPPOSITORY 100
MG
Tier 3
clindamycin phosphate vaginal cream 2 %
Tier 1
CLINDESSE VAGINAL CREAM,EXTENDED
RELEASE 2 %
Tier 3
Vaginal Antibacterial - Sulfonamides
AVC VAGINAL VAGINAL CREAM 15 %
Tier 2
Vaginal Antifungal - Imidazoles
GYNAZOLE-1 VAGINAL CREAM 2 %
Tier 3
MICONAZOLE-3 VAGINAL SUPPOSITORY
200 MG
Tier 1
Vaginal Antifungal - Triazoles
TERAZOL 3 VAGINAL CREAM 0.8 %
Tier 3
221
Drug Name
Drug Tier
TERAZOL 7 VAGINAL CREAM 0.4 %
Tier 3
terconazole vaginal cream 0.4 %, 0.8 %
Tier 1
terconazole vaginal suppository 80 mg
Tier 1
Notes
Vaginal Antiprotozoal-Antibacterial - Nitroimidazole Derivatives
METROGEL VAGINAL VAGINAL GEL 0.75
%
Tier 3
metronidazole vaginal gel 0.75 %
Tier 1
VANDAZOLE VAGINAL GEL 0.75 %
Tier 2
Vaginal Antiseptic Mixtures
FEM PH VAGINAL GEL 0.9-0.025 %
Tier 3
RELAGARD VAGINAL GEL 0.9-0.025 %
Tier 3
Vaginal Estrogens
ESTRACE VAGINAL CREAM 0.01 % (0.1
MG/GRAM)
Tier 2
ESTRING VAGINAL RING 2 MG
Tier 3
FEMRING VAGINAL RING 0.05 MG/24 HR,
0.1 MG/24 HR
Tier 3
PREMARIN VAGINAL CREAM 0.625
MG/GRAM
Tier 2
VAGIFEM VAGINAL TABLET 10 MCG
Tier 3
Vaginal Progestins
CRINONE VAGINAL GEL 4 %
222
Tier 3
Medical Only Drugs
Drug Name
Drug Tier
Notes
ABILIFY INTRAMUSCULAR SOLUTION
9.75 MG/1.3 ML
Tier 6
30D
ABILIFY MAINTENA INTRAMUSCULAR
MG
Tier 6
30D
ABILIFY MAINTENA INTRAMUSCULAR
MG
Tier 6
HYCAMTIN INTRAVENOUS RECON SOLN
4 MG
Tier 6
30D
LUPRON DEPOT INTRAMUSCULAR
SYRINGE KIT 7.5 MG
Tier 6
30D
INTRAMUSCULAR SYRINGE KIT 22.5 MG
Tier 6
30D
INTRAMUSCULAR SYRINGE KIT 30 MG
Tier 6
30D
INTRAMUSCULAR SYRINGE KIT 45 MG
Tier 6
30D
ORENCIA (WITH MALTOSE)
INTRAVENOUS RECON SOLN 250 MG
Tier 6
PA; 30D
REMICADE INTRAVENOUS RECON SOLN
100 MG
Tier 6
PA; 30D
REVATIO INTRAVENOUS SOLUTION 10
MG/12.5 ML
Tier 6
TEMODAR INTRAVENOUS RECON SOLN
100 MG
Tier 6
223
Index
GAMMAGARD S-D (IGA
&LT .................................. 61
8-MOP ................................ 134
abacavir ................................ 38
abacavir-lamivudinezidovudine ........................ 39
ABILIFY .............. 99, 106, 223
ABILIFY DISCMELT . 99, 106
ABILIFY MAINTENA ...... 223
ABRAXANE ........................ 56
ABSORICA ........................ 125
ABSTRAL............................ 18
acamprosate ........................ 113
ACANYA ........................... 126
acarbose .............................. 156
ACCOLATE....................... 215
ACCUPRIL .......................... 66
ACCURETIC ....................... 67
ACD-A ............................... 189
acebutolol ............................. 76
ACEON ................................ 66
ACETADOTE ...................... 31
acetaminophen-codeine ........ 21
ACETASOL HC ................ 212
acetazolamide ....................... 81
acetic acid ........................... 212
acetylcysteine ............... 31, 218
ACIPHEX........................... 176
ACIPHEX SPRINKLE ...... 176
acitretin ............................... 134
ACTEMRA .......................... 25
ACTHAR H.P. ................... 154
ACTIGALL ........................ 175
ACTIMMUNE ..................... 36
ACTIQ .................................. 18
ACTIVELLA ..................... 160
ACTONEL ......................... 159
ACTOPLUS MET .............. 157
ACTOPLUS MET XR ....... 157
ACTOS ............................... 169
ACULAR ........................... 207
ACULAR LS ...................... 207
ACUVAIL (PF) .................. 207
acyclovir ....................... 44, 135
acyclovir sodium .................. 44
ACZONE ............................ 125
ADACEL(TDAP
ADOLESN/ADULT)(PF) 63
224
ADAGEN ........................... 199
ADALAT CC ....................... 78
adapalene ............................ 129
ADCETRIS .................... 51, 58
ADCIRCA ............................ 84
ADDERALL ...... 102, 108, 111
ADDERALL XR ........ 102, 108
adefovir ................................. 43
ADEMPAS ........................... 84
ADIPEX-P .......................... 147
ADOXA................................ 48
ADRENACLICK ................. 80
ADRIAMYCIN .................... 57
ADRUCIL ............................ 52
ADULT LOW DOSE
ASPIRIN ........................ 192
ADVAIR DISKUS ............. 218
ADVAIR HFA ................... 218
ADVICOR ............................ 73
AEROSPAN ....................... 214
AFEDITAB CR .................... 78
AFINITOR ........................... 55
AFINITOR DISPERZ .......... 55
AGGRENOX...................... 192
AGRYLIN .......................... 192
AKNE-MYCIN .................. 130
AKTEN (PF) ...................... 208
ALA-CORT ........................ 137
ALAGESIC LQ .................... 24
ALA-QUIN ........................ 131
ALA-SCALP ...................... 137
ALAWAY .......................... 205
ALBENZA ........................... 34
albuterol sulfate .................. 217
ALCAINE .......................... 208
alclometasone ..................... 137
ALCORTIN A .................... 131
ALDACTAZIDE .................. 82
ALDACTONE................ 68, 81
ALDARA ........................... 141
ALDURAZYME ................ 199
alendronate ......................... 159
ALFERON N ...................... 142
alfuzosin ............................. 185
ALIMTA .............................. 51
ALINIA ................................ 36
ALKERAN ........................... 50
allopurinol .......................... 189
ALOCRIL ...........................208
ALOMIDE ..........................208
ALOPRIM ..........................189
ALOQUIN ..........................130
ALORA .............................. 161
ALOXI ................................ 174
ALPHAGAN P ...................210
ALPHANINE SD ...............190
alprazolam ............................85
ALPRAZOLAM INTENSOL
..........................................85
ALREX ............................... 206
ALSUMA ...........................109
ALTABAX .........................130
ALTACE ..............................66
ALTAVERA (28) ...............118
ALTOPREV .........................74
ALUVEA ............................136
ALVESCO ..........................214
ALYACEN 1/35 (28) .........118
ALYACEN 7/7/7 (28) ........123
amantadine HCl ....................98
AMARYL ...........................157
AMBIEN ............................113
AMBIEN CR ......................113
AMBISOME.........................34
amcinonide .........................137
AMERGE ...........................109
AMETHIA ..........................117
AMETHIA LO ...................117
AMETHYST ......................118
amifostine crystalline............59
amiloride ...............................82
amiloride-hydrochlorothiazide
..........................................82
aminocaproic acid ...............191
amiodarone ...........................72
AMITIZA ...........................179
amitriptyline .........................96
amitriptyline-chlordiazepoxide
..........................................96
amlodipine ............................78
amlodipine-atorvastatin ........75
amlodipine-benazepril ..........66
ammonium lactate ..............136
AMNESTEEM ...................125
amoxapine.............................96
amoxicil-clarithromy-lansopraz
........................................ 182
amoxicillin............................ 33
amoxicillin-pot clavulanate .. 33
AMPHETAMINE SALT
COMBO ......... 103, 108, 111
ampicillin.............................. 33
AMPYRA ........................... 203
AMRIX............................... 197
AMTURNIDE ...................... 84
ANACAINE ....................... 145
ANADROL-50 ................... 154
ANAFRANIL ....................... 96
anagrelide ........................... 192
ANALPRAM E .................... 31
ANALPRAM-HC................. 31
ANAPROX........................... 27
ANAPROX DS .................... 27
ANASPAZ ......................... 177
anastrozole ............................ 52
ANCOBON .......................... 35
ANDRODERM .................. 154
ANDROGEL ...................... 154
ANDROID ......................... 154
ANDROXY ........................ 154
ANGELIQ .......................... 160
ANIMI-3 WITH VITAMIN D
........................................ 152
ANSAID ............................... 27
ANTABUSE....................... 114
ANTARA ............................. 73
antipyrine-benzocaine ........ 212
ANTIVERT ........................ 173
ANUCORT-HC .................... 30
ANUSOL-HC ....................... 30
ANZEMET ......................... 174
APEXICON E .................... 137
APIDRA ............................. 168
APIDRA SOLOSTAR ....... 168
APLENZIN .......................... 93
APOKYN ............................. 98
AppendixE .......................... 15
apraclonidine ...................... 210
APRI ................................... 118
APRISO .............................. 179
APTIOM............................... 89
APTIVUS ............................. 47
ARANELLE (28) ............... 123
ARANESP (IN
POLYSORBATE) .......... 190
ARAVA ................................ 26
ARBINOXA ....................... 213
ARCALYST ......................... 24
ARCAPTA NEOHALER .. 216,
217
ARESTIN ........................... 202
ARICEPT ........................... 115
ARICEPT ODT .................. 115
ARIMIDEX .......................... 52
ARIXTRA .......................... 191
ARMOUR THYROID ....... 171
AROMASIN ......................... 52
ARTHROTEC 50 ................. 26
ARTHROTEC 75 ................. 26
ARTISS .............................. 145
ARZERRA ........................... 53
ASACOL HD ..................... 179
ASCOMP WITH CODEINE 21
ASMANEX TWISTHALER
........................................ 214
aspirin ........................... 29, 193
ASPIR-LOW ................ 29, 192
ASTAGRAF XL................. 194
ASTEPRO .......................... 220
ASTRINGYN ..................... 191
ATACAND .......................... 69
ATACAND HCT ................. 69
ATELVIA ........................... 159
atenolol ................................. 75
atenolol-chlorthalidone ......... 79
ATGAM ............................... 62
ATIVAN ............................... 85
ATOPICLAIR .................... 136
atorvastatin ........................... 74
atovaquone............................ 36
atovaquone-proguanil ........... 36
ATRALIN .......................... 129
ATRIPLA ............................. 39
atropine ............................... 205
ATROVENT ...................... 219
ATROVENT HFA ............. 216
AUBAGIO.......................... 203
AUBRA .............................. 118
AUGMENTIN ................ 33, 34
AUGMENTIN ES-600 ......... 34
AUGMENTIN XR ............... 34
AURODEX ........................ 212
AUVI-Q ................................ 80
AVALIDE ............................ 69
AVANDAMET .................. 157
AVANDARYL ...................158
AVANDIA .........................169
AVAPRO ..............................69
AVAR ......................... 126, 127
AVAR LS ...........................127
AVAR-E .............................130
AVAR-E GREEN ...............131
AVAR-E LS .......................127
AVASTIN.............................49
AVC VAGINAL ................221
AVELOX ..............................42
AVELOX ABC PACK .........42
AVIANE .............................118
AVIDOXY ...........................48
AVINZA ...............................18
AVITA ................................ 129
AVODART.........................185
AVONEX ...........................202
AVONEX
ADMINISTRATION PACK
........................................202
AXERT ............................... 109
AXIRON.............................154
AYGESTIN ........................170
azacitidine .............................52
AZASAN ............................195
AZASITE ...........................210
azathioprine ........................195
azelastine ....................205, 220
AZELEX.....................126, 144
AZILECT .............................98
azithromycin .........................45
Azithromycin ........................45
AZOPT ............................... 207
AZOR ...................................68
AZULFIDINE ....................179
AZULFIDINE EN-TABS ..179
AZURETTE (28) ................117
bacitracin ............................209
bacitracin-polymyxin B ......209
baclofen .............................. 197
BACMIN ............................151
BACTRIM ............................34
BACTRIM DS ......................34
BACTROBAN ...................130
BACTROBAN NASAL .....219
balsalazide ..........................179
BALZIVA (28) ...................118
BANZEL ..............................92
BARACLUDE ......................43
225
BAYER CHEWABLE
ASPIRIN .................. 29, 193
BAYER PLUS EXTRA
STRENGTH ..................... 29
BD AUTOSHIELD PEN
NEEDLE ........................ 198
BD ECLIPSE LUER-LOK. 198
BD INSULIN PEN NEEDLE
UF SHORT ..................... 198
BD INSULIN SYRINGE
ULTRA-FINE ................ 198
BECONASE AQ ................ 220
belladonna alkaloids-opium 179
BELLADONNA-OPIUM .. 179
BELVIQ ............................. 147
benazepril ............................. 66
benazepril-hydrochlorothiazide
.......................................... 67
BENICAR ............................ 69
BENICAR HCT ................... 69
BENLYSTA ......................... 26
BENSAL HP ...................... 142
BENTYL ............................ 178
BENZAC AC WASH......... 128
BENZACLIN ..................... 127
BENZACLIN PUMP ......... 127
benzalkonium chloride ....... 115
BENZAMYCIN ................. 127
BENZAMYCINPAK ......... 127
BENZEFOAM ................... 128
BENZEFOAM ULTRA ..... 128
BENZEPRO ....................... 128
benzonatate ......................... 214
benzoyl peroxide ................ 128
benzphetamine .................... 147
benztropine ........................... 98
BEPREVE .......................... 205
BERINERT ........................ 189
BESIVANCE ..................... 209
BETADINE OPHTHALMIC
PREP .............................. 210
BETAGAN ......................... 207
betamethasone dipropionate
........................................ 137
betamethasone valerate ...... 137
betamethasone, augmented. 137
BETAPACE ................... 72, 76
BETAPACE AF ............. 72, 76
BETASERON .................... 202
betaxolol ....................... 75, 208
226
bethanechol chloride........... 188
BETHKIS ............................. 33
BETIMOL .......................... 208
BETOPTIC S ...................... 208
BEYAZ ............................... 118
BIAXIN .......................... 45, 46
BIAXIN XL .......................... 46
BIAXIN XL PAK ................. 46
bicalutamide ......................... 51
BICNU.................................. 50
BIDIL ................................... 85
BIFERA RX ....................... 149
BILTRICIDE ........................ 34
BINOSTO ........................... 159
BIOTHRAX ......................... 64
