formulary - Physicians Plus

Transcription

FORMULARY
Health Insurance Marketplace
Four Tier Formulary
August 1
2015
P+6129-1410
Physicians Plus Formulary
Alphabetical Index
Last updated 7/31/2015
INTRODUCTION
Physicians Plus Insurance Corporation (Physicians Plus) maintains a Drug Formulary as a guide for prescribers
of ambulatory medications and select medications administered by a healthcare professional (e.g. clinic,
infusion center). The Physicians Plus Pharmacy and Therapeutics (P&T) Committee of physicians and
pharmacists reviews and approves the agents listed based on efficacy, comparative studies, safety, drug
interactions, side effects, pharmacokinetics and cost-effectiveness. Prescribers are notified in the bi-annual
newsletter about formulary updates and changes. All formulary changes are posted to the website by the 30th
of every month after each P&T meeting. Physicians receive a copy of the formulary upon joining the plan and
have the option of receiving it annually thereafter. Physicians Plus reserves the right to change the
formulary and any pharmacy benefit-related program at any time without notice. The Physicians
Plus website maintains a current version of the drug formulary at:



http://www.pplusic.com/documents/upload/marketplace-formulary-document.pdf (Adobe Acrobat
Reader is necessary to view the document).
A hard copy may be requested and sent via mail by contacting Pharmacy Services via phone at 608260-7803 or 800-545-5015, or via email at [email protected].
Drug formulary information is also available using RxManager. RxManager is accessible using MyChart
on a desktop or using our iPhone/Android App. The App can be downloaded from:
o iTunes (for iPhone, iPad, or iPod): http://itunes.apple.com/us/app/rxmanager/id540771801?mt=8
o Google Play (for Android-based smartphones):
https://play.google.com/store/apps/details?id=com.pplus.rxmanager&feature=search_result#?t=
W10.
Your comments and suggestions are vital for continued success of this formulary. Please send your comments
or formulary requests to:
Director of Pharmacy Services
Physicians Plus Insurance Corporation
P.O. Box 2078
Madison, WI 53701-2078
Phone: 608-260-7803 or 800-545-5015
Fax: 608-327-0324
www.pplusic.com
DRUG COVERAGE
At a retail network pharmacy all members may receive a 34 day supply of medication or as defined by quantity
limits on the formulary. At select retail network pharmacies some qualified medications may be available for
a three month supply for three copays or the cost of the medication whichever is less. All specialty
medications must be obtained at an in-network specialty pharmacy. Specialty medications will only be available
for a 30 day supply or as defined by quantity limits on the formulary.
For most drug benefit plans, formulary insulin copays are at a Tier 2 level. There is a limit of 20 mL (2 vials) of
insulin per insulin type per 34 day supply (whichever is greater). If a member requires a higher quantity per
month, the member, pharmacy, or provider may call Physicians Plus Pharmacy Services and request an
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Alphabetical Index
exception to the quantity limits or submit the request using the Prior Authorization process. Please review
the Prior Authorization (PA) procedure for details regarding non-preferred drugs.
New medications not reviewed by the Physicians Plus P&T Committee for placement at a formulary Tier level
are not covered. For medications not listed on the Physicians Plus formulary, the medication is not covered
and the member is responsible for 100% of the cost. There is a Prior Authorization exception process for
non-preferred medications. If the exception process is denied or not pursued, the patient is responsible for
100% of the cost. Physicians Plus does have a Discount Drug program that provides members with access to
negotiated discounts for these non-preferred drugs (some restrictions apply), see the Discount Drug Program
for more details.
Expedited Prior Authorization Procedure/Exception Procedure
Starting January 1, 2015 Physicians Plus will have an expedited PA process that can be used in urgent
circumstances such as when the medical condition will seriously jeopardize the individual’s life, health, ability
to function, or the individual is already currently using the non-formulary medication with no coverage at any
tier level. It must include the information prescribed in the above ‘PA Procedure/Exception Procedure’ as
well as the following: be labeled or requested as “Expedited 24-Hour PA Process”, have the reason or
description of harm that could reasonably occur if a decision is not rendered within 24 hours, and a
justification supporting that all formulary medications (on any tier) would be ineffective, less effective, or have
information regarding why or how a switch to a formulary alternative would cause harm or destabilization of
the patient’s condition. The expedited prior authorization procedure/exception process can be initiated by
having the prescriber call 608-260-7803 or faxing information to 608-327-0324 Monday through Friday before
5pm. For expedited reviews on weekends (between Friday 5pm and Sunday 5pm) and holidays (before 5pm
the last day of the holiday period), please call 608-381-4723 or fax 608-327-0324 and state this is a “24-Hour
Expedited Review Process” as well as the member name, date of birth, preferred pharmacy telephone number,
required information for an expedited review as described above, and a preferred call back number.
The Discount Drug Program allows a Physicians Plus member to obtain the Physicians Plus contracted rate
for a medication that is not on formulary. The member is responsible for 100% of the cost of the medication
as well as a minimal fee. Medications paying through the discount drug wrap will not be accumulated towards
the deductible or maximum out-of-pocket. To use the Discount Drug Program the claim needs to be
adjudicated on-line at the pharmacy at the time of the sale. Discount Drug Program does not apply to
excluded medications, prior authorization medications, or other medications as determined by Physicians Plus.
This program is subject to change without notification.
Drug coverage is based on the formulary status of the drug.
 Generic drugs: Medications available from one or more manufacturers that are no longer patent
protected
 Brand drugs: Medications which are patent protected and usually available from one manufacturer
only
 First-Tier (Tier 1): Preferred generics and select brands; Lower copayment (usually $10-$25 per
copay) for Tier 1 formulary drugs
 Second-Tier (Tier 2): Preferred brands and select generics; Higher copayment (usually $35-$70 per
copay or a 30% coinsurance) for Tier 2 formulary drugs
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Alphabetical Index



Third-Tier (Tier 3): Non-preferred generics and non-preferred brands that may require a PA or
generally covered at 50% coinsurance
Fourth-Tier (Tier 4): Specialty drugs may require filling at an in-network specialty pharmacy and
most require PA; medications which require filling at an in-network specialty pharmacy are designated
with “SP” on the formulary document. Member costs can range between $40 and $250 per
prescription per month. Specialty drugs often have 10% coinsurance up to either a $100 maximum per
copayment per month or $250 maximum per copayment per month.
$0 copay (Tier 5): Select generic and select brand medications for $0 copay
GENERIC SUBSTITUTION POLICY
Physicians Plus supports the use of generic medications. Physicians Plus establishes that when an equivalent
generic becomes available for a Tier 2 brand product, the brand product is either removed from the formulary
or placed at Tier 3 (non-preferred, higher copay level). When the drug is removed from formulary, the
member is responsible for 100% of the cost of the prescription. If your prescriber believes it is medically
necessary to receive the brand product, a PA request must be submitted for review with clinical
documentation.
In drug classes where there are several products, only certain products within that class may be on the
formulary. By limiting the products available, drug costs are reduced through use of generic drugs, costeffective choices, and manufacturer rebates.
SPECIAL CODES KEY

Parenthesis “(drug name)”: indicates a brand name example. Only the generic version is covered
as a formulary (Tier 1) drug.

PA - Prior Authorization (PA) Drug: Prior Authorization criteria established. The P&T
Committee decided that coverage is available when specific clinical criteria and circumstances are met.
Prescribers must follow the PA procedure to request coverage of the medication and if applicable the
facility where the medication is being administered.
Prescriber’s office must fax a completed “Prior Authorization Request Form” to Physicians Plus
Pharmacy Services at 608-327-0324. Forms are available at
http://www.pplusic.com/providers/pharmacy or call Pharmacy Services at 608-260-7803 or 800-5455015, or email at [email protected] to request a form. For expedited 24-hour prior
authorization process please call 608-260-7803 or fax 608-327-0324 Monday through Friday before
5pm. For expedited reviews on weekends (between Friday 5pm and Sunday 5pm) and holidays (before
5pm the last day of the holiday period), please call 608-381-4723 or fax 608-327-0324.
PA Procedure/Exception Procedure
Prior authorization (PA) or requesting a formulary exception is a process whereby the prescriber
reviews the PA criteria, completes a standard or medication-specific PA request form, and faxes or
mails it to Physicians Plus Pharmacy Services as indicated on the form. Documentation of medical
necessity includes an adequate trial of all formulary drugs in the same class with stated reasons for
failure: intolerability, allergy, inadequate or inappropriate response. Members may also initiate the PA
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Alphabetical Index
process by contacting their prescriber, through Rx Manager, email at [email protected], or
Physicians Plus Pharmacy Services at 608-260-7803 or 800-545-5015. Information provided is
reviewed by the Physicians Plus Clinical Pharmacists under the direction of the Medical Director.
Notification regarding the decision is made in writing to the prescriber and member. To obtain a copy
of the standard or medication-specific PA forms, visit http://www.pplusic.com/providers/pharmacy or
contact Pharmacy Services via phone (608-260-7803 or 800-545-5015; fax 608-327-0324), or email at
[email protected].
PA drugs are medications identified with a ‘PA’ symbol and have specific criteria that must be fulfilled
for coverage. Prior authorization criteria can be found on the medication-specific PA request forms
found on the website by brand or generic name. All members require a PA approval by Physicians Plus
for coverage of PA drugs.

NTI – Narrow Therapeutic Index medications. Both the brand (Tier 2) and the generic (Tier 1)
medications are considered formulary based upon efficacy and safety issues (e.g.
levothyroxine/Synthroid, warfarin/Coumadin, phenytoin/Dilantin, etc.).

TS – Voluntary Tablet Splitting Program. Members choosing to tablet split and use #15 tablets
per month will receive a coinsurance reduction or a HALF-copay for drugs in this program. More
information about the program may be found at http://www.pplusic.com/documents/upload/p5347tablet-splitting-program.pdf. Members may call Pharmacy Services to obtain a FREE tablet splitter.
Physicians Plus reserves the right to change this list at any time without notice.

QL – Quantity limit. The quantity listed is the quantity per month limitation. For Physicians Plus,
the drug benefit allows coverage for a maximum of 34 days supply per prescription claim. For
medications with a higher strength available, members must use the higher strength with any dose
increases. If a member requires a higher quantity per month, prior authorization is required.
Limitations below specify the maximum amount of tablets per copay and the maximum number of
copays per month. Larger quantities require a PA/exception request.
In addition, formulary test strips have a quantity limit of up to 50 test strips per 90 day supply for
members not on blood glucose lowering drug therapy. For members on blood glucose lowering drug
therapy, the quantity limit is up to 150 test strips per 30 day supply.
There is a limit of 20 mL (2 vials) of insulin per insulin type per 34 day supply (whichever is greater). If
a member requires a higher quantity per month, the member, pharmacy, or provider may call
Physicians Plus Pharmacy Services with the daily dose for immediate authorization or submit a prior
authorization request for review.

SP – Specialty Drug. All specialty drugs must be filled at an in-network specialty pharmacy. Most
specialty drugs require prior authorization. If approved, these products are covered at the Tier 4
coinsurance level (usually a percent coinsurance with a maximum amount per prescription per month).

PF – Partial Fill.During the first three months of treatment with these medications, members will
have the first 16 days filled, and the member will pay half of their normal monthly copay. For the next
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Alphabetical Index
12-14 days fill (to complete the first month), the member will pay the other half of the normal copay.
Each month thereafter a one month supply will be available for one copay.

R90 – 90-Day-at-Retail: Select medications can be filled at 90-Day-at-Retail pharmacy locations for a 90
day supply of medication. Some medications are excluded from this program including but not limited to
the following classes: controlled substances (i.e. anything with a DEA Controlled Substance Schedule
between CII and CIV, antibiotics, and specialty medications).

ST – Step Therapy required. Prior to receiving coverage, a trial of prerequisite medication(s) is
necessary. Submission of a prior authorization request may be required. Some medications do not
require a PA form/exception request if the prerequisite medication(s) have been filled within the
pharmacy claims system. If the step therapy requirement has been met, tier level that the medication
is covered at is determined by Physicians Plus and may be at the specified Tier level (e.g. Tier 3ST=if
step therapy is fulfilled the medication is covered at Tier 3).

Therapeutic Interchange. Other formulary medication substitutions within the same drug class
require a prescription by the prescriber.

AL – Age limit. Medications are covered without prior authorization for members in the designated
age range. Consideration for coverage for those outside the age range may be made through the
submission of a PA request. For example, budesonide respules require a PA/exception request for
members aged 9 years and older.

