2Q13 - 4D Manage Formulary

Transcription

Preferred Drug
ist
2Q13
What Pharmacy Benefits Do I Have?
You employer has chosen either a 2-tier;
3-tier or 4-tier Prescription Drug Plan
with an open formulary. This means
that your plan covers medications that
are on the Preferred Drug List – also
known as a formulary, as well as many
others that are not. Your plan many not
cover certain medications, even though
some may be listed on the Preferred
Drug List. Please see the plan
documents provided by your employer
for a complete description of your
pharmacy benefit, or call the Member
Services number on your ID card.
The tiers identify the number of number
or the level of your covered medications.
CoPay/Tier
Tier 1
Tier 2
Tier 3
Tier 4
Description
Covered preferred generic
(formulary) medications.
Covered preferred brand
name (formulary)
medications
Covered non-preferred
generic and brand (nonformulary) medications
Preferred and NonPreferred self-injectable
drugs covered by your
plan. Insulin is excluded
in Tier 4 and will be in
either tiers 2 or 3.
All plans have a “mandatory generic”
substitution policy that requires a
generic drug be dispensed when
available, unless otherwise specified by
the prescribing doctor. If you have a 3Tier plan, if the brand name drugs with a
generic available is dispensed you will
be responsible for your tier-3 co-pay.
Please review the plan benefits provided
by your employer to determine how and
or if any cost-sharing requirements for
brand name drugs with a generic apply
to you.
What is a Preferred Drug List (PDL)?
The PDL is a list of preferred drugs
which have been approved by the Food
and Drug Administration (FDA), and are
considered safe and cost effective. The
drug list includes brand name and
generic medications and is updated
regularly. Drug on the PDL are
generally covered as long as the drug is
medically necessary and plan rules are
followed. Coverage is not limited to
drugs on the Preferred Drug List.
The Preferred Drug List is subject to
change. We choose drugs for the PDL
based upon medical necessity, safety and
cost.
How is the Preferred Drug List
Developed and Who Decides What Is
Covered?
The 4D Pharmacy-Preferred Drug List
features FDA-approved medications that
are considered safe and cost-effective. It
includes both brand-name and generic
medications. We choose drugs for the
Preferred Drug List based on reliable
medical data, safety and cost.
A Pharmacy and Therapeutics (P&T)
Committee meets regularly to review
new drugs and new information about
drugs already on the market. This
committee reviews available information
concerning safety, effectiveness and
current use in therapy. They also review
the scientific evidence from several
databases, including relevant findings of
Federal government agencies,
pharmaceutical manufacturers, medical
professional associations, national
commissions and peer-reviewed
journals.
follow your doctor's advice, even if a
prescribed drug is not covered.
Why does the Preferred Drug List
Change?
Changes to the Preferred Drug List.
The Preferred Drug List is updated on an
ongoing basis. Drugs can be added to or
removed from the Preferred Drug List at
any time. We might also move a drug
from one coverage tier to another.
As brand-name medications lose
their patents and generic versions
become available, the brandname medication may be covered
at a higher copayment while the
generic medication may be
covered at a lower copayment.
The FDA approves many new
medications throughout the year.
Medications can be withdrawn
from the market or may become
available without a prescription.
Over-the-counter (OTC) drugs
are not generally covered under a
prescription plan.
Some plans do not cover non-preferred
("formulary excluded") drugs. Other
plans may cover them, but at more cost
to you. Also, there may be some specific
drugs listed on the Preferred Drug List
that your plan does not cover, such as
contraceptives, infertility medications,
erectile dysfunction medications and
diabetic supplies.
You and your doctor are responsible for
making the final decision about what
medications you need to take. If you are
taking a drug that is not covered or nonpreferred, ask your doctor about
alternative drugs. You should always
We may add or delete drugs from the
PDL at any time. Drugs may also move
from one coverage tier to another.
Changes are made to the PDL because:
Brand name medications lose
their patent protections and
generic versions become
available.
New medications are approved
by the FDA. Open formularies
often cover new drugs before
they are reviewed by the P&T
Committee.
Medications are sometimes
withdrawn from the market or
becomes and over-the-counter
drug (OTC). Some plans have
chosen to cover OTC drugs –
please refer to the plan
documents provided by your
employer.
New medical evidence is
published.
Any drug not listed on the
preferred drug list is considered
their 3.
What is Prior Authorization and Why
Is It Required?
Prior Authorization is a process that
encourages appropriate and cost
effective use of medications by allowing
coverage under certain conditions.
Prior Authorization promotes:
Compliance with dosing
guidelines;
Assists your health care provider
avoid duplicate therapies that
may be inappropriate;
Monitors that a medication is
being used for generally accepted
medical criteria.
If a drug on your plan requires Prior
Authorization, your doctor must contact
us for approval.
If we approve the request, the
medication will then be covered at the
applicable copay tier.
If the request is denied, your doctor will
be notified. You may still purchase the
medication for the full price.
Why Do Some Medications Have
Quantity Limits?
These limits help your doctor and
pharmacist check that medications are
used appropriately and promote patient
safety. The Quantity Limits are set
based upon medical guidelines, FDA
approved recommendations from the
manufacturer. Quantity limit programs
include:
Once-daily dosing
Limit coverage to a specific
number of units for a defined
period of time.
Coverage in excess of the plan allowed
limits are not a covered benefit.
Step-Therapy – What is this?
Step-Therapy programs are also referred
to as prerequisite programs – meaning
that certain drug use is required before a
step therapy drug will be approved under
your specific plan.
Step-Therapy promotes the use of
equally effective, lower cost drugs first.
The list of medications requiring prior
authorization, quantity limits or steptherapy are subject to change.
Formulary List – Key
italic
Age
Gender
Generic name
Age Edit may be applicable
Gender Edit may be
applicable
Prior
Prior Authorization may be
Auth
applicable
Qty.
Quantity Limit may be
Limit
applicable
Rider
Rider may be required to
coverage
Specialty Specialty Pharmacy
dispensing may be applicable
Step Edit Step-Therapy may be
applicable
Preferred Drug ist A phabetica
Drug Name
8-MOP
ABILIFY
ABILIFY DISC
ABSTRAL
ACANYA
acarbose
ACCOLATE
ACCU CHEK family of test strips
ACCUHIST
ACCUNEB
ACCUPRIL
ACCURETIC
ACCUTANE
acebutolol
ACEON
acetaminophen/codeine
acetazolamide
ACIPHEX
acita
ACTEMRA
ACTIMMUNE
ACTIQ
ACTIVELLA
ACTIVELLA (4/1/11)
ACTONEL
ACTOPLUS MET
ACTOPLUS MET XR
ACTOS (eff 9/11/12)
ACULAR
ACULAR LS
ACULAR PF
acyclovir
ADALAT CC
adapalene
ADCIRCA
ADDERALL
ADDERALL XR
ADOXA
ADVAIR DISKUS
ADVAIR HFA
ADVATE
ADVICOR
AEROBID
AEROBID-M
afeditab
AFINITOR
AGGRENOX
Copay
Tier
2
2
2
3
3
1
3
3
3
3
3
3
3
1
3
1
1
3
1
3
2
3
2
3
2
2
3
3
2
2
2
1
3
1
3
3
3
3
2
2
2
3
3
2
1
3
2
Dispensing Edits
Specialty
Qty. Limit
Qty. Limit, Rider
Qty. Limit
Qty. Limit
Prior Auth
Qty. Limit
Specialty
Specialty
Qty. Limit
Gender
Gender
Qty. Limit
Qty. Limit
Age
Prior Auth
Qty. Limit
Prior Auth
Qty. Limit
Qty. Limit
Specialty
Qty. Limit
Qty. Limit
Qty. Limit
Prior Auth., Specialty
1
Drug Name
AGRYLIN
AKDARA
AKINETON
AKNE-MYCIN
ak-pred
ALAMAST
albuterol sulfate
albuterol sulfate (GE: Accuneb®)
albuterol/ipratropium
alclometasone
alcohol swab
ALDACTAZIDE
ALDACTAZIDE 50/50
ALDACTONE
ALDARA
ALDURAZYME
alendronate
ALESSE
alfuzosin hcl
ALINIA
ALKERAN
ALLEFEN CDX
ALLEGRA
ALLEGRA-D
ALOCRIL
ALODOX
ALOMIDE
ALORA
ALPHAGAN P
ALPHANATE
ALPHANINE SD
alprazolam
alprazolam ER
alprazolam rapidis
alprostadil
ALREX
ALTACE
ALTOPREV
ALUPENT
ALUVEA
ALVESCO HFA
AMALPRED Plus
amantadine
AMARYL
AMBIEN
AMBIEN CR
amcinonide
Copay
Tier
2
2
2
2
1
3
1
3
1
1
1
3
3
3
3
2
1
3
1
2
2
3
3
3
2
3
2
3
2
2
2
1
1
1
1
3
3
3
2
3
2
2
1
3
3
3
1
Dispensing Edits
Qty. Limit, Rider
Qty. Limit
Age, Gender
Qty. Limit
Qty. Limit
Gender, Qty. Limit
Specialty
Specialty
Qty. Limit
Age, Qty. Limit
Qty. Limit
2
Drug Name
AMERGE
AMEVIVE
amiloride
amiloride/HCTZ
aminophylline
amiodarone
AMITIZA
amitriptyline
amlodipine
amlodipine besy/benazepril
amlodipine/benazepril
amlodipine/valsartan
amlodipine/valsartan/hctz
amnesteem
amoxapine
amoxicillin
amoxicillin/K clavulanate
AMOXIL
amphetamine salts
amphetamine salts ER
ampicillin
AMPYRA
AMRIX
AMTURNIDE (Eff 7/1/11)
amyl nitrate
ANADROL
anagrelide
ANALPRAM ADVANCED
ANAMANTLE HC
anastrozole
ANCOBON
ANDRODERM
ANDROGEL
ANGELIQ
ANGELIQ
ANTABUSE
ANTARA
anthralin
antipyrine/benzocaine
ANZEMET
APIDRA
APOKYN
apri
APRISO
APTIVUS
ARALEN
aranelle
Copay
Tier
3
3
1
1
1
1
3
1
1
1
1
1
1
2
1
1
1
1
1
1
1
3
3
2
1
2
1
3
3
1
3
3
2
3
3
3
3
1
1
2
3
2
1
3
2
3
1
Dispensing Edits
Qty. Limit
Specialty
Qty. Limit
Qty. Limit
Qty. Limit
Specialty
Qty. Limit
Gender
Qty. Limit
Specialty
Age, Gender
Prior Auth
Age, Gender
3
Drug Name
ARANESP
ARAVA
ARCALYST
ARCAPTA NEOHALER
ARICEPT/ARICEPT ODT
ARIMIDEX
ARIXTRA
ARMOUR THYROID
AROMASIN
ARTHROTEC
ASACOL
ASMANEX
aspirin/codeine
ASTELIN NASAL
ASTEPRO
ATACAND
ATACAND HCT
ATELVIA
atenolol
atenolol/chlorthalidone
atorvastatin (Eff 12/1/2011)
atorvastatin/amlodipine
ATRALIN
ATRAPRO CP
ATRIPLA
ATROVENT HFA
ATROVENT NASAL
AUBAGIO
AUGMENTIN
AUGMENTIN ES
AUGMENTIN XR
AURSTAT
AUVI-Q
AVALIDE
AVANDAMET
AVANDARYL
AVANDIA
AVAPRO
AVAR E LS
AVAR GREEN
AVAR LS CLEANSER
AVAR LS, E
AVELOX
AVELOX ABC
aviane
AVINZA
AVODART
ASACOL HD
Copay
Tier
2
3
3
3
3
3
3
2
3
2
2
2
1
3
3
3
3
2
1
1
1
1
2
3
2
2
2
3
3
3
3
3
2
3
2
2
2
3
3
3
3
3
2
2
1
3
2
Dispensing Edits
Specialty
Specialty
Qty. Limit, Specialty
Specialty
Qty. Limit
Qty. Limit
Qty. Limit
Qty. Limit
Qty. Limit
Qty. Limit
Qty. Limit
Prior Auth, Specialty
Qty. Limit
Qty. Limit
Age, Gender
Qty. Limit
Step Therapy
4
Drug Name
AVONEX
AVONEX PEN
AXERT
AXID
AXIRON
AZASAN
AZASITE
azathioprine
azelastine (08/01/10)
AZELEX
AZILECT
azithromycin
AZMACORT
AZOPT
AZOR
AZOR (8/1/11)
AZULFIDINE ENTAB
AZULFIDINE+A191
B NEXA
bacitracin
bacitracin/neomycin/polymyxin
bacitracin/polymyxin
bacitracine/polymyxin/neomycin/hydrocortisone
baclofen
BACTROBAN CR, OINT
BACTROBAN NASAL
BAL-CARE DHA ESSENTIAL
balsalazide
BARACLUDE
BD Insulin Syringes
BD Pen Needles
BEBULIN VH
BECONASE AQ
benazepril
benazepril/HCTZ
BENEFIX
BENICAR
BENICAR HCT
BENZACLIN
BENZAMYCIN
BENZEFOAM ULTRA
BENZIQ
BENZIQ LS
BENZIQ WASH
benzoyl peroxide
benzoyl peroxide pads
benzoyl peroxide/urea
Copay
Tier
2
2
3
3
3
2
3
1
1
2
2
1
2
2
3
2
3
3
3
1
1
1
1
1
3
3
3
1
2
3
2
2
3
1
1
3
2
2
3
3
3
2
2
2
1
1
1
Dispensing Edits
Qty. Limit
Qty. Limit
Qty. Limit
Qty. Limit
Qty. Limit
Age, Gender
Qty. Limit, Rider
Qty. Limit, Rider
Specialty
Specialty
Qty. Limit
Qty. Limit
5
Drug Name
benztropine
BEPREVE
BESAVANCE
betamethasone valerate
BETAPACE
BETAPACE AF
BETASERON
betaxolol
betaxolol
bethamethasone diprop (augmented)
bethanechol
BETIMOL
BETOPTIC-S
BEYAZ
BIAXIN
BIAXIN XL
bicalutamide
BIDIL
BIG-STAR
bimatoprost
BINOSTO
BIO-THROID
bisoprolol fumarate
bisoprolol/HCTZ
BLEPHAMIDE S.O.P.
B-NEXA
BONIVA
Botulinum toxin
BRAVELLE
BREEZE 2 Test Strips
BREVICON
BRILINTA
brimonidine
bromocriptine
BRONCAP
BROVANA
budeprion
budeprion XL
bumetanide
BUMEX
BUPHENYL
BUPIVACAINE HCL-NS
bupreenorphine
bupropion
bupropion SR
buspirone
butalbital/APAP/caffeine/codeine
Copay
Tier
1
3
3
1
3
3
3
1
1
1
1
2
2
3
3
3
1
2
3
1
3
3
1
1
2
3
3
3
2
2
3
3
1
1
3
3
1
1
1
3
2
3
1
1
1
1
1
Dispensing Edits
Age, Gender
Qty. Limit, Rider
Qty. Limit
Prior Auth
Rider
Qty. Limit, Rider
Age, Gender
Prior Auth
Prior Auth., Qty. Limit
6
Drug Name
butalbital/aspirin/codeine
BUTISOL SODIUM
butorphanol
BUTRANS
BYDUREON
BYETTA
BYSTOLIC
CADUET (Eff 1/15/12)
CALAN
CALAN SR
calcipotriene
calcipotriene
CALCITONIN NASAL
CAMBIA
camila
CAMPRAL
CANASA
CAPITAL/CODEINE
CAPOTEN
CAPOZIDE
captopril
captorpril/HCTZ
CARAC
CARAFATE
CARBAGLU
carbamazapine xl
carbamazepine
carbidopa/levodopa
carbidopa/levodopa rapidis
carbidopa/levodopa SR
carboptic
CARDENE
CARDENE SR
CARDIZEM
CARDIZEM CD
CARDIZEM LA
CARDURA
CARDURA XL
carisoprodol
carisoprodol/aspirin
carisoprodol/aspirin/codeine
CARNITOR
carteolol
cartia XL
carvidilol
CASODEX
CATAPRES
Copay
Tier
1
2
1
3
3
2
3
3
3
3
1
1
1
3
1
3
2
3
3
3
1
1
3
3
3
1
1
1
1
1
1
3
3
3
3
3
3
3
1
1
1
2
1
1
1
2
3
Dispensing Edits
Qty. Limit
Qty. Limit
Qty. Limit
Qty. Limit
Qty. Limit
Age, Gender
Qty. Limit
Qty. Limit
Qty. Limit
Qty. Limit
Specialty
7
Drug Name
CATAPRES-TTS
CAVERJECT
CAYSTON
CAYSTON Inh
CEDAX
CEENU
cefaclor
cefaclor ER
cefadroxil
cefdinir
cefpodoxime
cefprozil
CEFTIN
cefuroxime
CEFZIL
CELEBREX
CELESTONE
CELEXA
CELLCEPT
CELONTIN
CENESTIN
CENFOL
CENHIST
CENTANY
cephalexin
CESAMET
cesia
CETACAINE KIT, SPRAY, OINT
CETACAINE LIQ
CETROTIDE
chloral hydrate
chlordiazepodide/amitriptyline
chlordiazepoxide
chloroquine
chlorpromazine
chlorpropamide
chlorthalidone
chlorthiazide
chlorzoxazone
cholestyramine
chorionic gonadotropin
CIALIS
CICLODAN
ciclopirox
ciclopirox gel, shampoo
CILODAN CLEANSER
cilostazol
Copay
Tier
3
3
3
3
3
2
1
1
1
1
1
1
3
1
3
2
3
3
3
2
3
3
3
3
1
3
1
3
3
3
1
1
1
1
1
1
1
1
1
1
1
2
3
1
1
3
1
Dispensing Edits
Qty. Limit
Specialty
Specialty
Specialty
Gender
Age, Gender
Rider
Prior Auth
Rider
Qty. Limit
8
Drug Name
cimetidine
CIMZIA
CIPRO
CIPRO HC
CIPRO XR
CIPRODEX
ciprofloxacin
ciprofloxacin
ciprofloxacin ER
citalopram
CITRANATAL 90 DHA
CITRANATAL B-CALM
CITRANATAL HARMONY
CITRANATAL HARMONY
CITRANATAL HARMONY
CITRNATAL-BA CALM
claravis
CLARIFOAM EF
CLARINEX
CLARINEX REDITAB
CLARINEX-D
clarithromycin
clarithromycin SR
clarithromycin xl
CLEANSE & TREAT PLUS KIT
CLEANSE/TREAT PAD
CLENIA
CLEOCIN VAGINAL
CLIMARA
CLIMARA PRO WEEKLY
CLINDACIN PAC
clindamax
clindamaycin (vaginal)
clindamycin
clindamycin
clindamycin foam
CLINDESSE
clobetasol
clobevate
CLOBEX (lotion, shampoo,)
CLOBEX SPRAY
CLODERM
CLOMID
clomiphene
clomipramine
clonazepam
clonazepam - disintigrating tab
Copay
Tier
1
3
3
2
3
2
1
1
1
1
3
3
3
3
3
3
1
2
3
3
3
1
1
1
3
3
3
3
3
3
3
3
1
1
1
1
3
1
1
1
2
1
3
1
1
1
1
Dispensing Edits
Age, Qty. Limit
Prior Auth
Qty. Limit
Qty. Limit
Qty. Limit
Gender
Gender
Gender, Qty. Limit
Gender
Gender
Rider
Rider
9
Drug Name
clonidine
clonidine patch
clopidogrel bisulfate
clorazepate
CLORPRES
clotrimazole/betamethasone
clozapine
CLOZARIL
COARTEM
COCET Plus
CODAR D
CODAR GF
codeine phosphate
codeine sulfate
COGENTIN
COLAZAL
COLCRYS
COLESTID
colestipol
colistimethate sodium
colocort
COLY-MYCIN M
COLY-MYCINS-S
COLYTE
COMBIGAN
COMBIPATCH
COMBIVENT
COMBIVENT RESPIMAT
COMBIVIR
COMBIVIR (4/1/12)
COMBUNOX
COMFORT PAC - MELOXICAM
COMFORT PAC - NAPROXEN
COMFORT PAC - TIZANIDINE
COMFORT PAC CYCLOBENZAPRINE
COMPLERA
compro
COMTAN
CONCERTA
CONTOUR Test Strips
CONZIP
COPAXONE
COPEGUS
CORDARONE
CORDRAN
COREG
COREG CR
Copay
Tier
1
1
1
1
3
1
1
3
2
3
3
3
1
1
3
2
2
3
1
1
1
2
2
3
2
2
2
2
2
3
2
3
3
3
3
2
1
2
2
2
3
2
3
3
2
3
3
Dispensing Edits
Gender
Qty. Limit
Qty. Limit, Rider
10
Drug Name
CORGARD
CORTAMAX
CORTANE-B
CORTIFOAM
cortisone AC
cortomycin
CORVITE FE
CORZALL
CORZALL PE
CORZALL PLUS
CORZIDE
COSOPT
COUMADIN
COVERA-HS
COZAAR
CREON
CRESTOR
CRINONE
CRIXIVAN
cromolyn sodium ophth
cromolyn soduim nebulizer
cryselle
CUVPOSA
cyanocobalmin
CYCLESSA
cyclobenzaprine ER
cyclobenzaprine hcl
cyclophosphamide
CYCLOSET
cyclosporine
cyclosporine modified
CYMBALTA
CYSTADANE
CYSTAGON
CYTADREN
DALIRESP
DANTRIUM
dapsone
DARAPRIM
DAYPRO
DAYTRANA
DAZIDOX
DDAVP
DECLOMYCIN
DELOS
DELZICOL
Copay
Tier
3
3
3
2
1
1
3
3
3
3
3
3
3
3
3
2
2
3
2
1
1
1
3
1
3
1
1
1
3
1
1
3
2
2
3
3
3
1
2
3
3
3
3
3
3
Dispensing Edits
Qty. Limit
Qty. Limit
Qty. Limit
Qty. Limit
Age, Rider
Age, Gender
Age, Gender
Prior Auth
Qty. Limit
Age
3
11
Drug Name
DEMADEX
demeclocycline
DEMEROL
DEMSER
DEMULEN
DENAVIR
DEPAKOTE
DEPAKOTE ER
DEPAKOTE SPRINKLE
DEPLIN
DEPO-PROVERA
DEPO-PROVERA
DERMATOP
desipramine
desmopressin
DESOGEN
DESONATE
desonide
DESONIL + PLUS
DESOWEN KIT
desoximetasone
DESOXYN
DETROL
DETROL LA
dexacidin
dexamethasone
dexamethasone phosphate
dexamethasone/neomycin/ polymyxin
dexasol
dexasporin
DEXEDRINE
DEXILANT
dexmethylphenidate
dextroamphetamine
dextroamphetamine CR
dextrostat
DIAMOX
DIASTAT
diazepam
DIBENZYLINE
diclofenac
diclofenac ophth
diclofenac potassium
diclofenac sodium XR
dicloxacillin sodium
didanosine delayed release
DIDRONEL
Copay
Tier
3
1
3
3
3
3
3
3
3
3
2
3
3
1
1
3
3
1
3
3
1
3
2
2
1
1
1
1
1
1
3
2
1
1
1
2
3
2
1
2
1
1
1
1
1
1
2
Dispensing Edits
Age, Gender
Age, Qty. Limit
Age
Age, Gender
Qty. Limit
12
Drug Name
DIFFERIN
DIFLUCAN (all other strengths)
DIFLUCAN 150mg
DIGIBAR
digitek
digoxin
DILACOR XR
DILATRATE SR
diltia XT
diltiazem
diltiazem CD/ER/XT
diltiazem SR
DILUADID
DIOVAN
DIOVAN HCT
DIPENTUM
dipivefrin
DIPROLENE AF
disopyramide
DISPERMOX
disulfiram
DITROPAN
DITROPAN XL
DIURIL
divalproex sodium DR
divalproex sodium ER
divalproex sodium sprinkle
divalproex sodium SR
DIVIGEL
DONATUSS XP ORAL
donepezil hcl
DONNATAL ELIX
DORAL
DORYX
dorzolamide
dorzolamide hcl ophthalmic
dorzolamide/tilomol ophthalmic
DOVONEX
doxazosin
doxepin cr
doxepin hcl
doxy-caps
doxycycline hyclate
doxycycline monohydrate
doxycycline monohydrate 150mg
DRITHOCREME HP
DRITHO-SCALP
Copay
Tier
3
3
3
3
1
1
3
3
1
1
1
1
3
3
3
2
1
3
1
3
1
3
3
3
1
1
1
1
3
3
1
3
2
3
1
1
1
3
1
1
1
1
1
1
1
3
2
Dispensing Edits
Age
Qty. Limit
Qty. Limit
Gender
Qty. Limit
Qty. Limit
Prior Auth
13
Drug Name
DUAC
DUET DHA BALANCED
DUET DHA BALANCED <geq>
DUET DHA COMPLETE
DUET DHA COMPLETE <geq>
DUET DHC EC
DUETACT
DULERA
DUONEB
DURAGESIC
DURASAL
DURICEF
DYAZIDE
DYMISTA
DYNABAC
DYNACIN
DYNACIRC CR
dypridamole
DYRENIUM
DYSPORT
e.e.s.