bisoprolol fumarate............... 75
bisoprolol-hydrochlorothiazide
.......................................... 79
BIVIGAM ............................ 61
bleomycin ............................. 58
BLEPH-10 .......................... 210
BLEPHAMIDE .................. 204
BLEPHAMIDE S.O.P. ....... 204
BONIVA ............................ 159
BONTRIL PDM ................. 147
BOSULIF ............................. 56
BOTOX .............................. 196
BP 10-1 ............................... 127
BP FOAM........................... 128
BP WASH .......................... 128
BP-50% UREA................... 142
B-PLEX PLUS ................... 151
BPO .................................... 128
BRAVELLE ....................... 163
BREO ELLIPTA ................ 218
BREVICON (28) ................ 118
BRIELLYN ........................ 118
BRILINTA ......................... 192
brimonidine ........................ 210
BRINTELLIX ...................... 96
BRISDELLE ...................... 170
BROMFED DM ................. 221
bromfenac ........................... 207
bromocriptine ....................... 98
BROVANA ........................ 217
BUCALSEP........................ 201
budesonide .......... 180, 215, 220
BUFFERIN ........................... 29
bumetanide ........................... 81
BUNAVAIL ....................... 113
BUPAP .................................24
BUPHENYL .......................200
bupivacaine ...........................30
bupivacaine (PF) ...................30
bupivacaine-dextrosewater(PF) ..........................30
buprenorphine .....................113
buprenorphine-naloxone .....113
BUPROBAN ......................114
bupropion HCl ..............93, 114
buspirone ..............................86
BUSULFEX .........................49
BUTALBITAL COMPOUND
W/CODEINE ....................21
butalbital-acetaminop-caf-cod
..........................................21
butalbital-acetaminophen .....24
butalbital-acetaminophen-caff
..........................................24
butalbital-aspirin-caffeine.....29
BUTISOL ...........................112
butorphanol tartrate ..............23
BUTRANS ...........................23
BYDUREON ......................158
BYETTA ............................158
BYSTOLIC...........................75
cabergoline .........................170
CA-DTPA .............................32
CADUET ..............................75
CAFCIT .............................. 108
CAFERGOT .......................109
caffeine citrated ..................108
CALAN .......................... 72, 79
CALAN SR ..........................79
calcipotriene .......................134
calcipotriene-betamethasone
........................................130
calcitonin (salmon) .............160
CALCITRENE ...................134
calcitriol ...................... 134, 153
calcium acetate ...........149, 182
CALCIUM FOLINATE
(LEUCOVORIN) .............59
CAMBIA ........27, 28, 109, 110
CAMILA ............................122
CAMPRAL .........................114
CAMPTOSAR ......................57
CAMRESE .........................117
CAMRESE LO ...................117
CANASA ............................179
candesartan ........................... 69
candesartan-hydrochlorothiazid
.......................................... 69
CANTIL ............................. 178
CAPACET............................ 24
capecitabine .......................... 52
CAPEX ............................... 137
CAPITAL WITH CODEINE
.......................................... 21
CAPRELSA ......................... 56
captopril ................................ 66
captopril-hydrochlorothiazide
.......................................... 67
CARAC .............................. 133
CARAFATE ....................... 182
CARBAGLU ...................... 200
carbamazepine ...... 89, 104, 105
CARBATROL.............. 89, 105
carbidopa .............................. 98
carbidopa-levodopa .............. 97
carbidopa-levodopaentacapone ........................ 97
carbinoxamine maleate ....... 213
carboplatin ............................ 55
CARDENE IV ...................... 78
CARDENE SR ..................... 78
CARDIZEM ......................... 77
CARDIZEM CD .................. 77
CARDIZEM LA ................... 77
CARDURA .......................... 83
CARDURA XL .................... 83
CARIMUNE NF
NANOFILTERED ........... 61
carisoprodol ........................ 197
carisoprodol-ASA-codeine . 198
carisoprodol-aspirin ............ 196
CARNITOR ............... 199, 200
carteolol .............................. 208
CARTIA XT ......................... 77
carvedilol .............................. 68
CASODEX ........................... 51
CATAFLAM ........................ 27
CATAPRES ......................... 80
CATAPRES-TTS-1.............. 80
CATAPRES-TTS-2.............. 80
CATAPRES-TTS-3.............. 80
CAYSTON ........................... 47
CAZIANT (28) ................... 123
CEDAX ................................ 41
cefaclor ................................. 40
cefadroxil .............................. 40
cefdinir.................................. 41
cefditoren pivoxil ................. 41
cefpodoxime ......................... 41
cefprozil .......................... 40, 41
ceftibuten .............................. 41
CEFTIN ................................ 41
cefuroxime axetil .................. 41
CELEBREX ......................... 26
CELEXA .............................. 93
CELLCEPT ................ 194, 195
CELONTIN .......................... 92
CEM-UREA ....................... 142
CENESTIN ......................... 161
CENTANY ......................... 130
cephalexin ............................. 40
CEREBYX ........................... 89
CEREZYME ...................... 199
CERUBIDINE ...................... 58
CERVARIX VACCINE (PF)
.......................................... 64
CERVIDIL ......................... 153
CESAMET ......................... 173
CETRAXAL....................... 212
CETROTIDE ...................... 169
cevimeline .......................... 202
CHANTIX .......................... 114
CHANTIX CONTINUING
MONTH BOX ................ 115
CHANTIX CONTINUING
MONTH PAK ................ 115
CHANTIX STARTING
MONTH BOX ................ 115
CHANTIX STARTING
MONTH PAK ................ 115
CHATEAL ......................... 118
CHEMET.............................. 32
CHENODAL ...................... 175
chlordiazepoxide HCl ........... 85
chlordiazepoxide-clidinium 179
chlorhexidine gluconate .... 115,
201
chloroquine phosphate .......... 36
chlorothiazide ....................... 82
chloroxylenol-pramoxine ... 211
chlorpheniramine-hydrocodone
........................................ 219
chlorpromazine ................... 101
chlorpropamide ................... 157
chlorthalidone ....................... 82
chlorzoxazone .....................197
cholestyramine (with sugar) .72
choline & magnesium
salicylate ...........................29
CIALIS ............................... 146
CICLODAN ...............131, 132
ciclopirox ............................132
ciclopirox-ure-camph-mentheuc...................................132
cilostazol .............................192
CILOXAN ..........................209
cimetidine ...................175, 176
CIMZIA ........................ 24, 180
CIMZIA POWDER FOR
RECONST ......................180
CIMZIA STARTER KIT ....25,
181
CINRYZE ...........................189
CIPRO ..................................42
CIPRO HC ..........................211
CIPRO XR ..........................187
CIPRODEX ........................211
ciprofloxacin .........42, 210, 212
ciprofloxacin (mixture) .......187
cisplatin.................................55
citalopram .............................93
cladribine ..............................51
CLARAVIS ........................125
CLARIFOAM EF ...............127
CLARINEX ........................214
CLARINEX-D 12 HOUR ..213
CLARIS CLARIFYING
WASH ....................127, 144
clarithromycin.......................46
CLEANSING WASH .127, 144
clemastine ...........................213
CLEOCIN .....................45, 221
CLEOCIN T .......................126
CLEVIPREX ........................78
CLIMARA ..........................161
CLIMARA PRO .................160
CLINDACIN P ...................126
CLINDAGEL .....................126
clindamycin HCl ...................45
clindamycin palmitate HCl ...45
clindamycin phosphate ......126,
221
clindamycin-benzoyl peroxide
........................................127
CLINDESSE.......................221
227
CLINPRO 5000 .................. 200
clobetasol .................... 137, 138
clobetasol-emollient ........... 138
CLOBEX ............................ 138
clocortolone pivalate .......... 138
CLODAN ........................... 138
CLODERM ........................ 138
clomiphene citrate .............. 170
clomipramine........................ 96
clonazepam ............... 85, 86, 87
clonidine ............................... 80
clonidine HCl ....................... 80
clopidogrel .......................... 193
clorazepate dipotassium ....... 86
CLORPRES.......................... 80
clotrimazole ................ 132, 201
clotrimazole-betamethasone
........................................ 133
clozapine............................. 100
CLOZARIL ........................ 100
COARTEM .......................... 36
codeine sulfate ...................... 18
codeine-guaifenesin ............ 219
COGENTIN ......................... 98
COLAZAL ......................... 179
colchicine-probenecid ........ 189
COLCRYS ......................... 189
COLESTID........................... 72
colestipol .............................. 72
Colestipol ............................. 72
COLOCORT ...................... 180
COLY-MYCIN S ............... 211
COLYTE WITH FLAVOR
PACKS ........................... 181
COMBIGAN ...................... 207
COMBIPATCH .................. 161
COMBIVENT RESPIMAT 218
COMBIVIR .......................... 39
COMETRIQ ......................... 55
COMPAZINE..................... 173
COMPLERA ........................ 39
COMPRO ........................... 173
COMTAN............................. 98
CONCERTA ...................... 103
CONDYLOX ..................... 142
CONSTULOSE .................. 181
CONZIP ............................... 18
COPAXONE ...................... 203
COPEGUS............................ 44
CORDARONE ..................... 72
228
CORDRAN ........................ 138
CORDRAN TAPE LARGE
ROLL.............................. 138
CORDRAN TAPE SMALL
ROLL.............................. 138
COREG ................................ 68
COREG CR .......................... 68
CORGARD .......................... 76
CORMAX .......................... 138
CORTANE-B ............. 211, 212
CORTEF............................. 163
CORTENEMA ................... 180
CORTIFOAM .................... 180
cortisone ............................. 163
CORTISPORIN .......... 131, 211
CORTISPORIN-TC ........... 211
CORVITE FREE ................ 151
CORZIDE ............................. 83
COSMEGEN ........................ 57
COSOPT............................. 207
COSOPT (PF)..................... 207
COUMADIN ...................... 189
COVARYX ........................ 160
COVARYX H.S. ................ 160
COZAAR.............................. 69
cpm-pseudoephedhydrocodone ................... 219
CREON .............................. 175
CRESTOR ............................ 74
CRESYLATE ..................... 212
CRINONE .................. 169, 222
CRIXIVAN .......................... 47
cromolyn ............... 54, 208, 215
CRYSELLE (28) ................ 118
CUPRIMINE .................. 26, 32
CUTIVATE ........................ 138
CUVPOSA ......................... 202
cyanocobalamin (vitamin B12)................................... 153
CYCLAFEM 1/35 (28) ...... 118
CYCLAFEM 7/7/7 (28) ..... 123
CYCLESSA (28) ................ 123
cyclobenzaprine .................. 197
CYCLOGYL ...................... 205
CYCLOMYDRIL............... 204
cyclopentolate ..................... 205
cyclophosphamide ................ 50
cycloserine ............................ 39
CYCLOSET ....................... 156
cyclosporine........................ 194
cyclosporine modified ........194
CYKLOKAPRON ..............191
CYMBALTA ........................95
cyproheptadine ...................213
CYRAMZA ..........................57
CYSTADANE ....................200
CYSTAGON ......................184
CYSTARAN.......................207
cytarabine (PF) .....................52
CYTOGAM ..........................61
CYTOMEL .........................172
CYTOTEC ..........................177
CYTOVENE.........................42
CYTRA K CRYSTALS .....185
CYTRA-2 ...........................185
CYTRA-3 ...........................185
D.H.E.45 .............................109
dacarbazine ...........................50
DACOGEN...........................52
dactinomycin ........................57
DALIRESP .........................216
danazol ................................ 165
DANTRIUM...............197, 198
dantrolene ...........................198
dapsone .................................36
DARAPRIM .........................36
DASETTA 1/35 (28) ..........118
DASETTA 7/7/7 (28) .........123
daunorubicin .........................58
DAUNOXOME ....................58
DAYPRO ..............................28
DAYSEE ............................117
DAYTRANA ......................103
DDAVP .............................. 155
DEBACTEROL ..................201
deferoxamine ........................32
DELATESTRYL ................154
DELESTROGEN ...............161
DELZICOL.........................179
DEMADEX ..........................81
demeclocycline .....................48
DEMEROL ...........................18
DEMSER ..............................83
DENAVIR ..........................135
DENTA 5000 PLUS ...........200
DENTAGEL .......................200
DEPACON ...........................87
DEPAKENE .................87, 105
DEPAKOTE .................87, 105
DEPAKOTE ER ...87, 105, 109
DEPAKOTE SPRINKLES . 87,
105
DEPEN TITRATABS .... 26, 32
DEPOCYT (PF) ................... 52
DEPO-ESTRADIOL .......... 161
DEPO-MEDROL ............... 163
DEPO-PROVERA 55, 116, 117
DEPO-SUBQ PROVERA 104
........................................ 117
DEPO-TESTOSTERONE.. 154
DERMA-SMOOTHE/FS
BODY OIL ..................... 138
DERMA-SMOOTHE/FS
SCALP OIL .................... 138
DERMATOP ...................... 138
DERMAZENE ................... 133
DERMOTIC OIL ............... 212
DESFERAL.......................... 32
desipramine .......................... 96
desmopressin .............. 155, 156
DESOGEN ......................... 118
desogestrel-ethinyl estradiol
........................................ 119
DESONATE ....................... 138
desonide.............................. 138
DESOWEN ........................ 138