$0 - $0 copay. Medications are available for a $0 monthly copay if a prescription is written and
submitted to the participating pharmacy, and the claim is run through the Physicians Plus pharmacy
claims system. Formulary agents with a $0 copay with a prescription include:
fluoride supplements (AL 6mo-6yrs)
iron supplements (AL 6-12mo)
Zostavax (>59yrs)
Nicotine Cessation Medications
(6mos/yr)*
folic acid (women)
prenatal vitamins (women)
Influenza Vaccine (IM,nasal)
select oral contraceptives
select Vitamin D (>64yrs)
PEG-3350 (>49yrs,one annually)**
OTC – OTC covered. Most over-the-counter (OTC) medications are excluded from coverage. However,
those designated with ‘OTC’ may be covered with a written prescription, filled by a participating pharmacy,
and if the claim is run through the Physicians Plus pharmacy claims system.
NC – Not covered. Medication is not covered because a formulary equivalent is available, formulary
alternatives are available, the drug has not been reviewed by P&T Committee, or the drug is excluded from
coverage by the medical certificate. For example, Vaniqa cream is not covered for cosmetic indications.
MB – Medical Benefit. Physicians Plus has select medical benefit medications that have set prior
authorization criteria. If a prior authorization is approved, medical benefit drugs may be covered under the
medical benefit coverage at an in-network facility. If a prior authorization is not obtained or not approved for
these medical benefit drugs and facility prior to administration, the member will be responsible for 100% of
the cost of the drug and associated administration fees. In general, drugs covered under the medical benefit
are drugs administered by a healthcare professional to a member. Medications obtained at an outpatient
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Alphabetical Index
pharmacy and administered to a member by themselves or family member are generally considered
underneath the pharmacy benefit. Physicians Plus reserves the right to determine which drugs are
under the medical or pharmacy benefit. In addition, Physicians Plus also reserves the right to
change the medical benefit drugs to the list of MB drugs requiring prior authorization at any
time without notice.
DME – Durable Medical Expense. For the pharmacy benefit, examples of DME include formulary spacers
for asthma treatment and formulary diabetic test strips. Formulary DME benefits are usually 20% coinsurance
and typically do not correspond to drug benefit tiers (e.g. diabetic test strips). Preferred level of coverage may
vary between each pharmacy benefit plan. Please see your Summary of Benefit Sheet. Non-preferred
pharmacy DME benefits are either 50% coinsurance or not covered.
EXCLUSIONS
1.) Over –the-counter (OTC) drugs unless specified on the Physicians Plus formulary document.
a. A prescription written by a participating provider would need to be filled through the
Physicians Plus pharmacy claims system to allow coverage of these formulary OTC products.
Examples of OTC covered products include guaifenesin w/codeine syrup and select artificial
tear ophth drops.
2.) Weight modification drugs
3.) Growth hormone (PA required)
 Providers MUST complete a medication-specific PA/exception request form (found at
http://www.pplusic.com/providers/pharmacy under ‘Drug PA forms’ for ‘Growth Hormone’).
 Growth hormone is covered at the plan’s Tier 4 Specialty Tier when fulfilling all the prior
authorization criteria. If criteria are not fulfilled, member is responsible for the full cost of the
medication.
4.) Anabolic steroids are only covered for replacement
5.) Infertility drugs
6.) Drugs used for sexual dysfunction
7.) Medications not reviewed by the P&T Committee
Medication Name
Generic Name
Tier
Special
Code
Drug Class
Subclass
8-MOP
abacavir(ZIAGEN Equiv)
abacavir/lamivudine/zidovudine
(TRIZAVIR equiv)
ABSTRAL
ACANYA
methoxsalen
abacavir sulfate
2
4
4
R90
R90
Dermatologic
Infectious Disease
Infectious Disease
Eczema and Psoriasis Agents
Antiviral - CMV/HIV/Hepatitis B
fentanyl transmucosal
clindamycin phosphate/benzoyl peroxide
NC
NC
CNS
Dermatologic
acarbose (PRECOSE equiv)
ACCOLATE
ACCUNEB
ACCUTANE
acebutolol
ACEON
acarbose
zafirlukast
albuterol nebulizer solution
isotretinoin
acebutolol
perindopril
1
NC
NC
NC
1
NC
Endocrine
Respiratory
Respiratory
Dermatologic
Cardiovascular
Cardiovascular
Narcotics
Topical Acne (Rx strength only
covered)
Dibaetes - Other Oral
Oral Respiratory Medications
Other Inhaled Medications
Oral Acne
Beta Blockers
ACE-Inhibitors
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Alphabetical Index
Medication Name
Generic Name
Tier
ACEROLA C
acetaminophen/ codeine
acetaminophen/
isometheptene/caffeine
acetaminophen/butalbital
acetaminophen/butalbital/ caffeine
acetaminophen/butalbital/
caffeine/codeine
acetaminophen/codeine (TYLENOL
#3 equiv)
acetaminophen/dichloralphenazone/is
ometheptene (MIDRIN equiv)
acetaminophen/hydrocodone
acetaminophen/oxycodone
acetaminophen/phenyltoloxamine
ascorbic acid
acetaminophen/ codeine
acetaminophen/isometheptene/ caffeine
1
1
3
acetaminophen/butalbital
acetaminophen/butalbital/caffeine
acetaminophen/butalbital/caffeine/
codeine
acetaminophen/codeine
Special
Code
Drug Class
Subclass
Vitamins
CNS
CNS
Vitamin C Preparations
Narcotics
Migraine
1
1
1
CNS
CNS
CNS
Migraine
Migraine
Migraine
1
CNS
Narcotics
acetaminophen/dichloralphenazone/
isometheptene
acetaminophen/hydrocodone
acetaminophen/oxycodone
acetaminophen/phenyltolxamine
1
CNS
Migraine
1
1
3
CNS
CNS
CNS
acetaminophen/tramadol
ACETASOL HC
acetazolamide caps(DIAMOX
SEQUELS equiv)
acetazolamide tabs (DIAMOX equiv.)
acetic acid (ACETASOL equiv)
acetaminophen/tramadol
acetic acid/hydrocortisone
acetazolamide
3
1
1
CNS
Opthalmic/Otic
Opthalmic/Otic
Narcotics
Narcotics
NSAIDs/Pain Relief/Pain
Medications
Narcotics
Misc. Ear Products
Glaucoma
acetazolamide
acetic acid
1
1
Diuretics
Irrigants
acetic acid (ACETASOL equiv)
acetic acid/hydrocortisone otic
(VOSOL HC equiv.)
acetylcysteine (MUCOMYST equiv)
ACTHAR H.P.
actic acid/aluminum
ACTIMMUNE
ACTIQ
ACTIVELLA
acetic acid
acetic acid/hydrocortisone otic
2
NC
Cardiovascular
Antibacterials and
Antiseptics
Opthalmic/Otic
Opthalmic/Otic
acetylcysteine
corticotropin
actic acid/aluminum
interferon gamma
fentanyl oral
estradiol/norethindrone
1
NC
1
NC
NC
NC
Respiratory
Endocrine
Opthalmic/Otic
Infectious Disease
CNS
Endocrine
ACTONEL (except 150mg)
ACTONEL W/ CALCIUM
ACTOPLUS MET XR
ACUVAIL
acyclovir
ACZONE
risendronate
risendronate/calcium
pioglitazone/metformin XR
ketorolac opth
acyclovir
dapsone
2
NC
NC
3
1
2
Endocrine
Endocrine
Endocrine
Opthalmic/Otic
Infectious Disease
Dermatologic
adapalene cream, gel (DIFFERIN
equiv)
ADCIRCA
adapalene cream, gel
1
tadalafil
NC
ADDERALL XR
ADOXA
ADRENACLICK
ADVAIR
ADVICOR
AEROCHAMBER
AFINITOR
AGGRASTAT
amphetamine/dextroamphetamine
doxyccyline monohydrate
epinephrine
fluticasone-salmeterol
niacin/lovastatin
spacer for inhaler
everolimus
tirofiban/sodium chloride
1
NC
NC
3
3
1
4
4
AHIST
A-HYDROCORT
chlorcyclazine
hydrocortisone sodium succinate
2
1
AK-CON
AK-DILATE
AKNE-MYCIN
naphazoline opthalmic
phenylephrine opthalmic
erythromycin base
3
NC
2
AK-PENTOLATE
AK-POLY-BAC
AKTEN
ALAGESIC LQ
ALAMAST
ALA-QUIN
ALAVERT
ALAVERT ALLERGY SINUS
cyclopentalate opth
bacitracin/polymixin B sulfate
lidocaine opthalmic
butalbital/asprin/caffeine
pemirolast opth
clioquinol/hydrocortisone
loratadine
loratadine/PSE
3
1
3
1
NC
2
NC
NC
Other Respiratory Medications
Adrenal Hormones
Misc. Ear Products
Misc. Anti-Infectives
Narcotics
Hormone Replacement - Oral
Estrogen/Progestin
Osteoporosis-Bisphosphonates
Diabetes- Other Oral
Eye NSAIDS - Inflammation
Other Antiviral
Topical Acne//Prescription
strength only covered
Vasodialators/Nitrates/Misc.
Cardiovascualar
CNS Stimulants
Oral Acne
Inhaled Corticosteroids
Cholesterol Lowering- Statins
Miscellaneous Products
Ocology/Cancer
Blood Related (Anti-Platelet,
Clotting, Blood Building)
Antihistamines (Allergy, Cold)
Antiinflammatory/Immunology/Immun
osuppressants
Eye Allergy
Other Misc Eye Products
covered)
Glaucoma
Migraine
Eye Allergy
Topical Other
QL-2
AL< 35
Dermatologic
Cardiovascular
QL-60
ST
ST
PA,PF,SP
CNS
Dermatologic
Respiratory
Respiratory
Cardiovascular
Respiratory
Oncology
Cardiovascular
Respiratory
Oncology
OTC
Opthalmic/Otic
Opthalmic/Otic
Dermatologic
Opthalmic/Otic
Opthalmic/Otic
Opthalmic/Otic
CNS
Opthalmic/Otic
Dermatologic
Respiratory
Respiratory
PA=Prior authorization required QL=Quantity Limit
SP=Specialty Pharmacy
ST=Step therapy
AL=Age Limit
PF=Partial Fill
TS=Tab Splitting
NTI=Narrow Therapeutic
R90=90-Day-at-Retail
$0=$0 copay avail w/Rx
CAPS = Brand, lower case=generics
Misc. Ear Products
Misc. Ear Products
8
Alphabetical Index
Medication Name
Generic Name
Tier
Special
Code
ALAVERT REDITABS
ALAWAY
ALBELON
ALBENZA
albuterol neb soln
albuterol sulfate tabs
albuterol/ipratropium (DUONEB
Equiv)
alclometasone (Aclovate Equiv)
alcohol, dehydrated
ALDACTAZIDE
alendronate (FOSAMAX Equiv)
ALFERON N
alfuzosin
ALINIA
ALKERAN
ALLEGRA (BOTH Rx and OTC-all
preparations)
Allopurinol
loratadine ODT
ketotifen opthalmic
naphazoline opthalmic
albendazolle
albuterol sulfate
albuterol sulate
albuterol/ipratropium
NC
NC
NC
NC
1
1
3
alclometasone
ethyl alcohol
spironolactone/HCTZ
alendronate
inerferon alfa N3
alfuzosin
nitazoxanide
melphalan
fexofenadine
1
1
2
1
4
1
2
4
NC
allopurinol
1
almotriptan (AXERT equiv)
almotriptan
3
ALOCRIL
nedocromil opthalmic
3
ALOE VESTA SKIN CONDITIONER
2
ALOMIDE
ALORA
dimethicone
2
lodoxamide opthalmic
estradiol twice weekly patch
2
NC
ALPHAGAN P
alprazolam (XANAX Equiv // ODT
and XR not covered)
ALREX
ALTAVERA
ALTOPREV
aluminum chloride (DRYSOL Equiv)
brimonidine opthalmic
alprazolam
NC
1
loteprednol opthalmic
levonogestrel/ethinyl estradiol
lovastatin ER
aluminum chloride
2
$0
NC
1
QL-2
Opthalmic/Otic
Endocrine
Cardiovascular
Dermatologic
ALVESCO
ALYACEN
amantadine
amcinonide
AMERGE
A-METHAPRED
ciclesonide inhaled
norethindrone/ethinyl estradiol
amantadine
amcinonide
naratriptan
methylprednisolone
3
$0
1
1
NC
1
ST
Respiratory
Endocrine
Infectious Disease
Dermatologic
CNS
Oncology
AMETHIA
AMETHIA LO
amethyst (LYBREL equiv)
AMICAR
aminocaproic acid
NC
NC
NC
NC
Endocrine
Endocrine
Endocrine
Cardiovascular
amilioride (MIDAMOR Equiv)
amiloride/HCTZ
aminobenzoate potassium (POTABA
Equiv)
AMINOCAPROIC ACID
amiloride
amiloride/HCTZ
aminobenzoate potassium
1
NC
NC
Cardiovascular
Cardiovascular
Endocrine
AMINOCAPROIC ACID
4
aminophylline
amiodarone
AMITIZA
amitriptyline
amitriptyline/chlordiazepoxide
amitriptyline/perphenazine
amlodipine (NORVASC equiv)
amlodipine/atorvastatin(CADUET
Equiv)
amlodipine/benazepril (LOTREL
equiv)
amlodipine/valsartan (EXFORGE equiv)
aminophylline
amiodarone
lubiprostone
amitriptyline
amitriptyline/chlordiazepoxide
amitriptyline/perphenazine
amlodipine
amlodipine/atorvastatin
NC
1
2
1
1
1
1
NC
amlodipine/benazepril
amlodipine/valsartan
QL-2 vials
SP
PA
ST,QL9/18
Drug Class
Subclass
Respiratory
Opthalmic/Otic
Opthalmic/Otic
Infectious Disease
Respiratory
Respiratory
Respiratory
Eye Allergy
Eye Allergy
Anti-Parasitics
Dermatologic
CNS
Cardiovascular
Endocrine
Infectious Disease
Genitourinary
Infectious Disease
Oncology
Respiratory
Corticosteroids
Other CNS
Diuretics
Other Antiviral
Urinary Incontinence/BPH
Anti-parasitics
Oncology/Cancer
Oncology
Anti-inflammatory / Immunology/
Immunosuppressants
Migraine - Triptans
CNS
Opthalmic/Otic
Dermatologic
QL-2
Opthalmic/Otic
Endocrine
Opthalmic/Otic
CNS
Anti-inflammatory / Immunology/
Immunosuppressants
Topical Other
Eye Allergy
Hormone Replacement Transdermal Estrogen/Progestin
Glaucoma
Antianxiety
Respiratory
Cardiovascular
Gastoenterology
CNS
CNS
CNS
Cardiovascular
Cardiovascular
Contraceptives: Monophasic
Topical Antibacterial//Rx Strength
Only
Other Antiviral
Corticosteroids
Migraines - CNS Triptans
Anti-inflammatory /Immunology/
Immunosuppressants
Contraceptives: Bi- or Tri-phasic
Diuretics
Diuretics
Elecrolytes/Minerals/
Supplements//Rx Only
Antiarrhythmics
Constipation/Misc GI
Antidepressants - Tricyclic
Antianxiety
Antipsychotics
Calcium Channel Blockers
NC
Cardiovascular
ACE-Inhibitors
NC
Cardiovascular
Angiotensin II Antagonists (ARBs)
PA
PA
Cardiovascular
ST=Step therapy
AL=Age Limit
PF=Partial Fill
TS=Tab Splitting
9
Alphabetical Index
Medication Name
Generic Name
Tier
ammonium lactate
ammonium lactate
1
AMNESTEEM (ACCUTANE Equiv)
amoxapine
amoxicillin capsules
amoxicillin tablets (500mg
EXCLUDED)
amoxicillin/clavulante (AUGMENTIN
Equiv)
amoxicillin/clavulante
XR(AUGMENTIN ES Equiv)
ampehtamine/dextroamphetamine XR
(ADDERALL XR Equiv)
(ADDERALL Equiv)
ampicillin
AMPYRA
AMTURNIDE
isotretinoin
amoxapine
amoxicillin capsules
amoxicillin
4
1
1
3
Special
Code
Drug Class
Subclass
Dermatologic
Dermatologic
CNS
Infectious Disease
Infectious Disease
Antivirals, Antiparasitic, and
Other Topicals - Rx Strength
Only Covered
Oral Acne
Penicillins
Penicillins
1
Infectious Disease
Penicillins
amoxicillin/clavulante XR
1
Infectious Disease
Penicillins
amphetamine/dextroamphetamine XR
NC
CNS
CNS Stimulants (ADD/ADHD)
1
TS
CNS
ampicillin
dalfampridine
aliskirin/amlodipine/HCTZ
1
4
NC
PA,SP
Infectious Disease
CNS
Cardiovascular
ANADROL-50
oxymethalone
2
PA
Endocrine
anagrelide (AGRYLIN Equiv)
anagrilide
1
Cardiovascular
ANALPRAM HC CREAM
hydrocortisone/pramoxine
NC
Dermatologic
ANALPRAM LOTION
NC
Dermatologic
ANAMANTALE
hydrocortisone/lidocaine
NC
Dermatologic
anastrazole (ARIMIDEX Equiv)
ANDRODERM
anastrazole
testosterone
1
2
PA
Oncology
Endocrine
ANDROGEL
testosterone
2
PA
Endocrine
ANDROID
methyltestosterone
NC
ANDROXY
fluoxymesterone
1
ANECTINE
ANGELIQ
succinylchloride
estradiol/drosperidone
2
NC
ANORO ELLIPTA
antipyrine/benzocaine
ANZEMET
AOZR
APEXICON
APEXICON E
APIDRA
umeclidinium/vilanterol
antipyrine/benzocaine otic
dolesetron mesylate
amlodipine/olmesartan
diflorisone
diflorisone/emollient
insulin glulisine
2
1
2
NC
NC
1
3
APLENZIN
APOKYN
apraclonidine (Iopitine)
APRI (DESOGEN Equiv)
APRISO
APTIVUS
ARALEN
aranelle
ARANESP
bupriopion HBr
apomorphine
apraclonidine opth
desogestrol/ethinyl estradiol
mesalamine
tipranavir
chloroquine
darbapoetin
NC
4
1
$0
NC
4
NC
NC
4
ARCALYST
rilonacept
4
ARCAPTA
ARICEPT
indacaterol
donepezil
NC
2
Penicillins
Multiple Sclerosis
Hormone Replacement
(Testosterone/Progesterone)
Only Covered
Only Covered
Only Covered
Oncology/Cancer
Hormone Replacement
Hormone Replacement
Hormone Replacement
Hormone Replacement
Antianiety
Estrogen/Progestin
Other Inhaled
Misc Ear Products
Nausea/Vomitting
Angiotensin II Antagonists (ARB's)
Corticosteroids
Corticosteroids
Diabetes - Insulin and Other
Injectables
Other Antidepressants
Parkinson's Disease
Glaucoma
Contraceptives : Monophasic
Anti-Malarials
osuppressants
Alzheimers Disease/Other
Neurological Disease
Endocrine
PA
Endocrine
CNS
Endocrine
QL-2
ST
PA,SP
QL-2
PA, QL-4,
SP
PA,SP
Respiratory
Opthalmic/Otic
Gastoenterology
Cardiovascular
Dermatologic
Dermatologic
Endocrine
CNS
CNS
Opthalmic/Otic
Endocrine
Gastoenterology
Infectious Disease
Infectious Disease
Endocrine
Cardiovascular
Oncology
Respiratory
CNS
ST=Step therapy
AL=Age Limit
PF=Partial Fill
TS=Tab Splitting
10
Alphabetical Index
Medication Name
Generic Name
Tier
Special
Code
aripiprazole (ABILIFY equiv)
ARMOUR THYROID
AROMASIN
ARTHROTEC
aripiprazole
thyroid, dessicated
examestane
diclofenac/misoprostol
2
2
NC
NC
artificial tears
artificial tears
ASACOL HD
ascorbic acid
ASMANEX TWISTHALER and HFA
aspirin
polyvinyl alcohol/povidone
hypromellose/peg 400/glycerin
mesalamine 800mg DR
ascorbic acid
mometasone furoate
aspirin
NC
NC
2
1
2
$0
aspirin ec
aspirin w/ eneteric coating
1
CNS
aspirin/butalbital/caffeine (FIORINAL
Equiv)
aspirin/carisoporodol
aspirin/carisoprol/caffeine
aspirin/dipyridamole (AGGRENOX
equiv)
asprin/butalbital/caffeine/codeine
(FIORINAL w/ CODEINE Equiv)
ASTAGRAF
aspirin/butalbital/caffeine
NC
CNS
aspirin/carisoporodol
aspirin/carisoprol/caffeine
aspirin/dipyridamole
NC
NC
3
CNS
CNS
Cardiovascular
asprin/butalbital/caffeine/codeine
NC
tacrolimus
NC
SP
Endocrine
Astelin
ASTEPRO
Azelastine
azelastine nasal
2
2
QL-2
Respiratory
Respiratory
ATACAND
ATACAND HCT
atenolol (TENORMIN Equiv)
atenolol-chlorthalidone
atorvaquone/proguanil (MALARONE
equiv)
atorvastatin
ATRALIN
candesartan
candesartan/HCTZ
atenolol
atenolol-chlorthalidone
atorvaquone/proguanil
3
NC
1
1
1
atorvastatin
tretinoin
1
NC
ATRIPLA
atropine opthalmic
atropine sulfate
efavirenz/ amtricitabine/tenofavir
atropine opthalmic
atropine sulfate
4
1
1
ATROVENT HFA
AUBAGIO
AUGMENTIN
AVAGE
AVANDAMET
AVANDARYL
AVANDIA
AVAR LS
AVC cream
AVELOX
AVIANE (ALESSE Equiv)
AVINZA
AVODART
AVONEX
AXID
AXIRON
ipratopium bromide
teriflunamide
tazarotene
rosiglitazone/metformin
rosiglitazone/glipizide
rosiglitazone
sulfacetamide/sulfur
sulfanilamide cream
moxifloxacin
morphine sulfate
dutasteride
interferon beta-1A
nizatidine
testosterone topical solution
3
4
2
2
2
NC
2
2
2
3
$0
2
2
4
NC
NC
AYGESTIN
AZAMCORT
AZASAN
norethindrone acetate tablet
triamcinolone acetonide
azathioprine
NC
NC
NC
AZASITE
azathioprine (IMURAN equiv)
azithromycin opthalmic
azathioprine
2
1
QL-2
Opthalmic/Otic
Oncology
azelastine nasal (ASTELIN equiv)
azelastine nasal
2
QL-2
Respiratory
azelastine nasal (ASTEPRO equiv)
azelastine nasal
NC
QL-2
Respiratory
azelastine ophth (OPTIVAR equiv)
azelastine ophth
1
TS,R90
NTI
AL
PA, ST
Drug Class
Subclass
CNS
Endocrine
Oncology
CNS
Antipsychotics
Misc Hormones
Oncology/Cancer
Medications
Dry Eye Preparations
Miscellaneous GI
Vitamin C Preparations (Rx Only)
Medications
Medications
Muscle Relaxants/Muscle Spasms
Opthalmic/Otic
Opthalmic/Otic
Gastroenterology
Vitamins
Respiratory
CNS
CNS
Cardiovascular
Cardiovascular
Cardiovascular
Cardiovascular
Infectious Disease
QL-45, TS
QL-2
ST
PA,SP
AL>35
QL-60
SP
Cardiovascular
Dermatologic
Infectious Disease
Opthalmic/Otic
Gastoenterology
Respiratory
Immunology
Infectious Disease
Dermatologic
Endocrine
Endocrine
Endocrine
Dermatologic
Infectious Disease
Infectious Disease
Endocrine
CNS
Genitourinary
CNS
Gastoenterology
Endocrine
Endocrine
Respiratory
Oncology
Ophthalmic/Otic
ST=Step therapy
AL=Age Limit
PF=Partial Fill
TS=Tab Splitting
Migraine
Migraine
Anti-inflammatory/Immunology/
Immunosuppressants
Nasal Corticosteroids
Nasal Corticosteroids/
Antihistamines
Angiotensin II Agonists
Angiotensin II Agonists
Beta-Blockers
Beta-Blockers
Anti-Malarials
covered)
Multiple Sclerosis
Penicillins
Other Topical Agents?
Diabetes - TZD
Diabetes - TZD
Diabetes - TZD
Topical Antibacterials
Anti-infectives
Quinolones
Narcotics
Multiple Sclerosis
H2 Antagonists/Ulcer
Hormone Replacement
(Testosterone/Progesterone
Miscellaneous Hormonees
osuppressants
Opthalmic Antibiotics
Immunosuppressants
Antihistamines
Antihistamines
Eye Allergy
11
Alphabetical Index
Medication Name
Generic Name
Tier
AZELEX
azelaic acid
2
AZILECT
azithromycin
AZOPT
AZOR
AZTREONA
AZURETTE (MIRCETTE Equiv)
bacitracin opthalmic ointment
bacitracin/hc/neomycin/polymyxin B
ointment
bacitracin/hydrocortisone/ neomycin
rasgiline
azithromycin
brinzolamide opthalmic
amlodipine/olmesartan
cayston
desogestrrel/ethinyl estradiol
bacitracin opthalmic ointment
bacitracin/hc/neomycin/polymyxin B
ointment
bacitracin/hydrocortisone/neomycin
2
1
2
NC
4
$0
1
1
baclofen
BACTROBAN CREAM
Drug Class
Subclass
Dermatologic
CNS
Infectious Disease
Opthalmic/Otic
Cardiovascular
covered)
Parkinson's Disease
Macrolide/Ketolide
Glaucoma
Endocrine
Opthalmic/Otic
Ophthalmic/Otic
Eye Anti-Infectives
Eye NSAIDs - Inflammation
2
Dermatologic
baclofen
mupirocin calcium
1
NC
CNS
Dermatologic
BACTROBAN NASAL
mupirocin calcium
1
Dermatologic
BACTROBAN OINTMENT
mupirocin calcium
NC
Dermatologic
BAL IN OIL
balsalazide
BALZIVA (OVCON 35 Equiv)
BANZEL (Tabs and Liquid)
BARACLUDE
BAYCADRON
dimercaprol
balsalazide
rufinamide
entecavir
dexamethasone elixir
2
1
NC
2
NC
1
Antidotes
Gastoenterology
Endocrine
CNS
Infectious Disease
Oncology
BECONASE AQ
beclomethasone nasal
3
belladonna/opium
belladonna/phenobarbitol
1
1
BELSOMRA
benazepril (LOTENSIN Equiv)
benazepril/amlodipine
benazepril/HCTZ
BENGAY VANISHING SCENT
BENICAR
BENICAR HCT
BENTYL
BENZACLIN
belladonna/opium
belladonna/phenobarbitol/hyosciamine/sc
opalamine
suvorexant
benazepril
benazepril/amlodipine
benazepril/HCTZ
menthol
olmesartan
olmesartan/HCTZ
dicyclomine
clindamycin/benzoyl peroxide
Topical Antibacterial Prescription Strength Only
Only
Only
Only
Misc Antidotes
Anticonvulsants
AntiInflammatory/Immunology/Immun
osupressants
Antihistamines
Narcotics
Antispasmodic/Antidiarrheal
benzalkonium chloride
BENZAMYCIN
benzalkonium chloride
erythromycin/benzoyl peroxide
1
2
Dermatologic
Dermatologic
benzonatate
benzoyl peroxide (Rx Strengths Only)
benzonatate
benzoyl peroxide
1
1
Respiratory
Dermatologic
benzphetamine
benztropine
BEPREVE
BESIVANCE
BETADINE
betamethasone dipropionate
betamethasone valerate
BETASERON
betaxolol opth
betaxolol tabs
bethanechol (URECHOLINE equiv)
BETIMOL
BETOPTIC S
bexarotene (TARGRETIN equiv)
BEYAZ
benzphetamine
benztropine
bepostastine besilate opth
besifloxicin
providone/iodine
interferon beta-1b
betaxolol
betaxolol tabs
bethanechol
timolol opthalmic
betaxolol HCL opthalmic
bexarotene
drospinerone/ethinyl
estradiol/levomefolate
bicalutamide
sodium citrate/citric acid
NC
1
NC
3
2
1
1
4
1
1
1
2
2
4
NC
CNS
CNS
Opthalmic/Otic
Opthalmic/Otic
Opthalmic/Otic
Dermatologic
Dermatologic
Cardiovascular
Opthalmic/Otic
Cardiovascular
Genitourinary
Opthalmic/Otic
Opthalmic/Otic
Oncology
Endocrine
bicalutamide (CASODEX equiv)
BICITRA
3
1
NC
1
NC
3
3
2
2
1
NC
Special
Code
AL< 35
QL-2
PA
QL-2
QL-2
PA
ST
Respiratory
CNS
Gastoenterology
ST
ST
ST
PA,SP
QL-2
QL-2
QL-2
PA,PF,SP
CNS
Cardiovascular
Cardiovascular
Cardiovascular
Dermatologic
Cardiovascular
Cardiovascular
Gastoenterology
Dermatologic
Oncology
Endocrine
ST=Step therapy
AL=Age Limit
PF=Partial Fill
TS=Tab Splitting
Hypnotics
ACE-Inhibitors
Miscellaneous Topicals
covered)
Topical Antibacterial
covered)
Cough and Cold
covered)
CNS Stimulants (Obesity)
Parkinson's Disease
Eye Allergy
Eye Anti-Infectives
Eye Anti-Infectives
Corticosteroids
Corticosteroids
Multiple Sclerosis
Glaucoma
Beta Blockers
Glaucoma
Glaucoma
Oncology/Cancer
Oncology/Cancer
Elecrolytes/Minerals/Supplements/
/Rx Only
12
Alphabetical Index
Medication Name
Generic Name
Tier
Special
Code
Drug Class
Subclass
BIDIL
isosorbide dinaitrate/hydralazine
NC
Cardiovascular
Opthalmic/Otic
Vasodialators/Nitrates/Misc.
Cardiovascualar
Anti-parasitics
Topical Antibacterials
Beta-Blockers
Beta-Blockers
Eye Anti-infectives
Oncology/Cancer
Topical Acne - Prescription
Strength Only Covered
Hormone Replacement –
Infertility
covered)
Glaucoma
BILTRICIDE
BINOSTO
BION TEARS
BIONECT
bisoprolol (ZEBETA equiv)
bisoprolol/HCTZ (ZIAC equiv)
BLEPH-10
BLEPHAMIDE (and S.O.P)
BOSULIF
BP WASH ACNE TREATMENT
praziquantel
allendronate effervescent tab
dextran 70/hypromellose/PF
hyaluronate sodium
bisoprolol
bisoprolol/HCTZ
sulfacetamide ophth
prednisolone/sulfacetamide opth
bosutinib
benzoyl peroxide
2
NC
3
2
3
NC
NC
2
4
1
BPO
benzoyl peroxide
1
BRAVELLE
urofollitropin
NC
SP
Endocrine
BREO ELLIPTA
BREVICON
BREVOXYL
Fluticasone/vilanterol
benzoyl peroxide
3
3
NC
ST
Respiratory Agents
Endocrine
Dermatologic
BRILINTA
ticagrelor
3
PA,ST
Cardiovascular
brimonidine ophth (ALPHAGAN
equiv)
BROMDAY
bromfenac ophth (XIBROM equiv)
bromocriptine mesylate
brompheniramine
BROVANA
BROVEX SR
budeprion SR
budeprion XL (WELLBUTRIN XL
equiv)
budesonide EC (ENTOCORT EC
equiv)
budesonide nasal
brimonidine opthalmic
1
QL-2
bromfenac sodium
bromfenac ophth
brompheniramine
arformoterol inhaler
pseudoephedrine/brompheniramine
bupropion sr
bupropion xl
3
3
1
NC
NC
2
1
1
QL-2
QL-2
QL-30
Opthalmic/Otic
Ophthalmic/Otic
CNS
Respiratory
Respiratory
Respiratory
CNS
CNS
Parkinson's Disease
Cough and Cold
budesonide
1
PA
Gastroenterology
Constipation/Miscellaneous GI
budesonide nasal
3
ST,QL-2
Respiratory
budesonide respules
bumetanide
BUPHENYL
budesonide respules
bumetanide
sodium phenylbutyrate
2
1
4
PA, AL< 9
Gastroenterology
Cardiovascular
Endocrine
buprenorphine
buprenorphine/naloxone
(SUBOXONE tab equiv)
buproban (ZYBAN equiv)
buprenorphine
2
1
CNS
CNS
Antihistamines
Diuretics
Electrolytes/Minerals/Supplements
- Prescription Only
Alcohol/Drug Cessation
buproban
1
CNS
Smoking Cessation
bupropion
bupropion SR (WELLBUTRIN SR
equiv)
bupropion XL
buspirone
butalbital/apap/caffeine
butalbital/aspirin/caffeine
butalbital/caffeine/apap/codeine
butalbital/codeine compound
BUTISOL
butorphanol nasal spray
BUTRANS
BYDUREON
BYETTA
bupropion
bupropion SR
1
1*
CNS
CNS
bupropion XL
buspirone
butalbital/apap/caffeine
butalbital/aspirin/caffeine
butalbital/caffeine/apap/codeine
butalbital/asprin/caffeine/codeine
butabarbital
butorphanol nasal spray
buprenorphine patch
exenatide microspheres (weekly)
exenatide
1
1
1
1
1
1
2
1
3
3
3
CNS
CNS
CNS
CNS
CNS
CNS
CNS
CNS
CNS
Endocrine
Endocrine
BYSTOLIC
cabergoline (DOSTINEX equiv)
calcipotriene (DOVONEX equiv)
calcitonin nasal spray (MIACALCIN ns
equiv)
calcitriol
nebivolol
cabergoline
calcipotriene
calcitonin nasal
NC
1
2
1
Cardiovascular
Endocrine
Dermatologic
Endocrine
calcitriol
1
Endocrine
Antianxiety
Migraine
Migraine
Migraine
Migraine
Hypnotics
Migraine
Narcotics
Diabetes - Injection
Injectables
Beta Blockers
Miscellaneous Hormones
Eczema and Psoriasis agents
Calcium Metabolism/
Osteoporosis/ Miscellaneous
- Prescription Only
OTC
PA,SP
Infectious Disease
Endocrine
Opthalmic/Otic
Dermatologic
Cardiovascular
Cardiovascular
Ophthalmic/Otic
Opthalmic/Otic
Oncology
Dermatologic
Dermatologic
SP
QL6mo/yr
TS, QL*
TS
ST
ST
ST=Step therapy
AL=Age Limit
PF=Partial Fill
TS=Tab Splitting
13
Alphabetical Index
Medication Name
Generic Name
Tier
Special
Code
Drug Class
Subclass
calcitriol oint (VECTICAL equiv)
calcium acetate (PHOSLO equiv)
calcitriol
calcium acetate
NC
1
Dermatologic
Endocrine
CNS
CNS
- Prescription Only
- Prescription Only
Medications
Contraceptives: Mono-phasic
Contraceptives : Bi- or Tri-phasic
Anti-TB
Cough and Cold
Oncology/Cancer
Corticosteroids
Narcotics
Oncology/Cancer
ACE-Inhibitors
ACE-Inhibitors
Other Topicals - Prescription
Anticonvulsants
Anticonvulsants
calcium folinate
leucovorin calcium
1
Endocrine
CAMBIA
diclofenac potassium
NC
CNS
CAMILA
CAMPRAL
CAMRESE
CAMRESE LO
CANASA
CANTIL
CAPASTAT SULFATE
CAPCOF
capecitabine
CAPEX SHAMPOO
CAPITAL W-CODEINE
CAPRELSA
captopril (CAPOTEN equiv)
captopril/HCTZ
CARAC
norethindrone
acamprosate
levonorgestrel/ethinyl estradiol
mesalamine suppositories
mepenzolate
capreomycin
chloripheniramine/phenylephrine/codeine
capecitabine
fluocinolone acetonide
codeine/apap
vandetanib
captopril
captopril/HCTZ
fluorouracil
$0
2
NC
NC
2
2
2
2
4
2
2
4
1
NC
4
Endocrine
CNS
Endocrine
Endocrine
Gastroenterology
Gastroenterology
Infectious Disease
Respiratory
Oncology
Dermatologic
CNS
Oncology
Cardiovascular
Cardiovascular
Dermatologic
carbamazepine (TEGRETOL equiv)
carbamazepine ER (CARBATROL ER
equiv)
carbamazepine SR (TEGRETOL XR
equiv)
CARBATROL ER
carbidopa/levodopa (SINEMETequiv)
carbidopa/levodopa cr (SINEMET CR
equiv)
carbidopa/levodopa odt (PARCOPA
equiv)
carbidopa/levodopa/ entacapone
(STALEVO equiv)
carbinoxamine
CARDIZEM LA
CARDURA XL
carisoprodol (SOMA equiv)
carisoprodol compound
carisoprodol compound w/ codeine
CARMOL HC
carbamazepine
carbamazepine ER
1
1
NTI
NTI
carbamazepine SR
1
NTI
CNS
Anticonvulsants
carbamazepine ER
carbidopa/levodopa
carbidopa/levodopa cr
2
1
1
NTI
CNS
CNS
CNS
Anticonvulsants
Parkinson's Disease
Parkinson’s Disease
carbidopa/levodopa odt
1
CNS
carbidopa/levodopa/entacapone
1
CNS
Parkinson's Disease
carbinoxamine
diltiazem tab SR 24H
doxazosin XL
carisoprodol
carisoprodol/aspirin
carisoprodol/aspirin/codeine
hydrocortisone/urea
NC
NC
NC
1
1
1
NC
Respiratory
Cardiovascular
Cardiovascular
CNS
CNS
CNS
Dermatologic
CARMOL SCALP
sulfacetamide/urea
NC
Dermatologic
CARMOL-40
urea
NC
Dermatologic
CARNITOR SF
carteolol ophth (OCUPRESS equiv)
CARTIA XT (CARDIZEM CD equiv)
carvedilol (COREG equiv)
CATAPRES-TTS
CAVERJECT
CAYSTON neb soln
CAZIANT
CEDAX
CEENU
cefaclor (CECLOR equiv)
cefadroxil (capsules only, DURICEF
equiv)
cefdinir (OMNICEF equiv)
cefditoren
cefixime susp(SUPRAX susp equiv)
cefpodoxime (VANTIN equiv)
levocarnitine
carteolol ophth
diltiazem cap ER 24H
carvedilol
clonidine transdermal
alprostadil intracavernous
aztreonam lysine
desogestrel/ethinyl estradiol
ceftibuten
lomustine
cefaclor
cefadroxil
2
1
1
1
NC
NC
4
NC
NC
4
3
1
Oncology
Ophthalmic/Otic
Cardiovascular
Cardiovascular
Cardiovascular
Miscellaneous
Respiratory
Endocrine
Infectious Disease
Oncology
Infectious Disease
Infectious Disease
Adrenergics
Muscle Relaxants/Muscle Spasm
Oncology/Cancer
Glaucoma
Beta Blockers
Adrenergics
Cephalosporins
Oncology/Cancer
Cephalosporins
Cephalosporins
cefdinir
cefditoren
cefixime susp
cefpodoxime
1
NC
3
1
Infectious Disease
Infectious Disease
Infectious Disease
Infectious Disease
Cephalosporins
Cephalosporins
Cephalosporins
Cephalosporins
PA,SP
PA
QL-2
PA
ST=Step therapy
AL=Age Limit
PF=Partial Fill
TS=Tab Splitting
14
Alphabetical Index
Medication Name
Generic Name
Tier
Special
Code
Drug Class
Subclass
Infectious Disease
Infectious Disease
Infectious Disease
Cephalosporins
Cephalosporins
Cephalosporins
CNS
cefprozil (CEFZIL equiv)
ceftriaxone
cefuroxime (tablets only, CEFTIN
equiv)
celecoxib (CELEBREX equiv)
cefprozil
ceftriaxone sodium
cefuroxime axetil
3
1
1
celecoxib
2
CELONTIN
CENESTIN
methsuxsimide
conjugated estrogens tab
2
2
CENOLATE
ascorbate sodium
2
Endocrine
CENTERGY
cephalexin (KEFLEX equiv)
CERVIDIL
CESAMET
