CIGNA-HEALTHSPRING COMPREHENSIVE FORMULARY (List of

Transcription

2014
CIGNA-HEALTHSPRING
COMPREHENSIVE FORMULARY
(List of Covered Drugs)
Cigna-HealthSpring Formulario completo
(Lista de medicamentos en cobertura)
HPMS Approved Formulary File Submission 14010, Version 9
Envío de archivo de Formulario 14010 aprobado por HPMS, Versión 9
PLANS COVERED
Planes en cobertura:
Cigna-HealthSpring Preferred (HMO)
Cigna-HealthSpring Preferred AR (HMO)
Cigna-HealthSpring Preferred KNX (HMO)
Cigna-HealthSpring Preferred NGA (HMO)
Cigna-HealthSpring Preferred SMS (HMO)
Cigna-HealthSpring Preferred Plus (HMO)
Cigna-HealthSpring Premier NMS (HMO-POS)
Cigna-HealthSpring Premier (HMO-POS)
Cigna-HealthSpring Premier KNX (HMO-POS)
Cigna-HealthSpring Premier NGA (HMO-POS)
Cigna-HealthSpring Preferred (PPO)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN.
Favor de leer: Este documento incluye información sobre los medicamentos que se cubren con este plan.
This formulary was updated on August 2013. For more recent information or other questions, please contact Cigna-HealthSpring
Customer Service at 1-800-668-3813 or, for TTY users, 711, 7 days a week, 8 a.m. - 8 p.m., or visit www.mycignahealthspring.com.
Este formulario se actualizó el Agosto de 2013. Para información más actualizada u otras preguntas, favor de contactar al
Departamento de servicio al cliente de Cigna-HealthSpring, al 1-800-668-3813 o, para los usuarios de TTY, 711, 7 días de la
semana, 8 a.m. - 8 p.m., o visite www.mycignahealthspring.com.
This information is available for free in other languages. Please call our customer service number at 1-800-668-3813 (TTY 711),
7 days a week, 8 a.m. - 8 p.m. Esta información está disponible de forma gratuita en otros idiomas. Favor de contactar a nuestro
Departamento de servicio al cliente al 1-800-668-3813 (TTY 711), 7 días de la semana, 8 a.m. - 8 p.m.
Cigna-HealthSpring is contracted with Medicare for HMO, PPO and PDP plans and with select State Medicaid programs.
Enrollment in Cigna-HealthSpring depends on contract renewal.
Cigna-HealthSpring tiene contrato con Medicare para planes HMO, PPO y PDP y con ciertos programas estatales de Medicaid.
La inscripción en Cigna-HealthSpring depende de la renovación de contrato.
Y0036_14_8134BL_FINAL_1 Approved 08052013 © 2013 Cigna
Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still
contains the drugs you take.
When this drug list (formulary) refers to “we,” “us”, or “our,” it means Cigna-HealthSpring. When it refers to “plan” or “our plan,” it
means Cigna-HealthSpring Preferred Plus (HMO), or Cigna-HealthSpring Preferred (HMO), or Cigna-HealthSpring Preferred AR
(HMO), or Cigna-HealthSpring Preferred KNX (HMO), or Cigna-HealthSpring Preferred NGA (HMO), or Cigna-HealthSpring
Preferred SMS (HMO), or Cigna-HealthSpring Premier (HMO-POS), or Cigna-HealthSpring Premier KNX (HMO-POS), or CignaHealthSpring Premier NGA (HMO-POS), Cigna-HealthSpring Premier NMS (HMO-POS), or Cigna-HealthSpring Preferred (PPO).
This document includes a list of the drugs (formulary) for our plan which is current as of August 2013. For an updated formulary,
please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back
cover pages.
You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network,
premium and/or copayments/coinsurance may change on January 1, 2015.
What is the Cigna-HealthSpring Comprehensive Formulary?
A formulary is a list of covered drugs selected by Cigna-HealthSpring in consultation with a team of health care providers, which
represents the prescription therapies believed to be a necessary part of a quality treatment program. Cigna-HealthSpring will
generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a CignaHealthSpring network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please
review your Evidence of Coverage.
Can the Formulary (drug list) change?
Generally, if you are taking a drug on our 2014 formulary that was covered at the beginning of the year, we will not discontinue or
reduce coverage of the drug during the 2014 coverage year except when a new, less expensive generic drug becomes available
or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such
as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the
same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have
continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan,
except for cases in which you can save additional money or we can ensure your safety.
If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a
drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes
effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the
drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the
drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug.
The enclosed formulary is current as of August 2013. To get updated information about the drugs covered by CignaHealthSpring, please contact us. Our contact information appears on the front and back cover pages. If there are significant
changes made to the printed formulary within the covered year, you may be notified by mail identifying the changes. Formularies
located on our website are reviewed and updated on a monthly basis.
How do I use the Formulary?
There are two ways to find your drug within the formulary:
Medical Condition
The formulary begins on page 46. 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,
Y0036_14_8134BL_FINAL_1 Approved 08052013
A1
“CARDIOVASCULAR AGENTS”. If you know what your drug is used for, look for the category name in the list that begins on
page 46. 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 Alphabetic Drug List section that begins
on page 2. The Alphabetical Drug List provides a list of all of the drugs included in this document. Both brand name drugs
and generic drugs are in the Drug List. Look in the Alphabetical Drug List section of the document and find your drug. Next to
your drug, you will see the drug tier, requirements/limits, and page number where you can find coverage information. Turn to
the page listed in the Alphabetical Drug List section and find the name of your drug in the first column of the list.
What are generic drugs?
Cigna-HealthSpring covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the
same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.
Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

Prior Authorization: Cigna-HealthSpring requires you or your physician to get prior authorization for certain drugs. This
means that you will need to get approval from Cigna-HealthSpring before you fill your prescriptions. If you don’t get
approval, Cigna-HealthSpring may not cover the drug.

Quantity Limits: For certain drugs, Cigna-HealthSpring limits the amount of the drug that Cigna-HealthSpring will cover.
For example, Cigna-HealthSpring provides 30 (capsules) per prescription for DEXILANT. This may be in addition to a
standard one-month or three-month supply.

Step Therapy: In some cases, Cigna-HealthSpring requires you to first try certain drugs to treat your medical condition
before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition,
Cigna-HealthSpring may not cover Drug B unless you try Drug A first. If Drug A does not work for you, CignaHealthSpring will then cover Drug B.
You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 46. You can
also get more information about the restrictions applied to specific covered drugs by visiting our Web site. Our contact information,
along with the date we last updated the formulary, appears on the front and back cover pages.
You can ask Cigna-HealthSpring to make an exception to these restrictions or limits or for a list of other, similar drugs that may
treat your health condition. See the section, “How do I request an exception to the Cigna-HealthSpring’s formulary?” on page A3
for information about how to request an exception.
Ordering your medication through a mail order pharmacy for home delivery.
Taking your prescription medication is important to your health. Filling your prescriptions through one of our mail order
pharmacies is an easy and reliable way to get your medication delivered to your home on time, every time – so that you never run
out. Just like the pharmacy you use today, there are licensed pharmacists available to answer your questions and put you at ease.
Each prescription is filled carefully and reviewed against your known allergies, health conditions and any other medications you
may be taking. You can contact your selected mail order pharmacy at any time 24 hours a day/ 7 days a week for one-on-one
conversations from the privacy of your home. If needed, the mail order pharmacy can contact your doctor to talk about other
medication options that may work better for you. Also, there may be additional cost savings by ordering your medication through
one of the mail order pharmacies for home delivery within our network. For more information, please contact our Customer
Service Department at the number located on the front and back cover of this document.
A2
What if my drug is not on the Formulary?
If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service and ask if your drug
is covered. If you learn that Cigna-HealthSpring does not cover your drug, you have two options:

You can ask Customer Service for a list of similar drugs that are covered by Cigna-HealthSpring. When you receive the
list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Cigna-HealthSpring.

You can ask Cigna-HealthSpring to make an exception and cover your drug. See below for information about how to
request an exception.
How do I request an exception to the Cigna-HealthSpring’s Formulary?
You can ask Cigna-HealthSpring to make an exception to our coverage rules. There are several types of exceptions that you can
ask us to make.

You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined
cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.

You can ask us to waive coverage restrictions or limits on your drug. For example, for certain a drug, Cigna-HealthSpring
limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and
cover a greater amount.

You can ask us to provide a tiering exception for a higher cost sharing drug to be covered at a lower cost-sharing tier. If
your drug is contained in our Non-Preferred Brand tier or the Non-Preferred Generic tier, you can ask us to cover it at the
cost-sharing amount that applies to drugs in the respective Preferred Brand or Preferred Generic tier instead. This would
lower the amount you must pay for your drug. If your drug is contained in our Brand tier you can ask to cover it at the
cost-sharing amount that applies to drugs in the respective Generic tier if all generic alternatives in the lower cost tier
used to treat the same condition/disease are determined to be not as effective as the Brand. Please note, if we grant
your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the
drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in the Specialty tier.
Generally, Cigna-HealthSpring will only approve your request for an exception if the alternative drugs included on the plan’s
formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition
and/or would cause you to have adverse medical effects.
You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When
you request a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber
or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s
supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be
seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no
later than 24 hours after we get a supporting statement from your doctor or other prescriber.
What do I do before I can talk to my doctor about changing my drugs or requesting an exception?
As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug
that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can
fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request
a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action
for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.
A3
For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day
supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply,
we will not pay for these drugs, even if you have been a member of the plan less than 90 days.
If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with 93-day
transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover
more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our
formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a
31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.
In order to accommodate unexpected transitions of our members that do not leave time for advanced planning, such as level-ofcare changes due to discharge from a hospital to a nursing facility or to a home, Cigna-HealthSpring will allow a one-time 31-day
supply (unless the prescription is written for fewer days).
For more information
For more detailed information about your Cigna-HealthSpring prescription drug coverage, please review your Evidence of
Coverage and other plan materials.
If you have questions about Cigna-HealthSpring, please contact us. Our contact information, along with the date we last updated
the formulary, appears on the front and back cover pages.
If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-6334227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or, visit www.medicare.gov.
A4
Cigna-HealthSpring’s Formulary
The comprehensive formulary below provides coverage information about all of the drugs covered by Cigna-HealthSpring. If you
have trouble finding your drug in the list, turn to the Alphabetical Drug List that begins on page 2.
The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., DEXILANT) and generic drugs are listed
in lower-case italics (e.g., simvastatin).
The information in the Requirements/Limits column tells you if Cigna-HealthSpring has any special requirements for coverage of
your drug.
Some Cigna-HealthSpring plans offer additional prescription drug coverage in the coverage gap. Please refer to your Evidence of
Coverage to see if your plan has this coverage and for more information.
We provide quantity limits on certain drugs which are indicated with a QL in the Alphabetical Drug list on page 2 along with the
amount dispensed per the days supplied. (For example: Dexilant 30/30; this means the drug Dexilant is limited to 30 capsules per
30 days).
Key:
B/D = This prescription drug has a Part B versus D administrative prior authorization requirement. This drug may be covered
under Medicare Part B or D depending on circumstances. Information may need to be submitted describing use and setting of the
drug to make the determination.
MO = Mail Order, this drug is a maintenance medication
PA = This drug requires prior authorization
QL = This drug has quantity limits
ST = This drug has step therapy requirements
Drug Tier and Cost-Share Table start on page A12.
A5
Formulario completo de
Cigna-HealthSpring
para el 2014
(Lista de medicamentos en cobertura)
Envío de archivo de Formulario 14010 aprobado por HPMS, Versión 9
Planes en cobertura:
Cigna-HealthSpring Preferred AR (HMO)
Cigna-HealthSpring Preferred KNX (HMO)
Cigna-HealthSpring Preferred NGA (HMO)
Cigna-HealthSpring Preferred SMS (HMO)
Cigna-HealthSpring Preferred Plus (HMO)
Cigna-HealthSpring Premier NMS (HMO-POS)
Cigna-HealthSpring Premier (HMO-POS)
Cigna-HealthSpring Premier KNX (HMO-POS)
Cigna-HealthSpring Premier NGA (HMO-POS)
Cigna-HealthSpring Preferred (PPO)
FAVOR DE LEER: ESTE DOCUMENTO INCLUYE INFORMACIÓN
SOBRE LOS MEDICAMENTOS QUE SE CUBREN CON ESTE PLAN
A6
Nota para los miembros: Este formulario de medicamentos ha cambiado desde el año pasado. Favor de revisar el
documento y asegurarse de que los medicamentos que toma aún se encuentren en la lista.
Cuando esta lista de medicamentos (formulario) se refiera a “nosotros”, “nos”, o “nuestro”, esto significa CignaHealthSpring. Cuando se refiera al “plan” o “nuestro plan”, significa Cigna-HealthSpring Preferred Plus (HMO), o CignaHealthSpring Preferred (HMO), o Cigna-HealthSpring Preferred AR (HMO), o Cigna-HealthSpring Preferred KNX (HMO), o
Cigna-HealthSpring Preferred NGA (HMO), o Cigna-HealthSpring Preferred SMS (HMO), o Cigna-HealthSpring Premier
(HMO-POS), o Cigna-HealthSpring Premier KNX (HMO-POS), o Cigna-HealthSpring Premier NGA (HMO-POS), o CignaHealthspring Premier NMS (HMO-POS), o Cigna-HealthSpring Preferred (PPO).
Este documento incluye una lista de los medicamentos (formulario) para nuestro plan, la cual se actualizó el agosto de
2013. Para una versión actualizada del formulario, por favor póngase en contacto con nosotros. Nuestra información de
contacto, junto con la fecha de la última actualización del formulario, aparece en la portada y al reverso.
Por lo general, debe acudir a farmacias de la red para usar su beneficio de medicamentos recetados. Es posible que los
beneficios, el formulario, las farmacias de la red, las primas y/o copagos/coseguros cambien el 1 de enero de 2015.
¿Qué es el Formulario completo de Cigna-HealthSpring?
Un formulario es una lista de medicamentos que selecciona Cigna-HealthSpring, en conjunto con un equipo de proveedores de
servicios de atención médica, y que representa las terapias con medicamentos recetados que se considera son una parte
esencial de un programa de tratamiento de calidad. En general, Cigna-HealthSpring cubre los medicamentos incluidos en el
formulario, siempre que sean médicamente necesarios, la receta se surta en una farmacia de la red de Cigna-HealthSpring y se
respeten las otras reglas del plan. Para más información sobre cómo surtir sus recetas, consulte la Evidencia de cobertura.
¿Puede cambiar el Formulario (lista de medicamentos)?
Por lo general, si está tomando un medicamento que se encontraba en nuestro Formulario del 2014 a principios del año, no
dejaremos, ni reduciremos la cobertura del medicamento durante el año de cobertura del 2014, a menos que ponga a la
venta un medicamento genérico más económico o se presente información adversa sobre la seguridad o efectividad del
medicamento. Otros tipos de cambios que se hagan al formulario, como el retiro de algún medicamento, no afectaran a
miembros que estén tomando dicho medicamento. Éste seguirá estando disponible y al mismo costo compartido para
dichos miembros, por el resto del año de cobertura. Creemos que es muy importante que tenga acceso continuo durante el
año de cobertura a los medicamentos que estaban disponibles cuando seleccionó nuestro plan, a menos que se presente la
opción de que ahorre dinero o podamos garantizar su seguridad.
Si quitamos medicamentos del formulario, agregamos previa autorización, límites de cantidad y/o restricciones de terapia
escalonada a un medicamento o movemos un medicamento a un nivel de costo compartido más alto, debemos notificar a
los miembros que tomen dicho medicamento con al menos 60 días de anticipación a la fecha en que entre en vigencia el
cambio o cuando el miembro renueve el medicamento, momento en que recibirá un suministro de 60 días. Si la Food and
Drug Administration considera que un medicamento de nuestro formulario es poco seguro o el fabricante lo retira del
mercado, retiraremos inmediatamente el medicamento del formulario y daremos aviso a los miembros que lo tomen. El
formulario adjunto se actualizó en agosto de 2013. Para obtener información actualizada sobre los medicamentos que
cubre Cigna-HealthSpring, por favor póngase en contacto con nosotros. Nuestra información aparece en la portada y al
reverso. En caso de que se hagan cambios importantes al formulario impreso dentro del año en cobertura, es posible que
se le avise por correo sobre cuáles son los cambios. El formulario de nuestra página de internet se revisa y actualiza cada
mes.
A7
¿Cómo utilizo el formulario?
Existen dos formas de encontrar un medicamento en el formulario:
Problema médico
El formulario comienza en la página 46. Los medicamentos de este formulario están agrupados en categorías por tipo de
problema médico que tratan. Por ejemplo, los medicamentos para tratar una afección cardíaca se incluyen dentro de la
categoría, “AGENTES CARDIOVASCULARES”. Si sabe para lo que se utiliza el medicamento, busque la categoría en la lista
que comienza en la página 46. Después, busque el medicamento bajo dicha categoría.
Lista por orden alfabético
Si no está seguro de la categoría bajo la cual debe buscar, busque el medicamento en la sección de la Lista por orden
alfabético de medicamentos que comienza en la página 2. La lista por orden alfabético de medicamentos proporciona un
listado de todos los medicamentos que aparecen en el documento. Tanto los medicamentos de marca como los genéricos
están en la Lista de medicamentos. Busque en la sección de la Lista por orden alfabético de medicamentos del documento y
encuentre su medicamento. Junto al medicamento, encontrará el nivel del medicamento, los límites/requisitos y el número de
la página donde puede encontrar información sobre la cobertura. Vaya a la página indicada en la sección de la Lista por
orden alfabético de medicamentos y localice el nombre del medicamento en la primera columna de la lista.
¿Qué son los medicamentos genéricos?
Cigna-HealthSpring cubre tanto los medicamentos de marca como los genéricos. Un medicamento genérico está aprobado
por la FDA por tener el mismo ingrediente activo que el medicamento de marca. En general, los medicamentos genéricos
cuestan menos que los de marca.
¿Existe alguna restricción en la cobertura?
Algunos medicamentos que entran en cobertura pueden tener requisitos o límites adicionales de cobertura. Estos requisitos y
límites pueden incluir:

Autorización previa: Cigna-HealthSpring exige que usted o su médico obtengan una autorización previa para ciertos
medicamentos. Esto significa que necesitará de la aprobación de Cigna-HealthSpring antes de surtir sus recetas
médicas. Si no obtiene la aprobación, es posible que Cigna-HealthSpring no cubra el medicamento.

Límites de cantidad: Para ciertos medicamentos, Cigna-HealthSpring limita la cantidad de medicamento que entran en
cobertura. Por ejemplo, Cigna-HealthSpring proporciona 30 (cápsulas) por receta médica de DEXILANT. Esto puede ser,
además de un suministro normal de un mes ó tres meses.

Terapia escalonada: En algunos casos, Cigna-HealthSpring le pedirá que pruebe primero con determinados
medicamentos para tratar su enfermedad, antes de cubrir otros. Por ejemplo, si un medicamento A y un medicamento B
sirven para tratar su condición médica, es posible que Cigna-HealthSpring no cubra el medicamento B a menos que
usted pruebe el medicamento A, primero. Si el medicamento A no funciona, entonces Cigna-HealthSpring cubrirá el
medicamento B.
Para saber si un medicamento tiene algún requisito o límite adicional, consulte el formulario que comienza en la página 46.
Puede obtener más información sobre las restricciones que se aplican a ciertos medicamentos visitando nuestra página de
Internet. Nuestra información de contacto, junto con la fecha de la última actualización del formulario, aparece en la portada
y al reverso.
A8
Puede solicitarle a Cigna-HealthSpring que haga una excepción a estas restricciones o límites, o pedirle una lista de otros
medicamentos similares que pueden tratar su condición de salud. Consulte la sección “¿Cómo solicito una excepción para el
formulario de Cigna-HealthSpring?" en la página A9 para obtener información sobre cómo solicitar una excepción.
Ordenar su medicamento a través de una farmacia de orden por correo y así recibirlo en su casa.
Tomar su medicamento es importante para su salud. Surtir sus medicamentos a través de una de nuestras farmacias de orden
por correo es una manera fácil y confiable de recibir su medicamento en su casa de manera puntual, y sin falta – por lo tanto
nunca se quedará sin medicamento. Así como en la farmacia a la que acude actualmente, hay farmacéuticos autorizados
disponibles para responder sus preguntas y facilitarle las cosas. Cada receta se surte y revisa cuidadosamente dependiendo sus
alergias conocidas, condiciones de salud y cualquier otro medicamento que pueda estar tomando. Puede ponerse en contacto
con su farmacia de orden por correo seleccionada en cualquier momento las 24 horas del día, los 7 días de la semana para
conversar personalmente desde la privacidad de su casa. En caso de ser necesario, la farmacia de orden por correo puede
ponerse en contacto con su médico para hablar sobre otras opciones de medicamentos que puedan funcionarle mejor. Además,
puede haber ahorros adicionales al ordenar sus medicamentos a través de una de las farmacias de orden por correo dentro de
nuestra red. Para más información, por favor póngase en contacto con nuestro Departamento de servicio al cliente al número
que aparece en la portada y al reverso de este documento.
¿Qué pasa si mi medicamento no se encuentra en el formulario?
En caso de que su medicamento no se incluya en este formulario (lista de medicamentos en cobertura), debe primero contactar
al Departamento de servicio al cliente y preguntar si su medicamento entra en cobertura. En caso de que le confirmen que
Cigna-HealthSpring no cubre su medicamento, tiene dos opciones:

Puede solicitar al Departamento de servicio al cliente una lista de medicamentos similares que entren en la cobertura de
Cigna-HealthSpring. Cuando la reciba, muéstresela a su médico y pídale que le recete un medicamento similar que entre
en la cobertura de Cigna-HealthSpring.

Puede pedirle a Cigna-HealthSpring que haga una excepción y cubra su medicamento. Consulte a continuación la
información sobre cómo solicitar una excepción.
¿Cómo solicito una excepción al formulario de Cigna-HealthSpring’s?
Puede pedirle a Cigna-HealthSpring que haga una excepción a sus reglas de cobertura. Existen varios tipos de excepciones que
puede solicitar que hagamos.

Puede solicitarnos que cubramos un medicamento, incluso si no se encuentra en nuestro formulario. Si lo aprobamos, el
medicamento se cubrirá a un nivel de costo compartido predeterminado, y no podrá solicitarnos que le brindemos el
medicamento a un nivel de costo compartido menor.