EDARBI
EDECRIN
EDEX
EDURANT
EFFEXOR
EFFEXOR XR
EFFIENT
EFUDEX
EGRIFTA
ELDEPRYL
ELESTAT
ELESTRIN
ELIDEL
ELIMIRON
ELOCON
EMADINE
EMCYT
EMEND
Emollient Combo #32
EMSAM
EMTRIVA
ENABLEX
enalapril
enalapril/HCTZ
ENBREL
ENJUVIA
Copay
Tier
2
3
1
3
1
3
3
2
3
3
3
3
3
3
3
3
3
1
2
3
1
3
3
3
2
3
3
2
3
3
2
3
3
2
2
3
3
2
3
1
2
2
3
1
1
2
3
Dispensing Edits
Gender
Gender
Gender
Qty. Limit
Qty. Limit
Prior Auth
Qty. Limit
Prior Auth
Gender
Specialty
Gender
14
Drug Name
ENLYTE
enoxaparin
enpresse
ENTOCORT EC
EPICREAM
EPIDUO
epinastine hcl
epinephrine
EPIPEN
EPIPEN-JR
EPISIL
EPIVIR
EPIVIR (4/1/12)
EPIVIR HBV
EPOGEN
eprosartan mesylate
EPZICOM
EQUETRO
ergoloid mesylate
ERIVEDGE
errin
ERTACZO
erythrocin
erythromycin
erythromycin
erythromycin
erythromycin delayed relase particles
erythromycin ethylsuccinate
erythromycin/benzoyl peroxide
escitalopram oxalate
ESCLIM
estazolam
ESTRACE
ESTRACE VAGINAL
ESTRADERM
estradiol patch
estradiol tab
estradiol/norethidrome acetate
estradiol-noreth ac
ESTRASORB
ESTRATEST
ESTRATEST HS
ESTRING
ESTROGEL
estropipate
ESTROSTEP FE
ethambutol
Copay
Tier
3
1
1
2
3
3
1
1
2
2
3
2
3
2
2
1
2
3
1
3
1
3
1
1
1
1
1
1
1
1
3
1
3
2
3
1
1
1
1
3
3
3
2
2
1
3
1
Dispensing Edits
Qty. Limit
Age, Gender
Specialty
Specialty
Age, Gender
Gender
Gender
Gender
Gender
Gender, Qty. Limit
Gender
Gender
Gender
Gender
Gender
Gender
Gender
Gender
Gender
Age, Gender
15
Drug Name
ETHINYL ESTRADIOL/DROSPIRENONE
ethosuximide
etodolac
etodolac ER
etoposide
EULEXIN
EURAX
EVAMIST
EVISTA
EVOCLIN
EVOXAC
EXALGO
EXELDERM
EXELON
exemestane
EXFORGE, EXFORGE HCT
EXTAVIA
EXTINA
EYLEA
E-Z DISK
FABRAZYME
FACTIVE
famciclovir
famciclovir
famciclovir
famotidine
FAMVIR
FANAPT
FANATREX
FANSIDAR
FARSETON
FASLODEX
FAST TAKE test strips
favciclovir
FAZACLO
FEIBA VH IMMUNO
felbamate
FELBATOL
FELBATOL (4/1/12)
felodipine
FEMARA
FEMCON FE
FEMHRT
FEMHRT LOW DOSE
FEMRING
FEMTRACE
fenofibrate
Copay
Tier
1
1
1
1
1
2
3
3
2
3
3
3
3
3
1
3
3
3
3
3
2
3
1
1
1
1
3
3
3
2
2
2
3
1
3
2
1
2
3
1
3
3
3
3
2
3
1
Dispensing Edits
Age, Gender
Specialty
Specialty
Gender
Specialty
Prior Auth
Specialty
Specialty
Qty. Limit, Rider
Specialty
Age, Gender
Gender
Gender
Gender
Gender
16
Drug Name
fenofibrate
FENOGLIDE
fenoprofen
fentanyl citrate
fentanyl citrate lozenge
fentanyl transdermal
fentanyl transmucosal lozenge
FENTORA
FERRIPROX
FERVIA
FEXMID
fexofenadine
fexophenadine/Pseudoephedrine
FINACEA
FINACEA PLUS
finasteride
FIORICET/CODEINE
FIORINAL/CODEINE
FIRAZYR
FIRMAGON
FIRST LANSOPRAZOLE
FIRST OMEPRAZOLE Susp
flacoxate
flecanide
FLECTOR
FLOMAX
FLONASE
FLO-PRED
FLOVENT DISKUS
FLOVENT HFA
FLOXIN OTIC
flubiprofen
fluconazole (all other strengths)
fluconazole 150mg
flucytosine
fludrocort
FLUMADINE
flunisolide
fluocinolone acetonide
fluocinonide
fluorometholone
fluor-op
FLUOROPLEX
fluorouracil
fluoxetine
fluoxymesterone
fluphenazine
Copay
Tier
1
3
1
1
1
1
1
3
3
3
3
1
1
3
3
1
3
3
3
2
3
3
1
1
2
3
3
3
2
2
2
1
1
1
1
1
1
1
1
1
1
1
3
1
1
1
1
Dispensing Edits
Qty. Limit
Qty. Limit
Qty. Limit
Specialty
Specialty
Age
Qty. Limit
Qty. Limit
Qty. Limit
17
Drug Name
flurbiprofen
flutamide
fluticasone
fluticasone propionate nasal
fluvastatin sod
fluvoxamine
FML FORTE
FML LIQUIFILM
FML S.O.P.
FOCALIN
FOCALIN XR
folic acid
FOLLISTIM AQ
FOLTX
fondaparinux
FORADIL
FORFIVO XL
FORTAMET
FORTEO
FORTESTA
fortical
FOSAMAX
FOSAMAX PLUS D
fosaprepitant
fosinapril
fosinapril/HCTZ
FOSRENOL
FRAGMIN
FREESTYLE LITE Test Strips
FROVA
frovatriptan succinate
FULYZAQ
furosemide
FUSION PLUS
FUZEON
gabapentin
GABARONE
GABITRIL
galantamine hbr
ganciclovir
GASTROCROM
GELNIQUE
GELX
gemfibrozil
GENADUR
GENERESS DE
gengraf
Copay
Tier
1
1
1
1
1
3
3
2
3
2
1
3
3
2
2
3
3
3
3
1
3
3
1
1
1
2
2
3
3
1
3
1
3
2
1
3
3
1
1
2
3
3
1
3
3
1
Dispensing Edits
Qty. Limit
Qty. Limit
Rider
Qty. Limit
Qty. Limit, Rider
Qty. Limit
Qty. Limit
Age, Gender
18
Drug Name
GENOTROPIN
gentamicin
gentamicin
GEODON
GEREF
GESTICARE DHA
gianvi
GIAZO
GILENYA
GILTUSS TR
GLEEVEC
glimepiride
glipizide
glipizide ER/XL
glipizide/metformin
gluburide
GLUCAGON
GLUCOPHAGE
GLUCOPHAGE XR
Glucose Test Strips (all other brands)
GLUCOVANCE
GLUMETZA
glyburide micronized
glyburide/metformin
glycolax
glycon
GLYSET
GLYSET
GOLYTELY
GONAL-F
GONAL-F RFF
GRALISE
GRANIRELIX
granisetron
GRIFULVIN V
GRIS-PEG
guanabenz
guanfacine
guinidine sulfate
GYNAZOLE-1
gynodiol
HALDOL D
HALFLYTELY
halobetasol propionate
HALOG
haloperidol
HECTOROL
Copay
Tier
2
1
1
3
3
3
1
3
3
3
2
1
1
1
1
1
3
3
3
3
3
3
1
1
1
1
3
2
3
2
2
3
3
1
2
2
1
1
1
3
1
3
2
1
3
1
2
Dispensing Edits
Age, Gender
Age, Gender
Specialty
Qty. Limit, Rider
Rider
Rider
Rider
Qty. Limit
Gender
Gender
Rider
19
Drug Name
HELIDAC
HELIXATE FS
HEMENATAL OB
HEMENATAL OB + DHA COMBO
HEMOFIL M
heparin
HEPSERA
HEXALEN
HISTEX SR
HMS
HORIZANT
HUMALOG pdts
HUMATE-P
HUMATROPE
HUMIRA
HUMULIN
hydralazine
hydralazine/HCTZ
HYDREA
hydrochlorothiazide (HTCZ)
hydrocodone bit/APAP
hydrocodone/acetaminophen
Hydrocort/Parmoxn SKN CLNSR #16
Hydrocort/Pramoxine
hydrocortison valerate
hydrocortisone
hydrocortisone
hydrocortisone acetate
hydrocortisone butyrate
hydrocortisone/clioquinol
hydrocortisone/iodoquinol
hydrocortisone/pramoxine
hydromorphone
hydroxychloroquine sulfate
hydroxyne pamoate
hydroxyurea
hydroxyzine hcl
HYLASE
HYLATOPIC P;LUS-AURSTAT
HYLATOPIC PLUS
HYLATOPIC, HYLATOPIC PLUS
hyscyamine
HYTRIN
HYZAAR
ibandronate sodium
IBUDONE
ibuprofen
Copay
Tier
3
3
3
3
2
1
3
2
3
2
3
2
2
3
2
2
1
1
3
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
3
3
3
3
1
3
3
1
3
1
Dispensing Edits
Specialty
Age, Qty. Limit
Age, Qty. Limit
Specialty
Qty. Limit
Specialty
Specialty
Qty. Limit
20
Drug Name
ICLUSIG
ILARIS
ILVERO
IMDUR
imipramine hcl
imipramine pm
imiquimod
IMITREX
IMURAN
INCIVEK
INCRELEX
indapamide
INDERAL
INDERAL LA
INDERIDE
indomethacin
indomethacin ER
INFERGEN
INLYTA
INNOHEP
INNOPRAN XL
INOVA
INSPRA
insulin syringes
INTELENCE
INTERMEZZO
INTRON-A
INTUNIV
INVEGA
INVEGA Syringe
INVIRASE
IOPIDINE
ipratropium inhaler
ipratropium nasal
IPRIVASK
IQUIX
irbesartan
irbesartan/HCTZ
IRESSA
IROSPAN
ISENTRESS
ISMO
ISO CARBACHOL
isoniazid
ISOPTIN SR
ISOPTO CARPINE
ISORDIL
Copay
Tier
3
3
3
3
1
1
1
3
2
2
11/
1
3
3
3
1
1
3
3
2
3
3
2
1
2
3
2
3
3
3
2
1
1
1
3
2
1
1
2
3
2
3
2
1
3
2
3
Dispensing Edits
Specialty
Specialty
Qty. Limit
Qty. Limit, Rider
Specialty
Qty. Limit
Qty. Limit
Specialty
21
Drug Name
isosorbide dinitrate
isosorbide mononitrate
isotretinoin
isoxuprine
isradipine
ISTALOL
itraconazole
JAKAFI
JALYN
JANUMET
JANUMET XR
JANUVIA
JAYLN (Eff. 7/1/11)
JENTADUETO
JETREA
jolessa
jolivette
junel
junel FE
JUVISYNC
KADIAN
KALBITOR
KALETRA
KALYDECO
KAPIDEX
KAPVAY
kariva
KAZANO
kelnor
KEPPRA
KEPPRA XR
KERALYT
KERLONE
KETEK
KETOCON + PLUS
ketoconazole
ketoconazole
KETODAN
ketopofen
ketoprofen ER
ketorolac
KINERET
KLARON
KLONOPIN
KLONOPIN WAFER
KOATE-DVI
KOGENATE FS
Copay
Tier
1
1
1
1
1
3
1
3
2
2
2
2
2
3
3
1
1
1
1
3
2
3
2
3
3
3
1
3
1
3
3
3
3
3
3
1
1
3
1
1
1
3
3
3
3
3
3
Dispensing Edits
Prior Auth
Age, Gender
Age, Gender
Age, Gender
Age, Gender
Qty. Limit
Specialty
Age, Gender
Age, Gender
Specialty
Specialty
22
Drug Name
KOGENATE FS IV
KOMBIGLYZE XR
KOMBIGLYZE XR (8/1/11)
KORLYM
KRISTALOSE
KUVAN
KYNAMRO
KYTRIL
labatelol
lacticare/hydrocortisone
lactulose
LAMICTAL
LAMICTAL XR
LAMISIL
lamivudine
lamivudine-zidovudine
lamotrigine
lamotrigine XR
lancets
LANOXICAP
LANOXIN
LANTUS
LARIAM
LASIX
lasoprazole cap
lasoprazole rap dr
LASTACAFT
LATUDA
LAVOCLEN
leena
leflunomide
LESCOL
LESCOL XL
lessina
LETAIRIS
letrozole
letrozole
leucovorin calcium
LEUKERAN
LEUKINE
leuprolide
leuprolide
LEVAQUIN
LEVATOL
LEVELEN
LEVEMIR
levetiracetam
Copay
Tier
3
3
2
3
3
3
3
3
1
1
1
3
3
3
1
1
1
1
2
3
3
2
2
3
1
1
3
3
3
1
1
3
3
1
2
1
1
1
2
2
1
1
3
3
3
2
1
Dispensing Edits
Specialty
Specialty
Qty. Limit
Qty. Limit, Rider
Age, Gender
Qty. Limit
Qty. Limit
Age, Gender
Specialty
Specialty
Rider
Age, Gender
23
Drug Name
levetiracetam ER
LEVITRA
LEVLITE
levobunolol
levocetirizine dihydrochloride
levofloxacin (1/16/12) oral
levofloxacin ophth
levomefolate calcium
levora
levorphanol
LEVOTHROID
levothyroxine
LEVOXYL
LEVULAN
LEXAPRO
LEXIVA
LIALDA
LIDAMANTLE HC
lidocaine
lidocaine/hydrocortisone
lidocaine/prilocaine
LIDODERM
LIDOVIR
lindane
LIPITOR
LIPITOR (Eff 12/1/2011)
LIPOFEN
LIQUADD
lisinopril
lisinopril/HCTZ
lithium carbonate
lithium carbonate CR
lithium citrate
LITHOBID
LIVOLO
l-methylfolate calcium
LO LOESTRIN FE
LO/OVRAL
LODOSYN
LOESTRIN
LOESTRIN FE
LOESTRIN FE 24
LOFIBRA
loperamide
LOPID
LOPRESSOR
LOPRESSOR HCT
Copay
Tier
1
3
3
1
1
1
1
1
1
1
3
1
3
3
3
2
3
3
1
1
1
3
2
3
2
3
3
2
1
1
1
1
1
3
3
1
3
3
2
3
3
3
3
1
3
3
3
Dispensing Edits
Qty. Limit
Age, Gender
Qty. Limit
Age, Gender
Qty. Limit
Qty. Limit
Qty. Limit
Qty. Limit
Age, Gender
Age, Gender
Age, Gender
Age, Gender
24
Drug Name
LOPROX (Cr., lotion, susp)
LOPROX (gel, shampoo)
loratadine
lorazepam
LORCET
LORCET PLUS
LORTAB
LORZONE
LORZONE
losartan
losartan
losartan/hctz
losartan/HCTZ
LOTEMAX
LOTENSIN
LOTENSIN HCT
LOTREL
LOTRISONE
LOTRONEX
lovastatin
LOVAZA
LOVENOX
low-ogestrel
loxapine
LUMIGAN
LUNESTA
LUPRON
LUPRON
LUPRON DEPOT
lutera
LUVERIS
LUVOX CR
LUXIQ
LYBREL
LYCELLE
LYRICA
LYSORDREN
LYSTEDA
MACROBID
MACUGEN
MAGNACET
MAKENA
MALARONE
maldemar
MARNATAL F
MARPLAN
marprotaline
Copay
Tier
3
3
1
1
3
3
3
3
3
1
1
1
1
2
3
3
3
3
2
1
3
3
1
1
3
3
3
3
3
1
3
3
3
3
3
2
2
3
2
3
3
3
2
1
3
2
1
Dispensing Edits
Qty. Limit
Age, Gender
Specialty
Rider
Specialty
Age, Gender
Rider
Age, Gender
Specialty
Qty. Limit
Specialty
25
Drug Name
MATULANE
MAVIK
MAXAIR AUTOHALER
MAXALT
MAXALT MLT
MAXARON FORTE
MAXIDONE
MAXZIDE
MEBARAL
meclizine
meclofenamate sodium
medroxyprogesterone
medroxyprogesterone
mefenamic acid
mefloquine
MEGACE
MEGACE ES
megestrol
meloxicam
MENEST
MENOPUR
MENOSTAR
MENTANX
meperidine
meperidine/promethazine
mephobarbital
meprobamate
MEPRON
meprozine
mercaptopurine
mesalamine
MESNEX
MESTINON
MESTINON TIMESPAN
METADATE CD
METADATE ER
METAGLIP
metaproterenol
metaxalone
metformin
metformin ER 24 (Fortamet®)
metformin XR
methadose
methanamine hippurate
methanamine madelate
methazolamide
methimazole
Copay
Tier
2
3
3
3
3
3
3
3
3
1
1
1
1
1
1
3
3
1
1
3
3
3
3
1
1
1
1
2
1
1
1
2
2
2
3
3
3
1
1
1
1
1
1
1
1
1
1
Dispensing Edits
Qty. Limit
Qty. Limit
Age, Qty. Limit
Gender
Gender
Rider
Gender
Specialty
Qty. Limit
Qty. Limit
26
Drug Name
METHITEST
methocarbamol
methotrexate
methychlorthiazide
methyldopa
methyldopa/HCTZ
methylin
METHYLIN (Chew. Soln)
methylin ER
methylphenidate
methylphenidate CD
methylphenidate ER
methylphenidate LA
methylphenidate SR
methylprednisolone
methyltestesterone
metipranolol
metoclopramide
metolazone
metoprolol succinate SR
metoprolol tartrate
metoprolol/HCTZ
METOZZOLV ODT
METROCREAM
METROGEL 1% ONLY
METROGEL VAG
METROLOTION
metronidazole
metronidazole
metronidazole SR
METVIXIA
MEVACOR
mexiletine
MIACALCIN injection
MIACALCIN NASAL
MICARDIS
MICARDIS HCT
microgestin
microgestin FE
micronefrin
MICROZIDE
midazolam
MIGRANAL
MILLIPRED
MINIPRESS
MINIRIN
MINOCIN
Copay
Tier
2
1
1
1
1
1
1
3
1
1
1
1
1
1
1
1
1
1
1
1
1
1
3
3
3
3
3
1
1
1
3
3
1
2
3
3
3
1
1
1
3
1
2
3
3
2
3
Dispensing Edits
Qty. Limit
Qty. Limit
Qty. Limit
Qty. Limit
Qty. Limit
Gender
Specialty
Age, Gender
Age, Gender
Qty. Limit
Age
27
Drug Name
minocycline
minocycline ER
minoxidyl
MIRAPEX
MIRCETTE
mirtazapine
mirtazapine ODT
misoprostol
MISTOSOL
MOBIC
modafinil
MODICON 0.5/35
moexipril
moexipril/HCTZ
mometasone
MONARC-M
monessa
MONOCLATE-P
MONODOX
MONOKET
MONONINE
montelukast sod (10mg tab, 4mg, 5mg chew)
MONUROL
MORGIDOX
morphine sulfate
morphine sulfate CR
morphine sulfate ER Pel
MS CONTIN
MUGARD
mupirocin
MYAMBUTOL
MYFORTIC
MYLERAN
MYOZYME
myrac
MYRBETRIQ
nabumetone
nadolol
nadolol/bendroflumethiazide
NAFTIN
NALFON
naltrexone
NAMENDA
nandrolone deconate
NAPRELAN
naproxen
NAPROXEN COMFORT PAC
Copay
Tier
1
1
1
3
3
1
3
1
3
3
1
3
1
1
1
2
1
2
3
3
3
1
3
3
1
1
3
3
2
1
2
2
2
2
1
3
1
1
1
3
3
1
2
1
3
1
3
Dispensing Edits
Age, Gender
Age, Gender
Specialty
Age, Gender
