3-tier QHP forumulary

Transcription

Effective: August 1, 2016
Large Group Non-Qualified Health Plans
Small Group Non-Qualified Health Plans
3 Tier Formulary
(List of Covered Drugs)
What is the Drug List?
Also called a “formulary” by doctors and pharmacists, the Drug List is
an extensive list of safe and effective, FDA-approved, brand name and
generic prescription drugs used to treat the most common medical
conditions.
The Health First Pharmacy and Therapeutics Committee (P&T), a
panel of physicians and pharmacists, developed our Drug List and
updates it regularly. The list includes quality drugs available to you at
reasonable cost. Only those medications that have successfully passed
federally required clinical testing and evaluation and have been proven
effective are included. The P&T Committee reviews and evaluates all
available literature about a drug when updating the list.
About Tiers
Most covered prescription drugs will be categorized into one of three
tiers. The cost of drugs varies widely, even though several different
medications may be used to treat the same condition. What you pay for
the prescription depends upon what tier the drug is listed in. Health
First Health Plans and Insurance (The Plan) offers many benefit plans
that can vary in coverage for each tier. Details about your specific
benefit for each tier are included in The Plan’s Summary of Benefits.
Prescriptions that exceed a 30 day supply will default to a 90 day
supply copay (this does not apply to coinsurances). For coinsurances,
2016 Commercial 3 Tier Formulary
you will always pay a percentage of the total cost after the applicable
deductible is met.
 Tier 1 —Generic Drugs
 Tier 2 — Preferred Brand Name Drugs and some generics
 Tier 3 — Non-Preferred Brand Name Drugs and some generics
 Tier 3 (SP) — Specialty Drugs (Must obtain from Health First
Family Pharmacy and limited to a 30-day supply.)
For members who reside outside the state of Florida, an exception will
be considered to allow the medication to be filled at another pharmacy.
Please contact Customer Service Department to initiate this process.
 NCS — No Cost Share
Generic drugs are prescription drugs that are identified by their
chemical name. When the patent has expired on a brand name drug,
the FDA permits new manufacturers to create an equivalent of the
brand name drug and make it available to the public. Generally, more
than one manufacturer will create generic versions, although often the
same pharmaceutical firm that produces the brand name drug also
makes the generic version. This prompts competitive pricing of the
generic version and usually results in a less expensive drug.
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What will my expenses be?
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Every plan is different, and your financial obligation will vary based on
your specific plan. You are responsible for any cost sharing your plan
requires.

What is a deductible?
A deductible is a set dollar amount that you must pay each calendar
year before your health plan starts paying. If your plan includes an
integrated pharmacy deductible, it will accumulate with your in-network
medical deductible. Refer to your plan documents to see when your
deductible starts over for your plan.
This formulary is current as of August 1, 2016. To get updated
information about covered drugs, please visit our Web site at
myHFHP.org or call Customer Service toll-free at 1.855.443.4735
(TTY/TDD relay: 1.800.955.8771) Monday through Friday from 8 a.m.
to 6 p.m.
What is the difference between a copayment and coinsurance?
Copayments and coinsurance are types of member cost sharing, and
they represent the portion of covered prescription expenses members
must pay. A copayment is a flat dollar amount while coinsurance is a
percentage of the total allowable charges.
Are there any restrictions on my coverage?
What does out-of-pocket maximum mean?
The out-of-pocket maximum protects you from catastrophic medical
and prescription drug expenses by limiting how much you have to pay
during the benefit year. Your cost sharing for covered prescription
drugs (deductible, coinsurance and copayment) all accumulate with
your in-network medical out-of-pocket maximum. Refer to your plan
documents to see when your out-of-pocket maximum starts over for
your plan and to verify the specific cost sharing you have for specific
tiers.
The Drug List is subject to change
In order to continue to offer a safe and cost effective selection of
prescription drugs, The Plan periodically makes changes to the Drug
List. These changes may include removing medications, adding
restrictions, and/or covering a drug at a higher tier. Updated formularies
are posted to the website as changes are made. The following list
represents some of the most common scenarios in which changes to
drug coverage will occur:
 Throughout the year, new medications are approved by the FDA. It
is the policy of The Plan that new drugs will be excluded for 6
months from the date of FDA approval, during which time the
Health First P&T Committee can review the drug for safety and
efficacy.
When a medication is withdrawn from the market due to safety
reasons or if it becomes available over-the-counter (OTC). At the
time that a medication on the HFP Drug List becomes available
OTC, it may be excluded from coverage from that point forward.
When a brand-name prescription drug loses its patent and the
equivalent generic form is added to the Drug List, the brand-name
drug may be moved to Tier 3 or removed from the formulary.
Some covered drugs may have additional requirements or limits on
coverage. These requirements and limits may include:
 Prior Authorization: The Plan requires you and/or your physician
to get prior authorization for certain drugs. This means that you will
need to get approval from us before you fill your prescriptions. In
order for The Plan to pay for these drugs, the physician ordering the
prescription is required to submit all medical information to The
Plan documenting the medical necessity. These drugs are identified
in the Drug List.
 Step Therapy: In some cases, The Plan requires you to first try
certain drugs to treat your medical condition before we will cover
another drug for that condition. For example, if Drug A and Drug B
both treat your medical condition, we may not cover drug B unless you
try Drug A first. If Drug A does not work for you, we will then cover
Drug B. A complete list of drugs which require step therapy is listed in
the reference table on page 8.
 Quantity Limits: For some covered drugs, there is a maximum
amount that will be covered by The Plan over a certain period of time.
For example, The Plan covers 30 tablets every 30 days or 90 tablets
every 90 days for Jalyn.
How can I make the most of my prescription drug
benefit?
Prescription drug costs continue to rise every year and can represent a
significant part of your healthcare expenses. The Plan helps you pay for
your medications by sharing the cost with you and providing substantial
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discounts for covered medications. To help you manage your drug costs,
here are some money-saving tips to consider:
 Use Tier 1 generic medications whenever possible. Generic drugs
are the chemical equivalent of brand-name drugs, and are just as
effective in most cases. If you take generic drugs you will generally
pay less, so talk to your doctor to see if switching to a generic
equivalent of any brand-name you are taking is appropriate. Please
see the list of drugs below to determine which drugs are included in
Tier 1.
 See if your prescription pills can be split in half. For some
medications, pills may be available in different strengths but still have
the same price. If you need one of these select medications, your
doctor may be able to write your prescription for double the strength
and half of the number of pills you’d normally need. Then you’d split
them in half, so you’d get the proper dose—saving up to 50 percent of
the cost! The drugs that may be eligible for the Pill-Splitting program
are marked with the symbol (1/2) on the drug list. Review this
information with your doctor if your drug qualifies.
The following are NOT covered by The Plan:
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What if my drug is not on the Formulary?
If your drug is not included in this formulary, you should first contact
Customer Service and confirm that your drug is not covered. If you learn
that The Plan does not cover your drug, you have two options:
 You can ask Customer Service for a list of similar drugs that are
covered by The Plan. When you receive the list, show it to your
doctor and ask if switching to a covered medication is appropriate.
 You can ask your physician to send The Plan information requesting
we make an exception and cover your drug.
If The Plan approves the request for an exception to the formulary, the
approved drug will be covered at the Tier 3 cost share.
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Compounded drugs
Cosmetics or any drugs used for cosmetic purposes (such as
Retin-A, Rogaine, Topical Minoxidil, and Vaniqa)
Diabetic supplies, blood glucose monitors and test strips
other than those manufactured by Abbott under the product
name Freestyle, Precision, and test strips®
Erectile dysfunction drugs (such as Viagra)
Infertility drugs (such as Clomid)
Injectables (except insulin, Imitrex, and those requiring prior
authorization)
Multivitamins and nutritional supplements (except
prescription pre-natal vitamins)
Nicotine products
Nonprescriptive supplies or substances
Oral and topical antifungals for onychomycosis (such as
Lamisil, Sporanox, and Penlac)
Over-the-counter (OTC) medications (such as Lotrimin,
Zantac 75, Pepcid AC or their generic formulations), or any
drug for which a similar over-the-counter version is available
All new drugs approved by the FDA will be excluded from the
preferred drug list/formulary unless the Health First P&T
Committee, in its sole discretion, decides to waive this
exclusion for a particular drug.
Support garments
Syringes, needles, or other disposable supplies (except
those used with insulin)
Excluded drugs
The Plan does not provide coverage for all drugs. In addition to the
drugs marked “excluded” in this drug list, newly FDA approved drugs
are not covered unless the Health First P&T Committee in its sole
discretion approves these drugs for coverage. The Plan will
automatically exclude a particular drug if a generic version becomes
available and an entire class of drugs if a particular drug within that
class becomes available over the counter.
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Health First Health Plans and Insurance Formulary
The formulary provides coverage information about some of the drugs covered by The Plan. If you have trouble finding your drug in the list, turn to the
Index that begins on page 86. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., PRADAXA) and generic drugs
are listed in lower-case italics (e.g., lisinopril).
The information in the Notes column tells you if The Plan has any special requirements for coverage of your drug.
Specialty Pharmacy (SP):
Must be obtained from Health First Family Pharmacy and are limited to a 30-day supply. For members who reside outside the state of Florida, an
exception will be considered to allow the medication to be filled at another pharmacy. Please contact Customer Service Department to initiate this
process.
Prior Authorization (PA):
The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from The Plan before
you fill your prescriptions. If you don't get approval, the drug will not be covered.
Quantity Limit (QL):
Quantity Limits may also be listed. For example, “30/30 days” would mean your coverage of this drug is limited to 30 pills every 30 days. Prescriptions
written for more than the suggested Quantity Limits will only be honored up to the listed amount unless an exception is requested by your physician and
approved by The Plan.
Step Therapy (ST):
In some cases, The Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For
example, if Drug A and Drug B both treat your medical condition, we may not cover drug B unless you try Drug A first. If Drug A does not work for you,
we will then cover Drug B. A complete list of drugs which require step therapy is listed in the reference table on page 8.
Pill Splitting (1/2): You may be able to split these pills in half. Begin by asking your doctor if pill-splitting is right for you. If it is, your doctor will write your
prescription for half the number of pills and double the strength you normally need. For example, instead of 30 pills of 20 mg, you’d get a prescription for
15 pills of 40 mg. Then you or the pharmacy can split them in half for the correct dose. This way, you save 50 percent of the cost.
Maintenance Drug (MD):
You may be taking these drugs on a long-term basis. Maintenance medications are generally those used to treat chronic conditions and long-term
conditions. **Some exceptions may apply (i.e. certain medications used for ADHD, asthma/COPD rescue, acute pain, and acute infections).
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Preventive Care Medications: $0 Cost-share Medications and Products
The Affordable Care Act (ACA), commonly known as health care reform, was signed into federal law in 2010. The ACA requires private insurers to cover
certain preventive services without any patient cost-sharing (i.e., copayments, coinsurance and deductible) when they are delivered by a network
provider.
The Department of Health and Human Services (HHS) has recognized several recommending bodies (e.g., United States Preventive Services Task
Force [USPSTF], Advisory Committee on Immunization Practices [ACIP], and Health Resources and Services Administration [HRSA]) who have
identified several medication categories that fall within the preventive health mandate.
The following products, prescription medications and specific over-the-counter (OTC) medications (notated in Tier NCS throughout this formulary) are
available to our members at no ($0) cost-sharing when:


Prescribed by a health care professional (all prescription and OTC medications will require a prescription)
Age and/or gender appropriate
U.S. Preventive Services Task Force A & B Recommendation Medications and Supplements
 Aspirin for Cardiovascular Disease (Generic only - 325 mg, 81 mg tablets) – males age 45 - 79 and females age 55 – 79
 Aspirin for Preeclampsia (Generic only 81 mg tablets) – females less than 55 years of age
 Vitamin D (50000 unit capsules)
 Iron (Ferrous Sulfate, 325 mg tablets)
 Folic Acid (1 mg tablets)
 Pediatric Multiple Vitamins w/ Fluoride (1 mg chewable tablets, 0.5 mg/mL solution)
 Pediatric Multiple Vitamins w/ Iron (15 mg chewable tablets, 10 mg/mL drops)
 Sodium Fluoride (1 mg tablets, 1 mg chewable tablets)
Bowel Preparation for Colon Rectal Cancer Screening
 For adults 50 years of age and older with a limit of 3 prescriptions per year
Coverages include the following generic products:
 Bisacodyl
 Magnesium citrate,
 Milk of magnesia
 PEG-3350-Electrolyte products
Tobacco Cessation Medications
If you need help to quit smoking or using tobacco products, these preventive medications will be available at $0 cost-share. To qualify, you must be:
 18 years of age or older and
 Receiving counseling and have a prescription from a health care provider
Up to two, 3-month treatment courses are covered at no cost each year. Any additional treatment may be subject to a cost-share. Covered treatment
regimens include:
 Nicotine replacement therapy (nicotine patches, nicotine gum, nicotine lozenges, nicotine inhaler, nicotine nasal spray)
 Chantix
 Generic Zyban (bupropion)
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Breast Cancer Preventive Medications
 For women who are at increased risk for breast cancer but who have not had breast cancer, medications such as tamoxifen or raloxifene are
available at $0 cost-share.
 If you are 35 years of age or older and have not had breast cancer, talk to your doctor about your risk. If appropriate, your doctor may offer to
prescribe one of these risk-reducing medications.
 Your doctor can then submit a Prior Authorization request to get the medication approved at $0 cost-share if coverage criteria are met.
Contraceptive Methods
Oral contraceptives – combined:
 AZURETTE, BEKYREE, DESOGESTREL-EE, KARIVA, KIMIDESS, NECON, PIMTREA, VIORELE
 ALTAVERA, ALYACEN, APRI, AUBRA, AVIANE, BALZIVA, BLISOVI, BRIELLYN, CHATEAL, CRYSELLE, CYCLAFEM, CYRED
 DASETTA, DELYLA, DESOGESTREL-EE, DROSPIRENONE-EE, ELINEST, EMOQUETTE, ENSKYCE, ESTARYLLA, FALMINA
 GIANVI, GILDAGIA, GILDESS, JULEBRER, JUNEL, KELNOR, KURVELO, LARIN, LAYOLIS, LESSINA, LEVONORGESTREL-EE
 LEVORA, LOMEDIA, LORYNA, LOW-OGESTREL, LUTERA, MARLISSA, MICROGESTIN, MONO-LINYAH, MONONESSA, NECON
 NIKKI, NORETHIN-EE, NORGESTIMATE-EE, NORINYL, NORTREL, OCELLA, OGESTREL, ORSYTHIA, PHILITH, PIRMELLA, PORTIA
 PREVIFEM, RECLIPSEN, SOLIA, SPRINTEC, SRONYX, SYEDA, TARINA, VESTURA, VYFEMLA, WERA, WYMZYA, ZARAH
 ZENCHENT, ZOVIA
Oral contraceptives – extended/continuous use:
 AMETHYST, LEVONORGESTREL-ETHINYL ESTRAD ORAL TABLET 90-20MCG; AMETHIA, ASHLYNA, CAMRESE, DAYSEE, INTROVALE,
JOLESSA, LEVONORGEST-ETH ESTRAD 91-DAY ORAL TABLET; QUASENSE, SETLAKIN
Oral Contraceptives – progestin only
 CAMILA, DEBLITANE, ERRIN, HEATHER, JENCYCLA, JOLIVETTE, LYZA, NORA-BE, NORETHINDRONE, NORLYROC, SHAROBEL 0.35 MG
Injection:
 MEDROXYPROGESTERONE 150 MG INJ
Patch:
 XULANE PATCH (generic OrthoEvra)
Vaginal Ring:
 NUVARING (Vaginal Ring)
Emergency Contraception-Progestin:
 ECONTRA EZ, FALLBACK SOLO, LEVONORGESTREL 0.75 MG, MY WAY, NEXT CHOICE ONE DOSE, OPCICON ONE-STEP
Emergency Contraception- Ulipristal Acetate:
 ELLA
Implantable Rod:
 NEXPLANON
IUD – Copper:
 PARAGUARD
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IUD – Progestin:
 MIRENA
Diaphragm with Spermicide:
 OMNIFLEX DIAPHRAM
Contraceptive Methods Continued
Sponge with Spermicide:
 TODAY SPONGE
Cervical Cap with Spermicide:
 FEMCAP, PRENTIF
Female Condom:
 FC FEMALE CONDOM
Spermicide alone:
 NONOXYNOL-9 GEL
*** The FDA Birth Control Guide additionally lists sterilization surgery for men and male condoms, but the HRSA Guidelines exclude services relating to
a man’s reproductive capacity.
If you have any questions regarding your eligibility for preventive care medications and preventive contraceptive coverage, please contact your employer
or call Customer Service toll-free at 1.855.443.4735 (TTY/TDD relay: 1.800.955.8771) Monday through Friday from 8 a.m. to 6 p.m.
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Step Therapy Reference Table
Step Therapy Reference Table
Drug Name
Drug that must be tried first
Drug Name
Drug that must be tried first
ACTONEL
alendronate
PATANASE
Veramyst or fluticasone nasal
AVANDIA
Any pioglitazone containing product
RELPAX
sumatriptan
AXERT
sumatriptan
RENAGEL
calcium acetate 667 mg
CELEBREX/CELECOXIB
meloxicam
RENVELA
CYCLOSET
Any metformin containing product
sumatriptan
ESZOPICLONE
Zolpidem IR
RIZATRIPTAN;
RIZATRIPTAN ODT
EURAX CREAM
permethrin AND lindane topical products
TOLAZAMIDE
Any glipizide containing product AND any
glimepiride containing product
EXELDERM
ketoconazole AND clotrimazole topical
products
TOLBUTAMIDE
Any glipizide containing product AND any
glimepiride containing product
TREXIMET
sumatriptan
ULORIC
allopurinol
VIIBRYD
Trial of any two (2) of the following drugs:
bupropion, citalopram, duloxetine,
escitalopram, fluoxetine, mirtazapine,
paroxetine, sertraline, trazodone, venlafaxine
FOSRENAL
FROVA
sumatriptan
GLYSET
Any metformin containing product
LEVATOL
Any Tier 1 or Tier 2 formulary beta blocker
LYRICA
gabapentin
METFORMIN SR24 HR
OSMOSTIC
Trial of metformin ER (generic Glucophage
XL)
WELCHOL
cholestyramine or colestipol
NARATRIPTAN
sumatriptan
ZOLMITRIPTAN;
ZOLMITRIPTAN ODT
sumatriptan
NASONEX
ZOMIG NASAL
sumatriptan
OMNARIS
OXISTAT
ketoconazole AND clotrimazole topical
products
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Covered Generic Drugs
The following brand name drugs have generic alternatives that may be a cost savings to you
Brand Name Drug
Brand Tier
Generic Alternative
CRESTOR
T3
atorvastatin, simvastatin
DEXILANT
T2
omeprazole, pantoprazole
BENICAR
T2
losartan
Formulary Changes
Drug Name
New Requirements/
Change
Previous Tier
New Tier
Effective Date
EPIPEN & EPIPEN JR
ADD
--
T2
2/15/2016
VENTOLIN HFA INHALATION AEROSOL,
SOLUTION
ADD
--
T2
4/25/2016
QL (36 GM per 31 days)
REPATHA SUBCUTANEOUS
ADD
--
T3 (SP)
4/25/2016
PA
PRALUENT SUBCUTANEOUS
ADD
--
T3 (SP)
4/25/2016
PA
ENTRESTO ORAL TABLET
ADD
--
T3
4/25/2016
PA
TIER CHANGE
T2
T1
4/25/2016
QL CHANGE
T1
T1
4/25/2016
celecoxib oral capsule
TIER CHANGE;
ST REMOVED
T3
T2
4/25/2016
XARELTO ORAL TABLET
PA REMOVED
T3
T3
8/1/2016
ADD
--
T3
8/1/2016
valsartan oral tablet
sumatriptan succinate oral tablet
ELIQUIS ORAL TABLET
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Limits
QL increased to 18 EA per
31 days
PA REMOVED
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Formulary Changes
Drug Name
Change
Previous Tier
New Tier
Effective Date
TIKOSYN ORAL CAPSULE
ADD
--
T3
8/1/2016
rosuvastatin calcium oral tablet
ADD
--
T3
8/1/2016
diclofenac sod. 1% transdermal gel
ADD
--
T2
8/1/2016
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New Requirements/
Limits
QL (31 EA per 31 days)
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Drug Name
Tier Notes
Drug Name
ADHD/ANTI-NARCOLEPSY/ANTIOBESITY/ANOREXIANTS
Tier Notes
STIMULANTS - MISC.
DAYTRANA TRANSDERMAL
PATCH
T3
ADHD AGENT - SELECTIVE ALPHA ADRENERGIC AGONISTS
guanfacine hcl er oral tablet extended
release 24 hr
dexmethylphenidate hcl er oral
capsule extended release 24 hour
T2
dexmethylphenidate hcl oral tablet
T1
FOCALIN XR ORAL CAPSULE
EXTENDED RELEASE 24 HOUR 25
MG, 35 MG
T2
T2
ADHD AGENT - SELECTIVE NOREPINEPHRINE REUPTAKE
INHIBITOR
STRATTERA ORAL CAPSULE
T2
MD
AMPHETAMINE MIXTURES
ADDERALL XR ORAL CAPSULE
EXTENDED RELEASE 24 HOUR
T2
methylphenidate hcl er (la) oral
T2
amphetamine-dextroamphetamine oral
tablet
T1
methylphenidate hcl er oral tablet
extended release 24 hr
T2
methylphenidate hcl er oral tablet
extendedrelease
T2
methylphenidate hcl oral solution
T1
methylphenidate hcl oral tablet
T1
methylphenidate hcl oral tablet
chewable
T1
AMPHETAMINES
dextroamphetamine sulfate er oral
T1
dextroamphetamine sulfate oral tablet
T1
methamphetamine hcl oral tablet
T2
VYVANSE ORAL CAPSULE
T2
modafinil oral tablet
T3 PA; MD; QL (31 EA
(SP) per 31 days)
(SP) per 31 days)
ANOREXIANTS NON-AMPHETAMINE
phentermine hcl oral capsule 15 mg
T1
QL (180 EA Max Qty
Per Fill Retail)
NUVIGIL ORAL TABLET
phentermine hcl oral capsule 30 mg,
37.5 mg
T1
QL (90 EA Max Qty
Per Fill Retail)
AMINOGLYCOSIDES
phentermine hcl oral tablet
T1
QL (90 EA Max Qty
Per Fill Retail)
PA Prior Authorization required
QL Quantity Limit applies
NCS No Cost Share ($0)
AMINOGLYCOSIDES
neomycin sulfate oral tablet
ST Step Therapy
½
SP Specialty Pharmacy
T1
Qualifies for pill splitting
MD Maintenance Drug
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Drug Name
Tier Notes
paromomycin sulfate oral capsule
T1
streptomycin sulfate intramuscular
solution reconstituted
T2
Drug Name
Tier Notes
diclofenac sodium er oral tablet
T1
MD
diclofenac sodium oral tablet delayed
release
T1
MD
ANTI-TNF-ALPHA - MONOCLONOAL ANTIBODIES
etodolac er oral tablet extended
release 24 hr
T1
MD
HUMIRA PEDIATRIC CROHNS
START SUBCUTANEOUS
T3 PA; MD
(SP)
etodolac oral capsule
T1
MD
HUMIRA PEN SUBCUTANEOUS
T3 PA; MD
(SP)
etodolac oral tablet
T1
MD
fenoprofen calcium oral tablet
T3
MD
flurbiprofen oral tablet
T1
MD
ibuprofen oral tablet 400 mg, 600 mg,
800 mg
T1
MD
indomethacin oral capsule
T1
ketoprofen oral capsule
T1
ketorolac tromethamine oral tablet
T1
meclofenamate sodium oral capsule
T3
mefenamic acid oral capsule
T1
meloxicam oral suspension
T1
MD
meloxicam oral tablet
T1
MD
nabumetone oral tablet
T1
MD
naproxen dr oral tablet delayed
release 375 mg
T1
naproxen dr oral tablet delayed
release 500 mg
T1
MD
naproxen oral tablet
T1
MD
ANALGESICS - ANTI-INFLAMMATORY
HUMIRA PEN-CROHNS STARTER T3 PA; MD
SUBCUTANEOUS
(SP)
HUMIRA PEN-PSORIASIS
STARTER SUBCUTANEOUS
T3 PA; MD
(SP)
HUMIRA SUBCUTANEOUS
T3 PA; MD
(SP)
CYCLOOXYGENASE 2 (COX-2) INHIBITORS
celecoxib oral capsule
T2
MD
GOLD COMPOUNDS
RIDAURA ORAL CAPSULE
T3 MD
(SP)
INTERLEUKIN-1 BLOCKERS
ARCALYST SUBCUTANEOUS
SOLUTION RECONSTITUTED
T3 PA; MD
(SP)
NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDS)
diclofenac potassium oral tablet
T1
MD
ST Step Therapy
½
MD
MD
MD Maintenance Drug
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Drug Name
Tier Notes
Drug Name
Tier Notes
naproxen sodium oral tablet 275 mg,
550 mg
T1
MD
butalbital-aspirin-caffeine oral
capsule
oxaprozin oral tablet
T1
MD
SALICYLATES
piroxicam oral capsule
T1
MD
sulindac oral tablet
T1
MD
aspirin ec low dose oral tablet delayed NCS
release
tolmetin sodium oral capsule
T2
MD
tolmetin sodium oral tablet
T2
MD
PYRIMIDINE SYNTHESIS INHIBITORS
leflunomide oral tablet
T1
MD; QL (31 EA per 31
days)
SOLUBLE TUMOR NECROSIS FACTOR RECEPTOR AGENTS
ENBREL SUBCUTANEOUS
T3 PA; MD
(SP)
ENBREL SUBCUTANEOUS KIT
T3 PA; MD; QL (8 EA per
(SP) 31 days)
ENBREL SURECLICK
SUBCUTANEOUS
T3 PA; MD
(SP)
ANALGESICS - NONNARCOTIC
T1
aspirin ec oral tablet delayed release
NCS
aspirin low dose oral tablet chewable
NCS
aspirin low dose oral tablet delayed
release
NCS
aspirin low strength oral tablet
chewable
NCS
aspirin oral tablet 325 mg
NCS
aspirin oral tablet chewable
NCS
ANALGESICS - OPIOID
CODEINE COMBINATIONS
acetaminophen-codeine #2 oral tablet
T1
QL (248 EA per 31
days)
T1
QL (248 EA per 31
days)
T1
QL (248 EA per 31
days)
acetaminophen-codeine oral solution
T1
acetaminophen-codeine oral tablet
T1
ASCOMP-CODEINE ORAL
CAPSULE
T1
ANALGESICS-SEDATIVES
butalbital-acetaminophen oral tablet
T1
butalbital-apap-caffeine oral capsule
T1
butalbital-apap-caffeine oral tablet
50-325-40 mg
T1
butalbital-asa-caffeine oral capsule
T1
ST Step Therapy
½
QL (248 EA per 31
days)
MD Maintenance Drug
Version 4
Page 13
Drug Name
Tier Notes
Drug Name
Tier Notes
butalbital-apap-caff-cod oral capsule
T1
meperidine hcl oral tablet
T1
butalbital-asa-caff-codeine oral
capsule
T1
meperitab oral tablet 50 mg
T1
methadone hcl oral tablet
T1
morphine sulfate (concentrate) oral
solution 100 mg/5ml
T1
morphine sulfate er oral tablet
extendedrelease
T2
morphine sulfate oral solution
T1
morphine sulfate oral tablet
T1
HYDROCODONE COMBINATIONS
hydrocodone-acetaminophen oral
solution 7.5-325 mg/15ml
T1
tablet 10-300 mg, 5-300 mg, 7.5-300
mg
T1
tablet 10-325 mg, 5-325 mg, 7.5-325
mg
T1
QL (248 EA per 31
days)
hydrocodone-ibuprofen oral tablet 5200 mg, 7.5-200 mg
T1
QL (155 EA per 31
days)
IBUDONE ORAL TABLET 5-200
MG
T1
QL (155 EA per 31
days)
QL (403 EA per 31
days)
NUCYNTA ER ORAL TABLET
EXTENDED RELEASE 12 HR
NUCYNTA ORAL TABLET
OPANA ER ORAL
fentanyl citrate buccal lollipop
T1
T3 PA
(SP)
fentanyl transdermal patch 72 hr 100
mcg/hr, 12 mcg/hr, 25 mcg/hr, 50
mcg/hr, 75 mcg/hr
T1
hydromorphone hcl oral tablet
T1
levorphanol tartrate oral tablet
T3
QL (248 EA per 31
days)
QL (248 EA per 31
days)
T3 PA
(SP)
T3
oxycodone hcl oral solution
T3
oxycodone hcl oral tablet 10 mg, 20
mg, 5 mg
T1
oxycodone hcl oral tablet 15 mg, 30
mg
T1
oxymorphone hcl er oral tablet
T3
oxymorphone hcl oral tablet
T2
ST Step Therapy
½
QL (248 EA per 31
days)
PA
T3 QL (61 EA per 31
(SP) Days)
OPIOID AGONISTS
codeine sulfate oral tablet
QL (248 EA per 31
days)
QL (248 EA per 31
days)
QL (62 EA per 31
Days)
MD Maintenance Drug
Version 4
Page 14
Drug Name
Tier Notes
tramadol hcl er (biphasic) oral tablet
extended release 24 hr 100 mg, 200
mg
T2
QL (31 EA per 31
Days)
tramadol hcl er (biphasic) oral tablet
extended release 24 hr 300 mg
T3
QL (31 EA per 31
Days)
tramadol hcl er oral tablet extended
release 24 hr 100 mg, 200 mg
T2
QL (31 EA per 31
Days)
tramadol hcl er oral tablet extended
release 24 hr 300 mg
T3
tramadol hcl oral tablet
T1
BUTRANS TRANSDERMAL
PATCH WEEKLY
T2
pentazocine-naloxone hcl oral tablet
T1
SUBOXONE SUBLINGUAL FILM
T2
MD
TRAMADOL COMBINATIONS
tramadol-acetaminophen oral tablet
ANDROGENS-ANABOLIC
QL (372 EA per 31
days)
oxandrolone oral tablet
T1
ANABOLIC STEROIDS
T1
MD
ANDROGEL PUMP
TRANSDERMAL
T2
PA; MD; QL (300 GM
per 31 days)
ANDROGEL TRANSDERMAL
20.25 MG/1.25GM (1.62%), 25
MG/2.5GM (1%)
T2
PA; MD
ANDROGEL TRANSDERMAL 40.5
MG/2.5GM (1.62%), 50 MG/5GM
(1%)
T2
PA; MD; QL (300 GM
per 31 days)
danazol oral capsule
T1
testosterone cypionate intramuscular
solution 100 mg/ml, 200 mg/ml
T1
PA; MD
testosterone enanthate intramuscular
solution
T1
PA; MD
testosterone transdermal 12.5 mg/act
(1%), 25 mg/2.5gm, 25 mg/2.5gm
(1%), 50 mg/5gm, 50 mg/5gm (1%)
T2
PA; QL (300 GM per
31 days)
ANDROGENS
ENDOCET ORAL TABLET 10-325
MG, 2.5-325 MG, 5-325 MG, 7.5-325
MG
T1
oxycodone-acetaminophen oral tablet
10-325 mg, 2.5-325 mg, 5-325 mg,
7.5-325 mg
T1
oxycodone-aspirin oral tablet
T1
oxycodone-ibuprofen oral tablet
T1
QL (155 EA per 31
days)
ROXICET ORAL TABLET
T1
QL (248 EA per 31
days)
QL (248 EA per 31
days)
QL (248 EA per 31
days)
OPIOID PARTIAL AGONISTS
buprenorphine hcl sublingual tablet
sublingual
T1
butorphanol tartrate injection solution
T1
Tier Notes
QL (31 EA per 31
Days)
OPIOID COMBINATIONS
Drug Name
ST Step Therapy
½
MD Maintenance Drug
Version 4
Page 15
Drug Name
Tier Notes
Drug Name
Tier Notes
ANORECTAL AGENTS
BILTRICIDE ORAL TABLET
T3
INTRARECTAL STEROIDS
ivermectin oral tablet
T2
hydrocortisone enema
T1
ANTIANGINAL AGENTS
NITRATE VASODILATING AGENTS
RECTIV OINTMENT
ANTIANGINALS-OTHER
T3
RANEXA ORAL TABLET
RECTAL ANESTHETIC/STEROIDS
T3
MD
isosorbide dinitrate er oral tablet
extendedrelease
T1
MD
isosorbide dinitrate oral tablet
T1
MD
isosorbide mononitrate er oral tablet
T1
MD
isosorbide mononitrate oral tablet
T1
MD
NITRATES
ANALPRAM ADVANCED
COMBINATION KIT
T3
hydrocortisone ace-pramoxine cream
T1
lidocaine-hydrocortisone ace
T1
lidocaine-hydrocortisone ace cream
T1
lidocaine-hydrocortisone ace kit
T1
PROCORT CREAM
T2
MD
T2
MINITRAN TRANSDERMAL
PATCH 24 HR
T3
PROCTOFOAM HC FOAM
T3
MD
anucort-hc suppository
T1
NITRO-BID TRANSDERMAL
OINTMENT
hydrocortisone acetate suppository
T1
nitroglycerin transdermal patch 24 hr
T1
MD
PROCTO-PAK CREAM
T1
T2
PROCTOSOL HC CREAM
T1
NITROSTAT SUBLINGUAL
TABLET SUBLINGUAL 0.3 MG, 0.6
MG
PROCTOZONE-HC CREAM
T1
T2
ANTHELMINTICS
NITROSTAT SUBLINGUAL
TABLET SUBLINGUAL 0.4 MG
ANTHELMINTICS
ANTIANXIETY AGENTS
RECTAL STEROIDS
ALBENZA ORAL TABLET
MD
ANTIANXIETY AGENTS - MISC.
