GHP Family Formulary - Geisinger Health Plan

Transcription

What is the GHP Family Formulary?
A formulary is a list of drugs selected by GHP Family, which represents medications believed to
be a necessary part of a quality treatment program.
This formulary is up to date at the time of print. For the most up to date information, please go
to our website at www.GHPFamily.com
Can the Formulary change?
The plan may add or remove drugs from the formulary. If we remove drugs from our formulary,
or add restrictions on a drug such as a requirement for prior authorization, quantity limits and/or
step therapy restrictions on a drug, we must notify affected members of the change at least 30
days before the change becomes effective. See section, “Are there any requirements or limits on
my drugs?” for more information.
How do I use the Formulary?
There are two ways to find your drug within the formulary:
Medical Condition
The formulary begins on page 8. The drugs in this formulary are grouped into categories
depending on the type of medical conditions that they are used to treat. For example, drugs used
to treat a heart condition are listed under the category, “Cardiovascular Agents”. If you know
what your drug is used for, look for the category name in the list that begins on page 8. 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 I-1. 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.
The first column of the formulary lists the formulary drug. Brand drugs are printed in all upper
case letters (e.g. ADVAIR DISKUS). Generic drugs are printed in all lower case italic letters
(e.g. simvastatin). Drug names that appear in parenthesis after the generic covered drugs are the
name of the brand medication. The brand name in parenthesis, appear for reference only to assist
in identifying the generic medication and does NOT indicate that the brand name drug is on the
formulary.
The second column of the formulary lists the tier the drug is covered on. Tier 1 contains generic
medications. Tier 2 contains brand name medications. Drugs listed as OTC are over-the-counter
medications. See the section titled “Medical Benefit Drugs” for an explanation of drugs that are
listed as “Medical Benefit.”
The third and final column of the formulary lists any requirements or limits that may apply to the
drug. See the section titled “Are there any requirements or limits on my drugs” below.
Sometimes a drug comes in multiple forms (e.g., drops, liquid, tablet, syrup, etc.). If this column
lists a specific drug form then only that form is included in the formulary.
What if my drug is not on the Formulary?
If your drug is not included in this formulary, you should first contact Member Services and
confirm that your drug is not listed.
What are generic drugs?
GHP Family covers both brand name drugs and generic drugs. If your doctor prescribes a brand
name drug and a generic is available, your pharmacist will give you the generic version of that
drug. A generic drug is approved by the Federal Food & Drug Administration (FDA) as having
the same active ingredient as the brand name drug and is just as safe and effective. Generally,
generic drugs cost less than brand name drugs. Prescriptions written as “brand medically
necessary” by your doctor will require prior authorization.
Are Over-the-Counter (OTC) drugs covered?
Certain OTC medications are listed on the formulary. OTC drugs will require a prescription
from your doctor.
Dispensing Limits
GHP Family will cover up to a 34-day supply of your medication unless the prescription is
written for less by your physician or the medication is subject to a quantity limit restriction. A
medication may be refilled when 85% has been used. If for some reason you need a refill before
85% of the medication has been used please call GHP Family Pharmacy Services at (855) 5526028 or (570) 214-3554 for assistance.
GHP Family will grant one early refill if you are traveling outside of Pennsylvania and will run
out of medication before you return home. GHP Family will allow this once per medication per
member per year. Your pharmacy should contact GHP Family Pharmacy Services at (855) 5526028 or (570) 214-3554 to obtain a vacation supply. Any additional requests for a vacation
supply will require prior authorization.
Requests to replace medications that are lost, stolen, or destroyed must be reviewed by GHP
Family Pharmacy Services. Members should contact GHP Family Pharmacy Services at (855)
552-6028 or (570) 214-3554 for more information.
Blood Glucose Monitors
Members are entitled to receive one new blood glucose monitor every two years. No prior
authorization is required for formulary Blood Glucose Meters (Glucometers) and formulary
glucose test strips up to 200 strips per month. Larger quantities of test strips, non-formulary
glucometers and non-formulary test strips require prior authorization. Prior authorization will
also be required for members needing a new blood glucose monitor before two years have
passed. Please contact GHP Family Pharmacy Services at (855) 552-6028 or (570) 214-3554 for
more information.
Formulary Blood Glucose Meters and Test Strips include:
•
•
•
•
•
•
•
•
•
One Touch Basic
One Touch Ultra
One Touch Ultra 2
One Touch Ultra Smart
One Touch Ultramini
One Touch Ultralink
One Touch Verio IQ
Sure Step
Sure Step Pro
Medical Benefit Drugs
Medical benefit drugs are drugs dispensed and administered in a physician’s office. This
formulary does not list all drugs available as a medical benefit. Several medical benefit drugs
are listed in this formulary as “Medical Benefit” in the Tier column but only for the purposes of
alerting members, physicians, and pharmacies that prior authorization or other formulary
restrictions may apply to these drugs. All medical benefit drugs that require a prior authorization
are listed on this formulary. Any questions regarding the coverage of medical benefit drugs
should be directed to GHP Family Member Services at (800) 544-3907.
Vaccines
Influenza (Flu) vaccines are available to members at a retail pharmacy without a prescription.
Other vaccines are considered a medical benefit and should be administered by your physician.
Are there any requirements or limits on my drugs?
Some drugs may have additional requirements or limits. These requirements and limits may
include:
•
Prior Authorization: GHP Family requires your physician to get prior approval for
certain drugs. This means that your prescriber will need to get approval from GHP
Family before you fill prescriptions for these drugs. Without this approval, GHP Family
will not pay for the drug. If GHP denies the prior authorization request, you can appeal
the decision. Please see the GHP member handbook, section 15, Complaint, Appeal and
Fair Hearing Processes, for information about filing an appeal.
•
Quantity Limits: For certain drugs, GHP Family has limits to the amount of the drug
that you can get. If your prescriber wants you to have more than the limit, your
prescriber must request prior authorization.
•
Step Therapy: In some cases, GHP Family requires you to first try certain drugs to treat
your medical condition before we will approve another drug for that condition. For
example, if Drug A and Drug B both treat your medical condition, GHP Family may not
approve Drug B unless you try Drug A first. If Drug A does not work for you, GHP
Family will then approve Drug B. Your prescriber may request prior authorization if
Drug A does not work for you or if you cannot take Drug A.
•
Specialty Pharmacy: Specialty medications can only be filled by certain pharmacies in
the GHP Family network. Specialty drugs are medications used to treat complex
diseases. These medications usually require specialized handling and monitoring. If you
are taking a specialty medicine or if you have a question about finding a specialty
pharmacy, please call GHP Family Pharmacy Services at (855) 552-6028 or (570) 2143554. Specialty medications have the words, “Specialty Drug” next to them in the
formulary.
The following abbreviations are found within column three of this formulary and indicate
the requirements and limits listed above:
ABBREVIATION
PA
QL
ST
Specialty Drug
DESCRIPTION
EXPLANATION
Utilization Management Restrictions
Your physician is required to get prior
authorization from GHP Family before you fill
Prior Authorization
your prescription for this drug. Without prior
Restriction
approval, GHP Family will not pay for this drug.
GHP Family limits the amount of this drug that can
Quantity Limit
be obtained per prescription, or within a specific
Restriction
time frame.
Before GHP Family will approve this drug, you
Step Therapy
must first try another drug(s) to treat your medical
Restriction
condition. This drug may only be approved if the
other drug(s) does not work for you.
Some drugs are not available at your retail
pharmacy. These drugs are called specialty drugs
and can be obtained at specialty pharmacies. To
Specialty Drug
find out how and where to obtain a specialty drug,
please contact GHP Family Pharmacy Services at
(855) 552-6028 or (570) 214-3554.
How much will I pay for my drugs?
Pharmacy copays will apply to members 18 years of age and older unless otherwise listed below.
Brand name prescription drugs have a $3 copayment. Generic prescription and over-the-counter
drugs have a $1 copayment. Services cannot be denied if the member is unable to afford the
copay.
There are no copays for:
• Pregnant women (including the postpartum period which ends 60 days after delivery)
• Children under 18 years of age
• Medical benefit drugs
• Members in a nursing home
• Members in an Intermediate Care Facility for Mental Retardation or Intermediate Care
Facility for Other Related Conditions
• Family planning drugs or supplies
• Drugs, including immunizations, when dispensed and/or administered by a physician
• Title IV-B Foster Care and IV-E Foster Care and Adoption Assistance
• Members eligible under the Breast and Cervical Cancer Prevention and Treatment Programs
• There is no copay for the following groups of medications:
o
o
o
o
o
o
o
o
o
Antihypertensives (high blood pressure)
Antidiabetes (high blood sugar)
Anticonvulsants (seizure)
Cardiovascular preparations (heart disease)
Antipsychotics (except those that are controlled substance antianxiety drugs)
Antineoplastics (cancer drugs)
Antiglaucoma drugs
Anti-Parkinson’s drugs
HIV/AIDS drugs
Non-covered medications
The following medications are not eligible for coverage under the Medical Assistance Program:
•
•
•
•
•
•
•
•
•
Drugs that are designated by the FDA as less than effective (DESI) drugs
Any drug marketed by a drug company that does not participate in the Medicaid Rebate
Program
Drugs used for weight loss
Drugs used for cosmetic purposes or hair growth
Drugs used for fertility
Drugs used for erectile dysfunction
Cough and cold medications for members over 21 years of age
Drugs and devices classified as experimental
Drugs ordered by a prescribed who has been barred or suspended from participating the MA
program
What if my drug requires prior authorization?
If you learn that GHP Family requires prior authorization of your drug, you have two options:
•
You can ask GHP Family Pharmacy Services for a list of similar drugs that are on the
GHP Family formulary. You can call GHP Family Pharmacy Services at (855) 552-6028
or (570) 214-3554. When you receive the list, show it to your doctor and ask him or her
if one of these drugs will work for you.
•
Your physician can ask GHP Family for approval of your drug through a prior
authorization. See below for information about how your physician can request a prior
authorization.
What if I need a drug that is not listed on the GHP Family Formulary?
•
Your physician can ask us to approve your drug even if it is not on our formulary.
What if I need an amount that exceeds the GHP Family Formulary limit?
•
If your drug has a quantity limit, your physician can ask us to approve a higher amount.
Generally, GHP Family will only approve your physician’s request if the alternative drugs
included on the plan’s formulary would not be as effective in treating your condition and/or
would cause you to have a negative medical effect.
We must make our decision within 24 hours of getting your prescriber’s request. If a decision
cannot be made within the 24 hour timeframe, GHP Family will authorize a temporary supply of
the medication. If your prescription is for an ongoing medication, a 15 day temporary supply
will be authorized. If your prescription is for a new medication, a 5 day temporary or emergency
supply of medication will be authorized. Members are limited to one emergency supply per
medication every 180 days.
A member whose prescription rejects for prior authorization or other utilization management
criteria should not be turned away at the pharmacy without receiving a temporary or emergency
supply of medication unless the dispensing pharmacist feels that dispensing the medication
would jeopardize the health and safety of the member.
Drug Name
Drug Tier
Requirements/Limits
Analgesics
Analgesics, Miscellaneous
acetaminophen with codeine solution
acetaminophen with codeine tablet: 300mg30mg
butalb/acetaminophen/caffeine capsule: 50300-40, 50-325-40; solution, tablet
butalbit/acetamin/caff/codeine capsule: 50300-30
butalbital/acetaminophen tablet: 50mg325mg
butalbital/acetaminophen tablet: 50mg325mg
butalbital/aspirin/caffeine
codeine sulfate
CODEINE SULFATE
DISKETS
fentanyl citrate
fentanyl patch td72: 12mcg/hr, 25mcg/hr,
50mcg/hr
fentanyl patch td72: 75mcg/hr, 100mcg/hr
hydrocodone/acetaminophen solution: 2.5167/5, 10-325/15
hydrocodone/acetaminophen solution: 10300/15
hydrocodone/acetaminophen solution: 7.5325/15
hydrocodone/acetaminophen tablet: 5mg325mg, 7.5-325mg, 10mg-325mg
hydrocodone/acetaminophen tablet: 5mg300mg, 7.5-300mg, 10mg-300mg
hydrocodone/ibuprofen
hydromorphone hcl tablet: 2mg, 4mg
hydromorphone hcl tablet: 8mg
ibuprofen/oxycodone hcl
(Acetaminophen with
Codeine)
(Tylenol-Codeine
No.3)
(Tylenol-Codeine
No.3)
(Tylenol-Codeine
No.3)
(Fioricet)
1
QL: 166.67 in 1 days
1
QL: 12 in 1 days
1
QL: 13 in 1 days
1
QL: 6 in 1 days
(Fioricet with Codeine)
1
(Tencon)
1
(Tencon)
1
(Fiorinal)
(Codeine Sulfate)
(Actiq)
(Duragesic)
1
1
1
1
1
1
(Duragesic)
(Lortab)
1
1
QL: 20 in 30 days
(Lortab)
1
QL: 67.5 in 1 days
(Lortab)
1
QL: 90 in 1 days
(Norco)
1
QL: 12 in 1 days
(Norco)
1
QL: 13 in 1 days
(Ibudone)
(Dilaudid)
(Dilaudid)
(Ibuprofen/Oxycodone
HCl)
1
1
1
1
QL: 5 in 1 days
QL: 6 in 1 days
QL: 8 in 1 days
QL: 4 in 1 days
1
QL: 6 in 1 days
QL: 6 in 1 days
QL: 3 in 1 days
PA, QL: 120 in 30 days
QL: 10 in 30 days
1
Geisinger Family 2016 Formulary
Formulary ID: 82128.000, Version: 4Q2016
Effective: October 01, 2016
Drug Name
levorphanol tartrate
meperidine hcl solution, tablet
methadone hcl oral conc, tablet
methadone hcl tablet sol
methadone hcl solution
morphine sulfate cap er pel: 30mg, 50mg,
100mg; tablet er: 15mg, 30mg, 100mg
morphine sulfate cap er pel: 10mg, 20mg,
60mg, 80mg; tablet er: 60mg, 200mg
morphine sulfate supp.rect
morphine sulfate solution: 20mg/5ml
MORPHINE SULFATE
oxycodone hcl solution
oxycodone hcl capsule, oral conc, tablet
oxycodone hcl/acetaminophen solution: 5325/5ml
oxycodone hcl/acetaminophen tablet: 2.5325mg, 5mg-325mg, 7.5-325mg, 10mg325mg
oxycodone hcl/aspirin
oxymorphone hcl tablet
tramadol hcl tab er 24h: 200mg, 300mg
tramadol hcl tab er 24h: 100mg
tramadol hcl tablet
tramadol hcl/acetaminophen
acetaminophen capsule: 500mg; elixir,
liquid: 160mg/5ml; supp.rect: 120mg,
650mg; tab chew: 80mg; tablet: 500mg
acetaminophen/phenyltolx tablet: 325mg30mg
PRIALT
Drug Tier
Requirements/Limits