Puede solicitarnos que retiremos las restricciones o los límites de cobertura de su medicamento. Por ejemplo, para
ciertos medicamentos, Cigna-HealthSpring limita la cantidad de medicamento que cubrirá. Si su medicamento tiene un
límite de cantidad, puede solicitarnos que no apliquemos el límite y cubramos una cantidad mayor.
Puede pedirnos que le demos una excepción de nivel para que cubramos un medicamento que tenga un costo compartido mayor
a un nivel de costo compartido menor. En caso de que su medicamento se encuentre en nuestro nivel de medicamentos de
marca no preferida o el nivel de medicamentos genéricos no preferidos, puede solicitarnos la cobertura de su medicamento a la
cantidad de pago compartido que se aplique al medicamento de marca preferida o medicamentos genéricos preferidos. De esta
manera se reduciría la cantidad que deba pagar por su medicamento. En caso de que su medicamento se encuentre en nuestro
nivel de medicamentos de marca, puede solicitarnos la cobertura de su medicamento a la cantidad de pago compartido que se
aplique a los medicamentos en el nivel genérico respectivo si todas las alternativas genéricas en el nivel de costo compartido
menor usadas para tratar la misma condición/enfermedad no son tan efectivas como el medicamento de marca. Recuerde que si
aceptamos su solicitud para cubrir un medicamento que no se encuentre en nuestro formulario, es posible que no pueda
pedirnos que le demos un nivel más alto de cobertura para el medicamento. Además, es posible que no pueda pedirnos un nivel
más alto de cobertura por medicamentos que se encuentren en el nivel de medicamentos especiales.
A9
Por lo general, Cigna-HealthSpring sólo aprobará su solicitud de excepción si los medicamentos alternativos incluidos en el
formulario del plan, los medicamentos de un costo compartido más bajo o aquellos a los que se les aplican restricciones de uso
adicionales, no tuviesen la misma efectividad para tratar su enfermedad y/o le ocasionaran efectos médicos adversos.
Póngase en contacto con nosotros para solicitar una decisión sobre la cobertura inicial en el caso de una excepción al formulario,
al nivel o a la restricción de uso. Cuando solicite una excepción al formulario, al nivel o a la restricción de uso, debe
presentar una declaración de su médico o la persona que le recete, que respalde su solicitud. Por lo general, debemos
tomar una decisión en un plazo de 72 horas, a partir del momento en que presente la declaración del médico que le hizo la
receta. Puede solicitar una respuesta más expedita (rápida) si usted o su médico creen que su salud resultaría afectada por la
espera del plazo de 72 horas para obtener una respuesta. En caso de que se autorice la respuesta rápida, le daremos una
respuesta en un término de 24 horas después de que recibamos la declaración de su médico o de la persona que realizó la
receta médica.
¿Qué debo hacer antes de decirle a mi médico que quiero cambiar mis medicamentos o solicitar una excepción?
Como miembro nuevo o continuo de nuestro plan, puede estar tomando medicamentos que no se encuentran en nuestro
formulario. O bien, es posible que esté tomando un medicamento que se encuentre en nuestro formulario, pero su capacidad
para obtenerlo es limitada. Por ejemplo, puede requerir de nuestra autorización previa antes de surtir sus recetas. Hable con su
médico para determinar si debe cambiar a un medicamento que entre en cobertura o solicitar una excepción al formulario para
que se cubra el medicamento que está tomando. Mientras habla con su médico para determinar la medida correcta a seguir,
podremos cubrir su medicamento en ciertos casos durante los primeros 90 días de su membresía en nuestro plan.
Para cada uno de los medicamentos que no se encuentran en nuestro formulario, o que están limitados, daremos una cobertura
temporal de un suministro de 30 días (a menos que su receta indique un suministro de menos días) cuando acuda a surtir su
receta en un farmacia de la red. Después de su suministro de 30 días, dejaremos de cubrir el costo de estos medicamentos,
incluso si usted ha sido miembro de este plan por menos de 90 días.
Si usted vive en un centro de atención médica de largo plazo, le permitiremos volver a surtir su receta hasta que le hayamos
proporcionado un suministro de transición temporal de 93 días, consistente con el incremento de dispensación, (a menos que su
receta indique un suministro de menos días). Cubriremos más de un relleno (refill) de dichos medicamentos por los primeros 90
días que usted sea miembro de nuestro plan. En caso de que necesite de un medicamento que no se encuentre en el formulario
o que esté limitado, y ya tenga más 90 días de ser miembro de nuestro plan, cubriremos un suministro de emergencia de 31 días
del medicamento (a menos que su receta indique un suministro de menos días) mientras solicita que se haga una excepción al
formulario.
Para adaptar transiciones inesperadas de nuestros miembros que no permiten hacer planes con anticipación, como los cambios
de nivel de atención para pasar de un hospital a un centro de enfermería especializada o al hogar, Cigna-HealthSpring permitirá
un único suministro de 31 días (a menos que la receta sea por menos días).
Para más información
Para obtener información más detallada sobre su cobertura de medicamentos recetados de Cigna-HealthSpring, consulte su
Evidencia de cobertura y otros materiales del plan.
Si tiene alguna pregunta sobre Cigna-HealthSpring, por favor póngase en contacto con nosotros. Nuestra información de
contacto, junto con la fecha de la última actualización del formulario, aparece en la portada y al reverso.
Si tiene preguntas generales sobre la cobertura de medicamentos recetados de Medicare, llame a Medicare al 1-800-MEDICARE
(1-800-633-4227), las 24 horas del día, los 7 días de la semana. Los usuarios de TTY deben llamar al 1-877-486-2048. O bien,
visite www.medicare.gov.
A10
Formulario de Cigna-HealthSpring’s
El formulario completo siguiente ofrece información sobre la cobertura de todos los medicamentos que cubre Cigna-HealthSpring.
En caso de que tenga problemas para encontrar su medicamento en la lista, consulte la Lista por orden alfabético de
medicamentos que comienza en la página 2.
La primera columna de la tabla indica el nombre del medicamento. Los nombres de los medicamentos de marca están en
mayúscula (p. ej. DEXILANT) y los de medicamentos genéricos en minúscula y cursiva (p. ej. simvastatin).
La información en la columna de Requisitos/Límites indica si Cigna-HealthSpring tiene algún requisito especial para la cobertura
de su medicamento.
[Algunos planes de Cigna-HealthSpring ofrecen cobertura de medicamentos recetados adicional durante el hueco en la
cobertura. Por favor consulte su Evidencia de cobertura para saber si su plan tiene esta cobertura y para más información.]
Brindamos límites de cantidad para ciertos medicamentos que están indicados con QL en la lista por orden alfabético que
comienza en la página 2 junto con la cantidad despachada para los días suministrados. (Por ejemplo: Dexilant 30/30; esto
significa que el medicamento Dexilant está limitado a 30 cápsulas por 30 días).
Clave:
B/D = Este medicamento tiene un requisito de autorización de la Parte B vs la Parte D. El medicamento puede entrar en
cobertura con la Parte B o la D de Medicare, dependiendo de las circunstancias. Debe enviarse información que describa
el uso y la base del medicamento para tomar esta decisión.
MO = Orden por correo; este medicamento es un medicamento de mantenimiento.
PA =
Este medicamento requiere de autorización previa.
QL =
Este medicamento tiene límite de cantidad.
ST =
Este medicamento tiene requerimientos de terapia escalonada.
La Tabla de niveles de medicamentos y costos compartidos comienza en la página A12.
A11
Drug Tier and Cost-Share Table / Tabla de nivel de medicamentos y costos compartidos
The following table represents the plan name, plan service area, the drug tier number as it appears in the formulary, and the costshare amount for that tier number. Tier 1 is for Preferred Generic drugs. Tier 2 is for Non-Preferred Generic drugs. Tier number 3
is for Preferred Brand drugs. Tier number 4 is for Non-Preferred Brand drugs. Tier 5 is Specialty drugs. You may also refer to your
Evidence of Coverage document for additional details.
There may be additional cost savings by ordering your medication through one of the mail order pharmacies for home
delivery within our network. For more information, please contact our Customer Service Department at the number
located on the front and back cover of this document.
To locate your drug cost, please refer to the tables below to find your service area and the Medicare Advantage plan in
which you are currently enrolled in or would like to enroll in.
La siguiente tabla representa el nombre del plan, el área de servicio del plan, el número de nivel de medicamento, tal y como
aparece en el formulario, y la cantidad de costo compartido para ese número de nivel. El nivel 1 es para los medicamentos
genéricos preferidos. El nivel 2 es el nivel para los medicamentos genéricos no preferidos. El nivel 3 es para los medicamentos
de marca preferida. El nivel 4 es el nivel para los medicamentos de marca no preferida. El nivel 5 es para los medicamentos de
especialidad. [El nivel 6 es sólamente para los planes de Cigna-HealthSpring y se denomina como Medicamentos seleccionados
para personas diabéticas.] Para obtener más detalles, puede también consultar su Evidencia de cobertura.
Es posible que haya ahorros adicionales al ordenar su medicamento a través de una de las farmacias de orden por
correo de nuestra red. Para más información, por favor póngase en contacto con nuestro Departamento de servicio al
cliente al número que aparece al frente y al reverso de este documento.
Para localizar el costo de su medicamento, por favor consulte las tablas que están a continuación para encontrar su área
de servicio y el plan Medicare Advantage en el que actualmente está inscrito o en el que le gustaría inscribirse.
A12
Service Area / Área de servicio: Alabama
Plan Name
Counties
Nombre del plan
Condados
H0150-001
Cigna-HealthSpring
Preferred (HMO)
Autauga, Baldwin, Bibb, Blount , Cherokee,
Chilton, Colbert , Cullman, Dallas, DeKalb,
Elmore, Etowah, Fayette, Jackson ,
Jefferson, Lamar, Lauderdale , Lawrence ,
Limestone, Lowndes, Madison, Mobile,
Montgomery, Morgan, Shelby, St. Clair,
Talladega, Tuscaloosa, Walker, AL
Member Cost-Share for
Retail Pharmacy Drugs
(one month supply)
Drug Tier
Nivel del medicamento
1 (Preferred Generic)
Home Delivery of Drugs
by Mail
(3 month supply)
Costo compartido del
miembro para los
medicamentos de la
farmacia de venta al
menudeo (un mes de
suministro)
$3 copay/ de copago
miembro para los
medicamentos de orden
por correo
(3 meses de suministro)
$0 copay/ de copago
$12 copay/ de copago
1 (Genéricos preferidos)
2 (Non-Preferred Generic)
2 (Genéricos no preferidos)
3 (Preferred Brand)
3 (Marca preferida)
4 (Non-Preferred Brand)
4 (Marca no preferida)
33% coinsurance /
de coseguro
5 (Specialty
5 (Especialidad)
A13
33% coinsurance /
de coseguro
Service Area / Área de servicio: Arkansas
Plan Name
Counties
Nombre del plan
Condados
H3945-006
Cigna-HealthSpring
Preferred AR (HMO)
Crittenden , AR
(one month supply)
Drug Tier
miembro para los
medicamentos de la
menudeo (un mes de
suministro)
by Mail
(3 month supply)
miembro para los
por correo
3 (Preferred Brand)
$3 copay/ de copago
$0 copay/ de copago
33% coinsurance /
de coseguro
33% coinsurance /
de coseguro
$7 copay/ de copago
3 (Marca preferida)
5 (Specialty
5 (Especialidad)
H4871-001
Cigna-HealthSpring
Preferred (PPO)
Howard, AR
3 (Preferred Brand)
3 (Marca preferida)
33% coinsurance /
de coseguro
5 (Specialty
5 (Especialidad)
A14
33% coinsurance /
de coseguro
Service Area / Área de servicio: Arkansas (con’t)
Plan Name
Counties
Nombre del plan
Condados
H6972-001
Cigna-HealthSpring
Preferred (HMO)
Conway, Crawford, Franklin, Johnson,
Logan, Pope, Scott, Sebastian, Yell, AR
(one month supply)
Drug Tier
miembro para los
medicamentos de la
menudeo (un mes de
suministro)
by Mail
(3 month supply)
miembro para los
por correo
3 (Preferred Brand)
$2 copay/ de copago
$0 copay/ de copago
3 (Marca preferida)
5 (Specialty
33% coinsurance /
de coseguro
5 (Especialidad)
A15
33% coinsurance /
de coseguro
Service Area / Área de servicio: Delaware
Plan Name
Counties
Nombre del plan
Condados
H2108-022
Cigna-HealthSpring
Preferred HMO)
Kent, New Castle, Sussex, DE
(one month supply)
Drug Tier
miembro para los
medicamentos de la
menudeo (un mes de
suministro)
by Mail
(3 month supply)
miembro para los
por correo
3 (Preferred Brand)
$8 copay/ de copago
29% coinsurance /
de coseguro
29% coinsurance /
de coseguro
$5 copay/ de copago
$6 copay/ de copago
33% coinsurance /
de coseguro
33% coinsurance /
de coseguro
3 (Marca preferida)
5 (Specialty
5 (Especialidad)
H2108-028
Cigna-HealthSpring
Preferred Plus (HMO)
Kent, New Castle, Sussex, DE
3 (Preferred Brand)
3 (Marca preferida)
5 (Specialty
5 (Especialidad)
A16
Service Area / Área de servicio: Florida
Plan Name
Counties
Nombre del plan
Condados
H5410-018
Cigna-HealthSpring
Premier (HMO-POS)
Bay, Escambia , Santa Rosa , FL
(one month supply)
Drug Tier
miembro para los
medicamentos de la
menudeo (un mes de
suministro)
by Mail
(3 month supply)
miembro para los
por correo
3 (Preferred Brand)
$3 copay/ de copago
$0 copay/ de copago
33% coinsurance /
de coseguro
33% coinsurance /
de coseguro
3 (Marca preferida)
5 (Specialty
5 (Especialidad)
A17
Service Area / Área de servicio: Georgia
Plan Name
Counties
Nombre del plan
Condados
H0439-001
Cigna-HealthSpring
Preferred (HMO)
Clayton , Cobb* , DeKalb , Fulton ,
Gwinett , GA : * Cobb Partial Counties:
30006, 30007, 30060, 30061, 30063,
30065, 30067, 30068, 30069, 30080,
30081, 30082, 30126, 30168, 30339
(one month supply)
Drug Tier
miembro para los
medicamentos de la
menudeo (un mes de
suministro)
by Mail
(3 month supply)
miembro para los
por correo
3 (Preferred Brand)
$3 copay/ de copago
$0 copay/ de copago
33% coinsurance /
de coseguro
33% coinsurance /
de coseguro
$3 copay/ de copago
$0 copay/ de copago
33% coinsurance /
de coseguro
33% coinsurance /
de coseguro
3 (Marca preferida)
5 (Specialty
5 (Especialidad)
H2165-005
Cigna-HealthSpring
Preferred NGA (HMO)
Catoosa, Dade, Walker, GA
3 (Preferred Brand)
3 (Marca preferida)
5 (Specialty
5 (Especialidad)
A18
Service Area / Área de servicio: Georgia
Plan Name
Counties
Nombre del plan
Condados
H2165-011
Cigna-HealthSpring
Premier NGA (HMO-POS)
Catoosa, Dade, Walker, GA
(one month supply)
Drug Tier
miembro para los
medicamentos de la
menudeo (un mes de
suministro)
by Mail
(3 month supply)
miembro para los
por correo
3 (Preferred Brand)
$3 copay/ de copago
$0 copay/ de copago
33% coinsurance /
de coseguro
33% coinsurance /
de coseguro
3 (Marca preferida)
5 (Specialty)
5 (Especialidad)
A19
Service Area / Área de servicio: Illinois
Plan Name
Counties
Nombre del plan
Condados
H1415-021
Cigna-HealthSpring
Premier (HMO-POS)
Cook, DuPage, Kane, Will, IL
(one month supply)
Drug Tier
miembro para los
medicamentos de la
menudeo (un mes de
suministro)
by Mail
(3 month supply)
miembro para los
por correo
3 (Preferred Brand)
$5 copay/ de copago
$6 copay/ de copago
$5 copay/ de copago
$6 copay/ de copago
33% coinsurance /
de coseguro
33% coinsurance /
de coseguro
3 (Marca preferida)
5 (Specialty
5 (Especialidad)
A20
Service Area / Área de servicio: Indiana
Plan Name
Counties
Nombre del plan
Condados
H3945-003
Cigna-HealthSpring
Premier (HMO-POS)
Lake , IN
(one month supply)
Drug Tier
miembro para los
medicamentos de la
menudeo (un mes de
suministro)
by Mail
(3 month supply)
miembro para los
por correo
3 (Preferred Brand)
$5 copay/ de copago
$6 copay/ de copago
$5 copay/ de copago
$6 copay/ de copago
33% coinsurance /
de coseguro
33% coinsurance /
de coseguro
3 (Marca preferida)
5 (Specialty
5 (Especialidad)
A21
Service Area / Área de servicio: Maryland
Plan Name
Counties
Nombre del plan
Condados
H2108-022
Cigna-HealthSpring
Preferred (HMO)
Anne Arundel, Baltimore, Baltimore City,
Harford, Howard, Montgomery, Prince
George’s MD
(one month supply)
Drug Tier
miembro para los
medicamentos de la
menudeo (un mes de
suministro)
by Mail
(3 month supply)
miembro para los
por correo
3 (Preferred Brand)
$8 copay/ de copago
29% coinsurance /
de coseguro
29% coinsurance /
de coseguro
$5 copay/ de copago
$6 copay/ de copago
33% coinsurance /
de coseguro
33% coinsurance /
de coseguro
3 (Marca preferida)
5 (Specialty
5 (Especialidad)
H2108-028
Cigna-HealthSpring
Montgomery, Prince George’s, MD
3 (Preferred Brand)
3 (Marca preferida)
5 (Specialty
5 (Especialidad)
A22
Service Area / Área de servicio: Mississippi (con’t)
Plan Name
Counties
Nombre del plan
Condados
H4407-002
Cigna-HealthSpring
Preferred SMS (HMO)
Covington, Forrest, George, Hancock,
Harrison, Hinds , Jackson, Jones, Lamar,
Marion, Pearl River, Perry, Rankin , Stone,
MS
(one month supply)
Drug Tier
miembro para los
medicamentos de la
menudeo (un mes de
suministro)
by Mail
(3 month supply)
miembro para los
por correo
3 (Preferred Brand)
$3 copay/ de copago
$0 copay/ de copago
33% coinsurance /
de coseguro
33% coinsurance /
de coseguro
$3 copay/ de copago
$0 copay/ de copago
3 (Marca preferida)
5 (Specialty
5 (Especialidad)
H4407-022
Cigna-HealthSpring
Premier NMS (HMO-POS)
DeSoto, Marshall , Tate , MS
3 (Preferred Brand)
3 (Marca preferida)
33% coinsurance /
de coseguro
33% coinsurance /
de coseguro
5 (Specialty
5 (Especialidad)
A23
Service Area / Área de servicio: North Carolina
Plan Name
Counties
Nombre del plan
Condados
H9725-001
Cigna-HealthSpring
Preferred (HMO)
Cabarrus, Davidson, Davie, Forsyth,
Gaston, Rowan, Stokes, Yadkin, NC
(one month supply)
Drug Tier
miembro para los
medicamentos de la
menudeo (un mes de
suministro)
by Mail
(3 month supply)
miembro para los
por correo
3 (Preferred Brand)
$3 copay/ de copago
$0 copay/ de copago
3 (Marca preferida)
33% coinsurance /
de coseguro
33% coinsurance /
de coseguro
5 (Specialty)
5 (Especialidad)
A24
Service Area / Área de servicio: Oklahoma
Plan Name
Counties
Nombre del plan
Condados
H4125-001
Adair, Delaware, Haskell, Le Flore,
McCurtain, Ottawa, Pushmataha,
Sequoyah, OK
(one month supply)
Drug Tier
miembro para los
medicamentos de la
menudeo (un mes de
suministro)
by Mail
(3 month supply)
miembro para los
por correo
3 (Preferred Brand)
$2 copay/ de copago
$0 copay/ de copago
$95 copay/ de copago 3
33% coinsurance /
de coseguro
33% coinsurance /
de coseguro
3 (Marca preferida)
5 (Specialty
5 (Especialidad)
A25
Service Area / Área de servicio: Pennsylvania
Plan Name
Counties
Nombre del plan
Condados
H3949-002
Cigna-HealthSpring
Preferred (HMO)
Bucks, Chester, Cumberland, Delaware,
Lancaster, Montgomery, Philadelphia, York,
PA
(one month supply)
Drug Tier
miembro para los
medicamentos de la
menudeo (un mes de
suministro)
by Mail
(3 month supply)
miembro para los
por correo
3 (Preferred Brand)
$4 copay/ de copago
$3 copay/ de copago
33% coinsurance /
de coseguro
33% coinsurance /
de coseguro
$4 copay/ de copago
$3 copay/ de copago
$8 copay/ de copago
33% coinsurance /
de coseguro
33% coinsurance /
de coseguro
3 (Marca preferida)
5 (Specialty)
5 (Especialidad)
H3949-013
Cigna-HealthSpring
Bucks, Chester, Delaware, Montgomery,
Philadelphia, PA
3 (Preferred Brand)
3 (Marca preferida)
5 (Specialty)
5 (Especialidad)
A26
Service Area / Área de servicio: Pennsylvania (con’t)
Plan Name
Counties
Nombre del plan
Condados
H3949-027
Cigna-HealthSpring
Premier (HMO-POS)
Bucks, Montgomery, Philadelphia, PA
(one month supply)
Drug Tier
miembro para los
medicamentos de la
menudeo (un mes de
suministro)
$7 copay/ de copago
3 (Preferred Brand)
by Mail
(3 month supply)
miembro para los
por correo
3 (Marca preferida)
28% coinsurance /
de coseguro
28% coinsurance /
de coseguro
5 (Specialty)
5 (Especialidad)
A27
Service Area / Área de servicio: South Carolina
Plan Name
Counties
Nombre del plan
Condados
H7020-001
Cigna-HealthSpring
Preferred (HMO)
Cherokee , Chester , Greenville ,
Spartanburg , York , SC.
(one month supply)
Drug Tier
miembro para los
medicamentos de la
menudeo (un mes de
suministro)
by Mail
(3 month supply)
miembro para los
por correo
3 (Preferred Brand)
$3 copay/ de copago
$0 copay/ de copago
3 (Marca preferida)
33% coinsurance /
de coseguro
33% coinsurance /
de coseguro
5 (Specialty)
5 (Especialidad)
A28
Service Area / Área de servicio: Tennessee
Plan Name
Counties
Nombre del plan
Condados
H4454-002
Cigna-HealthSpring
Preferred (HMO)
Bedford, Benton, Bledsoe , Bradley,
Cannon, Carroll, Cheatham, Chester, Clay,
Coffee, Crockett, Cumberland, Davidson,
Decatur, DeKalb, Dickson, Fayette,
Fentress, Franklin, Gibson, Giles , Grundy,
Hamilton, Hardeman, Hardin, Haywood,
Henderson, Hickman, Houston, Humphreys,
Jackson, Lauderdale , Lawrence , Lewis,
Lincoln , Macon, Madison, Marion, Marshall,
Maury, McMinn, McNairy, Meigs, Monroe ,
Montgomery, Moore, Overton, Perry, Pickett,
Polk , Putnam, Rhea , Robertson,
Rutherford, Sequatchie, Shelby, Smith,
Stewart, Sumner, Tipton, Trousdale, Van
Buren, Warren, Wayne, White, Williamson,
Wilson, TN
(one month supply)
Drug Tier
miembro para los
medicamentos de la
menudeo (un mes de
suministro)
by Mail
(3 month supply)
miembro para los
por correo
3 (Preferred Brand)
$3 copay/ de copago
$0 copay/ de copago
3 (Marca preferida)
33% coinsurance /
de coseguro
33% coinsurance /
de coseguro
5 (Specialty)
5 (Especialidad)
A29
Service Area / Área de servicio: Tennessee (con’t)
Plan Name
Counties
Nombre del plan
Condados
H4454-030
Cigna-HealthSpring
Premier (HMO-POS)
Bedford, Benton, Bledsoe , Bradley,
Cannon, Carroll, Cheatham, Chester, Clay,
Coffee, Crockett, Cumberland, Davidson,
Decatur, DeKalb, Dickson, Fayette,
Fentress, Franklin, Gibson, Giles , Grundy,
Hamilton, Hardeman, Hardin, Haywood,
Henderson, Hickman, Houston, Humphreys,
Jackson, Lauderdale , Lawrence , Lewis,
Lincoln , Macon, Madison, Marion, Marshall,
Maury, McMinn, McNairy, Meigs, Monroe ,
Montgomery, Moore, Overton, Perry, Pickett,
Polk , Putnam, Rhea , Robertson,
Rutherford, Sequatchie, Shelby, Smith,
Stewart, Sumner, Tipton, Trousdale, Van
Buren, Warren, Wayne, White, Williamson,
Wilson, TN
(one month supply)
Drug Tier
miembro para los
medicamentos de la
menudeo (un mes de
suministro)
by Mail