Specialty
Specialty
Specialty
Specialty
28
Drug Name
naproxen sodium
naratriptan
NARDIL
NASACORT AQ
NASAREL
NASONEX
NASOTUSS
NATA KOMPLETE
NATAZIA
nateglinide
NATROBA
NATURE_THYROID
NATURETIN
NEBUPENT
necon
NEEVO COMBO PK
NEEVO, NEEVO DHA
nefazodone
nemoycin/polymyxin/gramicidin
NEOBENZ MICRO
neomycin
neomycin/polymyxin/ hydrocortisone
neomycin/polymyxin/ hydrocortisone
NEORAL
NESINA
NESTABS
NESTABS DHA
NEULASTA
NEUPOGEN
NEUPRO (Transdermal)
NEURONTIN
NEVANAC
NEXA PLUS
NEXA SELECT
NEXA SELECT
NEXAVAR
NEXICLON XR
NEXIUM
NIASPAN
nicardipine
NICAZEL
NICOMIDE
nifedical CC
nifedical XL
nifedipine
nifedipine CR/ER/SR
NILANDRON
Copay
Tier
1
1
3
3
3
3
3
3
3
1
2
2
3
3
1
3
3
1
1
3
1
1
1
3
3
3
3
2
2
3
3
2
3
3
3
2
3
3
2
1
3
3
1
1
1
1
2
Dispensing Edits
Qty. Limit
Age, Gender
Age
Specialty
Specialty
Specialty
Age, Gender
Age, Gender
Specialty
29
Drug Name
nimodipine
NIMOTOP
NIRAVAM
NIRON KOMPLETE
nisolpidine er
NITROBID
NITRO-DUR
nitrofurantoin
nitrofurantoin macrocrystal
nitroglycerin
nitroglycerin SL
nitroglycerin SR
NITROLINGUAL
NITROSTAT
nitro-transdermal
nizatidine
nora-be
NORCO
NORDETTE
NORDITROPIN
NORDITROPIN AQ
norethindrone acetate
NORINYL
NORITATE
NORMELGEL AG
NOROXIN
NORPACE
NOR-QD
nortrel
nortriptyline
NORVASC
NORVIR
NOTUSS NXD
NOTUSS NXD
novarel
Novofine Pen Needles
NOVOLIN
NOVOLOG
NOVOSEVEN
Novotwist Needles
NOXAFIL
NUCORT
NUEDEXTA
NULYTELY
NUOX
NUTROPIN
NUVAIL
Copay
Tier
1
3
3
3
1
3
3
1
1
1
1
1
2
2
1
1
1
3
3
3
3
1
3
2
3
3
3
3
1
1
3
2
3
3
1
2
2
2
2
2
3
3
3
3
3
2
3
Dispensing Edits
Age, Gender
Age, Gender
Gender
Age, Gender
Age, Gender
Age, Gender
Rider
Qty. Limit, Rider
Specialty
Qty. Limit, Rider
30
Drug Name
NUVARING
NUVIGIL
NUZON
nystatin
nystatin
nystatin vag
nystatin/triamcinolone
OB COMPLETE W/DHA
ocella
octreotide acetate
ofloxacin
ofloxacin
ofloxacin otic
OFORTA
OGEN
ogestrel
olanzapine
olanzapine zydis
OLEPTRO ER
OLUX
OLUX-E
OMACOR
OMECLAMOX-PAK
omeprazole
omeprazole/sodium bicarf
OMNARIS
OMNICEF
OMNITROPE
ondesetron
ONE TOUCH family of test strips
ONFI
ONGLYZA
ONGLYZA (8/1/11)
ONMEL
ONSOLIS
OPANA
OPANA ER
OPTIPRANOLOL
OPTIVAR
ORACEA
ORAMORPH SR
ORAP
ORAPRED
ORAXYL
ORBIVAN
ORENCIA
ORFADIN
Copay
Tier
3
2
3
1
1
1
1
3
1
1
1
1
1
3
3
1
1
1
3
3
3
3
3
1
1
3
3
3
1
3
3
3
2
3
3
3
3
2
2
3
3
2
3
3
3
3
2
Dispensing Edits
Age, Gender
Gender
Age, Gender
Specialty
Gender
Age, Gender
Qty. Limit
Qty. Limit, Rider
Specialty
31
Drug Name
orphenadrine cpd
orphenadrine ER
orphenadrine/aspirin/caffeine
ORTHO EVRA
ORTHO MICRONOR
ORTHO TRI-CYCLEN
ORTHO TRI-CYCLEN LO
ORTHO-CEPT
ORTHO-CYCELN
ORTHO-NESIC
ORTHO-NOVUM
OSCION
OSENI
OSMOPREP
OVACE
OVCON
OVIDREL
oxaprozin
oxazepam
oxcarbazepine
OXECTA
OXISTAT
OXSORALEN-UL
OXTELLAR XR
oxybutynin
oxybutynin SR
oxycodone
oxycodone/acetaminophen
oxycodone/aspirin
oxycodone/ibuprofen
OXYCONTIN CR
OXYCONTIN CR (Eff 4/1/12)
oxyfast
OXYIR
OXYTROL
PACERONE
PACNEX LP
pamidronate
PANCREAZE
PANRETIN
pantoprazole
papaverine ER
PARCOPA
PARLODEL
PARNATE
paromomycin
paroxetine
Copay
Tier
1
1
1
2
3
3
2
3
3
3
3
3
3
2
3
3
3
1
1
1
3
3
2
3
1
1
3
1
1
1
3
2
1
2
3
3
3
1
2
3
1
1
2
3
3
1
1
Dispensing Edits
Age, Gender
Age, Gender
Age, Gender
Age, Gender
Age, Gender
Age, Gender
Age, Gender
Age, Gender
Rider
Specialty
Qty. Limit
Qty. Limit
32
Drug Name
paroxetine CR/ER
PATADAY
PATANASE
PATANOL
PAXIL
PAXIL CR
PCE
PEDIADERM AF, HC, TA
PEDIATEX TDM
peg 3350
PEGASYS
PEGASYS
PEGASYS PROCLICK
PEG-INTRON
penicillin VK
PENLAC
PENNSAID
PENTASA
pentazocine/acetaminophen
pentazocine/naltrexone
pentoxifylline
PEPCID
PERCOCET
PERCODAN
PERFORMIST
pergnyl
perindopril erbumine
PERIOSTAT
permethrin
perphenazine
perphenazine/amitriptyline
PERSANTINE
PERTZYE
PEXEVA
phenelzine sulfate
phenobarbital
phenytoin extended
phenytoin sodium
PHOSLO
PHOSLYRA
PHOSPHOLINE
phrenilin/caffeine/codeine
pilocar
pilocarpine
pilocarpine
PILOPINE HS
Copay
Tier
1
2
3
2
3
3
1
3
3
1
2
2
2
2
1
3
3
2
1
1
1
3
3
3
3
1
1
1
3
1
1
1
3
2
3
1
1
1
1
2
3
2
1
1
1
1
2
Dispensing Edits
Rider
33
Drug Name
piloptic
pindolol
pioglitazone/glimepiride
piroxicam
PLAVIX
PLAVIX (Eff 6/1/2012)
PLENDIL
PLETAL
PLEXION (cloth, emulsion)
PLEXION SCT
PLEXION TS
PLIAGLIS
plioglitazone
PNV FOLIC ACID + IRON
PNV-DHA PLUS
PNV-IRON
POLIBAR ORAL SUSP
POLY VI FLOR W/IRON
poly-dex
polyethylene glycol
POLYHIST forte
polymyxin B/trimethoprim
POLY-PRED
POLY-VI-FLOR
PONSTEL
PONTOCAINE
portia
potassium chloride
POTIGA
PRADAXA
PRAM-HCA
pramipexole di-hcl
PRANDIN
PRAVACHOL
pravastatin
prazosin
PRECISION family of test strips
PRECOSE
PRED-G
PRED-G S.O.P.
prednicarbate
prednisolone
prednisolone ophthalmic
prednisone
PREFERA OB
PREFEST
PREFLIN
Copay
Tier
1
1
1
1
2
3
3
2
2
2
2
3
1
3
3
3
3
3
1
1
3
1
3
3
3
3
1
1
3
2
3
1
2
3
1
1
3
3
2
2
1
1
1
1
3
3
3
Dispensing Edits
Age, Gender
Qty. Limit, Rider
Gender
Prior Auth
34
Drug Name
PREMARIN
PREMARIN VAGINAL
PREMPHASE
PREMPRO
PRENATA
PRENATAL PLUS
prenatal vitamins (oral)
PRENATE DHA
PRENATE ELITE
PRENATE ESSENTIAL
PRENATE MINI
PRENATE PLUS
PRENEXA
PREPOIK
PREQUE 10
PREVACID
PREVACID NAPRAPAC
prevalite
previfem
PREVPAC
PREZISTA
PRILOSEC
PRILOSEC OTC
PRIMALEV
primaquine
primidone
principen
PRINIVIL
PRINZIDE
PRISTIQ
PROAIR HFA
procainamide
procainamide ER
PROCARDIA
PROCARDIA XL
PROCHIEVE
prochlorperazine
PROCLEAR CAP
PROCLYCEM
PROCRIT
PROFILNINE
PROGESTERONE VAGINAL
PROGRAF
PROHIST CD
PROHIST CF
PROHIST LQ
PROLEX DM
Copay
Tier
2
2
2
2
3
3
1
3
3
3
3
3
3
3
3
3
2
1
1
2
2
3
1
3
1
1
1
3
3
2
2
1
1
3
3
3
1
3
2
2
2
2
2
3
3
3
3
Dispensing Edits
Gender
Gender
Gender
Gender
Qty. Limit
Age, Gender
Rider
Age, Rider
Specialty
Specialty
Age, Rider
Specialty
35
Drug Name
promethazine
PROMETIUM
PROMISEB COMPLETE
PRONESTYL
PRONESTYL SR
propafenone
propafernone hcl
propafernone hcl er
PROPINE
PROPLEX T
propoxyphene
propranolol
propranolol SR
propranolol/HCTZ
propylthiouracil
PROSCAR
PROTECT BONE
PROTECT IRON
PROTECT NATAL
PROTONIX
PROTOPIC
PROTROPIN
PROVENTIL HFA
PROVIGIL
PROZAC
PROZAC WEEKLY
prudoxin
PULMICORT FLEXHALER
PULMICORT RESPULES
PULMOZYNE
PUREFE OB PLUS
PUREFE PLUS
PURINETHOL
PYLERA
pyrazinamide
pyridostigmine
QNASL
quasense
QUESTRAN
quetiaprine fumarate
quinapril
quinaretic
quinerva
quinidine gluconate
quinine sulfate
QUIXIN
QVAR
Copay
Tier
1
2
2
3
3
1
1
1
1
2
1
1
1
1
1
3
3
3
3
3
3
3
3
2
3
3
1
2
2
2
3
3
2
3
1
1
3
1
3
1
1
1
1
1
1
3
2
Dispensing Edits
Gender
Specialty
Qty. Limit
Qty. Limit
Age, Gender
Age, Gender
Age, Gender
Qty. Limit
36
Drug Name
ramipril
RANEXA
ranitidine
RAPAFLO
RAPAMUNE
RAPIFLUX
rauwolfia/bendroflumethazide
Copay
Tier
1
3
1
3
3
3
1
RAVICTI
3
3
3
2
RAZADYNE/RAZADYNE ER
REBETOL
REBIF
REBIF REBIDOSE
reclipsen
RECOMBINATE
RECTIV
REFACTO
RELENZA
RELION - NOT COVERED
RELISTOR
RELPAX
REMERON
REMERON ODT
REMESENSE
REMICADE
RENAGEL
RENVELA
REPREXAIN
REPRONEX
REQUIP
REQUIP XL
REQUIP XL
RESCON JR
RESCRIPTOR
reserpine
RESPA C&C IR
RESTASIS
RESTORIL (7.5MG, 22.5MG)
RETIN-A
RETIN-A MICRO
RETROVIR
REVATIO
REV-EYES
REVLIMID
REYATAZ
REZYST
RHEUMATREX
2
1
3
3
2
3
Dispensing Edits
Age
Specialty
Age, Gender
Specialty
Specialty
X
3
2
3
3
3
3
2
3
3
3
2
2
3
3
2
1
3
2
3
3
3
3
2
2
2
2
3
2
Qty. Limit
Rider
Age
Age
Specialty
37
Drug Name
RHINOCORT AQ
ribasphere
ribavirin
RIDAURA
RIFAMATE
rifampin
RIFATER
RILUTEK
rimantadine
RIMSO
RIOMET
RISPERDAL
RISPERDAL M
risperidone
RITALIN
RITALIN LA
RITALIN SR
rivastigmine tartrate
rizatriptan benzoate
rizatriptan benzoate rapidis
ropinirole hcl
ROSADAN
ROSULA
ROSULA CLK
ROSULA NS
ROSULA/ROSULA CLK/ROSULA NS
ROWASA enema
ROXICET
ROZEREM
RYTHMOL
RYTHMOL SR
RYZOLT
SAFYRAL
SAIZEN
SALAGEN
SALICYLIC ACID
salsalate
SALVAX DUO PLUS FOAM
SANCTURA
SANCTURA XR
SANDIMMUNE
SANDOSTATIN
SAPHRIS
SARAFEM
SAVELLA
SE BPO CLEANSER
SE BPO WASH
Copay
Tier
3
1
1
2
3
1
3
2
1
2
3
3
2
1
3
3
3
1
1
1
1
3
3
3
3
3
2
3
3
3
3
3
3
3
3
2
1
3
3
3
3
3
3
3
3
3
3
Dispensing Edits
Specialty
Specialty
Qty. Limit
Qty. Limit
Qty. Limit
Qty. Limit
Qty. Limit
Specialty
Specialty
38
Drug Name
SEASONALE
SEASONIQUE
SECONAL
SECTRAL
selegiline
selenium sulfide
selfemra
SELZENTRY
SEMPREX-D
SENSIPAR
SEREVENT DISKUS
SEROQUEL
SEROQUEL XR
SEROSTIM
sertraline
SILENOR
silver sulfadiazine
SILVRSTAT
SIMCOR
simvastatin
SINEMET
SINEMET CR
SINGULAIR
SINGULAIR (10mg tab, 4mg, 5mg chew)
SKELAXIN
SKELID
SKLICE
SMZ/TMP
sod. Sulfacetamide/sulfur
SODIUM SULFACETAMIDE-SULFUR GEL
SOLARAZE
solia
SOLODYN
SOMATULINE
SOMAVERT
SONATA
SORIATANE
SORILUX
sorine
sotalol
sotalol AF
SPECTRACEF
SPIRIVA
spironolactone
spironolactone/HCTZ
SPORANOX
sprintec
Copay
Tier
3
3
2
3
1
1
1
2
3
2
2
3
2
3
1
3
1
3
3
1
3
3
2
3
3
2
3
1
1
3
3
1
3
3
3
3
3
3
1
1
1
2
2
1
1
3
1
Dispensing Edits
Age, Gender
Age, Gender
Qty. Limit
Qty. Limit
Age, Gender
Specialty
Prior Auth
Age, Gender
39
Drug Name
SPRIX
SPRYCEL
sronyx
STAFLEX
STAGESIC
STALEVO
STARLIX
STATUSS GREEN
STAXYN
STELARA
STIMATE
STIVARGA
STRATTERA
STRIANT
STRIBILID
SUBOXONE
SUBOXONE Film
SUBSYS
SUBUTEX
SUCRAID
sucralafate
SULAR
sulfacetamide sod
sulfacetamide sod
sulfacetamide sod./sulfur susp
sulfacetamide sod/sulfar/urea
sulfacetamide sodium
sulfacetamide sodium/prednisolone
SULFACETAMIDE SODIUM-SULFUR
SULFACET-R
sulfacet-sulf in urea emul & Sunscreen Cr kit
sulfadiazine
sulfasalazine
sulfasalazine ER
sulfazine
sulfazine EC
sulfisoxazole
sulindac
SUMADAN
SUMADIN, SUMADIN CO
sumatriptan inj
sumatriptan nasal spray
sumatriptan tab
SUMAVEL
SUMAXIN
SUPRAX
SUPRENZA ODT
Copay
Tier
3
2
1
3
3
2
3
3
3
3
2
3
3
2
3
3
2
3
3
2
1
3
1
1
1
1
1
1
1
3
1
1
1
1
1
1
1
1
3
3
1
1
1
3
3
3
3
Dispensing Edits
Age, Gender
Qty. Limit
Specialty
Age
Preclusive Edit
Qty. Limit
Qty. Limit
Qty. Limit
Qty. Limit
40
Drug Name
SURPREP
SUSTIVA
SUTENT
SYLATRON
SYLATRON PK
SYMBICORT
SYMBYAX
SYMETREL
SYMLIN
SYNAGIS
SYNALAR
SYNALGOS DC
SYNERA
SYNTEST DS/HS
SYNTHROID
TACHOSIL
TAGAMET
TAGRETIN
TALACEN
TALCONEX
TALWIN NX
TAMBOCOR
TAMIFLU
tamoxifen
tamsulosin hcl
TAPAZOLE
TARCEVA
TARGRETIN
TARKA
TASIGNA
TASMAR
TAZORAC
taztia XT
tebamide
TEGRETOL
TEGRETOL XL
TEKAMLO
TEKEURNA/TEKTURNA HCT
temazepam
temazepam (7.5MG, 22.5MG)
TEMODAR
temozolomide
TENEX
tenitoin 10mg
TENORETIC
TENORMIN
TERAZOL
Copay
Tier
2
2
2
3
2
2
3
3
3
2
3
3
3
3
3
3
3
3
2
3
2
2
3
1
1
2
2
2
3
2
2
2
1
1
3
3
2
2
1
3
2
1
3
1
3
3
3
Dispensing Edits
Specialty
Prior Auth
Gender
Step Therapy
Specialty
Specialty
Specialty
Gender
41
Drug Name
terazosin
terbinafine
terbutaline
terconazole
TESTIM
TESTOPEL
testosterone enanthate
testosterone enanthate
testoterone propionate
tetracycline
TEVETEN
TEVETEN HCT
TEV-TROPIN
THALITONE
THALOMID
THEO-24
theocap
theochron
theophylline ER
thioridazine
thiothixene
THYROLAR
TIAZAC
ticlopidine
TIKOSYN
TIMOLIDE
timolol
timolol maleate
timolol maleate ophth
TINDAMAX
tioconazole
tizanidine cap
tizanidine tab
TL-SELECT DHA
TOBI
TOBRADEX
TOBRADEX ST
tobramycin
TOFRANIL PM
tolazamide
tolbutabamide
tolmetin sodium
TOPAMAX
topiramate
TOPROL XL
torsemide
TOVIAZ
Copay
Tier
1
1
1
1
2
3
1
1
1
1
3
3
3
3
2
3
1
1
1
1
1
3
3
1
3
3
1
1
1
3
1
3
1
3
1
2
2
1
3
1
1
1
3
1
3
1
2
Dispensing Edits
Gender
Specialty
Gender
Gender
Specialty
42
Drug Name
TOZAL
TRACER BG test strips
TRACLEER
TRACLEER (Eff 12.11.2012)
TRADJENTA
tramadol
tramadol 24 HR TBMP
tramadol er
tramadol/acetaminophen
TRANDATE
trandolapril
tranexamic acid
TRANSDERM-SCOP
tranylcypromine sulfate
TRAVATAN
TRAVATAN Z
trazadone
TRELSTAR
TREXALL
TREXIMET
triamcinolone
triamcinolone acetate nasal spray
triamterene/HCTZ
TRIAZ
triazolam
TRIBENZOR
TRICODE AR
TRICOR
trifluoperazine
trifluridine
TRIGLIDE
triheyphenidyl
TRILEPTAL
TRI-LEVLEN
trilyte
trimethobenzamide
trimethoprim
trimox
trinessa
TRI-NORINYL
TRIPHASIL
triple antibotic
TRIPLIX
tri-previfem
tri-sprintec
TRIVEEN-U
TRI-VITAMIN W/FL
Copay
Tier
3
3
3
2
3
1
3
1
1
3
1
1
2
1
2
2
1
3
2
3
1
1
1
3
1
2
3
3
1
1
3
1
3
3
1
1
1
1
1
3
3
1
3
1
1
3
3
Dispensing Edits
Qty. Limit, Rider
Qty. Limit
Qty. Limit
Qty. Limit
Qty. Limit
Qty. Limit
Qty. Limit
Specialty
Specialty
Qty. Limit
Age, Gender
Age, Gender
Age, Gender
Age, Gender
Age, Gender
Age, Gender
Age, Gender
43
Drug Name
trivora
TRIZIVIR
TROPAZONE