(Levorphanol Tartrate)
(Demerol)
(Dolophine HCl)
(Methadone HCl)
(Methadone HCl)
(Morphine Sulfate ER)
1
1
1
1
1
1
QL: 12 in 1 days
QL: 3 in 1 days
QL: 60 in 1 days
QL: 3 in 1 days
(Morphine Sulfate ER)
1
QL: 4 in 1 days
(Morphine Sulfate)
(Morphine Sulfate)
(Morphine Sulfate)
(Morphine Sulfate)
1
1
1
1
1
1
1
1
QL: 45 in 1 days
QL: 9 in 1 days
QL: 90 in 1 days
QL: 6 in 1 days
QL: 43.33 in 1 days
QL: 6 in 1 days
QL: 61 in 1 days
1
QL: 12 in 1 days
(Oxycodone HCl)
(Roxicodone)
(Oxycodone HCl/
Acetaminophen)
(OxycodoneAcetaminophen)
(Percodan)
(Opana)
(Ultram ER)
(Ultram ER)
(Ultram)
(Ultracet)
(Acetaminophen)
1
1
1
1
1
1
OTC
(Acetaminophen/
Phenyltolx)
OTC
Medical
BenefitSpecialty
Drug
Nonsteroidal Anti-Inflammatory Agents
(Celebrex)
celecoxib
(Choline Sal/Mag
choline sal/mag salicylate
Salicylate)
COMFORT PAC-IBUPROFEN
1
1
QL: 6 in 1 days
QL: 12 in 1 days
QL: 6 in 1 days
QL: 30 in 30 days
QL: 90 in 30 days
QL: 240 in 30 days
QL: 240 in 30 days
PA
ST, QL: 60 in 30 days
1
2
Drug Name
COMFORT PAC-MELOXICAM
COMFORT PAC-NAPROXEN
diclofenac potassium
diclofenac sodium tab er 24h, tablet dr
diclofenac sodium gel (gram): 1%
diflunisal
etodolac
fenoprofen calcium tablet
flurbiprofen
ibuprofen oral susp: 100mg/5ml; tablet:
400mg, 600mg, 800mg
indomethacin
ketoprofen capsule
ketorolac tromethamine tablet
meclofenamate sodium
mefenamic acid
meloxicam
methyl salicylate
nabumetone
naproxen sodium tablet: 275mg, 550mg
naproxen
oxaprozin
piroxicam
salsalate
sulindac
tolmetin sodium
VOLTAREN
aspirin supp.rect, tab chew: 81mg; tablet:
325mg; tablet dr: 81mg, 325mg
ibuprofen drops susp, oral susp: 100mg/
5ml; tab chew, tablet: 200mg
naproxen sodium tablet: 220mg
Drug Tier
(Cataflam)
(Diclofenac Sodium)
(Voltaren)
(Diflunisal)
(Etodolac)
(Fenoprofen Calcium)
(Flurbiprofen)
(Ibuprofen)
(Indomethacin)
(Ketoprofen)
(Ketorolac
Tromethamine)
(Meclofenamate
Sodium)
(Ponstel)
(Mobic)
(Methyl Salicylate)
(Nabumetone)
(Anaprox Ds)
(Naprosyn)
(Daypro)
(Feldene)
(Salsalate)
(Sulindac)
(Tolmetin Sodium)
1
1
1
1
1
1
1
1
1
1
1
1
1
Requirements/Limits
PA
QL: 20 per fill
1
(Aspirin)
1
1
1
1
1
1
1
1
1
1
1
2
OTC
(Children'S Advil)
OTC
(Naproxen Sodium)
OTC
PA
Anesthetics
Local Anesthetics
benzocaine drops
lidocaine hcl cream (g), jel (ml), jel/pf app:
2%; solution
lidocaine oint. (g)
lidocaine adh. patch
(Benzocaine)
(Pre-Attached Lta Kit)
1
1
(Lidocaine)
(Lidoderm)
1
1
3
Drug Name
lidocaine/hydrocortisone ac
lidocaine/prilocaine
RELADOR PAK
benzocaine gel (gram): 20%
Drug Tier
(Lidocaine/
Hydrocortisone Ac)
(EMLA)
(Hurricaine)
Requirements/Limits
1
1
1
OTC
Anti-Addiction/Substance Abuse Treatment Agents
Anti-Addiction/Substance Abuse Treatment Agents
(Campral)
acamprosate calcium
(Buprenorphine HCl)
buprenorphine hcl
(Suboxone)
buprenorphine hcl/naloxone hcl
(Zyban)
bupropion hcl
(Antabuse)
disulfiram
naloxone hcl syringe
(Naloxone HCl)
(Naltrexone HCl)
naltrexone hcl
NARCAN
SUBOXONE
nicotine polacrilex gum: 2mg, 4mg;
(Nicorette)
lozenge
nicotine patch td24: 7mg/24hr, 14mg/24hr, (Nicoderm Cq)
21mg/24hr
VIVITROL
1
1
1
1
1
1
1
2
2
OTC
PA
PA
PA
OTC
Medical
BenefitSpecialty
Drug
Antianxiety Agents
Benzodiazepines
alprazolam tab er 24h: 2mg, 3mg; tab
rapdis: 2mg; tablet: 2mg
alprazolam tab er 24h: 0.5mg, 1mg; tab
rapdis: 0.25mg, 0.5mg, 1mg; tablet:
0.25mg, 0.5mg, 1mg
chlordiazepoxide hcl
clonazepam tab rapdis: 2mg; tablet: 2mg
clonazepam tab rapdis: 0.125mg, 0.25mg,
0.5mg, 1mg; tablet: 0.5mg, 1mg
diazepam kit
diazepam solution
diazepam oral conc
diazepam tablet
flurazepam hcl capsule: 30mg
(Xanax)
1
QL: 2 in 1 days
(Xanax)
1
QL: 4 in 1 days
(Chlordiazepoxide
HCl)
(Klonopin)
(Klonopin)
1
QL: 4 in 1 days
1
1
QL: 10 in 1 days
QL: 20 in 1 days
(Diastat Acudial)
(Diazepam)
(Diazepam)
(Valium)
(Flurazepam HCl)
1
1
1
1
1
QL: 5 in 30 days
QL: 40 in 1 days
QL: 8 in 1 days
QL: 4 in 1 days
QL: 1 in 1 days
4
Drug Name
flurazepam hcl capsule: 15mg
lorazepam tablet: 0.5mg, 1mg
lorazepam oral conc, tablet: 2mg
oxazepam
temazepam
triazolam tablet: 0.25mg
triazolam tablet: 0.125mg
Drug Tier
Requirements/Limits
(Flurazepam HCl)
(Ativan)
(Ativan)
(Oxazepam)
(Restoril)
(Halcion)
(Halcion)
1
1
1
1
1
1
1
QL: 2 in 1 days
QL: 10 in 1 days
QL: 5 in 1 days
QL: 4 in 1 days
QL: 1 in 1 days
QL: 2 in 1 days
QL: 4 in 1 days
(Neomycin Sulfate)
(Tobi)
1
1
2
PA
PA Specialty Drug
(Cleocin HCl)
(Cleocin Palmitate)
(Zyvox)
(Zyvox)
(Hiprex)
(Methenamine
Mandelate)
(Flagyl)
1
1
1
1
1
1
Antibacterials
Aminoglycosides
neomycin sulfate
tobramycin in 0.225% nacl
TOBI
Antibacterials, Miscellaneous
clindamycin hcl
clindamycin palmitate hcl
linezolid susp recon
linezolid tablet
methenamine hippurate
methenamine mandelate
metronidazole
METRONIDAZOLE
nitrofurantoin macrocrystal
nitrofurantoin monohyd/m-cryst
nitrofurantoin
trimethoprim
vancomycin hcl capsule, vial: 5g, 500mg
SIVEXTRO tablet
XIFAXAN tablet: 550mg
XIFAXAN tablet: 200mg
ZYVOX tablet
ZYVOX susp recon
DALVANCE
(Macrodantin)
(Macrobid)
(Furadantin)
(Trimethoprim)
(Vancocin HCl)
SIVEXTRO vial
Cephalosporins
cefaclor
cefadroxil
cefdinir
cefpodoxime proxetil
(Cefaclor)
(Cefadroxil)
(Cefdinir)
(Cefpodoxime Proxetil)
1
1
1
1
1
1
1
2
2
2
2
2
Medical
Benefit
Medical
Benefit
PA
QL: 2 in 1 days
PA
PA
PA, QL: 2 in 1 days
PA
PA
PA
1
1
1
1
5
Drug Name
cefuroxime axetil
cephalexin capsule: 250mg, 500mg; susp
recon, tablet
AVYCAZ
Macrolides
azithromycin packet, susp recon, tablet
clarithromycin susp recon, tablet
ery e-succ/sulfisoxazole
erythromycin base
erythromycin ethylsuccinate tablet
erythromycin stearate
ERYPED 200
ERYPED 400
Penicillins
amoxicillin capsule, susp recon, tab chew,
tablet
amoxicillin/potassium clav
ampicillin trihydrate
dicloxacillin sodium
penicillin v potassium
Quinolones
ciprofloxacin hcl
ciprofloxacin
levofloxacin solution, tablet
ofloxacin
Sulfonamides
sulfamethoxazole/trimethoprim oral susp,
tablet
sulfasalazine
Tetracyclines
doxycycline hyclate capsule, tablet
doxycycline monohydrate capsule: 50mg,
100mg; susp recon, tablet
minocycline hcl capsule, tablet
tetracycline hcl
TETRACYCLINE HCL
Drug Tier
(Ceftin)
(Keflex)
Requirements/Limits
1
1
Medical
Benefit
(Zithromax)
(Biaxin)
(Ery E-Succ/
Sulfisoxazole)
(Erythromycin Base)
(Erythromycin
Ethylsuccinate)
(Erythromycin
Stearate)
PA
1
1
1
1
1
1
2
2
(Amoxicillin)
1
(Augmentin)
(Ampicillin Trihydrate)
(Dicloxacillin Sodium)
(Penicillin V
Potassium)
1
1
1
1
(Cipro)
(Cipro)
(Levaquin)
(Ofloxacin)
1
1
1
1
(Bactrim DS)
1
(Azulfidine)
1
(Vibramycin)
(Avidoxy)
1
1
(Minocin)
(Tetracycline HCl)
1
1
1
6
Drug Name
Drug Tier
Requirements/Limits
Anticancer Agents
Anticancer Agents
anastrozole
bexarotene
bicalutamide
capecitabine
cyclophosphamide tablet
CYCLOPHOSPHAMIDE
etoposide capsule
exemestane
flutamide
hydroxyurea
imatinib mesylate
letrozole
lomustine
megestrol acetate
mercaptopurine
methotrexate sodium
nilutamide
tamoxifen citrate
TEMODAR capsule: 20mg
temozolomide
tretinoin
AFINITOR
ALECENSA
ALKERAN tablet
BOSULIF
CABOMETYX
CAPRELSA
carboplatin
COMETRIQ
COTELLIC
EMCYT
ERIVEDGE
(Arimidex)
(Targretin)
(Casodex)
(Xeloda)
(Cyclophosphamide)
(Etoposide)
(Aromasin)
(Flutamide)
(Hydrea)
(Gleevec)
(Femara)
(Lomustine)
(Megestrol Acetate)
(Purinethol)
(Methotrexate Sodium)
(Nilandron)
(Tamoxifen Citrate)
(Temodar)
(Tretinoin)
(Carboplatin)
FARYDAK
GILOTRIF
GLEEVEC
GLEOSTINE
HEXALEN
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
PA
PA
Age must be >= 44 (PA
Required for < 44)
PA
PA, QL: 8 in 1 days
PA (Specialty Drug)
PA, QL: 1 in 1 days
PA (Specialty Drug)
PA (Specialty Drug)
PA, QL: 3 in 1 days
(Specialty Drug)
PA
7
Drug Name
Drug Tier
HYCAMTIN capsule
IBRANCE
2
2
ICLUSIG
IMBRUVICA
2
2
INLYTA
INLYTA
JAKAFI
2
2
2
LENVIMA
LEUKERAN
LONSURF
LYNPARZA
LYSODREN
MATULANE
MEKINIST tablet: 2mg
2
2
2
2
2
2
2
MEKINIST tablet: 0.5mg
2
MYLERAN
NEXAVAR
2
2
NILANDRON
NINLARO
ODOMZO
POMALYST
REVLIMID
2
2
2
2
2
SPRYCEL
STIVARGA
2
2
SUTENT
TAFINLAR
2
2
TAGRISSO
2
TARCEVA tablet: 100mg, 150mg
2
TARCEVA tablet: 25mg
2
Requirements/Limits
(Specialty Drug)
PA
PA, QL: 4 in 1 days
(Specialty Drug)
PA
PA (Specialty Drug)
(Specialty Drug)
PA, QL: 3 in 1 days
(Specialty Drug)
(Specialty Drug)
(Specialty Drug)
(Specialty Drug)
PA, QL: 1 in 1 days
PA (Specialty Drug)
(Specialty Drug)
PA
(Specialty Drug)
PA (Specialty Drug)
(Specialty Drug)
PA, QL: 1 in 1 days
(Specialty Drug)
PA NSO, QL: 1 in 1
days (Specialty Drug)
PA NSO, QL: 3 in 1
days (Specialty Drug)
8
Drug Name
Drug Tier
Requirements/Limits
TARGRETIN capsule
TASIGNA
TEMODAR capsule: 5mg, 100mg, 140mg,
180mg, 250mg
TYKERB
VENCLEXTA STARTING PACK
VENCLEXTA tablet: 50mg
VOTRIENT
2
2
2
PA
PA
2
2
2
2
2
2
XALKORI
XALKORI
2
2
PA (Specialty Drug)
PA, QL: 1 in 1 days
PA, QL: 2 in 1 days
PA, QL: 4 in 1 days
(Specialty Drug)
(Specialty Drug)
XELODA
ZELBORAF
2
2
ZOLINZA
ZYKADIA
2
2
ZYTIGA
2
ABRAXANE
Medical
Benefit
Medical
Benefit
Medical
Benefit
Medical
Benefit
Medical
Benefit
Medical
Benefit
Medical
Benefit
Medical
Benefit
Medical
Benefit
ARRANON
ARZERRA
BELEODAQ
BLINCYTO
CLOLAR
CYRAMZA
DACOGEN
DARZALEX
(Specialty Drug)
PA
PA, QL: 5 in 1 days
(Specialty Drug)
(Specialty Drug)
PA
PA
PA
PA
PA
PA
PA
PA
PA
9
Drug Name
Drug Tier
ELOXATIN
Medical
Benefit
Medical
Benefit
Medical
Benefit
Medical
Benefit
Medical
Benefit
Medical
Benefit
Medical
Benefit
Medical
Benefit
Medical
Benefit
Medical
Benefit
Medical
Benefit
Medical
Benefit
Medical
Benefit
Medical
Benefit
Medical
Benefit
Medical
Benefit
Medical
Benefit
Medical
Benefit
Medical
Benefit
Medical
Benefit
Medical
Benefit
EMPLICITI
ERWINAZE
HALAVEN
IMLYGIC
ISTODAX
IXEMPRA
JEVTANA
KEYTRUDA
KYPROLIS
MARQIBO
ONIVYDE
OPDIVO
PORTRAZZA
SYLVANT
SYNRIBO
TECENTRIQ
TORISEL
UNITUXIN
VECTIBIX
VELCADE
Requirements/Limits
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
10
Drug Name
Drug Tier
YONDELIS
ZEVALIN
ADCETRIS
AVASTIN
GAZYVA
HYCAMTIN vial
KADCYLA
LUPRON DEPOT
oxaliplatin
(Eloxatin)
PERJETA
RITUXAN
Medical
Benefit
Medical
Benefit
Medical
BenefitSpecialty
Drug
Medical
BenefitSpecialty
Drug
Medical
BenefitSpecialty
Drug
Medical
BenefitSpecialty
Drug
Medical
BenefitSpecialty
Drug
Medical
BenefitSpecialty
Drug
Medical
BenefitSpecialty
Drug
Medical
BenefitSpecialty
Drug
Medical
BenefitSpecialty
Drug
Requirements/Limits
PA
PA
PA
PA
PA
11
Drug Name
Drug Tier
YERVOY
Medical
BenefitSpecialty
Drug
Medical
BenefitSpecialty
Drug
ZALTRAP
Requirements/Limits
PA
PA
Anticholinergic Agents
Antimuscarinics/Antispasmodics
propantheline bromide
(Propantheline
Bromide)
1
(Tegretol)
(Depakote ER)
(Zarontin)
(Felbatol)
(Neurontin)
(Lamictal)
(Keppra)
(Trileptal)
(Phenobarbital)
(Dilantin)
(Dilantin)
(Mysoline)
(Gabitril)
(Topamax)
(Depakene)
(Depakene)
(Zonegran)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
Anticonvulsants
Anticonvulsants
carbamazepine
divalproex sodium
ethosuximide solution
felbamate
gabapentin
lamotrigine tab ds pk, tablet, tb chw dsp
levetiracetam solution, tab er 24h, tablet
oxcarbazepine
phenobarbital
phenytoin sodium extended
phenytoin
primidone
tiagabine hcl
topiramate cap sprink, tablet
valproic acid (as sodium salt) solution
valproic acid
zonisamide
BANZEL
DILANTIN capsule: 30mg
GABITRIL tablet: 12mg, 16mg
LYRICA capsule: 225mg, 300mg
LYRICA capsule: 25mg, 50mg, 75mg,
100mg, 150mg, 200mg
PA
Antidementia Agents
Antidementia Agents
donepezil hcl tab rapdis, tablet: 5mg, 10mg (Aricept)
1
Required for < 18)
12
Drug Name
memantine hcl tablet
memantine hcl solution
rivastigmine tartrate
Drug Tier
(Namenda)
(Namenda)
(Exelon)
NAMENDA solution, tablet
1
1
1
2
Requirements/Limits
Age must be >= 18
Required for < 18)
Required for < 18)
Antidepressants
Antidepressants
amitriptyline hcl
amitriptyline/chlordiazepoxide
amoxapine
bupropion hcl
citalopram hydrobromide tablet: 40mg
citalopram hydrobromide tablet: 10mg,
20mg
citalopram hydrobromide solution
clomipramine hcl
desipramine hcl
doxepin hcl
duloxetine hcl capsule dr: 30mg
duloxetine hcl capsule dr: 20mg, 60mg
escitalopram oxalate tablet
escitalopram oxalate solution
fluoxetine hcl solution
fluoxetine hcl capsule: 10mg; tablet: 10mg
fluoxetine hcl capsule: 40mg
fluoxetine hcl capsule: 20mg; tablet: 20mg
FLUOXETINE HCL
fluvoxamine maleate tablet: 25mg
imipramine hcl
imipramine pamoate
mirtazapine
nefazodone hcl
nortriptyline hcl
paroxetine hcl tab er 24h: 12.5mg; tablet:
10mg, 20mg, 40mg
(Amitriptyline HCl)
(Amitriptyline/
Chlordiazepoxide)
(Amoxapine)
(Wellbutrin XL)
(Celexa)
(Celexa)
(Citalopram
Hydrobromide)
(Anafranil)
(Norpramin)
(Doxepin HCl)
(Cymbalta)
(Cymbalta)
(Lexapro)
(Lexapro)
(Fluoxetine HCl)
(Fluoxetine HCl)
(Prozac)
(Prozac)
(Fluvoxamine Maleate)
(Tofranil)
(Tofranil-Pm)
(Remeron)
(Nefazodone HCl)
(Pamelor)
(Paxil)
1
1
1
1
1
1
QL: 1 in 1 days
QL: 1.5 in 1 days
1
QL: 20 in 1 days
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
QL: 1 in 1 days
QL: 2 in 1 days
QL: 1 in 1 days
QL: 20 in 1 days
QL: 20 in 1 days
QL: 3 in 1 days
QL: 2 in 1 days
QL: 4 in 1 days
QL: 1 in 1 days
QL: 1 in 1 days
QL: 1.5 in 1 days
QL: 3 in 1 days
QL: 1 in 1 days
13
Drug Name
paroxetine hcl tab er 24h: 25mg, 37.5mg;
tablet: 30mg
perphenazine/amitriptyline hcl
sertraline hcl tablet: 25mg, 50mg
sertraline hcl oral conc
sertraline hcl tablet: 100mg
trazodone hcl
venlafaxine hcl cap er 24h: 37.5mg
venlafaxine hcl cap er 24h: 150mg
venlafaxine hcl cap er 24h: 75mg; tablet
Drug Tier
(Paxil)
1
(Perphenazine/
Amitriptyline HCl)
(Zoloft)
(Zoloft)
(Zoloft)
(Trazodone HCl)
(Effexor XR)
(Effexor XR)
(Effexor XR)
1
1
1
1
1
1
1
1
Requirements/Limits
QL: 2 in 1 days
QL: 1.5 in 1 days
QL: 10 in 1 days
QL: 2 in 1 days
QL: 1 in 1 days
QL: 2 in 1 days
QL: 3 in 1 days
Antidiabetic Agents
Antidiabetic Agents, Miscellaneous
(Precose)
acarbose
metformin hcl tab er 24h, tablet
(Glucophage)
(Starlix)
nateglinide
(Actos)
pioglitazone hcl
(Prandin)
repaglinide
INVOKAMET
INVOKANA
JANUMET XR
JANUMET
JANUVIA
JARDIANCE
SYNJARDY
TANZEUM
VICTOZA 3-PAK
Insulins
LANTUS SOLOSTAR
LANTUS
LEVEMIR FLEXTOUCH
LEVEMIR
NOVOLIN 70-30
NOVOLIN N
NOVOLIN R
NOVOLOG FLEXPEN
NOVOLOG MIX 70-30 FLEXPEN
NOVOLOG MIX 70-30
NOVOLOG
TOUJEO SOLOSTAR
1
1
1
1
1
2
2
2
2
2
2
2
2
2
ST
ST, QL: 1 in 1 days
ST, QL: 2 in 1 days
ST
ST
2
2
2
2
2
2
2
2
2
2
2
2
Age must be >= 18
ST, QL: 2 in 1 days
ST, QL: 1 in 1 days
14
Drug Name
Sulfonylureas
glimepiride
glipizide
glipizide/metformin hcl
glyburide
glyburide,micronized
glyburide/metformin hcl
Drug Tier
(Amaryl)
(Glucotrol)
(Glipizide/Metformin
HCl)
(Glyburide)
(Glynase)
(Glucovance)
1
1
1
(Clotrimazole)
1
(Lotrisone)
(Econazole Nitrate)
(Diflucan)
(Gris-Peg)
(Griseofulvin,
Microsize)
(Sporanox)
(Ketoconazole)
1
1
1
1
1
Requirements/Limits
1
1
1
Antifungals
Antifungals
clotrimazole cream (g): 1%; solution: 1%;
troche
clotrimazole/betamethasone dip
econazole nitrate
fluconazole
griseofulvin ultramicrosize
griseofulvin, microsize
itraconazole
ketoconazole cream (g), foam: 2%;
shampoo, tablet
miconazole nitrate supp.vag: 200mg
MICONAZOLE NITRATE powder: n/a
nystatin
nystatin/triamcin
NYSTATIN
terbinafine hcl tablet
voriconazole susp recon, tablet
GRIFULVIN V
clotrimazole cream/appl: 1%, 2%; solution:
1%; tablet
miconazole nitrate aero powd: 2%; cmb pf
crm: 200mg-2%; cream (g): 2%; kit:
200mg-2%; powder: 2%
MICONAZOLE NITRATE aero powd
terbinafine hcl cream (g)
tolnaftate aero powd: 1%; powder: 1%;
solution
undecylenic acid solution: 25%
CRESEMBA vial
(Miconazole Nitrate)
1
1
(Gyne-Lotrimin-7)
1
1
1
1
1
1
1
2
OTC
(Lotrimin AF)
OTC
(Lamisil At)
(Tinactin)
OTC
OTC
OTC
(Nystatin)
(Nystatin/Triamcin)
(Lamisil)
(Vfend)
(Undecylenic Acid)
OTC
Medical
Benefit
PA
PA
PA
15
Drug Name
Drug Tier
ERAXIS (WATER DILUENT)
Medical
Benefit
Requirements/Limits
PA
Antihistamines
Antihistamines
cyproheptadine hcl
diphenhydramine hcl capsule: 50mg
fexofenadine hcl tablet: 60mg, 180mg
levocetirizine dihydrochloride
promethazine hcl
cetirizine hcl solution: 1mg/ml; tab chew