CESIA (CYCLESSA equiv)
cetirizine chewable OTC (ZYRTEC
chew equiv)
cetirizine syrup OTC (ZYRTEC syrup
equiv)
cetirizine tablet OTC (ZYRTEC OTC
equiv)
cetirizine-pseudoephedrine OTC
(ZYRTEC-D OTC equiv)
cetrotide
phenylephrine/chlorpheniramine
cephalexin
dinoprostone
nabilone
cetirizine chewable OTC
1
1
2
2
NC
NC
Respiratory
Infectious Disease
Oxytocics
Gastroenterology
Endocrine
Respiratory
Medications
Anticonvulsants
Estrogen/Progestin
- Prescription Only
Cough and Cold
Cephalosporins
Labor Induction Agents
Nausea/Vomiting
cetirizine syrup OTC
NC
Respiratory
cetirizine tablet OTC
NC
Respiratory
cetirizine-pseudoephedrine OTC
NC
Respiratory
cetrotide
4
Endocrine
cevimeline (EVOXAC equiv)
CHANTIX
CHEMET
chenodiol
chloral hydrate
chlordiazepoxide
chlordiazepoxide/amitriptyline
chlordiazepoxide/clindium (LIBRAX
equiv)
chlorhexidine
chloroquine (ARALEN equiv)
chlorpheniramine
chlorpheniramine ER
chlorpheniramine-pseudoephedrine
chlorpromazine
chlorpropamide
chlorthalidone
chlorzoxazone
cholestyramine (powder cans only, light
not covered)
choline magnesium trisalicylate
CHROMAGEN
cevimeline
varenicline
succimer
chenodiol
chloral hydrate
chlordiazepoxide
chlordiazepoxide/amitriptyline
chlordiazepoxide/clindium
NC
$0
2
2
1
1
1
1
Endocrine
CNS
Antidotes
Gastroenterology
CNS
CNS
CNS
Gastroenterology
Hormone Replacement Infertility
Miscellaneous, Oral
Smoking Cessation
Misc Antidotes
Hypnotics
Antianxiety
Antianxiety
chlorhexidine gluconate
chloroquine
chlorpheniramine
chlorpheniramine ER
chlorpheniramine-pseudoephedrine
chlorpromazine
chlorpropamide
chlorthalidone
chlorzoxazone
cholestyramine
1
1
NC
NC
NC
1
3
1
1
1
Infectious Disease
Infectious Disease
Respiratory
Respiratory
Respiratory
CNS
Endocrine
Cardiovascular
CNS
Cardiovascular
Miscellaneous Anti-infectives
Anti-Malarials
Antipsychotics
Diabetes - Sulfonylureas
Diuretics
Cholesterol Lowering - Other
choline magnesium trisalicylate
iron/C/B12
1
NC
CNS
Endocrine
CIALIS
ciclopirox shampoo (LOPROX equiv)
tadalafil
ciclopirox
3
1
ciclopirox solution, 8%
ciclopirox
NC
Dermatologic
ciclopirox topical
ciclopirox
1
Dermatologic
cilostazol
cilostazol
1
Cardiovascular
CILOXAN
cimetidine (TAGAMET equiv)
CIMZIA
ciprofloxacin ophth oint
cimetidine
certolizumab pegol
1
1
4
CIPRO HC OTIC
CIPRO Suspension
CIPRODEX otic
ciprofloxacin (CIPRO equiv)
ciprofloxacin er (CIPRO XL equiv)
ciprofloxacin ophth (CILOXAN drops
equiv)
ciprofloxacin/hydrocortisone
ciprofloxacin oral suspension
ciprofloxacin/dexamethasone otic
ciprofloxacin
ciprofloxacin er
ciprofloxacin ophth
3
2
2
1
NC
1
Migraine
- Prescription Only
Topical Antifungal//Prescription
Topical Antifungal - Prescription
Blood Related (Antiplatelet,
Eye Anti-infectives
Injectable Biologics for
Rheumatologic Disorders
Miscellaneous Ear Products
Quinolones
Quinolones
Quinolones
Eye Anti-infectives
PA, QL30
PA,SP
QL
PA,ST
QL-2
PA,SP
PA
QL-2
CNS
Endocrine
Miscellaneous
Dermatologic
Ophthalmic/Otic
Gastroenterology
Gastroenterology
Ophthalmic/Otic
Infectious Disease
Ophthalmic/Otic
Infectious Disease
Infectious Disease
Ophthalmic/Otic
ST=Step therapy
AL=Age Limit
PF=Partial Fill
TS=Tab Splitting
15
Alphabetical Index
Medication Name
Generic Name
Tier
Special
Code
Drug Class
Subclass
Ophthalmic/Otic
CNS
Endocrine
Antidepressants - SSRI/SNRI
- Prescription Only
Oral Acne
Macrolide/Ketolide
Macrolide/Ketolide
Corticosteroids
Corticosteroids
Corticosteroids - Very High
Potency
Corticosteroids - Medium to High
Potency
Antianxiety
Anticonvulsants
ciprofloxacin otic (CETRAXAL equiv)
citalopram (CELEXA equiv)
CITRANATAL B-CALM
ciprofloxacin otic
citalopram
prenatal vitamin combination
NC
1
2
claravis (ACCUTANE equiv)
CLARIFOAM EF
isotretinoin
sulfacetamide sodium/sulfur
4
NC
Dermatologic
Dermatologic
CLARINEX D
CLARINEX SYRUP
clarithromycin (BIAXIN equiv)
clarithromycin er (BIAXIN XL equiv)
CLARITIN
CLARITIN D
CLARITIN REDITABS
CLARITIN SYRUP
CLEAR EYES REDNESS RELIEF
Clemastine fumarate
CLEOCIN vaginal supp
CLIMARA
desloratadine-pseudoephedrine
desloratadine syrup
clarithromycin
clarithromycin xl
loratadine tablet
loratadine-pseudoephedrine
loratadine ODT
loratadine syrup
naphazoline/glycerin
clemastine fumarate
clindamycin vaginal suppository
estradiol weekly patch
NC
NC
1
1
NC
NC
NC
NC
NC
1
2
2
Respiratory
Respiratory
Infectious Disease
Infectious Disease
Respiratory
Respiratory
Respiratory
Respiratory
Opthalmic/Otic
Respiratory
Infectious Disease
Endocrine
CLIMARA PRO
estradiol/levonorgestrel transdermal
2
Endocrine
CLINDACIN P
clindamycin phosphate
1
Dermatologic
CLINDAGEL
2
Dermatologic
clindamycin
clindamycin phosphate/benzoyl
peroxide
clindamycin topical
clindamycin
clindamycin phosphate/benzoyl
peroxide
clindamycin
1
1
Infectious Disease
Dermatologic
1
Dermatologic
clindamycin vaginal
clobetasol propionate
clobetasol propionate emollient
CLOBEX spray
clindamycin vaginal cream
clobetasol propionate emollient
1
1
1
2
Infectious Disease
Dermatologic
Dermatologic
Dermatologic
CLODERM
clocortolone pivalate
3
Dermatologic
clomiphene citrate (CLOMID Equiv)
clomiphene citrate
1
Endocrine
clomipramine
clonazepam (KLONOPIN equiv)
clonazepam ODT (KLONOPIN ODT
equiv)
clonidine patch (CATAPRES-TTS equiv)
clonidine tablets
clopidogrel (PLAVIX equiv)
clomipramine
clonazepam
clonazepam ODT
1
1
NC
CNS
CNS
CNS
clonidine patch
clonidine tablets
clopidogrel
NC
1
1
Cardiovascular
Cardiovascular
Cardiovascular
clorazepate
CLORPRES
clotrimazole topical
clorazepate
chlorthalidone/clonidine
clotrimazole
1
NC
1
CNS
Cardiovascular
Dermatologic
clotrimazole troche (MYCELEX troche
equiv)
clotrimazole/betamethasone
(LOTRISONE cream equiv)
clozapine (CLOZARIL equiv)
codeine sulfate
CO-GESIC
COGNEX
clotrimazole troche
1
Infectious Disease
dipropionate
clozapine
codeine
hydrocodone/acetaminophen
tacrine
1
Dermatologic
1
1
1
NC
TS
CNS
CNS
CNS
CNS
COLCRYS
colchicine
2
QL-60
colestipol granules, tablets (COLESTID
equiv)
colistimethate
COLY-MYCIN S OTIC
colestipol granules, tablets
1
Oncology
Immunology
Cardiovascular
Potency
Antipsychotics
Narcotics
Narcotics
Alzheimer's Disease/Other
Immunosuppressants
colistin (colistimethate NA)
neomycin/colistin sulfate/
hydrocortisone otic
brimonidine/timolol opth
4
NC
SP
Infectious Disease
Ophthalmic/Otic
Macrolide/Ketolide
2
QL-2
Ophthalmic/Otic
Glaucoma
COMBIGAN
TS
NTI
ST=Step therapy
AL=Age Limit
PF=Partial Fill
TS=Tab Splitting
Adrenergics
Adrenergics
Antianxiety
Adrenergics
Anti-Fungals
16
Alphabetical Index
Medication Name
Generic Name
Tier
Special
Code
Drug Class
Subclass
Endocrine
Oncology/Cancer
Multiple Sclerosis
Antiviral-Hepatitis
Potency
Potency
Beta Blockers
Immunosuppressants
Miscellaneous
Immunosuppressants
COMBIPATCH
estradiol/norethindrone patch
2
COMBIVENT RESPIMAT
COMETRIQ
COMPLERA
CONCERTA
CONDYLOX
albuterol-ipratropium inhaler
cabozantinib
emtricitab/rilpivirine/tenofov
methylphenidate ER
podofilox gel
3
4
4
NC
2
QL-2
PA
Respiratory
Oncology
Infectious Disease
CNS
Dermatologic
COPAXONE
COPEGUS
CORDRAN
glatiramer acetate
ribavirin
flurandrenolide
4
NC
2
SP
CNS
Infectious Diesease
Dermatologic
CORDRAN SP
flurandrenolide
3
COREG CR
CORTEF
carvedilol CR
hydrocortisone
2
3
CORTIFOAM
cortisone acetate
hydrocortisone rectal foam
cortisone acetate
2
1
CORTISPORIN
2
COSOPT
COSOPT PF
COTAB A
COUMADIN
neomycin/bacitracin/polymyxin/
hydrocortisone ointment
dorzolamide/timolol ophthalmic
dorzolamide/timolol/pf
chlorphinerimine/codeine
warfarin
COVARYX
esterified estrogens/methyltestosterone
1
Endocrine
COVARYX H.S.
esterified estrogens/methyltestosterone
1
Endocrine
CREON
CRESTOR
CRINONE
amylase/lipase/protease
rosuvastatin
progesterone gel
2
2
4
CRIXIVAN
cromolyn (GASTROCROM equiv)
cromolyn nebulizer solution
cromolyn opth (CROLOM equiv)
CRYSELLE (LO-OVRAL equiv)
CUPRIMINE
indinavir
cromolyn
cromolyn nebulizer solution
cromolyn opth
norgestrel/ethinyl estradiol
penicillamine
4
1
1
1
$0
2
CUTIVATE (CREAM AND
OINTMENT)
CYANOCOBALAMIN INJECTION
fluticasone propionate (cream and
ointment)
cyanocobalamin inj
NC
Dermatologic
1
Endocrine
CYCLAFEM
CYCLESSA 777
cyclobenzaprine (FLEXERIL equiv)
CYCLOGYL
CYCLOMYDRIL
cyclopentolate ophth (CYCLOGYL
equiv)
cyclophosphamide
CYCLOSET
cyclosporine (NEORAL/GENGRAF
Equiv)
cyclosporine (SANDIMMUNE equiv)
cyclobenzaprine
cyclopentolate opth
cyclopentolate/phenylephrine ophth
cyclopentolate
$0
NC
1
2
2
1
Endocrine
Endocrine
CNS
Opthalmic/Otic
Ophthalmic/Otic
Ophthalmic/Otic
cyclophosphamide
cyclosporine modified
1
3
4
Oncology
Endocrine
Oncology
cyclosporine
4
Oncology
CYMBALTA 20 MG & 60 MG
CYMBALTA 30MG
cyproheptadine
CYSTADANE
CYSTAGON
CYTOMEL
D.H.E.45
DALIRESP
danazol (DANOCRINE equiv)
duloxetine
duloxetine
cyproheptadine
betaine
cystamine bitartrate
liothyronine
dihydroergotamine
roflumilast
danazol
NC
NC
1
2
4
2
2
2
1
CNS
CNS
Respiratory
Oncology
Genitourinary
Endocrine
CNS
Respiratory
Endocrine
NC
3
2
2
Dermatologic
PA,QL-45
Cardiovascular
Oncology
Gastroenterology
Oncology
QL-2
Ophthalmic/Otic
NTI
Ophthalmic/Otic
Ophthalmic
Respiratory
Cardiovascular
QL-750
QL-45,TS
PA,SP
QL-2
QL-2
QL-2
PA,SP
Gastroenterology
Cardiovascular
Endocrine
Infectious Disease
Gastroenterology
Respiratory
Ophthalmic/Otic
Endocrine
Oncology
ST=Step therapy
AL=Age Limit
PF=Partial Fill
TS=Tab Splitting
Glaucoma
Glaucoma
Cough and Cold
Hormone Replacement Estrogens/Progestins
Hormone Replacement Estrogens/Progestins
Cholesterol Lowering - Statins
Hormone Replacement Testosterone/Progesterone
Eye Allergy
Immunosuppressants
Corticosteroids Electrolytes/Minerals/Supplements
- Prescription Only
Other Miscellaneous Eye Products
Oncology/Cancer
Other Hormones
Immunosuppressants
Immunosuppressants
Oncology/Cancer
Other Genitourinary
Migraine
Oral Respiratory
17
Alphabetical Index
Medication Name
Generic Name
Tier
Special
Code
Drug Class
Subclass
CNS
Infectious Disease
Infectious Disease
CNS
Endocrine
Dermatologic
dantrolene (DANTRIUM equiv)
dapsone
DARAPRIM
DAYTRANA
DDAVP
DELOS
dantrolene
dapsone
pyrimethamine
methylphenidate patch
desmopressin
benzoyl peroxide
1
1
2
2
NC
2
DELZICOL
DEMADEX
demeclocycline
DEMSER
DEMULEN
DEPAKENE
DEPAKOTE
DEPAKOTE ER
DEPAKOTE SPRINKLES
DEPEN
mesalamine 400mg
torsemide
demeclocycline
metyrosine
ethynodiol/ethinyl estradiol
valproic acid
divalproex sodium
divalproex sodium er
divalproex sodium sprinkle
penicillamine
2
3
1
1
NC
NC
2
2
2
2
DEPO PROVERA
DEPO-TESTOSTERONE
medroxyprogesterone acetate inj
testosterone cypionate injection
NC
NC
Endocrine
Endocrine
DERMA-SMOOTH-FS
fluocinolone/shower cap
NC
Dermatologic
DERMATOP
desipramine
desloratadine ODT (CLARINEX
REDITABS equiv)
desloratadine tablets (CLARINEX
equiv)
desmopressin
desonide (DESONATE equiv)
DESOWEN
prednicarbate
desipramine
desloratadine ODT
NC
1
NC
Dermatologic
CNS
Respiratory
Macrolide/Ketolide
Anti-Malarials
Diuretics
Sulfonamides/Tetracyclines
Miscellaneous Antihypertensives
Anticonvulsants
Anticonvulsants
Anticonvulsants
Anticonvulsants
Immunosuppressants
Contraceptives : Other
Corticosteroids
desloratadine
3
Respiratory
desmopressin actate
desonide
desonide emollient combo
1
1
NC
Endocrine
Dermatologic
Dermatologic
desoximetasone
desoximetasone
1
Dermatologic
DESOXYN
DETROL LA
dexamethasone
methamphetamine
tolterodine
dexamethasone
NC
NC
1
CNS
Genitourinary
Oncology
DEXAMETHASONE INTENSOL
dexamethasone drops
1
Oncology
dexamethasone opth
dexchlorpheniramine
DEXILANT
dexmethylphenidate (FOCALIN equiv)
dexmethylphenidate XR (FOCALIN XR
equiv)
DEXPAK
dexamethasone opth
dexchlorpheniramine
dexlansoprazole
dexmethylphenidate
dexmethylphenidate XR
1
NC
3
1
2
Corticosteroids - Low Potency
Potency
Potency
Immunosuppressants
Immunosuppressants
dexamethasone
2
Oncology
dextroamphetamine (DEXEDRINE
equiv)
DIALYVITE
dextroamphetamine
1
CNS
folic acid/vitamin B complex
NC
Endocrine
diazepam
diazepam rectal gel (DIASTAT equiv)
DIBENZYLINE
diazepam
diazepam rectal gel
phenoxybenzamine
1
4
2
CNS
CNS
Cardiovascular
diclofenac ophth (VOLTAREN ophth
equiv)
diclofenac potassium (CATAFLAM
equiv)
diclofenac sodium (VOLTAREN equiv)
diclofenac opth
1
diclofenac potassium
3
CNS
diclofenac sodium
1
CNS
diclofenac sodium gel (SOLARAZE
equiv)
diclofenac sodium
4
QL-30
NTI
NTI
NTI
QL-2
ST, QL-90
ST, QL-30
QL-2
PA
Gastroenterology
Cardiovascular
Infectious Disease
Cardiovascular
Endocrine
CNS
CNS
CNS
CNS
Oncology
Ophthalmic/Otic
Respiratory
Gastroenterology
CNS
CNS
Ophthalmic/Otic
Dermatologic
ST=Step therapy
AL=Age Limit
PF=Partial Fill
TS=Tab Splitting
osuppressants
- Prescription Only
Antianxiety
Anticonvulsants
Vasodilators/Nitrates/Miscellaneo
us Cardiovascular
Medications
Medications
18
Alphabetical Index
Medication Name
Generic Name
Tier
Special
Code
Drug Class
Subclass
CNS
Medications
Penicillins
Osteoporosis - Bisphosphonates
Potency
Medications
Antiarrhythmics
Migraine
diclofenac sodium SR
diclofenac sodium SR
NC
dicloxacillin
dicyclomine
didanosine (VIDEX equiv)
DIDRONEL
DIFFERIN (3% Gel Only)
dicloxacillin
dicyclomine
didanosine
etidronate
adapalene
1
1
4
NC
2
DIFICID
diflorasone diacetate
fidaxomicin
diflorasone diacetate
4
1
diflunisal
diflunisal
1
digoxin (LANOXIN equiv)
dihydroergotamine injection (D.H.E.
equiv)
DILANTIN
DILATRATE-SR
digoxin
dihydroergotamine injection
1
1
NTI
Cardiovascular
CNS
phenytoin
isosorbide dinitrate
2
2
NTI
CNS
Cardiovascular
DILT-CD
diltiazem (CARDIZEM equiv)
diltiazem ER
diltiazem LA (CARDIZEM LA equiv)
diltiazem XR (DILACOR XR equiv)
DILTZAC ER
DIPENTUM
diphenhydramine
diphenoxylate/atropine (LOMOTIL
equiv)
DIPROLENE
DILTIAZEM HCL
diltiazem
diltiazem
diltiazem LA
diltiazem XR
diltiazem
olsalazine
diphenhydramine
diphenoxylate/atropine
1
1
1
NC
1
1
2
1
1
Cardiovascular
Cardiovascular
Cardiovascular
Cardiovascular
Cardiovascular
Cardiovascular
Gastroenterology
Respiratory
Gastroenterology
NC
Dermatologic
dipyridamole
dipyridamole
1
Cardiovascular
disopyramide
disulfiram (ANTABUSE equiv)
divalproex sodium
DIVIGEL
disopyramide
disulfiram
divalproex sodium (ir, er, sprinkle caps)
estradiol topical gel
1
1
1
NC
Cardiovascular
CNS
CNS
Endocrine
DOLGIC PLUS
donepezil (ARICEPT equiv), except
23mg
DORYX
dorzolamide ophth (TRUSOPT equiv)
dorzolamide/timolol ophth (COSOPT
equiv)
DOVONEX SOLUTION
butalbitol/acetaminophen/caffeine
donepezil
2
1
doxycycline hyclate
dorzolamide ophth
dorzolamide/timolol ophth
NC
1
1
calcipotriene
NC
Dermatologic
doxazosin (CARDURA equiv)
doxepin
doxycycline capsules
doxycycline hyclate
DRITHOCREME HP
DRITHO-SCALP
doxazosin
doxepin
doxycycline monohydrate
doxycycline hyclate
anthralin
anthralin
1
1
1
1
2
NC
Cardiovascular
CNS
Dermatologic
Infectious Disease
Dermatologic
Dermatologic
dronabinol (MARINOL equiv)
drospirone/ethinyl estradiol
DROXIA
DUAVEE
dronabinol
drospirone/ethinyl estradiol
hydroxyurea
bazedoxifene
4
$0
2
2
Gastroenterology
Endocrine
Oncology
Endocrine
DUEXIS
DULCOLAX STOOL SOFTENER
DULERA
duloxetine (20mg,60mg)
duloxetine (30mg)
DUONEB
DUREZOL
DUTOPROL
ibuprofen/famotidine
docusate sodium
mometasone/formoterol
duloxetine
duloxetine
albuterol-ipratropium nebulizer solution
difluprednate ophth
metoprolol succinate/HCTZ
NC
1
2
2
2
NC
3
2
Gastroenterology
Gastroenterology
Respiratory
CNS
CNS
Respiratory
Ophthalmic/Otic
Cardiovascular
Infectious Disease
Gastroenterology
Infectious Disease
Endocrine
Dermatologic
PA,SP
NTI
Infectious Disease
Dermatologic
CNS
NTI
CNS
CNS
QL-2
QL-2
QL-60
QL-30
PA
Dermatologic
Ophthalmic/Otic
Ophthalmic/Otic
ST=Step therapy
AL=Age Limit
PF=Partial Fill
TS=Tab Splitting
Anticonvulsants
us Cardiovascular
Potency
Antiarrhythmics
Anticonvulsants
Hormone Replacement - Topical
Estrogen/Progestin
Migraine
Oral Acne
Glaucoma
Glaucoma
Adrenergics
Oral Acne
Other Topical Agents?
Nausea/Vomiting
Oncology/Cancer
Estrogen/Progestin
Beta Blockers
19
Alphabetical Index
Medication Name
Generic Name
Tier
Special
Code
Drug Class
Subclass
Respiratory
Antihistamines
Diuretics
Diuretics
Hypnotics
Macrolide/Ketolide
DYMISTA
azelastine/fluticasone nasal
NC
DYNACIRC CR
DYRENIUM
econazole nitrate topical
isradipine CR
triamterene
econazole nitrate
NC
2
1
EDECRIN
EDEX
EDULAR
EDURANT
EES, ERYPRED
EFFEXOR
EFFEXOR XR
EFFIENT
ethacrynic acid
alprostadil intracavernous
zolpidem sublingual
rilpivirine
erythromycin ethyl succinate
venlafaxine
venlafaxine ER
prasugrel
3
NC
NC
4
NC
NC
NC
2
EFUDEX
fluorouracil
3
EGRIFTA
ELESTAT
ELESTRIN
tesamorelin acetate
epinastine opth
4
3
NC
ELIDEL
pimecrolimus
2
ELIGARD
ELIMITE
leuprolide
permetherin topical
4
NC
ELINEST
ELIQUIS
apixaban
$0
2
Endocrine
Cardiovascular
ELIXOPHYLLIN
ELLA
ELMIRON
ELOCON
theophylline
ulipristal
pentosan polysulfate sodium
mometasone furoate
2
$0
2
NC
Respiratory
Endocrine
Genitourinary
Dermatologic
EMADINE
EMBEDA
EMCYT
EMEND
EMGEL
emedastine opth
morphine sulfate/naltrexone
estramustine
aprepitant
erythromycin base/ethanol
2
NC
4
2
1
EMLA
lidocaine/prilocaine
3
EMOQUETTE
EMSAM
EMTRIVA
ENABLEX
enalapril
enalapril/HCTZ
ENBREL
selegiline patch
emtricitabine
darifenacin
enalapril
enalapril/HCTZ
etanercept
$0
3
4
3
1
1
4
ENCORA
multivitamins with iron
NC
Endocrine
ENDOMETRIN
progesterone suppository
NC
Endocrine
ENDURANT
ENJUVIA
rilpivirine
NC
NC
Infectious Disease
Endocrine
enoxaparin (LOVENOX equiv)
enoxaparin
4
ENPRESSE (TRIPHASIL equiv)
entacapone (COMTAN equiv)
entecavir
ENTOCORT EC
entacapone
entecavir
budesonide
$0
1
4
NC
Cardiovascular
Cardiovascular
Dermatologic
ST
QL-30
Cardiovascular
Miscellaneous
CNS
Infectious Disease
Infectious Disease
CNS
CNS
Cardiovascular
Dermatologic
PA
Endocrine
Opthalmic/Otic
Endocrine
Dermatologic
PA,SP
QL-2
PA
PA,QL-6
Endocrine
Dermatologic
Ophthalmic/Otic
CNS
Oncology
Gastroenterology
Dermatologic
Dermatologic
PA
ST, PA,SP
QL-28
syr/14
ds,SP
SP
Endocrine
CNS
Infectious Disease
Genitourinary
Cardiovascular
Cardiovascular
Gastroenterology
Cardiovascular
Endocrine
CNS
Infectious Disease
Gastroenterology
ST=Step therapy
AL=Age Limit
PF=Partial Fill
TS=Tab Splitting
Other Miscellaneous Hormones
Eye Allergy
Estrogen/Progestin
Conceptives : Monophasic
Other Contraceptives
Other Genitourinary
Potency
Eye Allergy
Narcotics
Oncology/Cancer
Nausea/Vomiting
ACE-Inhibitors
ACE-Inhibitors
- Prescription Only
Estrogen/Progestin
Parkinson's Disease
20
Alphabetical Index
Medication Name
Generic Name
Tier
Special
Code
Drug Class
Subclass
Dermatologic
Eye Allergy
Anticonvulsants
Diuretics
Antipsychotics
Calcium Metabolism/
Calcium Metabolism/
Peripheral Vasodialators
Migraine
Migraine
Cancer
Contraceptives : Progestin-Only
Macrolide/Ketolide
Macrolide/Ketolide
Macrolide/Ketolide
Macrolide/Ketolide
Macrolide/Ketolide
Macrolide/Ketolide
Eye Anti-infectives
Macrolide/Ketolide
Macrolide/Ketolide
Proton Pump Inhibitors/Ulcer
Estrogen/Progestin
Hypnotics
Estrogen/Progestin
Estrogen/Progestin
Estrogen/Progestin
Estrogen/Progestin
Estrogen/Progestin
Estrogen/Progestin
Estrogen/Progestin
EPIDUO
adapalene/benzoyl peroxide
NC
epinastine (ELESTAT equiv)
epinephrine injection
EPIPEN, EPIPEN JR
EPITOL
EPIVIR
eplerenone
EPOGEN
epinastine opth
carbamazepine
lamivudine
eplerenone
erythropoeitin
3
NC
2
1
4
NC
4
eprosartan (TEVETEN equiv)
EPZICOM
EQUETRO
ergocalciferol
eprosartan
abacavir/lamivudine
carbamazepine
ergocalciferol (vitamin D2)
NC
4
NC
$0
ergocalciferol 50,000 unit capsule
1
Endocrine
ergoloid mesylates
ERGOMAR
ergotamine/caffeine
ERIVEDGE
ERRIN (ORTHO MICRONOR)
ERTACZO
ergoloid mesylates
ergotamine tartrate
ergotamine/caffeine
vismodegib
norethindrone
sertaconazole nitrate
1
2
1
4
$0
2
Cardiovascular
CNS
CNS
Oncology
Endocrine
Dermatologic
ERY
1
Dermatologic
ERYPED
ERY-TAB
ERYTHROCIN
erythromycin
ERYTHROMYCIN
erythromycin ophth
erythromycin topical
erythromycin ethylsuccinate
erythromycin base
erythromycin stearate
erythromycin base
erythromycin ophth
erythromycin topical
2
2
2
1
1
1
1
1
Infectious Disease
Infectious Disease
Infectious Disease
Infectious Disease
Infectious Disease
Infectious Disease
Ophthalmic/Otic
Dermatologic
1
Dermatologic
erythromycin/sulfisoxazole
ERYTHROMYCIN-SULFISOXAZOLE
escitalopram (LEXAPRO equiv)
esomeprazole (NEXIUM equiv)
essian
1
1
1
3
NC
Infectious Disease
Infectious Disease
CNS
Gastroenterology
Endocrine
estazolam
ESTRACE
erythromycin/sulfisoxazole
erythromycin succinate/sulfisoxazole
escitalopram
esomeprazole
esterified estrogen/methyltestosterone
tab
estazolam
estradiol vaginal cream
1
2
CNS
Endocrine
ESTRADERM
NC
Endocrine
estradiol patch
estradiol patch
1
Endocrine
estradiol tab
estradiol tab
1
Endocrine
estradiol/norethindrone tab
(ACTIVELLA equiv)
ESTRASORB
1
Endocrine
NC
Endocrine
ESTRING
estradiol vaginal ring
2
ESTROGEL
NC
Endocrine
estropipate tab
estropipate tab
1
Endocrine
ESTROSTEP FE
norethindrone acetate/ethinyl
estradiol/iron fumarate
eszopiclone
ethambutol
ethinyl estradiol/norethindrone tab
3
Endocrine
1
1
2
CNS
Infectious Disease
Endocrine
ethosuximide
1
CNS
eszopiclone (LUNESTA equiv)
ethambutol
(FEMHRT equiv)
ethosuximide
QL-4
NTI
SP
PA,QL4,SP
AL>64
PA,SP
QL-2
TS,QL-45
ST
QL-1
Ophthalmic/Otic
Respiratory
Respiratory
CNS
Antivirals
Cardiovascular
Cardiovascular
Cardiovascular
Infectious Disease
CNS
Endocrine
Endocrine
ST=Step therapy
AL=Age Limit
PF=Partial Fill
TS=Tab Splitting
Hypnotics
Anti-TB
Estrogen/Progestin
Anticonvulsants
21
Alphabetical Index
Medication Name
Generic Name
Tier
Special
Code
Drug Class
Subclass
Endocrine
CNS
Medications
Medications
Oncology/Cancer
Estrogen/Progestin
Calcium Metabolism/
Oncology/Cancer
- Prescription Only
Multiple Sclerosis
Quinolones
Other Antiviral
Antipsychotics
Anti-Malarials
Oncology/Cancer
Diabetes – Other Oral
Oncology/Cancer
Antipsychotics
Anticonvulsants
etidronate
etodolac
etidronate
etodolac
1
1
etodolac SR
etodolac SR
NC
etoposide
EURAX
etoposide
crotamiton topical
4
2
EVAMIST
estradiol spray
NC
Endocrine
EVISTA
raloxifene
NC
Endocrine
EVOCLIN
NC
Dermatologic
EXELDERM
sulconazole nitrate
2
Dermatologic
EXELON
rivastigmine
NC
CNS
EXELON PATCH
rivastigmine transdermal
2
CNS
exemestane
EXFORGE HCT
EXJADE
exemestane
amlodipine/valsartan/HCTZ
deferasirox
4
NC
4
PA
EXTAVIA
FACTIVE
FALMINA
famciclovir
famotidine
FANAPT
FANSIDAR
FARESTON
FARXIGA
FASLODEX
FAZACLO ODT
felbamate (FELBATOL equiv)
felodipine
FEMCON FE CHEWABLE
4
NC
$0
1
1
2
NC
4
3
4
NC
2
1
NC
PA,SP
FEMRING
interferon beta 1b
gemifloxacin
famciclovir
famotidine
iloperidone
pyrimethamine/sulfadoxine
toremifene
dapagliflozin
fulvestrant
clozapine ODT
felbamate
felodipine
estradiol vaginal ring
2
QL-1
FEMTRACE
estradiol acetate
3
Endocrine
fenofibrate
fenofibrate (ANTARA equiv)
fenofibrate (FENOGLIDE equiv)
fenofibrate (Lofibra equiv)
fenofibrate (TRICOR equiv)
fenoprofen
fenofibrate
fenofibrate micronized
fenofibrate
fenofibrate
fenofibrate
fenoprofen
1
1
NC
1
1
3
Cardiovascular
Cardiovascular
Cardiovascular
Cardiovascular
Cardiovascular
CNS
fentanyl citrate
fentanyl patches
FENTORA
FER-IN-SOL
fentanyl citrate lozenge
fentanyl patches
fentanyl oral
ferrous sulfate
3
1
NC
$0
FER-IRON
ferrous sulfate
$0
FEROTRIN
iron fumarate/vitamin c/b12
2
ferrex 150 forte
iron polysaccharide
NC
Endocrine
ferrex 150 forte plus
iron/vitamin c/b12/calcium
NC
Endocrine
ferrex 28
iron/vitamin c/b12
NC
Endocrine
CNS
PA
SP
PA
PA
QL-60
QL-10
AL
(6mos6yrs)
AL
(6mos6yrs)
Oncology
Dermatologic
Oncology
Cardiovascular
Endocrine
CNS
Infectious Disease
Endocrine
Infectious Disease
Gastroenterology
CNS
Infectious Disease
Oncology
Endocrine
Oncology
CNS
CNS
Cardiovascular
Endocrine
Endocrine
CNS
CNS
CNS
Endocrine
Estrogen/Progestin
Estrogen/Progestin
Cholesterol Lowering - Fibrates
Medications
Narcotics
Narcotics
Narcotics
- Prescription Only
Endocrine
- Prescription Only
Endocrine
- Prescription Only
- Prescription Only
- Prescription Only
- Prescription Only
ST=Step therapy
AL=Age Limit
PF=Partial Fill
TS=Tab Splitting
22
Alphabetical Index
Medication Name
Generic Name
Tier
Special
Code
Drug Class
Subclass
Endocrine
- Prescription Only
- Prescription Only
- Prescription Only
- Prescription Only
FERROCITE
ferous fumarate
1
FERROGELS FORTE
iron/vitamin c/b12/FA
1
Endocrine
ferrous fumarate
ferrous fumarate
1
Endocrine
ferrous sulfate
serrous sulfate
1
Endocrine
fexofenadine tablet (ALLEGRA equiv)
fexofenadine-pseudoephedrine (12 &
24 hour) (ALLEGRA-D equiv)
FIBRICOR
FINACEA
fexofenadine tablet
fexofenadine-pseudoephedrine (12 & 24
hour)
fenofibric acid
azelaic acid
NC
NC
Respiratory
Respiratory
NC
2
AL>35
Endocrine
Dermatologic
FINACEA PLUS
azelaic acid/ceramide
2
AL>35
Dermatologic
finasteride
FIORINAL
FIRAZYR
finasteride
aspirin/butalbital/caffeine
icatibant
1
NC
4
SP,PA
Genitourinary
CNS
Oncology
FIRMAGON
FIRST-BXN
degarelix
nystatin/lidocaine/diphenhyd
NC
2
FIRST-MOUTHWASH BLM
FIRST-OMEPRAZOLE
Fish Oil, Omega-3 Soft Gel
FLAREX
flavoxate
flecainide
FLECTOR PATCH
MG/AL/simeth/diphenhyd/lidocaine
omeprazole compound kit
Fish Oil, Omega-3 Soft Gel
fluorometholone
flavoxate
flecainide
diclofenac epolamine topical
2
NC
NC
2
1
1
NC
FLEXERIL
FLOVENT DISKUS
FLOVENT HFA
FLUCAINE
fluconazole
flucytosine (ANCOBON equiv)
fludrocortisone
cyclobenzaprine
fluticasone proprionate
fluticasone proprionate
proparacine/fluorescein opth
fluconazole
flucytosine
fludrocortisone
3
3
3
2
1
1
1
FLUMIST
flunisolide nasal (NASAREL equiv)
influenza A and B nasal mist
flunisolide nasal
$0
3
fluocinolone
fluocinolone otic (DERMOTIC equiv)
fluocinolone w/ shower cap
fluocinonide
fluocinolone
fluocinolone otic
fluocinolone w/ shower cap
fluocinonide
1
1
1
1
FLUOCINONIDE-E
FLUORABON
fluosinonide emollient
sodium fluoride
1
$0
AL
Dermatologic
Endocrine
FLUOR-A-DAY
sodium fluoride
$0
AL
Endocrine
FLUOR-A-DAY
sodium fluoride/Xylitol
2
FLUORIDE
sodium fluoride
$0
AL
Endocrine
FLUORITAB
sodium fluoride
$0
AL
Endocrine
fluorometholone opth
FLUOROPLEX
fluorometholone opth
fluorouracil
1
2
QL-2
Ophthalmic/Otic
Dermatologic
fluorouracil topical
fluorouracil
1
Dermatologic
fluoxetine (10,20, and 40mg)
fluoxetine (60mg)
fluoxetine
fluoxetine
1
NC
CNS
CNS
SP
Oncology
Dermatologic
Miscellaneous Dental
Gastroenterology
Cardiovascular
Opthalmic/Otic
Gastroenterology
Cardiovascular
CNS
ST
ST
ST
QL-2
CNS
Respiratory
Respiratory
Opthalmic/Otic
Infectious Disease
Infectious Disease
Oncology
Vaccines
Respiratory
Dermatologic
Ophthalmic/Otic
Dermatologic
Dermatologic
Endocrine
ST=Step therapy
AL=Age Limit
PF=Partial Fill
TS=Tab Splitting
Migraine
Immunosuppressants
Oncology/Cancer
Topical Analgesic (Oral)
Antiarrhythmics
Medications
Miscellaneous Eye Products
Anti-Fungals
Anti-Fungals
Immunosuppressants
Miscellaneous Vaccines
Antihistamines
Corticosteroids
Potency
Corticosteroids
- Prescription Only
Electrolytes/Minerals/
Supplements - Prescription Only
- Prescription Only
23
Alphabetical Index
Medication Name
Generic Name
Tier
Special
Code
Drug Class
Subclass
PA
Endocrine
AL
CNS
CNS
Miscellaneous
CNS
CNS
Antipsychotics
Antipsychotics
FLUORIDE PREPARATIONS
Hypnotics
Medications
Miscellaneous
Oncology/Cancer
Corticosteroids – Medium to
High Potency
Antihistamines
Potency
- Prescription Only
- Prescription Only
- Prescription Only
Diabetes - Other Oral
Calcium Metabolism/
ACE-Inhibitors
ACE-Inhibitors
Migraine - Triptans
Diuretics
Anticonvulsants
Anticonvulsants
- Prescription Only
fluoxymesterone
fluoxymesterone
1
fluphenazine decanoate
fluphenazine HCL
FLURA-DROPS
flurazepam
flurbiprofen
fluphenazine decanoate
fluphenazine
sodium fluoride
flurazepam
flurbiprofen
1
1
$0
1
1
flurbiprofen 0.03% ophthalmic solution
FLURIA
flutamide
fluticasone propionate lotion
(CUTIVATE equiv)
fluticasone propionate nasal (FLONASE
equiv)
fluticasone topical
flurbiprofen ophth
influenza A and B vaccine
flutamide
fluticasone propionate lotion
1
$0
1
1
QL-2
Ophthalmic/Otic
Vaccines
Oncology
Dermatologic
fluticasone nasal
1
QL-2
Respiratory
fluticasone propionate
1
fluvastatin (LESCOL equiv)
FLUVIRIN
fluvoxamine (LUVOX equiv)
FLUZONE
FML DROPS
FML FORTE DROPS
FML LIQUIFILM
FML S.O.P.
FOLASTIN
fluvastatin
influenza A and B vaccine
fluvoxamine
Influenza A and B vaccine
fluoromethalone ophth
cyanocobalamin/iron/pyridoxine
3
$0
1
$0
NC
2
NC
2
1
QL-30
folic acid
folic acid (0.4mg, 0.8mg, 1mg)
$0
(women)
folic acid
folic acid
1
FOLINATAL PLUS B
prenatal vitamin preparation
$0
folitab
ferrous sulfate/vitamin c/iron
NC
FOLLISTIM AQ
follitropin
NC
FOLPACE RX
vitamin B preparation
2
Endocrine
FOLTABS PRENATAL+DHA
prenatal multivitamin
NC
Endocrine
FOLTX
cyanocobalamin/folic acid/pyridoxine
NC
Endocrine
fondaparinux (ARIXTRA equiv)
fondaparinux
4
FORADIL
FORFIVO XL
FORTAMET
FORTEO
formoterol inhaler
bupropion HCl
metformin ER
teriparatide
2
NC
NC
4
FORTESTA
testosterone gel
NC
Endocrine
FOSAMAX SOLUTION
FOSAMAX-D
fosinopril
fosinopril/HCTZ
FOSRENOL
alendronate solution
alendronate/vit d
fosinopril
fosinopril/HCTZ
lanthanum
NC
NC
3
NC
2
Endocrine
Endocrine
Cardiovascular
Cardiovascular
Endocrine
FRAGMIN
dalteparin
4
FROVA
furosemide
FUZEON
gabapentin
GABITRIL
galantamine
frovatriptan
furosemide
enfurvitide
gabapentin
tiagabine
galantamine
3
1
4
1
2
1
GALZIN
zinc acetate
NC
Dermatologic
QL-90,TS
QL-2
QL-2
QL-2
QL-2
Cardiovascular
Vaccines
CNS
Vaccines
Ophthalmic/Otic
Ophthalmic/Otic
Ophthalmic/Otic
Opthalmic/Otic
Endocrine
Endocrine
Endocrine
(women)
Endocrine
Endocrine
SP
PA,QL4,SP
QL-2
PA,SP
PA,QL28,SP
ST
TS
PA
Endocrine
Cardiovascular
Respiratory
CNS
Endocrine
Endocrine
Cardiovascular
CNS
Cardiovascular
Infectious Disease
CNS
CNS
CNS
Endocrine
ST=Step therapy
AL=Age Limit
PF=Partial Fill
TS=Tab Splitting
24
Alphabetical Index
Medication Name
Generic Name
Tier
Special
Code
Drug Class
Subclass
Infectious Disease
Endocrine
Gastroenterology
Gastroenterology
Endocrine
Miscellaneous GI
Miscellaneous, Oral
NC
1
NC
Genitourinary
Cardiovascular
Endocrine
4
Oncology
Immunosuppressants
Growth Hormones
Eye Anti-infectives
ganciclovir
ganirelix
ganciclovir
ganirelix
NC
4
GATTEX
GAVILYTE-C