(3 month supply)
miembro para los
por correo
3 (Preferred Brand)
$3 copay/ de copago
$0 copay/ de copago
33% coinsurance /
de coseguro
33% coinsurance /
de coseguro
3 (Marca preferida)
5 (Specialty)
5 (Especialidad)
A30
Service Area / Área de servicio: Tennessee (con’t)
Plan Name
Counties
Nombre del plan
Condados
H4454-031
Cigna-HealthSpring
Preferred KNX (HMO)
Anderson, Blount, Campbell , Cocke,
Grainger, Hamblen, Hancock , Jefferson,
Knox, Loudon, Morgan , Roane, Scott ,
Sevier, Union, TN.
(one month supply)
Drug Tier
miembro para los
medicamentos de la
menudeo (un mes de
suministro)
by Mail
(3 month supply)
miembro para los
medicamentos de
orden por correo
3 (Preferred Brand)
$5 copay/ de copago
$6 copay/ de copago
33% coinsurance /
de coseguro
33% coinsurance /
de coseguro
$3 copay/ de copago
$0 copay/ de copago
3 (Marca preferida)
5 (Specialty)
5 (Especialidad)
H4454-032
Cigna- HealthSpring
Premier KNX (HMO-POS)
Anderson, Blount, Campbell , Cocke,
Grainger, Hamblen, Hancock , Jefferson,
Knox, Loudon, Morgan , Roane, Scott ,
Sevier, Union, TN.
3 (Preferred Brand)
3 (Marca preferida)
33% coinsurance /
de coseguro
33% coinsurance /
de coseguro
5 (Specialty
5 (Especialidad)
A31
Service Area / Área de servicio: Texarkana
Plan Name
Counties
Nombre del plan
Condados
H2676-001
Cigna-HealthSpring
Preferred (PPO)
Miller, AR;
Bowie, Cass, Titus, TX
(one month supply)
Drug Tier
miembro para los
medicamentos de la
menudeo (un mes de
suministro)
by Mail
(3 month supply)
miembro para los
medicamentos de
orden por correo
3 (Preferred Brand)
$7 copay/ de copago
33% coinsurance /
de coseguro
33% coinsurance /
de coseguro
3 (Marca preferida)
5 (Specialty)
5 (Especialidad)
A32
Service Area / Área de servicio: Texas
Plan Name
Counties
Nombre del plan
Condados
H2165-018
Cherokee, Grayson, Gregg, Hale,
Henderson, Hockley, Lubbock, Rains,
Rusk, Smith, Upshur, Van Zandt, Wood, TX
(one month supply)
Drug Tier
miembro para los
medicamentos de la
menudeo (un mes de
suministro)
by Mail
(3 month supply)
miembro para los
medicamentos de
orden por correo
$3 copay/ de copago
$0 copay/ de copago
$8 copay/ de copago
33% coinsurance /
de coseguro
33% coinsurance /
de coseguro
$0 copay/ de copago
$0 copay/ de copago
$4 copay/ de copago
$3 copay/ de copago
33% coinsurance /
de coseguro
33% coinsurance /
de coseguro
3 (Preferred Brand)
3 (Marca preferida)
5 (Specialty)
5 (Especialidad)
H4513-001
Cigna-HealthSpring
Preferred (HMO)
Angelina, Brazoria, Cameron, Chambers,
Fort Bend, Galveston*, Hardin, Harris,
Hidalgo, Jasper, Jefferson, Liberty,
Montgomery, Nacogdoches, Newton,
Orange, Polk, Sabine, San Augustine, San
Jacinto, Shelby, Tyler, Walker, Waller,
Webb, Willacy, TX: *Galveston partial
counties: 77510, 77511, 77517, 77518,
77539, 77546, 77549, 77563, 77565,
77568, 77573, 77574, 77590, 77591, 77592
3 (Preferred Brand)
3 (Marca preferida)
5 (Specialty)
5 (Especialidad)
A33
Service Area / Área de servicio: Texas (con’t)
Plan Name
Counties
Nombre del plan
Condados
H4528-001
Cigna-HealthSpring
Preferred (HMO)
Bexar, Collin, Dallas, Denton, El Paso,
Ellis, Hood, Johnson, Parker, Rockwall,
Tarrant, Wise, TX
(one month supply)
Drug Tier
miembro para los
medicamentos de la
menudeo (un mes de
suministro)
by Mail
(3 month supply)
miembro para los
medicamentos de
orden por correo
$3 copay/ de copago
$0 copay/ de copago
$8 copay/ de copago
33% coinsurance /
de coseguro
33% coinsurance /
de coseguro
$3 copay/ de copago
$0 copay/ de copago
$8 copay/ de copago
33% coinsurance /
de coseguro
33% coinsurance /
de coseguro
3 (Preferred Brand)
3 (Marca preferida)
5 (Specialty)
5 (Especialidad)
H7787-001
Cigna-HealthSpring
Preferred (PPO)
Cherokee, Collin, Dallas, Denton, Grayson,
Gregg, Hale, Henderson, Hockley,
Johnson, Kaufmann, Lubbock, Rains,
Rockwall, Rusk, Smith, Tarrant, Upshur,
Van Zandt, Wood, TX
3 (Preferred Brand)
3 (Marca preferida)
5 (Specialty)
5 (Especialidad)
A34
Service Area / Área de servicio: Texas (con’t)
Plan Name
Counties
Nombre del plan
Condados
H7811-001
Cigna-HealthSpring
Preferred (HMO)
Armstrong, Carson, Deaf Smith, Oldham,
Potter, Randall, TX
(one month supply)
Drug Tier
miembro para los
medicamentos de la
menudeo (un mes de
suministro)
by Mail
(3 month supply)
miembro para los
medicamentos de
orden por correo
$2 copay/ de copago
$0 copay/ de copago
33% coinsurance /
de coseguro
33% coinsurance /
de coseguro
$2 copay/ de copago
$0 copay/ de copago
33% coinsurance /
de coseguro
33% coinsurance /
de coseguro
3 (Preferred Brand)
3 (Marca preferida)
5 (Specialty)
5 (Especialidad)
H7811-002
Cigna-HealthSpring
Preferred (HMO)
Gregg, Harrison, Henderson, TX
3 (Preferred Brand)
3 (Marca preferida)
5 (Specialty)
5 (Especialidad)
A35
Service Area / Área de servicio: Washington, D.C.
Plan Name
Counties
Nombre del plan
Condados
H2108-028
Cigna-HealthSpring
Washington, D.C.
(one month supply)
Drug Tier
miembro para los
medicamentos de la
menudeo (un mes de
suministro)
Home Delivery of
Drugs
by Mail
(3 month supply)
miembro para los
medicamentos de
orden por correo
(3 meses de
suministro)
$5 copay/ de copago
$6 copay/ de copago
3 (Preferred Brand)
3 (Marca preferida)
33% coinsurance /
de coseguro
33% coinsurance /
de coseguro
5 (Specialty)
5 (Especialidad)
A36
My Medications / Mis medicamentos
In this section, you can write down all of the medications you are currently taking. You can then find your drug in the following
formulary pages, look and see what tier your drug is on. Once you find out what tier your drug is on, you can look at the charts
before this page and locate your cost-share for that drug. If you need help locating your drugs and cost-share, please call
Customer Service at 1-800-668-3813, 7 days a week/ 8 a.m. – 8 p.m. TTY users can call 711.
En esta sección puede escribir todos los medicamentos que toma actualmente; de esta manera, puede encontrar su
medicamento en las siguientes páginas del formulario, así como buscar y ver en qué nivel está su medicamento. Una vez que
encuentre el nivel en el que está su medicamento, puede buscar en las tablas anteriores a esta página y localizar su costo
compartido para ese medicamento. Si necesita ayuda para localizar sus medicamentos y el costo compartido, por favor llame al
Departamento de servicio al ciento al 1-800-668-3813, los 7 días de la semana/ 8 a.m. – 8 p.m. Los usuarios de TTY pueden
llamar al 711.
My Medications /
Mis medicamentos
Page Number in the
Formulary /
Número de página
en el formulario
Cost-Share through
Cigna-HealthSpring /
Costo compartido a
través de
Cigna-HealthSpring
A37
Generic Available? /
¿Existe un genérico
disponible?
Generic Cost-Share
/ Costo compartido
del genérico
This page intentionally left blank.
Esta página se dejó en blanco intencionalmente.
A38
This page intentionally left blank.
Esta página se dejó en blanco intencionalmente.
1
Drug Name
Drug Tier
Reqs / Limits
Page
Drug Name
Drug Tier
Reqs / Limits
Page
A
ACTIMMUNE
5
PA
75
abacavir
2
MO
60
ACTONEL TABS
3
QL(1/28) MO
75
ABELCET
4
PA
55
150MG
ABILIFY INJ
4
59
ACTONEL TABS
3
QL(4/28) MO
75
ABILIFY ORAL
3
QL(900/30) MO
59
35MG
SOLN
ACTONEL TABS
3
QL(30/30) MO
75
30MG, 5MG
ABILIFY TABS
3
QL(30/30) MO
59
acyclovir
2
61
ABILIFY
3
QL(60/30) MO
59
DISCMELT
acyclovir sodium
4
61
ABILIFY
5
ST
59
ADACEL
4
75
MAINTENA INJ
ADAGEN
5
PA MO
69
300MG
adriamycin inj
4
B/D PA
56
ABRAXANE
5
B/D PA
56
20mg
absorica caps
2
68
ADVAIR DISKUS
3
QL(60/30) MO
78
10mg, 20mg
ADVAIR HFA
3
QL(24/30) MO
78
acarbose
2
QL(90/30) MO
62
AEROCHAMBE
3
QL(1/365)
76
acebutolol hcl
2
MO
65
R MAX VALVED
acetaminophen/c
2
QL(150/30)
46
HOLDING
affeine/dihydroco
CHAMBER
deine bitartrate
W/COMFORTSE
acetaminophen/c
2
QL(5000/30)
46
AL MASK
odeine oral soln
AEROCHAMBE
3
QL(1/365)
76
acetaminophen/c
2
QL(240/30)
46
R PLUS FLOWodeine tabs
VU
300mg 60mg
AEROCHAMBE
3
QL(1/365)
76
acetaminophen/c
2
QL(360/30)
46
R PLUS FLOWodeine tabs
VU/LARGE
300mg 15mg
MASK
acetaminophen/c
2
QL(360/30)
46
AEROCHAMBE
3
QL(1/365)
76
odeine #3
R PLUS FLOWacetasol hc
2
78
VU/MASK
acetazolamide
2
MO
66
QL(1/365)
76
AEROCHAMBE
3
acetazolamide er
2
MO
78
R PLUS FLOWacetazolamide
4
66
VU/SMALL
sodium
MASK
acetic acid otic
2
78
AEROCHAMBE
3
QL(1/365)
76
soln
R Z-STAT
acetylcysteine
2
B/D PA
79
PLUS/MEDIUM
MASK
inhalation soln
afeditab cr
2
MO
66
ACTHIB
4
75
AFINITOR
5
PA QL(30/30)
57
acticin
2
58
Key: QL= Quantity Limits listed as (qty/days); PA=Prior Authorization may be required; ST= Step Therapy rules apply; B/D=
Drugs covered under Medicare Part B or Part D; MO= Mail Order
Clave: QL= Los límites de cantidad se indican como (cant./días); PA=Es posible que se requiera de autorización previa; ST= Se
aplican las reglas de la terapia escalonada; B/D= Medicamentos en cobertura de Medicare Parte B o Parte D; MO= Orden por
correo
2
Drug Name
AGGRENOX
a-hydrocort
ak-poly-bac
ALA SCALP
ALBENZA
albuterol sulfate
nebu 0.5%
albuterol sulfate
nebu 0.083%
albuterol sulfate
nebu
0.63mg/3ml,
1.25mg/3ml
albuterol sulfate
syrp
albuterol sulfate
tabs
albuterol sulfate
er
alclometasone
dipropionate
alcohol preps
pads
ALDURAZYME
alendronate
sodium tabs
35mg, 70mg
alendronate
sodium tabs
10mg, 40mg,
5mg
ALIMTA INJ
500MG
ALINIA
allopurinol
allopurinol
sodium
ALOCRIL
ALORA
Drug Tier
3
4
2
3
3
1
1
2
1
1
2
Reqs / Limits
Page
QL(60/30) MO
64
70
48
70
58
B/D PA QL(360/30) 79
MO
B/D PA QL(375/30) 79
MO
B/D PA QL(375/30) 79
MO
MO
MO
MO
2
79
79
79
70
1
48
5
1
PA
QL(4/28) MO
69
75
2
QL(30/30) MO
75
5
3
1
4
3
3
B/D PA
MO
PA
56
58
55
55
77
72
Drug Name
Drug Tier
ALOXI
alprazolam tabs
0.25mg, 0.5mg
alprazolam tabs
2mg
alprazolam tabs
1mg
alprazolam odt
tbdp 0.25mg,
0.5mg
alprazolam odt
tbdp 2mg
alprazolam odt
tbdp 1mg
amantadine hcl
caps
amantadine hcl
syrp
amantadine hcl
tabs
AMBISOME
amcinonide
a-methapred inj
40mg
amifostine
amikacin sulfate
inj 1gm/4ml,
50mg/ml
amiloride hcl
amiloride/hydroc
hlorothiazide
aminophylline
AMINOSYN
AMINOSYN
7%/ELECTROLY
TES
AMINOSYN
8.5%/ELECTRO
LYTES
Reqs / Limits
Page
4
2
B/D PA
QL(90/30)
54
61
2
QL(150/30)
61
2
QL(300/30)
61
2
QL(90/30)
61
2
QL(150/30)
61
2
QL(300/30)
61
2
MO
61
2
61
2
MO
61
4
2
4
PA
55
70
70
4
4
B/D PA
56
48
2
1
MO
MO
67
67
4
4
4
B/D PA
B/D PA
79
80
80
4
B/D PA
80
Key: QL= Quantity Limits listed as (qty/days); PA=Prior Authorization may be required; ST= Step Therapy rules apply; B/D= Drugs
covered under Medicare Part B or Part D; MO= Mail Order
correo
3
Drug Name
Drug Tier
Reqs / Limits
Page
Drug Name
Drug Tier
Reqs / Limits
Page
amoxicillin caps
1
50
AMINOSYN II
4
B/D PA
80
amoxicillin chew
2
50
AMINOSYN II
4
B/D PA
80
4.25/DEXTROS
amoxicillin susr
1
50
E25%
amoxicillin tabs
2
50
AMINOSYN II
4
B/D PA
80
amoxicillin/clavul
2
50
5/DEXTROSE
anate potassium
25
chew
AMINOSYN II
4
B/D PA
80
amoxicillin/clavul
2
50
8.5%/ELECTRO
anate potassium
LYTES
susr
AMINOSYN M
4
B/D PA
80
amoxicillin/clavul
2
50
AMINOSYN4
B/D PA
80
anate potassium
HBC
tabs 250mg
AMINOSYN-HF
4
B/D PA
80
125mg
AMINOSYN-PF
4
B/D PA
80
amoxicillin/clavul
2
50
AMINOSYN-PF
4
B/D PA
80
anate potassium
7%
er
amiodarone hcl
4
65
amoxicillin/potas
2
50
inj 50mg/ml
sium clavulanate
amiodarone hcl
2
MO
65
susr
tabs 200mg,
amoxicillin/potas
2
50
400mg
sium clavulanate
AMITIZA
3
QL(60/30) MO
70
tabs
amitriptyline hcl
2
PA MO
54
amphetamine/de
2
QL(60/30) MO
68
tabs 150mg
xtroamphetamin
amitriptyline hcl
1
PA MO
54
e cp24
tabs 100mg,
amphetamine/de
2
QL(90/30) MO
68
10mg, 25mg,
xtroamphetamin
50mg, 75mg
e tabs
amlodipine
1
MO
66
AMPHOTEC INJ
4
PA
55
besylate
50MG
2
MO
66
amlodipine
amphotericin b
4
PA
55
besylate/benaze
ampicillin caps
2
50
pril hcl
ampicillin susr
2
50
amlodipine
2
MO
66
250mg/5ml
besylate/benaze
ampicillin sodium
4
50
pril hydrochloride
ampicillin4
50
ammonium
2
68
sulbactam inj
lactate
10gm 5gm, 2gm
amnesteem
2
68
1gm
amoxapine
2
MO
54
AMPYRA
5
PA QL(60/30)
68
correo
4
Drug Name
AMTURNIDE
ANADROL-50
anagrelide
hydrochloride
anastrozole
ANDROGEL
GEL
25MG/2.5GM,
50MG/5GM
ANDROGEL
PUMP GEL
1.62%
ANDROGEL
PUMP GEL 1%
ANDROXY
APOKYN
apraclonidine
apri
APRISO
APTIVUS
aranelle
ARANESP
ALBUMIN FREE
INJ
25MCG/0.42ML,
25MCG/ML,
40MCG/0.4ML,
40MCG/ML,
60MCG/0.3ML,
60MCG/ML
ARANESP
ALBUMIN FREE
INJ
100MCG/0.5ML,
100MCG/ML,
150MCG/0.3ML,
200MCG/0.4ML,
200MCG/ML,
300MCG/0.6ML,
Drug Tier
Reqs / Limits
Page
Drug Name
3
5
2
ST MO
PA
MO
66
72
64
2
3
QL(30/30) MO
PA MO
57
72
300MCG/ML,
500MCG/ML
ARCALYST
ARRANON
ARZERRA INJ
100MG/5ML
ascomp/codeine
astramorph
ATELVIA
atenolol
atenolol/chlorthal
idone
ATGAM
atorvastatin
calcium
ATRIPLA
atropine sulfate
inj 0.05mg/ml,
0.1mg/ml
ATROVENT HFA
augmented
betamethasone
dipropionate
AUGMENTIN
SUSR
125MG/5ML
31.25MG/5ML
AVASTIN INJ
100MG/4ML
AVELOX INJ
AVELOX TABS
AVELOX ABC
PACK
aviane
AVODART
AVONEX
AVONEX PEN
AZACTAM IN
ISO-OSMOTIC
3
PA
72
3
PA MO
72
3
5
2
2
3
5
2
4
PA
PA QL(60/30) MO
MO
MO
MO
MO
MO
PA
72
58
78
72
75
60
72
64
5
PA
64
Drug Tier
5
4
5
Reqs / Limits
PA
B/D PA MO
PA QL(360/30)
Page
75
56
58
2
4
3
1
1
QL(4/28) MO
MO
MO
46
46
75
65
65
4
2
B/D PA
QL(30/30) MO
74
67
5
4
MO
60
69
3
2
QL(26/30) MO
79
70
3
5
50
B/D PA
4
3
3
2
3
5
5
4
58
51
51
51
MO
MO
PA QL(4/28)
PA QL(4/28)
72
70
75
68
50
correo
5
Drug Name
Drug Tier
Reqs / Limits
Page
Drug Name
Drug Tier
Reqs / Limits
Page
DEXTROSE
BANZEL TABS
4
PA MO
52
AZASAN
3
B/D PA MO
74
200MG
AZASITE
3
50
BARACLUDE
3
MO
61
azathioprine
2
MO
74
bd needle/30g x
2
QL(200/30) MO
76
azathioprine
4
74
1/2
sodium
bd pen
2
QL(200/30) MO
76
needle/mini/ultraf
azelastine hcl
2
77
ine/31g x 3/16
ophthalmic soln
bd pen
2
QL(200/30) MO
76
azelastine hcl
2
QL(60/30)
78
needle/nano/ultr
nasal soln
a fine/32g x 4mm
AZILECT
3
53
bd pen
2
76
azithromycin inj
4
50
needle/ultrafine/2
500mg
9g x 12.7mm
azithromycin
2
QL(3/30)
50
benazepril hcl
1
MO
65
pack
benazepril
2
MO
65
azithromycin
2
QL(75/30)
50
hcl/hydrochloroth
susr 200mg/5ml
iazide
azithromycin
2
QL(150/30)
50
BENICAR
3
QL(30/30) ST MO 65
susr 100mg/5ml
BENICAR HCT
3
QL(30/30) ST MO 65
azithromycin
2
QL(12/28)
51
benztropine
4
PA
58
tabs
mesylate inj
AZOPT
3
78
benztropine
1
PA MO
58
aztreonam
4
50
mesylate tabs
B
2mg
baciim
4
48
benztropine
2
PA MO
58
bacitracin
2
48
mesylate tabs
ophthalmic oint
0.5mg, 1mg
bacitracin/polym
2
48
betamethasone
2
70
yxin b
dipropionate
baclofen tabs
1
MO
60
betamethasone
2
70
10mg
valerate
baclofen tabs
2
MO
60
MO
65
betaxolol hcl
2
20mg
betaxolol hcl
2
MO
65
BACTROBAN
3
48
bethanechol
2
70
NASAL
chloride
2
MO
75
balsalazide
bicalutamide
2
74
disodium
BICNU
4
B/D PA
56
balziva
2
MO
72
bisoprolol
2
MO
65
BANZEL SUSP
5
PA MO
52
fumarate
BANZEL TABS
5
PA MO
52
bisoprolol
1
MO
65
400MG
correo
6
Drug Name
fumarate/hydroc
hlorothiazide
bleomycin
sulfate
BLEPHAMIDE
blephamide
s.o.p.
BOOSTRIX
BOSULIF
briellyn
BRILINTA
brimonidine
tartrate
ophthalmic soln
0.2%
bromfenac
bromocriptine
mesylate
budeprion sr
tb12 100mg
budeprion sr
tb12 150mg
budesonide cp24
budesonide susp
bumetanide inj
bumetanide tabs
0.5mg, 1mg
bumetanide tabs
2mg
BUPHENYL
buprenorphine
hcl inj
buprenorphine
hcl subl
buprenorphine
hcl/naloxone hcl
buproban
bupropion hcl
bupropion hcl er
Drug Tier
4
Reqs / Limits
B/D PA
3
2
4
5
2
3
2
2
2
Page
56
51
51
PA
QL(60/30) MO
MO
MO
75
57
72
64
78
77
58
2
QL(60/30) MO
53
2
QL(90/30) MO
53
2
2
4
1
75
B/D PA QL(120/30) 78
67
MO
67
2
MO
67
5
4
MO
PA
69
47
2
PA QL(24/30)
47
2
2
2
2
PA QL(90/30)
QL(60/30) MO
MO
QL(60/30) MO
47
47
53
53
Drug Name
Drug Tier
tb12 200mg
bupropion hcl sr
tb12 150mg
bupropion hcl sr
tb12 100mg,
200mg
bupropion hcl sr
tb12 150mg
bupropion hcl xl
tb24 300mg
bupropion hcl xl
tb24 150mg
buspirone hcl
tabs 10mg, 5mg
buspirone hcl
tabs 15mg,
30mg, 7.5mg
BUSULFEX
butalbital/acetam
inophen/caffeine/
codeine
butorphanol
tartrate inj
butorphanol
tartrate nasal
soln
BYDUREON
BYETTA
C
cabergoline
cafergot
calcipotriene
crea
calcipotriene
external soln
calcipotriene oint
calcitoninsalmon
calcitriol caps
Reqs / Limits
Page
2
PA QL(60/30) MO 47
2
QL(60/30) MO
53
2
QL(90/30) MO
53
2
QL(30/30) MO
53
2
QL(90/30) MO
53
1
61
2
61
5
2
B/D PA
PA QL(180/30)
4
56
46
46
2
QL(5/30)
46
3
3
QL(4/28)
QL(2.4/30) MO
62
62
2
2
2
73
55
68
2
68
2
2
QL(120/30)
QL(3.7/30) MO
68
75
2
B/D PA MO
75
correo
7
Drug Name
Drug Tier
Reqs / Limits
Page
Drug Name
Drug Tier
Reqs / Limits
Page
calcitriol inj
4
B/D PA
75
cartia xt
2
MO
66
calcitriol oral soln
2
B/D PA MO
75
carvedilol
1
MO
65
CEENU
3
56
calcium acetate
2
MO
80
cefaclor caps
2
49
caps
calcium acetate
2
MO
80
cefaclor er
2
49
tabs 667mg
cefadroxil
2
49
calcium folinate
4
56
cefazolin sodium
4
49
camila
2
MO
73
inj 10gm, 1gm,
CAMPRAL
3
PA QL(180/30) MO 47
1gm 5%, 500mg
CANCIDAS
5
PA
55
cefazolin
4
49
candesartan
2
MO
67
sodium/dextrose
cilexetil/hydrochl
inj 2gm 3%
orothiazide
cefdinir
2
49
CAPASTAT
4
56
cefepime inj
4
49
SULFATE
1gm, 1gm/50ml
CAPRELSA
5
PA
56
5%, 2gm,
captopril
1
MO
65
2gm/100ml,
captopril/hydroch
2
MO
65
2gm/50ml 5%
lorothiazide
cefotaxime
4
49
CARAC
3
68
sodium
CARAFATE
3
MO
70
cefotetan
4
50
SUSP
cefoxitin sodium
4
49
CARBAGLU
5
69
inj 10gm, 1gm,
carbamazepine
2
MO
52
2gm
carbamazepine
2
52
cefpodoxime
2
49
er cp12
proxetil
carbamazepine
2
MO
52
cefprozil
2
49
er tb12
ceftazidime inj
4
49
carbidopa/levodo
2
MO
58
1gm, 2gm, 6gm
pa
ceftazidime/dextr
4
49
2
MO
58
carbidopa/levodo
ose
pa cr
ceftriaxone in
4
49
carbidopa/levodo
2
MO
58
iso-osmotic
pa er
dextrose
2
MO
58
carbidopa/levodo
ceftriaxone
4
49
pa odt
sodium
carbidopa/levodo
2
MO
58
cefuroxime axetil
2
49
pa/entacapone
cefuroxime
4
50
carboplatin inj
4
B/D PA
56
sodium inj
150mg/15ml
1.5gm, 7.5gm,
carteolol hcl
2
MO
78
750mg
correo
8
Drug Name
CELEBREX
CELESTONE
CELLCEPT
SUSR
CELLCEPT
INTRAVENOUS
CELONTIN
cephalexin caps
250mg, 500mg
cephalexin susr
cephalexin tabs
CEREZYME
cerubidine
CERVARIX
CHANTIX
CHANTIX
STARTING
MONTH PAK
CHEMET
chloramphenicol
sodium
succinate
chlorhexidine
gluconate oral
rinse
chloroquine
phosphate
chlorothiazide
chlorothiazide
sodium
chlorpromazine
hcl inj
chlorpromazine
hcl tabs
chlorthalidone
tabs 25mg,
50mg
chlorzoxazone
cholestyramine
Drug Tier
Reqs / Limits
Page
3
3
3
QL(60/30) ST MO 47
70
B/D PA
74
4
B/D PA
74
3
1
MO
52
50
2
2
5
4
4
3
3
B/D PA
B/D PA
PA QL(340/365)
PA QL(106/365)
3
1
50
50
69
56
75
47
47
80
48
1
68
2
MO
58
2
4
MO
B/D PA
67
67
4
58
2
MO
58
1
MO
67
2
2
PA MO
MO
80
67
Drug Name
cholestyramine
light
chorionic
gonadotropin
ciclopirox sham
ciclopirox susp
ciclopirox nail
lacquer
ciclopirox
olamine
cidofovir
cilostazol
CILOXAN OINT
cimetidine
cimetidine hcl inj
cimetidine hcl
oral soln
CIPRO HC
CIPRODEX
ciprofloxacin inj
400mg/40ml
ciprofloxacin er
ciprofloxacin hcl
ophthalmic soln
ciprofloxacin hcl
tabs 100mg,
750mg
ciprofloxacin hcl
tabs 250mg,
500mg
ciprofloxacin i.v.in d5w
cisplatin inj
100mg/100ml
citalopram
hydrobromide
oral soln
citalopram
hydrobromide
Drug Tier
Reqs / Limits
Page
2
MO
67
4
PA
72
2
2
2
55
55
55
2
55
5
2
3
2
4
2
60
64
51
69
69
69
MO
MO
MO
3
3
4
51
51
51
2
2
51
51
2
51
1
51
4
51
4
B/D PA
56
1
QL(600/30) MO
53
1
QL(30/30) MO
53
correo
9
Drug Name
Drug Tier
Reqs / Limits
Page
Drug Name
Drug Tier
Reqs / Limits
Page
tabs 40mg
SE 5%
citalopram
1
QL(60/30) MO
53
CLINIMIX
4
B/D PA
62
hydrobromide
5%/DEXTROSE
tabs 10mg,
15%
20mg
CLINIMIX
4
B/D PA
62
cladribine
4
B/D PA
56
5%/DEXTROSE
claravis
2
68
20%
CLINIMIX
4
B/D PA
80
clarithromycin
2
51
5%/DEXTROSE
clarithromycin er
2
QL(60/30)
51
25%
clindamycin hcl
2
48
CLINIMIX E
3
B/D PA
62
clindamycin
2
48
4.25%/DEXTRO
phosphate crea
SE 25%
4
48
clindamycin
clinisol sf 15%
4
B/D PA
80
phosphate inj
clobetasol
2
70
150mg/ml
propionate crea
clindamycin
2
68
clobetasol
2
71
phosphate
propionate
external soln
external soln
clindamycin
2
68
clobetasol
2
71
phosphate gel
propionate foam
clindamycin
2
68
clobetasol
2
71
phosphate lotn
propionate gel
clindamycin
2
68
clobetasol
2
71
phosphate swab
propionate oint
clindamycin
4
48
clobetasol
2
70
phosphate addpropionate e
vantage
CLOLAR
4
B/D PA
56
CLINIMIX
4
B/D PA
80
clomipramine hcl
2
PA MO
54
2.75%/DEXTRO
clonazepam tabs
2
QL(90/30)
52
SE 5%
0.5mg, 1mg
clinimix
4
B/D PA
80
clonazepam tabs
2
QL(300/30)
52
4.25%/dextrose
2mg
10%
clonazepam odt
2
QL(90/30)
52
clinimix
4
B/D PA
62
tbdp 0.125mg,
4.25%/dextrose
0.25mg, 0.5mg,
20%
1mg
clinimix
4
B/D PA
80
clonazepam odt
2
QL(300/30)
52
4.25%/dextrose
tbdp 2mg
25%
2
QL(4/28) MO
64
clonidine hcl
CLINIMIX
4
B/D PA
80
ptwk 0.1mg/24hr,
4.25%/DEXTRO
correo
10
Drug Name
0.2mg/24hr
clonidine hcl
ptwk 0.3mg/24hr
clonidine hcl tabs
0.3mg
clonidine hcl tabs
0.1mg, 0.2mg
clopidogrel tabs
300mg
clopidogrel tabs
75mg
clorazepate
dipotassium tabs
3.75mg, 7.5mg
clorazepate
dipotassium tabs
15mg
clotrimazole
external crea
clotrimazole
external soln
clotrimazole troc
clotrimazole/beta
methasone
dipropionate
clozapine
CLOZAPINE
ODT TBDP
100MG
clozapine odt
tbdp 12.5mg,
25mg
COARTEM
co-gesic
COLCRYS
colestipol hcl
colistimethate
sodium
colocort
Drug Tier
Reqs / Limits
Page
2
QL(8/28) MO
64
2
MO
64
1
MO
64
2
QL(1/30) MO
64
2
QL(30/30) MO
64
2
QL(90/30)
52
2
QL(120/30)
52
2
55
2
55
2
2
55
71
2
4
60
60
4
3
2
3
2
4
2
MO
60
QL(240/30)
MO
MO
58
46
55
67
49
75
Drug Name
Drug Tier
COMBIGAN
COMBIVENT
RESPIMAT
COMETRIQ
COMPLERA
compro
COMVAX
constulose
COPAXONE
COREG CR
cortisone acetate
CORTISPORINTC
COSMEGEN
COUMADIN INJ
CREON CPEP
120000UNIT
24000UNIT
76000UNIT,
15000UNIT
3000UNIT
9500UNIT,
30000UNIT
6000UNIT
19000UNIT,
60000UNIT
12000UNIT
38000UNIT
CRESTOR
CRIXIVAN
cromolyn sodium
conc
cromolyn sodium
ophthalmic soln
cromolyn sodium
nebu
cryselle-28
CUBICIN
CUPRIMINE
Reqs / Limits
Page
3
3
MO
QL(8/30) MO
78
79
5
5
2
4
1
5
3
2
3
PA
MO
56
60
58
75
70
68
65
71
78
5
4
3
B/D PA
MO
56
63
69
3
3
2
QL(30/30) MO
MO
MO
67
60
69
MO
PA QL(30/30)
MO
2
77
2
B/D PA MO
79
2
5
3
MO
B/D PA
72
49
80
correo
11
Drug Name
Drug Tier
Reqs / Limits
Page
Drug Name
Drug Tier
Reqs / Limits
Page
DEPEN
3
80
curity gauze
2
68
TITRATABS
pads 2x2
DEPO4
72
cyclophosphami
4
B/D PA
56
ESTRADIOL
de inj
DEPO-MEDROL
4
71
cyclophosphami
2
B/D PA
56
INJ 20MG/ML
de tabs
DEPO4
73
cycloserine
2
56
PROVERA
CYCLOSET
4
62
desipramine hcl
2
MO
54
cyclosporine
2
B/D PA
74
desloratadine
2
QL(30/30)
78
caps
desloratadine odt
2
QL(30/30)
78
cyclosporine inj
4
B/D PA
74
desmopressin
4
72
cyclosporine
2
B/D PA
74
acetate inj
modified
desmopressin
2
MO
72
CYMBALTA
3
QL(60/30) MO
53
acetate nasal
cyproheptadine
1
78
soln
hcl
desmopressin
2
MO
72
CYSTADANE
5
69
acetate tabs
CYSTAGON
3
69
desonide lotn
2
71
cytarabine
4
B/D PA
56
desonide oint
2
71
cytarabine
4
B/D PA
56
desoximetasone
2
71
aqueous
crea
D
desoximetasone
2
71
dacarbazine
4
B/D PA
56
gel
DACOGEN
5
57
desoximetasone
2
71
dactinomycin
5
B/D PA
57
oint 0.25%
DALIRESP