T2
ST Step Therapy
½
MD Maintenance Drug
Version 4
Page 16
Drug Name
Tier Notes
MD
Drug Name
Tier Notes
buspirone hcl oral tablet
T1
hydroxyzine hcl intramuscular
solution
T1
disopyramide phosphate oral capsule
hydroxyzine hcl oral solution
T1
NORPACE CR ORAL CAPSULE
hydroxyzine hcl oral syrup
T1
procainamide hcl injection solution
T2
hydroxyzine hcl oral tablet
T1
T1
MD
hydroxyzine pamoate oral capsule
T1
quinidine gluconate er oral tablet
extendedrelease
meprobamate oral tablet
T1
quinidine sulfate er oral tablet
extendedrelease
T2
MD
quinidine sulfate oral tablet
T1
MD
flecainide acetate oral tablet
T1
MD
propafenone hcl er oral capsule
extended release 12 hour
T2
MD
propafenone hcl oral tablet
T1
MD
amiodarone hcl oral tablet 200 mg,
400 mg
T1
MD
MULTAQ ORAL TABLET
T2
MD
TIKOSYN ORAL CAPSULE
T3
MD
BENZODIAZEPINES
alprazolam er oral tablet extended
release 24 hr
T1
alprazolam oral tablet
T1
alprazolam xr oral tablet extended
release 24 hr
T1
chlordiazepoxide hcl oral capsule
T1
clorazepate dipotassium oral tablet
T1
DIAZEPAM INTENSOL ORAL
CONCENTRATE
T3
PA
diazepam oral concentrate
T3
PA
diazepam oral solution 1 mg/ml
T1
diazepam oral tablet
T1
lorazepam oral concentrate
T1
lorazepam oral tablet
T1
T1
MD
T3 PA; MD
(SP)
ANTIARRHYTHMICS TYPE I-C
ANTIARRHYTHMICS TYPE III
ANTIASTHMATIC AND
BRONCHODILATOR AGENTS
5-LIPOXYGENASE INHIBITORS
ZYFLO CR ORAL TABLET
ANTIARRHYTHMICS
ANTIARRHYTHMICS TYPE I-A
ST Step Therapy
½
(SP) per 31 days)
MD Maintenance Drug
Version 4
Page 17
Drug Name
Tier Notes
Drug Name
ADRENERGIC COMBINATIONS
ADVAIR DISKUS INHALATION
AEROSOL POWDER, BREATH
ACTIVATED
T2
days)
ADVAIR HFA INHALATION
AEROSOL†
T2
MD; QL (12 GM per 31
days)
ANORO ELLIPTA INHALATION
ACTIVATED
T2
MD
BREO ELLIPTA INHALATION
ACTIVATED
T2
COMBIVENT RESPIMAT
INHALATION AEROSOL,
SOLUTION
T2
DULERA INHALATION
AEROSOL†
T2
ipratropium-albuterol inhalation
solution
MD
Tier Notes
cromolyn sodium inhalation
nebulization solution
T1
MD
albuterol sulfate inhalation
T1
MD
albuterol sulfate oral syrup
T1
MD
albuterol sulfate oral tablet
T1
MD
ARCAPTA NEOHALER
INHALATION CAPSULE
T3
MD
BETA ADRENERGICS
BROVANA INHALATION
NEBULIZATION SOLUTION
T3 PA; MD
(SP)
levalbuterol hcl inhalation
T3
MD
metaproterenol sulfate oral syrup
T1
MD
days)
metaproterenol sulfate oral tablet
T2
MD
T1
MD
PROVENTIL HFA INHALATION
AEROSOL, SOLUTION
T2
QL (13.4 GM per 31
Days)
SYMBICORT INHALATION
AEROSOL† 160-4.5 MCG/ACT
T3
ST; MD; QL (10.2 GM
per 31 days)
SEREVENT DISKUS INHALATION
ACTIVATED
T2
days)
SYMBICORT INHALATION
AEROSOL† 80-4.5 MCG/ACT
T3
ST; MD; QL (13.8 GM
per 31 days)
STRIVERDI RESPIMAT
INHALATION AEROSOL,
SOLUTION
T2
MD
terbutaline sulfate oral tablet
T1
MD
VENTOLIN HFA INHALATION
AEROSOL, SOLUTION
T2
QL (36 GM per 31
days)
MD
ANTI-IGE MONOCLONAL ANTIBODIES
XOLAIR SUBCUTANEOUS
T3 PA; MD
(SP)
ANTI-INFLAMMATORY AGENTS
ST Step Therapy
½
MD Maintenance Drug
Version 4
Page 18
Drug Name
Tier Notes
Drug Name
BRONCHODILATORS - ANTICHOLINERGICS
Tier Notes
ASMANEX 30 METERED DOSES
INHALATION AEROSOL
POWDER, BREATH ACTIVATED
T2
MD; QL (1 EA per 31
Days)
INHALATION AEROSOL
T2
MD; QL (1 EA per 31
Days)
INHALATION AEROSOL
T2
MD; QL (1 EA per 31
Days)
ASMANEX HFA INHALATION
AEROSOL†
T2
LEUKOTRIENE RECEPTOR ANTAGONISTS
days)
montelukast sodium oral packet
T1
MD
budesonide inhalation suspension
T1
MD
montelukast sodium oral tablet
T1
days)
T2
MD; QL (124 EA per
31 days)
montelukast sodium oral tablet
chewable
T1
days)
FLOVENT DISKUS INHALATION
ACTIVATED
T2
zafirlukast oral tablet
T1
FLOVENT HFA INHALATION
AEROSOL†
days)
ATROVENT HFA INHALATION
AEROSOL, SOLUTION
T3
days)
ipratropium bromide inhalation
solution
T1
MD
SPIRIVA HANDIHALER
INHALATION CAPSULE
T2
days)
SPIRIVA RESPIMAT INHALATION
AEROSOL, SOLUTION
T2
MD
days)
MIXED ADRENERGICS
epinephrine hcl injection solution 1
mg/ml
T3
STEROID INHALANTS
INHALATION AEROSOL
T2
INHALATION AEROSOL
T2
MD; QL (1 EA per 31
Days)
XANTHINES
aminophylline intravenous solution
T1
theophylline er oral tablet extended
release 12 hr
T1
MD
theophylline er oral tablet extended
release 24 hr
T2
MD
JANTOVEN ORAL TABLET
T1
MD
warfarin sodium oral tablet
T1
MD
ANTICOAGULANTS
COUMARIN ANTICOAGULANTS
MD; QL (1 EA per 31
Days)
ST Step Therapy
½
MD Maintenance Drug
Version 4
Page 19
Drug Name
Tier Notes
DIRECT FACTOR XA INHIBITORS
ELIQUIS ORAL TABLET
T3
XARELTO ORAL TABLET 10 MG
T3
days)
XARELTO ORAL TABLET 15 MG,
20 MG
T3
MD
HEPARINS AND HEPARINOID-LIKE AGENTS
heparin sodium (porcine) injection
solution 1000 unit/ml, 10000 unit/ml,
20000 unit/ml, 5000 unit/ml
T1
heparin sodium (porcine) pf injection
solution
T1
fondaparinux sodium subcutaneous
solution
T3 PA
(SP)
THROMBIN INHIBITORS - SELECTIVE DIRECT &
REVERSIBLE
PRADAXA ORAL CAPSULE 150
MG, 75 MG
T2
MD
ANTICONVULSANTS
clonazepam oral tablet
T1
diazepam
T3
MD
ANTICONVULSANTS - MISC.
enoxaparin sodium injection solution
T3 QL (24 ML per 30
(SP) Days)
enoxaparin sodium subcutaneous
solution 100 mg/ml, 150 mg/ml
T3 QL (28 ML per 30
(SP) Days)
solution 120 mg/0.8ml, 80 mg/0.8ml
T3 QL (22.4 ML per 30
(SP) Days)
solution 30 mg/0.3ml
T3 QL (8.4 ML per 30
(SP) Days)
T3 QL (11.2 ML per 30
(SP) Days)
T3 QL (16.8 ML per 30
(SP) Days)
SYNTHETIC HEPARINOID-LIKE AGENTS
Tier Notes
ANTICONVULSANTS - BENZODIAZEPINES
LOW MOLECULAR WEIGHT HEPARINS
Drug Name
BANZEL ORAL SUSPENSION
T3 PA; MD
(SP)
BANZEL ORAL TABLET
T3 PA; MD
(SP)
carbamazepine er oral capsule
T1
MD
carbamazepine er oral tablet extended
release 12 hr
T1
MD
carbamazepine oral suspension
T1
MD
carbamazepine oral tablet
T1
MD
carbamazepine oral tablet chewable
T1
MD
gabapentin oral capsule 100 mg, 300
mg
T1
MD; QL (372 EA per
31 days)
gabapentin oral capsule 400 mg
T1
MD; QL (279 EA per
31 days)
ST Step Therapy
½
MD Maintenance Drug
Version 4
Page 20
Drug Name
Tier Notes
Drug Name
Tier Notes
gabapentin oral solution
T1
MD; QL (2232 ML per
31 days)
gabapentin oral tablet 600 mg
T1
MD; QL (186 EA per
31 days)
POTIGA ORAL TABLET
gabapentin oral tablet 800 mg
T1
MD; QL (140 EA per
31 days)
primidone oral tablet
T1
MD
LAMICTAL ODT ORAL KIT
T2
topiramate oral capsule sprinkle
T1
MD
LAMICTAL ODT ORAL TABLET
DISPERSIBLE
T2
topiramate oral tablet
T1
MD
lamotrigine oral tablet
T1
MD
lamotrigine oral tablet chewable
T1
MD
levetiracetam er oral tablet extended
T1
MD; QL (186 EA per
31 days)
levetiracetam er oral tablet extended
T1
MD; QL (124 EA per
31 days)
levetiracetam oral solution
T1
MD
levetiracetam oral tablet 750 mg,
1000 mg
T1
days)
levetiracetam oral tablet 250 mg
T1
days)
levetiracetam oral tablet 500 mg
T1
LYRICA ORAL CAPSULE 100 MG,
150 MG, 200 MG, 25 MG, 50 MG, 75
MG
T3
LYRICA ORAL CAPSULE 225 MG,
300 MG
T3
Days)
MD; QL (186 EA per
31 days)
ST; MD; QL (93 EA
per 31 days)
ST; MD; QL (62 EA
per 31 days)
oxcarbazepine oral suspension
T1
MD
oxcarbazepine oral tablet
T1
MD
T3 PA; MD
(SP)
VIMPAT ORAL SOLUTION
T3 PA; MD; QL (1240 ML
(SP) per 31 days)
VIMPAT ORAL TABLET
(SP) per 31 days)
zonisamide oral capsule
T1
MD
CARBAMATES
felbamate oral suspension
T3 MD
(SP)
felbamate oral tablet
T3 MD
(SP)
GABA MODULATORS
GABITRIL ORAL TABLET 12 MG,
16 MG
T3 MD
(SP)
SABRIL ORAL TABLET
T3 PA
(SP)
tiagabine hcl oral tablet 2 mg
T3 MD
(SP)
tiagabine hcl oral tablet 4 mg
T3 MD; QL (124 EA per
(SP) 31 days)
ST Step Therapy
½
MD Maintenance Drug
Version 4
Page 21
Drug Name
Tier Notes
Drug Name
HYDANTOINS
Tier Notes
mirtazapine oral tablet dispersible
PEGANONE ORAL TABLET
T3
MD
phenytoin oral suspension 125 mg/5ml
T1
MD
phenytoin sodium extended oral
capsule
T1
MD
T3
MD
ethosuximide oral capsule
T1
MD
ethosuximide oral solution
T1
MD
T1
MD
divalproex sodium oral capsule
sprinkle
T1
MD
divalproex sodium oral tablet delayed
release
T1
MD
valproic acid oral capsule
T1
MD
valproic acid oral solution
T1
MD
valproic acid oral syrup
T1
MD
bupropion hcl er (sr) oral tablet
T1
days)
bupropion hcl er (xl) oral tablet
T1
days)
bupropion hcl oral tablet
T1
MD
maprotiline hcl oral tablet
T2
MD
BRINTELLIX ORAL TABLET
T2
MD
nefazodone hcl oral tablet 100 mg,
150 mg, 250 mg, 50 mg
T1
days)
nefazodone hcl oral tablet 200 mg
T1
days)
trazodone hcl oral tablet
T1
MD
MODIFIED CYCLICS
VALPROIC ACID
divalproex sodium er oral tablet
days)
ANTIDEPRESSANTS - MISC.
SUCCINIMIDES
CELONTIN ORAL CAPSULE
T1
VIIBRYD ORAL KIT
T3 ST; QL (31 EA per 31
(SP) days)
VIIBRYD ORAL TABLET
T3 ST; MD; QL (31 EA
(SP) per 31 days)
ANTIDEPRESSANTS
MONOAMINE OXIDASE INHIBITORS (MAOIS)
ALPHA-2 RECEPTOR ANTAGONISTS (TETRACYCLICS)
EMSAM TRANSDERMAL PATCH
24 HR
mirtazapine oral tablet 15 mg, 7.5 mg
mirtazapine oral tablet 30 mg, 45 mg
T1
T1
days)
days)
T3 PA; MD
(SP)
MARPLAN ORAL TABLET
T3
MD
phenelzine sulfate oral tablet
T1
MD
ST Step Therapy
½
MD Maintenance Drug
Version 4
Page 22
Drug Name
tranylcypromine sulfate oral tablet
Tier Notes
T2
Drug Name
MD
SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS)
Tier Notes
duloxetine hcl oral capsule delayed
release particles 20 mg, 60 mg
T2
Days)
citalopram hydrobromide oral
solution
T1
MD
release particles 30 mg
T2
Days)
citalopram hydrobromide oral tablet
T1
MD
release particles 40 mg
T2
days)
escitalopram oxalate oral solution
T1
MD
T1
MD; 1/2
PRISTIQ ORAL TABLET
T2
escitalopram oxalate oral tablet 10
mg, 20 mg
days)
T1
MD
venlafaxine hcl er oral capsule
extended release 24 hour 150 mg
T1
escitalopram oxalate oral tablet 5 mg
days)
fluoxetine hcl oral capsule 10 mg, 20
mg
T1
days)
T1
days)
fluoxetine hcl oral capsule 40 mg
T1
days)
venlafaxine hcl er oral capsule
extended release 24 hour 37.5 mg, 75
mg
venlafaxine hcl oral tablet
T1
days)
fluoxetine hcl oral solution
T1
MD
fluvoxamine maleate oral tablet
T1
MD
TRICYCLIC AGENTS
paroxetine hcl er oral tablet extended
release 24 hr
T1
MD
amitriptyline hcl oral tablet
T1
MD
amoxapine oral tablet
T2
MD
paroxetine hcl oral tablet
T1
MD
clomipramine hcl oral capsule
T1
MD
PAXIL ORAL SUSPENSION
T3
MD
desipramine hcl oral tablet
T1
MD
PEXEVA ORAL TABLET
T3
MD
doxepin hcl oral capsule
T1
MD
sertraline hcl oral concentrate
T1
MD
doxepin hcl oral concentrate
T1
MD
sertraline hcl oral tablet
T1
days)
imipramine hcl oral tablet
T1
MD
imipramine pamoate oral capsule
T3
MD
nortriptyline hcl oral capsule
T1
MD
SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS
(SNRIS)
ST Step Therapy
½
MD Maintenance Drug
Version 4
Page 23
Drug Name
Tier Notes
protriptyline hcl oral tablet
T1
MD
SURMONTIL ORAL CAPSULE
T3
MD
trimipramine maleate oral capsule
T3
MD
Drug Name
metformin hcl oral tablet 850 mg
ALPHA-GLUCOSIDASE INHIBITORS
acarbose oral tablet
T1
days)
GLYSET ORAL TABLET
T3
ST; MD
days)
GLUCAGEN HYPOKIT INJECTION
T2
GLUCAGON EMERGENCY
INJECTION KIT
T2
PROGLYCEM ORAL SUSPENSION
T2
MD
DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS
ANTIDIABETIC - AMYLIN ANALOGS
TRADJENTA ORAL TABLET
SYMLINPEN 120
SUBCUTANEOUS
T2
MD
SYMLINPEN 60 SUBCUTANEOUS
T2
MD
metformin hcl er (osm) oral tablet
T2
ST; MD; QL (62 EA
per 31 days)
metformin hcl er (osm) oral tablet
T2
ST; MD; QL (155 EA
per 31 days)
metformin hcl er oral tablet extended
T1
MD; QL (124 EA per
31 days)
metformin hcl er oral tablet extended
T1
days)
T1
days)
T1
MD; QL (155 EA per
31 days)
T2
MD
DIPEPTIDYL PEPTIDASE-4 INHIBITOR-BIGUANIDE
COMBINATIONS
JENTADUETO ORAL TABLET
BIGUANIDES
T1
DIABETIC OTHER
ANTIDIABETICS
Tier Notes
T2
MD
DOPAMINE RECEPTOR AGONISTS - ERGOT DERIVATIVES
CYCLOSET ORAL TABLET
T3
ST; MD
HUMAN INSULIN
HUMULIN R U-500
(CONCENTRATED)
SUBCUTANEOUS SOLUTION
T3 MD; QL (20 ML per 28
(SP) days)
LEVEMIR FLEXTOUCH
SUBCUTANEOUS
T2
MD; QL (60 ML per 31
days)
LEVEMIR SUBCUTANEOUS
SOLUTION
T2
days)
NOVOLIN 70/30 RELION
SUBCUTANEOUS SUSPENSION
T2
days)
ST Step Therapy
½
MD Maintenance Drug
Version 4
Page 24
Drug Name
Tier Notes
Drug Name
Tier Notes
NOVOLIN 70/30 SUBCUTANEOUS
SUSPENSION
T2
days)
BYETTA 10 MCG PEN
SUBCUTANEOUS
T2
MD; QL (4.8 ML per
31 days)
NOVOLIN N RELION
T2
days)
BYETTA 5 MCG PEN
SUBCUTANEOUS
T2
MD; QL (4.8 ML per
31 days)
NOVOLIN N SUBCUTANEOUS
SUSPENSION
T2
days)
TANZEUM SUBCUTANEOUS
T2
MD
NOVOLIN R INJECTION
SOLUTION
T2
days)
nateglinide oral tablet
T1
days)
NOVOLIN R RELION INJECTION
SOLUTION
T2
days)
repaglinide oral tablet
T2
Days)
NOVOLOG FLEXPEN
SUBCUTANEOUS
T2
days)
NOVOLOG MIX 70/30 FLEXPEN
SUBCUTANEOUS
T2
days)
NOVOLOG MIX 70/30
T2
days)
NOVOLOG PENFILL
SUBCUTANEOUS
T2
NOVOLOG SUBCUTANEOUS
SOLUTION
T2
TRESIBA FLEXTOUCH
SUBCUTANEOUS
T2
days)
days)
days)
INCRETIN MIMETIC AGENTS (GLP-1 RECEPTOR AGONISTS)
BYDUREON SUBCUTANEOUS
T2
MD
BYDUREON SUBCUTANEOUS
SUSPENSION RECONSTITUTED
T2
MD
MEGLITINIDE ANALOGUES
SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT1)
INHIBITORS
JARDIANCE ORAL TABLET
T2
MD
SULFONYLUREA-BIGUANIDE COMBINATIONS
glipizide-metformin hcl oral tablet
2.5-250 mg
T1
MD; QL (248 EA per
31 days)
glipizide-metformin hcl oral tablet
2.5-500 mg, 5-500 mg
T1
MD; QL (124 EA per
31 days)
glyburide-metformin oral tablet 1.25250 mg
T1
MD; QL (248 EA per
31 days)
glyburide-metformin oral tablet 2.5500 mg, 5-500 mg
T1
MD; QL (124 EA per
31 days)
chlorpropamide oral tablet
T1
MD
glimepiride oral tablet 1 mg
T1
MD; QL (248 EA per
31 days)
SULFONYLUREAS
ST Step Therapy
½
MD Maintenance Drug
Version 4
Page 25
Drug Name
Tier Notes
Drug Name
Tier Notes
T1
MD; QL (124 EA per
31 days)
tolbutamide oral tablet
T3
T1
days)
glipizide er oral tablet extended
release 24 hr 10 mg
T1
days)
release 24 hr 2.5 mg
T1
MD; QL (248 EA per
31 days)
release 24 hr 5 mg
T1
MD; QL (124 EA per
31 days)
ANTIDIARRHEALS
glipizide oral tablet 10 mg
T1
MD; QL (124 EA per
31 days)
diphenatol oral tablet
T1
glipizide oral tablet 5 mg
T1
MD; QL (248 EA per
31 days)
diphenoxylate-atropine oral liquid†
T1
diphenoxylate-atropine oral tablet
T1
loperamide hcl oral capsule
T1
MOTOFEN ORAL TABLET
T3
ST; MD
SULFONYLUREA-THIAZOLIDINEDIONE COMBINATIONS
pioglitazone hcl-glimepiride oral
tablet
T2
days)
AVANDIA ORAL TABLET
T3
ST; MD
pioglitazone hcl oral tablet
T1
MD
THIAZOLIDINEDIONES
ANTIPERISTALTIC AGENTS
glipizide xl oral tablet extended
release 24 hr
T1
MD
glyburide micronized oral tablet 1.5
mg, 3 mg
T1
MD; QL (124 EA per
31 days)
glyburide micronized oral tablet 6 mg
T1
days)
MD
ANTIDOTES
ANTIDOTES - CHELATING AGENTS
CHEMET ORAL CAPSULE
T3
glyburide oral tablet 1.25 mg
T1
MD; QL (496 EA per
31 days)
EXJADE ORAL TABLET SOLUBLE
T3 PA; MD
(SP)
glyburide oral tablet 2.5 mg
T1
MD; QL (248 EA per
31 days)
FERRIPROX ORAL TABLET
T3 PA
(SP)
glyburide oral tablet 5 mg
T1
MD; QL (124 EA per
31 days)
OPIOID ANTAGONISTS
ST; MD
ANTIEMETICS
tolazamide oral tablet
T3
naltrexone hcl oral tablet
ST Step Therapy
½
T1
MD Maintenance Drug
Version 4
Page 26
Drug Name
Tier Notes
5-HT2 RECEPTOR ANTAGONISTS
ANZEMET ORAL TABLET
T3 PA
(SP)
Drug Name
Tier Notes
flucytosine oral capsule
T3
(SP)
griseofulvin microsize oral suspension
T1
granisetron hcl oral tablet
T1
nystatin oral tablet
T1
ondansetron hcl oral solution
T1
terbinafine hcl oral tablet
T1
ondansetron hcl oral tablet 24 mg
T1
IMIDAZOLES
ondansetron hcl oral tablet 4 mg, 8
mg
T1
ketoconazole oral tablet
ondansetron oral tablet dispersible
T1
meclizine hcl oral tablet
T1
TIGAN INTRAMUSCULAR
SOLUTION
T3
trimethobenzamide hcl oral capsule
T1
T1
itraconazole oral capsule
T2
PA
NOXAFIL ORAL SUSPENSION
T3 PA
(SP)
voriconazole oral tablet
T3 PA
(SP)
ANTIHISTAMINES
CESAMET ORAL CAPSULE
T3 PA
(SP)
dronabinol oral capsule
T3 PA; QL (62 EA per 31
(SP) days)
SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR
ANTAGONISTS
T3
PA; QL (62 EA per 31
days)
ANTIHISTAMINES - ETHANOLAMINES
carbinoxamine maleate oral tablet
T2
clemastine fumarate oral syrup
T1
clemastine fumarate oral tablet 2.68
mg
T1
diphenhydramine hcl injection
solution
T1
ANTIHISTAMINES - NON-SEDATING
ANTIFUNGALS
levocetirizine dihydrochloride oral
solution
ANTIFUNGALS
fluconazole oral tablet
PA
ANTIEMETICS - MISCELLANEOUS
T1
TRIAZOLES
ANTIEMETICS - ANTICHOLINERGIC
EMEND ORAL CAPSULE
ST Step Therapy
½
T1
MD
MD Maintenance Drug
Version 4
Page 27
Drug Name
levocetirizine dihydrochloride oral
tablet
Tier Notes
T1
MD
ANTIHISTAMINES - PHENOTHIAZINES
Drug Name
Tier Notes
micronized colestipol hcl oral tablet
T1
MD
PREVALITE ORAL PACKET
T1
MD
PREVALITE ORAL POWDER
T1
MD
WELCHOL ORAL TABLET
T3
ST; MD
PHENADOZ SUPPOSITORY
T1
promethazine hcl injection solution
T1
promethazine hcl oral solution
T1
MD
T1
fenofibrate micronized oral capsule
134 mg, 200 mg, 67 mg
T1
promethazine hcl oral syrup
promethazine hcl oral tablet
T1
fenofibrate oral tablet 145 mg, 48 mg
T2
MD
promethazine hcl suppository
T1
fenofibrate oral tablet 160 mg, 54 mg
T1
MD
PROMETHEGAN SUPPOSITORY
T1
fenofibric acid oral capsule delayed
release
T2
MD
gemfibrozil oral tablet
T1
MD
FIBRIC ACID DERIVATIVES
ANTIHISTAMINES - PIPERIDINES
cyproheptadine hcl oral tablet
T1
MD
HMG COA REDUCTASE INHIBITORS
ANTIHYPERLIPIDEMICS
ANTIHYPERLIPIDEMICS - MISC.