desoximetasone .................. 139
DESOXYN ................. 103, 108
desvenlafaxine ...................... 95
DETROL ............................ 188
DETROL LA ...................... 188
dexamethasone ................... 163
DEXAMETHASONE
INTENSOL .................... 163
dexamethasone sodium phos
(PF) ................................. 163
dexamethasone sodium
phosphate................ 163, 206
DEXEDRINE SPANSULE
........................ 103, 108, 111
DEXFERRUM ................... 149
DEXILANT ........................ 176
dexmethylphenidate ........... 103
DEXPAK 10 DAY ............. 163
DEXPAK 13 DAY ............. 163
DEXPAK 6 DAY ............... 163
dexrazoxane .......................... 58
dextroamphetamine ... 103, 108,
111, 112
dextroamphetamineamphetamine .......... 103, 108
DIABETA .......................... 157
DIALYVITE ...................... 148
DIAMOX SEQUELS ........... 81
DIASTAT ............................. 87
DIASTAT ACUDIAL .......... 87
diazepam ......................... 86, 87
DIAZEPAM INTENSOL ..... 86
DIBENZYLINE ................... 83
DICLEGIS .......................... 173
diclofenac potassium ............ 27
diclofenac sodium 27, 133, 144,
207
diclofenac-misoprostol ......... 26
dicloxacillin .......................... 47
dicyclomine ........................ 179
didanosine............................. 38
DIDREX ............................. 147
diethylpropion .................... 147
DIFFERIN .......................... 129
DIFICID ............................... 46
diflorasone .......................... 139
DIFLUCAN .................... 34, 35
diflunisal ............................... 29
DIGOX ................................. 81
digoxin .................................. 81
dihydrocodeine-aspirin-caff . 22
dihydroergotamine.............. 109
DILANTIN ........................... 89
DILANTIN EXTENDED..... 89
DILANTIN INFATABS ...... 89
DILANTIN-125.................... 89
DILATRATE-SR ................. 70
DILAUDID .................... 18, 19
diltiazem HCl ....................... 77
DILT-XR .............................. 77
DIOVAN .............................. 70
DIOVAN HCT ..................... 69
DIPENTUM ....................... 180
diphenhydramine HCl 112, 213
diphenoxylate-atropine ....... 173
Diphenoxylate-Atropine ..... 172
DIPROLENE ...................... 139
DIPROLENE AF ................ 139
dipyridamole ....................... 192
disopyramide ........................ 71
disulfiram............................ 114
DITROPAN XL ................. 188
DIURIL ................................ 82
divalproex .......87, 88, 105, 109
DIVIGEL ............................161
DOCEFREZ .........................56
docetaxel ...............................56
DOLOPHINE .......................19
donepezil.....................115, 116
DONNATAL ......................179
DORAL .............................. 112
DORYX ................................ 48
dorzolamide ........................207
dorzolamide-timolol ...........207
DOVONEX ........................134
doxazosin ..............................83
doxepin .................................96
Doxepin ................................ 96
doxercalciferol ....................199
DOXIL ..................................58
doxorubicin HCl pegliposomal ..........................58
doxycycline hyclate ......48, 202
doxycycline monohydrate ....48
DRISDOL ...........................153
DRITHOCREME HP .........134
dronabinol ...........................173
drospirenone-ethinyl estradiol
........................................119
DROXIA.............................193
DRYSOL DAB-O-MATIC 133
DUAC .................................127
DUETACT .........................158
DUEXIS ...............................26
DULERA ............................218
DURAFLU .........................221
DURAGESIC .......................19
DUREZOL .........................206
DUTOPROL .........................79
DYAZIDE ............................82
DYMISTA ..........................220
DYRENIUM.........................82
DYSPORT ..........................196
E.E.S. 400 .............................46
E.E.S. GRANULES ..............46
EC-NAPROSYN ..................28
econazole ............................132
ECOTRIN .....................29, 193
ECOTRIN LOW STRENGTH
..................................29, 193
EDARBI ...............................70
EDARBYCLOR ...................69
EDECRIN .............................81
229
EDLUAR ............................ 113
ED-SPAZ ........................... 177
EDURANT ........................... 37
EEMT ................................. 160
EEMT HS ........................... 160
EFFER-K............................ 151
EFFEXOR XR...................... 95
EFFIENT ............................ 193
EFUDEX ............................ 133
EGRIFTA ........................... 165
ELAPRASE ........................ 199
ELDEPRYL ......................... 98
ELDERCAPS ..................... 152
ELENZAPATCH ............... 143
ELESTAT........................... 205
ELESTRIN ......................... 161
ELETONE .......................... 136
ELIDEL .............................. 135
ELIGARD ............................ 54
ELIMITE ............................ 146
ELINEST ............................ 119
ELIPHOS ........................... 182
ELIQUIS ............................ 190
ELITEK .............................. 189
ELIXOPHYLLIN ............... 216
ELLA .................................. 125
ELLENCE ............................ 58
ELMIRON .......................... 184
ELOCON ............................ 139
ELOXATIN .......................... 55
ELSPAR ............................... 52
EMADINE ......................... 205
EMCYT ................................ 53
EMEND.............................. 174
EMLA................................. 143
EMOQUETTE ................... 119
EMSAM ............................... 93
EMTRIVA ............................ 38
ENABLEX ......................... 188
enalapril maleate .................. 66
enalapril-hydrochlorothiazide
.......................................... 67
ENBREL .............................. 24
ENBREL SURECLICK ....... 24
ENDOCET ........................... 23
ENDODAN .......................... 23
ENDOMETRIN ................. 169
ENGERIX-B (PF) ................ 60
ENGERIX-B PEDIATRIC
(PF) ................................... 61
230
ENJUVIA ........................... 162
enoxaparin .................. 191, 192
ENPRESSE ........................ 123
ENSKYCE.......................... 119
entacapone ............................ 98
ENTEREG ............................ 32
ENTOCORT EC................. 180
ENTYVIO .......................... 180
ENULOSE .......................... 174
EPANED .............................. 66
EPIDUO ............................. 129
EPIFOAM .......................... 141
epinastine ............................ 205
epinephrine ........................... 80
EPIPEN 2-PAK .................... 80
EPIPEN JR 2-PAK ............... 80
epirubicin .............................. 58
EPITOL ........................ 89, 105
EPIVIR ................................. 38
EPIVIR HBV ........................ 43
eplerenone ...................... 68, 81
EPOGEN ............................ 190
epoprostenol (glycine) .......... 84
eprosartan ............................. 70
EPZICOM ............................ 39
EQUETRO ......................... 105
ERBITUX ............................. 59
ergocalciferol (vitamin D2) 153
ergoloid ............................... 116
ERGOMAR ........................ 109
ERIVEDGE .......................... 53
ERRIN ................................ 122
ERTACZO.......................... 132
ERY PADS ......................... 126
ERYPED 200 ....................... 46
ERYPED 400 ....................... 46
ERY-TAB ............................. 46
ERYTHROCIN (AS
STEARATE) .................... 46
erythromycin ................ 46, 210
erythromycin ethylsuccinate. 46
erythromycin with ethanol.. 126
erythromycin-benzoyl peroxide
........................................ 127
escitalopram oxalate ............. 93
ESGIC .................................. 24
esomeprazole strontium ...... 176
ESTARYLLA ..................... 119
estazolam ............................ 112
ESTRACE .................. 162, 222
estradiol .............................. 162
estradiol valerate .................162
estradiol-norethindrone acet
........................................161
ESTRING ...........................222
ESTROGEL ........................162
estrogens-methyltestosterone
........................................160
estropipate...........................162
ESTROSTEP FE-28 ...........123
eszopiclone .........................113
ethambutol ............................40
ethosuximide.........................92
ethyl chloride ......................144
etidronate disodium ............159
etodolac.................................28
ETOPOPHOS .......................53
etoposide ...............................53
EUFLEXXA .......................196
EURAX .............................. 146
EVAMIST ..........................162
EVISTA .............................. 170
EVOCLIN...........................126
EVOXAC ...........................202
EVZIO ..................................32
EXALGO ER........................19
EXELDERM ......................132
EXELON ............................116
exemestane ...........................52
EXFORGE ............................68
EXFORGE HCT ...................68
EXJADE ...............................32
EXODERM ........................131
EXOTIC-HC.......................211
EXTAVIA ..................202, 203
EXTINA .............................132
FABIOR .............................129
FABRAZYME ...................198
FACTIVE .............................42
FALMINA (28) ..................119
famciclovir ............................45
famotidine ...........................176
FAMVIR...............................45
FANAPT.............................100
FARESTON .........................56
FASLODEX .........................53
FAZACLO ..........................100
felbamate ..............................87
FELBATOL ..........................87
FELDENE ............................27
felodipine .............................. 78
FEM PH.............................. 222
FEMARA ............................. 52
FEMCON FE...................... 119
FEMHRT LOW DOSE ...... 161
FEMRING .......................... 222
fenofibrate ............................ 73
fenofibrate micronized ......... 73
fenofibrate nanocrystallized . 73
fenofibric acid ...................... 73
fenofibric acid (choline) ....... 73
FENOGLIDE ....................... 73
fenoprofen ............................ 28
fentanyl ................................. 19
fentanyl citrate ...................... 19
FENTORA ........................... 19
FERAHEME ...................... 149
FERIVA ............................. 149
FEROTRINSIC .................. 149
FERRALET 90 DUAL-IRON
DELIVERY .................... 149
FERRAPLUS 90 ................ 150
FERRIPROX ........................ 32
FERRLECIT....................... 149
FERROGELS FORTE ....... 150
FETZIMA............................. 95
FEXMID............................. 197
FIBRICOR ........................... 73
FINACEA................... 126, 144
finasteride ........................... 185
FIORICET ............................ 24
FIORICET WITH CODEINE
.......................................... 22
FIORINAL ........................... 29
FIORINAL-CODEINE #3 ... 22
FIRAZYR ............................. 77
FIRMAGON......................... 54
FIRST-HYDROCORTISONE
........................................ 139
FLAGYL .............................. 36
FLAGYL ER ........................ 37
FLAREX ............................ 206
flavoxate ............................. 188
FLEBOGAMMA DIF .......... 61
flecainide .............................. 71
FLECTOR .......................... 144
FLOLAN .............................. 84
FLOMAX ........................... 185
FLONASE .......................... 220
FLO-PRED ......................... 164
FLOVENT DISKUS .......... 215
FLOVENT HFA ................. 215
floxuridine ............................ 52
FLUARIX 2014-2015 (PF) .. 64
FLUARIX QUAD 2014-2015
(PF) ................................... 64
FLUBLOK 2014-2015 (PF) . 64
FLUCELVAX 2014-2015 (PF)
.......................................... 64
fluconazole ........................... 35
fluconazole in NaCl (iso-osm)
.......................................... 35
flucytosine ............................ 35
fludarabine ............................ 51
fludrocortisone.................... 170
FLULAVAL 2014-2015....... 64
FLULAVAL 2014-2015 (PF)
.......................................... 64
FLULAVAL QUAD 20142015 .................................. 64
FLULAVAL QUAD 20142015 (PF) .......................... 64
FLUMADINE ...................... 45
flunisolide ........................... 220
fluocinolone ................ 139, 141
fluocinolone acetonide oil .. 212
fluocinolone-shower cap .... 139
fluocinonide ........................ 139
FLUORIDEX DAILY
DEFENSE ...................... 200
FLUORIDEX SENSITIVITY
RELIEF .......................... 200
fluorometholone ................. 206
FLUOROPLEX .................. 133
fluorouracil ................... 52, 133
fluoxetine ........................ 93, 94
fluphenazine decanoate ...... 101
fluphenazine HCl ................ 101
flurazepam .......................... 112
flurbiprofen ........................... 28
flurbiprofen sodium ............ 207
flutamide............................... 51
fluticasone .................. 139, 220
fluvastatin ............................. 74
FLUVIRIN 2014-2015 ......... 64
FLUVIRIN 2014-2015 (PF) . 65
fluvoxamine .......................... 94
FLUZONE 2013-2014 (PF) . 65
FLUZONE 2014-2015 ......... 65
FLUZONE 2014-2015 (PF) . 65
FLUZONE HIGH-DOSE
2014-15 (PF) .....................65
FLUZONE INTRADERM
2014-15 (PF) .....................65
FLUZONE PEDI 2013-2014
(PF) ...................................65
..........................................65
(PF) ...................................65
FLUZONE QUAD PEDI
2014-15 (PF) .....................65
FML FORTE ......................206
FML LIQUIFILM ..............206
FML S.O.P..........................206
FOCALIN ...........................103
FOCALIN XR ....................103
FOLBEE PLUS ..................148
FOLGARD OS ...................149
FOLGARD RX ...........152, 153
folic acid .............................153
FOLIVANE-F.....................150
FOLLISTIM AQ ................163
FOLOTYN ...........................51
FOLTRATE ........................153
fomepizole ............................31
fondaparinux .......................191
FORADIL AEROLIZER....217
FORFIVO XL .......................93