3
PA QL(30/30) MO 79
DESVENLAFAXI
3
QL(30/30) MO
53
danazol
2
72
NE ER
dantrolene
2
60
dexamethasone
2
71
sodium caps
elix
dapsone
2
MO
56
dexamethasone
1
71
DAPTACEL
4
75
tabs 0.5mg,
DARAPRIM
3
58
0.75mg, 4mg
daunorubicin hcl
4
B/D PA
57
dexamethasone
2
71
inj 5mg/ml
tabs 1.5mg,
DAUNOXOME
5
B/D PA
57
1mg, 2mg, 6mg
decavac
4
75
DEXAMETHASO
3
71
DELZICOL
3
MO
75
NE
INTENSOL
DEMECLOCYCL
2
51
4
71
dexamethasone
INE HCL
sodium
DENAVIR
3
61
phosphate inj
depade
2
PA
47
correo
12
Drug Name
dexamethasone
sodium
phosphate
ophthalmic soln
DEXILANT
dexmethylphenid
ate hcl
dexrazoxane
dextroamphetam
ine sulfate tabs
5mg
dextroamphetam
ine sulfate tabs
10mg
dextroamphetam
ine sulfate er
cp24 10mg, 5mg
dextroamphetam
ine sulfate er
cp24 15mg
dextrose
10%/nacl 0.45%
dextrose 5%
/electrolyte #48
viaflex
dextrose 10%
flex container
dextrose
10%/nacl 0.2%
dextrose
2.5%/nacl 0.45%
dextrose
2.5%/sodium
chloride 0.45%
dextrose 5%
dextrose
5%/lactated
ringers
dextrose 5%/nacl
Drug Tier
Reqs / Limits
2
Page
Drug Name
77
0.2%
dextrose 5%/nacl
0.225%
dextrose 5%/nacl
0.33%
dextrose 5%/nacl
0.45%
dextrose 5%/nacl
0.9%
dextrose
5%/potassium
chloride 0.15%
dextrose
5%/sodium
chloride 0.2%
dextrose
5%/sodium
chloride 0.45%
DIAZEPAM GEL
diazepam oral
soln
diazepam tabs
DIBENZYLINE
diclofenac
potassium
diclofenac
sodium
diclofenac
sodium dr tbec
25mg, 50mg
diclofenac
sodium dr tbec
75mg
diclofenac
sodium er
dicloxacillin
sodium
dicyclomine hcl
caps
3
2
QL(30/30) MO
QL(60/30) MO
70
68
4
2
B/D PA
QL(90/30) MO
57
68
2
2
2
4
4
QL(180/30) MO
QL(90/30) MO
QL(120/30) MO
68
68
68
62
80
4
62
4
62
4
62
4
4
4
4
62
62
80
62
Drug Tier
Reqs / Limits
Page
4
62
4
62
4
62
4
62
4
81
4
62
4
62
3
2
52
61
QL(1200/30)
2
3
2
QL(120/30)
MO
61
64
47
2
MO
77
2
MO
48
1
MO
48
2
MO
48
2
50
1
69
correo
13
Drug Name
Drug Tier
Reqs / Limits
Page
Drug Name
Drug Tier
Reqs / Limits
Page
dicyclomine hcl
2
69
divalproex
2
MO
52
oral soln
sodium
dicyclomine hcl
1
69
divalproex
2
MO
52
tabs
sodium dr
didanosine
2
MO
60
divalproex
2
MO
52
diflorasone
2
71
sodium er
diacetate
DOCEFREZ
5
B/D PA
57
diflunisal
2
MO
48
docetaxel inj
5
B/D PA
57
digoxin inj
4
PA
66
20mg/ml,
digoxin tabs
1
QL(30/30) MO
66
80mg/4ml,
0.125mg
80mg/8ml
digoxin tabs
1
PA MO
66
donepezil hcl
2
QL(30/30) MO
53
0.25mg
tabs 5mg
dihydroergotami
3
55
donepezil hcl
2
QL(60/30) MO
53
ne mesylate inj
tabs 10mg
dilantin caps
2
MO
52
donepezil hcl
2
QL(30/30) MO
53
30mg
tbdp 5mg
dilt-cd cp24
2
MO
66
donepezil hcl
2
QL(60/30) MO
53
120mg, 180mg,
tbdp 10mg
300mg
dorzolamide hcl
2
MO
66
diltiazem cd
2
MO
66
dorzolamide
2
MO
78
diltiazem hcl inj
4
66
hcl/timolol
100mg,
maleate
25mg/5ml,
doxazosin
1
QL(30/30) MO
64
50mg/10ml
mesylate tabs
diltiazem hcl tabs
1
MO
66
1mg, 2mg, 4mg
diltiazem hcl er
2
MO
66
doxazosin
1
QL(60/30) MO
65
cp12
mesylate tabs
diltiazem hcl er
2
MO
66
8mg
cp24 120mg,
PA MO
54
doxepin hcl
2
doxorubicin hcl
2
B/D PA
57
180mg, 300mg,
360mg, 420mg
inj 2mg/ml
dilt-xr cp24
2
MO
66
DOXORUBICIN
5
B/D PA
57
180mg, 240mg
HCL LIPOSOME
diltzac
2
MO
66
doxycycline caps
2
51
75mg
diphenoxylate/atr
2
69
opine
doxycycline
1
51
hyclate caps
disulfiram tabs
2
47
doxycycline
2
51
250mg
disulfiram tabs
2
MO
47
hyclate cpep
doxycycline
4
51
500mg
correo
14
Drug Name
hyclate inj
doxycycline
hyclate tabs
100mg
doxycycline
hyclate tabs
20mg
doxycycline
monohydrate
dronabinol
DROXIA
DULERA
duramorph
DUREZOL
E
E.E.S.
GRANULES
econazole nitrate
EDARBI
EDARBYCLOR
EDECRIN
EDURANT
ELAPRASE
ELIDEL
ELIGARD INJ
30MG
ELIGARD INJ
45MG
ELIGARD INJ
7.5MG
ELIGARD INJ
22.5MG
ELIQUIS
ELITEK
ELLENCE INJ
200MG/100ML
ELMIRON
ELSPAR
EMCYT
Drug Tier
Reqs / Limits
1
51
2
51
2
2
3
3
4
3
Page
51
PA QL(90/30)
MO
QL(13/30)
54
56
78
46
77
3
51
2
3
3
3
3
5
3
4
55
QL(30/30) ST MO 65
QL(30/30) ST
65
MO
67
60
PA
69
68
PA QL(1/120)
73
4
PA QL(1/180)
73
4
PA QL(1/30)
73
4
PA QL(1/90)
73
3
5
4
3
4
3
PA QL(60/30)
B/D PA
B/D PA
63
56
57
B/D PA
70
57
56
Drug Name
Drug Tier
EMEND CAPS
40MG
EMEND CAPS
125MG
EMEND CAPS
80MG
EMSAM
EMTRIVA
enalapril maleate
enalapril
maleate/hydrochl
orothiazide
ENBREL
ENBREL
SURECLICK
endocet tabs
650mg 10mg
endocet tabs
500mg 7.5mg
endocet tabs
325mg 10mg,
325mg 5mg,
325mg 7.5mg
ENGERIX-B
ENOXAPARIN
SODIUM INJ
120MG/0.8ML
ENOXAPARIN
SODIUM INJ
100MG/ML,
150MG/ML
ENOXAPARIN
SODIUM INJ
30MG/0.3ML
ENOXAPARIN
SODIUM INJ
40MG/0.4ML
ENOXAPARIN
SODIUM INJ
Reqs / Limits
Page
3
B/D PA QL(1/30)
54
3
B/D PA QL(2/30)
54
3
B/D PA QL(6/30)
54
3
3
1
1
MO
MO
MO
MO
53
60
65
65
5
5
PA QL(8/28)
PA QL(8/28)
74
74
2
QL(180/30)
46
2
QL(240/30)
46
2
QL(360/30)
46
4
5
B/D PA
QL(22.4/30)
75
63
5
QL(28/30)
63
4
QL(8.4/30)
63
4
QL(11.2/30)
63
4
QL(16.8/30)
63
correo
15
Drug Name
Drug Tier
Reqs / Limits
Page
Drug Name
Drug Tier
Reqs / Limits
Page
60MG/0.6ML
ethylsuccinate
ENOXAPARIN
4
QL(22.4/30)
63
erythromycin/ben
2
68
SODIUM INJ
zoyl peroxide
80MG/0.8ML
erythromycin/sulf
2
51
ENOXAPARIN
4
QL(84/30)
63
isoxazole
SODIUM INJ
escitalopram
2
QL(600/30) MO
53
300MG/3ML
oxalate oral soln
enpresse-28
2
MO
72
escitalopram
2
QL(60/30) MO
54
entacapone
2
MO
58
oxalate tabs
enulose
1
MO
70
estradiol ptwk
2
PA QL(8/28) MO 72
epinastine hcl
2
77
estradiol tabs
2
PA MO
72
estradiol valerate
4
72
epinephrine hcl
4
79
estradiol/norethin
2
PA MO
72
EPIPEN-JR 23
QL(2/30)
79
drone acetate
PAK
ESTRING
3
QL(1/90) MO
72
epirubicin hcl inj
4
B/D PA
57
ethambutol hcl
2
56
50mg/25ml
epirubicin hcl inj
5
B/D PA
57
ethosuximide
2
MO
52
200mg/100ml
etidronate
2
76
EPIVIR ORAL
3
disodium
MO
60
etodolac
2
MO
48
SOLN
etodolac er
2
MO
48
EPIVIR HBV
3
MO
60
EPZICOM
5
MO
60
ETOPOPHOS
4
B/D PA
57
ETOPOSIDE INJ
3
B/D PA
57
ERBITUX
5
B/D PA
58
EVISTA
3
QL(30/30) MO
73
ERIVEDGE
5
PA QL(30/30)
57
EXELON ORAL
3
QL(180/30) MO
53
errin
2
MO
73
ery
2
51
SOLN
EXELON PT24
3
QL(30/30) MO
53
ERYPED 200
3
51
exemestane
2
57
ERYPED 400
3
51
EXFORGE
3
MO
66
ERY-TAB
3
51
EXFORGE HCT
3
MO
66
ERYTHROCIN
4
51
EXJADE TBSO
4
MO
80
LACTOBIONAT
125MG
E
EXJADE TBSO
5
MO
80
erythrocin
2
51
250MG, 500MG
stearate
F
erythromycin
2
51
FABRAZYME
5
B/D PA
69
external soln
famciclovir
2
QL(21/7)
61
51
erythromycin gel
2
famotidine
inj
4
69
erythromycin oint
2
51
famotidine tabs
2
MO
69
erythromycin
2
51
40mg
base
famotidine tabs
1
MO
70
erythromycin
2
51
correo
16
Drug Name
20mg
famotidine
premixed
FANAPT TABS
6MG
FANAPT TABS
10MG, 12MG,
1MG, 2MG,
4MG, 8MG
FANAPT
TITRATION
PACK
FARESTON
FASLODEX
FAZACLO
felbamate
felodipine er
FEMRING
fenofibrate caps
fenofibrate tabs
fenofibrate
micronized
fenoprofen
calcium
fentanyl
fentanyl citrate
FENTANYL
CITRATE ORAL
TRANSMUCOS
AL
finasteride tabs
5mg
firmagon inj
80mg
firmagon inj
120mg
flavoxate hcl
flecainide
acetate
Drug Tier
Reqs / Limits
4
5
4
4
Page
69
QL(60/30) ST
QL(60/30) ST
QL(16/30) ST
59
59
3
5
4
2
2
3
2
2
2
MO
MO
56
56
60
52
66
72
67
67
67
2
MO
48
2
4
5
QL(15/30)
46
46
46
2
4
MO
B/D PA
ST
MO
MO
MO
59
QL(120/30)
QL(30/30) MO
B/D PA QL(2/28)
70
73
4
B/D PA QL(2/365) 73
2
2
MO
MO
70
65
Drug Name
FLOVENT
DISKUS AEPB
250MCG/BLIST,
50MCG/BLIST
FLOVENT
DISKUS AEPB
100MCG/BLIST
FLOVENT HFA
AERO
44MCG/ACT
FLOVENT HFA
AERO
110MCG/ACT,
220MCG/ACT
fluconazole susr
fluconazole tabs
100mg, 200mg,
50mg
fluconazole tabs
150mg
fluconazole in
dextrose
fluconazole in
nacl
flucytosine
fludarabine
phosphate
fludrocortisone
acetate
flunisolide nasal
soln 29mcg/act
fluocinolone
acetonide crea
fluocinolone
acetonide
external soln
fluocinolone
acetonide oil
fluocinolone
Drug Tier
Reqs / Limits
Page
3
QL(120/30) MO
78
3
QL(180/30) MO
78
3
QL(22/30) MO
78
3
QL(24/30) MO
78
2
2
1
55
55
QL(8/30)
55
4
55
4
55
2
4
B/D PA
55
57
2
MO
71
2
QL(75/30)
78
2
71
1
71
2
71
2
71
correo
17
Drug Name
Drug Tier
Reqs / Limits
Page
Drug Name
Drug Tier
Reqs / Limits
Page
acetonide oint
propionate crea
fluocinonide
2
71
fluticasone
2
71
fluocinonide-e
2
71
propionate oint
2
QL(16/30)
78
fluticasone
fluorometholone
2
77
propionate susp
FLUOROPLEX
3
68
fluvastatin caps
2
QL(30/30) MO
67
fluorouracil inj
4
B/D PA
56
20mg
2.5gm/50ml
fluvastatin caps
2
QL(60/30) MO
67
fluorouracil crea
2
MO
68
40mg
fluorouracil
2
MO
68
fluvoxamine
2
MO
54
external soln
maleate
fluoxetine dr
2
MO
54
fluvoxamine
2
QL(60/30)
54
fluoxetine hcl
2
QL(30/30) MO
54
maleate
er
cp24
caps 10mg
150mg
fluoxetine hcl
2
QL(60/30) MO
54
fluvoxamine
2
QL(90/30)
54
caps 40mg
maleate er cp24
fluoxetine hcl
2
QL(120/30) MO
54
100mg
caps 20mg
FOLOTYN
5
B/D PA
56
fluoxetine hcl
2
MO
54
fomepizole
5
76
oral soln
fondaparinux
4
QL(7/30)
63
fluoxetine hcl
2
MO
54
sodium inj
tabs 20mg
2.5mg/0.5ml
fluoxetine hcl
2
QL(30/30) MO
54
FONDAPARINU
5
QL(5.6/30)
63
tabs 10mg
X SODIUM INJ
fluphenazine
4
58
5MG/0.4ML
decanoate
FONDAPARINU
5
QL(8.4/30)
63
fluphenazine hcl
2
MO
58
X SODIUM INJ
conc
7.5MG/0.6ML
fluphenazine hcl
2
MO
58
QL(11.2/30)
63
FONDAPARINU
5
elix
X SODIUM INJ
fluphenazine hcl
4
58
10MG/0.8ML
inj
FORADIL
3
QL(60/30) MO
79
fluphenazine hcl
1
MO
58
AEROLIZER
tabs 1mg
FORTEO
5
PA QL(2.4/28)
76
fluphenazine hcl
2
MO
58
foscarnet sodium
4
60
tabs 10mg,
fosinopril sodium
2
MO
65
2.5mg, 5mg
fosinopril
2
MO
65
flurbiprofen
2
MO
48
sodium/hydrochl
flurbiprofen
2
MO
77
orothiazide
sodium
fosphenytoin
4
52
74
flutamide
2
sodium
fluticasone
2
71
correo
18
Drug Name
FOSRENOL
CHEW 1000MG
FOSRENOL
CHEW 750MG
FOSRENOL
CHEW 500MG
freamine iii inj
72meq/l
600mg/100ml
810mg/100ml
3meq/l
14mg/100ml
1190mg/100ml
240mg/100ml
590mg/100ml
770mg/100ml
620mg/100ml
450mg/100ml
480mg/100ml
10mmole/l
115mg/100ml
950mg/100ml
500mg/100ml
10meq/l
340mg/100ml
130mg/100ml
560mg/100ml
FREAMINE III
3%
furosemide inj
furosemide oral
soln
furosemide tabs
FUSILEV
FUZEON
G
gabapentin
GABITRIL TABS
16MG
Drug Tier
Reqs / Limits
Page
3
QL(150/30) ST MO 70
3
QL(180/30) ST MO 70
3
QL(270/30) ST MO 70
4
4
4
2
B/D PA
81
B/D PA
81
MO
67
67
1
5
5
MO
MO
67
57
60
2
3
MO
QL(90/30)
52
52
Drug Name
GABITRIL TABS
12MG
galantamine
hydrobromide
cp24
galantamine
hydrobromide
oral soln
galantamine
hydrobromide
tabs
gamastan s/d
GAMMAGARD
LIQUID
GAMUNEX-C
INJ
10GM/100ML,
2.5GM/25ML,
20GM/200ML,
5GM/50ML
GAMUNEX-C
INJ 1GM/10ML
ganciclovir
GARDASIL
gemcitabine
gemcitabine hcl
gemfibrozil
generlac
gengraf
gentak oint
gentamicin
sulfate crea
gentamicin
sulfate inj
gentamicin
sulfate oint 0.1%
gentamicin
sulfate
ophthalmic soln
Drug Tier
Reqs / Limits
Page
3
QL(120/30)
52
2
QL(30/30) MO
53
2
QL(200/30)
53
2
QL(60/30) MO
53
4
5
B/D PA
B/D PA
74
74
5
B/D PA
74
4
B/D PA
75
4
4
4
5
2
2
2
2
2
B/D PA
60
75
56
56
67
70
74
48
48
B/D PA
B/D PA
MO
MO
B/D PA
4
48
2
48
2
48
correo
19
Drug Name
Drug Tier
Reqs / Limits
Page
Drug Name
Drug Tier
Reqs / Limits
Page
griseofulvin
2
55
gentamicin
4
48
microsize
sulfate/0.9%
GRIS-PEG
3
55
sodium chloride
guanidine hcl
1
56
inj 0.9mg/ml
0.9%, 1.2mg/ml
H
0.9%, 1.4mg/ml
HALAVEN
5
PA
57
0.9%, 1.6mg/ml
halobetasol
2
71
0.9%, 1mg/ml
propionate
0.9%
haloperidol conc
2
MO
58
gentamicin
4
48
haloperidol tabs
1
MO
58
sulfate/sodium
0.5mg, 1mg,
chloride
2mg, 5mg
GEODON INJ
4
QL(60/30)
59
haloperidol tabs
2
MO
59
GLEEVEC
5
PA QL(60/30)
57
10mg, 20mg
glimepiride tabs
1
QL(30/30) MO
62
haloperidol
4
58
1mg, 2mg
decanoate
glimepiride tabs
1
QL(60/30) MO
62
haloperidol
4
58
4mg
lactate
glipizide
1
MO
62
HAVRIX
4
75
glipizide er
1
MO
62
3
B/D PA MO
76
HECTOROL
glipizide xl tb24
1
MO
62
CAPS
2.5mg
HECTOROL INJ
4
B/D PA
76
glipizide/metform
1
MO
62
heparin sodium
4
63
in hcl
inj 10000unit/ml,
GLUCAGEN
4
62
1000unit/ml,
HYPOKIT
20000unit/ml,
glyburide
2
PA MO
62
2000unit/ml,
glyburide
2
PA MO
62
2500unit/ml,
micronized
5000unit/ml
glyburide/metfor
2
PA MO
62
heparin
4
64
min hcl
sodium/d5w
4
69
glycopyrrolate inj
heparin
4
64
4mg/20ml
sodium/nacl
glycopyrrolate
2
69
0.9%
tabs
4
64
heparin
GLYSET
3
MO
62
sodium/sodium
granisetron hcl
4
B/D PA
55
chloride 0.9%
inj 0.1mg/ml,
premix
1mg/ml
hepatamine
4
B/D PA
81
granisetron hcl
2
B/D PA QL(60/30) 55
HEPSERA
5
QL(30/30) MO
61
tabs
HERCEPTIN
5
B/D PA
58
correo
20
Drug Name
HEXALEN
HUMALOG
HUMALOG
KWIKPEN
humalog mix
50/50
humalog mix
50/50 kwikpen
humalog mix
75/25
humalog mix
75/25 kwikpen
HUMIRA INJ
20MG/0.4ML
HUMIRA INJ
40MG/0.8ML
HUMIRA PEN
HUMIRA PENCROHNS
DISEASESTART
ER
humulin 70/30
humulin 70/30
pen
humulin n
humulin n u-100
pen
humulin r
humulin r u-500
(concentrated)
hydralazine hcl
inj
hydralazine hcl
tabs
hydrochlorothiazi
de caps
hydrochlorothiazi
de tabs 25mg,
50mg
Drug Tier
Reqs / Limits
Page
Drug Name
5
3
3
MO
MO
56
63
63
3
MO
63
3
MO
63
3
MO
63
hydrochlorothiazi
de tabs 12.5mg
hydrocodone
bitartrate/acetam
inophen tabs
750mg 10mg
hydrocodone/ace
taminophen oral
soln
hydrocodone/ace
taminophen tabs
750mg 7.5mg
hydrocodone/ace
taminophen tabs
650mg 10mg,
650mg 7.5mg,
660mg 10mg
hydrocodone/ace
taminophen tabs
500mg 10mg,
500mg 2.5mg,
500mg 5mg,
500mg 7.5mg
hydrocodone/ace
taminophen tabs
325mg 10mg,
325mg 5mg,
325mg 7.5mg
hydrocodone/ibu
profen tabs
7.5mg 200mg
hydrocortisone
crea 1%, 2.5%
hydrocortisone
lotn
hydrocortisone
lotn
hydrocortisone
oint 1%, 2.5%
3
MO
63
5
PA QL(2/28)
74
5
PA QL(4/28)
74
5
5
PA QL(4/28)
PA QL(6/28)
74
74
3
3
MO
MO
63
63
3
3
MO
MO
63
63
3
3
MO
MO
63
63
4
2
1
1
67
MO
MO
MO
67
67
67
Drug Tier
Reqs / Limits
Page
2
MO
67
2
QL(150/30)
46
2
QL(3600/30)
46
2
QL(150/30)
46
2
QL(180/30)
46
2
QL(240/30)
46
2
QL(360/30)
46
2
QL(150/30)
47
1
71
2
71
2
71
2
71
correo
21
Drug Name
Drug Tier
Reqs / Limits
Page
Drug Name
Drug Tier
Reqs / Limits
Page
hydrocortisone
2
71
pamoate
tabs
imiquimod
2
68
hydrocortisone
2
71
IMOVAX
4
75
butyrate
RABIES
hydrocortisone
2
71
(H.D.C.V.)
valerate
INCIVEK
5
PA QL(180/30)
61
hydrocortisone/a
2
78
INCRELEX
4
PA
72
cetic acid
indapamide
1
MO
67
HYDROMORPH
4
47
INFANRIX
4
75
ONE HCL INJ
INFERGEN INJ
5
PA
61
1MG/ML,
15MCG/0.5ML
2MG/ML,
infumorph 200
4
46
500MG/50ML
infumorph 500
4
46
hydromorphone
4
47
INLYTA TABS
5
PA QL(120/30)
57
hcl inj 2mg/ml
5MG
hydromorphone
2
QL(1200/30)
47
INLYTA TABS
5
PA QL(240/30)
57
hcl liqd
1MG
hydromorphone
2
QL(240/30)
47
INTELENCE
5
QL(60/30)
60
hcl tabs
TABS 200MG
hydroxychloroqui
2
MO
58
INTELENCE
5
QL(120/30) MO
60
ne sulfate
TABS 100MG
hydroxyurea
2
56
INTELENCE
5
QL(180/30) MO
60
I
TABS 25MG
ibandronate
2
QL(1/28)
76
INTRALIPID INJ
4
B/D PA
76
sodium
1.7% 30%
ibuprofen susp
1
MO
48
intralipid inj
4
B/D PA
76
ibuprofen tabs
1
MO
48
2.25% 20%
400mg, 600mg,
INTRON-A
4
61
800mg
INTRON-A
4
61
ICLUSIG
5
PA
57
W/DILUENT INJ
idarubicin hcl inj
5
B/D PA
57
10MU, 18MU
10mg/10ml
INVANZ
4
50
ifosfamide inj
4
B/D PA
56
INVEGA TB24
5
QL(30/30) ST
59
1gm, 3gm
9MG
ifosfamide/mesn
5
B/D PA
56
INVEGA TB24
4
QL(30/30) ST
59
a
1.5MG, 3MG
ILARIS
5
PA
75
INVEGA TB24
4
QL(60/30) ST
59
imipenem/cilasta
2
50
6MG
tin
INVEGA
4
QL(0.25/28)
59
imipramine hcl
2
PA MO
54
SUSTENNA INJ
imipramine
2
PA MO
54
39MG/0.25ML
correo
22
Drug Name
INVEGA
SUSTENNA INJ
78MG/0.5ML
INVEGA
SUSTENNA INJ
117MG/0.75ML
INVEGA
SUSTENNA INJ
156MG/ML
INVEGA
SUSTENNA INJ
234MG/1.5ML
INVIRASE
IPOL
INACTIVATED
IPV
ipratropium
bromide
inhalation soln
ipratropium
bromide nasal
soln 0.06%
ipratropium
bromide nasal
soln 0.03%
ipratropium
bromide/albutero
l sulfate
irbesartan
irbesartan/hydro
chlorothiazide
irinotecan inj
100mg/5ml
ISENTRESS
CHEW 100MG
ISENTRESS
CHEW 25MG
ISENTRESS
TABS
Drug Tier
4
Reqs / Limits
Page
Drug Name
QL(0.5/28)
59
isolytem/dextrose 5%
isoniazid inj
isoniazid syrp
isoniazid tabs
100mg
isoniazid tabs
300mg
isosorbide
dinitrate
isosorbide
dinitrate er
isosorbide
mononitrate
isosorbide
mononitrate er
isotonic
gentamicin inj
0.8mg/ml 0.9%,
1.2mg/ml 0.9%,
1.6mg/ml 0.9%,
1mg/ml 0.9%
isradipine
ISTODAX
itraconazole
IXEMPRA KIT
IXIARO
J
JAKAFI
JALYN
jantoven
JANUMET
JANUMET XR
TB24 500MG
50MG
JANUMET XR
TB24 1000MG
100MG, 1000MG
50MG
5
QL(0.75/28)
59
5
QL(1/28)
59
5
5
4
QL(1.5/28)
MO
59
60
75
2
B/D PA QL(300/30) 79
MO
2
QL(30/30) MO
79
2
QL(60/30) MO
79
2
B/D PA QL(540/30) 79
MO
1
1
MO
MO
65
65
4
B/D PA
57
5
QL(180/30)
60
5
QL(360/30)
60
5
QL(60/30) MO
60
Drug Tier
4
Reqs / Limits
B/D PA
Page
81
4
2
2
56
56
56
1
56
2
MO
67
2
MO
67
2
MO
67
2
MO
67
4
48
2
5
2
5
4
MO
PA MO
PA QL(120/30)
B/D PA
66
57
55
57
75
5
3
2
3
3
PA QL(60/30)
MO
MO
QL(60/30) MO
QL(30/30) MO
57
70
64
62
62
3
QL(60/30) MO
62
correo
23
Drug Name
Drug Tier
Reqs / Limits
Page
Drug Name
Drug Tier
Reqs / Limits
Page
JANUVIA
3
QL(30/30) MO
62
ketoconazole
2
55
JENTADUETO
3
QL(60/30) MO
62
sham
JE-VAX
4
75
ketoconazole
2
55
JEVTANA
5
B/D PA
57
tabs
junel 1.5/30
2
MO
72
ketoprofen
2
MO
48
junel 1/20
2
MO
72
ketoprofen er
2
MO
48
ketorolac
2
77
junel fe 1.5/30
2
MO
72
tromethamine
junel fe 1/20
2
MO
72
ophthalmic soln
JUVISYNC
3
QL(30/30) MO
62
kionex powd
2
80
K
KADCYLA
5
PA
58
klor-con
2
MO
81
KALETRA ORAL
5
MO
60
klor-con m10
2
MO
81
SOLN
klor-con m20
1
MO
81
KALETRA TABS
5
MO
60
KUVAN
5
PA
69
KYPROLIS
5
PA QL(6/28)
56
200MG 50MG
L
KALETRA TABS
4
MO
60
100MG 25MG
labetalol hcl inj
4
65
KAPVAY
3
68
labetalol hcl tabs
2
MO
65
kariva
2
MO
72
laclotion
2
68
kcl
4
62
LACRISERT
3
77
0.075%/d5w/nacl
lactated ringers
4
81
0.45%
inj 3meq/l
kcl 0.15%/d5w/
4
62
109meq/l
nacl 0.3%
28meq/l 4meq/l
kcl 0.15%/d5w/lr
4
63
130meq/l
kcl
lactated ringers
4
80
4
63
0.15%/d5w/nacl
dextrose 5%
0.2%
viaflex
kcl
4
63
lactated ringers
4
77
0.15%/d5w/nacl
irrigation
0.45%
lactated ringers
4
81
kcl
4
63
viaflex
0.15%/d5w/nacl
lactulose
2
MO
70
0.9%
LAMICTAL
3
52
kcl
4
63
STARTER/NOT
0.3%/d5w/nacl
TAKING
0.45%
CARBAMAZEPI
kelnor 1/35
2
MO
72
NE
KETEK
3
QL(20/30)
51
LAMICTAL
3
52
ketoconazole
2
55
STARTER/TAKI
crea
NG
correo
24
Drug Name
CARBAMAZEPI
NE/NOT
TAKING
VALPROATE
LAMICTAL
STARTER/TAKI
NG
VALPROATE
lamivudine
lamivudine/zidov
udine
lamotrigine
lamotrigine er
LANOXIN
PEDIATRIC
lansoprazole
lantus
lantus solostar
latanoprost
LATUDA TABS
120MG, 20MG,
40MG
LATUDA TABS
80MG
LAZANDA
leflunomide
lessina
LETAIRIS
letrozole
leucovorin
calcium inj
100mg,
10mg/ml,
350mg, 500mg,
50mg
leucovorin
calcium tabs
LEUKERAN
LEUKINE
Drug Tier
Reqs / Limits
3
2
5
Page
52
MO
MO
60
60
2
2
4
MO
MO
PA
52
52
66
2
3
3
2
4
QL(30/30) MO
MO
MO
QL(5/30)
QL(30/30) ST MO
70
63
63
77
59
4
QL(60/30) ST MO 59
5
2
2
5
2
4
PA QL(28/28)
QL(30/30) MO
MO
PA QL(30/30)
QL(30/30)
47
75
72
79
57
57
2
57
3
5
56
64
PA
Drug Name
Drug Tier
leuprolide
acetate
levemir
levemir flexpen
levetiracetam inj
levetiracetam
oral soln
levetiracetam
tabs
levetiracetam er
levobunolol hcl
ophthalmic soln
0.5%
levobunolol hcl
ophthalmic soln
0.25%
levocarnitine inj
levocarnitine oral
soln
levocarnitine
tabs
levocetirizine
dihydrochloride
oral soln
levocetirizine
dihydrochloride
tabs
levofloxacin inj
levofloxacin tabs
levofloxacin in
d5w
levora 0.15/3028
levorphanol
tartrate
LEVOTHROID
levothyroxine
sodium tabs
LEVOXYL
Reqs / Limits
Page
4
PA QL(30/30)
73
3
3
4
2
MO
MO
MO
63
63
52
52
2
MO
52
2
1
MO
52
78
2
MO
78
4
2
B/D PA
B/D PA MO
77
77
2
MO
77
2
QL(300/30)
78
2
QL(30/30)
78
4
2
4
51
51
51
2
MO
72
2
QL(180/30)
46
3
1
MO
MO
73
73
3
MO
73
correo
25
Drug Name
Drug Tier
Reqs / Limits
Page
Drug Name
Drug Tier
Reqs / Limits
Page
lorazepam tabs
2
QL(120/30) MO
61
LEXIVA SUSP
4
MO
60
losartan
LEXIVA TABS
5
MO
60
1
QL(30/30) MO
65
lidocaine oint
2
47
potassium tabs
lidocaine hcl
2
47
100mg
external soln
losartan
1
QL(60/30) MO
65
lidocaine hcl inj
4
47
potassium tabs
25mg, 50mg
0.5%, 1%, 2%
losartan
1
QL(30/30) MO
65
lidocaine hcl inj
4
65
potassium/hydro
10mg/ml
chlorothiazide
lidocaine hcl jelly
2
47
tabs 12.5mg
lidocaine viscous
1
47
100mg, 25mg
lidocaine/prilocai
2
47
100mg
ne crea
1
QL(60/30) MO
65
losartan
LIDODERM
3
PA QL(90/30)
47
potassium/hydro
LINCOCIN
4
49
chlorothiazide
lindane
2
58
tabs 12.5mg
liothyronine
4
73
50mg
sodium inj
LOTRONEX
5
QL(60/30) MO
70
liothyronine
2
MO
73
lovastatin tabs
2
QL(60/30) MO
67
sodium tabs
40mg
LIPOFEN
3
67
lovastatin tabs
1
QL(60/30) MO
67
liposyn iii inj
4
B/D PA
77
10mg, 20mg
1.8% 2.5% 30%
LOVAZA
3
QL(120/30)
67
lisinopril
1
MO
65
low-ogestrel
2
MO
72
lisinopril/hydrochl
1
MO
65
loxapine
2
MO
59
orothiazide
succinate
lithium carbonate
1
MO
61
LUMIGAN
3
QL(5/30) MO
77
caps 300mg
LUMIZYME
5
PA
69
lithium carbonate
2
MO
61
LUPRON
5
PA QL(1/30)
73
caps 150mg,
DEPOT
600mg
LUPRON
5
PA QL(1/30)
73
lithium carbonate
2
MO
61
DEPOT-PED INJ
tabs
11.25MG, 15MG
lithium carbonate
2
MO
61
LUPRON
4
PA QL(1/30)
74
er
DEPOT-PED INJ
LODOSYN
3
MO
58
11.25MG, 30MG
lofene
2
69
2
MO
72
lutera
2
69
lonox
LUVOX CR
3
QL(90/30)
54
loperamide hcl
2
69
LYRICA CAPS
3
QL(60/30) MO
52
caps
225MG, 25MG,
lorazepam conc
2
QL(120/30) MO
61
correo
26
Drug Name
300MG
LYRICA CAPS
100MG, 150MG,
200MG, 50MG,
75MG
LYRICA ORAL
SOLN
LYSODREN
M
magnesium
sulfate inj 50%
MAKENA
malathion
maprotiline hcl
MARPLAN
MATULANE
matzim la tb24
240mg
meclizine hcl
tabs
meclofenamate
sodium
MEDROL TABS
2MG
medroxyprogest
erone acetate inj
medroxyprogest
erone acetate
tabs
mefloquine hcl
megestrol
acetate susp
megestrol
acetate tabs
40mg
megestrol
acetate tabs
20mg
MEKINIST
Drug Tier
3
3
Reqs / Limits
QL(90/30) MO
QL(900/30)
3
Page
52
52
73
4
B/D PA
81
5
2
2
3
5
2
B/D PA
72
58
53
53
56
66
MO
MO
MO
2
2
54
MO
3
48
71
4
QL(1/90)
73
1
MO
73
2
2
MO
PA
58
73
2
PA
73
1
5
PA
PA
73
57
Drug Name
meloxicam tabs
melphalan
hydrochloride
MENACTRA
MENEST
MENOMUNEA/C/Y/W-135
MENOSTAR
MENVEO
MEPRON
mercaptopurine
meropenem
mesalamine
enem
mesalamine kit
mesna
MESNEX TABS
MESTINON
TIMESPAN
metadate er
metaproterenol
sulfate
metformin hcl
metformin hcl er
tb24 500mg,
750mg
methadone hcl
conc
methadone hcl
inj
methadone hcl
oral soln
10mg/5ml
methadone hcl
oral soln
5mg/5ml
methadone hcl
tabs
methadose tabs
Drug Tier
1
5
4
3
4
Reqs / Limits
Page
MO
B/D PA
48
56
PA
75
57
75
3
4
5
2
2
2
PA
72
75
58
56
50
75
2
2
4
3
MO
B/D PA
75
57
57
56
2
2
QL(90/30) MO
MO
68
79
1
1
MO
MO
62
62
2
QL(500/30)
46
4
B/D PA
46
2
QL(2000/30)
46
2
QL(4000/30)
46
2
QL(360/30)
46
2
QL(360/30)
46
correo
27
Drug Name
Drug Tier
Reqs / Limits
Page
Drug Name
Drug Tier
Reqs / Limits
Page
methazolamide
2
MO
78
metoprolol
2
MO
66
methenamine
2
49
succinate er
hippurate
metoprolol
4
66
methimazole
2
MO
74
tartrate inj
methotrexate
2
74
metoprolol
1
MO
66
methotrexate
4
74
tartrate tabs
metoprolol/hydro
2
MO
66
sodium
chlorothiazide
methscopolamin
2
69
METROGEL
3
49
e bromide
methyldopate hcl
2
PA
64
metronidazole
2
49
methylphenidate
2
QL(90/30) MO
68
crea
hcl
metronidazole
2
49
methylphenidate
2
QL(60/30) MO
68
gel 0.75%
hcl er tbcr 10mg
metronidazole
2
49
methylphenidate
2
QL(90/30) MO
68
lotn
hcl er tbcr 20mg
metronidazole
1
49
methylphenidate
2
QL(90/30) MO
68
tabs
hcl sr
metronidazole in
4
49
methylprednisolo
2
71
nacl 0.79%
ne
metronidazole
2
49
methylprednisolo
2
71
vaginal
ne
mexiletine hcl
2
MO
65
methylprednisolo
4
71
MIACALCIN INJ
4
76
ne acetate
microgestin
2
MO
72
methylprednisolo
2
71
1.5/30
ne dose pack