omega-3-acid ethyl esters oral capsule
T2
MD
VASCEPA ORAL CAPSULE
T2
MD
BILE ACID SEQUESTRANTS
atorvastatin calcium oral tablet 10 mg
T1
days)
atorvastatin calcium oral tablet 20
mg, 40 mg, 80 mg
T1
MD; 1/2; QL (31 EA
per 31 days)
CRESTOR ORAL TABLET
T3
MD; 1/2; QL (31 EA
per 31 days)
cholestyramine light oral packet
T1
MD
cholestyramine light oral powder
T1
MD
fluvastatin sodium oral capsule
T1
MD
cholestyramine oral packet
T1
MD
lovastatin oral tablet
T1
MD
cholestyramine oral powder
T1
MD
pravastatin sodium oral tablet
T1
days)
colestipol hcl oral granules
T1
MD
rosuvastatin calcium oral tablet
T3
colestipol hcl oral tablet
T1
MD
days)
ST Step Therapy
½
MD Maintenance Drug
Version 4
Page 28
Drug Name
simvastatin oral tablet
Tier Notes
T1
Drug Name
days)
Tier Notes
lisinopril-hydrochlorothiazide oral
tablet
T1
MD
INTEST CHOLEST ABSORP INHIB-HMG COA REDUCTASE
INHIB COMB
moexipril-hydrochlorothiazide oral
tablet
T1
MD
LIPTRUZET ORAL TABLET
T2
Days)
quinapril-hydrochlorothiazide oral
tablet
T1
MD
VYTORIN ORAL TABLET
T3
MD
ACE INHIBITORS
INTESTINAL CHOLESTEROL ABSORPTION INHIBITORS
benazepril hcl oral tablet
T1
MD
ZETIA ORAL TABLET
captopril oral tablet
T1
MD
enalapril maleate oral tablet
T1
MD
fosinopril sodium oral tablet
T1
MD
lisinopril oral tablet
T1
MD
moexipril hcl oral tablet
T1
MD
perindopril erbumine oral tablet
T2
MD
quinapril hcl oral tablet
T1
MD
ramipril oral capsule
T1
MD
trandolapril oral tablet
T1
MD
T2
MD
NICOTINIC ACID DERIVATIVES
niacin er (antihyperlipidemic) oral
tablet extendedrelease
T2
MD
NIACOR ORAL TABLET
T1
MD
ANTIHYPERTENSIVES
ACE INHIBITOR & CALCIUM CHANNEL BLOCKER
COMBINATIONS
amlodipine besy-benazepril hcl oral
capsule
T3
days)
ACE INHIBITORS & THIAZIDE/THIAZIDE-LIKE
benazepril-hydrochlorothiazide oral
tablet
T1
captopril-hydrochlorothiazide oral
tablet
T1
enalapril-hydrochlorothiazide oral
tablet
T1
fosinopril sodium-hctz oral tablet
T1
MD
MD
ADRENOLYTICS-CENTRAL & THIAZIDE/THIAZIDE-LIKE
COMB
methyldopa-hydrochlorothiazide oral
tablet
T1
MD
AGENTS FOR PHEOCHROMOCYTOMA
MD
DIBENZYLINE ORAL CAPSULE
MD
ANGIOTENSIN II RECEPTOR ANTAG & CA CHANNEL
BLOCKER COMB
ST Step Therapy
½
T3
MD Maintenance Drug
Version 4
Page 29
Drug Name
Tier Notes
Drug Name
Tier Notes
amlodipine besylate-valsartan oral
tablet
T2
MD
ANGIOTENSIN II RECEPTOR ANT-CA CHANNEL BLOCKERTHIAZIDES
AZOR ORAL TABLET
T2
MD
amlodipine-valsartan-hctz oral tablet
T2
MD
TRIBENZOR ORAL TABLET
T2
MD
ANGIOTENSIN II RECEPTOR ANTAG & THIAZIDE/THIAZIDELIKE
BENICAR HCT ORAL TABLET
T2
MD
candesartan cilexetil-hctz oral tablet
T2
Days)
irbesartan-hydrochlorothiazide oral
tablet
T1
MD
losartan potassium-hctz oral tablet
T1
MD
valsartan-hydrochlorothiazide oral
tablet
T1
MD
ANTIADRENERGICS - CENTRALLY ACTING
clonidine hcl oral tablet
T1
MD
clonidine hcl transdermal patch
weekly
T1
MD
guanfacine hcl oral tablet
T1
MD
methyldopa oral tablet
T1
MD
ANTIADRENERGICS - PERIPHERALLY ACTING
doxazosin mesylate oral tablet
T1
MD
ANGIOTENSIN II RECEPTOR ANTAGONISTS
prazosin hcl oral capsule
T1
MD
BENICAR ORAL TABLET
T2
MD; 1/2
terazosin hcl oral capsule
T1
MD
candesartan cilexetil oral tablet
T2
Days)
BETA BLOCKER & DIURETIC COMBINATIONS
atenolol-chlorthalidone oral tablet
T1
MD
bisoprolol-hydrochlorothiazide oral
tablet
T1
MD
metoprolol-hydrochlorothiazide oral
tablet
T1
MD
propranolol-hctz oral tablet
T1
MD
eprosartan mesylate oral tablet
T2
MD
irbesartan oral tablet 150 mg, 75 mg
T1
MD
irbesartan oral tablet 300 mg
T1
MD; 1/2
losartan potassium oral tablet 100 mg,
50 mg
T1
MD; 1/2
losartan potassium oral tablet 25 mg
T1
MD
telmisartan oral tablet
T3
MD
valsartan oral tablet
T1
MD; 1/2
DIRECT RENIN INHIBITORS & CALCIUM CHANNEL
BLOCKER COMB
TEKAMLO ORAL TABLET
ST Step Therapy
½
T2
MD
MD Maintenance Drug
Version 4
Page 30
Drug Name
Tier Notes
Drug Name
Tier Notes
DIRECT RENIN INHIBITORS & THIAZIDE/THIAZIDE-LIKE
COMB
XIFAXAN ORAL TABLET 550 MG
(SP) per 31 days)
TEKTURNA HCT ORAL TABLET
ANTI-INFECTIVE MISC. - COMBINATIONS
T2
MD
DIRECT RENIN INHIBITORS
TEKTURNA ORAL TABLET
T2
MD
DIRECT RENIN INHIBITORS-CA CHANNEL BLOCKERTHIAZIDE COMB
AMTURNIDE ORAL TABLET
T2
MD
sulfamethoxazole-trimethoprim
intravenous solution
T1
sulfamethoxazole-trimethoprim oral
suspension 200-40 mg/5ml
T1
sulfamethoxazole-trimethoprim oral
tablet
T1
SELECTIVE ALDOSTERONE RECEPTOR ANTAGONISTS
(SARAS)
ANTIPROTOZOAL AGENTS
eplerenone oral tablet
ALINIA ORAL SUSPENSION
RECONSTITUTED
T3
PA
ALINIA ORAL TABLET
T3
PA
atovaquone oral suspension
T3
T1
MD
VASODILATORS
hydralazine hcl oral tablet
T1
MD
minoxidil oral tablet
T1
MD
ANTI-INFECTIVE AGENTS - MISC.
dapsone oral tablet
ANTI-INFECTIVE AGENTS - MISC.
metronidazole oral tablet
PENTAM INJECTION SOLUTION
RECONSTITUTED
trimethoprim oral tablet
LEPROSTATICS
T2
MD
LINCOSAMIDES
T1
T3 PA
(SP)
T1
clindamycin hcl oral capsule
T1
clindamycin palmitate hcl oral
T1
OXAZOLIDINONES
vancomycin hcl oral capsule
T3 PA
(SP)
linezolid oral suspension reconstituted
T3 PA
(SP)
XIFAXAN ORAL TABLET 200 MG
(SP) Days)
linezolid oral tablet
T3 PA
(SP)
ST Step Therapy
½
MD Maintenance Drug
Version 4
Page 31
Drug Name
Tier Notes
Drug Name
ZYVOX ORAL SUSPENSION
RECONSTITUTED
T3 PA
(SP)
cycloserine oral capsule
T3
ethambutol hcl oral tablet
T1
MD
isoniazid oral syrup
T1
MD
isoniazid oral tablet
T1
MD
PRIFTIN ORAL TABLET
T3
pyrazinamide oral tablet
T1
rifabutin oral capsule
T3
rifampin oral capsule
T1
TRECATOR ORAL TABLET
T3
POLYMYXINS
polymyxin b sulfate injection solution
reconstituted
T1
ANTIMALARIALS
ANTIMALARIAL COMBINATIONS
atovaquone-proguanil hcl oral tablet
T1
COARTEM ORAL TABLET
T3
ANTIMALARIALS
MD
Tier Notes
MD
ANTINEOPLASTICS AND ADJUNCTIVE
THERAPIES
chloroquine phosphate oral tablet
T1
DARAPRIM ORAL TABLET
T2
hydroxychloroquine sulfate oral tablet
T1
MD
mefloquine hcl oral tablet
T1
MD
BUSULFEX INTRAVENOUS
SOLUTION
T3 PA
(SP)
primaquine phosphate oral tablet
T2
MD
HEXALEN ORAL CAPSULE
quinine sulfate oral capsule
T3
T3 PA
(SP)
ALKYLATING AGENTS
ANDROGEN BIOSYNTHESIS INHIBITORS
ANTIMYASTHENIC AGENTS
ZYTIGA ORAL TABLET
ANTIMYASTHENIC AGENTS
guanidine hcl oral tablet
T1
pyridostigmine bromide er oral tablet
extendedrelease
T3
MD
pyridostigmine bromide oral tablet
T1
MD
ANTIADRENALS
ANTIMYCOBACTERIAL AGENTS
ANTIMYCOBACTERIAL AGENTS
T3 PA; SP; MD
(SP)
LYSODREN ORAL TABLET
T2
ANTIANDROGENS
bicalutamide oral tablet
T1
MD
flutamide oral capsule
T1
MD
ST Step Therapy
½
MD Maintenance Drug
Version 4
Page 32
Drug Name
NILANDRON ORAL TABLET
XTANDI ORAL CAPSULE
Tier Notes
T2
Drug Name
MD
Tier Notes
methotrexate sodium injection solution
reconstituted
T3 PA; SP; MD
(SP)
TABLOID ORAL TABLET
ANTIESTROGENS
FARESTON ORAL TABLET
tamoxifen citrate oral tablet 10 mg
tamoxifen citrate oral tablet 20 mg
T1
T3 PA
(SP)
fluorouracil intravenous solution
T2
mercaptopurine oral tablet
T1
methotrexate oral tablet
T1
methotrexate sodium (pf) injection
solution 1 gm/40ml, 100 mg/4ml, 25
mg/ml, 250 mg/10ml, 50 mg/2ml
T1
methotrexate sodium injection solution
T1
T3 PA
(SP)
ANTINEOPLASTIC - MTOR KINASE INHIBITORS
AFINITOR ORAL TABLET
T3 PA; MD
(SP)
ANTINEOPLASTIC - MULTIKINASE INHIBITORS
NEXAVAR ORAL TABLET
T3 PA; MD
(SP)
SUTENT ORAL CAPSULE
T3 PA; MD
(SP)
ANTINEOPLASTIC - TYROSINE KINASE INHIBITORS
ANTIMETABOLITES
capecitabine oral tablet
ZOLINZA ORAL CAPSULE
PA; PA only applies to
NCS eligibility as part
of Preventive Services
Coverage (Breast
Cancer Prevention)
PA; MD; PA only
applies to NCS
eligibility as part of
Preventive Services
Coverage (Breast
Cancer Prevention)
T3 PA
(SP)
ANTINEOPLASTIC - HISTONE DEACETYLASE INHIBITORS
T3 MD
(SP)
T1
T1
CAPRELSA ORAL TABLET
T3 PA
(SP)
GLEEVEC ORAL TABLET
T3 PA; MD
(SP)
SPRYCEL ORAL TABLET
T3 PA; MD
(SP)
TARCEVA ORAL TABLET
T3 PA; MD
(SP)
TASIGNA ORAL CAPSULE
T3 PA; MD
(SP)
MD
ST Step Therapy
½
MD Maintenance Drug
Version 4
Page 33
Drug Name
Tier Notes
Drug Name
TYKERB ORAL TABLET
T3 PA; MD
(SP)
ESTROGENS-ANTINEOPLASTIC
VOTRIENT ORAL TABLET
T3 PA
(SP)
XALKORI ORAL CAPSULE
T3 PA; MD
(SP)
hydroxyurea oral capsule
INTRON A INJECTION SOLUTION
T3 PA; MD
(SP)
T1
MD
T3 PA; MD
(SP)
INTRON A INJECTION SOLUTION T3 PA; MD
RECONSTITUTED
(SP)
MATULANE ORAL CAPSULE
TICE BCG INTRAVESICAL
EMCYT ORAL CAPSULE
T3 PA
(SP)
FOLIC ACID ANTAGONISTS RESCUE AGENTS
leucovorin calcium oral tablet
T3
IMIDAZOTETRAZINES
ANTINEOPLASTICS MISC.
ACTIMMUNE SUBCUTANEOUS
SOLUTION
Tier Notes
T3
(SP)
NCS
temozolomide oral capsule
T3 PA
(SP)
JANUS ASSOCIATED KINASE (JAK) INHIBITORS
JAKAFI ORAL TABLET
T3 PA; MD
(SP)
LHRH ANALOGS
leuprolide acetate injection kit
T3 PA; MD
(SP)
LUPRON DEPOT
INTRAMUSCULAR KIT 11.25 MG,
22.5 MG, 30 MG, 7.5 MG
T3 PA; MD
(SP)
T3 PA
(SP)
anastrozole oral tablet
T1
MD
LUPRON DEPOT
INTRAMUSCULAR KIT 3.75 MG,
45 MG
exemestane oral tablet
T1
MD
NITROGEN MUSTARDS
letrozole oral tablet
T3
MD
cyclophosphamide oral capsule
T3
LEUKERAN ORAL TABLET
T2
AROMATASE INHIBITORS
CHEMOTHERAPY ADJUNCTS - KERATINOCYTE GROWTH
FACTORS
KEPIVANCE INTRAVENOUS
T3
(SP)
melphalan hcl intravenous solution
reconstituted
T3
(SP)
PROGESTINS-ANTINEOPLASTIC
ST Step Therapy
½
MD Maintenance Drug
Version 4
Page 34
Drug Name
Tier Notes
megestrol acetate oral suspension 40
mg/ml, 400 mg/10ml, 800 mg/20ml
T1
megestrol acetate oral tablet
T1
MD
Drug Name
Tier Notes
tolcapone oral tablet
T3 MD
(SP)
DECARBOXYLASE INHIBITORS
RETINOIDS
T3
MD
T1
MD
SELECTIVE RETINOID X RECEPTOR AGONISTS
carbidopa-levodopa er oral tablet
extendedrelease
bexarotene oral capsule
carbidopa-levodopa oral tablet
T1
MD
tretinoin oral capsule
carbidopa oral tablet
T3 PA
(SP)
T3 PA; MD
(SP)
ANTIPARKINSON AGENTS
ANTIPARKINSON ANTICHOLINERGICS
benztropine mesylate oral tablet
T1
MD
trihexyphenidyl hcl oral elixir
T1
MD
trihexyphenidyl hcl oral tablet
T1
MD
amantadine hcl oral capsule
T1
amantadine hcl oral tablet
LEVODOPA COMBINATIONS
NONERGOLINE DOPAMINE RECEPTOR AGONISTS
pramipexole dihydrochloride er oral
tablet extended release 24 hr 0.375
mg, 0.75 mg, 1.5 mg, 3 mg, 4.5 mg
T3 PA; MD
(SP)
pramipexole dihydrochloride oral
tablet
T1
MD
ropinirole hcl er oral tablet extended
release 24 hr
T1
MD
MD
ropinirole hcl oral tablet
T1
MD
T1
MD
PERIPHERAL COMT INHIBITORS
bromocriptine mesylate oral capsule
T1
MD
entacapone oral tablet
T3
MD
bromocriptine mesylate oral tablet
T1
MD
ANTIPARKINSON MONOAMINE OXIDASE INHIBITORS
ANTIPSYCHOTICS/ANTIMANIC
AGENTS
AZILECT ORAL TABLET
T3
MD
ANTIMANIC AGENTS
selegiline hcl oral capsule
T1
MD
lithium carbonate er oral tablet
extendedrelease
T1
MD
selegiline hcl oral tablet
T1
MD
lithium carbonate oral capsule
T1
MD
ANTIPARKINSON DOPAMINERGICS
CENTRAL/PERIPHERAL COMT INHIBITORS
ST Step Therapy
½
MD Maintenance Drug
Version 4
Page 35
Drug Name
Tier Notes
Drug Name
Tier Notes
lithium carbonate oral tablet
T1
MD
haloperidol lactate oral concentrate
T1
MD
lithium oral solution
T1
MD
haloperidol oral tablet
T1
MD
ANTIPSYCHOTICS - MISC.
DIBENZODIAZEPINES
LATUDA ORAL TABLET
T3
MD
clozapine oral tablet
T1
MD
ziprasidone hcl oral capsule
T1
days)
FAZACLO ORAL TABLET
DISPERSIBLE
T3
PA; MD
T3
PA; MD
BENZISOXAZOLES
DIBENZO-OXEPINO PYRROLES
FANAPT ORAL TABLET
T3
PA; MD
FANAPT TITRATION PACK ORAL
TABLET
T3
PA
INVEGA SUSTENNA
INTRAMUSCULAR SUSPENSION
T3
PA; MD
quetiapine fumarate oral tablet
T1
days)
RISPERDAL CONSTA
RECONSTITUTED
T3
PA; MD
SEROQUEL XR ORAL TABLET
T3
PA; MD
RISPERIDONE M-TAB ORAL
TABLET DISPERSIBLE 0.5 MG, 1
MG, , 2 MG, 3 MG, 4 MG
T1
T1
MD
risperidone oral solution
T1
MD
chlorpromazine hcl oral tablet
T1
MD
risperidone oral tablet
T1
MD
COMPRO SUPPOSITORY
T1
risperidone oral tablet dispersible
T1
MD
fluphenazine hcl oral concentrate
T2
MD
fluphenazine hcl oral elixir
T2
MD
fluphenazine hcl oral tablet
T1
MD
perphenazine oral tablet
T1
MD
DIBENZOTHIAZEPINES
DIBENZOXAZEPINES
MD
haloperidol decanoate intramuscular
solution
T1
haloperidol lactate injection solution
T1
loxapine succinate oral capsule
PHENOTHIAZINES
BUTYROPHENONES
SAPHRIS SUBLINGUAL TABLET
SUBLINGUAL
MD
ST Step Therapy
½
MD Maintenance Drug
Version 4
Page 36
Drug Name
Tier Notes
Drug Name
Tier Notes
prochlorperazine edisylate injection
solution
T1
EPZICOM ORAL TABLET
T3 PA; MD
(SP)
prochlorperazine maleate oral tablet
T1
KALETRA ORAL SOLUTION
prochlorperazine suppository
T1
T3 PA; MD
(SP)
thioridazine hcl oral tablet
T1
MD
KALETRA ORAL TABLET
T3 PA; MD
(SP)
trifluoperazine hcl oral tablet
T1
MD
lamivudine-zidovudine oral tablet
T3 MD
(SP)
aripiprazole oral solution
T3
MD
TRUVADA ORAL TABLET
aripiprazole oral tablet 10 mg, 20 mg,
30 mg
T3
PA; MD; 1/2; QL (31
EA per 31 days)
T3 PA; MD
(SP)
aripiprazole oral tablet 15 mg, 2 mg, 5
mg
T3
QUINOLINONE DERIVATIVES
PA; MD; QL (31 EA
per 31 days)
ANTIRETROVIRALS - CCR5 ANTAGONISTS (ENTRY
INHIBITOR)
SELZENTRY ORAL TABLET
THIENBENZODIAZEPINES
(SP) per 31 days)
olanzapine oral tablet
T1
MD
ANTIRETROVIRALS - FUSION INHIBITORS
olanzapine oral tablet dispersible
T1
MD
FUZEON SUBCUTANEOUS
T1
MD
THIOXANTHENES
T3 PA; MD
(SP)
ANTIRETROVIRALS - INTEGRASE INHIBITORS
thiothixene oral capsule
ISENTRESS ORAL TABLET
ANTIVIRALS
(SP) per 31 days)
ANTIRETROVIRAL COMBINATIONS
ANTIRETROVIRALS - PROTEASE INHIBITORS
abacavir-lamivudine-zidovudine oral
tablet
T3 PA; MD
(SP)
APTIVUS ORAL CAPSULE
T3 PA; MD
(SP)
ATRIPLA ORAL TABLET
(SP) per 31 days)
APTIVUS ORAL SOLUTION
T3 PA; MD
(SP)
COMPLERA ORAL TABLET
T3 MD
(SP)
CRIXIVAN ORAL CAPSULE
T3 PA; MD
(SP)
ST Step Therapy
½
MD Maintenance Drug
Version 4
Page 37
Drug Name
Tier Notes
Drug Name
Tier Notes
INVIRASE ORAL CAPSULE
T3 PA; MD
(SP)
INTELENCE ORAL TABLET 25
MG
T3 PA; MD
(SP)
INVIRASE ORAL TABLET
T3 PA; MD
(SP)
nevirapine er oral tablet extended
release 24 hr
T3 PA; MD
(SP)
LEXIVA ORAL SUSPENSION
T3 PA; MD
(SP)
nevirapine oral suspension
T3 PA; MD
(SP)
LEXIVA ORAL TABLET
T3 PA; MD
(SP)
nevirapine oral tablet
T3 PA; MD
(SP)
NORVIR ORAL CAPSULE
T3 PA; MD
(SP)
RESCRIPTOR ORAL TABLET
T3 PA; MD
(SP)
NORVIR ORAL SOLUTION
T3 PA; MD
(SP)
SUSTIVA ORAL CAPSULE
T3 PA; MD
(SP)
NORVIR ORAL TABLET
T3 PA; MD
(SP)
SUSTIVA ORAL TABLET
T3 PA; MD
(SP)
PREZISTA ORAL TABLET 150 MG, T3 PA; MD
600 MG, 75 MG
(SP)
VIRAMUNE ORAL SUSPENSION
T3 PA; MD
(SP)
REYATAZ ORAL CAPSULE 150
MG, 200 MG, 300 MG
T3 PA; MD
(SP)
T3 PA; MD
(SP)
VIRACEPT ORAL TABLET
T3 PA; MD
(SP)
VIRAMUNE XR ORAL TABLET
EXTENDED RELEASE 24 HR 100
MG
ANTIRETROVIRALS - RTI-NON-NUCLEOSIDE ANALOGUES
EDURANT ORAL TABLET
T3 PA; MD
(SP)
MG
(SP) per 31 days)
MG
(SP) per 31 days)
ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUESPURINES
abacavir sulfate oral tablet
T3 PA; MD
(SP)
didanosine oral capsule delayed
release
T3 PA; MD
(SP)
VIDEX ORAL SOLUTION
RECONSTITUTED
T3 PA; MD
(SP)
ST Step Therapy
½
MD Maintenance Drug
Version 4
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Drug Name
Tier Notes
Drug Name
Tier Notes
ZIAGEN ORAL SOLUTION
T3 PA; MD
(SP)
VIREAD ORAL POWDER
T3 PA; MD
(SP)
ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUESPYRIMIDINES
VIREAD ORAL TABLET
T3 PA; MD
(SP)
EMTRIVA ORAL CAPSULE
T3 PA; MD
(SP)
CMV AGENTS
EMTRIVA ORAL SOLUTION
T3 PA; MD
(SP)
lamivudine oral solution
T3 PA; MD
(SP)
lamivudine oral tablet 150 mg, 300 mg
T3 PA; MD
(SP)
VALCYTE ORAL SOLUTION
RECONSTITUTED
T3 PA; MD
(SP)
valganciclovir hcl oral tablet
T3 PA; MD
(SP)
HEPATITIS B AGENTS
adefovir dipivoxil oral tablet
T3 PA
(SP)
ANTIRETROVIRALS - RTI-NUCLEOSIDE ANALOGUESTHYMIDINES
BARACLUDE ORAL SOLUTION
T3 PA; MD
(SP)
RETROVIR INTRAVENOUS
SOLUTION
T3 PA
(SP)
entecavir oral tablet
T3 PA; MD
(SP)
stavudine oral capsule
T3 PA; MD
(SP)
EPIVIR HBV ORAL SOLUTION
T3 PA; MD
(SP)
stavudine oral solution reconstituted
T3 PA; MD
(SP)
lamivudine oral tablet 100 mg
T3 PA; MD
(SP)
zidovudine oral capsule
T3 PA; MD
(SP)
TYZEKA ORAL TABLET
T3 PA; MD
(SP)
zidovudine oral syrup
T3 PA; MD
(SP)
HEPATITIS C AGENTS
zidovudine oral tablet
T3 PA; MD
(SP)
ANTIRETROVIRALS - RTI-NUCLEOTIDE ANALOGUES
PEG-INTRON REDIPEN PAK 4
SUBCUTANEOUS KIT
T3 PA
(SP)
PEG-INTRON REDIPEN
SUBCUTANEOUS KIT
T3 PA
(SP)
ST Step Therapy
½
MD Maintenance Drug
Version 4
Page 39
Drug Name
Tier Notes
Drug Name
Tier Notes
PEG-INTRON SUBCUTANEOUS
KIT
T3 PA
(SP)
ASSORTED CLASSES
ribavirin oral capsule
T3 PA
(SP)
THALOMID ORAL CAPSULE
ribavirin oral tablet
T3 PA
(SP)
CHELATING AGENTS
SOVALDI ORAL TABLET
T3 PA; MD
(SP)
ANTILEPROTICS
HERPES AGENTS - PURINE ANALOGUES
T3 PA; MD
(SP)
DEPEN TITRATABS ORAL
TABLET
T3
SYPRINE ORAL CAPSULE
T3
MD
CYCLOSPORINE ANALOGS
acyclovir oral capsule
T1
MD
acyclovir oral suspension
T1
MD
acyclovir oral tablet
T1
MD
valacyclovir hcl oral tablet
T1
days)
cyclosporine modified oral capsule
T1
MD
cyclosporine modified oral solution
T1
MD
cyclosporine oral capsule
T1
MD
GENGRAF ORAL SOLUTION
T1
MD
HERPES AGENTS - THYMIDINE ANALOGUES
IMMUNE GLOBULIN IMMUNOSUPPRESSANTS
famciclovir oral tablet
THYMOGLOBULIN
INTRAVENOUS SOLUTION
RECONSTITUTED
T3
INFLUENZA AGENTS
rimantadine hcl oral tablet
T1
IMMUNOMODULATORS FOR MYELODYSPLASTIC
SYNDROMES
NEURAMINIDASE INHIBITORS
RELENZA DISKHALER
INHALATION AEROSOL
T3 PA
(SP)
T3
TAMIFLU ORAL SUSPENSION
RECONSTITUTED 6 MG/ML
T3
REVLIMID ORAL CAPSULE
T3 PA; MD
(SP)
INOSINE MONOPHOSPHATE DEHYDROGENASE INHIBITORS
TAMIFLU ORAL CAPSULE
T3 PA
(SP)
QL (62 EA per 31
Days)
mycophenolate mofetil oral capsule
T1
MD
mycophenolate mofetil oral tablet
T1
MD
IRRIGATION SOLUTIONS
ST Step Therapy
½
MD Maintenance Drug
Version 4
Page 40
Drug Name
Tier Notes
PHYSIOLYTE IRRIGATION
SOLUTION
T1
sterile water for irrigation irrigation
solution
T1
Drug Name
Tier Notes
BETA BLOCKERS
ALPHA-BETA BLOCKERS
MACROLIDE IMMUNOSUPPRESSANTS
PROGRAF ORAL CAPSULE
T3
MD
RAPAMUNE ORAL SOLUTION
T2
MD
sirolimus oral tablet
T2
MD
tacrolimus oral capsule
T2
MD
carvedilol oral tablet
T1
MD
COREG CR ORAL CAPSULE
T2
MD
labetalol hcl oral tablet
T1
MD
BETA BLOCKERS CARDIO-SELECTIVE
acebutolol hcl oral capsule
T1
MD
atenolol oral tablet
T1
MD
betaxolol hcl oral tablet
T1
MD
bisoprolol fumarate oral tablet
T1
MD
BYSTOLIC ORAL TABLET 10 MG,
20 MG, 5 MG
T2
MD; 1/2
BYSTOLIC ORAL TABLET 2.5 MG
T2
MD
T1
days)
T1
MD
LEVATOL ORAL TABLET
T3
MD
nadolol oral tablet
T1
Days)
SELECTIVE T-CELL COSTIMULATION BLOCKERS
pindolol oral tablet
T2
MD
NULOJIX INTRAVENOUS
propranolol hcl er oral capsule
T1
MD
ZORTRESS ORAL TABLET
T3 PA; MD
(SP)
POTASSIUM REMOVING RESINS
kalexate oral powder
T3
KIONEX ORAL POWDER
T3
KIONEX ORAL SUSPENSION
T1
sodium polystyrene sulfonate oral
powder
T3
metoprolol succinate er oral tablet
extended release 24 hr 25 mg, 50 mg,
100 mg, 200 mg
sodium polystyrene sulfonate oral
suspension
T1
metoprolol tartrate oral tablet
SPS ORAL SUSPENSION
T1
BETA BLOCKERS NON-SELECTIVE
PURINE ANALOGS
azathioprine oral tablet
T1
MD
T3 PA; MD
(SP)
ST Step Therapy
½
MD Maintenance Drug
Version 4
Page 41
Drug Name
Tier Notes
propranolol hcl oral solution
T2
MD
propranolol hcl oral tablet
T1
MD
sotalol hcl (af) oral tablet
T1
MD
sotalol hcl oral tablet
T1
MD
timolol maleate oral tablet
T1
MD
BIOLOGICALS MISC
ALLERGENIC EXTRACTS
Drug Name
Tier Notes
diltiazem hcl er beads oral capsule
T1
MD
diltiazem hcl er coated beads oral
T1
MD
diltiazem hcl er coated beads oral
tablet extended release 24 hr
T1
MD
diltiazem hcl er oral capsule extended
release 12 hour
T1
MD
GRASTEK SUBLINGUAL TABLET
SUBLINGUAL
T2
diltiazem hcl er oral capsule extended
release 24 hour
T1
MD
RAGWITEK SUBLINGUAL
TABLET SUBLINGUAL
T2
diltiazem hcl oral tablet
T1
MD
dilt-xr oral capsule extended release
24 hour
T1
MD
felodipine er oral tablet extended
release 24 hr
T1
MD
CALCIUM CHANNEL BLOCKERS
isradipine oral capsule
T2
MD
CALCIUM CHANNEL BLOCKERS
MATZIM LA ORAL TABLET
MG
T1
MD
BIOLOGICALS MISC
ADAGEN INTRAMUSCULAR
SOLUTION
T3 PA; MD
(SP)
amlodipine besylate oral tablet
T1
MD
CARDIZEM LA ORAL TABLET
MG
T3
MD
MATZIM LA ORAL TABLET
MG, 300 MG, 360 MG, 420 MG
T1
CARTIA XT ORAL CAPSULE
T1
MD
nicardipine hcl oral capsule
T1
MD
T1
MD
diltiazem cd oral capsule extended
release 24 hour
T1
MD
NIFEDICAL XL ORAL TABLET
nifedipine er oral tablet extended
release 24 hr
T1
MD
ST Step Therapy
½
MD Maintenance Drug
Version 4
Page 42
Drug Name
Tier Notes
Drug Name
Tier Notes
nifedipine er osmotic release oral
T1
MD
PULMONARY HYPERTENSION - ENDOTHELIN RECEPTOR
ANTAGONISTS
nifedipine oral capsule
T1
MD
LETAIRIS ORAL TABLET
nimodipine oral capsule
T1
T3 PA; MD
(SP)
nisoldipine er oral tablet extended
release 24 hr
T1
MD
TRACLEER ORAL TABLET
T3 PA; MD
(SP)
TAZTIA XT ORAL CAPSULE
T1
MD
verapamil hcl er oral capsule
T1
MD
verapamil hcl er oral tablet
extendedrelease
T1
MD
verapamil hcl oral tablet
T1
MD
PULMONARY HYPERTENSION - PHOSPHODIESTERASE
INHIBITORS
ADCIRCA ORAL TABLET
T3 PA; MD
(SP)
sildenafil citrate oral tablet
T3 PA
(SP)
CEPHALOSPORINS
CEPHALOSPORINS - 1ST GENERATION
CARDIOTONICS
cefadroxil oral capsule
T1
cefadroxil oral suspension
reconstituted
T1
cefadroxil oral tablet
T1
cefazolin sodium injection solution
reconstituted 300 gm
T1
T1
PROSTAGLANDIN VASODILATORS
cephalexin oral capsule 250 mg, 500
mg
REMODULIN INJECTION
SOLUTION
T3 PA; MD
(SP)
cephalexin oral suspension
reconstituted
T1
VENTAVIS INHALATION
SOLUTION
T3 PA; MD
(SP)
CEPHALOSPORINS - 2ND GENERATION
CARDIAC GLYCOSIDES
DIGITEK ORAL TABLET
T1
MD
DIGOX ORAL TABLET
T1
MD
digoxin oral solution
T2
MD
digoxin oral tablet
T1
MD
CARDIOVASCULAR AGENTS - MISC.