GELCLAIR
NC
1
NC
GENGRAF
teduglutide
polyethylene glycol/electrolyte packets
sodium hyaluronate/ pvp/glyrrhetinic
acid
oxybutynin topical
gemfibrozil
estradiol/iron fumarate chewable
GENOTROPIN
gentamicin opth
gentamicin topical
somatropin
gentamicin opth
gentamicin
NC
1
1
QL-2
Endocrine
Ophthalmic/Otic
Dermatologic
GENTEAL
3
OTC
Opthalmic/Otic
GENTEAL MILD
GENTEAL MILD TO MODERATE
GENTEAL PM
GENTEAL SEVERE
GESTICARE
carboxymethylcellulose/hypromellose
opth
hypromellose opth
hypromellose opth
hypromellose opth oint
hypromellose opth gel
3
3
3
3
2
OTC
OTC
OTC
OTC
Opthalmic/Otic
Opthalmic/Otic
Opthalmic/Otic
Opthalmic/Otic
Endocrine
gianvi (YAZ equiv)
GILDESS FE (LOESTRIN FE equiv)
GILENYA
GILOTRIF
GLEEVEC
glimepiride (AMARYL equiv)
glipizide
glipizide ER (GLUCOTROL equiv)
GLUCAGON EMERGENCY KIT
GLUMETZA
glyburide (MICRONASE equiv)
glyburide micronized
glyburide/metformin
glycine
ethinyl estradiol/drospirenone
norethindrone acetate/ethinyl estradiol
fingolimod
afatanib dimaleate
imatinib
glimepiride
glipizide
glipizide ER
glucagon, human recombinant
metformin ER
glyburide
glyburide micronized
glyburide/metformin
glycine
NC
$0
4
4
4
1
1
1
2
NC
1
1
1
1
glycolic acid
glycopyrolate
GLYSET
GOLYTELY
GONAL-F
clycolic acid
glycopyrolate
miglitol
polyethylene glycol/electrolytes
follitropin
3
1
2
NC
NC
GORDO-UREA
urea
2
Dermatologic
GORMEL 10
urea
1
Dermatologic
GRALISE
gramicidin/neomycin/ polymyxin ophth
granisetron
GRANISOL
GRASTEK
GRIFULVIN (BRAND)
griseofulvin
GRISEOFULVIN
GRISEOFULVIN ULTRAMICROSIZE
GRIS-PEG
guaifenesin/codeine syrup
guanabenz
guanfacine
guanfacine ER (INTUNIV equiv)
GYNAZOLE-1
HALDOL DECANOATE
gabapentin SR
gramicidin/neomycin/polymyxin ophth
granisetron
granisetron
timothy grass pollen
griseofulvin
griseofulvin
griseofulvin, microsize
griseofulvin, ultramicrosize
griseofulvin
guaifenesin/codeine syrup
guanabenz
guanfacine
guanfacine ER
butoconazole vaginal cream
haloperidol decanoate
NC
1
NC
NC
4
NC
1
2
2
NC
1
NC
1
2
NC
NC
CNS
Ophthalmic/Otic
Gastroenterology
Gastroenterology
Respiratory
Infectious Disease
Infectious Disease
Infectious Disease
Infectious Disease
Infectious Disease
Respiratory
Cardiovascular
Cardiovascular
CNS
Infectious Disease
CNS
GELNIQUE
gemfibrozil
GENERESS FE
PA,SP
SP
PA,SP
PA
PA,SP
QL-30
SP
PA,SP
OTC
PA
Endocrine
Endocrine
Immunology
Oncology
Oncology
Endocrine
Endocrine
Endocrine
Endocrine
Endocrine
Endocrine
Endocrine
Endocrine
Infectious Disease
Dermatologic
Gastroenterology
Endocrine
Gastroenterology
Endocrine
ST=Step therapy
AL=Age Limit
PF=Partial Fill
TS=Tab Splitting
- Prescription Only
Multiple Sclerosis
Oncology/Cancer
Oncology/Cancer
Diabetes - Other
Diabetes - Combination Product
Anticonvulsants
Eye Anti-infectives
Nausea/Vomiting
Nausea/Vomiting
Anti-Fungals
Anti-Fungals
Anti-Fungals
Anti-Fungals
Anti-Fungals
Cough and Cold
Adrenergics
Adrenergics
Anti-Fungals
Antipsychotics
25
Alphabetical Index
Medication Name
Generic Name
HALFLYTELY BOWEL PREP
Tier
Special
Code
Drug Class
Subclass
Gastroenterology
Potency
Potency
Antipsychotics
Antipsychotics
Antipsychotics
Antiviral-Hepatitis
Antiviral - Hepatitis
Immunosuppressants
Calcium Metabolism/
- Prescription Only
- Prescription Only
- Prescription Only
- Prescription Only
Oncology/Cancer
Anti-Inflammatory
Immunology/Immunosupssants
Cough and Cold
Anticonvulsants
Injectables
Injectables
Growth Hormones
Injectables
Injectables
Injectables
Injectables
Oncology/Cancer
Cough and Cold
us Cardiovascular
Diuretics
Diuretics
Narcotics
Cough and Cold
Cough and Cold
Narcotics
NC
halobetasol
polyethylene
glycol/electrolytes/bisacodyl
halobetasol propionate
1
Dermatologic
HALOG
halcinonide
2
Dermatologic
haloperidol
haloperidol lactate
HARVONI
HARVONI
HEATHER
HECORIA
haloperidol
haloperidol lactate
sofosbuvir/ledipasvir
sofosbuvir/ledipasvir
norethindrone
tacrolimus
1
1
1
3
3
$0
NC
CNS
CNS
CNS
Infectious Diesease
Infectious Disease
Endocrine
Endocrine
HECTOROL
doxercalciferol
3
Endocrine
HEMATOGEN FA
iron fumarate/vitamin c/b12/folic acid
1
Endocrine
HEMATOGEN FORTE
iron fumarate/vitamin c/b12
1
Endocrine
HEMOCYTE
ferous fumarate
$0
Endocrine
HEMOCYTE-F
ferrous fumarate/folic acid
2
Endocrine
heparin sodium
heparin sodium
1
Cardiovascular
HEPSERA
HEXALEN
HIZENTRA
adefovir
altretamine
immuneglobulin
4
4
4
homatropine ophth
homatropone/hydrocodone
HORIZANT
HUMALOG
homatropine opth
hydrocodone/homatropine
gabapentin ER
insulin lispro
1
1
3
2
QL-2
QL-20
Ophthalmic/Otic
Respiratory
CNS
Endocrine
HUMALOG MIX 50/50
insulin NPL/insulin lispro
2
QL-20
Endocrine
HUMATROPE
HUMIRA
somatropin
adalimumab
NC
4
PA,SP
Endocrine
Gastroenterology
HUMULIN 50/50
human insulin mix
2
QL-20
Endocrine
HUMULIN 70/30
human insulin mix
2
QL-20
Endocrine
HUMULIN N
human insulin isophane
2
QL-20
Endocrine
HUMULIN R
human insulin
2
QL-20
Endocrine
HYCAMTIN
HYCODAN
hydralazine
topotecan
hydralazine HCL
4
3
1
PA, SP
Oncology
Respiratory
Cardiovascular
hydralazine/HCTZ
hydrochlorothiazide (HCTZ)
hydrocodone/chloriphenerimine
hydrocodone/ibuprofen
hydrocortisone
hydralazine/HCTZ
hydrochlorothiazide (HCTZ)
hydrocodone/chloripheniramine
hydrocortisone topical (cream, oint,
lotion)
NC
1
1
NC
1
NC
1
Cardiovascular
Cardiovascular
CNS
Respiratory
Respiratory
CNS
Dermatologic
hydrocortisone
hydrocortisone inj
1
Dermatologic
hydrocortisone
hydrocortisone acetate
hydrocortisone acetate
hydrocortisone (enema, rectal crm)
hydrocortisone rectal
hydrocortisone acetate (rectal foam and
lotion)
1
1
2
Gastroenterology
Gastroenterology
Gastroenterology
PA,ST,SP
PA,SP,ST
SP
PA
PA
Infectious Disease
Oncology
Immunology
ST=Step therapy
AL=Age Limit
PF=Partial Fill
TS=Tab Splitting
26
Alphabetical Index
Medication Name
Generic Name
Tier
Special
Code
Drug Class
Subclass
Gastroenterology
Immunosuppressants
Ear Antibacterials
hydrocortisone acetate suppositories
(10 and 25mg only, 30mg NC)
hydrocortisone butyrate
hydrocortisone oral
hydrocortisone rectal
1
hydrocortisone oral tabs
1
1
Dermatologic
Oncology
hydrocortisone valerate
hydrocortisone/acetic acid otic
(ACETASOL Equiv)
(ANAMANTLE, LIDAMANTLE equiv)
hydrocortisone/acetic acid otic
1
1
Dermatologic
Opthalmic/Otic
1
Dermatologic
(PRAMOSONE equiv)
1
Dermatologic
HYDROMET
hydromorphone
hydromorphone ER
hydroquinone
hydromorphone
hydromorphone
hydroquinone
1
1
NC
NC
Respiratory
CNS
CNS
Dermatologic
hydroxocobalamin
hydroxocobalamin
1
Endocrine
hydroxychloroquine
hydroxychloroquine
1
Oncology
hydroxyurea
hydroxyzine syrup
hydroxyzine tablet
hyoscyamine (LEVSIN equiv)
hyoscyamine CR (LEVBID equiv)
HYPERCARE
hydroxyurea
hydroxyzine syrup
hydroxyzine tablet
hyoscyamine
hyoscyamine cr
aluminum chloride
1
1
1
1
1
1
Oncology
Respiratory
Respiratory
Gastroenterology
Gastroenterology
Dermatologic
HYPOTEARS
ibandronate (BONIVA equiv)
ibuprofen
polyethylene glycol/pva opth drops
ibandronate
ibuprofen (Rx strengths only)
NC
3
1
Opthalmic/Otic
Endocrine
CNS
ibuprofen/oxycodone
ICLUSIG
IFEREX 150
ibuprofen/oxycodone
ponatanib hcl
iron polysaccaride complex
NC
4
1
IFEREX 150 FORTE
1
ILARIS
ILEVRO
IMBRUVICA
imipramine
imiquimod (ALDARA equiv)
iron polysaccaride complex + b12/folic
acid
cankinumab
nepafenac opth
ibrutinib
imipramine
imiquimod
4
3
4
1
2
PA
PA
CNS
Opthalmic/Otic
Oncology
CNS
Dermatologic
imiquimod cream (ZYCLARA equiv)
imiquimod
2
QL-56
Dermatologic
4
2
3
1
PA
Endocrine
Respiratory
Cardiovascular
CNS
INCRELEX
INCRUSE ELLIPTA
indapamide
indomethacin, SR
mecasermin
umeclidinium
indapamide
indomethacin
PA, SP
CNS
Oncology
Endocrine
Endocrine
INFED
iron dextran complex
2
Endocrine
INFERGEN
INLYTA
INNOHEP
interferon alfacon
axitinib
tinzaparin
4
4
3
INNOPRAN XL
INTAL
INTEGRILIN
propranolol LA
cromolyn inhaler
eptifibatide
2
NC
3
Cardiovascular
Respiratory
Cardiovascular
INTELENCE
INTENSOL
etravirine
alprazolam concentrate
4
NC
Infectious Disease
CNS
SP
PA, SP
Infectious Disease
Oncology
Cardiovascular
ST=Step therapy
AL=Age Limit
PF=Partial Fill
TS=Tab Splitting
Cough and Cold
Narcotics
Narcotics
- Prescription Only
Immunosuppressants
Oncology/Cancer
Medications
Narcotics
Oncology/Cancer
- Prescription Only
- Prescription Only
Miscellaneous
Oncology/Cancer
Growth Hormones
Other Inhaled
Diuretics
Medications
- Prescription Only
Cancer
Beta Blockers
Antianxiety
27
Alphabetical Index
Medication Name
Generic Name
Tier
Special
Code
Drug Class
Subclass
CNS
Oncology
CNS
Infectious Disease
Endocrine
Endocrine
Dermatologic
Hypnotics
Oncology/Cancer
Antipsychotics
Glaucoma
Growth Hormones
Nasal Corticosteroids
INTERMEZZO
INTRON A
INVEGA
INVIRASE
INVOKAMET
INVOKANA
IODOFLEX
zolpidem sublingual
interferon alfa 2b
paliperidone
saquinivir mesylate
canagliflozin/metformin
canagliflozin
cadexomer iodine
NC
4
2
4
3
3
NC
iodosorb gel
cadexomer iodine
1
Dermatologic
IOPIDINE
IPLEX
ipratropium nasal (ATROVENT
NASAL equiv)
ipratropium nebulizer solution
IQUIX
irbesartan (AVAPRO equiv)
irbesartan/HCTZ (AVALIDE equiv)
IRESSA
ISENTRESS
ISOCHRON
apraclonidine HCL
mecasermin
ipratropium nasal
2
NC
1
Opthalmic/Otic
Endocrine
Respiratory
ipratropium nebulizer solution
levofloxacin opth
irbesartan
irbesartan/HCTZ
gefitinib
raltegravir
isosorbide dinaitrate
1
NC
1
NC
4
4
1
Respiratory
Ophthalmic/Otic
Cardiovascular
Cardiovascular
Oncology
Infectious Disease
Cardiovascular
ISONARIF
isoniazid
ISOPTO ATROPINE
ISOPTO CARBACHOL
ISOPTO CARPINE
ISOPTO HOMATROPINE
ISOPTO HYOSCINE
ISORDIL
isoniazid/rifampin
isoniazid
atropine opth
carbachol ophth
pilocarpine opth
homatropine ophth
scopolamine ophth
isosorbide dinatrate
1
1
2
2
2
2
2
2
1
Cardiovascular
isosorbide mononitrate
isosorbide mononitrate
1
Cardiovascular
isotretinoin
ISOXSUPRINE
isotretinoin
isoxpurine
1
1
Dermatologic
Cardiovascular
isradipine
ISTALOL
itraconazole
JAKAFI
JALYN
JANTOVEN
isradipine
timolol opth
itraconazole
ruxilnib phosphate
duasteride/tamsulosin
warfarin
1
2
4
4
3
1
Cardiovascular
Ophthalmic/Otic
Infectious Disease
Oncology
Genitourinary
Cardiovascular
JANUMET
JANUMET XR (QL on 50/500)
JANUVIA
JINTELI (FEMHRT equiv)
sitagliptin/metformin
sitagliptin/metformin ER
sitagliptin
3
3
3
1
JOLESSA
JOLIVETTE (NOR-QD equiv)
JUNEL
JUNEL (LOESTRIN equiv)
JUNEL FE (LOESTRIN equiv)
$0
$0
$0
$0
$0
JUVISYNC
KADIAN
KALETRA
KALEXATE
norethindrone
sitagliptin/simvastatin
morpine sulfate ER caps
lopinavir/ritonavir
sodium polystyrene sulfonate
3
2
2
NC
ST, QL-30
Endocrine
CNS
Infectious Disease
Endocrine
KALYDECO
KAPVAY
KARIVA (MIRCETTE equiv)
KAYEXALATE
ivacaftor
clonidine SR
NC
NC
$0
NC
SP
Respiratory
CNS
Endocrine
Endocrine
KAZANO
alogliptin/metformin
2
PA,SP
PA
PA
QL-2
QL-2
QL-2
QL-2
PA
PA,SP
NTI
ST
ST, QL-30
ST, QL-30
Infectious Disease
Infectious Disease
Ophthalmic/Otic
Ophthalmic/Otic
Opthalmic/Otic
Ophthalmic/Otic
Ophthalmic/Otic
Cardiovascular
Endocrine
Endocrine
Endocrine
Endocrine
Endocrine
Endocrine
Endocrine
Endocrine
Endocrine
Endocrine
ST=Step therapy
AL=Age Limit
PF=Partial Fill
TS=Tab Splitting
Eye Anti-infectives
Oncology/Cancer
Vasodialators/Nitrates/Miscellane
ous Cardiovascular
Anti-TB
Anti-TB
Glaucoma
glaucoma
Vasodialators/Nitrates/Miscellane
ous Cardiovascular
us Cardiovascular
us Cardiovascular
Oral Acne
us Cardiovascular
Glaucoma
Anti-Fungals
Oncology/Cancer
Estrogen/Progestin
Diabetes - Other
Narcotic
- Prescription Only
- Prescription Only
diabetes - Other
28
Alphabetical Index
Medication Name
Generic Name
Tier
Special
Code
Drug Class
Subclass
Endocrine
- Prescription Only
Macrolide/Ketolide
Anti-Fungals
Anti-Fungals
Medications
Medications
K-DUR
potassium chloride
NC
KELNOR
KERAFOAM 30%
urea
$0
2
Endocrine
Dermatologic
KERAFOAM 42%
urea
2
Dermatologic
KERALAC
urea
2
Dermatologic
KETEK
ketoconazole (EXTINA equiv)
telithromycin
ketoconazole
3
NC
Infectious Disease
Dermatologic
ketoconazole gel (XOLEGEL equiv)
ketoconazole gel
NC
Dermatologic
ketoconazole tabs
ketoconazole topical (Excludes Gel)
ketoprofen
ketoconazole oral tabs
ketoconazole topical (excludes gel)
ketoprofen
1
2
3
ST
Infectious Disease
Infectious Disease
CNS
ketorolac
ketorolac
1
QL-20
CNS
ketorolac ophth (ACULAR, ACULAR
LS equiv)
KINERET
ketorolac ophthalmic
1
QL-2
Ophthalmic/Otic
anakinra
4
PA,SP
Oncology
KINEVAC
KIONEX
sinacide
2
1
Gastroenterology
Endocrine
KLARON
sulfacetamide sodium
NC
Dermatologic
KLOR-CON
potassium chloride
1
Endocrine
KLOR-CON M15
potassium chloride
1
Endocrine
KLOR-CON-EF
potassium bicarbonate/citric acid
1
Endocrine
KOMBIGLYZE
KOMBIGLYZE 2.5/1000 only
K-PHOS
saxagliptan/metformin ER
saxagliptan/metformin ER
potassium phosphate/sodium phosphate
3
3
NC
K-PHOS M.F.
Tier 2
Endocrine
K-PHOS NEUTRAL
potassium phosphate/sodium
phosphate, monobasic
phosphorus #1
Tier 2
Endocrine
K-PHOS NO.2
potassium phosphate/sodium phosphate
Tier 2
Endocrine
K-PHOS ORIGINAL
potassium phosphate monobasic
Tier 2
Endocrine
KUVAN
KYNAMRO
labetalol
LAC-HYDRIN
sapropterin dihydrochloride
mipomersen
labetalol hcl
ammonium lactate topical
4
NC
1
NC
LACRISERT
lactated ringers solution
lactic acid
hydroxypropyl cellulose opth
lactated ringers solution
lactic acid
NC
1
1
Opthalmic/Otic
Infectious Disease
Dermatologic
lactulose solution
LAMICTAL (GRN/ORANGE)
LAMICTAL ODT
lamivudine (EPIVIR equiv)
lamivudine/zidovudine (COMBIVIR
equiv)
lamotrigine
lactulose solution
lamotrigine
lamotrigine ODT
lamivudine
lamivudine/zidovudine
1
2
NC
4
4
Gastroenterology
CNS
CNS
Infectious Disease
Infectious Disease
Miscellaneous GI
- Prescription Only
- Prescription Only
- Prescription Only
- Prescription Only
Diabetes - Other
Diabetes - Other
- Prescription Only
- Prescription Only
- Prescription Only
- Prescription Only
- Prescription Only
Beta Blockers
Antibiotic/Antivirals Misc
Anticonvulsants
Anticonvulsants
lamotrigine
1
CNS
Anticonvulsants
ST,QL-30
ST,QL-60
PA,SP
SP
SP
TS, QL120
Endocrine
Endocrine
Endocrine
Endocrine
Endocrine
Cardiovascular
Dermatologic
ST=Step therapy
AL=Age Limit
PF=Partial Fill
TS=Tab Splitting
29
Alphabetical Index
Medication Name
Generic Name
Tier
Special
Code
Drug Class
Subclass
Endocrine
Anticonvulsants
Antiarrhythmics
antiarrhythmics
Proton Pump Inhibitors
Injectables
Injectables
Monophasic Contraceptives
Ophthalmic/Otic
Ophthalmic/Otic
CNS
Eye Allergy
Glaucoma
Antipsychotics
Dermatologic
lamotrigine ER (LAMICTAL XR equiv)
LAMPRENE
LANOXIN
LANOXIN
lansoprazole
LANTUS
lamotrigine ER
clofazimine
digoxin
digoxin
lansoprazole
insulin glargine
NC
NC
2
2
2
2
NTI
NTI
QL-60
QL-20
CNS
Infectious Disease
Cardiovascular
Cardiovascular
Gastroenterology
Endocrine
LANTUS SOLOSTAR
insulin glargine
2
QL-20
Endocrine
LARIN FE
$0
LASTACAFT
latanoprost (XALATAN equiv)
LATUDA
Ethinyl estradiol/ferrous
fumarate/norethindrone
alcaftadine
latanoprost ophth
lurasidone
LAVOCLEN-8
benzoyl peroxide skin cleansers
1
LAZANDA
LAZERFORMALYDE
fentanyl nasal
formaldehyde
NC
NC
CNS
Dermatologic
LEENA (TRI-NORINYL equiv)
leflunomide
leflunomide
NC
1
Endocrine
Oncology
LESCOL XR
LESSINA(LEVLITE equiv)
LETAIRIS
fluvastatin SR
ambrisentan
NC
$0
4
Cardiovascular
Endocrine
Cardiovascular
letrozole (FEMARA equiv)
leucovorin
LEUKERAN
LEUKINE
letrozole
leucovorin
chlorambucil
sargramostim
1
2
4
4
leuprolide
levalbuterol nebulizer solution
LEVEMIR
leuprolide
levalbuterol nebulizer solution
insulin detemir
LEVEMIR FLEXTOUCH
NC
1
2
QL-2
PA,TS,QL
-30
PA
PA
Oncology
Oncology
Oncology
Cardiovascular
4
3
2
PA,SP
ST, AL<9
QL-20
Endocrine
Respiratory
Endocrine
insulin detemir
2
QL-20
Endocrine
levetiracetam (KEPPRA equiv)
levetiracetam XR (KEPPRA XR equiv)
LEVITRA
LEVLEN
levobunolol ophth (BETAGAN equiv)
levocarnitine
levocetirizine (XYZAL equiv)
levofloxacin (LEVAQUIN equiv)
levofloxacin opth (QUIXIN equiv)
levomefolate calcium (DEPLIN equiv)
levetiracetam
levetiracetam
vardenafil
levobunolol ophth
levocarnitine
levocetirizine
levofloxacin
levofloxacin opth
levomefolate calcium
1
NC
NC
NC
1
1
NC
1
3
NC
LEVONEST
levonogesterol
(LOSEASONIQUE equiv)
(LYBREL equiv)
LEVORA-28 (LEVLEN equiv)
levorphanol
LEVOTHROID
levothyroxine
LEVOXYL
LEVULAN KERASTICK
levonogesterol/ethinyl estradiol
levonogesterol
$0
$0
NC
Endocrine
Endocrine
Endocrine
Narcotics
Immunosuppressants
us Cardiovascular
Oncology/Cancer
Oncology/Cancer
Oncology/Cancer
Injectables
Injectables
Anticonvulsants
Anticonvulsants
Glaucoma
Oncology/Cancer
Quinolones
Eye Anti-infectives
- Prescription Only
NC
Endocrine
levorphanol
levothyroxine
levothyroxine
levothyroxine
aminolevulinic acid HCL
$0
1
2
1
2
2
Endocrine
CNS
Endocrine
Endocrine
Endocrine
Dermatologic
LEXIVA
LEXXEL
LIALDA
fosamprenavir
enalapril/felodipine
mesalamine
4
NC
NC
Infectious Disease
Cardiovascular
Gastroenterology
Narcotics
ACE-Inhibitors
PA,QL45,SP
QL-2
CNS
CNS
Miscellaneous
Endocrine
Ophthalmic/Otic
Oncology
Respiratory
Infectious Disease
Ophthalmic/Otic
Endocrine
ST=Step therapy
AL=Age Limit
PF=Partial Fill
TS=Tab Splitting
30
Alphabetical Index
Medication Name
Generic Name
Tier
Special
Code
Drug Class
Subclass
CNS
Medications
Medications
LIDAMANTLE HC
hydrocortisone/lidocaine topical
NC
lidocaine
lidocaine HCL topical
1
Dermatologic
lidocaine
lidocaine
1
Dermatologic
lidocaine patches
lidocaine patches
2
lidocaine viscous
lidocaine hcl oral
1
1
Topical Oral
Preparations
Dermatologic
LIDOCAINE-HYDROCORTISONE
lidocaine/hydrocortisone
1
Dermatologic
LIDORX
lidocaine 3% oint
NC
Dermatologic
lindane
lindane
1
Dermatologic
linezolid (ZYVOX equiv)
LINZESS
linezolid
linaclotide
2
2
LIORESAL INTRATHECAL
liothyronine
LIPITOR
LIPOFEN
lisinopril
lisinopril/HCTZ
lithium
lithium ER
LITHOBID
LITHOSTAT
LIVALO
LO LOESTRIN FE
2
1
NC
NC
1
1
1
1
2
1
NC
NC
LOTRONEX
lovastatin (MEVACOR equiv)
LOVAZA
LOVENOX
baclofen
liothyronine
atorvastatin
fenofibrate
lisinopril
lisinopril/HCTZ
lithium
lithium ER
lithium
actohydroxamic acid
pitavastatin
carbidopa
fenofibrate, micronized
lomustine
loperamide
apraclonidine ophthalmic solution
loratadine syrup
loratadine tablet
lorazepam
chlorzoxazone
losartan
losartan/HCTZ
loteprednol opth
dipropionate
alosetron
lovastatin
omega-3 acid ethyl esters
enoxaparin
LOW-OGESTREL (LO-OVRAL equiv)
loxapine
LOZI-FLUR
loxapine
sodium fluoride
$0
1
1
LOCOID
LODOSYN
LOESTRIN 24 FE
LOESTRIN FE
LOFIBRA
lomustine
LO-OVRAL
loperamide
LOPIDINE
loratadine syrup
loratadine tablet
lorazepam
LORZONE
losartan (COZAAR equiv)
losartan/HCTZ (HYZAAR equiv)
LOSEASONIQUE
LOTEMAX
LOTRISONE
2
4
3
3
NC
4
3
1
NC
NC
NC
1
3
1
1
NC
3
2
2
1
NC
4
PA
PA
PA, QL30
NTI
PA
PA
TS
TS
QL-2
PA
QL-45,TS
PA,SP
CNS
Infectious Disease
Gastroenterology
CNS
Endocrine
Cardiovascular
Cardiovascular
Cardiovascular
Cardiovascular
CNS
CNS
CNS
Genitourinary
Cardiovascular
Endocrine
ACE-Inhibitors
ACE-Inhibitors
Antipsychotics
Antipsychotics
Antipsychotics
Dermatologic
CNS
Endocrine
Endocrine
Cardiovascular
Oncology
Endocrine
Gastoenterology
Ophthalmic/Otic
Respiratory
Respiratory
CNS
CNS
Cardiovascular
Cardiovascular
Endocrine
Ophthalmic/Otic
Dermatologic
Oncology/Cancer
Antidiarrheal (GI)
Glaucoma
Antianxiety
Cortico
Gastroenterology
Cardiovascular
Cardiovascular
Cardiovascular
Antipsychotics
- Prescription Only
Endocrine
CNS
Endocrine
ST=Step therapy
AL=Age Limit
PF=Partial Fill
TS=Tab Splitting
31
Alphabetical Index
Medication Name
Generic Name
Tier
Special
Code
Drug Class
Subclass
Opthalmic/Otic
Opthalmic/Otic
Endocrine
Eye Allergy
- Prescription Only
Glaucoma
Potency
Anticonvulsants
LUBRICANT EYE
LUBRICANT REDNESS EYE DROPS
LUDENT FLUORIDE
propylene glycol opth
hypromellulose/naphazoline opth
sodium fluoride
NC
3
$0
LUFYLIN GG
LUFYLLIN
LUMIGAN
LUPRON
LUPRON DEPOT
LUPRON DEPOT PED
LUTERA (ALESSE equiv)
LUVOX
LUXIQ
guaifenesin-dyphylline
dyphylline
bimatoprost opth
leuprolide
leuprolide
leuprolide
fluvoxamine
NC
NC
2
4
4
4
$0
NC
NC
LYBREL
LYRICA
pregabalin
NC
2
LYSODREN
LYZA
MACRODANTIN
magnesium chloride
mitotane
norethindrone
nitrofurantoin macrocrystal
magnesium chloride
4
$0
2
1
magnesium oxide
magnesium oxide
1
Endocrine
magnesium sulfate
magnesium sulfate
1
Endocrine
MAKENA
hydroxyprogesterone caproate
NC
malathion
malathion
1
Dermatologic
maprotiline
MAR-COF BP
MARLISSA
MARPLAN
MATULANE
MAXAQUIN
MAXIDEX
mebendazole
meclizine
meclofenamate
maprotiline
bromphin/pseudoephedrine/codeine
isocarboxazid
procarbazine
lomefloxacin
dexamethasone opth
mebendazole
meclizine
meclofenamate
1
2
$0
NC
4
NC
2
3
1
3
CNS
Infectious Disease
Endocrine
CNS
Oncology
Infectious Disease
Ophthalmic/Otic
Infectious Disease
Gastroenterology
CNS
MEDROL
methylprednisolone
3
Oncology
medroxyprogesterone
medroxyprogesterone
1
Endocrine
medroxyprogesterone injection
mefenamic acid (PONSTEL equiv)
medroxyprogesterone injection
mefenamic acid
NC
3
Endocrine
CNS
mefloquine
megestrol oral susp
megestrol susp (MEGACE ES equiv)
megestrol tabs
MEKINIST
meloxicam
mefloquine
megestrol acaetate suspension
megestrol susp
megestrol acaetate tabs
trametinib
meloxicam
1
1
2
4
NC
1
Infectious Disease
Endocrine
Endocrine
Oncology
Oncology
CNS
MENEST
esterified estrogens
3
MENOPUR
menotropin
NC
SP
Endocrine
MENOSTAR
estradiol weekly patch
2
QL-4
Endocrine
MENTAX
butenafine HCL
NC
Dermatologic
meperidine
mephobarbital
MEPHYTON
meperidine
mephobarbital
phytonadione
1
NC
2
CNS
CNS
Cardiovascular
meprobamate
meprobamate
1
CNS
OTC
QL-2
PA,SP
PA,SP
PA,SP
PA, QL120
PA,SP
SP
PA, SP
QL-2
SP
QL-45
Respiratory
Respiratory
Ophthalmic/Otic
Endocrine
Endocrine
Endocrine
Endocrine
CNS
Dermatologic
Endocrine
CNS
Oncology
Endocrine
Genitourinary
Endocrine
Endocrine
Endocrine
ST=Step therapy
AL=Age Limit
PF=Partial Fill
TS=Tab Splitting
Oncology/Cancer
- Prescription Only
- Prescription Only
- Prescription Only
Cough and Cold
Oncology/Cancer
Quinolones
Anti-Parasitics
Nausea/Vomiting
Medications
Immunosuppressants
Medications
Anti-Malarials
Oncology/Cancer
Oncology/Cancer
Medications
Estrogen/Progestin
Narcotics
Antianxiety
Antianxiety
32
Alphabetical Index
Medication Name
Generic Name
Tier
Special
Code
Drug Class
Subclass
Infectious Disease
Oncology
CNS
Gastroenterology
Oncology
CNS
CNS
Endocrine
MEPRON
mercaptopurine
MERIDIA
mesalamine rectal (ROWASA equiv)
MESNEX
METADATE CD
METADATE ER
METANX
atovaquone
mercaptopurine
sibutramine
mesalamine rectal
mesna
methylphenidate
methylphenidate
methylfolate b6-b12
2
1
NC
1
2
NC
NC
NC
metaproterenol oral
metaproterenol inhaled
metaxalone
metformin (GLUCOPHAGE equiv)
metformin XR (GLUCOPHAGE XR
equiv) (1000mg EXCLUDED)
metformin/glipizide (METAGLIP equiv)
metformin/glyburide (GLUCOVANCE
equiv)
methadone
methamphetamine
methazolamide
methenamine
methenamine hippurate
methenamine madelate
METHERGINE
methimazole
METHITEST
metaproterenol oral
metaproterenol inhaled
metaxalone
metformin
metformin XR
3
NC
1
1
1
Respiratory
Respiratory
CNS
Endocrine
Endocrine
Anti-Parasitics
Oncology/Cancer
Oncology/Cancer
- Prescription Only
metformin/glipizide
metformin/glyburide
NC
1
Endocrine
Endocrine
methadone
methamphetamine
methazolamide
methenamine
methenamine hippurate
methenamine madelate
methylergonovine
methimazole
methyltestosterone
1
1
1
1
1
1
NC
1
2
CNS
CNS
Ophthalmic/Otic
Infectious Disease
Infectious Disease
Infectious Disease
Endocrine
Endocrine
Endocrine
methocarbamol
methotrexate
methotrexate sodium
methscopolamine
methyclothiazide
methyldopa
methyldopa/HCTZ
methylene blue
methylergonovine (METHERGINE
equiv)
METHYLIN
methylphenidate
methylphenidate CD (RITALIN LA
equiv)
methylphenidate ER (CONCERTA
equiv)
methylprednisolone
methocarbamol
methotrexate
methotrexate sodium/PF
methscopolamine bromide
methyclothiazide
methyldopa
methyldopa/HCTZ
methylene blue
methylergonovine
1
1
1
1
3
1
NC
1
1
CNS
Oncology
Oncology
Gastroenterology
Cardiovascular
Cardiovascular
Cardiovascular
Antidotes
Endocrine
Narcotics
Glaucoma
Oncology/Cancer
Oncology/Cancer
Diuretics
Adrenergics
Adrenergics
Miscellaneous Antidotes
methylphenidate ER
methylphenidate
methylphenidate (all except 10mg)
2
1
1
CNS
CNS
CNS
methylphenidate ER
1
CNS
methylprednisolone
1
Oncology
methylprednisolone acetate
methylprednisolone acetate
1
Oncology
methylprednisolone sodium succinate
methylprednisolone sodium succinate
1
Oncology
metipranolol opth
metoclopramide
metolazone
metoprolol succinate ER (Toprol XL
equiv)
metoprolol tartrate
METOZOLV ODT
METROCREAM
metipranolol opth
metoclopramide
metolazone
metoprolol succinate
1
1
1
1
Immunosuppressants
Immunosuppressants
Immunosuppressants
Glaucoma
Nausea/Vomiting
Diuretics
Beta Blockers
metoprolol tartrate
metoclopramide odt
metronidazole topical
NC
1
NC
NC
Cardiovascular
Cardiovascular
Gastroenterology
Dermatologic
METROGEL TOPICAL
metronidazole topical gel
2
Dermatologic
METROGEL VAGINAL
metronidazole
metronidazole topical
metronidazole vaginal
metronidazole oral tablets
metronidazole topical topical (cream,
lotion, gel, vaginal gel)
mexiletine
NC
1
1
Infectious Disease
Infectious Disease
Dermatologic
1
Cardiovascular
mexiletine
PA
QL-2
PA
Ophthalmic/Otic
Gastroenterology
Cardiovascular
Cardiovascular
ST=Step therapy
AL=Age Limit
PF=Partial Fill
TS=Tab Splitting
Beta Blockers
Beta Blockers
Nausea/Vomiting
Antiarrhythmics
33
Alphabetical Index
Medication Name
Generic Name
Tier
Special
Code
Drug Class
Subclass
Endocrine
Calcium Metabolism/
Calcium Metabolism/
Anti-fungals
MIAALCIN NASAL
calcitonin nasal
2
MIACALCIN INJECTION
calcitonin injection
2
Endocrine
MICARDIS
MICARDIS HCT
miconazole-3
MICRHOGARD
MICROCHAMBER
MICROGESTIN (LOESTRIN equiv)
MICROGESTIN FE (LOESTRIN equiv)
telmisartan
telmisartan/HCTZ
miconazole suppositories
RHO immunoglobulin
spacer for inhaler
norethindrone
midazolam
midodrine
NC
NC
NC
NC
NC
$0
$0
Cardiovascular
Cardiovascular
Infectious Disease
Infectious Disease
Respiratory
Endocrine
Endocrine
NC
1
1
Endocrine
CNS
Cardiovascular
NC
CNS
MIGERGOT
MIGRAGESIC IDA
MIGRANAL
MILLIPRED
acetaminophen/dichloralphenazone/
isometheptene
ergotamine/caffeine
isometheptene/apap/dichloralphenazone
dihydroergotamine nasal
prednisolone acetate
1
1
2
1
CNS
CNS
CNS
Oncology
MILLIPRED DP
1
Oncology
MIMVEY
MIMYX
emollient combination no. 35 cream
$0
NC
Endocrine
Dermatologic
minocycline
minoxidil tabs
minocycline
minoxidil
1
1
Infectious Disease
Cardiovascular
MIRCETTE
mirtazapine
misoprostol
mitomycin
MITOSOL
MOBAN
modafinil (PROVIGIL equiv)
MODICON
moexipril
moexipril/HCTZ
mometasone furoate topical
mirtazapine
misoprostol
mitomycin
mitomycin opth kit
molindone
modafinil
moexipril
moexipril/HCTZ
mometasone furoate (cream, ointment)
NC
1
1
NC
2
2
4
NC
3
NC
1
Endocrine
CNS
Gastroenterology
Infectious Disease
Opthalmic/Otic
CNS
CNS
Endocrine
Cardiovascular
Cardiovascular
Dermatologic
MONONESSA (ORTHO-CYCLEN
equiv)
montelukast (SINGULAIR equiv)
MONUROL
morphine
morphine SR (KADIAN equiv)
norgestimate/ethinyl estradiol
$0
Endocrine
Migraine
Migraine
Migraine
osupressants
osupressants
us Cardiovascular
Other GI/Ulcer
Miscellaneous Anti-Infectives
Glaucoma
Antipsychotics
ACE-Inhibitors
ACE-Inhibitors
Potency
montelukast
fosfomycin
morphine
morphine SR (all except 10 and 200mg
strength)
morphine ER
1
NC
1
1
Respiratory
Infectious Disease
CNS
CNS
Narcotics
Narcotics
CNS
Narcotics
Gastroenterology
Gastoenterology
Gastroenterology
Antidiarrheal (GI)
NC
2
NC
NC
NC
2
1
Infectious Disease
Opthalmic/Otic
Oncology
Respiratory
Endocrine
Cardiovascular
Endocrine
2
Endocrine
Penicillins
Eye Antibacterial Preparations
Oncology/Cancer
Miscellaneous Oral
Antiarrhythmics
- Prescription Only
- Prescription Only
MICRONOR
midazolam
midodrine
MIDRIN
morphine sulfate ER (MS CONTIN
equiv)
MOTOFEN
MOVANTIK
MOVIPREP
MOXATAG
MOXEZA
MOZOBIL
MUCOMYST
MUGARD
MULTAQ
multigen
multivitamin w/ fluoride
difenoxin hcl/atropine sulfate
naloxegol
polyethylene glycol/electrolytes /sodium
ascorbate
amoxicillin ER
moxifloxacin opth
plerixafor
acetylcysteine
carbonomer homopolymer liquid
dronedarone
multivitamin with iron (RX only)
multivitamin w/ fluoride
SP
QL-30
ST
QL-60
1
3
3
3
ST
ST=Step therapy
AL=Age Limit
PF=Partial Fill
TS=Tab Splitting
Hypnotics
us Cardiovascular
Migraine
34
Alphabetical Index
Medication Name
Generic Name
Tier
Special
Code
Drug Class
Subclass
QL-30 g
Dermatologic
SP
Miscellaneous
Endocrine
Infectious Disease
Oncology
Anti-TB
Immunosuppressants
- Prescription Only
Immunosuppressants
Oncology/Cancer
Anticonvulsants
Medications
Beta Blockers
Beta Blockers
Narcotics
Medications
Eye Allergy
Eye Allergy
Medications
Medications
Medications
Migraine - Triptans
mupirocin ointment
mupirocin ointment/cream
1
MUSE
My Way (PLAN B ONE STEP equiv)
MYCOBUTIN
mycophenolate mofetil (CELLCEPT
equiv)
MYDRIACYL
MYFERON-150 FORTE
alprostadil urethral
levonorgestrel
rifabutin
mycophenolate mofetil
NC
$0
2
4
3
1
QL-2
Ophthalmic/Otic
Endocrine
MYFORTIC
tropicamide ophth
iron polysaccharide complex/vitamin
b12/folic acid
mycophenolic sodium
4
SP
Oncology
MYLERAN
MYRBETRIQ
MYSOLINE
MYZILRA (TRIPHASIL eqiuv)
nabumetone
busulfan
mirabegron
primidone
nabumetone
4
3
3
$0
1
PA
Oncology
Genitourinary
CNS
Endocrine
CNS
nadolol
nadolol/bendroflumethiazide
NAFTIN
nadolol
nadolol/bendroflumethiazide
naftifine HCL
1
NC
2
Cardiovascular
Cardiovascular
Dermatologic
NALBUPHINE HCL
NALFON
nalbuphine
fenoprofen calcium
1
3
CNS
CNS
naloxone
naltrexone
NAMENDA
naloxone
naltrexone
memantine
1
1
2
CNS
CNS
CNS
NAMENDA XR
memantine
2
CNS
naphazoline hcl
NAPHCON-A OTC
NAPRELAN
naphazoline
naphazoline/pheniramine
naproxen sodium ER
NC
NC
NC
Opthalmic/Otic
Ophthalmic/Otic
CNS
naproxen
naproxen
1
CNS
naproxen sodium
naproxen sodium
1
CNS
naratriptan
naratriptan
3
NARDIL
NASALCROM OTC
phenelzine
cromolyn nasal
NC
NC
NASCOBAL SPRAY
cyanocobalamin spray
NC
NASONEX
mometasone nasal
2
QL-2
Respiratory
NATACYN
NATAZIA
nateglinide
NATROBA
natamycin ophth
estrodiol valerate/dienogest
nateglinide
spinosad
2
NC
3
3
QL-2
Ophthalmic/Otic
Endocrine
Endocrine
Dermatologic
NATURE-THROID
NEBUPENT
NEBUSAL
NECON (ORTHO NOVUM equiv)
NECON 7/7/7 (MODICON equiv)
nefazodone
NEMBUTAL
neomycin