2
MO
72
microgestin 1/20
methylprednisolo
4
71
microgestin fe
2
MO
72
ne
microgestin fe
2
MO
73
sodiumsuccinate
1.5/30
inj 125mg, 1gm,
midodrine hcl
2
64
40mg
migergot
2
55
metipranolol
2
MO
78
MIMVEY
3
PA
73
metoclopramide
4
69
minitran
2
MO
67
hcl inj
minocycline hcl
2
51
metoclopramide
1
MO
69
minoxidil tabs
2
MO
67
hcl oral soln
mirtazapine
2
QL(30/30) MO
53
metoclopramide
1
MO
69
mirtazapine odt
2
QL(30/30) MO
53
hcl tabs 10mg
tbdp 30mg,
metoclopramide
2
MO
69
45mg
hcl tabs 5mg
misoprostol
2
MO
70
metolazone
2
MO
67
mitomycin
4
B/D PA
57
correo
28
Drug Name
MITOXANTRON
E HCL
M-M-R II
W/DILUENT 10
DOSE
MODAFINIL
TABS 100MG
MODAFINIL
TABS 200MG
moexipril hcl
moexipril/hydroc
hlorothiazide
mometasone
furoate crea
mometasone
furoate external
soln
mometasone
furoate oint
montelukast
sodium
morphine sulfate
inj 0.5mg/ml,
10mg/ml,
1mg/ml, 5mg/ml
morphine sulfate
er tbcr
MOVIPREP
MOXEZA
MOZOBIL
MULTAQ
mupirocin oint
mupirocin
calcium
MUSTARGEN
MYCOBUTIN
mycophenolate
mofetil
mydral
Drug Tier
3
Reqs / Limits
Page
Drug Name
B/D PA
57
MYFORTIC
N
nabumetone
nadolol tabs
80mg
nadolol tabs
20mg, 40mg
nadolol/bendroflu
methiazide
nafcillin sodium
NAFTIN CREA
NAFTIN GEL
1%
NAGLAZYME
nalbuphine hcl
naloxone hcl
naltrexone hcl
NAMENDA
ORAL SOLN
NAMENDA
TABS 10MG
NAMENDA
TABS 5MG
NAMENDA
TITRATION PAK
naphazoline hcl
naproxen susp
naproxen tabs
250mg
naproxen tabs
375mg, 500mg
naproxen dr
naproxen sodium
tabs 275mg,
550mg
naratriptan hcl
NASONEX
NATACYN
nateglinide
4
75
4
PA QL(30/30) MO 80
5
PA QL(60/30) MO 80
2
2
MO
MO
2
71
2
71
2
2
71
QL(30/30) MO
4
2
65
65
79
46
QL(90/30)
46
3
3
5
3
2
2
70
51
B/D PA QL(9.6/30) 64
QL(60/30) MO
65
49
49
4
3
2
B/D PA
2
B/D PA
56
56
74
77
Drug Tier
Reqs / Limits
Page
3
B/D PA
74
2
2
MO
MO
48
66
1
MO
66
2
MO
66
4
3
3
50
55
55
5
4
4
2
3
PA
PA
QL(300/30) MO
69
47
47
47
53
3
QL(60/30) MO
53
3
QL(90/30) MO
53
3
QL(49/28) MO
53
2
2
2
MO
MO
77
48
48
1
MO
48
2
2
MO
MO
48
48
2
3
3
2
QL(9/30)
QL(34/30)
55
78
55
62
QL(90/30) MO
correo
29
Drug Name
Drug Tier
Reqs / Limits
Page
Drug Name
Drug Tier
Reqs / Limits
Page
NEBUPENT
3
B/D PA
58
NIASPAN
3
QL(60/30) MO
67
necon 0.5/35-28
2
MO
73
nicardipine hcl
2
MO
66
necon 1/35
2
MO
73
caps
necon 10/11-28
2
MO
73
nicardipine hcl inj
4
66
nefazodone hcl
2
QL(60/30) MO
53
NICOTROL
3
PA QL(504/30)
47
neomycin sulfate
INHALER
2
48
tabs
NICOTROL NS
3
PA QL(40/30)
47
neomycin/bacitra
2
49
nifediac cc
2
MO
66
cin/polymyxin
nifedical xl
2
MO
66
neomycin/polym
4
48
nifedipine er
2
MO
66
yxin b sulfates
NILANDRON
3
74
2
49
neomycin/polym
nimodipine
2
MO
66
yxin/bacitracin/hy
nisoldipine
2
MO
66
drocortisone
nisoldipine er
2
MO
66
neomycin/polym
2
77
nitrofurantoin
2
PA QL(900/365)
49
yxin/dexamethas
nitrofurantoin
2
PA QL(90/365)
49
one
macrocrystalline
neomycin/polym
2
49
nitrofurantoin
2
PA QL(90/365)
49
yxin/gramicidin
monohydrate
neomycin/polym
2
78
nitroglycerin inj
4
67
yxin/hc
nitroglycerin pt24
2
MO
67
neomycin/polym
2
49
nitroglycerin
2
67
yxin/hydrocortiso
lingual
ne
translingual soln
neomycin/polym
2
49
nitroglycerin
2
MO
67
yxin/hydrocortiso
transdermal pt24
ne
0.1mg/hr
NEULASTA
5
PA
64
NITROSTAT
3
MO
68
NEUMEGA
5
PA MO
64
nizatidine caps
2
MO
70
NEUPOGEN INJ
5
PA
64
nora-be
2
MO
73
300MCG/0.5ML,
MO
73
norethindrone
2
480MCG/0.8ML,
acetate
480MCG/1.6ML
NORITATE
3
49
NEUTREXIN
5
58
normosol-m in
4
B/D PA
81
NEVIRAPINE
2
MO
60
d5w
SUSP
NORMOSOL-R
4
B/D PA
81
nevirapine tabs
2
MO
60
normosol-r in
4
B/D PA
63
NEXAVAR
5
PA
57
d5w
NEXIUM
3
QL(30/30) MO
70
nortrel 0.5/35
2
MO
73
NEXIUM I.V.
4
MO
70
(28)
niacor
2
MO
82
nortrel 1/35
2
MO
73
correo
30
Drug Name
nortrel 7/7/7
nortriptyline hcl
caps 50mg,
75mg
nortriptyline hcl
caps 10mg,
25mg
nortriptyline hcl
oral soln
NORVIR
novarel
novofine
30gx8mm
novofine 31
novofine
32gx6mm
novofine
autocover
30gx8mm
novotwist
30gx8mm
novotwist
32gx5mm
NOXAFIL
NUEDEXTA
NULOJIX
nyamyc
nystatin crea
nystatin oint
nystatin powd
100000unit/gm
nystatin susp
nystatin tabs
nystatin/triamcin
olone
nystop
O
OCTREOTIDE
ACETATE INJ
Drug Tier
2
2
1
Reqs / Limits
Page
Drug Name
MO
MO
73
54
100MCG/ML,
200MCG/ML,
50MCG/ML
OCTREOTIDE
ACETATE INJ
1000MCG/ML,
500MCG/ML
ofloxacin
ogestrel
olanzapine inj
olanzapine tabs
olanzapine odt
olanzapine/fluox
etine
omeprazole cpdr
40mg
omeprazole cpdr
10mg, 20mg
ONCASPAR
ondansetron hcl
inj
ondansetron hcl
oral soln
ondansetron hcl
tabs 24mg
ondansetron hcl
tabs 4mg, 8mg
ondansetron odt
ONFI TABS
10MG, 5MG
ONFI TABS
20MG
ONTAK
ORAP
ORFADIN
orphenadrine
citrate er
orsythia
OSMOPREP
MO
2
54
54
3
4
3
MO
PA
QL(200/30) MO
60
72
77
2
2
QL(200/30) MO
QL(200/30) MO
77
77
2
QL(200/30)
77
2
QL(200/30)
77
2
QL(200/30)
77
5
3
5
2
2
2
2
PA QL(600/30)
PA
PA MO
55
68
74
55
55
55
55
2
2
2
55
55
55
2
55
4
PA
74
Drug Tier
5
2
2
4
2
2
2
Reqs / Limits
PA
Page
74
QL(30/30) MO
QL(30/30) MO
QL(30/30) MO
51
73
59
59
59
59
2
QL(30/30) MO
70
2
QL(60/30) MO
70
5
4
B/D PA
57
55
MO
2
55
2
QL(5/30)
55
2
QL(90/30)
55
2
3
QL(90/30)
QL(60/30)
55
52
3
QL(120/30)
52
5
3
5
2
B/D PA
MO
MO
PA
57
59
69
80
2
3
73
69
correo
31
Drug Name
Drug Tier
Reqs / Limits
Page
Drug Name
Drug Tier
Reqs / Limits
Page
oxacillin sodium
4
50
325mg 10mg,
oxaliplatin inj
5
B/D PA
57
325mg 5mg,
100mg/20ml
325mg 7.5mg
oxandrolone tabs
2
PA QL(60/30)
72
oxycodone/aspiri
2
QL(360/30)
47
10mg
n
oxandrolone tabs
2
PA QL(120/30)
72
oxycodone/ibupr
2
QL(150/30)
47
ofen
2.5mg
OXYCONTIN
4
PA QL(60/30)
46
oxaprozin
2
MO
48
oxymorphone
2
QL(60/30)
46
oxazepam
2
QL(120/30) MO
61
hydrochloride er
oxcarbazepine
2
53
P
susp
PACERONE
3
MO
65
oxcarbazepine
2
MO
53
tabs
TABS 100MG
pacerone tabs
2
MO
65
OXSORALEN
3
68
200mg
ULTRA
oxybutynin
1
MO
70
paclitaxel inj
4
B/D PA
57
chloride tabs
300mg/50ml
oxybutynin
2
QL(30/30) MO
70
pamidronate
4
MO
76
disodium inj
chloride er tb24
30mg/10ml,
5mg
6mg/ml,
oxybutynin
2
QL(60/30) MO
70
90mg/10ml
chloride er tb24
pancrelipase
2
69
10mg, 15mg
oxycodone hcl
2
QL(240/30)
47
PANRETIN
3
58
caps
pantoprazole
2
QL(30/30) MO
70
oxycodone hcl
2
QL(360/30)
47
sodium tbec
conc
parcaine
2
77
oxycodone hcl
2
QL(1200/30)
47
paromomycin
2
48
oral soln
sulfate
oxycodone hcl
2
QL(240/30)
47
paroxetine hcl
2
QL(60/30) MO
54
tabs
tabs 30mg,
oxycodone/aceta
2
QL(240/30)
47
40mg
minophen caps
paroxetine hcl
1
QL(30/30) MO
54
oxycodone/aceta
2
QL(180/30)
47
tabs 10mg
minophen tabs
paroxetine hcl
1
QL(60/30) MO
54
650mg 10mg
tabs 20mg
oxycodone/aceta
2
QL(240/30)
47
paroxetine hcl er
2
QL(30/30) MO
54
minophen tabs
tb24 12.5mg
500mg 7.5mg
paroxetine hcl er
2
QL(60/30) MO
54
oxycodone/aceta
2
QL(360/30)
47
tb24 37.5mg
minophen tabs
paroxetine hcl er
2
QL(90/30) MO
54
correo
32
Drug Name
tb24 25mg
PASER
PATADAY
PATANOL
PAXIL SUSP
pedi-dri
PEDVAX HIB
peg
3350/electrolytes
PEGANONE
PEG-INTRON
INJ
50MCG/0.5ML
PEG-INTRON
REDIPEN
PEG-INTRON
REDIPEN PAK 4
penicillin g
potassium
penicillin v
potassium oral
soln
penicillin v
potassium tabs
250mg
penicillin v
potassium tabs
500mg
PENTAM 300
pentostatin
pentoxifylline er
PERFOROMIST
periogard
PERJETA
permethrin crea
perphenazine
perphenazine/a
mitriptyline
PFIZERPEN-G
Drug Tier
Reqs / Limits
3
3
3
3
2
4
2
Page
56
77
77
54
55
75
70
3
5
MO
PA
53
61
5
PA
61
5
PA
61
4
50
1
50
1
50
2
50
3
5
2
3
1
5
2
2
2
58
B/D PA
56
MO
66
B/D PA QL(120/30) 79
68
PA
58
58
MO
59
PA MO
54
4
50
Drug Name
Drug Tier
phenadoz
phenelzine
sulfate
phenobarbital
phenobarbital
phenytoin
phenytoin
sodium
phenytoin
sodium extended
physiolyte
physiosol
irrigation
PICATO
pilocarpine hcl
tabs
PILOCARPINE
HCL
OPHTHALMIC
SOLN
pilocarpine
hydrochloride
PILOPINE HS
pindolol
PIOGLITAZONE
HCL
PIOGLITAZONE
HCL/METFORMI
N HCL
pioglitazone hclglimepiride
piperacillin
sodium/
tazobactam
sodium
piperacillin
sodium/tazobact
am sodium
piroxicam
Reqs / Limits
Page
2
2
PA
MO
79
53
2
2
2
4
MO
MO
MO
52
52
53
53
2
MO
53
4
4
4
2
77
77
ST
MO
3
57
68
78
2
MO
68
3
1
2
MO
MO
QL(30/30) MO
78
66
62
2
QL(90/30) MO
62
2
QL(30/30) MO
62
4
50
4
50
2
MO
48
correo
33
Drug Name
Drug Tier
Reqs / Limits
Page
Drug Name
Drug Tier
Reqs / Limits
Page
0.3%/d5w
podofilox
2
68
polycin b
2
49
potassium
4
81
chloride
poly-dex
2
77
0.3%/nacl
polyethylene
2
70
0.9%/viaflex
glycol 3350
potassium
2
MO
81
powd
chloride cr
polymyxin b
4
49
potassium
2
MO
80
sulfate
chloride er cpcr
POMALYST
5
PA QL(21/28)
57
potassium
2
MO
80
portia-28
2
MO
73
chloride er cpcr
potassium
4
81
potassium
2
MO
81
chloride inj
chloride
er
tbcr
10meq/100ml,
10meq, 20meq
20meq/100ml,
potassium
1
MO
81
2meq/ml,
chloride sr
30meq/100ml,
POTIGA
3
PA QL(90/30) MO 52
40meq/100ml
PRADAXA
3
PA QL(60/30)
64
potassium
2
81
CAPS 150MG
chloride liqd
PRADAXA
3
PA QL(120/30)
64
potassium
4
63
CAPS 75MG
chloride 0.15%
pramipexole
2
QL(90/30) MO
58
d5w/nacl 0.33%
dihydrochloride
potassium
4
63
PRANDIN
3
MO
62
chloride 0.15%
pravastatin
1
QL(30/30) MO
67
d5w/nacl 0.45%
sodium tabs
viaflex
10mg, 20mg,
potassium
4
81
80mg
chloride 0.15%
pravastatin
1
QL(60/30) MO
67
nacl 0.9%
sodium tabs
potassium
4
81
40mg
chloride
prazosin hcl
1
MO
65
0.15%/d5w
PRED MILD
3
78
potassium
4
63
PRED-G
3
78
chloride 0.22%
PRED-G S.O.P.
3
78
d5w/nacl 0.45%
potassium
4
63
prednicarbate
2
71
chloride
prednisolone
2
78
0.224%/d5w/nacl
acetate
0.45%
prednisolone
2
71
potassium
4
81
sodium
chloride
phosphate oral
correo
34
Drug Name
soln 15mg/5ml,
5mg/5ml
PREDNISOLON
E SODIUM
PHOSPHATE
ORAL SOLN
25MG/5ML
prednisolone
sodium
phosphate
ophthalmic soln
prednisone oral
soln
prednisone tabs
50mg
prednisone tabs
10mg, 1mg,
2.5mg, 20mg,
5mg
PREDNISONE
INTENSOL
pregnyl w/diluent
benzyl
alcohol/nacl
PREMARIN
CREA
PREMARIN INJ
PREMARIN
TABS
premasol inj
56meq/l
320mg/100ml
730mg/100ml
190mg/100ml
3meq/l
20mg/100ml
300mg/100ml
220mg/100ml
290mg/100ml
Drug Tier
2
Reqs / Limits
MO
Page
71
1
78
2
72
2
72
1
72
3
72
4
PA
72
3
MO
73
4
3
MO
73
PA QL(30/30) MO 73
4
B/D PA
81
Drug Name
Drug Tier
490mg/100ml
840mg/100ml
490mg/100ml
200mg/100ml
290mg/100ml
410mg/100ml
230mg/100ml
5meq/l
15mg/100ml
250mg/100ml
120mg/100ml
140mg/100ml
470mg/100ml
prevalite
previfem
PREVPAC
PREZISTA
SUSP
PREZISTA
TABS 800MG
PREZISTA
TABS 400MG,
600MG
PREZISTA
TABS 150MG
PREZISTA
TABS 75MG
PRIFTIN
primaquine
phosphate
primidone
PRIMSOL
PRISTIQ
PROAIR HFA
probenecid
probenecid/colch
icine
PROCALAMINE
prochlorperazine
Reqs / Limits
Page
2
2
3
5
MO
MO
67
73
49
60
5
QL(30/30) MO
60
5
QL(60/30) MO
60
4
QL(180/30) MO
61
4
QL(360/30) MO
61
3
1
56
58
2
3
3
3
2
2
MO
4
2
B/D PA
QL(30/30) MO
QL(17/30) MO
MO
MO
52
49
54
79
55
55
82
59
correo
35
Drug Name
Drug Tier
Reqs / Limits
Page
Drug Name
Drug Tier
Reqs / Limits
Page
supp 25mg,
prochlorperazine
4
59
50mg
edisylate
prochlorperazine
1
59
propafenone hcl
2
MO
65
propafenone hcl
2
MO
65
maleate tabs
10mg
er
prochlorperazine
2
59
propantheline
2
69
maleate tabs
bromide
proparacaine hcl
2
77
5mg
PROCRIT INJ
5
PA
64
propranolol hcl
4
66
20000UNIT/ML,
inj
40000UNIT/ML
propranolol hcl
2
MO
66
PROCRIT INJ
4
PA
64
oral soln
propranolol hcl
2
MO
66
10000UNIT/ML,
2000UNIT/ML,
tabs 60mg
3000UNIT/ML,
propranolol hcl
1
MO
66
tabs 10mg,
4000UNIT/ML
proctocream hc
2
72
20mg, 40mg,
procto-pak
2
72
80mg
propranolol hcl
2
MO
66
proctosol hc
2
72
er
proctozone-hc
2
72
propranolol/hydr
2
MO
66
progesterone
2
MO
73
ochlorothiazide
caps
propylthiouracil
2
MO
74
PROGLYCEM
3
MO
63
PROQUAD
4
75
PROGRAF INJ
4
B/D PA
74
PROSOL
4
B/D PA
82
PROLASTIN-C
5
B/D PA MO
79
PROTOPIC
3
68
PROLEUKIN
5
B/D PA
57
protriptyline hcl
2
MO
54
PROLIA
4
QL(1/180) ST
76
PROVENGE
5
B/D PA
75
PROMACTA
5
PA QL(30/30)
64
PRUDOXIN
3
68
promethazine hcl
4
PA
79
inj
PULMOZYME
5
B/D PA
79
promethazine hcl
2
PA
79
pyrazinamide
2
56
pyridostigmine
2
56
supp
bromide
promethazine hcl
2
PA
79
syrp
Q
promethazine hcl
2
PA
79
quasense
2
MO
73
tabs 12.5mg,
quetiapine
2
QL(90/30) MO
59
50mg
fumarate
promethazine hcl
1
PA
79
quinapril hcl
1
MO
65
tabs 25mg
quinapril/hydroch
2
MO
65
promethazine vc
2
PA
79
lorothiazide
promethegan
2
PA
79
quinine sulfate
1
58
correo
36
Drug Name
QVAR
R
RABAVERT
ramipril
RANEXA TB12
1000MG
RANEXA TB12
500MG
ranitidine hcl
caps
ranitidine hcl inj
150mg/6ml
ranitidine hcl
syrp
ranitidine hcl
tabs 150mg,
300mg
RAPAFLO
RAPAMUNE
REBETOL ORAL
SOLN
REBIF
REBIF
TITRATION
PACK
RECLAST
reclipsen
RECOMBIVAX
HB INJ
10MCG/ML,
40MCG/ML
regonol
REGRANEX
RELISTOR INJ
12MG/0.6ML
RELISTOR INJ
12MG/0.6ML
RELISTOR INJ
8MG/0.4ML
Drug Tier
Reqs / Limits
Page
Drug Name
3
QL(18/30) MO
78
4
1
3
75
MO
65
QL(60/30) ST MO 66
3
QL(120/30) ST MO 66
2
MO
REMICADE
REMODULIN
RENVELA PACK
RENVELA TABS
RESCRIPTOR
RESTASIS
RETROVIR IV
INFUSION
REVLIMID CAPS
10MG, 15MG,
2.5MG, 25MG,
5MG
REYATAZ CAPS
100MG
REYATAZ CAPS
150MG, 200MG,
300MG
RIBAPAK
ribasphere
ribavirin
RIDAURA
rifampin caps
rifampin inj
RIFATER
RILUTEK
riluzole
rimantadine hcl
ringers injection
ringers irrigation
RIOMET
RISPERDAL
CONSTA
risperidone oral
soln
risperidone tabs
0.25mg, 0.5mg,
1mg, 2mg, 3mg
risperidone tabs
4mg
4
70
70
2
MO
70
1
MO
70
3
3
4
QL(30/30) MO
B/D PA
PA
70
74
61
5
5
PA QL(6/28)
PA QL(4.2/28)
75
75
4
2
4
B/D PA
MO
B/D PA
76
73
75
4
3
4
PA
PA QL(18/30)
56
68
69
4
PA QL(28/28)
69
4
PA QL(12/30)
70
Drug Tier
Reqs / Limits
Page
5
5
3
3
3
3
4
PA
B/D PA
QL(180/30) MO
QL(540/30) MO
MO
QL(64/30) MO
74
79
70
70
60
77
60
5
PA QL(21/28)
56
4
MO
61
5
MO
61
5
2
2
3
2
4
3
5
4
2
4
4
3
4
PA
PA
PA
MO
61
61
61
75
56
56
56
68
68
61
82
77
62
59
2
QL(360/30) MO
59
2
QL(90/30) MO
59
2
QL(120/30) MO
59
MO
correo
37
Drug Name
Drug Tier
Reqs / Limits
Page
Drug Name
Drug Tier
Reqs / Limits
Page
SENSIPAR
5
QL(120/30) MO
73
risperidone m2
QL(90/30) MO
59
TABS 90MG
tab
SENSIPAR
5
QL(180/30) MO
73
risperidone odt
2
QL(90/30) MO
59
TABS 60MG
tbdp 0.25mg,
SEREVENT
3
QL(60/30) MO
79
0.5mg, 1mg,
DISKUS
2mg, 3mg
SEROQUEL XR
3
QL(30/30) MO
59
risperidone odt
2
QL(120/30) MO
59
TB24 150MG,
tbdp 4mg
200MG
RITUXAN
5
PA
58
SEROQUEL XR
3
QL(60/30) MO
59
rivastigmine
2
QL(60/30) MO
53
TB24 300MG,
tartrate
400MG, 50MG
rizatriptan
2
55
sertraline hcl
2
QL(300/30) MO
54
benzoate
conc
ropinirole hcl
2
MO
58
sertraline hcl
2
QL(30/30) MO
54
ROTATEQ
3
75
tabs 25mg,
roxicet tabs
2
QL(360/30)
47
50mg
ROZEREM
3
QL(30/30)
80
sertraline hcl
2
QL(60/30) MO
54
S
tabs 100mg
SABRIL PACK
5
PA QL(200/30) MO 52
SILDENAFIL
3
PA QL(90/30)
79
SABRIL TABS
5
PA QL(180/30) MO 52
CITRATE
SAIZEN INJ
5
PA
72
SIMULECT
5
B/D PA
75
5MG
simvastatin
1
QL(30/30) MO
67
SAIZEN
5
PA
72
sodium
4
80
CLICK.EASY
SAMSCA TABS
5
PA QL(60/30)
80
bicarbonate inj
30MG
7.5%, 8.4%
SAMSCA TABS
5
PA QL(90/30)
80
sodium chloride
4
82
15MG
inj 0.9%,
SANDOSTATIN
5
PA
74
2.5meq/ml, 3%,
LAR DEPOT
5%
sodium chloride
4
82
SANTYL
3
69
0.45% viaflex
SAPHRIS
3
QL(60/30) MO
59
sodium chloride
4
77
selegiline hcl
2
MO
53
0.9%
selenium sulfide
1
69
SODIUM
4
B/D PA
67
lotn
EDECRIN
SELZENTRY
5
QL(60/30) MO
60
sodium fluoride
1
82
TABS 150MG
tabs
SELZENTRY
5
QL(120/30) MO
60
sodium lactate
4
80
TABS 300MG
inj
SENSIPAR
3
QL(360/30) MO
73
sodium
2
80
TABS 30MG
correo
38
Drug Name
polystyrene
sulfonate susp
15gm/60ml
sodium
sulfacetamide
ophthalmic soln
SOLTAMOX
SOLU-CORTEF
INJ 250MG
SOLU-CORTEF
INJ 1000MG,
500MG
SOMATULINE
DEPOT
SOMAVERT INJ
15MG, 20MG
SOMAVERT INJ
10MG
SORIATANE
sorine
sotalol hcl tabs
160mg, 240mg,
80mg
sotalol hcl (af)
SPIRIVA
HANDIHALER
spironolactone
tabs 25mg
spironolactone
tabs 100mg,
50mg
spironolactone/h
ydrochlorothiazid
e
SPORANOX
ORAL SOLN
sprintec 28
SPRYCEL
sps
Drug Tier
Reqs / Limits
2
Page
51
3
4
56
72
4
75
5
PA
74
5
PA QL(60/30)
74
5
PA QL(90/30)
74
5
2
2
PA
MO
MO
69
65
65
2
3
MO
QL(30/30) MO
65
79
1
MO
67
2
MO
67
2
3
2
5
2
MO
PA
MO
PA
67
55
73
57
80
Drug Name
Drug Tier
sronyx
stagesic
stavudine
sterile water
irrigation
STIMATE
STIVARGA
STRATTERA
streptomycin
sulfate
STRIBILD
STROMECTOL
SUBOXONE
sucralfate tabs
sulfacetamide
sodium
ophthalmic soln
sulfacetamide
sodium susp
sulfacetamide
sodium/prednisol
one sodium
phosphate
sulfadiazine
sulfamethoxazol
e/trimethoprim inj
sulfamethoxazol
e/trimethoprim
susp
sulfamethoxazol
e/trimethoprim
tabs
sulfamethoxazol
e/trimethoprim
ds
sulfasalazine
tabs
sulfazine
sulfazine ec
Reqs / Limits
Page
2
2
2
4
MO
QL(240/30)
MO
73
47
60
77
3
5
3
4
MO
PA QL(84/21)
MO
72
57
68
48
5
3
3
2
2
MO
60
58
47
70
51
PA QL(90/30)
MO
2
69
2
51
2
4
51
51
1
51
1
51
1
51
2
MO
75
2
2
MO
MO
75
75
correo
39
Drug Name
Drug Tier
Reqs / Limits
Page
Drug Name
Drug Tier
Reqs / Limits
Page
sulindac
2
MO
48
bd insulin
2
76
sumatriptan
2
QL(12/30)
55
syringe
sumatriptan
2
QL(8/30)
55
ultrafine/0.3ml/31
succinate inj
g x 5/16
sumatriptan
2
QL(9/30)
55
2
76
bd insulin
succinate tabs
syringe
sumatriptan
2
QL(8/30)
55
ultrafine/0.5ml/30
succinate refill
g x 1/2
SUPRAX SUSR
3
50
bd insulin
2
76
100MG/5ML,
syringe
200MG/5ML
ultrafine/1ml/31g
SUPRAX TABS
3
50
x 5/16
SUSTIVA
3
MO
60
bd insulin
2
QL(200/30)
76
SUTENT
5
PA
57
syringe
SYLATRON
5
PA
57
ultrafine/uSYMBICORT
3
QL(11/30) MO
78
100/0.3ml/31g x
AERO
15/64
160MCG/ACT
bd insulin
2
QL(200/30)
76
syringe
4.5MCG/ACT
ultrafine/uSYMBICORT
3
QL(14/30) MO
78
100/0.5ml/31g x
AERO
15/64
80MCG/ACT
bd insulin
2
QL(200/30)
76
4.5MCG/ACT
syringe
SYMLINPEN
3
PA QL(11/30) MO 62
120
ultrafine/uSYMLINPEN 60
3
PA QL(6/30) MO 62
100/1ml/31g x
SYNAGIS INJ
5
PA
75
15/64
2
QL(200/30) MO
76
50MG/0.5ML
h-e-b incontrol
pen needles
SYNAREL
5
PA MO
74
29gx12mm
SYNERCID
4
49
kmart valu plus
3
QL(200/30) MO
76
SYNRIBO
5
PA
57
insulin
SYNTHROID
3
MO
73
syringe/0.5ml/29
SYPRINE
3
80
g
SYRINGES
monoject insulin
2
QL(200/30) MO
77
aurora pen
2
QL(200/30) MO
76
syringe/detach
needles 31g x
needle/1ml/27g x
8mm
1/2
bd insulin
2
76
monoject insulin
2
QL(200/30) MO
77
syringe
syringe/safety/pe
safetyglide/1ml/2
rm
9g x 1/2
correo
40
Drug Name
needle/0.3ml/29g
x 1/2
monoject insulin
syringe/u100/0.5ml/30g x
5/16
monoject insulin
syringe/u100/1ml/30g x
5/16 misc null
ulticare insulin
1/2
ulticare insulin
5/16
ulticare insulin
syringe/u100/1ml/30g x
1/2
T
TABLOID
tacrolimus
TAFINLAR
TAMIFLU CAPS
45MG, 75MG
TAMIFLU CAPS
30MG
TAMIFLU SUSR
tamoxifen citrate
tamsulosin hcl
TARCEVA
TARGRETIN
TASIGNA
TASMAR
TAXOTERE
TAZICEF INJ
Drug Tier
2
2
2
Reqs / Limits
QL(200/30) MO
QL(200/30) MO
QL(200/30) MO
Page
77
77
77
2
QL(200/30) MO
77
2
QL(200/30) MO
77
3
2
5
3
B/D PA
PA
QL(56/365)
56
74
57
61
3
QL(112/365)
61
3
2
2
5
5
5
5
5
4
QL(700/365)
MO
MO
PA
61
56
70
57
58
57
58
57
50
PA
MO
B/D PA
Drug Name
Drug Tier
1GM/50ML
4.4%
tazicef inj 1gm,
2gm, 6gm
TAZORAC
CREA
TAZORAC GEL
taztia xt
TEFLARO
TEGRETOL-XR
TB12 100MG
TEKAMLO
TEKTURNA
TEKTURNA HCT
temazepam
TEMODAR INJ
terazosin hcl
caps 1mg, 5mg
terazosin hcl
caps 10mg, 2mg
terbinafine hcl
tabs
terbutaline
sulfate inj
terbutaline
sulfate tabs
terconazole
TESTIM
testosterone
cypionate
testosterone
enanthate
tetanus toxoid
adsorbed
tetanus/diphtheri
a toxoidsadsorbed adult
tetracycline hcl
TEXACORT
Reqs / Limits
4
Page
50
3
QL(120/30)
69
3
2
4
3
QL(100/30)
MO
MO
69
66
50
53
3
3
3
2
5
1
ST MO
ST MO
ST MO
QL(90/365) MO
B/D PA
QL(30/30) MO
66
66
66
80
56
65
1
QL(60/30) MO
65
1
QL(180/365)
55
4
2
79
MO
79
2
3
4
PA MO
PA
55
72
72
4
PA
72
4
75
4
75
1
3
51
72
correo
41
Drug Name
Drug Tier
Reqs / Limits
Page
Drug Name
Drug Tier
Reqs / Limits
Page
tizanidine hcl
2
MO
60
THALOMID
5
PA QL(60/30)
56
tabs
CAPS 150MG,
TOBI
5
B/D PA
48
200MG, 50MG
TOBRADEX
3
78
THALOMID
5
PA QL(90/30)
56
OINT
CAPS 100MG
tobramycin
4
48
THEO-24
3
MO
79
sulfate inj
theochron
2
MO
79
10mg/ml,
theophylline cr
2
MO
79
80mg/2ml
theophylline er
2
79
tobramycin
2
48
tb12 200mg
sulfate
theophylline er
2
MO
79
ophthalmic soln
tb12 300mg,
tobramycin/dexa
2
78
450mg
methasone
theophylline er
2
MO
79
TOBREX OINT
3
48
tb24
tolazamide
2
MO
62
thioridazine hcl
2
PA MO
59
tolmetin sodium
2
MO
48
thiotepa
4
B/D PA
56
tolterodine
1
70
thiothixene caps
2
MO
59
10mg, 1mg, 5mg
tartrate
thiothixene caps
1
MO
59
topiramate
2
MO
52
2mg
topotecan hcl inj
5
B/D PA
57
THYMOGLOBUL
3
B/D PA
75
4mg
IN
TORISEL
3
B/D PA
74
THYROLAR-1
3
MO
73
torsemide tabs
2
MO
67
THYROLAR-1/2
3
MO
73
tpn electrolytes
4
B/D PA
82
THYROLAR-1/4
3
MO
73
TRACLEER
5
PA QL(60/30)
79
THYROLAR-2
3
MO
73
TRADJENTA
3
QL(30/30) MO
62
THYROLAR-3
3
MO
73
tramadol hcl
2
QL(240/30)
47
tiagabine
2
QL(90/30) MO
52
tramadol hcl er
2
QL(30/30)
46
hydrochloride
tb24
tabs 4mg
tramadol
2
QL(240/30)
47
tiagabine
2
QL(180/30) MO
52
hydrochloride/ac
hydrochloride
etaminophen
tabs 2mg
trandolapril
2
MO
65
TIKOSYN
3
MO
65
tranexamic acid
2
PA
64
TIMENTIN
4
50
inj
timolol maleate
2
MO
66
tranexamic acid
2
64
tabs
tabs
timolol maleate
1
MO
78
3
QL(12/36)
54
TRANSDERMophthalmic soln
SCOP
tis-u-sol
4
77
tranylcypromine
2
MO
53
correo
42
Drug Name
sulfate
TRAVASOL
TRAVATAN Z
trazodone hcl
tabs 300mg
trazodone hcl
tabs 100mg,
150mg, 50mg
TREANDA INJ
25MG
TREANDA INJ
100MG
TRECATOR
TRELSTAR
DEPOT
MIXJECT
TRELSTAR LA
MIXJECT
TRELSTAR
MIXJECT
tretinoin caps
tretinoin crea
tretinoin gel
tretinoin
microsphere
triamcinolone
acetonide crea
triamcinolone
acetonide lotn
triamcinolone
acetonide oint
triamcinolone in
orabase
triamterene/hydr
ochlorothiazide
triderm
trifluoperazine
hcl
trifluridine
Drug Tier
4
3
2
1
Reqs / Limits
B/D PA
QL(5/30) MO
MO
MO
Page
82
77
53
53
4
B/D PA
56
5
B/D PA
56
PA QL(1/28)
56
74
3
5
5
PA QL(1/84)
74
5
PA QL(1/168)
74
2
2
2
2
MO
PA QL(45/30) MO
PA QL(45/30) MO
PA QL(45/30) MO
58
69
69
69
2
72
2
72
2
72
2
68
1
1
2
2
MO
67
MO
72
59
61
Drug Name
Drug Tier
trihexyphenidyl
hcl elix
trihexyphenidyl
hcl tabs 5mg
trihexyphenidyl
hcl tabs 2mg
tri-legest fe
trilyte
trimethoprim
trimethoprim
sulfate/polymyxin
b sulfate
trimipramine
maleate
tri-previfem
TRISENOX
tri-sprintec
trivora-28
TRIZIVIR
tropicamide
TRUVADA
TWINRIX
TYGACIL
TYKERB
TYPHIM VI
TYSABRI
TYZEKA
TYZINE
TYZINE
PEDIATRIC
NASAL DROPS
U
u-cort
ULORIC
UNITHROID
ursodiol
UVADEX
V
valacyclovir hcl
Reqs / Limits
Page
2
PA MO
58
2
PA MO
58
1
PA MO
58
2
2
2
2
MO
73
70
49
49
2
PA MO
54
2
4
2
2
5
2
5
4
4
5
4
5
3
3
3
MO
B/D PA
MO
MO
MO
73
57
73
73
60
77
60
75
49
57
75
75
61
79
79
MO
PA
PA
PA MO
2
3
3
2
4
ST
MO
MO
72
55
73
69
69
2
QL(30/30)
61
correo
43
Drug Name
Drug Tier
Reqs / Limits
Page
Drug Name
Drug Tier
Reqs / Limits
Page
VALCYTE
5
MO
60
verapamil hcl inj
4
66
valproate sodium
4
52
verapamil hcl
1
MO
66
valproic acid
2
MO
52
tabs 120mg,
valsartan/hydroc
2
MO
65
80mg
hlorothiazide
verapamil hcl
2
MO
66
VANCOMYCIN
5
QL(40/30)
49
tabs 40mg
HCL CAPS
verapamil hcl er
2
MO
66
125MG
VESICARE
3
QL(30/30) MO
70
VANCOMYCIN
5
QL(80/30)
49
VICTOZA
3
QL(9/30)
62
HCL CAPS
VICTRELIS
5
PA QL(360/30)
61
250MG
VIDAZA
5
B/D PA
57
VANCOMYCIN
5
49
VIDEX
3
MO
60
HCL INJ
PEDIATRIC
5000MG, 750MG
VIGAMOX
3
51
VANCOMYCIN
4
49
VIIBRYD KIT
4
QL(30/30) ST
54
HCL INJ
VIIBRYD TABS
4
QL(30/30) ST MO 54
1000MG, 10GM,
VIMPAT INJ
4
QL(1200/30)
53
500MG
VIMPAT ORAL
3
QL(1200/30) MO 53