chlorpheniramine maleate syrup: 2mg/5ml;
tablet er
clemastine fumarate tablet: 1.34mg
diphenhydramine hcl capsule: 25mg;
liquid: 12.5mg/5ml; tablet: 25mg
fexofenadine hcl tablet: 60mg
loratadine tab rapdis
loratadine/pseudoephedrine tab er 12h:
5mg-120mg
(Cyproheptadine HCl)
(Benadryl)
(Allegra)
(Xyzal)
(Promethazine HCl)
(Zyrtec)
(Chlor-Trimeton)
1
1
1
1
1
OTC
OTC
(Tavist)
(Benadryl)
OTC
OTC
(Allegra Allergy)
(Claritin)
(Claritin-D 12 hour)
OTC
OTC
OTC
Anti-infectives (Skin and Mucous Membrane)
Anti-infectives (Skin and Mucous Membrane)
(Cleocin)
clindamycin phosphate
(Metrogel-Vaginal)
metronidazole
terconazole cream/appl: 0.4%, 0.8%;
(Terazol 7)
supp.vag
ABREVA
1
1
1
OTC
Antimigraine Agents
Antimigraine Agents
naratriptan hcl
(Amerge)
1
rizatriptan benzoate
(Maxalt)
1
sumatriptan succinate
(Imitrex)
1
QL: 16 in 28 days (QL
applies to all oral
Antimigraine agents
combined)
applies to all oral
Antimigraine agents
combined)
applies to all oral
Antimigraine agents
combined)
16
Drug Name
Drug Tier
sumatriptan
(Imitrex)
1
zolmitriptan
(Zomig)
1
(Dapsone)
(Myambutol)
(Isoniazid)
(Pyrazinamide)
(Rifadin)
1
1
1
1
1
(Meclizine HCl)
(Zofran)
(Zofran Odt)
(Prochlorperazine
Maleate)
(Prochlorperazine)
(Phenadoz)
(Tigan)
1
1
1
1
Requirements/Limits
applies to all oral
Antimigraine agents
combined)
applies to all oral
Antimigraine agents
combined)
Antimycobacterials
Antimycobacterials
dapsone
ethambutol hcl
isoniazid solution, tablet
pyrazinamide
rifampin capsule
Antinausea Agents
Antinausea Agents
meclizine hcl tablet: 12.5mg, 25mg
ondansetron hcl solution, tablet: 4mg, 8mg
ondansetron
prochlorperazine maleate
prochlorperazine
promethazine hcl supp.rect, tablet
trimethobenzamide hcl capsule
AKYNZEO
EMEND capsule: 40mg
EMEND capsule: 125mg
EMEND capsule: 80mg
EMEND cap ds pk
EMEND susp recon
VARUBI
meclizine hcl tablet: 12.5mg
ALOXI
(Meclizine HCl)
EMEND vial
1
1
1
2
2
2
2
2
2
2
OTC
Medical
Benefit
Medical
Benefit
QL: 6 in 30 days
PA
PA
Antiparasite Agents
Antiparasite Agents
atovaquone
atovaquone/proguanil hcl
(Mepron)
(Malarone)
1
1
17
Drug Name
chloroquine phosphate
hydroxychloroquine sulfate
mefloquine hcl
paromomycin sulfate
tinidazole
ALBENZA
BILTRICIDE
MEPRON
Drug Tier
(Chloroquine
Phosphate)
(Plaquenil)
(Mefloquine HCl)
(Paromomycin Sulfate)
(Tindamax)
Requirements/Limits
1
1
1
1
1
2
2
2
QL: 4 per fill
Antiparkinsonian Agents
Antiparkinsonian Agents
amantadine hcl
benztropine mesylate tablet
bromocriptine mesylate
(Amantadine HCl)
(Benztropine Mesylate)
(Bromocriptine
Mesylate)
(Cabergoline)
(Sinemet 25-100)
(Stalevo 200)
(Mirapex)
(Requip)
(Eldepryl)
(Trihexyphenidyl HCl)
1
1
1
1
1
1
1
Antipsychotic Agents
aripiprazole tablet
(Abilify)
1
aripiprazole solution
(Abilify)
1
chlorpromazine hcl tablet
(Chlorpromazine HCl)
1
clozapine tablet: 25mg, 50mg
(Clozaril)
1
clozapine tablet: 200mg
(Clozaril)
1
clozapine tablet: 100mg
(Clozaril)
1
cabergoline
carbidopa/levodopa
carbidopa/levodopa/entacapone
pramipexole di-hcl tablet
ropinirole hcl tablet
selegiline hcl
trihexyphenidyl hcl
1
1
1
Antipsychotic Agents
Age must be >= 18, QL:
30 in 30 days (PA
Required for < 18)
900 in 30 days (PA
Required for < 18)
Required for < 18)
3 in 1 days (PA Required
for < 18)
for < 18)
for < 18)
18
Drug Name
Drug Tier
Requirements/Limits
(Fluphenazine
Decanoate)
(Fluphenazine HCl)
1
1
haloperidol lactate oral conc
(Haloperidol
Decanoate)
(Haloperidol Lactate)
haloperidol
(Haloperidol)
1
loxapine succinate
(Loxapine Succinate)
1
olanzapine tablet
(Zyprexa)
1
perphenazine
perphenazine
(Perphenazine)
(Perphenazine)
1
1
pimozide
(Orap)
1
quetiapine fumarate tablet: 300mg, 400mg
(Seroquel)
1
quetiapine fumarate tablet: 50mg, 100mg
(Seroquel)
1
quetiapine fumarate tablet: 200mg
(Seroquel)
1
quetiapine fumarate tablet: 25mg
(Seroquel)
1
risperidone tablet
(Risperdal)
1
risperidone solution
(Risperdal)
1
thioridazine hcl
(Thioridazine HCl)
1
thiothixene
(Thiothixene)
1
Required for < 18)
Required for < 18)
Required for < 18)
Required for < 18)
Required for < 18)
Required for < 18)
for < 18)
Age must be >= 18
Required for < 18)
Required for < 18)
for < 18)
for < 18)
for < 18)
for < 18)
for < 18)
for < 18)
Required for < 18)
Required for < 18)
fluphenazine decanoate
fluphenazine hcl elixir, oral conc, tablet
haloperidol decanoate
1
1
19
Drug Name
Drug Tier
Requirements/Limits
Required for < 18)
60 in 30 days (PA
Required for < 18)
30 in 30 days (PA
Required for < 18)
PA, QL: 2 in 1 days
Required for < 18)
PA
trifluoperazine hcl
(Trifluoperazine HCl)
1
ziprasidone hcl
(Geodon)
1
ABILIFY tablet
2
NUPLAZID
ORAP
2
2
ARISTADA
Medical
Benefit
Medical
BenefitSpecialty
Drug
Medical
BenefitSpecialty
Drug
Medical
BenefitSpecialty
Drug
Medical
BenefitSpecialty
Drug
Medical
BenefitSpecialty
Drug
ABILIFY MAINTENA
INVEGA SUSTENNA
INVEGA TRINZA
RISPERDAL CONSTA
ZYPREXA RELPREVV
PA
PA
PA
PA
PA
Antivirals (Systemic)
Antiretrovirals
abacavir sulfate
abacavir/lamivudine/zidovudine
didanosine
lamivudine tablet: 100mg
(Ziagen)
(Trizivir)
(Videx EC)
(Epivir Hbv)
(Epivir Hbv)
(Epivir Hbv)
1
1
1
1
1
1
QL: 2 in 1 days
QL: 2 in 1 days
QL: 1 in 1 days
QL: 1 in 1 days
QL: 2 in 1 days
20
Drug Name
lamivudine solution
lamivudine/zidovudine
nevirapine tab er 24h: 400mg
nevirapine tab er 24h: 100mg
nevirapine tablet
nevirapine oral susp
stavudine capsule
stavudine soln recon
zidovudine capsule
zidovudine syrup
zidovudine tablet
APTIVUS solution
APTIVUS capsule
ATRIPLA
COMPLERA
CRIXIVAN capsule: 200mg
CRIXIVAN capsule: 400mg
DESCOVY
EDURANT
Drug Tier
(Epivir)
(Combivir)
(Viramune XR)
(Viramune XR)
(Viramune)
(Viramune)
(Zerit)
(Zerit)
(Retrovir)
(Retrovir)
(Zidovudine)
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
EMTRIVA capsule
EMTRIVA solution
EPIVIR solution
EPZICOM
EVOTAZ
FUZEON
2
2
2
2
2
2
GENVOYA
INTELENCE tablet: 100mg, 200mg
INTELENCE tablet: 25mg
INVIRASE capsule
INVIRASE tablet
ISENTRESS powd pack
ISENTRESS tab chew: 25mg; tablet
ISENTRESS tab chew: 100mg
KALETRA tablet: 100mg-25mg
KALETRA solution
KALETRA tablet: 200mg-50mg
LEXIVA tablet
LEXIVA oral susp
NORVIR capsule, tablet
2
2
2
2
2
2
2
2
2
2
2
2
2
2
Requirements/Limits
QL: 30 in 1 days
QL: 2 in 1 days
QL: 1 in 1 days
QL: 3 in 1 days
QL: 2 in 1 days
QL: 40 in 1 days
QL: 2 in 1 days
QL: 80 in 1 days
QL: 6 in 1 days
QL: 60 in 1 days
QL: 2 in 1 days
QL: 10 in 1 days
QL: 4 in 1 days
QL: 1 in 1 days
QL: 1 in 1 days
QL: 3 in 1 days
QL: 6 in 1 days
QL: 1 in 1 days
QL: 2 in 1 days, QL: 34
in 34 days
QL: 1 in 1 days
QL: 24 in 1 days
QL: 30 in 1 days
QL: 1 in 1 days
QL: 1 in 1 days
QL: 2 in 1 days
(Specialty Drug)
QL: 1 in 1 days
QL: 2 in 1 days
QL: 4 in 1 days
QL: 10 in 1 days
QL: 4 in 1 days
QL: 2 in 1 days
QL: 4 in 1 days
QL: 6 in 1 days
QL: 10 in 1 days
QL: 14 in 1 days
QL: 4 in 1 days
QL: 2 in 1 days
QL: 28 in 1 days
QL: 12 in 1 days
21
Drug Name
NORVIR solution
ODEFSEY
PREZCOBIX
PREZISTA tablet: 75mg, 150mg, 400mg
PREZISTA tablet: 800mg
PREZISTA oral susp
PREZISTA tablet: 600mg
RESCRIPTOR tab disper
RESCRIPTOR tablet
REYATAZ capsule: 100mg
REYATAZ capsule: 300mg
REYATAZ capsule: 150mg, 200mg
REYATAZ powd pack
SELZENTRY tablet: 150mg
SELZENTRY tablet: 300mg
STRIBILD
SUSTIVA tablet
SUSTIVA capsule: 200mg
SUSTIVA capsule: 50mg
TIVICAY
TRIUMEQ
TRIZIVIR
TRUVADA
VIDEX
VIRACEPT tablet: 625mg
VIRACEPT tablet: 250mg
VIRAMUNE XR tab er 24h: 400mg
VIRAMUNE XR tab er 24h: 100mg
VIREAD tablet
VITEKTA
ZIAGEN solution
Antivirals, Miscellaneous
rimantadine hcl
RELENZA
TAMIFLU capsule
TAMIFLU susp recon
SYNAGIS
Drug Tier
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
(Rimantadine HCl)
1
2
2
2
Medical
BenefitSpecialty
Drug
Requirements/Limits
QL: 16 in 1 days
QL: 1 in 1 days
QL: 1 in 1 days
QL: 1 in 1 days
QL: 13.35 in 1 days
QL: 2 in 1 days
QL: 12 in 1 days
QL: 6 in 1 days
QL: 1 in 1 days
QL: 2 in 1 days
QL: 6 in 1 days
QL: 2 in 1 days
QL: 4 in 1 days
QL: 1 in 1 days
QL: 1 in 1 days
QL: 2 in 1 days
QL: 3 in 1 days
QL: 2 in 1 days
QL: 1 in 1 days
QL: 2 in 1 days
QL: 1 in 1 days
QL: 40 in 1 days
QL: 4 in 1 days
QL: 9 in 1 days
QL: 1 in 1 days
QL: 3 in 1 days
QL: 1 in 1 days
QL: 1 in 1 days
QL: 30 in 1 days
QL: 20 in 365 days
QL: 10 in 180 days
QL: 120 in 180 days
22
Drug Name
Drug Tier
Requirements/Limits
Hcv Antivirals
HARVONI
2
SOVALDI
2
ZEPATIER
2
Interferons
INTRON A
PEGASYS PROCLICK
PEGASYS
PEGINTRON REDIPEN
PEGINTRON
SYLATRON
2
2
2
2
2
2
Specialty Drug
Specialty Drug
Specialty Drug
Specialty Drug
Specialty Drug
Specialty Drug
1
1
1
1
1
1
2
(Oral Formulations)
(Lovenox)
(Lovenox)
(Lovenox)
1
1
1
QL: 11.2 in 14 days
QL: 16.8 in 14 days
QL: 22.4 in 14 days
(Lovenox)
1
QL: 28 in 14 days
(Lovenox)
(Arixtra)
(Arixtra)
(Arixtra)
(Arixtra)
(Heparin
Sodium,Porcine)
(Heparin
Sodium,Porcine/PF)
(Jantoven)
1
1
1
1
1
1
QL: 8.4 in 14 days
QL: 11.2 in 14 days
QL: 5.6 in 14 days
QL: 7 in 14 days
QL: 8.4 in 14 days
Nucleosides and Nucleotides
acyclovir
acyclovir
entecavir
famciclovir
ribavirin capsule: 200mg; tablet: 200mg
valacyclovir hcl
BARACLUDE
(Zovirax)
(Zovirax)
(Baraclude)
(Famvir)
(Ribavirin)
(Valtrex)
Specialty Drug
Specialty Drug
Specialty Drug
Blood Products/Modifiers/Volume Expanders
Anticoagulants
enoxaparin sodium syringe: 40mg/0.4ml
enoxaparin sodium syringe: 80mg/0.8ml,
120mg/.8ml
enoxaparin sodium syringe: 100mg/ml,
150mg/ml; vial
fondaparinux sodium syringe: 10mg/0.8ml
fondaparinux sodium syringe: 5mg/0.4ml
fondaparinux sodium syringe: 2.5mg/0.5
fondaparinux sodium syringe: 7.5mg/0.6
heparin sodium,porcine vial: 1000/ml,
5000/ml, 10000/ml, 20000/ml
heparin sodium,porcine/pf vial: 5000/0.5ml
warfarin sodium
1
1
23
Drug Name
Drug Tier
ELIQUIS
PRADAXA
XARELTO
Blood Formation Modifiers
ARANESP
EPOGEN
LEUKINE
NEULASTA
NEUMEGA
NEUPOGEN
PROCRIT
GRANIX
2
2
2
2
2
2
2
2
2
2
Medical
Benefit
Medical
Benefit
Medical
BenefitSpecialty
Drug
Medical
BenefitSpecialty
Drug
RUCONEST
BERINERT
CINRYZE
Hematologic Agents, Miscellaneous
aminocaproic acid solution, tablet
(Aminocaproic Acid)
(Agrylin)
anagrelide hcl
ADVATE
ALPHANATE
1
1
2
2
ELOCTATE
FEIBA NF
HELIXATE FS
HEMOFIL M
HUMATE-P
KOATE-DVI
KOGENATE FS
MONOCLATE-P
NOVOEIGHT
OBIZUR
RECOMBINATE
2
2
2
2
2
2
2
2
2
2
2
Requirements/Limits
PA
PA Specialty Drug
PA Specialty Drug
PA
PA Specialty Drug
PA
PA Specialty Drug
PA Specialty Drug
PA
PA
PA
PA
PA Specialty Drug
PA , QL: 34 days supply
per fill, SP; Specialty
Drug
PA Specialty Drug
PA Specialty Drug
PA Specialty Drug
PA Specialty Drug
PA Specialty Drug
PA Specialty Drug
PA Specialty Drug
PA Specialty Drug
PA
PA
PA Specialty Drug
24
Drug Name
Drug Tier
WILATE
XYNTHA SOLOFUSE
XYNTHA
PRAXBIND
Platelet-Aggregation Inhibitors
aspirin/dipyridamole
cilostazol
clopidogrel bisulfate tablet: 75mg
pentoxifylline
ticlopidine hcl
AGGRENOX
EFFIENT
2
2
2
Medical
Benefit
(Aggrenox)
(Pletal)
(Plavix)
(Pentoxifylline)
(Ticlopidine HCl)
1
1
1
1
1
2
2
Requirements/Limits
PA
PA
PA
PA
QL: 30 in 30 days
PA
Caloric Agents
Caloric Agents
dextrose
(Dextrose)
2
Cardiovascular Agents
Alpha-Adrenergic Agents
clonidine hcl
doxazosin mesylate
guanfacine hcl
methyldopa
methyldopa/hydrochlorothiazide
(Catapres)
(Cardura)
(Tenex)
(Methyldopa)
(Methyldopa/
Hydrochlorothiazide)
(Midodrine HCl)
midodrine hcl
(Minipress)
prazosin hcl
Angiotensin II Receptor Antagonists
(Atacand)
candesartan cilexetil
(Atacand HCT)
candesartan/hydrochlorothiazid
(Teveten)
eprosartan mesylate
(Avapro)
irbesartan
(Avalide)
irbesartan/hydrochlorothiazide
(Cozaar)
losartan potassium
(Hyzaar)
losartan/hydrochlorothiazide
(Diovan HCT)
valsartan/hydrochlorothiazide
ENTRESTO
Angiotensin-Converting Enzyme Inhibitors
(Lotensin)
benazepril hcl
(Lotensin HCT)
benazepril/hydrochlorothiazide
(Captopril)
captopril
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
PA, QL: 2 in 1 days
1
1
1
25
Drug Name
captopril/hydrochlorothiazide
enalapril maleate
enalapril/hydrochlorothiazide
fosinopril sodium
fosinopril/hydrochlorothiazide
lisinopril
lisinopril/hydrochlorothiazide
quinapril hcl
quinapril/hydrochlorothiazide
ramipril
trandolapril
Antiarrhythmic Agents
amiodarone hcl tablet
disopyramide phosphate
flecainide acetate
mexiletine hcl
propafenone hcl tablet
quinidine sulfate tablet
Beta-Adrenergic Blocking Agents
acebutolol hcl
atenolol
atenolol/chlorthalidone
betaxolol hcl
bisoprolol fumarate
bisoprolol fumarate/hctz
carvedilol
labetalol hcl tablet
metoprolol succinate
metoprolol tartrate tablet: 25mg, 50mg,
100mg
metoprolol/hydrochlorothiazide
nadolol
pindolol
propranolol hcl cap sa 24h, solution, tablet
propranolol/hydrochlorothiazid
sotalol hcl
timolol maleate
Drug Tier
(Captopril/
(Vasotec)
(Vaseretic)
(Fosinopril Sodium)
(Fosinopril/
(Zestril)
(Zestoretic)
(Accupril)
(Accuretic)
(Altace)
(Mavik)
1
1
1
1
1
1
(Cordarone)
(Norpace)
(Tambocor)
(Mexiletine HCl)
(Rythmol)
(Quinidine Sulfate)
1
1
1
1
1
1
(Sectral)
(Tenormin)
(Tenoretic 50)
(Betaxolol HCl)
(Zebeta)
(Ziac)
(Coreg)
(Trandate)
(Toprol XL)
(Lopressor)
1
1
1
1
1
1
1
1
1
1
(Lopressor HCT)
(Corgard)
(Pindolol)
(Propranolol HCl)
(Propranolol/
Hydrochlorothiazid)
(Betapace AF)
(Timolol Maleate)
1
1
1
1
1
Requirements/Limits
1
1
1
1
1
1
1
26
Drug Name
Drug Tier
Calcium-Channel Blocking Agents
diltiazem hcl various dosage and/or
(Cardizem CD)
strengths are available
verapamil hcl cap24h pct, cap24h pel,
(Calan SR)
tablet, tablet er
Cardiovascular Agents, Miscellaneous
digoxin tablet
(Lanoxin)
DIGOXIN
epinephrine auto injct
(Epinephrine)
hydralazine hcl tablet
(Hydralazine HCl)
EPIPEN 2-PAK
EPIPEN JR 2-PAK
Dihydropyridines
(Norvasc)
amlodipine besylate
(Lotrel)
amlodipine besylate/benazepril
(Felodipine)
felodipine
(Isradipine)
isradipine
(Adalat CC)
nifedipine
(Nimodipine)
nimodipine
(Sular)
nisoldipine
Diuretics
(Amiloride HCl)
amiloride hcl
(Amiloride/
amiloride/hydrochlorothiazide
bumetanide tablet
(Bumetanide)
(Chlorothiazide)
chlorothiazide
(Chlorthalidone)
chlorthalidone
furosemide solution, tablet
(Lasix)
(Microzide)
hydrochlorothiazide
(Indapamide)
indapamide
(Zaroxolyn)
metolazone
torsemide tablet
(Demadex)
(Maxzide-25 Mg)
triamterene/hydrochlorothiazid
DIURIL
Dyslipidemics
(Lipitor)
atorvastatin calcium
(Questran)
cholestyramine (with sugar)
(Questran Light)
cholestyramine/aspartame
(Colestid)
colestipol hcl
(Tricor)
fenofibrate nanocrystallized
fenofibrate tablet: 40mg, 54mg, 160mg
(Fenoglide)
Requirements/Limits
1
1
1
1
1
1
2
2
QL: 2 in 30 days
QL: 2 in 30 days
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
Age must be <= 2
1
1
1
1
1
1
27
Drug Name
fenofibrate,micronized capsule: 67mg,
134mg, 200mg
fenofibric acid (choline)
fenofibric acid
gemfibrozil
lovastatin
niacin tab er 24h
pravastatin sodium
rosuvastatin calcium
simvastatin
KYNAMRO
Drug Tier
(Antara)
1
(Trilipix)
(Fibricor)
(Lopid)
(Mevacor)
(Niaspan)
(Pravachol)
(Crestor)
(Zocor)
1
1
1
1
1
1
1
1
2
PRALUENT PEN
PRALUENT SYRINGE
REPATHA PUSHTRONEX
2
2
2
REPATHA SURECLICK
2
REPATHA SYRINGE
2
ZETIA
niacin (inositol niacinate) capsule:
(No Flush Niacin)
400(500mg)
NIACIN FLUSH FREE
niacin capsule er: 125mg, 250mg, 500mg; (Niacin)
tablet: 50mg, 100mg, 500mg; tablet er:
1000mg
(Niacinamide)
niacinamide
(Fish Oil Omega-3)
omega-3 fatty acids/fish oil
Renin-Angiotensin-Aldosterone System Inhibitors
(Inspra)
eplerenone
(Aldactazide)
spironolact/hydrochlorothiazid
(Aldactone)
spironolactone
Vasodilators
(Isordil Titradose)
isosorbide dinitrate
(Imdur)
isosorbide mononitrate
(Minoxidil)
minoxidil
nitroglycerin capsule er, patch td24, tab
(Nitro-Dur)
subl
NITROSTAT
Requirements/Limits
Specialty Drug
PA Specialty Drug
PA Specialty Drug
QL: 3.5 in 28 days
Specialty Drug
Specialty Drug
Specialty Drug
2
OTC
OTC
OTC
OTC
OTC
1
1
1
1
1
1
1
2
28
Drug Name
Drug Tier
Requirements/Limits
Central Nervous System Agents
Central Nervous System Agents
caffeine citrated solution
dexmethylphenidate hcl tablet
dextroamphetamine sulfate capsule er: 5mg
dextroamphetamine sulfate capsule er:
10mg, 15mg; tablet: 5mg, 10mg
dextroamphetamine/amphetamine cap er
24h: 5mg, 10mg, 15mg, 25mg
dextroamphetamine/amphetamine cap er
24h: 20mg, 30mg; tablet: 15mg, 30mg
dextroamphetamine/amphetamine tablet:
5mg, 7.5mg, 10mg, 12.5mg, 20mg
guanfacine hcl
lithium carbonate
lithium citrate
methylphenidate hcl cpbp 30-70: 20mg,
40mg, 50mg, 60mg; tab er 24: 18mg,
27mg, 54mg; tablet er: 10mg
methylphenidate hcl cpbp 30-70: 30mg; tab
er 24: 36mg
methylphenidate hcl cpbp 30-70: 10mg
methylphenidate hcl solution
methylphenidate hcl tablet, tablet er: 20mg
AMPYRA
(Cafcit)
(Focalin)
(Dexedrine)
(Dextroamphetamine
Sulfate)
(Adderall XR)
1
1
1
1
Age must be <= 2
QL: 60 in 30 days
QL: 30 in 30 days
QL: 120 in 30 days
1
QL: 30 in 30 days
(Adderall XR)
1
QL: 60 in 30 days
(Adderall)
1
QL: 90 in 30 days
(Intuniv)
(Lithium Carbonate)
(Lithium Citrate)
(Concerta)
1
1
1
1
QL: 30 in 30 days
(Concerta)
1
QL: 60 in 30 days
(Metadate Cd)
(Methylin)
(Ritalin)
1
1
1
2
2
QL: 120 in 30 days
QL: 450 in 30 days
QL: 90 in 30 days
Specialty Drug
2
2
STRATTERA capsule: 10mg, 40mg,
60mg, 80mg, 100mg
STRATTERA capsule: 18mg
STRATTERA capsule: 25mg
Contraceptives
Contraceptives
AMETHYST
desog-e.estradiol/e.estradiol
desogestrel-ethinyl estradiol
ethinyl estradiol/drospirenone
ethynodiol d-ethinyl estradiol
levonorgestrel tablet: 0.75mg, 1.5mg
levonorgestrel-ethin estradiol tablet: 0.10.02, 0.15-0.03, 6-5-10, 90-20mcg
(Mircette)
(Desogen)
(Yaz)
(Ethynodiol D-Ethinyl
Estradiol)
(Plan B One-Step)
(Amethyst)
1
1
1
1
1
1
1
29
Drug Name
l-norgest/e.estradiol-e.estrad tbdspk 3mo:
100-20(84), 150-30(84)
noreth-ethinyl estradiol/iron
norethindrone ac-eth estradiol
norethindrone
norethindrone-e.estradiol-iron
norethindrone-ethinyl estrad
norethindrone-mestranol
norgestimate-ethinyl estradiol
norgestrel-ethinyl estradiol
CAYA CONTOURED
norelgestromin/ethin.estradiol
NUVARING
ORTHO ALL-FLEX each
ORTHO ALL-FLEX kit
WIDE SEAL DIAPHRAGM
AIMSCO
CONCEPTROL
CONDOMS
DUREX AVANTI BARE
FANTASY
FC CONDOM, FEMALE
FC2 FEMALE CONDOM
GYNOL II
KIMONO MAXX
KIMONO MICROTHIN AQUA LUBE
KIMONO MICROTHIN each: n/a
KIMONO MICROTHIN each: n/a
KIMONO TEXTURED
KIMONO
levonorgestrel tablet: 1.5mg
nonoxynol 9 foam/appl
TODAY CONTRACEPTIVE SPONGE
TRUSTEX CONDOM
TRUSTEX LATEX CONDOM
TRUSTEX
TRUSTEX-RIA each: n/a
TRUSTEX-RIA each: n/a
VCF
Drug Tier
(Seasonique)
1
(Generess Fe)
(Loestrin)
(Ortho Micronor)
(Loestrin 24 Fe)
(Ortho-Novum)
(Norinyl 1+50)
(Ortho Tri-Cyclen Lo)
(Norgestrel-Ethinyl
Estradiol)
1
1
1
1
1
1
1
1
(Ortho Evra)
(Levonorgestrel)
(Nonoxynol 9)
2
2
2
2
2
2
OTC
OTC
OTC
OTC
OTC
OTC
OTC
OTC
OTC
OTC
OTC
OTC
OTC
OTC
OTC
OTC
OTC
OTC
OTC
OTC
OTC
OTC
OTC
Requirements/Limits
QL: 48 in 30 days
QL: 48 in 30 days
QL: 48 in 30 days
QL: 48 in 30 days
QL: 48 in 30 days
QL: 48 in 30 days
QL: 48 in 30 days
QL: 48 in 30 days
QL: 48 in 30 days
QL: 48 in 30 days
QL: 48 in 30 days
QL: 48 in 30 days
QL: 48 in 30 days
QL: 48 in 30 days
QL: 48 in 30 days
30
Drug Name
Drug Tier
IMPLANON
Requirements/Limits
Medical
BenefitSpecialty
Drug
Cough And Cold Products
Cough And Cold Products
benzonatate capsule: 100mg, 200mg
bromphenira/pseudoephed/codein liquid:
1.3-10-6.3
brompheniram/phenylephrine/dm liquid
guaifenesin/codeine phosphate liquid: 10010mg/5, 100-6.3/5, 225-7.5/5
guaifenesin/dm/pseudoephedrine tablet:
400-20-60
hydrocodone bit/homatrop me-br
hydrocodone/chlorphen p-stirex
promethazine hcl/codeine
(Zonatuss)
(Bromphenira/
Pseudoephed/Codein)
(Ala-Hist Dm)
(M-Clear Wc)
1
1
Age must be <= 20
Age must be <= 20
1
1
Age must be <= 20
Age must be <= 20
(Poly-Vent Dm)
1
Age must be <= 20
(Hydrocodone Bit/
Homatrop Me-Br)
(Hydrocodone/
Chlorphen P-Stirex)
(Promethazine HCl/
Codeine)
1
Age must be <= 20
1
Age must be <= 20
1
Age must be <= 20
1
OTC
Age must be <= 20
Age must be <= 20
OTC
Age must be <= 20
OTC
Age must be <= 20
TUSSI PRES-B
dextromethorphan hbr syrup: 5mg/5ml
(Dextromethorphan
Hbr)
dm/p-ephed/acetaminoph/doxylam capsule: (Dm/P-Ephed/
15-30-325
Acetaminoph/
Doxylam)
guaifenesin liquid: 100mg/5ml
(Robitussin MucusChest Congest)
(Phenylephrine HCl/
phenylephrine hcl/acetaminophn
Acetaminophn)
pseudoephedrine hcl liquid: 30mg/5ml
(Pseudoephedrine HCl)
OTC
OTC
Dental And Oral Agents
Dental And Oral Agents
chlorhexidine gluconate
pilocarpine hcl
sodium fluoride cream (g), gel (gram),
solution: 0.2%
stannous fluoride soln(gram)
triamcinolone acetonide
(Peridex)
(Salagen)
(Prevident 5000 Plus)
1
1
1
(Stannous Fluoride)
(Triamcinolone
Acetonide)
1
1
31
Drug Name
Drug Tier
ARESTIN
Medical
BenefitSpecialty
Drug
Requirements/Limits
PA
Dermatological Agents
Dermatological Agents, Other
ammonium lactate cream (g): 12%; lotion:
12%
benzoyl peroxide microspheres
benzoyl peroxide cleanser: 7%, 9%; foam,
gel (gram): 4%, 5%, 8%, 10%; kit: 4%-5%;
towelette: 3%, 6%, 9%
BP WASH cleanser: 2.5%, 7%, 10%
calcipotriene
fluorouracil
imiquimod
isotretinoin capsule: 10mg, 20mg, 30mg,
40mg
lactic acid
podofilox
pramoxine hcl foam
salicylic acid lotion: 6%; shampoo: 6%
salicylic acid/ceramide cmb #1
sulfacetamide sodium cleanser: 10%
(Ammonium Lactate)
1
(Benzoyl Peroxide
Microspheres)
(Benzoyl Peroxide)
1
(Dovonex)
(Carac)
(Aldara)
(Isotretinoin)
(Lactic Acid)
(Condylox)
(Proctofoam)
(Salicylic Acid)
(Salex)
(Sulfacetamide
Sodium)
(Sumadan)
sulfacetamide sodium/sulfur cleanser,
cream (g): 9.8%-4.8%, 10%-2%; foam:
10%-5%; lotion: 10-5%(w/w); med. pad,
suspension
urea cream (g), foam: 35%; gel (ml), gel/pf (Aluvea)
app, lotion
SANTYL
ACNE MEDICATION
benzoyl peroxide lotion: 10%
(Benzoyl Peroxide)
cod liver oil/zinc oxide oint. (g): 40%
(Cod Liver Oil/Zinc
Oxide)
diethyltoluamide aero powd: 25%; spray:
(Diethyltoluamide)
25%, 40%
DR. SMITH'S RASH-SKIN
zinc oxide oint. (g): 10%, 20%; paste (g)
(Boudreauxs)
1
1
1
1
1
1
PA
1
1
1
1
1
1
1
1
2
OTC
OTC
OTC
OTC
OTC
OTC
32
Drug Name
zinc oxide/petrolatum,white cream (g), oint.
(g): n/a
Dermatological Antibacterials
clindamycin phos/benzoyl perox
clindamycin phosphate foam, gel (gram),
lotion, med. swab, solution: 1%
erythromycin base/ethanol
Drug Tier
(Zinc Oxide/
Petrolatum,White)
OTC
(Duac)
(Cleocin T)
1
1
(Erythromycin Base/
Ethanol)
(Benzamycin)
(Gentamicin Sulfate)
(Metrogel)
1
erythromycin/benzoyl peroxide
gentamicin sulfate
metronidazole cream (g): 0.75%; gel
(gram), lotion
(Bactroban)
mupirocin calcium
(Bactroban)
mupirocin
(Selenium Sulfide)
selenium sulfide
(Silvadene)
silver sulfadiazine
(Klaron)
sulfacetamide sodium
bacitracin oint. (g): 500unit/g
(Bacitracin)
bacitracin/polymyxin b sulfate oint. (g):
(Bacitracin/Polymyxin
500-10k/g
B Sulfate)
neomycn/baci zn/pmyx bs/pramox oint. (g): (Neomycn/Baci Zn/
3.5-10k-10
Pmyx Bs/Pramox)
Dermatological Anti-Inflammatory Agents
(Amcinonide)
amcinonide
(Betamethasone
betamethasone dipropionate
Dipropionate)
betamethasone valerate cream (g), lotion, (Betamethasone
oint. (g)
Valerate)
(Diprolene AF)
betamethasone/propylene glyc
clobetasol propionate cream (g), foam, gel (Temovate)
(gram), lotion, oint. (g), shampoo, solution
desonide cream (g), lotion: 0.05%; oint. (g) (Desowen)
(Topicort)
desoximetasone
(Diflorasone Diacetate)
diflorasone diacetate
(Derma-Smoothe-Fs)
fluocinolone acetonide
fluocinonide cream (g): 0.05%; gel (gram), (Vanos)
oint. (g), solution
(Cutivate)
fluticasone propionate
(Hydrocort/Pramoxn/
hydrocort/pramoxn/skn clnsr#16
Skn Clnsr#16)
(Locoid)
hydrocortisone butyrate
Requirements/Limits
1
1
1
1
1
1
1
1
OTC
OTC
OTC
1
1
1
1
1
1
1
1
1
1
1
1
1
33
Drug Name
hydrocortisone valerate
hydrocortisone cream (g): 1%, 2.5%;
cream/appl, enema, lotion: 2.5%; oint. (g):
1%, 2.5%
hydrocortisone/lidocaine/aloe kit: 2.53%(7g)
lidocaine/hydrocortisone ac
mometasone furoate
tacrolimus
triamcinolone acetonide cream (g):
0.025%, 0.1%, 0.5%; lotion, oint. (g)
ELIDEL
PROCTOFOAM-HC
PROTOPIC
hydrocortisone oint. (g): 0.5%
Dermatological Retinoids
adapalene cream (g), gel (gram): 0.1%
tretinoin microspheres
tretinoin
tretinoin
tretinoin/emollient base
Scabicides and Pediculicides
lindane
malathion
permethrin cream (g)
permethrin spray: 0.5%
piperonyl butoxide/pyrethrins shampoo:
4%-0.33%
Drug Tier
(Hydrocortisone
Valerate)
(Anusol-HC)
(Hydrocortisone/
Lidocaine/Aloe)
(Lidocaine/
Hydrocortisone Ac)
(Elocon)
(Protopic)
(Triamcinolone
Acetonide)
Requirements/Limits
1
1
1
1
1
1
1
(Hydrocortisone)
2
2
2
OTC
(Differin)
(Retin-A Micro)
(Retin-A)
(Retin-A)
1
1
1
1
(Tretinoin/Emollient
Base)
1
(Lindane)
(Ovide)
(Elimite)
(Permethrin)
(Piperonyl Butoxide/
Pyrethrins)
1
1
1
OTC
OTC
PA
PA
PA
Age must be <= 30
Age must be <= 30
Age must be <= 30 (PA
Required for > 30)
Age must be <= 30
Devices
Devices
1ST CHOICE LANCETS
1ST TIER UNILET COMFORTOUCH
ACCU-CHEK FASTCLIX
ACCU-CHEK SAFE-T-PRO PLUS
ACCU-CHEK SAFE-T-PRO
ACCU-CHEK SOFTCLIX
ACCU-CHEK
2
2
2
2
2
2
2
34
Drug Name
Drug Tier
ACTI-LANCE
ADVANCED TRAVEL LANCETS
ADVOCATE LANCET
ADVOCATE LANCETS
ALTERNATE SITE LANCETS
ASSURE HAEMOLANCE PLUS each:
18gauge, 21gauge, 25gauge, 28gauge
ASSURE LANCE PLUS
ASSURE LANCE
AURORA SUPER THIN LANCETS
BD MICROTAINER LANCETS
BD ULTRA-FINE II
BD ULTRA-FINE
BLOOD LANCETS
BULLSEYE MINI SAFETY LANCETS
CAREONE
CARESENS
CLEVER CHEK LANCETS
COAGUCHEK
COLOR LANCETS
COMFORT EZ
COMFORT LANCETS
DROPLET LANCETS
EASY COMFORT
EASY TOUCH LANCETS
EASY TOUCH
EASY TWIST AND CAP LANCETS
EMBRACE
E-Z JECT LANCETS
EZ SMART LANCETS
E-ZJECT LANCETS
FIFTY50 SAFETY SEAL LANCETS
FINE 30 UNIVERSAL LANCETS
FINGERSTIX
FORA LANCETS
FORACARE LANCETS
FREESTYLE LANCETS
FREESTYLE UNISTIK 2
GLUCOCOM LANCETS
GLUCOCOM
GLUCOSOURCE
Requirements/Limits
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
35
Drug Name
Drug Tier
GMATE
HEALTHY ACCENTS UNILET LANCET
INCONTROL SUPER THIN LANCETS
INCONTROL ULTRA THIN LANCETS
INJECT EASE LANCETS
INVACARE LANCETS
KINNEY BRAND LANCETS
LANCETS THIN
LANCETS ULTRA THIN
LANCETS
LANCING DEVICE
LITE TOUCH
LUER-LOK SYRINGE-NEEDLE
MAJOR COMFORT
MEDI-LANCE
MEDISENSE THIN LANCETS
MEDLANCE PLUS
MICRO THIN LANCETS
MICROLET
MICROTAINER LANCETS
MONOJECT INSULIN SYRINGE
MONOLET LANCETS
MONOLET THIN LANCETS
MYGLUCOHEALTH LANCETS
NOVA SAFETY LANCETS
NOVA SUREFLEX
ON CALL LANCET
ON CALL PLUS LANCET
ONE TOUCH DELICA
ONETOUCH DELICA each
ONETOUCH DELICA kit
ONETOUCH FINEPOINT LANCETS
ONETOUCH LANCETS
ONETOUCH SURESOFT
ONETOUCH ULTRA CONTROL SOLN
ONETOUCH ULTRA SMART
ONETOUCH ULTRA SYSTEM
ONETOUCH ULTRA TEST STRIPS
ONETOUCH ULTRA2
ONETOUCH ULTRALINK
ONETOUCH ULTRAMINI
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
Requirements/Limits
QL: 1 in 730 days
QL: 1 in 730 days
QL: 1 in 730 days
QL: 1 in 730 days
QL: 200 in 30 days
QL: 1 in 730 days
QL: 1 in 730 days
QL: 1 in 730 days
36
Drug Name
ONETOUCH VERIO FLEX
ONETOUCH VERIO IQ
ONETOUCH VERIO SYNC
ONETOUCH VERIO each: n/a
ONETOUCH VERIO strip
ON-THE-GO
OPTICHAMBER DIAMOND
OPTICHAMBER each
OPTICHAMBER spacer
pen needle, diabetic
PENLET PLUS BLOOD SAMPLER
PRESSURE ACTIVATED LANCETS
PRO COMFORT LANCETS
PRODIGY LANCETS
PRODIGY TWIST TOP LANCET
PUSH BUTTON SAFETY LANCETS
RELIAMED SAFETY SEAL LANCETS
RELIAMED
RELION THIN
RENEW ADVANCED MICROLANCETS
RIGHTEST GL300 LANCETS
SAFETY LANCETS
SAFETY SEAL LANCETS
SAFETY-LET
SINGLE-LET
SMART SENSE LANCETS
SMART SENSE
SMARTDIABETES VANTAGE
SMARTEST LANCET
SOFT TOUCH
SOLUS V2 LANCETS
SOLUS V2
STERILANCE TL
sub-q insulin device, 40 unit
Drug Tier
(Pen Needle, Diabetic)
(Sub-Q Insulin Device,
40 Unit)
SUPER THIN LANCETS
SURE COMFORT LANCETS
SURE-LANCE
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
Requirements/Limits
QL: 1 in 730 days
QL: 1 in 730 days
QL: 200 in 30 days
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
37
Drug Name
SURESTEP PRO kit
SURESTEP PRO strip
SURE-TOUCH
syringe and needle,insulin,1ml
syringe-needle,insulin,0.5 ml
syring-needl,disp,insul,0.3 ml
Drug Tier
(Syringe and
Needle,Insulin,1ml)
(SyringeNeedle,Insulin,0.5 Ml)
(SyringNeedl,Disp,Insul,0.3
Ml)
TECHLITE LANCETS
TELCARE
THIN LANCETS
TOPCARE UNIVERSAL1 LANCET
TOPCARE UNIVERSAL1 THIN
LANCET
TRUEPLUS LANCETS
ULTICARE disp syrin
ULTICARE each
ULTILET BASIC
ULTILET CLASSIC
ULTILET LANCETS
ULTILET SAFETY
ULTRA THIN LANCETS
ULTRA THIN PLUS LANCETS
ULTRA THIN PLUS
ULTRALANCE
ULTRA-THIN II LANCETS
ULTRA-THIN II
ULTRATLC LANCETS
UNILET COMFORTOUCH
UNILET EXCELITE II
UNILET EXCELITE
UNILET GP LANCET
UNILET LANCET
UNILET LANCETS
UNISTIK 3 EXTRA
UNISTIK 3
UNISTIK CZT
UNISTIK SAFETY
UNISTIK TOUCH
2
2
2
2
Requirements/Limits
QL: 200 in 30 days
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
38
Drug Name
Drug Tier
UNIVERSAL 1
SOLESTA
Requirements/Limits
2
Medical
BenefitSpecialty
Drug
Enzyme Replacement/Modifiers
Enzyme Replacement/Modifiers
lipase/protease/amylase
CREON
CYSTAGON
KUVAN
PULMOZYME
STRENSIQ
ZAVESCA
ZENPEP
ALDURAZYME
(Zenpep)
ELAPRASE
ELITEK
FABRAZYME
KANUMA
MYOZYME
NAGLAZYME
VIMIZIM
XIAFLEX
ADAGEN
CEREZYME
1
2
2
2
2
2
2
2
Medical
Benefit
Medical
Benefit
Medical
Benefit
Medical
Benefit
Medical
Benefit
Medical
Benefit
Medical
Benefit
Medical
Benefit
Medical
Benefit
Medical
BenefitSpecialty
Drug
Medical
BenefitSpecialty
Drug
Specialty Drug
PA Specialty Drug
PA Specialty Drug
PA Specialty Drug
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
39
Drug Name
Drug Tier
ELELYSO
Medical
BenefitSpecialty
Drug
Medical
BenefitSpecialty
Drug
Medical
BenefitSpecialty
Drug
LUMIZYME
VPRIV
Requirements/Limits
PA
PA
PA
Eye, Ear, Nose, Throat Agents
Eye, Ear, Nose, Throat Agents, Miscellaneous
(Isopto Atropine)
atropine sulfate
azelastine hcl spray/pump: 137mcg
(Astepro)
azelastine hcl drops
(Optivar)
(Carteolol HCl)
carteolol hcl
(Cromolyn Sodium)
cromolyn sodium
(Cyclogyl)
cyclopentolate hcl
(Elestat)
epinastine hcl
(Isopto Homatropine)
homatropine hbr
ipratropium bromide spray: 21mcg
(Atrovent)
ipratropium bromide spray: 42mcg
(Atrovent)
(Naphazoline HCl)
naphazoline hcl
olopatadine hcl drops
(Patanol)
phenylephrine hcl drops: 2.5%, 10%
(Mydfrin)
oxymetazoline hcl spray: 0.05%
(Afrin)
(Phenol/Sodium
phenol/sodium phenolate
Phenolate)
phenylephrine hcl spray: 1%
(Neo-Synephrine)
(Polyethylene Glycol/
polyethylene glycol/polyvinyl
Polyvinyl)
polyvinyl alcohol drops: 1.4%
(Polyvinyl Alcohol)
sodium chloride drops: 5%; oint. (g): 5%; (Sodium Chloride)
spray: 0.65%
ILUVIEN
1
1
1
1
1
1
1
1
1
1
1
1
1
OTC
OTC
QL: 1.2 in 1 days
QL: 1.1 in 1 days
QL: 1.5 in 1 days
OTC
OTC
OTC
OTC
Medical
Benefit
PA
40
Drug Name
Drug Tier
LUCENTIS
Requirements/Limits
Medical
BenefitSpecialty
Drug
Eye, Ear, Nose, Throat Anti-Infectives Agents
(Acetic Acid/
acetic acid/aluminum acetate
Aluminum Acetate)
(Vosol HC)
acetic acid/hydrocortisone
(Antipyrine/
antipyrine/benzocaine
Benzocaine)
(Bacitracin)
bacitracin
(Bacitracin/Polymyxin
bacitracin/polymyxin b sulfate
B Sulfate)
(Ciloxan)
ciprofloxacin hcl
erythromycin base oint. (g): 5mg/g
(Erythromycin Base)
(Garamycin)
gentamicin sulfate
(Levofloxacin)
levofloxacin
(Maxitrol)
neo/polymyx b sulf/dexameth
(Neomycin Su/Baci Zn/
neomycin su/baci zn/poly/hc
Poly/HC)
neomycin su/bacitra/polymyxin oint. (g):
(Neomycin Su/Bacitra/
3.5mg-400
Polymyxin)
(Cortisporin)
neomycin/polymyxin b sulf/hc
(Neosporin)
neomycin/polymyxn b/gramicidin
(Ocuflox)
ofloxacin
(Polytrim)
polymyxin b sulf/trimethoprim
(Sulfacetamide
sulfacetamide sodium
Sodium)
(Sulfacetamide/
sulfacetamide/prednisolone sp
Prednisolone Sp)
(Tobrex)
tobramycin
(Tobradex)
tobramycin/dexamethasone
(Viroptic)
trifluridine
Eye, Ear, Nose, Throat Anti-Inflammatory Agents
(Dexasol)
dexamethasone sod phosphate
(Diclofenac Sodium)
diclofenac sodium
flunisolide spray: 29mcg
(Flunisolide)
flunisolide spray: 25mcg
(Flunisolide)
(Dermotic)
fluocinolone acetonide oil
(FML)
fluorometholone
(Flonase)
fluticasone propionate
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
QL: 1 in 1 days
QL: 0.54 in 1 days
41
Drug Name
ketorolac tromethamine
prednisolone acetate
prednisolone sod phosphate
triamcinolone acetonide
FML S.O.P.