neomycin,colistin,hydrocortisone otic
(COLY-MYCIN S Equiv)
hydrocortisone opth
neomycin/polymixin B irrigation
neomycin/polymixin B/gramicidin
thyroid, dessicated
pentamidine
sodium chloride for inhalation 6%
nefazodone
pentobarbitol
neomycin tabs
neomycin/colistin sulfate/
hydrocortisone otic
hydrocortisone opth
neomycin/polymixin B irrigation
neomycin/polymixin B/gramicidin opth
2
2
3
$0
$0
1
2
1
NC
1
1
1
ST, QL9/18
CNS
CNS
Respiratory
Endocrine
Infectious Disease
Respiratory
Endocrine
Endocrine
CNS
CNS
Infectious Disease
Opthalmic/Otic
Antihistamines
- Prescription Only
Antihistamines
Eye Anti-infectives
Other Respiratory
Narcotics
Ophthalmic/Otic
Infectious Disease
Opthalmic/Otic
Irrigants
Endocrine
TS
QL-2
ST=Step therapy
AL=Age Limit
PF=Partial Fill
TS=Tab Splitting
35
Alphabetical Index
Medication Name
Generic Name
Tier
Special
Code
Drug Class
Subclass
Dermatologic
neomycin/polymixin/dexamethasone
topical
neomycin/polymyxin/ dexamethasone
ophth
neomycin/polymyxin/hydrocortisone
otic
NEORAL
neomycin/polymixin/dexamethasone
topical
neomycin/polymyxin B/ dexamethasone
ophth
neomycin/polymyxin/hydrocortisone
otic
1
1
QL-2
Ophthalmic/Otic
Immunosuppressants
1
QL-2
Ophthalmic/Otic
4
NTI
Oncology
Immunosuppressants
Cough and Cold
Diuretics
Parkinson's Disease
Parkinson's Disease
Anticonvulsants
Oncology/Cancer
Adrenergics
NEO-SYNEPHRINE
NESINA
netolazone
NEULASTA
phenylephrine hcl injection
alogliptin
netolazone
pegfilgrastim
2
2
NC
4
NEUMEGA
oprelvekin
4
NEUPOGEN
filgrastim
4
NEUPRO
NEUPRO
NEURONTIN
NEVANAC
nevirapine (VIRAMUNE equiv)
NEXAVAR
NEXICLON XR
next choice one dose
niacin
niacin ER
NIASPAN
nicardipine
nicardipine SR (CARDENE SR equiv)
nicotine gum
nicotine lozenge
nicotine patch
NICOTROL INHALER
NICOTROL NS
NIFEDIAC CC
NIFEDICAL XL
nifedipine
nifedipine ER (ADALAT CC equiv)
NILANDRON
nimodipine
NIMOTOP
nisoldipine
NITRO-BID
rotigotine
rotigotine
gabapentin
nepafenac opth
nevirapine
sorafenib
clonidine XR
levonorgestrel
niacin (otc)
niacin ER
niacin ER
nicardipine
nicardipine SR
nicotine gum
nicotine lozenge
nicotine patch
nicotine inhaler
nicotine spray
nifedipine
nifedipine
nifedipine
nifedipine ER
nilutamide
nimodipine
nimodipine
nisoldipine
nitroglycerin ointment
2
2
NC
2
4
4
NC
$0
NC
2
NC
NC
NC
$0
$0
$0
$0
$0
1
1
1
1
4
2
2
2
2
NITRO-DUR
nitroglycerin patch
2
Cardiovascular
nitrofurantoin (MACRODANTIN
equiv)
nitrofurantoin mono-macro
(MACROBID equiv)
nitroglycerin patch/tablets
nitrofurantoin macro
1
Infectious Disease
Smoking Cessation
Smoking Cessation
Smoking Cessation
Smoking Cessation
Smoking Cessation
us Cardiovascular
us Cardiovascular
nitrofurantoin mono-macro
1
Infectious Disease
nitroglycerin patch/tablets
1
Cardiovascular
NITROLINGUAL
nitroglycerin spray
NC
Cardiovascular
NITROMIST
nitroglycerin aerosol
NC
Cardiovascular
NITROSTAT
nitroglycerin tablets
2
nizatidine
NIZORAL
nizatidine
ketoconazole
3
NC
Gastroenterology
Dermatologic
NORA-BE
NORCO
NORDETTE
NORDITROPIN
norethindrone acetate
norethindrone
somatropin pen
norethindrone acetate
$0
NC
NC
4
1
Endocrine
CNS
Endocrine
Endocrine
Endocrine
norethindrone tab
norethindrone tab
$0
us Cardiovascular
us Cardiovascular
us Cardiovascular
us Cardiovascular
Narcotics
Growth Hormones
PA, QL4,SP
SP
PA,QL4,SP
PA
QL-2
PA,PF,SP
ST
QL
QL
QL
QL
PA
NTI
PA, SP
Infectious Disease
Endocrine
Cardiovascular
Cardiovascular
Cardiovascular
Cardiovascular
CNS
CNS
CNS
Ophthalmic/Otic
Infectious Disease
Oncology
Cardiovascular
Endocrine
Cardiovascular
Cardiovascular
Cardiovascular
Cardiovascular
CNS
CNS
CNS
CNS
CNS
Cardiovascular
Cardiovascular
Cardiovascular
Cardiovascular
Endocrine
Cardiovascular
Cardiovascular
Cardiovascular
Cardiovascular
Cardiovascular
Endocrine
ST=Step therapy
AL=Age Limit
PF=Partial Fill
TS=Tab Splitting
36
Alphabetical Index
Medication Name
Generic Name
Tier
Special
Code
Drug Class
Subclass
Endocrine
Endocrine
Dermatologic
Quinolones
Antiarrhythmics
- Prescription Only
Injectables
Injectables
Injectables
Injectables
Anti-Fungals
Topical Corticosteroids
Narcotics
Alzheimer’s Disease/Other
- Prescription Only
Narcotics
Growth Hormones
Growth Hormones
Growth Hormones
norgestimate-ethinyl estradiol
NORINYL
NORITATE
norgestimate-ethinyl estradiol
metronidazole
$0
3
2
NOROXIN
NORPACE CR
NOR-QD
nortrel (ORTHO NOVUM equiv)
nortrel 7/7/7 (MODICON equiv)
nortriptyline
NORVIR
NOVAFERRUM
norfloxacin
disopyramide CR
norethindrone
nortriptyline
ritonavir
iron polysaccharides complex
3
2
3
$0
$0
1
4
2
NOVAREL
HCG human chorionic gonadotropin
4
PA,SP
Endocrine
NOVOLIN N
NPH human insulin isophane
3
PA,QL-20
Endocrine
NOVOLIN R
insulin regular, human
3
PA,QL-20
Endocrine
NOVOLOG 70/30
insulin aspart
3
PA,QL-20
Endocrine
NOVOLOG 70/30
insulin aspart
3
ST,QL-20
Endocrine
NOXAFIL
NP THYROID
NPLATE
posaconazole
throid, pork
romiplostim
4
1
4
PA
Infectious Disease
Endocrine
Cardiovascular
NUCORT
NUCYNTA ER
NUDEXTA
NU-IRON 150
hydrocortisone actate/aloe vera lotion
tapentadol
dextromethorphan/quinidine
iron polysaccharide complex
2
3
2
$0
NULYTELY
NUMORPHIN
NUOX
oxymorphone injection
benzoyl peroxide/sulfur
NC
NC
2
Gastroenterology
CNS
Dermatologic
NUTROPIN
NUTROPIN AQ
NUTROPIN Depot
NUVARING
NUVIGIL
somatropin
somatropin
somatropin
etonorgestrel/ethinyl estradiol
armodafinil
NC
NC
NC
$0
3
Endocrine
Endocrine
Endocrine
Endocrine
CNS
nystatin
nystatin
1
nystatin vaginal
nystatin/triamcinolone
nystatin vaginal tablet
nystatin/triamcinolone
1
1
Infectious Disease
Dermatologic
NYSTOP
nystatin powder
1
Dermatologic
ocella (YASMIN equiv)
octreotide
OCUFEN
ofloxacin
ofloxacin opth
ofloxacin otic
OFORTA
OGESTREL
olanzapine (ZYPREXA equiv)
olanzapine ODT (ZYPREXA ZYDIS
equiv)
olanzapine/fluoxetine (SYMBYAX
equiv)
OLEPTRO
olopatadine (PATANASE equiv)
octreotide
flurbiprofen opth
ofloxacin tablets
Ofloxacin opth
ofloxacin otic
fludarabine
olanzapine
olanzapine ODT
$0
4
NC
3
1
1
NC
NC
1
1
olanzapine/fluoxetine
NC
trazodone er
olopatadine
NC
2
OLUX
OLUX-E
Clobetasol
2
NC
OLYSIO
simeprevir
4
Infectious Disease
Cardiovascular
Endocrine
Endocrine
Endocrine
CNS
Infectious Disease
Endocrine
PA,SP
QL-60
PA
QL-60
50mg
PA,SP
QL-2
TS
QL-60
QL-2
Dermatologic
CNS
CNS
Endocrine
Dermatologic
Endocrine
Endocrine
Ophthalmic/Otic
Infectious Disease
Opthalmic/Otic
Ophthalmic/Otic
Oncology
Endocrine
CNS
CNS
Quinolones
Eye Anti-Infectives
Ear Anti-infectives
Oncology/Cancer
Antipsychotics
Antipsychotics
CNS
Antipsychotics
CNS
Respiratory
Antihistamines
Corticosteroids – High Potency
Potency
Dematologic
Dermatologic
PA,SP,B
Infectious Disease
ST=Step therapy
AL=Age Limit
PF=Partial Fill
TS=Tab Splitting
37
Alphabetical Index
Medication Name
Generic Name
Tier
Special
Code
Drug Class
Subclass
Gastroenterology
Cardiovascular
Gastroenterology
Gastroenterology
Respiratory
Antihistamines
Growth Hormones
Oncology/Cancer
Nausea/Vomiting
Anticonvulsants
Narcotics
Eye Allergy
Narcotics
miscellaneous products
Glaucoma
Oral Acne
Antipsychotics
Anti-fungals
Migraine
OMECLAMOX-PAK
omeprazole
omeprazole/sodium bicarbonate
OMNARIS
omeprazole/clarithromycin/amoxixicllin
omeprazole
ciclesonide nasal
1
2
1
3
3
OMNIPRED
OMNITROPE
ONCASPAR
ondansetron
ONFI
ONGLYZA
ONSOLIS
OPCON A OTC
opium tincture
OPTICHAMBER
OPTICHAMBER W/ MASK
OPTIPRANOLOL
ORACEA
ORAP
ORAVIG
ORBIVAN
ORENCIA
prednisolone acetate opth
somatropin
pegaspargase
ondansetron (tabs and odt)
clobazam
saxagliptin
fentanyl transmucosal film
naphazoline
opium tincture
spacer for inhaler
pediatric mask for inhaler
metipranolol opth
doxycycline monohydrate
pimozide
miconazole buccal
acetaminophen/butalbital/caffeine
abatacept
NC
NC
4
1
2
3
NC
NC
1
1
1
NC
NC
2
NC
NC
4
ORINASE
orphenadrine citrate
orphenadrine citrate ER
orphenadrine compound forte
ORSYTHIA
ORTHO ALL-FLEX
ORTHO MICRONOR / NOR-QD
equiv
ORTHO TRI-CYCLEN
ORTHO TRI-CYCLEN LO
ORTHO-CYCLEN
ORTHO-NOVUM (1/35, 1/50)
ORTHO-NOVUM 7/7/7
OSENI
OSMOPREP
OVACE
tolbutamide
orphenadrine citrate
orphenadrine citrate ER
orphenadrine/aspirin/caffeine
silicone or latex diaphragm
norethindrone
NC
1
3
1
$0
DM
$0
Endocrine
CNS
CNS
CNS
Endocrine
Endocrine
Endocrine
alogliptin/pioglitazone
sodium phosphate
NC
$0
NC
NC
NC
2
NC
2
Endocrine
Endocrine
Endocrine
Endocrine
Endocrine
Endocrine
Gastroenterology
Dermatologic
OVACE PLUS
2
Dermatologic
OVCON
OVIDE
malathion
NC
NC
Endocrine
Dermatologic
OVIDREL
NC
Endocrine
oxandrolone
oxandrolone
1
oxaprozin
oxaprozin
1
oxazepam
oxcarbazepine
OXISTAT
oxazepam
oxcarbazepine
oxiconazole nitrate
1
1
2
OXSORALEN
methoxsalen
2
Dermatologic
OXSORALEN-ULTRA
methoxsalen, rapid
2
Dermatologic
OXTELLAR XR
oxybutynin (DITROPAN equiv)
oxybutynin XL (DITROPAN XL equiv)
oxycodone
oxycodone ER (OXYCONTIN equiv)
oxcarbazepine ER
oxybutynin
oxybutynin XL
oxycodone IR
oxycodone ER
NC
1
1
1
2
CNS
Genitourinary
Genitourinary
CNS
CNS
PA,ST
ST,QL-2
PA
PA
ST, QL-30
PA,SP
PA
Ophthalmic/Otic
Endocrine
Oncology
Gastroenterology
CNS
Endocrine
CNS
Ophthalmic/Otic
CNS
Respiratory
Respiratory
Ophthalmic/Otic
Dermatologic
CNS
Infectious Disease
CNS
Oncology
Endocrine
CNS
TS
QL-30
PA, QL120
CNS
CNS
Dermatologic
ST=Step therapy
AL=Age Limit
PF=Partial Fill
TS=Tab Splitting
Medications
Antianxiety
Anticonvulsants
Anticonvulsants
Narcotics
Narcotics
38
Alphabetical Index
Medication Name
Generic Name
Tier
Special
Code
Drug Class
Subclass
CNS
CNS
CNS
Genitourinary
CNS
Narcotics
Narcotics
Narcotics
Non-Narcotic Pain Relievers
PA, QL750
PA, QL750
Gastroenterology
Gastroenterology
Dermatologic
Dermatologic
QL-60
Gastroenterology
Miscellaneous
Gastroenterology
Ophthalmic/Otic
Corticosteroids
CNS
Infectious Disease
CNS
Anti-Parasitics
CNS
Infectious Disease
Ophthalmic/Otic
Ophthalmic/Otic
Gastroenterology
Anti-TB
Eye Allergy
Eye Allergy
CNS
Infectious Disease
Infectious Disease
Dermatologic
oxycodone/apap
oxymorphone (OPANA equiv)
oxymorphone ER (OPANA ER equiv)
OXYTROL
pain relief
oxycodone/acetaminophen
oxymorphone
oxymorphone ER
oxybutynin patch
acetaminophen
1
3
3
NC
1
PANCREAZE
pancrelipase
2
pancrelipase
pancrelipase
2
PANDEL
PANRETIN
hydrocortisone probutate
alitretinoin
2
2
pantoprazole
papaverine
paregoric
PAREMYD
pantoprazole
papaverine
paregoric
hydroxyamphetamine/tropicamide
ophth
tranylcypromine
paromomycin
paroxetine
1
NC
1
2
paroxetine CR
PASER
PATADAY
PATANOL
peg-3350 and electrolytes
(GOLYTELY/COLYTE equiv)
PEGANONE
PEGASYS
PEG-INTRON
penciclovir (DENAVIR equiv)
paroxetine CR
aminosalicyclic acid
olopatadine opth
olopatadine 0.1% ophthalmic solution
NC
2
2
2
1**
ethotoin
pegylated interferon
penciclovir
2
3
4
NC
penicillin G potassium
penicillin VK
PENLAC
penicillin Injection
penicillin VK
ciclopirox
1
1
NC
Infectious Disease
Infectious Disease
Dermatologic
PENNSAID
diclofenac topical
NC
CNS
PENTAM 300
pentamidine
PENTASA
pentazocine/acetaminophen
pentazocine/naloxone
pentoxifylline
pentamide isethionate
pentamidine
mesalamine
pentazocine/acetaminophen
pentazocine/naloxone
pentoxifylline
2
2
2
1
1
1
Infectious Disease
Infectious Disease
Gastroenterology
CNS
CNS
Cardiovascular
PERFOROMIST
PERGONAL
formoterol nebulizer solution
menotropin
NC
NC
Respiratory
Endocrine
PERIACTIN
perindopril
permethrin topical
cycloheptadine
perindopril
permethrin topical
1
3
1
Respiratory
Cardiovascular
Dermatologic
perphenazine
perphenazine/amitriptyline
PERTZYE
PEXEVA
phenazopyridine
phenelzine sulfate
phenobarbital
phenobarbital/hyoscyamine/
atropine/scopolamine (DONNATAL
equiv)
phentermine
phenylephrine
PHENYTEK
perphenazine
perphenazine/amitriptyline
lipase/protease/amylase
paroxetine
phenazopyridine
phenelzine sulfate
phenobarbital
phenobarbital/hyoscyamine/atropine/sco
polamine
1
1
2
NC
1
1
1
NC
CNS
CNS
Gastroenterology
CNS
Genitourinary
CNS
CNS
Gastroenterology
Anticonvulsants
Penicillins
Penicillins
Medications
Anti-Parasitics
Anti-Parasitics
Narcotics
Narcotics
Asthma/Allergy
ACE-Inhibitors
Antipsychotics
Antipsychotics
Other Genitourinary
Anticonvulsants
phentermine
phenylephrine
phenytoin
NC
1
NC
CNS
Ophthalmic/Otic
CNS
Eye Allergy
Anticonvulsants
PARNATE
paromomycin
paroxetine
NC
1
1
OTC
QL-2
TS
PA, QL-2
PA,QL
QL
PA,SP
SP
PA
QL-2
ST=Step therapy
AL=Age Limit
PF=Partial Fill
TS=Tab Splitting
39
Alphabetical Index
Medication Name
Generic Name
Tier
Special
Code
Subclass
CNS
CNS
CNS
Dermatologic
phenytoin
phenytoin sodium extended
phenytoin sodiun
PHISOHEX
Phenytoin sodium
phenytoin sodium extended
phenytoin sodium
hexachlorophene
1
1
2
2
phluorivit-fe
multivitamins with fluoride/iron drops
NC
Endocrine
PHOS-LO
calcium acetate
NC
Endocrine
PHOSLYRA
calcium acetate
2
PHOSPHA 250 NEUTRAL
phosphorus #1
1
PHOSPHOLINE IODIDE
PHRENILIN FORTE
phytonadione
echothiophate ophth
butalbital/acetaminophen
phytonadione
2
2
2
PICATO
ingenol
NC
Dermatologic
pilocarpine opthalmic drops
pilocarpine opthalmic gel
pilocarpine tabs
PILOPINE HS
pindolol
PINNACAINE
pioglitazone (ACTOS equiv)
pioglitazone/glimepiride (DUETACT
equiv)
pioglitazone/metformin (ACTOPLUS
MET equiv)
piroxicam
pilocarpine opthalmic drops
pilocarpine opthalmic gel
pilocarpine tabs
pilocarpine opth
pindolol
benzocaine otic
pioglitazone
pioglitazone/glimepiride
1
1
1
2
1
1
2
NC
Opthalmic/Otic
Opthalmic/Otic
Genitourinary
Opthalmic/Otic
Cardiovascular
Opthalmic/Otic
Endocrine
Endocrine
Anticonvulsants
Anticonvulsants
Anticonvulsants
- Prescription Only
- Prescription Only
- Prescription Only
- Prescription Only
Glaucoma
Migraine
- Prescription Only
Glaucoma
Glaucoma
Glaucoma
Beta Blockers
Misc Ear
Diabetes - TZD
Diabetes - TZD
pioglitazone/metformin
2
Endocrine
Diabetes - TZD
piroxicam
1
CNS
PLAN B
PLEXION
levonorgestrel
NC
NC
Endocrine
Dermatologic
PNEUMOVAX
PODOCON-25
pneumococcal conjugate vaccine
PODOPHYLLUM RESIN
$0
1
Vaccines
Dermatologic
podofilox
podofilox
1
Dermatologic
POLY HIST DHC
POLY HIST NC
polyethylene glycol 3350/electrolytes
POLY-IRON 150 FORTE
pyrilam.phenyle/dihydrocodeine
pseudoephedrine/codeine/triprolidn
iron ps complex/B12/folic acid
2
2
1
1
Infectious Disease
Infectious Disease
Gastroenterology
Endocrine
polymyxin B /trimethoprim ophth
polymyxin B 10,000u - trimethoprim
1mg ophthalmic solution
polysaccharide iron
1
Medications
Miscellaneous Oral Vaccines
Cough and Cold
Cough and Cold
- Prescription Only
Eye Anti-infectives
1
Endocrine
2
Infectious Disease
POMALYST
PORTIA
POTABA
phenylephrine/dihydrocodeine/guafenise
n
pomalidamide
potassium aminobenzoate
potassium chloride
potassium chloride
1
Endocrine
potassium citrate
potassium citrate
1
Endocrine
potassium citrate/citric acid
potassium citrate/citric acid
1
Endocrine
potassium hydroxide
potassium hydroxide
1
Dermatologic
potassium iodide
potassium iodide
NC
Endocrine
polysaccharide iron
POLY-TUSSIN EX
4
$0
2
NTI
Drug Class
QL20mL/d
Endocrine
QL-2
Ophthalmic/Otic
CNS
Endocrine
QL-2
PA, SP
NTI
Endocrine
Ophthalmic/Otic
Oncology
Endocrine
Endocrine
ST=Step therapy
AL=Age Limit
PF=Partial Fill
TS=Tab Splitting
- Prescription Only
Cough and Cold
Oncology/Cancer
- Prescription Only
- Prescription Only
- Prescription Only
- Prescription Only
40
Alphabetical Index
Medication Name
Generic Name
Tier
Special
Code
Drug Class
Subclass
PA, QL90 (50mg
QL-180)
CNS
Anticonvulsants
Ophthalmic/Otic
ST, QL-60
Cardiovascular
Parkinson's Disease
Parkinson's Disease
Adrenergics
Potency
Immunosuppressants
Anti-inflammatory/Immunology
/Immunosuppressants
/Immunosuppressants
Estrogen/Progestin
Hormone Replacement- Infertility
Estrogen/Progestin
Estrogen/Progestin
Estrogen/Progestin
Estrogen/Progestin
- Prescription Only
- Prescription Only
- Prescription Only
labor induction agents
- Prescription Only
- Prescription Only
- Prescription Only
- Prescription Only
Anti-TB
- Prescription Only
Anti-Malarials
Anticonvulsants
POTIGA
ezogabine
2
PR OTIC
NC
PRADAXA
acetic acid/antipyrine/ benzocaine/
aluminum
dabigatran exetilate
pramipexole
pramipexole ER (MIRAPEX ER equiv)
PRAMOSONE
pramipexole
pramipexole ER
1
NC
NC
CNS
CNS
Dermatologic
PRANDIMET
PRANDIN
pravastatin
prazosin
PRECOSE
PRED FORTE
PRED MILD
PRED-G
prednicarbate
repaglinide/metformin
repaglinide
pravastatin
prazosin
acarbose
gentamicin/prednisolone
prednicarbate
2
2
1
1
NC
NC
2
2
1
Endocrine
Endocrine
Cardiovascular
Cardiovascular
Endocrine
Ophthalmic/Otic
Ophthalmic/Otic
Ophthalmic/Otic
Dermatologic
prednisolone
prednisolone
1
prednisolone sodium phosphate
prednisolone/sulfacetamide
prednisone
prednisone
1
1
1
1
PREDNISONE INTENSOL
prednisone
1
Oncology
PREFEST
estradiol/norgestimate tab
NC
Endocrine
PREGNYL
PREMARIN
HCG human chorionic gonadatropin
NC
2
Endocrine
Endocrine
PREMARIN CREAM
conjugated estrogen vaginal cream
2
Endocrine
PREMPHASE
2
Endocrine
2
Endocrine
prenatal
conjugated estrogens/
medroxyprogesterone tab
conjugated estrogens/
medroxyprogesterone tab
prenatal multivitamin/Fe/FA
PRENATAL PLUS
NC
Endocrine
prenatal vitamins
NC
Endocrine
PREPIDIL
PREPOPIK
PREVACID NAPRAPAC
PREVACID SOLUTAB
PREVIDENT
dionoprostone
citric acid/magnesium oxide/picosulfate
lansoprazole/naproxen
lansoprazole
sodium fluoride
2
2
NC
3
1
oxytocics
Gastroenterology
Gastroenterology
Gastroenterology
Endocrine
PREVIDENT
sodium fluoride
2
Endocrine
PREVIDENT 5000
sodium fluoride
2
Endocrine
PREVIDENT 5000 ENAMEL PROTECT
sodium fluoride/potassium nitrate
2
Endocrine
PREVIFEM
PREVPAC
PREZISTA
PRIFTIN
PRILOSEC OTC
PRIMACARE
lansoprazole/amoxicillin/clarithromycin
darunavir
rifapentine
omeprazole
$0
NC
4
NC
3
NC
Endocrine
Gastroenterology
Infectious Disease
Infectious Disease
Gastroenterology
Endocrine
primaquine
primidone
primaquine
primidone
1
1
PREMPRO
3
$0
TS,QL-30
QL-2
QL-2
Oncology
QL-2
QL-2
QL-2
(women)
ST
QL-120
Ophthalmic/Otic
Ophthalmic/Otic
Ophthalmic/Otic
Oncology
Endocrine
Infectious Disease
CNS
ST=Step therapy
AL=Age Limit
PF=Partial Fill
TS=Tab Splitting
41
Alphabetical Index
Medication Name
Generic Name
Tier
Special
Code
Drug Class
Subclass
CNS
Respiratory
Oncology
Oncology
Gastroenterology
Gastroenterology
Respiratory
Respiratory
Respiratory
Respiratory
Gastroenterology
Cardiovascular
Gastroenterology
Ophthalmic/Otic
Ophthalmic/Otic
Cardiovascular
Cardiovascular
Cardiovascular
Endocrine
Genitourinary
Immunosuppressants
Antiarrhythmics
Nausea/Vomiting
Nausea/Vomiting
- Prescription Only
Immunosuppressants
Oncology/Cancer
Nausea/Vomiting
Nausea/Vomiting
Cough and Cold
Cough and Cold
Cough and Cold
Cough and Cold
Nausea/Vomiting
Antiarrhythmics
Glaucoma
Beta Blockers
Beta Blockers
Beta Blockers
Other Genitourinary
PRISTIQ
PROAIR HFA
probenecid
probenecid/colchicine
desvenlafaxine
albuterol HFA
probenecid
probenecid/colchicine
3
NC
1
1
procainamide
PROCENTRA
PROCHIEVE gel
procainamide
dextroamphetamine
progesterone gel
3
NC
NC
Cardiovascular
CNS
Endocrine
prochlorperazine edisylate
prochlorperazine maleate
PROCRIT
prochlorperazine edisylate
prochlorperazine maleate (oral/rectal)
erythropoeitin
1
1
4
Gastroenterology
Gastroenterology
Cardiovascular
PROCTOFOAM-HC
PROCTO-PAK
PROCTOSOL-HC
PROFASI
hydrocortisone
hydrocortisone rectal cream
2
1
1
NC
PROFERRIN-FORTE
iron polypeptide/folic acid
2
Endocrine
progesterone
progesterone, micronized
1
Endocrine
progesterone injection
progesterone injection
NC
Endocrine
progesterone micronized
(PROMETRIUM equiv)
progesterone micronized
1
Endocrine
NC
Endocrine
PROGRAF
tacrolimus
NC
Oncology
PROLEUKIN
PROMACTA
aldesleukin
eltrombopag
NC
4
promethazine oral
promethazine suppositories
promethazine VC
promethazine VC-Codeine
promethazine/codeine
promethazine-DM
PROMETHEGAN
propafenone
propantheline
proparacaine ophth
PROPINE
propranolol
propranolol LA (INDERAL LA equiv)
propranolol/HCTZ
propylthiouracil
PROSED-DS
promethazine oral (tabs, syrup)
promethazine suppositories
phenylephrine/promethazine
phenylephrine/promethazine/codeine
promethazine/codeine
detromethorophan/promethazine
promethazine hcl
propafenone
propantheline
proparacaine opth
dipivefrin
propranolol
propranolol er
propranolol/HCTZ
propylthiouracil
methenamine/salicylate/methelyne
blue/benzoic acid
dinoprostone
1
1
1
1
1
1
1
1
1
1
NC
1
1
1
1
NC
2
oxytocics
labor induction agents
pantoprazole
Pralidoxime auto-injector
protriptyline
albuterol HFA
fluoxetine
doxepin
3
2
3
NC
NC
2
Gastroenterology
Antidotes
CNS
Respiratory
CNS
Dermatologic
pseudoephedrine
pseudoephedrine
NC
Respiratory
PSORCON
diflorasone topical
NC
Dermatologic
PULMICORT FLEXHALER
PULMOZYME
PURALUBE
PURE & GENTLE EYE DROPS
PURIXAN
budesonide
dornase alfa inhaled
mineral oil/white petrolatum opth oint
hypromellose opth
mercaptopurine
2
4
1
1
4
Miscellaneous Antidotes
Antihistamines
Potency
Oncology/Cancer
PROSTIN E2 VAGINAL
SUPPOSITORY
PROTONIX
PROTOPAM CHLORIDE
protriptyline
PROVENTIL
PROZAC WEEKLY
PRUDOXIN
PA,QL4,SP
SP
PA,SP
QL-2
PA,SP
PA
Gastroenterology
Gastroenterology
Gastroenterology
Endocrine
Oncology
Cardiovascular
Respiratory
Respiratory
Opthalmic/Otic
Ophthalmic/Otic
Oncology
ST=Step therapy
AL=Age Limit
PF=Partial Fill
TS=Tab Splitting
42
Alphabetical Index
Medication Name
Generic Name
Tier
Special
Code
Drug Class
Subclass
Gastroenterology
Infectious Disease
CNS
Anti-TB
- Prescription Only
Anti-Malarials
Antipsychotics
ACE-Inhibitors
ACE-Inhibitors
Antiarrhythmics
Antiarrhythmics
Anti-Malarials
Eye Anti-infectives
Eye Anti-infectives
Topical Antibacterial –
Prescription Strength Only
Calcium Metabolism/
ACE-Inhibitors
us Cardiovascular
Immunosuppressants
Other Endocrine
/Immunosuppressants
Multiple Sclerosis
Eye Allergy
PYLERA
pyrazinamide
pyridostigmine
bismuth/metonidazole/tetracycline
pyrazinamide
pyridostigmine
NC
1
1
pyridostigmine (MESTINON equiv)
pyridostigmine
3
CNS
pyridoxine
pyridoxine
1
Endocrine
pyrogallic acid
pyrogallol
2
Dermatologic
QNASL
QUALAQUIN
QUASENSE (SEASONALE equiv)
QUELICIN
QUESTRAN LIGHT powder, packets
QUESTRAN packets
quetiapine (SEROQUEL equiv)
QUILLIVANT XR
quinapril
quinapril/HCTZ
quinidine gluconate
quinidine sulfate
quinine sulfate
QUIXIN
QUIXIN
QUTENZA
beclomethasone nasal
quinine sulfate caps
succinylcholine chloride
cholestyramine light powder, packets
cholestyramine packets
quetiapine
methylyphenidate ER susp
quinapril
quinapril/HCTZ
quinidine gluconate
quinidine sulfate
quinine sulfate caps
levofloxacin opth
levofloxacin opth
capsaicin skin cleanser
3
NC
NC
2
NC
NC
1
NC
3
NC
1
1
NC
2
2
NC
Respiratory
Infectious Disease
Endocrine
CNS
Cardiovascular
Cardiovascular
CNS
CNS
Cardiovascular
Cardiovascular
Cardiovascular
Cardiovascular
Infectious Disease
Ophthalmic/Otic
Opthalmic/Otic
Dermatologic
QVAR
rabeprazole (ACIPHEX equiv)
RAGWITEK
raloxifene
beclomethasone
rabeprazole
short ragweed pollen
raloxifene
2
2
4
2***
ramipril
RANEXA
ramipril
ranolazine
3
2
ranitidine (ZANTAC equiv)
RAPAFLO
RAPAMUNE
ranitidine
silodosin
sirolimus
1
3
4
RAVICTI
RAYOS
glycerol phenylbutyrate
prednisone ER
NC
NC
Endocrine
Oncology
RAZADYNE
galantamine
NC
CNS
REBETOL
REBETRON
REBIF
RECLIPSEN(DESOGEN equiv)
RECTIV
REDNESS RELIEF
REFISSA
ribavirin solution
interferon alfa/ribavirin
interferon beta-1a
nitroglycerin rectal oint
naphazoline/glycerin opth
tretinoin
NC
NC
4
$0
NC
1
1
Infectious Disease
Infectious Disease
CNS
Endocrine
Gastroenterology
Opthalmic/Otic
Dermatologic
REFRESH
REFRESH CLASSIC
REFRESH DRY EYE THERAPY
REFRESH LACRI-LUBE
REFRESH OPTIVE
REFRESH OPTIVE ADVANCED
3
3
3
3
3
3
OTC
OTC
OTC
OTC
OTC
OTC
Opthalmic/Otic
Opthalmic/Otic
Opthalmic/Otic
Opthalmic/Otic
Opthalmic/Otic
Opthalmic/Otic
REFRESH OPTIVE SENSITIVE
REGRANEX
phenylephrine/polyvinyl alcohol opth
polyvinyl alcohol/povidone opth
polysorbate 80/glycerin opth
carboxymethylcellulose/glycerin
carboxymethylcellulose/glycerin/polysor
bate 80
carboxymethylcellulose/glycerin/PF
becaplermin
3
2
OTC
PA
Opthalmic/Otic
Dermatologic
RELENZA
zanamivir
2
Infectious Disease
RELISTOR
methylnaltrexone
4
QL-2
Rx/yr
PA
Other Antiviral
Gastroenterology
TS
QL-30
QL-30
PA,SP
Respiratory
Gastoenterology
Respiratory
Endocrine
Cardiovascular
Cardiovascular
QL-30
SP
PA,SP
Gastroenterology
Genitourinary
Oncology
ST=Step therapy
AL=Age Limit
PF=Partial Fill
TS=Tab Splitting
43
Alphabetical Index
Medication Name
Generic Name
Tier
Special
Code
Subclass
CNS
Migraine - Triptans
Cardiovascular
us Cardiovascular
- Prescription Only
- Prescription Only
- Prescription Only
Hormone Replacement- Infertility
Glaucoma
us Cardiovascular
Antianxiety
Oncology/Cancer
Cough and Cold
osuppressants
Immunosuppressants
Anti-TB
Anti-TB
Parkinson's Disease
Other Antiviral
RELPAX
eletriptan
3
REMODULIN
treprostinil
4
RENACIDIN
2
Endocrine
RENAGEL
citric acid/g-lactone/magnesium
carbonate
sevelamer
NC
Endocrine
RENOVA
tretinoin
2
RENVELA
sevelamer carbonate
2
REPRONEX
RESCRIPTOR
RESCULA
reserpine
menotropins
delaviradine
unoprostone isopropyl
reserpine
NC
4
3
1
SP
Endocrine
Infectious Disease
Opthalmic/Otic
Cardiovascular
RESTASIS
RESTORIL
RETIN-A
cyclosporine opth
temazepam
tretinoin
2
NC
NC
PA,QL-2
Ophthalmic/Otic
CNS
Dermatologic
RETIN-A MICRO
tretinoin microsphere
2
AL<35
Dermatologic
RETROVIR
REVIA
REVLIMID
REYATAZ
REZIRA
RHEUMATREX
zidovudine
naltrexone
lenalidomide
atazanavir
pseudoephedrine/hydrocodone
methotrexate sodium
NC
NC
4
4
2
2
RIBAPAK
RIBASPHERE
RIBATAB
ribavirin
RIDAURA
ribavirin
ribavirin
ribavirin
ribavirin
auranofin
4
4
4
4
2
rifampin
RIFATER
RILUTEK
rimantadine
ringers irrigation solution
rifampin
isoniazid/pyrazinamide
riluzole
rimantadine
ringers solution
1
2
4
1
1
Infectious Disease
Infectious Disease
CNS
Infectious Disease
Infectious Disease
NC
NC
1
Endocrine
Endocrine
Endocrine
RIOMET
risedronate DR (ATELVIA equiv)
risendronate 150 mg (ACTONEL
equiv)
RISPERDAL
risperidone
RITALIN LA
rivastigmine
metformin liquid
risedronate DR
risendronate
ST, QL6/12
PA
Drug Class
AL<35
Dermatologic
Endocrine
PA,SP
SP
SP
SP
SP
Infectious Disease
CNS
Oncology
Infectious Disease
Respiratory
Oncology
Infectious Disease
Infectious Disease
Infectious Disease
Infectious Disease
Oncology
risperidone
risperidone
methylphenidate (10mg only)
rivastigmine
NC
1
2
NC
1
QL-12/24
CNS
2
QL-12/24
CNS
Migraine - Triptans
ROFERON
ropinirole
ropinirole SR (REQUIP XL equiv)
ROSAC
rizatriptan (max 12 tabs/copay, 2
copays/month)
rizatriptan ODT(max 12 tabs/copay, 2
copays/month)
interferon alfa 2a
ropinirole
ropinirole SR
sulfacetamide/sulfur cream
Antipsychotics
Antipsychotics
Migraine - Triptans
NC
1
NC
NC
Infectious Disease
CNS
CNS
Dermatologic
ROSANIL
sulfacetamide/sulfur skin cleanser
NC
Dermatologic
ROSULA
sulfacetamide sodium/sulfur/urea
NC
Dermatologic
ROWASA
mesalamine rectal
2
Gastroenterology
Parkinson's Disease
Parkinson's Disease
rizatriptan (MAXALTequiv)
rizatriptan (MLT equiv)
TS
CNS
CNS
CNS
CNS
ST=Step therapy
AL=Age Limit
PF=Partial Fill
TS=Tab Splitting
44
Alphabetical Index
Medication Name
Generic Name
ROXICET
Tier
Special
Code
Drug Class
Subclass
CNS
Narcotics
2
CNS
Narcotics
NC
NC
NC
CNS
CNS
Respiratory
Hypnotics
Narcotics
Antihistamines
Antiarrhythmics
Anticonvulsants
Conceptives : Monophasic
oxycodone/acetaminophen (excludes
5/500)
oxycodone/acetaminophen (excludes
5/500)
ramelteon
tramadol ODT
phenylephrine/chlor-tan
1
NC
4
NC
SAIZEN
SALAGEN
SALEX
propafenone SR
vigabatrin
drospinerone/ethinyl estradiol/
levomefolate
somatropin
pilocarpine
salicylic acid/ceramide CMB #1
NC
NC
NC
Endocrine
Endocrine
Dermatologic
SALICYLIC ACID
salicylic acid
1
Dermatologic
NC
Dermatologic
salsalate
salsalate
1
CNS
SAMSCA
tolvaptan
4
SANCTURA
SANCTURA SR
SANCUSO
SANDIMMUNE
trospium
trospium ER
granisetron patch
cyclosporine
NC
NC
NC
4
SANDOSTATIN
SANTYL
octreotide
collagenase clostridium
NC
2
SAPHRIS
SAVELLA
asenapine
milnacipran
2
2
scopolamine hydrobromide
sdium chloride vial
scopolomine hydrobromide
bacteriostatic sodium chloride vial
1
3
Gastroenterology
Endocrine
SEASONALE
SEASONIQUE
SEB-PREV
NC
NC
NC
Endocrine
Endocrine
Dermatologic
SECONAL
SE-DONNA PB HYOS
2
1
CNS
Gastroenterology
selegiline
selenium sulfide topical
SELZENTRY
SENSIPAR
secobarbital
phenobarbital/hyoscyamine/atropine/sco
polamine
selegiline
selenium sulfide (shampoo, topical susp)
maraviroc
cinacalcet
1
1
4
4
CNS
Dermatologic
Infectious Disease
Endocrine
SEREVENT
SEROMYCIN
SEROQUEL XR
SEROSTIM
sertraline
sevelamer
salmeterol inhaler
cycloserine
quetiapine XR
somatropin
sertraline
sevelamer carbonate
NC
2
3
4
1
2
SF 5000 PLUS
sodium fluoride
1
Endocrine
sildenafil (REVATIO equiv)
sildenafil
NC
Cardiovascular
SILENOR
doxepin
NC
CNS
ROXICET
ROZEREM
RYBIX
RYNATAN
RYTHMOL SR
SABRIL
SAFYRAL
PA,SP
PA, QL10, SP
NTI
SP
PA, QL60
SP
PA, SP
TS
Cardiovascular
CNS
Endocrine
Cardiovascular
Genitourinary
Genitourinary
Gastroenterology
Oncology
Endocrine
Dermatologic
CNS
CNS
Respiratory
Infectious Disease
CNS
Endocrine
CNS
Endocrine
ST=Step therapy
AL=Age Limit
PF=Partial Fill
TS=Tab Splitting
Growth Hormones
Miscellaneous Oral
Medications
Diuretics
Nausea/Vomiting
osuppressants
Antipsychotics
- Prescription Only
Hypnotics
Parkinson's Disease
Calcium Metabolism/
Anti-TB
Antipsychotics
Growth Hormones
- Presription Only
- Prescription Only
us Cardiovascular
Hypnotics
45
Alphabetical Index
Medication Name
Generic Name
Tier
Special
Code
Drug Class
Subclass
Dermatologic
- Prescription Only
electrolytes/Minerals/Supplements
- Prescription Only
- Prescription Only
- Prescription Only
- Prescription Only
- Prescription Only
- Prescription Only
- Prescription Only
Oral Acne
Oncology/Cancer
Growth Hormones
Hypnotics
Beta Blockers
Beta Blockers
Oral Acne
Antiviral-Hepatitis
Cephalosporins
Diuretics
Diuretics
Anti-Parasitics
Medications
Oncology/Cancer
- Prescription Only
SILVADENE
silver sulfadiazine
NC
silver nitrate
silver nitrate
1
Dermatologic
silver sulfadiazine
silver sulfadiazine
1
Dermatologic
SIMCOR
SIMPONI
simvastatin/niacin
golimumab
3
NC
ST
Cardiovascular
Immunology
simvastatin 5,10,20,40mg
simvastatin 80mg
SKELID
SKLICE
simvastatin
simvastatin
tiludronate
ivermectin topical
1
1
NC
3
QL-45,TS
QL-15,TS
Cardiovascular
Cardiovascular