VANCOMYCIN
5
49
SOLN
HCL IN
VIMPAT TABS
3
QL(60/30) MO
53
DEXTROSE
vinblastine
4
B/D PA
57
VAQTA
4
75
sulfate
VARIVAX
4
75
vincasar pfs
4
B/D PA
57
vincristine sulfate
4
B/D PA
57
VECTIBIX INJ
3
B/D PA
58
vinorelbine
4
B/D PA
57
100MG/5ML
tartrate inj
VECTICAL
3
69
50mg/5ml
VELCADE
5
B/D PA
57
VIRACEPT
5
MO
61
velivet
2
MO
73
viramune susp
3
MO
60
venlafaxine hcl
2
QL(120/30) MO
54
VIRAMUNE XR
3
60
venlafaxine hcl
2
QL(30/30) MO
54
VIREAD
5
MO
60
er cp24 37.5mg
VIVELLE-DOT
3
PA
73
venlafaxine hcl
2
QL(60/30) MO
54
VOLTAREN
3
QL(1000/30) ST
69
er cp24 150mg
venlafaxine hcl
2
QL(90/30) MO
54
VORAXAZE
5
B/D PA
77
55
er cp24 75mg
voriconazole inj
4
PA
voriconazole
5
PA
55
venlafaxine hcl
2
QL(30/30) MO
54
tabs
er tb24 37.5mg
VOTRIENT
5
PA QL(120/30)
57
venlafaxine hcl
2
QL(60/30) MO
54
VPRIV
5
PA
69
er tb24 150mg
W
venlafaxine hcl
2
QL(90/30) MO
54
warfarin sodium
1
MO
64
er tb24 75mg
correo
44
Drug Name
WELCHOL
X
XALKORI
XARELTO TABS
10MG, 20MG
XARELTO TABS
15MG
XENAZINE
TABS 12.5MG
XENAZINE
TABS 25MG
XGEVA
XIFAXAN TABS
200MG
XIFAXAN TABS
550MG
XOLAIR
XOLEGEL
XOLOX
XTANDI
XYREM
Y
YERVOY
yf-vax
Z
zafirlukast
zaleplon
ZALTRAP
ZANOSAR
ZAVESCA
zazole supp
ZELBORAF
ZEMPLAR CAPS
ZENPEP
ZETIA
ZIAGEN ORAL
SOLN
zidovudine
ZINECARD INJ
Drug Tier
3
Reqs / Limits
Page
Drug Name
MO
67
250MG
ziprasidone hcl
ZIRGAN
ZMAX
zoledronic acid
inj 5mg/100ml
zoledronic acid
inj 4mg/5ml
ZOLINZA
zolpidem tartrate
ZOMETA INJ
4MG/5ML
ZOMETA INJ
4MG/100ML
ZONALON
zonisamide
ZORTRESS
TABS 0.25MG
ZORTRESS
TABS 0.5MG,
0.75MG
ZOSTAVAX
ZOSYN INJ 5%
2GM/50ML
0.25GM/50ML,
5% 3GM/50ML
0.375GM/50ML
zovia 1/35e
zovia 1/50e
ZOVIRAX CREA
ZOVIRAX OINT
ZYCLARA
ZYLET
ZYPREXA
RELPREVV
ZYTIGA
ZYVOX
5
3
PA QL(60/30)
PA QL(30/30)
57
64
3
PA QL(60/30)
64
5
PA QL(90/30)
68
5
PA QL(120/30)
68
5
3
PA
PA QL(9/30)
76
49
3
PA QL(60/30)
49
5
3
3
5
5
PA
QL(240/30)
PA QL(120/30)
PA QL(540/30)
80
55
47
74
80
5
4
B/D PA
58
75
2
2
5
4
5
2
5
3
3
3
3
MO
QL(90/365)
PA
B/D PA
QL(30/30) MO
MO
79
80
58
56
69
55
58
76
69
67
60
2
4
MO
B/D PA
60
57
PA QL(240/30)
B/D PA
Drug Tier
Reqs / Limits
Page
2
3
3
4
QL(60/30) MO
ST
QL(60/30)
B/D PA
60
60
51
76
5
B/D PA
76
5
2
5
QL(120/30)
PA QL(90/365)
B/D PA
57
80
76
4
B/D PA
76
3
2
4
MO
B/D PA
69
52
74
5
B/D PA
74
4
4
75
50
2
2
3
3
3
3
5
MO
MO
73
73
61
61
69
48
60
5
5
PA QL(120/30)
PA
57
49
correo
45
Drug Name
Drug Reqs/Limits
Drug Name
Drug Reqs/Limits
Drug Name
Drug Reqs/Limits
Tier
Tier
Tier
ANALGESICS
hen/caffeine
CITRATE
/dihydrocod
ORAL
OPIOID ANALGESICS, LONGeine
TRANSMU
ACTING
bitartrate
COSAL
astramorph
4
acetaminop
2
QL(360/30)
hydrocodon
2
QL(150/30)
duramorph
4
hen/codeine
e
fentanyl
2
QL(15/30)
#3
bitartrate/ac
infumorph
4
acetaminop
2
QL(5000/3
etaminophe
200
n tabs
hen/codeine
0)
infumorph
4
oral
soln
750mg;
500
acetaminop
2
QL(240/30)
10mg
levorphanol
2
QL(180/30)
hen/codeine
hydrocodon
2
QL(3600/3
tartrate
tabs
300mg;
e/acetamino
0)
methadone
2
QL(500/30)
60mg
phen oral
hcl conc
acetaminop
2
QL(360/30)
soln
methadone
4
B/D PA
hen/codeine
hydrocodon
2
QL(150/30)
hcl inj
tabs
300mg;
e/acetamino
methadone
2
QL(2000/3
15mg
phen tabs
hcl oral soln
0)
ascomp/cod
2
PA
750mg;
10mg/5ml
eine
QL(360/30)
7.5mg
methadone
2
QL(4000/3
butalbital/ac
2
PA
hydrocodon
2
QL(180/30)
hcl oral soln
0)
etaminophe
QL(180/30)
e/acetamino
5mg/5ml
n/caffeine/c
phen tabs
methadone
2
QL(360/30)
odeine
650mg;
hcl tabs
butorphanol
4
10mg,
methadose
2
QL(360/30)
tartrate
inj
650mg;
tabs
butorphanol
2
QL(5/30)
7.5mg,
morphine
2
QL(90/30)
tartrate
660mg;
sulfate er
nasal soln
10mg
tbcr
co-gesic
2
QL(240/30)
hydrocodon
2
QL(240/30)
morphine
4
e/acetamino
endocet
2
QL(180/30)
sulfate inj
phen tabs
tabs 650mg;
0.5mg/ml,
500mg;
10mg
10mg/ml,
endocet
2
QL(240/30)
10mg,
1mg/ml,
tabs
500mg;
500mg;
5mg/ml
7.5mg
2.5mg,
OXYCONTI
4
PA
endocet
2
QL(360/30)
500mg;
N
QL(60/30)
tabs 325mg;
5mg,
oxymorphon
2
QL(60/30)
10mg,
500mg;
e
7.5mg
325mg;
hydrochlorid
5mg,
2
QL(360/30)
hydrocodon
e er
325mg;
e/acetamino
tramadol hcl
2
QL(30/30)
7.5mg
phen tabs
er tb24
fentanyl
4
325mg;
OPIOID ANALGESICS, SHORTcitrate
10mg,
ACTING
FENTANYL
5
QL(120/30)
325mg;
acetaminop
2
QL(150/30)
correo
46
Drug Name
5mg,
325mg;
7.5mg
hydrocodon
e/ibuprofen
tabs 7.5mg;
200mg
HYDROMO
RPHONE
HCL INJ
1MG/ML,
2MG/ML,
500MG/50M
L
hydromorph
one hcl inj
2mg/ml
hydromorph
one hcl liqd
hydromorph
one hcl tabs
LAZANDA
Drug
Tier
2
Reqs/Limits
QL(150/30)
4
4
2
2
5
QL(1200/3
0)
QL(240/30)
PA
QL(28/28)
Drug Name
Drug
Tier
2
Reqs/Limits
oxycodone/
QL(360/30)
acetaminop
hen tabs
325mg;
10mg,
325mg;
5mg,
325mg;
7.5mg
oxycodone/
2
QL(360/30)
aspirin
oxycodone/i
2
QL(150/30)
buprofen
roxicet tabs
2
QL(360/30)
stagesic
2
QL(240/30)
tramadol hcl
2
QL(240/30)
tramadol
2
QL(240/30)
hydrochlorid
e/acetamino
phen
XOLOX
3
QL(240/30)
ANESTHETICS
LOCAL ANESTHETICS
lidocaine hcl
2
external
soln
lidocaine hcl
4
inj 0.5%,
1%, 2%
lidocaine hcl
2
jelly
lidocaine
2
oint
lidocaine
1
viscous
lidocaine/pril
2
ocaine crea
LIDODERM
3
PA
QL(90/30)
ANTI-ADDICTION/SUBSTANCE
ABUSE TREATMENT AGENTS
ALCOHOL DETERRENTS/ANTICRAVING
CAMPRAL
3
PA
QL(180/30)
Drug Name
Drug
Tier
Reqs/Limits
MO
PA
depade
2
disulfiram
2
tabs 250mg
disulfiram
2
MO
tabs 500mg
naltrexone
2
PA
hcl
OPIOID ANTAGONISTS
buprenorphi
4
PA
ne hcl inj
buprenorphi
2
PA
ne hcl subl
QL(24/30)
buprenorphi
2
PA
ne
QL(90/30)
hcl/naloxon
e hcl
naloxone
4
hcl
SUBOXON
3
PA
E
QL(90/30)
SMOKING CESSATION AGENTS
buproban
2
QL(60/30)
MO
bupropion
2
PA
hcl sr tb12
QL(60/30)
150mg
MO
CHANTIX
3
PA
QL(340/36
5)
CHANTIX
3
PA
STARTING
QL(106/36
MONTH
5)
PAK
NICOTROL
3
PA
INHALER
QL(504/30)
NICOTROL
3
PA
NS
QL(40/30)
ANTI-INFLAMMATORY AGENTS
NONSTEROIDAL ANTIINFLAMMATORY DRUGS
CELEBREX
3
QL(60/30)
ST MO
diclofenac
2
MO
potassium
nalbuphine
4
hcl
oxycodone
2
QL(240/30)
hcl caps
oxycodone
2
QL(360/30)
hcl conc
oxycodone
2
QL(1200/3
hcl oral soln
0)
oxycodone
2
QL(240/30)
hcl tabs
oxycodone/
2
QL(240/30)
acetaminop
hen caps
oxycodone/
2
QL(180/30)
acetaminop
hen tabs
650mg;
10mg
oxycodone/
2
QL(240/30)
acetaminop
hen tabs
500mg;
7.5mg
correo
47
Drug Name
Drug
Tier
2
Reqs/Limits
Drug Name
Drug Reqs/Limits
Drug Name
Drug Reqs/Limits
Tier
Tier
diclofenac
MO
ANTIBACTERIALS
neomycin
2
sodium dr
sulfate tabs
AMINOGLYCOSIDES
tbec 25mg,
neomycin/p
4
amikacin
4
50mg
olymyxin
b
sulfate inj
diclofenac
1
MO
sulfates
1gm/4ml,
sodium dr
paromomyci
2
50mg/ml
tbec 75mg
n sulfate
gentak oint
2
streptomyci
4
diclofenac
2
MO
gentamicin
2
n sulfate
sodium er
sulfate crea
diflunisal
2
MO
TOBI
5
B/D PA
gentamicin
4
etodolac
2
MO
tobramycin
4
sulfate inj
sulfate
inj
etodolac er
2
MO
gentamicin
2
fenoprofen
2
MO
10mg/ml,
sulfate oint
calcium
80mg/2ml
0.1%
flurbiprofen
2
MO
tobramycin
2
gentamicin
2
ibuprofen
1
MO
sulfate
sulfate
susp
ophthalmic
ophthalmic
ibuprofen
1
MO
soln
soln
TOBREX
3
tabs 400mg,
4
gentamicin
OINT
600mg,
sulfate/0.9%
800mg
ZYLET
3
sodium
ketoprofen
2
MO
ANTIBACTERIALS, OTHER
chloride inj
ketoprofen
2
MO
0.9mg/ml;
ak-poly-bac
2
er
0.9%,
alcohol
1
meclofenam
2
MO
1.2mg/ml;
preps pads
ate sodium
0.9%,
baciim
4
meloxicam
1
MO
1.4mg/ml;
bacitracin
2
tabs
0.9%,
ophthalmic
nabumetone
2
MO
1.6mg/ml;
oint
naproxen dr
2
MO
0.9%,
bacitracin/p
2
naproxen
2
MO
1mg/ml;
olymyxin b
sodium tabs
0.9%
BACTROBA
3
275mg,
gentamicin
4
N NASAL
550mg
sulfate/sodi
chloramphe
1
naproxen
2
MO
nicol sodium
um chloride
susp
isotonic
4
succinate
naproxen
2
MO
gentamicin
clindamycin
2
tabs 250mg
inj
hcl
naproxen
1
MO
clindamycin
4
0.8mg/ml;
tabs 375mg,
phosphate
0.9%,
500mg
1.2mg/ml;
add-vantage
oxaprozin
2
MO
0.9%,
clindamycin
2
piroxicam
2
MO
1.6mg/ml;
phosphate
sulindac
2
MO
0.9%,
crea
tolmetin
2
MO
1mg/ml;
clindamycin
4
sodium
0.9%
phosphate
correo
48
Drug Name
inj
150mg/ml
colistimethat
e sodium
CUBICIN
LINCOCIN
methenamin
e hippurate
METROGE
L
metronidazo
le crea
metronidazo
le gel
0.75%
metronidazo
le in nacl
0.79%
metronidazo
le lotn
metronidazo
le tabs
metronidazo
le vaginal
mupirocin
calcium
mupirocin
oint
neomycin/b
acitracin/pol
ymyxin
neomycin/p
olymyxin/ba
citracin/hydr
ocortisone
neomycin/p
olymyxin/gr
amicidin
neomycin/p
olymyxin/hy
drocortisone
nitrofurantoi
n
Drug
Tier
Reqs/Limits
Drug Name
macrocrysta
lline
nitrofurantoi
n
monohydrat
e
NORITATE
polycin b
polymyxin b
sulfate
PREVPAC
PRIMSOL
SYNERCID
trimethoprim
trimethoprim
sulfate/poly
myxin b
sulfate
TYGACIL
VANCOMY
CIN HCL
CAPS
125MG
VANCOMY
CIN HCL
CAPS
250MG
VANCOMY
CIN HCL IN
DEXTROSE
VANCOMY
CIN HCL
INJ
5000MG,
750MG
VANCOMY
CIN HCL
INJ
1000MG,
10GM,
500MG
XIFAXAN
TABS
200MG
XIFAXAN
TABS
Drug
Tier
Reqs/Limits
Drug Name
550MG
ZYVOX
Drug
Tier
Reqs/Limits
5
PA
BETA-LACTAM,
CEPHALOSPORINS
5
B/D PA
cefaclor
2
4
caps
2
3
cefaclor er
2
2
cefadroxil
2
3
4
cefazolin
4
sodium inj
2
3
10gm, 1gm,
3
1gm; 5%,
2
4
500mg
2
cefazolin
4
2
sodium/dext
4
rose inj
2gm; 3%
cefdinir
2
2
4
cefepime inj
4
5
QL(40/30)
1gm,
1
1gm/50ml;
5%, 2gm,
2
2gm/100ml,
5
QL(80/30)
2gm/50ml;
2
5%
cefotaxime
4
2
sodium
5
cefoxitin
4
2
sodium inj
10gm, 1gm,
5
2gm
2
cefpodoxim
2
e proxetil
cefprozil
2
ceftazidime
4
2
4
inj 1gm,
2gm, 6gm
ceftazidime/
4
2
dextrose
ceftriaxone
4
in iso2
PA
3
PA
osmotic
QL(900/36
QL(9/30)
dextrose
5)
ceftriaxone
4
nitrofurantoi
2
PA
3
PA
sodium
QL(60/30)
n
QL(90/365)
cefuroxime
2
correo
49
4
2
PA
QL(90/365)
Drug Name
Drug
Tier
Reqs/Limits
Drug Name
Drug
Tier
Reqs/Limits
Drug Name
Drug
Tier
2
Reqs/Limits
axetil
susr
dicloxacillin
cefuroxime
4
amoxicillin
2
sodium
sodium inj
tabs
nafcillin
4
1.5gm,
amoxicillin/c
2
sodium
7.5gm,
lavulanate
oxacillin
4
potassium
750mg
sodium
cephalexin
1
chew
penicillin g
4
caps
amoxicillin/c
2
potassium
250mg,
lavulanate
penicillin v
1
500mg
potassium
potassium
er
cephalexin
2
oral soln
susr
amoxicillin/c
2
penicillin v
1
cephalexin
2
lavulanate
potassium
tabs
potassium
tabs 250mg
SUPRAX
3
susr
penicillin v
2
SUSR
amoxicillin/c
2
potassium
100MG/5ML
lavulanate
tabs 500mg
,
PFIZERPE
4
potassium
200MG/5ML
N-G
tabs 250mg;
SUPRAX
3
125mg
piperacillin
4
sodium/
TABS
amoxicillin/p
2
4
otassium
tazobactam
TAZICEF
clavulanate
sodium
INJ
1GM/50ML;
susr
piperacillin
4
4.4%
amoxicillin/p
sodium/tazo
2
tazicef inj
4
bactam
otassium
1gm, 2gm,
clavulanate
sodium
6gm
TIMENTIN
4
tabs
TEFLARO
4
ampicillin
2
ZOSYN INJ
4
caps
5%;
BETA-LACTAM, OTHER
2GM/50ML;
ampicillin
4
AZACTAM
4
0.25GM/50
sodium
IN ISOampicillin
2
ML, 5%;
OSMOTIC
susr
3GM/50ML;
DEXTROSE
250mg/5ml
0.375GM/50
aztreonam
4
ML
ampicillin4
cefotetan
4
sulbactam
MACROLIDES
imipenem/cil
2
inj 10gm;
astatin
AZASITE
3
5gm, 2gm;
INVANZ
4
azithromyci
4
1gm
n inj 500mg
meropenem
2
AUGMENTI
3
azithromyci
2
QL(3/30)
BETA-LACTAM, PENICILLINS
N
SUSR
n pack
amoxicillin
1
125MG/5ML
azithromyci
2
QL(75/30)
caps
;
n susr
amoxicillin
2
31.25MG/5
200mg/5ml
chew
ML
azithromyci
2
QL(150/30)
amoxicillin
1
correo
50
Drug Name
Drug
Tier
Reqs/Limits
Drug Name
Drug
Tier
3
3
2
Reqs/Limits
Drug Name
Drug
Tier
Reqs/Limits
n susr
CIPRO HC
soln
100mg/5ml
CIPRODEX
sulfacetami
2
ciprofloxacin
azithromyci
2
QL(12/28)
de
n tabs
er
sodium/pred
clarithromyc
2
ciprofloxacin
2
nisolone
hcl
sodium
in
clarithromyc
2
QL(60/30)
ophthalmic
phosphate
in er
soln
sulfadiazine
2
E.E.S.
3
sulfamethox
1
ciprofloxacin
2
GRANULES
hcl tabs
azole/trimet
ery
2
hoprim ds
100mg,
ERY-TAB
3
sulfamethox
4
750mg
ERYPED
3
ciprofloxacin
1
azole/trimet
hoprim inj
200
hcl tabs
ERYPED
3
250mg,
sulfamethox
1
400
500mg
azole/trimet
ERYTHRO
4
ciprofloxacin
4
hoprim susp
sulfamethox
1
CIN
i.v.-in d5w
azole/trimet
LACTOBIO
ciprofloxacin
4
hoprim tabs
NATE
inj
erythrocin
2
400mg/40ml
TETRACYCLINES
stearate
levofloxacin
4
DEMECLO
2
erythromyci
2
in d5w
CYCLINE
n base
levofloxacin
4
HCL
erythromyci
2
inj
doxycycline
2
n
levofloxacin
2
caps 75mg
ethylsuccina
tabs
doxycycline
1
te
MOXEZA
3
hyclate caps
erythromyci
2
ofloxacin
2
doxycycline
2
n external
VIGAMOX
3
hyclate
soln
SULFONAMIDES
cpep
erythromyci
2
BLEPHAMI
3
doxycycline
4
n gel
DE
hyclate inj
erythromyci
2
blephamide
2
doxycycline
1
n oint
hyclate tabs
s.o.p.
KETEK
3
QL(20/30)
erythromyci
2
100mg
ZMAX
3
QL(60/30)
doxycycline
2
n/sulfisoxaz
QUINOLONES
ole
hyclate tabs
AVELOX
3
sodium
2
20mg
sulfacetami
doxycycline
2
ABC PACK
AVELOX
4
de
monohydrat
e
INJ
ophthalmic
AVELOX
3
soln
minocycline
2
TABS
sulfacetami
2
hcl
CILOXAN
3
de sodium
tetracycline
1
OINT
ophthalmic
hcl
correo
51
Drug Name
Drug Reqs/Limits
Tier
ANTICONVULSANTS
ANTICONVULSANTS, OTHER
levetiraceta
2
m er
levetiraceta
4
m inj
levetiraceta
2
MO
m oral soln
levetiraceta
2
MO
m tabs
phenobarbit
2
MO
al
POTIGA
3
PA
QL(90/30)
MO
CALCIUM CHANNEL MODIFYING
AGENTS
CELONTIN
3
MO
ethosuximid
2
MO
e
LYRICA
3
QL(60/30)
CAPS
MO
225MG,
25MG,
300MG
LYRICA
3
QL(90/30)
CAPS
MO
100MG,
150MG,
200MG,
50MG,
75MG
LYRICA
3
QL(900/30)
ORAL
SOLN
zonisamide
2
MO
GAMMA-AMINOBUTYRIC ACID
(GABA) AUGMENTING AGENTS
clonazepam
2
QL(90/30)
odt tbdp
0.125mg,
0.25mg,
0.5mg, 1mg
clonazepam
2
QL(300/30)
odt tbdp
Drug Name
2mg
clonazepam
tabs 0.5mg,
1mg
clonazepam
tabs 2mg
clorazepate
dipotassium
tabs
3.75mg,
7.5mg
clorazepate
dipotassium
tabs 15mg
DIAZEPAM
GEL
divalproex
sodium
divalproex
sodium dr
divalproex
sodium er
gabapentin
GABITRIL
TABS
16MG
GABITRIL
TABS
12MG
ONFI TABS
10MG, 5MG
ONFI TABS
20MG
primidone
SABRIL
PACK
Drug
Tier
Reqs/Limits
Drug Name
Drug
Tier
4
Reqs/Limits
valproate
2
QL(90/30)
sodium
valproic acid
2
MO
GLUTAMATE REDUCING AGENTS
2
QL(300/30)
felbamate
2
MO
LAMICTAL
3
2
QL(90/30)
STARTER/
NOT
TAKING
CARBAMAZ
EPINE
2
QL(120/30)
LAMICTAL
3
STARTER/T
AKING
3
CARBAMAZ
EPINE/NOT
2
MO
TAKING
VALPROAT
2
MO
E
LAMICTAL
3
2
MO
STARTER/T
AKING
2
MO
VALPROAT
3
QL(90/30)
E
lamotrigine
2
MO
lamotrigine
2
MO
3
QL(120/30)
er
topiramate
2
MO
SODIUM CHANNEL AGENTS
3
QL(60/30)
BANZEL
5
PA MO
SUSP
3
QL(120/30)
BANZEL
5
PA MO
TABS
2
MO
400MG
5
PA
BANZEL
4
PA MO
QL(200/30)
TABS
MO
200MG
SABRIL
5
PA
carbamazep
2
MO
TABS
QL(180/30)
ine
MO
carbamazep
2
tiagabine
2
QL(90/30)
ine er cp12
hydrochlorid
MO
carbamazep
2
MO
e tabs 4mg
ine er tb12
tiagabine
2
QL(180/30)
dilantin caps
2
MO
hydrochlorid
MO
30mg
e tabs 2mg
fosphenytoi
4
correo
52
Drug Name
n sodium
oxcarbazepi
ne susp
oxcarbazepi
ne tabs
PEGANON
E
phenytoin
phenytoin
sodium
phenytoin
sodium
extended
TEGRETOL
-XR TB12
100MG
VIMPAT INJ
Drug
Tier
Reqs/Limits
2
2
MO
Drug Name
Drug
Tier
Reqs/Limits
Drug Name
hydrobromid
e oral soln
galantamine
2
QL(60/30)
hydrobromid
MO
e tabs
rivastigmine
2
QL(60/30)
tartrate
MO
N-METHYL-D-ASPARTATE (NMDA)
RECEPTOR ANTAGONIST
NAMENDA
3
QL(300/30)
ORAL
MO
SOLN
NAMENDA
3
QL(60/30)
TABS
MO
10MG
NAMENDA
3
QL(90/30)
TABS 5MG
MO
NAMENDA
3
QL(49/28)
TITRATION
MO
PAK
ANTIDEPRESSANTS
ANTIDEPRESSANTS, OTHER
budeprion sr
2
QL(60/30)
tb12 100mg
MO
budeprion sr
2
QL(90/30)
tb12 150mg
MO
bupropion
2
MO
hcl
bupropion
2
QL(60/30)
hcl er tb12
MO
200mg
bupropion
2
QL(60/30)
hcl sr tb12
MO
100mg,
200mg
bupropion
2
QL(90/30)
hcl sr tb12
MO
150mg
bupropion
2
QL(30/30)
hcl xl tb24
MO
300mg
bupropion
2
QL(90/30)
hcl xl tb24
MO
150mg
maprotiline
2
MO
hcl
mirtazapine
Drug
Tier
Reqs/Limits
2
QL(30/30)
MO
QL(30/30)
MO
mirtazapine
2
odt tbdp
3
MO
30mg, 45mg
nefazodone
2
QL(60/30)
2
MO
hcl
MO
4
trazodone
2
MO
hcl tabs
2
MO
300mg
trazodone
1
MO
hcl tabs
3
MO
100mg,
150mg,
50mg
4
QL(1200/3
MONOAMINE OXIDASE
0)
INHIBITORS
VIMPAT
3
QL(1200/3
AZILECT
3
ORAL
0) MO
EMSAM
3
MO
SOLN
MARPLAN
3
MO
VIMPAT
3
QL(60/30)
phenelzine
2
MO
TABS
MO
sulfate
ANTIDEMENTIA AGENTS
selegiline
2
MO
CHOLINESTERASE INHIBITORS
hcl
tranylcypro
2
MO
donepezil
2
QL(30/30)
mine sulfate
hcl tabs
MO
5mg
SEROTONIN/NOREPINEPHRINE
donepezil
2
QL(60/30)
REUPTAKE INHIBITORS
hcl tabs
MO
citalopram
1
QL(600/30)
10mg
hydrobromid
MO
donepezil
2
QL(30/30)
e oral soln
hcl tbdp
MO
citalopram
1
QL(30/30)
5mg
hydrobromid
MO
donepezil
2
QL(60/30)
e tabs 40mg
hcl tbdp
MO
citalopram
1
QL(60/30)
10mg
hydrobromid
MO
EXELON
3
QL(180/30)
e tabs
ORAL
MO
10mg, 20mg
SOLN
CYMBALTA
3
QL(60/30)
EXELON
3
QL(30/30)
MO
PT24
MO
DESVENLA
3
QL(30/30)
galantamine
2
QL(30/30)
FAXINE ER
MO
hydrobromid
MO
escitalopra
2
QL(600/30)
e cp24
m oxalate
MO
galantamine
2
QL(200/30)
oral soln
correo
53
Drug Name
Drug
Tier
2
Reqs/Limits
Drug Name
Drug
Tier
Reqs/Limits
Drug Name
Drug
Tier
Reqs/Limits
escitalopra
QL(60/30)
hcl tabs
MO
25mg,
m oxalate
MO
20mg
50mg, 75mg
tabs
PAXIL
3
amoxapine
2
MO
fluoxetine dr
2
MO
clomipramin
2
PA MO
SUSP
fluoxetine
2
QL(30/30)
PRISTIQ
3
QL(30/30)
e hcl
MO
hcl caps
MO
desipramine
2
MO
sertraline
2
QL(300/30)
10mg
hcl
hcl conc
MO
fluoxetine
2
QL(60/30)
doxepin hcl
2
PA MO
hcl caps
MO
sertraline
2
QL(30/30)
imipramine
2
PA MO
40mg
hcl tabs
MO
hcl
25mg, 50mg
imipramine
2
PA MO
fluoxetine
2
QL(120/30)
hcl caps
MO
sertraline
2
QL(60/30)
pamoate
nortriptyline
2
MO
20mg
hcl tabs
MO
hcl caps
fluoxetine
2
MO
100mg
50mg, 75mg
hcl oral soln
venlafaxine
2
QL(120/30)
fluoxetine
2
MO
hcl
MO
nortriptyline
1
MO
hcl caps
hcl tabs
venlafaxine
2
QL(30/30)
20mg
10mg, 25mg
hcl er cp24
MO
fluoxetine
2
QL(30/30)
nortriptyline
2
37.5mg
hcl tabs
MO
venlafaxine
2
QL(60/30)
hcl oral soln
10mg
hcl er cp24
MO
perphenazin
2
PA MO
150mg
e/amitriptyli
fluvoxamine
2
MO
ne
maleate
venlafaxine
2
QL(90/30)
fluvoxamine
2
QL(60/30)
hcl er cp24
MO
protriptyline
2
MO
maleate er
75mg
hcl
cp24 150mg
venlafaxine
2
QL(30/30)
trimipramine
2
PA MO
2
QL(90/30)
fluvoxamine
hcl er tb24
MO
maleate
maleate er
37.5mg
ANTIEMETICS
cp24 100mg
venlafaxine
2
QL(60/30)
ANTIEMETICS, OTHER
LUVOX CR
3
QL(90/30)
hcl er tb24
MO
meclizine
2
paroxetine
2
QL(30/30)
150mg
hcl tabs
venlafaxine
2
QL(90/30)
hcl er tb24
MO
TRANSDER
3
QL(12/36)
hcl er tb24
MO
12.5mg
M-SCOP
paroxetine
2
QL(60/30)
75mg
EMETOGENIC THERAPY
hcl er tb24
MO
VIIBRYD
4
QL(30/30)
ADJUNCTS
37.5mg
KIT
ST
ALOXI
4
B/D PA
paroxetine
2
QL(90/30)
VIIBRYD
4
QL(30/30)
dronabinol
2
PA
hcl er tb24
MO
TABS
ST MO
QL(90/30)
25mg
TRICYCLICS
EMEND
3
B/D PA
paroxetine
2
QL(60/30)
amitriptyline
2
PA MO
CAPS
QL(1/30)
hcl tabs
MO
hcl tabs
40MG
30mg, 40mg
150mg
EMEND
3
B/D PA
paroxetine
1
QL(30/30)
amitriptyline
1
PA MO
CAPS
QL(2/30)
hcl tabs
MO
hcl tabs
125MG
10mg
100mg,
EMEND
3
B/D PA
paroxetine
1
QL(60/30)
10mg,
correo
54
Drug Name
Drug
Tier
Reqs/Limits
Drug Name
Drug
Tier
Reqs/Limits
Drug Name
Drug
Tier
2
2
3
Reqs/Limits
CAPS
QL(6/30)
nitrate
nystop
80MG
fluconazole
4
pedi-dri
SPORANO
PA
granisetron
4
B/D PA
in dextrose
hcl inj
fluconazole
4
X ORAL
0.1mg/ml,
in nacl
SOLN
1mg/ml
fluconazole
2
terbinafine
1
QL(180/36
susr
hcl tabs
5)
granisetron
2
B/D PA
fluconazole
2
hcl tabs
QL(60/30)
terconazole
2
tabs 100mg,
ondansetron
4
voriconazol
4
PA
200mg,
hcl inj
e inj
50mg
ondansetron
2
voriconazol
5
PA
hcl oral soln
e tabs
fluconazole
1
QL(8/30)
ondansetron
2
QL(5/30)
tabs 150mg
XOLEGEL
3
hcl tabs
flucytosine
2
zazole supp
2
24mg
GRIS-PEG
3
ANTIGOUT AGENTS
ondansetron
2
QL(90/30)
griseofulvin
2
ANTIGOUT AGENTS
hcl tabs
microsize
allopurinol
1
MO
4mg, 8mg
itraconazole
2
PA
allopurinol
4
ondansetron
2
QL(90/30)
QL(120/30)
sodium
odt
ketoconazol
2
COLCRYS
3
MO
e crea
ANTIFUNGALS
probenecid
2
MO
ketoconazol
2
ANTIFUNGALS
probenecid/
2
MO
e sham
ABELCET
4
PA
colchicine
ketoconazol
2
AMBISOME
4
PA
ULORIC
3
ST
e
tabs
AMPHOTE
4
PA
ANTIMIGRAINE AGENTS
NAFTIN
3
C INJ 50MG
ERGOT ALKALOIDS
CREA
amphoterici
4
PA
cafergot
2
NAFTIN
3
nb
dihydroergot
3
GEL 1%
CANCIDAS
5
PA
amine
NATACYN
3
ciclopirox
2
mesylate inj
NOXAFIL
5
PA
nail lacquer
migergot
2
QL(600/30)
ciclopirox
2
SEROTONIN (5-HT) 1B/1D
nyamyc
2
olamine
RECEPTOR AGONISTS
nystatin
2
ciclopirox
2
naratriptan
2
QL(9/30)
crea
sham
hcl
nystatin oint
2
ciclopirox
2
rizatriptan
2
nystatin
2
susp
benzoate
powd
clotrimazole
2
sumatriptan
2
QL(12/30)
100000unit/
external
sumatriptan
2
QL(8/30)
gm
crea
succinate inj
nystatin
2
clotrimazole
2
sumatriptan
2
QL(8/30)
susp
external
succinate
nystatin
2
soln
refill
tabs
clotrimazole
2
sumatriptan
2
QL(9/30)
nystatin/tria
2
troc
succinate
mcinolone
econazole
2
correo
55
Drug Name
Drug
Tier
Reqs/Limits
tabs
ANTIMYASTHENIC AGENTS
PARASYMPATHOMIMETICS
guanidine
1
hcl
MESTINON
3
TIMESPAN
pyridostigmi
2
ne bromide
regonol
4
ANTIMYCOBACTERIALS
ANTIMYCOBACTERIALS, OTHER
dapsone
2
MO
MYCOBUTI
3
N
ANTITUBERCULARS
CAPASTAT
4
SULFATE
cycloserine
2
ethambutol
2
hcl
isoniazid inj
4
isoniazid
2
syrp
isoniazid
2
tabs 100mg
isoniazid
1
tabs 300mg
PASER
3
PRIFTIN
3
pyrazinamid
2
e
rifampin
2
caps
rifampin inj
4
RIFATER
3
TRECATOR
3
ANTINEOPLASTICS
ALKYLATING AGENTS
BICNU
4
B/D PA
BUSULFEX
5
B/D PA
CEENU
3
cyclophosph
4
B/D PA
amide inj
cyclophosph
2
B/D PA
Drug Name
Drug
Tier
Reqs/Limits
Drug Name
Drug Reqs/Limits
Tier
ANTIMETABOLITES
ALIMTA INJ
5
B/D PA
500MG
cladribine
4
B/D PA
CLOLAR
4
B/D PA
cytarabine
4
B/D PA
cytarabine
4
B/D PA
aqueous
DROXIA
3
MO
ELITEK
5
B/D PA
fluorouracil
4
B/D PA
inj
2.5gm/50ml
FOLOTYN
5
B/D PA
gemcitabine
4
B/D PA
gemcitabine
5
B/D PA
hcl
hydroxyurea
2
mercaptopu
2
rine
pentostatin
5
B/D PA
TABLOID
3
ANTINEOPLASTICS
KYPROLIS
5
PA
QL(6/28)
ANTINEOPLASTICS, OTHER
ABRAXANE
5
B/D PA
adriamycin
4
B/D PA
inj 20mg
amifostine
4
B/D PA
ARRANON
4
bleomycin
4
B/D PA
sulfate
calcium
4
folinate
carboplatin
4
B/D PA
inj
150mg/15ml
cerubidine
4
B/D PA
cisplatin inj
4
B/D PA
100mg/100
ml
COMETRIQ
5
PA
COSMEGE
5
B/D PA
N
amide tabs
dacarbazine
4
B/D PA
HEXALEN
5
ifosfamide
4
B/D PA
inj 1gm,
3gm
ifosfamide/
5
B/D PA
mesna
LEUKERAN
3
MATULANE
5
melphalan
5
B/D PA
hydrochlorid
e
MUSTARG
4
B/D PA
EN
TEMODAR
5
B/D PA
INJ
thiotepa
4
B/D PA
TREANDA
4
B/D PA
INJ 25MG
TREANDA
5
B/D PA
INJ 100MG
ZANOSAR
4
B/D PA
ANTIANGIOGENIC AGENTS
CAPRELSA
5
PA
REVLIMID
5
PA
CAPS
QL(21/28)
10MG,
15MG,
2.5MG,
25MG, 5MG
THALOMID
5
PA
CAPS
QL(60/30)
150MG,
200MG,
50MG
THALOMID
5
PA
CAPS
QL(90/30)
100MG
ANTIESTROGENS/MODIFIERS
EMCYT
3
FARESTON
3
MO
FASLODEX
5
B/D PA
SOLTAMOX
3
tamoxifen
2
MO
citrate
correo
56
Drug Name
DACOGEN
dactinomyci
n
daunorubici
n hcl inj
5mg/ml
DAUNOXO
ME
dexrazoxan
e
DOCEFREZ
docetaxel inj
20mg/ml,
80mg/4ml,
80mg/8ml
doxorubicin
hcl inj
2mg/ml
DOXORUBI
CIN HCL
LIPOSOME
ELLENCE
INJ
200MG/100
ML
ELSPAR
epirubicin
hcl inj
50mg/25ml
epirubicin
hcl inj
200mg/100
ml
ERIVEDGE
Drug
Tier
5
5
4
Reqs/Limits
B/D PA
B/D PA
5
B/D PA
4
B/D PA
5
5
B/D PA
B/D PA
2
B/D PA
5
B/D PA
4
B/D PA
4
4
B/D PA
B/D PA
5
B/D PA
5
PA
QL(30/30)
B/D PA
Drug Name
ISTODAX
IXEMPRA
KIT
JAKAFI
JEVTANA
leucovorin
calcium inj
100mg,
10mg/ml,
350mg,
500mg,
50mg
leucovorin
calcium tabs
MEKINIST
MENEST
mesna
MESNEX
TABS
mitomycin
MITOXANT
RONE HCL
ONCASPA
R
ONTAK
oxaliplatin
inj
100mg/20ml
paclitaxel inj
300mg/50ml
PICATO
POMALYST
Drug
Tier
5
5
Reqs/Limits
5
PA
QL(60/30)
B/D PA
5
4
PA MO
B/D PA
2
5
3
2
4
PA
PA
B/D PA
4
3
B/D PA
B/D PA
5
B/D PA
5
5
B/D PA
B/D PA
4
B/D PA
4
5
ST
PA
QL(21/28)
B/D PA
Drug Name
vincristine
sulfate
vinorelbine
tartrate inj
50mg/5ml
ZINECARD
INJ 250MG