TRUE TRACK test strips
TRUSOPT
TRUVADA
TUDORZA
TUSSIONEX
TWINJECT
TYKERB
TYLENOL/CODEINE
TYLOX
TYVASO
TYZEKA
UCERIS
ULESFIA
ULORIC
ULTRACET
ULTRAM
ULTRAM ER
ULTRASE
ULTRAVATE
ULTRAVATE X
UNIPHYL
UNIRETIC
UNITHROID
UNIVASC
URAMAXIN
URAMAXIN GT
URECHOLINE
URELLE
UREX
URISPAS
UROCIT-K
UROCIT-K
UROGESIC-BLUE
UROXATRAL
URSO
URSO FORTE
ursodiol
ursodiol
UTA
UTAC
VAGIFEM
VAGIFEM Tab
valacyclovir
VALCYTE
Copay
Tier
1
2
3
3
3
2
3
3
2
2
3
3
3
3
2
2
3
3
3
2
3
3
3
3
3
3
3
3
3
3
2
3
2
3
2
3
3
3
1
1
3
3
2
2
1
3
Dispensing Edits
Age, Gender
Qty. Limit, Rider
Qty. Limit
Qty. Limit
Specialty
Qty. Limit
Qty. Limit
Gender
Gender
44
Drug Name
valsartan
valsartan/HCTZ
VALTREX
VALTURNA
vanatrip
vandazole
VANDETANIB
VANOS
VANTIN
VASCEPA
VASCULERA
VASERETIC
VASODILAN
VASOTEC
VAYACOG
VAYARIN
VAYAROL
V-COF
veetids
velivet
VELTIN
VENATAL - FA
VENELEX OIN
venlafaxine
venlafaxine ER caps
venlafaxine OSM 24H
VENTAVIS
VENTOLIN HFA
VEPESID
VERAMYST
verapamil
verapamil 24 HR Pel
verapamil SR/ER/CE/XR
VERDESO
VEREGEN
VERELAN
VERELAN PM
VESANOID
VESICARE
VEXOL
VFEND
V-HIST
VIAGRA
VIBRAMYCIN
VIBRATAB
VICODIN
VICODIN ES
Copay
Tier
1
1
3
2
1
1
3
3
3
3
3
3
3
3
3
3
3
3
1
1
3
3
3
1
1
3
3
2
2
3
1
1
1
3
3
3
3
2
3
2
3
3
2
3
3
3
3
Dispensing Edits
Gender
Specialty
Age, Gender
Specialty
Specialty
Prior Auth
Qty. Limit
45
Drug Name
VICODIN HP
VICOPROFEN
VICTOZA
VICTRELIS
VIDEX
VIDEX EC
VIGAMOX
VIIBRYD
VIMOVO
VIOKASE
VIRACEPT
VIRAMUNE
VIRAMUNE XR
VIRASAL
VIRAZOLE
VIREAD
VIRT-VITE
VISICOL
VITAFOL-ONE
VITAFOL PLUS
VITAMEDMD ONE RX
VIVA CT
VIVELLE/VIVELLE DOT
VOL-NATE
VOL-PLUS
VOL-TAB RX
VOLTAREN
VOLTAREN
VOLTAREN GEL
VOLTAREN XR
VOPAC
VOSPIRE ER
VOTRIENT
VPRIV
VUSION
VYTORIN
VYVANSE
warfarin
WELCHOL
WELLBUTRIN
WELLBUTRIN SR
WELLBUTRIN XL
WESTHROID
XALATAN
XANAX XR
XARELTO (Eff 12/1/11)
XELODA
Copay
Tier
3
3
3
3
3
3
2
3
3
2
2
2
3
3
2
2
3
3
3
3
3
2
3
3
2
3
2
3
3
3
3
3
3
2
3
2
1
2
3
3
3
2
2
3
2
2
Dispensing Edits
Specialty
Age, Qty. Limit
Gender, Qty. Limit
Specialty
Qty. Limit
Qty. Limit
Qty. Limit
46
Drug Name
XERESE
XIAFLEX
XIBROM
XIFAXAN
XODOL
XOLAIR
XOLEGEL
XOPENEX
XOPENEX HFA
XYNTHA
XYREM
XYZAL
YASMIN
YAZ
yohimbine
ZACARE
ZACLIR
zafirlukast
zalepon
ZANAFLEX
ZANTAC
ZANTAC (syrup)
ZARONTIN
ZAROXOLYN
ZAVESCA
zazole
Z-COF I
ZEBETA
ZEGERID
ZEMPLAR
ZEN PEP
ZERIT
ZESTORETIC
ZESTRIL
ZETIA
ZETONNA
ZIAC
ZIAGEN
ZIANA
zidovudine
ZINOTIC/ZINOTIC ES
ziprasidone
ZIRGAN
ZITHROMAX
ZMAX
ZOCOR
ZODERM
Copay
Tier
3
3
3
3
3
3
2
3
3
2
3
3
3
3
1
3
3
1
1
3
3
3
3
3
3
1
3
3
3
2
2
2
3
3
2
3
3
2
3
1
3
1
3
3
3
3
3
Dispensing Edits
Specialty
Age, Prior Auth
Age, Prior Auth
Qty. Limit
Age, Gender
Age, Gender
Qty. Limit
Specialty
Gender
Qty. Limit
47
Drug Name
ZOFRAN
ZOFRAN ODT
ZOLINZA
ZOLOFT
zolpidem
zolpidem tartrate cr
ZOLPIMIST
ZOLVIT
ZOMETA
ZOMIG
ZOMIG ZMT
ZONALON
ZONATUSS
ZONEGRAN
zonisamide
ZORBTIVE
ZORTRESS
ZOTEX-PE, EX, D
zovia
ZOVIRAX
ZOVIRAX (topical)
Z-PRAM
ZPREXA
ZULPLENZ
ZUTRIPRO
ZYDONE
ZYFLO/ZYFLO CR
ZYLET
ZYMAR
ZYPRAM
ZYPREXA
ZYPREXA ZYDIS
ZYTAZE
ZYTIGA
ZYVOX
Copay
Tier
3
3
2
3
1
1
3
2
3
3
3
3
3
3
1
3
3
3
1
3
2
3
2
3
3
3
3
3
2
3
3
3
2
3
3
Dispensing Edits
Qty. Limit
Qty. Limit
Specialty
Qty. Limit
Qty. Limit
Specialty
Age, Gender
Qty. Limit
Specialty
Prior Auth
48
Therapeutic Preferred Drug List
Therapeutic Class
Antineoplastic
Agents
Therapeutic
Class II
Adrenal Steroid
Inhibitors
Alkylating
Agents
Anti-Androgenic
Agent
Antimetabolites
Antineoplastic
Enzyme Inhibitor
Antineoplastic
Hormonal
Agents
Drug Name
Co-pay
Tier
Dispensing Edits
CYTADREN
3
(blank)
ALKERAN
CEENU
cyclophosphamide
HEXALEN
LEUKERAN
MYLERAN
TEMODAR
temozolomide
2
2
1
2
2
2
2
1
(blank)
Specialty
(blank)
Specialty
(blank)
Specialty
Specialty
(blank)
ZYTIGA
mercaptopurine
methotrexate
OFORTA
PURINETHOL
TREXALL
XELODA
3
1
1
3
2
2
2
Specialty
Specialty
(blank)
(blank)
Specialty
GLEEVEC
IRESSA
NEXAVAR
SPRYCEL
SUTENT
TARCEVA
TASIGNA
VANDETANIB
2
2
2
2
2
2
2
3
Specialty
Specialty
Specialty
Specialty
Specialty
anastrozole
ARIMIDEX
AROMASIN
bicalutamide
CASODEX
DEPO-PROVERA
EMCYT
EULEXIN
exemestane
FARSETON
FEMARA
flutamide
letrozole
1
3
3
1
2
2
2
2
1
2
3
1
1
(blank)
Specialty
(blank)
Specialty
(blank)
Specialty
Specialty
leuprolide
LUPRON
LUPRON DEPOT
1
3
3
Specialty
(blank)
Specialty
(blank)
(blank)
Specialty
Specialty
49
Therapeutic Class
Therapeutic
Class II
Antineoplastic,
System Enzyme
Inh
Hedgehog
Pathway Inh
Immunomodulat
ors
JAK Inh
LHRH(GNRH)
Agonist
Miotic Inhibitors
Miscellaneous
Mtor Kinase
Inhibitor
SERM
Skin and
Mucous
Membrane
Systemic
Enzyme Inh
Blood Products
Anticoagulant
Drug Name
LYSORDREN
MEGACE
MEGACE ES
megestrol
NILANDRON
tamoxifen
Co-pay
Tier
2
3
3
1
2
1
Dispensing Edits
Specialty
(blank)
(blank)
(blank)
(blank)
(blank)
ICLUSIG
3
Specialty
ERIVEDGE
3
Specialty
REVLIMID
THALOMID
JAKAFI
2
2
3
Specialty
Specialty
(blank)
FIRMAGON
TRELSTAR
etoposide
VEPESID
ACTIMMUNE
HYDREA
hydroxyurea
INTRON-A
leucovorin calcium
MATULANE
MESNEX
TARGRETIN
tenitoin 10mg
TYKERB
VESANOID
ZOLINZA
2
3
1
2
2
3
1
2
1
2
2
2
1
2
2
2
Specialty
Specialty
Specialty
Specialty
Specialty
(blank)
(blank)
(blank)
(blank)
(blank)
Specialty
(blank)
Specialty
Specialty
Specialty
AFINITOR
FASLODEX
3
2
Specialty
METVIXIA
3
Specialty
INLYTA
STIVARGA
VOTRIENT
ARIXTRA
COUMADIN
enoxaparin
fondaparinux
FRAGMIN
heparin
3
3
3
3
3
1
2
2
1
Specialty
Specialty
(blank)
Qty. Limit
Qty. Limit
Qty. Limit
50
Therapeutic Class
Therapeutic
Class II
Antiinhibitor
Coagulant Cplx
Blood Plasma
FACTOR
Factor IX
Complex
Factor IX Non
Recombinant
Factor IX
Recombinant
Factor VIIa
Factor VIII
Human
Factor VIII
Recombinant
Gauchers
Disease
Hematopoetic
Growth Factor
Platlet
Aggregation
Inhibitor
Drug Name
INNOHEP
LOVENOX
warfarin
Co-pay
Tier
2
3
1
Dispensing Edits
Qty. Limit
Qty. Limit
(blank)
FEIBA VH IMMUNO
TACHOSIL
XYNTHA
2
3
2
Specialty
(blank)
BEBULIN VH
PROPLEX T
2
2
Specialty
Specialty
ALPHANINE SD
MONONINE
PROFILNINE
2
3
2
Specialty
Specialty
Specialty
BENEFIX
NOVOSEVEN
3
2
Specialty
Specialty
ALPHANATE
HEMOFIL M
HUMATE-P
KOATE-DVI
MONARC-M
MONOCLATE-P
2
2
2
3
2
2
Specialty
Specialty
Specialty
Specialty
Specialty
Specialty
ADVATE
HELIXATE FS
KOGENATE FS
KOGENATE FS IV
RECOMBINATE
REFACTO
2
3
3
3
3
2
Specialty
Specialty
Specialty
Specialty
Specialty
Specialty
ZAVESCA
3
Specialty
ARANESP
EPOGEN
LEUKINE
NEULASTA
NEUPOGEN
PROCRIT
2
2
2
2
2
2
Specialty
Specialty
Specialty
Specialty
Specialty
Specialty
AGGRENOX
AGRYLIN
anagrelide
cilostazol
clopidogrel bisulfate
dypridamole
2
2
1
1
1
1
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
51
Therapeutic Class
Therapeutic
Class II
Cardiovascular
Lipotropics
Cardiovascular
System
ACE Inhibitors
and Combos
Agiotensin
Recep Antag
Alpha-Beta
Drug Name
PERSANTINE
PLAVIX
PLAVIX (Eff
6/1/2012)
PLETAL
ticlopidine
VASCEPA
Co-pay
Tier
3
2
Dispensing Edits
(blank)
(blank)
3
2
1
3
(blank)
(blank)
(blank)
(blank)
ACCUPRIL
ACCURETIC
ACEON
ALTACE
benazepril
benazepril/HCTZ
CAPOTEN
CAPOZIDE
captopril
captorpril/HCTZ
enalapril
enalapril/HCTZ
fosinapril
fosinapril/HCTZ
lisinopril
lisinopril/HCTZ
LOTENSIN
LOTENSIN HCT
MAVIK
moexipril
moexipril/HCTZ
PRINIVIL
PRINZIDE
quinapril
quinaretic
ramipril
trandolapril
UNIRETIC
UNIVASC
VASERETIC
VASOTEC
ZESTORETIC
ZESTRIL
3
3
3
3
1
1
3
3
1
1
1
1
1
1
1
1
3
3
3
1
1
1
3
3
1
1
1
1
3
3
3
3
3
3
Qty. Limit
Qty. Limit
(blank)
Age, Qty. Limit
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
Age
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
losartan
losartan/hctz
carvidilol
1
1
1
(blank)
(blank)
(blank)
52
Therapeutic Class
Therapeutic
Class II
Blockers
Anaphalaxis
Therapy Agents
Anthyperlipidemi
c
Antiadrenergic
Antihypertensive
s
Antianginal Nitrates
Drug Name
Co-pay
Tier
Dispensing Edits
COREG
COREG CR
labatelol
TRANDATE
3
3
1
3
(blank)
(blank)
(blank)
(blank)
AUVI-Q
epinephrine
EPIPEN
EPIPEN-JR
TWINJECT
2
1
2
2
2
(blank)
(blank)
(blank)
(blank)
Qty. Limit
KYNAMRO
3
CARDURA
CARDURA XL
CATAPRES
CATAPRES-TTS
clonidine
clonidine patch
doxazosin
guanabenz
guanfacine
HYTRIN
methyldopa
MINIPRESS
prazosin
reserpine
TENEX
terazosin
3
3
3
3
1
1
1
1
1
3
1
3
1
1
3
1
(blank)
Qty. Limit
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
amyl nitrate
DILATRATE SR
IMDUR
ISMO
ISORDIL
isosorbide dinitrate
isosorbide
mononitrate
MONOKET
NITROBID
NITRO-DUR
nitroglycerin
nitroglycerin SL
nitroglycerin SR
NITROLINGUAL
1
3
3
3
3
1
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
1
3
3
3
1
1
1
2
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
53
Therapeutic Class
Therapeutic
Class II
Antianginal Other
Antiarrhythmic
Type 1-A
Antiarrhythmic
Type 1-B
Antiarrhythmic
Type 1-C
Antiarrhythmic
Type III
Anticoagulant
Antihyperlipidemi
c - Bile
Sequestrants
Antihyperlipidemi
c - Fibric Acid
Derivative
Drug Name
NITROSTAT
nitro-transdermal
Co-pay
Tier
2
1
Dispensing Edits
(blank)
(blank)
RANEXA
3
(blank)
disopyramide
guinidine sulfate
NORPACE
procainamide
procainamide ER
PRONESTYL
PRONESTYL SR
quinidine gluconate
1
1
3
1
1
3
3
1
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
mexiletine
1
(blank)
flecanide
propafenone
propafernone hcl
propafernone hcl er
RYTHMOL
RYTHMOL SR
TAMBOCOR
1
1
1
1
3
3
2
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
amiodarone
CORDARONE
PACERONE
TIKOSYN
EFFIENT
PRADAXA
XARELTO (Eff
12/1/11)
1
3
3
3
2
2
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
2
(blank)
cholestyramine
COLESTID
colestipol
prevalite
QUESTRAN
WELCHOL
1
3
1
1
3
2
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
ANTARA
fenofibrate
FENOGLIDE
gemfibrozil
LIPOFEN
LOFIBRA
3
1
3
1
3
3
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
54
Therapeutic Class
Therapeutic
Class II
Antihyperlipidemi
c - HMG CoA
Reductase Inh
Antihyperlipidemi
c - HMG CoA
Reductase Inh
combo
Antihyperlipidemi
c - Intestinal
Cholesterol
Absorp. Inh
Antihyperlipidemi
c - Other
ARB and
Combos
Drug Name
LOPID
TRICOR
TRIGLIDE
TRIPLIX
Co-pay
Tier
3
3
3
3
Dispensing Edits
(blank)
(blank)
(blank)
(blank)
3
3
Qty. Limit
Qty. Limit
1
Qty. Limit
3
2
3
3
2
(blank)
Qty. Limit
(blank)
Qty. Limit
Qty. Limit
Qty. Limit
3
3
1
3
3
1
3
1
3
3
Qty. Limit
Qty. Limit
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
Qty. Limit
(blank)
atorvastatin/amlodipin
e
1
Qty. Limit
ZETIA
2
(blank)
LOVAZA
NIASPAN
3
2
(blank)
(blank)
amlodipine/valsartan
amlodipine/valsartan/
hctz
ATACAND
ATACAND HCT
AVALIDE
AVAPRO
AZOR
AZOR (8/1/11)
1
(blank)
1
3
3
3
3
3
2
(blank)
Qty. Limit
Qty. Limit
Qty. Limit
Qty. Limit
(blank)
(blank)
ADVICOR
ALTOPREV
atorvastatin (Eff
12/1/2011)
CADUET (Eff
1/15/12)
CRESTOR
fluvastatin sod
LESCOL
LESCOL XL
LIPITOR
LIPITOR (Eff
12/1/2011)
LIVOLO
lovastatin
MEVACOR
PRAVACHOL
pravastatin
SIMCOR
simvastatin
VYTORIN
ZOCOR
(blank)
55
Therapeutic Class
Therapeutic
Class II
Beta Blocker
Cardioselective
& Combos
Drug Name
BENICAR
BENICAR HCT
COZAAR
DIOVAN
DIOVAN HCT
EDARBI
eprosartan mesylate
EXFORGE,
EXFORGE HCT
HYZAAR
irbesartan
irbesartan/HCTZ
losartan
losartan/hctz
MICARDIS
MICARDIS HCT
TEVETEN
TEVETEN HCT
valsartan
valsartan/HCTZ
VALTURNA
acebutolol
atenolol
atenolol/chlorthalidon
e
BETAPACE
BETAPACE AF
betaxolol
bisoprolol fumarate
bisoprolol/HCTZ
BYSTOLIC
CORGARD
KERLONE
LOPRESSOR
LOPRESSOR HCT
metoprolol succinate
SR
metoprolol tartrate
SECTRAL
TENORETIC
TENORMIN
TOPROL XL
ZEBETA
ZIAC
Co-pay
Tier
2
2
3
3
3
3
1
Dispensing Edits
Qty. Limit
Qty. Limit
Qty. Limit
(blank)
Qty. Limit
(blank)
(blank)
3
3
1
1
1
1
3
3
3
3
1
1
2
(blank)
(blank)
Qty. Limit
Qty. Limit
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
1
1
(blank)
(blank)
1
3
3
1
1
1
3
3
3
3
3
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
Qty. Limit
(blank)
(blank)
(blank)
(blank)
1
1
3
3
3
3
3
3
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
56
Therapeutic Class
Therapeutic
Class II
Beta Blocker
Non-Selective &
Combos
Calcium Channel
Blocker
Drug Name
Co-pay
Tier
Dispensing Edits
CORZIDE
INDERAL
INDERAL LA
INDERIDE
INNOPRAN XL
LEVATOL
metoprolol/HCTZ
nadolol
nadolol/bendroflumet
hiazide
pindolol