Endocrine
Dermatologic
sodium bicarbonate
sodium bicarbonate
1
Endocrine
sodium chloride
sodium chloride irrigation
1
Dermatologic
sodium chloride 3% for inhalation
sodium chloride injection
sodium chloride 3% for inhalation
0.9 % sodium chloride
1
1
Respiratory
Endocrine
sodium fluoride
sodium fluoride
$0,
sodium fluoride
sodium fluoride
1
Endocrine
sodium fluoride cream or gel
sodium fluoride
NC
Endocrine
sodium fluoride rinse
sodium fluoride
1
Endocrine
sodium hydroxide
sodium hydroxide
3
Endocrine
1
Endocrine
sodium sulfacetamide/sulfur
sodium sulfacetamide/sulfur
1
Dermatologic
sodium sulfacetamide/urea
sodium sulfacetamide/urea
1
Dermatologic
SOLODYN
SOLTAMOX
SOMA
SOMATULINE DEPOT
SOMAVERT
SOMNOTE
sorbitol
minocycline ER
tamoxifen citrate soln
carisoprodol
lanreotide
pegvisomant
chloral hydrate
sorbitol
NC
4
NC
NC
NC
1
1
sorbitol/mannitol
sorbitol/mannitol
1
Dermatologic
SORIATANE
sotalol
sotalol AF
SOTRET
SOVALDI
SOVALDI
SPECTRACEF
spinosad (NATROBA equiv)
acitretin
sotalol
sotalol AF
isotretinoin
sofosbuvir
sofosbuvir
cefditoren
spinosad
4
1
NC
NC
4
4
NC
NC
Dermatologic
Cardiovascular
Cardiovascular
Dermatologic
Infectious Diesease
Infectious Disease
Infectious Disease
Dermatologic
SPIRIVA HANDIHALER
SPIRIVA RESPIMAT
spironolactone
spironolactone/HCTZ
SPORANOX
SPRINTEC (ORTHO-CYCLEN equiv)
SPRIX
tiotropium inhaler
tiotropium bromide
spironolactone
spironolactone/HCTZ
itraconazole solution
ketorolac nasal
3
3
1
1
2
$0
NC
ST
ST
Respiratory
Respiratory
Cardiovascular
Cardiovascular
Infectious Disease
Endocrine
CNS
SPRYCEL
SPS
dasatinib
4
2
PA,PF,SP
Oncology
Endocrine
AL
PA
PA,ST,SP
PA,SP
Endocrine
Dermatologic
Oncology
CNS
Endocrine
Endocrine
CNS
Dermatologic
ST=Step therapy
AL=Age Limit
PF=Partial Fill
TS=Tab Splitting
46
Alphabetical Index
Medication Name
Generic Name
Tier
Special
Code
Drug Class
Subclass
Endocrine
Infectious Disease
CNS
Miscellaneous
Dematologic
Opthalmic/Otic
Opthalmic/Otic
Endocrine
Oncology
CNS
Endocrine
SRONYX (LEVLITE equiv)
stavudine
STAVZOR
STAXYN
STELARA
STERILE LUBRICANT
STERILUBE
STIMATE
STIVARGA
STRATTERA
STRIANT
stavudine
valproic acid SA
vardenafil ODT
ustekinumab
carboxymethylcellulose sodium
desmopressin
regorafenib
atomoxetine
testosterone buccal
$0
4
NC
NC
NC
NC
NC
2
4
2
3
STRIBILD
4
Infectious Disease
2
2
NC
NC
NC
Infectious Disease
CNS
CNS
CNS
Gastroenterology
Anti-Parasitics
Drug/Alcohol Cessation
Narcotics
sucralfate
sulfacetamide ophth
elvitegravir/cobicistat/emtricitabine/teno
fovir disoproxil
ivermectin
fentanyl sublingual spray
buprenorphine
sodium sulfate/mag sulfate/PEG/
electrolytes
sucralfate
sulfacetamide ophth (oint, susp)
Anticonvulsants
Injectable Biologics
Oncology/Cancer
Gastroenterology
Ophthalmic/Otic
Dermatologic
sulfacetamide topical
sulfacetamide topical
1
sulfacetamide/prednisolone
sulfacetamide/urea
sulfacetamide/urea
1
1
sulfadiazine
sulfamethoxazole/trimethoprim
SULFAMIDE
SULFAMYLON
sulfadiazine
sulfamethoxazole/trimethoprim
sulfacetamide sodium opth
mafenide acetate
1
1
1
2
sulfasalazine
SULFAZINE EC
sulfisoxazole
sulindac
sulfasalazine
sulfasalazine
sulfisoxazole
sulindac
1
1
NC
1
sumatriptan injection
sumatriptan nasal (20 mg Only)
sumatriptan tablets
SUMAVEL DOSEPRO
SUPRAX (capsules and chewable
tablets)
SUPREP BOWEL PREP
SURVANTA
SUSTIVA
SUTENT
SYEDA (YASMIN equiv)
SYLATRON
SYMBICORT
SYMLIN
sumatriptan tablets
cefixime
2
2
NC
1
NC
3
Other GI/Ulcer
Eye Anti-infectives
Topical Antibacterial//Prescription
strengths only covered
Medications
Migraine - Triptans
Migraine - Triptans
Migraine - Triptans
Migraine - Triptans
Migraine - Triptans
Cephalosporins
sodium/potassium/mag sulfate
beractant
efavirenz
sunitinib
budesonide-formoterol
pramlintide
3
2
4
4
$0
NC
2
NC
SYNAREL
SYNERA
nafarelin nasal
lidocaine/tetracaine
4
NC
PA,SP
Endocrine
Dermatologic
SYNRIBO
SYNTHROID
SYPRINE
SYSTANE
TABLOID
TACLONEX
tacrolimus
omacetaxine mepesuccinate
levothyroxine
trientine
propylene glycol/PEG 400
thioguanine
calcipotriene/betamethasone
tacrolimus
NC
2
4
3
4
4
4
SP
NTI
Oncology
Endocrine
Antidotes
Opthalmic/Otic
Oncology
Dermatologic
Oncology
STROMECTOL
SUBOXONE film
SUBSYS
SUBUTEX
SUCLEAR
1
1
1
SP
SP
PA,SP
PA
QL-2
Dermatologic
QL-2
AL<35
Ophthalmic/Otic
Dermatologic
Infectious Disease
Infectious Disease
Ophthalmic/Otic
Dermatologic
Gastroenterology
Infectious Disease
Infectious Disease
CNS
QL-6/12
QL-6/12
QL-9/18
PA,PF,SP
SP
PA
PA
PA,SP
CNS
CNS
CNS
CNS
CNS
Infectious Disease
Gastroenterology
Respiratory
Infectious Disease
Oncology
Endocrine
Infectious Disease
Respiratory
Endocrine
ST=Step therapy
AL=Age Limit
PF=Partial Fill
TS=Tab Splitting
Oncology/Cancer
Injectables
Oncology/Cancer
Misc Antidotes
Oncology/Cancer
Immunosuppressants
47
Alphabetical Index
Medication Name
Generic Name
Tier
Special
Code
Drug Class
Subclass
Dermatologic
Oncology/Cancer
Medications
Antiarrhythmics
Other Antiviral
tacrolimus (PROTOPIC equiv)
tacrolimus
2
TAFINLAR
TALWIN
dabrafenib mesylate
pentazocine lactate
NC
3
SP
Oncology
CNS
TAMBOCOR
TAMIFLU
flecainide
oseltamivir
2
2
Cardiovascular
Infectious Disease
tamoxifen
tamsulosin (FLOMAX equiv)
TANZEUM
tamoxifen
tamsulosin
albiglutide
1***
1
2
NTI
QL-2Rxs
/year
TARCEVA
TARGRETIN GEL
erlotinib
bexarotene topical
4
2
PA,PF,SP
Oncology
Dermatologic
TARKA
TASIGNA
TAZORAC
TAZTIA XT
TEARS NATURALE FORTE
TEARS NATURALE PM
TECFIDERA
TEGRETOL
TEGRETOL XR
TEKAMLO
TEKTURNA
trandolapril/verapamil
nilotinib
tazarotene
diltiazem
dextran/hypromellose/glycerin opth
dimethyl fumarate
carbamazepine
carbamazepine SR
aliskiren/amlodipine
aliskiren
NC
4
2
1
3
3
4
2
2
NC
3
TEKTURNA HCT
aliskiren/HCTZ
NC
Cardiovascular
temazepam
TEMODAR
TEMOVATE
temazepam
temozolomide
1
NC
3
CNS
Oncology
Dermatologic
temozolomide (TEMODAR equiv)
terazosin
terbinafine tablets
terbutaline sulfate tablets
terconazole vaginal
terramycin w/ polymixin
Test strips - Abbott (Freestyle,
Freestyle Lite, Precision)
Test strips - Bayer (Ascensia, Contour,
Breeze)
Test Strips - ONE TOUCH,
ACCUCHEK (Lifescan, Roche)
TESTIM
temozolomide
terazosin
terbinafine
terbutaline sulfate tablets
terconazole vaginal
oxytetracycline w/polymixin
test strips
4
1
1
1
1
2
NC
test strips
NC
test strips (QL-150 on diabetes drug
therapy)
testosterone topical
2
NC
Endocrine
NC
Endocrine
testosterone enanthate injection
testosterone enanthate injection
2
PA
Endocrine
TESTRED
methyltestosterone
2
PA
Endocrine
tetracaine opth
tetracycline
TETRAVISC
TETRAVISC FORTE
TEVETEN HCT
TEV-TROPIN
TEXACORT
THALOMID
theophylline CR
theophylline ER tablet 24 hour
THERA TEARS
THEROBEC PLUS
tetracaine opth
tetracycline
tetracaine opth
tetracaine forte opth
eprosartan/HCTZ
somatropin
hydrocortisone
thalidomide
theophylline cr
theophylline ER tablet 24 hour
carboxymethylcellulose sodium
multivitamins with iron
1
1
1
1
NC
NC
2
4
1
1
NC
NC
QL-2
Ophthalmic/Otic
Infectious Disease
Ophthalmic/Otic
Ophthalmic/Otic
Cardiovascular
Endocrine
Dermatologic
Oncology
Respiratory
Respiratory
Opthalmic/Otic
Endocrine
PA,PF,SP
OTC
OTC
PA,SP
NTI
NTI
QL-45
PA, SP
Oncology
Genitourinary
Endocrine
Cardiovascular
Oncology
Dermatologic
Cardiovascular
Opthalmic/Otic
Opthalmic/Otic
CNS
CNS
CNS
Cardiovascular
Cardiovascular
Oncology
Cardiovascular
Infectious Disease
Respiratory
Infectious Disease
Opthalmic/Otic
Endocrine
Endocrine
QL50/3mo
QL-2
QL-2
PA, SP
Endocrine
ST=Step therapy
AL=Age Limit
PF=Partial Fill
TS=Tab Splitting
Oncology/Cancer
Injectables
Oncology/Cancer
ACE-Inhibitors
Oncology/Cancer
Multiple Sclerosis
Anticonvulsants
Anticonvulsants
ACE-Inhibitors
us Cardiovascular
us Cardiovascular
Hypnotics
Oncology/Cancer
Potency
Oncology/Cancer
Adrenergics
Anti-Fungals
Diabetes - Test
Strips/Meters/Supplies
Diabetes - Test
Diabetes - Test
Growth Hormones
Corticosteroids
Oncology/Cancer
- Prescription Only
48
Alphabetical Index
Medication Name
Generic Name
Tier
Special
Code
Drug Class
Subclass
Endocrine
- Prescription Only
Oncology/Cancer
Other Genitourinary
Antipsychotics
Antipsychotics
anticonvulsants
anticonvulsants
Antiarrhythmics
thiamine
thiamine hcl
1
thioguanine
THIOLA
thioridazine
thiothixene
THROMBIN-JMI
thioguanine
tiopronin
thioridazine
thiothixene
thrombin (bovine)
2
2
1
1
4
Oncology
Genitourinary
CNS
CNS
Cardiovascular
THYROLAR
tiagabine
tiagabine
ticlopidine
liotrix
tiagabine hcl
tiagabine
ticlopidine
2
1
2
1
Endocrine
CNS
CNS
Cardiovascular
TIKOSYN
TILLIA FE (ESTROSTEP FE equiv)
4
$0
TIMOLIDE
timolol
timolol ophth (TIMOPTIC, XE equiv)
TIMOPTIC
TIMOPTIC SE
tinidazole (TINDAMAX equiv)
TIROSINT
tizanidine capsules
tizanidine tablets
TL GARD RX
dofetilide
timolol/HCTZ
timolol maleate tab
timolol opth drops/gel
timolol opth
timolol gel
tinidazole
levothyroxine
tizanidine capsules
tizanidine tablets
cyanocobalamin/folic acid/pyridoxine
TL-FOL 500
ferous sulfate/vitamin C/folic acid
1
TOBI
TOBI PODHALER
TOBRADEX
4
NC
2
TOBRADEX ST
tobramycin inj for inh
tobramycin opth
tobramycin/dexamethasone opth
TOBREX
TOFRANIL PM
tolazamide
tolbutamine
tolcapone (TASMAR equiv)
TOLINASE
tolmetin
tobramycin inhalation
tobramycin inhalation
tobramycin/dexamethasone ophth
(oint/susp)
tobramycin/dexamethasone opth
tobramycin inj for inh
tobramycin opth
tobramycin/dexamethasone ophth
tobramycin opth oint
imipramine
tolazamide
tolbutamine
tolcapone
tolazamide
tolmetin
tolterodine (DETROL equiv)
TOPAMAX
TOPICORT
tolterodine
topiramate
desoximetasone
2
NC
3
topiramate
torsemide
TOVIAZ
TRACLEER
topiramate
torsemide
fesoterodine
bosentan
1
3
2
4
TS
TRADJENTA
tramadol
tramadol ER (RYZOLT equiv)
trandolapril
tranexamic acid
linagliptin
tramadol
tramadol ER
trandolapril
tranexamic acid
3
1
3
3
4
ST, QL-30
QL-30
Endocrine
CNS
CNS
Cardiovascular
Cardiovascular
tranexamic acid (LYSTEDA equiv)
tanexamic acid
1
QL-30
Cardiovascular
TRANSDERM SCOP
tranylcypromine
TRAVATAN
TRAVATAN Z
trazodone
TRECATOR
tretinoin capsules
scopolamine transdermal
tranylcypromine sulfate
travoprost ophth
travoprost ophth
trazodone
ethionamide
tretinoin capsules
2
1
NC
2
1
2
4
QL-10
Gastroenterology
CNS
Ophthalmic/Otic
Ophthalmic/Otic
CNS
Infectious Disease
Oncology
3
3
1
NC
NC
NC
2
3
1
3
3
NC
1
1
2
NC
3
3
2
NC
3
PA, SP
QL-2
TS
Cardiovascular
Endocrine
Cardiovascular
Cardiovascular
Ophthalmic/Otic
Ophthalmic/Otic
Ophthalmic/Otic
Infectious Disease
Endocrine
CNS
CNS
Endocrine
Endocrine
PA,SP
QL-2
QL-2
QL-2
Respiratory
Respiratory
Ophthalmic/Otic
Opthalmic/Otic
Infectious Disease
Ophthalmic/Otic
Ophthalmic/Otic
Opthalmic/Otic
CNS
Endocrine
Endocrine
CNS
Endocrine
CNS
Genitourinary
CNS
Dermatologic
PA,SP
QL-2
TS
PA, SP
CNS
Cardiovascular
Genitourinary
Cardiovascular
ST=Step therapy
AL=Age Limit
PF=Partial Fill
TS=Tab Splitting
Beta Blockers
Beta Blockers
Glaucoma
Glaucoma
Glaucoma
Anti-Parasitics
- Prescription Only
- Prescription Only
Eye Anti-infectives
Parkinson's Disease
Medications
Anticonvulsants
Potency
Anticonvulsants
Diuretics
us Cardiovascular
Narcotics
Narcotics
ACE-Inhibitors
Nausea/Vomiting
Glaucoma
Glaucoma
Anti-TB
Oncology/Cancer
49
Alphabetical Index
Medication Name
Generic Name
Tier
Special
Code
Subclass
Dermatologic
Immunosuppressants
Migraine - Triptans
Potency
tretinoin microsphere (gel only
covered)
tretinoin topical
tretinoin microspehere gel
1
tretinoin (gel, cream)
1
TREXALL
methotrexate
NC
Oncology
TREXIMET
triamcinolone
sumatriptan/naproxen
NC
1
CNS
Dermatologic
1
triamcinolone nasal (NASACORT AQ
equiv)
triamterene/HCTZ
TRIAZ
triamcinolone nasal
NC
Topical Oral
Preparations
Respiratory
triamterene/HCTZ
benzoyl peroxide
1
NC
Cardiovascular
Dermatologic
triazolam
TRIBENZOR
TRI-CHLOR
TRICITRATES
triazolam
olmesartan/amlodipine/HCTZ
trichloroacetic acid
sodium/potassium/citric acid
preparation
iron fumarate/vitamin c/b12/folic acid
combinationFE FUMARATE/VIT C/B12IF/FA
trifluoroperazine
trifluridine ophth
fenofibrate
trihexyphenidyl
fenofibric acid
fluocinolone/hydroquinone/tretinoin
topical
1
NC
2
1
CNS
Cardiovascular
Dermatologic
Endocrine
1
Endocrine
TRILYTE
trimethobenzamide
trimethoprim
trimethoprim/sulfamethoxazole
trimipramine (SURMONTIL equiv)
TRINESSA (ORTHO TRI-CYCLEN
equiv)
TRI-NORINYL
TRIPHASIL
TRI-PREVIFEM (ORTHO TRI-CYCLEN
equiv)
TRI-SPRINTEC (ORTHO TRICYCLEN equiv)
tri-vitamin drops w/ iron and fluoride
trimethobenzamide
trimethoprim
trimethoprim/sulfamethoxazole
trimipramine
NC
NC
1
1
NC
$0
TRIVORA (TRIPHASIL equiv)
TRIZIVIR
TROPICACYL
TROPICAMIDE
trospium
TRUSOPT
TRUVADA
TRYMINE CG
TUDORZA PRESSAIR
TUSSICAPS
TUSSIONEX PENNKINETIC
TWYNSTA
TYKEKA
TYKERB
TYLENOL-CODEINE NO.3
TYLENOL-CODEINE NO.4
TYVASO
TRICON
trifluoroperazine
trifluridine ophthalmic
TRIGLIDE
trihexyphenidyl
TRI-LEGEST FE (ESTROSTEP FE equiv)
TRI-LEVLEN
TRI-LINYAH
TRILIPIX
TRI-LUMA
1
1
3
1
$0
ST,
AL<35
AL<35
Drug Class
Dermatologic
Antihistamines
Diuretics
Hypnotics
Miscellaneous Topical Agents
- Prescription Only
- Prescription Only
CNS
Ophthalmic/Otic
Cardiovascular
CNS
Endocrine
Antipsychotics
Eye Anti-infectives
Parkinson's Disease
Endocrine
Endocrine
Cardiovascular
Dermatologic
Gastroenterology
Gastroenterology
Infectious Disease
Infectious Disease
CNS
Endocrine
Contraceptives :
Nausea/Vomiting
NC
NC
$0
Endocrine
Endocrine
Endocrine
$0
Endocrine
vitamins a, c, and d/iron/fluoride
NC
Endocrine
tropicamide ophthalmic solution
tropicamide opthalmic solution
trospium
dorzolamide opth soln
emtricitabine/tenofovir
guaifenisen/codeine
aclidinium bromide
chloripheniramine/hydrocodone
chloripheniramine/hydrocodone
amlodipine/telmisartan
telbivudine
lapatinib
acetaminophen with codeine
acetaminophen with codeine
treprostonil neb
$0
NC
1
1
NC
NC
4
1
3
NC
NC
NC
4
4
2
2
4
Endocrine
Infectious Disease
Ophthalmic/Otic
Opthalmic/Otic
Genitourinary
Ophthalmic/Otic
Infectious Disease
Respiratory
Respiratory
Respiratory
Respiratory
Cardiovascular
Oncology
Oncology
CNS
CNS
Cardiovascular
- Prescription Only
Miscellaneous Eye Products
Glaucoma
Cough and Cold
Cough and Cold
Cough and Cold
Oncology/Cancer
Oncology/Cancer
Narcotics
Narcotics
us Cardiovascular
NC
$0
2
NC
QL-2
QL-60
QL-2
ST
ST
PA
PA,SP
PA,SP
ST=Step therapy
AL=Age Limit
PF=Partial Fill
TS=Tab Splitting
50
Alphabetical Index
Medication Name
Generic Name
Tier
Special
Code
PA,SP
Drug Class
Subclass
Infectious Disease
Respiratory
Antihistamines
Immunosuppressants
Narcotics
Narcotics
Potency
Corticosteroids
- Prescription Only
Estrogen/Progestin
Other Antiviral
Anticonvulsants
ACE-Inhibitors
TYZEKA
TYZINE
telbivudine
tetrahydrozoline hcl nasal
4
3
ULESFIA
benzyl alcohol topical
3
Dermatologic
ULORIC
febuxostat
3
Oncology
ULTRA MIDE 25
urea
1
Dermatologic
ULTRACET
ULTRAM ER
ULTRAVATE
tramadol/acetaminophen
tramadol ER
halobetasol propionate
NC
NC
3
CNS
CNS
Dermatologic
ULTRAVATE X
ULTRESA
UMECTA
halobeatasol/lactic acid
urea
2
2
2
PA
Dermatologic
Gastroenterology
Dermatologic
UNIPHYL
UNITHROID
urea
theophylline
levothyroxine
urea
NC
1
1
NTI
Respiratory
Endocrine
Dermatologic
URISPAS
UROCIT-K
flavoxate
potassium citrate
2
3
Genitourinary
Endocrine
UROXATRAL
ursodiol
VAGIFEM
alfuzosin
ursodiol
estradiol vaginal tab
NC
1
2
Genitourinary
Gastroenterology
Endocrine
valacyclovir
VALCYTE
valproate
valsartan (DIOVAN equiv)
valsartan/HCTZ (DIOVAN HCT equiv)
VALTURNA
VANAMIDE
valacyclovir
valganciclovir
valproic acid
valsartan
valsartan/HCTZ
aliskiren/valsartan
urea topical
1
4
1
1
NC
NC
NC
vancomycin (VANCOCIN PULVULES
equiv)
vandetanib
VANIQUA
vancomycin oral
4
vandetanib
eflornithine topical
4
NC
VANOS
fluocinonide
NC
Dermatologic
vasopressin
VELIVET (CYCLESSA equiv)
VENELEX
vasopressin
balsam peru/castor oil
1
NC
2
Endocrine
Endocrine
Dermatologic
venlafaxine (EFFEXOR equiv)
venlafaxine ER capsules (EFFEXOR XR
equiv)
venlafaxine ER tablets (225 mg ONLY)
VENTAVIS
venlafaxine
venlafaxine ER
1
1
QL-30
QL-30
CNS
CNS
venlafaxine ER
iloprost inhaled
2
4
PA,SP
CNS
Cardiovascular
VENTOLIN HFA inhaler
VERAMYST
albuterol HFA
fluticasone furoate nasal
2
2
QL-2
QL-2
Respiratory
Respiratory
verapamil
verapamil SR (tablets only, ISOPTIN SR
equiv)
VERDESO
verapamil
verapamil ER
1
1
Cardiovascular
Cardiovascular
desonide
NC
Dermatologic
TS
SP
Infectious Disease
Infectious Disease
CNS
Cardiovascular
Cardiovascular
Cardiovascular
Dermatologic
Infectious Disease
PA
Oncology
Dermatologic
ST=Step therapy
AL=Age Limit
PF=Partial Fill
TS=Tab Splitting
Oncology/Cancer
Potency
Other Hormones
us Cardiovascular
Antihistamines
51
Alphabetical Index
Medication Name
Generic Name
Tier
Special
Code
Drug Class
Subclass
Dermatologic
Infectious Disease
Immunosuppressants
Anti-Parasitics
Narcotics
Injectables
PA,SP
Infectious Disease
Infectious Diesease
Antiviral-Hepatitis
4
PA,SP
Infectious Disease
VEREGEN
sinecatechins
2
VERIPRED 20
2
VESICARE
VEXOL
VFEND
VIAGRA
VIBRAMYCIN SYRUP
VICOPROFEN
VICTOZA
solifenacin
rimexolone opth
voriconazole
sildenafil
doxycycline syrup
liraglutide
2
2
NC
NC
NC
NC
2
VICTRELIS
boceprevir
4
VIDEX
VIEKIRA PAK
4
4
VIGAMOX
VIIBRYD
VIMOVO
didanosine
ombitasvir/paritaprevir/ritonavir/
dasabuvir
ombitasvir/paritaprevir/ritonavir/
dasabuvir
moxifloxacin ophth
vilazodone
naproxen/esomeprazole
2
NC
3
QL-2
Ophthalmic/Otic
CNS
CNS
VIMPAT
lacosamide
2
CNS
VIOKACE
pancrelipase
2
Gastroenterology
VIORELE
VIRACEPT
VIRAMUNE XR
VIREAD
VIRT-VITE
nelfinavir
nevirapine extended release
tenofovir
pyridoxine/cyanocobalamin/folic acid
$0
2
2
4
1
PA, QL60
PA,QL750
Eye Anti-infectives
Antidepressants – SSRI/SNRI
Medications
Anticonvulsants
Endocrine
Infectious Disease
Infectious Disease
Infectious Disease
Endocrine
VISICOL
VISINE
VISINE
3
3
3
VISINE
vitamin D2
sodium phosphate
PEG 400/hypromellose/glycerin
testrahydroz/PEG
400/hypromellose/glycerin
PEG 400/hypromellose/glycerin
- Prescription Only
NC
1
Opthalmic/Otic
Endocrine
vitamin K
phytonadione (vitamin K)
2
Endocrine
VITEKTA
VITRASERT
VIVELLE-DOT
elvitegravir
ganciclovir
2
2
NC
Infectious Disease
Opthalmic/Otic
Endocrine
VIVITROL
naltrexone microspheres
4
VIVOTIF
VOLTAREN GEL
typhoid vaccine (live oral)
diclofenac gel
NC
NC
VOLTAREN OPTH
voriconazole (VFEND equiv)
VOTRIENT
VUSION
diclofenac ophth
voriconazole
pazopanib
miconazole nitrate/zinc oxide
NC
4
4
NC
PA
PA,PF,SP
Ophthalmic/Otic
Infectious Disease
Oncology
Dermatologic
VYTORIN
VYVANSE
warfarin (COUMADIN equiv)
ezetimibe/simvastatin
lisdexamfetamine
warfarin
2
2
1
QL-30,TS
QL-60
NTI
Cardiovascular
CNS
Cardiovascular
WATER
sterile water for irigation
1
Anti-Infectives
WATER
bacteriostatic water for injection
1
Endocrine
WATER
water/methyparaben/polyparaben
1
Endocrine
WELCHOL
colesevelam
2
Cardiovascular
VIEKIRA PAK
Oncology
QL-2
PA,QL360,SP
OTC
OTC
SP
Genitourinary
Ophthalmic/Otic
Infectious Disease
Infectious Disease
CNS
Endocrine
Gastroenterology
Opthalmic/Otic
Opthalmic/Otic
Endocrine
Vaccines
CNS
ST=Step therapy
AL=Age Limit
PF=Partial Fill
TS=Tab Splitting
- Prescription Only
- Prescription Only
Eye Anti-infectives
- Prescription Only
Miscellaneous Oral Vaccines
Medications
Anti-Fungals
Oncology/Cancer
- Prescription Only
- Prescription Only
52
Alphabetical Index
Medication Name
Generic Name
Tier
Special
Code
Drug Class
Subclass
Dermatologic
Corticosteroids
Endocrine
Ophthalmic/Otic
Oncology
Cardiovascular
Glaucoma
Oncology/Cancer
Anti-inflammatory
Oncology/Cancer
Parkinson's Disease
Other Topicals
Osteoporosis Agents
Oncology/Cancer
WESTCORT
2
WESTHROID
XALATAN
XALKORI
XARELTO
thyroid, dessicated
latanoprost ophth
crizotinib
rivaroxaban
NC
NC
4
2
XELJANZ
XELODA
XENADERM
tofacitinib
capecitabine
trypsin/balsam/castor oil
NC
NC
NC
XENAZINE
XENICAL
XERAC AC
tetrabenazine
orlistat
aluminum chloride
3
NC
2
XERESE
acyclovir/hydrocortisone
NC
Dermatologic
XGEVA
XIBROM
XIFAXAN
XIGDUO XR
XOLEGEL
denosumab
bromfenac ophth
rifaximin
dapagliflozin/metformin
ketoconazole
NC
NC
3
3
NC
Endocrine
Ophthalmic/Otic
Infectious Disease
Endocrine
Dermatologic
XTANDI
XULANE patch (ORTHO EVRA
PATCH equiv)
XYREM
YASMIN
YAZ
YODOXIN
ZADITOR OTC
zafirlukast (ACCOLATE equiv)
zaleplon (SONATA equiv)
ZAMICET
ZANTAC
ZARAH (YASMIN equiv)
ZAVESCA
enzalutamide
norelgestromin/ethinyl estradiol
4
$0
sodium oxybate
iodoquinol
ketotifen ophth
zafirlukast
zaleplon
ranitidine
miglustat
NC
NC
$0
2
NC
1
1
3
NC
$0
4
ZEBUTAL
ZEGERID
ZELAPAR
ZELBORAF
ZEMPLAR
butalbital/acetaminophen/caffeine
selegiline
vemurafenib
paricalcitol
1
NC
2
4
4
ZENCHENET (OVCON equiv)
ZENPEP
NC
2
ZERIT
ZETIA
ZETONNA
ZEVALIN
ZIAGEN
ZIANA
stavudine
exetimibe
ciclesonide nasal
ibritumomab tiuxetan
abacavir sulfate
clindamycin/tretinoin
NC
2
3
NC
4
NC
zidovudine
zinc sulfate granules
zidovudine
zinc sulfate granules
4
NC
Infectious Disease
Endocrine
ZIOPTAN
ziprasidone (GEODON equiv)
ZIRGAN
ZITHRANOL
tafluprost ophthalmic
ziprasidone
ganciclovir ophthalmic
anthralin
3
2
2
3
Ophthalmic/Otic
CNS
Ophthalmic/Otic
Dermatologic
ZMAX
ZOLADEX
ZOLINZA
zolpidem (AMBIEN equiv)
azithromycin SR suspension
goserelin
vorinostat
zolpidem
NC
4
4
1
PA, SP
Immunology
Oncology
Dermatologic
PA
PA,SP
QL-30
PA, SP
PA,SP
PA,QL750
TS
ST,QL-2
PA
PA,PF,SP
CNS
CNS
Dermatologic
Oncology
Endocrine
CNS
Endocrine
Endocrine
Infectious Disease
Ophthalmic/Otic
Respiratory
CNS
CNS
Gastroenterology
Endocrine
Endocrine
CNS
Gastroenterology
CNS
Oncology
Endocrine
Endocrine
Gastroenterology
Infectious Disease
Cardiovascular
Respiratory
Oncology
Infectious Disease
Dermatologic
Infectious Disease
Oncology
Oncology
CNS
ST=Step therapy
AL=Age Limit
PF=Partial Fill
TS=Tab Splitting
Anticonvulsants
Anti-Parasitics
Eye Allergy
Hypnotics
Narcotics
Calcium Metabolism/
Migraine
Parkinson's Disease
Oncology/Cancer
Calcium Metabolism/
Oncology/Cancer
Antivirals, HIV/CMV/Hepatitis
- Prescription Only
Glaucoma
Antipsychotics
Eye Anti-infectives
Macrolide/Ketolide
Oncology/Cancer
Oncology/Cancer
Hypnotics
53
Alphabetical Index
Medication Name
Generic Name
Tier
zolpidem ER (AMBIEN CR equiv)
ZOLPIMIST
ZOLVIT
ZOMIG
zolpidem ER
zolpidem spray
hydrocodone/apap
zolmitriptan
NC
NC
2
3
ZOMIG ZMT
zolmitriptan odt
3
ZONALON
doxepin hcl cream
2
zonisamide
ZONTIVITY
zonisamide
vorapaxar
Special
Code
ST, QL6/12
ST, QL6/12
1
3
ZORBTIVE
ZORTRESS
ZOSTAVAX
ZOVIA (DEMULEN equiv)
ZOVIRAX
ZUPLENZ
ZYCLARA
somatropin
everolimus
herpes zoster vaccination
acyclovir topical
ondansetron strips
imiquimod
4
4
$0
$0
NC
NC
2
ZYDONE
ZYFLO
ZYKADIA
ZYLET
ZYMAR
ZYMAXID
ZYRTEC
ZYTIGA
zileutin
ceritinib
oteprednol/tobramycin ophth
gatifloxacin ophthalmic
gatifloxacin ophthalmic
cetirizine
abiraterone
NC
NC
4
3
NC
2
NC
4
Drug Class
Subclass
CNS
CNS
CNS
CNS
Hypnotics
Hypnotics
Narcotics
Migraine
CNS
Migraine
Dermatologic
Anticonvulsants
Growth Hormones
Oncology/Cancer
Other Antiviral
Nausea/Vomiting
Other Topicals
Narcotics
Oncology/Cancer
Eye Anti-Infectives
Eye Anti-infectives
Oncology/Cancer
CNS
Cardiovascular
PA, SP
SP
AL >59
PA
QL-2
PA,SP
Endocrine
Oncology
Vaccines
Endocrine
Infectious Disease
Gastroenterology
Dermatologic
CNS
Respiratory
Oncology
Ophthalmic/Otic
Opthalmic/Otic
Ophthalmic/Otic
Respiratory
Oncology
* This medication is covered at a zero dollar copay when used for smoking cessation only and for a maximum annual duration of 6 months, please call 608-260-7803 for details
** This medications is covered at a zero dollar copay up to once annually for members aged 50 years or greater, please call 608-260-7803 for details
*** Please note for primary prevention (prophylaxis/first-line prevention prior to a cancer diagnosis) this medication may be covered at a Tier 5 $0 copay based on Affordable Care Act
Women’s Healthcare Reform Laws; please contact Physicians Plus Pharmacy Services at 608-320-1104 or 800-545-5015 with questions to see if you may be eligible
ST=Step therapy
AL=Age Limit
PF=Partial Fill
TS=Tab Splitting
54
Prior Authorization Drug Forms
For those drugs that require prior authorization but are not listed below, please use the
Standard Prior Authorization (PA) Request: Medication PA Request Form
Forms listed alphabetically by the drug’s brand name
A
Actemra (tocilizumab) – MB
Acthar Gel (repository corticotropin)
Adempas (riociguat)
Amitiza (lubiprostone)
Ampyra (dalfampridine)
Androgel (testosterone gel)
Androderm (testosterone transdermal)
Apokyn (apomorphine)
Arcalyst (rilonacept) – MB
Aubagio (teriflunomide)
Avita (tretinoin 0.025%)
Azelex (azelaic acid 20%)
B
Banzel (rufinamide)
Benlysta (belimumab) – MB
Berinert (C1 Esterase Inhibitor) - MB
Betaseron (interferon beta-1b)
Boniva (ibandronate intravenous) - MB
C
Carimune NF (immune globulin) - MB
Cayston (aztreonam lysine Inhalation Solution)
Cerezyme (imiglucerase) - MB
Cimzia (certolizumab)
Cinryze (C1 Esterase Inhibitor) - MB
Compounds (>$100)
D
Differin (adapalene)
Dificid (fidaxomicin)
Dutoprol (metoprolol succinate / HCTZ)
E
Elelyso (taliglucerase alfa) - MB
Emsam Patch (selegilene)
Entocort EC (budesonide)
Erivedge (vismodegib)
Extavia (interferon beta-1b)
F
Fanapt (iloperidone)
Finacea (azelaic acid 15%)
Firazyr (icatibant)
generic Flebogamma (immune globulin) - MB
Forteo (teriparatide)
G
generic Gammagard Liquid (immune globulin) - MB
Gammagard S/D (immune globulin) - MB
Gammaplex (immune globulin) - MB
Gammar-P I.V. (immune globulin) - MB
Gamunex (immune globulin) - MB
Gilenya (fingolimod)
Glucose Test Strip Quantity Limit
Growth Hormone - Initiation
Growth Hormone - Continuation
H
Hereditary Angioedema
Hizentra (immune globulin) - MB
Humira (adalimumab)
I
Ilaris (canakinumab) – MB
Immunoglobulin (IV & SC) - MB
Intuniv (guanfacine)
Invega (paliperidone)
K
Kalbitor (ecallantide) — MB
L
Latuda (lurasidone)
Letairis (ambrisentan)
Lidoderm Patch (lidocaine patch 5%)
Linzess (linaclotide)
Lovaza (omega-3-acids)
Lyrica (pregabalin)
M
Mekinist (trametinib)
Metozolv ODT (metoclopramide)
Multiple Sclerosis (interferons)
N
Noxafil (posaconazole)
Nplate (romiplostim)
O
Olysio (simeprevir)
Onfi (clobazam)
Oral Cancer Drugs
Orencia (abatacept) - MB
Opsumit (macitentan)
Oxandrin (oxandrolone)
55
P
Patanol (olopatadine ophthalmic)
Potiga (ezogabine)
Privigen (immune globulin) - MB
Prolia (denosumab) – MB
Promacta (eltrombopag)
R
Rebif (interferon beta-1a)
Reclast (zoledronic acid intravenous) - MB
Regranex (becaplermin)
Relistor (methylnaltrexone)
Remicade (infliximab) - MB
Renova (tretinoin 0.02%)
Restasis (cyclosporine ophthalmic)
Retin-A-Micro (tretinoin)
Rituxan (rituximab) - MB
S
Sabril (vigabatrin)
Samsca (tolvaptan)
Savella (milnacipran)
Sovaldi (sofosbuvir)
Sporanox (itraconazole)
Synagis (palivizumab) - MB
T
Taclonex (betamethasone dipropionate 0.064%
calcipotriene 0.005%)
Tafinlar (dabrafenib)
Tecfidera (dimethyl fumarate)
Testim (testosterone gel)
Testosterone Replacement
Tikosyn (dofetilide)
TNF Inhibitor
Toprol XL (metoprolol succinate)
Tracleer (bosentan)
Tretinoin & Vitamin A Analogues (topical)
Tysabri (natalizumab) – MB
U
V
Vfend (voriconazole)
Victrelis (boceprevir)
Vimpat (lacosamide)
Vivaglobin (immune globulin) - MB
Vivitrol (naltrexone IM) - Medical and Pharmacy
Benefit Drug
X
Xeljanz (tofacitinib)
Xenazine (tetrabenazine)
Xolair (omalizumab) - MB
Xylocaine (Lidocaine) Infusion for chronic pain
Y
Yervoy (ipilimumab) - MB
Z
Zavesca (miglustat)
Zelboraf (vemurafenib)
Zenpep (pancrelipase)
Forms listed alphabetically by their drug’s generic name
A
abatacept (Orencia) - MB
adalimumab (Humira)
adapalene (Differin)
ambrisentan (Letairis)
apomorphine (Apokyn)
azelaic acid 15% (Finacea)
azelaic acid 20% (Azelex)
aztreonam lysine Inhalation Solution (Cayston)
B
becaplermin (Regranex)
belimumab (Benlysta) – MB
betamethasone dipropionate 0.064% calcipotriene
0.005% (Taclonex)
boceprevir (Victrelis)
bosentan (Tracleer)
budesonide (Entocort EC)
56
C
C1 Esterase Inhibitor (Berinert) - MB
C1 Esterase Inhibitor (Cinryze) - MB
canakinumab (Ilaris) – MB
certolizumab (Cimzia)
clobazam (Onfi)
cyclosporine ophthalmic (Restasis)
Compounds (>$100)
D
dabrafenib (Tafinlar)
dalfampridine (Ampyra)
denosumab (Prolia) – MB
dimethyl fumarate (Tecfidera)
dofetilide (Tikosyn)
E
ecallantide (Kalbitor) - MB
eltrombopag (Promacta)
ezogabine (Potiga)
F
fidaxomicin (Dificid)
fingolimod (Gilenya)
G
Glucose Test Strip Quantity Limit
Growth Hormone - Initiation
Growth Hormone - Continuation
guanfacine (Intuniv)
I
ibandronate intravenous (Boniva) - MB
icatibant (Firazyr)
iloperidone (Fanapt)
Imiglucerase (Cerezyme) - MB
Immunoglobulin (IV & SC) - MB
infliximab (Remicade) - MB
interferon beta-1a (Rebif)
interferon beta-1b (Betaseron)
interferon beta-1b (Extavia)
ipilimumab (Yervoy) - MB
itraconazole (Sporanox)
L
lacosamide (Vimpat)
lidocaine infusion for chronic pain
lidocaine patch 5% (Lidoderm Patch)
linaclotide (Linzess)
lubiprostone (Amitiza)
lurasidone (Latuda)
M
macitentan (Opsumit)
methylnaltrexone (Relistor)
metoclopramide (Metozolv ODT)
metoprolol succinate (Toprol XL)
metoprolol succinate / HCTZ (Dutoprol)
miglustat (Zavesca)
milnacipran (Savella)
Multiple Sclerosis (Interferons)
N
Naltrexone IM (Vivitrol) - Medical and Pharmacy
Benefit Drug
natalizumab (Tysabri) - MB
O
olopatadine ophthalmic (Patanol)
omalizumab (Xolair) - MB
omega-3-acids (Lovaza)
Oral Cancer Drugs
oxandrolone (Oxandrin)
P
paliperidone (Invega)
palivizumab (Synagis) - MB
pancrelipase (Zenpep)
posaconazole (Noxafil)
pregabalin (Lyrica)
R
repository corticotropin (Acthar Gel)
rilonacept (Arcalyst) – MB
riociguat (Adempas)
rituximab (Rituxan) - MB
romiplostim (Nplate)
rufinamide (Banzel)
S
selegilene (Emsam patch)
simeprevir (Olysio)
sofosbuvir (Sovaldi)
T
taliglucerase alfa (Elelyso) - MB
teriflunomide (Aubagio)
teriparatide (Forteo)
tetrabenazine (Xenazine)
TNF Inhibitor
tocilizumab (Actemra) – MB
tofacitinib (Xeljanz)
tolvaptan (Samsca)
trametinib (Mekinist)
Tretinoin & Vitamin A Analogues (topical)
57
V
vemurafenib (Zelboraf)
vigabatrin (Sabril)
vismodegib (Erivedge)
voriconazole (Vfend)
Z
zoledronic acid intravenous (Reclast) - MB
Clarification on PA forms that contain more than one drug