ZOLINZA
ZYTIGA
Drug
Tier
4
Reqs/Limits
B/D PA
4
B/D PA
4
B/D PA
5
5
QL(120/30)
PA
QL(120/30)
AROMATASE INHIBITORS, 3RD
GENERATION
anastrozole
2
QL(30/30)
MO
exemestane
2
letrozole
2
QL(30/30)
ENZYME INHIBITORS
ETOPOPH
4
B/D PA
OS
ETOPOSID
3
B/D PA
E INJ
topotecan
5
B/D PA
hcl inj 4mg
MOLECULAR TARGET INHIBITORS
AFINITOR
5
PA
QL(30/30)
BOSULIF
5
PA
GLEEVEC
5
PA
QL(60/30)
INLYTA
5
PA
TABS 5MG
QL(120/30)
INLYTA
5
PA
TABS 1MG
QL(240/30)
NEXAVAR
5
PA
SPRYCEL
5
PA
STIVARGA
5
PA
QL(84/21)
SUTENT
5
PA
TARCEVA
5
PA
TASIGNA
5
PA
TYKERB
5
PA
VOTRIENT
5
PA
QL(120/30)
XALKORI
5
PA
QL(60/30)
PROLEUKI
5
fludarabine
4
N
phosphate
SYLATRON
5
PA
FUSILEV
5
SYNRIBO
5
PA
TAFINLAR
5
PA
HALAVEN
5
PA
ICLUSIG
5
PA
TAXOTERE
5
B/D PA
idarubicin
5
B/D PA
TRISENOX
4
B/D PA
hcl inj
VELCADE
5
B/D PA
10mg/10ml
VIDAZA
5
B/D PA
vinblastine
4
B/D PA
irinotecan
4
B/D PA
inj
sulfate
100mg/5ml
vincasar pfs
4
B/D PA
correo
57
Drug Name
ZELBORAF
Drug
Tier
5
Reqs/Limits
PA
QL(240/30)
MONOCLONAL ANTIBODIES
ARZERRA
5
B/D PA MO
INJ
100MG/5ML
AVASTIN
5
B/D PA
INJ
100MG/4ML
ERBITUX
5
B/D PA
HERCEPTI
5
B/D PA
N
KADCYLA
5
PA
PERJETA
5
PA
RITUXAN
5
PA
VECTIBIX
3
B/D PA
INJ
100MG/5ML
YERVOY
5
B/D PA
ZALTRAP
5
PA
RETINOIDS
PANRETIN
3
TARGRETI
5
N
tretinoin
2
MO
caps
ANTIPARASITICS
ANTHELMINTICS
ALBENZA
3
STROMEC
3
TOL
ANTIPROTOZOALS
ALINIA
3
chloroquine
2
MO
phosphate
COARTEM
3
DARAPRIM
3
hydroxychlo
2
MO
roquine
sulfate
mefloquine
2
MO
hcl
MEPRON
5
NEBUPENT
3
B/D PA
NEUTREXI
5
Drug Name
Drug
Tier
Reqs/Limits
N
PENTAM
3
300
primaquine
1
phosphate
quinine
1
sulfate
PEDICULICIDES/SCABICIDES
acticin
2
lindane
2
malathion
2
permethrin
2
crea
ANTIPARKINSON AGENTS
ANTICHOLINERGICS
benztropine
4
PA
mesylate inj
benztropine
1
PA MO
mesylate
tabs 2mg
benztropine
2
PA MO
mesylate
tabs 0.5mg,
1mg
trihexypheni
2
PA MO
dyl hcl elix
trihexypheni
2
PA MO
dyl hcl tabs
5mg
trihexypheni
1
PA MO
dyl hcl tabs
2mg
ANTIPARKINSON AGENTS, OTHER
entacapone
2
MO
TASMAR
5
MO
DOPAMINE AGONISTS
APOKYN
5
PA
QL(60/30)
MO
bromocriptin
2
MO
e mesylate
pramipexole
2
QL(90/30)
dihydrochlor
MO
ide
ropinirole
2
MO
Drug Name
Drug
Tier
Reqs/Limits
hcl
DOPAMINE PRECURSORS/LAMINO ACID DECARBOXYLASE
INHIBITORS
carbidopa/le
2
MO
vodopa
carbidopa/le
2
MO
vodopa cr
carbidopa/le
2
MO
vodopa er
carbidopa/le
2
MO
vodopa odt
carbidopa/le
2
MO
vodopa/enta
capone
LODOSYN
3
MO
ANTIPSYCHOTICS
1ST GENERATION/TYPICAL
chlorpromaz
4
ine hcl inj
chlorpromaz
2
MO
ine hcl tabs
compro
2
fluphenazin
4
e decanoate
fluphenazin
2
MO
e hcl conc
fluphenazin
2
MO
e hcl elix
fluphenazin
4
e hcl inj
fluphenazin
1
MO
e hcl tabs
1mg
fluphenazin
2
MO
e hcl tabs
10mg,
2.5mg, 5mg
haloperidol
2
MO
conc
haloperidol
4
decanoate
haloperidol
4
lactate
haloperidol
1
MO
correo
58
Drug Name
Drug
Tier
Reqs/Limits
Drug Name
Drug
Tier
Reqs/Limits
Drug Name
Drug
Tier
Reqs/Limits
tabs 0.5mg,
TABS 6MG
ST
120MG,
1mg, 2mg,
FANAPT
4
QL(60/30)
20MG,
TABS
ST
5mg
40MG
haloperidol
2
MO
10MG,
LATUDA
4
QL(60/30)
tabs 10mg,
TABS
ST MO
12MG,
20mg
80MG
1MG, 2MG,
loxapine
2
MO
4MG, 8MG
olanzapine
4
succinate
FANAPT
4
QL(16/30)
inj
ORAP
3
MO
TITRATION
ST
olanzapine
2
QL(30/30)
perphenazin
2
MO
PACK
odt
MO
e
olanzapine
2
QL(30/30)
GEODON
4
QL(60/30)
prochlorper
2
INJ
tabs
MO
azine
INVEGA
4
QL(0.25/28
olanzapine/f
2
QL(30/30)
prochlorper
4
SUSTENNA
)
luoxetine
MO
azine
INJ
quetiapine
2
QL(90/30)
edisylate
39MG/0.25
fumarate
MO
prochlorper
1
ML
RISPERDA
4
azine
INVEGA
4
QL(0.5/28)
L CONSTA
maleate
SUSTENNA
risperidone
2
QL(90/30)
tabs 10mg
INJ
m-tab
MO
prochlorper
2
78MG/0.5M
risperidone
2
QL(90/30)
azine
L
MO
odt tbdp
maleate
INVEGA
5
QL(0.75/28
0.25mg,
tabs 5mg
SUSTENNA
)
0.5mg, 1mg,
thioridazine
2
PA MO
INJ
2mg, 3mg
117MG/0.75
risperidone
2
QL(120/30)
hcl
thiothixene
2
MO
ML
odt tbdp
MO
caps 10mg,
INVEGA
5
QL(1/28)
4mg
1mg, 5mg
SUSTENNA
risperidone
2
QL(360/30)
thiothixene
1
MO
INJ
oral soln
MO
156MG/ML
risperidone
2
QL(90/30)
caps 2mg
trifluoperazi
2
MO
INVEGA
5
QL(1.5/28)
tabs
MO
ne hcl
SUSTENNA
0.25mg,
INJ
0.5mg, 1mg,
2ND GENERATION/ATYPICAL
234MG/1.5
2mg, 3mg
ABILIFY
3
QL(60/30)
ML
risperidone
2
QL(120/30)
DISCMELT
MO
INVEGA
5
QL(30/30)
tabs
4mg
MO
ABILIFY INJ
4
TB24 9MG
ST
SAPHRIS
3
QL(60/30)
ABILIFY
5
ST
INVEGA
4
QL(30/30)
MO
MAINTENA
TB24
ST
SEROQUEL
3
QL(30/30)
INJ 300MG
XR TB24
MO
1.5MG,
ABILIFY
3
QL(900/30)
150MG,
3MG
ORAL
MO
INVEGA
4
QL(60/30)
200MG
SOLN
TB24
6MG
ST
SEROQUEL
3
QL(60/30)
ABILIFY
3
QL(30/30)
LATUDA
4
QL(30/30)
XR TB24
MO
TABS
MO
TABS
ST
MO
300MG,
FANAPT
5
QL(60/30)
correo
59
Drug Name
Drug
Tier
Reqs/Limits
400MG,
50MG
ziprasidone
2
QL(60/30)
hcl
MO
ZYPREXA
5
RELPREVV
TREATMENT-RESISTANT
clozapine
2
CLOZAPIN
4
E ODT
TBDP
100MG
clozapine
4
MO
odt tbdp
12.5mg,
25mg
FAZACLO
4
ST
ANTISPASTICITY AGENTS
ANTISPASTICITY AGENTS
baclofen
1
MO
tabs 10mg
baclofen
2
MO
tabs 20mg
dantrolene
2
sodium
caps
tizanidine
2
MO
hcl tabs
ANTIVIRALS
ANTI-CYTOMEGALOVIRUS (CMV)
AGENTS
cidofovir
5
foscarnet
4
sodium
ganciclovir
4
B/D PA
VALCYTE
5
MO
ZIRGAN
3
ST
ANTI-HIV AGENTS, NONNUCLEOSIDE REVERSE
TRANSCRIPTASE INHIBITORS
ATRIPLA
5
MO
COMPLER
5
MO
A
EDURANT
3
INTELENC
5
QL(60/30)
Drug Name
Drug
Tier
Reqs/Limits
Drug Name
Drug
Tier
Reqs/Limits
E TABS
SOLN
200MG
zidovudine
2
MO
INTELENC
5
QL(120/30)
ANTI-HIV AGENTS, OTHER
E TABS
MO
FUZEON
5
MO
100MG
ISENTRES
5
QL(180/30)
INTELENC
5
QL(180/30)
S CHEW
E TABS
MO
100MG
25MG
ISENTRES
5
QL(360/30)
NEVIRAPIN
2
MO
S CHEW
E SUSP
25MG
nevirapine
2
MO
ISENTRES
5
QL(60/30)
tabs
S TABS
MO
RESCRIPT
3
MO
SELZENTR
5
QL(60/30)
OR
Y TABS
MO
STRIBILD
5
MO
150MG
SUSTIVA
3
MO
SELZENTR
5
QL(120/30)
viramune
3
MO
Y TABS
MO
susp
300MG
VIRAMUNE
3
ANTI-HIV AGENTS, PROTEASE
XR
INHIBITORS
ANTI-HIV AGENTS, NUCLEOSIDE
APTIVUS
5
MO
AND NUCLEOTIDE REVERSE
CRIXIVAN
3
MO
TRANSCRIPTASE INHIBITORS
INVIRASE
5
MO
abacavir
2
MO
KALETRA
5
MO
didanosine
2
MO
ORAL
EMTRIVA
3
MO
SOLN
EPIVIR
3
MO
KALETRA
5
MO
HBV
TABS
EPIVIR
3
MO
200MG;
ORAL
50MG
SOLN
KALETRA
4
MO
EPZICOM
5
MO
TABS
lamivudine
2
MO
100MG;
lamivudine/z
5
MO
25MG
idovudine
LEXIVA
4
MO
RETROVIR
4
SUSP
IV
LEXIVA
5
MO
INFUSION
TABS
stavudine
2
MO
NORVIR
3
MO
TRIZIVIR
5
MO
PREZISTA
5
TRUVADA
5
MO
SUSP
VIDEX
3
MO
PREZISTA
5
QL(30/30)
PEDIATRIC
TABS
MO
VIREAD
5
MO
800MG
ZIAGEN
3
MO
PREZISTA
5
QL(60/30)
ORAL
TABS
MO
correo
60
Drug Name
Drug
Tier
Reqs/Limits
Drug Name
Drug
Tier
4
4
Reqs/Limits
Drug Name
Drug
Tier
2
Reqs/Limits
400MG,
INTRON-A
alprazolam
QL(150/30)
600MG
INTRON-A
odt tbdp
2mg
PREZISTA
4
QL(180/30)
W/DILUENT
INJ 10MU,
alprazolam
2
QL(300/30)
TABS
MO
150MG
18MU
odt tbdp
PREZISTA
4
QL(360/30)
1mg
PEG5
PA
TABS
MO
INTRON
alprazolam
2
QL(90/30)
75MG
INJ
tabs
REYATAZ
4
MO
50MCG/0.5
0.25mg,
CAPS
ML
0.5mg
PEG5
PA
alprazolam
2
QL(150/30)
100MG
REYATAZ
5
MO
INTRON
tabs 2mg
alprazolam
2
QL(300/30)
CAPS
REDIPEN
PEG5
PA
tabs 1mg
150MG,
INTRON
200MG,
buspirone
1
REDIPEN
300MG
hcl tabs
PAK 4
10mg, 5mg
VIRACEPT
5
MO
buspirone
2
REBETOL
4
PA
ANTI-INFLUENZA AGENTS
hcl
tabs
ORAL
amantadine
2
MO
15mg,
SOLN
hcl caps
RIBAPAK
5
PA
30mg,
amantadine
2
ribasphere
2
PA
7.5mg
hcl syrp
ribavirin
2
PA
diazepam
2
QL(1200/3
amantadine
2
MO
TYZEKA
3
PA
MO
oral
soln
0)
hcl tabs
VICTRELIS
5
PA
diazepam
2
QL(120/30)
rimantadine
2
QL(360/30)
tabs
hcl
lorazepam
2
QL(120/30)
ANTIHERPETIC AGENTS
TAMIFLU
3
QL(56/365)
conc
MO
CAPS
acyclovir
2
lorazepam
2
QL(120/30)
45MG,
acyclovir
4
tabs
MO
75MG
sodium
oxazepam
2
QL(120/30)
TAMIFLU
3
QL(112/36
DENAVIR
3
MO
CAPS
5)
famciclovir
2
QL(21/7)
BIPOLAR AGENTS
trifluridine
2
30MG
TAMIFLU
3
QL(700/36
valacyclovir
2
QL(30/30)
MOOD STABILIZERS
hcl
SUSR
5)
lithium
1
MO
ZOVIRAX
3
carbonate
ANTIHEPATITIS AGENTS
CREA
caps 300mg
BARACLUD
3
MO
ZOVIRAX
3
lithium
2
MO
E
OINT
carbonate
HEPSERA
5
QL(30/30)
ANXIOLYTICS
caps
MO
150mg,
ANXIOLYTICS, OTHER
INCIVEK
5
PA
600mg
QL(180/30)
alprazolam
2
QL(90/30)
lithium
2
MO
INFERGEN
5
PA
odt tbdp
carbonate
INJ
0.25mg,
er
15MCG/0.5
0.5mg
lithium
2
MO
ML
correo
61
Drug Name
Drug
Tier
Reqs/Limits
Drug Name
Drug
Tier
1
Reqs/Limits
Drug Name
Drug
Tier
Reqs/Limits
carbonate
metformin
MO
0.45%
tabs
hcl
dextrose
4
10% flex
metformin
1
MO
BLOOD GLUCOSE REGULATORS
hcl er tb24
container
ANTIDIABETIC AGENTS
500mg,
dextrose
4
acarbose
2
QL(90/30)
750mg
10%/nacl
MO
0.2%
nateglinide
2
QL(90/30)
BYDUREO
3
QL(4/28)
MO
dextrose
4
N
PIOGLITAZ
2
QL(30/30)
2.5%/nacl
BYETTA
3
QL(2.4/30)
ONE
HCL
MO
0.45%
MO
dextrose
4
pioglitazone
2
QL(30/30)
CYCLOSET
4
hclMO
2.5%/sodiu
glimepiride
1
QL(30/30)
glimepiride
m chloride
tabs 1mg,
MO
PIOGLITAZ
2
QL(90/30)
0.45%
2mg
dextrose
5%
4
ONE
MO
glimepiride
1
QL(60/30)
HCL/METF
dextrose
4
tabs 4mg
MO
ORMIN
5%/nacl
glipizide
1
MO
HCL
0.2%
glipizide er
1
MO
PRANDIN
3
MO
dextrose
4
glipizide xl
1
MO
RIOMET
3
MO
5%/nacl
tb24 2.5mg
SYMLINPE
3
PA
0.225%
glipizide/met
1
MO
dextrose
4
N
120
QL(11/30)
formin hcl
5%/nacl
MO
glyburide
2
PA MO
SYMLINPE
3
PA
0.33%
glyburide
2
PA MO
dextrose
4
N 60
QL(6/30)
micronized
MO
5%/nacl
glyburide/m
2
PA MO
tolazamide
2
MO
0.45%
etformin hcl
TRADJENT
3
QL(30/30)
dextrose
4
GLYSET
3
MO
A
MO
5%/nacl
JANUMET
3
QL(60/30)
VICTOZA
3
QL(9/30)
0.9%
MO
dextrose
4
GLYCEMIC AGENTS
JANUMET
3
QL(30/30)
5%/sodium
clinimix
4
B/D PA
XR TB24
MO
chloride
4.25%/dextr
500MG;
0.2%
ose 20%
50MG
dextrose
4
CLINIMIX
4
B/D PA
JANUMET
3
QL(60/30)
5%/sodium
5%/DEXTR
XR TB24
MO
chloride
OSE 15%
1000MG;
0.45%
CLINIMIX
4
B/D PA
100MG,
GLUCAGE
4
5%/DEXTR
1000MG;
N
HYPOKIT
OSE 20%
50MG
kcl
4
CLINIMIX
E
3
B/D PA
JANUVIA
3
QL(30/30)
0.075%/d5w
4.25%/DEX
MO
/nacl 0.45%
TROSE
JENTADUE
3
QL(60/30)
kcl
4
25%
TO
MO
0.15%/d5w/
dextrose
4
JUVISYNC
3
QL(30/30)
nacl 0.3%
10%/nacl
MO
correo
62
Drug Name
kcl
0.15%/d5w/l
r
kcl
0.15%/d5w/
nacl 0.2%
kcl
0.15%/d5w/
nacl 0.45%
kcl
0.15%/d5w/
nacl 0.9%
kcl
0.3%/d5w/n
acl 0.45%
normosol-r
in d5w
potassium
chloride
0.15%
d5w/nacl
0.33%
potassium
chloride
0.15%
d5w/nacl
0.45%
viaflex
potassium
chloride
0.22%
d5w/nacl
0.45%
potassium
chloride
0.224%/d5w
/nacl 0.45%
PROGLYCE
M
Drug
Tier
4
Reqs/Limits
Drug Name
mix 50/50
kwikpen
humalog
mix 75/25
humalog
mix 75/25
kwikpen
humulin
70/30
humulin
70/30 pen
humulin n
humulin n u100 pen
humulin r
humulin r u500
(concentrate
d)
lantus
lantus
solostar
levemir
levemir
flexpen
Drug
Tier
Reqs/Limits
Drug Name
Drug
Tier
Reqs/Limits
30MG/0.3M
L
3
MO
ENOXAPAR
4
QL(11.2/30
4
IN SODIUM
)
3
MO
INJ
40MG/0.4M
4
L
3
MO
ENOXAPAR
4
QL(16.8/30
IN SODIUM
)
4
3
MO
INJ
60MG/0.6M
3
MO
L
4
3
MO
ENOXAPAR
4
QL(22.4/30
IN SODIUM
)
3
MO
INJ
4
B/D PA
3
MO
80MG/0.8M
L
4
ENOXAPAR
4
QL(84/30)
IN SODIUM
INJ
3
MO
3
MO
300MG/3ML
fondaparinu
4
QL(7/30)
4
x sodium inj
3
MO
3
MO
2.5mg/0.5ml
FONDAPAR
5
QL(5.6/30)
INUX
BLOOD
SODIUM
PRODUCTS/MODIFIERS/VOLUME
INJ
EXPANDERS
4
5MG/0.4ML
ANTICOAGULANTS
FONDAPAR
5
QL(8.4/30)
COUMADIN
4
INUX
INJ
SODIUM
ELIQUIS
3
PA
INJ
QL(60/30)
7.5MG/0.6M
4
ENOXAPAR
5
QL(22.4/30
L
IN SODIUM
)
FONDAPAR
5
QL(11.2/30
INJ
INUX
)
120MG/0.8
3
MO
SODIUM
ML
INJ
ENOXAPAR
5
QL(28/30)
10MG/0.8M
INSULINS
IN SODIUM
L
HUMALOG
3
MO
INJ
heparin
4
HUMALOG
3
MO
100MG/ML,
sodium inj
KWIKPEN
150MG/ML
10000unit/m
humalog
3
MO
ENOXAPAR
4
QL(8.4/30)
l,
mix 50/50
IN SODIUM
1000unit/ml,
humalog
3
MO
INJ
correo
63
Drug Name
Drug
Tier
Reqs/Limits
Drug Name
Drug
Tier
5
Reqs/Limits
Drug Name
Drug
Tier
Reqs/Limits
20000unit/m
ARANESP
PA
4000UNIT/
l,
ALBUMIN
ML
2000unit/ml,
FREE INJ
PROMACT
5
PA
2500unit/ml,
100MCG/0.
A
QL(30/30)
5000unit/ml
5ML,
COAGULANTS
heparin
4
100MCG/M
BRILINTA
3
QL(60/30)
sodium/d5w
L,
MO
heparin
4
150MCG/0.
tranexamic
2
PA
sodium/nacl
3ML,
acid inj
0.9%
200MCG/0.
tranexamic
2
4ML,
heparin
4
acid tabs
sodium/sodi
200MCG/M
PLATELET MODIFYING AGENTS
um chloride
L,
AGGRENO
3
QL(60/30)
0.9% premix
300MCG/0.
X
MO
jantoven
2
MO
6ML,
cilostazol
2
MO
PRADAXA
3
PA
300MCG/M
clopidogrel
2
QL(1/30)
CAPS
QL(60/30)
L,
tabs 300mg
MO
150MG
500MCG/M
clopidogrel
2
QL(30/30)
PRADAXA
3
PA
L
tabs 75mg
MO
CAPS
QL(120/30)
LEUKINE
5
PA
CARDIOVASCULAR AGENTS
75MG
MOZOBIL
5
B/D PA
ALPHA-ADRENERGIC AGONISTS
QL(9.6/30)
warfarin
1
MO
clonidine hcl
2
QL(4/28)
NEULASTA
5
PA
sodium
ptwk
MO
XARELTO
3
PA
NEUMEGA
5
PA MO
0.1mg/24hr,
TABS
QL(30/30)
NEUPOGE
5
PA
0.2mg/24hr
10MG,
N INJ
clonidine hcl
2
QL(8/28)
20MG
300MCG/0.
ptwk
MO
XARELTO
3
PA
5ML,
0.3mg/24hr
TABS
QL(60/30)
480MCG/0.
clonidine hcl
2
MO
15MG
8ML,
tabs 0.3mg
480MCG/1.
BLOOD FORMATION MODIFIERS
clonidine hcl
1
MO
6ML
anagrelide
2
MO
tabs 0.1mg,
PROCRIT
5
PA
hydrochlorid
0.2mg
INJ
e
methyldopat
2
PA
20000UNIT/
ARANESP
4
PA
e hcl
ML,
ALBUMIN
midodrine
2
40000UNIT/
FREE INJ
hcl
ML
25MCG/0.4
ALPHA-ADRENERGIC BLOCKING
PROCRIT
4
PA
2ML,
AGENTS
INJ
25MCG/ML,
DIBENZYLI
3
10000UNIT/
40MCG/0.4
NE
ML,
ML,
doxazosin
1
QL(30/30)
2000UNIT/
40MCG/ML,
mesylate
MO
ML,
60MCG/0.3
tabs 1mg,
3000UNIT/
ML,
2mg, 4mg
ML,
60MCG/ML
correo
64
Drug Name
Drug
Tier
1
Reqs/Limits
Drug Name
Drug
Tier
Reqs/Limits
Drug Name
Drug
Tier
Reqs/Limits
doxazosin
QL(60/30)
drochlorothi
400mg
mesylate
MO
azide
flecainide
2
MO
acetate
tabs 8mg
ANGIOTENSIN-CONVERTING
prazosin hcl
1
MO
lidocaine hcl
4
ENZYME (ACE) INHIBITORS
terazosin
1
QL(30/30)
inj 10mg/ml
benazepril
1
MO
hcl caps
MO
mexiletine
2
MO
hcl
1mg, 5mg
hcl
benazepril
2
MO
terazosin
1
QL(60/30)
MULTAQ
3
QL(60/30)
hcl/hydrochl
hcl caps
MO
MO
orothiazide
10mg, 2mg
PACERON
3
MO
captopril
1
MO
E TABS
ANGIOTENSIN II RECEPTOR
captopril/hy
2
MO
100MG
ANTAGONISTS
drochlorothi
pacerone
2
MO
BENICAR
3
QL(30/30)
azide
tabs 200mg
enalapril
1
MO
ST MO
propafenon
2
MO
BENICAR
3
QL(30/30)
maleate
e hcl
HCT
ST MO
enalapril
1
MO
propafenon
2
MO
EDARBI
3
QL(30/30)
maleate/hyd
e hcl er
ST MO
rochlorothia
sorine
2
MO
EDARBYCL
3
QL(30/30)
zide
sotalol hcl
2
MO
OR
ST
fosinopril
2
MO
(af)
irbesartan
1
MO
sodium
2
MO
sotalol hcl
irbesartan/h
1
MO
fosinopril
2
MO
tabs 160mg,
ydrochloroth
sodium/hydr
240mg,
iazide
ochlorothiaz
80mg
losartan
1
QL(30/30)
ide
TIKOSYN
3
MO
potassium
MO
lisinopril
1
MO
BETA-ADRENERGIC BLOCKING
tabs 100mg
lisinopril/hyd
1
MO
AGENTS
rochlorothia
losartan
1
QL(60/30)
potassium
MO
zide
acebutolol
2
MO
tabs 25mg,
moexipril hcl
2
MO
hcl
50mg
moexipril/hy
2
MO
atenolol
1
MO
losartan
1
QL(30/30)
drochlorothi
atenolol/chl
1
MO
potassium/h
MO
azide
orthalidone
ydrochloroth
betaxolol hcl
2
MO
quinapril hcl
1
MO
bisoprolol
2
MO
iazide tabs
quinapril/hy
2
MO
12.5mg;
drochlorothi
fumarate
100mg,
azide
bisoprolol
1
MO
25mg;
ramipril
1
MO
fumarate/hy
100mg
trandolapril
2
MO
drochlorothi
azide
losartan
1
QL(60/30)
ANTIARRHYTHMICS
potassium/h
MO
carvedilol
1
MO
amiodarone
4
ydrochloroth
COREG CR
3
MO
hcl inj
iazide tabs
labetalol
hcl
4
50mg/ml
12.5mg;
inj
amiodarone
2
MO
50mg
labetalol hcl
2
MO
hcl tabs
valsartan/hy
2
MO
tabs
200mg,
correo
65
Drug Name
Drug
Tier
2
Reqs/Limits
Drug Name
Drug
Tier
Reqs/Limits
Drug Name
Drug
Tier
Reqs/Limits
metoprolol
MO
besylate/be
er
succinate er
nazepril
taztia xt
2
MO
hydrochlorid
verapamil
2
MO
metoprolol
4
tartrate inj
e
hcl er
metoprolol
1
MO
cartia xt
2
MO
verapamil
4
hcl inj
tartrate tabs
dilt-cd cp24
2
MO
metoprolol/h
2
MO
120mg,
verapamil
1
MO
ydrochloroth
180mg,
hcl tabs
iazide
300mg
120mg,
nadolol tabs
2
MO
dilt-xr cp24
2
MO
80mg
180mg,
verapamil
2
MO
80mg
nadolol tabs
1
MO
240mg
hcl tabs
20mg, 40mg
diltiazem cd
2
MO
40mg
nadolol/ben
2
MO
diltiazem hcl
2
MO
CARDIOVASCULAR AGENTS,
er cp12
droflumethia
OTHER
diltiazem hcl
2
MO
zide
AMTURNID
3
ST MO
pindolol
1
MO
er cp24
E
propranolol
2
MO
120mg,
digoxin inj
4
PA
hcl er
180mg,
digoxin tabs
1
QL(30/30)
propranolol
4
300mg,
0.125mg
MO
hcl inj
360mg,
digoxin tabs
1
PA MO
420mg
propranolol
2
MO
0.25mg
diltiazem hcl
4
hcl oral soln
LANOXIN
4
PA
propranolol
2
MO
inj 100mg,
PEDIATRIC
hcl tabs
25mg/5ml,
pentoxifyllin
2
MO
60mg
50mg/10ml
e er
1
MO
diltiazem hcl
1
MO
propranolol
RANEXA
3
QL(60/30)
hcl tabs
tabs
TB12
ST MO
10mg,
diltzac
2
MO
1000MG
20mg,
EXFORGE
3
MO
RANEXA
3
QL(120/30)
40mg, 80mg
EXFORGE
3
MO
TB12
ST MO
propranolol/
2
MO
HCT
500MG
hydrochlorot
felodipine er
2
MO
TEKAMLO
3
ST MO
hiazide
isradipine
2
MO
TEKTURNA
3
ST MO
matzim la
2
MO
timolol
2
MO
TEKTURNA
3
ST MO
tb24 240mg
maleate
HCT
tabs
nicardipine
2
MO
DIURETICS, CARBONIC
hcl caps
CALCIUM CHANNEL BLOCKING
ANHYDRASE INHIBITORS
nicardipine
4
AGENTS
acetazolami
2
MO
hcl
inj
afeditab cr
2
MO
de
nifediac cc
2
MO
amlodipine
1
MO
acetazolami
4
nifedical
xl
2
MO
besylate
de sodium
nifedipine er
2
MO
amlodipine
2
MO
dorzolamide
2
MO
nimodipine
2
MO
besylate/be
hcl
nisoldipine
2
MO
nazepril hcl
DIURETICS, LOOP
nisoldipine
2
MO
amlodipine
2
MO
correo
66
Drug Name
Drug
Tier
4
Reqs/Limits
Drug Name
Drug
Tier
1
Reqs/Limits
Drug Name
Drug
Tier
Reqs/Limits
bumetanide
chlorthalido
MO
MO
inj
ne tabs
DYSLIPIDEMICS, OTHER
25mg, 50mg
bumetanide
1
MO
cholestyram
2
MO
tabs 0.5mg,
hydrochlorot
1
MO
ine
1mg
hiazide caps
cholestyram
2
MO
hydrochlorot
1
MO
bumetanide
2
MO
ine light
hiazide tabs
tabs 2mg
colestipol
2
MO
EDECRIN
3
MO
25mg, 50mg
hcl
furosemide
4
hydrochlorot
2
MO
LOVAZA
3
QL(120/30)
inj
hiazide tabs
NIASPAN
3
QL(60/30)
furosemide
2
MO
12.5mg
MO
indapamide
1
MO
oral soln
prevalite
2
MO
furosemide
1
MO
metolazone
2
MO
WELCHOL
3
MO
tabs
DYSLIPIDEMICS, FIBRIC ACID
ZETIA
3
QL(30/30)
SODIUM
4
B/D PA
DERIVATIVES
MO
EDECRIN
fenofibrate
2
VASODILATORS, DIRECT-ACTING
torsemide
2
MO
caps
ARTERIAL
tabs
fenofibrate
2
MO
hydralazine
4
DIURETICS, POTASSIUM-SPARING
micronized
hcl inj
amiloride
2
MO
fenofibrate
2
MO
hydralazine
2
MO
hcl
tabs
hcl tabs
amiloride/hy
1
MO
gemfibrozil
2
MO
minoxidil
2
MO
drochlorothi
LIPOFEN
3
tabs
azide
DYSLIPIDEMICS, HMG COA
VASODILATORS, DIRECT-ACTING
spironolacto
1
MO
REDUCTASE INHIBITORS
ARTERIAL/VENOUS
ne tabs
atorvastatin
2
QL(30/30)
isosorbide
2
MO
25mg
calcium
MO
dinitrate
spironolacto
2
MO
CRESTOR
3
QL(30/30)
isosorbide
2
MO
ne tabs
MO
dinitrate er
100mg,
fluvastatin
2
QL(30/30)
isosorbide
2
MO
50mg
caps 20mg
MO
mononitrate
spironolacto
2
MO
fluvastatin
2
QL(60/30)
isosorbide
2
MO
ne/hydrochl
caps 40mg
MO
mononitrate
orothiazide
lovastatin
2
QL(60/30)
er
triamterene/
1
MO
tabs 40mg
MO
minitran
2
MO
hydrochlorot
lovastatin
1
QL(60/30)
nitroglycerin
4
hiazide
tabs 10mg,
MO
inj
DIURETICS, THIAZIDE
20mg
nitroglycerin
2
candesartan
2
MO
pravastatin
1
QL(30/30)
lingual
cilexetil/hydr
sodium tabs
MO
translingual
ochlorothiaz
10mg,
soln
ide
20mg, 80mg
nitroglycerin
2
MO
chlorothiazi
2
MO
pravastatin
1
QL(60/30)
pt24
de
sodium tabs
MO
nitroglycerin
2
MO
chlorothiazi
4
B/D PA
40mg
transdermal
de sodium
simvastatin
1
QL(30/30)
correo
67
Drug Name
Drug
Tier
Reqs/Limits
pt24
0.1mg/hr
NITROSTA
3
MO
T
CENTRAL NERVOUS SYSTEM
AGENTS
ATTENTION DEFICIT
HYPERACTIVITY DISORDER
AGENTS, AMPHETAMINES
amphetamin
2
QL(60/30)
e/dextroamp
MO
hetamine
cp24
amphetamin
2
QL(90/30)
e/dextroamp
MO
hetamine
tabs
dextroamph
2
QL(90/30)
etamine
MO
sulfate er
cp24 10mg,
5mg
dextroamph
2
QL(120/30)
etamine
MO
sulfate er
cp24 15mg
dextroamph
2
QL(90/30)
etamine
MO
sulfate tabs
5mg
dextroamph
2
QL(180/30)
etamine
MO
sulfate tabs
10mg
ATTENTION DEFICIT
HYPERACTIVITY DISORDER
AGENTS, NON-AMPHETAMINES
dexmethylp
2
QL(60/30)
henidate hcl
MO
KAPVAY
3
metadate er
2
QL(90/30)
MO
methylpheni
2
QL(90/30)
date hcl
MO
methylpheni
2
QL(60/30)
Drug Name
Drug
Tier
Reqs/Limits
Drug Name
date hcl er
MO
tbcr 10mg
methylpheni
2
QL(90/30)
date hcl er
MO
tbcr 20mg
methylpheni
2
QL(90/30)
date hcl sr
MO
STRATTER
3
MO
A
CENTRAL NERVOUS SYSTEM,
OTHER
NUEDEXTA
3
PA
RILUTEK
5
riluzole
4
XENAZINE
5
PA
TABS
QL(90/30)
12.5MG
XENAZINE
5
PA
TABS
QL(120/30)
25MG
MULTIPLE SCLEROSIS AGENTS
AMPYRA
5
PA
QL(60/30)
AVONEX
5
PA
PEN
QL(4/28)
COPAXON
5
PA
E
QL(30/30)
DENTAL AND ORAL AGENTS
DENTAL AND ORAL AGENTS
chlorhexidin
1
e gluconate
oral rinse
periogard
1
pilocarpine
2
MO
hcl tabs
pilocarpine
2
MO
hydrochlorid
e
triamcinolon
2
e in orabase
DERMATOLOGICAL AGENTS
DERMATOLOGICAL AGENTS
absorica
2
caps 10mg,
20mg
ammonium
lactate
amnesteem
calcipotrien
e crea
calcipotrien
e external
soln
calcipotrien
e oint
CARAC
claravis
clindamycin
phosphate
external
soln
clindamycin
phosphate
gel
clindamycin
phosphate
lotn
clindamycin
phosphate
swab
curity gauze
pads 2"x2"
ELIDEL
erythromyci
n/benzoyl
peroxide
FLUOROPL
EX
fluorouracil
crea
fluorouracil
external
soln
imiquimod
laclotion
OXSORALE
N ULTRA
podofilox
PROTOPIC
PRUDOXIN
REGRANE
Drug
Tier
2
Reqs/Limits
2
2
2
2
QL(120/30)
3
2
2
2
2
2
2
3
2
3
2
MO
2
MO
2
2
3
2
3
3
3
PA
correo
68
Drug Name
X
SANTYL
selenium
sulfide lotn
SORIATAN
E
sulfacetami
de sodium
susp
TAZORAC
CREA
TAZORAC
GEL
tretinoin
crea
Drug
Tier
Reqs/Limits
Drug Name
Drug
Tier
Reqs/Limits
Drug Name
Drug
Tier
Reqs/Limits
9500UNIT,
e bromide
3
30000UNIT;
GASTROINTESTINAL AGENTS,
1
6000UNIT;
OTHER
19000UNIT,
cromolyn
2
MO
5
PA
60000UNIT;
sodium
12000UNIT;
conc
2
38000UNIT
diphenoxyla
2
CYSTADAN
5
te/atropine
E
lofene
2
3
QL(120/30)
CYSTAGO
3
lonox
2
N
loperamide
2
3
QL(100/30)
ELAPRASE
5
PA
hcl caps
FABRAZYM
5
B/D PA
metoclopra
4
2
PA
E
mide hcl inj
QL(45/30)
KUVAN
5
PA
metoclopra
1
MO
LUMIZYME
5
PA
MO
mide hcl
NAGLAZYM
5
PA
tretinoin gel
2
PA
oral soln
E
QL(45/30)
metoclopra
1
MO
ORFADIN
5
MO
MO
mide hcl
tretinoin
2
PA
pancrelipas
2
tabs 10mg
microsphere
QL(45/30)
e
metoclopra
2
MO
MO
VPRIV
5
PA
mide hcl
UVADEX
4
ZAVESCA
5
tabs 5mg
VECTICAL
3
ZENPEP
3
OSMOPRE
3
VOLTAREN
3
QL(1000/3
GASTROINTESTINAL AGENTS
P
0) ST
ANTISPASMODICS,
RELISTOR
4
PA
ZONALON
3
GASTROINTESTINAL
INJ
QL(18/30)
ZYCLARA
3
12MG/0.6M
atropine
4
ENZYME
L
sulfate inj
REPLACEMENT/MODIFIERS
RELISTOR
4
PA
0.05mg/ml,
ENZYME
INJ
QL(28/28)
0.1mg/ml
REPLACEMENT/MODIFIERS
12MG/0.6M
dicyclomine
1
L
ADAGEN
5
PA MO
hcl caps
ursodiol
2
MO
ALDURAZY
5
PA
dicyclomine
2
ME
hcl oral soln
HISTAMINE2 (H2) RECEPTOR
BUPHENYL
5
MO
dicyclomine
1
ANTAGONISTS
CARBAGLU
5
hcl tabs
cimetidine
2
MO
CEREZYME
5
B/D PA
glycopyrrola
4
cimetidine
4
te inj
CREON
3
MO
hcl inj
4mg/20ml
CPEP
cimetidine
2
MO
120000UNI
glycopyrrola
2
hcl oral soln
T;
te tabs
famotidine
4
methscopol
2
24000UNIT;
inj
76000UNIT,
amine
famotidine
4
bromide
15000UNIT;
premixed
propanthelin
2
3000UNIT;
famotidine
2
MO
correo
69
Drug Name
Drug
Tier
Reqs/Limits
tabs 40mg
famotidine
1
MO
tabs 20mg
nizatidine
2
MO
caps
ranitidine
2
MO
hcl caps
ranitidine
4
hcl inj
150mg/6ml
ranitidine
2
MO
hcl syrp
ranitidine
1
MO
hcl tabs
150mg,
300mg
IRRITABLE BOWEL SYNDROME
AGENTS
AMITIZA
3
QL(60/30)
MO
LOTRONEX
5
QL(60/30)
MO
LAXATIVES
constulose
1
MO
enulose
1
MO
generlac
2
MO
lactulose
2
MO
MOVIPREP
3
peg
2
3350/electro
lytes
polyethylen
2
e glycol
3350 powd
RELISTOR
4
PA
INJ
QL(12/30)
8MG/0.4ML
trilyte
2
PROTECTANTS
CARAFATE
3
MO
SUSP
misoprostol
2
MO
sucralfate
2
MO
tabs
PROTON PUMP INHIBITORS
Drug Name
DEXILANT
lansoprazol
e
NEXIUM
Drug
Tier
3
2
3
Reqs/Limits
QL(30/30)
MO
QL(30/30)
MO
QL(30/30)
MO
MO
NEXIUM
4
I.V.
omeprazole
2
QL(30/30)
cpdr 40mg
MO
omeprazole
2
QL(60/30)
cpdr 10mg,
MO
20mg