FORMADON .......................60
formaldehyde ........................60
formaldehyde (bulk) .............60
FORMA-RAY ......................60
FORTAMET.......................168
FORTAVIT ........................152
FORTEO.............................159
FORTESTA ........................155
FORTICAL.........................160
FOSAMAX.........................159
FOSAMAX PLUS D ..........159
FOSCAVIR ..........................42
fosinopril...............................67
fosinopril-hydrochlorothiazide
..........................................67
FOSRENOL .......................182
FRAGMIN ..........................192
FROVA............................... 109
FULYZAQ .........................172
FURADANTIN ..................186
furosemide ............................82
231
FUSILEV ............................. 59
FUZEON .............................. 37
FYCOMPA .......................... 86
gabapentin ............................ 88
GABITRIL ........................... 88
galantamine ........................ 116
GALZIN ............................... 31
GAMASTAN S/D ................ 61
GAMMAGARD LIQUID .... 61
GAMMAGARD S/D ........... 61
GAMMAKED ...................... 61
GAMMAPLEX .................... 61
GAMUNEX-C ............... 61, 62
ganciclovir sodium ............... 42
ganirelix .............................. 169
GARAMYCIN ................... 209
GARDASIL (PF).................. 64
GASTROCROM .................. 54
gatifloxacin ......................... 210
GATTEX 30-VIAL ............ 183
GATTEX ONE-VIAL ........ 183
GAVILYTE-C .................... 181
GAVILYTE-G ................... 181
GAVILYTE-N ................... 181
GELNIQUE ........................ 188
GEL-ONE........................... 196
gemcitabine .......................... 52
gemfibrozil ........................... 73
GEMZAR ............................. 52
GENERESS FE .................. 119
GENERLAC....................... 174
GENGRAF ......................... 194
GENOTROPIN .......... 165, 183
................................ 165, 183
GENTAK ........................... 209
gentamicin .................. 130, 209
GEODON ..................... 99, 106
GIANVI (28) ...................... 119
GIAZO ............................... 180
GILDAGIA ........................ 119
GILDESS ........................... 119
GILDESS FE ...................... 119
GILENYA .......................... 203
GILOTRIF ............................ 49
GLASSIA ........................... 218
GLEEVEC ............................ 56
GLIADEL WAFER.............. 50
glimepiride ......................... 157
glipizide .............................. 157
232
glipizide-metformin ............ 157
GLUCAGEN HYPOKIT ... 154
GLUCAGON EMERGENCY
........................................ 154
GLUCOPHAGE ................. 168
GLUCOPHAGE XR .......... 168
glucose ................................ 154
GLUCOTROL .................... 157
GLUCOTROL XL ............. 157
GLUCOVANCE ................ 157
GLUMETZA ...................... 168
glyburide ............................. 157
glyburide micronized .......... 157
glyburide-metformin .......... 157
GLYCATE ......................... 178
glycopyrrolate ..................... 178
GLYNASE ......................... 157
GLYSET ............................. 156
GOLYTELY ....................... 181
GONAL-F .......................... 163
GONAL-F RFF .................. 163
GONAL-F RFF REDI-JECT
........................................ 163
GORDONS UREA ............. 136
GRALISE ........................... 112
GRALISE 30-DAY STARTER
PACK ............................. 112
granisetron .......................... 174
GRANISOL ........................ 174
GRANIX ............................ 190
GRANULEX ...................... 137
GRASTEK............................ 60
GRIFULVIN V..................... 35
griseofulvin microsize .......... 35
griseofulvin ultramicrosize ... 35
GRIS-PEG
(ULTRAMICROSIZE) .... 35
GRX HICORT 25 ................. 30
guanfacine ............................ 80
guanidine ............................ 195
GYNAZOLE-1 ................... 221
HALAVEN ........................... 53
HALCION .......................... 112
HALDOL............................ 101
HALDOL DECANOATE .. 101
halobetasol propionate ........ 139
HALOG .............................. 139
haloperidol .......................... 101
haloperidol decanoate ......... 101
haloperidol lactate .............. 101
HAVRIX (PF) ......................60
HEATHER .........................122
HECORIA ..........................194
HECTOROL .......................199
HEMANGEOL .....................76
HEMATINIC/FOLIC ACID
........................................150
HEMATOGEN FA .............150
HEMATOGEN FORTE .....150
HEMATRON-AF ...............150
HEMAX .............................150
HEMOCYTE-F ..................150
HEMOCYTE-PLUS ...........150
HEPSERA ............................43
HERCEPTIN ........................59
HETLIOZ ...........................108
HEXALEN ...........................50
HIPREX .............................. 186
HIZENTRA ..........................62
HOMATROPAIRE ............205
homatropine HBr ................205
HORIZANT ........................111
HPR ....................................136
HPR PLUS..........................136
HUMALOG ........................168
HUMALOG KWIKPEN ....168
HUMALOG MIX 50-50.....167
HUMALOG MIX 50-50
KWIKPEN ......................167
HUMALOG MIX 75-25.....167
HUMALOG MIX 75-25
KWIKPEN ......................167
HUMATROPE ...........165, 183
HUMIRA ..............................25
HUMIRA CROHN'S DIS
START PCK .....................25
HUMIRA PEN .....................25
HUMIRA PSORIASIS
STARTER PACK .............25
HUMULIN 70/30 ...............166
HUMULIN 70/30 KWIKPEN
........................................167
HUMULIN N .....................167
HUMULIN N KWIKPEN ..167
HUMULIN R......................167
HUMULIN R U-500 ..........167
HYALGAN ........................196
HYCAMTIN.................57, 223
HYCET .................................22
hydralazine ...........................81
HYDREA ............................. 52
HYDRO 35 ......................... 142
HYDRO 40 ......................... 142
hydrochlorothiazide .............. 82
hydrocodone-acetaminophen 22
hydrocodone-homatropine . 219
hydrocodone-ibuprofen ........ 22
hydrocortisone .... 139, 164, 180
hydrocortisone acet-aloe vera
........................................ 141
hydrocortisone acetate .......... 30
hydrocortisone butyrate ..... 139,
140
hydrocortisone valerate ...... 140
hydrocortisone-acetic acid.. 212
hydrocortisone-pramoxine .. 31,
140, 141
HYDROMET ..................... 219
hydromorphone .................... 19
hydroxychloroquine ............. 36
hydroxyurea .......................... 52
hydroxyzine HCl .................. 85
hydroxyzine pamoate ........... 85
HYLATOPIC ..................... 136
HYLATOPIC PLUS .......... 136
HYOPHEN ......................... 187
hyoscyamine sulfate ... 177, 178
HYOSYNE ......................... 178
HYPERCARE .................... 134
HYPERHEP B S/D .............. 62
HYPERHEP B S-D
NEONATAL .................... 62
HYPERRHO S/D ................. 62
HYPER-SAL ...................... 115
HYZAAR ............................. 69
ibandronate ......................... 159
IBUDONE ............................ 22
ibuprofen .............................. 28
ibuprofen-oxycodone ........... 23
IC GREEN.......................... 146
ICLUSIG .............................. 55
IDAMYCIN PFS .................. 58
idarubicin .............................. 58
IFEREX 150 FORTE ......... 150
IFEX ..................................... 50
ifosfamide ............................. 50
ifosfamide-mesna ................. 50
ILARIS (PF) ......................... 24
ILEVRO ............................. 207
ILOTYCIN ......................... 210
IMBRUVICA ................. 53, 56
IMDUR ................................. 70
imipramine HCl .................... 96
imipramine pamoate ............. 96
imiquimod .......................... 141
IMITREX ................... 109, 110
IMITREX STATDOSE KIT
REFILL .......................... 110
IMITREX STATDOSE PEN
........................................ 110
IMURAN ............................ 195
INCRELEX ........................ 169
indapamide ........................... 82
INDERAL LA ...................... 76
INDERAL XL ...................... 76
INDOCIN ............................. 28
indocyanine green............... 146
indomethacin .................. 28, 29
INFANRIX (DTAP) (PF) ..... 63
INFED ................................ 149
INLYTA ............................... 56
INNOPRAN XL ................... 76
INSPRA .......................... 68, 81
INTEGRA F ....................... 150
INTEGRA PLUS ................ 150
INTELENCE ........................ 37
INTERMEZZO .................. 113
INTRON A ........................... 54
INTROVALE ..................... 119
INTUNIV ER ..................... 102
INVEGA ............................. 100
INVEGA SUSTENNA ....... 100
INVIRASE ........................... 47
INVOKANA ...................... 156
IODOFLEX .......................... 60
iodoquinol-HC .................... 133
IODOSORB.......................... 60
IOPIDINE ................... 210, 211
ipratropium bromide ... 216, 219
ipratropium-albuterol.......... 218
IPRIVASK.......................... 193
irbesartan .............................. 70
irbesartan-hydrochlorothiazide
.......................................... 69
irinotecan .............................. 57
IROSPAN 24/6 ................... 150
ISENTRESS ......................... 37
ISOCHRON.......................... 70
isoniazid.......................... 39, 40
ISOPTO ATROPINE ......... 205
ISOPTO CARBACHOL ....203
ISOPTO CARPINE ............203
ISOPTO HOMATROPINE 205
ISOPTO HYOSCINE .........205
ISORDIL ..............................70
ISORDIL TITRADOSE .......70
isosorbide dinitrate ...............70
isosorbide mononitrate .........70
isoxsuprine............................83
isradipine ..............................78
ISTALOL ...........................208
ISTODAX.............................53
itraconazole...........................35
IXIARO (PF) ........................66
JAKAFI ................................ 54
JALYN ............................... 184
JANTOVEN .......................189
JANUMET .........................158
JANUMET XR ...................158
JANUVIA ...........................156
JENCYCLA ........................122
JENTADUETO ..................158
JEVTANA ............................56
JINTELI .............................. 161
JOLESSA ...........................119
JOLIVETTE .......................122
JUBLIA .............................. 133
JUNEL 1.5/30 (21) .............119
JUNEL 1/20 (21) ................119
JUNEL FE 1.5/30 (28) .......119
JUNEL FE 1/20 (28) ..........119
JUXTAPID ...........................75
KADCYLA.....................51, 58
KADIAN ..............................19
KALBITOR ..........................83
KALETRA ...........................39
KALYDECO ......................218
KAPVAY ...........................102
KARBINAL ER .........213, 214
KARIVA (28) .....................117
KAYEXALATE .................148
KAZANO ...........................158
K-EFFERVESCENT ..........151
KEFLEX ...............................40
KELNOR 1/35 (28) ............119
KENALOG .................140, 164
KEPPRA ...............................92
KEPPRA XR ........................92
KERAFOAM ......................142
KERALAC .........................142
233
KERALYT RX ................... 142
KETEK ................................. 45
ketoconazole ................. 34, 132
KETODAN......................... 132
ketoprofen............................. 28
ketorolac ....................... 27, 207
ketotifen fumarate .............. 205
KHEDEZLA......................... 95
KINERET ............................. 25
KINRIX (PF) ........................ 63
KIONEX............................. 148
KLARON ........................... 126
KLONOPIN ................... 86, 87
KLOR-CON ....................... 151
KLOR-CON 10 .................. 151
KLOR-CON M15 ............... 151
KLOR-CON M20 ............... 151
KLOR-CON/EF ................. 151
KOMBIGLYZE XR ........... 158
KORLYM........................... 156
K-PHOS NO 2 .................... 185
K-PHOS ORIGINAL ......... 185
K-PHOS-NEUTRAL . 150, 185
KRISTALOSE ................... 181
KRYSTEXXA.................... 189
K-TAB................................ 151
KURVELO ......................... 119
KUVAN ............................. 200
KYNAMRO ......................... 72
L norgest&E estradiol-E estrad
........................................ 117
labetalol ................................ 68
LAC-HYDRIN ................... 136
LACRISERT ...................... 203
lactated ringers ................... 152
lactic acid............................ 136
LACTIC ACID E ............... 136
lactulose...................... 174, 181
LAMICTAL ......................... 90
LAMICTAL ODT ........ 90, 105
LAMICTAL ODT STARTER
(BLUE) ..................... 91, 105
(GREEN) .................. 91, 105
(ORANGE)............... 91, 105
LAMICTAL STARTER
(BLUE) KIT ............. 91, 105
LAMICTAL STARTER
(GREEN) KIT .......... 91, 105
234
LAMICTAL STARTER
(ORANGE) KIT ....... 91, 106
LAMICTAL XR ................... 91
LAMICTAL XR STARTER
(BLUE) ............................. 91
LAMICTAL XR STARTER
(GREEN) .......................... 91
LAMICTAL XR STARTER
(ORANGE) ....................... 91
LAMISIL .............................. 34
lamivudine ............................ 38
lamivudine-zidovudine ......... 39
lamotrigine.................... 91, 106
LANOXIN ............................ 81
lansoprazole ........................ 176
LANTUS ............................ 167
LANTUS SOLOSTAR....... 168
LARIN 1.5/30 (21) ............. 120
LARIN 1/20 (21) ................ 120
LARIN FE .......................... 120
LASIX .................................. 82
LASTACAFT ..................... 205
latanoprost .......................... 211
LATRIX XM ...................... 142
LATUDA.............................. 99
LAZANDA ........................... 19
LEENA 28 .......................... 123
leflunomide........................... 26
LESCOL ............................... 74
LESCOL XL......................... 74
LESSINA............................ 120
LETAIRIS ............................ 84
letrozole ................................ 52
leucovorin calcium ............... 59
LEUKERAN ........................ 50
LEUKINE ........................... 191
leuprolide .............................. 54
LEVACET ............................ 29
levalbuterol HCl ................. 217
LEVAQUIN ......................... 42
LEVATOL............................ 76
LEVBID ............................. 178
LEVEMIR .......................... 168