Drug Tier
(Acular LS)
(Pred Forte)
(Prednisolone Sod
Phosphate)
(Nasacort Aq)
Requirements/Limits
1
1
1
1
2
QL: 0.57 in 1 days
Gastrointestinal Agents
Antiflatulents
simethicone capsule: 125mg, 180mg
(Simethicone)
Antiulcer Agents And Acid Suppressants
(Cimetidine HCl)
cimetidine hcl
cimetidine tablet: 200mg, 300mg, 400mg, (Cimetidine)
800mg
famotidine oral susp, tablet: 20mg, 40mg
(Pepcid)
(Prevacid)
lansoprazole
(Cytotec)
misoprostol
(Axid)
nizatidine
omeprazole capsule dr
(Prilosec)
pantoprazole sodium tablet dr
(Protonix)
(Aciphex)
rabeprazole sodium
ranitidine hcl capsule, syrup, tablet:
(Zantac)
150mg, 300mg
(Carafate)
sucralfate
NEXIUM suspdr pkt
PREVACID tab rap dr
PROTONIX granpkt dr
cimetidine tablet: 200mg
(Cimetidine)
omeprazole tablet dr
(Omeprazole)
ranitidine hcl tablet: 75mg
(Zantac 75)
Gastrointestinal Agents, Other
(Gastrocrom)
cromolyn sodium
dicyclomine hcl capsule, solution, tablet
(Bentyl)
(Lomotil)
diphenoxylate hcl/atropine
glycopyrrolate tablet
(Robinul)
(Lactulose)
lactulose
loperamide hcl capsule: 2mg
(Loperamide HCl)
metoclopramide hcl solution, tablet
(Reglan)
sodium bicarbonate tablet: 325mg
(Sodium Bicarbonate)
(Sodium Polystyrene
sodium polystyrene sulfon/sorb
Sulfon/Sorb)
OTC
1
1
1
1
1
1
1
1
1
1
1
2
2
2
OTC
OTC
OTC
QL: 30 in 30 days
1
1
1
1
1
1
1
1
1
42
Drug Name
sodium polystyrene sulfonate
ursodiol
CHOLBAM
VELTASSA
aluminum hydroxide
bismuth subsalicylate oral susp: 262mg/
15ml, 525mg/15ml; tab chew: 262mg;
tablet: 262mg
calcium carbonate tab chew: 200(500)mg,
300mg(750), 400(1000), 500(1250)
loperamide hcl liquid: 1mg/5ml; tablet:
2mg
mag carb/al hydrox/alginic ac oral susp:
358-95/15
mag hydrox/al hydrox/simeth oral susp:
200-200-20
magnesium carbonate/al hydrox tab chew:
105-160mg
magnesium oxide tablet: 400mg
mg trisilicate/alh/nahco3/aa
Laxatives
bisac/nacl/nahco3/kcl/peg 3350
peg 3350/na sulf,bicarb,cl/kcl
polyethylene glycol 3350 powd pack: 17g;
powder: 17g/dose
sodium chloride/nahco3/kcl/peg
bisacodyl supp.rect: 10mg; tablet dr: 5mg
calcium polycarbophil tablet: 625mg
docusate sodium syrup: 60mg/15ml
magnesium citrate solution: n/a
magnesium hydroxide
methylcellulose (with sugar)
methylcellulose tablet
MILK OF MAGNESIA
psyllium husk capsule: 0.52g
sennosides/docusate sodium tablet: 8.6mg50mg
Drug Tier
(Sodium Polystyrene
Sulfonate)
(Urso)
1
(Aluminum Hydroxide)
(Pepto-Bismol)
1
2
2
OTC
OTC
(Tums)
OTC
(Imodium A-D)
OTC
(Gaviscon)
OTC
(Rulox)
OTC
(Magnesium
Carbonate/Al Hydrox)
(Magox 400)
(Gaviscon)
OTC
(Halflytely-Bisacodyl)
(Golytely)
(Polyethylene Glycol
3350)
(Nulytely with Flavor
Packs)
(Dulcolax)
(Fibercon)
(Docusate Sodium)
(Magnesium Citrate)
(Phillips' Milk Of
Magnesia)
(Methylcellulose (With
Sugar))
(Citrucel)
(Metamucil)
(Sennosides/Docusate
Sodium)
Requirements/Limits
PA
PA, QL: 1 in 1 days
OTC
OTC
1
1
1
1
OTC
OTC
OTC
OTC
OTC
OTC
OTC
OTC
OTC
OTC
43
Drug Name
Phosphate Binders
calcium acetate
FOSRENOL tab chew
RENAGEL
RENVELA
Drug Tier
(Phoslo)
1
2
2
2
Requirements/Limits
PA
Genitourinary Agents
Antispasmodics, Urinary
(Flavoxate HCl)
flavoxate hcl
(Oxybutynin Chloride)
oxybutynin chloride
tolterodine tartrate tablet
(Detrol)
trospium chloride tablet
(Sanctura)
Genitourinary Agents, Miscellaneous
(Uroxatral)
alfuzosin hcl
(Phenazopyridine HCl)
phenazopyridine hcl
(Flomax)
tamsulosin hcl
(Terazosin HCl)
terazosin hcl
1
1
1
1
1
1
1
1
Hormonal Agents, Stimulant/Replacement/Modifying
Androgens
danazol
fluoxymesterone
oxandrolone
testosterone cypionate
testosterone enanthate
(Danazol)
(Fluoxymesterone)
(Oxandrin)
(Depo-Testosterone)
(Testosterone
Enanthate)
1
1
1
1
1
ANDRODERM
Estrogens and Antiestrogens
estradiol tablet
(Estrace)
(Activella)
estradiol/norethindrone acet
(Estropipate)
estropipate
(Evista)
raloxifene hcl
PREMARIN cream/appl, tablet
PREMPHASE
PREMPRO
Glucocorticoids/Mineralocorticoids
(Cortisone Acetate)
cortisone acetate
DEXAMETHASONE INTENSOL
(Dexamethasone Sod
Phosphate)
(Dexamethasone)
dexamethasone
(Fludrocortisone
fludrocortisone acetate
Acetate)
2
PA
1
1
1
1
2
2
2
1
1
1
1
1
44
Drug Name
hydrocortisone
methylprednisolone
prednisolone sod phosphate solution: 5mg/
5ml, 15mg/5ml
prednisone
Pituitary
desmopressin acetate tablet
desmopressin acetate solution, spray/pump
NORDITROPIN FLEXPRO
NUTROPIN AQ NUSPIN
NUTROPIN AQ
NUTROPIN
SANDOSTATIN LAR DEPOT
Drug Tier
(Cortef)
(Medrol)
(Orapred)
1
1
1
(Prednisone)
1
(DDAVP)
(DDAVP)
LUPRON DEPOT-PED
SUPPRELIN LA
Progestins
HYDROXYPROGESTERONE
CAPROATE
medroxyprogesterone acetate syringe
medroxyprogesterone acetate tablet, vial
megestrol acetate oral susp: 400mg/10ml
norethindrone acetate
progesterone
progesterone,micronized
hydroxyprogesterone caproate
QL: 0.3 in 1 days
PA Specialty Drug
PA Specialty Drug
PA Specialty Drug
PA Specialty Drug
PA
PA
1
(Depo-Provera)
(Provera)
(Megace Es)
(Aygestin)
(Progesterone)
(Prometrium)
(Hydroxyprogesterone
Caproate)
MAKENA
Thyroid and Antithyroid Agents
levothyroxine sodium tablet
liothyronine sodium tablet
methimazole
1
1
2
2
2
2
Medical
Benefit
Medical
BenefitSpecialty
Drug
Medical
BenefitSpecialty
Drug
Requirements/Limits
(Synthroid)
(Cytomel)
(Tapazole)
1
1
1
1
1
1
Medical
Benefit
Medical
BenefitSpecialty
Drug
QL: 1 in 84 days
PA NSO
PA NSO
1
1
1
45
Drug Name
potassium iodide
potassium iodide/iodine
propylthiouracil
ARMOUR THYROID
SYNTHROID
THYROGEN
Drug Tier
(Potassium Iodide)
(Potassium Iodide/
Iodine)
(Propylthiouracil)
Requirements/Limits
1
1
1
2
2
Medical
BenefitSpecialty
Drug
Immunological Agents
Immunological Agents
azathioprine
cyclosporine capsule
cyclosporine, modified capsule: 25mg,
50mg, 100mg; solution
leflunomide
mycophenolate mofetil capsule, tablet
sirolimus
tacrolimus
ASTAGRAF XL
CIMZIA syringekit
ENBREL pen injctr, syringe
(Imuran)
(Sandimmune)
(Neoral)
1
1
1
(Arava)
(Cellcept)
(Rapamune)
(Prograf)
1
1
1
1
2
2
2
ENBREL vial
2
HUMIRA PEDIATRIC CROHN'S
2
HUMIRA PEN CROHN-UC-HS
STARTER
2
HUMIRA PEN PSORIASIS-UVEITIS
2
HUMIRA PEN
2
HUMIRA syringekit: 10mg/0.2ml, 20mg/
0.4ml
HUMIRA syringekit: 40mg/0.8ml
2
2
KINERET
2
PA Specialty Drug
Specialty Drug
Specialty Drug
Specialty Drug
(Starter Kit for Crohn's/
Ulcerative Colitis);
Specialty Drug
Specialty Drug
Specialty Drug
Specialty Drug
Specialty Drug
PA Specialty Drug
46
Drug Name
Drug Tier
ORENCIA syringe
2
RAPAMUNE
RIDAURA
ZORTRESS
BIVIGAM
2
2
2
Medical
Benefit
Medical
Benefit
Medical
Benefit
Medical
Benefit
Medical
Benefit
Medical
Benefit
Medical
Benefit
Medical
Benefit
Medical
Benefit
Medical
Benefit
Medical
BenefitSpecialty
Drug
Medical
BenefitSpecialty
Drug
Medical
BenefitSpecialty
Drug
Medical
BenefitSpecialty
Drug
CARIMUNE NF NANOFILTERED
FLEBOGAMMA DIF vial: 10%
FLEBOGAMMA DIF vial: 5%
GAMMAKED
GAMMAPLEX
HYQVIA IG COMPONENT
HYQVIA
OCTAGAM
PRIVIGEN
CIMZIA kit
CYTOGAM
GAMMAGARD LIQUID
GAMUNEX-C
Requirements/Limits
Specialty Drug
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
47
Drug Name
Drug Tier
HIZENTRA
Medical
BenefitSpecialty
Drug
Medical
BenefitSpecialty
Drug
Medical
BenefitSpecialty
Drug
Medical
BenefitSpecialty
Drug
Medical
BenefitSpecialty
Drug
Medical
BenefitSpecialty
Drug
Medical
BenefitSpecialty
Drug
ILARIS
NULOJIX
ORENCIA vial
RHOGAM ULTRA-FILTERED PLUS
TYSABRI
WINRHO SDF
Vaccines
VIVOTIF
2
Requirements/Limits
PA
PA
PA
PA
PA
QL: 4 per fill
Inflammatory Bowel Disease Agents
Inflammatory Bowel Disease Agents
(Colazal)
balsalazide disodium
(Entocort EC)
budesonide
(Sfrowasa)
mesalamine
ASACOL HD
DELZICOL
1
1
1
2
2
Irrigating Solutions
Irrigating Solutions
water for irrigation,sterile
(Water For
Irrigation,Sterile)
1
48
Drug Name
Drug Tier
Requirements/Limits
Metabolic Bone Disease Agents
Metabolic Bone Disease Agents
alendronate sodium
calcitonin,salmon,synthetic
calcitriol capsule, solution
ibandronate sodium tablet
FORTEO
(Fosamax)
(Miacalcin)
(Rocaltrol)
(Boniva)
BONIVA syringe
ibandronate sodium syringe
(Boniva)
PROLIA
XGEVA
RECLAST
1
1
1
1
2
Medical
Benefit
Medical
Benefit
Medical
Benefit
Medical
Benefit
Medical
BenefitSpecialty
Drug
QL: 0.13 in 1 days
Specialty Drug
PA
PA
PA
PA
QL: 100 in 365 days
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
allopurinol
bethanechol chloride
buspirone hcl
colchicine/probenecid
finasteride tablet: 5mg
hydroxyzine hcl solution, tablet
hydroxyzine pamoate
leucovorin calcium tablet
levocarnitine (with sugar)
levocarnitine tablet
methylergonovine maleate tablet
probenecid
pyridostigmine bromide tablet
water for injection,sterile
(Zyloprim)
(Urecholine)
(Buspirone HCl)
(Colchicine/
Probenecid)
(Propecia)
(Hydroxyzine HCl)
(Vistaril)
(Leucovorin Calcium)
(Carnitor)
(Carnitor)
(Methylergonovine
Maleate)
(Probenecid)
(Mestinon)
(Water For
Injection,Sterile)
AVONEX PEN
AVONEX kit
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
PA Specialty Drug
PA Specialty Drug
49
Drug Name
Drug Tier
AVONEX syringekit
BETASERON
COPAXONE syringe: 40mg/ml
2
2
2
COPAXONE syringe: 20mg/ml
2
GILENYA
GLUCAGEN
GLUCAGON EMERGENCY KIT
ORENCIA CLICKJECT
2
2
2
2
REBIF REBIDOSE
REBIF
STELARA
SYNAREL
TECFIDERA
melatonin tablet: 3mg
MELATONIN tablet
ORA PLUS
ORA SWEET
ORA-BLEND SF
ORA-BLEND
ORA-SWEET-SF
GEL-ONE
(Melatonin)
HYALGAN
KALBITOR
MONOVISC
MYOBLOC
NPLATE
ORTHOVISC
PROVENGE
SIGNIFOR LAR
2
2
2
2
2
OTC
OTC
OTC
OTC
OTC
OTC
OTC
Medical
Benefit
Medical
Benefit
Medical
Benefit
Medical
Benefit
Medical
Benefit
Medical
Benefit
Medical
Benefit
Medical
Benefit
Medical
Benefit
Requirements/Limits
PA Specialty Drug
Specialty Drug
QL: 12 in 28 days
Specialty Drug
QL: 30 in 30 days
Specialty Drug
Specialty Drug
QL: 2 in 30 days
QL: 2 in 30 days
Specialty Drug
PA Specialty Drug
PA Specialty Drug
PA Specialty Drug
PA, QL: 0.89 in 1 days
Specialty Drug
PA
PA
PA
PA
PA
PA
PA
PA
PA
50
Drug Name
Drug Tier
SIMPONI ARIA
Medical
Benefit
Medical
Benefit
Medical
Benefit
Medical
Benefit
Medical
Benefit
Medical
BenefitSpecialty
Drug
Medical
BenefitSpecialty
Drug
Medical
BenefitSpecialty
Drug
Medical
BenefitSpecialty
Drug
Medical
BenefitSpecialty
Drug
Medical
BenefitSpecialty
Drug
Medical
BenefitSpecialty
Drug
Medical
BenefitSpecialty
Drug
SUPARTZ FX
SUPARTZ
VORAXAZE
XEOMIN
ACTEMRA vial
BENLYSTA
BOTOX
DYSPORT
ENTYVIO
EUFLEXXA
LEMTRADA
LUPANETA PACK
Requirements/Limits
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
51
Drug Name
Drug Tier
REMICADE
Medical
BenefitSpecialty
Drug
Medical
BenefitSpecialty
Drug
Medical
BenefitSpecialty
Drug
Medical
BenefitSpecialty
Drug
SOLIRIS
SYNVISC
SYNVISC-ONE
Requirements/Limits
PA
PA
Ophthalmic Agents
Antiglaucoma Agents
acetazolamide
betaxolol hcl
brimonidine tartrate
dorzolamide hcl
dorzolamide hcl/timolol maleat
latanoprost
levobunolol hcl
methazolamide
pilocarpine hcl
timolol maleate
travoprost (benzalkonium)
(Acetazolamide)
(Betaxolol HCl)
(Alphagan P)
(Trusopt)
(Cosopt)
(Xalatan)
(Betagan)
(Neptazane)
(Isopto Carpine)
(Timolol Maleate)
(Travoprost
(Benzalkonium))
PILOPINE HS
SIMBRINZA
1
1
1
1
1
1
1
1
1
1
1
2
2
Radioactive Agents
Radioactive Agents
XOFIGO
Medical
Benefit
PA
Replacement Preparations
Replacement Preparations
KLOR-CON 10
KLOR-CON 8
KLOR-CON
1
1
1
52
Drug Name
phosphorus #1 tablet: 250mg
potassium chloride capsule er, liquid,
packet, tab er prt, tablet er
potassium citrate tablet er: 5meq, 10meq
sodium chloride vial: 4meq/ml
K-PHOS ORIGINAL
calcium carb/vit d3/minerals tablet:
600mg-400
calcium carbonate oral susp
calcium carbonate/vitamin d3 tab chew,
tablet: 500mg-200, 600mg-400
calcium citrate/vitamin d3 tablet: 250mg200, 315mg-200, 315mg-250
Drug Tier
(K-Phos Neutral)
(Potassium Chloride)
(Urocit-K)
(Sodium Chloride)
Requirements/Limits
1
1
(Caltrate 600 + D Plus)
1
1
2
OTC
(Os-Cal)
(Os-Cal with D)
OTC
OTC
(Citracal + D)
OTC
Respiratory Tract Agents
Anti-Inflammatories, Inhaled Corticosteroids
budesonide ampul-neb: 0.5mg/2ml
(Pulmicort)
budesonide ampul-neb: 0.25mg/2ml
(Pulmicort)
budesonide ampul-neb: 1mg/2ml
(Pulmicort)
ADVAIR DISKUS
ADVAIR HFA
ARNUITY ELLIPTA
BREO ELLIPTA
DULERA
FLOVENT DISKUS
1
1
1
2
2
2
2
2
2
FLOVENT HFA
2
Antileukotrienes
montelukast sodium
Bronchodilators
albuterol sulfate vial-neb
albuterol sulfate syrup, tab er 12h, tablet
albuterol sulfate solution
ipratropium bromide
ipratropium/albuterol sulfate
terbutaline sulfate tablet
theophylline anhydrous elixir, solution, tab
er 12h: 100mg, 200mg, 300mg, 450mg; tab
er 24h
VENTOLIN HFA hfa aer ad: 90mcg
ANORO ELLIPTA
(Singulair)
1
(Accuneb)
(Albuterol Sulfate)
(Albuterol Sulfate)
(Ipratropium Bromide)
(Duoneb)
(Terbutaline Sulfate)
(Theophylline
Anhydrous)
1
1
1
1
1
1
1
1
2
QL: 120 in 30 days
QL: 240 in 30 days
QL: 60 in 30 days
PA, QL: 2 in 1 days
PA, QL: 0.4 in 1 days
Requried for > 11)
Requried for > 17)
QL: 18 in 1 days
QL: 6 in 1 days
QL: 15 in 1 days
QL: 18 in 1 days
QL: 36 in 30 days
53
Drug Name
ATROVENT HFA
COMBIVENT RESPIMAT
COMBIVENT
SEREVENT DISKUS blst w/dev: 50mcg
SPIRIVA RESPIMAT
SPIRIVA
XOPENEX HFA
Respiratory Tract Agents, Other
acetylcysteine
cromolyn sodium
sodium chloride for inhalation
Drug Tier
2
2
2
2
2
2
2
(Acetadote)
(Cromolyn Sodium)
(Sodium Chloride For
Inhalation)
1
1
1
DALIRESP
KALYDECO
2
2
ORKAMBI
2
CINQAIR
Medical
Benefit
Medical
Benefit
Medical
BenefitSpecialty
Drug
Medical
BenefitSpecialty
Drug
Medical
BenefitSpecialty
Drug
Medical
BenefitSpecialty
Drug
Medical
BenefitSpecialty
Drug
NUCALA
ARALAST NP
GLASSIA
PROLASTIN C
XOLAIR
ZEMAIRA
Requirements/Limits
QL: 0.86 in 1 days
QL: 4 in 30 days
QL: 30 in 30 days
PA, QL: 1 in 1 days
QL: 8 in 1 days
PA, QL: 2 in 1 days
Specialty Drug
PA, QL: 4 in 1 days
Specialty Drug
PA
PA
PA
PA
PA, QL: 34 per fill (34
Days Supply per 1 Fill)
PA
PA (34 Days Supply per
1 Fill)
54
Drug Name
Drug Tier
Requirements/Limits
Skeletal Muscle Relaxants
Skeletal Muscle Relaxants
baclofen
carisoprodol
chlorzoxazone
COMFORT PAC-CYCLOBENZAPRINE
COMFORT PAC-TIZANIDINE
cyclobenzaprine hcl tablet: 5mg, 10mg
dantrolene sodium capsule
methocarbamol tablet
tizanidine hcl
(Baclofen)
(Soma)
(Parafon Forte DSC)
(Fexmid)
(Dantrium)
(Robaxin)
(Zanaflex)
1
1
1
1
1
1
1
1
1
(Lunesta)
(Provigil)
(Sonata)
(Ambien)
1
1
1
1
Sleep Disorder Agents
Sleep Disorder Agents
eszopiclone
modafinil
zaleplon
zolpidem tartrate tablet
QL: 1 in 1 days
Urine And Feces Contents
Ketones
KETOSTIX REAGENT
2
Vasodilating Agents
Vasodilating Agents
sildenafil citrate tablet
ADCIRCA
LETAIRIS
(Revatio)
TRACLEER
1
2
2
2
FLOLAN
Medical
BenefitSpecialty
Drug
Medical
BenefitSpecialty
Drug
Medical
BenefitSpecialty
Drug
REMODULIN
VELETRI
(Specialty Drug)
(Specialty Drug)
PA
PA
PA
55
Drug Name
Drug Tier
Requirements/Limits
Vitamins and Minerals
Vitamins and Minerals
b complex w-c no.20/folic acid capsule:
1mg
cyanocobalamin (vitamin b-12) vial
cyanocobalamin/fa/pyridoxine tablet: 0.52.2-25
ergocalciferol (vitamin d2) capsule
folic acid tablet: 1mg
mecobal/levomefolat ca/b6 phos tablet: 2-335mg
mv,min #10/fa/d3/alip acid/lut
NEPHROCAPS capsule: 1mg
pedi m.vit no.17 with fluoride
pedi multivit #22/vit d3/vit k
pedi multivit #65/vit d3/vit k
pnv with ca,no.72/iron/fa
pnv#71/iron/folic acid/dha
pnv#79/iron/fa/lmfolate ca/dha
MEPHYTON
ascorbic acid tablet: 100mg, 250mg
b complex w-c no.20/folic acid capsule:
1mg
beta-carotene(a)-vits c,e/mins tablet: n/a
cholecalciferol (vitamin d3) capsule:
10000unit; tablet: 400unit
cyanocobalamin (vitamin b-12) tablet:
100mcg, 500mcg
fa/mv,ca,iron,min/lycopene/lut tablet: 0.4162-18
ferrous fumarate tablet: 324(106)mg
ferrous gluconate tablet: 240(27)mg,
324(37.5)
(Nephrocaps)
1
(Vitamin B-12)
(Folgard Rx)
1
1
(Drisdol)
(Folic Acid)
(Mecobal/Levomefolat
Ca/B6 Phos)
(Mv,Min #10/Fa/D3/
Alip Acid/Lut)
1
1
1
(Pedi M.Vit No.17 with
Fluoride)
(Pedi Multivit #22/Vit
D3/Vit K)
(Pedi Multivit #65/Vit
D3/Vit K)
(Pnv with Ca,No.72/
Iron/Fa)
(Pnv#71/Iron/Folic
Acid/Dha)
(Neevo Dha)
1
1
1
1
1
1
1
1
2
OTC
(Vitamin C, Vitamin C
with Rose Hips)
(B Complex W-C
No.20/Folic Acid)
(Beta-Carotene(A)-Vits
C,E/Mins)
(Vitamin D3)
OTC
(Vitamin B-12)
OTC
(A Thru Z)
OTC
(Ferrets)
(Fergon)
OTC
OTC
OTC
OTC
56
Drug Name
ferrous sulfate tablet: 134mg, 325(65)mg;
tablet er: 47.5iron, 140(45)mg
ferrous sulfate, dried
folic acid tablet: 0.4mg, 0.8mg, 1mg
folic acid/multivit-min/lutein tablet: 0.4mg250
folic acid/mv,fe,min tablet: 0.4mg-18mg
iron aspgly,ps/c/succinic acid
iron polysaccharide complex capsule:
150mg
multivit with iron-minerals tablet: n/a
multivitamin with iron tab chew: n/a
multivitamin with minerals/lut tablet: n/a
multivitamin/iron/folic acid tablet: 18mg0.4mg
multivit-min/fa/lycopen/lutein tablet: .4300-250
multivits,ca,minerals/iron/fa tablet: 500-180.4
mv,ca,iron,min/fa/phytosterol tablet: 3-200400
mv,fe,min/lutein tablet: n/a
niacinamide tablet
pnv95/ferrous fumarate/fa tablet: 28mg0.8mg
POLY-VI-SOL WITH IRON
PRENATAL 19
prenatal vit/iron fumarate/fa tablet: 27mg0.8mg, 28mg-0.8mg
pyridoxine hcl tablet: 100mg
riboflavin tablet: 25mg, 50mg
thiamine hcl tablet: 50mg
vitamin e capsule: 200unit
Drug Tier
(Fer-in-sol, Slow Fe,
Feosol)
(Ferrous Sulfate, Dried)
(Folic Acid)
(Essential Woman 50+)
(Folic Acid/
Mv,Fe,Min)
(Iron Aspgly,Ps/C/
Succinic Acid)
(Pic 200)
OTC
OTC
OTC
OTC
OTC
OTC
OTC
(Multivit with IronMinerals)
(Multivitamin with
Iron)
(Multivitamin with
Minerals/Lut)
(One Daily Plus Iron)
OTC
(Biocel)
OTC
(Multivits,Ca,Minerals/
Iron/Fa)
(Century Cardio)
OTC
OTC
(Mv,Fe,Min/Lutein)
(Niacinamide)
(Prenatal)
OTC
OTC
OTC
(Prenatal Vit/Iron
Fumarate/Fa)
(Vitamin B6)
(Vitamin B2)
(Vitamin B1)
(Vitamin E)
Requirements/Limits
OTC
OTC
OTC
OTC
OTC
OTC
OTC
OTC
OTC
OTC
57
INDEX
1ST CHOICE LANCETS ..... 34
1ST TIER UNILET
COMFORTOUCH............ 34
abacavir sulfate..................... 20
abacavir/lamivudine/zidovudine
........................................... 20
ABILIFY............................... 20
ABILIFY MAINTENA ........ 20
ABRAXANE .......................... 9
ABREVA .............................. 16
acamprosate calcium .............. 4
acarbose................................ 14
ACCU-CHEK ....................... 34
ACCU-CHEK FASTCLIX ... 34
ACCU-CHEK SAFE-T-PRO 34
ACCU-CHEK SAFE-T-PRO
PLUS................................. 34
ACCU-CHEK SOFTCLIX ... 34
acebutolol hcl........................ 26
acetaminophen ........................ 2
acetaminophen with codeine... 1
acetaminophen/phenyltolx ...... 2
acetazolamide ....................... 52
acetic acid/aluminum acetate 41
acetic acid/hydrocortisone.... 41