pantoprazol
2
QL(30/30)
e sodium
MO
tbec
GENITOURINARY AGENTS
ANTISPASMODICS, URINARY
flavoxate hcl
2
MO
oxybutynin
2
QL(30/30)
chloride er
MO
tb24 5mg
oxybutynin
2
QL(60/30)
chloride er
MO
tb24 10mg,
15mg
1
MO
oxybutynin
chloride
tabs
tolterodine
1
tartrate
VESICARE
3
QL(30/30)
MO
BENIGN PROSTATIC
HYPERTROPHY AGENTS
AVODART
3
MO
finasteride
2
QL(30/30)
tabs 5mg
MO
JALYN
3
MO
RAPAFLO
3
QL(30/30)
MO
tamsulosin
2
MO
hcl
GENITOURINARY AGENTS, OTHER
bethanechol
2
Drug Name
Drug
Tier
Reqs/Limits
chloride
ELMIRON
3
PHOSPHATE BINDERS
FOSRENOL
3
QL(150/30)
CHEW
ST MO
1000MG
FOSRENOL
3
QL(180/30)
CHEW
ST MO
750MG
FOSRENOL
3
QL(270/30)
CHEW
ST MO
500MG
RENVELA
3
QL(180/30)
PACK
MO
RENVELA
3
QL(540/30)
TABS
MO
HORMONAL AGENTS,
STIMULANT/REPLACEMENT/MODI
FYING (ADRENAL)
GLUCOCORTICOIDS/MINERALOCO
RTICOIDS
a-hydrocort
4
a4
methapred
inj 40mg
ALA SCALP
3
alclometaso
2
ne
dipropionate
amcinonide
2
augmented
2
betamethas
one
dipropionate
betamethas
2
one
dipropionate
betamethas
2
one valerate
CELESTON
3
E
clobetasol
2
propionate
crea
clobetasol
2
correo
70
Drug Name
Drug
Tier
Reqs/Limits
Drug Name
Drug
Tier
Reqs/Limits
Drug Name
Drug
Tier
Reqs/Limits
propionate e
0.5mg,
2.5%
clobetasol
2
0.75mg,
hydrocortiso
2
propionate
4mg
ne tabs
external
dexamethas
2
hydrocortiso
2
one tabs
soln
ne valerate
clobetasol
2
MEDROL
3
1.5mg, 1mg,
propionate
2mg, 6mg
TABS 2MG
methylpredn
2
foam
diflorasone
2
clobetasol
2
isolone
diacetate
propionate
fludrocortiso
2
MO
methylpredn
4
isolone
gel
ne acetate
clobetasol
2
fluocinolone
2
acetate
propionate
acetonide
methylpredn
2
oint
crea
isolone
dose pack
clotrimazole
2
fluocinolone
1
/betamethas
acetonide
methylpredn
4
isolone
one
external
sodiumsucci
dipropionate
soln
cortisone
2
fluocinolone
2
nate inj
acetate
acetonide
125mg,
4
DEPOoil
1gm, 40mg
MEDROL
fluocinolone
2
mometason
2
INJ
acetonide
e furoate
20MG/ML
oint
crea
desonide
2
fluocinonide
2
mometason
2
lotn
e furoate
fluocinonide
2
desonide
2
-e
external
oint
fluticasone
2
soln
desoximeta
2
propionate
mometason
2
sone crea
crea
e furoate
fluticasone
2
desoximeta
2
oint
propionate
prednicarbat
2
sone gel
desoximeta
2
oint
e
sone oint
halobetasol
2
prednisolon
2
0.25%
propionate
e sodium
hydrocortiso
2
dexamethas
2
phosphate
ne butyrate
one elix
oral soln
DEXAMETH
3
hydrocortiso
1
15mg/5ml,
ASONE
ne crea 1%,
5mg/5ml
INTENSOL
2.5%
PREDNISO
2
MO
dexamethas
4
hydrocortiso
2
LONE
one sodium
ne lotn
SODIUM
hydrocortiso
2
PHOSPHAT
phosphate
inj
ne lotn
E ORAL
dexamethas
1
hydrocortiso
2
SOLN
ne oint 1%,
one tabs
25MG/5ML
correo
71
Drug Name
Drug
Tier
3
Reqs/Limits
Drug Name
Drug
Tier
Reqs/Limits
Drug Name
Drug
Tier
Reqs/Limits
PREDNISO
nasal soln
enanthate
NE
desmopress
2
MO
ESTROGENS
INTENSOL
in acetate
ALORA
3
PA
prednisone
2
tabs
apri
2
MO
oral soln
INCRELEX
4
PA
aranelle
2
MO
prednisone
2
novarel
4
PA
aviane
2
MO
tabs 50mg
pregnyl
4
PA
balziva
2
MO
prednisone
1
w/diluent
briellyn
2
tabs 10mg,
benzyl
cryselle-28
2
MO
1mg, 2.5mg,
alcohol/nacl
DEPO4
20mg, 5mg
SAIZEN
5
PA
ESTRADIO
CLICK.EAS
procto-pak
2
L
proctocream
2
Y
enpresse-28
2
MO
hc
SAIZEN INJ
5
PA
estradiol
2
PA
proctosol hc
2
5MG
ptwk
QL(8/28)
STIMATE
3
MO
proctozone2
MO
hc
HORMONAL AGENTS,
estradiol
2
PA MO
SOLU4
tabs
CORTEF
FYING (SEX
estradiol
4
INJ 250MG
HORMONES/MODIFIERS)
valerate
TEXACORT
3
ANABOLIC STEROIDS
estradiol/nor
2
PA MO
triamcinolon
2
ethindrone
ANADROL5
PA
e acetonide
acetate
50
crea
ESTRING
3
QL(1/90)
oxandrolone
2
PA
triamcinolon
2
MO
tabs 10mg
QL(60/30)
e acetonide
FEMRING
3
MO
oxandrolone
2
PA
lotn
junel 1.5/30
2
MO
tabs 2.5mg
QL(120/30)
triamcinolon
2
junel 1/20
2
MO
ANDROGENS
e acetonide
junel
fe
2
MO
ANDROGE
3
PA MO
oint
1.5/30
L GEL
triderm
1
junel fe 1/20
2
MO
25MG/2.5G
u-cort
2
kariva
2
MO
M,
HORMONAL AGENTS,
kelnor 1/35
2
MO
50MG/5GM
lessina
2
MO
ANDROGE
3
PA
FYING (PITUITARY)
levora
2
MO
L PUMP
HORMONAL AGENTS,
0.15/30-28
GEL 1.62%
low-ogestrel
2
MO
ANDROGE
3
PA MO
FYING (PITUITARY)
lutera
2
MO
L PUMP
MAKENA
5
B/D
PA
chorionic
4
PA
GEL 1%
MENOSTA
3
PA
gonadotropi
ANDROXY
3
PA
R
n
danazol
2
microgestin
2
MO
desmopress
4
TESTIM
3
PA MO
1.5/30
in acetate
testosterone
4
PA
microgestin
2
MO
inj
cypionate
1/20
desmopress
2
MO
testosterone
4
PA
microgestin
2
MO
in acetate
correo
72
Drug Name
fe
microgestin
fe 1.5/30
MIMVEY
necon
0.5/35-28
necon 1/35
necon
10/11-28
nortrel
0.5/35 (28)
nortrel 1/35
nortrel 7/7/7
ogestrel
orsythia
portia-28
PREMARIN
CREA
PREMARIN
INJ
PREMARIN
TABS
previfem
quasense
reclipsen
sprintec 28
sronyx
tri-legest fe
tri-previfem
tri-sprintec
trivora-28
velivet
VIVELLEDOT
zovia 1/35e
zovia 1/50e
Drug
Tier
Reqs/Limits
2
MO
3
2
PA
MO
2
2
MO
MO
2
MO
2
2
2
2
2
3
MO
MO
MO
4
MO
3
PA
QL(30/30)
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
MO
PA
2
2
2
2
2
2
2
2
2
2
3
MO
MO
2
MO
2
MO
PROGESTINS
2
MO
4
Drug Name
Drug
Tier
Reqs/Limits
gesterone
acetate tabs
megestrol
2
PA
acetate
susp
megestrol
2
PA
acetate tabs
40mg
megestrol
1
PA
acetate tabs
20mg
nora-be
2
MO
norethindro
2
MO
ne acetate
progesteron
2
MO
e caps
SELECTIVE ESTROGEN
RECEPTOR MODIFYING AGENTS
EVISTA
3
QL(30/30)
MO
HORMONAL AGENTS,
FYING (THYROID)
HORMONAL AGENTS,
FYING (THYROID)
LEVOTHRO
3
MO
ID
levothyroxin
1
MO
e sodium
tabs
LEVOXYL
3
MO
liothyronine
4
sodium inj
liothyronine
2
MO
sodium tabs
SYNTHROI
3
MO
D
THYROLAR
3
MO
-1
THYROLAR
3
MO
-1/2
THYROLAR
3
MO
-1/4
THYROLAR
3
MO
Drug Name
Drug
Tier
Reqs/Limits
-2
THYROLAR
3
MO
-3
UNITHROID
3
MO
HORMONAL AGENTS,
SUPPRESSANT (ADRENAL)
HORMONAL AGENTS,
SUPPRESSANT (ADRENAL)
LYSODREN
3
HORMONAL AGENTS,
SUPPRESSANT (PARATHYROID)
HORMONAL AGENTS,
SUPPRESSANT (PARATHYROID)
SENSIPAR
3
QL(360/30)
TABS
MO
30MG
SENSIPAR
5
QL(120/30)
TABS
MO
90MG
SENSIPAR
5
QL(180/30)
TABS
MO
60MG
HORMONAL AGENTS,
SUPPRESSANT (PITUITARY)
HORMONAL AGENTS,
SUPPRESSANT (PITUITARY)
cabergoline
2
ELIGARD
4
PA
INJ 30MG
QL(1/120)
ELIGARD
4
PA
INJ 45MG
QL(1/180)
ELIGARD
4
PA
INJ 7.5MG
QL(1/30)
ELIGARD
4
PA
INJ 22.5MG
QL(1/90)
firmagon inj
4
B/D PA
80mg
QL(2/28)
firmagon inj
4
B/D PA
120mg
QL(2/365)
leuprolide
4
PA
acetate
QL(30/30)
LUPRON
5
PA
DEPOT
QL(1/30)
LUPRON
5
PA
DEPOTQL(1/30)
camila
DEPOPROVERA
errin
2
MO
medroxypro
4
QL(1/90)
gesterone
acetate inj
medroxypro
1
MO
correo
73
Drug Name
Drug
Tier
Reqs/Limits
Drug Name
Drug Reqs/Limits
Tier
SUPPRESSANT (SEX
HORMONES/MODIFIERS)
ANTIANDROGENS
bicalutamid
2
e
flutamide
2
NILANDRO
3
N
XTANDI
5
PA
QL(120/30)
HORMONAL AGENTS,
SUPPRESSANT (THYROID)
ANTITHYROID AGENTS
methimazol
2
MO
e
propylthiour
2
MO
acil
IMMUNOLOGICAL AGENTS
IMMUNE SUPPRESSANTS
AZASAN
3
B/D PA MO
azathioprine
2
MO
azathioprine
4
sodium
CELLCEPT
4
B/D PA
INTRAVEN
OUS
CELLCEPT
3
B/D PA
SUSR
cyclosporine
2
B/D PA
caps
cyclosporine
4
B/D PA
inj
cyclosporine
2
B/D PA
modified
ENBREL
5
PA
QL(8/28)
ENBREL
5
PA
SURECLIC
QL(8/28)
K
gengraf
2
B/D PA
HUMIRA
5
PA
INJ
QL(2/28)
20MG/0.4M
L
HUMIRA
5
PA
Drug Name
Drug
Tier
Reqs/Limits
PED INJ
INJ
QL(4/28)
11.25MG,
40MG/0.8M
15MG
L
LUPRON
4
PA
HUMIRA
5
PA
DEPOTQL(1/30)
PEN
QL(4/28)
PED INJ
HUMIRA
5
PA
11.25MG,
PENQL(6/28)
30MG
CROHNS
OCTREOTI
4
PA
DISEASES
DE
TARTER
methotrexat
2
ACETATE
INJ
e
methotrexat
4
100MCG/M
e sodium
L,
mycophenol
2
B/D PA
200MCG/M
L,
ate mofetil
MYFORTIC
3
B/D PA
50MCG/ML
OCTREOTI
5
PA
NULOJIX
5
PA MO
DE
PROGRAF
4
B/D PA
ACETATE
INJ
INJ
RAPAMUN
3
B/D PA
1000MCG/
E
ML,
REMICADE
5
PA
500MCG/M
tacrolimus
2
B/D PA
L
TORISEL
3
B/D PA
ZORTRESS
4
B/D PA
SANDOSTA
5
PA
TIN LAR
TABS
DEPOT
0.25MG
SOMATULI
5
PA
ZORTRESS
5
B/D PA
TABS
NE DEPOT
0.5MG,
SOMAVER
5
PA
0.75MG
T INJ
QL(60/30)
15MG,
IMMUNIZING AGENTS, PASSIVE
20MG
ATGAM
4
B/D PA
SOMAVER
5
PA
gamastan
4
B/D PA
T INJ 10MG
QL(90/30)
s/d
SYNAREL
5
PA MO
GAMMAGA
5
B/D PA
TRELSTAR
5
PA
RD LIQUID
DEPOT
QL(1/28)
GAMUNEX5
B/D PA
MIXJECT
C INJ
TRELSTAR
5
PA
10GM/100M
LA
QL(1/84)
L,
MIXJECT
2.5GM/25M
TRELSTAR
5
PA
L,
MIXJECT
QL(1/168)
20GM/200M
HORMONAL AGENTS,
L,
correo
74
Drug Name
Drug
Tier
Reqs/Limits
Drug Name
Drug
Tier
Reqs/Limits
Drug Name
Drug Reqs/Limits
Tier
GLUCOCORTICOIDS
budesonide
2
cp24
colocort
2
methylpredn
2
isolone
SOLU4
CORTEF
INJ
1000MG,
500MG
SULFONAMIDES
sulfasalazin
2
MO
e tabs
sulfazine
2
MO
sulfazine ec
2
MO
METABOLIC BONE DISEASE
AGENTS
METABOLIC BONE DISEASE
AGENTS
ACTONEL
3
QL(1/28)
TABS
MO
150MG
ACTONEL
3
QL(4/28)
TABS
MO
35MG
ACTONEL
3
QL(30/30)
TABS
MO
30MG, 5MG
alendronate
1
QL(4/28)
sodium tabs
MO
35mg, 70mg
alendronate
2
QL(30/30)
sodium tabs
MO
10mg,
40mg, 5mg
ATELVIA
3
QL(4/28)
MO
calcitonin2
QL(3.7/30)
salmon
MO
calcitriol
2
B/D PA MO
caps
calcitriol inj
4
B/D PA
calcitriol oral
2
B/D PA MO
soln
5GM/50ML
ED IPV
GAMUNEX4
B/D PA
IXIARO
4
C INJ
JE-VAX
4
1GM/10ML
M-M-R II
4
THYMOGL
3
B/D PA
W/DILUENT
OBULIN
10 DOSE
MENACTR
4
IMMUNOMODULATORS
A
ACTIMMUN
5
PA
MENOMUN
4
E
E-A/C/Y/WARCALYST
5
PA
135
AVONEX
5
PA
MENVEO
4
QL(4/28)
PEDVAX
4
ILARIS
5
PA
HIB
leflunomide
2
QL(30/30)
PROQUAD
4
MO
RABAVERT
4
PROVENG
5
B/D PA
RECOMBIV
4
B/D PA
E
AX HB INJ
REBIF
5
PA
10MCG/ML,
QL(6/28)
40MCG/ML
REBIF
5
PA
ROTATEQ
3
TITRATION
QL(4.2/28)
tetanus
4
PACK
toxoid
RIDAURA
3
MO
adsorbed
SIMULECT
5
B/D PA
tetanus/diph
4
SYNAGIS
5
PA
theria
INJ
toxoids50MG/0.5M
adsorbed
L
adult
TYSABRI
5
PA
TWINRIX
4
VACCINES
TYPHIM
VI
4
ACTHIB
4
VAQTA
4
ADACEL
4
VARIVAX
4
BOOSTRIX
4
yf-vax
4
CERVARIX
4
ZOSTAVAX
4
COMVAX
4
INFLAMMATORY BOWEL DISEASE
DAPTACEL
4
AGENTS
decavac
4
AMINOSALICYLATES
ENGERIX-B
4
B/D PA
APRISO
3
MO
GARDASIL
4
balsalazide
2
MO
HAVRIX
4
disodium
IMOVAX
4
DELZICOL
3
MO
RABIES
mesalamine
2
(H.D.C.V.)
enem
INFANRIX
4
mesalamine
2
MO
IPOL
4
kit
INACTIVAT
correo
75
Drug Name
etidronate
disodium
FORTEO
Drug
Tier
2
Reqs/Limits
Drug Name
Drug
Tier
Reqs/Limits
Drug Name
Drug
Tier
Reqs/Limits
MASK
syringe
AEROCHA
3
QL(1/365)
ultrafine/1ml
/31g x 5/16"
5
PA
MBER
PLUS
bd insulin
2
QL(200/30)
QL(2.4/28)
HECTOROL
3
B/D PA MO
FLOW-VU
syringe
CAPS
ultrafine/uAEROCHA
3
QL(1/365)
HECTOROL
4
B/D PA
MBER
100/0.3ml/3
INJ
PLUS
1g x 15/64"
ibandronate
2
QL(1/28)
FLOWbd insulin
2
QL(200/30)
sodium
VU/LARGE
syringe
MIACALCIN
4
ultrafine/uMASK
INJ
100/0.5ml/3
AEROCHA
3
QL(1/365)
pamidronate
4
MO
MBER
1g x 15/64"
disodium inj
PLUS
bd insulin
2
QL(200/30)
30mg/10ml,
FLOWsyringe
6mg/ml,
VU/MASK
ultrafine/u90mg/10ml
100/1ml/31g
AEROCHA
3
QL(1/365)
PROLIA
4
QL(1/180)
x 15/64"
MBER
ST
bd
2
QL(200/30)
PLUS
RECLAST
4
B/D PA
FLOWneedle/30g
MO
XGEVA
5
PA
x 1/2"
VU/SMALL
ZEMPLAR
3
B/D PA
bd pen
2
QL(200/30)
MASK
CAPS
AEROCHA
3
QL(1/365)
needle/mini/
MO
zoledronic
4
B/D PA
MBER Zultrafine/31g
acid inj
STAT
x 3/16"
5mg/100ml
PLUS/MEDI
bd pen
2
QL(200/30)
needle/nano
zoledronic
5
B/D PA
UM MASK
MO
acid inj
aurora pen
2
QL(200/30)
/ultra
4mg/5ml
needles 31g
MO
fine/32g x
ZOMETA
x 8mm
4mm
5
B/D PA
bd insulin
2
bd pen
2
INJ
syringe
needle/ultraf
4MG/5ML
ZOMETA
4
B/D PA
safetyglide/
ine/29g x
INJ
1ml/29g x
12.7mm
4MG/100ML
1/2"
fomepizole
5
h-e-b
2
QL(200/30)
bd insulin
2
MISCELLANEOUS THERAPEUTIC
syringe
incontrol
MO
AGENTS
ultrafine/0.3
pen needles
29gx12mm
ml/31g x
AGENTS
5/16"
INTRALIPID
4
B/D PA
AEROCHA
3
QL(1/365)
bd insulin
2
INJ 1.7%;
MBER MAX
syringe
30%
VALVED
ultrafine/0.5
intralipid inj
4
B/D PA
HOLDING
ml/30g
x
2.25%;
20%
CHAMBER
1/2"
kmart valu
3
QL(200/30)
W/COMFO
plus
insulin
MO
bd
insulin
2
RTSEAL
correo
76
Drug Name
syringe/0.5
ml/29g
lactated
ringers
irrigation
levocarnitin
e inj
levocarnitin
e oral soln
levocarnitin
e tabs
liposyn iii inj
1.8%; 2.5%;
30%
monoject
insulin
syringe/deta
ch
needle/1ml/
27g x 1/2"
monoject
insulin
syringe/safe
ty/perm
needle/0.3m
l/29g x 1/2"
monoject
insulin
syringe/u100/0.5ml/3
0g x 5/16"
monoject
insulin
syringe/u100/1ml/30g
x 5/16" misc
null
novofine
30gx8mm
novofine 31
Drug
Tier
Reqs/Limits
4
Drug Name
Drug
Tier
2
Reqs/Limits
Drug Name
novotwist
QL(200/30)
30gx8mm
novotwist
2
QL(200/30)
32gx5mm
physiolyte
4
physiosol
4
irrigation
ringers
4
irrigation
sodium
4
chloride
0.9%
sterile water
4
irrigation
tis-u-sol
4
ulticare
2
QL(200/30)
insulin
MO
0g x 1/2"
ulticare
2
QL(200/30)
insulin
MO
1g x 5/16"
ulticare
2
QL(200/30)
insulin
MO
syringe/u100/1ml/30g
x 1/2"
VORAXAZE
5
B/D PA
OPHTHALMIC AGENTS
OPHTHALMIC PROSTAGLANDIN
AND PROSTAMIDE ANALOGS
latanoprost
2
QL(5/30)
LUMIGAN
3
QL(5/30)
MO
TRAVATAN
3
QL(5/30)
Z
MO
OPHTHALMIC AGENTS, OTHER
LACRISER
3
T
mydral
2
naphazoline
2
hcl
parcaine
proparacain
e hcl
RESTASIS
Drug
Tier
2
2
Reqs/Limits
3
QL(64/30)
MO
tropicamide
2
OPHTHALMIC ANTI-ALLERGY
2
B/D PA MO
AGENTS
ALOCRIL
3
2
MO
azelastine
2
hcl
4
B/D PA
ophthalmic
soln
cromolyn
2
2
QL(200/30)
sodium
MO
ophthalmic
soln
epinastine
2
hcl
PATADAY
3
2
QL(200/30)
PATANOL
3
MO
OPHTHALMIC ANTIINFLAMMATORIES
bromfenac
2
dexamethas
2
one sodium
2
QL(200/30)
phosphate
MO
ophthalmic
soln
diclofenac
2
MO
sodium
2
QL(200/30)
DUREZOL
3
MO
fluoromethol
2
one
flurbiprofen
2
MO
sodium
ketorolac
2
3
QL(200/30)
tromethamin
MO
e
2
QL(200/30)
ophthalmic
MO
soln
novofine
2
QL(200/30)
neomycin/p
2
32gx6mm
MO
olymyxin/de
novofine
2
QL(200/30)
xamethason
autocover
e
30gx8mm
poly-dex
2
correo
77
4
B/D PA
Drug Name
Drug
Tier
3
3
3
Reqs/Limits
Drug Name
Drug
Tier
Reqs/Limits
Drug Name
Drug
Tier
3
Reqs/Limits
PRED MILD
OPHTHALM
FLOVENT
QL(22/30)
PRED-G
IC SOLN
HFA AERO
MO
PRED-G
PILOPINE
3
MO
44MCG/AC
S.O.P.
HS
T
prednisolon
2
timolol
1
MO
FLOVENT
3
QL(24/30)
e acetate
maleate
HFA AERO
MO
prednisolon
1
110MCG/A
ophthalmic
e sodium
soln
CT,
phosphate
220MCG/A
OTIC AGENTS
ophthalmic
CT
OTIC AGENTS
soln
flunisolide
2
QL(75/30)
acetasol hc
2
TOBRADEX
3
nasal
soln
acetic acid
2
OINT
29mcg/act
otic soln
fluticasone
2
QL(16/30)
tobramycin/
2
CORTISPO
3
propionate
dexamethas
RIN-TC
susp
one
hydrocortiso
2
NASONEX
3
QL(34/30)
OPHTHALMIC ANTIGLAUCOMA
ne/acetic
QVAR
3
QL(18/30)
AGENTS
acid
MO
acetazolami
2
MO
neomycin/p
2
SYMBICOR
3
QL(11/30)
de er
olymyxin/hc
T
AERO
MO
apraclonidin
2
MO
neomycin/p
2
160MCG/A
e
olymyxin/hy
CT;
AZOPT
3
drocortisone
4.5MCG/AC
betaxolol hcl
2
MO
RESPIRATORY TRACT AGENTS
T
brimonidine
2
MO
ANTI-INFLAMMATORIES, INHALED
SYMBICOR
3
QL(14/30)
tartrate
CORTICOSTEROIDS
T AERO
MO
ophthalmic
ADVAIR
3
QL(60/30)
80MCG/AC
soln 0.2%
DISKUS
MO
T;
carteolol hcl
2
MO
ADVAIR
3
QL(24/30)
4.5MCG/AC
COMBIGAN
3
MO
HFA
MO
T
dorzolamide
2
MO
budesonide
2
B/D PA
ANTIHISTAMINES
hcl/timolol
susp
QL(120/30)
maleate
azelastine
2
QL(60/30)
DULERA
3
QL(13/30)
hcl
nasal
levobunolol
1
MO
FLOVENT
3
QL(120/30)
hcl
soln
DISKUS
MO
cyproheptad
1
ophthalmic
AEPB
ine hcl
soln 0.5%
250MCG/BL
levobunolol
2
MO
desloratadin
2
QL(30/30)
IST,
hcl
e
50MCG/BLI
ophthalmic
desloratadin
2
QL(30/30)
ST
soln 0.25%
e
odt
FLOVENT
3
QL(180/30)
methazolam
2
MO
levocetirizin
2
QL(300/30)
DISKUS
MO
ide
e
AEPB
metipranolol
2
MO
dihydrochlor
100MCG/BL
ide oral soln
PILOCARPI
3
IST
NE HCL
levocetirizin
2
QL(30/30)
correo
78
Drug Name
Drug
Tier
Reqs/Limits
Drug Name
Drug
Tier
Reqs/Limits
Drug Name
Drug
Tier
Reqs/Limits
e
sulfate
R
dihydrochlor
SPIRIVA
3
QL(30/30)
metaprotere
2
MO
ide tabs
HANDIHAL
MO
nol sulfate
phenadoz
2
PA
ER
PERFORO
3
B/D PA
promethazin
4
PA
MIST
QL(120/30)
BRONCHODILATORS,
PROAIR
3
QL(17/30)
e hcl inj
PHOSPHODIESTERASE
promethazin
2
PA
HFA
MO
INHIBITORS (XANTHINES)
e hcl supp
SEREVENT
3
QL(60/30)
aminophyllin
4
promethazin
2
PA
DISKUS
MO
e
e hcl syrp
terbutaline
4
THEO-24
3
MO
promethazin
2
PA
sulfate inj
theochron
2
MO
terbutaline
2
MO
e hcl tabs
theophylline
2
MO
12.5mg,
sulfate
tabs
cr
50mg
MAST CELL STABILIZERS
theophylline
2
promethazin
1
PA
er tb12
cromolyn
2
B/D PA MO
e hcl tabs
200mg
sodium
25mg
theophylline
2
MO
nebu
promethega
2
PA
er tb12
PULMONARY
n supp
300mg,
ANTIHYPERTENSIVES
25mg, 50mg
450mg
LETAIRIS
5
PA
ANTILEUKOTRIENES
theophylline
2
MO
QL(30/30)
montelukast
2
QL(30/30)
er tb24
REMODULI
5
B/D PA
sodium
MO
BRONCHODILATORS,
N
zafirlukast
2
MO
SYMPATHOMIMETIC
SILDENAFI
3
PA
BRONCHODILATORS,
albuterol
2
MO
L CITRATE
QL(90/30)
ANTICHOLINERGIC
TRACLEER
5
PA
sulfate er
ATROVENT
3
QL(26/30)
albuterol
1
B/D PA
QL(60/30)
sulfate nebu
QL(360/30)
HFA
MO
RESPIRATORY TRACT AGENTS,
COMBIVEN
3
QL(8/30)
0.5%
MO
OTHER
T
MO
albuterol
1
B/D PA
acetylcystei
2
B/D PA
RESPIMAT
sulfate nebu
QL(375/30)
ne
ipratropium
2
B/D PA
0.083%
MO
inhalation
albuterol
2
B/D PA
bromide
QL(300/30)
soln
inhalation
MO
sulfate nebu
QL(375/30)
DALIRESP
3
PA
0.63mg/3ml,
MO
soln
QL(30/30)
ipratropium
2
QL(30/30)
1.25mg/3ml
MO
bromide
MO
albuterol
1
MO
PROLASTI
5
B/D PA MO
nasal soln
sulfate syrp
N-C
0.06%
albuterol
1
MO
promethazin
2
PA
ipratropium
2
QL(60/30)
sulfate tabs
e vc
bromide
MO
epinephrine
4
PULMOZY
5
B/D PA
nasal soln
hcl
ME
0.03%
EPIPEN-JR
3
QL(2/30)
TYZINE
3
ipratropium
2
B/D PA
2-PAK
TYZINE
3
bromide/alb
QL(540/30)
FORADIL
3
QL(60/30)
PEDIATRIC
uterol
MO
AEROLIZE
MO
correo
79
Drug Name
Drug
Tier
Reqs/Limits
Drug Name
Drug Reqs/Limits
Drug Name
Drug Reqs/Limits
Tier
Tier
NASAL
ELECTROLYTE/MINERAL
II
DROPS
MODIFIERS
4.25/DEXT
ROSE25%
XOLAIR
5
PA
CHEMET
3
AMINOSYN
4
B/D PA
SKELETAL MUSCLE RELAXANTS
CUPRIMIN
3
II
E
SKELETAL MUSCLE RELAXANTS
5/DEXTRO
DEPEN
3
chlorzoxazo
2
PA MO
SE 25
TITRATABS
ne
AMINOSYN
4
B/D PA
EXJADE
4
MO
orphenadrin
2
PA
II
TBSO
e citrate er
8.5%/ELEC
125MG
SLEEP DISORDER AGENTS
TROLYTES
EXJADE
5
MO
GABA RECEPTOR MODULATORS
AMINOSYN
4
B/D PA
TBSO
temazepam
2
QL(90/365)
M
250MG,
MO
AMINOSYN
4
B/D PA
500MG
zaleplon
2
QL(90/365)
-HBC
kionex powd
2
zolpidem
2
PA
AMINOSYN
4
B/D PA
SAMSCA
5
PA
tartrate
QL(90/365)
-HF
TABS
QL(60/30)
SLEEP DISORDERS, OTHER
AMINOSYN
4
B/D PA
30MG
MODAFINIL
4
PA
-PF
SAMSCA
5
PA
TABS
QL(30/30)
AMINOSYN
4
B/D PA
TABS
QL(90/30)
100MG
MO
-PF 7%
15MG
MODAFINIL
5
PA
calcium
2
MO
sodium
4
TABS
QL(60/30)
acetate tabs
bicarbonate
200MG
MO
667mg
inj 7.5%,
phenobarbit
2
MO
CLINIMIX
4
B/D PA
8.4%
al
2.75%/DEX
sodium
4
ROZEREM
3
QL(30/30)
TROSE 5%
lactate inj
XYREM
5
PA
clinimix
4
B/D PA
sodium
2
QL(540/30)
4.25%/dextr
polystyrene
THERAPEUTIC
ose 10%
sulfonate
NUTRIENTS/MINERALS/
clinimix
4
B/D PA
susp
ELECTROLYTES
4.25%/dextr
15gm/60ml
ELECTROLYTES/MINERALS
ose 25%
sps
2
calcium
2
MO
CLINIMIX
4
B/D PA
SYPRINE
3
acetate
4.25%/DEX
ELECTROLYTE/MINERAL
caps
TROSE 5%
REPLACEMENT
lactated
4
CLINIMIX
4
B/D PA
AMINOSYN
4
B/D PA
ringers
5%/DEXTR
AMINOSYN
4
B/D PA
dextrose 5%
OSE 25%
7%/ELECT
viaflex
clinisol
sf
4
B/D PA
ROLYTES
potassium
2
MO
15%
AMINOSYN
4
B/D PA
chloride er
dextrose
4
8.5%/ELEC
cpcr
5%
TROLYTES
THERAPEUTIC
/electrolyte
AMINOSYN
4
B/D PA
NUTRIENTS/MINERALS/ELECTROL
#48 viaflex
II
YTES
dextrose
4
AMINOSYN
4
B/D PA
correo
80
Drug Name
Drug
Tier
Reqs/Limits
Drug Name
Drug
Tier
Reqs/Limits
Drug Name
Drug
Tier
4
Reqs/Limits
5%/lactated
5%
potassium
ringers
klor-con
2
MO
chloride inj
dextrose
4
klor-con
2
MO
10meq/100
5%/potassiu
m10
ml,
m chloride
klor-con
1
MO
20meq/100
0.15%
ml,
m20
lactated
4
2meq/ml,
FREAMINE
4
B/D PA
III 3%
ringers inj
30meq/100
freamine iii
4
B/D PA
3meq/l;
ml,
inj 72meq/l;
109meq/l;
40meq/100
600mg/100
28meq/l;
ml
ml;
4meq/l;
potassium
2
810mg/100
130meq/l
chloride liqd
ml; 3meq/l;
lactated
4
potassium
1
MO
14mg/100ml
ringers
chloride sr
4
B/D PA
viaflex
premasol inj
;
1190mg/100
magnesium
4
B/D PA
56meq/l;
ml;
sulfate inj
320mg/100
240mg/100
50%
ml;
4
B/D PA
ml;
normosol-m
730mg/100
in d5w
590mg/100
ml;
ml;
NORMOSO
4
B/D PA
190mg/100
770mg/100
L-R
ml; 3meq/l;
4
ml;
potassium
20mg/100ml
chloride
620mg/100
;
ml;
0.15% nacl
300mg/100
0.9%
450mg/100
ml;
ml;
potassium
4
220mg/100
480mg/100
chloride
ml;
290mg/100
ml;
0.15%/d5w
10mmole/l;
potassium
4
ml;
490mg/100
115mg/100
chloride
ml;
ml;
0.3%/d5w
950mg/100
potassium
4
840mg/100
ml;
chloride
ml;
500mg/100
0.3%/nacl
490mg/100
ml; 10meq/l;
0.9%/viaflex
ml;
potassium
2
MO
340mg/100
200mg/100
ml;
chloride cr
ml;
130mg/100
potassium
2
MO
290mg/100
ml;
ml;
chloride er
410mg/100
560mg/100
cpcr
ml
potassium
2
MO
ml;
chloride er
230mg/100
hepatamine
4
B/D PA
isolyte4
B/D PA
tbcr 10meq,
ml; 5meq/l;
20meq
15mg/100ml
m/dextrose
correo
81
Drug Name
;
250mg/100
ml;
120mg/100
ml;
140mg/100
ml;
470mg/100
ml
PROCALA
MINE
PROSOL
ringers
injection
sodium
chloride
0.45%
viaflex
sodium
chloride inj
0.9%,
2.5meq/ml,
3%, 5%
sodium
fluoride tabs
tpn
electrolytes
TRAVASOL
niacor
Drug
Tier
Reqs/Limits
4
B/D PA
4
4
B/D PA
4
4
1
4
B/D PA
4
B/D PA
VITAMINS
2
MO
correo
82
Needles And Syringes
Drug Name
Drug Reqs/Limits
Drug Name
Drug Reqs/Limits
Tier
Tier
Drug Name
Drug Reqs/Limits
needle/mini/
MO
100/0.3ml/3
Tier
ultrafine/31g
0g x 1/2"
x
3/16"
ulticare
2
QL(200/30)
AGENTS
bd
pen
2
QL(200/30)
insulin
MO
needle/nano
MO
syringe/uAGENTS
100/0.5ml/3
/ultra
aurora pen
2
QL(200/30)
fine/32g x
1g x 5/16"
needles 31g
MO
4mm
ulticare
2
QL(200/30)
x 8mm
bd pen
2
insulin
MO
bd insulin
2
needle/ultraf
syringe/usyringe
ine/29g x
100/1ml/30g
safetyglide/
x 1/2"
12.7mm
1ml/29g x
h-e-b
2
QL(200/30)
1/2"
incontrol
MO
bd insulin
2
pen
needles
syringe
29gx12mm
ultrafine/0.3
kmart valu
3
QL(200/30)
ml/31g x
plus insulin
MO
5/16"
syringe/0.5
bd insulin
2
ml/29g
syringe
monoject
2
QL(200/30)
ultrafine/0.5
insulin
MO
ml/30g x
syringe/deta
1/2"
ch
bd insulin
2
needle/1ml/
syringe
27g x 1/2"
ultrafine/1ml
monoject
2
QL(200/30)
/31g x 5/16"
insulin
MO
bd insulin
2
QL(200/30)
syringe/safe
syringe
ty/perm
ultrafine/uneedle/0.3m
100/0.3ml/3
l/29g x 1/2"
1g x 15/64"
monoject
2
QL(200/30)
bd insulin
2
QL(200/30)
insulin
MO
syringe
syringe/uultrafine/u100/0.5ml/3
100/0.5ml/3
0g x 5/16"
1g x 15/64"
monoject
2
QL(200/30)
bd insulin
2
QL(200/30)
insulin
MO
syringe
syringe/uultrafine/u100/1ml/30g
100/1ml/31g
x 5/16" misc
x 15/64"
null
bd
2
QL(200/30)
ulticare
2
QL(200/30)
needle/30g
MO
insulin
MO
x 1/2"
syringe/ubd pen
2
QL(200/30)
correo
83
www.mycignahealthspring.com
This formulary was updated on August 2013. For more recent information or other questions, please contact Cigna-HealthSpring
Customer Service at 1-800-668-3813 or, for TTY users, 711, 7 days a week, 8 a.m. - 8 p.m., or visit www.mycignahealthspring.com.
Este formulario se actualizó el Agosto de 2013. Para información más actualizada u otras preguntas, favor de contactar al
Departamento de servicio al cliente de Cigna-HealthSpring, al 1-800-668-3813 o, para los usuarios de TTY, 711, 7 días de la
semana, 8 a.m. - 8 p.m., o visite www.mycignahealthspring.com.

CIGNA-HEALTHSPRING COMPREHENSIVE FORMULARY (List of

Transcription

Similar documents

Cuidado para paciente interno Cuidado para paciente externo

Anuario de Investigación en Adicciones

Validación y verificación de métodos en el laboratorio clínico

EXTRACCIÓN DE LA FRACCIÓN PROTEICA UTILIZANDO DOS

revista de la academia puertorriqueña de jurisprudencia y

Libro inicial para el paciente - Adipex-P

Descargar Fichero

Propuesta para una nueva política hacia Colombia

Cheese is HEROIN. - Today Foundation

Diario de Alimentación y Estado Físico - Adipex-P