Berinert (C1 Esterase Inhibitor) – Medical Benefit Drug
Cinryze (C1 Esterase Inhibitor) – Medical Benefit Drug
Firazyr (icatibant)
Kalbitor (ecallantide)—Medical Benefit Drug
Immunoglobulins (IV & SC)









Carimune NF (immune globulin) – Medical Benefit Drug
Generic Flebogamma (immune globulin) – Medical Benefit Drug
Generic Gammagard Liquid (immune globulin) – Medical Benefit Drug
Gammagard S/D (immune globulin) – Medical Benefit ex (immune globulin) – Medical Benefit Drug
Gammar-P I.V. (immune globulin) – Medical Benefit Drug
Gamunex (immune globulin) – Medical Benefit Drug
Hizentra (immune globulin) – Medical Benefit Drug
Privigen (immune globulin) – Medical Benefit Drug
Vivaglobin (immune globulin) – Medical Benefit Drug




Berinert (C1 Esterase Inhibitor) – Medical Benefit Drug
Cinryze (C1 Esterase Inhibitor) – Medical Benefit Drug
Firazyr (icatibant)
Kalbitor (ecallantide)—Medical Benefit Drug
Immunoglobulins (IV & SC)








Carimune NF (immune globulin) – Medical Benefit Drug
Flebogamma (immune globulin) – Medical Benefit Drug
Gammagard Liquid (immune globulin) – Medical Benefit Drug
Gammagard S/D (immune globulin) – Medical Benefit Drug
Gammaplex (immune globulin) – Medical Benefit Drug
Gammar-P I.V. (immune globulin) – Medical Benefit Drug
Gamunex (immune globulin) – Medical Benefit Drug
Hizentra (immune globulin) – Medical Benefit Drug
58