acetylcysteine ........................ 54
ACNE MEDICATION ......... 32
ACTEMRA ........................... 51
ACTI-LANCE....................... 35
acyclovir................................ 23
ADAGEN.............................. 39
adapalene.............................. 34
ADCETRIS ........................... 11
ADCIRCA............................. 55
ADVAIR DISKUS................ 53
ADVAIR HFA ...................... 53
ADVANCED TRAVEL
LANCETS......................... 35
ADVATE .............................. 24
ADVOCATE LANCET........ 35
ADVOCATE LANCETS...... 35
AFINITOR.............................. 7
AGGRENOX ........................ 25
AIMSCO ............................... 30
AKYNZEO ........................... 17
ALBENZA............................ 18
albuterol sulfate .................... 53
ALDURAZYME................... 39
ALECENSA............................ 7
alendronate sodium............... 49
alfuzosin hcl .......................... 44
ALKERAN ............................. 7
allopurinol............................. 49
ALOXI .................................. 17
ALPHANATE....................... 24
alprazolam .............................. 4
ALTERNATE SITE LANCETS
........................................... 35
aluminum hydroxide.............. 43
amantadine hcl...................... 18
amcinonide............................ 33
AMETHYST......................... 29
amiloride hcl ......................... 27
amiloride/hydrochlorothiazide
........................................... 27
aminocaproic acid ................ 24
amiodarone hcl ..................... 26
amitriptyline hcl .................... 13
amitriptyline/chlordiazepoxide
........................................... 13
amlodipine besylate .............. 27
amlodipine besylate/benazepril
........................................... 27
ammonium lactate................. 32
amoxapine ............................. 13
amoxicillin............................... 6
amoxicillin/potassium clav...... 6
ampicillin trihydrate ............... 6
AMPYRA ............................. 29
anagrelide hcl ....................... 24
anastrozole.............................. 7
ANDRODERM..................... 44
ANORO ELLIPTA ............... 53
antipyrine/benzocaine ........... 41
APTIVUS.............................. 21
ARALAST NP ...................... 54
ARANESP ............................ 24
ARESTIN.............................. 32
aripiprazole........................... 18
ARISTADA .......................... 20
ARMOUR THYROID .......... 46
ARNUITY ELLIPTA ........... 53
ARRANON............................. 9
ARZERRA.............................. 9
ASACOL HD........................ 48
ascorbic acid......................... 56
aspirin ..................................... 3
aspirin/dipyridamole............. 25
ASSURE HAEMOLANCE
PLUS................................. 35
ASSURE LANCE................. 35
ASSURE LANCE PLUS ...... 35
ASTAGRAF XL ................... 46
atenolol ................................. 26
atenolol/chlorthalidone......... 26
atorvastatin calcium.............. 27
atovaquone............................ 17
atovaquone/proguanil hcl ..... 17
ATRIPLA.............................. 21
atropine sulfate ..................... 40
ATROVENT HFA ................ 54
AURORA SUPER THIN
LANCETS......................... 35
AVASTIN ............................. 11
AVONEX........................ 49, 50
AVONEX PEN ..................... 49
AVYCAZ................................ 6
azathioprine .......................... 46
azelastine hcl......................... 40
azithromycin............................ 6
I-1
b complex w-c no.20/folic acid
........................................... 56
bacitracin ........................ 33, 41
bacitracin/polymyxin b sulfate
..................................... 33, 41
baclofen................................. 55
balsalazide disodium............. 48
BANZEL............................... 12
BARACLUDE ...................... 23
BD MICROTAINER
LANCETS......................... 35
BD ULTRA-FINE ................ 35
BD ULTRA-FINE II............. 35
BELEODAQ ........................... 9
benazepril hcl........................ 25
benazepril/hydrochlorothiazide
........................................... 25
BENLYSTA.......................... 51
benzocaine........................... 3, 4
benzonatate ........................... 31
benzoyl peroxide ................... 32
benzoyl peroxide microspheres
........................................... 32
benztropine mesylate............. 18
BERINERT ........................... 24
beta-carotene(a)-vits c,e/mins56
betamethasone dipropionate. 33
betamethasone valerate ........ 33
betamethasone/propylene glyc
........................................... 33
BETASERON ....................... 50
betaxolol hcl.................... 26, 52
bethanechol chloride............. 49
bexarotene............................... 7
bicalutamide............................ 7
BILTRICIDE ........................ 18
bisac/nacl/nahco3/kcl/peg 3350
........................................... 43
bisacodyl ............................... 43
bismuth subsalicylate ............ 43
bisoprolol fumarate............... 26
bisoprolol fumarate/hctz ....... 26
BIVIGAM ............................. 47
BLINCYTO ............................ 9
BLOOD LANCETS.............. 35
BONIVA ............................... 49
BOSULIF................................ 7
BOTOX................................. 51
BP WASH............................. 32
BREO ELLIPTA................... 53
brimonidine tartrate.............. 52
bromocriptine mesylate......... 18
bromphenira/pseudoephed/
codein................................ 31
brompheniram/phenylephrine/
dm...................................... 31
budesonide ...................... 48, 53
BULLSEYE MINI SAFETY
LANCETS......................... 35
bumetanide............................ 27
buprenorphine hcl................... 4
buprenorphine hcl/naloxone hcl
............................................. 4
bupropion hcl .................... 4, 13
buspirone hcl......................... 49
butalb/acetaminophen/caffeine1
butalbit/acetamin/caff/codeine 1
butalbital/acetaminophen ....... 1
butalbital/aspirin/caffeine....... 1
cabergoline ........................... 18
CABOMETYX ....................... 7
caffeine citrated .................... 29
calcipotriene ......................... 32
calcitonin,salmon,synthetic... 49
calcitriol................................ 49
calcium acetate ..................... 44
calcium carb/vit d3/minerals 53
calcium carbonate........... 43, 53
calcium carbonate/vitamin d353
calcium citrate/vitamin d3 .... 53
calcium polycarbophil .......... 43
candesartan cilexetil ............. 25
candesartan/hydrochlorothiazid
........................................... 25
capecitabine ............................ 7
CAPRELSA ............................ 7
captopril................................ 25
captopril/hydrochlorothiazide
........................................... 26
carbamazepine ...................... 12
carbidopa/levodopa .............. 18
carbidopa/levodopa/entacapone
........................................... 18
carboplatin.............................. 7
CAREONE............................ 35
CARESENS .......................... 35
CARIMUNE NF
NANOFILTERED ............ 47
carisoprodol.......................... 55
carteolol hcl .......................... 40
carvedilol .............................. 26
CAYA CONTOURED.......... 30
cefaclor ................................... 5
cefadroxil ................................ 5
cefdinir .................................... 5
cefpodoxime proxetil............... 5
cefuroxime axetil..................... 6
celecoxib ................................. 2
cephalexin ............................... 6
CEREZYME ......................... 39
cetirizine hcl.......................... 16
chlordiazepoxide hcl ............... 4
chlorhexidine gluconate........ 31
chloroquine phosphate.......... 18
chlorothiazide ....................... 27
chlorpheniramine maleate .... 16
chlorpromazine hcl ............... 18
chlorthalidone ....................... 27
chlorzoxazone ....................... 55
CHOLBAM........................... 43
cholecalciferol (vitamin d3).. 56
cholestyramine (with sugar) . 27
cholestyramine/aspartame .... 27
choline sal/mag salicylate....... 2
cilostazol ............................... 25
cimetidine.............................. 42
cimetidine hcl ........................ 42
CIMZIA .......................... 46, 47
CINQAIR.............................. 54
I-2
CINRYZE ............................. 24
ciprofloxacin ........................... 6
ciprofloxacin hcl ............... 6, 41
citalopram hydrobromide ..... 13
clarithromycin......................... 6
clemastine fumarate .............. 16
CLEVER CHEK LANCETS 35
clindamycin hcl ....................... 5
clindamycin palmitate hcl ....... 5
clindamycin phos/benzoyl perox
........................................... 33
clindamycin phosphate.... 16, 33
clobetasol propionate............ 33
CLOLAR................................. 9
clomipramine hcl .................. 13
clonazepam ............................. 4
clonidine hcl.......................... 25
clopidogrel bisulfate ............. 25
clotrimazole........................... 15
clotrimazole/betamethasone dip
........................................... 15
clozapine ............................... 18
COAGUCHEK ..................... 35
cod liver oil/zinc oxide .......... 32
codeine sulfate ........................ 1
CODEINE SULFATE ............ 1
colchicine/probenecid ........... 49
colestipol hcl ......................... 27
COLOR LANCETS .............. 35
COMBIVENT....................... 54
COMBIVENT RESPIMAT .. 54
COMETRIQ............................ 7
COMFORT EZ ..................... 35
COMFORT LANCETS ........ 35
COMFORT PACCYCLOBENZAPRINE .... 55
COMFORT PAC-IBUPROFEN
............................................. 2
COMFORT PACMELOXICAM.................... 3
COMFORT PAC-NAPROXEN
............................................. 3
COMFORT PACTIZANIDINE.................... 55
COMPLERA......................... 21
CONCEPTROL .................... 30
CONDOMS........................... 30
COPAXONE......................... 50
cortisone acetate ................... 44
COTELLIC ............................. 7
CREON ................................. 39
CRESEMBA ......................... 15
CRIXIVAN ........................... 21
cromolyn sodium....... 40, 42, 54
cyanocobalamin (vitamin b-12)
........................................... 56
cyanocobalamin/fa/pyridoxine
........................................... 56
cyclobenzaprine hcl .............. 55
cyclopentolate hcl ................. 40
cyclophosphamide................... 7
CYCLOPHOSPHAMIDE....... 7
cyclosporine .......................... 46
cyclosporine, modified .......... 46
cyproheptadine hcl................ 16
CYRAMZA............................. 9
CYSTAGON......................... 39
CYTOGAM .......................... 47
DACOGEN ............................. 9
DALIRESP ........................... 54
DALVANCE........................... 5
danazol.................................. 44
dantrolene sodium................. 55
dapsone ................................. 17
DARZALEX ........................... 9
DELZICOL ........................... 48
DESCOVY............................ 21
desipramine hcl..................... 13
desmopressin acetate ............ 45
desog-e.estradiol/e.estradiol. 29
desogestrel-ethinyl estradiol. 29
desonide ................................ 33
desoximetasone ..................... 33
dexamethasone...................... 44
DEXAMETHASONE
INTENSOL ....................... 44
..................................... 41, 44
dexmethylphenidate hcl......... 29
dextroamphetamine sulfate ... 29
dextroamphetamine/
amphetamine ..................... 29
dextromethorphan hbr .......... 31
dextrose ................................. 25
diazepam ................................. 4
diclofenac potassium............... 3
diclofenac sodium ............. 3, 41
dicloxacillin sodium ................ 6
dicyclomine hcl ..................... 42
didanosine ............................. 20
diethyltoluamide.................... 32
diflorasone diacetate............. 33
diflunisal ................................. 3
digoxin................................... 27
DIGOXIN ............................. 27
DILANTIN ........................... 12
diltiazem hcl .......................... 27
diphenhydramine hcl............. 16
diphenoxylate hcl/atropine.... 42
DISKETS ................................ 1
disopyramide phosphate ....... 26
disulfiram ................................ 4
DIURIL ................................. 27
divalproex sodium................. 12
dm/p-ephed/acetaminoph/
doxylam ............................. 31
docusate sodium.................... 43
donepezil hcl ......................... 12
dorzolamide hcl..................... 52
dorzolamide hcl/timolol maleat
........................................... 52
doxazosin mesylate................ 25
doxepin hcl ............................ 13
doxycycline hyclate ................. 6
doxycycline monohydrate........ 6
DR. SMITH'S RASH-SKIN . 32
DROPLET LANCETS.......... 35
I-3
DULERA .............................. 53
duloxetine hcl ........................ 13
DUREX AVANTI BARE..... 30
DYSPORT ............................ 51
EASY COMFORT................ 35
EASY TOUCH ..................... 35
EASY TOUCH LANCETS .. 35
EASY TWIST AND CAP
LANCETS......................... 35
econazole nitrate................... 15
EDURANT ........................... 21
EFFIENT............................... 25
ELAPRASE .......................... 39
ELELYSO............................. 40
ELIDEL................................. 34
ELIQUIS ............................... 24
ELITEK................................. 39
ELOCTATE.......................... 24
ELOXATIN .......................... 10
EMBRACE ........................... 35
EMCYT................................... 7
EMEND ................................ 17
EMPLICITI........................... 10
EMTRIVA ............................ 21
enalapril maleate .................. 26
enalapril/hydrochlorothiazide
........................................... 26
ENBREL ............................... 46
enoxaparin sodium................ 23
entecavir................................ 23
ENTRESTO .......................... 25
ENTYVIO............................. 51
epinastine hcl ........................ 40
epinephrine ........................... 27
EPIPEN 2-PAK..................... 27
EPIPEN JR 2-PAK ............... 27
EPIVIR.................................. 21
eplerenone............................. 28
EPOGEN............................... 24
eprosartan mesylate .............. 25
EPZICOM ............................. 21
ERAXIS WATER DILUENT16
ergocalciferol (vitamin d2) ... 56
ERIVEDGE............................. 7
ERWINAZE.......................... 10
ery e-succ/sulfisoxazole .......... 6
ERYPED 200 .......................... 6
ERYPED 400 .......................... 6
erythromycin base............. 6, 41
erythromycin base/ethanol.... 33
erythromycin ethylsuccinate ... 6
erythromycin stearate ............. 6
erythromycin/benzoyl peroxide
........................................... 33
escitalopram oxalate............. 13
estradiol ................................ 44
estradiol/norethindrone acet. 44
estropipate............................. 44
eszopiclone............................ 55
ethambutol hcl....................... 17
ethinyl estradiol/drospirenone
........................................... 29
ethosuximide ......................... 12
ethynodiol d-ethinyl estradiol 29
etodolac................................... 3
etoposide ................................. 7
EUFLEXXA ......................... 51
EVOTAZ............................... 21
exemestane .............................. 7
E-Z JECT LANCETS ........... 35
EZ SMART LANCETS........ 35
E-ZJECT LANCETS ............ 35
fa/mv,ca,iron,min/lycopene/lut
........................................... 56
FABRAZYME...................... 39
famciclovir ............................ 23
famotidine ............................. 42
FANTASY ............................ 30
FARYDAK ............................. 7
FC CONDOM, FEMALE..... 30
FC2 FEMALE CONDOM.... 30
FEIBA NF............................. 24
felbamate............................... 12
felodipine............................... 27
fenofibrate ............................. 27
fenofibrate nanocrystallized.. 27
fenofibrate,micronized .......... 28
fenofibric acid ....................... 28
fenofibric acid (choline)........ 28
fenoprofen calcium.................. 3
fentanyl.................................... 1
fentanyl citrate ........................ 1
ferrous fumarate.................... 56
ferrous gluconate .................. 56
ferrous sulfate ....................... 57
ferrous sulfate, dried............. 57
fexofenadine hcl .................... 16
FIFTY50 SAFETY SEAL
LANCETS......................... 35
finasteride ............................. 49
FINE 30 UNIVERSAL
LANCETS......................... 35
FINGERSTIX ....................... 35
flavoxate hcl .......................... 44
FLEBOGAMMA DIF........... 47
flecainide acetate .................. 26
FLOLAN............................... 55
FLOVENT DISKUS............. 53
FLOVENT HFA ................... 53
fluconazole ............................ 15
fludrocortisone acetate ......... 44
flunisolide.............................. 41
fluocinolone acetonide .......... 33
fluocinolone acetonide oil..... 41
fluocinonide........................... 33
fluorometholone .................... 41
fluorouracil ........................... 32
fluoxetine hcl......................... 13
FLUOXETINE HCL............. 13
fluoxymesterone .................... 44
fluphenazine decanoate......... 19
fluphenazine hcl .................... 19
flurazepam hcl..................... 4, 5
flurbiprofen ............................. 3
flutamide ................................. 7
fluticasone propionate .... 33, 41
fluvoxamine maleate ............. 13