ST Step Therapy
½
MD Maintenance Drug
Version 4
Page 43
Drug Name
Tier Notes
cefaclor er oral tablet extended
release 12 hr
T2
cefaclor oral capsule
T1
cefprozil oral suspension reconstituted
T1
cefprozil oral tablet
T1
CEFTIN ORAL SUSPENSION
RECONSTITUTED
T3
cefuroxime axetil oral tablet
T1
T1
cefdinir oral suspension reconstituted
T1
cefixime oral suspension reconstituted
T3
cefpodoxime proxetil oral tablet
T1
ceftriaxone sodium injection solution
reconstituted 1 gm, 2 gm, 250 mg, 500
mg
T1
ceftriaxone sodium intravenous
solution reconstituted 10 gm
T1
BIPHASIC CONTRACEPTIVES - ORAL
AZURETTE ORAL TABLET
NCS
BEKYREE ORAL TABLET
NCS
desogestrel-ethinyl estradiol oral
tablet 0.15-0.02/0.01 mg (21/5)
NCS
KARIVA ORAL TABLET
NCS
KIMIDESS ORAL TABLET
NCS
LO LOESTRIN FE ORAL TABLET
T3
NECON 10/11 (28) ORAL TABLET
NCS
PIMTREA ORAL TABLET
NCS
viorele oral tablet
NCS
ALTAVERA ORAL TABLET
NCS
alyacen 1/35 oral tablet
NCS
APRI ORAL TABLET
NCS
AUBRA ORAL TABLET
NCS
AVIANE ORAL TABLET
NCS
BALZIVA ORAL TABLET
NCS
BEYAZ ORAL TABLET
CONTRACEPTIVES
Tier Notes
MD
COMBINATION CONTRACEPTIVES - ORAL
CEPHALOSPORINS - 3RD GENERATION
cefdinir oral capsule
Drug Name
T2
BLISOVI ORAL TABLET
NCS
briellyn oral tablet
NCS
CHATEAL ORAL TABLET
NCS
CRYSELLE-28 ORAL TABLET
NCS
CYCLAFEM 1/35 ORAL TABLET
NCS
CYRED ORAL TABLET
NCS
DASETTA 1/35 ORAL TABLET
NCS
DELYLA ORAL TABLET
NCS
desogestrel-ethinyl estradiol oral
tablet 0.15-30 mg-mcg
NCS
ST Step Therapy
½
MD
MD Maintenance Drug
Version 4
Page 44
Drug Name
Tier Notes
Drug Name
Tier Notes
drospirenone-ethinyl estradiol oral
tablet
NCS
LARIN FE 1/20 ORAL TABLET
NCS
LESSINA ORAL TABLET
NCS
ELINEST ORAL TABLET
NCS
NCS
ENSKYCE ORAL TABLET
NCS
levonorgestrel-ethinyl estrad oral
tablet 0.1-20 mg-mcg, 0.15-30 mgmcg
NCS
EMOQUETTE ORAL TABLET
ESTARYLLA ORAL TABLET
NCS
LEVORA 0.15/30 (28) ORAL
TABLET
NCS
FALMINA ORAL TABLET
NCS
LOMEDIA 24 FE ORAL TABLET
NCS
LORYNA ORAL TABLET
NCS
LOW-OGESTREL ORAL TABLET
NCS
LUTERA ORAL TABLET
NCS
marlissa oral tablet
NCS
MICROGESTIN 1.5/30 ORAL
TABLET
NCS
MICROGESTIN 1/20 ORAL
TABLET
NCS
MICROGESTIN FE 1.5/30 ORAL
TABLET
NCS
MICROGESTIN FE 1/20 ORAL
TABLET
NCS
GENERESS FE ORAL TABLET
CHEWABLE
T3
MD
GIANVI ORAL TABLET
NCS
GILDAGIA ORAL TABLET
NCS
GILDESS 1.5/30 ORAL TABLET
NCS
GILDESS 1/20 ORAL TABLET
NCS
GILDESS FE 1.5/30 ORAL TABLET NCS
GILDESS FE 1/20 ORAL TABLET
NCS
JUNEL 1.5/30 ORAL TABLET
NCS
JUNEL 1/20 ORAL TABLET
NCS
JUNEL FE 1.5/30 ORAL TABLET
NCS
JUNEL FE 1/20 ORAL TABLET
NCS
KELNOR 1/35 ORAL TABLET
NCS
MINASTRIN 24 FE ORAL TABLET
CHEWABLE
KURVELO ORAL TABLET
NCS
MONO-LINYAH ORAL TABLET
NCS
LARIN 1.5/30 ORAL TABLET
NCS
MONONESSA ORAL TABLET
NCS
LARIN 1/20 ORAL TABLET
NCS
NECON 0.5/35 (28) ORAL TABLET
NCS
LARIN FE 1.5/30 ORAL TABLET
NCS
ST Step Therapy
½
T3
MD
MD Maintenance Drug
Version 4
Page 45
Drug Name
Tier Notes
Drug Name
NCS
SAFYRAL ORAL TABLET
NCS
SOLIA ORAL TABLET
NCS
norethin ace-eth estrad-fe oral tablet
1-20 mg-mcg
NCS
SPRINTEC 28 ORAL TABLET
NCS
SRONYX ORAL TABLET
NCS
norethindrone acet-ethinyl est oral
tablet
NCS
SYEDA ORAL TABLET
NCS
norethin-eth estradiol-fe oral tablet
chewable
NCS
TARINA FE 1/20 ORAL TABLET
NCS
VESTURA ORAL TABLET
NCS
norgestimate-eth estradiol oral tablet
NCS
VYFEMLA ORAL TABLET
NCS
WERA ORAL TABLET
NCS
WYMZYA FE ORAL TABLET
CHEWABLE
NCS
T2
MD
NORINYL 1+50 (28) ORAL
TABLET
T2
NORTREL 0.5/35 (28) ORAL
TABLET
NCS
NORTREL 1/35 (21) ORAL
TABLET
NCS
NORTREL 1/35 (28) ORAL
TABLET
NCS
OCELLA ORAL TABLET
NCS
OGESTREL ORAL TABLET
NCS
ORSYTHIA ORAL TABLET
NCS
PHILITH ORAL TABLET
NCS
PIRMELLA 1/35 ORAL TABLET
NCS
XULANE TRANSDERMAL PATCH NCS
WEEKLY
PORTIA-28 ORAL TABLET
NCS
COMBINATION CONTRACEPTIVES – VAGINAL
PREVIFEM ORAL TABLET
NCS
NUVARING VAGINAL RING
RECLIPSEN ORAL TABLET
NCS
CONTINUOUS CONTRACEPTIVES – ORAL
MD
Tier Notes
YASMIN 28 ORAL TABLET
T1
MD
YAZ ORAL TABLET
T1
MD
ZARAH ORAL TABLET
NCS
ZENCHENT FE ORAL TABLET
CHEWABLE
NCS
ZENCHENT ORAL TABLET
NCS
ZOVIA ORAL TABLET
NCS
COMBINATION CONTRACEPTIVES – TRANSDERMAL
ST Step Therapy
½
NCS
MD Maintenance Drug
Version 4
Page 46
Drug Name
Tier Notes
Drug Name
Tier Notes
AMETHYST ORAL TABLET
NCS
INTROVALE ORAL TABLET
NCS
levonorgestrel-ethinyl estrad oral
tablet 90-20 mcg
NCS
JOLESSA ORAL TABLET
NCS
levonorgest-eth estrad 91-day oral
tablet 0.1-0.02 & 0.01 mg, 0.15-0.03
&0.01 mg
NCS
levonorgest-eth estrad 91-day oral
tablet 0.15-0.03 mg
NCS
QUASENSE ORAL TABLET
NCS
NCS
COPPER CONTRACEPTIVES - IUD
PARAGARD INTRAUTERINE
COPPER INTRAUTERINE
INTRAUTERINE DEVICE
NCS
EMERGENCY CONTRACEPTIVES
ECONTRA EZ ORAL TABLET
NCS
SETLAKIN ORAL TABLET
ELLA ORAL TABLET
NCS
FOUR PHASE CONTRACEPTIVES – ORAL
FALLBACK SOLO ORAL TABLET
NCS
NATAZIA ORAL TABLET
levonorgestrel oral tablet
NCS
PROGESTIN CONTRACEPTIVES – IMPLANTS
MY WAY ORAL TABLET
NCS
NEXT CHOICE ONE DOSE ORAL
TABLET
NCS
NEXPLANON SUBCUTANEOUS
IMPLANT
OPCICON ONE-STEP ORAL
TABLET
NCS
T2
NCS
PROGESTIN CONTRACEPTIVES – INJECTABLE
medroxyprogesterone acetate
intramuscular suspension
NCS
EXTENDED-CYCLE CONTRACEPTIVES – ORAL
PROGESTIN CONTRACEPTIVES – IUD
AMETHIA LO ORAL TABLET
NCS
NCS
AMETHIA ORAL TABLET
NCS
MIRENA INTRAUTERINE
INTRAUTERINE DEVICE
ASHLYNA ORAL TABLET
NCS
SKYLA INTRAUTERINE
INTRAUTERINE DEVICE
T2
CAMRESE LO ORAL TABLET
NCS
CAMRESE ORAL TABLET
NCS
DAYSEE ORAL TABLET
NCS
MD
PROGESTIN CONTRACEPTIVES – ORAL
CAMILA ORAL TABLET
NCS
DEBLITANE ORAL TABLET
NCS
ST Step Therapy
½
MD Maintenance Drug
Version 4
Page 47
Drug Name
Tier Notes
Drug Name
Tier Notes
ERRIN ORAL TABLET
NCS
NCS
HEATHER ORAL TABLET
NCS
norgestim-eth estrad triphasic oral
tablet
JENCYCLA ORAL TABLET
NCS
NORTREL 7/7/7 ORAL TABLET
NCS
JOLIVETTE ORAL TABLET
NCS
PIRMELLA 7/7/7 ORAL TABLET
NCS
LYZA ORAL TABLET
NCS
TILIA FE ORAL TABLET
NCS
NORA-BE ORAL TABLET
NCS
TRI-ESTARYLLA ORAL TABLET
NCS
norethindrone oral tablet
NCS
TRI-LEGEST FE ORAL TABLET
NCS
NORLYROC ORAL TABLET
NCS
TRI-LINYAH ORAL TABLET
NCS
SHAROBEL ORAL TABLET
NCS
TRIPHASIC CONTRACEPTIVES – ORAL
alyacen 7/7/7 oral tablet
NCS
ARANELLE ORAL TABLET
NCS
CAZIANT ORAL TABLET
NCS
CESIA ORAL TABLET
NCS
CYCLAFEM 7/7/7 ORAL TABLET
NCS
DASETTA 7/7/7 ORAL TABLET
NCS
ENPRESSE-28 ORAL TABLET
NCS
LEENA ORAL TABLET
NCS
LEVONEST ORAL TABLET
NCS
levonorg-eth estrad triphasic oral
tablet
NCS
MYZILRA ORAL TABLET
NCS
NECON 7/7/7 ORAL TABLET
NCS
TRI-LO-SPRINTEC ORAL TABLET NCS
TRINESSA (28) ORAL TABLET
NCS
TRI-PREVIFEM ORAL TABLET
NCS
TRI-SPRINTEC ORAL TABLET
NCS
TRIVORA (28) ORAL TABLET
NCS
VELIVET ORAL TABLET
NCS
CORTICOSTEROIDS
GLUCOCORTICOSTEROIDS
budesonide er oral capsule extended
release 24 hour
T3
(SP)
cortisone acetate oral tablet
T1
dexamethasone oral solution
T2
dexamethasone oral tablet
T1
dexamethasone sodium phosphate
injection solution
T1
hydrocortisone oral tablet
T1
ST Step Therapy
½
MD
MD Maintenance Drug
Version 4
Page 48
Drug Name
Tier Notes
Drug Name
Tier Notes
methylprednisolone (pak) oral tablet
T1
hydromet oral syrup
T1
methylprednisolone acetate injection
suspension 40 mg/ml, 80 mg/ml
T1
DECONGESTANT & ANTIHISTAMINE
methylprednisolone oral tablet
T1
MILLIPRED DP ORAL TABLET
T2
prednisolone oral solution
promethazine vc oral syrup
T1
promethazine vc plain oral syrup
T1
promethazine-phenylephrine oral
syrup
T1
T1
prednisolone oral syrup
T1
MISC. RESPIRATORY INHALANTS
prednisolone sodium phosphate oral
solution
T1
prednisolone sodium phosphate oral
tablet dispersible
T2
sodium chloride inhalation
nebulization solution 0.9 %, 10 %, 3
%, 7 %
prednisone (pak) oral tablet
T1
acetylcysteine inhalation solution
PREDNISONE INTENSOL ORAL
CONCENTRATE
T1
NON-NARC ANTITUSSIVE-ANTIHISTAMINE
prednisone oral solution
T1
prednisone oral tablet
T1
MUCOLYTICS
promethazine-dm oral syrup
T1
T1
T1
NON-NARC ANTITUSSIVE-DECONGESTANTANTIHISTAMINE
MINERALOCORTICOIDS
fludrocortisone acetate oral tablet
T1
MD
BROMFED DM ORAL SYRUP
T1
pseudoeph-bromphen-dm oral syrup
T1
COUGH/COLD/ALLERGY
OPIOID ANTITUSSIVE-ANTIHISTAMINE
ANTITUSSIVE – NONNARCOTIC
promethazine-codeine oral syrup
benzonatate oral capsule
T1
OPIOID ANTITUSSIVE-DECONGESTANT-ANTIHISTAMINE
ANTITUSSIVE – OPIOID
hydrocodone-homatropine oral syrup
T1
hydrocodone-homatropine oral tablet
T1
T1
phenyleph-promethazine-cod oral
syrup
T1
promethazine vc/codeine oral syrup
T1
ST Step Therapy
½
MD Maintenance Drug
Version 4
Page 49
Drug Name
Tier Notes
DERMATOLOGICALS
ACNE ANTIBIOTICS
Drug Name
Tier Notes
AVAR CLEANSER EXTERNAL
EMULSION
T2
CLINDACIN ETZ EXTERNAL
SWAB
T1
AVAR-E EMOLLIENT EXTERNAL
CREAM
T1
CLINDACIN-P EXTERNAL SWAB
T1
AVAR-E GREEN EXTERNAL
CREAM
T1
CLINDAMAX EXTERNAL
T1
T1
BENZAMYCINPAK EXTERNAL
PACKET
T3
CLINDAMAX EXTERNAL
LOTION
T1
benzoyl peroxide-erythromycin
external
T1
clindamycin phosphate external
clindamycin phosphate external foam
T1
T1
clindamycin phosphate external lotion
T1
clindamycin phos-benzoyl perox
external
clindamycin phosphate external
solution
T1
EPIDUO EXTERNAL
T3
T2
clindamycin phosphate external swab
T1
PRASCION EXTERNAL
EMULSION
ery external pad
T1
PRASCION FC EXTERNAL PAD
T2
erythromycin external
T1
PRASCION RA EXTERNAL
CREAM
T1
erythromycin external pad
T1
T1
ROSANIL CLEANSER EXTERNAL
EMULSION
T2
erythromycin external solution
sulfacetamide sodium (acne) external
lotion
T1
ROSULA EXTERNAL PAD
T2
ss 10-2 external solution
T2
sulfacetamide sodium external
suspension
T1
sss 10-5 external cream
T1
sss 10-5 external foam
T2
sulfacetamide sodium-sulfur external
cream 10-2 %, 9.8-4.8 %
T2
ACNE COMBINATIONS
ACANYA EXTERNAL
T3
ST Step Therapy
½
MD Maintenance Drug
Version 4
Page 50
Drug Name
Tier Notes
Drug Name
Tier Notes
cream 10-5 %
T1
benzoyl peroxide cleanser external
lotion 6 %
T1
emulsion
T2
benzoyl peroxide external 10 %, 2.5 %
T1
benzoyl peroxide external foam 5.3 %
T1
foam
T2
benzoyl peroxide short contact
external foam
T1
liquid† 10-2 %, 9-4.5 %, 9.8-4.8 %
T2
CLARAVIS ORAL CAPSULE
T3
(SP)
lotion 10-5 %
T2
MYORISAN ORAL CAPSULE
T3
(SP)
pad
T2
suspension 10-5 %
T2
sulfacetamide-sulfur in urea external
T2
sulfacetamide-sulfur in urea external
emulsion
T2
VELTIN EXTERNAL
T3
ZIANA EXTERNAL
T3
T1
adapalene external cream
T1
tretinoin external 0.01 %, 0.025 %
T1
tretinoin external cream
T1
tretinoin microsphere external
T2
tretinoin microsphere pump external
T2
T3
(SP)
AGENTS FOR EXTERNAL GENITAL AND PERIANAL WARTS
adapalene external 0.1 %
ATRALIN EXTERNAL
T2
ZENATANE ORAL CAPSULE
ACNE PRODUCTS
AMNESTEEM ORAL CAPSULE
PR BENZOYL PEROXIDE WASH
EXTERNAL LIQUID†
VEREGEN EXTERNAL
OINTMENT
T2
ANTIBIOTIC STEROID COMBINATIONS - TOPICAL
T3
(SP)
T3
CORTISPORIN EXTERNAL
CREAM
T3
CORTISPORIN EXTERNAL
OINTMENT
T3
ST Step Therapy
½
MD Maintenance Drug
Version 4
Page 51
Drug Name
Tier Notes
ANTIBIOTICS - TOPICAL
Drug Name
Tier Notes
ciclopirox olamine external
suspension
T1
MENTAX EXTERNAL CREAM
T2
ALTABAX EXTERNAL
OINTMENT
T2
gentamicin sulfate external cream
T1
naftifine hcl external cream
T3
gentamicin sulfate external ointment
T1
NAFTIN EXTERNAL 1 %
T3
mupirocin external ointment
T1
NAFTIN EXTERNAL CREAM 2 %
T3
ANTIFUNGALS - TOPICAL COMBINATIONS
nystatin external cream
T1
clotrimazole-betamethasone external
cream
T1
nystatin external ointment
T3
nystatin external powder
T1
clotrimazole-betamethasone external
lotion
T1
NYSTOP EXTERNAL POWDER
T1
DERMAZENE EXTERNAL CREAM
T1
hydrocortisone-iodoquinol external
cream
T1
nystatin-triamcinolone external cream
T1
ANTINEOPLASTIC ANTIMETABOLITES - TOPICAL
nystatin-triamcinolone external
ointment
T1
CARAC EXTERNAL CREAM
T3
T2
VUSION EXTERNAL OINTMENT
T3
FLUOROPLEX EXTERNAL
CREAM
fluorouracil external cream 0.5 %
T3
fluorouracil external cream 5 %
T1
fluorouracil external solution
T1
ANTI-INFLAMMATORY AGENTS - TOPICAL
ANTIFUNGALS - TOPICAL
diclofenac sodium 1% transdermal gel
T2
VOLTAREN TRANSDERMAL
T3
CICLODAN EXTERNAL
SOLUTION
T1
ciclopirox external
T1
ciclopirox external shampoo
T1
ANTINEOPLASTIC OR PREMALIGNANT LESIONS - TOPICAL
MISC.
ciclopirox external solution
T1
PICATO EXTERNAL
ciclopirox olamine external cream
T1
T3 PA
(SP)
½
ST Step Therapy
MD Maintenance Drug
Version 4
Page 52
Drug Name
Tier Notes
ANTINEOPLASTIC OR PREMALIGNANT LESIONS - TOPICAL
NSAID'S
diclofenac sodium transdermal
T3 PA
(SP)
ANTINEOPLASTIC RETINOIDS - TOPICAL
PANRETIN EXTERNAL
T3 PA
(SP)
ANTIPRURITICS - TOPICAL
ZONALON EXTERNAL CREAM
T3
ANTIPSORIATICS - SYSTEMIC
Drug Name
Tier Notes
PROMISEB EXTERNAL CREAM
T3
selenium sulf-pyrithione-urea external
shampoo
T3
ANTISEBORRHEIC PRODUCTS
selenium sulfide external lotion
T1
sodium sulfacetamide external
shampoo
T3
sulfacetamide sodium external
T3
sulfacetamide sodium external liquid†
T1
ANTIVIRALS - TOPICAL
8-MOP ORAL CAPSULE
T3 MD
(SP)
acyclovir external ointment
T3
acitretin oral capsule
T3 PA; MD
(SP)
DENAVIR EXTERNAL CREAM
T2
methoxsalen rapid oral capsule
T3 MD
(SP)
ZOVIRAX EXTERNAL CREAM
T3
calcipotriene external cream
T1
calcipotriene external ointment
T1
calcipotriene external solution
T1
TAZORAC EXTERNAL
T3
TAZORAC EXTERNAL CREAM
T3
T3 PA
(SP)
ANTISEBORRHEIC COMBINATIONS
QL (15 GM per 31
days)
BURN PRODUCTS
ANTIPSORIATICS
VECTICAL EXTERNAL
OINTMENT
QL (60 GM per 31
days)
silver sulfadiazine external cream
T1
SSD EXTERNAL CREAM
T1
SULFAMYLON EXTERNAL
CREAM
T3
THERMAZENE EXTERNAL
CREAM
T1
CORTICOSTEROIDS - TOPICAL
alclometasone dipropionate external
cream
ST Step Therapy
½
T2
MD Maintenance Drug
Version 4
Page 53
Drug Name
Tier Notes
Drug Name
Tier Notes
alclometasone dipropionate external
ointment
T2
clobetasol propionate emulsion
external foam
T3
amcinonide external cream
T1
clobetasol propionate external
T1
betamethasone dipropionate aug
external
T1
clobetasol propionate external cream
T1
clobetasol propionate external foam
T3
external cream
T1
clobetasol propionate external lotion
T1
external lotion
T1
ointment
T1
external ointment
T1
shampoo
T1
betamethasone dipropionate external
cream
T1
solution
T1
lotion
T1
clocortolone pivalate external cream
T1
T1
ointment
T1
clocortolone pivalate pump external
cream
CLODAN EXTERNAL SHAMPOO
T1
betamethasone valerate external
cream
T1
CLODERM EXTERNAL CREAM
T1
T3
CLODERM PUMP EXTERNAL
CREAM
T1
betamethasone valerate external foam
lotion
T1
CORDRAN EXTERNAL LOTION
T3
CORDRAN EXTERNAL TAPE
T3
ointment
T1
CORMAX SCALP APPLICATION
EXTERNAL SOLUTION
T1
CAPEX EXTERNAL SHAMPOO
T2
desonide external cream
T1
clobetasol propionate e external
cream
T1
desonide external lotion
T1
ST Step Therapy
½
MD Maintenance Drug
Version 4
Page 54
Drug Name
Tier Notes
desonide external ointment
T1
desoximetasone external
T1
desoximetasone external cream
T1
desoximetasone external ointment
0.25 %
T1
diflorasone diacetate external cream
T3
fluocinolone acetonide body external
oil
Drug Name
Tier Notes
halobetasol propionate external
ointment
T1
HALOG EXTERNAL OINTMENT
T3
hydrocortisone acetate external cream
T1
hydrocortisone butyr lipo base
external cream
T3
T1
hydrocortisone butyrate external
cream
T1
fluocinolone acetonide external cream
0.01 %
T1
ointment
T1
fluocinolone acetonide external
solution
T1
solution
T1
fluocinolone acetonide scalp external
oil
T1
hydrocortisone external cream
T1
hydrocortisone external lotion
T1
fluocinonide external
T1
hydrocortisone external ointment
T1
fluocinonide external cream 0.05 %
T1
T1
fluocinonide external ointment
T1
hydrocortisone valerate external
cream
fluocinonide external solution
T1
hydrocortisone valerate external
ointment
T1
fluocinonide-e external cream
T1
LOCOID EXTERNAL LOTION
T3
fluticasone propionate external cream
T1
mometasone furoate external cream
T1
fluticasone propionate external lotion
T2
mometasone furoate external ointment
T1
fluticasone propionate external
ointment
T1
mometasone furoate external solution
T1
halobetasol propionate external cream
T1
prednicarbate external cream
T2
prednicarbate external ointment
T2
ST Step Therapy
½
MD Maintenance Drug
Version 4
Page 55
Drug Name
Tier Notes
triamcinolone acetonide external
aerosol, solution
T3
cream
T1
lotion
T1
ointment
T1
Drug Name
Tier Notes
SANTYL EXTERNAL OINTMENT
T3
IMIDAZOLE-RELATED ANTIFUNGALS - TOPICAL
clotrimazole external cream
T1
clotrimazole external solution
T1
econazole nitrate external cream
T1
ERTACZO EXTERNAL CREAM
T3 PA
(SP)
EMOLLIENT/KERATOLYTIC AGENTS
EXELDERM EXTERNAL CREAM
T3
ST
REA LO 39 EXTERNAL CREAM
T1
T3
ST
REA LO 40 EXTERNAL CREAM
T1
EXELDERM EXTERNAL
SOLUTION
REMEVEN EXTERNAL CREAM
T1
ketoconazole external cream
T1
urea external
T1
ketoconazole external shampoo
T1
urea external cream
T1
OXISTAT EXTERNAL CREAM
T3
urea external lotion
T1
urea nail external
T1
urea nail film external suspension
T1
X-VIATE EXTERNAL CREAM
T1
IMMUNOMODULATORS IMIDAZOQUINOLINAMINES TOPICAL
imiquimod external cream
T3 QL (12 EA per 31 days)
(SP)
KERATOLYTIC/ANTIMITOTIC AGENTS
EMOLLIENT/KERATOLYTIC COMBINATIONS
CONDYLOX EXTERNAL
T3
urea hydrating external foam
podofilox external solution
T1
salicylic acid external
T1
T1
EMOLLIENTS
ammonium lactate external cream
T1
salicylic acid external cream
T1
ammonium lactate external lotion
T1
salicylic acid external foam
T1
salicylic acid external lotion
T1
ENZYMES - TOPICAL
ST
ST Step Therapy
½
MD Maintenance Drug
Version 4
Page 56
Drug Name
salicylic acid external shampoo
Tier Notes
Drug Name
T1
LOCAL ANESTHETICS - TOPICAL
lidocaine external ointment
T1
lidocaine external patch
T3
lidocaine hcl external
T1
lidocaine hcl external cream
T1
lidocaine hcl external lotion
T1
lidocaine hcl external solution
T1
T2
tacrolimus external ointment
T3
HYLATOPIC PLUS EXTERNAL
FOAM
T3
NEOSALUS EXTERNAL FOAM
T3
TETRIX EXTERNAL KIT
T3
MISC. TOPICAL
HYPERCARE EXTERNAL
SOLUTION
T1
PIGMENTING AGENTS
OXSORALEN EXTERNAL LOTION
MACROLIDE IMMUNOSUPPRESSANTS - TOPICAL
ELIDEL EXTERNAL CREAM
Tier Notes
PA
MISC. DERMATOLOGICAL PRODUCTS
T2
ROSACEA AGENTS
FINACEA EXTERNAL
T3
metronidazole external 0.75 %
T1
metronidazole external 1 %
T3
metronidazole external cream
T1
metronidazole external lotion
T1
ROSADAN EXTERNAL
T1
ROSADAN EXTERNAL CREAM
T1
ELETONE EXTERNAL CREAM
T3
ELETONE TWINPACK EXTERNAL
CREAM
T3
EPICERAM EXTERNAL
EMULSION
T3
HPR EXTERNAL FOAM
T3
SCABICIDES & PEDICULICIDES
HPR PLUS EXTERNAL CREAM
T3
EURAX EXTERNAL CREAM
T3
ST
HPR PLUS EXTERNAL FOAM
T3
EURAX EXTERNAL LOTION
T3
ST
HYLATOPIC EXTERNAL FOAM
T3
lindane external lotion
T1
HYLATOPIC PLUS EXTERNAL
CREAM
T3
lindane external shampoo
T1
malathion external lotion
T1
permethrin external cream
T1
ST Step Therapy
½
MD Maintenance Drug
Version 4
Page 57
Drug Name
Tier Notes
Drug Name
Tier Notes
SKLICE EXTERNAL LOTION
T3
DIAGNOSTIC DRUGS
ULESFIA EXTERNAL LOTION
T3
GLUCAGEN DIAGNOSTIC
INJECTION SOLUTION
RECONSTITUTED
STEROID-LOCAL ANESTHETIC COMBINATIONS
CORTANE-B EXTERNAL LOTION
T3
EPIFOAM EXTERNAL FOAM
T3
hydrocortisone ace-pramoxine
external cream
T1
SODIUM CHLORIDE
THERMOJECT SYS INJECTION
SOLUTION
PRAMOSONE EXTERNAL
LOTION
T3
DIAGNOSTIC TESTS
DIAGNOSTIC PRODUCTS, MISC.