LEVEMIR FLEXPEN ........ 168
LEVEMIR FLEXTOUCH . 168
levetiracetam ........................ 92
levobunolol ......................... 208
levocarnitine ....................... 200
levocarnitine (with sugar) ... 200
levofloxacin .................. 42, 210
LEVONEST (28) ................123
levonorgestrel .....................125
levonorgestrel-ethinyl estrad
........................................120
LEVOPHED (BITARTRATE)
..........................................80
LEVORA-28.......................120
levorphanol tartrate ...............19
levothyroxine ......................172
LEVOXYL .........................172
LEVSIN .............................. 178
LEVSIN/SL ........................178
LEVULAN .........................144
LEXAPRO ............................94
LEXIVA .........................47, 48
LIALDA .............................180
LIBRAX (WITH
CLIDINIUM) .................179
lidocaine .......................30, 145
lidocaine HCl ........30, 145, 201
LIDOCAINE VISCOUS ....202
lidocaine-hydrocortisone-aloe
..........................................31
lidocaine-prilocaine ............143
LIDODERM .......................145
LIDORX .............................145
lindane ................................ 146
LINZESS ....................179, 181
liothyronine.........................172
LIPITOR ...............................74
LIPODOX.............................58
LIPOFEN ..............................73
LIPOSYN III ......................152
LIPTRUZET .........................75
lisinopril ................................ 67
lisinopril-hydrochlorothiazide
..........................................67
lithium carbonate ................107
lithium citrate......................107
LITHOBID .........................107
LITHOSTAT ......................185
LIVALO ...............................74
LO LOESTRIN FE .....117, 120
LOCOID .............................140
LOCOID LIPOCREAM .....140
LODOSYN ...........................98
LOESTRIN 1.5/30 (21) ......120
LOESTRIN 1/20 (21) .........120
LOESTRIN FE 1.5/30 (28) 120
LOESTRIN FE 1/20 (28) ...120
LOFIBRA ............................. 73
LOMEDIA 24 FE ............... 120
LOMOTIL .......................... 173
lomustine .............................. 50
loperamide .......................... 172
LOPID .................................. 73
LOPRESSOR ....................... 75
LOPRESSOR HCT .............. 79
LOPROX ............................ 132
lorazepam ............................. 86
LORAZEPAM INTENSOL . 86
LORCET PLUS.................... 22
LORTAB 10-325.................. 22
LORTAB 5-325.................... 22
LORTAB 7.5-325................. 22
LORTAB ELIXIR ................ 22
LORYNA (28).................... 120
LORZONE ......................... 197
losartan ................................. 70
losartan-hydrochlorothiazide 69
LOSEASONIQUE ............. 118
LOTEMAX ........................ 206
LOTENSIN .......................... 67
LOTENSIN HCT ................. 67
LOTREL............................... 66
LOTRISONE ...................... 133
LOTRONEX .............. 179, 181
LOUTREX ................. 134, 136
lovastatin .............................. 74
LOVAZA ............................. 75
LOVENOX......................... 192
LOW-OGESTREL (28) ..... 120
loxapine succinate .............. 101
LOXITANE ........................ 101
LTA PRE-ATTACHED ....... 30
LUFYLLIN ........................ 216
LUMIGAN ......................... 211
LUMIZYME ...................... 199
LUNESTA .......................... 113
LUPRON DEPOT ...... 169, 223
LUPRON DEPOT (3
MONTH) ................ 169, 223
LUPRON DEPOT (4
MONTH) ........................ 223
LUPRON DEPOT (6
MONTH) ........................ 223
LUPRON DEPOT-PED ..... 169
LUPRON DEPOT-PED (3
MONTH) ........................ 169
LUSTRA ............................ 136
LUTERA (28)..................... 120
LUVOX CR .......................... 94
LUXIQ................................ 140
LYRICA ............................... 88
LYSIPLEX PLUS .............. 148
LYSODREN ......................... 51
LYSTEDA .......................... 191
LYZA ................................. 122
MACROBID ...................... 186
MACRODANTIN .............. 186
mafenide acetate ................. 135
MAGNEBIND 400............. 182
MAKENA .......................... 170
MALARONE ....................... 36
MALARONE PEDIATRIC . 36
malathion ............................ 146
maprotiline............................ 96
MARCAINE ......................... 30
MARCAINE (PF)................. 30
MARCAINE SPINAL (PF).. 30
MARGESIC ......................... 24
MARINOL ......................... 173
MARLISSA ........................ 120
MARPLAN .......................... 93
MARTEN-TAB .................... 24
MATULANE........................ 50
MATZIM LA ....................... 77
MAVIK ................................ 67
MAXALT ........................... 110
MAXALT-MLT ................. 110
MAXIDEX ......................... 206
MAXITROL ....................... 204
MAXZIDE............................ 82
MAXZIDE-25MG ................ 82
meclizine ............................ 173
meclofenamate...................... 26
MEDROL ........................... 164
MEDROL (PAK) ............... 164
medroxyprogesterone . 117, 170
mefenamic acid..................... 26
mefloquine ............................ 36
MEGACE ........................... 147
MEGACE ES ..................... 147
megestrol ...................... 55, 147
MEKINIST ........................... 55
meloxicam ............................ 27
melphalan ............................. 50
MENACTRA (PF) ............... 63
MENEST ............................ 162
MENOMUNE - A/C/Y/W-135
..........................................63
MENOPUR.........................162
MENOSTAR ......................162
MENTAX ...........................131
MENVEO A-C-Y-W-135-DIP
(PF) ...................................63
meperidine ............................19
MEPHYTON ......................153
meprobamate ........................86
MEPRON .............................36
mercaptopurine .....................51
mesalamine .........................180
mesna ....................................59
MESNEX ..............................59
MESTINON .......................195
MESTINON TIMESPAN ..195
METADATE CD................103
METADATE ER ................103
metaproterenol ....................218
metaxalone ..........................197
metformin ...................168, 169
methadone.............................19
METHADONE INTENSOL 20
METHADOSE .....................20
methamphetamine.......103, 108
methazolamide ......................81
methenamine hippurate ......186
methenamine mandelate .....186
methimazole .......................159
METHITEST ......................155
methocarbamol ...................197
methotrexate sodium ............51
methotrexate sodium (PF) ....51
methscopolamine ................178
methyclothiazide...................83
methyldopa ...........................80
methyldopahydrochlorothiazide ..........80
methylergonovine ...............170
METHYLIN ...............103, 111
methylphenidate .........104, 111
methylprednisolone ............164
methylprednisolone acetate 164
methylprednisolone sodium
succ .................................164
methyltestosterone ..............155
metipranolol ........................208
metoclopramide HCl ..........177
metolazone ............................83
235
metoprolol succinate ............ 75
metoprolol ta-hydrochlorothiaz
.......................................... 79
metoprolol tartrate ................ 75
METOZOLV ODT ............. 177
METROCREAM................ 126
METROGEL ...................... 126
METROGEL VAGINAL ... 221
METROLOTION ............... 126
metronidazole ....... 37, 126, 221
MEVACOR .......................... 74
mexiletine ............................. 71
MIACALCIN ..................... 160
MICARDIS .......................... 70
MICARDIS HCT ................. 69
MICONAZOLE-3 .............. 221
MICRHOGAM ULTRAFILTERED PLUS ............ 62
MICROGESTIN 1.5/30 (21)
........................................ 120
MICROGESTIN 1/20 (21) . 120
MICROGESTIN FE 1.5/30
(28) ................................. 120
MICROGESTIN FE 1/20 (28)
........................................ 120
MICROZIDE ........................ 83
Midazolam.......................... 112
midodrine ............................. 80
MIFEPREX ........................ 154
MIGERGOT ....................... 109
MIGRAGESIC IDA ........... 109
MIGRANAL ...................... 109
MILLIPRED....................... 164
MILLIPRED DP ................ 164
MIMVEY ........................... 161
MIMVEY LO ..................... 161
MINASTRIN 24 FE ........... 121
MINIPRESS ......................... 83
MINITRAN .......................... 70
MINIVELLE ...................... 162
MINOCIN ............................ 49
minocycline .................. 49, 125
minoxidil .............................. 81
MIRAPEX ............................ 98
MIRAPEX ER ...................... 99
MIRCETTE (28) ................ 118
MIRENA ............................ 117
mirtazapine ........................... 92
MIRVASO ......................... 144
misoprostol ......................... 177
236
mitomycin ............................. 58
mitoxantrone......................... 58
MOBIC ................................. 27
modafinil ............................ 111
MODERIBA ......................... 44
MODERIBA DOSE PACK.. 44
MODICON (28) ................. 121
moexipril .............................. 67
moexipril-hydrochlorothiazide
.......................................... 67
mometasone ........................ 140
MONODOX ......................... 49
MONO-LINYAH ............... 121
MONONESSA (28) ........... 121
MONSEL'S......................... 191
montelukast ........................ 215
MONUROL ........................ 187
MORGIDOX ........................ 49
MORGIDOX 1X100 ............ 49
morphine............................... 20
morphine concentrate ........... 20
MOTOFEN ......................... 173
MOVIPREP ........................ 181
MOXATAG.......................... 33
MOXEZA ........................... 210
moxifloxacin......................... 42
MOZOBIL .......................... 190
MS CONTIN ........................ 20
MULTAQ ............................. 72
mupirocin............................ 130
mupirocin calcium .............. 130
MUSTARGEN ..................... 50
MY WAY ........................... 125
MYAMBUTOL .................... 40
MYCOBUTIN ................ 40, 48
mycophenolate mofetil ....... 195
mycophenolate sodium ....... 195
MYDRIACYL .................... 205
MYFORTIC ....................... 195
MYLERAN .......................... 49
MYOBLOC ........................ 196
MYORISAN ....................... 125
MYOZYME ....................... 199
MYRBETRIQ .................... 185
MYSOLINE ......................... 86
MYZILRA .......................... 123
NABI-HB ............................. 62
nabumetone .......................... 27
nadolol .................................. 76
nadolol-bendroflumethiazide 83
NAFTIN .............................131
NAGLAZYME ...................199
NALFON ..............................28
naltrexone .............................32
NAMENDA ........................116
NAMENDA TITRATION
PAK ................................ 116
NAMENDA XR .................116
NAPRELAN CR ..................28
NAPRO....................... 115, 144
NAPROSYN.........................28
naproxen ...............................28
naproxen sodium ..................28
naratriptan ...........................110
NARDIL ...............................93
NASCOBAL.......................153
NASONEX .........................220
NATACYN.........................210
NATAZIA ..........................123
nateglinide ..........................156
NATROBA .........................146
NATURE-THROID ...........171
NAVELBINE .......................57
NEBUPENT .........................47
NEBUSAL ..........................115
NECON 0.5/35 (28)............121
NECON 1/35 (28)...............121
NECON 1/50 (28)...............121
NECON 10/11 (28).............118
NECON 7/7/7 (28) .............123
nefazodone ............................94
neomycin ..............................33
neomycin-bacitracin-poly-HC
........................................204
neomycin-bacitracinpolymyxin .......................209
neomycin-polymyxindexameth.........................204
neomycin-polymyxingramicidin .......................209
neomycin-polymyxin-HC ..204,
211
NEO-POLYCIN .................209
NEORAL ............................194
NEOSALUS .......................136
NEOSPORIN (NEO-POLYMGRAMICID)...................209
NEOSPORIN GU IRRIGANT
........................................184
NEO-SYNALAR ................131
NEPHROCAPS .................. 148
NEPHROCAPS QT ........... 148
NEPHRO-VITE RX ........... 148
NEPTAZANE ...................... 81
NESINA ............................. 156
NEUAC .............................. 127
NEULASTA ....................... 190
NEUMEGA ........................ 193
NEUPOGEN ...................... 190
NEUPRO .............................. 99
NEURIN-SL ............... 152, 153
NEURONTIN....................... 88
NEVANAC ........................ 207
nevirapine ............................. 37
NEXAVAR .......................... 55
NEXIUM ............................ 176
NEXIUM PACKET ........... 176
NEXPLANON ................... 116
NEXT CHOICE ONE DOSE
........................................ 125
niacin .................................... 74
NIACOR............................... 74
NIASPAN EXTENDEDRELEASE ........................ 74
nicardipine ............................ 78
NICAZEL ........................... 148
NICAZEL FORTE ............. 148
NICODERM CQ ................ 114
NICOMIDE ........................ 152
NICORELIEF..................... 114
NICORETTE ...................... 114
nicotine ............................... 114
nicotine (polacrilex) ........... 114
NICOTROL........................ 114
NICOTROL NS.................. 114
NIFEDICAL XL .................. 78
nifedipine.............................. 78
NILANDRON ...................... 51
nimodipine............................ 79
NIPENT ................................ 51
nisoldipine ............................ 78
NITRO-BID ......................... 70
NITRO-DUR .................. 70, 71
nitrofurantoin ...................... 186
nitrofurantoin macrocrystal 187
nitrofurantoin monohyd/mcryst ................................ 187
nitroglycerin ......................... 71
NITROLINGUAL ................ 71
NITROMIST ........................ 71
NITROPRESS ...................... 81
NITROSTAT ........................ 71
NIVATOPIC PLUS ............ 136
nizatidine ............................ 176