FML S.O.P. ........................... 42
folic acid.......................... 56, 57
I-4
folic acid/multivit-min/lutein. 57
folic acid/mv,fe,min............... 57
fondaparinux sodium ............ 23
FORA LANCETS................. 35
FORACARE LANCETS ...... 35
FORTEO ............................... 49
fosinopril sodium .................. 26
fosinopril/hydrochlorothiazide
........................................... 26
FOSRENOL.......................... 44
FREESTYLE LANCETS ..... 35
FREESTYLE UNISTIK 2 .... 35
furosemide............................. 27
FUZEON............................... 21
gabapentin............................. 12
GABITRIL............................ 12
GAMMAGARD LIQUID..... 47
GAMMAKED....................... 47
GAMMAPLEX..................... 47
GAMUNEX-C ...................... 47
GAZYVA.............................. 11
GEL-ONE ............................. 50
gemfibrozil ............................ 28
gentamicin sulfate ........... 33, 41
GENVOYA........................... 21
GILENYA............................. 50
GILOTRIF .............................. 7
GLASSIA.............................. 54
GLEEVEC .............................. 7
GLEOSTINE........................... 7
glimepiride ............................ 15
glipizide................................. 15
glipizide/metformin hcl ......... 15
GLUCAGEN......................... 50
GLUCAGON EMERGENCY
KIT.................................... 50
GLUCOCOM........................ 35
GLUCOCOM LANCETS..... 35
GLUCOSOURCE ................. 35
glyburide ............................... 15
glyburide,micronized ............ 15
glyburide/metformin hcl........ 15
glycopyrrolate ....................... 42
GMATE ................................ 36
GRANIX ............................... 24
GRIFULVIN V ..................... 15
griseofulvin ultramicrosize ... 15
griseofulvin, microsize .......... 15
guaifenesin ............................ 31
guaifenesin/codeine phosphate
........................................... 31
guaifenesin/dm/
pseudoephedrine ............... 31
guanfacine hcl................. 25, 29
GYNOL II............................. 30
HALAVEN ........................... 10
haloperidol............................ 19
haloperidol decanoate .......... 19
haloperidol lactate ................ 19
HARVONI ............................ 23
HEALTHY ACCENTS
UNILET LANCET ........... 36
HELIXATE FS ..................... 24
HEMOFIL M ........................ 24
heparin sodium,porcine ........ 23
heparin sodium,porcine/pf .... 23
HEXALEN.............................. 7
HIZENTRA........................... 48
homatropine hbr.................... 40
HUMATE-P.......................... 24
HUMIRA .............................. 46
HUMIRA PEDIATRIC
CROHN'S.......................... 46
HUMIRA PEN...................... 46
HUMIRA PEN CROHN-UCHS STARTER................... 46
HUMIRA PEN PSORIASISUVEITIS ........................... 46
HYALGAN........................... 50
HYCAMTIN ..................... 8, 11
hydralazine hcl...................... 27
hydrochlorothiazide .............. 27
hydrocodone bit/homatrop mebr ....................................... 31
hydrocodone/acetaminophen .. 1
hydrocodone/chlorphen p-stirex
........................................... 31
hydrocodone/ibuprofen ........... 1
hydrocort/pramoxn/skn
clnsr#16............................. 33
hydrocortisone ................ 34, 45
hydrocortisone butyrate ........ 33
hydrocortisone valerate ........ 34
hydrocortisone/lidocaine/aloe
........................................... 34
hydromorphone hcl ................. 1
hydroxychloroquine sulfate... 18
hydroxyprogesterone caproate
........................................... 45
HYDROXYPROGESTERONE
CAPROATE ..................... 45
hydroxyurea ............................ 7
hydroxyzine hcl ..................... 49
hydroxyzine pamoate ............ 49
HYQVIA............................... 47
HYQVIA IG COMPONENT 47
ibandronate sodium .............. 49
IBRANCE ............................... 8
ibuprofen ................................. 3
ibuprofen/oxycodone hcl......... 1
ICLUSIG................................. 8
ILARIS.................................. 48
ILUVIEN .............................. 40
imatinib mesylate .................... 7
IMBRUVICA.......................... 8
imipramine hcl ...................... 13
imipramine pamoate ............. 13
imiquimod ............................. 32
IMLYGIC ............................. 10
IMPLANON ......................... 31
INCONTROL SUPER THIN
LANCETS......................... 36
INCONTROL ULTRA THIN
LANCETS......................... 36
indapamide............................ 27
indomethacin........................... 3
INJECT EASE LANCETS ... 36
INLYTA.................................. 8
I-5
INTELENCE......................... 21
INTRON A............................ 23
INVACARE LANCETS....... 36
INVEGA SUSTENNA ......... 20
INVEGA TRINZA................ 20
INVIRASE............................ 21
INVOKAMET ...................... 14
INVOKANA ......................... 14
ipratropium bromide....... 40, 53
ipratropium/albuterol sulfate 53
irbesartan.............................. 25
irbesartan/hydrochlorothiazide
........................................... 25
iron aspgly,ps/c/succinic acid57
iron polysaccharide complex 57
ISENTRESS.......................... 21
isoniazid ................................ 17
isosorbide dinitrate ............... 28
isosorbide mononitrate ......... 28
isotretinoin ............................ 32
isradipine .............................. 27
ISTODAX ............................. 10
itraconazole........................... 15
IXEMPRA............................. 10
JAKAFI................................... 8
JANUMET............................ 14
JANUMET XR ..................... 14
JANUVIA ............................. 14
JARDIANCE ........................ 14
JEVTANA............................. 10
KADCYLA ........................... 11
KALBITOR .......................... 50
KALETRA............................ 21
KALYDECO......................... 54
KANUMA............................. 39
ketoconazole.......................... 15
ketoprofen ............................... 3
ketorolac tromethamine .... 3, 42
KETOSTIX REAGENT ....... 55
KEYTRUDA......................... 10
KIMONO .............................. 30
KIMONO MAXX................. 30
KIMONO MICROTHIN ...... 30
KIMONO MICROTHIN
AQUA LUBE.................... 30
KIMONO TEXTURED ........ 30
KINERET ............................. 46
KINNEY BRAND LANCETS
........................................... 36
KLOR-CON.......................... 52
KLOR-CON 10..................... 52
KLOR-CON 8....................... 52
KOATE-DVI......................... 24
KOGENATE FS ................... 24
K-PHOS ORIGINAL............ 53
KUVAN ................................ 39
KYNAMRO.......................... 28
KYPROLIS ........................... 10
labetalol hcl .......................... 26
lactic acid.............................. 32
lactulose ................................ 42
lamivudine....................... 20, 21
lamivudine/zidovudine .......... 21
lamotrigine............................ 12
LANCETS............................. 36
LANCETS THIN .................. 36
LANCETS ULTRA THIN.... 36
LANCING DEVICE............. 36
lansoprazole.......................... 42
LANTUS............................... 14
LANTUS SOLOSTAR ......... 14
latanoprost ............................ 52
leflunomide............................ 46
LEMTRADA ........................ 51
LENVIMA .............................. 8
LETAIRIS............................. 55
letrozole................................... 7
leucovorin calcium................ 49
LEUKERAN ........................... 8
LEUKINE ............................. 24
LEVEMIR............................. 14
LEVEMIR FLEXTOUCH .... 14
levetiracetam......................... 12
levobunolol hcl...................... 52
levocarnitine ......................... 49
levocarnitine (with sugar)..... 49
levocetirizine dihydrochloride
........................................... 16
levofloxacin ....................... 6, 41
levonorgestrel ................. 29, 30
levonorgestrel-ethin estradiol29
levorphanol tartrate ................ 2
levothyroxine sodium ............ 45
LEXIVA................................ 21
lidocaine.................................. 3
lidocaine hcl............................ 3
lidocaine/hydrocortisone ac... 4,
34
lidocaine/prilocaine ................ 4
lindane................................... 34
linezolid................................... 5
liothyronine sodium .............. 45
lipase/protease/amylase........ 39
lisinopril................................ 26
lisinopril/hydrochlorothiazide
........................................... 26
LITE TOUCH ....................... 36
lithium carbonate .................. 29
lithium citrate........................ 29
l-norgest/e.estradiol-e.estrad 30
lomustine ................................. 7
LONSURF .............................. 8
loperamide hcl ................ 42, 43
loratadine.............................. 16
loratadine/pseudoephedrine . 16
lorazepam................................ 5
losartan potassium ................ 25
losartan/hydrochlorothiazide 25
lovastatin............................... 28
loxapine succinate................. 19
LUCENTIS ........................... 41
LUER-LOK SYRINGENEEDLE ........................... 36
LUMIZYME ......................... 40
LUPANETA PACK.............. 51
LUPRON DEPOT................. 11
LUPRON DEPOT-PED........ 45
LYNPARZA ........................... 8
LYRICA................................ 12
I-6
LYSODREN ........................... 8
mag carb/al hydrox/alginic ac
........................................... 43
mag hydrox/al hydrox/simeth 43
magnesium carbonate/al hydrox
........................................... 43
magnesium citrate................. 43
magnesium hydroxide ........... 43
magnesium oxide................... 43
MAJOR COMFORT............. 36
MAKENA ............................. 45
malathion .............................. 34
MARQIBO............................ 10
MATULANE .......................... 8
meclizine hcl.......................... 17
meclofenamate sodium............ 3
mecobal/levomefolat ca/b6 phos
........................................... 56
MEDI-LANCE...................... 36
MEDISENSE THIN LANCETS
........................................... 36
MEDLANCE PLUS.............. 36
medroxyprogesterone acetate45
mefenamic acid ....................... 3
mefloquine hcl....................... 18
megestrol acetate .............. 7, 45
MEKINIST ............................. 8
melatonin............................... 50
MELATONIN....................... 50
meloxicam ............................... 3
memantine hcl ....................... 13
meperidine hcl......................... 2
MEPHYTON ........................ 56
MEPRON.............................. 18
mercaptopurine ....................... 7
mesalamine ........................... 48
metformin hcl ........................ 14
methadone hcl ......................... 2
methazolamide ...................... 52
methenamine hippurate........... 5
methenamine mandelate.......... 5
methimazole .......................... 45
methocarbamol ..................... 55
methotrexate sodium ............... 7
methyl salicylate...................... 3
methylcellulose...................... 43
methylcellulose (with sugar) . 43
methyldopa............................ 25
methyldopa/
hydrochlorothiazide .......... 25
methylergonovine maleate .... 49
methylphenidate hcl .............. 29
methylprednisolone ............... 45
metoclopramide hcl............... 42
metolazone ............................ 27
metoprolol succinate............. 26
metoprolol tartrate................ 26
metoprolol/hydrochlorothiazide
........................................... 26
metronidazole.............. 5, 16, 33
METRONIDAZOLE .............. 5
mexiletine hcl ........................ 26
mg trisilicate/alh/nahco3/aa . 43
miconazole nitrate................. 15
MICONAZOLE NITRATE .. 15
MICRO THIN LANCETS.... 36
MICROLET .......................... 36
MICROTAINER LANCETS 36
midodrine hcl ........................ 25
MILK OF MAGNESIA ........ 43
minocycline hcl ....................... 6
minoxidil ............................... 28
mirtazapine ........................... 13
misoprostol............................ 42
modafinil ............................... 55
mometasone furoate .............. 34
MONOCLATE-P.................. 24
MONOJECT INSULIN
SYRINGE ......................... 36
MONOLET LANCETS ........ 36
MONOLET THIN LANCETS
........................................... 36
MONOVISC ......................... 50
montelukast sodium............... 53
morphine sulfate...................... 2
MORPHINE SULFATE ......... 2
multivit with iron-minerals ... 57
multivitamin with iron........... 57
multivitamin with minerals/lut
........................................... 57
multivitamin/iron/folic acid .. 57
multivit-min/fa/lycopen/lutein57
multivits,ca,minerals/iron/fa . 57
mupirocin .............................. 33
mupirocin calcium ................ 33
mv,ca,iron,min/fa/phytosterol57
mv,fe,min/lutein..................... 57
mv,min #10/fa/d3/alip acid/lut
........................................... 56
mycophenolate mofetil .......... 46
MYGLUCOHEALTH
LANCETS......................... 36
MYLERAN............................. 8
MYOBLOC........................... 50
MYOZYME.......................... 39
nabumetone ............................. 3
nadolol .................................. 26
NAGLAZYME ..................... 39
naloxone hcl ............................ 4
naltrexone hcl.......................... 4
NAMENDA .......................... 13
naphazoline hcl ..................... 40
naproxen ................................. 3
naproxen sodium..................... 3
naratriptan hcl ...................... 16
NARCAN................................ 4
nateglinide............................. 14
nefazodone hcl ...................... 13
neo/polymyx b sulf/dexameth 41
neomycin su/baci zn/poly/hc . 41
neomycin su/bacitra/polymyxin
........................................... 41
neomycin sulfate...................... 5
neomycin/polymyxin b sulf/hc41
neomycin/polymyxn b/
gramicidin ......................... 41
neomycn/baci zn/pmyx bs/
pramox .............................. 33
NEPHROCAPS..................... 56
I-7
NEULASTA ......................... 24
NEUMEGA........................... 24
NEUPOGEN ......................... 24
nevirapine ............................. 21
NEXAVAR ............................. 8
NEXIUM............................... 42
niacin..................................... 28
niacin (inositol niacinate) ..... 28
NIACIN FLUSH FREE ........ 28
niacinamide..................... 28, 57
nicotine.................................... 4
nicotine polacrilex .................. 4
nifedipine............................... 27
NILANDRON......................... 8
nilutamide ............................... 7
nimodipine............................. 27
NINLARO............................... 8
nisoldipine............................. 27
nitrofurantoin.......................... 5
nitrofurantoin macrocrystal.... 5
nitrofurantoin monohyd/m-cryst
............................................. 5
nitroglycerin.......................... 28
NITROSTAT ........................ 28
nizatidine............................... 42
nonoxynol 9........................... 30
NORDITROPIN FLEXPRO. 45
norelgestromin/ethin.estradiol
........................................... 30
noreth-ethinyl estradiol/iron. 30
norethindrone........................ 30
norethindrone acetate ........... 45
norethindrone ac-eth estradiol
........................................... 30
norethindrone-e.estradiol-iron
........................................... 30
norethindrone-ethinyl estrad 30
norethindrone-mestranol ...... 30
norgestimate-ethinyl estradiol
........................................... 30
norgestrel-ethinyl estradiol... 30
nortriptyline hcl .................... 13
NORVIR ......................... 21, 22
NOVA SAFETY LANCETS 36
NOVA SUREFLEX.............. 36
NOVOEIGHT ....................... 24
NOVOLIN 70-30 .................. 14
NOVOLIN N ........................ 14
NOVOLIN R......................... 14
NOVOLOG........................... 14
NOVOLOG FLEXPEN ........ 14
NOVOLOG MIX 70-30........ 14
NOVOLOG MIX 70-30
FLEXPEN ......................... 14
NPLATE ............................... 50
NUCALA.............................. 54
NULOJIX.............................. 48
NUPLAZID........................... 20
NUTROPIN .......................... 45
NUTROPIN AQ.................... 45
NUTROPIN AQ NUSPIN .... 45
NUVARING ......................... 30
nystatin.................................. 15
NYSTATIN........................... 15
nystatin/triamcin ................... 15
OBIZUR................................ 24
OCTAGAM .......................... 47
ODEFSEY............................. 22
ODOMZO ............................... 8
ofloxacin............................ 6, 41
olanzapine ............................. 19
olopatadine hcl...................... 40
omega-3 fatty acids/fish oil... 28
omeprazole............................ 42
ON CALL LANCET............. 36
ON CALL PLUS LANCET.. 36
ondansetron........................... 17
ondansetron hcl..................... 17
ONE TOUCH DELICA........ 36
ONETOUCH DELICA......... 36
ONETOUCH FINEPOINT
LANCETS......................... 36
ONETOUCH LANCETS...... 36
ONETOUCH SURESOFT.... 36
ONETOUCH ULTRA
CONTROL SOLN ............ 36
ONETOUCH ULTRA SMART
........................................... 36
ONETOUCH ULTRA
SYSTEM........................... 36
ONETOUCH ULTRA TEST
STRIPS ............................. 36
ONETOUCH ULTRA2 ........ 36
ONETOUCH ULTRALINK. 36
ONETOUCH ULTRAMINI . 36
ONETOUCH VERIO ........... 37
ONETOUCH VERIO FLEX 37
ONETOUCH VERIO IQ ...... 37
ONETOUCH VERIO SYNC 37
ONIVYDE ............................ 10
ON-THE-GO......................... 37
OPDIVO ............................... 10
OPTICHAMBER.................. 37