propranolol
propranolol SR
propranolol/HCTZ
sorine
sotalol
sotalol AF
TIMOLIDE
timolol maleate
3
3
3
3
3
3
1
1
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
1
1
1
1
1
1
1
1
3
1
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
ADALAT CC
afeditab
amlodipine
CALAN
CALAN SR
CARDENE
CARDENE SR
CARDIZEM
CARDIZEM CD
CARDIZEM LA
cartia XL
COVERA-HS
DILACOR XR
diltia XT
diltiazem
diltiazem CD/ER/XT
diltiazem SR
DYNACIRC CR
felodipine
ISOPTIN SR
isradipine
nicardipine
nifedical CC
nifedical XL
nifedipine
3
1
1
3
3
3
3
3
3
3
1
3
3
1
1
1
1
3
1
3
1
1
1
1
1
Qty. Limit
Qty. Limit
Qty. Limit
Qty. Limit
Qty. Limit
(blank)
(blank)
(blank)
Qty. Limit
Qty. Limit
Qty. Limit
Qty. Limit
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
57
Therapeutic Class
Therapeutic
Class II
Cardiac
Glycoside
CCB Combo
CombinationsMisc
Direct Renin
Inhibitor
Diuretic Carbonic
Anhydrase Inh
Diuretic - Loop
Drug Name
nifedipine CR/ER/SR
nimodipine
NIMOTOP
nisolpidine er
NORVASC
PLENDIL
PROCARDIA
PROCARDIA XL
SULAR
taztia XT
TIAZAC
verapamil
verapamil 24 HR Pel
verapamil
SR/ER/CE/XR
VERELAN
VERELAN PM
digitek
digoxin
LANOXICAP
LANOXIN
AMTURNIDE (Eff
7/1/11)
TEKAMLO
amlodipine
besy/benazepril
amlodipine/benazepril
BIDIL
CLORPRES
hydralazine/HCTZ
LOTREL
methyldopa/HCTZ
rauwolfia/bendroflum
ethazide
TARKA
TEKEURNA/TEKTUR
NA HCT
acetazolamide
DIAMOX
methazolamide
bumetanide
BUMEX
DEMADEX
EDECRIN
furosemide
Co-pay
Tier
1
1
3
1
3
3
3
3
3
1
3
1
1
Dispensing Edits
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
1
3
3
(blank)
(blank)
(blank)
1
1
3
3
(blank)
(blank)
(blank)
(blank)
2
2
Qty. Limit
(blank)
1
1
2
3
1
3
1
(blank)
Qty. Limit
(blank)
(blank)
(blank)
(blank)
(blank)
1
3
(blank)
(blank)
2
(blank)
1
3
1
1
3
3
3
1
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
58
Therapeutic Class
Therapeutic
Class II
Diuretic Potassium
Sparing &
Combos
Diuretic - SARAs
Diuretic Thiazide/Thiazid
e Like
DPP4 Combo
Hemorreologic
Agents
Lipotropic
PAH
Pheochromocyto
ma
Platlet
Aggregation
Inhibitor
Potassium
Replacement
Pulmonary
Hypertension
Drug Name
LASIX
torsemide
Co-pay
Tier
3
1
Dispensing Edits
(blank)
(blank)
ALDACTAZIDE
ALDACTAZIDE 50/50
ALDACTONE
amiloride
amiloride/HCTZ
DYAZIDE
DYRENIUM
MAXZIDE
spironolactone
spironolactone/HCTZ
triamterene/HCTZ
INSPRA
3
3
3
1
1
3
2
3
1
1
1
2
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
chlorthalidone
chlorthiazide
DIURIL
hydrochlorothiazide
(HTCZ)
indapamide
methychlorthiazide
metolazone
MICROZIDE
NATURETIN
THALITONE
ZAROXOLYN
JUVISYNC
1
1
3
(blank)
(blank)
(blank)
1
1
1
1
3
3
3
3
3
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
pentoxifylline
OMACOR
ADCIRCA
1
3
3
(blank)
(blank)
Prior Auth
DEMSER
DIBENZYLINE
3
2
(blank)
(blank)
BRILINTA
3
Prior Auth
potassium chloride
1
(blank)
LETAIRIS
REVATIO
TRACLEER (Eff
2
2
(blank)
2
12.11.2012)
59
Therapeutic Class
Therapeutic
Class II
Sympatholytic
Thrombin Inh
Vasodilators
Central Nervous
System
ADD/ADHD
ALS Agent
Analgesic
Analgesic Narcotic
Analgesic/Antyp
yretic
Anorexiant
Antianxiety Benzodiazepines
Antianxiety Misc
Anticonvulsant
Drug Name
TYVASO
VENTAVIS
NEXICLON XR
IPRIVASK
hydralazine
isoxuprine
minoxidyl
papaverine ER
VASODILAN
Co-pay
Tier
3
3
3
3
1
1
1
1
3
Dispensing Edits
(blank)
(blank)
(blank)
Specialty
(blank)
(blank)
(blank)
(blank)
(blank)
INTUNIV
KAPVAY
RILUTEK
RELISTOR
3
3
2
3
(blank)
(blank)
Specialty
(blank)
BUTRANS
COCET Plus
CONZIP
EXALGO
hydrocodone
bit/APAP
ONSOLIS
ZOLVIT
3
3
3
3
(blank)
(blank)
(blank)
(blank)
1
3
2
(blank)
(blank)
(blank)
SALAGEN
SUPRENZA ODT
3
3
(blank)
(blank)
alprazolam
alprazolam ER
alprazolam rapidis
chlordiazepoxide
clorazepate
diazepam
lorazepam
NIRAVAM
oxazepam
XANAX XR
1
1
1
1
1
1
1
3
1
3
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
buspirone
hydroxyne pamoate
hydroxyzine hcl
meprobamate
FANATREX
ONFI
OXTELLAR XR
POTIGA
1
1
1
1
3
3
3
3
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
60
Therapeutic Class
Therapeutic
Class II
Anticonvulsants Benzodiapines
Anticonvulsants Carbamates
Anticonvulsants GABA Modulator
Anticonvulsants Hydantoin
Anticonvulsants Misc
Anticonvulsants Succinamide
Anticonvulsants Valpric Acid
Drug Name
Co-pay
Tier
Dispensing Edits
clonazepam
clonazepam disintigrating tab
DIASTAT
KLONOPIN
KLONOPIN WAFER
1
(blank)
1
2
3
3
(blank)
(blank)
(blank)
(blank)
felbamate
FELBATOL
FELBATOL (4/1/12)
1
2
3
(blank)
(blank)
(blank)
GABITRIL
3
(blank)
phenytoin extended
phenytoin sodium
1
1
(blank)
(blank)
carbamazapine xl
carbamazepine
gabapentin
GABARONE
KEPPRA
KEPPRA XR
LAMICTAL
LAMICTAL XR
lamotrigine
lamotrigine XR
levetiracetam
levetiracetam ER
LYRICA
NEURONTIN
oxcarbazepine
primidone
TEGRETOL
TEGRETOL XL
TOPAMAX
topiramate
TRILEPTAL
ZONEGRAN
zonisamide
1
1
1
3
3
3
3
3
1
1
1
1
2
3
1
1
3
3
3
1
3
3
1
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
CELONTIN
ethosuximide
ZARONTIN
2
1
3
(blank)
(blank)
(blank)
DEPAKOTE
DEPAKOTE ER
3
3
(blank)
(blank)
61
Therapeutic Class
Therapeutic
Class II
Antidementia Alzheimers Dx
Antidepressant Alpha 2
Receptor
Agonist
Antidepressant MAO Inhibitor
Antidepressant Misc
Antidepressant SNRI
Drug Name
DEPAKOTE
SPRINKLE
divalproex sodium
DR
divalproex sodium ER
divalproex sodium
sprinkle
divalproex sodium SR
ARICEPT/ARICEPT
ODT
donepezil hcl
EXELON
galantamine hbr
NAMENDA
RAZADYNE/RAZAD
YNE ER
rivastigmine tartrate
Co-pay
Tier
Dispensing Edits
3
(blank)
1
1
(blank)
(blank)
1
1
(blank)
(blank)
3
1
3
1
2
(blank)
(blank)
(blank)
(blank)
(blank)
3
1
(blank)
(blank)
mirtazapine
mirtazapine ODT
REMERON
REMERON ODT
1
3
3
3
(blank)
(blank)
(blank)
(blank)
EMSAM
MARPLAN
NARDIL
PARNATE
phenelzine sulfate
tranylcypromine
sulfate
2
2
3
3
1
(blank)
(blank)
(blank)
(blank)
(blank)
1
(blank)
budeprion
budeprion XL
bupropion
bupropion SR
marprotaline
nefazodone
trazadone
WELLBUTRIN
WELLBUTRIN SR
WELLBUTRIN XL
1
1
1
1
1
1
1
3
3
3
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
CYMBALTA
EFFEXOR
EFFEXOR XR
PRISTIQ
3
3
3
2
(blank)
(blank)
(blank)
(blank)
62
Therapeutic Class
Therapeutic
Class II
Antidepressant SSRI
Antidepressant Tricyclic Agent
Antidepressante
- Tricyclic Agent
Antiemetic
Antiparkinson
Antiparkinson Anticholinergic
Antiparkinson COMT Inh
Antiparkinson Dopaminergic
Drug Name
venlafaxine
venlafaxine ER caps
venlafaxine OSM 24H
Co-pay
Tier
1
1
3
Dispensing Edits
(blank)
(blank)
(blank)
CELEXA
citalopram
escitalopram oxalate
fluoxetine
fluvoxamine
LEXAPRO
LUVOX CR
paroxetine
paroxetine CR/ER
PAXIL
PAXIL CR
PEXEVA
PROZAC
PROZAC WEEKLY
RAPIFLUX
sertraline
ZOLOFT
3
1
1
1
1
3
3
1
1
3
3
3
3
3
3
1
3
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
amitriptyline
amoxapine
clomipramine
desipramine
doxepin hcl
imipramine hcl
imipramine pm
nortriptyline
TOFRANIL PM
vanatrip
1
1
1
1
1
1
1
1
3
1
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
OLEPTRO ER
promethazine
NEUPRO
(Transdermal)
3
1
(blank)
(blank)
3
(blank)
AKINETON
benztropine
COGENTIN
triheyphenidyl
2
1
3
1
(blank)
(blank)
(blank)
(blank)
COMTAN
TASMAR
2
2
(blank)
(blank)
amantadine
1
(blank)
63
Therapeutic Class
Therapeutic
Class II
Antiparkinson Monoamine
Oxidase Inh
Antiparkinsonism
Antiparkison
Adjuncts
Antipsychotic Atyptical
Drug Name
APOKYN
bromocriptine
carbidopa/levodopa
carbidopa/levodopa
rapidis
carbidopa/levodopa
SR
MIRAPEX
PARCOPA
PARLODEL
pramipexole di-hcl
REQUIP
REQUIP XL
ropinirole hcl
SINEMET
SINEMET CR
STALEVO
SYMETREL
Co-pay
Tier
2
1
1
Dispensing Edits
Specialty
(blank)
(blank)
1
(blank)
1
3
2
3
1
2
2
1
3
3
2
3
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
AZILECT
ELDEPRYL
selegiline
REQUIP XL
2
2
1
3
(blank)
(blank)
(blank)
(blank)
LODOSYN
2
(blank)
ABILIFY
ABILIFY DISC
clozapine
CLOZARIL
FANAPT
FAZACLO
GEODON
INVEGA
olanzapine
olanzapine zydis
quetiaprine fumarate
RISPERDAL
RISPERDAL M
risperidone
SAPHRIS
SEROQUEL
SEROQUEL XR
ziprasidone
ZPREXA
ZYPREXA
2
2
1
3
3
3
3
3
1
1
1
3
2
1
3
3
2
1
2
3
(blank)
(blank)
(blank)
(blank)
Prior Auth
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
64
Therapeutic Class
Therapeutic
Class II
Antipsychotic Combo
Antipsychotics
Atypical
Antispychotic
Chemical
Dependency
Fibromyalgia
Lithium
Migraine Agents
Drug Name
ZYPREXA ZYDIS
chlordiazepodide/amit
riptyline
perphenazine/amitript
yline
SYMBYAX
chlorpromazine
compro
EQUETRO
fluphenazine
HALDOL D
haloperidol
INVEGA Syringe
loxapine
perphenazine
prochlorperazine
thioridazine
thiothixene
trifluoperazine
Co-pay
Tier
3
Dispensing Edits
(blank)
1
(blank)
1
3
1
1
3
1
3
1
3
1
1
1
1
1
1
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
Rider
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
LATUDA
3
(blank)
ANTABUSE
CAMPRAL
disulfiram
naltrexone
SAVELLA
lithium carbonate
lithium carbonate CR
lithium citrate
LITHOBID
AMERGE
AXERT
FROVA
frovatriptan succinate
IMITREX
MAXALT
MAXALT MLT
MIGRANAL
naratriptan
RELPAX
rapidis
sumatriptan inj
sumatriptan nasal
spray
3
3
1
1
3
1
1
1
3
3
3
3
1
3
3
3
2
1
2
1
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
Qty. Limit
Qty. Limit
Qty. Limit
Qty. Limit
(blank)
Qty. Limit
Qty. Limit
Qty. Limit
Qty. Limit
Qty. Limit
Qty. Limit
1
1
Qty. Limit
Qty. Limit
1
Qty. Limit
65
Therapeutic Class
Therapeutic
Class II
Movement
Disorder
Multiple
Sclerosis
Muscle
Relaxants and
Combinations
Narcotic Combo
Drug Name
sumatriptan tab
SUMAVEL
TREXIMET
ZOMIG
ZOMIG ZMT
Co-pay
Tier
1
3
3
3
3
Dispensing Edits
Qty. Limit
Qty. Limit
Qty. Limit
Qty. Limit
Qty. Limit
HORIZANT
3
(blank)
AUBAGIO
AVONEX
AVONEX PEN
BETASERON
COPAXONE
EXTAVIA
GILENYA
REBIF
REBIF REBIDOSE
3
2
2
3
2
3
3
2
2
LORZONE
metaxalone
acetaminophen/codei
ne
aspirin/codeine
butalbital/APAP/caffei
ne/codeine
butalbital/aspirin/code
ine
CAPITAL/CODEINE
COMBUNOX
FIORICET/CODEINE
FIORINAL/CODEINE
hydrocodone/acetami
nophen
IBUDONE
LORCET
LORCET PLUS
LORTAB
MAGNACET
MAXIDONE
meperidine/prometha
zine
meprozine
NORCO
ORBIVAN
oxycodone/acetamino
phen
oxycodone/aspirin
3
1
(blank)
(blank)
1
1
(blank)
(blank)
1
(blank)
1
3
2
3
3
(blank)
(blank)
(blank)
(blank)
(blank)
1
3
3
3
3
3
3
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
1
1
3
3
(blank)
(blank)
(blank)
(blank)
1
1
(blank)
(blank)
66
Therapeutic Class
Therapeutic
Class II
Narcotic - Partial
Agonist
Narcotic
Agonists
Drug Name
oxycodone/ibuprofen
pentazocine/acetamin
ophen
PERCOCET
PERCODAN
phrenilin/caffeine/cod
eine
PRIMALEV
REPREXAIN
ROXICET
STAFLEX
STAGESIC
SYNALGOS DC
TALACEN
tramadol/acetaminop
hen
TYLENOL/CODEINE
TYLOX
ULTRACET
VICODIN
VICODIN ES
VICODIN HP
VICOPROFEN
VOPAC
XODOL
ZYDONE
bupreenorphine
butorphanol
pentazocine/naltrexo
ne
SUBOXONE
SUBOXONE Film
SUBUTEX
TALWIN NX
ACTIQ
AVINZA
codeine phosphate
codeine sulfate
DAZIDOX
DEMEROL
DILUADID
DURAGESIC
fentanyl citrate
fentanyl citrate
lozenge
fentanyl transdermal
Co-pay
Tier
1
Dispensing Edits
(blank)
1
3
3
(blank)
(blank)
(blank)
1
3
3
3
3
3
3
2
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
1
3
3
3
3
3
3
3
3
3
3
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
1
1
(blank)
1
3
2
3
2
(blank)
(blank)
3
3
1
1
3
3
3
3
1
Qty. Limit
Qty. Limit
(blank)
(blank)
(blank)
(blank)
(blank)
Qty. Limit
(blank)
1
1
Qty. Limit
Qty. Limit
67
Therapeutic Class
Therapeutic
Class II
Narcotic
Analgesic
NDRIS
PMS
Postherpetic
Neuralgia Agent
Pseudobulbar
Affect Agent
Psychotherapeut
ic & Neurological
Agents
Drug Name
fentanyl transmucosal
lozenge
FENTORA
hydromorphone
KADIAN
levorphanol
meperidine
methadose
morphine sulfate
morphine sulfate CR
morphine sulfate ER
Pel
MS CONTIN
OPANA
OPANA ER
ORAMORPH SR
oxycodone
OXYCONTIN CR
OXYCONTIN CR (Eff
4/1/12)
oxyfast
OXYIR
propoxyphene
RYZOLT
tramadol
tramadol 24 HR
TBMP
tramadol er
ULTRAM
ULTRAM ER
Co-pay
Tier
Dispensing Edits
1
3
1
2
1
1
1
1
1
Qty. Limit
(blank)
(blank)
Qty. Limit
(blank)
(blank)
(blank)
(blank)
(blank)
3
3
3
3
3
3
3
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
Qty. Limit
2
1
2
1
3
1
Qty. Limit
(blank)
(blank)
(blank)
Qty. Limit
Qty. Limit
3
1
3
3
Qty.