Privigen (immune globulin) – Medical Benefit Drug
Vivaglobin (immune globulin) – Medical Benefit Drug
Multiple Sclerosis Interferons



Betaseron (interferon beta-1b)
Extavia (interferon beta-1b)
Rebif (interferon beta-1a)
Oral Cancer (may not be a comprehensive list – list may change at any time for any reason)
Afinitor, Alkeran, Bosulif, capecitabine, Caprelsa, Cometriq, Emcyt, Erivedge, etoposide, exemestane, Fareston,
Gleevec, Gilotrif, Hexalen, Hycamtin, Iclusig, Imbruvica, Inlyta, Jakafi, Leukeran, Lomustine, Lysodren, Matulane,
Myleran, Nexavar, Nilandron, Pomalyst, Purixan, Revlimid, Soltamox, Sprycel, Stivarga, Sutent, Tabloid, Tarceva,
Targretin, Tasigna, temozolomide, Thalomid, Tretinoin, Tykerb, Votrient, Xalkori, Xtandi, Zolinza, Zykadia, Zytiga



Androderm (testosterone transdermal)
Androgel (testosterone gel)
Testim (testosterone gel)
TNF Inhibitor


Humira (adalimumab)
Cimzia (certolizumab)
Tretinoin and Vitamin A Analogues (topical)






Avita (tretinoin 0.025%)
Azelex (azelaic acid 20%)
Differin (adapalene)
Finacea (azelaic acid 15%)
Renova (tretinoin 0.02%)
Retin-A-Micro (tretinoin)
59

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