OPTICHAMBER DIAMOND
........................................... 37
ORA PLUS ........................... 50
ORA SWEET........................ 50
ORA-BLEND ....................... 50
ORA-BLEND SF .................. 50
ORAP.................................... 20
ORA-SWEET-SF.................. 50
ORENCIA....................... 47, 48
ORENCIA CLICKJECT....... 50
ORKAMBI............................ 54
ORTHO ALL-FLEX............. 30
ORTHOVISC........................ 50
oxaliplatin ............................. 11
oxandrolone .......................... 44
oxaprozin................................. 3
oxazepam................................. 5
oxcarbazepine ....................... 12
oxybutynin chloride............... 44
oxycodone hcl.......................... 2
oxycodone hcl/acetaminophen 2
oxycodone hcl/aspirin ............. 2
oxymetazoline hcl.................. 40
oxymorphone hcl..................... 2
pantoprazole sodium............. 42
paromomycin sulfate............. 18
I-8
paroxetine hcl.................. 13, 14
pedi m.vit no.17 with fluoride 56
pedi multivit #22/vit d3/vit k . 56
pedi multivit #65/vit d3/vit k . 56
peg 3350/na sulf,bicarb,cl/kcl43
PEGASYS............................. 23
PEGASYS PROCLICK ........ 23
PEGINTRON........................ 23
PEGINTRON REDIPEN ...... 23
pen needle, diabetic .............. 37
penicillin v potassium ............. 6
PENLET PLUS BLOOD
SAMPLER ........................ 37
pentoxifylline......................... 25
PERJETA.............................. 11
permethrin............................. 34
perphenazine ......................... 19
perphenazine/amitriptyline hcl
........................................... 14
phenazopyridine hcl .............. 44
phenobarbital........................ 12
phenol/sodium phenolate ...... 40
phenylephrine hcl.................. 40
phenylephrine hcl/
acetaminophn.................... 31
phenytoin............................... 12
phenytoin sodium extended ... 12
phosphorus #1....................... 53
pilocarpine hcl ................ 31, 52
PILOPINE HS....................... 52
pimozide ................................ 19
pindolol ................................. 26
pioglitazone hcl..................... 14
piperonyl butoxide/pyrethrins34
piroxicam ................................ 3
pnv with ca,no.72/iron/fa ...... 56
pnv#71/iron/folic acid/dha.... 56
pnv#79/iron/fa/lmfolate ca/dha
........................................... 56
pnv95/ferrous fumarate/fa .... 57
podofilox ............................... 32
polyethylene glycol 3350....... 43
polyethylene glycol/polyvinyl 40
polymyxin b sulf/trimethoprim
........................................... 41
polyvinyl alcohol................... 40
POLY-VI-SOL WITH IRON 57
POMALYST ........................... 8
PORTRAZZA ....................... 10
potassium chloride ................ 53
potassium citrate................... 53
potassium iodide ................... 46
potassium iodide/iodine ........ 46
PRADAXA ........................... 24
PRALUENT PEN ................. 28
PRALUENT SYRINGE ....... 28
pramipexole di-hcl ................ 18
pramoxine hcl........................ 32
pravastatin sodium................ 28
PRAXBIND .......................... 25
prazosin hcl........................... 25
prednisolone acetate ............. 42
prednisolone sod phosphate. 42,
45
prednisone............................. 45
PREMARIN.......................... 44
PREMPHASE ....................... 44
PREMPRO............................ 44
PRENATAL 19..................... 57
prenatal vit/iron fumarate/fa. 57
PRESSURE ACTIVATED
LANCETS......................... 37
PREVACID........................... 42
PREZCOBIX ........................ 22
PREZISTA............................ 22
PRIALT................................... 2
primidone .............................. 12
PRIVIGEN............................ 47
PRO COMFORT LANCETS 37
probenecid............................. 49
prochlorperazine................... 17
prochlorperazine maleate ..... 17
PROCRIT.............................. 24
PROCTOFOAM-HC ............ 34
PRODIGY LANCETS.......... 37
PRODIGY TWIST TOP
LANCET........................... 37
progesterone ......................... 45
progesterone,micronized....... 45
PROLASTIN C..................... 54
PROLIA ................................ 49
promethazine hcl............. 16, 17
promethazine hcl/codeine ..... 31
propafenone hcl .................... 26
propantheline bromide.......... 12
propranolol hcl ..................... 26
propranolol/hydrochlorothiazid
........................................... 26
propylthiouracil .................... 46
PROTONIX .......................... 42
PROTOPIC ........................... 34
PROVENGE ......................... 50
pseudoephedrine hcl ............. 31
psyllium husk......................... 43
PULMOZYME ..................... 39
PUSH BUTTON SAFETY
LANCETS......................... 37
pyrazinamide......................... 17
pyridostigmine bromide ........ 49
pyridoxine hcl........................ 57
quetiapine fumarate .............. 19
quinapril hcl.......................... 26
quinapril/hydrochlorothiazide
........................................... 26
quinidine sulfate.................... 26
rabeprazole sodium............... 42
raloxifene hcl ........................ 44
ramipril ................................. 26
ranitidine hcl......................... 42
RAPAMUNE ........................ 47
REBIF ................................... 50
REBIF REBIDOSE............... 50
RECLAST............................. 49
RECOMBINATE.................. 24
RELADOR PAK..................... 4
RELENZA ............................ 22
RELIAMED.......................... 37
I-9
RELIAMED SAFETY SEAL
LANCETS......................... 37
RELION THIN ..................... 37
REMICADE.......................... 52
REMODULIN....................... 55
RENAGEL............................ 44
RENEW ADVANCED
MICRO-LANCETS .......... 37
RENVELA............................ 44
repaglinide ............................ 14
REPATHA PUSHTRONEX. 28
REPATHA SURECLICK..... 28
REPATHA SYRINGE.......... 28
RESCRIPTOR ...................... 22
REVLIMID ............................. 8
REYATAZ............................ 22
RHOGAM ULTRAFILTERED PLUS............. 48
ribavirin ................................ 23
riboflavin............................... 57
RIDAURA ............................ 47
rifampin................................. 17
RIGHTEST GL300 LANCETS
........................................... 37
rimantadine hcl ..................... 22
RISPERDAL CONSTA........ 20
risperidone ............................ 19
RITUXAN............................. 11
rivastigmine tartrate ............. 13
rizatriptan benzoate .............. 16
ropinirole hcl ........................ 18
rosuvastatin calcium ............. 28
RUCONEST ......................... 24
SAFETY LANCETS ............ 37
SAFETY SEAL LANCETS . 37
SAFETY-LET....................... 37
salicylic acid ......................... 32
salicylic acid/ceramide cmb #1
........................................... 32
salsalate .................................. 3
SANDOSTATIN LAR DEPOT
........................................... 45
SANTYL............................... 32
selegiline hcl ......................... 18
selenium sulfide..................... 33
SELZENTRY........................ 22
sennosides/docusate sodium . 43
SEREVENT DISKUS........... 54
sertraline hcl ......................... 14
SIGNIFOR LAR ................... 50
sildenafil citrate .................... 55
silver sulfadiazine ................. 33
SIMBRINZA......................... 52
simethicone ........................... 42
SIMPONI ARIA ................... 51
simvastatin ............................ 28
SINGLE-LET........................ 37
sirolimus................................ 46
SIVEXTRO............................. 5
SMART SENSE.................... 37
SMART SENSE LANCETS. 37
SMARTDIABETES
VANTAGE ....................... 37
SMARTEST LANCET......... 37
sodium bicarbonate............... 42
sodium chloride............... 40, 53
sodium chloride for inhalation
........................................... 54
sodium chloride/nahco3/kcl/peg
........................................... 43
sodium fluoride ..................... 31
sodium polystyrene sulfon/sorb
........................................... 42
sodium polystyrene sulfonate 43
SOFT TOUCH ...................... 37
SOLESTA ............................. 39
SOLIRIS ............................... 52
SOLUS V2 ............................ 37
SOLUS V2 LANCETS ......... 37
sotalol hcl.............................. 26
SOVALDI ............................. 23
SPIRIVA ............................... 54
SPIRIVA RESPIMAT .......... 54
spironolact/hydrochlorothiazid
........................................... 28
spironolactone....................... 28
SPRYCEL ............................... 8
stannous fluoride................... 31
stavudine ............................... 21
STELARA............................. 50
STERILANCE TL ................ 37
STIVARGA ............................ 8
STRATTERA ....................... 29
STRENSIQ ........................... 39
STRIBILD............................. 22
SUBOXONE........................... 4
sub-q insulin device, 40 unit . 37
sucralfate............................... 42
sulfacetamide sodium 32, 33, 41
sulfacetamide sodium/sulfur . 32
sulfacetamide/prednisolone sp
........................................... 41
sulfamethoxazole/trimethoprim6
sulfasalazine............................ 6
sulindac ................................... 3
sumatriptan ........................... 17
sumatriptan succinate ........... 16
SUPARTZ............................. 51
SUPARTZ FX....................... 51
SUPER THIN LANCETS..... 37
SUPPRELIN LA................... 45
SURE COMFORT LANCETS
........................................... 37
SURE-LANCE...................... 37
SURESTEP PRO .................. 38
SURE-TOUCH ..................... 38
SUSTIVA.............................. 22
SUTENT ................................. 8
SYLATRON ......................... 23
SYLVANT............................ 10
SYNAGIS ............................. 22
SYNAREL ............................ 50
SYNJARDY.......................... 14
SYNRIBO ............................. 10
SYNTHROID ....................... 46
SYNVISC ............................. 52
SYNVISC-ONE.................... 52
syringe and needle,insulin,1ml
........................................... 38
I-10
syringe-needle,insulin,0.5 ml 38
syring-needl,disp,insul,0.3 ml 38
tacrolimus ....................... 34, 46
TAFINLAR............................. 8
TAGRISSO ............................. 8
TAMIFLU............................. 22
tamoxifen citrate ..................... 7
tamsulosin hcl ....................... 44
TANZEUM ........................... 14
TARCEVA.............................. 8
TARGRETIN.......................... 9
TASIGNA ............................... 9
TECENTRIQ ........................ 10
TECFIDERA......................... 50
TECHLITE LANCETS ........ 38
TELCARE............................. 38
temazepam............................... 5
TEMODAR......................... 7, 9
temozolomide .......................... 7
terazosin hcl .......................... 44
terbinafine hcl ....................... 15
terbutaline sulfate ................. 53
terconazole............................ 16
testosterone cypionate........... 44
testosterone enanthate .......... 44
tetracycline hcl........................ 6
TETRACYCLINE HCL ......... 6
theophylline anhydrous......... 53
thiamine hcl........................... 57
THIN LANCETS .................. 38
thioridazine hcl ..................... 19
thiothixene............................. 19
THYROGEN......................... 46
tiagabine hcl.......................... 12
ticlopidine hcl........................ 25
timolol maleate................ 26, 52
tinidazole............................... 18
TIVICAY .............................. 22
tizanidine hcl......................... 55
TOBI ....................................... 5
tobramycin ............................ 41
tobramycin in 0.225% nacl ..... 5
tobramycin/dexamethasone... 41
TODAY CONTRACEPTIVE
SPONGE ........................... 30
tolmetin sodium....................... 3
tolnaftate ............................... 15
tolterodine tartrate................ 44
TOPCARE UNIVERSAL1
LANCET........................... 38
TOPCARE UNIVERSAL1
THIN LANCET ................ 38
topiramate ............................. 12
TORISEL .............................. 10
torsemide............................... 27
TOUJEO SOLOSTAR.......... 14
TRACLEER.......................... 55
tramadol hcl ............................ 2
tramadol hcl/acetaminophen .. 2
trandolapril ........................... 26
travoprost (benzalkonium) .... 52
trazodone hcl......................... 14
tretinoin............................. 7, 34
tretinoin microspheres .......... 34
tretinoin/emollient base ........ 34
triamcinolone acetonide. 31, 34,
42
triamterene/hydrochlorothiazid
........................................... 27
triazolam ................................. 5
trifluoperazine hcl................. 20
trifluridine ............................. 41
trihexyphenidyl hcl................ 18
trimethobenzamide hcl .......... 17
trimethoprim ........................... 5
TRIUMEQ ............................ 22
TRIZIVIR ............................. 22
trospium chloride .................. 44
TRUEPLUS LANCETS ....... 38
TRUSTEX............................. 30
TRUSTEX CONDOM.......... 30
TRUSTEX LATEX CONDOM
........................................... 30
TRUSTEX-RIA .................... 30
TRUVADA ........................... 22
TUSSI PRES-B..................... 31
TYKERB................................. 9
TYSABRI ............................. 48
ULTICARE........................... 38
ULTILET BASIC ................. 38
ULTILET CLASSIC............. 38
ULTILET LANCETS ........... 38
ULTILET SAFETY .............. 38
ULTRA THIN LANCETS.... 38
ULTRA THIN PLUS............ 38
ULTRA THIN PLUS
LANCETS......................... 38
ULTRALANCE.................... 38
ULTRA-THIN II................... 38
ULTRA-THIN II LANCETS 38
ULTRATLC LANCETS....... 38
undecylenic acid.................... 15
UNILET COMFORTOUCH 38
UNILET EXCELITE ............ 38
UNILET EXCELITE II ........ 38
UNILET GP LANCET ......... 38
UNILET LANCET ............... 38
UNILET LANCETS ............. 38
UNISTIK 3............................ 38
UNISTIK 3 EXTRA ............. 38
UNISTIK CZT ...................... 38
UNISTIK SAFETY .............. 38
UNISTIK TOUCH................ 38
UNITUXIN ........................... 10
UNIVERSAL 1..................... 39
urea ....................................... 32
ursodiol ................................. 43
valacyclovir hcl..................... 23
valproic acid ......................... 12
valproic acid (as sodium salt)12
valsartan/hydrochlorothiazide
........................................... 25
vancomycin hcl........................ 5
VARUBI ............................... 17
VCF....................................... 30
VECTIBIX............................ 10
VELCADE............................ 10
VELETRI.............................. 55
VELTASSA .......................... 43
I-11
VENCLEXTA......................... 9
VENCLEXTA STARTING
PACK.................................. 9
venlafaxine hcl ...................... 14
VENTOLIN HFA ................. 53
verapamil hcl ........................ 27
VICTOZA 3-PAK................. 14
VIDEX .................................. 22
VIMIZIM .............................. 39
VIRACEPT ........................... 22
VIRAMUNE XR .................. 22
VIREAD ............................... 22
vitamin e................................ 57
VITEKTA ............................. 22
VIVITROL.............................. 4
VIVOTIF............................... 48
VOLTAREN ........................... 3
VORAXAZE......................... 51
voriconazole.......................... 15
VOTRIENT............................. 9
VPRIV................................... 40
warfarin sodium .................... 23
water for injection,sterile...... 49
water for irrigation,sterile .... 48
WIDE SEAL DIAPHRAGM 30
WILATE ............................... 25
WINRHO SDF...................... 48
XALKORI............................... 9
XARELTO............................ 24
XELODA ................................ 9
XEOMIN............................... 51
XGEVA................................. 49
XIAFLEX ............................. 39
XIFAXAN............................... 5
XOFIGO ............................... 52
XOLAIR ............................... 54
XOPENEX HFA................... 54
XYNTHA.............................. 25
XYNTHA SOLOFUSE ........ 25
YERVOY.............................. 12
YONDELIS........................... 11
zaleplon ................................. 55
ZALTRAP............................. 12
ZAVESCA ............................ 39
ZELBORAF............................ 9
ZEMAIRA ............................ 54
ZENPEP................................ 39
ZEPATIER............................ 23
ZETIA ................................... 28
ZEVALIN ............................. 11
ZIAGEN................................ 22
zidovudine ............................. 21
zinc oxide .............................. 32
zinc oxide/petrolatum,white .. 33
ziprasidone hcl ...................... 20
ZOLINZA ............................... 9
zolmitriptan ........................... 17
zolpidem tartrate................... 55
zonisamide............................. 12
ZORTRESS........................... 47
ZYKADIA .............................. 9
ZYPREXA RELPREVV ...... 20
ZYTIGA.................................. 9
ZYVOX................................... 5
I-12

GHP Family Formulary - Geisinger Health Plan

Transcription

Similar documents

Printable Formulary

Health Share of Oregon/Providence (Medicaid)

2016 AlohaCare Advantage Plus Formulary (HMO SNP) (List of

Cardiovascular Agents - Meridian Health Plan

2015 Providence Health Plan Formulary