TOPICAL ANESTHETIC COMBINATIONS
lidocaine-prilocaine external cream
T1
lidocaine-prilocaine external kit
T1
SYNERA EXTERNAL PATCH
T3
PA
TOPICAL SELECTIVE RETINOID X RECEPTOR AGONISTS
TARGRETIN EXTERNAL
T3 PA
(SP)
TOPICAL STEROID COMBINATIONS
calcipotriene-betameth diprop
external ointment
T3
PA
T2
DIAGNOSTIC PRODUCTS
FREESTYLE INSULINX TEST IN
VITRO STRIP
T2
MD; QL (200 EA per
31 Days)
FREESTYLE LITE TEST IN VITRO
STRIP
T2
MD; QL (200 EA per
31 Days)
FREESTYLE TEST IN VITRO
STRIP
T2
MD; QL (200 EA per
31 Days)
PRECISION XTRA BLOOD
GLUCOSE IN VITRO STRIP
T2
MD
T2
MD
DIGESTIVE AIDS
CREON ORAL CAPSULE
DELAYED RELEASE PARTICLES
WOUND DRESSINGS
PRUTECT EXTERNAL EMULSION
T1
DIGESTIVE ENZYMES
T3
WOUND CARE - GROWTH FACTOR AGENTS
REGRANEX EXTERNAL
T2
DIURETICS
CARBONIC ANHYDRASE INHIBITORS
acetazolamide oral tablet
T1
acetazolamide sodium injection
T2
ST Step Therapy
½
MD
MD Maintenance Drug
Version 4
Page 58
Drug Name
methazolamide oral tablet
Tier Notes
T1
MD
DIURETIC COMBINATIONS
amiloride-hydrochlorothiazide oral
tablet
T1
MD
spironolactone-hctz oral tablet
T1
MD
triamterene-hctz oral capsule 37.5-25
mg
T1
MD
triamterene-hctz oral tablet
T1
MD
T1
MD
LOOP DIURETICS
bumetanide oral tablet
EDECRIN ORAL TABLET
T3 PA; MD
(SP)
furosemide oral solution 10 mg/ml, 8
mg/ml
T1
MD
furosemide oral tablet
T1
MD
torsemide oral tablet
T1
MD
POTASSIUM SPARING DIURETICS
amiloride hcl oral tablet
T1
MD
DYRENIUM ORAL CAPSULE
T3
MD
spironolactone oral tablet
T1
MD
THIAZIDES AND THIAZIDE-LIKE DIURETICS
Drug Name
Tier Notes
hydrochlorothiazide oral capsule
T1
MD
hydrochlorothiazide oral tablet
T1
MD
indapamide oral tablet
T1
MD
methyclothiazide oral tablet
T2
MD
metolazone oral tablet
T1
MD
alendronate sodium oral tablet 10 mg,
40 mg, 5 mg
T1
days)
alendronate sodium oral tablet 35 mg,
70 mg
T1
MD; QL (4 EA per 28
days)
etidronate disodium oral tablet
T2
MD
ibandronate sodium oral tablet
T1
MD
ENDOCRINE AND METABOLIC
AGENTS - MISC.
BISPHOSPHONATES
pamidronate disodium intravenous
solution
T3 PA
(SP)
pamidronate disodium intravenous
T3 PA
(SP)
risedronate sodium oral tablet 150
mg, 35 mg, 5 mg
T3
ST; MD
risedronate sodium oral tablet 30 mg
T3
ST
chlorothiazide oral tablet
T1
MD
zoledronic acid intravenous solution 5 T3 PA; MD
mg/100ml
(SP)
chlorthalidone oral tablet 25 mg, 50
mg
T1
MD
CALCIMIMETIC AGENTS
ST Step Therapy
½
MD Maintenance Drug
Version 4
Page 59
Drug Name
Tier Notes
Drug Name
SENSIPAR ORAL TABLET
T3 MD
(SP)
paricalcitol oral capsule
T3
INCRELEX SUBCUTANEOUS
SOLUTION
MD
CARNITINE REPLENISHER - AGENTS
T1
MD
levocarnitine oral tablet
T1
MD
DOPAMINE RECEPTOR AGONISTS
T1
MD
T3 PA; MD
(SP)
OMNITROPE SUBCUTANEOUS
SOLUTION
T3 PA; MD
(SP)
OMNITROPE SUBCUTANEOUS
T3 PA; MD
(SP)
calcitriol oral solution
T1
MD
doxercalciferol oral capsule
T3
PA; MD
T3
(SP)
T3 PA; MD
(SP)
T3 PA; MD; QL (2.4 ML
(SP) per 31 days)
PHENYLKETONURIA TREATMENT - AGENTS
KUVAN ORAL TABLET SOLUBLE
T3 PA; MD
(SP)
RANK LIGAND (RANKL) INHIBITORS
prolia subcutaneous solution
HYPERPARATHYROID TREATMENT - VITAMIN D ANALOGS
MD
SYNAREL NASAL SOLUTION
FORTEO SUBCUTANEOUS
SOLUTION
T3 PA; MD
(SP)
T1
T3 PA
(SP)
PARATHYROID HORMONE AND DERIVATIVES
HEREDITARY TYROSINEMIA TYPE 1 (HT-1) TREATMENT AGENTS
calcitriol oral capsule
LUPRON DEPOT-PED
INTRAMUSCULAR KIT
NAGLAZYME INTRAVENOUS
SOLUTION
GROWTH HORMONES
ORFADIN ORAL CAPSULE
T3 PA; MD
(SP)
MUCOPOLYSACCHARIDOSIS VI (MPS VI) - AGENTS
GROWTH HORMONE RECEPTOR ANTAGONISTS
somavert subcutaneous solution
reconstituted
PA; MD
LHRH/GNRH AGONIST ANALOG PITUITARY SUPPRESSANTS
levocarnitine oral solution
cabergoline oral tablet
T3
INSULIN-LIKE GROWTH FACTORS (SOMATOMEDINS)
CALCITONINS
calcitonin (salmon) nasal solution
Tier Notes
T3 PA; MD
(SP)
SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERMS)
ST Step Therapy
½
MD Maintenance Drug
Version 4
Page 60
Drug Name
Tier Notes
raloxifene hcl oral tablet
T2
PA; MD; PA only
applies to NCS
eligibility as part of
Preventive Services
Coverage (Breast
Cancer Prevention); QL
(31 EA per 31 days)
SELECTIVE VASOPRESSIN V2-RECEPTOR ANTAGONISTS
SAMSCA ORAL TABLET
Drug Name
T3 PA
(SP)
SOMATOSTATIC AGENTS
Tier Notes
EEMT HS ORAL TABLET
T1
MD
est estrogens-methyltest ds oral tablet
T1
MD
est estrogens-methyltest hs oral tablet
T1
MD
est estrogens-methyltest oral tablet
T1
MD
CLIMARA PRO TRANSDERMAL
PATCH WEEKLY
T3
MD
COMBIPATCH TRANSDERMAL
PATCH BIWEEKLY
T2
MD
estradiol-norethindrone acet oral
tablet
T1
MD
JINTELI ORAL TABLET
T2
MD
ESTROGEN & PROGESTIN
octreotide acetate injection solution
100 mcg/ml, 1000 mcg/ml, 200
mcg/ml, 50 mcg/ml, 500 mcg/ml
T3 PA; MD
(SP)
SANDOSTATIN LAR DEPOT
INTRAMUSCULAR KIT
T3 PA; MD
(SP)
LOPREEZA ORAL TABLET
T1
MD
MIMVEY LO ORAL TABLET
T1
MD
SOMATULINE DEPOT
SUBCUTANEOUS SOLUTION
T3 PA; MD
(SP)
MIMVEY ORAL TABLET
T1
MD
norethindrone-eth estradiol oral tablet
T2
MD
PREMPHASE ORAL TABLET
T2
MD
PREMPRO ORAL TABLET
T2
MD
UREA CYCLE DISORDER - AGENTS
BUPHENYL ORAL TABLET
T3 PA
(SP)
ESTROGENS
VASOPRESSIN
desmopressin ace spray refrig nasal
solution
T1
MD
DEPO-ESTRADIOL
INTRAMUSCULAR OIL
T2
MD
desmopressin acetate oral tablet
T1
MD
DIVIGEL TRANSDERMAL
T3
MD
ESTROGENS
ENJUVIA ORAL TABLET
T2
MD
ESTROGEN & ANDROGEN
estradiol oral tablet
T1
MD
ST Step Therapy
½
MD Maintenance Drug
Version 4
Page 61
Drug Name
Tier Notes
Drug Name
Tier Notes
estradiol transdermal patch biweekly
T2
MD
GALLSTONE SOLUBILIZING AGENTS
estradiol transdermal patch weekly
T1
MD
ursodiol oral capsule
T1
MD
ESTROGEL TRANSDERMAL
T3
MD
ursodiol oral tablet
T1
MD
estropipate oral tablet
T1
MD
GASTROINTESTINAL ANTIALLERGY AGENTS
MENEST ORAL TABLET
T3
PA; MD
cromolyn sodium oral concentrate
MINIVELLE TRANSDERMAL
PATCH BIWEEKLY
T2
MD
GASTROINTESTINAL CHLORIDE CHANNEL ACTIVATORS
PREMARIN ORAL TABLET
T2
MD
AMITIZA ORAL CAPSULE
ESTROGEN-SELECTIVE ESTROGEN
RECEPTOR MODULATOR COMB
T2
MD
days)
T1
metoclopramide hcl oral tablet
T1
IBS AGENT - GUANYLATE CYCLASE-C (GC-C) AGONISTS
T2
MD
IBS AGENT - SELECTIVE 5-HT2 RECEPTOR ANTAGONISTS
FLUOROQUINOLONES
ciprofloxacin hcl oral tablet
T1
ciprofloxacin oral suspension
reconstituted
T3
ciprofloxacin-ciproflox hcl er oral
T1
levofloxacin oral solution
T1
levofloxacin oral tablet
T1
ofloxacin oral tablet 400 mg
T1
alosetron hcl oral tablet
(SP) per 31 days)
INFLAMMATORY BOWEL AGENTS
GASTROINTESTINAL AGENTS - MISC.
metoclopramide hcl oral solution
LINZESS ORAL CAPSULE
FLUOROQUINOLONES
T2
MD
GASTROINTESTINAL STIMULANTS
ESTROGEN-SELECTIVE ESTROGEN RECEPTOR MODULATOR
COMB
DUAVEE ORAL TABLET
T1
APRISO ORAL CAPSULE
T2
balsalazide disodium oral capsule
T1
CANASA SUPPOSITORY
T3
MD
DIPENTUM ORAL CAPSULE
T3
MD
LIALDA ORAL TABLET
DELAYED RELEASE
T2
MD
ST Step Therapy
½
MD; QL (124 EA per
31 days)
MD Maintenance Drug
Version 4
Page 62
Drug Name
Tier Notes
mesalamine enema
T1
MD
mesalamine-cleanser kit
T1
MD
sulfasalazine oral tablet
T1
MD
sulfasalazine oral tablet delayed
release
T1
MD
SULFAZINE EC ORAL TABLET
DELAYED RELEASE
T1
SULFAZINE ORAL TABLET
T1
Drug Name
Tier Notes
dutasteride oral capsule
T2
days)
finasteride oral tablet 5 mg
T1
MD
ALPHA 1-ADRENOCEPTOR ANTAGONISTS
MD
MD
alfuzosin hcl er oral tablet extended
release 24 hr
T2
MD
tamsulosin hcl oral capsule
T1
MD
CITRATES
INTESTINAL ACIDIFIERS
cytra-2 oral solution
T1
enulose oral solution
T1
MD
CYTRA-3 ORAL SYRUP
T3
generlac oral solution
T1
MD
T1
lactulose encephalopathy oral solution
T1
MD
potassium citrate er oral tablet
extendedrelease
tricitrates oral solution
T3
PHOSPHATE BINDER AGENTS
CYSTINOSIS AGENTS
calcium acetate (phos binder) oral
capsule
T1
calcium acetate oral capsule
T1
MD
GENITOURINARY IRRIGANTS
FOSRENOL ORAL TABLET
CHEWABLE
T2
ST; MD
sodium chloride irrigation solution
RENAGEL ORAL TABLET
T2
ST; MD
RENVELA ORAL TABLET
T3
ST; MD
MD
CYSTAGON ORAL CAPSULE
ELMIRON ORAL CAPSULE
PA; MD
T1
T2
T2
PROSTATIC HYPERTROPHY AGENT COMBINATIONS
5-ALPHA REDUCTASE INHIBITORS
T3
INTERSTITIAL CYSTITIS AGENTS
GENITOURINARY AGENTS MISCELLANEOUS
AVODART ORAL CAPSULE
MD
dutasteride-tamsulosin hcl oral
capsule
T2
days)
JALYN ORAL CAPSULE
T2
days)
days)
ST Step Therapy
½
MD Maintenance Drug
Version 4
Page 63
Drug Name
Tier Notes
Drug Name
URINARY ANALGESICS
phenazopyridine hcl oral tablet 100
mg, 200 mg
T1
GOUT AGENTS
T1
T2
days)
aspirin-dipyridamole er oral capsule
T2
days)
dipyridamole oral tablet
MD
T1
MD
T1
MD
clopidogrel bisulfate oral tablet 75 mg
T1
days)
EFFIENT ORAL TABLET
T2
MD
ticlopidine hcl oral tablet
T1
MD
QUINAZOLINE AGENTS
GOUT AGENTS
allopurinol oral tablet
T1
MD
colchicine oral capsule
T2
MD
colchicine oral tablet
T2
MD
COLCRYS ORAL TABLET
T2
MD
ULORIC ORAL TABLET
T2
ST; MD
T1
MD
anagrelide hcl oral capsule
THIENOPYRIDINE DERIVATIVES
URICOSURICS
probenecid oral tablet
AGGRENOX ORAL CAPSULE
PLATELET AGGREGATION INHIBITORS
GOUT AGENT COMBINATIONS
colchicine-probenecid oral tablet
Tier Notes
HEMATOPOIETIC AGENTS
AGENTS FOR GAUCHER DISEASE
HEMATOLOGICAL AGENTS - MISC.
ZAVESCA ORAL CAPSULE
CYCLOPENTYLTRIAZOLOPYRIMIDINE (CPTP) DERIVATIVES
BRILINTA ORAL TABLET
T2
MD
HEMATORHEOLOGIC AGENTS
pentoxifylline er oral tablet
extendedrelease
MD
PHOSPHODIESTERASE III INHIBITORS
cilostazol oral tablet
CYTOTOXIC AGENTS
DROXIA ORAL CAPSULE
T1
T1
MD
T3 PA; MD
(SP)
T2
MD
ERYTHROPOIETINS
PROCRIT INJECTION SOLUTION
10000 UNIT/ML, 2000 UNIT/ML,
20000 UNIT/ML, 3000 UNIT/ML,
4000 UNIT/ML
(SP) per 31 days)
PLATELET AGGREGATION INHIBITOR COMBINATIONS
ST Step Therapy
½
MD Maintenance Drug
Version 4
Page 64
Drug Name
Tier Notes
Drug Name
PROCRIT INJECTION SOLUTION
40000 UNIT/ML
T3 PA; MD; QL (6 ML per
(SP) 31 days)
HEPATITIS C AGENT - COMBINATIONS
FOLIC ACID/FOLATES
Tier Notes
HEPATITIS C AGENT - COMBINATIONS
HARVONI ORAL TABLET
folic acid oral tablet 1 mg
NCS
folic acid oral tablet 400 mcg, 800
mcg
NCS
T3 PA
(SP)
HYPNOTICS
BARBITURATE HYPNOTICS
GRANULOCYTE COLONY-STIMULATING FACTORS (G-CSF)
NEULASTA SUBCUTANEOUS
T3 PA
(SP)
NEUPOGEN INJECTION
SOLUTION
T3 PA
(SP)
phenobarbital oral elixir
T1
MD
phenobarbital oral tablet
T1
MD
BENZODIAZEPINE HYPNOTICS
estazolam oral tablet
T1
GRANULOCYTE/MACROPHAGE COLONY-STIMULATING
FACTOR(GM-CSF)
flurazepam hcl oral capsule
T1
temazepam oral capsule
T1
LEUKINE INTRAVENOUS
triazolam oral tablet
T1
T3 PA
(SP)
HYPNOTICS - TRICYCLIC AGENTS
IRON
iron oral tablet 325 (65 fe) mg
NCS
iron supplement oral tablet
NCS
SILENOR ORAL TABLET
NON-BENZODIAZEPINE - GABA-RECEPTOR MODULATORS
THROMBOPOIETIN (TPO) RECEPTOR AGONISTS
PROMACTA ORAL TABLET
T3
T3 PA; MD
(SP)
eszopiclone oral tablet
T2
ST
zaleplon oral capsule
T1
zolpidem tartrate oral tablet
T1
HEMOSTATICS
LAXATIVES
HEMOSTATICS - SYSTEMIC
BOWEL EVACUANT COMBINATIONS
tranexamic acid intravenous solution
T3
PA
tranexamic acid oral tablet
T1
MD
COLYTE WITH FLAVOR PACKS
ORAL SOLUTION
RECONSTITUTED 227.1 GM
ST Step Therapy
½
T2
MD Maintenance Drug
Version 4
Page 65
Drug Name
Tier Notes
Drug Name
GAVILYTE-C ORAL SOLUTION
RECONSTITUTED
NCS
KRISTALOSE ORAL PACKET
T2
MD
lactulose oral solution
T1
MD
GAVILYTE-G ORAL SOLUTION
RECONSTITUTED
NCS
GAVILYTE-H ORAL KIT
NCS
GAVILYTE-N WITH FLAVOR
PACK ORAL SOLUTION
RECONSTITUTED
NCS
MOVIPREP ORAL SOLUTION
RECONSTITUTED
T3
phosphate laxative oral solution 0.92.4 gm/5ml
NCS
peg 3350/electrolytes oral solution
reconstituted
NCS
saline laxative oral solution 0.9-2.4
gm/5ml, 2.7-7.2 gm/5ml
NCS
peg 3350-kcl-na bicarb-nacl oral
NCS
SALINE LAXATIVES
peg-3350/electrolytes oral solution
reconstituted
NCS
PEG-PREP ORAL KIT
NCS
SUPREP BOWEL PREP ORAL
SOLUTION
TRILYTE ORAL SOLUTION
RECONSTITUTED
constulose oral solution
polyethylene glycol 3350 oral packet
NCS
polyethylene glycol 3350 oral powder
NCS
T2
magnesium citrate oral solution
NCS
milk of magnesia oral suspension
NCS
STIMULANT LAXATIVES
bisacodyl ec oral tablet delayed
release
T3
NCS
FLEET LAXATIVE ORAL TABLET NCS
DELAYED RELEASE
NCS
MACROLIDES
AZITHROMYCIN
NCS
T1
MD
NCS
gentlelax oral powder
NCS
NCS
OSMOPREP ORAL TABLET
gavilax oral powder
MIRALAX ORAL PACKET
SALINE LAXATIVE MIXTURES
LAXATIVES - MISCELLANEOUS
CLEARLAX ORAL POWDER
Tier Notes
azithromycin oral packet
T1
azithromycin oral suspension
reconstituted
T1
ST Step Therapy
½
MD Maintenance Drug
Version 4
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Drug Name
azithromycin oral tablet
Tier Notes
T1
T2
clarithromycin oral suspension
reconstituted
T2
clarithromycin oral tablet
T2
Tier Notes
PRENTIF CAVITY-RIM CERV CAP NCS
VAGINAL DEVICE
CLARITHROMYCIN
clarithromycin er oral tablet extended
release 24 hr
Drug Name
CONDOMS - FEMALE
FC FEMALE CONDOM
NCS
FC2 FEMALE CONDOM
NCS
DIAPHRAGMS
OMNIFLEX DIAPHRAGM
VAGINAL DIAPHRAGM
ERYTHROMYCINS
E.E.S. 400 ORAL TABLET
T1
GAUZE PADS & DRESSINGS
E.E.S. GRANULES ORAL
T3
CURITY GAUZE PAD 2"X2"
ERY-TAB ORAL TABLET
DELAYED RELEASE
T2
ERYTHROCIN STEARATE ORAL
TABLET
T3
erythromycin base oral tablet
T1
erythromycin ethylsuccinate oral
tablet
T1
T3 PA
(SP)
MEDICAL DEVICES
FREESTYLE FREEDOM LITE KIT
T2
MD
FREESTYLE INSULINX SYSTEM
KIT
T2
MD
FREESTYLE LANCETS
T2
MD; QL (200 EA per
31 days)
FREESTYLE LITE DEVICE
T2
MD
PRECISION XTRA MONITOR
DEVICE
T2
MD
SURE-TOUCH LANCETS
UNIVERSAL
T2
MD; QL (200 EA per
31 days)
T2
MD; QL (100 EA per
31 days)
NEEDLES & SYRINGES
CERVICAL CAPS
FEMCAP VAGINAL DEVICE
T2
GLUCOSE MONITORING TEST SUPPLIES
FIDAXOMICIN
DIFICID ORAL TABLET
NCS
NCS
clickfine pen needles 31g x 6 mm , 31g
x 8 mm
ST Step Therapy
½
MD Maintenance Drug
Version 4
Page 67
Drug Name
Tier Notes
Drug Name
Tier Notes
insulin syringe/needle 28g x 1/2" 0.5
ml, 28g x 1/2" 1 ml
T2
MD; QL (100 EA per
31 days)
almotriptan malate oral tablet
T3
ST; QL (12 EA per 31
days)
NOVOFINE
T2
MD; QL (100 EA per
31 days)
FROVA ORAL TABLET
T3
ST; QL (9 EA per 31
Days)
NOVOFINE AUTOCOVER
T2
MD; QL (100 EA per
31 days)
naratriptan hcl oral tablet
T2
ST
RELPAX ORAL TABLET
T3
NOVOTWIST
T2
MD; QL (100 EA per
31 days)
Days)
rizatriptan benzoate oral tablet
T1
Days)
rizatriptan benzoate oral tablet
dispersible
T1
days)
sumatriptan succinate oral tablet
T1
QL (18 EA per 31
Days)
sumatriptan succinate subcutaneous 4
mg/0.5ml, 6 mg/0.5ml
T3
QL (8 ML per 31 days)
sumatriptan succinate subcutaneous
solution 6 mg/0.5ml
T3
zolmitriptan oral tablet
T2
days)
zolmitriptan oral tablet dispersible
T2
days)
ZOMIG NASAL SOLUTION
T3
Days)
sure comfort pen needles 31g x 5 mm
T2
MD; QL (100 EA per
31 days)
ULTILET INSULIN SYRINGE
SHORT 30G X 5/16" 0.3 ML
T2
MD; QL (100 EA per
31 days)
MIGRAINE PRODUCTS
ERGOT COMBINATIONS
MIGERGOT SUPPOSITORY
T3
MIGRAINE PRODUCTS
dihydroergotamine mesylate injection
solution
T2
ERGOMAR SUBLINGUAL
TABLET SUBLINGUAL
T3
MIGRANAL NASAL SOLUTION
T3
SELECTIVE SEROTONIN AGONIST-NSAID COMBINATIONS
TREXIMET ORAL TABLET
T2
ST; QL (9 EA per 31
days)
SELECTIVE SEROTONIN AGONISTS 5-HT(1)
MINERALS & ELECTROLYTES
CHLORIDE
ammonium chloride intravenous
solution
ST Step Therapy
½
T1
MD Maintenance Drug
Version 4
Page 68
Drug Name
Tier Notes
ELECTROLYTES PARENTERAL
ISOLYTE-S PH 7.4 INTRAVENOUS
SOLUTION
T1
FLUORIDE
Drug Name
Tier Notes
KLOR-CON ORAL PACKET
T1
MD
KLOR-CON ORAL TABLET
EXTENDEDRELEASE
T1
MD
potassium chloride crys er oral tablet
extendedrelease
T1
MD
fluoritab oral tablet chewable
NCS
LUDENT ORAL TABLET
CHEWABLE
NCS
potassium chloride er oral capsule
extended release
T1
MD
NAFRINSE ORAL TABLET
CHEWABLE
NCS
potassium chloride er oral tablet
extendedrelease
T1
MD
sodium fluoride oral solution
NCS
potassium chloride oral packet
T1
MD
sodium fluoride oral tablet 1.1 (0.5 f)
mg
NCS
potassium chloride oral solution
T1
MD
sodium fluoride oral tablet 2.2 (1 f)
mg
NCS
BD POSIFLUSH INTRAVENOUS
SOLUTION
T1
sodium fluoride oral tablet chewable
NCS
sodium chloride flush intravenous
solution
T1
sodium chloride injection solution 0.9
%
T1
SODIUM
PHOSPHATE
phospha 250 neutral oral tablet
T1
POTASSIUM
MOUTH/THROAT/DENTAL AGENTS
KLOR-CON 10 ORAL TABLET
EXTENDEDRELEASE
T1
MD
KLOR-CON M10 ORAL TABLET
EXTENDEDRELEASE
T1
MD
EXTENDEDRELEASE
T1
MD
EXTENDEDRELEASE
T1
MD
ANESTHETICS TOPICAL ORAL - COMBINATIONS
FIRST-MOUTHWASH BLM
MOUTH/THROAT SUSPENSION
T2
ANESTHETICS TOPICAL ORAL
lidocaine hcl mouth/throat solution
T1
lidocaine viscous mouth/throat
solution
T1
ST Step Therapy
½
MD Maintenance Drug
Version 4
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Drug Name
Tier Notes
ANTI-INFECTIVE COMBINATIONS - THROAT
FIRST-BXN MOUTHWASH
MOUTH/THROAT SUSPENSION
T2
ANTI-INFECTIVES - THROAT
clotrimazole mouth/throat lozenge
T1
clotrimazole mouth/throat troche
T1
nystatin mouth/throat suspension
T1
ANTISEPTICS - MOUTH/THROAT
chlorhexidine gluconate mouth/throat
solution
T1
PAROEX MOUTH/THROAT
SOLUTION
T1
T3
PREVIDENT 5000 SENSITIVE
DENTAL PASTE
T3
Tier Notes
PREVIDENT 5000 BOOSTER PLUS
DENTAL PASTE
T3
MD
PREVIDENT 5000 DRY MOUTH
DENTAL
T3
MD
PREVIDENT 5000 PLUS DENTAL
CREAM
T3
MD
PREVIDENT DENTAL
T3
MD
PREVIDENT MOUTH/THROAT
SOLUTION
T3
MD
sf 5000 plus dental cream
T1
MD
sf dental
T1
MD
T1
MD
SALIVA STIMULANTS
pilocarpine hcl oral tablet
DENTAL PRODUCTS - COMBINATIONS
PREVIDENT 5000 ENAMEL
PROTECT DENTAL PASTE
Drug Name
MD
MD
STEROIDS - MOUTH/THROAT
triamcinolone acetonide mouth/throat
paste
T1
MULTIVITAMINS
FLUORIDE DENTAL PRODUCTS
PED MV W/ FLUORIDE
DENTA 5000 PLUS DENTAL
CREAM
T1
MD
multi vitamin/fluoride oral tablet
chewable
NCS
DENTAGEL DENTAL
T1
MD
multi-vitamin/fluoride oral solution
NCS
neutral sodium fluoride mouth/throat
solution
T1
MD
multi-vitamin/fluoride oral tablet
chewable 0.5 mg
NCS
PREVIDENT 5000 BOOSTER
DENTAL PASTE
T3
MD
multivitamins/fluoride oral tablet
chewable 1 mg
NCS
ST Step Therapy
½
MD Maintenance Drug
Version 4
Page 70
Drug Name
Tier Notes
PED MV W/ IRON
Drug Name
Tier Notes
tizanidine hcl oral tablet
child chewable vitamins/iron oral
tablet chewable
NCS
polyvitamin/iron oral solution
NCS
dantrolene sodium oral capsule
T1
NASAL ANTIBIOTICS
pnv tabs 29-1 oral tablet
T3
prenatabs fa oral tablet
T1
BACTROBAN NASAL NASAL
OINTMENT
PRENATABS RX ORAL TABLET
T3
pretab oral tablet
T1
MD
T2
NASAL ANTICHOLINERGICS
ipratropium bromide nasal solution
T1
MD
azelastine hcl nasal solution
T1
MD
olopatadine hcl nasal solution
T3
ST
flunisolide nasal solution 25 mcg/act
(0.025%)
T1
days)
fluticasone propionate nasal
suspension
T1
days)
NASONEX NASAL SUSPENSION
T3
ST; MD
OMNARIS NASAL SUSPENSION
T3
ST; MD
VERAMYST NASAL SUSPENSION
T2
days)
NASAL ANTIHISTAMINES
PRENATAL MV & MIN W/FE-FA-DHA
T2
MUSCULOSKELETAL THERAPY
AGENTS
NASAL STEROIDS
CENTRAL MUSCLE RELAXANTS
baclofen oral tablet
T1
carisoprodol oral tablet 350 mg
T1
chlorzoxazone oral tablet
T1
cyclobenzaprine hcl oral tablet
T1
metaxalone oral tablet 800 mg
T1
methocarbamol oral tablet
T1
orphenadrine citrate er oral tablet
T1
tizanidine hcl oral capsule
T1
T1
NASAL AGENTS - SYSTEMIC AND
TOPICAL
CO-NATAL FA ORAL TABLET
MD
DIRECT MUSCLE RELAXANTS
PRENATAL MV & MIN W/FE-FA
VITAFOL-OB+DHA ORAL
T1
MD
TOPICAL DECONGESTANTS
TYZINE NASAL SOLUTION 0.05 %
T2
MD
ST Step Therapy
½
MD Maintenance Drug
Version 4
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Drug Name
Tier Notes
Drug Name
*NEPRILYSIN INHIB (ARNI)-ANGIOTENSIN II RECEPT ANTAG
COMB***
*NEPRILYSIN INHIB (ARNI)-ANGIOTENSIN II RECEPT ANTAG
COMB***
ENTRESTO ORAL TABLET
T3
PA; MD
OPHTHALMIC AGENTS
T2
MD
BETA-BLOCKERS - OPHTHALMIC COMBINATIONS
COMBIGAN OPHTHALMIC
SOLUTION
T2
COSOPT PF OPHTHALMIC
SOLUTION
T2
dorzolamide hcl-timolol mal
ophthalmic solution
T1
days)
Days)
MD
BETA-BLOCKERS - OPHTHALMIC
betaxolol hcl ophthalmic solution
T2
MD
BETIMOL OPHTHALMIC
SOLUTION
T2
MD
BETOPTIC-S OPHTHALMIC
SUSPENSION
T2
carteolol hcl ophthalmic solution
T1
MD
ISTALOL OPHTHALMIC
SOLUTION
T3
MD
levobunolol hcl ophthalmic solution
T1
MD
metipranolol ophthalmic solution
T1
MD
timolol maleate ophthalmic gel
forming solution
T1
MD
timolol maleate ophthalmic solution
T1
MD
atropine sulfate ophthalmic solution
T1
MD
cyclopentolate hcl ophthalmic solution
T1
MD
HOMATROPAIRE OPHTHALMIC
SOLUTION
T3
MD
homatropine hbr ophthalmic solution
T3
MD
ISOPTO HYOSCINE
OPHTHALMIC SOLUTION
T2
MD
tropicamide ophthalmic solution
T2
MD
CYCLOPLEGIC MYDRIATICS
ALPHA ADRENERGIC AGONIST & CARBONIC ANHYDRASE
INHIB COMB
SIMBRINZA OPHTHALMIC
SUSPENSION
Tier Notes
MD
MIOTICS - CHOLINESTERASE INHIBITORS
PHOSPHOLINE IODIDE
OPHTHALMIC SOLUTION
RECONSTITUTED
T2
MD
OPHTHALMIC ANTIALLERGIC
ALOCRIL OPHTHALMIC
SOLUTION
T3
ALOMIDE OPHTHALMIC
SOLUTION
T3
azelastine hcl ophthalmic solution
T1
ST Step Therapy
½
MD Maintenance Drug
Version 4
Page 72
Drug Name
Tier Notes
Drug Name
Tier Notes
BEPREVE OPHTHALMIC
SOLUTION
T3
gentamicin sulfate ophthalmic
ointment
T1
cromolyn sodium ophthalmic solution
T1
gentamicin sulfate ophthalmic solution
T1
EMADINE OPHTHALMIC
SOLUTION
T3
levofloxacin ophthalmic solution
T1
T2
epinastine hcl ophthalmic solution
T2
MOXEZA OPHTHALMIC
SOLUTION
LASTACAFT OPHTHALMIC
SOLUTION
T3
ofloxacin ophthalmic solution
T1
tobramycin ophthalmic solution
T1
olopatadine hcl ophthalmic solution
T2
T2
VIGAMOX OPHTHALMIC
SOLUTION
T2
PATADAY OPHTHALMIC
SOLUTION
T2
PATANOL OPHTHALMIC
SOLUTION
T2
ZYMAXID OPHTHALMIC
SOLUTION
QL (10 ML per 31
days)
OPHTHALMIC ANTIFUNGAL
OPHTHALMIC ANTIBIOTICS
AZASITE OPHTHALMIC
SOLUTION
T3
bacitracin ophthalmic ointment
T1
BESIVANCE OPHTHALMIC
SUSPENSION
T3
CILOXAN OPHTHALMIC
OINTMENT
T2
ciprofloxacin hcl ophthalmic solution
T1
erythromycin ophthalmic ointment
T1
GENTAK OPHTHALMIC
OINTMENT
T1
NATACYN OPHTHALMIC
SUSPENSION
T2
OPHTHALMIC ANTI-INFECTIVE COMBINATIONS
ak-poly-bac ophthalmic ointment
T1
bacitracin-polymyxin b ophthalmic
ointment
T1
neomycin-bacitracin zn-polymyx
ophthalmic ointment
T1
neomycin-polymyxin-gramicidin
ophthalmic solution
T1
polymyxin b-trimethoprim ophthalmic
solution
T1
triple antibiotic ophthalmic ointment
T1
ST Step Therapy
½
MD Maintenance Drug
Version 4
Page 73
Drug Name
Tier Notes
Drug Name
OPHTHALMIC ANTIVIRALS
trifluridine ophthalmic solution
T1
ZIRGAN OPHTHALMIC
T3
OPHTHALMIC CARBONIC ANHYDRASE INHIBITORS
T2
days)
dorzolamide hcl ophthalmic solution
T1
MD
naphazoline hcl ophthalmic solution
T1
OPHTHALMIC IMMUNOMODULATORS
RESTASIS OPHTHALMIC
EMULSION
T2
ketorolac tromethamine ophthalmic
solution
T1
NEVANAC OPHTHALMIC
SUSPENSION
T2
ALPHAGAN P OPHTHALMIC
SOLUTION 0.1 %
T2
apraclonidine hcl ophthalmic solution
T1
brimonidine tartrate ophthalmic
solution
T1
MD
T1
BLEPHAMIDE S.O.P.