NIZORAL .......................... 132
NODOLOR ........................ 109
NORA-BE .......................... 123
NORCO ................................ 22
NORDITROPIN FLEXPRO
................................ 166, 183
................................ 166, 183
norethindrone (contraceptive)
........................................ 123
norethindrone acetate ......... 170
norgestimate-ethinyl estradiol
........................................ 123
NORINYL 1+35 (28) ......... 121
NORINYL 1+50 (28) ......... 121
NORITATE ........................ 126
NORMOSOL-R IN 5 %
DEXTROSE ................... 149
NOROXIN............................ 42
NORPACE ........................... 71
NORPACE CR ..................... 71
NORPRAMIN ...................... 96
NOR-QD ............................ 123
NORTREL 0.5/35 (28) ....... 121
NORTREL 1/35 (21) .......... 121
NORTREL 1/35 (28) .......... 121
NORTREL 7/7/7 (28) ......... 124
nortriptyline .......................... 96
NORVASC ........................... 78
NORVIR ............................... 48
NOVACORT ...................... 141
NOVAFERRUM ................ 150
NOVAREL ......................... 166
NOVOLIN 70/30 ................ 167
NOVOLIN N ...................... 167
NOVOLIN R ...................... 167
NOVOLOG ........................ 168
NOVOLOG FLEXPEN ...... 168
NOVOLOG MIX 70-30 ..... 167
NOVOLOG MIX 70-30
FLEXPEN ...................... 167
NOVOLOG PENFILL ....... 168
NOXAFIL ............................ 35
NP THYROID .................... 171
NPLATE ............................. 194
NUCORT............................ 141
NUCYNTA...........................20
NUCYNTA ER ....................20
NUEDEXTA ......................112
NULEV............................... 178
NULOJIX ...........................195
NULYTELY WITH FLAVOR
PACKS ...........................181
NUOX.................................129
NUTRESTORE ..148, 152, 183
NUTRICAP ........................152
NUTROPIN AQ .........166, 183
NUTROPIN AQ NUSPIN .166,
183
NUVARING .......................124
NUVIGIL ...........................111
NYAMYC ..........................131
NYMALIZE .........................79
nystatin ................. 34, 131, 201
nystatin-triamcinolone ........133
NYSTOP.............................131
OCELLA ............................121
OCTAGAM ..........................62
octreotide acetate ........171, 183
OCUFEN ............................207
OCUFLOX .........................210
ofloxacin ...............42, 210, 212
OGEN 2.5 ...........................162
OGESTREL (28) ................121
olanzapine ...................102, 106
olanzapine-fluoxetine ...........97
OLUX-E .............................140
OLYSIO ...............................43
OMECLAMOX-PAK.........182
omega-3 acid ethyl esters .....75
omeprazole .........................176
omeprazole-sodium
bicarbonate .....................177
OMNARIS ..........................220
OMNIPRED .......................206
OMNITROPE .............166, 184
ONCASPAR .........................53
ondansetron.........................174
ondansetron HCl .................174
ondansetron HCl (PF) .........174
ONFI .....................................87
ONGLYZA .........................156
ONMEL ................................ 35
ONXOL ................................ 57
OPANA ................................ 20
OPANA ER ..........................20
237
opium tincture .................... 172
OPSUMIT ............................ 84
OPTIVAR........................... 205
ORACEA ..................... 49, 144
ORACIT ............................. 186
ORALONE ......................... 201
ORAP ................................. 101
ORAPRED ODT ................ 164
ORENCIA ............................ 25
ORENCIA (WITH
MALTOSE) .................... 223
ORENITRAM ...................... 84
ORFADIN .......................... 200
orphenadrine citrate ............ 197
ORSYTHIA ........................ 121
ORTHO EVRA .................. 124
ORTHO MICRONOR........ 123
ORTHO TRI-CYCLEN (28)
........................................ 124
ORTHO TRI-CYCLEN LO
(28) ................................. 124
ORTHO-NOVUM 1/35 (28)
........................................ 121
ORTHO-NOVUM 7/7/7 (28)
........................................ 124
ORTHOVISC ..................... 196
OSCIMIN ........................... 178
OSCIMIN SL ..................... 178
OSCIMIN SR ..................... 178
OSENI ................................ 159
OSMOPREP ....................... 181
OSPHENA ......................... 170
OTEZLA .............................. 26
OTEZLA STARTER............ 26
OTIC CARE (ANTIPYRINE)
........................................ 212
OTICIN .............................. 212
OTICIN HC (BAK FREE) . 211
OTOMAX-HC ................... 211
OTOZIN ............................. 212
OVACE PLUS ................... 134
OVACE PLUS SHAMPOO
........................................ 134
OVACE PLUS WASH....... 134
OVCON-35 (28)................. 121
OVIDE ............................... 146
OVIDREL .......................... 166
oxaliplatin ............................. 55
OXANDRIN....................... 154
oxandrolone ........................ 154
238
oxaprozin .............................. 28
oxazepam .............................. 86
oxcarbazepine ....................... 89
OXECTA .............................. 20
OXISTAT ........................... 132
OXSORALEN .................... 144
OXSORALEN ULTRA ..... 134
OXTELLAR XR .................. 89
oxybutynin chloride ............ 188
oxycodone ...................... 20, 21
oxycodone-acetaminophen ... 23
oxycodone-aspirin ................ 23
OXYCONTIN ...................... 21
oxymorphone ........................ 21
OXYTROL ......................... 188
PACERONE ......................... 72
paclitaxel .............................. 57
PACNEX ............................ 128
PACNEX MX..................... 128
PAIN EASE ........................ 143
PAMELOR ........................... 96
pamidronate ........................ 159
PAMINE ............................. 178
PAMINE FORTE ............... 178
PANCREAZE .................... 175
PANCRELIPASE 5000 ...... 175
PANDEL ............................ 140
PANRETIN ........................ 133
pantoprazole ....................... 176
PARAFON FORTE DSC ... 197
PARAGARD T 380A. 117, 198
paregoric ............................. 172
paricalcitol .......................... 199
PARLODEL ......................... 98
PARNATE............................ 93
paromomycin ........................ 32
paroxetine HCl ..................... 94
PASER.................................. 39
PATADAY ......................... 205
PATANASE ....................... 220
PATANOL ......................... 205
PAXIL .................................. 94
PAXIL CR ............................ 94
PCE....................................... 46
PEDIAPRED ...................... 164
PEDIATEX TD .................. 212
PEDI-DRI ........................... 131
PEG 3350-Electrolytes ....... 181
PEG 3350-GRX.................. 115
PEG-3350 WITH FLAVOR
PACKS ...........................182
PEGANONE.........................89
PEGASYS ............................43
PEGASYS CONVENIENCE
PACK ...............................43
PEGASYS PROCLICK........43
PEGINTRON .......................43
PEGINTRON REDIPEN......43
penicillin V potassium ..........47
PENLAC.............................132
PENNSAID ........................144
PENTACEL (PF)..................64
PENTAM ..............................47
pentamidine ..........................47
PENTASA ..........................180
pentazocine-naloxone ...........23
pentostatin.............................51
pentoxifylline ......................191
PEPCID .............................. 176
PERCOCET ..........................23
PERCODAN.........................23
PERFOROMIST.................217
PERIDEX ...........................201
perindopril erbumine ............67
PERIOGARD .....................201
permethrin...........................146
perphenazine .......................101
perphenazine-amitriptyline ...96
PERSANTINE ....................192
PERTZYE...........................175
PEXEVA ..............................94
Pharmacy Prior Authorization
Form .................................14
PHENADOZ.......................173
phenazopyridine .................186
phendimetrazine tartrate .....147
phenelzine .............................93
phenobarbital ................86, 112
phentermine ........................147
phenylephrine HCl..............207
PHENYTEK .........................89
phenytoin ..............................89
phenytoin sodium extended ..89
PHILITH.............................121
PHOSLO.............................182
PHOSLYRA .......................182
PHOSPHA 250 NEUTRAL
................................ 150, 185
PHOSPHASAL ..................187
PHOSPHOLINE IODIDE .. 203
PHYSICIANS EZ USE FLU
2012-13............................. 65
PHYSIOLYTE ................... 149
PHYSIOSOL IRRIGATION
........................................ 149
phytonadione (bulk) ........... 153
PICATO ............................. 133
pilocarpine HCl .......... 202, 204
PIMTREA (28) ................... 118
pindolol................................. 76
PINNACAINE ................... 212
pioglitazone ........................ 169
pioglitazone-glimepiride .... 158
pioglitazone-metformin ...... 158
PIRMELLA ................ 121, 124
piroxicam.............................. 27
PITRESSIN ........................ 156
PLAN B ONE-STEP .......... 125
PLAQUENIL ....................... 36
PLAVIX ............................. 193
PLETAL ............................. 192
PLEXION ........................... 127
PLEXION CLEANSING
CLOTHS ........................ 127
PLIAGLIS .......................... 145
PNEUMOVAX 23 ............... 63
PODOCON......................... 142
podofilox ............................ 142
Polyethylene Glycol 3350 .. 181
POLY-IRON 150 FORTE.. 150
polymyxin B sulf-trimethoprim
........................................ 209
POLYTRIM ....................... 209
POMALYST ........................ 57
PONSTEL ............................ 27
PONTOCAINE .................. 145
PORTIA ............................. 121
POTABA ............................ 153
potassium bicarb & chloride
........................................ 150
potassium bicarb-citric acid 151
potassium chloride.............. 151
potassium citrate................. 186
potassium citrate-citric acid 186
POTIGA ............................... 91
PRADAXA......................... 193
PRAMCORT ........................ 31
pramipexole .......................... 99
PRAMOSONE ................... 141
PRAMOSONE E ................ 141
PRANDIMET ..................... 156
PRANDIN .......................... 156
PRAVACHOL...................... 74
pravastatin ............................ 74
prazosin ................................ 83
PRECOSE .......................... 156
PRED FORTE .................... 206
PRED MILD....................... 206
PRED-G.............................. 204
PRED-G S.O.P. .................. 204
prednicarbate ...................... 140
prednisolone ....................... 164
prednisolone acetate ........... 206
prednisolone sodium phosphate
................................ 164, 206
prednisone .......................... 164
PREDNISONE INTENSOL
........................................ 164
PREFEST ........................... 161
PREGNYL.......................... 166
PREMARIN ............... 162, 222
PREMPHASE .................... 161
PREMPRO ......................... 161
PRENAPLUS ..................... 152
PREPIDIL .......................... 153
PREPOPIK ......................... 182
PRESERA .......................... 136
PREVACID ........................ 176
PREVACID SOLUTAB..... 176
PREVALITE ........................ 73
PREVIDENT ...................... 200
PREVIDENT 5000 PLUS .. 201
PREVIDENT 5000
SENSITIVE .................... 201
PREVIFEM ........................ 121
PREVNAR 13 (PF) .............. 63
PREVPAC .......................... 182
PREZISTA ........................... 47
PRIALT ................................ 18
PRIFTIN ......................... 40, 48
PRILOSEC ................. 176, 177
primaquine ............................ 36
primidone.............................. 86
PRIMLEV ............................ 23
PRIMSOL............................. 34
PRINIVIL ............................. 67
PRISTIQ ............................... 95
PRIVIGEN ........................... 62
PROAIR HFA .................... 217
probenecid ..........................189
PROCARDIA .......................78
PROCARDIA XL .................78
PROCENTRA ....................108
prochlorperazine .................173
prochlorperazine maleate ....173
PROCORT ............................31
PROCRIT ...........................190
PROCTOCORT ..............30, 31
PROCTOFOAM HC ............31
PROCTO-PAK .....................30
PROCTOSOL HC ................31
PROCTOZONE-HC .............31
PROCYSBI.........................184
PROGESTERONE IN OIL 170
progesterone micronized ....170
PROGLYCEM ...................154
PROGRAF ..........................194
PROLENSA .......................207
PROLEUKIN .......................54
PROLIA .............................. 170
PROMACTA ......................194
promethazine ......173, 213, 214
Promethazine ..............213, 214
PROMETHAZINE VC ......212
PROMETHAZINE VCCODEINE.......................219
promethazine-codeine.........219
promethazine-DM...............221
PROMETHEGAN ..............173
PROMETRIUM .................170
PROMISEB ................135, 136
propafenone ..........................71
propantheline ......................178
proparacaine .......................208
PROPECIA .........................145
propranolol ...........................76
propranolol-hydrochlorothiazid
..........................................83
propylthiouracil ..................159
PROSCAR ..........................185
PROSED/DS (ATROPINE
FREE) .............................187
PROSTIN E2 ......................154
PROSTIN VR PEDIATRIC .83
PROTECT PLUS................152
PROTONIX ........................177
PROTOPIC .........................135
protriptyline ..........................96
PROVENGE .........................54
239
PROVENTIL HFA ............. 217
PROVERA ......................... 170
PROVIGIL ......................... 111
PROZAC .............................. 94
PROZAC WEEKLY ............ 94
PRUCLAIR ........................ 136
PRUDOXIN ....................... 145
PRUMYX ........................... 136
PULMICORT ..................... 215
PULMICORT FLEXHALER
........................................ 215
PULMOSAL ...................... 115
PULMOZYME................... 218
PUREVIT DUALFE PLUS 152
PURINETHOL ..................... 52
PURIXAN ............................ 52
PYLERA ............................ 182