Qty.
Qty.
Qty.
ABSTRAL
OXECTA
SUBSYS
FORFIVO XL
SARAFEM
selfemra
3
3
3
3
3
1
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
GRALISE
3
(blank)
NUEDEXTA
3
(blank)
ergoloid mesylate
modafinil
NUVIGIL
ORAP
PROVIGIL
1
1
2
2
2
(blank)
(blank)
(blank)
(blank)
(blank)
Limit
Limit
Limit
Limit
68
Therapeutic Class
Therapeutic
Class II
Sedative/Hypnoti
c - Barbiturate
Sedative/Hypnoti
c - NonBarbiturate
SSRI, 5HT1A
Partial Agonist
Stimulants Amphetamines
Stimulants Methylphenidate
Drug Name
STRATTERA
XYREM
Co-pay
Tier
3
3
Dispensing Edits
(blank)
(blank)
BUTISOL SODIUM
MEBARAL
mephobarbital
phenobarbital
RESTORIL (7.5MG,
22.5MG)
SECONAL
temazepam (7.5MG,
22.5MG)
2
3
1
1
(blank)
(blank)
(blank)
(blank)
3
2
(blank)
(blank)
3
(blank)
AMBIEN
AMBIEN CR
chloral hydrate
DORAL
estazolam
INTERMEZZO
LUNESTA
midazolam
ROZEREM
SILENOR
SONATA
temazepam
triazolam
zalepon
zolpidem
zolpidem tartrate cr
3
3
1
2
1
3
3
1
3
3
3
1
1
1
1
1
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
VIIBRYD
3
(blank)
ADDERALL
ADDERALL XR
amphetamine salts
amphetamine salts
ER
DESOXYN
DEXEDRINE
dextroamphetamine
dextroamphetamine
CR
dextrostat
VYVANSE
3
3
1
(blank)
Qty. Limit
(blank)
1
3
3
1
Qty. Limit
(blank)
(blank)
(blank)
1
2
2
Qty. Limit
(blank)
Qty. Limit
CONCERTA
DAYTRANA
2
3
Qty. Limit
69
Therapeutic Class
Dermatology
Therapeutic
Class II
Acne Agents
Drug Name
dexmethylphenidate
FOCALIN
FOCALIN XR
LIQUADD
METADATE CD
METADATE ER
methylin
METHYLIN (Chew.
Soln)
methylin ER
methylphenidate
methylphenidate CD
methylphenidate ER
methylphenidate LA
methylphenidate SR
RITALIN
RITALIN LA
RITALIN SR
ACANYA
ACCUTANE
acita
adapalene
AKNE-MYCIN
amnesteem
ATRALIN
AVAR GREEN
AVAR LS, E
AZELEX
BENZACLIN
BENZAMYCIN
BENZEFOAM
ULTRA
BENZIQ
BENZIQ LS
BENZIQ WASH
benzoyl peroxide
benzoyl peroxide
pads
benzoyl
peroxide/urea
claravis
CLARIFOAM EF
CLEANSE/TREAT
PAD
clindamax
clindamycin
clindamycin foam
Co-pay
Tier
1
3
2
2
3
3
1
Dispensing Edits
(blank)
Qty. Limit
Qty. Limit
Qty. Limit
Qty. Limit
Qty. Limit
(blank)
3
1
1
1
1
1
1
3
3
3
3
3
1
1
2
2
2
3
3
2
3
3
Qty. Limit
Qty. Limit
(blank)
Qty. Limit
Qty. Limit
Qty. Limit
(blank)
Qty. Limit
Qty. Limit
(blank)
(blank)
Prior Auth
(blank)
Age
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
3
2
2
2
1
(blank)
(blank)
(blank)
(blank)
(blank)
1
(blank)
1
1
2
(blank)
Prior Auth
(blank)
3
3
1
1
(blank)
(blank)
(blank)
(blank)
70
Therapeutic Class
Therapeutic
Class II
Anesthetic
Antibacterial
Drug Name
DELOS
DIFFERIN
DUAC
EPIDUO
erythromycin
erythromycin/benzoyl
peroxide
EVOCLIN
INOVA
isotretinoin
KLARON
LAVOCLEN
METROCREAM
METROGEL 1%
ONLY
METROLOTION
metronidazole
NEOBENZ MICRO
NORITATE
NUOX
OSCION
PLEXION (cloth,
emulsion)
PLEXION SCT
PLEXION TS
RETIN-A
RETIN-A MICRO
SE BPO WASH
sod.
Sulfacetamide/sulfur
sulfacetamide sod
SULFACET-R
sulfacet-sulf in urea
emul & Sunscreen Cr
kit
TRIAZ
VELTIN
ZACARE
ZACLIR
ZIANA
ZODERM
CETACAINE KIT,
SPRAY, OINT
CETACAINE LIQ
PLIAGLIS
PONTOCAINE
NORMELGEL AG
Co-pay
Tier
3
3
2
3
1
Dispensing Edits
(blank)
Age
(blank)
(blank)
(blank)
1
3
3
1
3
3
3
(blank)
(blank)
(blank)
Prior Auth
(blank)
(blank)
(blank)
3
3
1
3
2
3
3
(blank)
(blank)
(blank)
Age
(blank)
(blank)
(blank)
2
2
2
3
3
3
(blank)
(blank)
(blank)
Age
Age
(blank)
1
1
3
(blank)
(blank)
(blank)
1
3
3
3
3
3
3
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
3
3
3
3
3
(blank)
(blank)
(blank)
(blank)
(blank)
71
Therapeutic Class
Therapeutic
Class II
Antibiotic Topical
Antifungal
Antifungal
Combo - Topical
Anti-infective
Sulfonamide
Anti-infective
Sulfunamide
Anti-infective,
Sulfonamide
Drug Name
SILVRSTAT
BACTROBAN CR,
OINT
BACTROBAN
NASAL
CENTANY
CLINDACIN PAC
gentamicin
mupirocin
CICLODAN
ciclopirox
ciclopirox gel,
shampoo
CILODAN
CLEANSER
clotrimazole/betamet
hasone
CORTAMAX
ERTACZO
EXELDERM
hydrocortisone/clioqui
nol
hydrocortisone/iodoq
uinol
ketoconazole
KETODAN
LOPROX (Cr., lotion,
susp)
LOPROX (gel,
shampoo)
LOTRISONE
NAFTIN
nystatin
nystatin/triamcinolone
OXISTAT
PENLAC
VUSION
XOLEGEL
Co-pay
Tier
3
Dispensing Edits
(blank)
3
(blank)
3
3
3
1
1
3
1
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
1
(blank)
3
(blank)
1
3
3
3
(blank)
(blank)
(blank)
(blank)
1
(blank)
1
1
3
(blank)
(blank)
(blank)
3
(blank)
3
3
3
1
1
3
3
2
2
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
KETOCON + PLUS
SULFACETAMIDE
SODIUM-SULFUR
3
(blank)
1
(blank)
ROSULA
ROSULA CLK
ROSULA NS
silver sulfadiazine
SUMADIN,
SUMADIN CO
3
3
3
1
(blank)
(blank)
(blank)
(blank)
3
(blank)
72
Therapeutic Class
Therapeutic
Class II
Antineoplastic &
Keratolytics Topical
Antiparasitics
Antipruritics &
Anesthetics Topical
Antipsoriatic
agent
Antiseborrheic
Antiviral Topical
Antiviral/Antiinflammatory
Corticosteroids -
Drug Name
Co-pay
Tier
Dispensing Edits
CARAC
EFUDEX
FLUOROPLEX
fluorouracil
LEVULAN
PANRETIN
SOLARAZE
TAGRETIN
LYCELLE
NATROBA
ULESFIA
3
3
3
1
3
3
3
3
3
2
2
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
doxepin cr
lidocaine
lidocaine/prilocaine
LIDODERM
prudoxin
SYNERA
ZONALON
1
1
1
3
1
3
3
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
anthralin
calcipotriene
DOVONEX
DRITHOCREME HP
DRITHO-SCALP
OXSORALEN-UL
SORIATANE
SORILUX
TAZORAC
CLENIA
EXTINA
OVACE
ROSULA/ROSULA
CLK/ROSULA NS
selenium sulfide
sulfacetamide sod
sulfacetamide
sod/sulfar/urea
1
1
3
3
2
2
3
3
2
3
3
3
(blank)
(blank)
(blank)
(blank)
(blank)
Specialty
Prior Auth
(blank)
(blank)
(blank)
(blank)
(blank)
3
1
1
(blank)
(blank)
(blank)
1
(blank)
DENAVIR
LIDOVIR
ZOVIRAX (topical)
3
2
2
(blank)
(blank)
(blank)
XERESE
alclometasone
3
1
(blank)
(blank)
73
Therapeutic Class
Therapeutic
Class II
Topical
Drug Name
amcinonide
ANAMANTLE HC
betamethasone
valerate
bethamethasone
diprop (augmented)
clobetasol
clobevate
CLOBEX (lotion,
shampoo,)
CLOBEX SPRAY
CLODERM
CORDRAN
DERMATOP
DESONATE
desonide
DESOWEN KIT
desoximetasone
DIPROLENE AF
ELOCON
fluocinolone
acetonide
fluocinonide
fluticasone
halobetasol
propionate
HALOG
Hydrocort/Parmoxn
SKN CLNSR #16
Hydrocort/Pramoxine
hydrocortison
valerate
hydrocortisone
hydrocortisone
acetate
hydrocortisone
butyrate
hydrocortisone/pramo
xine
lacticare/hydrocortiso
ne
LIDAMANTLE HC
lidocaine/hydrocortiso
ne
LUXIQ
mometasone
NUCORT
NUZON
Co-pay
Tier
Dispensing Edits
1
3
(blank)
(blank)
1
(blank)
1
1
1
(blank)
(blank)
(blank)
1
2
1
2
3
3
1
3
1
3
3
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
1
1
1
(blank)
(blank)
(blank)
1
3
(blank)
(blank)
1
1
(blank)
(blank)
1
1
(blank)
(blank)
1
(blank)
1
(blank)
1
(blank)
1
3
(blank)
(blank)
1
3
1
3
3
(blank)
(blank)
(blank)
(blank)
(blank)
74
Therapeutic Class
Therapeutic
Class II
Emollient
Hemorrhoidal
Agent
Hemorrhoidal
Prep
Immunomulating
Agents - Topical
Irritants
Keratolytic
Drug Name
OLUX
OLUX-E
PENNSAID
prednicarbate
SYNALAR
TALCONEX
triamcinolone
ULTRAVATE
ULTRAVATE X
VANOS
VERDESO
ATRAPRO CP
AURSTAT
Emollient Combo #32
EPICREAM
HYLATOPIC P;LUSAURSTAT
HYLATOPIC PLUS
HYLATOPIC,
HYLATOPIC PLUS
PEDIADERM AF,
HC, TA
PROMISEB
COMPLETE
TROPAZONE
ANALPRAM
ADVANCED
Co-pay
Tier
3
3
3
1
3
3
1
3
3
3
3
3
3
1
3
Dispensing Edits
(blank)
(blank)
(blank)
(blank)
(blank)
Step Therapy
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
3
3
(blank)
(blank)
3
(blank)
3
(blank)
2
3
(blank)
(blank)
3
(blank)
PRAM-HCA
3
(blank)
AKDARA
ALDARA
ELIDEL
imiquimod
PROTOPIC
ORTHO-NESIC
ALUVEA
CLEANSE & TREAT
PLUS KIT
DURASAL
KERALYT
PACNEX LP
SALICYLIC ACID
SALVAX DUO PLUS
FOAM
SE BPO CLEANSER
URAMAXIN
URAMAXIN GT
2
3
2
1
3
3
3
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
3
3
3
3
2
(blank)
(blank)
(blank)
(blank)
(blank)
3
3
3
3
(blank)
(blank)
(blank)
(blank)
75
Therapeutic Class
Therapeutic
Class II
Local Anesthetic
Miscellaneous
Nitrate, Rectal
Oral Mucositis
Protectant
Protective
Rosacea
Scabicides
&Pediculicides
Steroid Combo Topical
Sulfonamide
Endocrine
Tetracycline
Wound Healing
Androgen
Drug Name
VIRASAL
BUPIVACAINE HCLNS
VEREGEN
RECTIV
MUGARD
NUVAIL
GENADUR
HYLASE
FINACEA
FINACEA PLUS
ORACEA
ROSADAN
Co-pay
Tier
3
Dispensing Edits
(blank)
3
3
3
2
3
3
3
3
3
3
3
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
EURAX
lindane
permethrin
SKLICE
3
3
1
3
(blank)
(blank)
(blank)
(blank)
DESONIL + PLUS
AVAR E LS
AVAR LS
CLEANSER
SODIUM
SULFACETAMIDESULFUR GEL
sulfacetamide
sod./sulfur susp
SUMADAN
SUMAXIN
MORGIDOX
VENELEX OIN
ANADROL
ANDRODERM
ANDROGEL
AXIRON
fluoxymesterone
FORTESTA
METHITEST
methyltestesterone
nandrolone deconate
STRIANT
TESTIM
TESTOPEL
testosterone
enanthate
testoterone
propionate
3
3
(blank)
(blank)
3
(blank)
3
(blank)
1
3
3
3
3
2
3
2
3
1
3
2
1
1
2
2
3
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
1
(blank)
1
(blank)
76
Therapeutic Class
Therapeutic
Class II
Antidiuretic
Agent
Antihyperglycemi
c-Glucocorticoid
Receptor Blk
Antipsychotic Atyptical
Antithyroid
Contraceptive Oral
Contraceptive Transdermal
Contraceptive Vaginal
Contraceptives Inj
Contraceptives Oral
Drug Name
Co-pay
Tier
Dispensing Edits
DDAVP
desmopressin
MINIRIN
STIMATE
3
1
2
2
Age
Age
Age
Age
KORLYM
3
Specialty
GLYSET
methimazole
propylthiouracil
TAPAZOLE
3
1
1
2
(blank)
(blank)
(blank)
(blank)
NATAZIA
3
(blank)
ORTHO EVRA
2
Age, Gender
NUVARING
3
Age, Gender
DEPO-PROVERA
medroxyprogesterone
3
1
Age, Qty. Limit
Age, Qty. Limit
ALESSE
apri
aranelle
aviane
BEYAZ
BREVICON
camila
cesia
cryselle
CYCLESSA
DEMULEN
DESOGEN
enpresse
errin
ESTROSTEP FE
ETHINYL
ESTRADIOL/DROSP
IRENONE
FEMCON FE
GENERESS DE
jolessa
jolivette
junel
junel FE
kariva
3
1
1
1
3
3
1
1
1
3
3
3
1
1
3
Age,
Age,
Age,
Age,
Age,
Age,
Age,
Age,
Age,
Age,
Age,
Age,
Age,
Age,
Age,
Gender
Gender
Gender
Gender
Gender
Gender
Gender
Gender
Gender
Gender
Gender
Gender
Gender
Gender
Gender
1
3
3
1
1
1
1
1
Age,
Age,
Age,
Age,
Age,
Age,
Age,
Age,
Gender
Gender
Gender
Gender
Gender
Gender
Gender
Gender
77
Therapeutic Class
Therapeutic
Class II
Drug Name
kelnor
leena
lessina
LEVELEN
LEVLITE
levora
LO/OVRAL
LOESTRIN
LOESTRIN FE
LOESTRIN FE 24
low-ogestrel
lutera
LYBREL
microgestin
microgestin FE
MIRCETTE
MODICON 0.5/35
monessa
necon
nora-be
NORDETTE
NORINYL
NOR-QD
nortrel
ocella
ogestrel
ORTHO MICRONOR
ORTHO TRICYCLEN
ORTHO TRICYCLEN LO
ORTHO-CEPT
ORTHO-CYCELN
ORTHO-NOVUM
OVCON
portia
previfem
quasense
reclipsen
SAFYRAL
SEASONALE
SEASONIQUE
solia
sprintec
sronyx
TRI-LEVLEN
Co-pay
Tier
1
1
1
3
3
1
3
3
3
3
1
1
3
1
1
3
3
1
1
1
3
3
3
1
1
1
3
Dispensing Edits
Age, Gender
Age, Gender
Age, Gender
Age, Gender
Age, Gender
Age, Gender
Age, Gender
Age, Gender
Age, Gender
Age, Gender
Age, Gender
Age, Gender
Age, Gender
Age, Gender
Age, Gender
Age, Gender
Age, Gender
Age, Gender
Age, Gender
Age, Gender
Age, Gender
Age, Gender
Age, Gender
Age, Gender
Age, Gender
Age, Gender
Age, Gender
3
Age, Gender
2
3
3
3
3
1
1
1
1
3
3
3
1
1
1
3
Age, Gender
Age, Gender
Age, Gender
Age, Gender
Age, Gender
Age, Gender
Age, Gender
Age, Gender
Age, Gender
(blank)
Age, Gender
Age, Gender
Age, Gender
Age, Gender
Age, Gender
Age, Gender
78
Therapeutic Class
Therapeutic
Class II
Dopamine
Receptor
Agonist
DPP4 Combo
DPP4 Inhbitor
Estrogen/Proges
tin
w/antiminealcort
Estrogens
Estrogens
Combo
Drug Name
trinessa
TRI-NORINYL
TRIPHASIL
tri-previfem
tri-sprintec
trivora
velivet
YASMIN
YAZ
zovia
Co-pay
Tier
1
3
3
1
1
1
1
3
3
1
Dispensing Edits
Age, Gender
Age, Gender
Age, Gender
Age, Gender
Age, Gender
Age, Gender
Age, Gender
Age, Gender
Age, Gender
Age, Gender
3
3
3
Prior Auth
(blank)
(blank)
2
(blank)
ANGELIQ
ALORA
CENESTIN
CLIMARA
DIVIGEL
ELESTRIN
ENJUVIA
ESCLIM
ESTRACE
ESTRADERM
estradiol patch
estradiol tab
ESTRASORB
ESTROGEL
estropipate
EVAMIST
gynodiol
MENEST
MENOSTAR
OGEN
PREMARIN
VAGIFEM Tab
VIVELLE/VIVELLE
DOT
3
3
3
3
3
3
3
3
3
3
1
1
3
2
1
3
1
3
3
3
2
2
(blank)
Gender, Qty. Limit
Gender
Gender
Gender
Gender
Gender
Gender
Gender
Gender
Gender, Qty. Limit
Gender
Gender
Gender
Gender
Gender
Gender
Gender
Gender
Gender
Gender
Gender
2
Gender, Qty. Limit
ACTIVELLA
ACTIVELLA (4/1/11)
ANGELIQ
2
3
3
Gender
Gender
Gender
CYCLOSET
JENTADUETO
KOMBIGLYZE XR
KOMBIGLYZE XR
(8/1/11)
79
Therapeutic Class
Therapeutic
Class II
Fertility Agents
Glucocorticoid
Glucose
Elevating Agents
Growth Hormone
Agents
Drug Name
CLIMARA PRO
WEEKLY
COMBIPATCH
estradiol/norethidrom
e acetate
estradiol-noreth ac
ESTRATEST
ESTRATEST HS
FEMHRT
FEMHRT LOW
DOSE
FEMTRACE
PREFEST
PREMPHASE
PREMPRO
SYNTEST DS/HS
BRAVELLE
CETROTIDE
chorionic
gonadotropin
CLOMID
clomiphene
FOLLISTIM AQ
GONAL-F
GONAL-F RFF
GRANIRELIX
leuprolide
LUPRON
LUVERIS
MENOPUR
novarel
OVIDREL
pergnyl
REPRONEX
UCERIS
Co-pay
Tier
Dispensing Edits
3
2
Gender, Qty. Limit
Gender
1
1
3
3
3
Gender
Gender
Gender
Gender
Gender
3
3
3
2
2
3
2
3
Gender
Gender
Gender
Gender
Gender
Gender
Rider
Rider
1
3
1
3
2
2
3
1
3
3
3
1
3
1
3
Rider
Rider
Rider
Rider
Rider
Rider
Rider
Rider
Rider
Rider
Rider
Rider
Rider
Rider
Rider
(blank)
GLUCAGON
PROCLYCEM
3
2
(blank)
(blank)
EGRIFTA
GENOTROPIN
GEREF
HUMATROPE
INCRELEX
NORDITROPIN
NORDITROPIN AQ
NUTROPIN
3
2
3
3
Prior Auth
(blank)
11/
3
3
2
80
Therapeutic Class
Therapeutic
Class II
Metabolic
Modifiers
Oral
Contraceptive
Oral
Contraceptives
Progestins
Steroids
Steroids
(Glucocorticoids)
Thyroid
Thyroid
Hormones
Drug Name
OMNITROPE
PROTROPIN
SAIZEN
SEROSTIM
SOMAVERT
TEV-TROPIN
ZORBTIVE
Co-pay
Tier
3
3
3
3
3
3
3
Dispensing Edits
ALDURAZYME
BUPHENYL
CARNITOR
CYSTADANE
FABRAZYME
HECTOROL
MYOZYME
ORFADIN
SENSIPAR
SUCRAID
ZEMPLAR
2
2
2
2
2
2
2
2
2
2
2
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
gianvi
1
Age, Gender
LO LOESTRIN FE
MAKENA
medroxyprogesterone
norethindrone acetate
PROMETIUM
fludrocort
3
3
1
1
2
1
(blank)
Gender
Gender
Gender
(blank)
CELESTONE
cortisone AC
dexamethasone
ENTOCORT EC
FLO-PRED
hydrocortisone
methylprednisolone
MILLIPRED
ORAPRED
prednisolone
prednisone
WESTHROID
3
1
1
2
3
1
1
3
3
1
1
2
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
ARMOUR THYROID
BIO-THROID
LEVOTHROID
levothyroxine
LEVOXYL
2
3
3
1
3
(blank)
(blank)
(blank)
(blank)
(blank)
81
Therapeutic Class
Endocrine Diabetes
Therapeutic
Class II
Alpha
Glucosidase Inh
Amylin Analog
Biguanides &
Combo
Diabetic
Supplies
(Requires Plan
Rider)
Drug Name
NATURE_THYROID
SYNTHROID
THYROLAR
UNITHROID
Co-pay
Tier
2
3
3
3
Dispensing Edits
(blank)
(blank)
(blank)
(blank)
acarbose
GLYSET
PRECOSE
SYMLIN
1
2
3
3
(blank)
(blank)
(blank)
Prior Auth
FORTAMET
glipizide/metformin
GLUCOPHAGE
GLUCOPHAGE XR
GLUCOVANCE
GLUMETZA
glyburide/metformin
METAGLIP
metformin
metformin ER 24
(Fortamet®)
metformin XR
RIOMET
3
1
3
3
3
3
1
3
1
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
1
1
3
(blank)
(blank)
(blank)
3
1
3
2
3
Qty.