OPHTHALMIC OINTMENT
T2
OPHTHALMIC NONSTEROIDAL ANTI-INFLAMMATORY
AGENTS
neomycin-polymyxin-dexameth
ophthalmic ointment
T1
bromfenac sodium (once-daily)
ophthalmic solution
T2
neomycin-polymyxin-dexameth
ophthalmic suspension 3.5-10000-0.1
T1
bromfenac sodium ophthalmic
solution
T2
TOBRADEX OPHTHALMIC
OINTMENT
T2
diclofenac sodium ophthalmic solution
T1
TOBRADEX ST OPHTHALMIC
SUSPENSION
T2
flurbiprofen sodium ophthalmic
solution
T1
tobramycin-dexamethasone
ophthalmic suspension
T1
ILEVRO OPHTHALMIC
SUSPENSION
T2
ZYLET OPHTHALMIC
SUSPENSION
T3
OPHTHALMIC LOCAL ANESTHETICS
days)
days)
OPHTHALMIC STEROID COMBINATIONS
bacitra-neomycin-polymyxin-hc
ophthalmic ointment
proparacaine hcl ophthalmic solution
QL (10 ML per 31
days)
OPHTHALMIC SELECTIVE ALPHA ADRENERGIC AGONISTS
AZOPT OPHTHALMIC
SUSPENSION
OPHTHALMIC DECONGESTANTS
Tier Notes
T2
ST Step Therapy
½
MD Maintenance Drug
Version 4
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Drug Name
Tier Notes
OPHTHALMIC STEROIDS
Drug Name
Tier Notes
latanoprost ophthalmic solution
T1
MD
ALREX OPHTHALMIC
SUSPENSION
T2
LUMIGAN OPHTHALMIC
SOLUTION 0.01 %
T3
MD; QL (5 ML per 31
days)
dexamethasone sodium phosphate
ophthalmic solution
T1
TRAVATAN Z OPHTHALMIC
SOLUTION
T2
MD; QL (5 ML per 31
days)
DUREZOL OPHTHALMIC
EMULSION
T2
ZIOPTAN OPHTHALMIC
SOLUTION
T2
MD
fluorometholone ophthalmic
suspension
T1
OTIC AGENTS
FML OPHTHALMIC OINTMENT
T3
LOTEMAX OPHTHALMIC
OINTMENT
T3
LOTEMAX OPHTHALMIC
SUSPENSION
T2
prednisolone acetate ophthalmic
suspension
T1
prednisolone sodium phosphate
ophthalmic solution
T1
VEXOL OPHTHALMIC
SUSPENSION
T3
OTIC AGENTS - MISCELLANEOUS
acetic acid otic solution
T1
OTIC ANALGESIC COMBINATIONS
antipyrine-benzocaine otic solution
5.4-1.4 %, 54-14 mg/ml
T1
oticin otic liquid†
T1
OTIC ANTI-INFECTIVES
ofloxacin otic solution
T1
OTIC STEROID-ANTI-INFECTIVE COMBINATIONS
OPHTHALMIC SULFONAMIDES
CIPRO HC OTIC SUSPENSION
T2
CIPRODEX OTIC SUSPENSION
T2
sulfacetamide sodium ophthalmic
ointment
T1
COLY-MYCIN S OTIC
SUSPENSION
T2
sulfacetamide sodium ophthalmic
solution
T1
CORTISPORIN-TC OTIC
SUSPENSION
T2
neomycin-polymyxin-hc otic solution
T1
PROSTAGLANDINS - OPHTHALMIC
ST Step Therapy
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Drug Name
neomycin-polymyxin-hc otic
suspension
Tier Notes
T1
Drug Name
Tier Notes
PCSK9 INHIBITORS
PRALUENT SUBCUTANEOUS
T3 PA; MD
(SP)
REPATHA SUBCUTANEOUS
T3 PA; MD
(SP)
REPATHA SURECLICK
SUBCUTANEOUS
T3 PA; MD
(SP)
OTIC STEROIDS
ACETASOL HC OTIC SOLUTION
T1
fluocinolone acetonide otic oil
T1
hydrocortisone-acetic acid otic
solution
T1
PENICILLINS
OXYTOCICS
AMINOPENICILLINS
OXYTOCICS
methylergonovine maleate oral tablet
T1
PASSIVE IMMUNIZING AGENTS
IMMUNE SERUMS
amoxicillin oral capsule
T1
amoxicillin oral suspension
reconstituted
T1
amoxicillin oral tablet
T1
amoxicillin oral tablet chewable
T1
ampicillin oral capsule
T1
T2
CARIMUNE NF INTRAVENOUS
SOLUTION RECONSTITUTED 12
GM, 6 GM
T3 PA; MD
(SP)
GAMMAGARD INJECTION
SOLUTION 2.5 GM/25ML
T3 PA
(SP)
ampicillin oral suspension
reconstituted 250 mg/5ml
GAMMAGARD INJECTION
SOLUTION 30 GM/300ML
T3 PA; MD
(SP)
NATURAL PENICILLINS
VARIZIG INJECTION SOLUTION
RECONSTITUTED
NCS
VARIZIG INTRAMUSCULAR
SOLUTION
NCS
VARIZIG INTRAMUSCULAR
NCS
penicillin v potassium oral solution
reconstituted
T1
penicillin v potassium oral tablet
T1
PENICILLIN COMBINATIONS
amoxicillin-pot clavulanate er oral
T1
PCSK9 INHIBITORS
ST Step Therapy
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Drug Name
Tier Notes
Drug Name
Tier Notes
amoxicillin-pot clavulanate oral
suspension reconstituted
T1
ALCOHOL DETERRENTS
MD
T1
acamprosate calcium oral tablet
delayed release
T3
amoxicillin-pot clavulanate oral tablet
amoxicillin-pot clavulanate oral tablet
chewable
T1
disulfiram oral tablet
T1
MD
ANTI-CATAPLECTIC AGENTS
PENICILLINASE-RESISTANT PENICILLINS
dicloxacillin sodium oral capsule
XYREM ORAL SOLUTION
T1
T3 PA
(SP)
PHARMACEUTICAL ADJUVANTS
BENZODIAZEPINES & TRICYCLIC AGENTS
SEMI SOLID VEHICLES
chlordiazepoxide-amitriptyline oral
tablet
polyethylene glycol 3350 powder
T1
T1
CHOLINOMIMETICS - ACHE INHIBITORS
PROGESTINS
PROGESTINS
medroxyprogesterone acetate oral
tablet
T1
MD
megestrol acetate oral suspension 625
mg/5ml
T1
MD
norethindrone acetate oral tablet
T1
MD
progesterone intramuscular oil
T1
progesterone micronized oral capsule
T1
MD
PROTEASE-ACTIVATED RECEPTOR-1
(PAR-1) ANTAGONISTS
donepezil hcl oral tablet 10 mg, 5 mg
T1
days)
donepezil hcl oral tablet dispersible
T1
days)
galantamine hydrobromide er oral
T1
days)
galantamine hydrobromide oral
solution
T1
MD; QL (620 ML per
31 days)
galantamine hydrobromide oral tablet
T1
days)
rivastigmine tartrate oral capsule
T1
days)
T2
MD
PROTEASE-ACTIVATED RECEPTOR-1 (PAR-1) ANTAGONISTS
ZONTIVITY ORAL TABLET
T2
MD
FIBROMYALGIA AGENT - SNRIS
SAVELLA ORAL TABLET
PSYCHOTHERAPEUTIC AND
NEUROLOGICAL AGENTS - MISC.
MD
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Drug Name
SAVELLA TITRATION PACK
ORAL
Tier Notes
Drug Name
T2
MULTIPLE SCLEROSIS AGENTS - INTERFERONS
AVONEX INTRAMUSCULAR KIT
AVONEX PEN INTRAMUSCULAR
T3 PA; MD
(SP)
T3 PA; MD
(SP)
AVONEX PREFILLED
INTRAMUSCULAR
T3 PA; MD
(SP)
BETASERON SUBCUTANEOUS
KIT
(SP) per 31 Days)
TECFIDERA ORAL CAPSULE
DELAYED RELEASE 240 MG
(SP) per 31 days)
T3
MD; QL (360 ML per
31 days)
NAMENDA ORAL SOLUTION
T3
MD; QL (360 ML per
31 days)
T1
MD
T3 PA
(SP)
PREMENSTRUAL DYSPHORIC DISORDER (PMDD) AGENTS SSRIS
(SP) per 365 days)
memantine hcl oral solution
T3
GRALISE STARTER ORAL
TECFIDERA ORAL CAPSULE
DELAYED RELEASE 120 MG
N-METHYL-D-ASPARTATE (NMDA) RECEPTOR
ANTAGONISTS
memantine hcl oral tablet 5 (28)-10
(21) mg
days)
POSTHERPETIC NEURALGIA (PHN) AGENTS
(SP) days)
(SP) per 30 days)
T3
perphenazine-amitriptyline oral tablet
TECFIDERA ORAL
COPAXONE SUBCUTANEOUS 40
MG/ML
memantine hcl oral tablet 10 mg, 5 mg
PHENOTHIAZINES & TRICYCLIC AGENTS
MULTIPLE SCLEROSIS AGENTS - NRF2 PATHWAY
ACTIVATORS
MULTIPLE SCLEROSIS AGENTS
Tier Notes
fluoxetine hcl (pmdd) oral capsule
T1
MD
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS MISC.
ergoloid mesylates oral tablet
T1
MD
ORAP ORAL TABLET
T2
MD
pimozide oral tablet
T2
MD
SMOKING DETERRENTS
bupropion hcl er (smoking det) oral
NCS QL (336 EA per 365
days)
CHANTIX CONTINUING MONTH
PAK ORAL TABLET
NCS
CHANTIX ORAL TABLET
NCS
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Drug Name
Tier Notes
Drug Name
Tier Notes
CHANTIX STARTING MONTH
PAK ORAL TABLET
NCS
PULMOZYME INHALATION
SOLUTION
(SP) per 31 days)
nicotine polacrilex mouth/throat gum
days)
SGLT1 INHIBITOR - DPP-4 INHIBITOR
COMBINATIONS
nicotine polacrilex mouth/throat
lozenge
days)
SGLT1 INHIBITOR - DPP-4 INHIBITOR COMBINATIONS
nicotine transdermal patch 24 hr 14
mg/24hr, 21 mg/24hr
days)
nicotine transdermal patch 24 hr 7
mg/24hr
days)
NICOTROL INHALATION
INHALER
days)
NICOTROL NS NASAL SOLUTION NCS QL (6720 ML per 365
days)
SPHINGOSINE 1-PHOSPHATE (S1P) RECEPTOR
MODULATORS
GILENYA ORAL CAPSULE
(SP) per 31 days)
THIENBENZODIAZEPINES & SSRIS
olanzapine-fluoxetine hcl oral capsule
T1
MD
RESPIRATORY AGENTS - MISC.
ALPHA-PROTEINASE INHIBITOR (HUMAN)
ZEMAIRA INTRAVENOUS
T3 PA; MD
(SP)
GLYXAMBI ORAL TABLET
SULFONAMIDES
SULFONAMIDES
sulfadiazine oral tablet
T2
TETRACYCLINES
TETRACYCLINES
demeclocycline hcl oral tablet
T2
doxycycline hyclate oral capsule
T1
doxycycline hyclate oral tablet
T1
doxycycline monohydrate oral capsule
100 mg, 50 mg
T1
doxycycline monohydrate oral tablet
100 mg, 50 mg, 75 mg
T1
minocycline hcl oral capsule
T1
minocycline hcl oral tablet
T1
tetracycline hcl oral capsule
T1
THYROID AGENTS
methimazole oral tablet
MD
ANTITHYROID AGENTS
HYDROLYTIC ENZYMES
T2
ST Step Therapy
½
T1
MD
MD Maintenance Drug
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Drug Name
propylthiouracil oral tablet
Tier Notes
Drug Name
Tier Notes
KINRIX INTRAMUSCULAR
SUSPENSION
NCS
T1
MD
ARMOUR THYROID ORAL
TABLET
T2
MD
PEDIARIX INTRAMUSCULAR
SUSPENSION
NCS
levothyroxine sodium oral tablet
T1
MD
PENTACEL INTRAMUSCULAR
NCS
liothyronine sodium oral tablet
T1
MD
NATURE-THROID ORAL TABLET
T2
MD
QUADRACEL INTRAMUSCULAR
SUSPENSION
NCS
np thyroid oral tablet
T1
MD
NCS
SYNTHROID ORAL TABLET
T2
MD
TENIVAC INTRAMUSCULAR
INJECTABLE
UNITHROID ORAL TABLET
T1
MD
tetanus-diphtheria toxoids td
NCS
TRIHIBIT PRESERVATIVE FREE
INTRAMUSCULAR KIT
NCS
NCS
THYROID HORMONES
TOXOIDS
TOXOID COMBINATIONS
ADACEL INTRAMUSCULAR
SUSPENSION
NCS
TRIPEDIA PRESERVATIVE FREE
BOOSTRIX INTRAMUSCULAR
SUSPENSION 5-2.5-18.5
NCS
TOXOIDS
DAPTACEL INTRAMUSCULAR
SUSPENSION
NCS
tetanus toxoid adsorbed intramuscular NCS
solution
DECAVAC INTRAMUSCULAR
INJECTABLE
NCS
ULCER DRUGS
diphtheria-tetanus toxoids dt
NCS
INFANRIX INTRAMUSCULAR
SUSPENSION
NCS
ANTICHOLINERGIC COMBINATIONS
chlordiazepoxide-clidinium oral
capsule
T1
MD
DONNATAL ORAL ELIXIR
T3
MD
DONNATAL ORAL TABLET
T3
MD
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Drug Name
Tier Notes
ANTISPASMODICS
Drug Name
Tier Notes
nizatidine oral capsule
T1
MD
dicyclomine hcl oral capsule
T1
nizatidine oral solution
T1
MD
dicyclomine hcl oral solution
T1
ranitidine hcl oral capsule
T1
MD
dicyclomine hcl oral tablet
T1
ranitidine hcl oral syrup
T1
MD
ranitidine hcl oral tablet
T1
MD
CARAFATE ORAL SUSPENSION
T2
MD
sucralfate oral suspension
T2
MD
sucralfate oral tablet
T1
MD
DEXILANT ORAL CAPSULE
DELAYED RELEASE
T2
days)
FIRST-LANSOPRAZOLE ORAL
SUSPENSION
T2
MD
lansoprazole oral capsule delayed
release
T2
MD
omeprazole oral capsule delayed
release
T1
MD
pantoprazole sodium oral tablet
delayed release
T1
MD
ra omeprazole oral tablet delayed
release
T1
MD
BELLADONNA ALKALOIDS
atropine sulfate injection solution 0.05
mg/ml, 0.1 mg/ml
T3
MISC. ANTI-ULCER
hyoscyamine sulfate er oral tablet
T1
MD
hyoscyamine sulfate oral elixir
T1
MD
hyoscyamine sulfate oral solution
T1
MD
hyoscyamine sulfate oral tablet
T1
MD
hyoscyamine sulfate oral tablet
dispersible
T1
MD
hyoscyamine sulfate sublingual tablet
sublingual
T1
MD
hyosyne oral solution
T1
MD
oscimin sr oral tablet extended release
12 hr
T1
MD
H-2 ANTAGONISTS
cimetidine hcl oral solution
T1
MD
cimetidine oral tablet
T1
MD
famotidine oral suspension
reconstituted
T1
MD
famotidine oral tablet
T1
MD
PROTON PUMP INHIBITORS
QUATERNARY ANTICHOLINERGICS
CANTIL ORAL TABLET
T3
MD
glycopyrrolate oral tablet
T1
MD
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Drug Name
Tier Notes
methscopolamine bromide oral tablet
T1
MD
propantheline bromide oral tablet
T2
MD
Drug Name
ULCER DRUGS - PROSTAGLANDINS
misoprostol oral tablet
T1
MD
URINARY ANTI-INFECTIVES
T1
days)
trospium chloride oral tablet
T3
MD
VESICARE ORAL TABLET
T2
days)
bethanechol chloride oral tablet
methenamine hippurate oral tablet
T1
MONUROL ORAL PACKET
T3
nitrofurantoin macrocrystal oral
capsule 100 mg, 50 mg
T1
nitrofurantoin monohyd macro oral
capsule
T1
nitrofurantoin oral suspension
T1
T1
URINARY ANTISPASMODICS - DIRECT MUSCLE RELAXANTS
flavoxate hcl oral tablet
T1
MD
VACCINES
BACTERIAL VACCINE COMBINATIONS
MENHIBRIX INTRAMUSCULAR
NCS
BACTERIAL VACCINES
URINARY ANTISPASMODICS
URINARY ANTISPASMODIC - ANTIMUSCARINICS
(ANTICHOL)
oxybutynin chloride er oral tablet
extended release 24 hr 10 mg, 15 mg
T1
oxybutynin chloride er oral tablet
T2
oxybutynin chloride oral tablet
T1
MD
tolterodine tartrate oral tablet
T1
days)
TOVIAZ ORAL TABLET
T2
days)
trospium chloride er oral capsule
URINARY ANTISPASMODICS - CHOLINERGIC AGONISTS
URINARY ANTI-INFECTIVES
Tier Notes
MD
MD
ACTHIB INTRAMUSCULAR
NCS
BEXSERO INTRAMUSCULAR
NCS
BIOTHRAX INTRAMUSCULAR
SUSPENSION
NCS
MENACTRA INTRAMUSCULAR
INJECTABLE
NCS
MENOMUNE SUBCUTANEOUS
INJECTABLE
NCS
MENVEO INTRAMUSCULAR
NCS
ST Step Therapy
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Drug Name
Tier Notes
Drug Name
Tier Notes
PEDVAX HIB INTRAMUSCULAR
SOLUTION
NCS
AFLURIA INTRAMUSCULAR
SUSPENSION
NCS
PEDVAX HIB INTRAMUSCULAR
SUSPENSION
NCS
AFLURIA PRESERVATIVE FREE
INTRAMUSCULAR
NCS
PNEUMOVAX 23 INJECTION
INJECTABLE
NCS
CERVARIX INTRAMUSCULAR
SUSPENSION
NCS
PREVNAR 13 INTRAMUSCULAR
SUSPENSION
NCS QL (0.5 ML Max Qty
Per Fill Retail)
ENGERIX-B INTRAMUSCULAR
INJECTABLE
NCS
TRUMENBA INTRAMUSCULAR
TYPHIM VI INTRAMUSCULAR
SOLUTION 25 MCG/0.5ML
NCS
FLUARIX INTRAMUSCULAR
NCS
FLUBLOK INTRAMUSCULAR
SOLUTION
NCS
VIVOTIF BERNA VACCINE ORAL NCS
CAPSULE DELAYED RELEASE
FLUCELVAX INTRAMUSCULAR
NCS
VIVOTIF ORAL CAPSULE
DELAYED RELEASE
FLULAVAL INTRAMUSCULAR
INJECTABLE
NCS
NCS
NCS
FLUMIST NASAL LIQUID†
MIXED VACCINE COMBINATIONS
COMVAX INTRAMUSCULAR
SUSPENSION
NCS
VIRAL VACCINE COMBINATIONS
NCS
FLUVIRIN INTRAMUSCULAR
NCS
M-M-R II SUBCUTANEOUS
INJECTABLE
NCS
FLUVIRIN PRESERVATIVE FREE
INTRAMUSCULAR
NCS
PROQUAD SUBCUTANEOUS
INJECTABLE
NCS
FLUZONE HIGH-DOSE
INTRAMUSCULAR
NCS
TWINRIX INTRAMUSCULAR
SUSPENSION
NCS
FLUZONE INTRADERMAL
DEVICE
NCS
FLUZONE INTRAMUSCULAR
INJECTABLE
NCS
VIRAL VACCINES
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Drug Name
Tier Notes
Drug Name
Tier Notes
NCS
ZOSTAVAX SUBCUTANEOUS
NCS
HAVRIX INTRAMUSCULAR
SUSPENSION
NCS
VAGINAL PRODUCTS
IMOVAX RABIES
INTRAMUSCULAR INJECTABLE
NCS
IPOL INJECTION INJECTABLE
NCS
GARDASIL 9 INTRAMUSCULAR
IMIDAZOLE-RELATED ANTIFUNGALS
GYNAZOLE-1 VAGINAL CREAM
T3
terconazole vaginal cream
T1
terconazole vaginal suppository
T1
IXIARO INTRAMUSCULAR
SUSPENSION
NCS
ZAZOLE VAGINAL CREAM
T1
NCS
ZAZOLE VAGINAL
SUPPOSITORY
T1
RABAVERT INTRAMUSCULAR
RECOMBIVAX HB INJECTION
SUSPENSION 10 MCG/ML, 40
MCG/ML, 5 MCG/0.5ML
NCS
ROTARIX ORAL SUSPENSION
RECONSTITUTED
SPERMICIDES
OPTIONS CONCEPTROL
VAGINAL
NCS
NCS
OPTIONS GYNOL II
CONTRACEPTIVE VAGINAL
NCS
ROTATEQ ORAL SOLUTION
NCS
SHUR-SEAL CONTRACEPTIVE
VAGINAL
NCS
ROTATEQ ORAL SUSPENSION
NCS
TODAY SPONGE VAGINAL
NCS
VAGINAL ANTI-INFECTIVES
VAQTA INTRAMUSCULAR
SUSPENSION 25 UNIT/0.5ML, 50
UNIT/ML
NCS
VARIVAX SUBCUTANEOUS
INJECTABLE
NCS
YF-VAX SUBCUTANEOUS
INJECTABLE
NCS
CLEOCIN VAGINAL
SUPPOSITORY
T2
clindamycin phosphate vaginal cream
T1
metronidazole vaginal
T1
VANDAZOLE VAGINAL
T1
VAGINAL ESTROGENS
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Drug Name
Tier Notes
ESTRACE VAGINAL CREAM
T2
MD
PREMARIN VAGINAL CREAM
T2
MD
VAGIFEM VAGINAL TABLET
T2
MD
AUVI-Q INJECTION
T2
EPIPEN 2-PAK INJECTION
T2
EPIPEN JR 2-PAK INJECTION
T2
VASOPRESSORS
ANAPHYLAXIS THERAPY AGENTS
VASOPRESSORS
midodrine hcl oral tablet
T1
VITAMINS
VITAMIN B-3
niacin er oral tablet extendedrelease
750 mg
T2
MD
VITAMIN D
ergocalciferol oral capsule
NCS
vitamin d (ergocalciferol) oral capsule NCS QL (4 EA per 31 days)
ST Step Therapy
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Index of Drugs
8-MOP.......................................................... 53
abacavir sulfate ............................................ 38
abacavir-lamivudine-zidovudine.................. 37
acamprosate calcium ................................... 77
ACANYA .................................................... 50
acarbose ....................................................... 24
acebutolol hcl ............................................... 41
acetaminophen-codeine ............................... 13
acetaminophen-codeine #2 .......................... 13
ACETASOL HC .......................................... 76
acetazolamide .............................................. 58
acetazolamide sodium .................................. 58
acetic acid .................................................... 75
acetylcysteine ............................................... 49
acitretin ........................................................ 53
ACTHIB ....................................................... 82
ACTIMMUNE ............................................. 34
acyclovir ................................................. 40, 53
ADACEL ..................................................... 80
ADAGEN ..................................................... 42
adapalene ..................................................... 51
ADCIRCA.................................................... 43
ADDERALL XR ......................................... 11
adefovir dipivoxil ......................................... 39
ADVAIR DISKUS....................................... 18
ADVAIR HFA ............................................. 18
AFINITOR ................................................... 33
AFLURIA .................................................... 83
AFLURIA PRESERVATIVE FREE ........... 83
AGGRENOX ............................................... 64
ak-poly-bac .................................................. 73
ALBENZA ................................................... 16
albuterol sulfate ........................................... 18
alclometasone dipropionate ................... 53, 54
alendronate sodium...................................... 59
alfuzosin hcl er ............................................ 63
ALINIA ....................................................... 31
allopurinol ................................................... 64
almotriptan malate ...................................... 68
ALOCRIL .................................................... 72
ALOMIDE................................................... 72
alosetron hcl ................................................ 62
ALPHAGAN P ............................................ 74
alprazolam ................................................... 17
alprazolam er .............................................. 17
alprazolam xr .............................................. 17
ALREX ........................................................ 75
ALTABAX .................................................. 52
ALTAVERA ............................................... 44
alyacen 1/35 ................................................ 44
alyacen 7/7/7 ............................................... 48
amantadine hcl ............................................ 35
amcinonide .................................................. 54
AMETHIA................................................... 47
AMETHIA LO ............................................ 47
AMETHYST ............................................... 47
amiloride hcl................................................ 59
amiloride-hydrochlorothiazide .................... 59
aminophylline .............................................. 19
amiodarone hcl ............................................ 17
AMITIZA .................................................... 62
amitriptyline hcl .......................................... 23
amlodipine besy-benazepril hcl ................... 29
amlodipine besylate ..................................... 42
amlodipine besylate-valsartan .................... 30
amlodipine-valsartan-hctz ........................... 30
ammonium chloride ..................................... 68
ammonium lactate ....................................... 56
AMNESTEEM ............................................ 51
amoxapine ................................................... 23
amoxicillin ................................................... 76
amoxicillin-pot clavulanate ......................... 77
Version 4
amoxicillin-pot clavulanate er ..................... 76
amphetamine-dextroamphetamine ............... 11
ampicillin ..................................................... 76
AMTURNIDE.............................................. 31
anagrelide hcl .............................................. 64
ANALPRAM ADVANCED ........................ 16
anastrozole ................................................... 34
ANDROGEL................................................ 15
ANDROGEL PUMP .................................... 15
ANORO ELLIPTA ...................................... 18
antipyrine-benzocaine .................................. 75
anucort-hc .................................................... 16
ANZEMET .................................................. 27
apraclonidine hcl ......................................... 74
APRI ............................................................ 44
APRISO ....................................................... 62
APTIVUS ..................................................... 37
ARANELLE ................................................ 48
ARCALYST ................................................ 12
ARCAPTA NEOHALER ............................ 18
aripiprazole .................................................. 37
ARMOUR THYROID ................................. 80
ASCOMP-CODEINE .................................. 13
ASHLYNA .................................................. 47
ASMANEX 120 METERED DOSES ......... 19
ASMANEX 14 METERED DOSES ........... 19
ASMANEX 7 METERED DOSES ............. 19
ASMANEX HFA ......................................... 19
aspirin .......................................................... 13
aspirin ec...................................................... 13
aspirin ec low dose....................................... 13
aspirin low dose ........................................... 13
aspirin low strength ..................................... 13
aspirin-dipyridamole er ................................ 64
atenolol ........................................................ 41
Page 86
atenolol-chlorthalidone ............................... 30
atorvastatin calcium .................................... 28
atovaquone .................................................. 31
atovaquone-proguanil hcl ........................... 32
ATRALIN ................................................... 51
ATRIPLA .................................................... 37
atropine sulfate ...................................... 72, 81
ATROVENT HFA ...................................... 19
AUBRA ....................................................... 44
AUVI-Q ....................................................... 85
AVANDIA .................................................. 26
AVAR CLEANSER .................................... 50
AVAR-E EMOLLIENT .............................. 50
AVAR-E GREEN........................................ 50
AVIANE ...................................................... 44
AVODART ................................................. 63
AVONEX .................................................... 78
AVONEX PEN............................................ 78
AVONEX PREFILLED .............................. 78
AZASITE .................................................... 73
azathioprine ................................................. 41
azelastine hcl ......................................... 71, 72
AZILECT .................................................... 35
azithromycin .......................................... 66, 67
AZOPT ........................................................ 74
AZOR .......................................................... 30
AZURETTE ................................................ 44
bacitracin..................................................... 73
bacitracin-polymyxin b ................................ 73
bacitra-neomycin-polymyxin-hc .................. 74
baclofen ....................................................... 71
BACTROBAN NASAL .............................. 71
balsalazide disodium ................................... 62
BALZIVA ................................................... 44
BANZEL ..................................................... 20
BARACLUDE............................................. 39
BD POSIFLUSH ......................................... 69
BEKYREE................................................... 44
benazepril hcl .............................................. 29
benazepril-hydrochlorothiazide ................... 29
BENICAR .................................................... 30
BENICAR HCT ........................................... 30
BENZAMYCINPAK ................................... 50
benzonatate .................................................. 49
benzoyl peroxide .......................................... 51
benzoyl peroxide cleanser ............................ 51
benzoyl peroxide short contact .................... 51
benzoyl peroxide-erythromycin .................... 50
benztropine mesylate .................................... 35
BEPREVE .................................................... 73
BESIVANCE ............................................... 73
betamethasone dipropionate ........................ 54
betamethasone dipropionate aug ................. 54
betamethasone valerate ............................... 54
BETASERON .............................................. 78
betaxolol hcl ........................................... 41, 72
bethanechol chloride .................................... 82
BETIMOL .................................................... 72
BETOPTIC-S ............................................... 72
bexarotene .................................................... 35
BEXSERO ................................................... 82
BEYAZ ........................................................ 44
bicalutamide................................................. 32
BILTRICIDE ............................................... 16
BIOTHRAX ................................................. 82
bisacodyl ec .................................................. 66
bisoprolol fumarate...................................... 41
bisoprolol-hydrochlorothiazide ................... 30
BLEPHAMIDE S.O.P. ................................ 74
BLISOVI 24 FE ........................................... 44
BOOSTRIX.................................................. 80
BREO ELLIPTA .......................................... 18
briellyn ......................................................... 44
BRILINTA ................................................... 64
brimonidine tartrate ..................................... 74
BRINTELLIX .............................................. 22
BROMFED DM ........................................... 49
bromfenac sodium ........................................ 74
Version 4
bromfenac sodium (once-daily) ................... 74
bromocriptine mesylate ............................... 35
BROVANA ................................................. 18
budesonide ................................................... 19
budesonide er .............................................. 48
bumetanide .................................................. 59
BUPHENYL ................................................ 61
buprenorphine hcl ....................................... 15
bupropion hcl .............................................. 22
bupropion hcl er (smoking det) ................... 78
bupropion hcl er (sr) ................................... 22
bupropion hcl er (xl).................................... 22
buspirone hcl ............................................... 17
BUSULFEX ................................................ 32
butalbital-acetaminophen ............................ 13
butalbital-apap-caff-cod .............................. 14
butalbital-apap-caffeine .............................. 13
butalbital-asa-caff-codeine ......................... 14
butalbital-asa-caffeine................................. 13
butalbital-aspirin-caffeine ........................... 13
butorphanol tartrate .................................... 15
BUTRANS .................................................. 15
BYDUREON ............................................... 25
BYETTA 10 MCG PEN.............................. 25
BYETTA 5 MCG PEN................................ 25
BYSTOLIC ................................................. 41
cabergoline .................................................. 60
calcipotriene ................................................ 53
calcipotriene-betameth diprop .................... 58
calcitonin (salmon) ...................................... 60
calcitriol ...................................................... 60
calcium acetate ............................................ 63
calcium acetate (phos binder) ..................... 63
CAMILA ..................................................... 47
CAMRESE .................................................. 47
CAMRESE LO ............................................ 47
CANASA..................................................... 62
candesartan cilexetil.................................... 30
candesartan cilexetil-hctz ............................ 30
Page 87
CANTIL ....................................................... 81
capecitabine ................................................. 33
CAPEX ........................................................ 54
CAPRELSA ................................................. 33
captopril ....................................................... 29
captopril-hydrochlorothiazide ..................... 29
CARAC ........................................................ 52
CARAFATE ................................................ 81
carbamazepine ............................................. 20
carbamazepine er ......................................... 20
carbidopa ..................................................... 35
carbidopa-levodopa ..................................... 35
carbidopa-levodopa er ................................. 35
carbinoxamine maleate ................................ 27
CARDIZEM LA .......................................... 42
CARIMUNE NF .......................................... 76
carisoprodol ................................................. 71
carteolol hcl ................................................. 72
CARTIA XT ................................................ 42
carvedilol ..................................................... 41
CAZIANT .................................................... 48
cefaclor ........................................................ 44
cefaclor er .................................................... 44
cefadroxil ..................................................... 43
cefazolin sodium........................................... 43
cefdinir ......................................................... 44
cefixime ........................................................ 44
cefpodoxime proxetil .................................... 44
cefprozil........................................................ 44
CEFTIN........................................................ 44
ceftriaxone sodium ....................................... 44
cefuroxime axetil .......................................... 44
celecoxib ...................................................... 12
CELONTIN.................................................. 22
cephalexin .................................................... 43
CERVARIX ................................................. 83
CESAMET ................................................... 27
CESIA .......................................................... 48
CHANTIX.................................................... 78
CHANTIX CONTINUING MONTH PAK 78
CHANTIX STARTING MONTH PAK...... 79
CHATEAL .................................................. 44
CHEMET..................................................... 26
child chewable vitamins/iron....................... 71
chlordiazepoxide hcl.................................... 17
chlordiazepoxide-amitriptyline ................... 77
chlordiazepoxide-clidinium ......................... 80
chlorhexidine gluconate .............................. 70
chloroquine phosphate ................................ 32
chlorothiazide .............................................. 59
chlorpromazine hcl ...................................... 36
chlorpropamide ........................................... 25
chlorthalidone ............................................. 59
chlorzoxazone .............................................. 71
cholestyramine............................................. 28
cholestyramine light .................................... 28
CICLODAN ................................................ 52
ciclopirox ..................................................... 52
ciclopirox olamine ....................................... 52
cilostazol ...................................................... 64
CILOXAN ................................................... 73
cimetidine .................................................... 81
cimetidine hcl .............................................. 81
CIPRO HC ................................................... 75
CIPRODEX ................................................. 75
ciprofloxacin ................................................ 62
ciprofloxacin hcl .................................... 62, 73
ciprofloxacin-ciproflox hcl er ...................... 62
citalopram hydrobromide ............................ 23
CLARAVIS ................................................. 51
clarithromycin ............................................. 67
clarithromycin er ......................................... 67
CLEARLAX ................................................ 66
clemastine fumarate .................................... 27
CLEOCIN .................................................... 84
clickfine pen needles .................................... 67
CLIMARA PRO .......................................... 61
CLINDACIN ETZ ....................................... 50
Version 4
CLINDACIN-P ............................................ 50
CLINDAMAX ............................................. 50
clindamycin hcl ............................................ 31
clindamycin palmitate hcl ............................ 31
clindamycin phos-benzoyl perox .................. 50
clindamycin phosphate........................... 50, 84
clobetasol propionate................................... 54
clobetasol propionate e ................................ 54
clobetasol propionate emulsion ................... 54
clocortolone pivalate ................................... 54
clocortolone pivalate pump.......................... 54
CLODAN ..................................................... 54
CLODERM .................................................. 54
CLODERM PUMP ...................................... 54
clomipramine hcl ......................................... 23
clonazepam .................................................. 20
clonidine hcl ................................................. 30
clopidogrel bisulfate .................................... 64
clorazepate dipotassium............................... 17
clotrimazole............................................ 56, 70
clotrimazole-betamethasone ........................ 52
clozapine ...................................................... 36
COARTEM .................................................. 32
codeine sulfate ............................................. 14
colchicine ..................................................... 64
colchicine-probenecid .................................. 64
COLCRYS ................................................... 64
colestipol hcl ................................................ 28
COLY-MYCIN S ......................................... 75
COLYTE WITH FLAVOR PACKS ........... 65
COMBIGAN ................................................ 72
COMBIPATCH ........................................... 61
COMBIVENT RESPIMAT ......................... 18
COMPLERA ................................................ 37
COMPRO..................................................... 36
COMVAX .................................................... 83
CO-NATAL FA ........................................... 71
CONDYLOX ............................................... 56
constulose ..................................................... 66
Page 88
COPAXONE ............................................... 78
CORDRAN ................................................. 54
COREG CR ................................................. 41
CORMAX SCALP APPLICATION ........... 54
CORTANE-B .............................................. 58
cortisone acetate.......................................... 48
CORTISPORIN ........................................... 51
CORTISPORIN-TC .................................... 75
COSOPT PF ................................................ 72
CREON ....................................................... 58
CRESTOR ................................................... 28
CRIXIVAN ................................................. 37
cromolyn sodium ............................. 18, 62, 73
CRYSELLE-28 ........................................... 44
CURITY GAUZE........................................ 67
CYCLAFEM 1/35 ....................................... 44
CYCLAFEM 7/7/7 ...................................... 48
cyclobenzaprine hcl ..................................... 71
cyclopentolate hcl ........................................ 72
cyclophosphamide ....................................... 34
cycloserine ................................................... 32
CYCLOSET ................................................ 24
cyclosporine................................................. 40
cyclosporine modified.................................. 40
cyproheptadine hcl ...................................... 28
CYRED ....................................................... 44
CYSTAGON ............................................... 63
cytra-2 ......................................................... 63
CYTRA-3 .................................................... 63
danazol ........................................................ 15
dantrolene sodium ....................................... 71
dapsone ........................................................ 31
DAPTACEL ................................................ 80
DARAPRIM ................................................ 32
DASETTA 1/35 ........................................... 44
DASETTA 7/7/7.......................................... 48
DAYSEE ..................................................... 47
DAYTRANA............................................... 11
DEBLITANE............................................... 47
DECAVAC .................................................. 80
DELYLA...................................................... 44
demeclocycline hcl ....................................... 79
DENAVIR.................................................... 53
DENTA 5000 PLUS .................................... 70