pyrazinamide ........................ 40
PYRIDIUM ........................ 186
pyridostigmine bromide ..... 195
PYROGALLIC ACID ........ 144
QNASL............................... 220
QSYMIA ............................ 146
QUALAQUIN ...................... 36
QUARTETTE .................... 123
QUASENSE ....................... 122
quazepam ............................ 112
QUDEXY XR ...................... 90
QUESTRAN......................... 73
quetiapine ................... 102, 106
QUILLIVANT XR ............. 104
quinapril ............................... 67
quinapril-hydrochlorothiazide
.......................................... 67
quinidine gluconate .............. 71
quinidine sulfate ................... 71
quinine sulfate ...................... 36
QVAR................................. 215
rabeprazole ......................... 177
RADIOGARDASE .............. 31
RAGWITEK......................... 60
raloxifene............................ 171
ramipril ................................. 67
RANEXA ............................. 71
ranitidine HCl ..................... 176
RAPAFLO .......................... 185
RAPAMUNE ..................... 195
RAVICTI............................ 200
RAYOS .............................. 165
RAZADYNE ...................... 116
240
RAZADYNE ER ................ 116
REBETOL ............................ 44
REBIF (WITH ALBUMIN)
........................................ 203
REBIF REBIDOSE ............ 203
REBIF TITRATION PACK
........................................ 203
RECLAST .......................... 160
RECLIPSEN (28) ............... 122
RECTACORT-HC ............... 31
RECTIV................................ 30
REGENECARE WITH ALOE
........................................ 145
REGIMEX .......................... 147
REGLAN ............................ 177
REGRANEX ...................... 146
RELAGARD ...................... 222
RELENZA DISKHALER .... 45
RELISTOR ........................... 32
RELPAX ............................ 110
REMERON .......................... 92
REMERON SOLTAB .......... 92
REMEVEN......................... 142
REMICADE ............... 181, 223
REMODULIN ...................... 84
RENAGEL ......................... 182
RENA-VITE RX ................ 148
RENO CAPS ...................... 148
RENVELA ......................... 183
repaglinide .......................... 156
REPREXAIN........................ 22
REPRONEX ....................... 162
REQ49+ ...................... 149, 152
REQUIP................................ 99
REQUIP XL ......................... 99
RESCRIPTOR ...................... 37
RESCULA .......................... 211
reserpine ............................... 85
RESTASIS.......................... 206
RESTORIL ......................... 112
RETIN-A ............................ 129
RETIN-A MICRO .............. 129
RETIN-A MICRO PUMP .. 129
RETROVIR .......................... 38
REVATIO .................... 84, 223
REVLIMID .......................... 57
REYATAZ ........................... 48
REZIRA.............................. 219
RHEUMATREX .................. 25
RHINOCORT AQUA ........ 220
RHOGAM ULTRAFILTERED PLUS ............62
RIAX ..................................129
RIBAPAK DOSE PACK .....44
RIBASPHERE ......................44
RIBATAB DOSE PACK .....44
ribavirin ................................ 44
RIDAURA ............................25
rifabutin .......................... 40, 48
RIFADIN ........................40, 48
RIFAMATE ..........................40
rifampin .......................... 40, 48
RIFATER .............................40
RILUTEK ...........................195
riluzole ................................ 195
rimantadine ...........................45
RIOMET .............................169
risedronate ..........................160
RISPERDAL ..............100, 106
RISPERDAL CONSTA .....100
RISPERDAL M-TAB 100, 107
risperidone ..................100, 107
RITALIN ....................104, 111
RITALIN LA ......................104
RITALIN SR ......................104
RITUXAN ............................53
rivastigmine tartrate ............116
rizatriptan ............................110
ROBAXIN ..........................197
ROBAXIN-750...................197
ROBINUL ..........................178
ROBINUL FORTE .............178
ROCALTROL ....................153
rocuronium .........................196
ropinirole ..............................99
ROSADAN .........................126
ROSANIL ...........................127
ROTARIX ......................63, 66
ROWASA ...........................180
ROXICET .............................23
ROXICODONE ....................21
ROZEREM .........................108
RYTHMOL ..........................71
RYTHMOL SR ....................72
SABRIL ................................ 88
SAFYRAL ..........................122
SAIZEN ...................... 166, 184
SAIZEN CLICK.EASY ....166,
184
SALACYN .........................142
SALAGEN ......................... 202
SALEX ............................... 142
salicylic acid ............... 142, 143
salicylic acid-ammon lact-aloe
........................................ 142
SALKERA ......................... 142
salsalate ................................ 29
SALVAX ............................ 143
SALVAX DUO PLUS ....... 142
SAMSCA ............................. 82
SANCTURA ...................... 188
SANCUSO ......................... 174
SANDIMMUNE ................ 194
SANDOSTATIN ........ 171, 184
SANDOSTATIN LAR
DEPOT ................... 171, 184
SANTYL ............................ 137
SAPHRIS ..................... 99, 107
SAPHRIS (BLACK
CHERRY) ................ 99, 107
SARAFEM ........................... 94
SAVELLA .................... 95, 108
SCALACORT .................... 140
SEASONIQUE ................... 118
SEB-PREV ......................... 135
SECONAL SODIUM ......... 112
SECTRAL ............................ 76
selegiline HCl ....................... 98
selenium sulfide.................. 135
SELRX ............................... 135
SELZENTRY ....................... 37
SEMPREX-D ..................... 213
SENSIPAR ......................... 160
SEREVENT DISKUS ........ 217
SEROPHENE ..................... 170
SEROQUEL ............... 102, 107
SEROQUEL XR ........ 102, 107
SEROSTIM ................ 166, 184
sertraline ............................... 94
SF 5000 PLUS .................... 201
SIDEROL ........................... 150
SIGNIFOR ......................... 171
sildenafil ............................... 84
SILENOR ........................... 113
SILVADENE ..................... 135
silver nitrate ........................ 130
silver nitrate applicators ..... 142
SIMBRINZA ...................... 204
SIMCOR............................... 74
SIMPONI ............................. 25
SIMPONI ARIA ................... 25
simvastatin ............................ 74
SINEMET ............................. 97
SINEMET CR ...................... 97
SINGLE USE EZ FLU 201213 (PF) .............................. 65
SINGLE USE EZ FLU 201314 (PF) ........................ 65, 66
SINGULAIR ...................... 215
SIRTURO ............................. 39
SITAVIG .............................. 44
SKELAXIN ........................ 197
SKLICE .............................. 146
SKYLA ............................... 117
sodium chloride .................. 115
sodium fluoride................... 201
sodium hyaluronate ............ 144
sodium phenylbutyrate ....... 200
sodium polystyrene sulfonate
........................................ 148
SOLARAZE ....................... 133
SOLIRIS ............................. 191
SOLODYN ................... 49, 125
SOLTAMOX ........................ 56
SOLU-CORTEF ................. 165
SOLU-CORTEF (PF) ......... 165
SOLU-MEDROL ............... 165
SOLU-MEDROL (PF) ....... 165
SOMA ................................ 197
SOMATULINE DEPOT .... 171
SOMAVERT ...................... 165
SONATA ............................ 113
SORIATANE ..................... 134
SORILUX ........................... 134
SORINE.......................... 72, 76
sotalol ............................. 72, 77
SOTALOL AF ...................... 72
SOVALDI ............................ 43
SPECTRACEF ..................... 41
spinosad .............................. 146
SPIRIVA WITH
HANDIHALER .............. 216
spironolactone ................ 68, 81
spironolacton-hydrochlorothiaz
.......................................... 82
SPORANOX ........................ 35
SPORANOX PULSEPAK ... 35
SPRAY AND STRETCH ... 143
SPRINTEC (28) ................. 122
SPRIX ................................... 27
SPRYCEL.............................56
SPS .....................................149
SRONYX ............................122
SSD .....................................135
SSS 10-4 .............................127
SSS 10-5 .............................127
ST JOSEPH ASPIRIN ..29, 193
ST. JOSEPH ASPIRIN .29, 193
STALEVO 100 .....................97
STALEVO 125 .....................97
STALEVO 150 .....................97
STALEVO 200 .....................97
STALEVO 50 .......................97
STALEVO 75 .......................97
stannous fluoride ................201
STARLIX ...........................156
stavudine ...............................38
STAVZOR ....................88, 106
STELARA ..........................130
STIMATE ...........................156
STIVARGA ..........................55
STRATTERA .....................104
STRIANT ...........................155
STRIBILD ............................38
STROMECTOL ...................34
STROVITE FORTE ...........152
STROVITE ONE................152
SUBOXONE ......................113
SUBSYS ...............................21
SUCRAID...........................175
sucralfate.............................182
SULAR .................................78
sulfacetamide sodium .135, 210
sulfacetamide sodium (acne)
........................................126
sulfacetamide sodium-sulfur
........................................128
sulfacetamide sodium-urea .135
sulfacetamide sod-sulfur-urea
................................ 127, 145
sulfacetamide-prednisolone 204
sulfadiazine ...........................48
sulfamethoxazole-trimethoprim
..........................................34
SULFAMYLON .................135
sulfasalazine .......................180
SULFAZINE ......................180
sulindac .................................27
SUMADAN ........................128
sumatriptan .........................110
241
sumatriptan succinate ......... 110
SUMAVEL DOSEPRO ..... 110
SUMAXIN ......................... 128
SUMAXIN TS.................... 128
SUPARTZ .......................... 196
SUPPRELIN LA ................ 169
SUPRAX .............................. 41
SUPRENZA ....................... 147
SUPREP ............................. 182
SURMONTIL....................... 96
SUSTIVA ............................. 37
SUTENT............................... 56
SYEDA............................... 122
SYLATRON......................... 54
SYLATRON 4-PACK.......... 54
SYMAX FASTABS ........... 178
SYMAX-SL ....................... 178
SYMAX-SR ....................... 178
SYMBICORT..................... 218
SYMBYAX .......................... 97
SYMLINPEN 120 .............. 158
SYMLINPEN 60 ................ 158
SYNAGIS............................. 60
SYNALAR ......................... 140
SYNALGOS-DC .................. 22
SYNAREL ......................... 169
SYNERA ............................ 145
SYNRIBO ............................ 58
SYNTHROID ..................... 172
SYNVISC ........................... 196
SYNVISC-ONE ................. 196
SYPRINE ............................. 32
TABLOID ............................ 52
TACLONEX ...................... 130
tacrolimus ........................... 194
TAFINLAR .......................... 55
TAMIFLU ............................ 45
tamoxifen.............................. 56
tamsulosin........................... 185
TANDEM PLUS ................ 152
TANZEUM ........................ 158
TAPAZOLE ....................... 159
TARCEVA ........................... 53
TARGRETIN ............... 56, 133
TARKA ................................ 66
TARON-CRYSTALS ........ 186
TASIGNA ............................ 56
TASMAR ............................. 97
TAXOTERE ......................... 57
TAZORAC ......................... 134
242
TAZTIA XT ......................... 78
TECFIDERA ...................... 203
TEFLARO ............................ 41
TEGRETOL ................. 90, 106
TEGRETOL XR ........... 90, 106
TEKAMLO .......................... 85
TEKTURNA ........................ 85
TEKTURNA HCT ............... 85
telmisartan ............................ 70
telmisartan-hydrochlorothiazid
.......................................... 69
temazepam .......................... 112
TEMODAR .................. 50, 223
TEMOVATE ...................... 140
temozolomide ....................... 51
TENCON .............................. 24
TENEX ................................. 80
TENIVAC (PF) .................... 63
TENORETIC 100 ................. 79
TENORETIC 50 ................... 79
TENORMIN ......................... 75
TERAZOL 3 ....................... 221
TERAZOL 7 ....................... 221
terazosin................................ 83
terbinafine ............................. 34
terbutaline ........................... 218
terconazole.......................... 221
TERSI FOAM .................... 135
TESSALON PERLES ........ 214
TESTIM.............................. 155
TESTOPEL ........................ 155
testosterone ......................... 155
testosterone cypionate ........ 155
testosterone enanthate......... 155
TESTRED .......................... 155
TETCAINE ........................ 208
tetracaine HCl (PF) ............. 208
tetracycline ........................... 49
TETRAVISC FORTE ........ 208
TEVETEN ............................ 70
TEVETEN HCT ................... 69
TEV-TROPIN ............ 166, 184
TEXACORT ....................... 140
THALOMID ................... 36, 57
THEO-24 ............................ 216
THEOCHRON ................... 216
theophylline ........................ 216
THERACYS ................... 55, 63
THERMAZENE ................. 135
THIOLA ............................. 184
thioridazine .........................101
thiotepa .................................50
thiothixene ..........................101
THROMBI-GEL.................191
THROMBI-PAD ................191
THYROGEN ......................146
THYROLAR-1 ...................171
THYROLAR-1/2 ................171
THYROLAR-1/4 ................171
THYROLAR-2 ...................171
THYROLAR-3 ...................171
tiagabine ...............................88
TIAZAC ...............................78
TICE BCG ......................55, 63
ticlopidine ...........................193
TIGAN ................................ 173
TIKOSYN.............................72