Qty.
Qty.
Qty.
Qty.
2
Qty. Limit, Rider
2
Qty. Limit, Rider
3
Qty. Limit, Rider
3
Qty. Limit, Rider
3
1
2
Qty. Limit, Rider
Qty. Limit, Rider
Qty. Limit, Rider
2
2
Qty. Limit, Rider
Qty. Limit, Rider
3
3
Qty. Limit, Rider
Qty. Limit, Rider
ACCU CHEK family
of test strips
alcohol swab
BD Insulin Syringes
BD Pen Needles
BIG-STAR
BREEZE 2 Test
Strips
CONTOUR Test
Strips
FAST TAKE test
strips
FREESTYLE LITE
Test Strips
Glucose Test Strips
(all other brands)
insulin syringes
lancets
Novofine Pen
Needles
Novotwist Needles
ONE TOUCH family
of test strips
PRECISION family of
Limit, Rider
Limit, Rider
Limit, Rider
Limit, Rider
Limit, Rider
82
Therapeutic Class
Therapeutic
Class II
DPP4
DPP4 Combo
DPP-4 Inhibitor
DPP-IV Inh
DPP-IV Inh &
Combo
Incretin Mimetic
Agent
Insulin
Meglitinides
Sulfonylureas
TZD & Combo
Drug Name
test strips
TRACER BG test
strips
TRUE TRACK test
strips
NESINA
KAZANO
OSENI
TRIBENZOR
TRADJENTA
ONGLYZA
ONGLYZA (8/1/11)
Co-pay
Tier
Dispensing Edits
3
Qty. Limit, Rider
3
3
3
3
2
3
3
2
Qty. Limit, Rider
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
JANUMET
JANUMET XR
JANUVIA
2
2
2
(blank)
(blank)
(blank)
BYDUREON
BYETTA
VICTOZA
APIDRA
HUMALOG pdts
HUMULIN
LANTUS
LEVEMIR
NOVOLIN
NOVOLOG
RELION - NOT
COVERED
nateglinide
PRANDIN
STARLIX
AMARYL
chlorpropamide
glimepiride
glipizide
glipizide ER/XL
gluburide
glyburide micronized
glycon
tolazamide
tolbutabamide
ACTOPLUS MET
ACTOPLUS MET XR
ACTOS (eff 9/11/12)
AVANDAMET
AVANDARYL
3
2
3
3
2
2
2
2
2
2
(blank)
Qty. Limit
Specialty
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
1
2
3
3
1
1
1
1
1
1
1
1
1
2
3
3
2
2
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
X
83
Therapeutic Class
Gastrointestinal
Therapeutic
Class II
Antidiarrheal
Antiemetic
Antiinflammatory
Anti-nausea
Antispasmotic/A
nticholinergic
Bowel
Evacuants
Chronic
Constipation
Agent
Diagnostic
Diagnostic
Dietary
Supplement
Drug Name
AVANDIA
DUETACT
pioglitazone/glimepiri
de
plioglitazone
FULYZAQ
REZYST
ANZEMET
CESAMET
EMEND
fosaprepitant
granisetron
KYTRIL
maldemar
ondesetron
tebamide
TRANSDERM-SCOP
trimethobenzamide
ZOFRAN
ZOFRAN ODT
ZULPLENZ
Co-pay
Tier
2
3
Dispensing Edits
(blank)
(blank)
1
1
3
3
2
3
3
1
1
3
1
1
1
2
1
3
3
3
(blank)
(blank)
(blank)
(blank)
Qty. Limit
(blank)
(blank)
(blank)
Qty. Limit
Qty. Limit
(blank)
Qty. Limit
(blank)
(blank)
(blank)
Qty. Limit
Qty. Limit
(blank)
Z-PRAM
ZYPRAM
loperamide
3
3
1
(blank)
(blank)
(blank)
CUVPOSA
DONNATAL ELIX
3
3
(blank)
(blank)
COLYTE
GOLYTELY
HALFLYTELY
NULYTELY
OSMOPREP
peg 3350
polyethylene glycol
trilyte
VISICOL
3
3
2
3
2
1
1
1
3
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
AMITIZA
E-Z DISK
DIGIBAR
POLIBAR ORAL
SUSP
3
3
3
(blank)
(blank)
(blank)
3
(blank)
VAYACOG
VAYARIN
3
3
(blank)
(blank)
84
Therapeutic Class
Therapeutic
Class II
Gallstone
Solubilizing
Agent
H. pylori Agent
H-2 Antagonists
H-Pyloria Agent
IBS
Inflammatory
Bowel Agents
Laxative
Laxatives
Miscellaneous
Drug Name
VAYAROL
Co-pay
Tier
3
Dispensing Edits
(blank)
URSO
URSO FORTE
ursodiol
HELIDAC
PREVPAC
PYLERA
AXID
cimetidine
famotidine
nizatidine
PEPCID
ranitidine
TAGAMET
ZANTAC
ZANTAC (syrup)
OMECLAMOX-PAK
LOTRONEX
3
3
1
3
2
3
3
1
1
1
3
1
3
3
3
3
2
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
Qty. Limit
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
APRISO
ASACOL
ASACOL HD
AZULFIDINE ENTAB
AZULFIDINE+A191
balsalazide
CANASA
COLAZAL
DIPENTUM
GIAZO
LIALDA
mesalamine
PENTASA
ROWASA enema
sulfasalazine
sulfasalazine ER
sulfazine
sulfazine EC
PREPOIK
SURPREP
glycolax
KRISTALOSE
lactulose
CARAFATE
GASTROCROM
metoclopramide
3
(blank)
2
3
3
1
2
2
2
3
3
1
2
2
1
1
1
1
3
2
1
3
1
3
2
1
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
85
Therapeutic Class
Therapeutic
Class II
Motility Stimulant
Nausea
NSAID/PPI
Pancreatic
Enzymes
Proton Pump Inh
Rectal Steroids
Tx-Chronic
Inflammatory
Bowel
Genitourinary
System
BPH/Micturition
Cystinosis
Agents
Interstitial
Cystitis Agnes
Overactive
Bladder
Phosphate
Binders
Drug Name
misoprostol
sucralafate
METOZZOLV ODT
ZOLPIMIST
VIMOVO
Co-pay
Tier
1
1
3
3
3
Dispensing Edits
(blank)
(blank)
(blank)
(blank)
(blank)
CREON
PANCREAZE
PERTZYE
ULTRASE
VIOKASE
ZEN PEP
ACIPHEX
DEXILANT
FIRST
LANSOPRAZOLE
FIRST
OMEPRAZOLE Susp
KAPIDEX
lasoprazole cap
lasoprazole rap dr
NEXIUM
omeprazole
omeprazole/sodium
bicarf
pantoprazole
PREVACID
PRILOSEC
PRILOSEC OTC
PROTONIX
ZEGERID
colocort
CORTIFOAM
2
2
2
2
2
2
3
2
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
Qty. Limit
(blank)
3
Age
3
3
1
1
3
1
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
1
1
3
3
1
3
3
1
2
(blank)
(blank)
(blank)
(blank)
Rider
(blank)
(blank)
(blank)
(blank)
DELZICOL
3
(blank)
RAPAFLO
3
(blank)
CYSTAGON
2
(blank)
ELIMIRON
RIMSO
2
2
(blank)
(blank)
MYRBETRIQ
3
(blank)
FOSRENOL
PHOSLO
2
2
(blank)
(blank)
86
Therapeutic Class
Therapeutic
Class II
Prostatic
Hypertrophy
Agents
Urinary
Antibacterials
Urinary
Antiinfectives &
Combo
Urinary
Antispasmotics
Drug Name
RENAGEL
RENVELA
Co-pay
Tier
2
3
Dispensing Edits
(blank)
(blank)
alfuzosin hcl
AVODART
finasteride
FLOMAX
JAYLN (Eff. 7/1/11)
PROSCAR
tamsulosin hcl
UROXATRAL
1
2
1
3
2
3
1
3
(blank)
Step Therapy
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
UROGESIC-BLUE
2
(blank)
MACROBID
methanamine
hippurate
methanamine
madelate
MONUROL
nitrofurantoin
nitrofurantoin
macrocrystal
URELLE
UREX
UTA
UTAC
2
(blank)
1
(blank)
1
3
1
(blank)
(blank)
(blank)
1
3
2
3
3
(blank)
(blank)
(blank)
(blank)
(blank)
1
2
2
3
3
3
1
3
1
1
1
3
3
3
2
3
3
3
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
bethanechol
DETROL
DETROL LA
DITROPAN
DITROPAN XL
ENABLEX
flacoxate
GELNIQUE
hyscyamine
oxybutynin
oxybutynin SR
OXYTROL
SANCTURA
SANCTURA XR
TOVIAZ
URECHOLINE
URISPAS
VESICARE
87
Therapeutic Class
Therapeutic
Class II
Urinary PH
Modifier
Vaginal AntiInfectives
Vaginal
Estrogens
Vaginal
Progestins
Immunological
Agents
Immunosuppres
sive Agents
Infections and
Infestations
Antibacterial Betalactam
Antibacterials Aminoglycosides
Drug Name
Co-pay
Tier
Dispensing Edits
UROCIT-K
2
3
(blank)
(blank)
CLEOCIN VAGINAL
clindamaycin
(vaginal)
CLINDESSE
GYNAZOLE-1
METROGEL VAG
nystatin vag
TERAZOL
terconazole
tioconazole
vandazole
zazole
3
Gender
1
3
3
3
1
3
1
1
1
1
Gender
Gender
Gender
Gender
Gender
Gender
Gender
Gender
Gender
Gender
ESTRACE VAGINAL
ESTRING
FEMRING
PREMARIN
VAGINAL
VAGIFEM
2
2
2
Gender
Gender
Gender
2
2
Gender
Gender
CRINONE
PROCHIEVE
PROGESTERONE
VAGINAL
3
3
Age, Rider
Age, Rider
2
Age, Rider
AZASAN
azathioprine
CELLCEPT
cyclosporine
cyclosporine modified
gengraf
IMURAN
MYFORTIC
NEORAL
PROGRAF
RAPAMUNE
SANDIMMUNE
2
1
3
1
1
1
2
2
3
2
3
3
(blank)
(blank)
Specialty
(blank)
(blank)
(blank)
(blank)
Specialty
Specialty
Specialty
Specialty
Specialty
NICAZEL
3
(blank)
neomycin
paromomycin
TOBI
1
1
1
(blank)
(blank)
Specialty
88
Therapeutic Class
Therapeutic
Class II
Antibacterials Ampicillins and
Combinations
Antibacterials Cephalosporins,
1st Generation
2nd Generation
3rd Generation
Antibacterials Fluoroquinolone
s
Drug Name
Co-pay
Tier
Dispensing Edits
amoxicillin
amoxicillin/K
clavulanate
AMOXIL
ampicillin
AUGMENTIN
AUGMENTIN ES
AUGMENTIN XR
DISPERMOX
principen
trimox
1
(blank)
1
1
1
3
3
3
3
1
1
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
cefadroxil
cephalexin
DURICEF
1
1
3
(blank)
(blank)
(blank)
cefaclor
cefaclor ER
cefprozil
CEFTIN
cefuroxime
CEFZIL
1
1
1
3
1
3
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
CEDAX
cefdinir
cefpodoxime
OMNICEF
SPECTRACEF
SUPRAX
VANTIN
3
1
1
3
2
3
3
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
AVELOX
AVELOX ABC
CIPRO
CIPRO XR
ciprofloxacin
ciprofloxacin ER
FACTIVE
LEVAQUIN
levofloxacin (1/16/12)
oral
2
2
3
3
1
1
3
3
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
1
(blank)
89
Therapeutic Class
Therapeutic
Class II
Antibacterials Ketolides
Antibacterials Macrolides
Antibacterials Miscellaneous
Antibacterials Penicillins
Antibacterials Sulfonamides
Antibacterials Tetracyclines
Drug Name
NOROXIN
ofloxacin
Co-pay
Tier
3
1
Dispensing Edits
(blank)
(blank)
KETEK
3
(blank)
azithromycin
BIAXIN
BIAXIN XL
clarithromycin
clarithromycin SR
clarithromycin xl
DYNABAC
e.e.s.
erythrocin
erythromycin
erythromycin delayed
relase particles
erythromycin
ethylsuccinate
PCE
ZITHROMAX
ZMAX
1
3
3
1
1
1
3
1
1
1
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
1
(blank)
1
1
3
3
(blank)
(blank)
(blank)
(blank)
clindamycin
metronidazole
metronidazole SR
NEBUPENT
TINDAMAX
trimethoprim
XIFAXAN
ZYVOX
1
1
1
3
3
1
3
3
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
Prior Auth
dicloxacillin sodium
penicillin VK
veetids
1
1
1
(blank)
(blank)
(blank)
SMZ/TMP
sulfadiazine
sulfisoxazole
1
1
1
(blank)
(blank)
(blank)
ADOXA
ALODOX
DECLOMYCIN
demeclocycline
DORYX
doxy-caps
doxycycline hyclate
doxycycline
3
3
3
1
3
1
1
1
Prior Auth
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
90
Therapeutic Class
Therapeutic
Class II
Antifungals
Anti-Infective
Agents Miscellanous
Antimalarials
and
Combinations
Drug Name
monohydrate
doxycycline
monohydrate 150mg
DYNACIN
MINOCIN
minocycline
minocycline ER
MONODOX
myrac
ORAXYL
PERIOSTAT
SOLODYN
tetracycline
VIBRAMYCIN
VIBRATAB
ANCOBON
DIFLUCAN (all other
strengths)
DIFLUCAN 150mg
fluconazole (all other
strengths)
fluconazole 150mg
flucytosine
GRIFULVIN V
GRIS-PEG
itraconazole
ketoconazole
LAMISIL
NOXAFIL
nystatin
ONMEL
SPORANOX
terbinafine
VFEND
Co-pay
Tier
Dispensing Edits
1
3
3
1
1
3
1
3
3
3
1
3
3
3
Prior Auth
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
3
3
(blank)
Qty. Limit
1
1
1
2
2
1
1
3
3
1
3
3
1
3
(blank)
Qty. Limit
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
Prior Auth
colistimethate sodium
COLY-MYCIN M
1
2
(blank)
(blank)
ARALEN
chloroquine
COARTEM
DARAPRIM
FANSIDAR
hydroxychloroquine
sulfate
LARIAM
3
1
2
2
2
Prior Auth
Prior Auth
(blank)
(blank)
(blank)
1
2
(blank)
(blank)
91
Therapeutic Class
Therapeutic
Class II
Antimycobacteri
al Agents
Antiprotozal
Agents
Antiretroviral
Combo
Antiretrovirals Chemokine
Receptor
Antagonist
Antiretrovirals Fusion Inhibitors
Antiretrovirals Integrase
Inhibitors
Antiretrovirals Non-Nucleoside
Reverse
Transcriptase
Inhibitors
(NNRTIs)
Antiretrovirals NRTI/NNRTI
Combination
Antiretrovirals Nucleoside
(NRTI) and
Nucleoside
(NtRI) Analogs
Drug Name
MALARONE
mefloquine
primaquine
quinerva
quinine sulfate
Co-pay
Tier
2
1
1
1
1
Dispensing Edits
(blank)
(blank)
(blank)
(blank)
(blank)
dapsone
ethambutol
isoniazid
MYAMBUTOL
pyrazinamide
RIFAMATE
rifampin
RIFATER
1
1
1
2
1
3
1
3
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
ALINIA
MEPRON
2
2
(blank)
(blank)
COMPLERA
2
(blank)
SELZENTRY
2
(blank)
FUZEON
2
ISENTRESS
2
INTELENCE
RESCRIPTOR
SUSTIVA
VIRAMUNE
VIRAMUNE XR
2
2
2
2
3
ATRIPLA
2
COMBIVIR
COMBIVIR (4/1/12)
didanosine delayed
release
EMTRIVA
2
3
(blank)
(blank)
1
2
92
Therapeutic Class
Therapeutic
Class II
Antiretrovirals Protease
Inhibitors
Antiviral - HIV
Antivirals - CMV
Agents
Antivirals Hepatitis Agents
Antivirals Herpes Agents
Drug Name
EPIVIR
EPIVIR (4/1/12)
EPZICOM
lamivudine
lamivudinezidovudine
RETROVIR
TRIZIVIR
TRUVADA
VIDEX
VIDEX EC
VIREAD
ZERIT
ZIAGEN
zidovudine
Co-pay
Tier
Dispensing Edits
2
3
2
1
1
3
2
2
3
3
2
2
2
1
(blank)
(blank)
(blank)
APTIVUS
CRIXIVAN
INVIRASE
KALETRA
LEXIVA
NORVIR
PREZISTA
REYATAZ
VIRACEPT
EDURANT
2
2
2
2
2
2
2
2
2
2
(blank)
ganciclovir
VALCYTE
1
3
(blank)
(blank)
BARACLUDE
COPEGUS
EPIVIR HBV
HEPSERA
INFERGEN
PEGASYS
PEG-INTRON
REBETOL
ribasphere
ribavirin
SYLATRON
SYLATRON PK
TYZEKA
2
3
2
3
3
2
2
3
1
1
3
2
3
acyclovir
famciclovir
1
1
(blank)
(blank)
Specialty
Specialty
93
Therapeutic Class
Therapeutic
Class II
Antivirals Influenza Agents
Antivirals Respiratory
Syncytial Virus
(RSV) Agents
Betalactam
HEP-C
Hep-C NS3/4A
Serine Protease
Inh
Miscellaneous
HIV/AIDS
Monoclonal
antibody
Ammonia Inh
Ammonia
Inhibitor
Antifibinolytic
Anti-inflamatory
cytokine,
interleukin-1beta
Anti-inflamatory
interleukin 1
receptor
antagonist
Antipsoriatic
agent
Bone Resportion
Inh
Botulinum Toxin
- Type A
BPH, 5-AlphaRed Inh/Alpha-1
Adr Antg Combo
Brandykinin B2
Recept Antag
Drug Name
FAMVIR
favciclovir
valacyclovir
VALTREX
ZOVIRAX
Co-pay
Tier
3
1
1
3
3
Dispensing Edits
(blank)
(blank)
(blank)
(blank)
(blank)
FLUMADINE
RELENZA
rimantadine
TAMIFLU
1
3
1
3
(blank)
(blank)
(blank)
(blank)
VIRAZOLE
CAYSTON
CAYSTON Inh
PEGASYS
PEGASYS
PROCLICK
2
3
3
2
Specialty
(blank)
2
(blank)
INCIVEK
VICTRELIS
STRIBILID
2
3
3
Preclusive Edit
SYNAGIS
RAVICTI
2
3
(blank)
CARBAGLU
LYSTEDA
tranexamic acid
3
3
1
(blank)
Qty. Limit
Qty. Limit
ILARIS
3
(blank)
ARCALYST
3
Specialty
8-MOP
AMEVIVE
2
3
Specialty
Specialty
ZOMETA
3
DYSPORT
3
Prior Auth
JALYN
2
(blank)
FIRAZYR
3
Specialty
94
Therapeutic Class
Therapeutic
Class II
CYSTIC
FIB.TRANSMEM
B
CONDUCT.REG
.(CFTR)POTEN
TIATOR
Dental
Dietary
Supplement
Disease
Modifying
Anthrheumatic
agent
Drugs to Treat
Impotency
Electrolyte
Depleter
Gout