DENTAGEL ................................................ 70
DEPEN TITRATABS .................................. 40
DEPO-ESTRADIOL.................................... 61
DERMAZENE ............................................. 52
desipramine hcl ............................................ 23
desmopressin ace spray refrig ..................... 61
desmopressin acetate ................................... 61
desogestrel-ethinyl estradiol ........................ 44
desonide ................................................. 54, 55
desoximetasone ............................................ 55
dexamethasone ............................................. 48
dexamethasone sodium phosphate ......... 48, 75
DEXILANT ................................................. 81
dexmethylphenidate hcl ................................ 11
dexmethylphenidate hcl er ........................... 11
dextroamphetamine sulfate .......................... 11
dextroamphetamine sulfate er ...................... 11
diazepam ................................................ 17, 20
DIAZEPAM INTENSOL ............................ 17
DIBENZYLINE ........................................... 29
diclofenac potassium .................................... 12
diclofenac sodium ...................... 12, 52, 53, 74
diclofenac sodium er .................................... 12
dicloxacillin sodium ..................................... 77
dicyclomine hcl ............................................ 81
didanosine .................................................... 38
DIFICID ....................................................... 67
diflorasone diacetate.................................... 55
DIGITEK ..................................................... 43
DIGOX ......................................................... 43
digoxin.......................................................... 43
dihydroergotamine mesylate ........................ 68
diltiazem cd .................................................. 42
diltiazem hcl ................................................. 42
Version 4
diltiazem hcl er ............................................ 42
diltiazem hcl er beads .................................. 42
diltiazem hcl er coated beads ...................... 42
dilt-xr ........................................................... 42
DIPENTUM ................................................ 62
diphenatol .................................................... 26
diphenhydramine hcl ................................... 27
diphenoxylate-atropine ................................ 26
diphtheria-tetanus toxoids dt ....................... 80
dipyridamole ................................................ 64
disopyramide phosphate .............................. 17
disulfiram..................................................... 77
divalproex sodium ....................................... 22
divalproex sodium er ................................... 22
DIVIGEL ..................................................... 61
donepezil hcl ................................................ 77
DONNATAL ............................................... 80
dorzolamide hcl ........................................... 74
dorzolamide hcl-timolol mal ....................... 72
doxazosin mesylate ...................................... 30
doxepin hcl .................................................. 23
doxercalciferol............................................. 60
doxycycline hyclate...................................... 79
doxycycline monohydrate ............................ 79
dronabinol ................................................... 27
drospirenone-ethinyl estradiol ..................... 45
DROXIA ..................................................... 64
DUAVEE..................................................... 62
DULERA ..................................................... 18
duloxetine hcl .............................................. 23
DUREZOL .................................................. 75
dutasteride ................................................... 63
dutasteride-tamsulosin hcl ........................... 63
DYRENIUM ............................................... 59
E.E.S. 400 .................................................... 67
E.E.S. GRANULES..................................... 67
econazole nitrate ......................................... 56
ECONTRA EZ ............................................ 47
EDECRIN .................................................... 59
Page 89
EDURANT .................................................. 38
EEMT HS..................................................... 61
EFFIENT...................................................... 64
ELETONE.................................................... 57
ELETONE TWINPACK ............................. 57
ELIDEL........................................................ 57
ELINEST ..................................................... 45
ELIQUIS ...................................................... 20
ELLA ........................................................... 47
ELMIRON ................................................... 63
EMADINE ................................................... 73
EMCYT........................................................ 34
EMEND ....................................................... 27
EMOQUETTE ............................................. 45
EMSAM ....................................................... 22
EMTRIVA ................................................... 39
enalapril maleate ......................................... 29
enalapril-hydrochlorothiazide ..................... 29
ENBREL ...................................................... 13
ENBREL SURECLICK ............................... 13
ENDOCET ................................................... 15
ENGERIX-B ................................................ 83
ENJUVIA ..................................................... 61
enoxaparin sodium ....................................... 20
ENPRESSE-28............................................. 48
ENSKYCE ................................................... 45
entacapone ................................................... 35
entecavir ....................................................... 39
ENTRESTO ................................................. 72
enulose ......................................................... 63
EPICERAM ................................................. 57
EPIDUO ....................................................... 50
EPIFOAM .................................................... 58
epinastine hcl ............................................... 73
epinephrine hcl............................................. 19
EPIPEN 2-PAK ............................................ 85
EPIPEN JR 2-PAK ...................................... 85
EPIVIR HBV ............................................... 39
eplerenone .................................................... 31
eprosartan mesylate .................................... 30
EPZICOM ................................................... 37
ergocalciferol .............................................. 85
ergoloid mesylates ....................................... 78
ERGOMAR ................................................. 68
ERRIN ......................................................... 48
ERTACZO................................................... 56
ery ................................................................ 50
ERY-TAB .................................................... 67
ERYTHROCIN STEARATE ...................... 67
erythromycin .......................................... 50, 73
erythromycin base ....................................... 67
erythromycin ethylsuccinate ........................ 67
escitalopram oxalate ................................... 23
est estrogens-methyltest ............................... 61
est estrogens-methyltest ds .......................... 61
est estrogens-methyltest hs .......................... 61
ESTARYLLA .............................................. 45
estazolam ..................................................... 65
ESTRACE ................................................... 85
estradiol ................................................. 61, 62
estradiol-norethindrone acet ....................... 61
ESTROGEL................................................. 62
estropipate ................................................... 62
eszopiclone .................................................. 65
ethambutol hcl ............................................. 32
ethosuximide ................................................ 22
etidronate disodium ..................................... 59
etodolac ....................................................... 12
etodolac er ................................................... 12
EURAX ....................................................... 57
EXELDERM ............................................... 56
exemestane................................................... 34
EXJADE ...................................................... 26
FALLBACK SOLO .................................... 47
FALMINA ................................................... 45
famciclovir ................................................... 40
famotidine .................................................... 81
FANAPT ..................................................... 36
Version 4
FANAPT TITRATION PACK .................... 36
FARESTON ................................................. 33
FAZACLO ................................................... 36
FC FEMALE CONDOM ............................. 67
FC2 FEMALE CONDOM ........................... 67
felbamate ...................................................... 21
felodipine er ................................................. 42
FEMCAP...................................................... 67
fenofibrate .................................................... 28
fenofibrate micronized ................................. 28
fenofibric acid .............................................. 28
fenoprofen calcium....................................... 12
fentanyl ......................................................... 14
fentanyl citrate ............................................. 14
FERRIPROX................................................ 26
FINACEA .................................................... 57
finasteride .................................................... 63
FIRST-BXN MOUTHWASH ..................... 70
FIRST-LANSOPRAZOLE .......................... 81
FIRST-MOUTHWASH BLM ..................... 69
flavoxate hcl ................................................. 82
flecainide acetate ......................................... 17
FLEET LAXATIVE .................................... 66
FLOVENT DISKUS .................................... 19
FLOVENT HFA .......................................... 19
FLUARIX .................................................... 83
FLUBLOK ................................................... 83
FLUCELVAX .............................................. 83
fluconazole ................................................... 27
flucytosine .................................................... 27
fludrocortisone acetate ................................ 49
FLULAVAL ................................................ 83
FLUMIST .................................................... 83
flunisolide..................................................... 71
fluocinolone acetonide ........................... 55, 76
fluocinolone acetonide body ........................ 55
fluocinolone acetonide scalp........................ 55
fluocinonide.................................................. 55
fluocinonide-e .............................................. 55
Page 90
fluoritab ....................................................... 69
fluorometholone........................................... 75
FLUOROPLEX ........................................... 52
fluorouracil ............................................ 33, 52
fluoxetine hcl ............................................... 23
fluoxetine hcl (pmdd) ................................... 78
fluphenazine hcl ........................................... 36
flurazepam hcl ............................................. 65
flurbiprofen .................................................. 12
flurbiprofen sodium ..................................... 74
flutamide ...................................................... 32
fluticasone propionate ........................... 55, 71
fluvastatin sodium........................................ 28
FLUVIRIN .................................................. 83
FLUVIRIN PRESERVATIVE FREE ......... 83
fluvoxamine maleate .................................... 23
FLUZONE ................................................... 83
FLUZONE HIGH-DOSE ............................ 83
FML ............................................................. 75
FOCALIN XR ............................................. 11
folic acid ...................................................... 65
fondaparinux sodium ................................... 20
FORTEO ..................................................... 60
fosinopril sodium ......................................... 29
fosinopril sodium-hctz ................................. 29
FOSRENOL ................................................ 63
FREESTYLE FREEDOM LITE ................. 67
FREESTYLE INSULINX SYSTEM .......... 67
FREESTYLE INSULINX TEST ................ 58
FREESTYLE LANCETS ............................ 67
FREESTYLE LITE ..................................... 67
FREESTYLE LITE TEST........................... 58
FREESTYLE TEST .................................... 58
FROVA ....................................................... 68
furosemide ................................................... 59
FUZEON ..................................................... 37
gabapentin ............................................. 20, 21
GABITRIL .................................................. 21
galantamine hydrobromide ......................... 77
galantamine hydrobromide er...................... 77
GAMMAGARD .......................................... 76
GARDASIL 9 .............................................. 84
gavilax .......................................................... 66
GAVILYTE-C ............................................. 66
GAVILYTE-G ............................................. 66
GAVILYTE-H ............................................. 66
GAVILYTE-N WITH FLAVOR PACK ..... 66
gemfibrozil ................................................... 28
GENERESS FE ............................................ 45
generlac........................................................ 63
GENGRAF ................................................... 40
GENTAK ..................................................... 73
gentamicin sulfate .................................. 52, 73
gentlelax ....................................................... 66
GIANVI ....................................................... 45
GILDAGIA .................................................. 45
GILDESS 1.5/30 .......................................... 45
GILDESS 1/20 ............................................. 45
GILDESS FE 1.5/30 .................................... 45
GILDESS FE 1/20 ....................................... 45
GILENYA .................................................... 79
GLEEVEC ................................................... 33
glimepiride ............................................. 25, 26
glipizide ........................................................ 26
glipizide er ................................................... 26
glipizide xl .................................................... 26
glipizide-metformin hcl ................................ 25
GLUCAGEN DIAGNOSTIC ...................... 58
GLUCAGEN HYPOKIT ............................. 24
GLUCAGON EMERGENCY ..................... 24
glyburide ...................................................... 26
glyburide micronized ................................... 26
glyburide-metformin .................................... 25
glycopyrrolate .............................................. 81
GLYSET ...................................................... 24
GLYXAMBI ................................................ 79
GRALISE STARTER .................................. 78
granisetron hcl ............................................. 27
Version 4
GRASTEK................................................... 42
griseofulvin microsize.................................. 27
guanfacine hcl ............................................. 30
guanfacine hcl er ......................................... 11
guanidine hcl ............................................... 32
GYNAZOLE-1 ............................................ 84
halobetasol propionate ................................ 55
HALOG ....................................................... 55
haloperidol .................................................. 36
haloperidol decanoate ................................. 36
haloperidol lactate ...................................... 36
HARVONI................................................... 65
HAVRIX ..................................................... 84
HEATHER .................................................. 48
heparin sodium (porcine) ............................ 20
heparin sodium (porcine) pf ........................ 20
HEXALEN .................................................. 32
HOMATROPAIRE ..................................... 72
homatropine hbr .......................................... 72
HPR ............................................................. 57
HPR PLUS .................................................. 57
HUMIRA ..................................................... 12
HUMIRA PEDIATRIC CROHNS START 12
HUMIRA PEN ............................................ 12
HUMIRA PEN-CROHNS STARTER ........ 12
HUMIRA PEN-PSORIASIS STARTER .... 12
HUMULIN R U-500 (CONCENTRATED) 24
hydralazine hcl ............................................ 31
hydrochlorothiazide..................................... 59
hydrocodone-acetaminophen ...................... 14
hydrocodone-homatropine .......................... 49
hydrocodone-ibuprofen ............................... 14
hydrocortisone ................................. 16, 48, 55
hydrocortisone ace-pramoxine .............. 16, 58
hydrocortisone acetate .......................... 16, 55
hydrocortisone butyr lipo base .................... 55
hydrocortisone butyrate .............................. 55
hydrocortisone valerate ............................... 55
hydrocortisone-acetic acid .......................... 76
Page 91
hydrocortisone-iodoquinol ........................... 52
hydromet ...................................................... 49
hydromorphone hcl ...................................... 14
hydroxychloroquine sulfate .......................... 32
hydroxyurea ................................................. 34
hydroxyzine hcl ............................................ 17
hydroxyzine pamoate ................................... 17
HYLATOPIC ............................................... 57
HYLATOPIC PLUS .................................... 57
hyoscyamine sulfate ..................................... 81
hyoscyamine sulfate er ................................. 81
hyosyne ......................................................... 81
HYPERCARE .............................................. 57
ibandronate sodium ..................................... 59
IBUDONE.................................................... 14
ibuprofen ...................................................... 12
ILEVRO ....................................................... 74
imipramine hcl ............................................. 23
imipramine pamoate .................................... 23
imiquimod .................................................... 56
IMOVAX RABIES ...................................... 84
INCRELEX .................................................. 60
indapamide................................................... 59
indomethacin ................................................ 12
INFANRIX .................................................. 80
insulin syringe/needle .................................. 68
INTELENCE................................................ 38
INTRON A................................................... 34
INTROVALE ............................................... 47
INVEGA SUSTENNA ................................ 36
INVIRASE ................................................... 38
IPOL ............................................................. 84
ipratropium bromide .............................. 19, 71
ipratropium-albuterol .................................. 18
irbesartan ..................................................... 30
irbesartan-hydrochlorothiazide ................... 30
iron ............................................................... 65
iron supplement ............................................ 65
ISENTRESS ................................................. 37
ISOLYTE-S PH 7.4 ..................................... 69
isoniazid....................................................... 32
ISOPTO HYOSCINE .................................. 72
isosorbide dinitrate...................................... 16
isosorbide dinitrate er ................................. 16
isosorbide mononitrate ................................ 16
isosorbide mononitrate er ........................... 16
isradipine ..................................................... 42
ISTALOL .................................................... 72
itraconazole ................................................. 27
ivermectin .................................................... 16
IXIARO ....................................................... 84
JAKAFI ....................................................... 34
JALYN ........................................................ 63
JANTOVEN ................................................ 19
JARDIANCE ............................................... 25
JENCYCLA................................................. 48
JENTADUETO ........................................... 24
JINTELI....................................................... 61
JOLESSA .................................................... 47
JOLIVETTE ................................................ 48
JUNEL 1.5/30 .............................................. 45
JUNEL 1/20 ................................................. 45
JUNEL FE 1.5/30 ........................................ 45
JUNEL FE 1/20 ........................................... 45
KALETRA .................................................. 37
kalexate ........................................................ 41
KARIVA ..................................................... 44
KELNOR 1/35 ............................................. 45
KEPIVANCE .............................................. 34
ketoconazole .......................................... 27, 56
ketoprofen .................................................... 12
ketorolac tromethamine ......................... 12, 74
KIMIDESS .................................................. 44
KINRIX ....................................................... 80
KIONEX ...................................................... 41
KLOR-CON ................................................ 69
KLOR-CON 10 ........................................... 69
KLOR-CON M10 ........................................ 69
Version 4
KLOR-CON M15 ........................................ 69
KLOR-CON M20 ........................................ 69
KRISTALOSE ............................................. 66
KURVELO .................................................. 45
KUVAN ....................................................... 60
labetalol hcl ................................................. 41
lactulose ....................................................... 66
lactulose encephalopathy ............................. 63
LAMICTAL ODT ........................................ 21
lamivudine .................................................... 39
lamivudine-zidovudine ................................. 37
lamotrigine ................................................... 21
lansoprazole ................................................. 81
LARIN 1.5/30 .............................................. 45
LARIN 1/20 ................................................. 45
LARIN FE 1.5/30......................................... 45
LARIN FE 1/20............................................ 45
LASTACAFT .............................................. 73
latanoprost ................................................... 75
LATUDA ..................................................... 36
LEENA ........................................................ 48
leflunomide................................................... 13
LESSINA ..................................................... 45
LETAIRIS .................................................... 43
letrozole........................................................ 34
leucovorin calcium ....................................... 34
LEUKERAN ................................................ 34
LEUKINE .................................................... 65
leuprolide acetate......................................... 34
levalbuterol hcl ............................................ 18
LEVATOL ................................................... 41
LEVEMIR .................................................... 24
LEVEMIR FLEXTOUCH ........................... 24
levetiracetam ................................................ 21
levetiracetam er ........................................... 21
levobunolol hcl ............................................. 72
levocarnitine ................................................ 60
levocetirizine dihydrochloride ............... 27, 28
levofloxacin ............................................ 62, 73
Page 92
LEVONEST ................................................ 48
levonorgest-eth estrad 91-day ..................... 47
levonorgestrel .............................................. 47
levonorgestrel-ethinyl estrad ................. 45, 47
levonorg-eth estrad triphasic ....................... 48
LEVORA 0.15/30 (28) ................................ 45
levorphanol tartrate .................................... 14
levothyroxine sodium ................................... 80
LEXIVA ...................................................... 38
LIALDA ...................................................... 62
lidocaine ...................................................... 57
lidocaine hcl .......................................... 57, 69
lidocaine viscous ......................................... 69
lidocaine-hydrocortisone ace ...................... 16
lidocaine-prilocaine .................................... 58
lindane ......................................................... 57
linezolid ....................................................... 31
LINZESS ..................................................... 62
liothyronine sodium ..................................... 80
LIPTRUZET ................................................ 29
lisinopril ...................................................... 29
lisinopril-hydrochlorothiazide..................... 29
lithium.......................................................... 36
lithium carbonate .................................. 35, 36
lithium carbonate er .................................... 35
LO LOESTRIN FE ...................................... 44
LOCOID ...................................................... 55
LOMEDIA 24 FE ........................................ 45
loperamide hcl ............................................. 26
LOPREEZA................................................. 61
lorazepam .................................................... 17
LORYNA .................................................... 45
losartan potassium ...................................... 30
losartan potassium-hctz ............................... 30
LOTEMAX ................................................. 75
lovastatin ..................................................... 28
LOW-OGESTREL ...................................... 45
loxapine succinate ....................................... 36
LUDENT ..................................................... 69
LUMIGAN ................................................... 75
LUPRON DEPOT ........................................ 34
LUPRON DEPOT-PED ............................... 60
LUTERA ...................................................... 45
LYRICA ....................................................... 21
LYSODREN ................................................ 32
LYZA ........................................................... 48
magnesium citrate ........................................ 66
malathion ..................................................... 57
maprotiline hcl ............................................. 22
marlissa ........................................................ 45
MARPLAN .................................................. 22
MATULANE ............................................... 34
MATZIM LA ............................................... 42
meclizine hcl................................................. 27
meclofenamate sodium ................................. 12
medroxyprogesterone acetate ................ 47, 77
mefenamic acid ............................................ 12
mefloquine hcl .............................................. 32
megestrol acetate ................................... 35, 77
meloxicam .................................................... 12
melphalan hcl ............................................... 34
memantine hcl .............................................. 78
MENACTRA ............................................... 82
MENEST...................................................... 62
MENHIBRIX ............................................... 82
MENOMUNE .............................................. 82
MENTAX .................................................... 52
MENVEO .................................................... 82
meperidine hcl .............................................. 14
meperitab ..................................................... 14
meprobamate................................................ 17
mercaptopurine ............................................ 33
mesalamine .................................................. 63
mesalamine-cleanser.................................... 63
metaproterenol sulfate ................................. 18
metaxalone ................................................... 71
metformin hcl ............................................... 24
metformin hcl er ........................................... 24
Version 4
metformin hcl er (osm) ................................ 24
methadone hcl.............................................. 14
methamphetamine hcl .................................. 11
methazolamide ............................................. 59
methenamine hippurate ............................... 82
methimazole ................................................. 79
methocarbamol ............................................ 71
methotrexate ................................................ 33
methotrexate sodium.................................... 33
methotrexate sodium (pf) ............................. 33
methoxsalen rapid ....................................... 53
methscopolamine bromide ........................... 82
methyclothiazide .......................................... 59
methyldopa .................................................. 30
methyldopa-hydrochlorothiazide................. 29
methylergonovine maleate ........................... 76
methylphenidate hcl ..................................... 11
methylphenidate hcl er ................................ 11
methylphenidate hcl er (la).......................... 11
methylprednisolone ..................................... 49
methylprednisolone (pak) ............................ 49
methylprednisolone acetate ......................... 49
metipranolol ................................................ 72
metoclopramide hcl ..................................... 62
metolazone ................................................... 59
metoprolol succinate er ............................... 41
metoprolol tartrate ...................................... 41
metoprolol-hydrochlorothiazide .................. 30
metronidazole .................................. 31, 57, 84
MICROGESTIN 1.5/30............................... 45
MICROGESTIN 1/20.................................. 45
MICROGESTIN FE 1.5/30 ......................... 45
MICROGESTIN FE 1/20 ............................ 45
micronized colestipol hcl ............................. 28
midodrine hcl ............................................... 85
MIGERGOT ................................................ 68
MIGRANAL ............................................... 68
milk of magnesia ......................................... 66
MILLIPRED DP.......................................... 49
Page 93
MIMVEY ..................................................... 61
MIMVEY LO............................................... 61
MINASTRIN 24 FE ..................................... 45
MINITRAN.................................................. 16
MINIVELLE ................................................ 62
minocycline hcl ............................................ 79
minoxidil ...................................................... 31
MIRALAX ................................................... 66
MIRENA ...................................................... 47
mirtazapine .................................................. 22
misoprostol................................................... 82
M-M-R II ..................................................... 83
modafinil ...................................................... 11
moexipril hcl ................................................ 29
moexipril-hydrochlorothiazide .................... 29
mometasone furoate ..................................... 55
MONO-LINYAH ......................................... 45
MONONESSA ............................................. 45
montelukast sodium ...................................... 19
MONUROL ................................................. 82
morphine sulfate........................................... 14
morphine sulfate (concentrate) .................... 14
morphine sulfate er ...................................... 14
MOTOFEN .................................................. 26
MOVIPREP ................................................. 66
MOXEZA .................................................... 73
MULTAQ .................................................... 17
multi vitamin/fluoride................................... 70
multi-vitamin/fluoride .................................. 70
multivitamins/fluoride .................................. 70
mupirocin ..................................................... 52
MY WAY..................................................... 47
mycophenolate mofetil ................................. 40
MYORISAN ................................................ 51
MYZILRA ................................................... 48
nabumetone .................................................. 12
nadolol ......................................................... 41
NAFRINSE .................................................. 69
naftifine hcl .................................................. 52
NAFTIN ...................................................... 52
NAGLAZYME ............................................ 60
naltrexone hcl .............................................. 26
NAMENDA................................................. 78
naphazoline hcl............................................ 74
naproxen ...................................................... 12
naproxen dr ................................................. 12
naproxen sodium ......................................... 13
naratriptan hcl ............................................. 68
NASONEX .................................................. 71
NATACYN ................................................. 73
NATAZIA ................................................... 47
nateglinide ................................................... 25
NATURE-THROID .................................... 80
NECON 0.5/35 (28) .................................... 45
NECON 1/35 (28) ....................................... 46
NECON 1/50 (28) ....................................... 46
NECON 10/11 (28) ..................................... 44
NECON 7/7/7 .............................................. 48
nefazodone hcl ............................................. 22
neomycin sulfate .......................................... 11
neomycin-bacitracin zn-polymyx ................. 73
neomycin-polymyxin-dexameth ................... 74
neomycin-polymyxin-gramicidin ................. 73
neomycin-polymyxin-hc ......................... 75, 76
NEOSALUS ................................................ 57
NEULASTA ................................................ 65
NEUPOGEN ............................................... 65
neutral sodium fluoride ............................... 70
NEVANAC ................................................. 74
nevirapine .................................................... 38
nevirapine er................................................ 38
NEXAVAR ................................................. 33
NEXPLANON............................................. 47
NEXT CHOICE ONE DOSE ...................... 47
niacin er ....................................................... 85
niacin er (antihyperlipidemic) ..................... 29
NIACOR ...................................................... 29