TILIA FE ............................124
timolol maleate .............77, 208
TIMOPTIC .........................208
TIMOPTIC OCUDOSE (PF)
........................................208
TIMOPTIC-XE...................208
TINDAMAX ........................37
tinidazole ..............................37
TIROSINT ..........................172
TISSEEL VHSD .................191
TIVICAY ..............................37
tizanidine ............................197
TL TRISEB (WITH
TELMESTEINE) ....135, 136
TOBI .....................................33
TOBI PODHALER ..............33
TOBRADEX ......................204
TOBRADEX ST .................204
tobramycin ..........................209
tobramycin in 0.225 % NaCl 33
tobramycin-dexamethasone 205
TOBREX ............................209
TOFRANIL ..........................96
TOFRANIL-PM ...................97
tolazamide...........................157
tolbutamide .........................157
tolmetin .................................27
tolterodine ...........................188
TOPAMAX ..........................90
TOPICORT.........................140
TOPIRAGEN .......................90
topiramate .............................90
TOPOSAR ............................53
topotecan .............................. 57
TOPROL XL ........................ 76
torsemide .............................. 82
TOTECT............................... 59
TOVIAZ ............................. 188
TRACLEER ......................... 84
TRADJENTA ..................... 156
tramadol ................................ 21
tramadol-acetaminophen ...... 24
TRANDATE ........................ 68
trandolapril ........................... 67
tranexamic acid .................. 191
TRANSDERM-SCOP ........ 173
TRANXENE T-TAB............ 86
tranylcypromine ................... 93
TRAVATAN Z .................. 211
travoprost (benzalkonium) . 211
trazodone .............................. 94
TREAGAN OTIC .............. 212
TREANDA ........................... 50
TRECATOR ......................... 40
TRELSTAR .......................... 54
tretinoin ...................... 129, 130
tretinoin (chemotherapy) ...... 56
tretinoin (emollient)............ 144
tretinoin microsphere.......... 130
TRETIN-X ......................... 129
TREXALL............................ 51
TREXIMET ........................ 110
triamcinolone acetonide .... 141,
165, 201, 220
triamterene-hydrochlorothiazid
.......................................... 82
TRIANEX .......................... 141
triazolam ............................. 112
TRIBENZOR ....................... 68
TRI-BUFFERED ASPIRIN . 30
TRI-CHLOR....................... 143
TRICITRATES .................. 186
TRICOR ............................... 73
TRIDERM .......................... 141
TRI-ESTARYLLA ............. 124
trifluoperazine .................... 101
trifluridine........................... 210
TRIGLIDE ........................... 73
trihexyphenidyl..................... 98
TRI-LEGEST FE................ 124
TRILEPTAL......................... 90
TRI-LINYAH ..................... 124
TRILIPIX ............................. 73
TRILYTE WITH FLAVOR
PACKETS ...................... 182
trimethobenzamide ............. 173
trimethoprim ......................... 34
TRINESSA (28) ................. 124
TRI-NORINYL (28)........... 124
TRI-PREVIFEM (28) ......... 124
TRI-SPRINTEC (28) .......... 124
TRIVORA (28)................... 124
TRIZIVIR ............................. 39
TROKENDI XR ................... 90
tropicamide ......................... 205
trospium .............................. 188
TRUSOPT .......................... 207
TRUVADA .......................... 39
TUDORZA PRESSAIR .... 216,
217
TUSSICAPS ....................... 219
TUSSIGON ........................ 219
TUSSIONEX PENNKINETIC
ER ................................... 219
TWYNSTA .......................... 68
TYKERB .............................. 49
TYLENOL-CODEINE #3 .... 22
TYLENOL-CODEINE #4 .... 22
TYSABRI ........................... 202
TYVASO .............................. 84
TYVASO REFILL KIT........ 84
TYVASO STARTER KIT ... 84
TYZEKA .............................. 43
TYZINE...................... 220, 221
UCERIS .............................. 180
U-CORT ............................. 141
ULESFIA............................ 146
ULORIC ............................. 189
ULTRACET ......................... 24
ULTRAM ............................. 21
ULTRAM ER ....................... 21
ULTRAVATE .................... 141
ULTRESA .......................... 175
UMECTA ........................... 143
UMECTA PD ..................... 143
UNIRETIC ........................... 68
UNITHROID ...................... 172
UNIVASC ............................ 67
UR N-C............................... 187
URAMAXIN ...................... 143
URAMAXIN GT ................ 143
urea ............................. 136, 143
UREA NAIL STICK .......... 143
URECHOLINE...................188
URELLE .............................187
URETRON D-S ..................187
URIBEL .............................. 187
URIMAR-T ........................187
URIN DS ............................187
UROCIT-K 10 ....................186
UROCIT-K 15 ....................186
UROCIT-K 5 ......................186
UROGESIC-BLUE ............187
UROQID-ACID NO.2 ........186
UROXATRAL ...................185
URSO 250 ..........................175
URSO FORTE ....................175
ursodiol ............................... 175
URYL .................................187
USTELL .............................187
UTA ....................................187
UTOPIC .............................. 143
VAGIFEM ..........................222
valacyclovir ..........................44
VALCHLOR ......................133
VALCYTE ...........................42
VALIUM ..............................86
valproic acid .................88, 106
valproic acid (as sodium salt)
..................................88, 106
valsartan ................................ 70
valsartan-hydrochlorothiazide
..........................................69
VALTREX ...........................44
VANCOCIN .........................42
vancomycin...........................43
VANDAZOLE ...................222
VANOS .............................. 141
VANOXIDE-HC ................129
VANTAS ............................169
VARIVAX (PF)..............63, 66
VARIZIG ..............................62
VASCEPA ............................75
VASERETIC ........................68
VASOLEX .........................137
VASOTEC ............................67
V-C FORTE........................152
VECAMYL ..........................83
VECTIBIX ...........................59
VECTICAL ........................134
VELCADE ...........................56
VELETRI .............................84
243
VELIVET TRIPHASIC
REGIMEN (28) .............. 124
VELTIN ............................. 128
VENELEX ......................... 146
venlafaxine ........................... 95
VENTAVIS .......................... 84
VENTOLIN HFA ............... 217
VERAMYST ...................... 220
verapamil ........................ 72, 79
VERDESO ......................... 141
VERDROCET ...................... 22
VEREGEN ......................... 141
VERELAN ........................... 79
VERELAN PM .................... 79
VERIPRED 20 ................... 165
VERSACLOZ .................... 100
VESICARE ........................ 188
VESTURA (28) .................. 122
VEXOL .............................. 206
VFEND................................. 35
VIBRAMYCIN .................... 49
VIC-FORTE ....................... 152
VICODIN ............................. 23
VICODIN ES ....................... 23
VICODIN HP ....................... 23
VICOPROFEN ..................... 23
VICTOZA 3-PAK .............. 158
VICTRELIS ......................... 43
VIDAZA............................... 52
VIDEX 2 GRAM PEDIATRIC
.......................................... 38
VIDEX 4 GRAM PEDIATRIC
.......................................... 38
VIDEX EC ........................... 38
VIGAMOX......................... 210
VIIBRYD ............................. 95
VIMOVO ............................. 26
VIMPAT............................... 88
VINATE DHA ................... 152
vinblastine ............................ 57
vinorelbine............................ 57
VIOKACE .......................... 175
VIORELE (28) ................... 118
VIRACEPT .......................... 48
VIRAMUNE .................. 37, 38
VIRAMUNE XR .................. 38
VIRASAL........................... 143
VIRAZOLE .......................... 48
VIREAD ............................... 39
VIROPTIC ......................... 210
244
VIRT-VITE PLUS ............. 148
VISTARIL ............................ 85
VISTIDE .............................. 42
VISUDYNE........................ 208
VITAMIN D2 ..................... 153
VITUZ ................................ 219
VIVACTIL ........................... 97
VIVELLE-DOT.................. 162
VIVITROL ......................... 114
VOGELXO ......................... 155
VOL-CARE RX ................. 148
VOLTAREN ...................... 144
VOLTAREN-XR.................. 27
voriconazole ......................... 35
VOSOL-HC ........................ 212
VOSPIRE ER ..................... 218
VOTRIENT .......................... 56
VPRIV ................................ 199
VP-ZEL .............................. 148
VUSION ............................. 132
VYFEMLA (28) ................. 122
VYTONE............................ 131
VYTORIN 10-10 .................. 75
VYTORIN 10-20 .................. 75
VYTORIN 10-40 .................. 75
VYTORIN 10-80 .................. 75
VYVANSE ......................... 104
warfarin .............................. 189
WELCHOL .......................... 73
WELLBUTRIN .................... 93
WELLBUTRIN SR .............. 93
WELLBUTRIN XL .............. 93
WERA (28)......................... 122
WESTHROID .................... 171
WP THYROID ................... 172
WYMZYA FE .................... 122
XALATAN ......................... 211
XALKORI ............................ 56
XANAX................................ 86
XANAX XR ......................... 86
XARELTO ......................... 190
XARTEMIS XR ................... 23
XELJANZ ............................ 26
XELODA.............................. 52
XENAZINE ........................ 111
XENICAL .......................... 147
XEOMIN ............................ 196
XERAC AC ........................ 134
XERESE ............................. 135
XGEVA .............................. 170
XIAFLEX ...........................196
XIFAXAN ............................48
XODOL 10/300 ....................23
XODOL 5/300 ......................23
XODOL 7.5/300 ...................23
XOLAIR .............................215
XOLEGEL ..........................132
XOPENEX .........................217
XOPENEX HFA ................217
XTANDI ...............................51
XULANE ............................124
X-VIATE ....................137, 143
XYLOCAINE .....................202
XYREM .............................. 111
XYZAL............................... 214
YASMIN (28) .....................122
YAZ (28) ............................122
YERVOY .............................53
YODOXIN ...........................32
ZADITOR...........................205
zafirlukast ...........................215
zaleplon............................... 113
ZAMICET ............................23
ZANAFLEX .......................197
ZANOSAR ...........................58
ZANTAC ............................176
ZARAH .............................. 122
ZARONTIN ..........................92
ZAROXOLYN .....................83
ZAVESCA ..........................200
ZEBETA ...............................76
ZEGERID ...........................177
ZELAPAR ............................98
ZELBORAF .........................55
ZEMPLAR .........................199
ZEMURON ........................196
ZENATANE .......................125
ZENCHENT (28) ...............122
ZENCHENT FE .................122
ZENCIA .............................128
ZENPEP .............................175
ZENZEDI ...........104, 108, 112
ZEOSA ............................... 122
ZERIT ...................................38
ZESTORETIC ......................68
ZESTRIL ..............................67
ZETIA...................................74
ZETONNA .........................220
ZEVALIN (Y-90) .................55
ZIAC .....................................79
ZIAGEN ............................... 38
ZIANA ............................... 128
zidovudine ............................ 39
zinc sulfate.......................... 151
ZINECARD .......................... 58
ZIOPTAN (PF) ................... 211
ziprasidone HCl ............ 99, 107
ZIPSOR ................................ 27
ZIRGAN ............................. 210
ZITHRANOL ..................... 134
ZITHRANOL-RR .............. 134
ZITHROMAX ...................... 46
ZITHROMAX TRI-PAK ..... 46
ZITHROMAX Z-PAK ......... 47
ZMAX .................................. 47
ZN-DTPA ............................. 32
ZOCOR ................................ 74
ZOFRAN (AS
HYDROCHLORIDE) .... 174
ZOFRAN ODT ................... 174
ZOHYDRO ER .................... 21
ZOLADEX ........................... 54
zoledronic acid ................... 160
zoledronic acid-mannitol-water
........................................ 160
ZOLINZA ............................. 54
zolmitriptan ........................ 110
ZOLOFT ............................... 94
zolpidem ............................. 113
ZOLPIMIST ....................... 113
ZOMETA ........................... 160
ZOMIG ............................... 110
ZOMIG ZMT ..................... 110
ZONALON ......................... 145
ZONATUSS ....................... 214
ZONEGRAN ........................ 92
zonisamide ............................ 92
ZONTIVITY ...................... 193
ZORBTIVE ................ 166, 184
ZORTRESS ........................ 195
ZORVOLEX ........................ 27
ZOSTAVAX (PF) .......... 63, 66
ZOVIA 1/35E (28) .............122
ZOVIA 1/50E (28) .............122
ZOVIRAX ..............44, 45, 135
ZUBSOLV ..........................113
ZUPLENZ ..........................174
ZUTRIPRO.........................219
ZYBAN .............................. 114
ZYCLARA .........................142
ZYFLO ............................... 214
ZYFLO CR .........................214
ZYKADIA ............................56
ZYLET ............................... 205
ZYLOPRIM ........................189
ZYMAXID .........................210
ZYPREXA ..................102, 107
ZYPREXA RELPREVV ....102
ZYPREXA ZYDIS .....102, 107
ZYTIGA .........................49, 51
ZYVOX ................................ 47
245

2015 Drug Formulary - HealthPlus of Michigan

Transcription

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