Immunosuppres
sive Agents
Joint
Contracture,
Collagenase
Enzyme
Metabolic Dx
Enzyme
Replacement
Metallic Poison
Agent
Monoclonal
antibody
Neuromuscular
Blocking Agent
Nutritional
Supplement
Oral Mucositis
PKU
Plasma Kallkrein
Inh
Somatostatic
Tx Neuromusc
Transmission
Drug Name
Co-pay
Tier
Dispensing Edits
KALYDECO
REMESENSE
3
3
(blank)
PREFLIN
3
Prior Auth
ACTEMRA
3
Specialty
alprostadil
CAVERJECT
CIALIS
EDEX
LEVITRA
STAXYN
VIAGRA
yohimbine
1
3
2
3
3
3
2
1
Qty. Limit
Qty. Limit
Qty. Limit
Qty. Limit
Qty. Limit
Qty. Limit
Qty. Limit
(blank)
PHOSLYRA
ULORIC
3
2
(blank)
(blank)
ZORTRESS
3
Specialty
XIAFLEX
3
Specialty
VPRIV
3
FERRIPROX
3
(blank)
STELARA
3
Specialty
Botulinum toxin
3
Prior Auth
ZYTAZE
EPISIL
KUVAN
2
3
3
(blank)
(blank)
(blank)
KALBITOR
octreotide acetate
SANDOSTATIN
SOMATULINE
3
1
3
3
Specialty
Specialty
Specialty
Specialty
AMPYRA
3
Specialty
95
Therapeutic Class
Musculoskeletal
System
Therapeutic
Class II
(blank)
Analgesic
Antiarthritic
Antimyasthenic
Agents
Antirheumatic
Agents
Calcium
Regulators
DMARD
Immunomodulat
ors
Muscle
Relaxants and
Combinations
Drug Name
GELX
Co-pay
Tier
3
Dispensing Edits
(blank)
salsalate
COLCRYS
1
2
(blank)
(blank)
MESTINON
MESTINON
TIMESPAN
pyridostigmine
2
(blank)
2
1
(blank)
(blank)
ARAVA
leflunomide
RHEUMATREX
RIDAURA
3
1
2
2
(blank)
(blank)
(blank)
(blank)
ACTONEL
alendronate
ATELVIA
BINOSTO
BONIVA
CALCITONIN NASAL
DIDRONEL
FORTEO
fortical
FOSAMAX
FOSAMAX PLUS D
ibandronate sodium
MIACALCIN injection
MIACALCIN NASAL
pamidronate
SKELID
ORENCIA
2
1
2
3
3
1
2
3
1
3
3
1
2
3
1
2
3
Qty. Limit
Qty. Limit
(blank)
(blank)
Qty. Limit
(blank)
(blank)
(blank)
(blank)
(blank)
Qty. Limit
(blank)
(blank)
(blank)
(blank)
Specialty
CIMZIA
ENBREL
HUMIRA
KINERET
REMICADE
3
2
2
3
3
AMRIX
baclofen
carisoprodol
carisoprodol/aspirin
carisoprodol/aspirin/c
odeine
chlorzoxazone
COMFORT PAC -
3
1
1
1
(blank)
(blank)
(blank)
(blank)
1
1
3
(blank)
(blank)
(blank)
96
Therapeutic Class
Therapeutic
Class II
NSAID
Drug Name
TIZANIDINE
COMFORT PAC
CYCLOBENZAPRIN
E
cyclobenzaprine ER
cyclobenzaprine hcl
DANTRIUM
FEXMID
methocarbamol
orphenadrine cpd
orphenadrine ER
orphenadrine/aspirin/
caffeine
SKELAXIN
tizanidine cap
tizanidine tab
ZANAFLEX
ARTHROTEC
CAMBIA
CELEBREX
COMFORT PAC MELOXICAM
COMFORT PAC NAPROXEN
DAYPRO
diclofenac
diclofenac potassium
diclofenac sodium XR
etodolac
etodolac ER
fenoprofen
FLECTOR
flurbiprofen
ibuprofen
indomethacin
indomethacin ER
ketopofen
ketoprofen ER
ketorolac
meclofenamate
sodium
mefenamic acid
meloxicam
MOBIC
nabumetone
NALFON
NAPRELAN
Co-pay
Tier
Dispensing Edits
3
1
1
3
3
1
1
1
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
1
3
3
1
3
2
3
2
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
Qty. Limit
(blank)
3
(blank)
3
3
1
1
1
1
1
1
2
1
1
1
1
1
1
1
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
1
1
1
3
1
3
3
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
97
Therapeutic Class
Ophthalmic
Agents
Therapeutic
Class II
Selective
Estrogen
Receptor
Modlator
(SERM)
Antibiotic Topical
Antifibroptic
Agents
Antihistamine
Antiinflammatory
Antiviral
Glaucoma Adrenergic
Agents
Glaucoma Beta-blockers
Drug Name
naproxen
NAPROXEN
COMFORT PAC
naproxen sodium
oxaprozin
piroxicam
PONSTEL
PREVACID
NAPRAPAC
SPRIX
sulindac
tolmetin sodium
VOLTAREN
VOLTAREN GEL
VOLTAREN XR
Co-pay
Tier
1
Dispensing Edits
(blank)
3
1
1
1
3
(blank)
(blank)
(blank)
(blank)
(blank)
2
3
1
1
3
3
3
Qty. Limit
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
EVISTA
2
(blank)
BESAVANCE
3
(blank)
MISTOSOL
BEPREVE
LASTACAFT
3
3
3
(blank)
(blank)
(blank)
ILVERO
ZIRGAN
3
3
(blank)
(blank)
ALPHAGAN P
brimonidine
COMBIGAN
dipivefrin
IOPIDINE
PROPINE
2
1
2
1
1
1
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
betaxolol
BETIMOL
BETOPTIC-S
carteolol
ISTALOL
levobunolol
metipranolol
OPTIPRANOLOL
timolol
timolol maleate ophth
1
2
2
1
3
1
1
2
1
1
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
98
Therapeutic Class
Therapeutic
Class II
Glaucoma Carbonic
Anhydrase
Inhibitors
Glaucoma Miotics
Glaucoma Prostaglandins
GlaucomaProstaglandins
Miotic
Ophthalmic
Antihistamines
and NSAIDs
Drug Name
AZOPT
COSOPT
dorzolamide
dorzolamide hcl
ophthalmic
dorzolamide/tilomol
ophthalmic
TRUSOPT
Co-pay
Tier
Dispensing Edits
2
3
1
Qty. Limit
Qty. Limit
Qty. Limit
1
(blank)
1
3
Qty. Limit
Qty. Limit
carboptic
ISO CARBACHOL
ISOPTO CARPINE
PHOSPHOLINE
pilocar
pilocarpine
PILOPINE HS
piloptic
REV-EYES
1
2
2
2
1
1
2
1
2
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
LUMIGAN
TRAVATAN
TRAVATAN Z
XALATAN
3
2
2
2
(blank)
Qty. Limit
Qty. Limit
Qty. Limit
bimatoprost
pilocarpine
1
1
(blank)
(blank)
ACULAR
ACULAR LS
ACULAR PF
ALAMAST
ALOCRIL
ALOMIDE
cromolyn sodium
ophth
diclofenac ophth
ELESTAT
EMADINE
epinastine hcl
flubiprofen
NEVANAC
OPTIVAR
PATADAY
PATANOL
2
2
2
3
2
2
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
1
1
3
3
1
1
2
2
2
2
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
99
Therapeutic Class
Therapeutic
Class II
Ophthalmic Antiinfectives
Ophthalmic
Immunomodulat
ors
Ophthalmic
Steroidal Antiinflammatory
Drugs
Drug Name
VOLTAREN
XIBROM
Co-pay
Tier
2
3
Dispensing Edits
(blank)
(blank)
3
1
(blank)
(blank)
1
1
1
1
1
2
1
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
AZASITE
bacitracin
bacitracin/neomycin/p
olymyxin
bacitracin/polymyxin
ciprofloxacin
erythromycin
gentamicin
IQUIX
levofloxacin ophth
nemoycin/polymyxin/
gramicidin
ofloxacin
polymyxin
B/trimethoprim
QUIXIN
sulfacetamide sodium
tobramycin
trifluridine
triple antibotic
VIGAMOX
ZYMAR
1
1
(blank)
(blank)
1
3
1
1
1
1
2
2
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
RESTASIS
2
(blank)
ak-pred
ALREX
bacitracine/polymyxin
/neomycin/hydrocortis
one
BLEPHAMIDE S.O.P.
dexacidin
dexamethasone
phosphate
dexamethasone/neo
mycin/ polymyxin
dexasol
dexasporin
fluorometholone
fluor-op
FML FORTE
FML LIQUIFILM
FML S.O.P.
1
3
(blank)
(blank)
1
2
1
(blank)
(blank)
(blank)
1
(blank)
1
1
1
1
1
3
3
2
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
100
Therapeutic Class
Therapeutic
Class II
Proteolytic
Enzyme
Vasc.
Endothelial
Growth Factor
Antag
Otic Agents
Anti-Infective
Agents Miscellanous
Otic Antiinfectives
Otic
Combinations
Respiratory Tract
Agents
Antiasthmatics Anticholinergics
Antiasthmatics Monocolonal
Antibodies
Antihistamine
Antihistamine
Decongestant
Combo
Drug Name
HMS
LOTEMAX
neomycin/polymyxin/
hydrocortisone
poly-dex
POLY-PRED
PRED-G
PRED-G S.O.P.
prednisolone
ophthalmic
sulfacetamide
sodium/prednisolone
TOBRADEX
TOBRADEX ST
VEXOL
ZYLET
Co-pay
Tier
2
2
Dispensing Edits
(blank)
(blank)
1
1
3
2
2
(blank)
(blank)
(blank)
(blank)
(blank)
1
(blank)
1
2
2
2
3
(blank)
(blank)
(blank)
(blank)
(blank)
JETREA
3
(blank)
EYLEA
MACUGEN
3
3
Specialty
Specialty
CORTANE-B
3
(blank)
FLOXIN OTIC
ofloxacin otic
2
1
(blank)
(blank)
antipyrine/benzocaine
CIPRO HC
CIPRODEX
COLY-MYCINS-S
cortomycin
neomycin/polymyxin/
hydrocortisone
ZINOTIC/ZINOTIC
ES
1
2
2
2
1
(blank)
(blank)
(blank)
(blank)
(blank)
1
(blank)
3
(blank)
ATROVENT HFA
ipratropium inhaler
SPIRIVA
2
1
2
(blank)
(blank)
(blank)
XOLAIR
meclizine
3
1
(blank)
ACCUHIST
3
(blank)
101
Therapeutic Class
Therapeutic
Class II
AntiInflammatory
Agents
(nebulizer)
Antisussive
Narcotic
Antitussive
Decogestant
Antitussive, Non
Narcotic
Bronchodilator
Bronchodilators Sympathomimeti
cs
Drug Name
CENHIST
CORZALL
CORZALL PE
CORZALL PLUS
RESCON JR
RESPA C&C IR
V-HIST
Co-pay
Tier
3
3
3
3
3
3
3
Dispensing Edits
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
cromolyn soduim
nebulizer
1
(blank)
ZUTRIPRO
3
(blank)
GILTUSS TR
V-COF
3
3
(blank)
(blank)
PROLEX DM
ZONATUSS
ARCAPTA
NEOHALER
3
3
(blank)
(blank)
3
(blank)
3
2
2
1
(blank)
Qty. Limit
Qty. Limit
(blank)
3
1
2
3
2
(blank)
(blank)
(blank)
(blank)
(blank)
2
2
3
2
(blank)
(blank)
(blank)
(blank)
3
1
1
3
2
3
2
2
1
3
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
ACCUNEB
ADVAIR DISKUS
ADVAIR HFA
albuterol sulfate
albuterol sulfate (GE:
Accuneb®)
albuterol/ipratropium
ALUPENT
BROVANA
COMBIVENT
COMBIVENT
RESPIMAT
DULERA
DUONEB
FORADIL
MAXAIR
AUTOHALER
metaproterenol
micronefrin
PERFORMIST
PROAIR HFA
PROVENTIL HFA
SEREVENT DISKUS
SYMBICORT
terbutaline
TUDORZA
102
Therapeutic Class
Therapeutic
Class II
Bronchodilators Xanthines
COPD
Corticosteroids
Cough and Cold
Cystic Fibrosis
Agents
Inhaled
Corticosteroids
Leukotriene
Modulators
Drug Name
VENTOLIN HFA
VOSPIRE ER
XOPENEX
XOPENEX HFA
Co-pay
Tier
2
3
3
3
Dispensing Edits
(blank)
(blank)
Age, Prior Auth
Age, Prior Auth
aminophylline
BRONCAP
THEO-24
theocap
theochron
theophylline ER
UNIPHYL
DALIRESP
AMALPRED Plus
CODAR D
CODAR GF
HISTEX SR
NASOTUSS
NOTUSS NXD
PEDIATEX TDM
POLYHIST forte
PROCLEAR CAP
PROHIST CD
PROHIST CF
PROHIST LQ
STATUSS GREEN
TRICODE AR
Z-COF I
ZOTEX-PE, EX, D
1
3
3
1
1
1
3
3
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
Qty. Limit
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
PULMOZYNE
2
AEROBID
AEROBID-M
ALVESCO HFA
ASMANEX
AZMACORT
FLOVENT DISKUS
FLOVENT HFA
PULMICORT
FLEXHALER
PULMICORT
RESPULES
QVAR
3
2
2
2
2
2
2
(blank)
Qty. Limit
(blank)
Qty. Limit
Qty. Limit
Qty. Limit
Qty. Limit
2
Qty. Limit
2
2
Qty. Limit
Qty. Limit
3
Qty. Limit
1
(blank)
ACCOLATE
montelukast sod
(10mg tab, 4mg, 5mg
103
Therapeutic Class
Therapeutic
Class II
Mouth and
Throat Products
Narcotic
Antitussive
Combo
Nasal Antiallergy
Nasal
Anticholinergics
Nasal Steroid
Nasal steroid
combo
Nasal Steroids
Non-Sedating
Antihistamines
and
Combinations
Drug Name
chew)
Co-pay
Tier
Dispensing Edits
SINGULAIR
SINGULAIR (10mg
tab, 4mg, 5mg chew)
zafirlukast
ZYFLO/ZYFLO CR
2
Qty. Limit
3
1
3
Qty. Limit
Qty. Limit
Qty. Limit
EVOXAC
3
(blank)
ALLEFEN CDX
ASTELIN NASAL
ASTEPRO
azelastine (08/01/10)
PATANASE
3
3
3
1
3
(blank)
Qty. Limit
Qty. Limit
Qty. Limit
(blank)
ATROVENT NASAL
ipratropium nasal
ZETONNA
2
1
3
(blank)
(blank)
Qty. Limit
DYMISTA
BECONASE AQ
FLONASE
flunisolide
fluticasone
propionate nasal
NASACORT AQ
NASAREL
NASONEX
OMNARIS
QNASL
RHINOCORT AQ
triamcinolone acetate
nasal spray
VERAMYST
3
3
3
1
Qty. Limit
(blank)
(blank)
(blank)
1
3
3
3
3
3
3
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
1
3
(blank)
(blank)
3
3
3
3
3
1
Qty. Limit
Qty. Limit
Qty. Limit
Qty. Limit
Qty. Limit
(blank)
1
(blank)
1
1
Qty. Limit
(blank)
ALLEGRA
ALLEGRA-D
CLARINEX
CLARINEX REDITAB
CLARINEX-D
fexofenadine
fexophenadine/Pseud
oephedrine
levocetirizine
dihydrochloride
loratadine
104
Therapeutic Class
Therapeutic
Class II
Upper
Respiratory Cough/Cold/Aller
gy Combinations
Vitamin
B-12 preparation
B-Vitamin
Folic acid
Folic Acid Prep
Iron
Iron
Replacement
Miscellaneous
Multivitamin
Pediatric Vitamin
Prenatal
Prenatal Vitamin
Drug Name
XYZAL
Co-pay
Tier
3
Dispensing Edits
Qty. Limit
SEMPREX-D
TUSSIONEX
cyanocobalmin
CENFOL
folic acid
levomefolate calcium
DEPLIN
ENLYTE
l-methylfolate calcium
IROSPAN
3
3
1
3
1
1
3
3
1
3
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
FERVIA
MAXARON FORTE
FUSION PLUS
VIRT-VITE
NICOMIDE
POLY VI FLOR
W/IRON
POLY-VI-FLOR
TRI-VITAMIN W/FL
NEXA SELECT
B NEXA
BAL-CARE DHA
ESSENTIAL
CITRANATAL 90
DHA
CITRANATAL BCALM
CITRANATAL
HARMONY
CITRNATAL-BA
CALM
DONATUSS XP
ORAL
DUET DHA
BALANCED <geq>
DUET DHA
COMPLETE
DUET DHA
COMPLETE <geq>
DUET DHC EC
GESTICARE DHA
HEMENATAL OB
HEMENATAL OB +
DHA COMBO
MARNATAL F
3
3
3
3
3
(blank)
(blank)
(blank)
(blank)
(blank)
3
3
3
3
3
(blank)
(blank)
(blank)
(blank)
Age, Gender
3
(blank)
3
(blank)
3
Age, Qty. Limit
3
(blank)
3
(blank)
3
(blank)
1
Gender
3
Gender
1
3
3
3
Gender
(blank)
Age, Gender
Age, Qty. Limit
3
3
Age, Qty. Limit
(blank)
105
Therapeutic Class
Therapeutic
Class II
Vitamin
Drug Name
NATA KOMPLETE
NEEVO COMBO PK
NEEVO, NEEVO
DHA
NESTABS
NESTABS DHA
NEXA PLUS
NEXA SELECT
NIRON KOMPLETE
OB COMPLETE
W/DHA
PNV FOLIC ACID +
IRON
PNV-DHA PLUS
PNV-IRON
PREFERA OB
PRENATA
PRENATAL PLUS
prenatal vitamins
(oral)
PRENATE DHA
PRENATE ELITE
PRENATE
ESSENTIAL
PRENATE MINI
PRENATE PLUS
PRENEXA
PREQUE 10
PROTECT NATAL
PUREFE OB PLUS
PUREFE PLUS
TL-SELECT DHA
TRIVEEN-U
VENATAL - FA
VITAFOL-ONE
VITAFOL PLUS
VITAMEDMD ONE
RX
VIVA CT
VOL-NATE
VOL-PLUS
VOL-TAB RX
B-NEXA
CORVITE FE
DUET DHA
BALANCED
PROTECT BONE
PROTECT IRON
Co-pay
Tier
3
3
Dispensing Edits
(blank)
(blank)
3
3
3
3
3
3
(blank)
(blank)
(blank)
Age, Gender
Age, Gender
(blank)
3
(blank)
3
3
3
3
3
3
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
1
3
3
(blank)
(blank)
(blank)
3
3
3
3
3
3
3
3
3
3
3
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
Age, Gender
Age, Gender
Gender
Age, Gender
(blank)
3
(blank)
3
3
3
3
2
3
3
Age, Qty. Limit
(blank)
(blank)
(blank)
(blank)
(blank)
(blank)
3
3
3
(blank)
(blank)
(blank)
106
Therapeutic Class
Therapeutic
Class II
Vitamin B Prep
Vitamins, misc.
Drug Name
TOZAL
VASCULERA
FOLTX
MENTANX
Co-pay
Tier
3
3
3
3
Dispensing Edits
(blank)
(blank)
(blank)
(blank)
107

2Q13 - 4D Manage Formulary

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