nicardipine hcl ............................................. 42
Version 4
nicotine......................................................... 79
nicotine polacrilex ....................................... 79
NICOTROL ................................................. 79
NICOTROL NS ........................................... 79
NIFEDICAL XL .......................................... 42
nifedipine...................................................... 43
nifedipine er ................................................. 42
nifedipine er osmotic release ....................... 43
NILANDRON .............................................. 33
nimodipine.................................................... 43
nisoldipine er ............................................... 43
NITRO-BID ................................................. 16
nitrofurantoin ............................................... 82
nitrofurantoin macrocrystal ......................... 82
nitrofurantoin monohyd macro .................... 82
nitroglycerin ................................................. 16
NITROSTAT ............................................... 16
nizatidine ...................................................... 81
NORA-BE .................................................... 48
norethin ace-eth estrad-fe ............................ 46
norethindrone ............................................... 48
norethindrone acetate .................................. 77
norethindrone acet-ethinyl est ..................... 46
norethindrone-eth estradiol ......................... 61
norethin-eth estradiol-fe ............................... 46
norgestimate-eth estradiol ........................... 46
norgestim-eth estrad triphasic ..................... 48
NORINYL 1+50 (28)................................... 46
NORLYROC................................................ 48
NORPACE CR............................................. 17
NORTREL 0.5/35 (28) ................................ 46
NORTREL 1/35 (21) ................................... 46
NORTREL 1/35 (28) ................................... 46
NORTREL 7/7/7 .......................................... 48
nortriptyline hcl ........................................... 23
NORVIR ...................................................... 38
NOVOFINE ................................................. 68
NOVOFINE AUTOCOVER ....................... 68
NOVOLIN 70/30 ......................................... 25
Page 94
NOVOLIN 70/30 RELION ......................... 24
NOVOLIN N ............................................... 25
NOVOLIN N RELION ............................... 25
NOVOLIN R ............................................... 25
NOVOLIN R RELION ............................... 25
NOVOLOG ................................................. 25
NOVOLOG FLEXPEN ............................... 25
NOVOLOG MIX 70/30 .............................. 25
NOVOLOG MIX 70/30 FLEXPEN ............ 25
NOVOLOG PENFILL ................................ 25
NOVOTWIST ............................................. 68
NOXAFIL ................................................... 27
np thyroid .................................................... 80
NUCYNTA ................................................. 14
NUCYNTA ER ........................................... 14
NULOJIX .................................................... 41
NUVARING ................................................ 46
NUVIGIL .................................................... 11
nystatin ............................................ 27, 52, 70
nystatin-triamcinolone................................. 52
NYSTOP ..................................................... 52
OCELLA ..................................................... 46
octreotide acetate ........................................ 61
ofloxacin .......................................... 62, 73, 75
OGESTREL................................................. 46
olanzapine ................................................... 37
olanzapine-fluoxetine hcl ............................ 79
olopatadine hcl ...................................... 71, 73
omega-3-acid ethyl esters ............................ 28
omeprazole .................................................. 81
OMNARIS................................................... 71
OMNIFLEX DIAPHRAGM ....................... 67
OMNITROPE .............................................. 60
ondansetron ................................................. 27
ondansetron hcl ........................................... 27
OPANA ER ................................................. 14
OPCICON ONE-STEP................................ 47
OPTIONS CONCEPTROL ......................... 84
OPTIONS GYNOL II CONTRACEPTIVE 84
ORAP ........................................................... 78
ORFADIN .................................................... 60
orphenadrine citrate er ................................ 71
ORSYTHIA ................................................. 46
oscimin sr ..................................................... 81
OSMOPREP ................................................ 66
oticin ............................................................ 75
oxandrolone ................................................. 15
oxaprozin...................................................... 13
oxcarbazepine .............................................. 21
OXISTAT .................................................... 56
OXSORALEN ............................................. 57
oxybutynin chloride ...................................... 82
oxybutynin chloride er ................................. 82
oxycodone hcl............................................... 14
oxycodone-acetaminophen ........................... 15
oxycodone-aspirin ........................................ 15
oxycodone-ibuprofen.................................... 15
oxymorphone hcl .......................................... 14
oxymorphone hcl er...................................... 14
pamidronate disodium ................................. 59
PANRETIN .................................................. 53
pantoprazole sodium .................................... 81
PARAGARD INTRAUTERINE COPPER . 47
paricalcitol ................................................... 60
PAROEX...................................................... 70
paromomycin sulfate .................................... 12
paroxetine hcl............................................... 23
paroxetine hcl er .......................................... 23
PATADAY .................................................. 73
PATANOL ................................................... 73
PAXIL .......................................................... 23
PEDIARIX ................................................... 80
PEDVAX HIB ............................................. 83
peg 3350/electrolytes ................................... 66
peg 3350-kcl-na bicarb-nacl ........................ 66
peg-3350/electrolytes ................................... 66
PEGANONE ................................................ 22
PEG-INTRON.............................................. 40
Version 4
PEG-INTRON REDIPEN ........................... 39
PEG-INTRON REDIPEN PAK 4 ............... 39
PEG-PREP................................................... 66
penicillin v potassium .................................. 76
PENTACEL................................................. 80
PENTAM..................................................... 31
pentazocine-naloxone hcl ............................ 15
pentoxifylline er ........................................... 64
perindopril erbumine ................................... 29
permethrin ................................................... 57
perphenazine ............................................... 36
perphenazine-amitriptyline ......................... 78
PEXEVA ..................................................... 23
PHENADOZ ............................................... 28
phenazopyridine hcl .................................... 64
phenelzine sulfate ........................................ 22
phenobarbital .............................................. 65
phentermine hcl ........................................... 11
phenyleph-promethazine-cod ...................... 49
phenytoin ..................................................... 22
phenytoin sodium extended ......................... 22
PHILITH ..................................................... 46
phospha 250 neutral .................................... 69
phosphate laxative ....................................... 66
PHOSPHOLINE IODIDE ........................... 72
PHYSIOLYTE ............................................ 41
PICATO....................................................... 52
pilocarpine hcl ............................................. 70
pimozide ...................................................... 78
PIMTREA ................................................... 44
pindolol ........................................................ 41
pioglitazone hcl ........................................... 26
pioglitazone hcl-glimepiride........................ 26
PIRMELLA 1/35 ......................................... 46
PIRMELLA 7/7/7 ........................................ 48
piroxicam ..................................................... 13
PNEUMOVAX 23 ...................................... 83
pnv tabs 29-1 ............................................... 71
podofilox ...................................................... 56
Page 95
polyethylene glycol 3350........................ 66, 77
polymyxin b sulfate ...................................... 32
polymyxin b-trimethoprim ............................ 73
polyvitamin/iron ........................................... 71
PORTIA-28 .................................................. 46
potassium chloride ....................................... 69
potassium chloride crys er ........................... 69
potassium chloride er ................................... 69
potassium citrate er...................................... 63
POTIGA ....................................................... 21
PR BENZOYL PEROXIDE WASH ........... 51
PRADAXA .................................................. 20
PRALUENT ................................................. 76
pramipexole dihydrochloride ....................... 35
pramipexole dihydrochloride er .................. 35
PRAMOSONE ............................................. 58
PRASCION .................................................. 50
PRASCION FC ............................................ 50
PRASCION RA ........................................... 50
pravastatin sodium ....................................... 28
prazosin hcl .................................................. 30
PRECISION XTRA BLOOD GLUCOSE ... 58
PRECISION XTRA MONITOR ................. 67
prednicarbate ............................................... 55
prednisolone................................................. 49
prednisolone acetate .................................... 75
prednisolone sodium phosphate............. 49, 75
prednisone .................................................... 49
prednisone (pak) .......................................... 49
PREDNISONE INTENSOL ........................ 49
PREMARIN ........................................... 62, 85
PREMPHASE .............................................. 61
PREMPRO ................................................... 61
prenatabs fa ................................................. 71
PRENATABS RX ........................................ 71
PRENTIF CAVITY-RIM CERV CAP ........ 67
pretab ........................................................... 71
PREVALITE ................................................ 28
PREVIDENT ............................................... 70
PREVIDENT 5000 BOOSTER................... 70
PREVIDENT 5000 BOOSTER PLUS ........ 70
PREVIDENT 5000 DRY MOUTH ............. 70
PREVIDENT 5000 ENAMEL PROTECT . 70
PREVIDENT 5000 PLUS ........................... 70
PREVIDENT 5000 SENSITIVE................. 70
PREVIFEM ................................................. 46
PREVNAR 13 ............................................. 83
PREZISTA .................................................. 38
PRIFTIN ...................................................... 32
primaquine phosphate ................................. 32
primidone..................................................... 21
PRISTIQ ...................................................... 23
probenecid ................................................... 64
procainamide hcl ......................................... 17
prochlorperazine ......................................... 37
prochlorperazine edisylate .......................... 37
prochlorperazine maleate............................ 37
PROCORT................................................... 16
PROCRIT .............................................. 64, 65
PROCTOFOAM HC ................................... 16
PROCTO-PAK ............................................ 16
PROCTOSOL HC ....................................... 16
PROCTOZONE-HC .................................... 16
progesterone ................................................ 77
progesterone micronized ............................. 77
PROGLYCEM ............................................ 24
PROGRAF................................................... 41
prolia ........................................................... 60
PROMACTA ............................................... 65
promethazine hcl ......................................... 28
promethazine vc ........................................... 49
promethazine vc plain ................................. 49
promethazine vc/codeine ............................. 49
promethazine-codeine ................................. 49
promethazine-dm ......................................... 49
promethazine-phenylephrine ....................... 49
PROMETHEGAN ....................................... 28
PROMISEB ................................................. 53
Version 4
propafenone hcl ........................................... 17
propafenone hcl er ....................................... 17
propantheline bromide ................................. 82
proparacaine hcl .......................................... 74
propranolol hcl ............................................ 42
propranolol hcl er ........................................ 41
propranolol-hctz .......................................... 30
propylthiouracil ........................................... 80
PROQUAD .................................................. 83
protriptyline hcl ........................................... 24
PROVENTIL HFA ...................................... 18
PRUTECT .................................................... 58
pseudoeph-bromphen-dm ............................. 49
PULMOZYME ............................................ 79
pyrazinamide ................................................ 32
pyridostigmine bromide ............................... 32
pyridostigmine bromide er ........................... 32
QUADRACEL ............................................. 80
QUASENSE ................................................. 47
quetiapine fumarate ..................................... 36
quinapril hcl ................................................. 29
quinapril-hydrochlorothiazide ..................... 29
quinidine gluconate er ................................. 17
quinidine sulfate ........................................... 17
quinidine sulfate er ...................................... 17
quinine sulfate .............................................. 32
ra omeprazole .............................................. 81
RABAVERT ................................................ 84
RAGWITEK ................................................ 42
raloxifene hcl ............................................... 61
ramipril ........................................................ 29
RANEXA ..................................................... 16
ranitidine hcl ................................................ 81
RAPAMUNE ............................................... 41
REA LO 39 .................................................. 56
REA LO 40 .................................................. 56
RECLIPSEN ................................................ 46
RECOMBIVAX HB .................................... 84
RECTIV ....................................................... 16
Page 96
REGRANEX ............................................... 58
RELENZA DISKHALER ........................... 40
RELPAX ..................................................... 68
REMEVEN .................................................. 56
REMODULIN ............................................. 43
RENAGEL .................................................. 63
RENVELA .................................................. 63
repaglinide................................................... 25
REPATHA................................................... 76
REPATHA SURECLICK ........................... 76
RESCRIPTOR ............................................. 38
RESTASIS................................................... 74
RETROVIR ................................................. 39
REVLIMID ................................................. 40
REYATAZ .................................................. 38
ribavirin ....................................................... 40
RIDAURA ................................................... 12
rifabutin ....................................................... 32
rifampin ....................................................... 32
rimantadine hcl............................................ 40
risedronate sodium ...................................... 59
RISPERDAL CONSTA .............................. 36
risperidone................................................... 36
RISPERIDONE M-TAB ............................. 36
rivastigmine tartrate .................................... 77
rizatriptan benzoate ..................................... 68
ropinirole hcl ............................................... 35
ropinirole hcl er........................................... 35
ROSADAN .................................................. 57
ROSANIL CLEANSER .............................. 50
ROSULA ..................................................... 50
rosuvastatin calcium .................................... 28
ROTARIX ................................................... 84
ROTATEQ .................................................. 84
ROXICET .................................................... 15
SABRIL ....................................................... 21
SAFYRAL ................................................... 46
salicylic acid .......................................... 56, 57
saline laxative .............................................. 66
SAMSCA ..................................................... 61
SANDOSTATIN LAR DEPOT ................... 61
SANTYL ...................................................... 56
SAPHRIS ..................................................... 36
SAVELLA ................................................... 77
SAVELLA TITRATION PACK ................. 78
selegiline hcl ................................................ 35
selenium sulfide............................................ 53
selenium sulf-pyrithione-urea ...................... 53
SELZENTRY ............................................... 37
SENSIPAR ................................................... 60
SEREVENT DISKUS .................................. 18
SEROQUEL XR .......................................... 36
sertraline hcl ................................................ 23
SETLAKIN .................................................. 47
sf 70
sf 5000 plus .................................................. 70
SHAROBEL ................................................ 48
SHUR-SEAL CONTRACEPTIVE .............. 84
sildenafil citrate ........................................... 43
SILENOR ..................................................... 65
silver sulfadiazine ........................................ 53
SIMBRINZA................................................ 72
simvastatin ................................................... 29
sirolimus....................................................... 41
SKLICE........................................................ 58
SKYLA ........................................................ 47
sodium chloride................................ 49, 63, 69
sodium chloride flush ................................... 69
SODIUM CHLORIDE THERMOJECT SYS
.................................................................. 58
sodium fluoride ............................................ 69
sodium polystyrene sulfonate ....................... 41
sodium sulfacetamide ................................... 53
SOLIA .......................................................... 46
SOMATULINE DEPOT .............................. 61
somavert ....................................................... 60
sotalol hcl ..................................................... 42
sotalol hcl (af) .............................................. 42
Version 4
SOVALDI ................................................... 40
SPIRIVA HANDIHALER .......................... 19
SPIRIVA RESPIMAT ................................. 19
spironolactone ............................................. 59
spironolactone-hctz ..................................... 59
SPRINTEC 28 ............................................. 46
SPRYCEL ................................................... 33
SPS .............................................................. 41
SRONYX..................................................... 46
ss 10-2.......................................................... 50
SSD.............................................................. 53
sss 10-5 ........................................................ 50
stavudine ...................................................... 39
sterile water for irrigation ........................... 41
STRATTERA .............................................. 11
streptomycin sulfate ..................................... 12
STRIVERDI RESPIMAT ........................... 18
SUBOXONE ............................................... 15
sucralfate ..................................................... 81
sulfacetamide sodium ...................... 50, 53, 75
sulfacetamide sodium (acne) ....................... 50
sulfacetamide sodium-sulfur.................. 50, 51
sulfacetamide-sulfur in urea ........................ 51
sulfadiazine .................................................. 79
sulfamethoxazole-trimethoprim ................... 31
SULFAMYLON .......................................... 53
sulfasalazine ................................................ 63
SULFAZINE ............................................... 63
SULFAZINE EC ......................................... 63
sulindac ....................................................... 13
sumatriptan succinate.................................. 68
SUPREP BOWEL PREP............................. 66
sure comfort pen needles ............................. 68
SURE-TOUCH LANCETS UNIVERSAL . 67
SURMONTIL .............................................. 24
SUSTIVA .................................................... 38
SUTENT ...................................................... 33
SYEDA ........................................................ 46
SYMBICORT .............................................. 18
Page 97
SYMLINPEN 120 ........................................ 24
SYMLINPEN 60 .......................................... 24
SYNAREL ................................................... 60
SYNERA...................................................... 58
SYNTHROID .............................................. 80
SYPRINE ..................................................... 40
TABLOID .................................................... 33
tacrolimus .............................................. 41, 57
TAMIFLU .................................................... 40
tamoxifen citrate .......................................... 33
tamsulosin hcl .............................................. 63
TANZEUM .................................................. 25
TARCEVA................................................... 33
TARGRETIN ............................................... 58
TARINA FE 1/20 ......................................... 46
TASIGNA .................................................... 33
TAZORAC ................................................... 53
TAZTIA XT ................................................. 43
TECFIDERA................................................ 78
TEKAMLO .................................................. 30
TEKTURNA ................................................ 31
TEKTURNA HCT ....................................... 31
telmisartan ................................................... 30
temazepam.................................................... 65
temozolomide ............................................... 34
TENIVAC .................................................... 80
terazosin hcl ................................................. 30
terbinafine hcl .............................................. 27
terbutaline sulfate ........................................ 18
terconazole ................................................... 84
testosterone .................................................. 15
testosterone cypionate .................................. 15
testosterone enanthate ................................. 15
tetanus toxoid adsorbed................................ 80
tetanus-diphtheria toxoids td ........................ 80
tetracycline hcl ............................................. 79
TETRIX ....................................................... 57
THALOMID ................................................ 40
theophylline er ............................................. 19
THERMAZENE .......................................... 53
thioridazine hcl ............................................ 37
thiothixene ................................................... 37
THYMOGLOBULIN .................................. 40
tiagabine hcl ................................................ 21
TICE BCG ................................................... 34
ticlopidine hcl .............................................. 64
TIGAN......................................................... 27
TIKOSYN ................................................... 17
TILIA FE ..................................................... 48
timolol maleate ...................................... 42, 72
tizanidine hcl ............................................... 71
TOBRADEX ............................................... 74
TOBRADEX ST.......................................... 74
tobramycin ................................................... 73
tobramycin-dexamethasone ......................... 74
TODAY SPONGE ...................................... 84
tolazamide ................................................... 26
tolbutamide .................................................. 26
tolcapone ..................................................... 35
tolmetin sodium ........................................... 13
tolterodine tartrate ...................................... 82
topiramate ................................................... 21
torsemide ..................................................... 59
TOVIAZ ...................................................... 82
TRACLEER ................................................ 43
TRADJENTA .............................................. 24
tramadol hcl ................................................ 15
tramadol hcl er ............................................ 15
tramadol hcl er (biphasic) ........................... 15
tramadol-acetaminophen............................. 15
trandolapril ................................................. 29
tranexamic acid ........................................... 65
tranylcypromine sulfate ............................... 23
TRAVATAN Z............................................ 75
trazodone hcl ............................................... 22
TRECATOR ................................................ 32
TRESIBA FLEXTOUCH............................ 25
tretinoin ................................................. 35, 51
Version 4
tretinoin microsphere ................................... 51
tretinoin microsphere pump ......................... 51
TREXIMET ................................................. 68
triamcinolone acetonide......................... 56, 70
triamterene-hctz ........................................... 59
triazolam ...................................................... 65
TRIBENZOR ............................................... 30
tricitrates ...................................................... 63
TRI-ESTARYLLA ...................................... 48
trifluoperazine hcl ........................................ 37
trifluridine .................................................... 74
trihexyphenidyl hcl ....................................... 35
TRIHIBIT PRESERVATIVE FREE ........... 80
TRI-LEGEST FE ......................................... 48
TRI-LINYAH .............................................. 48
TRI-LO-SPRINTEC .................................... 48
TRILYTE ..................................................... 66
trimethobenzamide hcl ................................. 27
trimethoprim ................................................ 31
trimipramine maleate ................................... 24
TRINESSA (28) ........................................... 48
TRIPEDIA PRESERVATIVE FREE .......... 80
triple antibiotic............................................. 73
TRI-PREVIFEM .......................................... 48
TRI-SPRINTEC ........................................... 48
TRIVORA (28) ............................................ 48
tropicamide .................................................. 72
trospium chloride ......................................... 82
trospium chloride er ..................................... 82
TRUMENBA ............................................... 83
TRUVADA .................................................. 37
TWINRIX .................................................... 83
TYKERB...................................................... 34
TYPHIM VI ................................................. 83
TYZEKA...................................................... 39
TYZINE ....................................................... 71
ULESFIA ..................................................... 58
ULORIC ....................................................... 64
ULTILET INSULIN SYRINGE SHORT .... 68
Page 98
UNITHROID ............................................... 80
urea .............................................................. 56
urea hydrating ............................................. 56
urea nail ...................................................... 56
urea nail film ............................................... 56
ursodiol ........................................................ 62
VAGIFEM ................................................... 85
valacyclovir hcl ........................................... 40
VALCYTE .................................................. 39
valganciclovir hcl ........................................ 39
valproic acid ................................................ 22
valsartan ...................................................... 30
valsartan-hydrochlorothiazide .................... 30
vancomycin hcl ............................................ 31
VANDAZOLE ............................................ 84
VAQTA ....................................................... 84
VARIVAX................................................... 84
VARIZIG..................................................... 76
VASCEPA ................................................... 28
VECTICAL ................................................. 53
VELIVET .................................................... 48
VELTIN....................................................... 51
venlafaxine hcl ............................................. 23
venlafaxine hcl er ........................................ 23
VENTAVIS ................................................. 43
VENTOLIN HFA ........................................ 18
VERAMYST ............................................... 71
verapamil hcl ............................................... 43
verapamil hcl er........................................... 43
VEREGEN .................................................. 51
VESICARE ................................................. 82
VESTURA................................................... 46
VEXOL ....................................................... 75
VIDEX......................................................... 38
VIGAMOX .................................................. 73
VIIBRYD ..................................................... 22
VIMPAT ...................................................... 21
viorele .......................................................... 44
VIRACEPT .................................................. 38
VIRAMUNE ................................................ 38
VIRAMUNE XR ......................................... 38
VIREAD ...................................................... 39
VITAFOL-OB+DHA ................................... 71
vitamin d (ergocalciferol) ............................ 85
VIVOTIF...................................................... 83
VIVOTIF BERNA VACCINE .................... 83
VOLTAREN ................................................ 52
voriconazole ................................................. 27
VOTRIENT.................................................. 34
VUSION ...................................................... 52
VYFEMLA .................................................. 46
VYTORIN.................................................... 29
VYVANSE .................................................. 11
warfarin sodium ........................................... 19
WELCHOL .................................................. 28
WERA .......................................................... 46
WYMZYA FE ............................................. 46
XALKORI.................................................... 34
XARELTO ................................................... 20
XIFAXAN.................................................... 31
XOLAIR ...................................................... 18
XTANDI ...................................................... 33
XULANE ..................................................... 46
X-VIATE ..................................................... 56
XYREM ....................................................... 77
YASMIN 28 ................................................. 46
YAZ ............................................................. 46
YF-VAX ...................................................... 84
zafirlukast .................................................... 19
zaleplon ....................................................... 65
ZARAH ....................................................... 46
ZAVESCA................................................... 64
ZAZOLE ..................................................... 84
ZEMAIRA ................................................... 79
ZENATANE ................................................ 51
ZENCHENT ................................................ 46
ZENCHENT FE .......................................... 46
ZETIA ......................................................... 29
ZIAGEN ...................................................... 39
ZIANA......................................................... 51
zidovudine .................................................... 39
ZIOPTAN .................................................... 75
ziprasidone hcl ............................................ 36
ZIRGAN ...................................................... 74
zoledronic acid ............................................ 59
ZOLINZA .................................................... 33
zolmitriptan ................................................. 68
zolpidem tartrate ......................................... 65
ZOMIG ........................................................ 68
ZONALON .................................................. 53
zonisamide ................................................... 21
ZONTIVITY ............................................... 77
ZORTRESS ................................................. 41
ZOSTAVAX ............................................... 84
ZOVIA......................................................... 46
ZOVIRAX ................................................... 53
ZYFLO CR .................................................. 17
ZYLET ........................................................ 74
ZYMAXID .................................................. 73
ZYTIGA ...................................................... 32
ZYVOX ....................................................... 32
This formulary was updated on 08/01/2016. For more recent information or other questions, please call Customer Service toll-free at 1.855.443.4735
(TTY/TDD relay: 1.800.955.8771) Monday through Friday from 8 a.m. to 6 p.m. or visit myHFHP.org.
Version 4
Page 99
Health First Commercial Plans, Inc. and Health First Insurance, Inc. are both doing business under the name Health First Health Plans. Health First
Health Plans does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in
the administration of the plan, including enrollment and benefit determinations.
Version 4
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3-tier QHP forumulary

Transcription

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